{ "application": "SREMAN", "version": 1, "exportedAt": "2026-10-07T11:09:08.654Z", "database": "PubMed", "pico": { "reviewName": "Test 1", "population": "Human", "intervention": "Polymorphisms", "comparator": "Wild allele", "outcome": "Association", "studyDesign": "Observational", "inclusionCriteria": "Articles relevant to the PECOS", "exclusionCriteria": "Articles not relevant to the PECOS" }, "searchQuery": "", "searchHistory": [ { "id": "search_1791355890868", "database": "PubMed", "query": "vishnu shivam", "searchedAt": "2026-10-07T06:51:30.868Z", "initialCount": 6, "retrievedCount": 6, "segments": [ { "startDate": null, "endDate": null, "count": 6 } ], "queryTranslation": "shivam, vishnu[Author]" }, { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 134, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" }, { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 134, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" }, { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 134, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "activeScreeningTab": "unscreened", "databaseStatistics": { "multipleSearchOccurrences": 0, "importedRecords": 30555, "totalRecords": 30963 }, "articles": [ { "id": "000e95e2-cdb3-48a0-915f-508f9bb5da32", "pmid": "", "title": "Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications", "imported": false, "abstract": "Abstract - Background Radiotherapy as part of head and neck cancer treatment leaves patients requiring much dental rehabilitation in a compromised environment that is difficult for the patient and the dental team to manage. Objectives To assess the effects of maintaining the patient's natural dentition during radiotherapy in comparison to extracting teeth before radiotherapy in areas that are difficult to access by the patient and the dentist, should reduction in mouth opening occur after radiotherapy to the jaws. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 22 November 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 22 November 2012), EMBASE via OVID (1980 to 22 November 2012), CANCERLIT via PubMed (1950 to 22 November 2012), CINAHL via EBSCO (1980 to 22 November 2012) and reference lists of articles. We advertised for currently ongoing studies via the Cochrane Oral Health Group website and the Cochrane Oral Health Group Twitter feed. Selection criteria Randomised controlled trials comparing extraction of teeth prior to radiotherapy with leaving teeth in situ during radiotherapy to the jaws. Data collection and analysis Three review authors independently assessed the results of the searches for inclusion in the review. Main results No randomised controlled trials were found. Authors' conclusions There are no randomised controlled trials to assess the effect of extracting teeth prior to radiotherapy compared to leaving teeth in the mouth during radiotherapy to the jaws. Plain language summary Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications This review aimed to assess if removing the back teeth before radiotherapy would mean that patients had fewer tooth‐related problems after radiotherapy as part of head and neck cancer treatment, when compared to not removing the teeth. Electronic and handsearching found 357 titles of studies but none of them met the inclusion criteria for the review. There is currently no evidence available to answer this complex question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Eliyas, S; Al‐Khayatt, A; Porter, RWJ; Briggs, P", "articleTypes": [], "doi": "10.1002/14651858.CD008857.pub2", "decision": "Include", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "00179114-0a6e-4fae-94c7-60a9b82ddcda", "pmid": "", "title": "Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common, life‐shortening, genetic disorder in populations of Northern European descent caused by the mutation of a single gene that codes for the production of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. This protein coordinates the transport of salt (and bicarbonate) across cell surfaces, and the mutation most notably affects the airways. In the lungs of people with CF, the defective protein compromises mucociliary clearance and makes the airway prone to chronic infection and inflammation, damaging the structure of the airways and eventually leading to respiratory failure. In addition, abnormalities in the truncated CFTR protein lead to other systemic complications, including malnutrition, diabetes and subfertility. Five classes of mutation have been described, depending on the impact of the mutation on the processing of the CFTR protein in the cell. In class I mutations, premature termination codons prevent the production of any functional protein, resulting in severe CF. Therapies targeting class I mutations aim to enable the normal cellular mechanism to read through the mutation, potentially restoring the production of the CFTR protein. This could, in turn, normalise salt transport in the cells and decrease the chronic infection and inflammation that characterises lung disease in people with CF. This is an update of a previously published review. Objectives To evaluate the benefits and harms of ataluren and similar compounds on clinically important outcomes in people with CF with class I mutations (premature termination codons). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles. The last search of the Cochrane Cystic Fibrosis Trials Register was conducted on 7 March 2022. We searched clinical trial registries maintained by the European Medicines Agency, the US National Institutes of Health and the World Health Organization. The last search of the clinical trials registries was conducted on 4 October 2022. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing ataluren and similar compounds (specific therapies for class I mutations) with placebo in people with CF who have at least one class I mutation. Data collection and analysis For the included trials, the review authors independently extracted data, assessed the risk of bias and evaluated the certainty of the evidence using GRADE; trial authors were contacted for additional data. Main results Our searches identified 56 references to 20 trials; of these, 18 trials were excluded. Both the included parallel RCTs compared ataluren to placebo for 48 weeks in 517 participants (males and females; age range six to 53 years) with CF who had at least one nonsense mutation (a type of class I mutation). The certainty of evidence and risk of bias assessments for the trials were moderate overall. Random sequence generation, allocation concealment and blinding of trial personnel were well documented; participant blinding was less clear. Some participant data were excluded from the analysis in one trial that also had a high risk of bias for selective outcome reporting. PTC Therapeutics Incorporated sponsored both trials with grant support from the Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the National Institutes of Health. The trials reported no difference between treatment groups in terms of quality of life, and no improvement in respiratory function measures. Ataluren was associated with a higher rate of episodes of renal impairment (risk ratio 12.81, 95% confidence interval 2.46 to 66.65; P = 0.002; I 2 = 0%; 2 trials, 517 participants). The trials reported no treatment effect for ataluren for the review's secondary outcomes of pulmonary exacerbation, computed tomography score, weight, body mass index and sweat chloride. No deaths were reported in the trials. The earlier trial performed a post hoc subgroup analysis of participants not receiving concomitant chronic inhaled tobramycin (n = 146). This analysis demonstrated favourable results for ataluren (n = 72) for the relative change in forced expiratory volume in one second (FEV 1 ) per cent (%) predicted and pulmonary exacerbation rate. The later trial aimed to prospectively assess the efficacy of ataluren in participants not concomitantly receiving inhaled aminoglycosides, and found no difference between ataluren and placebo in FEV 1 % predicted and pulmonary exacerbation rate. Authors' conclusions There is currently insufficient evidence to determine the effect of ataluren as a therapy for people with CF with class I mutations. One trial reported favourable results for ataluren in a post hoc subgroup analysis of participants not receiving chronic inhaled aminoglycosides, but these were not reproduced in the later trial, suggesting that the earlier results may have occurred by chance. Future trials should carefully assess for adverse events, notably renal impairment, and consider the possibility of drug interactions. Cross‐over trials should be avoided, given the potential for the treatment to change the natural history of CF. Plain language summary Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis Review question Can ataluren (and similar compounds specifically targeting class I mutations in cystic fibrosis (CF)) improve the quality of life and lung function of people with CF without having adverse effects? Key messages What is CF? In people with CF, the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. This especially affects the airways, causing the airway surface to dry out and making it difficult to clear thick mucus. This leads to progressive infection and damages the lungs, shortening life expectancy. How will ataluren treat CF? In people with certain CF genetic mutations where the genetic instructions for producing the CFTR protein are interrupted (known as premature termination codon or class I mutations), ataluren (and similar medicines) may be able to skip over the break in the faulty gene sequence and allow the body to produce a corrected version of the CFTR protein. By correcting the protein, the airway surface should remain hydrated, allowing people with CF to better clear their mucus and so develop fewer lung infections. What did we want to find out? We wanted to know whether ataluren can improve the quality of life and lung function of people with CF, and whether it can do so without any side effects. We also wanted to measure the effects on lung infections (need for hospital visits or additional antibiotics), survival, nutritional status (weight, body mass index and height) and whether treatment was cost‐effective. What did we do? We searched for trials that directly compared drugs such as ataluren to placebo (treatment not containing an active drug) or to a different treatment for these specific genetic mutations in any people with CF. What did we find? We found two trials including 517 people (males and females between 6 and 53 years of age) comparing ataluren to a placebo. The trials lasted 48 weeks and everyone taking part in the trials had at least one gene with a class I mutation. Key results In people taking ataluren, there was no improvement in clinical outcomes such as quality of life, lung function, exacerbations (flare up of disease), sweat chloride (salt) levels or weight compared with people taking placebo. The trials found that kidney damage was more common in people taking ataluren. The earlier trial analysed their results in a way not originally planned to see whether the effects of ataluren and placebo were different in people using inhaled tobramycin (an antibiotic) on a long‐term basis compared with people not taking the inhaled antibiotic. In people taking ataluren but not using inhaled tobramycin, lung function declined at a slower rate and there were fewer exacerbations than in people in the placebo group also not using inhaled tobramycin. The later trial specifically recruited people not taking tobramycin to see whether this really was an effect of the antibiotic, but the investigators did not find any difference between the ataluren and placebo groups for changes in lung function or exacerbations. This suggests that the earlier results occurred by chance. There were no deaths and we did not find any differences between ataluren and placebo in side effects or nutritional status. Neither trial reported on hospitalisations, extra courses of antibiotics or cost‐effectiveness. We have not found enough high‐quality evidence to determine the effect of ataluren for treating CF. We recommend that future trials are designed and reported clearly so that their results can be included in a systematic review. What are the limitations of the evidence? We are moderately confident in our findings, but there is some uncertainty due to how widely the results varied between participants. We are satisfied that everyone taking part had an equal chance of being in either group (ataluren or placebo) and that no one could work out which group the next person would be put into (so that healthier people did not receive the treatment and make the results seem better). We believe that the clinicians running the trials and those taking part in the trials did not know which treatment each person was receiving. We have some concerns about the emphasis the investigators of one trial placed on the results of a comparison they had not planned (the use of long‐term inhaled tobramycin). Unfortunately, that trial did not report all its results clearly. Sometimes, the results were reported in a way that meant they could not be used in this review, and sometimes the information was not reported at all. This affected our confidence in the overall results. Trial funding sources Both trials were sponsored by PTC Therapeutics Incorporated, who make ataluren. The Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the US National Institutes of Health also supported the trials. How up to date is this evidence? We last searched for evidence on 4 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aslam, AA; Sinha, IP; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD012040.pub3", "decision": "Exclude", "reason": "Not relevant", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "00255ce8-0ef3-40f6-ab99-2dfa6dabf813", "pmid": "", "title": "Music‐based therapeutic interventions for people with dementia", "imported": false, "abstract": "Abstract - Background Dementia is a clinical syndrome with a number of different causes. It is characterised by deterioration in cognitive, behavioural, social and emotional functioning. Pharmacological interventions are available but have limited effect on many of the syndrome's features. However, receptivity to music may remain until the late phases of dementia, and music‐based therapeutic interventions (which include, but are not limited to, music therapy) are suitable for people with advanced dementia. As there is uncertainty about the effectiveness of music‐based therapeutic interventions, trials are being conducted to evaluate this. This review updates one last published in 2018 and examines the current evidence for the effects of music‐based interventions for people with dementia. Objectives To assess the effects of music‐based therapeutic interventions for people with dementia on emotional well‐being (including quality of life), mood disturbance or negative affect (i.e. depressive symptoms and anxiety), behavioural problems (i.e. overall behavioural problems or neuropsychiatric symptoms, and more specifically agitation or aggression), social behaviour and cognition, at the end of therapy and four or more weeks after the end of treatment, and to assess any adverse effects. Search methods We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organisation's meta‐register‐the International Clinical Trials Registry Platform on 30 November 2023. Selection criteria We included randomised controlled trials of music‐based therapeutic interventions (of at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music. Data collection and analysis Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data from included studies and assess their risk of bias. If necessary, we contacted trial authors to ask for additional data, such as relevant subscales. We pooled data using the random‐effects model. We assessed the certainty of the evidence for our two comparisons and our main outcomes of interest using GRADE. Main results We included 30 studies with 1720 randomised participants that were conducted in 15 countries. Twenty‐eight studies with 1366 participants contributed data to meta‐analyses. Ten studies contributed data to long‐term outcomes. Participants had dementia of varying degrees of severity and resided in institutions in most of the studies. Seven studies delivered an individual intervention; the other studies delivered the intervention to groups. Most interventions involved both active and receptive elements of musical experience. The studies were at high risk of performance bias and some were at high risk of detection or other bias. For music‐based therapeutic interventions compared to usual care, we found moderate‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions probably improved depressive symptoms slightly (standardised mean difference (SMD) −0.23, 95% confidence interval (CI) −0.42 to −0.04; 9 studies, 441 participants), and we found low‐certainty evidence that it may have improved overall behavioural problems (SMD −0.31, 95% CI −0.60 to −0.02; 10 studies, 385 participants). We found moderate‐certainty evidence that music‐based therapeutic interventions likely did not improve agitation or aggression (SMD −0.05, 95% CI −0.27 to 0.17; 11 studies, 503 participants). Low to very low certainty evidence showed that they did not improve emotional well‐being (SMD 0.14, 95% CI ‐0.29 to 0.56; 4 studies, 154 participants), anxiety (SMD −0.15, 95% CI −0.39 to 0.09; 7 studies, 282 participants), social behaviour (SMD 0.22, 95% CI −0.14 to 0.57; 2 studies; 121 participants) or cognition (SMD 0.19, 95% CI −0.02 to 0.41; 7 studies, 353 participants). Low or very‐low ‐certainty evidence showed that music‐based therapeutic interventions may not have been more effective than usual care in the long term (four weeks or more after the end of treatment) for any of the outcomes. For music‐based therapeutic interventions compared to other interventions, we found low‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions may have been more effective than the other activities for social behaviour (SMD 0.52, 95% CI 0.08 to 0.96; 4 studies, 84 participants). We found very low‐certainty evidence of a positive effect on anxiety (SMD −0.75, 95% CI −1.27 to −0.24; 10 studies, 291 participants). For all other outcomes, low‐certainty evidence showed no evidence of an effect: emotional well‐being (SMD 0.20, 95% CI −0.09 to 0.49; 9 studies, 298 participants); depressive symptoms (SMD −0.14, 95% CI ‐0.36 to 0.08; 10 studies, 359 participants); agitation or aggression (SMD 0.01, 95% CI −0.31 to 0.32; 6 studies, 168 participants); overall behavioural problems (SMD −0.08, 95% CI −0.33 to 0.17; 8 studies, 292 participants) and cognition (SMD 0.12, 95% CI −0.21 to 0.45; 5 studies; 147 participants). We found low or very‐low certainty evidence that music‐based therapeutic interventions may not have been more effective than other interventions in the long term (four weeks or more after the end of treatment) for any of the outcomes. Adverse effects were inconsistently measured or recorded, but no serious adverse events were reported. Authors' conclusions When compared to usual care, providing people with dementia with at least five sessions of a music‐based therapeutic intervention probably improves depressive symptoms and may improve overall behavioural problems at the end of treatment. When compared to other activities, music‐based therapeutic interventions may improve social behaviour at the end of treatment. No conclusions can be reached about the outcome of anxiety as the certainty of the evidence is very low. There may be no effects on other outcomes at the end of treatment. There was no evidence of long‐term effects from music‐based therapeutic interventions. Adverse effects may be rare, but the studies were inconsistent in their reporting of adverse effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions. Plain language summary Does music‐based therapy help people with dementia? Key messages · Compared to usual care (i.e. without specific activities), providing people with dementia with music‐based therapy sessions probably improves depression, and may improve overall behavioural problems. · Compared to other activities, music‐based therapy may improve social behaviour, but we are unsure if it improves anxiety. · These effects may not last beyond the end of treatment. · There is no evidence that music‐based therapy makes a difference to the emotional well‐being, agitation or cognition (e.g. thinking and remembering) of people with dementia, although there is uncertainty about this. · There is uncertainty in the evidence for long‐term effects, but no long‐term effects were observed in the studies. · Adverse effects (unwanted side effects) may be rare, but the studies were inconsistent in their reporting, so we need more evidence before we can reach reliable conclusions. Why offer music‐based therapy to people with dementia? People with dementia gradually develop increasing difficulty with thinking and daily activities. Dementia is often associated with emotional and behavioural problems and may decrease a person's quality of life. In the later stages of dementia, it may be difficult for people to communicate with words, but even when they can no longer speak, they may still be able to hum or play along with music. Therapy involving music may therefore be especially suitable for people with dementia to improve their lives. Who provides music‐based therapy? Music therapists are certified to work with individuals or groups of people, using music to try to help meet their physical, psychological and social needs. Other professionals may also be trained to provide similar therapies. What did we want to find out? We wanted to find out if, for people with dementia, music‐based therapy works better than usual care or other activities, such as painting. We were interested in whether the therapy changed these outcomes at the end of treatment: · emotional well‐being including quality of life; · depression and anxiety; · agitation or aggression and overall behavioural problems; · social behaviour; and · cognition (e.g. thinking and remembering). We also wanted to find out if there were any long‐term effects after therapy ended or any unwanted effects. What did we do? We searched for studies in which people with dementia were randomly allocated to receive music‐based therapy (of at least five sessions) or to a comparison group with no activities or different activities. We combined the results of the studies to estimate the effects of music‐based therapy as accurately as possible. We also rated our level of confidence in the findings. What did we find? We found 30 studies performed in 15 countries. The studies involved 1720 people with dementia of varying severity. In most of the studies, the participants lived in nursing homes. Seven studies delivered the music‐based therapy to individuals; the other studies delivered the intervention to groups. We were able to use results from 28 studies involving 1366 people with dementia for one or more outcomes at the end of treatment. Ten studies contributed information about long‐term results. Main results At the end of treatment Music‐based therapy probably improves depression and may improve overall behavioural problems, compared with providing usual care. Music‐based therapy may improve social behaviour compared to other activities. We were less confident about the effects of music‐based therapy on anxiety compared to other activities. The available evidence does not suggest any benefit of music‐based therapy for emotional well‐being (including quality of life), agitation and aggression, or cognition, but the evidence is limited and there is uncertainty about this. In the longer term Some studies measured outcomes four weeks or more after treatment ended. We did not find any lasting effects, but there were fewer results measured in the longer term, and we are uncertain about this evidence. Further studies are likely to have a significant impact on what we know about the effects of music‐based therapy for people with dementia, so it is important that research continues. What are the limitations of the evidence? There was variation in the quality of the studies and how well they were reported. In all studies, participants and personnel might have known which treatment participants were getting, and in some, the assessors might have known this as well. This could have affected the results. Regarding effects at the end of music‐based therapy, we are moderately confident in the evidence for the beneficial effect on depression compared to usual care. We have little confidence in the effects or lack of effects on any of the other outcomes. Adverse effects were rarely reported. How up to date is this evidence? This review updates our previous review. We added eight new studies and reached new conclusions. The evidence is current to 30 November 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "van der Steen, JT; van der Wouden, JC; Methley, AM; Smaling, HJ A; Vink, AC; Bruinsma, MS", "articleTypes": [], "doi": "10.1002/14651858.CD003477.pub5", "decision": "Exclude", "reason": "Duplicate", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "002bae2f-ad69-457d-898e-4e23c6e6c906", "pmid": "", "title": "Graft interposition for preventing Frey's syndrome in patients undergoing parotidectomy", "imported": false, "abstract": "Abstract - Background Frey's syndrome is characterised by transient flushing and sometimes facial sweating in the area of the auriculotemporal nerve. It most commonly occurs after parotidectomy, but other causes may include submandibular gland surgery, mandibular condylar fracture, obstetric (forceps) trauma, sympathectomy and metabolic disease. Although the pathophysiology of Frey's syndrome remains controversial, the generally accepted hypothesis is that it occurs as the result of injury to the auriculotemporal nerve. There is currently no clear evidence to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome, therefore the prevention of this symptom during surgery is important. The main method used for prevention is the interposition of a graft between the skin flap and the parotid bed during surgery. Biomaterials, allograft or autograft can be used for this purpose. Objectives To evaluate the effects and safety of biomaterial, allograft or autograft interposition for the prevention of Frey's syndrome in patients undergoing parotidectomy, and to identify its effect on prevention and delayed occurrence. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Cochrane Register of Controlled Trials (CENTRAL; 2019, Issue 2); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 5 February 2019. Selection criteria We included randomised controlled trials (RCTs) in patients with parotid disease (including tumours, inflammation, trauma etc.) undergoing parotidectomy with a minimal follow‐up period of six months. We planned to include trials with interventions including biomaterial, allograft or autograft interposition alone or in combination with other surgical techniques. We included trials that compared any graft interposition and no graft interposition, or different graft interpositions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were incidence rate of Frey's syndrome assessed clinically (Minor's starch‐iodine test) and other complications (postoperative infection, subjective painful or restricted cervical movement, scar spread, rejection of the graft, complications related to the donor site such as accessory nerve injury and haematoma). Our secondary outcome measures were incidence rate of Frey's syndrome assessed by participants (by questionnaire) and sweating area assessed by Minor's starch‐iodine test. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included three RCTs (124 participants), two of which we assessed as at high risk of bias and one at unclear risk of bias. All studies were hospital‐based and recruited participants undergoing superficial parotidectomy. Most participants were diagnosed with benign lesions of the parotid gland. Participants were followed up for more than six months. The studies evaluated the two comparisons shown below: Sternocleidomastoid muscle flap versus no flap Two studies assessed this comparison. Both assessed the effects of the sternocleidomastoid muscle flap procedure on the incidence rate of Frey's syndrome assessed clinically but neither showed a significant difference between groups (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.23; 24 participants and RR 1.23, 95% CI 0.88 to 1.73; 36 participants; very low‐certainty evidence). We did not pool the data due to the high heterogeneity (I² = 87%). One study found that the sternocleidomastoid muscle flap may result in little or no difference in other complications including haematoma (RR 2.18, 95% CI 0.09 to 50.16; 36 participants; low‐certainty evidence), subjective painful or restricted cervical movement (RR 0.54, 95% CI 0.14 to 2.05; 36 participants; low‐certainty evidence) and scar spread in the cervical region (RR 0.71, 95% CI 0.05 to 10.54; 36 participants; low‐certainty evidence). Both studies reported the incidence rate of Frey's syndrome assessed by participants, with one reporting no events in either group and the other finding no evidence of a difference (RR 0.63, 95% CI 0.32 to 1.26; 36 participants; low‐certainty evidence). Acellular dermal matrix versus no graft Only one study assessed this comparison. Use of an acellular dermal matrix graft may result in little or no difference to the incidence rate of Frey's syndrome (assessed clinically) in comparison with the no graft group, but the evidence is very uncertain (RR 0.08, 95% CI 0.00 to 1.25; 30 participants; very low‐certainty evidence). Acellular dermal matrix may slightly increase the wound infection rate compared with control (RR 17.00, 95% CI 1.02 to 282.67; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence of seromas or sialoceles (RR 2.33, 95% CI 0.66 to 8.23; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence rate of Frey's syndrome (assessed by participants) in comparison with the no graft group (RR 0.33, 95% CI 0.04 to 3.04; 64 participants; low‐certainty evidence). Authors' conclusions The evidence for the effectiveness of graft interposition in preventing Frey's syndrome is of low or very low certainty. The use of acellular dermal matrix may be associated with an increase in the wound infection rate, and little or no difference in the incidence of seromas or sialoceles. Further studies are needed to draw reliable conclusions. Plain language summary Grafts for preventing Frey's syndrome after surgery to the parotid (salivary) glands Review question Does the use of a graft during surgery to the parotid glands prevent Frey's syndrome? Background The clinical symptoms of Frey's syndrome include sweating and flushing of the cheek when eating and chewing. It results from abnormal regrowth of damaged autonomic nerve fibres of the parotid glands, for example during surgery for parotid gland tumours. It is unclear whether placing a graft between the skin flap and the parotid bed during surgery can prevent this syndrome. Various types of grafts can be used, including biomaterial or skin, muscle or other tissue from the patient. These grafts may possibly hinder the abnormal connections of the nerves controlling the sweat glands and parotid glands when the cut nerves are re‐linking after surgery. Study characteristics We included three studies with 124 participants in this review, but the quality of these studies was not ideal. All of the participants in the studies had tumours of the parotid glands and were undergoing surgery to part of the glands. The studies assessed two types of grafts, tissue obtained from the sternocleidomastoid muscle and a biomaterial (a collagen framework without cells). Key results Two studies compared a tissue graft obtained from the sternocleidomastoid muscle to no graft. It is not known whether this type of tissue graft can prevent Frey's syndrome because the available evidence is very uncertain. One study compared a biomaterial graft to no graft. This type of graft may result in little or no difference to the incidence rate of Frey's syndrome, but the evidence is very uncertain. It may make the patient's wound slightly more likely to become infected. Certainty of the evidence The evidence in this review is mostly of low or very low certainty, because of the small number of studies on this question and the risk of bias in these studies. The findings must therefore be treated with caution and further studies are needed to draw reliable conclusions. The evidence in this review is up to date to 5 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ye, L; Cao, Y; Yang, W; Wu, F; Lin, J; Li, L; Li, C", "articleTypes": [], "doi": "10.1002/14651858.CD012323.pub2", "decision": "Exclude", "reason": "Review article", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "00317387-61bd-4fe4-9b7e-fb7772772759", "pmid": "", "title": "Eplerenone for hypertension", "imported": false, "abstract": "Abstract - Background Eplerenone is an aldosterone receptor blocker that is chemically derived from spironolactone. In Canada, it is indicated for use as adjunctive therapy to reduce mortality for heart failure patients with New York Heart Association (NYHA) class II systolic chronic heart failure and left ventricular systolic dysfunction. It is also used as adjunctive therapy for patients with heart failure following myocardial infarction. Additionally, it is indicated for the treatment of mild and moderate essential hypertension for patients who cannot be treated adequately with other agents. It is important to determine the clinical impact of all antihypertensive medications, including aldosterone antagonists, to support their continued use in essential hypertension. No previous systematic reviews have evaluated the effect of eplerenone on cardiovascular morbidity, mortality, and magnitude of blood pressure lowering in patients with hypertension. Objectives To assess the effects of eplerenone monotherapy versus placebo for primary hypertension in adults. Outcomes of interest were all‐cause mortality, cardiovascular events (fatal or non‐fatal myocardial infarction), cerebrovascular events (fatal or non fatal strokes), adverse events or withdrawals due to adverse events, and systolic and diastolic blood pressure. Search methods We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers up to 3 March 2016. We handsearched references from retrieved studies to identify any studies missed in the initial search. We also searched for unpublished data by contacting the corresponding authors of the included studies and pharmaceutical companies involved in conducting studies on eplerenone monotherapy in primary hypertension. The search had no language restrictions. Selection criteria We selected randomized placebo‐controlled trials studying adult patients with primary hypertension. We excluded studies in people with secondary or gestational hypertension and studies where participants were receiving multiple antihypertensives. Data collection and analysis Three review authors independently reviewed the search results for studies meeting our criteria. Three review authors independently extracted data and assessed trial quality using a standardized data extraction form. A fourth independent review author resolved discrepancies or disagreements. We performed data extraction and synthesis using a standardized format on Covidence. We conducted data analysis using Review Manager 5. Main results A total of 1437 adult patients participated in the five randomized parallel group studies, with treatment durations ranging from 8 to 16 weeks. The daily doses of eplerenone ranged from 25 mg to 400 mg daily. Meta‐analysis of these studies showed a reduction in systolic blood pressure of 9.21 mmHg (95% CI −11.08 to −7.34; I 2 = 58%) and a reduction of diastolic pressure of 4.18 mmHg (95% CI −5.03 to −3.33; I 2 = 0%) (moderate quality evidence). There may be a dose response effect for eplerenone in the reduction in systolic blood pressure at doses of 400 mg/day. However, this finding is uncertain, as it is based on a single included study with low quality evidence. Overall there does not appear to be a clinically important dose response in lowering systolic or diastolic blood pressure at eplerenone doses of 50 mg to 400 mg daily. There did not appear to be any differences in the number of patients who withdrew due to adverse events or the number of patients with at least one adverse event in the eplerenone group compared to placebo. However, only three of the five included studies reported adverse events. Most of the included studies were of moderate quality, as we judged multiple domains as being at unclear risk in the 'Risk of bias' assessment. Authors' conclusions Eplerenone 50 to 200 mg/day lowers blood pressure in people with primary hypertension by 9.21 mmHg systolic and 4.18 mmHg diastolic compared to placebo, with no difference of effect between doses of 50 mg/day to 200 mg/day. A dose of 25 mg/day did not produce a statistically significant reduction in systolic or diastolic blood pressure and there is insufficient evidence for doses above 200 mg/day. There is currently no available evidence to determine the effect of eplerenone on clinically meaningful outcomes such as mortality or morbidity in hypertensive patients. The evidence available on side effects is insufficient and of low quality, which makes it impossible to draw conclusions about potential harm associated with eplerenone treatment in hypertensive patients. Plain language summary Eplerenone for high blood pressure Review question The aim of this review was to determine the effectiveness of eplerenone for reducing blood pressure, its side effect profile, and its impact on clinically meaningful outcomes such as mortality and morbidity. Background Clinicians have used eplerenone to treat high blood pressure since 2002. It is important to determine the clinical impact of all antihypertensive medications used in patients to support their continued use in essential hypertension. We searched multiple databases and found five eligible studies in 1437 people who received either eplerenone or no medication in a random fashion. Study characteristics The doses of eplerenone used in these studies ranged from 25 mg to 400 mg daily. These studies followed patients for 8 to 16 weeks while on therapy. None of the studies reported on the clinically meaningful outcomes of eplerenone, such as whether eplerenone can reduce heart attacks, stroke, or death compared to placebo. Only three of the five studies reported on side effects. Key results There is currently no evidence that eplerenone has a beneficial effect on life expectancy or complications rleated to hypertension (e.g. heart attack, stroke). Evidence for risk of side effects with eplerenone is limited and of poor quality; it is difficult to tell the extent of possible harm with eplerenone versus placebo. This meta‐analysis shows that eplerenone 50 to 200 mg/day reduces systolic blood pressure by approximately 9 mmHg and diastolic blood pressure by 4 mmHg compared to taking no medication. Quality of the evidence We judged the five included trials to be of moderate quality, as authors did not extensively describe portions of their methodology.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tam, TSC, Wu, MHY, Masson, SC, Tsang, MP, Stabler, SN, Kinkade, A, Tung, A, Tejani, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008996.pub2", "decision": "Exclude", "reason": "Animal study", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.749Z" }, { "id": "00338724-7178-47b2-9496-ecdedf8fe1fe", "pmid": "", "title": "Progesterone receptor modulators for endometriosis", "imported": false, "abstract": "Abstract - Rationale Endometriosis is defined as the presence of endometrium‐like tissue developing outside the uterine cavity. This condition is oestrogen‐dependent and thus is seen primarily during the reproductive years. Owing to their antiproliferative effects on the endometrium, progesterone receptor modulators (PRMs) have been advocated for the treatment of endometriosis. This is an update of a Cochrane review previously published in 2017. Objectives To assess the effectiveness and safety of progesterone receptor modulators (PRMs) in the management of endometriosis. Search methods To identify studies, we searched online sources, including the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, ClinicalTrials.gov and the WHO (World Health Organization) trial registry up to 16 April 2026. We also checked reference lists and contacted study authors and experts. Eligibility criteria We included randomised controlled trials (RCTs) comparing PRMs with placebo, no treatment or other medical treatment, in women with symptomatic endometriosis. Outcomes Our critical outcomes were overall pain; improvement in the most troublesome symptom, including dysmenorrhoea and dyspareunia; and adverse events resulting from the PRM intervention. Our important outcomes included quality of life (QoL) and patient satisfaction with treatment. Risk of bias We used the Cochrane tool RoB 2 to assess the risk of bias in the outcomes of this review. Synthesis methods Two review authors independently assessed studies against the inclusion criteria, extracted data and assessed risk of bias, consulting a third review author where required. We analysed dichotomous outcomes using Mantel‐Haenszel odds ratios (ORs), 95% confidence intervals (CIs) and the fixed‐effect model. We analysed continuous outcomes using the mean difference (MD) between groups, presented with 95% CIs. We employed the GRADE approach to assess the certainty of the evidence as high, moderate, low or very low. Included studies No new studies were eligible for inclusion in this update. Of the nine studies (922 women) already included in the review, two compared mifepristone versus placebo or compared different doses of mifepristone, and four either compared gestrinone versus danazol, gestrinone versus gonadotropin‐releasing hormone (GnRH) analogues or compared different doses of gestrinone. One study compared asoprisnil versus placebo. The asoprisnil study did not provide extractable numerical data and was included in the narrative synthesis only. Two of the studies did not report any of the review's prespecified outcomes. Synthesis of results Certainty of the evidence We judged the certainty of evidence as low to very low. The main limitations of the evidence were serious risk of bias (associated with poor reporting of methods and high or unclear rates of attrition), very serious imprecision (associated with low event rates and wide confidence intervals, with some large effect estimates) and serious indirectness (outcomes assessed in selected subgroups). PRM versus placebo Mifepristone versus placebo These results are based on one study (360 participants) that measured outcomes after three months. The study did not report overall pain. At three months, mifepristone may improve dysmenorrhoea (OR 0.07, 95% CI 0.03 to 0.15; 1 study, 342 participants; low‐certainty evidence), suggesting that if 40% of women taking placebo experience dysmenorrhoea, then between 3% and 10% of women taking mifepristone will do so. We are uncertain whether mifepristone improves dyspareunia (OR 0.23, 95% CI 0.10 to 0.51; 1 study, 223 participants; very low‐certainty evidence). However, mifepristone may increase hot flushes (OR 28.79, 95% CI 3.93 to 210.73; 1 study, 360 participants; low‐certainty evidence). Mifepristone may make little or no difference after three months of treatment to the prevalence of nausea (OR 1.72, 95% CI 0.20 to 15.03; 1 study, 360 participants; low‐certainty evidence). PRM versus other medical treatment Gestrinone versus danazol These results are based on two studies (302 participants) that measured outcomes after six months. We are uncertain of the effects of gestrinone relative to danazol on the improvement of overall pain (dichotomous outcome: participants reporting no or mild pelvic pain counted as 'improved') (OR 0.47, 95% CI 0.04 to 5.70; 1 study, 38 participants), dysmenorrhoea (Not estimable; 1 study, 38 participants), or dyspareunia (OR 1.00, 95% CI 0.13 to 7.94; 1 study, 38 participants (all very low‐certainty evidence). We are uncertain about the effects of gestrinone relative to danazol on hot flushes (OR 0.79, 95% CI 0.50 to 1.26; 2 studies, 302 participants; very low‐certainty evidence). There may be little or no difference between gestrinone and danazol in rates of nausea (OR 1.36, 95% CI 0.84 to 2.19; 2 studies, 302 participants; low‐certainty evidence). Gestrinone versus a GnRH analogue (leuprorelin) These results are based on one study (55 participants) that measured outcomes after six months. There may be little to no difference between gestrinone and leuprorelin in non‐menstrual pain (MD −0.41, 95% CI −1.76 to 0.94; 1 study, 55 participants; low‐certainty evidence). Women taking gestrinone may have higher dysmenorrhoea scores than those taking leuprorelin (MD 0.82, 95% CI 0.15 to 1.49; 1 study, 55 participants; low‐certainty evidence), but gestrinone may improve dyspareunia more than leuprorelin (MD −1.16, 95% CI −2.08 to −0.24; 1 study, 52 participants; low‐certainty evidence). There may be lower rates of hot flushes with gestrinone than leuprorelin (OR 0.20, 95% CI 0.06 to 0.63; 1 study, 55 participants; low‐certainty evidence). There may be little or no difference between gestrinone and leuprorelin in rates of nausea (OR 1.04, 95% CI 0.06 to 17.49; 1 study, 55 participants; low‐certainty evidence). Authors' conclusions Mifepristone may improve dysmenorrhoea in women with endometriosis, but it might increase the prevalence of adverse events, such as hot flushes. The evidence is very uncertain regarding its effect on dyspareunia. Gestrinone may be less effective than leuprorelin in treating dysmenorrhoea, but it may improve dyspareunia. It may be associated with lower rates of hot flushes and similar rates of nausea. We are uncertain about the effect of gestrinone compared to danazol. We found insufficient evidence to permit firm conclusions about the safety and effectiveness of other progesterone receptor modulators. Funding This Cochrane review had no dedicated funding. Registration Protocol (2012) DOI: 10.1002/14651858.CD009881 Review (2017) DOI: 10.1002/14651858.CD009881.pub2 Plain language summary What are the benefits and risks of medicines called progesterone receptor modulators (PRMs) for treating endometriosis (a condition where tissue grows outside the womb)? Key messages In the management of endometriosis (a condition where tissue grows outside the womb), studies that compared a progesterone receptor modulator (PRM; a medicine that changes how the hormone progesterone acts in the body) against placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested) found that a PRM called mifepristone may improve painful periods. However, it may cause hot flushes. A PRM called gestrinone may be less effective than medicines known as gonadotropin‐releasing hormone (GnRH) analogues (which reduce the amount of oestrogen made by the ovaries) for treating painful periods, but may improve pain during sex. Gestrinone may also cause fewer hot flushes. We do not know how gestrinone compares to a treatment called danazol in terms of pain not related to periods, painful periods or pain during sex. We do not know whether gestrinone or danazol causes more unwanted effects. Future studies should compare progesterone receptor modulators with medicines currently used to treat endometriosis symptoms and focus on assessing pain using recognised and reliable methods. Larger, well‐designed studies are also needed to assess the benefits and unwanted effects of progesterone receptor modulators other than mifepristone and gestrinone. What is endometriosis? Endometriosis is a condition where tissue similar to the lining of the womb (uterus) grows outside the womb. Endometriosis is oestrogen‐dependent and thus is seen mainly during the reproductive years. It can cause pain in the tummy area (abdomen), generally during periods (menstruation) or associated with sexual intercourse. Endometriosis is treated through different types of medical or surgical treatment. Progesterone receptor modulators (PRMs) are medicines that change how the hormone progesterone acts in the body. PRMs include mifepristone, gestrinone, ulipristal acetate, vilaprisan and asoprisnil. Because they can slow down or stop the growth of tissue in the lining of the uterus, they have been suggested as a treatment for endometriosis. What did we want to find out? We wanted to know whether, in patients with endometriosis, PRMs are better than placebo ('dummy' treatment), no treatment or other medical treatment for improving overall pain, pain during periods and pain during sexual intercourse. We also wanted to know if these medications were safe by assessing unwanted effects experienced by patients, such as hot flushes and feeling sick (nausea). What did we do? We searched for studies that investigated the effectiveness of PRMs for symptoms associated with endometriosis and whether they caused unwanted effects. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included nine studies involving 922 women aged 18 to 45 years. Most studies tested the PRMs mifepristone or gestrinone. One study tested asoprisnil, but the study was published only as a short summary without results that we could use. Two of the studies did not measure any of the effects we were interested in. Main results Progesterone receptor modulators versus placebo When compared to a placebo, mifepristone: may reduce painful periods after three months of treatment (based on 1 study of 342 women); may cause more unwanted effects, such as hot flushes (1 study, 360 women); may make little or no difference to nausea (1 study, 360 women); and we are uncertain whether mifepristone reduces pain during sex (1 study, 223 women). Progesterone receptor modulators versus other medical treatment When compared to danazol, one study of 38 women showed that: we do not know whether gestrinone improves pain symptoms after six months of treatment (1 study, 38 women); we do not know whether gestrinone causes more or fewer hot flushes or makes no difference (2 studies, 302 women); and gestrinone and danazol may cause similar rates of nausea, but the results are very uncertain (2 studies, 302 women). When compared to a GnRH analogue (leuprorelin), one study of 55 women found that: gestrinone may be less efficient in treating painful periods after six months of treatment (1 study, 55 women); but gestrinone may reduce pain during sex (1 study, 52 women); gestrinone may be similar to leuprorelin in terms of general pain experienced (1 study, 55 women); gestrinone may cause fewer hot flushes and similar levels of nausea (1 study, 55 women). What are the limitations of the evidence? Our confidence in the evidence is low to very low, mainly because some studies had one or more of these problems: they did not have many people taking part; they focused on specific settings or populations; they used methods likely to introduce errors in their results; they did not clearly report how they were conducted; they did not clearly report whether the people taking part knew which treatment they had received, which could have affected the study results. How up to date is this evidence? This review updates a previous review. The evidence is up to date to April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Grammatis, AL, Gibbons, T, Anucha, EN, Becker, CM", "articleTypes": [], "doi": "10.1002/14651858.CD009881.pub3", "decision": "Include", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.138Z" }, { "id": "005eca30-29f9-4a64-9de9-24560e80b92f", "pmid": "", "title": "Exercise-induced Erythropoiesis: the Mechanistic of Angiotensin II", "imported": false, "abstract": "The major aims are to determine the effect of acute (single dose) blockade of ANGII receptor 1 (AT1) on the EPO response to a single session of endurance exercise, as well as determine the effect of chronic (8-week) blockade of AT1 on ET-induced adaptations in total circulating red blood volume and hemoglobin.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.240Z" }, { "id": "007d4135-c181-4eee-bc56-e2162fa024f6", "pmid": "", "title": "Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer", "imported": false, "abstract": "Abstract - Background Radioactive iodine treatment for differentiated thyroid cancer possibly results in xerostomia. Amifostine has been used to prevent the effects of irradiation to salivary glands. To date, the effects of amifostine on salivary glands in radioactive iodine treated differentiated thyroid cancer remain uncertain. Objectives To assess the effects of amifostine on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer. Search methods Studies were obtained from computerized searches of MEDLINE, EMBASE, The Cochrane Library and paper collections of conferences held in Chinese. Selection criteria Randomised controlled clinical trials and quasi‐randomised controlled clinical trials comparing the effects of amifostine on salivary glands after radioactive iodine treatment for differentiated thyroid cancer with placebo and a duration of follow up of at least three months. Data collection and analysis Two authors independently assessed risk of bias and extracted data. Main results Two trials with 130 patients (67 and 63 patients randomised to intervention versus control) were included. Both studies had a low risk of bias. Amifostine versus placebo showed no statistically significant differences in the incidence of xerostomia (130 patients, two studies), the decrease of scintigraphically measured uptake of technetium‐99m by salivary or submandibular glands at twelve months (80 patients, one study), and the reduction of blood pressure (130 patients, two studies). Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Meta‐analysis was not performed on the function of salivary glands measured by technetium‐99m scintigraphy at three months after high dose radioactive iodine treatment due to the highly inconsistent findings across studies (I 2 statistic 99%). None of the included trials investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions Results from two randomised controlled clinical trials suggest that the amifostine has no significant radioprotective effects on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer patients. Moreover, no health‐related quality of life and other patient‐oriented outcomes were evaluated in the two included trials. Randomised controlled clinical trials with low risk of bias investigating patient‐oriented outcomes are needed to guide treatment choice. Plain language summary Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer Thyroid cancer is the most common malignancy of the endocrine system consisting of several subtypes like papillary carcinoma (accounting for 80% of cases) and follicular carcinoma (accounting for 11% of cases). These are collectively referred to as 'differentiated thyroid cancer'. Treatment with radioactive iodine after surgery (ablation of the thyroid gland or 'thyroidectomy') is important for the detection of metastatic disease and for the destruction of the remaining thyroid tissue with microscopic cancer. After radioactive iodine treatment, adverse effects may happen in the salivary glands and cause salivary gland swelling and pain, usually involving the parotid. The symptoms may develop immediately after a therapeutic dose of radioactive iodine or months later and progress in intensity with time. Secondary complications reported include dry mouth ('xerostomia') and taste alterations. Amifostine is thought to be a radioprotector of salivary glands used in conjunction with radioiodine therapy. This medication is administered intravenously and was reported to ameliorate the damage of salivary glands caused by radioactive iodine therapy. We found only two randomised controlled trials in which the effects of amifostine were compared with placebo. The two randomised clinical trials investigated 130 patients treated with high dose radioactive iodine for thyroid cancer. Altogether data from the two trials suggest that amifostine has no obvious protective effects on the salivary glands in these patients. Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Until better data become available, the use of sour candy or lemon juice to increase salivation might be more appropriate during radioactive iodine treatment for patients with differentiated thyroid cancer. Patients should be well informed of the importance of hydration, acid stimulation and glandular massage after radioactive iodine treatment. In addition, early recognition and treatment of xerostomia may improve outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Ma, C; Xie, J; Chen, Q; Wang, G; Zuo, S", "articleTypes": [], "doi": "10.1002/14651858.CD007956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "0089fe73-2557-4cac-9ce0-520704d4b20f", "pmid": "", "title": "Control interventions in randomised trials among people with mental health disorders", "imported": false, "abstract": "Abstract - Background Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated. Objectives To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait‐list versus no‐treatment, (ii) usual care versus wait‐list or no‐treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait‐list or no‐treatment. Wait‐list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. Search methods In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers. Selection criteria We included randomised trials assessing patients with a mental health disorder that compared wait‐list, usual care, or placebo interventions with wait‐list or no‐treatment . Data collection and analysis Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane’s risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre‐planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random‐effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed‐effect model). Main results We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep‐wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait‐list versus no‐treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait‐list or no‐treatment and found a SMD –0.33 (95% CI ‐0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait‐list or no‐treatment was SMD −0.37 (95% CI −0.49 to −0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger’s test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD ‐0.49 (95% CI −0.64 to −0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait‐list or no‐treatment on benefits was SMD ‐0.14 (95% CI −0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD −0.21 (95% CI −0.35 to −0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep‐wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed‐effect model in a sensitivity analysis on the comparison for usual care versus wait‐list and no‐treatment, the results were significant with an SMD of –0.46 (95 % CI –0.64 to –0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains. Authors' conclusions We found marked variations in effects between placebo versus no‐treatment and wait‐list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait‐list or no‐treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research. Plain language summary Control interventions in randomised trials for people with a mental health disorder This systematic review assesses the effects of different control interventions in randomised trials including patients with a mental health disorder. In randomised trials, patients are assigned by chance to one of two or more groups – usually an experimental intervention and a control intervention. There are many types of control interventions in mental health intervention research. Some of the most common are different types of placebos that lack what is assumed to be the active component in the experimental intervention, and usual care, where patients receive the standard treatment for their mental health disorder in the area where they live. Two other types of control interventions are wait‐list or no‐treatment where patients receive no trial‐related care during the study (although some patients may receive care outside the studies). Wait‐list patients are often offered the experimental intervention after the trial has been finalised if it is likely to provide more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. We searched for randomised trials with patients with mental health disorders where wait‐list, usual care, or placebo interventions were compared with either wait‐list or no‐treatment. We looked at differences between all the types of control interventions on beneficial effects and whether they caused any adverse effects. We included 96 trials with a total of 4200 participants. Only 83 trials (3614 participants) provided usable data. Fifteen different mental health disorders were included. We found that all the trials were at high risk of bias in how they had been conducted, which reduced the interpretability of our findings. However, the risk of bias was mostly due to lack of blinding in the placebo studies, which may be seen as an aspect of the review's methodological question rather than a flaw with the review itself. We found no clinically important differences for usual care or wait‐list control interventions in the main analyses, however in our secondary analyses we found a clinically important favourable difference for usual care. In general, placebo control interventions tended to be favourable over no‐treatment or wait‐list control interventions across mental health disorders. We found no clinically important differences on adverse events. This review suggests that different control interventions have a tendency to yield very different estimates for the effects of the experimental intervention and that the choice of control intervention has a large impact on how effective a mental health treatment appears to be. Control interventions in trials with patients with mental health disorders are often poorly reported upon, and guidelines are needed to inform researchers on how to properly design, report, and interpret these trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Faltinsen, E; Todorovac, A; Staxen Bruun, L; Hróbjartsson, A; Gluud, C; Kongerslev, MT; Simonsen, E; Storebø, OJ", "articleTypes": [], "doi": "10.1002/14651858.MR000050.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "008d3117-18de-4f3a-b14e-b0f94d8aaaee", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 1. Commonly‐used classes of drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres ( ˜ 8200 feet ). Acute hypoxia, acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude. In this review, the first in a series of three about preventive strategies for HAI, we assess the effectiveness of six of the most recommended classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of commonly‐used pharmacological interventions for preventing acute HAI. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), LILACS and trial registries in January 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text terms to search. Selection criteria We included randomized‐controlled and cross‐over trials conducted in any setting where commonly‐used classes of drugs were used to prevent acute HAI. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Main results We included 64 studies (78 references) and 4547 participants in this review, and classified 12 additional studies as ongoing. A further 12 studies await classification, as we were unable to obtain the full texts. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. Risks of bias were unclear for several domains, and a considerable number of studies did not report adverse events of the evaluated interventions. We found 26 comparisons, 15 of them comparing commonly‐used drugs versus placebo. We report results for the three most important comparisons: Acetazolamide versus placebo (28 parallel studies; 2345 participants) The risk of AMS was reduced with acetazolamide (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.56; I 2 = 0%; 16 studies; 2301 participants; moderate quality of evidence). No events of HAPE were reported and only one event of HACE (RR 0.32, 95% CI 0.01 to 7.48; 6 parallel studies; 1126 participants; moderate quality of evidence). Few studies reported side effects for this comparison, and they showed an increase in the risk of paraesthesia with the intake of acetazolamide (RR 5.53, 95% CI 2.81 to 10.88, I 2 = 60%; 5 studies, 789 participants; low quality of evidence). Budenoside versus placebo (2 parallel studies; 132 participants) Data on budenoside showed a reduction in the incidence of AMS compared with placebo (RR 0.37, 95% CI 0.23 to 0.61; I 2 = 0%; 2 studies, 132 participants; low quality of evidence). Studies included did not report events of HAPE or HACE, and they did not find side effects (low quality of evidence). Dexamethasone versus placebo (7 parallel studies; 205 participants) For dexamethasone, the data did not show benefits at any dosage (RR 0.60, 95% CI 0.36 to 1.00; I2 = 39%; 4 trials, 176 participants; low quality of evidence). Included studies did not report events of HAPE or HACE, and we rated the evidence about adverse events as of very low quality. Authors' conclusions Our assessment of the most commonly‐used pharmacological interventions suggests that acetazolamide is an effective pharmacological agent to prevent acute HAI in dosages of 250 to 750 mg/day. This information is based on evidence of moderate quality. Acetazolamide is associated with an increased risk of paraesthesia, although there are few reports about other adverse events from the available evidence. The clinical benefits and harms of other pharmacological interventions such as ibuprofen, budenoside and dexamethasone are unclear. Large multicentre studies are needed for most of the pharmacological agents evaluated in this review, to evaluate their effectiveness and safety. Plain language summary Drugs commonly‐used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and breathing conditions that can occur while travelling to altitudes above 2500 metres ( ˜ 8200 feet ). HAI is generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but may affect the brain or the lungs in different individuals. In this review, we assessed the most commonly‐used drugs to prevent the onset of this illness. Study characteristics The evidence is current to January 2017. We included 64 studies related to six different types of drugs recommended for HAI prevention. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. The participants' ages ranged between 16 and 65 years. Eleven studies included people at a high risk of this condition due to their history of HAI or other illnesses such as asthma. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. In 23 of the included studies, the source of funding was unclear. Only 18 studies declared their possible conflicts of interests. We classed 24 more studies as still ongoing or waiting for assessment. Key results Our findings suggest that acetazolamide is an effective treatment for the prevention of acute HAI in dosages of 250 to 750 mg/day, when this drug is compared to a placebo (i.e. a pill with no active agent). Most of the available information relates to the prevention of uncomplicated HAI (headache, nausea, vomiting and tiredness) rather than to more serious brain or lung problems. We also found that acetazolamide is associated with an increased risk of paraesthesia in the fingers (i.e. a sensation of tingling, tickling, pricking, or burning of the skin), although this outcome is not well reported in the available evidence. The benefits and harms of other drugs such as ibuprofen, budenoside and dexamethasone are unclear, due to the small number of studies. Quality of the evidence We rated the quality of the evidence as moderate to very low. Several studies had quality shortcomings, including their use of small numbers of participants and a lack of reporting of important outcomes such as side effects. For most of the drugs covered by the studies, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Nieto Estrada, VH; Molano Franco, D; Medina, RD; Gonzalez Garay, AG; Martí‐Carvajal, AJ; Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD009761.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "009cbe51-1e08-49d3-bc42-8e32dfbbfaee", "pmid": "", "title": "The Effects of the Dopamine Receptor Agonist Pramipexole on Reward and Emotion Related Information Processing in Healthy Volunteers", "imported": false, "abstract": "The dopamine agonist pramipexole has recently been suggested as a potential novel antidepressant drug. While preliminary clinical data hint at its efficacy in treating depressive symptoms, our current understanding of its impact on neurocognitive processes is relatively limited. This is in part because mechanistic studies have largely focused on the effects of single-dose treatments. However, such acute administration of dopaminergic drugs likely has different cognitive effects than the more prolonged administration that is used clinically. This study therefore aims to explore and characterise the neurocognitive effects of more prolonged pramipexole treatment. Forty healthy volunteers will be randomly allocated to 12 to 15 days of treatment with either pramipexole or placebo. Study participants as well as researchers will be blinded as to which treatment is used. Before and after treatment all participants will perform a set of psychological tasks and questionnaires evaluating reward-based learning, emotional information processing, motivational vigour and subjective experience. Furthermore, functional magnetic resonance imaging (fMRI) will be used to compare neural activity during emotion and reward processing between the two treatment groups. We hypothesises that pramipexole might enhance reward sensitivity, motivational vigour, and pleasure experience and could induce positive biases in emotional information processing.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.239Z" }, { "id": "00b98248-9ddb-47eb-bd9e-0d2c14352b86", "pmid": "", "title": "Laboratory‐based molecular test alternatives to RT‐PCR for the diagnosis of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Diagnosing people with a SARS‐CoV‐2 infection played a critical role in managing the COVID‐19 pandemic and remains a priority for the transition to long‐term management of COVID‐19. Initial shortages of extraction and reverse transcription polymerase chain reaction (RT‐PCR) reagents impaired the desired upscaling of testing in many countries, which led to the search for alternatives to RNA extraction/purification and RT‐PCR testing. Reference standard methods for diagnosing the presence of SARS‐CoV‐2 infection rely primarily on real‐time reverse transcription‐polymerase chain reaction (RT‐PCR). Alternatives to RT‐PCR could, if sufficiently accurate, have a positive impact by expanding the range of diagnostic tools available for the timely identification of people infected by SARS‐CoV‐2, access to testing and the use of resources. Objectives To assess the diagnostic accuracy of alternative (to RT‐PCR assays) laboratory‐based molecular tests for diagnosing SARS‐CoV‐2 infection. Search methods We searched the COVID‐19 Open Access Project living evidence database from the University of Bern until 30 September 2020 and the WHO COVID‐19 Research Database until 31 October 2022. We did not apply language restrictions. Selection criteria We included studies of people with suspected or known SARS‐CoV‐2 infection, or where tests were used to screen for infection, and studies evaluating commercially developed laboratory‐based molecular tests for the diagnosis of SARS‐CoV‐2 infection considered as alternatives to RT‐PCR testing. We also included all reference standards to define the presence or absence of SARS‐CoV‐2, including RT‐PCR tests and established clinical diagnostic criteria. Data collection and analysis Two authors independently screened studies and resolved disagreements by discussing them with a third author. Two authors independently extracted data and assessed the risk of bias and applicability of the studies using the QUADAS‐2 tool. We presented sensitivity and specificity, with 95% confidence intervals (CIs), for each test using paired forest plots and summarised results using average sensitivity and specificity using a bivariate random‐effects meta‐analysis. We illustrated the findings per index test category and assay brand compared to the WHO's acceptable sensitivity and specificity threshold for diagnosing SARS‐CoV‐2 infection using nucleic acid tests. Main results We included data from 64 studies reporting 94 cohorts of participants and 105 index test evaluations, with 74,753 samples and 7517 confirmed SARS‐CoV‐2 cases. We did not identify any published or preprint reports of accuracy for a considerable number of commercially produced NAAT assays. Most cohorts were judged at unclear or high risk of bias in more than three QUADAS‐2 domains. Around half of the cohorts were considered at high risk of selection bias because of recruitment based on COVID status. Three quarters of 94 cohorts were at high risk of bias in the reference standard domain because of reliance on a single RT‐PCR result to determine the absence of SARS‐CoV‐2 infection or were at unclear risk of bias due to a lack of clarity about the time interval between the index test assessment and the reference standard, the number of missing results, or the absence of a participant flow diagram. For index tests categories with four or more evaluations and when summary estimations were possible, we found that: a) For RT‐PCR assays designed to omit/adapt RNA extraction/purification, the average sensitivity was 95.1% (95% CI 91.1% to 97.3%), and the average specificity was 99.7% (95% CI 98.5% to 99.9%; based on 27 evaluations, 2834 samples and 1178 SARS‐CoV‐2 cases); b) For RT‐LAMP assays, the average sensitivity was 88.4% (95% CI 83.1% to 92.2%), and the average specificity was 99.7% (95% CI 98.7% to 99.9%; 24 evaluations, 29,496 samples and 2255 SARS‐CoV‐2 cases); c) for TMA assays, the average sensitivity was 97.6% (95% CI 95.2% to 98.8%), and the average specificity was 99.4% (95% CI 94.9% to 99.9%; 14 evaluations, 2196 samples and 942 SARS‐CoV‐2 cases); d) for digital PCR assays, the average sensitivity was 98.5% (95% CI 95.2% to 99.5%), and the average specificity was 91.4% (95% CI 60.4% to 98.7%; five evaluations, 703 samples and 354 SARS‐CoV‐2 cases); e) for RT‐LAMP assays omitting/adapting RNA extraction, the average sensitivity was 73.1% (95% CI 58.4% to 84%), and the average specificity was 100% (95% CI 98% to 100%; 24 evaluations, 14,342 samples and 1502 SARS‐CoV‐2 cases). Only two index test categories fulfil the WHO‐acceptable sensitivity and specificity requirements for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. In addition, WHO‐acceptable performance criteria were met for two assays out of 35 when tests were used according to manufacturer instructions. At 5% prevalence using a cohort of 1000 people suspected of SARS‐CoV‐2 infection, the positive predictive value of RT‐PCR assays omitting/adapting RNA extraction/purification will be 94%, with three in 51 positive results being false positives, and around two missed cases. For TMA assays, the positive predictive value of RT‐PCR assays will be 89%, with 6 in 55 positive results being false positives, and around one missed case. Authors' conclusions Alternative laboratory‐based molecular tests aim to enhance testing capacity in different ways, such as reducing the time, steps and resources needed to obtain valid results. Several index test technologies with these potential advantages have not been evaluated or have been assessed by only a few studies of limited methodological quality, so the performance of these kits was undetermined. Only two index test categories with enough evaluations for meta‐analysis fulfil the WHO set of acceptable accuracy standards for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. These assays might prove to be suitable alternatives to RT‐PCR for identifying people infected by SARS‐CoV‐2, especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence, including reliance on retrospective samples without information about the symptom status of participants and the timing of assessment. No extrapolation of found accuracy data for these two alternatives to any test brands using the same techniques can be made as, for both groups, one test brand with high accuracy was overrepresented with 21/26 and 12/14 included studies, respectively. Although we used a comprehensive search and had broad eligibility criteria to include a wide range of tests that could be alternatives to RT‐PCR methods, further research is needed to assess the performance of alternative COVID‐19 tests and their role in pandemic management. Plain language summary How accurate are alternative laboratory‐based molecular tests (to RT‐PCR with prior RNA extraction/purification) for identifying people infected by SARS‐CoV‐2? Key messages: * Transcription‐mediated amplification (TMA) tests and commercially available reverse transcription polymerase chain reaction (RT‐PCR) tests specifically designed to omit/adapt RNA extraction/purification appear accurate enough to replace the method of RT‐PCR with prior RNA (a molecule essential for most biological functions) extraction/purification for identifying people infected by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence. * The accuracy of other types of laboratory‐based molecular alternatives to RT‐PCR is below World Health Organisation (WHO) recommended standards or lacks a sufficient volume of evidence to draw reliable conclusions. *The extrapolation of accuracy data from the evaluated tests to any other test brand(s) using the same techniques will be challenging since main categories are overrepresented by highly accurate individual test brands. Further evaluation of these tests in real clinical practice scenarios is needed. What are alternative laboratory‐based molecular assays for identifying people infected by SARS‐CoV‐2? Laboratory‐based molecular assays (tests) aim to confirm or rule out SARS‐CoV‐2 infection in people. Alternatives to RT‐PCR assays have been developed to minimise the steps needed to process samples in the laboratory or use fewer resources to obtain the same valid results. For this review, we focus on tests commercially developed by a manufacturer, providing instructions for their professional use. Why is this question important? People with suspected SARS‐CoV‐2 infection should know if they are infected to self‐isolate, receive treatment, and inform close contacts. Failure to detect SARS‐CoV‐2 when it is present risks spreading infection and results in missed opportunities for prevention. Diagnosing SARS‐CoV‐2 infection when it is not present may lead to unnecessary self‐isolation and testing of close contacts. Currently, testing to confirm SARS‐CoV‐2 infection relies on a laboratory molecular test called RT‐PCR. This requires specialist equipment and can take 24 hours to produce a result. If assays that take less time or use readily available resources were sufficiently accurate to replace RT‐PCR testing, this could increase the number of tests that could be done, allow faster diagnosis and enable people to take appropriate action more quickly. What did we want to find out? We wanted to know whether commercially developed, alternative laboratory‐based molecular tests are accurate enough to diagnose SARS‐CoV‐2 infection compared to RT‐PCR. What did we do? We looked for studies investigating these tests in people (or samples) that were also tested for SARS‐CoV‐2 infection using RT‐PCR which modified RT‐PCR by removing or altering components of this testing process. What did we find? We included 105 evaluations evaluating alternatives to RT‐PCR in the review. The main results are based on 74,753 samples, and SARS‐CoV‐2 infection was confirmed in 7517 of these samples. Most evaluations (27/105) concerned various test types specifically designed to omit/adapt RNA extraction/purification. Twenty‐four of 105 evaluations concerned various test types operating at one temperature (isothermal tests) rather than cycling through different temperatures. Twenty‐four of 105 evaluations were concerned with various test types that combined these two alternative approaches. Main results Only tests specifically designed to omit/adapt RNA extraction/purification and TMA assays with RNA extraction (a type of isothermal test) met WHO‐acceptable standards for confirming and ruling out SARS‐CoV‐2. For illustration, the results of these studies indicate that in a group of 1000 people, 50 of whom (5%) actually have SARS‐CoV‐2: * For tests specifically designed to omit/adapt RNA extraction/purification: ‐51 people would test positive for SARS‐CoV‐2. Of these, three people (6%) would not have SARS‐CoV‐2 (false‐positive result). ‐949 people would test negative for SARS‐CoV‐2. Of these, two people (0.2%) would actually have SARS‐CoV‐2 (false‐negative result) *For TMA tests with RNA extraction: ‐55 people would test positive for SARS‐CoV‐2. Of these, six people (10%) would not have SARS‐CoV‐2 (false‐positive result). ‐945 people would test negative for SARS‐CoV‐2. Of these, one person (0.1%) would actually have SARS‐CoV‐2 (false‐negative result) What are the limitations of the evidence? Most included studies did not provide information on participants who underwent testing, such as whether they had symptoms or were close contacts of a SARS‐CoV‐2 case. We also had concerns about the method of recruiting participants for the majority of included studies, which may have resulted in an overestimation of the accuracy of these methods. In addition, the method used to determine whether individuals did not have SARS‐CoV‐2 infection was not considered reliable for most studies, which may have resulted in underestimating the accuracy of these methods. Some studies did not follow the manufacturers' instructions for using the test. Results from different test brands using the same technique varied. What does this mean? The studies included in this review suggest that two laboratory‐based molecular tests might be accurate enough to replace or supplement RT‐PCR tests with prior RNA extraction/purification for the diagnosis of SARS‐CoV‐2 infection: RT‐PCR tests developed to omit or adapt RNA extraction or purification and TMA isothermal tests (retaining an RNA extraction step). Other alternative tests to RT‐PCR were assessed just by a few studies of limited methodological quality, and their performance should be evaluated by additional studies. Furthermore, data in these studies mostly relied on samples acquired in the past (compared to current or future samples), thus further evaluation of these tests in real clinical practice scenarios is required. Also, decisions on the optimal test for a specific setting will be driven not only by diagnostic accuracy, but also by other factors such as test complexity, time to result, acceptability to those being tested, and the setting in which the tests are to be used. How up‐to‐date is this review? This review includes evidence published up to 31 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Arevalo-Rodriguez, I; Mateos-Haro, M; Dinnes, J; Ciapponi, A; Davenport, C; Buitrago-Garcia, D; Bennouna-Dalero, T; Roqué-Figuls, M; Van den Bruel, A; von Eije, KJ; Emperador, D; Hooft, L; Spijker, R; Leeflang, MMG; Takwoingi, Y; Deeks, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD015618", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "00bdc2a9-e913-45f2-8c4c-4f48dba34d18", "pmid": "", "title": "Homeopathic medicinal products for preventing and treating acute respiratory tract infections in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common and may lead to complications. Most children experience between three and six ARTIs annually. Although most infections are self‐limiting, symptoms can be distressing. Many treatments are used to control symptoms and shorten illness duration. Most treatments have minimal benefit and may lead to adverse events. Oral homeopathic medicinal products could play a role in childhood ARTI management if evidence for their effectiveness is established. This is an update of a review first published in 2018. Objectives To assess the effectiveness and safety of oral homeopathic medicinal products compared with placebo or conventional therapy to prevent and treat ARTIs in children. Search methods We searched CENTRAL (2022, Issue 3), including the Cochrane Acute Respiratory Infections Specialised Register, MEDLINE (1946 to 16 March 2022), Embase (2010 to 16 March 2022), CINAHL (1981 to 16 March 2022), AMED (1985 to 16 March 2022), CAMbase (searched 16 March 2022), and British Homeopathic Library (searched 26 June 2013 ‐ no longer operating). We also searched the WHO ICTRP and ClinicalTrials.gov (16 March 2022), checked references, and contacted study authors to identify additional studies. Selection criteria We included double‐blind randomised controlled trials (RCTs) or double‐blind cluster‐RCTs comparing oral homeopathy medicinal products with identical placebo or self‐selected conventional treatments to prevent or treat ARTIs in children aged 0 to 16 years. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results In this 2022 update, we identified three new RCTs involving 251 children, for a total of 11 included RCTs with 1813 children receiving oral homeopathic medicinal products or a control treatment (placebo or conventional treatment) for ARTIs. All studies focused on upper respiratory tract infections (URTIs), with only one study including some lower respiratory tract infections (LRTIs). Six treatment studies examined the effect on URTI recovery, and five studies investigated the effect on preventing URTIs after one to four months of treatment. Two treatment and three prevention studies involved homeopaths individualising treatment. The other studies used predetermined, non‐individualised treatments. All studies involved highly diluted homeopathic medicinal products, with dilutions ranging from 1 x 10 ‐4 to 1 x 10 ‐200 . We identified several limitations to the included studies, in particular methodological inconsistencies and high attrition rates, failure to conduct intention‐to‐treat analysis, selective reporting, and apparent protocol deviations. We assessed three studies as at high risk of bias in at least one domain, and many studies had additional domains with unclear risk of bias. Four studies received funding from homeopathy manufacturers; one study support from a non‐government organisation; two studies government support; one study was co‐sponsored by a university; and three studies did not report funding support. Methodological inconsistencies and significant clinical and statistical heterogeneity precluded robust quantitative meta‐analysis. Only four outcomes were common to more than one study and could be combined for analysis. Odds ratios (OR) were generally small with wide confidence intervals (CI), and the contributing studies found conflicting effects, so there was little certainty that the efficacy of the intervention could be ascertained. All studies assessed as at low risk of bias showed no benefit from oral homeopathic medicinal products, whilst trials at unclear or high risk of bias reported beneficial effects. For the comparison of individualised homeopathy versus placebo or usual care for the prevention of ARTIs, two trials reported on disease severity; due to heterogeneity the data were not combined, but neither study demonstrated a clinically significant difference. We combined data from two trials for the outcome need for antibiotics (OR 0.79, 95% CI 0.35 to 1.76; low‐certainty evidence). For the comparison of non‐individualised homeopathy versus placebo or usual care for the prevention of ARTIs, only the outcome recurrence of ARTI was reported by more than one trial; data from three studies were combined for this outcome (OR 0.60, 95% CI 0.21 to 1.72; low‐certainty evidence). For the comparison of both individualised and non‐individualised homeopathy versus placebo or usual care for the treatment of ARTIs, two studies provided data on short‐term cure (OR 1.31, 95% CI 0.09 to 19.54) and long‐term cure (OR 1.01, 95% CI 0.10 to 9.96; very low‐certainty evidence). The studies demonstrated an opposite direction of effect for both outcomes. Six studies reported on disease severity but were not combined as they used different scoring systems and scales. Three studies reported adverse events (OR 0.79, 95% CI 0.16 to 4.03; low‐certainty evidence). Authors' conclusions Pooling of five prevention and six treatment studies did not show any consistent benefit of homeopathic medicinal products compared to placebo on ARTI recurrence or cure rates in children. We assessed the certainty of the evidence as low to very low for the majority of outcomes. We found no evidence to support the efficacy of homeopathic medicinal products for ARTIs in children. Adverse events were poorly reported, and we could not draw conclusions regarding safety. Plain language summary What are the benefits and risks of oral homeopathic medicines in preventing and treating acute respiratory tract infections in children? Key messages Homeopathy is a type of complementary and alternative medicine. It is based on two main ideas: that substances that may cause illness or symptoms in a healthy person can, in very small doses, treat those symptoms in a person who is unwell; and that molecules in highly diluted substances retain a memory of the original substance. Due to a lack of solid evidence, the benefits and risks of oral homeopathic medicines for preventing and treating acute respiratory tract infections (ARTIs) in children are unclear. Studies of lower quality in design and reporting often suggest a possible benefit for oral homeopathic medicines, but studies of higher quality do not find benefit. What are respiratory tract infections? Respiratory infections are commonly caused by viruses, especially colds and influenza, though some lung and ear infections are caused by bacteria. It may be difficult to tell these infections apart, and sometimes they occur together. Most such infections improve without treatment, but sometimes symptoms persist after the initial infection has gone. Treatment is therefore aimed at relieving symptoms. Why is this important in children? Children have on average three to six respiratory tract infections each year. Although most are mild and treatable, they are sometimes acute (serious, swift, or sudden onset) respiratory tract infections that may require hospital treatment, but very rarely result in death. How are ARTIs treated? Antibiotic medicines taken orally (by mouth/swallowed, usually in the form of a tablet, pill, lozenge, or liquid) are often prescribed for ARTIs, even though they are ineffective against viruses. Homeopathic medicines may treat ARTIs with few side effects, but their effectiveness and safety has not been well researched. What did we want to find out? We wanted to know whether homeopathic medicines help children with ARTIs. We were interested in the effect of homeopathic medicines compared to placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) or to usual care therapies for ARTIs. We were also interested in the effect of homeopathic medicines on improvement in the severity or symptoms of infection, the need for antibiotics, duration of illness (that would affect days off school or days off work for parents), symptom reappearance, and any medicine adverse effects. What did we do? We searched for randomised controlled trials (studies where people are randomly assigned to one of two or more treatment groups) that investigated whether oral homeopathic medicines, compared to placebo or usual care ARTI therapies, were effective in the prevention or treatment of ARTIs in children aged up to 16 years. We compared and summarised the results of the studies, and rated our confidence in the evidence based on factors such as study methods and number of participants. What did we find? We found 11 studies involving 1813 children (5 studies for prevention and 6 studies for treatment of ARTIs). All studies investigated upper respiratory tract (from the nose to the windpipe (trachea)) infections, but one study combined reporting of upper and lower respiratory tract (from the windpipe to the lungs and pleura (membranes covering the lungs)) infections, so the numbers of children with upper or lower ARTIs is unknown. Main results In the treatment or prevention of ARTIs in children, homeopathic medicines showed little or no beneficial effects, whether individualised by a trained homeopath or a standard commercially available homeopathic therapy (11 studies, 1813 children). Where results could be combined, there was little or no difference between groups for short‐term cure (2 studies, 155 participants) or long‐term cure (2 studies, 155 participants), but the evidence is very uncertain. There may be little or no difference between groups for prevention of ARTI (3 studies, 735 participants). There was no important difference between homeopathy and placebo groups for parents' time off work, antibiotic use, or adverse events. We are unsure about the safety of homeopathic medicines because data on adverse events were poorly reported. Overall, the findings of this review do not support the use of homeopathic medicinal products for ARTIs in children. What are the limitations of the evidence? We have little confidence in the evidence because the studies involved only small numbers of children, used different types of homeopathic medicines for various ARTIs, contained numerous biases, and failed to report information about important outcomes. Further research could provide results that differ from the results of this review. How up‐to‐date is this evidence? The evidence is current to 16 March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hawke, K, King, D, van Driel, ML, McGuire, TM", "articleTypes": [], "doi": "10.1002/14651858.CD005974.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.768Z" }, { "id": "00e10cfb-262b-4fce-9e62-fc2f52c3667e", "pmid": "", "title": "The Effects of Taste Receptors Regulation in Upper Airway Innate Immunity of CF Patients", "imported": false, "abstract": "The project is intended to be realised in two phases. In the first stage, a case control study will be performed. In the second phase, double-blind, placebo controlled cross-over study will be conducted. The first stage it to compare innate immunity activation and Pseudomonas aeruginosa (Pa) expression between Pa positive and negative patients. In the second phase the effects of inhaled lactizole- TAS3R inhibitor will be assessed.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "00ed8d26-4536-4680-a718-a86533bd34a7", "pmid": "", "title": "Omega‐3 fatty acids for bipolar disorder", "imported": false, "abstract": "Abstract - Background Bipolar disorder is a complex psychiatric disorder and is amongst the top thirty causes of worldwide disability. Mood stabilisers are the primary pharmacological intervention, both in the treatment of acute episodes and in prophylaxis. There is, however, mounting evidence that dietary supplementation with omega‐3 fatty acids may be beneficial in psychiatric conditions, particularly those involving disturbances of mood. Objectives To review the efficacy of omega‐3 fatty acids as either a monotherapy or an adjunctive treatment for bipolar disorder. Search methods Electronic searches of the following databases were performed: CCDANCTR‐Studies and CCDANCTR‐References were searched on 12/2/2008, Supplementary searches were carried out on Biological Abstracts, CINAHL, The Cochrane Library, CCDAN Register, EMBASE, MEDLINE, and PsycINFO. The search strategy also included cited reference searching, personal contact with all authors of studies initially included and contact with the omega‐3 producing pharmaceutical companies. Selection criteria All relevant randomised controlled trials were included in the review. Studies involving males and females of all ages with a diagnosis of bipolar disorder qualified for inclusion. Studies using any type or dose of omega‐3 fatty acid treatment as monotherapy or in addition to standard pharmacotherapy were eligible. The primary outcome was symptom severity; and secondary outcomes were adverse effects, dropout and satisfaction with treatment. Data collection and analysis Two review authors independently inspected the citations identified from the search. Potentially relevant abstracts were identified and full papers ordered and reassessed for inclusion and methodological quality. All relevant data were extracted. The weighted mean difference (WMD) was used for continuous outcome data, with 95% confidence intervals (CI). Main results Five studies met inclusion criteria for the review, however, methodological quality was highly variable. Only one study, involving 75 participants, provided data for analysis, and showed a benefit of active treatment over control for depression symptom levels (WMD ‐3.93, 95% CI ‐7.00 to ‐0.86)and Clinical Global Impression scores (WMD ‐0.75, 95% CI ‐1.33 to ‐0.17) but not for mania (WMD ‐2.81, 95% CI ‐7.68 to 1.90). No serious adverse effects were reported in the five studies. The pattern of dropout was highly variable between studies. Authors' conclusions Results from one study showed positive effects of omega‐3 as an adjunctive treatment for depressive but not manic symptoms in bipolar disorder. These findings must be regarded with caution owing to the limited data available. There is an acute need for well‐designed and executed randomised controlled trials in this field. Plain language summary Omega‐3 fatty acids for bipolar disorder This systematic review investigated the efficacy of omega‐3 fatty acids for bipolar disorder. Five randomised controlled trials met inclusion criteria for the review. Only one trial provided data that could be analysed, investigating ethyl‐EPA as an adjunctive treatment in a mixed outpatient population. Some positive benefits were found for depressive symptoms but not for mania, and no adverse events were reported. There is currently insufficient evidence on which to base any clear recommendations concerning omega‐3 fatty acids for bipolar disorder. However, given the general health benefits and safety of omega‐3, the preliminary evidence from this review provides a strong case for well‐powered, high‐quality trials in specific index populations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Montgomery, P; Richardson, AJ", "articleTypes": [], "doi": "10.1002/14651858.CD005169.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "0115d85f-e8da-4815-9fa2-d687cde6604e", "pmid": "", "title": "Chinese herbal medicine for schizophrenia", "imported": false, "abstract": "Abstract - Background Traditional Chinese medicine (TCM) was the main form of treatment in China for psychiatric illnesses until the development of antipsychotic drugs in the 1950's. Antipsychotic drugs have become the primary intervention for schizophrenia, although herbal medicines can still form part of the treatment. Objectives To review Chinese herbal medicine, used alone or as part of a TCM approach, for people with schizophrenia and related psychoses. Search methods We undertook electronic searches of the Cochrane Schizophrenia Group's register (December 2003), the Traditional Chinese Medical Literature Analysis and Retrieval Database (TCMLARS) (October 2003), Chinese Biomedical Database (CBM) (December 2003), China National Knowledge Infrastructure Database (May 2004), Complementary Medicine Database (AMED) (December 2003). We contacted the Chinese Cochrane Centre, the Cochrane Complementary Medicine Field and first authors of included studies and inspected reference lists for additional studies. Selection criteria We included all relevant randomised controlled trials involving people with schizophrenia‐like illnesses, allocated to Chinese herbal medicine, including any Chinese herbs (single or mixture), compared with placebo/no treatment or antipsychotic drugs. We updated this search July 2012 and added 45 new trials to the awaiting classification section. Data collection and analysis We independently extracted data and calculated fixed effects relative risk (RR), the 95% confidence intervals (CI) for homogeneous dichotomous data, and, where appropriate, the number needed to treat (NNT) on an intention‐to‐treat basis. For continuous data, we calculated weighted mean differences (WMD). Main results Only one small trial of the seven included studies truly evaluated TCM for schizophrenia. The other trials evaluated Chinese herbs for schizophrenia. We found one study comparing Chinese herbal medicine with antipsychotic drugs. Data for the global state outcome 'no change/worse' favoured people allocated to antipsychotic medication (n=90, RR 1.88 CI 1.2 to 2.9, NNH 4 CI 2 to 12). Six trials compared Chinese herbal medicine in combination with antipsychotic with antipsychotic drugs alone. One trial found global state 'not improved/worse' favoured the herbal medicine/antipsychotic combination (n=123, RR 0.19 CI 0.1 to 0.6, NNT 6 CI 5 to 11). Two studies (n=103) also found short‐term data from the Clinical Global Impression scale favoured the herbal medicine plus antipsychotic group (WMD ‐0.46 CI ‐0.9 to ‐0.1) compared with those given only antipsychotics. Significantly fewer people in the experimental group left the study early compared with those given antipsychotics alone (n=1004, 6 RCTs, RR 0.30 CI 0.16 to 0.58, NNT 21 CI 18 to 35). Reports of constipation were significantly lower in the treatment group compared to those receiving antipsychotics (n=67, 1 RCT, RR 0.03 CI 0.0 to 0.5, NNH 2 CI 2 to 4). Authors' conclusions Chinese herbal medicines, given in a Western biomedical context, may be beneficial for people with schizophrenia when combined with antipsychotics. Traditional Chinese medicine is also under‐evaluated, but results from one pioneering study that attempted to evaluate TCM should encourage further trials. Note: the 45 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed. Plain language summary Chinese herbal medicine for schizophrenia Antipsychotic medication is the mainstay of treatment for people with schizophrenia, and although effective, still leaves some people with distressing symptoms and/or disabling adverse effects. Safer and more effective health care interventions are needed. Traditional Chinese medicine (TCM) has been used to treat mental health disorders, including schizophrenia, for more than 2000 years. Chinese herbs may also have antipsychotic properties when used in a Western biomedical context. In this review we sought and found trials relevant to the effects of both approaches for schizophrenia. Traditional Chinese medicine methodology has been evaluated for schizophrenia, but the one included study was too limited in terms of sample size and study length to guide good practice. However, this pioneering study does show that TCM can be evaluated for its efficacy for people with schizophrenia , and should encourage trialists to undertake further, more comprehensive trials in this area. The use of Chinese herbs in a Western medicine context, without incorporating TCM methodology, has been evaluated in six trials, although again these are limited by their sample size and study length. The results of these six trials suggest that using Chinese herbs alone for psychotic symptoms may not be indicated, but if used in conjunction with Western antipsychotic drugs, they may be beneficial in terms of mental state, global functioning and decrease of adverse effects. However, further trials are needed before the effects of TCM for people with schizophrenia can be evaluated with any real confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Rathbone, J; Zhang, L; Zhang, M; Xia, J; Liu, X; Yang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD003444.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "01161320-10e5-4fba-8044-b92e47a6a7d9", "pmid": "", "title": "Oral Astragalus (Huang qi) for preventing frequent episodes of acute respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common in children and can involve both upper and lower airways. Many children experience frequent ARTI episodes or recurrent respiratory tract infections (RRTIs) in early life, which creates challenges for paediatricians, primary care physicians, parents and carers of children. In China, Astragalus (Huang qi), alone or in combination with other herbs, is used by Traditional Chinese Medicine (TCM) practitioners in the form of a water extract, to reduce the risk of ARTIs; it is believed to stimulate the immune system. Better understanding of the therapeutic mechanisms of Astragalus may provide insights into ARTI prevention, and consequently reduced antibiotic use. Objectives To assess the effectiveness and safety of oral Astragalus for preventing frequent episodes of acute respiratory tract infections (ARTIs) in children in community settings. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2015), MEDLINE (Ovid) (1946 to 31 December 2015), Embase (Elsevier) (1974 to 31 December 2015), AMED (Ovid) (1985 to 31 December 2015), Chinese National Knowledge Infrastructure (CNKI) (1979 to 31 December 2015) and Chinese Scientific Journals full text database (CQVIP) (1989 to 31 December 2015), China Biology Medicine disc (CBM 1976 to 31 December 2015) and Wanfang Data Knowledge Service Platform (WanFang) (1998 to 31 December 2015). Selection criteria We included randomised controlled trials (RCTs) comparing oral Astragalus as a sole Chinese herbal preparation with placebo to prevent frequent episodes of ARTIs in children. Data collection and analysis We used standard Cochrane methodological procedures for this review. We assessed search results to identify relevant studies. We planned to extract data using standardised forms. Disagreements were to be resolved through discussion. Risk of bias was to be assessed using the Cochrane 'Risk of bias' tool. We planned to use mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) or odds ratio (OR) to analyse dichotomous data, both with 95% confidence intervals (CIs). Main results We identified 6080 records: 3352 from English language databases, 2724 from Chinese databases, and four from other sources. Following initial screening and deduplication, we obtained 120 full‐text papers for assessment. Of these, 21 were not RCTs; 55 did not meet the inclusion criteria because: participants were aged over 14 years; definition was not included for recurrent or frequent episodes; Astragalus preparation was not an intervention; Astragalus preparation was in the formula but was not the sole agent; the Astragalus preparation was not administered orally; or Astragalus was used for treatment rather than prevention of ARTI. A further 44 studies were excluded because they were not placebo‐controlled, although other inclusion criteria were fulfilled. No RCTs met our inclusion criteria. Authors' conclusions We found insufficient evidence to enable assessment of the effectiveness and safety of oral Astragalus as a sole intervention to prevent frequent ARTIs in children aged up to 14 years. Plain language summary Can oral Astragalus (Huang qi) prevent frequent acute respiratory tract infections in children? Review question We assessed evidence for the benefits and harms of oral Astragalus used alone to prevent frequent episodes of acute respiratory infections (ARTIs) in children aged up to 14 years, compared to a dummy treatment. ARTIs include colds, sore throats, laryngitis, influenza, bronchitis and pneumonia. Background Many therapies are used to prevent ARTIs, especially in children. Astragalus, is a widely used and available herbal therapy that has been used for thousands of years in China to help prevent ARTIs. It is thought to boost immunity. Almost one in five children experience frequent ARTIs and treatment accounts for up to 75% of all prescribed antibiotics for children. Because most ARTIs are caused by viruses, antibiotics are not effective in treating these illnesses. Search date We searched the literature up to 31 December 2015. Study characteristics We identified 6080 potentially relevant records. After removing duplicate records, and those that did not meet our inclusion criteria, we obtained 120 full‐text studies. We carefully assessed these studies for possible inclusion. We excluded most studies because: they presented unclear diagnosis criteria; Astragalus preparation was used with other agents; or Astragalus was not compared with a dummy treatment. No studies met our inclusion criteria and so we were unable to analyse any results. Study funding sources We could not assess study funding sources. Key results We did not find any studies that compared use of oral Astragalus alone with a dummy treatment to prevent frequent episodes of ARTI in children aged up to 14 years. Well‐designed, conducted and reported studies investigating this issue are needed to enable assessment in the future. Quality of the evidence We could not assess evidence quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Su, G, Chen, X, Liu, Z, Yang, L, Zhang, L, Stålsby Lundborg, C, Wen, Z, Guo, X, Qin, X, Liang, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.744Z" }, { "id": "012298e0-683e-4580-8b70-d88ab3774d09", "pmid": "", "title": "Isolation and Establishment of Gustatory Cell Lines in Patients Operated on for Cancer of the Mobile Tongue - ImmortTasteCELL", "imported": false, "abstract": "In terms of incidence, cancer of the tongue is one of the leading cancers in France. Moreover, this cancer is associated with physiological complications ranging from swallowing disorders to loss of taste. Following surgery, impaired perception of food taste may lead to cachexia. It is therefore necessary to carry out research in the field of impaired taste, notably with regard to the regeneration of taste buds. However, there is currently no available functional model of taste bud cells.", "journal": "", "year": "2017", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "012b99ac-305a-40f8-bcee-7e7bab9e1037", "pmid": "", "title": "Bitter Taste and Allele-specific Expression of the Human TAS2R38 Gene", "imported": false, "abstract": "This single-site, within-subject experimental basic research study is designed to analyze the hypothesis that allele-specific expression of the bitter taste receptor T2R38 in taste tissue of individuals heterozygous for the taste receptor gene TAS2R38 correlates with that in nasal epithelium, and is responsible for differences in acyl-homoserine lactone-induced respiratory defenses. Subjects will include 100 predominantly European adults without chronic rhinosinusitis who will be undergoing a sinonasal procedure for reconstructive purposes. All subjects will provide saliva samples for genotyping, from which 25 subjects heterozygous for TAS2R38 (AVI/PAV) will be identified. These individuals will be asked to complete a beverage frequency questionnaire and taste test prior to the procedure that will evaluate for a number of compounds, among them bitter ligands specific to T2R38. Their tongue will also be photographed to evaluate the anatomy of their fungiform papillae, the mushroom-like structures on the tongue which contain taste buds. Subjects will subsequently provide nasal epithelium and taste tissue, which will be processed to 1) evaluate for allele-specific expression of TAS2R38 mRNA in both the taste and nasal tissue, with the nasal tissue concurrently being cultured in an air-liquid interface system to 2) assess the AHL-induced respiratory defenses of ciliary beat frequency (CBF) and nitric oxide (NO) production. Should subjects require a subsequent sinonasal procedure for clinically-determined reasons, taste and nasal tissue will again be obtained and analyzed for TAS2R38 mRNA, allowing for 3) longitudinal evaluation of mRNA expression level.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.230Z" }, { "id": "01346c74-035a-4792-a403-4a19dcd953e7", "pmid": "", "title": "Topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antiseptics, a possible treatment for CSOM, inhibit the micro‐organisms that may be responsible for the infection. Antiseptics can be used alone or in addition to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). However, the effects of topical antiseptics for CSOM remain unclear. This is an update of a review last published in 2020, with one new study added. It is one of a suite of seven Cochrane reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To assess the effects of topical antiseptics for people with CSOM. Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The date of the latest search was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antiseptic agent of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antiseptics (a) compared to placebo or no intervention, and (b) compared to another topical antiseptic (e.g. topical antiseptic A versus topical antiseptic B). Within each comparison, we separated studies into (a) those in which both groups of participants had received aural toileting in addition to the topical antiseptics, and those where neither group had received aural toileting, and (b) those in which both groups had received some other concomitant treatment (such as antibiotics) and those with no such concomitant treatment. Data collection and analysis We used standard Cochrane methodological procedures. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results We found one new study (32 participants) in this update, for a total of six included studies with 435 participants (over four studies), plus 222 ears that could not be accounted for in participant numbers (in two studies). Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics (boric acid versus acetic acid, and boric acid versus hydrogen peroxide). The two core comparisons of interest are reported below; other comparisons are described in the Results section of the review. No study measured health‐related quality of life or ear pain. 1. Topical antiseptic versus placebo or no treatment Three studies (297 participants plus 174 ears) compared topical antiseptics with no treatment. Evidence from one study (unclear number of participants, 174 ears) is very uncertain about the effect of a single application of povidone iodine in hydroxypropyl methyl‐cellulose (HPMC) on resolution of ear discharge at one week compared to HPMC alone; however, these results were only provided by ear (rather than by participant) and therefore could not be used quantitatively (very low‐certainty evidence). One study (254 children; cluster‐RCT) found that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge after four weeks compared with dry mopping alone, but the evidence is very uncertain (risk ratio (RR) 1.73, 95% confidence interval (CI) 1.21 to 2.47; 180 participants; very low‐certainty evidence). We made adjustments to the data to account for the intracluster correlation. This study narratively described no clear differences in suspected ototoxicity or hearing outcomes between study arms, but the evidence is very uncertain (very low‐certainty evidence). Evidence from one study (43 children; 58 ears) is very uncertain about the effect of antiseptics on serious complications. The study reported one case of mastoiditis and one of meningitis with focal encephalitis; however, it was unclear whether these were detected pre‐randomisation or during/after treatment. 2. Topical antiseptics versus no treatment/placebo, where both study arms received systemic antibiotics One study (32 participants) compared topical povidone iodine with placebo (saline) in conjunction with oral amoxicillin and dry mopping. Topical povidone iodine with oral amoxicillin and dry mopping may increase resolution of ear discharge at one to two weeks (RR 3.25, 95% CI 1.35 to 7.84; 32 participants; low‐certainty evidence). The study narratively reported no ototoxicity in the topical antiseptic arm; however, this was unclear for the placebo group, so we do not know if povidone iodine increases suspected ototoxicity (low‐certainty evidence). The study did not assess resolution of ear discharge after four weeks, hearing, or serious complications. Authors' conclusions We are very uncertain about the effect of topical antiseptics on improving resolution of ear discharge in people with CSOM given the low and very low certainty of the evidence, which was mostly due to risk of bias and imprecision. However, there is some evidence suggesting that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge compared with dry mopping alone, and that topical povidone iodine may be more effective than placebo (where both arms used systemic beta‐lactam antibiotics and dry mopping). There is insufficient evidence to draw any conclusions about harmful effects. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and risks of topical antiseptics for treating long‐term middle ear infection (chronic suppurative otitis media)? Key messages • Due to a lack of studies, we are very uncertain of the benefits and risks of topical antiseptics in the treatment of chronic suppurative otitis media (long‐term middle ear infection). • We need more information about possible harmful effects of topical antiseptics, as these were not well reported in the studies. What was studied in the review? Chronic suppurative otitis media (CSOM) is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (eardrum). The main symptoms are ear discharge and hearing loss. Topical antiseptics (antiseptics put directly into the ear as ear drops or as a powder) are sometimes used to treat CSOM. Topical antiseptics kill or stop the growth of the micro‐organisms that may be responsible for the infection. Topical antiseptics can be used on their own or added to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). Applying topical antiseptics can cause irritation of the skin within the outer ear, which may result in discomfort, pain, or itching. Some antiseptics (such as alcohol) can be toxic to the inner ear (ototoxicity), which means they may cause irreparable hearing loss (sensorineural), dizziness, or ringing in the ear (tinnitus). What is the aim of this review? The aim of this Cochrane review was to find out the benefits and risks of topical antiseptics compared to placebo (dummy medicine) or no treatment for CSOM. We also wanted to know whether one topical antiseptic was more effective than another. We collected and analysed all relevant studies to answer this question. This is an update of a review last published in 2020, with one new study added. What are the main results of the review? We included a total of six studies in the review. The total number of people in the studies was unclear, as two studies only reported how many ears were treated. However, there were 435 participants plus 222 ears (between 111 and 222 participants) that could not be accounted for in participant numbers. Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics. Different types of antiseptics were used, some in the form of ear drops and others as powders. No study measured health‐related quality of life or ear pain. Topical antiseptic versus placebo or no treatment (with a background treatment of ear cleaning) Three studies (297 participants plus 174 ears) compared topical antiseptics with placebo/no treatment. Based on evidence from one study (unclear number of participants, 174 ears), we do not know if a single application of antiseptic (povidone iodine plus hydroxypropyl methyl‐cellulose) resolves ear discharge at one to two weeks compared with no treatment. Another study (180 children) compared topical antiseptics (boric acid in alcohol ear drops) with no topical antiseptics. All children also had their ears cleaned daily using cotton wool sticks (dry mopping). It is unclear if antiseptics (boric acid) led to an increase in resolution of ear discharge at four weeks or at three to four months compared with no antiseptics. The same study (254 participants) also reported no clear difference between groups in hearing or suspected ototoxicity (hearing or balance problems that develop as a result of taking a medicine), but the evidence is very uncertain. A third study (43 children; 58 ears) found no clear evidence that antiseptics have any effect on serious complications, but it is not known if this was assessed before, during, or after treatment. Topical antiseptic (povidone iodine) versus no treatment/placebo, where both study groups received systemic antibiotics One study (32 participants) compared one antiseptic (povidone iodine) with placebo (saline). All participants also received oral antibiotics (amoxicillin) and ear cleaning. This study found that topical povidone iodine, when given in addition to antibiotics and ear cleaning, may increase the number of people with resolution of ear discharge at between one and two weeks, compared with placebo plus antibiotics and ear cleaning. We do not know if povidone iodine increases suspected ototoxicity. In their report, the study authors stated there was no ototoxicity in participants in the topical antiseptic group, but this was unclear for the placebo group. There was no information on resolution of ear discharge after four weeks, hearing, or serious complications. What are the limitations of the evidence? There is limited information on certain population groups or treatments. Also, the evidence in the review comes from studies that were not conducted recently. How up‐to‐date is the review? The evidence is current to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K; Chong, LY; Bhutta, MF; Daw, J; Veselinović, T; Morris, PS; Vijayasekaran, S; Schilder, AGM; Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013055.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "014103e5-f46d-43ae-ba0f-3fe08ab9e54c", "pmid": "", "title": "Prophylactic Treatment of Episodic Cluster Headache With an Angiotensin II Receptor Blocker (Candesartan Cilexetil); a Randomized, Placebo Controlled Parallel Study", "imported": false, "abstract": "The purpose of this study is to determine whether candesartan cilexetil are effective prophylactic treatment of episodic Cluster headache", "journal": "", "year": "2005", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.148Z" }, { "id": "016446ec-6e67-4d2b-b85d-e186f1ce0796", "pmid": "", "title": "Changes in Gut Microbiota and Postprandial GLP-1 Concentration Due to Sucralose Consumption", "imported": false, "abstract": "Recently, it has been proposed that the consumption of non-nutritive sweeteners, including sucralose, it's not harmless and is related with metabolic effects. Some studies have reported that sucralose produces alterations in glucose homeostasis. In vitro studies indicate that sucralose can interact with sweet taste receptors (T1R2 and T1R3) in the intestine, thus increasing the expression of glucose transporters including the sodium-glucose cotransporter type 1 (SGLT1) and the glucose transporter 2 (GLUT2), increasing glucose absorption. This interaction with intestinal sweet taste receptors also generates an increase in the secretion of the incretins glucagon-like peptide type 1 (GLP-1) and the glucose-dependent insulinotropic polypeptide (GIP), which might enhance the postprandial insulin release. However, these results are preliminary and it's desirable to confirm if sucralose consumption is associated with glucose metabolism modifications using an appropriate methodological design and with gold standard methods. The aim of this triple-blind, placebo-controlled, parallel, randomized clinical trial is to confirm the changes in insulin sensitivity associated with sucralose consumption in humans, to identify whether these changes are in the liver or skeletal muscle and to investigate the pathophysiological mechanisms generating these changes. Specifically, we will investigate if sucralose generates a dysbiosis in the gut microbiota that could be related to insulin resistance by increasing concentrations of lipopolysaccharide, a toxin found in Gram-negative bacteria that triggers a low-grade inflammation known as metabolic endotoxemia. In addition, the changes in postprandial concentrations of GLP-1, glucose, insulin, and C-peptide due to the combination of sucralose with a mixed meal will be investigated. The results of this study will determine if sucralose consumption, frequently used as a non-nutritive sweetener, is associated to significant changes in glucose homeostasis in humans.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.240Z" }, { "id": "0186f459-c726-4755-8d91-bd72cdc84b95", "pmid": "", "title": "Guided imagery for treating hypertension in pregnancy", "imported": false, "abstract": "Abstract - Background Hypertension (high blood pressure) in pregnancy carries a high risk of maternal morbidity and mortality. Although antihypertensive drugs are commonly used, they have adverse effects on mothers and fetuses. Guided imagery is a non‐pharmacological technique that has the potential to lower blood pressure among pregnant women with hypertension. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. Objectives To determine the effect of guided imagery as a non‐pharmacological treatment of hypertension in pregnancy and its influence on perinatal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, and two trials registers (October 2018). We also searched relevant conference proceedings and journals, and scanned the reference lists of retrieved studies. Selection criteria We included randomised controlled trials (RCTs). We would have included RCTs using a cluster‐randomised design, but none were identified. We excluded quasi‐RCTs and cross‐over trials. We sought intervention studies of various guided imagery techniques performed during pregnancy in comparison with no intervention or other non‐pharmacological treatments for hypertension (e.g. quiet rest, music therapy, aromatherapy, relaxation therapy, acupuncture, acupressure, massage, device‐guided slow breathing, hypnosis, physical exercise, and yoga). Data collection and analysis Three review authors independently assessed the trials for inclusion, extracted data, and assessed risk of bias for the included studies. We checked extracted data for accuracy, and resolved differences in assessments by discussion. We assessed the certainty of the evidence using the GRADE approach. Main results We included two small trials (involving a total of 99 pregnant women) that compared guided imagery with quiet rest. The trials were conducted in Canada and the USA. We assessed both trials as at high risk of performance bias, and low risk of attrition bias; one trial was at low risk for selection, detection, and reporting bias, while the other was at unclear risk for the same domains. We could not perform a meta‐analysis because the two included studies reported different outcomes, and the frequency of the intervention was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks, or until the baby was born (whichever came first). In the other study, the intervention included guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for four total hours; the participants were instructed to practice the procedures twice daily and complete at least three relief relaxation breaks each day. The control groups were similar ‐ one was quiet rest, and the other was quiet rest as bed rest. None of our primary outcomes were reported in the included trials: severe hypertension (either systolic blood pressure of 160 mmHg or higher, or diastolic blood pressure of 110 mmHg or higher); severe pre‐eclampsia, or perinatal death (stillbirths plus deaths in the first week of life). Only one of the secondary outcomes was measured. Low‐certainty evidence from one trial (69 women) suggests that guided imagery may make little or no difference in the use of antihypertensive drugs (risk ratio 1.27, 95% confidence interval 0.72 to 2.22). Authors' conclusions There is insufficient evidence to inform practice about the use of guided imagery for hypertension in pregnancy. The available evidence for this review topic is sparse, and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. There was low‐certainty evidence that guided imagery made little or no difference to the use of antihypertensive drugs, downgraded because of imprecision. The two included trials did not report on any of the primary outcomes of this review. We did not identify any trials comparing guided imagery with no intervention, or with another non‐pharmacological method for hypertension. Large and well‐designed RCTs are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with short‐term and long‐term maternal and neonatal health. Trials could also consider utilisation and costs of health service. Plain language summary Guided imagery for treating hypertension in pregnancy What is the issue? Some women have long‐term high blood pressure, or hypertension, whereas approximately 10% of pregnant women develop high blood pressure as a complication of pregnancy. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. It can be performed by oneself, one‐to‐one, or in groups with an instructor using audio or scripts. Why is this important? High blood pressure during pregnancy is associated with an increased risk of the mother developing pre‐eclampsia with proteinuria, eclampsia with seizures and liver and blood disorders, and kidney failure. The baby of a pregnant woman with high blood pressure is more likely to be born too soon, be too small, and may need neonatal intensive care. High blood pressure drugs are recommended for women with severe high blood pressure and pre‐eclampsia because of the risk of life‐threatening complications, but such drugs can have adverse effects for the mother (including headache, decreased mental alertness, and exercise intolerance). Such drugs can also cross the placenta and may affect the unborn baby, and are not generally recommended for pregnant women with mild to moderate high blood pressure, which is when other ways of managing blood pressure are sought. Guided imagery is a non‐pharmacological technique that could potentially lower blood pressure among pregnant women with hypertension and improve pregnancy outcomes for the mother and her baby. What evidence did we find? We searched for evidence (October 2018) and found two trials (involving 99 women) conducted in Canada and the USA. Both trials compared guided imagery with quiet rest. There were no trials comparing guided imagery with no intervention, or other with another non‐pharmacological method for hypertension. The two included studies reported different outcomes and the Intervention frequency was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks or until the baby was born (whichever came first). The other study involved guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for a total of four hours; the women were instructed to practice the procedures twice daily and complete at least three relaxation breaks each day. The control groups between the two studies were similar ‐ one used quiet rest and the other used quiet rest as bed rest. Neither trial reported data for our main outcomes of interest: severe hypertension, severe pre‐eclampsia, or death of the baby during birth or within the first week of life. The trials provided data for only one of our secondary outcomes of interest. Low‐certainty evidence from the one trial (69 women) suggests that, compared with quiet rest, guided imagery may make little or no difference in the use of antihypertensive drugs. What does this mean? We included two small trials comparing guided imagery with quiet rest. We did not identify any trials comparing guided imagery with no intervention, or another non‐pharmacological treatment for hypertension. The available evidence for this review is sparse and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. The included trials did not report on any of the main outcomes in this review and only provided low‐certainty evidence on the uncertain effect on the use of antihypertensive drugs. There is insufficient evidence to inform practice about using guided imagery for hypertension in pregnancy. Large and well‐designed studies are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with the short‐term and long‐term health of mothers and their babies. The trials should also consider the use and costs of health services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Haruna, M; Matsuzaki, M; Ota, E; Shiraishi, M; Hanada, N; Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD011337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "018dc763-2b4b-423a-bd34-1fa89630eaa9", "pmid": "", "title": "Zinc for prevention and treatment of the common cold", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Nault, D, Machingo, TA, Shipper, AG, Antiporta, DA, Hamel, C, Nourouzpour, S, Konstantinidis, M, Phillips, E, Lipski, EA, Wieland, LS", "articleTypes": [], "doi": "10.1002/14651858.CD014914.pub2 AB - Abstract - Background The common cold is an acute, self‐limiting viral respiratory illness. Symptoms include nasal congestion and mucus discharge, sneezing, sore throat, cough, and general malaise. Given the frequency of colds, they are a public health burden and a significant cause of lost work productivity and school absenteeism. There are no established interventions to prevent colds or shorten their duration. However, zinc supplements are commonly recommended and taken for this purpose. Objectives To assess the effectiveness and safety of zinc for the prevention and treatment of the common cold. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and LILACS to 22 May 2023, and searched Web of Science Core Collection and two trials registries to 14 June 2023. We also used reference checking, citation searching, and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) in children or adults that tested any form of zinc against placebo to prevent or treat the common cold or upper respiratory infection (URTI). We excluded zinc interventions in which zinc was combined with other minerals, vitamins, or herbs (e.g. a multivitamin, or mineral supplement containing zinc). Data collection and analysis We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We independently extracted data. When necessary, we contacted study authors for additional information. We assessed zinc (type and route) with placebo in the prevention and treatment of the common cold. Primary outcomes included the proportion of participants developing colds (for analyses of prevention trials only), duration of cold (measured in days from start to resolution of the cold), adverse events potentially due to zinc supplements (e.g. unpleasant taste, loss of smell, vomiting, stomach cramps, and diarrhoea), and adverse events considered to be potential complications of the common cold (e.g. respiratory bacterial infections). Main results We included 34 studies (15 prevention, 19 treatment) involving 8526 participants. Twenty‐two studies were conducted on adults and 12 studies were conducted on children. Most trials were conducted in the USA (n = 18), followed by India, Indonesia, Iran, and Turkey (two studies each), and Australia, Burkina Faso, Colombia, Denmark, Finland, Tanzania, Thailand, and the UK (one study each). The 15 prevention studies identified the condition as either common cold (n = 8) or URTI (n = 7). However, almost all therapeutic studies (17/19) focused on the common cold. Most studies (17/34) evaluated the effectiveness of zinc administered as lozenges (3 prevention; 14 treatment) in acetate, gluconate, and orotate forms; gluconate lozenges were the most common (9/17). Zinc gluconate was given at doses between 45 and 276 mg/day for between 4.5 and 21 days. Five (5/17) lozenge studies gave acetate lozenges and two (2/17) gave both acetate and gluconate lozenges. One (1/17) lozenge study administered intranasal ( gluconate ) and lozenge ( orotate ) zinc in tandem for cold treatment. Of the 17/34 studies that did not use lozenges, 1/17 gave capsules, 3/17 administered dissolved powders, 5/17 gave tablets, 4/17 used syrups, and 4/17 used intranasal administration. Most studies were at unclear or high risk of bias in at least one domain. There may be little or no reduction in the risk of developing a cold with zinc compared to placebo (risk ratio (RR) 0.93, 95% CI 0.85 to 1.01; I 2 = 20%; 9 studies, 1449 participants; low‐certainty evidence). There may be little or no reduction in the mean number of colds that occur over five to 18 months of follow‐up (mean difference (MD) ‐0.90, 95% CI ‐1.93 to 0.12; I 2 = 96%; 2 studies, 1284 participants; low‐certainty evidence). When colds occur, there is probably little or no difference in the duration of colds in days (MD ‐0.63, 95% CI ‐1.29 to 0.04; I² = 77%; 3 studies, 740 participants; moderate‐certainty evidence), and there may be little or no difference in global symptom severity (standardised mean difference (SMD) 0.04, 95% CI ‐0.35 to 0.43; I² = 0%; 2 studies, 101 participants; low‐certainty evidence). When zinc is used for cold treatment, there may be a reduction in the mean duration of the cold in days (MD ‐2.37, 95% CI ‐4.21 to ‐0.53; I² = 97%; 8 studies, 972 participants; low‐certainty evidence), although it is uncertain whether there is a reduction in the risk of having an ongoing cold at the end of follow‐up (RR 0.52, 95% CI 0.21 to 1.27; I² = 65%; 5 studies, 357 participants; very low‐certainty evidence), or global symptom severity (SMD ‐0.03, 95% CI ‐0.56 to 0.50; I² = 78%; 2 studies, 261 participants; very low‐certainty evidence), and there may be little or no difference in the risk of a change in global symptom severity (RR 1.02, 95% CI 0.85 to 1.23; 1 study, 114 participants; low‐certainty evidence). Thirty‐one studies reported non‐serious adverse events (2422 participants). It is uncertain whether there is a difference in the risk of adverse events with zinc used for cold prevention (RR 1.11, 95% CI 0.84 to 1.47; I 2 = 0%; 7 studies, 1517 participants; very low‐certainty evidence) or an increase in the risk of serious adverse events (RR 1.67, 95% CI 0.78 to 3.57; I 2 = 0%; 3 studies, 1563 participants; low‐certainty evidence). There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment (RR 1.34, 95% CI 1.15 to 1.55; I 2 = 44%; 2084 participants, 16 studies; moderate‐certainty evidence); no treatment study provided information on serious adverse events. No study provided clear information about adverse events considered to be potential complications of the common cold. Authors' conclusions The findings suggest that zinc supplementation may have little or no effect on the prevention of colds but may reduce the duration of ongoing colds, with an increase in non‐serious adverse events. Overall, there was wide variation in interventions (including concomitant therapy) and outcomes across the studies, as well as incomplete reporting of several domains, which should be considered when making conclusions about the efficacy of zinc for the common cold. Plain language summary Zinc for the prevention and treatment of the common cold Key messages 
‐ There may be little or no reduction in the risk of developing a cold with zinc supplements compared to placebo. ‐ For people who already have a cold, there may be a reduction in how long the cold lasts with zinc supplements compared to placebo. ‐ There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment. What is the common cold? 
The common cold is primarily a viral infection of the upper respiratory tract. There is no specific combination of symptoms that defines a cold, but symptoms can include nasal congestion, sneezing, sore throat, cough, fatigue, and runny nose, with or without fever. Most people usually recover from this illness without medical treatment; however, there are no definitive treatments to prevent colds or shorten their duration. Given the frequency of colds in adults and children, they are a public health burden and a significant cause of lost work productivity and school absenteeism. Prevention and treatment for the common cold with zinc is an ongoing interest. What did we want to find out? 
We wanted to find out if zinc was better than placebo at reducing the risk of developing a cold and shortening the duration of existing colds. A placebo is a substance similar in appearance to a treatment, but that has no known therapeutic effect. Placebos help assess the effects of the belief that a treatment has been received versus treatment actually being received. We also wanted to find out if zinc was associated with any adverse effects (e.g. harms), especially harms considered to be potential complications of the common cold. Additionally, we looked at self‐reported overall cold severity, individual symptom severity, individual symptom duration, and days missed from work or school. What did we do? 
We searched six databases and two clinical trials registers for studies comparing zinc with placebo for the treatment or prevention of the common cold in adults and children. We compared and summarised the results of the studies, and we found and rated our confidence in the evidence based on specific factors such as risk of bias and study methods. What did we find? 
We found 34 studies of cold prevention or treatment. The studies were conducted in 13 countries, a majority taking place in the USA. Twelve studies were conducted on children (aged under 18 years) and 22 studies were conducted on adults. Most treatments ended with self‐reported resolution of symptoms, and the minimum treatment period was five days with a maximum period of 540 days. Most of the studies were funded by an organisation with ties to related commerce/industry or did not report their funding. The remainder were funded by private clinics, non‐government foundations, universities, or governmental entities. We assessed the effects of: ‐ zinc as a preventative measure; and ‐ zinc as a treatment measure. We obtained the following results: Zinc for prevention Compared with placebo, taking zinc may make little to no difference in preventing people from catching a cold (9 studies, 1449 people). Preventative zinc also probably makes little to no difference to the length of the cold if one has been caught (3 studies, 740 participants) and may make little to no difference to the severity of the symptoms experienced (2 studies, 101 people). Negative side effects were reported by people taking either zinc or placebo; irregularities in taste and stomach upset were the most common. Zinc for treatment Zinc taken for treatment of a cold may reduce the length of time that symptoms are present, by approximately two days, when compared with placebo (8 studies, 972 people). However, we have little confidence in the evidence supporting this conclusion. It is unclear whether zinc makes a difference to the severity of the cold symptoms experienced (2 studies, 261 people). Negative side effects were reported more frequently for those taking zinc as a cold treatment when compared to those taking placebo; irregularities in taste and stomach upset were the most common. Studies administering intranasal zinc did not report any cases of anosmia (loss of sense of smell) but information about specific side effects is uncertain. What are the limitations of the evidence? 
Our confidence in the evidence is mostly low to very low, and the results of further research could differ from the results of this review. Several factors reduced our confidence in the evidence. Firstly, some studies did not report adequately on how people in the studies were randomly placed into treatment groups, meaning that differences between the study groups could be due to differences between the participants and not the treatments. Secondly, some studies used widely different ways of delivering treatments. Finally, due to the large differences between studies in the approaches used to test the effectiveness of zinc, it is likely that additional studies are required before any firm conclusions can be drawn. How up‐to‐date is this evidence? 
The evidence is current to 22 May 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.754Z" }, { "id": "01a9197c-cd0e-4a16-be9f-18783547dcf4", "pmid": "", "title": "Zinc supplementation for improving pregnancy and infant outcome", "imported": false, "abstract": "Abstract - Background It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy, such as prolonged labour, atonic postpartum haemorrhage, pregnancy‐induced hypertension, preterm labour and post‐term pregnancies, although these associations have not yet been established. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Objectives 1. To compare the effects on maternal, fetal, neonatal and infant outcomes in healthy pregnant women receiving zinc supplementation versus no zinc supplementation, or placebo.
2. To assess the above outcomes in a subgroup analysis reviewing studies performed in women who are, or are likely to be, zinc‐deficient. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (3 July 2020), and reference lists of retrieved studies. Selection criteria Randomised trials of zinc supplementation versus no zinc supplementation or placebo administration during pregnancy, earlier than 27 weeks' gestation. We excluded quasi‐randomised controlled trials. We intended to include studies presented only as abstracts, if they provided enough information or, if necessary, by contacting authors to analyse them against our criteria; we did not find any such studies. Data collection and analysis Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information. We assessed the certainty of the evidence using GRADE. Main results For this update, we included 25 randomised controlled trials (RCTs) involving over 18,000 women and their babies. The overall risk of bias was low in half of the studies. The evidence suggests that zinc supplementation may result in little or no difference in reducing preterm births (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.74 to 1.03; 21 studies, 9851 participants; low‐certainty evidence). Further, zinc supplementation may make little or no difference in reducing the risk of stillbirth (RR 1.22, 95% CI 0.80 to 1.88; 7 studies, 3295 participants; low‐certainty evidence), or perinatal deaths (RR 1.10, 95% CI 0.81 to 1.51; 2 studies, 2489 participants; low‐certainty evidence). It is unclear whether zinc supplementation reduces neonatal death, because the certainty of the evidence is very low. Finally, for other birth outcomes, zinc supplementation may make little or no difference to mean birthweight (MD 13.83, 95% CI ‐15.81 to 43.46; 22 studies, 7977 participants; low‐certainty evidence), and probably makes little or no difference in reducing the risk of low birthweight (RR 0.94, 95% CI 0.79 to 1.13; 17 studies, 7399 participants; moderate‐certainty evidence) and small‐for‐gestational age babies when compared to placebo or no zinc supplementation (RR 1.02, 95% CI 0.92 to 1.12; 9 studies, 5330 participants; moderate‐certainty evidence). We did not conduct subgroup analyses, as very few studies used normal zinc populations. Authors' conclusions There is not enough evidence that zinc supplementation during pregnancy results in improvements in maternal or neonatal outcomes. Future research to address ways of improving the overall nutritional status of pregnant women, particularly in low‐income regions, and not looking at zinc in isolation, should be an urgent priority. Plain language summary Zinc supplementation for improving pregnancy and infant outcome What is the issue? In low‐ and middle‐income countries, many women have poor diets and are deficient in key micronutrients that are required for good health. This is especially concerning during pregnancy, when energy and nutrient needs are greater for both the mother and the growing baby. Zinc plays a critical role in normal growth and development. Deficiency in zinc could lead to adverse health outcomes, such as being born too soon or too small. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Why is this important? Although severe zinc deficiency is rare, it is estimated that mild‐to‐moderate deficiency is common in several regions of the world. Studies of human pregnancy and zinc supplementation, including those from low‐ and middle‐income countries, have failed to document a consistent beneficial effect on fetal growth, length of gestation, and early newborn survival. What evidence did we find? We searched for studies in July 2020. This updated review now includes 25 randomised controlled trials, involving over 18,000 women and their babies. We found that zinc supplementation in pregnancy may make little to no difference in reducing the risk of preterm births, stillbirths, or deaths around the time of birth, when compared to no zinc supplementation or placebo. Zinc supplementation may make little or no difference to the birthweight of babies, and probably makes little or no difference to the number of babies born either with a low birthweight or small for their gestational age, when compared with no zinc supplementation, or with giving a placebo. We cannot be sure whether zinc supplementation reduces death in newborns, because the certainty of the evidence is very low. What does this mean? There is not enough evidence that zinc supplementation during pregnancy results in better outcomes for women and their babies. Finding ways to improve women's overall nutritional status, particularly in low‐income areas, will do more to improve the health of mothers and babies than supplementing pregnant women with zinc alone. This should be an urgent research priority for the future.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carducci, B; Keats, EC; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD000230.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "01b9a32e-1b76-4b49-b203-9d7ebeeef220", "pmid": "", "title": "Acute Effects of the Two Alternative Sweeteners D-allulose and Erythritol on Gastrointestinal Hormone Secretion and Glycemic Control", "imported": false, "abstract": "The aim of this project is to investigate the effect of intragastric (ig) D-allulose on metabolic parameters in general and to investigate the effect of sweet taste receptor blockade on GI hormone responses, glycemic control, gastric emptying (GE) rates and appetite-related sensations to ig administration of erythritol and D-allulose.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.237Z" }, { "id": "01bb9833-2232-40dd-9fb1-03f421ef09bc", "pmid": "", "title": "Enteral nutrition for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Prevention of relapse is a major issue in the management of quiescent Crohn's disease (CD). Current therapies (e.g. methotrexate, biologics, 6‐mercaptopurine and azathioprine) may be effective for maintaining remission in CD, but these drugs may cause significant adverse events. Interventions that are effective and safe for maintenance of remission in CD are desirable. Objectives The primary objectives were to evaluate the efficacy and safety of enteral nutrition for the maintenance of remission in CD and to assess the impact of formula composition on effectiveness. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and clinicaltrials.gov from inception to 27 July 2018. We also searched references of retrieved studies and reviews. Selection criteria Randomised controlled trials (RCTs) including participants of any age with quiescent CD were considered for inclusion. Studies that compared enteral nutrition with no intervention, placebo or any other intervention were selected for review. Data collection and analysis Two authors independently screened studies for inclusion, extracted data and assessed methodological quality using the Cochrane risk of bias tool. The primary outcome was clinical or endoscopic relapse as defined by the primary studies. Secondary outcomes included anthropometric measures (i.e. height and weight), quality of life (QoL), adverse events, serious adverse events and withdrawal due to adverse events. We calculated the risk ratio and 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated the mean difference and 95% CI. A random‐effects model was used for the statistical analysis. We used the GRADE criteria to assess the overall certainty of the evidence supporting the primary outcome and selected secondary outcomes. Main results Four RCTs (262 adult participants) met the inclusion criteria. One study (N = 33) compared an elemental diet to a non‐elemental (polymeric) diet. One study (N = 51) compared a half elemental diet to a regular free diet. Another study (N = 95) compared an elemental diet to 6‐mercaptopurine (6‐MP) or a no treatment control group. One study (N= 83) compared a polymeric diet to mesalamine. Two studies were rated as high risk of bias due to lack of blinding or incomplete outcome data. The other two studies were judged to have an unclear risk of bias. The studies were not pooled due to differences in control interventions and the way outcomes were assessed. The effect of an elemental diet compared to a polymeric diet on remission rates or withdrawal due to adverse events is uncertain. Fifty‐eight per cent (11/19) of participants in the elemental diet group relapsed at 12 months compared to 57% (8/14) of participants in the polymeric diet group (RR 1.01, 95% CI 0.56 to 1.84; very low certainty evidence). Thirty‐two per cent (6/19) of participants in the elemental diet group were intolerant to the enteral nutritional formula because of taste or smell and were withdrawn from the study in the first 2 weeks compared to zero participants (0/14) in the polymeric diet group (RR 9.75, 95% CI 0.59 to 159.93; low certainty evidence). Anthropometric measures, QoL, adverse events and serious adverse events were not reported as outcomes. The effect of an elemental diet (half of total daily calorie requirements) compared to a normal free diet on relapse rates is uncertain. Thirty‐five per cent (9/26) of participants in the elemental diet group relapsed at 12 months compared to 64% (16/25) of participants in the free diet group (RR 0.54, 95% CI 0.30 to 0.99; very low certainty evidence). No adverse events were reported. This study reported no differences in weight change between the two diet groups. Height and QoL were not reported as outcomes. The effect of an elemental diet compared to 6‐MP on relapse rates or adverse events is uncertain. Thirty‐eight per cent (12/32) of participants in the elemental diet group relapsed at 12 months compared to 23% (7/30) of participants in the 6‐MP group (RR 1.61; 95% CI 0.73 to 3.53; very low certainty evidence). Three per cent (1/32) of participants in the elemental diet group had an adverse event compared to 13% (4/30) of participants in the 6‐MP group (RR 0.23, 95% CI 0.03 to 1.98; low certainty evidence). Adverse events in the elemental diet group included surgery due to worsening CD. Adverse events in the 6‐MP group included liver injury (n = 2), hair loss (n = 1) and surgery due to an abscess (n = 1). No serious adverse events or withdrawals due to adverse events were reported. Weight, height and QoL were not reported as outcomes The effect of a polymeric diet compared to mesalamine on relapse rates and weight is uncertain. Forty‐two per cent (18/43) of participants in the polymeric diet group relapsed at 6 months compared to 55% (22/40) of participants in the mesalamine group (RR 0.76; 95% CI 0.49 to 1.19; low certainty evidence). The mean difference in weight gain over the study period was 1.9 kg higher in the polymeric diet group compared to mesalamine (95% CI ‐4.62 to 8.42; low certainty evidence). Two participants in the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had an adverse event. Height, QoL, serious adverse events and withdrawal due to adverse events were not reported as outcomes. Authors' conclusions The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the efficacy and safety of enteral nutrition in quiescent CD can be drawn. More research is needed to determine the efficacy and safety of using enteral nutrition as maintenance therapy in CD. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available. Plain language summary Enteral nutrition (liquid feeds) for maintenance of remission in Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disease of the intestines that frequently occurs in the lower part of the small intestine (ileum). Symptoms include abdominal pain, diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms the disease is considered 'active'. When the symptoms stop, it is called 'remission'. When people in remission experience symptoms it is called a 'relapse'. What is enteral nutrition? Enteral nutrition is a feeding method where a person's daily caloric intake is delivered via a liquid diet using the GI tract. Enteral nutrition can be administered by mouth or by tube feeding, where a tube is inserted through the nose or abdomen into the stomach to deliver the liquid feed. Enteral nutrition is a form of nutritional therapy for Crohn's disease patients. The mechanism by which enteral nutrition may influence inflammation is unknown and is being studied. Enteral nutrition can be classified as elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets are composed of amino‐acids (organic compounds), fats, sugars, vitamins and minerals. Elemental diets are easily absorbed and digested. Non‐elemental diets are based on oligopeptide (organic compounds composed of 2 to 20 amino‐acids) or whole protein sources. Non‐elemental diets are best for people who can digest and absorb nutrients without difficulty. What is 6‐mercaptopurine? 6‐Mercaptopurine is an immunosuppressive drug that is thought to reduce inflammation in people with Crohn's disease by blocking the immune system. What is mesalamine? Mesalamine is a 5‐aminosalicylic acid drug. 5‐Aminosalicylic drugs are thought to treat Crohn's disease by reducing inflammation in the gastrointestinal tract. These drugs are usually taken by mouth. What did the researchers investigate? The researchers studied whether enteral nutrition helps to maintain remission in people with Crohn's disease. The researchers also investigated whether one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) for maintaining remission in people with Crohn's disease. What did the researchers find? Four studies including 262 adult participants with Crohn's disease in remission were included. One study (33 participants) compared an elemental diet to a non‐elemental (polymeric) diet. One study (51 participants) compared an elemental diet to a normal diet (no supplements). One study (95 participants) compared an elemental diet to 6‐mercaptopurine or a no treatment control group. One study (83 participants) compared a non‐elemental polymeric diet to mesalamine. The researchers searched the medical literature extensively up to 27 July 2018. The study comparing an elemental diet to a polymeric diet found no difference in remission rates at 12 months. Six elemental diet participants were not able to tolerate the enteral nutritional formula because of taste or smell and were withdrawn from the study. Participants who received half of their total daily calorie requirements as elemental diet and the remaining half by normal diet had a lower chance of relapse at 12 months compared to participants who received a free diet. No side effects were reported in this study. The study comparing an elemental diet to 6‐mercaptopurine did not show any difference in relapse rates at 12 months. There was no difference in side effect rates. The only side effect reported in the elemental diet group was surgery due to worsening Crohn's disease. Side effects in the 6‐mercaptopurine group included liver injury in two participants, hair loss in one participant and surgery to treat an abscess in one participant. The study comparing a polymeric diet to mesalamine found no difference in relapse rates at six months. Two participants the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had side effects. No serious side effects were reported in any of the studies. The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the effectiveness and safety of enteral nutrition for maintenance of remission in Crohn's disease can be drawn. More research is needed to determine the effectiveness and safety of using enteral nutrition as maintenance therapy in Crohn's disease. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Akobeng, AK; Zhang, D; Gordon, M; MacDonald, JK", "articleTypes": [], "doi": "10.1002/14651858.CD005984.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "01c30a7f-5376-41da-b7d1-92bc7b58e238", "pmid": "", "title": "Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery", "imported": false, "abstract": "Abstract - Background Postoperative pain may lead to adverse effects on the body, which might result in an increase in morbidity. Its management therefore poses a unique challenge for the clinician. Major shoulder surgery is associated with severe postoperative pain, and different modalities are available to manage such pain, including opioid and non‐opioid analgesics, local anaesthetics infiltrated into and around the shoulder joint and regional anaesthesia. All of these techniques, alone or in combination, have been used to treat the postoperative pain of major shoulder surgery but with varying success. Objectives The objective of this review was to compare the analgesic efficacy of continuous interscalene brachial plexus block (ISBPB) with parenteral opioid analgesia for pain relief after major shoulder surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12), MEDLINE (1950 to December 2012), EMBASE (1980 to December 2012), Web of Science (1954 to December 2012), CINAHL (1982 to December 2012) and bibliographies of published studies. Selection criteria We included randomized controlled trials assessing the effectiveness of continuous ISBPB compared with different forms of parenteral opioid analgesia in relieving pain in adult participants undergoing elective major shoulder surgery. Data collection and analysis Two review authors independently assessed trial quality and extracted outcome data. Main results We included two randomized controlled trials (147 participants). A total of 17 participants were excluded from one trial because of complications related to continuous ISBPB (16) or parenteral opioid analgesia (one). Thus we have information on 130 participants (66 in the continuous ISBPB group and 64 in the parenteral opioid group). The studies were clinically heterogeneous. No meta‐analysis was undertaken. However, results of the two included studies showed better pain relief with continuous ISBPB following major shoulder surgery and a lower incidence of complications when interscalene block is performed under ultrasound guidance rather than without it. Authors' conclusions Because of the small number of studies (two) relevant to the subject and the high risk of bias of the selected studies, no reasonable conclusion can be drawn. Plain language summary Comparison of an upper limb nerve block using local anaesthetic with opioid analgesia for pain relief following major shoulder surgery Pain following surgical procedures can sometimes increase the incidence of complications in the body. It is important to manage this pain effectively. Major shoulder surgery can cause severe pain. Effectively treating this pain will help reduce complications and will promote early mobilization. A wide range of methods are used to treat pain after major shoulder surgery, including administration of opioid (derived from opium) and non‐opioid pain killers and administration of drugs that produce numbness and hence pain relief in and around the shoulder joint or around the nerves supplying the upper limb. We compared the usefulness of a continuous upper limb nerve block performed by injecting local anaesthetic into the neck close to where the nerves originate (interscalene brachial plexus block—ISBPB group) with the administration of opioid pain killers into a vein, into a muscle or under the skin (any route other than by mouth)—the parenteral opioid group. Evidence obtained is current to December 2012. We included two studies involving 147 participants. Seventeen participants were excluded (16 from the ISBPB group and one from the other), leaving 130 participants: 66 in the ISBPB group and 64 in the parenteral opioid group. The studies were of medium to low quality because of issues with study design, and one of the trials was sponsored by a drug company. The severity of pain was assessed by the patient using a numerical scale on which zero was considered as no pain and 10 or 100 as the worst imaginable pain for 72 hours in one study and 48 hours in the other. The severity of postoperative pain was significantly less for the ISBPB group at all time points in one study and at all but one time point in the other study. No concrete conclusions can be drawn because of the small number of studies, which were not of high quality. However, from the available evidence, it can be seen that in one of the trials, the requirement for additional painkiller (piritramide) was significantly higher in the parenteral opioid group, whereas the other trial did not mention this. The incidence of nausea and vomiting was significantly less in the ISBPB group when compared with the parenteral opioid group. Complications related to ISBPB were virtually eliminated when ultrasound was used to perform ISBPB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ullah, H; Samad, K; Khan, FA", "articleTypes": [], "doi": "10.1002/14651858.CD007080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "01c6aa02-7b5a-4b7d-875d-b7a1eaa3ab35", "pmid": "", "title": "Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people", "imported": false, "abstract": "Abstract - Background There is evidence that water‐loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well‐being are compromised. Objectives To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water‐loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water‐loss dehydration was defined primarily as including everyone with either impending or current water‐loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). Search methods Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases ( The Cochrane Library ), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. Selection criteria Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. Data collection and analysis Diagnostic accuracy of each test was assessed against the best available reference standard for water‐loss dehydration (serum or plasma osmolality cut���off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water‐loss dehydration (including either impending or current water‐loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water‐loss dehydration, but restricted to current dehydration in the final review. We conducted bivariate random‐effects meta‐analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre‐specified cut‐off points investigated. Pre‐set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre‐specifying three cut‐offs for each continuous test may have led to missing a cut‐off with useful sensitivity and specificity, we conducted post‐hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut‐off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. Main results There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water‐loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years. We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut‐offs for each continuous outcome) for diagnostic accuracy of water‐loss dehydration (primary target condition) and of current dehydration (secondary target condition). Only three tests showed any ability to diagnose water‐loss dehydration (including both impending and current water‐loss dehydration) as stand‐alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post‐hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study. Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97). There was sufficient evidence to suggest that several stand‐alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people. No tests were found consistently useful in diagnosing current water‐loss dehydration. Authors' conclusions There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water‐loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated. Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy. Plain language summary Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people Water‐loss dehydration results from drinking too little fluid. It is common in older people and associated with increased risk of many health problems. We wanted to find out whether simple tests (like skin turgor, dry mouth, urine colour and bioelectrical impedance) can usefully tell us whether an older person (aged at least 65 years) is drinking enough. Within the review we assessed 67 different tests, but no tests were consistently useful in telling us whether older people are drinking enough, or are dehydrated. Some tests did appear useful in some studies, and these promising tests should be re‐checked to see whether they are useful in specific older populations. There was sufficient evidence to suggest that some tests should not be used to indicate dehydration. Tests that should not be used include dry mouth, feeling thirsty, heart rate, urine colour, and urine volume.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hooper, L, Abdelhamid, A, Attreed, NJ, Campbell, WW, Channell, AM, Chassagne, P, Culp, KR, Fletcher, SJ, Fortes, MB, Fuller, N, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD009647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.822Z" }, { "id": "01cbae17-69a9-4a3d-9d7f-bc7a95858e68", "pmid": "", "title": "Ivermectin for preventing and treating COVID‐19", "imported": false, "abstract": "Abstract - Background Ivermectin, an antiparasitic agent, inhibits the replication of viruses in vitro. The molecular hypothesis of ivermectin's antiviral mode of action suggests an inhibitory effect on severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) replication in early stages of infection. Currently, evidence on ivermectin for prevention of SARS‐CoV‐2 infection and COVID‐19 treatment is conflicting. Objectives To assess the efficacy and safety of ivermectin plus standard of care compared to standard of care plus/minus placebo, or any other proven intervention for people with COVID‐19 receiving treatment as inpatients or outpatients, and for prevention of an infection with SARS‐CoV‐2 (postexposure prophylaxis). Search methods We searched the Cochrane COVID‐19 Study Register, Web of Science (Emerging Citation Index and Science Citation Index), WHO COVID‐19 Global literature on coronavirus disease, and HTA database weekly to identify completed and ongoing trials without language restrictions to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022. Selection criteria We included randomized controlled trials (RCTs) comparing ivermectin to standard of care, placebo, or another proven intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. Co‐interventions had to be the same in both study arms. For this review update, we reappraised eligible trials for research integrity: only RCTs prospectively registered in a trial registry according to WHO guidelines for clinical trial registration were eligible for inclusion. Data collection and analysis We assessed RCTs for bias, using the Cochrane RoB 2 tool. We used GRADE to rate the certainty of evidence for outcomes in the following settings and populations: 1) to treat inpatients with moderate‐to‐severe COVID‐19, 2) to treat outpatients with mild COVID‐19 (outcomes: mortality, clinical worsening or improvement, (serious) adverse events, quality of life, and viral clearance), and 3) to prevent SARS‐CoV‐2 infection (outcomes: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, admission to hospital, mortality, adverse events and quality of life). Main results We excluded seven of the 14 trials included in the previous review version; six were not prospectively registered and one was non‐randomized. This updated review includes 11 trials with 3409 participants investigating ivermectin plus standard of care compared to standard of care plus/minus placebo. No trial investigated ivermectin for prevention of infection or compared ivermectin to an intervention with proven efficacy. Five trials treated participants with moderate COVID‐19 (inpatient settings); six treated mild COVID‐19 (outpatient settings). Eight trials were double‐blind and placebo‐controlled, and three were open‐label. We assessed around 50% of the trial results as low risk of bias. We identified 31 ongoing trials. In addition, there are 28 potentially eligible trials without publication of results, or with disparities in the reporting of the methods and results, held in ‘awaiting classification’ until the trial authors clarify questions upon request. Ivermectin for treating COVID‐19 in inpatient settings with moderate‐to‐severe disease We are uncertain whether ivermectin plus standard of care compared to standard of care plus/minus placebo reduces or increases all‐cause mortality at 28 days (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.14 to 2.51; 3 trials, 230 participants; very low‐certainty evidence); or clinical worsening, assessed by participants with new need for invasive mechanical ventilation or death at day 28 (RR 0.82, 95% CI 0.33 to 2.04; 2 trials, 118 participants; very low‐certainty evidence); or serious adverse events during the trial period (RR 1.55, 95% CI 0.07 to 35.89; 2 trials, 197 participants; very low‐certainty evidence). Ivermectin plus standard of care compared to standard of care plus placebo may have little or no effect on clinical improvement, assessed by the number of participants discharged alive at day 28 (RR 1.03, 95% CI 0.78 to 1.35; 1 trial, 73 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.04, 95% CI 0.61 to 1.79; 3 trials, 228 participants; low‐certainty evidence); and on viral clearance at 7 days (RR 1.12, 95% CI 0.80 to 1.58; 3 trials, 231 participants; low‐certainty evidence). No trial investigated quality of life at any time point. Ivermectin for treating COVID‐19 in outpatient settings with asymptomatic or mild disease Ivermectin plus standard of care compared to standard of care plus/minus placebo probably has little or no effect on all‐cause mortality at day 28 (RR 0.77, 95% CI 0.47 to 1.25; 6 trials, 2860 participants; moderate‐certainty evidence) and little or no effect on quality of life, measured with the PROMIS Global‐10 scale (physical component mean difference (MD) 0.00, 95% CI ‐0.98 to 0.98; and mental component MD 0.00, 95% CI ‐1.08 to 1.08; 1358 participants; high‐certainty evidence). Ivermectin may have little or no effect on clinical worsening, assessed by admission to hospital or death within 28 days (RR 1.09, 95% CI 0.20 to 6.02; 2 trials, 590 participants; low‐certainty evidence); on clinical improvement, assessed by the number of participants with all initial symptoms resolved up to 14 days (RR 0.90, 95% CI 0.60 to 1.36; 2 trials, 478 participants; low‐certainty evidence); on serious adverse events (RR 2.27, 95% CI 0.62 to 8.31; 5 trials, 1502 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.24, 95% CI 0.87 to 1.76; 5 trials, 1502 participants; low‐certainty evidence); and on viral clearance at day 7 compared to placebo(RR 1.01, 95% CI 0.69 to 1.48; 2 trials, 331 participants; low‐certainty evidence). None of the trials reporting duration of symptoms were eligible for meta‐analysis. Authors' conclusions For outpatients, there is currently low‐ to high‐certainty evidence that ivermectin has no beneficial effect for people with COVID‐19. Based on the very low‐certainty evidence for inpatients, we are still uncertain whether ivermectin prevents death or clinical worsening or increases serious adverse events, while there is low‐certainty evidence that it has no beneficial effect regarding clinical improvement, viral clearance and adverse events. No evidence is available on ivermectin to prevent SARS‐CoV‐2 infection. In this update, certainty of evidence increased through higher quality trials including more participants. According to this review's living approach, we will continually update our search. Plain language summary Ivermectin for preventing and treating COVID‐19 Is ivermectin effective for COVID‐19? Key messages We found no evidence to support the use of ivermectin for treating COVID‐19 or preventing SARS‐CoV‐2 infection. The evidence base improved slightly in this update, but is still limited. Evaluation of ivermectin is continuing in 31 ongoing trials, and we will update this review again when their results become available. What is ivermectin? Ivermectin is a medicine used to treat parasites, such as intestinal parasites in animals, and scabies in humans. It is inexpensive and is widely used in regions of the world where parasitic infestations are common. It has few unwanted effects. Medical regulators have not approved ivermectin for COVID‐19. What did we want to find out? We wanted to update our knowledge of whether ivermectin reduces death, illness, and length of infection in people with COVID‐19, or is useful in prevention of the infection. We included trials comparing the medicine to placebo (dummy treatment), usual care, or treatments for COVID‐19 that are known to work to some extent, such as dexamethasone. We excluded trials comparing ivermectin to other medicines that do not work, like hydroxychloroquine, or whose effectiveness against COVID‐19 is uncertain. We evaluated the effects of ivermectin in infected people on: – people dying;
– whether people's COVID‐19 got better or worse;
– quality of life;
– serious and non‐serious unwanted effects;
– viral clearance. For prevention, we sought the effect on preventing SARS‐CoV‐2 infection and COVID‐19 disease. What did we do? We searched for randomized controlled trials that investigated ivermectin to prevent or treat COVID‐19. People treated in hospital or as outpatients had to have laboratory‐confirmed COVID‐19. In this update, we also investigated the trustworthiness of the trials and only included them if they fulfilled clear ethical and scientific criteria. We compared and summarized the results of the trials and rated our confidence in the evidence, based on common criteria such as trial methods and sizes. What did we find? We excluded seven of the 14 trials included in the previous review as these trials did not fulfil the expected ethical and scientific criteria. Together with four new trials, we included 11 trials with 3409 participants that investigated ivermectin combined with any usual care compared to the same usual care or placebo. For treatment, there were five trials of people in hospital with moderate COVID‐19 and six trials of outpatients with mild COVID‐19. The trials used different doses of ivermectin and different durations of treatment. No trial investigated ivermectin to prevent SARS‐CoV‐2 infection. We also found 31 ongoing trials, and an additional 28 trials still requiring clarification from the authors or not yet published. Main results Treating people in hospital with COVID‐19 We do not know whether ivermectin compared with placebo or usual care 28 days after treatment: – leads to more or fewer deaths (3 trials, 230 people); 
– worsens or improves patients' condition, assessed by need for ventilation or death (2 trials, 118 people);
– increases or reduces serious unwanted events (2 trials, 197 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – improving patients' condition, assessed by discharge from hospital (1 trial, 73 people);
– non‐serious unwanted events (3 trials, 228 participants). Seven days after treatment, ivermectin may make little or no difference to reduction of negative COVID‐19 tests (3 trials, 231 participants) compared with placebo or usual care. Treating outpatients with COVID‐19 Ivermectin compared with placebo or usual care 28 days after treatment, probably makes little or no difference to people dying (6 trials, 2860 people). Ivermectin compared with placebo or usual care 28 days after treatment, makes little or no difference to quality of life (1 trial, 1358 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – worsening patients' condition, assessed by admission to hospital or death (2 trials, 590 people);
– serious unwanted events (5 trials, 1502 people); 
– non‐serious unwanted events (5 trials, 1502 participants); 
– improving people's COVID‐19 symptoms in the 14 days after treatment (2 trials, 478 people);
– number of people with negative COVID‐19 tests 7 days after treatment (2 trials, 331 people). What are the limitations of the evidence? Our confidence in the evidence, especially for outpatients, improved since the last review version, because we could look at more participants included in high‐quality trials. Although we are quite certain regarding our results on risk of people dying and quality of life, the confidence in the evidence is still low for many other outpatient and inpatient outcomes because there were only few events measured. The methods differed between trials, and they did not report everything we were interested in, such as relevant outcomes. How up to date is this evidence? The systematic literature search is up to date to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Popp, M; Reis, S; Schießer, S; Hausinger, RIlona; Stegemann, M; Metzendorf, M-I; Kranke, P; Meybohm, P; Skoetz, N; Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015017.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "01daa397-4779-49f4-b850-829b51de9fee", "pmid": "", "title": "Melatonin and agomelatine for preventing seasonal affective disorder", "imported": false, "abstract": "Abstract - Background Seasonal affective disorder (SAD) is a seasonal pattern of recurrent major depressive episodes that most commonly starts in autumn or winter and remits in spring. The prevalence of SAD depends on latitude and ranges from 1.5% to 9%. The predictable seasonal aspect of SAD provides a promising opportunity for prevention in people who have a history of SAD. This is one of four reviews on the efficacy and safety of interventions to prevent SAD; we focus on agomelatine and melatonin as preventive interventions. Objectives To assess the efficacy and safety of agomelatine and melatonin (in comparison with each other, placebo, second‐generation antidepressants, light therapy, psychological therapy or lifestyle interventions) in preventing SAD and improving person‐centred outcomes among adults with a history of SAD. Search methods We searched Ovid MEDLINE (1950‐ ), Embase (1974‐ ), PsycINFO (1967‐ ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 19 June 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD‐CTR) (all years to 11 August 2015). Furthermore, we searched the Cumulative Index to Nursing and Allied Health Literature, Web of Science, the Cochrane Library , the Allied and Complementary Medicine Database and international trial registers (to 19 June 2018). We also conducted a grey literature search and handsearched the reference lists of included studies and pertinent review articles. Selection criteria To examine efficacy, we included randomised controlled trials (RCTs) on adults with a history of winter‐type SAD who were free of symptoms at the beginning of the study. For adverse events, we intended also to include non‐randomised studies. We planned to include studies that compared agomelatine versus melatonin, or agomelatine or melatonin versus placebo, any second‐generation antidepressant, light therapy, psychological therapies or lifestyle changes. We also intended to compare melatonin or agomelatine in combination with any of the comparator interventions mentioned above versus the same comparator intervention as monotherapy. Data collection and analysis Two review authors screened abstracts and full‐text publications, abstracted data and assessed risk of bias of included studies independently. We intended to pool data in a meta‐analysis using a random‐effects model, but included only one study. Main results We identified 3745 citations through electronic searches and reviews of reference lists after deduplication of search results. We excluded 3619 records during title and abstract review and assessed 126 full‐text papers for inclusion in the review. Only one study, providing data of 225 participants, met our eligibility criteria and compared agomelatine (25 mg/day) with placebo. We rated it as having high risk of attrition bias because nearly half of the participants left the study before completion. We rated the certainty of the evidence as very low for all outcomes, because of high risk of bias, indirectness, and imprecision. The main analysis based on data of 199 participants rendered an indeterminate result with wide confidence intervals (CIs) that may encompass both a relevant reduction as well as a relevant increase of SAD incidence by agomelatine (risk ratio (RR) 0.83, 95% CI 0.51 to 1.34; 199 participants; very low‐certainty evidence). Also the severity of SAD may be similar in both groups at the end of the study with a mean SIGH‐SAD (Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders) score of 8.3 (standard deviation (SD) 9.4) in the agomelatine group and 10.1 (SD 10.6) in the placebo group (mean difference (MD) ‐1.80, 95% CI ‐4.58 to 0.98; 199 participants; very low‐certainty evidence). The incidence of adverse events and serious adverse events may be similar in both groups. In the agomelatine group, 64 out of 112 participants experienced at least one adverse event, while 61 out of 113 did in the placebo group (RR 1.06, 95% CI 0.84 to 1.34; 225 participants; very low‐certainty evidence). Three out of 112 patients experienced serious adverse events in the agomelatine group, compared to 4 out of 113 in the placebo group (RR 0.76, 95% CI 0.17 to 3.30; 225 participants; very low‐certainty evidence). No data on quality of life or interpersonal functioning were reported. We did not identify any studies on melatonin. Authors' conclusions Given the uncertain evidence on agomelatine and the absence of studies on melatonin, no conclusion about efficacy and safety of agomelatine and melatonin for prevention of SAD can currently be drawn. The decision for or against initiating preventive treatment of SAD and the treatment selected should consider patient preferences and reflect on the evidence base of all available treatment options. Plain language summary Melatonin and agomelatine for prevention of winter depression Why is this review important? Many people in northern latitudes suffer from seasonal affective disorder (SAD), which occurs as a reaction to reduced sunlight. Three‐quarters of those affected are women. Lethargy, overeating, craving for carbohydrates and depressed mood are common symptoms. In some people, SAD becomes depression that seriously affects their daily lives. Up to two‐thirds experience depressive symptoms every winter. Who might be interested in this review? General practitioners, psychiatrists, pharmacists, other health professionals working in adult mental health services, and researchers could be interested in the results of this review. Anyone who has experienced winter depression, or who has friends or relatives who have experienced winter depression might also be interested. What questions does this review aim to answer? Because of the seasonal pattern and high recurrence of SAD, melatonin or agomelatine could be used to prevent the onset of depressed mood. The goal of this report is to examine whether benefits outweigh harms of melatonin or agomelatine when used to prevent onset of a new depressive episode in people with a history of SAD who were free of symptoms when the preventive intervention started. To date, this question has not been examined in a systematic way. This is one of four reviews on the efficacy and potential harms of interventions to prevent SAD. Which studies were included in the review? We searched databases up to June 2018 for studies on melatonin or agomelatine for prevention of winter depression. Among 3745 records, we found one randomised controlled study comparing agomelatine with placebo for one year. All 225 participants had a history of winter depression but were not depressed when the prevention study started. What does evidence from the review reveal? The included study showed neither a clear effect in favour nor against agomelatine as a preventive treatment. In addition, the certainty of evidence for all outcomes was very low, making it impossible to draw any conclusions about the efficacy and safety of agomelatine for the prevention of winter depression. No evidence on melatonin for prevention of SAD was identified. Doctors need to discuss with persons with a history of SAD that currently evidence on agomelatine or melatonin for preventive treatment options for SAD is inconclusive, therefore treatment selection should be strongly based on peoples' preferences and reflect on the evidence base of all available treatment options. What should happen next? Review authors recommend that future studies should evaluate the efficacy of agomelatine or melatonin in preventing SAD and should directly compare these interventions against other treatment options, such as light therapy, antidepressants, or psychological therapies to determine the best treatment option for prevention of SAD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nussbaumer‐Streit, B, Greenblatt, A, Kaminski‐Hartenthaler, A, Van Noord, MG, Forneris, CA, Morgan, LC, Gaynes, BN, Wipplinger, J, Lux, LJ, Winkler, D, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011271.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.740Z" }, { "id": "01eaa133-0352-4a7b-88e1-92d1817bb0bc", "pmid": "", "title": "Interventions for American cutaneous and mucocutaneous leishmaniasis", "imported": false, "abstract": "Abstract - Background On the American continent, cutaneous and mucocutaneous leishmaniasis (CL and MCL) are diseases associated with infection by several species of Leishmania parasites. Pentavalent antimonials remain the first‐choice treatment. There are alternative interventions, but reviewing their effectiveness and safety is important as availability is limited. This is an update of a Cochrane Review first published in 2009. Objectives To assess the effects of interventions for all immuno‐competent people who have American cutaneous and mucocutaneous leishmaniasis (ACML). Search methods We updated our database searches of the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and CINAHL to August 2019. We searched five trials registers. Selection criteria Randomised controlled trials (RCTs) assessing either single or combination treatments for ACML in immuno‐competent people, diagnosed by clinical presentation and Leishmania infection confirmed by smear, culture, histology, or polymerase chain reaction on a biopsy specimen. The comparators were either no treatment, placebo only, or another active compound. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our key outcomes were the percentage of participants 'cured' at least three months after the end of treatment, adverse effects, and recurrence. We used GRADE to assess evidence certainty for each outcome. Main results We included 75 studies (37 were new), totalling 6533 randomised participants with ATL. The studies were mainly conducted in Central and South America at regional hospitals, local healthcare clinics, and research centres. More male participants were included (mean age: roughly 28.9 years (SD: 7.0)). The most common confirmed species were L. braziliensis , L. panamensis , and L. mexicana . The most assessed interventions and comparators were non‐antimonial systemics (particularly oral miltefosine) and antimonials (particularly meglumine antimoniate (MA), which was also a common intervention), respectively. Three studies included moderate‐to‐severe cases of mucosal leishmaniasis but none included cases with diffuse cutaneous or disseminated CL, considered the severe cutaneous form. Lesions were mainly ulcerative and located in the extremities and limbs. The follow‐up (FU) period ranged from 28 days to 7 years. All studies had high or unclear risk of bias in at least one domain (especially performance bias). None of the studies reported the degree of functional or aesthetic impairment, scarring, or quality of life. Compared to placebo, at one‐year FU, intramuscular (IM) MA given for 20 days to treat L. braziliensis and L. panamensis infections in ACML may increase the likelihood of complete cure (risk ratio (RR) 4.23, 95% confidence interval (CI) 0.84 to 21.38; 2 RCTs, 157 participants; moderate‐certainty evidence), but may also make little to no difference, since the 95% CI includes the possibility of both increased and reduced healing (cure rates), and IMMA probably increases severe adverse effects such as myalgias and arthralgias (RR 1.51, 95% CI 1.17 to 1.96; 1 RCT, 134 participants; moderate‐certainty evidence). IMMA may make little to no difference to the recurrence risk, but the 95% CI includes the possibility of both increased and reduced risk (RR 1.79, 95% CI 0.17 to 19.26; 1 RCT, 127 participants; low‐certainty evidence). Compared to placebo, at six‐month FU, oral miltefosine given for 28 days to treat L. mexicana , L. panamensis and L. braziliensis infections in American cutaneous leishmaniasis (ACL) probably improves the likelihood of complete cure (RR 2.25, 95% CI 1.42 to 3.38), and probably increases nausea rates (RR 3.96, 95% CI 1.49 to 10.48) and vomiting (RR 6.92, 95% CI 2.68 to 17.86) (moderate‐certainty evidence). Oral miltefosine may make little to no difference to the recurrence risk (RR 2.97, 95% CI 0.37 to 23.89; low‐certainty evidence), but the 95% CI includes the possibility of both increased and reduced risk (all based on 1 RCT, 133 participants). Compared to IMMA, at 6 to 12 months FU, oral miltefosine given for 28 days to treat L. braziliensis , L. panamensis , L. guyanensis and L. amazonensis infections in ACML may make little to no difference to the likelihood of complete cure (RR 1.05, 95% CI 0.90 to 1.23; 7 RCTs, 676 participants; low‐certainty evidence). Based on moderate‐certainty evidence (3 RCTs, 464 participants), miltefosine probably increases nausea rates (RR 2.45, 95% CI 1.72 to 3.49) and vomiting (RR 4.76, 95% CI 1.82 to 12.46) compared to IMMA. Recurrence risk was not reported. For the rest of the key comparisons, recurrence risk was not reported, and risk of adverse events could not be estimated. Compared to IMMA, at 6 to 12 months FU, oral azithromycin given for 20 to 28 days to treat L. braziliensis infections in ACML probably reduces the likelihood of complete cure (RR 0.51, 95% CI 0.34 to 0.76; 2 RCTs, 93 participants; moderate‐certainty evidence). Compared to intravenous MA (IVMA) and placebo, at 12 month FU, adding topical imiquimod to IVMA, given for 20 days to treat L. braziliensis , L. guyanensis and L. peruviana infections in ACL probably makes little to no difference to the likelihood of complete cure (RR 1.30, 95% CI 0.95 to 1.80; 1 RCT, 80 participants; moderate‐certainty evidence). Compared to MA, at 6 months FU, one session of local thermotherapy to treat L. panamensis and L. braziliensis infections in ACL reduces the likelihood of complete cure (RR 0.80, 95% CI 0.68 to 0.95; 1 RCT, 292 participants; high‐certainty evidence). Compared to IMMA and placebo, at 26 weeks FU, adding oral pentoxifylline to IMMA to treat CL (species not stated) probably makes little to no difference to the likelihood of complete cure (RR 0.86, 95% CI 0.63 to 1.18; 1 RCT, 70 participants; moderate‐certainty evidence). Authors' conclusions Evidence certainty was mostly moderate or low, due to methodological shortcomings, which precluded conclusive results. Overall, both IMMA and oral miltefosine probably result in an increase in cure rates, and nausea and vomiting are probably more common with miltefosine than with IMMA. Future trials should investigate interventions for mucosal leishmaniasis and evaluate recurrence rates of cutaneous leishmaniasis and its progression to mucosal disease. Plain language summary What are the benefits and risks of different treatments for American (muco)cutaneous leishmaniasis (a parasitic disease of the skin and mucous membranes)? Why this question is important American (muco)cutaneous leishmaniasis (ACML) is a disfiguring disease that affects people in Central and South America. It is caused by parasites that are transmitted to humans by sandflies. Different forms of ACML have different symptoms. People with the cutaneous form develop skin sores that often heal within a few months without treatment, but can leave scars. In people with mucosal or mucocutaneous leishmaniasis, destructive sores develop in the protective lining (mucous membranes) of the nose, mouth and throat. To compare the effectiveness and risks of the many treatments for ACML, we reviewed evidence from research studies (randomised controlled trials). We looked for information on the proportion of people whose sores had healed three months or more after treatment, unwanted effects, quality of life, re‐appearance of sores, damage associated with the disease and prevention of scarring. How we identified and assessed the evidence First, we searched for all relevant studies. We then compared the results, summarised the evidence, and assessed the certainty of the evidence. What we found We found 75 studies on 6533 people (approximately 75% male; average age: 29 years). ‐ One study investigated children (2 to 12 years).
‐ Most studies (67) involved people with cutaneous leishmaniasis.
‐ Eight studies investigated people with mucosal or mucocutaneous leishmaniasis.
‐ The parasite Leishmania braziliensis caused the disease in 52 studies.
‐ Studies were conducted at regional hospitals, local clinics, and research centres.
‐ Studies lasted between 28 days and seven years.
‐ Most studies reported their funding source: the US army funded eight studies, industry funded 10, and institutional grants funded 33 (five of these also reported industry funding). Treatments were mainly compared to a placebo (fake treatment) or meglumine antimoniate (an antimonial). Here we report this review's main results. We were only able to report the risk of recurrence and side effects for the comparisons of meglumine antimoniate (MA) or miltefosine versus placebo and miltefosine versus MA. Main results Antimonials Compared to placebo, MA may increase chances of complete healing of ACML, but treatment effects vary, so it is possible that it may make little to no difference. MA probably increases the likelihood of pain in the muscles or joints. There may be little to no difference in the risk of developing the disease again, but there is also a possibility of increased or reduced risk due to the wide range of effects seen. Non‐antimonials Miltefosine probably improves chances of complete healing of American cutaneous leishmaniasis (ACL) compared to placebo, but there may be little to no difference compared to treatment with MA in ACML. Miltefosine may make little to no difference to the risk of developing ACL again when compared to placebo, but treatment effects on recurrence varied, so it may also increase or decrease the risk. Miltefosine probably increases the likelihood of vomiting or nausea when compared to either placebo or MA in ACML. We do not know the effect on recurrence of miltefosine compared to MA. Azithromycin probably reduces chances of complete healing of ACML compared to MA. Imiquimod in combination with MA probably makes little to no difference to the chance of complete healing of ACL compared to MA in combination with placebo. Physical therapies Thermotherapy lowers the chance of complete healing of ACL compared to MA. Immuno‐chemotherapy Pentoxifylline plus MA probably makes little to no difference to chances of complete healing of ACML compared with MA plus placebo. No study reported information about damage, prevention of scarring, or quality of life. What this means The main findings of this review suggest that: ‐ MA and miltefosine probably increase chances of complete healing; and
‐ vomiting or nausea are probably more common with miltefosine, and joint or muscle ache is probably more common with MA. The evidence was mostly of moderate certainty, so the true results are likely close to what we found. Evidence was limited by the inclusion of very few people in some studies, and participants or investigators knowing which treatments they were receiving. How‐up‐to date is this review? The evidence in this Cochrane Review is current to August 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Pinart, M; Rueda, J-R; Romero, GAS; Pinzón-Flórez, CE; Osorio-Arango, K; Silveira Maia-Elkhoury, AN; Reveiz, L; Elias, VM; Tweed, JA", "articleTypes": [], "doi": "10.1002/14651858.CD004834.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "0208f97f-5713-48e1-84f3-fb56818215e1", "pmid": "", "title": "Oral xanthines as maintenance treatment for asthma in children", "imported": false, "abstract": "Abstract - Background Xanthines have been used in the treatment of asthma as a bronchodilator, though they may also have anti‐inflammatory effects. The current role of xanthines in the long‐term treatment of childhood asthma needs to be reassessed. Objectives To determine the efficacy of xanthines (e.g. theophylline) in the maintenance treatment of paediatric asthma. Search methods A search of the Cochrane Airways Group Specialised Register was undertaken with predefined search terms. Searches are current to May 2008. Selection criteria Randomised controlled trials, lasting at least four weeks comparing a xanthine with placebo, regular short‐acting beta‐agonist (SABA), inhaled corticosteroids (ICS), cromoglycate (SCG), ketotifen (KET) or leukotriene antagonist, in children with diagnosed with chronic asthma between 18 months and 18 years old. Data collection and analysis Two reviewers independently selected each study for inclusion in the review and extracted data. Primary outcome was percentage of symptom‐free days. Main results Thirty‐six studies (2838 participants) were included. Xanthine versus placebo (18 studies): The proportion of symptom free days was larger with xanthine compared with placebo (7.97% [95% CI 3.41, 12.53]). Rescue medication usage was lower with xanthine, with no significant difference in symptom scores or hospitalisations. FEV 1 , and PEF were better with xanthine. Xanthine was associated with non ‐ specific side‐effects. Data from behavioural scores were inconclusive. Xanthine versus ICS (four studies) : Exacerbations were less frequent with ICS, but no significant difference on lung function was observed. Individual studies reported significant improvements in symptom measures in favour of steroids, and one study reported a difference in growth rate in favour of xanthine. No difference was observed for study withdrawal or tremor. Xanthine was associated with more frequent headache and nausea. Xanthine versus regular SABA (10 studies): No significant difference in symptoms, rescue medication usage and spirometry. Individual studies reported improvement in PEF with beta‐agonist. Beta‐agonist treatment led to fewer hospitalisations and headaches. Xanthine was associated with less tremor. Xanthine versus SCG (six studies ): No significant difference in symptoms, exacerbations and rescue medication. Sodium cromoglycate was associated with fewer gastro‐intestinal side‐effects than xanthine. Xanthine versus KET (one study): No statistical tests of significance between xanthine and ketotifen were reported. : Xanthine + ICS versus placebo + same dose ICS (three studies) : Results were conflicting due to clinical/methodological differences, and could not be aggregated. Xanthine + ICS versus ICS + leukotriene (one study): Results from one trial One small parallel study did not measure the primary outcome of symptoms; differences between treatments in end of treatment values were not statistically significant. Authors' conclusions Xanthines as first‐line preventer alleviate symptoms and reduce requirement for rescue medication in children with mild to moderate asthma. When compared with ICS they were less effective in preventing exacerbations. Xanthines had similar efficacy as single preventative agent compared with regular SABA and SCG. Evidence on AEs (adverse effects) was equivocal: there was evidence for increased AEs overall, but no evidence that any specific AE (including effects on behaviour and attention) occurred more frequently than with placebo. There is insufficient evidence from available studies to make firm conclusions about the effectiveness of xanthines as add‐on preventative treatment to ICS, and there are no published paediatric studies comparing xanthines with alternatives in this role. Our data suggest that xanthines are only suitable as first‐line preventative asthma therapy in children when ICS are not available. Pre‐trial exposure to the agents assessed may have pre‐disposed the trial populations to tolerate the drug, and may have threatened blinding. They may have a role as add‐on therapy in more severe asthma not controlled by ICS, but further studies are needed to examine this, and to define the risk‐benefit ratio compared with other agents. Plain language summary The effects of oral xanthines (e.g. theophylline) for chronic asthma in children Xanthines (e.g. theophylline) are a group of drugs thought to have helpful preventative and reliever properties in the treatment of asthma in children. This review of studies has established that there is evidence for useful effects of these drugs in terms of symptom relief and lung function, but also some evidence of side‐effects. As a primary preventative therapy , whilst there is evidence that xanthines are effective, this review suggests that more effective alternative treatment options (inhaled steroids) are available. In children with more severe asthma, the role of xanthines as an add‐on therapy has only been assessed in a small number of trials, which report mixed effects. More studies in this area would help to generate a more reliable overview of the effects of treatment in these children. Xanthines are an effective preventative treatment in childhood asthma, but less effective than inhaled steroids, and with a less favourable side‐effect profile. There is insufficient evidence at present to assess their role as \"add‐on\" preventer treatment versus newer alternatives. Some of the trials exposed the children they recruited to a pre‐trial phase of xanthine in order to maintain effective dosing during the trial. This could have made the trial participants less representative of the general population by making them more inclined to tolerate the study drug. This exposure also may have meant that they could recognise what drug they were taking during the blinded phase of the study.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Seddon, P; Bara, A; Lasserson, TJ; Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "022ee0f6-d13a-41a3-8862-24fa3130100b", "pmid": "", "title": "Eplerenone for hypertension", "imported": false, "abstract": "Abstract - Background Eplerenone is an aldosterone receptor blocker that is chemically derived from spironolactone. In Canada, it is indicated for use as adjunctive therapy to reduce mortality for heart failure patients with New York Heart Association (NYHA) class II systolic chronic heart failure and left ventricular systolic dysfunction. It is also used as adjunctive therapy for patients with heart failure following myocardial infarction. Additionally, it is indicated for the treatment of mild and moderate essential hypertension for patients who cannot be treated adequately with other agents. It is important to determine the clinical impact of all antihypertensive medications, including aldosterone antagonists, to support their continued use in essential hypertension. No previous systematic reviews have evaluated the effect of eplerenone on cardiovascular morbidity, mortality, and magnitude of blood pressure lowering in patients with hypertension. Objectives To assess the effects of eplerenone monotherapy versus placebo for primary hypertension in adults. Outcomes of interest were all‐cause mortality, cardiovascular events (fatal or non‐fatal myocardial infarction), cerebrovascular events (fatal or non fatal strokes), adverse events or withdrawals due to adverse events, and systolic and diastolic blood pressure. Search methods We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers up to 3 March 2016. We handsearched references from retrieved studies to identify any studies missed in the initial search. We also searched for unpublished data by contacting the corresponding authors of the included studies and pharmaceutical companies involved in conducting studies on eplerenone monotherapy in primary hypertension. The search had no language restrictions. Selection criteria We selected randomized placebo‐controlled trials studying adult patients with primary hypertension. We excluded studies in people with secondary or gestational hypertension and studies where participants were receiving multiple antihypertensives. Data collection and analysis Three review authors independently reviewed the search results for studies meeting our criteria. Three review authors independently extracted data and assessed trial quality using a standardized data extraction form. A fourth independent review author resolved discrepancies or disagreements. We performed data extraction and synthesis using a standardized format on Covidence. We conducted data analysis using Review Manager 5. Main results A total of 1437 adult patients participated in the five randomized parallel group studies, with treatment durations ranging from 8 to 16 weeks. The daily doses of eplerenone ranged from 25 mg to 400 mg daily. Meta‐analysis of these studies showed a reduction in systolic blood pressure of 9.21 mmHg (95% CI −11.08 to −7.34; I 2 = 58%) and a reduction of diastolic pressure of 4.18 mmHg (95% CI −5.03 to −3.33; I 2 = 0%) (moderate quality evidence). There may be a dose response effect for eplerenone in the reduction in systolic blood pressure at doses of 400 mg/day. However, this finding is uncertain, as it is based on a single included study with low quality evidence. Overall there does not appear to be a clinically important dose response in lowering systolic or diastolic blood pressure at eplerenone doses of 50 mg to 400 mg daily. There did not appear to be any differences in the number of patients who withdrew due to adverse events or the number of patients with at least one adverse event in the eplerenone group compared to placebo. However, only three of the five included studies reported adverse events. Most of the included studies were of moderate quality, as we judged multiple domains as being at unclear risk in the 'Risk of bias' assessment. Authors' conclusions Eplerenone 50 to 200 mg/day lowers blood pressure in people with primary hypertension by 9.21 mmHg systolic and 4.18 mmHg diastolic compared to placebo, with no difference of effect between doses of 50 mg/day to 200 mg/day. A dose of 25 mg/day did not produce a statistically significant reduction in systolic or diastolic blood pressure and there is insufficient evidence for doses above 200 mg/day. There is currently no available evidence to determine the effect of eplerenone on clinically meaningful outcomes such as mortality or morbidity in hypertensive patients. The evidence available on side effects is insufficient and of low quality, which makes it impossible to draw conclusions about potential harm associated with eplerenone treatment in hypertensive patients. Plain language summary Eplerenone for high blood pressure Review question The aim of this review was to determine the effectiveness of eplerenone for reducing blood pressure, its side effect profile, and its impact on clinically meaningful outcomes such as mortality and morbidity. Background Clinicians have used eplerenone to treat high blood pressure since 2002. It is important to determine the clinical impact of all antihypertensive medications used in patients to support their continued use in essential hypertension. We searched multiple databases and found five eligible studies in 1437 people who received either eplerenone or no medication in a random fashion. Study characteristics The doses of eplerenone used in these studies ranged from 25 mg to 400 mg daily. These studies followed patients for 8 to 16 weeks while on therapy. None of the studies reported on the clinically meaningful outcomes of eplerenone, such as whether eplerenone can reduce heart attacks, stroke, or death compared to placebo. Only three of the five studies reported on side effects. Key results There is currently no evidence that eplerenone has a beneficial effect on life expectancy or complications rleated to hypertension (e.g. heart attack, stroke). Evidence for risk of side effects with eplerenone is limited and of poor quality; it is difficult to tell the extent of possible harm with eplerenone versus placebo. This meta‐analysis shows that eplerenone 50 to 200 mg/day reduces systolic blood pressure by approximately 9 mmHg and diastolic blood pressure by 4 mmHg compared to taking no medication. Quality of the evidence We judged the five included trials to be of moderate quality, as authors did not extensively describe portions of their methodology.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tam, TSC; Wu, MHY; Masson, SC; Tsang, MP; Stabler, SN; Kinkade, A; Tung, A; Tejani, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "02362785-e48d-4e29-852f-4192d17db69b", "pmid": "", "title": "Metformin for endometrial hyperplasia", "imported": false, "abstract": "Abstract - Background Endometrial cancer is one of the most common gynaecological cancers in the world. Rates of endometrial cancer are rising, in part because of rising obesity rates. Endometrial hyperplasia is a precancerous condition in women that can lead to endometrial cancer if left untreated. Endometrial hyperplasia occurs more commonly than endometrial cancer. Progesterone tablets that are currently used to treat women with endometrial hyperplasia are associated with adverse effects in up to 84% of women. A levonorgestrel intrauterine device may improve compliance, but it is invasive, is not acceptable to all women, and is associated with irregular vaginal bleeding in 82% of cases. Therefore, an alternative treatment for women with endometrial hyperplasia is needed. Metformin, a drug that is often used to treat people with diabetes, has been shown, in some human studies, to reverse endometrial hyperplasia. However, the effectiveness and safety of metformin for treatment of endometrial hyperplasia remain uncertain. This is an update of a review first published in 2017. Objectives To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia. Search methods We searched the Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, PubMed, Embase, Google Scholar, OpenGrey, LILACS, and two trials registers from inception to 5 September 2022. We searched the bibliographies of all relevant studies, and contacted experts in the field for any additional trials. Selection criteria We included randomised controlled trials (RCTs) and cross‐over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo, no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type. Data collection and analysis Two review authors independently assessed studies for eligibility, extracted data from included studies, assessed the risk of bias in the included studies, and assessed the certainty of the evidence for each outcome. We resolved disagreements by discussion or by deferring to a third review author. When study details were missing, review authors contacted the study authors. The primary outcome of this review was regression of endometrial hyperplasia histology (with or without atypia) towards normal histology. Main results We included seven RCTs, in which a total of 387 women took part. In the comparison, Metformin plus megestrol versus megestrol alone, we rated the certainty of the evidence as low for the outcome, regression of endometrial hyperplasia. We rated the quality of the evidence as very low for the rest of the outcomes, in all three comparisons. Although there was a low risk of selection bias, there was a high risk of bias in the blinding of personnel and outcome assessment (performance bias and detection bias) in many studies. This update identified four new RCTs and six ongoing RCTs. Metformin versus megestrol We are uncertain whether metformin increases the regression of endometrial hyperplasia towards normal histology over megestrol (odds ratio (OR) 4.89, 95% confidence interval (CI) 1.56 to 15.32; P = 0.006; 2 RCTs, 83 participants; I² = 7%; very low‐certainty evidence). This evidence suggests that if the rate of regression with megestrol is 61%, the rate of regression with metformin would be between 71% and 96%. It is unresolved whether metformin results in different rates of abnormal uterine bleeding or hysterectomy compared to megestrol. No study in this comparison reported progression of hyperplasia to endometrial cancer, recurrence of endometrial hyperplasia, health‐related quality of life, or adverse effects during treatment. Metformin plus megestrol versus megestrol monotherapy The combination of metformin and megestrol may enhance the regression of endometrial hyperplasia towards normal histology more than megestrol alone (OR 3.27, 95% CI 1.65 to 6.51; P = 0.0007; 4 RCTs, 258 participants; I² = 0%, low‐certainty evidence). This suggests that if the rate of regression with megestrol monotherapy is 54%, the rate of regression with the addition of metformin would be between 66% and 84%. In one study, 3/8 (37.5%) of participants who took metformin had nausea that settled without further treatment. It is unresolved whether the combination of metformin and megestrol results in different rates of recurrence of endometrial hyperplasia, progression of endometrial hyperplasia to endometrial cancer, or hysterectomy compared to megestrol monotherapy. No study in this comparison reported abnormal uterine bleeding, or health‐related quality of life. Metformin plus levonorgestrel (intrauterine system) versus levonorgestrel (intrauterine system) monotherapy We are uncertain whether there is a difference between groups in the regression of endometrial hyperplasia towards normal histology (OR 0.29, 95% CI 0.01 to 7.56; 1 RCT, 46 participants; very low‐certainty evidence). This evidence suggests that if the rate of regression with levonorgestrel monotherapy is 96%, the rate of regression with the addition of metformin would be between 73% and 100%. It is unresolved whether the combination of metformin and levonorgestrel results in different rates of abnormal uterine bleeding, hysterectomy, or the development of adverse effects during treatment compared to levonorgestrel monotherapy. No study in this comparison reported recurrence of endometrial hyperplasia, progression of hyperplasia to endometrial cancer, or health‐related quality of life. Authors' conclusions Review authors found insufficient evidence to either support or refute the use of metformin, specifically megestrol acetate, given alone or in combination with standard therapy, for the treatment of women with endometrial hyperplasia. Robustly designed and adequately powered randomised controlled trials, yielding long‐term outcome data are still needed to address this clinical question. Plain language summary Metformin for endometrial hyperplasia Review question Is metformin an effective and safe treatment for women with endometrial hyperplasia? Background Endometrial cancer (cancer of the lining of the womb) is a common cancer that affects the reproductive organs in women worldwide. Endometrial hyperplasia (thickening of the lining of the womb) is a precancerous condition in women that can lead to endometrial cancer if left untreated. Successful treatment of women with endometrial hyperplasia can prevent endometrial cancer. Endometrial hyperplasia is usually treated by providing progesterone hormone tablets, inserting a levonorgestrel‐releasing intrauterine system (LNG‐IUS) into the womb, advising women with extra weight to lose weight, or performing a hysterectomy for women who do not want a future pregnancy. However, progesterone tablets are associated with side effects in up to 84% of women, and this can prevent women from completing treatment. Also, progesterone tablets do not always work, and endometrial hyperplasia can return in up to 14% to 30% of women after treatment. The LNG‐IUS is associated with irregular vaginal bleeding in up to 82% of women. Many women find it painful to use, or find it otherwise unacceptable. Therefore, an alternative treatment for endometrial hyperplasia is required. Metformin, an oral tablet that is usually used to treat diabetes, has been shown to cure endometrial hyperplasia in some human studies. Although women taking metformin may experience side effects, treatment is usually well tolerated. If women experience fewer side effects when taking metformin rather than progesterone tablets, and if metformin effectively treats endometrial hyperplasia, women would be more willing to complete treatment, and the cure rate would improve. This could reduce the number of women who end up with endometrial cancer. However, the effectiveness and safety of metformin used to treat women with endometrial hyperplasia remain uncertain. Study characteristics We included seven randomised controlled trials in which a total of 387 women took part. Five studies compared metformin to megestrol (a form of progesterone), and one study compared metformin plus megestrol to megestrol alone. Women in all studies received treatment for three to six months. The evidence is current to 5 September 2022. Key results Studies on metformin alone versus megestrol alone provided insufficient evidence to show differences in effectiveness for curing endometrial hyperplasia. Studies on metformin plus megestrol versus megestrol alone found that metformin may improve the thickened walls of the womb, but the evidence is uncertain about other outcomes. One small study provided insufficient evidence to support or refute the use of metformin plus the LNG‐IUS or the LNG‐IUS alone. Certainty of the evidence We rated the certainty of the evidence as low to very‐low for all outcomes, because of limitations in the way the studies were designed, and small sample sizes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Shiwani, H, Clement, NS, Daniels, JP, Atiomo, W", "articleTypes": [], "doi": "10.1002/14651858.CD012214.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.781Z" }, { "id": "023ccbab-b408-4ff8-be35-cb32183474a9", "pmid": "", "title": "Alpha‐blockers as medical expulsive therapy for ureteral stones", "imported": false, "abstract": "Abstract - Background Ureteral colic is a common reason for patients to seek medical care. Alpha‐blockers are commonly used to improve stone passage through so‐called medical expulsive therapy (MET), but their effectiveness remains controversial. This is an update of a 2014 Cochrane review; since that time, several large randomised controlled trials (RCTs) have been reported, making this update relevant. Objectives To assess effects of alpha‐blockers compared with standard therapy for ureteral stones 1 cm or smaller confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease. Search methods On 18 November 2017, we searched CENTRAL, MEDLINE Ovid, and Embase. We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials. We checked all references of included and review articles and conference proceedings for articles relevant to this review. We sent letters to investigators to request information about unpublished or incomplete studies. Selection criteria We included RCTs of ureteral stone passage in adult patients that compared alpha‐blockers versus standard therapy. Data collection and analysis Two review authors screened studies for inclusion and extracted data using standard methodological procedures. We performed meta‐analysis using a random‐effects model. Primary outcomes were stone clearance and major adverse events; secondary outcomes were stone expulsion time, number of pain episodes, use of diclofenac, hospitalisation, and surgical intervention. We assessed the quality of evidence on a per‐outcome basis using the GRADE approach. Main results We included 67 studies with 10,509 participants overall. Of these, 15 studies with 5787 participants used a placebo. Stone clearance: Based on the overall analysis, treatment with an alpha‐blocker may result in a large increase in stone clearance (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.36 to 1.55; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that the likely effect is probably smaller (RR 1.16, 95% CI 1.07 to 1.25; moderate‐quality evidence), corresponding to 116 more (95% CI 51 more to 182 more) stone clearances per 1000 participants. Major adverse events: Based on the overall analysis, treatment with an alpha‐blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that alpha‐blockers likely increase the risk of major adverse events slightly (RR 2.09, 95% CI 1.13 to 3.86), corresponding to 29 more (95% CI 3 more to 75 more) major adverse events per 1000 participants. Patients treated with alpha‐blockers may experience shorter stone expulsion times (mean difference (MD) ‐3.40 days, 95% CI ‐4.17 to ‐2.63; low‐quality evidence), may use less diclofenac (MD ‐82.41, 95% CI ‐122.51 to ‐42.31; low‐quality evidence), and likely require fewer hospitalisations (RR 0.51, 95% CI 0.34 to 0.77; moderate‐quality evidence), corresponding to 69 fewer hospitalisations (95% CI 93 fewer to 32 fewer) per 1000 participants. Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI 0.53 to 1.02; low‐quality evidence), corresponding to 28 fewer surgical interventions (95% CI 51 fewer to 2 more) per 1000 participants. A predefined subgroup analysis (test for subgroup differences; P = 0.002) suggests that effects of alpha‐blockers may vary with stone size, with RR of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or smaller versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones larger than 5 mm. We found no evidence suggesting possible subgroup effects based on stone location or alpha‐blocker type. Authors' conclusions For patients with ureteral stones, alpha‐blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha‐blockers may be less effective for smaller (5 mm or smaller) than for larger stones (greater than 5 mm). Plain language summary Alpha‐blockers for ureteral stones in adult patients with symptoms of stone disease Review question Does medical treatment with alpha‐blockers improve the outcomes of patients with stones stuck in their ureter? Background Stones stuck in the ureter, which is the tube that transports urine from the kidney to the bladder, often cause pain and make people see a doctor. Depending on which part of the ureter the stone is stuck in and the size of the stone, it will often pass into the bladder on its own over the course of weeks. If the stone does not come out by itself, people often need to have procedures done to remove the stone. Alpha‐blockers are medications that relax muscles in the urinary tract and may make the stone pass into the bladder faster. However, they can cause unwanted effects. We updated an existing Cochrane Review from 2014 to look into the effects of alpha‐blockers. Study characteristics Based on our latest search of the literature from November 2017, we included 64 studies with 10,509 participants. Of these, 15 studies compared alpha‐blockers with placebo with 5787 participants. A placebo is a pill that looks and tastes exactly like the real medication, so participants did not know what they were getting. These were the higher‐quality studies, which we trusted more. Key results Based on the subset of higher‐quality studies that used a placebo, alpha‐blockers likely resulted in more people passing their stones. However, these patients are likely to experience slightly more serious unwanted effects of this medication. People taking alpha‐blockers may pass their stones in a shorter time, may use less diclofenac (which is a type of pain medication), and are likely to be admitted to the hospital less often. Meanwhile, the need for surgery for their stones was similar. Upon completing additional analyses, we found that effects of alpha‐blockers may be different in people with small (5 mm or smaller) versus larger (larger than 5 mm) stones. It appears that this medication works better in people with larger stones. We could find no difference in how well alpha‐blockers work, no matter where in the ureter the stone is stuck or what type of alpha‐blocker is used. Authors' conclusions For patients with stones stuck in the ureter, alpha‐blockers likely make passing the stone easier but cause slightly more unwanted effects. It appears that alpha‐blockers work better in people with larger (greater than 5 mm) rather than smaller (5 mm or smaller) stones. Quality of the evidence The quality of the evidence for most outcomes was moderate or low, meaning that we have moderate or low confidence in most of the reported results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Campschroer, T; Zhu, X; Vernooij, RWM; Lock, MTWT", "articleTypes": [], "doi": "10.1002/14651858.CD008509.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "024c3f2b-ed78-49ac-bb61-6bd479152cfc", "pmid": "", "title": "Effect of alcohol on blood pressure", "imported": false, "abstract": "Abstract - Background Alcohol is consumed by over 2 billion people worldwide. It is a common substance of abuse and its use can lead to more than 200 disorders including hypertension. Alcohol has both acute and chronic effects on blood pressure. This review aimed to quantify the acute effects of different doses of alcohol over time on blood pressure and heart rate in an adult population. Objectives Primary objective To determine short‐term dose‐related effects of alcohol versus placebo on systolic blood pressure and diastolic blood pressure in healthy and hypertensive adults over 18 years of age. Secondary objective To determine short‐term dose‐related effects of alcohol versus placebo on heart rate in healthy and hypertensive adults over 18 years of age. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to March 2019: the Cochrane Hypertension Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2), in the Cochrane Library; MEDLINE (from 1946); Embase (from 1974); the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. We also contacted authors of relevant articles regarding further published and unpublished work. These searches had no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing effects of a single dose of alcohol versus placebo on blood pressure (BP) or heart rate (HR) in adults (≥ 18 years of age). Data collection and analysis Two review authors (ST and CT) independently extracted data and assessed the quality of included studies. We also contacted trial authors for missing or unclear information. Mean difference (MD) from placebo with 95% confidence interval (CI) was the outcome measure, and a fixed‐effect model was used to combine effect sizes across studies. Main results We included 32 RCTs involving 767 participants. Most of the study participants were male (N = 642) and were healthy. The mean age of participants was 33 years, and mean body weight was 78 kilograms. Low‐dose alcohol (< 14 g) within six hours (2 RCTs, N = 28) did not affect BP but did increase HR by 5.1 bpm (95% CI 1.9 to 8.2) (moderate‐certainty evidence). Medium‐dose alcohol (14 to 28 g) within six hours (10 RCTs, N = 149) decreased systolic blood pressure (SBP) by 5.6 mmHg (95% CI ‐8.3 to ‐3.0) and diastolic blood pressure (DBP) by 4.0 mmHg (95% CI ‐6.0 to ‐2.0) and increased HR by 4.6 bpm (95% CI 3.1 to 6.1) (moderate‐certainty evidence for all). Medium‐dose alcohol within 7 to 12 hours (4 RCTs, N = 54) did not affect BP or HR. Medium‐dose alcohol > 13 hours after consumption (4 RCTs, N = 66) did not affect BP or HR. High‐dose alcohol (> 30 g) within six hours (16 RCTs, N = 418) decreased SBP by 3.5 mmHg (95% CI ‐6.0 to ‐1.0), decreased DBP by 1.9 mmHg (95% CI‐3.9 to 0.04), and increased HR by 5.8 bpm (95% CI 4.0 to 7.5). The certainty of evidence was moderate for SBP and HR, and was low for DBP. High‐dose alcohol within 7 to 12 hours of consumption (3 RCTs, N = 54) decreased SBP by 3.7 mmHg (95% CI ‐7.0 to ‐0.5) and DBP by 1.7 mmHg (95% CI –4.6 to 1.8) and increased HR by 6.2 bpm (95% CI 3.0 to 9.3). The certainty of evidence was moderate for SBP and HR, and low for DBP. High‐dose alcohol ≥ 13 hours after consumption (4 RCTs, N = 154) increased SBP by 3.7 mmHg (95% CI 2.3 to 5.1), DBP by 2.4 mmHg (95% CI 0.2 to 4.5), and HR by 2.7 bpm (95% CI 0.8 to 4.6) (moderate‐certainty evidence for all). Authors' conclusions High‐dose alcohol has a biphasic effect on BP; it decreases BP up to 12 hours after consumption and increases BP > 13 hours after consumption. High‐dose alcohol increases HR at all times up to 24 hours. Findings of this review are relevant mainly to healthy males, as only small numbers of women were included in the included trials. Plain language summary Alcohol has a biphasic effect on blood pressure and increases heart rate Review question We reviewed available evidence about the short‐term effects of different doses of alcoholic drinks compared to non‐alcoholic drinks on blood pressure and heart rate in adults (≥ 18 years) with both normal and raised blood pressure. Background Drinking excessive alcohol is considered one of the most common causes of raised blood pressure. We wanted to quantify the effects of a single dose of alcohol on blood pressure and heart rate within 24 hours of consumption. Study characteristics We included 32 randomised controlled trials involving 767 participants published up to March 2019. Although these trials included adults from 18 to 96 years of age with various health conditions, most study participants were young healthy males. The source of funding was not reported for a majority of the studies. Key results For low doses of alcohol, we found that one glass of alcohol had little to no effect on blood pressure and increased heart rate within six hours of drinking. We are moderately certain that medium‐dose alcohol decreased blood pressure and increased heart rate within six hours of consumption. We did not see any significant change in blood pressure or heart rate after that, but the evidence was limited. We are also moderately certain that high‐dose alcohol decreased blood pressure within six hours, and the effect lasted up to 12 hours. After that, blood pressure was found to be increased. Heart rate increased significantly after alcohol consumption and remained increased at all times measured. Thus alcohol decreases blood pressure initially (up to 12 hours after ingestion) and increases blood pressure after that. Alcohol consistently increases heart rate at all times within 24 hours of consumption.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Tasnim, S; Tang, C; Musini, VM; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD012787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "0255767b-4f7e-4a71-b458-d653947ddcd8", "pmid": "", "title": "Topiramate for neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background Topiramate is an antiepileptic drug with multiple possible mechanisms of action. Antiepileptic drugs are widely used to treat chronic neuropathic pain (pain due to nerve damage) and fibromyalgia, and many guidelines recommend them. Objectives To assess the analgesic efficacy and associated adverse events of topiramate for chronic neuropathic pain and fibromyalgia in adults (aged 18 years and above). Search methods On 8 May 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We reviewed the bibliographies of all randomised trials identified and review articles, and also searched two clinical trial databases, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform, to identify additional published or unpublished data. Selection criteria We included randomised controlled trials (RCTs) with double‐blind assessment of participant outcomes following two weeks of treatment or longer (though the emphasis of the review was on studies of eight weeks or longer) that used a placebo or active comparator. Data collection and analysis We extracted efficacy and adverse event data, and two study authors examined issues of study quality independently. We performed analysis using two tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First tier studies did not use last‐observation‐carried‐forward (LOCF) or other imputation methods for dropouts. The second tier used data that failed to meet this standard; second tier results were therefore subject to potential bias. Main results We included four studies with 1684 participants. Three parallel‐group placebo comparisons were in painful diabetic neuropathy (1643 participants), and one cross‐over study with diphenhydramine as an active placebo (41 participants) was in lumbar radiculopathy. Doses of topiramate were titrated up to 200 mg/day or 400 mg/day. All studies had one or more sources of potential major bias, as they either used LOCF imputation or were of small size. No study provided first tier evidence for an efficacy outcome. There was no convincing evidence for efficacy of topiramate at 200 to 400 mg/day over placebo. Eighty‐two per cent of participants taking topiramate 200 to 400 mg/day experienced at least one adverse event, as did 71% with placebo, and the number needed to treat for an additional harmful effect (NNTH) was 8.6 (95% confidence interval (CI) 4.9 to 35). There was no difference in serious adverse events recorded (6.6% versus 7.5%). Adverse event withdrawals with 400 mg daily were much more common with topiramate (27%) than with placebo (8%), with an NNTH of 5.4 (95% CI 4.3 to 7.1). Lack of efficacy withdrawal was less frequent with topiramate (12%) than placebo (18%). Weight loss was a common event in most studies. No deaths attributable to treatment were reported. Authors' conclusions Topiramate is without evidence of efficacy in diabetic neuropathic pain, the only neuropathic condition in which it has been adequately tested. The data we have includes the likelihood of major bias due to LOCF imputation, where adverse event withdrawals are much higher with active treatment than placebo control. Despite the strong potential for bias, no difference in efficacy between topiramate and placebo was apparent. Plain language summary Topiramate for treating neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (for example from a fall, a cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in treating neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our knowledge about fibromyalgia is even less advanced, but fibromyalgia can respond to the same medicines as neuropathic pain. Topiramate is a medicine used to treat epilepsy, and so it might be a useful medicine for neuropathic pain or fibromyalgia. On 8 May 2013, we performed searches to look for clinical trials on the use of topiramate to treat neuropathic pain or fibromyalgia. We found four studies of reasonable quality that tested topiramate against placebo for a number of weeks. Almost all of the 1684 people in the studies had painful limbs because of damaged nerves caused by diabetes. Topiramate did not help the pain and was no different from placebo except in causing more side‐effects, which made many more people withdraw from the studies early. About 3 people in 10 withdrew because of side‐effects with topiramate compared with 1 in 10 with placebo. Topiramate has not been shown to work as a pain medicine in diabetic neuropathy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ, Derry, S, Lunn, MPT, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008314.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.102Z" }, { "id": "02652047-68c0-432b-9a3f-4ae95f1c155e", "pmid": "", "title": "Dual antibiotics for bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is a chronic respiratory disease characterised by abnormal and irreversible dilatation of the smaller airways and associated with a mortality rate greater than twice that of the general population. Antibiotics serve as front‐line therapy for managing bacterial load, but their use is weighed against the development of antibiotic resistance. Dual antibiotic therapy has the potential to suppress infection from multiple strains of bacteria, leading to more successful treatment of exacerbations, reduced symptoms, and improved quality of life. Further evidence is required on the efficacy of dual antibiotics in terms of management of exacerbations and extent of antibiotic resistance. Objectives To evaluate the effects of dual antibiotics in the treatment of adults and children with bronchiectasis. Search methods We identified studies from the Cochrane Airways Group Specialised Register (CAGR), which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED), and PsycINFO, as well as studies obtained by handsearching of journals/abstracts. We also searched the following trial registries: US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. We imposed no restriction on language of publication. We conducted our search in October 2017. Selection criteria We searched for randomised controlled trials comparing dual antibiotics versus a single antibiotic for short‐term (< 4 weeks) or long‐term management of bronchiectasis diagnosed in adults and/or children by bronchography, plain film chest radiography, or high‐resolution computed tomography. Primary outcomes included exacerbations, length of hospitalisation, and serious adverse events. Secondary outcomes were response rates, emergence of resistance to antibiotics, systemic markers of infection, sputum volume and purulence, measures of lung function, adverse events/effects, deaths, exercise capacity, and health‐related quality of life. We did not apply outcome measures as selection criteria. Data collection and analysis Two review authors independently screened the titles and abstracts of 287 records, along with the full text of seven reports. Two studies met review inclusion criteria. Two review authors independently extracted outcome data and assessed risk of bias . We extracted data from only one study and conducted GRADE assessments for the following outcomes: successful treatment of exacerbation; response rates; and serious adverse events. Main results Two randomised trials assessed the effectiveness of oral plus inhaled dual therapy versus oral monotherapy in a total of 118 adults with a mean age of 62.8 years. One multi‐centre trial compared inhaled tobramycin plus oral ciprofloxacin versus ciprofloxacin alone, and one single‐centre trial compared nebulised gentamicin plus systemic antibiotics versus a systemic antibiotic alone. Published papers did not report study funding sources. Effect estimates from one small study with 53 adults showed no evidence of treatment benefit with oral plus inhaled dual therapy for the following primary outcomes at the end of the study: successful management of exacerbation ‐ cure at day 42 (odds ratio (OR) 0.66, 95% confidence interval (CI) 0.22 to 2.01; 53 participants; one study; very low‐quality evidence); number of participants with Pseudomonas aeruginosa eradication at day 21 (OR 2.33, 95% CI 0.66 to 8.24; 53 participants; one study; very low‐quality evidence); and serious adverse events (OR 0.48, 95% CI 0.08 to 2.87; 53 participants; one study; very low‐quality evidence). Similarly, researchers provided no evidence of treatment benefit for the following secondary outcomes: clinical response rates ‐ relapse at day 42 (OR 0.57, 95% CI 0.12 to 2.69; 53 participants; one study; very low‐quality evidence); microbiological response rate at day 21 ‐ eradicated (OR 2.40, 95% CI 0.67 to 8.65; 53 participants; one study; very low‐quality evidence); and adverse events ‐ incidence of wheeze (OR 5.75, 95% CI 1.55 to 21.33). Data show no evidence of benefit in terms of sputum volume, lung function, or antibiotic resistance. Outcomes from a second small study with 65 adults, available only as an abstract, were not included in the quantitative data synthesis. The included studies did not report our other primary outcomes: duration; frequency; and time to next exacerbation; nor our secondary outcomes: systemic markers of infection; exercise capacity; and quality of life. We did not identify any trials that included children. Authors' conclusions A small number of studies in adults have generated high‐quality evidence that is insufficient to inform robust conclusions, and studies in children have provided no evidence. We identified only one dual‐therapy combination of oral and inhaled antibiotics. Results from this single trial of 53 adults that we were able to include in the quantitative synthesis showed no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, serious adverse events, sputum volume, lung function, and antibiotic resistance. Further high‐quality research is required to determine the efficacy and safety of other combinations of dual antibiotics for both adults and children with bronchiectasis, particularly in terms of antibiotic resistance. Plain language summary Dual antibiotics for bronchiectasis Background to the question Bronchiectasis is a lung disease involving abnormal airways, leading to repeated chest infections, and associated with a mortality rate more than twice that of the general population. Although previously considered a relatively rare disease, numbers appear to be increasing, particularly for those over 75 years in low/middle‐income countries. Antibiotics are the main therapy for chest infection, but their use must be weighed against potential side effects and the risk of increasing resistance to antibiotic therapy. One strategy to improve response and/or reduce antibiotic resistance involves giving two antibiotic agents at the same time: dual antibiotic therapy. This review therefore aimed to evaluate the effects of dual antibiotics for treatment of adults and children with bronchiectasis. Study characteristics In October 2017, we identified two relevant studies comparing oral plus inhaled dual therapy versus oral therapy alone. They included a total of 118 adults with an average age of 62.8 years. One study compared inhaled tobramycin plus oral ciprofloxacin with oral ciprofloxacin, and the second study compared inhaled gentamicin plus a systemic (affecting the whole body, rather than just the lungs) antibiotic with a systemic antibiotic alone. Only a research summary was available for the latter. Published papers did not report study funding sources Main results Results from one small trial of 53 adults show no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, the occurrence of serious unwanted events, amount of phlegm, lung function, or resistance to antibiotic treatment. However, we found insufficient evidence to permit confident conclusions about their use. Quality of the evidence The overall quality of the evidence was very poor, largely because one of the studies was not well described and included few participants. Information on exacerbations, exercise ability, and quality of life was not reported. We did not identify any trials that compared other types of dual antibiotic therapy, and we found none that included children. Therefore uncertainty remains concerning the use of dual antibiotics, and further high‐quality studies are needed to examine the role of dual antibiotics in the treatment of adults and children with bronchiectasis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Felix, LM; Grundy, S; Milan, SJ; Armstrong, R; Harrison, H; Lynes, D; Spencer, S", "articleTypes": [], "doi": "10.1002/14651858.CD012514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "026d241d-77d8-4808-b0a5-2078b8a3a4e5", "pmid": "", "title": "Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Das, RR, Singh, M, Naik, SS", "articleTypes": [], "doi": "10.1002/14651858.CD011597.pub3 AB - Abstract - Background Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases children's risk of developing pneumonia. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited. This is an update of a Cochrane Review first published in 2018. Objectives To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia. Search methods We searched CENTRAL, MEDLINE, Embase, and two trial registries on 28 December 2021. We applied no language restrictions. Selection criteria We included randomised controlled trials (RCTs) that compared vitamin D supplementation with placebo in children (aged one month to five years) hospitalised with acute community‐acquired pneumonia, as defined by the World Health Organization (WHO) acute respiratory infection guidelines. For this update, we reappraised eligible trials according to research integrity criteria, excluding RCTs published from April 2018 that were not prospectively registered in a trials registry according to WHO or Clinical Trials Registry – India (CTRI) guidelines (it was not mandatory to register clinical trials in India before April 2018). Data collection and analysis Two review authors independently assessed trials for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with number of participants in each group. We used standard methodological procedures expected by Cochrane. Main results In this update, we included three new trials involving 468 children, bringing the total number of trials to seven, with 1601 children (631 with pneumonia and 970 with severe or very severe pneumonia). We categorised three previously included studies and three new studies as 'awaiting classification' based on the research integrity screen.
Five trials used a single bolus dose of vitamin D (300,000 IU in one trial and 100,000 IU in four trials) at the onset of illness or within 24 hours of hospital admission; one used a daily dose of oral vitamin D (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used variable doses (on day 1, 20,000 IU in children younger than six months, 50,000 IU in children aged six to 12 months, and 100,000 IU in children aged 13 to 59 months; followed by 10,000 IU/day for four days or until discharge). Three trials performed microbiological diagnosis of pneumonia, radiological diagnosis of pneumonia, or both. Vitamin D probably has little or no effect on the time to resolution of acute illness (mean difference (MD) −1.28 hours, 95% confidence interval (CI) −5.47 to 2.91; 5 trials, 1188 children; moderate‐certainty evidence). We do not know if vitamin D has an effect on the duration of hospitalisation (MD 4.96 hours, 95% CI −8.28 to 18.21; 5 trials, 1023 children; very low‐certainty evidence). We do not know if vitamin D has an effect on mortality rate (risk ratio (RR) 0.69, 95% CI 0.44 to 1.07; 3 trials, 584 children; low‐certainty evidence). The trials reported no major adverse events. According to GRADE criteria, the evidence was of very low‐to‐moderate certainty for all outcomes, owing to serious trial limitations, inconsistency, indirectness, and imprecision. Three trials received funding: one from the New Zealand Aid Corporation, one from an institutional grant, and one from multigovernment organisations (Bangladesh, Sweden, and UK). The remaining four trials were unfunded. Authors' conclusions Based on the available evidence, we are uncertain whether vitamin D supplementation has important effects on outcomes of acute pneumonia when used as an adjunct to antibiotics. The trials reported no major adverse events. Uncertainty in the evidence is due to imprecision, risk of bias, inconsistency, and indirectness. Plain language summary Is vitamin D an effective and safe addition to antibiotics for treating children with acute pneumonia? What is pneumonia, and how can it be treated? Pneumonia is inflammation (swelling) of the lungs caused by an infection. Treatment for pneumonia includes antibiotics, providing oxygen through a mask, and other supportive therapies. Vitamin D boosts immune defences and reduces excessive inflammation: these effects may help children recover from an episode of pneumonia. What did we want to find out? We wanted to find out if vitamin D, taken together with antibiotics, can help children to recover from an episode of pneumonia. What did we do? We searched for trials that looked at vitamin D compared with placebo (dummy treatment) in children aged between one month and five years who had pneumonia. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. Study characteristics We included seven trials involving 1601 children from low‐ and middle‐income countries. In five trials, children received a single large dose of vitamin D when they joined the trial or within 24 hours of admission to hospital. In two trials, children received vitamin D for five days. One trial excluded children with normal vitamin D levels. Two trials reported the cause of children's pneumonia. Key results Vitamin D probably has little or no effect on the time it takes children to get better from pneumonia. We do not know if vitamin D has an effect on the time children spend in hospital or the number of children who die. The studies reported no major harmful events. What are the limitations of the evidence? We have only moderate confidence in the evidence on the time it took children to recover from pneumonia, because all children in this comparison were from low‐income regions, so the results may not apply to higher‐income populations. We have little confidence in the evidence on death rate, because of the same applicability problem outlined above, and because the result was compatible with both appreciable benefit and harm. We have very little confidence in the evidence on time spent in hospital, because of the same applicability problem outlined above, because the children and health providers in one study knew what the allocated treatment was, and because the results were very inconsistent across the studies included in the comparison. How up to date is the evidence? The evidence is current to 28 December 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.099Z" }, { "id": "027832ca-6a8b-4028-9254-062c12a91b45", "pmid": "", "title": "Genital ulcer disease treatment for reducing sexual acquisition of HIV", "imported": false, "abstract": "Abstract - Background Genital ulcer disease by virtue of disruption of the mucosal surfaces may enhance HIV acquisition. Genital ulcer disease treatment with resolution of the ulcers may therefore contribute in reducing the sexual acquisition of HIV. Objectives To determine the effects of treatment of genital ulcer disease on sexual acquisition of HIV. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, LILACS, NLM Gateway, Web of Science, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and reference lists of relevant publications for eligible studies published between 1980 and August 2011. Selection criteria Randomized controlled trials of any treatment intervention aimed at curing genital ulcer disease compared with an alternative treatment, placebo, or no treatment. We included only trials whose unit of randomization was the individual with confirmed genital ulcer. Data collection and analysis We independently selected studies and extracted data in duplicate; resolving discrepancies by discussion, consensus, and arbitration by third review author. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI). Main results There were three randomized controlled trials that met our inclusion criteria recruited HIV‐negative participants with chancroid (two trials with 143 participants) and primary syphilis (one trial with 30 participants). The syphilis study, carried out in the US between 1995 and 1997, randomized participants to receive a single 2.0 g oral dose of azithromycin (11 participants); two 2.0 g oral doses of azithromycin administered six to eight days apart (eight participants); or benzathine penicillin G administered as either 2.4 million units intramuscular injection once or twice seven days apart (11 participants). No participant in the trial seroconverted during 12 months of follow‐up. The chancroid trials, conducted in Kenya by 1990, found no significant differences in HIV seroconversion rates during four to 12 weeks of follow‐up between 400 and 200 mg single oral doses of fleroxacin (one trial, 45 participants; RR 3.00; 95% CI 0.29 to 30.69), or between 400 mg fleroxacin and 800 mg sulfamethoxazole plus 160 mg trimethoprim (one trial, 98 participants; RR 0.33; 95% CI 0.04 to 3.09). Adverse events reported were mild to moderate in severity, and included Jarisch‐Herxheimer reactions and gastrointestinal symptoms. The differences between the treatment arms in the incidence of adverse events were not significant. The quality of this evidence on the effectiveness of genital ulcer disease treatment in reducing sexual acquisition of HIV, according to GRADE methodology, is of very low quality. Authors' conclusions At present, there is insufficient evidence to determine whether curative treatment of genital ulcer disease would reduce the risk of HIV acquisition. The very low quality of the evidence implies that the true effect of genital ulcer disease treatment on sexual acquisition of HIV may be substantially different from the effect estimated from currently available data. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not. Plain language summary Genital ulcer disease treatment for reducing sexual acquisition of HIV The presence of a genital ulcer would provide an entry point for the HIV virus if an HIV‐negative individual with an ulcer has unprotected sexual intercourse with an HIV‐infected person. Treatment of the condition causing the genital ulcer would allow the ulcer to heal and therefore reduce the chances of HIV acquisition. This review assessed whether giving treatment for diseases that present with ulcers in the genital region would reduce sexual acquisition of HIV. Three studies were identified involving 173 HIV‐negative patients with genital ulcers. These studies did not provide sufficient evidence that treatment of genital ulcer diseases reduces sexual acquisition of HIV infection. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mutua, FM, M'Imunya, JM, Wiysonge, CS", "articleTypes": [], "doi": "10.1002/14651858.CD007933.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.101Z" }, { "id": "02785d22-8f16-47b8-a03c-c3b0a7b22c9f", "pmid": "", "title": "Systemic opioids versus other analgesics and sedatives for postoperative pain in neonates", "imported": false, "abstract": "Abstract - Background Neonates may undergo surgery because of malformations such as diaphragmatic hernia, gastroschisis, congenital heart disease, and hypertrophic pyloric stenosis, or complications of prematurity, such as necrotizing enterocolitis, spontaneous intestinal perforation, and retinopathy of prematurity that require surgical treatment. Options for treatment of postoperative pain include opioids, non‐pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported. The assessment of the effects of opioids is of utmost importance, especially for neonates in substantial pain during the postoperative period. Objectives To evaluate the benefits and harms of systemic opioid analgesics in neonates who underwent surgery on all‐cause mortality, pain, and significant neurodevelopmental disability compared to no intervention, placebo, non‐pharmacological interventions, different types of opioids, or other drugs. Search methods We searched Cochrane CENTRAL, MEDLINE via PubMed and CINAHL in May 2021. We searched the WHO ICTRP, clinicaltrials.gov, and ICTRP trial registries. We searched conference proceedings, and the reference lists of retrieved articles for RCTs and quasi‐RCTs. Selection criteria We included randomized controlled trials (RCTs) conducted in preterm and term infants of a postmenstrual age up to 46 weeks and 0 days with postoperative pain where systemic opioids were compared to 1) placebo or no intervention; 2) non‐pharmacological interventions; 3) different types of opioids; or 4) other drugs. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods, all‐cause mortality during initial hospitalization, major neurodevelopmental disability, and cognitive and educational outcomes in children more than five years old. We used the fixed‐effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) for continuous data. We used GRADE to assess the certainty of evidence for each outcome. Main results We included four RCTs enrolling 331 infants in four countries across different continents. Most studies considered patients undergoing large or medium surgical procedures (including major thoracic or abdominal surgery), who potentially required pain control through opioid administration after surgery. The randomized trials did not consider patients undergoing minor surgery (including inguinal hernia repair) and those individuals exposed to opioids before the beginning of the trial. Two RCTs compared opioids with placebo; one fentanyl with tramadol; and one morphine with paracetamol. No meta‐analyses could be performed because the included RCTs reported no more than three outcomes within the prespecified comparisons. Certainty of the evidence was very low for all outcomes due to imprecision of the estimates (downgrade by two levels) and study limitations (downgrade by one level). Comparison 1: opioids versus no treatment or placebo Two trials were included in this comparison, comparing either tramadol or tapentadol with placebo. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of tramadol compared with placebo on all‐cause mortality during initial hospitalization (RR 0.32, 95% Confidence Interval (CI) 0.01 to 7.70; RD ‐0.03, 95% CI ‐0.10 to 0.05, 71 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 2: opioids versus non‐pharmacological interventions No trials were included in this comparison. Comparison 3: head‐to‐head comparisons of different opioids One trial comparing fentanyl with tramadol was included in this comparison. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of fentanyl compared with tramadol on all‐cause mortality during initial hospitalization (RR 0.99, 95% CI 0.59 to 1.64; RD 0.00, 95% CI ‐0.13 to 0.13, 171 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 4: opioids versus other analgesics and sedatives One trial comparing morphine with paracetamol was included in this comparison. The evidence is very uncertain about the effect of morphine compared with paracetamol on COMFORT pain scores (MD 0.10, 95% CI ‐0.85 to 1.05; 71 participants, 1 study; I² = not applicable). No data were reported on the other critical outcomes, i.e. major neurodevelopmental disability; cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization; retinopathy of prematurity; or intraventricular hemorrhage. Authors' conclusions Limited evidence is available on opioid administration for postoperative pain in newborn infants compared to either placebo, other opioids, or paracetamol. We are uncertain whether tramadol reduces mortality compared to placebo; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether fentanyl reduces mortality compared to tramadol; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether morphine reduces pain compared to paracetamol; none of the studies reported major neurodevelopmental disability, cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization, retinopathy of prematurity, or intraventricular hemorrhage. We identified no studies comparing opioids versus non‐pharmacological interventions. Plain language summary Are opioids the best choice for managing pain in babies after surgery? Key messages • We did not find enough good‐quality evidence about the benefits and risks of opioids (a group of pain‐relieving medicines) to manage pain after surgery in babies. We found only four studies and they had not enrolled enough babies to give reliable results. • Larger, well‐designed studies are needed to give better estimates of the benefits and potential harms of opioids, other medicines and non‐medicine‐based treatments. Why are opioids given to manage pain after surgery in babies? Babies (particularly in the first four weeks after birth) often have to have surgeries. Similar to adults, they need constant pain management after these operations and opioids are commonly used for post‐surgery pain relief in babies. What did we want to find out? We wanted to find out the impact of giving opioids to babies having surgery, compared to: 1) no treatment or placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested); 2) non‐medicine‐based treatments (such as sweet solutions); 3) other medicines; or 4) different types of opioids. What did we do? We searched for studies that compared opioids with the four treatments described above. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included four studies that involved 331 babies. The biggest study was in 171 babies and the smallest study was in 15 babies. • Two studies compared opioids with placebo: it is unclear if opioids have an effect on mortality; no studies reported pain, long‐term development, vision problems (retinopathy of prematurity) or bleeding to the brain (intraventricular hemorrhage). • One study compared one type of opioid to another type of opioid: it is unclear if fentanyl has an effect on mortality compared to tramadol; no studies reported pain, long‐term development, vision problems or bleeding to the brain. • One study compared an opioid to a different type of pain‐relieving medicine: it is unclear if the opioid morphine has an effect on pain compared with paracetamol; no studies reported long‐term development, mortality, vision problems or bleeding to the brain. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results of our outcomes. Also, it is possible that people in the studies were aware of what treatment they were given. Not all the studies provided data about everything that we were interested in. How up‐to‐date is this review? 
We searched for studies that were available up to May 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kinoshita, M; Stempel, KS; Borges do Nascimento, IJ; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD014876.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "02a620f7-a73e-4e2a-9d9e-bc6c97dc442b", "pmid": "", "title": "Pharmacological and nutritional treatment for McArdle disease (Glycogen Storage Disease type V)", "imported": false, "abstract": "Abstract - Background McArdle disease (Glycogen Storage Disease type V) is caused by an absence of muscle phosphorylase leading to exercise intolerance, myoglobinuria rhabdomyolysis and acute renal failure. This is an update of a review first published in 2004. Objectives To review systematically the evidence from randomised controlled trials (RCTs) of pharmacological or nutritional treatments for improving exercise performance and quality of life in McArdle disease. Search methods We searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE on 11 August 2014. Selection criteria We included RCTs (including cross‐over studies) and quasi‐RCTs. We included unblinded open trials and individual patient studies in the discussion. Interventions included any pharmacological agent or nutritional supplement. Primary outcome measures included any objective assessment of exercise endurance (for example aerobic capacity (VO 2 ) max, walking speed, muscle force or power and fatigability). Secondary outcome measures included metabolic changes (such as reduced plasma creatine kinase and a reduction in the frequency of myoglobinuria), subjective measures (including quality of life scores and indices of disability) and serious adverse events. Data collection and analysis Three review authors checked the titles and abstracts identified by the search and reviewed the manuscripts. Two review authors independently assessed the risk of bias of relevant studies, with comments from a third author. Two authors extracted data onto a specially designed form. Main results We identified 31 studies, and 13 fulfilled the criteria for inclusion. We described trials that were not eligible for the review in the Discussion. The included studies involved a total of 85 participants, but the number in each individual trial was small; the largest treatment trial included 19 participants and the smallest study included only one participant. There was no benefit with: D‐ribose, glucagon, verapamil, vitamin B 6 , branched chain amino acids, dantrolene sodium, and high‐dose creatine. Minimal subjective benefit was found with low dose creatine and ramipril only for patients with a polymorphism known as the D/D angiotensin converting enzyme (ACE) phenotype. A carbohydrate‐rich diet resulted in better exercise performance compared with a protein‐rich diet. Two studies of oral sucrose given at different times and in different amounts before exercise showed an improvement in exercise performance. Four studies reported adverse effects. Oral ribose caused diarrhoea and symptoms suggestive of hypoglycaemia including light‐headedness and hunger. In one study, branched chain amino acids caused a deterioration of functional outcomes. Dantrolene was reported to cause a number of adverse effects including tiredness, somnolence, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of myalgia. Authors' conclusions Although there was low quality evidence of improvement in some parameters with creatine, oral sucrose, ramipril and a carbohydrate‐rich diet, none was sufficiently strong to indicate significant clinical benefit. Plain language summary Drug and nutritional treatment for McArdle disease Review question We reviewed the evidence about the effects of drug and nutritional treatment for McArdle disease. Background McArdle disease (also known as glycogen storage disease type V) is a disorder affecting muscle metabolism. The condition is caused by the lack of an enzyme called muscle phosphorylase. This results in an inability to break down glycogen 'fuel' stores. McArdle disease leads to pain and fatigue with strenuous exercise. Sometimes severe muscle damage develops and occasionally this results in acute reversible kidney failure. Study characteristics After a wide search, we identified 13 randomised studies that included 85 participants with McArdle disease. This is an update of a review first published in 2004. We found no new trials at this update. Key results and quality of the evidence The review found no benefit compared with placebo with the following treatments: D‐ribose, glucagon, verapamil, vitamin B 6 , oral branched chain amino acids, dantrolene sodium, high‐dose creatine and ramipril. Low dose creatine and ramipril produced minimal benefit for patients who also have the D/D angiotensin converting enzyme (ACE) phenotype. Taking low dose creatine supplements had a minor benefit in improving exercise tolerance in a small number of people with the condition. Taking a sugary drink before planned strenuous exercise can improve performance but this treatment is not practical for day‐to‐day living. A diet rich in carbohydrate may be superior to a diet rich in protein. Adverse effects were reported in four studies. Oral ribose caused symptoms suggestive of a low blood sugar including light‐headedness, hunger and diarrhoea. One study of branched chain amino acids resulted in a deterioration in participants. Dantrolene was reported to cause a number of side‐effects including tiredness, sleepiness, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause any side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of muscle pain. The quality of these studies was low due to the small number of participants; the largest number in one trial was 19 and one trial had only one participant. The evidence is current to August 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Quinlivan, R, Martinuzzi, A, Schoser, B", "articleTypes": [], "doi": "10.1002/14651858.CD003458.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.082Z" }, { "id": "02a93dbc-b775-43b4-a2fe-7630042f5e0e", "pmid": "", "title": "Intranasal fentanyl for the management of acute pain in children", "imported": false, "abstract": "Abstract - Background Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula. Objectives We identified and evaluated all randomized controlled trials (RCTs) and quasi‐randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of \"rescue analgesia,\" patient/parental satisfaction and patient mortality. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014). Selection criteria We included RCTs comparing INF versus any other pharmacological/non‐pharmacological intervention for the treatment of children in acute pain (aged < 18 years). Data collection and analysis Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions. Main results Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a “bad taste” and vomiting with INF. Overall the risk of bias in all studies was considered low. Authors' conclusions INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non‐inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause. Plain language summary Intranasal fentanyl for the treatment of children in acute pain Background Pain is the most common reason why patients are seen in emergency departments (EDs). The challenging nature of treating children in acute severe pain is reflected in the medical literature by poor pain management in this population. We reviewed evidence on the effect of intranasal fentanyl (INF) (a strong pain relief drug, similar to morphine) compared with any other pain‐relieving technique for treatment of children in acute severe pain. Study characteristics We included studies with children (younger than 18 years of age) suffering from acute severe pain as a result of injury or medical illness. The target intervention was INF administered for pain relief compared with any other drug intervention for pain relief (e.g. intravenous morphine) or non‐drug intervention (e.g. limb splinting, wound dressing) provided in the emergency setting. The evidence is current to January 2014. Key results We identified three studies that included 313 children with acute severe pain resulting from broken bones of the upper and lower limbs. These trials compared INF versus morphine administered by a needle into a muscle (intramuscular morphine) or via a drip into a vein (intravenous morphine), as well as standard concentration INF versus high concentration INF. The collective study population in these trials consisted of children three to 15 years of age. Males accounted for approximately two‐thirds of the overall study population. The review concluded that INF may be an effective analgesic for the treatment of children in acute moderate to severe pain, and its administration appears to cause minimal distress to children; however, the evidence is insufficient to permit judgement of the effects of INF compared with intramuscular or intravenous morphine. No serious adverse events (e.g. opiate toxicity, death) were reported. Limitations Limitations of this review include the following: Few studies (three) were eligible for inclusion; no study examined the use of INF in children younger than three years of age; no study included children with pain resulting from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Murphy, A, O'Sullivan, R, Wakai, A, Grant, TS, Barrett, MJ, Cronin, J, McCoy, SC, Hom, J, Kandamany, N", "articleTypes": [], "doi": "10.1002/14651858.CD009942.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.752Z" }, { "id": "02cbab57-e7b2-4d2e-a429-588cd90c2e7a", "pmid": "", "title": "Physical therapy for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Bell's palsy (idiopathic facial paralysis) is commonly treated by various physical therapy strategies and devices, but there are many questions about their efficacy. Objectives To evaluate physical therapies for Bell's palsy (idiopathic facial palsy). Search methods We searched the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2011), MEDLINE (January 1966 to February 2011), EMBASE (January 1946 to February 2011), LILACS (January 1982 to February 2011), PEDro (from 1929 to February 2011), and CINAHL (January 1982 to February 2011). We included searches in clinical trials register databases until February 2011. Selection criteria We selected randomised or quasi‐randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention. Data collection and analysis Two authors independently scrutinised titles and abstracts identified from the search results. Two authors independently carried out risk of bias assessments, which took into account secure methods of randomisation, allocation concealment, observer blinding, patient blinding, incomplete outcome data, selective outcome reporting and other bias. Two authors independently extracted data using a specially constructed data extraction form. We undertook separate subgroup analyses of participants with more and less severe disability. Main results For this update to the original review, the search identified 65 potentially relevant articles. Twelve studies met the inclusion criteria (872 participants). Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies compared or combined some form of physical therapy with acupuncture (360 participants). For most outcomes we were unable to perform meta‐analysis because the interventions and outcomes were not comparable. For the primary outcome of incomplete recovery after six months, electrostimulation produced no benefit over placebo (moderate quality evidence from one study with 86 participants). Low quality comparisons of electrostimulation with prednisolone (an active treatment) (149 participants), or the addition of electrostimulation to hot packs, massage and facial exercises (22 participants), reported no significant differences. Similarly a meta‐analysis from two studies, one of three months and the other of six months duration (142 participants) found no statistically significant difference in synkinesis, a complication of Bell's palsy, between participants receiving electrostimulation and controls. A single low quality study (56 participants), which reported at three months, found worse functional recovery with electrostimulation (mean difference (MD) 12.00 points (scale of 0 to 100) 95% confidence interval (CI) 1.26 to 22.74). Two trials of facial exercises, both at high risk of bias, found no difference in incomplete recovery at six months when exercises were compared to waiting list controls or conventional therapy. There is evidence from a single small study (34 participants) of moderate quality that exercises are beneficial on measures of facial disability to people with chronic facial palsy when compared with controls (MD 20.40 points (scale of 0 to 100), 95% CI 8.76 to 32.04) and from another single low quality study with 145 people with acute cases treated for three months, in which significantly fewer participants developed facial motor synkinesis after exercise (risk ratio 0.24, 95% CI 0.08 to 0.69). The same study showed statistically significant reduction in time for complete recovery, mainly in more severe cases (47 participants, MD ‐2.10 weeks, 95% CI ‐3.15 to ‐1.05) but this was not a prespecified outcome in this meta analysis. Acupuncture studies did not provide useful data as all were short and at high risk of bias. None of the studies included adverse events as an outcome. Authors' conclusions There is no high quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. There is low quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases. There is low quality evidence that facial exercise reduces sequelae in acute cases. The suggested effects of tailored facial exercises need to be confirmed with good quality randomised controlled trials. Plain language summary Physical treatments for idiopathic facial paralysis Bell's palsy is an acute disorder of the facial nerve, which produces full or partial loss of movement on one side of the face. The facial palsy gets completely better without treatment in most, but not all, people. Physical therapies, such as exercise, biofeedback, laser treatment, electrotherapy, massage and thermotherapy, are used to hasten recovery, improve facial function and minimise sequelae. For this updated review we found a total of 12 studies with 872 participants, most with high risk of bias. Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies combined some form of physical therapy and compared with acupuncture (360 participants). There is evidence from a single study of moderate quality that exercises are beneficial to people with chronic facial palsy when compared with controls and from another low quality study that it is possible that facial exercises could help to reduce synkinesis (a complication of Bell's palsy), and the time to recover. There is insufficient evidence to decide whether electrical stimulation works, to identify risks of these treatments or to assess whether the addition of acupuncture to facial exercises or other physical therapy could produce improvement. In conclusion, tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases, and early facial exercise may reduce recovery time and long term paralysis in acute cases, but the evidence for this is of poor quality. More trials are needed to assess the effects of facial exercises and any risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Teixeira, LJ, Valbuza, JS, Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006283.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.758Z" }, { "id": "02ccc6ae-a83a-4e1d-9f90-51af4245f330", "pmid": "", "title": "Convalescent plasma for people with COVID‐19", "imported": false, "abstract": "Abstract - Rationale Convalescent plasma (CP) may reduce mortality in people with viral respiratory diseases, and is being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). A thorough understanding of the current body of evidence regarding the benefits and risks of this intervention is required. Objectives To assess the effectiveness and safety of convalescent plasma transfusion in the treatment of people with COVID‐19. Search methods To identify completed and ongoing studies, we searched CENTRAL, MEDLINE, Embase, the Epistemonikos COVID‐19 L*OVE Platform, and clinical trial registries to October 2024. Eligibility criteria We included randomised controlled trials (RCTs) evaluating convalescent plasma for people with COVID‐19, irrespective of disease severity, age, gender, or ethnicity. We excluded studies investigating other coronavirus diseases or standard immunoglobulin. Outcomes We used the GRADE approach to rate the certainty of evidence for the following outcomes: all‐cause mortality (up to day 28), worsening and improvement of clinical status (for individuals with moderate to severe disease), hospital admission or death, COVID‐19 symptoms resolution (for individuals with mild disease), quality of life (QoL), grade 3/4 adverse events, and serious adverse events. Risk of bias We used RoB 2 to assess bias in included studies. Synthesis methods We followed standard Cochrane methodology. Included studies We included 48 RCTs (24,518 participants), 15 of which were added in this update. We also identified 36 new ongoing studies and 33 completed studies awaiting classification. Synthesis of results Individuals with a confirmed diagnosis of COVID‐19 and moderate to severe disease Forty‐two RCTs investigated the use of CP for 21,393 participants with moderate to severe disease. Of these, 36 RCTs (20,798 participants) compared CP to placebo or standard care, five (604 participants) to standard plasma, and one (190 participants) to human immunoglobulin. In the full review, we performed subgroup analyses by antibody detection, time since symptom onset, country income level, and key comorbidities. Convalescent plasma versus placebo or standard care alone CP does not reduce all‐cause mortality at up to day 28 (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.90 to 1.03; 31 RCTs, 20,798 participants; high‐certainty evidence). It has little to no impact on the need for invasive mechanical ventilation, or death (RR 1.03, 95% CI 0.98 to 1.08; 8 RCTs, 15,189 participants; high‐certainty evidence) and has no impact on whether participants are discharged from hospital (RR 1.00, 95% CI 0.97 to 1.02; 9 RCTs, 13,930 participants; high‐certainty evidence). CP may have little to no impact on QoL (MD 1.00, 95% CI −2.14 to 4.14; 1 RCT, 483 participants; low‐certainty evidence). CP may have little to no impact on the risk of grade 3/4 adverse events (RR 1.17, 95% CI 0.96 to 1.42; 6 RCTs, 2392 participants; low‐certainty evidence). It probably has little to no effect on the risk of serious adverse events (RR 1.19, 95% CI 1.02 to 1.38; 11 studies, 5298 participants; moderate‐certainty evidence). Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.77, 95% CI 0.53 to 1.10; 5 RCTs, 604 participants; very low‐certainty evidence) and whether it increases the need for invasive mechanical ventilation, or death (RR 5.59, 95% CI 0.29 to 108.38; 1 study, 34 participants; very low‐certainty evidence). The evidence is uncertain about whether convalescent plasma reduces or increases the risk of grade 3/4 adverse events (1 RCT, 248 participants). The evidence is also uncertain about whether CP reduces the risk of serious adverse events (RR 0.82, 95% CI 0.57 to 1.17; 4 RCTs, 447 participants; very low‐certainty evidence). No studies in this comparison reported clinical improvement or QoL. Individuals with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease Six RCTs investigated the use of CP for 2761 participants with mild disease. Four RCTs (1164 participants) compared CP to placebo or standard care alone, and two (1597 participants) to standard plasma. Convalescent plasma versus placebo or standard care alone The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (odds ratio (OR) 1.24, 95% CI 0.33 to 4.60; 3 RCTs, 1004 participants; very low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.45, 95% CI 0.04 to 4.81; 2 RCTs, 493 participants; very low‐certainty evidence). It may have little to no impact on time to COVID‐19 symptom resolution (hazard ratio (HR) 1.05, 95% CI 0.85 to 1.30; 1 RCT, 376 participants) and on the risk of grade 3/4 adverse events (RR 1.29, 95% CI 0.75 to 2.19; 1 RCT, 376 participants), both with low‐certainty evidence. The evidence is uncertain about whether CP has an impact on the risk of serious adverse events (RR 0.84, 95% CI 0.56 to 1.26; 2 RCTs, 494 participants; very low‐certainty evidence). No studies in this comparison reported other critical outcomes. Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.41, 95% CI 0.05 to 3.06; 2 RCTs, 1597 participants; very low‐certainty evidence). It probably reduces admission to hospital or death within 28 days (RR 0.50, 95% CI 0.32 to 0.78; 2 RCTs, 1597 participants; moderate‐certainty evidence). CP may have little to no effect on initial symptom resolution at up to day 28 (RR 1.12, 95% CI 0.82 to 1.54; 1 RCT, 416 participants; low‐certainty evidence). Neither study in this comparison reported other critical outcomes. Authors' conclusions Compared with placebo or standard care, high‐certainty evidence shows that CP does not reduce mortality in individuals with moderate to severe disease and has little to no effect on clinical improvement or worsening. CP probably has little to no effect on serious adverse events. Publication of ongoing studies might resolve some of the uncertainties around CP therapy for people with asymptomatic or mild disease. This review was previously a living systematic review, from the first version published in 2020 until our last search in October 2024. The research question is no longer a priority for decision‐making, new studies are less frequently published, and research that might impact the conclusions of the review is no longer emerging. Funding The European Commission, Belgium SUPorting high quality evaluation of COVID‐19 convalescent plasma thrOughouT Europe (SUPPORT‐E, grant number 101015756) supported this review. Registration Protocol registered with the Center for Open Science on 17 April 2020 (DOI: 10.17605/OSF.IO/DWF53). Access the 2023 version of this review here: DOI: 10.1002/14651858.CD013600.pub6. Plain language summary Does plasma (a blood product) from people who have recovered from COVID‐19 help treat COVID‐19? Key messages We are very confident that plasma from the blood of people who have recovered from COVID‐19 (convalescent plasma) does not help people with moderate to severe COVID‐19. Convalescent plasma may make little or no difference to people with mild COVID‐19. We still need more evidence about people with mild COVID‐19, those with no symptoms, and those with a weaker immune system. What is convalescent plasma? The body produces antibodies as one of its defences against infection. Antibodies are found in part of the blood called plasma. Plasma from people who have recovered from the COVID‐19 virus contains COVID‐19 antibodies. It can be used to make convalescent plasma, which is plasma that contains these antibodies. Convalescent plasma has been used successfully to treat some viruses. This treatment (given by a drip or injection) is generally well‐tolerated, but can cause unwanted effects. What did we want to find out? We wanted to find out whether convalescent plasma helps people with confirmed COVID‐19. We looked at: deaths from any cause; worsening of people's condition, measured by the number of people who needed a ventilator (a machine that helps people breathe) or died; improvement in people's condition, measured by the number of people discharged from hospital; quality of life; unwanted effects. What did we do? We searched for studies that investigated convalescent plasma to treat people with COVID‐19. Studies could take place anywhere in the world and include people with mild, moderate, or severe COVID‐19. Where possible, we combined the studies’ results to analyse them. We rated our confidence in the evidence, based on factors such as study methods and the number of people included. What did we find? We found 48 studies with 24,518 participants. Of these, 42 studies included people with moderate to severe COVID‐19, and six studies included people with mild COVID‐19. The following findings compare convalescent plasma with placebo (a 'dummy' treatment that does not contain any medicine but is given in the same way as the medicine being tested) or the standard care given to people with COVID‐19. People with moderate to severe COVID‐19 In people with moderate to severe COVID‐19, convalescent plasma: makes no difference to deaths from any cause up to 28 days after treatment. About 230 of 1000 people given placebo or standard care died, compared to 220 of 1000 people given convalescent plasma (31 studies, 20,798 people). makes little to no difference to needing support from a ventilator or dying . About 291 of 1000 people given placebo or standard care needed a ventilator or died, compared to 300 of 1000 people given convalescent plasma (8 studies, 15,189 people). makes no difference to people being discharged from hospital. About 670 of 1000 people in both groups were discharged from hospital (9 studies, 13,930 people). may result in no difference in people's quality of life (1 study, 483 people). probably makes no difference to serious unwanted effects. About 109 of 1000 people given placebo or standard care had serious unwanted effects, compared to 129 of 1000 people given convalescent plasma (11 studies, 5298 people). People with mild COVID‐19 We are uncertain whether convalescent plasma reduces deaths from any cause up to 28 days after treatment. About 8 of 1000 people given placebo or standard care died, compared to 10 of 1000 people given convalescent plasma (3 studies, 1004 people). We are uncertain whether convalescent plasma reduces admission to hospital or death within 28 days after treatment. About 106 of 1000 people given placebo or standard care were admitted to hospital or died, compared to 48 of 1000 people given convalescent plasma (2 studies, 493 people). Convalescent plasma may result in no difference in the time until COVID‐19 symptoms resolved (1 study, 376 people). None of the studies measured people's quality of life. We are uncertain whether convalescent plasma has an impact on serious unwanted effects. About 174 of 1000 people given placebo or standard care had serious unwanted effects, compared to 150 of 1000 people given convalescent plasma (2 studies, 494 people). What are the limitations of the evidence? For people with moderate to severe COVID‐19, we are very confident in the evidence about the number of deaths from any cause, and whether people's condition worsened or improved, because the results are drawn from many high‐quality studies with consistent results. We are only moderately confident about the evidence for serious unwanted effects because studies often reported these effects only for people treated with convalescent plasma, or did not report them. For people with mild COVID‐19, we have little to no confidence in the evidence because we could not identify enough consistent results from many of the studies. We still have little evidence about quality of life and about the effects of convalescent plasma for people with mild disease. How up to date is this evidence? This updates our previous review published in 2023. The evidence is current to October 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Iannizzi, C, Chai, KL, Piechotta, V, Monsef, I, Wood, EM, Lamikanra, AA, Roberts, DJ, McQuilten, Z, So-Osman, C, Jindal, A, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013600.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.821Z" }, { "id": "02d68a28-4b92-4b8c-b385-376f0f15ee9b", "pmid": "", "title": "Interventions for treating oral leukoplakia to prevent oral cancer", "imported": false, "abstract": "Abstract - Background Oral leukoplakia is a relatively common oral lesion that, in a small proportion of people, precedes the development of oral cancer. Most leukoplakias are asymptomatic; therefore, the primary objective of treatment should be to prevent onset of cancer. This review updates our previous review, published in 2006. Objectives To assess the effectiveness, safety and acceptability of treatments for leukoplakia in preventing oral cancer. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 16 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) ( the Cochrane Library , 2016, Issue 4), MEDLINE Ovid (1946 to 16 May 2016), Embase Ovid (1980 to 16 May 2016) and CancerLit via PubMed (1950 to 16 May 2016). We searched the metaRegister of Controlled Trials (to 10 February 2015), ClinicalTrials.gov (to 16 May 2016) and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials (to 16 May 2016). We placed no restrictions on the language or date of publication when searching electronic databases. Selection criteria We included randomised controlled trials (RCTs) that enrolled people with a diagnosis of oral leukoplakia and compared any treatment versus placebo or no treatment. Data collection and analysis We collected data using a data extraction form. Oral cancer development, demonstrated by histopathological examination, was our primary outcome. Secondary outcomes were clinical resolution of the lesion, improvement of histological features and adverse events. We contacted trial authors for further details when information was unclear. When valid and relevant data were available, we conducted a meta‐analysis of the data using a fixed‐effect model when we identified fewer than four studies with no heterogeneity. For dichotomous outcomes, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We assessed risk of bias in studies by using the Cochrane tool. We assessed the overall quality of the evidence by using standardised criteria (Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE)). Main results We included 14 studies (909 participants) in this review. Surgical interventions, including laser therapy and cryotherapy, have never been studied by means of an RCT that included a no treatment or placebo arm. The included trials tested a range of medical and complementary treatments, in particular, vitamin A and retinoids (four studies); beta carotene or carotenoids (three studies); non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically ketorolac and celecoxib (two studies); herbal extracts (four studies), including tea components, a Chinese herbal mixture and freeze‐dried black raspberry gel; bleomycin (one study); and Bowman‐Birk inhibitor (one study). We judged one study to be at low risk of bias, seven at unclear risk and six at high risk. In general, we judged the overall quality of the evidence to be low or very low, so findings are uncertain and further research is needed. Five studies recorded cancer incidence, only three of which provided useable data. None of the studies provided evidence that active treatment reduced the risk of oral cancer more than placebo: systemic vitamin A (RR 0.11, 95% CI 0.01 to 2.05; 85 participants, one study); systemic beta carotene (RR 0.71, 95% CI 0.24 to 2.09; 132 participants, two studies); and topical bleomycin (RR 3.00, 95% CI 0.32 to 27.83; 20 participants, one study). Follow‐up ranged between two and seven years. Some individual studies suggested effectiveness of some proposed treatments, namely, systemic vitamin A, beta carotene and lycopene, for achieving clinical resolution of lesions more often than placebo. Similarly, single studies found that systemic retinoic acid and lycopene may provide some benefit in terms of improvement in histological features. Some studies also reported a high rate of relapse. Side effects of varying severity were often described; however, it seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Authors' conclusions Surgical treatment for oral leukoplakia has not been assessed in an RCT that included a no treatment or placebo comparison. Nor has cessation of risk factors such as smoking been assessed. The available evidence on medical and complementary interventions for treating people with leukoplakia is very limited. We do not currently have evidence of a treatment that is effective for preventing the development of oral cancer. Treatments such as vitamin A and beta carotene may be effective in healing oral lesions, but relapses and adverse effects are common. Larger trials of longer duration are required to properly evaluate the effects of leukoplakia treatments on the risk of developing oral cancer. High‐quality research is particularly needed to assess surgical treatment and to assess the effects of risk factor cessation in people with leukoplakia. Plain language summary Interventions for treating oral leukoplakia to prevent oral cancer Review question People with oral leukoplakia are at higher risk of developing oral cancer than those with normal oral mucosa. This review, produced through Cochrane Oral Health , seeks to evaluate whether people affected by leukoplakia can benefit from surgical, medical or complementary treatments, either local or systemic. In particular, we conducted this review to find out which, if any, treatment is able to prevent people with leukoplakia of the mouth from getting oral cancer. This review updates our previous review published in 2006. Background Oral leukoplakia is a white patch formed in the mouth lining that cannot be rubbed off. It often does not hurt and may go unnoticed for years. People with leukoplakia develop oral cancer more often than people without it. Preventing this is critical because rates of oral cancer survival longer than five years after diagnosis are low. Drugs, surgery and other therapies have been tried for treatment of oral leukoplakia. Objectives This review aimed to evaluate whether treatments for oral leukoplakia are effective in preventing oral cancer, and safe and acceptable to patients. Study characteristics The evidence on which this review is based is up‐to‐date as of May 2016. We found 14 randomised controlled trials (RCTs) of medical and complementary treatments, which involved 909 participants in total. Treatments included herbal extracts, anti‐inflammatory drugs, vitamin A, beta carotene supplements and others. Surgical treatment has not been compared with placebo or no treatment in an RCT. Key results Cancer development was measured in studies of three treatments: systemic vitamin A, systemic beta carotene and topical bleomycin. None of these treatments showed effectiveness in preventing cancer development, as measured up to two years for vitamin A and beta carotene, and seven years for bleomycin. Some individual studies of vitamin A and beta carotene suggested that these treatments may be effective for improving or healing oral lesions. However, some studies observed a high rate of relapse in participants whose lesions were initially resolved by treatment. Most treatments caused side effects of differing severity in a high proportion of participants. It seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Quality of the evidence The available evidence is very limited. Most interventions were assessed by only one small study. Most studies had problems in the way they were conducted, making their results unreliable. We judged the quality of evidence for the outcome of cancer development to be very low. Author conclusions Larger, better studies of longer duration are required. As well as further studies of drug treatment and alternative treatments like vitamins, studies are needed to evaluate the effectiveness and safety of surgery, and of stopping risk factor habits such as smoking.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lodi, G; Franchini, R; Warnakulasuriya, S; Varoni, EM; Sardella, A; Kerr, AR; Carrassi, A; MacDonald, LCI; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD001829.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "02e54bab-1769-400f-bf1a-f00c0382b7bc", "pmid": "", "title": "Nutritional labelling for healthier food or non‐alcoholic drink purchasing and consumption", "imported": false, "abstract": "Abstract - Background Nutritional labelling is advocated as a means to promote healthier food purchasing and consumption, including lower energy intake. Internationally, many different nutritional labelling schemes have been introduced. There is no consensus on whether such labelling is effective in promoting healthier behaviour. Objectives To assess the impact of nutritional labelling for food and non‐alcoholic drinks on purchasing and consumption of healthier items. Our secondary objective was to explore possible effect moderators of nutritional labelling on purchasing and consumption. Search methods We searched 13 electronic databases including CENTRAL, MEDLINE and Embase to 26 April 2017. We also handsearched references and citations and sought unpublished studies through websites and trials registries. Selection criteria Eligible studies: were randomised or quasi‐randomised controlled trials (RCTs/Q‐RCTs), controlled before‐and‐after studies, or interrupted time series (ITS) studies; compared a labelled product (with information on nutrients or energy) with the same product without a nutritional label; assessed objectively measured purchasing or consumption of foods or non‐alcoholic drinks in real‐world or laboratory settings. Data collection and analysis Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of bias' tool and GRADE to assess the quality of evidence. We pooled studies that evaluated similar interventions and outcomes using a random‐effects meta‐analysis, and we synthesised data from other studies in a narrative summary. Main results We included 28 studies, comprising 17 RCTs, 5 Q‐RCTs and 6 ITS studies. Most (21/28) took place in the USA, and 19 took place in university settings, 14 of which mainly involved university students or staff. Most (20/28) studies assessed the impact of labelling on menus or menu boards, or nutritional labelling placed on, or adjacent to, a range of foods or drinks from which participants could choose. Eight studies provided participants with only one labelled food or drink option (in which labelling was present on a container or packaging, adjacent to the food or on a display board) and measured the amount consumed. The most frequently assessed labelling type was energy (i.e. calorie) information (12/28). Eleven studies assessed the impact of nutritional labelling on purchasing food or drink options in real‐world settings, including purchases from vending machines (one cluster‐RCT), grocery stores (one ITS), or restaurants, cafeterias or coffee shops (three RCTs, one Q‐RCT and five ITS). Findings on vending machines and grocery stores were not interpretable, and were rated as very low quality. A meta‐analysis of the three RCTs, all of which assessed energy labelling on menus in restaurants, demonstrated a statistically significant reduction of 47 kcal in energy purchased (MD −46.72 kcal, 95% CI −78.35, −15.10, N = 1877). Assuming an average meal of 600 kcal, energy labelling on menus would reduce energy purchased per meal by 7.8% (95% CI 2.5% to 13.1%). The quality of the evidence for these three studies was rated as low, so our confidence in the effect estimate is limited and may change with further studies. Of the remaining six studies, only two (both ITS studies involving energy labels on menus or menus boards in a coffee shop or cafeteria) were at low risk of bias, and their results support the meta‐analysis. The results of the other four studies which were conducted in a restaurant, cafeterias (2 studies) or a coffee shop, were not clearly reported and were at high risk of bias. Seventeen studies assessed the impact of nutritional labels on consumption in artificial settings or scenarios (henceforth referred to as laboratory studies or settings). Of these, eight (all RCTs) assessed the effect of labels on menus or placed on a range of food options. A meta‐analysis of these studies did not conclusively demonstrate a reduction in energy consumed during a meal (MD −50 kcal, 95% CI −104.41, 3.88, N = 1705). We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. Six laboratory studies (four RCTs and two Q‐RCTs) assessed the impact of labelling a single food or drink option (such as chocolate, pasta or soft drinks) on energy consumed during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant difference in energy (kcal) consumed (SMD 0.05, 95% CI −0.17 to 0.27, N = 732). However, the confidence intervals were wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. There was no evidence that nutritional labelling had the unintended harm of increasing energy purchased or consumed. Indirect evidence came from five laboratory studies that involved mislabelling single nutrient content (i.e. placing low energy or low fat labels on high‐energy foods) during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant increase in energy (kcal) consumed (SMD 0.19, 95% CI −0.14to 0.51, N = 718). The effect was small and the confidence intervals wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence from these studies as very low, providing very little confidence in the effect estimate. Authors' conclusions Findings from a small body of low‐quality evidence suggest that nutritional labelling comprising energy information on menus may reduce energy purchased in restaurants. The evidence assessing the impact on consumption of energy information on menus or on a range of food options in laboratory settings suggests a similar effect to that observed for purchasing, although the evidence is less definite and also of low quality. Accordingly, and in the absence of observed harms, we tentatively suggest that nutritional labelling on menus in restaurants could be used as part of a wider set of measures to tackle obesity. Additional high‐quality research in real‐world settings is needed to enable more certain conclusions. Further high‐quality research is also needed to address the dearth of evidence from grocery stores and vending machines and to assess potential moderators of the intervention effect, including socioeconomic status. Plain language summary Nutritional labelling to promote healthier consumption and purchasing of food or drinks A poor diet including excessive energy intake is an important cause of ill health. Nutritional labelling may help people to make healthier food choices. What is the aim of this review? This review investigated whether nutritional labels (i.e. labels providing information about nutritional content) persuade people to buy or consume different (healthy) kinds of food. We searched for all available evidence to answer this question and found 28 studies. Key messages There is evidence to suggest that nutritional labelling, with energy information (e.g. calorie counts) on menus, may reduce energy purchased in restaurants, but more high‐quality studies are needed to make this finding more certain. What was studied in the review? Some studies assessed buying food or drinks from vending machines, grocery stores, restaurants, cafeterias, or coffee shops. Others assessed the amount of food or drink consumed during a snack or meal in an artificial setting or scenario (referred to as laboratory studies or settings). What are the main results of the review? Nutritional labelling on restaurant menus reduced the amount of energy (i.e. calories) purchased, but the quality of the three studies that contributed to this finding was low, so our confidence in the effect estimate is limited and may change with further studies. Eight studies assessed this same type of intervention in laboratory settings, but instead of evaluating how much energy participants purchased, these studies evaluated how much energy participants consumed. These studies did not conclusively demonstrate a reduction in energy consumed when menus or foods were labelled, and they were also of low quality. In addition, six laboratory studies assessed how much energy participants consumed when they were given one food or drink option with or without labels, and five laboratory studies assessed how much energy participants consumed when foods were experimentally labelled as low energy or low fat when they were actually high‐energy foods (i.e. mislabelling). Results from these two groups of studies were inconclusive and of low, or in the case of mislabelling studies, very low quality. We found some studies that assessed labelling on vending machines and grocery stores, but their results were not easy to interpret, so we could not use them to inform this review. How up‐to‐date is this review? The evidence is current to 26 April 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Crockett, RA; King, SE; Marteau, TM; Prevost, AT; Bignardi, G; Roberts, NW; Stubbs, B; Hollands, GJ; Jebb, SA", "articleTypes": [], "doi": "10.1002/14651858.CD009315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "02e978c9-969f-4716-8d4d-ee651eacb705", "pmid": "", "title": "Vitamin D supplementation for chronic liver diseases in adults", "imported": false, "abstract": "Abstract - Background Vitamin D deficiency is often reported in people with chronic liver diseases. Improving vitamin D status could therefore be beneficial for people with chronic liver diseases. Objectives To assess the beneficial and harmful effects of vitamin D supplementation in adults with chronic liver diseases. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index‐Science. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We scanned bibliographies of relevant publications and enquired experts and pharmaceutical companies as to additional trials. All searches were up to November 2020. Selection criteria Randomised clinical trials that compared vitamin D at any dose, duration, and route of administration versus placebo or no intervention in adults with chronic liver diseases. Vitamin D could have been administered as supplemental vitamin D (vitamin D 3 (cholecalciferol) or vitamin D 2 (ergocalciferol)), or an active form of vitamin D (1α‐hydroxyvitamin D (alfacalcidol), 25‐hydroxyvitamin D (calcidiol), or 1,25‐dihydroxyvitamin D (calcitriol)). Data collection and analysis We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of evidence. Main results We included 27 randomised clinical trials with 1979 adult participants. This review update added 12 trials with 945 participants. We assessed all trials at high risk of bias. All trials had a parallel‐group design. Eleven trials were conducted in high‐income countries and 16 trials in middle‐income countries. Ten trials included participants with chronic hepatitis C, five trials participants with liver cirrhosis, 11 trials participants with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. All of the included trials reported the baseline vitamin D status of participants. Participants in nine trials had baseline serum 25‐hydroxyvitamin D levels at or above vitamin D adequacy (20 ng/mL), whilst participants in the remaining 18 trials were vitamin D insufficient (less than 20 ng/mL). Twenty‐four trials administered vitamin D orally, two trials intramuscularly, and one trial intramuscularly and orally. In all 27 trials, the mean duration of vitamin D supplementation was 6 months, and the mean follow‐up of participants from randomisation was 7 months. Twenty trials (1592 participants; 44% women; mean age 48 years) tested vitamin D 3 (cholecalciferol); three trials (156 participants; 28% women; mean age 54 years) tested vitamin D 2 ; four trials (291 participants; 60% women; mean age 52 years) tested 1,25‐dihydroxyvitamin D; and one trial (18 participants; 0% women; mean age 52 years) tested 25‐hydroxyvitamin D. One trial did not report the form of vitamin D. Twelve trials used a placebo, whilst the other 15 trials used no intervention in the control group. Fourteen trials appeared to be free of vested interest. Eleven trials did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on all‐cause mortality (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.51 to 1.45; 27 trials; 1979 participants). The mean follow‐up was 7 months (range 1 to 18 months). We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on liver‐related mortality (RR 1.62, 95% CI 0.08 to 34.66; 1 trial; 18 participants) (follow‐up: 12 months); serious adverse events such as hypercalcaemia (RR 5.00, 95% CI 0.25 to 100.8; 1 trial; 76 participants); myocardial infarction (RR 0.75, 95% CI 0.08 to 6.81; 2 trials; 86 participants); thyroiditis (RR 0.33, 95% CI 0.01 to 7.91; 1 trial; 68 participants); circular haemorrhoidal prolapse (RR 3.00, 95% CI 0.14 to 65.9; 1 trial; 20 participants); bronchopneumonia (RR 0.33, 95% CI 0.02 to 7.32; 1 trial 20 participants); and non‐serious adverse events. The certainty of evidence for all outcomes is very low. We found no data on liver‐related morbidity such as gastrointestinal bleeding, hepatic encephalopathy, hepatorenal syndrome, ascites, or liver cancer. There were also no data on health‐related quality of life. The evidence is also very uncertain regarding the effect of vitamin D versus placebo or no intervention on rapid, early, and sustained virological response in people with chronic hepatitis C. Authors' conclusions Given the high risk of bias and insufficient power of the included trials and the very low certainty of the available evidence, vitamin D supplementation versus placebo or no intervention may increase or reduce all‐cause mortality, liver‐related mortality, serious adverse events, or non‐serious adverse events in adults with chronic liver diseases. There is a lack of data on liver‐related morbidity and health‐related quality of life. Further evidence on clinically important outcomes analysed in this review is needed. Plain language summary Vitamin D supplementation for chronic liver diseases Review question Is vitamin D supplementation beneficial or harmful for adults with chronic liver diseases? Background The available evidence on vitamin D and chronic liver diseases in adults is inconclusive. The aim of this systematic review (a summary of results of available healthcare trials) was to analyse the benefits and harms of the different forms of vitamin D in people with chronic liver diseases. Study characteristics Twenty‐seven trials with 1979 adult participants provided data for this review. This review update added 12 trials with 945 participants. The 1979 trial participants were randomly assigned to vitamin D compared with placebo (dummy pill) or no treatment. Eleven trials were conducted in high‐income countries, and 16 trials in middle‐income countries. The age range of the participants was 28 years to 61 years, and on average 44% were women. Ten trials included people with chronic hepatitis C, five trials people with liver cirrhosis, 11 trials people with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. There were no trials including people with chronic hepatitis B or inherited liver diseases. All of the included trials reported the baseline vitamin D status of participants. Vitamin D administration lasted on average six months, and most trials used the cholecalciferol (vitamin D 3 ) form. Funding Fourteen trials appeared to be free of vested interest that could bias the trial results. Eleven trials may not have been free of vested interest, as they did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We found no difference between trials without industry support compared to trials at risk of industry support in our analysis. Key results There is not enough evidence to determine whether vitamin D has beneficial or harmful effects, or has little to no effect on chronic liver diseases in adults. There were too few participants in the individual trials as well as in our evidence synthesis. The trials were at high risk of bias so we lack fair assessments of the benefits and harms of vitamin D in this population. Neither benefits nor harms of vitamin D supplementation in people with chronic liver diseases can be excluded. There were no trials including people with chronic hepatitis B and inherited liver diseases. Quality of the evidence We judged all trials to be at high risk of bias (that is an underestimation or overestimation of the true intervention effect). The certainty of evidence is very low. Currentness of evidence The evidence is current to November 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Bjelakovic, M; Nikolova, D; Bjelakovic, G; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD011564.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "02eced9f-9fd1-497e-8afe-ad7aff2a72c8", "pmid": "", "title": "Metformin for endometrial hyperplasia", "imported": false, "abstract": "Abstract - Background Endometrial cancer is one of the most common gynaecological cancers in the world. Rates of endometrial cancer are rising, in part because of rising obesity rates. Endometrial hyperplasia is a precancerous condition in women that can lead to endometrial cancer if left untreated. Endometrial hyperplasia occurs more commonly than endometrial cancer. Progesterone tablets that are currently used to treat women with endometrial hyperplasia are associated with adverse effects in up to 84% of women. A levonorgestrel intrauterine device may improve compliance, but it is invasive, is not acceptable to all women, and is associated with irregular vaginal bleeding in 82% of cases. Therefore, an alternative treatment for women with endometrial hyperplasia is needed. Metformin, a drug that is often used to treat people with diabetes, has been shown, in some human studies, to reverse endometrial hyperplasia. However, the effectiveness and safety of metformin for treatment of endometrial hyperplasia remain uncertain. This is an update of a review first published in 2017. Objectives To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia. Search methods We searched the Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, PubMed, Embase, Google Scholar, OpenGrey, LILACS, and two trials registers from inception to 5 September 2022. We searched the bibliographies of all relevant studies, and contacted experts in the field for any additional trials. Selection criteria We included randomised controlled trials (RCTs) and cross‐over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo, no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type. Data collection and analysis Two review authors independently assessed studies for eligibility, extracted data from included studies, assessed the risk of bias in the included studies, and assessed the certainty of the evidence for each outcome. We resolved disagreements by discussion or by deferring to a third review author. When study details were missing, review authors contacted the study authors. The primary outcome of this review was regression of endometrial hyperplasia histology (with or without atypia) towards normal histology. Main results We included seven RCTs, in which a total of 387 women took part. In the comparison, Metformin plus megestrol versus megestrol alone, we rated the certainty of the evidence as low for the outcome, regression of endometrial hyperplasia. We rated the quality of the evidence as very low for the rest of the outcomes, in all three comparisons. Although there was a low risk of selection bias, there was a high risk of bias in the blinding of personnel and outcome assessment (performance bias and detection bias) in many studies. This update identified four new RCTs and six ongoing RCTs. Metformin versus megestrol We are uncertain whether metformin increases the regression of endometrial hyperplasia towards normal histology over megestrol (odds ratio (OR) 4.89, 95% confidence interval (CI) 1.56 to 15.32; P = 0.006; 2 RCTs, 83 participants; I² = 7%; very low‐certainty evidence). This evidence suggests that if the rate of regression with megestrol is 61%, the rate of regression with metformin would be between 71% and 96%. It is unresolved whether metformin results in different rates of abnormal uterine bleeding or hysterectomy compared to megestrol. No study in this comparison reported progression of hyperplasia to endometrial cancer, recurrence of endometrial hyperplasia, health‐related quality of life, or adverse effects during treatment. Metformin plus megestrol versus megestrol monotherapy The combination of metformin and megestrol may enhance the regression of endometrial hyperplasia towards normal histology more than megestrol alone (OR 3.27, 95% CI 1.65 to 6.51; P = 0.0007; 4 RCTs, 258 participants; I² = 0%, low‐certainty evidence). This suggests that if the rate of regression with megestrol monotherapy is 54%, the rate of regression with the addition of metformin would be between 66% and 84%. In one study, 3/8 (37.5%) of participants who took metformin had nausea that settled without further treatment. It is unresolved whether the combination of metformin and megestrol results in different rates of recurrence of endometrial hyperplasia, progression of endometrial hyperplasia to endometrial cancer, or hysterectomy compared to megestrol monotherapy. No study in this comparison reported abnormal uterine bleeding, or health‐related quality of life. Metformin plus levonorgestrel (intrauterine system) versus levonorgestrel (intrauterine system) monotherapy We are uncertain whether there is a difference between groups in the regression of endometrial hyperplasia towards normal histology (OR 0.29, 95% CI 0.01 to 7.56; 1 RCT, 46 participants; very low‐certainty evidence). This evidence suggests that if the rate of regression with levonorgestrel monotherapy is 96%, the rate of regression with the addition of metformin would be between 73% and 100%. It is unresolved whether the combination of metformin and levonorgestrel results in different rates of abnormal uterine bleeding, hysterectomy, or the development of adverse effects during treatment compared to levonorgestrel monotherapy. No study in this comparison reported recurrence of endometrial hyperplasia, progression of hyperplasia to endometrial cancer, or health‐related quality of life. Authors' conclusions Review authors found insufficient evidence to either support or refute the use of metformin, specifically megestrol acetate, given alone or in combination with standard therapy, for the treatment of women with endometrial hyperplasia. Robustly designed and adequately powered randomised controlled trials, yielding long‐term outcome data are still needed to address this clinical question. Plain language summary Metformin for endometrial hyperplasia Review question Is metformin an effective and safe treatment for women with endometrial hyperplasia? Background Endometrial cancer (cancer of the lining of the womb) is a common cancer that affects the reproductive organs in women worldwide. Endometrial hyperplasia (thickening of the lining of the womb) is a precancerous condition in women that can lead to endometrial cancer if left untreated. Successful treatment of women with endometrial hyperplasia can prevent endometrial cancer. Endometrial hyperplasia is usually treated by providing progesterone hormone tablets, inserting a levonorgestrel‐releasing intrauterine system (LNG‐IUS) into the womb, advising women with extra weight to lose weight, or performing a hysterectomy for women who do not want a future pregnancy. However, progesterone tablets are associated with side effects in up to 84% of women, and this can prevent women from completing treatment. Also, progesterone tablets do not always work, and endometrial hyperplasia can return in up to 14% to 30% of women after treatment. The LNG‐IUS is associated with irregular vaginal bleeding in up to 82% of women. Many women find it painful to use, or find it otherwise unacceptable. Therefore, an alternative treatment for endometrial hyperplasia is required. Metformin, an oral tablet that is usually used to treat diabetes, has been shown to cure endometrial hyperplasia in some human studies. Although women taking metformin may experience side effects, treatment is usually well tolerated. If women experience fewer side effects when taking metformin rather than progesterone tablets, and if metformin effectively treats endometrial hyperplasia, women would be more willing to complete treatment, and the cure rate would improve. This could reduce the number of women who end up with endometrial cancer. However, the effectiveness and safety of metformin used to treat women with endometrial hyperplasia remain uncertain. Study characteristics We included seven randomised controlled trials in which a total of 387 women took part. Five studies compared metformin to megestrol (a form of progesterone), and one study compared metformin plus megestrol to megestrol alone. Women in all studies received treatment for three to six months. The evidence is current to 5 September 2022. Key results Studies on metformin alone versus megestrol alone provided insufficient evidence to show differences in effectiveness for curing endometrial hyperplasia. Studies on metformin plus megestrol versus megestrol alone found that metformin may improve the thickened walls of the womb, but the evidence is uncertain about other outcomes. One small study provided insufficient evidence to support or refute the use of metformin plus the LNG‐IUS or the LNG‐IUS alone. Certainty of the evidence We rated the certainty of the evidence as low to very‐low for all outcomes, because of limitations in the way the studies were designed, and small sample sizes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Shiwani, H; Clement, NS; Daniels, JP; Atiomo, W", "articleTypes": [], "doi": "10.1002/14651858.CD012214.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "0315cb21-f6b6-44a4-83f3-4adbd1596e1b", "pmid": "", "title": "Dietary advice with or without oral nutritional supplements for disease‐related malnutrition in adults", "imported": false, "abstract": "Abstract - Background Disease‐related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social‐care costs. Dietary advice (DA) encouraging consumption of energy‐ and nutrient‐rich foods rather than oral nutritional supplements (ONS) may be an initial treatment. Objectives To examine evidence that DA with/without ONS in adults with disease‐related malnutrition improves survival, weight, anthropometry and quality of life (QoL). Search methods We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021. Selection criteria Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease‐related malnutrition in any healthcare setting compared with no advice, ONS or DA alone. Data collection and analysis Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence. Main results We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity. Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years. DA versus no advice ‐ 24 RCTs (3523 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three‐month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI ‐0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat‐free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS ‐ 12 RCTs (852 participants) All outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD ‐0.14 kg (95% CI ‐2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS ‐ 22 RCTs (1286 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD ‐1.07 (95% CI ‐4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS ‐ 31 RCTs (3308 participants) Evidence was moderate‐ to low‐certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD ‐0.12 (95% CI ‐2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS ‐ 13 RCTs (1315 participants) Evidence was low‐ to very low‐certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD ‐1.81 (95% CI ‐3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI ‐0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point. Authors' conclusions We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow‐up required for benefits to emerge were inconsistent for all other outcomes. There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient‐centred and healthcare outcomes are needed to address the questions in this review. Plain language summary Advice on diet for adults with malnutrition that is the result of disease Review question Can dietary advice with or without oral nutritional supplements (ONS) improve disease‐related malnutrition in adults? Background Ill people often have a poor appetite or feel sick because of medicines or other treatments and eat less than usual. Eating less over a longer time can cause weight loss, malnutrition, more health problems and death. Healthcare professionals may offer advice about dietary changes to help people to re‐establish good eating habits. They might recommend high‐protein and high‐energy foods so that these people can gain weight and improve their nutrition and general health. It is common for sick people to be offered ONS with or without advice about changing their food intake. To find the best answer to our review question, we looked for studies that compared five different treatment options: dietary advice compared with no advice; dietary advice compared with ONS; dietary advice plus ONS compared with dietary advice; dietary advice plus ONS if appropriate compared with no dietary advice; and dietary advice plus ONS compared with no dietary advice and no ONS. To make these comparisons fair, we looked for randomised controlled trials (RCTs), where the people taking part had an equal chance (like the flip of a coin) of being in either group that was being compared. Search date The evidence is current to: 01 March 2021. Study characteristics We found 94 studies (with a total of 10,284 people) that we could include in our review. Although older people have a higher risk of malnutrition, the people in these studies ranged from 17 to over 80 years of age and they were living either at home, in the community, or in hospital. They had a wide range of health conditions, including cancer, dementia and kidney disease. The studies reported on the participants for the length of their hospital stay or in some people in the community for up to six and a half years. Key results There is no evidence that any of the treatments affected how long many of the people in the studies lived. They did report some positive changes in energy intake (measured in calories), protein intake, weight, muscle bulk and quality of life. There were some reductions in complications and the length of time spent in hospital. However, there is no clear evidence about which treatment is the most helpful or the time it takes to achieve any benefit. Few studies reported results separately for men and women and so we cannot comment on whether there were any overall differences by sex. No studies recorded information about adverse events (harms) so we cannot offer a summary about possible harms. More research is needed to work out the best ways to help people who are losing weight because of illness in order to improve their clinical outcomes and quality of life. Certainty of the evidence Overall we rated the certainty of the evidence as low for most results, which means that we cannot be confident about the findings we report. There were several reasons for this. Some of the treatment comparisons that we looked at had only a few studies and some of those had small numbers of participants. There were problems with the design of some studies that may have affected the results. Some people knew which treatment they were receiving. We think this may influence the way that they reported some changes, e.g. their energy and protein intake, body weight and quality of life. We think that the way the decision about which group a person went into at the start of the study may have affected the results for some outcomes, e.g. change in weight, change in muscle bulk and mortality. We needed to see particular results to help us understand whether adults living with disease‐related malnutrition can improve their survival, weight and general quality of life if they receive advice about diet with or without ONS. None of the studies reported all of the results that we needed to do this. We were not able to estimate whether participants gain any benefits from the treatments, such as shortening the length of hospital stay, lowering the risk of readmission to hospital or developing complications. The low certainty of evidence, with no evidence in many areas, means we cannot make statements about any benefits and the possible disadvantages of these treatments despite the fact they are being used extensively in clinical practice. We recommend that future studies should be designed to measure these important patient‐centred and healthcare outcomes as well as any potential harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Baldwin, C; de van der Schueren, MAE; Kruizenga, HM; Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD002008.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "0323090f-0172-4fc0-9d8c-20fdb0aa86e3", "pmid": "", "title": "Optimum duration of regimens for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background The optimal duration for Helicobacter pylori (H. pylori) eradication therapy is controversial, with recommendations ranging from 7 to 14 days. Several systematic reviews have attempted to address this issue but have given conflicting results and limited their analysis to proton pump inhibitor (PPI), two antibiotics (PPI triple) therapy. We performed a systematic review and meta‐analysis to investigate the optimal duration of multiple H. pylori eradication regimens. Objectives The primary objective was to assess the relative effectiveness of different durations (7, 10 or 14 days) of a variety of regimens for eradicating H. pylori . The primary outcome was H. pylori persistence. The secondary outcome was adverse events. Search methods The Cochrane Library , MEDLINE, EMBASE, and CINAHL were searched up to December 2011 to identify eligible randomised controlled trials (RCTs). We also searched the proceedings of six conferences from 1995 to 2011, dissertations and theses, and grey literature. There were no language restrictions applied to any search. Selection criteria Only parallel group RCTs assessing the efficacy of one to two weeks duration of first line H. pylori eradication regimens in adults were eligible. Within each regimen, the same combinations of drugs at the same dose were compared over different durations. Studies with at least two arms comparing 7, 10, or 14 days were eligible. Enrolled participants needed to be diagnosed with at least one positive test for H. pylori on the basis of a rapid urease test (RUT), histology, culture, urea breath test (UBT), or a stool antigen test (HpSA) before treatment. Eligible trials needed to confirm eradication of H. pylori as their primary outcome at least 28 days after completion of eradication treatment. Trials using only serology or a polymerase chain reaction (PCR) to determine H. pylori infection or eradication were excluded. Data collection and analysis Study eligibility and data extraction were performed by two independent review authors. Data analyses were performed within each type of intervention, for both primary and secondary outcomes. The relative risk (RR) and number needed to treat (NNT)/number needed to harm (NNTH) according to duration of therapy were calculated using the outcomes of H. pylori persistence and adverse events. A random‐effects model was used. Subgroup analyses and sensitivity analyses were planned a priori. Main results In total, 75 studies met the inclusion criteria. Eight types of regimens were reported with at least two comparative eligible durations. They included: PPI + two antibiotics triple therapy (n = 59), PPI bismuth‐based quadruple therapy (n = 6), PPI + three antibiotics quadruple therapy (n = 1), PPI dual therapy (n = 2), histamine H 2 ‐receptor antagonist (H 2 RA) bismuth quadruple therapy (n = 3), H 2 RA bismuth‐based triple therapy (n = 2), H 2 RA + two antibiotics triple therapy (n = 3), and bismuth + two antibiotics triple therapy (n = 2). Some studies provided data for more than one regimen or more than two durations. For the PPI triple therapy, 59 studies with five regimens were reported: PPI + clarithromycin + amoxicillin (PCA); PPI + clarithromycin + a nitroimidazole (PCN); PPI + amoxicillin + nitroimidazole (PAN); PPI + amoxicillin + a quinolone (PAQ); and PPI + amoxicillin + a nitrofuran (PANi). Regardless of type and dose of antibiotics, increased duration of PPI triple therapy from 7 to 14 days significantly increased the H. pylor i eradication rate (45 studies, 72.9% versus 81.9%), the RR for H. pylori persistence was 0.66 (95% CI 0.60 to 0.74), NNT was 11 (95% CI 9 to 14). Significant effects were seen in the subgroup of PCA (34 studies, RR 0.65, 95% CI 0.57 to 0.75; NNT 12, 95% CI 9 to 16); PAN (10 studies, RR 0.67, 95% CI 0.52 to 0.86; NNT = 11, 95% CI 8 to 25); and in PAQ (2 studies, RR 0.37, 95% CI 0.16 to 0.83; NNT 3, 95% CI 2 to 10); but not in PCN triple therapy (4 studies, RR 0.87, 95% CI 0.71 to 1.07). Significantly increased eradication rates were also seen for PPI triple therapy with 10 versus 7 days (24 studies, 79.9% versus 75.7%; RR 0.80, 95% CI 0.72 to 0.89; NNT 21, 95% CI 15 to 38) and 14 versus 10 days (12 studies, 84.4% versus 78.5%; RR 0.72, 95% CI 0.58 to 0.90; NNT 17, 95% CI 11 to 46); especially in the subgroup of PAC for 10 versus 7 days (17 studies, RR 0.80, 95% CI 0.70 to 0.91) and for 14 versus 10 days (10 studies, RR 0.69, 95% CI 0.52 to 0.91). A trend towards increased H. pylori eradication rates was seen with increased duration of PCN for 10 versus 7 days, and of PAN for 10 versus 7 days and 14 versus 10 days, though this was not statistical significant. The proportion of patients with adverse events, defined by authors, was marginally significantly increased only between 7 days and 14 days (15.5% versus 19.4%; RR 1.21, 95% CI 1.06 to 1.37; NNTH 31, 95% CI 18 to 104) but not for other duration comparisons. The proportion of patients discontinuing treatment due to adverse events was not significantly different between treatment durations. Only limited data were reported for different durations of regimens other than PPI triple therapy. No significant difference of the eradication rate was seen for all regimens according to different durations except for H 2 RA bismuth quadruple therapy, where a significantly higher eradication rate was seen for 14 days versus 7 days, however only one study reported outcome data. Authors' conclusions Increasing the duration of PPI‐based triple therapy increases H. pylori eradication rates. For PCA, prolonging treatment duration from 7 to 10 or from 10 to 14 days is associated with a significantly higher eradication rate. The optimal duration of therapy for PCA and PAN is at least 14 days. More data are needed to confirm if there is any benefit of increasing the duration of therapy for PCN therapy. Information is limited for regimens other than PPI triple therapy; more studies are needed to draw meaningful conclusions for optimal duration of other H. pylori eradication regimens. Plain language summary Ideal length of treatment for Helicobacter pylori ( H. pylori ) eradication The ideal duration of therapy for H. pylori eradication is controversial, with recommendations ranging from 7 to 14 days. A proton pump inhibitor (PPI) plus two antibiotics is the most commonly used first treatment to remove H. pylori infection. Current data suggest that increasing the length of treatment to 14 days of a PPI plus amoxicillin and clarithromycin or amoxicillin and a nitroimidazole significantly increases the eradication rate, while increasing the adverse events by a small amount. Based on the overall evidence, the ideal length of treatment with a PPI plus amoxicillin and clarithromycin is at least 14 days.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Yuan, Y; Ford, AC; Khan, KJ; Gisbert, JP; Forman, D; Leontiadis, GI; Tse, F; Calvet, X; Fallone, C; Fischbach, L; Oderda, G; Bazzoli, F; Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD008337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "032ada3d-e18f-4541-9b36-92fd5df52405", "pmid": "", "title": "A Phase 1/2 Study of REGN7075 (EGFRxCD28 Costimulatory Bispecific Antibody) in Combination With Cemiplimab in Patients With Advanced Solid Tumors", "imported": false, "abstract": "This study is researching an investigational drug called marlotamig (REGN7075) by itself and in combination with cemiplimab with or without chemotherapy. The study is focused on patients with certain solid tumors that are in an advanced stage.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.159Z" }, { "id": "032cbc08-f626-44eb-9bf5-838b7ec3bade", "pmid": "", "title": "Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco", "imported": false, "abstract": "Abstract - Background Overeating and harmful alcohol and tobacco use have been linked to the aetiology of various non‐communicable diseases, which are among the leading global causes of morbidity and premature mortality. As people are repeatedly exposed to varying sizes and shapes of food, alcohol and tobacco products in environments such as shops, restaurants, bars and homes, this has stimulated public health policy interest in product size and shape as potential targets for intervention. Objectives 1) To assess the effects of interventions involving exposure to different sizes or sets of physical dimensions of a portion, package, individual unit or item of tableware on unregulated selection or consumption of food, alcohol or tobacco products in adults and children. 2) To assess the extent to which these effects may be modified by study, intervention and participant characteristics. Search methods We searched CENTRAL, MEDLINE, EMBASE, PsycINFO, eight other published or grey literature databases, trial registries and key websites up to November 2012, followed by citation searches and contacts with study authors. This original search identified eligible studies published up to July 2013, which are fully incorporated into the review. We conducted an updated search up to 30 January 2015 but further eligible studies are not yet fully incorporated due to their minimal potential to change the conclusions. Selection criteria Randomised controlled trials with between‐subjects (parallel‐group) or within‐subjects (cross‐over) designs, conducted in laboratory or field settings, in adults or children. Eligible studies compared at least two groups of participants, each exposed to a different size or shape of a portion of a food (including non‐alcoholic beverages), alcohol or tobacco product, its package or individual unit size, or of an item of tableware used to consume it, and included a measure of unregulated selection or consumption of food, alcohol or tobacco. Data collection and analysis We applied standard Cochrane methods to select eligible studies for inclusion and to collect data and assess risk of bias. We calculated study‐level effect sizes as standardised mean differences (SMDs) between comparison groups, measured as quantities selected or consumed. We combined these results using random‐effects meta‐analysis models to estimate summary effect sizes (SMDs with 95% confidence intervals (CIs)) for each outcome for size and shape comparisons. We rated the overall quality of evidence using the GRADE system. Finally, we used meta‐regression analysis to investigate statistical associations between summary effect sizes and variant study, intervention or participant characteristics. Main results The current version of this review includes 72 studies, published between 1978 and July 2013, assessed as being at overall unclear or high risk of bias with respect to selection and consumption outcomes. Ninety‐six per cent of included studies (69/72) manipulated food products and 4% (3/72) manipulated cigarettes. No included studies manipulated alcohol products. Forty‐nine per cent (35/72) manipulated portion size, 14% (10/72) package size and 21% (15/72) tableware size or shape. More studies investigated effects among adults (76% (55/72)) than children and all studies were conducted in high‐income countries ‐ predominantly in the USA (81% (58/72)). Sources of funding were reported for the majority of studies, with no evidence of funding by agencies with possible commercial interests in their results. A meta‐analysis of 86 independent comparisons from 58 studies (6603 participants) found a small to moderate effect of portion, package, individual unit or tableware size on consumption of food (SMD 0.38, 95% CI 0.29 to 0.46), providing moderate quality evidence that exposure to larger sizes increased quantities of food consumed among children (SMD 0.21, 95% CI 0.10 to 0.31) and adults (SMD 0.46, 95% CI 0.40 to 0.52). The size of this effect suggests that, if sustained reductions in exposure to larger‐sized food portions, packages and tableware could be achieved across the whole diet, this could reduce average daily energy consumed from food by between 144 and 228 kcal (8.5% to 13.5% from a baseline of 1689 kcal) among UK children and adults. A meta‐analysis of six independent comparisons from three studies (108 participants) found low quality evidence for no difference in the effect of cigarette length on consumption (SMD 0.25, 95% CI ‐0.14 to 0.65). One included study (50 participants) estimated a large effect on consumption of exposure to differently shaped tableware (SMD 1.17, 95% CI 0.57 to 1.78), rated as very low quality evidence that exposure to shorter, wider bottles (versus taller, narrower bottles) increased quantities of water consumed by young adult participants. A meta‐analysis of 13 independent comparisons from 10 studies (1164 participants) found a small to moderate effect of portion or tableware size on selection of food (SMD 0.42, 95% CI 0.24 to 0.59), rated as moderate quality evidence that exposure to larger sizes increased the quantities of food people selected for subsequent consumption. This effect was present among adults (SMD 0.55, 95% CI 0.35 to 0.75) but not children (SMD 0.14, 95% CI ‐0.06 to 0.34). In addition, a meta‐analysis of three independent comparisons from three studies (232 participants) found a very large effect of exposure to differently shaped tableware on selection of non‐alcoholic beverages (SMD 1.47, 95% CI 0.52 to 2.43), rated as low quality evidence that exposure to shorter, wider (versus taller, narrower) glasses or bottles increased the quantities selected for subsequent consumption among adults (SMD 2.31, 95% CI 1.79 to 2.83) and children (SMD 1.03, 95% CI 0.41 to 1.65). Authors' conclusions This review found that people consistently consume more food and drink when offered larger‐sized portions, packages or tableware than when offered smaller‐sized versions. This suggests that policies and practices that successfully reduce the size, availability and appeal of larger‐sized portions, packages, individual units and tableware can contribute to meaningful reductions in the quantities of food (including non‐alcoholic beverages) people select and consume in the immediate and short term. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. We are unable to highlight clear implications for tobacco or alcohol policy due to identified gaps in the current evidence base. Plain language summary Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco Review question We reviewed the evidence to establish by how much the amounts of food, alcohol or tobacco adults and children select or consume change in response to being presented with larger or smaller‐sized (or differently shaped) portions or packages of these products, or of items of tableware (such as plates or glasses) used to consume them. Study characteristics This review includes 72 randomised controlled trials (RCTs) published up to July 2013 that compared at least two groups of participants, each presented with a different size of a portion, package or item of tableware. Included studies measured the amounts of food, alcohol or tobacco selected and/or consumed by participants, typically over a period of one day or less. Almost all of the included studies investigated food, with only three tobacco studies and no alcohol studies found. Almost all assessed participants' responses to different sizes rather than different shapes. The average age of participants in the different studies ranged from three to 55 years, with more studies involving adults than children and most conducted in the USA. Sources of funding were reported for the majority of studies and there was no evidence of study funding by agencies with commercial interests in their results. Key findings and quality of evidence Effects of size on consumption: We found evidence that people consistently ate more food or drank more non‐alcoholic drinks when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. We estimate the size of this effect to be small to moderate among both children and adults. If an effect of this size were sustained across the whole diet it would be equivalent to around a 12% to 16% change in average daily energy intake from food among UK adults. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations arising from incomplete or unclear reporting of methods and procedures. From three tobacco studies, we found no effect of longer compared with shorter cigarettes on the amounts of tobacco consumed. We rated the overall quality of evidence for this effect as low due to concerns about study limitations and not having enough evidence. Effects of shape on consumption: One study found that adults provided with shorter, wider bottles drank larger amounts of water from them, having already poured more, compared with those provided with taller, narrower bottles. However, we rated the quality of this evidence as very low, due to very serious concerns about study limitations and not having enough evidence (only one study with outcome data from 50 participants). Effects of size on selection: We further found that adults, but not children, consistently chose (selected) more food (including non‐alcoholic drinks) when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. The estimated size of this effect was again small to moderate. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations. Effects of shape on selection: Evidence from three studies suggested that adults and children provided with shorter, wider bottles or glasses selected increased quantities of non‐alcoholic beverages for subsequent consumption, compared with those provided with taller, narrower bottles or glasses. We rated the quality of this evidence as low, again due to concerns about study limitations and unexplained variation in effects between the three studies. Conclusions Overall, this review provides the most conclusive evidence to date that acting to reduce the size, availability and appeal of larger‐sized portions, packages and tableware has potential to reduce the quantities of food that people select and consume by meaningful amounts. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. Our findings highlight the need for further research that aims to reduce uncertainties about these effects and address identified gaps in the evidence base, including not having enough evidence for longer‐term effects and the absence of evidence about alcohol products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hollands, GJ, Shemilt, I, Marteau, TM, Jebb, SA, Lewis, HB, Wei, Y, Higgins, JPT, Ogilvie, D", "articleTypes": [], "doi": "10.1002/14651858.CD011045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.815Z" }, { "id": "035dad8c-1b6e-41ee-a8fa-fc596bd6ba9c", "pmid": "", "title": "Laboratory‐based molecular test alternatives to RT‐PCR for the diagnosis of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Diagnosing people with a SARS‐CoV‐2 infection played a critical role in managing the COVID‐19 pandemic and remains a priority for the transition to long‐term management of COVID‐19. Initial shortages of extraction and reverse transcription polymerase chain reaction (RT‐PCR) reagents impaired the desired upscaling of testing in many countries, which led to the search for alternatives to RNA extraction/purification and RT‐PCR testing. Reference standard methods for diagnosing the presence of SARS‐CoV‐2 infection rely primarily on real‐time reverse transcription‐polymerase chain reaction (RT‐PCR). Alternatives to RT‐PCR could, if sufficiently accurate, have a positive impact by expanding the range of diagnostic tools available for the timely identification of people infected by SARS‐CoV‐2, access to testing and the use of resources. Objectives To assess the diagnostic accuracy of alternative (to RT‐PCR assays) laboratory‐based molecular tests for diagnosing SARS‐CoV‐2 infection. Search methods We searched the COVID‐19 Open Access Project living evidence database from the University of Bern until 30 September 2020 and the WHO COVID‐19 Research Database until 31 October 2022. We did not apply language restrictions. Selection criteria We included studies of people with suspected or known SARS‐CoV‐2 infection, or where tests were used to screen for infection, and studies evaluating commercially developed laboratory‐based molecular tests for the diagnosis of SARS‐CoV‐2 infection considered as alternatives to RT‐PCR testing. We also included all reference standards to define the presence or absence of SARS‐CoV‐2, including RT‐PCR tests and established clinical diagnostic criteria. Data collection and analysis Two authors independently screened studies and resolved disagreements by discussing them with a third author. Two authors independently extracted data and assessed the risk of bias and applicability of the studies using the QUADAS‐2 tool. We presented sensitivity and specificity, with 95% confidence intervals (CIs), for each test using paired forest plots and summarised results using average sensitivity and specificity using a bivariate random‐effects meta‐analysis. We illustrated the findings per index test category and assay brand compared to the WHO's acceptable sensitivity and specificity threshold for diagnosing SARS‐CoV‐2 infection using nucleic acid tests. Main results We included data from 64 studies reporting 94 cohorts of participants and 105 index test evaluations, with 74,753 samples and 7517 confirmed SARS‐CoV‐2 cases. We did not identify any published or preprint reports of accuracy for a considerable number of commercially produced NAAT assays. Most cohorts were judged at unclear or high risk of bias in more than three QUADAS‐2 domains. Around half of the cohorts were considered at high risk of selection bias because of recruitment based on COVID status. Three quarters of 94 cohorts were at high risk of bias in the reference standard domain because of reliance on a single RT‐PCR result to determine the absence of SARS‐CoV‐2 infection or were at unclear risk of bias due to a lack of clarity about the time interval between the index test assessment and the reference standard, the number of missing results, or the absence of a participant flow diagram. For index tests categories with four or more evaluations and when summary estimations were possible, we found that: a) For RT‐PCR assays designed to omit/adapt RNA extraction/purification, the average sensitivity was 95.1% (95% CI 91.1% to 97.3%), and the average specificity was 99.7% (95% CI 98.5% to 99.9%; based on 27 evaluations, 2834 samples and 1178 SARS‐CoV‐2 cases); b) For RT‐LAMP assays, the average sensitivity was 88.4% (95% CI 83.1% to 92.2%), and the average specificity was 99.7% (95% CI 98.7% to 99.9%; 24 evaluations, 29,496 samples and 2255 SARS‐CoV‐2 cases); c) for TMA assays, the average sensitivity was 97.6% (95% CI 95.2% to 98.8%), and the average specificity was 99.4% (95% CI 94.9% to 99.9%; 14 evaluations, 2196 samples and 942 SARS‐CoV‐2 cases); d) for digital PCR assays, the average sensitivity was 98.5% (95% CI 95.2% to 99.5%), and the average specificity was 91.4% (95% CI 60.4% to 98.7%; five evaluations, 703 samples and 354 SARS‐CoV‐2 cases); e) for RT‐LAMP assays omitting/adapting RNA extraction, the average sensitivity was 73.1% (95% CI 58.4% to 84%), and the average specificity was 100% (95% CI 98% to 100%; 24 evaluations, 14,342 samples and 1502 SARS‐CoV‐2 cases). Only two index test categories fulfil the WHO‐acceptable sensitivity and specificity requirements for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. In addition, WHO‐acceptable performance criteria were met for two assays out of 35 when tests were used according to manufacturer instructions. At 5% prevalence using a cohort of 1000 people suspected of SARS‐CoV‐2 infection, the positive predictive value of RT‐PCR assays omitting/adapting RNA extraction/purification will be 94%, with three in 51 positive results being false positives, and around two missed cases. For TMA assays, the positive predictive value of RT‐PCR assays will be 89%, with 6 in 55 positive results being false positives, and around one missed case. Authors' conclusions Alternative laboratory‐based molecular tests aim to enhance testing capacity in different ways, such as reducing the time, steps and resources needed to obtain valid results. Several index test technologies with these potential advantages have not been evaluated or have been assessed by only a few studies of limited methodological quality, so the performance of these kits was undetermined. Only two index test categories with enough evaluations for meta‐analysis fulfil the WHO set of acceptable accuracy standards for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. These assays might prove to be suitable alternatives to RT‐PCR for identifying people infected by SARS‐CoV‐2, especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence, including reliance on retrospective samples without information about the symptom status of participants and the timing of assessment. No extrapolation of found accuracy data for these two alternatives to any test brands using the same techniques can be made as, for both groups, one test brand with high accuracy was overrepresented with 21/26 and 12/14 included studies, respectively. Although we used a comprehensive search and had broad eligibility criteria to include a wide range of tests that could be alternatives to RT‐PCR methods, further research is needed to assess the performance of alternative COVID‐19 tests and their role in pandemic management. Plain language summary How accurate are alternative laboratory‐based molecular tests (to RT‐PCR with prior RNA extraction/purification) for identifying people infected by SARS‐CoV‐2? Key messages: * Transcription‐mediated amplification (TMA) tests and commercially available reverse transcription polymerase chain reaction (RT‐PCR) tests specifically designed to omit/adapt RNA extraction/purification appear accurate enough to replace the method of RT‐PCR with prior RNA (a molecule essential for most biological functions) extraction/purification for identifying people infected by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence. * The accuracy of other types of laboratory‐based molecular alternatives to RT‐PCR is below World Health Organisation (WHO) recommended standards or lacks a sufficient volume of evidence to draw reliable conclusions. *The extrapolation of accuracy data from the evaluated tests to any other test brand(s) using the same techniques will be challenging since main categories are overrepresented by highly accurate individual test brands. Further evaluation of these tests in real clinical practice scenarios is needed. What are alternative laboratory‐based molecular assays for identifying people infected by SARS‐CoV‐2? Laboratory‐based molecular assays (tests) aim to confirm or rule out SARS‐CoV‐2 infection in people. Alternatives to RT‐PCR assays have been developed to minimise the steps needed to process samples in the laboratory or use fewer resources to obtain the same valid results. For this review, we focus on tests commercially developed by a manufacturer, providing instructions for their professional use. Why is this question important? People with suspected SARS‐CoV‐2 infection should know if they are infected to self‐isolate, receive treatment, and inform close contacts. Failure to detect SARS‐CoV‐2 when it is present risks spreading infection and results in missed opportunities for prevention. Diagnosing SARS‐CoV‐2 infection when it is not present may lead to unnecessary self‐isolation and testing of close contacts. Currently, testing to confirm SARS‐CoV‐2 infection relies on a laboratory molecular test called RT‐PCR. This requires specialist equipment and can take 24 hours to produce a result. If assays that take less time or use readily available resources were sufficiently accurate to replace RT‐PCR testing, this could increase the number of tests that could be done, allow faster diagnosis and enable people to take appropriate action more quickly. What did we want to find out? We wanted to know whether commercially developed, alternative laboratory‐based molecular tests are accurate enough to diagnose SARS‐CoV‐2 infection compared to RT‐PCR. What did we do? We looked for studies investigating these tests in people (or samples) that were also tested for SARS‐CoV‐2 infection using RT‐PCR which modified RT‐PCR by removing or altering components of this testing process. What did we find? We included 105 evaluations evaluating alternatives to RT‐PCR in the review. The main results are based on 74,753 samples, and SARS‐CoV‐2 infection was confirmed in 7517 of these samples. Most evaluations (27/105) concerned various test types specifically designed to omit/adapt RNA extraction/purification. Twenty‐four of 105 evaluations concerned various test types operating at one temperature (isothermal tests) rather than cycling through different temperatures. Twenty‐four of 105 evaluations were concerned with various test types that combined these two alternative approaches. Main results Only tests specifically designed to omit/adapt RNA extraction/purification and TMA assays with RNA extraction (a type of isothermal test) met WHO‐acceptable standards for confirming and ruling out SARS‐CoV‐2. For illustration, the results of these studies indicate that in a group of 1000 people, 50 of whom (5%) actually have SARS‐CoV‐2: * For tests specifically designed to omit/adapt RNA extraction/purification: ‐51 people would test positive for SARS‐CoV‐2. Of these, three people (6%) would not have SARS‐CoV‐2 (false‐positive result). ‐949 people would test negative for SARS‐CoV‐2. Of these, two people (0.2%) would actually have SARS‐CoV‐2 (false‐negative result) *For TMA tests with RNA extraction: ‐55 people would test positive for SARS‐CoV‐2. Of these, six people (10%) would not have SARS‐CoV‐2 (false‐positive result). ‐945 people would test negative for SARS‐CoV‐2. Of these, one person (0.1%) would actually have SARS‐CoV‐2 (false‐negative result) What are the limitations of the evidence? Most included studies did not provide information on participants who underwent testing, such as whether they had symptoms or were close contacts of a SARS‐CoV‐2 case. We also had concerns about the method of recruiting participants for the majority of included studies, which may have resulted in an overestimation of the accuracy of these methods. In addition, the method used to determine whether individuals did not have SARS‐CoV‐2 infection was not considered reliable for most studies, which may have resulted in underestimating the accuracy of these methods. Some studies did not follow the manufacturers' instructions for using the test. Results from different test brands using the same technique varied. What does this mean? The studies included in this review suggest that two laboratory‐based molecular tests might be accurate enough to replace or supplement RT‐PCR tests with prior RNA extraction/purification for the diagnosis of SARS‐CoV‐2 infection: RT‐PCR tests developed to omit or adapt RNA extraction or purification and TMA isothermal tests (retaining an RNA extraction step). Other alternative tests to RT‐PCR were assessed just by a few studies of limited methodological quality, and their performance should be evaluated by additional studies. Furthermore, data in these studies mostly relied on samples acquired in the past (compared to current or future samples), thus further evaluation of these tests in real clinical practice scenarios is required. Also, decisions on the optimal test for a specific setting will be driven not only by diagnostic accuracy, but also by other factors such as test complexity, time to result, acceptability to those being tested, and the setting in which the tests are to be used. How up‐to‐date is this review? This review includes evidence published up to 31 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Arevalo-Rodriguez, I, Mateos-Haro, M, Dinnes, J, Ciapponi, A, Davenport, C, Buitrago-Garcia, D, Bennouna-Dalero, T, Roqué-Figuls, M, Van den Bruel, A, von Eije, KJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015618", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.135Z" }, { "id": "03640667-c74f-4016-a9d9-518ca705ed91", "pmid": "", "title": "A Phase II, Single Arm, Open Label, Study on the Safety, Efficacy, Pharmacokinetics & Pharmacodynamics of Quizartinib + Chemotherapy and as Single-agent After High Dose Therapy in Newly Diagnosed Pediatric FLT3-ITD+ and NPM1wt AML Patients", "imported": false, "abstract": "The CHIP-AML22 Master protocol has the overall aim of increasing the cure rate in newly diagnosed pediatric de novo AML patients, while avoiding unnecessary toxicity. The linked Quizartinib trial (CHIP-AML22/Quizartinib) is a phase II, single arm, open label, study on the safety, efficacy, pharmacokinetics and pharmacodynamics of quizartinib in combination with chemotherapy and as single-agent after high dose therapy in newly diagnosed pediatric AML patients with a FLT3-ITD mutation and NPM1 wild-type.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.251Z" }, { "id": "03797fff-83dd-43b4-8d89-3228c06dac57", "pmid": "", "title": "Preoperative statin therapy for adults undergoing cardiac surgery", "imported": false, "abstract": "Abstract - Background Despite significant advances in surgical techniques and perioperative care, people undertaking cardiac surgery due to cardiovascular disease are more prone to the development of postoperative adverse events. Statins (5‐hydroxy‐3‐methylglutaryl‐co‐enzyme A (HMG‐CoA) reductase inhibitors) are well‐known for their anti‐inflammatory and antioxidant effects and are established for primary and secondary prevention of coronary artery disease. In addition, statins are thought to have clinical benefits in perioperative outcomes in people undergoing cardiac surgery. This review is an update of a review that was first published in 2012 and updated in 2015. Objectives To evaluate the benefits and harms of preoperative statin therapy in adults undergoing cardiac surgery compared to standard of care or placebo. Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2023), Ovid MEDLINE (1980 to 14 September 2023), and Ovid Embase (1980 to 2023 (week 36)). We applied no language restrictions. Selection criteria We included all randomised controlled trials (RCTs) comparing any statin treatment before cardiac surgery, for any given duration and dose, versus no preoperative statin therapy (standard of care) or placebo. We excluded trials without a registered trial protocol and trials without approval by an institutional ethics committee. Data collection and analysis We used standard Cochrane methodology. Primary outcomes were short‐term mortality and major adverse cardiovascular events. Secondary outcomes were myocardial infarction, atrial fibrillation, stroke, renal failure, length of intensive care unit (ICU) stay, length of hospital stay and adverse effects related to statin therapy. We reported effect measures as risk ratios (RRs) or mean differences (MDs) with corresponding 95% confidence intervals (CIs). We used the RoB 1 tool to assess the risk of bias in included trials, and GRADE to assess the certainty of the evidence. Main results We identified eight RCTs (five new to this review) including 5592 participants. Pooled analysis showed that statin treatment before surgery may result in little to no difference in the risk of postoperative short‐term mortality (RR 1.36, 95% CI 0.72 to 2.59; I 2 = 0%; 6 RCTs, 5260 participants; low‐certainty evidence; note 2 RCTs reported 0 events in both groups so RR calculated from 4 RCTs with 5143 participants). We are very uncertain about the effect of statins on major adverse cardiovascular events (RR 0.93, 95% CI 0.77 to 1.13; 1 RCT, 2406 participants; very low‐certainty evidence). Statins probably result in little to no difference in myocardial infarction (RR 0.88, 95% CI 0.73 to 1.06; I 2 = 0%; 5 RCTs, 4645 participants; moderate‐certainty evidence), may result in little to no difference in atrial fibrillation (RR 0.87, 95% CI 0.72 to 1.05; I 2 = 60%; 8 RCTs, 5592 participants; low‐certainty evidence), and may result in little to no difference in stroke (RR 1.47, 95% CI 0.90 to 2.40; I 2 = 0%; 4 RCTs, 5143 participants; low‐certainty evidence). We are very uncertain about the effect of statins on renal failure (RR 1.04, 95% CI 0.80 to 1.34; I 2 = 57%; 4 RCTs, 4728 participants; very low‐certainty evidence). Additionally, statins probably result in little to no difference in length of ICU stay (MD 1.40 hours, 95% CI −1.62 to 4.41; I 2 = 43%; 3 RCTs, 4528 participants; moderate‐certainty evidence) and overall hospital stay (MD −0.31 days, 95% CI −0.64 to 0.03; I 2 = 84%; 5 RCTs, 4788 participants; moderate‐certainty evidence). No study had any individual risk of bias domain classified as high. However, two studies were at high risk of bias overall given the classification of unclear risk of bias in three domains. Authors' conclusions In this updated Cochrane review, we found no evidence that statin use in the perioperative period of elective cardiac surgery was associated with any clinical benefit or worsening, when compared with placebo or standard of care. Compared with placebo or standard of care, statin use probably results in little to no difference in MIs, length of ICU stay and overall hospital stay; and may make little to no difference to mortality, atrial fibrillation and stroke. We are very uncertain about the effects of statins on major harmful cardiac events and renal failure. The certainty of the evidence validating this finding varied from moderate to very low, depending on the outcome. Future trials should focus on assessing the impact of statin therapy on mortality and major adverse cardiovascular events. Plain language summary Is it better to take statins before undergoing heart‐related surgery? Key messages – Taking statins may make little to no difference to death within 30 days of surgery, irregular heart rhythms and stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off); and probably results in little to no difference in heart attacks, length of intensive care unit stay and overall hospital stay. We are very uncertain about the effects of statins on kidney failure and harmful effects from statin treatment. – Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. What are the dangers of cardiac surgery and how may statins help? Cardiac surgeries can effectively treat people with heart and circulation problems. However, undergoing cardiac surgery also increases the risk of death, heart attack, stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off), irregular heart rhythms and kidney failure. This is partly because more than half of people undergoing cardiac surgery are over 70 years of age. To reduce these risks, we should try to improve recovery rates by preventing these problems from occurring before, during and after surgery. Statins are medications used throughout the world to lower blood cholesterol (a fatty substance found in the blood that may block blood vessels) levels and reduce the chances of cardiovascular issues becoming worse. Studies have shown that fewer people who had built up dangerous amounts of cholesterol in their blood vessels (arteries) died while taking statins. However, the potential benefits of taking statins in people undergoing cardiac surgery are unclear. What did we want to find out? We wanted to find out whether taking statins before undergoing cardiac surgery could help reduce the risk of: – death occurring shortly after surgery; or
– developing other heart or kidney problems. We also wanted to find out if there were any changes in the quality of care associated with cardiac surgeries for people who had been taking statins, such as reducing the length of hospital stay or intensive care unit stay, or if there were any harmful effects from statin treatment. What did we do? We searched for studies published up to September 2023 that compared treatment with statins to treatment with a placebo (a pretend medicine that looks or tastes identical to the medicine being tested) or usual care in people undergoing cardiac surgeries. Contrary to previous versions of this review, we only included trials that we were sure were approved by an ethical review board. What did we find? We found eight studies involving 5592 people with an average age of 63 years and 79% were men. Of these, 2798 people were treated with statins and 2794 people were not treated with statins before cardiac surgery. The smallest study included 57 people and the largest involved 2406 people. All studies were conducted in hospitals affiliated with universities in Asia, Europe and North America. Each study used different statin types (atorvastatin, fluvastatin, simvastatin, pravastatin or rosuvastatin) and doses (between 20 mg and 80 mg). Main results In people undergoing cardiac surgery, compared to no statin treatment, statin treatment: – probably results in little to no difference in heart attacks (5 studies, 4645 people), length of intensive care unit stay (3 studies, 4528 people) and overall hospital stay (5 studies, 4788 people); – may make little to no difference to death within 30 days of surgery (6 studies, 5260 people), irregular heart rhythm (8 studies, 5592 people) and stroke (4 studies, 5143 people). We are very uncertain about the effects of statins on major harmful cardiac events (1 study, 2406 people) and kidney failure (4 studies, 4728 people). What are the limitations of the evidence? We are moderately confident in our findings that there were probably little to no differences in the risk of heart attack, length of hospital and intensive care unit stay. However, we have little to very little confidence about our other findings, namely the most important finding we were looking for, which was a reduction in death. This is because most of the studies had many differences between them, there were fewer comparative cases than expected, and the studies did not always provide information about the statin intervention or treatment outcomes we were interested in. In addition, all studies used a different approach to statin treatment, which made them difficult to compare. Overall, this lowered our confidence in the evidence. Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. How up to date is this evidence? This is an update of a Cochrane review. The evidence is up to date to September 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Marques Antunes, M; Nunes-Ferreira, A; Duarte, GS; Gouveia e Melo, R; Sucena Rodrigues, B; Guerra, NC; Nobre, A; Pinto, FJ; Costa, J; Caldeira, D", "articleTypes": [], "doi": "10.1002/14651858.CD008493.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "037f51be-2356-4a72-9272-f57f76926d13", "pmid": "", "title": "Tartrazine exclusion for allergic asthma", "imported": false, "abstract": "Abstract - Background Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There has been conflicting evidence as to whether tartrazine causes exacerbations of asthma with some studies finding a positive association especially in individuals with cross‐sensitivity to aspirin. Objectives To assess the overall effect of tartrazine (exclusion or challenge) in the management of asthma. Search methods A search was carried out on the Cochrane Airways Group Specialised Register. Bibliographies of each RCT was searched for additional papers. Authors of identified RCTs were contacted for further information. Searches are updated annually and are current as of February 2006. Selection criteria RCTs of oral administration of tartrazine (as a challenge) versus placebo or dietary avoidance of tartrazine versus normal diet were considered. Studies which focused upon allergic asthma, were also included. Studies of tartrazine exclusion for other allergic conditions such as hay fever, allergic rhinitis and eczema were only considered if the results for subjects with asthma were separately identified. Trials could be in either adults or children with asthma or allergic asthma (e.g. sensitivity to aspirin or food items known to contain tartrazine). Data collection and analysis Study quality was assessed and data abstracted by two reviewers independently. Outcomes were analysed using RevMan 4.1.1. Main results Ninety four abstracts were found, of which 20 were potentially relevant. Six? met the inclusion criteria, but only three presented results in a format that permitted analysis and none could be combined in a meta‐analysis. In none of the studies did tartrazine challenge or avoidance in diet significantly alter asthma outcomes. Authors' conclusions Due to the paucity of available evidence, it is not possible to provide firm conclusions as to the effects of tartrazine on asthma control. However, the six RCTs that could be included in this review all arrived at the same conclusion. Routine tartrazine exclusion may not benefit most patients, except those very few individuals with proven sensitivity. Plain language summary Tartrazine exclusion for allergic asthma Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There is no evidence that tartrazine makes asthma worse or avoiding it makes asthma patients any better.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Ardern, K", "articleTypes": [], "doi": "10.1002/14651858.CD000460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "03872811-7371-43e1-aa4c-ae4cfb05f4c5", "pmid": "", "title": "Dietary advice with or without oral nutritional supplements for disease‐related malnutrition in adults", "imported": false, "abstract": "Abstract - Background Disease‐related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social‐care costs. Dietary advice (DA) encouraging consumption of energy‐ and nutrient‐rich foods rather than oral nutritional supplements (ONS) may be an initial treatment. Objectives To examine evidence that DA with/without ONS in adults with disease‐related malnutrition improves survival, weight, anthropometry and quality of life (QoL). Search methods We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021. Selection criteria Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease‐related malnutrition in any healthcare setting compared with no advice, ONS or DA alone. Data collection and analysis Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence. Main results We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity. Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years. DA versus no advice ‐ 24 RCTs (3523 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three‐month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI ‐0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat‐free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS ‐ 12 RCTs (852 participants) All outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD ‐0.14 kg (95% CI ‐2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS ‐ 22 RCTs (1286 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD ‐1.07 (95% CI ‐4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS ‐ 31 RCTs (3308 participants) Evidence was moderate‐ to low‐certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD ‐0.12 (95% CI ‐2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS ‐ 13 RCTs (1315 participants) Evidence was low‐ to very low‐certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD ‐1.81 (95% CI ‐3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI ‐0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point. Authors' conclusions We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow‐up required for benefits to emerge were inconsistent for all other outcomes. There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient‐centred and healthcare outcomes are needed to address the questions in this review. Plain language summary Advice on diet for adults with malnutrition that is the result of disease Review question Can dietary advice with or without oral nutritional supplements (ONS) improve disease‐related malnutrition in adults? Background Ill people often have a poor appetite or feel sick because of medicines or other treatments and eat less than usual. Eating less over a longer time can cause weight loss, malnutrition, more health problems and death. Healthcare professionals may offer advice about dietary changes to help people to re‐establish good eating habits. They might recommend high‐protein and high‐energy foods so that these people can gain weight and improve their nutrition and general health. It is common for sick people to be offered ONS with or without advice about changing their food intake. To find the best answer to our review question, we looked for studies that compared five different treatment options: dietary advice compared with no advice; dietary advice compared with ONS; dietary advice plus ONS compared with dietary advice; dietary advice plus ONS if appropriate compared with no dietary advice; and dietary advice plus ONS compared with no dietary advice and no ONS. To make these comparisons fair, we looked for randomised controlled trials (RCTs), where the people taking part had an equal chance (like the flip of a coin) of being in either group that was being compared. Search date The evidence is current to: 01 March 2021. Study characteristics We found 94 studies (with a total of 10,284 people) that we could include in our review. Although older people have a higher risk of malnutrition, the people in these studies ranged from 17 to over 80 years of age and they were living either at home, in the community, or in hospital. They had a wide range of health conditions, including cancer, dementia and kidney disease. The studies reported on the participants for the length of their hospital stay or in some people in the community for up to six and a half years. Key results There is no evidence that any of the treatments affected how long many of the people in the studies lived. They did report some positive changes in energy intake (measured in calories), protein intake, weight, muscle bulk and quality of life. There were some reductions in complications and the length of time spent in hospital. However, there is no clear evidence about which treatment is the most helpful or the time it takes to achieve any benefit. Few studies reported results separately for men and women and so we cannot comment on whether there were any overall differences by sex. No studies recorded information about adverse events (harms) so we cannot offer a summary about possible harms. More research is needed to work out the best ways to help people who are losing weight because of illness in order to improve their clinical outcomes and quality of life. Certainty of the evidence Overall we rated the certainty of the evidence as low for most results, which means that we cannot be confident about the findings we report. There were several reasons for this. Some of the treatment comparisons that we looked at had only a few studies and some of those had small numbers of participants. There were problems with the design of some studies that may have affected the results. Some people knew which treatment they were receiving. We think this may influence the way that they reported some changes, e.g. their energy and protein intake, body weight and quality of life. We think that the way the decision about which group a person went into at the start of the study may have affected the results for some outcomes, e.g. change in weight, change in muscle bulk and mortality. We needed to see particular results to help us understand whether adults living with disease‐related malnutrition can improve their survival, weight and general quality of life if they receive advice about diet with or without ONS. None of the studies reported all of the results that we needed to do this. We were not able to estimate whether participants gain any benefits from the treatments, such as shortening the length of hospital stay, lowering the risk of readmission to hospital or developing complications. The low certainty of evidence, with no evidence in many areas, means we cannot make statements about any benefits and the possible disadvantages of these treatments despite the fact they are being used extensively in clinical practice. We recommend that future studies should be designed to measure these important patient‐centred and healthcare outcomes as well as any potential harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Baldwin, C; de van der Schueren, MAE; Kruizenga, HM; Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD002008.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "0388f5f5-a681-444e-9238-c8318df6b0d9", "pmid": "", "title": "Snoezelen for dementia", "imported": false, "abstract": "Abstract - Background Snoezelen, multi‐sensory stimulation, provides sensory stimuli to stimulate the primary senses of sight, hearing, touch, taste and smell, through the use of lighting effects, tactile surfaces, meditative music and the odour of relaxing essential oils. The rationale for this lies in the proposition that the provision of a sensory environment for people with dementia places fewer demands on their intellectual abilities but capitalizes on their residual sensorimotor abilities. The clinical application of snoezelen often varies in form, nature, principles and procedures. Such variations not only make the examination of the therapeutic values of snoezelen difficult, but also impede the clinical development of snoezelen in dementia care. A systematic review of evidence for the efficacy of snoezelen in the care of people with dementia is therefore needed to inform future clinical applications and research directions. Objectives To examine the clinical efficacy of snoezelen (or multisensory stimulation) for older people with dementia and their caregivers. Search methods The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 23 March 2008 using the terms: snoezelen OR \"multi‐sensory*\". The CDCIG Specialized Register contains records from all major health care databases ( The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources. The reviewers hand‐searched PubMed and the ISI Web of Science. Selection criteria Randomized controlled trials and quasi‐randomized controlled trials in which snoezelen or multi‐sensory programmes was used as an intervention for older people suffering from any forms of dementia. Data collection and analysis The two reviewers independently reviewed and assessed the quality of the trials. Main results Two new trials were included in this update. Baker 2003 was an expanded study of Baker 2001 reported in the previous version. Both Baker 2003 and van Weert 2005 examined the short‐term and longer‐term effects of snoezelen on behaviour, mood, and communication of people with moderate to severe dementia. The format of implementation was different in the two trials: one was session‐based snoezelen programme (Baker 2003), whilst the other was a 24‐hour integrated snoezelen care (van Weert 2005). Owing to the differences in study methodology, the results of the two trials were not pooled for analysis. The session‐based snoezelen programme (Baker 2003) did not show any effects on behaviour, mood, cognition and communication / interaction in the short term (during or immediately after sessions) or longer term (at post‐intervention or 1‐month post‐intervention follow‐up). Likewise, the 24‐hour integrated snoezelen care (van Weert 2005) failed to demonstrate any significant short‐term and longer term effects on behaviour, mood and interaction. Authors' conclusions A more vigorous review methodology was adopted in this update. The study of Kragt 1997, reported in the previous version, was excluded because the snoezelen programme only consisted of three sessions, which was considered too brief for a therapeutic intervention. Two new trials were reviewed. Meta‐analyses could not be performed because of the limited number of trials and different study methods of the available trials. Overall, there is no evidence showing the efficacy of snoezelen for dementia. There is a need for more reliable and sound research‐based evidence to inform and justify the use of snoezelen in dementia care. Plain language summary No evidence of the efficacy of snoezelen or multi‐sensory stimulation programmes for people with dementia Snoezelen (or multi‐sensory stimulation) has become a commonly used intervention to manage maladaptive behaviours and to promote positive mood of older people with dementia. Originally, two randomised clinical trials were available for this review. Some short‐term benefits were documented in promoting adaptive behaviours in people with dementia during and immediately after their participation in the sessions. In this update, two new trials were included and revealed two different forms of applying snoezelen to dementia care. One is a session‐based snoezelen programme while the other is a 24‐hour integrated snoezelen care programme. Both trials did not show any significant effects on behaviour, interaction, and mood of people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Chung, JCC; Lai, CKY", "articleTypes": [], "doi": "10.1002/14651858.CD003152", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "039ac19b-f452-47bc-87b5-6c1c701f6db5", "pmid": "", "title": "A Randomized, Double Blinded, Placebo-controlled, Multicenter, Phase III Study to Evaluate the Efficacy and Safety of Losartan in Early Immunoglobulin A Nephropathy (IgAN) Patients", "imported": false, "abstract": "Immunoglobulin A nephropathy (IgAN) is the most common glomerulonephritis worldwide. IgAN is progressive, particularly when patients have a significant proteinuria (proteinuria >1g/g creatinine), impaired kidney function, or elevated blood pressure. In 10 years, nearly 20-40% of these IgAN patients progress to end-stage renal disease (ESRD). Early IgAN is tentatively defined when proteinuria is insignificant and kidney function and blood pressure are normal. Patients with early IgAN rarely progress to ESRD. However, 30-40% of patients with early IgAN ultimately developed a significant proteinuria and hypertension in 10 years. Therefore, earlier intervention may be needed if it can prevent the development of a significant proteinuria and hypertension. Since angiotensin ll receptor blocker (ARB) is drug of choice in reducing proteinuria and controlling blood pressure, the investigators hypothesized that early introduction of ARB may be beneficial in preventing the significant proteinuria development in early IgAN patients. To prove the hypothesis, the investigators plan the current interventional study.", "journal": "", "year": "2017", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "03a2567d-f4c1-492c-9c60-c42be9a898a2", "pmid": "", "title": "Opioids for restless legs syndrome", "imported": false, "abstract": "Abstract - Background Restless legs syndrome (RLS) is a distressing and common neurological disorder that may have a huge impact in the quality of life of those with frequent and intense symptoms. Patients complain of unpleasant sensations in the legs, at or before bedtime, and feel an urge to move the legs, which improves with movement, such as walking. Symptoms start with the patient at rest (e.g. sitting or lying down), and follow a circadian pattern, increasing during the evening or at night. Many pharmacological intervention are available for RLS, including drugs used to treat Parkinson's disease (L‐Dopa and dopaminergic agonists), epilepsy (anticonvulsants), anxiety (benzodiazepines), and pain (opioids). Dopaminergic drugs are those most frequently used for treatment of RLS, but some patients do not respond effectively and require other medication. Opioids, a class of medications used to treat severe pain, seem to be effective in treating RLS symptoms, and are recommended for patients with severe symptoms, because RLS and pain appear to share the same mechanism in the central nervous system. All available drugs are associated to some degree with side effects, which can impede treatment. Opioids are associated with adverse events such as constipation, tolerance, and dependence. This justifies the conduct of a systematic review to ascertain whether opioids are safe and effective for treatment of RLS. Objectives To asses the effects of opioids compared to placebo treatment for restless legs syndrome in adults. Search methods We searched the Cochrane Central Register of Controlled trials, CENTRAL 2016, issue 4 and MEDLINE, EMBASE, and LILACS up to April 2016, using a search strategy adapted by Cochraneto identify randomised clinical trials. We checked the references of each study and established personal communication with other authors to identify any additional studies. We considered publications in all languages. Selection criteria Randomised controlled clinical trials of opioid treatment in adults with idiopathic RLS. Data collection and analysis Two review authors independently screened articles, independently extracted data into a standard form, and assessed for risk of bias. If necessary, they discussed discrepancies with a third researcher to resolve any doubts. Main results We included one randomised clinical trial (N = 304 randomised; 204 completed; 276 analysed) that evaluated opioids (prolonged release oxycodone/naloxone) versus placebo. After 12 weeks, RSL symptoms had improved more in the drug group than in the placebo group (using the IRLSSS: MD ‐7.0; 95% CI ‐9.69 to ‐4.31 and the CGI: MD ‐1.11; 95% CI ‐1.49 to ‐0.73). More patients in the drug group than in the placebo group were drug responders (using the IRLSSS: RR 1.82; 95% CI 1.37 to 2.42 and the CGI: RR1.92; 95% ICI 1.49 to 2.48). The proportion of remitters was greater in the drug group than in the placebo group (using the IRLSSS: RR 2.14; 95% CI 1.45 to 3.16). Quality of life scores also improved more in the drug group than in the placebo group (MD ‐0.73; 95% CI ‐1.1 to ‐0.36). Quality of sleep was improved more in the drug group measured by sleep adequacy (MD ‐0.74; 95% CI ‐1.15 to ‐0.33), and sleep quantity (MD 0.89; 95% CI 0.52 to 1.26). There was no difference between groups for daytime somnolence, trouble staying awake during the day, or naps during the day. More adverse events were reported in the drug group (RR 1.22; 95% CI 1.07 to 1.39). The major adverse events were gastrointestinal problems, fatigue, and headache. Authors' conclusions Opioids seem to be effective for treating RLS symptoms, but there are no definitive data regarding the important problem of safety. This conclusion is based on only one study with a high dropout rate (low quality evidence). Plain language summary Opiods for restless legs syndrome Background Restless legs syndrome (RLS) is a very common neurological disorder in which patients complain of an intense need to move their legs, and unpleasant sensations felt deep in their legs, all occurring while at rest, mostly at bedtime. The number of patients complaining of RLS varies according to race, gender, age, country, and health status. About 5% to 10% of people are affected; , and, among these, 2% to 5% need continual pharmacological treatment (medication). When RLS does not respond to medications generally used for Parkinsons Disease and epilepsy, their doctors often prescribe opioids. Question Are opioids effective and safe for people with RLS? Methods We searched the literature for studies in any language, published or not, that considered opioids for the treatment of RLS Results We included one randomised controlled clinical trial with moderate risk of bias that tested a combination of oxycodone and naloxone against placebo capsules, taken twice daily in participants whodid not respond to more usual medications. Researchers used the International RLS severity scale to find out if patients were improved after 12 weeks of treatment. Particpants receiving the combined oxycodone and naloxone reported improvement in RLS symptoms, Quality of life, and sleep quality; 42% of the drug group were symptom‐free. Discussion The study was well designed overall, but was at a high risk of bias due to the high percentage of participants who withdrew from treatment (attrition bias). Eighty‐four percent of the drug group developed adverse events, which were mostly related to the gastrointestinal system, headache, fatigue, and sleepiness (somnolence); 9.8% left the study because of the adverse events. Conclusion The use of opioids for the treatment of RLS in patients resistant to conventional treatment is supported by low‐quality evidence. Prescription of these medications should be based on clinical experience, and caution used due to the potential for abuse, dependency, and adverse events. No patient on opioids complained that their symptoms worsened.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "de Oliveira, CO, Carvalho, LBC, Carlos, K, Conti, C, de Oliveira, MM, Prado, LBF, Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006941.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.777Z" }, { "id": "03b81c30-9f6a-4d05-a56b-8d16876cc93b", "pmid": "", "title": "Lycopene for the prevention of prostate cancer", "imported": false, "abstract": "Abstract - Background Prostate cancer is a common cause of death in developed countries, yet the benefits of screening for prostate cancer still remain controversial. A prostate‐specific antigen (PSA) test result greater than 4 ng/mL (nanograms/millilitre) has commonly been used as the cut‐off level for seeking further tests to diagnose the presence (or absence) of prostate cancer. An increase in PSA levels may not necessarily be associated with an increased risk of prostate cancer, as PSA levels may also be increased in men with benign prostatic hyperplasia and prostatitis. Despite the uncertainty of the net benefit of early detection and treatment, safe and effective methods to prevent prostate cancer are of value. Consumers, seeking greater involvement in their healthcare, are increasingly turning to lifestyle modification and complementary and alternative medicines (CAMs) to maintain their health and prevent disease. Lycopene is a member of the carotenoid family, which is found abundantly in tomatoes, tomato‐based products, strawberries, and watermelon. It has been hypothesised that lycopene is a strong antioxidant, which may lower the risk of cancer (including prostate cancer) in people who have diets rich in lycopene. Objectives To determine whether lycopene reduces the incidence of prostate cancer and prostate cancer‐specific mortality. Secondary objectives include changes in PSA levels, prostate symptoms and the nature of adverse events associated with lycopene use. Search methods Electronic searches were conducted across MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases. No language or other limitations were imposed. Selection criteria Randomised controlled trials (RCTs) that investigated the use of lycopene for the prevention of prostate cancer were eligible for inclusion in this review. Data collection and analysis A search of electronic databases, performed in August 2011, identified 64 citations. All articles were selected for full‐text review. From these citations, three studies were identified as meeting the inclusion criteria. Handsearching did not provide any additional studies. Main results Three RCTs, with a total of 154 participants were included in this review. None of the studies reported data on prostate cancer mortality. All of the included studies differed with respect to design, participants included and allocation of lycopene. This clinical heterogeneity limits the value on the pooled estimated of the meta‐analyses. The methodological quality of two of the three included studies was assessed as posing a 'high' risk of bias. Meta‐analysis indicated no statistical difference in PSA levels between men randomised to receive lycopene and the comparison group (MD (mean difference) ‐0.34, 95% CI (confidence interval) ‐2.01 to 1.32). Only one study reported incidence of prostate cancer (10% in the lycopene group versus 30% in control group). The level of lycopene was also not statistically different in men randomised to receive lycopene and the comparison group (MD 0.39 µg/mL (micrograms/millilitre), 95% CI ‐0.19 to 0.98). No other meta‐analyses were possible since other outcomes assessed only had one study contributing data. Authors' conclusions Given that only three RCTs were included in this systematic review, and the high risk of bias in two of the three studies, there is insufficient evidence to either support, or refute, the use of lycopene for the prevention of prostate cancer. Similarly, there is no robust evidence from RCTs to identify the impact of lycopene consumption upon the incidence of prostate cancer, prostate symptoms, PSA levels or adverse events. Plain language summary Lycopene for the prevention of prostate cancer Prostate cancer is a common form of cancer affecting men worldwide. Pharmaceutical interventions, such as 5‐alpha reductase inhibitors, have been identified as potentially preventing prostate cancer incidence in men. Many men modify lifestyle and consume complementary and alternative medicines to maintain better health and prevent disease. Lycopene is a supplement that has been suggested may assist in the prevention of prostate cancer due to its antioxidant effects. The objective of this systematic review was to identify the effectiveness of lycopene in the prevention of prostate cancer. This review identified 3 relevant studies, comprising 154 participants in total. Two of the studies were assessed to be of 'high' risk of bias. Meta‐analysis of two studies indicated no statistical difference in prostate specific antigen (PSA) levels between men randomised to receive lycopene and the comparison group (MD ‐0.34, 95% CI ‐2.01 to 1.32). None of the studies assessed prostate cancer mortality. No other meta‐analyses were possible since other outcomes assessed only had one study contributing data.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Ilic, D; Forbes, KM; Hassed, C", "articleTypes": [], "doi": "10.1002/14651858.CD008007.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "03ba5537-a5ee-4a29-adb0-43a12329d80f", "pmid": "", "title": "Interactions of Human Gut Microbiota With Intestinal Sweet Taste Receptors", "imported": false, "abstract": "The purpose of this study is to collect data to examine whether short-term consumption of non-caloric artificial sweeteners (NCASs), such as saccharin, can lead to changes in blood sugar levels and in the composition of the bacteria in the large intestine.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "03be5ad7-17a0-42c8-82a9-4577f82a4e7e", "pmid": "", "title": "Interventions to reduce harm from continued tobacco use", "imported": false, "abstract": "Abstract - Background Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced‐exposure tobacco products (PREPs), as an alternative to cigarettes. Objectives To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long‐term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco? Search methods We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free‐text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. Selection criteria Randomized or quasi‐randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention. Data collection and analysis We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long‐term smoking abstinence), using fixed‐effect models. Where it was not possible to meta‐analyse data, we summarized findings narratively. Main results Twenty‐four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically‐heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as ‘low’ or ‘very low’, due to imprecision and indirectness. A ‘low’ grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A ‘very low’ grade means we are very uncertain about the estimate. Authors' conclusions People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high‐quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high‐quality RCTs are conducted, and that these also measure the long‐term health effects of treatments. Plain language summary Can smokers be helped to reduce the harm caused by cigarette smoking by smoking fewer cigarettes or using different tobacco products? Background The best thing to do to reduce the harms caused by smoking is to quit, but some people may not want to do this or may feel that they are unable to stop smoking completely. Cutting down the number of cigarettes smoked daily or using different tobacco products, such as chewing tobacco or low‐tar cigarettes, may reduce some of the harm caused by smoking. It may also help people to stop smoking completely in the long term. On the other hand, reducing smoking or using other tobacco products may not improve health and could reduce a person's motivation to quit smoking altogether. It is important that we review the evidence to find out whether these approaches could help smokers who do not want to or cannot quit to reduce the harm caused by their smoking. We were mainly interested in whether these approaches improved the health of smokers, but also looked at smoking reduction and quitting rates. Study characteristics We found 20 randomised controlled trials that tested ways to help people to cut down the number of cigarettes they smoked. Some of these just advised smokers to smoke less, but most also provided them with a product to help them cut down: nicotine replacement therapy (NRT), varenicline, bupropion, electronic cigarettes (ecigs), or snus (a form of smokeless, oral tobacco). We also found four randomized controlled trials that tested the effects of using cigarettes designed to reduce the damage caused by smoking: reduced tar, carbon or nicotine cigarettes. Most of the studies used NRT to help people to reduce their smoking. All of the studies included people who were not planning to quit smoking soon. The research is current to October 2015. Key results Eight studies (with 3081 smokers) found that using NRT roughly doubled the likelihood of halving the number of cigarettes smoked each day, compared to using a placebo. Using NRT in this way also nearly doubled the likelihood of quitting completely. One trial each tested bupropion, varenicline, ecigs and snus to help reduce the harms caused by smoking, and there was no evidence that any of these treatments helped smokers to reduce the number of cigarettes they were smoking each day. This may be because there has not yet been enough research into these methods. Only one of the trials testing cigarettes designed to reduce risk measured their effect on the number of people quitting smoking. It found that people were not more likely to quit smoking if they used reduced‐nicotine cigarettes than if they smoked their usual cigarettes. We did not find any trials which reported the long‐term health effects of the treatments, and so it remains uncertain how much health benefit there is from reducing the number of cigarettes smoked each day or smoking cigarettes designed to be less harmful. Quality of evidence The tobacco industry funded three of the included studies of cigarettes designed to reduce risk. None of the studies looked at whether there had been a long‐term change in the health of the users. We rate the quality of the evidence looking at how many people quit smoking as 'low' or 'very low', generally because the findings are based on a small number of studies. We need more studies to investigate methods of reducing the harm caused by continued smoking. These need to measure the health of the users over a long period.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lindson‐Hawley, N, Hartmann‐Boyce, J, Fanshawe, TR, Begh, R, Farley, A, Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD005231.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.775Z" }, { "id": "03cad814-5e7c-4798-bc5a-4ea584f6c339", "pmid": "", "title": "Omega‐6 fats for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐6 fats are polyunsaturated fats vital for many physiological functions, but their effect on cardiovascular disease (CVD) risk is debated. Objectives To assess effects of increasing omega‐6 fats (linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA)) on CVD and all‐cause mortality. Search methods We searched CENTRAL, MEDLINE and Embase to May 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher versus lower omega‐6 fat intake in adults with or without CVD, assessing effects over at least 12 months. We included full texts, abstracts, trials registry entries and unpublished studies. Outcomes were all‐cause mortality, CVD mortality, CVD events, risk factors (blood lipids, adiposity, blood pressure), and potential adverse events. We excluded trials where we could not separate omega‐6 fat effects from those of other dietary, lifestyle or medication interventions. Data collection and analysis Two authors independently screened titles/abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias of included trials. We wrote to authors of included studies. Meta‐analyses used random‐effects analysis, while sensitivity analyses used fixed‐effects and limited analyses to trials at low summary risk of bias. We assessed GRADE quality of evidence for 'Summary of findings' tables. Main results We included 19 RCTs in 6461 participants who were followed for one to eight years. Seven trials assessed the effects of supplemental GLA and 12 of LA, none DGLA or AA; the omega‐6 fats usually displaced dietary saturated or monounsaturated fats. We assessed three RCTs as being at low summary risk of bias. Primary outcomes : we found low‐quality evidence that increased intake of omega‐6 fats may make little or no difference to all‐cause mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.88 to 1.12, 740 deaths, 4506 randomised, 10 trials) or CVD events (RR 0.97, 95% CI 0.81 to 1.15, 1404 people experienced events of 4962 randomised, 7 trials). We are uncertain whether increasing omega‐6 fats affects CVD mortality (RR 1.09, 95% CI 0.76 to 1.55, 472 deaths, 4019 randomised, 7 trials), coronary heart disease events (RR 0.88, 95% CI 0.66 to 1.17, 1059 people with events of 3997 randomised, 7 trials), major adverse cardiac and cerebrovascular events (RR 0.84, 95% CI 0.59 to 1.20, 817 events, 2879 participants, 2 trials) or stroke (RR 1.36, 95% CI 0.45 to 4.11, 54 events, 3730 participants, 4 trials), as we assessed the evidence as being of very low quality. We found no evidence of dose‐response or duration effects for any primary outcome, but there was a suggestion of greater protection in participants with lower baseline omega‐6 intake across outcomes. Additional key outcomes : we found increased intake of omega‐6 fats may reduce myocardial infarction (MI) risk (RR 0.88, 95% CI 0.76 to 1.02, 609 events, 4606 participants, 7 trials, low‐quality evidence). High‐quality evidence suggests increasing omega‐6 fats reduces total serum cholesterol a little in the long term (mean difference (MD) −0.33 mmol/L, 95% CI −0.50 to −0.16, I 2 = 81%; heterogeneity partially explained by dose, 4280 participants, 10 trials). Increasing omega‐6 fats probably has little or no effect on adiposity (body mass index (BMI) MD −0.20 kg/m 2 , 95% CI −0.56 to 0.16, 371 participants, 1 trial, moderate‐quality evidence). It may make little or no difference to serum triglycerides (MD −0.01 mmol/L, 95% CI −0.23 to 0.21, 834 participants, 5 trials), HDL (MD −0.01 mmol/L, 95% CI −0.03 to 0.02, 1995 participants, 4 trials) or low‐density lipoprotein (MD −0.04 mmol/L, 95% CI −0.21 to 0.14, 244 participants, 2 trials, low‐quality evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐6 fats on cardiovascular health, mortality, lipids and adiposity to date, using previously unpublished data. We found no evidence that increasing omega‐6 fats reduces cardiovascular outcomes other than MI, where 53 people may need to increase omega‐6 fat intake to prevent 1 person from experiencing MI. Although benefits of omega‐6 fats remain to be proven, increasing omega‐6 fats may be of benefit in people at high risk of MI. Increased omega‐6 fats reduce serum total cholesterol but not other blood fat fractions or adiposity. Plain language summary Omega‐6 fats to prevent and treat heart and circulatory diseases Review question We reviewed randomised trials (participants had an equal chance to be assigned to either treatment) examining effects of higher omega‐6 fats compared to lower omega‐6 fats on deaths and heart and circulatory diseases (cardiovascular diseases (CVD), which include heart attacks and strokes). Background Omega‐6 fats are essential, we must obtain some from food. They are important for regulating energy production (part of metabolism), bone, skin and hair health. Many foods contain omega‐6 fats, particularly vegetable oils and nuts. Omega‐6 fats include linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA). Some evidence suggests that a higher intake of omega‐6 fats, along with a lower intake of saturated fat (from animal sources such as meat and cheese) can reduce coronary heart disease. In contrast, there is concern that high levels of omega‐6 fats may worsen cardiovascular risk by increasing inflammation. Overall, there is no conclusive evidence on the benefits or harms of omega‐6 fat intake on heart and circulatory diseases or on other health outcomes. Study characteristics Evidence in this review is current to May 2017. We found 19 studies recruiting 6461 adults. These studies assessed the effects of higher compared to lower omega‐6 fat intake on heart and circulatory diseases as well as deaths. We found that three trials were highly trustworthy (with good designs that produce reliable evidence). Studies took place in North America, Asia, Europe and Australia, and eight were funded only by national or charitable agencies. Participants increased their omega‐6 fats or maintained their usual fats for at least one year and up to eight years. Key results We found that increasing omega‐6 fats may make little or no difference to deaths or cardiovascular events but may reduce risk of heart attacks (low‐quality evidence). Evidence was weakened by study design problems, small numbers of events, low numbers of participants from developing countries, and few women. Evidence suggests that increasing omega‐6 fats reduces blood cholesterol (high‐quality evidence), probably has little or no effect on body weight adjusted for height (all moderate‐quality evidence), and may make little or no difference to triglycerides, high‐density lipoprotein (HDL, the 'good' cholesterol) or low‐density lipoprotein (LDL, the 'bad' cholesterol, low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hooper, L, Al‐Khudairy, L, Abdelhamid, AS, Rees, K, Brainard, JS, Brown, TJ, Ajabnoor, SM, O'Brien, AT, Winstanley, LE, Donaldson, DH, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011094.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.143Z" }, { "id": "03cbb4f4-ca77-4693-8194-82a09bd2bc5d", "pmid": "", "title": "Helminth therapy (worms) for allergic rhinitis", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a disorder of the nasal membranes and surrounding tissues, and a worldwide cause of illness and disability. Helminths are complex tissue‐dwelling or lumen‐dwelling organisms that inhabit larger organisms and are frequently asymptomatic. Helminths modulate the natural immune responses of their human hosts, and may prevent or cure immune‐mediated or allergic diseases (e.g. allergic rhinitis) in the host. Non‐randomised studies support this hypothesis. Objectives To assess the safety and effectiveness of helminth therapy in people with allergic rhinitis. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2011. Selection criteria All randomised controlled trials where the intervention was any helminth species or combination of helminth species, administered to people with allergic rhinitis in any dose, by any route and for any duration of exposure. We accepted both intermittent and persistent allergic rhinitis patients. Data collection and analysis We independently extracted data and assessed eligibility and risk of bias using a standardised data collection form. We resolved any disagreement through discussion. We combined dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), presenting both with 95% confidence intervals (CI). Main results We found five reports of two single‐centre, placebo‐controlled, double‐blinded studies (130 participants). Participants in both studies were a mix of adults with either intermittent or persistent allergic rhinitis. Both studies had a low risk of bias. One study, with 12 weeks’ follow‐up, used a single percutaneous application of 10 Necator americanus (i.e. human hookworm) larvae. The other study, with 24 weeks’ follow‐up, used three‐weekly oral dosing with 2500 Trichuris suis (i.e. pig whipworm) eggs in aqueous suspension. Of 17 outcomes evaluated in this review, eight were positive (i.e. favoured helminths). Participants taking helminths had no reduction in allergic rhinitis symptoms, percentage of well days (i.e. days with minimal symptoms and no use of medication for allergic rhinitis), lung function measures and quality of life scores. Total use of medication for allergic rhinitis (eye drops, nasal sprays, tablets) did not change; however, in the helminth group there was a statistically significant reduction in the percentage of days during the grass pollen season when participants needed to take tablets as rescue medication for their allergic rhinitis symptoms (MD –14.0%, 95% CI –26.6 to –1.40); in a typical 60‐day pollen season this 14% reduction translates into 19 days when tablets would be needed in the helminth group versus 27 days when tablets would be needed in the placebo group. Participants taking helminths percutaneously (i.e. as hookworm larvae) had local skin itching and redness in the first few days after administration. Participants taking helminths were more likely to report any gastrointestinal adverse event (RR 1.79, 95% CI 1.31 to 2.45), moderate or severe abdominal pain (RR 7.67, 95% CI 1.87 to 31.57), moderate or severe flatulence (RR 2.01, 95% CI 1.06 to 3.81) and moderate or severe diarrhoea (RR 1.99, 95% CI 1.18 to 3.37). There was no difference between the helminth and placebo groups in the incidence of serious adverse events, and in study withdrawals. Authors' conclusions There is currently insufficient evidence on the efficacy, tolerability and likely costs of helminth therapy to support its use in the routine management of allergic rhinitis. Administered to humans in carefully measured doses, helminths appear to be safe. More preclinical studies should be performed, before larger and extended duration trials of helminths for allergic rhinitis are carried out. Future studies should collect and report comparative data on the costs of helminth therapy versus conventional pharmacotherapy. Plain language summary Helminth therapy (worms) for allergic rhinitis Allergic rhinitis is a common health problem affecting about 500 million people worldwide; its prevalence is increasing. The symptoms of allergic rhinitis include sneezing, and an itchy, runny and blocked nose. Several classes of drugs are used to treat allergic rhinitis, but these drugs may be ineffective, and some drug classes have side effects after long‐term use. Drugs may also be relatively expensive. Helminths are complex multicellular organisms that inhabit larger organisms, and in humans are often symptomless. Helminths modulate (that is, optimally adjust) the immune systems of their hosts and it is thought that this property of helminths could be used therapeutically, to prevent or treat allergic diseases, such as allergic rhinitis. We included two well‐designed studies with a total of 130 adult participants, each study using a different species of gastrointestinal helminth (human hookworm in one study and pig whipworm in the other) as the intervention. Both studies found no significant efficacy from helminths, although one helminth species ( Trichuris suis , the pig whipworm) reduced the need for participants to take tablets as ‘rescue medication’ during the grass pollen season. Adverse events such as abdominal pain and flatulence were commoner in the helminth group, but the two helminths species studied did not cause serious adverse reactions. Currently there is insufficient evidence to support the use of helminths for allergic rhinitis in routine clinical practice. More preclinical studies are needed, before larger and extended duration clinical trials of helminths for allergic rhinitis are performed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Croft, AM, Bager, P, Garg, SK", "articleTypes": [], "doi": "10.1002/14651858.CD009238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.785Z" }, { "id": "03d5fdeb-f109-4e66-8c71-9daf9507dc73", "pmid": "", "title": "Multiple micronutrient powders for home (point‐of‐use) fortification of foods in pregnant women", "imported": false, "abstract": "Abstract - Background It is estimated that 32 million pregnant women suffer from anaemia worldwide. Due to increased metabolic demands, pregnant women are particularly vulnerable to anaemia and vitamin and mineral deficiencies, leading to adverse health effects in both the mother and her baby. Despite the demonstrated benefits of prenatal supplementation with iron and folic acid or multiple micronutrients, poor adherence to routine supplementation has limited the effectiveness of this intervention in many settings. Micronutrient powders for point‐of‐use fortification are packed, single‐dose sachets containing vitamins and minerals that can be added onto prepared food to improve its nutrient profile. The use of multiple micronutrient powders for point‐of‐use fortification of foods in pregnant women could be an alternative intervention to prenatal micronutrient supplementation. Objectives To assess the effects of prenatal home (point‐of‐use) fortification of foods with multiple micronutrient powders on maternal and newborn health. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and the International Clinical Trials Registry Platform ( ICTRP ) (31 January 2015). We also contacted relevant agencies to identify ongoing and unpublished studies. Selection criteria Randomised controlled trials (both individual and cluster randomisation) and quasi‐randomised trials, irrespective of language or publication status. The intervention was micronutrient powders for point‐of‐use fortification of foods, containing at least three micronutrients with one of them being iron, provided to pregnant women of any gestational age and parity. Five comparison groups were considered: no intervention/placebo, iron and folic acid supplements, iron‐only supplements, folic‐acid only supplements, and multiple micronutrients in supplements. Data collection and analysis Two review authors independently assessed the eligibility of studies, extracted and checked data accuracy, and assessed the risk of bias of included studies. Main results Our search identified 12 reports (relating to six studies). We included two cluster‐randomised controlled trials (involving 1172 women) ‐ these trials were considered to be at a moderate to high risk of bias due to methodological limitations. One trial is ongoing, and three studies were excluded. Micronutrient powders for point‐of‐use fortification of foods versus iron and folic acid supplements One trial (involving 478 pregnant women attending 42 antenatal care centres) compared micronutrient powders containing iron, folic acid, vitamin C and zinc with iron and folic acid tablets provided daily from 14 to 22 weeks to 32 weeks' gestation. The trial did not report on any of this review's primary outcomes: maternal anaemia at or near term, maternal iron deficiency, maternal mortality, adverse effects, low birthweight, preterm births. Nor did the trial report on the majority of this review's secondary outcomes, with the exception of maternal adherence. Adherence to micronutrient powders was lower than adherence to iron and folic acid supplements (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.66 to 0.87, one study, n = 405). Micronutrient powders for point‐of‐use fortification of foods versus same multiple micronutrients in supplements One study (involving 694 pregnant women from 18 communities), compared micronutrient powders containing iron, folic acid, vitamin C, zinc, iodine, vitamin E and vitamin B 12 with tablets containing the same seven micronutrients. There was no difference in maternal anaemia at 37 weeks of gestation (RR 0.92, 95% CI 0.53 to 1.59, one study, n = 470, very low quality evidence ). The trial did not report on any of this review's other primary outcomes in relation to maternal iron deficiency, maternal mortality, adverse effects, low birthweight, or preterm birth. In terms of this review's secondary outcomes, the included trial did not report on the majority of this review's prespecified secondary outcomes with one exception ‐ there was no clear difference in maternal haemoglobin Hb or near term (mean difference (MD) 1.0 g/L, 95% CI ‐1.77 to 3.77, one study, n = 470). Authors' conclusions Limited evidence suggests that micronutrient powders for point‐of‐use fortification of foods have no clear difference as multiple micronutrient supplements on maternal anaemia ( very low quality evidence ) and Hb at or near term. There is limited evidence to suggest that women were more likely to adhere to taking tablets than using micronutrient powders. The overall quality of evidence was judged very low (due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes. Therefore, more evidence is needed to assess the potential benefits or harms of the use of micronutrient powders in pregnant women on maternal and infant health outcomes. Future trials should also assess adherence to micronutrient powders and be adequately powered to evaluate the effects on birth outcomes and morbidity. Plain language summary Powders of iron plus other micronutrients for home (point‐of‐use) fortification of foods consumed by pregnant women Pregnant women are particularly vulnerable to nutrient deficiencies due to the requirements of the growing baby during the pregnancy. In low‐income countries, many women have diets with low content of vitamins and minerals, and they participate in long hours of physical labour. They are also exposed to recurrent infections, which make nutritional deficiencies worse. Thus, lack of adequate nutrition can contribute to the poor health of these women their babies. Iron and folic acid supplements in pregnancy are widely recommended. However, getting the supplements to the women and encouraging them to take them is particularly challenging. Micronutrient powders containing iron, vitamin A, zinc and other vitamins and minerals are usually packaged in single‐use sachets and can be sprinkled onto any semi‐solid food at home or in any other place where meals are to be consumed. The use of micronutrient powders to fortify foods may overcome this problem with micronutrient supplements. Micronutrient powders have already been shown to be effective in reducing anaemia and iron deficiency in young children and so may be useful for pregnant women. This review looked at the use of micronutrient powders in pregnancy, compared with micronutrient supplements or with no additional micronutrients. We found only two studies involving a total of 1172 women, undertaken in Bangladesh and Mexico. The overall quality of evidence was judged very low (with a high risk of bias due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes of this review. One trial compared micronutrient powders with iron and folate supplements, and the other trial compared micronutrient powders with the same nutrients but given as supplements. Overall, micronutrient powders fortification of foods had a similar effect as multiple micronutrient supplements on anaemia in mothers at or near term ( very low quality evidence ) or the mother's haemoglobin (Hb) at or near term. The study that compared micronutrient powders with iron and folic acid supplements reported that women were more likely to take iron and folic acid tablets than micronutrient powders. Nearly all of the review's important outcomes were not reported in the included studies. Therefore, more evidence is needed for both mother and infant health outcomes in order to adequately evaluate the use of micronutrient powders in pregnant women.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Suchdev, PS; Peña‐Rosas, JP; De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD011158.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "03d61822-661d-4354-9eaf-5be84030bfd1", "pmid": "", "title": "Determination of Perinatal Exposure to Non-caloric Sweeteners. Implications for the Development of Preferences for Sweet Taste, and Weight Gain During the First Year of Life", "imported": false, "abstract": "During last years, non-caloric sweeteners (NCSs) have been increasingly incorporated into foodstuffs in replacement of sucrose in Chile. This situation has reached a point where it is currently difficult to find sugary foods without NCSs. As a result, the voluntary and involuntary consumption of these additives is growing significantly in the population, increasing the risk of exceeding the acceptable daily intake (ADI), especially for children. This situation is worrying as recent evidence suggests that NCSs are not inert in the body and can trigger adverse metabolic effects. For example, the consumption of beverages with NCSs has been shown to favor the development of obesity and type-2 diabetes in children and adults, and a recent study reported that the intake of NCSs during pregnancy was associated with a greater weight gain of the child at one year. It is likely that certain NCSs pass into the amniotic fluid and that the fetus is exposed to some of these compounds during pregnancy. This situation would persist in the infant through breast milk, as some studies detected sucralose and acesulfame-K in this fluid, even in mothers who claimed not to consume them. However, the real impact of NCS exposure during the neonatal period on the child health has been few studied. Therefore, the aim of this study is to determine the concentration of NCSs in samples of amniotic liquid and breastmilk and to correlate these data with the NCS intake by the mothers. Mothers/children will be classified in quintiles according to the results obtained. In the children from quintiles 1 and 5, we will also study whether neonatal exposure to NCSs may affect the sweet taste threshold and the preferences for this taste, the levels of salivary insulin and the weight gain in the first year. Breastmilk microbiota and child fecal microbiota will be also evaluated.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.147Z" }, { "id": "03f2d0fe-cc09-45a6-b57b-984d1a13686a", "pmid": "", "title": "Guided imagery for treating hypertension in pregnancy", "imported": false, "abstract": "Abstract - Background Hypertension (high blood pressure) in pregnancy carries a high risk of maternal morbidity and mortality. Although antihypertensive drugs are commonly used, they have adverse effects on mothers and fetuses. Guided imagery is a non‐pharmacological technique that has the potential to lower blood pressure among pregnant women with hypertension. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. Objectives To determine the effect of guided imagery as a non‐pharmacological treatment of hypertension in pregnancy and its influence on perinatal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, and two trials registers (October 2018). We also searched relevant conference proceedings and journals, and scanned the reference lists of retrieved studies. Selection criteria We included randomised controlled trials (RCTs). We would have included RCTs using a cluster‐randomised design, but none were identified. We excluded quasi‐RCTs and cross‐over trials. We sought intervention studies of various guided imagery techniques performed during pregnancy in comparison with no intervention or other non‐pharmacological treatments for hypertension (e.g. quiet rest, music therapy, aromatherapy, relaxation therapy, acupuncture, acupressure, massage, device‐guided slow breathing, hypnosis, physical exercise, and yoga). Data collection and analysis Three review authors independently assessed the trials for inclusion, extracted data, and assessed risk of bias for the included studies. We checked extracted data for accuracy, and resolved differences in assessments by discussion. We assessed the certainty of the evidence using the GRADE approach. Main results We included two small trials (involving a total of 99 pregnant women) that compared guided imagery with quiet rest. The trials were conducted in Canada and the USA. We assessed both trials as at high risk of performance bias, and low risk of attrition bias; one trial was at low risk for selection, detection, and reporting bias, while the other was at unclear risk for the same domains. We could not perform a meta‐analysis because the two included studies reported different outcomes, and the frequency of the intervention was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks, or until the baby was born (whichever came first). In the other study, the intervention included guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for four total hours; the participants were instructed to practice the procedures twice daily and complete at least three relief relaxation breaks each day. The control groups were similar ‐ one was quiet rest, and the other was quiet rest as bed rest. None of our primary outcomes were reported in the included trials: severe hypertension (either systolic blood pressure of 160 mmHg or higher, or diastolic blood pressure of 110 mmHg or higher); severe pre‐eclampsia, or perinatal death (stillbirths plus deaths in the first week of life). Only one of the secondary outcomes was measured. Low‐certainty evidence from one trial (69 women) suggests that guided imagery may make little or no difference in the use of antihypertensive drugs (risk ratio 1.27, 95% confidence interval 0.72 to 2.22). Authors' conclusions There is insufficient evidence to inform practice about the use of guided imagery for hypertension in pregnancy. The available evidence for this review topic is sparse, and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. There was low‐certainty evidence that guided imagery made little or no difference to the use of antihypertensive drugs, downgraded because of imprecision. The two included trials did not report on any of the primary outcomes of this review. We did not identify any trials comparing guided imagery with no intervention, or with another non‐pharmacological method for hypertension. Large and well‐designed RCTs are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with short‐term and long‐term maternal and neonatal health. Trials could also consider utilisation and costs of health service. Plain language summary Guided imagery for treating hypertension in pregnancy What is the issue? Some women have long‐term high blood pressure, or hypertension, whereas approximately 10% of pregnant women develop high blood pressure as a complication of pregnancy. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. It can be performed by oneself, one‐to‐one, or in groups with an instructor using audio or scripts. Why is this important? High blood pressure during pregnancy is associated with an increased risk of the mother developing pre‐eclampsia with proteinuria, eclampsia with seizures and liver and blood disorders, and kidney failure. The baby of a pregnant woman with high blood pressure is more likely to be born too soon, be too small, and may need neonatal intensive care. High blood pressure drugs are recommended for women with severe high blood pressure and pre‐eclampsia because of the risk of life‐threatening complications, but such drugs can have adverse effects for the mother (including headache, decreased mental alertness, and exercise intolerance). Such drugs can also cross the placenta and may affect the unborn baby, and are not generally recommended for pregnant women with mild to moderate high blood pressure, which is when other ways of managing blood pressure are sought. Guided imagery is a non‐pharmacological technique that could potentially lower blood pressure among pregnant women with hypertension and improve pregnancy outcomes for the mother and her baby. What evidence did we find? We searched for evidence (October 2018) and found two trials (involving 99 women) conducted in Canada and the USA. Both trials compared guided imagery with quiet rest. There were no trials comparing guided imagery with no intervention, or other with another non‐pharmacological method for hypertension. The two included studies reported different outcomes and the Intervention frequency was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks or until the baby was born (whichever came first). The other study involved guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for a total of four hours; the women were instructed to practice the procedures twice daily and complete at least three relaxation breaks each day. The control groups between the two studies were similar ‐ one used quiet rest and the other used quiet rest as bed rest. Neither trial reported data for our main outcomes of interest: severe hypertension, severe pre‐eclampsia, or death of the baby during birth or within the first week of life. The trials provided data for only one of our secondary outcomes of interest. Low‐certainty evidence from the one trial (69 women) suggests that, compared with quiet rest, guided imagery may make little or no difference in the use of antihypertensive drugs. What does this mean? We included two small trials comparing guided imagery with quiet rest. We did not identify any trials comparing guided imagery with no intervention, or another non‐pharmacological treatment for hypertension. The available evidence for this review is sparse and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. The included trials did not report on any of the main outcomes in this review and only provided low‐certainty evidence on the uncertain effect on the use of antihypertensive drugs. There is insufficient evidence to inform practice about using guided imagery for hypertension in pregnancy. Large and well‐designed studies are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with the short‐term and long‐term health of mothers and their babies. The trials should also consider the use and costs of health services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Haruna, M, Matsuzaki, M, Ota, E, Shiraishi, M, Hanada, N, Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD011337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.755Z" }, { "id": "03f85d6a-e78e-49e2-985a-be7e0b934747", "pmid": "", "title": "Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months", "imported": false, "abstract": "Abstract - Background Bronchiolitis is one of the most common respiratory problems in the first year of life. The sputum of infants with bronchiolitis has increased deoxyribonucleic acid (DNA) content, leading to mucous plugging and airway obstruction. Recombinant human deoxyribonuclease (rhDNase), an enzyme that digests extracellular DNA, might aid the clearance of mucus and relieve peripheral airway obstruction. Objectives To determine the effect of nebulised rhDNase on the severity and duration of viral bronchiolitis in children younger than 24 months of age in the hospital setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 7 which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July Week 4, 2012), EMBASE (1974 to August 2012) and LILACS (1982 to August 2012). Selection criteria Randomised controlled trials (RCTs) using nebulised rhDNase alone or with concomitant therapy in children younger than 24 months of age hospitalised with acute bronchiolitis. Data collection and analysis Two review authors independently performed literature searches, assessed trial quality and extracted data. We obtained unpublished data from trial authors. We used Review Manager 5.1 to pool treatment effects expressed as the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI). Main results Three RCTs (333 participants) were identified, two of which were multicentre trials comprising only participants positive for respiratory syncytial virus (RSV). The other trial enrolled participants clinically diagnosed with bronchiolitis from a hospital in Italy. All studies used 2.5 mL (1 mg/mL) of nebulised rhDNase compared with placebo either as a daily or a twice daily dose. Adjunctive therapy included nebulised salbutamol, steroids, supplemental oxygen, intravenous fluids or tube feeding, nasal washing, nasal decongestants and antibiotics. Overall, nebulised rhDNase showed no benefit in clinically meaningful outcomes. Meta‐analysis favoured the control group with a shorter duration of hospital stay (MD 0.50; 95% CI 0.10 to 0.90, P = 0.01) and better clinical score improvement (SMD ‐0.24; 95% CI ‐0.50 to 0.01, P = 0.06). The largest trial showed no difference in supplemental oxygen use or intensive care unit (ICU) admission. In one RCT, four out of 11 patients in the treatment group had atelectasis. Two of these patients showed distinctive clinical improvement after nebulised rhDNase. There was no significant difference in adverse events. These included temporary desaturation, temporary coughing, increased coughing, facial rash, hoarseness, dyspnoea and bad taste, reported in a total of 11 patients from both treatment groups. Authors' conclusions The results based on the three included studies in this review did not support the use of nebulised rhDNase in children under 24 months of age hospitalised with acute bronchiolitis. In these patients, treatment did not shorten the length of hospitalisation or improve clinical outcomes. It might have a role in severe bronchiolitis complicated by atelectasis, but further clinical studies would need to be performed. Plain language summary Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months Bronchiolitis is the most common respiratory illness leading to hospitalisations in infants. Viral infections, particularly respiratory syncytial virus, are the usual cause, which lead to blockage of the small airways of the lungs due to inflammation and increased mucus production. Afflicted children have fever, cough, wheezing and difficulty breathing. Treatment is usually supportive. In bronchiolitis, the mucus produced contains large amounts of DNA, which makes it thicker and stickier. Removal of this DNA facilitates clearance of the mucus. RhDNase is an enzyme that breaks down DNA and hence may improve symptoms. We performed this review to assess the effect of rhDNase delivered through a nebuliser in children under 24 months old hospitalised for bronchiolitis. We identified three randomised controlled trials involving 333 children up to 24 months of age hospitalised with bronchiolitis. All three studies compared nebulised rhDNase with placebo. Any additional treatments were given to both groups. Overall, the studies did not show that nebulised rhDNase shortened the duration of hospital admission, or improved the severity of symptoms. No serious side effects were reported by any of the studies. One study showed that in patients suffering from atelectasis, a severe complication of bronchiolitis wherein the lung does not expand completely, nebulised rhDNase treatment resulted in a distinct improvement within two days. To confirm this beneficial effect, further clinical studies in patients with severe bronchiolitis are needed. Currently, the use of this treatment in young children hospitalised with bronchiolitis is not recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Enriquez, A; Chu, IW; Mellis, C; Lin, WY", "articleTypes": [], "doi": "10.1002/14651858.CD008395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "04008226-7eda-4104-92f0-89d14283cb5b", "pmid": "", "title": "N‐acetylcysteine as an adjuvant therapy for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) is one of the most common pathogens to establish and cause infection in human beings, affecting about 50% of the world's population. Prevalence may be as high as 83% in Latin American countries and as low as 17% in North America. Approximately 20% of infected people will manifest disease; people at high risk include those who live in low‐ and middle‐income countries with poor sanitary conditions, since the mechanism of transmission seems to be oral‐oral or faecal‐oral (mostly during infancy). There are several antibiotic regimens to treat the infection, but antibiotic resistance is growing around the world. New adjuvant drugs — such as probiotics, statins, curcumin, and N‐acetylcysteine (NAC) — are being tested to enhance eradication rates. N‐acetylcysteine can destabilise the biofilm structure; it also has synergic action with antibiotics, and bactericidal effects. In addition, NAC has antioxidant properties, and has a primary mucolytic effect by reducing the thickness of the gastric mucus layer, both of which may exert beneficial adjuvant effects on H pylori eradication. Objectives To assess the efficacy and safety of N‐acetylcysteine as an adjuvant therapy to antibiotics for Helicobacter pylori eradication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to April 2018), Embase (1988 to April 2018), CINAHL (1982 to April 2018), LILACS (1982 to April 2018), grey literature databases and trials registries. We handsearched the reference lists of relevant studies. We screened 726 articles and assessed 18 for eligibility. Selection criteria We included randomised controlled trials (RCTs) of any antibiotic regimen plus NAC, in adults infected with H pylori . To be included, trials had to use a control consisting of the same antibiotic regimen with or without placebo. Outcomes of interest were eradication rates, and gastrointestinal, toxic, and allergic adverse events. Reporting of the primary outcomes listed here was not an inclusion criterion for the review. Data collection and analysis Two review authors independently reviewed and extracted data and completed the 'Risk of bias' assessments. A third review author independently confirmed the 'Risk of bias' assessments. We used Review Manager 5 software for data analysis. We contacted study authors if there was missing information. Main results We included eight RCTs (with a total of 559 participants) in this review. The studies recruited outpatients aged between 17 and 76 years who were referred to endoscopy centres in several different countries. The certainty of evidence was reduced for most outcomes due to the poor methodological quality of included studies; issues mainly related to the generation of allocation sequence, allocation concealment, and blinding (this last domain related specifically to adverse outcomes). We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates, compared with the addition of placebo or no NAC (38.8% versus 49.1%, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.51 to 1.08; participants = 559; studies = eight; very low‐certainty evidence). A post‐hoc sensitivity analysis, in which we removed studies that tested antibiotic regimens no longer recommended in clinical practice, showed that the addition of NAC may improve eradication rates compared to control (27.2% versus 37.6%, RR 0.71, 95% CI 0.53 to 0.94; participants = 397; published studies = five). We are uncertain whether NAC is associated with a higher risk of gastrointestinal adverse events compared to control (23.9% versus 18.9%, RR 1.25, 95% CI 0.85 to 1.85; participants = 336; studies = five; very low‐certaintyevidence), or allergic adverse events (2% versus 0%, RR 2.98, 95% CI 0.32 to 27.74; participants = 336; studies = five; very low‐certainty evidence). There were no reports of toxic adverse events amongst included studies. Authors' conclusions We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates compared with the addition of placebo or no NAC. Due to the clinical, statistical and methodological heterogeneity found in included studies, and the uncertainty observed when analysing therapy subgroups, any possible beneficial effect of NAC should be regarded cautiously. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed, randomised clinical studies should be conducted, with good reporting standards and appropriate collection of efficacy and safety outcomes, especially for current recommended antibiotic regimens. Plain language summary N‐acetylcysteine taken with antibiotics for treatment of Helicobacter pylori infection Review question Is the addition of N‐acetylcysteine to antibiotics safe and does it improve cure rates for Helicobacter pylori infection? Background Helicobacter pylori ( H pylori ) is a bacteria that lives in the stomach and might cause several diseases such as gastric cancer, ulcer disease, and others. Colonisation occurs in about one‐half of the world's population and is more common in countries with poor sanitary conditions. People become infected by consuming contaminated water. The infection is treated using antibiotics and a drug which reduces acid production in the stomach. However, rates of antibiotic resistance are rising around the world, which is reducing the cure rates even with treatment. New medications are being tested to improve cure rates. One of these medications is N‐acetylcysteine (NAC). NAC is a drug that helps to dissolve mucus in respiratory diseases. It can be taken by mouth (orally) or injected into a vein (intravenous). NAC can destroy some mechanisms of survival of H pylori and could improve cure rates. Study characteristics We included eight studies (specifically, randomised controlled trials (RCTs)) with a total of 559 people aged between 17 and 76 years old. The evidence is current to April 2018. All studies recruited outpatients from endoscopy centres (centres that specialise in an examination done with a flexible tube with a camera that is inserted into stomach) in several countries. The antibiotic combinations tested were very different in the included studies, as were the doses of NAC (600 mg to 1800 mg per day). NAC was compared with placebo (dummy pill) or nothing. Key results We are uncertain whether the addition of NAC to antibiotics improves H pylori cure rates compared with the addition of placebo or no NAC. Any possible beneficial effect of NAC should be regarded cautiously because the included studies were very different and of low certainty, with some flaws that could have compromised their results and consequently, the results of this review. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed randomised clinical studies, with good reporting standards and appropriate collection of effectiveness and safety outcomes should be done, especially for current recommended antibiotic combinations. Quality of the evidence The overall certainty of the evidence for eradication rates ranged from very low to low. Five studies provided information on adverse events (side effects), and the certainy of evidence was very low. The included studies were poorly conducted and this reduced our confidence in the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fontes, LES, Martimbianco, ALC, Zanin, C, Riera, R", "articleTypes": [], "doi": "10.1002/14651858.CD012357.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.762Z" }, { "id": "04047acc-94dd-470e-906d-7dfca3552812", "pmid": "", "title": "Intranasal steroids for acute sinusitis", "imported": false, "abstract": "Abstract - Background Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school. Objectives We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis in adults and children. Search methods We searched CENTRAL 2013, Issue 4, MEDLINE (January 1966 to May week 2, 2013), EMBASE (1990 to May 2013) and bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) comparing INCS treatment to placebo or no intervention in adults and children with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop‐outs before the end of the study, rates of relapse, complications and return to school or work. Data collection and analysis Two review authors independently extracted data, assessed trial quality and resolved discrepancies by consensus. Main results No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well‐designed and double‐blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow‐up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta‐analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% confidence interval (CI) 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop‐out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS. Authors' conclusions Current evidence is limited for acute sinusitis confirmed by radiology or nasal endoscopy but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy. Plain language summary Steroids for acute sinusitis in adults and children Acute sinusitis is a common reason for primary care visits; it is one of the 10 most common diagnoses in outpatient clinics, presenting with various symptoms and signs that include purulent nasal discharge and congestion and cough lasting beyond the typical seven to 10 days of a viral upper respiratory infection. There have been suggestions, based on studies of allergic rhinitis and chronic sinusitis, that intranasal corticosteroids (INCS) may relieve symptoms and hasten recovery in acute sinusitis due to their anti‐inflammatory properties. A critical systematic review of the literature found four well‐conducted, randomised, placebo‐controlled intervention studies, involving 1943 participants treated for 15 or 21 days. The results suggest that there may be a modest effect with INCS in the resolution or improvement of symptoms. Only minor adverse events such as epistaxis, headache and nasal itching were reported. Given the small number of studies included in this review, it is recommended that further randomised controlled trials be conducted. The evidence is up to date as of May 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zalmanovici Trestioreanu, A; Yaphe, J", "articleTypes": [], "doi": "10.1002/14651858.CD005149.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "042e6d87-437f-429d-8909-6b69d6e03333", "pmid": "", "title": "Combined aclidinium bromide and long‐acting beta2‐agonist for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Several dual bronchodilator combinations of long‐acting beta 2 ‐agonist (LABA) and long‐acting muscarinic antagonist (LAMA) have been approved for treatment of stable chronic obstructive pulmonary disease (COPD). The current GOLD (Global Initiative for Chronic Obstructive Lung Disease) recommendations suggest the use of LABA/LAMA combinations in people with group B COPD with persistent symptoms, group C COPD with further exacerbations on LAMA therapy alone and group D COPD with or without inhaled corticosteroids (ICS). Fixed‐dose combination (FDC) of aclidinium/formoterol is one of the approved LABA/LAMA therapies for people with stable COPD. Objectives To assess the efficacy and safety of combined aclidinium bromide and long‐acting beta 2 ‐agonists in stable COPD. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov, World Health Organization (WHO) trials portal, United States Food and Drug Administration (FDA) and manufacturers' websites as well as the reference list of published trials up to 12 October 2018. Selection criteria Parallel‐group randomised controlled trials (RCTs) assessing combined aclidinium bromide and LABAs in people with stable COPD. Data collection and analysis We used standard methodological procedures expected by Cochrane for data collection and analysis. The primary outcomes were exacerbations requiring a short course of an oral steroid or antibiotic, or both; quality of life measured by a validated scale and non‐fatal serious adverse events (SAEs). Where the outcome or study details were not reported, we contacted the study investigators or pharmaceutical company trial co‐ordinators (or both) for missing data. Main results We identified RCTs comparing aclidinium/formoterol FDC versus aclidinium, formoterol or placebo only. We included seven multicentre trials of four to 52 weeks' duration conducted in outpatient settings. There were 5921 participants, whose mean age ranged from 60.7 to 64.7 years, mostly men with a mean smoking pack‐years of 46.4 to 61.3 of which 43.9% to 63.4% were current smokers. They had a moderate‐to‐severe degree of COPD with a mean postbronchodilator forced expiratory volume in one second (FEV 1 ) between 50.5% and 61% of predicted normal and the baseline mean FEV 1 of 1.23 L to 1.43 L. We assessed performance and detection biases as low for all studies whereas selection, attrition and reporting biases were either low or unclear. FDC versus aclidinium There was no evidence of a difference between FDC and aclidinium for exacerbations requiring steroids or antibiotics, or both (OR 0.95, 95% CI 0.71 to 1.27; 2 trials, 2156 participants; moderate‐certainty evidence); quality of life measured by St George's Respiratory Questionnaire (SGRQ) total score (MD –0.92, 95% CI –2.15 to 0.30); participants with significant improvement in SGRQ score (OR 1.17, 95% CI 0.97 to 1.41; 2 trials, 2002 participants; moderate‐certainty evidence); non‐fatal SAE (OR 1.19, 95% CI 0.79 to 1.80; 3 trials, 2473 participants; moderate‐certainty evidence); hospital admissions due to severe exacerbations (OR 0.62, 95% CI 0.29 to 1.29; 2 trials, 2156 participants; moderate‐certainty evidence) or adverse events (OR 0.95, 95% CI 0.76 to 1.18; 3 trials, 2473 participants; moderate‐certainty evidence). Compared with aclidinium, FDC improved symptoms (Transitional Dyspnoea Index (TDI) focal score: MD 0.37, 95% CI 0.07 to 0.68; 2 trials, 2013 participants) with a higher chance of achieving a minimal clinically important difference (MCID) of at least one unit improvement (OR 1.34, 95% CI 1.11 to 1.62; high‐certainty evidence); the number needed to treat for an additional beneficial outcome (NNTB) being 14 (95% CI 9 to 39). FDC versus formoterol When compared to formoterol, combination therapy reduced exacerbations requiring steroids or antibiotics, or both (OR 0.78, 95% CI 0.62 to 0.99; 3 trials, 2694 participants; high‐certainty evidence); may decrease SGRQ total score (MD –1.88, 95% CI –3.10 to –0.65; 2 trials, 2002 participants; low‐certainty evidence; MCID for SGRQ is 4 units); increased TDI focal score (MD 0.42, 95% CI 0.11 to 0.72; 2 trials, 2010 participants) with more participants attaining an MCID (OR 1.30, 95% CI 1.07 to 1.56; high‐certainty evidence) and an NNTB of 16 (95% CI 10 to 60). FDC lowered the risk of adverse events compared to formoterol (OR 0.78, 95% CI 0.65 to 0.93; 5 trials, 3140 participants; high‐certainty evidence; NNTB 22). However, there was no difference between FDC and formoterol for hospital admissions, all‐cause mortality and non‐fatal SAEs. FDC versus placebo Compared with placebo, FDC demonstrated no evidence of a difference in exacerbations requiring steroids or antibiotics, or both (OR 0.82, 95% CI 0.60 to 1.12; 2 trials, 1960 participants; moderate‐certainty evidence) or hospital admissions due to severe exacerbations (OR 0.55, 95% CI 0.25 to 1.18; 2 trials, 1960 participants; moderate‐certainty evidence), although estimates were uncertain. Quality of life measure by SGRQ total score was significantly better with FDC compared to placebo (MD –2.91, 95% CI –4.33 to –1.50; 2 trials, 1823 participants) resulting in a corresponding increase in SGRQ responders who achieved at least four units decrease in SGRQ total score (OR 1.72, 95% CI 1.39 to 2.13; high‐certainty evidence) with an NNTB of 7 (95% CI 5 to 12). FDC also improved symptoms measured by TDI focal score (MD 1.32, 95% CI 0.96 to 1.69; 2 studies, 1832 participants) with more participants attaining at least one unit improvement in TDI focal score (OR 2.51, 95% CI 2.02 to 3.11; high‐certainty evidence; NNTB 4). There were no differences in non‐fatal SAEs, adverse events and all‐cause mortality between FDC and placebo. Combination therapy significantly improved trough FEV 1 compared to aclidinium, formoterol or placebo. Authors' conclusions FDC improved dyspnoea and lung function compared to aclidinium, formoterol or placebo, and this translated into an increase in the number of responders on combination treatment. Quality of life was better with combination compared to formoterol or placebo. There was no evidence of a difference between FDC and monotherapy or placebo for exacerbations, hospital admissions, mortality, non‐fatal SAEs or adverse events. Studies reported a lower risk of moderate exacerbations and adverse events with FDC compared to formoterol; however, larger studies would yield a more precise estimate for these outcomes. Plain language summary Are combined aclidinium and long‐acting beta 2 ‐agonist inhalers effective and safe for people with stable COPD? Background Chronic obstructive pulmonary disease (COPD) is a disease of the lungs that causes airways to narrow. As a result, people with COPD experience symptoms of breathlessness and cough with sputum production which worsen over time. It is mainly caused by smoking or inhaling dust. In people with COPD, inhalers that contain medicines to widen the airways are generally given to relieve symptoms. Long‐acting medicines whose action lasts for at least half a day or one day are preferred. Aclidinium and formoterol (a long‐acting beta 2 ‐agonist medicine) are such inhalers. We wanted to find out how a combination of aclidinium and long‐acting beta 2 ‐agonist fare against either inhaler alone and dummy (placebo) inhaler. Study characteristics We could only identify studies on aclidinium and formoterol combination and included seven studies involving 5921 people with COPD which ranged from four weeks to one year long. Most participants were men in their 60s, moderate‐to‐heavy smokers, around half of whom were current smokers. They had moderate‐to‐severe symptoms of COPD when they started treatment. People in the studies took either combined inhalers containing aclidinium and formoterol or aclidinium or formoterol or placebo through a similar inhaler. Both people doing the research and people in the study did not know which treatment participants were getting. The conclusions of this review are current to October 2018. Key results People taking combined inhaler and aclidinium inhaler were not different in terms of flare‐ups that need additional medicines, quality of life, hospitalisations, side effects or serious side effects. However, they were less breathless than those taking aclidinium inhaler. Fourteen people with COPD would need to be treated with combined inhalers to have one additional person with a clinically significant improvement in breathlessness. People on combined inhalers were likely to have fewer flare‐ups, side effects and symptoms and a better quality of life compared to those taking formoterol inhaler. But, there was little or no difference in hospital admissions due to severe flare‐ups, serious side effects or the risk of dying. When compared to dummy inhalers, people taking combined inhalers experienced less breathlessness and better quality of life. Seven people with COPD would need to be treated with combined inhaler to achieve a significant improvement in quality of life than dummy inhaler. For flare‐ups, hospital admissions, side effects, serious side effects and death, there was no difference between combined and dummy inhalers. The lungs worked better in people taking combined inhalers than those taking only one drug or dummy inhaler. Quality of the evidence We had to interpret the results carefully as all the included studies were sponsored by pharmaceutical companies, which could have led to bias. However, the included studies were generally conducted in a systematic and acceptable manner. We are confident that combined inhalers are more effective than single or dummy inhalers at improving breathlessness and lung function. However, we are less certain about its effects on flare‐ups, hospital admissions, quality of life and side effects. Conclusion Combined inhalers are more effective than individual or dummy inhalers for relieving breathlessness and improving lung performance. They also lead to better quality of life than formoterol or dummy inhalers. However, they are not different from individual or dummy inhalers in terms of flare‐ups or hospital admissions. These combined inhalers have similar safety profiles as individual or dummy inhalers in terms of death, side effects or serious side effects. Combined inhalers probably had lesser side effects and moderate flare‐ups than formoterol, but further studies are needed to confidently support this finding. In summary, the combined inhalers are an effective option for treatment of COPD and appear to have a similar safety profile to individual or dummy inhalers.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ni, H, Moe, S, Soe, Z, Myint, KT, Viswanathan, KN", "articleTypes": [], "doi": "10.1002/14651858.CD011594.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.773Z" }, { "id": "0438481b-660f-47b5-849d-757ca5d79d26", "pmid": "", "title": "Pharmacological and nutritional treatment for McArdle disease (Glycogen Storage Disease type V)", "imported": false, "abstract": "Abstract - Background McArdle disease (Glycogen Storage Disease type V) is caused by an absence of muscle phosphorylase leading to exercise intolerance, myoglobinuria rhabdomyolysis and acute renal failure. This is an update of a review first published in 2004. Objectives To review systematically the evidence from randomised controlled trials (RCTs) of pharmacological or nutritional treatments for improving exercise performance and quality of life in McArdle disease. Search methods We searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE on 11 August 2014. Selection criteria We included RCTs (including cross‐over studies) and quasi‐RCTs. We included unblinded open trials and individual patient studies in the discussion. Interventions included any pharmacological agent or nutritional supplement. Primary outcome measures included any objective assessment of exercise endurance (for example aerobic capacity (VO 2 ) max, walking speed, muscle force or power and fatigability). Secondary outcome measures included metabolic changes (such as reduced plasma creatine kinase and a reduction in the frequency of myoglobinuria), subjective measures (including quality of life scores and indices of disability) and serious adverse events. Data collection and analysis Three review authors checked the titles and abstracts identified by the search and reviewed the manuscripts. Two review authors independently assessed the risk of bias of relevant studies, with comments from a third author. Two authors extracted data onto a specially designed form. Main results We identified 31 studies, and 13 fulfilled the criteria for inclusion. We described trials that were not eligible for the review in the Discussion. The included studies involved a total of 85 participants, but the number in each individual trial was small; the largest treatment trial included 19 participants and the smallest study included only one participant. There was no benefit with: D‐ribose, glucagon, verapamil, vitamin B 6 , branched chain amino acids, dantrolene sodium, and high‐dose creatine. Minimal subjective benefit was found with low dose creatine and ramipril only for patients with a polymorphism known as the D/D angiotensin converting enzyme (ACE) phenotype. A carbohydrate‐rich diet resulted in better exercise performance compared with a protein‐rich diet. Two studies of oral sucrose given at different times and in different amounts before exercise showed an improvement in exercise performance. Four studies reported adverse effects. Oral ribose caused diarrhoea and symptoms suggestive of hypoglycaemia including light‐headedness and hunger. In one study, branched chain amino acids caused a deterioration of functional outcomes. Dantrolene was reported to cause a number of adverse effects including tiredness, somnolence, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of myalgia. Authors' conclusions Although there was low quality evidence of improvement in some parameters with creatine, oral sucrose, ramipril and a carbohydrate‐rich diet, none was sufficiently strong to indicate significant clinical benefit. Plain language summary Drug and nutritional treatment for McArdle disease Review question We reviewed the evidence about the effects of drug and nutritional treatment for McArdle disease. Background McArdle disease (also known as glycogen storage disease type V) is a disorder affecting muscle metabolism. The condition is caused by the lack of an enzyme called muscle phosphorylase. This results in an inability to break down glycogen 'fuel' stores. McArdle disease leads to pain and fatigue with strenuous exercise. Sometimes severe muscle damage develops and occasionally this results in acute reversible kidney failure. Study characteristics After a wide search, we identified 13 randomised studies that included 85 participants with McArdle disease. This is an update of a review first published in 2004. We found no new trials at this update. Key results and quality of the evidence The review found no benefit compared with placebo with the following treatments: D‐ribose, glucagon, verapamil, vitamin B 6 , oral branched chain amino acids, dantrolene sodium, high‐dose creatine and ramipril. Low dose creatine and ramipril produced minimal benefit for patients who also have the D/D angiotensin converting enzyme (ACE) phenotype. Taking low dose creatine supplements had a minor benefit in improving exercise tolerance in a small number of people with the condition. Taking a sugary drink before planned strenuous exercise can improve performance but this treatment is not practical for day‐to‐day living. A diet rich in carbohydrate may be superior to a diet rich in protein. Adverse effects were reported in four studies. Oral ribose caused symptoms suggestive of a low blood sugar including light‐headedness, hunger and diarrhoea. One study of branched chain amino acids resulted in a deterioration in participants. Dantrolene was reported to cause a number of side‐effects including tiredness, sleepiness, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause any side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of muscle pain. The quality of these studies was low due to the small number of participants; the largest number in one trial was 19 and one trial had only one participant. The evidence is current to August 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Quinlivan, R; Martinuzzi, A; Schoser, B", "articleTypes": [], "doi": "10.1002/14651858.CD003458.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "044c2190-53aa-4ff9-87a5-b52649438bc9", "pmid": "", "title": "Effect of alcohol on blood pressure", "imported": false, "abstract": "Abstract - Background Alcohol is consumed by over 2 billion people worldwide. It is a common substance of abuse and its use can lead to more than 200 disorders including hypertension. Alcohol has both acute and chronic effects on blood pressure. This review aimed to quantify the acute effects of different doses of alcohol over time on blood pressure and heart rate in an adult population. Objectives Primary objective To determine short‐term dose‐related effects of alcohol versus placebo on systolic blood pressure and diastolic blood pressure in healthy and hypertensive adults over 18 years of age. Secondary objective To determine short‐term dose‐related effects of alcohol versus placebo on heart rate in healthy and hypertensive adults over 18 years of age. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to March 2019: the Cochrane Hypertension Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2), in the Cochrane Library; MEDLINE (from 1946); Embase (from 1974); the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. We also contacted authors of relevant articles regarding further published and unpublished work. These searches had no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing effects of a single dose of alcohol versus placebo on blood pressure (BP) or heart rate (HR) in adults (≥ 18 years of age). Data collection and analysis Two review authors (ST and CT) independently extracted data and assessed the quality of included studies. We also contacted trial authors for missing or unclear information. Mean difference (MD) from placebo with 95% confidence interval (CI) was the outcome measure, and a fixed‐effect model was used to combine effect sizes across studies. Main results We included 32 RCTs involving 767 participants. Most of the study participants were male (N = 642) and were healthy. The mean age of participants was 33 years, and mean body weight was 78 kilograms. Low‐dose alcohol (< 14 g) within six hours (2 RCTs, N = 28) did not affect BP but did increase HR by 5.1 bpm (95% CI 1.9 to 8.2) (moderate‐certainty evidence). Medium‐dose alcohol (14 to 28 g) within six hours (10 RCTs, N = 149) decreased systolic blood pressure (SBP) by 5.6 mmHg (95% CI ‐8.3 to ‐3.0) and diastolic blood pressure (DBP) by 4.0 mmHg (95% CI ‐6.0 to ‐2.0) and increased HR by 4.6 bpm (95% CI 3.1 to 6.1) (moderate‐certainty evidence for all). Medium‐dose alcohol within 7 to 12 hours (4 RCTs, N = 54) did not affect BP or HR. Medium‐dose alcohol > 13 hours after consumption (4 RCTs, N = 66) did not affect BP or HR. High‐dose alcohol (> 30 g) within six hours (16 RCTs, N = 418) decreased SBP by 3.5 mmHg (95% CI ‐6.0 to ‐1.0), decreased DBP by 1.9 mmHg (95% CI‐3.9 to 0.04), and increased HR by 5.8 bpm (95% CI 4.0 to 7.5). The certainty of evidence was moderate for SBP and HR, and was low for DBP. High‐dose alcohol within 7 to 12 hours of consumption (3 RCTs, N = 54) decreased SBP by 3.7 mmHg (95% CI ‐7.0 to ‐0.5) and DBP by 1.7 mmHg (95% CI –4.6 to 1.8) and increased HR by 6.2 bpm (95% CI 3.0 to 9.3). The certainty of evidence was moderate for SBP and HR, and low for DBP. High‐dose alcohol ≥ 13 hours after consumption (4 RCTs, N = 154) increased SBP by 3.7 mmHg (95% CI 2.3 to 5.1), DBP by 2.4 mmHg (95% CI 0.2 to 4.5), and HR by 2.7 bpm (95% CI 0.8 to 4.6) (moderate‐certainty evidence for all). Authors' conclusions High‐dose alcohol has a biphasic effect on BP; it decreases BP up to 12 hours after consumption and increases BP > 13 hours after consumption. High‐dose alcohol increases HR at all times up to 24 hours. Findings of this review are relevant mainly to healthy males, as only small numbers of women were included in the included trials. Plain language summary Alcohol has a biphasic effect on blood pressure and increases heart rate Review question We reviewed available evidence about the short‐term effects of different doses of alcoholic drinks compared to non‐alcoholic drinks on blood pressure and heart rate in adults (≥ 18 years) with both normal and raised blood pressure. Background Drinking excessive alcohol is considered one of the most common causes of raised blood pressure. We wanted to quantify the effects of a single dose of alcohol on blood pressure and heart rate within 24 hours of consumption. Study characteristics We included 32 randomised controlled trials involving 767 participants published up to March 2019. Although these trials included adults from 18 to 96 years of age with various health conditions, most study participants were young healthy males. The source of funding was not reported for a majority of the studies. Key results For low doses of alcohol, we found that one glass of alcohol had little to no effect on blood pressure and increased heart rate within six hours of drinking. We are moderately certain that medium‐dose alcohol decreased blood pressure and increased heart rate within six hours of consumption. We did not see any significant change in blood pressure or heart rate after that, but the evidence was limited. We are also moderately certain that high‐dose alcohol decreased blood pressure within six hours, and the effect lasted up to 12 hours. After that, blood pressure was found to be increased. Heart rate increased significantly after alcohol consumption and remained increased at all times measured. Thus alcohol decreases blood pressure initially (up to 12 hours after ingestion) and increases blood pressure after that. Alcohol consistently increases heart rate at all times within 24 hours of consumption.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Tasnim, S; Tang, C; Musini, VM; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD012787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "0458ae20-8686-49be-b95d-3434c47668c1", "pmid": "", "title": "Pharmacological intervention for irritability, aggression, and self‐injury in autism spectrum disorder (ASD)", "imported": false, "abstract": "Abstract - Background Pharmacological interventions are frequently used for people with autism spectrum disorder (ASD) to manage behaviours of concern, including irritability, aggression, and self‐injury. Some pharmacological interventions might help treat some behaviours of concern, but can also have adverse effects (AEs). Objectives To assess the effectiveness and AEs of pharmacological interventions for managing the behaviours of irritability, aggression, and self‐injury in ASD. Search methods We searched CENTRAL, MEDLINE, Embase, 11 other databases and two trials registers up to June 2022. We also searched reference lists of relevant studies, and contacted study authors, experts and pharmaceutical companies. Selection criteria We included randomised controlled trials of participants of any age with a clinical diagnosis of ASD, that compared any pharmacological intervention to an alternative drug, standard care, placebo, or wait‐list control. Data collection and analysis We used standard Cochrane methods. Primary outcomes were behaviours of concern in ASD, (irritability, aggression and self‐injury); and AEs. Secondary outcomes were quality of life, and tolerability and acceptability. Two review authors independently assessed each study for risk of bias, and used GRADE to judge the certainty of the evidence for each outcome. Main results We included 131 studies involving 7014 participants in this review. We identified 26 studies as awaiting classification and 25 as ongoing. Most studies involved children (53 studies involved only children under 13 years), children and adolescents (37 studies), adolescents only (2 studies) children and adults (16 studies), or adults only (23 studies). All included studies compared a pharmacological intervention to a placebo or to another pharmacological intervention. Atypical antipsychotics versus placebo At short‐term follow−up (up to 6 months), atypical antipsychotics probably reduce irritability compared to placebo (standardised mean difference (SMD) −0.90, 95% confidence interval (CI) −1.25 to −0.55, 12 studies, 973 participants; moderate‐certainty evidence), which may indicate a large effect. However, there was no clear evidence of a difference in aggression between groups (SMD −0.44, 95% CI −0.89 to 0.01; 1 study, 77 participants; very low‐certainty evidence). Atypical antipsychotics may also reduce self‐injury (SMD −1.43, 95% CI −2.24 to −0.61; 1 study, 30 participants; low‐certainty evidence), possibly indicating a large effect. There may be higher rates of neurological AEs (dizziness, fatigue, sedation, somnolence, and tremor) in the intervention group (low‐certainty evidence), but there was no clear evidence of an effect on other neurological AEs. Increased appetite may be higher in the intervention group (low‐certainty evidence), but we found no clear evidence of an effect on other metabolic AEs. There was no clear evidence of differences between groups in musculoskeletal or psychological AEs. Neurohormones versus placebo At short‐term follow‐up, neurohormones may have minimal to no clear effect on irritability when compared to placebo (SMD −0.18, 95% CI −0.37 to −0.00; 8 studies; 466 participants; very low‐certainty evidence), although the evidence is very uncertain. No data were reported for aggression or self ‐injury. Neurohormones may reduce the risk of headaches slightly in the intervention group, although the evidence is very uncertain. There was no clear evidence of an effect of neurohormones on any other neurological AEs, nor on any psychological, metabolic, or musculoskeletal AEs (low‐ and very low‐certainty evidence). Attention‐deficit hyperactivity disorder (ADHD)‐related medications versus placebo At short‐term follow‐up, ADHD‐related medications may reduce irritability slightly (SMD −0.20, 95% CI −0.40 to −0.01; 10 studies, 400 participants; low‐certainty evidence), which may indicate a small effect. However, there was no clear evidence that ADHD‐related medications have an effect on self‐injury (SMD −0.62, 95% CI −1.63 to 0.39; 1 study, 16 participants; very low‐certainty evidence). No data were reported for aggression. Rates of neurological AEs (drowsiness, emotional AEs, fatigue, headache, insomnia, and irritability), metabolic AEs (decreased appetite) and psychological AEs (depression) may be higher in the intervention group, although the evidence is very uncertain (very low‐certainty evidence). There was no evidence of a difference between groups for any other metabolic, neurological, or psychological AEs (very low‐certainty evidence). No data were reported for musculoskeletal AEs. Antidepressants versus placebo At short‐term follow‐up, there was no clear evidence that antidepressants have an effect on irritability (SMD −0.06, 95% CI −0.30 to 0.18; 3 studies, 267 participants; low‐certainty evidence). No data for aggression or self‐injury were reported or could be included in the analysis. Rates of metabolic AEs (decreased energy) may be higher in participants receiving antidepressants (very low‐certainty evidence), although no other metabolic AEs showed clear evidence of a difference. Rates of neurological AEs (decreased attention) and psychological AEs (impulsive behaviour and stereotypy) may also be higher in the intervention group (very low‐certainty evidence) although the evidence is very uncertain. There was no clear evidence of any difference in the other metabolic, neurological, or psychological AEs (very low‐certainty evidence), nor between groups in musculoskeletal AEs (very low‐certainty evidence). Risk of bias We rated most of the studies across the four comparisons at unclear overall risk of bias due to having multiple domains rated as unclear, very few rated as low across all domains, and most having at least one domain rated as high risk of bias. Authors' conclusions Evidence suggests that atypical antipsychotics probably reduce irritability, ADHD‐related medications may reduce irritability slightly, and neurohormones may have little to no effect on irritability in the short term in people with ASD. There was some evidence that atypical antipsychotics may reduce self‐injury in the short term, although the evidence is uncertain. There was no clear evidence that antidepressants had an effect on irritability. There was also little to no difference in aggression between atypical antipsychotics and placebo, or self‐injury between ADHD‐related medications and placebo. However, there was some evidence that atypical antipsychotics may result in a large reduction in self‐injury, although the evidence is uncertain. No data were reported (or could be used) for self‐injury or aggression for neurohormones versus placebo. Studies reported a wide range of potential AEs. Atypical antipsychotics and ADHD‐related medications in particular were associated with an increased risk of metabolic and neurological AEs, although the evidence is uncertain for atypical antipsychotics and very uncertain for ADHD‐related medications. The other drug classes had minimal or no associated AEs. Plain language summary Which medications reduce irritability, aggression or self‐harm in people with autism spectrum disorder (ASD)? Key messages • Only 3 classes of medications showed any reduction in irritability, aggression or self‐harm when compared to placebo (a dummy medication). Atypical (second‐generation) antipsychotic medications probably reduce irritability and aggression, but appear to have little to no effect on self‐injury. Attention deficit hyperactivity disorder (ADHD)‐related medications may reduce irritability, although the evidence is uncertain. Neurohormones (oxytocin and secretin) may also reduce irritability, but we are very uncertain about the evidence. • Antidepressants appear to have no effect on irritability. Studies did not report on the effects of antidepressants, ADHD‐related medications and neurohormones on aggression or self‐injury. • Studies reported a wide range of unwanted effects, but only atypical antipsychotics, ADHD‐related medications, and neurohormones showed evidence of a higher risk of any unwanted effects compared to placebo. What is autism spectrum disorder (ASD)? Autism is a disorder that affects a child's physical, mental and behavioural development. It is a lifelong disability that starts in childhood but continues throughout adulthood. People with autism may find it difficult to communicate and interact with the world. However, autism affects each person differently and may be more or less severe in different people, so it is described as a 'spectrum' disorder. Some people with autism spectrum disorder (ASD) may be irritable, angry or aggressive, or hurt themselves physically (self‐injury), which are 'behaviours of concern' that can be difficult to manage and distressing for the person. How are behaviours of concern managed? Behaviours of concern are frequently managed with various types of medications that have been developed to treat other conditions. This means that their effectiveness for behaviours of concern is largely unknown, and they may cause serious and varied unwanted effects that affect all parts of the body. For example: • the heart and lungs; • the stomach and digestive system; • the immune system; • movement, joints and bones; and • mood and emotion. What did we want to find out? We wanted to know which types of medication were effective in reducing behaviours of concern in people with ASD and whether they caused unwanted effects. What did we do? We searched for studies that investigated any medication used to manage behaviours of concern. Studies compared the medication with placebo (a dummy medication) or another medication. People in the studies could be adults or children, but all had ASD with behaviours of concern. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 131 studies with 7014 people. Most studies involved children, although some studies involved both children and adults, or adults only. Studies looked at a wide range of medications, including those usually used to treat schizophrenia or bipolar disorder, depression, attention deficit hyperactivity disorder (ADHD), convulsions, emotional problems, heart and lungs, dementia, Parkinson's, and anxiety. Atypical (second‐generation) antipsychotics are usually used to treat schizophrenia or bipolar disorder. They probably reduce irritability, but they may have little to no effect on aggression and self‐injury. People receiving antipsychotics might be more likely to experience unwanted effects such as increased appetite, dizziness, sedation (slowed thought and movement), sleepiness, tiredness and tremor compared to those receiving no treatment or other medications. People receiving antipsychotics may be no more or less likely than those receiving placebo to experience other unwanted effects. Neurohormones (such as oxytocin and secretin) may have a minimal to small effect on irritability but no studies reported data for the effects of neurohormones on self‐harm or aggression. People receiving neurohormones may be no more or less likely than those receiving placebo to experience unwanted effects. ADHD‐related medications may reduce irritability but may have no effect on self‐injury. No studies reported data for aggression. People receiving ADHD‐related medications might be more likely to experience unwanted effects such as drowsiness, tiredness, headache, difficulties sleeping, and decreased appetite. But they may be no more or less likely than those receiving placebo to experience other unwanted effects. Antidepressants may have little to no effect on irritability. No studies reported useful data for aggression and self‐injury. People receiving antidepressants might be more likely to experience unwanted effects such as impulsive behaviour and making repetitive movements or sounds (stereotypy) compared to placebo. But they may be no more or less likely than those receiving placebo to experience other types of unwanted effects. What are the limitations of the evidence? Most of the studies lasted less than 3 months, and very few studies involved adults. Therefore, we are uncertain if the same effects would be seen over a longer period of time or in adults. How up‐to‐date is the evidence? The review authors searched for studies that had been published up to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Iffland, M, Livingstone, N, Jorgensen, M, Hazell, P, Gillies, D", "articleTypes": [], "doi": "10.1002/14651858.CD011769.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.819Z" }, { "id": "0459d332-a2f9-4152-9b26-848124585de3", "pmid": "", "title": "Needle size for vaccination procedures in children and adolescents", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane Review first published in 2015. The conclusions have not changed. Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller the diameter of the needle (e.g. a 23 G needle is 0.6 mm in diameter, whereas a 25 G needle is 0.5 mm in diameter). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. Guidelines conflict regarding the sizes of needles that should be used for vaccinating children and adolescents. Objectives To assess the effects of using needles of different sizes for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration). Search methods We updated our searches of CENTRAL, MEDLINE, Embase, and CINAHL to October 2017. We also searched proceedings of vaccine conferences and two trials registers. Selection criteria Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years. Data collection and analysis Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system. Main results We included five trials involving 1350 participants in the original review. The updated review identified no new trials. The evidence from two small trials (one trial including infants and one including adolescents) was insufficient to allow any definitive statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity. The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials included infants predominantly aged from two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole‐cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP‐Hib) and hepatitis B (DTwP‐Hib‐Hep B) antigen components. Primary outcomes Incidence of vaccine‐preventable diseases: No trials reported this outcome. Procedural pain and crying: Using a wider gauge 23 G 25 mm needle may slightly reduce procedural pain (low‐quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate‐quality evidence) compared with a narrower gauge 25 G 25 mm needle (one trial, 320 participants). The effects are probably not large enough to be clinically relevant. Secondary outcomes Immune response: There is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between use of 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP‐Hib vaccine at ages two, three, and four months (moderate‐quality evidence, one trial, numbers of participants in analyses range from 309 to 402. The immune response to the pertussis antigen was not measured). Severe and non‐severe local reactions: 25 mm needles (either 25 G or 23 G) probably lead to fewer severe and non‐severe local reactions after DTwP‐Hib vaccination compared with 25 G 16 mm needles (moderate‐quality evidence, one trial, 447 to 458 participants in analyses). We estimate that one fewer infant will experience a severe local reaction (extensive redness and swelling) after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat for an additional beneficial outcome (NNTB) with a 25 G 25 mm needle: 25 (95% confidence interval (CI) 15 to 100); NNTB with a 23 G 25 mm needle: 25 (95% CI 17 to 100)). We estimate that one fewer infant will experience a non‐severe local reaction (any redness, swelling, tenderness, or hardness (composite outcome)) at 24 hours after the first vaccine dose for every 5 or 6 infants vaccinated with a 25 mm rather than a 16 mm needle (NNTB with a 25 G 25 mm needle: 5 (95% CI 4 to 10); NNTB with a 23 G 25 mm needle: 6 (95% CI 4 to 13)). The results are similar after the second and third vaccine doses. Using a narrow gauge 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with a wider gauge 23 G 25 mm needle, but the effect estimates are imprecise (low‐quality evidence, two trials, 100 to 459 participants in analyses). Systemic reactions: The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of postvaccination fever and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence. Authors' conclusions Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole‐cell pertussis antigen component. These vaccines are predominantly used in low‐ and middle‐income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain. Plain language summary Needle size for vaccination procedures in children and adolescents Background Vaccines contain antigens that make the body's immune system produce antibodies that can protect against disease, which is known as an immune response. Antigens are modified or partial forms of the virus, bacteria, or toxin that cause the disease that the vaccine protects against. Because the antigen is altered from its original form, it cannot cause disease, but it can produce an immune response. Vaccines can be injected using needles of different lengths and gauges. The needle gauge (G) refers to the width (diameter) of the needle. The higher the gauge number, the narrower the needle. For example, a 25 G needle is approximately 0.5 mm in diameter and is narrower than a 23 G needle, which has a diameter of 0.6 mm. Guidelines conflict regarding the lengths and gauges of needles that should be used for vaccinating children and adolescents. Review question We wanted to find out if the length and gauge of needles used to vaccinate children and adolescents has an influence on the: 1) immune response to the injected vaccine; 2) pain experienced during the vaccination procedure; 3) occurrence of reactions such as swelling, tenderness, and redness at the site where the vaccine is given; fever (high temperature); and other side effects that can occur after vaccination. Quality of the evidence We included five studies involving 1350 people. We rated the quality of the evidence from studies as very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. There were problems with the design of some studies, and data were insufficient to answer some parts of our review question. The quality of the evidence from two studies was too low to allow us to draw any conclusions about the effects of the needles compared in the studies. However, there was sufficient evidence from the remaining three studies to allow us to reach conclusions. Study characteristics The three studies that allowed us to reach conclusions involved 1135 healthy infants aged mostly between two and six months. The infants were vaccinated in the thigh with either 25 G 25 mm (narrow, long needles), 23 G 25 mm (wide, long needles), or 25 G 16 mm needles (narrow, short needles). The needles were inserted at right angles (90° angle) into the skin and pushed down into the muscle of the thigh. The vaccines injected were combination vaccines designed to protect against several diseases including diphtheria (D), tetanus (T), whooping cough (pertussis), and Haemophilus influenzae type b disease (Hib). The vaccines all contained whole‐cell pertussis (wP) vaccine antigens. These vaccines are commonly used in low‐ and middle‐income countries but not in high‐income countries. Our review findings are therefore most relevant to low‐ and middle‐income countries. Key findings We found moderate‐quality evidence that infants vaccinated in the thigh with 25 mm needles probably have fewer severe reactions (extensive redness and swelling in the thigh) after DTwP‐Hib vaccination than infants vaccinated with 16 mm needles. We also found that the longer needles probably lead to fewer non‐severe reactions such as mild swelling, tenderness, and redness after vaccination. The immune response to the vaccine is probably similar with the long and the short needles. We found low‐quality evidence that the wide, long needle may slightly reduce the pain of the vaccination procedure compared with the narrow, long needle. We found moderate‐quality evidence that the wide, long needle probably slightly reduces the duration of crying immediately following vaccination compared with the narrow, long needle. The differences in pain and crying between use of the wide and narrow needles are probably too small to be of any practical importance. We found low‐quality evidence that infants vaccinated with the narrow, long needle may have slightly fewer non‐severe reactions than infants vaccinated with the wide, long needle. We do not know if needle size has an effect on fever or other reactions that sometimes occur after vaccination including drowsiness, loss of appetite, and vomiting due to the very low quality of the evidence. The evidence in our review is current to October 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Beirne, PV, Hennessy, S, Cadogan, SL, Shiely, F, Fitzgerald, T, MacLeod, F", "articleTypes": [], "doi": "10.1002/14651858.CD010720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.826Z" }, { "id": "046b055a-a05c-4759-ae6e-745b5a5f0d38", "pmid": "", "title": "Interventions for American cutaneous and mucocutaneous leishmaniasis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Pinart, M, Rueda, J-R, Romero, GAS, Pinzón-Flórez, CE, Osorio-Arango, K, Silveira Maia-Elkhoury, AN, Reveiz, L, Elias, VM, Tweed, JA", "articleTypes": [], "doi": "10.1002/14651858.CD004834.pub3 AB - Abstract - Background On the American continent, cutaneous and mucocutaneous leishmaniasis (CL and MCL) are diseases associated with infection by several species of Leishmania parasites. Pentavalent antimonials remain the first‐choice treatment. There are alternative interventions, but reviewing their effectiveness and safety is important as availability is limited. This is an update of a Cochrane Review first published in 2009. Objectives To assess the effects of interventions for all immuno‐competent people who have American cutaneous and mucocutaneous leishmaniasis (ACML). Search methods We updated our database searches of the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and CINAHL to August 2019. We searched five trials registers. Selection criteria Randomised controlled trials (RCTs) assessing either single or combination treatments for ACML in immuno‐competent people, diagnosed by clinical presentation and Leishmania infection confirmed by smear, culture, histology, or polymerase chain reaction on a biopsy specimen. The comparators were either no treatment, placebo only, or another active compound. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our key outcomes were the percentage of participants 'cured' at least three months after the end of treatment, adverse effects, and recurrence. We used GRADE to assess evidence certainty for each outcome. Main results We included 75 studies (37 were new), totalling 6533 randomised participants with ATL. The studies were mainly conducted in Central and South America at regional hospitals, local healthcare clinics, and research centres. More male participants were included (mean age: roughly 28.9 years (SD: 7.0)). The most common confirmed species were L. braziliensis , L. panamensis , and L. mexicana . The most assessed interventions and comparators were non‐antimonial systemics (particularly oral miltefosine) and antimonials (particularly meglumine antimoniate (MA), which was also a common intervention), respectively. Three studies included moderate‐to‐severe cases of mucosal leishmaniasis but none included cases with diffuse cutaneous or disseminated CL, considered the severe cutaneous form. Lesions were mainly ulcerative and located in the extremities and limbs. The follow‐up (FU) period ranged from 28 days to 7 years. All studies had high or unclear risk of bias in at least one domain (especially performance bias). None of the studies reported the degree of functional or aesthetic impairment, scarring, or quality of life. Compared to placebo, at one‐year FU, intramuscular (IM) MA given for 20 days to treat L. braziliensis and L. panamensis infections in ACML may increase the likelihood of complete cure (risk ratio (RR) 4.23, 95% confidence interval (CI) 0.84 to 21.38; 2 RCTs, 157 participants; moderate‐certainty evidence), but may also make little to no difference, since the 95% CI includes the possibility of both increased and reduced healing (cure rates), and IMMA probably increases severe adverse effects such as myalgias and arthralgias (RR 1.51, 95% CI 1.17 to 1.96; 1 RCT, 134 participants; moderate‐certainty evidence). IMMA may make little to no difference to the recurrence risk, but the 95% CI includes the possibility of both increased and reduced risk (RR 1.79, 95% CI 0.17 to 19.26; 1 RCT, 127 participants; low‐certainty evidence). Compared to placebo, at six‐month FU, oral miltefosine given for 28 days to treat L. mexicana , L. panamensis and L. braziliensis infections in American cutaneous leishmaniasis (ACL) probably improves the likelihood of complete cure (RR 2.25, 95% CI 1.42 to 3.38), and probably increases nausea rates (RR 3.96, 95% CI 1.49 to 10.48) and vomiting (RR 6.92, 95% CI 2.68 to 17.86) (moderate‐certainty evidence). Oral miltefosine may make little to no difference to the recurrence risk (RR 2.97, 95% CI 0.37 to 23.89; low‐certainty evidence), but the 95% CI includes the possibility of both increased and reduced risk (all based on 1 RCT, 133 participants). Compared to IMMA, at 6 to 12 months FU, oral miltefosine given for 28 days to treat L. braziliensis , L. panamensis , L. guyanensis and L. amazonensis infections in ACML may make little to no difference to the likelihood of complete cure (RR 1.05, 95% CI 0.90 to 1.23; 7 RCTs, 676 participants; low‐certainty evidence). Based on moderate‐certainty evidence (3 RCTs, 464 participants), miltefosine probably increases nausea rates (RR 2.45, 95% CI 1.72 to 3.49) and vomiting (RR 4.76, 95% CI 1.82 to 12.46) compared to IMMA. Recurrence risk was not reported. For the rest of the key comparisons, recurrence risk was not reported, and risk of adverse events could not be estimated. Compared to IMMA, at 6 to 12 months FU, oral azithromycin given for 20 to 28 days to treat L. braziliensis infections in ACML probably reduces the likelihood of complete cure (RR 0.51, 95% CI 0.34 to 0.76; 2 RCTs, 93 participants; moderate‐certainty evidence). Compared to intravenous MA (IVMA) and placebo, at 12 month FU, adding topical imiquimod to IVMA, given for 20 days to treat L. braziliensis , L. guyanensis and L. peruviana infections in ACL probably makes little to no difference to the likelihood of complete cure (RR 1.30, 95% CI 0.95 to 1.80; 1 RCT, 80 participants; moderate‐certainty evidence). Compared to MA, at 6 months FU, one session of local thermotherapy to treat L. panamensis and L. braziliensis infections in ACL reduces the likelihood of complete cure (RR 0.80, 95% CI 0.68 to 0.95; 1 RCT, 292 participants; high‐certainty evidence). Compared to IMMA and placebo, at 26 weeks FU, adding oral pentoxifylline to IMMA to treat CL (species not stated) probably makes little to no difference to the likelihood of complete cure (RR 0.86, 95% CI 0.63 to 1.18; 1 RCT, 70 participants; moderate‐certainty evidence). Authors' conclusions Evidence certainty was mostly moderate or low, due to methodological shortcomings, which precluded conclusive results. Overall, both IMMA and oral miltefosine probably result in an increase in cure rates, and nausea and vomiting are probably more common with miltefosine than with IMMA. Future trials should investigate interventions for mucosal leishmaniasis and evaluate recurrence rates of cutaneous leishmaniasis and its progression to mucosal disease. Plain language summary What are the benefits and risks of different treatments for American (muco)cutaneous leishmaniasis (a parasitic disease of the skin and mucous membranes)? Why this question is important American (muco)cutaneous leishmaniasis (ACML) is a disfiguring disease that affects people in Central and South America. It is caused by parasites that are transmitted to humans by sandflies. Different forms of ACML have different symptoms. People with the cutaneous form develop skin sores that often heal within a few months without treatment, but can leave scars. In people with mucosal or mucocutaneous leishmaniasis, destructive sores develop in the protective lining (mucous membranes) of the nose, mouth and throat. To compare the effectiveness and risks of the many treatments for ACML, we reviewed evidence from research studies (randomised controlled trials). We looked for information on the proportion of people whose sores had healed three months or more after treatment, unwanted effects, quality of life, re‐appearance of sores, damage associated with the disease and prevention of scarring. How we identified and assessed the evidence First, we searched for all relevant studies. We then compared the results, summarised the evidence, and assessed the certainty of the evidence. What we found We found 75 studies on 6533 people (approximately 75% male; average age: 29 years). ‐ One study investigated children (2 to 12 years).
‐ Most studies (67) involved people with cutaneous leishmaniasis.
‐ Eight studies investigated people with mucosal or mucocutaneous leishmaniasis.
‐ The parasite Leishmania braziliensis caused the disease in 52 studies.
‐ Studies were conducted at regional hospitals, local clinics, and research centres.
‐ Studies lasted between 28 days and seven years.
‐ Most studies reported their funding source: the US army funded eight studies, industry funded 10, and institutional grants funded 33 (five of these also reported industry funding). Treatments were mainly compared to a placebo (fake treatment) or meglumine antimoniate (an antimonial). Here we report this review's main results. We were only able to report the risk of recurrence and side effects for the comparisons of meglumine antimoniate (MA) or miltefosine versus placebo and miltefosine versus MA. Main results Antimonials Compared to placebo, MA may increase chances of complete healing of ACML, but treatment effects vary, so it is possible that it may make little to no difference. MA probably increases the likelihood of pain in the muscles or joints. There may be little to no difference in the risk of developing the disease again, but there is also a possibility of increased or reduced risk due to the wide range of effects seen. Non‐antimonials Miltefosine probably improves chances of complete healing of American cutaneous leishmaniasis (ACL) compared to placebo, but there may be little to no difference compared to treatment with MA in ACML. Miltefosine may make little to no difference to the risk of developing ACL again when compared to placebo, but treatment effects on recurrence varied, so it may also increase or decrease the risk. Miltefosine probably increases the likelihood of vomiting or nausea when compared to either placebo or MA in ACML. We do not know the effect on recurrence of miltefosine compared to MA. Azithromycin probably reduces chances of complete healing of ACML compared to MA. Imiquimod in combination with MA probably makes little to no difference to the chance of complete healing of ACL compared to MA in combination with placebo. Physical therapies Thermotherapy lowers the chance of complete healing of ACL compared to MA. Immuno‐chemotherapy Pentoxifylline plus MA probably makes little to no difference to chances of complete healing of ACML compared with MA plus placebo. No study reported information about damage, prevention of scarring, or quality of life. What this means The main findings of this review suggest that: ‐ MA and miltefosine probably increase chances of complete healing; and
‐ vomiting or nausea are probably more common with miltefosine, and joint or muscle ache is probably more common with MA. The evidence was mostly of moderate certainty, so the true results are likely close to what we found. Evidence was limited by the inclusion of very few people in some studies, and participants or investigators knowing which treatments they were receiving. How‐up‐to date is this review? The evidence in this Cochrane Review is current to August 2019.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.785Z" }, { "id": "046dee67-9c72-4ee4-813e-afbbaf6e5130", "pmid": "", "title": "Sodium channel blockers for cystic fibrosis", "imported": false, "abstract": "Abstract - Background People with cystic fibrosis (CF) have increased transport of the salt, sodium across their airway lining. Over‐absorption of sodium results in the dehydration of the liquid that lines the airway surface and (along with defective chloride secretion) is a primary defect in people with CF. Objectives To determine whether the topical administration of drugs that block sodium transport improves the respiratory condition of people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We contacted principal investigators known to work in the field, previous authors and pharmaceutical companies who manufacture ion transport agents for unpublished or follow‐up data. Most recent search of the Group's register: 19 December 2013. Selection criteria Published or unpublished randomised controlled trials (RCTs) or quasi‐randomised controlled trials of sodium channel blockers compared to placebo or another sodium channel blocker or the same sodium channel blocker at a different dosing regimen. Data collection and analysis Two authors independently extracted data. Meta‐analysis was limited due to differing study designs. Main results Five RCTs, with a total of 226 participants, examining the topical administration of the short‐acting sodium channel blocker, amiloride, compared to placebo were identified as eligible for inclusion in the review. In three studies over six months, there was a significant difference found in the difference in relative change in FVC in favour of placebo (weighted mean difference 1.51% (95% confidence interval ‐2.77 to ‐0.25), although heterogeneity was evident. A two‐week study demonstrated that hypertonic saline with amiloride pre‐treatment did not result in a significant improvement in respiratory function or mucus clearance, in contrast to pre‐treatment with placebo. There were no significant differences identified in other clinically relevant outcomes. Authors' conclusions We found no evidence that the topical administration of a short‐acting sodium channel blocker improves respiratory condition in people with cystic fibrosis and some limited evidence of deterioration in lung function. Plain language summary Drugs to control the movement of salt in the lungs of people with cystic fibrosis Usually salt is absorbed from liquid on the surface of the lungs to stop fluid building up there. In cystic fibrosis too much salt is absorbed and there is little liquid left on the airway surfaces. As a result people with cystic fibrosis have problems clearing their lungs of sticky secretions. Thus the lungs are left open to infection. Drugs applied directly to the lungs may prevent too much salt being absorbed. This may lead to better clearance of mucus and less lung infection and damage. The review includes five studies with a total of 226 participants. All studies looked at short‐acting drugs applied directly to the lungs compared to placebo. When the results from three studies over six months were combined, the placebo group showed a slower rate of decline in forced vital capacity than the treatment group. However, each of these differed in their results. A further study showed that people receiving a sodium channel blocker before receiving hypertonic saline did not achieve better lung function or mucus clearance than those receiving placebo before hypertonic saline. We found no evidence that short‐acting sodium channel blockers administered directly to the lungs improve respiratory status in people with cystic fibrosis. There was even some limited evidence of a decline in lung function. Trials of long‐acting sodium channel blockers are ongoing.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Burrows, EF; Southern, KW; Noone, PG", "articleTypes": [], "doi": "10.1002/14651858.CD005087.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "0472bcc7-4705-475a-b459-bf669ba6b532", "pmid": "", "title": "Inhaled sodium cromoglycate for asthma in children", "imported": false, "abstract": "Abstract - Background Sodium cromoglycate has been recommended as maintenance treatment for childhood asthma for many years. Its use has decreased since 1990, when inhaled corticosteroids became popular, but it is still used in many countries. Objectives To determine the efficacy of sodium cromoglycate compared to placebo in the prophylactic treatment of children with asthma. Search methods We searched the Cochrane Airways Group Trials Register (October 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library Issue 3, 2009), MEDLINE (January 1966 to October 2009), EMBASE (January 1985 to October 2009) and reference lists of articles. We also contacted the pharmaceutical company manufacturing sodium cromoglycate. Selection criteria All double‐blind, placebo‐controlled randomised trials, which addressed the effectiveness of inhaled sodium cromoglycate as maintenance therapy, studying children aged 0 up to 18 years with asthma. Data collection and analysis Two authors independently assessed trial quality and extracted data. We pooled study results. Main results Of 3500 titles retrieved from the literature, 24 papers reporting on 23 studies could be included in the review. The studies were published between 1970 and 1997 and together included 1026 participants. Most were cross‐over studies. Few studies provided sufficient information to judge the concealment of allocation. Four studies provided results for the percentage of symptom‐free days. Pooling the results did not reveal a statistically significant difference between sodium cromoglycate and placebo. For the other pooled outcomes, most of the symptom‐related outcomes and bronchodilator use showed statistically significant results, but treatment effects were small. Considering the confidence intervals of the outcome measures, a clinically relevant effect of sodium cromoglycate cannot be excluded. The funnel plot showed an under‐representation of small studies with negative results, suggesting publication bias. Authors' conclusions There is insufficient evidence to be sure about the efficacy of sodium cromoglycate over placebo. Publication bias is likely to have overestimated the beneficial effects of sodium cromoglycate as maintenance therapy in childhood asthma. Plain language summary The effects of sodium cromoglycate compared with placebo for chronic asthma in children In this review we aimed to determine whether there is evidence for the effectiveness of inhaled sodium cromoglycate as maintenance treatment in children with chronic asthma. Most of the studies were carried out in small groups of patients. Furthermore, we suspect that not all studies undertaken have been published. The results show that there is insufficient evidence to be sure about the beneficial effect of sodium cromoglycate compared to placebo. However, for several outcome measures the results favoured sodium cromoglycate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "van der Wouden, JC, Uijen, JHJM, Bernsen, RMD, Tasche, MJA, de Jongste, JC, Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002173.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.755Z" }, { "id": "047b3f28-4eb3-4b45-bf1e-a45cb6e68616", "pmid": "", "title": "Pharmacologic Augmentation of TMS for Depression With D-serine", "imported": false, "abstract": "The goal of this study is to test whether combining D-serine with 30 treatments of a) iTBS and b) 18-Hz protocols will enhance clinical outcomes compared to rTMS with placebo (i.e., sugar pill). The investigators hypothesize that NMDA receptor activation via D-serine combined with repeated sessions of rTMS will produce greater clinical outcomes than iTBS with placebo and 18-Hz with placebo.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.244Z" }, { "id": "04967bb1-03e0-41b6-b6e5-251c93d14f08", "pmid": "", "title": "Rinse‐free hand wash for reducing absenteeism among preschool and school children", "imported": false, "abstract": "Abstract - Background Illness‐related absenteeism is an important problem among preschool and school children for low‐, middle‐ and high‐ income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse‐free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness‐related absenteeism in preschool and school children. Objectives 1. To assess the effectiveness of rinse‐free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse‐free hand washing products are the most effective (if head‐to‐head comparisons exist), and what effect additional strategies in combination with rinse‐free hand washing have on the outcomes of interest. Search methods In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied. Selection criteria Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse‐free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions. Data collection and analysis Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings. Main results This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most‐notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse‐free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low‐certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse‐free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse‐free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low‐certainty evidence), which indicates rinse‐free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse‐free' group (eight days absent per 1000). There may be little to no difference between rinse‐free hand washing and 'no rinse‐free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low‐certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very‐low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse‐free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very‐low certainty evidence). Authors' conclusions The findings of this review may have identified a small yet potentially beneficial effect of rinse‐free hand washing regimes on illness‐related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse‐free hand washing regimens in order to provide more conclusive, higher‐certainty evidence regarding its impact. When considering the use of a rinse‐free hand washing program in a local setting, there needs to be consideration of the current rates of illness‐related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings. Plain language summary Rinse‐free hand wash for reducing absenteeism among preschool and school children Background Absenteeism from schooling is costly to parents, schools and governments and sustained absence is detrimental to student learning. Illness‐related absenteeism is a significant contributor to absenteeism from school, but can also result in parents missing work due to catching the illness themselves or having to stay home to care for their children. There are several strategies currently used to reduce illness‐related absenteeism, a common method is the implementation of appropriate hand hygiene practices. However, hand hygiene using soap and water is not always practical, and alternatives may prove to be more effective in reducing the overall rate of illness‐related absenteeism. One such alternative is the use of rinse‐free hand wash. Review question This review was designed to investigate if the use of rinse‐free hand wash can reduce the number of days spent absent from school in preschool and school children compared to no rinse‐free hand wash usage. Study characteristics The searches returned 19 relevant studies with a total of 30,747 participants. Eight studies were conducted in the USA, two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to14 years). These studies were quite varied in the composition and application of the rinse‐free hand washing program. Only two studies included information on the primary outcome (absenteeism due to any reason), whilst for absenteeism for any illness there were six studies that provided information. The evidence presented is up to date to February 2020. Key results The application of, and adherence to a rinse‐free hand wash, hand hygiene program may be associated with small, but potentially beneficial effects in reducing the number of days students were absent from school due to illness compared to no rinse‐free hand wash, hygiene program. However rinse‐free hand washing may be no different to controls at reducing absenteeism for any reason. There may also be no difference in the number of skin irritations between students who received the rinse‐free hand wash compared to those who used soap and water. Most students and teachers responded favorably to using rinse‐free hand wash and complied relatively well with its use. Certainty of the evidence The certainty of the evidence included in this review was low or very low, mainly due to the included studies using poor methods, providing imprecise data, and being very inconsistent from one another. This means that we have low and very‐low certainty, or confidence, in these results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Munn, Z, Tufanaru, C, Lockwood, C, Stern, C, McAneney, H, Barker, TH", "articleTypes": [], "doi": "10.1002/14651858.CD012566.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.786Z" }, { "id": "04bec8fa-0833-4a52-84d4-4dc68a78201d", "pmid": "", "title": "Influence of Medication Palatability on Prescribing Habits of Pediatric Prescribers", "imported": false, "abstract": "The purpose of this study is to see if a medication taste test influences the prescribing habits of pediatric prescribers at Mayo Clinic.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "04cb58f4-2040-497f-b5fe-f8b5e2d140e6", "pmid": "", "title": "Iodine fortification of foods and condiments, other than salt, for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency disorders (IDD) affect close to 1.9 billion people worldwide, and are a major public health concern in many countries. Among children, iodine deficiency is the main cause of potentially preventable deficits of central nervous system development and impairment of cognitive function, as well as goitre and hypothyroidism in people of all ages. Salt iodisation is the preferred strategy for IDD prevention and control, however, in some instances where salt is not the major condiment, alternate vehicles for iodine fortification have been considered. Objectives To assess the effects of fortifying foods, beverages, condiments, or seasonings other than salt with iodine alone or in conjunction with other micronutrients, on iodine status and health‐related outcomes in all populations. Search methods Studies were identified through systematic searches of the following databases from their start date to January 2018: Cochrane Public Health Group Specialised Register; CENTRAL; MEDLINE; MEDLINE in Process; Embase; Web of Science; CINAHL; POPLINE; AGRICOLA; BIOSIS; Food Science and Technology Abstracts; OpenGrey; Bibliomap and TRoPHI; AGRIS; IBECS; Scielo; Global Index Medicus‐AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched reference list of relevant articles, conference proceedings, and databases of ongoing trials, and contacted experts and relevant organisations to identify any unpublished work. We applied no language or date restrictions. Selection criteria Studies were eligible if they were randomised or quasi‐randomised controlled trials (RCT) with randomisation at either the individual or cluster level (including cross‐over trials), non‐randomised RCTs, or prospective observational studies with a control group, such as cohort studies, controlled before‐and‐after studies, and interrupted time series. We included studies that examined the effects of fortification of food, beverage, condiment, or seasoning with iodine alone, or in combination with other micronutrients versus the same unfortified food, or no intervention. We considered the following measures: death (all‐cause), goitre, physical development, mental development, cognitive function and motor skill development, cretinism, hypothyroidism, adverse effects (any reported by trialists), urinary iodine concentration, thyroid‐stimulating hormone (TSH) concentration, and serum thyroglobulin concentration. We included all populations, including pregnant women, from any country. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias of included studies. We used random‐effects meta‐analyses to combine data and generate an overall estimate of treatment effect, when more than one study examined the same outcome measure. The overall effect estimate was calculated as the mean difference (MD) or standardised mean difference (SMD) between the intervention group and the comparison group for continuous outcomes, and as odds ratio (OR) for dichotomous outcomes. We assessed the level of heterogeneity through the I² statistic. We conducted post‐hoc subgroup analyses to explore possible sources of heterogeneity, and sensitivity analyses to check the robustness of the findings from the primary analyses. We assessed the quality of the evidence for each outcome using the GRADE framework. Where it was not possible to pool the results in a meta‐analysis, we provided a narrative summary of the outcomes. Main results Eleven studies met the criteria, providing 14 comparisons, and capturing data on 4317 participants. Seven studies were RCTs, three were cluster non‐RCTs, and one was a randomised cross‐over design. Seven studies were carried out among school children (N = 3636), three among women of reproductive age (N = 648), and one among infants (N = 33). The studies used diverse types of food as vehicle for iodine delivery: biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. Daily amounts of iodine provided ranged from 35 µg/day to 220 µg/day; trial duration ranged from 11 days to 48 weeks. Five studies examined the effect of iodine fortification alone, two against the same unfortified food, and three against no intervention. Six studies evaluated the effect of cofortification of iodine with other micronutrients versus the same food without iodine but with different levels of other micronutrients. We assessed one study to be at low risk of bias for all bias domains, three at low risk of bias for all domains apart from selective reporting, and seven at an overall rating of high risk of bias. No study assessed the primary outcomes of death, mental development, cognitive function, cretinism, or hypothyroidism, or secondary outcomes of TSH or serum thyroglobulin concentration. Two studies reported the effects on goitre, one on physical development measures, and one on adverse effects. All studies assessed urinary iodine concentration. The effects of iodine fortification compared to control on goitre prevalence (OR 1.60, 95% CI 0.60 to 4.31; 1 non‐RCT, 83 participants; very low‐quality evidence), and five physical development measures were uncertain (1 non‐RCT, 83 participants; very low‐quality evidence): weight (MD 0.23 kg, 95% CI ‐6.30 to 6.77); height (MD ‐0.66 cm, 95% CI ‐4.64 to 3.33); weight‐for‐age (MD 0.05, 95% CI ‐0.59 to 0.69); height‐for‐age (MD ‐0.30, 95% CI ‐0.75 to 0.15); and weight‐for‐height (MD ‐0.21, 95% CI ‐0.51 to 0.10). One study reported that there were no adverse events observed during the cross‐over trial (low‐quality evidence). Pooled results from RCTs showed that urinary iodine concentration significantly increased following iodine fortification (SMD 0.59, 95% CI 0.37 to 0.81; 6 RCTs, 2032 participants; moderate‐quality evidence). This is equivalent to an increase of 38.32 µg/L (95% CI 24.03 to 52.61 µg/L). This effect was not observed in the meta‐analysis of non‐RCTs (SMD 0.25, 95% CI ‐0.16 to 0.66; 3 non‐RCTs, 262 participants; very low‐quality evidence). Sensitivity analyses did not change the effect observed in the primary analyses. Authors' conclusions The evidence on the effect of iodine fortification of foods, beverages, condiments, or seasonings other than salt on reducing goitre, improving physical development measures, and any adverse effects is uncertain. However, our findings suggest that the intervention likely increases urinary iodine concentration. Additional, adequately powered, high‐quality studies on the effects of iodine fortification of foods on these, and other important outcomes, as well as its efficacy and safety, are required. Plain language summary Adding iodine to foods, other than salt, to prevent diseases caused by inadequate iodine intake Background and review question Many people around the world do not consume enough iodine. This is a problem because iodine is important for normal childhood growth and brain development, and for ensuring a healthy adult population. Inadequate intake of iodine can lead to health problems, such as intellectual disability and goitre (enlargement of the thyroid gland). Currently, the main strategy to increase the amount of iodine consumed in populations recommended by the World Health Organization is adding iodine to salt. However, in some areas where salt is not the major condiment, adding iodine to other foods has also been explored. The aim of our study was to examine the effect of adding iodine to foods, beverages, condiments, or seasonings, other than salt, on iodine nutrition status and health‐related outcomes in all populations. Study characteristics We searched for articles from different sources including published research papers, unpublished reports, and through direct communication with experts and organisations working to address iodine and micronutrient deficiency. We last searched the databases in January 2018. Eleven studies, which captured data on 4317 participants (3636 children, 648 women of reproductive age, and 33 infants), met our inclusion criteria. The type of foods used as vehicle to deliver iodine differed between the studies, and included biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. The amount of iodine provided to participants ranged from 35 µg/day to 220 µg/day, and study duration ranged from 11 days to 48 weeks. Of the 11 studies included, five examined the effect of adding iodine alone to foods compared to either no intervention or the same foods without iodine; while six evaluated the effect of adding iodine plus other micronutrients to foods compared to the same foods without iodine, but with different levels of other micronutrients. Key results No study evaluated the effect of adding iodine to foods on death, mental development, cognitive function, cretinism (a condition characterized by impaired control of physical movement and intellectual disability), hypothyroidism (underactive thyroid), thyroid‐stimulating hormone concentration, or serum thyroglobulin concentration (these are biological markers that indicate the presence of iodine deficiency when concentration in the blood is high). Two studies reported on the effect of the intervention on goitre, one study assessed five physical development measures (weight, height, weight‐for‐age, height‐for‐age, and weight‐for‐height scores), and one examined adverse effects. All studies assessed urinary iodine concentration (the concentration of iodine secreted in the urine, which indicates the presence of iodine deficiency when concentration is low in a population group, rather than in an individual). We combined the data that met our requirements in these studies in a meta‐analysis. We are uncertain of the effects of iodine fortification on the proportion of participants with goitre, or on any of the five physical development measures. One study reported narratively that no adverse effects were observed during the trial. We found a significant increase of 38.32 µg/L in urinary iodine concentration after adding iodine to foods, compared to the groups that did not have iodine added, from studies of higher quality. Quality of the evidence Using GRADE, we rated the quality of the evidence as very low for goitre and physical development measures, due to study limitations (risk of bias) and imprecise results, and low for adverse events due to indirectness and imprecise results. We rated the quality of the evidence for urinary iodine concentration, from studies in which participants were allocated to treatment groups at random (gold standard design for clinical research), as moderate. On the other hand, quality of the evidence for urinary iodine concentration from studies without this random element was rated as very low, due to study limitations and imprecise results. Conclusion Overall, there is no clear evidence on the effect of the intervention on reducing the proportion of people with goitre, improving physical growth, or adverse events. However, our results show that adding iodine to foods likely increases urinary iodine concentration. Additional studies to better quantify the effect of the intervention on these outcomes, as well as other outcomes, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Santos, JAR, Christoforou, A, Trieu, K, McKenzie, BL, Downs, S, Billot, L, Webster, J, Li, M", "articleTypes": [], "doi": "10.1002/14651858.CD010734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.801Z" }, { "id": "0502e398-5f39-449f-8913-3fab281af57e", "pmid": "", "title": "Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease", "imported": false, "abstract": "Abstract - Background Thyrotropin‐releasing hormones (TRH) added to prenatal corticosteroids has been suggested as a way to further reduce breathing problems and neonatal lung disease in infants born preterm. Objectives To assess the effects of giving prenatal TRH in addition to corticosteroids to women at risk of preterm birth for the prevention of neonatal respiratory disease. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013) and reference lists of retrieved studies. We also contacted trial authors. Selection criteria Randomised controlled trials in women at sufficient risk of preterm birth to warrant the use of prenatal corticosteroids to promote lung maturity. TRH and corticosteroids were compared with corticosteroids, with or without placebo. Data collection and analysis All assessments of trial eligibility, risk of bias and data extractions were independently carried out by at least two review authors. Main results Over 4600 women were recruited into the 15 trials included in the review, however two trials did not contribute any outcome data to the review. The trials had a moderate risk of bias. Overall, prenatal TRH, in addition to corticosteroids, did not reduce the risk of death prior to hospital discharge (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.86 to 1.27, six trials, 3694 infants), neonatal respiratory distress syndrome (average RR 1.05, 95% CI 0.91 to 1.22, nine trials, 3833 infants), or chronic lung disease (RR 1.01, 95% CI 0.85 to 1.19, five trials, 2511 infants), and did not improve any of the secondary fetal, neonatal or childhood outcomes assessed by intention‐to‐treat analyses. Indeed, the data showed prenatal TRH to have adverse effects for women and their infants. All side effects reported (nausea, vomiting, light headedness, urgency of micturition, facial flushing) were significantly more likely to occur in women receiving TRH. In the infants, prenatal TRH increased the risk of needing respiratory support (RR 1.16, 95% CI 1.03 to 1.29, three trials, 1969 infants), and of having a low Apgar score at five minutes (RR 1.48, 95% CI 1.14 to 1.92, three trials, 1969 infants). Only three trials provided data on childhood follow‐up, and while one trial suggested poorer outcomes for infants who were exposed to prenatal TRH, the other two trials, that assessed infants using an established developmental instrument, showed no clear differences between groups in follow‐up outcomes. Sensitivity analyses by trial quality, or subgroups with differing times from entry to birth, or different dose regimens of TRH, did not change these findings. Authors' conclusions Prenatal TRH in addition to corticosteroids, given to women at risk of preterm birth, does not improve infant outcomes and can cause maternal side effects. Plain language summary Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease Thyrotropin‐releasing hormone (TRH) given with corticosteroids does not improve the benefit of corticosteroids on the lungs of babies born too early, and may increase harm. Babies born preterm (before 37 weeks of pregnancy) are at risk of breathing difficulties (such as respiratory distress syndrome). TRH increases thyroid hormones in the baby and it has been thought that adding TRH to corticosteroids for women giving birth early may increase the benefit of corticosteroids on the baby's lungs. This review included 15 trials, of a moderate risk of bias, that involved over 4600 women and their babies. In this review, TRH, given with corticosteroids to women at risk of early birth, was not shown to further reduce the breathing difficulties for the babies. Babies born to mothers who had received TRH with corticosteroids, were more likely to require support for breathing than babies born to mothers who received only corticosteroids. Women receiving TRH were more likely to experience adverse side effects, such as nausea, vomiting and flushing than women who only received corticosteroids. Therefore, based on the current available evidence, TRH is not recommended to be given to women at risk of preterm birth for preventing neonatal respiratory disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Crowther, CA; Alfirevic, Z; Han, S; Haslam, RR", "articleTypes": [], "doi": "10.1002/14651858.CD000019.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "0504a616-9f75-4efe-83f6-3698470f7106", "pmid": "", "title": "Momordica charantia for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Momordica charantia (bitter gourd) is not only a nutritious vegetable but it is also used in traditional medical practices to treat type 2 diabetes mellitus. Experimental studies with animals and humans suggested that the vegetable has a possible role in glycaemic control. Objectives To assess the effects of mormodica charantia for type 2 diabetes mellitus. Search methods Several electronic databases were searched, among these were The Cochrane Library (Issue 1, 2012), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2012), combined with handsearches. No language restriction was used. Selection criteria We included randomised controlled trials (RCTs) that compared momordica charantia with placebo or a control intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently extracted data. Risk of bias of the trials was evaluated using the parameters of randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. A meta‐analysis was not performed given the quality of data and the variability of preparations of momordica charantia used in the interventions (no similar preparation was tested twice). Main results Four randomised controlled trials with up to three months duration and investigating 479 participants met the inclusion criteria. Risk of bias of these trials (only two studies were published as a full peer‐reviewed publication) was generally high. Two RCTs compared the effects of preparations from different parts of the momordica charantia plant with placebo on glycaemic control in type 2 diabetes mellitus. There was no statistically significant difference in the glycaemic control with momordica charantia preparations compared to placebo. When momordica charantia was compared to metformin or glibenclamide, there was also no significant change in reliable parameters of glycaemic control. No serious adverse effects were reported in any trial. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions There is insufficient evidence on the effects of momordica charantia for type 2 diabetes mellitus. Further studies are therefore required to address the issues of standardization and the quality control of preparations. For medical nutritional therapy, further observational trials evaluating the effects of momordica charantia are needed before RCTs are established to guide any recommendations in clinical practice. Plain language summary Momordica charantia for type 2 diabetes mellitus Mormordica charantia (bitter gourd or bitter melon) is a climbing perennial that is characterized by elongated, warty fruit‐like gourds or cucumbers and is native to the tropical belt. Although momordica charantia is commonly used in traditional medical practices, along with research suggesting its benefits for people with type 2 diabetes, the current evidence does not warrant using the plant in treating this disease. This review of trials found only four studies which had an overall low quality. Three trials showed no significant differences between momordica charantia and placebo or antidiabetic drugs (glibenclamide and metformin) in the blood sugar response. The duration of treatment ranged from four weeks to three months, and altogether 479 patients with type 2 diabetes mellitus participated. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Adverse effects were mostly moderate, including diarrhoea and abdominal pain. However, reporting of adverse effects was incomplete in the included studies. There are many varieties of preparations of momordica charantia, as well as variations in its use as a vegetable. Further studies are needed to assess the quality of the various momordica charantia preparations as well as to further evaluate its use in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Ooi, CP; Yassin, Z; Hamid, TA", "articleTypes": [], "doi": "10.1002/14651858.CD007845.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "05070238-ff34-49a7-baa2-8534216ab4f2", "pmid": "", "title": "Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Das, RR, Singh, M, Naik, SS", "articleTypes": [], "doi": "10.1002/14651858.CD011597.pub3 AB - Abstract - Background Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases children's risk of developing pneumonia. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited. This is an update of a Cochrane Review first published in 2018. Objectives To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia. Search methods We searched CENTRAL, MEDLINE, Embase, and two trial registries on 28 December 2021. We applied no language restrictions. Selection criteria We included randomised controlled trials (RCTs) that compared vitamin D supplementation with placebo in children (aged one month to five years) hospitalised with acute community‐acquired pneumonia, as defined by the World Health Organization (WHO) acute respiratory infection guidelines. For this update, we reappraised eligible trials according to research integrity criteria, excluding RCTs published from April 2018 that were not prospectively registered in a trials registry according to WHO or Clinical Trials Registry – India (CTRI) guidelines (it was not mandatory to register clinical trials in India before April 2018). Data collection and analysis Two review authors independently assessed trials for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with number of participants in each group. We used standard methodological procedures expected by Cochrane. Main results In this update, we included three new trials involving 468 children, bringing the total number of trials to seven, with 1601 children (631 with pneumonia and 970 with severe or very severe pneumonia). We categorised three previously included studies and three new studies as 'awaiting classification' based on the research integrity screen.
Five trials used a single bolus dose of vitamin D (300,000 IU in one trial and 100,000 IU in four trials) at the onset of illness or within 24 hours of hospital admission; one used a daily dose of oral vitamin D (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used variable doses (on day 1, 20,000 IU in children younger than six months, 50,000 IU in children aged six to 12 months, and 100,000 IU in children aged 13 to 59 months; followed by 10,000 IU/day for four days or until discharge). Three trials performed microbiological diagnosis of pneumonia, radiological diagnosis of pneumonia, or both. Vitamin D probably has little or no effect on the time to resolution of acute illness (mean difference (MD) −1.28 hours, 95% confidence interval (CI) −5.47 to 2.91; 5 trials, 1188 children; moderate‐certainty evidence). We do not know if vitamin D has an effect on the duration of hospitalisation (MD 4.96 hours, 95% CI −8.28 to 18.21; 5 trials, 1023 children; very low‐certainty evidence). We do not know if vitamin D has an effect on mortality rate (risk ratio (RR) 0.69, 95% CI 0.44 to 1.07; 3 trials, 584 children; low‐certainty evidence). The trials reported no major adverse events. According to GRADE criteria, the evidence was of very low‐to‐moderate certainty for all outcomes, owing to serious trial limitations, inconsistency, indirectness, and imprecision. Three trials received funding: one from the New Zealand Aid Corporation, one from an institutional grant, and one from multigovernment organisations (Bangladesh, Sweden, and UK). The remaining four trials were unfunded. Authors' conclusions Based on the available evidence, we are uncertain whether vitamin D supplementation has important effects on outcomes of acute pneumonia when used as an adjunct to antibiotics. The trials reported no major adverse events. Uncertainty in the evidence is due to imprecision, risk of bias, inconsistency, and indirectness. Plain language summary Is vitamin D an effective and safe addition to antibiotics for treating children with acute pneumonia? What is pneumonia, and how can it be treated? Pneumonia is inflammation (swelling) of the lungs caused by an infection. Treatment for pneumonia includes antibiotics, providing oxygen through a mask, and other supportive therapies. Vitamin D boosts immune defences and reduces excessive inflammation: these effects may help children recover from an episode of pneumonia. What did we want to find out? We wanted to find out if vitamin D, taken together with antibiotics, can help children to recover from an episode of pneumonia. What did we do? We searched for trials that looked at vitamin D compared with placebo (dummy treatment) in children aged between one month and five years who had pneumonia. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. Study characteristics We included seven trials involving 1601 children from low‐ and middle‐income countries. In five trials, children received a single large dose of vitamin D when they joined the trial or within 24 hours of admission to hospital. In two trials, children received vitamin D for five days. One trial excluded children with normal vitamin D levels. Two trials reported the cause of children's pneumonia. Key results Vitamin D probably has little or no effect on the time it takes children to get better from pneumonia. We do not know if vitamin D has an effect on the time children spend in hospital or the number of children who die. The studies reported no major harmful events. What are the limitations of the evidence? We have only moderate confidence in the evidence on the time it took children to recover from pneumonia, because all children in this comparison were from low‐income regions, so the results may not apply to higher‐income populations. We have little confidence in the evidence on death rate, because of the same applicability problem outlined above, and because the result was compatible with both appreciable benefit and harm. We have very little confidence in the evidence on time spent in hospital, because of the same applicability problem outlined above, because the children and health providers in one study knew what the allocated treatment was, and because the results were very inconsistent across the studies included in the comparison. How up to date is the evidence? The evidence is current to 28 December 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.760Z" }, { "id": "05279c80-db3f-4263-8bd3-cd2d77203295", "pmid": "", "title": "A Randomized Cross-Over Study to Investigate the Effect of the Non-Nutritive Sweetener Sucralose on Glucose Metabolism in Patients with Type 1 Diabetes", "imported": false, "abstract": "The goal of this randomized crossover study is to test the prediction that consuming carbohydrates will affect insulin release differently depending on whether Non-Nutritive Sweeteners (NNSs) are consumed simultaneously. We aim to determine whether the predicted effects are associated with oral or post-oral sweet taste receptor signaling,. Our study will focus on patients diagnosed with type 1 diabetes (T1D) who are using an artificial pancreas (AP) system, as it allows us to monitor glucose and insulin levels over time.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "0539ac1b-b5c9-47c1-9dcd-2019cb151683", "pmid": "", "title": "Nutritional labelling for healthier food or non‐alcoholic drink purchasing and consumption", "imported": false, "abstract": "Abstract - Background Nutritional labelling is advocated as a means to promote healthier food purchasing and consumption, including lower energy intake. Internationally, many different nutritional labelling schemes have been introduced. There is no consensus on whether such labelling is effective in promoting healthier behaviour. Objectives To assess the impact of nutritional labelling for food and non‐alcoholic drinks on purchasing and consumption of healthier items. Our secondary objective was to explore possible effect moderators of nutritional labelling on purchasing and consumption. Search methods We searched 13 electronic databases including CENTRAL, MEDLINE and Embase to 26 April 2017. We also handsearched references and citations and sought unpublished studies through websites and trials registries. Selection criteria Eligible studies: were randomised or quasi‐randomised controlled trials (RCTs/Q‐RCTs), controlled before‐and‐after studies, or interrupted time series (ITS) studies; compared a labelled product (with information on nutrients or energy) with the same product without a nutritional label; assessed objectively measured purchasing or consumption of foods or non‐alcoholic drinks in real‐world or laboratory settings. Data collection and analysis Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of bias' tool and GRADE to assess the quality of evidence. We pooled studies that evaluated similar interventions and outcomes using a random‐effects meta‐analysis, and we synthesised data from other studies in a narrative summary. Main results We included 28 studies, comprising 17 RCTs, 5 Q‐RCTs and 6 ITS studies. Most (21/28) took place in the USA, and 19 took place in university settings, 14 of which mainly involved university students or staff. Most (20/28) studies assessed the impact of labelling on menus or menu boards, or nutritional labelling placed on, or adjacent to, a range of foods or drinks from which participants could choose. Eight studies provided participants with only one labelled food or drink option (in which labelling was present on a container or packaging, adjacent to the food or on a display board) and measured the amount consumed. The most frequently assessed labelling type was energy (i.e. calorie) information (12/28). Eleven studies assessed the impact of nutritional labelling on purchasing food or drink options in real‐world settings, including purchases from vending machines (one cluster‐RCT), grocery stores (one ITS), or restaurants, cafeterias or coffee shops (three RCTs, one Q‐RCT and five ITS). Findings on vending machines and grocery stores were not interpretable, and were rated as very low quality. A meta‐analysis of the three RCTs, all of which assessed energy labelling on menus in restaurants, demonstrated a statistically significant reduction of 47 kcal in energy purchased (MD −46.72 kcal, 95% CI −78.35, −15.10, N = 1877). Assuming an average meal of 600 kcal, energy labelling on menus would reduce energy purchased per meal by 7.8% (95% CI 2.5% to 13.1%). The quality of the evidence for these three studies was rated as low, so our confidence in the effect estimate is limited and may change with further studies. Of the remaining six studies, only two (both ITS studies involving energy labels on menus or menus boards in a coffee shop or cafeteria) were at low risk of bias, and their results support the meta‐analysis. The results of the other four studies which were conducted in a restaurant, cafeterias (2 studies) or a coffee shop, were not clearly reported and were at high risk of bias. Seventeen studies assessed the impact of nutritional labels on consumption in artificial settings or scenarios (henceforth referred to as laboratory studies or settings). Of these, eight (all RCTs) assessed the effect of labels on menus or placed on a range of food options. A meta‐analysis of these studies did not conclusively demonstrate a reduction in energy consumed during a meal (MD −50 kcal, 95% CI −104.41, 3.88, N = 1705). We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. Six laboratory studies (four RCTs and two Q‐RCTs) assessed the impact of labelling a single food or drink option (such as chocolate, pasta or soft drinks) on energy consumed during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant difference in energy (kcal) consumed (SMD 0.05, 95% CI −0.17 to 0.27, N = 732). However, the confidence intervals were wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. There was no evidence that nutritional labelling had the unintended harm of increasing energy purchased or consumed. Indirect evidence came from five laboratory studies that involved mislabelling single nutrient content (i.e. placing low energy or low fat labels on high‐energy foods) during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant increase in energy (kcal) consumed (SMD 0.19, 95% CI −0.14to 0.51, N = 718). The effect was small and the confidence intervals wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence from these studies as very low, providing very little confidence in the effect estimate. Authors' conclusions Findings from a small body of low‐quality evidence suggest that nutritional labelling comprising energy information on menus may reduce energy purchased in restaurants. The evidence assessing the impact on consumption of energy information on menus or on a range of food options in laboratory settings suggests a similar effect to that observed for purchasing, although the evidence is less definite and also of low quality. Accordingly, and in the absence of observed harms, we tentatively suggest that nutritional labelling on menus in restaurants could be used as part of a wider set of measures to tackle obesity. Additional high‐quality research in real‐world settings is needed to enable more certain conclusions. Further high‐quality research is also needed to address the dearth of evidence from grocery stores and vending machines and to assess potential moderators of the intervention effect, including socioeconomic status. Plain language summary Nutritional labelling to promote healthier consumption and purchasing of food or drinks A poor diet including excessive energy intake is an important cause of ill health. Nutritional labelling may help people to make healthier food choices. What is the aim of this review? This review investigated whether nutritional labels (i.e. labels providing information about nutritional content) persuade people to buy or consume different (healthy) kinds of food. We searched for all available evidence to answer this question and found 28 studies. Key messages There is evidence to suggest that nutritional labelling, with energy information (e.g. calorie counts) on menus, may reduce energy purchased in restaurants, but more high‐quality studies are needed to make this finding more certain. What was studied in the review? Some studies assessed buying food or drinks from vending machines, grocery stores, restaurants, cafeterias, or coffee shops. Others assessed the amount of food or drink consumed during a snack or meal in an artificial setting or scenario (referred to as laboratory studies or settings). What are the main results of the review? Nutritional labelling on restaurant menus reduced the amount of energy (i.e. calories) purchased, but the quality of the three studies that contributed to this finding was low, so our confidence in the effect estimate is limited and may change with further studies. Eight studies assessed this same type of intervention in laboratory settings, but instead of evaluating how much energy participants purchased, these studies evaluated how much energy participants consumed. These studies did not conclusively demonstrate a reduction in energy consumed when menus or foods were labelled, and they were also of low quality. In addition, six laboratory studies assessed how much energy participants consumed when they were given one food or drink option with or without labels, and five laboratory studies assessed how much energy participants consumed when foods were experimentally labelled as low energy or low fat when they were actually high‐energy foods (i.e. mislabelling). Results from these two groups of studies were inconclusive and of low, or in the case of mislabelling studies, very low quality. We found some studies that assessed labelling on vending machines and grocery stores, but their results were not easy to interpret, so we could not use them to inform this review. How up‐to‐date is this review? The evidence is current to 26 April 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Crockett, RA; King, SE; Marteau, TM; Prevost, AT; Bignardi, G; Roberts, NW; Stubbs, B; Hollands, GJ; Jebb, SA", "articleTypes": [], "doi": "10.1002/14651858.CD009315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "056383c7-0c3f-4bec-89aa-986a5475f861", "pmid": "", "title": "Celiac Disease and Vitamin Status: Evaluation of the Effect of Supplementation With a Probiotic (VIVOMIXX®) on Vitamin B6, B12, 25'OH D, Folic Acid and Omocystein Levels, Metabolic and Inflammatory Status, and Gut Microbiota Metabolomics in a Cohoort of Celiac Patients", "imported": false, "abstract": "Celiac disease is a disorder caused by a disregulation of the immune system which leads to immune response to gluten. Diet therapy is the gold standard of treatment, and the only effective one. Macronutrients and micronutrients deficiency (vitamin D, folic acid, vitamin B12, vitamin B6, iron and zinc), which is in any case far more common in patients who don't follow gluten free diet, can persist in a subset of patients who follow gluten-free diet. Supplementation of vitamins in these patients may have a beneficial role. A recent study in a murine model showed that supplementation with probiotic VIVOMIXX® leads to an increase in expression of vitamin D receptors in proximal and distal colon.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.243Z" }, { "id": "056e139d-ee20-4202-a043-e44a4f47aae4", "pmid": "", "title": "Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Chronic infection with Pseudomonas aeruginosa (PA) in cystic fibrosis (CF) is a source of much morbidity and mortality. Eradication of early PA infection is possible, but can recur in many individuals. We sought to examine strategies to delay the time to PA recurrence in people with CF. Objectives To establish whether secondary prevention strategies, using antibiotics or other therapies, increase the chances of people with CF remaining free from PA infection following successful eradication therapy. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries and the reference lists of relevant articles and reviews. Date of last search: 21 August 2019. Selection criteria Randomised controlled trials (and quasi‐randomised trials where the risk of bias was low) comparing any treatment modality aimed at preventing recurrence of PA infection with placebo, standard therapy or any other treatment modality in people with CF who have undergone successful eradication of PA. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias. Quality of the evidence was assessed using GRADE. Conflicts were resolved by discussion and the opinion of a third review author was sought where necessary. Only a subset of participants in the included trial were eligible, therefore individual participant data were requested and obtained from the trial investigators. Main results We included one trial (n = 306) in the review; however, only 253 participants had undergone successful eradication of PA, so fulfilling the inclusion criteria for our review. Information presented relates only to the included subset of participants. The trial recruited children aged one to 12 years (mean (standard deviation (SD)) age of 5.8 (3.5) years), 129 participants (51.0%) were female and the median follow‐up was 494 days. We compared cycled therapy with tobramycin inhalation solution (TIS), in which participants underwent 28 days of TIS every three months, with culture‐based therapy, in which participants were only prescribed medication when a quarterly sputum sample was positive for PA. Reasons for downgrading the quality of the evidence included applicability (only included children), incomplete outcome data and a small number of participants. The time to next isolation of PA was probably shorter with cycled TIS therapy than with culture‐based therapy, hazard ratio (HR) 2.04 days (95% confidence interval (CI) 1.28 to 3.26) (moderate‐quality evidence). This is in contrast to the main publication of the only included trial, which examined rate of PA positivity rather than time to PA infection and included participants not eligible for inclusion in this review. At the end of the trial, there was no difference between the cycled and culture‐based groups in the change from baseline in forced expiratory volume in one second (FEV 1 ) L, mean difference (MD) 0.0 L (95% CI ‐0.09 to 0.09) or in FEV 1 % predicted, MD 0.70% (95% CI ‐4.33 to 5.73) (both very low‐quality evidence). There was no difference in the change from baseline for FVC between the groups. There was also no difference in the frequency of pulmonary exacerbations between groups, MD ‐0.18 (95% CI ‐0.51 to 0.14) (moderate‐quality evidence). Similarly, there was no difference between groups in the risk of participants developing novel resistant bacteria, RR 1.00 (95% CI 0.67 to 1.5) (moderate‐quality evidence). There were more severe adverse events in the cycled group, but the type of treatment probably makes little or no difference to the results, RR 0.65 (95% CI 0.39 to 1.11) (moderate‐quality evidence). There was no difference between groups in the change in weight or height from baseline or in rates of adherence to tobramycin or all trial medicines. The included trial did not assess changes in quality of life, the time to chronic infection with PA or the cost‐effectiveness of treatment. Authors' conclusions Cycled TIS therapy may be beneficial in prolonging the time to recurrence of PA after successful eradication, but further trials are required, specifically addressing this question and in both adults and children. Plain language summary Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis Review question We reviewed evidence about the effect of treatments given to people with cystic fibrosis (CF) to prevent recurrence of infection with bacteria called Pseudomonas aeruginosa (PA) after it has been successfully treated. Background People with CF experience frequent, severe chest infections. These infections may be caused by bacteria that do not cause disease in healthy people, such as PA. PA is an important infection in CF since if it is not treated early it cannot be cleared from the lungs (termed chronic PA). When it cannot be cleared from the lungs, it causes ongoing damage to the lung tissue as well as worse chest infections. People with CF who have chronic PA may be more unwell than those without it. Early treatment can remove PA from the lungs of people with CF, but infection can happen again and is difficult to prevent. We want to know if giving extra treatment after the PA has been successfully treated, can prolong the time to the next infection. The treatment could be antibiotics or another treatment, for example something that helps the person's immune system fight the PA. Search date The evidence is current to: 21 August 2019. Trial characteristics We included one trial with 306 participants. Only 253 of these people had had successful treatment of PA and so could be included in our review. There were only children in the trial who were aged between one and 12 years old; 51% were girls. The trial compared treatment with one month of an inhaled antibiotic every three months ('cycled treatment') with antibiotic treatment given only when the person was found to have PA ('culture‐based treatment'). People were selected randomly to have either cycled or culture‐based treatment. The trial followed people up for an average of 70 weeks. Key results Taking into the account the certainty of the evidence, we believe that the time to the next isolation of PA was probably shorter with cycled therapy than with culture‐based therapy. We found that PA recurred in a quarter of participants in the culture‐based group by 249 days but in the cycled group it took 505 days; giving cycled treatment doubled the time to a new infection with PA compared with culture‐based treatment. This is in contrast to the main publication of the only included trial, which looked at the rate of positive PA cultures rather than the time to a new infection of PA and included participants not eligible for inclusion in this review. There was no difference between the groups in: pulmonary function (a measure of how well someone's lungs are working); in the number of people having chest infections; in the change in height and weight from the beginning to th end of the trial; in how many people took all the doses of the medications; in how many people developed infections with new bacteria; or in how many people had a serious complication. The trial did not give information about the effect of the two treatments on individuals' quality of life, the time until the development of chronic PA or the cost‐effectiveness of the treatment. Quality of the evidence The quality of most of the evidence was moderate. As the trial only included children, we cannot be sure if the cycled treatment would have the same effect in teenagers or adults with CF. Further trials including both adults and children are needed to help answer the question. Trials designed to specifically answer this question are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Palser, S, Smith, S, Nash, EF, Agarwal, A, Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD012300.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.800Z" }, { "id": "0575d14c-011d-48a7-83ad-c8d5e42094b7", "pmid": "", "title": "Vitamin C for preventing and treating pneumonia", "imported": false, "abstract": "Abstract - Background Pneumonia is one of the most common serious infections, causing two million deaths annually among young children in low‐income countries. In high‐income countries pneumonia is most significantly a problem of the elderly. Objectives To assess the prophylactic and therapeutic effects of vitamin C on pneumonia. Search methods We searched CENTRAL 2013, Issue 3, MEDLINE (1950 to March week 4, 2013), EMBASE (1974 to April 2013) and Web of Science (1955 to April 2013). Selection criteria To assess the therapeutic effects of vitamin C, we selected placebo‐controlled trials. To assess prophylactic effects, we selected controlled trials with or without a placebo. Data collection and analysis Two review authors independently read the trial reports and extracted data. Main results We identified three prophylactic trials which recorded 37 cases of community‐acquired pneumonia in 2335 people. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. Two trials examined military recruits and the third studied boys from \"lower wage‐earning classes\" attending a boarding school in the UK during World War II. Each of these three trials found a statistically significant (80% or greater) reduction in pneumonia incidence in the vitamin C group. We identified two therapeutic trials involving 197 community‐acquired pneumonia patients. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. That trial studied elderly patients in the UK and found lower mortality and reduced severity in the vitamin C group; however, the benefit was restricted to the most ill patients. The other therapeutic trial studied adults with a wide age range in the former Soviet Union and found a dose‐dependent reduction in the duration of pneumonia with two vitamin C doses. We identified one prophylactic trial recording 13 cases of hospital‐acquired pneumonia in 37 severely burned patients; one‐day administration of vitamin C had no effect on pneumonia incidence. The identified studies are clinically heterogeneous which limits their comparability. The included studies did not find adverse effects of vitamin C. Authors' conclusions The prophylactic use of vitamin C to prevent pneumonia should be further investigated in populations who have a high incidence of pneumonia, especially if dietary vitamin C intake is low. Similarly, the therapeutic effects of vitamin C should be studied, especially in patients with low plasma vitamin C levels. The current evidence is too weak to advocate prophylactic use of vitamin C to prevent pneumonia in the general population. Nevertheless, therapeutic vitamin C supplementation may be reasonable for pneumonia patients who have low vitamin C plasma levels because its cost and risks are low. Plain language summary Vitamin C for preventing and treating pneumonia Pneumonia is an infection of the lungs usually caused by bacteria and viruses. Its clinical diagnosis is sometimes difficult. Pneumonia is more common in young children and in the aged. In low‐income countries it causes two million deaths annually among young children. In the USA it is the most common cause of death from infection. Vitamin C was identified in the early 1900s and suggestions that one of its biological roles may be to resist infections are supported by numerous animal studies. We looked for studies in humans and found three trials with a total of 2335 participants that looked at whether vitamin C prevents pneumonia in the community. Two of these preventive trials studied soldiers while the third studied boys in a UK boarding school in the 1940s. Two therapeutic trials with a total of 197 pneumonia patients looked at whether vitamin C might be beneficial for pneumonia patients. One studied patients aged 66 to 94 years in the UK with pneumonia. The other therapeutic trial was conducted in the former Soviet Union but the social and nutritional backgrounds of the patients were not described. One study with 37 burns patients examined the effect of vitamin C on hospital‐acquired pneumonia. Our searches were up‐date‐as of April 2013. Five of the identified trials found preventive or therapeutic benefits of vitamin C against pneumonia but the study on hospital‐acquired pneumonia found no effect. The overall quality of the studies was good. However, the five trials with positive findings were carried out in such extraordinary conditions that the results should not be extrapolated to the general population. Therefore, more research is needed. In the meantime, supplementing pneumonia patients who have low plasma vitamin C levels may be reasonable because of its safety and low cost. None of the five trials reported noteworthy adverse effects of vitamin C.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H; Louhiala, P", "articleTypes": [], "doi": "10.1002/14651858.CD005532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "05865c12-1188-43e6-bbd7-a51a76bec856", "pmid": "", "title": "Antibody tests for identification of current and past infection with SARS‐CoV‐2", "imported": false, "abstract": "Abstract - Background The diagnostic challenges associated with the COVID‐19 pandemic resulted in rapid development of diagnostic test methods for detecting SARS‐CoV‐2 infection. Serology tests to detect the presence of antibodies to SARS‐CoV‐2 enable detection of past infection and may detect cases of SARS‐CoV‐2 infection that were missed by earlier diagnostic tests. Understanding the diagnostic accuracy of serology tests for SARS‐CoV‐2 infection may enable development of effective diagnostic and management pathways, inform public health management decisions and understanding of SARS‐CoV‐2 epidemiology. Objectives To assess the accuracy of antibody tests, firstly, to determine if a person presenting in the community, or in primary or secondary care has current SARS‐CoV‐2 infection according to time after onset of infection and, secondly, to determine if a person has previously been infected with SARS‐CoV‐2. Sources of heterogeneity investigated included: timing of test, test method, SARS‐CoV‐2 antigen used, test brand, and reference standard for non‐SARS‐CoV‐2 cases. Search methods The COVID‐19 Open Access Project living evidence database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) was searched on 30 September 2020. We included additional publications from the Evidence for Policy and Practice Information and Co‐ordinating Centre (EPPI‐Centre) ‘COVID‐19: Living map of the evidence’ and the Norwegian Institute of Public Health ’NIPH systematic and living map on COVID‐19 evidence’. We did not apply language restrictions. Selection criteria We included test accuracy studies of any design that evaluated commercially produced serology tests, targeting IgG, IgM, IgA alone, or in combination. Studies must have provided data for sensitivity, that could be allocated to a predefined time period after onset of symptoms, or after a positive RT‐PCR test. Small studies with fewer than 25 SARS‐CoV‐2 infection cases were excluded. We included any reference standard to define the presence or absence of SARS‐CoV‐2 (including reverse transcription polymerase chain reaction tests (RT‐PCR), clinical diagnostic criteria, and pre‐pandemic samples). Data collection and analysis We use standard screening procedures with three reviewers. Quality assessment (using the QUADAS‐2 tool) and numeric study results were extracted independently by two people. Other study characteristics were extracted by one reviewer and checked by a second. We present sensitivity and specificity with 95% confidence intervals (CIs) for each test and, for meta‐analysis, we fitted univariate random‐effects logistic regression models for sensitivity by eligible time period and for specificity by reference standard group. Heterogeneity was investigated by including indicator variables in the random‐effects logistic regression models. We tabulated results by test manufacturer and summarised results for tests that were evaluated in 200 or more samples and that met a modification of UK Medicines and Healthcare products Regulatory Agency (MHRA) target performance criteria. Main results We included 178 separate studies (described in 177 study reports, with 45 as pre‐prints) providing 527 test evaluations. The studies included 64,688 samples including 25,724 from people with confirmed SARS‐CoV‐2; most compared the accuracy of two or more assays (102/178, 57%). Participants with confirmed SARS‐CoV‐2 infection were most commonly hospital inpatients (78/178, 44%), and pre‐pandemic samples were used by 45% (81/178) to estimate specificity. Over two‐thirds of studies recruited participants based on known SARS‐CoV‐2 infection status (123/178, 69%). All studies were conducted prior to the introduction of SARS‐CoV‐2 vaccines and present data for naturally acquired antibody responses. Seventy‐nine percent (141/178) of studies reported sensitivity by week after symptom onset and 66% (117/178) for convalescent phase infection. Studies evaluated enzyme‐linked immunosorbent assays (ELISA) (165/527; 31%), chemiluminescent assays (CLIA) (167/527; 32%) or lateral flow assays (LFA) (188/527; 36%). Risk of bias was high because of participant selection (172, 97%); application and interpretation of the index test (35, 20%); weaknesses in the reference standard (38, 21%); and issues related to participant flow and timing (148, 82%). We judged that there were high concerns about the applicability of the evidence related to participants in 170 (96%) studies, and about the applicability of the reference standard in 162 (91%) studies. Average sensitivities for current SARS‐CoV‐2 infection increased by week after onset for all target antibodies. Average sensitivity for the combination of either IgG or IgM was 41.1% in week one (95% CI 38.1 to 44.2; 103 evaluations; 3881 samples, 1593 cases), 74.9% in week two (95% CI 72.4 to 77.3; 96 evaluations, 3948 samples, 2904 cases) and 88.0% by week three after onset of symptoms (95% CI 86.3 to 89.5; 103 evaluations, 2929 samples, 2571 cases). Average sensitivity during the convalescent phase of infection (up to a maximum of 100 days since onset of symptoms, where reported) was 89.8% for IgG (95% CI 88.5 to 90.9; 253 evaluations, 16,846 samples, 14,183 cases), 92.9% for IgG or IgM combined (95% CI 91.0 to 94.4; 108 evaluations, 3571 samples, 3206 cases) and 94.3% for total antibodies (95% CI 92.8 to 95.5; 58 evaluations, 7063 samples, 6652 cases). Average sensitivities for IgM alone followed a similar pattern but were of a lower test accuracy in every time slot. Average specificities were consistently high and precise, particularly for pre‐pandemic samples which provide the least biased estimates of specificity (ranging from 98.6% for IgM to 99.8% for total antibodies). Subgroup analyses suggested small differences in sensitivity and specificity by test technology however heterogeneity in study results, timing of sample collection, and smaller sample numbers in some groups made comparisons difficult. For IgG, CLIAs were the most sensitive (convalescent‐phase infection) and specific (pre‐pandemic samples) compared to both ELISAs and LFAs (P < 0.001 for differences across test methods). The antigen(s) used (whether from the Spike‐protein or nucleocapsid) appeared to have some effect on average sensitivity in the first weeks after onset but there was no clear evidence of an effect during convalescent‐phase infection. Investigations of test performance by brand showed considerable variation in sensitivity between tests, and in results between studies evaluating the same test. For tests that were evaluated in 200 or more samples, the lower bound of the 95% CI for sensitivity was 90% or more for only a small number of tests (IgG, n = 5; IgG or IgM, n = 1; total antibodies, n = 4). More test brands met the MHRA minimum criteria for specificity of 98% or above (IgG, n = 16; IgG or IgM, n = 5; total antibodies, n = 7). Seven assays met the specified criteria for both sensitivity and specificity. In a low‐prevalence (2%) setting, where antibody testing is used to diagnose COVID‐19 in people with symptoms but who have had a negative PCR test, we would anticipate that 1 (1 to 2) case would be missed and 8 (5 to 15) would be falsely positive in 1000 people undergoing IgG or IgM testing in week three after onset of SARS‐CoV‐2 infection. In a seroprevalence survey, where prevalence of prior infection is 50%, we would anticipate that 51 (46 to 58) cases would be missed and 6 (5 to 7) would be falsely positive in 1000 people having IgG tests during the convalescent phase (21 to 100 days post‐symptom onset or post‐positive PCR) of SARS‐CoV‐2 infection. Authors' conclusions Some antibody tests could be a useful diagnostic tool for those in whom molecular‐ or antigen‐based tests have failed to detect the SARS‐CoV‐2 virus, including in those with ongoing symptoms of acute infection (from week three onwards) or those presenting with post‐acute sequelae of COVID‐19. However, antibody tests have an increasing likelihood of detecting an immune response to infection as time since onset of infection progresses and have demonstrated adequate performance for detection of prior infection for sero‐epidemiological purposes. The applicability of results for detection of vaccination‐induced antibodies is uncertain. Plain language summary What is the diagnostic accuracy of antibody tests for the detection of infection with the COVID‐19 virus? Background COVID‐19 is an infectious disease caused by the SARS‐CoV‐2 virus that spreads easily between people in a similar way to the common cold or ‘flu’. Most people with COVID‐19 have a mild‐to‐moderate respiratory illness, and some may have no symptoms (asymptomatic infection). Others experience severe symptoms and need specialist treatment and intensive care. In response to COVID‐19 infection, the immune system develops proteins called antibodies that can attack the virus as it circulates in their blood. People who have been vaccinated against COVID‐19 also produce these antibodies against the virus. Tests are available to detect antibodies in peoples' blood, which may indicate that they currently have COVID‐19 or have had it previously, or it may indicate that they have been vaccinated (although this group was not the focus of this review). Why are accurate tests important? Accurate testing allows identification of people who need to isolate themselves to prevent the spread of infection, or who might need treatment for their infection. Failure of diagnostic tests to detect infection with COVID‐19 when it is present (a false negative result) may delay treatment and risk further spread of infection to others. Incorrect diagnosis of COVID‐19 when it is not present (a false positive result) may lead to unnecessary further testing, treatment, and isolation of the person and close contacts. Accurate identification of people who have previously had COVID‐19 is important in measuring disease spread and assessing the success of public health interventions. To determine the accuracy of an antibody test in identifying COVID‐19, test results are compared in people known to have (or have had) COVID‐19 and in people known not to have (or have had) COVID‐19. The criteria used to determine whether people are known or not known to have COVID‐19 is called the ‘reference standard’. Many studies use a test called reverse transcriptase polymerase chain reaction (RT‐PCR) as the reference standard, with samples taken from the nose and throat. Additional tests that can be used include measuring symptoms, like coughing or high temperature, or ‘imaging’ tests like chest X‐rays. People known not to have COVID‐19 are sometimes identified from stored blood samples taken before COVID‐19 existed, or from patients with symptoms confirmed to be caused by other diseases. What did the review study? We wanted to find out whether antibody tests: ‐ are able to diagnose infection in people with or without symptoms of COVID‐19, and ‐ can be used to find out if someone has already had COVID‐19. The studies we included in our review looked at three types of antibodies. Most commonly, antibody tests measure two types known as IgG and IgM, but some tests only measure a single type of antibody or different combinations of the three types of antibodies (IgA, IgG, IgM). What did we do? We looked for studies that measured the diagnostic accuracy of antibody tests to detect current or past COVID‐19 infection and compared them with reference standard criteria. Since there are many antibody tests available, we included studies assessing any antibody test compared with any reference standard. People could be tested in hospital or in the community. The people tested may have been confirmed to have, or not to have, COVID‐19 infection, or they may be suspected of having COVID‐19. Study characteristics We found 178 relevant studies. Studies took place in Europe (94), Asia (45), North America (35), Australia (2), and South America (2). Seventy‐eight studies included people who were in hospital with suspected or confirmed COVID‐19 infection and 14 studies included people in community settings. Several studies included people from multiple settings (35) or did not report where the participants were recruited from (39). One hundred and forty‐one studies included recent infection cases (mainly week 1 to week 3 after onset of symptoms), and many also included people tested later (from day 21 onwards after infection) (117). Main results In participants that had COVID‐19 and were tested one week after symptoms developed, antibody tests detected only 27% to 41% of infections. In week 2 after first symptoms, 64% to 79% of infections were detected, rising to 78% to 88% in week 3. Tests that specifically detected IgG or IgM antibodies were the most accurate and, when testing people from 21 days after first symptoms, they detected 93% of people with COVID‐19. Tests gave false positive results for 1% of those without COVID‐19. Below we illustrate results for two different scenarios. If 1000 people were tested for IgG or IgM antibodies during the third week after onset of symptoms and only 20 (2%) of them actually had COVID‐19: ‐ 26 people would test positive. Of these, 8 people (31%) would not have COVID‐19 (false positive result). ‐ 974 people would test negative. Of these, 2 people (0.2%) would actually have COVID‐19 (false negative result). If 1000 people with no symptoms for COVID‐19 were tested for IgG antibodies and 500 (50%) of them had previously had COVID‐19 infection more than 21 days previously: ‐ 455 people would test positive. Of these, 6 people (1%) would not have been infected (false positive result). ‐ 545 people would test negative. Of these, 51 (9%) would actually have had a prior COVID‐19 infection (false negative result). How reliable were the results of the studies of this review? We have limited confidence in the evidence for several reasons. The number of samples contributed by studies for each week post‐symptom onset was often small, and there were sometimes problems with how studies were conducted. Participants included in the studies were often hospital patients who were more likely to have experienced severe symptoms of COVID‐19. The accuracy of antibody tests for detecting COVID‐19 in these patients may be different from the accuracy of the tests in people with mild or moderate symptoms. It is not possible to identify by how much the test results would differ in other populations. Who do the results of this review apply to? A high percentage of participants were in hospital with COVID‐19, so were likely to have more severe disease than people with COVID‐19 who were not hospitalised. Only a small number of studies assessed these tests in people with no symptoms. The results of the review may therefore be more applicable to those with severe disease than people with mild symptoms. Studies frequently did not report whether participants had symptoms at the time samples were taken for testing making it difficult to fully separate test results for early‐phase infection as opposed to later‐phase infections. The studies in our review assessed several test methods across a global population, therefore it is likely that test results would be similar in most areas of the world. What are the implications of this review? The review shows that antibody tests could have a useful role in detecting if someone has had COVID‐19, but the timing of test use is important. Some antibody tests may help to confirm COVID‐19 infection in people who have had symptoms for more than two weeks but who have been unable to confirm their infection using other methods. This is particularly useful if they are experiencing potentially serious symptoms that may be due to COVID‐19 as they may require specific treatment. Antibody tests may also be useful to determine how many people have had a previous COVID‐19 infection. We could not be certain about how well the tests work for people who have milder disease or no symptoms, or for detecting antibodies resulting from vaccination. How up‐to‐date is this review? This review updates our previous review. The evidence is up‐to‐date to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Fox, T, Geppert, J, Dinnes, J, Scandrett, K, Bigio, J, Sulis, G, Hettiarachchi, D, Mathangasinghe, Y, Weeratunga, P, Wickramasinghe, D, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.824Z" }, { "id": "059bc67a-1511-46bf-97e2-583cb6602b9d", "pmid": "", "title": "Echinacea for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Echinacea plant preparations (family Asteraceae ) are widely used in Europe and North America for common colds. Most consumers and physicians are not aware that products available under the term Echinacea differ appreciably in their composition, mainly due to the use of variable plant material, extraction methods and the addition of other components. Objectives To assess whether there is evidence that Echinacea preparations are effective and safe compared to placebo in the prevention and treatment of the common cold. Search methods We searched CENTRAL 2013, Issue 5, MEDLINE (1946 to May week 5, 2013), EMBASE (1991 to June 2013), CINAHL (1981 to June 2013), AMED (1985 to February 2012), LILACS (1981 to June 2013), Web of Science (1955 to June 2013), CAMBASE (no time limits), the Centre for Complementary Medicine Research (1988 to September 2007), WHO ICTRP and clinicaltrials.gov (last searched 5 June 2013), screened references and asked experts in the field about published and unpublished studies. Selection criteria Randomized controlled trials (RCTs) comparing mono‐preparations of Echinacea with placebo. Data collection and analysis At least two review authors independently assessed eligibility and trial quality and extracted data. The primary efficacy outcome was the number of individuals with at least one cold in prevention trials and the duration of colds in treatment trials. For all included trials the primary safety and acceptability outcome was the number of participants dropping out due to adverse events. We assessed trial quality using the Cochrane 'Risk of bias' tool. Main results Twenty‐four double‐blind trials with 4631 participants including a total of 33 comparisons of Echinacea preparations and placebo met the inclusion criteria. A variety of different Echinacea preparations based on different species and parts of plant were used. Evidence from seven trials was available for preparations based on the aerial parts of Echinacea purpurea. Ten trials were considered to have a low risk of bias, six to have an unclear risk of bias and eight to have a high risk of bias. Ten trials with 13 comparisons investigated prevention and 15 trials with 20 comparisons investigated treatment of colds (one trial addressed both prevention and treatment). Due to the strong clinical heterogeneity of the studies we refrained from pooling for the main analysis. None of the 12 prevention comparisons reporting the number of patients with at least one cold episode found a statistically significant difference. However a post hoc pooling of their results, suggests a relative risk reduction of 10% to 20%. Of the six treatment trials reporting data on the duration of colds, only two showed a significant effect of Echinacea over placebo. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. Authors' conclusions Echinacea products have not here been shown to provide benefits for treating colds, although, it is possible there is a weak benefit from some Echinacea products : the results of individual prophylaxis trials consistently show positive (if non‐significant) trends, although potential effects are of questionable clinical relevance. Plain language summary Echinacea for preventing and treating the common cold Preparations of the plant Echinacea are widely used in some European countries and in North America for common colds. Echinacea preparations available on the market differ greatly as different types (species) and parts (herb, root or both) of the plant are used, different manufacturing methods (drying, alcoholic extraction or pressing out the juice from fresh plants) are used and sometimes also other herbs are added. We reviewed 24 controlled clinical trials with 4631 participants investigating the effectiveness of several different Echinacea preparations for preventing and treating common colds or induced rhinovirus infections. Our review shows that a variety of products prepared from different Echinacea species, different plant parts and in a different form have been compared to placebo in randomized trials. Due to the significant differences in the preparations tested, it was difficult to draw strong conclusions. Five trials were rated as having a low risk of bias in all five categories of the Cochrane 'Risk of bias' tool. Five more trials were rated as low risk of bias, having an unclear risk of bias in only one category. Eight trials were rated as having a high risk of bias in at least one category and the remaining six as having an unclear risk of bias. The majority of trials investigated whether taking Echinacea preparations after the onset of cold symptoms shortens the duration, compared with placebo. Although it seems possible that some Echinacea products are more effective than a placebo for treating colds, the overall evidence for clinically relevant treatment effects is weak. In general, trials investigating Echinacea for preventing colds did not show statistically significant reductions in illness occurrence. However, nearly all prevention trials pointed in the direction of small preventive effects. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. The evidence is current to July 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Karsch‐Völk, M, Barrett, B, Kiefer, D, Bauer, R, Ardjomand‐Woelkart, K, Linde, K", "articleTypes": [], "doi": "10.1002/14651858.CD000530.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.760Z" }, { "id": "05aff24c-c56c-4bf2-9d38-ee14182d292b", "pmid": "", "title": "Crave Crush: Sugar Cravings and ad Lib Candy Uptake", "imported": false, "abstract": "The purpose of the research is to determine if participants who take \"Crave Crush\" will report lower cravings and palatability ratings of candy as compared to subjects who receive the placebo. Participants are self-selected university students who pass our table and verbally agree to participate in a research study about taste preferences. Data will be recorded anonymously.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "05bb789e-23a2-42a5-a291-b8c643e0c5fe", "pmid": "", "title": "Fortification of condiments and seasonings with iron for preventing anaemia and improving health", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jalal, CSB, De-Regil, LM, Pike, V, Mithra, P", "articleTypes": [], "doi": "10.1002/14651858.CD009604.pub2 AB - Abstract - Background Anaemia affects approximately 1.8 billion people worldwide; over 60% of anaemia cases globally are due to iron deficiency (ID). Iron deficiency and anaemia contribute to the global burden of disease and affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortification of food with iron, alone or in combination with other nutrients, is an effective intervention to control ID. Condiments and seasonings are ideal food vehicles for iron fortification in countries where they are commonly used. Objectives To determine the effects and safety of condiment and seasoning fortification with iron alone or iron plus other micronutrients on iron deficiency, anaemia, and health‐related outcomes in the general population. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 24 January 2023. We also searched the International clinical trials registry platform (ICTRP) for any ongoing trials. Selection criteria We included randomised controlled trials (RCTs) (randomisation at individual or cluster level), non‐randomised controlled trials, interrupted time series with at least three measure points both before and after intervention, and controlled before‐after studies. Participants were populations of any age (including pregnant women), from any country, excluding those with critical illness or severe co‐morbidities. We included interventions in which condiments or seasonings have been fortified with any combination of iron and other vitamins and minerals, irrespective of the fortification technology used. Data collection and analysis Two review authors independently screened and assessed the eligibility of studies. Disagreements were resolved through discussion or input from a third review author. Two review authors extracted the data and assessed the risk of bias in all the included studies. We followed the methods laid out by Cochrane and used GRADE criteria for assessing certainty of the evidence. Main results Our search identified 15,902 records after removal of duplicates. We included 16 studies with 20,512 participants (18,410 participants after adjusting for clustering effects). They were all carried out in upper‐middle‐ and lower‐middle‐income countries. Three studies were controlled before‐after studies, one was non‐randomised trial, and 12 were RCTs (including three cluster RCTs). Six studies took place in schools; seven in communities; and one each in a nursery/kindergarten, tea estate, and factory. Three studies involved only women, one study involved both women and their children, and all other studies focused on children and/or adolescents. Nine studies used salt as a vehicle for iron fortification, three used fish sauce, two used soy sauce, one used curry powder, and one a \"seasoning powder\". The dose of iron received by participants ranged from 4.4 mg to 55 mg/day. The sample sizes in the trials ranged from 123 to 14,398, and study durations ranged from three months to two years. Twelve RCTs contributed data for meta‐analysis. Six trials compared iron‐fortified condiments versus the unfortified condiment, and six trials provided data comparing iron fortification in combination with other micronutrients versus the same condiment with other micronutrients, but no added iron. In one trial, the fortificant contained micronutrients that may have affected the absorption of iron. Overall no studies were assessed as having a low risk of bias. All included studies were assessed to have a high overall risk of bias, with the most concerns being around allocation concealment, blinding, and random sequence generation. There was very high heterogeneity amongst studies in almost all examined outcomes. Condiments/seasonings fortified with iron versus unfortified condiments/seasonings We are uncertain about whether consuming condiments/seasonings fortified with iron in comparison to the same unfortified condiment reduces anaemia at the end of intervention (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.18 to 0.65; 2328 participants; 4 studies; very low‐certainty of evidence). We are uncertain about whether consuming iron‐fortified condiments increases haemoglobin concentrations (mean difference (MD) 6.40 (g/L), 95% CI ‐0.62 to 13.41; 2808 participants; 5 studies; very low‐certainty evidence). Fortification of condiments/seasonings with iron probably slightly reduces ID (RR 0.33, 95% CI 0.11 to 1.01; 391 participants; 2 studies; moderate‐certainty evidence). We are uncertain about whether fortification with iron increases ferritin concentration (MD 14.81 (µg/L), 95% CI 5.14 to 24.48; 4459 participants; 6 studies; very low‐certainty evidence). Condiments/seasonings fortified with iron plus other micronutrients versus condiments/seasonings fortified with other micronutrients except iron Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia (RR 0.59, 95% CI 0.40 to 0.89; 1007 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification of condiments/seasonings with iron plus other micronutrients will improve haemoglobin concentration (MD 6.22 g/dL, 95% CI 1.60 to 10.83; 1270 participants; 5 studies; very low‐certainty evidence). It may reduce ID (RR 0.36, 95% CI 0.19 to 0.69; 1154 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification with iron plus other micronutrients improves ferritin concentration (MD 10.63 µg/L, 95% CI 2.40 to 18.85; 1251 participants; 5 studies; very low ‐certainty evidence). Condiments/seasonings fortified with iron versus no intervention No trial reported data on this comparison. No studies reported adverse effects. Funding sources do not appear to have distorted the results in any of the assessed trials. Authors' conclusions We are uncertain whether consuming iron‐fortified condiments/seasonings reduces anaemia, improves haemoglobin concentration, or improves ferritin concentration. It may reduce ID. Findings about ferritin should be interpreted with caution since its concentrations increase during inflammation. Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia, and we are uncertain whether this will improve haemoglobin concentration or ferritin concentration. More studies are needed to determine the true effect of iron‐fortified condiments/seasonings on preventing anaemia and improving health. The effects of this intervention on other health outcomes like malaria incidence, growth and development are unclear. Plain language summary Adding iron to condiments and seasonings for preventing anaemia and improving health Key messages ‐ Adding iron to condiments/seasonings may slightly improve iron status and reduce iron deficiency. When iron is added along with other micronutrients, it may reduce anaemia. Unwanted effects were not reported. ‐ There was a lot of variation between the studies included in this review, making it more difficult to draw definitive conclusions. The effects of fortifying condiments and seasonings with iron should continue to be examined in populations consuming them through well‐designed studies. What is anaemia? Iron deficiency is one of the most common nutritional deficiencies throughout the world and contributes significantly to the global burden of disease. Multiple factors cause anaemia, including insufficient iron intake (the most common cause of anaemia), and it affects approximately 1.8 billion people worldwide. In general, low‐income countries have more anaemia than higher‐income countries. Iron deficiency and anaemia have several lifetime consequences that can affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortifying condiments or seasonings with iron may be a useful and cost‐effective approach to help reduce iron deficiency. To date, there has been no systematic assessment of the safety and effectiveness of this intervention to inform policymaking. What did we want to find out? If fortifying condiments and seasonings with iron alone or iron plus other micronutrients improves measures of iron nutrition in the general population, in particular: ‐ anaemia; ‐ haemoglobin concentration; ‐ iron deficiency; ‐ iron status (including ferritin, transferrin saturation, and more). We also wanted to find out if consuming iron‐fortified condiments/seasonings was associated with any unwanted effects. What did we do? 
We searched for studies that provided iron‐fortified condiments/seasonings to one group, and condiments/seasonings not fortified with iron to another. We compared and summarised the results of the studies and rated our confidence in the evidence, based on study characteristics. What did we find? We identified 16 studies that involved 18,410 participants in middle‐income countries, most within schools or communities, with study durations ranging from three months to two years. The type of iron‐fortified condiments/seasonings used included salt, fish sauce, soy sauce, and seasoning powders. The dose of iron received by participants ranged from 4.4mg to 55 mg/day. Compared to unfortified condiments/seasonings, those which are iron‐fortified likely improve iron deficiency slightly. We are uncertain whether they reduce anaemia, improve haemoglobin, or other measures of iron status. Condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia; we are uncertain about whether they improve haemoglobin or ferritin concentrations. They may improve iron deficiency and total iron binding capacity. No studies reported adverse effects. More studies are needed to determine the effect of iron‐fortified condiments/seasonings on health such as malaria incidence, growth and development and any potential adverse effects. What are the limitations of the evidence? Our confidence in the evidence is very low to moderate; several factors reduced our confidence in the evidence. Firstly, we observed limitations in the way few studies were conducted with respect to the recruitment of people to assign interventions (this means that differences between the groups could be due to differences between people rather than between the treatments). Secondly, people in some studies may have been aware of which treatment they were getting. Also, not all the studies provided data about everything that were interested in, and results were inconsistent across the different studies. Finally, some studies were small. The results of future research could differ from the results of this review. How up to date is this evidence? The evidence is up‐to‐date to January 2023. What this means We judged the evidence in this review as very low to moderate certainty, which means we are not certain of the effect of condiments/seasonings with added iron on the reduction of anaemia and iron deficiency in people.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.788Z" }, { "id": "05c89d48-63fe-4d65-9491-3ffbaf748837", "pmid": "", "title": "Long‐acting muscarinic antagonists (LAMA) added to combination long‐acting beta₂‐agonists and inhaled corticosteroids (LABA/ICS) versus LABA/ICS for adults with asthma", "imported": false, "abstract": "Abstract - Background Maintenance treatment with long‐acting beta 2 ‐agonists and inhaled corticosteroids (LABA/ICS) can relieve asthma symptoms and reduce the frequency of exacerbations, but there are limited treatment options for people who do not gain control on combination LABA/ICS. Long‐acting muscarinic antagonists (LAMA) are a class of inhaled drug which have been effective for people with chronic obstructive pulmonary disease and are now becoming available for people with asthma to take alongside their LABA/ICS inhaler. Objectives To assess the effects of adding a long‐acting muscarinic antagonist (LAMA) to combination long‐acting beta 2 ‐agonists (LABA) and inhaled corticosteroids (ICS) in adults whose asthma is not well controlled by LABA/ICS. Search methods We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to January 2016. We also searched ClinicalTrials.gov, the WHO trials portal, and reference lists of other reviews, and we contacted trial authors for additional information. Selection criteria We included parallel randomised controlled trials (RCTs) of at least 12 weeks' duration. Studies met the inclusion criteria if they compared LAMA as an add‐on to LABA/ICS versus LABA/ICS alone for adults with asthma. We included studies reported as full text, those published as abstract only, and unpublished data. Primary outcomes were exacerbations requiring oral corticosteroids (OCS), validated measures of asthma control, and serious adverse events (including mortality). Data collection and analysis Two review authors screened searches and independently extracted details on risk of bias and numerical data. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MD) using a random‐effects model. We rated all outcomes using GRADE. Main results We found four double‐blind, double‐dummy trials comparing LAMA to placebo, including 1197 people with asthma taking combination LABA/ICS. One of the trials was designed to study glycopyrronium bromide but was withdrawn prior to enrolment, and the other three all studied tiotropium bromide (mostly 5 µg once daily via Respimat) over 48 to 52 weeks. People in the trials had a mean forced expiratory volume in one second (FEV 1 ) of 55% of their predicted value, indicating severe asthma. People randomised to take tiotropium add‐on had fewer exacerbations requiring oral corticosteroids than those continuing to take LABA/ICS alone, but the confidence intervals did not rule out no difference (OR 0.76, 95% CI 0.57 to 1.02; moderate quality evidence). Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS would have to take oral corticosteroids for an exacerbation compared with 271 if they took tiotropium as well (95% CI 218 to 333 per 1000). Analyses comparing the number of exacerbations per patient in each group (rate ratio) and the time until first exacerbation (hazard ratio) were in keeping with the main result. Quality of life, as measured by the Asthma Quality of Life Questionnaire (AQLQ) was no better for those taking tiotropium add‐on than for those taking LABA/ICS alone when considered in light of the 0.5 minimal clinically important difference on the scale (MD 0.09, 95% CI − 0.03 to 0.20), and evidence for whether tiotropium increased or decreased serious adverse events in this population was inconsistent (OR 0.60, 95% CI 0.24 to 1.47; I 2 = 76%). Within the secondary outcomes, exacerbations requiring hospital admission were too rare to tell whether tiotropium was beneficial over LABA/ICS alone. There was high quality evidence showing benefits to lung function (trough FEV 1 and forced vital capacity (FVC)) and potentially small benefits to asthma control. People taking tiotropium add‐on were less likely to experience non‐serious adverse events. Authors' conclusions Tiotropium add‐on may have additional benefits over LABA/ICS alone in reducing the need for rescue oral steroids in people with severe asthma. The effect was imprecise, and there was no evidence for other LAMA preparations. Possible benefits on quality of life were negligible, and evidence for the effect on serious adverse events was inconsistent. There are likely to be small added benefits for tiotropium Respimat 5 µg daily on lung function and asthma control over LABA/ICS alone and fewer non‐serious adverse events. The benefit of tiotropium add‐on on the frequency of hospital admission is still unknown, despite year‐long trials. Ongoing and future trials should clearly describe participants' background medications to help clinicians judge how the findings relate to stepwise care. If studies test LAMAs other than tiotropium Respimat for asthma, they should be at least six months long and use accepted and validated outcomes to allow comparisons of the safety and effectiveness between different preparations. Plain language summary Does adding tiotropium, a long‐acting muscarinic antagonist (LAMA), to combination therapy (LABA/ICS) help to control asthma? Adding the LAMA tiotropium Respimat inhaler to combination LABA/ICS inhaler may reduce the need for rescue oral steroids. A noticeable benefit on quality of life is unlikely, and we couldn't tell if it reduced hospital admissions, but adding tiotropium has some benefit on lung function, asthma control, and non‐serious side effects. More detail about the studies and results: Taking a daily inhaler containing a long‐acting beta 2 ‐agonist and an inhaled corticosteroid (LABA/ICS) can improve symptoms and reduce the likelihood of asthma attacks. If this doesn't help, another type of inhaled drug called a long‐acting muscarinic antagonist (LAMA), which has been effective for people with other breathing conditions, is now available for people with asthma to take as well as their LABA/ICS inhaler. We wanted to find out whether adding a LAMA to LABA/ICS is better than continuing LABA/ICS alone for adults with asthma. We found four relevant studies, but one was withdrawn before anyone was signed up. The other three compared a LAMA called tiotropium Respimat to placebo for around a year, with participants in both groups continuing to take their usual LABA/ICS inhaler. People generally had quite poor lung function when they entered the studies, suggesting their asthma was not well controlled ‐ in respiratory medicine, this is known as 'severe asthma'. Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS had to take a course of oral steroids compared with 271 if they took tiotropium as well. However, uncertainty in the results meant that rather than there being 271 people taking oral steroids, there could be anywhere from 218 to 333 people per 1000 who would have to take oral steroids, so we couldn't be sure of the benefit. Quality of life scores were not that different between those who took tiotropium and those who didn't. The studies showed different results for whether people taking tiotropium were more likely to suffer a serious side effect, but fewer people had non‐serious side effects if they took tiotropium. We couldn't tell whether taking tiotropium on top of LABA/ICS reduced the number of people who had to go to hospital for an asthma attack because it didn't happen often enough for us to have confidence in the result. There was high quality evidence that showed benefits to lung function and probably small benefits on measures of asthma control.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Kew, KM; Dahri, K", "articleTypes": [], "doi": "10.1002/14651858.CD011721.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "05dc14ca-42b2-45d4-967c-bd4bbe201a94", "pmid": "", "title": "N‐acetylcysteine as an adjuvant therapy for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) is one of the most common pathogens to establish and cause infection in human beings, affecting about 50% of the world's population. Prevalence may be as high as 83% in Latin American countries and as low as 17% in North America. Approximately 20% of infected people will manifest disease; people at high risk include those who live in low‐ and middle‐income countries with poor sanitary conditions, since the mechanism of transmission seems to be oral‐oral or faecal‐oral (mostly during infancy). There are several antibiotic regimens to treat the infection, but antibiotic resistance is growing around the world. New adjuvant drugs — such as probiotics, statins, curcumin, and N‐acetylcysteine (NAC) — are being tested to enhance eradication rates. N‐acetylcysteine can destabilise the biofilm structure; it also has synergic action with antibiotics, and bactericidal effects. In addition, NAC has antioxidant properties, and has a primary mucolytic effect by reducing the thickness of the gastric mucus layer, both of which may exert beneficial adjuvant effects on H pylori eradication. Objectives To assess the efficacy and safety of N‐acetylcysteine as an adjuvant therapy to antibiotics for Helicobacter pylori eradication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to April 2018), Embase (1988 to April 2018), CINAHL (1982 to April 2018), LILACS (1982 to April 2018), grey literature databases and trials registries. We handsearched the reference lists of relevant studies. We screened 726 articles and assessed 18 for eligibility. Selection criteria We included randomised controlled trials (RCTs) of any antibiotic regimen plus NAC, in adults infected with H pylori . To be included, trials had to use a control consisting of the same antibiotic regimen with or without placebo. Outcomes of interest were eradication rates, and gastrointestinal, toxic, and allergic adverse events. Reporting of the primary outcomes listed here was not an inclusion criterion for the review. Data collection and analysis Two review authors independently reviewed and extracted data and completed the 'Risk of bias' assessments. A third review author independently confirmed the 'Risk of bias' assessments. We used Review Manager 5 software for data analysis. We contacted study authors if there was missing information. Main results We included eight RCTs (with a total of 559 participants) in this review. The studies recruited outpatients aged between 17 and 76 years who were referred to endoscopy centres in several different countries. The certainty of evidence was reduced for most outcomes due to the poor methodological quality of included studies; issues mainly related to the generation of allocation sequence, allocation concealment, and blinding (this last domain related specifically to adverse outcomes). We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates, compared with the addition of placebo or no NAC (38.8% versus 49.1%, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.51 to 1.08; participants = 559; studies = eight; very low‐certainty evidence). A post‐hoc sensitivity analysis, in which we removed studies that tested antibiotic regimens no longer recommended in clinical practice, showed that the addition of NAC may improve eradication rates compared to control (27.2% versus 37.6%, RR 0.71, 95% CI 0.53 to 0.94; participants = 397; published studies = five). We are uncertain whether NAC is associated with a higher risk of gastrointestinal adverse events compared to control (23.9% versus 18.9%, RR 1.25, 95% CI 0.85 to 1.85; participants = 336; studies = five; very low‐certaintyevidence), or allergic adverse events (2% versus 0%, RR 2.98, 95% CI 0.32 to 27.74; participants = 336; studies = five; very low‐certainty evidence). There were no reports of toxic adverse events amongst included studies. Authors' conclusions We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates compared with the addition of placebo or no NAC. Due to the clinical, statistical and methodological heterogeneity found in included studies, and the uncertainty observed when analysing therapy subgroups, any possible beneficial effect of NAC should be regarded cautiously. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed, randomised clinical studies should be conducted, with good reporting standards and appropriate collection of efficacy and safety outcomes, especially for current recommended antibiotic regimens. Plain language summary N‐acetylcysteine taken with antibiotics for treatment of Helicobacter pylori infection Review question Is the addition of N‐acetylcysteine to antibiotics safe and does it improve cure rates for Helicobacter pylori infection? Background Helicobacter pylori ( H pylori ) is a bacteria that lives in the stomach and might cause several diseases such as gastric cancer, ulcer disease, and others. Colonisation occurs in about one‐half of the world's population and is more common in countries with poor sanitary conditions. People become infected by consuming contaminated water. The infection is treated using antibiotics and a drug which reduces acid production in the stomach. However, rates of antibiotic resistance are rising around the world, which is reducing the cure rates even with treatment. New medications are being tested to improve cure rates. One of these medications is N‐acetylcysteine (NAC). NAC is a drug that helps to dissolve mucus in respiratory diseases. It can be taken by mouth (orally) or injected into a vein (intravenous). NAC can destroy some mechanisms of survival of H pylori and could improve cure rates. Study characteristics We included eight studies (specifically, randomised controlled trials (RCTs)) with a total of 559 people aged between 17 and 76 years old. The evidence is current to April 2018. All studies recruited outpatients from endoscopy centres (centres that specialise in an examination done with a flexible tube with a camera that is inserted into stomach) in several countries. The antibiotic combinations tested were very different in the included studies, as were the doses of NAC (600 mg to 1800 mg per day). NAC was compared with placebo (dummy pill) or nothing. Key results We are uncertain whether the addition of NAC to antibiotics improves H pylori cure rates compared with the addition of placebo or no NAC. Any possible beneficial effect of NAC should be regarded cautiously because the included studies were very different and of low certainty, with some flaws that could have compromised their results and consequently, the results of this review. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed randomised clinical studies, with good reporting standards and appropriate collection of effectiveness and safety outcomes should be done, especially for current recommended antibiotic combinations. Quality of the evidence The overall certainty of the evidence for eradication rates ranged from very low to low. Five studies provided information on adverse events (side effects), and the certainy of evidence was very low. The included studies were poorly conducted and this reduced our confidence in the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fontes, LES; Martimbianco, ALC; Zanin, C; Riera, R", "articleTypes": [], "doi": "10.1002/14651858.CD012357.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "05e69321-44fa-4ebc-9e3c-d1b49248bb9c", "pmid": "", "title": "A Study on the Correlation Between Oral Health and Delirium in Surgical Inpatients", "imported": false, "abstract": "Delirium is a clinical syndrome characterized by acute attention deficits, altered consciousness, and fluctuating cognitive dysfunction, typically triggered by multifactorial causes such as physical illness, medication use, or postoperative stress . As the most common complication in hospitalized patients, delirium is highly prevalent among elderly surgical populations, with postoperative delirium (POD) occurring in 7.5%-27.5% of cases, and rates rising to 50%-70% in intensive care unit (ICU) patients . Its onset is closely associated with poor prognoses, including long-term postoperative cognitive decline , increased mortality, prolonged hospitalization, and elevated healthcare costs (annual costs in the United States ranging from 38billionto152 billion) . Early prevention and screening of POD are therefore critical to improving patient outcomes and reducing healthcare burdens.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.249Z" }, { "id": "05e9ab66-8f64-428a-bfbe-4c32c55f2a13", "pmid": "", "title": "Intranasal corticosteroids for non‐allergic rhinitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Segboer, C, Gevorgyan, A, Avdeeva, K, Chusakul, S, Kanjanaumporn, J, Aeumjaturapat, S, Reeskamp, LF, Snidvongs, K, Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010592.pub2 AB - Abstract - Background Non‐allergic rhinitis is defined as dysfunction and non‐infectious inflammation of the nasal mucosa that is caused by provoking agents other than allergens or microbes. It is common, with an estimated prevalence of around 10% to 20%. Patients experience symptoms of nasal obstruction, anterior rhinorrhoea/post‐nasal drip and sneezing. Several subgroups of non‐allergic rhinitis can be distinguished, depending on the trigger responsible for symptoms; these include occupation, cigarette smoke, hormones, medication, food and age. On a cellular molecular level different disease mechanisms can also be identified. People with non‐allergic rhinitis often lack an effective treatment as a result of poor understanding and lack of recognition of the underlying disease mechanism. Intranasal corticosteroids are one of the most common types of medication prescribed in patients with rhinitis or rhinosinusitis symptoms, including those with non‐allergic rhinitis. However, it is unclear whether intranasal corticosteroids are truly effective in these patients. Objectives To assess the effects of intranasal corticosteroids in the management of non‐allergic rhinitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 7); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 July 2019. Selection criteria Randomised controlled trials (RCTs) comparing intranasal corticosteroids, delivered by any means and in any volume, with (a) placebo/no intervention or (b) other active treatments in adults and children (aged ≥ 12 years). Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were patient‐reported disease severity and a
 significant adverse effect ‐ epistaxis. Secondary outcomes were (disease‐specific) health‐related quality of life, objective measurements of airflow and other adverse events. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 34 studies (4452 participants); however, only 13 studies provided data for our main comparison, intranasal corticosteroids versus placebo. The participants were mainly defined as patients with perennial rhinitis symptoms and negative allergy tests. No distinction between different pheno‐ and endotypes could be made, although a few studies only included a specific phenotype such as pregnancy rhinitis, vasomotor rhinitis, rhinitis medicamentosa or senile rhinitis. Most studies were conducted in a secondary or tertiary healthcare setting. No studies reported outcomes beyond three months follow‐up. Intranasal corticosteroid dosage in the review ranged from 50 µg to 2000 µg daily. Intranasal corticosteroids versus placebo Thirteen studies (2045 participants) provided data for this comparison. These studies used different scoring systems for patient‐reported disease severity, so we pooled the data in each analysis using the standardised mean difference (SMD). Intranasal corticosteroid treatment may improve patient‐reported disease severity as measured by total nasal symptom score compared with placebo at up to four weeks (SMD ‐0.74, 95% confidence interval (CI) ‐1.15 to ‐0.33; 4 studies; 131 participants; I 2 = 22%) (low‐certainty evidence). However, between four weeks and three months the evidence is very uncertain (SMD ‐0.24, 95% CI ‐0.67 to 0.20; 3 studies; 85 participants; I 2 = 0%) (very low‐certainty evidence). Intranasal corticosteroid treatment may slightly improve patient‐reported disease severity as measured by total nasal symptom score change from baseline when compared with placebo at up to four weeks (SMD ‐0.15, 95% CI ‐0.25 to ‐0.05; 4 studies; 1465 participants; I 2 = 35%) (low‐certainty evidence) . All four studies evaluating the risk of epistaxis showed that there is probably a higher risk in the intranasal corticosteroids group (65 per 1000) compared to placebo (31 per 1000) (risk ratio (RR) 2.10, 95% CI 1.24 to 3.57; 4 studies; 1174 participants; I 2 = 0%) (moderate‐certainty evidence). The absolute risk difference (RD) was 0.04 with a number needed to treat for an additional harmful outcome (NNTH) of 25 (95% CI 16.7 to 100). Only one study reported numerical data for quality of life. It did report a higher quality of life score in the intranasal corticosteroids group (152.3 versus 145.6; SF‐12v2 range 0 to 800); however, this disappeared at longer‐term follow‐up (148.4 versus 145.6) (low‐certainty evidence). Only two studies provided data for the outcome objective measurements of airflow. These data could not be pooled because they used different methods of outcome measurement. Neither found a significant difference between the intranasal corticosteroids and placebo group (rhinomanometry SMD ‐0.46, 95% CI ‐1.06 to 0.14; 44 participants; peak expiratory flow rate SMD 0.78, 95% CI ‐0.47 to 2.03; 11 participants) (very low‐certainty evidence). Intranasal corticosteroids probably resulted in little or no difference in the risk of other adverse events compared to placebo (RR 0.99, 95% CI 0.87 to 1.12; 3 studies; 1130 participants; I 2 = 0%) (moderate‐certainty evidence) . Intranasal corticosteroids versus other treatments Only one or a few studies assessed each of the other comparisons (intranasal corticosteroids versus saline irrigation, intranasal antihistamine, capsaicin, cromoglycate sodium, ipratropium bromide, intranasal corticosteroids combined with intranasal antihistamine, intranasal corticosteroids combined with intranasal antihistamine and intranasal corticosteroids with saline compared to saline alone). It is therefore uncertain whether there are differences between intranasal corticosteroids and other active treatments for any of the outcomes reported. Authors' conclusions Overall, the certainty of the evidence for most outcomes in this review was low or very low. It is unclear whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. However, intranasal corticosteroids probably have a higher risk of the adverse effect epistaxis. There are very few studies comparing intranasal corticosteroids to other treatment modalities making it difficult to draw conclusions. Plain language summary Intranasal corticosteroids for non‐allergic rhinitis Review question We wanted to find out whether intranasal corticosteroids (steroids applied into the nose) are effective for the treatment of rhinitis that is not caused by allergy. Background Non‐allergic rhinitis is a chronic disease of the nose, which is not caused by infection or allergies. People with non‐allergic rhinitis experience symptoms that affect their quality of life, such as nasal obstruction, runny nose and sneezing. Non‐allergic rhinitis patients can be divided into different subgroups who have different underlying causes for their disease. The underlying causes of non‐allergic rhinitis are not fully understood, therefore treatment is often unsuccessful in these patients. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation. They are the most commonly prescribed drug in other chronic diseases of the nose and sinuses, such as allergic rhinitis and chronic rhinosinusitis. Intranasal corticosteroid treatment can be delivered with sprays or drops and for different time periods. Study characteristics We included 34 randomised controlled trials (RCTs) with a total of 4452 participants in this review. Most of the studies were relatively small, although the largest study had 983 patients in total. All of the patients were either adults or adolescents (aged between 12 and 18 years old) with non‐allergic rhinitis. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Nine studies were sponsored by the pharmaceutical industry or had commercial sponsors. One study was funded by the government. In several studies, the pharmaceutical industry or commercial sponsor may have provided medications, but the funding role was unclear. Funding was not reported in eight studies. Key results Intranasal corticosteroids compared with placebo It is uncertain whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. They may improve patient‐reported disease severity compared with placebo at up to four weeks, however this evidence is of low certainty. Treatment with intranasal corticosteroids probably increases the risk of epistaxis (nosebleed) but there is no difference in the risk of other adverse effects. It is not possible to tell from this review whether there is a difference between the different concentrations, delivery methods or treatment plans of intranasal corticosteroids. There are no good‐quality studies assessing changes in quality of life with intranasal corticosteroids. Intranasal corticosteroids compared with other treatments There is not enough evidence to know whether intranasal corticosteroid treatment is better, worse or the same as using other treatment strategies such as saline irrigation, intranasal antihistamines, capsaicin or ipratropium bromide for non‐allergic rhinitis. Certainty of the evidence Overall, the evidence for intranasal corticosteroids compared with placebo for most outcomes was either low‐certainty (our confidence in the effect estimate is low) or very low‐certainty (our confidence in the effect estimate is very low). This was because most studies were very small and used different methods to measure the same outcome. This evidence is up to date to July 2019.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.092Z" }, { "id": "05ecc40b-3a60-4f80-b19b-94bdf2282123", "pmid": "", "title": "A 6-month Multicenter, Randomized, Double-blind, Placebo-controlled Study to Evaluate the Efficacy, Safety and PK/PD of an age-and Body Weight-adjusted Oral Finerenone Regimen, in Addition to an ACEI or ARB, for the Treatment of Children, 6 Months to <18 Years of Age, With Chronic Kidney Disease and Proteinuria", "imported": false, "abstract": "Researchers are looking for a better way to treat children who have chronic kidney disease (CKD), which is long-term kidney disease, and proteinuria, a condition in which a person´s kidneys leak protein into the urine.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.155Z" }, { "id": "05ee7587-a24f-4941-b924-f2eb181eb871", "pmid": "", "title": "Melatonin for the prevention and treatment of jet lag", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Herxheimer, A, Petrie, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD001520 AB - Abstract - Background Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Objectives To assess the effectiveness of oral melatonin taken in different dosage regimens for alleviating jet lag after air travel across several time zones. Search methods We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsychLit and Science Citation Index electronically, and the journals 'Aviation, Space and Environmental Medicine' and 'Sleep' by hand. We searched citation lists of relevant studies for other relevant trials. We asked principal authors of relevant studies to tell us about unpublished trials. Reports of adverse events linked to melatonin use outside randomised trials were searched for systematically in 'Side Effects of Drugs' (SED) and SED Annuals, 'Reactions Weekly', MEDLINE, and the adverse drug reactions databases of the WHO Uppsala Monitoring Centre (UMC) and the US Food & Drug Administration. An updating search was carried out on 12/2/2008 but no new studies were identified. Selection criteria Randomised trials in airline passengers, airline staff or military personnel given oral melatonin, compared with placebo or other medication. Outcome measures should consist of subjective rating of jet lag or related components, such as subjective well being, daytime tiredness, onset and quality of sleep, psychological functioning, duration of return to normal, or indicators of circadian rhythms. Data collection and analysis Ten trials met the inclusion criteria. All compared melatonin with placebo; one in addition compared it with a hypnotic, zolpidem. Nine of the trials were of adequate quality to contribute to the assessment, one had a design fault and could not be used in the assessment. 
 Reports of adverse events outside trials were found through MEDLINE, 'Reactions Weekly', and in the WHO UMC database. Main results Eight of the ten trials found that melatonin, taken close to the target bedtime at the destination (10pm to midnight), decreased jet‐lag from flights crossing five or more time zones. Daily doses of melatonin between 0.5 and 5mg are similarly effective, except that people fall asleep faster and sleep better after 5mg than 0.5mg. Doses above 5mg appear to be no more effective. The relative ineffectiveness of 2mg slow‐release melatonin suggests that a short‐lived higher peak concentration of melatonin works better. The estimated number needed to treat (NNT) is 2, based on the only two trials that gave the necessary data. The benefit is likely to be greater the more time zones are crossed, and less for westward flights. The timing of the melatonin dose is important: if it is taken at the wrong time, early in the day, it is liable to cause sleepiness and delay adaptation to local time. The incidence of other side effects is low. Case reports suggest that people with epilepsy, and patients taking warfarin may come to harm from melatonin. Authors' conclusions Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be. The pharmacology and toxicology of melatonin needs systematic study, and routine pharmaceutical quality control of melatonin products must be established. The effects of melatonin in people with epilepsy, and a possible interaction with warfarin, need investigation. Plain language summary Melatonin for the prevention and treatment of jet lag Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.779Z" }, { "id": "05ef8703-c86f-4109-9ba9-4ac8493c5eff", "pmid": "", "title": "A Randomized, Double-blind, Placebo-controlled, Crossover Study to Evaluate the Influence of the A118G Polymorphism in the mu Opioid Receptor Gene (OPRM1) on Effects of GSK1521498 and Naltrexone on Physiological and Behavioural Markers of Brain Function in Healthy Social Drinkers", "imported": false, "abstract": "A total of at least 48 healthy subjects with a history of social drinking will be recruited into this single-centre, randomized, double-blind, cross-over study. Subjects will be genetically stratified to result in equal numbers of A118G 'AA' homozygotes (n=24) and A118G 'G' carriers (n=24).", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "05fc070d-c628-4904-9b34-d0579752587e", "pmid": "", "title": "Melatonin in cancer treatment", "imported": false, "abstract": "Abstract - Rationale Preserving health‐related quality of life is an aspect of care that requires constant attention from the time of cancer diagnosis. Melatonin has been used to diminish treatment‐related side effects and cancer symptoms, and as a medication to regulate circadian rhythm. An up‐to‐date systematic review is needed to investigate the current evidence concerning possible beneficial effects of melatonin on quality of life and sleep in cancer patients. Objectives To evaluate the benefits and harms of melatonin for preserving health‐related quality of life and sleep in cancer patients. Search methods To identify studies for inclusion in this review, we used CENTRAL, MEDLINE, 10 other databases, and four trial registers, together with reference checking, citation searching, and contact with study authors. The latest search date was 10 September 2024. Eligibility criteria We included randomised controlled trials (RCTs) of adults (18 years or over) with histologically proven cancer of any stage that evaluated melatonin (alone or in combination with standard anticancer treatment) versus no treatment or placebo (alone or in combination with standard anticancer treatment), or standard anticancer treatment. Standard anticancer treatment refers to treatments to stop or prevent cancer, including chemotherapy, radiation therapy, surgery, immunotherapy, and hormonal therapies (such as androgen deprivation therapy). Outcomes The primary outcomes of interest were quality of life and sleep quality within three months, and melatonin‐related adverse events. Other outcomes included survival, disease‐free survival, progression‐free survival, tumour response, and anticancer treatment‐related harms. Risk of bias We used Cochrane's risk of bias tool (RoB 1) to assess the risk of bias in the studies included in the review. Synthesis methods We synthesised results for each outcome using random‐effects meta‐analysis. The effect size was presented as risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CI). If this was not possible, due to the nature of the data, we synthesised results in a narrative format. We used GRADE to assess the certainty of evidence for each outcome. Included studies We identified 30 RCTs (reported in 49 publications) involving 5093 adult participants with cancer (2470 males, 2228 females, 395 not reported). Studies were conducted in a hospital setting and took place in at least 10 countries. We assessed two studies at low risk of bias and the other 28 at high risk of bias. Synthesis of results Melatonin plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life score (MD 2.60, 95% CI −14.53 to 19.73; 1 study, 126 participants; very low certainty evidence), and sleep score (MD 2.80, 95% CI 0.18 to 5.42; 1 study, 50 participants; very low certainty evidence) within three months. We are also very uncertain about potential adverse effects of melatonin: headache (RR 2.77, 95% CI 0.33 to 23.14; 1 study, 25 participants; very low certainty evidence); fatigue (RR 1.02, 95% CI 0.90 to 1.17; 2 studies, 170 participants; very low certainty evidence); and nausea (RR 1.01, 95% CI 0.66 to 1.56; 1 study, 146 participants; very low certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of high risk of bias, small sample size, the width of the 95% confidence interval, and indirectness due to inadequate reporting of cancer type. Melatonin plus standard treatment versus standard treatment No data are available relating to quality of life and sleep within three months. The evidence is very uncertain about headaches (experienced by 15 of 820 participants in melatonin groups, with no data available for control groups; 2 studies, 1640 participants; very low certainty evidence). Melatonin likely reduces the incidence of fatigue (RR 0.46, 95% CI 0.39 to 0.55; 10 studies, 1359 participants; moderate‐certainty evidence) and may reduce nausea (RR 0.85, 95% CI 0.72 to 1.00; 6 studies, 710 participants; low‐certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of the high risk of bias and the width of the 95% confidence interval. Melatonin (topical use) plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life (one study reported no difference between groups, both having the same median score of 66.7; 48 participants; very low certainty evidence). No data are available relating to sleep and adverse events (including headache, dizziness, fatigue, and nausea). We downgraded the certainty of the evidence because of the high risk of bias, small sample size, and insufficient data. Authors' conclusions The available evidence is of very low certainty, so we are unable to draw conclusions about the effects of melatonin on quality of life and sleep at three months in people receiving treatment for cancer. There may be no difference in adverse events between melatonin plus standard treatment and placebo plus standard treatment, but the evidence is very uncertain. Data were lacking for some outcomes, such as dizziness. Melatonin used alongside standard treatment probably reduces the risk of fatigue and may reduce nausea when compared to standard treatment alone. Since the evidence base for melatonin in people with cancer is limited due to insufficient data and risks of bias in study design, the decision for or against using melatonin as an adjunct to cancer treatment cannot easily be made at the current time. Funding This Cochrane Review was partially funded by AG Biologische Krebstherapie, Deutsche Krebshilfe (grant numbers 70‐301 and 109863). The funding agency had no role in the design or conduct of the study. Registration The protocol for this review is available via DOI 10.1002/14651858.CD010145. Plain language summary For cancer patients, what are the benefits and risks of taking the hormone melatonin? Key messages Due to a lack of robust evidence, the effects of melatonin on quality of life and sleep quality in people receiving treatment for cancer are unclear. Melatonin might not increase the risk of adverse events, but the available evidence is not strong enough for us to be certain. Well designed studies using melatonin over a period of up to three months are needed to give better estimates of the benefits and risks. What is melatonin? Melatonin is a hormone produced in the body to regulate the daily sleep and wakefulness cycle. It has been suggested that melatonin may improve sleep quality and quality of life, which are very important in cancer treatment. Moreover, there is research suggesting that melatonin is effective against solid tumours and may be effective for the treatment of cancer. What did we want to find out? We wanted to find out if melatonin can be used in cancer treatment, particularly for preserving the quality of life and sleep quality of cancer patients. We also wanted to find out if melatonin causes any unwanted side effects ('adverse events'). What did we do? We searched for studies that looked at melatonin used with other standard cancer treatments compared with standard cancer treatments used alone or with placebo (fake treatment). What did we find? We found 30 studies that involved 5093 cancer patients, both men and women, with cancer of any type. The studies were conducted in 10 countries around the world. We focused on the effects of melatonin over a period of three months. When compared to placebo plus standard cancer treatments, it is unclear if melatonin has an effect on quality of life and sleep. Melatonin may have little to no effect on potential adverse events like headache, fatigue, and nausea, but we are very uncertain about these results. No results are available for dizziness. We found no studies to help us answer our questions about quality of life and sleep quality when melatonin is used with standard cancer treatments compared to the standard treatment alone. However, the studies did evaluate potential adverse events that might be related to melatonin, and they found that melatonin probably reduces the risk of tiredness (fatigue), and may reduce the risk of feeling sick (nausea). It is unclear if melatonin has an effect on headaches. No results are available for dizziness. When melatonin is used topically, such as in a cream to put on the skin or in a mouth wash, it is unclear if it has an effect on quality of life. We found no studies to help us answer our questions about sleep quality. No data are available for adverse events like headache, fatigue, nausea, and dizziness, as these are not relevant if the melatonin is used topically. It is unclear if melatonin has any other unwanted effects when used topically. What are the limitations of the evidence? We are not confident in the evidence because it is possible that people in the studies were aware of which treatment they were getting. The evidence relating to some benefits and risks we are interested in does not cover all cancer types, or it is based on only a few cases. How up to date is this evidence? The evidence is up‐to‐date to September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Yu, ZY, Peng, RY, Cheng, N, Wang, RT, Nan, MD, Milazzo, S, Pilkington, K, Seely, D, Horneber, M, Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010145.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.753Z" }, { "id": "06070e33-666f-467f-b95c-57dbd5fa377d", "pmid": "", "title": "Short‐course oral steroids as an adjunct therapy for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of a short course of oral corticosteroids as an adjunct ('add‐on') therapy in people with chronic rhinosinusitis who are already on standard treatments. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids to placebo or no treatment, where all patients were also receiving pharmacological treatment for chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score, and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results Two trials with a total of 78 participants met the inclusion criteria. Both the populations and the 'standard' treatments differed in the two studies. Oral steroids as an adjunct to intranasal corticosteroids One trial in adults with nasal polyps included 30 participants. All participants used intranasal corticosteroids and were randomised to either short‐course oral steroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 21‐day treatment course) or no additional treatment. None of the primary outcome measures of interest in this review were reported by the study. There may have been an important reduction in the size of the polyps (measured by the nasal polyps score, a secondary outcome measure) in patients receiving oral steroids and intranasal corticosteroids, compared to intranasal corticosteroids alone (mean difference (MD) ‐0.46, 95% confidence interval (CI) ‐0.87 to ‐0.05; 30 participants; scale 1 to 4) at the end of treatment (21 days). This corresponds to a large effect size, but we are very uncertain about this estimate as we judged the study to be at high risk of bias. Moreover, longer‐term data were not available and the other outcomes of interest were not reported. Oral steroids as an adjunct to antibiotics One trial in children (mean age of eight years) without nasal polyps included 48 participants. The trial compared oral corticosteroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 15‐day treatment course) with placebo in participants who also received a 30‐day course of antibiotics. This study addressed one of the primary outcome measures (disease severity) and one secondary outcome (CT score). For disease severity the four key symptoms used to define chronic rhinosinusitis in children (nasal blockage, nasal discharge, facial pressure, cough) were combined into one score. There was a greater improvement in symptom severity 30 days after the start of treatment in patients who received oral steroids and antibiotics compared with placebo and antibiotics (MD ‐7.10, 95% CI ‐9.59 to ‐4.61; 45 participants; scale 0 to 40). The observed mean difference corresponds to a large effect size. At the same time point there was a difference in CT scan score (MD ‐2.90, 95% CI ‐4.91 to ‐0.89; 45 participants; scale 0 to 24). We assessed the quality of the evidence to be low . There were no data available for the longer term (three months). Authors' conclusions There might be an improvement in symptom severity, polyps size and condition of the sinuses when assessed using CT scans in patients taking oral corticosteroids when these are used as an adjunct therapy to antibiotics or intranasal corticosteroids, but the quality of the evidence supporting this is low or very low (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). It is unclear whether the benefits of oral corticosteroids as an adjunct therapy are sustained beyond the short follow‐up period reported (up to 30 days), as no longer‐term data were available. There were no data in this review about the adverse effects associated with short courses of oral corticosteroids as an adjunct therapy. More research in this area, particularly research evaluating longer‐term outcomes and adverse effects, is required. Plain language summary Short‐term oral corticosteroids in addition to other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of adding a short course (typically up to 14 days) of corticosteroid given by mouth to people with chronic rhinosinusitis who were also receiving another type of treatment (such as corticosteroids delivered through the nose). Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling inflammation and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included two randomised controlled trials with a total of 78 participants. One trial involved 30 adults with nasal polyps. Participants received either intranasal corticosteroids and oral corticosteroids or only intranasal corticosteroids. The only result reported of interest to this review was whether the size of the nasal polyps was reduced, when these treatments were completed (three weeks). One trial involved 48 children (mean age of eight years) with chronic rhinosinusitis but no nasal polyps. Participants received either antibiotics and oral corticosteroids or only antibiotics and a placebo (sugar pill). The oral corticosteroids and placebo were given for 15 days and the antibiotics were given for 30 days. The trial reported findings when the antibiotic treatment was completed (at one month). Key results At the end of a three‐week treatment course, people who took both intranasal corticosteroids and oral steroids may have had smaller nasal polyps than people who just received intranasal corticosteroids. The trial did not follow up people to determine whether the polyp size increased after the end of the trial. The trial did not provide information on adverse events or other outcomes important to patients, such as symptom severity or quality of life. Children who received both antibiotics and oral corticosteroids seemed to have a lower total symptom score and better computerised tomography (CT) scan score after treatment compared with children who received antibiotics and control treatment. The reporting of adverse effects in this trial was not very clear and so is difficult to tell if any participant experienced gastrointestinal disturbances, mood changes or difficulty in sleeping. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be very low (we are very uncertain about the estimate) as the evidence comes from one trial that has a low number of participants. The trial had a high risk of bias due to the way it was conducted. The trial did not report adverse events and did not report results after the end of treatment. We judged the quality of the evidence for oral steroids plus antibiotics for children to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate) as the evidence comes from one small trial. The trial did not have a high risk of bias, but it only included children without nasal polyps, who might not have the same results as adults with nasal polyps. The trial did not report results after the end of treatment and the adverse effects of treatment were not well reported.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K; Chong, LY; Hopkins, C; Philpott, C; Schilder, AGM; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "06104d93-22cc-4b83-957f-7cb47fb8c1c3", "pmid": "", "title": "Metabolic and bariatric surgery in adults with obesity and diabetes mellitus: a network meta‐analysis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E, Gorenflo, L, Schwarzer, G, Stadelmaier, J, Wallerer, S, Marjanovic, G, Fink, JM, Lehane, C, Metzendorf, MI, Meerpohl, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015622.pub2 AB - Abstract - Rationale Obesity and its associated comorbidities, particularly type 2 diabetes (T2D), have reached epidemic dimensions globally. Both conditions are related to an increased risk of serious health outcomes and impose a substantial burden on those affected. Metabolic and bariatric surgery (MBS) may offer a therapeutic option for achieving sustained weight loss, improving comorbidities and thereby enhancing long���term quality of life. Objectives To investigate the medium‐ and long‐term benefits and harms of different MBS procedures compared with each other and to non‐surgical treatment on outcomes relevant to adults with obesity and T2D, and to obtain a clinically meaningful ranking of these interventions by considering both randomised controlled trials (RCTs) and cohort studies. Search methods We searched MEDLINE, Cochrane CENTRAL, CINAHL, LILACS, BASE as well as the WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 25 June 2024. We did not apply any language restrictions. Eligibility criteria We included RCTs and both prospective and retrospective cohort studies with a minimum follow‐up of three years in adults (≥ 18 years) with obesity (body mass index ≥ 30 kg/m² or ethnic‐specific cut‐off values) and T2D. Eligible interventions include MBS procedures (i.e. laparoscopic adjustable gastric banding [LAGB], sleeve gastrectomy [SG], Roux‐en‐Y gastric bypass [RYGB], one‐anastomosis gastric bypass [OAGB], gastric plication [GCP], biliopancreatic diversion with duodenal switch, and their variations) or non‐surgical treatment (i.e. lifestyle intervention, medical treatment [LI/MT]). Outcomes Critical outcomes were medium‐ (≥ 3 to < 5 years) and long‐term (≥ 5 years) weight loss (%), waist circumference (cm), T2D remission (complete, partial), and serious adverse events (SAE). Important outcomes included all‐cause mortality, T2D complications, glycaemic control (glycated haemoglobin (HbA1c) in %) and health‐related quality of life (HRQoL). Risk of bias We used the Risk of Bias 2 (RoB 2) tool for RCTs and Risk Of Bias In Non‐randomized Studies – of Interventions (ROBINS‐I) for cohort studies. Synthesis methods We performed random‐effects network meta‐analyses based on the frequentist approach and ranked treatments by P scores. We rated the certainty of evidence according to the GRADE approach for long‐term outcomes (≥ 5 years). Included studies We included 18 studies (with 70 reports) with 15,282 participants in this review. Of these, 13 studies were RCTs (n = 911) and five were cohort studies (n = 14,371). Two RCTs compared MBS with LI/MT, ten compared two or three different MBS procedures and one with a 3‐arm design investigated two different MBS procedures as well as LI/MT. All cohort studies compared different MBS procedures. The networks were based on the following MBS procedures: RYGB, SG, OAGB, LAGB, GCP, and LI/MT. Synthesis of results NMA results (8 RCTs; n = 491) suggest greater long‐term weight loss after RYGB compared to LI/MT (MD ‐16.95%; 95% CI ‐24.19 to ‐9.71). OAGB (MD ‐12.10%; 95% CI ‐22.85 to ‐1.34) and SG (MD ‐9.40 %; 95% CI ‐17.45 to ‐1.34) may also result in greater weight loss compared to LI/MT, but the evidence is very uncertain. A reduction in waist circumference at long‐term follow‐up (6 RCTs; n = 348) is likely higher after RYGB compared to LI/MT (MD ‐12.34 cm; 95% CI ‐17.88 to ‐6.81). OAGB (MD: ‐13.28 cm; 95% CI ‐22.04 to ‐4.53) and SG (MD‐9.08 cm; 95% CI ‐15.74 to ‐2.43) may also lead to a higher reduction in waist circumference compared to LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effects of MBS procedures compared to LI/MT on long‐term complete T2D remission (9 RCTs; n = 536). All MBS procedures (8 RCTs; n = 588) may result more often in partial T2D remissions than LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effect of all MBS procedures compared to LI/MT on SAE (9 RCTs; n = 598) and all‐cause mortality in the long term (7 RCTs; n = 520). RYGB may reduce total long‐term T2D complications compared to LI/MT (Rate ratio (RaR) 0.17; 95% CI 0.03 to 0.89; 5 RCTs; n = 356), but the evidence is very uncertain. Based on NMA results (10 RCTs; n = 612), RYGB may reduce HbA1c compared to LI/MT (MD ‐1.44%; 95% CI ‐2.26 to ‐0.63). OAGB (MD ‐2.01%; 95%CI ‐3.42 to ‐0.60) and SG (MD ‐1.01%; 95%CI ‐1.94 to ‐0.08) may also reduce HbA1c compared to LI/MT, but the evidence is every uncertain. Both RYGB and SG may increase mental and physical components of HRQoL compared to LI/MT (both 2 RCTs; n = 118), but evidence is very uncertain. The inclusion of cohort studies in the analyses of percentage weight loss, partial type 2 diabetes remission, SAE, and all‐cause mortality confirmed the main findings. For most outcomes, the main reasons for downgrading certainty of evidence were related to risk of bias and imprecision. Authors' conclusions In people with obesity and T2D, RYGB, OAGB and, to a lesser extent, SG may lead to long‐term improvements in body weight, waist circumference, partial T2D remission, and HbA1c compared with LI/MT. However, due to imprecise results, the magnitude of the effects often remains uncertain or very uncertain. For other outcomes, especially complete T2D remission, SAE, all‐cause mortality and T2D complications, the evidence is mainly very uncertain, due to a low numbers of participants and events. When interpreting these findings, it should be noted that cohort studies were not, as originally planned, included in the certainty of evidence assessment, as these studies were judged to have a high or critical risk of bias. Larger and well‐designed studies may contribute to diminishing the existing uncertainties and enhancing our confidence in the findings. Funding This Cochrane review was funded by the German Federal Ministry of Education and Research (BMBF) (grant number: 01KG2201). Registration Protocol (2024) DOI: https://doi.org/10.1002/14651858.CD015622 PROSPERO ID: CRD42023457363 Plain language summary Review question What are the long‐term benefits and risks of different types of weight loss surgery (also called metabolic and bariatric surgery) to treat obesity and type 2 diabetes in adults? Key messages In people with obesity and type 2 diabetes, gastric (stomach) bypass (i.e. Roux‐en‐Y gastric bypass and one‐anastomosis gastric bypass) may be most beneficial for improving body weight, waist circumference, type 2 diabetes status and long‐term blood sugar levels at least five years after surgery, but for one‐anastomosis gastric bypass, we are very uncertain about the results. It is unclear whether the different surgical procedures have an effect on risks such as serious unwanted health effects and death from any cause at least five years after surgery. Larger and well‐designed studies may help reduce the existing uncertainties and increase our confidence in the findings. What are obesity and type 2 diabetes? 
Obesity is a condition with too many fat deposits that can damage health. In type 2 diabetes, the body has difficulty controlling blood sugar levels because the hormone insulin does not work properly. Type 2 diabetes often occurs in people with obesity, and both conditions increase the risk of premature death and other health problems, such as cardiovascular disease. How are obesity and type 2 diabetes treated? Lifestyle interventions such as nutrition, exercise, and behavioural programmes, along with medicines, are often used first for weight loss and improvement of diabetes status. When these do not work well, metabolic and bariatric surgery may be considered as an additional treatment option. There are a number of different types of bariatric surgery: gastric (stomach) banding; gastric sleeve (removal of a part of the stomach); Roux‐en‐Y gastric bypass (RYGB); one‐anastomosis gastric bypass, or mini‐gastric bypass; gastric plication (folding to make the stomach smaller); biliopancreatic diversion with duodenal switch. What did we want to find out? Which of the different types of surgery are the safest and most beneficial ones by comparing them with each other and with lifestyle and medication therapy regarding their long‐term (at least 5 years follow‐up) benefits and risks. Whether these surgical procedures improve body weight, waist circumference, type 2 diabetes status, long‐term blood sugar levels, and quality of life at least five years after surgery. Whether surgery affects serious unwanted health effects, death from any cause, and type 2 diabetes complications over this period. What did we do? 
We searched for studies involving people with obesity and type 2 diabetes. We included studies that compared at least two different surgical procedures, or surgery with lifestyle and medication treatment. We summarised and compared all treatments using a method called network meta‐analysis, and we rated our confidence in the results based on factors such as study methods and sample size. What did we find? 
We found 18 studies, including 15,282 people with obesity and type 2 diabetes. In 13 of these studies (including 911 people), participants were assigned randomly to two or more treatment groups. This is the best way to ensure that groups of people are similar. Five studies (with 14,371 people) used ‘real‐life’ observational data. The studies investigated surgical procedures such as gastric band, gastric sleeve, Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, and gastric plication. We found that: Roux‐en‐Y gastric bypass, may improve body weight and likely reduce waist circumference compared with lifestyle and medication treatment in the long term. One‐anastomosis gastric bypass and, to a lesser extent, gastric sleeve, may also improve body weight and waist circumference, but we are very uncertain about the results. Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, gastric sleeve, and gastric band may improve type 2 diabetes status, but we are very uncertain about the results. It is unclear whether the types of surgery have an effect on serious unwanted health effects or death from any cause. Roux‐en‐Y gastric bypass may reduce type 2 diabetes complications in the long term compared to non‐surgical treatments, but we are very uncertain about the results. Roux‐en‐Y gastric bypass may improve blood sugar levels compared to non‐surgical treatments. One‐anastomosis gastric bypass and gastric sleeve may also improve blood sugar levels, but we are very uncertain about the results. RYGB and SG may lead to a greater increase in health‐related quality of life than non‐surgical treatments, but again, we are very uncertain about the results. What are the limitations of the evidence? 
Our confidence in the evidence is often low to very low because the studies included only small numbers of people, and the results for some outcomes, especially serious unwanted health effects, death from any cause, and type 2 diabetes complications, were based on very few events. Moreover, for several surgical procedures, there were not enough studies to be certain about the outcomes. It is important to note that rating our confidence in findings was based only on studies in which participants were randomly assigned to groups and did not include observational studies. How up to date is this evidence? 
This evidence is up to date as of June 2024.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.137Z" }, { "id": "06183328-7b3f-41e5-9c21-16204b15c219", "pmid": "", "title": "Study of the Genetic Factors That Influence the Susceptibility to and Severity of COVID-19", "imported": false, "abstract": "COVID-19 is a viral disease induced by infection with the novel SARS-CoV-2 coronavirus. Infection arises from the inhalation of viral particles spread by an infected individual. The main virus entry pathways are the nose and mouth mucous membranes, particularly rich in ACE2 receptors, that are used by the virus to enter cells and begin its replication.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.247Z" }, { "id": "062d4bd4-09ef-4c72-bda2-9d7062ad3c72", "pmid": "", "title": "Intravenous iron versus oral iron versus no iron with or without erythropoiesis‐ stimulating agents (ESA) for cancer patients with anaemia: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Anaemia is common among cancer patients and they may require red blood cell transfusions. Erythropoiesis‐stimulating agents (ESAs) and iron might help in reducing the need for red blood cell transfusions. However, it remains unclear whether the combination of both drugs is preferable compared to using one drug. Objectives To systematically review the effect of intravenous iron, oral iron or no iron in combination with or without ESAs to prevent or alleviate anaemia in cancer patients and to generate treatment rankings using network meta‐analyses (NMAs). Search methods We identified studies by searching bibliographic databases (CENTRAL, MEDLINE, Embase; until June 2021). We also searched various registries, conference proceedings and reference lists of identified trials. Selection criteria We included randomised controlled trials comparing intravenous, oral or no iron, with or without ESAs for the prevention or alleviation of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in cancer patients. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Outcomes were on‐study mortality, number of patients receiving red blood cell transfusions, number of red blood cell units, haematological response, overall mortality and adverse events. We conducted NMAs and generated treatment rankings. We assessed the certainty of the evidence using GRADE. Main results Ninety‐six trials (25,157 participants) fulfilled our inclusion criteria; 62 trials (24,603 participants) could be considered in the NMA (12 different treatment options). Here we present the comparisons of ESA with or without iron and iron alone versus no treatment. Further results and subgroup analyses are described in the full text. On‐study mortality We estimated that 92 of 1000 participants without treatment for anaemia died up to 30 days after the active study period. Evidence from NMA (55 trials; 15,074 participants) suggests that treatment with ESA and intravenous iron (12 of 1000; risk ratio (RR) 0.13, 95% confidence interval (CI) 0.01 to 2.29; low certainty) or oral iron (34 of 1000; RR 0.37, 95% CI 0.01 to 27.38; low certainty) may decrease or increase and ESA alone (103 of 1000; RR 1.12, 95% CI 0.92 to 1.35; moderate certainty) probably slightly increases on‐study mortality. Additionally, treatment with intravenous iron alone (271 of 1000; RR 2.95, 95% CI 0.71 to 12.34; low certainty) may increase and oral iron alone (24 of 1000; RR 0.26, 95% CI 0.00 to 19.73; low certainty) may increase or decrease on‐study mortality. Haematological response We estimated that 90 of 1000 participants without treatment for anaemia had a haematological response. Evidence from NMA (31 trials; 6985 participants) suggests that treatment with ESA and intravenous iron (604 of 1000; RR 6.71, 95% CI 4.93 to 9.14; moderate certainty), ESA and oral iron (527 of 1000; RR 5.85, 95% CI 4.06 to 8.42; moderate certainty), and ESA alone (467 of 1000; RR 5.19, 95% CI 4.02 to 6.71; moderate certainty) probably increases haematological response. Additionally, treatment with oral iron alone may increase haematological response (153 of 1000; RR 1.70, 95% CI 0.69 to 4.20; low certainty). Red blood cell transfusions We estimated that 360 of 1000 participants without treatment for anaemia needed at least one transfusion. Evidence from NMA (69 trials; 18,684 participants) suggests that treatment with ESA and intravenous iron (158 of 1000; RR 0.44, 95% CI 0.31 to 0.63; moderate certainty), ESA and oral iron (144 of 1000; RR 0.40, 95% CI 0.24 to 0.66; moderate certainty) and ESA alone (212 of 1000; RR 0.59, 95% CI 0.51 to 0.69; moderate certainty) probably decreases the need for transfusions. Additionally, treatment with intravenous iron alone (268 of 1000; RR 0.74, 95% CI 0.43 to 1.28; low certainty) and with oral iron alone (333 of 1000; RR 0.92, 95% CI 0.54 to 1.57; low certainty) may decrease or increase the need for transfusions. Overall mortality We estimated that 347 of 1000 participants without treatment for anaemia died overall. Low‐certainty evidence from NMA (71 trials; 21,576 participants) suggests that treatment with ESA and intravenous iron (507 of 1000; RR 1.46, 95% CI 0.87 to 2.43) or oral iron (482 of 1000; RR 1.39, 95% CI 0.60 to 3.22) and intravenous iron alone (521 of 1000; RR 1.50, 95% CI 0.63 to 3.56) or oral iron alone (534 of 1000; RR 1.54, 95% CI 0.66 to 3.56) may decrease or increase overall mortality. Treatment with ESA alone may lead to little or no difference in overall mortality (357 of 1000; RR 1.03, 95% CI 0.97 to 1.10; low certainty). Thromboembolic events We estimated that 36 of 1000 participants without treatment for anaemia developed thromboembolic events. Evidence from NMA (50 trials; 15,408 participants) suggests that treatment with ESA and intravenous iron (66 of 1000; RR 1.82, 95% CI 0.98 to 3.41; moderate certainty) probably slightly increases and with ESA alone (66 of 1000; RR 1.82, 95% CI 1.34 to 2.47; high certainty) slightly increases the number of thromboembolic events. None of the trials reported results on the other comparisons. Thrombocytopenia or haemorrhage We estimated that 76 of 1000 participants without treatment for anaemia developed thrombocytopenia/haemorrhage. Evidence from NMA (13 trials, 2744 participants) suggests that treatment with ESA alone probably leads to little or no difference in thrombocytopenia/haemorrhage (76 of 1000; RR 1.00, 95% CI 0.67 to 1.48; moderate certainty). None of the trials reported results on other comparisons. Hypertension We estimated that 10 of 1000 participants without treatment for anaemia developed hypertension. Evidence from NMA (24 trials; 8383 participants) suggests that treatment with ESA alone probably increases the number of hypertensions (29 of 1000; RR 2.93, 95% CI 1.19 to 7.25; moderate certainty). None of the trials reported results on the other comparisons. Authors' conclusions When considering ESAs with iron as prevention for anaemia, one has to balance between efficacy and safety. Results suggest that treatment with ESA and iron probably decreases number of blood transfusions, but may increase mortality and the number of thromboembolic events. For most outcomes the different comparisons within the network were not fully connected, so ranking of all treatments together was not possible. More head‐to‐head comparisons including all evaluated treatment combinations are needed to fill the gaps and prove results of this review. Plain language summary Which combinations of medicines are best for the prevention and treatment of anaemia in people with cancer? Key messages • Giving medicines that stimulate the bone marrow to produce red blood cells (ESAs) with iron supplements probably decreases the number of blood transfusions, but may also cause more deaths and increase the number of unwanted effects, such as blood clots. • Because of missing data from the studies we could not compare the different treatment options to each other and rank them. • We need more studies that compare these medicines directly against each other. What is anaemia and why do people with cancer develop it? Anaemia develops when levels of red blood cells are too low. Red blood cells contain a protein called haemoglobin. Iron molecules in the haemoglobin bind to oxygen and carry it around the body. A lack of oxygen to the organs and tissues in the body makes people feel tired and lack energy, and they may be at greater risk of infections. People with cancer are particularly likely to suffer from anaemia. This might be because the cancers cause inflammation and prevent red blood cell production. Or it might be because treatments like chemotherapy slow down production of red blood cells in bone marrow. People suffering from anaemia may need blood transfusions. However, treatment with medicines that stimulate the production of red blood cells in bone marrow (called erythropoiesis‐stimulating agents or ESAs) and iron supplements may reduce the need for transfusions. What did we want to find out? We wanted to identify the most effective treatments for anaemia in people with cancer and whether they cause any unwanted effects. We were interested in whether iron supplements or ESAs given alone or together affect: • deaths; • haemoglobin levels; • blood transfusions; and • unwanted effects. We also wanted to know the best way to give the medicines: by injection (intravenous), or swallowed (oral). What did we do? We searched for studies that compared intravenous, oral or no iron with or without ESAs for the prevention or treatment of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in people with cancer. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and numbers of participants. We used statistical methods to compare multiple treatments against each other and rank them in order of effectiveness and unwanted effects. What did we find? We found 96 relevant studies with 25,157 people. People in the studies were different ages and were receiving a mix of anti‐cancer treatments or no treatment. They had different types of cancer. Ninety‐two studies reported data for our review. They included 24,603 people and compared 12 different treatment options for anaemia. The treatments included combinations of ESAs with intravenous or oral iron and placebo (something that looks, tastes and smells the same as the iron supplement or ESA but with no active ingredient). Not every study reported everything we were interested in, so we did not have enough information to compare each treatment with each of the other treatments. Treatment with ESAs when used on their own or with iron probably increases levels of red blood cells and reduces the need for red blood cell transfusions when compared with no treatment. We cannot rule out an increase in the risk of mortality with ESA in combination with iron, which also appeared to cause more deaths and lead to increased risk of harm caused by the formation of clots in the blood vessels. Our confidence in the findings Overall, we are moderately confident in the evidence that one treatment is better or worse than another. Our confidence is limited because we sometimes found very different results for the same treatments, meaning they could have been both good and bad for patients ‐ we did not have enough evidence to reach firm conclusions. Also, due to a lack of evidence we could not rank the treatments. How up to date is the evidence? The evidence is up‐to‐date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Adams, A; Scheckel, B; Habsaoui, A; Haque, M; Kuhr, K; Monsef, I; Bohlius, J; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012633.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "063e3962-1bd5-4578-9c55-28d67d06e939", "pmid": "", "title": "Dietary marine fatty acids (fish oil) for asthma in adults and children", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Thien, FCK, De Luca, S, Woods, RK, Abramson, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD001283 AB - Abstract - Background Epidemiological studies suggest that a diet high in marine fatty acids (fish oil) may have beneficial effects on inflammatory conditions such as rheumatoid arthritis and possibly asthma. Objectives (1) To determine the effect of marine n‐3 fatty acid (fish oil) supplementation in asthma.
 (2) To determine the effect of a diet high in fish oil in asthma. Search methods We searched the Cochrane Airways Group Specialised Register. We also searched bibliographies of retrieved trials and contacted fish oil manufacturers. Searches were current as of May 2010. Selection criteria We included randomised controlled trials in patients with asthma more than two years of age. The study duration had to be in excess of four weeks. Double blind trials were preferred, but we also reviewed single‐blind and open trials for possible inclusion. All four reviewers read each paper, blind to its identity. Decisions concerning inclusion were made by simple majority. We all performed quality assessment independently. Data collection and analysis The only comparison possible was between marine n‐3 fatty acid supplementation and placebo. There were insufficient trials to examine dietary manipulation alone. Main results Nine randomised controlled trials conducted between 1986 and 2001 satisfied the inclusion criteria. Seven were of parallel design and two were cross‐over studies. Eight compared fish oil with placebo whilst one compared high dose versus low dose marine n‐3 fatty acid supplementation. Two studies were conducted in children, whilst the remaining seven studies were conducted in adults. None of the included studies reported asthma exacerbations, health status or hospital admissions. There was no consistent effect on any of the analysable outcomes: FEV1, peak flow rate, asthma symptoms, asthma medication use or bronchial hyper reactivity. One of the studies performed in children which combined dietary manipulation with fish oil supplementation showed improved peak flow and reduced asthma medication use. There were no adverse events associated with fish oil supplements. Authors' conclusions There is little evidence to recommend that people with asthma supplement or modify their dietary intake of marine n‐3 fatty acids (fish oil) in order to improve their asthma control. Equally, there is no evidence that they are at risk if they do so. Plain language summary Dietary marine fatty acids (fish oil) for asthma in adults and children Eating more fish has been recommended as one way of possibly reducing asthma. Populations (such as Eskimo communities) with diets high in fish also have low rates of asthma. As diets in other communities have become higher in saturated fats, asthma has also increased. The theory has been that an ingredient in fish oil may reduce inflammation. Inflammation causes the swelling in the airways of the lungs that leads to asthma attacks. However, this review of trials found that people with asthma changing their diets to include more fish oil did not improve their asthma.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.074Z" }, { "id": "0653dfd6-ff40-4f31-9354-9834bf5a2a35", "pmid": "", "title": "Short‐course oral steroids as an adjunct therapy for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of a short course of oral corticosteroids as an adjunct ('add‐on') therapy in people with chronic rhinosinusitis who are already on standard treatments. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids to placebo or no treatment, where all patients were also receiving pharmacological treatment for chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score, and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results Two trials with a total of 78 participants met the inclusion criteria. Both the populations and the 'standard' treatments differed in the two studies. Oral steroids as an adjunct to intranasal corticosteroids One trial in adults with nasal polyps included 30 participants. All participants used intranasal corticosteroids and were randomised to either short‐course oral steroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 21‐day treatment course) or no additional treatment. None of the primary outcome measures of interest in this review were reported by the study. There may have been an important reduction in the size of the polyps (measured by the nasal polyps score, a secondary outcome measure) in patients receiving oral steroids and intranasal corticosteroids, compared to intranasal corticosteroids alone (mean difference (MD) ‐0.46, 95% confidence interval (CI) ‐0.87 to ‐0.05; 30 participants; scale 1 to 4) at the end of treatment (21 days). This corresponds to a large effect size, but we are very uncertain about this estimate as we judged the study to be at high risk of bias. Moreover, longer‐term data were not available and the other outcomes of interest were not reported. Oral steroids as an adjunct to antibiotics One trial in children (mean age of eight years) without nasal polyps included 48 participants. The trial compared oral corticosteroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 15‐day treatment course) with placebo in participants who also received a 30‐day course of antibiotics. This study addressed one of the primary outcome measures (disease severity) and one secondary outcome (CT score). For disease severity the four key symptoms used to define chronic rhinosinusitis in children (nasal blockage, nasal discharge, facial pressure, cough) were combined into one score. There was a greater improvement in symptom severity 30 days after the start of treatment in patients who received oral steroids and antibiotics compared with placebo and antibiotics (MD ‐7.10, 95% CI ‐9.59 to ‐4.61; 45 participants; scale 0 to 40). The observed mean difference corresponds to a large effect size. At the same time point there was a difference in CT scan score (MD ‐2.90, 95% CI ‐4.91 to ‐0.89; 45 participants; scale 0 to 24). We assessed the quality of the evidence to be low . There were no data available for the longer term (three months). Authors' conclusions There might be an improvement in symptom severity, polyps size and condition of the sinuses when assessed using CT scans in patients taking oral corticosteroids when these are used as an adjunct therapy to antibiotics or intranasal corticosteroids, but the quality of the evidence supporting this is low or very low (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). It is unclear whether the benefits of oral corticosteroids as an adjunct therapy are sustained beyond the short follow‐up period reported (up to 30 days), as no longer‐term data were available. There were no data in this review about the adverse effects associated with short courses of oral corticosteroids as an adjunct therapy. More research in this area, particularly research evaluating longer‐term outcomes and adverse effects, is required. Plain language summary Short‐term oral corticosteroids in addition to other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of adding a short course (typically up to 14 days) of corticosteroid given by mouth to people with chronic rhinosinusitis who were also receiving another type of treatment (such as corticosteroids delivered through the nose). Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling inflammation and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included two randomised controlled trials with a total of 78 participants. One trial involved 30 adults with nasal polyps. Participants received either intranasal corticosteroids and oral corticosteroids or only intranasal corticosteroids. The only result reported of interest to this review was whether the size of the nasal polyps was reduced, when these treatments were completed (three weeks). One trial involved 48 children (mean age of eight years) with chronic rhinosinusitis but no nasal polyps. Participants received either antibiotics and oral corticosteroids or only antibiotics and a placebo (sugar pill). The oral corticosteroids and placebo were given for 15 days and the antibiotics were given for 30 days. The trial reported findings when the antibiotic treatment was completed (at one month). Key results At the end of a three‐week treatment course, people who took both intranasal corticosteroids and oral steroids may have had smaller nasal polyps than people who just received intranasal corticosteroids. The trial did not follow up people to determine whether the polyp size increased after the end of the trial. The trial did not provide information on adverse events or other outcomes important to patients, such as symptom severity or quality of life. Children who received both antibiotics and oral corticosteroids seemed to have a lower total symptom score and better computerised tomography (CT) scan score after treatment compared with children who received antibiotics and control treatment. The reporting of adverse effects in this trial was not very clear and so is difficult to tell if any participant experienced gastrointestinal disturbances, mood changes or difficulty in sleeping. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be very low (we are very uncertain about the estimate) as the evidence comes from one trial that has a low number of participants. The trial had a high risk of bias due to the way it was conducted. The trial did not report adverse events and did not report results after the end of treatment. We judged the quality of the evidence for oral steroids plus antibiotics for children to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate) as the evidence comes from one small trial. The trial did not have a high risk of bias, but it only included children without nasal polyps, who might not have the same results as adults with nasal polyps. The trial did not report results after the end of treatment and the adverse effects of treatment were not well reported.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K; Chong, LY; Hopkins, C; Philpott, C; Schilder, AGM; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "066cf108-2bc6-433f-a43c-bbfa21ccc78c", "pmid": "", "title": "Melatonin for the prevention and treatment of jet lag", "imported": false, "abstract": "Abstract - Background Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Objectives To assess the effectiveness of oral melatonin taken in different dosage regimens for alleviating jet lag after air travel across several time zones. Search methods We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsychLit and Science Citation Index electronically, and the journals 'Aviation, Space and Environmental Medicine' and 'Sleep' by hand. We searched citation lists of relevant studies for other relevant trials. We asked principal authors of relevant studies to tell us about unpublished trials. Reports of adverse events linked to melatonin use outside randomised trials were searched for systematically in 'Side Effects of Drugs' (SED) and SED Annuals, 'Reactions Weekly', MEDLINE, and the adverse drug reactions databases of the WHO Uppsala Monitoring Centre (UMC) and the US Food & Drug Administration. An updating search was carried out on 12/2/2008 but no new studies were identified. Selection criteria Randomised trials in airline passengers, airline staff or military personnel given oral melatonin, compared with placebo or other medication. Outcome measures should consist of subjective rating of jet lag or related components, such as subjective well being, daytime tiredness, onset and quality of sleep, psychological functioning, duration of return to normal, or indicators of circadian rhythms. Data collection and analysis Ten trials met the inclusion criteria. All compared melatonin with placebo; one in addition compared it with a hypnotic, zolpidem. Nine of the trials were of adequate quality to contribute to the assessment, one had a design fault and could not be used in the assessment. 
 Reports of adverse events outside trials were found through MEDLINE, 'Reactions Weekly', and in the WHO UMC database. Main results Eight of the ten trials found that melatonin, taken close to the target bedtime at the destination (10pm to midnight), decreased jet‐lag from flights crossing five or more time zones. Daily doses of melatonin between 0.5 and 5mg are similarly effective, except that people fall asleep faster and sleep better after 5mg than 0.5mg. Doses above 5mg appear to be no more effective. The relative ineffectiveness of 2mg slow‐release melatonin suggests that a short‐lived higher peak concentration of melatonin works better. The estimated number needed to treat (NNT) is 2, based on the only two trials that gave the necessary data. The benefit is likely to be greater the more time zones are crossed, and less for westward flights. The timing of the melatonin dose is important: if it is taken at the wrong time, early in the day, it is liable to cause sleepiness and delay adaptation to local time. The incidence of other side effects is low. Case reports suggest that people with epilepsy, and patients taking warfarin may come to harm from melatonin. Authors' conclusions Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be. The pharmacology and toxicology of melatonin needs systematic study, and routine pharmaceutical quality control of melatonin products must be established. The effects of melatonin in people with epilepsy, and a possible interaction with warfarin, need investigation. Plain language summary Melatonin for the prevention and treatment of jet lag Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Herxheimer, A; Petrie, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD001520", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "0673b702-4656-4e65-864a-0d19046608b3", "pmid": "", "title": "A Randomized, Active-Controlled, Partially Blinded, Biomarker Select, Phase III Clinical Trial of Pembrolizumab as Monotherapy and in Combination With Cisplatin+5-Fluorouracil Versus Placebo+Cisplatin+5-Fluorouracil as First-Line Treatment in Subjects With Advanced Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma", "imported": false, "abstract": "This is a study of pembrolizumab (MK-3475) as first-line treatment for participants with advanced gastric or gastroesophageal junction (GEJ) adenocarcinoma. Participants whose tumors express programmed death-ligand 1 (PD-L1) will be randomly assigned to one of the three treatment arms of the study: pembrolizumab as monotherapy [pembro mono], pembrolizumab plus standard of care (SOC) chemotherapy with cisplatin plus 5-fluorouracil (5-FU) or capecitabine [pembro combo], or placebo plus SOC chemotherapy with cisplatin plus 5-fluorouracil (5-FU) or capecitabine [SOC].", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.251Z" }, { "id": "06890550-4039-4bfa-bd8c-6503189b976e", "pmid": "", "title": "Gut microbiome‐based interventions for the management of obesity in children and adolescents aged up to 19 years", "imported": false, "abstract": "Abstract - Background The epidemic of overweight and obesity affects more than 390 million children and adolescents aged 5 to 19 years and 37 million children under five years of age. Overweight and obesity are associated with both short‐ and long‐term consequences, including chronic inflammation, metabolic diseases, as well as alterations in the gut microbiome composition. Gut microbiome‐based approaches may impact microbiome‐related metrics such as diversity or the abundance of intestinal bacteria, which may be linked to obesity‐related outcomes. However, evidence regarding the effect of gut microbiome‐based interventions for the management of obesity is limited. Objectives To assess the effects of gut microbiome‐based interventions in the management of overweight or obesity in children and adolescents in all their diversity aged 0 to 19 years. Search methods We searched CENTRAL, MEDLINE, CINAHL, Web of Science Core Collection, BIOSIS Previews, Global Index Medicus (all regions), IBECS, SciELO, PAHO, PAHO IRIS, WHO IRIS, WHOLIS, Bibliomap, TRoPHI as well as ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 24 January 2025. We did not apply any language restrictions. Selection criteria We included randomised controlled trials that evaluated gut microbiome‐based interventions [i.e. prebiotics, probiotics, synbiotics, short‐chain fatty acids (SCFAs), and faecal microbiota transplantation (FMT)] compared to standard‐of‐care, placebo, or control interventions in children and adolescents aged 0 to 19 years with overweight or obesity. Data collection and analysis Two review authors independently screened titles and abstracts and full texts, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias 2 tool and certainty of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE), a framework for assessing the certainty of evidence and making recommendations in systematic reviews. Random‐effects meta‐analyses were performed unless only one study per outcome was available, for which fixed‐effect analyses were performed. Main results We found 17 studies (838 participants) from various countries, evaluating the effects of prebiotics, probiotics, synbiotics, SCFAs, and FMT on body mass index (BMI), body weight, waist circumference, total body fat percentage (%TBF), systolic and diastolic blood pressure, and adverse events. Of the 17 studies included, five studies were in adolescents aged 10 to 19 years, and 12 studies were in children and adolescents spanning both age groups, 0 to 19 years. Upon contacting authors for data grouped by age of the participants, no studies provided separate outcomes data for children and adolescents. The included studies were funded by either academic funding sources or grants from the public and private sectors. Additionally, 15 studies were classified as currently being conducted ('ongoing'). The certainty of evidence throughout was very low. In adolescents 10 to 19 years of age, probiotics compared to placebo or no intervention may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events. Similarly, FMT compared to placebo may have little to no effect on waist circumference, %TBF, blood pressure, and adverse events in this age group. According to one study with 41 participants and in children and adolescents 0 to 19 years of age, intervention with prebiotics compared to placebo may result in a small reduction in BMI (mean difference = ‐0.70, 95% CI = ‐1.25 to ‐0.15) and body weight (mean difference = ‐1.5, 95% CI = ‐2.61 to ‐0.39). Prebiotics compared to placebo may have little to no effect on waist circumference, %TBF, systolic blood pressure, and adverse events. No data were available on the effect of prebiotics on diastolic blood pressure. Probiotics compared to placebo may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events in children and adolescents (0 to 19 years). Synbiotics compared to placebo may result in a reduction in systolic blood pressure (mean difference = ‐40.00, 95% CI = ‐50.63 to ‐29.37) in children and adolescents (0 to 19 years); according to one study with 56 participants. The evidence is very uncertain about the effects of synbiotics compared to a placebo on BMI, body weight, waist circumference, blood pressure, and adverse events. No data were available on the effect of synbiotics compared to placebo on %TBF. Synbiotics, compared to probiotics, may have little to no effect on waist circumference, %TBF, and adverse events. No data were available on the effect of synbiotics compared to probiotics on BMI, body weight, and blood pressure. According to one study with 48 participants and very low‐certainty of evidence, SCFAs compared to placebo may result in a reduction in waist circumference (mean difference = ‐5.08, 95% CI = ‐7.40 to ‐2.76) and BMI (mean difference = ‐2.26, 95% CI = ‐3.24 to ‐1.28) in children and adolescents (0–19 years). SCFAs compared to placebo may have little to no effect on adverse events. No data were available on the effect of SCFAs on body weight, %TBF, and blood pressure. Adverse events, i.e. abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine, were reported in the prebiotics group but with very low incidence. Additionally, adverse events such as nausea and headache were reported in the SCFAs group, but with low incidence. Authors' conclusions In adolescents aged 10 to 19 years, gut microbiome‐based interventions may result in little to no difference in obesity‐related outcomes. In children and adolescents aged 0 to 19 years, prebiotics may result in a small reduction in BMI and body weight; synbiotics may result in a reduction in systolic blood pressure, and SCFAs may result in a reduction in BMI and waist circumference, albeit the certainty of evidence was very low. The evidence was of very low certainty due to few studies per comparison, small sample sizes, short intervention durations, and insufficient reporting of adverse events. More rigorous research examining different types of gut microbiome‐based interventions for the management of obesity is required in children and adolescents, both in clinical and community settings. Future trials should also report methods related to randomisation, blinding, and compliance, as well as include prespecified analysis plans. Plain language summary Review question How effective are the gut microbiome‐based interventions for the management of overweight or obesity in children and adolescents in all their diversity, aged 0 to 19 years? Key messages • It is unclear if gut microbiome‐based interventions (nutrition interventions targeting intestinal microbes) have an effect on body mass index (BMI), body weight, waist size, body fat percentage, measures of blood pressure, and adverse events in children and adolescents with overweight and obesity. • Further research, including larger trials, is required to understand the effects of gut microbiome‐based interventions for the management of overweight and obesity in children and adolescents. What is overweight or obesity? Overweight is a condition of excessive fat deposits, and obesity is a chronic disease characterised by excessive fat deposits that can affect most body systems, impair quality of life, and reduce life expectancy. BMI, calculated by dividing a person's weight in kilograms by their height in metres, squared, is often used to define overweight and obesity. How is overweight or obesity managed? Overweight or obesity may be managed through changes in diet, behavioural counselling for lifestyle modifications, medications, or surgery. Despite these approaches, this global epidemic affects more than 390 million children and adolescents aged 5 to 19 years, and 37 million children under five years of age as of 2022. Overweight or obesity is linked to abnormal metabolism and an imbalance in the gut microbiome. Published works have shown that nutrition interventions targeting the \"gut microbiome\" may have beneficial effects on body weight and body fat percentage. The gut microbiome is the community of harmless bacteria and other microorganisms in the human intestine needed for optimal health. What did we want to find out? We wanted to find out the effect of various nutritional interventions targeting the intestinal microbial community on BMI, body weight, waist circumference, total body fat percentage, blood pressure, and adverse events associated with the interventions amongst children and adolescents in all their diversity, aged 0 to 19 years. What did we do? We searched for studies that examined the effects of gut microbiome‐based interventions, including prebiotics (food ingredients that promote beneficial microbes in the gut), probiotics (live microbes that are good for health), synbiotics (a combination of both prebiotics and probiotics), short‐chain fatty acids (i.e. small fat molecules produced by intestinal bacteria by fermenting dietary fibre and non‐digestible carbohydrates), and faecal microbiota transplantation (i.e. a capsule containing stool microbes from a healthy donor), compared to standard‐of‐care (usual care), placebo, control, or no interventions in children and adolescents up to 19 years of age. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 17 studies involving 838 children and adolescents with overweight and obesity. The studies were conducted in different countries, including Spain, China, Taiwan, Canada, Mexico, Italy, Poland, Turkey, Iran, Thailand, Denmark, New Zealand, and the USA. Adolescents aged 10 to 19 years Nutrition interventions targeting intestinal microbes may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. Children and adolescents aged 0 to 19 years It is unclear if prebiotics have an effect on waist size, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that prebiotics compared to a dummy treatment (i.e. an intervention that does not contain any medicine but looks or tastes identical to the intervention being tested) may result in a small reduction in BMI and body weight, but the evidence is very uncertain. Probiotics compared to a dummy treatment may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. It is unclear if synbiotics have an effect on BMI, body weight, waist size, body fat percentage, diastolic blood pressure, and adverse events compared with a dummy treatment. One study found that synbiotics may result in a reduction in systolic blood pressure, but the evidence is very uncertain. It is unclear if short‐chain fatty acids have an effect on body weight, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that short‐chain fatty acids may result in a reduction in BMI and waist circumference, but the evidence is very uncertain. Side effects of the interventions were generally not reported in the included studies, but one study noted potential side effects such as abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine in the prebiotics group; however, the occurrence was very low. Nausea and headache were reported in another study in the short‐chain fatty acids group, but were minimal. What are the limitations of the evidence? The review's findings are limited by the small number of participants, the low number of available studies for each of the comparisons, the lack of long‐term data, and insufficient reporting of adverse effects. How up to date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fahim, SM; Huey, SL; Palma Molina, XE; Agarwal, N; Ridwan, P; Ji, N; Kibbee, M; Kuriyan, R; Finkelstein, JL; Mehta, S", "articleTypes": [], "doi": "10.1002/14651858.CD015875", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "069c5477-4a2d-483d-9f99-df12edcd5511", "pmid": "", "title": "Interventions for erosive lichen planus affecting mucosal sites", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cheng, S, Kirtschig, G, Cooper, S, Thornhill, M, Leonardi‐Bee, J, Murphy, R", "articleTypes": [], "doi": "10.1002/14651858.CD008092.pub2 AB - Abstract - Background Erosive lichen planus (ELP) affecting mucosal surfaces is a chronic autoimmune disease of unknown aetiology. It is often more painful and debilitating than the non‐erosive types of lichen planus. Treatment of erosive lichen planus is difficult and aimed at palliation rather than cure. Several topical and systemic agents have been used with varying results. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth. Objectives To assess the effects of interventions in the treatment of erosive lichen planus affecting the oral, anogenital, and oesophageal regions. Search methods We searched the following databases up to September 2009: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched reference lists of articles and online trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) that evaluated the effectiveness of any topical or systemic interventions for ELP affecting either the mouth, genital region, or both areas, in participants of any age, gender, or race. Data collection and analysis The primary outcome measures were as follows: (a) Pain reduction using a visual analogue scale rated by participants; 
 (b) Physician Global Assessment; and
 (c) Participant global self‐assessment. Changes in scores at the end of therapy compared with baseline were analysed. Main results Fifteen RCTs were included, giving a total of 473 participants with ELP (study sizes ranged between 8‐94). All studies involved oral sites only. Six studies included participants with non‐erosive lichen planus but only the erosive subgroup was included for intended subgroup analysis. We were unable to pool data from any of the nine studies with only ELP participants or any of the six studies with the ELP subgroup, due to small numbers and the heterogeneity of the interventions, design methods, and outcome variables between studies. One study involving 50 participants found that 0.025% clobetasol propionate administered as liquid microspheres significantly reduced pain compared to ointment (Mean difference (MD) ‐18.30, 95% confidence interval (CI) ‐28.57 to ‐8.03), but outcome data was only available in 45 participants (high risk of performance bias for blinding of participants, low/unclear risk of bias overall). However, in another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (high risk of performance and detection bias due to likely lack of blinding, low/unclear risk of bias overall). Aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo in a study involving 45 ELP participants (Risk ratio (RR) 6.16, 95% CI 2.35 to 16.13) (low risk of bias overall). No significant difference was seen in Physician Global Assessment in these three studies. In a small single study involving 20 ELP participants, 1% pimecrolimus cream was 7 times more likely to result in a strong improvement as rated by the Physician Global Assessment when compared to vehicle cream (RR 7.00, 95% CI 1.04 to 46.95) (low risk of bias overall). In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease as rated by the Physician Global Assessment, in favour of the ciclosporin group when compared to the vehicle (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (unclear risk of selection bias for allocation concealment, overall risk of bias low). No statistically significant benefits were shown for topical tacrolimus or fluticasone spray in two separate studies of 29 and 44 participants respectively. There is no overwhelming evidence for the efficacy of a single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candidiasis and dyspepsia. Authors' conclusions This review suggests that there is only weak evidence for the effectiveness of any of the treatments for oral ELP, whilst no evidence was found for genital ELP. More RCTs on a larger scale are needed in the oral and genital ELP populations. We suggest that future studies should have standardised outcome variables that are clinically important to affected individuals. We recommend the measurement of a clinical severity score and a participant‐rated symptom score using agreed and validated severity scoring tools. We also recommend the development of a validated combined severity scoring tool for both oral and genital populations. Plain language summary Treatments for erosive lichen planus affecting mucosal sites Erosive lichen planus (ELP) is a condition that affects the mouth, oesophagus (food pipe or gullet), and anogenital region. It is caused by an over‐active immune system. It is often more painful and debilitating than the non‐erosive types of lichen planus. Depending on the site involved, affected individuals may experience pain, and difficulty eating; passing urine; or having sexual intercourse. Treatment is difficult and aimed at controlling symptoms, rather than cure. Several creams and tablets have been used with varying results. This review looked at the effectiveness of treatments for ELP and included 15 studies, with 473 participants with ELP. All involved oral, but not genital, disease. Many studies were excluded either because they were not randomised controlled trials (where participants are divided into two groups at random) or because they recruited participants with all types of lichen planus, rather than just the erosive subtypes. All of these studies recruited small numbers of participants (12 to 94) and used a variety of different assessment methods and timings; hence, it was not possible to combine or compare results between studies directly. We found only weak evidence for the effectiveness of any of the treatments for oral ELP. None of the studies involved genital or oesophageal disease; hence, no evidence was found for the treatment of these conditions. One small study found that 0.025% clobetasol propionate (a very potent topical steroid) administered as a spray significantly reduced pain when compared to ointment. In another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (a potent topical steroid). In a study involving 45 ELP participants, aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo. In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease in favour of the ciclosporin group when compared to the vehicle. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candida (yeast) infection and pain or discomfort in the upper abdomen. Temporary burning was a common side‐effect reported with tacrolimus 0.1% ointment and pimecrolimus 0.1% cream. Overall, there was no overwhelming evidence for the effectiveness of any single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. This was mainly due to the lack of good‐quality, well‐conducted trials and small participant numbers. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.752Z" }, { "id": "06a0dcc4-b689-4370-9779-2ae477817954", "pmid": "", "title": "Fatty Acid Taste Thresholds: Caproic, Lauric, Oleic, Linoleic, Linolenic", "imported": false, "abstract": "Differences in human oral sensitivity for caproic, lauric, oleic, linoleic, and linolenic acids will be explored. Prior work indicates that there may be a learning effect in measuring detection thresholds for free fatty acids. This study is designed to determine the number of visits necessary to attenuate this learning effect and also to test whether this effect continues across different types of fatty acids or is specific to each fatty acid. This will aid in understanding how many visits are required to obtain reliable data and if less expensive fatty acids can be used to attenuate learning before testing thresholds for more expensive fatty acids.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "06b56929-5e23-4e90-9099-e19efea88b61", "pmid": "", "title": "Inhaled sodium cromoglycate for asthma in children", "imported": false, "abstract": "Abstract - Background Sodium cromoglycate has been recommended as maintenance treatment for childhood asthma for many years. Its use has decreased since 1990, when inhaled corticosteroids became popular, but it is still used in many countries. Objectives To determine the efficacy of sodium cromoglycate compared to placebo in the prophylactic treatment of children with asthma. Search methods We searched the Cochrane Airways Group Trials Register (October 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library Issue 3, 2009), MEDLINE (January 1966 to October 2009), EMBASE (January 1985 to October 2009) and reference lists of articles. We also contacted the pharmaceutical company manufacturing sodium cromoglycate. Selection criteria All double‐blind, placebo‐controlled randomised trials, which addressed the effectiveness of inhaled sodium cromoglycate as maintenance therapy, studying children aged 0 up to 18 years with asthma. Data collection and analysis Two authors independently assessed trial quality and extracted data. We pooled study results. Main results Of 3500 titles retrieved from the literature, 24 papers reporting on 23 studies could be included in the review. The studies were published between 1970 and 1997 and together included 1026 participants. Most were cross‐over studies. Few studies provided sufficient information to judge the concealment of allocation. Four studies provided results for the percentage of symptom‐free days. Pooling the results did not reveal a statistically significant difference between sodium cromoglycate and placebo. For the other pooled outcomes, most of the symptom‐related outcomes and bronchodilator use showed statistically significant results, but treatment effects were small. Considering the confidence intervals of the outcome measures, a clinically relevant effect of sodium cromoglycate cannot be excluded. The funnel plot showed an under‐representation of small studies with negative results, suggesting publication bias. Authors' conclusions There is insufficient evidence to be sure about the efficacy of sodium cromoglycate over placebo. Publication bias is likely to have overestimated the beneficial effects of sodium cromoglycate as maintenance therapy in childhood asthma. Plain language summary The effects of sodium cromoglycate compared with placebo for chronic asthma in children In this review we aimed to determine whether there is evidence for the effectiveness of inhaled sodium cromoglycate as maintenance treatment in children with chronic asthma. Most of the studies were carried out in small groups of patients. Furthermore, we suspect that not all studies undertaken have been published. The results show that there is insufficient evidence to be sure about the beneficial effect of sodium cromoglycate compared to placebo. However, for several outcome measures the results favoured sodium cromoglycate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "van der Wouden, JC, Uijen, JHJM, Bernsen, RMD, Tasche, MJA, de Jongste, JC, Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002173.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.777Z" }, { "id": "06c91ff5-e657-43a6-8393-5d2ea32c7d3f", "pmid": "", "title": "Antihypertensive Effects of Rosmarinus Officinalis L. Infusion Supplements in Male Patients With Mild Hypertension : A Randomized Double-Blind Placebo-Controlled Study", "imported": false, "abstract": "This study assessed the antihypertensive effect of rosemary tea through a placebo-controlled clinical study, angiotensin-converting enzyme (ACE) inhibition analysis, and in silico evaluation of interactions between rosemary bioactive compounds and the AT1R (Angiotensin II Type 1 Receptor).", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "06ccc05a-2f38-41e9-836d-b759ba27558f", "pmid": "", "title": "Perioperative nutrition interventions for women with ovarian cancer", "imported": false, "abstract": "Abstract - Background Women with ovarian cancer have been shown to be at significant risk of malnutrition with incidence rates described as being between 28% to 67%. Nutrition interventions may improve clinical outcomes positively, nutritional status or quality of life measures in this patient group. Objectives This review was conducted to assess the effects of nutrition interventions during the perioperative period for women with ovarian cancer. Search methods Electronic searches were conducted of the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 7), Medline (1946 to July week 4 2012), Embase (1980 to 2012 week 31), DARE (to 7th August 2012) AMED (1985 to April 2012), BNI (1992 to April 2012), CINAHL (to April 2012). We also searched trials databases, conference proceedings and related citation lists. Reference listings were handsearched. No restrictions were applied on language or date. Selection criteria Randomised controlled trials (RCTs) in which women 18 years and over with any stage of ovarian cancer, including recurrent cancer, were in the perioperative phase of treatment and received any type of nutrition intervention. Data collection and analysis Titles and abstracts were screened by two review authors with study selection discussed by a team. Pairs of review authors worked independently on data collection and compared findings. Main results A total of 4092 titles were screened and 14 full text reports reviewed; a single small study met the inclusion criteria. In the included RCT, 40 women (35 with ovarian cancer) had extensive elective surgery including bowel resection for treatment of gynaecological malignancy. Randomisation was made to either early oral feeding (oral fluids in the first 24 hours, solid foods on the following day) or to a 'traditional' feeding regimen where oral fluids and foods were delayed until there was evidence of bowel function. Most women in the early feeding group (14/18) were able to resume eating solid food one day after surgery. This resulted in a significantly shorter hospital stay with no increase in postoperative complications or change in quality of life measures in comparison with the women on the 'traditional' feeding regimen. The incidence of nausea and vomiting during the postoperative stay was similar in both groups and was noted in slightly more than half of the women. Overall survival was evaluated until 30 days following discharge from hospital; in this period, there was one death of a woman who had been in the 'traditional oral feeding' group, cause of death was not noted. We assessed risk of bias and found no high risk of bias was identified in the methodology and reporting of the included study, although there was an increased risk of bias due to the small size of the study in which not all of the women had ovarian cancer. Authors' conclusions Although women with ovarian cancer have been shown to be at risk of malnutrition, there is a lack of evidence derived from RCTs evaluating the identification, assessment and treatment of malnutrition during the perioperative phase of treatment. There is evidence from one small study that some women with ovarian cancer undergoing surgery with associated bowel resection may safely commence oral fluids within 24 hours of surgery and solid foods on the following day. Further research is required, including a RCT, to generate guidance concerning the treatment of malnutrition in this patient group. Plain language summary Nutrition for women who are having surgery for ovarian cancer Women who have ovarian cancer, (a cancer which develops in the two organs (ovaries) that produce eggs in women) are more likely to have difficulties with food and with eating a nourishing diet in comparison to women with other types of gynaecological cancers. One reason may be because the symptoms of ovarian cancer can be difficult to recognise. Women may have a lack of interest in food, feel full, feel sick or have a painful or swollen abdomen. Some women become thinner in parts of their bodies while becoming bigger around their abdomen due to an abnormal build up of fluid or large tumours. There may be no change in body weight or weight may increase, this can make it difficult to know which women are developing problems due to a poor food intake. Women who are unable to eat and drink well are at risk of becoming malnourished and may then have more complications from the treatments for ovarian cancer than women who are not malnourished. It is recommended that people who are having difficulties with eating and drinking should be identified and helped when they receive hospital care. Currently, there is no agreed method for finding and treating nutritional problems for women with ovarian cancer. In this review, the authors looked for studies (randomised controlled trials (RCTs)) from around the world to find out how women with ovarian cancer were assessed to see if they were eating and drinking well and what help they may be given with nutrition before or after surgery. A lack of information was found on this topic. One RCT was found where a small group of women (40 including 35 with ovarian cancer) requiring extensive elective surgery for gynaecological cancer including surgery to the gut, were able to restart eating normal foods on the day after surgery. They were able to leave hospital earlier and did not have more complications in the month after surgery than women who were not allowed to resume eating normal foods until at least three days after the operation. More studies are needed to confirm whether restarting normal eating one day after surgery can be recommended for women having surgery for ovarian cancer. More research is needed to provide information about how to identify and treat problems of malnutrition in women with ovarian cancer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Billson, HA, Holland, C, Curwell, J, Davey, VL, Kinsey, L, Lawton, LJ, Whitworth, AJ, Burden, S", "articleTypes": [], "doi": "10.1002/14651858.CD009884.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.100Z" }, { "id": "06d681e5-2660-4088-8746-23f3ca0e2b27", "pmid": "", "title": "Population‐level interventions in government jurisdictions for dietary sodium reduction", "imported": false, "abstract": "Abstract - Background Excess dietary sodium consumption is a risk factor for high blood pressure, stroke and cardiovascular disease. Currently, dietary sodium consumption in almost every country is too high. Excess sodium intake is associated with high blood pressure, which is common and costly and accounts for significant burden of disease. A large number of jurisdictions worldwide have implemented population‐level dietary sodium reduction initiatives. No systematic review has examined the impact of these initiatives. Objectives • To assess the impact of population‐level interventions for dietary sodium reduction in government jurisdictions worldwide. • To assess the differential impact of those initiatives by social and economic indicators. Search methods We searched the following electronic databases from their start date to 5 January 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); Cochrane Public Health Group Specialised Register; MEDLINE; MEDLINE In Process & Other Non‐Indexed Citations; EMBASE; Effective Public Health Practice Project Database; Web of Science; Trials Register of Promoting Health Interventions (TRoPHI) databases; and Latin American Caribbean Health Sciences Literature (LILACS). We also searched grey literature, other national sources and references of included studies. This review was conducted in parallel with a comprehensive review of national sodium reduction efforts under way worldwide ( Trieu 2015 ), through which we gained additional information directly from country contacts. We imposed no restrictions on language or publication status. Selection criteria We included population‐level initiatives (i.e. interventions that target whole populations, in this case, government jurisdictions, worldwide) for dietary sodium reduction, with at least one pre‐intervention data point and at least one post‐intervention data point of comparable jurisdiction. We included populations of all ages and the following types of study designs: cluster‐randomised, controlled pre‐post, interrupted time series and uncontrolled pre‐post. We contacted study authors at different points in the review to ask for missing information. Data collection and analysis Two review authors extracted data, and two review authors assessed risk of bias for each included initiative. We analysed the impact of initiatives by using estimates of sodium consumption from dietary surveys or urine samples. All estimates were converted to a common metric: salt intake in grams per day. We analysed impact by computing the mean change in salt intake (grams per day) from pre‐intervention to post‐intervention. Main results We reviewed a total of 881 full‐text documents. From these, we identified 15 national initiatives, including more than 260,000 people, that met the inclusion criteria. None of the initiatives were provided in lower‐middle‐income or low‐income countries. All initiatives except one used an uncontrolled pre‐post study design. Because of high levels of study heterogeneity (I 2 > 90%), we focused on individual initiatives rather than on pooled results. Ten initiatives provided sufficient data for quantitative analysis of impact (64,798 participants). As required by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) method, we graded the evidence as very low due to the risk of bias of the included studies, as well as variation in the direction and size of effect across the studies. Five of these showed mean decreases in average daily salt intake per person from pre‐intervention to post‐intervention, ranging from 1.15 grams/day less (Finland) to 0.35 grams/day less (Ireland). Two initiatives showed mean increase in salt intake from pre‐intervention to post‐intervention: Canada (1.66) and Switzerland (0.80 grams/day more per person); however in both countries the pre‐intervention data point was from several years prior to the initiation of the intervention. The remaining initiatives did not show a statistically significant mean change. Seven of the 10 initiatives were multi‐component and incorporated intervention activities of a structural nature (e.g. food product reformulation, food procurement policy in specific settings). Of those seven initiatives, four showed a statistically significant mean decrease in salt intake from pre‐intervention to post‐intervention, ranging from Finland to Ireland (see above), and one showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention (Switzerland; see above). Nine initiatives permitted quantitative analysis of differential impact by sex (men and women separately). For women, three initiatives (China, Finland, France) showed a statistically significant mean decrease, four (Austria, Netherlands, Switzerland, United Kingdom) showed no significant change and two (Canada, United States) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. For men, five initiatives (Austria, China, Finland, France, United Kingdom) showed a statistically significant mean decrease, three (Netherlands, Switzerland, United States) showed no significant change and one (Canada) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. Information was insufficient to indicate whether a differential change in mean salt intake occurred from pre‐intervention to post‐intervention by other axes of equity included in the PROGRESS framework (e.g. education, place of residence). We identified no adverse effects of these initiatives. The number of initiatives was insufficient to permit other subgroup analyses, including stratification by intervention type, economic status of country and duration (or start year) of the initiative. Many studies had methodological strengths, including large, nationally representative samples of the population and rigorous measurement of dietary sodium intake. However, all studies were scored as having high risk of bias, reflecting the observational nature of the research and the use of an uncontrolled study design. The quality of evidence for the main outcome was low. We could perform a sensitivity analysis only for impact. Authors' conclusions Population‐level interventions in government jurisdictions for dietary sodium reduction have the potential to result in population‐wide reductions in salt intake from pre‐intervention to post‐intervention, particularly if they are multi‐component (more than one intervention activity) and incorporate intervention activities of a structural nature (e.g. food product reformulation), and particularly amongst men. Heterogeneity across studies was significant, reflecting different contexts (population and setting) and initiative characteristics. Implementation of future initiatives should embed more effective means of evaluation to help us better understand the variation in the effects. Plain language summary National government initiatives to reduce salt intake in populations The problem 
 In almost all countries worldwide, most people eat too much salt. This is a problem because eating too much salt can cause high blood pressure, which can lead to health problems such as heart disease and stroke. To reduce the amount of salt eaten, governments in many countries have developed national salt reduction initiatives. The review question 
 Our aim was to examine whether national salt reduction initiatives have been effective in reducing the amount of salt consumed in those populations. Study characteristics 
 We searched research papers and government reports and had direct communication with individuals working in salt reduction in their respective countries. The evidence is current as of 5 January 2015, when we last searched electronic databases. Initiatives in 15 countries met the inclusion criteria. Ten of these countries provided sufficient data for quantitative analysis, gathered from studies that included 64,798 participants. Initiatives ranged from one activity (e.g. in Japan, which at the time of writing had a public information campaign) to many activities (e.g. in the United Kingdom, which provided five activities including on‐package nutrition information, restrictions on marketing to children and food product reformulation). Of the 15 countries that met inclusion criteria, seven provided information about funding source, of which six reported non‐industry funding. The other eight countries did not report a funding source for one or more data point(s). Key results and quality of the evidence 
 Five of the 10 countries included in the quantitative analysis (China, Finland, France, Ireland and England) showed a decrease in salt intake after the intervention. Two of the 10 countries (Canada, Switzerland) showed an increase in salt intake after the intervention, however, in both countries the only data available were from several years prior to the intervention starting. Because the initiatives were very different, we cannot present an overall finding of whether these types of initiatives work. When we focused on the subset of seven countries whose salt reduction initiatives included multiple components and were not focused solely on educating the public, we found that more than half (four of seven) showed a decrease in salt intake from pre‐intervention to post‐intervention. When we examined the nine initiatives that analysed men and women separately, we found that amongst men, more than half (five of nine) showed a decrease in salt intake after the intervention. Amongst women, the pattern of findings was less clear, with three of nine interventions showing a decrease, two showing an increase and four showing no change in salt intake. Low‐bias study designs, such as randomised controlled trials, typically are not suitable for evaluating complex initiatives such as these; therefore, we rated all of the studies included in this review as having low methodological quality. Large nationally representative samples of the population and careful measurement of dietary sodium intake were strengths of several studies. However, because of study design limitations, the trustworthiness of study results is not clear. Overall, our results show that national government initiatives have the potential to achieve population‐wide reductions in salt intake, especially amongst men, and particularly if they employ more than one strategy and include structural activities such as food product reformulation (i.e. food companies putting less salt in food products). The wide variation of results across the studies we found presents a challenge in interpreting the current evidence and this warrants more research to help us understand this.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McLaren, L; Sumar, N; Barberio, AM; Trieu, K; Lorenzetti, DL; Tarasuk, V; Webster, J; Campbell, NRC", "articleTypes": [], "doi": "10.1002/14651858.CD010166.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "06e5002c-2271-4e15-8cb0-ca6bde20936f", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: cytokines and growth factors", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulceration can lead to severe pain and difficulty with eating and drinking, which may necessitate opioid analgesics, hospitalisation and supplemental nutrition. These complications may disrupt cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining of the mouth, thus preventing or reducing oral mucositis and its negative effects. Objectives To assess the effects of cytokines and growth factors for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (searched 10 May 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4) in the Cochrane Library (searched 10 May 2017); MEDLINE Ovid (1946 to 10 May 2017); Embase Ovid (7 December 2015 to 10 May 2017); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 10 May 2017); and CANCERLIT PubMed (1950 to 10 May 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of cytokines and growth factors in patients with cancer receiving treatment. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 35 RCTs analysing 3102 participants. Thirteen studies were at low risk of bias, 12 studies were at unclear risk of bias, and 10 studies were at high risk of bias. Our main findings were regarding keratinocyte growth factor (KGF) and are summarised as follows. There might be a reduction in the risk of moderate to severe oral mucositis in adults receiving bone marrow/stem cell transplantation after conditioning therapy for haematological cancers (RR 0.89, 95% CI 0.80 to 0.99; 6 studies; 852 participants; low‐quality evidence). We would need to treat 11 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 6 to 112). There might be a reduction in the risk of severe oral mucositis in this population, but there is also some possibility of an increase in risk (RR 0.85, 95% CI 0.65 to 1.11; 6 studies; 852 participants; low‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to prevent the outcome to 14 to cause the outcome). There is probably a reduction in the risk of moderate to severe oral mucositis in adults receiving radiotherapy to the head and neck with cisplatin or fluorouracil (RR 0.91, 95% CI 0.83 to 1.00; 3 studies; 471 participants; moderate‐quality evidence). We would need to treat 12 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 7 to infinity). It is very likely that there is a reduction in the risk of severe oral mucositis in this population (RR 0.79, 95% CI 0.69 to 0.90; 3 studies; 471 participants; high‐quality evidence). We would need to treat 7 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to 15). It is likely that there is a reduction in the risk of moderate to severe oral mucositis in adults receiving chemotherapy alone for mixed solid and haematological cancers (RR 0.56, 95% CI 0.45 to 0.70; 4 studies; 344 participants; moderate‐quality evidence). We would need to treat 4 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 3 to 6). There might be a reduction in the risk of severe oral mucositis in this population (RR 0.30, 95% CI 0.14 to 0.65; 3 studies; 263 participants; low ‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 8 to 19). Due to the low volume of evidence, single‐study comparisons and insufficient sample sizes, we found no compelling evidence of a benefit for any other cytokines or growth factors and there was no evidence on children. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Authors' conclusions We are confident that KGF is beneficial in the prevention of oral mucositis in adults who are receiving: a) radiotherapy to the head and neck with cisplatin or fluorouracil; or b) chemotherapy alone for mixed solid and haematological cancers. We are less confident about a benefit for KGF in adults receiving bone marrow/stem cell transplant after conditioning therapy for haematological cancers because of multiple factors involved in that population, such as whether or not they received total body irradiation (TBI) and whether the transplant was autologous (the patients' own cells) or allogeneic (cells from a donor). KGF appears to be a relatively safe intervention. Due to limited research, we are not confident that there are any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Plain language summary Can cytokines and growth factors help prevent mouth soreness and ulcers (oral mucositis) in patients being treated for cancer? Review question This review has been produced to assess whether or not the use of cytokines and growth factors during cancer treatment, can help prevent mouth soreness and ulcers. Background Sore mouth and ulcers (oral mucositis) is a side effect of treatment for cancer including chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulcers can lead to severe pain and difficulty with eating and drinking. Sufferers may need strong painkillers, possibly have to go into hospital and even be fed through a tube into their stomach or their veins. These complications may disrupt their cancer therapy, meaning they are not receiving the best treatment, which may reduce survival. Cancer patients have weakened immune systems due to their treatment and are less able to fight infections. An ulcer is an open wound and there is a risk that bacteria can enter the body leading to infection or sepsis (a dangerous inflammatory reaction of the body to infection). Mouth soreness and ulcers can be costly to healthcare systems, yet there are few preventive interventions or treatments proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining the mouth, thus preventing or reducing oral mucositis and its negative effects. Study characteristics Authors from Cochrane Oral Health carried out this review of existing studies and the evidence is current up to 10 May 2017. It includes 35 studies (published between 1993 and 2017) with 3102 participants, all patients being treated for cancer, aged from 1 to 87 years old. Review authors included studies comparing cytokines and growth factors for the prevention of oral mucositis. The studies were carried out all over the world and often featured multiple sites, although most took place in high‐income countries. Main results The main findings were regarding keratinocyte growth factor (KGF). KGF is likely to reduce the risk of oral mucositis in adults who are receiving either radiotherapy to the head and neck with chemotherapy (cisplatin or fluorouracil), or chemotherapy alone for mixed solid and blood cancers. KGF may also reduce the risk of oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, but these results are less clear because of multiple complicating factors. KGF appears to be a relatively safe intervention. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Due to limited research, review authors are uncertain of any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Quality of the evidence For reducing oral mucositis in adults receiving radiotherapy to the head and neck with chemotherapy, review authors rated the evidence for KGF as moderate to high quality. For reducing oral mucositis in adults receiving chemotherapy alone for mixed solid and blood cancers, they rated the evidence for KGF as low to moderate quality. This evidence was downgraded due to there not being enough data and because some results have not yet been published. For reducing oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, they rated the evidence for KGF as low quality because results were not similar across the studies and some results have not yet been published. Evidence on side effects of KGF was poorly reported and inconsistent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P, Glenny, AM, Worthington, HV, Littlewood, A, Fernandez Mauleffinch, LM, Clarkson, JE, McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.754Z" }, { "id": "06fb80dd-3c93-4ec1-ad72-7d63bde8b67e", "pmid": "", "title": "The Effect of Caloric and Non-caloric Sweeteners on Hunger, Gastrointestinal Hormones as Well as on Antral and Duodenal Motility", "imported": false, "abstract": "In this study, the investigators aimed at evaluating the role of sweet taste receptors in the gastrointestinal tract (GIT). Intragastric administration of glucose, fructose or acesulfame-K were compared with placebo administration for their effects on gastrointestinal motility, gut hormone release (motilin, ghrelin, glucagon-like peptide-1 (GLP-1) and insulin) and hunger feelings.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.148Z" }, { "id": "06fdfdc0-7d84-40af-83b7-b4b89d409725", "pmid": "", "title": "A MULTICENTER, GLOBAL, RANDOMIZED, DOUBLE-BLIND STUDY OF AXITINIB PLUS BEST SUPPORTIVE CARE VERSUS PLACEBO PLUS BEST SUPPORTIVE CARE IN PATIENTS WITH ADVANCED HEPATOCELLULAR CARCINOMA FOLLOWING FAILURE OF ONE PRIOR ANTIANGIOGENIC THERAPY", "imported": false, "abstract": "The study is designed to demonstrate that axitinib plus best supportive care is superior to placebo plus best supportive care in prolonging survival in patients with advanced hepatocellular carcinoma.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "07087657-3a83-4ceb-90dc-f4384064ba05", "pmid": "", "title": "Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection", "imported": false, "abstract": "Abstract - Background Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted infections. The majority of women with genital herpes will have a recurrence during pregnancy. Transmission of the virus from mother to fetus typically occurs by direct contact with virus in the genital tract during birth. Objectives To assess the effectiveness of antenatal antiviral prophylaxis for recurrent genital herpes on neonatal herpes and maternal recurrences at delivery. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2006, Issue 4), MEDLINE (January 1966 to February 2007) and EMBASE (January 1974 to February 2007; handsearched conference proceedings; reviewed bibliographies of all relevant articles for further references; and contacted experts in the field. Selection criteria Randomized controlled trials which assessed the effectiveness of antivirals compared to placebo or no therapy, on neonatal herpes and maternal disease endpoints among pregnant women with genital herpes. Data collection and analysis Two authors independently applied study selection criteria and extracted data. Main results Seven randomized controlled trials (1249 participants) which met our inclusion criteria compared acyclovir to placebo or no treatment (five trials) and valacyclovir to placebo (two trials). The effect of antepartum antiviral prophylaxis on neonatal herpes could not be estimated. There were no cases of symptomatic neonatal herpes in the included studies in either the treatment or placebo groups. Women who received antiviral prophylaxis were significantly less likely to have a recurrence of genital herpes at delivery (relative risk (RR) 0.28, 95% confidence interval (CI) 0.18 to 0.43, I 2 = 0%). Women who received antiviral prophylaxis were also significantly less likely to have a cesarean delivery for genital herpes (RR 0.30, 95% CI 0.20 to 0.45, I 2 = 27.3%). Women who received antiviral prophylaxis were significantly less likely to have HSV detected at delivery (RR 0.14, 95% CI 0.05 to 0.39, I 2 = 0%). Authors' conclusions Women with recurrent genital herpes simplex virus should be informed that the risk of neonatal herpes is low. There is insufficient evidence to determine if antiviral prophylaxis reduces the incidence of neonatal herpes. Antenatal antiviral prophylaxis reduces viral shedding and recurrences at delivery and reduces the need for cesarean delivery for genital herpes. Limited information exists regarding the neonatal safety of prophylaxis. The risks, benefits, and alternatives to antenatal prophylaxis should be discussed with women who have a history and prophylaxis initiated for women who desire intervention. Plain language summary Use of antiviral drugs in late pregnancy for reducing the recurrence of genital herpes at labor and birth and reducing the risk of newborn HSV infection The incidence of herpes, a sexually transmitted disease, varies across the world. Among pregnant women with herpes, nearly 75% can expect at least one flare‐up during their pregnancy. Transmission of the virus from mother to baby typically occurs by direct contact with the virus during birth. It is often recommended that a cesarean should be offered to women with active lesions to reduce the risk of transmission to the baby. In addition, several antiviral agents are available for use both for therapy and for preventing a flare‐up. These antiviral drugs include acyclovir, penciclovir, valacyclovir, and famciclovir. The review assessed whether antiviral drugs given to pregnant women with herpes before a recurrence might be effective in reducing transmission to the baby. Seven studies were identified involving 1249 women. Giving antiviral drugs reduces viral shedding and recurrences at labor and birth. They also reduced the use of cesarean, but there is no evidence of reduction in neonatal herpes. Women should also be informed that the risk of the baby getting herpes during birth is low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Hollier, LM, Wendel, GD", "articleTypes": [], "doi": "10.1002/14651858.CD004946.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.807Z" }, { "id": "070b5c90-9884-49a6-b5f9-ffa66f2929b5", "pmid": "", "title": "Nutritional supplementation for hip fracture aftercare in older people", "imported": false, "abstract": "Abstract - Background Older people with hip fractures are often malnourished at the time of fracture, and subsequently have poor food intake. This is an update of a Cochrane review first published in 2000, and previously updated in 2010. Objectives To review the effects (benefits and harms) of nutritional interventions in older people recovering from hip fracture. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, MEDLINE In‐Process & Other Non‐Indexed Citations, Embase, CAB Abstracts, CINAHL, trial registers and reference lists. The search was last run in November 2015. Selection criteria Randomised and quasi‐randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture where the interventions were started within the first month after hip fracture. Data collection and analysis Two review authors independently selected trials, extracted data and assessed risk of bias. Where possible, we pooled data for primary outcomes which were: all cause mortality; morbidity; postoperative complications (e.g. wound infections, pressure sores, deep venous thromboses, respiratory and urinary infections, cardiovascular events); and 'unfavourable outcome' defined as the number of trial participants who died plus the number of survivors with complications. We also pooled data for adverse events such as diarrhoea. Main results We included 41 trials involving 3881 participants. Outcome data were limited and risk of bias assessment showed that trials were often methodologically flawed, with less than half of trials at low risk of bias for allocation concealment, incomplete outcome data, or selective reporting of outcomes. The available evidence was judged of either low or very low quality indicating that we were uncertain or very uncertain about the estimates. Eighteen trials evaluated oral multinutrient feeds that provided non‐protein energy, protein, vitamins and minerals. There was low‐quality evidence that oral feeds had little effect on mortality (24/486 versus 31/481; risk ratio (RR) 0.81 favouring supplementation, 95% confidence interval (CI) 0.49 to 1.32; 15 trials). Thirteen trials evaluated the effect of oral multinutrient feeds on complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was low‐quality evidence that the number of participants with complications may be reduced with oral multinutrient feeds (123/370 versus 157/367; RR 0.71, 95% CI 0.59 to 0.86; 11 trials). Based on very low‐quality evidence from six studies (334 participants), oral supplements may result in lower numbers with 'unfavourable outcome' (death or complications): RR 0.67, 95% CI 0.51 to 0.89. There was very low‐quality evidence for six studies (442 participants) that oral supplementation did not result in an increased incidence of vomiting and diarrhoea (RR 0.99, 95% CI 0.47 to 2.05). Only very low‐quality evidence was available from the four trials examining nasogastric multinutrient feeding. Pooled data from three heterogeneous trials showed no evidence of an effect of supplementation on mortality (14/142 versus 14/138; RR 0.99, 95% CI 0.50 to 1.97). One trial (18 participants) found no difference in complications. None reported on unfavourable outcome. Nasogastric feeding was poorly tolerated. One study reported no cases of aspiration pneumonia. There is very low‐quality evidence from one trial (57 participants, mainly men) of no evidence for an effect of tube feeding followed by oral supplementation on mortality or complications. Tube feeding, however, was poorly tolerated. There is very low‐quality evidence from one trial (80 participants) that a combination of intravenous feeding and oral supplements may not affect mortality but could reduce complications. However, this expensive intervention is usually reserved for people with non‐functioning gastrointestinal tracts, which is unlikely in this trial. Four trials tested increasing protein intake in an oral feed. These provided low‐quality evidence for no clear effect of increased protein intake on mortality (30/181 versus 21/180; RR 1.42, 95% CI 0.85 to 2.37; 4 trials) or number of participants with complications but very low‐quality and contradictory evidence of a reduction in unfavourable outcomes (66/113 versus 82/110; RR 0.78, 95% CI 0.65 to 0.95; 2 trials). There was no evidence of an effect on adverse events such as diarrhoea. Trials testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. Based on low‐quality evidence, one trial evaluating the use of dietetic assistants to help with feeding indicated that this intervention may reduce mortality (19/145 versus 36/157; RR 0.57, 95% CI 0.34 to 0.95) but not the number of participants with complications (79/130 versus 84/125). Authors' conclusions There is low‐quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low‐quality evidence that oral supplements may reduce 'unfavourable outcome' (death or complications) and that they do not result in an increased incidence of vomiting and diarrhoea. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding or nasogastric feeding in very malnourished people require further evaluation. Plain language summary Nutritional supplementation for older people after hip fracture Background and aim Older people with hip fractures are often malnourished at the time of their fracture and many have poor food intake while in hospital. Malnutrition may hinder recovery after hip fracture. We reviewed the effects of nutritional interventions in older people recovering from hip fracture. Search results We searched the scientific literature up to November 2015 and include 41 studies including 3881 participants. All nutritional interventions were started within one month of hip fracture. The studies had flaws in their methods that may affect the validity of their results. Some evidence was very low quality which means we are very unsure of the results. Key results Eighteen studies examined the use of additional oral feeds that provided energy from sources other than protein, protein, some vitamins and minerals. There was low‐quality evidence that these multinutrient oral feeds may not reduce mortality but that they may reduce the number of people with complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was very low‐quality evidence that oral multinutrient feeds may reduce unfavourable outcome (death or complications) and that they did not result in increased vomiting and diarrhoea. Four studies examined nasogastric tube feeding, where liquid food is delivered via a tube inserted into the nose and passed down into the stomach, with non‐protein energy, protein, some vitamins and minerals. These studies provided very low‐quality evidence that tube feeding, which was poorly tolerated, did not seem to make a difference to mortality or complications. Unfavourable outcome was not recorded and there was insufficient evidence on adverse events. One study provided very low‐quality evidence that nasogastric tube feeding followed by oral feeds may not affect mortality or complications. It reported that tube feeding was poorly tolerated. One study provided very low‐quality evidence that giving feed into a vein initially and then by mouth may not affect mortality but may reduce complications. However, we were surprised that this intervention was being used in people who seemed to be able to take nutrition orally. Increasing protein intake in an oral feed was tested in four studies. These provided low‐quality evidence of no clear effect on mortality or complications and very low‐quality evidence for a reduction in unfavourable outcome. Studies testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. One study, evaluating the use of dietetic assistants to help with feeding, provided low‐quality evidence that this may reduce mortality but not the numbers of people with complications. Conclusions Oral supplements with non‐protein energy, protein, vitamins and minerals started before or soon after surgery may prevent complications after hip fracture in older people but may not affect mortality. Adequately sized randomised studies with better design are required. We suggest that the role of dietetic assistants, and of peripheral venous feeding or nasogastric feeding in very malnourished patients, require further evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Avenell, A, Smith, TO, Curtain, JP, Mak, JCS, Myint, PK", "articleTypes": [], "doi": "10.1002/14651858.CD001880.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.770Z" }, { "id": "070c8dd9-26cc-4fd5-b364-3c76daad0c8c", "pmid": "", "title": "Drugs for treating giardiasis", "imported": false, "abstract": "Abstract - Background Giardiasis infection may be asymptomatic, or can cause diarrhoea (sometimes severe), weight loss, malabsorption, and, in children, failure to thrive. It is usually treated with metronidazole given three times daily for five to 10 days. Objectives To evaluate the relative effectiveness of alternative antibiotic regimens for treating adults or children with symptomatic giardiasis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6 2012); MEDLINE, EMBASE, LILACS and the International Clinical Trials Registry Platform Search Portal (3 July 2012). Selection criteria We included randomized controlled trials (RCT) comparing metronidazole administered for five to 10 days with any of the following drugs: metronidazole (single dose), tinidazole, albendazole, mebendazole, and nitazoxanide. The primary outcomes were parasitological and clinical cure. Data collection and analysis Two authors independently assessed studies for inclusion, performed the risk of bias assessment, and extracted data. We summarized data using risk ratios and mean differences and we presented the results in forest plots and performed meta‐analyses where possible. We assessed heterogeneity using the Chi 2 test, I 2 statistic and visual inspection; and we explored this by using subgroup analyses.We assessed the quality of evidence by using the GRADE approach. Main results We included 19 trials, involving 1817 participants, of which 1441 were children. Studies were generally small, with poor methods reporting. . Most reported parasitological outcomes rather than clinical improvement. Ten trials, from India, Mexico, Peru, Iran, Cuba, and Turkey, compared albendazole (400 mg once daily for five to 10 days) with metronidazole (250 mg to 500 mg three times daily for five to 10 days). This once‐daily regimen of albendazole is probably equivalent to metronidazole at achieving parasitological cure (RR 0.99, 95% CI 0.95 to 1.03; 932 participants, 10 trials; moderate quality evidence ), and improving symptoms (RR 0.98, 95% confidence interval (CI) 0.93 to 1.04; 483 participants, five trials; moderate quality evidence ), but the duration of follow‐up was short (two to three weeks). Albendazole probably has fewer side effects than metronidazole (gastrointestinal side effects: RR 0.29, 95% CI 0.13 to 0.63; 717 participants, eight trials; moderate quality evidence ; neurological side effects: RR 0.34, 95% CI 0.18 to 0.64; 453 participants, five trials; low quality evidence ). Five trials from Turkey, Spain and the UK compared mebendazole (200 mg three times daily for five to 10 days) with metronidazole (5 mg/kg (or 250 mg) three times daily for five to 10 days). These trials were small in size, and at high risk of bias. Consequently, reliable conclusions on the relative effectiveness cannot be made ( very low quality evidence) . Five further trials, from Iran, Spain and Peru, have evaluated shortened regimens of tinidazole (single dose; 179 participants, three trials), metronidazole (single dose; 55 participants, one trial), and nitazoxanide (three days; 55 participants, one trial). Again, these trials were at high risk of bias and too small to reliably detect or exclude important differences ( very low quality evidence) . Authors' conclusions Albendazole may be of similar effectiveness to metronidazole, may have fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes (such as diarrhoea) will help assess further alternatives. 15 April 2019 Update pending Studies awaiting assessment The CIDG is currently examining a new search conducted in April 2019 for potentially relevant studies. These studies have not yet been incorporated into this Cochrane Review. Plain language summary Drugs for treating giardiasis Giardiasis is an infection of the small intestine caused by a microscopic organism called Giardia lamblia . The infection is passed from person to person by ingesting faecally contaminated water or food. Symptoms frequently include diarrhoea, abdominal pain, flatulence, bloating, vomiting, and weight loss. In this review, we assess alternatives to the most commonly used treatment for giardiasis; metronidazole given orally for five or more days. We identified 19 trials involving 1817 participants, of which 1441 were children. Most trials had a small number of participants and were at high risk of bias. Albendazole is probably of similar effectiveness to metronidazole, probably has fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes are required to assess further alternatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Granados, CE, Reveiz, L, Uribe, LG, Criollo, CP", "articleTypes": [], "doi": "10.1002/14651858.CD007787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.082Z" }, { "id": "070cad3d-f5f6-4f9d-8012-6f6f98388370", "pmid": "", "title": "Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people", "imported": false, "abstract": "Abstract - Background There is evidence that water‐loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well‐being are compromised. Objectives To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water‐loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water‐loss dehydration was defined primarily as including everyone with either impending or current water‐loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). Search methods Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases ( The Cochrane Library ), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. Selection criteria Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. Data collection and analysis Diagnostic accuracy of each test was assessed against the best available reference standard for water‐loss dehydration (serum or plasma osmolality cut‐off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water‐loss dehydration (including either impending or current water‐loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water‐loss dehydration, but restricted to current dehydration in the final review. We conducted bivariate random‐effects meta‐analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre‐specified cut‐off points investigated. Pre‐set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre‐specifying three cut‐offs for each continuous test may have led to missing a cut‐off with useful sensitivity and specificity, we conducted post‐hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut‐off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. Main results There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water‐loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years. We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut‐offs for each continuous outcome) for diagnostic accuracy of water‐loss dehydration (primary target condition) and of current dehydration (secondary target condition). Only three tests showed any ability to diagnose water‐loss dehydration (including both impending and current water‐loss dehydration) as stand‐alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post‐hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study. Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97). There was sufficient evidence to suggest that several stand‐alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people. No tests were found consistently useful in diagnosing current water‐loss dehydration. Authors' conclusions There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water‐loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated. Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy. Plain language summary Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people Water‐loss dehydration results from drinking too little fluid. It is common in older people and associated with increased risk of many health problems. We wanted to find out whether simple tests (like skin turgor, dry mouth, urine colour and bioelectrical impedance) can usefully tell us whether an older person (aged at least 65 years) is drinking enough. Within the review we assessed 67 different tests, but no tests were consistently useful in telling us whether older people are drinking enough, or are dehydrated. Some tests did appear useful in some studies, and these promising tests should be re‐checked to see whether they are useful in specific older populations. There was sufficient evidence to suggest that some tests should not be used to indicate dehydration. Tests that should not be used include dry mouth, feeling thirsty, heart rate, urine colour, and urine volume.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hooper, L; Abdelhamid, A; Attreed, NJ; Campbell, WW; Channell, AM; Chassagne, P; Culp, KR; Fletcher, SJ; Fortes, MB; Fuller, N; Gaspar, PM; Gilbert, DJ; Heathcote, AC; Kafri, MW; Kajii, F; Lindner, G; Mack, GW; Mentes, JC; Merlani, P; Needham, RA; Olde Rikkert, MGM; Perren, A; Powers, J; Ranson, SC; Ritz, P; Rowat, AM; Sjöstrand, F; Smith, AC; Stookey, JJD; Stotts, NA; Thomas, DR; Vivanti, A; Wakefield, BJ; Waldréus, N; Walsh, NP; Ward, S; Potter, JF; Hunter, P", "articleTypes": [], "doi": "10.1002/14651858.CD009647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "07172dd1-c468-4ffb-8b72-3441241bf307", "pmid": "", "title": "Effects of Synbiotic Supplement on Anthropometric Parameters, Cardiovascular Disease Risk Factors, and Bone Metabolism Markers in Transplanted Kidney Patients on Chronic Post-kidney Transplant Phase Diet", "imported": false, "abstract": "The aim of this double-blind randomized clinical trial is to determine the effects of synbiotic supplement on cardiovascular disease risk factors and bone metabolism markers and depression, in transplanted kidney patients on chronic post-kidney transplant phase diet.This study is a double-blind, randomized controlled clinical trial with two parallel groups. 44 patients will be randomly assigned into synbiotic and control group. Transplanted kidney patients referring to the hospital clinics will be invited to participate. After assessing the entrance criteria, 7 cc blood samples are taken. The food recall is completed. Supplements are given to patients for 10-12 weeks. Serum concentrations of malondialdehyde; high sensitivity c-reactive protein; Soluble intercellular adhesion molecule-1; glucose; pentosidine; carboxy-methyl lysine; osteoprotegerin; Receptor activator of nuclear factor kappa-Β ligand; N-telopeptide; Intact parathyroid hormone; triglyceride; total cholesterol; High-density lipoprotein cholesterol; low-density lipoprotein cholesterol; lipoprotein-a; albumin; calcium; phosphorous; blood nitrogen urea; creatinine; and also systolic blood pressure; diastolic blood pressure; Weight; Body mass index; Waist circumference; Hip circumference; and questionnaires including quality of depression.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.155Z" }, { "id": "07181bf7-3b66-4e20-9c2d-11867f1cd5b8", "pmid": "", "title": "Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents", "imported": false, "abstract": "Abstract - Background Vomiting is a common manifestation of acute gastroenteritis in children and adolescents. When untreated it can be a hindrance to oral rehydration therapy, which is the cornerstone in the management of acute gastroenteritis. Evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in acute gastroenteritis in children. Objectives To assess the safety and effectiveness of antiemetics on gastroenteritis induced vomiting in children and adolescents. Search methods We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conferences.The search was re‐run and is up to date as on 20 July 2010. Selection criteria Randomized controlled trials comparing antiemetics with placebo or no treatment, in children and adolescents under the age of 18, for vomiting due to gastroenteritis. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We included seven trials involving 1,020 participants. Mean time to cessation of vomiting in one study was 0.34 days less with dimenhydrinate suppository compared to placebo (P value = 0.036). Pooled data from three studies comparing oral ondansetron with placebo showed: a reduction in the immediate hospital admission rate (RR 0.40, NNT 17, 95% CI 10 to 100) but no difference between the hospitalization rates at 72 hours after discharge from the Emergency Department (ED); a reduction in IV rehydration rates both during the ED stay (RR 0.41, NNT 5, 95% CI 4 to 8), and in follow‐up to 72 hours after discharge from the ED stay (worst‐best scenario for ondansetron RR 0.57, NNT 6, 95% CI 4 to 13) and an increase in the proportion of patients with cessation of vomiting (RR 1.34, NNT 5, 95% CI 3 to 7)). No significant difference was noted in the revisit rates or adverse events, although diarrhea was reported as a side effect in four of the five ondansetron studies. In one study the proportion of patients with cessation of vomiting in 24 hours was (58%) with IV ondansetron, (17%) placebo and (33%) in the metoclopramide group (P value = 0.039). Authors' conclusions Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting. Plain language summary Anti‐sickness medication for vomiting in acute stomach upsets in children Vomiting caused by acute gastroenteritis is very common in children and adolescents. Treatment of vomiting in children with acute gastroenteritis can be problematic and there is lack of agreement among clinicians on the indications for the use of antiemetics. There have also been concerns expressed about apparently unacceptable levels of side effects with some of the older generation of antiemetics. The small number of included trials provided evidence which appeared to favour the use of antiemetics over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. A single oral dose of ondansetron given to children with mild to moderate dehydration can control vomiting, avoid hospitalization and intravenous fluid administration which would otherwise be needed. There were no major side effects other than a few reports of increased frequency of diarrhea.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fedorowicz, Z; Jagannath, VA; Carter, B", "articleTypes": [], "doi": "10.1002/14651858.CD005506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "0725b1e9-d8cd-40bd-b04a-9e6e50c20a83", "pmid": "", "title": "Topical benzoyl peroxide for acne", "imported": false, "abstract": "Abstract - Background Acne is a common, economically burdensome condition that can cause psychological harm and, potentially, scarring. Topical benzoyl peroxide (BPO) is a widely used acne treatment; however, its efficacy and safety have not been clearly evaluated. Objectives To assess the effects of BPO for acne. Search methods We searched the following databases up to February 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of relevant randomised controlled trials (RCTs) and systematic reviews. Selection criteria We included RCTs that compared topical BPO used alone (including different formulations and concentrations of BPO) or as part of combination treatment against placebo, no treatment, or other active topical medications for clinically diagnosed acne (used alone or in combination with other topical drugs not containing BPO) on the face or trunk. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Primary outcome measures were 'participant global self‐assessment of acne improvement' and 'withdrawal due to adverse events in the whole course of a trial'. 'Percentage of participants experiencing any adverse event in the whole course of a trial' was a key secondary outcome. Main results We included 120 trials (29,592 participants randomised in 116 trials; in four trials the number of randomised participants was unclear). Ninety‐one studies included males and females. When reported, 72 trials included participants with mild to moderate acne, 26 included participants with severe acne, and the mean age of participants ranged from 18 to 30 years. Our included trials assessed BPO as monotherapy, as add‐on treatment, or combined with other active treatments, as well as BPO of different concentrations and BPO delivered through different vehicles. Comparators included different concentrations or formulations of BPO, placebo, no treatment, or other active treatments given alone or combined. Treatment duration in 80 trials was longer than eight weeks and was only up to 12 weeks in 108 trials. Industry funded 50 trials; 63 trials did not report funding. We commonly found high or unclear risk of performance, detection, or attrition bias. Trial setting was under‐reported but included hospitals, medical centres/departments, clinics, general practices, and student health centres. We reported on outcomes assessed at the end of treatment, and we classified treatment periods as short‐term (two to four weeks), medium‐term (five to eight weeks), or long‐term (longer than eight weeks). For 'participant‐reported acne improvement', BPO may be more effective than placebo or no treatment (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.12 to 1.45; 3 RCTs; 2234 participants; treatment for 10 to 12 weeks; low‐certainty evidence). Based on low‐certainty evidence, there may be little to no difference between BPO and adapalene (RR 0.99, 95% CI 0.90 to 1.10; 5 RCTs; 1472 participants; treatment for 11 to 12 weeks) or between BPO and clindamycin (RR 0.95, 95% CI 0.68 to 1.34; 1 RCT; 240 participants; treatment for 10 weeks) (outcome not reported for BPO versus erythromycin or salicylic acid). For 'withdrawal due to adverse effects', risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment (RR 2.13, 95% CI 1.55 to 2.93; 24 RCTs; 13,744 participants; treatment for 10 to 12 weeks; low‐certainty evidence); the most common causes of withdrawal were erythema, pruritus, and skin burning. Only very low‐certainty evidence was available for the following comparisons: BPO versus adapalene (RR 1.85, 95% CI 0.94 to 3.64; 11 RCTs; 3295 participants; treatment for 11 to 24 weeks; causes of withdrawal not clear), BPO versus clindamycin (RR 1.93, 95% CI 0.90 to 4.11; 8 RCTs; 3330 participants; treatment for 10 to 12 weeks; causes of withdrawal included local hypersensitivity, pruritus, erythema, face oedema, rash, and skin burning), erythromycin (RR 1.00, 95% CI 0.07 to 15.26; 1 RCT; 60 participants; treatment for 8 weeks; withdrawal due to dermatitis), and salicylic acid (no participants had adverse event‐related withdrawal; 1 RCT; 59 participants; treatment for 12 weeks). There may be little to no difference between these groups in terms of withdrawal; however, we are unsure of the results because the evidence is of very low certainty. For 'proportion of participants experiencing any adverse event', very low‐certainty evidence leaves us uncertain about whether BPO increased adverse events when compared with placebo or no treatment (RR 1.40, 95% CI 1.15 to 1.70; 21 RCTs; 11,028 participants; treatment for 10 to 12 weeks), with adapalene (RR 0.71, 95% CI 0.50 to 1.00; 7 RCTs; 2120 participants; treatment for 11 to 24 weeks), with erythromycin (no participants reported any adverse events; 1 RCT; 89 participants; treatment for 10 weeks), or with salicylic acid (RR 4.77, 95% CI 0.24 to 93.67; 1 RCT; 41 participants; treatment for 6 weeks). Moderate‐certainty evidence shows that the risk of adverse events may be increased for BPO versus clindamycin (RR 1.24, 95% CI 0.97 to 1.58; 6 RCTs; 3018 participants; treatment for 10 to 12 weeks); however, the 95% CI indicates that BPO might make little to no difference. Most reported adverse events were mild to moderate, and local dryness, irritation, dermatitis, erythema, application site pain, and pruritus were the most common. Authors' conclusions Current evidence suggests that BPO as monotherapy or add‐on treatment may be more effective than placebo or no treatment for improving acne, and there may be little to no difference between BPO and either adapalene or clindamycin. Our key efficacy evidence is based on participant self‐assessment; trials of BPO versus erythromycin or salicylic acid did not report this outcome. For adverse effects, the evidence is very uncertain regarding BPO compared with adapalene, erythromycin, or salicylic acid. However, risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment. Withdrawal may be linked to tolerability rather than to safety. Risk of mild to moderate adverse events may be higher with BPO compared with clindamycin. Further trials should assess the comparative effects of different preparations or concentrations of BPO and combination BPO versus monotherapy. These trials should fully assess and report adverse effects and patient‐reported outcomes measured on a standardised scale. Plain language summary Topical benzoyl peroxide for acne Review question We reviewed the evidence showing effects and safety of topical benzoyl peroxide (BPO), used alone or in combination. Eligible comparisons included placebo (an identical but inactive treatment), no treatment, or other active (medical) topical medications for treating acne (used alone or in combination with other topical drugs not containing BPO) (evidence is current to February 2019). The main outcomes of interest in this review were participant‐reported acne improvement and withdrawal from the study due to any side effects. More generally, we also considered the percentage of participants experiencing any side effects over the whole course of a trial. Background As a common skin disease, acne vulgaris affects the physical, mental, and social well‐being of millions of adolescents and young adults. A wide range of treatments for acne vulgaris are available, and topical BPO has been recommended as a priority therapy to be used alone or combined with other topical or oral treatments, depending on acne severity. However, the benefits and harms of BPO have yet to be evaluated. Study characteristics We included 120 studies (which comprised 29,592 people randomised in 116 trials; in four trials the number of randomised participants was unclear). Through our search, we found studies assessing different concentrations of BPO, BPO delivered through various means, or BPO used alone or given with other treatments that may or may not be considered as the primary treatment. These studies compared treatments against different concentrations or formulations of BPO, placebo, no treatment, or other medical treatments given alone or in combination. Most of the studies included male and female participants with mild to moderate acne; only 67% of studies reported participant age, which ranged between 18 and 30 years. Participants were treated for over eight weeks in nearly two‐thirds of the trials. Industry financially supported approximately two‐fifths of the trials, and more than half of the trials did not report their funding sources. Few studies reported where they were set, but locations included hospitals, medical centres, national medical institutes, clinics, medical departments, and general practices. Key results We found low‐certainty evidence to suggest that long‐term (i.e. given for longer than eight weeks) BPO treatment may increase self‐reported treatment success compared to placebo or no BPO treatment (three studies), but there may be little to no difference when BPO treatment is compared to adapalene (five studies) or clindamycin (one study). This outcome was not reported by studies comparing BPO treatment to erythromycin or salicylic acid. Long‐term BPO may lead to an increased chance of treatment discontinuation compared to placebo or no treatment (24 studies), with the most common causes being redness, itch, and skin burning (low‐certainty evidence). When medium‐ to long‐term BPO was compared to adapalene (11 studies), clindamycin (eight studies), erythromycin (one study), or salicylic acid (one study), we found only very low‐certainty evidence, meaning that although there may be little to no difference in withdrawal between these groups, we are not sure of the results. It should be noted that participant withdrawal may be linked to issues around treatment acceptability (dermatitis, rash, facial swelling, sensitivity) rather than to safety. Very low‐certainty evidence means that we are uncertain if BPO leads to more side effects among participants receiving medium‐ to long‐term BPO than among those given no treatment/placebo (21 studies), adapalene (seven studies), erythromycin (one study), or salicylic acid (one study). Medium‐term treatment with BPO may lead to increased risk of side effects when compared against clindamycin, but the effects of this treatment vary, so the treatment chosen may make little to no difference (six studies; moderate‐certainty evidence). Side effects reported in these studies were usually mild to moderate, and the most common were local dryness, irritation, eczema, redness, pain at the site of application, and pruritus. Certainty of the evidence For our key comparisons, we rated the certainty of evidence for 'participant‐reported acne improvement' as low. For the outcomes 'withdrawal due to adverse effects' and ‘percentage of participants having any adverse events', the evidence was mainly of very low certainty. Included trials were at high or unclear risk of bias, participant numbers were small, results were not consistent across trials, and we suspected publication bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Yang, Z; Zhang, Y; Lazic Mosler, E; Hu, J; Li, H; Zhang, Y; Liu, J; Zhang, Q", "articleTypes": [], "doi": "10.1002/14651858.CD011154.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "0729718f-62b7-40a8-a98e-60e6a8332cb4", "pmid": "", "title": "Interventions for preventing osteoradionecrosis of the jaws in adults receiving head and neck radiotherapy", "imported": false, "abstract": "Abstract - Background Osteoradionecrosis (ORN) of the jaws is among the most serious oral complications of head and neck cancer radiotherapy, arising from radiation‐induced fibro‐atrophic tissue injury, manifested by necrosis of osseous tissues and failure to heal, often secondary to operative interventions in the oral cavity. It is associated with considerable morbidity and has important quality of life ramifications. Since ORN is very difficult to treat effectively, preventive measures to limit the onset of this disease are needed; however, the effects of various preventive interventions has not been adequately quantified. Objectives To assess the effects of interventions for preventing ORN of the jaws in adult patients with head and neck cancer undergoing curative or adjuvant (i.e. non‐palliative) radiotherapy. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 5 November 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 10) in the Cochrane Library (searched 5 November 2019), MEDLINE Ovid (1946 to 5 November 2019), Embase Ovid (1980 to 5 November 2019), Allied and Complementary Medicine (AMED) Ovid (1985 to 5 November 2019), Scopus (1966 to 5 November 2019), Proquest Dissertations and Theses International (1861 to 5 November 2019) and Web of Science Conference Proceedings (1990 to 5 November 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We selected randomised controlled trials (RCTs) or quasi‐RCTs of adult patients 18 years or older with head and neck cancer who had undergone curative or adjuvant radiotherapy to the head and neck, who had received an intervention to prevent the onset of ORN. Eligible patients were those subjected to pre‐ or post‐irradiation dental evaluation. Management of these patients was to be with interventions independent of their cancer therapy, including but not limited to local, systemic, or behavioural interventions. Data collection and analysis Two review authors independently selected trials from search results, assessed risk of bias, and extracted relevant data for inclusion in the review. Authors of included studies were contacted to request missing data. We used standard methodological procedures expected by Cochrane. Main results Four studies were identified that met pre‐determined eligibility criteria, evaluating a total of 342 adults. From the four studies, all assessed as at high risk of bias, three broad interventions were identified that may potentially reduce the risk of ORN development: one study showed no reduction in ORN when using platelet‐rich plasma placed in the extraction sockets of prophylactically removed healthy mandibular molar teeth prior to radiotherapy (odds ratio (OR) 3.32, 95% confidence interval (CI) 0.58 to 19.09; one trial, 44 participants; very low‐certainty evidence). Another study involved comparing fluoride gel and high‐content fluoride toothpaste (1350 parts per million (ppm)) in prevention of post‐radiation caries, and found no difference between their use as no cases of ORN were reported (one trial, 220 participants; very low‐certainty evidence). The other two studies involved the use of perioperative hyperbaric oxygen (HBO) therapy and antibiotics. One study showed that treatment with HBO caused a reduction in the development of ORN in comparison to patients treated with antibiotics following dental extractions (risk ratio (RR) 0.18, 95% CI 0.43 to 0.76; one trial, 74 participants; very low‐certainty evidence). Another study found no difference between combined HBO and antibiotics compared to antibiotics alone prior to dental implant placement (RR 3.00, 95% CI 0.14 to 65.16; one trial, 26 participants; very low‐certainty evidence). Adverse effects of the different interventions were not reported clearly or were not important. Authors' conclusions Given the suboptimal reporting and inadequate sample sizes of the included studies, evidence regarding the interventions evaluated by the trials included in this review is uncertain. More well‐designed RCTs with larger samples are required to make conclusive statements regarding the efficacy of these interventions. Plain language summary Dental treatments for preventing damage to the jawbones in people with cancer receiving radiotherapy to the head and neck Review question With this Cochrane Review we tried to find out the best way to prevent the death and exposure of bone in the jaws of people who have had radiotherapy for head and neck cancer. This is a condition called osteoradionecrosis (ORN). Background ORN of the jaws is a serious problem which can happen after people have radiotherapy as part of their treatment for head and neck cancer. ORN refers to the death and exposure of bone that result from damage to the tissues due to being exposed to radiation. ORN is very difficult to treat and it is important that steps are taken to prevent it. In this review, we looked at any treatments that have been used to prevent ORN. Study characteristics This review is up‐to‐date as of 5 November 2019. The review includes four studies involving 342 adults who had received radiotherapy for the treatment of head and neck cancer. The review looks at three different ways to prevent ORN: ‐ the use of platelet‐rich plasma (PRP) in bone after removal of healthy teeth prior to radiotherapy. Plasma is a part of blood that contains special proteins that help the blood to clot, and PRP is concentrated plasma which supports cell growth. Injecting PRP into damaged tissue may stimulate the body to grow new, healthy cells to make it heal more quickly; ‐ taking out teeth because of tooth decay makes the risk of developing ORN greater. Preventing tooth decay in people having radiotherapy is very important. We looked at a study comparing using fluoride gel with a toothpaste with a higher level of fluoride than normal to prevent tooth decay after radiotherapy; ‐ hyperbaric oxygen therapy is breathing oxygen in a pressurized chamber to improve blood supply, which may help heal damaged tissue. Two studies compared the use of hyperbaric oxygen therapy for taking out teeth or placing dental implants with antibiotics. Antibiotics are drugs which stop or slow the growth of bacteria. Key results One study showed no reduction in ORN when using platelet‐rich plasma in bone after the removal of healthy teeth. Another study found no difference between fluoride gel and toothpaste with a higher level of fluoride than normal as no cases of ORN were reported. A third study showed that treatment with hyperbaric oxygen therapy caused a reduction in the development of ORN in comparison to patients treated with antibiotics following the removal of teeth. The fourth study found no difference between combined hyperbaric oxygen therapy and antibiotics compared to antibiotics alone. Harmful effects of the different interventions were not reported clearly or were not important. Certainty of the evidence The level of certainty we have in these findings is very low. This was due to high risk of bias, not all studies mentioning important details, and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to stop ORN of the jaws from happening or making it less severe in adults receiving head and neck radiotherapy. We suggest that more, well‐conducted, and bigger studies including more people, should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "El‐Rabbany, M, Duchnay, M, Raziee, HR, Zych, M, Tenenbaum, H, Shah, PS, Azarpazhooh, A", "articleTypes": [], "doi": "10.1002/14651858.CD011559.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.786Z" }, { "id": "0732d6e1-76d3-433a-bcc4-af62ca5c14b3", "pmid": "", "title": "Chinese medicinal herbs for the common cold", "imported": false, "abstract": "Abstract - Background Chinese medicinal herbs are frequently used to treat the common cold in China. Until now, their efficacy has not been systematically reviewed. Objectives To assess the effectiveness and safety of Chinese medicinal herbs for the common cold. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2008, issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to May 2008); EMBASE (1980 to May 2008); AMED (1985 to May 2008); the Chinese Biomedical Database (CBMdisc) (1978 to May 2008); and China National Knowledge Infrastructure (CNKI) (1994 to May 2008). Selection criteria Randomised controlled trials (RCTs) studying the efficacy of Chinese medicinal herb(s) for the treatment of the common cold. Data collection and analysis Four review authors telephoned the original trial authors of the RCTs identified by our searches to verify the randomisation procedure. Two review authors extracted and analysed data from trials which met the inclusion criteria. Main results We found17 studies involving 3212 patients. The methods of 15 studies were at high risk of bias. In only two studies was the risk of bias low. Trials used \"positive drugs\", of which the efficacy was not known, as controls. Different Chinese herbal preparations were tested in nearly all trials. In only one trial was a Chinese herbal preparation tested twice. In seven trials, six herbal preparations were found to be more effective at enhancing recovery than the control preparations. In the other 10 studies, seven herbal preparations were not shown to be significantly different from the control. One study did not describe the difference between the intervention and control groups. Authors' conclusions Chinese herbal medicines may shorten the symptomatic phase in patients with the common cold. However, the lack of trials of low enough risk of bias, or using a placebo or a drug clearly identified as a control, means that we are uncertain enough to be unable to recommend any kind of Chinese medicinal herbs for the common cold. Plain language summary Chinese medicinal herbs to treat the common cold The common cold is the most widespread acute respiratory tract illness affecting all age groups. Many Chinese herbal medicines are used to treat this illness in China. Although we included 17 trials, involving 3212 patients, in this review, the risk of bias was so high that the evidence did not support using any Chinese herbal preparation(s) for the common cold. Well‐designed clinical trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Zhang, X, Wu, T, Zhang, J, Yan, Q, Xie, L, Liu, GJ", "articleTypes": [], "doi": "10.1002/14651858.CD004782.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.744Z" }, { "id": "074f98b9-f7e0-4371-b26b-7672b29bbed0", "pmid": "", "title": "Nasal decongestants in monotherapy for the common cold", "imported": false, "abstract": "Abstract - Background Many treatments for the common cold exist and are sold over‐the‐counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited. Objectives To assess the efficacy, and short‐ and long‐term safety, of nasal decongestants used in monotherapy to alleviate symptoms of the common cold in adults and children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6, June 2016), which contains the Cochrane Acute Respiratory Infections (ARI) Specialised Register, MEDLINE (1946 to July 2016), Embase (2010 to 15 July 2016), CINAHL (1981 to 15 July 2016), LILACS (1982 to July 2016), Web of Science (1955 to July 2016) and clinical trials registers. Selection criteria Randomised controlled trials (RCTs) and cluster‐RCTs investigating the effectiveness and adverse effects of nasal decongestants compared with placebo for treating the common cold in adults and children. We excluded quasi‐RCTs. Data collection and analysis Three review authors independently extracted and summarised data on subjective measures of nasal congestion, overall patient well‐being score, objective measures of nasal airway resistance, adverse effects and general recovery. One review author acted as arbiter in cases of disagreement. We categorised trials as single and multi‐dose and analysed data both separately and together. We also analysed studies using an oral or topical nasal decongestant separately and together. Main results We included 15 trials with 1838 participants. Fourteen studies included adult participants only (aged 18 years and over). In six studies the intervention was a single dose and in nine studies multiple doses were used. Nine studies used pseudoephedrine and three studies used oxymetazoline. Other decongestants included phenylpropanolamine, norephedrine and xylometazoline. Phenylpropanolamine (or norephedrine) is no longer available on the market therefore we did not include the results of these studies in the meta‐analyses. Eleven studies used oral decongestants; four studies used topical decongestants. Participants were included after contracting the common cold. The duration of symptoms differed among studies; in 10 studies participants had symptoms for less than three days, in three studies symptoms were present for less than five days, one study counted the number of colds over one year, and one study experimentally induced the common cold. In the single‐dose studies, the effectiveness of a nasal decongestant was measured on the same day, whereas the follow‐up in multi‐dose studies ranged between one and 10 days. Most studies were conducted in university settings (N = eight), six at a specific university common cold centre. Three studies were conducted at a university in collaboration with a hospital and two in a hospital only setting. In two studies the setting was unclear. There were large differences in the reporting of outcomes and the reporting of methods in most studies was limited. Therefore, we judged most studies to be at low or unclear risk of bias. Pooling was possible for a limited number of studies only; measures of effect are expressed as standardised mean differences (SMDs). A positive SMD represents an improvement in congestion. There is no defined minimal clinically important difference for measures of subjective improvement in nasal congestion, therefore we used the SMDs as a guide to assess whether an effect was small (0.2 to 0.49), moderate (0.5 to 0.79) or large (≥ 0.8). Single‐dose decongestant versus placebo: 10 studies compared a single dose of nasal decongestant with placebo and their effectiveness was tested between 15 minutes and 10 hours after dosing. Seven of 10 studies reported subjective symptom scores for nasal congestion; none reported overall patient well‐being. However, pooling was not possible due to the large diversity in the measurement and reporting of symptoms of congestion. Two studies recorded adverse events. Both studies used an oral decongestant and each of them showed that there was no statistical difference between the number of adverse events in the treatment group versus the placebo group. Multi‐dose decongestant versus placebo: nine studies compared multiple doses of nasal decongestants with placebo, but only five reported on the primary outcome, subjective symptom scores for nasal congestion. Only one study used a topical decongestant; none reported overall patient well‐being. Subjective measures of congestion were significantly better for the treatment group compared with placebo approximately three hours after the last dose (SMD 0.49, 95% confidence interval (CI) 0.07 to 0.92; P = 0.02; GRADE: low‐quality evidence). However, the SMD of 0.49 only indicates a small clinical effect. Pooling was based on two studies, one oral and one topical, therefore we were unable to assess the effects of oral and topical decongestants separately. Seven studies reported adverse events (six oral and one topical decongestant); meta‐analysis showed that there was no statistical difference between the number of adverse events in the treatment group (125 per 1000) compared to the placebo group (126 per 1000). The odds ratio (OR) for adverse events in the treatment group was 0.98 (95% CI 0.68 to 1.40; P = 0.90; GRADE: low‐quality evidence). The results remained the same when we only considered studies using an oral decongestant (OR 0.95, 95% CI 0.65 to 1.39; P = 0.80; GRADE: low‐quality evidence). Authors' conclusions We were unable to draw conclusions on the effectiveness of single‐dose nasal decongestants due to the limited evidence available. For multiple doses of nasal decongestants, the current evidence suggests that these may have a small positive effect on subjective measures of nasal congestion in adults with the common cold. However, the clinical relevance of this small effect is unknown and there is insufficient good‐quality evidence to draw any firm conclusions. Due to the small number of studies that used a topical nasal decongestant, we were also unable to draw conclusions on the effectiveness of oral versus topical decongestants. Nasal decongestants do not seem to increase the risk of adverse events in adults in the short term. The effectiveness and safety of nasal decongestants in children and the clinical relevance of their small effect in adults is yet to be determined. Plain language summary Do nasal decongestants used alone relieve cold symptoms? Review question We wanted to find out if nasal decongestants used alone can ease nasal congestion symptoms in people with colds. Background Colds, although not serious, are common illnesses responsible for many visits to family doctors and days lost from work and school. Cold symptoms include runny nose, sore throat and sneezing, and they can last up to two weeks. There is no cure for colds; treatments only ease the symptoms. Many people use over‐the‐counter medicines such as nasal decongestants to treat cold symptoms. However, there is little evidence that nasal decongestants actually work. We wanted to find out if nasal decongestants help ease congestion caused by colds. We considered studies that used a nasal decongestant as the only treatment for colds. We looked at subjective symptoms of congestion ‐ this means that symptoms and overall well‐being were self‐rated by patients. Search date We searched for studies in July 2016. Study characteristics We included 15 studies with 1838 participants; 14 included only adults aged 18 years or over. Six studies used a single‐dose nasal decongestant and measured the effects on the day it was administered. Nine studies used multiple doses and the effects were measured between one and 10 days after first administration. Eleven studies used tablets or syrup and four studies used nasal sprays. Eight studies were conducted at universities, three at universities in collaboration with hospitals and two in hospitals. The setting was unclear in two studies. Study funding sources Nine studies were funded by drug manufacturers or agencies with commercial interests in the study results. Funding sources were unclear in six studies. Key results We were unable to draw conclusions about single‐dose nasal decongestants. We found a small benefit in the relief of nasal congestion from multiple doses, but it was unclear if this was beneficial for patients. No studies reported overall patient well‐being. There was no difference in the numbers of adverse events between people who used a nasal decongestant and those who did not. We could not determine if there was a difference in effects between decongestant tablets and nasal sprays. The results relate to adults; there was no evidence on the effectiveness or safety of nasal decongestants for children. Quality of the evidence We assessed the quality of the evidence for subjective cold symptoms as low for the multi‐dose studies ‐ there were few data and reporting was unclear. We also assessed the quality of the evidence for adverse events as low because of unclear reporting and because the estimates were not precise (there were wide confidence intervals ‐ a measure of statistical uncertainty).", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Deckx, L; De Sutter, AIM; Guo, L; Mir, NA; van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009612.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "076c459b-7c66-4306-9abd-84c1aea2c0eb", "pmid": "", "title": "External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion). Objectives To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. Search methods We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index‐Science (CPCI‐S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. Selection criteria We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. Data collection and analysis We used standard Cochrane methodology to collect data and performed a network meta‐analysis using the standard frequentist graph‐theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption. Main results We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy‐nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow‐up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low‐certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled. Authors' conclusions Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method. Plain language summary Electrical shocks (electrical cardioversion) and drugs (pharmacological cardioversion) for restoring normal rhythm in patients with atrial fibrillation or atrial flutter Key Messages ‐ Electrical cardioversion and some drugs can be used to restore the normal rhythm in patients with atrial fibrillation (AF) and atrial flutter. While electrical cardioversion is highly effective in dealing with all arrhythmias, the efficacy of drugs varies, with some being only moderately effective or not working at all in persistent AF and atrial flutter. ‐ Electrical cardioversion seems to be a very safe option. The risk of severe complications with cardioversion using drugs was low, but additional precautions are needed. ‐ We need further studies to find out if these treatment options also have a positive effect on quality of life, or if they lead to relevant differences in the duration of hospital stay. What is atrial fibrillation? AF is the most frequent abnormal heart rhythm seen in the world. Patients with this condition may feel their heart beating rapidly and irregularly. This can occur for separate brief or long episodes (paroxysmal AF) or it may become continuous (persistent AF). Atrial flutter is a similar abnormal rhythm that causes similar symptoms, can cause episodes of variable duration and can also become continuous. What is cardioversion? Cardioversion is a treatment to restore the rhythm of the heart back to normal (sinus rhythm). What did we want to find out? We wanted to know if delivering a controlled electrical shock (i.e. electrical cardioversion) and drugs (i.e. pharmacological cardioversion) are effective and safe when restoring heart rhythm back to normal. What did we do? We searched for studies that investigated electrical and pharmacological cardioversion compared to each other or placebo (a medicine that looks like the real medicine but that has no active ingredient). We compared and summarised the results of the studies and rated our trust in these results, based on factors such as study methods and size. What did we find? We found 112 studies. We were able to combine and analyse the results from 72 studies, with 15,968 participants aged between 47 and 72 years. Thirty‐five studies included patients with paroxysmal AF (AF that terminates spontaneously or with intervention within 7 days of onset), 26 studies of patients with persistent AF (AF that is continuously sustained beyond seven days, including episodes terminated by cardioversion after ≥ 7 days), and 14 trials included patients with atrial flutter. The remaining included a mix of paroxysmal, persistent AF and atrial flutter. Main results For patients with paroxysmal AF, electrical cardioversion with biphasic incremental energy, fast‐acting drugs like intravenous vernakalant, flecainide, ibutilide and antazoline, and slower‐acting and/or oral drugs such as quinidine, propafenone, amiodarone and sotalol are effective at restoring sinus rhythm. For patients with persistent AF, electrical cardioversion with biphasic energy seems to be the most effective option; bepridil, quinidine and amiodarone tablets may also be effective in selected cases. For patients with atrial flutter, electrical cardioversion followed by dofetilide are the most effective options. The risk of death and stroke is very low for patients having cardioversion procedures. Malignant arrhythmias (torsade de pointes, sustained ventricular tachycardia or ventricular fibrillation, all of which are associated with high 1‐year mortality rate) were observed for dofetilide, ibutilide, sotalol, quinidine and vernakalant, justifying the need for special care and closer monitoring when using these drugs. Duration of hospitalisation data was available in three studies but, as there were variable timings in these studies, we could not combine them to assess their joint effectiveness. These studies suggest that the duration of hospitalisation may be lower with electrical cardioversion. Heart failure was observed in some patients treated with propafenone, flecainide, sotalol, amiodarone, vernakalant, and placebo, and was not observed in patients receiving electrical cardioversion, suggesting that the latter approach should be the preferred one if concerns exist regarding the occurrence of this outcome. Phlebitis (i.e. inflammation of the vein caused by using injectable drugs) occurred frequently in patients treated with amiodarone, and dysgeusia (i.e. impairment of the sense of taste) and sneezing occurred frequently in patients receiving vernakalant. What are the limitations of the observed results? We are sure or moderately sure of the results for the efficacy of treatments available for persistent AF and atrial flutter. We are less sure about the results for some of the treatment options for paroxysmal AF. Not enough data are available regarding quality of life, and data were limited regarding duration of hospital stay. The risk of stroke or dying was very low. How up to date are the studies and information on this review? The included studies and information are current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Kukendrarajah, K; Ahmad, M; Carrington, M; Ioannou, A; Taylor, J; Razvi, Y; Papageorgiou, N; Mead, GE; Nevis, IF; D'Ascenzo, F; Wilton, SB; Lambiase, PD; Morillo, CA; Kwong, JSW; Providencia, R", "articleTypes": [], "doi": "10.1002/14651858.CD013255.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "076ffe84-f292-447f-9c7c-f41997a684c8", "pmid": "", "title": "Homeopathic Oscillococcinum® for preventing and treating influenza and influenza‐like illness", "imported": false, "abstract": "Abstract - Background Influenza is a highly infectious viral disease that is particularly common in the winter months. Oscillococcinum ® is a patented homeopathic medicine that is made from a 1% solution of wild duck heart and liver extract, which is then serially diluted 200 times with water and alcohol. Objectives To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Search methods We searched CENTRAL (2014, Issue 8), MEDLINE (1966 to August week 4, 2014), MEDLINE In‐Process & Other Non‐Indexed Citations (4 September 2014), AMED (2006 to September 2014), Web of Science (1985 to September 2014), LILACS (1985 to September 2014) and EMBASE (1980 to September 2014). We contacted the manufacturers of Oscillococcinum ® for information on further trials. Selection criteria Randomised, placebo‐controlled trials of Oscillococcinum ® in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Data collection and analysis Three review authors independently extracted data and assessed risk of bias in the eligible trials. Main results No new trials were included in this 2014 update. We included six studies: two prophylaxis trials (327 young to middle‐aged adults in Russia) and four treatment trials (1196 teenagers and adults in France and Germany). The overall standard of trial reporting was poor and hence many important methodological aspects of the trials had unclear risk of bias. There was no statistically significant difference between the effects of Oscillococcinum ® and placebo in the prevention of influenza‐like illness: risk ratio (RR) 0.48, 95% confidence interval (CI) 0.17 to 1.34, P value = 0.16. Two treatment trials (judged as 'low quality') reported sufficient information to allow full data extraction: 48 hours after commencing treatment, there was an absolute risk reduction of 7.7% in the frequency of symptom relief with Oscillococcinum ® compared with that of placebo (risk difference (RD) 0.077, 95% CI 0.03 to 0.12); the RR was 1.86 (95% CI 1.27 to 2.73; P value = 0.001). A significant but lesser effect was observed at three days (RR 1.27, 95% CI 1.03 to 1.56; P value = 0.03), and no significant difference between the groups was noted at four days (RR 1.11, 95% CI 0.98 to 1.27; P value = 0.10) or at five days (RR 1.06, 95% CI 0.96 to 1.16; P value = 0.25). One of the six studies reported one patient who suffered an adverse effect (headache) from taking Oscillococcinum ® . Authors' conclusions There is insufficient good evidence to enable robust conclusions to be made about Oscillococcinum ® in the prevention or treatment of influenza and influenza‐like illness. Our findings do not rule out the possibility that Oscillococcinum ® could have a clinically useful treatment effect but, given the low quality of the eligible studies, the evidence is not compelling. There was no evidence of clinically important harms due to Oscillococcinum ® . Plain language summary Homeopathic Oscillococcinum ® for preventing and treating influenza and influenza‐like illness Review question 
 To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Background 
 Influenza ('the flu') is a highly infectious viral respiratory disease. Other than treatments for complications (such as pneumonia), the conventional medical strategies for the prevention or treatment of flu are not entirely effective or satisfactory. Oscillococcinum ® is a highly diluted homeopathic preparation manufactured from wild duck heart and liver, which may be reservoirs of flu viruses. Some people take Oscillococcinum ® regularly over the winter months either to prevent flu or as a treatment for flu symptoms. Study characteristics 
 We included six studies, which comprised two prevention trials (a total of 327 young to middle‐aged adults in Russia) and four treatment trials (a total of 1196 teenagers and adults in France and Germany). Key results 
 The findings from the two prevention trials did not show that Oscillococcinum ® can prevent the onset of flu. Although the results from the four other clinical trials suggested that Oscillococcinum ® relieved flu symptoms at 48 hours, this might be due to bias in the trial methods. One patient reported headache after taking Oscillococcinum ® . The evidence is current to September 2014. Quality of the evidence 
 The overall standard of research reporting was poor, and thus many aspects of the trials' methods and results were at unclear risk of bias. We therefore judged the evidence overall as low quality, preventing clear conclusions from being made about Oscillococcinum ® in the prevention or treatment of flu and flu‐like illness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mathie, RT; Frye, J; Fisher, P", "articleTypes": [], "doi": "10.1002/14651858.CD001957.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "0784a8df-1578-4a51-b858-f76ac3ede97c", "pmid": "", "title": "Interventions for iatrogenic inferior alveolar and lingual nerve injury", "imported": false, "abstract": "Abstract - Background Iatrogenic injury of the inferior alveolar or lingual nerve or both is a known complication of oral and maxillofacial surgery procedures. Injury to these two branches of the mandibular division of the trigeminal nerve may result in altered sensation associated with the ipsilateral lower lip or tongue or both and may include anaesthesia, paraesthesia, dysaesthesia, hyperalgesia, allodynia, hypoaesthesia and hyperaesthesia. Injury to the lingual nerve may also affect taste perception on the affected side of the tongue. The vast majority (approximately 90%) of these injuries are temporary in nature and resolve within eight weeks. However, if the injury persists beyond six months it is deemed to be permanent. Surgical, medical and psychological techniques have been used as a treatment for such injuries, though at present there is no consensus on the preferred intervention, or the timing of the intervention. Objectives To evaluate the effects of different interventions and timings of interventions to treat iatrogenic injury of the inferior alveolar or lingual nerves. Search methods We searched the following electronic databases: the Cochrane Oral Health Group's Trial Register (to 9 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 9 October 2013) and EMBASE via OVID (1980 to 9 October 2013). No language restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials (RCTs) involving interventions to treat patients with neurosensory defect of the inferior alveolar or lingual nerve or both as a sequela of iatrogenic injury. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. We performed data extraction and assessment of the risk of bias independently and in duplicate. We contacted authors to clarify the inclusion criteria of the studies. Main results Two studies assessed as at high risk of bias, reporting data from 26 analysed participants were included in this review. The age range of participants was from 17 to 55 years. Both trials investigated the effectiveness of low‐level laser treatment compared to placebo laser therapy on inferior alveolar sensory deficit as a result of iatrogenic injury. Patient‐reported altered sensation was partially reported in one study and fully reported in another. Following treatment with laser therapy, there was some evidence of an improvement in the subjective assessment of neurosensory deficit in the lip and chin areas compared to placebo, though the estimates were imprecise: a difference in mean change in neurosensory deficit of the chin of 8.40 cm (95% confidence interval (CI) 3.67 to 13.13) and a difference in mean change in neurosensory deficit of the lip of 21.79 cm (95% CI 5.29 to 38.29). The overall quality of the evidence for this outcome was very low; the outcome data were fully reported in one small study of 13 patients, with differential drop‐out in the control group, and patients suffered only partial loss of sensation. No studies reported on the effects of the intervention on the remaining primary outcomes of pain, difficulty eating or speaking or taste. No studies reported on quality of life or adverse events. The overall quality of the evidence was very low as a result of limitations in the conduct and reporting of the studies, indirectness of the evidence and the imprecision of the results. Authors' conclusions There is clearly a need for randomised controlled clinical trials to investigate the effectiveness of surgical, medical and psychological interventions for iatrogenic inferior alveolar and lingual nerve injuries. Primary outcomes of this research should include: patient‐focused morbidity measures including altered sensation and pain, pain, quantitative sensory testing and the effects of delayed treatment. Plain language summary Treatments for accidental damage during surgery to the nerves supplying sensation to the tongue, lower lip and chin Review question The main question addressed by this review is how effective are different treatments and what are the best timings for these treatments following accidental damage during surgery to the nerves that supply sensation to the tongue, lower lip and chin. Background The nerves (alveolar and lingual) supplying sensation to the tongue, lower lip and chin, may be injured as a result of surgical treatments to the mouth and face, including surgery to remove lower wisdom teeth. The vast majority (90%) of these injuries are temporary and get better within eight weeks. However if they last for longer than six months they are considered to be permanent. Damage to these nerves can lead to altered sensation in the region of the lower lip and chin, or tongue or both. Furthermore, damage to the nerve supplying the tongue may lead to altered taste perception. These injuries can affect people's quality of life leading to emotional problems, problems with socialising and disabilities. Accidental injury after surgery can also give rise to legal action. There are many interventions or treatments available, surgical and non‐surgical, that may enhance recovery, including improving sensation. They can be grouped as. 1. Surgical – a variety of procedures.
 2. Laser treatment – low‐level laser treatment has been used to treat partial loss of sensation.
 3. Medical – treatment with drugs including antiepileptics, antidepressants and painkillers.
 4. Counselling – including cognitive behavioural and relaxation therapy, changing behaviour and hypnosis. Study characteristics The Cochrane Oral Health Group carried out this review, and the evidence is current as of 9 October 2013. There are two studies included, both published in 1996, which compared low‐level laser treatment to placebo or fake treatment for partial loss of sensation following surgery to the lower jaw. There were 15 participants in one study and 16 in the other, their ages ranging from 17 to 55 years. All had suffered accidental damage to nerves of the lower jaw and tongue causing some loss of sensation following surgery. Key results Low‐level laser therapy was the only treatment to be evaluated in the included studies and this was compared to fake or placebo laser therapy. No studies were found that evaluated other surgical, medical or counselling treatments. There was some evidence of an improvement when participants reported whether or not sensation was better in the lip and chin areas with low‐level laser therapy. This is based on the results of a single, small study, so the results should be interpreted with caution. No studies reported on the effects of the treatment on other outcomes such as pain, difficulty eating or speaking or taste. No studies reported on quality of life or harm. Quality of the evidence The overall quality of the evidence is very low as a result of limitations in the conduct and reporting of the two included studies and the low number of participants, and evidence from participants with only partial sensory loss.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Coulthard, P; Kushnerev, E; Yates, JM; Walsh, T; Patel, N; Bailey, E; Renton, TF", "articleTypes": [], "doi": "10.1002/14651858.CD005293.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "07963098-bfa1-4bdc-b84a-a37977cff973", "pmid": "", "title": "Treatment for primary postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries. Objectives To assess the effectiveness and safety of any intervention used for the treatment of primary PPH. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013). Selection criteria Randomised controlled trials comparing any interventions for the treatment of primary PPH. Data collection and analysis We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information. Main results Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review. Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41). Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering. Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre‐specified outcomes. One study compared lower segment compression but was too small to assess impact on primary outcomes. We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics. Authors' conclusions Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first‐line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit. The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy. Plain language summary Treatment for excessive bleeding after childbirth After a woman gives birth, womb muscles contract, clamping down on the blood vessels and helping to limit bleeding when the placenta has detached. If the muscles do not contract strongly enough, very heavy bleeding (postpartum haemorrhage) can occur, which can be life threatening. These situations are common in resource‐poor countries, and maternal mortality is about 100 times higher than in resource‐rich countries. It is a very serious problem that requires effective treatments that might avoid the use of surgery to remove the womb (hysterectomy). This is often the last treatment option and leaves the woman unable to have more children. In most settings, women are given a drug at the time of birth (before excessive bleeding occurs) to reduce the likelihood of excessive blood loss. However, despite this intervention, some women bleed excessively, and this review looked to see what interventions might be used to reduce the amount of blood lost by these women. Treatment options include drugs to increase muscles contractions (such as oxytocin, ergometrine and prostaglandins like misoprostol), drugs to help with blood clotting (haemostatic drugs such as tranexamic acid and recombinant activated factor VII), surgical techniques (such as tying off or blocking of the uterine artery) and radiological interventions (to assist in blocking the main artery to the womb by using gel foams). The review identified 10 randomised controlled trials involving 4052 women. Seven of these trials looked at a drug called misoprostol, which is a prostaglandin and so works by increasing muscle contractions. Overall, the trials suggest that misoprostol does not work as well as oxytocin infusion, and it has more side effects. However, oxytocin needs to be kept in a refrigerator, and so in settings where refrigeration and infusions are not readily available, misoprostol can be used. Other clinical trials looked into using other types of drugs or squeezing the main artery that supplies blood to the woman. The number of women included in these studies was too small for any useful conclusions regarding their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Mousa, HA, Blum, J, Abou El Senoun, G, Shakur, H, Alfirevic, Z", "articleTypes": [], "doi": "10.1002/14651858.CD003249.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.083Z" }, { "id": "07cb5eb3-8ed7-4896-8bdb-5d8364ee3cf9", "pmid": "", "title": "Muscle relaxants for pain management in rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background Pain management is a high priority for patients with rheumatoid arthritis (RA). Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan) and non‐benzodiazepines such as metaxalone (Skelaxin) or a combination of paracetamol and orphenadrine (Muscol)) and drugs that prevent increased muscle tone (baclofen and dantrolene). Despite a paucity of evidence supporting their use, antispasmodic and antispasticity muscle relaxants have gained widespread clinical acceptance as adjuvants in the management of patients with chronic musculoskeletal pain. Objectives The aim of this review was to determine the efficacy and safety of muscle relaxants in pain management in patients with RA. The muscle relaxants that were included in this review are the antispasmodic benzodiazepines (alprazolam, bromazepam, chlordiazepoxide,cinolazepam, clonazepam, cloxazolam, clorazepate, diazepam, estazolam, flunitrazepam, flurazepam, flutoprazepam, halazepam, ketazolam, loprazolam, lorazepam, lormetazepam, medazepam, midazolam, nimetazepam, nitrazepam, nordazepam, oxazepam, pinazepam, prazepam, quazepam, temazepam, tetrazepam, triazolam), antispasmodic non‐benzodiazepines (cyclobenzaprine, carisoprodol, chlorzoxazone, meprobamate, methocarbamol, metaxalone, orphenadrine, tizanidine and zopiclone), and antispasticity drugs (baclofen and dantrolene sodium). Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library, 4th quarter 2010), MEDLINE (1950 to week 1 November 2010), EMBASE (Week 44 2010), and PsycINFO (1806 to week 2 November 2010). We also searched the 2008 to 2009 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of reference lists of relevant articles. Selection criteria We included randomised controlled trials which compared a muscle relaxant to another therapy (active, including non‐pharmacological therapies, or placebo) in adult patients with RA and that reported at least one clinically relevant outcome. Data collection and analysis Two blinded review authors independently extracted data and assessed the risk of bias in the trials. Meta‐analyses were used to examine the efficacy of muscle relaxants on pain, depression, sleep and function, as well as their safety. Main results Six trials (126 participants) were included in this review. All trials were rated at high risk of bias. Five cross‐over trials evaluated a benzodiazepine, four assessed diazepam (n = 71) and one assessed triazolam (n = 15). The sixth trial assessed zopiclone (a non‐benzodiazepine) (n = 40) and was a parallel group study. No trial duration was longer than two weeks while three single dose trials assessed outcomes at 24 hours only. Overall the included trials failed to find evidence of a beneficial effect of muscle relaxants over placebo, alone (at 24 hrs, 1 or 2 weeks) or in addition to non‐steroidal anti‐inflammatory drugs (NSAIDs) (at 24 hrs), on pain intensity, function, or quality of life. Data from two trials of longer than 24 hours duration (n = 74) (diazepam and zopiclone) found that participants who received a muscle relaxant had significantly more adverse events compared with those who received placebo (number needed to harm (NNTH) 3, 95% CI 2 to 7). These were predominantly central nervous system side effects, including dizziness and drowsiness (NNTH 3, 95% CI 2 to 11). Authors' conclusions Based upon the currently available evidence in patients with RA, benzodiazepines (diazepam and triazolam) do not appear to be beneficial in improving pain over 24 hours or one week. The non‐benzodiazepine agent zopiclone also did not significantly reduce pain over two weeks. However, even short term muscle relaxant use (24 hours to 2 weeks) is associated with significant adverse events, predominantly drowsiness and dizziness. Plain language summary Muscle relaxants for pain management in rheumatoid arthritis This summary of a Cochrane review presents what we know from research about the effect of muscle relaxants on pain in patients with rheumatoid arthritis. The review shows that in people with rheumatoid arthritis: ‐ Muscle relaxants may not improve pain when taken as a single dose or for up to a two week period ‐ We are uncertain whether muscle relaxants affect functional status because of the very low quality of the evidence ‐ No trials were found that evaluated whether muscle relaxants affect quality of life ‐ No trials were found that evaluated whether antidepressants affect sleep ‐ We are uncertain whether muscle relaxants affect mood because of the very low quality of the evidence We also do not have precise information about side effects and complications. This is particularly true for rare but serious side effects. Possible side effects may include feeling tired or nauseous, headaches, blurred vision, a dry mouth, sexual dysfunction, or becoming dizzy or constipated. Rare complications may include increased suicidal thinking, liver inflammation, or a reduced white cell count. What is rheumatoid arthritis and what are muscle relaxants? When you have rheumatoid arthritis your immune system, which normally fights infection, attacks the lining of your joints. This makes your joints swollen, stiff, and painful. The small joints of your hands and feet are usually affected first. There is no cure for rheumatoid arthritis at present, so the treatments aim to relieve pain and stiffness and improve your ability to move. Muscle relaxants can be used to treat anxiety and promote sleep, and some people believe they may also reduce pain by acting on the nerves that cause pain, but this remains controversial. Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), Xanax, Ativan and non‐benzodiazepines such as Skelaxin, Muscol) and drugs that prevent increased muscle tone (baclofen and dantrolene). Best estimates of what happens to people with rheumatoid arthritis who take muscle relaxants: Pain at 24 hours: ‐ Non‐significant result. Pain at 1 to 2 weeks: ‐ Non‐significant result. Withdrawal due to adverse events, after 2 weeks: ‐ Non‐significant result. Total adverse events: ‐ 49 more people out of 100 experienced an adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 49%), ‐ 52 out of 100 people who took a muscle relaxant suffered an adverse event, ‐ 3 out of 100 people who took a placebo suffered an adverse event. Central nervous system (CNS) adverse events: ‐ 33 more people out of 100 experienced a CNS adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 33%), ‐ 39 out of 100 people who took a muscle relaxant suffered a CNS adverse event, ‐ 6 out of 100 people who took a placebo relaxant suffered a CNS adverse event. This record should be cited as: This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in the Cochrane Database of Systematic Reviews [Issue and date] © [year] The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464‐780X).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Richards, BL; Whittle, SL; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD008922.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "07d7ea88-cb47-4a72-a024-51df84aaaf4e", "pmid": "", "title": "Herbal medicines for fatty liver diseases", "imported": false, "abstract": "Abstract - Background Fatty liver disease is potentially a reversible condition that may lead to end‐stage liver disease. Since herbal medicines such as Crataegus pinnatifida and Salvia miltiorrhiza have increasingly been used in the management of fatty liver disease, a systematic review on herbal medicine for fatty liver disease is needed. Objectives To assess the beneficial and harmful effects of herbal medicines for people with alcoholic or non‐alcoholic fatty liver disease. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2012), MEDLINE, EMBASE, and Science Citation Index Expanded to 1 March 2012. We also searched the Chinese BioMedical Database, Traditional Chinese Medical Literature Analysis and Retrieval System, China National Knowledge Infrastructure, Chinese VIP Information, Chinese Academic Conference Papers Database and Chinese Dissertation Database, and the Allied and Complementary Medicine Database to 2 March 2012. Selection criteria We included randomised clinical trials comparing herbal medicines with placebo, no treatment, a pharmacological intervention, or a non‐pharmacological intervention such as diet or lifestyle, or Western interventions in participants with fatty liver disease. Data collection and analysis Two review authors extracted data independently. We used the 'risk of bias' tool to assess the risk of bias of the included trials. We assessed the following domains: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. We presented the effects estimates as risk ratios (RR) with 95% confidence intervals (CI) or as mean differences (MD) with 95% CI, depending on the variables of the outcome measures. Main results We included 77 randomised clinical trials, which included 6753 participants with fatty liver disease. The risks of bias (overestimation of benefits and underestimation of harms) was high in all trials. The mean sample size was 88 participants (ranging from 40 to 200 participants) per trial. Seventy‐five different herbal medicine products were tested. Herbal medicines tested in the randomised trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca) , proprietary herbal medicines commercially available, and combination formulas prescribed by practitioners. The most commonly used herbs were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia, Astragalus membranaceous, and Rheum palmatum . None of the trials reported death, hepatic‐related morbidity, quality of life, or costs. A large number of trials reported positive effects on putative surrogate outcomes such as serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases, ultrasound, and computed tomography scan. Twenty‐seven trials reported adverse effects and found no significant difference between herbal medicines versus control. However, the risk of bias of the included trials was high. The outcomes were ultrasound findings in 22 trials, liver computed tomography findings in eight trials, aspartate aminotransferase levels in 64 trials, alanine aminotransferase activity in 77 trials, and glutamyltransferase activities in 44 trials. Six herbal medicines showed statistically significant beneficial effects on ultrasound, four on liver computed tomography, 42 on aspartate aminotransferase activity, 49 on alanine aminotransferase activity, three on alkaline phosphatases activity, and 32 on glutamyltransferase activity compared with control interventions. Authors' conclusions Some herbal medicines seemed to have positive effects on aspartate aminotransferase, alanine aminotransferase, ultrasound, and computed tomography. We found no significant difference on adverse effects between herbal medicine and control groups. The findings are not conclusive due to the high risk of bias of the included trials and the limited number of trials testing individual herbal medicines. Accordingly, there is also high risk of random errors. Plain language summary Herbal medicines for fatty liver diseases Fatty liver disease is a potentially reversible illness where fat builds up within the cells of the liver. It may lead to the liver no longer being able to function properly; this is called end‐stage liver disease. This systematic review evaluated the effects and safety of herbal medicines (single herbs, branded herbal medicines, and prescribed formulas) for treating fatty liver disease. We included 77 randomised clinical trials in this review, which tested 75 herbal medicines. All trials had high risk of systematic errors (ie, bias or risk of overestimation of benefits and overestimation of harms) as well as high risks of random errors (ie, play of chance) due to the small number of people in the trials. Herbal medicines tested in the randomised clinical trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca ), commercially available branded herbal medicines, and combination formulas prescribed by practitioners. Herbs most commonly included as an ingredient in different products were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia , Astragalus membranaceous , and Rheum palmatum . We could not combine the results of the trials due to the range of different herbs used. We could not reach any conclusions about the use of herbal medicines for people with fatty liver disease as none of the trials reported results on death, liver‐related illnesses, quality of life, or costs. A number of trials showed positive effects of herbal medicines compared with control interventions on enzyme activity (enzymes are proteins that cause chemical reactions in the body; eg, serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases), ultrasound scan findings, and computed tomography scan findings. No serious adverse effects were reported for herbal medicines. However, the methodology of the trials had high risk of systematic errors (bias). Furthermore, the individual herbs were seldomly retested, and all trials had relatively low numbers of people, which increases the risk of random errors (play of chance). Therefore, the findings are inconclusive, and rigorously conducted randomised clinical trials are required to establish the benefits and harms of herbal medicines for fatty liver disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Liu, ZL, Xie, LZ, Zhu, J, Li, GQ, Grant, SJ, Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009059.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.113Z" }, { "id": "07dbcf91-b8f3-4797-b4f6-b00b00d843a1", "pmid": "", "title": "Preprocedural mouth rinses for preventing transmission of infectious diseases through aerosols in dental healthcare providers", "imported": false, "abstract": "Abstract - Background Aerosols and spatter are generated in a dental clinic during aerosol‐generating procedures (AGPs) that use high‐speed hand pieces. Dental healthcare providers can be at increased risk of transmission of diseases such as tuberculosis, measles and severe acute respiratory syndrome (SARS) through droplets on mucosae, inhalation of aerosols or through fomites on mucosae, which harbour micro‐organisms. There are ways to mitigate and contain spatter and aerosols that may, in turn, reduce any risk of disease transmission. In addition to personal protective equipment (PPE) and aerosol‐reducing devices such as high‐volume suction, it has been hypothesised that the use of mouth rinse by patients before dental procedures could reduce the microbial load of aerosols that are generated during dental AGPs. Objectives To assess the effects of preprocedural mouth rinses used in dental clinics to minimise incidence of infection in dental healthcare providers and reduce or neutralise contamination in aerosols. Search methods We used standard, extensive Cochrane search methods. The latest search date was 4 February 2022. Selection criteria We included randomised controlled trials and excluded laboratory‐based studies. Study participants were dental patients undergoing AGPs. Studies compared any preprocedural mouth rinse used to reduce contaminated aerosols versus placebo, no mouth rinse or another mouth rinse. Our primary outcome was incidence of infection of dental healthcare providers and secondary outcomes were reduction in the level of contamination of the dental operatory environment, cost, change in mouth microbiota, adverse events, and acceptability and feasibility of the intervention. Data collection and analysis Two review authors screened search results, extracted data from included studies, assessed the risk of bias in the studies and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random‐effects meta‐analysis to combine data Main results We included 17 studies with 830 participants aged 18 to 70 years. We judged three trials at high risk of bias, two at low risk and 12 at unclear risk of bias. None of the studies measured our primary outcome of the incidence of infection in dental healthcare providers. The primary outcome in the studies was reduction in the level of bacterial contamination measured in colony‐forming units (CFUs) at distances of less than 2 m (intended to capture larger droplets) and 2 m or more (to capture droplet nuclei from aerosols arising from the participant's oral cavity). It is unclear what size of CFU reduction represents a clinically significant amount. There is low‐ to very low‐certainty evidence that chlorhexidine (CHX) may reduce bacterial contamination, as measured by CFUs, compared with no rinsing or rinsing with water. There were similar results when comparing cetylpyridinium chloride (CPC) with no rinsing and when comparing CPC, essential oils/herbal mouthwashes or boric acid with water. There is very low‐certainty evidence that tempered mouth rinses may provide a greater reduction in CFUs than cold mouth rinses. There is low‐certainty evidence that CHX may reduce CFUs more than essential oils/herbal mouthwashes. The evidence for other head‐to‐head comparisons was limited and inconsistent. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or adverse events such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess acceptability of the intervention to patients or feasibility of implementation for dentists. Authors' conclusions None of the included studies measured the incidence of infection among dental healthcare providers. The studies measured only reduction in level of bacterial contamination in aerosols. None of the studies evaluated viral or fungal contamination. We have only low to very low certainty for all findings. We are unable to draw conclusions regarding whether there is a role for preprocedural mouth rinses in reducing infection risk or the possible superiority of one preprocedural rinse over another. Studies are needed that measure the effect of rinses on infectious disease risk among dental healthcare providers and on contaminated aerosols at larger distances with standardised outcome measurement. Plain language summary Does use of mouth rinse before a dental procedure reduce the risk of infection transmission from patient to health professional? Why is this question important? Many dental procedures generate droplets that settle on a surface quickly. If high‐speed instruments, such as a drill, are used, aerosols are generated, which consist of tiny particles that remain suspended in the air and that can be inhaled or that settle farther away on surfaces. These aerosols contain a variety of micro‐organisms and may transmit infections either through direct contact or indirectly through the contaminated surfaces. To prevent the spread of infection, it may help to reduce the number of micro‐organisms that are present in these aerosols. The use of mouth rinses before a dental procedure ('preprocedural mouth rinse') has been suggested as a possible way to reduce the amount of contamination of these aerosols. Chlorhexidine, povidone iodine and cetylpyridinium chloride (CPC) are some of the commonly used mouth rinses. They act by killing or inactivating the micro‐organisms in the mouth and thereby reducing the level of contamination in the aerosol that is generated. We wanted to find out whether rinsing the mouth before a dental procedure reduces the contamination of aerosols produced during dental procedures in practice and helps prevent the transmission of infectious diseases. How did we identify and evaluate the evidence? We searched for all relevant studies that compared mouth rinses used before dental procedures against placebo (fake treatment), no intervention or another mouth rinse considered to be inactive. We then compared the results, and summarised the evidence from all the studies. Finally, we assessed our confidence in the evidence. To do this, we considered factors such as the way studies were conducted, study sizes and consistency of findings across studies. What did we find? We found 17 studies that met our inclusion criteria. These studies used chlorhexidine, CPC, essential oil/herbal mouth rinses, povidone iodine and boric acid in comparison to no rinsing, or rinsing with water, saline (salt water) or another mouth rinse. None of the studies measured the how often dental healthcare providers became infected with micro‐organisms. All the included studies measured the level of bacterial contamination in droplets or aerosols in the dental clinic. They did not examine contamination with viruses or fungi. Most rinses decreased bacterial contamination in aerosols to some extent, but there was considerable variation in the effects and we do not know what size of reduction is necessary to reduce infection risk. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or side effects such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess whether patients were happy to use a mouth rinse or whether it was easy for dentists to implement. Overall, the results suggest that using a preprocedural mouth rinse may reduce the level of bacterial contamination in aerosols compared with no rinsing or rinsing with water, but we have only low or very low certainty that the evidence is reliable and we do not know how this reduction in contamination relates to the risk of infection. What does this mean? We have very little confidence in the evidence, and further studies may change the findings of our review. No studies measured infection risk or investigated viral or fungal contamination. How up‐to‐date is this review? The evidence in this Cochrane Review is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kumbargere Nagraj, S, Eachempati, P, Paisi, M, Nasser, M, Sivaramakrishnan, G, Francis, T, Verbeek, JH", "articleTypes": [], "doi": "10.1002/14651858.CD013826.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.751Z" }, { "id": "07dda3ea-98fd-4a31-bd3d-1f38186fcb0f", "pmid": "", "title": "Corticosteroids for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve are implicated in causing Bell's palsy. Corticosteroids have a potent anti‐inflammatory action that should minimise nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Objectives To determine the effectiveness and safety of corticosteroid therapy in people with Bell's palsy. Search methods On 4 March 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS. We reviewed the bibliographies of the randomised trials and contacted known experts in the field to identify additional published or unpublished trials. We also searched clinical trials registries for ongoing trials. Selection criteria Randomised trials and quasi‐randomised trials comparing different routes of administration and dosage schemes of corticosteroid or adrenocorticotrophic hormone therapy versus a control group receiving no therapy considered effective for this condition, unless the same therapy was given in a similar way to the experimental group. Data collection and analysis We used standard Cochrane methodology. The main outcome of interest was incomplete recovery of facial motor function (i.e. residual facial weakness). Secondary outcomes were cosmetically disabling persistent sequelae, development of motor synkinesis or autonomic dysfunction (i.e. hemifacial spasm, crocodile tears) and adverse effects of corticosteroid therapy manifested during follow‐up. Main results We identified seven trials, with 895 evaluable participants for this review. All provided data suitable for the primary outcome meta‐analysis. One of the trials was new since the last version of this Cochrane systematic review. Risk of bias in the older, smaller studies included some unclear‐ or high‐risk assessments, whereas we deemed the larger studies at low risk of bias. Overall, 79/452 (17%) participants allocated to corticosteroids had incomplete recovery of facial motor function six months or more after randomisation; significantly fewer than the 125/447 (28%) in the control group (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.50 to 0.80, seven trials, n = 895). The number of people who need to be treated with corticosteroids to avoid one incomplete recovery was 10 (95% CI 6 to 20). The reduction in the proportion of participants with cosmetically disabling sequelae six months after randomisation was very similar in the corticosteroid and placebo groups (RR 0.96, 95% CI 0.40 to 2.29, two trials, n = 75, low‐quality evidence). However, there was a significant reduction in motor synkinesis during follow‐up in participants receiving corticosteroids (RR 0.64, 95% CI 0.45 to 0.91, three trials, n = 485, moderate‐quality evidence). Three studies explicitly recorded the absence of adverse effects attributable to corticosteroids. One trial reported that three participants receiving prednisolone had temporary sleep disturbances and two trials gave a detailed account of adverse effects occurring in 93 participants, all non‐serious; the combined analysis of data from these three trials found no significant difference in adverse effect rates between people receiving corticosteroids and people receiving placebo (RR 1.04, 95% CI 0.71 to 1.51, n = 715). Authors' conclusions The available moderate‐ to high‐quality evidence from randomised controlled trials showed significant benefit from treating Bell's palsy with corticosteroids. Plain language summary Corticosteroids for Bell's palsy Review question What are the effects of corticosteroids on Bell's palsy? Background Bell's palsy is a paralysis or weakness of muscles in the face, usually on one side, with no certain cause. Symptoms usually recover, although not always. Reducing inflammation of the facial nerve using corticosteroid medicines (steroids) is thought to limit nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Study characteristics We identified seven clinical trials involving 895 people with one‐sided mild, moderate or severe Bell's palsy of unknown cause. All of these trials reported rates of incomplete recovery (the proportion of people left with facial weakness) and we were able to combine the results. People in the studies were aged from 2 to 84 years. They were treated with corticosteroids or placebo (inactive treatment), either alone or in combination with other therapies. One trial only involved children, from 24 months to 74 months old. The duration of the included studies for adults and children ranged from 157 days to 12 months. Key results and quality of the evidence Incomplete recovery According to moderate quality to high quality evidence, corticosteroids reduced the number of people left with facial weakness after Bell's palsy compared to placebo (a pretend medicine). This finding was based on data from seven studies involving 895 participants with Bell's palsy of varying degrees of severity. We calculated that to stop one person from being left with facial weakness, 10 people need to be treated. Five studies provided data on long‐term after‐effects of Bell's palsy following treatment. Two of the studies (75 participants) looked at persistent effects on facial appearance after six months or more. The effect was nearly the same for corticosteroids and placebo, showing that participants who had corticosteroids benefited slightly, although this evidence was low quality. Data from three studies (485 participants) showed clearly that people who received corticosteroids developed less motor synkinesis (unwanted facial movements) and crocodile tears (watery eyes when eating or chewing), compared with people who received placebo alone. This finding was based on moderate‐quality evidence. Side effects Three studies reported that no side effects could be attributed to corticosteroid treatment. Based on moderate‐quality evidence from three studies (715 participants), numbers experiencing side effects were similar with corticosteroids and placebo. The evidence is current to March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Madhok, VB, Gagyor, I, Daly, F, Somasundara, D, Sullivan, M, Gammie, F, Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001942.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.751Z" }, { "id": "07ef73f3-404e-4b2b-85f5-7bddbdceb557", "pmid": "", "title": "Topical antibiotics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection (involving more than one micro‐organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms are ear discharge and hearing loss. Topical antibiotics, the most common treatment for CSOM, aim to kill or inhibit the growth of micro‐organisms that may be responsible for the infection. Antibiotics can be used alone or with other treatments for CSOM, such as antiseptics or ear cleaning (aural toileting). This is an update of a Cochrane review first published in 2020 and one of a suite of seven reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To evaluate the benefits and harms of topical antibiotics (without steroids) for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials with at least a one week of follow‐up involving adults and children with chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antibiotic(s) of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic compared to placebo or no intervention, and compared to another topical antibiotic (e.g. topical antibiotic A versus topical antibiotic B). Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks and up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This update found one new study (100 participants). Overall, we included 18 studies with 1783 participants (in 16 studies), plus 108 ears that could not be accounted for in participant numbers (in two studies). 1. Topical antibiotics versus placebo or no treatment (with aural toilet in both arms and no other background treatment) One study (50 participants, data unavailable for 15 participants) compared a topical antibiotic (ciprofloxacin) with placebo (saline). All participants received aural toilet. Topical ciprofloxacin may increase resolution of discharge at one to up to two weeks compared with placebo (84% with antibiotic versus 12% with placebo; risk ratio (RR) 6.74, 95% confidence interval (CI) 1.82 to 24.99; 35 participants; very low‐certainty evidence). The study authors reported \"no medical side‐effects and worsening of audiological measurements related to this topical medication were detected.\" 2. Topical antibiotics versus placebo or no treatment (with use of oral antibiotics in both arms) Four studies (438 participants) compared topical antibiotics versus no treatment, with oral antibiotics in both arms. These compared topical ciprofloxacin to no treatment (3 studies, 190 participants) or topical ceftizoxime to no treatment (1 study, 248 participants). In each study, all participants received the same antibiotic systemically (oral ciprofloxacin or injected ceftizoxime). In at least one study, all participants received aural toilet. There were no useable data comparing topical ceftizoxime to no treatment. Topical antibiotics in addition to systemic antibiotics may increase resolution of ear discharge at one to up to two weeks compared with systemic antibiotics alone (resolution of discharge occurring in 88% with topical antibiotics versus 60% without topical antibiotics; RR 1.47, 95% CI 1.14 to 1.88; 1 study, 100 participants; low‐certainty evidence). One study (40 participants) stated \"no side effect was recorded in any patient\" (low‐certainty evidence). 3. Comparisons of different topical antibiotics Eight studies (794 participants, plus 40 ears) compared aminoglycosides (gentamicin, neomycin, or tobramycin) with quinolones (ciprofloxacin or ofloxacin). Resolution of discharge at one to up to two weeks may be higher in the quinolones group, but the evidence is very uncertain (RR 1.92, 95% CI 1.00 to 3.67; 7 studies, 794 participants; very low‐certainty evidence). There was considerable heterogeneity (I 2 = 97%). One study (308 participants) stated there were no differences between the different groups for resolution of ear discharge after four weeks (low‐certainty evidence). The evidence is very uncertain about the effects of topical antibiotics on ear pain (1 study reported no differences between groups). The evidence is very uncertain about the effects of topical antibiotics on hearing loss (2 studies reported no differences between groups). 4. Other comparisons We assessed five studies (501 participants, plus 68 ears) over the following three additional comparisons: quinolones versus aminoglycosides/polymyxin B with/without gramicidin, aminoglycosides versus trimethoprim‐sulphacetamide‐polymixin B, and rifampicin versus chloramphenicol. However, these results have not been included in the abstract. Authors' conclusions We are very uncertain about the effectiveness of topical antibiotics in improving resolution of ear discharge in people with CSOM because of the limited amount of low‐ or very low‐certainty evidence available. This was mostly due to risk of bias and imprecision. However, amongst this uncertainty, there is some evidence to suggest that the use of topical antibiotics may be effective when compared to placebo, or when used in addition to a systemic antibiotic. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine whether quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, harmful effects were poorly reported. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and harms of using topical antibiotics to treat chronic suppurative otitis media? Key messages – We are uncertain whether topical antibiotics reduce ear discharge of people with swelling and infection of the middle ear (called chronic suppurative otitis media). – Topical antibiotics may reduce ear discharge compared to placebo (a salt solution), but we are very uncertain. Topical antibiotics used in addition to an antibiotic given by mouth may reduce ear discharge. – Overall, we are very uncertain which type of topical antibiotic is the most effective. What is chronic suppurative otitis media? Chronic suppurative otitis media, also known as chronic otitis media, is a swelling and infection of the middle ear that lasts for two weeks or more. People with chronic suppurative otitis media usually have ear discharge that is difficult to get rid of or keeps coming back (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Topical antibiotics (administered into the ear canal as ear drops, ointments, sprays, or creams) are the most commonly used treatment for chronic suppurative otitis media. Topical antibiotics kill or stop the growth of the bacteria (germs) that may be responsible for the infection. Topical antibiotics can be used on their own or be added to other treatments for chronic suppurative otitis media, such as antiseptics (which also kill germs) or ear cleaning (aural toileting) or systemic antibiotics (antibiotics taken either by mouth or by an injection into a muscle or vein). What was the aim of this review? We wanted to find out how effective topical antibiotics are for people with chronic suppurative otitis media, and whether they cause unwanted effects. We also wanted to know whether one type of topical antibiotic was more beneficial or harmful than any other. In particular, we wanted to know whether topical antibiotics stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found one new study (100 participants). Overall, we found 18 studies examining at least 1783 people, but it was difficult to determine precisely how many people were included as some studies did not clearly report the number. Two studies included \"mainly children,\" three included only adults, whilst the remainder appeared to include both children and adults. None of the studies reported the inclusion of people considered at high risk of having chronic suppurative otitis media (for example, people with cleft palate (where the roof of the mouth of a baby does not join together during pregnancy) or Down's syndrome; or people whose immune system does not work well enough to fight germs). The studies used different types of antibiotics and combinations of antibiotics. Comparison of topical antibiotics to placebo or no treatment One study (50 people) compared topical antibiotics to a saline (salt water) ear wash. Topical antibiotics may reduce ear discharge more than the saline ear wash when assessed one to up to two weeks after treatment, but we are very uncertain. The evidence is very uncertain about unwanted effects and worsening of hearing measurements. The study did not measure quality of life and reported that there were no serious complications. Comparison of topical antibiotics in addition to systemic (oral or injected) antibiotics Four studies (438 people) compared treatment with topical antibiotic (ciprofloxacin) drops in addition to a systemic (oral or injected) antibiotic, but one study did not contribute data. Topical plus oral antibiotics may reduce ear discharge more than oral antibiotics alone at one to up to two weeks and two to up to four weeks. One study stated there were no unwanted effects. The studies did not measure quality of life and did not report any serious complications. Comparisons of different topical antibiotics Eight studies (794 participants plus 40 ears) compared an aminoglycoside antibiotic (gentamicin, neomycin, or tobramycin) with a quinolone antibiotic (ciprofloxacin or ofloxacin). Quinolones may reduce ear discharge better than aminoglycosides, but the evidence is very uncertain. One study (100 people) measured ear pain and reported no difference between the groups, but the evidence is very uncertain. Two studies measured hearing loss, but the evidence is very uncertain. What are the limitations of the evidence? There were several limitations with the studies. For example, the results varied widely between studies, there were small numbers of people included, there was a lack of recent data, and limited information on groups of people who are more likely to have chronic suppurative otitis media. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Brennan-Jones, CG; Head, K; Chong, LY; Daw, J; Veselinović, T; Schilder, AGM; Bhutta, MF", "articleTypes": [], "doi": "10.1002/14651858.CD013051.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "07f2c62d-1d05-479d-9bac-99bd51b26ddf", "pmid": "", "title": "Dietary marine fatty acids (fish oil) for asthma in adults and children", "imported": false, "abstract": "Abstract - Background Epidemiological studies suggest that a diet high in marine fatty acids (fish oil) may have beneficial effects on inflammatory conditions such as rheumatoid arthritis and possibly asthma. Objectives (1) To determine the effect of marine n‐3 fatty acid (fish oil) supplementation in asthma.
 (2) To determine the effect of a diet high in fish oil in asthma. Search methods We searched the Cochrane Airways Group Specialised Register. We also searched bibliographies of retrieved trials and contacted fish oil manufacturers. Searches were current as of May 2010. Selection criteria We included randomised controlled trials in patients with asthma more than two years of age. The study duration had to be in excess of four weeks. Double blind trials were preferred, but we also reviewed single‐blind and open trials for possible inclusion. All four reviewers read each paper, blind to its identity. Decisions concerning inclusion were made by simple majority. We all performed quality assessment independently. Data collection and analysis The only comparison possible was between marine n‐3 fatty acid supplementation and placebo. There were insufficient trials to examine dietary manipulation alone. Main results Nine randomised controlled trials conducted between 1986 and 2001 satisfied the inclusion criteria. Seven were of parallel design and two were cross‐over studies. Eight compared fish oil with placebo whilst one compared high dose versus low dose marine n‐3 fatty acid supplementation. Two studies were conducted in children, whilst the remaining seven studies were conducted in adults. None of the included studies reported asthma exacerbations, health status or hospital admissions. There was no consistent effect on any of the analysable outcomes: FEV1, peak flow rate, asthma symptoms, asthma medication use or bronchial hyper reactivity. One of the studies performed in children which combined dietary manipulation with fish oil supplementation showed improved peak flow and reduced asthma medication use. There were no adverse events associated with fish oil supplements. Authors' conclusions There is little evidence to recommend that people with asthma supplement or modify their dietary intake of marine n‐3 fatty acids (fish oil) in order to improve their asthma control. Equally, there is no evidence that they are at risk if they do so. Plain language summary Dietary marine fatty acids (fish oil) for asthma in adults and children Eating more fish has been recommended as one way of possibly reducing asthma. Populations (such as Eskimo communities) with diets high in fish also have low rates of asthma. As diets in other communities have become higher in saturated fats, asthma has also increased. The theory has been that an ingredient in fish oil may reduce inflammation. Inflammation causes the swelling in the airways of the lungs that leads to asthma attacks. However, this review of trials found that people with asthma changing their diets to include more fish oil did not improve their asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Thien, FCK; De Luca, S; Woods, RK; Abramson, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD001283", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "080ac8b2-b813-497a-83e1-27ce655d3fd8", "pmid": "", "title": "Anticoagulation for people receiving long‐term haemodialysis", "imported": false, "abstract": "Abstract - Background Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding. Objectives To assess the efficacy and safety of anticoagulation strategies (including both heparin and non‐heparin drugs) for long‐term HD in people with kidney failure. Any intervention preventing clotting within the extracorporeal circuit without establishing anticoagulation within the patient, such as regional citrate, citrate enriched dialysate, heparin‐coated dialysers, pre‐dilution haemodiafiltration (HDF), and saline flushes were also included. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to November 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐randomised controlled studies (quasi‐RCTs) evaluating anticoagulant agents administered during HD treatment in adults and children with kidney failure. Data collection and analysis Two authors independently assessed the risk of bias using the Cochrane tool and extracted data. Treatment effects were estimated using random effects meta‐analysis and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE). Main results We included 113 studies randomising 4535 participants. The risk of bias in each study was adjudicated as high or unclear for most risk domains. Compared to UFH, LMWH had uncertain effects on extracorporeal circuit thrombosis (3 studies, 91 participants: RR 1.58, 95% CI 0.46 to 5.42; I 2 = 8%; low certainty evidence), while major bleeding and minor bleeding were not adequately reported. Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH (2 studies, 82 participants: RR 0.34, 95% CI 0.14 to 0.85; I 2 = 0%; low certainty evidence). No studies reported data comparing regional citrate to UFH on risks of extracorporeal circuit thrombosis and major bleeding. The effects of very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors or heparin‐grafted membranes were uncertain due to insufficient data. The effects of different LMWH, different doses of LMWH, and the administration of LMWH anticoagulants using inlet versus outlet bloodline or bolus versus infusion were uncertain. Evidence to compare citrate to another citrate or control was scant. The effects of UFH compared to no anticoagulant therapy or different doses of UFH were uncertain. Death, dialysis vascular access outcomes, blood transfusions, measures of anticoagulation effect, and costs of interventions were rarely reported. No studies evaluated the effects of treatment on non‐fatal myocardial infarction, non‐fatal stroke and hospital admissions. Adverse events were inconsistently and rarely reported. Authors' conclusions Anticoagulant strategies, including UFH and LMWH, have uncertain comparative risks on extracorporeal circuit thrombosis, while major bleeding and minor bleeding were not adequately reported. Regional citrate may decrease minor bleeding, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported. Evidence supporting clinical decision‐making for different forms of anticoagulant strategies for HD is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes. Plain language summary Treatments to thin the blood during haemodialysis: which treatments reduce clotting problems without causing bleeding? What is the issue? When people have dialysis using a machine to clean their blood (called haemodialysis (HD)), blood‐thinning treatment helps prevent blood clots in the dialysis tubing. However, thinning the blood too much with treatment can lead to bleeding problems. There are several different medications to thin the blood, but it is not clear which is the best or the safest choice. What did we do? We searched for all the research trials that assessed the blood thinning treatments during HD for adults and children up until November 2023. We measured the certainty we could have about the results of this research using \"GRADE\". What did we find? We found 113 studies involving 4535 patients treated with HD. Patients were given different forms of blood thinning therapy. The treatment they got was decided by random chance (like the toss of a coin). Most of the studies looked at a treatment called \"low molecular weight heparin\" and compared this with standard blood thinning care (called \"standard heparin\"). Unfortunately, the studies included only a small number of patients and only looked for risks of clotting or bleeding during one or two months of therapy. Because of this short time frame, and other limitations of the research studies, we were very uncertain about the results. The current research doesn't tell us whether one blood thinning treatment is better or safer than another for patients during dialysis treatment. Conclusions We still can't be certain about the best way to thin the blood for HD treatment based on existing research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Natale, P, Palmer, SC, Ruospo, M, Longmuir, H, Dodds, B, Prasad, R, Batt, TJ, Jose, MD, Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD011858.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.107Z" }, { "id": "080bea0c-f54c-40ba-877d-27bf53013d19", "pmid": "", "title": "Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Romero, L, Huerfano, C, Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD012492.pub2 AB - Abstract - Background Chancroid is a genital ulcerative disease caused by Haemophilus ducreyi . This microorganism is endemic in Africa, where it can cause up to 10% of genital ulcers. Macrolides may be an effective alternative to treat chancroid and, based on their oral administration and duration of therapy, could be considered as first line therapy. Objectives To assess the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults. Search methods We searched the Cochrane STI Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, WHO ICTRP, ClinicalTrials.gov and Web of Science to 30 October 2017. We also handsearched conference proceedings and reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) comparing macrolides in different regimens or with other therapeutic alternatives for chancroid. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We resolved disagreements through consensus. We used the GRADE approach to assess the quality of the evidence. Main results Seven RCTs (875 participants) met our inclusion criteria, of which four were funded by industry. Five studies (664 participants) compared macrolides with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Low quality evidence suggested there was no difference between the groups after treatment in terms of clinical cure (risk ratio (RR) 1.09, 95% confidence interval (CI) 0.97 to 1.21; 2 studies, 340 participants with syndromic approach and RR 1.06, 95% CI 0.98 to 1.15; 5 studies, 348 participants with aetiological diagnosis) or improvement (RR 0.89, 95% CI 0.52 to 1.52; 2 studies, 340 participants with syndromic approach and RR 0.80, 95% CI 0.42 to 1.51; 3 studies, 187 participants with aetiological diagnosis). Based on low and very low quality evidence, there was no difference between macrolides and any other antibiotic treatments for microbiological cure (RR 0.93, 95% CI 0.74 to 1.16; 1 study, 45 participants) and minor adverse effects (RR 1.34, 95% CI 0.24 to 7.51; 3 studies, 412 participants). Two trials (269 participants) compared erythromycin with any other macrolide type. Low quality evidence suggested that, compared with azithromycin or rosaramicin, long courses of erythromycin did not increase clinical cure (RR 1.00, 95% CI 0.91 to 1.10; 2 studies, 269 participants with syndromic approach and RR 1.04, 95% CI 0.93 to 1.16; 2 studies, 211 participants with aetiological diagnosis), with a similar frequency of minor adverse effects between the groups (RR 1.14, 95% CI 0.63 to 2.06; 1 trial, 101 participants). For this comparison, subgroup analysis found no difference between HIV‐positive participants (RR 1.02, 95% CI 0.73 to 1.43; 1 study, 38 participants) and HIV‐negative participants (RR 1.04, 95% CI 0.94 to 1.14; 1 study, 89 participants). We downgraded the quality of evidence to low, because of imprecision, some limitations on risk of bias and heterogeneity. None of the trials reported serious adverse events, cost effectiveness and participant satisfaction. Authors' conclusions At present, the quality of the evidence on the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults is low, implying that we are uncertain about the estimated treatment effect. There is no statistically significant difference between the available therapeutic alternatives for the treatment of sexually active adults with genital ulcers compatible with chancroid. Low quality evidence suggests that azithromycin could be considered as the first therapeutic alternative, based on their mono‐dose oral administration, with a similar safety and effectiveness profile, when it is compared with long‐term erythromycin use. Due to sparse available evidence about the safety and effectiveness of macrolides to treat H ducreyi infection in people with HIV, these results should be taken with caution. Plain language summary Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults Review question 
 In this Cochrane Review, we assess the effectiveness and safety of macrolides in different regimens or with other treatments for H ducreyi infection in adults. Background Chancroid is a sexually transmitted infection (STI) caused by infection with a bacteria called Haemophilus ducreyi . It causes ulcers in the genital area and is endemic in some low‐income countries. Control and eradication of chancroid could reduce transmission of the STI from one sexual partner to another. Macrolides are antibiotics that could be effective and safe for treating H ducreyi infection. Trial characteristics We searched the available literature up to 30 October 2017 and we included seven trials with 875 participants. The trials recruited men and non‐pregnant women over the age of 16 years who presented with genital ulcers compatible with chancroid. Three studies included people with high‐risk sexual behaviour as migrant mine workers, sex workers and men with prostitute contact. All the trials tested for other STIs, and discarded people who were also infected with syphilis and herpes simple virus. One study included people with HIV. The most frequent antibiotic treatment was erythromycin with azithromycin as an alternative. They were compared with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Five studies compared two types of antibiotic and two studies compared different ways of treating with macrolides. Four trials were funded by pharmaceutical companies. Key results There was no difference between the types of antibiotics in sexually active adults with genital ulcers compatible with chancroid. Erythromycin is usually the first choice for treatment but low quality evidence suggested that azithromycin (as a single dose, oral (by mouth) administration) had similar safety and effectiveness. Because of sparse evidence about the safety and effectiveness of macrolides to treat Haemophilus ducreyi infection in people with HIV, these results should be taken with caution. Quality of evidence The quality of evidence was low as there was a risk of bias due to poor methods, people dropping out of the study and pharmaceutical companies sponsored four studies.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.111Z" }, { "id": "080d7172-3b31-4229-916e-920d0fedcfd5", "pmid": "", "title": "Breastfeeding for procedural pain in infants beyond the neonatal period", "imported": false, "abstract": "Abstract - Background Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin‐to‐skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk. Objectives To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin‐to‐skin contact, expressed breast milk, formula milk, bottle feeding, sweet‐tasting solutions (e.g. sucrose or glucose), distraction, or other interventions. Search methods We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In‐Process & Other Non‐Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials. Selection criteria We included RCTs and quasi‐RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet‐tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin‐to‐skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random‐effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information. Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38‐second reduction in cry time (MD ‐38, 95% CI ‐50 to ‐26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12‐month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7‐point reduction in standardised pain scores (SMD ‐1.7, 95% CI ‐2.2 to ‐1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD ‐3.6, ‐23 to 16). Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage. No included studies reported adverse events. Authors' conclusions We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin‐breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted. Plain language summary Does breastfeeding reduce vaccination pain in babies aged 1 to 12 months? Bottom line We found that breastfeeding before and during vaccination injections helped to reduce pain in most babies up to the age of one year. Background Needles are used for babies' early childhood vaccinations and medical care during childhood illnesses. These are essential, but painful. They cause distress for the babies and often their parents/caregivers, and can result in future anxiety and fear about needles. Breastfeeding during blood tests in newborn babies reduces pain. Breastfeeding when possible and feasible may also help to comfort babies and reduce their pain beyond the newborn period and throughout infancy. Study characteristics In February 2016 we searched the medical literature for studies examining the effectiveness of breastfeeding babies 1 to 12 months old during the use of needles. We compared effectiveness of breastfeeding in reducing pain (as scored by crying time and pain scores), to holding, babies lying flat, or the giving of water or sweet solutions. We found 10 studies with a total of 1066 infants. All studies examined if breastfeeding reduced pain during vaccinations. Key results Breastfeeding reduced crying in young babies having vaccinations. On average, breastfed babies cried for 38 seconds less than babies who were not breastfed (6 studies; 547 infants; moderate‐quality evidence), and pain scores were significantly lower (5 studies; 310 infants; moderate‐quality evidence). No studies reported on any harm (very low‐quality evidence). We could draw no conclusions on risk of harm while breastfeeding healthy babies during vaccination. Going forward: if mothers are breastfeeding, it could be considered when possible for babies during vaccinations. More evidence is needed to learn if breastfeeding helps older babies and babies in hospital during blood work or procedures such as insertion of drips. Quality of the evidence The quality of the evidence was moderate for crying time and pain scores. Most studies included younger infants aged 1 to 6 months. Further research including older infants up to 12 months of age may change our conclusions. In addition, the studies evaluated the effects of breastfeeding during vaccination. We do not know whether breastfeeding helps sick babies aged 1 to 12 months in hospital during blood sampling or drip insertion.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Harrison, D; Reszel, J; Bueno, M; Sampson, M; Shah, VS; Taddio, A; Larocque, C; Turner, L", "articleTypes": [], "doi": "10.1002/14651858.CD011248.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "080e8546-3caf-4988-abc6-e93dff05fb7b", "pmid": "", "title": "Zinc for the common cold", "imported": false, "abstract": "Reason for withdrawal from publication September 2016 updated withdrawal notice 
 This Cochrane Review was withdrawn in April 2015, and this withdrawal notice was updated in September 2016. The review was withdrawn as result of comments submitted via the Cochrane Library by Harri Hemilä in February 2015. Hemilä identified multiple errors in this Cochrane Review and made allegations of plagiarism of text and data from a previously published systematic review (Hemilä H. Zinc Lozenges may shorten the duration of colds: a systematic review. Open Respiratory Medicine Journal 2011;5:51‐58. dx.doi.org/10.2174/1874306401105010051). The comments referred to the version of this review first published in June 2013 (Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2013;(6):CD001364. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001364.pub4/full) . The Cochrane Acute Respiratory Infections Group, which maintains the review, withdrew the review in April 2015, pending an assessment of the errors reported, and the group referred the allegations of plagiarism to the Editor in Chief. The Editor in Chief notified the authors of the concerns, and followed the Committee for Publication Ethics (COPE) guidelines. Replication of text was identified in the Cochrane Review. This was limited to copying of short phrases and was acknowledged by the authors. The level of text plagiarism was minor and at a level that would be addressed by a correction. The Editor in Chief carried out further investigation into the alleged plagiarism of data, with the co‐operation of the review authors, who provided supplementary information in support of their work. The allegations related to the derivation of means and standard deviations of data from some of the included studies. Although the authors acknowledge and cite the Hemilä 2011 review, the Editor in Chief considered that the authors’ explanation regarding some similarities in presented data between the two reviews was not conclusive. This version of the review will therefore remain withdrawn. April 2015 withdrawal notice 
 This review was withdrawn due to concerns raised via the feedback mechanism regarding the calculation and analysis of data in the review in April 2015. Whilst it is not unusual for reviews to be withdrawn, the editorial group took the view that it would be better to take a cautious approach and explore the source and calculation of data used in the analysis in more detail, rather than keep the review on the Cochrane Database of Systematic Reviews for the time being. The editorial group responsible for this previously published document have withdrawn it from publication.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Singh, M; Das, RR", "articleTypes": [], "doi": "10.1002/14651858.CD001364.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "0823aa82-3411-402f-8a20-79d954f5b694", "pmid": "", "title": "Antibiotics for community‐acquired pneumonia in adult outpatients", "imported": false, "abstract": "Abstract - Background Lower respiratory tract infection (LRTI) is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Community‐acquired pneumonia (CAP) is a common condition that causes a significant disease burden for the community, particularly in children younger than five years, the elderly and immunocompromised people. Antibiotics are the standard treatment for CAP. However, increasing antibiotic use is associated with the development of bacterial resistance and side effects for the patient. Several studies have been published regarding optimal antibiotic treatment for CAP but many of these data address treatments in hospitalised patients. This is an update of our 2009 Cochrane Review and addresses antibiotic therapies for CAP in outpatient settings. Objectives To compare the efficacy and safety of different antibiotic treatments for CAP in participants older than 12 years treated in outpatient settings with respect to clinical, radiological and bacteriological outcomes. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (January 1966 to March week 3, 2014), EMBASE (January 1974 to March 2014), CINAHL (2009 to March 2014), Web of Science (2009 to March 2014) and LILACS (2009 to March 2014). Selection criteria We looked for randomised controlled trials (RCTs), fully published in peer‐reviewed journals, of antibiotics versus placebo as well as antibiotics versus another antibiotic for the treatment of CAP in outpatient settings in participants older than 12 years of age. However, we did not find any studies of antibiotics versus placebo. Therefore, this review includes RCTs of one or more antibiotics, which report the diagnostic criteria and describe the clinical outcomes considered for inclusion in this review. Data collection and analysis Two review authors (LMB, TJMV) independently assessed study reports in the first publication. In the 2009 update, LMB performed study selection, which was checked by TJMV and MMK. In this 2014 update, two review authors (SP, SM) independently performed and checked study selection. We contacted trial authors to resolve any ambiguities in the study reports. We compiled and analysed the data. We resolved differences between review authors by discussion and consensus. Main results We included 11 RCTs in this review update (3352 participants older than 12 years with a diagnosis of CAP); 10 RCTs assessed nine antibiotic pairs (3321 participants) and one RCT assessed four antibiotics (31 participants) in people with CAP. The study quality was generally good, with some differences in the extent of the reporting. A variety of clinical, bacteriological and adverse events were reported. Overall, there was no significant difference in the efficacy of the various antibiotics. Studies evaluating clarithromycin and amoxicillin provided only descriptive data regarding the primary outcome. Though the majority of adverse events were similar between all antibiotics, nemonoxacin demonstrated higher gastrointestinal and nervous system adverse events when compared to levofloxacin, while cethromycin demonstrated significantly more nervous system side effects, especially dysgeusia, when compared to clarithromycin. Similarly, high‐dose amoxicillin (1 g three times a day) was associated with higher incidence of gastritis and diarrhoea compared to clarithromycin, azithromycin and levofloxacin. Authors' conclusions Available evidence from recent RCTs is insufficient to make new evidence‐based recommendations for the choice of antibiotic to be used for the treatment of CAP in outpatient settings. Pooling of study data was limited by the very low number of studies assessing the same antibiotic pairs. Individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups. However, two studies did find significantly more adverse events with use of cethromycin as compared to clarithromycin and nemonoxacin when compared to levofloxacin. Multi‐drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations. Further studies focusing on diagnosis, management, cost‐effectiveness and misuse of antibiotics in CAP and LRTI are warranted in high‐, middle‐ and low‐income countries. Plain language summary Antibiotics for community‐acquired pneumonia in adolescent and adult outpatients Review question This review studied the effects of antibiotics on adolescents and adults with pneumonia acquired and treated in the community (as opposed to acquiring pneumonia in hospital and/or being treated for pneumonia in hospital). The evidence is current to March 2014. Background Lower respiratory tract infection is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Pneumonia, or infection of the lungs, is a common condition representing a significant disease burden for the community. Pneumonia is especially life‐threatening in children younger than five years, in older people and in people with other illnesses that may affect their immune system (such as diabetes or HIV/AIDS, or solid organ transplant recipients). Antibiotics are the most common treatment for pneumonia and these can vary in their effectiveness and adverse effects. Study characteristics We identified 11 trials (with 3352 participants older than 12 years with a diagnosis of community‐acquired pneumonia), fully published in peer‐reviewed journals, focused on treatment of pneumonia in adolescents and adults treated in the community in outpatient settings. This included five new trials included since our last review published in 2009. None of the trials included antibiotics versus placebo; all trials included one or more antibiotics. All participants were diagnosed with pneumonia based upon clinical diagnosis by the physician and chest X‐ray. Study funding sources All included trials were well conducted; nine of the 11 trials were sponsored by bio‐pharmaceutical companies manufacturing the antibiotics used in the study, or their authors were closely linked with the company. Key results Nine of the included trials compared different antibiotics and, hence, we could not combine the results of the individual trials to present our overall conclusion. There were some notable adverse events in seven studies: 1) erythromycin demonstrated significant gastrointestinal side effects compared to clarithromycin in two studies; 2) nemonoxacin demonstrated higher gastrointestinal (nausea, diarrhoea) and nervous system (dizziness, headache) adverse events compared to levofloxacin; 3) cethromycin demonstrated more side effects, especially a distortion of the sense of taste, than clarithromycin; 4) gastritis and diarrhoea were more common in the high‐dose amoxicillin group (1 g three times a day) compared to the other three antibiotic groups (clarithromycin, azithromycin and levofloxacin). Conclusion Unfortunately, there were not enough trials to compare the effects of different antibiotics for pneumonia acquired and treated in the community.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Pakhale, S, Mulpuru, S, Verheij, TJM, Kochen, MM, Rohde, GGU, Bjerre, LM", "articleTypes": [], "doi": "10.1002/14651858.CD002109.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.810Z" }, { "id": "083348a9-ec4d-4dfe-a27a-2bfb7d7a89a6", "pmid": "", "title": "Probiotics for the prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wei, D, Heus, P, van de Wetering, FT, van Tienhoven, G, Verleye, L, Scholten, RJPM", "articleTypes": [], "doi": "10.1002/14651858.CD008831.pub3 AB - Abstract - Background Treament‐related diarrhoea is one of the most common and troublesome adverse effects related to chemotherapy or radiotherapy in people with cancer. Its reported incidence has been as high as 50% to 80%. Severe treatment‐related diarrhoea can lead to fluid and electrolyte losses and nutritional deficiencies and could adversely affect quality of life (QoL). It is also associated with increased risk of infection in people with neutropenia due to anticancer therapy and often leads to treatment delays, dose reductions, or treatment discontinuation. Probiotics may be effective in preventing or treating chemotherapy‐ or radiotherapy‐induced diarrhoea. Objectives To evaluate the clinical effectiveness and side effects of probiotics used alone or combined with other agents for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 7), MEDLINE (1946 to July week 2, 2017), and Embase (1980 to 2017, week 30). We also searched prospective clinical trial registers and the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) investigating the effects of probiotics for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Data collection and analysis Two review authors independently selected studies, extracted data, and assessed risk of bias. We used random‐effects models for all meta‐analyses. If meta‐analysis was not possible, we summarised the results narratively. Main results We included 12 studies involving 1554 participants. Eleven studies were prevention studies, of which seven compared probiotics with placebo (887 participants), one compared two doses of probiotics with each other and with placebo (246 participants), and three compared probiotics with another active agent (216 participants).The remaining study assessed the effectiveness of probiotics compared with placebo for treatment of radiotherapy‐related diarrhoea (205 participants). For prevention of radiotherapy (with or without chemotherapy)‐induced diarrhoea, review authors identified five heterogeneous placebo‐controlled studies (with 926 participants analysed). Owing to heterogeneity, we could not carry out a meta‐analysis, except for two outcomes. For occurrence of any diarrhoea, risk ratios (RRs) ranged from 0.35 (95% confidence interval (CI) 0.26 to 0.47) to 1.0 (95% CI 0.94 to 1.06) (three studies; low‐certainty evidence). A beneficial effect of probiotics on quality of life could neither be demonstrated nor refuted (two studies; low‐certainty evidence). For occurrence of grade 2 or higher diarrhoea, the pooled RR was 0.75 (95% CI 0.55 to 1.03; four studies; 420 participants; low‐certainty evidence), and for grade 3 or higher diarrhoea, RRs ranged from 0.11 (95% CI 0.06 to 0.23) to 1.24 (95% CI 0.74 to 2.08) (three studies; low‐certainty evidence). For probiotic users, time to rescue medication was 36 hours longer in one study (95% CI 34.7 to 37.3), but another study reported no difference (moderate‐certainty evidence). For the need for rescue medication, the pooled RR was 0.50 (95% CI 0.15 to 1.66; three studies; 194 participants; very low‐certainty evidence). No study reported major differences between groups with respect to adverse effects. Although not mentioned explicitly, no studies reported deaths, except one in which one participant in the probiotics group died of myocardial infarction after three sessions of radiotherapy. Three placebo‐controlled studies, with 128 analysed participants, addressed prevention of chemotherapy‐induced diarrhoea. For occurrence of any diarrhoea, the pooled RR was 0.59 (95% CI 0.36 to 0.96; two studies; 106 participants; low‐certainty evidence). For all other outcomes, a beneficial effect of probiotics could be neither demonstrated nor refuted (one to two studies; 46 to 106 participants; all low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. Three studies compared probiotics with another intervention in 213 participants treated with radiotherapy (with or without chemotherapy). One very small study (21 participants) reported less diarrhoea six weeks after treatment when dietary counselling was provided (RR 0.30, 95% CI 0.11 to 0.81; very low‐certainty evidence). In another study (148 participants), grade 3 or 4 diarrhoea occurred less often in the probiotics group than in the control group (guar gum containing nutritional supplement) (odds ratio (OR) 0.38, 95% CI 0.16 to 0.89; low‐certainty evidence), and two studies (63 participants) found less need for rescue medication of probiotics versus another active treatment (RR 0.44, 95% CI 0.22 to 0.86; very low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. One placebo‐controlled study with 205 participants addressed treatment for radiotherapy‐induced diarrhoea and could not demonstrate or refute a beneficial effect of probiotics on average diarrhoea grade, time to rescue medication for diarrhoea (13 hours longer in the probiotics group; 95% CI ‐0.9 to 26.9 hours), or need for rescue medication (RR 0.74, 95% CI 0.53 to 1.03; moderate‐certainty evidence). This study did not address quality of life. No studies reported serious adverse events or diarrhoea‐related deaths. Authors' conclusions This review presents limited low‐ or very low‐certainty evidence supporting the effects of probiotics for prevention and treatment of diarrhoea related to radiotherapy (with or without chemotherapy) or chemotherapy alone, need for rescue medication, or occurrence of adverse events. All studies were underpowered and heterogeneous. Severe side effects were absent from all studies. Robust evidence on this topic must be provided by future methodologically well‐designed trials. Plain language summary Live micro‐organisms for prevention or treatment of diarrhoea in people with cancer who are treated with chemotherapy or radiotherapy Background 
 Up to 80% of people treated with chemotherapy or radiotherapy for cancer suffer from diarrhoea ‐ one of the most common and troublesome side effects. Severe diarrhoea can lead to dehydration (fluid and salts loss) and malnutrition from changes to digestion and bowel habits and could adversely affect quality of life. It is also associated with increased risk of infection in people with low white cell blood count related to cancer treatment. Diarrhoea often leads to delays in cancer treatment or the need to lower the dose or even discontinue cancer treatment. Foods containing live bacteria or yeast (probiotics) might have a beneficial effect on the occurrence and severity of diarrhoea. Aim of the review 
 To evaluate the effects of live micro‐organisms (probiotics) in preventing the occurrence or reducing the severity of diarrhoea in people with cancer who are receiving chemotherapy or radiotherapy. Main findings 
 Overall, the studies we found do not give a clear answer on whether probiotics reduce the occurrence or severity of diarrhoea, improve quality of life, or reduce the need for other medication. However, an analysis of only well‐performed studies demonstrated a beneficial effect for some outcomes. With regard to prevention of diarrhoea compared with placebo in participants treated with radiotherapy with or without chemotherapy, we are not able to conclude whether use of probiotics would be beneficial based on the five relevant studies. For prevention of diarrhoea due to chemotherapy alone, three studies suggested that use of probiotics may not reduce diarrhoea, and one study reported use of less rescue medication for diarrhoea. Three studies that compared probiotics with another agent for preventing diarrhoea in patients treated with radiotherapy with or without chemotherapy found beneficial effects of probiotics for the occurrence and severity of diarrhoea and the need for rescue medication. With respect to treatment of diarrhoea due to radiotherapy, we found only one study that did not demonstrate a clear effect of probiotics compared with placebo. No study reported serious adverse events nor deaths related to diarrhoea. Certainty of the evidence 
 The quality (certainty) of the evidence in prevention studies was low to very low. For the only study that assessed the effects of probiotics on treatment for diarrhoea, the certainty of the evidence was moderate. What are the conclusions? 
 Evidence supporting the effects of probiotics in preventing or treating diarrhoea related to cancer treatment is insufficient. However, probiotics appear to be safe, as no studies have found severe side effects.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.801Z" }, { "id": "0845ca18-581f-4df8-b6eb-24f777254e79", "pmid": "", "title": "Donepezil for dementia due to Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Alzheimer's disease is the most common cause of dementia in older people. One approach to symptomatic treatment of Alzheimer's disease is to enhance cholinergic neurotransmission in the brain by blocking the action of the enzyme responsible for the breakdown of the neurotransmitter acetylcholine. This can be done by a group of drugs known as cholinesterase inhibitors. Donepezil is a cholinesterase inhibitor. This review is an updated version of a review first published in 1998. Objectives To assess the clinical efficacy and safety of donepezil in people with mild, moderate or severe dementia due to Alzheimer's disease; to compare the efficacy and safety of different doses of donepezil; and to assess the effect of donepezil on healthcare resource use and costs. Search methods We searched Cochrane Dementia and Cognitive Improvement’s Specialized Register, MEDLINE, Embase, PsycINFO and a number of other sources on 20 May 2017 to ensure that the search was as comprehensive and up‐to‐date as possible. In addition, we contacted members of the Donepezil Study Group and Eisai Inc. Selection criteria We included all double‐blind, randomised controlled trials in which treatment with donepezil was administered to people with mild, moderate or severe dementia due to Alzheimer's disease for 12 weeks or more and its effects compared with those of placebo in a parallel group of patients, or where two different doses of donepezil were compared. Data collection and analysis One reviewer (JSB) extracted data on cognitive function, activities of daily living, behavioural symptoms, global clinical state, quality of life, adverse events, deaths and healthcare resource costs. Where appropriate and possible, we estimated pooled treatment effects. We used GRADE methods to assess the quality of the evidence for each outcome. Main results Thirty studies involving 8257 participants met the inclusion criteria of the review, of which 28 studies reported results in sufficient detail for the meta‐analyses. Most studies were of six months' duration or less. Only one small trial lasted 52 weeks. The studies tested mainly donepezil capsules at a dose of 5 mg/day or 10 mg/day. Two studies tested a slow‐release oral formulation that delivered 23 mg/day. Participants in 21 studies had mild to moderate disease, in five studies moderate to severe, and in four severe disease. Seventeen studies were industry funded or sponsored, four studies were funded independently of industry and for nine studies there was no information on source of funding. Our main analysis compared the safety and efficacy of donepezil 10 mg/day with placebo at 24 to 26 weeks of treatment. Thirteen studies contributed data from 3396 participants to this analysis. Eleven of these studies were multicentre studies. Seven studies recruited patients with mild to moderate Alzheimer's disease, two with moderate to severe, and four with severe Alzheimer's disease, with a mean age of about 75 years. Almost all evidence was of moderate quality, downgraded due to study limitations. After 26 weeks of treatment, donepezil compared with placebo was associated with better outcomes for cognitive function measured with the Alzheimer's Disease Assessment Scale‐Cognitive (ADAS‐Cog, range 0 to 70) (mean difference (MD) ‐2.67, 95% confidence interval (CI) ‐3.31 to ‐2.02, 1130 participants, 5 studies), the Mini‐Mental State Examination (MMSE) score (MD 1.05, 95% CI 0.73 to 1.37, 1757 participants, 7 studies) and the Severe Impairment Battery (SIB, range 0 to 100) (MD 5.92, 95% CI 4.53 to 7.31, 1348 participants, 5 studies). Donepezil was also associated with better function measured with the Alzheimer's Disease Cooperative Study activities of daily living score for severe Alzheimer's disease (ADCS‐ADL‐sev) (MD 1.03, 95% CI 0.21 to 1.85, 733 participants, 3 studies). A higher proportion of participants treated with donepezil experienced improvement on the clinician‐rated global impression of change scale (odds ratio (OR) 1.92, 95% CI 1.54 to 2.39, 1674 participants, 6 studies). There was no difference between donepezil and placebo for behavioural symptoms measured by the Neuropsychiatric Inventory (NPI) (MD ‐1.62, 95% CI ‐3.43 to 0.19, 1035 participants, 4 studies) or by the Behavioural Pathology in Alzheimer's Disease (BEHAVE‐AD) scale (MD 0.4, 95% CI ‐1.28 to 2.08, 194 participants, 1 study). There was also no difference between donepezil and placebo for Quality of Life (QoL) (MD ‐2.79, 95% CI ‐8.15 to 2.56, 815 participants, 2 studies). Participants receiving donepezil were more likely to withdraw from the studies before the end of treatment (24% versus 20%, OR 1.25, 95% CI 1.05 to 1.50, 2846 participants, 12 studies) or to experience an adverse event during the studies (72% vs 65%, OR 1.59, 95% 1.31 to 1.95, 2500 participants, 10 studies). There was no evidence of a difference between donepezil and placebo for patient total healthcare resource utilisation. Three studies compared donepezil 10 mg/day to donepezil 5 mg/day over 26 weeks. The 5 mg dose was associated with slightly worse cognitive function on the ADAS‐Cog, but not on the MMSE or SIB, with slightly better QoL and with fewer adverse events and withdrawals from treatment. Two studies compared donepezil 10 mg/day to donepezil 23 mg/day. There were no differences on efficacy outcomes, but fewer participants on 10 mg/day experienced adverse events or withdrew from treatment. Authors' conclusions There is moderate‐quality evidence that people with mild, moderate or severe dementia due to Alzheimer's disease treated for periods of 12 or 24 weeks with donepezil experience small benefits in cognitive function, activities of daily living and clinician‐rated global clinical state. There is some evidence that use of donepezil is neither more nor less expensive compared with placebo when assessing total healthcare resource costs. Benefits on 23 mg/day were no greater than on 10 mg/day, and benefits on the 10 mg/day dose were marginally larger than on the 5 mg/day dose, but the rates of withdrawal and of adverse events before end of treatment were higher the higher the dose. Plain language summary Donepezil for people with dementia due to Alzheimer's disease Review question What effects (benefits or harms) does donepezil have on people with dementia due to Alzheimer's disease? Background Alzheimer's disease is the most common cause of dementia. As the disease progresses, people lose the ability to remember, communicate, think clearly and perform the activities of daily living. Their behaviour may also change. In severe Alzheimer's disease people lose the ability to care for themselves. The most commonly used treatment for Alzheimer's disease are medicines known as acetylcholinesterase inhibitors. Donepezil is one of these medicines. It is taken as a pill once a day. In Alzheimer's disease, one of the changes in the brain is a reduced number of nerve cells called cholinergic neurones. These are nerve cells that signal to other cells using a chemical called acetylcholine. Acetylcholinesterase inhibitors, such as donepezil, work by preventing acetylcholine from being broken down. This may improve the symptoms of dementia. However, acetylcholine is also found elsewhere in the body and so drugs of this type may have unwanted effects. Review methods In this review we examined evidence about benefits and harms from studies that compared donepezil, taken for at least 12 weeks, to placebo (a dummy pill), or that compared different doses of donepezil. The studies had to be double‐blind and randomised, that is, the decision whether people taking part got donepezil or placebo had to be made randomly and neither they nor the researchers should have known which treatment they were getting while the trial was going on. This was to make the comparison as unbiased, or fair, as possible. We searched for studies up to May 2017. We assessed the quality of all the studies we included. When it was sensible to do so, we analysed the results of studies together to get an overall result. Key results We included 30 studies with 8257 participants. Most of the people in the studies had mild or moderate dementia due to Alzheimer's disease, but in nine studies they had moderate or severe dementia. Almost all of the studies lasted six months or less. The majority of the studies were known to have been funded by the manufacturer of donepezil. We found that people with Alzheimer's disease who took 10 mg of donepezil a day for six months did slightly better than people taking placebo, on scales measuring their cognitive function (e.g. thinking and remembering), how well they could manage their daily activities, and the overall impression of a trained researcher. We did not find any effect on behaviour or quality of life. People taking donepezil were more likely than those taking placebo to report side effects and to drop out of the studies. Most side effects were described as mild. Nausea, vomiting and diarrhoea were most common. Comparing 5 mg of donepezil a day with 10 mg/day, people on 5 mg had fewer side effects, but did slightly less well on cognitive function tests. A higher dose (23 mg/day) offered no advantages and was associated with more side effects. There is some evidence that use of donepezil is neither more nor less expensive than placebo when total health care costs are taken into account. Quality of the evidence In general, we thought that the quality of the evidence was moderate. The main factor reducing our confidence was concern that the results of some studies might have been biased by the way they were done. We cannot be sure that the results apply to treatment longer than six months. Conclusions After six months of treatment, there are benefits of donepezil that are large enough to measure in studies. It is associated with side effects that are mainly mild, but that may cause people to stop treatment. Being able to stabilise cognitive performance or ability to maintain activities of daily living may be important clinically. In terms of total healthcare costs the use of donepezil appears cost neutral. However, there does not appear to be an effect on quality of life. More data are still required from longer‐term clinical studies examining measures of disease progression or time to needing full time care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Birks, JS; Harvey, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD001190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "08627108-4d28-4316-bdd9-56bf15f37b46", "pmid": "", "title": "Inhaled hyperosmolar agents for bronchiectasis", "imported": false, "abstract": "Abstract - Background Mucus retention in the lungs is a prominent feature of bronchiectasis. The stagnant mucus becomes chronically colonised with bacteria, which elicit a host neutrophilic response. This fails to eliminate the bacteria, and the large concentration of host‐derived protease may contribute to the airway damage. The sensation of retained mucus is itself a cause of suffering, and the failure to maintain airway sterility probably contributes to the frequent respiratory infections experienced by many patients. Hypertonic saline inhalation is known to accelerate tracheobronchial clearance in many conditions, probably by inducing a liquid flux into the airway surface, which alters mucus rheology in a way favourable to mucociliary clearance. Inhaled dry powder mannitol has a similar effect. Such agents are an attractive approach to the problem of mucostasis, and deserve further clinical evaluation. Objectives To determine whether inhaled hyperosmolar substances are effective in the treatment of bronchiectasis. Search methods We searched the Cochrane Airways Group Specialised Register, trials registries, and the reference lists of included studies and review articles. Searches are current up to April 2014. Selection criteria Any randomised controlled trial (RCT) using hyperosmolar inhalation in patients with bronchiectasis not caused by cystic fibrosis. Data collection and analysis Two review authors assessed studies for suitability. We used standard methods recommended by The Cochrane Collaboration. Main results Eleven studies met the inclusion criteria of the review (1021 participants). Five studies on 833 participants compared inhaled mannitol with placebo but poor outcome reporting meant we could pool very little data and most outcomes were reported by only one study. One 12‐month trial on 461 participants provided results for exacerbations and demonstrated an advantage for mannitol in terms of time to first exacerbation (median time to exacerbation 165 versus 124 days for mannitol and placebo respectively (hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.63 to 0.96, P = 0.022) and number of days on antibiotics for bronchiectasis exacerbations was significantly better with mannitol (risk ratio (RR) 0.76, 95%CI 0.58 to 1.00, P = 0.0496). However, exacerbation rate per year was not significantly different between mannitol and placebo (RR 0.92 95% CI 0.78 to 1.08). The quality of this evidence was rated as moderate. There was also an indication, from only three trials, again based on moderate quality evidence, that mannitol improves health‐related quality of life (mean difference (MD) ‐2.05; 95% CI ‐3.69 to ‐0.40). An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo (OR 0.96; 95% CI 0.61 to 1.51). Two additional small trials on 25 participants compared mannitol versus no treatment and the data from these studies were inconclusive. Four studies (combined N = 113) compared hypertonic saline versus isotonic saline. On most outcomes there were conflicting results and the opportunities for the statistical aggregation of data from studies was very limited. It is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Authors' conclusions There is an indication from a single, large, unpublished study that inhaled mannitol increases time to first exacerbation in patients with bronchiectasis. In patients with near normal lung function, spirometry does not change dramatically with mannitol and adverse events are not more frequent than placebo. Further investigation is required in a patient population with impaired lung function. It is not possible to draw firm conclusions regarding the effect of nebulised hypertonic saline due to significant differences in the methodology, patient groups, and findings amongst the limited data available. The data suggest that it is unlikely to have benefit over isotonic saline in patients with milder disease, and hence future studies should test its use in those with more severe disease Plain language summary Inhaled hyperosmolar agents for bronchiectasis Review question We wanted to know if inhaled hyperosmolar agents ‐ treatments which help people cough up sputum ‐ may be helpful for people with bronchiectasis. We only included trials on people who had bronchiectasis and who did not have cystic fibrosis. Therefore we are unable to draw any conclusions for people with cystic fibrosis. Background Bronchiectasis is a lung condition that usually develops after a series of lung problems (such as childhood infections, problems in the lung structure, tuberculosis, and cystic fibrosis). A lot of mucus (phlegm) collects in the lungs, causing discomfort and the need to cough it up. The phlegm also collects bacteria, which can add to breathing difficulties and make people very ill by causing recurring lung infections that are difficult to clear with antibiotics. Breathing in (inhaling) hypertonic saline (salt solutions with a greater salt content than blood) liquids may help clear this mucus, as may the drug mannitol (inhaled in dry powder form). This is because the concentrated salt or sugar (mannitol) draws water into the mucus in the lung and makes it thinner and easier to cough out. Study characteristics We found 11 randomised controlled trials on 1021 participants that compared inhaled hyperosmolar agents versus no mucolytic treatment. Five studies compared inhaled mannitol versus placebo (with a total of 883 participants) and two very small studies (with a total of just 25 participants) compared inhaled mannitol with no treatment. We also found four studies (with a total of 113 participants) that compared hypertonic saline with isotonic (normal) saline. Key results For the comparison between mannitol and placebo only one study (a 12‐month trial with 461 participants) provided information on the number of people who had an exacerbation (or flare up) over the course of a year. This study showed that people who were treated with mannitol had 8% fewer exacerbations on average compared with placebo. Overall, we felt the quality of this evidence was moderate and new trials would be likely to change either how effective we think the treatment is or how confident we are about it. Three trials assessed the effect of mannitol on health‐related quality of life, and again the quality of the evidence was rated as moderate. An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo The trials comparing hypertonic saline with isotonic saline had conflicting results for most of the outcomes of interest. Because we were unable to combine the data, it is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Our analysis of adverse events between hypertonic saline versus isotonic saline showed no significant difference however this was based on a single study and the quality of the evidence was moderate. Quality of the evidence Details of how the patients in the trials were allocated to receive mannitol or not was clearly described in only one of the studies, and similarly only one of the hypertonic saline versus isotonic saline studies provided this information. The general lack of information on this point was considered carefully in the review in relation to our level of uncertainty in interpreting the results. Taking this into account, the quality of evidence was generally regarded as moderate both for the mannitol and hypertonic saline studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hart, A, Sugumar, K, Milan, SJ, Fowler, SJ, Crossingham, I", "articleTypes": [], "doi": "10.1002/14651858.CD002996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.791Z" }, { "id": "086e2dd5-9571-4dc8-beee-f0e2149ecb85", "pmid": "", "title": "Interventions for American cutaneous and mucocutaneous leishmaniasis", "imported": false, "abstract": "Abstract - Background On the American continent, cutaneous and mucocutaneous leishmaniasis (CL and MCL) are diseases associated with infection by several species of Leishmania parasites. Pentavalent antimonials remain the first‐choice treatment. There are alternative interventions, but reviewing their effectiveness and safety is important as availability is limited. This is an update of a Cochrane Review first published in 2009. Objectives To assess the effects of interventions for all immuno‐competent people who have American cutaneous and mucocutaneous leishmaniasis (ACML). Search methods We updated our database searches of the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and CINAHL to August 2019. We searched five trials registers. Selection criteria Randomised controlled trials (RCTs) assessing either single or combination treatments for ACML in immuno‐competent people, diagnosed by clinical presentation and Leishmania infection confirmed by smear, culture, histology, or polymerase chain reaction on a biopsy specimen. The comparators were either no treatment, placebo only, or another active compound. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our key outcomes were the percentage of participants 'cured' at least three months after the end of treatment, adverse effects, and recurrence. We used GRADE to assess evidence certainty for each outcome. Main results We included 75 studies (37 were new), totalling 6533 randomised participants with ATL. The studies were mainly conducted in Central and South America at regional hospitals, local healthcare clinics, and research centres. More male participants were included (mean age: roughly 28.9 years (SD: 7.0)). The most common confirmed species were L. braziliensis , L. panamensis , and L. mexicana . The most assessed interventions and comparators were non‐antimonial systemics (particularly oral miltefosine) and antimonials (particularly meglumine antimoniate (MA), which was also a common intervention), respectively. Three studies included moderate‐to‐severe cases of mucosal leishmaniasis but none included cases with diffuse cutaneous or disseminated CL, considered the severe cutaneous form. Lesions were mainly ulcerative and located in the extremities and limbs. The follow‐up (FU) period ranged from 28 days to 7 years. All studies had high or unclear risk of bias in at least one domain (especially performance bias). None of the studies reported the degree of functional or aesthetic impairment, scarring, or quality of life. Compared to placebo, at one‐year FU, intramuscular (IM) MA given for 20 days to treat L. braziliensis and L. panamensis infections in ACML may increase the likelihood of complete cure (risk ratio (RR) 4.23, 95% confidence interval (CI) 0.84 to 21.38; 2 RCTs, 157 participants; moderate‐certainty evidence), but may also make little to no difference, since the 95% CI includes the possibility of both increased and reduced healing (cure rates), and IMMA probably increases severe adverse effects such as myalgias and arthralgias (RR 1.51, 95% CI 1.17 to 1.96; 1 RCT, 134 participants; moderate‐certainty evidence). IMMA may make little to no difference to the recurrence risk, but the 95% CI includes the possibility of both increased and reduced risk (RR 1.79, 95% CI 0.17 to 19.26; 1 RCT, 127 participants; low‐certainty evidence). Compared to placebo, at six‐month FU, oral miltefosine given for 28 days to treat L. mexicana , L. panamensis and L. braziliensis infections in American cutaneous leishmaniasis (ACL) probably improves the likelihood of complete cure (RR 2.25, 95% CI 1.42 to 3.38), and probably increases nausea rates (RR 3.96, 95% CI 1.49 to 10.48) and vomiting (RR 6.92, 95% CI 2.68 to 17.86) (moderate‐certainty evidence). Oral miltefosine may make little to no difference to the recurrence risk (RR 2.97, 95% CI 0.37 to 23.89; low‐certainty evidence), but the 95% CI includes the possibility of both increased and reduced risk (all based on 1 RCT, 133 participants). Compared to IMMA, at 6 to 12 months FU, oral miltefosine given for 28 days to treat L. braziliensis , L. panamensis , L. guyanensis and L. amazonensis infections in ACML may make little to no difference to the likelihood of complete cure (RR 1.05, 95% CI 0.90 to 1.23; 7 RCTs, 676 participants; low‐certainty evidence). Based on moderate‐certainty evidence (3 RCTs, 464 participants), miltefosine probably increases nausea rates (RR 2.45, 95% CI 1.72 to 3.49) and vomiting (RR 4.76, 95% CI 1.82 to 12.46) compared to IMMA. Recurrence risk was not reported. For the rest of the key comparisons, recurrence risk was not reported, and risk of adverse events could not be estimated. Compared to IMMA, at 6 to 12 months FU, oral azithromycin given for 20 to 28 days to treat L. braziliensis infections in ACML probably reduces the likelihood of complete cure (RR 0.51, 95% CI 0.34 to 0.76; 2 RCTs, 93 participants; moderate‐certainty evidence). Compared to intravenous MA (IVMA) and placebo, at 12 month FU, adding topical imiquimod to IVMA, given for 20 days to treat L. braziliensis , L. guyanensis and L. peruviana infections in ACL probably makes little to no difference to the likelihood of complete cure (RR 1.30, 95% CI 0.95 to 1.80; 1 RCT, 80 participants; moderate‐certainty evidence). Compared to MA, at 6 months FU, one session of local thermotherapy to treat L. panamensis and L. braziliensis infections in ACL reduces the likelihood of complete cure (RR 0.80, 95% CI 0.68 to 0.95; 1 RCT, 292 participants; high‐certainty evidence). Compared to IMMA and placebo, at 26 weeks FU, adding oral pentoxifylline to IMMA to treat CL (species not stated) probably makes little to no difference to the likelihood of complete cure (RR 0.86, 95% CI 0.63 to 1.18; 1 RCT, 70 participants; moderate‐certainty evidence). Authors' conclusions Evidence certainty was mostly moderate or low, due to methodological shortcomings, which precluded conclusive results. Overall, both IMMA and oral miltefosine probably result in an increase in cure rates, and nausea and vomiting are probably more common with miltefosine than with IMMA. Future trials should investigate interventions for mucosal leishmaniasis and evaluate recurrence rates of cutaneous leishmaniasis and its progression to mucosal disease. Plain language summary What are the benefits and risks of different treatments for American (muco)cutaneous leishmaniasis (a parasitic disease of the skin and mucous membranes)? Why this question is important American (muco)cutaneous leishmaniasis (ACML) is a disfiguring disease that affects people in Central and South America. It is caused by parasites that are transmitted to humans by sandflies. Different forms of ACML have different symptoms. People with the cutaneous form develop skin sores that often heal within a few months without treatment, but can leave scars. In people with mucosal or mucocutaneous leishmaniasis, destructive sores develop in the protective lining (mucous membranes) of the nose, mouth and throat. To compare the effectiveness and risks of the many treatments for ACML, we reviewed evidence from research studies (randomised controlled trials). We looked for information on the proportion of people whose sores had healed three months or more after treatment, unwanted effects, quality of life, re‐appearance of sores, damage associated with the disease and prevention of scarring. How we identified and assessed the evidence First, we searched for all relevant studies. We then compared the results, summarised the evidence, and assessed the certainty of the evidence. What we found We found 75 studies on 6533 people (approximately 75% male; average age: 29 years). ‐ One study investigated children (2 to 12 years).
‐ Most studies (67) involved people with cutaneous leishmaniasis.
‐ Eight studies investigated people with mucosal or mucocutaneous leishmaniasis.
‐ The parasite Leishmania braziliensis caused the disease in 52 studies.
‐ Studies were conducted at regional hospitals, local clinics, and research centres.
‐ Studies lasted between 28 days and seven years.
‐ Most studies reported their funding source: the US army funded eight studies, industry funded 10, and institutional grants funded 33 (five of these also reported industry funding). Treatments were mainly compared to a placebo (fake treatment) or meglumine antimoniate (an antimonial). Here we report this review's main results. We were only able to report the risk of recurrence and side effects for the comparisons of meglumine antimoniate (MA) or miltefosine versus placebo and miltefosine versus MA. Main results Antimonials Compared to placebo, MA may increase chances of complete healing of ACML, but treatment effects vary, so it is possible that it may make little to no difference. MA probably increases the likelihood of pain in the muscles or joints. There may be little to no difference in the risk of developing the disease again, but there is also a possibility of increased or reduced risk due to the wide range of effects seen. Non‐antimonials Miltefosine probably improves chances of complete healing of American cutaneous leishmaniasis (ACL) compared to placebo, but there may be little to no difference compared to treatment with MA in ACML. Miltefosine may make little to no difference to the risk of developing ACL again when compared to placebo, but treatment effects on recurrence varied, so it may also increase or decrease the risk. Miltefosine probably increases the likelihood of vomiting or nausea when compared to either placebo or MA in ACML. We do not know the effect on recurrence of miltefosine compared to MA. Azithromycin probably reduces chances of complete healing of ACML compared to MA. Imiquimod in combination with MA probably makes little to no difference to the chance of complete healing of ACL compared to MA in combination with placebo. Physical therapies Thermotherapy lowers the chance of complete healing of ACL compared to MA. Immuno‐chemotherapy Pentoxifylline plus MA probably makes little to no difference to chances of complete healing of ACML compared with MA plus placebo. No study reported information about damage, prevention of scarring, or quality of life. What this means The main findings of this review suggest that: ‐ MA and miltefosine probably increase chances of complete healing; and
‐ vomiting or nausea are probably more common with miltefosine, and joint or muscle ache is probably more common with MA. The evidence was mostly of moderate certainty, so the true results are likely close to what we found. Evidence was limited by the inclusion of very few people in some studies, and participants or investigators knowing which treatments they were receiving. How‐up‐to date is this review? The evidence in this Cochrane Review is current to August 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Pinart, M; Rueda, J-R; Romero, GAS; Pinzón-Flórez, CE; Osorio-Arango, K; Silveira Maia-Elkhoury, AN; Reveiz, L; Elias, VM; Tweed, JA", "articleTypes": [], "doi": "10.1002/14651858.CD004834.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "086f6fec-cdf8-49b5-9c66-0f6bb2b59d14", "pmid": "", "title": "Antibiotic strategies for eradicating Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Respiratory tract infections with Pseudomonas aeruginosa occur in most people with cystic fibrosis (CF). Established chronic P aeruginosa infection is virtually impossible to eradicate and is associated with increased mortality and morbidity. Early infection may be easier to eradicate. This is an updated review. Objectives Does giving antibiotics for P aeruginosa infection in people with CF at the time of new isolation improve clinical outcomes (e.g. mortality, quality of life and morbidity), eradicate P aeruginosa infection, and delay the onset of chronic infection, but without adverse effects, compared to usual treatment or an alternative antibiotic regimen? We also assessed cost‐effectiveness. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings. Latest search: 24 March 2022. We searched ongoing trials registries. Latest search: 6 April 2022. Selection criteria We included randomised controlled trials (RCTs) of people with CF, in whom P aeruginosa had recently been isolated from respiratory secretions. We compared combinations of inhaled, oral or intravenous (IV) antibiotics with placebo, usual treatment or other antibiotic combinations. We excluded non‐randomised trials and cross‐over trials. Data collection and analysis Two authors independently selected trials, assessed risk of bias and extracted data. We assessed the certainty of the evidence using GRADE. Main results We included 11 trials (1449 participants) lasting between 28 days and 27 months; some had few participants and most had relatively short follow‐up periods. Antibiotics in this review are: oral – ciprofloxacin and azithromycin; inhaled – tobramycin nebuliser solution for inhalation (TNS), aztreonam lysine (AZLI) and colistin; IV – ceftazidime and tobramycin. There was generally a low risk of bias from missing data. In most trials it was difficult to blind participants and clinicians to treatment. Two trials were supported by the manufacturers of the antibiotic used. TNS versus placebo TNS may improve eradication; fewer participants were still positive for P aeruginosa at one month (odds ratio (OR) 0.06, 95% confidence interval (CI) 0.02 to 0.18; 3 trials, 89 participants; low‐certainty evidence) and two months (OR 0.15, 95% CI 0.03 to 0.65; 2 trials, 38 participants). We are uncertain whether the odds of a positive culture decrease at 12 months (OR 0.02, 95% CI 0.00 to 0.67; 1 trial, 12 participants). TNS (28 days) versus TNS (56 days) One trial (88 participants) comparing 28 days to 56 days TNS treatment found duration of treatment may make little or no difference in time to next isolation (hazard ratio (HR) 0.81, 95% CI 0.37 to 1.76; low‐certainty evidence). Cycled TNS versus culture‐based TNS One trial (304 children, one to 12 years old) compared cycled TNS to culture‐based therapy and also ciprofloxacin to placebo. We found moderate‐certainty evidence of an effect favouring cycled TNS therapy (OR 0.51, 95% CI 0.31 to 0.82), although the trial publication reported age‐adjusted OR and no difference between groups. Ciprofloxacin versus placebo added to cycled and culture‐based TNS therapy One trial (296 participants) examined the effect of adding ciprofloxacin versus placebo to cycled and culture‐based TNS therapy. There is probably no difference between ciprofloxacin and placebo in eradicating P aeruginosa (OR 0.89, 95% CI 0.55 to 1.44; moderate‐certainty evidence). Ciprofloxacin and colistin versus TNS We are uncertain whether there is any difference between groups in eradication of P aeruginosa at up to six months (OR 0.43, 95% CI 0.15 to 1.23; 1 trial, 58 participants) or up to 24 months (OR 0.76, 95% CI 0.24 to 2.42; 1 trial, 47 participants); there was a low rate of short‐term eradication in both groups. Ciprofloxacin plus colistin versus ciprofloxacin plus TNS One trial (223 participants) found there may be no difference in positive respiratory cultures at 16 months between ciprofloxacin with colistin versus TNS with ciprofloxacin (OR 1.28, 95% CI 0.72 to 2.29; low‐certainty evidence). TNS plus azithromycin compared to TNS plus oral placebo Adding azithromycin may make no difference to the number of participants eradicating P aeruginosa after a three‐month treatment phase (risk ratio (RR) 1.01, 95% CI 0.75 to 1.35; 1 trial, 91 participants; low‐certainty evidence); there was also no evidence of any difference in the time to recurrence. Ciprofloxacin and colistin versus no treatment A single trial only reported one of our planned outcomes; there were no adverse effects in either group. AZLI for 14 days plus placebo for 14 days compared to AZLI for 28 days We are uncertain whether giving 14 or 28 days of AZLI makes any difference to the proportion of participants having a negative respiratory culture at 28 days (mean difference (MD) ‐7.50, 95% CI ‐24.80 to 9.80; 1 trial, 139 participants; very low‐certainty evidence). Ceftazidime with IV tobramycin compared with ciprofloxacin (both regimens in conjunction with three months colistin) IV ceftazidime with tobramycin compared with ciprofloxacin may make little or no difference to eradication of P aeruginosa at three months, sustained to 15 months, provided that inhaled antibiotics are also used (RR 0.84, 95 % CI 0.65 to 1.09; P = 0.18; 1 trial, 255 participants; high‐certainty evidence). The results do not support using IV antibiotics over oral therapy to eradicate P aeruginosa , based on both eradication rate and financial cost. Authors' conclusions We found that nebulised antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with P aeruginosa . Eradication may be sustained in the short term. There is insufficient evidence to determine whether these antibiotic strategies decrease mortality or morbidity, improve quality of life, or are associated with adverse effects compared to placebo or standard treatment. Four trials comparing two active treatments have failed to show differences in rates of eradication of P aeruginosa . One large trial showed that intravenous ceftazidime with tobramycin is not superior to oral ciprofloxacin when inhaled antibiotics are also used. There is still insufficient evidence to state which antibiotic strategy should be used for the eradication of early P aeruginosa infection in CF, but there is now evidence that intravenous therapy is not superior to oral antibiotics. Plain language summary Different ways of giving antibiotics to clear Pseudomonas aeruginosa infection in people with cystic fibrosis Key messages ‐ Cystic fibrosis (CF) is an inherited condition where the airways often become blocked with mucus, and people with CF are more likely to get chest infections which cause more damage to the lungs. ‐ Pseudomonas aeruginosa ( P aeruginosa ) is often the cause of infection and is difficult to get rid of; antibiotics are the main treatment, but there are many different antibiotics, and they can be given in different ways. ‐ Inhaled antibiotics may be better than no treatment allowing most people to remain free of P aeruginosa after one month. ‐ There seems to be little difference in the other treatments we compared regarding how well they clear P aeruginosa from the lungs. What is cystic fibrosis? CF is the most common inherited condition that is life‐limiting. Sticky mucus builds up in the lungs of people with CF, which makes it difficult to breathe and can lead to chest infections. These chest infections can cause further lung damage and lead to breathing failure and death. A germ called P aeruginosa is often the cause of infection and is difficult to treat successfully, once it has persisted for longer than six months. What did we want to find out? We wanted to compare different combinations of inhaled, oral and intravenous (IV) antibiotics for clearing P aeruginosa in people with CF, to see if any single treatment works best and is more cost‐effective. What did we find? The review includes 11 studies with a total of 1449 people with CF, of any age or sex, who had mild to severe lung disease. The studies lasted from 28 days to 27 months. We could not combine many results as studies used different treatments. There were 10 different comparisons of antibiotic treatments: three studies compared inhaled antibiotics with a placebo (dummy treatment); two studies compared inhaled antibiotics for different lengths of time; two studies compared inhaled tobramycin with or without oral antibiotics depending on how the infection was detected; two studies compared inhaled antibiotics plus an oral antibiotic with inhaled antibiotics plus a placebo; one study compared two different inhaled antibiotics plus an oral antibiotic; and one study compared IV antibiotics with oral antibiotics. Most of the studies showed how well the treatments got rid of P aeruginosa as well as how they affected lung function, other germs, worsening of flare‐ups, and side effects. Main results Three small studies (of 89 people) treating early infection showed that after one month, inhaled antibiotics were better than no treatment and cleared P aeruginosa in most people, but our confidence in the evidence is low. There is likely to be little difference in the other treatments regarding how well they clear P aeruginosa from the lungs, although we found that inhaled antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with Pseudomonas aeruginosa. A study of IV ceftazidime with tobramycin in comparison with oral ciprofloxacin also showed neither group was better at getting rid of P aeruginosa, but we are more certain of the results and this means that it may be just as effective to treat with oral antibiotics. What are the limitations of the evidence? Some studies were carried out up to 30 years ago and the results may not apply today, and some studies were small. Most studies were quite short, so we could not show whether treatment made people with CF feel better or live longer. Given the treatments used in most of the studies, it would have been easy for people to guess which treatment they were receiving, which might have influenced some of the results. Two studies were supported by the pharmaceutical industry. Further research is needed to see whether clearing the infection completely improves the well‐being and quality of life in people with CF and to establish which antibiotic combination is best at clearing P aeruginosa . Overall our confidence in the evidence was moderate to very low, so further research is likely to change our confidence in the results. However, we have higher confidence in one recently published study, which means we can be more sure of the results. How up to date is this evidence? The studies we have reported on are the most up‐to‐date we could find. We last searched the literature in April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Langton Hewer, SC; Smith, S; Rowbotham, NJ; Yule, A; Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD004197.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "088a855c-96d5-4fe1-8dbe-013a93ac889a", "pmid": "", "title": "Determination of Perinatal Exposure to Non-caloric Sweeteners. Implications for the Development of Preferences for Sweet Taste, and Weight Gain During the First Year of Life", "imported": false, "abstract": "During last years, non-caloric sweeteners (NCSs) have been increasingly incorporated into foodstuffs in replacement of sucrose in Chile. This situation has reached a point where it is currently difficult to find sugary foods without NCSs. As a result, the voluntary and involuntary consumption of these additives is growing significantly in the population, increasing the risk of exceeding the acceptable daily intake (ADI), especially for children. This situation is worrying as recent evidence suggests that NCSs are not inert in the body and can trigger adverse metabolic effects. For example, the consumption of beverages with NCSs has been shown to favor the development of obesity and type-2 diabetes in children and adults, and a recent study reported that the intake of NCSs during pregnancy was associated with a greater weight gain of the child at one year. It is likely that certain NCSs pass into the amniotic fluid and that the fetus is exposed to some of these compounds during pregnancy. This situation would persist in the infant through breast milk, as some studies detected sucralose and acesulfame-K in this fluid, even in mothers who claimed not to consume them. However, the real impact of NCS exposure during the neonatal period on the child health has been few studied. Therefore, the aim of this study is to determine the concentration of NCSs in samples of amniotic liquid and breastmilk and to correlate these data with the NCS intake by the mothers. Mothers/children will be classified in quintiles according to the results obtained. In the children from quintiles 1 and 5, we will also study whether neonatal exposure to NCSs may affect the sweet taste threshold and the preferences for this taste, the levels of salivary insulin and the weight gain in the first year. Breastmilk microbiota and child fecal microbiota will be also evaluated.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.236Z" }, { "id": "089c077b-bad3-4540-906e-f58a58b132ac", "pmid": "", "title": "Cannabis‐based medicines and medical cannabis for adults with cancer pain", "imported": false, "abstract": "Abstract - Background Pain is a common symptom in people with cancer; 30% to 50% of people with cancer will experience moderate‐to‐severe pain. This can have a major negative impact on their quality of life. Opioid (morphine‐like) medications are commonly used to treat moderate or severe cancer pain, and are recommended for this purpose in the World Health Organization (WHO) pain treatment ladder. Pain is not sufficiently relieved by opioid medications in 10% to 15% of people with cancer. In people with insufficient relief of cancer pain, new analgesics are needed to effectively and safely supplement or replace opioids. Objectives To evaluate the benefits and harms of cannabis‐based medicines, including medical cannabis, for treating pain and other symptoms in adults with cancer compared to placebo or any other established analgesic for cancer pain. Search methods We used standard, extensive Cochrane search methods. The latest search date was 26 January 2023. Selection criteria We selected double‐blind randomised, controlled trials (RCT) of medical cannabis, plant‐derived and synthetic cannabis‐based medicines against placebo or any other active treatment for cancer pain in adults, with any treatment duration and at least 10 participants per treatment arm. Data collection and analysis We used standard Cochrane methods. The primary outcomes were 1. proportions of participants reporting no worse than mild pain; 2. Patient Global Impression of Change (PGIC) of much improved or very much improved and 3. withdrawals due to adverse events. Secondary outcomes were 4. number of participants who reported pain relief of 30% or greater and overall opioid use reduced or stable; 5. number of participants who reported pain relief of 30% or greater, or 50% or greater; 6. pain intensity; 7. sleep problems; 8. depression and anxiety; 9. daily maintenance and breakthrough opioid dosage; 10. dropouts due to lack of efficacy; 11. all central nervous system adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We identified 14 studies involving 1823 participants. No study assessed the proportions of participants reporting no worse than mild pain on treatment by 14 days after start of treatment. We found five RCTs assessing oromucosal nabiximols (tetrahydrocannabinol (THC) and cannabidiol (CBD)) or THC alone involving 1539 participants with moderate or severe pain despite opioid therapy. The double‐blind periods of the RCTs ranged between two and five weeks. Four studies with a parallel design and 1333 participants were available for meta‐analysis. There was moderate‐certainty evidence that there was no clinically relevant benefit for proportions of PGIC much or very much improved (risk difference (RD) 0.06, 95% confidence interval (CI) 0.01 to 0.12; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 8 to 100). There was moderate‐certainty evidence for no clinically relevant difference in the proportion of withdrawals due to adverse events (RD 0.04, 95% CI 0 to 0.08; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 16 to endless). There was moderate‐certainty evidence for no difference between nabiximols or THC and placebo in the frequency of serious adverse events (RD 0.02, 95% CI −0.03 to 0.07). There was moderate‐certainty evidence that nabiximols and THC used as add‐on treatment for opioid‐refractory cancer pain did not differ from placebo in reducing mean pain intensity (standardised mean difference (SMD) −0.19, 95% CI −0.40 to 0.02). There was low‐certainty evidence that a synthetic THC analogue (nabilone) delivered over eight weeks was not superior to placebo in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and non‐small cell lung cancer (2 studies, 89 participants, qualitative analysis). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that synthetic THC analogues were superior to placebo (SMD −0.98, 95% CI −1.36 to −0.60), but not superior to low‐dose codeine (SMD 0.03, 95% CI −0.25 to 0.32; 5 single‐dose trials; 126 participants) in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours (2 single‐dose trials; 66 participants). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that CBD oil did not add value to specialist palliative care alone in the reduction of pain intensity in people with advanced cancer. There was no difference in the number of dropouts due to adverse events and serious adverse events (1 study, 144 participants, qualitative analysis). We found no studies using herbal cannabis. Authors' conclusions There is moderate‐certainty evidence that oromucosal nabiximols and THC are ineffective in relieving moderate‐to‐severe opioid‐refractory cancer pain. There is low‐certainty evidence that nabilone is ineffective in reducing pain associated with (radio‐) chemotherapy in people with head and neck cancer and non‐small cell lung cancer. There is low‐certainty evidence that a single dose of synthetic THC analogues is not superior to a single low‐dose morphine equivalent in reducing moderate‐to‐severe cancer pain. There is low‐certainty evidence that CBD does not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. Plain language summary Cannabis‐based medicines for cancer pain Do medicines based on cannabis help adults with cancer pain? Key messages Cannabis‐based medicines (CbMs) did not relieve cancer pain that did not respond to morphine‐like medicines. The studies analysed did not allow any statement to be made on the place of these medications in the World Health Organization (WHO) analgesic ladder for cancer pain. Trials with CbMs in cancer need to be very much better designed than those conducted so far. Pain in cancer and its treatment One person in two or three who gets cancer will have pain that becomes moderate or severe in intensity. The pain tends to get worse as the cancer progresses. The WHO recommends taking morphine‐like medicines for moderate‐to‐severe pain from cancer, but 1 in 6 to 10 people with cancer pain do not experience sufficient pain relief from morphine‐like medicines. Several products based on the cannabis plant have been suggested as treatment for cancer pain. These products include inhaled or orally ingested herbal cannabis, and various oils, sprays or tablets containing active cannabis ingredients obtained from the plant, or made synthetically. Some people with cancer pain have reported that CbMs are effective for them, and that is often highlighted in the media. What did we want to find out? If CbMs relieved cancer pain in people living with cancer. If CbMs were associated with any unwanted or harmful effects. What did we do? We searched for clinical trials that examined CbMs compared to other medications to treat cancer pain in adults. We summarised the results of the studies and rated our confidence in the evidence, based on factors such as the methods and size of studies. What did we find? We found 14 studies involving 1823 people. The biggest study included 399 people and the smallest study included 10 people. Studies were conducted in countries around the world; most (six) were based in North America. Five studies used one dose of CbM and lasted less than one day. Other studies lasted between two and eight weeks. Pharmaceutical companies funded seven studies. Six studies compared a mouth spray with a plant‐derived combination of tetrahydrocannabinol (THC), the principal psychoactive constituent of cannabis, and cannabidiol (CBD), an anti‐inflammatory ingredient of cannabis, against a fake medication (placebo). Seven studies compared an artificial cannabinoid mimicking the effects of THC against placebo. Of these seven studies, two studies compared against a morphine‐like medication (codeine), too. One study compared CBD against placebo. We did not find studies with herbal cannabis. Main results Mouth spray with a plant‐derived combination of THC and CBD was probably not better than placebo in reducing pain in people with moderate‐to‐severe cancer pain despite opioid treatment. Thirty‐two out of 100 people reported to be much or very much improved by cannabis‐based mouth spray and 23 out of 100 people with mouth spray with placebo. A total of 19 out of 100 people withdrew early because of side effects by cannabis‐based mouth spray and 16 out of 100 people by mouth spray with placebo. There was no difference in serious side effects between the cannabis‐based mouth spray and a placebo mouth spray. Artificial cannabinoid mimicking the effects of THC may not be better than a fake medication in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and a certain type of lung cancer. A single dose of an artificial cannabinoid mimicking the effects of THC may be better than a single dose of placebo, but may not differ from a single small dose of a morphine‐like medication in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours. CBD may not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. We found no studies with medical cannabis. What are the limitations of the evidence? We are moderately confident in the evidence that a mouth spray with a plant‐derived combination of THC and CBD does not reduce severe cancer pain despite opioid treatment because studies did not provide information about everything that we could have used. We have little confidence in the evidence that an artificial cannabinoid mimicking the effects of THC (nabilone) does not reduce pain associated with chemotherapy or radiochemotherapy because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that artificial cannabinoids mimicking the effects of THC reduce cancer pain after the previous pain‐relieving medication was stopped some hours before because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that CBD added to standard palliative care does not reduce cancer pain because there was only one study available. How up to date is the evidence? The evidence is up to date to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Häuser, W, Welsch, P, Radbruch, L, Fisher, E, Bell, RF, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD014915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.750Z" }, { "id": "08abcc02-7b32-4e53-871a-440b4f3a56f9", "pmid": "", "title": "Chinese medicinal herbs for cholelithiasis", "imported": false, "abstract": "Abstract - Background Cholelithiasis is a common disease of the biliary tract. Chinese medicinal herbs are being used widely as an alternative treatment in people with cholelithiasis, but their beneficial or harmful effects have not been assessed systematically. Objectives To assess the beneficial and harmful effects of Chinese medicinal herbs in people with cholelithiasis. Search methods We conducted searches in the Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, Science Citation Index Expanded, Chinese Medicine Conference Disc, and Chinese Bio‐Medicine Disc to January 2013. We handsearched four Chinese journals. No language or year of publication restrictions were applied. Selection criteria Randomised clinical trials studying Chinese medicinal herbs for treatment of cholelithiasis. Data collection and analysis Two review authors (SJ, TG) independently extracted data. For dichotomous data, we estimated the risk ratio (RR), and for continuous data, we calculated the mean difference. We also calculated 95% confidence intervals (CI). Main results Eleven randomised trials with 1205 participants with asymptomatic or mild‐to‐moderate cholelithiasis were included. None of the randomised clinical trials compared a single Chinese medicinal herb with a Western medicine or with surgery. No placebo‐controlled trials were identified. In the trials comparing one Chinese herbal medicine (Gandanxiaoshi tablet) versus another (Aihuodantong tablet), there was no significant difference in the improvement of upper abdominal pain after the end of treatment (RR 1.21; 95% CI 0.71 to 2.05), and the heterogeneity among trials was not substantial. No other outcomes could be assessed. The remaining trials of Chinese medicinal herbs (Qingdan capsule, Danshu capsule, Paishi capsule, Rongdanpaishi capsule), did not offer specific data on symptoms, signs, or change in gallstones that would permit assessment of significant differences in curative effects between the treatment and control groups. No serious adverse events were reported. Authors' conclusions This review reveals no strong evidence that the analysed Chinese medicinal herbs have any beneficial effects on asymptomatic or mild‐to‐moderate cholelithiasis. Definitive conclusions will require much better designed randomised trials to reduce risk of bias and allow detailed assessment of clinical outcomes. Plain language summary Chinese medicinal herbs for cholelithiasis Cholelithiasis (gallstone disease) causes significant morbidity, severe complications, and economic burden worldwide. Though current surgical therapies are effective for gallstones, some types of gallstones (e.g., calcium bilirubinate calculi) cannot easily be eradicated by surgery and they often recur in the bile duct system, putting people at high risk of severe complications. The objective of this review was to evaluate the benefits and harms of Chinese medicinal herbs for people with cholelithiasis. Though some Chinese medicinal herbs appear to be safe for people with asymptomatic, mild, or moderate disease, they have not been conclusively shown to have curative effects on gallstones due to the low methodological quality (high risk of bias) of the included trials. Thus, randomised clinical trials with low risk of bias should be conducted to assess the effects of Chinese medicinal herbs before they can be used widely in the clinic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Gan, T, Chen, J, Jin, SJ, Wang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD004547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.739Z" }, { "id": "08cd35a8-b91d-4b99-8897-0918e47883cc", "pmid": "", "title": "Anabolic‐androgenic steroids for alcoholic liver disease", "imported": false, "abstract": "Abstract - Background Alcohol is one of the most common causes of liver disease in the Western World. Randomised clinical trials have examined the effects of anabolic‐androgenic steroids for alcoholic liver disease. Objectives To assess the beneficial and harmful effects of anabolic‐androgenic steroids for patients with alcoholic liver disease based on the results of randomised clinical trials. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Controlled Trials Register in The Cochrane Library , MEDLINE , EMBASE, LILACS, and Science Citation Index Expanded until June 2006. Electronic searches were combined with full text searches. Manufacturers and researchers in the field were also contacted. Selection criteria Randomised clinical trials studying patients with alcoholic steatosis, alcoholic fibrosis, alcoholic hepatitis, and/or alcoholic cirrhosis were included. Interventions encompassed anabolic‐androgenic steroids at any dose or duration versus placebo or no intervention. The trials could be double blind, single blind, or unblinded. The trials could be unpublished or published, and no language limitations were applied. Data collection and analysis Outcomes are assessed at maximal follow‐up. All analyses were performed according to the intention‐to‐treat method. The statistical package RevMan Analyses was used. The methodological quality of the randomised clinical trials was assessed. Main results Combining the results of five randomised clinical trials randomising 499 patients with alcoholic hepatitis and/or cirrhosis demonstrated no significant effects of anabolic‐androgenic steroids on mortality (relative risk (RR) 1.01, 95% confidence interval (CI) 0.79 to 1.29), liver‐related mortality (RR 0.83, 95% CI 0.60 to 1.15), complications of liver disease (RR 1.25, 95% CI 0.74 to 2.10), and liver histology. Anabolic‐androgenic steroids did not significantly affect a number of other outcome measures, including sexual function and liver biochemistry. Anabolic‐androgenic steroids were not associated with a significantly increased risk of non‐serious adverse events (RR 1.14, 95% CI 0.50 to 2.59) or with serious adverse events (RR 4.54, 95% CI 0.57 to 36.30). Authors' conclusions This systematic review could not demonstrate any significant beneficial effects of anabolic‐androgenic steroids on any clinically important outcomes (mortality, liver‐related mortality, liver complications, and histology) of patients with alcoholic liver disease. Plain language summary No evidence to support anabolic‐androgenic steroids for alcoholic liver disease Alcohol causes a major part of the liver diseases in the Western World. Several trials have addressed the effects of anabolic‐androgenic steroids for alcoholic liver disease. This systematic review could not demonstrate any significant effects of anabolic‐androgenic steroids on mortality, liver‐related mortality, liver complications, and histology of patients with alcoholic liver disease. Anabolic‐androgenic steroid intervention is not associated with a significant increase in non‐serious adverse events, but with the seldom occurrence of serious adverse events. Accordingly, there is no evidence supporting the use of anabolic‐androgenic steroids for alcoholic liver disease, but further randomised clinical trials may be needed to settle the question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Rambaldi, A, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD003045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.784Z" }, { "id": "08d3c647-365b-4bd2-8497-7b3e69ec9409", "pmid": "", "title": "Interventions for deliberately altering blood pressure in acute stroke", "imported": false, "abstract": "Abstract - Background It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001 and 2008. Objectives To assess the clinical effectiveness of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke. Search methods We searched the Cochrane Stroke Group Trials Register (last searched in February 2014), the Cochrane Database of Systematic reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 2), MEDLINE (Ovid) (1966 to May 2014), EMBASE (Ovid) (1974 to May 2014), Science Citation Index (ISI, Web of Science, 1981 to May 2014) and the Stroke Trials Registry (searched May 2014). Selection criteria Randomised controlled trials of interventions that aimed to alter blood pressure compared with control in participants within one week of acute ischaemic or haemorrhagic stroke. Data collection and analysis Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data. The review authors cross‐checked data and resolved discrepancies by discussion to reach consensus. We obtained published and unpublished data where available. Main results We included 26 trials involving 17,011 participants (8497 participants were assigned active therapy and 8514 participants received placebo/control). Not all trials contributed to each outcome. Most data came from trials that had a wide time window for recruitment; four trials gave treatment within six hours and one trial within eight hours. The trials tested alpha‐2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide‐like diuretics, and target‐driven blood pressure lowering. One trial tested phenylephrine. At 24 hours after randomisation oral ACEIs reduced systolic blood pressure (SBP, mean difference (MD) ‐8 mmHg, 95% confidence interval (CI) ‐17 to 1) and diastolic blood pressure (DBP, MD ‐3 mmHg, 95% CI ‐9 to 2), sublingual ACEIs reduced SBP (MD ‐12.00 mm Hg, 95% CI ‐26 to 2) and DBP (MD ‐2, 95%CI ‐10 to 6), oral ARA reduced SBP (MD ‐1 mm Hg, 95% CI ‐3 to 2) and DBP (MD ‐1 mm Hg, 95% CI ‐3 to 1), oral beta blockers reduced SBP (MD ‐14 mm Hg; 95% CI ‐27 to ‐1) and DBP (MD ‐1 mm Hg, 95% CI ‐9 to 7), intravenous (iv) beta blockers reduced SBP (MD ‐5 mm Hg, 95% CI ‐18 to 8) and DBP (‐5 mm Hg, 95% CI ‐13 to 3), oral CCBs reduced SBP (MD ‐13 mmHg, 95% CI ‐43 to 17) and DBP (MD ‐6 mmHg, 95% CI ‐14 to 2), iv CCBs reduced SBP (MD ‐32 mmHg, 95% CI ‐65 to 1) and DBP (MD ‐13, 95% CI ‐31 to 6), NO donors reduced SBP (MD ‐12 mmHg, 95% CI ���19 to ‐5) and DBP (MD ‐3, 95% CI ‐4 to ‐2) while phenylephrine, non‐significantly increased SBP (MD 21 mmHg, 95% CI ‐13 to 55) and DBP (MD 1 mmHg, 95% CI ‐15 to 16). Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05), stroke type (OR 0.98, 95% CI 0.92 to 1.05) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05). Treatment within six hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99) but not death (OR 0.70, 95% CI 0.38 to 1.26) at the end of the trial. Although death or dependency did not differ between people who continued pre‐stroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24), disability scores at the end of the trial were worse in participants randomised to continue treatment (Barthel Index, MD ‐3.2, 95% CI ‐5.8, ‐0.6). Authors' conclusions There is insufficient evidence that lowering blood pressure during the acute phase of stroke improves functional outcome. It is reasonable to withhold blood pressure‐lowering drugs until patients are medically and neurologically stable, and have suitable oral or enteral access, after which drugs can than be reintroduced. In people with acute stroke, CCBs, ACEI, ARA, beta blockers and NO donors each lower blood pressure while phenylephrine probably increases blood pressure. Further trials are needed to identify which people are most likely to benefit from early treatment, in particular whether treatment started very early is beneficial. Plain language summary Drug interventions for deliberately altering blood pressure in acute stroke Background: In people who have just had a stroke (a sudden brain attack due to either blockage or rupture of an artery in the brain), very high and very low blood pressures may be harmful. Therefore, drugs that raise low blood pressure or lower high blood pressure might be beneficial. Up to 50% of people admitted with acute stroke are taking blood pressure tablets on hospital admission and it is not clear whether these medications should be continued or discontinued in the acute situation. This review looked at those trials that deliberately altered blood pressure or compared continuing or stopping blood pressure‐lowering tablets taken before stroke. Study characteristics: This review is up‐to‐date to May 2014. We included 26 trials involving 17,011 participants: 24 trials assessed lowering blood pressure, one trial tested raising blood pressure, and two trials assessed what to do with drugs taken before stroke. All studies took place in hospitals that were used to treating people with stroke. Not all trials contributed information to all outcomes, and we have used data that were available in publications. Key results: There is insufficient evidence to say that lowering blood pressure saves lives or reduces disability in people with acute stroke. Immediately restarting blood pressure‐lowering drugs taken before the stroke may increase disability. Conclusion: More research is needed to identify those people who are most likely to benefit from altering blood pressure in acute stroke, the time window in which the treatment is likely to be of benefit, what types of stroke are likely to respond favourably, and the environment in which such treatment may be best given in routine practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bath, PMW, Krishnan, K", "articleTypes": [], "doi": "10.1002/14651858.CD000039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.729Z" }, { "id": "08e391ca-07e4-4175-b6cc-ad56ce212f71", "pmid": "", "title": "The effect of sample site and collection procedure on identification of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Sample collection is a key driver of accuracy in the diagnosis of SARS‐CoV‐2 infection. Viral load may vary at different anatomical sampling sites and accuracy may be compromised by difficulties obtaining specimens and the expertise of the person taking the sample. It is important to optimise sampling accuracy within cost, safety and accessibility constraints. Objectives To compare the sensitivity of different sampling collection sites and methods for the detection of current SARS‐CoV‐2 infection with any molecular or antigen‐based test. Search methods Electronic searches of the Cochrane COVID‐19 Study Register and the COVID‐19 Living Evidence Database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) were undertaken on 22 February 2022. We included independent evaluations from national reference laboratories, FIND and the Diagnostics Global Health website. We did not apply language restrictions. Selection criteria We included studies of symptomatic or asymptomatic people with suspected SARS‐CoV‐2 infection undergoing testing. We included studies of any design that compared results from different sample types (anatomical location, operator, collection device) collected from the same participant within a 24‐hour period. Data collection and analysis Within a sample pair, we defined a reference sample and an index sample collected from the same participant within the same clinical encounter (within 24 hours). Where the sample comparison was different anatomical sites, the reference standard was defined as a nasopharyngeal or combined naso/oropharyngeal sample collected into the same sample container and the index sample as the alternative anatomical site. Where the sample comparison was concerned with differences in the sample collection method from the same site, we defined the reference sample as that closest to standard practice for that sample type. Where the sample pair comparison was concerned with differences in personnel collecting the sample, the more skilled or experienced operator was considered the reference sample. Two review authors independently assessed the risk of bias and applicability concerns using the QUADAS‐2 and QUADAS‐C checklists, tailored to this review. We present estimates of the difference in the sensitivity (reference sample (%) minus index sample sensitivity (%)) in a pair and as an average across studies for each index sampling method using forest plots and tables. We examined heterogeneity between studies according to population (age, symptom status) and index sample (time post‐symptom onset, operator expertise, use of transport medium) characteristics. Main results This review includes 106 studies reporting 154 evaluations and 60,523 sample pair comparisons, of which 11,045 had SARS‐CoV‐2 infection. Ninety evaluations were of saliva samples, 37 nasal, seven oropharyngeal, six gargle, six oral and four combined nasal/oropharyngeal samples. Four evaluations were of the effect of operator expertise on the accuracy of three different sample types. The majority of included evaluations (146) used molecular tests, of which 140 used RT‐PCR (reverse transcription polymerase chain reaction). Eight evaluations were of nasal samples used with Ag‐RDTs (rapid antigen tests). The majority of studies were conducted in Europe (35/106, 33%) or the USA (27%) and conducted in dedicated COVID‐19 testing clinics or in ambulatory hospital settings (53%). Targeted screening or contact tracing accounted for only 4% of evaluations. Where reported, the majority of evaluations were of adults (91/154, 59%), 28 (18%) were in mixed populations with only seven (4%) in children. The median prevalence of confirmed SARS‐CoV‐2 was 23% (interquartile (IQR) 13%‐40%). Risk of bias and applicability assessment were hampered by poor reporting in 77% and 65% of included studies, respectively. Risk of bias was low across all domains in only 3% of evaluations due to inappropriate inclusion or exclusion criteria, unclear recruitment, lack of blinding, nonrandomised sampling order or differences in testing kit within a sample pair. Sixty‐eight percent of evaluation cohorts were judged as being at high or unclear applicability concern either due to inflation of the prevalence of SARS‐CoV‐2 infection in study populations by selectively including individuals with confirmed PCR‐positive samples or because there was insufficient detail to allow replication of sample collection. When used with RT‐PCR • There was no evidence of a difference in sensitivity between gargle and nasopharyngeal samples (on average ‐1 percentage points, 95% CI ‐5 to +2, based on 6 evaluations, 2138 sample pairs, of which 389 had SARS‐CoV‐2). • There was no evidence of a difference in sensitivity between saliva collection from the deep throat and nasopharyngeal samples (on average +10 percentage points, 95% CI ‐1 to +21, based on 2192 sample pairs, of which 730 had SARS‐CoV‐2). • There was evidence that saliva collection using spitting, drooling or salivating was on average ‐12 percentage points less sensitive (95% CI ‐16 to ‐8, based on 27,253 sample pairs, of which 4636 had SARS‐CoV‐2) compared to nasopharyngeal samples. We did not find any evidence of a difference in the sensitivity of saliva collected using spitting, drooling or salivating (sensitivity difference: range from ‐13 percentage points (spit) to –21 percentage points (salivate)). • Nasal samples (anterior and mid‐turbinate collection combined) were, on average, 12 percentage points less sensitive compared to nasopharyngeal samples (95% CI ‐17 to ‐7), based on 9291 sample pairs, of which 1485 had SARS‐CoV‐2. We did not find any evidence of a difference in sensitivity between nasal samples collected from the mid‐turbinates (3942 sample pairs) or from the anterior nares (8272 sample pairs). • There was evidence that oropharyngeal samples were, on average, 17 percentage points less sensitive than nasopharyngeal samples (95% CI ‐29 to ‐5), based on seven evaluations, 2522 sample pairs, of which 511 had SARS‐CoV‐2. A much smaller volume of evidence was available for combined nasal/oropharyngeal samples and oral samples. Age, symptom status and use of transport media do not appear to affect the sensitivity of saliva samples and nasal samples. When used with Ag‐RDTs • There was no evidence of a difference in sensitivity between nasal samples compared to nasopharyngeal samples (sensitivity, on average, 0 percentage points ‐0.2 to +0.2, based on 3688 sample pairs, of which 535 had SARS‐CoV‐2). Authors' conclusions When used with RT‐PCR, there is no evidence for a difference in sensitivity of self‐collected gargle or deep‐throat saliva samples compared to nasopharyngeal samples collected by healthcare workers when used with RT‐PCR. Use of these alternative, self‐collected sample types has the potential to reduce cost and discomfort and improve the safety of sampling by reducing risk of transmission from aerosol spread which occurs as a result of coughing and gagging during the nasopharyngeal or oropharyngeal sample collection procedure. This may, in turn, improve access to and uptake of testing. Other types of saliva, nasal, oral and oropharyngeal samples are, on average, less sensitive compared to healthcare worker‐collected nasopharyngeal samples, and it is unlikely that sensitivities of this magnitude would be acceptable for confirmation of SARS‐CoV‐2 infection with RT‐PCR. When used with Ag‐RDTs, there is no evidence of a difference in sensitivity between nasal samples and healthcare worker‐collected nasopharyngeal samples for detecting SARS‐CoV‐2. The implications of this for self‐testing are unclear as evaluations did not report whether nasal samples were self‐collected or collected by healthcare workers. Further research is needed in asymptomatic individuals, children and in Ag‐RDTs, and to investigate the effect of operator expertise on accuracy. Quality assessment of the evidence base underpinning these conclusions was restricted by poor reporting. There is a need for further high‐quality studies, adhering to reporting standards for test accuracy studies. Plain language summary How accurate are different types of sample collection for diagnosing COVID‐19 infection? Key messages • When used with RT‐PCR tests (a molecular test that detects genetic material in COVID‐19 using a technique called reverse transcription polymerase chain reaction), self‐collected gargle and deep throat saliva samples have a similar sensitivity compared to trained healthcare worker‐collected nasopharyngeal samples (taken from the back of the throat through the nose) in detecting COVID‐19. • When used with RT‐PCR, samples collected from the nose, oropharynx (throat via the mouth), oral cavity, and other saliva collection methods are less sensitive for detecting COVID‐19 compared to healthcare worker‐collected nasopharyngeal samples. • When used with rapid antigen tests (Ag‐RDTs; at‐home/self‐tests), samples collected from the nose have a similar sensitivity to healthcare worker‐collected nasopharyngeal samples in detecting COVID‐19. Why is improving the diagnosis of COVID‐19 important? Coronavirus disease (COVID‐19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). People with suspected COVID‐19 may decide to take a test to know whether they are infected, so that they can receive treatment, and follow recommended guidance to self‐isolate and inform close contacts. Not detecting COVID‐19 when it is present (a false negative result) risks spreading infection and results in missed opportunities for treatment. Types of sample collection methods for diagnosing COVID‐19? The type and quality of sample taken for confirmation of COVID‐19 affects the reliability of diagnosis. The most accurate type of sample to diagnose COVID‐19 is that taken by a trained healthcare worker from the back of the throat through the nose (a nasopharyngeal sample). This type of test detects genetic material in the virus using a technique called reverse transcription polymerase chain reaction (RT‐PCR). However, this sample is difficult to obtain correctly, causes discomfort and risks spreading infection if individuals cough or sneeze when the sample is taken. Alternative sample types, particularly those that can be self‐collected using rapid antigen tests (Ag‐RDTs; i.e. self‐tests), may reduce cost and discomfort and improve the safety of sampling. This may, in turn, improve access to and uptake of testing. What did we want to find out? We wanted to compare the sensitivity of different sample sites and collection methods in detecting COVID‐19 with molecular tests (RT‐PCR tests) or self‐based tests (Ag‐RDT tests). What did we do? We searched for studies that had compared the accuracy of nasopharyngeal samples to any alternative that could be used in patients outside of hospital, including nose (nasal) samples, throat samples taken through the mouth (oropharyngeal), gargle samples and saliva samples. We looked at the use of samples with either RT‐PCR or Ag‐RDTs. We also searched for studies that had compared different methods for taking samples, such as samples collected by a healthcare worker compared to those collected by individuals with no or minimal instructions. What did we find? The review included 106 studies with a total of 60,523 participants, of whom 11,045 had COVID‐19 infection. Fifty‐nine per cent of studies were conducted on adults and 79% on symptomatic or mixed symptomatic and asymptomatic participants. Sixty per cent of studies took place in Europe or the USA; just over half (55%) took place in dedicated COVID‐19 testing centres or in outpatient settings. Main results With RT‐PCR, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also test positive on self‐collected gargle samples or saliva samples (collected by coughing and then spitting (deep throat saliva)); ‐ 88% of positive nasopharyngeal samples collected by healthcare workers would also test positive with self‐ or healthcare worker‐collected nose samples; ‐ 87% of positive nasopharyngeal samples collected by healthcare workers would also be detected by saliva self‐collected using spitting, 84% by saliva self‐collected using drooling and 79% by saliva self‐collected by sucking on a swab; and ‐ 83% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐ or healthcare worker‐collected oropharyngeal samples. With Ag‐RDTs, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐collected or healthcare worker‐collected nose samples. Summary results The results of these studies indicate that in a group of 1000 people, of whom 230 (23%) have COVID‐19, then: when used with PCR, compared to healthcare worker‐collected nasopharyngeal samples: ‐ no cases of COVID‐19 would be missed using self‐collected gargle samples (12 less to 5 more) or deep throat saliva samples (2 less to 48 more); ‐ 28 (16 to 39) fewer cases of COVID‐19 infection would be detected using healthcare worker‐ or self‐collected nose sample; ‐ 30 (18 to 41) fewer cases of COVID‐19 infection would be detected by saliva self‐collected using spitting, 37 (12 to 62) fewer by saliva collected by drooling and 48 (12 to 85) fewer by saliva collected by sucking on a swab; ‐ 39 (12 to 67) fewer cases of COVID‐19 infection would be detected by healthcare worker‐ or self‐collected oropharyngeal samples; and when used with Ag‐RDTs, compared to healthcare worker‐collected nasopharyngeal samples: no cases of COVID‐19 infection would be missed using healthcare worker‐ or self‐collected nose samples. What are the limitations of the evidence? It was often not clear whether included studies deliberately excluded inadequate samples or whether the results of the more accurate nasopharyngeal sample were known when alternative samples were interpreted. This may have resulted in alternative sample types appearing more accurate than they are in practice, decreasing the number of missed cases of COVID‐19 infection. More than half of studies did not give information about how long participants had had symptoms at the time of sampling. This reduces our confidence in the comparison of different sample types. Most studies evaluated self‐collected samples by adults with symptoms for use with RT‐PCR; therefore, the findings of this review may not be applicable to asymptomatic individuals or children. For studies conducted with Ag‐RDTs, it is unclear whether sensitivity estimates of nose samples are applicable to home use (self‐collected and self‐interpreted). How up to date is this review? The evidence is current to 22 February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Davenport, C, Arevalo-Rodriguez, I, Mateos-Haro, M, Berhane, S, Dinnes, J, Spijker, R, Buitrago-Garcia, D, Ciapponi, A, Takwoingi, Y, Deeks, JJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014780", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.765Z" }, { "id": "08e81cb6-0b56-4e46-8df5-cb3736f440c1", "pmid": "", "title": "Antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze", "imported": false, "abstract": "Abstract - Background Worldwide, pneumonia is the leading cause of death amongst children under five years of age, and accounts for approximately two million deaths annually. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, and the severity of the disease. Treatment is then tailored according to the classification. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. The WHO recommends treating non‐severe pneumonia with oral antibiotics. Pneumonia is more commonly caused by viruses that do not require antibiotic treatment, but pneumonia caused by bacteria needs management with antibiotics to avoid complications. There is no clear way to quickly distinguish between viral and bacterial pneumonia. It is considered safe to give antibiotics, however, this may lead to the development of antibiotic resistance, and thus, limit their use in future infections. Therefore, it is essential to explore the efficacy of antibiotics for children with WHO‐defined non‐severe pneumonia and wheeze. Objectives To evaluate the efficacy of antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze. Search methods We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers (December 2020). Selection criteria We included randomised controlled trials (RCTs) evaluating the efficacy of antibiotic therapy versus no antibiotic therapy for children, aged 2 to 59 months, with non‐severe pneumonia and wheeze. We defined non‐severe pneumonia as 'a cough or difficulty in breathing, with rapid breathing (a respiratory rate of 50 breaths per minute or more for children aged 2 to 12 months, or a respiratory rate of 40 breaths per minute or more for children aged 12 to 59 months), chest indrawing and wheeze'. We excluded trials involving children with severe or very severe pneumonia, and non‐RCTs. Data collection and analysis Our primary outcomes were clinical cure and treatment failure; secondary outcomes were relapse, mortality, and treatment harms. We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Two review authors independently assessed the search results, extracted data, assessed risk of bias and the certainty of the evidence. We contacted the authors of two included trials and the author of the trial awaiting classification to obtain missing numerical outcome data. Main results We included three trials involving 3256 children aged between 2 to 59 months, who exhibited features of non‐severe pneumonia with wheeze. The included trials were multi‐centre, double‐blind, randomised, placebo‐controlled trials carried out in Malawi, Pakistan, and India. The children were treated with a three‐day course of amoxicillin or placebo, and were followed up for a total of two weeks. We assessed the included trials at overall low risk of bias for random sequence generation, allocation concealment, blinding, attrition bias, and selective reporting. Only one trial was assessed to be at high risk for blinding of outcome assessors. One trial is awaiting classification Antibiotic therapy may result in a reduction of treatment failure by 20% (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.68 to 0.94; three trials; 3222 participants; low‐certainty evidence). Antibiotic therapy probably results in little or no difference to clinical cure (RR 1.02, 95% CI 0.96 to 1.08; one trial; 456 participants; moderate‐certainty evidence), and in little or no difference to relapse (RR 1.00, 95% CI 0.74 to 1.34; three trials; 2795 participants; low‐certainty evidence), and treatment harms (RR 0.81, 95% CI 0.60 to 1.09; three trials, 3253 participants; low‐certainty evidence). Two trials (2112 participants ) reported on mortality; no deaths occurred in either group. One trial reported cases of hospitalisation, diarrhoea (with and without dehydration), rash (without itch), tremors, mild nausea and vomiting. Authors' conclusions We do not currently have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. There is a clear need for RCTs to address this question in children aged 2 to 59 months with 2014 WHO‐defined non‐severe pneumonia and wheeze. Plain language summary Comparing treatment of non‐severe pneumonia, in children aged 2 to 59 months, with and without antibiotics Review question 
We tried to identify whether there was a difference in the outcomes for children aged 2 to 59 months with non‐severe pneumonia and wheeze, treated with or without antibiotics. Background 
Pneumonia is an infection of the lungs. In children, it is one of the leading causes of deaths globally. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, severity of the disease and its treatment according to the severity. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. More commonly, pneumonia is caused by viruses that require supportive care rather than antibiotic treatment; however, pneumonia caused by bacteria should be treated with antibiotics to avoid complications. Since there is no clear way to quickly distinguish which organism actually caused the pneumonia, it is considered safe to give antibiotics. However, this may lead to the development of antibiotic resistance, and limit their use in future infections. The question is whether the use of antibiotics is justified in non‐severe pneumonia. Search date Our evidence is current to 23 December 2020. Study characteristics We included three trials (3256 children). They were conducted in four hospitals in three cities in Pakistan (Islamabad, Lahore and Rawalpindi), and in hospital outpatient departments in India and Malawi. The children were treated with a three‐day course of amoxicillin (antibiotic) or placebo, and followed up for two weeks. One trial is awaiting classification. Study funding source The included trials were supported by the USAID through INCLEN and IndiaClen; ARI Research Cell, Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and by a grant from the Bill & Melinda Gates Foundation. Key results Limited data showed a 20% reduction in treatment failure, however, no impact was observed on clinical cure, relapse, and treatment harms. No deaths were reported in either group. Our review did not have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. Certainty of the evidence The certainty of evidence for clinical cure was moderate. The certainty of evidence for treatment failure, relapse, and treatments harms was low, due to downgrading for imprecision and risk of bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lassi, ZS; Padhani, ZA; Das, JK; Salam, RA; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD009576.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "08e9c739-4798-4e87-a4b8-117dd8852cf4", "pmid": "", "title": "Green tea for weight loss and weight maintenance in overweight or obese adults", "imported": false, "abstract": "Abstract - Background Preparations of green tea are used as aids in weight loss and weight maintenance. Catechins and caffeine, both contained in green tea, are each believed to have a role in increasing energy metabolism, which may lead to weight loss. A number of randomised controlled trials (RCTs) evaluating the role of green tea in weight loss have been published; however, the efficacy of green tea preparations in weight loss remains unclear. Objectives To assess the efficacy and safety of green tea preparations for weight loss and weight maintenance in overweight or obese adults. Search methods We searched the following databases from inception to specified date as well as reference lists of relevant articles: The Cochrane Library (Issue 12, 2011), MEDLINE (December 2011), EMBASE (December 2011), CINAHL (January 2012), AMED (January 2012), Biological Abstracts (January 2012), IBIDS (August 2010), Obesity+ (January 2012), IPA (January 2012) and Web of Science (December 2011). Current Controlled Trials with links to other databases of ongoing trials was also searched. Selection criteria RCTs of at least 12 weeks' duration comparing green tea preparations to a control in overweight or obese adults. Data collection and analysis Three authors independently extracted data, assessed studies for risk of bias and quality, with differences resolved by consensus. Heterogeneity of included studies was assessed visually using forest plots and quantified using the I 2 statistic. We synthesised data using meta‐analysis and descriptive analysis as appropriate; subgroup and sensitivity analyses were conducted. Adverse effects reported in studies were recorded. Main results Due to the level of heterogeneity among studies, studies were divided into two groups; those conducted in Japan and those conducted outside Japan. Study length ranged between 12 and 13 weeks. Meta‐analysis of six studies conducted outside Japan showed a mean difference (MD) in weight loss of ‐0.04 kg (95% CI ‐0.5 to 0.4; P = 0.88; I 2 = 18%; 532 participants). The eight studies conducted in Japan were not similar enough to allow pooling of results and MD in weight loss ranged from ‐0.2 kg to ‐3.5 kg (1030 participants) in favour of green tea preparations. Meta‐analysis of studies measuring change in body mass index (BMI) conducted outside Japan showed a MD in BMI of ‐0.2 kg/m 2 (95% CI ‐0.5 to 0.1; P = 0.21; I 2 = 38%; 222 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed a reduction in BMI ranging from no effect to ‐1.3 kg/m 2 (1030 participants), in favour of green tea preparations over control. Meta‐analysis of five studies conducted outside Japan and measuring waist circumference reported a MD of ‐0.2 cm (95% CI ‐1.4 to 0.9; P = 0.70; I 2 = 58%; 404 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed effects on waist circumference ranging from a gain of 1 cm to a loss of 3.3 cm (1030 participants). Meta‐analysis for three weight loss studies, conducted outside Japan, with waist‐to‐hip ratio data (144 participants) yielded no significant change (MD 0; 95% CI ‐0.02 to 0.01). Analysis of two studies conducted to determine if green tea could help to maintain weight after a period of weight loss (184 participants) showed a change in weight loss of 0.6 to ‐1.6 kg, a change in BMI from 0.2 to ‐0.5 kg/m 2 and a change in waist circumference from 0.3 to ‐1.7 cm. In the eight studies that recorded adverse events, four reported adverse events that were mild to moderate, with the exception of two (green tea preparations group) that required hospitalisation (reported as not associated with the intervention). Nine studies reported on compliance/adherence, one study assessed attitude towards eating as part of the health‐related quality of life outcome. No studies reported on patient satisfaction, morbidity or cost. Authors' conclusions Green tea preparations appear to induce a small, statistically non‐significant weight loss in overweight or obese adults. Because the amount of weight loss is small, it is not likely to be clinically important. Green tea had no significant effect on the maintenance of weight loss. Of those studies recording information on adverse events, only two identified an adverse event requiring hospitalisation. The remaining adverse events were judged to be mild to moderate. Plain language summary Green tea for weight loss and weight maintenance in overweight or obese adults Green tea has a long history of many uses, one of which is helping overweight people to lose weight and to maintain weight loss. Believed to be able to increase a person's energy output, green tea weight loss preparations are extracts of green tea that contain a higher concentration of ingredients (catechins and caffeine) than the typical green tea beverage prepared from a tea bag and boiling water. This review looked at 15 weight loss studies and three studies measuring weight maintenance where some form of a green tea preparation was given to one group and results compared to a group receiving a control. Neither group knew whether they were receiving the green tea preparation or the control. A total of 1945 participants completed the studies, ranging in length from 12 to 13 weeks. In summary, the loss in weight in adults who had taken a green tea preparation was statistically not significant, was very small and is not likely to be clinically important. Similar results were found in studies that used other ways to measure loss in weight (body mass index, waist circumference). Studies examining the effect of green tea preparations on weight maintenance did not show any benefit compared to the use of a control preparation. Most adverse effects, such as nausea, constipation, abdominal discomfort and increased blood pressure, were judged to be mild to moderate and to be unrelated to the green tea or control intervention. No deaths were reported, although adverse events required hospitalisation. One study attempted to look at health‐related quality of life by asking participants about their attitudes towards eating. Nine studies tracked participants' compliance with green tea preparations. Studies did not include any information about the effects of green tea preparations on morbidity, costs or patient satisfaction.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Jurgens, TM, Whelan, AM, Killian, L, Doucette, S, Kirk, S, Foy, E", "articleTypes": [], "doi": "10.1002/14651858.CD008650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.107Z" }, { "id": "08edd46d-91f6-46d6-a8e2-52304ee344b8", "pmid": "", "title": "The Effect of Caloric and Non-caloric Sweeteners on Hunger, Gastrointestinal Hormones as Well as on Antral and Duodenal Motility", "imported": false, "abstract": "In this study, the investigators aimed at evaluating the role of sweet taste receptors in the gastrointestinal tract (GIT). Intragastric administration of glucose, fructose or acesulfame-K were compared with placebo administration for their effects on gastrointestinal motility, gut hormone release (motilin, ghrelin, glucagon-like peptide-1 (GLP-1) and insulin) and hunger feelings.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.237Z" }, { "id": "09038f35-b943-4b0b-b71b-b0d2f1c583e2", "pmid": "", "title": "Prostaglandins for management of retained placenta", "imported": false, "abstract": "Abstract - Background Retained placenta affects 0.5% to 3% of women following delivery and it is a major cause of maternal death due to postpartum haemorrhage. Usually, retained placenta has been managed by manual removal or curettage under anaesthesia, which may be associated with haemorrhage, infection and uterine perforation. Medical management to facilitate the delivery of the retained placenta could be a safe alternative avoiding surgical intervention. Objectives To assess the effectiveness and safety of prostaglandins for the management of retained placenta. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013), LILACS (1982 to 1 December 2013), SciELO (1998 to 1 December 2013), Web of Science (2001 to 1 December 2013), openSIGLE (1997 to 1 December 2013 ) , World Health Organization International Clinical Trials Registry Platform ( ICTRP ) (1 December 2013) and the metaRegister of Controlled Trials ( mRCT ) (1 December 2013) . We also contacted authors of included studies and reviewed the reference lists of retrieved studies. Selection criteria Randomised controlled clinical trials comparing the use of prostaglandins (or prostaglandin analogues) with placebo, expectant management, tocolytic drugs, any other prostaglandins or surgical interventions for the management of retained placenta after vaginal delivery of singleton live infants of 20 or more weeks of gestation. Data collection and analysis Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. Any disagreements were resolved through consensus or consultation with a third review author when required. Authors of the included studies were contacted for additional information. Main results We included three trials, involving 244 women. The studies were considered to be at high risk of bias. The prostaglandins used were PG E2 analogue (sulprostone) in 50 participants and PG E1 analogue (misoprostol) in 194 participants at a dose of 250 mcg and 800 mcg respectively. The prostaglandins compared with placebo, were not superior in reducing the rate of manual removal of placenta (average risk ratio (RR) 0.82; 95% confidence interval (CI) 0.54 to 1.27), severe postpartum haemorrhage (RR 0.80; 95% CI 0.55 to 1.15), need for blood transfusion (RR 0.72; 95% CI 0.43 to 1.22), mean blood loss (mean difference (MD) ‐205.26 mL; 95% CI ‐536.31 to 125.79, random‐effects) and the mean time from injection to placental removal (MD ‐7.00 minutes; 95% CI ‐21.20 to 7.20). Side‐effects were no different between groups (vomiting, headache, pain and nausea between injection and discharge from the labour ward), with the exception of shivering, which was more frequent in women receiving prostaglandins (RR 10.00; 95% CI 1.40 to 71.49). We did not obtain any data for the primary outcomes of maternal mortality and the need to add another therapeutic uterotonic. Authors' conclusions Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes) or side‐effects (vomiting, headache, pain and nausea between injection and discharge from the labour ward) except for 'shivering' which was more frequent in women who received prostaglandin. The included studies were of poor quality and there is little confidence in the effect estimates; the true effect is likely to be substantially different. We can not make any recommendations about changes to clinical practice. More high‐quality research in this area is needed. Plain language summary Prostaglandins for management of retained placenta Medical research evidence is sparse and insufficient to support the routine use of the prostaglandins for the management of retained placenta. Retained placenta affects 0.5% to 3% of women following delivery and is a major cause of maternal death caused by postpartum haemorrhage. A retained placenta is usually managed by manual removal or curettage under anaesthesia (which is not always immediately available). Surgical procedures themselves can be associated with haemorrhage and also infection and uterine perforation. Prostaglandins or their analogues, administered by any route, could be an alternative treatment especially in developing countries. Such medical management may facilitate the delivery of the retained placenta and be a safer alternative to surgery. The review identified three randomised controlled studies (involving 244 women) that compared the use of prostaglandins with placebo. Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and need for blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes). The prostaglandin was administered by intravenous infusion (E2 analogue sulprostone) in one study including 50 women and was orally or sublingually administered (E1 analogue misoprostol) in the other two studies including 194 women. Shivering was more frequent in women receiving the prostaglandin but there were no clear differences in vomiting, headache, maternal pain or nausea compared with placebo. The trials were small and of poor methodological quality. The quality of evidence is very low due to study limitations, inconsistency and imprecise results (few women and outcome events with wide confidence intervals). Two studies were stopped early due to an apparent benefit.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Grillo‐Ardila, CF, Ruiz‐Parra, AI, Gaitán, HG, Rodriguez‐Malagon, N", "articleTypes": [], "doi": "10.1002/14651858.CD010312.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.777Z" }, { "id": "0915ad42-1713-4d10-a985-86a833b1bfa9", "pmid": "", "title": "Antiamoebic drugs for treating amoebic colitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gonzales, MLM, Dans, LF, Sio‐Aguilar, J", "articleTypes": [], "doi": "10.1002/14651858.CD006085.pub3 AB - Abstract - Background Infection with the protozoan Entamoeba histolytica is common in low‐ and middle‐income countries, and up to 100,000 people with severe disease die every year. Adequate therapy for amoebic colitis is necessary to reduce illness, prevent development of complicated disease and extraintestinal spread, and decrease transmission. Objectives To evaluate antiamoebic drugs for treating amoebic colitis. Search methods We searched the available literature up to 22 March 2018. We searched the Cochrane Infectious Diseases Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, m RCT, and conference proceedings. We contacted individual researchers, organizations, and pharmaceutical companies, and we checked reference lists. Selection criteria Randomized controlled trials of antiamoebic drugs given alone or in combination, compared with placebo or another antiamoebic drug, for treating adults and children with a diagnosis of amoebic colitis. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of trials and extracted and analysed the data. We calculated clinical and parasitological failure rates and rates of relapse and adverse events as risk ratios (RRs) with 95% confidence intervals (CIs), using a random‐effects model. We determined statistical heterogeneity and explored possible sources of heterogeneity using subgroup analyses. We carried out sensitivity analysis by using trial quality to assess the robustness of reported results. Main results In total, 41 trials (4999 participants) met the inclusion criteria of this review. In this update, we added four trials to the 37 trials included in the first published review version. Thirty trials were published over 20 years ago. Only one trial used adequate methods of randomization and allocation concealment, was blinded, and analysed all randomized participants. Only one trial used an E histolytica stool antigen test, and two trials used amoebic culture. Tinidazole may be more effective than metronidazole for reducing clinical failure (RR 0.28, 95% CI 0.15 to 0.51; 477 participants, eight trials; low‐certainty evidence) and is probably associated with fewer adverse events (RR 0.65, 95% CI 0.46 to 0.92; 477 participants, 8 trials; moderate‐certainty evidence). Compared with metronidazole, combination therapy may result in fewer parasitological failures (RR 0.36, 95% CI 0.15 to 0.86; 720 participants, 3 trials; low‐certainty evidence), but we are uncertain which combination is more effective than another. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Authors' conclusions Compared with metronidazole, tinidazole may be more effective in reducing clinical failure and may be associated with fewer adverse events. Combination drug therapy may be more effective for reducing parasitological failure compared with metronidazole alone. However, these results are based mostly on small trials conducted over 20 years ago with a variety of poorly defined outcomes. Tests that detect E histolytica more accurately are needed, particularly in countries where concomitant infection with other bacteria and parasites is common. 11 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (22 Mar, 2018) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Antiamoebic drugs for treating amoebic colitis What is the aim of this review? This Cochrane Review aims to determine the effectiveness and safety of drugs used to treat people with amoebic colitis, which is an infection of the large intestines caused by the parasite, Entamoeba histolytica . Cochrane researchers searched for all relevant studies to answer this question and included 41 relevant studies in this review. Key messages Tinidazole may be more effective than metronidazole for reducing clinical symptoms and may be associated with fewer adverse events. Combination therapy resulted in fewer parasitological failures than occurred with metronidazole alone. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Better quality randomized trials using accurate diagnostic methods and standardized outcomes are needed to evaluate the efficacy of drugs for treating individuals with amoebic colitis. What was studied in the review? Entamoeba histolytica is distributed throughout the world and is commonly acquired by ingestion of contaminated food or water. An estimated 40 to 50 million people infected with E histolytica develop amoebic colitis or extraintestinal abscesses, resulting in up to 100,000 deaths per year. Metronidazole is currently the standard therapy for treating adults and children with invasive amoebiasis, but it may not be sufficient to eliminate amoebic cysts from the intestine. Some unpleasant adverse effects have been associated with metronidazole, and the possibility of parasite resistance to metronidazole has led to the development of alternative drugs. Combinations of metronidazole with other drugs that eradicate surviving cysts in the intestines have been recommended, so evidence to support this approach needs to be assessed. This review compares different drugs used against amoebic colitis, alone or in combination, and also assesses single‐dose regimens versus longer regimens. What are the main results of the review? This review included 41 studies, most of which were conducted in countries considered to be highly endemic for amoebiasis. Most trials were old: 30 were conducted before 1998. Trials varied in the inclusion criteria used to enrol participants and in the definition and timing of measured outcomes. Stool microscopy with direct wet saline smear was the method used most often to detect the presence of E histolytica in stools. Study participants ranged in age from seven months to 80 years. Included trials reported a variety of comparisons and involved 25 individual drugs, two herbal products, and 15 different combinations. The review shows that in individuals with amoebic colitis, tinidazole may be better for reducing clinical symptoms (low‐certainty evidence) and probably results in fewer adverse events when compared with metronidazole (moderate‐certainty evidence). However, we do not know whether it is more effective for eradicating amoebae from the stools. Combination drug therapy may be more effective than metronidazole alone for eradicating amoebae (low‐certainty evidence), but we are uncertain which drug combination is most effective, and if combination treatment will lead to more rapid resolution of clinical symptoms or in more adverse events (very low‐certainty evidence). Evidence is insufficient to allow conclusions regarding efficacy of the other antiamoebic drugs. How up‐to‐date is this review? 
 The review authors searched for studies that had been published up to 22 March 2018.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.064Z" }, { "id": "0920831c-f8f7-4d8c-9867-9a93ed6c8151", "pmid": "", "title": "Triclosan/copolymer containing toothpastes for oral health", "imported": false, "abstract": "Abstract - Background Periodontal disease and dental caries are highly prevalent oral diseases that can lead to pain and discomfort, oral hygiene and aesthetic problems, and eventually tooth loss, all of which can be costly to treat and are a burden to healthcare systems. Triclosan is an antibacterial agent with low toxicity, which, along with a copolymer for aiding retention, can be added to toothpastes to reduce plaque and gingivitis (inflammation of the gums). It is important that these additional ingredients do not interfere with the anticaries effect of the fluoride present in toothpastes, and that they are safe. Objectives To assess the effects of triclosan/copolymer containing fluoride toothpastes, compared with fluoride toothpastes, for the long‐term control of caries, plaque and gingivitis in children and adults. Search methods We searched the Cochrane Oral Health's Trials Register (to 19 August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 7), MEDLINE via OVID (1946 to 19 August 2013), Embase via OVID (1980 to 19 August 2013), and the US National Institutes of Health Trials Register ( clinicaltrials.gov ) (to 19 August 2013). We applied no restrictions regarding language or date of publication in the searches of the electronic databases. Selection criteria We included randomised controlled trials (RCTs) assessing the effects triclosan/copolymer containing toothpastes on oral health. Data collection and analysis Two review authors independently assessed the search results against the inclusion criteria for this review, extracted data and carried out risk of bias assessments. We attempted to contact study authors for missing information or clarification when feasible. We combined sufficiently similar studies in meta‐analyses using random‐effects models when there were at least four studies (fixed‐effect models when fewer than four studies), reporting mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data. Main results We included 30 studies, analysing 14,835 participants, in this review. We assessed 10 studies (33%) as at low risk of bias, nine (30%) as at high risk of bias and 11 (37%) as unclear. Plaque Compared with control, after six to seven months of use, triclosan/copolymer toothpaste reduced plaque by 0.47 on a 0 to 5 scale (MD ‐0.47, 95% confidence interval (CI) ‐0.60 to ‐0.34, 20 studies, 2675 participants, moderate‐quality evidence). The control group mean was 2.17, representing a 22% reduction in plaque. After six to seven months of use, it also reduced the proportion of sites scoring 3 to 5 on a 0 to 5 scale by 0.15 (MD ‐0.15, 95% CI ‐0.20 to ‐0.10, 13 studies, 1850 participants, moderate‐quality evidence). The control group mean was 0.37, representing a 41% reduction in plaque severity. Gingivitis After six to nine months of use, triclosan/copolymer toothpaste reduced inflammation by 0.27 on a 0 to 3 scale (MD ‐0.27, 95% CI ‐0.33 to ‐0.21, 20 studies, 2743 participants, moderate‐quality evidence). The control group mean was 1.22, representing a 22% reduction in inflammation. After six to seven months of use, it reduced the proportion of bleeding sites (i.e. scoring 2 or 3 on the 0 to 3 scale) by 0.13 (MD ‐0.13, 95% CI ‐0.17 to ‐0.08, 15 studies, 1998 participants, moderate‐quality evidence). The control group mean was 0.27, representing a 48% reduction in bleeding. Periodontitis After 36 months of use, there was no evidence of a difference between triclosan/copolymer toothpaste and control in the development of periodontitis (attachment loss) (RR 0.92, 95% CI 0.67 to 1.27, one study, 480 participants, low‐quality evidence). Caries After 24 to 36 months of use, triclosan/copolymer toothpaste slightly reduced coronal caries when using the decayed and filled surfaces (DFS) index (MD ‐0.16, 95% CI ‐0.31 to ‐0.02, four studies, 9692 participants, high‐quality evidence). The control group mean was 3.44, representing a 5% reduction in coronal caries. After 36 months of use, triclosan/copolymer toothpaste probably reduced root caries (MD ‐0.31, 95% CI ‐0.39 to ‐0.23, one study, 1357 participants, moderate‐quality evidence). Calculus After six months of use, triclosan/copolymer toothpaste may have reduced the mean total calculus per participant by 2.12 mm (MD ‐2.12 mm, 95% CI ‐3.39 to ‐0.84, two studies, 415 participants, low‐quality evidence). The control group mean was 14.61 mm, representing a 15% reduction in calculus. Adverse effects There were no data available for meta‐analysis regarding adverse effects, but 22 studies (73%) reported that there were no adverse effects caused by either the experimental or control toothpaste. There was considerable heterogeneity present in the meta‐analyses for plaque, gingivitis and calculus. Plaque and gingivitis showed such consistent results that it did not affect our conclusions, but the reader may wish to interpret the results with more caution. Authors' conclusions There was moderate‐quality evidence showing that toothpastes containing triclosan/copolymer, in addition to fluoride, reduced plaque, gingival inflammation and gingival bleeding when compared with fluoride toothpastes without triclosan/copolymer. These reductions may or may not be clinically important, and are evident regardless of initial plaque and gingivitis levels, or whether a baseline oral prophylaxis had taken place or not. High‐quality evidence showed that triclosan/copolymer toothpastes lead to a small reduction in coronal caries. There was weaker evidence to show that triclosan/copolymer toothpastes may have reduced root caries and calculus, but insufficient evidence to show whether or not they prevented periodontitis. There do not appear to be any serious safety concerns regarding the use of triclosan/copolymer toothpastes in studies up to three years in duration. Plain language summary Triclosan/copolymer containing toothpastes for oral health Review question This Cochrane Review has been conducted to assess the effects of using a toothpaste containing triclosan (an antibacterial ingredient) plus copolymer (an ingredient to reduce the amount of triclosan that is washed away by rinsing or saliva) plus fluoride (a mineral that prevents tooth decay) compared with using a fluoride toothpaste (without triclosan/copolymer) for oral health. Background Gum disease and dental decay are the main reasons for tooth loss. Unless brushed away, plaque (a sticky film containing bacteria) can build up on the teeth. This can lead to gingivitis (a swelling and redness of the gums that affects most adults), which, if not treated, can then lead to a more serious form of gum disease called periodontitis (which affects up to one out of every five adults aged 35 to 44 years worldwide). Periodontitis can cause pain, eating difficulties, an unpleasant facial appearance and eventually tooth loss. Plaque build‐up can also lead to tooth decay, a problem affecting up to 90% of schoolchildren in industrialised countries, and the majority of adults. Vast healthcare resources are used worldwide to treat gum disease and tooth decay, which are both preventable. Currently there is a lot of ongoing research into possible links between periodontitis and other medical conditions such as diabetes, rheumatoid arthritis, heart disease and also to the premature (too early) birth of underweight babies. Adding an effective and safe antibacterial ingredient to toothpastes could be an easy and low‐cost answer to these problems. It is thought that triclosan could fight the harmful bacteria in plaque while also reducing the swelling that leads to serious gum disease. It is important that adding triclosan to fluoride toothpastes does not reduce the beneficial effects that fluoride has on preventing tooth decay. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 19 August 2013. It includes 30 studies published from 1990 to 2012 in which 14,835 participants were randomised to receive a triclosan/copolymer containing fluoride toothpaste or a fluoride toothpaste that did not include triclosan/copolymer. The toothpaste that was used in most of the studies is sold by the manufacturer Colgate. Key results The evidence produced shows benefits in using a triclosan/copolymer fluoride toothpaste when compared with a fluoride toothpaste (without triclosan/copolymer). There was a 22% reduction in plaque, a 22% reduction in gingivitis, a 48% reduction in bleeding gums and a 5% reduction in tooth decay. There was insufficient evidence to show a difference between either toothpaste in preventing periodontitis. There was no evidence of any harmful effects associated with the use of triclosan/copolymer toothpastes in studies up to three years in length. Quality of the evidence The evidence relating to plaque and gingivitis was considered to be of moderate quality. The evidence on tooth decay was high quality, while the evidence on periodontitis was low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Riley, P, Lamont, T", "articleTypes": [], "doi": "10.1002/14651858.CD010514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.085Z" }, { "id": "0940fc6f-29f0-4fd7-88da-394b4b893905", "pmid": "", "title": "A Randomized Placebo-Controlled Study to Assess the Efficacy and Safety of AF-219, a P2X3 Receptor Antagonist, in Subjects With Idiopathic Pulmonary Fibrosis (IPF) With Persistent Cough", "imported": false, "abstract": "A randomized, double-blind, placebo-controlled, crossover, dose escalation study of gefapixant (AF-219) in participants with Idiopathic Pulmonary Fibrosis (IPF) with persistent cough.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.262Z" }, { "id": "09849a4e-6760-4ae0-9fe0-bef18c1a333e", "pmid": "", "title": "Interventions for cleaning dentures in adults", "imported": false, "abstract": "Abstract - Background Removing denture plaque may be essential for maintaining the oral health of edentulous people. Brushing and soaking in chemical products are two of the most commonly used methods of cleaning dentures. Objectives To evaluate the effectiveness and safety of different methods for cleansing removable dentures. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to May 2009); CENTRAL ( The Cochrane Library 2009, Issue 2); MEDLINE (1965 to May 2009); EMBASE (1980 to May 2009); LILACS (1980 to May 2009); and CINAHL (1997 to May 2009). There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing any mechanical method (e.g. brushing or ultrasound) or chemical (e.g. enzymes, sodium hypochlorite, oral rinses or peroxide solutions) in adults over the age of 18 wearing removable partial dentures or complete dentures. The primary outcomes considered were the health of denture bearing areas (soft tissues, periodontal tissues and teeth) and participants' satisfaction and preference. Secondary outcomes included denture plaque coverage area, indicators of halitosis and microbial counts on abutment teeth, soft tissues or denture base or saliva. Data collection and analysis Two independent review authors screened and extracted information from, and independently assessed the risk of bias in the included trials. Main results Although six RCTs were included in this review, the wide range of different interventions and outcome variables did not permit pooling of data in a meta‐analysis. Isolated reports indicated that chemicals and brushing appear to be more effective than placebo in the reduction of plaque coverage and microbial counts of anaerobes and aerobes on complete denture bases. Authors' conclusions There is a lack of evidence about the comparative effectiveness of the different denture cleaning methods considered in this review. Few well designed RCTs were found. Future research should focus on comparisons between mechanical and chemical methods; the assessment of the association of methods, primary variables and costs should also receive future attention. Plain language summary Interventions for cleaning dentures in adults Plaque formed on the surfaces of removable dentures can have a significant impact on oral health, as long as it can lead to infection of denture‐supporting mucosa (stomatitis), gum inflammation (gingivitis) and tooth decay. Denture plaque can be removed by several different methods which include: brushing with paste, soaking in chemicals (e.g. effervescent tablets or bleach) and using special devices (a microwave oven or ultrasonic device). This review found weak evidence in support of soaking of dentures in effervescent tablets or enzymatic solutions and that brushing with paste can remove plaque and kill microbes better than inactive treatments. It is, however, unclear which is the most effective and there is a paucity of data on the use of alternative methods. Futures studies should aim to provide reliable information about which method is more effective in maintaining oral health of removable denture wearers. The scarce data found was restricted to the cleansing of complete dentures made from an acrylic resin base. Further research should also investigate how removable partial dentures can be cleaned, and in particular on the corrosive effects of cleaners on their metallic components.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "de Souza, RF, de Freitas Oliveira Paranhos, H, Lovato da Silva, CH, Abu‐Naba'a, L, Fedorowicz, Z, Gurgan, CA", "articleTypes": [], "doi": "10.1002/14651858.CD007395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.745Z" }, { "id": "09acb8fe-87b6-44e7-b12d-a276e602f5c9", "pmid": "", "title": "Drugs for treating giardiasis", "imported": false, "abstract": "Abstract - Background Giardiasis infection may be asymptomatic, or can cause diarrhoea (sometimes severe), weight loss, malabsorption, and, in children, failure to thrive. It is usually treated with metronidazole given three times daily for five to 10 days. Objectives To evaluate the relative effectiveness of alternative antibiotic regimens for treating adults or children with symptomatic giardiasis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6 2012); MEDLINE, EMBASE, LILACS and the International Clinical Trials Registry Platform Search Portal (3 July 2012). Selection criteria We included randomized controlled trials (RCT) comparing metronidazole administered for five to 10 days with any of the following drugs: metronidazole (single dose), tinidazole, albendazole, mebendazole, and nitazoxanide. The primary outcomes were parasitological and clinical cure. Data collection and analysis Two authors independently assessed studies for inclusion, performed the risk of bias assessment, and extracted data. We summarized data using risk ratios and mean differences and we presented the results in forest plots and performed meta‐analyses where possible. We assessed heterogeneity using the Chi 2 test, I 2 statistic and visual inspection; and we explored this by using subgroup analyses.We assessed the quality of evidence by using the GRADE approach. Main results We included 19 trials, involving 1817 participants, of which 1441 were children. Studies were generally small, with poor methods reporting. . Most reported parasitological outcomes rather than clinical improvement. Ten trials, from India, Mexico, Peru, Iran, Cuba, and Turkey, compared albendazole (400 mg once daily for five to 10 days) with metronidazole (250 mg to 500 mg three times daily for five to 10 days). This once‐daily regimen of albendazole is probably equivalent to metronidazole at achieving parasitological cure (RR 0.99, 95% CI 0.95 to 1.03; 932 participants, 10 trials; moderate quality evidence ), and improving symptoms (RR 0.98, 95% confidence interval (CI) 0.93 to 1.04; 483 participants, five trials; moderate quality evidence ), but the duration of follow‐up was short (two to three weeks). Albendazole probably has fewer side effects than metronidazole (gastrointestinal side effects: RR 0.29, 95% CI 0.13 to 0.63; 717 participants, eight trials; moderate quality evidence ; neurological side effects: RR 0.34, 95% CI 0.18 to 0.64; 453 participants, five trials; low quality evidence ). Five trials from Turkey, Spain and the UK compared mebendazole (200 mg three times daily for five to 10 days) with metronidazole (5 mg/kg (or 250 mg) three times daily for five to 10 days). These trials were small in size, and at high risk of bias. Consequently, reliable conclusions on the relative effectiveness cannot be made ( very low quality evidence) . Five further trials, from Iran, Spain and Peru, have evaluated shortened regimens of tinidazole (single dose; 179 participants, three trials), metronidazole (single dose; 55 participants, one trial), and nitazoxanide (three days; 55 participants, one trial). Again, these trials were at high risk of bias and too small to reliably detect or exclude important differences ( very low quality evidence) . Authors' conclusions Albendazole may be of similar effectiveness to metronidazole, may have fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes (such as diarrhoea) will help assess further alternatives. 15 April 2019 Update pending Studies awaiting assessment The CIDG is currently examining a new search conducted in April 2019 for potentially relevant studies. These studies have not yet been incorporated into this Cochrane Review. Plain language summary Drugs for treating giardiasis Giardiasis is an infection of the small intestine caused by a microscopic organism called Giardia lamblia . The infection is passed from person to person by ingesting faecally contaminated water or food. Symptoms frequently include diarrhoea, abdominal pain, flatulence, bloating, vomiting, and weight loss. In this review, we assess alternatives to the most commonly used treatment for giardiasis; metronidazole given orally for five or more days. We identified 19 trials involving 1817 participants, of which 1441 were children. Most trials had a small number of participants and were at high risk of bias. Albendazole is probably of similar effectiveness to metronidazole, probably has fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes are required to assess further alternatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Granados, CE, Reveiz, L, Uribe, LG, Criollo, CP", "articleTypes": [], "doi": "10.1002/14651858.CD007787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.766Z" }, { "id": "09af0bb0-d499-4d93-bdb0-0b7a0b9401b8", "pmid": "", "title": "Lifestyle interventions for chronic gout", "imported": false, "abstract": "Abstract - Background Although lifestyle interventions are commonly recommended in the management of patients with chronic gout, the evidence from trial data for their benefits and safety has not been previously examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with chronic gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies on 5 April 2013. We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials (RCTs or CCTs) which compared lifestyle interventions to another therapy (active or placebo) in patients with chronic gout. Outcomes of interest were changes in gout attack frequency, joint pain, serum urate levels, tophus size, function, quality of life and adverse effects. Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (120 participants), at moderate risk of bias, was included in the review. Patients were randomised to one of three interventions: either skim milk powder (SMP) enriched with glycomacropeptide (GMP) and G600, non‐enriched SMP or lactose powder, over a three‐month period. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the three‐month study period. Low quality evidence indicated that there was no difference between the SMP/GMP/G600 group and combined control groups (SMP and lactose powder) at three months (mean difference (MD) ‐0.21, 95% confidence interval (CI) ‐0.76 to 0.34). There were no significant between‐group differences in terms of withdrawals due to adverse effects (risk ratio (RR) 1.27, 95% CI 0.53 to 3.03), and serious adverse events resulting in hospitalisation (2/40 SMP/GMP/G600 group versus 3/80 controls; RR 1.33, 95% CI 0.23 to 7.66). Gastrointestinal adverse effects were the most commonly reported. Pain from self reported gout flares, measured on a 10‐point Likert scale, improved more in the SMP/GMP/G600 group compared to controls (MD ‐1.03, 95% CI ‐1.96 to ‐0.10), an absolute difference of 10% (absolute risk difference ‐0.10, 95% CI ‐0.20 to ‐0.01). This is unlikely to be of clinical significance. There was no significant difference in physical function between SMP/GMP/G600 and the control groups at three‐month followup (MD ‐0.03, 95% CI ‐0.14 to 0.08). Tophus regression and serum urate normalisation were not reported in this study. Authors' conclusions While there is good evidence from observational studies of an association between various lifestyle risk factors and gout development, there is a paucity of high‐quality evidence from randomised controlled trials to either support or refute the use of lifestyle modifications for improving outcomes in people with chronic gout. Plain language summary Lifestyle interventions for chronic gout This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with chronic gout. There was one study included in this review which looked at the benefits and safety of consuming skim milk powder (SMP) enriched with two components of dairy products (glycomacropeptide (GMP) and G600 milk fat extract) compared to standard skim milk or lactose powder in reducing the frequency of gout attacks over a three‐month period. The review shows that, in people with chronic gout : Compared with standard skim milk or lactose powder, SMP enriched with GMP and G600 may not reduce the frequency of gout attacks, may not improve physical function, but may reduce pain. We do not know if consuming these dairy preparations improves tophus size (tophi are gout crystal deposits commonly found in skin, on the surface of joints or in cartilage) or blood uric acid levels, as these were not reported. We do not have precise information about side effects and complications. Possible side effects may include nausea or diarrhoea. What is gout and what are lifestyle interventions? Gout is a very common form of painful joint inflammation (arthritis) caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness and swelling of affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic makeup, being overweight, ingesting certain medications (e.g. diuretics), having impaired kidney function and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Although medications are the mainstay of gout treatment, given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as losing weight, stopping smoking, exercising more, drinking more coffee and dairy products, and consuming less sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout. Best estimate of what happens to people with gout who consume enriched skim milk powder: Gout attacks People who consumed enriched skim milk powder had 0.21 fewer gout attacks per month at 3 months (or 2.5 fewer gout attacks per year) . ‐ People who consumed enriched skim milk powder had 0.49 gout attacks per month (or 6 gout attacks per year). ‐ People who consumed standard skim milk powder or lactose had 0.70 gout attacks per month (or 8 gout attacks per year). Withdrawals due to adverse events 4 more people out of 100 who consumed enriched skim milk powder discontinued the supplement at 3 months (4% more withdrawals absolute change, from 10% fewer to 18% more). ‐ 18 out of 100 stopped consuming enriched skim milk powder. ‐ 14 out of 100 stopped consuming standard skim milk powder or lactose. Pain (lower score means less pain) People who consumed enriched skim milk powder rated their pain 1 point lower on a 0 to 10 point pain scale (10% absolute improvement; 20% to 1% improvement) at 3 months. ‐ People who consumed enriched skim milk powder rated their pain to be 0.67 points on a scale of 0 to 10. ‐ People who consumed standard skim milk powder or lactose rated their pain to be 1.7 points on a scale of 0 to 10. Physical function (lower score means better function) People who consumed enriched skim milk powder rated their function 0.03 better (0.14 better to 0.08 worse) on a 0 to 3 point scale (1% absolute improvement; 5% improvement to 3% worse) at 3 months. ‐ People who consumed enriched skim milk powder rated their function to be 0.08 points on a scale of 0 to 3. ‐ People who consumed standard skim milk powder or lactose rated their function to be 0.11 points on a scale of 0 to 3. Serious adverse events 1 more person out of 100 who consumed enriched skim milk powder reported a serious adverse event. ‐ 5 out of 100 who consumed enriched skim milk powder had a serious adverse event. ‐ 4 out of 100 who consumed standard skim milk powder or lactose had a serious adverse event.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY; Sriranganathan, MK; Edwards, CJ; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "09c78184-f8d0-454f-9ed2-7f87b1fb5fbd", "pmid": "", "title": "Effects of Single-dose Semaglutide on Cognition and Energy in Healthy Volunteers", "imported": false, "abstract": "Semaglutide is a glucagon-like peptide 1 receptor agonist (GLP-1RA). It is a safe medication approved for use in type-2 diabetes mellitus (T2DM) and obesity. Primarily, it works by counteracting insulin-resistance and inducing weight loss. It also acts on several other interconnected neurobiological, immunological (esp. inflammatory), endocrine-metabolic, and gut-brain axis processes that play a role in depressive symptoms. Its effects on cognition and energy are currently unknown. In this study we are using semaglutide as an experimental tool to further investigate these relationships.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.241Z" }, { "id": "09c941f9-03ed-4d68-9bd2-ffb8587583fc", "pmid": "", "title": "Colchicine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Colchicine has been used for patients with primary biliary cirrhosis because of its immunomodulatory and antifibrotic potential. The therapeutical responses to colchicine in randomised clinical trials were inconsistent. Objectives To evaluate the beneficial and harmful effects of colchicine in patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials on The Cochrane Library , MEDLINE, EMBASE (September 2003) , and manual searches of bibliographies. We contacted authors of trials and pharmaceutical companies. Selection criteria Randomised clinical trials comparing colchicine with any kind of control therapy were included irrespective of language, year of publication, and publication status. Data collection and analysis The primary outcomes were the number of deaths and the number of death and/or patients who underwent liver transplantation. Dichotomous outcomes were reported as relative risk (RR) with 95% confidence interval (CI). We examined intervention effects by using both a fixed effect model and a random effects model. Heterogeneity was investigated by subgroup analyses and sensitivity analyses. Main results Eleven randomised clinical trials involving 716 patients with primary biliary cirrhosis fulfilled the inclusion criteria. No significant differences were detected between colchicine and placebo/no intervention on the number of deaths (RR 1.21, 95% CI 0.71 to 2.06), the number of deaths and/or patients who underwent liver transplantation (RR 1.00, 95% CI 0.67 to 1.49), liver complications, liver biochemical variables, liver histological measurements, and adverse events. Trial methodology was generally low and some trials had high drop‐out rate. A best‐worst‐case‐scenario analysis showed no significant effect of colchicine on mortality (RR 0.59, 95%CI 0.30 to 1.15), while a worst‐best‐case‐scenario analysis showed a significant detrimental effect of colchicine on mortality (RR 2.28, 95% CI 1.17 to 4.44). Colchicine significantly decreased the number of patients without improvement of pruritus (RR 0.75, 95% CI 0.65 to 0.87). However, this estimate was based on only 156 patients from three trials. The effect of the combined treatment with ursodeoxycholic acid was not significantly different from that of colchicine alone. Authors' conclusions We did not find evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis. As we are not able to exclude a detrimental effect of colchicine, we suggest that it is only used in randomised clinical trials. Plain language summary No convincing evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis Primary biliary cirrhosis is a rare, chronic liver disease of unknown etiology. Colchicine, a plant alkaloid, has been used to treat patients with primary biliary cirrhosis and was tested in randomised clinical trials. When all identified trials were combined, colchicine appeared to be not significantly different from placebo/no intervention in respect to mortality, mortality and/or patients who underwent liver transplantation, liver complications, liver biochemistry, liver histology, and the occurrences of adverse events. Colchicine may reduce pruritus, but this finding may be due to bias. The addition of ursodeoxycholic acid did not significantly influence the effect of colchicine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "09d45d90-3d85-4bf8-af1f-4475741a773a", "pmid": "", "title": "Antibiotics versus topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity. It is characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Antibiotics and antiseptics kill or inhibit the micro‐organisms that may be responsible for the infection. Antibiotics can be applied topically or administered systemically via the oral or injection route. Antiseptics are always directly applied to the ear (topically). Objectives To assess the benefits and harms of antibiotics versus antiseptics for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP). The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving adults and children who had chronic ear discharge of unknown cause or CSOM, where ear discharge had continued for more than two weeks. The intervention was any single, or combination of, antibiotic agent, whether applied topically (without steroids) or systemically. The comparison was any single, or combination of, topical antiseptic agent, applied as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The comparisons were 1. topical antiseptics compared to topical antibiotics, and 2. topical antiseptics compared to systemic antibiotics. We further separated these comparisons into those in which a. both groups of participants received aural toileting in addition to the intervention, or b. both groups received some other add‐on therapy treatment (such as systemic antibiotics) to both arms. Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This updated review included eight new studies. Overall, we identified 15 studies (2371 participants) across seven comparisons with antibiotics compared to acetic acid, aluminium acetate, boric acid, and povidone‐iodine. None of the included studies reported health‐related quality of life or serious complications. 1. Topical antibiotics (quinolones or aminoglycosides) versus topical antiseptic (acetic acid) We included seven studies (835 participants). Acetic acid may increase resolution of ear discharge when compared to aminoglycoside at one to two weeks (low‐certainty evidence). It is very uncertain whether acetic acid may increase resolution of ear discharge at one to two weeks when compared to topical quinolone. Results after four weeks were only presented narratively. It is very uncertain whether acetic acid may cause more ear pain, discomfort, local irritation, or combinations of these compared to topical antibiotics (aminoglycosides and quinolones) (risk ratio (RR) 0.20, 95% confidence interval (CI) 0.03 to 1.12; I 2 = 0%; 3 studies, 277 participants; very low‐certainty evidence). An additional two studies (350 participants) provided narrative results. There may be little to no difference in hearing between groups reported narratively (quinolones; low‐certainty evidence). The evidence is very uncertain for serious complications (aminoglycosides) or suspected ototoxicity (aminoglycosides) (very low‐certainty evidence). 2. Topical antibiotics (quinolones) versus topical antiseptic (boric acid) We included two studies (532 participants). Topical quinolones are likely to increase resolution of ear discharge at one to two weeks compared with boric acid ear drops (RR 1.86, 95% CI 1.48 to 2.35; 1 study, 411 participants; moderate‐certainty evidence). This means that one additional person will have resolution of ear discharge for every four people receiving topical antibiotics (compared with boric acid) at two weeks. No study reported results for ear discharge after four weeks. There may be less ear pain, discomfort, or irritation with quinolones compared with boric acid (RR 0.56, 95% CI 0.32 to 0.98; 2 studies, 510 participants; low‐certainty evidence). Suspected ototoxicity and serious complications were not reported. Topical quinolones may result in a greater improvement in mean hearing from baseline compared to topical boric acid (mean difference (MD) 2.79 decibels, 95% CI 0.48 to 5.10; 1 study, 390 participants; low‐certainty evidence), but this difference may not be clinically significant. 3. Topical antibiotics (quinolones) versus topical antiseptic (povidone‐iodine) We included one study (40 participants). It is very uncertain if there is a difference between quinolones and povidone‐iodine with respect to resolution of ear discharge at one to two weeks (RR 1.02, 95% CI 0.82 to 1.26; 1 RCT, 39 participants; very low‐certainty evidence). The study reported qualitatively that there were no differences between the groups for hearing and no participants developed ototoxic effects (very low‐certainty evidence). There were no results reported for resolution of ear discharge beyond four weeks; ear pain, discomfort, or irritation; or serious complications. 4. Topical antibiotics versus topical antiseptic (aluminium acetate) We included one study (51 participants; 60 ears) that presented results for resolution of ear discharge at two to four weeks results narratively. No other results were reported. 5. Other comparisons Five studies (966 participants) were assessed over an additional three comparisons; however, these results have not been included in the abstract. Authors' conclusions Treatment of CSOM with topical antibiotics (quinolones) likely results in an increase in resolution of ear discharge compared with boric acid at up to two weeks. There was limited evidence for the efficacy of other topical antibiotics or topical antiseptics and so we are unable to draw conclusions. Harmful effects were not well reported. Limitations of the review include lack of recent data, limitations in the quality of included studies, and limited information on certain population groups or interventions. Plain language summary Which are better, antibiotics or topical antiseptics, for treating chronic suppurative otitis media? Key message – There is limited evidence comparing topical antibiotics with topical antiseptics in people with swelling and infection of the middle ear (called chronic suppurative otitis media). The evidence is very uncertain whether antibiotics or topical antiseptics are more effective for reducing ear discharge, except that topical antibiotics are likely to be more effective than boric acid (an antiseptic). What is chronic suppurative otitis media? Chronic suppurative otitis media is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (where the eardrum has a hole or tear in it). The main symptoms of chronic suppurative otitis media are ear discharge (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Antibiotics (which kill bacteria) are the most commonly used treatment for chronic suppurative otitis media. Antibiotics can either be 'topical' (put into the ear canal as ear drops, ointments, sprays, or creams) or 'systemic' (taken either by mouth or by an injection into a muscle or vein). Topical antiseptics (antiseptics put directly into the ear as ear drops or powders) are a possible treatment for chronic suppurative otitis media. Both antibiotics and topical antiseptics kill or stop the growth of the germs that may be responsible for the infection. Antibiotics and topical antiseptics can be used on their own or added to other treatments for chronic suppurative otitis media, such as other antibiotics or ear cleaning (called aural toileting). It was important in this review to examine whether there were any unwanted effects from using antibiotics and antiseptics, such as irritation of the skin within the outer ear, which may cause discomfort, pain, or itching. Some antibiotics and antiseptics (such as alcohol) can also be toxic to the inner ear (called ototoxicity), which means that they may cause permanent hearing loss, dizziness, or ringing in the ear (called tinnitus). What was the aim of this review? We wanted to compare antibiotics and antiseptics for the treatment of chronic suppurative otitis media. In particular, we wanted to know whether they stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found 15 studies, which included 2371 people, that compared antibiotics to a variety of antiseptics (acetic acid, boric acid, povidone‐iodine, and aluminium acetate). One study recruited only children, two studies recruited only adults, and 12 studies included both adults and children. About 40 in every 100 people were females. We presented the main comparisons below. Comparison of antibiotics to acetic acid We included seven studies (835 people). We have little to no confidence in the evidence of whether topical antibiotics or acetic acid improved ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to boric acid We included two studies (532 people). Topical antibiotics (quinolones) are likely to be better than boric acid at reducing ear discharge after one to two weeks. There may also be less ear discomfort (pain, irritation, and bleeding). Topical quinolones may result in a greater improvement in hearing compared to topical boric acid, but this difference may be too small for the person to notice a difference. Comparison of antibiotics to povidone‐iodine We included one study (40 people). We have little to no confidence in the evidence of whether topical or systemic antibiotics or povidone‐iodine improve the resolution of ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to aluminium acetate We included one study (51 people) that stated there was improvement in ear discharge at two to four weeks, but they did not present their results in a way that we could use. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. What are the limitations of the evidence? The studies were small with many being poorly reported, and results varied widely between studies. We also need more information about harmful effects. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K; Chong, LY; Bhutta, MF; Daw, J; Veselinović, T; Morris, PS; Vijayasekaran, S; Schilder, AGM; Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013056.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "09d5c8fa-0970-44b5-93b9-570ec53718ca", "pmid": "", "title": "Full‐mouth treatment modalities (within 24 hours) for periodontitis in adults", "imported": false, "abstract": "Abstract - Background Periodontitis is a highly prevalent, chronic inflammation that causes damage to the soft tissues and bones supporting the teeth. Conventional treatment is quadrant scaling and root planing (the second step of periodontal therapy), which comprises scaling and root planing of teeth in one quadrant of the mouth at a time, with the four different sessions separated by at least one week. Alternative protocols for anti‐infective periodontal therapy have been introduced to help enhance treatment outcomes: full‐mouth scaling (subgingival instrumentation of all quadrants within 24 hours), or full‐mouth disinfection (subgingival instrumentation of all quadrants in 24 hours plus adjunctive antiseptic). We use the older term 'scaling and root planing' (SRP) interchangeably with the newer term 'subgingival instrumentation' in this iteration of the review, which updates one originally published in 2008 and first updated in 2015. Objectives To evaluate the clinical effects of full‐mouth scaling or full‐mouth disinfection (within 24 hours) for the treatment of periodontitis compared to conventional quadrant subgingival instrumentation (over a series of visits at least one week apart) and to evaluate whether there was a difference in clinical effects between full‐mouth disinfection and full‐mouth scaling. Search methods An information specialist searched five databases up to 17 June 2021 and used additional search methods to identify published, unpublished and ongoing studies. Selection criteria We included randomised controlled trials (RCTs) lasting at least three months that evaluated full‐mouth scaling and root planing within 24 hours, with or without adjunctive use of an antiseptic, compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of (chronic) periodontitis according to the International Classification of Periodontal Diseases from 1999. A new periodontitis classification was launched in 2018; however, we used the 1999 classification for inclusion or exclusion of studies, as most studies used it. We excluded studies of people with systemic disorders, taking antibiotics or with the older diagnosis of 'aggressive periodontitis'. Data collection and analysis Several review authors independently conducted data extraction and risk of bias assessment (based on randomisation method, allocation concealment, examiner blinding and completeness of follow‐up). Our primary outcomes were tooth loss and change in probing pocket depth (PPD); secondary outcomes were change in probing attachment (i.e. clinical attachment level (CAL)), bleeding on probing (BOP), adverse events and pocket closure (the number/proportion of sites with PPD of 4 mm or less after treatment). We followed Cochrane's methodological guidelines for data extraction and analysis. Main results We included 20 RCTs, with 944 participants, in this updated review. No studies assessed the primary outcome tooth loss. Thirteen trials compared full‐mouth scaling and root planing within 24 hours without the use of antiseptic (FMS) versus control, 13 trials compared full‐mouth scaling and root planing within 24 hours with adjunctive use of an antiseptic (FMD) versus control, and six trials compared FMS with FMD. Of the 13 trials comparing FMS versus control, we assessed three at high risk of bias, six at low risk of bias and four at unclear risk of bias. We assessed our certainty about the evidence as low or very low for the outcomes in this comparison. There was no evidence for a benefit for FMS over control for change in PPD, gain in CAL or reduction in BOP at six to eight months (PPD: mean difference (MD) 0.03 mm, 95% confidence interval (CI) –0.14 to 0.20; 5 trials, 148 participants; CAL: MD 0.10 mm, 95% CI –0.05 to 0.26; 5 trials, 148 participants; BOP: MD 2.64%, 95% CI –8.81 to 14.09; 3 trials, 80 participants). There was evidence of heterogeneity for BOP (I² = 50%), but none for PPD and CAL. Of the 13 trials comparing FMD versus control, we judged four at high risk of bias, one at low risk of bias and eight at unclear risk of bias. At six to eight months, there was no evidence for a benefit for FMD over control for change in PPD or CAL (PPD: MD 0.11 mm, 95% CI –0.04 to 0.27; 6 trials, 224 participants; low‐certainty evidence; CAL: 0.07 mm, 95% CI –0.11 to 0.24; 6 trials, 224 participants; low‐certainty evidence). The analyses found no evidence of a benefit for FMD over control for BOP (very low‐certainty evidence). There was no evidence of heterogeneity for PPD or CAL, but considerable evidence of heterogeneity for BOP, attributed to one study. There were no consistent differences in these outcomes between intervention and control (low‐ to very low‐certainty evidence). Of the six trials comparing FMS and FMD, we judged two trials at high risk of bias, one at low risk of bias and three as unclear. At six to eight months, there was no evidence of a benefit of FMD over FMS for change in PPD or gain in CAL (PPD: MD –0.11 mm, 95% CI –0.30 to 0.07; P = 0.22; 4 trials, 112 participants; low‐certainty evidence; CAL: MD –0.05 mm, 95% CI –0.23 to –0.13; P = 0.58; 4 trials, 112 participants; low‐certainty evidence). There was no evidence of a difference between FMS and FMD for BOP at any time point (P = 0.98; 2 trials, 22 participants; low‐ to very low‐certainty evidence). There was evidence of heterogeneity for BOP (I² = 52%), but not for PPD or CAL. Thirteen studies predefined adverse events as an outcome; three reported an event after FMD or FMS. The most important harm identified was an increase in body temperature. We assessed the certainty of the evidence for most comparisons and outcomes as low because of design limitations leading to risk of bias, and the small number of trials and participants, leading to imprecision in the effect estimates. Authors' conclusions The inclusion of nine new RCTs in this updated review has not changed the conclusions of the previous version of the review. There is still no clear evidence that FMS or FMD approaches provide additional clinical benefit compared to conventional mechanical treatment for adult periodontitis. In practice, the decision to select one approach to non‐surgical periodontal therapy over another should include patient preference and the convenience of the treatment schedule. Plain language summary Treating all teeth (full mouth) within 24 hours for gum disease (periodontitis) in adults Background Long‐lasting gum disease (periodontitis) is a common chronic inflammatory disease that causes damage to soft tissues (gums) and bone around teeth, and can result in tooth loss. Non‐surgical treatments are used to stop and control the disease. These are based on 'subgingival instrumentation', that is, the mechanical removal of bacteria below the gums from the infected root surfaces of the teeth. Conventional treatment is carried out in two to four sessions over several weeks, scaling a different section (or 'quadrant') of the mouth each time. This has traditionally been known as 'scaling and root planing' (SRP). An alternative approach is to treat the whole mouth within 24 hours in one or two sessions (known as full‐mouth scaling (FMS)). When an antiseptic agent (like chlorhexidine) is added to FMS, the intervention is called full‐mouth disinfection (FMD). The rationale for using these full‐mouth approaches is to reduce the likelihood of re‐infection in already treated sites. Review question This review, produced within Cochrane Oral Health, is the second update of one we originally published in 2008. It evaluates the effectiveness of full‐mouth treatments within 24 hours (FMS and FMD) compared to conventional treatment over a number of weeks, and whether there is a difference between FMS and FMD. The evidence is current up to June 2021. Study characteristics The included studies were randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that evaluated a full‐mouth approach to subgingival instrumentation, with at least three months of monitoring (follow‐up). Both FMS and FMD were compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of chronic periodontitis and we excluded studies of people with aggressive periodontitis, systemic disorders (affecting other part of the body) or who were taking antibiotics. We included nine new studies in this update and we excluded one trial that had been included in the previous version of the review. In total, the review now includes 20 studies that involved 944 participants. Key results Treatment effects of FMS and FMD are modest and there are no clear implications for periodontal care. Neither treatment was superior to the usual treatment of scaling and root planing a quarter of the mouth at a time. The most important harm identified was an increased body temperature after FMS or FMD treatments, reported in three out of 13 studies. In practice, the decision to select one approach over another will be based on preference and convenience for patient and dentist. Certainty of the evidence Our confidence in the results is low for most comparisons and outcomes, due to the small number of studies and participants involved, and limitations in study designs. The addition of nine studies has not changed the findings of our previous version of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jervøe-Storm, P-M, Eberhard, J, Needleman, I, Worthington, HV, Jepsen, S", "articleTypes": [], "doi": "10.1002/14651858.CD004622.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.764Z" }, { "id": "09e526e8-a239-4bef-a817-46c1fdad849d", "pmid": "", "title": "Adjunctive systemic antimicrobials for the non‐surgical treatment of periodontitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Khattri, S, Kumbargere Nagraj, S, Arora, A, Eachempati, P, Kusum, CK, Bhat, KG, Johnson, TM, Lodi, G", "articleTypes": [], "doi": "10.1002/14651858.CD012568.pub2 AB - Abstract - Background Systemic antimicrobials can be used as an adjunct to mechanical debridement (scaling and root planing (SRP)) as a non‐surgical treatment approach to manage periodontitis. A range of antibiotics with different dosage and combinations are documented in the literature. The review follows the previous classification of periodontitis as all included studies used this classification. Objectives To assess the effects of systemic antimicrobials as an adjunct to SRP for the non‐surgical treatment of patients with periodontitis. Search methods Cochrane Oral Health's Information Specialist searched the following databases to 9 March 2020: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, and Embase. The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included randomized controlled trials (RCTs) which involved individuals with clinically diagnosed untreated periodontitis. Trials compared SRP with systemic antibiotics versus SRP alone/placebo, or with other systemic antibiotics. Data collection and analysis We selected trials, extracted data, and assessed risk of bias in duplicate. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE. Main results We included 45 trials conducted worldwide involving 2664 adult participants. 14 studies were at low, 8 at high, and the remaining 23 at unclear overall risk of bias. Seven trials did not contribute data to the analysis. We assessed the certainty of the evidence for the 10 comparisons which reported long‐term follow‐up (≥ 1 year). None of the studies reported data on antimicrobial resistance and patient‐reported quality of life changes. Amoxicillin + metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐16.20%, 95% CI ‐25.87 to ‐6.53; 1 study, 44 participants); clinical attachment level (CAL) (MD ‐0.47 mm, 95% CI ‐0.90 to ‐0.05; 2 studies, 389 participants); probing pocket depth (PD) (MD ‐0.30 mm, 95% CI ‐0.42 to ‐0.18; 2 studies, 389 participants); and percentage of bleeding on probing (BOP) (MD ‐8.06%, 95% CI ‐14.26 to ‐1.85; 2 studies, 389 participants) was of very low certainty. Only the results for closed pockets and BOP showed a minimally important clinical difference (MICD) favouring amoxicillin + metronidazole + SRP. Metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐12.20%, 95% CI ‐29.23 to 4.83; 1 study, 22 participants); CAL (MD ‐1.12 mm, 95% CI ‐2.24 to 0; 3 studies, 71 participants); PD (MD ‐1.11 mm, 95% CI ‐2.84 to 0.61; 2 studies, 47 participants); and percentage of BOP (MD ‐6.90%, 95% CI ‐22.10 to 8.30; 1 study, 22 participants) was of very low certainty. Only the results for CAL and PD showed an MICD favouring the MTZ + SRP group. Azithromycin + SRP versus SRP for chronic/aggressive periodontitis: we found no evidence of a difference in percentage of closed pockets (MD 2.50%, 95% CI ‐10.19 to 15.19; 1 study, 40 participants); CAL (MD ‐0.59 mm, 95% CI ‐1.27 to 0.08; 2 studies, 110 participants); PD (MD ‐0.77 mm, 95% CI ‐2.33 to 0.79; 2 studies, 110 participants); and percentage of BOP (MD ‐1.28%, 95% CI ‐4.32 to 1.76; 2 studies, 110 participants) (very low‐certainty evidence for all outcomes). Amoxicillin + clavulanate + SRP versus SRP for chronic periodontitis: the evidence from 1 study, 21 participants for CAL (MD 0.10 mm, 95% CI ‐0.51 to 0.71); PD (MD 0.10 mm, 95% CI ‐0.17 to 0.37); and BOP (MD 0%, 95% CI ‐0.09 to 0.09) was of very low certainty and did not show a difference between the groups. Doxycycline + SRP versus SRP in aggressive periodontitis: the evidence from 1 study, 22 participants for CAL (MD ‐0.80 mm, 95% CI ‐1.49 to ‐0.11); and PD (MD ‐1.00 mm, 95% CI ‐1.78 to ‐0.22) was of very low certainty, with the doxycycline + SRP group showing an MICD in PD only. Tetracycline + SRP versus SRP for aggressive periodontitis: we found very low‐certainty evidence of a difference in long‐term improvement in CAL for the tetracycline group (MD ‐2.30 mm, 95% CI ‐2.50 to ‐2.10; 1 study, 26 participants). Clindamycin + SRP versus SRP in aggressive periodontitis: we found very low‐certainty evidence from 1 study, 21 participants of a difference in long‐term improvement in CAL (MD ‐1.70 mm, 95% CI ‐2.40 to ‐1.00); and PD (MD ‐1.80 mm, 95% CI ‐2.47 to ‐1.13) favouring clindamycin + SRP. Doxycycline + SRP versus metronidazole + SRP for aggressive periodontitis: there was very low‐certainty evidence from 1 study, 27 participants of a difference in long‐term CAL (MD 1.10 mm, 95% CI 0.36 to 1.84); and PD (MD 1.00 mm, 95% CI 0.30 to 1.70) favouring metronidazole + SRP. Clindamycin + SRP versus metronidazole + SRP for aggressive periodontitis: the evidence from 1 study, 26 participants for CAL (MD 0.20 mm, 95% CI ‐0.55 to 0.95); and PD (MD 0.20 mm, 95% CI ‐0.38 to 0.78) was of very low certainty and did not show a difference between the groups. Clindamycin + SRP versus doxycycline + SRP for aggressive periodontitis: the evidence from 1 study, 23 participants for CAL (MD ‐0.90 mm, 95% CI ‐1.62 to ‐0.18); and PD (MD ‐0.80 mm, 95% CI ‐1.58 to ‐0.02) was of very low certainty and did not show a difference between the groups. Most trials testing amoxicillin, metronidazole, and azithromycin reported adverse events such as nausea, vomiting, diarrhoea, mild gastrointestinal disturbances, and metallic taste. No serious adverse events were reported. Authors' conclusions There is very low‐certainty evidence (for long‐term follow‐up) to inform clinicians and patients if adjunctive systemic antimicrobials are of any help for the non‐surgical treatment of periodontitis. There is insufficient evidence to decide whether some antibiotics are better than others when used alongside SRP. None of the trials reported serious adverse events but patients should be made aware of the common adverse events related to these drugs. Well‐planned RCTs need to be conducted clearly defining the minimally important clinical difference for the outcomes closed pockets, CAL, PD, and BOP. Plain language summary What are the benefits and risks of using antibiotics as well as cleaning by a dental care professional to treat gum disease? Why is this question important? Gum disease is a common condition in which the gums become swollen, sore or infected. It is caused by bacteria that accumulate on gums and teeth. Diseased gums may bleed when people brush their teeth, and may cause bad breath. If gum disease is not treated, teeth can become loose and eventually fall out. This can affect a person’s ability to chew and speak. It can also make people feel self‐conscious about their appearance. Dental‐care professionals can clean teeth and gums to remove excess bacteria from the mouth. They use special instruments – typically, an ultrasound scraper followed by specialised hand‐held instruments – to scrape bacteria from the teeth, and stop these from affecting the gums. Antibiotics (medicines that kill bacteria) taken by mouth (orally) can be used alongside professional cleaning, to remove bacteria from the area between the teeth and gums. However, there are potential risks associated with antibiotics, such as allergic reactions and antibiotic resistance (changes in bacteria after exposure to antibiotics, that allow the bacteria to survive future antibiotic treatment). We conducted a review of the evidence from research studies to find out about the benefits and risks of using antibiotics alongside professional dental cleaning to treat gum disease. We also wanted to know if some antibiotics work better than others in this situation. How did we identify and evaluate the evidence? First, we searched for randomized controlled studies (clinical studies where people are randomly put into one of two or more treatment groups), because these studies provide the most robust evidence about the effects of a treatment. We then compared the results, and summarized the evidence from all the studies. Finally, we rated our confidence in the evidence, based on factors such as study methods and sizes, and the consistency of findings across studies. What did we find? We found 45 studies that involved a total of 2664 people over the age of 18 who had gum disease. The studies compared professional cleaning plus antibiotics against professional cleaning alone, or compared different antibiotics used alongside professional cleaning against one another. We cannot tell whether antibiotics reduce gum disease in the long term (one year or more after treatment), or whether some antibiotics are better than others. This is because we have very little confidence in the evidence we found. We cannot tell whether antibiotics are associated with unwanted effects, because we have too little confidence in the evidence. The most commonly reported unwanted effects were temporary, mild gastrointestinal disturbances, such as nausea, vomiting, diarrhoea, or a metallic taste in the mouth. No serious unwanted effects were reported. No studies reported on antimicrobial resistance or changes in people’s quality of life. What does this mean? We do not know whether: ‐ using antibiotics alongside professional cleaning is beneficial for treating gum disease in the long term (more than one year after treatment);
‐ using antibiotics alongside professional cleaning is associated with unwanted effects; or
‐ some antibiotics are better than others for treating gum disease alongside professional cleaning. Our confidence in the available evidence is very low. The results of our review are likely to change if more evidence becomes available. Future studies should clearly define what qualifies as a minimally important improvement in gum disease. How‐up‐to date is this review? The evidence in this Cochrane Review is current to March 2020.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.072Z" }, { "id": "09f29a90-d5b9-47fe-85de-1eb696efbd78", "pmid": "", "title": "Desferrioxamine mesylate for managing transfusional iron overload in people with transfusion‐dependent thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. Desferrioxamine mesylate (desferrioxamine) is one of the most widely used iron chelators. Substantial data have shown the beneficial effects of desferrioxamine, although adherence to desferrioxamine therapy is a challenge. Alternative oral iron chelators, deferiprone and deferasirox, are now commonly used. Important questions exist about whether desferrioxamine, as monotherapy or in combination with an oral iron chelator, is the best treatment for iron chelation therapy. Objectives To determine the effectiveness (dose and method of administration) of desferrioxamine in people with transfusion‐dependent thalassaemia. To summarise data from trials on the clinical efficacy and safety of desferrioxamine for thalassaemia and to compare these with deferiprone and deferasirox. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We also searched MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus ongoing trials registers and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). All searches were updated to 5 March 2013. Selection criteria Randomised controlled trials comparing desferrioxamine with placebo, with another iron chelator, or comparing two schedules or doses of desferrioxamine, in people with transfusion‐dependent thalassaemia. Data collection and analysis Six authors working independently were involved in trial quality assessment and data extraction. For one trial, investigators supplied additional data upon request. Main results A total of 22 trials involving 2187 participants (range 11 to 586 people) were included. These trials included eight comparisons between desferrioxamine alone and deferiprone alone; five comparisons between desferrioxamine combined with deferiprone and deferiprone alone; eight comparisons between desferrioxamine alone and desferrioxamine combined with deferiprone; two comparisons of desferrioxamine with deferasirox; and two comparisons of different routes of desferrioxamine administration (bolus versus continuous infusion). Overall, few trials measured the same or long‐term outcomes. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage; none of these included a comparison with deferasirox. Five trials reported a total of seven deaths; three in patients who received desferrioxamine alone, two in patients who received desferrioxamine and deferiprone. A further death occurred in a patient who received deferiprone in another who received deferasirox alone. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. One trial planned five years of follow up but was stopped early due to the beneficial effects of a reduction in serum ferritin levels in those receiving combined desferrioxamine and deferiprone treatment compared with deferiprone alone. The results of this and three other trials suggest an advantage of combined therapy with desferrioxamine and deferiprone over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no evidence for the improved efficacy of combined desferrioxamine and deferiprone therapy against monotherapy from direct or indirect measures of liver iron. Earlier trials measuring the cardiac iron load indirectly by measurement of the magnetic resonance imaging T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, meta‐analysis of two trials showed a significantly lower left ventricular ejection fraction in patients who received desferrioxamine alone compared with those who received combination therapy using desferrioxamine with deferiprone. Adverse events were recorded by 18 trials. These occurred with all treatments, but were significantly less likely with desferrioxamine than deferiprone in one trial, relative risk 0.45 (95% confidence interval 0.24 to 0.84) and significantly less likely with desferrioxamine alone than desferrioxamine combined with deferiprone in two other trials, relative risk 0.33 (95% confidence interval 0.13 to 0.84). In particular, four studies reported permanent treatment withdrawal due to adverse events from deferiprone; only one of these reported permanent withdrawals associated with desferrioxamine. Adverse events also occurred at a higher frequency in patients who received deferasirox than desferrioxamine in one trial. Eight trials reported local adverse reactions at the site of desferrioxamine infusion including pain and swelling. Adverse events associated with deferiprone included joint pain, gastrointestinal disturbance, increases in liver enzymes and neutropenia; adverse events associated with deferasirox comprised increases in liver enzymes and renal impairment. Regular monitoring of white cell counts has been recommended for deferiprone and monitoring of liver and renal function for deferasirox. In summary, desferrioxamine and the oral iron chelators deferiprone and deferasirox produce significant reductions in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised clinical trials to suggest that any one of these has a greater reduction of clinically significant end organ damage, although in two trials, combination therapy with desferrioxamine and deferiprone showed a greater improvement in left ventricular ejection fraction than desferrioxamine used alone. Authors' conclusions Desferrioxamine is the recommended first‐line therapy for iron overload in people with thalassaemia major and deferiprone or deferasirox are indicated for treating iron overload when desferrioxamine is contraindicated or inadequate. Oral deferasirox has been licensed for use in children aged over six years who receive frequent blood transfusions and in children aged two to five years who receive infrequent blood transfusions. In the absence of randomised controlled trials with long‐term follow up, there is no compelling evidence to change this conclusion. Worsening iron deposition in the myocardium in patients receiving desferrioxamine alone would suggest a change of therapy by intensification of desferrioxamine treatment or the use of desferrioxamine and deferiprone combination therapy. Adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. People treated with all chelators must be kept under close medical supervision and treatment with deferiprone or deferasirox requires regular monitoring of neutrophil counts or renal function respectively. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcomes of deferiprone, deferasirox and desferrioxamine. Plain language summary Desferrioxamine mesylate (desferrioxamine) for managing excess iron levels in the blood of people with thalassaemia who depend on blood transfusions Haemoglobin carries oxygen in the blood. In thalassaemia, a genetic disease, sometimes the body cannot produce enough haemoglobin. This can be managed by receiving regular blood transfusions, but may lead to excess iron in the body which must be removed to prevent organ damage. Iron is removed by iron chelation therapy using a substance called an iron chelator. This works by sticking to excess iron molecules in the body. When patients go to the toilet, this excess iron leaves the body. Three iron chelators are commonly used. One (desferrioxamine) is injected and two (deferiprone and deferasirox) are taken orally. Deferasirox is licensed for use in children. Desferrioxamine is inconvenient and expensive; motivating researchers to find safe, effective oral iron chelators. We found 22 randomised controlled trials comparing iron chelators. These do not provide enough information about death or organ damage. However, they showed all three chelators performed similarly well in removing excess iron. Several trials found combining desferrioxamine and deferiprone removed more excess iron than using just one iron chelator. Trials showing side effects must be considered carefully. Side effects with desferrioxamine included pain or skin reactions at the injection site and joint pain. Side effects with deferiprone included joint pain, nausea, stomach upsets and low white blood cell count. Side effects with deferasirox included skin rashes, increases in liver enzymes and reduced kidney function. Low white blood cell count and reduced kidney function are important side effects and in patients receiving deferiprone or deferasirox these should be monitored regularly. Patients were three times more likely to experience a side effect when deferiprone and desferrioxamine were combined, compared with desferrioxamine alone. Three studies showed that patients using deferiprone were two and a half times more likely to have joint pain compared with using desferrioxamine alone. We have found no evidence for changing current treatment recommendations, which state that deferiprone or deferasirox should be used to remove excess iron when desferrioxamine cannot be used or is inadequate. The Food and Drug Administration in the United States of America have approved deferiprone only as \"last resort treatment of iron overload in thalassemia\". Larger randomised control trials of iron chelation therapy are needed, using standardised agreed measures of iron levels and organ damage to allow comparison of such valuable treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA, Brunskill, SJ, Doree, C, Gooding, S, Chowdhury, O, Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004450.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.137Z" }, { "id": "09fa2bfe-270b-49d0-9b82-7f18868a2efe", "pmid": "", "title": "Combination inhaled steroid and long‐acting beta₂‐agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background The long‐acting bronchodilator tiotropium and single‐inhaler combination therapy of inhaled corticosteroids and long‐acting beta 2 ‐agonists (ICS/LABA) are commonly used for maintenance treatment of patients with chronic obstructive pulmonary disease (COPD). Combining these treatments, which have different mechanisms of action, may be more effective than administering the individual components. Objectives To assess relative effects of the following treatments on markers of exacerbations, symptoms, quality of life and lung function in patients with COPD. • Tiotropium plus LABA/ICS versus tiotropium. • Tiotropium plus LABA/ICS versus LABA/ICS. Search methods We searched the Cochrane Airways Group Specialised Register of Trials (April 2015), ClinicalTrials.gov ( www.ClinicalTrials.gov ), the World Health Organization (WHO) trials portal and reference lists of relevant articles. Selection criteria We included parallel, randomised controlled trials (RCTs) lasting three months or longer conducted to compare ICS and LABA combination therapy in addition to inhaled tiotropium versus tiotropium alone or combination therapy alone. Data collection and analysis We independently assessed trials for inclusion, then extracted data on trial quality and outcome results. We contacted study authors to ask for additional information. We collected trial information on adverse effects. Main results Tiotropium plus LABA/ICS versus tiotropium We included six studies (1902 participants) with low risk of bias that compared tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy versus tiotropium alone. We found no statistically significant differences in mortality between treatments (odds ratio (OR) 1.80, 95% confidence interval (CI) 0.55 to 5.91; two studies; 961 participants) as well as in the all‐cause hospitalisations (OR 0.84, 95% CI 0.53 to 1.33; two studies; 961 participants). The effect on exacerbations was heterogeneous among trials and was not meta‐analysed. Health‐related quality of life measured by St. George’s Respiratory Questionnaire (SGRQ) showed a statistically significant improvement in total scores with use of tiotropium + LABA/ICS compared with tiotropium alone (mean difference (MD) ‐3.46, 95% CI ‐5.05 to ‐1.87; four studies; 1446 participants). Lung function was significantly different in the combined therapy (tiotropium + LABA/ICS) group, although average benefit with this therapy was small. None of the included studies included exercise tolerance as an outcome. A pooled estimate of these studies did not show a statistically significant difference in adverse events (OR 1.16, 95% CI 0.92 to 1.47; four studies; 1363 participants), serious adverse events (OR 0.86, 95% CI 0.57 to 1.30; four studies; 1758 participants) and pneumonia (Peto OR 1.62, 95% CI 0.54 to 4.82; four studies; 1758 participants). Tiotropium plus LABA/ICS versus LABA/ICS One of the six studies (60 participants) also compared combined therapy (tiotropium + LABA/ICS) versus LABA/ICS therapy alone. This study was affected by lack of power; therefore results did not allow us to draw conclusions for this comparison. Authors' conclusions This review update includes three additional studies and provides new low quality evidence supporting the finding that tiotropium + LABA/ICS‐based therapy improves the disease‐specific quality of life. The current evidence is insufficient to support the benefit of tiotropium + LABA/ICS‐based therapy for mortality, hospital admission or exacerbations (moderate and low quality evidence). Compared with use of tiotropium alone, tiotropium + LABA/ICS‐based therapy does not seem to increase undesirable effects nor serious non‐fatal adverse events. Plain language summary Are tiotropium plus combination inhalers better than tiotropium or combination inhalers alone for the treatment of COPD? Background Chronic obstructive pulmonary disease (COPD) is a lung disease that includes the conditions chronic bronchitis and/or emphysema. COPD is characterised by narrowing of the airways and lung tissue destruction. Symptoms include breathlessness and long‐term cough. Symptoms of COPD are treatable, but the condition cannot be reversed or cured. It is usually brought on by airway irritants, such as smoking or inhaled dust. Inhalers with bronchodilators (which allow the airways in the lungs to relax and expand) and/or anti‐inflammatory agents are commonly used to ease symptoms and minimise the long‐term decline in health caused by COPD. Examples of these treatments are tiotropium, which is a bronchodilator, and combination inhalers, which contain another type of bronchodilator (long‐acting beta‐agonists) together with anti‐inflammatory agents (steroids). These treatments work in different ways and therefore might be more beneficial if used together. Study characteristics This review found six studies, involving 1902 participants, comparing the long‐term efficacy and side effects of tiotropium combined with combination inhalers for treatment of patients with COPD. Not all of the people included in these studies had COPD that was severe enough to be recommended for combined therapy according to current guidelines. Key results Current evidence shows potential benefits of treatment with tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy through increased health‐related quality of life and a small improvement i n lung function in patients receiving this combined therapy. However, this evidence does not allow us to draw conclusions about the effects of these treatments on mortality, hospitalisation for all causes and exacerbations. The frequency of serious and non‐serious adverse events was not increased in either of the two groups. Quality of the evidence Overall, we assessed the evidence presented in this review to be of moderate or low quality, which means we are reasonably confident in some of the findings, but less confident in others.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Rojas‐Reyes, MX, García Morales, OM, Dennis, RJ, Karner, C", "articleTypes": [], "doi": "10.1002/14651858.CD008532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.756Z" }, { "id": "09fc97b0-08f1-4c86-b61e-a9e7b355b108", "pmid": "", "title": "Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Harmful alcohol use is defined as unhealthy alcohol use that results in adverse physical, psychological, social, or societal consequences and is among the leading risk factors for disease, disability and premature mortality globally. The burden of harmful alcohol use is increasing in low‐ and middle‐income countries (LMICs) and there remains a large unmet need for indicated prevention and treatment interventions to reduce harmful alcohol use in these settings. Evidence regarding which interventions are effective and feasible for addressing harmful and other patterns of unhealthy alcohol use in LMICs is limited, which contributes to this gap in services. Objectives To assess the efficacy and safety of psychosocial and pharmacologic treatment and indicated prevention interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs. Search methods We searched for randomized controlled trials (RCTs) indexed in the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, the Cochrane Clinical Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, and the Latin American and Caribbean Health Sciences Literature (LILACS) through 12 December 2021. We searched clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, Web of Science, and Opengrey database to identify unpublished or ongoing studies. We searched the reference lists of included studies and relevant review articles for eligible studies. Selection criteria All RCTs comparing an indicated prevention or treatment intervention (pharmacologic or psychosocial) versus a control condition for people with harmful alcohol use in LMICs were included. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 66 RCTs with 17,626 participants. Sixty‐two of these trials contributed to the meta‐analysis. Sixty‐three studies were conducted in middle‐income countries (MICs), and the remaining three studies were conducted in low‐income countries (LICs). Twenty‐five trials exclusively enrolled participants with alcohol use disorder. The remaining 51 trials enrolled participants with harmful alcohol use, some of which included both cases of alcohol use disorder and people reporting hazardous alcohol use patterns that did not meet criteria for disorder. Fifty‐two RCTs assessed the efficacy of psychosocial interventions; 27 were brief interventions primarily based on motivational interviewing and were compared to brief advice, information, or assessment only. We are uncertain whether a reduction in harmful alcohol use is attributable to brief interventions given the high levels of heterogeneity among included studies (Studies reporting continuous outcomes: Tau² = 0.15, Q =139.64, df =16, P<.001, I² = 89%, 3913 participants, 17 trials, very low certainty; Studies reporting dichotomous outcomes: Tau²=0.18, Q=58.26, df=3, P<.001, I² =95%, 1349 participants, 4 trials, very low certainty). The other types of psychosocial interventions included a range of therapeutic approaches such as behavioral risk reduction, cognitive‐behavioral therapy, contingency management, rational emotive therapy, and relapse prevention. These interventions were most commonly compared to usual care involving varying combinations of psychoeducation, counseling, and pharmacotherapy. We are uncertain whether a reduction in harmful alcohol use is attributable to psychosocial treatments due to high levels of heterogeneity among included studies (Heterogeneity: Tau² = 1.15; Q = 444.32, df = 11, P<.001; I²=98%, 2106 participants, 12 trials, very low certainty). Eight trials compared combined pharmacologic and psychosocial interventions with placebo, psychosocial intervention alone, or another pharmacologic treatment. The active pharmacologic study conditions included disulfiram, naltrexone, ondansetron, or topiramate. The psychosocial components of these interventions included counseling, encouragement to attend Alcoholics Anonymous, motivational interviewing, brief cognitive‐behavioral therapy, or other psychotherapy (not specified). Analysis of studies comparing a combined pharmacologic and psychosocial intervention to psychosocial intervention alone found that the combined approach may be associated with a greater reduction in harmful alcohol use (standardized mean difference (standardized mean difference (SMD))=‐0.43, 95% confidence interval (CI): ‐0.61 to ‐0.24; 475 participants; 4 trials; low certainty). Four trials compared pharmacologic intervention alone with placebo and three with another pharmacotherapy. Drugs assessed were: acamprosate, amitriptyline, baclofen disulfiram, gabapentin, mirtazapine, and naltrexone. None of these trials evaluated the primary clinical outcome of interest, harmful alcohol use. Thirty‐one trials reported rates of retention in the intervention. Meta‐analyses revealed that rates of retention between study conditions did not differ in any of the comparisons (pharmacologic risk ratio (RR) = 1.13, 95% CI: 0.89 to 1.44, 247 participants, 3 trials, low certainty; pharmacologic in addition to psychosocial intervention: RR = 1.15, 95% CI: 0.95 to 1.40, 363 participants, 3 trials, moderate certainty). Due to high levels of heterogeneity, we did not calculate pooled estimates comparing retention in brief (Heterogeneity: Tau² = 0.00; Q = 172.59, df = 11, P<.001; I 2 = 94%; 5380 participants; 12 trials, very low certainty) or other psychosocial interventions (Heterogeneity: Tau² = 0.01; Q = 34.07, df = 8, P<.001; I 2 = 77%; 1664 participants; 9 trials, very low certainty). Two pharmacologic trials and three combined pharmacologic and psychosocial trials reported on side effects. These studies found more side effects attributable to amitriptyline relative to mirtazapine, naltrexone and topiramate relative to placebo, yet no differences in side effects between placebo and either acamprosate or ondansetron. Across all intervention types there was substantial risk of bias. Primary threats to validity included lack of blinding and differential/high rates of attrition. Authors' conclusions In LMICs there is low‐certainty evidence supporting the efficacy of combined psychosocial and pharmacologic interventions on reducing harmful alcohol use relative to psychosocial interventions alone. There is insufficient evidence to determine the efficacy of pharmacologic or psychosocial interventions on reducing harmful alcohol use largely due to the substantial heterogeneity in outcomes, comparisons, and interventions that precluded pooling of these data in meta‐analyses. The majority of studies are brief interventions, primarily among men, and using measures that have not been validated in the target population. Confidence in these results is reduced by the risk of bias and significant heterogeneity among studies as well as the heterogeneity of results on different outcome measures within studies. More evidence on the efficacy of pharmacologic interventions, specific types of psychosocial interventions are needed to increase the certainty of these results. Plain language summary Interventions to reduce harmful alcohol use in low‐ and middle‐income countries Why is this review important? Harmful alcohol use is one of the main contributors to the global burden of disease. In low‐ and middle‐income countries, harmful alcohol use is increasing. However, services to prevent and treat harmful alcohol use are limited. One contributor to the lack of available services is the limited information about which intervention approaches are effective in reducing harmful alcohol use and whether these approaches are feasible and acceptable in low‐resource settings. In order to prevent the physical, psychological, and societal burden of harmful alcohol use, it is important that effective interventions are available to reduce alcohol‐related harm. What is the goal of this review? The goal of this review is to summarize evidence on whether psychosocial and pharmacologic interventions are able to reduce harmful alcohol use in low‐ and middle‐income countries. We also aim to evaluate the safety of treatments and how many people remain in treatment until its completion. What does the research say? We identified 66 randomized controlled trials that evaluated the effect of interventions on reducing harmful alcohol use. Most of these studies assessed psychosocial interventions (n = 52 studies), six assessed pharmacologic interventions alone, and eight assessed combined pharmacologic and psychosocial interventions. The majority of included trials were funded by government agencies (36 trials) followed by multiple public and private funders (8 trials) or private foundations (5 trials). Seventeen trials did not report the funding source. We are uncertain whether brief psychosocial interventions and other psychosocial interventions reduce harmful alcohol use. Combined pharmacologic and psychosocial interventions may reduce harmful alcohol use relative to psychosocial interventions combined with placebo, yet the certainty of the evidence has been assessed as low. No studies were found that looked at the effect of pharmacologic interventions alone on harmful alcohol use. We did not find evidence that rates of retention differed between study conditions for any of the intervention types. Certainty of evidence: The certainty of evidence on the effect of brief and other psychosocial interventions on harmful alcohol use was very low due to lack of masking, differential attrition and missing data, selective outcome reporting, high heterogeneity, and differences in patient populations. The certainty of evidence on the effect of combined pharmacologic and psychosocial interventions on harmful alcohol use was low due to lack of blinding, incomplete outcome data, and heterogeneity in the pharmacologic interventions under investigation. No studies evaluated the effect of pharmacologic interventions alone on harmful alcohol use. The evidence is current to 12 December 2021. What are the next steps? Future research on interventions to reduce harmful alcohol use is needed to address some of the limitations described in this review. Studies evaluating similar interventions across studies and contexts are needed to improve generalizability and understand the necessary characteristics of and conditions for effective intervention. Studies must utilize measurement tools that are valid in the population they are studying. Lastly, studies must be designed to reduce the risk of bias leading to the high degree of uncertainty in the results reported in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, MC; Kane, J; Alto, M; Giusto, A; Lovero, K; Stockton, M; McClendon, J; Nicholson, T; Wainberg, ML.; Johnson, RM; Tol, WAnton", "articleTypes": [], "doi": "10.1002/14651858.CD013350.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "09ff3ce1-17de-402e-b70d-b31855e4af73", "pmid": "", "title": "Sensory stimulation for brain injured individuals in coma or vegetative state", "imported": false, "abstract": "Abstract - Background Coma and vegetative state follow traumatic brain injury in about one out of eight patients, and in patients with non traumatic injury the prognosis is worse. The use of sensory stimulation for coma and vegetative state has gained popularity during the 1980's but beliefs and opinions about its effectiveness vary substantially among health professionals. Objectives To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. Search methods We searched the Injuries Group specialised register, the Cochrane Controlled trials register, EMBASE, MEDLINE, CINAHL and PSYCHLIT from 1966 to January 2002, without language restriction. Reference lists of articles were scanned and we contacted experts in the area to find other relevant studies. Selection criteria Randomised or controlled trials that compared sensory stimulation programmes with standard rehabilitation in patients in coma or vegetative state. Data collection and analysis Abstracts and papers found were screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality resolving disagreement by consensus. Main results Three studies were identified with 68 patients in total. The overall methodological quality was poor and studies differed widely in terms of outcomes measures, study design and conduct. We therefore did not carry out any quantitative synthesis but reviewed results of available studies qualitatively. Authors' conclusions This systematic review indicates that there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state. Plain language summary No strong evidence about the effects of sensory stimulation for a brain‐injured person in a coma About half of people in a coma (deep unconsciousness) because of traumatic brain injury will wake within a year of the accident. Speeding recovery to allow people to wake sooner is a priority for them and their family. One type of treatment uses sensory stimulation to try to keep the person's brain working normally. Sensory stimulation methods vary greatly, from one or two hourly sessions of a day, through to shorter sessions every hour for 12 to 14 hours a day. The review found there is no strong evidence to determine whether sensory stimulation benefits people in comas.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Lombardi, FFL, Taricco, M, De Tanti, A, Telaro, E, Liberati, A", "articleTypes": [], "doi": "10.1002/14651858.CD001427", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.086Z" }, { "id": "0a024ac5-f923-48e3-bd45-61dcf51c67db", "pmid": "", "title": "Oral antifungal medication for toenail onychomycosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kreijkamp‐Kaspers, S, Hawke, K, Guo, L, Kerin, G, Bell‐Syer, SEM, Magin, P, Bell‐Syer, SV, van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD010031.pub2 AB - Abstract - Background Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence‐based choice for treatment. Objectives To assess the effects of oral antifungal treatments for toenail onychomycosis. Search methods We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies. Selection criteria RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years. We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high‐risk domain was 'blinding of personnel and participants'. We found high‐quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine‐treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate‐quality evidence). There was high‐quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu‐like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate‐quality evidence). Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low‐quality evidence). There is moderate‐quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate‐quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low‐quality evidence). Common adverse events in both groups included headache, viral infection, and nausea. Moderate‐quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate‐quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin‐treated participants) along with nausea and vomiting (in azole‐treated participants). Very low‐quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants). There is low‐quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low‐quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin‐treated participants) as well as taste loss and nausea (in terbinafine‐treated participants). No studies addressed recurrence rate for this comparison. No study addressed quality of life. Authors' conclusions We found high‐quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate‐quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate‐quality evidence). Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate‐quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low‐quality evidence). Only four comparisons assessed recurrence rate: low‐quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them. Only a limited number of studies reported adverse events, and the severity of the events was not taken into account. Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding. Plain language summary What is the best medication for a fungal infection of the toenail? Review question We aimed to find out which medications, taken by mouth for at least six weeks, are the most effective at curing fungal infection of the toenail, a condition that is known as onychomycosis, in people of any age. We compared these medications to each other or placebo (an inactive drug or treatment). Background Fungal infection of the toenails is a common condition, which has a low risk of complications and associated health risks. However, for those severely affected, it might affect normal daily activities. Medication taken by mouth appears to cure the condition more quickly and effectively than topical treatment. There are three main antifungal medications: griseofulvin, different medications in the azole group (itraconazole, fluconazole, albaconazole, posaconazole, ravuconazole), and terbinafine. We wanted to assess the following two main outcomes. 1. Does the nail look normal after treatment (clinical cure)?
 2. Is the nail free from fungus at a microscopic level (mycological cure)? Study characteristics We identified 48 studies with 10,200 participants of both sexes. The average age of the participants across studies ranged from 36 to 68; most studies included participants aged 18 and over. Our included studies compared the three main groups of medication against each other or to placebo. Most studies took place in outpatient dermatology settings in the USA and Europe. The participants mainly had fungal infection under the toenails. A small number of studies included a specific group of participants, such as those with diabetes. All but one study looked at fungal infections caused by dermatophyte, which are fungi that digest keratin. Study duration ranged from 4 months to 2 years, with most lasting 12 to 15 months. Key results The evidence is current to October 2016. We found high‐quality evidence that compared with placebo, both terbinafine and azoles are more effective for achieving a normal‐looking nail and curing the toenail infection (i.e. looking at the microscopic level to see if the fungus is gone). Terbinafine or azoles may also prevent the infection reoccurring more than placebo (low‐quality evidence). There was probably no significant difference in the risk of adverse events reported when comparing either azoles or terbinafine with placebo (moderate‐quality evidence). The most common adverse events amongst terbinafine‐treated and azole‐treated participants included stomach problems and headache. We found that compared to azoles, terbinafine was probably more effective in curing the nails in terms of appearance and infection (moderate‐quality evidence). The risk of side effects was probably the same for both treatments (moderate‐quality evidence), and the most common adverse events in both groups were headache, viral infection, and rash. There may be no difference in recurrence rate (low‐quality evidence). A third type of treatment, griseofulvin, was probably as effective as the azole medications in curing the nails in terms of appearance and infection (moderate‐quality evidence), but it may be less effective than terbinafine when assessing the same outcomes (low‐quality evidence). Griseofulvin caused more side effects than the other two treatments, although the quality of the evidence was moderate (compared to azole) to low (compared to terbinafine). The most common adverse events in both groups included stomach problems and feeling sick. We are uncertain about the effect of griseofulvin compared to azoles on the rate of recurrence, and studies comparing terbinafine and griseofulvin did not assess this outcome. Quality of the evidence The evidence for the primary outcomes of cure (in terms of appearance and infection) was high to moderate quality except for the comparisons of griseofulvin versus terbinafine (low quality) and combination terbinafine plus azole versus terbinafine alone (very low quality). The evidence quality for side effects was mainly moderate, but two comparisons had low evidence for this outcome. Not all comparisons measured recurrence rate, and the available evidence was based on low‐ to very low‐quality evidence. No studies reported on participants' quality of life. Many studies had problems in the study design: it was often unclear how they decided which participants would receive which treatment or ensured that participants weren't aware of the treatment allocation. Many studies also did not use a placebo.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.070Z" }, { "id": "0a07946d-b0cd-42c8-917e-b63ea86310cc", "pmid": "", "title": "Prostaglandins for management of retained placenta", "imported": false, "abstract": "Abstract - Background Retained placenta affects 0.5% to 3% of women following delivery and it is a major cause of maternal death due to postpartum haemorrhage. Usually, retained placenta has been managed by manual removal or curettage under anaesthesia, which may be associated with haemorrhage, infection and uterine perforation. Medical management to facilitate the delivery of the retained placenta could be a safe alternative avoiding surgical intervention. Objectives To assess the effectiveness and safety of prostaglandins for the management of retained placenta. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013), LILACS (1982 to 1 December 2013), SciELO (1998 to 1 December 2013), Web of Science (2001 to 1 December 2013), openSIGLE (1997 to 1 December 2013 ) , World Health Organization International Clinical Trials Registry Platform ( ICTRP ) (1 December 2013) and the metaRegister of Controlled Trials ( mRCT ) (1 December 2013) . We also contacted authors of included studies and reviewed the reference lists of retrieved studies. Selection criteria Randomised controlled clinical trials comparing the use of prostaglandins (or prostaglandin analogues) with placebo, expectant management, tocolytic drugs, any other prostaglandins or surgical interventions for the management of retained placenta after vaginal delivery of singleton live infants of 20 or more weeks of gestation. Data collection and analysis Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. Any disagreements were resolved through consensus or consultation with a third review author when required. Authors of the included studies were contacted for additional information. Main results We included three trials, involving 244 women. The studies were considered to be at high risk of bias. The prostaglandins used were PG E2 analogue (sulprostone) in 50 participants and PG E1 analogue (misoprostol) in 194 participants at a dose of 250 mcg and 800 mcg respectively. The prostaglandins compared with placebo, were not superior in reducing the rate of manual removal of placenta (average risk ratio (RR) 0.82; 95% confidence interval (CI) 0.54 to 1.27), severe postpartum haemorrhage (RR 0.80; 95% CI 0.55 to 1.15), need for blood transfusion (RR 0.72; 95% CI 0.43 to 1.22), mean blood loss (mean difference (MD) ‐205.26 mL; 95% CI ‐536.31 to 125.79, random‐effects) and the mean time from injection to placental removal (MD ‐7.00 minutes; 95% CI ‐21.20 to 7.20). Side‐effects were no different between groups (vomiting, headache, pain and nausea between injection and discharge from the labour ward), with the exception of shivering, which was more frequent in women receiving prostaglandins (RR 10.00; 95% CI 1.40 to 71.49). We did not obtain any data for the primary outcomes of maternal mortality and the need to add another therapeutic uterotonic. Authors' conclusions Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes) or side‐effects (vomiting, headache, pain and nausea between injection and discharge from the labour ward) except for 'shivering' which was more frequent in women who received prostaglandin. The included studies were of poor quality and there is little confidence in the effect estimates; the true effect is likely to be substantially different. We can not make any recommendations about changes to clinical practice. More high‐quality research in this area is needed. Plain language summary Prostaglandins for management of retained placenta Medical research evidence is sparse and insufficient to support the routine use of the prostaglandins for the management of retained placenta. Retained placenta affects 0.5% to 3% of women following delivery and is a major cause of maternal death caused by postpartum haemorrhage. A retained placenta is usually managed by manual removal or curettage under anaesthesia (which is not always immediately available). Surgical procedures themselves can be associated with haemorrhage and also infection and uterine perforation. Prostaglandins or their analogues, administered by any route, could be an alternative treatment especially in developing countries. Such medical management may facilitate the delivery of the retained placenta and be a safer alternative to surgery. The review identified three randomised controlled studies (involving 244 women) that compared the use of prostaglandins with placebo. Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and need for blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes). The prostaglandin was administered by intravenous infusion (E2 analogue sulprostone) in one study including 50 women and was orally or sublingually administered (E1 analogue misoprostol) in the other two studies including 194 women. Shivering was more frequent in women receiving the prostaglandin but there were no clear differences in vomiting, headache, maternal pain or nausea compared with placebo. The trials were small and of poor methodological quality. The quality of evidence is very low due to study limitations, inconsistency and imprecise results (few women and outcome events with wide confidence intervals). Two studies were stopped early due to an apparent benefit.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Grillo‐Ardila, CF, Ruiz‐Parra, AI, Gaitán, HG, Rodriguez‐Malagon, N", "articleTypes": [], "doi": "10.1002/14651858.CD010312.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.117Z" }, { "id": "0a08346d-4ed4-4126-b00c-b4348b08e5fd", "pmid": "", "title": "Colchicine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Colchicine has been used for patients with primary biliary cirrhosis because of its immunomodulatory and antifibrotic potential. The therapeutical responses to colchicine in randomised clinical trials were inconsistent. Objectives To evaluate the beneficial and harmful effects of colchicine in patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials on The Cochrane Library , MEDLINE, EMBASE (September 2003) , and manual searches of bibliographies. We contacted authors of trials and pharmaceutical companies. Selection criteria Randomised clinical trials comparing colchicine with any kind of control therapy were included irrespective of language, year of publication, and publication status. Data collection and analysis The primary outcomes were the number of deaths and the number of death and/or patients who underwent liver transplantation. Dichotomous outcomes were reported as relative risk (RR) with 95% confidence interval (CI). We examined intervention effects by using both a fixed effect model and a random effects model. Heterogeneity was investigated by subgroup analyses and sensitivity analyses. Main results Eleven randomised clinical trials involving 716 patients with primary biliary cirrhosis fulfilled the inclusion criteria. No significant differences were detected between colchicine and placebo/no intervention on the number of deaths (RR 1.21, 95% CI 0.71 to 2.06), the number of deaths and/or patients who underwent liver transplantation (RR 1.00, 95% CI 0.67 to 1.49), liver complications, liver biochemical variables, liver histological measurements, and adverse events. Trial methodology was generally low and some trials had high drop‐out rate. A best‐worst‐case‐scenario analysis showed no significant effect of colchicine on mortality (RR 0.59, 95%CI 0.30 to 1.15), while a worst‐best‐case‐scenario analysis showed a significant detrimental effect of colchicine on mortality (RR 2.28, 95% CI 1.17 to 4.44). Colchicine significantly decreased the number of patients without improvement of pruritus (RR 0.75, 95% CI 0.65 to 0.87). However, this estimate was based on only 156 patients from three trials. The effect of the combined treatment with ursodeoxycholic acid was not significantly different from that of colchicine alone. Authors' conclusions We did not find evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis. As we are not able to exclude a detrimental effect of colchicine, we suggest that it is only used in randomised clinical trials. Plain language summary No convincing evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis Primary biliary cirrhosis is a rare, chronic liver disease of unknown etiology. Colchicine, a plant alkaloid, has been used to treat patients with primary biliary cirrhosis and was tested in randomised clinical trials. When all identified trials were combined, colchicine appeared to be not significantly different from placebo/no intervention in respect to mortality, mortality and/or patients who underwent liver transplantation, liver complications, liver biochemistry, liver histology, and the occurrences of adverse events. Colchicine may reduce pruritus, but this finding may be due to bias. The addition of ursodeoxycholic acid did not significantly influence the effect of colchicine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.117Z" }, { "id": "0a352084-a5ea-462a-a3f6-75ea037e1c1f", "pmid": "", "title": "Misoprostol for intrauterine device placement", "imported": false, "abstract": "Abstract - Rationale Identifying effective approaches to reduce pain and improve providers' ease of intrauterine device (IUD) placement may reduce barriers to IUD access and use. The cervical softening and dilation effects of misoprostol might make IUD placement less painful for women and technically easier for providers. However, evidence suggests that misoprostol does not improve many outcomes and may only be helpful for some patients (e.g. those with a recent failed IUD placement). Objectives To examine the effect of misoprostol for routine IUD placement on patient and provider outcomes compared to placebo or no treatment. Search methods In November 2021 we searched CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ClinicalTrials.gov. We conducted update searches in July 2022 and September 2024. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in July 2025. Eligibility criteria We included randomized controlled trials (RCTs) of women undergoing interval IUD placement (i.e. placement outside the postabortion or postpartum period) that compared misoprostol to placebo or no treatment. We included trials that examined the placement of currently available levonorgestrel (LNG)‐releasing IUDs, or any copper T IUD, for women of any age, of any parity, and for any indication. Outcomes Our core critical and important outcomes were pain (during tenaculum placement, during IUD placement, and after IUD placement before clinic discharge); providers' ease of placement; need for cervical dilation; placement success; patient satisfaction; misoprostol side effects (preplacement abdominal pain or cramping, and diarrhea); and adverse events (vasovagal reaction). Risk of bias We used the Risk of Bias 2 tool (RoB 2) to assess the risk of bias for outcomes. Synthesis methods We synthesized results for each outcome using meta‐analysis. We calculated mean differences (MD) for continuous outcomes using inverse variance estimation and random‐effects models. We calculated risk ratios (RR) for dichotomous outcomes using Mantel‐Haenszel estimation and random‐effects models. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included 14 RCTs with a total of 1972 women. The trials were conducted in North America, South America, Europe and Africa, and were published between 2007 and 2022. Synthesis of results The results below summarize the effect of misoprostol on outcomes compared to placebo or no treatment. Pain: misoprostol results in little to no difference in pain during tenaculum placement (MD −0.73, 95% confidence interval [CI] −1.19 to −0.28; 3 RCTs, 261 women; high‐certainty evidence) and after IUD placement before clinic discharge (MD −0.01, 95% CI −0.45 to 0.43; 5 RCTs, 448 women; high‐certainty evidence). Misoprostol may result in little to no difference in pain during IUD placement (MD −0.47, 95% CI −1.23 to 0.29; 7 RCTs, 766 women; low‐certainty evidence). Providers' ease of placement: misoprostol may result in little to no difference in a clinically meaningful effect on ease of IUD placement for providers (MD −0.89, 95% CI −1.55 to −0.22; 8 RCTs, 848 women; low‐certainty evidence). Need for cervical dilation: misoprostol may result in little to no difference in need for cervical dilation for women without a recent failed placement attempt (RR 0.84, 95% CI 0.38 to 1.85; 6 RCTs, 562 women; low‐certainty evidence). Misoprostol probably results in little to no difference in need for cervical dilation for women with a recent failed placement attempt (RR 0.88, 95% CI 0.56 to 1.36; 1 RCT, 90 women; moderate‐certainty evidence). Placement success: misoprostol probably results in little to no difference in placement success for women without a recent failed placement attempt (RR 1.01, 95% CI 0.98 to 1.04; 12 RCTs, 1579 women; moderate‐certainty evidence) but probably results in a slight increase in placement success for women with a recent failed placement attempt (RR 1.41, 95% CI 1.09 to 1.83; 1 RCT, 90 women; moderate‐certainty evidence). Patient satisfaction: misoprostol may increase women's satisfaction with the IUD placement procedure, but the evidence is very uncertain (MD 2.00, 95% CI −0.05 to 4.06; 2 RCTs, 226 women; very low‐certainty evidence) Misoprostol side effects before clinic discharge: misoprostol probably results in an increase in preplacement abdominal pain or cramping (RR 2.14, 95% CI 1.42 to 3.23; 7 RCTs, 781 women; moderate‐certainty evidence)and probably results in a slight increase in diarrhea (RR 1.76, 95% CI 1.01 to 3.06; 9 RCTs, 940 women; moderate‐certainty evidence). Adverse events before clinic discharge: misoprostol may result in little to no difference in vasovagal reaction (RR 0.94, 95% CI 0.37 to 2.37; 6 RCTs [3 RCTs had 0 events], 780 women; low‐certainty evidence). We downgraded the evidence due to serious concerns about inconsistency and serious or very serious concerns about imprecision. Authors' conclusions Evidence from RCTs of women seeking routine IUD placement suggests that receiving misoprostol compared to placebo or no treatment makes little to no difference to pain during tenaculum placement or after IUD placement; and may make little to no difference to pain during IUD placement. Misoprostol may make little to no difference to reduced vasovagal reaction, improved providers' ease of placement, or reduced need for cervical dilation; and probably makes little to no difference to placement success, except for women with a recent failed IUD placement attempt, where misoprostol probably leads to a clinically meaningful increase in placement success. Misoprostol use probably leads to clinically important increases in harms, specifically preplacement abdominal pain or cramping and diarrhea. Misoprostol may increase patient satisfaction with the IUD placement procedure, but the evidence is very uncertain. The number of available RCTs did not support examining effect modifiers such as prior vaginal delivery status, misoprostol dose, or IUD type. Funding This review was supported in part by an appointment to the Research Participation Program at the Centers for Disease Control and Prevention (CDC) administered by the Oak Ridge Institute for Science and Education. Registration Protocol (2022): doi.org/10.1002/14651858.CD015584 Plain language summary Is misoprostol an effective treatment for routine intrauterine device (IUD) placement and does it cause unwanted effects? Key messages Using misoprostol (a medication that softens and widens the cervix ‐ the neck of the womb) before placing an intrauterine device (IUD ‐ a contraceptive device placed inside the womb) makes little to no difference to pain when a tool (a tenaculum) is used to hold the cervix in place during IUD placement or pain after IUD placement. It may make little to no difference to pain during placement, ease of placement for providers, or need for cervical widening; and probably makes little to no difference to placement success, except for women who recently tried unsuccessfully to have an IUD placed. Misoprostol‐related unwanted effects like stomach cramps and diarrhea probably increase, but it may make little to no difference to other unwanted events. We don't know whether misoprostol use affects women's satisfaction with the procedure. What is an intrauterine device? An intrauterine device (IUD) is a small t‐shaped device inserted through the cervix (the neck of the womb) into the womb to prevent pregnancy. IUDs need to be placed by a trained doctor, nurse, or healthcare provider. IUD placement may be a painful procedure, and it may be more difficult for women who have not had a baby or who have already tried unsuccessfully to have an IUD placed. Serious unwanted events are rare with IUD placement but women may experience non‐serious unwanted effects similar to period pain (cramps) or light bleeding. What is misoprostol? Misoprostol is a medication that is commonly used to start labor and to treat bleeding following birth. It causes the cervix to soften and widen, and so might make IUD placement less painful for women and easier for providers. Misoprostol may cause some unwanted effects like cramps, sickness or diarrhea. Sometimes women may feel dizzy, sweaty or light‐headed. An IUD is an effective and reversible contraceptive method, so identifying ways to reduce pain and improve ease of placement for providers may reduce barriers to IUD access and use. What did we want to find out? We wanted to find out if misoprostol reduces pain, makes IUD placement easier for providers, reduces the need for other methods to widen the cervix, improves placement success and women's satisfaction with the procedure, and whether it causes unwanted effects. What did we do? We searched for studies that examined misoprostol for routine IUD placement compared to placebo (a sham medication) or no treatment. We combined and analyzed the studies' results and rated our confidence in the evidence, based on factors such as study methods. What did we find? We found 14 RCTs with 1972 women. The studies took place in North America, South America, Europe, and Africa. All the studies compared misoprostol with placebo or no treatment. Main results Pain. Misoprostol: results in little to no difference in pain during tenaculum placement (a tenaculum is a tool that holds the cervix in place during IUD placement) (3 studies, 261 women); may result in little to no difference in pain during IUD placement (7 studies, 766 women); results in little to no difference in pain after IUD placement before leaving the clinic (5 studies, 448 women). Providers' ease of placing the IUD Misoprostol may result in little to no difference in ease of IUD placement for providers (8 studies, 848 women). Need for cervical dilation. Misoprostol: may result in little to no difference in the need for cervical widening for women without a recent failed placement attempt (6 studies, 562 women); probably results in little to no difference in the need for cervical widening for women with a recent failed placement attempt (1 study, 90 women). Placement success. Misoprostol: probably results in little to no difference in placement success for women without a recent failed placement attempt (12 studies, 1579 women); probably results in a slight increase in placement success for women with a recent failed placement attempt (1 study, 90 women). Patient satisfaction We are not sure whether misoprostol increases patient satisfaction with the IUD placement procedure (2 studies, 226 women). Unwanted effects. Misoprostol: probably results in an increase in stomach cramps (7 studies, 781 women); probably results in a slight increase in diarrhea (9 studies, 940 women); may result in little to no difference in dizziness or light‐headedness (6 studies, 780 women). What are the limitations of the evidence? Some studies did not report key information about what we wanted to know, and some studies were different from each other, so we couldn't include them in our analyses. We had planned to examine whether certain factors affected the results, such as whether women had previously given birth vaginally, the dose of misoprostol used, or the type of IUD placed, but there were not enough studies to do this in a meaningful way. How up to date is this evidence? The evidence is up to date to 23 September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Zapata, LB, Snyder, E, Nguyen, AT, Kapp, N, Ti, A, Whiteman, MK, Curtis, KM", "articleTypes": [], "doi": "10.1002/14651858.CD015584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.748Z" }, { "id": "0a373ddf-3793-4e05-a0a7-f2f43a95b6bd", "pmid": "", "title": "Open versus closed surgical exposure of canine teeth that are displaced in the roof of the mouth", "imported": false, "abstract": "Abstract - Background Palatally displaced canines or PDCs are upper permanent canines, commonly known as 'eye' teeth, that are displaced in the roof of the mouth. This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. PDCs are a frequent dental anomaly, present in 2% to 3% of young people. Management of this problem is both time consuming and expensive. It involves surgical exposure (uncovering) followed by fixed braces for two to three years to bring the canine into alignment within the dental arch. Two techniques for exposing palatal canines are routinely used in the UK: the closed technique and the open technique. The closed technique involves uncovering the canine, attaching an eyelet and gold chain and then suturing the palatal mucosa back over the tooth. The tooth is then moved into position covered by the palatal mucosa. The open technique involves uncovering the canine tooth and removing the overlying palatal tissue to leave it uncovered. The orthodontist can then see the crown of the canine to align it. Objectives To assess the effects of using either an open or closed surgical method to expose canines that have become displaced in the roof of the mouth, in terms of success and other clinical and patient‐reported outcomes. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 24 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (in the Cochrane Library, 2017, Issue 1), MEDLINE Ovid (1946 to 24 February 2017), and Embase Ovid (1980 to 24 February 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised and quasi‐randomised controlled trials assessing young people receiving surgical treatment to correct upper PDCs. There was no restriction on age, presenting malocclusion or type of active orthodontic treatment undertaken. We included unilaterally and bilaterally displaced canines. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias in the included studies. We attempted to contact study authors for missing data or clarification where feasible. We followed statistical guidelines from the Cochrane Handbook for Systematic Reviews of Interventions for data synthesis. Main results We included three studies, involving 146 participants. Two studies were assessed as being at high risk of bias. The main finding of the review was that the two techniques may be equally successful at exposing PDCs (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.93 to 1.06; three studies, 141 participants analysed, low‐quality evidence). One surgical failure was due to detachment of the gold chain (closed group). One study reported on complications following surgery and found two in the closed group: a post‐operative infection requiring antibiotics and pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to pool data for dental aesthetics, patient‐reported pain and discomfort, periodontal health and treatment time; however, individual studies did not find any differences between the surgical techniques (low‐ to very low‐quality evidence). Authors' conclusions Currently, the evidence suggests that neither the open or closed surgical technique for exposing palatally displaced maxillary canine teeth is superior for any of the outcomes included in this review; however, we considered the evidence to be low quality, with two of the three included studies being at high risk of bias. This suggests the need for more high‐quality studies. Three ongoing clinical trials have been identified and it is hoped that these will produce data that can be pooled to increase the degree of certainty in these findings. Plain language summary Open versus closed surgical exposure of eye teeth that are displaced in the roof of the mouth Review question Is it better to use an open or closed surgical method to expose eye teeth ('canines') that have become displaced in the roof of the mouth? Background Permanent canine teeth in the upper jaw usually erupt into the mouth between the ages of 11 to 12 years. In 2% to 3% of young people, the canine teeth fail to erupt (grow down) and become displaced in the roof of the mouth (palate).This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. Management of this problem is both time consuming and expensive. It usually involves surgical exposure (uncovering), followed by fixed orthodontic braces for two to three years, to move the canine into the correct position. Two surgical techniques are routinely used in the UK: the closed technique involves uncovering the buried tooth, gluing an attachment onto the exposed tooth and repositioning the palatal flap. Shortly after surgery, an orthodontic brace is used to apply gentle forces to bring the canine into its correct position within the dental arch. The canine moves into position beneath the gum. An alternative method is the open technique, which involves surgically uncovering the canine tooth as before, but instead of placing an attachment onto the exposed tooth, a window of gum from around the tooth is removed and a dressing (pack) placed to cover the exposed area. Approximately 10 days later, this pack is removed and the canine is allowed to erupt naturally. Once the tooth has erupted sufficiently for an orthodontic attachment to be glued onto its surface, orthodontic braces are used to bring the tooth in line with the other teeth. Study characteristics The evidence in this review is up‐to‐date as of February 2017. Authors with Cochrane Oral Health found three relevant studies, involving 146 participants who had eye teeth displaced in the roof of the mouth, either on one or both sides. The majority of participants were female and the average age in the studies ranged from 14 to 17 years. Two studies were designed in a way that made them likely to be biased. Key results We combined results from three studies and found that one technique did not seem to have an advantage over the other for ensuring the movement of the tooth into the correct position without the need for repeat surgery. Five out of 141 participants analysed were surgical failures, one of which was due to the complication of detachment of the gold chain during surgery. One study reported complications after surgery and found one participant in the closed group had a post‐operative infection requiring antibiotics and another participant in the closed group experienced pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to combine results from studies for any other outcomes, but individual studies did not show evidence of a difference between the two techniques for pain, discomfort, appearance, gum health, length of treatment time or cost (low to very low quality evidence). Quality of the evidence Overall, we assessed the quality of the evidence as low, which means we cannot be certain of the findings. Author conclusions It does not seem that one surgical technique is better than the other for moving displaced eye teeth into the correct position, or for other outcomes, but this finding is uncertain because the quality of the evidence is low. This suggests the need for more high‐quality studies. Three studies are currently in process. When they are completed, we will include them in an update of this review and may be able to reach firmer conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Parkin, N; Benson, PE; Thind, B; Shah, A; Khalil, I; Ghafoor, S", "articleTypes": [], "doi": "10.1002/14651858.CD006966.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "0a84b2a6-dc29-4242-85e0-64f281144685", "pmid": "", "title": "Evaluation of the Efficacy of CANNABIDIOL on the Pruritus in Children With Hereditary Epidermolysis Bullosa", "imported": false, "abstract": "Hereditary epidermolysis bullosa (HEB) is a heterogeneous group of rare genetic diseases, characterized by fragility of the skin and mucous membranes, which results in the appearance of mucocutaneous bullae and erosions during minimal trauma. Pruritus is a neuropathic pain mainly related to activation of unmyelinated cutaneous C nerve fibers and is very common in patients with HEB. It is the cause of trophic disorders, aggravation of certain wounds, appearance of new bubbles. In addition, this chronic pruritus can also have a major psychological impact on the patient and his family. However, these therapies used in the pruritus of patients with HEB have often proven to be ineffective.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.265Z" }, { "id": "0a97adb4-f845-4554-9fad-5a5ef6e7bd0a", "pmid": "", "title": "Systemic opioids versus other analgesics and sedatives for postoperative pain in neonates", "imported": false, "abstract": "Abstract - Background Neonates may undergo surgery because of malformations such as diaphragmatic hernia, gastroschisis, congenital heart disease, and hypertrophic pyloric stenosis, or complications of prematurity, such as necrotizing enterocolitis, spontaneous intestinal perforation, and retinopathy of prematurity that require surgical treatment. Options for treatment of postoperative pain include opioids, non‐pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported. The assessment of the effects of opioids is of utmost importance, especially for neonates in substantial pain during the postoperative period. Objectives To evaluate the benefits and harms of systemic opioid analgesics in neonates who underwent surgery on all‐cause mortality, pain, and significant neurodevelopmental disability compared to no intervention, placebo, non‐pharmacological interventions, different types of opioids, or other drugs. Search methods We searched Cochrane CENTRAL, MEDLINE via PubMed and CINAHL in May 2021. We searched the WHO ICTRP, clinicaltrials.gov, and ICTRP trial registries. We searched conference proceedings, and the reference lists of retrieved articles for RCTs and quasi‐RCTs. Selection criteria We included randomized controlled trials (RCTs) conducted in preterm and term infants of a postmenstrual age up to 46 weeks and 0 days with postoperative pain where systemic opioids were compared to 1) placebo or no intervention; 2) non‐pharmacological interventions; 3) different types of opioids; or 4) other drugs. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods, all‐cause mortality during initial hospitalization, major neurodevelopmental disability, and cognitive and educational outcomes in children more than five years old. We used the fixed‐effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) for continuous data. We used GRADE to assess the certainty of evidence for each outcome. Main results We included four RCTs enrolling 331 infants in four countries across different continents. Most studies considered patients undergoing large or medium surgical procedures (including major thoracic or abdominal surgery), who potentially required pain control through opioid administration after surgery. The randomized trials did not consider patients undergoing minor surgery (including inguinal hernia repair) and those individuals exposed to opioids before the beginning of the trial. Two RCTs compared opioids with placebo; one fentanyl with tramadol; and one morphine with paracetamol. No meta‐analyses could be performed because the included RCTs reported no more than three outcomes within the prespecified comparisons. Certainty of the evidence was very low for all outcomes due to imprecision of the estimates (downgrade by two levels) and study limitations (downgrade by one level). Comparison 1: opioids versus no treatment or placebo Two trials were included in this comparison, comparing either tramadol or tapentadol with placebo. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of tramadol compared with placebo on all‐cause mortality during initial hospitalization (RR 0.32, 95% Confidence Interval (CI) 0.01 to 7.70; RD ‐0.03, 95% CI ‐0.10 to 0.05, 71 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 2: opioids versus non‐pharmacological interventions No trials were included in this comparison. Comparison 3: head‐to‐head comparisons of different opioids One trial comparing fentanyl with tramadol was included in this comparison. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of fentanyl compared with tramadol on all‐cause mortality during initial hospitalization (RR 0.99, 95% CI 0.59 to 1.64; RD 0.00, 95% CI ‐0.13 to 0.13, 171 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 4: opioids versus other analgesics and sedatives One trial comparing morphine with paracetamol was included in this comparison. The evidence is very uncertain about the effect of morphine compared with paracetamol on COMFORT pain scores (MD 0.10, 95% CI ‐0.85 to 1.05; 71 participants, 1 study; I² = not applicable). No data were reported on the other critical outcomes, i.e. major neurodevelopmental disability; cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization; retinopathy of prematurity; or intraventricular hemorrhage. Authors' conclusions Limited evidence is available on opioid administration for postoperative pain in newborn infants compared to either placebo, other opioids, or paracetamol. We are uncertain whether tramadol reduces mortality compared to placebo; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether fentanyl reduces mortality compared to tramadol; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether morphine reduces pain compared to paracetamol; none of the studies reported major neurodevelopmental disability, cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization, retinopathy of prematurity, or intraventricular hemorrhage. We identified no studies comparing opioids versus non‐pharmacological interventions. Plain language summary Are opioids the best choice for managing pain in babies after surgery? Key messages • We did not find enough good‐quality evidence about the benefits and risks of opioids (a group of pain‐relieving medicines) to manage pain after surgery in babies. We found only four studies and they had not enrolled enough babies to give reliable results. • Larger, well‐designed studies are needed to give better estimates of the benefits and potential harms of opioids, other medicines and non‐medicine‐based treatments. Why are opioids given to manage pain after surgery in babies? Babies (particularly in the first four weeks after birth) often have to have surgeries. Similar to adults, they need constant pain management after these operations and opioids are commonly used for post‐surgery pain relief in babies. What did we want to find out? We wanted to find out the impact of giving opioids to babies having surgery, compared to: 1) no treatment or placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested); 2) non‐medicine‐based treatments (such as sweet solutions); 3) other medicines; or 4) different types of opioids. What did we do? We searched for studies that compared opioids with the four treatments described above. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included four studies that involved 331 babies. The biggest study was in 171 babies and the smallest study was in 15 babies. • Two studies compared opioids with placebo: it is unclear if opioids have an effect on mortality; no studies reported pain, long‐term development, vision problems (retinopathy of prematurity) or bleeding to the brain (intraventricular hemorrhage). • One study compared one type of opioid to another type of opioid: it is unclear if fentanyl has an effect on mortality compared to tramadol; no studies reported pain, long‐term development, vision problems or bleeding to the brain. • One study compared an opioid to a different type of pain‐relieving medicine: it is unclear if the opioid morphine has an effect on pain compared with paracetamol; no studies reported long‐term development, mortality, vision problems or bleeding to the brain. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results of our outcomes. Also, it is possible that people in the studies were aware of what treatment they were given. Not all the studies provided data about everything that we were interested in. How up‐to‐date is this review? 
We searched for studies that were available up to May 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kinoshita, M; Stempel, KS; Borges do Nascimento, IJ; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD014876.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "0aa91ee9-b253-4ae7-9456-6911238b324f", "pmid": "", "title": "Oral nutritional interventions in hospitalised older people at nutritional risk: a network meta‐analysis of individual participant data", "imported": false, "abstract": "Abstract - Rationale Malnutrition affects 35% to 64% of hospitalised older people, and is associated with adverse health outcomes such as disease complications and hospital readmission. Identifying effective nutritional interventions is essential to improve clinical outcomes and reduce healthcare costs in this population. Objectives To evaluate the effects of various nutritional interventions, compared with either a control group (standard care or placebo) or each other, on patient‐relevant outcomes in hospitalised older people at risk of or with established malnutrition, and to rank the effects of these different interventions using network meta‐analysis (NMA) based on individual participant data (IPD). Search methods We searched CENTRAL, MEDLINE, five other databases, and two trial registries to 2 July 2024, and checked the reference lists of included studies and relevant systematic reviews. Eligibility criteria We included older people (≥ 65 years) hospitalised for different acute conditions at risk of or with malnutrition enrolled in randomised controlled trials (RCTs) comparing oral nutritional interventions with control or each other. For RCTs that met our inclusion criteria, either fully or partially, we requested IPD from the study authors. If we did not receive a response or IPD were unavailable, we used published aggregated data. We excluded RCTs that only partially met the eligibility criteria if neither IPD nor sufficient aggregated data were obtainable. Outcomes Critical outcomes were all‐cause mortality, serious adverse events (SAEs), and functional status (e.g. activities of daily living). Important outcomes were health‐related quality of life (HRQoL), length of hospital stay (LOS), body weight, and fat‐free mass. The main outcome assessment time point was at hospital discharge or 30 days after randomisation. Risk of bias We used the Cochrane risk of bias 2 (RoB 2) tool. Synthesis methods For each outcome, we first analysed IPD within each study. Second, we pooled results in an NMA which also included the aggregated data from RCTs without available IPD. We performed random‐effects NMAs based on the frequentist approach and ranked treatments by P‐scores. We rated the certainty of evidence using the GRADE approach. Included studies We included 21 RCTs (72 reports; 12 RCTs with IPD) with 3309 older participants (mean age ranged from 75 to 85 years; 1863 participants with IPD) with different acute conditions. Interventions included the provision of additional protein (three studies), energy supplements (two studies), oral nutritional supplements (ONS; eight studies), individualised feeding support (two studies), and comprehensive individualised nutritional care (eight studies). In all but two RCTs, interventions were compared to control (standard care with or without a placebo). We judged 16.1% of outcome assessments to be at low risk of bias and 16.8% at high risk. Synthesis of results ONS may reduce all‐cause mortality (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.25 to 0.84; absolute risk difference 57 fewer deaths per 1000 people, 95% CI 79 fewer to 17 fewer; low‐certainty evidence) compared to control, while comprehensive individualised nutritional care may show little to no effect (RR 0.98, 95% CI 0.55 to 1.73; 1 fewer per 1000 people, 95% CI 26 fewer to 46 more; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 13 RCTs, 2728 participants; Q between designs: not applicable (NA)). ONS may reduce SAEs compared to control (RR 0.56, 95% CI 0.32 to 0.95; 84 fewer SAEs per 1000 people, 95% CI 131 fewer to 10 fewer; Q between designs: Q 1.95, df 2, P = 0.3772; low‐certainty evidence ). For all other treatment comparisons, the evidence is very uncertain (NMA with 14 RCTs, 2184 participants). Comprehensive individualised nutritional care may make little to no difference in activities of daily living compared to control (standardised mean difference (SMD) 0.06, 95% CI −0.08 to 0.20; low‐certainty evidence) and ONS compared to energy supplements (SMD −0.15, 95% CI −0.53 to 0.23; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 5 RCTs, 1128 participants; Q between designs: NA). Energy supplements probably make little to no difference in HRQoL compared with ONS (mean difference (MD) 0.01, 95% CI −0.06 to 0.08; Q between designs: NA; moderate‐certainty evidence). All other comparisons of different nutritional interventions may make little to no difference to HRQoL (NMA with 3 RCTs, 1513 participants). The provision of additional protein, energy supplements, ONS, and comprehensive individualised nutritional care may make little to no difference in LOS compared to control (18 RCTs, 3013 participants; Q between designs: Q 2.86, df 3, P = 0.4145). Body weight (16 RCTs, 2114 participants; Q between designs: Q 2.03, df 3, P = 0.5655) may increase with ONS when compared to control (MD 0.9 kg, 95% CI 0.37 to 1.42) or comprehensive individualised nutritional care (MD 1.00 kg, 95% CI 0.12 to 1.87), but the evidence is very uncertain. Energy supplements and ONS probably have similar effects on body weight (MD 0.11 kg, 95% CI −0.85 to 0.63; moderate‐certainty evidence). For fat‐free mass, no meta‐analysis was possible. One RCT (102 participants) compared ONS with energy supplements and found little or no difference between groups (MD 0.13 kg, 95% CI −0.63 to 0.90; low‐certainty evidence), while evidence regarding the effects of additional protein compared with control was very uncertain (1 RCT, 19 participants). Rankings of treatments by P‐scores were not consistent across outcomes. Authors' conclusions In older hospitalised people at risk of or with malnutrition, oral nutritional supplements may reduce mortality and SAEs compared to control 30 days after randomisation . For other outcomes, there may be little or no differences in results. Overall, the evidence was of low to very low certainty, primarily due to a limited number of studies and participants per comparison. The comparison of treatment effects across outcomes was constrained by variations in network structure. When interpreting the results, the heterogeneity of the population in terms of acute and chronic conditions needs to be considered. To improve certainty, adequately powered studies with robust methodologies should compare interventions with controls as well as against each other. Funding The German Federal Ministry of Education and Research funded this work (grant number: 01KG2102). Registration Protocol (2022) doi.org/10.1002/14651858.CD015468 Plain language summary What are the benefits and risks of different types of nutritional support for older, hospitalised people who are malnourished or at risk of malnutrition? Key messages Compared to standard hospital care, specialised foods and drinks may reduce the chances of dying and of having a serious negative health event one month after hospital admission. In terms of people's ability to perform basic daily activities, their quality of life, length of hospital stay, and body weight, we are either very uncertain about the benefits and risks of the different types of nutritional support, or evidence shows they may make little or no difference compared to standard hospital care. Larger and well‐designed studies comparing different types of nutritional support may increase our confidence in these findings. What is malnutrition? People become malnourished when their intake of energy and protein is not enough to meet their body's needs. This condition can reduce someone's fat and muscle stores. Being malnourished threatens people's health and compromises the immune system's ability to fight infections. Older people who are malnourished are at higher risk of disease complications, losing their independence, and dying than non‐malnourished older people. They also experience a lower quality of life. Older people may become malnourished or be at risk of malnutrition for several reasons, including having a reduced appetite, chewing problems, physical limitations (e.g. unable to stand for long periods to prepare meals), and loneliness. Older people in hospital are particularly prone to malnutrition. They may not eat enough at a time when their illness increases their energy and protein needs. Malnutrition affects roughly one‐third to two‐thirds of hospitalised older people. How is malnutrition treated? There is a wide range of treatments for malnutrition, including: specialised foods and beverages that provide extra energy, protein, and other nutrients; practical help with eating and drinking; additional snacks, protein‐rich foods or supplements; nutritional counselling; or tailored combinations of these approaches. What did we want to find out? In older, hospitalised people who are malnourished or at risk of malnutrition, we wanted to know if different types of nutritional support are better than standard care at: reducing the risk of dying and serious negative health events (e.g. complications such as infections or wound healing); improving people's ability to perform basic daily activities and their quality of life; reducing time spent in hospital; and boosting people's body weight and muscle mass. We also wanted to know which type of nutritional support works best. What did we do? We searched for studies in people 65 years and older who were in hospital and malnourished or at risk of malnutrition. We included studies that compared one type of nutritional support to another type, or compared nutritional support to standard hospital care (i.e. usual hospital food service), sometimes in combination with a 'dummy treatment' that looked identical to the supplements tested. We summarised and compared all treatments, and rated our confidence in the results based on factors such as study methods and the numbers of people included. What did we find? We found 21 studies involving 3309 hospitalised older people with different acute conditions. We grouped the treatments they received into five categories: specialised foods and drinks; protein‐enriched foods or supplements; energy supplements; personalised feeding support from an assistant (who would, for example, accommodate food preferences, adjust someone's position, and help with eating); multi‐component personalised nutritional care from a dietitian or nutritionist (who would, for example, modify foods or offer counselling). Main findings Compared to standard hospital care, after a month in hospital, specialised foods and drinks may: reduce the chance of death: they may lead to 57 fewer deaths per 1000 people; reduce serious negative health events: they may lead to 84 fewer events per 1000 people. Compared to standard hospital care, we are either very uncertain about the effects of specialised foods and drinks, protein‐enriched foods or supplements, energy supplements, personalised feeding support, and multi‐component personalised nutritional care, or these treatments may make little or no difference to people's: ability to perform basic daily activities; quality of life; length of hospital stay; body weight and muscle mass. When we compared the different types of nutritional support to each other, we did not find that any one approach worked better than all others in improving the results we measured. What are the limitations of the evidence? Our confidence in the findings is low or very low for several reasons. Some studies used methods that may have led to errors in the results. Studies often involved too few people, or did not look at everything we were interested in, such as muscle mass as outcome or comparisons of different types of nutritional support. Moreover, older people in hospital have different illnesses and functional abilities, and we could not assess how the different types of nutritional support work for different people. How current is this evidence? The evidence is current to 2 July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E; Schwarzer, G; Stadelmaier, J; Lohner, S; Grummich, K; Dagnelie, PC; Beck, AM; Beelen, J; Botella-Carretero, JI; Faxén-Irving, G; Hickson, M; Iff, S; Johansen, A; Sharma, Y; Sorensen, JM; Kaegi-Braun, N; Wunderle, C; Bongaerts, B; Meerpohl, JJ; Norman, K; Schuetz, P; Torbahn, G; Visser, M; Volkert, D; Schwingshackl, L", "articleTypes": [], "doi": "10.1002/14651858.CD015468.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "0aa953a5-d526-4c7f-975d-1f443cacb4aa", "pmid": "", "title": "Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months", "imported": false, "abstract": "Abstract - Background Bronchiolitis is one of the most common respiratory problems in the first year of life. The sputum of infants with bronchiolitis has increased deoxyribonucleic acid (DNA) content, leading to mucous plugging and airway obstruction. Recombinant human deoxyribonuclease (rhDNase), an enzyme that digests extracellular DNA, might aid the clearance of mucus and relieve peripheral airway obstruction. Objectives To determine the effect of nebulised rhDNase on the severity and duration of viral bronchiolitis in children younger than 24 months of age in the hospital setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 7 which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July Week 4, 2012), EMBASE (1974 to August 2012) and LILACS (1982 to August 2012). Selection criteria Randomised controlled trials (RCTs) using nebulised rhDNase alone or with concomitant therapy in children younger than 24 months of age hospitalised with acute bronchiolitis. Data collection and analysis Two review authors independently performed literature searches, assessed trial quality and extracted data. We obtained unpublished data from trial authors. We used Review Manager 5.1 to pool treatment effects expressed as the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI). Main results Three RCTs (333 participants) were identified, two of which were multicentre trials comprising only participants positive for respiratory syncytial virus (RSV). The other trial enrolled participants clinically diagnosed with bronchiolitis from a hospital in Italy. All studies used 2.5 mL (1 mg/mL) of nebulised rhDNase compared with placebo either as a daily or a twice daily dose. Adjunctive therapy included nebulised salbutamol, steroids, supplemental oxygen, intravenous fluids or tube feeding, nasal washing, nasal decongestants and antibiotics. Overall, nebulised rhDNase showed no benefit in clinically meaningful outcomes. Meta‐analysis favoured the control group with a shorter duration of hospital stay (MD 0.50; 95% CI 0.10 to 0.90, P = 0.01) and better clinical score improvement (SMD ‐0.24; 95% CI ‐0.50 to 0.01, P = 0.06). The largest trial showed no difference in supplemental oxygen use or intensive care unit (ICU) admission. In one RCT, four out of 11 patients in the treatment group had atelectasis. Two of these patients showed distinctive clinical improvement after nebulised rhDNase. There was no significant difference in adverse events. These included temporary desaturation, temporary coughing, increased coughing, facial rash, hoarseness, dyspnoea and bad taste, reported in a total of 11 patients from both treatment groups. Authors' conclusions The results based on the three included studies in this review did not support the use of nebulised rhDNase in children under 24 months of age hospitalised with acute bronchiolitis. In these patients, treatment did not shorten the length of hospitalisation or improve clinical outcomes. It might have a role in severe bronchiolitis complicated by atelectasis, but further clinical studies would need to be performed. Plain language summary Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months Bronchiolitis is the most common respiratory illness leading to hospitalisations in infants. Viral infections, particularly respiratory syncytial virus, are the usual cause, which lead to blockage of the small airways of the lungs due to inflammation and increased mucus production. Afflicted children have fever, cough, wheezing and difficulty breathing. Treatment is usually supportive. In bronchiolitis, the mucus produced contains large amounts of DNA, which makes it thicker and stickier. Removal of this DNA facilitates clearance of the mucus. RhDNase is an enzyme that breaks down DNA and hence may improve symptoms. We performed this review to assess the effect of rhDNase delivered through a nebuliser in children under 24 months old hospitalised for bronchiolitis. We identified three randomised controlled trials involving 333 children up to 24 months of age hospitalised with bronchiolitis. All three studies compared nebulised rhDNase with placebo. Any additional treatments were given to both groups. Overall, the studies did not show that nebulised rhDNase shortened the duration of hospital admission, or improved the severity of symptoms. No serious side effects were reported by any of the studies. One study showed that in patients suffering from atelectasis, a severe complication of bronchiolitis wherein the lung does not expand completely, nebulised rhDNase treatment resulted in a distinct improvement within two days. To confirm this beneficial effect, further clinical studies in patients with severe bronchiolitis are needed. Currently, the use of this treatment in young children hospitalised with bronchiolitis is not recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Enriquez, A; Chu, IW; Mellis, C; Lin, WY", "articleTypes": [], "doi": "10.1002/14651858.CD008395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "0ab3ad12-7b23-466d-84a9-ff0d2988b818", "pmid": "", "title": "Probiotics for the prevention of Clostridioides difficile‐associated diarrhea in adults and children", "imported": false, "abstract": "Abstract - Rationale Antibiotics can disturb gastrointestinal microbiota, which may lead to reduced resistance to pathogens such as Clostridioides difficile . Probiotics are live microbial preparations that, when administered in adequate amounts, may confer a health benefit to the host, and are a potential C difficile infection prevention strategy. Objectives To assess the benefits and harms of probiotics for preventing C difficile ‐associated diarrhea (CDAD) in adults and children receiving an antibiotic for any reason. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, and Ovid Embase from 18 March 2017 (search date of the previous version of the review) to 3 March 2025. Eligibility criteria We included randomized controlled trials with a placebo, alternative prophylaxis, or no‐treatment control investigating probiotics (any strain or dose) for the prevention of CDAD in adults and children receiving an antibiotic for any reason. Outcomes The critical outcome was incidence of CDAD. Important outcomes included detection of C difficile in stool (i.e. colonization in absence of symptoms), adverse events, antibiotic‐associated diarrhea (AAD), and length of hospital stay. Risk of bias Two review authors independently assessed risk of bias using Cochrane's RoB 1 tool. Synthesis methods We pooled dichotomous outcomes (e.g . incidence of CDAD) using a random‐effects complete‐case model to calculate the risk ratio (RR) and absolute risk reduction (ARR) and corresponding 95% confidence interval (95% CI). We pooled continuous outcomes (e.g. length of hospital stay) using a random‐effects model to calculate the mean difference (MD) and corresponding 95% CI. We conducted sensitivity analyses to explore the impact of missing outcome data on benefits and harms outcomes. To investigate heterogeneity, we conducted a priori subgroup analyses on risk of bias, probiotic dose, probiotic species, adults versus children, inpatients versus outpatients, and the event rate in the control group for developing CDAD (low 0% to 2%; moderate 3% to 5%; high > 5%). The certainty of the evidence for each outcome was independently assessed using the GRADE approach. Included studies Eight new studies (n = 4595) met our inclusion criteria, for a total of 47 included studies (n = 15,260). Although we noted a high risk of bias in individual studies for sequence generation or allocation concealment, this did not impact our findings. Around 30% of studies lacked a published protocol or clinical trial registration, and in some cases there were inconsistencies between the reported methods and published results. We noted authors' affiliation with a probiotic company and financial support received from probiotic companies in 28 studies. Synthesis of results Evidence from 38 trials (13,179 participants) suggests that probiotics may result in a small absolute risk reduction (ARR) of 1.6% (incidence of 1.6% [110/6787] in the probiotic group versus 3.2% [203/6392] in the control group), and a relative risk reduction (RRR) of 50% (RR 0.50, 95% CI 0.38 to 0.64; P < 0.001; low‐certainty evidence) in incidence of CDAD. Twenty‐seven of 38 trials had missing CDAD data, ranging from 2% to 45%. Our complete‐case CDAD results proved robust to sensitivity analyses of plausible and worst‐plausible assumptions regarding missing outcome data. Pooled results from 16 trials (1302 participants) suggest that probiotics may result in a small absolute reduction in C difficile in stool (i.e. colonization in absence of symptoms) (ARR 2.1%; incidence of 14.9% [101/677] in the probiotic group versus 16.2% [101/625] in the control group; RR 0.87, 95% CI 0.68 to 1.11; P = 0.27; low‐certainty evidence). Thirty‐seven studies (11,911 participants) reported on adverse events. Our pooled analysis indicates that probiotics probably result in a small ARR of 1.7% (incidence of 10.9% [669/6148] in the probiotic group versus 12.2% [701/5763] in the control group), and an RRR of 14.0% (RR 0.86, 95% CI 0.72 to 1.01; P = 0.074; moderate‐certainty evidence). The most common adverse events in both the treatment and control groups were abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. Pooled results from 40 studies (13,419 participants) suggest that probiotics may result in a large ARR of 9% (incidence of 23% [1592/6901] in the probiotic group versus 27.4% [1787/6518] in the control group), and an RRR of 33% (RR 0.67, 95% CI 0.57 to 0.78; P < 0.001; low‐certainty evidence) in incidence of AAD. Only seven trials (6553 participants) investigated length of hospital stay. There is likely little to no difference in length of hospital stay between treatment and control groups (MD −0.07, 95% CI −0.35 to 0.21; P = 0.63; moderate‐certainty evidence). We downgraded the certainty of evidence for CDAD and AAD due to the low number of events or publication bias. We observed some variability in CDAD control group event rate (< 2% to > 5%) that may impact the applicability of evidence depending on clinical setting. We downgraded the certainty of evidence for adverse events due to variation between the results of the studies and for hospital stay due to selective reporting. Authors' conclusions The currently available evidence suggests that probiotics may be effective for preventing CDAD, suggesting that for every 65 people taking probiotics, one case of CDAD may be prevented (number needed to treat for an additional beneficial outcome of 65, 95% CI 48 to 97). There are probably fewer adverse events in the probiotic group. The short‐term use of probiotics may have a small absolute benefit, and is likely not associated with adverse effects when used in patient populations receiving systemic antibiotics who are not immunocompromised. Large trials comparing probiotics with placebo in people with a low baseline risk of CDAD are needed. Funding There was no source of funding for this update. Registration The original review was done in 2013 by Johnston and colleagues, for which the protocol was developed. We followed the methods specified in the 2017 review, while modifying the search strategy and risk of bias assessment for selective reporting for this update. Plain language summary What are the benefits and harms of probiotics for preventing Clostridioides difficile‐ associated diarrhea in adults and children receiving antibiotics for any reason? Key messages In people prescribed antibiotics, probiotics may be effective in preventing Clostridioides difficile ‐associated diarrhea (CDAD), and may reduce the risk of antibiotic‐associated diarrhea. Probiotics probably do not result in harm when taken with an antibiotic, with fewer mild to moderate unwanted effects in the group receiving probiotic than the group receiving placebo (dummy treatment) or no treatment. In those taking antibiotics who do not have a weakened immune system, the short‐term use of probiotics may offer a small benefit, and are likely not harmful. However, additional large studies comparing probiotics with placebo in people with a low risk of CDAD are needed. What is Clostridioides difficile ‐associated diarrhea (CDAD) ? Antibiotics are among the most prescribed medications worldwide. Antibiotic treatment may disturb the balance of organisms that normally populate the gut. This can result in a range of symptoms, most notably diarrhea. C difficile is a particularly dangerous organism that may colonize and infect the gut if the microbial balance has been disrupted. The effects of C difficile infection can vary, with some people having no symptoms, and others suffering diarrhea, severe inflammation, enlargement of the colon, or even death. The cost of treatment is expensive, and the financial burden on the medical system is substantial. What are probiotics? Probiotics are live microorganisms (bacteria or yeast) that provide health benefits when given in adequate amounts. They help to prevent potential disturbances to the gut microbial balance that are associated with antibiotic use, and to reduce the risk of growing harmful bacteria. Probiotics can be found in dietary supplements or yogurts and are widely available as capsules sold in health food stores and supermarkets. As 'functional food' or 'good bacteria,' probiotics have been suggested as a means of both preventing and treating CDAD. What did we want to find out? We wanted to know if probiotics prevent CDAD in adults and children receiving antibiotic therapy, and whether probiotics cause any unwanted effects. The researchers searched the medical literature extensively up to 3 March 2025. What did we do? We searched for studies that compared probiotics (any strain or dose) versus placebo (dummy treatment), alternative preventive treatment, or no treatment for the prevention of CDAD in adults and children receiving antibiotic therapy for any reason. We compared and summarized the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included 47 studies with a total of 15,260 adults and children who received antibiotic therapy along with probiotics, assessing CDAD or C difficile growth. Thirty‐eight studies (13,179 participants) assessed the effectiveness of probiotics for preventing CDAD. Our results suggest that probiotics may result in a small reduction in the risk of CDAD compared to placebo or no treatment. Probiotics may result in a small reduction in C difficile growth (16 studies, 1302 participants). Thirty‐seven studies (11,911 participants) looked at unwanted effects. Our results show that probiotics probably result in a small reduction in the risk of developing unwanted effects compared to placebo or no treatment. The most commonly reported unwanted effects included abdominal cramping, nausea, fever, soft stools, flatulence (gas), and taste disturbance, and were more common in the placebo or no‐treatment group. Forty studies (13,419 participants) reported on antibiotic‐associated diarrhea (AAD); probiotics may result in a large reduction in the risk of AAD compared to placebo or no treatment. Seven studies (6553 participants) reporting on length of hospital stay showed likely little to no difference between probiotics and placebo or no treatment. What are the limitations of the evidence? The studies we reviewed used different types of probiotics, but they didn't directly compare one probiotic to another. This lack of direct comparisons makes it harder to determine which probiotic works best. We have moderate to little confidence in the available evidence. Our confidence is limited because in some studies, people who dropped out of the study or were not followed up on resulted in missing information. The two largest studies in our analysis did not show a clear benefit of probiotics for preventing CDAD. How up‐to‐date is this evidence? The evidence is current to 3 March 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Esmaeilinezhad, Z, Ghosh, NR, Walsh, CM, Steen, JP, Burgman, AM, Mertz, D, Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD006095.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.088Z" }, { "id": "0ab426ec-011b-4231-8759-fab7d09fb752", "pmid": "", "title": "Interventions for pityriasis rosea", "imported": false, "abstract": "Abstract - Background Pityriasis rosea is a scaly, itchy rash that mainly affects young adults and lasts for 2 to 12 weeks. The effects of many available treatments are uncertain. This is an update of a Cochrane Review first published in 2007. Objectives To assess the effects of interventions for the management of pityriasis rosea in any individual diagnosed by a medical practitioner. Search methods We updated our searches of the following databases to October 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched five trials registers. We also checked the reference lists of included and excluded studies, contacted trial authors, scanned the abstracts from major dermatology conference proceedings, and searched the CAB Abstracts database. We searched PubMed for adverse effects to November 2018. Selection criteria Randomised controlled trials of interventions in pityriasis rosea. Treatment could be given in a single therapy or in combination. Eligible comparators were no treatment, placebo, vehicle only, another active compound, or placebo radiation treatment. Data collection and analysis We used standard methodological procedures expected by the Cochrane. Our key outcomes were good or excellent rash improvement within two weeks, rated separately by the participant and medical practitioner; serious adverse events; resolution of itch within two weeks (participant‐rated); reduction in itch score within two weeks (participant‐rated); and minor participant‐reported adverse events not requiring withdrawal of the treatment. Main results We included 14 trials (761 participants). In general, risk of selection bias was unclear or low, but risk of performance bias and reporting bias was high for 21% of the studies. Participant age ranged from 2 to 60 years, and sex ratio was similar. Disease severity was measured by various severity indices, which the included studies did not categorise. Six studies were conducted in India, three in Iran, two in the Philippines, and one each in Pakistan, the USA, and China. The included studies were conducted in dermatology departments and a paediatric clinic. Study duration ranged from 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding source. The included studies assessed macrolide antibiotics, an antiviral agent, phototherapy, steroids and antihistamine, and Chinese medicine. None of the studies measured participant‐rated good or excellent rash improvement. All reported outcomes were assessed within two weeks of treatment, except for adverse effects, which were measured throughout treatment. There is probably no difference between oral clarithromycin and placebo in itch resolution (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.47 to 1.52; 1 study, 28 participants) or rash improvement (medical practitioner‐rated) (RR 1.13, 95% CI 0.89 to 1.44; 1 study, 60 participants). For this comparison, there were no serious adverse events (1 study, 60 participants); minor adverse events and reduction in itch score were not measured; and all evidence was of moderate quality. When compared with placebo, erythromycin may lead to increased rash improvement (medical practitioner‐rated) (RR 4.02, 95% CI 0.28 to 56.61; 2 studies, 86 participants, low‐quality evidence); however, the 95% CI indicates that the result may also be compatible with a benefit of placebo, and there may be little or no difference between treatments. Itch resolution was not measured, but one study measured reduction in itch score, which is probably larger with erythromycin (MD 3.95, 95% CI 3.37 to 4.53; 34 participants, moderate‐quality evidence). In the same single, small trial, none of the participants had a serious adverse event, and there was no clear difference between groups in minor adverse events, which included gastrointestinal upset (RR 2.00, CI 0.20 to 20.04; moderate‐quality evidence). Two trials compared oral azithromycin to placebo or vitamins. There is probably no difference between groups in itch resolution (RR 0.83, 95% CI 0.28 to 2.48) or reduction in itch score (MD 0.04, 95% CI −0.35 to 0.43) (both outcomes based on one study; 70 participants, moderate‐quality evidence). Low‐quality evidence from two studies indicates there may be no difference between groups in rash improvement (medical practitioner‐rated) (RR 1.02, 95% CI 0.52 to 2.00; 119 participants). In these same two studies, no serious adverse events were reported, and there was no clear difference between groups in minor adverse events, specifically mild abdominal pain (RR 5.82, 95% CI 0.72 to 47.10; moderate‐quality evidence). Acyclovir was compared to placebo, vitamins, or no treatment in three trials (all moderate‐quality evidence). Based on one trial (21 participants), itch resolution is probably higher with placebo than with acyclovir (RR 0.34, 95% CI 0.12 to 0.94); reduction in itch score was not measured. However, there is probably a significant difference between groups in rash improvement (medical practitioner‐rated) in favour of acyclovir versus all comparators (RR 2.45, 95% CI 1.33 to 4.53; 3 studies, 141 participants). Based on the same three studies, there were no serious adverse events in either group, and there was probably no difference between groups in minor adverse events (only one participant in the placebo group experienced abdominal pain and diarrhoea). One trial compared acyclovir added to standard care (calamine lotion and oral cetirizine) versus standard care alone (24 participants). The addition of acyclovir may lead to increased itch resolution (RR 4.50, 95% CI 1.22 to 16.62) and reduction in itch score (MD 1.26, 95% CI 0.74 to 1.78) compared to standard care alone. Rash improvement (medical practitioner‐rated) was not measured. The trial reported no serious adverse events in either group, and there may be no difference between groups in minor adverse events, such as headache (RR 7.00, 95% CI 0.40 to 122.44) (all results based on low‐quality evidence). Authors' conclusions When compared with placebo or no treatment, oral acyclovir probably leads to increased good or excellent, medical practitioner‐rated rash improvement. However, evidence for the effect of acyclovir on itch was inconclusive. We found low‐ to moderate‐quality evidence that erythromycin probably reduces itch more than placebo. Small study sizes, heterogeneity, and bias in blinding and selective reporting limited our conclusions. Further research is needed to investigate different dose regimens of acyclovir and the effect of antivirals on pityriasis rosea. Plain language summary Treatments for pityriasis rosea Background Pityriasis rosea is a common scaly rash prevalent in young adults. A patch of redness and scales is followed by widespread rash. Pityriasis rosea usually resolves within 2 to 12 weeks; however, the rash can resemble a serious contagious skin condition, causing concern. Moreover, pityriasis rosea can cause moderate to severe itching, making effective treatment necessary. Review question We wanted to evaluate the effectiveness and safety of treatments for pityriasis rosea. Eligible treatments were topical, systemic (oral or injected medicines that work throughout the entire body), or light therapy, given alone or in combination with another treatment, and compared against no treatment, placebo (an identical but inactive treatment), vehicle (inactive ingredients that help deliver an active treatment) only, or another active treatment. As spontaneous recovery usually occurs between 2 and 12 weeks in cases of untreated pityriasis rosea, we considered outcomes reported at two weeks. Study characteristics The evidence is current to October 2018. We included 14 studies with a total of 761 participants aged between 2 and 60 years (similar numbers of males and females). Most studies were conducted in Asia in dermatology departments and lasted between 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding sources. Disease severity was assessed by various measures, but participants were not categorised into mild, moderate, or severe disease. Important treatments assessed by the studies included various antibiotics and acyclovir (a drug meant to treat herpes infections), which were compared to placebo, no treatment, or standard care. Additional treatments included phototherapy, corticosteroids and antihistamine, and Chinese medicine (potenline). Most studies assessed treatment used for one week. All reported outcomes were assessed within two weeks of treatment, except for side effects, which were measured throughout treatment. None of the included studies reported on the participant's rating of rash improvement. Itch was always participant‐assessed. Rash improvement was rated as good or excellent. There is probably no difference between clarithromycin and placebo in medical practitioner‐rated rash improvement or itch resolution, and no serious adverse events were reported (all moderate‐quality evidence). Reduction in itch score and minor side effects were not measured. Similarly, there may be no difference in medical practitioner‐rated rash improvement between azithromycin and placebo or vitamins, but erythromycin may lead to increased rash improvement when compared to placebo; however, the results show there may be a benefit with placebo or little or no difference between treatments (low‐quality evidence for both outcomes). There is probably no difference between azithromycin and comparators in itch resolution or reduction in itch score; there was no clear difference in minor side effects, such as mild abdominal pain (both moderate‐quality evidence). When comparing erythromycin to placebo, itch resolution was not measured, but there is probably a greater reduction in itch score with erythromycin. There was no clear difference in the likelihood of minor side effects, such as gastrointestinal upset, between groups (moderate‐quality evidence for both outcomes). A single study suggested that acyclovir is probably less effective than placebo in achieving itch resolution (but itch score reduction was not measured). However, results from three studies indicate that acyclovir is probably significantly more beneficial than placebo, no treatment, or vitamin tablets in medical practitioner‐rated rash improvement. There is probably no difference between acyclovir and placebo in the incidence of minor side effects: one participant in the placebo group experienced mild abdominal pain and diarrhoea (all outcomes based on moderate‐quality evidence). A single trial indicated that acyclovir used in combination with standard care (calamine (anti‐itch lotion) and the antihistamine cetirizine) may reduce itch score and increase itch resolution (low‐quality evidence). Medical practitioner‐rated rash improvement was not measured. There may be no difference between groups in minor side effects, such as headache, increased sleep, sickness, and impact on taste. None of the studies reported serious adverse events (low‐ to moderate‐quality evidence). Quality of the evidence The quality of the evidence for the main comparisons was low to moderate. Many of the results were based on a small number of trials, with a low number of participants. There was also some variation amongst the trial results and concerns over study design.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Contreras‐Ruiz, J; Peternel, S; Jiménez Gutiérrez, C; Culav‐Koscak, I; Reveiz, L; Silbermann‐Reynoso, MDL", "articleTypes": [], "doi": "10.1002/14651858.CD005068.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "0abf0a41-9a05-457e-826d-9bc1d3d5ea3e", "pmid": "", "title": "Paediatric formulations of artemisinin‐based combination therapies for treating uncomplicated malaria in children", "imported": false, "abstract": "Abstract - Background In endemic malarial areas, young children have high levels of malaria morbidity and mortality. The World Health Organization recommends oral artemisinin‐based combination therapy (ACT) for treating uncomplicated malaria. Paediatric formulations of ACT have been developed to make it easier to treat children. Objectives To evaluate evidence from trials on the efficacy, safety, tolerability, and acceptability of paediatric ACT formulations compared to tablet ACT formulations for uncomplicated P falciparum malaria in children up to 14 years old. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; the Latin American and Caribbean Health Science Information database (LILACS); ISI Web of Science; Google Scholar; Scopus; and the metaRegister of Controlled Trials (mRCT) to 11 December 2019. Selection criteria We included randomised controlled clinical trials (RCTs) of paediatric versus non‐paediatric formulated ACT in children aged 14 years or younger with acute uncomplicated malaria. Data collection and analysis Two authors independently assessed eligibility and risk of bias, and carried out data extraction. We analyzed the primary outcomes of efficacy, safety and tolerability of paediatric versus non‐paediatric ACT using risk ratios (RR) and 95% confidence intervals (CI). Secondary outcomes were: treatment failure on the last day of observation (day 42), fever clearance time, parasite clearance time, pharmacokinetics, and acceptability. Main results Three trials met the inclusion criteria. Two compared a paediatric dispersible tablet formulation against crushed tablets of artemether‐lumefantrine (AL) and dihydroartemisinin‐piperaquine (DHA‐PQ), and one trial assessed artemether‐lumefantrine formulated as powder for suspension compared with crushed tablets. The trials were carried out between 2006 and 2015 in sub‐Saharan Africa (Benin, Mali, Mozambique, Tanzania, Kenya, Democratic Republic of the Congo, Burkina Faso, and The Gambia). In all three trials, the paediatric and control ACT achieved polymerase chain reaction (PCR)‐adjusted treatment failure rates of < 10% on day 28 in the per‐protocol (PP) population. For the comparison of dispersible versus crushed tablets, the two trials did not detect a difference for treatment failure by day 28 (PCR‐adjusted PP population: RR 1.35, 95% CI 0.49 to 3.72; 1061 participants, 2 studies, low‐certainty evidence). Similarly, for the comparison of suspension versus crushed tablet ACT, we did not detect any difference in treatment failure at day 28 (PCR‐adjusted PP population: RR 1.64, 95% CI 0.55 to 4.87; 245 participants, 1 study). We did not detect any difference in serious adverse events for the comparison of dispersible versus crushed tablets (RR 1.05, 95% CI 0.38 to 2.88; 1197 participants, 2 studies, low‐certainty evidence), or for the comparison of suspension versus crushed tablet ACT (RR 0.74, 95% CI 0.17 to 3.26; 267 participants, 1 study). In the dispersible ACT arms, drug‐related adverse events occurred in 9% of children in the AL study and 34% of children in the DHA‐PQ study. In the control arms, drug‐related adverse events occurred in 12% of children in the AL study and in 42% of children in the DHA‐PQ study. Drug‐related adverse events were lower in the dispersible ACT arms (RR 0.78, 95% CI 0.62 to 0.99; 1197 participants, 2 studies, moderate‐certainty evidence). There was no detected difference in the rate of drug‐related adverse events for suspension ACT versus crushed tablet ACT (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study). Drug‐related vomiting appeared to be less common in the dispersible ACT arms (RR 0.75, 95% CI 0.56 to 1.01; 1197 participants, 2 studies, low‐certainty evidence) and in the suspension ACT arm (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study), but both analyses were underpowered. No study assessed acceptability. Authors' conclusions Trials did not demonstrate a difference in efficacy between paediatric dispersible or suspension ACT when compared with the respective crushed tablet ACT for treating uncomplicated P falciparum malaria in children. However, the evidence is of low to moderate certainty due to limited power. There appeared to be fewer drug‐related adverse events with dispersible ACT compared to crushed tablet ACT. None of the included studies assessed acceptability of paediatric ACT formulation. Plain language summary Treating uncomplicated malaria in children: do child‐friendly formulations of medicines work better than usual tablet formulations? What is the aim of this review? We wanted to find out about the potential benefits and harms of child‐friendly formulations of artemisinin‐based combination therapy (ACT) to treat uncomplicated malaria in children. We searched for studies that investigated the use of child‐friendly formulations of ACTs, compared with the usual ACT tablet formulations, to treat uncomplicated malaria in children aged under 14 years. We looked for randomized controlled studies, in which the treatments the children received were decided at random. This type of study usually gives the most reliable evidence about the effects of a treatment. We found three relevant studies of two child‐friendly formulations. Key messages Child‐friendly formulations of ACT probably work as well as crushed tablets to treat uncomplicated malaria in children, and probably cause fewer unwanted effects. What was studied in this review? Malaria is a tropical disease spread by mosquitoes infected with Plasmodium parasites. The most common, and most serious, type of malaria is caused by Plasmodium falciparum . This parasite causes high levels of illness and death, particularly in young children in regions where malaria is widespread. Malaria can be a mild illness, but is sometimes severe and life‐threatening if not treated soon enough or with the right medicines. Medicines based on artemisinin, a compound derived from a plant ( Artemisia annua ), are commonly taken by mouth (orally) to treat malaria in combination with other drugs. The World Health Organization recommends treating uncomplicated malaria with oral artemisinin‐based combination therapy (called ACT). Oral ACT tablets are often crushed to help make them easier for children to swallow. New formulations of oral ACTs have been developed especially for children, such as syrups, and granules, powders or tablets that can be dissolved in water, and which may be flavoured. What are the main results of this review? We found three relevant studies in 1306 children (aged 6 months to 11 years) with uncomplicated malaria. The studies were conducted in sub‐Saharan Africa between 2006 and 2015. All studies were funded by pharmaceutical companies that made child‐friendly formulations of the ACTs. The studies compared crushed ACT tablets to child‐friendly formulations of ACTs: these were dissolvable tablets of artemether‐lumefantrine or dihydroartemisinin‐piperaquine, or artemether‐lumefantrine syrup. We were interested in: · whether children remained cured of malaria after 28 days (measured by absence of Plasmodium parasites in the blood); and · whether the medicines caused any unwanted effects. None of the studies looked at how any of the medicine formulations were accepted by children. There may be little or no difference between the child‐friendly formulations of ACTs (dissolvable tablets or syrup) and the usual crushed tablets for how many children: · were successfully treated after 28 days; or · experienced serious unwanted effects. The crushed ACT tablets and the child‐friendly formulations successfully treated most cases of uncomplicated malaria. After 28 days the rates of treatment failure were similar in both groups. On average, 59 of every 1000 children taking crushed ACT tablets and 62 of every 1000 children taking dissolvable tablets would still have Plasmodium infection (2 studies; 1139 children). Similar numbers of serious unwanted effects were reported for the usual crushed tablets and the dissolvable tablets (2 studies; 1197 children) or syrup (1 study; 267 children), therefore differences as a result of the formulation are unlikely. A dissolvable tablet probably reduces unwanted effects of the medicine, including vomiting (throwing up), compared with the usual crushed tablets. Children taking dissolvable tablets had fewer unwanted effects associated with the medicine (139 of every 1000 children) than those taking crushed tablets (178 of every 1000 children). There was no difference in the number of unwanted effects found in the study with the syrup formulation compared with the usual crushed tablets. Our confidence in our results is low to moderate. The results come from a small number of studies. All studies were supported by manufacturers of the child‐friendly formulations, which could have affected how the studies were designed, conducted, and reported. How up‐to‐date is this review? We searched for studies that had been published up to 11 December 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bélard, S, Ramharter, M, Kurth, F", "articleTypes": [], "doi": "10.1002/14651858.CD009568.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.075Z" }, { "id": "0ac03a47-0dad-4428-b7c5-2eb13b51cad4", "pmid": "", "title": "Xiao Chai Hu Tang, a herbal medicine, for chronic hepatitis B", "imported": false, "abstract": "Abstract - Background Chronic hepatitis B is associated with high morbidity and mortality. Chronic hepatitis B requires long‐term management aiming at reduction of the risks of hepatocellular inflammatory necrosis, liver fibrosis, decompensated liver cirrhosis, liver failure, and liver cancer, and improving health‐related quality of life. The Chinese herbal medicine formula Xiao Chai Hu Tang has been used to decrease discomfort and replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established with rigorous review methodology. Objectives To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and seven other databases to 1 March 2019. We also searched the World Health Organization International Clinical Trials Registry Platform ( www.who.int/ictrp ), ClinicalTrials.gov ( www.clinicaltrials.gov/ ), and the Chinese Clinical Trial Registry for ongoing or unpublished trials to 1 March 2019. Selection criteria We included randomised clinical trials, irrespective of publication status, language, and blinding, comparing Xiao Chai Hu Tang formula versus no intervention or placebo in people with chronic hepatitis B. We included participants of any sex and age, diagnosed with chronic hepatitis B according to guidelines or as defined by the trialists. We allowed co‐interventions when the co‐interventions were administered equally to all the intervention groups. Data collection and analysis Review authors independently retrieved data from reports and after correspondence with investigators. Our primary outcomes were all‐cause mortality, serious adverse events, and health‐related quality of life. Our secondary outcomes were hepatitis B‐related mortality, hepatitis B‐related morbidity, and adverse events considered 'not to be serious'. We presented the meta‐analysed results as risk ratios (RR) with 95% confidence intervals (CI). We assessed the risks of bias using risk of bias domains with predefined definitions. We used GRADE methodology to evaluate our certainty in the evidence. Main results We included 10 randomised clinical trials with 934 participants, but only five trials with 490 participants provided data for analysis. All the trials compared Xiao Chai Hu Tang formula with no intervention. All trials appeared to have been conducted and published only in China. The included trials assessed heterogeneous forms of Xiao Chai Hu Tang formula, administered for three to eight months. One trial included participants with hepatitis B and comorbid tuberculosis, and one trial included participants with hepatitis B and liver cirrhosis. The remaining trials included participants with hepatitis B only. All the trials were at high risk of bias, and the certainty of evidence for all outcomes that provided data for analyses was very low. We downgraded the evidence by one or two levels because of outcome risk of bias, inconsistency or heterogeneity of results (opposite direction of effect), indirectness of evidence (use of surrogate outcomes instead of clinically relevant outcomes), imprecision of results (the CIs were wide), and publication bias (small sample size of the trials). Additionally, 47 trials lacked the necessary methodological information needed to ensure the inclusion of these trials in our review. None of the included trials aimed to assess clinically relevant outcomes such as all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, or hepatitis B‐related morbidity. The effects of Xiao Chai Hu Tang formula on the proportion of participants with adverse events considered 'not to be serious' is uncertain (RR 0.43, 95% CI 0.02 to 11.98; I 2 = 69%; very low‐certainty evidence). Only three trials with 222 participants reported the proportion of people with detectable hepatitis B virus DNA (HBV‐DNA), but the evidence that Xiao Chai Hu Tang formula reduces the presence of HBV‐DNA in the blood (a surrogate outcome) is uncertain (RR 0.62, 95% CI 0.45 to 0.85; I 2 = 0%; very low‐certainty evidence). Only two trials with 160 participants reported the proportion of people with detectable hepatitis B virus e‐antigen (HBeAg; a surrogate outcome) (RR 0.72, 95% CI 0.50 to 1.02; I 2 = 38%; very low‐certainty evidence) and the evidence is uncertain. The evidence is also uncertain for separately reported adverse events considered 'not to be serious'. Funding: two of the 10 included trials received academic funding from government or hospital. None of the remaining eight trials reported information on funding. Authors' conclusions The clinical effects of Xiao Chai Hu Tang formula for chronic hepatitis B remain unclear. The included trials were small and of low methodological quality. Despite the wide use of Xiao Chai Hu Tang formula, we lack data on all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, and hepatitis B‐related morbidity. The evidence in this systematic review comes from data obtained from a maximum three trials. We graded the certainty of evidence as very low for adverse events considered not to be serious and the surrogate outcomes HBeAg and HBV‐DNA. We found a large number of trials which lacked clear description of their design and conduct, and hence, these trials are not included in the present review. As all identified trials were conducted in China, there might be a concern about the applicability of this review outside China. Large‐sized, high‐quality randomised sham‐controlled trials with homogeneous groups of participants and transparent funding are lacking. Plain language summary Xiao Chai Hu Tang, a Chinese herbal medicine formula, for chronic hepatitis B Review question To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B virus infection. Background Chronic hepatitis B virus infection is a common liver disease, associated with high morbidity (illness) and death. It causes psychological stress and is a burden to people with chronic hepatitis B and their families. Xiao Chai Hu Tang formula has been used for treating people with chronic hepatitis B as it is believed that it decreases discomfort and prevents the replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established in reviews with rigorous review methodology. Search date The review includes trials published up to 1 March 2019. Study characteristics We included 10 randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) with 934 participants. All trials compared Xiao Chai Hu Tang formula with no treatment. The trials assessed different formulas and doses for three to eight months. One trial included participants with tuberculosis (a disease of the lungs that can make you cough mucous), and one trial included participants with liver cirrhosis (scarring). Only five trials with 490 participants provided data for analysis Study funding sources Two of the 10 included trials reported receiving academic funding. None of the remaining eight trials reported information of support or funding. Key results None of the 10 included trials reported data on all‐cause mortality (death from any cause), serious side effects (untoward medical occurrences that result in serious outcomes such as death or disability), health‐related quality of life (a measure of physical, mental, emotional, and social functioning a measure of a person's satisfaction with their life and health), hepatitis B‐related death, and hepatitis B‐related morbidity. We are uncertain whether Xiao Chai Hu Tang formula versus no intervention has a positive or negative effect regarding side effects considered 'not to be serious', the proportion of people with detectable HBeAg (a hepatitis B viral protein that indicates active viral replication), and separately reported side effects considered 'not to be serious'. Xiao Chai Hu Tang formula compared with no intervention seems to reduce the proportion of people with detectable HBV‐DNA (which is used to indicate how much hepatitis B virus is in the blood) but the reliability of this finding is low. Surrogate outcomes are markers that are used in research as a substitute for a clinically meaningful measure that directly measures patient outcomes. We cannot always be certain that such surrogate outcomes are reliable substitutes for important outcomes as they need to be officially examined. Caution is needed with this beneficial finding as the trials are at high risk of bias, and this outcome has not yet been proven relevant to patients. We identified an additional 47 studies as potential randomised clinical trials, but the data they reported were of no use. Accordingly, properly designed randomised clinical trials are needed before the benefits and harms of Xiao Chai Hu Tang formula for chronic hepatitis B can be determined. Reliability of the evidence The reliability of the evidence on the use of Xiao Chai Hu Tang formula in people with chronic hepatitis B virus in terms of its beneficial or harmful effects on death, health‐related quality of life, risk of dying due to hepatitis B virus infection, and serious side effects cannot be determined as no trials aimed to explore these. The reliability of the evidence that Xiao Chai Hu Tang formula, when compared with no intervention, in terms of side effects considered 'not to be serious', the proportion of people with detectable HBV‐DNA, and the proportion of people with detectable HBeAg is very low. These assessments of the reliability of the evidence are due to the poor design and reporting of the included trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kong, DZ, Liang, N, Yang, GL, Zhang, Z, Liu, Y, Li, J, Liu, X, Liang, S, Nikolova, D, Jakobsen, JC, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.744Z" }, { "id": "0ae5fe08-399d-4a2e-a56c-963feb867e52", "pmid": "", "title": "Eplerenone for hypertension", "imported": false, "abstract": "Abstract - Background Eplerenone is an aldosterone receptor blocker that is chemically derived from spironolactone. In Canada, it is indicated for use as adjunctive therapy to reduce mortality for heart failure patients with New York Heart Association (NYHA) class II systolic chronic heart failure and left ventricular systolic dysfunction. It is also used as adjunctive therapy for patients with heart failure following myocardial infarction. Additionally, it is indicated for the treatment of mild and moderate essential hypertension for patients who cannot be treated adequately with other agents. It is important to determine the clinical impact of all antihypertensive medications, including aldosterone antagonists, to support their continued use in essential hypertension. No previous systematic reviews have evaluated the effect of eplerenone on cardiovascular morbidity, mortality, and magnitude of blood pressure lowering in patients with hypertension. Objectives To assess the effects of eplerenone monotherapy versus placebo for primary hypertension in adults. Outcomes of interest were all‐cause mortality, cardiovascular events (fatal or non‐fatal myocardial infarction), cerebrovascular events (fatal or non fatal strokes), adverse events or withdrawals due to adverse events, and systolic and diastolic blood pressure. Search methods We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers up to 3 March 2016. We handsearched references from retrieved studies to identify any studies missed in the initial search. We also searched for unpublished data by contacting the corresponding authors of the included studies and pharmaceutical companies involved in conducting studies on eplerenone monotherapy in primary hypertension. The search had no language restrictions. Selection criteria We selected randomized placebo‐controlled trials studying adult patients with primary hypertension. We excluded studies in people with secondary or gestational hypertension and studies where participants were receiving multiple antihypertensives. Data collection and analysis Three review authors independently reviewed the search results for studies meeting our criteria. Three review authors independently extracted data and assessed trial quality using a standardized data extraction form. A fourth independent review author resolved discrepancies or disagreements. We performed data extraction and synthesis using a standardized format on Covidence. We conducted data analysis using Review Manager 5. Main results A total of 1437 adult patients participated in the five randomized parallel group studies, with treatment durations ranging from 8 to 16 weeks. The daily doses of eplerenone ranged from 25 mg to 400 mg daily. Meta‐analysis of these studies showed a reduction in systolic blood pressure of 9.21 mmHg (95% CI −11.08 to −7.34; I 2 = 58%) and a reduction of diastolic pressure of 4.18 mmHg (95% CI −5.03 to −3.33; I 2 = 0%) (moderate quality evidence). There may be a dose response effect for eplerenone in the reduction in systolic blood pressure at doses of 400 mg/day. However, this finding is uncertain, as it is based on a single included study with low quality evidence. Overall there does not appear to be a clinically important dose response in lowering systolic or diastolic blood pressure at eplerenone doses of 50 mg to 400 mg daily. There did not appear to be any differences in the number of patients who withdrew due to adverse events or the number of patients with at least one adverse event in the eplerenone group compared to placebo. However, only three of the five included studies reported adverse events. Most of the included studies were of moderate quality, as we judged multiple domains as being at unclear risk in the 'Risk of bias' assessment. Authors' conclusions Eplerenone 50 to 200 mg/day lowers blood pressure in people with primary hypertension by 9.21 mmHg systolic and 4.18 mmHg diastolic compared to placebo, with no difference of effect between doses of 50 mg/day to 200 mg/day. A dose of 25 mg/day did not produce a statistically significant reduction in systolic or diastolic blood pressure and there is insufficient evidence for doses above 200 mg/day. There is currently no available evidence to determine the effect of eplerenone on clinically meaningful outcomes such as mortality or morbidity in hypertensive patients. The evidence available on side effects is insufficient and of low quality, which makes it impossible to draw conclusions about potential harm associated with eplerenone treatment in hypertensive patients. Plain language summary Eplerenone for high blood pressure Review question The aim of this review was to determine the effectiveness of eplerenone for reducing blood pressure, its side effect profile, and its impact on clinically meaningful outcomes such as mortality and morbidity. Background Clinicians have used eplerenone to treat high blood pressure since 2002. It is important to determine the clinical impact of all antihypertensive medications used in patients to support their continued use in essential hypertension. We searched multiple databases and found five eligible studies in 1437 people who received either eplerenone or no medication in a random fashion. Study characteristics The doses of eplerenone used in these studies ranged from 25 mg to 400 mg daily. These studies followed patients for 8 to 16 weeks while on therapy. None of the studies reported on the clinically meaningful outcomes of eplerenone, such as whether eplerenone can reduce heart attacks, stroke, or death compared to placebo. Only three of the five studies reported on side effects. Key results There is currently no evidence that eplerenone has a beneficial effect on life expectancy or complications rleated to hypertension (e.g. heart attack, stroke). Evidence for risk of side effects with eplerenone is limited and of poor quality; it is difficult to tell the extent of possible harm with eplerenone versus placebo. This meta‐analysis shows that eplerenone 50 to 200 mg/day reduces systolic blood pressure by approximately 9 mmHg and diastolic blood pressure by 4 mmHg compared to taking no medication. Quality of the evidence We judged the five included trials to be of moderate quality, as authors did not extensively describe portions of their methodology.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tam, TSC; Wu, MHY; Masson, SC; Tsang, MP; Stabler, SN; Kinkade, A; Tung, A; Tejani, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "0afb99a9-d755-4811-a0e8-b57df130a3fd", "pmid": "", "title": "Interventions for leg cramps in pregnancy", "imported": false, "abstract": "Abstract - Background Many women experience leg cramps in pregnancy. They become more common as pregnancy progresses and are especially troublesome at night. Objectives The objective of this review was to assess methods of preventing and treating leg cramps in pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2001). We updated this search on 4 July 2011 and added the results to the awaiting classification section. Selection criteria Randomised trials of treatments for leg cramps in pregnancy. Data collection and analysis Trial quality was assessed and data were extracted independently by two reviewers. Main results Five trials involving 352 women were included. The trials were of moderate quality. The only placebo‐controlled trial of calcium treatment showed no evidence of benefit. Trials comparing sodium chloride with placebo (odds ratio 0.54, 95% confidence interval 0.23 to 1.29) and calcium with sodium chloride (odds ratio 1.23, 95% confidence intervals 0.47 to 3.27 ) showed no evidence of benefit. Placebo controlled trials of multivitamin with mineral supplements (odds ratio 0.23, 95% confidence intervals 0.05 to 1.01) and magnesium (odds ratio 0.18, 95% confidence intervals 0.05 to 0.60) provided some suggestion of benefit. Authors' conclusions The evidence that calcium reduces cramp is weak and seems to depend on placebo effect. The evidence for sodium chloride is stronger but the results of the sodium chloride trial may no longer be relevant because of dietary changes which include an increased sodium intake in the general population. It is not possible to recommend multivitamins with mineral supplementation, as it is not clear which ingredient, if any, is helping. If a woman finds cramp troublesome in pregnancy, the best evidence is for magnesium lactate or citrate taken as 5mmol in the morning and 10mmol in the evening. [Note: The five citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Interventions for leg cramps in pregnancy Sodium supplements may decrease the number of cramp attacks experienced by women in pregnancy but the effect is slight. Calcium is of no benefit. The evidence of benefit for magnesium is stronger. Multivitamin and mineral supplements also seem to help but the relevance of this is unclear as the preparation used contained twelve separate constituents and it is not possible to discover which of these was effective, or indeed if there was synergy between constituents. There is a theoretical risk that sodium supplementation could raise blood pressure. It is unlikely that magnesium supplementation would be harmful at the suggested doses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Young, G, Jewell, D", "articleTypes": [], "doi": "10.1002/14651858.CD000121", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.062Z" }, { "id": "0b155aeb-9c66-4e6e-8271-1bade06c638b", "pmid": "", "title": "Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Benson, PE, Parkin, N, Dyer, F, Millett, DT, Germain, P", "articleTypes": [], "doi": "10.1002/14651858.CD003809.pub4 AB - Abstract - Background Early dental decay or demineralised lesions (DLs, also known as white spot lesions) can appear on teeth during fixed orthodontic (brace) treatment. Fluoride reduces decay in susceptible individuals, including orthodontic patients. This review compared various forms of topical fluoride to prevent the development of DLs during orthodontic treatment. This is the second update of the Cochrane Review first published in 2004 and previously updated in 2013. Objectives The primary objective was to evaluate whether topical fluoride reduces the proportion of orthodontic patients with new DLs after fixed appliances. The secondary objectives were to examine the effectiveness of different modes of topical fluoride delivery in reducing the proportions of orthodontic patients with new DLs, as well as the severity of lesions, in terms of number, size and colour. Participant‐assessed outcomes, such as perception of DLs, and oral health‐related quality of life data were to be included, as would reports of adverse effects. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 1 February 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library (searched 1 February 2019), MEDLINE Ovid (1946 to 1 February 2019), and Embase Ovid (1980 to 1 February 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Parallel‐group, randomised controlled trials comparing the use of a fluoride‐containing product versus a placebo, no treatment or a different type of fluoride treatment, in which the outcome of enamel demineralisation was assessed at the start and at the end of orthodontic treatment. Data collection and analysis At least two review authors independently, in duplicate, conducted risk of bias assessments and extracted data. Authors of trials were contacted to obtain missing data or to ask for clarification of aspects of trial methodology. Cochrane's statistical guidelines were followed. Main results This update includes 10 studies and contains data from nine studies, comparing eight interventions, involving 1798 randomised participants (1580 analysed). One report contained insufficient information and the authors have been contacted. We assessed two studies as at low risk of bias, six at unclear risk of bias, and two at high risk of bias. Two placebo (non‐fluoride) controlled studies, at low risk of bias, investigated the professional application of varnish (7700 or 10,000 parts per million (ppm) fluoride (F)), every six weeks and found insufficient evidence of a difference regarding its effectiveness in preventing new DLs (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.14 to 1.93; 405 participants; low‐certainty evidence). One placebo (non‐fluoride) controlled study, at unclear risk of bias, provides a low level of certainty that fluoride foam (12,300 ppm F), professionally applied every two months, may reduce the incidence of new DLs (12% versus 49%) after fixed orthodontic treatment (RR 0.26, 95% CI 0.11 to 0.57; 95 participants). One study, at unclear risk of bias, also provides a low level of certainty that use of a high‐concentration fluoride toothpaste (5000 ppm F) by patients may reduce the incidence of new DLs (18% versus 27%) compared with a conventional fluoride toothpaste (1450 ppm F) (RR 0.68, 95% CI 0.46 to 1.00; 380 participants). There was no evidence for a difference in the proportions of orthodontic patients with new DLs on the teeth after treatment with fixed orthodontic appliances for the following comparisons:
 ‐ an amine fluoride and stannous fluoride toothpaste/mouthrinse combination versus a sodium fluoride toothpaste/mouthrinse,
 ‐ an amine fluoride gel versus a non‐fluoride placebo applied by participants at home once a week and by professional application every three months,
 ‐ resin‐modified glass ionomer cement versus light‐cured composite resin for bonding orthodontic brackets,
 ‐ a 250 ppm F mouthrinse versus 0 ppm F placebo mouthrinse,
 ‐ the use of an intraoral fluoride‐releasing glass bead device attached to the brace versus a daily fluoride mouthrinse. The last two comparisons involved studies that were assessed at high risk of bias, because a substantial number of participants were lost to follow‐up. Unfortunately, although the internal validity and hence the quality of the studies has improved since the first version of the review, they have compared different interventions; therefore, the findings are only considered to provide low level of certainty, because none has been replicated by follow‐up studies, in different settings, to confirm external validity. A patient‐reported outcome, such as concern about the aesthetics of any DLs, was still not included as an outcome in any study. Reports of adverse effects from topical fluoride applications were rare and unlikely to be significant. One study involving fluoride‐containing glass beads reported numerous breakages. Authors' conclusions This review found a low level of certainty that 12,300 ppm F foam applied by a professional every 6 to 8 weeks throughout fixed orthodontic treatment, might be effective in reducing the proportion of orthodontic patients with new DLs. In addition, there is a low level of certainty that the patient use of a high fluoride toothpaste (5000 ppm F) throughout orthodontic treatment, might be more effective than a conventional fluoride toothpaste. These two comparisons were based on single studies. There was insufficient evidence of a difference regarding the professional application of fluoride varnish (7700 or 10,000 ppm F). Further adequately powered, randomised controlled trials are required to increase the certainty of these findings and to determine the best means of preventing DLs in patients undergoing fixed orthodontic treatment. The most accurate means of assessing adherence with the use of fluoride products by patients and any possible adverse effects also need to be considered. Future studies should follow up participants beyond the end of orthodontic treatment to determine the effect of DLs on patient satisfaction with treatment. Plain language summary Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment Review question 
 Ugly white or brown marks sometimes appear on the teeth during treatment with braces to straighten teeth. These are due to early tooth decay and usually occur with fixed, glued‐on 'train track', braces, which make it more difficult to clean the teeth. We know that fluoride in toothpaste helps to prevent tooth decay and think that if extra fluoride is given to people wearing fixed braces, it will protect them from getting these marks. The aim of this Cochrane Oral Health's review was to look at how well fluorides help to prevent early tooth decay during fixed brace treatment and to find out the best way to get fluoride to the teeth. Background 
 Wearing a fixed brace makes it harder for people to keep their teeth clean and may also cause pain. Pain can make it more difficult for people to brush their teeth. This can lead to a build‐up of dental plaque around the brackets that attach the fixed brace to the teeth, and if the plaque stays on the tooth for long enough, it will cause early tooth decay, which looks like white or brown marks (demineralised lesions, also known as white spot lesions). People often wear braces for 18 months or longer and if the decay is left to progress, it can cause holes, which are sometimes bad enough to need fillings to be done in the teeth. Fluoride helps the tooth to heal, reducing tooth decay in people who are at risk of developing it. People receiving fixed brace treatment may be given different forms of fluoride treatment. It is important to think about how the fluoride gets to the teeth. Does the fluoride need to be placed by a dentist or dental nurse, or can people having treatment with braces apply the fluoride to their own teeth? Study characteristics 
 This review is up‐to‐date as of 1 February 2019. The review includes 10 studies but we could only use the information from nine studies involving 1798 randomised people. We have asked for more information about one study. The review looks at eight different ways of applying fluoride to the teeth. People taking part in the studies were all having treatment with fixed braces. The number of people with new decay on the teeth at end of fixed brace treatment, as well as the amount of decay in each person, were measured and counted. We compared the following treatments:
 ‐ dentist or nurse‐applied fluoride e.g. varnish, gel or foam,
 ‐ patient‐applied/used fluoride e.g. toothpaste, mouthwash, gel or foam, and
 ‐ materials that release fluoride over time e.g. glues, elastic bands. Key results 
 One study showed that when the dentist applies a foam with a high level of fluoride in it onto the teeth every time the patient is seen, this might reduce the risk of new decay. Another study found that if patients use a toothpaste with a higher level of fluoride than normal, then this might also reduce the risk of new marks on their teeth. No studies have shown that other ways of giving the teeth extra fluoride reduced the number and/or size of new decay on teeth in people wearing fixed braces. Harmful effects of the different ways of giving the teeth more fluoride were not reported in any of the included studies. Certainty of the evidence 
 The level of belief we have in these findings is low, due to the lack of studies testing the same fluorides and showing the same results. We suggest that more, well‐conducted studies should be done in this area.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.759Z" }, { "id": "0b24b154-8991-47a0-ac0b-da90e6c362db", "pmid": "", "title": "Selenium for preventing cancer", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Vinceti, M, Filippini, T, Del Giovane, C, Dennert, G, Zwahlen, M, Brinkman, M, Zeegers, MPA, Horneber, M, D'Amico, R, Crespi, CM", "articleTypes": [], "doi": "10.1002/14651858.CD005195.pub4 AB - Abstract - Background This review is the third update of the Cochrane review \"Selenium for preventing cancer\". Selenium is a naturally occurring element with both nutritional and toxicological properties. Higher selenium exposure and selenium supplements have been suggested to protect against several types of cancer. Objectives To gather and present evidence needed to address two research questions: 1. What is the aetiological relationship between selenium exposure and cancer risk in humans?
 2. Describe the efficacy of selenium supplementation for cancer prevention in humans. Search methods We updated electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), MEDLINE (Ovid, 2013 to January 2017, week 4), and Embase (2013 to 2017, week 6), as well as searches of clinical trial registries. Selection criteria We included randomised controlled trials (RCTs) and longitudinal observational studies that enrolled adult participants. Data collection and analysis We performed random‐effects (RE) meta‐analyses when two or more RCTs were available for a specific outcome. We conducted RE meta‐analyses when five or more observational studies were available for a specific outcome. We assessed risk of bias in RCTs and in observational studies using Cochrane's risk assessment tool and the Newcastle‐Ottawa Scale, respectively. We considered in the primary analysis data pooled from RCTs with low risk of bias. We assessed the certainty of evidence by using the GRADE approach. Main results We included 83 studies in this updated review: two additional RCTs (10 in total) and a few additional trial reports for previously included studies. RCTs involved 27,232 participants allocated to either selenium supplements or placebo. For analyses of RCTs with low risk of bias, the summary risk ratio (RR) for any cancer incidence was 1.01 (95% confidence interval (CI) 0.93 to 1.10; 3 studies, 19,475 participants; high‐certainty evidence). The RR for estimated cancer mortality was 1.02 (95% CI 0.80 to 1.30; 1 study, 17,448 participants). For the most frequently investigated site‐specific cancers, investigators provided little evidence of any effect of selenium supplementation. Two RCTs with 19,009 participants indicated that colorectal cancer was unaffected by selenium administration (RR 0.99, 95% CI 0.69 to 1.43), as were non‐melanoma skin cancer (RR 1.16, 95% CI 0.30 to 4.42; 2 studies, 2027 participants), lung cancer (RR 1.16, 95% CI 0.89 to 1.50; 2 studies, 19,009 participants), breast cancer (RR 2.04, 95% CI 0.44 to 9.55; 1 study, 802 participants), bladder cancer (RR 1.07, 95% CI 0.76 to 1.52; 2 studies, 19,009 participants), and prostate cancer (RR 1.01, 95% CI 0.90 to 1.14; 4 studies, 18,942 participants). Certainty of the evidence was high for all of these cancer sites, except for breast cancer, which was of moderate certainty owing to imprecision, and non‐melanoma skin cancer, which we judged as moderate certainty owing to high heterogeneity. RCTs with low risk of bias suggested increased melanoma risk. Results for most outcomes were similar when we included all RCTs in the meta‐analysis, regardless of risk of bias. Selenium supplementation did not reduce overall cancer incidence (RR 0.99, 95% CI 0.86 to 1.14; 5 studies, 21,860 participants) nor mortality (RR 0.81, 95% CI 0.49 to 1.32; 2 studies, 18,698 participants). Summary RRs for site‐specific cancers showed limited changes compared with estimates from high‐quality studies alone, except for liver cancer, for which results were reversed. In the largest trial, the Selenium and Vitamin E Cancer Trial, selenium supplementation increased risks of alopecia and dermatitis, and for participants with highest background selenium status, supplementation also increased risk of high‐grade prostate cancer. RCTs showed a slightly increased risk of type 2 diabetes associated with supplementation. A hypothesis generated by the Nutritional Prevention of Cancer Trial ‐ that individuals with low blood selenium levels could reduce their risk of cancer (particularly prostate cancer) by increasing selenium intake ‐ has not been confirmed. As RCT participants have been overwhelmingly male (88%), we could not assess the potential influence of sex or gender. We included 15 additional observational cohort studies (70 in total; over 2,360,000 participants). We found that lower cancer incidence (summary odds ratio (OR) 0.72, 95% CI 0.55 to 0.93; 7 studies, 76,239 participants) and lower cancer mortality (OR 0.76, 95% CI 0.59 to 0.97; 7 studies, 183,863 participants) were associated with the highest category of selenium exposure compared with the lowest. Cancer incidence was lower in men (OR 0.72, 95% CI 0.46 to 1.14, 4 studies, 29,365 men) than in women (OR 0.90, 95% CI 0.45 to 1.77, 2 studies, 18,244 women). Data show a decrease in risk of site‐specific cancers for stomach, colorectal, lung, breast, bladder, and prostate cancers. However, these studies have major weaknesses due to study design, exposure misclassification, and potential unmeasured confounding due to lifestyle or nutritional factors covarying with selenium exposure beyond those taken into account in multi‐variable analyses. In addition, no evidence of a dose‐response relation between selenium status and cancer risk emerged. Certainty of evidence was very low for each outcome. Some studies suggested that genetic factors might modify the relation between selenium and cancer risk ‐ an issue that merits further investigation. Authors' conclusions Well‐designed and well‐conducted RCTs have shown no beneficial effect of selenium supplements in reducing cancer risk (high certainty of evidence). Some RCTs have raised concerns by reporting a higher incidence of high‐grade prostate cancer and type 2 diabetes in participants with selenium supplementation. No clear evidence of an influence of baseline participant selenium status on outcomes has emerged in these studies. Observational longitudinal studies have shown an inverse association between selenium exposure and risk of some cancer types, but null and direct relations have also been reported, and no systematic pattern suggesting dose‐response relations has emerged. These studies suffer from limitations inherent to the observational design, including exposure misclassification and unmeasured confounding. Overall, there is no evidence to suggest that increasing selenium intake through diet or supplementation prevents cancer in humans. However, more research is needed to assess whether selenium may modify the risk of cancer in individuals with a specific genetic background or nutritional status, and to investigate possible differential effects of various forms of selenium. Plain language summary Selenium for preventing cancer Review question 
 We reviewed the evidence investigating the relation between selenium intake and cancer prevention. This review updates the most recent Cochrane review on this topic ( Vinceti 2014) , which was an update of Dennert 2011 . Background 
 Selenium is a naturally occurring element that individuals are exposed to mainly through food consumption, although exposure can also occur through air, drinking water, and dietary supplements. Small amounts of selenium are essential for certain biological functions in humans, but slightly higher amounts can pose a toxicity risk, making selenium an element with a narrow, but as yet not well‐defined, safe range of exposure. Selenium occurs in many different chemical forms with different biological activity. From the late 1960s, a few observational studies reported that people with high levels of selenium in their diet or in their body tissues had lower risk of cancer, and some laboratory studies showed that selenium could inhibit the growth of cancer cells. This led to widespread interest in selenium supplements and claims that taking such supplements could prevent cancer. Since that time, many more observational studies have been conducted to compare cancer rates among individuals with high and low selenium exposure. More recently, several randomised controlled trials designed to assess whether selenium supplementation can prevent cancer have been carried out. These trials played a major role in enhancing our understanding of the relation between selenium and cancer risk as a result of their stronger study design as compared with observational studies. The most recent trials in particular have shown high methodological quality and statistical power. Several trials focused on whether selenium could prevent prostate cancer. Study characteristics 
 This review includes 10 trials in which adults were randomly assigned to receive selenium supplements or placebo, and 70 observational studies in which adults were followed over time to determine whether their baseline selenium status was associated with their risk of cancer. The evidence is current to January 2017. Key results 
 All of the high‐quality randomised trials reported no effect of selenium on reducing overall risk of cancer or risk of particular cancers, including the most investigated outcome ‐ prostate cancer. Some trials unexpectedly suggested that selenium may increase risks of high‐grade prostate cancer, type 2 diabetes, and dermatological abnormalities. Observational studies have yielded inconsistent evidence of a possible effect of selenium exposure on cancer risk, with no evidence of a dose‐response relation. When we pooled results of these studies, overall they suggested an inverse relation between cancer exposure and subsequent incidence of any cancer or some specific cancers, such as colon and prostate cancer. However, observational studies have major weaknesses. The selenium exposure status of participants could have been misclassified owing to limitations of the indicators of selenium exposure used, as well as to uncertainty regarding the particular selenium species contributing to overall exposure. In addition, unmeasured confounding from lifestyle or nutritional factors ‐ a major and well‐known source of bias in nutritional epidemiology studies of observational design ‐ could have been present. Therefore, the internal validity of these studies is limited. Currently, the hypothesis that increasing selenium intake may reduce cancer risk is not supported by epidemiological evidence. Additional research is needed to assess whether selenium may affect the risk of cancer in individuals with specific genetic backgrounds or nutritional status, and to determine how the various chemical forms of selenium compounds may have different effects on cancer risk.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.745Z" }, { "id": "0b26c47d-2ff4-49ba-a861-49c7f2030937", "pmid": "", "title": "Antihypertensive Effects of Rosmarinus Officinalis L. Infusion Supplements in Male Patients With Mild Hypertension : A Randomized Double-Blind Placebo-Controlled Study", "imported": false, "abstract": "This study assessed the antihypertensive effect of rosemary tea through a placebo-controlled clinical study, angiotensin-converting enzyme (ACE) inhibition analysis, and in silico evaluation of interactions between rosemary bioactive compounds and the AT1R (Angiotensin II Type 1 Receptor).", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "0b33ab0b-9465-4bcf-a542-ea292e0b6e2f", "pmid": "", "title": "Antibiotic treatment for the sexual partners of women with bacterial vaginosis", "imported": false, "abstract": "Abstract - Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of BV after antibiotic treatment. Therefore, the treatment of sexual partners could decrease the recurrence of infection and possibly the burden of the disease. Objectives To assess the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for BV. Search methods We searched the Cochrane Sexually Transmitted Infections Group Specialized Register (23 July 2016), CENTRAL (1991 to 23 July 2016), MEDLINE (1946 to 23 July 2016), Embase (1974 to 23 July 2016), LILACS (1982 to 23 July 2016), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (23 July 2016), ClinicalTrials.gov (23 July 2016) and the Web of Science™ (2001 to 23 July 2016). We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) that compared the concurrent use of any antibiotic treatment with placebo, no intervention or any other intervention by the sexual partners of women treated for BV. Data collection and analysis Three review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach. Main results Seven RCTs (1026 participants) met our inclusion criteria, and pharmaceutical industry funded four of these trials. Five trials (854 patients) compared any antibiotic treatment of sexual partners with placebo. Based on high quality evidence, antibiotic treatment does not increase the rate of clinical or symptomatic improvement in women during the first week (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.96 to 1.03; 712 participants, four studies; RR 1.06, 95% CI 1.00 to 1.12; 577 patients, three studies, respectively), between the first and fourth week (RR 1.02, 95% CI 0.94 to 1.11; 590 participants, three studies; RR 0.93, 95% CI 0.84 to 1.03; 444 participants, two studies; respectively) or after the fourth week (RR 0.98, 95% CI 0.90 to 1.07; 572 participants, four studies; RR 1.03, 95% CI 0.90 to 1.17; 296 participants, two studies; respectively). Antibiotic treatment does not led to a lower recurrence during the first and fourth week (RR 1.28, 95% CI 0.68 to 2.43; 218 participants, one study; low quality evidence) or after the fourth week of treatment (RR 1.00, 95% CI 0.67 to 1.52; 372 participants, three studies; low quality evidence) in women, but increases the frequency of adverse events (most frequently gastrointestinal symptoms) reported by sexual partners (RR 2.55, 95% CI 1.55 to 4.18; 477 participants, three studies; low quality evidence).
 
 Two trials (172 participants) compared any antibiotic treatment for sexual partners with no intervention. When we compared it with no intervention, the effects of antibiotic treatment on recurrence rate after the fourth week (RR 1.71, 95% CI 0.65 to 4.55; 51 participants, one study), clinical improvement between the first and fourth week (RR 0.93, 95% CI 0.70 to 1.25; 152 participants, two studies) and symptomatic improvement after the fourth week (RR 0.66, 95% CI 0.39 to 1.11; 70 participants, one study) were imprecise and there were no differences between groups. We downgraded the quality of the evidence to low or very low. Authors' conclusions High quality evidence shows that antibiotic treatment for sexual partners of women with BV, compared with placebo, does not increase the rate of clinical or symptomatic improvement during the first, between the first and fourth or after the fourth week into the women. Low quality evidence suggests that antibiotic treatment does not led to a lower recurrence rate during the first and fourth or after the fourth week of treatment into the women, but increases the frequency of adverse events reported by sexual partners. Finally, compared with no intervention, antibiotic treatment does not decrease the recurrence rate after the fourth week and does not increase the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week into the women, respectively. Plain language summary Antibiotic treatment for the sexual partners of women with bacterial vaginosis Review question We assessed the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for bacterial vaginosis (BV). Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of infection after antibiotic treatment. Therefore, the treatment of sexual partners could offer the advantages of decreasing the recurrence of infection and possibly reducing the burden of the disease. Trial characteristics Cochrane researchers searched the available literature up to the 23 July 2016 and included seven trials with 1026 participants. The trials included sexually‐active non‐pregnant women between 17 and 56 years of age, either single or married, with symptomatic BV. Four studies only included women involved into a monogamous heterosexual relationship and there was no information about this for the remaining trials. Six trials used 5‐nitroimidazoles to treat the sexual partner, four trials used metronidazole and two trials used tinidazole; only one study used a lincosamide for treatment. Five trials compared antibiotic versus placebo (854 participants) and two trials compared antibiotic treatment with no intervention (172 participants). Pharmaceutical companies funded four of the included trials. Key results Compared with placebo, antibiotic treatment for the sexual partners of women treated for BV had no effects on clinical or symptomatic improvement in women, regardless of the time period over which the trials assessed these outcomes (during the first, between the first and fourth, or after the fourth week). Furthermore, antibiotic treatment of the sexual partner may have no effect on the recurrence of BV up to 12 weeks after treatment, but may increase the frequency of minor adverse events reported by sexual partners. Compared with no intervention, treatment of sexual partners of women with BV may have no effect on decreasing the recurrence rate or over the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week, respectively. Quality of evidence The quality of evidence was high for the outcomes of clinical and symptomatic improvement. The quality of evidence was very low for recurrence due to some limitations regarding risk of bias and imprecision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Amaya‐Guio, J; Viveros‐Carreño, DA; Sierra‐Barrios, EM; Martinez‐Velasquez, MY; Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD011701.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "0b6c6889-015d-4410-91eb-698889ba631d", "pmid": "", "title": "Omega‐3 fatty acids supplementation for autism spectrum disorders (ASD)", "imported": false, "abstract": "Abstract - Background It has been suggested that impairments associated with autism spectrum disorders (ASD) may be partially explained by deficits of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. Objectives To review the efficacy of omega‐3 fatty acids for improving core features of ASD (for example, social interaction, communication, and stereotypies) and associated symptoms. Search methods We searched the following databases on 2 June 2010: CENTRAL (2010, Issue 2), MEDLINE (1950 to May Week 3 2010), EMBASE (1980 to 2010 Week 21), PsycINFO (1806 to current), BIOSIS (1985 to current), CINAHL (1982 to current), Science Citation Index (1970 to current), Social Science Citation Index (1970 to current), metaRegister of Controlled Trials (20 November 2008) and ClinicalTrials.gov (10 December 2010). Dissertation Abstracts International was searched on 10 December 2008, but was no longer available to the authors or editorial base in 2010. Selection criteria All randomised controlled trials of omega‐3 fatty acids supplementation compared to placebo in individuals with ASD. Data collection and analysis Three authors independently selected studies, assessed them for risk of bias and extracted relevant data. We conducted meta‐analysis of the included studies for three primary outcomes (social interaction, communication, and stereotypy) and one secondary outcome (hyperactivity). Main results We included two trials with a total of 37 children diagnosed with ASD who were randomised into groups that received either omega‐3 fatty acids supplementation or a placebo. We excluded six trials because they were either non‐randomised controlled trials, did not contain a control group, or the control group did not receive a placebo. Overall, there was no evidence that omega‐3 supplements had an effect on social interaction (mean difference (MD) 0.82, 95% confidence interval (CI) ‐2.84 to 4.48, I 2 = 0%), communication (MD 0.62, 95% CI ‐0.89 to 2.14, I 2 = 0%), stereotypy (MD 0.77, 95% CI ‐0.69 to 2.22, I 2 = 8%), or hyperactivity (MD 3.46, 95% CI ‐0.79 to 7.70, I 2 = 0%). Authors' conclusions To date there is no high quality evidence that omega‐3 fatty acids supplementation is effective for improving core and associated symptoms of ASD. Given the paucity of rigorous studies in this area, there is a need for large well‐conducted randomised controlled trials that examine both high and low functioning individuals with ASD, and that have longer follow‐up periods. Plain language summary Omega‐3 fatty acids for autism spectrum disorders (ASD) It has been suggested that difficulties associated with ASD may be explained in part by lack of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. The purpose of this review was to assess the evidence for the effectiveness of omega‐3 supplementation for core features of ASD and associated symptoms. We found only two small randomised controlled trials that evaluated omega‐3 fatty acids for ASD. There is insufficient evidence that omega‐3 fatty acids supplementation is an effective treatment for ASD. However, high quality large randomised controlled trials are needed before definite recommendations about this treatment can be made.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "James, S, Montgomery, P, Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD007992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.762Z" }, { "id": "0b740df8-dab8-462b-8199-6b432f060a79", "pmid": "", "title": "Smoking Cessation on the Human Airway: Mucus Secretion, Inflammatory and Proteomic Profile in Nasal Lavage and miRNAs in Blood", "imported": false, "abstract": "Smoking cessation improves health conditions with reduction of the risk factors for cardiovascular and respiratory disease, as functional capacity and quality of life. Smoking cessation has positive effects on the miRNAs regulation, however, genomics has been little explored. Smoking and aging induces changes miRNAs. Among the changes in airway epithelial cells, miR-125 called attention because it is enrolled in the suppression of ERBB7 (tirosin kinase receptors), a codified sequence of the growth factor receptor (EGFR) frequently expressed in cancer. The reduction of miR-125 expression may reduce cancer suppression resulting in cancer development. Other miRNA changes can be observed, such as miR-218 that were found in smokers airway epithelial cells as in MiR-15b that were found in lung tissue of COPD smokers. These miRNAs participated in the signalling pathway of TGF-β enrolled in leukocyte migration and cell proliferation. The investigators hypothesize that smoking cessation has a role in the regulation or reduction in the genetic changes smoking-induced. The investigators will assess the subject genomic profile at the baseline, 6 months and 12 months after smoking cessation.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.158Z" }, { "id": "0b7a81c5-e9b4-4ee4-bbc6-5b3fb7b5d089", "pmid": "", "title": "Point‐of‐use fortification of foods with micronutrient powders containing iron in children of preschool and school‐age", "imported": false, "abstract": "Abstract - Background Approximately 600 million children of preschool and school age are anaemic worldwide. It is estimated that at least half of the cases are due to iron deficiency. Point‐of‐use fortification of foods with micronutrient powders (MNP) has been proposed as a feasible intervention to prevent and treat anaemia. It refers to the addition of iron alone or in combination with other vitamins and minerals in powder form, to energy‐containing foods (excluding beverages) at home or in any other place where meals are to be consumed. MNPs can be added to foods either during or after cooking or immediately before consumption without the explicit purpose of improving the flavour or colour. Objectives To assess the effects of point‐of‐use fortification of foods with iron‐containing MNP alone, or in combination with other vitamins and minerals on nutrition, health and development among children at preschool (24 to 59 months) and school (five to 12 years) age, compared with no intervention, a placebo or iron‐containing supplements. Search methods In December 2016, we searched the following databases: CENTRAL, MEDLINE, Embase, BIOSIS, Science Citation Index, Social Science Citation Index, CINAHL, LILACS, IBECS, Popline and SciELO. We also searched two trials registers in April 2017, and contacted relevant organisations to identify ongoing and unpublished trials. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs trials with either individual or cluster randomisation. Participants were children aged between 24 months and 12 years at the time of intervention. For trials with children outside this age range, we included studies where we were able to disaggregate the data for children aged 24 months to 12 years, or when more than half of the participants were within the requisite age range. We included trials with apparently healthy children; however, we included studies carried out in settings where anaemia and iron deficiency are prevalent, and thus participants may have had these conditions at baseline. Data collection and analysis Two review authors independently assessed the eligibility of trials against the inclusion criteria, extracted data from included trials, assessed the risk of bias of the included trials and graded the quality of the evidence. Main results We included 13 studies involving 5810 participants from Latin America, Africa and Asia. We excluded 38 studies and identified six ongoing/unpublished trials. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. No trials compared the effects of MNP versus iron‐containing supplements (as drops, tablets or syrup). The sample sizes in the included trials ranged from 90 to 2193 participants. Six trials included participants younger than 59 months of age only, four included only children aged 60 months or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. The iron doses varied from 2.5 mg to 30 mg of elemental iron. Four trials reported giving 10 mg of elemental iron as sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), chelated ferrous sulphate or microencapsulated ferrous fumarate. Three trials gave 12.5 mg of elemental iron as microencapsulated ferrous fumarate. Three trials gave 2.5 mg or 2.86 mg of elemental iron as NaFeEDTA. One trial gave 30 mg and one trial provided 14 mg of elemental iron as microencapsulated ferrous fumarate, while one trial gave 28 mg of iron as ferrous glycine phosphate. In comparison with receiving no intervention or a placebo, children receiving iron‐containing MNP for point‐of‐use fortification of foods had lower risk of anaemia prevalence ratio (PR) 0.66, 95% confidence interval (CI) 0.49 to 0.88, 10 trials, 2448 children; moderate‐quality evidence) and iron deficiency (PR 0.35, 95% CI 0.27 to 0.47, 5 trials, 1364 children; moderate‐quality evidence) and had higher haemoglobin (mean difference (MD) 3.37 g/L, 95% CI 0.94 to 5.80, 11 trials, 2746 children; low‐quality evidence). Only one trial with 115 children reported on all‐cause mortality (zero cases; low‐quality evidence). There was no effect on diarrhoea (risk ratio (RR) 0.97, 95% CI 0.53 to 1.78, 2 trials, 366 children; low‐quality evidence). Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children. However, information on mortality, morbidity, developmental outcomes and adverse effects is still scarce. Plain language summary Powdered vitamins and minerals added to foods at the point‐of‐use reduces anaemia and iron deficiency in preschool‐ and school‐age children Background to the question Approximately one billion people worldwide are deficient in at least one vitamin or mineral (also known of micronutrients). Iron, vitamin A, zinc and iodine deficiencies are very frequent among children of preschool (aged 24 months to less than 5 years) and school age (5 to 12 years of age), limiting their health and daily physical performance. Anaemia, the condition in which red blood cells have limited capacity to carry oxygen, frequently results after prolonged iron deficiency. Point‐of‐use fortification with powdered vitamins and minerals has been proposed as a public health intervention to reduce micronutrient deficiencies in children. In this process, a powdered premix containing iron, and possibly other vitamins and minerals, is added to foods either during or after cooking, or immediately before consumption to improve their nutritious value but not their flavour or colour. In some cases, point‐of‐use fortification is also known as home fortification. Review question What are the effects of point‐of‐use fortification of foods with iron‐containing micronutrient powders (MNP) alone, or in combination with other vitamins and minerals, on nutrition, health and development among children of preschool and school age (24 months to 12 years of age) compared with no intervention, a placebo (dummy pill) or regular iron‐containing supplements (as drops, tablets or syrup)? Study characteristics This review included 13 trials with 5810 participants from Latin America, Africa and Asia. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. Six trials included participants younger than 59 months of age only, four included only children aged 60 months of age or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. We searched existing clinical trials in December 2016 and ongoing trials in April 2017. We also contacted relevant institutions for additional information upon publication of the protocol and in April 2017. Key results The review found that children receiving iron‐containing MNP for point‐of‐use fortification of foods were at significantly lower risk of having anaemia and iron deficiency and had higher haemoglobin concentrations. We did not find any positive or negative effect on diarrhoea or mortality, but the data on these two outcomes were very limited. Quality of the evidence We rated the overall quality of the evidence for the provision of multiple MNP versus no intervention or placebo as moderate for anaemia, iron deficiency and adverse effects. We judged the evidence to be of low quality for haemoglobin, mortality and diarrhoea, and to be very low‐quality for ferritin. In general, the most common risk of bias in the studies was the lack of blinding for participants, personnel and outcome assessors. Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children and seems feasible for public health purposes. However, future research should aim to increase the body of evidence on mortality, morbidity, developmental outcomes and adverse effects. Due to the lack of trials, we were unable to determine at this time if this intervention has comparable effects to those observed with iron supplements (provided as drops, tablets or syrup).", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "De‐Regil, LM; Jefferds, MED; Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009666.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "0b838819-9396-4744-810a-8f2d1e94f518", "pmid": "", "title": "Intravenous iron versus oral iron versus no iron with or without erythropoiesis‐ stimulating agents (ESA) for cancer patients with anaemia: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Anaemia is common among cancer patients and they may require red blood cell transfusions. Erythropoiesis‐stimulating agents (ESAs) and iron might help in reducing the need for red blood cell transfusions. However, it remains unclear whether the combination of both drugs is preferable compared to using one drug. Objectives To systematically review the effect of intravenous iron, oral iron or no iron in combination with or without ESAs to prevent or alleviate anaemia in cancer patients and to generate treatment rankings using network meta‐analyses (NMAs). Search methods We identified studies by searching bibliographic databases (CENTRAL, MEDLINE, Embase; until June 2021). We also searched various registries, conference proceedings and reference lists of identified trials. Selection criteria We included randomised controlled trials comparing intravenous, oral or no iron, with or without ESAs for the prevention or alleviation of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in cancer patients. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Outcomes were on‐study mortality, number of patients receiving red blood cell transfusions, number of red blood cell units, haematological response, overall mortality and adverse events. We conducted NMAs and generated treatment rankings. We assessed the certainty of the evidence using GRADE. Main results Ninety‐six trials (25,157 participants) fulfilled our inclusion criteria; 62 trials (24,603 participants) could be considered in the NMA (12 different treatment options). Here we present the comparisons of ESA with or without iron and iron alone versus no treatment. Further results and subgroup analyses are described in the full text. On‐study mortality We estimated that 92 of 1000 participants without treatment for anaemia died up to 30 days after the active study period. Evidence from NMA (55 trials; 15,074 participants) suggests that treatment with ESA and intravenous iron (12 of 1000; risk ratio (RR) 0.13, 95% confidence interval (CI) 0.01 to 2.29; low certainty) or oral iron (34 of 1000; RR 0.37, 95% CI 0.01 to 27.38; low certainty) may decrease or increase and ESA alone (103 of 1000; RR 1.12, 95% CI 0.92 to 1.35; moderate certainty) probably slightly increases on‐study mortality. Additionally, treatment with intravenous iron alone (271 of 1000; RR 2.95, 95% CI 0.71 to 12.34; low certainty) may increase and oral iron alone (24 of 1000; RR 0.26, 95% CI 0.00 to 19.73; low certainty) may increase or decrease on‐study mortality. Haematological response We estimated that 90 of 1000 participants without treatment for anaemia had a haematological response. Evidence from NMA (31 trials; 6985 participants) suggests that treatment with ESA and intravenous iron (604 of 1000; RR 6.71, 95% CI 4.93 to 9.14; moderate certainty), ESA and oral iron (527 of 1000; RR 5.85, 95% CI 4.06 to 8.42; moderate certainty), and ESA alone (467 of 1000; RR 5.19, 95% CI 4.02 to 6.71; moderate certainty) probably increases haematological response. Additionally, treatment with oral iron alone may increase haematological response (153 of 1000; RR 1.70, 95% CI 0.69 to 4.20; low certainty). Red blood cell transfusions We estimated that 360 of 1000 participants without treatment for anaemia needed at least one transfusion. Evidence from NMA (69 trials; 18,684 participants) suggests that treatment with ESA and intravenous iron (158 of 1000; RR 0.44, 95% CI 0.31 to 0.63; moderate certainty), ESA and oral iron (144 of 1000; RR 0.40, 95% CI 0.24 to 0.66; moderate certainty) and ESA alone (212 of 1000; RR 0.59, 95% CI 0.51 to 0.69; moderate certainty) probably decreases the need for transfusions. Additionally, treatment with intravenous iron alone (268 of 1000; RR 0.74, 95% CI 0.43 to 1.28; low certainty) and with oral iron alone (333 of 1000; RR 0.92, 95% CI 0.54 to 1.57; low certainty) may decrease or increase the need for transfusions. Overall mortality We estimated that 347 of 1000 participants without treatment for anaemia died overall. Low‐certainty evidence from NMA (71 trials; 21,576 participants) suggests that treatment with ESA and intravenous iron (507 of 1000; RR 1.46, 95% CI 0.87 to 2.43) or oral iron (482 of 1000; RR 1.39, 95% CI 0.60 to 3.22) and intravenous iron alone (521 of 1000; RR 1.50, 95% CI 0.63 to 3.56) or oral iron alone (534 of 1000; RR 1.54, 95% CI 0.66 to 3.56) may decrease or increase overall mortality. Treatment with ESA alone may lead to little or no difference in overall mortality (357 of 1000; RR 1.03, 95% CI 0.97 to 1.10; low certainty). Thromboembolic events We estimated that 36 of 1000 participants without treatment for anaemia developed thromboembolic events. Evidence from NMA (50 trials; 15,408 participants) suggests that treatment with ESA and intravenous iron (66 of 1000; RR 1.82, 95% CI 0.98 to 3.41; moderate certainty) probably slightly increases and with ESA alone (66 of 1000; RR 1.82, 95% CI 1.34 to 2.47; high certainty) slightly increases the number of thromboembolic events. None of the trials reported results on the other comparisons. Thrombocytopenia or haemorrhage We estimated that 76 of 1000 participants without treatment for anaemia developed thrombocytopenia/haemorrhage. Evidence from NMA (13 trials, 2744 participants) suggests that treatment with ESA alone probably leads to little or no difference in thrombocytopenia/haemorrhage (76 of 1000; RR 1.00, 95% CI 0.67 to 1.48; moderate certainty). None of the trials reported results on other comparisons. Hypertension We estimated that 10 of 1000 participants without treatment for anaemia developed hypertension. Evidence from NMA (24 trials; 8383 participants) suggests that treatment with ESA alone probably increases the number of hypertensions (29 of 1000; RR 2.93, 95% CI 1.19 to 7.25; moderate certainty). None of the trials reported results on the other comparisons. Authors' conclusions When considering ESAs with iron as prevention for anaemia, one has to balance between efficacy and safety. Results suggest that treatment with ESA and iron probably decreases number of blood transfusions, but may increase mortality and the number of thromboembolic events. For most outcomes the different comparisons within the network were not fully connected, so ranking of all treatments together was not possible. More head‐to‐head comparisons including all evaluated treatment combinations are needed to fill the gaps and prove results of this review. Plain language summary Which combinations of medicines are best for the prevention and treatment of anaemia in people with cancer? Key messages • Giving medicines that stimulate the bone marrow to produce red blood cells (ESAs) with iron supplements probably decreases the number of blood transfusions, but may also cause more deaths and increase the number of unwanted effects, such as blood clots. • Because of missing data from the studies we could not compare the different treatment options to each other and rank them. • We need more studies that compare these medicines directly against each other. What is anaemia and why do people with cancer develop it? Anaemia develops when levels of red blood cells are too low. Red blood cells contain a protein called haemoglobin. Iron molecules in the haemoglobin bind to oxygen and carry it around the body. A lack of oxygen to the organs and tissues in the body makes people feel tired and lack energy, and they may be at greater risk of infections. People with cancer are particularly likely to suffer from anaemia. This might be because the cancers cause inflammation and prevent red blood cell production. Or it might be because treatments like chemotherapy slow down production of red blood cells in bone marrow. People suffering from anaemia may need blood transfusions. However, treatment with medicines that stimulate the production of red blood cells in bone marrow (called erythropoiesis‐stimulating agents or ESAs) and iron supplements may reduce the need for transfusions. What did we want to find out? We wanted to identify the most effective treatments for anaemia in people with cancer and whether they cause any unwanted effects. We were interested in whether iron supplements or ESAs given alone or together affect: • deaths; • haemoglobin levels; • blood transfusions; and • unwanted effects. We also wanted to know the best way to give the medicines: by injection (intravenous), or swallowed (oral). What did we do? We searched for studies that compared intravenous, oral or no iron with or without ESAs for the prevention or treatment of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in people with cancer. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and numbers of participants. We used statistical methods to compare multiple treatments against each other and rank them in order of effectiveness and unwanted effects. What did we find? We found 96 relevant studies with 25,157 people. People in the studies were different ages and were receiving a mix of anti‐cancer treatments or no treatment. They had different types of cancer. Ninety‐two studies reported data for our review. They included 24,603 people and compared 12 different treatment options for anaemia. The treatments included combinations of ESAs with intravenous or oral iron and placebo (something that looks, tastes and smells the same as the iron supplement or ESA but with no active ingredient). Not every study reported everything we were interested in, so we did not have enough information to compare each treatment with each of the other treatments. Treatment with ESAs when used on their own or with iron probably increases levels of red blood cells and reduces the need for red blood cell transfusions when compared with no treatment. We cannot rule out an increase in the risk of mortality with ESA in combination with iron, which also appeared to cause more deaths and lead to increased risk of harm caused by the formation of clots in the blood vessels. Our confidence in the findings Overall, we are moderately confident in the evidence that one treatment is better or worse than another. Our confidence is limited because we sometimes found very different results for the same treatments, meaning they could have been both good and bad for patients ‐ we did not have enough evidence to reach firm conclusions. Also, due to a lack of evidence we could not rank the treatments. How up to date is the evidence? The evidence is up‐to‐date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Adams, A; Scheckel, B; Habsaoui, A; Haque, M; Kuhr, K; Monsef, I; Bohlius, J; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012633.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "0b854f7b-b0cf-4a94-984b-ece4907128df", "pmid": "", "title": "Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Benson, PE, Parkin, N, Dyer, F, Millett, DT, Germain, P", "articleTypes": [], "doi": "10.1002/14651858.CD003809.pub4 AB - Abstract - Background Early dental decay or demineralised lesions (DLs, also known as white spot lesions) can appear on teeth during fixed orthodontic (brace) treatment. Fluoride reduces decay in susceptible individuals, including orthodontic patients. This review compared various forms of topical fluoride to prevent the development of DLs during orthodontic treatment. This is the second update of the Cochrane Review first published in 2004 and previously updated in 2013. Objectives The primary objective was to evaluate whether topical fluoride reduces the proportion of orthodontic patients with new DLs after fixed appliances. The secondary objectives were to examine the effectiveness of different modes of topical fluoride delivery in reducing the proportions of orthodontic patients with new DLs, as well as the severity of lesions, in terms of number, size and colour. Participant‐assessed outcomes, such as perception of DLs, and oral health‐related quality of life data were to be included, as would reports of adverse effects. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 1 February 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library (searched 1 February 2019), MEDLINE Ovid (1946 to 1 February 2019), and Embase Ovid (1980 to 1 February 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Parallel‐group, randomised controlled trials comparing the use of a fluoride‐containing product versus a placebo, no treatment or a different type of fluoride treatment, in which the outcome of enamel demineralisation was assessed at the start and at the end of orthodontic treatment. Data collection and analysis At least two review authors independently, in duplicate, conducted risk of bias assessments and extracted data. Authors of trials were contacted to obtain missing data or to ask for clarification of aspects of trial methodology. Cochrane's statistical guidelines were followed. Main results This update includes 10 studies and contains data from nine studies, comparing eight interventions, involving 1798 randomised participants (1580 analysed). One report contained insufficient information and the authors have been contacted. We assessed two studies as at low risk of bias, six at unclear risk of bias, and two at high risk of bias. Two placebo (non‐fluoride) controlled studies, at low risk of bias, investigated the professional application of varnish (7700 or 10,000 parts per million (ppm) fluoride (F)), every six weeks and found insufficient evidence of a difference regarding its effectiveness in preventing new DLs (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.14 to 1.93; 405 participants; low‐certainty evidence). One placebo (non‐fluoride) controlled study, at unclear risk of bias, provides a low level of certainty that fluoride foam (12,300 ppm F), professionally applied every two months, may reduce the incidence of new DLs (12% versus 49%) after fixed orthodontic treatment (RR 0.26, 95% CI 0.11 to 0.57; 95 participants). One study, at unclear risk of bias, also provides a low level of certainty that use of a high‐concentration fluoride toothpaste (5000 ppm F) by patients may reduce the incidence of new DLs (18% versus 27%) compared with a conventional fluoride toothpaste (1450 ppm F) (RR 0.68, 95% CI 0.46 to 1.00; 380 participants). There was no evidence for a difference in the proportions of orthodontic patients with new DLs on the teeth after treatment with fixed orthodontic appliances for the following comparisons:
 ‐ an amine fluoride and stannous fluoride toothpaste/mouthrinse combination versus a sodium fluoride toothpaste/mouthrinse,
 ‐ an amine fluoride gel versus a non‐fluoride placebo applied by participants at home once a week and by professional application every three months,
 ‐ resin‐modified glass ionomer cement versus light‐cured composite resin for bonding orthodontic brackets,
 ‐ a 250 ppm F mouthrinse versus 0 ppm F placebo mouthrinse,
 ‐ the use of an intraoral fluoride‐releasing glass bead device attached to the brace versus a daily fluoride mouthrinse. The last two comparisons involved studies that were assessed at high risk of bias, because a substantial number of participants were lost to follow‐up. Unfortunately, although the internal validity and hence the quality of the studies has improved since the first version of the review, they have compared different interventions; therefore, the findings are only considered to provide low level of certainty, because none has been replicated by follow‐up studies, in different settings, to confirm external validity. A patient‐reported outcome, such as concern about the aesthetics of any DLs, was still not included as an outcome in any study. Reports of adverse effects from topical fluoride applications were rare and unlikely to be significant. One study involving fluoride‐containing glass beads reported numerous breakages. Authors' conclusions This review found a low level of certainty that 12,300 ppm F foam applied by a professional every 6 to 8 weeks throughout fixed orthodontic treatment, might be effective in reducing the proportion of orthodontic patients with new DLs. In addition, there is a low level of certainty that the patient use of a high fluoride toothpaste (5000 ppm F) throughout orthodontic treatment, might be more effective than a conventional fluoride toothpaste. These two comparisons were based on single studies. There was insufficient evidence of a difference regarding the professional application of fluoride varnish (7700 or 10,000 ppm F). Further adequately powered, randomised controlled trials are required to increase the certainty of these findings and to determine the best means of preventing DLs in patients undergoing fixed orthodontic treatment. The most accurate means of assessing adherence with the use of fluoride products by patients and any possible adverse effects also need to be considered. Future studies should follow up participants beyond the end of orthodontic treatment to determine the effect of DLs on patient satisfaction with treatment. Plain language summary Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment Review question 
 Ugly white or brown marks sometimes appear on the teeth during treatment with braces to straighten teeth. These are due to early tooth decay and usually occur with fixed, glued‐on 'train track', braces, which make it more difficult to clean the teeth. We know that fluoride in toothpaste helps to prevent tooth decay and think that if extra fluoride is given to people wearing fixed braces, it will protect them from getting these marks. The aim of this Cochrane Oral Health's review was to look at how well fluorides help to prevent early tooth decay during fixed brace treatment and to find out the best way to get fluoride to the teeth. Background 
 Wearing a fixed brace makes it harder for people to keep their teeth clean and may also cause pain. Pain can make it more difficult for people to brush their teeth. This can lead to a build‐up of dental plaque around the brackets that attach the fixed brace to the teeth, and if the plaque stays on the tooth for long enough, it will cause early tooth decay, which looks like white or brown marks (demineralised lesions, also known as white spot lesions). People often wear braces for 18 months or longer and if the decay is left to progress, it can cause holes, which are sometimes bad enough to need fillings to be done in the teeth. Fluoride helps the tooth to heal, reducing tooth decay in people who are at risk of developing it. People receiving fixed brace treatment may be given different forms of fluoride treatment. It is important to think about how the fluoride gets to the teeth. Does the fluoride need to be placed by a dentist or dental nurse, or can people having treatment with braces apply the fluoride to their own teeth? Study characteristics 
 This review is up‐to‐date as of 1 February 2019. The review includes 10 studies but we could only use the information from nine studies involving 1798 randomised people. We have asked for more information about one study. The review looks at eight different ways of applying fluoride to the teeth. People taking part in the studies were all having treatment with fixed braces. The number of people with new decay on the teeth at end of fixed brace treatment, as well as the amount of decay in each person, were measured and counted. We compared the following treatments:
 ‐ dentist or nurse‐applied fluoride e.g. varnish, gel or foam,
 ‐ patient‐applied/used fluoride e.g. toothpaste, mouthwash, gel or foam, and
 ‐ materials that release fluoride over time e.g. glues, elastic bands. Key results 
 One study showed that when the dentist applies a foam with a high level of fluoride in it onto the teeth every time the patient is seen, this might reduce the risk of new decay. Another study found that if patients use a toothpaste with a higher level of fluoride than normal, then this might also reduce the risk of new marks on their teeth. No studies have shown that other ways of giving the teeth extra fluoride reduced the number and/or size of new decay on teeth in people wearing fixed braces. Harmful effects of the different ways of giving the teeth more fluoride were not reported in any of the included studies. Certainty of the evidence 
 The level of belief we have in these findings is low, due to the lack of studies testing the same fluorides and showing the same results. We suggest that more, well‐conducted studies should be done in this area.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.780Z" }, { "id": "0b9f083c-7e52-48db-80ac-8a4cdea84e37", "pmid": "", "title": "Individual Nutritional Support With High Protein Formula With Modified Sensory Component for H&N Cancer Patients on Chemo and Radiotherapy", "imported": false, "abstract": "Nutritional deficiency and subsequent weight loss in patients with head and neck cancer is a common problem and a negative predictor of treatment outcomes and mortality, as well as quality of life. Nutritional support for patients is a prerequisite for the successful management of cancer patients. Sensory changes can be side effects of chemotherapy or ionizing radiation, which damages sensory receptors in the area of radiation, disrupts the function of the salivary glands, leading to hyposalivation and a decrease in taste. Individual choice of nutrition based on sensory sensations can significantly improve the quality of life of patients and ensure timely correction of their eating behavior.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.238Z" }, { "id": "0bab4dbc-3203-43d0-a208-6f3ca66f4050", "pmid": "", "title": "Laboratory‐based molecular test alternatives to RT‐PCR for the diagnosis of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Diagnosing people with a SARS‐CoV‐2 infection played a critical role in managing the COVID‐19 pandemic and remains a priority for the transition to long‐term management of COVID‐19. Initial shortages of extraction and reverse transcription polymerase chain reaction (RT‐PCR) reagents impaired the desired upscaling of testing in many countries, which led to the search for alternatives to RNA extraction/purification and RT‐PCR testing. Reference standard methods for diagnosing the presence of SARS‐CoV‐2 infection rely primarily on real‐time reverse transcription‐polymerase chain reaction (RT‐PCR). Alternatives to RT‐PCR could, if sufficiently accurate, have a positive impact by expanding the range of diagnostic tools available for the timely identification of people infected by SARS‐CoV‐2, access to testing and the use of resources. Objectives To assess the diagnostic accuracy of alternative (to RT‐PCR assays) laboratory‐based molecular tests for diagnosing SARS‐CoV‐2 infection. Search methods We searched the COVID‐19 Open Access Project living evidence database from the University of Bern until 30 September 2020 and the WHO COVID‐19 Research Database until 31 October 2022. We did not apply language restrictions. Selection criteria We included studies of people with suspected or known SARS‐CoV‐2 infection, or where tests were used to screen for infection, and studies evaluating commercially developed laboratory‐based molecular tests for the diagnosis of SARS‐CoV‐2 infection considered as alternatives to RT‐PCR testing. We also included all reference standards to define the presence or absence of SARS‐CoV‐2, including RT‐PCR tests and established clinical diagnostic criteria. Data collection and analysis Two authors independently screened studies and resolved disagreements by discussing them with a third author. Two authors independently extracted data and assessed the risk of bias and applicability of the studies using the QUADAS‐2 tool. We presented sensitivity and specificity, with 95% confidence intervals (CIs), for each test using paired forest plots and summarised results using average sensitivity and specificity using a bivariate random‐effects meta‐analysis. We illustrated the findings per index test category and assay brand compared to the WHO's acceptable sensitivity and specificity threshold for diagnosing SARS‐CoV‐2 infection using nucleic acid tests. Main results We included data from 64 studies reporting 94 cohorts of participants and 105 index test evaluations, with 74,753 samples and 7517 confirmed SARS‐CoV‐2 cases. We did not identify any published or preprint reports of accuracy for a considerable number of commercially produced NAAT assays. Most cohorts were judged at unclear or high risk of bias in more than three QUADAS‐2 domains. Around half of the cohorts were considered at high risk of selection bias because of recruitment based on COVID status. Three quarters of 94 cohorts were at high risk of bias in the reference standard domain because of reliance on a single RT‐PCR result to determine the absence of SARS‐CoV‐2 infection or were at unclear risk of bias due to a lack of clarity about the time interval between the index test assessment and the reference standard, the number of missing results, or the absence of a participant flow diagram. For index tests categories with four or more evaluations and when summary estimations were possible, we found that: a) For RT‐PCR assays designed to omit/adapt RNA extraction/purification, the average sensitivity was 95.1% (95% CI 91.1% to 97.3%), and the average specificity was 99.7% (95% CI 98.5% to 99.9%; based on 27 evaluations, 2834 samples and 1178 SARS‐CoV‐2 cases); b) For RT‐LAMP assays, the average sensitivity was 88.4% (95% CI 83.1% to 92.2%), and the average specificity was 99.7% (95% CI 98.7% to 99.9%; 24 evaluations, 29,496 samples and 2255 SARS‐CoV‐2 cases); c) for TMA assays, the average sensitivity was 97.6% (95% CI 95.2% to 98.8%), and the average specificity was 99.4% (95% CI 94.9% to 99.9%; 14 evaluations, 2196 samples and 942 SARS‐CoV‐2 cases); d) for digital PCR assays, the average sensitivity was 98.5% (95% CI 95.2% to 99.5%), and the average specificity was 91.4% (95% CI 60.4% to 98.7%; five evaluations, 703 samples and 354 SARS‐CoV‐2 cases); e) for RT‐LAMP assays omitting/adapting RNA extraction, the average sensitivity was 73.1% (95% CI 58.4% to 84%), and the average specificity was 100% (95% CI 98% to 100%; 24 evaluations, 14,342 samples and 1502 SARS‐CoV‐2 cases). Only two index test categories fulfil the WHO‐acceptable sensitivity and specificity requirements for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. In addition, WHO‐acceptable performance criteria were met for two assays out of 35 when tests were used according to manufacturer instructions. At 5% prevalence using a cohort of 1000 people suspected of SARS‐CoV‐2 infection, the positive predictive value of RT‐PCR assays omitting/adapting RNA extraction/purification will be 94%, with three in 51 positive results being false positives, and around two missed cases. For TMA assays, the positive predictive value of RT‐PCR assays will be 89%, with 6 in 55 positive results being false positives, and around one missed case. Authors' conclusions Alternative laboratory‐based molecular tests aim to enhance testing capacity in different ways, such as reducing the time, steps and resources needed to obtain valid results. Several index test technologies with these potential advantages have not been evaluated or have been assessed by only a few studies of limited methodological quality, so the performance of these kits was undetermined. Only two index test categories with enough evaluations for meta‐analysis fulfil the WHO set of acceptable accuracy standards for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. These assays might prove to be suitable alternatives to RT‐PCR for identifying people infected by SARS‐CoV‐2, especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence, including reliance on retrospective samples without information about the symptom status of participants and the timing of assessment. No extrapolation of found accuracy data for these two alternatives to any test brands using the same techniques can be made as, for both groups, one test brand with high accuracy was overrepresented with 21/26 and 12/14 included studies, respectively. Although we used a comprehensive search and had broad eligibility criteria to include a wide range of tests that could be alternatives to RT‐PCR methods, further research is needed to assess the performance of alternative COVID‐19 tests and their role in pandemic management. Plain language summary How accurate are alternative laboratory‐based molecular tests (to RT‐PCR with prior RNA extraction/purification) for identifying people infected by SARS‐CoV‐2? Key messages: * Transcription‐mediated amplification (TMA) tests and commercially available reverse transcription polymerase chain reaction (RT‐PCR) tests specifically designed to omit/adapt RNA extraction/purification appear accurate enough to replace the method of RT‐PCR with prior RNA (a molecule essential for most biological functions) extraction/purification for identifying people infected by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence. * The accuracy of other types of laboratory‐based molecular alternatives to RT‐PCR is below World Health Organisation (WHO) recommended standards or lacks a sufficient volume of evidence to draw reliable conclusions. *The extrapolation of accuracy data from the evaluated tests to any other test brand(s) using the same techniques will be challenging since main categories are overrepresented by highly accurate individual test brands. Further evaluation of these tests in real clinical practice scenarios is needed. What are alternative laboratory‐based molecular assays for identifying people infected by SARS‐CoV‐2? Laboratory‐based molecular assays (tests) aim to confirm or rule out SARS‐CoV‐2 infection in people. Alternatives to RT‐PCR assays have been developed to minimise the steps needed to process samples in the laboratory or use fewer resources to obtain the same valid results. For this review, we focus on tests commercially developed by a manufacturer, providing instructions for their professional use. Why is this question important? People with suspected SARS‐CoV‐2 infection should know if they are infected to self‐isolate, receive treatment, and inform close contacts. Failure to detect SARS‐CoV‐2 when it is present risks spreading infection and results in missed opportunities for prevention. Diagnosing SARS‐CoV‐2 infection when it is not present may lead to unnecessary self‐isolation and testing of close contacts. Currently, testing to confirm SARS‐CoV‐2 infection relies on a laboratory molecular test called RT‐PCR. This requires specialist equipment and can take 24 hours to produce a result. If assays that take less time or use readily available resources were sufficiently accurate to replace RT‐PCR testing, this could increase the number of tests that could be done, allow faster diagnosis and enable people to take appropriate action more quickly. What did we want to find out? We wanted to know whether commercially developed, alternative laboratory‐based molecular tests are accurate enough to diagnose SARS‐CoV‐2 infection compared to RT‐PCR. What did we do? We looked for studies investigating these tests in people (or samples) that were also tested for SARS‐CoV‐2 infection using RT‐PCR which modified RT‐PCR by removing or altering components of this testing process. What did we find? We included 105 evaluations evaluating alternatives to RT‐PCR in the review. The main results are based on 74,753 samples, and SARS‐CoV‐2 infection was confirmed in 7517 of these samples. Most evaluations (27/105) concerned various test types specifically designed to omit/adapt RNA extraction/purification. Twenty‐four of 105 evaluations concerned various test types operating at one temperature (isothermal tests) rather than cycling through different temperatures. Twenty‐four of 105 evaluations were concerned with various test types that combined these two alternative approaches. Main results Only tests specifically designed to omit/adapt RNA extraction/purification and TMA assays with RNA extraction (a type of isothermal test) met WHO‐acceptable standards for confirming and ruling out SARS‐CoV‐2. For illustration, the results of these studies indicate that in a group of 1000 people, 50 of whom (5%) actually have SARS‐CoV‐2: * For tests specifically designed to omit/adapt RNA extraction/purification: ‐51 people would test positive for SARS‐CoV‐2. Of these, three people (6%) would not have SARS‐CoV‐2 (false‐positive result). ‐949 people would test negative for SARS‐CoV‐2. Of these, two people (0.2%) would actually have SARS‐CoV‐2 (false‐negative result) *For TMA tests with RNA extraction: ‐55 people would test positive for SARS‐CoV‐2. Of these, six people (10%) would not have SARS‐CoV‐2 (false‐positive result). ‐945 people would test negative for SARS‐CoV‐2. Of these, one person (0.1%) would actually have SARS‐CoV‐2 (false‐negative result) What are the limitations of the evidence? Most included studies did not provide information on participants who underwent testing, such as whether they had symptoms or were close contacts of a SARS‐CoV‐2 case. We also had concerns about the method of recruiting participants for the majority of included studies, which may have resulted in an overestimation of the accuracy of these methods. In addition, the method used to determine whether individuals did not have SARS‐CoV‐2 infection was not considered reliable for most studies, which may have resulted in underestimating the accuracy of these methods. Some studies did not follow the manufacturers' instructions for using the test. Results from different test brands using the same technique varied. What does this mean? The studies included in this review suggest that two laboratory‐based molecular tests might be accurate enough to replace or supplement RT‐PCR tests with prior RNA extraction/purification for the diagnosis of SARS‐CoV‐2 infection: RT‐PCR tests developed to omit or adapt RNA extraction or purification and TMA isothermal tests (retaining an RNA extraction step). Other alternative tests to RT‐PCR were assessed just by a few studies of limited methodological quality, and their performance should be evaluated by additional studies. Furthermore, data in these studies mostly relied on samples acquired in the past (compared to current or future samples), thus further evaluation of these tests in real clinical practice scenarios is required. Also, decisions on the optimal test for a specific setting will be driven not only by diagnostic accuracy, but also by other factors such as test complexity, time to result, acceptability to those being tested, and the setting in which the tests are to be used. How up‐to‐date is this review? This review includes evidence published up to 31 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Arevalo-Rodriguez, I; Mateos-Haro, M; Dinnes, J; Ciapponi, A; Davenport, C; Buitrago-Garcia, D; Bennouna-Dalero, T; Roqué-Figuls, M; Van den Bruel, A; von Eije, KJ; Emperador, D; Hooft, L; Spijker, R; Leeflang, MMG; Takwoingi, Y; Deeks, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD015618", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "0bbacf77-71d7-4969-a736-c6d98f30d136", "pmid": "", "title": "Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2010 and previously updated in 2011. Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period. Objectives To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 4 July 2013. Selection criteria We included randomised controlled trials in which oral rinses, mouthwashes and sprays, used pre‐ and postoperatively, have been compared with placebo in adults or children undergoing tonsillectomy, with or without adenoidectomy. Data collection and analysis Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently. Main results We included seven trials (593 participants; 397 children and 196 adults). The period of follow‐up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre‐specified primary outcomes and none for the secondary outcomes. The risk of bias was high in most of the included trials. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage. Authors' conclusions Poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well‐constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data. Plain language summary Oral rinses, mouthwashes and sprays for improving outcomes following tonsillectomy Tonsillectomy is one of the most common operations performed in adults and children. Pain and bleeding following the operation are common. Postoperative tonsillectomy medication should aim to minimise some of these symptoms. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the period just after surgery. This review included seven studies involving 593 participants (397 children and 196 adults) and is up to date as of July 2013. The risk of bias was high in most of the included trials. We found that lidocaine spray appeared to be more effective than a placebo saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation when they used another spray containing benzydamine but this was not sufficient to discontinue its usage. Further research should aim to provide reliable evidence for people to make informed decisions as to whether these treatments can be effective in reducing the most common symptoms and complications following tonsillectomy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fedorowicz, Z; van Zuuren, EJ; Nasser, M; Carter, B; Al Langawi, JH", "articleTypes": [], "doi": "10.1002/14651858.CD007806.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "0bbde8d6-f62e-4e9b-9e9c-c1843fab9e21", "pmid": "", "title": "Acupuncture for Bell's palsy", "imported": false, "abstract": "Abstract - Background Bell's palsy or idiopathic facial palsy is an acute facial paralysis due to inflammation of the facial nerve. A number of studies published in China have suggested acupuncture is beneficial for facial palsy. Objectives The objective of this review was to examine the efficacy of acupuncture in hastening recovery and reducing long‐term morbidity from Bell's palsy. Search methods We updated the searches of the Cochrane Neuromuscular Disease Group Trials Specialized Register (24 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2010), MEDLINE (January 1966 to May 2010), EMBASE (January 1980 to May 2010), AMED (January 1985 to May 2010), LILACS (from January 1982 to May 2010) and the Chinese Biomedical Retrieval System (January 1978 to May 2010) for randomised controlled trials using 'Bell's palsy' and its synonyms, 'idiopathic facial paralysis' or 'facial palsy' as well as search terms including 'acupuncture'. Chinese journals in which we thought we might find randomised controlled trials relevant to our study were handsearched. We reviewed the bibliographies of the randomised trials and contacted the authors and known experts in the field to identify additional published or unpublished data. Selection criteria We included all randomised controlled trials involving acupuncture by needle insertion in the treatment of Bell's palsy irrespective of any language restrictions. Data collection and analysis Two review authors identified potential articles from the literature search, extracted data and assessed quality of each trial independently. All disagreements were resolved by discussion between the review authors. Main results The literature search and handsearching identified 49 potentially relevant articles. Of these, six RCTs were included involving 537 participants with Bell's palsy. Two more possible trials were identified in the update than the previous version of this systematic review, but both were excluded because they were not real RCTs. Of the six included trials, five used acupuncture while the other one used acupuncture combined with drugs. No trial reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. Authors' conclusions The quality of the included trials was inadequate to allow any conclusion about the efficacy of acupuncture. More research with high quality trials is needed. Plain language summary Acupuncture for Bell's palsy Bell's palsy or idiopathic facial palsy is the most common disorder affecting the facial nerves and results in weakness or paralysis on one side of the face. The paralysis causes distortion of the face and interferes with normal functions, such as closing the eye and eating. It is thought to be caused by inflammation of the facial nerve. According to Traditional Chinese Medicine, facial paralysis is known as 'deviated mouth'. It was attributed to 'wind' by past dynasties. 'Qi' refers to the vital substances comprising the human body and the physiological functions of viscera and bowels, channels and collaterals. It maintains life activities and reflects the resistance of the human body. Deficiency of 'qi' allows the invasion of exogenous pathogenic wind. Acupuncture is part of Traditional Chinese Medicine and dates back thousands of years. It involves inserting fine needles into specific points on the skin or applying various other techniques to the acupuncture points to bring about healing. In Bell's palsy, acupuncture treatment might have numerous beneficial effects. This review aimed to review systematically all randomised controlled trials and controlled clinical trials, which examined the effectiveness of acupuncture by needle insertion for Bell's palsy. Six studies including a total of 537 participants met the inclusion criteria. Five studies used acupuncture while the other used acupuncture combined with drugs. No trials reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. More research with high quality trials is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, N; Zhou, M; He, L; Zhou, D; Li, N", "articleTypes": [], "doi": "10.1002/14651858.CD002914.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "0bdb287f-6255-4c92-88f4-1b8898e03903", "pmid": "", "title": "Alterations in Nutrient-sensing Mechanisms May Play a Role in Symptom Generation in Patients With IBS", "imported": false, "abstract": "Clinical data, fresh feces and intestinal mucosal tissues of patients with diarrheal IBS were collected. High performance liquid chromatography, immunohistochemistry and immunofluorescence were used to study the amino acid levels in feces of patients with IBS, the expression of taste receptors in intestinal mucosa, and the correlation between symptoms of abdominal pain and diarrhea and the expression of taste receptors, so as to obtain the conclusion that \"intestinal amino acid perception abnormalities exist in patients with IBS. And correlated with clinical symptoms.\"", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "0beafdc6-c750-4efb-85b7-f5bf8e6568fb", "pmid": "", "title": "Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta‐analyses", "imported": false, "abstract": "Abstract - Background Tobacco smoking is the leading preventable cause of death and disease worldwide. Stopping smoking can reduce this harm and many people would like to stop. There are a number of medicines licenced to help people quit globally, and e‐cigarettes are used for this purpose in many countries. Typically treatments work by reducing cravings to smoke, thus aiding initial abstinence and preventing relapse. More information on comparative effects of these treatments is needed to inform treatment decisions and policies. Objectives To investigate the comparative benefits, harms and tolerability of different smoking cessation pharmacotherapies and e‐cigarettes, when used to help people stop smoking tobacco. Search methods We identified studies from recent updates of Cochrane Reviews investigating our interventions of interest. We updated the searches for each review using the Cochrane Tobacco Addiction Group (TAG) specialised register to 29 April 2022. Selection criteria We included randomised controlled trials (RCTs), cluster‐RCTs and factorial RCTs, which measured smoking cessation at six months or longer, recruited adults who smoked combustible cigarettes at enrolment (excluding pregnant people) and randomised them to approved pharmacotherapies and technologies used for smoking cessation worldwide (varenicline, cytisine, nortriptyline, bupropion, nicotine replacement therapy (NRT) and e‐cigarettes) versus no pharmacological intervention, placebo (control) or another approved pharmacotherapy. Studies providing co‐interventions (e.g. behavioural support) were eligible if the co‐intervention was provided equally to study arms. Data collection and analysis We followed standard Cochrane methods for screening, data extraction and risk of bias (RoB) assessment (using the RoB 1 tool). Primary outcome measures were smoking cessation at six months or longer, and the number of people reporting serious adverse events (SAEs). We also measured withdrawals due to treatment. We used Bayesian component network meta‐analyses (cNMA) to examine intervention type, delivery mode, dose, duration, timing in relation to quit day and tapering of nicotine dose, using odds ratios (OR) and 95% credibility intervals (CrIs). We calculated an effect estimate for combination NRT using an additive model. We evaluated the influence of population and study characteristics, provision of behavioural support and control arm rates using meta‐regression. We evaluated certainty using GRADE. Main results Of our 332 eligible RCTs, 319 (835 study arms, 157,179 participants) provided sufficient data to be included in our cNMA. Of these, we judged 51 to be at low risk of bias overall, 104 at high risk and 164 at unclear risk, and 118 reported pharmaceutical or e‐cigarette/tobacco industry funding. Removing studies at high risk of bias did not change our interpretation of the results. Benefits We found high‐certainty evidence that nicotine e‐cigarettes (OR 2.37, 95% CrI 1.73 to 3.24; 16 RCTs, 3828 participants), varenicline (OR 2.33, 95% CrI 2.02 to 2.68; 67 RCTs, 16,430 participants) and cytisine (OR 2.21, 95% CrI 1.66 to 2.97; 7 RCTs, 3848 participants) were associated with higher quit rates than control. In absolute terms, this might lead to an additional eight (95% CrI 4 to 13), eight (95% CrI 6 to 10) and seven additional quitters per 100 (95% CrI 4 to 12), respectively. These interventions appeared to be more effective than the other interventions apart from combination NRT (patch and a fast‐acting form of NRT), which had a lower point estimate (calculated additive effect) but overlapping 95% CrIs (OR 1.93, 95% CrI 1.61 to 2.34). There was also high‐certainty evidence that nicotine patch alone (OR 1.37, 95% CrI 1.20 to 1.56; 105 RCTs, 37,319 participants), fast‐acting NRT alone (OR 1.41, 95% CrI 1.29 to 1.55; 120 RCTs, 31,756 participants) and bupropion (OR 1.43, 95% CrI 1.26 to 1.62; 71 RCTs, 14,759 participants) were more effective than control, resulting in two (95% CrI 1 to 3), three (95% CrI 2 to 3) and three (95% CrI 2 to 4) additional quitters per 100 respectively. Nortriptyline is probably associated with higher quit rates than control (OR 1.35, 95% CrI 1.02 to 1.81; 10 RCTs, 1290 participants; moderate‐certainty evidence), resulting in two (CrI 0 to 5) additional quitters per 100. Non‐nicotine/placebo e‐cigarettes (OR 1.16, 95% CrI 0.74 to 1.80; 8 RCTs, 1094 participants; low‐certainty evidence), equating to one additional quitter (95% CrI ‐2 to 5), had point estimates favouring the intervention over control, but CrIs encompassed the potential for no difference and harm. There was low‐certainty evidence that tapering the dose of NRT prior to stopping treatment may improve effectiveness; however, 95% CrIs also incorporated the null (OR 1.14, 95% CrI 1.00 to 1.29; 111 RCTs, 33,156 participants). This might lead to an additional one quitter per 100 (95% CrI 0 to 2). Harms There were insufficient data to include nortriptyline and non‐nicotine EC in the final SAE model. Overall rates of SAEs for the remaining treatments were low (average 3%). Low‐certainty evidence did not show a clear difference in the number of people reporting SAEs for nicotine e‐cigarettes, varenicline, cytisine or NRT when compared to no pharmacotherapy/e‐cigarettes or placebo. Bupropion may slightly increase rates of SAEs, although the CrI also incorporated no difference (moderate certainty). In absolute terms bupropion may cause one more person in 100 to experience an SAE (95% CrI 0 to 2). Authors' conclusions The most effective interventions were nicotine e‐cigarettes, varenicline and cytisine (all high certainty), as well as combination NRT (additive effect, certainty not rated). There was also high‐certainty evidence for the effectiveness of nicotine patch, fast‐acting NRT and bupropion. Less certain evidence of benefit was present for nortriptyline (moderate certainty), non‐nicotine e‐cigarettes and tapering of nicotine dose (both low certainty). There was moderate‐certainty evidence that bupropion may slightly increase the frequency of SAEs, although there was also the possibility of no increased risk. There was no clear evidence that any other tested interventions increased SAEs. Overall, SAE data were sparse with very low numbers of SAEs, and so further evidence may change our interpretation and certainty. Future studies should report SAEs to strengthen certainty in this outcome. More head‐to‐head comparisons of the most effective interventions are needed, as are tests of combinations of these. Future work should unify data from behavioural and pharmacological interventions to inform approaches to combined support for smoking cessation. Plain language summary How effective are medications and e‐cigarettes for quitting smoking, and what works best? Key messages Some medicines and e‐cigarettes (handheld devices that work by heating liquid that usually contains nicotine and flavourings) can help people to quit smoking for six months or longer. E‐cigarettes, and the medicines cytisine (otherwise known as Tabex) and varenicline (otherwise known as Chantix and Champix), appear to help the most people to quit smoking, followed by using two types of nicotine replacement therapy at once (nicotine patch and another type, such as gum or lozenge). We need more evidence on possible long‐term harms of e‐cigarettes and medicines to help people quit smoking, but there were very low numbers of serious harms found. Stopping smoking Tobacco smoking is bad for people's health and stopping can lead to significant improvements. Most people would like to quit smoking and there are medicines and e‐cigarettes available to help people to do that. These medicines are called nicotine replacement therapy, cytisine, varenicline, bupropion (sometimes known as Zyban or Wellbutrin) and nortriptyline (sometimes known as Norpress). Nortriptyline is only available for quitting smoking in New Zealand, and cytisine is not available in many countries. At time of writing, there are shortages of varenicline due to a manufacturing issue. These medicines and e‐cigarettes can be provided alongside behavioural support, such as counselling. Stop smoking medications and e‐cigarettes are designed to reduce people's craving to smoke. By finding out more information on how these treatments compare to each other, we hope this review will be used to decide the best treatments to help people stop smoking. Why we did this Cochrane Review We wanted to find out: ‐ which treatments (medicines and e‐cigarettes) help people to stop smoking; ‐ how these treatments compare to each other; ‐ whether there are ways of providing these treatments that mean they are more likely to help people stop smoking (e.g. different doses or treatment lengths); ‐ whether these treatments are likely to cause serious harms; and ‐ whether certain treatments are better tolerated, as indicated by fewer people leaving a study due to treatment. What did we do? We searched for studies that looked at these treatments to help adults quit smoking. We looked for randomised controlled trials, where the treatments people received were decided at random. This type of study usually gives the most reliable evidence about the effects of treatments. We compared all treatments with each other using a method called network meta‐analysis. Search date: 29 April 2022 What we found We found 332 studies that met our criteria and 319 of these provided information that we could use in our analyses. These included 157,179 adults who smoked tobacco cigarettes. Most of the studies took place in the USA or Europe. The studies compared the effects of the stop smoking treatments listed above with: ‐ no medicine/e‐cigarettes for stopping smoking; ‐ e‐cigarettes that did not contain nicotine; ‐ placebo (a dummy medication); and ‐ other types of stop smoking medicine or e‐cigarettes. What are the main results of our review? E‐cigarettes, varenicline and cytisine were most likely to help people quit smoking. For every 100 people, 10 to 19 are likely to quit using an e‐cigarette; 12 to 16 using varenicline; and 10 to 18 using cytisine. This is compared to the 6 in 100 people likely to quit when using no medicine/e‐cigarette or placebo. People using two forms of nicotine replacement therapy at the same time, for example, a combination of nicotine patch and nicotine gum, seemed to have similar rates of quitting to people using e‐cigarettes, varenicline and cytisine. Nicotine patches alone, another form of nicotine replacement therapy alone (such as gum, lozenge) and bupropion appeared to help fewer people quit but still work better than no medicine/e‐cigarette or placebo (8, 9 and 9 people per 100, respectively). Nortriptyline appeared to result in the lowest number of people quitting smoking; for every 100 people using nortriptyline 6 to 11 are likely to quit. We are moderately confident that bupropion could rarely cause some serious health effects. The information we have for other treatments does not provide clear evidence of serious harms. For all treatments, findings suggest very few people experience serious harms when using them. How confident are we in our results? We are confident that e‐cigarettes, cytisine, varenicline, nicotine replacement therapy and bupropion help people stop smoking. We do not expect more evidence will change these results. However, more evidence on how these treatments compare to one another, particularly in relation to harms, would be useful. Due to the nature of our analyses we were not able to judge our confidence in the evidence for combination nicotine replacement therapy (two types used together). We are moderately confident that nortriptyline also helps people to stop smoking, but are less confident in our results for non‐nicotine e‐cigarettes and for potential harms of most of the treatments. We still need more evidence on potential harms and hope more studies will report on these in future; however, nicotine replacement therapy has been used since the 1980s with no evidence of serious harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lindson, N, Theodoulou, A, Ordóñez-Mena, JM, Fanshawe, TR, Sutton, AJ, Livingstone-Banks, J, Hajizadeh, A, Zhu, S, Aveyard, P, Freeman, SC, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015226.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.725Z" }, { "id": "0bf8a3b4-9fc8-4c8b-98b7-4b3b5a669806", "pmid": "", "title": "Interventions for American cutaneous and mucocutaneous leishmaniasis", "imported": false, "abstract": "Abstract - Background On the American continent, cutaneous and mucocutaneous leishmaniasis (CL and MCL) are diseases associated with infection by several species of Leishmania parasites. Pentavalent antimonials remain the first‐choice treatment. There are alternative interventions, but reviewing their effectiveness and safety is important as availability is limited. This is an update of a Cochrane Review first published in 2009. Objectives To assess the effects of interventions for all immuno‐competent people who have American cutaneous and mucocutaneous leishmaniasis (ACML). Search methods We updated our database searches of the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and CINAHL to August 2019. We searched five trials registers. Selection criteria Randomised controlled trials (RCTs) assessing either single or combination treatments for ACML in immuno‐competent people, diagnosed by clinical presentation and Leishmania infection confirmed by smear, culture, histology, or polymerase chain reaction on a biopsy specimen. The comparators were either no treatment, placebo only, or another active compound. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our key outcomes were the percentage of participants 'cured' at least three months after the end of treatment, adverse effects, and recurrence. We used GRADE to assess evidence certainty for each outcome. Main results We included 75 studies (37 were new), totalling 6533 randomised participants with ATL. The studies were mainly conducted in Central and South America at regional hospitals, local healthcare clinics, and research centres. More male participants were included (mean age: roughly 28.9 years (SD: 7.0)). The most common confirmed species were L. braziliensis , L. panamensis , and L. mexicana . The most assessed interventions and comparators were non‐antimonial systemics (particularly oral miltefosine) and antimonials (particularly meglumine antimoniate (MA), which was also a common intervention), respectively. Three studies included moderate‐to‐severe cases of mucosal leishmaniasis but none included cases with diffuse cutaneous or disseminated CL, considered the severe cutaneous form. Lesions were mainly ulcerative and located in the extremities and limbs. The follow‐up (FU) period ranged from 28 days to 7 years. All studies had high or unclear risk of bias in at least one domain (especially performance bias). None of the studies reported the degree of functional or aesthetic impairment, scarring, or quality of life. Compared to placebo, at one‐year FU, intramuscular (IM) MA given for 20 days to treat L. braziliensis and L. panamensis infections in ACML may increase the likelihood of complete cure (risk ratio (RR) 4.23, 95% confidence interval (CI) 0.84 to 21.38; 2 RCTs, 157 participants; moderate‐certainty evidence), but may also make little to no difference, since the 95% CI includes the possibility of both increased and reduced healing (cure rates), and IMMA probably increases severe adverse effects such as myalgias and arthralgias (RR 1.51, 95% CI 1.17 to 1.96; 1 RCT, 134 participants; moderate‐certainty evidence). IMMA may make little to no difference to the recurrence risk, but the 95% CI includes the possibility of both increased and reduced risk (RR 1.79, 95% CI 0.17 to 19.26; 1 RCT, 127 participants; low‐certainty evidence). Compared to placebo, at six‐month FU, oral miltefosine given for 28 days to treat L. mexicana , L. panamensis and L. braziliensis infections in American cutaneous leishmaniasis (ACL) probably improves the likelihood of complete cure (RR 2.25, 95% CI 1.42 to 3.38), and probably increases nausea rates (RR 3.96, 95% CI 1.49 to 10.48) and vomiting (RR 6.92, 95% CI 2.68 to 17.86) (moderate‐certainty evidence). Oral miltefosine may make little to no difference to the recurrence risk (RR 2.97, 95% CI 0.37 to 23.89; low‐certainty evidence), but the 95% CI includes the possibility of both increased and reduced risk (all based on 1 RCT, 133 participants). Compared to IMMA, at 6 to 12 months FU, oral miltefosine given for 28 days to treat L. braziliensis , L. panamensis , L. guyanensis and L. amazonensis infections in ACML may make little to no difference to the likelihood of complete cure (RR 1.05, 95% CI 0.90 to 1.23; 7 RCTs, 676 participants; low‐certainty evidence). Based on moderate‐certainty evidence (3 RCTs, 464 participants), miltefosine probably increases nausea rates (RR 2.45, 95% CI 1.72 to 3.49) and vomiting (RR 4.76, 95% CI 1.82 to 12.46) compared to IMMA. Recurrence risk was not reported. For the rest of the key comparisons, recurrence risk was not reported, and risk of adverse events could not be estimated. Compared to IMMA, at 6 to 12 months FU, oral azithromycin given for 20 to 28 days to treat L. braziliensis infections in ACML probably reduces the likelihood of complete cure (RR 0.51, 95% CI 0.34 to 0.76; 2 RCTs, 93 participants; moderate‐certainty evidence). Compared to intravenous MA (IVMA) and placebo, at 12 month FU, adding topical imiquimod to IVMA, given for 20 days to treat L. braziliensis , L. guyanensis and L. peruviana infections in ACL probably makes little to no difference to the likelihood of complete cure (RR 1.30, 95% CI 0.95 to 1.80; 1 RCT, 80 participants; moderate‐certainty evidence). Compared to MA, at 6 months FU, one session of local thermotherapy to treat L. panamensis and L. braziliensis infections in ACL reduces the likelihood of complete cure (RR 0.80, 95% CI 0.68 to 0.95; 1 RCT, 292 participants; high‐certainty evidence). Compared to IMMA and placebo, at 26 weeks FU, adding oral pentoxifylline to IMMA to treat CL (species not stated) probably makes little to no difference to the likelihood of complete cure (RR 0.86, 95% CI 0.63 to 1.18; 1 RCT, 70 participants; moderate‐certainty evidence). Authors' conclusions Evidence certainty was mostly moderate or low, due to methodological shortcomings, which precluded conclusive results. Overall, both IMMA and oral miltefosine probably result in an increase in cure rates, and nausea and vomiting are probably more common with miltefosine than with IMMA. Future trials should investigate interventions for mucosal leishmaniasis and evaluate recurrence rates of cutaneous leishmaniasis and its progression to mucosal disease. Plain language summary What are the benefits and risks of different treatments for American (muco)cutaneous leishmaniasis (a parasitic disease of the skin and mucous membranes)? Why this question is important American (muco)cutaneous leishmaniasis (ACML) is a disfiguring disease that affects people in Central and South America. It is caused by parasites that are transmitted to humans by sandflies. Different forms of ACML have different symptoms. People with the cutaneous form develop skin sores that often heal within a few months without treatment, but can leave scars. In people with mucosal or mucocutaneous leishmaniasis, destructive sores develop in the protective lining (mucous membranes) of the nose, mouth and throat. To compare the effectiveness and risks of the many treatments for ACML, we reviewed evidence from research studies (randomised controlled trials). We looked for information on the proportion of people whose sores had healed three months or more after treatment, unwanted effects, quality of life, re‐appearance of sores, damage associated with the disease and prevention of scarring. How we identified and assessed the evidence First, we searched for all relevant studies. We then compared the results, summarised the evidence, and assessed the certainty of the evidence. What we found We found 75 studies on 6533 people (approximately 75% male; average age: 29 years). ‐ One study investigated children (2 to 12 years).
‐ Most studies (67) involved people with cutaneous leishmaniasis.
‐ Eight studies investigated people with mucosal or mucocutaneous leishmaniasis.
‐ The parasite Leishmania braziliensis caused the disease in 52 studies.
‐ Studies were conducted at regional hospitals, local clinics, and research centres.
‐ Studies lasted between 28 days and seven years.
‐ Most studies reported their funding source: the US army funded eight studies, industry funded 10, and institutional grants funded 33 (five of these also reported industry funding). Treatments were mainly compared to a placebo (fake treatment) or meglumine antimoniate (an antimonial). Here we report this review's main results. We were only able to report the risk of recurrence and side effects for the comparisons of meglumine antimoniate (MA) or miltefosine versus placebo and miltefosine versus MA. Main results Antimonials Compared to placebo, MA may increase chances of complete healing of ACML, but treatment effects vary, so it is possible that it may make little to no difference. MA probably increases the likelihood of pain in the muscles or joints. There may be little to no difference in the risk of developing the disease again, but there is also a possibility of increased or reduced risk due to the wide range of effects seen. Non‐antimonials Miltefosine probably improves chances of complete healing of American cutaneous leishmaniasis (ACL) compared to placebo, but there may be little to no difference compared to treatment with MA in ACML. Miltefosine may make little to no difference to the risk of developing ACL again when compared to placebo, but treatment effects on recurrence varied, so it may also increase or decrease the risk. Miltefosine probably increases the likelihood of vomiting or nausea when compared to either placebo or MA in ACML. We do not know the effect on recurrence of miltefosine compared to MA. Azithromycin probably reduces chances of complete healing of ACML compared to MA. Imiquimod in combination with MA probably makes little to no difference to the chance of complete healing of ACL compared to MA in combination with placebo. Physical therapies Thermotherapy lowers the chance of complete healing of ACL compared to MA. Immuno‐chemotherapy Pentoxifylline plus MA probably makes little to no difference to chances of complete healing of ACML compared with MA plus placebo. No study reported information about damage, prevention of scarring, or quality of life. What this means The main findings of this review suggest that: ‐ MA and miltefosine probably increase chances of complete healing; and
‐ vomiting or nausea are probably more common with miltefosine, and joint or muscle ache is probably more common with MA. The evidence was mostly of moderate certainty, so the true results are likely close to what we found. Evidence was limited by the inclusion of very few people in some studies, and participants or investigators knowing which treatments they were receiving. How‐up‐to date is this review? The evidence in this Cochrane Review is current to August 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Pinart, M; Rueda, J-R; Romero, GAS; Pinzón-Flórez, CE; Osorio-Arango, K; Silveira Maia-Elkhoury, AN; Reveiz, L; Elias, VM; Tweed, JA", "articleTypes": [], "doi": "10.1002/14651858.CD004834.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "0bfa29b2-39dc-4cd5-87cc-6c52af52c2f2", "pmid": "", "title": "Helminth therapy (worms) for allergic rhinitis", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a disorder of the nasal membranes and surrounding tissues, and a worldwide cause of illness and disability. Helminths are complex tissue‐dwelling or lumen‐dwelling organisms that inhabit larger organisms and are frequently asymptomatic. Helminths modulate the natural immune responses of their human hosts, and may prevent or cure immune‐mediated or allergic diseases (e.g. allergic rhinitis) in the host. Non‐randomised studies support this hypothesis. Objectives To assess the safety and effectiveness of helminth therapy in people with allergic rhinitis. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2011. Selection criteria All randomised controlled trials where the intervention was any helminth species or combination of helminth species, administered to people with allergic rhinitis in any dose, by any route and for any duration of exposure. We accepted both intermittent and persistent allergic rhinitis patients. Data collection and analysis We independently extracted data and assessed eligibility and risk of bias using a standardised data collection form. We resolved any disagreement through discussion. We combined dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), presenting both with 95% confidence intervals (CI). Main results We found five reports of two single‐centre, placebo‐controlled, double‐blinded studies (130 participants). Participants in both studies were a mix of adults with either intermittent or persistent allergic rhinitis. Both studies had a low risk of bias. One study, with 12 weeks’ follow‐up, used a single percutaneous application of 10 Necator americanus (i.e. human hookworm) larvae. The other study, with 24 weeks’ follow‐up, used three‐weekly oral dosing with 2500 Trichuris suis (i.e. pig whipworm) eggs in aqueous suspension. Of 17 outcomes evaluated in this review, eight were positive (i.e. favoured helminths). Participants taking helminths had no reduction in allergic rhinitis symptoms, percentage of well days (i.e. days with minimal symptoms and no use of medication for allergic rhinitis), lung function measures and quality of life scores. Total use of medication for allergic rhinitis (eye drops, nasal sprays, tablets) did not change; however, in the helminth group there was a statistically significant reduction in the percentage of days during the grass pollen season when participants needed to take tablets as rescue medication for their allergic rhinitis symptoms (MD –14.0%, 95% CI –26.6 to –1.40); in a typical 60‐day pollen season this 14% reduction translates into 19 days when tablets would be needed in the helminth group versus 27 days when tablets would be needed in the placebo group. Participants taking helminths percutaneously (i.e. as hookworm larvae) had local skin itching and redness in the first few days after administration. Participants taking helminths were more likely to report any gastrointestinal adverse event (RR 1.79, 95% CI 1.31 to 2.45), moderate or severe abdominal pain (RR 7.67, 95% CI 1.87 to 31.57), moderate or severe flatulence (RR 2.01, 95% CI 1.06 to 3.81) and moderate or severe diarrhoea (RR 1.99, 95% CI 1.18 to 3.37). There was no difference between the helminth and placebo groups in the incidence of serious adverse events, and in study withdrawals. Authors' conclusions There is currently insufficient evidence on the efficacy, tolerability and likely costs of helminth therapy to support its use in the routine management of allergic rhinitis. Administered to humans in carefully measured doses, helminths appear to be safe. More preclinical studies should be performed, before larger and extended duration trials of helminths for allergic rhinitis are carried out. Future studies should collect and report comparative data on the costs of helminth therapy versus conventional pharmacotherapy. Plain language summary Helminth therapy (worms) for allergic rhinitis Allergic rhinitis is a common health problem affecting about 500 million people worldwide; its prevalence is increasing. The symptoms of allergic rhinitis include sneezing, and an itchy, runny and blocked nose. Several classes of drugs are used to treat allergic rhinitis, but these drugs may be ineffective, and some drug classes have side effects after long‐term use. Drugs may also be relatively expensive. Helminths are complex multicellular organisms that inhabit larger organisms, and in humans are often symptomless. Helminths modulate (that is, optimally adjust) the immune systems of their hosts and it is thought that this property of helminths could be used therapeutically, to prevent or treat allergic diseases, such as allergic rhinitis. We included two well‐designed studies with a total of 130 adult participants, each study using a different species of gastrointestinal helminth (human hookworm in one study and pig whipworm in the other) as the intervention. Both studies found no significant efficacy from helminths, although one helminth species ( Trichuris suis , the pig whipworm) reduced the need for participants to take tablets as ‘rescue medication’ during the grass pollen season. Adverse events such as abdominal pain and flatulence were commoner in the helminth group, but the two helminths species studied did not cause serious adverse reactions. Currently there is insufficient evidence to support the use of helminths for allergic rhinitis in routine clinical practice. More preclinical studies are needed, before larger and extended duration clinical trials of helminths for allergic rhinitis are performed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Croft, AM; Bager, P; Garg, SK", "articleTypes": [], "doi": "10.1002/14651858.CD009238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "0c049f0c-290b-4764-b952-58f24f39d553", "pmid": "", "title": "Study of the Effect of Lactisole on the Responses to Intragastric Glucose Solution", "imported": false, "abstract": "The purpose of the study is to determine whether the sweet taste receptors in the gut are involved in sensing sweet substances and controlling appetite and the amount we eat. Lactisole is a substance commonly used in food products to reduce the perceived sweetness of certain sugars and sweeteners. The aim of this study is to investigate whether the responses to a glucose solution, intragastrically administered to healthy male and female volunteers, is affected by the presence of lactisole in the gut. Understanding the mechanisms by which nutrients are initially detected in the gut and how they influence food intake is critical to the development of novel food products that could reduce food consumption.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.239Z" }, { "id": "0c0b1036-3d5f-4a49-9aa1-f55865217d3d", "pmid": "", "title": "Breastfeeding or breast milk for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Pain in the neonate is associated with acute behavioural and physiological changes. Cumulative pain is associated with morbidities, including adverse neurodevelopmental outcomes. Studies have shown a reduction in changes in physiological parameters and pain score measurements following pre‐emptive analgesic administration in neonates experiencing pain or stress. Non‐pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for analgesia. This is an update of a review first published in 2006 and updated in 2012. Objectives The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries (ICTRP, ISRCTN and clinicaltrials.gov) in August 2022; searches were limited from 2011 forwards. We checked the reference lists of included studies and relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates. We included both term (≥ 37 completed weeks postmenstrual age) and preterm infants (< 37 completed weeks' postmenstrual age) up to a maximum of 44 weeks' postmenstrual age. The study must have reported on either physiological markers of pain or validated pain scores. Data collection and analysis We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a mean difference (MD). We used the GRADE approach to assess the certainty of evidence. Main results Of the 66 included studies, 36 evaluated breastfeeding, 29 evaluated supplemental breast milk and one study compared them against each other. The procedures conducted in the studies were: heel lance (39), venipuncture (11), intramuscular vaccination (nine), eye examination for retinopathy of prematurity (four), suctioning (four) and adhesive tape removal as procedure (one). We noted marked heterogeneity in the control interventions and pain assessment measures amongst the studies. Since many studies included multiple arms with breastfeeding/supplemental breast milk as the main comparator, we were not able to synthesise all interventions together. Individual interventions are compared to breastfeeding/supplemental breast milk and reported. The numbers of studies/participants presented with the findings are not taken from pooled analyses (as is usual in Cochrane Reviews), but are the overall totals in each comparison. Overall, the included studies were at low risk of bias except for masking of intervention and outcome assessment, where nearly one‐third of studies were at high risk of bias. Breastfeeding versus control Breastfeeding may reduce the increase in heart rate compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration of sucrose/glucose (20% to 33%) with skin‐to‐skin contact (low‐certainty evidence, 8 studies, 784 participants). Breastfeeding likely reduces the duration of crying compared to no intervention, lying on table, rocking, heel warming, holding by mother, skin‐to‐skin contact, bottle feeding mother's milk and moderate concentration of glucose (moderate‐certainty evidence, 16 studies, 1866 participants). Breastfeeding may reduce percentage time crying compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration sucrose and moderate concentration of sucrose with skin‐to‐skin contact (low‐certainty evidence, 4 studies, 359 participants). Breastfeeding likely reduces the Neonatal Infant Pain Scale (NIPS) score compared to no intervention, holding by mother, heel warming, music, EMLA cream, moderate glucose concentration, swaddling, swaddling and holding (moderate‐certainty evidence, 12 studies, 1432 participants). Breastfeeding may reduce the Neonatal Facial Coding System (NFCS) score compared to no intervention, holding, pacifier and moderate concentration of glucose (low‐certainty evidence, 2 studies, 235 participants). Breastfeeding may reduce the Douleur Aigue Nouveau‐né (DAN) score compared to positioning, holding or placebo (low‐certainty evidence, 4 studies, 709 participants). In the majority of the other comparisons there was little or no difference between the breastfeeding and control group in any of the outcome measures. Supplemental breast milk versus control Supplemental breast milk may reduce the increase in heart rate compared to water or no intervention (low‐certainty evidence, 5 studies, 336 participants). Supplemental breast milk likely reduces the duration of crying compared to positioning, massage or placebo (moderate‐certainty evidence, 11 studies, 1283 participants). Supplemental breast milk results in little or no difference in percentage time crying compared to placebo or glycine (low‐certainty evidence, 1 study, 70 participants). Supplemental breast milk results in little or no difference in NIPS score compared to no intervention, pacifier, moderate concentration of sucrose, eye drops, gentle touch and verbal comfort, and breast milk odour and verbal comfort (low‐certainty evidence, 3 studies, 291 participants). Supplemental breast milk may reduce NFCS score compared to glycine (overall low‐certainty evidence, 1 study, 40 participants). DAN scores were lower when compared to massage and water; no different when compared to no intervention, EMLA and moderate concentration of sucrose; and higher when compared to rocking or pacifier (low‐certainty evidence, 2 studies, 224 participants). Due to the high number of comparator interventions, other measures of pain were assessed in a very small number of studies in both comparisons, rendering the evidence of low certainty. The majority of studies did not report on adverse events, considering the benign nature of the intervention. Those that reported on adverse events identified none in any participants. Subgroup analyses were not conducted due to the small number of studies. Authors' conclusions Moderate‐/low‐certainty evidence suggests that breastfeeding or supplemental breast milk may reduce pain in neonates undergoing painful procedures compared to no intervention/positioning/holding or placebo or non‐pharmacological interventions. Low‐certainty evidence suggests that moderate concentration (20% to 33%) glucose/sucrose may lead to little or no difference in reducing pain compared to breastfeeding. The effectiveness of breast milk for painful procedures should be studied in the preterm population, as there are currently a limited number of studies that have assessed its effectiveness in this population. Plain language summary Breastfeeding or breast milk for procedural pain in newborn babies Review question We investigated how well breastfeeding or supplemental breast milk (expressed breast milk given via feeding tube or by placing breast milk in baby's mouth) works as a pain reliever in newborn babies while they undergo painful procedures (e.g. vaccination, heel prick, blood sampling for tests or eye examinations). The babies' pain responses (e.g. changes in heart rate, oxygen level, blood pressure, percentages of crying time, duration of crying etc.) were assessed by health care professionals to measure the pain that babies are experiencing. Background Breastfeeding may provide pain relief for newborn babies undergoing painful procedures. Medication for pain relief is commonly given for major painful procedures, but may not be given for minor painful procedures such as blood sampling (by heel prick or taking a sample from a vein). There are different forms of non‐drug strategies that can be used to reduce pain in babies, such as holding or swaddling them, sucking on a pacifier, or giving sweet solutions (such as sucrose or glucose). Different studies done in newborn babies have shown that breastfeeding may be a good way to reduce the pain they feel when subjected to minor painful procedures. These studies have been done in full‐term babies, and they have shown that breastfeeding may be effective by demonstrating that it reduces babies' crying time and various pain scores that have been validated for babies. Breast milk given by syringe has not shown the same efficacy as breastfeeding itself. Very few studies have been done in preterm babies, and so new studies are needed to determine if the use of supplemental breast milk in these small babies is effective in reducing their pain. Study characteristics We searched the medical literature thoroughly up to 1 August 2022 for studies that investigated the pain‐relieving effect of breastfeeding or supplemental breast milk for minor medical procedures in newborn full‐term and preterm neonates We included randomised trials only, as they provide the most reliable medical evidence. We identified 66 studies that reported on a total of more than 6200 infants in this Cochrane Review. Thirty‐six studies evaluated breastfeeding, 29 studies evaluated supplemental breast milk, while one study compared both against each other. In over half of the studies, pain relief was during a heel prick procedure. In others, it was during vaccination, drawing blood from a vein or other procedures. The studies used a variety of comparative groups, for example, placebo, no intervention, maternal holding, skin‐to‐skin contact, similar volume of water, a pacifier, routine care, various concentrations of sucrose or glucose, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), swaddling, heel warmth, anaesthetic cream for the skin, or a combination of these. The studies used a wide variety of pain scales as well as changes in heart rate and blood pressure and cry duration to assess pain. Study funding sources The studies included in the review were not externally funded according to information given in the reports. Key results Newborn babies in the breastfeeding group experienced a lower heart rate, shorter duration of cry, lower percentage of cry time and lower scores on the Neonatal Infant Pain Scale than babies who received no intervention. Moderate concentrations of glucose/sucrose may have similar effectiveness to breastfeeding. Studies of supplemental breast milk showed variable results. Supplemental breast milk was found to have a lower increase in heart rate when compared to water, and a lower duration of crying when compared to placebo. What are the limitations of the evidence We are moderately confident that breastfeeding reduces pain as assessed by heart rate, cry duration or validated pain scale compared to no intervention. Supplemental breast milk for painful procedures may reduce pain when compared to no intervention or placebo. Due to the high number of comparator groups, other measures of pain were assessed in a very small number of studies. The majority of the studies did not report on any unwanted or harmful effects of treatment. Those that did this identified no unwanted or harmful effects of treatment in any infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Shah, PS, Torgalkar, R, Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD004950.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.069Z" }, { "id": "0c28c3b4-5d72-46a7-b7ea-9680e025974f", "pmid": "", "title": "Interventions for palliative symptom control in COVID‐19 patients", "imported": false, "abstract": "Abstract - Background Individuals dying of coronavirus disease 2019 (COVID‐19) may experience distressing symptoms such as breathlessness or delirium. Palliative symptom management can alleviate symptoms and improve the quality of life of patients. Various treatment options such as opioids or breathing techniques have been discussed for use in COVID‐19 patients. However, guidance on symptom management of COVID‐19 patients in palliative care has often been derived from clinical experiences and guidelines for the treatment of patients with other illnesses. An understanding of the effectiveness of pharmacological and non‐pharmacological palliative interventions to manage specific symptoms of COVID‐19 patients is required. Objectives To assess the efficacy and safety of pharmacological and non‐pharmacological interventions for palliative symptom control in individuals with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), Embase, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), medRxiv); Web of Science Core Collection (Science Citation Index Expanded, Emerging Sources); CINAHL; WHO COVID‐19 Global literature on coronavirus disease; and COAP Living Evidence on COVID‐19 to identify completed and ongoing studies without language restrictions until 23 March 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. Selection criteria We followed standard Cochrane methodology as outlined in the Cochrane Handbook for Systematic Reviews of Interventions . We included studies evaluating palliative symptom management for individuals with a confirmed diagnosis of COVID‐19 receiving interventions for palliative symptom control, with no restrictions regarding comorbidities, age, gender, or ethnicity. Interventions comprised pharmacological as well as non‐pharmacological treatment (e.g. acupressure, physical therapy, relaxation, or breathing techniques). We searched for the following types of studies: randomized controlled trials (RCT), quasi‐RCTs, controlled clinical trials, controlled before‐after studies, interrupted time series (with comparison group), prospective cohort studies, retrospective cohort studies, (nested) case‐control studies, and cross‐sectional studies. We searched for studies comparing pharmacological and non‐pharmacological interventions for palliative symptom control with standard care. We excluded studies evaluating palliative interventions for symptoms caused by other terminal illnesses. If studies enrolled populations with or exposed to multiple diseases, we would only include these if the authors provided subgroup data for individuals with COVID‐19. We excluded studies investigating interventions for symptom control in a curative setting, for example patients receiving life‐prolonging therapies such as invasive ventilation. Data collection and analysis We used a modified version of the Newcastle Ottawa Scale for non‐randomized studies of interventions (NRSIs) to assess bias in the included studies. We included the following outcomes: symptom relief (primary outcome); quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We rated the certainty of evidence using the GRADE approach. As meta‐analysis was not possible, we used tabulation to synthesize the studies and histograms to display the outcomes. Main results Overall, we identified four uncontrolled retrospective cohort studies investigating pharmacological interventions for palliative symptom control in hospitalized patients and patients in nursing homes. None of the studies included a comparator. We rated the risk of bias high across all studies. We rated the certainty of the evidence as very low for the primary outcome symptom relief, downgrading mainly for high risk of bias due to confounding and unblinded outcome assessors. Pharmacological interventions for palliative symptom control We identified four uncontrolled retrospective cohort studies (five references) investigating pharmacological interventions for palliative symptom control. Two references used the same register to form their cohorts, and study investigators confirmed a partial overlap of participants. We therefore do not know the exact number of participants, but individual reports included 61 to 2105 participants. Participants received multimodal pharmacological interventions: opioids, neuroleptics, anticholinergics, and benzodiazepines for relieving dyspnea (breathlessness), delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms. Primary outcome: symptom relief All identified studies reported this outcome. For all symptoms (dyspnea, delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms), a majority of interventions were rated as completely or partially effective by outcome assessors (treating clinicians or nursing staff). Interventions used in the studies were opioids, neuroleptics, anticholinergics, and benzodiazepines. We are very uncertain about the effect of pharmacological interventions on symptom relief (very low‐certainty evidence). The initial rating of the certainty of evidence was low since we only identified uncontrolled NRSIs. Our main reason for downgrading the certainty of evidence was high risk of bias due to confounding and unblinded outcome assessors. We therefore did not find evidence to confidently support or refute whether pharmacological interventions may be effective for palliative symptom relief in COVID‐19 patients. Secondary outcomes We planned to include the following outcomes: quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We did not find any data for these outcomes, or any other information on the efficacy and safety of used interventions. Non‐pharmacological interventions for palliative symptom control None of the identified studies used non‐pharmacological interventions for palliative symptom control. Authors' conclusions We found very low certainty evidence for the efficacy of pharmacological interventions for palliative symptom relief in COVID‐19 patients. We found no evidence on the safety of pharmacological interventions or efficacy and safety of non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. The evidence presented here has no specific implications for palliative symptom control in COVID‐19 patients because we cannot draw any conclusions about the effectiveness or safety based on the identified evidence. More evidence is needed to guide clinicians, nursing staff, and caregivers when treating symptoms of COVID‐19 patients at the end of life. Specifically, future studies ought to investigate palliative symptom control in prospectively registered studies, using an active‐controlled setting, assess patient‐reported outcomes, and clearly define interventions. The publication of the results of ongoing studies will necessitate an update of this review. The conclusions of an updated review could differ from those of the present review and may allow for a better judgement regarding pharmacological and non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. Plain language summary Which treatments are best for symptoms in COVID‐19 patients at the end of life? The burden of symptoms at the end of life of COVID‐19 patients and helpful treatments COVID‐19 patients may show symptoms such as breathlessness or delirium at the end of life. The goal of palliative medicine is to relieve such symptoms with specific treatments. Treatments can be drugs, for example opioids, or non‐drugs, such as breathing techniques or relaxation. What was the aim of our review? To explore how well different interventions (drugs and non‐drugs) work for the treatment of palliative symptoms in COVID‐19 patients at the end of life. We included patients of all ages and with all comorbidities (additional medical conditions). What type of studies did we search for? We searched selected medical databases and trial registries until 23 March 2021. We included studies looking at how well different palliative treatments work to relieve COVID‐19‐associated symptoms at the end of life. We wanted to compare studies investigating different medicines or therapies, but we only found studies without a comparison group. Only one study reported the specific drugs used for individual symptoms. Key results We found four studies that were published in five papers. Individual papers included between 61 and 2105 participants, and two papers partially reported on the same participants. All of the included studies investigated different drug treatments for palliative symptom management in people with COVID‐19. Drugs for symptom control at the end of life All of the included studies reported on the effectiveness of palliative care for symptom relief. In all studies, clinicians or nursing staff rated symptom relief rather than the patients themselves. Since the quality of the evidence was very low, we do not know the true effect of drug treatments on symptom relief and have very low confidence in the results of the studies. We did not find any data on quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; or safety of the drug treatments. Non‐drug therapies for symptom control at the end of life We did not find any data on the benefits and harms of non‐drug therapies for symptom control of COVID‐19 patients at the end of life. Conclusions Based on our findings, we could not draw any conclusions on palliative symptom control of people with COVID‐19. Future studies need to be designed better so that we can determine which treatments work for symptom control in people with COVID‐19.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Andreas, M, Piechotta, V, Skoetz, N, Grummich, K, Becker, M, Joos, L, Becker, G, Meissner, W, Boehlke, C", "articleTypes": [], "doi": "10.1002/14651858.CD015061", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.767Z" }, { "id": "0c343c57-2026-49fd-ac5a-322ffe977b94", "pmid": "", "title": "Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age", "imported": false, "abstract": "Abstract - Background According to global prevalence analysis studies, acute upper respiratory tract infections (URTIs) are the most common acute infectious disease in children, especially in preschool children. Acute URTIs lead to an economic burden on families and society. Vitamin A refers to the fat‐soluble compound all‐trans‐retinol and also represents retinol and its active metabolites. Vitamin A interacts with both the innate immune system and the adaptive immune system and improves the host's defences against infections. Correlation studies show that serum retinol deficiency was associated with a higher risk of respiratory tract infections. Therefore, vitamin A supplementation may be important in preventing acute URTIs. Objectives To assess the effectiveness and safety of vitamin A supplements for preventing acute upper respiratory tract infections in children up to seven years of age. Search methods We searched CENTRAL, MEDLINE, Embase, the Chinese Biomedical Literature Database, and two trial registration platforms to 8 June 2023. We also checked the reference lists of all primary studies and reviewed relevant systematic reviews and trials for additional references. We imposed no language or publication restrictions. Selection criteria We included randomised controlled trials (RCTs), which evaluated the role of vitamin A supplementation in the prevention of acute URTIs in children up to seven years of age. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Main results We included six studies (27,351 participants). Four studies were RCTs and two were cluster‐RCTs. The included studies were all conducted in lower‐middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas with a high local prevalence of malnutrition and xerophthalmia. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. We judged the included studies to be at either a high or unclear risk of bias for random sequence generation, incomplete outcome data, and blinding. Primary outcomes Six studies reported the incidence of acute URTIs during the study period. Five studies reported the number of acute URTIs over a period of time, but there was population heterogeneity and the results were presented in different forms, therefore only three studies were meta‐analysed. We are uncertain of the effect of vitamin A supplementation on the number of acute URTIs over two weeks (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.92 to 1.09; I 2 = 44%; 3 studies, 22,668 participants; low‐certainty evidence). Two studies reported the proportion of participants with an acute URTI. We are uncertain of the effect of vitamin A supplementation on the proportion of participants with an acute URTI (2 studies, 15,535 participants; low‐certainty evidence). Only one study (116 participants) reported adverse events. No infant in either the placebo or vitamin A group was found to have feeding difficulties (failure to feed or vomiting), a bulging fontanelle, or neurological signs before or after vitamin A administration (very low‐certainty evidence). Secondary outcomes Two studies (296 participants) reported the severity of subjective symptoms, presented by the mean duration of acute URTI. Vitamin A may have little to no effect on the mean duration of acute URTI (very low‐certainty evidence). Authors' conclusions The evidence for the use of vitamin A supplementation to prevent acute URTI is uncertain, because population, dose and duration of interventions, and outcomes vary between studies. From generally very low‐ to low‐certainty evidence, we found that there may be no benefit in the use of vitamin A supplementation to prevent acute URTI in children up to seven years of age. More RCTs are needed to strengthen the current evidence. Future research should report over longer time frames using validated tools and consistent reporting, and ensure adequate power calculations, to allow for easier synthesis of data. Finally, it is important to assess vitamin A supplementation for preschool children with vitamin A deficiency. Plain language summary Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age Background Acute upper respiratory tract infections (URTIs) are the most common acute infectious diseases in children, especially in preschool children. Vitamin A has a positive role in the immune system and may improve the host's defences against infections. Studies show that children with vitamin deficiency are more likely to suffer from respiratory tract infections. Therefore, we assessed the role of vitamin A supplementation in the prevention of acute upper respiratory tract infections in preschool children (up to seven years of age). Review question What is the role of vitamin A supplementation in the prevention of acute URTIs in preschool children (up to seven years of age), compared to no supplementation? Search date We searched for evidence up to 8 June 2023. Study characteristics All included studies were conducted in lower‐ and middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas more likely to experience malnutrition and dry eye. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. Key results We included six studies involving 27,351 participants. We have very low to low confidence in the evidence provided by the studies. Five studies reported the number of acute URTIs over a period of time. The included studies varied by population and the results were presented in different forms, so we could only combine three studies together (meta‐analysis). We are uncertain if vitamin A supplementation lowers the number of acute URTIs over a two‐week period (three studies, 22,668 participants). Two studies reported the proportion of participants with acute URTI. The effect of vitamin A supplementation on the proportion of participants with acute URTI is uncertain (two studies, 15,535 participants). Only one study (116 participants) reported adverse events and none occurred in infants in the placebo or vitamin A groups. Two studies (296 participants) reported the severity of subjective symptoms, presented by the average duration of acute URTIs. Vitamin A may have little to no effect on the average duration of acute URTIs. Authors' conclusions From evidence in which we have very low to low confidence, we found that there may be no benefit in using vitamin A supplementation to prevent acute URTIs in children up to seven years of age. High‐quality studies focusing on preschool children with vitamin A deficiency are needed to identify whether vitamin A supplementation may be effective.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Cheng, X, Li, D, Yang, C, Chen, B, Xu, P, Zhang, L", "articleTypes": [], "doi": "10.1002/14651858.CD015306.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.783Z" }, { "id": "0c37719a-6f64-4789-aa43-ceeced90c8dc", "pmid": "", "title": "Interventions for latent autoimmune diabetes (LADA) in adults", "imported": false, "abstract": "Abstract - Background Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes. Objectives To compare interventions used for LADA. Search methods Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta‐analysis or descriptive methods. Main results Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow‐up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: ‐1.3% (95% confidence interval (CI) ‐2.4 to ‐0.1; P = 0.03, 160 participants, four studies, follow‐up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C‐peptide, but insulin maintained stimulated C‐peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow‐up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C‐peptide levels (20 μg group) were maintained after five years. Short term (three months) follow‐up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C‐peptide levels compared to insulin alone (0.07 µg/L (95% CI ‐0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C‐peptide levels in the vitamin D group but declining fasting C‐peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow‐up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health‐related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes). Authors' conclusions Two studies show SU leading to earlier insulin dependence and a meta‐analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 μg) have been suggested to maintain fasting and stimulated C‐peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA. Plain language summary Interventions for latent autoimmune diabetes (LADA) in adults LADA is a condition that at diagnosis looks like type 2 diabetes (non‐insulin requiring diabetes mellitus) but actually is a type 1 diabetes, where the patient will become insulin requiring. In the UK approximately 3.6% of people who look like they have type 2 diabetes actually have type 1 diabetes, while other studies suggest the prevalence is higher and treatment for these patients may need to be different from that used in type 2 diabetes. 
 We identified 15 publications (10 studies) looking at 1019 patients who were followed between three months to 10 years. We found many of the publications had poor quality of reporting and had small numbers of participants. However, there does seem to be evidence from this review that the drug sulphonylurea (like glibenclamide or glyburide, gliclazide) could make patients insulin dependent sooner and it does not control blood sugar as well as insulin. Therefore, this suggests that this drug should not be a first line treatment for patients with LADA. In addition, insulin combined with vitamin D, or Chinese herbs may maintain natural insulin production better than insulin alone. Similarly, glutamic acid decarboxylase (GAD65) may maintain natural insulin production. However, there was no conclusive evidence that any of the other remaining treatment methods were better than each other. Studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic attacks. This review represents very early days of our understanding of the best way to treat LADA. It is limited by the poor reporting quality of the studies, small sample sizes, no clear single definition of LADA and many of the studies being carried out in different ethnic groups (China, Japan, Cuba, UK, Sweden) with different clinical care systems. 
 None of the publications reported on complications of diabetes, health‐related quality of life, costs or health service utilisation. All but one of the publications reported there were no deaths. 
 In summary, this review demonstrates that insulin treatment may be preferable compared to sulphonylurea treatment but there is little evidence regarding other forms of treatment. Future studies are needed, should have a clear definition of LADA, investigate patient‐important outcomes and use a common method of measuring stimulated C‐peptide (a marker of natural insulin production reflecting improved beta‐cell function of the pancreas).", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Brophy, S; Davies, H; Mannan, S; Brunt, H; Williams, R", "articleTypes": [], "doi": "10.1002/14651858.CD006165.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "0c5d7db0-85c3-49e8-bb35-b609fc1b5225", "pmid": "", "title": "Evaluation of Balance Tablets in Reducing Vitamin and Mineral Deficiencies in Patients Using GLP-1 Receptor Agonists for Weight Loss", "imported": false, "abstract": "Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), including Ozempic (semaglutide) and Saxenda (liraglutide), are gaining traction in treating obesity and its associated diseases due to their capacity to facilitate substantial weight loss through mechanisms such as appetite suppression and delayed gastric emptying. Clinical trials have consistently shown that patients prescribed GLP-1 RAs can achieve significant body weight reductions when combined with appropriate dosing and lifestyle modifications.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.238Z" }, { "id": "0c626c9a-9347-40e6-af06-dd79703d6c75", "pmid": "", "title": "Interventions for improving adherence to ocular hypotensive therapy", "imported": false, "abstract": "Abstract - Background Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open‐angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence. Objectives To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma. Data collection and analysis At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity. Main results Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow‐up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross‐over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive. Authors' conclusions Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes. Plain language summary Interventions for helping people use eye drops as prescribed for raised eye pressure or glaucoma A large number of people do not use eye drops as prescribed. Glaucoma is a slowly progressive eye disease, which can result in severe vision loss. Drops prescribed for raised eye pressure or glaucoma are aimed at lowering the pressure to assist in reducing the rate of progression, or preventing the conversion of raised eye pressure to glaucoma. It is important that these eye drops are used continually, usually for life. Approximately one‐third of people who are prescribed eye drops for the first time fail to continue collecting prescriptions within the first year and even when patients collect prescriptions they do not always use the drops as frequently as they should. A number of reasons are thought to be the cause, for example, forgetfulness, being prescribed a large number of medications, difficulties instilling drops, lack of knowledge about glaucoma, a busy lifestyle and seeing no benefit. This review is based on 16 studies (1565 participants) that tried out different methods to help people to use drops as prescribed. All the studies took place in industrialised countries (Belgium, Denmark, France, Greece, Iceland, Japan, Sweden, Switzerland, UK and USA) and recruited participants in outpatient clinics. The following interventions were included: simplifying drop routines, reminder devices, automated telephone service, providing information about glaucoma and offering advice regarding day to day issues with eye care. Those studies which combined the provision of information about glaucoma and eye drops with other interventions, such as helping people to fit instillation of eye drops into their daily routine, appear to be more successful. Unfortunately, not all of these studies were of high quality and, therefore, until more evidence is available we cannot recommend any particular method. Good quality research is needed in this area in order to develop a better understanding of patients' individual needs and to help us provide more effective eye care services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Waterman, H, Evans, JR, Gray, TA, Henson, D, Harper, R", "articleTypes": [], "doi": "10.1002/14651858.CD006132.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.805Z" }, { "id": "0c760813-2284-4951-a85b-0f0f08f7b865", "pmid": "", "title": "Zinc supplementation for the promotion of growth and prevention of infections in infants less than six months of age", "imported": false, "abstract": "Abstract - Background Zinc is a vital micronutrient for humans and is essential for protein synthesis, cell growth, and differentiation. Severe zinc deficiency can lead to slower physical, cognitive and sexual growth, cause skin disorders, decrease immunity, increase incidence of acute illnesses in infants and children and contribute to childhood stunting. By estimation, 17.3% of the world population is at risk of inadequate zinc intake. Such nutritional impairment increases the risk of diarrhoea and pneumonia by 20%, as well as leads to a global loss of more than 16 million disability‐adjusted life years in children less than five years of age. Not only does zinc deficiency affect lives, it adds to the considerable financial burden on depleted resources in countries that are most affected. By preventing or curing this deficiency, we can improve childhood mortality, morbidity and growth. Objectives To assess the effectiveness of zinc supplementation for the promotion of growth, reduction in mortality, and the prevention of infections in infants less than six months of age. Search methods We used the standard search strategy of the Cochrane Neonatal Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 4), MEDLINE via PubMed (1966 to 18 May 2018), Embase (1980 to 18 May 2018), and CINAHL (1982 to 18 May 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials . An updated search from 1 January 2018 to 29 January 2020 was run in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria All randomised controlled (individual and cluster randomised) and quasi‐randomised trials of zinc supplementation in healthy, term infants, less than six months of age comparing infant mortality, incidence of diarrhoea or respiratory illnesses, growth and/or serum zinc levels were eligible. Data collection and analysis Two review authors screened search results (title and abstracts) and relevant full texts. Studies fulfilling prespecified inclusion criteria were included with any disagreements resolved by consensus. Extraction and analysis were then conducted. We used the GRADE approach to assess the quality of evidence as indicated by certainty in effect estimates. Main results Eight studies (with 85,629 infants) were included and five studies were meta‐analysed, out of which four studies compared zinc with placebo, and one compared zinc plus riboflavin versus riboflavin. Certain growth outcomes after six months of intervention (Weight for Age Z‐scores (WAZ) (standardised mean difference) (SMD) 0.16, 95% CI 0.03 to 0.29; three studies, n = 955; fixed‐effect; heterogeneity Chi² P = 0.96); I² = 0%); change in WAZ (SMD 0.16, 95% CI 0.07 to 0.25; one study, n = 386; fixed‐effect); (Weight‐for‐Length Z‐score (WLZ) (SMD 0.15, 95% CI 0.02 to 0.28; three studies, n = 955; fixed‐effect; heterogeneity: Chi² P = 0.81); I² = 0%); (change in WLZ (SMD 0.17, 95% CI 0.06 to 0.28; one study, n = 386; fixed‐effect)) were positively affected by zinc supplementation compared to placebo. A single study reported no difference in the incidence of diarrhoea and lower respiratory tract infection with zinc supplementation. Zinc had no effect on mortality in children younger than 12 months. When zinc plus riboflavin was compared to riboflavin only, significant improvement was observed in the incidence of wasting at 24 months (risk ratio (RR) 0.59, 95% CI 0.37 to 0.96; one study, n = 296; fixed‐effect), but significant worsening of incidence of stunting was present at 21 months (RR 1.53, 95% CI 1.09 to 2.16; one study, n = 298; fixed‐effect). Authors' conclusions There was a significant positive impact of zinc supplementation on WAZ and WLZ after six months of intervention in infants compared to placebo. When a combined supplement of zinc and riboflavin was compared to riboflavin, there was a significant reduction in wasting at 24 months, but stunting at 21 months was negatively affected. Although included trials were of good‐to‐moderate quality, evidence that could be meta‐analysed was based on a few studies which affected the overall quality of results. Regardless, there is a need for strong trials conducted in infants younger than six months before a strong recommendation can be made supporting zinc supplementation in this age group. Plain language summary Zinc supplementation for improving the health and survival of infants less than six months old Review question: does zinc supplementation reduce mortality, morbidity and increase growth in infants aged less than six months old? Background: zinc deficiency is prevalent in the world. Adequate zinc levels are linked to decreased deaths, illnesses and improved growth in all populations particularly in developing countries. Zinc supplementation in older children has shown some positive effects. Study characteristics: we searched for studies through January 2020 that enrolled healthy infants aged less than six months old and provided at least six months of zinc supplementation. We included eight studies that covered zinc supplementation compared with placebo, zinc and riboflavin compared with riboflavin only, zinc, riboflavin and B complex vitamins compared with riboflavin and B complex vitamins. Key results and certainty of evidence: zinc had no effect on decreasing deaths or illnesses in children younger than 12 months. Moderate‐ to good‐certainty evidence from three studies suggested an increase in weight‐for‐age Z‐scores and weight‐for‐length Z‐scores after zinc supplementation for six months compared to placebo only. Only one study could be analysed for zinc and riboflavin supplementation compared to riboflavin only, and the results suggested a decrease in wasting after 24 months of supplementation and an increase in stunting after 21 months. Conclusion: with this evidence, we cannot strongly recommend clinicians to prescribe zinc supplements to children under six months of age. We also encourage the development of trials that will provide zinc as well as other micronutrients in this age group and for such trials to evaluate outcomes such as death, disease, side effects and growth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lassi, ZS, Kurji, J, Oliveira, CSD, Moin, A, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD010205.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.080Z" }, { "id": "0c7d322b-7a51-48a4-949f-81fd47472ffb", "pmid": "", "title": "Chinese medicinal herbs for cholelithiasis", "imported": false, "abstract": "Abstract - Background Cholelithiasis is a common disease of the biliary tract. Chinese medicinal herbs are being used widely as an alternative treatment in people with cholelithiasis, but their beneficial or harmful effects have not been assessed systematically. Objectives To assess the beneficial and harmful effects of Chinese medicinal herbs in people with cholelithiasis. Search methods We conducted searches in the Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, Science Citation Index Expanded, Chinese Medicine Conference Disc, and Chinese Bio‐Medicine Disc to January 2013. We handsearched four Chinese journals. No language or year of publication restrictions were applied. Selection criteria Randomised clinical trials studying Chinese medicinal herbs for treatment of cholelithiasis. Data collection and analysis Two review authors (SJ, TG) independently extracted data. For dichotomous data, we estimated the risk ratio (RR), and for continuous data, we calculated the mean difference. We also calculated 95% confidence intervals (CI). Main results Eleven randomised trials with 1205 participants with asymptomatic or mild‐to‐moderate cholelithiasis were included. None of the randomised clinical trials compared a single Chinese medicinal herb with a Western medicine or with surgery. No placebo‐controlled trials were identified. In the trials comparing one Chinese herbal medicine (Gandanxiaoshi tablet) versus another (Aihuodantong tablet), there was no significant difference in the improvement of upper abdominal pain after the end of treatment (RR 1.21; 95% CI 0.71 to 2.05), and the heterogeneity among trials was not substantial. No other outcomes could be assessed. The remaining trials of Chinese medicinal herbs (Qingdan capsule, Danshu capsule, Paishi capsule, Rongdanpaishi capsule), did not offer specific data on symptoms, signs, or change in gallstones that would permit assessment of significant differences in curative effects between the treatment and control groups. No serious adverse events were reported. Authors' conclusions This review reveals no strong evidence that the analysed Chinese medicinal herbs have any beneficial effects on asymptomatic or mild‐to‐moderate cholelithiasis. Definitive conclusions will require much better designed randomised trials to reduce risk of bias and allow detailed assessment of clinical outcomes. Plain language summary Chinese medicinal herbs for cholelithiasis Cholelithiasis (gallstone disease) causes significant morbidity, severe complications, and economic burden worldwide. Though current surgical therapies are effective for gallstones, some types of gallstones (e.g., calcium bilirubinate calculi) cannot easily be eradicated by surgery and they often recur in the bile duct system, putting people at high risk of severe complications. The objective of this review was to evaluate the benefits and harms of Chinese medicinal herbs for people with cholelithiasis. Though some Chinese medicinal herbs appear to be safe for people with asymptomatic, mild, or moderate disease, they have not been conclusively shown to have curative effects on gallstones due to the low methodological quality (high risk of bias) of the included trials. Thus, randomised clinical trials with low risk of bias should be conducted to assess the effects of Chinese medicinal herbs before they can be used widely in the clinic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Gan, T, Chen, J, Jin, SJ, Wang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD004547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.075Z" }, { "id": "0c854012-669a-4c1f-88d1-854eef4c321b", "pmid": "", "title": "Ready‐to‐use therapeutic food (RUTF) for home‐based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age", "imported": false, "abstract": "Abstract - Background Management of severe acute malnutrition (SAM) in children comprises two potential phases: stabilisation and rehabilitation. During the initial stabilisation phase, children receive treatment for dehydration, electrolyte imbalances, intercurrent infections and other complications. In the rehabilitation phase (applicable to children presenting with uncomplicated SAM or those with complicated SAM after complications have been resolved), catch‐up growth is the main focus and the recommended energy and protein requirements are much higher. In‐hospital rehabilitation of children with SAM is not always desirable or practical ‐ especially in rural settings ‐ and home‐based care can offer a better solution. Ready‐to‐use therapeutic food (RUTF) is a widely used option for home‐based rehabilitation, but the findings of our previous review were inconclusive. Objectives To assess the effects of home‐based RUTF used during the rehabilitation phase of SAM in children aged between six months and five years on recovery, relapse, mortality and rate of weight gain. Search methods We searched the following databases in October 2018: CENTRAL, MEDLINE, Embase, six other databases and three trials registers. We ran separate searches for cost‐effectiveness studies, contacted researchers and healthcare professionals in the field, and checked bibliographies of included studies and relevant reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs, where children aged between six months and five years with SAM were, during the rehabilitation phase, treated at home with RUTF compared to an alternative dietary approach, or with different regimens and formulations of RUTF compared to each other. We assessed recovery, deterioration or relapse and mortality as primary outcomes; and rate of weight gain, time to recovery, anthropometrical changes, cognitive development and function, adverse outcomes and acceptability as secondary outcomes. Data collection and analysis We screened for eligible studies, extracted data and assessed risk of bias of those included, independently and in duplicate. Where data allowed, we performed a random‐effects meta‐analysis using Review Manager 5, and investigated substantial heterogeneity through subgroup and sensitivity analyses. For the main outcomes, we evaluated the quality of the evidence using GRADE, and presented results in a 'Summary of findings' table per comparison. Main results We included 15 eligible studies (n = 7976; effective sample size = 6630), four of which were cluster trials. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. Six studies received funding or donations from industry whereas eight did not, and one study did not report the funding source. The overall risk of bias was high for six studies, unclear for three studies, and low for six studies. Among the 14 studies that contributed to meta‐analyses, none (n = 5), some (n = 5) or all (n = 4) children were stabilised in hospital prior to commencement of the study. One small study included only children known to be HIV‐infected, another study stratified the analysis for 'recovery' according to HIV status, while the remaining studies included HIV‐uninfected or untested children. Across all studies, the intervention lasted between 8 and 16 weeks. Only five studies followed up children postintervention (maximum of six months), and generally reported on a limited number of outcomes. We found seven studies with 2261 children comparing home‐based RUTF meeting the World Health Organization (WHO) recommendations for nutritional composition (referred to in this review as standard RUTF) with an alternative dietary approach (effective sample size = 1964). RUTF probably improves recovery (risk ratio (RR) 1.33; 95% confidence interval (CI) 1.16 to 1.54; 6 studies, 1852 children; moderate‐quality evidence), and may increase the rate of weight gain slightly (mean difference (MD) 1.12 g/kg/day, 95% CI 0.27 to 1.96; 4 studies, 1450 children; low‐quality evidence), but we do not know the effects on relapse (RR 0.55, 95% CI 0.30 to 1.01; 4 studies, 1505 children; very low‐quality evidence) and mortality (RR 1.05, 95% CI 0.51 to 2.16; 4 studies, 1505 children; very low‐quality evidence). Two quasi‐randomised cluster trials compared standard, home‐based RUTF meeting total daily nutritional requirements with a similar RUTF but given as a supplement to the usual diet (213 children; effective sample size = 210). Meta‐analysis showed that standard RUTF meeting total daily nutritional requirements may improve recovery (RR 1.41, 95% CI 1.19 to 1.68; low‐quality evidence) and reduce relapse (RR 0.11, 95% CI 0.01 to 0.85; low‐quality evidence), but the effects are unknown for mortality (RR 1.36, 95% CI 0.46 to 4.04; very low‐quality evidence) and rate of weight gain (MD 1.21 g/kg/day, 95% CI ‐ 0.74 to 3.16; very low‐quality evidence). Eight studies randomised 5502 children (effective sample size = 4456) and compared standard home‐based RUTF with RUTFs of alternative formulations (e.g. using locally available ingredients, containing less or no milk powder, containing specific fatty acids, or with added pre‐ and probiotics). For recovery, it made little or no difference whether standard or alternative formulation RUTF was used (RR 1.03, 95% CI 0.99 to 1.08; 6 studies, 4188 children; high‐quality evidence). Standard RUTF decreases relapse (RR 0.84, 95% CI 0.72 to 0.98; 6 studies, 4188 children; high‐quality evidence). However, it probably makes little or no difference to mortality (RR 1.00, 95% CI 0.80 to 1.24; 7 studies, 4309 children; moderate‐quality evidence) and may make little or no difference to the rate of weight gain (MD 0.11 g/kg/day, 95% CI −0.32 to 0.54; 6 studies, 3807 children; low‐quality evidence) whether standard or alternative formulation RUTF is used. Authors' conclusions Compared to alternative dietary approaches, standard RUTF probably improves recovery and may increase rate of weight gain slightly, but the effects on relapse and mortality are unknown. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given as a supplement to the usual diet, but the effects on mortality and rate of weight gain are not clear. When comparing RUTFs with different formulations, the current evidence does not favour a particular formulation, except for relapse, which is reduced with standard RUTF. Well‐designed, adequately powered, pragmatic RCTs with standardised outcome measures, stratified by HIV status, and that include diarrhoea as an outcome, are needed. Plain language summary Ready‐to‐use therapeutic food (RUTF) as home‐based treatment for severely malnourished children between six months and five years Background Malnourished children usually look very thin or wasted and they have a high risk of death and illness. Treating severely malnourished children in hospitals is not always desirable or practical in rural settings, and home‐based treatment may be better. Home‐based treatment can be food prepared by a caregiver (such as flour porridge or energy‐ and nutrient‐dense locally available foods), or ready‐to‐use therapeutic food (RUTF) provided by a clinic. RUTF is usually made according to a standard, energy‐rich composition defined by the World Health Organization (WHO). Typically, the ingredients for standard RUTF include milk powder, sugar, peanut butter, vegetable oil, vitamins and minerals; but ingredients vary depending on local availability, cost and acceptability. Benefits of RUTF include a long shelf life without refrigeration and they require no preparation. This is an update of our previous review, where definite conclusions about the effects of RUTF could not be drawn from the four studies that were available at that time. Review question We assessed standard RUTF compared to an alternative dietary approach (e.g. flour porridge or locally available foods) and examined whether smaller amounts and different formulations of RUTF can achieve similar health outcomes in severely malnourished children aged between six months and five years. The main health outcomes that we investigated were recovery from severe malnutrition, deterioration or relapse, death and the rate of weight gain. Included study characteristics We searched databases for studies up to the October 2018, and found 15 studies with 7976 children. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. One small study included only children infected with HIV, another study analysed children with and without HIV separately for the main outcome (recovery), while the other studies included children who were not infected with HIV or who were untested. Overall, we judged six studies to be at high risk of bias, three studies to be at unclear risk of bias, and six studies to be at low risk of bias. (With 'risk of bias', we mean the extent to which the methods used in a study enable it to determine the truth.) All the studies lasted between 8 and 16 weeks. Only five studies followed up children after the study (for a maximum of six months), and generally reported on a limited number of outcomes. Of our 15 included studies, six were linked to funding or donations from industry, one did not report the source of funding, and eight studies reported funding where sponsors did not include industry. Key findings Compared to alternative dietary approaches, standard RUTF probably improves recovery (moderate‐quality evidence) and may increase the rate of weight gain slightly (low‐quality evidence), but the effects on relapse and death are unknown (very low‐quality evidence). With 'quality of evidence' we mean how confident we are that the particular finding represents the true effect. For example, 'very low‐quality' means we are very uncertain about the finding, 'low‐quality evidence' means the future research is very likely to change the finding, 'moderate‐quality evidence' means that future studies may change this finding, and 'high‐quality evidence' means that it is unlikely that future studies will change the finding. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given supplementary to the usual diet (low‐quality evidence), but for death and the rate of weight gain, the effects are not known (very low‐quality evidence). When comparing RUTFs of different formulations, it makes little or no difference for recovery whether a standard or alternative formulation RUTF is used (high‐quality evidence). For relapse, using standard RUTF decreases relapse (high‐quality evidence). It probably makes little or no difference to death (moderate‐quality evidence) and to the rate of weight gain (low‐quality evidence) whether standard or alternative formulation RUTF is used. Well‐designed, randomised controlled trials (experimental studies where participants meeting the inclusion criteria have an equal chance of being allocated to any of the intervention or control groups) in which analyses have been performed separately for children with and without HIV, and that also measure and report on diarrhoea occurrence, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Schoonees, A; Lombard, MJ; Musekiwa, A; Nel, E; Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD009000.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "0c865b10-42a6-49c0-a9ab-0bf21966735d", "pmid": "", "title": "Nebuliser systems for drug delivery in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Nebuliser systems are used to deliver medications to the lungs, to control the symptoms and the progression of lung disease in people with cystic fibrosis (CF). There are many different nebulised‐medications prescribed for people with CF and there are many different types of nebuliser systems. Some of these nebulised medications are licenced for, and can be taken via only one type of nebuliser system; some are licensed for, and can be taken via more than one type of nebuliser system. This is an update to a previous systematic review. Objectives To assess the time efficiency, effectiveness, safety, cost and impact of use (e.g. burden of care, adherence, quality of life (QoL)) of different nebuliser systems, when used with different inhaled medications for people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching of relevant journals and abstract books containing conference proceedings. We searched the reference lists of each study for additional publications and approached the manufacturers of both nebuliser systems and nebulised medications for published and unpublished data. We also searched online trial registries. Date of the most recent search: 9 August 2023. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing nebuliser systems, including conventional nebulisers, vibrating mesh technology (VMT) systems, adaptive aerosol delivery (AAD) systems and ultrasonic nebuliser systems. Data collection and analysis Two review authors independently assessed studies for inclusion. They also independently extracted data and assessed the risk of bias. A third review author assessed studies where agreement could not be reached. They assessed the certainty of the evidence using GRADE. Main results The search identified 216 studies with 33 of these (2270 participants) included in the review. These studies compared the delivery of tobramycin, colistin, dornase alfa, hypertonic saline and other solutions through the different nebuliser systems in children and adults with CF. This review demonstrates variability in the delivery of medication depending on the nebuliser system used. The certainty of the evidence ranged from low to very low. Some conventional nebuliser systems providing higher flows, higher respirable fractions, and smaller particles decrease treatment time, increase deposition (the amount of drug reaching the lung), and may be preferred by people with CF, as compared to other conventional nebuliser systems providing lower flows, lower respirable fractions and larger particles. Newer nebuliser systems using AAD, or VMT (or both) reduce treatment time compared to conventional systems. Deposition (as a percentage of priming dose) with AAD is greater than with conventional systems. VMT systems may give greater deposition than conventional systems when measuring sputum levels. The available data indicate that these newer systems are safe when used with an appropriate priming dose, which may be different to the priming dose used for conventional systems. There is an indication that adherence is maintained or improved and that individuals prefer AAD or VMT systems, but also that some nebuliser systems using VMT may be subject to increased system failures. There is limited, unclear evidence on the impact of different nebuliser systems on lung function and a lack of data on the impact of different nebuliser systems on our outcomes of quality of life (QoL), adverse effects, respiratory exacerbations and related implications, adherence, satisfaction, cost and device reliability. Authors' conclusions Newer technologies e.g. AAD and VMT have advantages over conventional systems in terms of treatment time, deposition as a percentage of priming dose, preference and adherence. Data are lacking for all varieties of medications which are used in CF care, including different inhaled antibiotics or hypertonic saline, with all delivery (nebuliser system) possibilities. Long‐term RCTs are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as QoL and burden of care), safe and effective dosing levels of a wide variety of medications, clinical outcomes (such as hospitalisations and need for antibiotics), and an economic evaluation of their use. There are insufficient data to establish whether one nebuliser system is better than another overall. Clinicians should be aware of the variability in the performance of different nebuliser systems, compatibility with specific nebulised medication, and they must work with their patients to choose the best nebuliser system for each individual. This is likely to be an ongoing process as the needs and circumstances of each individual change over time. Plain language summary Nebulisers for giving medication for cystic fibrosis Key messages 1. Newer technologies have advantages over conventional systems in terms of treatment time, the amount of drug reaching the lung, preference, and adherence. 2. Not all medications used in treating cystic fibrosis can be delivered by the same nebuliser, and data are lacking for some of the different nebuliser and drug combinations. 3. Long‐term studies are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as quality of life, effective dosing levels, and hospitalisations). What is cystic fibrosis? People with cystic fibrosis have sticky mucus in their lungs which is difficult to get rid of and which can cause infection if it builds up. How are nebulisers used as part of cystic fibrosis treatment? Nebulisers are used to deliver medications to the lungs to control the symptoms and the progression of disease. They change a liquid medication into a mist, so it can be breathed in. Different types of nebuliser systems are used with different medications. 1. Conventional systems ‐ a machine pushes out a constant mist of medication at high speed. 2. Adaptive aerosol delivery systems ‐ like conventional systems, also monitor breathing and only deliver the medication while the person is breathing in. 3. Vibrating mesh technology systems move the liquid medication through a metal mesh to generate a mist with similar‐sized droplets which is delivered constantly. 4. Adaptive aerosol delivery systems with vibrating mesh technology combination between the two systems. 5. Ultrasonic systems use a crystal to vibrate the liquid medication at a high frequency and turn it into a mist which is delivered constantly. What did we want to find out? How well do the different nebuliser systems deliver each inhaled medication (how much medication is delivered into the lungs, and what is the impact on lung function)? Are they safe or do they have any side effects? We also wanted to know how these nebuliser systems affect people with cystic fibrosis in terms of treatment burden, adherence to treatment regimen and their quality of life. What did we do? We assessed 33 studies (2270 adults and children)and compared different types of nebuliser systems for delivering: tobramycin; colistin; dornase alfa; hypertonic saline; and other nebulised medications. What did we find? Conventional systems which have faster air flows and smaller medication droplets decrease treatment time and deliver more medication into the lung than other conventional systems, which have slower air flows and larger medication droplets. Nebulisers use newer technologies, e.g. adaptive aerosol delivery system or vibrating mesh technology, deliver the medication faster and may deliver more of the medication into the lung. These newer systems appear safe when used with the correct amount of medication, which may be different to that used in a conventional system. Some studies suggest that people with cystic fibrosis may prefer these newer systems and may take more of their medication when using them. However, more research is needed into what dose of medication is needed for the different systems, which medications suit which technologies best and how these newer nebuliser technologies affect quality of life, burden of treatment, additional treatment needed (such as oral or intravenous antibiotics) and treatment costs. What are the limitations of the evidence? There were lots of different systems studied, and often we only had a few studies for each comparison. Also, the studies we found were quite small and results varied. We had concerns around at least some aspects of the design of every study which affected our confidence in the results. How up to date is this evidence? We last looked for evidence on 9 August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Stanford, G; Morrison, L; Brown, C", "articleTypes": [], "doi": "10.1002/14651858.CD007639.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "0c92b298-337d-4b75-aac8-088fec4a877e", "pmid": "", "title": "Acupuncture for acute management and rehabilitation of traumatic brain injury", "imported": false, "abstract": "Abstract - Background Traumatic brain injury (TBI) can be life threatening depending on the severity of the insult to the brain. It can also cause a range of debilitating sequelae which require cognitive, motor, communication, emotional, or behavioral rehabilitation of varying intensity and duration. A number of studies conducted and published in China have suggested that acupuncture may be beneficial in the acute treatment and rehabilitation of TBI. Objectives To determine the efficacy and safety of acupuncture in the acute management or rehabilitation (or both) of patients with a TBI, including cognitive, neurological, motor, communication, emotional, or behavioral complications, or a combination of such complications. Search methods We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials ( The Cochrane Library ), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO and others. We also searched the Chinese Acupuncture Studies Register, the Studies Register of the Cochrane Complementary Medicine Field, NCCAM, and NIH Clinical Studies Database. Three major Mainland Chinese academic literature databases (CNKI, VIP and Wang Fang Data) were also searched using keywords in simplified Chinese. We searched all databases through December 2009, and some searches have been updated to October 2012. Selection criteria Randomized controlled studies evaluating different variants of acupuncture and involving participants of any age who had suffered a TBI. Included trials compared acupuncture with placebo or sham treatment, or acupuncture plus other treatments compared with the same other treatments. We excluded trials that only compared different variants of acupuncture or compared acupuncture alone against other treatments alone, as they did not yield the net effect of acupuncture. Data collection and analysis Two review authors identified potential articles from the literature search and extracted data independently using a data extraction form. We performed methodological assessment of included studies using the Cochrane Collaboration's tool for assessing risk of bias. We were unable to perform quantitative data analysis due to insufficient included studies and available data. Main results Four RCTs, including 294 participants, reported outcomes specified by this review. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The results seem to suggest that acupuncture is efficacious for these indications, however the low methodological quality of these studies renders the results questionable. No adverse effects of acupuncture were reported in any of the studies. Authors' conclusions The low methodological quality of the included studies does not allow us to make conclusive judgments on the efficacy and safety of acupuncture in either the acute treatment and/or rehabilitation of TBI. Its beneficial role for these indications remains uncertain. Further research with high quality trials is required. Plain language summary Acupuncture for acute management and rehabilitation of traumatic brain injury Acupuncture used for the acute treatment, rehabilitation (or both) of traumatic brain injury (TBI) has been studied in China. We conducted a systematic review to evaluate the efficacy and safety of acupuncture for these conditions. Four randomized controlled trials were eligible for inclusion in this review, involving 294 patients. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The studies were of low methodological quality and were diverse in their objectives, participant characteristics, acupuncture modalities and strategies, and outcome measures. The small number of studies together with their low methodological quality means that they are inadequate to allow any conclusion to be drawn about the efficacy and safety of acupuncture in the treatment of TBI. Further methodologically robust studies are needed to generate evidence‐based conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wong, V, Cheuk, DKL, Lee, S, Chu, V", "articleTypes": [], "doi": "10.1002/14651858.CD007700.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.752Z" }, { "id": "0ca42c4b-213d-41be-afb9-7f9e14fdde3d", "pmid": "", "title": "Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status", "imported": false, "abstract": "Abstract - Background Iron deficiency is an important micronutrient deficiency contributing to the global burden of disease, and particularly affects children, premenopausal women, and people in low‐resource settings. Anaemia is a possible consequence of iron deficiency, although clinical and functional manifestations of anemia can occur without iron deficiency (e.g. from other nutritional deficiencies, inflammation, and parasitic infections). Direct nutritional interventions, such as large‐scale food fortification, can improve micronutrient status, especially in vulnerable populations. Given the highly successful delivery of iodine through salt iodisation, fortifying salt with iodine and iron has been proposed as a method for preventing iron deficiency anaemia. Further investigation of the effect of double‐fortified salt (i.e. with iron and iodine) on iron deficiency and related outcomes is warranted. Objectives To assess the effect of double‐fortified salt (DFS) compared to iodised salt (IS) on measures of iron and iodine status in all age groups. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases, and two trial registries up to April 2021. We also searched relevant websites, reference lists, and contacted the authors of included studies. Selection criteria All prospective randomised controlled trials (RCTs), including cluster‐randomised controlled trials (cRCTs), and controlled before‐after (CBA) studies, comparing DFS with IS on measures of iron and iodine status were eligible, irrespective of language or publication status. Study reports published as abstracts were also eligible. Data collection and analysis Three review authors applied the study selection criteria, extracted data, and assessed risk of bias. Two review authors rated the certainty of the evidence using GRADE. When necessary, we contacted study authors for additional information. We assessed RCTs, cRCTs and CBA studies using the Cochrane RoB 1 tool and Cochrane Effective Practice and Organisation of Care (EPOC) tool across the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other potential sources of bias due to similar baseline characteristics, similar baseline outcome assessments, and declarations of conflicts of interest and funding sources. We also assessed cRCTs for recruitment bias, baseline imbalance, loss of clusters, incorrect analysis, and comparability with individually randomised studies. We assigned studies an overall risk of bias judgement (low risk, high risk, or unclear). Main results We included 18 studies (7 RCTs, 7 cRCTs, 4 CBA studies), involving over 8800 individuals from five countries. One study did not contribute to analyses. All studies used IS as the comparator and measured and reported outcomes at study endpoint. With regards to risk of bias, five RCTs had unclear risk of bias, with some concerns in random sequence generation and allocation concealment, while we assessed two RCTs to have a high risk of bias overall, whereby high risk was noted in at least one or more domain(s). Of the seven cRCTs, we assessed six at high risk of bias overall, with one or more domain(s) judged as high risk and one cRCT had an unclear risk of bias with concerns around allocation and blinding. The four CBA studies had high or unclear risk of bias for most domains. The RCT evidence suggested that, compared to IS, DFS may slightly improve haemoglobin concentration (mean difference (MD) 0.43 g/dL, 95% confidence interval (CI) 0.23 to 0.63; 13 studies, 4564 participants; low‐certainty evidence), but DFS may reduce urinary iodine concentration compared to IS (MD −96.86 μg/L, 95% CI −164.99 to −28.73; 7 studies, 1594 participants; low‐certainty evidence), although both salts increased mean urinary iodine concentration above the cut‐off deficiency. For CBA studies, we found DFS made no difference in haemoglobin concentration (MD 0.26 g/dL, 95% CI −0.10 to 0.63; 4 studies, 1397 participants) or urinary iodine concentration (MD −17.27 µg/L, 95% CI −49.27 to 14.73; 3 studies, 1127 participants). No studies measured blood pressure. For secondary outcomes reported in RCTs, DFS may result in little to no difference in ferritin concentration (MD −3.94 µg/L, 95% CI −20.65 to 12.77; 5 studies, 1419 participants; low‐certainty evidence) or transferrin receptor concentration (MD −4.68 mg/L, 95% CI −11.67 to 2.31; 5 studies, 1256 participants; low‐certainty evidence) compared to IS . However, DFS may reduce zinc protoporphyrin concentration (MD −27.26 µmol/mol, 95% CI −47.49 to −7.03; 3 studies, 921 participants; low‐certainty evidence) and result in a slight increase in body iron stores (MD 1.77 mg/kg, 95% CI 0.79 to 2.74; 4 studies, 847 participants; low‐certainty evidence). In terms of prevalence of anaemia, DFS may reduce the risk of anaemia by 21% (risk ratio (RR) 0.79, 95% CI 0.66 to 0.94; P = 0.007; 8 studies, 2593 participants; moderate‐certainty evidence). Likewise, DFS may reduce the risk of iron deficiency anaemia by 65% (RR 0.35, 95% CI 0.24 to 0.52; 5 studies, 1209 participants; low‐certainty evidence). Four studies measured salt intake at endline, although only one study reported this for both groups. Two studies reported prevalence of goitre, while one CBA study measured and reported serum iron concentration. One study reported adverse effects. No studies measured hepcidin concentration. Authors' conclusions Our findings suggest DFS may have a small positive impact on haemoglobin concentration and the prevalence of anaemia compared to IS, particularly when considering efficacy studies. Future research should prioritise studies that incorporate robust study designs and outcome measures (e.g. anaemia, iron status measures) to better understand the effect of DFS provision to a free‐living population (non‐research population), where there could be an added cost to purchase double‐fortified salt. Adequately measuring salt intake, both at baseline and endline, and adjusting for inflammation will be important to understanding the true effect on measures of iron status. Plain language summary Fortification of salt with iron and iodine compared to salt fortified with iodine only for improving iron and iodine status Key messages Compared to iodised salt, double‐fortified salt (salt fortified with iron and iodine) may improve some measures of iron and iodine nutrition, such as haemoglobin (i.e. the substance that gives red blood cells their colour) concentrations and body iron stores. However, it may reduce urinary iodine concentration and may make little or no difference to ferritin (i.e. iron‐storage protein) concentrations and transferrin receptor (i.e. protein that affects the uptake of iron) concentrations. It probably also reduces the prevalence of anaemia (lack of haemoglobin), and may reduce the prevalence of iron deficiency anaemia (lack of iron), compared to iodised salt. Well‐designed studies that assess the effects of double‐fortified salt within non‐research populations (i.e. real‐life settings), and that measure salt intake, including changes in salt consumption, are needed. What is iron deficiency? Almost two billion people experience a deficiency in a vitamin or mineral (or both), with women and children in resource‐limited settings most frequently affected. Iron‐related deficiencies are among the most common deficiencies in the world and have important short‐ and long‐term health consequences. Interventions to provide iron frequently include iron supplementation, including iron tablets, powders, or syrups. However, these have known barriers, and food fortification strategies may be attractive alternatives. Salt is one of few universally consumed food vehicles. Iodised salt is fortified to provide 100% of a person's iodine requirements and is highly effective. Double‐fortified salt was developed to provide 30% of a person's daily dietary iron requirement and 100% of their iodine requirement. In some resource‐limited settings, where iron‐related deficiencies are a common problem, there has been interest in making double‐fortified salt more available to the public. This calls for further understanding of the effect of double‐fortified salt on related outcomes. What did we want to find out? If double‐fortified salt is better than salt fortified with iodine alone for improving measures of iron and iodine‐related nutrition, in particular: ‐ haemoglobin concentration; ‐ urinary iodine concentration; ‐ blood pressure; ‐ ferritin concentration; ‐ transferrin receptor concentration; ‐ prevalence of anaemia; ‐ prevalence of iron deficiency anaemia. What did we do? We looked for studies that provided double‐fortified salt to one group of participants and iodised salt to another. We compared their results, and rated our confidence in the evidence, based on factors such as study methods and sample size. What did we find? We identified 18 studies, involving over 8800 individuals from five countries; 13 studies were conducted in India. In 13 studies the intervention lasted between 6 and 12 months; in two studies it lasted 3 months, and in single studies it lasted for 18 months, 24 months, or the duration was unclear. Nine studies were conducted in children and adolescents (5 to 17 years), four in adults (18 years and older), and five included multiple age groups. All studies compared double‐fortified salt to iodised salt. Most studies were funded by non‐profit organisations, university grants or academic institutes. In four studies, double‐fortified salt was provided by a commercial organisation, and in three studies the funding source unclear. Compared to iodised salt, double‐fortified salt may improve haemoglobin concentration and body iron stores slightly, and probably reduces the prevalence of anaemia by 21%. However, double‐fortified salt may also reduce urinary iodine concentration compared to iodised salt and may make little or no difference in ferritin and transferrin receptor concentration. Double‐fortified salt may reduce the prevalence of iron deficiency anaemia by 65%, compared to iodised salt, although this conclusion is uncertain because of some problems with the way the studies were conducted. Very few studies measured zinc protoporphyrin concentration, adverse effects, prevalence of goitre and salt intake. One study measured serum iron concentration. No studies measured blood pressure or hepcidin concentration. What are the limitations of the evidence? We have relatively low confidence in the evidence for the outcomes: haemoglobin, urinary iodine, ferritin, and transferrin receptor concentration, and prevalence of iron deficiency anaemia. Not all studies provided data about all outcomes of interest; studies delivered the intervention differently; and studies were small, both in number and size. For the prevalence of anaemia, we are moderately confident in the evidence because studies used different ways of delivering the intervention. Care should be taken in interpreting our findings in relation to public health policy and programmes. Most studies were conducted in monitored research settings and double‐fortified salt was provided without an added cost. We are unsure if the effect we observed would be the same in real‐life (i.e. non‐research population), where purchasing double‐fortified salt could increase the cost. More studies looking at the effect of double‐fortified salt within real‐life settings are needed to understand the true effects of double‐fortified salt with greater certainty. Given the changing guidelines for salt intake, future studies should measure salt intake to understand if double‐fortified salt should be considered to prevent anaemia at the population level and how to integrate double‐fortified salt into the supply chain. How up to date is this evidence? The evidence is up to date to April 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Baxter, J-AB; Carducci, B; Kamali, M; Zlotkin, SH; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD013463.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "0ca7adb1-1b6c-4fd1-a0b8-e147bd8d5b6b", "pmid": "", "title": "Tartrazine exclusion for allergic asthma", "imported": false, "abstract": "Abstract - Background Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There has been conflicting evidence as to whether tartrazine causes exacerbations of asthma with some studies finding a positive association especially in individuals with cross‐sensitivity to aspirin. Objectives To assess the overall effect of tartrazine (exclusion or challenge) in the management of asthma. Search methods A search was carried out on the Cochrane Airways Group Specialised Register. Bibliographies of each RCT was searched for additional papers. Authors of identified RCTs were contacted for further information. Searches are updated annually and are current as of February 2006. Selection criteria RCTs of oral administration of tartrazine (as a challenge) versus placebo or dietary avoidance of tartrazine versus normal diet were considered. Studies which focused upon allergic asthma, were also included. Studies of tartrazine exclusion for other allergic conditions such as hay fever, allergic rhinitis and eczema were only considered if the results for subjects with asthma were separately identified. Trials could be in either adults or children with asthma or allergic asthma (e.g. sensitivity to aspirin or food items known to contain tartrazine). Data collection and analysis Study quality was assessed and data abstracted by two reviewers independently. Outcomes were analysed using RevMan 4.1.1. Main results Ninety four abstracts were found, of which 20 were potentially relevant. Six? met the inclusion criteria, but only three presented results in a format that permitted analysis and none could be combined in a meta‐analysis. In none of the studies did tartrazine challenge or avoidance in diet significantly alter asthma outcomes. Authors' conclusions Due to the paucity of available evidence, it is not possible to provide firm conclusions as to the effects of tartrazine on asthma control. However, the six RCTs that could be included in this review all arrived at the same conclusion. Routine tartrazine exclusion may not benefit most patients, except those very few individuals with proven sensitivity. Plain language summary Tartrazine exclusion for allergic asthma Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There is no evidence that tartrazine makes asthma worse or avoiding it makes asthma patients any better.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Ardern, K", "articleTypes": [], "doi": "10.1002/14651858.CD000460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "0cb222cf-6fd9-4856-b791-507425a5a50c", "pmid": "", "title": "Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long‐term central venous catheters in infants and children", "imported": false, "abstract": "Abstract - Background Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015. Objectives To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long‐term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC). Data collection and analysis Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random‐effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review. Main results We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin. Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC‐associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC‐associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low‐certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate‐certainty evidence), and not reported in the remaining studies. Authors' conclusions The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC‐associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains. Plain language summary Replacing heparin flushing with saline flushing to prevent complications in long‐term central venous catheters in children Background A central venous catheter (CVC) is a long, thin, flexible tube which is inserted into a large central vein. This enables access to the blood stream for people with serious medical conditions to receive medications and fluids, as well as the collection of blood specimens. Long‐term CVCs are used to access the blood system in children with complex medical conditions like cancer. To stop the catheter from becoming blocked it is usual to use heparin, a drug that prevents clots forming, to flush the catheter. However, some studies have shown that heparin is not necessary, and that normal saline (a sterile salt water solution) can be safely used instead. Heparin may be associated with complications, such as bleeding and infection, along with higher costs for healthcare providers. While the complications such as infections and occlusions are uncommon, practices vary around the world and there are many inconsistencies regarding the best flush solution to use to prevent complications in long‐term catheters. Study characteristics and key results This review included randomised controlled trials (clinical studies where people were randomly assigned into one of two or more treatment groups) that compared the use of saline and heparin to prevent blockage, and other complications related to long‐term catheters. The evidence is current to 9 April 2019. Two review authors independently reviewed the studies. We included four studies with a total of 255 participants in the review. The four trials were all undertaken in large teaching (tertiary) hospitals, and directly compared the use of saline and heparin. The studies were, however, very different in the way they compared saline and heparin, with different concentrations of heparin and different frequencies of flushes reported. We were able to combine the results of two studies: the analysis showed imprecise results for the blocking of catheters and blood stream infections for normal saline versus heparin. One study reported the duration of catheter placement to be similar between the two study arms. Certainty of the evidence The overall certainty of the evidence ranged from moderate to very low. There was high risk of bias for blinding, there were differences between the studies methods and interventions, inconsistent results between the studies, and not all studies reported all outcomes of interest. We found there was not enough evidence to determine which solution, saline or heparin, is more effective for reducing complications. Further research is required and is likely to have an important impact in this area. This review is an update of a review first published in 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bradford, NK, Edwards, RM, Chan, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD010996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.111Z" }, { "id": "0ce76ba4-0814-4dfe-bab4-3732455625fc", "pmid": "", "title": "Investigating the Synergistic Potential of Music as an Adjunct to Ketamine Therapy for Chronic Noncancer Pain", "imported": false, "abstract": "Intravenous (IV) ketamine is a treatment option for patients with chronic pain that does not respond to standard therapies, primarily working by blocking NMDA receptors in the brain. Beyond pain relief, ketamine can produce dissociative sensations, classifying it as an atypical psychedelic or mind-altering drug, and may enable patients to reprocess their pain similarly to experiences with traditional psychedelics. At the Montreal General Hospital's pain clinic, the investigators have observed patients frequently listening to music during ketamine infusions, and recent research indicates that music-especially when self-selected by patients-might provide additional pain-relieving benefits by influencing central mechanisms related to pain perception and interpretation. This intersection of music and pain relief is garnering substantial scientific interest as recent advances provide more insight into the neuroscience of music and its effects on brain regions involved in emotion, sensation, memory, and pain.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.157Z" }, { "id": "0cec88d5-680a-40e0-8ea7-6124ac044051", "pmid": "", "title": "Benperidol for schizophrenia", "imported": false, "abstract": "Abstract - Background Benperidol is a relatively old antipsychotic drug that has been marketed since 1966. It has been used in Germany for 30 years but is also available in Belgium, Greece, Italy, the Netherlands and the UK. Benperidol is a butyrophenone antipsychotic, with the highest neuroleptic potency in terms of D2 receptor blockade. Those taking it are therefore reputed to be at high risk of extrapyramidal side‐effects, but benperidol's unusual profile may render it valuable to certain subgroups of people with schizophrenia. Objectives To examine the clinical effects and safety of benperidol for those with schizophrenia and schizophrenia‐like psychoses. Search methods We searched the Cochrane Schizophrenia Group's register (March 2009) for this update. Selection criteria We included all randomised controlled trials that compared benperidol with other treatments for people with schizophrenia, or schizophrenia‐like psychoses. Data collection and analysis We reliably selected studies, quality rated them and extracted data. We independently extracted data but excluded data if loss to follow up was greater than 50%. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results The update yielded no further studies for inclusion in the review. We identified only one unpublished poorly randomised controlled trial (N=40, duration 30 days, comparison perphenazine). Although benperidol was inferior to perphenazine (1 RCT, N=40, global state no better or worse RR 8.0 CI 2.1 to 30, NNH 1.4 CI 1 to 2) poor reporting suggests that an overestimate of effect is likely. It was not possible to report other outcomes. Authors' conclusions Currently, there are insufficient data from randomised trials to assess the clinical effects of benperidol. This compound merits further research interest. Plain language summary Benperidol for schizophrenia Benperidol is a relatively old drug that is used for the treatment of schizophrenia in several European countries. We identified only one small, poorly reported, unpublished, randomised trial comparing benperidol with another antipsychotic. Unfortunately the quality of reporting is so poor that the results cannot be considered reliable. Although benperidol was first marketed in 1966, more trials on this drug are justified as with the advent of new compounds there is a danger that inexpensive drugs such as benperidol remain under‐researched and overlooked.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Schwarz, C; Hartung, B; Leucht, S", "articleTypes": [], "doi": "10.1002/14651858.CD003083.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "0d005ac3-a67b-4602-ad9f-9abe2cece1df", "pmid": "", "title": "Mindfulness‐enhanced parenting programmes for improving the psychosocial outcomes of children (0 to 18 years) and their parents", "imported": false, "abstract": "Abstract - Background Emotional and behavioural difficulties (EBD) in children are common, characterised by externalising or internalising behaviours that can be highly stable over time. EBD are an important cause of functional disability in childhood, and predictive of poorer psychosocial, academic, and occupational functioning into adolescence and adulthood. The prevalence, stability, and long‐term consequences of EBD highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Multiple factors contribute to the aetiology of EBD in children, and parenting plays an important role. The relationship between parenting and EBD has been described as bidirectional, with parents and children shaping one another’s behaviour. One consequence of bidirectionality is that parents with insufficient parenting skills may become involved in increasingly negative behaviours when dealing with non‐compliance in children. This can have a cyclical effect, exacerbating child behavioural difficulties and further increasing parental distress. Behavioural or skills‐based parenting training can be highly effective in addressing EBD in children. However, emotional dysregulation may intercept some parents' ability to implement parenting skills, and there is recognition that skills‐based interventions may benefit from adjunct components that better target parental emotional responses. Mindful parenting interventions have demonstrated some efficacy in improving child outcomes via improvements in parental emotion regulation, and there is potential for mindfulness training to enhance the effectiveness of standard parent training programmes. Objectives To assess the effectiveness of mindfulness‐enhanced parent training programmes on the psychosocial functioning of children (aged 0 to 18 years) and their parents. Search methods We searched the following databases up to April 2023: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, PsycINFO, Sociological Abstracts, Social Sciences Citation Index, Conference Proceedings Citation Index – Social Science & Humanities, AMED, ERIC, ProQuest Dissertations & Theses, Cochrane Database of Systematic Reviews, Campbell Collaboration Library of Systematic Reviews, as well as the following trials registers: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also contacted organisations/experts in the field. Selection criteria We included randomised and quasi‐randomised trials. Participants were parents or caregivers of children under the age of 18. The intervention was mindfulness‐enhanced parent training programmes compared with a no‐intervention, waitlist, or attentional control, or a parent training programme with no mindfulness component. The intervention must have combined mindfulness parent training with behavioural or skills‐based parent training. We defined parent training programmes in terms of the delivery of a standardised and manualised intervention over a specified and limited period, on a one‐to‐one or group‐basis, with a well‐defined mindfulness component. The mindfulness component must have included mindfulness training (breath, visualisation, listening, or other sensory focus) and an explicit focus on present‐focused attention and non‐judgemental acceptance. Data collection and analysis We followed standard Cochrane procedures. Main results Eleven studies met our inclusion criteria, including one ongoing study. The studies compared a mindfulness‐enhanced parent training programme with a no‐treatment, waitlist, or attentional control (2 studies); a parent training programme with no mindfulness component (5 studies); both a no‐treatment, waitlist, or attentional control and a parent training programme with no mindfulness component (4 studies). We assessed all studies as being at an unclear or high risk of bias across multiple domains. We pooled child and parent outcome data from 2118 participants to produce effect estimates. No study explicitly reported on self‐compassion, and no adverse effects were reported in any of the studies. Mindfulness‐enhanced parent training programmes compared to a no‐treatment, waitlist, or attentional control Very low certainty evidence suggests there may be a small to moderate postintervention improvement in child emotional and behavioural adjustment (standardised mean difference (SMD) −0.46, 95% confidence interval (CI) −0.96 to 0.03; P = 0.06, I 2 = 62%; 3 studies, 270 participants); a small improvement in parenting skills (SMD 0.22, 95% CI 0.06 to 0.39; P = 0.008, I 2 = 0%; 3 studies, 587 participants); and a moderate decrease in parental depression or anxiety (SMD −0.50, 95% CI −0.96 to −0.04; P = 0.03; 1 study, 75 participants). There may also be a moderate to large decrease in parenting stress (SMD −0.79, 95% CI −1.80 to 0.23; P = 0.13, I 2 = 82%; 2 studies, 112 participants) and a small improvement in parent mindfulness (SMD 0.21, 95% CI −0.14 to 0.56; P = 0.24, I 2 = 69%; 3 studies, 515 participants), but we were not able to exclude little to no effect for these outcomes. Mindfulness‐enhanced parent training programmes compared to parent training with no mindfulness component Very low certainty evidence suggests there may be little to no difference postintervention in child emotional and behavioural adjustment (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.71, I 2 = 64%; 5 studies, 203 participants); parenting skills (SMD 0.13, 95% CI −0.16 to 0.42; P = 0.37, I 2 = 16%; 3 studies, 319 participants); and parent mindfulness (SMD 0.11, 95% CI −0.19 to 0.41; P = 0.48, I 2 = 44%; 4 studies, 412 participants). There may be a slight decrease in parental depression or anxiety (SMD −0.24, 95% CI −0.83 to 0.34; P = 0.41; 1 study, 45 participants; very low certainty evidence), though we cannot exclude little to no effect, and a moderate decrease in parenting stress (SMD −0.51, 95% CI −0.84 to −0.18; P = 0.002, I 2 = 2%; 3 studies, 150 participants; low certainty evidence). Authors' conclusions Mindfulness‐enhanced parenting training may improve some parent and child outcomes, with no studies reporting adverse effects. Evidence for the added value of mindfulness training to skills‐based parenting training programmes is suggestive at present, with moderate reductions in parenting stress. Given the very low to low certainty evidence reviewed here, these estimates will likely change as more high‐quality studies are produced. Plain language summary Mindfulness‐enhanced parenting programs for improving outcomes for children and their parents Key messages • Mindfulness‐enhanced parent training programmes may improve some child and parent outcomes, including child emotional and behavioural adjustment, parenting skills, parental depression or anxiety, parenting stress, and parent mindfulness. • When mindfulness parent training is combined with a skills‐based parent training programme, this may decrease parenting stress. • The current body of evidence is limited, with more research needed to be confident in our findings. Children's emotional and behavioural difficulties Emotional and behavioural difficulties in children are common, and are characterised by a range of externalising and/or internalising behaviours that can be highly stable over time. They are an important cause of functional disability in childhood, and predictive of poor psychosocial, academic, and occupational functioning into adolescence and beyond. The prevalence, stability, and long‐term consequences of emotional and behavioural difficulties highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Why mindfulness‐enhanced parent training? Parenting plays an important role in the development and/or maintenance of emotional and behavioural difficulties in children. Traditional behavioural or skills‐based parent training programmes have been shown to have a positive impact on a range of child and parent outcomes, but they do not work for all parents. One reason for this might be that parents' emotional reactions could prevent them from using parenting skills effectively. Including additional components into parenting training that aim to improve parental emotional responses may enhance the outcomes of these programmes. Recent research shows that mindful parenting interventions may promote positive outcomes for parents and children by improving parents' ability to regulate emotions and stress. Combining mindful parenting approaches with traditional parent training programmes may therefore be beneficial for both parents and their children. What did we want to find out? We explored whether behavioural or skills‐based parent training programmes with a mindfulness component – 'mindfulness‐enhanced' parent training programmes – can improve outcomes for children and their caregivers. What did we do? We searched a range of sources for literature that evaluated the effectiveness of mindfulness‐enhanced parent training programmes, including electronic databases, trial registries, and organisations and experts in the field. We included studies evaluating these interventions using randomised controlled trials (studies where participants are randomly assigned to one of two or more treatment groups) or quasi experimental designs (where participants are assigned to different treatment groups using a method that is not truly random). We included studies that assessed child emotional and behavioural adjustment, and/or a range of parent outcomes, including parenting skills, parenting stress, depression or anxiety, mindfulness or self‐compassion. What did we find out? We included 11 studies and data from 2118 participants in the review. The studies compared the outcomes of children or parents (or both) who participated in a mindfulness‐enhanced parent training programme to the outcomes of children or parents (or both) who did not participate in parent training, or who participated in an alternate behavioural or skills‐based parent training programme. When we combined the findings from these studies, we found that mindfulness‐enhanced parent training, when compared to no intervention, may improve child emotional and behavioural adjustment, parenting skills, parenting stress, parental depression and anxiety, and mindfulness, but we are very uncertain about these results. Evidence for the added value of mindfulness training when included in a skills‐based parent training programme suggests that mindfulness training may further promote reductions in parenting stress, and may also further reduce parental depression or anxiety, but we are uncertain about these results. It is unclear from the current body of evidence whether adding mindfulness training to a skills‐based parent training intervention has any further effect on child emotional and behavioural adjustment, parenting skills, or mindfulness. No studies reported adverse effects or measured self‐compassion. What are the limitations of the evidence? We are not confident in the overall body of evidence. This is primarily because there was a lot of variation across the interventions and the participant groups, as well as how the outcomes were measured. The studies were also usually quite small, and participants were likely to be aware of what intervention they were receiving, which can sometimes influence the results. It is likely that these findings will change as more studies are undertaken in this area of research. How up‐to‐date is this evidence? We searched for and included research up to April 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Featherston, R, Barlow, J, Song, Y, Haysom, Z, Loy, B, Tufford, L, Shlonsky, A", "articleTypes": [], "doi": "10.1002/14651858.CD012445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.134Z" }, { "id": "0d09127c-d875-4a74-b217-db3651f0066c", "pmid": "", "title": "Adhesives for fixed orthodontic bands", "imported": false, "abstract": "Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. It has been shown that the quality of treatment result obtained with fixed appliances is much better than with removable appliances. Fixed appliances are, therefore, favoured by most orthodontists for treatment. The success of a fixed orthodontic appliance depends on the metal attachments (brackets and bands) being attached securely to the teeth so that they do not become loose during treatment. Brackets are usually attached to the front and side teeth, whereas bands (metal rings that go round the teeth) are more commonly used on the back teeth (molars). A number of adhesives are available to attach bands to teeth and it is important to understand which group of adhesives bond most reliably, as well as reducing or preventing dental decay during the treatment period. Objectives To evaluate the effectiveness of the adhesives used to attach bands to teeth during fixed appliance treatment, in terms of:
 (1) how often the bands come off during treatment; and
 (2) whether they protect the banded teeth against decay during fixed appliance treatment. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (searched 2 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 2 June 2016), MEDLINE Ovid (1946 to 2 June 2016) and EMBASE Ovid (1980 to 2 June 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised and controlled clinical trials (RCTs and CCTs) (including split‐mouth studies) of adhesives used to attach orthodontic bands to molar teeth were selected. Patients with full arch fixed orthodontic appliance(s) who had bands attached to molars were included. Data collection and analysis All review authors were involved in study selection, validity assessment and data extraction without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Five RCTs and three CCTs were identified as meeting the review's inclusion criteria. All the included trials were of split‐mouth design. Four trials compared chemically cured zinc phosphate and chemically cured glass ionomer; three trials compared chemically cured glass ionomer cement with light cured compomer; one trial compared chemically cured glass ionomer with a chemically cured glass phosphonate. Data analysis was often inappropriate within the studies meeting the inclusion criteria. Authors' conclusions There is insufficient high quality evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth. Further RCTs are required. Plain language summary Adhesives for fixed orthodontic bands There is insufficient evidence to determine the most effective adhesive for attaching orthodontic bands to molar teeth in patients with full arch fixed orthodontic appliances.
 Orthodontic treatment involves using fixed or removable appliances (braces) on teeth to correct their position. It has been shown that the quality of treatment result obtained with fixed dental appliances is much better than with removable appliances. The success of a fixed dental appliance depends on the metal attachments (brackets and bands) being securely attached to the teeth so that they do not become loose during treatment. Brackets are usually attached to teeth other than molars, where bands (metal rings that go round the teeth) are more commonly used. There is insufficient evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Millett, DT; Glenny, AM; Mattick, RCR; Hickman, J; Mandall, NA", "articleTypes": [], "doi": "10.1002/14651858.CD004485.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "0d35fe39-a6b2-49cb-ae18-bddbcfb87ba4", "pmid": "", "title": "New generation antidepressants for depression in children and adolescents: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Major depressive disorders have a significant impact on children and adolescents, including on educational and vocational outcomes, interpersonal relationships, and physical and mental health and well‐being. There is an association between major depressive disorder and suicidal ideation, suicide attempts, and suicide. Antidepressant medication is used in moderate to severe depression; there is now a range of newer generations of these medications. Objectives To investigate, via network meta‐analysis (NMA), the comparative effectiveness and safety of different newer generation antidepressants in children and adolescents with a diagnosed major depressive disorder (MDD) in terms of depression, functioning, suicide‐related outcomes and other adverse outcomes. The impact of age, treatment duration, baseline severity, and pharmaceutical industry funding was investigated on clinician‐rated depression (CDRS‐R) and suicide‐related outcomes. Search methods We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR)), together with Ovid Embase, MEDLINE and PsycINFO till March 2020. Selection criteria Randomised trials of six to 18 year olds of either sex and any ethnicity with clinically diagnosed major depressive disorder were included. Trials that compared the effectiveness of newer generation antidepressants with each other or with a placebo were included. Newer generation antidepressants included: selective serotonin reuptake inhibitors; selective norepinephrine reuptake inhibitors (SNRIs); norepinephrine reuptake inhibitors; norepinephrine dopamine reuptake inhibitors; norepinephrine dopamine disinhibitors (NDDIs); and tetracyclic antidepressants (TeCAs). Data collection and analysis Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed risk of bias. We analysed dichotomous data as Odds Ratios (ORs), and continuous data as Mean Difference (MD) for the following outcomes: depression symptom severity (clinician rated), response or remission of depression symptoms, depression symptom severity (self‐rated), functioning, suicide related outcomes and overall adverse outcomes. Random‐effects network meta‐analyses were conducted in a frequentist framework using multivariate meta‐analysis. Certainty of evidence was assessed using Confidence in Network Meta‐analysis (CINeMA). We used \"informative statements\" to standardise the interpretation and description of the results. Main results Twenty‐six studies were included. There were no data for the two primary outcomes (depressive disorder established via clinical diagnostic interview and suicide), therefore, the results comprise only secondary outcomes. Most antidepressants may be associated with a \"small and unimportant\" reduction in depression symptoms on the CDRS‐R scale (range 17 to 113) compared with placebo (high certainty evidence: paroxetine: MD ‐1.43, 95% CI ‐3.90, 1.04; vilazodone: MD ‐0.84, 95% CI ‐3.03, 1.35; desvenlafaxine MD ‐0.07, 95% CI ‐3.51, 3.36; moderate certainty evidence: sertraline: MD ‐3.51, 95% CI ‐6.99, ‐0.04; fluoxetine: MD ‐2.84, 95% CI ‐4.12, ‐1.56; escitalopram: MD ‐2.62, 95% CI ‐5.29, 0.04; low certainty evidence: duloxetine: MD ‐2.70, 95% CI ‐5.03, ‐0.37; vortioxetine: MD 0.60, 95% CI ‐2.52, 3.72; very low certainty evidence for comparisons between other antidepressants and placebo). There were \"small and unimportant\" differences between most antidepressants in reduction of depression symptoms (high‐ or moderate‐certainty evidence). Results were similar across other outcomes of benefit. In most studies risk of self‐harm or suicide was an exclusion criterion for the study. Proportions of suicide‐related outcomes were low for most included studies and 95% confidence intervals were wide for all comparisons. The evidence is very uncertain about the effects of mirtazapine (OR 0.50, 95% CI 0.03, 8.04), duloxetine (OR 1.15, 95% CI 0.72, 1.82), vilazodone (OR 1.01, 95% CI 0.68, 1.48), desvenlafaxine (OR 0.94, 95% CI 0.59, 1.52), citalopram (OR 1.72, 95% CI 0.76, 3.87) or vortioxetine (OR 1.58, 95% CI 0.29, 8.60) on suicide‐related outcomes compared with placebo. There is low certainty evidence that escitalopram may \"at least slightly\" reduce odds of suicide‐related outcomes compared with placebo (OR 0.89, 95% CI 0.43, 1.84). There is low certainty evidence that fluoxetine (OR 1.27, 95% CI 0.87, 1.86), paroxetine (OR 1.81, 95% CI 0.85, 3.86), sertraline (OR 3.03, 95% CI 0.60, 15.22), and venlafaxine (OR 13.84, 95% CI 1.79, 106.90) may \"at least slightly\" increase odds of suicide‐related outcomes compared with placebo. There is moderate certainty evidence that venlafaxine probably results in an \"at least slightly\" increased odds of suicide‐related outcomes compared with desvenlafaxine (OR 0.07, 95% CI 0.01, 0.56) and escitalopram (OR 0.06, 95% CI 0.01, 0.56). There was very low certainty evidence regarding other comparisons between antidepressants. Authors' conclusions Overall, methodological shortcomings of the randomised trials make it difficult to interpret the findings with regard to the efficacy and safety of newer antidepressant medications. Findings suggest that most newer antidepressants may reduce depression symptoms in a small and unimportant way compared with placebo. Furthermore, there are likely to be small and unimportant differences in the reduction of depression symptoms between the majority of antidepressants. However, our findings reflect the average effects of the antidepressants, and given depression is a heterogeneous condition, some individuals may experience a greater response. Guideline developers and others making recommendations might therefore consider whether a recommendation for the use of newer generation antidepressants is warranted for some individuals in some circumstances. Our findings suggest sertraline, escitalopram, duloxetine, as well as fluoxetine (which is currently the only treatment recommended for first‐line prescribing) could be considered as a first option. Children and adolescents considered at risk of suicide were frequently excluded from trials, so that we cannot be confident about the effects of these medications for these individuals. If an antidepressant is being considered for an individual, this should be done in consultation with the child/adolescent and their family/caregivers and it remains critical to ensure close monitoring of treatment effects and suicide‐related outcomes (combined suicidal ideation and suicide attempt) in those treated with newer generation antidepressants, given findings that some of these medications may be associated with greater odds of these events. Consideration of psychotherapy, particularly cognitive behavioural therapy, as per guideline recommendations, remains important. Plain language summary Newer generation antidepressants for depression in children and adolescents: a network meta‐analysis How well do newer formulations of antidepressants work for children and adolescents with clinical depression? Children and adolescents (6 to 18 years) with depression (also called ‘major depressive disorder’) experience a range of negative impacts in all areas of their lives and have an increased risk of suicide, suicidal thinking and suicide attempts. Antidepressants have been shown to reduce symptoms of depression, but can also increase the risk of suicide‐related outcomes. Who will be interested in this research? The research in this Cochrane Review will interest: ‐ people who decide policy, and influence decisions about the prescription of antidepressant medicines to children and adolescents; ‐ people who prescribe these medicines to children and adolescents; ‐ children and adolescents with depression; and ‐ those who support and care for them (including their parents and caregivers and clinicians who provide treatment). What did we want to find out? We wanted to find out how well newer formulations (called ‘new generation’) antidepressants work to improve depression in children and adolescents aged 6 to 18 years. New generation antidepressants are those that have been developed recently. They are sometimes referred to as ‘second‐‘ and ‘third‐generation’ antidepressants; they do not include older formulations (tricyclic antidepressants or monoamine oxidase inhibitors). We wanted to know how these antidepressants affect: ‐ symptoms of depression; ‐ recovery: no longer meeting diagnostic criteria for major depressive disorder; ‐ response or remission: scores on a scale indicating an important reduction in depression or no longer experiencing depression; ‐ ability to function in daily life; ‐ suicide‐related outcomes; and ‐ whether they cause any unwanted effects in children and adolescents. What did we do? We searched for studies that tested new generation antidepressants on children or adolescents (or both) who had been diagnosed with a major depressive disorder. We identified 26 such studies. We then assessed the trustworthiness of those studies, and synthesized the findings across the studies. What does the evidence from the review tell us? Most newer antidepressants probably reduce depression symptoms better than a placebo (a 'dummy' treatment that does not contain any medicine but looks identical to the medicine being tested). However, the reduction is small and may not be experienced as important by children and adolescents, their parents and caregivers, or clinicians. When different medications are compared against each other, there may be only small and unimportant differences between most of them for the reduction of symptoms. Our findings reflect what happens on average to individuals, but some individuals may experience a greater response. This might lead to recommendations being made for the use of antidepressants for some individuals in some circumstances. Our findings suggest that sertraline, escitalopram, duloxetine and fluoxetine can be used if medication is being considered. The impact of medication on depression symptoms should be closely monitored by those prescribing the medication, especially as suicide‐related thinking and behaviour may be increased in those taking these medications. Close monitoring of suicide‐related behaviours is vital in those treated with new generation antidepressants. What should happen next? The studies that provided this evidence largely excluded children and adolescents who: ‐ were already thinking about suicide and wanting to take their own lives (i.e. had suicidal ideation); ‐ were self‐harming; ‐ had other mental health conditions; and ‐ had psychosocial difficulties. Future research should aim to understand the impacts of these medicines in children and adolescents with these problems, who are more typical of those who request clinical services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Hetrick, SE, McKenzie, JE, Bailey, AP, Sharma, V, Moller, CI, Badcock, PB, Cox, GR, Merry, SN, Meader, N", "articleTypes": [], "doi": "10.1002/14651858.CD013674.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.791Z" }, { "id": "0d41356e-793e-4c59-b434-75c91acf7423", "pmid": "", "title": "Short courses of antibiotics for children and adults with bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is an important cause of respiratory morbidity in both developing and developed countries. Antibiotics are considered standard therapy in the treatment of this condition but it is unknown whether short courses (four weeks or less) are efficacious. Objectives To determine whether short courses of antibiotics (i.e. less than or equal to four weeks) for treatment of acute and stable state bronchiectasis, in adults and children, are efficacious when compared to placebo or usual care. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library ), MEDLINE, EMBASE, OLDMEDLINE, CINAHL, AMED and PsycINFO and handsearching of respiratory journals and meeting abstracts were performed by the Cochrane Airways Group up to February 2011. Selection criteria Only randomised controlled trials were considered. Adults and children with bronchiectasis (defined clinically or radiologically) were included. Patients with cystic fibrosis were excluded. Data collection and analysis Two review authors independently reviewed the titles, abstracts and citations to assess eligibility for inclusion. Only one study fulfilled the inclusion criteria and thus meta‐analysis could not be performed. Main results The single eligible study showed a small benefit, when compared to placebo, of four weeks of inhaled antibiotic therapy in adults with bronchiectasis and pseudomonas in their sputum. There were no studies in children and no studies on oral or intravenous antibiotics. Authors' conclusions There is insufficient evidence in the current literature to make reasonable conclusions about the efficacy of short course antibiotics in the management of adults and children with bronchiectasis. Until further evidence is available, adherence to current treatment guidelines is recommended. Plain language summary Short courses of antibiotics for children and adults with bronchiectasis There is a paucity of evidence to conclude whether short courses of antibiotics (i.e. less than or equal to four weeks) are equivalent or superior to placebo in the treatment of stable or exacerbation state bronchiectasis. One single study showed some benefit of short‐course inhaled antibiotics over placebo, in terms of microbiological response and subjective improvement in medical condition, although this was balanced against an increase in adverse effects and antimicrobial resistance in the treatment group. Given the potential benefits of shorter duration antibiotic therapy in bronchiectasis, further RCTs are clearly needed to answer this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Wurzel, D; Marchant, JM; Yerkovich, ST; Upham, JW; Masters, IB; Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD008695.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "0d59c561-2a48-498d-a9bc-13dd7bfdf08d", "pmid": "", "title": "Blood pressure lowering efficacy of beta‐blockers as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Beta‐blockers are one of the more commonly prescribed classes of anti‐hypertensive drugs, both as first‐line and second‐line. Objectives To quantify the effect on systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and withdrawals due to adverse effects of beta‐blocker therapy when given as a second‐line drug in adult patients with primary hypertension. Search methods CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1966‐Aug 2009), EMBASE (1988‐Aug 2009) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized controlled trials comparing a beta‐blocker in combination with a drug from another class of anti‐hypertensive drugs compared with that drug alone for a duration of 3 to 12 weeks in patients with primary hypertension were included. Data collection and analysis Two reviewers independently extracted the data and assessed trial quality of each included study. Main results 20 double‐blind RCTs evaluated the BP lowering efficacy of beta‐blockers as second‐line drug in 3744 hypertensive patients (baseline BP of 158/102 mmHg; mean duration of 7 weeks). The BP reduction from adding a beta‐blocker as the second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. A reduction in BP was seen with adding a beta‐blocker to thiazide diuretics or calcium channel blockers at doses as low as 0.25 times the manufacturer's recommended starting dose. The BP lowering efficacy of beta‐blockers as a second drug was 6/4 mmHg at 1 times the starting dose and 8/6 mmHg at 2 times the starting dose. Beta‐blockers reduced heart rate by 10 beats/min at 1 to 2 times the starting dose. Beta‐blockers did not statistically significantly increase withdrawals due to adverse effects but this was likely due to the lack of reporting of this outcome in 35% of the included RCTs. Authors' conclusions Addition of a beta‐blocker to diuretics or calcium‐channel blockers reduces BP by 6/4mmHg at 1 times the starting dose and by 8/6 mmHg at 2 times the starting dose. When the blood pressure lowering effect of beta‐blockers from this review was compared to that of thiazide diuretics from our previous review ( Chen 2009 ), second‐line beta‐blockers reduce systolic BP to the same extent as second‐line thiazide diuretics, but reduce diastolic BP to a greater degree. The different effect on diastolic BP means that beta‐blockers have little or no effect on pulse pressure whereas thiazides cause a significant dose‐related decrease in pulse pressure. This difference in the pattern of BP lowering with beta‐blockers as compared to thiazides might be the explanation for the fact that beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than thiazide diuretics, particularly in older individuals. Plain language summary Beta‐blockers lower blood pressure when given as a second drug Beta‐blockers are commonly used in the treatment for high blood pressure (BP). In this review, we asked how much do beta‐blockers reduce BP when used as the second drug to treat hypertension. Twenty trials lasting an average of 7 weeks were found in the world scientific literature to answer this question. The data showed that the addition of a beta‐blocker to thiazide diuretics or calcium channel blockers reduced BP by 8/6 mmHg when given at doses 2 times the recommended starting dose. When we compared these results with our previous review of the blood pressure lowering effect of thiazide diuretics as second line drug, we found that beta‐blockers have a different pattern of BP lowering. This different pattern of effect on blood pressure might explain why first‐line beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than first‐line thiazide diuretics, particularly in older individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, JMH; Heran, BS; Perez, MI; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007185.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "0d6a7dea-71de-46c8-8b18-ec555ea424d1", "pmid": "", "title": "Oral deferiprone for iron chelation in people with thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. A commonly used iron chelator, deferiprone, has been found to be pharmacologically efficacious. However, important questions exist about the efficacy and safety of deferiprone compared to another iron chelator, desferrioxamine. Objectives To summarise data from trials on the clinical efficacy and safety of deferiprone and to compare the clinical efficacy and safety of deferiprone with desferrioxamine for thalassaemia. Search methods We searched the Cochrane Cystic fibrosis and Genetic Disorders Group's Haemoglobinopathies trials Register and MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus registers of ongoing trials and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). We also contacted the manufacturers of deferiprone and desferrioxamine. All searches were updated to 05 March 2013. Selection criteria Randomised controlled trials comparing deferiprone with another iron chelator; or comparing two schedules or doses of deferiprone, in people with transfusion‐dependent thalassaemia. Data collection and analysis Two authors independently assessed trials for risk of bias and extracted data. Missing data were requested from the original investigators. Main results A total of 17 trials involving 1061 participants (range 13 to 213 participants per trial) were included. Of these, 16 trials compared either deferiprone alone with desferrioxamine alone, or a combined therapy of deferiprone and desferrioxamine with either deferiprone alone or desferrioxamine alone; one compared different schedules of deferiprone. There was little consistency between outcomes and limited information to fully assess the risk of bias of most of the included trials. Four trials reported mortality; each reported the death of one individual receiving deferiprone with or without desferrioxamine. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage. Earlier trials measuring the cardiac iron load indirectly by magnetic resonance imaging (MRI) T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, a meta‐analysis of two trials suggested that left ventricular ejection fraction was significantly reduced in patients who received desferrioxamine alone compared with combination therapy. One trial, which planned five years of follow up, was stopped early due to the beneficial effects of combined treatment compared with deferiprone alone in terms of serum ferritin levels reduction. The results of this and three other trials suggest an advantage of combined therapy over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no conclusive or consistent evidence for the improved efficacy of combined deferiprone and desferrioxamine therapy over monotherapy from direct or indirect measures of liver iron. Both deferiprone and desferrioxamine produce a significant reduction in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised controlled trials to suggest that either has a greater reduction of clinically significant end organ damage. Evidence of adverse events were observed in all treatment groups. Occurrence of any adverse event was significantly more likely with deferiprone than desferrioxamine in one trial, RR 2.24 (95% CI 1.19 to 4.23). Meta‐analysis of a further two trials showed a significant increased risk of adverse events associated with combined deferiprone and desferrioxamine compared with desferrioxamine alone, RR 3.04 (95% CI 1.18 to 7.83). The most commonly reported adverse event was joint pain, which occurred significantly more frequently in patients receiving deferiprone than desferrioxamine, RR 2.64 (95% CI 1.21 to 5.77). Other common adverse events included gastrointestinal disturbances as well as neutropenia or leucopenia, or both. Authors' conclusions In the absence of data from randomised controlled trials, there is no evidence to suggest the need for a change in current treatment recommendations; namely that deferiprone is indicated for treating iron overload in people with thalassaemia major when desferrioxamine is contraindicated or inadequate. Intensified desferrioxamine treatment (by either subcutaneous or intravenous route) or use of other oral iron chelators, or both, remains the established treatment to reverse cardiac dysfunction due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently only gave support for deferiprone to be used as a last resort for treating iron overload in thalassaemia, myelodysplasia and sickle cell disease. However, there is evidence that adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcome of deferiprone with desferrioxamine. Plain language summary The use of the iron chelator deferiprone in people with thalassaemia who are dependent on blood transfusions In thalassaemia sometimes the body cannot produce enough haemoglobin. Regular blood transfusions can manage this, but may lead to excess iron in the body, which, if not removed, may damage major organs. Iron chelation therapy removes excess iron; one common chelator is deferiprone. Questions exist about whether deferiprone is as good and safe as the most widely‐used iron chelator, desferrioxamine. Desferrioxamine is administered by a needle under the skin or into a vein, and was the standard monotherapy for 20 years. Seventeen randomised controlled trials compared deferiprone with desferrioxamine. They report little data on death or end organ damage, so we report the effects of therapy using mainly other markers. Removing excess iron was assessed by iron concentration in the blood and liver; heart function; and the amount of iron passed in urine. However, the amount of iron removed with either deferiprone or desferrioxamine was not consistent; one reason being that outcomes were measured differently. This makes it difficult to compare results between trials. Adverse events included joint pain, nausea, stomach upsets and low white blood cell count with deferiprone and pain or skin reactions at the injection site and joint pain with desferrioxamine. In one trial, the risk of an adverse event with deferiprone was twice that of the risk with desferrioxamine. Two further trials showed a three‐fold increased risk of an adverse event with combined deferiprone and desferrioxamine therapy compared with desferrioxamine alone. We found no evidence to change current recommendations to treat iron overload in thalassaemia with deferiprone when desferrioxamine cannot be used or is inadequate. Intensified desferrioxamine treatment or use of other oral iron chelators (or both of these) remains the established treatment to reverse heart problems due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently gave support for deferiprone only to be used as a last resort treatment in patients with thalassaemia, myelodysplasia and sickle cell disease. The danger of raised liver enzymes or a very low white blood cell count with deferiprone means that this treatment should not be used unless close monitoring of full blood counts and liver function is possible. Large trials of chelation therapy with standardised measures of iron stores and end organ damage are needed so valuable trial data can be compared and analysed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA; Brunskill, SJ; Doree, C; Chowdhury, O; Gooding, S; Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004839.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "0d6b78e3-2446-4883-8473-b2a2e18dada9", "pmid": "", "title": "Interventions for preventing oral mucositis for patients with cancer receiving treatment", "imported": false, "abstract": "Abstract - Background Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers). Objectives To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment. Search methods Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL ( The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Selection criteria Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer. Data collection and analysis Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random‐effects models. Main results A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta‐analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte‐colony stimulating factor (G‐CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate. Authors' conclusions Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent. Plain language summary Interventions for preventing oral mucositis for patients with cancer receiving treatment Treatment for cancer (including bone marrow transplant) can cause oral mucositis (severe ulcers in the mouth). This painful condition can cause difficulties in eating, drinking and swallowing, and may also be associated with infections which may require the patient to stay longer in hospital. Different strategies are used to try and prevent this condition, and the review of trials found that some of these are effective. Two interventions, cryotherapy (ice chips) and keratinocyte growth factor (palifermin®) showed some benefit in preventing mucositis. Sucralfate is effective in reducing the severity of mucositis, and a further seven interventions, aloe vera, amifostine, intravenous glutamine, granulocyte‐colony stimulating factor (G‐CSF), honey, laser and antibiotic lozenges containing polymixin/tobramycin/amphotericin (PTA) showed weaker evidence of benefit. These were evaluated in patients with different types of cancer, undergoing different types of cancer treatment. Benefits may be restricted to the disease and treatment combinations evaluated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Worthington, HV; Clarkson, JE; Bryan, G; Furness, S; Glenny, A-M; Littlewood, A; McCabe, MG; Meyer, S; Khalid, T; Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD000978.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "0d82eb06-f02f-48fb-8f3d-dd070802efcd", "pmid": "", "title": "Clonidine for pain in non‐ventilated infants", "imported": false, "abstract": "Abstract - Background Critically ill newborn infants undergo a variety of painful procedures or experience a variety of painful conditions during their early life in the neonatal unit. In the critically ill paediatric and neonatal population, clonidine is prescribed as an adjunct to opioids or benzodiazepines aiming to reduce the doses of these drugs that are required for analgesia or sedation, or to facilitate weaning from mechanical ventilation. It has been shown that clonidine premedication might have a positive effect on postoperative pain in children. Objectives To assess the benefit and harms of clonidine for the prevention or treatment of procedural pain; postoperative pain; or pain associated with clinical conditions in non‐ventilated neonates. Search methods We used the standard search strategy of Cochrane Neonatal to search the CENTRAL, MEDLINE via PubMed, Embase, and CINAHL to December 2018. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials. We ran an updated search from 1 January 2018 to 11 March 2020 in CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials, and cluster trials comparing clonidine to placebo or no treatment, opioids, paracetamol, dexmedetomidine, or non‐pharmacological pain‐reducing interventions for the management of procedural pain, postoperative pain, and pain associated with clinical conditions in preterm and term newborns. Data collection and analysis Two review authors independently planned to extract data (e.g. number of participants, birth weight, gestational age, modality of administration, and dose of clonidine) and assess the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow‐up). The primary outcome considered was pain: for procedural pain, the mean values of each analgesia scale assessed during the procedure and at one to two hours after the procedure; for postoperative pain and for pain associated with clinical conditions, the mean values of each analgesia scale assessed at 30 minutes, three hours, and 12 hours after the administration of the intervention. We planned to use the GRADE approach to assess the quality of evidence. Main results Our search strategy yielded 3383 references. Two review authors independently assessed all references for inclusion. We did not find any completed studies for inclusion. We excluded three trials where clonidine was administered for spinal anaesthesia. Authors' conclusions We did not find any studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of clonidine for the prevention or treatment of procedural or postoperative pain, or pain associated with clinical conditions in neonates. Plain language summary Clonidine for painful procedures and conditions in infants Review question: does clonidine administration reduce pain in newborns exposed to painful procedures or conditions? Background: newborns admitted to the hospital are exposed to a number of painful procedures which might include blood sampling, lumbar puncture (a medical procedure where a needle is inserted into the spinal canal, usually to collect cerebrospinal fluid for testing), tubes in the stomach, different types of catheters, and minor surgical procedures such as neonatal circumcision. In addition, newborns might have pain because of clinical conditions, such as, fractured bone, pain following traumatic vaginal birth, disease of the skin (open skin lesions from an inherited skin disorder), or intestines (necrotising enterocolitis (inflammation)). All babies, and especially those born too early (preterm), are very sensitive to pain. Moreover, the experience of repeated episodes of pain might cause problems, such as an altered development of the nervous system, in early life and an increased pain sensitivity when they grow up. Most of the medicines to manage pain and stress in babies have side effects, and might also harm the immature developing brain by inducing death of cells (apoptosis) in the brain. Study characteristics: we searched for studies up to 11 March 2020. The aim of this review was to assess if clonidine could reduce pain in newborns. This medicine can be given through injections, using a tube in the stomach (nasogastric tube), through the skin, and as spinal anaesthesia. However, the latter is not in the focus of this review as it is used for babies undergoing specific surgical procedures. Clonidine works on the brain modifying responses and reducing stress and agitation. Furthermore, clonidine may reduce pain, especially if used in combination with other medicines. Key results: we found no studies for our review. Three studies were excluded because clonidine was given for spinal anaesthesia, whereas our review focuses on other indications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Romantsik, O, Calevo, MG, Norman, E, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD013104.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.128Z" }, { "id": "0d852c35-5596-4161-be23-708a35ef5e9e", "pmid": "", "title": "Omega 3 fatty acids for preventing or slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Lawrenson, JG, Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD010015.pub3 AB - Abstract - Background Evidence from animal models and observational studies in humans has suggested that there is an inverse relationship between dietary intake of omega 3 long‐chain polyunsaturated fatty acids (LCPUFA) and risk of developing age‐related macular degeneration (AMD) or progression to advanced AMD. Objectives To review the evidence that increasing the levels of omega 3 LCPUFA in the diet (either by eating more foods rich in omega 3 or by taking nutritional supplements) prevents AMD or slows the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 1), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2015), EMBASE (January 1980 to February 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to February 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 February 2015. Selection criteria We included randomised controlled trials (RCTs) where increased dietary intake of omega 3 LCPUFA was compared to placebo or no intervention with the aim of preventing the development of AMD, or slowing its progression. Data collection and analysis Both authors independently selected studies, assessed them for risk of bias and extracted data. One author entered data into RevMan 5 and the other author checked the data entry. We conducted a meta‐analysis for one primary outcome, progression of AMD, using a fixed‐effect inverse variance model. Main results We included two RCTs in this review, in which 2343 participants with AMD were randomised to receive either omega 3 fatty acid supplements or a placebo. The trials, which had a low risk of bias, were conducted in the USA and France. Overall, there was no evidence that people who took omega 3 fatty acid supplements were at decreased (or increased risk) of progression to advanced AMD (pooled hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.84 to 1.10, high quality evidence). Similarly, people taking these supplements were no more (or less) likely to lose 15 or more letters of visual acuity (USA study HR 0.96, 95% CI 0.84 to 1.10; French study at 36 months risk ratio (RR) 1.25, 95% CI 0.69 to 2.26, participants = 230). The number of adverse events was similar in the intervention and placebo groups (USA study participants with one or more serious adverse event RR 1.00, 95% CI 0.91 to 1.09, participants = 2080; French study total adverse events RR 1.05, 95% CI 0.97 to 1.13, participants = 263). Authors' conclusions This review found that omega 3 LCPUFA supplementation in people with AMD for periods up to five years does not reduce the risk of progression to advanced AMD or the development of moderate to severe visual loss. No published randomised trials were identified on dietary omega 3 fatty acids for primary prevention of AMD. Currently available evidence does not support increasing dietary intake of omega 3 LCPUFA for the explicit purpose of preventing or slowing the progression of AMD. Plain language summary Omega 3 fatty acids for preventing and slowing the progression of age‐related macular degeneration Review question 
 We asked the question whether increased dietary intake of omega 3 fatty acids prevented or slowed the progression of age‐related macular degeneration. Background 
 Age‐related macular degeneration (AMD) is an eye condition that affects the central area of the retina (light‐sensitive tissue at the back of the eye). AMD is associated with a loss of detailed vision and adversely affects tasks such as reading, driving and face recognition. In the absence of a cure, there has been considerable interest in the role of modifiable risk factors to prevent or slow down the progression of AMD. Evidence from population studies suggests that people who have a diet with relatively high levels of omega 3 fatty acids (such as those derived from fish oils) are less likely to develop AMD. Study characteristics 
 We searched for studies up to 2 February 2015. We identified two trials with a total of 2343 participants. The trials were conducted in the USA and France and investigated the use of fish oil supplements in people with AMD who were at high risk of progressing to advanced disease. We judged the studies to be at low risk of bias. One study was funded by government grants and the other study was funded by the manufacturer of the dietary supplement. Key results 
 These studies found that omega 3 supplementation for periods up to five years did not reduce the rate of progression to advanced AMD or reduce significant visual loss compared to a placebo. The incidence of adverse effects was similar in the intervention and placebo groups. Quality of the evidence 
 We judged the quality of the evidence on rate of progression to AMD to be high, and the quality of the evidence for other outcomes to be moderate because the estimates were imprecise.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.738Z" }, { "id": "0d88eec0-2020-4eaa-8119-9990a6504179", "pmid": "", "title": "Maternal Characteristics Associated With Child Growth and Adiposity. Search for Nutrigenomic Biomarkers in Peripheral Blood", "imported": false, "abstract": "The goal of this observational study is to investigate the concentrations of leptin, insulin, liver expressed antimicrobial peptide 2 (LEAP2), and cortisol in plasma and breast milk and their relationship with eating behavior, growth, adiposity and with the levels of these hormones in infants, comparing mothers with normal weight and with pre-pregnancy overweight/obesity. The main question[s] it aims to answer are:", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.239Z" }, { "id": "0dbcfa31-b3ee-4a25-a96b-9e55d2ff6b39", "pmid": "", "title": "Effect of cocoa on blood pressure", "imported": false, "abstract": "Abstract - Background High blood pressure is an important risk factor for cardiovascular disease, contributing to about 50% of cardiovascular events worldwide and 37% of cardiovascular‐related deaths in Western populations. Epidemiological studies suggest that cocoa‐rich products reduce the risk of cardiovascular disease. Flavanols found in cocoa have been shown to increase the formation of endothelial nitric oxide which promotes vasodilation and therefore blood pressure reduction. Here we update previous meta‐analyses on the effect of cocoa on blood pressure. Objectives To assess the effects on blood pressure of chocolate or cocoa products versus low‐flavanol products or placebo in adults with or without hypertension when consumed for two weeks or longer. Search methods This is an updated version of the review initially published in 2012. In this updated version, we searched the following electronic databases from inception to November 2016: Cochrane Hypertension Group Specialised Register, CENTRAL, MEDLINE and Embase. We also searched international trial registries, and the reference lists of review articles and included trials. Selection criteria Randomised controlled trials (RCTs) investigating the effects of chocolate or cocoa products on systolic and diastolic blood pressure in adults for a minimum of two weeks duration. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias in each trial. We conducted random‐effects meta‐analyses on the included studies using Review Manager 5. We explored heterogeneity with subgroup analyses by baseline blood pressure, flavanol content of control group, blinding, age and duration. Sensitivity analyses explored the influence of unusual study design. Main results Thirty‐five trials (including 40 treatment comparisons) met the inclusion criteria. Of these, we added 17 trials (20 treatment comparisons) to the 18 trials (20 treatment comparisons) in the previous version of this updated review. Trials provided participants with 30 to 1218 mg of flavanols (mean = 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. The control group received either a flavanol‐free product (n = 26 treatment comparisons) or a low‐flavanol‐containing cocoa powder (range 6.4 to 88 mg flavanols (mean = 55 mg, 13 treatment comparisons; 259 mg, 1 trial). Meta‐analyses of the 40 treatment comparisons involving 1804 mainly healthy participants revealed a small but statistically significant blood pressure‐reducing effect of flavanol‐rich cocoa products compared with control in trials of two to 18 weeks duration (mean nine weeks):
 Mean difference systolic blood pressure (SBP) (95% confidence interval (CI): ‐1.76 (‐3.09 to ‐0.43) mmHg, P = 0.009, n = 40 treatment comparisons, 1804 participants;
 Mean difference diastolic blood pressure (DBP) (95% CI): ‐1.76 (‐2.57 to ‐0.94) mmHg, P < 0.001, n = 39 treatment comparisons, 1772 participants. Baseline blood pressure may play a role in the effect of cocoa on blood pressure. While systolic blood pressure was reduced significantly by 4 mmHg in hypertensive people (n = 9 treatment comparisons, 401 participants), and tended to be lowered in prehypertensive people (n= 8 treatment comparisons, 340 participants), there was no significant difference in normotensive people (n = 23 treatment comparisons, 1063 participants); however, the test for subgroup differences was of borderline significance (P = 0.08; I 2 = 60%), requiring further research to confirm the findings. Subgroup meta‐analysis by blinding suggested a trend towards greater blood pressure reduction in unblinded trials compared to double‐blinded trials, albeit statistically not significant. Further research is needed to confirm whether participant expectation may influence blood pressure results. Subgroup analysis by type of control (flavanol‐free versus low‐flavanol control) did not reveal a significant difference. Whether the age of participants plays a role in the effect of cocoa on blood pressure, with younger participants responding with greater blood pressure reduction, needs to be further investigated. Sensitivity analysis excluding trials with authors employed by trials sponsoring industry (33 trials, 1482 participants) revealed a small reduction in effect size, indicating some reporting bias. Due to the remaining heterogeneity, which we could not explain in terms of blinding, flavanol content of the control groups, age of participants, or study duration, we downgraded the quality of the evidence from high to moderate. Results of subgroup analyses should be interpreted with caution and need to be confirmed or refuted in trials using direct randomised comparisons. Generally, cocoa products were highly tolerable, with adverse effects including gastrointestinal complaints and nausea being reported by 1% of participants in the active cocoa intervention group and 0.4% of participants in the control groups (moderate‐quality evidence). Authors' conclusions This review provides moderate‐quality evidence that flavanol‐rich chocolate and cocoa products cause a small (2 mmHg) blood pressure‐lowering effect in mainly healthy adults in the short term. These findings are limited by the heterogeneity between trials, which could not be explained by prespecified subgroup analyses, including blinding, flavanol content of the control groups, age of participants, or study duration. However, baseline blood pressure may play a role in the effect of cocoa on blood pressure; subgroup analysis of trials with (pre)hypertensive participants revealed a greater blood pressure‐reducing effect of cocoa compared to normotensive participants with borderline significance. Long‐term trials investigating the effect of cocoa on clinical outcomes are also needed to assess whether cocoa has an effect on cardiovascular events and to assess potential adverse effects associated with chronic ingestion of cocoa products. Plain language summary Effect of cocoa on blood pressure Review question We assessed the effect of cocoa products on blood pressure in adults when consumed daily for at least two weeks. We found 35 studies, covering 40 treatment comparisons. Background Dark chocolate and cocoa products are rich in chemical compounds called flavanols. Flavanols have attracted interest as they might help to reduce blood pressure, a known risk factor for cardiovascular disease (disorders of the heart and blood vessels). The blood pressure‐lowering properties of flavanols are thought to be related to widening of the blood vessels, caused by nitric oxide. Study characteristics Studies were short, mostly between two and12 weeks, with only one of 18 weeks. The studies involved 1804 mainly healthy adults. They provided participants with 30 to 1218 mg of flavanols (average of 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. Seven of the studies were funded by companies with a commercial interest in their results, and the reported effect was slightly larger in these studies, indicating possible bias. The evidence is current to November 2016. Key results Meta‐analysis of 40 treatment comparisons revealed a small but statistically significant lowering of blood pressure (systolic and diastolic) of 1.8 mmHg. This small reduction in blood pressure might complement other treatment options and might contribute to reducing the risk of cardiovascular disease. We investigated whether participants' blood pressure at the start of the study, their age, an awareness of group allocation (active or control), the flavanol content used in the control group, or how long the study lasted may explain variations between trials. While blood pressure status (high blood pressure or normal blood pressure) is a likely factor in the effect size of cocoa on blood pressure, the impact of other factors needs to be confirmed or rejected in further trials. Side effects including digestive complaints and dislike of the trial product were reported by only 1% of people in the active cocoa intervention group and 0.4% of people in the control groups. Longer‐term trials are needed to establish whether regularly eating flavanol‐rich cocoa products has a beneficial effect on blood pressure and cardiovascular health over time, and whether there are any side effects of long‐term use of cocoa products on a daily basis. Quality of evidence The evidence is of moderate quality. We were unable to identify any randomised controlled trials that tested the effect of long‐term daily use of cocoa products on blood pressure, and there were no trials that measured the health consequences of high blood pressure, such as heart attacks or strokes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Ried, K; Fakler, P; Stocks, NP", "articleTypes": [], "doi": "10.1002/14651858.CD008893.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "0dbdc5e0-3cc1-472a-9c39-f2fde4c49c72", "pmid": "", "title": "The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement", "imported": false, "abstract": "Abstract - Background The World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework is an holistic, settings‐based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed. Objectives To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well‐being of students and their academic achievement. Search methods We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov , Current controlled trials , and WHO International Clinical Trials Registry Platform . We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles. Selection criteria We included cluster‐randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school’s ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements. Data collection and analysis At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random‐effects meta‐analyses to provide a summary of results across studies. Main results We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand‐washing (2), multiple risk behaviours (7), cycle‐helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self‐reported data and high attrition rates for some studies. In addition, there was a lack of long‐term follow‐up data for most studies. We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta‐analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school‐related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement. Authors' conclusions The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well‐designed research is required to establish the effectiveness of this approach for other health topics and academic achievement. Plain language summary The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement Background Health and education are strongly connected: healthy children achieve better results at school, which in turn are associated with improved health later in life. This relationship between health and education forms the basis of the World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework, an approach to promoting health in schools that addresses the whole school environment. Although the HPS framework is used in many schools, we currently do not know if it is effective. This review aimed to assess whether the HPS framework can improve students’ health and well‐being and their performance at school. Study characteristics We searched 20 health, education, and social science databases, as well as trials registries and relevant websites, for cluster‐randomised controlled trials of school‐based interventions aiming to improve the health of young people aged four to 18 years. We only included trials of programmes that addressed all three points in the HPS framework: including health education in the curriculum; changing the school’s social or physical environment, or both; and involving students’ families or the local community, or both. Key results We found 67 trials, comprising 1345 schools and 98 districts, that fulfilled our criteria. These focused on a wide range of health topics, including physical activity, nutrition, substance use (tobacco, alcohol, and drugs), bullying, violence, mental health, sexual health, hand‐washing, cycle‐helmet use, sun protection, eating disorders, and oral health. For each study, two review authors independently extracted relevant data and assessed the risk of the study being biased. We grouped together studies according to the health topic(s) they focused on. We found that interventions using the HPS approach were able to reduce students’ body mass index (BMI), increase physical activity and fitness levels, improve fruit and vegetable consumption, decrease cigarette use, and reduce reports of being bullied. However, we found little evidence of an effect on BMI when age and gender were taken into account (zBMI), and no evidence of effectiveness on fat intake, alcohol and drug use, mental health, violence, and bullying others. We did not have enough data to draw conclusions about the effectiveness of the HPS approach for sexual health, hand‐washing, cycle‐helmet use, eating disorders, sun protection, oral health or academic outcomes. Few studies discussed whether the health promotion activities, or the collection of data relating to these, could have caused any harm to the students involved. Quality of the evidence Overall, the quality of evidence was low to moderate. We identified some problems with the way studies were conducted, which may have introduced bias, including many studies relying on students’ accounts of their own behaviours (rather than these being measured objectively) and high numbers of students dropping out of studies. These problems, and the small number of studies included in our analysis, limit our ability to draw clear conclusions about the effectiveness of the HPS framework in general. Conclusions Overall, we found some evidence to suggest the HPS approach can produce improvements in certain areas of health, but there are not enough data to draw conclusions about its effectiveness for others. We need more studies to find out if this approach can improve other aspects of health and how students perform at school.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Langford, R, Bonell, CP, Jones, HE, Pouliou, T, Murphy, SM, Waters, E, Komro, KA, Gibbs, LF, Magnus, D, Campbell, R", "articleTypes": [], "doi": "10.1002/14651858.CD008958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.823Z" }, { "id": "0dc21f44-49d6-4a77-81a3-0e1a027f0ab4", "pmid": "", "title": "Role of Sweet Taste Signaling in Glucose Regulation", "imported": false, "abstract": "Data from several studies show that consuming a diet high in low-calorie sweeteners (LCS), mainly in diet sodas, is linked to the same metabolic disorders as consuming a diet high in added sugars, including an increased risk of developing type 2 diabetes. Sweet taste receptors, once thought to be unique to the mouth, have now been discovered in other parts of the body, including the intestine and the pancreas, where they play a role in blood sugar control. These newly identified receptors provide new avenues to explore how LCS may affect metabolism and health. This project is designed to examine the role of sweet taste signaling, both in the mouth and in the gut, on blood sugar control and how habitual consumption of LCS may affect sweet taste signaling and metabolism in people with obesity.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.143Z" }, { "id": "0dc91355-d824-4f5d-8f21-eaa2fa77c1f5", "pmid": "", "title": "Antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze", "imported": false, "abstract": "Abstract - Background Worldwide, pneumonia is the leading cause of death amongst children under five years of age, and accounts for approximately two million deaths annually. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, and the severity of the disease. Treatment is then tailored according to the classification. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. The WHO recommends treating non‐severe pneumonia with oral antibiotics. Pneumonia is more commonly caused by viruses that do not require antibiotic treatment, but pneumonia caused by bacteria needs management with antibiotics to avoid complications. There is no clear way to quickly distinguish between viral and bacterial pneumonia. It is considered safe to give antibiotics, however, this may lead to the development of antibiotic resistance, and thus, limit their use in future infections. Therefore, it is essential to explore the efficacy of antibiotics for children with WHO‐defined non‐severe pneumonia and wheeze. Objectives To evaluate the efficacy of antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze. Search methods We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers (December 2020). Selection criteria We included randomised controlled trials (RCTs) evaluating the efficacy of antibiotic therapy versus no antibiotic therapy for children, aged 2 to 59 months, with non‐severe pneumonia and wheeze. We defined non‐severe pneumonia as 'a cough or difficulty in breathing, with rapid breathing (a respiratory rate of 50 breaths per minute or more for children aged 2 to 12 months, or a respiratory rate of 40 breaths per minute or more for children aged 12 to 59 months), chest indrawing and wheeze'. We excluded trials involving children with severe or very severe pneumonia, and non‐RCTs. Data collection and analysis Our primary outcomes were clinical cure and treatment failure; secondary outcomes were relapse, mortality, and treatment harms. We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Two review authors independently assessed the search results, extracted data, assessed risk of bias and the certainty of the evidence. We contacted the authors of two included trials and the author of the trial awaiting classification to obtain missing numerical outcome data. Main results We included three trials involving 3256 children aged between 2 to 59 months, who exhibited features of non‐severe pneumonia with wheeze. The included trials were multi‐centre, double‐blind, randomised, placebo‐controlled trials carried out in Malawi, Pakistan, and India. The children were treated with a three‐day course of amoxicillin or placebo, and were followed up for a total of two weeks. We assessed the included trials at overall low risk of bias for random sequence generation, allocation concealment, blinding, attrition bias, and selective reporting. Only one trial was assessed to be at high risk for blinding of outcome assessors. One trial is awaiting classification Antibiotic therapy may result in a reduction of treatment failure by 20% (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.68 to 0.94; three trials; 3222 participants; low‐certainty evidence). Antibiotic therapy probably results in little or no difference to clinical cure (RR 1.02, 95% CI 0.96 to 1.08; one trial; 456 participants; moderate‐certainty evidence), and in little or no difference to relapse (RR 1.00, 95% CI 0.74 to 1.34; three trials; 2795 participants; low‐certainty evidence), and treatment harms (RR 0.81, 95% CI 0.60 to 1.09; three trials, 3253 participants; low‐certainty evidence). Two trials (2112 participants ) reported on mortality; no deaths occurred in either group. One trial reported cases of hospitalisation, diarrhoea (with and without dehydration), rash (without itch), tremors, mild nausea and vomiting. Authors' conclusions We do not currently have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. There is a clear need for RCTs to address this question in children aged 2 to 59 months with 2014 WHO‐defined non‐severe pneumonia and wheeze. Plain language summary Comparing treatment of non‐severe pneumonia, in children aged 2 to 59 months, with and without antibiotics Review question 
We tried to identify whether there was a difference in the outcomes for children aged 2 to 59 months with non‐severe pneumonia and wheeze, treated with or without antibiotics. Background 
Pneumonia is an infection of the lungs. In children, it is one of the leading causes of deaths globally. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, severity of the disease and its treatment according to the severity. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. More commonly, pneumonia is caused by viruses that require supportive care rather than antibiotic treatment; however, pneumonia caused by bacteria should be treated with antibiotics to avoid complications. Since there is no clear way to quickly distinguish which organism actually caused the pneumonia, it is considered safe to give antibiotics. However, this may lead to the development of antibiotic resistance, and limit their use in future infections. The question is whether the use of antibiotics is justified in non‐severe pneumonia. Search date Our evidence is current to 23 December 2020. Study characteristics We included three trials (3256 children). They were conducted in four hospitals in three cities in Pakistan (Islamabad, Lahore and Rawalpindi), and in hospital outpatient departments in India and Malawi. The children were treated with a three‐day course of amoxicillin (antibiotic) or placebo, and followed up for two weeks. One trial is awaiting classification. Study funding source The included trials were supported by the USAID through INCLEN and IndiaClen; ARI Research Cell, Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and by a grant from the Bill & Melinda Gates Foundation. Key results Limited data showed a 20% reduction in treatment failure, however, no impact was observed on clinical cure, relapse, and treatment harms. No deaths were reported in either group. Our review did not have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. Certainty of the evidence The certainty of evidence for clinical cure was moderate. The certainty of evidence for treatment failure, relapse, and treatments harms was low, due to downgrading for imprecision and risk of bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lassi, ZS; Padhani, ZA; Das, JK; Salam, RA; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD009576.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "0de32f0d-2898-479d-912a-cffa2948bacf", "pmid": "", "title": "Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status", "imported": false, "abstract": "Abstract - Background Iron deficiency is an important micronutrient deficiency contributing to the global burden of disease, and particularly affects children, premenopausal women, and people in low‐resource settings. Anaemia is a possible consequence of iron deficiency, although clinical and functional manifestations of anemia can occur without iron deficiency (e.g. from other nutritional deficiencies, inflammation, and parasitic infections). Direct nutritional interventions, such as large‐scale food fortification, can improve micronutrient status, especially in vulnerable populations. Given the highly successful delivery of iodine through salt iodisation, fortifying salt with iodine and iron has been proposed as a method for preventing iron deficiency anaemia. Further investigation of the effect of double‐fortified salt (i.e. with iron and iodine) on iron deficiency and related outcomes is warranted. Objectives To assess the effect of double‐fortified salt (DFS) compared to iodised salt (IS) on measures of iron and iodine status in all age groups. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases, and two trial registries up to April 2021. We also searched relevant websites, reference lists, and contacted the authors of included studies. Selection criteria All prospective randomised controlled trials (RCTs), including cluster‐randomised controlled trials (cRCTs), and controlled before‐after (CBA) studies, comparing DFS with IS on measures of iron and iodine status were eligible, irrespective of language or publication status. Study reports published as abstracts were also eligible. Data collection and analysis Three review authors applied the study selection criteria, extracted data, and assessed risk of bias. Two review authors rated the certainty of the evidence using GRADE. When necessary, we contacted study authors for additional information. We assessed RCTs, cRCTs and CBA studies using the Cochrane RoB 1 tool and Cochrane Effective Practice and Organisation of Care (EPOC) tool across the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other potential sources of bias due to similar baseline characteristics, similar baseline outcome assessments, and declarations of conflicts of interest and funding sources. We also assessed cRCTs for recruitment bias, baseline imbalance, loss of clusters, incorrect analysis, and comparability with individually randomised studies. We assigned studies an overall risk of bias judgement (low risk, high risk, or unclear). Main results We included 18 studies (7 RCTs, 7 cRCTs, 4 CBA studies), involving over 8800 individuals from five countries. One study did not contribute to analyses. All studies used IS as the comparator and measured and reported outcomes at study endpoint. With regards to risk of bias, five RCTs had unclear risk of bias, with some concerns in random sequence generation and allocation concealment, while we assessed two RCTs to have a high risk of bias overall, whereby high risk was noted in at least one or more domain(s). Of the seven cRCTs, we assessed six at high risk of bias overall, with one or more domain(s) judged as high risk and one cRCT had an unclear risk of bias with concerns around allocation and blinding. The four CBA studies had high or unclear risk of bias for most domains. The RCT evidence suggested that, compared to IS, DFS may slightly improve haemoglobin concentration (mean difference (MD) 0.43 g/dL, 95% confidence interval (CI) 0.23 to 0.63; 13 studies, 4564 participants; low‐certainty evidence), but DFS may reduce urinary iodine concentration compared to IS (MD −96.86 μg/L, 95% CI −164.99 to −28.73; 7 studies, 1594 participants; low‐certainty evidence), although both salts increased mean urinary iodine concentration above the cut‐off deficiency. For CBA studies, we found DFS made no difference in haemoglobin concentration (MD 0.26 g/dL, 95% CI −0.10 to 0.63; 4 studies, 1397 participants) or urinary iodine concentration (MD −17.27 µg/L, 95% CI −49.27 to 14.73; 3 studies, 1127 participants). No studies measured blood pressure. For secondary outcomes reported in RCTs, DFS may result in little to no difference in ferritin concentration (MD −3.94 µg/L, 95% CI −20.65 to 12.77; 5 studies, 1419 participants; low‐certainty evidence) or transferrin receptor concentration (MD −4.68 mg/L, 95% CI −11.67 to 2.31; 5 studies, 1256 participants; low‐certainty evidence) compared to IS . However, DFS may reduce zinc protoporphyrin concentration (MD −27.26 µmol/mol, 95% CI −47.49 to −7.03; 3 studies, 921 participants; low‐certainty evidence) and result in a slight increase in body iron stores (MD 1.77 mg/kg, 95% CI 0.79 to 2.74; 4 studies, 847 participants; low‐certainty evidence). In terms of prevalence of anaemia, DFS may reduce the risk of anaemia by 21% (risk ratio (RR) 0.79, 95% CI 0.66 to 0.94; P = 0.007; 8 studies, 2593 participants; moderate‐certainty evidence). Likewise, DFS may reduce the risk of iron deficiency anaemia by 65% (RR 0.35, 95% CI 0.24 to 0.52; 5 studies, 1209 participants; low‐certainty evidence). Four studies measured salt intake at endline, although only one study reported this for both groups. Two studies reported prevalence of goitre, while one CBA study measured and reported serum iron concentration. One study reported adverse effects. No studies measured hepcidin concentration. Authors' conclusions Our findings suggest DFS may have a small positive impact on haemoglobin concentration and the prevalence of anaemia compared to IS, particularly when considering efficacy studies. Future research should prioritise studies that incorporate robust study designs and outcome measures (e.g. anaemia, iron status measures) to better understand the effect of DFS provision to a free‐living population (non‐research population), where there could be an added cost to purchase double‐fortified salt. Adequately measuring salt intake, both at baseline and endline, and adjusting for inflammation will be important to understanding the true effect on measures of iron status. Plain language summary Fortification of salt with iron and iodine compared to salt fortified with iodine only for improving iron and iodine status Key messages Compared to iodised salt, double‐fortified salt (salt fortified with iron and iodine) may improve some measures of iron and iodine nutrition, such as haemoglobin (i.e. the substance that gives red blood cells their colour) concentrations and body iron stores. However, it may reduce urinary iodine concentration and may make little or no difference to ferritin (i.e. iron‐storage protein) concentrations and transferrin receptor (i.e. protein that affects the uptake of iron) concentrations. It probably also reduces the prevalence of anaemia (lack of haemoglobin), and may reduce the prevalence of iron deficiency anaemia (lack of iron), compared to iodised salt. Well‐designed studies that assess the effects of double‐fortified salt within non‐research populations (i.e. real‐life settings), and that measure salt intake, including changes in salt consumption, are needed. What is iron deficiency? Almost two billion people experience a deficiency in a vitamin or mineral (or both), with women and children in resource‐limited settings most frequently affected. Iron‐related deficiencies are among the most common deficiencies in the world and have important short‐ and long‐term health consequences. Interventions to provide iron frequently include iron supplementation, including iron tablets, powders, or syrups. However, these have known barriers, and food fortification strategies may be attractive alternatives. Salt is one of few universally consumed food vehicles. Iodised salt is fortified to provide 100% of a person's iodine requirements and is highly effective. Double‐fortified salt was developed to provide 30% of a person's daily dietary iron requirement and 100% of their iodine requirement. In some resource‐limited settings, where iron‐related deficiencies are a common problem, there has been interest in making double‐fortified salt more available to the public. This calls for further understanding of the effect of double‐fortified salt on related outcomes. What did we want to find out? If double‐fortified salt is better than salt fortified with iodine alone for improving measures of iron and iodine‐related nutrition, in particular: ‐ haemoglobin concentration; ‐ urinary iodine concentration; ‐ blood pressure; ‐ ferritin concentration; ‐ transferrin receptor concentration; ‐ prevalence of anaemia; ‐ prevalence of iron deficiency anaemia. What did we do? We looked for studies that provided double‐fortified salt to one group of participants and iodised salt to another. We compared their results, and rated our confidence in the evidence, based on factors such as study methods and sample size. What did we find? We identified 18 studies, involving over 8800 individuals from five countries; 13 studies were conducted in India. In 13 studies the intervention lasted between 6 and 12 months; in two studies it lasted 3 months, and in single studies it lasted for 18 months, 24 months, or the duration was unclear. Nine studies were conducted in children and adolescents (5 to 17 years), four in adults (18 years and older), and five included multiple age groups. All studies compared double‐fortified salt to iodised salt. Most studies were funded by non‐profit organisations, university grants or academic institutes. In four studies, double‐fortified salt was provided by a commercial organisation, and in three studies the funding source unclear. Compared to iodised salt, double‐fortified salt may improve haemoglobin concentration and body iron stores slightly, and probably reduces the prevalence of anaemia by 21%. However, double‐fortified salt may also reduce urinary iodine concentration compared to iodised salt and may make little or no difference in ferritin and transferrin receptor concentration. Double‐fortified salt may reduce the prevalence of iron deficiency anaemia by 65%, compared to iodised salt, although this conclusion is uncertain because of some problems with the way the studies were conducted. Very few studies measured zinc protoporphyrin concentration, adverse effects, prevalence of goitre and salt intake. One study measured serum iron concentration. No studies measured blood pressure or hepcidin concentration. What are the limitations of the evidence? We have relatively low confidence in the evidence for the outcomes: haemoglobin, urinary iodine, ferritin, and transferrin receptor concentration, and prevalence of iron deficiency anaemia. Not all studies provided data about all outcomes of interest; studies delivered the intervention differently; and studies were small, both in number and size. For the prevalence of anaemia, we are moderately confident in the evidence because studies used different ways of delivering the intervention. Care should be taken in interpreting our findings in relation to public health policy and programmes. Most studies were conducted in monitored research settings and double‐fortified salt was provided without an added cost. We are unsure if the effect we observed would be the same in real‐life (i.e. non‐research population), where purchasing double‐fortified salt could increase the cost. More studies looking at the effect of double‐fortified salt within real‐life settings are needed to understand the true effects of double‐fortified salt with greater certainty. Given the changing guidelines for salt intake, future studies should measure salt intake to understand if double‐fortified salt should be considered to prevent anaemia at the population level and how to integrate double‐fortified salt into the supply chain. How up to date is this evidence? The evidence is up to date to April 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Baxter, J-AB, Carducci, B, Kamali, M, Zlotkin, SH, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD013463.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.122Z" }, { "id": "0de9b392-e60a-4d8a-8951-3e0c68b000c5", "pmid": "", "title": "Physical interventions to interrupt or reduce the spread of respiratory viruses", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jefferson, T, Dooley, L, Ferroni, E, Al-Ansary, LA, van Driel, ML, Bawazeer, GA, Jones, MA, Hoffmann, TC, Clark, J, Beller, EM, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD006207.pub6 AB - Abstract - Background Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID‐19) caused by SARS‐CoV‐2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID‐19 pandemic. Objectives To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. Search methods We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies. Selection criteria We included randomised controlled trials (RCTs) and cluster‐RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission. Data collection and analysis We used standard Cochrane methodological procedures. Main results We included 11 new RCTs and cluster‐RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID‐19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID‐19 pandemic. Many studies were conducted during non‐epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID‐19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high‐income countries; crowded inner city settings in low‐income countries; and an immigrant neighbourhood in a high‐income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster‐RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster‐RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza‐like illness (ILI)/COVID‐19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate‐certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory‐confirmed influenza/SARS‐CoV‐2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate‐certainty evidence). Harms were rarely measured and poorly reported (very low‐certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low‐certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low‐certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory‐confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate‐certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low‐certainty evidence). One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non‐inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID‐19 patients. Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta‐analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate‐certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory‐confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low‐certainty evidence), and laboratory‐confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low‐certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low‐certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low‐certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports. Authors' conclusions The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory‐confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under‐investigated. There is a need for large, well‐designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs. Plain language summary Do physical measures such as hand‐washing or wearing masks stop or slow down the spread of respiratory viruses? Key messages 
We are uncertain whether wearing masks or N95/P2 respirators helps to slow the spread of respiratory viruses based on the studies we assessed. Hand hygiene programmes may help to slow the spread of respiratory viruses. How do respiratory viruses spread? 
Respiratory viruses are viruses that infect the cells in your airways: nose, throat, and lungs. These infections can cause serious problems and affect normal breathing. They can cause flu (influenza), severe acute respiratory syndrome (SARS), and COVID‐19. People infected with a respiratory virus spread virus particles into the air when they cough or sneeze. Other people become infected if they come into contact with these virus particles in the air or on surfaces on which they land. Respiratory viruses can spread quickly through a community, through populations and countries (causing epidemics), and around the world (causing pandemics). Physical measures to try to prevent respiratory viruses spreading between people include: · washing hands often; · not touching your eyes, nose, or mouth; · sneezing or coughing into your elbow; · wiping surfaces with disinfectant; · wearing masks, eye protection, gloves, and protective gowns; · avoiding contact with other people (isolation or quarantine); · keeping a certain distance away from other people (distancing); and · examining people entering a country for signs of infection (screening). What did we want to find out? 
We wanted to find out whether physical measures stop or slow the spread of respiratory viruses from well‐controlled studies in which one intervention is compared to another, known as randomised controlled trials. What did we do? 
We searched for randomised controlled studies that looked at physical measures to stop people acquiring a respiratory virus infection. We were interested in how many people in the studies caught a respiratory virus infection, and whether the physical measures had any unwanted effects. What did we find? 
We identified 78 relevant studies. They took place in low‐, middle‐, and high‐income countries worldwide: in hospitals, schools, homes, offices, childcare centres, and communities during non‐epidemic influenza periods, the global H1N1 influenza pandemic in 2009, epidemic influenza seasons up to 2016, and during the COVID‐19 pandemic. We identified five ongoing, unpublished studies; two of them evaluate masks in COVID‐19. Five trials were funded by government and pharmaceutical companies, and nine trials were funded by pharmaceutical companies. No studies looked at face shields, gowns and gloves, or screening people when they entered a country. We assessed the effects of: · medical or surgical masks; · N95/P2 respirators (close‐fitting masks that filter the air breathed in, more commonly used by healthcare workers than the general public); and · hand hygiene (hand‐washing and using hand sanitiser). We obtained the following results: Medical or surgical masks Ten studies took place in the community, and two studies in healthcare workers. Compared with wearing no mask in the community studies only, wearing a mask may make little to no difference in how many people caught a flu‐like illness/COVID‐like illness (9 studies; 276,917 people); and probably makes little or no difference in how many people have flu/COVID confirmed by a laboratory test (6 studies; 13,919 people). Unwanted effects were rarely reported; discomfort was mentioned. N95/P2 respirators Four studies were in healthcare workers, and one small study was in the community. Compared with wearing medical or surgical masks, wearing N95/P2 respirators probably makes little to no difference in how many people have confirmed flu (5 studies; 8407 people); and may make little to no difference in how many people catch a flu‐like illness (5 studies; 8407 people), or respiratory illness (3 studies; 7799 people). Unwanted effects were not well‐reported; discomfort was mentioned. Hand hygiene Following a hand hygiene programme may reduce the number of people who catch a respiratory or flu‐like illness, or have confirmed flu, compared with people not following such a programme (19 studies; 71,210 people), although this effect was not confirmed as statistically significant reduction when ILI and laboratory‐confirmed ILI were analysed separately. Few studies measured unwanted effects; skin irritation in people using hand sanitiser was mentioned. What are the limitations of the evidence? 
Our confidence in these results is generally low to moderate for the subjective outcomes related to respiratory illness, but moderate for the more precisely defined laboratory‐confirmed respiratory virus infection, related to masks and N95/P2 respirators. The results might change when further evidence becomes available. Relatively low numbers of people followed the guidance about wearing masks or about hand hygiene, which may have affected the results of the studies. How up to date is this evidence? 
We included evidence published up to October 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.799Z" }, { "id": "0e0beaa8-d71f-4d7d-b54d-5421f2e21a96", "pmid": "", "title": "Fish oil for kidney transplant recipients", "imported": false, "abstract": "Abstract - Background Calcineurin inhibitors used in kidney transplantation for immunosuppression have adverse effects that may contribute to nephrotoxicity and increased cardiovascular risk profile. Fish oils are rich in very long chain omega‐3 fatty acids, which may reduce nephrotoxicity by improving endothelial function and reduce rejection rates through their immuno‐modulatory effects. They may also modify the cardiovascular risk profile. Hence, fish oils may potentially prolong graft survival and reduce cardiovascular mortality. Objectives This review aimed to look at the benefits and harms of fish oil treatment in ameliorating the kidney and cardiovascular adverse effects of CNI‐based immunosuppressive therapy in kidney transplant recipients. Search methods We searched the Cochrane Kidney and Transplant Specialised Register (up to 17 March 2016) through contact with the Information Specialist using search terms relevant to this review. Selection criteria All randomised controlled trials (RCTs) and quasi‐RCTs of fish oils in kidney transplant recipients on a calcineurin inhibitor‐based immunosuppressive regimen. RCTs of fish oil versus statins were included. Data collection and analysis Data was extracted and the quality of studies assessed by two authors, with differences resolved by discussion with a third independent author. Dichotomous outcomes were reported as risk ratio (RR) and continuous outcome measures were reported as the mean difference (MD) with 95% confidence intervals using the random effects model. Heterogeneity was assessed using a Chi 2 test on n‐1 degrees of freedom and the I 2 statistic. Data not suitable for pooling were tabulated and described. Main results Fifteen studies (733 patients) were suitable for analysis. All studies were small and had variable methodology. Fish oil did not significantly affect patient or graft survival, acute rejection rates, or calcineurin inhibitor toxicity when compared to placebo. Overall SCr was significantly lower in the fish oil group compared to placebo (5 studies, 237 participants: MD ‐30.63 µmol/L, 95% CI ‐59.74 to ‐1.53; I 2 = 88%). In the subgroup analysis, this was only significant in the long‐course (six months or more) group (4 studies, 157 participants: MD ‐37.41 µmol/L, 95% CI ‐69.89 to ‐4.94; I 2 = 82%). Fish oil treatment was associated with a lower diastolic blood pressure (4 studies, 200 participants: MD ‐4.53 mm Hg, 95% CI ‐7.60 to ‐1.45) compared to placebo. Patients receiving fish oil for more than six months had a modest increase in HDL (5 studies, 178 participants: MD 0.12 mmol/L, 95% CI 0.03 to 0.21; I 2 = 47%) compared to placebo. Fish oil effects on lipids were not significantly different from low‐dose statins. There was insufficient data to analyse cardiovascular outcomes. Fishy aftertaste and gastrointestinal upset were common but did not result in significant patient drop‐out. Authors' conclusions There is insufficient evidence from currently available RCTs to recommend fish oil therapy to improve kidney function, rejection rates, patient survival or graft survival. The improvements in HDL cholesterol and diastolic blood pressure were too modest to recommend routine use. To determine a benefit in clinical outcomes, future RCTs will need to be adequately powered with these outcomes in mind. Plain language summary Fish oil for kidney transplant recipients This review set out to assess any benefit or harm in using fish oil to reduce the risk of kidney damage and heart disease in people who have had a kidney transplant and are receiving standard drugs to prevent rejection. Information from 15 studies was used and showed that fish oils provide a slight improvement in HDL cholesterol and diastolic blood pressure. These studies did not provide enough information on the differences in the risk of death, heart disease, kidney transplant rejection or kidney function between patients receiving fish oils and those receiving placebo. There appeared to be no harmful effects of taking fish oil. The benefits of taking fish oil after a kidney transplant are a mild improvement in some heart disease risk factors. There was not enough information to show any benefit in preventing heart disease or reduction in kidney function. Larger, better studies are needed before regular use of fish oil can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lim, AKH, Manley, KJ, Roberts, MA, Fraenkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD005282.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.073Z" }, { "id": "0e13097f-bab6-484b-97de-fb8ac827f8e3", "pmid": "", "title": "A MULTICENTER, GLOBAL, RANDOMIZED, DOUBLE-BLIND STUDY OF AXITINIB PLUS BEST SUPPORTIVE CARE VERSUS PLACEBO PLUS BEST SUPPORTIVE CARE IN PATIENTS WITH ADVANCED HEPATOCELLULAR CARCINOMA FOLLOWING FAILURE OF ONE PRIOR ANTIANGIOGENIC THERAPY", "imported": false, "abstract": "The study is designed to demonstrate that axitinib plus best supportive care is superior to placebo plus best supportive care in prolonging survival in patients with advanced hepatocellular carcinoma.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.162Z" }, { "id": "0e24c29c-8d8e-448b-8ed6-1efd67e70fe4", "pmid": "", "title": "Antithyroid drug regimen for treating Graves' hyperthyroidism", "imported": false, "abstract": "Abstract - Background Antithyroid drugs are widely used in the therapy of hyperthyroidism. There are wide variations in the dose, regimen or duration of treatment used by health professionals. Objectives To assess the effects of dose, regimen and duration of antithyroid drug therapy for Graves' hyperthyroidism. Search methods We searched seven databases and reference lists. Selection criteria Randomised and quasi‐randomised trials of antithyroid medication for Graves' hyperthyroidism. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Pooling of data for primary outcomes, and select exploratory analyses were undertaken. Main results Twenty‐six randomised trials involving 3388 participants were included. Overall the quality of trials, as reported, was poor. None of the studies investigated incidence of hypothyroidism, changes in weight, health‐related quality of life, ophthalmopathy progression or economic outcomes. Four trials examined the effect of duration of therapy on relapse rates, and when using the titration regimen 12 months was superior to six months, but there was no benefit in extending treatment beyond 18 months. Twelve trials examined the effect of block‐replace versus titration block‐regimens. The relapse rates were similar in both groups at 51% in the block‐replace group and 54% in the titration block‐group (OR 0.86, 95% confidence interval (CI) 0.68 to1.08) though adverse effects (rashes (10% versus 6%) and withdrawing due to side effects (16% versus 9%)) were significantly higher in the block‐replace group. Three studies considered the addition of thyroxine with continued low dose antithyroid therapy after initial therapy with antithyroid drugs. There was significant heterogeneity between the studies and the difference between the two groups was not significant (OR 0.58, 95% CI 0.05 to 6.21). Four studies considered the addition of thyroxine alone after initial therapy with antithyroid drugs. There was no significant difference in the relapse rates between the groups after 12 months follow‐up (OR 1.15, 95% CI 0.79 to 1.67). Two studies considered the addition of immunosuppressive agents. The results which were in favour of the interventions would need to be validated in other populations. Authors' conclusions The evidence suggests that the optimal duration of antithyroid drug therapy for the titration regimen is 12 to 18 months. The titration (low dose) regimen had fewer adverse effects than the block‐replace (high dose) regimen and was no less effective. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Immunosuppressive therapies need further evaluation. Plain language summary Antithyroid drug regimen for treating Graves' hyperthyroidism People who have Graves' hyperthyroidism have thyroid glands which are releasing too much thyroid hormone. This can cause goitres (swelling in the neck around the thyroid gland), sweating, bowel or menstrual problems, and other, especially eye symptoms (ophthalmopathy). Treatments include anti‐thyroid drugs, surgery or radiation to reduce thyroid tissue. There are several choices to be made when considering the drug treatment of Graves' hyperthyroidism including the choice of drug, dose, duration of therapy, addition of thyroid hormone (thyroxine) and when to discontinue therapy. The antithyroid drugs which were used in the included randomised controlled trials (RCTs) comprised carbimazole, propylthiouracil and methimazole. Twenty‐six RCTs involving 3388 participants were identified. The majority of participants in all the studies were female (83% in the studies reporting sex distribution). The mean age was 40 years. The duration of follow up was between two to five years in eleven trials. In high dose ('block‐replace') versus low dose ('titration') studies the duration of therapy was six months in two studies, 18 months in four studies and 12 months in the remaining trials. The main outcome was the relapse rate of hyperthyroidism over one year after completion of drug treatment and this was the primary outcome in all the studies assessed. There were no deaths reported in any of the studies. None of the studies detailed incidence of hypothyroidism, changes in weight during the course of therapy, health‐related quality of life, ophthalmopathy progression or economic outcomes. The evidence (based on four studies) suggests that the optimal duration of antithyroid drug therapy for the low dose regimen is 12 to 18 months. The low dose regimen had fewer adverse effects than the high dose regimen and was no less effective in trials (based on 12 trials) of equal duration. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Studies using immunosuppressive agents need further validation of safety and efficacy in controlled trials among different populations. Data regarding side effects and number of participants withdrawn from therapy due to side effects were available in seven studies. The number of participants reporting rashes was significantly higher in the high versus low dose group (10% versus 6%). The number of participants withdrawing due to side effects were also significantly higher in the high versus low dose group (16% versus 9%).", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Abraham, P; Avenell, A; McGeoch, SC; Clark, LF; Bevan, JS", "articleTypes": [], "doi": "10.1002/14651858.CD003420.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "0e52b336-66a1-4de9-a3f8-207c700b720e", "pmid": "", "title": "Topiramate for neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background Topiramate is an antiepileptic drug with multiple possible mechanisms of action. Antiepileptic drugs are widely used to treat chronic neuropathic pain (pain due to nerve damage) and fibromyalgia, and many guidelines recommend them. Objectives To assess the analgesic efficacy and associated adverse events of topiramate for chronic neuropathic pain and fibromyalgia in adults (aged 18 years and above). Search methods On 8 May 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We reviewed the bibliographies of all randomised trials identified and review articles, and also searched two clinical trial databases, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform, to identify additional published or unpublished data. Selection criteria We included randomised controlled trials (RCTs) with double‐blind assessment of participant outcomes following two weeks of treatment or longer (though the emphasis of the review was on studies of eight weeks or longer) that used a placebo or active comparator. Data collection and analysis We extracted efficacy and adverse event data, and two study authors examined issues of study quality independently. We performed analysis using two tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First tier studies did not use last‐observation‐carried‐forward (LOCF) or other imputation methods for dropouts. The second tier used data that failed to meet this standard; second tier results were therefore subject to potential bias. Main results We included four studies with 1684 participants. Three parallel‐group placebo comparisons were in painful diabetic neuropathy (1643 participants), and one cross‐over study with diphenhydramine as an active placebo (41 participants) was in lumbar radiculopathy. Doses of topiramate were titrated up to 200 mg/day or 400 mg/day. All studies had one or more sources of potential major bias, as they either used LOCF imputation or were of small size. No study provided first tier evidence for an efficacy outcome. There was no convincing evidence for efficacy of topiramate at 200 to 400 mg/day over placebo. Eighty‐two per cent of participants taking topiramate 200 to 400 mg/day experienced at least one adverse event, as did 71% with placebo, and the number needed to treat for an additional harmful effect (NNTH) was 8.6 (95% confidence interval (CI) 4.9 to 35). There was no difference in serious adverse events recorded (6.6% versus 7.5%). Adverse event withdrawals with 400 mg daily were much more common with topiramate (27%) than with placebo (8%), with an NNTH of 5.4 (95% CI 4.3 to 7.1). Lack of efficacy withdrawal was less frequent with topiramate (12%) than placebo (18%). Weight loss was a common event in most studies. No deaths attributable to treatment were reported. Authors' conclusions Topiramate is without evidence of efficacy in diabetic neuropathic pain, the only neuropathic condition in which it has been adequately tested. The data we have includes the likelihood of major bias due to LOCF imputation, where adverse event withdrawals are much higher with active treatment than placebo control. Despite the strong potential for bias, no difference in efficacy between topiramate and placebo was apparent. Plain language summary Topiramate for treating neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (for example from a fall, a cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in treating neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our knowledge about fibromyalgia is even less advanced, but fibromyalgia can respond to the same medicines as neuropathic pain. Topiramate is a medicine used to treat epilepsy, and so it might be a useful medicine for neuropathic pain or fibromyalgia. On 8 May 2013, we performed searches to look for clinical trials on the use of topiramate to treat neuropathic pain or fibromyalgia. We found four studies of reasonable quality that tested topiramate against placebo for a number of weeks. Almost all of the 1684 people in the studies had painful limbs because of damaged nerves caused by diabetes. Topiramate did not help the pain and was no different from placebo except in causing more side‐effects, which made many more people withdraw from the studies early. About 3 people in 10 withdrew because of side‐effects with topiramate compared with 1 in 10 with placebo. Topiramate has not been shown to work as a pain medicine in diabetic neuropathy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ; Derry, S; Lunn, MPT; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008314.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "0e70e05f-cdf2-49de-badd-7e9f6a9bd744", "pmid": "", "title": "Enteral tube feeding for people with severe dementia", "imported": false, "abstract": "Abstract - Background The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing. Objectives To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021. Selection criteria We included randomised controlled trials (RCTs), or controlled non‐randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post‐pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers. Data collection and analysis Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non‐randomised Studies of Interventions' (ROBINS‐I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre‐agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta‐analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study. Main results We found no eligible RCTs. We included fourteen controlled, non‐randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low‐certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate‐certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very‐low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low‐certainty evidence. Five studies reported a variety of harm‐related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia. Authors' conclusions We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here. Plain language summary Enteral tube feeding for people with severe dementia What are the advantages and problems of tube feeding people with severe dementia? Key messages Tube feeding may not increase the length of time people with severe dementia live compared to no tube feeding. The risk of developing a pressure sore is probably higher with a feeding tube than with no tube. No studies looked at quality of life.We need more and better studies to investigate tube feeding people with severe dementia. Future studies should focus on a broader range of outcomes including, pain, quality of life and the impact on carers What is tube feeding? Somebody who can’t eat or drink through their mouth may be given liquid food through a tube into their stomach. This is called enteral tube feeding. The tube passes through their nose into their stomach (a nasogastric tube), or is inserted into the stomach through a small cut in their belly (percutaneous endoscopic gastrostomy or PEG). Why is this important for people with dementia? People with dementia often have difficulties eating and drinking. During the early stages of dementia, they may forget to eat, chew food without swallowing, or be confused at mealtimes. Some people experience changes in the taste and smell of food. In the later stages of dementia, people often have difficulties swallowing. It can be difficult to ensure they receive appropriate food and fluids. People with severe dementia need full‐time care, and it is often their families who care for them. It is difficult to decide whether or not to tube‐feed someone with dementia because the feeding tube can be uncomfortable or even painful, and may cause other unwanted effects such as pneumonia, worsen bowel or bladder control, as well as bleeding, swelling and infection. People with severe dementia may be confused or distressed by the tube and may try to remove it. What did we want to find out? We wanted to know whether tube feeding helps people with severe dementia who have problems with eating and swallowing. We were interested in the effect of tube feeding on: how long people lived; their quality of life (well‐being); and the development or healing of pressure sores (also known as bed sores). What did we do? 
We searched for studies that investigated whether: PEG compared to no tube; a nasogastric tube compared to no tube; orPEG, nasogastric and other types of tube feeding compared to no tube was effective and whether tube feeding caused any unwanted effects in adults of any age with severe dementia and poor intake of food and drink. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 14 studies that included 49,714 participants. Of these, 6203 were tube‐fed and 43,511 were not. Participants with no feeding tube were given standard care or standard care with extra treatments to encourage eating and drinking. Main results In people with severe dementia, compared to no tube feeding: PEG may make no difference to how long people live (4 studies, 36,816 people), and leads to a small increase in the chance of developing pressure sores (1 study, 4421 people). we don’t know if nasogastric tube feeding increases the length of time people live or increases their chance of developing pressure sores, because none of our included studies gave information about these points. Studies of people with either PEG or nasogastric tubes showed tube feeding may increase the length of time people live (4 studies, 1696 people), and may slightly increase the chance of developing pressure sores (3 studies, 351 people). None of our included studies reported quality of life. What are the limitations of the evidence? We have moderate confidence in our finding that pressure ulcers were more common in people who were fed with a PEG tube. However, we have little to very little confidence for our other findings. Three main factors reduced our confidence in the evidence. Firstly, people in the studies were not randomly placed into different treatment groups. This means that differences between the groups could be due to differences between people rather than between the treatments. However, due to ethical considerations it would be very difficult to do this in future studies. Secondly, results were very inconsistent across the different studies. Finally, some studies were very small. The results of further research could differ from the results of this review. How up to date is this evidence? The evidence is up to date to 14 April 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Davies, N; Barrado-Martín, Y; Vickerstaff, V; Rait, G; Fukui, A; Candy, B; Smith, CH; Manthorpe, J; Moore, KJ; Sampson, EL", "articleTypes": [], "doi": "10.1002/14651858.CD013503.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "0e95ba25-0019-4e47-84ce-1ec47d5ce355", "pmid": "", "title": "Interventions for the prevention and management of oropharyngeal candidiasis associated with HIV infection in adults and children", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Pienaar, ED, Young, T, Holmes, H", "articleTypes": [], "doi": "10.1002/14651858.CD003940.pub3 AB - Abstract - Background Oral candidiasis (OC) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Left untreated, these lesions contribute considerably to the morbidity associated with HIV infection. Interventions aimed at preventing and treating HIV‐associated oral candidal lesions form an integral component of maintaining the quality of life for affected individuals. Objectives To determine the effects of any intervention in preventing or treating OC in children and adults with HIV infection. Search methods The search strategy was based on that of the Cochrane HIV/AIDS Review Group. The following electronic databases were searched for randomised controlled trials for the years 1982 to 2005: Medline, AIDSearch, EMBASE and CINAHL. The Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectiveness, and the Cochrane Central Register of Controlled Trials (CENTRAL) were also searched through May 2005. The abstracts of relevant conferences, including the International Conferences on AIDS and the Conference on Retroviruses and Opportunistic Infections, as indexed by AIDSLINE, were also reviewed. The strategy was iterative, in that references of included studies were searched for additional references. All languages were included. The updated database search was done for the period 2005 up to 2009. The following databases were searched: Medline, EMBASE, the Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectivenes s and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library. AIDSearch was not searched for the updated search as it ceased publication during 2008. Selection criteria Randomised controlled trials (RCTs) of palliative, preventative or curative therapy were considered, irrespective of whether the control group received a placebo. Participants were HIV positive adults and children. Data collection and analysis Two authors independently assessed the methodological quality of the trials and extracted data. Study authors were contacted for additional data where necessary. Main results For the first publication of the review in 2006, forty studies were retrieved. Twenty eight trials (n=3225) met inclusion criteria. During the update search for the review a, further six studies were identified. Of these, five met the inclusion criteria and were included in the review. The review now includes 33 studies (n=3445): 22 assessing treatment and 11 assessing prevention of oropharyngeal candidiasis. Six studies were done in developing countries, 16 in the United States of America and the remainder in Europe. Treatment 
 Treatment was assessed in the majority of trials looking at both clinical and mycological cures. In the majority of comparisons there was only one trial. Compared to nystatin, fluconazole favoured clinical cure in adults (1 RCT; n=167; RR 1.69; 95% CI 1.27 to 2.23). There was no difference with regard to clinical cure between fluconazole compared to ketoconazole (2 RCTs; n=83; RR 1.27; 95% CI 0.97 to 1.66), itraconazole (2 RCTs; n=434; RR 1.05; 95% CI 0.94 to 1.16), clotrimazole (2 RCTs; n=358; RR 1.14; 95% CI 0.92 to 1.42) or posaconazole (1 RCT; n=366; RR1.32; 95% CI 0.36 to 4.83). Two trials compared different dosages of fluconazole with no difference in clinical cure. When compared with clotrimazole, both fluconazole (2 RCTs; n=358; RR 1.47; 95% CI 1.16 to 1.87) and itraconazole (1 RCT; n=123; RR 2.20; 95% CI 1.43 to3.39) proved to be better for mycological cure. Both gentian violet (1 RCT; n=96; RR 5.28; 95% CI 1.23 to 22.55) and ketoconazole (1 RCT; n=92; RR 5.22; 95% CI 1.21 to 22.53) were superior to nystatin in bringing about clinical cure. A single trial compared gentian violet with lemon juice and lemon grass with no significant difference in clinical cure between the groups. 
 
 Prevention 
 Successful prevention was defined as the prevention of a relapse while receiving prophylaxis. Fluconazole was compared with placebo in five studies (5 RCTs; n=599; RR 0.61; 95% CI 0.5 to 0.74) and with no treatment in another (1 RCT; n=65; RR 0.16; 95% CI 0.08 to 0.34). In both instances the prevention of clinical episodes was favoured by fluconazole. Comparing continuous fluconazole treatment with intermittent treatment (2 RCTs; n=891; RR 0.65; 95% CI 0.23 to 1.83), there was no significant difference between the two treatment arms. Chlorhexidine was compared with normal saline in a single study with no significant difference between the treatment arms. Authors' conclusions Five new studies were added to the review, but their results do not alter the final conclusion of the review. Implications for practice 
 Due to there being only one study in children, it is not possible to make recommendations for treatment or prevention of OC in children. Amongst adults, there were few studies per comparison. Due to insufficient evidence, no conclusion could be made about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole or ketoconazole with regard to OC prophylaxis. In comparison to placebo, fluconazole is an effective preventative intervention. However, the potential for resistant Candida organisms to develop, as well as the cost of prophylaxis, might impact the feasibility of implementation. No studies were found comparing fluconazole with other interventions. The direction of findings suggests that ketoconazole, fluconazole, itraconazole and clotrimazole improved the treatment outcomes. Implications for research 
 It is encouraging that low‐cost alternatives are being tested, but more research needs to be on in this area and on interventions like gentian violet and other less expensive anti‐fungal drugs to treat OC. More well‐designed treatment trials with larger samples are needed to allow for sufficient power to detect differences in not only clinical, but also mycological, response and relapse rates. There is also a strong need for more research to be done on the treatment and prevention of OC in children as it is reported that OC is the most frequent fungal infection in children and adolescents who are HIV positive. More research on the effectiveness of less expensive interventions also needs to be done in resource‐poor settings. Currently few trials report outcomes related to quality of life, nutrition, or survival. Future researchers should consider measuring these when planning trials. Development of resistance remains under‐studied and more work must be done in this area. It is recommended that trials be more standardised and conform more closely to CONSORT. Plain language summary Interventions for the prevention and management of oral thrush associated with HIV infection in adults and children Oral candidiasis (thrush) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Interventions aimed at preventing and treating HIV‐associated oral thrush form an integral component of maintaining the quality of life for affected individuals. This review evaluated the effects of interventions in preventing or treating oral thrush in children and adults with HIV infection. Thirty three trials (n=3445) were included. Twenty two trials investigated treatment and eleven trials investigate prevention. There was no difference with regard to clinical cure between fluconazole compared to ketoconazole, itraconazole, clotrimazole and posaconazole. Fluconazole, gentian violet and ketoconazole were superior to nystatin. Compared to placebo and no treatment, fluconazole was effective in preventing clinical episodes from occurring. Continuous fluconazole was better than intermittent treatment. Insufficient evidence was found to come to any conclusion about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole, ketoconazole or chlorhexidine with regard to OC prophylaxis.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.756Z" }, { "id": "0e9bb271-72d3-4ec7-8cb7-4904c7a50151", "pmid": "", "title": "Interventions for chronic blepharitis", "imported": false, "abstract": "Abstract - Background Blepharitis, an inflammatory condition associated with itchiness, redness, flaking, and crusting of the eyelids, is a common eye condition that affects both children and adults. It is common in all ethnic groups and across all ages. Although infrequent, blepharitis can lead to permanent alterations to the eyelid margin or vision loss from superficial keratopathy (abnormality of the cornea), corneal neovascularization, and ulceration. Most importantly, blepharitis frequently causes significant ocular symptoms such as burning sensation, irritation, tearing, and red eyes as well as visual problems such as photophobia and blurred vision. The exact etiopathogenesis is unknown, but suspected to be multifactorial, including chronic low‐grade infections of the ocular surface with bacteria, infestations with certain parasites such as demodex, and inflammatory skin conditions such as atopy and seborrhea. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. Objectives To examine the effectiveness of interventions in the treatment of chronic blepharitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 1), MEDLINE (January 1950 to February 2012), EMBASE (January 1980 to February 2012), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 9 February 2012. Selection criteria We included randomized controlled trials (RCTs) and quasi‐randomized controlled trials (CCTs) in which participants were adults aged 16 years or older and clinically diagnosed with chronic blepharitis. We also included trials where participants with chronic blepharitis were a subset of the participants included in the study and data were reported separately for these participants. Interventions within the scope of this review included medical treatment and lid hygiene measures. Data collection and analysis Two authors independently assessed search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. Data were meta‐analyzed for studies comparing similar interventions and reporting comparable outcomes with the same timing. Otherwise, results for included studies were summarized in the text. Main results There were 34 studies (2169 participants with blepharitis) included in this review: 20 studies (14 RCTs and 6 CCTs) included 1661 participants with anterior or mixed blepharitis and 14 studies (12 RCTs and 2 CCTs) included 508 participants with posterior blepharitis (MGD). Due to the heterogeneity of study characteristics among the included studies, with respect to follow‐up periods and types of interventions, comparisons, and condition of participants, our ability to perform meta‐analyses was limited. Topical antibiotics were shown to provide some symptomatic relief and were effective in eradicating bacteria from the eyelid margin for anterior blepharitis. Lid hygiene may provide symptomatic relief for anterior and posterior blepharitis. The effectiveness of other treatments for blepharitis, such as topical steroids and oral antibiotics, were inconclusive. Authors' conclusions Despite identifying 34 trials related to treatments for blepharitis, there is no strong evidence for any of the treatments in terms of curing chronic blepharitis. Commercial products are marketed to consumers and prescribed to patients without substantial evidence of effectiveness. Further research is needed to evaluate the effectiveness of such treatments. Any RCT designed for this purpose should separate participants by type of condition (e.g. staphylococcal blepharitis or MGD) in order to minimize imbalances between groups (type I errors) and to achieve statistical power for analyses (prevent type II errors). Medical interventions and commercial products should be compared with conventional lid hygiene measures, such as warm compresses and eyelid margin washing, to determine effectiveness, as well as head‐to‐head to show comparative effectiveness between treatments. Outcomes of interest should be patient‐centered and measured using validated questionnaires or scales. It is important that participants be followed long‐term, at least one year, to assess chronic outcomes properly. Plain language summary Interventions for blepharitis Blepharitis, defined as inflammation of the eyelids, is a common eye condition and affects both children and adults. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. There were 34 studies (2169 participants with blepharitis) included in the review, 20 of which included participants with anterior blepharitis and 14 of which included participants with posterior blepharitis. For anterior blepharitis, topical antibiotics provided some symptomatic relief and were effective in clearing bacteria from the eyelid margins. There was no difference between the types of topical antibiotics used. Topical steroids also provided some symptomatic relief; however, they were ineffective in eliminating bacteria. Lid hygiene, including warm compresses and lid scrubs, showed some symptomatic relief in both anterior and posterior blepharitis. Overall, there was no strong evidence for any of the treatments in terms of curing chronic blepharitis. Further research should be done to evaluate the effectiveness of treatments for blepharitis, with particular attention paid to adequate diagnosis and classification of the disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lindsley, K; Matsumura, S; Hatef, E; Akpek, EK", "articleTypes": [], "doi": "10.1002/14651858.CD005556.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "0eaaa8ed-0088-4ffe-8da1-a1c2577ae73c", "pmid": "", "title": "Laxatives for the management of constipation in people receiving palliative care", "imported": false, "abstract": "Abstract - Background This article describes the second update of a Cochrane review on the effectiveness of laxatives for the management of constipation in people receiving palliative care. Previous versions were published in 2006 and 2010 where we also evaluated trials of methylnaltrexone; these trials have been removed as they are included in another review in press. In these earlier versions, we drew no conclusions on individual effectiveness of different laxatives because of the limited number of evaluations. This is despite constipation being common in palliative care, generating considerable suffering due to the unpleasant physical symptoms and the availability of a wide range of laxatives with known differences in effect in other populations. Objectives To determine the effectiveness and differential efficacy of laxatives used to manage constipation in people receiving palliative care. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library ), MEDLINE, EMBASE, CINAHL and Web of Science (SCI & CPCI‐S) for trials to September 2014. Selection criteria Randomised controlled trials (RCTs) evaluating laxatives for constipation in people receiving palliative care. Data collection and analysis Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity. Main results We identified five studies involving the laxatives lactulose, senna, co‐danthramer, misrakasneham, docusate and magnesium hydroxide with liquid paraffin. Overall, the study findings were at an unclear risk of bias. As all five studies compared different laxatives or combinations of laxatives, it was not possible to perform a meta‐analysis. There was no evidence on whether individual laxatives were more effective than others or caused fewer adverse effects. Authors' conclusions This second update found that laxatives were of similar effectiveness but the evidence remains limited due to insufficient data from a few small RCTs. None of the studies evaluated polyethylene glycol or any intervention given rectally. There is a need for more trials to evaluate the effectiveness of laxatives in palliative care populations. Extrapolating findings on the effectiveness of laxatives evaluated in other populations should proceed with caution. This is because of the differences inherent in people receiving palliative care that may impact, in a likely negative way, on the effect of a laxative. Plain language summary Laxatives for the management of constipation in people receiving palliative care Background People with an incurable illness may receive palliative care, which involves making the person as comfortable as possible by controlling pain and other distressing symptoms. People receiving palliative care commonly experience constipation. This is as a result of the use of medicines (e.g. morphine) for pain control, as well as disease, dietary and mobility factors. There is a wide range of laxatives available. The aim of this review was to determine what we know about the effectiveness of laxatives for the management of constipation in people receiving palliative care. Study characteristics We searched medical databases for clinical trials of the use of laxatives for constipation in people receiving palliative care. Two review authors assessed study quality and extracted data. Key results and quality of evidence We identified five studies involving 370 people. The laxatives evaluated were lactulose, senna, co‐danthramer combined with poloxamer, docusate and magnesium hydroxide combined with liquid paraffin. Misrakasneham was also evaluated; this is a traditional Indian medicine and is used as a laxative, containing castor oil, ghee, milk and 21 types of herbs. There was no evidence on which laxative provided the best treatment. However, the review was limited as the evidence was from only five small trials and patient preference and cost were under evaluated. Further rigorous, independent trials are needed to evaluate the effectiveness of laxatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Candy, B, Jones, L, Larkin, PJ, Vickerstaff, V, Tookman, A, Stone, P", "articleTypes": [], "doi": "10.1002/14651858.CD003448.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.760Z" }, { "id": "0eb0c6d4-3b4c-4f28-8505-6e3586e03c56", "pmid": "", "title": "Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age", "imported": false, "abstract": "Abstract - Background Vitamin and mineral deficiencies, particularly those of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Multiple micronutrient powders (MNPs) are single‐dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi‐solid food for children six months of age or older. The use of MNPs for home or point‐of‐use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out‐of‐date. Objectives To assess the effects and safety of home (point‐of‐use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi‐solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point‐of‐use fortification. Search methods We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs with individual randomisation or cluster‐randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron‐containing supplements, which is standard practice. Data collection and analysis Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, and assessed the risk of bias of included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence. Main results We included 29 studies (33,147 children) conducted in low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty‐six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron‐only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate‐certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high‐certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low‐certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate‐certainty evidence) at follow‐up compared with children receiving the control intervention. We did not find an effect on weight‐for‐age (MD 0.02, 95% CI −0.03 to 0.07; 10 studies; 9287 children; moderate‐certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all‐cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low‐certainty evidence) and haemoglobin concentrations (MD −2.81 g/L, 95% CI −10.84 to 5.22; 2 studies; 278 children; very low‐certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low‐certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Authors' conclusions Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Plain language summary Using a vitamin and mineral powder, mixed into complementary foods, to improve health and nutrition in children under two years of age Review question Does using a vitamin and mineral powder, mixed into complementary foods, improve health and nutrition in children under two years of age? Background Deficiencies of vitamins and minerals, particularly of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Exclusive breastfeeding until six months of age, followed by complementary feeding combined with continued breastfeeding for at least two years, is recommended to maintain children's adequate health and nutrition. After six months of age, infants start to receive semi‐solid foods, but the quantities of vitamins and minerals can be insufficient to fulfil all of their requirements for growth and development. Multiple micronutrient powders (MNPs) are single‐dose packets of powder containing iron, vitamin A, zinc, and other vitamins and minerals that can be mixed into any semi‐solid food at home or at any other point of use, to increase the content of essential vitamins and minerals in the diet of infants and young children during this period. This is done without making any other changes to their usual diet. Study characteristics We searched up to July 2019 for all studies that assessed the use of MNP for improving the health and nutrition of children under two years of age. We included 29 studies that involved 33,147 infants and young children from low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean. Twenty‐six studies with 27,051 children contributed data. Of these 26 studies, 24 compared the use of MNP versus no intervention or placebo, and 2 compared the use of MNP versus an iron‐only supplement (iron drops) given daily. We found that a variety of MNP formulations containing between 5 and 22 vitamins and minerals were given for 2 to 44 months to infants and young children aged 6 to 23 months. Most studies were funded by government programmes or foundations; only 2 were funded by industry. Key results The use of MNP containing at least iron, zinc, and vitamin A for home fortification of foods was associated with reduced risk of anaemia of 18% and iron deficiency of 53% in children aged six months to two years compared with no intervention. Also, haemoglobin concentration and iron status improved. Studies did not find any effects on growth. There was no additional benefit in reducing risk of anaemia and improving haemoglobin concentration compared to usually recommended iron drops or syrups; however, only two studies compared these different interventions. No trials reported death attributable to the intervention. Information on deaths, side effects, and morbidity, including malaria and diarrhoea, was scarce. The use of MNP was beneficial for young children 6 to 23 months of age, independent of whether they lived in settings with different anaemia and malaria backgrounds and regardless of the length of the intervention. MNP is better than no intervention or placebo and may be comparable to daily iron supplementation.The benefits of this intervention as a child survival strategy or for developmental outcomes are still unclear, and further investigation is required. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Certainty of the evidence For the comparison of MNP versus no intervention or placebo, we judged the certainty of evidence to be moderate for anaemia and high for iron deficiency. The certainty of evidence for all other outcomes in this comparison was either low or moderate. Two trials that compared the use of MNP versus iron supplement showed similar effects on anaemia and haemoglobin but less diarrhoea; however, we judged the certainty of evidence as low for anaemia and very low for haemoglobin concentration due to the small number of study participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Suchdev, PS; Jefferds, MED; Ota, E; da Silva Lopes, K; De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD008959.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "0ebc116e-5931-44c4-b321-445bb5da1ae2", "pmid": "", "title": "Interventions for erosive lichen planus affecting mucosal sites", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cheng, S, Kirtschig, G, Cooper, S, Thornhill, M, Leonardi‐Bee, J, Murphy, R", "articleTypes": [], "doi": "10.1002/14651858.CD008092.pub2 AB - Abstract - Background Erosive lichen planus (ELP) affecting mucosal surfaces is a chronic autoimmune disease of unknown aetiology. It is often more painful and debilitating than the non‐erosive types of lichen planus. Treatment of erosive lichen planus is difficult and aimed at palliation rather than cure. Several topical and systemic agents have been used with varying results. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth. Objectives To assess the effects of interventions in the treatment of erosive lichen planus affecting the oral, anogenital, and oesophageal regions. Search methods We searched the following databases up to September 2009: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched reference lists of articles and online trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) that evaluated the effectiveness of any topical or systemic interventions for ELP affecting either the mouth, genital region, or both areas, in participants of any age, gender, or race. Data collection and analysis The primary outcome measures were as follows: (a) Pain reduction using a visual analogue scale rated by participants; 
 (b) Physician Global Assessment; and
 (c) Participant global self‐assessment. Changes in scores at the end of therapy compared with baseline were analysed. Main results Fifteen RCTs were included, giving a total of 473 participants with ELP (study sizes ranged between 8‐94). All studies involved oral sites only. Six studies included participants with non‐erosive lichen planus but only the erosive subgroup was included for intended subgroup analysis. We were unable to pool data from any of the nine studies with only ELP participants or any of the six studies with the ELP subgroup, due to small numbers and the heterogeneity of the interventions, design methods, and outcome variables between studies. One study involving 50 participants found that 0.025% clobetasol propionate administered as liquid microspheres significantly reduced pain compared to ointment (Mean difference (MD) ‐18.30, 95% confidence interval (CI) ‐28.57 to ‐8.03), but outcome data was only available in 45 participants (high risk of performance bias for blinding of participants, low/unclear risk of bias overall). However, in another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (high risk of performance and detection bias due to likely lack of blinding, low/unclear risk of bias overall). Aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo in a study involving 45 ELP participants (Risk ratio (RR) 6.16, 95% CI 2.35 to 16.13) (low risk of bias overall). No significant difference was seen in Physician Global Assessment in these three studies. In a small single study involving 20 ELP participants, 1% pimecrolimus cream was 7 times more likely to result in a strong improvement as rated by the Physician Global Assessment when compared to vehicle cream (RR 7.00, 95% CI 1.04 to 46.95) (low risk of bias overall). In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease as rated by the Physician Global Assessment, in favour of the ciclosporin group when compared to the vehicle (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (unclear risk of selection bias for allocation concealment, overall risk of bias low). No statistically significant benefits were shown for topical tacrolimus or fluticasone spray in two separate studies of 29 and 44 participants respectively. There is no overwhelming evidence for the efficacy of a single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candidiasis and dyspepsia. Authors' conclusions This review suggests that there is only weak evidence for the effectiveness of any of the treatments for oral ELP, whilst no evidence was found for genital ELP. More RCTs on a larger scale are needed in the oral and genital ELP populations. We suggest that future studies should have standardised outcome variables that are clinically important to affected individuals. We recommend the measurement of a clinical severity score and a participant‐rated symptom score using agreed and validated severity scoring tools. We also recommend the development of a validated combined severity scoring tool for both oral and genital populations. Plain language summary Treatments for erosive lichen planus affecting mucosal sites Erosive lichen planus (ELP) is a condition that affects the mouth, oesophagus (food pipe or gullet), and anogenital region. It is caused by an over‐active immune system. It is often more painful and debilitating than the non‐erosive types of lichen planus. Depending on the site involved, affected individuals may experience pain, and difficulty eating; passing urine; or having sexual intercourse. Treatment is difficult and aimed at controlling symptoms, rather than cure. Several creams and tablets have been used with varying results. This review looked at the effectiveness of treatments for ELP and included 15 studies, with 473 participants with ELP. All involved oral, but not genital, disease. Many studies were excluded either because they were not randomised controlled trials (where participants are divided into two groups at random) or because they recruited participants with all types of lichen planus, rather than just the erosive subtypes. All of these studies recruited small numbers of participants (12 to 94) and used a variety of different assessment methods and timings; hence, it was not possible to combine or compare results between studies directly. We found only weak evidence for the effectiveness of any of the treatments for oral ELP. None of the studies involved genital or oesophageal disease; hence, no evidence was found for the treatment of these conditions. One small study found that 0.025% clobetasol propionate (a very potent topical steroid) administered as a spray significantly reduced pain when compared to ointment. In another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (a potent topical steroid). In a study involving 45 ELP participants, aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo. In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease in favour of the ciclosporin group when compared to the vehicle. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candida (yeast) infection and pain or discomfort in the upper abdomen. Temporary burning was a common side‐effect reported with tacrolimus 0.1% ointment and pimecrolimus 0.1% cream. Overall, there was no overwhelming evidence for the effectiveness of any single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. This was mainly due to the lack of good‐quality, well‐conducted trials and small participant numbers. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.773Z" }, { "id": "0ee6a822-95be-4107-bd80-bdd476da85c7", "pmid": "", "title": "Central Dopamine Receptors In Obesity", "imported": false, "abstract": "Central dopamine is thought to play a significant role in obesity. In support of this idea, animal studies and one human positron emission tomography (PET) study have found reduced postsynaptic D2-like receptor availability in the striatum in obesity, with lower D2 receptor availability associated with higher weight. In addition, reward sensitivity and hedonic responses, known to be related to dopamine function, have also been implicated in obesity and obesity-related eating behavior. These reports have led to the concept that dopaminergic abnormalities (e.g. reduced D2-like receptors) influence reward sensitivity, leading to altered eating behaviors and eventually obesity. However, there are several critical limitations of the human D2 receptor studies that limit the strength of their conclusions and thus the interpretations and speculations embedded in literature that relies on this work. First, estimates of D2-like receptors in humans have been confounded by potential differences in endogenous dopamine release since the PET ligand (raclopride) used is known to be displaceable from receptors by endogenous dopamine. Second, failure to rigorously screen obese individuals for diabetes confounds conclusions, since diabetes has been independently associated with dopaminergic abnormalities such as reduced D2-like receptors and muted dopamine release in diabetic rats. Finally, no human studies have addressed whether reduced D2-like receptor levels are a risk factor for obesity, a consequence of engaging in obesity-related behaviors or being obese or all of the above.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "0f04921b-5a58-4708-b369-ded5bd24ef9f", "pmid": "", "title": "Sensory environment on health‐related outcomes of hospital patients", "imported": false, "abstract": "Abstract - Background Hospital environments have recently received renewed interest, with considerable investments into building and renovating healthcare estates. Understanding the effectiveness of environmental interventions is important for resource utilisation and providing quality care. Objectives To assess the effect of hospital environments on adult patient health‐related outcomes. Search methods We searched: the Cochrane Central Register of Controlled Trials (last searched January 2006); MEDLINE (1902 to December 2006); EMBASE (January 1980 to February 2006); 14 other databases covering health, psychology, and the built environment; reference lists; and organisation websites. This review is currently being updated (MEDLINE last search October 2010), see Studies awaiting classification. Selection criteria Randomised and non‐randomised controlled trials, controlled before‐and‐after studies, and interrupted times series of environmental interventions in adult hospital patients reporting health‐related outcomes. Data collection and analysis Two review authors independently undertook data extraction and 'Risk of bias' assessment. We contacted authors to obtain missing information. For continuous variables, we calculated a mean difference (MD) or standardized mean difference (SMD), and 95% confidence intervals (CI) for each study. For dichotomous variables, we calculated a risk ratio (RR) with 95% confidence intervals (95% CI). When appropriate, we used a random‐effects model of meta‐analysis. Heterogeneity was explored qualitatively and quantitatively based on risk of bias, case mix, hospital visit characteristics, and country of study. Main results Overall, 102 studies have been included in this review. Interventions explored were: 'positive distracters', to include aromas (two studies), audiovisual distractions (five studies), decoration (one study), and music (85 studies); interventions to reduce environmental stressors through physical changes, to include air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), and temperature (one study); and multifaceted interventions (two studies). We did not find any studies meeting the inclusion criteria to evaluate: art, access to nature for example, through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music may improve patient‐reported outcomes such as anxiety; however, the benefit for physiological outcomes, and medication consumption has less support. There are few studies to support or refute the implementation of physical changes, and except for air quality, the included studies demonstrated that physical changes to the hospital environment at least did no harm. Authors' conclusions Music may improve patient‐reported outcomes in certain circumstances, so support for this relatively inexpensive intervention may be justified. For some environmental interventions, well designed research studies have yet to take place. Plain language summary Sensory environment on health‐related outcomes of hospital patients The hospital environment (such as sounds, pictures, aromas, design, air quality, furnishings, architecture, and layout), may have an impact on the health of patients within it. This review aims to summarise the best available evidence on hospital environments, in order to help people involved in the design of hospital environments make decisions that will benefit patients' health. The review identified 102 relevant studies, 85 of which were on the use of music in hospital. Other environmental aspects considered were: aromas (two studies), audiovisual distractions (five studies), decoration (one study), air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), temperature (one study), and multiple design changes (two studies). No studies meeting the inclusion criteria were found to evaluate: art, access to nature for example through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music in hospital may help improve patient‐reported outcomes such as anxiety; however, there is less evidence to support the use of music for physiological outcomes (such as reducing heart rate and blood pressure) and for reducing the use of medications. For other aspects of hospital environments, there are not very many well designed studies to help with making evidence‐based design decisions. The studies that have been included in this review show that physical changes made to 'improve' the hospital environment on the whole do no harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Drahota, A, Ward, D, Mackenzie, H, Stores, R, Higgins, B, Gal, D, Dean, TP", "articleTypes": [], "doi": "10.1002/14651858.CD005315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.143Z" }, { "id": "0f1394af-cf7e-4e1a-b2bf-7208d8e7602c", "pmid": "", "title": "The Effect of Artificial Sweeteners on Blood Glucose Response", "imported": false, "abstract": "The purpose of this study is to determine whether the presece of the artificial sweeteners aspartame, saccharin and asceulfame-k affect the blood glucose responses to an orally incested glucose solution.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.256Z" }, { "id": "0f14e771-08be-4f33-a96e-2c0846d6e797", "pmid": "", "title": "Paroxetine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Paroxetine is the most potent inhibitor of the reuptake of serotonin of all selective serotonin reuptake inhibitors (SSRIs) and has been studied in many randomised controlled trials (RCTs). However, these comparative studies provided contrasting findings and systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to paroxetine alone. The present systematic review assessed the efficacy and tolerability profile of paroxetine in comparison with tricyclics (TCAs), SSRIs and newer or non‐conventional agents. Objectives 1. To determine the efficacy of paroxetine in comparison with other anti‐depressive agents in alleviating the acute symptoms of Major Depressive Disorder. 2. To review acceptability of treatment with paroxetine in comparison with other anti‐depressive agents. 3. To investigate the adverse effects of paroxetine in comparison with other anti‐depressive agents. Search methods We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR, to 30 September 2012), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Reference lists of relevant papers and previous systematic reviews were handsearched. Pharmaceutical companies marketing paroxetine and experts in this field were contacted for supplemental data. Selection criteria All randomised controlled trials allocating participants with major depression to paroxetine versus any other antidepressants (ADs), both conventional (such as TCAs, SSRIs) and newer or non‐conventional (such as hypericum). For trials which had a cross‐over design, only results from the first randomisation period were considered. Data collection and analysis Two review authors independently checked eligibility and extracted data using a standard form. Data were then entered in RevMan 5.2 with a double‐entry procedure. Information extracted included study and participant characteristics, intervention details, settings and efficacy, acceptability and tolerability measures. Main results A total of 115 randomised controlled trials (26,134 participants) were included. In 54 studies paroxetine was compared with older ADs, in 21 studies with another SSRI, and in 40 studies with a newer or non‐conventional antidepressant other than SSRIs. For the primary outcome (patients who responded to treatment), paroxetine was more effective than reboxetine at increasing patients who responded early to treatment (Odds Ratio (OR): 0.66, 95% Confidence Interval (CI) 0.50 to 0.87, number needed to treat to provide benefit (NNTb) = 16, 95% CI 10 to 50, at one to four weeks, 3 RCTs, 1375 participants, moderate quality of evidence), and less effective than mirtazapine (OR: 2.39, 95% CI 1.42 to 4.02, NNTb = 8, 95% CI 5 to 14, at one to four weeks, 3 RCTs, 726 participants, moderate quality of evidence). Paroxetine was less effective than citalopram in improving response to treatment (OR: 1.54, 95% CI 1.04 to 2.28, NNTb = 9, 95% CI 5 to 102, at six to 12 weeks, 1 RCT, 406 participants, moderate quality of evidence). We found no clear evidence that paroxetine was more or less effective compared with other antidepressants at increasing response to treatment at acute (six to 12 weeks), early (one to four weeks), or longer term follow‐up (four to six months). Paroxetine was associated with a lower rate of adverse events than amitriptyline, imipramine and older ADs as a class, but was less well tolerated than agomelatine and hypericum. Included studies were generally at unclear or high risk of bias due to poor reporting of allocation concealment and blinding of outcome assessment, and incomplete reporting of outcomes. Authors' conclusions Some possibly clinically meaningful differences between paroxetine and other ADs exist, but no definitive conclusions can be drawn from these findings. In terms of response, there was a moderate quality of evidence that citalopram was better than paroxetine in the acute phase (six to 12 weeks), although only one study contributed data. In terms of early response to treatment (one to four weeks) there was moderate quality of evidence that mirtazapine was better than paroxetine and that paroxetine was better than reboxetine. However there was no clear evidence that paroxetine was better or worse compared with other antidepressants at increasing response to treatment at any time point. Even if some differences were identified, the findings from this review are better thought as hypothesis forming rather than hypothesis testing and it would be reassuring to see the conclusions replicated in future trials. Finally, most of included studies were at unclear or high risk of bias, and were sponsored by the drug industry. The potential for overestimation of treatment effect due to sponsorship bias should be borne in mind. Plain language summary Paroxetine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms such as appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, inappropriate guilt and morbid thoughts of death. Although medication and psychological treatments are both effective for major depression, antidepressant drugs remain the mainstay of treatment in moderate to severe major depression. However, head‐to‐head comparisons of such drugs provide contrasting findings as to whether they are effective. This review of the research on the effect of an antidepressant drug called paroxetine was conducted to shed light on the field of drug treatment for depression. In September 2012 we searched, in a wide ranging way, for all the useful studies (randomised controlled trials) which had been completed which compared paroxetine with any other antidepressant in treating people with depression. One hundred and fifteen studies were included in this review, with a total of 26,134 people. We grouped the studies according to the types of drug they compared paroxetine against; we then analysed the combined findings of these groups of studies. For the primary outcome (number of people who responded to treatment) paroxetine was more effective than reboxetine, but less effective than mirtazapine (in the early phase: one to four weeks follow‐up) and probably citalopram (at endpoint: six weeks follow‐up). There was some evidence that paroxetine is less well tolerated than agomelatine and St John's Wort, as more patients allocated to paroxetine experienced at least some side effects (though this finding for St John's Wort was only based on one study). In conclusion, some possibly meaningful differences between paroxetine and other antidepressants exist, but no definitive concluions can be drawn due to the limited number of studies per comparison. In addition, most of included studies were sponsored by the drug industry, which means they might potentially have overestimated the effect of paroxetine. Therefore, the results of this review should be interpreted with caution.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Purgato, M, Papola, D, Gastaldon, C, Trespidi, C, Magni, LR, Rizzo, C, Furukawa, TA, Watanabe, N, Cipriani, A, Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006531.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.110Z" }, { "id": "0f2bf2e4-9b75-4ba2-ad94-6f8d853c515c", "pmid": "", "title": "Etude du contrôle hédonique de la Prise Alimentaire Par l'Analyse Des Potentiels évoqués Gustatifs", "imported": false, "abstract": "Taste perception plays an important role in maintaining nutritional balance. Gustatory evoked potentials (GEP) can be detected in response to an intermittent stimulation of the gustatory receptors by a primary flavour. GEP are non invaisve, painless and safe.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.236Z" }, { "id": "0f305f62-f84f-4c34-bdfd-d426970de967", "pmid": "", "title": "Macrolide antibiotics (including azithromycin) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a life‐limiting genetic condition, affecting over 90,000 people worldwide. CF affects several organs in the body, but airway damage has the most profound impact on quality of life (QoL) and survival. Causes of lower airway infection in people with CF are, most notably, Staphylococcus aureus in the early course of the disease and Pseudomonas aeruginosa at a later stage. Macrolide antibiotics, e.g. azithromycin and clarithromycin, are usually taken orally, have a broad spectrum of action against gram‐positive (e.g. S aureus ) and some gram‐negative bacteria (e.g. Haemophilus influenzae ), and may have a modifying role in diseases involving airway infection and inflammation such as CF. They are well‐tolerated and relatively inexpensive, but widespread use has resulted in the emergence of resistant bacteria. This is an updated review. Objectives To assess the potential effects of macrolide antibiotics on clinical status in terms of benefit and harm in people with CF. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals, and abstract books of conference proceedings. We last searched the Group's Cystic Fibrosis Trials Register on 2 November 2022. We last searched the trial registries WHO ICTRP and clinicaltrials.gov on 9 November 2022. We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow‐up data, where possible. Selection criteria We included randomised controlled trials of macrolide antibiotics in adults and children with CF. We compared them to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose or type of administration. Data collection and analysis Two authors independently extracted data and assessed risk of bias. We assessed the certainty of evidence using GRADE. Main results We included 14 studies (1467 participants) lasting 28 days to 36 months. All the studies assessed azithromycin: 11 compared oral azithromycin to placebo (1167 participants); one compared a high dose to a low dose (47 participants); one compared nebulised to oral azithromycin (45 participants); and one looked at weekly versus daily dose (208 participants). Oral azithromycin versus placebo There is a slight improvement in forced expiratory volume (FEV 1 % predicted) in one second in the azithromycin group at up to six months compared to placebo (mean difference (MD) 3.97, 95% confidence interval (CI) 1.74 to 6.19; high‐certainty evidence), although there is probably no difference at three months, (MD 2.70%, 95% CI ‐0.12 to 5.52), or 12 months (MD ‐0.13, 95% CI ‐4.96 to 4.70). Participants in the azithromycin group are probably at a decreased risk of pulmonary exacerbation with a longer time to exacerbation (hazard ratio (HR) 0.61, 95% CI 0.50 to 0.75; moderate‐certainty evidence). Mild side effects were common, but there was no difference between groups (moderate‐certainty evidence). There is no difference in hospital admissions at six months (odds ratio (OR) 0.61, 95% CI 0.36 to 1.04; high‐certainty evidence), or in new acquisition of P aeruginosa at 12 months (HR 1.00, 95% CI 0.64 to 1.55; moderate‐certainty evidence). High‐dose versus low‐dose azithromycin We are uncertain whether there is any difference in FEV 1 % predicted at six months between the two groups (no data available) or in the rate of exacerbations per child per month (MD ‐0.05 (95% CI ‐0.20 to 0.10)); very low‐certainty evidence for both outcomes. Only children were included in the study and the study did not report on any of our other clinically important outcomes. Nebulised azithromycin versus oral azithromycin We were unable to include any of the data into our analyses and have reported findings directly from the paper; we graded all evidence as being of very low certainty. The authors reported that there was a greater mean change in FEV 1 % predicted at one month in the nebulised azithromycin group (P < 0.001). We are uncertain whether there was a change in P aeruginosa count. Weekly azithromycin versus daily azithromycin There is probably a lower mean change in FEV 1 % predicted at six months in the weekly group compared to the daily group (MD ‐0.70, 95% CI ‐0.95 to ‐0.45) and probably also a longer period of time until first exacerbation in the weekly group (MD 17.30 days, 95% CI 4.32 days to 30.28 days). Gastrointestinal side effects are probably more common in the weekly group and there is likely no difference in admissions to hospital or QoL. We graded all evidence as moderate certainty. Authors' conclusions Azithromycin therapy is associated with a small but consistent improvement in respiratory function, a decreased risk of exacerbation and longer time to exacerbation at six months; but evidence for treatment efficacy beyond six months remains limited. Azithromycin appears to have a good safety profile (although a weekly dose was associated with more gastrointestinal side effects, which makes it less acceptable for long‐term therapy), with a relatively minimal treatment burden for people with CF, and it is inexpensive. A wider concern may be the emergence of macrolide resistance reported in the most recent study which, combined with the lack of long‐term data, means we do not feel that the current evidence is strong enough to support azithromycin therapy for all people with CF. Future research should report over longer time frames using validated tools and consistent reporting, to allow for easier synthesis of data. In particular, future trials should report important adverse events such as hearing impairment or liver disease. More data on the effects of azithromycin given in different ways and reporting on our primary outcomes would benefit decision‐making on whether and how to give macrolide antibiotics. Finally, it is important to assess azithromycin therapy for people with CF who are established on the relatively new cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies which correct the underlying molecular defect associated with CF (none of the trials included in the review are relevant to this population). Plain language summary Treatment with macrolide antibiotics (including azithromycin) for people with cystic fibrosis Review question What are the effects of macrolide antibiotics in people with cystic fibrosis (CF) and infection of their airways? Key messages ‐ People with CF are more prone to chest infections caused by bacteria that can be hard to treat. ‐ Macrolide antibiotics (such as azithromycin and clarithromycin) may lessen the effects of bacteria. ‐ One macrolide antibiotic, azithromycin, can improve lung function at six months compared to a placebo (treatment with no active ingredient) and may reduce the risk of getting a flare‐up of lung infection. We are not sure whether a higher dose of azithromycin is any better than a lower dose, or if azithromycin when inhaled is any better than azithromycin when swallowed (oral). Oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. ‐ Current evidence does not support longer‐term use of azithromycin for all people with CF. Introduction People with CF suffer from infections in their airways, often caused by the bug Pseudomonas aeruginosa , which is resistant to nearly all antibiotics that can be swallowed (oral). Macrolide antibiotics, e.g. azithromycin and clarithromycin, have no direct killing effect on Pseudomonas aeruginosa , but they may reduce the activity of these bacteria. What did we want to find out? We wanted to discover whether the use of macrolide antibiotics (usually taken orally) affected the health of people with CF and whether these drugs have any side effects. What did we do? We searched for studiesthat looked at the effects of macrolide antibiotics in children and adults with CF and summarised the evidence. What did we find? We found 14 studies, which put the total of 1467 children and adults into different treatment groups at random, which we included in this review. Eleven studies compared azithromycin to placebo, one compared two different doses of azithromycin (high versus low dose), one compared inhaled azithromycin to oral azithromycin, and one compared oral azithromycin once a week to once a day. Main results We found that there was a slight improvement in lung function in people that were given azithromycin compared to a placebo at six months and also that the risk of a flare‐up of infection was lower. The risk of side effects (such as vomiting, diarrhoea and headache) was similar in both groups, as was the chance of a new infection with Pseudomonas aeruginosa. In terms of lung function and flare‐up of infection, we were unsure whether a higher dose of azithromycin is better than a lower dose (but only one study in children examined dose), or whether inhaled azithromycin is better than oral azithromycin. Taking oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. What are the limitations of the evidence? We were unable to combine all the study results because they were measured in different ways and at different time points; future trials should address this issue. Also, now that many people with CF are being treated with the new modulator therapies (e.g. elexacaftor‐tezacaftor‐ivacaftor), it is important to assess how macrolide antibiotics affect the health of these people. In the studies we found for this review, none of the people taking part were being treated with modulator therapies. We are able to report the results of the studies that compared azithromycin to placebo with certainty as the studies were well conducted and included a larger number of participants. The evidence from the studies comparing high and low doses or nebulised and oral azithromycin was much less certain because the studies were small and there was risk of bias in the way they were carried out. We were moderately certain of the results of the study comparing weekly azithromycin to daily azithromycin. How up to date is this evidence? The studies we have reported are the most up to date we could find. We last searched for studies in November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Southern, KW; Solis-Moya, A; Kurz, D; Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD002203.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "0f406052-e1af-406a-9913-7763ebd8343f", "pmid": "", "title": "Diet or exercise, or both, for weight reduction in women after childbirth", "imported": false, "abstract": "Abstract - Background Weight retention after pregnancy may contribute to obesity. It is known that diet and exercise are recommended components of any weight loss programme in the general population. However, strategies to achieve healthy body weight among postpartum women have not been adequately evaluated. Objectives The objectives of this review were to evaluate the effect of diet, exercise or both for weight reduction in women after childbirth, and to assess the impact of these interventions on maternal body composition, cardiorespiratory fitness, breastfeeding performance and other child and maternal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012) and LILACS (31 January 2012). We scanned secondary references and contacted experts in the field. We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 30 April 2013 and added the results to the awaiting classification section of the review. Selection criteria All published and unpublished randomised controlled trials (RCTs) and quasi‐randomised trials of diet or exercise or both, among women during the postpartum period. Data collection and analysis Both review authors independently assessed trial quality and extracted data. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data. Data were analysed with a fixed‐effect model. A random‐effects model was used in the presence of heterogeneity. Main results Fourteen trials were included, but only 12 trials involving 910 women contributed data to outcome analysis. Women who exercised did not lose significantly more weight than women in the usual care group (two trials; n = 53; MD ‐0.10 kg; 95% confidence interval (CI) ‐1.90 to 1.71). Women who took part in a diet (one trial; n = 45; MD ‐1.70 kg; 95% CI ‐2.08 to ‐1.32), or diet plus exercise programme (seven trials; n = 573; MD ‐1.93 kg; 95% CI ‐2.96 to ‐0.89; random‐effects, T² = 1.09, I² = 71%), lost significantly more weight than women in the usual care group. There was no difference in the magnitude of weight loss between diet alone and diet plus exercise group (one trial; n = 43; MD 0.30 kg; 95% CI ‐0.06 to 0.66). The interventions seemed not to affect breastfeeding performance adversely. Authors' conclusions Evidence from this review suggests that both diet and exercise together and diet alone help women to lose weight after childbirth. Nevertheless, it may be preferable to lose weight through a combination of diet and exercise as this improves maternal cardiorespiratory fitness and preserves fat‐free mass, while diet alone reduces fat‐free mass. This needs confirmation in large trials of high methodological quality. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby. Plain language summary Diet or exercise, or both, for weight reduction in women carrying excess weight after childbirth Women naturally gain weight during pregnancy and many gradually lose it afterwards. Some women, though, find it difficult to lose the gained weight in the year or two following the birth of the baby and there is concern that this may be a health risk for them. The retention of weight gained during pregnancy may contribute to obesity, which can increase the risk of diabetes, heart disease and high blood pressure. It is suggested that women who return to their pre‐pregnancy weight by about six months have a lower risk of being overweight 10 years later. The review looked for randomised studies to assess the impact of dieting or exercise, or both, on women's weight loss in the months after giving birth. It paid particular attention to breastfeeding women to be sure that breastfeeding was not compromised. The review of trials found 14 studies, with 12 studies involving 910 women carrying excess weight after childbirth that contributed data for analysis. The findings suggest that diet combined with exercise or diet alone compared with usual care seemed to help with weight loss after giving birth. There is potential for these interventions to play a role in preventing future maternal obesity. There was not sufficient evidence to be sure that exercise or diet did not interfere with breastfeeding though it appeared not to in the included studies. It seems preferable to lose weight through a combination of dieting and exercise, compared to dieting alone, because exercise is thought to improve circulation and heart fitness, and to preserve lean body mass. Further research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Amorim Adegboye, AR; Linne, YM", "articleTypes": [], "doi": "10.1002/14651858.CD005627.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "0f42a0d8-6a59-4f5a-9f0c-12d67b5e3ed4", "pmid": "", "title": "Oral stimulation for promoting oral feeding in preterm infants", "imported": false, "abstract": "Abstract - Background Preterm infants (< 37 weeks' post‐menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co‐ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review. Objectives To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA. Search methods Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi‐randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis. Selection criteria Randomised and quasi‐randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non‐oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes. Data collection and analysis Following the updated search, two review authors screened the titles and abstracts of studies and full‐text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non‐oral or sham intervention. We performed meta‐analysis using a fixed‐effect model. Main results We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) ‐4.07 days, 95% confidence interval (CI) ‐4.81 to ‐3.32 days, 6 studies, 292 infants; I 2 =85%, very low‐certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD ‐4.33, 95% CI ‐5.97 to ‐2.68 days, 5 studies, 249 infants; i 2 =68%, very low‐certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non‐oral intervention Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non‐oral intervention (MD ‐7.17, 95% CI ‐8.04 to ‐6.29 days, 10 studies, 574 infants; I 2 =80%, very low‐certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD ‐6.15, 95% CI ‐8.63 to ‐3.66 days, 10 studies, 591 infants; I 2 =0%, low‐certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD ‐2.85, 95% CI ‐6.13 to 0.42, 3 studies, 268 infants; very low‐certainty evidence due to serious risk of bias, inconsistency and imprecision). Authors' conclusions There remains uncertainty about the effects of oral stimulation (versus either standard care or a non‐oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta‐analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well‐designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions. Plain language summary Effects of oral stimulation for oral feeding in preterm infants Review questions Do oral stimulation interventions that involve finger stimulation protocols in preterm infants born before 37 weeks' gestation: Reduce time (days) taken to achieve exclusive oral feeding? Reduce time (days) spent in Neonatal Intensive Care (NICU)? Reduce length of time (days) spent in hospital? Reduce length of time (days) that an infant spends on tube feeding (parenteral nutrition)? Background This is an update of the 2016 review. Many preterm infants have delayed establishment of oral (suck) feeding and are fed at first with feeding tubes or with intravenous (parenteral) nutrition. Development of oral feeding skills needs careful co‐ordination of sucking, swallowing and breathing. In preterm infants, the development of oral feeding can be challenging because of long hospitalisations, breathing difficulties and other medical conditions associated with preterm birth. Unpleasant and invasive procedures such as ventilation or frequent suctioning of secretions from the mouth or nose can negatively impact feeding skills. International guidelines for the transition from tube feeding to oral feeding vary widely. Healthcare providers use a range of interventions to improve sucking and feeding skills in preterm infants, and studies report faster transition time from tube feeds to oral feeds, reduced length of stay in hospital and improvement in infants' sucking skills. The first review in 2016 showed that while oral stimulation interventions appear to reduce length of hospital stay, reduce need for tube feeding and accelerate time to oral feeding, the studies were of poor methodological quality leaving some uncertainty about overall effects. This update assessed whether current research supports these findings and if the quality of studies has improved, leading to increased certainty of results. Study characteristics This review included randomised controlled trials (RCTs) that explored oral stimulation by finger stimulation only in preterm infants. Review authors identified studies to be included by searching electronic databases, clinical trials registers, peer‐reviewed journals and published conference proceedings. Search is up‐to‐date as of March 2022. Key results For this update, we added 12 new studies of variable quality with small numbers of participants, making a total of 28 included studies. As the certainty of evidence was considered 'low' to 'very low', it remains uncertain whether oral stimulation interventions can shorten the transition to oral feeding, reduce length of hospital stay and decrease time spent on parenteral nutrition, although there may be some potential benefit. No studies reported length of stay in NICU. No studies looked at longer‐term outcomes of the interventions (i.e. beyond six months). Certainty of evidence The numbers of infants in these studies were small, the methods employed by researchers varied in quality and the certainty of evidence is estimated to be 'low' to 'very low'.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, Z; O'Donnell, CPF; Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD009720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "0f7d8337-be7a-4cfd-b904-293b578a08c0", "pmid": "", "title": "Pharmacological interventions for cognitive decline in people with Down syndrome", "imported": false, "abstract": "Abstract - Background People with Down syndrome are vulnerable to developing dementia at an earlier age than the general population. Alzheimer's disease and cognitive decline in people with Down syndrome can place a significant burden on both the person with Down syndrome and their family and carers. Various pharmacological interventions, including donepezil, galantamine, memantine and rivastigmine, appear to have some effect in treating cognitive decline in people without Down syndrome, but their effectiveness for those with Down syndrome remains unclear. Objectives To assess the effectiveness of anti‐dementia pharmacological interventions and nutritional supplements for treating cognitive decline in people with Down syndrome. Search methods In January 2015, we searched CENTRAL, ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), Ovid MEDLINE, Embase, PsycINFO, seven other databases, and two trials registers. In addition, we checked the references of relevant reviews and studies and contacted study authors, other researchers and relevant drug manufacturers to identify additional studies. Selection criteria Randomised controlled trials (RCTs) of anti‐dementia pharmacological interventions or nutritional supplements for adults (aged 18 years and older) with Down syndrome, in which treatment was administered and compared with either placebo or no treatment. Data collection and analysis Two review authors independently assessed the risk of bias of included trials and extracted the relevant data. Review authors contacted study authors to obtain missing information where necessary. Main results Only nine studies (427 participants) met the inclusion criteria for this review. Four of these (192 participants) assessed the effectiveness of donepezil, two (139 participants) assessed memantine, one (21 participants) assessed simvastatin, one study (35 participants) assessed antioxidants, and one study (40 participants) assessed acetyl‐L‐carnitine. Five studies focused on adults aged 45 to 55 years, while the remaining four studies focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one between Norway and the UK, and one in Japan. Follow‐up periods in studies ranged from four weeks to two years. The reviewers judged all included studies to be at low or unclear risk of bias. Analyses indicate that for participants who received donepezil, scores in measures of cognitive functioning (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) ‐0.27 to 1.13) and measures of behaviour (SMD 0.42, 95% CI ‐0.06 to 0.89) were similar to those who received placebo. However, participants who received donepezil were significantly more likely to experience an adverse event (odds ratio (OR) 0.32, 95% CI 0.16 to 0.62). The quality of this body of evidence was low. None of the included donepezil studies reported data for carer stress, institutional/home care, or death. For participants who received memantine, scores in measures of cognitive functioning (SMD 0.05, 95% CI ‐0.43 to 0.52), behaviour (SMD ‐0.17, 95% CI ‐0.46 to 0.11), and occurrence of adverse events (OR 0.45, 95% CI 0.18 to 1.17) were similar to those who received placebo. The quality of this body of evidence was low. None of the included memantine studies reported data for carer stress, institutional/home care, or death. Due to insufficient data, it was possible to provide a narrative account only of the outcomes for simvastatin, antioxidants, and acetyl‐L‐carnitine. Results from one pilot study suggest that participants who received simvastatin may have shown a slight improvement in cognitive measures. Authors' conclusions Due to the low quality of the body of evidence in this review, it is difficult to draw conclusions about the effectiveness of any pharmacological intervention for cognitive decline in people with Down syndrome. Plain language summary Medications for cognitive decline in people with Down syndrome People with Down syndrome often experience cognitive decline (a deterioration in memory, language, thinking and judgment that are greater than normal age‐related changes) at a younger age and in greater numbers than the general population. Various medicines have been shown to improve, or at least slow down the progression of these symptoms in people without Down syndrome. Review question Do adults (18 years and older) with Down syndrome benefit from treatment with medicine to prevent cognitive decline, compared with other adults with Down syndrome who receive either fake medicine (placebos) or no medicine? Study characteristics In January 2015, we, a team of Cochrane researchers, searched for all medical studies that investigated the effect of any medicine or nutritional supplement on cognitive decline in adults with Down syndrome. We found nine relevant randomised controlled trials (this design produces the most reliable results) that we could include in this overview. These studies tested: ‐ donepezil, a medicine used to treat Alzheimer's disease (four studies); ‐ memantine, a medicine used to treat Alzheimer's disease (two studies); ‐ simvastatin, a (statin) medicine used to prevent heart disease (one study); ‐ a mixture of antioxidants, including forms of vitamins C and E, and alpha‐lipoic acid (one study); and ‐ acetyl‐L‐carnitine, a dietary supplement that has previously been used to treat dementia (one study). Five of the studies focused on adults aged 45 to 55 years and four focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one took place in Norway and the UK, and one study was conducted in Japan. Key results The nine studies we found examined the effects of five medicines that are, or have been, used to prevent cognitive decline. All the studies compared the medicine being tested with a placebo (a tablet or capsule that looked and tasted like the medicine, but which contained no medicine). Generally, those who received the medicine did no better than those who received the placebo in any of the areas assessed in the studies. The areas assessed included general functioning (including memory and thinking, speech, mood and behaviour); cognitive functioning (including memory, following what’s going on around you); adaptive behaviours (being able to do day‐to‐day tasks); or behaviour problems (such as being irritable or aggressive). The only medicine to show any positive effect was the statin, simvastatin. Preliminary findings from a very small study showed that simvastin had some benefit on improving memory compared to placebo. In the four donepezil studies, those participants given donepezil reported more headaches, dizziness, and nausea than participants given placebo. In the two memantine studies, there was no difference between participants given memantine or placebo for reports of headaches, dizziness, and nausea. Quality of the evidence Although the included studies were well conducted, most involved small numbers of participants and for many of the areas assessed we could not combine results from two or more studies. Overall, the quality of this evidence is low. We cannot be certain whether any of these medicines are effective. Running more trials with more people over a longer period of time would allow us answer this question with greater certainty. We could not find any trials that investigated many of the medicines used to prevent cognitive decline, and so research is needed to explore the effectiveness of these medications in the Down syndrome population.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Livingstone, N; Hanratty, J; McShane, R; Macdonald, G", "articleTypes": [], "doi": "10.1002/14651858.CD011546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "0f9b66f0-040d-4001-9449-96dc37f140ba", "pmid": "", "title": "Diet-induced Modification of Sweet Taste Perception and Preference", "imported": false, "abstract": "Overconsumption of carbohydrates has been implicated as a cause of significant public health problems including obesity and diabetes. The most effective approach to alter dietary pattern and improve public health is unknown. Gradual and abrupt changes in dietary pattern have been tried in small, uncontrolled trials, but it is not clear which approach is most effective. The primary objective of this study is to evaluate different approaches to changing dietary pattern for altering flavor perception in foods and beverages and for altering preference for flavor.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.234Z" }, { "id": "0fb7eec5-56ea-4407-a192-cb5964f1e8ac", "pmid": "", "title": "The effect of sample site and collection procedure on identification of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Sample collection is a key driver of accuracy in the diagnosis of SARS‐CoV‐2 infection. Viral load may vary at different anatomical sampling sites and accuracy may be compromised by difficulties obtaining specimens and the expertise of the person taking the sample. It is important to optimise sampling accuracy within cost, safety and accessibility constraints. Objectives To compare the sensitivity of different sampling collection sites and methods for the detection of current SARS‐CoV‐2 infection with any molecular or antigen‐based test. Search methods Electronic searches of the Cochrane COVID‐19 Study Register and the COVID‐19 Living Evidence Database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) were undertaken on 22 February 2022. We included independent evaluations from national reference laboratories, FIND and the Diagnostics Global Health website. We did not apply language restrictions. Selection criteria We included studies of symptomatic or asymptomatic people with suspected SARS‐CoV‐2 infection undergoing testing. We included studies of any design that compared results from different sample types (anatomical location, operator, collection device) collected from the same participant within a 24‐hour period. Data collection and analysis Within a sample pair, we defined a reference sample and an index sample collected from the same participant within the same clinical encounter (within 24 hours). Where the sample comparison was different anatomical sites, the reference standard was defined as a nasopharyngeal or combined naso/oropharyngeal sample collected into the same sample container and the index sample as the alternative anatomical site. Where the sample comparison was concerned with differences in the sample collection method from the same site, we defined the reference sample as that closest to standard practice for that sample type. Where the sample pair comparison was concerned with differences in personnel collecting the sample, the more skilled or experienced operator was considered the reference sample. Two review authors independently assessed the risk of bias and applicability concerns using the QUADAS‐2 and QUADAS‐C checklists, tailored to this review. We present estimates of the difference in the sensitivity (reference sample (%) minus index sample sensitivity (%)) in a pair and as an average across studies for each index sampling method using forest plots and tables. We examined heterogeneity between studies according to population (age, symptom status) and index sample (time post‐symptom onset, operator expertise, use of transport medium) characteristics. Main results This review includes 106 studies reporting 154 evaluations and 60,523 sample pair comparisons, of which 11,045 had SARS‐CoV‐2 infection. Ninety evaluations were of saliva samples, 37 nasal, seven oropharyngeal, six gargle, six oral and four combined nasal/oropharyngeal samples. Four evaluations were of the effect of operator expertise on the accuracy of three different sample types. The majority of included evaluations (146) used molecular tests, of which 140 used RT‐PCR (reverse transcription polymerase chain reaction). Eight evaluations were of nasal samples used with Ag‐RDTs (rapid antigen tests). The majority of studies were conducted in Europe (35/106, 33%) or the USA (27%) and conducted in dedicated COVID‐19 testing clinics or in ambulatory hospital settings (53%). Targeted screening or contact tracing accounted for only 4% of evaluations. Where reported, the majority of evaluations were of adults (91/154, 59%), 28 (18%) were in mixed populations with only seven (4%) in children. The median prevalence of confirmed SARS‐CoV‐2 was 23% (interquartile (IQR) 13%‐40%). Risk of bias and applicability assessment were hampered by poor reporting in 77% and 65% of included studies, respectively. Risk of bias was low across all domains in only 3% of evaluations due to inappropriate inclusion or exclusion criteria, unclear recruitment, lack of blinding, nonrandomised sampling order or differences in testing kit within a sample pair. Sixty‐eight percent of evaluation cohorts were judged as being at high or unclear applicability concern either due to inflation of the prevalence of SARS‐CoV‐2 infection in study populations by selectively including individuals with confirmed PCR‐positive samples or because there was insufficient detail to allow replication of sample collection. When used with RT‐PCR • There was no evidence of a difference in sensitivity between gargle and nasopharyngeal samples (on average ‐1 percentage points, 95% CI ‐5 to +2, based on 6 evaluations, 2138 sample pairs, of which 389 had SARS‐CoV‐2). • There was no evidence of a difference in sensitivity between saliva collection from the deep throat and nasopharyngeal samples (on average +10 percentage points, 95% CI ‐1 to +21, based on 2192 sample pairs, of which 730 had SARS‐CoV‐2). • There was evidence that saliva collection using spitting, drooling or salivating was on average ‐12 percentage points less sensitive (95% CI ‐16 to ‐8, based on 27,253 sample pairs, of which 4636 had SARS‐CoV‐2) compared to nasopharyngeal samples. We did not find any evidence of a difference in the sensitivity of saliva collected using spitting, drooling or salivating (sensitivity difference: range from ‐13 percentage points (spit) to –21 percentage points (salivate)). • Nasal samples (anterior and mid‐turbinate collection combined) were, on average, 12 percentage points less sensitive compared to nasopharyngeal samples (95% CI ‐17 to ‐7), based on 9291 sample pairs, of which 1485 had SARS‐CoV‐2. We did not find any evidence of a difference in sensitivity between nasal samples collected from the mid‐turbinates (3942 sample pairs) or from the anterior nares (8272 sample pairs). • There was evidence that oropharyngeal samples were, on average, 17 percentage points less sensitive than nasopharyngeal samples (95% CI ‐29 to ‐5), based on seven evaluations, 2522 sample pairs, of which 511 had SARS‐CoV‐2. A much smaller volume of evidence was available for combined nasal/oropharyngeal samples and oral samples. Age, symptom status and use of transport media do not appear to affect the sensitivity of saliva samples and nasal samples. When used with Ag‐RDTs • There was no evidence of a difference in sensitivity between nasal samples compared to nasopharyngeal samples (sensitivity, on average, 0 percentage points ‐0.2 to +0.2, based on 3688 sample pairs, of which 535 had SARS‐CoV‐2). Authors' conclusions When used with RT‐PCR, there is no evidence for a difference in sensitivity of self‐collected gargle or deep‐throat saliva samples compared to nasopharyngeal samples collected by healthcare workers when used with RT‐PCR. Use of these alternative, self‐collected sample types has the potential to reduce cost and discomfort and improve the safety of sampling by reducing risk of transmission from aerosol spread which occurs as a result of coughing and gagging during the nasopharyngeal or oropharyngeal sample collection procedure. This may, in turn, improve access to and uptake of testing. Other types of saliva, nasal, oral and oropharyngeal samples are, on average, less sensitive compared to healthcare worker‐collected nasopharyngeal samples, and it is unlikely that sensitivities of this magnitude would be acceptable for confirmation of SARS‐CoV‐2 infection with RT‐PCR. When used with Ag‐RDTs, there is no evidence of a difference in sensitivity between nasal samples and healthcare worker‐collected nasopharyngeal samples for detecting SARS‐CoV‐2. The implications of this for self‐testing are unclear as evaluations did not report whether nasal samples were self‐collected or collected by healthcare workers. Further research is needed in asymptomatic individuals, children and in Ag‐RDTs, and to investigate the effect of operator expertise on accuracy. Quality assessment of the evidence base underpinning these conclusions was restricted by poor reporting. There is a need for further high‐quality studies, adhering to reporting standards for test accuracy studies. Plain language summary How accurate are different types of sample collection for diagnosing COVID‐19 infection? Key messages • When used with RT‐PCR tests (a molecular test that detects genetic material in COVID‐19 using a technique called reverse transcription polymerase chain reaction), self‐collected gargle and deep throat saliva samples have a similar sensitivity compared to trained healthcare worker‐collected nasopharyngeal samples (taken from the back of the throat through the nose) in detecting COVID‐19. • When used with RT‐PCR, samples collected from the nose, oropharynx (throat via the mouth), oral cavity, and other saliva collection methods are less sensitive for detecting COVID‐19 compared to healthcare worker‐collected nasopharyngeal samples. • When used with rapid antigen tests (Ag‐RDTs; at‐home/self‐tests), samples collected from the nose have a similar sensitivity to healthcare worker‐collected nasopharyngeal samples in detecting COVID‐19. Why is improving the diagnosis of COVID‐19 important? Coronavirus disease (COVID‐19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). People with suspected COVID‐19 may decide to take a test to know whether they are infected, so that they can receive treatment, and follow recommended guidance to self‐isolate and inform close contacts. Not detecting COVID‐19 when it is present (a false negative result) risks spreading infection and results in missed opportunities for treatment. Types of sample collection methods for diagnosing COVID‐19? The type and quality of sample taken for confirmation of COVID‐19 affects the reliability of diagnosis. The most accurate type of sample to diagnose COVID‐19 is that taken by a trained healthcare worker from the back of the throat through the nose (a nasopharyngeal sample). This type of test detects genetic material in the virus using a technique called reverse transcription polymerase chain reaction (RT‐PCR). However, this sample is difficult to obtain correctly, causes discomfort and risks spreading infection if individuals cough or sneeze when the sample is taken. Alternative sample types, particularly those that can be self‐collected using rapid antigen tests (Ag‐RDTs; i.e. self‐tests), may reduce cost and discomfort and improve the safety of sampling. This may, in turn, improve access to and uptake of testing. What did we want to find out? We wanted to compare the sensitivity of different sample sites and collection methods in detecting COVID‐19 with molecular tests (RT‐PCR tests) or self‐based tests (Ag‐RDT tests). What did we do? We searched for studies that had compared the accuracy of nasopharyngeal samples to any alternative that could be used in patients outside of hospital, including nose (nasal) samples, throat samples taken through the mouth (oropharyngeal), gargle samples and saliva samples. We looked at the use of samples with either RT‐PCR or Ag‐RDTs. We also searched for studies that had compared different methods for taking samples, such as samples collected by a healthcare worker compared to those collected by individuals with no or minimal instructions. What did we find? The review included 106 studies with a total of 60,523 participants, of whom 11,045 had COVID‐19 infection. Fifty‐nine per cent of studies were conducted on adults and 79% on symptomatic or mixed symptomatic and asymptomatic participants. Sixty per cent of studies took place in Europe or the USA; just over half (55%) took place in dedicated COVID‐19 testing centres or in outpatient settings. Main results With RT‐PCR, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also test positive on self‐collected gargle samples or saliva samples (collected by coughing and then spitting (deep throat saliva)); ‐ 88% of positive nasopharyngeal samples collected by healthcare workers would also test positive with self‐ or healthcare worker‐collected nose samples; ‐ 87% of positive nasopharyngeal samples collected by healthcare workers would also be detected by saliva self‐collected using spitting, 84% by saliva self‐collected using drooling and 79% by saliva self‐collected by sucking on a swab; and ‐ 83% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐ or healthcare worker‐collected oropharyngeal samples. With Ag‐RDTs, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐collected or healthcare worker‐collected nose samples. Summary results The results of these studies indicate that in a group of 1000 people, of whom 230 (23%) have COVID‐19, then: when used with PCR, compared to healthcare worker‐collected nasopharyngeal samples: ‐ no cases of COVID‐19 would be missed using self‐collected gargle samples (12 less to 5 more) or deep throat saliva samples (2 less to 48 more); ‐ 28 (16 to 39) fewer cases of COVID‐19 infection would be detected using healthcare worker‐ or self‐collected nose sample; ‐ 30 (18 to 41) fewer cases of COVID‐19 infection would be detected by saliva self‐collected using spitting, 37 (12 to 62) fewer by saliva collected by drooling and 48 (12 to 85) fewer by saliva collected by sucking on a swab; ‐ 39 (12 to 67) fewer cases of COVID‐19 infection would be detected by healthcare worker‐ or self‐collected oropharyngeal samples; and when used with Ag‐RDTs, compared to healthcare worker‐collected nasopharyngeal samples: no cases of COVID‐19 infection would be missed using healthcare worker‐ or self‐collected nose samples. What are the limitations of the evidence? It was often not clear whether included studies deliberately excluded inadequate samples or whether the results of the more accurate nasopharyngeal sample were known when alternative samples were interpreted. This may have resulted in alternative sample types appearing more accurate than they are in practice, decreasing the number of missed cases of COVID‐19 infection. More than half of studies did not give information about how long participants had had symptoms at the time of sampling. This reduces our confidence in the comparison of different sample types. Most studies evaluated self‐collected samples by adults with symptoms for use with RT‐PCR; therefore, the findings of this review may not be applicable to asymptomatic individuals or children. For studies conducted with Ag‐RDTs, it is unclear whether sensitivity estimates of nose samples are applicable to home use (self‐collected and self‐interpreted). How up to date is this review? The evidence is current to 22 February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Davenport, C, Arevalo-Rodriguez, I, Mateos-Haro, M, Berhane, S, Dinnes, J, Spijker, R, Buitrago-Garcia, D, Ciapponi, A, Takwoingi, Y, Deeks, JJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014780", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.787Z" }, { "id": "0fbb947d-ba74-49ac-8612-5fed666fad82", "pmid": "", "title": "Treatments for iron‐deficiency anaemia in pregnancy", "imported": false, "abstract": "Abstract - Background Iron deficiency, the most common cause of anaemia in pregnancy worldwide, can be mild, moderate or severe. Severe anaemia can have very serious consequences for mothers and babies, but there is controversy about whether treating mild or moderate anaemia provides more benefit than harm. Objectives To assess the effects of different treatments for anaemia in pregnancy attributed to iron deficiency (defined as haemoglobin less than 11 g/dL or other equivalent parameters) on maternal and neonatal morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2011), CENTRAL (2011, Issue 5), PubMed (1966 to June 2011), the International Clinical Trials Registry Platform (ICTRP) (2 May 2011), Health Technology Assessment Program (HTA) (2 May 2011) and LATINREC (Colombia) (2 May 2011). Selection criteria Randomised controlled trials comparing treatments for anaemia in pregnancy attributed to iron deficiency. Data collection and analysis We identified 23 trials, involving 3.198 women. We assessed their risk of bias. Three further studies identified are awaiting classification. Main results Many of the trials were from low‐income countries; they were generally small and frequently methodologically poor. They covered a very wide range of differing drugs, doses and routes of administration, making it difficult to pool data. Oral iron in pregnancy showed a reduction in the incidence of anaemia (risk ratio 0.38, 95% confidence interval 0.26 to 0.55, one trial, 125 women) and better haematological indices than placebo (two trials). It was not possible to assess the effects of treatment by severity of anaemia. A trend was found between dose and reported adverse effects. Most trials reported no clinically relevant outcomes nor adverse effects. Although the intramuscular and intravenous routes produced better haematological indices in women than the oral route, no clinical outcomes were assessed and there were insufficient data on adverse effects, for example, on venous thrombosis and severe allergic reactions. Daily low‐dose iron supplements may be effective at treating anaemia in pregnancy with less gastrointestinal side effects compared with higher doses. Authors' conclusions Despite the high incidence and burden of disease associated with this condition, there is a paucity of good quality trials assessing clinical maternal and neonatal effects of iron administration in women with anaemia. Daily oral iron treatment improves haematological indices but causes frequent gastrointestinal adverse effects. Parenteral (intramuscular and intravenous) iron enhances haematological response, compared with oral iron, but there are concerns about possible important adverse effects (for intravenous treatment venous thrombosis and allergic reactions and for intramuscular treatment important pain, discolouration and allergic reactions). Large, good quality trials, assessing clinical outcomes (including adverse effects) as well as the effects of treatment by severity of anaemia are required. Plain language summary Treatments for anaemia in pregnancy thought to be due to iron deficiency When the blood has insufficient red cells, or the red cells carry insufficient haemoglobin to deliver adequate oxygen to the tissues, this is called anaemia. There is normally a reduction in the haemoglobin concentrations in the mother's blood during pregnancy, and this allows a better blood flow around the womb (uterus) and to the baby. This is sometime called physiological anaemia and needs no treatment. True anaemia, however, can be mild, moderate or severe and can cause weakness, tiredness and dizziness. Severe anaemia makes women at risk of cardiac failure and is very common in low‐income countries Anaemia has many causes including a shortage or iron, folic acid or vitamin B 12 . These are all required for making red cells and are available in a good diet. Iron shortage, however, is the most common cause of anaemia during pregnancy. Iron treatment can be given by mouth (oral), by injection into the muscle (intramuscular) or injection into the vein (intravenous). Blood transfusion or giving something which stimulates the body to produce more red cells (erythropoietin) are also possible treatments. In this review, we identified 23 trials involving 3198 pregnant women. Many of the trials were in low‐income countries and many treatment variations were studied. Oral iron reduced the incidence of anaemia but is known to sometimes cause constipation and nausea. Although the intramuscular and intravenous routes produced better levels of red cells and iron stores than the oral route, no clinical outcomes (such as pre‐eclampsia, preterm births, postpartum haemorrhage) were assessed and there were insufficient data on adverse effects. Intravenous treatment can cause venous thrombosis (blockages in the veins) and intramuscular treatment causes important pain and discolouration at the injection site. It was unclear if women and babies were healthier when women were given iron for mild or moderate anaemia during pregnancy. There were no studies on using blood transfusions. Overall, there was insufficient evidence to say when or how anaemia in pregnancy needs to or should be treated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Reveiz, L; Gyte, GML; Cuervo, LG; Casasbuenas, A", "articleTypes": [], "doi": "10.1002/14651858.CD003094.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "0fbc75b8-0e41-4e85-8b79-925c11f4ef22", "pmid": "", "title": "Interventions for fatigue management after traumatic brain injury", "imported": false, "abstract": "Abstract - Rationale Despite the high prevalence and medico‐social significance of fatigue in post‐traumatic brain injury (post‐TBI) populations, there are no validated management strategies to control this condition. It is timely to provide clinicians and patients with the best available evidence of the efficacy of current pharmacological and non‐pharmacological fatigue management practices. Objectives To assess the effectiveness of pharmacological and non‐pharmacological interventions for fatigue in people who have experienced a TBI. Search methods For this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO. We also searched relevant conference proceedings, and we searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for ongoing trials. The most recent searches were conducted on 12 February 2025. Eligibility criteria Eligible study designs were randomised controlled trials (RCTs) and randomised cross‐over trials (for pharmacological interventions only). Studies with participants of all ages (children and adults) with a TBI (of any severity) were included, where at least 75% of participants had a TBI. Any type of treatment for fatigue was considered. Four categories of interventions were prioritised: pharmacological, cognitive, stimulation/biofeedback, and psychoeducational. These interventions were compared to placebo groups, no treatment, or groups receiving other interventions. Outcomes The critical outcome was fatigue. Important outcomes include fatigue‐related outcomes of psychological functioning (depression and anxiety), cognitive functioning (processing speed), general quality of life, and daytime sleepiness. Risk of bias We assessed risk of bias using the original Cochrane risk of bias tool for RCTs (RoB 1). Synthesis methods We synthesised the results for each outcome by meta‐analysis where possible using mean differences (MDs) and standardised mean differences (SMDs) and a fixed‐effect model. Where meta‐analysis was not possible due to the nature of the data , we narratively reported the results. We used GRADE to assess the certainty of evidence for each outcome . We performed all statistical analyses using RevMan and presented results with 95% confidence intervals (CI). Included studies We included a total of 3518 trial participants (at baseline) across 40 studies, described in 49 publications. The 40 included studies are grouped by type of intervention. There were seven categories of interventions: pharmacological, cognitive, physical activity, stimulation/biofeedback, health visits, psychoeducational, and a final category for trials with multiple interventions (multi‐interventions). Four published studies identified in the most recent search are awaiting classification. Synthesis of results Pharmacological interventions (melatonin; recombinant human growth hormones (rhGH); psychostimulants; atorvastatin; monoaminergic stabiliser (‐)‐OSU6162) likely reduce fatigue slightly (SMD ‐0.25, 95% CI ‐0.44 to ‐0.06; 8 studies, 395 participants; moderate‐certainty evidence). Cognitive interventions (cognitive rehabilitation; technology‐enhanced training; functional skills training) may reduce fatigue slightly (MD ‐0.32, 95% CI ‐0.59 to ‐0.06; 6 studies, 222 participants; low‐certainty evidence). Stimulation/biofeedback interventions (light therapy; electrical/magnetic stimulation; acupressure) may reduce fatigue slightly, but the evidence is very uncertain (SMD ‐0.23, 95% CI ‐0.47 to 0.01; 8 studies, 295 participants; very low‐certainty evidence). Psychoeducation interventions (cognitive behavioural therapy; acceptance and commitment therapy; individualised occupational therapy; novel therapies) may reduce fatigue, but the evidence is very uncertain (SMD ‐0.55, 95% CI ‐0.74 to ‐0.35; 8 studies, 474 participants; very low‐certainty evidence). There may be little to no difference in psychological functioning (depression), psychological functioning (anxiety), cognitive functioning (processing speed), or daytime sleepiness. However, these results are very uncertain. Authors' conclusions There is very limited and moderate to very low‐certainty evidence from RCTs about treatments to reduce fatigue after TBI. Despite the prevalence of fatigue post‐TBI, we lack high‐quality studies that evaluate interventions to improve this disabling, but potentially treatable, symptom. There is a need for considerable further work to identify an effective treatment for fatigue in people with TBI. Funding This Cochrane review had no dedicated funding. Registration Protocol available via DOI: 10.1002/14651858.CD006448 Plain language summary Which treatments are effective for fatigue after traumatic brain injury? Key messages Medications (such as melatonin, growth hormones, brain stimulants, atorvastatin, or dopamine and serotonin regulators) likely reduce fatigue after a traumatic brain injury. Other treatments, such as talking therapies, sensory stimulation, and counselling, may reduce fatigue after a traumatic brain injury. Future studies should involve more people, including children and young people. They should investigate different kinds of treatments in different settings, and the severity and causes of traumatic brain injury. What is traumatic brain injury? Traumatic brain injury is damage to the brain following a bump or blow to the head. The injury might result from a traffic accident, fall, assault, sports injury, or an explosion. People with traumatic brain injury might experience headaches, become forgetful, and have difficulties sleeping and moving. They may also experience fatigue, which is defined as an overwhelming sense of tiredness unrelated to previous effort, which does not usually improve with rest. Fatigue makes it hard for people to concentrate and perform everyday activities, which affects their quality of life. How is fatigue after traumatic brain injury treated? Treatments for fatigue vary because the causes and symptoms of fatigue may be very different. Treatments include medication to stimulate or protect the brain, and hormones and antidepressants to help people sleep and improve their mood. Treatments that don’t involve medication include counselling, education, behavioural therapy and exercise. What did we want to find out? We mainly wanted to find out if different treatments reduce fatigue in people with traumatic brain injury. We were also interested in the effect of the treatments on people’s mood, memory or attention, quality of life, and sleepiness. What did we do? We searched for studies that randomly assigned people to receive treatment for fatigue, usual care (that is, no specific treatment for fatigue), or a placebo (dummy) treatment. We also looked at studies that compared different treatments. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 40 studies with 3518 adults and children living with traumatic brain injury. The studies took place in 12, mainly high‐income, countries in Europe, North America, and Oceania. They were conducted in different settings, including medical centres, rehabilitation clinics, military bases, clinical research facilities, and hospitals. Main results Fatigue Medications likely reduce fatigue after a traumatic brain injury (8 studies, 395 people). Medications included melatonin, growth hormones, psychostimulants, statins, and dopamine regulators. Other treatments (without medication) may reduce fatigue after a traumatic brain injury (31 studies, 2203 people). Treatments included cognitive behavioural therapy, technical‐enhanced training, functional skills training, sensory stimulation, electrical/magnetic stimulation, acupressure, counselling, acceptance and commitment therapy, individualised occupational therapy, cognitive symptom management rehabilitation therapy, aerobic exercise, prescribed light exercise, location of exercise, vestibular rehabilitation, health visits, and multi‐interventional therapies. For treatments with medication, there were some reported adverse (unwanted or harmful) events that are specific to particular studies. For other treatments (without medication), adverse events were often not reported. Fatigue‐related symptoms Medications may make little or no difference to depression, anxiety, processing speed, quality of life, and daytime sleepiness (21 studies, 1016 people). Of the treatments without medication, only cognitive therapy showed any noticeable effect; it may reduce anxiety (2 studies, 57 people). What are the limitations of the evidence? We have limited confidence in the evidence due to the small numbers of people in the different studies, and the variation in settings, treatments, ages of participants, and the severity and causes of traumatic brain injury. How up to date is this evidence? We searched for studies up to 12 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Senior, HE, Leung, JH, Meehan, B, Leao, S, Jordan, V, Barker-Collo, S, Crummey, S, Purdy, SC", "articleTypes": [], "doi": "10.1002/14651858.CD006448.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.818Z" }, { "id": "0fc3196c-4ab4-4e34-9efa-8f1733126f70", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Omega‐3 fatty acids (n‐3, fish oil) have been shown to have anti‐inflammatory properties. Therefore, n‐3 therapy may be beneficial in chronic inflammatory disorders such as ulcerative colitis. Objectives To systematically review the efficacy and safety of n‐3 for maintaining remission in ulcerative colitis (UC). Search methods The following databases were searched from their inception without language restriction: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Healthstar, PubMed, and ACP journal club. Experts were contacted for unpublished data. Selection criteria Randomized placebo‐controlled trials (RCT) of fish oil for maintenance of remission in UC were included. Studies must have enrolled patients (of any age group) who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. The primary outcome was relapse rate and the secondary outcome was frequency of adverse events. Other outcomes to assess efficacy were change in disease activity scores and time to first relapse. Data collection and analysis Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality. Meta‐analysis weighted by the Mantel‐Haenszel method was performed using RevMan 4.2.8 software. Random or fixed effect models were used according to degree of heterogeneity and subgroup analyses were performed to explore heterogeneity. A sensitivity analysis was performed excluding a study of questionable quality . Main results The three studies that were included used different formulation and dosing of n‐3 but none used enteric coated capsules. The pooled analysis showed a similar relapse rate in the n‐3 treated patients and controls (RR 1.02; 95% CI 0.51 to 2.03; P = 0.96). Combining the studies resulted in virtually no statistical heterogeneity (P = 0.93, I 2 = 0%). Various subgroup and sensitivity analyses showed similar results. However, the total number of patients enrolled in these studies was small (n = 138). No significant adverse events were recorded in any of the studies and not enough data were available to pool the other secondary outcomes for meta‐analysis. Authors' conclusions No evidence was found that supports the use of omega 3 fatty acids for maintenance of remission in UC. Further studies using enteric coated capsules may be justified. Plain language summary Omega 3 fatty acids for maintenance of remission in ulcerative colitis Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of ulcerative colitis patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of omega‐3 fatty acids to maintain remission in ulcerative colitis were reviewed. Three studies were included of which none reported a reduction in the rate of disease relapse in comparison with placebo. When the studies were pooled for meta‐analysis there was no benefit for omega 3 fatty acids. There were no serious side effects in any of the studies. None of the studies used enteric coated capsules which allow release of the fish oil in the small bowel. Non‐enteric coated omega‐3 fatty acids (fish oil) seem safe but ineffective for maintaining remission in ulcerative colitis. Further studies of enteric coated capsules may be justified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Turner, D, Steinhart, AH, Griffiths, AM", "articleTypes": [], "doi": "10.1002/14651858.CD006443.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.750Z" }, { "id": "0ff5c973-d9d2-47d6-92ac-e4d3e139f989", "pmid": "", "title": "Zolmitriptan for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a common, disabling condition and a burden for the individual, health services, and society. Zolmitriptan is an abortive medication for migraine attacks, belonging to the triptan family. These medicines work in a different way to analgesics such as paracetamol and ibuprofen. Objectives To determine the efficacy and tolerability of zolmitriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, and the Oxford Pain Relief Database, together with three online databases ( www.astrazenecaclinicaltrials.com , www.clinicaltrials.gov , and apps.who.int/trialsearch ) for studies to 12 March 2014. We also searched the reference lists of included studies and relevant reviews. Selection criteria We included randomised, double‐blind, placebo‐ or active‐controlled studies, with at least 10 participants per treatment arm, using zolmitriptan to treat a migraine headache episode. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate risk ratios and numbers needed to treat for an additional beneficial effect (NNT) or harmful effect (NNH) compared with placebo or a different active treatment. Main results Twenty‐five studies (20,162 participants) compared zolmitriptan with placebo or an active comparator. The evidence from placebo‐controlled studies was of high quality for all outcomes except 24 hour outcomes and serious adverse events where only limited data were available. The majority of included studies were at a low risk of performance, detection and attrition biases, but did not adequately describe methods of randomisation and concealment. Most of the data were for the 2.5 mg and 5 mg doses compared with placebo, for treatment of moderate to severe pain. For all efficacy outcomes, zolmitriptan surpassed placebo. For oral zolmitriptan 2.5 mg versus placebo, the NNTs were 5.0, 3.2, 7.7, and 4.1 for pain‐free at two hours, headache relief at two hours, sustained pain‐free during the 24 hours postdose, and sustained headache relief during the 24 hours postdose, respectively. Results for the oral 5 mg dose were similar to the 2.5 mg dose, while zolmitriptan 10 mg was significantly more effective than 5 mg for pain‐free and headache relief at two hours. For headache relief at one and two hours and sustained headache relief during the 24 hours postdose, but not pain‐free at two hours, zolmitriptan 5 mg nasal spray was significantly more effective than the 5 mg oral tablet. For the most part, adverse events were transient and mild and were more common with zolmitriptan than placebo, with a clear dose response relationship (1 mg to 10 mg). High quality evidence from two studies showed that oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people as oral sumatriptan 50 mg (66%, 67%, and 68% respectively), although not necessarily the same individuals. There was no significant difference in numbers experiencing adverse events. Single studies reported on other active treatment comparisons but are not described further because of the small amount of data. Authors' conclusions Zolmitriptan is effective as an abortive treatment for migraine attacks for some people, but is associated with increased adverse events compared to placebo. Zolmitriptan 2.5 mg and 5 mg benefited the same proportion of people as sumatriptan 50 mg, although not necessarily the same individuals, for headache relief at two hours. Plain language summary Zolmitriptan for acute migraine attacks in adults Migraine is a complex condition with a wide variety of symptoms. It affects about 1 person in 8, mainly women aged 30 to 50 years. For many people, the main feature is a painful, and often disabling, headache. Other symptoms include feeling sick, vomiting, disturbed vision, and sensitivity to light, sound, and smells. Zolmitriptan is one of the triptan family of drugs. It is used to treat migraine attacks when they occur, not to prevent attacks occurring. It is available as an oral tablet to swallow whole, an oral tablet to dissolve in the mouth, and a nasal spray. This review looked at 25 studies that involved over 20,000 participants reporting the effects of zolmitriptan on migraine attacks. Most information was for tablets taken by mouth. Overall methodological quality of the included studies was good, and treatment group sizes were large enough to avoid major bias. There were inconsistencies in the way use of rescue medication and adverse events were reported. A single oral dose of zolmitriptan relieved migraine headache pain in some people. Several different pain outcomes were reported. One outcome was pain reduced from moderate or severe to no pain at all two hours after taking treatment. An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 3 in 10 people (30%), compared with about 1 in 10 (10%) taking placebo. Another outcome was pain reduced from moderate or severe to no worse than mild pain two hours after taking treatment (called headache relief). An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 6 in 10 people (61%), compared with 3 in 10 (29%) taking placebo. Slightly better results were obtained with higher doses of 5 mg or 10 mg oral tablets, but the 10 mg dose was associated with more adverse events, most of which were of short duration and mild or moderate in severity. Results for the 5 mg nasal spray were generally similar to those for the oral tablet, but it was significantly better than the tablet at 1 hour. People with migraine want treatment that eliminates the headache and any associated symptoms quickly (maximum two hours) and prevents it returning (within 24 hours). Results indicate that with the 5 mg dose only 14% of those treated were pain‐free at 2 hours with no headache recurrence within 24 hours. Oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people (2 in 3) as oral sumatriptan 50 mg, with no difference in numbers experiencing adverse events. The individuals who respond to each drug may not be the same.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bird, S; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "10028fdd-90e6-4570-88e0-b13f9fe8b650", "pmid": "", "title": "Efficacy of Bitter Taste Blockers on Flavor Acceptance in Pediatric Populations", "imported": false, "abstract": "This proposal describes 2 basic research studies that will be conducted sequentially. Study 1 will test the efficacy of both classic and newly developed \"generally recognized as a safe\" (GRAS) bitter blockers on the perceived bitterness and acceptance of different classes of bitter-tasting compounds by children and compare their responses to adults. Because variations among and between children and adults in terms of sensitivity to different bitter compounds are due in part to genetically determined receptor variation, the investigators will consider genotype when assessing how well bitter blockers perform. In Study 2, the investigators aim to evaluate different methods (forced-choice procedures, hedonic face scales) used for testing children to determine their reliability and reproducibility.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.145Z" }, { "id": "101a85c1-fa3d-434a-85df-2ab1e46ac0df", "pmid": "", "title": "Ganoderma lucidum (Reishi mushroom) for cancer treatment", "imported": false, "abstract": "Abstract - Background Ganoderma lucidum is a natural medicine that is widely used and recommended by Asian physicians and naturopaths for its supporting effects on immune system. Laboratory research and a handful of preclinical trials have suggested that G. lucidum carries promising anticancer and immunomodulatory properties. The popularity of taking G. lucidum as an alternative medicine has been increasing in cancer patients. However, there is no systematic review that has been conducted to evaluate the actual benefits of G. lucidum in cancer treatment. Objectives To evaluate the clinical effects of G. lucidum on long‐term survival, tumour response, host immune functions and quality of life in cancer patients, as well as adverse events associated with its use. Search methods We searched an extensive set of databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, NIH, AMED, CBM, CNKI, CMCC and VIP Information/Chinese Scientific Journals Database was searched for randomised controlled trials (RCTs) in October 2011. Other strategies used were scanning the references of articles retrieved, handsearching of the International Journal of Medicinal Mushrooms and contact with herbal medicine experts and manufacturers of G. lucidum . For this update we updated the searches in February 2016. Selection criteria To be eligible for being included in this review, studies had to be RCTs comparing the efficacy of G. lucidum medications to active or placebo control in patients with cancer that had been diagnosed by pathology. All types and stages of cancer were eligible for inclusion. Trials were not restricted on the basis of language. Data collection and analysis Five RCTs met the inclusion criteria and were included in this review. Two independent review authors assessed the methodological quality of individual trials. Common primary outcomes were tumour response evaluated according to the World Health Organization (WHO) criteria, immune function parameters such as natural killer (NK)‐cell activity and T‐lymphocyte co‐receptor subsets, and quality of life measured by the Karnofsky scale score. No trial had recorded long‐term survival rates. Associated adverse events were reported in one study. A meta‐analysis was performed to pool available data from the primary trials. Results were gauged using relative risks (RR) and standard mean differences (SMD) for dichotomous and continuous data respectively, with a 95% confidence interval (CI). Main results The methodological quality of primary studies was generally unsatisfying and the results were reported inadequately in many aspects. Additional information was not available from primary trialists. The meta‐analysis results showed that patients who had been given G. lucidum alongside with chemo/radiotherapy were more likely to respond positively compared to chemo/radiotherapy alone (RR 1.50; 95% CI 0.90 to 2.51, P = 0.02). G. lucidum treatment alone did not demonstrate the same regression rate as that seen in combined therapy. The results for host immune function indicators suggested that G. lucidum simultaneously increases the percentage of CD3, CD4 and CD8 by 3.91% (95% CI 1.92% to 5.90%, P < 0.01), 3.05% (95% CI 1.00% to 5.11%, P < 0.01) and 2.02% (95% CI 0.21% to 3.84%, P = 0.03), respectively. In addition, leukocyte, NK‐cell activity and CD4/CD8 ratio were marginally elevated. Four studies showed that patients in the G. lucidum group had relatively improved quality of life in comparison to controls. One study recorded minimal side effects, including nausea and insomnia. No significant haematological or hepatological toxicity was reported. Authors' conclusions Our review did not find sufficient evidence to justify the use of G. lucidum as a first‐line treatment for cancer. It remains uncertain whether G. lucidum helps prolong long‐term cancer survival. However, G. lucidum could be administered as an alternative adjunct to conventional treatment in consideration of its potential of enhancing tumour response and stimulating host immunity. G. lucidum was generally well tolerated by most participants with only a scattered number of minor adverse events. No major toxicity was observed across the studies. Although there were few reports of harmful effect of G. lucidum , the use of its extract should be judicious, especially after thorough consideration of cost‐benefit and patient preference. Future studies should put emphasis on the improvement in methodological quality and further clinical research on the effect of G. lucidum on cancer long‐term survival are needed. An update to this review will be performed every two years. Plain language summary G. lucidum (Reishi mushroom) for cancer treatment There have been an increasing number of patients diagnosed with cancer each year. Certain malignancies have been a major cause of death in some populations. People who have been diagnosed with cancer want to do everything they can to combat the disease, manage its symptoms and cope with the side effects of radio/chemotherapy. Many turn to complementary and alternative medicine. G. lucidum extract is a medication that has been widely used by traditional Chinese medicine (TCM) practitioners for this regard. It is usually recommended as an immune system support supplement in cancer treatment. Latest laboratory research and preclinical trials of G. lucidum have shown promising results of its antitumour activity. However, clinical evidence of its efficacy is sparse and a systematic review is in need to provide collective information for health‐care consumers. Our review identified and subsequently included five relevant randomised controlled trials. A total of 373 subjects were analysed. A meta‐analysis was performed to pool available data from individual trials. Our results found that patients with G. lucidum extract in their anticancer regimen were 1.27 times more likely to respond to chemotherapy or radiotherapy than those without. However, the data failed to demonstrate significant effect on tumour shrinkage when it was used alone. In addition, G. lucidum could stimulate host immune functions by considerably increasing CD3, CD4 and CD8 lymphocyte percentages. Nevertheless, natural killer (NK)‐cell activity, which has been suggested to be an indicator of self‐defence against tumour cell, was marginally elevated. Patients in the G. lucidum group were found to have a relatively better quality of life after treatment than those in the control group. A few cases of minor side effect associated with G. lucidum treatment including nausea and insomnia were reported. There are limitations of the results from this systematic review. First, most included studies were small and there were concerns on the methodological quality of individual trials. Second, all participants in the individual trials were recruited from the Chinese population. Together, the robustness and applicability of the results were largely affected.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Jin, X; Ruiz Beguerie, J; Sze, DMY; Chan, GCF", "articleTypes": [], "doi": "10.1002/14651858.CD007731.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "106501d7-78a7-41be-a890-bb93afe4be40", "pmid": "", "title": "Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under", "imported": false, "abstract": "Abstract - Background Although complementary feeding is a universal practice, the methods and manner in which it is practiced vary between cultures, individuals and socioeconomic classes. The period of complementary feeding is a critical time of transition in the life of an infant, and inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. Educational interventions are widely acknowledged as effective in promoting public health strategy, and those aimed at improving complementary feeding practices provide information about proper complementary feeding practices to caregivers of infants/children. It is therefore important to summarise evidence on the effectiveness of educational interventions to improve the complementary feeding practices of caregivers of infants. Objectives To assess the effectiveness of educational interventions for improving the complementary feeding (weaning) practices of primary caregivers of children of complementary feeding age, and related health and growth outcomes in infants. Search methods In November 2017, we searched CENTRAL, MEDLINE, Embase, 10 other databases and two trials registers. We also searched the reference lists of relevant studies and reviews to identify any additional studies. We did not limit the searches by date, language or publication status. Selection criteria Randomised controlled trials (RCTs), comparing educational interventions to no intervention, usual practice, or educational interventions provided in conjunction with another intervention, so long as the educational intervention was only available in the experimental group and the adjunctive intervention was available to the control group. Study participants included caregivers of infants aged 4 to 24 months undergoing complementary feeding. Pregnant women who were expected to give birth and commence complementary feeding during the period of the study were also included. Data collection and analysis Two review authors independently extracted data on participants, settings, interventions, methodology and outcomes using a specifically‐developed and piloted data extraction form. We calculated risk ratios (RR) and 95% confidence intervals (CIs) for dichotomous data, and mean differences (MD) and 95% CIs for continuous data. Where data permitted, we conducted a meta‐analysis using a random‐effects model. We assessed the included studies for risk of bias and also assessed the quality of evidence using the GRADE approach. Main results We included 23 studies (from 35 reports) with a total of 11,170 caregiver‐infant pairs who were randomly assigned to receive an educational intervention delivered to the caregiver or usual care. Nineteen of the included studies were community‐based studies while four were facility‐based studies. In addition, 13 of the included studies were cluster‐randomised while the others were individually randomised. Generally, the interventions were focused on the introduction of complementary feeding at the appropriate time, the types and amount of complementary foods to be fed to infants, and hygiene. Using the GRADE criteria, we assessed the quality of the evidence as moderate, mostly due to inadequate allocation concealment and insufficient blinding. Educational interventions led to improvements in complementary feeding practices for age at introduction of complementary foods (average RR 0.88, 95% CI 0.83 to 0.94; 4 studies, 1738 children; moderate‐quality evidence) and hygiene practices (average RR 1.38, 95% CI 1.23 to 1.55; 4 studies, 2029 participants; moderate‐quality evidence). For duration of exclusive breastfeeding, pooled results were compatible with both a reduction and an increase in the outcome (average RR 1.58, 95% CI 0.77 to 3.22; 3 studies, 1544 children; very low‐quality evidence). There was limited (low to very low‐quality) evidence of an effect for all growth outcomes. Quality of evidence There is moderate to very low‐quality evidence that educational interventions can improve complementary feeding practices but insufficient evidence to conclude that it impacts growth outcomes. Authors' conclusions Overall, we found evidence that education improves complementary feeding practices. Plain language summary Educational interventions for improving complementary feeding practices Background Complementary feeding is the period when an infant moves from taking only breast milk or breast‐milk substitutes (such as infant formula) to family food. It is a critical period in the life of an infant. Inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. This is because inappropriate complementary feeding practices, such as introduction of semi‐solid foods too early (before six months of age), poor hygiene or giving foods that do not contain adequate nutrients, are all major causes of illness. Such illnesses include malnutrition, diarrhoea, poor growth, infections and poor mental development of children. Education has been proposed as an effective means of improving complementary feeding practices. Review question Does education improve complementary feeding practices of caregivers of infants as well as the health and growth of the infants? Study characteristics We searched for randomised controlled trials (a type of experiment in which people are randomly allocated to one or more treatment groups) up until November 2017. The search identified 23 studies involving a total of 11,170 caregivers and their children. The ages of the children ranged from birth to 24 months. The caregivers received educational interventions alone while the control group received no intervention, usual care or any other non‐educational intervention. The educational methods included printed materials such as leaflets, counselling, teaching sessions, peer support, videos and practical demonstrations. Generally, the education messages were focused on the introduction of semi‐solid foods at the appropriate age, the types and amount of complementary foods to be fed to infants, and hygiene. Key results Education reduced the number of caregivers that introduced semi‐solid foods to their infants before six months of age by up to 12% (moderate‐quality evidence). Hygiene practices of caregivers who received education also showed some improvement compared to those that did not (moderate‐quality evidence). In studies conducted in the community, education increased the duration of exclusive breastfeeding, but not in studies conducted in health facilities. There was no convincing evidence of an effect of education on the growth of children (low to very low‐quality evidence). We could not combine the results from different studies for diarrhoea, knowledge of caregivers and adequacy of complementary food. However, from the individual reports of the study authors, education led to a reduction in diarrhoea and an improvement in the knowledge of caregivers. It also led to improvement in the quality and quantity of complementary foods fed to infants. Overall, we found evidence that education improves complementary feeding practices.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Arikpo, D, Edet, ES, Chibuzor, MT, Odey, F, Caldwell, DM", "articleTypes": [], "doi": "10.1002/14651858.CD011768.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.826Z" }, { "id": "10700702-aca0-4177-a113-e28806683485", "pmid": "", "title": "Combination Therapies to Reduce the Nasopharyngeal Carriage of SARS-CoV-2 and Improve the Outcome of COVID-19 Infection in Ivory Coast (INTENSE-COV): a Phase IIb Randomized Clinical Trial", "imported": false, "abstract": "In January 2020, the new SARS-CoV-2 coronavirus was identified in China. The disease caused by this coronavirus was named COVID-19 by the World Health Organization (WHO). Since March 11, 2020, the WHO has described the global situation of COVID-19 as a pandemic. In Côte d'Ivoire, as in other African countries, the number of cases is increasing exponentially.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.250Z" }, { "id": "107191ea-d9f7-45c1-842f-29f5b6631474", "pmid": "", "title": "Inhaled anti‐pseudomonal antibiotics for long‐term therapy in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review. Objectives To evaluate the effects of long‐term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug‐sensitivity reactions and survival). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022. Selection criteria We selected trials where people with cystic fibrosis received inhaled anti‐pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi‐randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). Data collection and analysis Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system. Main results The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta‐analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low‐certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) ‐5.30 days, 95% CI ‐8.59 to ‐2.01; 1 trial, 245 participants; low‐certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta‐analyses. We are uncertain of the effect of the intervention on adverse events (very low‐certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEV 1 ) % predicted compared to tobramycin (MD ‐3.40%, 95% CI ‐6.63 to ‐0.17; 1 trial, 273 participants; moderate‐certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate‐certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high‐certainty evidence). Important treatment‐related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high. Authors' conclusions Long‐term treatment with inhaled anti‐pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer‐term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes. Plain language summary Inhaling antibiotics to treat lung infection in people with cystic fibrosis Review question Are inhaled antibiotics helpful against persistent infection with Pseudomonas aeruginosa in people with cystic fibrosis (CF)? Key messages As people with CF get older, they are more likely to become infected on a long‐term basis with Pseudomonas aeruginosa. This is the most common cause of chronic lung infection in people with CF . We wanted to find out whether antibiotics targeting Pseudomonas aeruginosa would reduce the effects of infection when they are breathed into the lungs. We wanted to learn whether this treatment would improve lung function, quality of life and survival. We also looked for any harmful effects. What is CF? Cystic fibrosis is an inherited disease which results in abnormal mucus in several parts of the body and mainly affects the lungs, which are susceptible to infection by certain bacteria. Infection causes inflammation which results in progressive damage to the lungs. What did we find? The review includes 18 trials with 3042 people with CF aged between five and 45 years of age . The trials lasted from three to 33 months. In 11 trials investigators compared inhaled antibiotics with a placebo (an inhaled substance without the medication in it) and people were selected for one treatment or the other randomly. Eight trials compared one inhaled antibiotic with either a different inhaled antibiotic or a different schedule of the same inhaled antibiotic. One of the trials compared an antibiotic both to placebo and to a different antibiotic and so fell into both groups. Main results Results from four trials showed that when compared to placebo, inhaled antibiotics may improve lung function and reduce the number of times the people with CF had a worsening of symptoms (exacerbation). Inhaled antibiotics may also mean fewer days off school or work (a measure of quality of life). They did not seem to have an effect on survival. We are not sure of the side effects of inhaled antibiotics, but tinnitus and changes in voice were reported more often in people inhaling antibiotics rather than the placebo. We did not find enough evidence to be able to comment on how inhaled antibiotics affect height and weight. Where the trials compared different inhaled antibiotics or schedules, there was only one trial in each of the eight different comparisons. The only differences we found in all these comparisons were for two outcomes. In one trial we found that aztreonam lysine probably improved lung function more than tobramycin, but no important differences were found in the other trials with regard to lung function. Aztreonam lysine also probably led to fewer people needing additional courses of antibiotics than tobramycin and there were fewer hospitalisations after levofloxacin compared to placebo. We noted that important side effects that were related to the treatment were not very common in the trials, but they were less common with tobramycin than with other antibiotics. What are the limitations of the evidence? The trials that we included in this review measured lung function in different ways and also how often people experienced a sudden worsening of symptoms. That made it difficult for us to combine the results of different trials to strengthen our evidence. We thought the overall certainty of evidence was low for most outcomes, mainly due to risks of bias within the trials and low event rates meaning results were not precise. How up to date is this evidence? The evidence is current to: 28 June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Smith, S, Rowbotham, NJ", "articleTypes": [], "doi": "10.1002/14651858.CD001021.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.771Z" }, { "id": "1079a546-2d4f-44bc-b572-292f8b13ac1a", "pmid": "", "title": "Preoperative fasting for preventing perioperative complications in children", "imported": false, "abstract": "Abstract - Background Children, like adults, are required to fast before general anaesthesia with the aim of reducing the volume and acidity of their stomach contents. It is thought that fasting reduces the risk of regurgitation and aspiration of gastric contents during surgery. Recent developments have encouraged a shift from the standard 'nil‐by‐mouth‐from‐midnight' fasting policy to more relaxed regimens. Practice has been slow to change due to questions relating to the duration of a total fast, the type and amount of intake permitted. Objectives To systematically assess the effects of different fasting regimens (duration, type and volume of permitted intake) and the impact on perioperative complications and patient well being (aspiration, regurgitation, related morbidity, thirst, hunger, pain, comfort, behaviour, nausea and vomiting) in children. Search methods We searched Cochrane Wounds Group Specialised Register (searched 25/6/09), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 2 2009), Ovid MEDLINE (1950 to June Week 2 2009), Ovid EMBASE (1980 to 2009 Week 25), EBSCO CINAHL (1982 to June Week 3 2009), the National Research Register, relevant conference proceedings and article reference lists and contacted experts. Selection criteria Randomised and quasi randomised controlled trials of preoperative fasting regimens for children were identified. Data collection and analysis Data extraction and trial quality assessment was conducted independently by three authors. Trial authors were contacted for additional information including adverse events. Main results This first update of the review identified two additional eligible studies, bringing the total number of included studies to 25 (forty seven randomised controlled comparisons involving 2543 children considered to be at normal risk of regurgitation or aspiration during anaesthesia). Only one incidence of aspiration and regurgitation was reported. Children permitted fluids up to 120 minutes preoperatively were not found to experience higher gastric volumes or lower gastric pH values than those who fasted. The children permitted fluids were less thirsty and hungry, better behaved and more comfortable than those who fasted. Clear fluids preoperatively did not result in a clinically important difference in children's gastric volume or pH. Evidence relating to the preoperative intake of milk was sparse. The volume of fluid permitted during the preoperative period did not appear to impact on children's intraoperative gastric volume or pH contents. Authors' conclusions There is no evidence that children who are denied oral fluids for more than six hours preoperatively benefit in terms of intraoperative gastric volume and pH compared with children permitted unlimited fluids up to two hours preoperatively. Children permitted fluids have a more comfortable preoperative experience in terms of thirst and hunger. This evidence applies only to children who are considered to be at normal risk of aspiration/regurgitation during anaesthesia. Plain language summary Preoperative fasting for children to prevent complications during surgery General anaesthetics inhibit the protective reflexes that stop the stomach contents reaching the lungs. In order to prevent the inadvertent inhalation of stomach contents, children are often advised to have nothing to eat or drink from the midnight before surgery. However, the review of trials found that drinking clear fluids up to a few hours before surgery did not increase the risk of regurgitation during or after surgery. Indeed there is an added benefit of a more comfortable preoperative experience in terms of thirst and hunger. Some children are considered more likely to regurgitate under anaesthetic, including those who are obese or have stomach disorders. More research is needed to determine whether these children can also safely drink up to a few hours before surgery.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brady, MC, Kinn, S, Ness, V, O'Rourke, K, Randhawa, N, Stuart, P", "articleTypes": [], "doi": "10.1002/14651858.CD005285.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.791Z" }, { "id": "10d31a05-cab1-4f86-bf73-c9d913facc74", "pmid": "", "title": "Music‐based therapeutic interventions for people with dementia", "imported": false, "abstract": "Abstract - Background Dementia is a clinical syndrome with a number of different causes. It is characterised by deterioration in cognitive, behavioural, social and emotional functioning. Pharmacological interventions are available but have limited effect on many of the syndrome's features. However, receptivity to music may remain until the late phases of dementia, and music‐based therapeutic interventions (which include, but are not limited to, music therapy) are suitable for people with advanced dementia. As there is uncertainty about the effectiveness of music‐based therapeutic interventions, trials are being conducted to evaluate this. This review updates one last published in 2018 and examines the current evidence for the effects of music‐based interventions for people with dementia. Objectives To assess the effects of music‐based therapeutic interventions for people with dementia on emotional well‐being (including quality of life), mood disturbance or negative affect (i.e. depressive symptoms and anxiety), behavioural problems (i.e. overall behavioural problems or neuropsychiatric symptoms, and more specifically agitation or aggression), social behaviour and cognition, at the end of therapy and four or more weeks after the end of treatment, and to assess any adverse effects. Search methods We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organisation's meta‐register‐the International Clinical Trials Registry Platform on 30 November 2023. Selection criteria We included randomised controlled trials of music‐based therapeutic interventions (of at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music. Data collection and analysis Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data from included studies and assess their risk of bias. If necessary, we contacted trial authors to ask for additional data, such as relevant subscales. We pooled data using the random‐effects model. We assessed the certainty of the evidence for our two comparisons and our main outcomes of interest using GRADE. Main results We included 30 studies with 1720 randomised participants that were conducted in 15 countries. Twenty‐eight studies with 1366 participants contributed data to meta‐analyses. Ten studies contributed data to long‐term outcomes. Participants had dementia of varying degrees of severity and resided in institutions in most of the studies. Seven studies delivered an individual intervention; the other studies delivered the intervention to groups. Most interventions involved both active and receptive elements of musical experience. The studies were at high risk of performance bias and some were at high risk of detection or other bias. For music‐based therapeutic interventions compared to usual care, we found moderate‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions probably improved depressive symptoms slightly (standardised mean difference (SMD) −0.23, 95% confidence interval (CI) −0.42 to −0.04; 9 studies, 441 participants), and we found low‐certainty evidence that it may have improved overall behavioural problems (SMD −0.31, 95% CI −0.60 to −0.02; 10 studies, 385 participants). We found moderate‐certainty evidence that music‐based therapeutic interventions likely did not improve agitation or aggression (SMD −0.05, 95% CI −0.27 to 0.17; 11 studies, 503 participants). Low to very low certainty evidence showed that they did not improve emotional well‐being (SMD 0.14, 95% CI ‐0.29 to 0.56; 4 studies, 154 participants), anxiety (SMD −0.15, 95% CI −0.39 to 0.09; 7 studies, 282 participants), social behaviour (SMD 0.22, 95% CI −0.14 to 0.57; 2 studies; 121 participants) or cognition (SMD 0.19, 95% CI −0.02 to 0.41; 7 studies, 353 participants). Low or very‐low ‐certainty evidence showed that music‐based therapeutic interventions may not have been more effective than usual care in the long term (four weeks or more after the end of treatment) for any of the outcomes. For music‐based therapeutic interventions compared to other interventions, we found low‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions may have been more effective than the other activities for social behaviour (SMD 0.52, 95% CI 0.08 to 0.96; 4 studies, 84 participants). We found very low‐certainty evidence of a positive effect on anxiety (SMD −0.75, 95% CI −1.27 to −0.24; 10 studies, 291 participants). For all other outcomes, low‐certainty evidence showed no evidence of an effect: emotional well‐being (SMD 0.20, 95% CI −0.09 to 0.49; 9 studies, 298 participants); depressive symptoms (SMD −0.14, 95% CI ‐0.36 to 0.08; 10 studies, 359 participants); agitation or aggression (SMD 0.01, 95% CI −0.31 to 0.32; 6 studies, 168 participants); overall behavioural problems (SMD −0.08, 95% CI −0.33 to 0.17; 8 studies, 292 participants) and cognition (SMD 0.12, 95% CI −0.21 to 0.45; 5 studies; 147 participants). We found low or very‐low certainty evidence that music‐based therapeutic interventions may not have been more effective than other interventions in the long term (four weeks or more after the end of treatment) for any of the outcomes. Adverse effects were inconsistently measured or recorded, but no serious adverse events were reported. Authors' conclusions When compared to usual care, providing people with dementia with at least five sessions of a music‐based therapeutic intervention probably improves depressive symptoms and may improve overall behavioural problems at the end of treatment. When compared to other activities, music‐based therapeutic interventions may improve social behaviour at the end of treatment. No conclusions can be reached about the outcome of anxiety as the certainty of the evidence is very low. There may be no effects on other outcomes at the end of treatment. There was no evidence of long‐term effects from music‐based therapeutic interventions. Adverse effects may be rare, but the studies were inconsistent in their reporting of adverse effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions. Plain language summary Does music‐based therapy help people with dementia? Key messages · Compared to usual care (i.e. without specific activities), providing people with dementia with music‐based therapy sessions probably improves depression, and may improve overall behavioural problems. · Compared to other activities, music‐based therapy may improve social behaviour, but we are unsure if it improves anxiety. · These effects may not last beyond the end of treatment. · There is no evidence that music‐based therapy makes a difference to the emotional well‐being, agitation or cognition (e.g. thinking and remembering) of people with dementia, although there is uncertainty about this. · There is uncertainty in the evidence for long‐term effects, but no long‐term effects were observed in the studies. · Adverse effects (unwanted side effects) may be rare, but the studies were inconsistent in their reporting, so we need more evidence before we can reach reliable conclusions. Why offer music‐based therapy to people with dementia? People with dementia gradually develop increasing difficulty with thinking and daily activities. Dementia is often associated with emotional and behavioural problems and may decrease a person's quality of life. In the later stages of dementia, it may be difficult for people to communicate with words, but even when they can no longer speak, they may still be able to hum or play along with music. Therapy involving music may therefore be especially suitable for people with dementia to improve their lives. Who provides music‐based therapy? Music therapists are certified to work with individuals or groups of people, using music to try to help meet their physical, psychological and social needs. Other professionals may also be trained to provide similar therapies. What did we want to find out? We wanted to find out if, for people with dementia, music‐based therapy works better than usual care or other activities, such as painting. We were interested in whether the therapy changed these outcomes at the end of treatment: · emotional well‐being including quality of life; · depression and anxiety; · agitation or aggression and overall behavioural problems; · social behaviour; and · cognition (e.g. thinking and remembering). We also wanted to find out if there were any long‐term effects after therapy ended or any unwanted effects. What did we do? We searched for studies in which people with dementia were randomly allocated to receive music‐based therapy (of at least five sessions) or to a comparison group with no activities or different activities. We combined the results of the studies to estimate the effects of music‐based therapy as accurately as possible. We also rated our level of confidence in the findings. What did we find? We found 30 studies performed in 15 countries. The studies involved 1720 people with dementia of varying severity. In most of the studies, the participants lived in nursing homes. Seven studies delivered the music‐based therapy to individuals; the other studies delivered the intervention to groups. We were able to use results from 28 studies involving 1366 people with dementia for one or more outcomes at the end of treatment. Ten studies contributed information about long‐term results. Main results At the end of treatment Music‐based therapy probably improves depression and may improve overall behavioural problems, compared with providing usual care. Music‐based therapy may improve social behaviour compared to other activities. We were less confident about the effects of music‐based therapy on anxiety compared to other activities. The available evidence does not suggest any benefit of music‐based therapy for emotional well‐being (including quality of life), agitation and aggression, or cognition, but the evidence is limited and there is uncertainty about this. In the longer term Some studies measured outcomes four weeks or more after treatment ended. We did not find any lasting effects, but there were fewer results measured in the longer term, and we are uncertain about this evidence. Further studies are likely to have a significant impact on what we know about the effects of music‐based therapy for people with dementia, so it is important that research continues. What are the limitations of the evidence? There was variation in the quality of the studies and how well they were reported. In all studies, participants and personnel might have known which treatment participants were getting, and in some, the assessors might have known this as well. This could have affected the results. Regarding effects at the end of music‐based therapy, we are moderately confident in the evidence for the beneficial effect on depression compared to usual care. We have little confidence in the effects or lack of effects on any of the other outcomes. Adverse effects were rarely reported. How up to date is this evidence? This review updates our previous review. We added eight new studies and reached new conclusions. The evidence is current to 30 November 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "van der Steen, JT, van der Wouden, JC, Methley, AM, Smaling, HJ A, Vink, AC, Bruinsma, MS", "articleTypes": [], "doi": "10.1002/14651858.CD003477.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.789Z" }, { "id": "10e0c3b8-1d22-45d7-bfc4-1801954b0fd6", "pmid": "", "title": "Antibiotics prior to amniotomy for reducing infectious morbidity in mother and infant", "imported": false, "abstract": "Abstract - Background Amniotomy (the deliberate rupture of membranes) was described almost two centuries ago and since then has been used both for induction and augmentation of labour ‐ which are common obstetric practices. Trends have shown a rise in the induction rates over the last decade and data suggest that the rate of labour inductions is increasing faster than the rate of pregnancy complications. Recent years have seen the emergence of a variety of other methods of induction of labour but amniotomy combined with oxytocin infusion remains the most commonly used method of augmentation of labour. The newer agents for induction are expensive and in resource‐poor settings amniotomy is still the chosen method for both induction and augmentation. As with any invasive procedure amniotomy can lead to infection, ascending from the vagina into the uterine cavity and can contribute significantly to both maternal and neonatal infectious morbidity. Objectives The objective of this review was to evaluate the prophylactic use of antibiotics versus placebo or no treatment prior to amniotomy on maternal and neonatal infectious morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014), the International Clinical Trials Registry Platform ( ICTRP ) and ClinicalTrials.gov (12 September 2014). Selection criteria Randomised controlled trials or cluster‐randomised trials comparing antibiotics prior to amniotomy versus placebo (or no treatment) were eligible for inclusion in this review but none were identified. Quasi‐randomised trials or cross‐over trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed one trial report for inclusion. In future updates of this review, two review authors will independently assess risk of bias and carry out data extraction. Data will be checked for accuracy. Main results We identified one trial report but this was excluded. No studies met the inclusion criteria for this review. Authors' conclusions High‐quality trials are needed to justify or refute the routine use of antibiotics at amniotomy for prevention of infection in the mother and infant. Future studies should be conducted, especially in resource‐constrained settings where amniotomy is still used as a means of induction of labour, in order to evaluate the routine use of antibiotics at amniotomy in these settings. Future research in this area should include important maternal and infant outcomes listed in this review and also consider cost effectiveness and side effects of antibiotic use, including the emergence of antibiotic‐resistant strains. Plain language summary Antibiotic use before amniotomy (artificially rupturing the membranes) for reducing infections in mother and infant The artificial rupture of the membranes (amniotomy) is a common obstetrical procedure. It may be done to either initiate or to augment labour, with or without oxytocin. This invasive procedure allows vaginal micro‐organisms access into the uterine cavity, which can in turn lead to infections in both the mother and the infant. A greater time interval between rupture of membranes and delivery, as with induction of labour, increases the chances of an infection. The purpose of this review was to evaluate the routine use of antibiotics immediately prior to amniotomy for both initiation and augmentation of labour using randomised controlled trials. However, our search only identified one trial which did not meet the inclusion criteria for this review. Consequently, there is no evidence to support or refute the routine use of antibiotics prior to amniotomy. Randomised controlled trials on this topic are needed, especially in resource‐constrained settings where amniotomy is still used as a means of inducing labour, to evaluate the routine use of antibiotics at amniotomy in such settings. Future research in this area should also consider cost effectiveness and side effects of antibiotic use including the emergence of antibiotic‐resistant strains.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ray, A; Ray, S", "articleTypes": [], "doi": "10.1002/14651858.CD010626.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "10f75e07-ebde-4f49-a9a8-30cd31dc9f0f", "pmid": "", "title": "Fish oil for induction of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Fish oil supplements, which are rich in n‐3 fatty acids, may reduce inflammation, decrease the need for anti‐inflammatory drugs, and promote normal weight gain in people with ulcerative colitis. Objectives This review evaluates the efficacy of fish oil for induction of remission in ulcerative colitis using all available randomised controlled trials. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, EMBASE, CINAHL, the database of ongoing trials and the reference lists of all publications of included or excluded trials were searched. Selection criteria Randomised controlled trials and quasi‐randomised controlled trials with active ulcerative colitis patients who were treated with fish oil. Data collection and analysis The reviewers performed study selection, assessment of methodological quality by using different approaches: including Cochrane assessment of allocation concealment and Jadad quality assessment score. Data extraction forms were used by the two reviewers to extract the data independently. Authors were contacted for additional information. Main results Six studies were included. Three were of cross‐over design and three were of parallel design. No data were pooled for analysis due to differences in outcomes and methodology among the included studies. One small study shows a positive benefit for induction of remission (RR 19.00; 95% CI 1.27 to 284.24). Some of the other included studies show some positive benefits for secondary outcomes. However, these results need to be interpreted with caution due to small study size and poor study quality. Authors' conclusions The current data does not allow for a definitive conclusion regarding the efficacy of fish oil. There is no adequate information to make recommendations for clinical practice. More research is required. Plain language summary Fish oil for the treatment of active ulcerative colitis Ulcerative colitis is an inflammation of the large intestine that causes diarrhea, abdominal pain, rectal bleeding and fever. Since there is no cure for the disease the aim of treatment is to cause a reduction of the unpleasant and painful signs and symptoms. Current, proven, treatment options for active ulcerative colitis include corticosteroids, aminosalicylates, immunosuppressive and biological agents. However, these drugs can cause side effects. New treatments which cause fewer side effects are being sought. Fish oil, which is rich in omega‐3 fatty acids may reduce inflammation and decrease the need for anti‐inflammatory drugs in patients with ulcerative colitis. Six studies looking at the effects of fish oil in active ulcerative colitis were included in the review. Study quality was mostly poor. One small study showed a positive benefit for the treatment of active ulcerative colitis. However, this result should be interpreted with caution due to small study size and poor study quality. Due to limited data there is not enough information available to determine whether fish oil treatment is effective for induction of remission in ulcerative colitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "De Ley, M, de Vos, R, Hommes, DW, Stokkers, PC", "articleTypes": [], "doi": "10.1002/14651858.CD005986.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.754Z" }, { "id": "10f976c3-ed3a-4f0d-80be-6eef8c31455e", "pmid": "", "title": "Calcitonin for metastatic bone pain", "imported": false, "abstract": "Abstract - Background Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastases. The hormone calcitonin has the potential to relieve pain and also retain bone density, thus reducing the risk of fractures. This review is an update of a previously published review in the Cochrane Library (2003, Issue 3) which was also updated in 2006 (Issue 3) and in 2011 (Issue 9). Objectives The main objective of the review is to determine the effectiveness of calcitonin to reduce metastatic bone pain in patients with painful bone metastases. Secondary objectives are to assess the benefits of calcitonin in reducing the incidence of bone complications (hypercalcemia, fractures and nervous compression) and improving patient survival, and to report any adverse effects of the treatment. Search methods We updated the electronic searches in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2015. We also searched registers of clinical trials in progress up to February 2015. Selection criteria We included studies if they were randomised, double‐blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. Data collection and analysis Two independent review authors performed study selection and data extraction. Only two studies (90 participants) were eligible for inclusion in the review and therefore meta‐analysis of the data was not possible. We performed intention‐to‐treat (ITT) analysis by imputing all missing values as adverse effects. Main results The overall quality of the evidence was very low. In this update no new studies were identified for inclusion; one additional study was excluded. Of the two small included studies, one study showed a non‐significant effect of calcitonin on the number of patients with complete pain relief (risk ratio (RR) 2.50; 95% confidence interval (CI) 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; 95% CI 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases, for improving quality of life or for patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.50; 95% CI 0.77 to 15.88). Authors' conclusions Current available research evidence is of very low quality and there is a lack of evidence to support the use of calcitonin for managing bone pain from bone metastases. Since the last version of this review, we did not identify any additional studies. Plain language summary Calcitonin used to treat metastatic bone pain People who have cancer which has spread to their bones and the nerves adjacent to the bones often suffer severe pain. There are several treatments to help relieve this pain: radiotherapy, analgesic drugs (pain killers) such as opioids, and bone‐modulating drugs such as bisphosphonates and calcitonin. Calcitonin has the potential to relieve pain and maintain bone strength, thus reducing the risk of broken bones. This review looked at the effectiveness of calcitonin for controlling pain from bone metastases. However, only two studies were found with very low quality evidence to support the use of calcitonin for patients suffering from bone pain. We updated the review in 2015 and did not find any more studies. There were slightly more side effects for the patients given calcitonin. Unless new studies provide additional relevant information about this treatment, other therapeutic approaches should be considered.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Martinez-Zapata, MJ; Roqué i Figuls, M; Català, E; Roman, Y; Alonso Coello, P", "articleTypes": [], "doi": "10.1002/14651858.CD003223.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "10fe476f-f6c4-4d2b-a5ab-7ed70e904ec6", "pmid": "", "title": "Nutritional support in children and young people with cancer undergoing chemotherapy", "imported": false, "abstract": "Abstract - Background It is well documented that malnutrition is a common complication of paediatric malignancy and its treatment. Malnutrition can often be a consequence of cancer itself or a result of chemotherapy. Nutritional support aims to reverse malnutrition seen at diagnosis, prevent malnutrition associated with treatment and promote weight gain and growth. The most effective and safe forms of nutritional support in children and young people with cancer are not known. Objectives To determine the effects of any form of parenteral (PN) or enteral (EN) nutritional support, excluding vitamin supplementation and micronutrient supplementation, in children and young people with cancer undergoing chemotherapy and to determine the effect of the nutritional content of PN and EN. This is an update of a previous Cochrane review. Search methods We searched the following databases for the initial review: CENTRAL ( The Cochrane Library , Issue 2, 2009), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), CINAHL (1982 to 2006), the National Research Register (2007) and Dissertations & Theses (2007). Experts in the field were also contacted for information on relevant trials. For this update, we searched the same electronic databases from 2006 to September 2013. We also scrutinised the reference lists of included articles to identify additional trials. Selection criteria Randomised or quasi‐randomised controlled trials comparing any form of nutritional support with another, or control, in children or young people with cancer undergoing chemotherapy. Data collection and analysis Two authors independently selected trials. At least two authors independently assessed quality and extracted data. We contacted trialists for missing information. Main results The current review included the eight trials from the initial review and six new trials which randomised 595 participants (< 21 years of age) with leukaemias or solid tumours undergoing chemotherapy. The trials were all of low quality with the exception of two of the trials looking at glutamine supplementation. One small trial found that compared to EN, PN significantly increased weight (mean difference (MD) 4.12, 95% CI 1.91 to 6.33), serum albumin levels (MD 0.70, 95% CI 0.14 to 1.26), calorie intake (MD 22.00, 95% CI 5.12 to 38.88) and protein intake (MD 0.80, 95% CI 0.45 to 1.15). One trial comparing peripheral PN and EN with central PN found that mean daily weight gain (MD ‐27.00, 95% CI ‐43.32 to ‐10.68) and energy intake (MD ‐15.00, 95% CI ‐26.81 to ‐3.19) were significantly less for the peripheral PN and EN group, whereas mean change in serum albumin was significantly greater for that group (MD 0.47, 95% CI 0.13 to 0.81, P = 0.008). Another trial with few participants found an increase in mean energy intake (% recommended daily amount) in children fed an energy dense feed compared to a standard calorie feed (MD +28%, 95% CI 17% to 39%). Three studies looked at glutamine supplementation. The evidence suggesting that glutamine reduces severity of mucositis was not statistically significant in two studies (RR 0.64, 95% CI 0.19 to 2.2 and RR 0.85, 95% CI 0.66 to 1.1) and differences in reduction of infection rates were also not significant in two studies (RR 1.0, 95% CI 0.72 to 1.4 and RR 0.98, 95% CI 0.63 to 1.51). Only one study compared olive oil based PN to standard lipid containing PN. Despite similar calorie contents in both feeds, the standard lipid formula lead to greater weight gain (MD ‐0.34 z‐scores, 95% CI ‐0.68 to 0.00). A single study compared standard EN with fructooligosaccharide containing EN. There was no difference in weight gain between groups (mean difference ‐0.12, 95% CI ‐0.57 to 0.33), with adverse effects (nausea) occurring equally between the groups (RR 0.92, 95% CI 0.48 to 1.74). Authors' conclusions There is limited evidence from individual trials to suggest that PN is more effective than EN in well‐nourished children and young people with cancer undergoing chemotherapy. The evidence for other methods of nutritional support remains unclear. Limited evidence suggests an energy dense feed increases mean daily energy intake and has a positive effect on weight gain. Evidence suggesting glutamine supplementation reduces incidence and severity of mucositis, infection rates and length of hospital stay is not statistically significant. Further research, incorporating larger sample sizes and rigorous methodology utilising valid and reliable outcome measures, is essential. Plain language summary Nutritional support in children and young people with cancer undergoing chemotherapy The provision of safe, appropriate and effective nutritional support for children and young people undergoing treatment for cancer is now well recognised as an important part of their care. It may help to reverse malnutrition seen at diagnosis, prevent malnutrition associated with the cancer, promote weight gain and growth and improve quality of life. Nutritional support may be provided by one of two methods: intravenous nutritional liquids delivered through a central or peripheral vein which bypass the gut (parenteral nutrition); or nutritional liquids or solids that pass through any part of the gut, regardless of method of delivery (e.g. orally or via a tube; enteral nutrition). We found evidence from one small trial to suggest that parenteral nutrition may result in an increase in weight, serum albumin levels and calorie and protein intake when compared to enteral nutrition (usual food intake). However, the effect of other methods of delivery of nutritional support remains unclear. Results from another small study suggested that the use of energy dense enteral feeds resulted in greater average daily energy intake and subsequently improved weight gain. Three studies looked at glutamine supplementation and did not show a benefit from its use. One study looked at the effect of using olive oil based parenteral feeds rather than those containing standard fats and found that it lead to less weight gain. One study considered the effect of adding fructooligosaccharide to enteral feeds and found that it did not effect the amount of weight gained or how often participants felt nauseated. No studies were identified that compared the nutritional content in either the PN or EN groups of studies. The trials were all of low quality and very different in terms of outcome measures used. In the future, much larger, rigorously conducted trials are needed in order to address this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Ward, EJ; Henry, LM; Friend, AJ; Wilkins, S; Phillips, RS", "articleTypes": [], "doi": "10.1002/14651858.CD003298.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "11015f0c-e1ea-4583-ba1b-95be27c200ba", "pmid": "", "title": "Preoperative fasting for preventing perioperative complications in children", "imported": false, "abstract": "Abstract - Background Children, like adults, are required to fast before general anaesthesia with the aim of reducing the volume and acidity of their stomach contents. It is thought that fasting reduces the risk of regurgitation and aspiration of gastric contents during surgery. Recent developments have encouraged a shift from the standard 'nil‐by‐mouth‐from‐midnight' fasting policy to more relaxed regimens. Practice has been slow to change due to questions relating to the duration of a total fast, the type and amount of intake permitted. Objectives To systematically assess the effects of different fasting regimens (duration, type and volume of permitted intake) and the impact on perioperative complications and patient well being (aspiration, regurgitation, related morbidity, thirst, hunger, pain, comfort, behaviour, nausea and vomiting) in children. Search methods We searched Cochrane Wounds Group Specialised Register (searched 25/6/09), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 2 2009), Ovid MEDLINE (1950 to June Week 2 2009), Ovid EMBASE (1980 to 2009 Week 25), EBSCO CINAHL (1982 to June Week 3 2009), the National Research Register, relevant conference proceedings and article reference lists and contacted experts. Selection criteria Randomised and quasi randomised controlled trials of preoperative fasting regimens for children were identified. Data collection and analysis Data extraction and trial quality assessment was conducted independently by three authors. Trial authors were contacted for additional information including adverse events. Main results This first update of the review identified two additional eligible studies, bringing the total number of included studies to 25 (forty seven randomised controlled comparisons involving 2543 children considered to be at normal risk of regurgitation or aspiration during anaesthesia). Only one incidence of aspiration and regurgitation was reported. Children permitted fluids up to 120 minutes preoperatively were not found to experience higher gastric volumes or lower gastric pH values than those who fasted. The children permitted fluids were less thirsty and hungry, better behaved and more comfortable than those who fasted. Clear fluids preoperatively did not result in a clinically important difference in children's gastric volume or pH. Evidence relating to the preoperative intake of milk was sparse. The volume of fluid permitted during the preoperative period did not appear to impact on children's intraoperative gastric volume or pH contents. Authors' conclusions There is no evidence that children who are denied oral fluids for more than six hours preoperatively benefit in terms of intraoperative gastric volume and pH compared with children permitted unlimited fluids up to two hours preoperatively. Children permitted fluids have a more comfortable preoperative experience in terms of thirst and hunger. This evidence applies only to children who are considered to be at normal risk of aspiration/regurgitation during anaesthesia. Plain language summary Preoperative fasting for children to prevent complications during surgery General anaesthetics inhibit the protective reflexes that stop the stomach contents reaching the lungs. In order to prevent the inadvertent inhalation of stomach contents, children are often advised to have nothing to eat or drink from the midnight before surgery. However, the review of trials found that drinking clear fluids up to a few hours before surgery did not increase the risk of regurgitation during or after surgery. Indeed there is an added benefit of a more comfortable preoperative experience in terms of thirst and hunger. Some children are considered more likely to regurgitate under anaesthetic, including those who are obese or have stomach disorders. More research is needed to determine whether these children can also safely drink up to a few hours before surgery.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brady, MC; Kinn, S; Ness, V; O'Rourke, K; Randhawa, N; Stuart, P", "articleTypes": [], "doi": "10.1002/14651858.CD005285.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "1103612e-ff26-4acf-9159-84f1b6f68db9", "pmid": "", "title": "Horticultural therapy for schizophrenia", "imported": false, "abstract": "Abstract - Background Horticultural therapy is defined as the process of utilising fruits, vegetables, flowers and plants facilitated by a trained therapist or healthcare provider, to achieve specific treatment goals or to simply improve a person's well‐being. It can be used for therapy or rehabilitation programs for cognitive, physical, social, emotional, and recreational benefits, thus improving the person's body, mind and spirit. Between 5% to 15% of people with schizophrenia continue to experience symptoms in spite of medication, and may also develop undesirable adverse effects, horticultural therapy may be of value for these people. Objectives To evaluate the effects of horticultural therapy for people with schizophrenia or schizophrenia‐like illnesses compared with standard care or other additional psychosocial interventions. Search methods We searched the Cochrane Schizophrenia Group Trials Register (Janurary 2013) and supplemented this by contacting relevant study authors, and manually searching reference lists. Selection criteria We included one randomised controlled trial (RCT) comparing horticultural therapy plus standard care with standard care alone for people with schizophrenia. Data collection and analysis We reliably selected, quality assessed and extracted data. For continuous outcomes, we calculated a mean difference (MD) and for binary outcomes we calculated risk ratio (RR), both with 95% confidence intervals (CI). We assessed risk of bias and created a 'Summary of findings' table using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. Main results We included one single blind study (total n = 24). The overall risk of bias in the study was considered to be unclear although the randomisation was adequate. It compared a package of horticultural therapy which consisted of one hour per day of horticultural activity plus standard care with standard care alone over two weeks (10 consecutive days) with no long‐term follow‐up. Only two people were lost to follow‐up in the study, both in the horticultural therapy group (1 RCT n = 24,RR 5.00 95% CI 0.27 to 94.34, very low quality evidence ). There was no clear evidence of a difference in Personal Wellbeing Index (PWI‐C) change scores between groups, however confidence intervals were wide (1 RCT n = 22, MD ‐0.90 95% CI ‐10.35 to 8.55, very low quality evidence ). At the end of treatment, the Depression Anxiety Stress Scale (DASS21) change scores in horticultural therapy group were greater than that in the control group (1 RCT n = 22, MD ‐23.70 CI ‐35.37 to ‐ 12.03, very low quality evidence). The only included study did not report on adverse effects of interventions. Authors' conclusions Based on the current very low quality data, there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. This therapy remains unproven and more and larger randomised trials are needed to increase high quality evidence in this area. Plain language summary Gardening activity as a therapy for schizophrenia Horticultural therapy is based on the therapeutic value of participating in garden activities such as growing fruit or vegetables and/or flowers. Gardening is thought to improve people's well‐being through being a recreational and sociable activity which may lead to improvements in people's thinking, new friendships and more positive emotions. The benefits of gardening can also apply to people with serious mental illness such as schizophrenia. Gardening reduces stress, which is important because stress can often lead to mental illness. Gardening is also hard work and a physical activity, and so motivates people with mental illness who often feel tired and apathetic. Weight gain is common for people with mental illness and gardening is good physical exercise. Since 5% to 15% of people with schizophrenia experience symptoms in spite of taking antipsychotic drugs and also because these drugs have debilitating side effects, horticultural therapy may be of value to these people. This review focuses on the effects of horticultural therapy for people with schizophrenia. An electronic search for relevant randomised trials was run in January 2013. Only one trial was included, it randomised a total of 24 people with schizophrenia to received either their standard care plus horticultural therapy or standard care only. The trial only lasted 2 weeks (10 consecutive days) with no long‐term follow‐up. There are few results and the quality of evidence was rated by the review authors to be very low quality. Some of the information from this one study favoured horticultural therapy but there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. More large, better conducted and reported trials are required to determine the effectiveness and benefits of horticultural therapy. This plain language summary has been written by a consumer Ben Gray, Service User and Service User Expert, Rethink Mental Illness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Liu, Y; Li, B; Sampson, SJ; Roberts, S; Zhang, G; Wu, W", "articleTypes": [], "doi": "10.1002/14651858.CD009413.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "110b1335-b5d4-4b3f-9420-f7070326d942", "pmid": "", "title": "Multisensory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Multisensory stimulation is a structured, developmentally appropriate intervention that provides simultaneous or sequential stimulation of two or more senses (e.g. tactile, auditory, visual, or vestibular) in a controlled and non‐stressful manner, with the aim of supporting early neurodevelopment in preterm infants. It has the potential to enhance physiological regulation in preterm infants by stabilizing key functions, such as respiratory patterns, heart rate, and oxygen saturation; reducing the need for respiratory support; and improving feeding performance and sleep regulation. Targeted multisensory interventions have also been associated with improved neurodevelopmental outcomes, including enhanced psychomotor development and visual function. Objectives To assess the benefits and harms of multisensory stimulation compared to any single sensory intervention or standard care on major neurodevelopmental disability, mortality, and growth in preterm infants. Search methods We searched CENTRAL, MEDLINE, Embase, Emcare, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 28 November 2025. We checked reference lists of included trials, and systematic reviews on sensory interventions. Eligibility criteria We included 18 randomized controlled trials (RCTs) comparing multisensory stimulation in preterm infants with no intervention (placebo or standard care), and one RCT comparing multisensory stimulation with single‐sense stimulation (tactile stimulation). Outcomes Our critical outcomes were major neurodevelopmental disability at 18 to 24 months: cerebral palsy (CP), developmental delay, intellectual impairment, blindness, sensorineural deafness; death during initial hospitalization; and total weight gain (grams), assessed at discharge. When comparing multisensory stimulation with single‐sense intervention, we also included weight gain during the intervention, an outcome added during the post‐hoc analysis. Important outcomes were duration of hospital stay, of NICU stay, and of respiratory support; and time until full oral feeding. Risk of bias We used the Cochrane tool, RoB 2. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RR) for dichotomous data, and mean differences (MDs) for continuous data, each with its 95% confidence intervals (CIs). We assessed statistical heterogeneity by calculating the I 2 statistic when we included more than two trials in a meta‐analysis. We evaluated the certainty of evidence using GRADE. Included studies We included 19 trials (1554 newborn infants): 18 studies compared multisensory stimulation with standard care; one compared multisensory stimulation with single‐sensory stimulation (tactile). In 10 studies, the primary aim was to assess the neurobehavioral outcomes of multisensory stimulation on preterm neo­nates. The other nine studies aimed to assess the impact of multisensory stimulation on weight gain during the intervention, weight gain until hospital discharge, length of neonatal intensive care unit (NICU) stay, length of hospital stay, time until full oral feeding, length of respiratory support, or a combination. In the abstract we report results for the critical outcomes only. We identified 13 ongoing studies. Four studies are awaiting assessment. Synthesis of results Multisensory stimulation compared to standard care No studies reported on these major neurodevelopmental disabilities, assessed at 18 to 24 months' corrected age (CA): developmental delay, intellectual impairment, blindness, or sensorineural deafness. One study reported on rates of CP at 12 months of age. The evidence is very uncertain about the effect of multisensory stimulation on CP (RR 0.67, 95% CI 0.28 to 1.58; I² not applicable; 1 study, 18 participants; very low‐certainty evidence). The evidence suggests that multisensory stimulation may result in little to no difference in death during initial hospitalization (RR 0.97, 95% CI 0.54 to 1.73; I² not applicable; 1 study, 395 participants; low‐certainty evidence). Multisensory stimulation may increase total weight gain prior to discharge (MD 72.67, 95% CI 68.23 to 77.12; I² = 0%; 3 studies, 474 participants; low‐certainty evidence). Multisensory stimulation compared to single‐sense (tactile) stimulation No studies reported on major neurodevelopmental disability, assessed at 18 to 24 months' CA, or death during initial hospitalization. The evidence is very uncertain about the effect of multisensory stimulation compared to tactile stimulation on weight gain during the intervention (MD −175.00, 95% CI −376.60 to 26.60; I² not applicable; 1 study, 20 participants; very low‐certainty evidence). The certainty of the evidence was low to very low across outcomes, primarily due to risk of bias, imprecision from small sample sizes and wide CIs, and in some cases, inconsistency. The evidence base was also limited by the lack of reporting of relevant outcomes and reliance on surrogate outcomes or shorter follow‐up periods. Authors' conclusions The available evidence on multisensory stimulation in preterm infants is limited and of low to very low certainty. No included studies reported on major neurodevelopmental disabilities at 18 to 24 months’ CA, which represented a critical outcome for this review. Evidence regarding the effect of multisensory stimulation on CP is very uncertain, as it is based on a single small study reporting a surrogate outcome at 12 months. Multisensory stimulation may result in little to no difference in mortality during the initial hospitalization. It may increase total weight gain prior to discharge. However, the clinical significance of this finding is uncertain, particularly given the low certainty of the evidence and the multifactorial nature of growth in preterm infants. The evidence is very uncertain about the effect of multisensory stimulation compared to single‐sense (tactile) stimulation on weight gain during the intervention. The only included study did not report major neurodevelopmental disabilities at 18 to 24 months’ CA, mortality during the initial hospitalization, or total weight gain prior to discharge, which represented the critical outcomes for this review. Overall, the current evidence does not allow firm conclusions about the effectiveness of multisensory stimulation in promoting development or preventing morbidity in preterm infants. Future studies on multisensory stimulation should use more rigorous designs, larger samples, and report interventions using the template for intervention description and replication (TIDieR) checklist to ensure transparency. They should also report essential outcomes, such as neonatal death, major neurodevelopmental disabilities, length of hospital and NICU stay, time to full oral feeding, duration of respiratory support, and weight gain, to better assess the long‑term effects of multisensory stimulation in preterm infants. Funding This Cochrane review had no dedicated funding . Registration Protocol available via DOI: 10.1002/14651858.CD016073 Plain language summary Does stimulating multiple senses (such as hearing, touch, taste, smell) of premature babies improve growth and healthy development or reduce the risk of death? Key messages Multisensory stimulation (the stimulation of more than one sense at a time) may support growth in preterm infants by increasing weight gain before discharge from the hospital. However, it is unclear whether it improves longer‐term developmental outcomes or reduces the risk of death, as the available evidence is limited and uncertain. When compared with stimulation of a single sense (touch alone), it is uncertain whether multisensory stimulation is better than touch alone at increasing weight gain during the intervention. What is multisensory stimulation, and how does it work? Multisensory stimulation means giving premature babies experiences that activate two or more of their senses. The senses involved and the types of stimulation used include the sense of: hearing — a parent’s voice, singing, or calming music; touch — massage or passive movements; smell and taste — a mother’s scent or breast milk; balance — gentle rocking or changing the baby's position; sight — soft, cycled lighting and simple shapes, colors, or moving patterns. During the newborn period, the brain grows very quickly. Providing positive sensory experiences at this time may help premature babies in several ways, such as supporting their memory, helping them regulate emotions, and improving early learning and development. What did we want to find out? We wanted to find out whether multisensory stimulation compared with single‑sense stimulation or standard care helps premature babies survive, grow, stay healthy, and develop well. Specifically, we wanted to find out whether multisensory stimulation might: reduce the number of babies with severe developmental problems at 18 to 24 months' age, such as cerebral palsy, delay in development, limitations in mental abilities, blindness, or deafness; reduce the number of babies who die during the newborn period or before hospital discharge; increase the amount of weight the infants gained by the time they left the hospital. We also looked at other important measures of the babies’ health, including: how long they stayed in the hospital or in the neonatal intensive care unit (NICU); how long it took before they could feed fully by mouth; how many days they needed breathing support. What did we do? We searched for studies in which multisensory stimulation began before the baby was discharged from the hospital after birth, and which compared multisensory stimulation with: no intervention or standard care; single‐sense stimulation. We summarized the results of the studies and rated our confidence in the evidence, based on factors, such as the size of the study (number of babies enrolled) and the methods used. What did we find? We included 19 studies (1544 premature babies). Eighteen of these studies compared multisensory stimulation with standard care, and one study compared multisensory stimulation with a single‑sense intervention (touch only). In 10 studies, the main goal was to examine how multisensory stimulation affects babies’ brain and behavioral development. The remaining nine studies focused on weight gain during the intervention, weight gain prior to hospital discharge, length of stay in the NICU, total length of hospital stay, time until the baby could feed fully by mouth, number of days the baby needed breathing support, or a combination of these measures. We also found 13 ongoing studies and 4 studies that have not yet been fully assessed. They may give us more useful information in the future. Main results None of the studies that compared multisensory stimulation with no intervention reported on the critical outcome major developmental disability at 18 to 24 months' corrected age. Only one study assessed a related outcome, cerebral palsy at 12 months. Because this study was very small, the evidence is very uncertain about whether multisensory stimulation modifies the risk of cerebral palsy. Multisensory stimulation may result in little or no difference in death before hospital discharge, although it was reported in only one large study. It may increase total weight gain prior to discharge, but the observed effect is small, and its clinical significance remains uncertain. Compared with single‐sense stimulation (touch), we could not tell whether multisensory stimulation helped babies gain more weight during the intervention. The only study we found comparing a multi‐ to single‐sensory intervention did not report the critical outcomes, such as major developmental problems at 18 to 24 months' corrected age, death during the first hospital stay, or total weight gain prior to discharge. What are the limitations of the evidence? We have limited confidence in these findings because many of the studies were small or not well‐designed. Several studies did not report the outcomes we were most interested in or did not provide enough data for us to analyze. Because of these limitations, the true effects of multisensory stimulation may be different from what we found. How up‐to‐date is this evidence? The evidence is up‐to‐date to 28 November 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Wróblewska-Seniuk, K, Lenells, M, Prescott, MG, Fiander, M, Soll, RF, Bruschettini, M, supported by Cochrane Sweden and Cochrane Neonatal,", "articleTypes": [], "doi": "10.1002/14651858.CD016073.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.729Z" }, { "id": "11285c61-c621-47d5-91f5-d8f996aa15ba", "pmid": "", "title": "Antibiotics to prevent complications following tooth extractions", "imported": false, "abstract": "Abstract - Background The most frequent indications for tooth extractions, generally performed by general dental practitioners, are dental caries and periodontal infections. Systemic antibiotics may be prescribed to patients undergoing extractions to prevent complications due to infection. This is an update of a review first published in 2012. Objectives To determine the effect of systemic antibiotic prophylaxis on the prevention of infectious complications following tooth extractions. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 16 April 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 3), MEDLINE Ovid (1946 to 16 April 2020), Embase Ovid (1980 to 16 April 2020), and LILACS (1982 to 16 April 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised, double‐blind, placebo‐controlled trials of systemic antibiotic prophylaxis in patients undergoing tooth extraction(s) for any indication. Data collection and analysis At least two review authors independently performed data extraction and 'Risk of bias' assessment for the included studies. We contacted trial authors for further details where these were unclear. For dichotomous outcomes, we calculated risk ratios (RR) and 95% confidence intervals (CI) using random‐effects models. For continuous outcomes, we used mean differences (MD) with 95% CI using random‐effects models. We examined potential sources of heterogeneity. We assessed the certainty of the body of evidence for key outcomes as high, moderate, low, or very low, using the GRADE approach. Main results We included 23 trials that randomised approximately 3206 participants (2583 analysed) to prophylactic antibiotics or placebo. Although general dentists perform dental extractions because of severe dental caries or periodontal infection, only one of the trials evaluated the role of antibiotic prophylaxis in groups of patients affected by those clinical conditions. We assessed 16 trials as being at high risk of bias, three at low risk, and four as unclear. Compared to placebo, antibiotics may reduce the risk of postsurgical infectious complications in patients undergoing third molar extractions by approximately 66% (RR 0.34, 95% CI 0.19 to 0.64; 1728 participants; 12 studies; low‐certainty evidence), which means that 19 people (95% CI 15 to 34) need to be treated with antibiotics to prevent one infection following extraction of impacted wisdom teeth. Antibiotics may also reduce the risk of dry socket by 34% (RR 0.66, 95% CI 0.45 to 0.97; 1882 participants; 13 studies; low‐certainty evidence), which means that 46 people (95% CI 29 to 62) need to take antibiotics to prevent one case of dry socket following extraction of impacted wisdom teeth. The evidence for our other outcomes is uncertain: pain, whether measured dichotomously as presence or absence (RR 0.59, 95% CI 0.31 to 1.12; 675 participants; 3 studies) or continuously using a visual analogue scale (0‐to‐10‐centimetre scale, where 0 is no pain) (MD −0.26, 95% CI −0.59 to 0.07; 422 participants; 4 studies); fever (RR 0.66, 95% CI 0.24 to 1.79; 475 participants; 4 studies); and adverse effects, which were mild and transient (RR 1.46, 95% CI 0.81 to 2.64; 1277 participants; 8 studies) (very low‐certainty evidence). We found no clear evidence that the timing of antibiotic administration (preoperative, postoperative, or both) was important. The included studies enrolled a subset of patients undergoing dental extractions, that is healthy people who had surgical extraction of third molars. Consequently, the results of this review may not be generalisable to all people undergoing tooth extractions. Authors' conclusions The vast majority (21 out of 23) of the trials included in this review included only healthy patients undergoing extraction of impacted third molars, often performed by oral surgeons. None of the studies evaluated tooth extraction in immunocompromised patients. We found low‐certainty evidence that prophylactic antibiotics may reduce the risk of infection and dry socket following third molar extraction when compared to placebo, and very low‐certainty evidence of no increase in the risk of adverse effects. On average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection. It is unclear whether the evidence in this review is generalisable to patients with concomitant illnesses or patients at a higher risk of infection. Due to the increasing prevalence of bacteria that are resistant to antibiotic treatment, clinicians should evaluate if and when to prescribe prophylactic antibiotic therapy before a dental extraction for each patient on the basis of the patient's clinical conditions (healthy or affected by systemic pathology) and level of risk from infective complications. Immunocompromised patients, in particular, need an individualised approach in consultation with their treating medical specialist. Plain language summary Are antibiotics an effective way to prevent infection following tooth removal? What is the problem? Teeth that are affected by decay or gum disease or painful wisdom teeth are often removed (extracted) by dentists. Tooth extraction is a surgical procedure that leaves a wound in the mouth that can become infected. Infection can lead to swelling, pain, development of pus, fever, as well as ‘dry socket’ (where the tooth socket is not filled by a blood clot, and there is severe pain and bad odour). These complications are unpleasant for patients and may cause difficulty with chewing, speaking, and teeth cleaning, and may even result in days off work or study. Treatment of infection is generally simple and involves drainage of the infection from the wound and patients receiving antibiotics. Why is this question important? Antibiotics work by killing the bacteria that cause infections, or by slowing their growth. However, some infections clear up by themselves. Taking antibiotics unnecessarily may stop them working effectively in future. This ‘antimicrobial resistance’ is a growing problem throughout the world. Antibiotics may also cause unwanted effects such as diarrhoea and nausea. Some patients may be allergic to antibiotics, and antibiotics may not mix well with other medicines. Dentists frequently give patients antibiotics at the time of the extraction as a precaution in order to prevent infection occurring in the first place. This may be unnecessary and may lead to unwanted effects. What did we want to find out? We wanted to know whether giving antibiotics as a preventive measure reduces infection and other complications after tooth extraction. We also wanted to understand whether antibiotics work differently in healthy people compared with people with health conditions such as diabetes or HIV. What did we do? We searched for studies that assessed the effectiveness of antibiotics compared to placebo (sham medicine), given when no infection was present in order to prevent infection following tooth extraction. Studies could include people of any age undergoing tooth extraction. Where possible, we pooled the studies’ results and analysed them together. We also assessed the quality of each study to judge the reliability (certainty) of evidence of individual studies and the body of evidence. What we found We found 23 included studies with a total of more than 3200 participants, who received either antibiotics (of different kinds and dosages) or placebo immediately before or just after tooth extraction, or both. Four studies were conducted in Spain, three each in Brazil, Sweden, and the UK, two in India, and one each in Colombia, Denmark, Finland, France, Poland, New Zealand, Nigeria, and the USA. All but one study included healthy patients in their 20s. Twenty‐one studies assessed the removal of wisdom teeth in hospital dental departments, one assessed the removal of other teeth and one assessed complex oral surgery. None of the included studies assessed tooth extraction in general dental practice for the removal of decayed teeth. Main results Antibiotics given just before or just after surgery (or both) may reduce the risk of infection and dry socket after the removal of wisdom teeth by oral surgeons. However, antibiotics may cause more (generally brief and minor) unwanted effects for these patients. We found no evidence that antibiotics prevent pain, fever, swelling, or problems with restricted mouth opening in patients who have had wisdom teeth removed. There was no evidence to judge the effects of preventive antibiotics for extractions of severely decayed teeth, teeth in diseased gums, or extractions in patients who are sick or have low immunity to infection. How reliable are the results? Our confidence in the results is limited because we had concerns about aspects of the design and reporting of all of the included studies. What does this mean? We did not find studies in patients with depressed immune systems, other illnesses, or in young children or older patients, therefore the results of our review probably do not apply to people who may be at high risk of infection. Also, extractions were mainly carried out by oral surgeons, so the review may not apply to dentists working in general practice. Another concern, which cannot be assessed by clinical studies (i.e. studies testing new medical approaches in people), is that widespread use of antibiotics by people who do not have an infection is likely to contribute to the development of antimicrobial resistance. We concluded that antibiotics given to healthy people when they are having teeth extracted may help prevent infection, but the decision to use an antibiotic should be judged on an individual patient basis based on their state of health and possible complications of getting an infection. How up‐to‐date is this review? This is an updated review. The evidence is current to April 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lodi, G; Azzi, L; Varoni, EM; Pentenero, M; Del Fabbro, M; Carrassi, A; Sardella, A; Manfredi, M", "articleTypes": [], "doi": "10.1002/14651858.CD003811.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "11382306-ee4e-4487-bf42-a6087e6cf03c", "pmid": "", "title": "Fortification of staple foods with zinc for improving zinc status and other health outcomes in the general population", "imported": false, "abstract": "Abstract - Background Zinc deficiency is a global nutritional problem, particularly in children and women residing in settings where diets are cereal based and monotonous. It has several negative health consequences. Fortification of staple foods with zinc may be an effective strategy for preventing zinc deficiency and improving zinc‐related health outcomes. Objectives To evaluate the beneficial and adverse effects of fortification of staple foods with zinc on health‐related outcomes and biomarkers of zinc status in the general population. Search methods We searched the following databases in April 2015: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3 of 12, 2015, the Cochrane Library), MEDLINE & MEDLINE In Process (OVID) (1950 to 8 April 2015), EMBASE (OVID) (1974 to 8 April 2015), CINAHL (1982 to April 2015), Web of Science (1900 to 9 April 2015), BIOSIS (1969 to 9 April 2015), POPLINE (1970 to April 2015), AGRICOLA, OpenGrey, BiblioMap, and Trials Register of Promoting Health Interventions (TRoPHI), besides regional databases (April 2015) and theses. We also searched clinical trial registries (17 March 2015) and contacted relevant organisations (May 2014) in order to identify ongoing and unpublished studies. Selection criteria We included randomised controlled trials, randomised either at the level of the individual or cluster. We also included non‐randomised trials at the level of the individual if there was a concurrent comparison group. We included non‐randomised cluster trials and controlled before‐after studies only if there were at least two intervention sites and two control sites. Interventions included fortification (central/industrial) of staple foods (cereal flours, edible fats, sugar, condiments, seasonings, milk and beverages) with zinc for a minimum period of two weeks. Participants were members of the general population who were over two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies, and assessed the risk of bias of the included studies. Main results We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Four trials compared the effect of zinc‐fortified staple foods with unfortified foods (comparison 1), and four compared zinc‐fortified staple foods in combination with other nutrients/factors with the same foods containing other nutrients or factors without zinc (comparison 2). The interventions lasted between one and nine months. We categorised most trials as having unclear or high risk of bias for randomisation, but low risk of bias for blinding and attrition. None of the studies in comparison 1 reported data on zinc deficiency. Foods fortified with zinc increased the serum or plasma zinc levels in comparison to foods without added zinc (mean difference (MD) 2.12 µmol/L, 95% confidence interval (CI) 1.25 to 3.00 µmol/L; 3 studies; 158 participants; low‐quality evidence). Participants consuming foods fortified with zinc versus participants consuming the same food without zinc had similar risk of underweight (average risk ratio 3.10, 95% CI 0.52 to 18.38; 2 studies; 397 participants; low‐quality evidence) and stunting (risk ratio (RR) 0.88, 95% CI 0.36 to 2.13; 2 studies; 397 participants; low‐quality evidence). A single trial of addition of zinc to iron in wheat flour did not find a reduction in proportion of zinc deficiency (RR 0.17, 95% CI 0.01 to 3.94; very low‐quality evidence). We did not find a difference in serum or plasma zinc levels in participants consuming foods fortified with zinc plus other micronutrients when compared with participants consuming the same foods with micronutrients but no added zinc (MD 0.03 µmol/L, 95% CI ‐0.67 to 0.72 µmol/L; 4 studies; 250 participants; low‐quality evidence). No trial in comparison 2 provided information about underweight or stunting. There was no reported adverse effect of fortification of foods with zinc on indicators of iron or copper status. Authors' conclusions Fortification of foods with zinc may improve the serum zinc status of populations if zinc is the only micronutrient used for fortification. If zinc is added to food in combination with other micronutrients, it may make little or no difference to the serum zinc status. Effects of fortification of foods with zinc on other outcomes including zinc deficiency, children’s growth, cognition, work capacity of adults, or on haematological indicators are unknown. Given the small number of trials and participants in each trial, further investigation of these outcomes is required. Plain language summary The effects of fortification of common foods with zinc on health outcomes Background It is believed that zinc deficiency is widespread globally, particularly in children and women living in low‐ and middle‐income countries. Cereal‐based foods are rich in dietary fibre and phytates, which reduce absorption of zinc from the intestine. As people in low‐income households eat a lot of cereal‐based foods, they are more likely to develop zinc deficiency. Fortification of common staple foods with zinc alone or in combination with other vitamins and minerals has been proposed as an intervention to increase intake of zinc in populations who consume these foods. Review question We evaluated the effects of fortification of staple foods with zinc on blood zinc levels and health‐related outcomes in the general population above two years of age. Study characteristics We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Key results and quality of the evidence The effect of fortification of foods with zinc on incidence of zinc deficiency is uncertain. Fortification of foods with zinc may slightly improve the blood zinc levels of populations if zinc is the only micronutrient used for fortification. Zinc added to food in combination with other micronutrients may make little or no difference to blood zinc levels. The fortification of foods with zinc may make little or no difference on incidence of underweight or stunting. The effects of fortification of foods with zinc on other outcomes, including wasting and weight/height, are unknown. Fortification of foods with zinc does not seem to have any adverse effect on indicators of iron or copper status. Most studies included in this review involved a small number of participants and were judged to be at low or unclear risk of bias. There were also some inconsistencies in the results across different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Shah, D, Sachdev, HS, Gera, T, De‐Regil, LM, Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010697.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.770Z" }, { "id": "1140a65e-51b3-4e55-b326-a514817ba75b", "pmid": "", "title": "Supplementation with multiple micronutrients for breastfeeding women for improving outcomes for the mother and baby", "imported": false, "abstract": "Abstract - Background Globally, more than two billion people are estimated to be deficient in key vitamins and minerals, particularly iodine, iron and zinc. The majority of these people live in low‐income settings and are typically deficient in more than one micronutrient. However, micronutrient deficiency among breastfeeding mothers and their infants also remains an issue in high‐income settings, specifically among women who avoid meat and/or milk, women who may lack sufficient supplies of vitamin B12 and vitamin D, and/or women who are iron‐deficient. Young children, pregnant and lactating women are particularly vulnerable to micronutrient deficiencies. They not only have a relatively greater need for vitamins and minerals because of their physiological state, but are also more susceptible to the harmful consequences of deficiencies. Multiple‐micronutrient supplementation might be an option to solve these problems. Objectives The objective of this review was to evaluate the effects of multiple‐micronutrient supplementation in breastfeeding mothers on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. Selection criteria Randomised controlled trials of multiple‐micronutrient supplementation of three or more micronutrients versus placebo, no supplementation or supplementation with two or fewer micronutrients, irrespective of dosage of micronutrients, in breastfeeding mothers. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We found no studies that compared multiple‐micronutrient supplementation (with three or more micronutrients) versus supplementation with two or fewer micronutrients. Two small studies (involving a total of 52 women) were included. One study compared multiple micronutrients with placebo and the other study compared multiple micronutrients with a group who received no supplementation. The studies were carried out in Brazil (36 adolescent mothers) and the USA (16 women) and included women with a low socioeconomic status. A lack of information in the study reports meant that risk of bias could not be adequately assessed (unclear risk of bias for many domains). There were no quantitative data for any of this review's outcomes so meta‐analysis was not possible. Neither of the studies reported on the primary outcomes of interest in this review: maternal morbidity (febrile illness, respiratory tract infection, diarrhoea) , adverse effects of micronutrients within three days of receiving the supplement , infant mortality (defined as a child dying before completing the first year of age) . One study reported qualitatively on maternal anaemia (a secondary outcome of this review) ‐ the study found that multiple‐micronutrient supplementation was effective for recuperating from anaemia but there were no data for inclusion in our analyses. Maternal satisfaction was not reported in the included studies. Similarly, none of this review's infant secondary outcomes were reported in the included studies: clinical micronutrient deficiency ; morbidity episodes (febrile illness, respiratory tract infection, diarrhoea, other) , adverse effects of micronutrients within three days of receiving the supplement . Authors' conclusions We found no evidence to quantitatively assess the effectiveness of multiple‐micronutrient supplementation in improving health outcomes in mother and baby. The results of this review are limited by the small numbers of studies available, small sample sizes and the studies not reporting on the outcomes of interest in this review. There is no evidence to evaluate potential adverse effects of multiple‐micronutrient supplements, particularly excess dosages. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Further research should focus on whether multiple‐micronutrient supplementation during lactation compared with none, a placebo or supplementation with fewer than two micronutrients is beneficial to maternal and infant health outcomes. Future studies should collect data on outcomes beyond micronutrient concentrations, for example: maternal and infant morbidity, adverse effects, maternal satisfaction, the risks of excess supplementation, and potential adverse interactions between the micronutrients and the other outcomes. This would help to bridge the gap between research on intermediary outcomes and health outcomes in order to develop sound policy in this field. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these affect maternal and infant health outcomes. Larger studies with longer follow‐up would improve the quality of studies and provide stronger evidence. In most of the included studies, bias could not be adequately assessed due to lack of information, therefore attention should be given to adequate methods of randomisation and allocation concealment, adequate methods of blinding of the participants, providers and the outcome assessors to improve the methodological quality of studies in this field. Plain language summary Multiple micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby The benefits and risks of multiple‐micronutrient supplementation during lactation are not clear from randomised controlled studies. Key vitamins and minerals, particularly iodine, iron and zinc, are required in small amounts to ensure normal body metabolism, physical growth and development. Nutrient deficiency affects nearly one third of the world’s population, especially in low‐ and middle‐income countries. Breastfeeding mothers need higher levels than usual in order to provide sufficient vitamins and minerals for their own health and that of their babies, particularly for normal functioning and the growth and development of the baby. Previous studies have assessed supplementation of individual micronutrients. This review looked at the use of multiple‐micronutrient supplements for breastfeeding women for improving outcomes for the mother and her baby. We searched for studies on 30 September 2015 and identified two small studies (involving 52 women) for inclusion in this review. The studies were carried out in Brazil and the USA and included women who had a low socioeconomic status. The studies were poorly reported and this lack of information made it difficult to determine whether the studies were at risk of bias. Neither of the studies provided data for any of this review's important outcomes: maternal illness (fever, respiratory infection, diarrhoea), adverse effects of micronutrients within three days of taking them, infant death (defined as a child dying before reaching one year of age). Similarly, there were no data for any of the other outcomes that we were interested in. For the mother, these outcomes were maternal anaemia, and women's satisfaction. For the baby, these outcomes were micronutrient deficiency; illness episodes (fever, respiratory infection, diarrhoea, other), adverse effects of micronutrients within three days of the woman receiving the supplement. However, one of the included studies reported that multiple‐micronutrient supplementation was effective for lactating women recuperating from anaemia. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Larger studies with longer‐term follow‐up would improve the quality of studies and provide stronger evidence. Further research should focus on whether multiple‐micronutrient supplementation during lactation (compared with no supplementation, a placebo or supplementation with fewer than two micronutrients) is beneficial to the mother and her baby and any associated adverse effects of the intervention. Futher studies should report on important outcomes such as those listed in this review and consider the risks of excess supplementation. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these effect outcomes for the mother and her baby.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Abe, SK; Balogun, OO; Ota, E; Takahashi, K; Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD010647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "11539b2c-bd77-4f9e-8c69-e9283a36b6e9", "pmid": "", "title": "Omega‐3 fatty acid supplementation for depression in children and adolescents", "imported": false, "abstract": "Abstract - Background Mental health disorders including major depressive disorder (MDD) are well recognized as major contributors to the global burden of disease among adolescents. The prevalence of adolescent depression is estimated to have increased by at least 25% during the COVID‐19 pandemic, compounding the already challenging problem of insufficient mental health service and service accessibility that existed prepandemic. Omega‐3 polyunsaturated fatty acid (PUFA) supplementation is currently recommended as a preventive treatment for depression in high‐risk adults as well as a second‐line monotherapy for adults with mild to moderate MDD, and adjunctive to antidepressants for adults with moderate to severe MDD. The benefits of omega‐3 PUFA intake on depressive illness have been hypothesized to occur as a result of their effect on neurotransmission, maintenance of membrane fluidity, and anti‐inflammatory action. A comprehensive synthesis and quantification of the existing evidence on omega‐3 PUFA's efficacy in treating depression among children and adolescents is essential for clinicians to provide informed guidance to young people and their families, especially considering the absence of current guidelines for this age group. Objectives Primary objective To determine the impact of omega‐3 PUFA supplementation versus a comparator (e.g. placebo, wait list controls, no treatment/supplementation, or standard care) on clinician‐diagnosed depression or self‐reported depression symptoms in children and adolescents. Secondary objectives To estimate the size of the effect of omega‐3 PUFAs on depression symptoms. To estimate the effect of each type of omega‐3 PUFA (EPA or DHA), compared with placebo, on depression. To determine if the effect is modified by dosage, format (capsule or liquid), sex, or age. To determine compliance and attrition for omega‐3 PUFAs as an intervention for depression in children and adolescents. To determine the safety of omega‐3 PUFAs as an intervention for depression in children and adolescents. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases, reference lists of included studies, grey literature, and relevant reviews. The latest search date was 18 May 2023. Selection criteria We included randomized controlled trials (RCTs) involving males and females aged 19 years or younger with diagnosed depression comparing omega‐3 PUFA supplementation to placebo, wait list control, no treatment/supplementation, or standard care. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were self‐reported depression symptoms and clinically diagnosed resolution of depression. Our secondary outcomes were attrition, adverse effects, and compliance with the intervention. We used GRADE to assess the certainty of evidence for key outcomes. Main results We included five trials with 228 participants in our meta‐analysis. All trials used a placebo comparator; intervention duration ranged from 10 to 16 weeks (median: 12 weeks). Omega‐3 PUFA supplementation compared to placebo may reduce self‐reported depression symptoms, but the evidence is very uncertain (standardized mean difference [SMD] −0.34, 95% confidence interval [CI] −0.85 to 0.17; lower SMD means greater improvement in depression due to omega‐3 PUFA; 5 trials, 185 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may have little to no effect on remission of depression symptoms compared to placebo, but the evidence is very uncertain (omega‐3 PUFA versus placebo: 50% versus 48%; odds ratio [OR] 1.11, 95% CI 0.45 to 2.75; 4 trials, 127 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in attrition (dropouts) compared to placebo (omega‐3 PUFA versus placebo: 18% versus 19%; OR 0.94, 95% CI 0.46 to 1.90; 5 trials, 228 participants; low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in adverse effects, with one study reporting more muscle cramps in the fish oil group (13/27 participants) compared to the placebo group (6/29 participants); one study reported more frequent defecation in the omega‐3 group (1/29 participants) and one study identified mild skin rash and unusual/manic behavior in the placebo group (2/27 participants). None of the included studies reported serious adverse effects. Authors' conclusions Based on five small studies, omega‐3 PUFA supplementation may reduce self‐reported depression symptoms, but the evidence is very uncertain. Omega‐3 PUFA supplementation may have little to no effect on depression remission compared to placebo, but the evidence is very uncertain. Omega‐3 PUFA supplementation may result in little to no difference in attrition or adverse effects. The studies observed no serious adverse effects. This review highlights early‐stage research on omega‐3 PUFA and depression in young people. The evidence on the effects of omega‐3 PUFA supplementation in improving self‐reported depression symptoms or achieving depression remission in children and adolescents is very uncertain. While no harms are evident, more data are needed to confirm potential risks. Addressing current limitations in the evidence base through the design and conduct of methodologically rigorous studies — larger sample sizes, varied dosages, eicosapentaenoic acid/docosahexaenoic acid ratios, treatment durations, and safety profiles — is crucial to advance our understanding of the role of omega‐3 PUFA supplementation for depression in children and adolescents. Plain language summary Is omega‐3 polyunsaturated fatty acid supplementation better than a placebo for treating depression among children and adolescents? Key messages – Due to a lack of robust evidence, the benefits and unwanted effects of omega‐3 polyunsaturated fatty acids (which are important fats that you must obtain from your diet) supplementation for treating depression among children and adolescents are unclear. – Larger, well‐designed studies are needed to give better estimates of the potential benefits and harms of omega‐3 polyunsaturated fatty acid supplementation for child and adolescent depression. Why is it important to find treatments for children and adolescents with depression? People with depression have a low mood or lose pleasure or interest in usual activities. It is a long‐lasting (chronic) disorder that is both serious and recurrent (it can return after periods of feeling well). It often begins during childhood and adolescence, affecting up to eight in every 100 children. Unfortunately, response to current treatments for depression in children and adolescents is poor, and relieving symptoms (remission) can be challenging. In recent studies, supplements of omega‐3 polyunsaturated fatty acids have shown promise as a potential treatment for depression in adults. Our body cannot make these beneficial fats, but they are naturally present in oily fish, marine sources, and certain nuts and seeds. They can also be given as daily supplements in capsule or liquid forms (for example, as cod liver oil capsules). What did we want to find out? We wanted to find out: – if omega‐3 polyunsaturated fatty acids supplementation works to decrease symptoms of depression in children and adolescents; and – if omega‐3 polyunsaturated fatty acids supplementation helps children and adolescents achieve remission from depression. We also wanted to know if omega‐3 polyunsaturated fatty acids supplementation can cause any unwanted effects. What did we do? We searched for studies in which children and adolescents were assigned randomly to two or more treatment groups that compared omega‐3 polyunsaturated fatty acids supplementation with a placebo (pretend treatment with the same appearance), on a waiting list, no treatment/supplementation, or usual care. This is the best way to ensure that groups of people are similar and that investigators do not know who is in which group. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found five studies that involved 228 children and adolescents ranging from 10 to 16 years of age with depression. The largest study included 60 people, and the smallest study included 28 people. Three studies were conducted in the USA, one in Israel, and one in Slovakia. Four studies lasted for around 12 weeks and one study lasted for 16 weeks. We found that omega‐3 polyunsaturated fatty acids supplementation may reduce self‐reported depression symptoms, but the results are very uncertain. If omega‐3 PUFA supplements and placebos were given to a group of 100 children and adolescents with depression, then 50 children receiving omega‐3 polyunsaturated fatty acids would achieve remission and 48 receiving the placebo would achieve remission. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results, and the studies were very small. To date, there is insufficient evidence to determine if omega‐3 polyunsaturated fatty acids supplementation improves depression for children and adolescents. How up to date is this evidence? The evidence is up to date to 18 May 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Campisi, SC; Zasowski, C; Bradley-Ridout, G; Schumacher, A; Szatmari, P; Korczak, D", "articleTypes": [], "doi": "10.1002/14651858.CD014803.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "115e54b9-13d5-41cc-a8a5-744b8779efff", "pmid": "", "title": "Serenoa repens for the treatment of lower urinary tract symptoms due to benign prostatic enlargement", "imported": false, "abstract": "Abstract - Background Benign prostatic hyperplasia (BPH) is a non‐malignant enlargement of the prostate, which can lead to obstructive and irritative lower urinary tract symptoms (LUTS). The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS associated with BPH is common. The extract of the berry of the American saw palmetto or dwarf palm plant, Serenoa repens (SR), which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of BPH. Objectives To assess the effects of Serenoa repens in the treatment of men with LUTS consistent with BPH. Search methods We performed a comprehensive search of multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to 16 September 2022, with no restrictions on language or publication status. Selection criteria We included randomized controlled trials of participants with BPH who were treated with Serenoa repens or placebo/no treatment. Data collection and analysis Two review authors independently assessed studies for inclusion at each stage and undertook data extraction and risk of bias assessment and GRADE assessment of the certainty of the evidence. We considered review outcomes measured up to 12 months after randomization as short term, and beyond 12 months as long term. Our main outcomes included urologic symptom scores, quality of life, and adverse events. Main results For this update, we narrowed the review question to only comparisons with placebo. We included 27 studies (of which 9 were new) involving a total of 4656 participants, 19 studies comparing Serenoa repens with placebo, and 8 studies comparing Serenoa repens in combination with other phytotherapeutic agents versus placebo. Most studies included men aged > 50 (mean age range 52 to 68) with moderate urologic symptoms (International Prostate Symptom Score [IPSS] range 8 to 19). Ten studies were funded by the pharmaceutical industry; two studies were funded by government agencies; and the remaining studies did not specify funding sources. Serenoa repens versus placebo or no intervention Results for this comparison are based on predefined sensitivity analyses limited to studies at low risk of bias. Serenoa repens results in little to no difference in urologic symptoms at short‐term follow‐up (3 to 6 months; IPSS score range 0 to 35, higher scores indicate worse symptoms; mean difference (MD) −0.90, 95% confidence interval (CI) −1.74 to −0.07; I 2 = 68%; 9 studies, 1681 participants; high‐certainty evidence). Serenoa repens results in little to no difference in the quality of life at short‐term follow‐up (3 to 6 months; IPSS quality of life domain range 0 to 6, higher scores indicate worse quality of life; MD −0.20, 95% CI −0.40 to −0.00; I 2 = 39%; 5 studies, 1001 participants; high‐certainty evidence). Serenoa repens probably results in little to no difference in adverse events (1 to 17 months; risk ratio (RR) 1.01, 95% CI 0.77 to 1.31; I 2 = 18%; 12 studies, 2399 participants; moderate‐certainty evidence). Based on 164 cases per 1000 men in the placebo group, this corresponds to 2 more (38 fewer to 51 more) per 1000 men in the Serenoa repens group. Serenoa repens results in little to no difference in urologic symptoms at long‐term follow‐up (12 to 17 months, IPSS score, MD 0.07, 95% CI −0.75 to 0.88; I 2 = 34%; 3 studies, 898 participants; high‐certainty evidence). Serenoa repens results in little to no difference in quality of life at long‐term follow‐up (12 to 17 months, IPSS quality of life, MD −0.11, 95% CI −0.41 to 0.19; I 2 = 65%; 3 studies, 882 participants; high‐certainty evidence). There were no data on long‐term adverse events for this comparison. Serenoa repens in combination with other phytotherapy versus placebo or no intervention Different phytotherapeutic agents that include Serenoa repens may result in little to no difference in urologic symptoms compared to placebo at short‐term follow‐up (12 to 24 weeks, IPSS score, MD −2.41, 95% CI −4.54 to −0.29; I 2 = 67%; 4 studies, 460 participants; low‐certainty evidence). We are very uncertain about the effects of these agents on quality of life (very low‐certainty evidence). These agents may result in little to no difference in the occurrence of adverse events; however, the CIs included substantial benefits and harms (12 to 48 weeks, RR 0.91, 95% CI 0.58 to 1.41; I 2 = 0%; 4 studies, 481 participants; low‐certainty evidence). Based on 132 cases per 1000 men in the placebo group, this corresponds to 12 fewer (55 fewer to 54 more) per 1000 men in the combined phytotherapeutic agents with Serenoa repens group. Authors' conclusions Serenoa repens alone provides little to no benefits for men with lower urinary tract symptoms due to benign prostatic enlargement. There is more uncertainty about the role of Serenoa repens in combination with other phytotherapeutic agents. Plain language summary Serenoa repens for benign prostatic hyperplasia Review question Does Serenoa repens alone or in combination with other phytotherapeutic agents improve symptoms in men with benign prostatic enlargement? Background An enlarged prostate may cause bothersome urinary tract symptoms, such as having to urinate often during the day or night, having a weak stream, and the feeling of not completely emptying the bladder. Besides other common drug interventions, using plants and herbs (phytotherapy) is common and has been growing steadily in most Western countries. The extract of the berry of the American saw palmetto, or dwarf palm plant, Serenoa repens , which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of this condition. Study characteristics We found 27 studies with 4656 men comparing Serenoa repens alone or in combination with other herbal products to a placebo (participants are made to believe they received treatment when in fact they did not). Most studies included men over 50 with moderate symptoms. Ten studies were funded by pharmaceutical organizations; two studies received government funding; and the remaining studies did not specify funding sources. Key results Based on the most trustworthy studies, Serenoa repens alone results in little to no difference in urinary tract symptoms or quality of life compared to placebo at three to six months. This treatment is also likely not associated with adverse events. Results were similar at 12 to 17 months. Serenoa repens in combination with other herbal products may result in little to no difference in urinary tract symptoms, but there is more uncertainty about effects on quality of life and adverse events. The findings of this review are current to 16 September 2022. Certainty of the evidence The certainty of the evidence is primarily high or moderate for Serenoa repens alone, but low for Serenoa repens in combination with other agents, meaning our confidence in the results is high, moderate, or low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Franco, JVA, Trivisonno, L, Sgarbossa, NJ, Alvez, GA, Fieiras, C, Escobar Liquitay, CM, Jung, JH", "articleTypes": [], "doi": "10.1002/14651858.CD001423.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.060Z" }, { "id": "11604ce6-3d65-4b38-9df8-9e2b16ce2ff5", "pmid": "", "title": "Antidepressants for pain management in adults with chronic pain: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well‐being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients’ global impression of change for certain chronic pain conditions. However, there has not been a network meta‐analysis (NMA) examining all antidepressants across all chronic pain conditions. Objectives To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache). Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022. Selection criteria We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double‐blind. We included RCTs with active comparators that were unable to be double‐blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow‐up was less than two weeks and those with fewer than 10 participants in each arm. Data collection and analysis Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta‐analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta‐Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta‐analysis (ROB‐MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB‐MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal. Main results This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo‐controlled (83), and parallel−armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short‐term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest‐ranked antidepressant with moderate‐ to high‐certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate‐certainty evidence) and continuous pain intensity (standardised mean difference (SMD) −0.31, 95% CI −0.39 to −0.24; 18 studies, 4959 participants; moderate‐certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD −0.22, 95% CI −0.39 to 0.06; 4 studies, 1866 participants; moderate‐certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD −0.5, 95% CI −0.78 to −0.22; 1 study, 406 participants; low‐certainty evidence), while duloxetine showed a small effect (SMD −0.16, 95% CI −0.22 to −0.1; 26 studies, 7952 participants; moderate‐certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest‐ranked antidepressants with moderate‐certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low‐certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes. Authors' conclusions Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high‐quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long‐term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point. Plain language summary How effective are antidepressants used to treat chronic pain and do they cause unwanted effects? Key messages • We are only confident in the effectiveness of one antidepressant: duloxetine. We found that a standard dose (60 mg) was effective, and that there is no benefit to using a higher dose. • We are uncertain about unwanted effects for any antidepressant as the data for this were very poor. Future research should address this. • In clinical practice for chronic pain, a standard dose of duloxetine may be considered before trying other antidepressants. • Adopting a person‐centred approach is critical. Pain is a very individual experience and certain medications may work for people even while the research evidence is inconclusive or unavailable. Future studies should last longer and focus on unwanted effects of antidepressants. What is chronic pain? Chronic pain is pain of any kind that lasts for more than three months. Over one‐third of people across the world experience chronic pain. This often affects people's mood and well‐being, and their ability to work and carry out daily tasks. How do antidepressants treat chronic pain? Antidepressants are medications originally developed to treat depression. Different types of antidepressants work in different ways. Antidepressants that work in the same way are grouped into classes. The most common classes are selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and serotonin‐noradrenalin reuptake inhibitors (SNRIs). Research suggests that antidepressants may be effective for pain because the same chemicals that affect mood might also affect pain. What did we want to find out? We wanted to find out if antidepressants were effective for managing chronic pain and whether they cause unwanted effects. What did we do? We searched for studies that compared any antidepressant with any other treatment for any type of chronic pain (except headache). We compared all the treatments against each other using a statistical method called network meta‐analysis. This method allows us to rank the effectiveness of the different antidepressants from best to worst. What did we find? We found 176 studies including 28,664 people with chronic pain. These studies investigated 89 different types or combinations of treatment. Studies mainly investigated the effect of antidepressants on three different types of pain: fibromyalgia (59 studies), nerve pain (49 studies), and musculoskeletal pain (e.g. osteoarthritis or low back pain; 40 studies). The most common antidepressant classes investigated were SNRIs (74 studies), TCAs (72 studies), and SSRIs (34 studies). The most common antidepressants investigated were: amitriptyline (a TCA; 43 studies); duloxetine (an SNRI; 43 studies), and milnacipran (an SNRI; 18 studies). Of the 146 studies that reported where their funding came from, pharmaceutical companies funded 72 studies. The average study lasted 10 weeks. Most of the studies compared an antidepressant with a placebo (which looks like the real medicine but doesn’t have any medicine in it), but some studies compared an antidepressant against a different type of medicine, a different antidepressant, a different type of treatment (like physiotherapy), or different doses of the same antidepressant. Most of the studies in this review reported information on pain relief and unwanted effects. Fewer studies reported on quality of life, sleep, and physical function. Main results • Duloxetine probably has a moderate effect on reducing pain and improving physical function. It was the antidepressant that we have the most confidence in. Higher doses of duloxetine probably provided no extra benefits than standard doses. For every 1000 people taking standard‐dose duloxetine, 435 will experience 50% pain relief compared with 287 who will experience 50% pain relief taking placebo. • Milnacipran may reduce pain, but we are not as confident in this result as duloxetine because there were fewer studies with fewer people involved. • Most studies excluded people with mental health conditions, meaning that participants were already in the 'normal' ranges for anxiety and depression at the beginning of studies. This limited our analysis for mood. Mirtazapine and duloxetine may improve mood, but we are very uncertain about the results. • We do not know about unwanted effects of using antidepressants for chronic pain; there are not enough data to be certain about the results. What are the limitations of the evidence? There are still a number of questions that we were unable to answer: • Aside from duloxetine and milnacipran, we do not have confidence in the results from any other antidepressant included in this review because there are not enough studies. • We do not know whether antidepressants are effective at treating pain in the long term. The average length of studies was 10 weeks. • There was no reliable evidence on the safety of taking antidepressants for chronic pain, both short‐ and long‐term. • We do not know how effective antidepressants are for people with both chronic pain and depression as the most studies excluded participants with depression and anxiety. How up to date is this evidence? This review is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Birkinshaw, H; Friedrich, CM; Cole, P; Eccleston, C; Serfaty, M; Stewart, G; White, S; Moore, RA; Phillippo, D; Pincus, T", "articleTypes": [], "doi": "10.1002/14651858.CD014682.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "1164be61-657b-40c1-a80d-eb4f7822f718", "pmid": "", "title": "Investigating Salt Taste Threshold in Patients Being Investigated for Primary Hyperaldosteronism Before and After Treatment.", "imported": false, "abstract": "This study looks at how hypertensive patients, with high levels of aldosterone (hyperaldosteronism) differ from hypertensive patients without hyperaldosteronism with regards to markers of salt appetite. It also looks at how salt appetite changes after treatment of hyperaldosteronism. Salt makes food taste good and when our bodies need salt our brains make us like salty food even more. A high salt diet contributes to hypertension and a low salt diet is an important aspect of the treatment of hypertension. Unfortunately patients find it difficult to adhere to a low salt diet. Aldosterone is produced by the adrenal glands, its release is stimulated by a salt need and it has been shown, in rodent models, to activate pathways in the brain which drive a salt appetite. Mice with enhanced activity of the aldosterone pathway in the brain become hypertensive due to increased salt intake. Hyperaldosteronism, in humans, results in hypertension. The contribution of salt appetite, as opposed to the effect of aldosterone on the kidney's retention of salt and other systems, is unknown. Human studies have shown that when a human has a salt appetite, the concentration at which they can detect the taste of salt reduces, they increase their preference for salty food, and they consume more salt.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.235Z" }, { "id": "116a35d7-7c6d-4114-812a-1c226c232f24", "pmid": "", "title": "Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Chronic obstructive pulmonary disease (COPD) is a chronic lung condition characterised by persistent respiratory symptoms and limited lung airflow, dyspnoea and recurrent exacerbations. Suboptimal therapy or non‐adherence may result in limited effectiveness of pharmacological treatments and subsequently poor health outcomes. Objectives To determine the efficacy and safety of interventions intended to improve adherence to single or combined pharmacological treatments compared with usual care or interventions that are not intended to improve adherence in people with COPD. Search methods We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register, CENTRAL, MEDLINE and Embase (search date 1 May 2020). We also searched web‐based clinical trial registers. Selection criteria RCTs included adults with COPD diagnosed by established criteria (e.g. Global Initiative for Obstructive Lung Disease). Interventions included change to pharmacological treatment regimens, adherence aids, education, behavioural or psychological interventions (e.g. cognitive behavioural therapy), communication or follow‐up by a health professional (e.g. telephone, text message or face‐to‐face), multi‐component interventions, and interventions to improve inhaler technique. Data collection and analysis We used standard Cochrane methodological procedures. Working in pairs, four review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We assessed confidence in the evidence for each primary outcome using GRADE. Primary outcomes were adherence, quality of life and hospital service utilisation. Adherence measures included the Adherence among Patients with Chronic Disease questionnaire (APCD). Quality of life measures included the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). Main results We included 14 trials (2191 participants) in the analysis with follow‐up ranging from six to 52 weeks. Age ranged from 54 to 75 years, and COPD severity ranged from mild to very severe. Trials were conducted in the USA, Spain, Germany, Japan, Jordan, Northern Ireland, Iran, South Korea, China and Belgium. Risk of bias was high due to lack of blinding. Evidence certainty was downgraded due to imprecision and small participant numbers. Single component interventions Six studies (55 to 212 participants) reported single component interventions including changes to pharmacological treatment (different roflumilast doses or different inhaler types), adherence aids (Bluetooth inhaler reminder device), educational (comprehensive verbal instruction), behavioural or psychological (motivational interview). Change in dose of roflumilast may result in little to no difference in adherence (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.22 to 1.99; studies = 1, participants = 55; low certainty). A Bluetooth inhaler reminder device did not improve adherence, but comprehensive verbal instruction from a health professional did improve mean adherence (prescription refills) (mean difference (MD) 1.00, 95% CI 0.46 to 1.54). Motivational interview improved mean adherence scores on the APCD scale (MD 22.22, 95% CI 8.42 to 36.02). Use of a single inhaler compared to two separate inhalers may have little to no impact on quality of life (SGRQ; MD 0.80, 95% CI –3.12 to 4.72; very low certainty). A Bluetooth inhaler monitoring device may provide a small improvement in quality of life on the CCQ (MD 0.40, 95% CI 0.07 to 0.73; very low certainty). Single inhaler use may have little to no impact on the number of people admitted to hospital compared to two separate inhalers (OR 1.47, 95% CI 0.75 to 2.90; very low certainty). Single component interventions may have little to no impact on the number of people expereincing adverse events (very low certainty evidence from studies of a change in pharmacotherapy or use of adherence aids). A change in pharmacotherapy may have little to no impact on exacerbations or deaths (very low certainty). Multi‐component interventions Eight studies (30 to 734 participants) reported multi‐component interventions including tailored care package that included adherence support as a key component or included inhaler technique as a component. A multi‐component intervention may result in more people adhering to pharmacotherapy compared to control at 40.5 weeks (risk ratio (RR) 1.37, 95% CI 1.18 to 1.59; studies = 4, participants = 446; I 2 = 0%; low certainty). There may be little to no impact on quality of life (SGRQ, Chronic Respiratory Disease Questionnaire, CAT) (studies = 3; low to very low certainty). Multi‐component interventions may help to reduce the number of people admitted to hospital for any cause (OR 0.37, 95% CI 0.22 to 0.63; studies = 2, participants = 877; low certainty), or COPD‐related hospitalisations (OR 0.15, 95% CI 0.07 to 0.34; studies = 2, participants = 220; moderate certainty). There may be a small benefit on people experiencing severe exacerbations. There may be little to no effect on adverse events, serious adverse events or deaths, but events were infrequently reported and were rare (low to very low certainty). Authors' conclusions Single component interventions (e.g. education or motivational interviewing provided by a health professional) can help to improve adherence to pharmacotherapy (low to very low certainty). There were slight improvements in quality of life with a Bluetooth inhaler device, but evidence is from one study and very low certainty. Change to pharmacotherapy (e.g. single inhaler instead of two, or different doses of roflumilast) has little impact on hospitalisations or exacerbations (very low certainty). There is no difference in people experiencing adverse events (all‐cause or COPD‐related), or deaths (very low certainty). Multi‐component interventions may improve adherence with education, motivational or behavioural components delivered by health professionals (low certainty). There is little to no impact on quality of life (low to very low certainty). They may help reduce the number of people admitted to hospital overall (specifically pharmacist‐led approaches) (low certainty), and fewer people may have COPD‐related hospital admissions (moderately certainty). There may be a small reduction in people experiencing severe exacerbations, but evidence is from one study (low certainty). Limited evidence found no difference in people experiencing adverse events, serious adverse events or deaths (low to very low certainty). The evidence presented should be interpreted with caution. Larger studies with more intervention types, especially single interventions, are needed. It is unclear which specific COPD subgroups would benefit, therefore discussions between health professionals and patients may help to determine whether they will help to improve health outcomes. Plain language summary Which approaches help people with COPD to maintain taking medication as prescribed? Review question Which approaches help people maintain taking prescribed medication(s), improve quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD)? Background COPD is a lung condition that can cause long‐term breathing problems and includes symptoms such as shortness of breath. Medications do exist that can help but sometimes people do not take them as prescribed. Different approaches could help people to take their medication as prescribed and help improve symptoms or quality of life and reduce hospital admissions. We wanted to find out if any approaches could help people with COPD take their medication(s) as prescribed. Studies identified and selected We searched databases to find the studies. Four people working in pairs looked at the lists of studies separately and agreed on which ones were included. The latest search for studies was conducted in May 2020. Study characteristics We included studies comparing simple ways to help improve medication use (e.g. different medication doses or single inhalers instead of two separate inhalers) to usual COPD care. We also included studies that tested combination approaches (e.g. information or training from nurses or pharmacists and monitoring medication use). What were the key results? We included 14 studies (2191 people) in our analysis. No studies were masked (people knew whether they were receiving an approach to help them with adherence or the alternative). Six studies used simple approaches (e.g. change to medication dosage, change to type of inhaler, or a Bluetooth inhaler reminder device), and eight studies used combined approaches (e.g. nurses or pharmacists giving advice or information about how to improve medication use). We were uncertain about the effects of a different medication dose on people adhering to medication because it was no different to usual care (one study). Two separate studies found that a Bluetooth inhaler reminder device or a change in oral medication dose did not help to improve adherence. Health professionals involved in giving information may help to improve adherence (one study). This was measured by prescription refills. Motivating people to change their behaviour could help to improve adherence their medication (one study). This was measured by people completing a questionnaire about adherence to their medication. One study found that a Bluetooth inhaler device might help to improve quality of life. There may be little to no difference between those using single inhalers in the number of people admitted to hospital compared to those using two separate inhalers (one study). We found no difference between single approaches and usual care on the number of people who had side effects. Combined approaches may help to improve the number of people taking their medication, but we were not confident of this finding (four studies). They may have little to no impact on quality of life (three studies). Combined approaches could be beneficial in reducing the number of people with COPD admitted to hospital for any reason or because of COPD symptoms (two studies). There was no difference between combined approaches and in the number of people who had adverse events. Take home message We could not say for certain that simple approaches are useful to help people with COPD to improve medication use because of very limited information. Combined approaches may help people to take their medication(s) as prescribed and can help to reduce the number of people admitted to hospital, however, more information is needed to help answer this question with confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Janjua, S; Pike, KC; Carr, R; Coles, A; Fortescue, R; Batavia, M", "articleTypes": [], "doi": "10.1002/14651858.CD013381.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "1173e2f4-f8f3-44db-8966-b983a1e89ef1", "pmid": "", "title": "Phytoestrogens for menopausal vasomotor symptoms", "imported": false, "abstract": "Abstract - Background Vasomotor symptoms, such as hot flushes and night sweats, are very common during the menopausal transition. Hormone therapy has traditionally been used as a highly effective treatment, but concerns about increased risk of some chronic diseases have markedly increased the interest of women in alternative treatments. Some of the most popular of these treatments are foods or supplements enriched with phytoestrogens—plant‐derived chemicals that have estrogenic action. Objectives To assess the efficacy, safety and acceptability of food products, extracts and dietary supplements containing high levels of phytoestrogens when compared with no treatment, placebo or hormone therapy for the amelioration of vasomotor menopausal symptoms (such as hot flushes and night sweats) in perimenopausal and postmenopausal women. Search methods Searches targeted the following electronic databases: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of randomised trials (29 July 2013), the Cochrane Register of Controlled Trials (CENTRAL; 29 July 2013), MEDLINE (inception to 29 July 2013), EMBASE (inception to 29 July 2013), AMED (1985 to 29 July 2013), PsycINFO (inception to 29 July 2013) and CINAHL (inception to 29 July 2013). Attempts were made to access grey literature by sending letters to pharmaceutical companies and performing searches of ongoing trial registers. Reference lists of included trials were also searched. Selection criteria Studies were included if they were randomised, included perimenopausal or postmenopausal participants with vasomotor symptoms (hot flushes or night sweats), lasted at least 12 weeks and provided interventions such as foods or supplements with high levels of phytoestrogens (not combined with other herbal treatments). Trials that included women who had breast cancer or a history of breast cancer were excluded. Data collection and analysis Selection of trials, extraction of data and assessment of quality were undertaken by at least two review authors. Most trials were too dissimilar for their results to be combined in a meta‐analysis, so these findings are provided in narrative 'Summary of results' tables. Studies were grouped into broad categories: dietary soy, soy extracts, red clover extracts, genistein extracts and other types of phytoestrogens. Five trials used Promensil, a red clover extract; results of these trials were combined in a meta‐analysis, and summary effect measures were calculated. Main results A total of 43 randomised controlled trials (4,364 participants) were included in this review. Very few trials provided data suitable for inclusion in a meta‐analysis. Among the five trials that yielded data assessing the daily frequency of hot flushes suitable for pooling, no significant difference overall was noted in the incidence of hot flushes between participants taking Promensil (a red clover extract) and those given placebo (mean difference (MD) ‐0.93, 95% confidence interval (CI) ‐1.95 to 0.10, I 2 = 31%). No evidence indicated a difference in percentage reduction in hot flushes in two trials between Promensil and placebo (MD 20.15, 95% CI ‐12.08 to 52.38, I 2 = 82%). Four trials that were not combined in meta‐analyses suggested that extracts with high (> 30 mg/d) levels of genistein consistently reduced the frequency of hot flushes. Individual results from the remaining trials were compared in broad subgroups such as dietary soy, soy extracts and other types of phytoestrogens that could not be combined. Some of these trials found that phytoestrogen treatments alleviated the frequency and severity of hot flushes and night sweats when compared with placebo, but many trials were small and were determined to be at high risk of bias. A strong placebo effect was noted in most trials, with a reduction in frequency ranging from 1% to 59% with placebo. No indication suggested that discrepant results were due to the amount of isoflavone in the active treatment arm, the severity of vasomotor symptoms or trial quality factors. Also, no evidence indicated that these treatments caused oestrogenic stimulation of the endometrium or the vagina or other adverse effects when used for up to two years. Authors' conclusions No conclusive evidence shows that phytoestrogen supplements effectively reduce the frequency or severity of hot flushes and night sweats in perimenopausal or postmenopausal women, although benefits derived from concentrates of genistein should be further investigated. Plain language summary Phytoestrogens for vasomotor menopausal symptoms Review question: This Cochrane review has evaluated whether phytoestrogen treatments reduce the number and severity of hot flushes and whether they are safe and acceptable. Background: Hormone therapy is an effective treatment for controlling the most common menopausal symptoms—hot flushes and night sweats. However, it is now recommended only in low doses given for the shortest possible time because of concerns about increased risk of some chronic diseases. Many women have started to use therapies that they perceive as 'natural' and safe, but they often do not have good information about the potential benefits and risks. Some of these therapies contain phytoestrogens—a group of plant‐derived chemicals that are thought to prevent or treat disease. Phytoestrogens are found in a wide variety of plants, some of which are foods, particularly soy, alfalfa and red clover. Study characteristics: This review found 43 RCTs conducted up to July 2013 that included 4,084 participants with hot flushes who were close to the menopause or were menopausal. Evidence obtained is current to July 2013. Key results: Some trials reported a slight reduction in hot flushes and night sweats with phytoestrogen‐based treatment. Extracts containing high levels of genistein (a substance derived from soy) appeared to reduce the number of daily hot flushes and need to be investigated further. Overall no indication suggested that other types of phytoestrogens work any better than no treatment. No evidence was found of harmful effects on the lining of the womb, stimulation of the vagina or other adverse effects with short‐term use. Quality of the evidence: Many of the trials in this review were small, of short duration and of poor quality, and the types of phytoestrogens used varied substantially.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lethaby, A; Marjoribanks, J; Kronenberg, F; Roberts, H; Eden, J; Brown, J", "articleTypes": [], "doi": "10.1002/14651858.CD001395.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "118528ee-5bea-4124-9624-4511caa318fc", "pmid": "", "title": "Nebulised hypertonic saline for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Hypertonic saline enhances mucociliary clearance and may lessen the destructive inflammatory process in the airways. This is an update of a previously published review. Objectives To investigate efficacy and tolerability of nebulised hypertonic saline treatment in people with cystic fibrosis (CF) compared to placebo or other treatments that enhance mucociliary clearance. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also searched ongoing trials databases. Most recent search: 25 April 2022. Selection criteria We included randomised and quasi‐randomised controlled trials assessing hypertonic saline compared to placebo or other mucolytic therapy, for any duration or dose regimen in people with CF (any age or disease severity). Data collection and analysis Two authors independently reviewed all identified trials and data, and assessed trial quality. We assessed the certainty of the evidence using GRADE. For cross‐over trials we stipulated a one‐week washout period. We planned to use results from a paired analysis in the review, but this was only possible in one trial. For other cross‐over trials, we chose to treat the trials as if they were parallel. Main results We included 24 trials (1318 participants, aged one month to 56 years); we excluded 29 trials, two trials are ongoing and six are awaiting classification. We judged 15 of the 24 included trials to have a high risk of bias due to participants' ability to discern the taste of the solutions. Hypertonic saline 3% to 7% versus placebo (stable disease) We are uncertain whether the regular use of nebulised hypertonic saline in stable lung disease leads to an improvement in forced expiratory volume in one second (FEV 1 ) % predicted at four weeks, (mean difference (MD) 3.30%, 95% confidence interval (CI) 0.71 to 5.89; 4 trials, 246 participants; very low‐certainty evidence). In preschool children we found no difference in lung clearance index (LCI) at four weeks, but a small improvement after 48 weeks of treatment with hypertonic saline compared to isotonic saline (MD ‐0.60, 95% CI ‐1.00 to ‐0.19; 2 trials, 192 participants). We are also uncertain whether hypertonic saline made a difference to mucociliary clearance, pulmonary exacerbations or adverse events compared to placebo. Hypertonic saline versus control (acute exacerbation) Two trials compared hypertonic saline to control, but only one provided data. There may be little or no difference in lung function measured by FEV 1 % predicted after hypertonic saline compared to isotonic saline (MD 5.10%, 95% CI ‐14.67 to 24.87; 1 trial, 130 participants). Neither trial reported any deaths or measures of sputum clearance. There were no serious adverse events. Hypertonic saline versus rhDNase Three trials compared a similar dose of hypertonic saline to recombinant deoxyribonuclease (rhDNase); two trials (61 participants) provided data for inclusion in the review. We are uncertain whether there was an effect of hypertonic saline on FEV 1 % predicted after three weeks (MD 1.60%, 95% CI ‐7.96 to 11.16; 1 trial, 14 participants; very low‐certainty evidence). At three months, rhDNase may lead to a greater increase in FEV 1 % predicted than hypertonic saline (5 mL twice daily) at 12 weeks in participants with moderate to severe lung disease (MD 8.00%, 95% CI 2.00 to 14.00; low‐certainty evidence). We are uncertain whether adverse events differed between the two treatments. No deaths were reported. Hypertonic saline versus amiloride One trial (12 participants) compared hypertonic saline to amiloride but did not report on most of our outcomes. The trial found that there was no difference between treatments in measures of sputum clearance (very low‐certainty evidence). Hypertonic saline compared with sodium‐2‐mercaptoethane sulphonate (Mistabron®) One trial (29 participants) compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate. The trial did not measure our primary outcomes. There was no difference between treatments in any measures of sputum clearance, courses of antibiotics or adverse events (very low‐certainty evidence). Hypertonic saline versus mannitol One trial (12 participants) compared hypertonic saline to mannitol, but did not report lung function at relevant time points for this review; there were no differences in sputum clearance, but mannitol was reported to be more 'irritating' (very low‐certainty evidence). Hypertonic saline versus xylitol Two trials compared hypertonic saline to xylitol, but we are uncertain whether there is any difference in FEV 1 % predicted or median time to exacerbation between groups (very low‐certainty evidence). No other outcomes were reported in the review. Hypertonic saline 7% versus hypertonic saline 3% We are uncertain whether there was an improvement in FEV 1 % predicted after treatment with 7% hypertonic saline compared with 3% (very low‐certainty evidence). Authors' conclusions We are very uncertain if regular use of nebulised hypertonic saline by adults and children over the age of 12 years with CF results in an improvement in lung function after four weeks (three trials; very low‐certainty evidence); there was no difference seen at 48 weeks (one trial; low‐certainty evidence). Hypertonic saline improved LCI modestly in children under the age of six years. Evidence from one small cross‐over trial in children indicates that rhDNase may lead to better lung function than hypertonic saline at three months; qualifying this, we highlight that while the study did demonstrate that the improvement in FEV 1 was greater with daily rhDNase, there were no differences seen in any of the secondary outcomes. Hypertonic saline does appear to be an effective adjunct to physiotherapy during acute exacerbations of lung disease in adults. However, for the outcomes assessed, the certainty of the evidence ranged from very low to low at best, according to the GRADE criteria. The role of hypertonic saline in conjunction with cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy now needs to be considered, and future research needs to focus on this aspect. Plain language summary Hypertonic saline (salt water with at least 3% salt) nebulised as a fine mist through a mask or mouthpiece for cystic fibrosis Review question Is inhaling hypertonic saline (salt water with at least 3% salt) as a mist through a mask or mouthpiece better for improving mucus clearance in the lungs of people with cystic fibrosis (CF) than a placebo (a mist with no or very little salt) or other agents? Background People with CF produce large amounts of thick mucus which is difficult to clear and blocks up their airways. Chest physiotherapy or medication, e.g. hypertonic saline, or both combined, are used to try and clear this mucus from the airways. Hypertonic saline is water with a concentration of 3% to 7% salt and is inhaled as a fine mist. This is an update of an earlier review. Key messages • We are uncertain whether inhaling nebulised hypertonic saline regularly improves lung function compared to placebo. • Nebulised hypertonic saline does seem to work well as an add‐on to physiotherapy. What did we do? We searched for studies that looked at the use of nebulised hypertonic saline compared to either a placebo or a different type of treatment for clearing mucus from the lungs. We compared the size and methods of the studies and stated how confident we were in the results. What did we find? We included 24 trials with 1318 people with CF aged between one month and 56 years. Two thirds of the trials compared hypertonic saline to a placebo (a dummy treatment); the remaining trials compared hypertonic saline to another type of mucus clearing treatment (including mannitol; rhDNase (Pulmozyme®); amiloride; Mistabron®; xylitol); and one trial compared 7% hypertonic saline with 3% hypertonic saline. Trials assessed different concentrations of hypertonic saline with different nebulisers and different treatment schedules; the most common treatment was twice‐daily 7% hypertonic saline and the most common nebuliser was ultrasonic. Most trials treated people with a bronchodilator to widen the airways before giving the hypertonic saline. Main results Hypertonic saline 3% to 7% versus placebo We are not sure whether hypertonic saline leads to an improvement in lung function in stable disease after four weeks. Two trials showed that there may be a small improvement in lung function (measured using the lung clearance index) with hypertonic saline compared to placebo in preschool children. We are also unsure whether hypertonic saline makes a difference to clearing mucus from the lungs, exacerbations or side effects compared to placebo. During exacerbations, we found that there may be little or no difference in lung function after hypertonic saline compared to placebo. The trials did not report any serious side effects and there were no deaths. One study compared 7% hypertonic saline with a lower concentration of hypertonic saline (3%); we are uncertain whether the higher concentration improved lung function. Hypertonic saline versus mucus mobilising treatments Three trials compared hypertonic saline with rhDNase and found that rhDNase may lead to an improvement in lung function compared to hypertonic saline after three months. We are unsure whether there is any difference in side effects. One trial compared hypertonic saline to amiloride and a further trial compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate (Mistabron®), but neither of the trials gave information about the effect of the treatments on lung function. Similarly, a trial comparing hypertonic saline with mannitol did not give information about the effects on lung function, but they did report that there was no difference between treatments in clearing mucus from the lungs. People taking mannitol said it was more irritating than hypertonic saline. Two trials compared hypertonic saline with xylitol, but we are unsure if there is any difference in lung function and none of our other outcomes were measured. What are the limitations of this evidence? We are not confident in the evidence from these trials. There is a high risk that people knew which treatment they were receiving in half the trials as they could taste the difference between the solutions. Other factors that made us unsure of the results were the small numbers of people taking part in the trials combined with a wide variation in results; also, some trials limited participants to those who could tolerate hypertonic saline or to certain age groups. How up to date is this evidence? The evidence is current to 25 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wark, P, McDonald, VM, Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD001506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.066Z" }, { "id": "1190f3c5-1486-47bd-9413-2f45a0190d58", "pmid": "", "title": "New generation antidepressants for depression in children and adolescents: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Major depressive disorders have a significant impact on children and adolescents, including on educational and vocational outcomes, interpersonal relationships, and physical and mental health and well‐being. There is an association between major depressive disorder and suicidal ideation, suicide attempts, and suicide. Antidepressant medication is used in moderate to severe depression; there is now a range of newer generations of these medications. Objectives To investigate, via network meta‐analysis (NMA), the comparative effectiveness and safety of different newer generation antidepressants in children and adolescents with a diagnosed major depressive disorder (MDD) in terms of depression, functioning, suicide‐related outcomes and other adverse outcomes. The impact of age, treatment duration, baseline severity, and pharmaceutical industry funding was investigated on clinician‐rated depression (CDRS‐R) and suicide‐related outcomes. Search methods We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR)), together with Ovid Embase, MEDLINE and PsycINFO till March 2020. Selection criteria Randomised trials of six to 18 year olds of either sex and any ethnicity with clinically diagnosed major depressive disorder were included. Trials that compared the effectiveness of newer generation antidepressants with each other or with a placebo were included. Newer generation antidepressants included: selective serotonin reuptake inhibitors; selective norepinephrine reuptake inhibitors (SNRIs); norepinephrine reuptake inhibitors; norepinephrine dopamine reuptake inhibitors; norepinephrine dopamine disinhibitors (NDDIs); and tetracyclic antidepressants (TeCAs). Data collection and analysis Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed risk of bias. We analysed dichotomous data as Odds Ratios (ORs), and continuous data as Mean Difference (MD) for the following outcomes: depression symptom severity (clinician rated), response or remission of depression symptoms, depression symptom severity (self‐rated), functioning, suicide related outcomes and overall adverse outcomes. Random‐effects network meta‐analyses were conducted in a frequentist framework using multivariate meta‐analysis. Certainty of evidence was assessed using Confidence in Network Meta‐analysis (CINeMA). We used \"informative statements\" to standardise the interpretation and description of the results. Main results Twenty‐six studies were included. There were no data for the two primary outcomes (depressive disorder established via clinical diagnostic interview and suicide), therefore, the results comprise only secondary outcomes. Most antidepressants may be associated with a \"small and unimportant\" reduction in depression symptoms on the CDRS‐R scale (range 17 to 113) compared with placebo (high certainty evidence: paroxetine: MD ‐1.43, 95% CI ‐3.90, 1.04; vilazodone: MD ‐0.84, 95% CI ‐3.03, 1.35; desvenlafaxine MD ‐0.07, 95% CI ‐3.51, 3.36; moderate certainty evidence: sertraline: MD ‐3.51, 95% CI ‐6.99, ‐0.04; fluoxetine: MD ‐2.84, 95% CI ‐4.12, ‐1.56; escitalopram: MD ‐2.62, 95% CI ‐5.29, 0.04; low certainty evidence: duloxetine: MD ‐2.70, 95% CI ‐5.03, ‐0.37; vortioxetine: MD 0.60, 95% CI ‐2.52, 3.72; very low certainty evidence for comparisons between other antidepressants and placebo). There were \"small and unimportant\" differences between most antidepressants in reduction of depression symptoms (high‐ or moderate‐certainty evidence). Results were similar across other outcomes of benefit. In most studies risk of self‐harm or suicide was an exclusion criterion for the study. Proportions of suicide‐related outcomes were low for most included studies and 95% confidence intervals were wide for all comparisons. The evidence is very uncertain about the effects of mirtazapine (OR 0.50, 95% CI 0.03, 8.04), duloxetine (OR 1.15, 95% CI 0.72, 1.82), vilazodone (OR 1.01, 95% CI 0.68, 1.48), desvenlafaxine (OR 0.94, 95% CI 0.59, 1.52), citalopram (OR 1.72, 95% CI 0.76, 3.87) or vortioxetine (OR 1.58, 95% CI 0.29, 8.60) on suicide‐related outcomes compared with placebo. There is low certainty evidence that escitalopram may \"at least slightly\" reduce odds of suicide‐related outcomes compared with placebo (OR 0.89, 95% CI 0.43, 1.84). There is low certainty evidence that fluoxetine (OR 1.27, 95% CI 0.87, 1.86), paroxetine (OR 1.81, 95% CI 0.85, 3.86), sertraline (OR 3.03, 95% CI 0.60, 15.22), and venlafaxine (OR 13.84, 95% CI 1.79, 106.90) may \"at least slightly\" increase odds of suicide‐related outcomes compared with placebo. There is moderate certainty evidence that venlafaxine probably results in an \"at least slightly\" increased odds of suicide‐related outcomes compared with desvenlafaxine (OR 0.07, 95% CI 0.01, 0.56) and escitalopram (OR 0.06, 95% CI 0.01, 0.56). There was very low certainty evidence regarding other comparisons between antidepressants. Authors' conclusions Overall, methodological shortcomings of the randomised trials make it difficult to interpret the findings with regard to the efficacy and safety of newer antidepressant medications. Findings suggest that most newer antidepressants may reduce depression symptoms in a small and unimportant way compared with placebo. Furthermore, there are likely to be small and unimportant differences in the reduction of depression symptoms between the majority of antidepressants. However, our findings reflect the average effects of the antidepressants, and given depression is a heterogeneous condition, some individuals may experience a greater response. Guideline developers and others making recommendations might therefore consider whether a recommendation for the use of newer generation antidepressants is warranted for some individuals in some circumstances. Our findings suggest sertraline, escitalopram, duloxetine, as well as fluoxetine (which is currently the only treatment recommended for first‐line prescribing) could be considered as a first option. Children and adolescents considered at risk of suicide were frequently excluded from trials, so that we cannot be confident about the effects of these medications for these individuals. If an antidepressant is being considered for an individual, this should be done in consultation with the child/adolescent and their family/caregivers and it remains critical to ensure close monitoring of treatment effects and suicide‐related outcomes (combined suicidal ideation and suicide attempt) in those treated with newer generation antidepressants, given findings that some of these medications may be associated with greater odds of these events. Consideration of psychotherapy, particularly cognitive behavioural therapy, as per guideline recommendations, remains important. Plain language summary Newer generation antidepressants for depression in children and adolescents: a network meta‐analysis How well do newer formulations of antidepressants work for children and adolescents with clinical depression? Children and adolescents (6 to 18 years) with depression (also called ‘major depressive disorder’) experience a range of negative impacts in all areas of their lives and have an increased risk of suicide, suicidal thinking and suicide attempts. Antidepressants have been shown to reduce symptoms of depression, but can also increase the risk of suicide‐related outcomes. Who will be interested in this research? The research in this Cochrane Review will interest: ‐ people who decide policy, and influence decisions about the prescription of antidepressant medicines to children and adolescents; ‐ people who prescribe these medicines to children and adolescents; ‐ children and adolescents with depression; and ‐ those who support and care for them (including their parents and caregivers and clinicians who provide treatment). What did we want to find out? We wanted to find out how well newer formulations (called ‘new generation’) antidepressants work to improve depression in children and adolescents aged 6 to 18 years. New generation antidepressants are those that have been developed recently. They are sometimes referred to as ‘second‐‘ and ‘third‐generation’ antidepressants; they do not include older formulations (tricyclic antidepressants or monoamine oxidase inhibitors). We wanted to know how these antidepressants affect: ‐ symptoms of depression; ‐ recovery: no longer meeting diagnostic criteria for major depressive disorder; ‐ response or remission: scores on a scale indicating an important reduction in depression or no longer experiencing depression; ‐ ability to function in daily life; ‐ suicide‐related outcomes; and ‐ whether they cause any unwanted effects in children and adolescents. What did we do? We searched for studies that tested new generation antidepressants on children or adolescents (or both) who had been diagnosed with a major depressive disorder. We identified 26 such studies. We then assessed the trustworthiness of those studies, and synthesized the findings across the studies. What does the evidence from the review tell us? Most newer antidepressants probably reduce depression symptoms better than a placebo (a 'dummy' treatment that does not contain any medicine but looks identical to the medicine being tested). However, the reduction is small and may not be experienced as important by children and adolescents, their parents and caregivers, or clinicians. When different medications are compared against each other, there may be only small and unimportant differences between most of them for the reduction of symptoms. Our findings reflect what happens on average to individuals, but some individuals may experience a greater response. This might lead to recommendations being made for the use of antidepressants for some individuals in some circumstances. Our findings suggest that sertraline, escitalopram, duloxetine and fluoxetine can be used if medication is being considered. The impact of medication on depression symptoms should be closely monitored by those prescribing the medication, especially as suicide‐related thinking and behaviour may be increased in those taking these medications. Close monitoring of suicide‐related behaviours is vital in those treated with new generation antidepressants. What should happen next? The studies that provided this evidence largely excluded children and adolescents who: ‐ were already thinking about suicide and wanting to take their own lives (i.e. had suicidal ideation); ‐ were self‐harming; ‐ had other mental health conditions; and ‐ had psychosocial difficulties. Future research should aim to understand the impacts of these medicines in children and adolescents with these problems, who are more typical of those who request clinical services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Hetrick, SE, McKenzie, JE, Bailey, AP, Sharma, V, Moller, CI, Badcock, PB, Cox, GR, Merry, SN, Meader, N", "articleTypes": [], "doi": "10.1002/14651858.CD013674.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.131Z" }, { "id": "1191e738-0576-45cd-93a6-68f188fade38", "pmid": "", "title": "Probiotics for the prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer", "imported": false, "abstract": "Abstract - Background Treament‐related diarrhoea is one of the most common and troublesome adverse effects related to chemotherapy or radiotherapy in people with cancer. Its reported incidence has been as high as 50% to 80%. Severe treatment‐related diarrhoea can lead to fluid and electrolyte losses and nutritional deficiencies and could adversely affect quality of life (QoL). It is also associated with increased risk of infection in people with neutropenia due to anticancer therapy and often leads to treatment delays, dose reductions, or treatment discontinuation. Probiotics may be effective in preventing or treating chemotherapy‐ or radiotherapy‐induced diarrhoea. Objectives To evaluate the clinical effectiveness and side effects of probiotics used alone or combined with other agents for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 7), MEDLINE (1946 to July week 2, 2017), and Embase (1980 to 2017, week 30). We also searched prospective clinical trial registers and the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) investigating the effects of probiotics for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Data collection and analysis Two review authors independently selected studies, extracted data, and assessed risk of bias. We used random‐effects models for all meta‐analyses. If meta‐analysis was not possible, we summarised the results narratively. Main results We included 12 studies involving 1554 participants. Eleven studies were prevention studies, of which seven compared probiotics with placebo (887 participants), one compared two doses of probiotics with each other and with placebo (246 participants), and three compared probiotics with another active agent (216 participants).The remaining study assessed the effectiveness of probiotics compared with placebo for treatment of radiotherapy‐related diarrhoea (205 participants). For prevention of radiotherapy (with or without chemotherapy)‐induced diarrhoea, review authors identified five heterogeneous placebo‐controlled studies (with 926 participants analysed). Owing to heterogeneity, we could not carry out a meta‐analysis, except for two outcomes. For occurrence of any diarrhoea, risk ratios (RRs) ranged from 0.35 (95% confidence interval (CI) 0.26 to 0.47) to 1.0 (95% CI 0.94 to 1.06) (three studies; low‐certainty evidence). A beneficial effect of probiotics on quality of life could neither be demonstrated nor refuted (two studies; low‐certainty evidence). For occurrence of grade 2 or higher diarrhoea, the pooled RR was 0.75 (95% CI 0.55 to 1.03; four studies; 420 participants; low‐certainty evidence), and for grade 3 or higher diarrhoea, RRs ranged from 0.11 (95% CI 0.06 to 0.23) to 1.24 (95% CI 0.74 to 2.08) (three studies; low‐certainty evidence). For probiotic users, time to rescue medication was 36 hours longer in one study (95% CI 34.7 to 37.3), but another study reported no difference (moderate‐certainty evidence). For the need for rescue medication, the pooled RR was 0.50 (95% CI 0.15 to 1.66; three studies; 194 participants; very low‐certainty evidence). No study reported major differences between groups with respect to adverse effects. Although not mentioned explicitly, no studies reported deaths, except one in which one participant in the probiotics group died of myocardial infarction after three sessions of radiotherapy. Three placebo‐controlled studies, with 128 analysed participants, addressed prevention of chemotherapy‐induced diarrhoea. For occurrence of any diarrhoea, the pooled RR was 0.59 (95% CI 0.36 to 0.96; two studies; 106 participants; low‐certainty evidence). For all other outcomes, a beneficial effect of probiotics could be neither demonstrated nor refuted (one to two studies; 46 to 106 participants; all low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. Three studies compared probiotics with another intervention in 213 participants treated with radiotherapy (with or without chemotherapy). One very small study (21 participants) reported less diarrhoea six weeks after treatment when dietary counselling was provided (RR 0.30, 95% CI 0.11 to 0.81; very low‐certainty evidence). In another study (148 participants), grade 3 or 4 diarrhoea occurred less often in the probiotics group than in the control group (guar gum containing nutritional supplement) (odds ratio (OR) 0.38, 95% CI 0.16 to 0.89; low‐certainty evidence), and two studies (63 participants) found less need for rescue medication of probiotics versus another active treatment (RR 0.44, 95% CI 0.22 to 0.86; very low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. One placebo‐controlled study with 205 participants addressed treatment for radiotherapy‐induced diarrhoea and could not demonstrate or refute a beneficial effect of probiotics on average diarrhoea grade, time to rescue medication for diarrhoea (13 hours longer in the probiotics group; 95% CI ‐0.9 to 26.9 hours), or need for rescue medication (RR 0.74, 95% CI 0.53 to 1.03; moderate‐certainty evidence). This study did not address quality of life. No studies reported serious adverse events or diarrhoea‐related deaths. Authors' conclusions This review presents limited low‐ or very low‐certainty evidence supporting the effects of probiotics for prevention and treatment of diarrhoea related to radiotherapy (with or without chemotherapy) or chemotherapy alone, need for rescue medication, or occurrence of adverse events. All studies were underpowered and heterogeneous. Severe side effects were absent from all studies. Robust evidence on this topic must be provided by future methodologically well‐designed trials. Plain language summary Live micro‐organisms for prevention or treatment of diarrhoea in people with cancer who are treated with chemotherapy or radiotherapy Background 
 Up to 80% of people treated with chemotherapy or radiotherapy for cancer suffer from diarrhoea ‐ one of the most common and troublesome side effects. Severe diarrhoea can lead to dehydration (fluid and salts loss) and malnutrition from changes to digestion and bowel habits and could adversely affect quality of life. It is also associated with increased risk of infection in people with low white cell blood count related to cancer treatment. Diarrhoea often leads to delays in cancer treatment or the need to lower the dose or even discontinue cancer treatment. Foods containing live bacteria or yeast (probiotics) might have a beneficial effect on the occurrence and severity of diarrhoea. Aim of the review 
 To evaluate the effects of live micro‐organisms (probiotics) in preventing the occurrence or reducing the severity of diarrhoea in people with cancer who are receiving chemotherapy or radiotherapy. Main findings 
 Overall, the studies we found do not give a clear answer on whether probiotics reduce the occurrence or severity of diarrhoea, improve quality of life, or reduce the need for other medication. However, an analysis of only well‐performed studies demonstrated a beneficial effect for some outcomes. With regard to prevention of diarrhoea compared with placebo in participants treated with radiotherapy with or without chemotherapy, we are not able to conclude whether use of probiotics would be beneficial based on the five relevant studies. For prevention of diarrhoea due to chemotherapy alone, three studies suggested that use of probiotics may not reduce diarrhoea, and one study reported use of less rescue medication for diarrhoea. Three studies that compared probiotics with another agent for preventing diarrhoea in patients treated with radiotherapy with or without chemotherapy found beneficial effects of probiotics for the occurrence and severity of diarrhoea and the need for rescue medication. With respect to treatment of diarrhoea due to radiotherapy, we found only one study that did not demonstrate a clear effect of probiotics compared with placebo. No study reported serious adverse events nor deaths related to diarrhoea. Certainty of the evidence 
 The quality (certainty) of the evidence in prevention studies was low to very low. For the only study that assessed the effects of probiotics on treatment for diarrhoea, the certainty of the evidence was moderate. What are the conclusions? 
 Evidence supporting the effects of probiotics in preventing or treating diarrhoea related to cancer treatment is insufficient. However, probiotics appear to be safe, as no studies have found severe side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wei, D; Heus, P; van de Wetering, FT; van Tienhoven, G; Verleye, L; Scholten, RJPM", "articleTypes": [], "doi": "10.1002/14651858.CD008831.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "1194e9d8-faeb-4475-830c-b4c75465bd09", "pmid": "", "title": "Preoperative statin therapy for adults undergoing cardiac surgery", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Marques Antunes, M, Nunes-Ferreira, A, Duarte, GS, Gouveia e Melo, R, Sucena Rodrigues, B, Guerra, NC, Nobre, A, Pinto, FJ, Costa, J, Caldeira, D", "articleTypes": [], "doi": "10.1002/14651858.CD008493.pub5 AB - Abstract - Background Despite significant advances in surgical techniques and perioperative care, people undertaking cardiac surgery due to cardiovascular disease are more prone to the development of postoperative adverse events. Statins (5‐hydroxy‐3‐methylglutaryl‐co‐enzyme A (HMG‐CoA) reductase inhibitors) are well‐known for their anti‐inflammatory and antioxidant effects and are established for primary and secondary prevention of coronary artery disease. In addition, statins are thought to have clinical benefits in perioperative outcomes in people undergoing cardiac surgery. This review is an update of a review that was first published in 2012 and updated in 2015. Objectives To evaluate the benefits and harms of preoperative statin therapy in adults undergoing cardiac surgery compared to standard of care or placebo. Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2023), Ovid MEDLINE (1980 to 14 September 2023), and Ovid Embase (1980 to 2023 (week 36)). We applied no language restrictions. Selection criteria We included all randomised controlled trials (RCTs) comparing any statin treatment before cardiac surgery, for any given duration and dose, versus no preoperative statin therapy (standard of care) or placebo. We excluded trials without a registered trial protocol and trials without approval by an institutional ethics committee. Data collection and analysis We used standard Cochrane methodology. Primary outcomes were short‐term mortality and major adverse cardiovascular events. Secondary outcomes were myocardial infarction, atrial fibrillation, stroke, renal failure, length of intensive care unit (ICU) stay, length of hospital stay and adverse effects related to statin therapy. We reported effect measures as risk ratios (RRs) or mean differences (MDs) with corresponding 95% confidence intervals (CIs). We used the RoB 1 tool to assess the risk of bias in included trials, and GRADE to assess the certainty of the evidence. Main results We identified eight RCTs (five new to this review) including 5592 participants. Pooled analysis showed that statin treatment before surgery may result in little to no difference in the risk of postoperative short‐term mortality (RR 1.36, 95% CI 0.72 to 2.59; I 2 = 0%; 6 RCTs, 5260 participants; low‐certainty evidence; note 2 RCTs reported 0 events in both groups so RR calculated from 4 RCTs with 5143 participants). We are very uncertain about the effect of statins on major adverse cardiovascular events (RR 0.93, 95% CI 0.77 to 1.13; 1 RCT, 2406 participants; very low‐certainty evidence). Statins probably result in little to no difference in myocardial infarction (RR 0.88, 95% CI 0.73 to 1.06; I 2 = 0%; 5 RCTs, 4645 participants; moderate‐certainty evidence), may result in little to no difference in atrial fibrillation (RR 0.87, 95% CI 0.72 to 1.05; I 2 = 60%; 8 RCTs, 5592 participants; low‐certainty evidence), and may result in little to no difference in stroke (RR 1.47, 95% CI 0.90 to 2.40; I 2 = 0%; 4 RCTs, 5143 participants; low‐certainty evidence). We are very uncertain about the effect of statins on renal failure (RR 1.04, 95% CI 0.80 to 1.34; I 2 = 57%; 4 RCTs, 4728 participants; very low‐certainty evidence). Additionally, statins probably result in little to no difference in length of ICU stay (MD 1.40 hours, 95% CI −1.62 to 4.41; I 2 = 43%; 3 RCTs, 4528 participants; moderate‐certainty evidence) and overall hospital stay (MD −0.31 days, 95% CI −0.64 to 0.03; I 2 = 84%; 5 RCTs, 4788 participants; moderate‐certainty evidence). No study had any individual risk of bias domain classified as high. However, two studies were at high risk of bias overall given the classification of unclear risk of bias in three domains. Authors' conclusions In this updated Cochrane review, we found no evidence that statin use in the perioperative period of elective cardiac surgery was associated with any clinical benefit or worsening, when compared with placebo or standard of care. Compared with placebo or standard of care, statin use probably results in little to no difference in MIs, length of ICU stay and overall hospital stay; and may make little to no difference to mortality, atrial fibrillation and stroke. We are very uncertain about the effects of statins on major harmful cardiac events and renal failure. The certainty of the evidence validating this finding varied from moderate to very low, depending on the outcome. Future trials should focus on assessing the impact of statin therapy on mortality and major adverse cardiovascular events. Plain language summary Is it better to take statins before undergoing heart‐related surgery? Key messages – Taking statins may make little to no difference to death within 30 days of surgery, irregular heart rhythms and stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off); and probably results in little to no difference in heart attacks, length of intensive care unit stay and overall hospital stay. We are very uncertain about the effects of statins on kidney failure and harmful effects from statin treatment. – Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. What are the dangers of cardiac surgery and how may statins help? Cardiac surgeries can effectively treat people with heart and circulation problems. However, undergoing cardiac surgery also increases the risk of death, heart attack, stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off), irregular heart rhythms and kidney failure. This is partly because more than half of people undergoing cardiac surgery are over 70 years of age. To reduce these risks, we should try to improve recovery rates by preventing these problems from occurring before, during and after surgery. Statins are medications used throughout the world to lower blood cholesterol (a fatty substance found in the blood that may block blood vessels) levels and reduce the chances of cardiovascular issues becoming worse. Studies have shown that fewer people who had built up dangerous amounts of cholesterol in their blood vessels (arteries) died while taking statins. However, the potential benefits of taking statins in people undergoing cardiac surgery are unclear. What did we want to find out? We wanted to find out whether taking statins before undergoing cardiac surgery could help reduce the risk of: – death occurring shortly after surgery; or
– developing other heart or kidney problems. We also wanted to find out if there were any changes in the quality of care associated with cardiac surgeries for people who had been taking statins, such as reducing the length of hospital stay or intensive care unit stay, or if there were any harmful effects from statin treatment. What did we do? We searched for studies published up to September 2023 that compared treatment with statins to treatment with a placebo (a pretend medicine that looks or tastes identical to the medicine being tested) or usual care in people undergoing cardiac surgeries. Contrary to previous versions of this review, we only included trials that we were sure were approved by an ethical review board. What did we find? We found eight studies involving 5592 people with an average age of 63 years and 79% were men. Of these, 2798 people were treated with statins and 2794 people were not treated with statins before cardiac surgery. The smallest study included 57 people and the largest involved 2406 people. All studies were conducted in hospitals affiliated with universities in Asia, Europe and North America. Each study used different statin types (atorvastatin, fluvastatin, simvastatin, pravastatin or rosuvastatin) and doses (between 20 mg and 80 mg). Main results In people undergoing cardiac surgery, compared to no statin treatment, statin treatment: – probably results in little to no difference in heart attacks (5 studies, 4645 people), length of intensive care unit stay (3 studies, 4528 people) and overall hospital stay (5 studies, 4788 people); – may make little to no difference to death within 30 days of surgery (6 studies, 5260 people), irregular heart rhythm (8 studies, 5592 people) and stroke (4 studies, 5143 people). We are very uncertain about the effects of statins on major harmful cardiac events (1 study, 2406 people) and kidney failure (4 studies, 4728 people). What are the limitations of the evidence? We are moderately confident in our findings that there were probably little to no differences in the risk of heart attack, length of hospital and intensive care unit stay. However, we have little to very little confidence about our other findings, namely the most important finding we were looking for, which was a reduction in death. This is because most of the studies had many differences between them, there were fewer comparative cases than expected, and the studies did not always provide information about the statin intervention or treatment outcomes we were interested in. In addition, all studies used a different approach to statin treatment, which made them difficult to compare. Overall, this lowered our confidence in the evidence. Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. How up to date is this evidence? This is an update of a Cochrane review. The evidence is up to date to September 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.133Z" }, { "id": "11a0515c-beb5-4fe7-8f09-db426dbc3783", "pmid": "", "title": "The effects of antimicrobial therapy on bacterial vaginosis in non‐pregnant women", "imported": false, "abstract": "Abstract - Background Bacterial vaginosis (BV) is a very common cause of vaginitis that has been associated with a high incidence of obstetric and gynaecologic complications and increased risk of HIV‐1 transmission. This has led to renewed research interest in its treatment. Objectives To assess the effects of antimicrobial agents on BV in non‐pregnant women. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE, LILACS, and African Healthline (December 2007); and proceedings of relevant international conferences (from 1981 to date). Selection criteria Randomised controlled trials comparing any two or more antimicrobial agents, or antimicrobial agents with placebo or no treatment, in women with clinical or Gram‐stain criteria of BV. Data collection and analysis Two authors independently assessed trial quality and extracted data from the original publications while the third author cross checked the data. Main results Twenty‐four trials involving 4422 participants were reviewed. Most examined symptomatic women only. Only seven trials analysed results by intention to treat; we re‐analysed the remainder. Compared with placebo, clindamycin showed a lower rate of treatment failure (relative risk (RR) 0.25, 95% confidence interval (CI) 0.16 to 0.37). Clindamycin and metronidazole showed identical rates of treatment failure, irrespective of regimen type, at two and four‐week follow up (RR 1.01, 95% CI 0.69 to 1.46; RR 0.91, 95% CI 0.70 to 1.18, respectively). Clindamycin tended to cause a lower rate of adverse events (RR 0.75, 95% CI 0.56 to 1.02); metallic taste, and nausea and vomiting were more common in the metronidazole group (RR 0.08, 95% CI 0.1 to 0.59; RR 0.23, 95% CI 0.10 to 0.51, respectively). Given intravaginally as gelatin tablets, lactobacillus was more effective than oral metronidazole (RR 0.20, 95% CI 0.05 to 0.08). Similarly, oral lactobacillus combined with metronidazole was more effective than metronidazole alone (RR 0.33, 95% CI 0.14 to 0.77). Clindamycin showed a lower rate of clinical failure than triple sulfonamide cream (RR 0.46, 95% CI 0.29 to 0.72). Hydrogen peroxide douche showed a higher rate of clinical failure (RR 1.75, 95% CI 1.02 to 3.00) and adverse events (RR 2.33, 95% CI 1.21 to 4.52) than a single 2 g dose of metronidazole. Authors' conclusions Clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus were effective for bacterial vaginosis. Hydrogen peroxide douche and triple sulphonamide cream were ineffective. Metronidazole caused metallic taste, nausea and vomiting. We need better‐designed trials with larger sample sizes to test the effectiveness of promising drugs. Plain language summary The effects of antimicrobial treatment on bacterial vaginosis in non‐pregnant women Bacterial vaginosis (BV) is a very common cause of symptomatic and asymptomatic vaginal infection. It has been associated with a high incidence of obstetric and gynaecologic complications and an increased risk of transmission of HIV (human immunodeficiency virus). This review evaluated the effectiveness and adverse effects of antimicrobial agents used to treat BV in non‐pregnant women. Twenty‐four trials involving 4422 women were reviewed. With regard to less treatment failure, clindamycin was superior to placebo but comparable to metronidazole, irrespective of the dose regimen. Metronidazole tended to cause a higher rate of adverse events, such as metallic taste and nausea and vomiting, than did clindamycin. Oral lactobacillus combined with metronidazole was more effective than metronidazole alone. Administered in an intravaginal gelatin tablet, lactobacillus was also more effective than oral metronidazole. Triple sulfonamide cream was less effective compared with clindamycin. Hydrogen peroxide douche was not as effective as a single 2 g dose of metronidazole yet caused more harms. Only one trial involved asymptomatic women and the result was not conclusive. There was insufficient evidence to reach a conclusion on the effectiveness of other promising drugs. Drugs effective for bacterial vaginosis include clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus. Adverse effects of metronidazole include metallic taste, and nausea and vomiting. Information on possible side effects of lactobacillus preparations is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Oduyebo, OO, Anorlu, RI, Ogunsola, FT", "articleTypes": [], "doi": "10.1002/14651858.CD006055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.751Z" }, { "id": "11b8b89e-e6a4-41ab-afe4-60bbba7bdb3a", "pmid": "", "title": "A Randomised Controlled Trial of a Duodenal Sleeve Bypass Device (EndoBarrier)Compared With Standard Medical Therapy for the Management of Obese Subjects With Type 2 Diabetes", "imported": false, "abstract": "The management of obesity is challenging and obesity surgery is by far the most effective treatment currently available. Recent medical research indicates that it also improves the management of blood glucose levels in people with type 2 diabetes. Obesity surgery carries different risks and benefits and it is important to balance these by choosing the right procedure for each patient. Therefore new effective strategies to prevent and reduce obesity and its complications such as type 2 diabetes mellitus are needed. This study is designed to see whether a new device called the EndoBarrier Gastrointestinal Liner helps patients manage their blood sugar levels and lose weight. It is a randomised, placebo controlled trial which compares the potential of the EndoBarrier device with conventional drug therapy, diet and exercise for obesity related type 2 diabetes, and their effectiveness on metabolic state (HbA1c reduced by 20% and blood pressure below 135/85), weight loss, and quality of life. It will further evaluate whether any other conditions that may be related to obesity could become less severe and collect information about complications to determine the safety of the device. The study will also perform various measurements and tests to understand the underlying mechanism of the device. After an initial screening visit to determine patients eligibility, they will be invited for 14 subsequent visits. Patients will be randomised into either having the EndoBarrier device or standard medical therapy treatment for 12 months followed by another 12 months follow-up period. They will also be routinely seen by specialist dietitian who will provide dietetic support throughout the study.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.269Z" }, { "id": "11c44c2d-755c-4155-a3fd-22a169f6948c", "pmid": "", "title": "Probiotic Modulation of Gut Microflora in Cirrhosis: Influence on Immune Function and Infections", "imported": false, "abstract": "Liver cirrhosis is the 10th most common cause of death in the western world. Infection is the most common precipitant of deterioration of liver function in cirrhosis. Endotoxin, derived from gram-negative organisms in the gut, can enter the circulation due to increased gut permeability and contributes to neutrophil dysfunction, infection risk and mortality in alcoholic cirrhotics. As probiotics decrease gram-negative organisms in the gut and/or decrease gut permeability, the investigators hypothesize that probiotic treatment would restore neutrophil function and prevent infection in alcoholic cirrhosis.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.238Z" }, { "id": "11cdc24a-8857-4edd-b278-d42d4687950f", "pmid": "", "title": "Systemic administration of local anesthetic agents to relieve neuropathic pain", "imported": false, "abstract": "Abstract - Background Lidocaine, mexiletine, tocainide, and flecainide are local anesthetics which give an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain. Interest reappeared decades later when patient series and clinical trials reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients. With the recent publication of clinical trials with high quality standards, we have reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to update our knowledge, to measure their benefit and harm, and to better define their role in therapy. Objectives To evaluate pain relief and adverse effect rates between systemic local anesthetic‐type drugs and other control interventions. Search methods We searched MEDLINE (1966 through 15 May 2004), EMBASE (January 1980 to December 2002), Cancer Lit (through 15 December 2002), Cochrane Central Register of Controlled Trials (2nd Quarter, 2004), System for Information on Grey Literature in Europe (SIGLE), and LILACS, from January 1966 through March 2001. We also hand searched conference proceedings, textbooks, original articles and reviews. Selection criteria We included trials with random allocation, that were double blinded, with a parallel or crossover design. The control intervention was a placebo or an analgesic drug for neuropathic pain from any cause. Data collection and analysis We collected efficacy and safety data from all published and unpublished trials. We calculated combined effect sizes using continuous and binary data for pain relief and adverse effects as primary and secondary outcome measurements, respectively. Main results Thirty‐two controlled clinical trials met the selection criteria; two were duplicate articles. The treatment drugs were intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (one trial), and tocainide (one trial). Twenty‐one trials were crossover studies, and nine were parallel. Lidocaine and mexiletine were superior to placebo [weighted mean difference (WMD) = ‐11; 95% CI: ‐15 to ‐7; P < 0.00001], and limited data showed no difference in efficacy (WMD = ‐0.6; 95% CI: ‐7 to 6), or adverse effects versus carbamazepine, amantadine, gabapentin or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life‐threatening toxicities. Sensitivity analysis identified data distribution in three trials as a probable source of heterogeneity. There was no publication bias. Authors' conclusions Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. Future trials should enroll specific diseases and test novel lidocaine analogs with better toxicity profiles. More emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful. Plain language summary Systemic administration of local anesthetic agents to relieve neuropathic pain Intravenous lidocaine and oral derivatives relieve pain from damage to the nervous system (neuropathic pain). In early reports, intravenous lidocaine and its oral analogs mexiletine and tocainide relieved neuropathic pain, a type of pain caused by disease in the nervous system. However, the evidence was conflicting. The authors reviewed all randomized studies comparing these drugs with placebo or with other analgesics and found that: local anesthetics were superior to placebo in decreasing intensity of neuropathic pain; limited data showed no difference in efficacy or adverse effects between local anesthetics and carbamazepine, amantadine, gabapentin or morphine; local anesthetics had more adverse effects than placebo; and local anesthetics were safe.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Challapalli, V, Tremont-Lukats, IW, McNicol, ED, Lau, J, Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD003345.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.756Z" }, { "id": "11deff54-dbfc-4be6-8887-eb906b2fca55", "pmid": "", "title": "Vitamin D for the treatment of inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Vitamin D possesses immunomodulatory properties and has been implicated in the pathogenesis and severity of inflammatory bowel disease (IBD). Animal studies and emerging epidemiological evidence have demonstrated an association between vitamin D deficiency and worse disease activity. However, the role of vitamin D for the treatment of IBD is unclear. Objectives To evaluate the benefits and harms of vitamin D supplementation as a treatment for IBD. Search methods We used standard, extensive Cochrane search methods. The latest search date was Jun 2023. Selection criteria We included randomised controlled trials (RCTs) in people of all ages with active or inactive IBD comparing any dose of vitamin D with another dose of vitamin D, another intervention, placebo, or no intervention. We defined doses as: vitamin D (all doses), any‐treatment‐dose vitamin D (greater than 400 IU/day), high‐treatment‐dose vitamin D (greater than 1000 IU/day), low‐treatment‐dose vitamin D (400 IU/day to 1000 IU/day), and supplemental‐dose vitamin D (less than 400 IU/day). Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. clinical response for people with active disease, 2. clinical relapse for people in remission, 3. quality of life, and 4. withdrawals due to adverse events. Our secondary outcomes were 5. disease activity at end of study, 6. normalisation of vitamin D levels at end of study, and 7. total serious adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We included 22 RCTs with 1874 participants. Study duration ranged from four to 52 weeks. Ten studies enroled people with Crohn's disease (CD), five enroled people with ulcerative colitis (UC), and seven enroled people with CD and people with UC. Seventeen studies included adults, three included children, and two included both. Four studies enroled people with active disease, six enroled people in remission, and 12 enroled both. We assessed each study for risk of bias across seven individual domains. Five studies were at low risk of bias across all seven domains. Ten studies were at unclear risk of bias in at least one domain but with no areas of high risk of bias. Seven studies were at high risk of bias for blinding of participants and assessors. Vitamin D (all doses) versus placebo or no treatment Thirteen studies compared vitamin D against placebo or no treatment. We could not draw any conclusions on clinical response for UC as the certainty of the evidence was very low (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.51 to 10.57; 1 study, 60 participants). There were no data on CD. There may be fewer clinical relapses for IBD when using vitamin D compared to placebo or no treatment (RR 0.57, 95% CI 0.34 to 0.96; 3 studies, 310 participants). The certainty of the evidence was low. We could not draw any conclusions on quality of life for IBD (standardised mean difference (SMD) −0.13, 95% CI −3.10 to 2.83 (the SMD value indicates a negligent decrease in quality of life, and the corresponding CIs indicate that the effect can range from a large decrease to a large increase in quality of life); 2 studies, 243 participants) or withdrawals due to adverse events for IBD (RR 1.97, 95% CI 0.18 to 21.27; 12 studies, 1251 participants; note 11 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 12). The certainty of the evidence was very low. High‐treatment‐dose vitamin D versus low‐treatment‐dose vitamin D Five studies compared high treatment vitamin D doses against low treatment vitamin D doses. There were no data on clinical response. There may be no difference in clinical relapse for CD (RR 0.48, 95% CI 0.23 to 1.01; 1 study, 34 participants). The certainty of the evidence was low. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 0.89, 95% CI 0.06 to 13.08; 3 studies, 104 participants; note 2 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 3). The data on quality of life and disease activity could not be meta‐analysed, were of very low certainty, and no conclusions could be drawn. Any‐treatment‐dose vitamin D versus supplemental‐dose vitamin D Four studies compared treatment doses of vitamin D against supplemental doses. There were no data on clinical response and relapse. There were no data on quality of life that could be meta‐analysed. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 3.09, 95% CI 0.13 to 73.17; 4 studies, 233 participants; note 3 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 4). Authors' conclusions There may be fewer clinical relapses when comparing vitamin D with placebo, but we cannot draw any conclusions on differences in clinical response, quality of life, or withdrawals, due to very low‐certainty evidence. When comparing high and low doses of vitamin D, there were no data for clinical response, but there may be no difference in relapse for CD. We cannot draw conclusions on the other outcomes due to very low certainty evidence. Finally, comparing vitamin D (all doses) to supplemental‐dose vitamin D, there were no data on clinical relapse or response, and we could not draw conclusions on other outcomes due to very low certainty evidence or missing data. It is difficult to make any clear recommendations for future research on the basis of the findings of this review. Future studies must be clear on the baseline populations, the purpose of vitamin D treatment, and, therefore, study an appropriate dosing strategy. Stakeholders in the field may wish to reach consensus on such issues prior to new studies. Plain language summary Vitamin D for the treatment of inflammatory bowel disease Key messages The data we presently have for the use of vitamin D for the treatment of inflammatory bowel disease are of very low quality, and we do not know whether it works or if it is safe. What is inflammatory bowel disease? Inflammatory bowel disease is a life‐long disease that affects the gut. Its two main types are ulcerative colitis and Crohn's disease. Ulcerative colitis only affects the large intestine. Crohn's disease can affect any part of the gut, from mouth to bottom. Common symptoms include bloody poo, diarrhoea, stomach ache, fever, weight loss, and fatigue. We do not know exactly what causes it, but it is probably a mix of genes, problems with the immune system, bacteria in the gut, and something in the environment. There is no known cure, but the symptoms are usually managed with medicines, such as steroids and immune system medications, and sometimes surgery. Most people with inflammatory bowel disease have times when they have symptoms (called active disease) and other times when their symptoms are under control (called remission). When symptoms reappear after being in remission, it is called relapse. What did we want to find out? We wanted to find out if vitamin D works for the treatment of inflammatory bowel disease, and whether it is safe to use. Specifically, we looked at improvement of symptoms for people with active disease; relapse for people in remission; quality of life; and withdrawals from the trial because of side effects. What did we do? We searched for randomised controlled trials (studies where people are assigned to one of two or more treatment groups using a random method) comparing vitamin D with any other treatment, standard treatment, or different doses of vitamin D. What did we find? We found 22 trials with 1874 participants with inflammatory bowel disease. The studies lasted from four to 52 weeks. Ten studies were on Crohn's disease, five on ulcerative colitis, and seven on participants who had either of these. Seventeen studies were on adults, three on children, and two on both. Four included people with active disease, six in remission, and 12 on a mix of both. The studies included doses of vitamin D used to treat deficiency and doses given as supplements. Thirteen studies compared vitamin D (all doses) against placebo (dummy treatment) or no other treatment. There was low‐quality evidence that there may be fewer clinical relapses when using vitamin D compared to placebo or no treatment. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Five studies compared high‐treatment‐doses to low‐treatment‐doses of vitamin D. There were no data on improvement of symptoms. There was low‐quality evidence that there may be no difference on relapse in Crohn's disease, but there were no data on ulcerative colitis. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Four studies compared treatment doses to supplement doses of vitamin D. There were no data on improvement of symptoms, relapses, or quality of life changes. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. What are the limitations of the evidence? The evidence is mostly of very low and low quality. This is because of problems with the way the studies were carried out, and problems with how the results were reported. Additionally, the individual studies did not make the same measurements, meaning that we did not have enough numbers of people to strengthen the results of the measures we looked for. How up‐to‐date is this review? This review is up‐to‐date to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wallace, C, Gordon, M, Sinopoulou, V, Limketkai, BN", "articleTypes": [], "doi": "10.1002/14651858.CD011806.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.824Z" }, { "id": "11f782f0-9808-4061-8c75-cfed3d5ed78e", "pmid": "", "title": "Multisensory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Multisensory stimulation is a structured, developmentally appropriate intervention that provides simultaneous or sequential stimulation of two or more senses (e.g. tactile, auditory, visual, or vestibular) in a controlled and non‐stressful manner, with the aim of supporting early neurodevelopment in preterm infants. It has the potential to enhance physiological regulation in preterm infants by stabilizing key functions, such as respiratory patterns, heart rate, and oxygen saturation; reducing the need for respiratory support; and improving feeding performance and sleep regulation. Targeted multisensory interventions have also been associated with improved neurodevelopmental outcomes, including enhanced psychomotor development and visual function. Objectives To assess the benefits and harms of multisensory stimulation compared to any single sensory intervention or standard care on major neurodevelopmental disability, mortality, and growth in preterm infants. Search methods We searched CENTRAL, MEDLINE, Embase, Emcare, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 28 November 2025. We checked reference lists of included trials, and systematic reviews on sensory interventions. Eligibility criteria We included 18 randomized controlled trials (RCTs) comparing multisensory stimulation in preterm infants with no intervention (placebo or standard care), and one RCT comparing multisensory stimulation with single‐sense stimulation (tactile stimulation). Outcomes Our critical outcomes were major neurodevelopmental disability at 18 to 24 months: cerebral palsy (CP), developmental delay, intellectual impairment, blindness, sensorineural deafness; death during initial hospitalization; and total weight gain (grams), assessed at discharge. When comparing multisensory stimulation with single‐sense intervention, we also included weight gain during the intervention, an outcome added during the post‐hoc analysis. Important outcomes were duration of hospital stay, of NICU stay, and of respiratory support; and time until full oral feeding. Risk of bias We used the Cochrane tool, RoB 2. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RR) for dichotomous data, and mean differences (MDs) for continuous data, each with its 95% confidence intervals (CIs). We assessed statistical heterogeneity by calculating the I 2 statistic when we included more than two trials in a meta‐analysis. We evaluated the certainty of evidence using GRADE. Included studies We included 19 trials (1554 newborn infants): 18 studies compared multisensory stimulation with standard care; one compared multisensory stimulation with single‐sensory stimulation (tactile). In 10 studies, the primary aim was to assess the neurobehavioral outcomes of multisensory stimulation on preterm neo­nates. The other nine studies aimed to assess the impact of multisensory stimulation on weight gain during the intervention, weight gain until hospital discharge, length of neonatal intensive care unit (NICU) stay, length of hospital stay, time until full oral feeding, length of respiratory support, or a combination. In the abstract we report results for the critical outcomes only. We identified 13 ongoing studies. Four studies are awaiting assessment. Synthesis of results Multisensory stimulation compared to standard care No studies reported on these major neurodevelopmental disabilities, assessed at 18 to 24 months' corrected age (CA): developmental delay, intellectual impairment, blindness, or sensorineural deafness. One study reported on rates of CP at 12 months of age. The evidence is very uncertain about the effect of multisensory stimulation on CP (RR 0.67, 95% CI 0.28 to 1.58; I² not applicable; 1 study, 18 participants; very low‐certainty evidence). The evidence suggests that multisensory stimulation may result in little to no difference in death during initial hospitalization (RR 0.97, 95% CI 0.54 to 1.73; I² not applicable; 1 study, 395 participants; low‐certainty evidence). Multisensory stimulation may increase total weight gain prior to discharge (MD 72.67, 95% CI 68.23 to 77.12; I² = 0%; 3 studies, 474 participants; low‐certainty evidence). Multisensory stimulation compared to single‐sense (tactile) stimulation No studies reported on major neurodevelopmental disability, assessed at 18 to 24 months' CA, or death during initial hospitalization. The evidence is very uncertain about the effect of multisensory stimulation compared to tactile stimulation on weight gain during the intervention (MD −175.00, 95% CI −376.60 to 26.60; I² not applicable; 1 study, 20 participants; very low‐certainty evidence). The certainty of the evidence was low to very low across outcomes, primarily due to risk of bias, imprecision from small sample sizes and wide CIs, and in some cases, inconsistency. The evidence base was also limited by the lack of reporting of relevant outcomes and reliance on surrogate outcomes or shorter follow‐up periods. Authors' conclusions The available evidence on multisensory stimulation in preterm infants is limited and of low to very low certainty. No included studies reported on major neurodevelopmental disabilities at 18 to 24 months’ CA, which represented a critical outcome for this review. Evidence regarding the effect of multisensory stimulation on CP is very uncertain, as it is based on a single small study reporting a surrogate outcome at 12 months. Multisensory stimulation may result in little to no difference in mortality during the initial hospitalization. It may increase total weight gain prior to discharge. However, the clinical significance of this finding is uncertain, particularly given the low certainty of the evidence and the multifactorial nature of growth in preterm infants. The evidence is very uncertain about the effect of multisensory stimulation compared to single‐sense (tactile) stimulation on weight gain during the intervention. The only included study did not report major neurodevelopmental disabilities at 18 to 24 months’ CA, mortality during the initial hospitalization, or total weight gain prior to discharge, which represented the critical outcomes for this review. Overall, the current evidence does not allow firm conclusions about the effectiveness of multisensory stimulation in promoting development or preventing morbidity in preterm infants. Future studies on multisensory stimulation should use more rigorous designs, larger samples, and report interventions using the template for intervention description and replication (TIDieR) checklist to ensure transparency. They should also report essential outcomes, such as neonatal death, major neurodevelopmental disabilities, length of hospital and NICU stay, time to full oral feeding, duration of respiratory support, and weight gain, to better assess the long‑term effects of multisensory stimulation in preterm infants. Funding This Cochrane review had no dedicated funding . Registration Protocol available via DOI: 10.1002/14651858.CD016073 Plain language summary Does stimulating multiple senses (such as hearing, touch, taste, smell) of premature babies improve growth and healthy development or reduce the risk of death? Key messages Multisensory stimulation (the stimulation of more than one sense at a time) may support growth in preterm infants by increasing weight gain before discharge from the hospital. However, it is unclear whether it improves longer‐term developmental outcomes or reduces the risk of death, as the available evidence is limited and uncertain. When compared with stimulation of a single sense (touch alone), it is uncertain whether multisensory stimulation is better than touch alone at increasing weight gain during the intervention. What is multisensory stimulation, and how does it work? Multisensory stimulation means giving premature babies experiences that activate two or more of their senses. The senses involved and the types of stimulation used include the sense of: hearing — a parent’s voice, singing, or calming music; touch — massage or passive movements; smell and taste — a mother’s scent or breast milk; balance — gentle rocking or changing the baby's position; sight — soft, cycled lighting and simple shapes, colors, or moving patterns. During the newborn period, the brain grows very quickly. Providing positive sensory experiences at this time may help premature babies in several ways, such as supporting their memory, helping them regulate emotions, and improving early learning and development. What did we want to find out? We wanted to find out whether multisensory stimulation compared with single‑sense stimulation or standard care helps premature babies survive, grow, stay healthy, and develop well. Specifically, we wanted to find out whether multisensory stimulation might: reduce the number of babies with severe developmental problems at 18 to 24 months' age, such as cerebral palsy, delay in development, limitations in mental abilities, blindness, or deafness; reduce the number of babies who die during the newborn period or before hospital discharge; increase the amount of weight the infants gained by the time they left the hospital. We also looked at other important measures of the babies’ health, including: how long they stayed in the hospital or in the neonatal intensive care unit (NICU); how long it took before they could feed fully by mouth; how many days they needed breathing support. What did we do? We searched for studies in which multisensory stimulation began before the baby was discharged from the hospital after birth, and which compared multisensory stimulation with: no intervention or standard care; single‐sense stimulation. We summarized the results of the studies and rated our confidence in the evidence, based on factors, such as the size of the study (number of babies enrolled) and the methods used. What did we find? We included 19 studies (1544 premature babies). Eighteen of these studies compared multisensory stimulation with standard care, and one study compared multisensory stimulation with a single‑sense intervention (touch only). In 10 studies, the main goal was to examine how multisensory stimulation affects babies’ brain and behavioral development. The remaining nine studies focused on weight gain during the intervention, weight gain prior to hospital discharge, length of stay in the NICU, total length of hospital stay, time until the baby could feed fully by mouth, number of days the baby needed breathing support, or a combination of these measures. We also found 13 ongoing studies and 4 studies that have not yet been fully assessed. They may give us more useful information in the future. Main results None of the studies that compared multisensory stimulation with no intervention reported on the critical outcome major developmental disability at 18 to 24 months' corrected age. Only one study assessed a related outcome, cerebral palsy at 12 months. Because this study was very small, the evidence is very uncertain about whether multisensory stimulation modifies the risk of cerebral palsy. Multisensory stimulation may result in little or no difference in death before hospital discharge, although it was reported in only one large study. It may increase total weight gain prior to discharge, but the observed effect is small, and its clinical significance remains uncertain. Compared with single‐sense stimulation (touch), we could not tell whether multisensory stimulation helped babies gain more weight during the intervention. The only study we found comparing a multi‐ to single‐sensory intervention did not report the critical outcomes, such as major developmental problems at 18 to 24 months' corrected age, death during the first hospital stay, or total weight gain prior to discharge. What are the limitations of the evidence? We have limited confidence in these findings because many of the studies were small or not well‐designed. Several studies did not report the outcomes we were most interested in or did not provide enough data for us to analyze. Because of these limitations, the true effects of multisensory stimulation may be different from what we found. How up‐to‐date is this evidence? The evidence is up‐to‐date to 28 November 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Wróblewska-Seniuk, K, Lenells, M, Prescott, MG, Fiander, M, Soll, RF, Bruschettini, M, supported by Cochrane Sweden and Cochrane Neonatal,", "articleTypes": [], "doi": "10.1002/14651858.CD016073.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.066Z" }, { "id": "120780f8-9f9a-4dbc-bfb3-4ee18af7876e", "pmid": "", "title": "Rituximab for people with multiple sclerosis", "imported": false, "abstract": "Abstract - Background Multiple sclerosis (MS) is the most common neurological cause of disability in young adults. Off‐label rituximab for MS is used in most countries surveyed by the International Federation of MS, including high‐income countries where on‐label disease‐modifying treatments (DMTs) are available. This updates the 2021 version of the review. Objectives To assess the benefits and harms of rituximab as 'first choice' and 'switching' treatment for adults with any form of MS. Search methods We searched CENTRAL , MEDLINE, Embase, CINAHL, and three trials registers on 31 December 2023, together with reference checking and contacting study authors to identify unpublished studies. Selection criteria We included randomised controlled trials (RCTs) and controlled non‐randomised studies of interventions (NRSIs) comparing rituximab with placebo or another DMT for adults with any form of MS. Data collection and analysis We followed standard Cochrane methods. We used RoB 1 to assess risk of bias in RCTs and ROBINS‐I in NRSIs. We assessed the certainty of evidence for critical and important prioritised outcomes using GRADE: disability worsening, relapse, serious adverse events (SAEs), health‐related quality of life (HRQoL), common infections, cancer, and mortality. We conducted separate analyses for rituximab as 'first choice' or as 'switching' treatment, relapsing or progressive MS, comparison with placebo or another DMT, and RCTs or NRSIs. Main results In this update, the number of study participants increased from 16,429 (15 studies) to 37,443 (28 studies; 13 new studies: 1 RCT and 12 NRSIs). The studies were conducted worldwide; most originated from high‐income countries (25 studies). Public institutions funded 22 (79%) of the studies. Most studies investigated the effects of rituximab on people with relapsing MS (19 studies; 27,500 (73%) participants). We identified 12 ongoing studies. Rituximab as 'first choice' for active relapsing MS None of the included studies compared rituximab to placebo. One RCT compared rituximab to dimethyl fumarate, with 24 months' follow‐up. Rituximab may reduce the recurrence of relapse (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.04 to 0.57; 195 participants; low‐certainty evidence). The evidence is very uncertain on disability worsening and SAEs. Rituximab may result in little to no difference in upper respiratory tract infections (rate ratio (RR) 1.03, 95% CI 0.79 to 1.34; low‐certainty evidence). The evidence is very uncertain for urinary tract, skin, and viral infections. HRQoL, cancer, and mortality were not reported. One NRSI compared rituximab to other DMTs, with 24 months' follow‐up. Disability worsening was not reported. Compared with interferon beta or glatiramer acetate, rituximab likely delays relapse (hazard ratio (HR) 0.14, 95% CI 0.05 to 0.39; 1 study, 335 participants; moderate‐certainty evidence). Compared with dimethyl fumarate and natalizumab, rituximab may delay relapse (dimethyl fumarate: HR 0.29, 95% CI 0.08 to 1.00; 1 study, 206 participants; low‐certainty evidence; natalizumab: HR 0.24, 95% CI 0.06 to 1.00; 1 study, 170 participants; low‐certainty evidence). The evidence for relapse is very uncertain when comparing rituximab to fingolimod. The effect on SAEs is uncertain due to very few events in all the comparison groups. No deaths were reported. HRQoL, common infections, and cancer were not reported. Rituximab as 'first choice' for primary progressive MS One RCT compared rituximab to placebo, with 24 months' follow‐up. Rituximab likely results in little or no difference in disability worsening (OR 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate‐certainty evidence). The evidence is very uncertain on relapse, SAEs, common infections, cancer, and mortality. HRQoL was not reported. None of the included studies compared rituximab as 'first choice' treatment to other DMTs for primary or secondary progressive MS. Rituximab as 'switching' treatment for relapsing MS One small RCT compared rituximab to placebo, with 12 months' follow‐up. Disability worsening was not reported. Rituximab may reduce recurrence of relapses (OR 0.38, 95% CI 0.16 to 0.93; 1 study, 104 participants; low‐certainty evidence). The evidence is very uncertain regarding SAEs, common infections, cancer, and mortality. HRQoL was not reported. Twelve NRSIs compared rituximab to other DMTs, with 24 months' follow‐up. The evidence on disability worsening is very uncertain in comparison with interferons or glatiramer acetate, natalizumab, alemtuzumab, and ocrelizumab. Rituximab likely delays time to relapse in comparison with interferons or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 study, 1383 participants; moderate‐certainty evidence), fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 study, 256 participants; moderate‐certainty evidence), and may result in little or no difference compared with natalizumab (HR 0.96, 95% CI 0.83 to 1.10; 3 studies, 1922 participants; low‐certainty evidence). The evidence is very uncertain on relapse in comparison with alemtuzumab. There is uncertainty regarding SAEs when comparing rituximab to natalizumab and fingolimod. Rituximab likely increases serious common infections when compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 study, 5477 participants; moderate‐certainty evidence) and natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 studies, 5001 participants; moderate‐certainty evidence). The evidence for common infections is very uncertain when comparing rituximab to fingolimod and ocrelizumab. Rituximab may slightly reduce the risk of cancer compared with natalizumab (HR 0.79, 95% CI 0.62 to 0.99; 2 studies, 6202 participants; low‐certainty evidence), whereas the evidence is very uncertain in comparison with fingolimod. The effect of rituximab on mortality is very uncertain due to very few events in all the comparison groups. HRQoL was not reported. Authors' conclusions For preventing relapses in relapsing MS, rituximab as 'first choice' and 'switching' treatment compares favourably with a wide range of approved DMTs. The protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab on primary progressive MS. There is limited evidence for long‐term adverse events of rituximab in people with MS. Evidence for serious adverse events, cancer, and mortality was of very low certainty due to few events. There is an increased risk of serious (hospital‐treated) infections with rituximab compared with other DMTs, although the absolute risk is low. High‐quality (prospectively registered) NRSIs should be conducted to draw more reliable conclusions about the potential benefits and harms of rituximab in people with MS. Plain language summary Is rituximab better for people with multiple sclerosis than other disease‐modifying medicines? Key messages • We are uncertain whether rituximab prevents disability worsening in people with any form of multiple sclerosis (MS). 
• Rituximab may offer moderate‐to‐large benefit against a range of other medicines in preventing relapses in relapsing MS, both in people treated with rituximab for the first time and in those given rituximab after other medicines failed to work or became unsuitable.
• Very few people given rituximab in the studies had serious unwanted/harmful events, developed cancer, or died over 24 months' follow‐up. What is multiple sclerosis (MS)? MS is a disease affecting the central nervous system, in which the body’s immune system mistakenly attacks the protective covering of nerve fibres, which leads to inflammation and damage. Communication between the brain and the rest of the body is affected, resulting in a wide range of symptoms. There are two main types: (1) relapsing MS, where someone has periods of relapse (worsening of symptoms) followed by remissions (improvement or complete recovery); and (2) progressive MS, where symptoms worsen over time, without distinct periods of improvement. Relapsing MS is more common. How is MS treated? There is no cure for MS, so the goal of treatment is to manage symptoms, reduce disease activity, slow progression, and improve quality of life. This involves giving people with MS disease‐modifying treatments (DMTs), in contrast to treatments which only manage symptoms. There are different kinds of disease‐modifying treatments for MS, including rituximab. Rituximab is: • a medicine given slowly via a needle in a vein (intravenous infusion) that can suppress certain immune cells;
• included in the World Health Organization (WHO) Model List of Essential Medicines for MS, which makes rituximab available worldwide. Rituximab is not always reimbursed by health systems because it is not licensed for MS by marketing authorities;
• a highly effective treatment. It's cheaper and is given less often than other approved medicines for MS. Treatment with rituximab requires specialist care and infusion facilities, but other approved medicines do too. What did we want to find out? We wanted to find out the effects of rituximab on people with any form of MS on: • disability worsening, relapse, and quality of life;
• unwanted effects, such as serious harmful effects, serious common infections, cancer, and death. What did we do? We searched for studies that compared rituximab with other infused medicines (e.g. natalizumab), injectable medicines (e.g. interferon beta, glatiramer acetate), and oral medicines (e.g. fingolimod, dimethyl fumarate). We compared and summarised the results of the included studies, and rated our confidence in the evidence, based on factors such as study methods and quality. What did we find? We found 28 studies that involved 37,443 people with MS and lasted one or two years. The biggest study involved 8600 people and the smallest, 27 people. Most people (27,500, 73% of all participants) had a relapsing form of MS, while only 813 (2%) had a progressive form. Three studies included 9130 (24%) people with all forms of MS. Most studies originated from high‐income countries. Public institutions funded 22 (79%) of the studies. MAIN RESULTS Relapsing forms of MS • We do not know if rituximab has an effect on long‐term disability worsening due to the short follow‐up period of the studies.
• For people treated with rituximab for the first time as well as those given rituximab after other medicines failed to work or became unsuitable, rituximab may reduce the risk of relapses compared with interferon beta or glatiramer acetate, dimethyl fumarate, fingolimod, and natalizumab (evidence from 16 studies). 
• Serious unwanted effects of rituximab are very few. However, we do not know if rituximab has an effect on long‐term serious unwanted effects due to the short follow‐up period of the studies.
• Rituximab likely increases serious common infections (i.e. hospital‐treated infections) compared with other approved medicines for MS. However, the likelihood of serious common infections occurring is low in terms of the total number of people being considered. Progressive forms of MS We do not know if rituximab has benefits for people with primary progressive MS. What are the main limitations of the evidence? Our confidence in the evidence is limited because of three main factors. First, people were not randomly placed into different treatment groups in most of the studies. This means that differences between the groups could be due to differences between participants rather than between the comparison treatments. Second, we found few studies in which participants were assigned randomly to different treatment groups. These studies were small and used methods likely to introduce errors in their results. Third, results originated from short‐term studies. This is an important issue for people with a lifelong disease such as MS, who need to know the long‐term benefits and unwanted effects of a medicine. How current is the evidence? This review updates our previous review. The evidence is current to 31 December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Filippini, G; Kruja, J; Del Giovane, C", "articleTypes": [], "doi": "10.1002/14651858.CD013874.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "123156af-3c78-43fc-a745-0513752dd861", "pmid": "", "title": "The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents", "imported": false, "abstract": "Abstract - Background Erythropoiesis‐stimulating agents (ESAs) are commonly used to treat chemotherapy‐induced anemia (CIA). However, about half of patients do not benefit. Objectives To evaluate the benefits and harms related to the use of iron as a supplement to ESA and iron alone compared with ESA alone in the management of CIA. Search methods We searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1 January 2016), MEDLINE (1950 to February 2016), and www.clinicaltrials.gov without using any language limits. Selection criteria All randomized controlled trials (RCTs) comparing 'iron plus ESA' or 'iron alone' versus 'ESA alone' in people with CIA were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included eight RCTs (12 comparisons) comparing ESA plus iron versus ESA alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone in people with CIA. None of the included RCTs reported overall survival. There was a beneficial effect of iron supplementation to ESAs compared with ESAs alone on hematopoietic response (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.09 to 1.26; P < 0.0001; 1712 participants; 11 comparisons; high‐quality evidence). Assuming a baseline risk of 35% to 80% for hematopoietic response without iron supplementation, between seven and 16 patients should be treated to achieve hematopoietic response in one patient. In subgroup analyses, RCTs that used intravenous (IV) iron favored ESAs and iron (RR 1.20 (95% CI 1.10 to 1.31); P < 0.00001; 1321 participants; eight comparisons), whereas we found no evidence for a difference in hematopoietic response in RCTs using oral iron (RR 1.04 (95% CI 0.87 to 1.24); P = 0.68; 391 participants; three comparisons). There was no evidence for a difference between the subgroups of IV and oral iron (P = 0.16). There was no evidence for a difference between the subgroups of types of iron (P = 0.31) and types of ESAs (P = 0.16) for hematopoietic response. The iron supplementation to ESAs might be beneficial as fewer participants treated with iron supplementation required red blood cell (RBC) transfusions compared to the number of participants treated with ESAs alone (RR 0.74 (95% CI 0.60 to 0.92); P = 0.007; 1719 participants; 11 comparisons; moderate‐quality evidence). Assuming a baseline risk of 7% to 40% for RBC transfusion without iron supplementation, between 10 and 57 patients should be treated to avoid RBC transfusion in one patient. We found no evidence for a difference in the median time to hematopoietic response with addition of iron to ESAs (hazard ratio (HR) 0.93 (95% CI 0.67 to 1.28); P = 0.65; 1042 participants; seven comparisons; low‐quality evidence). In subgroup analyses, RCTs in which dextran (HR 0.95 (95% CI 0.36 to 2.52); P = 0.92; 340 participants; three comparisons), sucrose iron (HR 1.15 (95% CI 0.60 to 2.21); P = 0.67; 102 participants; one comparison) and sulfate iron (HR 1.24 (95% CI 0.99 to 1.56); P = 0.06; 55 participants; one comparison) were used showed no evidence for difference between iron supplementation versus ESAs alone compared with RCTs in which gluconate (HR 0.78 (95% CI 0.65 to 0.94); P = 0.01; 464 participants; two comparisons) was used for median time to hematopoietic response (P = 0.02). There was no evidence for a difference between the subgroups of route of iron administration (P = 0.13) and types of ESAs (P = 0.46) for median time to hematopoietic response. Our results indicated that there could be improvement in the hemoglobin (Hb) levels with addition of iron to ESAs (mean difference (MD) 0.48 (95% CI 0.10 to 0.86); P = 0.01; 827 participants; seven comparisons; low‐quality evidence). In RCTs in which IV iron was used there was evidence for a difference (MD 0.84 (95% CI 0.21 to 1.46); P = 0.009; 436 participants; four comparisons) compared with oral iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) for mean change in Hb level (P = 0.03). RCTs in which dextran (MD 1.55 (95% CI 0.62 to 2.47); P = 0.001; 102 participants; two comparisons) was used showed evidence for a difference with iron supplementation versus ESAs alone compared with RCTs in which gluconate (MD 0.54 (95% CI ‐0.15 to 1.22); P = 0.12; 334 participants; two comparisons) and sulfate iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) were used for mean change in Hb level (P = 0.007). RCTs in which epoetin was used showed evidence for a difference with iron supplementation versus ESAs alone (MD 0.77 (95% CI 0.25 to 1.29); P = 0.004; 337 participants; five comparisons) compared with darbepoetin use (MD 0.10 (95% CI ‐0.13 to 0.33); P = 0.38; 490 participants; two comparisons) for mean change in Hb level (P = 0.02). We found no evidence for a difference in quality of life with addition of iron to ESAs (standardized mean difference 0.01 (95% CI ‐0.10 to 0.12); P = 0.88; 1124 participants; three RCTs; high‐quality evidence). We found no evidence for a difference in risk of grade III‐IV thromboembolic events (RR 0.95 (95% CI 0.54 to 1.65); P = 0.85; 783 participants; three RCTs; moderate‐quality evidence). The incidence of treatment‐related mortality (TRM) was 0% (997 participants; four comparisons; high‐quality evidence). Other common adverse events included vomiting, asthenia, and leukopenia, and were similar in both arms. Overall the risk of bias across outcomes was high to low. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown. Our main reasons for downgrading the quality of evidence were inconsistency across the included studies and imprecision of results. Authors' conclusions Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation. Plain language summary The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents Review question: Is iron alone or iron as a supplement to erythropoiesis‐stimulating agents (ESAs) superior to ESAs alone in the management of people diagnosed with chemotherapy‐induced anemia (CIA)? Background: The current treatment of CIA is ESAs, which increase the production of red blood cells (erythropoiesis), and in some cases ESAs and iron. In some cases, strategies such as no therapy or wait and watch with clinical oversight and red blood cell transfusion may be safe and suitable options. We conducted a systematic review to evaluate the benefits and harms of iron in the management of CIA. Search date: The evidence is current to February 2016. Study characteristics: We included eight industry‐funded randomized controlled trials (RCTs) comparing ESAs plus iron versus ESAs alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone. Study funding source: All the included trials were industry funded. Key results: Adding iron to ESAs improves the hematopoietic response in people with CIA. Use of iron with ESAs might reduce the risk of blood transfusions and improve hemoglobin. We found no improvement in quality of life with addition of iron. We found no evidence for a difference in time to hematopoietic response and risk of development of blood clot in veins of people with CIA treated with iron and ESAs compared with ESAs alone. There were zero treatment‐related deaths among 997 participants in the four trials that reported this outcome. Other harms included constipation, vomiting, and diarrhea, and were similar with ESAs and iron compared with ESAs alone. None of the trials reported data on survival. Quality of evidence: The quality of evidence for hematopoietic response was high. The quality of evidence for red blood cell transfusion was moderate, as the pooled estimate had large variation. The quality of evidence for change in hemoglobin and time to hematopoietic response was low, as the pooled estimates had large variation and results were not similar across studies. The quality of evidence for quality of life was high. The quality of evidence for risk of blood clots in veins was moderate due to variation in pooled estimate. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Mhaskar, R; Wao, H; Miladinovic, B; Kumar, A; Djulbegovic, B", "articleTypes": [], "doi": "10.1002/14651858.CD009624.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "12340319-2ce9-4c50-a817-67c511c66dae", "pmid": "", "title": "Sensitive Periods in Early Flavor Learning", "imported": false, "abstract": "Flavor is the primary dimension by which young children determine food acceptance. However, children are not merely miniature adults since sensory systems mature postnatally and their responses to certain tastes differ markedly from adults. Moreover, emerging research has revealed that there are sensitive periods during infancy such that early flavor experiences serve to modify later responses to flavors and foods. The proposed study aims to investigate this important issue by using as a model system a class of infant formulas which are hydrolyzed protein based and thus have very pronounced and distinctive flavors which are unpalatable to older-aged infants and adults. This research was initiated because of anecdotal reports by pediatricians that although it is easy to introduce this type of formula to infants during the first months of life, it becomes extremely difficult to do so later in infancy. Indeed, recent studies in the investigators' laboratory provided the first experimental demonstration that infants younger than 4 months of age willingly accept substantial amounts of, and satiate while feeding, a novel, protein hydrolysate formula. In marked contrast, infants older than 4 months reject the protein hydrolysate formula and this rejection occurs within the first minute of a feed, a finding that strongly suggests the sensory qualities of the formula are responsible, at least in part, for this rejection. Moreover, this rejection is not evident when the investigators test older-aged infants with other unfamiliar, but non-hydrolysate, formulas. In other words, the rejection appears to be in response to a particular component or components of protein hydrolysate formulas. This shift in acceptability can be ameliorated by prior exposure. That is, if these formulas are introduced to infants within the first few months of life and are fed continuously, they remain highly acceptable throughout infancy and early childhood. These observations implicate a sensitive period during development, occurring somewhere before 4 months of age, during which exposure to a formula, which is unpalatable to adults and infants over 4 months of age without exposure, renders it acceptable and presumably palatable. To the investigators' knowledge, this is the clearest example of a sensitive period in the development of responses to foods and flavors in humans thus far identified.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "12363981-82e1-46b7-aa6a-8fb292630e87", "pmid": "", "title": "Treatment for primary postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries. Objectives To assess the effectiveness and safety of any intervention used for the treatment of primary PPH. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013). Selection criteria Randomised controlled trials comparing any interventions for the treatment of primary PPH. Data collection and analysis We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information. Main results Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review. Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41). Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering. Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre‐specified outcomes. One study compared lower segment compression but was too small to assess impact on primary outcomes. We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics. Authors' conclusions Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first‐line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit. The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy. Plain language summary Treatment for excessive bleeding after childbirth After a woman gives birth, womb muscles contract, clamping down on the blood vessels and helping to limit bleeding when the placenta has detached. If the muscles do not contract strongly enough, very heavy bleeding (postpartum haemorrhage) can occur, which can be life threatening. These situations are common in resource‐poor countries, and maternal mortality is about 100 times higher than in resource‐rich countries. It is a very serious problem that requires effective treatments that might avoid the use of surgery to remove the womb (hysterectomy). This is often the last treatment option and leaves the woman unable to have more children. In most settings, women are given a drug at the time of birth (before excessive bleeding occurs) to reduce the likelihood of excessive blood loss. However, despite this intervention, some women bleed excessively, and this review looked to see what interventions might be used to reduce the amount of blood lost by these women. Treatment options include drugs to increase muscles contractions (such as oxytocin, ergometrine and prostaglandins like misoprostol), drugs to help with blood clotting (haemostatic drugs such as tranexamic acid and recombinant activated factor VII), surgical techniques (such as tying off or blocking of the uterine artery) and radiological interventions (to assist in blocking the main artery to the womb by using gel foams). The review identified 10 randomised controlled trials involving 4052 women. Seven of these trials looked at a drug called misoprostol, which is a prostaglandin and so works by increasing muscle contractions. Overall, the trials suggest that misoprostol does not work as well as oxytocin infusion, and it has more side effects. However, oxytocin needs to be kept in a refrigerator, and so in settings where refrigeration and infusions are not readily available, misoprostol can be used. Other clinical trials looked into using other types of drugs or squeezing the main artery that supplies blood to the woman. The number of women included in these studies was too small for any useful conclusions regarding their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Mousa, HA, Blum, J, Abou El Senoun, G, Shakur, H, Alfirevic, Z", "articleTypes": [], "doi": "10.1002/14651858.CD003249.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.767Z" }, { "id": "126828d8-8149-431b-a9a1-60ccaa54ad85", "pmid": "", "title": "Topiramate for the prophylaxis of episodic migraine in adults", "imported": false, "abstract": "Abstract - Background Some antiepileptic drugs but not others are useful in clinical practice for the prophylaxis of migraine. This might be explained by the variety of actions of these drugs in the central nervous system. The present review is part of an update of a Cochrane review first published in 2004, and previously updated (conclusions not changed) in 2007. Objectives To describe and assess the evidence from controlled trials on the efficacy and tolerability of topiramate for preventing migraine attacks in adult patients with episodic migraine. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2012, Issue 12), PubMed/MEDLINE (1966 to 15 January 2013), MEDLINE In‐Process (current week, 15 January 2013), and EMBASE (1974 to 15 January 2013) and handsearched Headache and Cephalalgia through January 2013. Selection criteria Studies were required to be prospective, controlled trials of topiramate taken regularly to prevent the occurrence of migraine attacks, to improve migraine‐related quality of life, or both. Data collection and analysis Two review authors independently selected studies and extracted data. For headache frequency data, we calculated mean differences (MDs) between topiramate and comparator (placebo, active control, or topiramate in a different dose) for individual studies and pooled these across studies. For dichotomous data on responders (patients with ≥ 50% reduction in headache frequency), we calculated odds ratios (ORs) and, in select cases, risk ratios (RRs); we also calculated numbers needed to treat (NNTs). We calculated MDs for selected quality of life instruments. Finally, we summarised data on adverse events from placebo‐controlled trials and calculated risk differences (RDs) and numbers needed to harm (NNHs). Main results Twenty papers describing 17 unique trials met the inclusion criteria. Analysis of data from nine trials (1737 participants) showed that topiramate reduced headache frequency by about 1.2 attacks per 28 days as compared to placebo (MD ‐1.20; 95% confidence interval (CI) ‐1.59 to ‐0.80). Data from nine trials (1190 participants) show that topiramate approximately doubled the proportion of responders relative to placebo (RR 2.02; 95% CI 1.57 to 2.60; NNT 4; 95% CI 3 to 6). Separate analysis of different topiramate doses produced similar MDs versus placebo at 50 mg (‐0.95; 95% CI ‐1.95 to 0.04; three studies; 520 participants), 100 mg (‐1.15; 95% CI ‐1.58 to ‐0.71; six studies; 1620 participants), and 200 mg (‐0.94; 95% CI ‐1.53 to ‐0.36; five studies; 804 participants). All three doses significantly increased the proportion of responders relative to placebo; ORs were as follows: for 50 mg, 2.35 (95% CI 1.60 to 3.44; three studies; 519 participants); for 100 mg, 3.49 (95% CI 2.23 to 5.45; five studies; 852 participants); and for 200 mg, 2.49 (95% CI 1.61 to 3.87; six studies; 1025 participants). All three doses also significantly improved three or more domains of quality of life as compared to placebo. Meta‐analysis of the three studies that included more than one dose of topiramate suggests that 200 mg is no more effective than 100 mg. With regard to mean headache frequency and/or responder rate, seven trials using active comparators found (a) no significant difference between topiramate and amitriptyline (one study, 330 participants); (b) no significant difference between topiramate and flunarizine (one study, 83 participants); (c) no significant difference between topiramate and propranolol (two studies, 342 participants); (d) no significant difference between topiramate and relaxation (one study, 61 participants); but (e) a slight significant advantage of topiramate over valproate (two studies, 120 participants). Relaxation improved migraine‐specific quality of life significantly more than topiramate. In trials of topiramate against placebo, seven adverse events (AEs) were reported by at least three studies. These were usually mild and of a non‐serious nature. Except for taste disturbance and weight loss, there were no significant differences in the frequency of AEs in general, or of the seven specific AEs, between placebo and topiramate 50 mg. AEs in general and all of the specific AEs except nausea were significantly more common on topiramate 100 mg than on placebo, with NNHs varying from 3 to 25, and the RDs versus placebo were even higher for topiramate 200 mg, with NNHs varying from 2 to 17. Authors' conclusions Meta‐analysis demonstrates that topiramate in a 100 mg/day dosage is effective in reducing headache frequency and reasonably well‐tolerated in adult patients with episodic migraine. This provides good evidence to support its use in routine clinical management. More studies designed specifically to compare the efficacy or safety of topiramate versus other interventions with proven efficacy in the prophylaxis of migraine are needed. Plain language summary Topiramate for preventing migraine attacks in adults Various medicines, collectively termed 'antiepileptics', are used to treat epilepsy. For several years, some of these drugs have also been used for preventing migraine attacks. For the present review, researchers in The Cochrane Collaboration reviewed the evidence about the effects of topiramate in adult patients (≥ 16 years of age) with 'episodic' migraine (headache on < 15 days per month). They examined research published up to 15 January 2013 and found 17 relevant studies. Compared with placebo, topiramate reduced the frequency of migraine headaches by approximately 1.2 per month (nine studies, 1737 participants). Patients were also about twice as likely to reduce the number of their migraine headaches by 50% or more with topiramate than with placebo (nine studies, 1190 participants). Side effects associated with topiramate were common but generally mild; topiramate can, however, cause birth defects and so should be used with caution in women of childbearing age. Further research is needed comparing topiramate with other active drugs used for preventing migraine attacks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Linde, M, Mulleners, WM, Chronicle, EP, McCrory, DC", "articleTypes": [], "doi": "10.1002/14651858.CD010610", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.735Z" }, { "id": "12867dc5-fc90-450e-a523-6592ff241bfa", "pmid": "", "title": "Interventions for treating oral leukoplakia to prevent oral cancer", "imported": false, "abstract": "Abstract - Background Oral leukoplakia is a relatively common oral lesion that, in a small proportion of people, precedes the development of oral cancer. Most leukoplakias are asymptomatic; therefore, the primary objective of treatment should be to prevent onset of cancer. This review updates our previous review, published in 2006. Objectives To assess the effectiveness, safety and acceptability of treatments for leukoplakia in preventing oral cancer. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 16 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) ( the Cochrane Library , 2016, Issue 4), MEDLINE Ovid (1946 to 16 May 2016), Embase Ovid (1980 to 16 May 2016) and CancerLit via PubMed (1950 to 16 May 2016). We searched the metaRegister of Controlled Trials (to 10 February 2015), ClinicalTrials.gov (to 16 May 2016) and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials (to 16 May 2016). We placed no restrictions on the language or date of publication when searching electronic databases. Selection criteria We included randomised controlled trials (RCTs) that enrolled people with a diagnosis of oral leukoplakia and compared any treatment versus placebo or no treatment. Data collection and analysis We collected data using a data extraction form. Oral cancer development, demonstrated by histopathological examination, was our primary outcome. Secondary outcomes were clinical resolution of the lesion, improvement of histological features and adverse events. We contacted trial authors for further details when information was unclear. When valid and relevant data were available, we conducted a meta‐analysis of the data using a fixed‐effect model when we identified fewer than four studies with no heterogeneity. For dichotomous outcomes, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We assessed risk of bias in studies by using the Cochrane tool. We assessed the overall quality of the evidence by using standardised criteria (Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE)). Main results We included 14 studies (909 participants) in this review. Surgical interventions, including laser therapy and cryotherapy, have never been studied by means of an RCT that included a no treatment or placebo arm. The included trials tested a range of medical and complementary treatments, in particular, vitamin A and retinoids (four studies); beta carotene or carotenoids (three studies); non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically ketorolac and celecoxib (two studies); herbal extracts (four studies), including tea components, a Chinese herbal mixture and freeze‐dried black raspberry gel; bleomycin (one study); and Bowman‐Birk inhibitor (one study). We judged one study to be at low risk of bias, seven at unclear risk and six at high risk. In general, we judged the overall quality of the evidence to be low or very low, so findings are uncertain and further research is needed. Five studies recorded cancer incidence, only three of which provided useable data. None of the studies provided evidence that active treatment reduced the risk of oral cancer more than placebo: systemic vitamin A (RR 0.11, 95% CI 0.01 to 2.05; 85 participants, one study); systemic beta carotene (RR 0.71, 95% CI 0.24 to 2.09; 132 participants, two studies); and topical bleomycin (RR 3.00, 95% CI 0.32 to 27.83; 20 participants, one study). Follow‐up ranged between two and seven years. Some individual studies suggested effectiveness of some proposed treatments, namely, systemic vitamin A, beta carotene and lycopene, for achieving clinical resolution of lesions more often than placebo. Similarly, single studies found that systemic retinoic acid and lycopene may provide some benefit in terms of improvement in histological features. Some studies also reported a high rate of relapse. Side effects of varying severity were often described; however, it seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Authors' conclusions Surgical treatment for oral leukoplakia has not been assessed in an RCT that included a no treatment or placebo comparison. Nor has cessation of risk factors such as smoking been assessed. The available evidence on medical and complementary interventions for treating people with leukoplakia is very limited. We do not currently have evidence of a treatment that is effective for preventing the development of oral cancer. Treatments such as vitamin A and beta carotene may be effective in healing oral lesions, but relapses and adverse effects are common. Larger trials of longer duration are required to properly evaluate the effects of leukoplakia treatments on the risk of developing oral cancer. High‐quality research is particularly needed to assess surgical treatment and to assess the effects of risk factor cessation in people with leukoplakia. Plain language summary Interventions for treating oral leukoplakia to prevent oral cancer Review question People with oral leukoplakia are at higher risk of developing oral cancer than those with normal oral mucosa. This review, produced through Cochrane Oral Health , seeks to evaluate whether people affected by leukoplakia can benefit from surgical, medical or complementary treatments, either local or systemic. In particular, we conducted this review to find out which, if any, treatment is able to prevent people with leukoplakia of the mouth from getting oral cancer. This review updates our previous review published in 2006. Background Oral leukoplakia is a white patch formed in the mouth lining that cannot be rubbed off. It often does not hurt and may go unnoticed for years. People with leukoplakia develop oral cancer more often than people without it. Preventing this is critical because rates of oral cancer survival longer than five years after diagnosis are low. Drugs, surgery and other therapies have been tried for treatment of oral leukoplakia. Objectives This review aimed to evaluate whether treatments for oral leukoplakia are effective in preventing oral cancer, and safe and acceptable to patients. Study characteristics The evidence on which this review is based is up‐to‐date as of May 2016. We found 14 randomised controlled trials (RCTs) of medical and complementary treatments, which involved 909 participants in total. Treatments included herbal extracts, anti‐inflammatory drugs, vitamin A, beta carotene supplements and others. Surgical treatment has not been compared with placebo or no treatment in an RCT. Key results Cancer development was measured in studies of three treatments: systemic vitamin A, systemic beta carotene and topical bleomycin. None of these treatments showed effectiveness in preventing cancer development, as measured up to two years for vitamin A and beta carotene, and seven years for bleomycin. Some individual studies of vitamin A and beta carotene suggested that these treatments may be effective for improving or healing oral lesions. However, some studies observed a high rate of relapse in participants whose lesions were initially resolved by treatment. Most treatments caused side effects of differing severity in a high proportion of participants. It seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Quality of the evidence The available evidence is very limited. Most interventions were assessed by only one small study. Most studies had problems in the way they were conducted, making their results unreliable. We judged the quality of evidence for the outcome of cancer development to be very low. Author conclusions Larger, better studies of longer duration are required. As well as further studies of drug treatment and alternative treatments like vitamins, studies are needed to evaluate the effectiveness and safety of surgery, and of stopping risk factor habits such as smoking.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lodi, G, Franchini, R, Warnakulasuriya, S, Varoni, EM, Sardella, A, Kerr, AR, Carrassi, A, MacDonald, LCI, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD001829.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.781Z" }, { "id": "12aec5f5-2102-474d-9ad7-01faabbdaff2", "pmid": "", "title": "Immediate‐release versus controlled‐release carbamazepine in the treatment of epilepsy", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, G, Saunders, M, Rigby, A, Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007124.pub5 AB - Abstract - Background Carbamazepine (CBZ) is a commonly used drug for epilepsy that is associated with troublesome adverse events including dizziness, double vision, drowsiness, poor co‐ordination and unsteadiness. These adverse events often occur during peaks in drug plasma concentration. These adverse events may limit the daily dose of CBZ that can be tolerated and reduce the chances of seizure control in patients who require high doses. A controlled‐release formulation of CBZ delivers the same dose over a longer period of time when compared to a standard immediate‐release formulation, thereby reducing post‐dose peaks in CBZ plasma concentration and potentially reducing adverse events. This is an updated version of the original Cochrane review published in Issue 12, 2014. Objectives To determine the efficacy of immediate‐release CBZ (IR CBZ) versus controlled‐release CBZ (CR CBZ) in patients diagnosed with epilepsy. The following review questions were investigated.
 (1) For newly diagnosed patients commencing CBZ, how do IR and CR formulations compare for efficacy and tolerability?
 (2) For patients on established treatment with IR CBZ but experiencing unacceptable adverse events, what is the effect on seizure control and the tolerability of a switch to a CR formulation versus remaining on the IR formulation? Search methods We searched the Cochrane Epilepsy Group Specialized Register, CENTRAL, and MEDLINE (Ovid) from inception to 30 August 2016. Selection criteria Randomised controlled trials comparing IR CBZ to CR CBZ in patients commencing monotherapy and patients presently treated with IR CBZ but experiencing unacceptable adverse events. Primary outcome measures included measures of seizure frequency, incidence of adverse events, proportion of patients with treatment failure and quality of life measures. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted the data and recorded relevant information on a standardised data extraction form. We used the Cochrane risk of bias tool to assess the methodological quality of included studies. The heterogeneity of the included trials with respect to the reporting of outcomes resulted in only a narrative, descriptive analysis being possible for both the categorical and time‐to‐event data. Main results Ten trials (296 participants) fulfilled the criteria for inclusion in this review. Only one study had a low risk of bias. Two studies had a high risk of bias and the rest of the studies were rated as unclear risk of bias. One trial included patients with newly diagnosed epilepsy and nine included patients on treatment with IR CBZ. Eight trials reported heterogeneous measures of seizure frequency with conflicting results. A statistically significant difference was observed in only one trial, with patients prescribed CR CBZ experiencing fewer seizures than patients prescribed IR CBZ. Nine trials reported measures of adverse events. There was a trend in favour of CR CBZ with four trials reporting a statistically significant reduction in adverse events compared to IR CBZ. A further two trials reported fewer adverse events with CR CBZ but the reduction was not statistically significant. One trial found no difference in adverse events, and another trial reported more adverse events in the CR CBZ group than the IR CBZ group, although the increase was not statistically significant. Authors' conclusions For this update no new eligible studies were identified and the conclusions drawn from the initial review remain unchanged. At present, data from trials do not confirm or refute an advantage for CR CBZ over IR CBZ for seizure frequency or adverse events in patients with newly diagnosed epilepsy. For trials involving epilepsy patients already prescribed IR CBZ, no conclusions can be drawn concerning the superiority of CR CBZ with respect to seizure frequency. There is a trend for CR CBZ to be associated with fewer adverse events when compared to IR CBZ. A change to CR CBZ may therefore be a worthwhile strategy in patients with acceptable seizure control on IR CBZ but experiencing unacceptable adverse events. The included trials were of small size and of poor methodological quality limiting the validity of this conclusion. Randomised controlled trials comparing CR CBZ to IR CBZ and using clinically relevant outcomes are required to inform the choice of CBZ preparation for patients with newly diagnosed epilepsy. Plain language summary Fast‐release versus slow‐release carbamazepine as medication for patients with epilepsy Background Epilepsy is a common brain disorder that is often treated with carbamazepine. With treatment, people often have fewer seizures but many people experience side effects. When carbamazepine is swallowed it is taken into the blood stream quickly and there is a sharp rise of drug levels in the blood. These 'peaks' may be associated with side effects such as dizziness, double vision, drowsiness, unsteadiness and poor co‐ordination. A type of carbamazepine that releases the medication into the body slowly may lessen these 'peaks' in the blood levels, possibly meaning fewer side effects. This review compared studies looking at the differences between a 'fast‐release' carbamazepine and a 'slow‐release' carbamazepine. Participants To be included in this review, all participants had to be diagnosed with epilepsy and be either just starting carbamazepine treatment or be already on it but with intolerable side effects. The participants could be of any age or gender. Studies Ten trials with a total of 296 people with epilepsy were included in the review. All 10 trials were randomised controlled trials (patients were compared in randomly assigned groups). All of the studies had at least two groups, one group taking fast‐release carbamazepine and one group taking slow‐release carbamazepine, and some also had a control group (a group of non‐epileptic people). The evidence is current to August 2016. Results Just one of 10 studies found a significant difference between the two carbamazepine types in the number of seizures experienced, with patients prescribed the slow‐release carbamazepine experiencing fewer seizures than patients prescribed the fast‐release drug. Patients taking slow‐release carbamazepine tended to experience fewer side effects. Quality of the evidence Out of the 10 trials in the review, only one study was judged to be of 'good' quality, and so the evidence in this review was rated as low quality. It must be stressed that there are not many studies assessing the differences between these two carbamazepine types and more studies are needed before we can make a definitive conclusion about one over the other.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.769Z" }, { "id": "12d852fb-4f40-493b-9ab4-5e16d4be9c3a", "pmid": "", "title": "Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders", "imported": false, "abstract": "Abstract - Background About 5% of school children have a specific learning disorder, defined as unexpected failure to acquire adequate abilities in reading, writing or mathematics that is not a result of reduced intellectual ability, inadequate teaching or social deprivation. Of these events, 80% are reading disorders. Polyunsaturated fatty acids (PUFAs), in particular, omega‐3 and omega‐6 fatty acids, which normally are abundant in the brain and in the retina, are important for learning. Some children with specific learning disorders have been found to be deficient in these PUFAs, and it is argued that supplementation of PUFAs may help these children improve their learning abilities. Objectives 1. To assess effects on learning outcomes of supplementation of polyunsaturated fatty acids (PUFAs) for children with specific learning disorders.
 2. To determine whether adverse effects of supplementation of PUFAs are reported in these children. Search methods In November 2015, we searched CENTRAL, Ovid MEDLINE, Embase, PsycINFO, 10 other databases and two trials registers. We also searched the reference lists of relevant articles. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing PUFAs with placebo or no treatment in children younger than 18 years with specific learning disabilities, as diagnosed in accordance with the fifth (or earlier) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5), or the 10th (or earlier) revision of the International Classification of Diseases (ICD‐10) or equivalent criteria. We included children with coexisting developmental disorders such as attention deficit hyperactivity disorder (ADHD) or autism. Data collection and analysis Two review authors (MLT and KHT) independently screened the titles and abstracts of articles identified by the search and eliminated all studies that did not meet the inclusion criteria. We contacted study authors to ask for missing information and clarification, when needed. We used the GRADE approach to assess the quality of evidence. Main results Two small studies involving 116 children, mainly boys between 10 and 18 years of age, met the inclusion criteria. One study was conducted in a school setting, the other at a specialised clinic. Both studies used three months of a combination of omega‐3 and omega‐6 supplements as the intervention compared with placebo. Although both studies had generally low risk of bias, we judged the risk of reporting bias as unclear in one study, and as high in the other study. In addition, one of the studies was funded by industry and reported active company involvement in the study. None of the studies reported data on the primary outcomes of reading, writing, spelling and mathematics scores, as assessed by standardised tests. Evidence of low quality indicates that supplementation of PUFAs did not increase the risk of gastrointestinal disturbances (risk ratio 1.43, 95% confidence interval 0.25 to 8.15; two studies, 116 children). Investigators reported no other adverse effects. Both studies reported attention deficit hyperactivity disorder (ADHD)‐related behaviour outcomes. We were unable to combine the results in a meta‐analysis because one study reported findings as a continuous outcome, and the other as a dichotomous outcome. No other secondary outcomes were reported. We excluded one study because it used a cointervention (carnosine), and five other studies because they did not provide a robust diagnosis of a specific learning disorder. We identified one ongoing study and found three studies awaiting classification. Authors' conclusions Evidence is insufficient to permit any conclusions about the effect of PUFAs on the learning abilities of children with specific learning disorders. Well‐designed RCTs with clearly defined populations of children with specific learning disorders who have been diagnosed by standardised diagnostic criteria are needed. Plain language summary Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders Review question We reviewed the evidence on the effects of polyunsaturated fatty acids (PUFAs), compared with placebo or no treatment, on reading, writing or mathematical abilities of children up to 18 years of age who have specific learning disorders. Background Children with specific learning disorders are those whose abilities in reading, spelling, writing and mathematics are considerably below what is expected for their age, and whose problems are not a result of lower intelligence, inadequate teaching or social deprivation. A child may have a single disorder, such as a reading disorder, or a combined disorder, such as a reading and mathematics disorder. Children may have other problems too, such as attention deficit hyperactivity disorder (ADHD), along with a specific learning disorder. Polyunsaturated fatty acids are known to be necessary for normal brain development and function. The best known PUFAs are the omega‐3 fatty acids, which include docosahexaenoic acid (commonly known as DHA), but the omega‐6 fatty acids are also well known. Polyunsaturated fatty acids must be obtained from foods or supplements, as the human body cannot make them from other types of fat. Because they are needed for normal brain growth and development, PUFAs might help children with specific learning disorders. Study characteristics The evidence is current to November 2015. We found two small studies involving 116 children that met our inclusion criteria. Both studies gave children a combination of omega‐3 and omega‐6 capsules as the intervention for three months. Most of these studies involved boys between 10 and 18 years of age ‐ one was conducted in a school setting, and the other at a specialised clinic. One of the studies was funded by the company that supplied the omega‐3 and omega‐6 supplements. Another study could not be included in this review because investigators added carnosine (an amino acid that is highly concentrated in the brain) to the PUFAs. Carnosine and PUFAs might have similar effects, so it would not be possible to separate the effects of the two ingredients. Review authors excluded five studies because it was not confirmed that a specific learning disorder was diagnosed in these children. Key results None of the included studies reported effects of PUFAs on reading, writing, spelling or mathematical abilities of children. Evidence of low quality (because studies included few participants and showed evidence of bias) suggests that using PUFAs did not increase the risk of minor disturbances to the digestive system. Included studies reported no other types of adverse effects. Both studies reported on ADHD‐related behaviour. However, the format of available data did not allow us to readily combine them or to reach any conclusions. Included studies reported no other secondary outcomes. Conclusion Evidence is not sufficient to support or refute the use of PUFAs in children with specific learning disorders.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Tan, ML; Ho, JJ; Teh, KH", "articleTypes": [], "doi": "10.1002/14651858.CD009398.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "12df0e72-5dcc-4a3a-b447-2f6fbd4d7209", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 1. Commonly‐used classes of drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres ( ˜ 8200 feet ). Acute hypoxia, acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude. In this review, the first in a series of three about preventive strategies for HAI, we assess the effectiveness of six of the most recommended classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of commonly‐used pharmacological interventions for preventing acute HAI. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), LILACS and trial registries in January 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text terms to search. Selection criteria We included randomized‐controlled and cross‐over trials conducted in any setting where commonly‐used classes of drugs were used to prevent acute HAI. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Main results We included 64 studies (78 references) and 4547 participants in this review, and classified 12 additional studies as ongoing. A further 12 studies await classification, as we were unable to obtain the full texts. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. Risks of bias were unclear for several domains, and a considerable number of studies did not report adverse events of the evaluated interventions. We found 26 comparisons, 15 of them comparing commonly‐used drugs versus placebo. We report results for the three most important comparisons: Acetazolamide versus placebo (28 parallel studies; 2345 participants) The risk of AMS was reduced with acetazolamide (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.56; I 2 = 0%; 16 studies; 2301 participants; moderate quality of evidence). No events of HAPE were reported and only one event of HACE (RR 0.32, 95% CI 0.01 to 7.48; 6 parallel studies; 1126 participants; moderate quality of evidence). Few studies reported side effects for this comparison, and they showed an increase in the risk of paraesthesia with the intake of acetazolamide (RR 5.53, 95% CI 2.81 to 10.88, I 2 = 60%; 5 studies, 789 participants; low quality of evidence). Budenoside versus placebo (2 parallel studies; 132 participants) Data on budenoside showed a reduction in the incidence of AMS compared with placebo (RR 0.37, 95% CI 0.23 to 0.61; I 2 = 0%; 2 studies, 132 participants; low quality of evidence). Studies included did not report events of HAPE or HACE, and they did not find side effects (low quality of evidence). Dexamethasone versus placebo (7 parallel studies; 205 participants) For dexamethasone, the data did not show benefits at any dosage (RR 0.60, 95% CI 0.36 to 1.00; I2 = 39%; 4 trials, 176 participants; low quality of evidence). Included studies did not report events of HAPE or HACE, and we rated the evidence about adverse events as of very low quality. Authors' conclusions Our assessment of the most commonly‐used pharmacological interventions suggests that acetazolamide is an effective pharmacological agent to prevent acute HAI in dosages of 250 to 750 mg/day. This information is based on evidence of moderate quality. Acetazolamide is associated with an increased risk of paraesthesia, although there are few reports about other adverse events from the available evidence. The clinical benefits and harms of other pharmacological interventions such as ibuprofen, budenoside and dexamethasone are unclear. Large multicentre studies are needed for most of the pharmacological agents evaluated in this review, to evaluate their effectiveness and safety. Plain language summary Drugs commonly‐used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and breathing conditions that can occur while travelling to altitudes above 2500 metres ( ˜ 8200 feet ). HAI is generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but may affect the brain or the lungs in different individuals. In this review, we assessed the most commonly‐used drugs to prevent the onset of this illness. Study characteristics The evidence is current to January 2017. We included 64 studies related to six different types of drugs recommended for HAI prevention. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. The participants' ages ranged between 16 and 65 years. Eleven studies included people at a high risk of this condition due to their history of HAI or other illnesses such as asthma. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. In 23 of the included studies, the source of funding was unclear. Only 18 studies declared their possible conflicts of interests. We classed 24 more studies as still ongoing or waiting for assessment. Key results Our findings suggest that acetazolamide is an effective treatment for the prevention of acute HAI in dosages of 250 to 750 mg/day, when this drug is compared to a placebo (i.e. a pill with no active agent). Most of the available information relates to the prevention of uncomplicated HAI (headache, nausea, vomiting and tiredness) rather than to more serious brain or lung problems. We also found that acetazolamide is associated with an increased risk of paraesthesia in the fingers (i.e. a sensation of tingling, tickling, pricking, or burning of the skin), although this outcome is not well reported in the available evidence. The benefits and harms of other drugs such as ibuprofen, budenoside and dexamethasone are unclear, due to the small number of studies. Quality of the evidence We rated the quality of the evidence as moderate to very low. Several studies had quality shortcomings, including their use of small numbers of participants and a lack of reporting of important outcomes such as side effects. For most of the drugs covered by the studies, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Nieto Estrada, VH, Molano Franco, D, Medina, RD, Gonzalez Garay, AG, Martí‐Carvajal, AJ, Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD009761.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.772Z" }, { "id": "130c11ab-2f95-4b0e-a82c-e48729fc8f37", "pmid": "", "title": "Models for delivery and co‐ordination of primary or secondary health care (or both) to older adults living in aged care facilities", "imported": false, "abstract": "Abstract - Background The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co‐ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost‐effectiveness of alternative models of providing health care to ACF residents. Objectives Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost‐effectiveness of the alternative models. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included individual and cluster‐randomised trials, and cost/cost‐effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co‐ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co‐ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline‐recommended care, health‐related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work‐related satisfaction and work‐related stress of ACF staff. Data collection and analysis Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. Main results We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co‐ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low‐certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I 2 = 53%; 8 trials, 1263 participants; low‐certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low‐certainty evidence) and adherence to guideline‐recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health‐related quality of life of ACF residents (MD ‐0.016, 95% CI ‐0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low‐certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate‐certainty evidence). We did not pool the cost‐effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co‐ordination of care), we are uncertain of the cost‐effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. Authors' conclusions Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health‐related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost‐effectiveness of alternative models of care due to the limited, disparate data available. Plain language summary Alternative ways to organise delivery of health care to older adults living in aged care facilities What is the aim of this review? This Cochrane review set out to determine if providing residents of aged care facilities (ACF) with the same care as usual care, just delivered in a different way (alternative models of care), is better in terms of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs. For example, are multidisciplinary teams (alternative model) a better way of delivering care to residents of ACFs compared to providing care through individual practitioners (usual care)? Key messages Compared to usual care, alternative models of care may reduce unplanned hospital admissions, but may make little or no difference to the number of emergency department visits and the health‐related quality of life of ACF residents, and probably make little or no difference to mortality. We are uncertain of the effect of alternative models of care on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guideline‐recommended care. Importantly, we are uncertain whether alternative models of care are cost‐effective due to the limited, conflicting data available. Studies differed widely in terms of intervention characteristics, health care settings and descriptions of usual care and this hindered many analyses in this review. Future studies should provide a detailed description of what intervention and usual care constitutes in their setting. What was studied in this review? The world's population is ageing and the number of persons living in residential ACFs is growing worldwide. ACF residents are often frail, elderly people with multiple health conditions that require intensive medical care. When an ACF is not able to deliver appropriate health care, residents are often transferred to a hospital for treatment. Such transfers are often burdensome and traumatic for ACF residents and their families and may lead to increased costs. Alternative models of care, designed to provide care that is better co‐ordinated and more timely, aim to reduce unnecessary hospital transfers and improve residents' well‐being. Alternative models of care may be more expensive to implement (e.g. employ more healthcare personnel) but may lead to cost savings down the line (e.g. more residents receive care in ACF, avoiding costly hospital transfers). The synthesised evidence in this review compares the effect of alternative models of care with usual care on the number of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs (i.e. does the model deliver better value for money compared to usual care). What are the main results of this review? We identified 40 studies (with in total 21,787 participants; three studies did not provide number of participants) conducted in 15 countries. The study participants differed with respect to their health needs. In 11 studies, the alternative model of care was aimed at all ACF residents (with mixed health needs/conditions). Other studies included residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers; 13 studies) or residents requiring a specific type of care (e.g. residents after discharge from a hospital; four studies). In most (31) of the studies, the alternative model of care focused on 'co‐ordination of care'. In three studies, the alternative models of care focused on 'who provides care' (e.g. nurse practitioner‐led care using best practice guide instead of GP‐led care) and in two studies, alternative models of care focused on 'where care is provided' (i.e. investigating alternative locations for the provision of care, for example within ACF versus outside of ACF). In four studies, the alternative models of care focused on the use of information and communications technology for the provision of care to ACF residents. In all studies, the alternative model of care was compared with usual care. We found that, compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits; however, the number of unplanned hospital admissions may be reduced. We are uncertain of the effect of alternative models of care on adverse events and adherence to clinical guideline‐recommended care compared with usual care. Alternative models of care may have little or no effect on ACF residents' health‐related quality of life and probably make little or no difference to mortality. Based on the findings of five studies that provided full economic evaluations (all alternative models of care focused on 'co‐ordination of care'), we are uncertain whether alternative models of care are more cost‐effective than usual care. What are the limitations of the evidence? Our confidence in the evidence is limited because participants in the studies were aware of which treatment they were getting. Usual care was poorly described by most of the studies. Usual care differs across countries and regions, so this lack of information limits our interpretation, contextualisation and generalisation of the comparisons. Not all of the studies provided data about outcomes we were looking to assess. How up‐to‐date is this review? The review authors searched for studies published up to October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Putrik, P, Grobler, L, Lalor, A, Ramsay, H, Gorelik, A, Karnon, J, Parker, D, Morgan, M, Buchbinder, R, O'Connor, D", "articleTypes": [], "doi": "10.1002/14651858.CD013880.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.141Z" }, { "id": "1313a365-2b59-4626-b742-dbcdf094b7db", "pmid": "", "title": "Identifying the Mechanisms of Gut-brain Axis to Sweet Sensing in Patients With Type 2 Diabetes Using Neuroimaging Techniques", "imported": false, "abstract": "Diabetes is a global challenge and the number of people affected by diabetes is expected to rise to 5.5 million by 2030, of which 90% are type 2 diabetes (T2D). Habitual high consumption of sugars is an important risk factor in the development, and progression, of type 2 diabetes (T2D). Several studies have now shown that individuals with T2D have reduced lingual sweet taste sensation and this in turns increases their sugar intake to achieve the same hedonic reward values compared to the healthy population. This subsequently will lead to development of diabetes or worsening of the blood sugar control.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "13261b5d-63ea-4e13-8f11-9d4f3a6e0b9f", "pmid": "", "title": "Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Nedocromil sodium and sodium cromoglycate inhaled shortly before exercise appear to reduce the severity of exercise‐induced bronchoconstriction. There is some debate over which drug may be more effective. Objectives The objective of this review was to compare the effects on post‐exercise lung function between prophylactic doses of nedocromil sodium (NSG) and sodium cromoglycate (SCG) in persons diagnosed with exercise‐induced bronchoconstriction. Search methods Randomized controlled trials were identified from the Cochrane Airways Review Group Asthma Register. Bibliographies of relevant studies and review articles were searched and primary authors, content experts and manufacturers of drugs were contacted for additional relevant studies. No language restrictions were applied. Searches were current as of December 2007. Selection criteria Randomized controlled trials comparing NCS to SCG in prophylactic treatment of exercise‐induced bronchoconstriction were eligible. Studies were included if: the participants, aged 6 or over, had a confirmed diagnosis of asthma with exercise‐induced bronchoconstriction, were subjected to an exercise challenge sufficient to trigger bronchoconstriction, and the measures of lung function were reported as either changes in forced expiratory volume in one second or peak expiratory flow rate. Data collection and analysis Data extraction and methodological quality assessments were conducted independently by two reviewers using standard forms and validated assessment criteria. In some cases results were extrapolated from graphs. Results from similar studies were pooled and reported as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CI) using the random effects model. Main results Nine studies (162 participants) are included in this review. No significant difference was noted between NCS and SCG with respect to the maximum percent decrease in FEV1 (WMD = ‐0.88; 95% CI: ‐4.50, 2.74), complete protection (i.e. maximum % fall FEV1 still =>10%); OR = 0.95; 95% CI: 0.50 to 1.8, clinical protection (i.e. < 50% improvement over placebo); OR = 0.71; 95% CI: 0.36 to 1.39; unpleasant taste (OR = 6.85; 95% CI: 0.77, 60.73), or sore throat (OR = 3.46; 95% CI: 0.32, 37.48). For these pooled comparisons, no statistically significant heterogeneity was identified. Subgroup analyses based on age, dosage of medications and timing of exercise post‐inhalation were consistent with the overall pooled analyses. Authors' conclusions No significant differences were evident between the effect of NCS and SCG during the immediate post‐exercise period in adults and children with EIB with regards to pulmonary function �� specifically maximum percent decrease in FEV1, complete protection, clinical protection, or side effects. Plain language summary Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. Two drugs, nedocromil sodium (Tilade) and sodium cromoglycate are sometimes used before exercise to prevent asthma. The review of trials found that both were similarly effective in relieving exercise‐induced asthma for both children and adults. More people have sore throats and an unpleasant after‐taste after using nedocromil sodium.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Kelly, KD, Spooner, C, Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD002731", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.759Z" }, { "id": "133cdb1d-1da6-4dbd-8087-bedb1d8182f5", "pmid": "", "title": "Treatment of U.S. Veterans With Mild Traumatic Brain Injury With Hyperbaric Oxygen Therapy", "imported": false, "abstract": "Mild traumatic brain (mTBI) injury affects 400,000 U.S. Veterans resulting in physical, cognitive and mental health symptoms. The Department of Defense (DoD) reported 26 suicides a day from mTBI despite ongoing care for the Veterans. The purpose of this pilot research study is to evaluate the effect of treating Veterans suffering from mTBI or persistent post-concussion syndrome with hyperbaric oxygen therapy (HBOT).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.251Z" }, { "id": "133ea8cc-bb59-4944-983b-d3b4dc7052e9", "pmid": "", "title": "Lifestyle interventions for acute gout", "imported": false, "abstract": "Abstract - Background Although lifestyle interventions are often recommended in the management of chronic gout, the evidence from trial data of the benefits and safety of using lifestyle interventions for treating acute gout attacks have not previously been examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with acute gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies (up to 5 April 2013). We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials which compared lifestyle interventions to another therapy (active or placebo) in patients with acute gout. Outcomes of interest were the change in participant‐reported pain in the target joint(s), target joint inflammation and function, health‐related quality of life (HRQoL), patient global assessment, study participant withdrawals due to adverse events (AEs) and serious adverse events (SAEs). Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (19 participants) at high risk of bias was included in the review. Patients were randomised to receive oral prednisolone and colchicine with or without concomitant topical ice therapy. Topical ice therapy provided significant additional benefit over oral prednisolone and colchicine alone with respect to pain, but did not significantly reduce swelling during acute gout episodes. Mean pain reduction with standard medical treatment was 4.4 cm on a 0 to 10 cm visual analogue scale (VAS) after one week; the addition of topical ice reduced pain by an additional 3.33 cm (95% CI 5.84 to 0.82), or an absolute reduction of 33% (8% to 58% reduction). Joint swelling was reduced by a mean of 3.8 cm in the standard medical treatment group; the addition of topical ice therapy did not reduce swelling significantly (mean difference (MD) 2.07 cm, 95% CI ‐1.56 to 5.70). Target joint function, HRQoL, patient global assessment, study participant withdrawals due to AEs and SEAs were not reported in this study. Authors' conclusions There is low quality evidence, from a single trial at high risk of bias, that the addition of topical ice therapy to oral prednisolone and colchicine for oligoarticular attacks of acute gout results in significantly greater pain reduction at one week. Plain language summary Lifestyle interventions for treating acute gout attacks This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with acute gout. There was one study included in this review, which looked at the benefits and safety of adding topical ice therapy to medications commonly used for treating acute gout (prednisolone and colchicine). Over a one week period, in addition to prednisolone and colchicine, ice was applied to the skin overlying the joints affected by acute gout, for half‐an‐hour, four times per day, to relieve symptoms of pain and warmth and to reduce signs of redness and swelling. The review shows that in people with acute gout: We are uncertain whether the reduction in pain seen with the addition of topical ice to standard treatment of prednisolone and colchicine, compared to prednisolone and colchicine alone, is a true effect because of the very low quality evidence. Joint function, health‐related quality of life, patient global assessment and side effects and complications were not reported. We often do not have precise information about side effects and complications. Topical ice is likely to be a safe intervention. What is gout and what are lifestyle interventions? Gout is a very common cause of painful joint inflammation (arthritis) and is caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness, warmth and swelling of the affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic make‐up, being overweight, ingesting certain medications (for example cyclosporine), having impaired kidney function, and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Medications are the mainstay of acute gout treatment. Given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as consuming more water, coffee, dairy milk and cherry juice, and having fewer sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout to prevent recurrence of attacks. Best estimate of what happens to people with acute gout using topical ice in addition to medications: Joint pain (lower score means less pain) People who used topical ice (for half‐an‐hour, four times per day for one week) in addition to medical treatment (oral prednisolone and colchicine) rated their pain 3.33 points lower on a 0 to 10 point pain scale (33% absolute improvement).
 ‐ People who used topical ice in addition to medical treatment (prednisolone and colchicine) rated their pain to be 2.25 points on a scale of 0 to 10.
 ‐ People who used medical treatment alone rated their pain to be 5.58 points on a scale of 0 to 10. ‐ Three people would need to be treated with topical ice for one person to benefit from pain relief. Adverse events Side effects or complications of using topical ice in addition to medical therapy were not reported in the study.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY; Sriranganathan, MK; Edwards, CJ; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010519.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "135ba116-ef46-4a01-b885-3d3e1b605ec9", "pmid": "", "title": "Long‐acting muscarinic antagonists (LAMA) added to combination long‐acting beta₂‐agonists and inhaled corticosteroids (LABA/ICS) versus LABA/ICS for adults with asthma", "imported": false, "abstract": "Abstract - Background Maintenance treatment with long‐acting beta 2 ‐agonists and inhaled corticosteroids (LABA/ICS) can relieve asthma symptoms and reduce the frequency of exacerbations, but there are limited treatment options for people who do not gain control on combination LABA/ICS. Long‐acting muscarinic antagonists (LAMA) are a class of inhaled drug which have been effective for people with chronic obstructive pulmonary disease and are now becoming available for people with asthma to take alongside their LABA/ICS inhaler. Objectives To assess the effects of adding a long‐acting muscarinic antagonist (LAMA) to combination long‐acting beta 2 ‐agonists (LABA) and inhaled corticosteroids (ICS) in adults whose asthma is not well controlled by LABA/ICS. Search methods We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to January 2016. We also searched ClinicalTrials.gov, the WHO trials portal, and reference lists of other reviews, and we contacted trial authors for additional information. Selection criteria We included parallel randomised controlled trials (RCTs) of at least 12 weeks' duration. Studies met the inclusion criteria if they compared LAMA as an add‐on to LABA/ICS versus LABA/ICS alone for adults with asthma. We included studies reported as full text, those published as abstract only, and unpublished data. Primary outcomes were exacerbations requiring oral corticosteroids (OCS), validated measures of asthma control, and serious adverse events (including mortality). Data collection and analysis Two review authors screened searches and independently extracted details on risk of bias and numerical data. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MD) using a random‐effects model. We rated all outcomes using GRADE. Main results We found four double‐blind, double‐dummy trials comparing LAMA to placebo, including 1197 people with asthma taking combination LABA/ICS. One of the trials was designed to study glycopyrronium bromide but was withdrawn prior to enrolment, and the other three all studied tiotropium bromide (mostly 5 µg once daily via Respimat) over 48 to 52 weeks. People in the trials had a mean forced expiratory volume in one second (FEV 1 ) of 55% of their predicted value, indicating severe asthma. People randomised to take tiotropium add‐on had fewer exacerbations requiring oral corticosteroids than those continuing to take LABA/ICS alone, but the confidence intervals did not rule out no difference (OR 0.76, 95% CI 0.57 to 1.02; moderate quality evidence). Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS would have to take oral corticosteroids for an exacerbation compared with 271 if they took tiotropium as well (95% CI 218 to 333 per 1000). Analyses comparing the number of exacerbations per patient in each group (rate ratio) and the time until first exacerbation (hazard ratio) were in keeping with the main result. Quality of life, as measured by the Asthma Quality of Life Questionnaire (AQLQ) was no better for those taking tiotropium add‐on than for those taking LABA/ICS alone when considered in light of the 0.5 minimal clinically important difference on the scale (MD 0.09, 95% CI − 0.03 to 0.20), and evidence for whether tiotropium increased or decreased serious adverse events in this population was inconsistent (OR 0.60, 95% CI 0.24 to 1.47; I 2 = 76%). Within the secondary outcomes, exacerbations requiring hospital admission were too rare to tell whether tiotropium was beneficial over LABA/ICS alone. There was high quality evidence showing benefits to lung function (trough FEV 1 and forced vital capacity (FVC)) and potentially small benefits to asthma control. People taking tiotropium add‐on were less likely to experience non‐serious adverse events. Authors' conclusions Tiotropium add‐on may have additional benefits over LABA/ICS alone in reducing the need for rescue oral steroids in people with severe asthma. The effect was imprecise, and there was no evidence for other LAMA preparations. Possible benefits on quality of life were negligible, and evidence for the effect on serious adverse events was inconsistent. There are likely to be small added benefits for tiotropium Respimat 5 µg daily on lung function and asthma control over LABA/ICS alone and fewer non‐serious adverse events. The benefit of tiotropium add‐on on the frequency of hospital admission is still unknown, despite year‐long trials. Ongoing and future trials should clearly describe participants' background medications to help clinicians judge how the findings relate to stepwise care. If studies test LAMAs other than tiotropium Respimat for asthma, they should be at least six months long and use accepted and validated outcomes to allow comparisons of the safety and effectiveness between different preparations. Plain language summary Does adding tiotropium, a long‐acting muscarinic antagonist (LAMA), to combination therapy (LABA/ICS) help to control asthma? Adding the LAMA tiotropium Respimat inhaler to combination LABA/ICS inhaler may reduce the need for rescue oral steroids. A noticeable benefit on quality of life is unlikely, and we couldn't tell if it reduced hospital admissions, but adding tiotropium has some benefit on lung function, asthma control, and non‐serious side effects. More detail about the studies and results: Taking a daily inhaler containing a long‐acting beta 2 ‐agonist and an inhaled corticosteroid (LABA/ICS) can improve symptoms and reduce the likelihood of asthma attacks. If this doesn't help, another type of inhaled drug called a long‐acting muscarinic antagonist (LAMA), which has been effective for people with other breathing conditions, is now available for people with asthma to take as well as their LABA/ICS inhaler. We wanted to find out whether adding a LAMA to LABA/ICS is better than continuing LABA/ICS alone for adults with asthma. We found four relevant studies, but one was withdrawn before anyone was signed up. The other three compared a LAMA called tiotropium Respimat to placebo for around a year, with participants in both groups continuing to take their usual LABA/ICS inhaler. People generally had quite poor lung function when they entered the studies, suggesting their asthma was not well controlled ‐ in respiratory medicine, this is known as 'severe asthma'. Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS had to take a course of oral steroids compared with 271 if they took tiotropium as well. However, uncertainty in the results meant that rather than there being 271 people taking oral steroids, there could be anywhere from 218 to 333 people per 1000 who would have to take oral steroids, so we couldn't be sure of the benefit. Quality of life scores were not that different between those who took tiotropium and those who didn't. The studies showed different results for whether people taking tiotropium were more likely to suffer a serious side effect, but fewer people had non‐serious side effects if they took tiotropium. We couldn't tell whether taking tiotropium on top of LABA/ICS reduced the number of people who had to go to hospital for an asthma attack because it didn't happen often enough for us to have confidence in the result. There was high quality evidence that showed benefits to lung function and probably small benefits on measures of asthma control.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Kew, KM, Dahri, K", "articleTypes": [], "doi": "10.1002/14651858.CD011721.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.769Z" }, { "id": "135bdf7e-6ab3-4809-8b12-3fb03552e670", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 2. Less commonly‐used drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of mainly cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres (˜ 8200 feet). Acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude ascent. In this second review, in a series of three about preventive strategies for HAI, we assessed the effectiveness of five of the less commonly used classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of five of the less commonly used pharmacological interventions for preventing acute HAI in participants who are at risk of developing high altitude illness in any setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in May 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text search terms. We scanned the reference lists and citations of included trials and any relevant systematic reviews that we identified for further references to additional trials. Selection criteria We included randomized controlled trials conducted in any setting where one of five classes of drugs was employed to prevent acute HAI: selective 5‐hydroxytryptamine(1) receptor agonists; N‐methyl‐D‐aspartate (NMDA) antagonist; endothelin‐1 antagonist; anticonvulsant drugs; and spironolactone. We included trials involving participants who are at risk of developing high altitude illness (AMS or HACE, or HAPE, or both). We included participants with and without a history of high altitude illness. We applied no age or gender restrictions. We included trials where the relevant medication was administered before the beginning of ascent. We excluded trials using these drugs during ascent or after ascent. Data collection and analysis We used the standard methodological procedures employed by Cochrane. Main results We included eight studies (334 participants, 9 references) in this review. Twelve studies are ongoing and will be considered in future versions of this review as appropriate. We have been unable to obtain full‐text versions of a further 12 studies and have designated them as 'awaiting classification'. Four studies were at a low risk of bias for randomization; two at a low risk of bias for allocation concealment. Four studies were at a low risk of bias for blinding of participants and personnel. We considered three studies at a low risk of bias for blinding of outcome assessors. We considered most studies at a high risk of selective reporting bias. We report results for the following four main comparisons. Sumatriptan versus placebo (1 parallel study; 102 participants) Data on sumatriptan showed a reduction of the risk of AMS when compared with a placebo (risk ratio (RR) = 0.43, CI 95% 0.21 to 0.84; 1 study, 102 participants; low quality of evidence). The one included study did not report events of HAPE, HACE or adverse events related to administrations of sumatriptan. Magnesium citrate versus placebo (1 parallel study; 70 participants) The estimated RR for AMS, comparing magnesium citrate tablets versus placebo, was 1.09 (95% CI 0.55 to 2.13; 1 study; 70 participants; low quality of evidence). In addition, the estimated RR for loose stools was 3.25 (95% CI 1.17 to 8.99; 1 study; 70 participants; low quality of evidence). The one included study did not report events of HAPE or HACE. Spironolactone versus placebo (2 parallel studies; 205 participants) Pooled estimation of RR for AMS was not performed due to considerable heterogeneity between the included studies (I² = 72%). RR from individual studies was 0.40 (95% CI 0.12 to 1.31) and 1.44 (95% CI 0.79 to 2.01; very low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Acetazolamide versus spironolactone (1 parallel study; 232 participants) Data on acetazolamide compared with spironolactone showed a reduction of the risk of AMS with the administration of acetazolamide (RR = 0.36, 95% CI 0.18 to 0.70; 232 participants; low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Authors' conclusions This Cochrane Review is the second in a series of three providing relevant information to clinicians and other interested parties on how to prevent high altitude illness. The assessment of five of the less commonly used classes of drugs suggests that there is a scarcity of evidence related to these interventions. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Overall, the evidence is limited due to the low number of studies identified (for most of the comparison only one study was identified); limitations in the quality of the evidence (moderate to low); and the number of studies pending classification (24 studies awaiting classification or ongoing). We lack the large and methodologically sound studies required to establish or refute the efficacy and safety of most of the pharmacological agents evaluated in this review. Plain language summary Medicines less commonly used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and lung conditions that can occur during travel to altitudes above 2500 metres (˜ 8200 feet). HAI‐related conditions are generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but primarily affect the brain (drowsiness, confusion or unconsciousness) or the lungs (cough, breathlessness) in different individuals. We assessed five classes of medicines less commonly used to prevent the onset of this illness in this review. Study characteristics The evidence is current to May 2017. We included eight studies and 334 participants related to five different classes of medicines sometimes recommended for HAI prevention. These medicines included those that mimic the action of serotonin at selected sites (selective 5‐hydroxytryptamine(1) receptor agonists), medicines that regulate the action of calcium (N‐methyl‐D‐aspartate (NMDA) antagonist), medicines that promote dilation of the blood vessels (endothelin‐1 antagonist), medicines that prevent a neuron (nerve cell) from 'firing' (initiating an action) and convulsions from developing (anticonvulsant medicines), as well as medicines that regulate the body´s sodium and water levels (spironolactone). All studies were undertaken in high altitude mountain areas. The participants ranged between 16 and 65 years of age. Only one study included people at a high risk of this condition due to their history of HAI. Four trials provided the intervention between one to three days prior to the ascent (50%), and three trials less than 24 hours prior (37.5%). The participants in all these studies reached a final altitude of between 3500 and 5895 metres above sea level. Only one of the eight included studies did not provide clear information about the source of funding (12.5%). Twenty‐four additional studies were classified as ongoing (12), or awaiting classification (12; unable to obtain full texts). Key results The assessment of the less commonly used pharmacological interventions suggest that there is a scarcity of evidence related to these interventions. For most of the assessed comparisons, we only found evidence from a single study. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Quality of the evidence The quality of the evidence was rated from low to very low. Several studies had quality shortcomings such as only having small sample sizes and therefore generating uncertain results. For most of the medicines evaluated, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Gonzalez Garay, AG; Molano Franco, D; Nieto Estrada, VH; Martí‐Carvajal, AJ; Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD012983", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "1365a254-a43b-4377-aac0-62aca2e4a537", "pmid": "", "title": "Zinc supplements for preventing otitis media", "imported": false, "abstract": "Abstract - Background Otitis media is inflammation of the middle ear and is usually caused by infection. It affects people of all ages but is particularly common in young children. Around 164 million people worldwide have long‐term hearing loss caused by this condition, 90% of them in low‐income countries. As zinc supplements prevent pneumonia in disadvantaged children, we wanted to investigate whether zinc supplements could also prevent otitis media. Objectives To evaluate whether zinc supplements prevent otitis media in adults and children of different ages. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (1950 to February week 4, 2014) and EMBASE (1974 to March 2014). Selection criteria Randomised, placebo‐controlled trials of zinc supplements given at least once a week for at least a month for preventing otitis media. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of the included trials and extracted and analysed data. We summarised results using risk ratios (RRs) or rate ratios for dichotomous data and mean differences (MDs) for continuous data. We combined trial results where appropriate. Main results No new trials were identified for inclusion in this update. We identified 12 trials for inclusion, 10 of which contributed outcomes data. There were a total of 6820 participants. In trials of healthy children living in low‐income communities, two trials did not demonstrate a significant difference between the zinc‐supplemented and placebo groups in the numbers of participants experiencing an episode of definite otitis media during follow‐up (3191 participants); another trial showed a significantly lower incidence rate of otitis media in the zinc group (rate ratio 0.69, 95% confidence interval (CI) 0.61 to 0.79, n = 1621). A small trial of 39 infants undergoing treatment for severe malnutrition suggested a benefit of zinc for the mean number of episodes of otitis media (mean difference (MD) ‐1.12 episodes, 95% CI ‐2.21 to ‐0.03). Zinc supplements did not seem to cause any serious adverse events but a small minority of children were reported to have vomited shortly after ingestion of the supplements. The trial evidence included is generally of good quality, with a low risk of bias. Authors' conclusions Evidence on whether zinc supplementation can reduce the incidence of otitis media in healthy children under the age of five years living in low‐ and middle‐income countries is mixed. There is some evidence of benefit in children being treated for marasmus (severe malnutrition), but this is based on one small trial and should therefore be treated with caution. Plain language summary Zinc supplements for preventing middle ear infections Background Middle ear infections are common, especially among young children, usually causing earache and some temporary (occasionally permanent) hearing loss. Zinc is an essential micronutrient, which has a role in the optimal functioning of the immune system and resistance to infection. It must be consumed regularly as it cannot be stored in the body. Some people, especially children in low‐ and middle‐income countries, may not have adequate zinc intake from food alone. Researchers have examined the potential role of zinc supplements in preventing infective illnesses. Therefore we wanted to discover whether zinc supplements have any role in preventing middle ear infections. Study characteristics The review authors searched the medical literature for studies up to March 2014. We searched for trials which compared middle ear infections in people randomly selected to receive zinc supplements or who did not receive supplements. We found 10 eligible studies, all conducted amongst young children. The total number of participants was 6820. Nine trials were conducted in low‐ and middle‐income countries. Seven trials were conducted on healthy children. Participants included both males and females. Results The results of the trials provided no convincing evidence that zinc supplements reduce the occurrence of middle ear infections in healthy children. However, in one small study of severely malnourished children, those receiving zinc supplements had fewer middle ear infections. The only adverse effect was vomiting. Quality of evidence The trial evidence included is generally of good quality, with a low risk of bias. All the included trials included otitis media only as a secondary outcome. Therefore, there was a potential to miss trials which were less publicised or less well indexed within the electronic databases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Gulani, A, Sachdev, HS", "articleTypes": [], "doi": "10.1002/14651858.CD006639.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.765Z" }, { "id": "136bb7cf-2bb9-4ca6-9875-c606805b4d95", "pmid": "", "title": "Interventions to prevent obesity in children aged 12 to 18 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or ‘activity’ levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review. Objectives To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta‐analyses. Sixty studies were based in high‐income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty‐one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short‐term follow‐up (mean difference (MD) ‐0.18, 95% confidence interval (CI) ‐0.41 to 0.06; 3 studies, 605 participants), medium‐term follow‐up (MD ‐0.65, 95% CI ‐1.18 to ‐0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long‐term follow‐up (MD ‐0.14, 95% CI ‐0.38 to 0.10; 2 studies, 1089 participants); all very low‐certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long‐term follow‐up (MD ‐0.30, 95% CI ‐1.67 to 1.07; 1 study, 44 participants); zBMI at short‐term (MD ‐0.06, 95% CI ‐0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium‐term (MD 0.02, 95% CI ‐0.17 to 0.21; 1 study, 112 participants) follow‐up; all low‐certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low‐certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short‐term follow‐up (MD ‐0.64, 95% CI ‐1.86 to 0.58; 6 studies, 1780 participants; low‐certainty evidence) and probably do not reduce zBMI at medium‐ (MD 0, 95% CI ‐0.04 to 0.05; 6 studies, 5335 participants) or long‐term (MD ‐0.05, 95% CI ‐0.12 to 0.02; 1 study, 985 participants) follow‐up; both moderate‐certainty evidence. Activity interventions do not reduce zBMI at short‐term follow‐up (MD 0.02, 95% CI ‐0.01 to 0.05; 7 studies, 4718 participants; high‐certainty evidence), but may reduce BMI slightly at medium‐term (MD ‐0.32, 95% CI ‐0.53 to ‐0.11; 3 studies, 2143 participants) and long‐term (MD ‐0.28, 95% CI ‐0.51 to ‐0.05; 1 study, 985 participants) follow‐up; both low‐certainty evidence. Seven studies (5428 participants; low‐certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short‐term follow‐up (MD 0.03, 95% CI ‐0.07 to 0.13; 11 studies, 3429 participants; high‐certainty evidence), and probably do not reduce BMI at medium‐term (MD 0.01, 95% CI ‐0.09 to 0.11; 8 studies, 5612 participants; moderate‐certainty evidence) or long‐term (MD 0.06, 95% CI ‐0.04 to 0.16; 6 studies, 8736 participants; moderate‐certainty evidence) follow‐up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD ‐0.09, 95% CI ‐0.2 to 0.02; 3 studies, 515 participants; very low‐certainty evidence), and they may not reduce zBMI at medium‐term (MD ‐0.05, 95% CI ‐0.1 to 0.01; 6 studies, 3511 participants; low‐certainty evidence) or long‐term (MD ‐0.02, 95% CI ‐0.05 to 0.01; 7 studies, 8430 participants; low‐certainty evidence) follow‐up. Four studies (2394 participants) reported data on serious adverse events (very low‐certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect. Authors' conclusions The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low‐certainty evidence that activity interventions may have a small beneficial effect on BMI at medium‐ and long‐term follow‐up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples. Plain language summary Do dietary and activity strategies help prevent obesity in children and young people aged 12 to 18 years? Key messages ‐ Strategies to encourage adolescents to change their diet or activity levels (or both), to prevent them becoming overweight or developing obesity make no or very little difference to their body mass index (BMI; an estimate of the amount of body fat according to height and weight). ‐ Based on the very little information available about serious adverse events, there appears to be little or no effect of dietary or activity strategies, or both, to results in serious harms (e.g. injuries). ‐ Due to a lack of evidence, future research should focus on community settings (e.g. in youth clubs) and research involving adolescents with disabilities. Why is preventing obesity in children and young people important? More adolescents are developing overweight and obesity worldwide. Being overweight as an adolescent can cause health problems, and people may be affected psychologically and in their social life. Puberty and moving into adulthood is a challenging time, and many struggle with their mental health. Overweight adolescents are likely to be overweight or obese as adults and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help adolescents modify their diet or activity (or both) were effective at preventing obesity. We also wanted to know if these strategies were associated with any serious harms. What did we do? We searched scientific databases for studies that looked at ways of preventing obesity in children aged 12 to 18 years. We excluded studies aimed at adolescents who were already overweight or living with obesity. However, we included studies where the sample was a whole group (e.g. a school), which may have included those living with overweight or obesity. We only included studies if the methods they used aimed to change the children's diet, their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed children into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 74 studies involving 83,407 children and young people. Sixty studies were based in high‐income countries (e.g. USA and in Europe). In 57 studies, the strategies were tried in schools, although 12 were based at home or other places like community settings (five studies) such as youth groups. Fifty‐one strategies were implemented for fewer than nine months; the shortest intervention lasted one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five studies were partly funded by industry (food suppliers, a PlayStation manufacturer, a gym equipment supplier, a healthcare device manufacturer and a private healthcare facility). Our analyses included results from 54 studies of 46,358 adolescents (20 studies did not report their results in a way that could be included in our analyses). We found that adolescents who were helped with a strategy to change their diet or activity levels (or both) either did not reduce their BMI, or any reduction was meagre, compared to adolescents who were not given a strategy. Only a few studies reported any possible harms of the interventions, and none identified serious harms. What are the limitations of the evidence? Overall, we have limited confidence in the beneficial effects of these interventions in preventing obesity in children and adolescents. It is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. Many studies had limitations in how they were done (e.g. in some studies, the methods used to randomly place people into groups were not adequate or the results of some of the studies were not analysed correctly). 3. There were not enough studies reporting particular types of outcomes, such as BMI (an estimate of the amount of body fat according to height and weight) or zBMI (comparison of a child’s BMI with other children of the same age and sex) for a particular duration of follow‐up to be certain about the results for some comparisons. Also, certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way that we could include them in our analyses (e.g. without any detail of the difference in change between the intervention and control groups) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for adolescents with disabilities, or whether those implemented in community settings are effective. How up to date is this evidence? This review supersedes our previous review. The evidence is up‐to‐date until February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F; Tomlinson, E; Davies, AL; Moore, THM; Dawson, S; Breheny, K; Savović, J; Hodder, RK; Wolfenden, L; Higgins, JPT; Summerbell, CD", "articleTypes": [], "doi": "10.1002/14651858.CD015330.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "13a3af54-55fb-485e-b2bb-145d9db41e68", "pmid": "", "title": "Effects on Sleep Quality and Bioelectrical Parameters of Cellular Health After Administration of a Plant Protein Supplement Combined With Ashwagandha and Rhodiola", "imported": false, "abstract": "This study evaluates whether a combination of plant protein with adaptogenic herbs (ashwagandha and rhodiola) can improve sleep quality in middle-aged adults with sleep disturbances.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.159Z" }, { "id": "13bbf99d-5a31-4e92-9501-3601a103feee", "pmid": "", "title": "Probiotics for the prevention of pediatric antibiotic‐associated diarrhea", "imported": false, "abstract": "Abstract - Background Antibiotics alter the microbial balance commonly resulting in antibiotic‐associated diarrhea (AAD). Probiotics may prevent AAD via providing gut barrier, restoration of the gut microflora, and other potential mechanisms of action. Objectives The primary objectives were to assess the efficacy and safety of probiotics (any specified strain or dose) used for the prevention of AAD in children. Search methods MEDLINE, Embase, CENTRAL, CINAHL, and the Web of Science (inception to 28 May 2018) were searched along with registers including the ISRCTN and Clinicaltrials.gov. We also searched the NICE Evidence Services database as well as reference lists from relevant articles. Selection criteria Randomized, parallel, controlled trials in children (0 to 18 years) receiving antibiotics, that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhea secondary to antibiotic use were considered for inclusion. Data collection and analysis Study selection, data extraction, and risk of bias assessment were conducted independently by two authors. Dichotomous data (incidence of AAD, adverse events) were combined using a pooled risk ratio (RR) or risk difference (RD), and continuous data (mean duration of diarrhea) as mean difference (MD), along with corresponding 95% confidence interval (95% CI). We calculated the number needed to treat for an additional beneficial outcome (NNTB) where appropriate. For studies reporting on microbiome characteristics using heterogeneous outcomes, we describe the results narratively. The certainty of the evidence was evaluated using GRADE. Main results Thirty‐three studies (6352 participants) were included. Probiotics assessed included Bacillus spp., Bifidobacterium spp., Clostridium butyricum , Lactobacilli spp. , Lactococcus spp., Leuconostoc cremoris , Saccharomyces spp., or Streptococcus spp., alone or in combination. The risk of bias was determined to be high in 20 studies and low in 13 studies. Complete case (patients who did not complete the studies were not included in the analysis) results from 33 trials reporting on the incidence of diarrhea show a precise benefit from probiotics compared to active, placebo or no treatment control. After 5 days to 12 weeks of follow‐up, the incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group (RR 0.45, 95% CI 0.36 to 0.56; I² = 57%, 6352 participants; NNTB 9, 95% CI 7 to 13; moderate certainty evidence). Nineteen studies had loss to follow‐up ranging from 1% to 46%. After making assumptions for those lost, the observed benefit was still statistically significant using an extreme plausible intention‐to‐treat (ITT) analysis, wherein the incidence of AAD in the probiotic group was 12% (436/3551) compared to 19% (664/3468) in the control group (7019 participants; RR 0.61; 95% CI 0.49 to 0.77; P <0.00001; I² = 70%). An a priori available case subgroup analysis exploring heterogeneity indicated that high dose (≥ 5 billion CFUs per day) is more effective than low probiotic dose (< 5 billion CFUs per day), interaction P value = 0.01. For the high dose studies the incidence of AAD in the probiotic group was 8% (162/2029) compared to 23% (462/2009) in the control group (4038 participants; RR 0.37; 95% CI 0.30 to 0.46; P = 0.06; moderate certainty evidence). For the low dose studies the incidence of AAD in the probiotic group was 8% (97/1155) compared to 13% (133/1059) in the control group (2214 participants; RR 0.68; 95% CI 0.46 to 1.01; P = 0.02). Again, assumptions for loss to follow‐up using an extreme plausible ITT analysis was statistically significant. For high dose studies the incidence of AAD in the probiotic group was 13% (278/2218) compared to 23% (503/2207) in control group (4425 participants; RR 0.54; 95% CI 0.42 to 0.70; P <0.00001; I² = 68%; moderate certainty evidence). None of the 24 trials (4415 participants) that reported on adverse events reported any serious adverse events attributable to probiotics. Adverse event rates were low. After 5 days to 4 weeks follow‐up, 4% (86/2229) of probiotics participants had an adverse event compared to 6% (121/2186) of control participants (RD 0.00; 95% CI ‐0.01 to 0.01; P < 0.00001; I² = 75%; low certainty evidence). Common adverse events included rash, nausea, gas, flatulence, abdominal bloating, and constipation. After 10 days to 12 weeks of follow‐up, eight studies recorded data on our secondary outcome, the mean duration of diarrhea; with probiotics reducing diarrhea duration by almost one day (MD ‐0.91; 95% CI ‐1.38 to ‐0.44; P <0.00001; low certainty evidence). One study reported on microbiome characteristics, reporting no difference in changes with concurrent antibiotic and probiotic use. Authors' conclusions The overall evidence suggests a moderate protective effect of probiotics for preventing AAD (NNTB 9, 95% CI 7 to 13). Using five criteria to evaluate the credibility of the subgroup analysis on probiotic dose, the results indicate the subgroup effect based on high dose probiotics (≥ 5 billion CFUs per day) was credible. Based on high‐dose probiotics, the NNTB to prevent one case of diarrhea is 6 (95% CI 5 to 9). The overall certainty of the evidence for the primary endpoint, incidence of AAD, based on high dose probiotics was moderate due to the minor issues with risk of bias and inconsistency related to a diversity of probiotic agents used. Evidence also suggests that probiotics may moderately reduce the duration of diarrhea, a reduction by almost one day. The benefit of high dose probiotics (e.g. Lactobacillus rhamnosus or Saccharomyces boulardii ) needs to be confirmed by a large well‐designed multi‐centered randomized trial. It is premature to draw firm conclusions about the efficacy and safety of 'other' probiotic agents as an adjunct to antibiotics in children. Adverse event rates were low and no serious adverse events were attributable to probiotics. Although no serious adverse events were observed among inpatient and outpatient children, including small studies conducted in the intensive care unit and in the neonatal unit, observational studies not included in this review have reported serious adverse events in severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter use and disorders associated with bacterial/fungal translocation. Plain language summary Probiotics for the prevention of antibiotic‐associated diarrhea in children What is antibiotic‐associated diarrhea? Antibiotic‐associated diarrhea (AAD) occurs when antibiotics disturb the natural balance of \"good\" and \"bad\" bacteria in the intestinal tract causing harmful bacteria to multiply beyond their normal numbers. The symptoms of AAD include frequent watery bowel movements and crampy abdominal pain. What are probiotics? Probiotics are found in dietary supplements or yogurts and contain potentially beneficial bacteria or yeast. Probiotics may restore the natural balance of bacteria in the intestinal tract. What did the researchers investigate? The researchers investigated whether probiotics prevent AAD in children receiving antibiotic therapy and whether probiotics causes any harms (side effects). The researchers searched the medical literature extensively up to May 28, 2018. What did the researchers find? Thirty‐three studies were reviewed and provide the best available evidence. The studies tested 6352 children (3 days to 17 years of age) who were receiving probiotics co‐administered with antibiotics to prevent AAD. The participants received probiotics ( Lactobacilli spp., Bifidobacterium spp., Streptococcus spp. , or Saccharomyces boulardii alone or in combination), placebo (pills not including probiotics), other treatments thought to prevent AAD (i.e. diosmectite or infant formula) or no treatment. The studies were short‐term, ranging in length from 5 days to 12 weeks. Analyses showed that probiotics are effective for preventing AAD. The incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group, demonstrating a moderate reduction (11% fewer will suffer diarrhea). For every 9 children treated, probiotics will prevent one case of diarrhea. Further, evidence suggests that higher dose probiotics (≥ 5 billion CFUs per day) reduce the incidence of AAD. Eight per cent (162/2029) of the high dose probiotics group had AAD compared to 23% (462/2009) in the control group, demonstrating a moderate to large reduction (15% fewer suffer diarrhea). Probiotics were generally well tolerated, and minor side effects (e.g. rash, nausea, gas, flatulence, abdominal bloating, constipation) occurred infrequently. . Evidence suggested that probiotics are effective for a moderate reduction in duration of diarrhea (almost one day). Among the various probiotics evaluated, Lactobacillus rhamnosus or Saccharomyces boulardii at 5 to 40 billion colony forming units/day appear most appropriate for preventing AAD in children receiving antibiotics. It is premature to draw conclusions about the effectiveness and safety of 'other' probiotic agents for preventing AAD. Although no serious probiotic‐related side effects were observed among the mostly otherwise healthy children who participated in the studies, serious side effects have been reported in observational studies not included in this review, including severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter (a flexible tube used to give medicines) use and disorders associated with bacterial or fungal translocation (the passage of bacteria from the gut to other areas of the body).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Guo, Q; Goldenberg, JZ; Humphrey, C; El Dib, R; Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD004827.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "13c8209e-9ebf-418e-a366-0f784d5e78a9", "pmid": "", "title": "Acupuncture for Bell's palsy", "imported": false, "abstract": "Abstract - Background Bell's palsy or idiopathic facial palsy is an acute facial paralysis due to inflammation of the facial nerve. A number of studies published in China have suggested acupuncture is beneficial for facial palsy. Objectives The objective of this review was to examine the efficacy of acupuncture in hastening recovery and reducing long‐term morbidity from Bell's palsy. Search methods We updated the searches of the Cochrane Neuromuscular Disease Group Trials Specialized Register (24 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2010), MEDLINE (January 1966 to May 2010), EMBASE (January 1980 to May 2010), AMED (January 1985 to May 2010), LILACS (from January 1982 to May 2010) and the Chinese Biomedical Retrieval System (January 1978 to May 2010) for randomised controlled trials using 'Bell's palsy' and its synonyms, 'idiopathic facial paralysis' or 'facial palsy' as well as search terms including 'acupuncture'. Chinese journals in which we thought we might find randomised controlled trials relevant to our study were handsearched. We reviewed the bibliographies of the randomised trials and contacted the authors and known experts in the field to identify additional published or unpublished data. Selection criteria We included all randomised controlled trials involving acupuncture by needle insertion in the treatment of Bell's palsy irrespective of any language restrictions. Data collection and analysis Two review authors identified potential articles from the literature search, extracted data and assessed quality of each trial independently. All disagreements were resolved by discussion between the review authors. Main results The literature search and handsearching identified 49 potentially relevant articles. Of these, six RCTs were included involving 537 participants with Bell's palsy. Two more possible trials were identified in the update than the previous version of this systematic review, but both were excluded because they were not real RCTs. Of the six included trials, five used acupuncture while the other one used acupuncture combined with drugs. No trial reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. Authors' conclusions The quality of the included trials was inadequate to allow any conclusion about the efficacy of acupuncture. More research with high quality trials is needed. Plain language summary Acupuncture for Bell's palsy Bell's palsy or idiopathic facial palsy is the most common disorder affecting the facial nerves and results in weakness or paralysis on one side of the face. The paralysis causes distortion of the face and interferes with normal functions, such as closing the eye and eating. It is thought to be caused by inflammation of the facial nerve. According to Traditional Chinese Medicine, facial paralysis is known as 'deviated mouth'. It was attributed to 'wind' by past dynasties. 'Qi' refers to the vital substances comprising the human body and the physiological functions of viscera and bowels, channels and collaterals. It maintains life activities and reflects the resistance of the human body. Deficiency of 'qi' allows the invasion of exogenous pathogenic wind. Acupuncture is part of Traditional Chinese Medicine and dates back thousands of years. It involves inserting fine needles into specific points on the skin or applying various other techniques to the acupuncture points to bring about healing. In Bell's palsy, acupuncture treatment might have numerous beneficial effects. This review aimed to review systematically all randomised controlled trials and controlled clinical trials, which examined the effectiveness of acupuncture by needle insertion for Bell's palsy. Six studies including a total of 537 participants met the inclusion criteria. Five studies used acupuncture while the other used acupuncture combined with drugs. No trials reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. More research with high quality trials is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, N; Zhou, M; He, L; Zhou, D; Li, N", "articleTypes": [], "doi": "10.1002/14651858.CD002914.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "13ca0023-32b8-4b2e-8bea-aaeaf4e9eaed", "pmid": "", "title": "Effects of opioid, hypnotic and sedating medications on sleep‐disordered breathing in adults with obstructive sleep apnoea", "imported": false, "abstract": "Abstract - Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by partial or complete upper airway occlusion during sleep, leading to intermittent cessation (apnoea) or reduction (hypopnoea) of airflow and dips in arterial oxygen saturation during sleep. Many patients with recognised and unrecognised OSA receive hypnotics, sedatives and opiates/opioids to treat conditions including pain, anxiety and difficulty sleeping. Concerns have been expressed that administration of these drugs to people with co‐existing OSA may worsen OSA. Objectives To investigate whether administration of sedative and hypnotic drugs exacerbates the severity of OSA (as measured by the apnoea‐hypopnoea index (AHI) or the 4% oxygen desaturation index (ODI)) in people with known OSA. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR) of trials. The search was current as of March 2015. Selection criteria Randomised, placebo‐controlled trials including adult participants with confirmed OSA, where participants were randomly assigned to use opiates or opioids, sedatives, hypnotics or placebo. We included participants already using continuous positive airway pressure (CPAP) or a mandibular advancement device. Data collection and analysis We used standard methodological procedures as recommended by The Cochrane Collaboration. Main results Fourteen studies examining the effects of 10 drugs and including a total of 293 participants contributed to this review. Trials were small, with only two trials, which used sodium oxybate, recruiting more than 40 participants, and all but three trials were of only one to three nights in duration. Most participants had mild to moderate OSA with a mean AHI of 11 to 25 events/h, and only two trials recruited patients with severe OSA. Two trials investigating the effects of ramelteon, a treatment option for insomnia, recruited adults over 60 years of age with OSA and concomitant insomnia. The drugs studied in this review included remifentanil (infusion) 0.75 mcg/kg/h, eszopiclone 3 mg, zolpidem 10 and 20 mg, brotizolam 0.25 mg, flurazepam 30 mg, nitrazepam 10 mg to 15 mg, temazepam 10 mg, triazolam 0.25 mg, ramelteon 8 mg and 16 mg and sodium oxybate 4.5 g and 9 g. We were unable to pool most of the data, with the exception of data for eszopiclone and ramelteon. None of the drugs in this review produced a significant increase in AHI or ODI. Two trials have shown a beneficial effect on OSA. One study showed that a single administration of eszopiclone 3 mg significantly decreased AHI compared with placebo (24 ± 4 vs 31 ± 5; P value < 0.05), and a second study of sodium oxybate 4.5 g showed a significant decrease in AHI compared with placebo (mean difference (MD) ‐7.41, 95% confidence interval (CI) ‐14.17 to ‐0.65; N = 48). Only four trials reported outcome data on ODI. No significant increase, in comparison with placebo, was shown with eszopiclone (21 (22 to 37) vs 28.0 (15 to 36); P value = NS), zolpidem (0.81 ± 0.29 vs 1.46 ± 0.53; P value = NS), flurazepam (18.6 ± 19 vs 19.6 ± 15.9; P value = NS) and temazepam (6.53 ± 9.4 vs 6.56 ± 8.3; P value = 0.98). A significant decrease in minimum nocturnal peripheral capillary oxygen saturation (SpO 2 ) was observed with zolpidem 20 mg (76.8 vs 85.2; P value = 0.002), flurazepam 30 mg (81.7 vs 85.2; P value = 0.002), remifentanil infusion (MD ‐7.00, 95% CI ‐11.95 to ‐2.05) and triazolam 0.25 mg in both rapid eye movement (REM) and non‐REM (NREM) sleep (MD ‐14.00, 95% CI ‐21.84 to ‐6.16; MD ‐10.20, 95% CI ‐16.08 to ‐4.32, respectively. One study investigated the effect of an opiate (remifentanil) on patients with moderate OSA. Remifentanil infusion did not significantly change AHI (MD 10.00, 95% CI ‐9.83 to 29.83); however it did significantly decrease the number of obstructive apnoeas (MD ‐9.00, 95% CI ‐17.40 to ‐0.60) and significantly increased the number of central apnoeas (MD 16.00, 95% CI ‐2.21 to 34.21). Similarly, although without significant effect on obstructive apnoeas, central apnoeas were increased in the sodium oxybate 9 g treatment group (MD 7.3 (18); P value = 0.005) in a cross‐over trial. Drugs studied in this review were generally well tolerated, apart from adverse events reported in 19 study participants prescribed remifentanil (n = 1), eszopiclone (n = 6), sodium oxybate (n = 9) or ramelteon (n = 3). Authors' conclusions The findings of this review show that currently no evidence suggests that the pharmacological compounds assessed have a deleterious effect on the severity of OSA as measured by change in AHI or ODI. Significant clinical and statistical decreases in minimum overnight SpO 2 were observed with remifentanil, zolpidem 20 mg and triazolam 0.25 mg. Eszopiclone 3 mg and sodium oxybate 4.5 g showed a beneficial effect on the severity of OSA with a reduction in AHI and may merit further assessment as a potential therapeutic option for a subgroup of patients with OSA. Only one trial assessed the effect of an opioid (remifentanil); some studies included CPAP treatment, whilst in a significant number of participants, previous treatment with CPAP was not stated and thus a residual treatment effect of CPAP could not be excluded. Most studies were small and of short duration, with indiscernible methodological quality.Caution is therefore required when such agents are prescribed for patients with OSA, especially outside the severity of the OSA cohorts and the corresponding dose of compounds given in the particular studies. Larger, longer trials involving patients across a broader spectrum of OSA severity are needed to clarify these results. Plain language summary Effects of opioid, hypnotic and sedating medications on obstructive sleep apnoea (OSA) in adults with known OSA Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by intermittent apnoeas (pauses in breathing) leading to dips in oxygen levels in the blood during sleep. Many people with known or unknown (undiagnosed) OSA receive hypnotics, sedatives and opiate/opioid drugs to treat other conditions including pain, anxiety and difficulty sleeping. Opiates/opioids are commonly prescribed to treat pain after major surgery. These drugs might make sleep apnoea worse ‐ increasing the frequency and duration of apnoeas. Review question We set out to look at evidence derived from randomised placebo‐controlled trials to identify the risks of these drugs for patients with known OSA. What we did We searched and reviewed all randomised placebo‐controlled trials involving adult patients with known OSA who received these drugs. Most of the trials were short at just one or two nights' duration, involved only a small number of patients and used poorly described methodology. Therefore it was difficult to find out the exact effects of these drugs on patients with OSA. Results We found 14 studies examining the effects of 10 drugs in trials including 293 people. Opiates and opioids (treatment of acute and chronic pain) Remifentanil infusion Remifentanil infusion did not significantly change severity of OSA as measured by numbers and duration of pauses in breathing during sleep, but it significantly lowered minimum oxygen levels during the night when compared with placebo. Sedatives and hypnotics 'Z drugs' (a treatment for insomnia, inability to fall asleep or inability to maintain sleep) Eszopiclone and zolpidem Eszopiclone did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, it reduced the severity of OSA, and it might be beneficial in treating this condition, although further studies are needed to assess this effect. Zolpidem did not significantly worsen OSA as measured by the numbers and duration of pauses in breathing during sleep, but in one trial, it significantly lowered minimum oxygen levels during the night when compared with placebo. Benzodiazepines (short‐term relief of severe anxiety, behavioural disturbance or agitation and panic disorders) Brotizolam, flurazepam, nitrazepam, temazepam and triazolam None of the drugs examined had significantly worsened OSA as measured by the numbers and duration of pauses in breathing during sleep. In small, single‐night studies, zolpidem 20 mg, flurazepam 20 mg and triazolam 0.25 mg showed a tendency to increase numbers and duration of pauses during sleep, which was not statistically significant, but these drugs significantly lowered minimum oxygen levels during the night when compared with placebo. Sodium oxybate (a treatment for narcolepsy, a condition causing excessive sleepiness during the day) Sodium oxybate was compared with placebo in two trials. Results showed that sodium oxybate did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, sodium oxybate 4.5 g reduced the severity of OSA and might have proved beneficial in treating this condition, although further studies are needed to assess this effect. Melatonin and melatonin‐related drugs Ramelteon (a treatment drug for insomnia) Ramelteon was assessed in older adults, over 60 years of age, with OSA and insomnia and was found not to worsen OSA. Results of this review show that the drugs studied do not worsen the severity of OSA as measured by the numbers and duration of pauses in breathing during sleep, but significant clinical and statistical decreases in minimum oxygen levels during the night were observed with remifentanil, zolpidem and triazolam; therefore prescribing these drugs for patients with OSA still warrants caution. Sodium oxybate 4.5 g and eszopiclone reduced the severity of OSA and might be beneficial in treating this condition; nonetheless further studies are needed to support these results. Bottom line The long‐term effect and potential side effects of sedative drugs in people with OSA need to be assessed in larger, longer and methodologically robust studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mason, M, Cates, CJ, Smith, I", "articleTypes": [], "doi": "10.1002/14651858.CD011090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.793Z" }, { "id": "13cc03e1-f82f-46fb-a8fc-96957bb568fc", "pmid": "", "title": "Pharmacological interventions for cognitive decline in people with Down syndrome", "imported": false, "abstract": "Abstract - Background People with Down syndrome are vulnerable to developing dementia at an earlier age than the general population. Alzheimer's disease and cognitive decline in people with Down syndrome can place a significant burden on both the person with Down syndrome and their family and carers. Various pharmacological interventions, including donepezil, galantamine, memantine and rivastigmine, appear to have some effect in treating cognitive decline in people without Down syndrome, but their effectiveness for those with Down syndrome remains unclear. Objectives To assess the effectiveness of anti‐dementia pharmacological interventions and nutritional supplements for treating cognitive decline in people with Down syndrome. Search methods In January 2015, we searched CENTRAL, ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), Ovid MEDLINE, Embase, PsycINFO, seven other databases, and two trials registers. In addition, we checked the references of relevant reviews and studies and contacted study authors, other researchers and relevant drug manufacturers to identify additional studies. Selection criteria Randomised controlled trials (RCTs) of anti‐dementia pharmacological interventions or nutritional supplements for adults (aged 18 years and older) with Down syndrome, in which treatment was administered and compared with either placebo or no treatment. Data collection and analysis Two review authors independently assessed the risk of bias of included trials and extracted the relevant data. Review authors contacted study authors to obtain missing information where necessary. Main results Only nine studies (427 participants) met the inclusion criteria for this review. Four of these (192 participants) assessed the effectiveness of donepezil, two (139 participants) assessed memantine, one (21 participants) assessed simvastatin, one study (35 participants) assessed antioxidants, and one study (40 participants) assessed acetyl‐L‐carnitine. Five studies focused on adults aged 45 to 55 years, while the remaining four studies focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one between Norway and the UK, and one in Japan. Follow‐up periods in studies ranged from four weeks to two years. The reviewers judged all included studies to be at low or unclear risk of bias. Analyses indicate that for participants who received donepezil, scores in measures of cognitive functioning (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) ‐0.27 to 1.13) and measures of behaviour (SMD 0.42, 95% CI ‐0.06 to 0.89) were similar to those who received placebo. However, participants who received donepezil were significantly more likely to experience an adverse event (odds ratio (OR) 0.32, 95% CI 0.16 to 0.62). The quality of this body of evidence was low. None of the included donepezil studies reported data for carer stress, institutional/home care, or death. For participants who received memantine, scores in measures of cognitive functioning (SMD 0.05, 95% CI ‐0.43 to 0.52), behaviour (SMD ‐0.17, 95% CI ‐0.46 to 0.11), and occurrence of adverse events (OR 0.45, 95% CI 0.18 to 1.17) were similar to those who received placebo. The quality of this body of evidence was low. None of the included memantine studies reported data for carer stress, institutional/home care, or death. Due to insufficient data, it was possible to provide a narrative account only of the outcomes for simvastatin, antioxidants, and acetyl‐L‐carnitine. Results from one pilot study suggest that participants who received simvastatin may have shown a slight improvement in cognitive measures. Authors' conclusions Due to the low quality of the body of evidence in this review, it is difficult to draw conclusions about the effectiveness of any pharmacological intervention for cognitive decline in people with Down syndrome. Plain language summary Medications for cognitive decline in people with Down syndrome People with Down syndrome often experience cognitive decline (a deterioration in memory, language, thinking and judgment that are greater than normal age‐related changes) at a younger age and in greater numbers than the general population. Various medicines have been shown to improve, or at least slow down the progression of these symptoms in people without Down syndrome. Review question Do adults (18 years and older) with Down syndrome benefit from treatment with medicine to prevent cognitive decline, compared with other adults with Down syndrome who receive either fake medicine (placebos) or no medicine? Study characteristics In January 2015, we, a team of Cochrane researchers, searched for all medical studies that investigated the effect of any medicine or nutritional supplement on cognitive decline in adults with Down syndrome. We found nine relevant randomised controlled trials (this design produces the most reliable results) that we could include in this overview. These studies tested: ‐ donepezil, a medicine used to treat Alzheimer's disease (four studies); ‐ memantine, a medicine used to treat Alzheimer's disease (two studies); ‐ simvastatin, a (statin) medicine used to prevent heart disease (one study); ‐ a mixture of antioxidants, including forms of vitamins C and E, and alpha‐lipoic acid (one study); and ‐ acetyl‐L‐carnitine, a dietary supplement that has previously been used to treat dementia (one study). Five of the studies focused on adults aged 45 to 55 years and four focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one took place in Norway and the UK, and one study was conducted in Japan. Key results The nine studies we found examined the effects of five medicines that are, or have been, used to prevent cognitive decline. All the studies compared the medicine being tested with a placebo (a tablet or capsule that looked and tasted like the medicine, but which contained no medicine). Generally, those who received the medicine did no better than those who received the placebo in any of the areas assessed in the studies. The areas assessed included general functioning (including memory and thinking, speech, mood and behaviour); cognitive functioning (including memory, following what’s going on around you); adaptive behaviours (being able to do day‐to‐day tasks); or behaviour problems (such as being irritable or aggressive). The only medicine to show any positive effect was the statin, simvastatin. Preliminary findings from a very small study showed that simvastin had some benefit on improving memory compared to placebo. In the four donepezil studies, those participants given donepezil reported more headaches, dizziness, and nausea than participants given placebo. In the two memantine studies, there was no difference between participants given memantine or placebo for reports of headaches, dizziness, and nausea. Quality of the evidence Although the included studies were well conducted, most involved small numbers of participants and for many of the areas assessed we could not combine results from two or more studies. Overall, the quality of this evidence is low. We cannot be certain whether any of these medicines are effective. Running more trials with more people over a longer period of time would allow us answer this question with greater certainty. We could not find any trials that investigated many of the medicines used to prevent cognitive decline, and so research is needed to explore the effectiveness of these medications in the Down syndrome population.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Livingstone, N; Hanratty, J; McShane, R; Macdonald, G", "articleTypes": [], "doi": "10.1002/14651858.CD011546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "13ec18d1-76ee-418b-a8ce-fb51b9439382", "pmid": "", "title": "Zinc for the common cold", "imported": false, "abstract": "Reason for withdrawal from publication September 2016 updated withdrawal notice 
 This Cochrane Review was withdrawn in April 2015, and this withdrawal notice was updated in September 2016. The review was withdrawn as result of comments submitted via the Cochrane Library by Harri Hemilä in February 2015. Hemilä identified multiple errors in this Cochrane Review and made allegations of plagiarism of text and data from a previously published systematic review (Hemilä H. Zinc Lozenges may shorten the duration of colds: a systematic review. Open Respiratory Medicine Journal 2011;5:51‐58. dx.doi.org/10.2174/1874306401105010051). The comments referred to the version of this review first published in June 2013 (Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2013;(6):CD001364. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001364.pub4/full) . The Cochrane Acute Respiratory Infections Group, which maintains the review, withdrew the review in April 2015, pending an assessment of the errors reported, and the group referred the allegations of plagiarism to the Editor in Chief. The Editor in Chief notified the authors of the concerns, and followed the Committee for Publication Ethics (COPE) guidelines. Replication of text was identified in the Cochrane Review. This was limited to copying of short phrases and was acknowledged by the authors. The level of text plagiarism was minor and at a level that would be addressed by a correction. The Editor in Chief carried out further investigation into the alleged plagiarism of data, with the co‐operation of the review authors, who provided supplementary information in support of their work. The allegations related to the derivation of means and standard deviations of data from some of the included studies. Although the authors acknowledge and cite the Hemilä 2011 review, the Editor in Chief considered that the authors’ explanation regarding some similarities in presented data between the two reviews was not conclusive. This version of the review will therefore remain withdrawn. April 2015 withdrawal notice 
 This review was withdrawn due to concerns raised via the feedback mechanism regarding the calculation and analysis of data in the review in April 2015. Whilst it is not unusual for reviews to be withdrawn, the editorial group took the view that it would be better to take a cautious approach and explore the source and calculation of data used in the analysis in more detail, rather than keep the review on the Cochrane Database of Systematic Reviews for the time being. The editorial group responsible for this previously published document have withdrawn it from publication.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Singh, M; Das, RR", "articleTypes": [], "doi": "10.1002/14651858.CD001364.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "13f8385d-75b8-41d1-b4c6-fe02eef535ad", "pmid": "", "title": "Immunosuppressive agents for myasthenia gravis", "imported": false, "abstract": "Abstract - Background The benefits of different immunosuppressants for myasthenia gravis (MG) are unclear. Objectives Assessment of immunosuppressant drug efficacy in MG. Search methods We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to July 2007), EMBASE (from January 1980 to July 2007), review and trial bibliographies and contacted trial authors. Selection criteria Types of studies: Randomised and quasi‐randomised controlled trials. Types of participants: Any age, any type or severity of MG regardless of concomitant treatment. Types of interventions: Any immunosuppressive agent. Types of outcome measures: Primary: 
 (1) Improvement or not at six months Secondary: 
 (1) Improvement or not at one year 
 (2) Need for other treatment, for example corticosteroid dose, at six months 
 (3) Number of exacerbations during the first year 
 (4) Acetylcholine receptor antibody titre after at least six months 
 (5) Occurrence of one or more adverse events at any time after the introduction of treatment. Data collection and analysis One author extracted and two checked the data. Main results Seven trials are included but few reported the outcomes selected for this review. A meta‐analysis of ciclosporin versus placebo from two trials (59 participants) ‐ one as monotherapy (20 participants) and the other with corticosteroids (39 participants) ‐ showed that it resulted in improvement of participants in the ciclosporin group compared with those in the placebo group, with a relative rate of improvement of 2.44 (95% confidence interval (CI) 1.13 to 5.27). In addition the weighted mean difference in QMG score between the ciclosporin and placebo groups was ‐0.34 (95% CI ‐0.52 to ‐0.17). Azathioprine (plus prednisolone for first month) had no significant benefit over prednisolone alone (41 participants). The effects of azathioprine plus prednisolone versus prednisolone plus placebo were similar (34 participants). Cyclophosphamide was reported to be statistically more efficacious than placebo at 12 months in corticosteroid‐dependent participants (23 participants), but no raw data were available. Trials of mycophenolate mofetil and tacrolimus did not provide relevant endpoint data for this review. All trials had low numbers of participants. Adverse event reporting was variable. Trial protocol heterogeneity prevented comparison of the different immunosuppressants. Authors' conclusions In generalised MG, limited evidence from small RCTs suggests that ciclosporin, as monotherapy or with corticosteroids, or cyclophosphamide with corticosteroids, significantly improve MG. 
 Limited evidence from RCTs shows no significant benefit from azathioprine (as monotherapy or with steroids), mycophenolate mofetil (as monotherapy or with either corticosteroids or ciclosporin) or tacrolimus (with corticosteroids or plasma exchange). Bigger, better‐designed, longer trials are needed. Plain language summary A review of the use of drugs that suppress the immune system (immunosuppressants) in myasthenia gravis. Myasthenia gravis (MG) is caused by antibodies produced by the immune system that impair the transmission of nerve impulses to muscles. This results in muscle weakness that characteristically fluctuates. About one person in every 10 000 ‐ 50 000 develops MG each year. The natural history of the disorder is typically a series of exacerbations and remissions. Severe attacks can be life‐threatening because of weakness of muscles involved in swallowing causing choking, and chest muscles causing difficulty with breathing. In MG, immunosuppressant drugs act mainly by reducing the production of antibodies. There were seven randomised controlled trials to include in this review. Each trial compared different interventions in generalised MG: (1) azathioprine plus initial prednisolone versus prednisolone ‐ 41 participants; (2) azathioprine plus prednisolone versus prednisolone plus placebo (dummy treatment) ‐ 34 participants; (3) ciclosporin monotherapy versus placebo ‐ 20 participants; (4) ciclosporin plus prednisolone versus prednisolone plus placebo ‐ 39 participants; (5) cyclophosphamide plus prednisolone versus prednisolone plus placebo ‐ 23 participants; (6) mycophenolate mofetil plus either ciclosporin or prednisolone or no immunosuppressants versus placebo plus either ciclosporin or prednisolone or no immunosuppressants trial ‐ 14 participants; (7) tacrolimus plus corticosteroids with or without plasma exchange versus no tacrolimus plus corticosteroids with or without plasma exchange trial ‐ 34 participants. It is difficult to draw useful clinical conclusions from this small number of often short‐term, randomised controlled trials. Each trial had relatively few participants and different trials used different study designs. The limited evidence available found that MG improved significantly with either ciclosporin (alone or in combination with corticosteroids) or cyclophosphamide (in combination with corticosteroids) compared with placebo. There is no clear evidence from randomised controlled trials of benefit for any of the immunosuppressant drugs used more commonly in MG ‐ azathioprine (alone or in combination with corticosteroids), mycophenolate mofetil (as monotherapy or in combination with either corticosteroids or ciclosporin) or tacrolimus (in combination with corticosteroids or plasma exchange or both). There is no randomised controlled trial of methotrexate in MG. Long‐term studies of the potentially formidable toxic effects of all of these drugs are lacking in MG.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Hart, IK; Sathasivam, S; Sharshar, T", "articleTypes": [], "doi": "10.1002/14651858.CD005224.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "140775cd-50a5-40c2-b2c1-91b8686cba8a", "pmid": "", "title": "Oncology, Undernutrition and Sensoriality: Links, Mechanisms and Levers for Action - Study ONDES", "imported": false, "abstract": "Cancers of the upper aerodigestive tract account for around 4% of all malignant tumours worldwide. Colon and liver cancer are the most common digestive cancers. The epidemiology of liver cancer is changing, and the number of deaths from liver cancer has increased by 25% worldwide (Huang 2022). In France, around 19,000 cancers of the upper aerodigestive tract and 88,000 new cases of digestive cancer are diagnosed each year (colon cancer remains the most common) (Globocan 2020). Patients with these two types of cancer are at particularly high risk of undernutrition (Pressoir 2010; Gyan 2018).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.243Z" }, { "id": "14122153-f941-4dab-bd00-327b9659872b", "pmid": "", "title": "Immunosuppressive agents for myasthenia gravis", "imported": false, "abstract": "Abstract - Background The benefits of different immunosuppressants for myasthenia gravis (MG) are unclear. Objectives Assessment of immunosuppressant drug efficacy in MG. Search methods We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to July 2007), EMBASE (from January 1980 to July 2007), review and trial bibliographies and contacted trial authors. Selection criteria Types of studies: Randomised and quasi‐randomised controlled trials. Types of participants: Any age, any type or severity of MG regardless of concomitant treatment. Types of interventions: Any immunosuppressive agent. Types of outcome measures: Primary: 
 (1) Improvement or not at six months Secondary: 
 (1) Improvement or not at one year 
 (2) Need for other treatment, for example corticosteroid dose, at six months 
 (3) Number of exacerbations during the first year 
 (4) Acetylcholine receptor antibody titre after at least six months 
 (5) Occurrence of one or more adverse events at any time after the introduction of treatment. Data collection and analysis One author extracted and two checked the data. Main results Seven trials are included but few reported the outcomes selected for this review. A meta‐analysis of ciclosporin versus placebo from two trials (59 participants) ‐ one as monotherapy (20 participants) and the other with corticosteroids (39 participants) ‐ showed that it resulted in improvement of participants in the ciclosporin group compared with those in the placebo group, with a relative rate of improvement of 2.44 (95% confidence interval (CI) 1.13 to 5.27). In addition the weighted mean difference in QMG score between the ciclosporin and placebo groups was ‐0.34 (95% CI ‐0.52 to ‐0.17). Azathioprine (plus prednisolone for first month) had no significant benefit over prednisolone alone (41 participants). The effects of azathioprine plus prednisolone versus prednisolone plus placebo were similar (34 participants). Cyclophosphamide was reported to be statistically more efficacious than placebo at 12 months in corticosteroid‐dependent participants (23 participants), but no raw data were available. Trials of mycophenolate mofetil and tacrolimus did not provide relevant endpoint data for this review. All trials had low numbers of participants. Adverse event reporting was variable. Trial protocol heterogeneity prevented comparison of the different immunosuppressants. Authors' conclusions In generalised MG, limited evidence from small RCTs suggests that ciclosporin, as monotherapy or with corticosteroids, or cyclophosphamide with corticosteroids, significantly improve MG. 
 Limited evidence from RCTs shows no significant benefit from azathioprine (as monotherapy or with steroids), mycophenolate mofetil (as monotherapy or with either corticosteroids or ciclosporin) or tacrolimus (with corticosteroids or plasma exchange). Bigger, better‐designed, longer trials are needed. Plain language summary A review of the use of drugs that suppress the immune system (immunosuppressants) in myasthenia gravis. Myasthenia gravis (MG) is caused by antibodies produced by the immune system that impair the transmission of nerve impulses to muscles. This results in muscle weakness that characteristically fluctuates. About one person in every 10 000 ‐ 50 000 develops MG each year. The natural history of the disorder is typically a series of exacerbations and remissions. Severe attacks can be life‐threatening because of weakness of muscles involved in swallowing causing choking, and chest muscles causing difficulty with breathing. In MG, immunosuppressant drugs act mainly by reducing the production of antibodies. There were seven randomised controlled trials to include in this review. Each trial compared different interventions in generalised MG: (1) azathioprine plus initial prednisolone versus prednisolone ‐ 41 participants; (2) azathioprine plus prednisolone versus prednisolone plus placebo (dummy treatment) ‐ 34 participants; (3) ciclosporin monotherapy versus placebo ‐ 20 participants; (4) ciclosporin plus prednisolone versus prednisolone plus placebo ‐ 39 participants; (5) cyclophosphamide plus prednisolone versus prednisolone plus placebo ‐ 23 participants; (6) mycophenolate mofetil plus either ciclosporin or prednisolone or no immunosuppressants versus placebo plus either ciclosporin or prednisolone or no immunosuppressants trial ‐ 14 participants; (7) tacrolimus plus corticosteroids with or without plasma exchange versus no tacrolimus plus corticosteroids with or without plasma exchange trial ‐ 34 participants. It is difficult to draw useful clinical conclusions from this small number of often short‐term, randomised controlled trials. Each trial had relatively few participants and different trials used different study designs. The limited evidence available found that MG improved significantly with either ciclosporin (alone or in combination with corticosteroids) or cyclophosphamide (in combination with corticosteroids) compared with placebo. There is no clear evidence from randomised controlled trials of benefit for any of the immunosuppressant drugs used more commonly in MG ‐ azathioprine (alone or in combination with corticosteroids), mycophenolate mofetil (as monotherapy or in combination with either corticosteroids or ciclosporin) or tacrolimus (in combination with corticosteroids or plasma exchange or both). There is no randomised controlled trial of methotrexate in MG. Long‐term studies of the potentially formidable toxic effects of all of these drugs are lacking in MG.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Hart, IK; Sathasivam, S; Sharshar, T", "articleTypes": [], "doi": "10.1002/14651858.CD005224.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "142ef80e-877b-4abe-9a42-c359e2424af0", "pmid": "", "title": "Different strategies for diagnosing gestational diabetes to improve maternal and infant health", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycaemia with onset or first recognition during pregnancy. If untreated, perinatal morbidity and mortality may be increased. Accurate diagnosis allows appropriate treatment. Use of different tests and different criteria will influence which women are diagnosed with GDM. This is an update of a review published in 2011 and 2015. Objectives To evaluate and compare different testing strategies for diagnosis of gestational diabetes mellitus to improve maternal and infant health while assessing their impact on healthcare service costs. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (9 January 2017) and reference lists of retrieved studies. Selection criteria We included randomised trials if they evaluated tests carried out to diagnose GDM. We excluded studies that used a quasi‐random model, cluster‐randomised or cross‐over trials. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. Main results We included a total of seven small trials, with 1420 women. One trial including 726 women was identified by this update and examined the two step versus one step approach. These trials were assessed as having varying risk of bias, with few outcomes reported. We prespecified six outcomes to be assessed for quality using the GRADE approach for one comparison: 75 g oral glucose tolerance test (OGTT) versus 100 g OGTT; data for only one outcome (diagnosis of gestational diabetes) were available for assessment. One trial compared three different methods of delivering glucose: a candy bar (39 women), a 50 g glucose polymer drink (40 women) and a 50 g glucose monomer drink (43 women). We have included the results reported by this trial as separate comparisons. No trial reported on measures of costs of health services. We examined six main comparisons. 75 g OGTT versus 100 g OGTT (1 trial, 248 women): women who received 75 g OGTT had a higher relative risk of being diagnosed with GDM (risk ratio (RR) 2.55, 95% confidence interval (CI) 0.96 to 6.75; very‐low quality evidence ). No data were reported for the following additional outcomes prespecified for GRADE assessment: caesarean section, macrosomia > 4.5 kg or however defined in the trial, long‐term type 2 diabetes maternal, long‐term type 2 diabetes infant and economic costs. Candy bar versus 50 g glucose monomer drink (1 trial, 60 women): more women receiving the candy bar, rather than glucose monomer, preferred the taste of the candy bar (RR 0.60, 95% CI 0.42 to 0.86) and 1‐hour glucose was less with the candy bar. There were no differences in the other outcomes reported (maternal side effects). No infant outcomes were reported or any review primary outcomes. 50 g glucose polymer drink versus 50 g glucose monomer drink (3 trials, 239 women): mean difference (MD) in gestation at birth was ‐0.80 weeks (1 trial, 100 women; 95% CI ‐1.69 to 0.09). Total side effects were less common with the glucose polymer drink (1 trial, 63 women; RR 0.21, 95% CI 0.07 to 0.59), and no clear difference in taste acceptability was reported (1 trial, 63 women; RR 0.99, 95% CI 0.76 to 1.29). Fewer women reported nausea following the 50 g glucose polymer drink compared with the 50 g glucose monomer drink (1 trial, 66 women; RR 0.29, 95% CI 0.11 to 0.78). No other measures of maternal morbidity or outcomes for the infant were reported. 50 g glucose food versus 50 g glucose drink (1 trial, 30 women): women receiving glucose in their food, rather than as a drink, reported fewer side effects (RR 0.08, 95% CI 0.01 to 0.56). No clear difference was noted in the number of women requiring further testing (RR 0.14, 95% CI 0.01 to 2.55). No other measures of maternal morbidity or outcome were reported for the infant or review primary outcomes. 75 g OGTT World Health Organization (WHO) criteria versus 75 g OGTT American Diabetes Association (ADA) criteria (1 trial, 116 women): no clear differences in included outcomes were observed between women who received the 75 g OGTT and were diagnosed using criteria based on WHO (1999) recommendations and women who received the 75 g OGTT and were diagnosed using criteria recommended by the ADA (1979). Outcomes measured included diagnosis of gestational diabetes (RR 1.47, 95% CI 0.66 to 3.25), caesarean section (RR 1.07, 95% CI 0.85 to 1.35), macrosomia defined as > 90th percentile by ultrasound or birthweight equal to or exceeding 4000 g (RR 0.73, 95% CI 0.19 to 2.79), stillbirth (RR 0.49, 95% CI 0.02 to 11.68) and instrumental birth (RR 0.21, 95% CI 0.01 to 3.94). No other secondary outcomes were reported. Two‐step approach (50 g oral glucose challenge test followed by selective 100 g OGTT Carpenter and Coustan criteria) versus one‐step approach (universal 75 g OGTT ADA criteria) (1 trial, 726 women): women allocated the two‐step approach had a lower risk of being diagnosed with GDM at 11 to 14 weeks' gestation compared to women allocated the one‐step approach (RR 0.51, 95% CI 0.28 to 0.95). No other primary or secondary outcomes were reported. Authors' conclusions There is insufficient evidence to suggest which strategy is best for diagnosing GDM. Large randomised trials are required to establish the best strategy for correctly identifying women with GDM. Plain language summary Different strategies for diagnosing gestational diabetes mellitus (GDM) to improve maternal and infant health What is the issue? We aimed to evaluate and compare different ways of diagnosing gestational diabetes mellitus (GDM). We searched for all relevant studies in January 2017. Why is this important? Between seven and 24 pregnant women in every 100 develop GDM. GDM is when there is an inability to process carbohydrates properly, which leads to high blood sugar (hyperglycaemia). GDM can result in increased risks of problems around the time of birth for the mother and her baby. Treatment can reduce these risks, and therefore diagnosing the condition accurately means that treatment can be given to improve the health of mothers and their babies. Different testing strategies aim to diagnose GDM. We wanted to compare the different strategies, to see how they affected the health of women and their infants, and to assess the cost of the strategies to the healthcare service. What evidence did we find? We found seven trials. A total of 1420 women were included, in settings in Turkey, Mexico, Nigeria, New Zealand, Canada and the USA. Across the trials, different testing approaches and criteria were evaluated as were different diagnostic tests including different oral glucose tolerance test loads; a glucose drink; a candy bar and food high in glucose. Women were given these items to eat/drink, and this was then followed by a blood test to measure blood sugar levels and questionnaires. In some tests, women were required to fast from the night before. The main outcomes we looked for were frequency of diagnosis, incidence of caesarean section, assisted birth and vaginal birth, and incidence of macrosomia in babies (larger than normal weight at birth). Other outcomes spanned a range, including any side effects of the tests, the mothers' preferences, and the health of the babies. There were a number of weaknesses among the studies: the methodology was not clear and there were important gaps in the data. The studies in this review do not provide enough evidence to guide clinical practice and health policy regarding identifying women with GDM. What does this mean? We are uncertain about which strategies to diagnose GDM are better, as we have assessed the quality of evidence as very low. Large randomised trials are needed to establish the best way for identifying women with GDM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Farrar, D, Duley, L, Dowswell, T, Lawlor, DA", "articleTypes": [], "doi": "10.1002/14651858.CD007122.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.753Z" }, { "id": "1438a7dd-c52b-4c22-bad3-f5012e078d55", "pmid": "", "title": "Skin‐to‐skin care for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Skin‐to‐skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal‐infant contact, is one non‐pharmacological intervention for pain control in infants. Objectives The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonates The secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants. Search methods For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi‐randomized trials. Selection criteria Studies with randomisation or quasi‐randomisation, double‐ or single‐blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals. Data collection and analysis The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed‐effect model was reported for continuous outcome measures. We included variations on type of tissue‐damaging procedure, provider of care, and duration of SSC. Main results Twenty‐five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes. Seventeen studies (n = 810) compared SSC to a no‐treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of −10.78 beats per minute (95% CI −13.63 to −7.93) favouring SSC. Meta‐analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI −4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta‐analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta‐analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = −34.16, 95% CI −42.86 to −25.45), and two (n = 100) following IM injection (MD = −8.83, 95% CI −14.63 to −3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD −3.21, 95% CI −3.94 to −2.47), at 60 seconds (3 studies; n = 156) (MD −1.64, 95% CI −2.86 to −0.43), and at 90 seconds (n = 156) (MD −1.28, 95% CI −2.53 to −0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI −1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta‐analysis findings. Eight studies compared SSC to another intervention with or without a no‐treatment control. Two cross‐over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no‐treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies. Authors' conclusions SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother‐providers to others, with non‐significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long‐term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions. Plain language summary Skin‐to‐skin care with newborns cuts down procedural pain Review question: Is skin‐to‐skin care effective in cutting down pain from procedures in newborns? Are there any safety issues? Background: Newborns wearing only a diaper being held next to their mother's bare chest is referred to as skin‐to‐skin contact and is also sometimes called 'kangaroo care' because of its similarity to the way kangaroo mothers care for their young. Newborns, especially those who must spend time in a Neonatal Intensive Care Unit, must have various tests and procedures as part of their care, for example heel stick, venous puncture, and injections. Giving analgesic drugs for these procedures can often pose problems so that alternatives to drugs must be found. Study characteristics: Twenty‐eight studies in which newborn babies who were by chance in the kangaroo care group or condition were included from an extensive search of the literature. Skin‐to‐skin care was clearly defined and could have been compared to no pain‐reducing strategies or other pain‐reducing strategies such as sweet taste. Studies were examined which examined well‐established signs of pain, both physiological and behavioural, as well as a combination of physiological and behavioural signs. Different providers of skin‐to‐skin care other than the mother were included. Key results: Kangaroo care appears to reduce the pain response to, and recovery from, these frequent procedures, although few studies could be combined to provide strong evidence. As far as it has been reported, skin‐to‐skin care is safe. Although it appears that skin‐to‐skin care is effective, the size of the benefit remains uncertain. Quality of evidence: The quality of evidence in these studies was generally low for the response to the actual procedure but was moderate for recovery from the procedure.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Johnston, C; Campbell‐Yeo, M; Disher, T; Benoit, B; Fernandes, A; Streiner, D; Inglis, D; Zee, R", "articleTypes": [], "doi": "10.1002/14651858.CD008435.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "144ee588-5ec5-46a0-9af7-6c43bdb5634a", "pmid": "", "title": "Pharmacological interventions for people with borderline personality disorder", "imported": false, "abstract": "Abstract - Background Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off‐label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods. Objectives To assess the effects of pharmacological treatment for people with BPD. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. Selection criteria Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events. Data collection and analysis At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. Main results We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty‐nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD ‐0.18, 95% confidence interval (CI) ‐0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD −0.27, 95% CI −0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD −0.07, 95% CI −0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self‐harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale‐Modified‐Self‐Injury item (0‐5 points), 95% CI −10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide‐related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI −0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD −0.26, 95% CI −1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD −0.36, 95% CI −1.96 to 1.25; 2 trials, 44 participants). Very low‐certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD −0.16, 95% CI −0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD −0.25, 95% CI ‐0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD −0.01, 95% CI ‐0.28 to 0.26; 2 trials, 214 participants). Low‐certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD −0.21, 95% CI −0.34 to ‐0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD −0.58, 95% CI ‐1.14 to ‐0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD −0.07, 95% CI ‐0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low‐certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non‐standardised. The available evidence on non‐serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified. Authors' conclusions This review included 18 more trials than the 2010 version, so larger meta‐analyses with more statistical power were feasible. We found mostly very low‐certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma‐related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples. Plain language summary What are the benefits and risks of medication for people with borderline personality disorder? Key messages This review is an update of a previous review on the same topic published in 2010. Although this review includes an additional 18 studies, the conclusions remain the same: there are probably no benefits and risks of medications for borderline personality disorder (BDP), but the evidence is unclear. Better and larger studies comparing the effects of medication with placebo are needed. Such studies should focus on men, adolescents and those with additional psychiatric diagnoses. What is BPD? BPD affects how a person interacts with others and understands one's self. Although its exact causes are unclear, it is thought to result from a combination of genetic and environmental factors (e.g. stressful or traumatic life events when growing up). Approximately 2% of adults and 3% of adolescents are affected. The symptoms of BPD can be grouped into four categories. Instability in mood: People with BPD may experience intense feelings that change rapidly and are difficult to control. They may also feel empty and abandoned much of the time. Cognitive distortions (disturbed patterns of thinking): People with BPD often have upsetting thoughts (e.g. they may think that they are a terrible person). They can have brief episodes of strange experiences (e.g. paranoid ideations or stress‐induced dissociative experiences (i.e. feeling detached from the world around them). Impulsive behaviour: People with BPD may act impulsively and do things that could harm themselves (e.g. when sad and depressed, they may self‐harm or have suicidal feelings). They might also engage in reckless behaviour (e.g. drug misuse). Intense but unstable relationships: People with BPD may find it difficult to keep stable relationships (e.g. they may feel very worried about being abandoned and might constantly text or call, or make threats to harm or kill themselves if the person leaves them). A person only needs to experience five out of nine criteria across these categories to be given a diagnosis of BPD. How is BPD treated? No medication has been approved for the treatment of BPD. Nonetheless, a large proportion of people with BPD are given medications for sustained periods of time to alleviate their symptoms. The type of medication given is chosen based on its known effects on other disorders with similar symptoms. Review question We wanted to find out whether medications to treat BPD work better or worse than placebo; whether one medication works better than another; or whether one combination of medications work better than another combination of medications. We wanted to look at how well medications worked on BPD severity, self‐harm, suicide‐related outcomes, and functioning (how well a person performs in everyday life). We also wanted to find out if medications are associated with any unwanted side effects. What did we do? We searched for studies that compared the effects of different medications with placebo, another medication, or a combination of medications, in people diagnosed with BPD. We compared and summarised the results and rated our confidence in the evidence based on factors such as sample size and methods used. Below, we present the findings from our key comparison: medication versus placebo. What did we find? We found 46 studies that involved 2769 people with BPD. The smallest study had 13 participants and the largest 451 participants. There were four studies with more than 100 participants. Except for one study that included men only, all studies included women. The average age of the participants ranged from 16 years to 39 years. Most studies were conducted in outpatient settings (31 studies) in Europe (20 studies) and lasted between four and 52 weeks. Pharmaceutical companies fully or partially funded 16 studies. The studies looked at the effects of 27 different medications, mostly classified as: 1) antipsychotics (drugs to treat psychosis where a person’s thoughts and mood are so impaired that the person has lost contact with reality); 2) antidepressants (drugs to treat depression); or 3) mood stabilisers (drugs to control and even out mood swings, reducing both high moods (mania) and low moods (depression)). Compared with placebo, medications seem to make little to no difference to BPD severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. They may make little to no difference as to whether a person continues in a study or drops out. Compared to placebo, antipsychotics and mood stabilisers may make little to no difference to the occurrence of unwanted or harmful effects. No study reported on the side effects of antidepressants. What are the limitations of the evidence? Our confidence in the evidence varied between very low and low. The results of future research could differ from the results of this review. Four main factors reduced our confidence in the evidence. First, not all of the studies provided data about everything that we were interested in. Second, the results were very inconsistent across the different studies. Third, there were not enough studies to be certain about the results of our outcomes. Fourth, many studies did not clearly report how they were conducted. How up‐to‐date is this evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Stoffers-Winterling, JM; Storebø, OJ; Pereira Ribeiro, J; Kongerslev, MT; Völlm, BA; Mattivi, JT; Faltinsen, E; Todorovac, A; Jørgensen, MS; Callesen, HE; Sales, CP; Schaug, JP; Simonsen, E; Lieb, K", "articleTypes": [], "doi": "10.1002/14651858.CD012956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "149afb19-5e56-4018-911f-2f07e46e9060", "pmid": "", "title": "Antihypertensive drug therapy for mild to moderate hypertension during pregnancy", "imported": false, "abstract": "Abstract - Background Antihypertensive drugs are often used in the belief that lowering blood pressure will prevent progression to more severe disease, and thereby improve pregnancy outcome. This Cochrane Review is an updated review, first published in 2001 and subsequently updated in 2007 and 2014. Objectives To assess the effects of antihypertensive drug treatments for women with mild to moderate hypertension during pregnancy. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (13 September 2017), and reference lists of retrieved studies. Selection criteria All randomised trials evaluating any antihypertensive drug treatment for mild to moderate hypertension during pregnancy, defined as systolic blood pressure 140 to 169 mmHg and/or diastolic blood pressure 90 to 109 mmHg. Comparisons were of one or more antihypertensive drug(s) with placebo, with no antihypertensive drug, or with another antihypertensive drug, and where treatment was planned to continue for at least seven days. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results For this update, we included 63 trials (data from 58 trials, 5909 women), with moderate to high risk of bias overall. We carried out GRADE assessments for the main 'antihypertensive drug versus placebo/no antihypertensive drug' comparison only. Evidence was graded from very low to moderate certainty, with downgrading mainly due to design limitations and imprecision.For many outcomes, trials contributing data evaluated different hypertensive drugs; while we did not downgrade for this indirectness, results should be interpreted with caution. Antihypertensive drug versus placebo/no antihypertensive drug (31 trials, 3485 women) Primary outcomes: moderate‐certainty evidence suggests that use of antihypertensive drug(s) probably halves the risk of developing severe hypertension (risk ratio (RR) 0.49; 95% confidence interval (CI) 0.40 to 0.60; 20 trials, 2558 women), but may have little or no effect on the risk of proteinuria/pre‐eclampsia (average risk ratio (aRR) 0.92; 95% CI 0.75 to 1.14; 23 trials, 2851 women; low‐certainty evidence). Moderate‐certainty evidence also shows that antihypertensive drug(s) probably have little or no effect in the risk of total reported fetal or neonatal death (including miscarriage) (aRR 0.72; 95% CI 0.50 to 1.04; 29 trials, 3365 women), small‐for‐gestational‐age babies (aRR 0.96; 95% CI 0.78 to 1.18; 21 trials, 2686 babies) or preterm birth less than 37 weeks (aRR 0.96; 95% CI 0.83 to 1.12; 15 trials, 2141 women). Secondary outcomes: we are uncertain of the effect of antihypertensive drug(s) on the risk of maternal death , severe pre‐eclampsia , or eclampsia, or impaired long‐term growth and development of the baby in infancy and childhood , because the certainty of this evidence is very low. There may be little or no effect on the risk of changed/stopped drugs due to maternal side‐effects, or admission to neonatal or intensive care nursery (low‐certainty evidence). There is probably little or no difference in the risk of elective delivery (moderate‐certainty evidence). Antihypertensive drug versus another antihypertensive drug (29 trials, 2774 women) Primary outcomes: beta blockers and calcium channel blockers together in the meta‐analysis appear to be more effective than methyldopa in avoiding an episode of severe hypertension (RR 0.70; 95% CI 0.56 to 0.88; 11 trials, 638 women). There was also an increase in this risk when other antihypertensive drugs were compared with calcium channel blockers (RR 1.86; 95% CI 1.09 to 3.15; 5 trials, 223 women), but no evidence of a difference when methyldopa and calcium channel blockers together were compared with beta blockers (RR1.18, 95% CI 0.95 to 1.48; 10 trials, 692 women). No evidence of a difference in the risk of proteinuria/pre‐eclampsia was found when alternative drugs were compared with methyldopa (aRR 0.78; 95% CI 0.58 to 1.06; 11 trials, 997 women), with calcium channel blockers (aRR: 1.24, 95% CI 0.70 to 2.19; 5 trials, 375 women), or with beta blockers (aRR 1.21, 95% CI 0.88 to 1.67; 12 trials, 1107 women). For the babies, we found no evidence of a difference in the risk of total reported fetal or neonatal death (including miscarriage) when comparing other antihypertensive drugs with methyldopa (aRR 0.77, 95% CI 0.52 to 1.14; 22 trials, 1791 babies), with calcium channel blockers (aRR 0.90, 95% CI 0.52 to 1.57; nine trials, 700 babies), or with beta blockers (aRR: 1.23, 95% CI 0.81 to 1.88; 19 trials, 1652 babies); nor in the risk for small‐for‐gestational age in the comparison with methyldopa (aRR 0.79, 95% CI 0.52 to 1.20; seven trials, 597 babies), with calcium channel blockers (aRR 1.05, 95% CI 0.64 to 1.73; four trials, 200 babies), or with beta blockers (average RR 1.13, 95% CI 0.80 to 1.60; 7 trials, 680 babies). No evidence of an overall difference among groups in the risk of preterm birth (less than 37 weeks) was found in the comparison with methyldopa (aRR: 0.91; 95% CI 0.68 to 1.22; 11 trials, 835 women), with calcium channel blockers (aRR 0.85, 95% CI 0.59 to 1.23; six trials, 330 women), or with beta blockers (aRR 1.22, 95% CI 0.90 to 1.66; 9 trials, 806 women). Secondary outcomes: There were no cases of maternal death and eclampsia. There is no evidence of a difference in the risk of severe pre‐eclampsia , changed/stopped drug due to maternal side‐effects , elective delivery, admission to neonatal or intensive care nursery when other antihypertensive drugs are compared with methyldopa, calcium channel blockers or beta blockers. Impaired long‐term growth and development in infancy and childhood was not reported for these comparisons. Authors' conclusions Antihypertensive drug therapy for mild to moderate hypertension during pregnancy reduces the risk of severe hypertension. The effect on other clinically important outcomes remains unclear. If antihypertensive drugs are used, beta blockers and calcium channel blockers appear to be more effective than the alternatives for preventing severe hypertension. High‐quality large sample‐sized randomised controlled trials are required in order to provide reliable estimates of the benefits and adverse effects of antihypertensive treatment for mild to moderate hypertension for both mother and baby, as well as costs to the health services, women and their families. Plain language summary Antihypertensive drug therapy for mild to moderate hypertension during pregnancy What is the issue? The aim of this review was to determine the benefits and adverse effects of blood pressure‐lowering drugs (antihypertensive drugs) for pregnant women with mild to moderate hypertension (high blood pressure). The other aim was to assess the benefits and adverse effects of these drugs for their babies. Why is this important? During pregnancy, up to one in 10 women have blood pressure readings that are above normal. For some women, their blood pressure remains slightly high (termed ‘mild to moderate high blood pressure’), with no apparent complications. Some of these women go on to develop very high blood pressure. Very high blood pressure can result in a medical emergency if it affects the woman’s organs (such as her liver, or brain in the form of a stroke). Also, it can seriously affect the growth and health of her baby. Drugs that lower blood pressure are used to treat mild to moderate high blood pressure, in the belief that this treatment will prevent the blood pressure from continuing to rise. Over the years, information from good quality research studies has been contradictory, so we cannot be sure if this drug treatment is worthwhile. What evidence did we find? This Cochrane Review is an update of a review that was first published in 2001 and updated in 2007 and 2014. We searched for randomised controlled trials in September 2017, and this review now includes data from 58 trials involving more than 5900 women. A total of 31 trials with 3485 women compared a number of different blood pressure‐lowering drugs to a placebo or no treatment. There were a further 29 trials involving 2774 women which compared one blood pressure‐lowering drug with another one. The evidence showed that treating pregnant women who had moderately raised blood pressure with blood pressure‐lowering drugs probably halved the number of the women developing severe high blood pressure (20 trials, 2558 women). However, blood pressure‐lowering drugs probably had little or no effect on the risk of the baby dying (29 trials, 3365 women), and there is insufficient data on maternal deaths to make a judgement on whether this risk is lowered (five trials, 525 women). The use of blood pressure‐lowering drugs may have little or no effect on the number of the women developing pre‐eclampsia (23 trials, 2851 women), or the number of women who had to change drugs because of side‐effects (16 trials, 1503 women). We found no difference in the number of babies born preterm, that is before 37 weeks (15 trials, 2141 women). There was also no difference in the number of babies born small for their gestational age (21 trials, 2686 babies). The quality of the evidence was mostly moderate (but for pre‐eclampsia it was low). This was due to a number of small studies, and problems with the way the studies were undertaken. The available evidence is still insufficient to demonstrate if there is any antihypertensive drug that is better than another. However, beta blockers and calcium channel blockers seem to be better than the alternative drugs for blood pressure control. What does this mean? More research is needed in order to confirm the true effect of antihypertensive drugs in mothers and in their babies, and to identify the drug which would be best.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abalos, E; Duley, L; Steyn, DW; Gialdini, C", "articleTypes": [], "doi": "10.1002/14651858.CD002252.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "14a46643-ae56-40a7-ada4-345c83fd3311", "pmid": "", "title": "CBD/THC Solution as a Pharmacological Strategy for Patients With Fibromyalgia. Single-center, Double-blind, Randomized, Placebo-controlled Clinical Trial Protocol (FibroCann)", "imported": false, "abstract": "Fibromyalgia is considered a chronic pain syndrome, non-inflammatory, of unknown etiology, which manifests itself in the musculoskeletal system in up to 2.5% of the general population, predominantly in females, mainly between 35 and 44 years old, having a direct impact on the quality of life of their patients (JUNIOR; GOLDENFUM; SIENA, 2012; HEYMANN et al., 2017). In 1990, eighteen (18) specific sites were defined as tender points which are used to better diagnose fibromyalgia (WOLFE et al., 2010). Due to its clinical and exclusion diagnosis, treatment usually starts late, which allows the progression of symptoms and corroborates its low efficiency in the long term (DE SOUSA BRAZ et al., 2011). Due to the ineffective results and significant side effects that conventional treatment with drugs such as antidepressants, analgesics and anti-inflammatory drugs can provide, patients, physicians and researchers are looking for new main or adjuvant treatments, pharmacological and non-pharmacological (DE SOUSA BRAZ et al. al., 2011). In this context, it has been seen that the use of Cannabis sativa as a therapeutic option in fibromyalgia is promising, especially in reducing the pain caused by the disease and also the adjuvant symptoms, such as depression and sleep disorders (YASSIN; ORON; ROBINSON, 2019). This result must occur due to the action of cannabinoids, such as CBD and THC, on cannabinoid receptors distributed in peripheral nerves, spinal cord and supraspinal region, sites responsible for the reception, transmission and perception of pain (STE-MARIE et al., 2012). Currently, cannabinoids are considered safe analgesics with considerable efficacy, which demonstrates potential as a therapeutic option in the treatment of chronic pain, particularly in patients refractory to other treatments (HAUSER et al., 2018). In addition to its action on the painful mechanisms of fibromyalgia, the antidepressant effects of Cannabis are of great value in the treatment of fibromyalgia. These effects are explained by the modulation on serotonin 5-HT1A receptors, which has its effect exerted especially by CBD (ESPEJO-PORRAS et al., 2013).", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.264Z" }, { "id": "14cb6b2d-bdd8-4674-b644-a3f023b36600", "pmid": "", "title": "Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their aetiology is unknown. The management of chronic rhinosinusitis with nasal polyps, aimed at improving these symptoms, includes both surgical and medical treatments, but there is no universally accepted management protocol. Objectives To assess the effectiveness of endonasal/endoscopic surgery versus medical treatment in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised controlled trials of any surgical intervention (e.g. polypectomy, endoscopic sinus surgery) versus any medical treatment (e.g. intranasal and/or systemic steroids), including placebo, in adult patients with chronic rhinosinusitis with nasal polyps. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Meta‐analysis was not possible due to the heterogeneity of the studies and the selective (incomplete) outcome reporting by the studies. Main results Four studies (231 participants randomised) are included in the review. No studies were at low risk of bias. The studies compared different types of surgery versus various types and doses of systemic and topical steroids and antibiotics. There were three comparison pairs: (1) endoscopic sinus surgery (ESS) versus systemic steroids (one study, n = 109), (2) polypectomy versus systemic steroids (two studies, n = 87); (3) ESS plus topical steroid versus antibiotics plus high‐dose topical steroid (one study, n = 35). All participants also received topical steroids but doses and types were the same between the treatment arms of each study, except for the study using antibiotics. In that study, the medical treatment arm had higher doses than the surgical arm. In two of the studies, the authors failed to report the outcomes of interest. Although there were important differences in the types of treatments and comparisons used in these studies, the results were similar. Primary outcomes: symptom scores and quality of life scores There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) failed to find a difference in generic health‐related quality of life scores. The quality of this evidence is low or very low . Endoscopic scores and other secondary outcomes Two studies reported endoscopic scores. One study (ESS versus systemic steroids) reported a large, significant effect size in the surgical group, with a mean difference (MD) in score of ‐1.5 (95% confidence interval (CI) ‐1.78 to ‐1.22, n = 95) on a scale of 0 to 3 (0 = no polyposis, 3 = severe polyposis). In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups (MD 2.3%, 95% CI ‐17.4% to 12.8%, n = 34). None of the included studies reported recurrence rates. No differences were found for any objective measurements or olfactory tests in those studies in which they were measured. Complications Complication rates were not reported in all studies, but rates of up to 21% for medical treatment and 14.3% for surgical treatment are described. Epistaxis was the most commonly reported complication with both medical and surgical treatments, with severe complications reported rarely. Authors' conclusions The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis with nasal polyps is of very low quality. The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. The one positive finding from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. As the overall evidence is of very low quality (serious methodological limitations, reporting bias, indirectness and imprecision) and insufficient to draw firm conclusions, further research to investigate this problem, which has significant implications for quality of life and healthcare service usage, is justified. Plain language summary Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps Background Nasal polyps are common, benign swellings of the lining of the nose. In some people they may cause no symptoms, but in others they may lead to nasal obstruction, congestion, facial pressure and anosmia (loss of sense of smell). The incidence of symptomatic nasal polyps increases with age and they are more common in men than in women. The cause of nasal polyps is not fully understood but they may be a result of chronic (long‐term) inflammation of the lining of the nose (termed 'chronic rhinosinusitis with nasal polyps'). Chronic rhinosinusitis with nasal polyps can be treated medically, for example with drugs such as topical (intranasal) steroid sprays, or with surgery (for example, nasal polypectomy with or without endoscopic sinus surgery (ESS)). However, it is unclear what is the most effective management strategy. Study characteristics Four randomised controlled trials, involving a total of 231 patients with chronic rhinosinusitis with nasal polyps, are included in this review. The number of patients in each study ranged from 34 to 109. The studies took place in ENT departments in several European countries. All patients were adults and most of the studies enrolled more men than women. In all studies the patients were randomly assigned to either surgery or medical treatment (such as antibiotics or steroid tablets or injections) in addition to topical steroids given as nasal sprays or drops. Both the type of surgery performed and the medical treatments used varied widely between the studies, and did not allow all of the studies to be looked at together. Rather, we considered the treatment groups in the four studies as three separate pairs of comparisons instead of simply 'surgical' versus 'medical' treatments. Key results The main outcome measures were patient‐reported disease‐specific symptom scores and health‐related quality of life scores, as well as generic health‐related quality of life scores. There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) did not find a difference in general health‐related quality of life scores. Two studies reported changes in polyp size (when looked at with an endoscope) using a score. One study (ESS versus systemic steroids) reported a significantly better score in the surgery group than in the steroids group at 12 months. In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups. There were no reported differences between the different medical and surgical treatment groups in any study for any other objective (clinician‐based) measurements. Complication rates were not reported in all studies, but nosebleeds (epistaxis) were the most commonly described complication with both medical and surgical treatment; severe complications were reported rarely in either group. Conclusion The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. One positive finding (polyps size scores) from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. There is not enough evidence to draw firm conclusions regarding the most appropriate treatment for this condition. Chronic rhinosinusitis with nasal polyps has significant implications for quality of life and the use of healthcare services. Further research to investigate this problem is justified. Quality of the evidence Overall, we found this evidence to be of low or very low quality. We have low confidence in the estimates of these studies; further research will very likely change these estimates. There were serious limitations in how the studies were carried out or reported (or both), and the number of participants involved was small. In addition, some of the treatment regimens used in the trials are no longer current standards of therapy for patients with chronic rhinosinusitis with nasal polyps. This evidence is up to date to 20 February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Rimmer, J, Fokkens, W, Chong, LY, Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.119Z" }, { "id": "14cc82c8-7bfb-40c0-aa15-0661b2689038", "pmid": "", "title": "Interventions for hirsutism (excluding laser and photoepilation therapy alone)", "imported": false, "abstract": "Abstract - Background Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen‐sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective. Objectives To assess the effects of interventions (except laser and light‐based therapies alone) for hirsutism. Search methods We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014. Selection criteria Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism. Data collection and analysis Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses. Main results We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty‐eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow‐up above 40%. Primary outcomes, 'participant‐reported improvement of hirsutism' and 'change in health‐related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin‐releasing hormone (GnRH) analogues)). Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one‐third of studies. The quality of evidence was moderate to very low for most outcomes. There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman‐Gallwey scores. The mean difference (MD) was ‐1.84 (95% confidence interval (CI) ‐3.86 to 0.18). There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman‐Gallwey scores more effectively than placebo (MD ‐7.60, 95% CI ‐10.53 to ‐4.67 and MD ‐7.20, 95% CI ‐10.15 to ‐4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87). Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman‐Gallwey scores (MD ‐7.69, 95% CI ‐10.12 to ‐5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD ‐1.90, 95% CI ‐5.01 to 1.21 and MD 0.49, 95% CI ‐1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI ‐0.58 to 3.56 and MD 0.40, 95% CI ‐1.18 to 1.98) (low quality evidence). Although there was very low quality evidence of a difference in reduction of Ferriman‐Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD ‐5.73, 95% CI ‐6.87 to ‐4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached. Metformin demonstrated no benefit over placebo in reduction of Ferriman‐Gallwey scores (MD 0.05, 95% CI ‐1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements. We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman‐Gallwey scores. Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman‐Gallwey scores (low quality evidence). Ferriman‐Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD ‐6.30, 95% CI ‐9.83 to ‐2.77) (very low quality evidence). Data showing reductions in Ferriman‐Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%). Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman‐Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs. Authors' conclusions Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision‐making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects. Further research should consist of well‐designed, rigorously reported, head‐to‐head trials examining OCPs combined with antiandrogens or 5α‐reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α‐reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment. Plain language summary Treatments for unwanted male pattern hair growth in women Background 
 Up to 5% to 10% of women are hirsute (hair in areas where normally only men have hairs such as moustache, beard area, chest, belly, back etc). The most common cause is polycystic ovary syndrome. Hirsutism can lead to psychological distress, low self esteem, decreased self image, depression, feelings of shame and social difficulties. Review question 
 Which treatments (except laser and light‐based therapies alone) work best for hirsutism? Study characteristics 
 We included 157 studies published up to June 2014, which examined 10,550 people. Participants included women with a mean age of 25 years. There was considerable variation in the quality of how the studies were conducted; more than half were not blinded and this may have had an impact on the reporting of the outcomes. Most studies were carried out in single centres in Europe and lasted six to 12 months. A range of treatments were evaluated, mostly in single studies. These included a few topical treatments, lifestyle modification, oral contraceptive pills (OCPs), medication to inhibit the effect of hormones that are responsible for male traits, and combination therapies. Participant‐assessed improvement and impact on quality of life were evaluated in a minority of the studies, whilst the majority of the studies measured physician‐assessed reduction in hirsutism, as well as androgen levels in the blood. Half of the studies reported adverse events and around one‐third other signs and symptoms, e.g. oily skin and menstrual irregularities that might be due to an increase of androgen levels in the blood. Key results 
 Oral contraceptive pills reduced the amount of hairs, but the reduction was not consistent across the studies, although two OCPs (ethinyl estradiol 35 µg + cyproterone acetate 2 mg compared to ethinyl estradiol 30 µg + desogestrel 0.15 mg) appeared to be effective in a way that can be considered important for women with hirsutism. Of the antiandrogen drugs, flutamide was considered to be more effective than placebo by both the women and the doctors. Spironolactone was also effective, but data were only available for the physicians' assessments. Finasteride did not show convincing effectiveness based on the evaluations of the hirsute women and those made by the investigators. The addition of cyproterone acetate (an antiandrogen) to OCP seemed to enhance the beneficial effect of OCPs on hair reduction. Insulin sensitisers (antidiabetic drugs) and lifestyle modification did not have any demonstrable benefit in terms of the severity of hirsutism. Unfortunately, the self assessments by the women, as well as the impact of hirsutism on their quality of life, were outcomes that were insufficiently addressed in the studies. The adverse events reported with the different drugs are well known, i.e. pain in the stomach and intestines, breast tenderness, reduced libido and dry skin with flutamide and finasteride; irregular bleeding with spironolactone; nausea, diarrhoea and abdominal bloating with metformin; and hot flushes, decreased libido, vaginal dryness, breast tenderness and headaches with the GnRH analogues. There were no important differences in blood androgen levels between the different treatment groups, OCPs had a positive effect on acne, and similarly insulin sensitisers improved the menstrual pattern. We were expecting to find evidence that combined therapies of an OCP with an antiandrogen were more effective than, for example, OCPs alone, but the lack of studies did not allow us to draw these conclusions. Overall we concluded that OCPs (especially with antiandrogenic activity), OCPs combined with cyproterone acetate, flutamide and spironolactone are effective in treating hirsutism. However, additional cosmetic measures (epilating, waxing, bleaching, electrolysis, laser and photoepilation) are generally required because all treatments need at least six to 12 months to reach the optimum effect. In addition, because of the distress associated with hirsutism and its impact on quality of life psychological support should be part of the treatment approach. Quality of the evidence 
 The overall quality of the evidence for the different outcomes was on average rated as moderate to very low. Important reasons for this were that studies were not blinded, or had a small sample size.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "van Zuuren, EJ; Fedorowicz, Z; Carter, B; Pandis, N", "articleTypes": [], "doi": "10.1002/14651858.CD010334.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "14f80aba-ef01-4f31-8508-2e239e35fa94", "pmid": "", "title": "Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age‐inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long‐term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega‐3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents. Objectives To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents. Search methods We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references. Selection criteria We included randomised and quasi‐randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD. Data collection and analysis We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow‐up; and cost. We used GRADE to assess the certainty of evidence for each outcome. Main results We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross‐over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega‐3 PUFA, six used a combined omega‐3/omega‐6 supplement, and two used an omega‐6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co‐intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega‐3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega‐3 PUFA plus atomoxetine to atomoxetine; omega‐3 PUFA plus physical training to physical training; and an omega‐3 or omega‐6 supplement plus methylphenidate to methylphenidate; and two trials compared omega‐3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months. Although we found low‐certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high‐certainty evidence that PUFA had no effect on parent‐rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) −0.08, 95% CI −0.24 to 0.07; 16 studies, 1166 participants). There was also high‐certainty evidence that parent‐rated inattention (medium‐term: SMD −0.01, 95% CI −0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium‐term: SMD 0.09, 95% CI −0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo. There was moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate‐certainty evidence that medium‐term loss to follow‐up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants). Authors' conclusions Although we found low‐certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high‐certainty evidence that PUFA had no effect on total parent‐rated ADHD symptoms. There was also high‐certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups. We found moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate‐certainty evidence that follow‐up was similar between groups. It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times. Plain language summary Polyunsaturated fatty acids (PUFA) supplements for attention deficit hyperactivity disorder (ADHD) in children and adolescents What is ADHD? Attention deficit hyperactivity disorder (ADHD) is a common problem in children and adolescents. Those affected may struggle to concentrate, feel restless, or act on impulse. As a result of these difficulties, ADHD can cause long‐term social, academic, and mental health problems. Medicines are the most frequently used treatments for ADHD, but they are not always effective and can cause unwanted side effects. What are polyunsaturated fatty acids (PUFA)? Polyunsaturated fatty acids (PUFA) are a type of fat. They are necessary for normal brain development and are found in foods such as fish (omega‐3 PUFA) and vegetable oils (omega‐6 PUFA). How could PUFA be useful in ADHD? There is some evidence that ADHD could be related to low levels of PUFA, in particular omega‐3 PUFA. PUFA supplements may therefore improve ADHD symptoms, behavioural problems, and related mental health symptoms such as anxiety and depression. What did we want to find out? We wanted to know whether PUFA supplements improve ADHD symptoms in children and adolescents with ADHD. Although there were some limited data in the original review that suggested PUFA improved symptoms of ADHD, there is currently little evidence that PUFA supplementation is beneficial. It was important to update the evidence to incorporate new studies that have been published since the original review. What did we do? We searched for all trials that compared PUFA to placebo (dummy pill), medicines, or psychological or medical therapies in children or adolescents with ADHD. We searched 13 databases and two trials registers up to October 2021. What did we find? We found 24 new studies in this update, bringing the total number of studies included in the review to 37, which involved more than 2374 children and adolescents with ADHD. Seven studies were conducted in Iran; four each in the USA and Israel; two each in Australia, Canada, New Zealand, Sweden, and the UK; and one each in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Thirty‐six studies compared PUFA to placebo. Treatment with PUFA lasted between two weeks and six months. Although there was some evidence that PUFA could improve ADHD symptoms in children and adolescents, most of the evidence indicated that PUFA did not improve ADHD symptoms such as inattention or hyperactivity‐impulsivity. PUFA probably makes little to no difference to overall side effects or whether a person drops out of a study (i.e. does not complete it). How confident are we about what we found? We are confident that PUFA has no effect on ADHD symptoms when compared to placebo. Although there was some evidence that ADHD symptoms may be more likely to improve in children and adolescents receiving PUFA compared to those receiving placebo, we have little confidence in this finding. We are fairly confident that there are no differences between PUFA and placebo groups in overall side effects or dropout. Limitations of the analyses included small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Gillies, D, Leach, MJ, Perez Algorta, G", "articleTypes": [], "doi": "10.1002/14651858.CD007986.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.802Z" }, { "id": "14fd2b93-717d-4ba6-b585-61e7393e2ec2", "pmid": "", "title": "Desferrioxamine mesylate for managing transfusional iron overload in people with transfusion‐dependent thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. Desferrioxamine mesylate (desferrioxamine) is one of the most widely used iron chelators. Substantial data have shown the beneficial effects of desferrioxamine, although adherence to desferrioxamine therapy is a challenge. Alternative oral iron chelators, deferiprone and deferasirox, are now commonly used. Important questions exist about whether desferrioxamine, as monotherapy or in combination with an oral iron chelator, is the best treatment for iron chelation therapy. Objectives To determine the effectiveness (dose and method of administration) of desferrioxamine in people with transfusion‐dependent thalassaemia. To summarise data from trials on the clinical efficacy and safety of desferrioxamine for thalassaemia and to compare these with deferiprone and deferasirox. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We also searched MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus ongoing trials registers and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). All searches were updated to 5 March 2013. Selection criteria Randomised controlled trials comparing desferrioxamine with placebo, with another iron chelator, or comparing two schedules or doses of desferrioxamine, in people with transfusion‐dependent thalassaemia. Data collection and analysis Six authors working independently were involved in trial quality assessment and data extraction. For one trial, investigators supplied additional data upon request. Main results A total of 22 trials involving 2187 participants (range 11 to 586 people) were included. These trials included eight comparisons between desferrioxamine alone and deferiprone alone; five comparisons between desferrioxamine combined with deferiprone and deferiprone alone; eight comparisons between desferrioxamine alone and desferrioxamine combined with deferiprone; two comparisons of desferrioxamine with deferasirox; and two comparisons of different routes of desferrioxamine administration (bolus versus continuous infusion). Overall, few trials measured the same or long‐term outcomes. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage; none of these included a comparison with deferasirox. Five trials reported a total of seven deaths; three in patients who received desferrioxamine alone, two in patients who received desferrioxamine and deferiprone. A further death occurred in a patient who received deferiprone in another who received deferasirox alone. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. One trial planned five years of follow up but was stopped early due to the beneficial effects of a reduction in serum ferritin levels in those receiving combined desferrioxamine and deferiprone treatment compared with deferiprone alone. The results of this and three other trials suggest an advantage of combined therapy with desferrioxamine and deferiprone over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no evidence for the improved efficacy of combined desferrioxamine and deferiprone therapy against monotherapy from direct or indirect measures of liver iron. Earlier trials measuring the cardiac iron load indirectly by measurement of the magnetic resonance imaging T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, meta‐analysis of two trials showed a significantly lower left ventricular ejection fraction in patients who received desferrioxamine alone compared with those who received combination therapy using desferrioxamine with deferiprone. Adverse events were recorded by 18 trials. These occurred with all treatments, but were significantly less likely with desferrioxamine than deferiprone in one trial, relative risk 0.45 (95% confidence interval 0.24 to 0.84) and significantly less likely with desferrioxamine alone than desferrioxamine combined with deferiprone in two other trials, relative risk 0.33 (95% confidence interval 0.13 to 0.84). In particular, four studies reported permanent treatment withdrawal due to adverse events from deferiprone; only one of these reported permanent withdrawals associated with desferrioxamine. Adverse events also occurred at a higher frequency in patients who received deferasirox than desferrioxamine in one trial. Eight trials reported local adverse reactions at the site of desferrioxamine infusion including pain and swelling. Adverse events associated with deferiprone included joint pain, gastrointestinal disturbance, increases in liver enzymes and neutropenia; adverse events associated with deferasirox comprised increases in liver enzymes and renal impairment. Regular monitoring of white cell counts has been recommended for deferiprone and monitoring of liver and renal function for deferasirox. In summary, desferrioxamine and the oral iron chelators deferiprone and deferasirox produce significant reductions in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised clinical trials to suggest that any one of these has a greater reduction of clinically significant end organ damage, although in two trials, combination therapy with desferrioxamine and deferiprone showed a greater improvement in left ventricular ejection fraction than desferrioxamine used alone. Authors' conclusions Desferrioxamine is the recommended first‐line therapy for iron overload in people with thalassaemia major and deferiprone or deferasirox are indicated for treating iron overload when desferrioxamine is contraindicated or inadequate. Oral deferasirox has been licensed for use in children aged over six years who receive frequent blood transfusions and in children aged two to five years who receive infrequent blood transfusions. In the absence of randomised controlled trials with long‐term follow up, there is no compelling evidence to change this conclusion. Worsening iron deposition in the myocardium in patients receiving desferrioxamine alone would suggest a change of therapy by intensification of desferrioxamine treatment or the use of desferrioxamine and deferiprone combination therapy. Adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. People treated with all chelators must be kept under close medical supervision and treatment with deferiprone or deferasirox requires regular monitoring of neutrophil counts or renal function respectively. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcomes of deferiprone, deferasirox and desferrioxamine. Plain language summary Desferrioxamine mesylate (desferrioxamine) for managing excess iron levels in the blood of people with thalassaemia who depend on blood transfusions Haemoglobin carries oxygen in the blood. In thalassaemia, a genetic disease, sometimes the body cannot produce enough haemoglobin. This can be managed by receiving regular blood transfusions, but may lead to excess iron in the body which must be removed to prevent organ damage. Iron is removed by iron chelation therapy using a substance called an iron chelator. This works by sticking to excess iron molecules in the body. When patients go to the toilet, this excess iron leaves the body. Three iron chelators are commonly used. One (desferrioxamine) is injected and two (deferiprone and deferasirox) are taken orally. Deferasirox is licensed for use in children. Desferrioxamine is inconvenient and expensive; motivating researchers to find safe, effective oral iron chelators. We found 22 randomised controlled trials comparing iron chelators. These do not provide enough information about death or organ damage. However, they showed all three chelators performed similarly well in removing excess iron. Several trials found combining desferrioxamine and deferiprone removed more excess iron than using just one iron chelator. Trials showing side effects must be considered carefully. Side effects with desferrioxamine included pain or skin reactions at the injection site and joint pain. Side effects with deferiprone included joint pain, nausea, stomach upsets and low white blood cell count. Side effects with deferasirox included skin rashes, increases in liver enzymes and reduced kidney function. Low white blood cell count and reduced kidney function are important side effects and in patients receiving deferiprone or deferasirox these should be monitored regularly. Patients were three times more likely to experience a side effect when deferiprone and desferrioxamine were combined, compared with desferrioxamine alone. Three studies showed that patients using deferiprone were two and a half times more likely to have joint pain compared with using desferrioxamine alone. We have found no evidence for changing current treatment recommendations, which state that deferiprone or deferasirox should be used to remove excess iron when desferrioxamine cannot be used or is inadequate. The Food and Drug Administration in the United States of America have approved deferiprone only as \"last resort treatment of iron overload in thalassemia\". Larger randomised control trials of iron chelation therapy are needed, using standardised agreed measures of iron levels and organ damage to allow comparison of such valuable treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA; Brunskill, SJ; Doree, C; Gooding, S; Chowdhury, O; Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004450.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "15133687-45b2-4d5a-af06-ff3276425372", "pmid": "", "title": "Silver acetate for smoking cessation", "imported": false, "abstract": "Abstract - Background Silver acetate produces an unpleasant taste when combined with cigarettes, thereby producing an aversive stimulus. It has been marketed in various forms with the aim of extinguishing the urge to smoke, by pairing the urge with an unpleasant stimulus. Objectives The aim of this review was to determine the effectiveness of silver acetate products (gum, lozenge, spray) in promoting smoking cessation. Search methods We searched the Cochrane Tobacco Addiction Group specialised trials register. Most recent search was in July 2012. Selection criteria We included randomised trials of silver acetate for smoking cessation with reports of smoking status at least six months after the beginning of treatment. Data collection and analysis We extracted data in duplicate on the type of subjects, the dose and form of silver acetate, the outcome measures, method of randomisation, and completeness of follow‐up. The main outcome measure was biochemically validated abstinence from smoking after at least six months follow‐up in patients smoking at baseline. Subjects lost to follow‐up were counted as continuing smokers. Where appropriate, we performed meta‐analysis using a fixed effects model. Main results Two studies provided long‐term follow‐up data on patients randomised to silver acetate or placebo. In one of these studies, there was a third arm, randomised to 2mg nicotine gum. The pooled risk ratio for quitting for silver acetate vs placebo was 1.04 (95% confidence interval 0.69 to 1.57). Authors' conclusions Existing trials show little evidence for a specific effect of silver acetate in promoting smoking cessation. The confidence intervals for the ratio are quite wide. However, the upper limit of the confidence intervals for a positive effect equates to an absolute increase in the smoking cessation rate of about 4%. Any effect of this agent is therefore likely to be smaller than nicotine replacement therapy. The lack of effect of silver acetate may reflect poor compliance with a treatment whose rationale is to create an unpleasant stimulus. Plain language summary Does silver acetate help people stop smoking Silver acetate products (gum, lozenge, and spray) produce an unpleasant metallic taste when combined with cigarettes, so they are used as a form of aversion therapy for smoking. However, the review of trials found little evidence to show that silver acetate helps smokers quit. Any beneficial effect of silver acetate is likely to be very small, and less than the effect already proven for nicotine replacement therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lancaster, T, Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000191.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.725Z" }, { "id": "152692fa-7d81-4c48-841e-5191d48cfedf", "pmid": "", "title": "Physical interventions to interrupt or reduce the spread of respiratory viruses", "imported": false, "abstract": "Abstract - Background Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID‐19) caused by SARS‐CoV‐2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID‐19 pandemic. Objectives To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. Search methods We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies. Selection criteria We included randomised controlled trials (RCTs) and cluster‐RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission. Data collection and analysis We used standard Cochrane methodological procedures. Main results We included 11 new RCTs and cluster‐RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID‐19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID‐19 pandemic. Many studies were conducted during non‐epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID‐19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high‐income countries; crowded inner city settings in low‐income countries; and an immigrant neighbourhood in a high‐income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster‐RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster‐RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza‐like illness (ILI)/COVID‐19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate‐certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory‐confirmed influenza/SARS‐CoV‐2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate‐certainty evidence). Harms were rarely measured and poorly reported (very low‐certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low‐certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low‐certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory‐confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate‐certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low‐certainty evidence). One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non‐inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID‐19 patients. Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta‐analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate‐certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory‐confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low‐certainty evidence), and laboratory‐confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low‐certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low‐certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low‐certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports. Authors' conclusions The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory‐confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under‐investigated. There is a need for large, well‐designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs. Plain language summary Do physical measures such as hand‐washing or wearing masks stop or slow down the spread of respiratory viruses? Key messages 
We are uncertain whether wearing masks or N95/P2 respirators helps to slow the spread of respiratory viruses based on the studies we assessed. Hand hygiene programmes may help to slow the spread of respiratory viruses. How do respiratory viruses spread? 
Respiratory viruses are viruses that infect the cells in your airways: nose, throat, and lungs. These infections can cause serious problems and affect normal breathing. They can cause flu (influenza), severe acute respiratory syndrome (SARS), and COVID‐19. People infected with a respiratory virus spread virus particles into the air when they cough or sneeze. Other people become infected if they come into contact with these virus particles in the air or on surfaces on which they land. Respiratory viruses can spread quickly through a community, through populations and countries (causing epidemics), and around the world (causing pandemics). Physical measures to try to prevent respiratory viruses spreading between people include: · washing hands often; · not touching your eyes, nose, or mouth; · sneezing or coughing into your elbow; · wiping surfaces with disinfectant; · wearing masks, eye protection, gloves, and protective gowns; · avoiding contact with other people (isolation or quarantine); · keeping a certain distance away from other people (distancing); and · examining people entering a country for signs of infection (screening). What did we want to find out? 
We wanted to find out whether physical measures stop or slow the spread of respiratory viruses from well‐controlled studies in which one intervention is compared to another, known as randomised controlled trials. What did we do? 
We searched for randomised controlled studies that looked at physical measures to stop people acquiring a respiratory virus infection. We were interested in how many people in the studies caught a respiratory virus infection, and whether the physical measures had any unwanted effects. What did we find? 
We identified 78 relevant studies. They took place in low‐, middle‐, and high‐income countries worldwide: in hospitals, schools, homes, offices, childcare centres, and communities during non‐epidemic influenza periods, the global H1N1 influenza pandemic in 2009, epidemic influenza seasons up to 2016, and during the COVID‐19 pandemic. We identified five ongoing, unpublished studies; two of them evaluate masks in COVID‐19. Five trials were funded by government and pharmaceutical companies, and nine trials were funded by pharmaceutical companies. No studies looked at face shields, gowns and gloves, or screening people when they entered a country. We assessed the effects of: · medical or surgical masks; · N95/P2 respirators (close‐fitting masks that filter the air breathed in, more commonly used by healthcare workers than the general public); and · hand hygiene (hand‐washing and using hand sanitiser). We obtained the following results: Medical or surgical masks Ten studies took place in the community, and two studies in healthcare workers. Compared with wearing no mask in the community studies only, wearing a mask may make little to no difference in how many people caught a flu‐like illness/COVID‐like illness (9 studies; 276,917 people); and probably makes little or no difference in how many people have flu/COVID confirmed by a laboratory test (6 studies; 13,919 people). Unwanted effects were rarely reported; discomfort was mentioned. N95/P2 respirators Four studies were in healthcare workers, and one small study was in the community. Compared with wearing medical or surgical masks, wearing N95/P2 respirators probably makes little to no difference in how many people have confirmed flu (5 studies; 8407 people); and may make little to no difference in how many people catch a flu‐like illness (5 studies; 8407 people), or respiratory illness (3 studies; 7799 people). Unwanted effects were not well‐reported; discomfort was mentioned. Hand hygiene Following a hand hygiene programme may reduce the number of people who catch a respiratory or flu‐like illness, or have confirmed flu, compared with people not following such a programme (19 studies; 71,210 people), although this effect was not confirmed as statistically significant reduction when ILI and laboratory‐confirmed ILI were analysed separately. Few studies measured unwanted effects; skin irritation in people using hand sanitiser was mentioned. What are the limitations of the evidence? 
Our confidence in these results is generally low to moderate for the subjective outcomes related to respiratory illness, but moderate for the more precisely defined laboratory‐confirmed respiratory virus infection, related to masks and N95/P2 respirators. The results might change when further evidence becomes available. Relatively low numbers of people followed the guidance about wearing masks or about hand hygiene, which may have affected the results of the studies. How up to date is this evidence? 
We included evidence published up to October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jefferson, T; Dooley, L; Ferroni, E; Al-Ansary, LA; van Driel, ML; Bawazeer, GA; Jones, MA; Hoffmann, TC; Clark, J; Beller, EM; Glasziou, PP; Conly, JM", "articleTypes": [], "doi": "10.1002/14651858.CD006207.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "1529e51f-9923-49dc-8056-eb30e2c6ba6c", "pmid": "", "title": "Investigating Salt Taste Threshold in Patients Being Investigated for Primary Hyperaldosteronism Before and After Treatment.", "imported": false, "abstract": "This study looks at how hypertensive patients, with high levels of aldosterone (hyperaldosteronism) differ from hypertensive patients without hyperaldosteronism with regards to markers of salt appetite. It also looks at how salt appetite changes after treatment of hyperaldosteronism. Salt makes food taste good and when our bodies need salt our brains make us like salty food even more. A high salt diet contributes to hypertension and a low salt diet is an important aspect of the treatment of hypertension. Unfortunately patients find it difficult to adhere to a low salt diet. Aldosterone is produced by the adrenal glands, its release is stimulated by a salt need and it has been shown, in rodent models, to activate pathways in the brain which drive a salt appetite. Mice with enhanced activity of the aldosterone pathway in the brain become hypertensive due to increased salt intake. Hyperaldosteronism, in humans, results in hypertension. The contribution of salt appetite, as opposed to the effect of aldosterone on the kidney's retention of salt and other systems, is unknown. Human studies have shown that when a human has a salt appetite, the concentration at which they can detect the taste of salt reduces, they increase their preference for salty food, and they consume more salt.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.256Z" }, { "id": "153dfaa2-d101-4afb-ad20-368d68d03efc", "pmid": "", "title": "Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users", "imported": false, "abstract": "Abstract - Background Prolonged treatment with benzodiazepines is common practice despite clinical recommendations of short‐term use. Benzodiazepines are used by approximately 4% of the general population, with increased prevalence in psychiatric populations and the elderly. After long‐term use it is often difficult to discontinue benzodiazepines due to psychological and physiological dependence. This review investigated if pharmacological interventions can facilitate benzodiazepine tapering. Objectives To assess the benefits and harms of pharmacological interventions to facilitate discontinuation of chronic benzodiazepine use. Search methods We searched the following electronic databases up to October 2017: Cochrane Drugs and Alcohol Group's Specialised Register of Trials, CENTRAL, PubMed, Embase, CINAHL, and ISI Web of Science. We also searched ClinicalTrials.gov, the WHO ICTRP, and ISRCTN registry, and checked the reference lists of included studies for further references to relevant randomised controlled trials. Selection criteria We included randomised controlled trials comparing pharmacological treatment versus placebo or no intervention or versus another pharmacological intervention in adults who had been treated with benzodiazepines for at least two months and/or fulfilled criteria for benzodiazepine dependence (any criteria). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 38 trials (involving 2543 participants), but we could only extract data from 35 trials with 2295 participants. Many different interventions were studied, and no single intervention was assessed in more than four trials. We extracted data on 18 different comparisons. The risk of bias was high in all trials but one. Trial Sequential Analysis showed imprecision for all comparisons. For benzodiazepine discontinuation, we found a potential benefit of valproate at end of intervention (1 study, 27 participants; risk ratio (RR) 2.55, 95% confidence interval (CI) 1.08 to 6.03; very low‐quality evidence) and of tricyclic antidepressants at longest follow‐up (1 study, 47 participants; RR 2.20, 95% CI 1.27 to 3.82; low‐quality evidence). We found potentially positive effects on benzodiazepine withdrawal symptoms of pregabalin (1 study, 106 participants; mean difference (MD) ‐3.10 points, 95% CI ‐3.51 to ‐2.69; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐1.00 points, 95% CI ‐1.13 to ‐0.87; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐3.57 points, 95% CI ‐5.34 to ‐1.80; very low‐quality evidence), tricyclic antidepressants (1 study, 38 participants; MD ‐19.78 points, 95% CI ‐20.25 to ‐19.31; very low‐quality evidence), and flumazenil (3 studies, 58 participants; standardised mean difference ‐0.95, 95% CI ‐1.71 to ‐0.19; very low‐quality evidence) at end of intervention. However, the positive effect of paroxetine on benzodiazepine withdrawal symptoms did not persist until longest follow‐up (1 study, 54 participants; MD ‐0.13 points, 95% CI ‐4.03 to 3.77; very low‐quality evidence). The following pharmacological interventions reduced symptoms of anxiety at end of intervention: carbamazepine (1 study, 36 participants; MD ‐6.00 points, 95% CI ‐9.58 to ‐2.42; very low‐quality evidence), pregabalin (1 study, 106 participants; MD ‐4.80 points, 95% CI ‐5.28 to ‐4.32; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐5.70 points, 95% CI ‐6.05 to ‐5.35; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐6.75 points, 95% CI ‐9.64 to ‐3.86; very low‐quality evidence), and flumazenil (1 study, 18 participants; MD ‐1.30 points, 95% CI ‐2.28 to ‐0.32; very low‐quality evidence). Two pharmacological treatments seemed to reduce the proportion of participants that relapsed to benzodiazepine use: valproate (1 study, 27 participants; RR 0.31, 95% CI 0.11 to 0.90; very low‐quality evidence) and cyamemazine (1 study, 124 participants; RR 0.33, 95% CI 0.14 to 0.78; very low‐quality evidence). Alpidem decreased the proportion of participants with benzodiazepine discontinuation (1 study, 25 participants; RR 0.41, 95% CI 0.17 to 0.99; number needed to treat for an additional harmful outcome (NNTH) 2.3 participants; low‐quality evidence) and increased the occurrence of withdrawal syndrome (1 study, 145 participants; RR 4.86, 95% CI 1.12 to 21.14; NNTH 5.9 participants; low‐quality evidence). Likewise, magnesium aspartate decreased the proportion of participants discontinuing benzodiazepines (1 study, 144 participants; RR 0.80, 95% CI 0.66 to 0.96; NNTH 5.8; very low‐quality evidence). Generally, adverse events were insufficiently reported. Specifically, one of the flumazenil trials was discontinued due to severe panic reactions. Authors' conclusions Given the low or very low quality of the evidence for the reported outcomes, and the small number of trials identified with a limited number of participants for each comparison, it is not possible to draw firm conclusions regarding pharmacological interventions to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Due to poor reporting, adverse events could not be reliably assessed across trials. More randomised controlled trials are required with less risk of systematic errors ('bias') and of random errors ('play of chance') and better and full reporting of patient‐centred and long‐term clinical outcomes. Such trials ought to be conducted independently of industry involvement. Plain language summary Medications for discontinuation of long‐term benzodiazepine use Background Benzodiazepines are widely prescribed for long‐term use despite recommendations of only short‐term use. It is often difficult to discontinue benzodiazepines after more than a few weeks of treatment due to the development of physical and psychological dependence. This review aimed to assess the effect and safety of medications to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Search date The evidence is current to October 2017. Study characteristics We identified 38 randomised controlled trials involving 2543 participants who had either been treated for more than two months with benzodiazepines, or who had been diagnosed with benzodiazepine dependence. We included studies irrespective of whether benzodiazepines were prescribed for anxiety, insomnia, or any other condition. The average age of participants was around 50 years, and the majority of participants were women in most studies. Twenty‐four trials were conducted in Europe; eight trials in the US or Canada; and six trials in Asia. The trials involved a wide range of medications to facilitate reduction or discontinuation of benzodiazepine use. Fourteen of the 38 included studies were partly funded by the drug manufacturer; nine studies were funded by government agencies; and 15 studies did not state the source of funding. The duration of the trials ranged between 1 and 24 weeks; the average trial duration was 9 weeks. Key results We extracted data on 18 different comparisons in a total of 2295 participants. We are uncertain whether valproate and tricyclic antidepressants increase the chance of discontinuing benzodiazepines, and whether benzodiazepine withdrawal symptoms are reduced by pregabalin, captodiame, paroxetine, tricyclic antidepressants, and flumazenil, as we assessed the quality of the evidence as very low. We are uncertain as to whether symptoms of anxiety after withdrawal of benzodiazepines are reduced by carbamazepine, pregabalin, captodiame, paroxetine, and flumazenil, as we assessed the quality of the evidence as very low. The effects of the evaluated medications were too uncertain to inform clinical practice due to risk of bias (systematic errors with overestimation of benefits and underestimation of harms) and risk of chance occurrence (random errors giving any result). Tolerability and safety were poorly reported across the included studies, making it impossible to assess the balance between possible benefits and adverse effects. Consequently, no conclusions can be drawn about the effectiveness of the interventions. Quality of the evidence The quality of the evidence was generally low or very low due to the small number of trials including a limited number of participants for each comparison; dissimilar results across studies; poor study design; and pronounced financial involvement of the pharmaceutical industry. Randomised controlled trials are therefore needed without risk of bias and random significant results involving long‐term assessments of participants conducted without involvement of industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Baandrup, L, Ebdrup, BH, Rasmussen, JØ, Lindschou, J, Gluud, C, Glenthøj, BY", "articleTypes": [], "doi": "10.1002/14651858.CD011481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.126Z" }, { "id": "154b7a86-6a77-4a20-93bf-39888b4aa731", "pmid": "", "title": "Horticultural therapy for schizophrenia", "imported": false, "abstract": "Abstract - Background Horticultural therapy is defined as the process of utilising fruits, vegetables, flowers and plants facilitated by a trained therapist or healthcare provider, to achieve specific treatment goals or to simply improve a person's well‐being. It can be used for therapy or rehabilitation programs for cognitive, physical, social, emotional, and recreational benefits, thus improving the person's body, mind and spirit. Between 5% to 15% of people with schizophrenia continue to experience symptoms in spite of medication, and may also develop undesirable adverse effects, horticultural therapy may be of value for these people. Objectives To evaluate the effects of horticultural therapy for people with schizophrenia or schizophrenia‐like illnesses compared with standard care or other additional psychosocial interventions. Search methods We searched the Cochrane Schizophrenia Group Trials Register (Janurary 2013) and supplemented this by contacting relevant study authors, and manually searching reference lists. Selection criteria We included one randomised controlled trial (RCT) comparing horticultural therapy plus standard care with standard care alone for people with schizophrenia. Data collection and analysis We reliably selected, quality assessed and extracted data. For continuous outcomes, we calculated a mean difference (MD) and for binary outcomes we calculated risk ratio (RR), both with 95% confidence intervals (CI). We assessed risk of bias and created a 'Summary of findings' table using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. Main results We included one single blind study (total n = 24). The overall risk of bias in the study was considered to be unclear although the randomisation was adequate. It compared a package of horticultural therapy which consisted of one hour per day of horticultural activity plus standard care with standard care alone over two weeks (10 consecutive days) with no long‐term follow‐up. Only two people were lost to follow‐up in the study, both in the horticultural therapy group (1 RCT n = 24,RR 5.00 95% CI 0.27 to 94.34, very low quality evidence ). There was no clear evidence of a difference in Personal Wellbeing Index (PWI‐C) change scores between groups, however confidence intervals were wide (1 RCT n = 22, MD ‐0.90 95% CI ‐10.35 to 8.55, very low quality evidence ). At the end of treatment, the Depression Anxiety Stress Scale (DASS21) change scores in horticultural therapy group were greater than that in the control group (1 RCT n = 22, MD ‐23.70 CI ‐35.37 to ‐ 12.03, very low quality evidence). The only included study did not report on adverse effects of interventions. Authors' conclusions Based on the current very low quality data, there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. This therapy remains unproven and more and larger randomised trials are needed to increase high quality evidence in this area. Plain language summary Gardening activity as a therapy for schizophrenia Horticultural therapy is based on the therapeutic value of participating in garden activities such as growing fruit or vegetables and/or flowers. Gardening is thought to improve people's well‐being through being a recreational and sociable activity which may lead to improvements in people's thinking, new friendships and more positive emotions. The benefits of gardening can also apply to people with serious mental illness such as schizophrenia. Gardening reduces stress, which is important because stress can often lead to mental illness. Gardening is also hard work and a physical activity, and so motivates people with mental illness who often feel tired and apathetic. Weight gain is common for people with mental illness and gardening is good physical exercise. Since 5% to 15% of people with schizophrenia experience symptoms in spite of taking antipsychotic drugs and also because these drugs have debilitating side effects, horticultural therapy may be of value to these people. This review focuses on the effects of horticultural therapy for people with schizophrenia. An electronic search for relevant randomised trials was run in January 2013. Only one trial was included, it randomised a total of 24 people with schizophrenia to received either their standard care plus horticultural therapy or standard care only. The trial only lasted 2 weeks (10 consecutive days) with no long‐term follow‐up. There are few results and the quality of evidence was rated by the review authors to be very low quality. Some of the information from this one study favoured horticultural therapy but there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. More large, better conducted and reported trials are required to determine the effectiveness and benefits of horticultural therapy. This plain language summary has been written by a consumer Ben Gray, Service User and Service User Expert, Rethink Mental Illness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Liu, Y, Li, B, Sampson, SJ, Roberts, S, Zhang, G, Wu, W", "articleTypes": [], "doi": "10.1002/14651858.CD009413.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.082Z" }, { "id": "157b2110-c245-4b45-a825-1ac8e7a167cf", "pmid": "", "title": "Xylitol‐containing products for preventing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is a highly prevalent chronic disease which affects the majority of people. It has been postulated that the consumption of xylitol could help to prevent caries. The evidence on the effects of xylitol products is not clear and therefore it is important to summarise the available evidence to determine its effectiveness and safety. Objectives To assess the effects of different xylitol‐containing products for the prevention of dental caries in children and adults. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 14 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , 2014, Issue 7), MEDLINE via OVID (1946 to 14 August 2014), EMBASE via OVID (1980 to 14 August 2014), CINAHL via EBSCO (1980 to 14 August 2014), Web of Science Conference Proceedings (1990 to 14 August 2014), Proquest Dissertations and Theses (1861 to 14 August 2014). We searched the US National Institutes of Health Trials Register ( http://clinicaltrials.gov ) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference and 95% confidence interval (CI). We used the continuous data to calculate prevented fractions (PF) and 95% CIs to summarise the percentage reduction in caries. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. As there were less than four studies included in the meta‐analysis, we used a fixed‐effect model. We planned to use a random‐effects model in the event that there were four or more studies in a meta‐analysis. Main results We included 10 studies that analysed a total of 5903 participants. One study was assessed as being at low risk of bias, two were assessed as being at unclear risk of bias, with the remaining seven being at high risk of bias. The main finding of the review was that, over 2.5 to 3 years of use, a fluoride toothpaste containing 10% xylitol may reduce caries by 13% when compared to a fluoride‐only toothpaste (PF ‐0.13, 95% CI ‐0.18 to ‐0.08, 4216 children analysed, low‐quality evidence). The remaining evidence on children, from small single studies with risk of bias issues and great uncertainty associated with the effect estimates, was insufficient to determine a benefit from xylitol products. One study reported that xylitol syrup (8 g per day) reduced caries by 58% (95% CI 33% to 83%, 94 infants analysed, low quality evidence) when compared to a low‐dose xylitol syrup (2.67 g per day) consumed for 1 year. The following results had 95% CIs that were compatible with both a reduction and an increase in caries associated with xylitol: xylitol lozenges versus no treatment in children (very low quality body of evidence); xylitol sucking tablets versus no treatment in infants (very low quality body of evidence); xylitol tablets versus control (sorbitol) tablets in infants (very low quality body of evidence); xylitol wipes versus control wipes in infants (low quality body of evidence). There was only one study investigating the effects of xylitol lozenges, when compared to control lozenges, in adults (low quality body of evidence). The effect estimate had a 95% CI that was compatible with both a reduction and an increase in caries associated with xylitol. Four studies reported that there were no adverse effects from any of the interventions. Two studies reported similar rates of adverse effects between study arms. The remaining studies either mentioned adverse effects but did not report any usable data, or did not mention them at all. Adverse effects include sores in the mouth, cramps, bloating, constipation, flatulence, and loose stool or diarrhoea. Authors' conclusions We found some low quality evidence to suggest that fluoride toothpaste containing xylitol may be more effective than fluoride‐only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse‐effects from such toothpastes. The effect estimate should be interpreted with caution due to high risk of bias and the fact that it results from two studies that were carried out by the same authors in the same population. The remaining evidence we found is of low to very low quality and is insufficient to determine whether any other xylitol‐containing products can prevent caries in infants, older children, or adults. Plain language summary Can xylitol used in products like sweets, candy, chewing gum and toothpaste help prevent tooth decay in children and adults? Review question This review has been produced to assess whether or not xylitol, a natural sweetener used in products such as sweets, candy, chewing gum and toothpaste, can help prevent tooth decay in children and adults. Background Tooth decay is a common disease affecting up to 90% of children and most adults worldwide. It impacts on quality of life and can be the reason for thousands of children needing dental treatment under general anaesthetic in hospital. However, it can easily be prevented and treated by good oral health habits such as brushing teeth regularly with toothpaste that contains fluoride and cutting down on sugary food and drinks. If left undisturbed, the unhelpful bacteria in the mouth ‐ which cause decay ‐ multiply and stick to the surfaces of teeth producing a sticky film. Then, when sugar is eaten or drank, the bad bacteria in the film are able to make acid resulting in tooth decay. Xylitol is a natural sweetener, which is equally as sweet as normal sugar (sucrose). As well as providing an alternative to sugar, it has other properties that are thought to help prevent tooth decay, such as increasing the production of saliva and reducing the growth of bad bacteria in the mouth so that less acid is produced. In humans, xylitol is known to cause possible side effects such as bloating, wind and diarrhoea. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 14 August 2014. It includes 10 studies published from 1991 to 2014 in which 7969 participants were randomised (5903 of whom were included in the analyses) to receive xylitol products or a placebo (a substitute without xylitol) or no treatment, and the amount of tooth decay was compared. One study included adults, the others included children aged from 1 month to 13 years. The products tested were the kind that are held in the mouth and sucked (lozenges, sucking tablets and sweets) or slowly released through a dummy/pacifier, as well as toothpastes, syrups, and wipes. Key results There is some evidence to suggest that using a fluoride toothpaste containing xylitol may reduce tooth decay in the permanent teeth of children by 13% over a 3 year period when compared to a fluoride‐only toothpaste. Over this period, there were no side effects reported by the children. The remaining evidence we found did not allow us to conclude whether or not any other xylitol‐containing products can prevent tooth decay in infants, older children, or adults. Quality of the evidence The evidence presented is of low to very low quality due to the small amount of available studies, uncertain results, and issues with the way in which they were conducted.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P, Moore, D, Ahmed, F, Sharif, MO, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD010743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.821Z" }, { "id": "15912008-51c7-4024-9335-957524d4ef1c", "pmid": "", "title": "Adhesives for bonded molar tubes during fixed brace treatment", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Millett, DT, Mandall, NA, Mattick, RCR, Hickman, J, Glenny, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008236.pub3 AB - Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. The success of a fixed appliance depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a fixed appliance. It can also be costly in terms of clinical time, materials and time lost from education/work for the patient. This is an update of the Cochrane review first published in 2011. A new full search was conducted on 15 February 2017 but no new studies were identified. We have only updated the search methods section in this new version. The conclusions of this Cochrane review remain the same. Objectives To evaluate the effectiveness of the adhesives used to attach bonded molar tubes, and the relative effectiveness of the adhesives used to attach bonded molar tubes versus adhesives used to attach bands, during fixed appliance treatment, in terms of: (1) how often the tubes (or bands) come off during treatment; and (2) whether they protect the bonded (or banded) teeth against decay. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (to 15 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library (searched 15 February 2017), MEDLINE Ovid (1946 to 15 February 2017), and Embase Ovid (1980 to 15 February 2017). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials of participants with full arch fixed orthodontic appliance(s) with molar tubes, bonded to first or second permanent molars. Trials which compared any type of adhesive used to bond molar tubes (stainless steel or titanium) with any other adhesive, were included. Trials were also included where: (1) a tube was bonded to a molar tooth on one side of an arch and a band cemented to the same tooth type on the opposite side of the same arch;
 (2) molar tubes had been allocated to one tooth type in one patient group and molar bands to the same tooth type in another patient group. Data collection and analysis The selection of papers, decision about eligibility and data extraction were carried out independently and in duplicate without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Two trials (n = 190), at low risk of bias, were included in the review and both presented data on first time failure at the tooth level. Pooling of the data showed a statistically significant difference in favour of molar bands, with a hazard ratio of 2.92 (95% confidence intervals (CI) 1.80 to 4.72). No statistically significant heterogeneity was shown between the two studies. Data on first time failure at the patient level were also available and showed statistically different difference in favour of molar bands (risk ratio 2.30; 95% CI 1.56 to 3.41) (risk of event for molar tubes = 57%; risk of event for molar bands 25%). One trial presented data on decalcification again showing a statistically significant difference in favour of molar bands. No other adverse events identified. Authors' conclusions From the two well‐designed and low risk of bias trials included in this review it was shown that the failure of molar tubes bonded with either a chemically‐cured or light‐cured adhesive was considerably higher than that of molar bands cemented with glass ionomer cement. One trial indicated that there was less decalcification with molar bands cemented with glass ionomer cement than with bonded molar tubes cemented with a light‐cured adhesive. However, given there are limited data for this outcome, further evidence is required to draw more robust conclusions. Plain language summary Adhesives for bonded molar tubes during fixed brace treatment Background Orthodontic treatment involves using fixed or removable dental braces to correct the positions of teeth. The success of dental braces depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a dental brace. Study characteristics The evidence in this review, which was carried out together with Cochrane Oral Health, is up‐to‐date as of 15 February 2017. We included two studies that evaluated 190 participants. Both trials were conducted in the UK and both compared bonded molar tubes with molar bands. Key results From the limited data of two studies at low risk of bias, it would appear that bonded molar tubes are associated with a higher failure rate than with molar bands.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.775Z" }, { "id": "15aabff9-aafa-48b2-95de-b1a5e2fb9ee4", "pmid": "", "title": "Brexpiprazole versus placebo or other antidepressive agents for treating depression", "imported": false, "abstract": "Abstract - Background Brexpiprazole is the newest antipsychotic drug approved as an adjunctive for treatment‐resistant depression. This systematic review provides comprehensive, high‐quality evidence for the effects of brexpiprazole in major depressive disorder (MDD) based on existing and emerging randomised controlled trials (RCTs). Objectives To evaluate the benefits and harms of brexpiprazole as monotherapy or adjunct treatment in the acute and longer‐term treatment of MDD compared to placebo or other antidepressive agents. Search methods We used standard, extensive Cochrane search methods. The latest search date was November 2021. Selection criteria We included RCTs in people with a history of non‐response to one or more antidepressant monotherapies comparing brexpiprazole as monotherapy or adjunct treatment with placebo or other antidepressive agents. Data collection and analysis We used standard Cochrane methods. Primary outcomes were 1. response to treatment, measured as number of participants who achieved 50% or more reduction of the score on a validated scale for depression, 2. dropouts due to any reason, and 3. dropouts due to adverse effects, all measured at eight weeks (acute treatment). Our secondary outcomes were 4. number of participants who responded to treatment after two and 18 weeks, number of participants who achieved remission after eight weeks, 5. total number of participants with any adverse events, 6. social functioning or adjustment, and 7. health‐related quality of life. We used GRADE to assess certainty of evidence for each outcome. Main results We retrieved nine studies with 3424 participants with treatment‐resistant depression, defined as lack of response to at least two trials of antidepressant monotherapy. The age of participants was 18 to 65 years in seven studies, 18 to 75 years in one study, and older than 65 years in one study. Inclusion criteria for all studies required a diagnosis of MDD with a current major depressive episode per Diagnostic and Statistical Manual of Mental Disorders Text Revision Fourth Edition criteria and additional criteria on minimal scores on Montgomery–Åsberg Depression Rating Scale (MADRS) and Hamilton Depression Rating Scale which varied across studies. Eight studies compared brexpiprazole as adjunctive treatment to an antidepressant versus placebo as adjunctive treatment to an antidepressant. One study added brexpiprazole or placebo to a combination of antidepressant and ketamine. Four studies used fixed dosages and five studies used flexible dosages of brexpiprazole. The manufacturer sponsored eight studies and one study was independently funded. Brexpiprazole was superior in achieving response at eight weeks (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.23 to 1.75; 8 studies, 3409 participants; high‐certainty evidence). More participants randomised to brexpiprazole dropped out due to any cause at eight weeks (OR 1.37, 95% CI 1.02 to 1.83; 7 studies, 2523 participants; high‐certainty evidence) or due to adverse effects (OR 2.88, 95% CI 1.37 to 6.05; 6 studies, 2472 participants; high‐certainty evidence). Brexpiprazole was superior to placebo when added to an antidepressant for achieving remission at eight weeks (OR 1.46, 95% CI 1.19 to 1.79; 7 studies, 3358 participants; high‐certainty evidence). When response was defined based on a change in the score on MADRS, brexpiprazole also demonstrated better efficacy than placebo (mean difference (MD) –1.39, 95% CI –1.96 to –0.82; 8 studies, 3263 participants; high‐certainty evidence). Compared to placebo, add‐on brexpiprazole is probably more likely to result in akathisia (OR 2.95, 95% CI 2.06 to 4.21; 7 studies, 3358 participants; moderate‐certainty evidence) and weight gain (OR 3.14, 95% CI 2.19 to 4.49; 9 studies, 3424 participants; moderate‐certainty evidence). The risk of bias varied between low and unclear for most studies. Only one study was at high risk of selective reporting bias and other bias; however, this study had a small sample size and its impact on overall risk of bias was not considered significant. The certainty of the evidence on five of the main outcomes (response to treatment, measured as number of participants who achieved response and change in depressive symptoms, remission, dropouts due to any cause, dropouts due to adverse effects) was high. The certainty of evidence for akathisia and weight gain was downgraded one level to moderate due to indirectness. Authors' conclusions Our review supports the superior efficacy of add‐on brexpiprazole in comparison to placebo in adults with treatment‐resistant depression for the short‐term and acute treatment of depression. Our findings were limited by the small number of studies and the moderate‐certainty evidence for the most common adverse effects (akathisia and weight gain). There was insufficient evidence for the effects of brexpiprazole for depression in older people or children. In addition, we found no studies that compared brexpiprazole to other antidepressants or where brexpiprazole was added after lack of response to only one antidepressant. We also lacked sufficient data to establish the long‐term efficacy of brexpiprazole as adjunctive treatment. Active comparators, long‐term studies in different age groups and cost‐effect analyses are needed to more precisely establish the clinical role of brexpiprazole in the treatment of MDD. Plain language summary What are the benefits and harms of brexpiprazole, a new antipsychotic medication, for the treatment of depression when compared to dummy tablets or antidepressants? Key messages – Brexpiprazole added to an antidepressant is better at reducing the symptoms of depression than placebo (dummy tablet) added to an antidepressant. – Brexpiprazole might be more commonly associated with weight gain and akathisia (a feeling of restlessness that causes a compelling need to move all the time). What is depression? Depression is a common mental health condition which leads to low mood, inability to experience pleasure, sleep disruption, weight loss, fatigue or low energy, slower speech and movements, feeling worthless or excessively guilty, being unable to concentrate and having thoughts of committing suicide. To be diagnosed with depression, a person should experience five or more of these symptoms, including low mood or loss of sense of pleasure for at least two weeks. How is the condition treated? Unless the symptoms of depression are mild, the first option for treatment is an antidepressant medication, but antidepressants only help in half of cases when prescribed for the first time. When an antidepressant is not enough to treat depression, one available option is to add another medication to help the effects of the antidepressant. Other options include changing the antidepressant to another antidepressant, talking therapy or stimulation of the brain through electrical pulses. Brexpiprazole is a new medication which can be added to an antidepressant that has not worked by itself. Brexpiprazole can be prescribed in doses from 0.5 mg to 3 mg for the treatment of depression. It has also been approved for the treatment of schizophrenia. What did we want to find out? We wanted to examine the effects of brexpiprazole in the treatment of depression when prescribed by itself or when added to another antidepressant and how its effects compare to the effects of antidepressants or placebo. To do so we explored several effects. First, we looked into how well brexpiprazole decreased the symptoms of depression. Second, we explored how many participants gave up taking part in the studies for any reason. Third, we investigated how many stopped participating because of the unwanted effects they experienced. Fourth, we explored what unwanted effects emerged with the use of brexpiprazole. We also wanted to know how brexpiprazole affected the quality of life of the participants and how it affected the way they functioned in their everyday lives. What did we do? We searched scientific databases for studies that reported the effects of brexpiprazole versus placebo or antidepressants for depression. We included only studies in which the participants were assigned randomly to one or the other treatment. Neither them nor the team that was evaluating the effects of the treatment knew what was prescribed and this helped to objectively evaluate the results without the knowledge of what was prescribed impacting on the outcome. We compared and summarised the results and evaluated how confident we were that the results of the studies represented the real effects of the medication. We based our confidence on different factors such as the size of the effects, the methods used, and what and how the results were reported. What did we find and what were the limitations of our findings? We found nine studies, which included 3424 participants; two‐thirds of them were women and one‐third were men. We only found studies in which brexpiprazole was added after the participants had tried treatment with two or more antidepressants on their own. We have a high level of confidence that brexpiprazole added to an antidepressant reduced the symptoms of depression more after eight weeks of treatment than placebo added to an antidepressant. Brexpiprazole was also more likely to lead to no symptoms of depression than placebo when either of them was added to an antidepressant. We are moderately confident that brexpiprazole caused weight gain or subjective feelings of restlessness more often than placebo. We are less confident about the results around these unwanted effects as we could not find information about how they were measured and whether all studies used the same methods to measure them. What did we fail to find? We found no studies that explored how brexpiprazole would work for children or older people who have depression. We wanted to find how brexpiprazole would work when given for depression for longer periods of time, such as 18 to 24 weeks, but we found only one study and its results were not enough to draw a conclusion. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 1 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ralovska, S, Koychev, I, Marinov, P, Furukawa, TA, Mulsant, B, Cipriani, A", "articleTypes": [], "doi": "10.1002/14651858.CD013866.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.107Z" }, { "id": "15ad3991-494b-4e2f-8263-d8eb1ee1b789", "pmid": "", "title": "Cannabis‐based medicines and medical cannabis for adults with cancer pain", "imported": false, "abstract": "Abstract - Background Pain is a common symptom in people with cancer; 30% to 50% of people with cancer will experience moderate‐to‐severe pain. This can have a major negative impact on their quality of life. Opioid (morphine‐like) medications are commonly used to treat moderate or severe cancer pain, and are recommended for this purpose in the World Health Organization (WHO) pain treatment ladder. Pain is not sufficiently relieved by opioid medications in 10% to 15% of people with cancer. In people with insufficient relief of cancer pain, new analgesics are needed to effectively and safely supplement or replace opioids. Objectives To evaluate the benefits and harms of cannabis‐based medicines, including medical cannabis, for treating pain and other symptoms in adults with cancer compared to placebo or any other established analgesic for cancer pain. Search methods We used standard, extensive Cochrane search methods. The latest search date was 26 January 2023. Selection criteria We selected double‐blind randomised, controlled trials (RCT) of medical cannabis, plant‐derived and synthetic cannabis‐based medicines against placebo or any other active treatment for cancer pain in adults, with any treatment duration and at least 10 participants per treatment arm. Data collection and analysis We used standard Cochrane methods. The primary outcomes were 1. proportions of participants reporting no worse than mild pain; 2. Patient Global Impression of Change (PGIC) of much improved or very much improved and 3. withdrawals due to adverse events. Secondary outcomes were 4. number of participants who reported pain relief of 30% or greater and overall opioid use reduced or stable; 5. number of participants who reported pain relief of 30% or greater, or 50% or greater; 6. pain intensity; 7. sleep problems; 8. depression and anxiety; 9. daily maintenance and breakthrough opioid dosage; 10. dropouts due to lack of efficacy; 11. all central nervous system adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We identified 14 studies involving 1823 participants. No study assessed the proportions of participants reporting no worse than mild pain on treatment by 14 days after start of treatment. We found five RCTs assessing oromucosal nabiximols (tetrahydrocannabinol (THC) and cannabidiol (CBD)) or THC alone involving 1539 participants with moderate or severe pain despite opioid therapy. The double‐blind periods of the RCTs ranged between two and five weeks. Four studies with a parallel design and 1333 participants were available for meta‐analysis. There was moderate‐certainty evidence that there was no clinically relevant benefit for proportions of PGIC much or very much improved (risk difference (RD) 0.06, 95% confidence interval (CI) 0.01 to 0.12; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 8 to 100). There was moderate‐certainty evidence for no clinically relevant difference in the proportion of withdrawals due to adverse events (RD 0.04, 95% CI 0 to 0.08; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 16 to endless). There was moderate‐certainty evidence for no difference between nabiximols or THC and placebo in the frequency of serious adverse events (RD 0.02, 95% CI −0.03 to 0.07). There was moderate‐certainty evidence that nabiximols and THC used as add‐on treatment for opioid‐refractory cancer pain did not differ from placebo in reducing mean pain intensity (standardised mean difference (SMD) −0.19, 95% CI −0.40 to 0.02). There was low‐certainty evidence that a synthetic THC analogue (nabilone) delivered over eight weeks was not superior to placebo in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and non‐small cell lung cancer (2 studies, 89 participants, qualitative analysis). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that synthetic THC analogues were superior to placebo (SMD −0.98, 95% CI −1.36 to −0.60), but not superior to low‐dose codeine (SMD 0.03, 95% CI −0.25 to 0.32; 5 single‐dose trials; 126 participants) in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours (2 single‐dose trials; 66 participants). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that CBD oil did not add value to specialist palliative care alone in the reduction of pain intensity in people with advanced cancer. There was no difference in the number of dropouts due to adverse events and serious adverse events (1 study, 144 participants, qualitative analysis). We found no studies using herbal cannabis. Authors' conclusions There is moderate‐certainty evidence that oromucosal nabiximols and THC are ineffective in relieving moderate‐to‐severe opioid‐refractory cancer pain. There is low‐certainty evidence that nabilone is ineffective in reducing pain associated with (radio‐) chemotherapy in people with head and neck cancer and non‐small cell lung cancer. There is low‐certainty evidence that a single dose of synthetic THC analogues is not superior to a single low‐dose morphine equivalent in reducing moderate‐to‐severe cancer pain. There is low‐certainty evidence that CBD does not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. Plain language summary Cannabis‐based medicines for cancer pain Do medicines based on cannabis help adults with cancer pain? Key messages Cannabis‐based medicines (CbMs) did not relieve cancer pain that did not respond to morphine‐like medicines. The studies analysed did not allow any statement to be made on the place of these medications in the World Health Organization (WHO) analgesic ladder for cancer pain. Trials with CbMs in cancer need to be very much better designed than those conducted so far. Pain in cancer and its treatment One person in two or three who gets cancer will have pain that becomes moderate or severe in intensity. The pain tends to get worse as the cancer progresses. The WHO recommends taking morphine‐like medicines for moderate‐to‐severe pain from cancer, but 1 in 6 to 10 people with cancer pain do not experience sufficient pain relief from morphine‐like medicines. Several products based on the cannabis plant have been suggested as treatment for cancer pain. These products include inhaled or orally ingested herbal cannabis, and various oils, sprays or tablets containing active cannabis ingredients obtained from the plant, or made synthetically. Some people with cancer pain have reported that CbMs are effective for them, and that is often highlighted in the media. What did we want to find out? If CbMs relieved cancer pain in people living with cancer. If CbMs were associated with any unwanted or harmful effects. What did we do? We searched for clinical trials that examined CbMs compared to other medications to treat cancer pain in adults. We summarised the results of the studies and rated our confidence in the evidence, based on factors such as the methods and size of studies. What did we find? We found 14 studies involving 1823 people. The biggest study included 399 people and the smallest study included 10 people. Studies were conducted in countries around the world; most (six) were based in North America. Five studies used one dose of CbM and lasted less than one day. Other studies lasted between two and eight weeks. Pharmaceutical companies funded seven studies. Six studies compared a mouth spray with a plant‐derived combination of tetrahydrocannabinol (THC), the principal psychoactive constituent of cannabis, and cannabidiol (CBD), an anti‐inflammatory ingredient of cannabis, against a fake medication (placebo). Seven studies compared an artificial cannabinoid mimicking the effects of THC against placebo. Of these seven studies, two studies compared against a morphine‐like medication (codeine), too. One study compared CBD against placebo. We did not find studies with herbal cannabis. Main results Mouth spray with a plant‐derived combination of THC and CBD was probably not better than placebo in reducing pain in people with moderate‐to‐severe cancer pain despite opioid treatment. Thirty‐two out of 100 people reported to be much or very much improved by cannabis‐based mouth spray and 23 out of 100 people with mouth spray with placebo. A total of 19 out of 100 people withdrew early because of side effects by cannabis‐based mouth spray and 16 out of 100 people by mouth spray with placebo. There was no difference in serious side effects between the cannabis‐based mouth spray and a placebo mouth spray. Artificial cannabinoid mimicking the effects of THC may not be better than a fake medication in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and a certain type of lung cancer. A single dose of an artificial cannabinoid mimicking the effects of THC may be better than a single dose of placebo, but may not differ from a single small dose of a morphine‐like medication in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours. CBD may not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. We found no studies with medical cannabis. What are the limitations of the evidence? We are moderately confident in the evidence that a mouth spray with a plant‐derived combination of THC and CBD does not reduce severe cancer pain despite opioid treatment because studies did not provide information about everything that we could have used. We have little confidence in the evidence that an artificial cannabinoid mimicking the effects of THC (nabilone) does not reduce pain associated with chemotherapy or radiochemotherapy because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that artificial cannabinoids mimicking the effects of THC reduce cancer pain after the previous pain‐relieving medication was stopped some hours before because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that CBD added to standard palliative care does not reduce cancer pain because there was only one study available. How up to date is the evidence? The evidence is up to date to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Häuser, W, Welsch, P, Radbruch, L, Fisher, E, Bell, RF, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD014915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.771Z" }, { "id": "15cde51d-3955-4c1e-954c-bd34e523cefd", "pmid": "", "title": "Smectite for acute infectious diarrhoea in children", "imported": false, "abstract": "Abstract - Background As mortality secondary to acute infectious diarrhoea has decreased worldwide, the focus shifts to adjuvant therapies to lessen the burden of disease. Smectite, a medicinal clay, could offer a complementary intervention to reduce the duration of diarrhoea. Objectives To assess the effects of smectite for treating acute infectious diarrhoea in children. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Pubmed), Embase (Ovid), LILACS, reference lists from studies and previous reviews, and conference abstracts, up to 27 June 2017. Selection criteria Randomized and quasi‐randomized trials comparing smectite to a control group in children aged one month to 18 years old with acute infectious diarrhoea. Data collection and analysis Two review authors independently screened abstracts and the full texts for inclusion, extracted data, and assessed risk of bias. Our primary outcomes were duration of diarrhoea and clinical resolution at day 3. We summarized continuous outcomes using mean differences (MD) and dichotomous outcomes using risk ratios (RR), with 95% confidence intervals (CI). Where appropriate, we pooled data in meta‐analyses and assessed heterogeneity. We explored publication bias using a funnel plot. Main results Eighteen trials with 2616 children met our inclusion criteria. Studies were conducted in both ambulatory and in‐hospital settings, and in both high‐income and low‐ or middle‐income countries. Most studies included children with rotavirus infections, and half included breastfed children. Smectite may reduce the duration of diarrhoea by approximately a day (MD ‐24.38 hours, 95% CI ‐30.91 to ‐17.85; 14 studies; 2209 children; low‐certainty evidence); may increase clinical resolution at day 3 (risk ratio (RR) 2.10, 95% CI 1.30 to 3.39; 5 trials; 312 children; low‐certainty evidence); and may reduce stool output (MD ‐11.37, 95% CI ‐21.94 to ‐0.79; 3 studies; 634 children; low‐certainty evidence). We are uncertain whether smectite reduces stool frequency, measured as depositions per day (MD ‐1.33, 95% CI ‐2.28 to ‐0.38; 3 studies; 954 children; very low‐certainty evidence). There was no evidence of an effect on need for hospitalization (RR 0.93, 95% CI 0.75 to 1.15; 2 studies; 885 children; low‐certainty evidence) and need for intravenous rehydration (RR 0.77, 95% CI 0.54 to 1.11; 1 study; 81 children; moderate‐certainty evidence). The most frequently reported side effect was constipation, which did not differ between groups (RR 4.71, 95% CI 0.56 to 39.19; 2 studies; 128 children; low‐certainty evidence). No deaths or serious adverse effects were reported. Authors' conclusions Based on low‐certainty evidence, smectite used as an adjuvant to rehydration therapy may reduce the duration of diarrhoea in children with acute infectious diarrhoea by a day; may increase cure rate by day 3; and may reduce stool output, but has no effect on hospitalization rates or need for intravenous therapy. 2 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (27 Jun, 2017) were included Plain language summary Smectite for treating children with acute diarrhoea What is the aim of this review? The aim of this Cochrane Review was to find out if smectite (or diosmectite), a medicinal clay commonly prescribed to people who have diarrhoea in order to reduce their stool output, helps children with acute diarrhoea. We collected and analysed all relevant studies to answer this question and found 18 relevant studies. Key messages Giving smectite to children with acute diarrhoea may reduce its duration. However, more high‐quality studies are still needed, including studies that assess different causes of diarrhoea and the economic effects of this treatment. What was studied in the review? Acute diarrhoea is one of the most common diseases in children. It is usually caused by a viral infection. The main aim of treatment is to maintain a good level of hydration. This is achieved with oral rehydration solutions, and few children need to be hospitalized or require intravenous rehydration. Still, even with proper hydration, having loose stools is a burden for both parents and patients. Smectite may help by reducing inflammation in the gut; by acting as a barrier to reduce the penetration of toxins; or by increasing water absorption. What are the main results? We found 18 relevant studies with 2616 children that were conducted in both high‐income and low‐ or middle‐income countries. These studies compared children receiving smectite with children receiving routine care or a placebo (a pill or liquid that contains no medicine). Eight studies were funded by the manufacturer. Smectite may reduce the duration of diarrhoea by one day (low‐certainty evidence); may increase the number of children cured by day 3 (low‐certainty evidence); and may slightly reduce the quantity of loose stools (low‐certainty evidence). We are uncertain whether smectite has an effect on how many stools children have (very low‐certainty evidence). It may not have an effect on how many children need to be hospitalized (low‐certainty evidence), and probably does not have an effect on how many children need intravenous rehydration (moderate‐certainty evidence). We found no reports of serious adverse effects. Minor adverse effects included constipation, vomiting, and bad taste, but these did not differ between groups. How up‐to‐date is this review? We searched for studies published up to 27 June 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pérez‐Gaxiola, G, Cuello‐García, CA, Florez, ID, Pérez‐Pico, VM", "articleTypes": [], "doi": "10.1002/14651858.CD011526.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.067Z" }, { "id": "15d7e989-7fcb-4fb1-b9f7-280a535b64cd", "pmid": "", "title": "Sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose or glucose with and without non‐nutritive sucking is frequently used as a non‐pharmacological intervention for needle‐related procedural pain relief in infants. Objectives To determine the effectiveness of sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet‐tasting solutions, or pharmacological or other non‐pharmacological pain‐relieving methods. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012); MEDLINE via Ovid (1966 to 2012); CINAHL via OVID (1982 to 2012). The World Health Organization International Clinical Trials Registry Platform was also searched for any ongoing trials. Clinical trial registries, conference proceedings and references for randomised controlled trials (RCTs) were also searched. An updated search was run to capture any new publications before finalising the review in April 2012 and no new included studies were identified. Two review authors (MK & JF) independently abstracted data and assessed quality using a standard form. Authors have been contacted for missing data. Selection criteria Randomised‐controlled trials using a sweet‐tasting solution to treat pain in healthy term infants (gestational age 37 weeks and over), between one month and 12 months of age who required needle‐related procedures. These procedures included but were not limited to: subcutaneous or intramuscular injections, venepuncture, and heel lance. Studies in which the painful procedure was circumcision, lumbar puncture or supra‐pubic bladder aspiration were not included as they are more severe and painful than needle‐related procedures. Control conditions included no treatment or placebo (water) or any other identical intervention (same appearance and consistency) without active ingredient, another sweet‐tasting solution, a pharmacological pain‐relieving method (e.g. paracetamol, topical anaesthetic cream), non‐pharmacological pain‐relieving method (e.g. distraction method, non‐nutritive sucking). Data collection and analysis Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Pain, Palliative and Supportive Care Group. We report mean differences (MD) with 95% confidence intervals (CI) using fixed‐effect models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. The Chi 2 test and I 2 statistic were used to assess between‐study heterogeneity. Main results Sixty‐five (65) studies were identified for possible inclusion in this review. Fourteen published RCTs with a total of 1551 participants met the inclusion criteria. Duration of cry was significantly reduced in infants who were administered a sweet‐tasting solution [MD ‐13.47 (95% CI ‐16.80 to ‐10.15)], P < 0.00001 compared with water. However, there was considerable heterogeneity between the studies (I 2 = 94%) that we were unable to explain. Meta‐analysis was not able to be undertaken for any of the other outcome measures, except for cry duration, because of differences in study design. However, most of the individual studies that measured pain found sucrose to significantly reduce pain compared with the control group. One study compared sucrose and Lidocaine‐prilocaine cream and no significant difference was found between the two treatments for the outcomes pain and cry duration. Due to the differences between the studies, we were unable to identify the optimal concentration, volume or method of administration of sweet‐tasting solutions in infants aged one to 12 months. Further large RCTs are needed. Authors' conclusions There is insufficient evidence to confidently judge the effectiveness of sweet‐tasting solutions in reducing needle‐related pain in infants (one month to 12 months of age). The treatments do, however, appear promising. Data from a series of individual trials are promising, as are the results from a subset meta‐analysis of studies measuring duration of crying. Further well controlled RCTs are warranted in this population to determine the optimal concentration, volume, method of administration, and possible adverse effects. Plain language summary Sweet‐tasting solutions for needle‐related pain in infants up to one year of age The use of needles that break the skin and cause pain is a common practice around the world with babies aged between one month and 12 months ( Appendix 4 ). In this review we were interested in whether giving babies sugar‐based solutions to taste when the needle breaks the skin will help reduce their pain. We found 14 separate studies that had asked this question. However, the differences between the studies were often too great to let us combine their findings. Overall, the studies show that different types of sugar‐based solutions were effective but we were not able to confidently assert that there is strong evidence for this treatment in reducing pain. We did find some evidence that babies may not cry for as long if given sugar‐based solutions. This review is broadly in agreement with two other reviews, one asking this question in younger children, and one in older children. There is a need for better studies in this field.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Kassab, M; Foster, JP; Foureur, M; Fowler, C", "articleTypes": [], "doi": "10.1002/14651858.CD008411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "15dffafd-7a58-43e8-9870-1f3d6defc5ed", "pmid": "", "title": "Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether metformin can prevent or delay T2DM and its complications in people with increased risk of developing T2DM is unknown. Objectives To assess the effects of metformin for the prevention or delay of T2DM and its associated complications in persons at increased risk for the T2DM. Search methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was March 2019. Selection criteria We included randomised controlled trials (RCTs) with a duration of one year or more comparing metformin with any pharmacological glucose‐lowering intervention, behaviour‐changing intervention, placebo or standard care in people with impaired glucose tolerance, impaired fasting glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or combinations of these. Data collection and analysis Two review authors read all abstracts and full‐text articles and records, assessed risk of bias and extracted outcome data independently. We used a random‐effects model to perform meta‐analysis and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using GRADE. Main results We included 20 RCTs randomising 6774 participants. One trial contributed 48% of all participants. The duration of intervention in the trials varied from one to five years. We judged none of the trials to be at low risk of bias in all 'Risk of bias' domains. Our main outcome measures were all‐cause mortality, incidence of T2DM, serious adverse events (SAEs), cardiovascular mortality, non‐fatal myocardial infarction or stroke, health‐related quality of life and socioeconomic effects.The following comparisons mostly reported only a fraction of our main outcome set.
 Fifteen RCTs compared metformin with diet and exercise with or without placebo: all‐cause mortality was 7/1353 versus 7/1480 (RR 1.11, 95% CI 0.41 to 3.01; P = 0.83; 2833 participants, 5 trials; very low‐quality evidence); incidence of T2DM was 324/1751 versus 529/1881 participants (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 3632 participants, 12 trials; moderate‐quality evidence); the reporting of SAEs was insufficient and diverse and meta‐analysis could not be performed (reported numbers were 4/118 versus 2/191; 309 participants; 4 trials; very low‐quality evidence); cardiovascular mortality was 1/1073 versus 4/1082 (2416 participants; 2 trials; very low‐quality evidence). One trial reported no clear difference in health‐related quality of life after 3.2 years of follow‐up (very low‐quality evidence). Two trials estimated the direct medical costs (DMC) per participant for metformin varying from $220 to $1177 versus $61 to $184 in the comparator group (2416 participants; 2 trials; low‐quality evidence). Eight RCTs compared metformin with intensive diet and exercise: all‐cause mortality was 7/1278 versus 4/1272 (RR 1.61, 95% CI 0.50 to 5.23; P = 0.43; 2550 participants, 4 trials; very low‐quality evidence); incidence of T2DM was 304/1455 versus 251/1505 (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 2960 participants, 7 trials; moderate‐quality evidence); the reporting of SAEs was sparse and meta‐analysis could not be performed (one trial reported 1/44 in the metformin group versus 0/36 in the intensive exercise and diet group with SAEs). One trial reported that 1/1073 participants in the metformin group compared with 2/1079 participants in the comparator group died from cardiovascular causes. One trial reported that no participant died due to cardiovascular causes (very low‐quality evidence). Two trials estimated the DMC per participant for metformin varying from $220 to $1177 versus $225 to $3628 in the comparator group (2400 participants; 2 trials; very low‐quality evidence). Three RCTs compared metformin with acarbose: all‐cause mortality was 1/44 versus 0/45 (89 participants; 1 trial; very low‐quality evidence); incidence of T2DM was 12/147 versus 7/148 (RR 1.72, 95% CI 0.72 to 4.14; P = 0.22; 295 participants; 3 trials; low‐quality evidence); SAEs were 1/51 versus 2/50 (101 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin with thiazolidinediones: incidence of T2DM was 9/161 versus 9/159 (RR 0.99, 95% CI 0.41 to 2.40; P = 0.98; 320 participants; 3 trials; low‐quality evidence). SAEs were 3/45 versus 0/41 (86 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin plus intensive diet and exercise with identical intensive diet and exercise: all‐cause mortality was 1/121 versus 1/120 participants (450 participants; 2 trials; very low‐quality evidence); incidence of T2DM was 48/166 versus 53/166 (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; 332 participants; 2 trials; very low‐quality evidence). One trial estimated the DMC of metformin plus intensive diet and exercise to be $270 per participant compared with $225 in the comparator group (94 participants; 1 trial; very‐low quality evidence). One trial in 45 participants compared metformin with a sulphonylurea. The trial reported no patient‐important outcomes. For all comparisons there were no data on non‐fatal myocardial infarction, non‐fatal stroke or microvascular complications. We identified 11 ongoing trials which potentially could provide data of interest for this review. These trials will add a total of 17,853 participants in future updates of this review. Authors' conclusions Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate‐quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate‐quality evidence). Likewise, the combination of metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of T2DM (very low‐quality evidence). Data on patient‐important outcomes such as mortality, macrovascular and microvascular diabetic complications and health‐related quality of life were sparse or missing. Plain language summary Metformin for prevention/delay of type 2 diabetes mellitus (T2DM) and associated complications in persons at increased risk for development of T2DM Review question Is the antidiabetic drug metformin able to prevent or delay the development of type 2 diabetes and its associated complications in people with moderately elevated blood sugar levels? Background People with moderately elevated blood sugar levels (often referred to as 'prediabetes') are said to have an increased risk for developing diabetes. Metformin is a blood sugar‐lowering medicine which has been used for a long time to treat people with type 2 diabetes. Type 2 diabetes, also known as adult‐onset diabetes, is the most common type of diabetes and prevents the body from using insulin properly (insulin resistance). Type 2 diabetes can have bad effects on health in the long term (diabetic complications), such as severe eye or kidney disease or 'diabetic feet', eventually resulting in foot ulcers. We investigated whether metformin can also be used to prevent or delay type 2 diabetes in people at increased risk. We examined the effects of metformin on patient‐important outcomes, such as complications of diabetes, death from any cause, health‐related quality of life and side effects of the drug. Study characteristics To be included, people had to have blood sugar levels higher than normal, but below the levels that are used to diagnose diabetes. We found 20 randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 6774 participants. The comparator group consisted of diet and exercise, intensive diet and exercise or another blood sugar‐lowering drug. One study dominated the evidence (48% of the total number of all participants). Twelve studies were performed in China. We only included studies with a treatment duration of one year or more. The treatment duration in the included studies varied from one to five years. This evidence is up to date as of March 2019. Key results Fifteen studies compared metformin against diet and exercise. Eight studies compared metformin against intensive diet and exercise and three studies compared metformin plus intensive diet and exercise against intensive diet and exercise only. When compared to standard diet and exercise metformin slightly reduces or delays development of diabetes. However, when compared to intensive diet and exercise, metformin does not provide an additional benefit in reducing or delaying development of diabetes. Seven studies compared metformin with another glucose‐lowering drug: three studies compared metformin with acarbose. Three studies compared metformin with a thiazolidinedione (such as pioglitazone). There was neither an advantage or disadvantage when comparing metformin with these drugs with respect to the development of diabetes. One study compared metformin with a sulphonylurea (glimepiride). The trial did not report patient‐important outcomes. In general, the reporting of serious side effects was sparse. Few participants died and we did not detect a clear difference between the intervention and comparator groups. We also did not detect an advantage or disadvantage of metformin in relation to health‐related quality of life. Our included studies did not report on non‐fatal heart attacks, strokes or complications of diabetes such as kidney or eye disease. Few studies estimated the direct medical costs. When compared to diet and exercise, metformin was more expensive. When compared to intensive diet and exercise, metformin was less expensive. We identified 11 ongoing studies which potentially could provide data for this review. These studies will add a total of 17,853 participants in future updates of our review. Future studies should investigate more patient‐important outcomes such as complications of diabetes and especially the side effects of the drugs. We do not know whether 'prediabetes' is just a condition defined by laboratory measurements, or whether it is in fact a real risk factor for diabetes. It is also unknown whether treatment of this condition translates into better patient‐important outcomes. Certainty of the evidence All included studies had problems in the way they were conduced or reported.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Madsen, KS; Chi, Y; Metzendorf, MI; Richter, B; Hemmingsen, B", "articleTypes": [], "doi": "10.1002/14651858.CD008558.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "15ed38bf-8746-43ff-839c-99b028aee2cc", "pmid": "", "title": "Targeting Triple-negative Breast Cancer or ER-positive, PR Positive her2 Negative by Alkaline Glucosodiene Molecules Via a Metabolic Pathway Phase I Clinical Trial", "imported": false, "abstract": "The diverse group of breast tumors known as triple-negative breast cancer (TNBC) which is lethally and deadly type of breast cancer and insensitive to endocrine therapy and HER2-targeted therapy because it lacks the expression of estrogen, progesterone, and human epidermal growth factor receptors TNBC makes up almost 15% of all invasive breast cancers, and of all breast tumor subtypes, it has the worst overall survival and the highest rate of metastatic occurrence. Cytotoxic chemotherapy is the main established systemic therapy for early and advanced TNBC disease at the moment because there is no authorized targeted therapy. Despite the fact that chemotherapy greatly improves clinical outcomes for TNBC patients, recurrence rates are still high and TNBC cancers frequently develop chemotherapeutic drug resistance ). In light of the few available therapy choices, so few choices for this subtype of breast cancer, and many cases are resistant to chemotherapy and recurrent and with a risk of high metastasis from previous literature and many experimental studies, the target of glucose environment is a promising weapon against this deadly type of breast cancer so glucose deprivation from tumor cells may cut the glucose entry as fuel to these cancer cells so this study uses a substitute energy fuel by using alkaline glucosodiene which is chemically invented by Maher M.AKL", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.153Z" }, { "id": "15f51230-7ce2-444b-a0ba-ca790643605a", "pmid": "", "title": "Gut microbiome‐based interventions for the management of obesity in children and adolescents aged up to 19 years", "imported": false, "abstract": "Abstract - Background The epidemic of overweight and obesity affects more than 390 million children and adolescents aged 5 to 19 years and 37 million children under five years of age. Overweight and obesity are associated with both short‐ and long‐term consequences, including chronic inflammation, metabolic diseases, as well as alterations in the gut microbiome composition. Gut microbiome‐based approaches may impact microbiome‐related metrics such as diversity or the abundance of intestinal bacteria, which may be linked to obesity‐related outcomes. However, evidence regarding the effect of gut microbiome‐based interventions for the management of obesity is limited. Objectives To assess the effects of gut microbiome‐based interventions in the management of overweight or obesity in children and adolescents in all their diversity aged 0 to 19 years. Search methods We searched CENTRAL, MEDLINE, CINAHL, Web of Science Core Collection, BIOSIS Previews, Global Index Medicus (all regions), IBECS, SciELO, PAHO, PAHO IRIS, WHO IRIS, WHOLIS, Bibliomap, TRoPHI as well as ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 24 January 2025. We did not apply any language restrictions. Selection criteria We included randomised controlled trials that evaluated gut microbiome‐based interventions [i.e. prebiotics, probiotics, synbiotics, short‐chain fatty acids (SCFAs), and faecal microbiota transplantation (FMT)] compared to standard‐of‐care, placebo, or control interventions in children and adolescents aged 0 to 19 years with overweight or obesity. Data collection and analysis Two review authors independently screened titles and abstracts and full texts, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias 2 tool and certainty of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE), a framework for assessing the certainty of evidence and making recommendations in systematic reviews. Random‐effects meta‐analyses were performed unless only one study per outcome was available, for which fixed‐effect analyses were performed. Main results We found 17 studies (838 participants) from various countries, evaluating the effects of prebiotics, probiotics, synbiotics, SCFAs, and FMT on body mass index (BMI), body weight, waist circumference, total body fat percentage (%TBF), systolic and diastolic blood pressure, and adverse events. Of the 17 studies included, five studies were in adolescents aged 10 to 19 years, and 12 studies were in children and adolescents spanning both age groups, 0 to 19 years. Upon contacting authors for data grouped by age of the participants, no studies provided separate outcomes data for children and adolescents. The included studies were funded by either academic funding sources or grants from the public and private sectors. Additionally, 15 studies were classified as currently being conducted ('ongoing'). The certainty of evidence throughout was very low. In adolescents 10 to 19 years of age, probiotics compared to placebo or no intervention may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events. Similarly, FMT compared to placebo may have little to no effect on waist circumference, %TBF, blood pressure, and adverse events in this age group. According to one study with 41 participants and in children and adolescents 0 to 19 years of age, intervention with prebiotics compared to placebo may result in a small reduction in BMI (mean difference = ‐0.70, 95% CI = ‐1.25 to ‐0.15) and body weight (mean difference = ‐1.5, 95% CI = ‐2.61 to ‐0.39). Prebiotics compared to placebo may have little to no effect on waist circumference, %TBF, systolic blood pressure, and adverse events. No data were available on the effect of prebiotics on diastolic blood pressure. Probiotics compared to placebo may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events in children and adolescents (0 to 19 years). Synbiotics compared to placebo may result in a reduction in systolic blood pressure (mean difference = ‐40.00, 95% CI = ‐50.63 to ‐29.37) in children and adolescents (0 to 19 years); according to one study with 56 participants. The evidence is very uncertain about the effects of synbiotics compared to a placebo on BMI, body weight, waist circumference, blood pressure, and adverse events. No data were available on the effect of synbiotics compared to placebo on %TBF. Synbiotics, compared to probiotics, may have little to no effect on waist circumference, %TBF, and adverse events. No data were available on the effect of synbiotics compared to probiotics on BMI, body weight, and blood pressure. According to one study with 48 participants and very low‐certainty of evidence, SCFAs compared to placebo may result in a reduction in waist circumference (mean difference = ‐5.08, 95% CI = ‐7.40 to ‐2.76) and BMI (mean difference = ‐2.26, 95% CI = ‐3.24 to ‐1.28) in children and adolescents (0–19 years). SCFAs compared to placebo may have little to no effect on adverse events. No data were available on the effect of SCFAs on body weight, %TBF, and blood pressure. Adverse events, i.e. abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine, were reported in the prebiotics group but with very low incidence. Additionally, adverse events such as nausea and headache were reported in the SCFAs group, but with low incidence. Authors' conclusions In adolescents aged 10 to 19 years, gut microbiome‐based interventions may result in little to no difference in obesity‐related outcomes. In children and adolescents aged 0 to 19 years, prebiotics may result in a small reduction in BMI and body weight; synbiotics may result in a reduction in systolic blood pressure, and SCFAs may result in a reduction in BMI and waist circumference, albeit the certainty of evidence was very low. The evidence was of very low certainty due to few studies per comparison, small sample sizes, short intervention durations, and insufficient reporting of adverse events. More rigorous research examining different types of gut microbiome‐based interventions for the management of obesity is required in children and adolescents, both in clinical and community settings. Future trials should also report methods related to randomisation, blinding, and compliance, as well as include prespecified analysis plans. Plain language summary Review question How effective are the gut microbiome‐based interventions for the management of overweight or obesity in children and adolescents in all their diversity, aged 0 to 19 years? Key messages • It is unclear if gut microbiome‐based interventions (nutrition interventions targeting intestinal microbes) have an effect on body mass index (BMI), body weight, waist size, body fat percentage, measures of blood pressure, and adverse events in children and adolescents with overweight and obesity. • Further research, including larger trials, is required to understand the effects of gut microbiome‐based interventions for the management of overweight and obesity in children and adolescents. What is overweight or obesity? Overweight is a condition of excessive fat deposits, and obesity is a chronic disease characterised by excessive fat deposits that can affect most body systems, impair quality of life, and reduce life expectancy. BMI, calculated by dividing a person's weight in kilograms by their height in metres, squared, is often used to define overweight and obesity. How is overweight or obesity managed? Overweight or obesity may be managed through changes in diet, behavioural counselling for lifestyle modifications, medications, or surgery. Despite these approaches, this global epidemic affects more than 390 million children and adolescents aged 5 to 19 years, and 37 million children under five years of age as of 2022. Overweight or obesity is linked to abnormal metabolism and an imbalance in the gut microbiome. Published works have shown that nutrition interventions targeting the \"gut microbiome\" may have beneficial effects on body weight and body fat percentage. The gut microbiome is the community of harmless bacteria and other microorganisms in the human intestine needed for optimal health. What did we want to find out? We wanted to find out the effect of various nutritional interventions targeting the intestinal microbial community on BMI, body weight, waist circumference, total body fat percentage, blood pressure, and adverse events associated with the interventions amongst children and adolescents in all their diversity, aged 0 to 19 years. What did we do? We searched for studies that examined the effects of gut microbiome‐based interventions, including prebiotics (food ingredients that promote beneficial microbes in the gut), probiotics (live microbes that are good for health), synbiotics (a combination of both prebiotics and probiotics), short‐chain fatty acids (i.e. small fat molecules produced by intestinal bacteria by fermenting dietary fibre and non‐digestible carbohydrates), and faecal microbiota transplantation (i.e. a capsule containing stool microbes from a healthy donor), compared to standard‐of‐care (usual care), placebo, control, or no interventions in children and adolescents up to 19 years of age. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 17 studies involving 838 children and adolescents with overweight and obesity. The studies were conducted in different countries, including Spain, China, Taiwan, Canada, Mexico, Italy, Poland, Turkey, Iran, Thailand, Denmark, New Zealand, and the USA. Adolescents aged 10 to 19 years Nutrition interventions targeting intestinal microbes may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. Children and adolescents aged 0 to 19 years It is unclear if prebiotics have an effect on waist size, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that prebiotics compared to a dummy treatment (i.e. an intervention that does not contain any medicine but looks or tastes identical to the intervention being tested) may result in a small reduction in BMI and body weight, but the evidence is very uncertain. Probiotics compared to a dummy treatment may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. It is unclear if synbiotics have an effect on BMI, body weight, waist size, body fat percentage, diastolic blood pressure, and adverse events compared with a dummy treatment. One study found that synbiotics may result in a reduction in systolic blood pressure, but the evidence is very uncertain. It is unclear if short‐chain fatty acids have an effect on body weight, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that short‐chain fatty acids may result in a reduction in BMI and waist circumference, but the evidence is very uncertain. Side effects of the interventions were generally not reported in the included studies, but one study noted potential side effects such as abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine in the prebiotics group; however, the occurrence was very low. Nausea and headache were reported in another study in the short‐chain fatty acids group, but were minimal. What are the limitations of the evidence? The review's findings are limited by the small number of participants, the low number of available studies for each of the comparisons, the lack of long‐term data, and insufficient reporting of adverse effects. How up to date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fahim, SM, Huey, SL, Palma Molina, XE, Agarwal, N, Ridwan, P, Ji, N, Kibbee, M, Kuriyan, R, Finkelstein, JL, Mehta, S", "articleTypes": [], "doi": "10.1002/14651858.CD015875", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.818Z" }, { "id": "161b050f-be2a-4a18-b028-73addbf324b5", "pmid": "", "title": "Preoperative carbohydrate treatment for enhancing recovery after elective surgery", "imported": false, "abstract": "Abstract - Background Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast‐track surgery protocols. Although fast‐track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis. Objectives To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data. Selection criteria We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time. Data collection and analysis Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis. Main results We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I‐II or I‐III. A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding. In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low‐quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference ‐0.13 days; 95% CI ‐0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high‐quality evidence). As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low‐quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation. Authors' conclusions Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases. Plain language summary Does giving patients carbohydrate supplements before planned surgery lead to improved recovery? Review question We reviewed the evidence on effects of carbohydrate supplements on the recovery of people undergoing planned surgical procedures. We found 27 studies investigating this question. Background Carbohydrate (sugar‐containing) nutritional supplements have become a routine part of the package of care for people undergoing planned surgical procedures. We wanted to discover whether carbohydrate supplements are a useful part of care packages used by doctors to improve recovery after planned surgical procedures. Study characteristics The evidence is current up to March 2014. We identified 27 studies and included the outcomes of 1976 participants. Studies investigated the outcomes of patients undergoing planned surgical procedures on the abdomen (18), the bones or joints (4), the heart (4) or the thyroid gland (1). Eighteen studies compared carbohydrate supplements versus an identical appearing placebo drink that did not contain carbohydrates; in six of these studies, an additional group of patients had nothing to eat or drink for at least six hours before surgery. In nine studies, taking carbohydrate supplements was compared with having nothing to eat or drink for six hours before surgery. The primary outcomes of length of hospital stay and complication rate were reported by 19 and 14 studies, respectively. Key results Patients given carbohydrates before planned surgical procedures went home between 0.04 and 0.56 days sooner than those receiving a placebo drink or having nothing to eat or drink before surgery. Carbohydrate supplements had little or no effect on complication rate or on how people feel in‐hospital during recovery from surgery. Quality of the evidence The overall quality of the evidence varied from very low to high. The quality of evidence in support of carbohydrate supplements resulting in a shorter hospital stay was very low because the included studies had important flaws in their design, a very wide range of results was described and evidence revealed that studies showing no differences in length of hospital stay may not have been published. When we looked only at well‐conducted studies, we found that carbohydrate supplements had little or no effect on length of hospital stay. The quality of evidence to support the effects of carbohydrate supplements on complication rate was low because issues with study design were identified and results were not similar across studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Smith, MD, McCall, J, Plank, L, Herbison, GP, Soop, M, Nygren, J", "articleTypes": [], "doi": "10.1002/14651858.CD009161.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.797Z" }, { "id": "161da74d-4b82-473f-8ea8-37c9426e2f12", "pmid": "", "title": "Laboratory‐based molecular test alternatives to RT‐PCR for the diagnosis of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Diagnosing people with a SARS‐CoV‐2 infection played a critical role in managing the COVID‐19 pandemic and remains a priority for the transition to long‐term management of COVID‐19. Initial shortages of extraction and reverse transcription polymerase chain reaction (RT‐PCR) reagents impaired the desired upscaling of testing in many countries, which led to the search for alternatives to RNA extraction/purification and RT‐PCR testing. Reference standard methods for diagnosing the presence of SARS‐CoV‐2 infection rely primarily on real‐time reverse transcription‐polymerase chain reaction (RT‐PCR). Alternatives to RT‐PCR could, if sufficiently accurate, have a positive impact by expanding the range of diagnostic tools available for the timely identification of people infected by SARS‐CoV‐2, access to testing and the use of resources. Objectives To assess the diagnostic accuracy of alternative (to RT‐PCR assays) laboratory‐based molecular tests for diagnosing SARS‐CoV‐2 infection. Search methods We searched the COVID‐19 Open Access Project living evidence database from the University of Bern until 30 September 2020 and the WHO COVID‐19 Research Database until 31 October 2022. We did not apply language restrictions. Selection criteria We included studies of people with suspected or known SARS‐CoV‐2 infection, or where tests were used to screen for infection, and studies evaluating commercially developed laboratory‐based molecular tests for the diagnosis of SARS‐CoV‐2 infection considered as alternatives to RT‐PCR testing. We also included all reference standards to define the presence or absence of SARS‐CoV‐2, including RT‐PCR tests and established clinical diagnostic criteria. Data collection and analysis Two authors independently screened studies and resolved disagreements by discussing them with a third author. Two authors independently extracted data and assessed the risk of bias and applicability of the studies using the QUADAS‐2 tool. We presented sensitivity and specificity, with 95% confidence intervals (CIs), for each test using paired forest plots and summarised results using average sensitivity and specificity using a bivariate random‐effects meta‐analysis. We illustrated the findings per index test category and assay brand compared to the WHO's acceptable sensitivity and specificity threshold for diagnosing SARS‐CoV‐2 infection using nucleic acid tests. Main results We included data from 64 studies reporting 94 cohorts of participants and 105 index test evaluations, with 74,753 samples and 7517 confirmed SARS‐CoV‐2 cases. We did not identify any published or preprint reports of accuracy for a considerable number of commercially produced NAAT assays. Most cohorts were judged at unclear or high risk of bias in more than three QUADAS‐2 domains. Around half of the cohorts were considered at high risk of selection bias because of recruitment based on COVID status. Three quarters of 94 cohorts were at high risk of bias in the reference standard domain because of reliance on a single RT‐PCR result to determine the absence of SARS‐CoV‐2 infection or were at unclear risk of bias due to a lack of clarity about the time interval between the index test assessment and the reference standard, the number of missing results, or the absence of a participant flow diagram. For index tests categories with four or more evaluations and when summary estimations were possible, we found that: a) For RT‐PCR assays designed to omit/adapt RNA extraction/purification, the average sensitivity was 95.1% (95% CI 91.1% to 97.3%), and the average specificity was 99.7% (95% CI 98.5% to 99.9%; based on 27 evaluations, 2834 samples and 1178 SARS‐CoV‐2 cases); b) For RT‐LAMP assays, the average sensitivity was 88.4% (95% CI 83.1% to 92.2%), and the average specificity was 99.7% (95% CI 98.7% to 99.9%; 24 evaluations, 29,496 samples and 2255 SARS‐CoV‐2 cases); c) for TMA assays, the average sensitivity was 97.6% (95% CI 95.2% to 98.8%), and the average specificity was 99.4% (95% CI 94.9% to 99.9%; 14 evaluations, 2196 samples and 942 SARS‐CoV‐2 cases); d) for digital PCR assays, the average sensitivity was 98.5% (95% CI 95.2% to 99.5%), and the average specificity was 91.4% (95% CI 60.4% to 98.7%; five evaluations, 703 samples and 354 SARS‐CoV‐2 cases); e) for RT‐LAMP assays omitting/adapting RNA extraction, the average sensitivity was 73.1% (95% CI 58.4% to 84%), and the average specificity was 100% (95% CI 98% to 100%; 24 evaluations, 14,342 samples and 1502 SARS‐CoV‐2 cases). Only two index test categories fulfil the WHO‐acceptable sensitivity and specificity requirements for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. In addition, WHO‐acceptable performance criteria were met for two assays out of 35 when tests were used according to manufacturer instructions. At 5% prevalence using a cohort of 1000 people suspected of SARS‐CoV‐2 infection, the positive predictive value of RT‐PCR assays omitting/adapting RNA extraction/purification will be 94%, with three in 51 positive results being false positives, and around two missed cases. For TMA assays, the positive predictive value of RT‐PCR assays will be 89%, with 6 in 55 positive results being false positives, and around one missed case. Authors' conclusions Alternative laboratory‐based molecular tests aim to enhance testing capacity in different ways, such as reducing the time, steps and resources needed to obtain valid results. Several index test technologies with these potential advantages have not been evaluated or have been assessed by only a few studies of limited methodological quality, so the performance of these kits was undetermined. Only two index test categories with enough evaluations for meta‐analysis fulfil the WHO set of acceptable accuracy standards for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. These assays might prove to be suitable alternatives to RT‐PCR for identifying people infected by SARS‐CoV‐2, especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence, including reliance on retrospective samples without information about the symptom status of participants and the timing of assessment. No extrapolation of found accuracy data for these two alternatives to any test brands using the same techniques can be made as, for both groups, one test brand with high accuracy was overrepresented with 21/26 and 12/14 included studies, respectively. Although we used a comprehensive search and had broad eligibility criteria to include a wide range of tests that could be alternatives to RT‐PCR methods, further research is needed to assess the performance of alternative COVID‐19 tests and their role in pandemic management. Plain language summary How accurate are alternative laboratory‐based molecular tests (to RT‐PCR with prior RNA extraction/purification) for identifying people infected by SARS‐CoV‐2? Key messages: * Transcription‐mediated amplification (TMA) tests and commercially available reverse transcription polymerase chain reaction (RT‐PCR) tests specifically designed to omit/adapt RNA extraction/purification appear accurate enough to replace the method of RT‐PCR with prior RNA (a molecule essential for most biological functions) extraction/purification for identifying people infected by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence. * The accuracy of other types of laboratory‐based molecular alternatives to RT‐PCR is below World Health Organisation (WHO) recommended standards or lacks a sufficient volume of evidence to draw reliable conclusions. *The extrapolation of accuracy data from the evaluated tests to any other test brand(s) using the same techniques will be challenging since main categories are overrepresented by highly accurate individual test brands. Further evaluation of these tests in real clinical practice scenarios is needed. What are alternative laboratory‐based molecular assays for identifying people infected by SARS‐CoV‐2? Laboratory‐based molecular assays (tests) aim to confirm or rule out SARS‐CoV‐2 infection in people. Alternatives to RT‐PCR assays have been developed to minimise the steps needed to process samples in the laboratory or use fewer resources to obtain the same valid results. For this review, we focus on tests commercially developed by a manufacturer, providing instructions for their professional use. Why is this question important? People with suspected SARS‐CoV‐2 infection should know if they are infected to self‐isolate, receive treatment, and inform close contacts. Failure to detect SARS‐CoV‐2 when it is present risks spreading infection and results in missed opportunities for prevention. Diagnosing SARS‐CoV‐2 infection when it is not present may lead to unnecessary self‐isolation and testing of close contacts. Currently, testing to confirm SARS‐CoV‐2 infection relies on a laboratory molecular test called RT‐PCR. This requires specialist equipment and can take 24 hours to produce a result. If assays that take less time or use readily available resources were sufficiently accurate to replace RT‐PCR testing, this could increase the number of tests that could be done, allow faster diagnosis and enable people to take appropriate action more quickly. What did we want to find out? We wanted to know whether commercially developed, alternative laboratory‐based molecular tests are accurate enough to diagnose SARS‐CoV‐2 infection compared to RT‐PCR. What did we do? We looked for studies investigating these tests in people (or samples) that were also tested for SARS‐CoV‐2 infection using RT‐PCR which modified RT‐PCR by removing or altering components of this testing process. What did we find? We included 105 evaluations evaluating alternatives to RT‐PCR in the review. The main results are based on 74,753 samples, and SARS‐CoV‐2 infection was confirmed in 7517 of these samples. Most evaluations (27/105) concerned various test types specifically designed to omit/adapt RNA extraction/purification. Twenty‐four of 105 evaluations concerned various test types operating at one temperature (isothermal tests) rather than cycling through different temperatures. Twenty‐four of 105 evaluations were concerned with various test types that combined these two alternative approaches. Main results Only tests specifically designed to omit/adapt RNA extraction/purification and TMA assays with RNA extraction (a type of isothermal test) met WHO‐acceptable standards for confirming and ruling out SARS‐CoV‐2. For illustration, the results of these studies indicate that in a group of 1000 people, 50 of whom (5%) actually have SARS‐CoV‐2: * For tests specifically designed to omit/adapt RNA extraction/purification: ‐51 people would test positive for SARS‐CoV‐2. Of these, three people (6%) would not have SARS‐CoV‐2 (false‐positive result). ‐949 people would test negative for SARS‐CoV‐2. Of these, two people (0.2%) would actually have SARS‐CoV‐2 (false‐negative result) *For TMA tests with RNA extraction: ‐55 people would test positive for SARS‐CoV‐2. Of these, six people (10%) would not have SARS‐CoV‐2 (false‐positive result). ‐945 people would test negative for SARS‐CoV‐2. Of these, one person (0.1%) would actually have SARS‐CoV‐2 (false‐negative result) What are the limitations of the evidence? Most included studies did not provide information on participants who underwent testing, such as whether they had symptoms or were close contacts of a SARS‐CoV‐2 case. We also had concerns about the method of recruiting participants for the majority of included studies, which may have resulted in an overestimation of the accuracy of these methods. In addition, the method used to determine whether individuals did not have SARS‐CoV‐2 infection was not considered reliable for most studies, which may have resulted in underestimating the accuracy of these methods. Some studies did not follow the manufacturers' instructions for using the test. Results from different test brands using the same technique varied. What does this mean? The studies included in this review suggest that two laboratory‐based molecular tests might be accurate enough to replace or supplement RT‐PCR tests with prior RNA extraction/purification for the diagnosis of SARS‐CoV‐2 infection: RT‐PCR tests developed to omit or adapt RNA extraction or purification and TMA isothermal tests (retaining an RNA extraction step). Other alternative tests to RT‐PCR were assessed just by a few studies of limited methodological quality, and their performance should be evaluated by additional studies. Furthermore, data in these studies mostly relied on samples acquired in the past (compared to current or future samples), thus further evaluation of these tests in real clinical practice scenarios is required. Also, decisions on the optimal test for a specific setting will be driven not only by diagnostic accuracy, but also by other factors such as test complexity, time to result, acceptability to those being tested, and the setting in which the tests are to be used. How up‐to‐date is this review? This review includes evidence published up to 31 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Arevalo-Rodriguez, I, Mateos-Haro, M, Dinnes, J, Ciapponi, A, Davenport, C, Buitrago-Garcia, D, Bennouna-Dalero, T, Roqué-Figuls, M, Van den Bruel, A, von Eije, KJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015618", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.817Z" }, { "id": "1645d0a3-1089-43f1-9afb-e6a47a1905c4", "pmid": "", "title": "Omega‐3 fatty acids for the treatment of dementia", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) from fish and plant sources are commonly considered as a promising non‐medical alternative to improve brain functions and slow down the progression of dementia. This assumption is mostly based on findings of preclinical studies and epidemiological research. Resulting explanatory models aim at the role omega‐3 PUFAs play in the development and integrity of the brain's neurons, their protective antioxidative effect on cell membranes and potential neurochemical mechanisms directly related to Alzheimer‐specific pathology. Epidemiological research also found evidence of malnutrition in people with dementia. Considering this and the fact that omega‐3 PUFA cannot be synthesised by humans, omega‐3 PUFAs might be a promising treatment option for dementia. Objectives To assess the efficacy and safety of omega‐3 polyunsaturated fatty acid (PUFA) supplementation for the treatment of people with dementia. Search methods We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 10 December 2015. We contacted manufacturers of omega‐3 supplements and scanned reference lists of landmark papers and included articles. Selection criteria We included randomised controlled trials (RCTs) in which omega‐3 PUFA in the form of supplements or enriched diets were administered to people with Alzheimer's disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), Parkinson's disease dementia (PDD) or frontotemporal dementia (FTD). Data collection and analysis The primary outcome measures of interest were changes in global and specific cognitive functions, functional performance, dementia severity and adverse effects. Two review authors independently selected studies, extracted data and assessed the quality of trials according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We received unpublished data from the trial authors and collected adverse effects information from the published articles. We conducted meta‐analyses for available outcome measures at six months. Main results We included three comparable randomised, placebo‐controlled trials investigating omega‐3 PUFA supplements in 632 participants with mild to moderate AD over six, 12 and 18 months. We found no studies investigating other types of dementia. All trials were of high methodological quality. The overall quality of evidence for most of the outcomes was high. There was no evidence of a benefit from omega‐3 PUFAs on cognitive function when measured at six months with the Alzheimer's Disease Assessment Scale ‐ Cognitive subscale (standardised mean difference (SMD) ‐0.02, 95% confidence interval (CI) ‐0.19 to 0.15; 566 participants; 3 studies; high quality evidence) or Mini‐Mental State Examination (mean difference (MD) 0.18, 95% CI ‐1.05 to 1.41; 202 participants; 2 studies; high quality evidence) or on activities of daily living (SMD ‐0.02, 95% CI ‐0.19 to 0.16; 544 participants; 2 studies; high quality evidence). There was also no effect at six months of treatment on severity of dementia measured with the Clinical Dementia Rating ‐ Sum of Boxes (MD ‐0.00, 95% CI ‐0.58 to 0.57; 542 participants; 2 studies; high quality evidence) or on quality of life measured with the Quality of Life Alzheimer's Disease scale (MD ‐0.10, 95% CI ‐1.28 to 1.08; 322 participants; 1 study; high quality evidence). There was no difference at six months on mental health measured with the Montgomery‐Åsberg Depression Rating Scale (MD ‐0.10, 95% CI ‐0.74 to 0.54; 178 participants: 1 study; high quality of evidence) or the Neuropsychiatric Inventory (SMD 0.10, 95% CI ‐0.07 to 0.27; 543 participants; 2 studies; high quality of evidence). One very small study showed a benefit for omega‐3 PUFAs in instrumental activities of daily living after 12 months of treatment (MD ‐3.50, 95% CI ‐4.30 to ‐2.70; 22 participants; moderate quality evidence). The included studies did not measure specific cognitive function. The studies did not report adverse events well. Two studies stated that all adverse events were mild and that they did not differ in overall frequency between omega‐3 PUFA and placebo groups. Data from one study showed no difference between groups in frequency of any adverse event (risk ratio (RR) 1.02, 95% CI 0.95 to 1.10; 402 participants; 1 study; moderate quality evidence) or any serious adverse event (RR 1.05, 95% CI 0.78 to 1.41; 402 participants; 1 study; high quality evidence) at 18 months of treatment. Authors' conclusions We found no convincing evidence for the efficacy of omega‐3 PUFA supplements in the treatment of mild to moderate AD. This result was consistent for all outcomes relevant for people with dementia. Adverse effects of omega‐3 PUFAs seemed to be low, but based on the evidence synthesised in this review, we cannot make a final statement on tolerability. The effects on other populations remain unclear. Plain language summary Omega‐3 fatty acids for the treatment of dementia Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) are assumed to have a beneficial effect on the function of the brain. It has been suggested that they might improve or delay decline in memory and ability to carry out everyday tasks in people with dementia. In this review, we investigated randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) comparing omega‐3 PUFAs, given in the form of supplements or enriched diets, with placebo (a pretend treatment) in people with the most common types of dementia. Included trials We included three trials that investigated 632 people with Alzheimer's disease of mild to moderate severity. We found no trials on other types of dementia. In all trials participants took either placebo or omega‐3 PUFA supplements. The quality of the trials was good. The participants were allocated to the groups randomly. The participants and most of the investigators did not know which treatment was given. Results When we combined the results of the trials, we found that taking omega‐3 PUFA supplements for six months had no effect on cognition (learning and understanding), everyday functioning, quality of life or mental health. One very small study observed that omega‐3 PUFAs improved cognitively complex daily activities, such as shopping, when taken for a longer period of time. However, the quality of the evidence was only moderate, so this should be confirmed in further trials. Omega‐3 PUFAs also had no effect on ratings of the overall severity of the illness. The trials did not report side effects very well, but none of the studies reported significant harmful effects on health. Conclusion Altogether, the quality of the evidence was moderate or high for most of the effects that we measured, but we found no evidence for either benefit or harm from omega‐3 PUFA supplements in people with mild to moderate Alzheimer's disease. The effects on people with other types of dementia remain unclear.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Burckhardt, M; Herke, M; Wustmann, T; Watzke, S; Langer, G; Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD009002.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "1695a0a6-cd0f-4e36-9de8-0609a5042697", "pmid": "", "title": "Neurogenic Mechanisms in Burning Mouth Syndrome With Focus on Localization and Desensibilization of Vanilloid Receptor TRPV1", "imported": false, "abstract": "Burning mouth syndrome (BMS) is characterized by a bilateral burning sensation in the anterior tongue, hard palate and lips in the absence of any clinical or laboratory findings. The term syndrome implicates the simultaneous presence of oral dryness (xerostomia) and altered taste (dysgeusia) in addition to the burning sensation in the oral mucosa. BMS is most often seen in women and is more frequent during menopause. The etiology and pathogenesis are still unclear but recent studies suggest that BMS is a neuropathic pain condition.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.149Z" }, { "id": "16a0f43b-a81b-4d58-b50e-accf1c03c316", "pmid": "", "title": "Impact of active placebo controls on estimated drug effects in randomised trials: a systematic review of trials with both active placebo and standard placebo", "imported": false, "abstract": "Abstract - Background An estimated 60% of pharmacological randomised trials use placebo control interventions to blind (i.e. mask) participants. However, standard placebos do not control for perceptible non‐therapeutic effects (i.e. side effects) of the experimental drug, which may unblind participants. Trials rarely use active placebo controls, which contain pharmacological compounds designed to mimic the non‐therapeutic experimental drug effects in order to reduce the risk of unblinding. A relevant improvement in the estimated effects of active placebo compared with standard placebo would imply that trials with standard placebo may overestimate experimental drug effects. Objectives We aimed to estimate the difference in drug effects when an experimental drug is compared with an active placebo versus a standard placebo control intervention, and to explore causes for heterogeneity. In the context of a randomised trial, this difference in drug effects can be estimated by directly comparing the effect difference between the active placebo and standard placebo intervention. Search methods We searched PubMed, CENTRAL, Embase, two other databases, and two trial registries up to October 2020. We also searched reference lists and citations and contacted trial authors. Selection criteria We included randomised trials that compared an active placebo versus a standard placebo intervention. We considered trials both with and without a matching experimental drug arm. Data collection and analysis We extracted data, assessed risk of bias, scored active placebos for adequacy and risk of unintended therapeutic effect, and categorised active placebos as unpleasant, neutral, or pleasant. We requested individual participant data from the authors of four cross‐over trials published after 1990 and one unpublished trial registered after 1990. Our primary inverse‐variance, random‐effects meta‐analysis used standardised mean differences (SMDs) of active versus standard placebo for participant‐reported outcomes at earliest post‐treatment assessment. A negative SMD favoured the active placebo. We stratified analyses by trial type (clinical or preclinical) and supplemented with sensitivity and subgroup analyses and meta‐regression. In secondary analyses, we investigated observer‐reported outcomes, harms, attrition, and co‐intervention outcomes. Main results We included 21 trials (1462 participants). We obtained individual participant data from four trials. Our primary analysis of participant‐reported outcomes at earliest post‐treatment assessment resulted in a pooled SMD of −0.08 (95% confidence interval (CI) −0.20 to 0.04; I 2 = 31%; 14 trials), with no clear difference between clinical and preclinical trials. Individual participant data contributed 43% of the weight of this analysis. Two of seven sensitivity analyses found more pronounced and statistically significant differences; for example, in the five trials with low overall risk of bias, the pooled SMD was −0.24 (95% CI −0.34 to −0.13). The pooled SMD of observer‐reported outcomes was similar to the primary analysis. The pooled odds ratio (OR) for harms was 3.08 (95% CI 1.56 to 6.07), and for attrition, 1.22 (95% CI 0.74 to 2.03). Co‐intervention data were limited. Meta‐regression found no statistically significant association with adequacy of the active placebo or risk of unintended therapeutic effect. Authors' conclusions We did not find a statistically significant difference between active and standard placebo control interventions in our primary analysis, but the result was imprecise and the CI compatible with a difference ranging from important to irrelevant. Furthermore, the result was not robust, because two sensitivity analyses produced a more pronounced and statistically significant difference. We suggest that trialists and users of information from trials carefully consider the type of placebo control intervention in trials with high risk of unblinding, such as those with pronounced non‐therapeutic effects and participant‐reported outcomes. Plain language summary Do treatment effects in randomised trials differ when using active placebo compared to standard placebo? Key messages 1. We found no clear difference in effect between active and standard placebos, but we are very uncertain about the results. 2. We suggest that researchers carefully consider the type of placebo when investigating medicines with clear side effects. What are standard placebos and active placebos? Blinding (or masking) is an important part of randomised trials and ensures that participants and healthcare providers are not influenced by knowing whether the participant is receiving the experimental treatment. If they had this knowledge, they might unintentionally overestimate (or underestimate) the effect of the treatment. One method of blinding is to give the non‐treated group of participants a placebo, which looks like the medicine (e.g. a tablet of similar shape, colour, smell, taste, and texture) but does not contain its active ingredients. Blinding with a placebo may not always be successful. The treatment may have side effects that distinguish it from the placebo so that the treatment effect is still not measured accurately. For this reason, some trials use active placebos, which mimic some of the side effects of the experimental medicine. However, it is unclear whether the choice of placebo type actually makes a difference to the treatment effects. What did we want to find out? We wanted to find out whether treatment effects in randomised trials differ when using active placebos compared to standard placebos. What did we do? We collected and analysed trials that directly compared the two types of placebo, or that compared both placebos with an experimental medicine. If people receiving active placebo experience better results than those receiving standard placebo, this difference might be due to them believing that they are receiving the experimental medicine. It would also mean that in trials that compare a medicine with standard placebo, the beneficial effect of the medicine is exaggerated. This is important if the measured benefits of the treatment are small or moderate and thus especially sensitive to changes in the methods used for the trial. What did we find? We included 21 trials in this review, covering subjects such as pain and psychiatry. We found no clear difference between the two types of placebo in participant‐reported outcomes (such as pain intensity). However, because the result was uncertain, the possible range of this result included both no difference and a potentially important difference in favour of active placebo. When we limited our analysis to higher‐quality trials, active placebos were more beneficial than standard placebos, but these trials were not typical clinical trials and might not be applicable to clinical scenarios.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Laursen, DRT, Nejstgaard, CH, Bjørkedal, E, Frost, AD, Hansen, MR, Paludan-Müller, AS, Prosenz, J, Werner, CP, Hróbjartsson, A", "articleTypes": [], "doi": "10.1002/14651858.MR000055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.742Z" }, { "id": "16acf632-dce5-4f98-b369-5e2b1da53ce3", "pmid": "", "title": "Zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance", "imported": false, "abstract": "Abstract - Background Diabetes is associated with long‐term damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity. Insulin resistance is a fundamental aspect of the aetiology of type 2 diabetes. Insulin resistance has been shown to be associated with atherosclerosis, dyslipidaemia, glucose intolerance, hyperuricaemia, hypertension and polycystic ovary syndrome. The mineral zinc plays a key role in the synthesis and action of insulin, both physiologically and in diabetes mellitus. Zinc seems to stimulate insulin action and insulin receptor tyrosine kinase activity. Objectives To assess the effects of zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance. Search methods This review is an update of a previous Cochrane systematic review published in 2007. We searched the Cochrane Library (2015, Issue 3), MEDLINE, EMBASE, LILACS and the ICTRP trial register (from inception to March 2015). There were no language restrictions. We conducted citation searches and screened reference lists of included studies. Selection criteria We included studies if they had a randomised or quasi‐randomised design and if they investigated zinc supplementation compared with placebo or no intervention in adults with insulin resistance living in the community. Data collection and analysis Two review authors selected relevant trials, assessed risk of bias and extracted data. Main results We included three trials with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Risk of bias was unclear for most studies regarding selection bias (random sequence generation, allocation concealment) and detection bias (blinding of outcome assessment). No study reported on our key outcome measures (incidence of type 2 diabetes mellitus, adverse events, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). Evaluation of insulin resistance as measured by the Homeostasis Model Assessment of Insulin Resistance (HOMA‐IR) showed neutral effects when comparing zinc supplementation with control (two trials; 114 participants). There were neutral effects for trials comparing zinc supplementation with placebo for total cholesterol, high‐density lipoprotein (HDL) cholesterol, low‐density lipoprotein (LDL) cholesterol and triglycerides (2 studies, 70 participants). The one trial comparing zinc supplementation with exercise also showed neutral effects for total cholesterol, HDL and LDL cholesterol, and a mean difference in triglycerides of ‐30 mg/dL (95% confidence interval (CI) ‐49 to ‐10) in favour of zinc supplementation (53 participants). Various surrogate laboratory parameters were also analysed in the included trials. Authors' conclusions There is currently no evidence on which to base the use of zinc supplementation for the prevention of type 2 diabetes mellitus. Future trials should investigate patient‐important outcome measures such as incidence of type 2 diabetes mellitus, health‐related quality of life, diabetic complications, all‐cause mortality and socioeconomic effects. Plain language summary Zinc supplementation for the prevention of type 2 diabetes mellitus Review question What are the effects of zinc supplementation compared with placebo or no treatment for the prevention of type 2 diabetes in adults with insulin resistance? Background Some studies have shown that zinc improves glucose levels (glycaemic control) in people with diabetes. As a consequence of diabetes long‐term complications may develop, such as kidney, nerve and eye disease. Also, the risk of cardiovascular complications like heart attacks and strokes is raised. Type 1 diabetes is a form of diabetes where the body cannot produce insulin any more. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity and is characterised by an increasing inability of the body to make good use of insulin (insulin resistance). The mineral zinc plays a key role in the action of insulin and theoretically zinc supplementation used by people with insulin resistance could prevent the onset of diabetes. Study characteristics We included three randomised controlled studies with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Key results No study reported on our patient‐important key outcomes (new onset of type 2 diabetes mellitus, side effects, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). The effects of zinc supplementation are uncertain regarding insulin resistance and lipid levels in the blood (mainly cholesterol and triglycerides). Quality of evidence The overall quality of the included studies was unclear because study authors did not provide important information for us to judge how the studies were performed (unclear risk of bias in most cases). In addition, the number of studies and participants is low and the study authors did not investigate important outcomes such as new onset of type 2 diabetes mellitus or side effects of zinc supplementation. Currentness of evidence This evidence is up to date as of March 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El Dib, R; Gameiro, OLF; Ogata, MSP; Módolo, NSP; Braz, LG; Jorge, EC; do Nascimento Junior, P; Beletate, V", "articleTypes": [], "doi": "10.1002/14651858.CD005525.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "16cee6de-44d4-4630-824e-df25493942bc", "pmid": "", "title": "Snoezelen for dementia", "imported": false, "abstract": "Abstract - Background Snoezelen, multi‐sensory stimulation, provides sensory stimuli to stimulate the primary senses of sight, hearing, touch, taste and smell, through the use of lighting effects, tactile surfaces, meditative music and the odour of relaxing essential oils. The rationale for this lies in the proposition that the provision of a sensory environment for people with dementia places fewer demands on their intellectual abilities but capitalizes on their residual sensorimotor abilities. The clinical application of snoezelen often varies in form, nature, principles and procedures. Such variations not only make the examination of the therapeutic values of snoezelen difficult, but also impede the clinical development of snoezelen in dementia care. A systematic review of evidence for the efficacy of snoezelen in the care of people with dementia is therefore needed to inform future clinical applications and research directions. Objectives To examine the clinical efficacy of snoezelen (or multisensory stimulation) for older people with dementia and their caregivers. Search methods The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 23 March 2008 using the terms: snoezelen OR \"multi‐sensory*\". The CDCIG Specialized Register contains records from all major health care databases ( The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources. The reviewers hand‐searched PubMed and the ISI Web of Science. Selection criteria Randomized controlled trials and quasi‐randomized controlled trials in which snoezelen or multi‐sensory programmes was used as an intervention for older people suffering from any forms of dementia. Data collection and analysis The two reviewers independently reviewed and assessed the quality of the trials. Main results Two new trials were included in this update. Baker 2003 was an expanded study of Baker 2001 reported in the previous version. Both Baker 2003 and van Weert 2005 examined the short‐term and longer‐term effects of snoezelen on behaviour, mood, and communication of people with moderate to severe dementia. The format of implementation was different in the two trials: one was session‐based snoezelen programme (Baker 2003), whilst the other was a 24‐hour integrated snoezelen care (van Weert 2005). Owing to the differences in study methodology, the results of the two trials were not pooled for analysis. The session‐based snoezelen programme (Baker 2003) did not show any effects on behaviour, mood, cognition and communication / interaction in the short term (during or immediately after sessions) or longer term (at post‐intervention or 1‐month post‐intervention follow‐up). Likewise, the 24‐hour integrated snoezelen care (van Weert 2005) failed to demonstrate any significant short‐term and longer term effects on behaviour, mood and interaction. Authors' conclusions A more vigorous review methodology was adopted in this update. The study of Kragt 1997, reported in the previous version, was excluded because the snoezelen programme only consisted of three sessions, which was considered too brief for a therapeutic intervention. Two new trials were reviewed. Meta‐analyses could not be performed because of the limited number of trials and different study methods of the available trials. Overall, there is no evidence showing the efficacy of snoezelen for dementia. There is a need for more reliable and sound research‐based evidence to inform and justify the use of snoezelen in dementia care. Plain language summary No evidence of the efficacy of snoezelen or multi‐sensory stimulation programmes for people with dementia Snoezelen (or multi‐sensory stimulation) has become a commonly used intervention to manage maladaptive behaviours and to promote positive mood of older people with dementia. Originally, two randomised clinical trials were available for this review. Some short‐term benefits were documented in promoting adaptive behaviours in people with dementia during and immediately after their participation in the sessions. In this update, two new trials were included and revealed two different forms of applying snoezelen to dementia care. One is a session‐based snoezelen programme while the other is a 24‐hour integrated snoezelen care programme. Both trials did not show any significant effects on behaviour, interaction, and mood of people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Chung, JCC; Lai, CKY", "articleTypes": [], "doi": "10.1002/14651858.CD003152", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "16dba538-7dac-49b4-8424-935ca622fe19", "pmid": "", "title": "Iodised salt for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency is the main cause for potentially preventable mental retardation in childhood, as well as causing goitre and hypothyroidism in people of all ages. It is still prevalent in large parts of the world. Objectives To assess the effects of iodised salt in comparison with other forms of iodine supplementation or placebo in the prevention of iodine deficiency disorders. Search methods We searched The Cochrane Library , MEDLINE, the Register of Chinese trials developed by the Chinese Cochrane Centre, and the Chinese Med Database, China National knowledge Infrastructure, and searched reference lists, databases of ongoing trials and the Internet. Selection criteria We included prospective controlled studies of iodised salt versus other forms of iodine supplementation or placebo in people living in areas of iodine deficiency. Studies reported mainly goitre rates and urinary iodine excretion as outcome measures. Data collection and analysis The initial data selection and quality assessment of trials was done independently by two reviewers. Subsequently, after the scope of the review was slightly widened from including only randomised controlled trials to including non‐randomised prospective comparative studies, a third reviewer repeated the trials selection and quality assessment. As the studies identified were not sufficiently similar and not of sufficient quality, we did not do a meta‐analysis but summarised the data in a narrative format. Main results We found six prospective controlled trials relating to our question. Four of these were described as randomised controlled trials, one was a prospective controlled trial that did not specify allocation to comparison groups, and one was a repeated cross‐sectional study comparing different interventions. Comparison interventions included non‐iodised salt, iodised water, iodised oil, and salt iodisation with potassium iodide versus potassium iodate. Numbers of participants in the trials ranged from 35 to 334; over 20,000 people were included in the cross‐sectional study. Three studies were in children only, two investigated both groups of children and adults and one investigated pregnant women. There was a tendency towards goitre reduction with iodised salt, although this was not significant in all studies. There was also an improved iodine status in most studies (except in small children in one of the studies), although urinary iodine excretion did not always reach the levels recommended by the WHO. None of the studies observed any adverse effects of iodised salt. Authors' conclusions The results suggest that iodised salt is an effective means of improving iodine status. No conclusions can be made about improvements in other, more patient‐oriented outcomes, such as physical and mental development in children and mortality. None of the studies specifically investigated development of iodine‐induced hyperthyroidism, which can be easily overlooked if just assessed on the basis of symptoms. High quality controlled studies investigating relevant long term outcome measures are needed to address questions of dosage and best means of iodine supplementation in different population groups and settings. Plain language summary Iodised salt for preventing iodine deficiency disorders Iodine deficiency causes mental retardation in children as well as enlarged thyroid glands (goitre) and deficiencies in thyroid hormones in people of all ages. It still exists in large parts of the world. This review looked at studies of iodised salt in the diet that included a comparison group. Six studies, most of them in children but some also in adults, were included. Iodine in the urine increased in all but one studies, but there was some concern that small children did not eat enough salt to achieve adequate iodine status. Some studies, but not all, also showed a reduction in the enlargement of the thyroid gland (goitre) that can accompany lack of iodine in the diet. Adverse effects were not reported, but these may not have been studied adequately. More high quality long term studies measuring outcomes related to child development, to deaths associated with iodine‐deficiency and to adverse effects are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Wu, T; Liu, GJ; Li, P; Clar, C", "articleTypes": [], "doi": "10.1002/14651858.CD003204", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "16e4338e-7e3b-4f42-9836-90b53b94137b", "pmid": "", "title": "Treatment of periodontitis for glycaemic control in people with diabetes mellitus", "imported": false, "abstract": "Abstract - Background Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontitis. Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus, and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement, or non‐surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe. This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care. Objectives To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis. Search methods An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. Selection criteria We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment or adjunctive antimicrobial therapy or both) to no active intervention or 'usual care' (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least 3 months and have measured HbA1c (glycated haemoglobin). Data collection and analysis At least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials, and assessed included trials for risk of bias. Where necessary and possible, we attempted to contact study authors. Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol). Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index, and probing pocket depth), quality of life, cost implications, and diabetic complications. Main results We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel‐RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 diabetes, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair, or poor. Most studies were carried out in secondary care. We assessed two studies as being at low risk of bias, 14 studies at high risk of bias, and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings. Moderate‐certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) ‐0.59% to ‐0.28%; ‐6.4 mmol/mol to ‐3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI ‐0.52% to ‐0.08%; ‐5.7 mmol/mol to ‐0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI ‐0.55% to ‐0.45%; ‐6.0 mmol/mol to ‐4.9 mmol/mol; 1 study, 264 participants). Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, adverse effects of periodontal treatments were not evaluated in most studies. Authors' conclusions Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate‐certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in this review. Plain language summary Does treatment for gum disease help people with diabetes control blood sugar levels? Review question The main question addressed by this review is: how effective is gum disease (periodontitis) treatment for controlling blood sugar levels (known as glycaemic control) in people with diabetes, compared to no active treatment or usual care? Background The aim of treating periodontitis is to reduce swelling and infection and stabilise the condition of the gums and supporting bone. The level of sugar in the blood is too high in people with diabetes, so keeping blood sugar levels under control is a key issue. Some clinical research suggests a relationship exists between gum disease treatment and glycaemic control. Glycaemic control can be measured in different ways. For this review, we focused on HbA1c, which shows average blood glucose levels over the preceding 3 months. It can be reported as a percentage (of total haemoglobin) or as mmol/mol (millimoles per mole). Excellent glycaemic control in a diabetic person might be around 6.5% or 48 mmol/mol. This review was carried out by authors working with the Cochrane Oral Health and is part one of an update of a review previously published in 2010 and 2015. This review evaluates gum disease treatment versus no active treatment or usual care. Part two of the review will compare different types of periodontal treatment. We carried out this review as it is important to discover if gum disease treatment does improve glycaemic control in order to ensure best use of clinical resources. Study characteristics We searched six research databases and found 35 relevant trials where people with diabetes and periodontitis were randomly allocated to an experimental group or a control group. The experimental groups received gum disease treatment called 'subgingival instrumentation', also known as scaling and root planing or deep cleaning. In some experimental groups, the deep cleaning was supplemented with instructions for cleaning teeth properly ('oral hygiene instruction'), or other gum treatments, for example, antimicrobials, which are used to treat infections. Control groups received no active treatment or 'usual care', which was oral hygiene instruction, support with oral hygiene, and/or removal of plaque above the gumline. The trials randomised 3249 participants in total. Almost all participants had type 2 diabetes, with a mix of good, fair, and poor diabetic control. Most of the studies were carried out in hospitals. The studies followed up participants for between 3 and 12 months. Key results Evidence from 30 trials (results from 2443 participants) showed that periodontitis treatment reduces blood sugar levels (measured by HbA1c) in diabetic patients on average by 0.43 percentage points (e.g. from 7.43% to 7%; 4.7 mmol/mol) 3 to 4 months after receiving the treatment compared with no active treatment or usual care. A difference of 0.30% (3.3 mmol/mol) was seen after 6 months (12 studies), and 0.50% (5.4 mmol/mol) at 12 months (one study). There were not enough studies measuring side effects to be able to evaluate the risk of harm from gum disease treatments. Certainty of the evidence Most of the studies were conducted in a way that meant they were at a high risk of bias or did not provide enough information for us to make a judgement on this. However, the consistency of our findings suggests they are reliable and future research is not likely to change them. In summary, currently there is moderate‐certainty evidence to support gum disease treatment (known as subgingival instrumentation) for controlling blood sugar levels in people with periodontitis (gum disease) and diabetes up to 12 months after the start of the periodontal treatment. Date of the search The evidence is current up to 7 September 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Simpson, TC, Clarkson, JE, Worthington, HV, MacDonald, L, Weldon, JC, Needleman, I, Iheozor-Ejiofor, Z, Wild, SH, Qureshi, A, Walker, A, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD004714.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.782Z" }, { "id": "1704c659-00cd-4d54-b830-542852ba9a5c", "pmid": "", "title": "Dietary sodium manipulation and asthma", "imported": false, "abstract": "Abstract - Background There is a wide geographical variation in the prevalence of asthma and observational studies have suggested that dietary sodium may play a role. Objectives To assess the effect of dietary sodium manipulation on asthma control. Search methods We carried out a search using the Cochrane Airways Group asthma register. We searched the bibliographies of included randomised controlled trials (RCTs) for additional studies. We carried out the most recent search in November 2010. Selection criteria We considered only RCTs that involved dietary sodium reduction or increased sodium intake in patients with asthma. Data collection and analysis Both review authors assessed study and extracted data. We conducted data analyses in RevMan 5 using mean differences and random effects. Main results We identified a total of nine studies in relation to sodium manipulation and asthma, of which five were in people with asthma (318 participants), and four in people with exercise‐induced asthma (63 participants). There were no significant benefits of salt restriction on the control of asthma. There was some evidence from the exercise‐induced asthma studies that a low sodium diet may improve lung function after exercise and possibly baseline lung function, but this is based on findings from a very small numbers of participants. Authors' conclusions This review did not find any evidence that dietary sodium reduction significantly improves asthma control. Although dietary sodium reduction may result in improvements in lung function in exercise‐induced asthma, the clinical significance of this effect is unclear. Plain language summary Does reducing the amount of salt in a diet improve asthma symptoms? A review of the current literature suggests that reduction in the amount of dietary sodium consumed has no significant effect on the symptoms of asthma but may be associated with improvements in some lung function measurements in exercise‐induced asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Pogson, Z; McKeever, T", "articleTypes": [], "doi": "10.1002/14651858.CD000436.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "17220538-aee3-4a73-9a7d-08635c342449", "pmid": "", "title": "Anticoagulation for people receiving long‐term haemodialysis", "imported": false, "abstract": "Abstract - Background Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding. Objectives To assess the efficacy and safety of anticoagulation strategies (including both heparin and non‐heparin drugs) for long‐term HD in people with kidney failure. Any intervention preventing clotting within the extracorporeal circuit without establishing anticoagulation within the patient, such as regional citrate, citrate enriched dialysate, heparin‐coated dialysers, pre‐dilution haemodiafiltration (HDF), and saline flushes were also included. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to November 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐randomised controlled studies (quasi‐RCTs) evaluating anticoagulant agents administered during HD treatment in adults and children with kidney failure. Data collection and analysis Two authors independently assessed the risk of bias using the Cochrane tool and extracted data. Treatment effects were estimated using random effects meta‐analysis and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE). Main results We included 113 studies randomising 4535 participants. The risk of bias in each study was adjudicated as high or unclear for most risk domains. Compared to UFH, LMWH had uncertain effects on extracorporeal circuit thrombosis (3 studies, 91 participants: RR 1.58, 95% CI 0.46 to 5.42; I 2 = 8%; low certainty evidence), while major bleeding and minor bleeding were not adequately reported. Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH (2 studies, 82 participants: RR 0.34, 95% CI 0.14 to 0.85; I 2 = 0%; low certainty evidence). No studies reported data comparing regional citrate to UFH on risks of extracorporeal circuit thrombosis and major bleeding. The effects of very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors or heparin‐grafted membranes were uncertain due to insufficient data. The effects of different LMWH, different doses of LMWH, and the administration of LMWH anticoagulants using inlet versus outlet bloodline or bolus versus infusion were uncertain. Evidence to compare citrate to another citrate or control was scant. The effects of UFH compared to no anticoagulant therapy or different doses of UFH were uncertain. Death, dialysis vascular access outcomes, blood transfusions, measures of anticoagulation effect, and costs of interventions were rarely reported. No studies evaluated the effects of treatment on non‐fatal myocardial infarction, non‐fatal stroke and hospital admissions. Adverse events were inconsistently and rarely reported. Authors' conclusions Anticoagulant strategies, including UFH and LMWH, have uncertain comparative risks on extracorporeal circuit thrombosis, while major bleeding and minor bleeding were not adequately reported. Regional citrate may decrease minor bleeding, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported. Evidence supporting clinical decision‐making for different forms of anticoagulant strategies for HD is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes. Plain language summary Treatments to thin the blood during haemodialysis: which treatments reduce clotting problems without causing bleeding? What is the issue? When people have dialysis using a machine to clean their blood (called haemodialysis (HD)), blood‐thinning treatment helps prevent blood clots in the dialysis tubing. However, thinning the blood too much with treatment can lead to bleeding problems. There are several different medications to thin the blood, but it is not clear which is the best or the safest choice. What did we do? We searched for all the research trials that assessed the blood thinning treatments during HD for adults and children up until November 2023. We measured the certainty we could have about the results of this research using \"GRADE\". What did we find? We found 113 studies involving 4535 patients treated with HD. Patients were given different forms of blood thinning therapy. The treatment they got was decided by random chance (like the toss of a coin). Most of the studies looked at a treatment called \"low molecular weight heparin\" and compared this with standard blood thinning care (called \"standard heparin\"). Unfortunately, the studies included only a small number of patients and only looked for risks of clotting or bleeding during one or two months of therapy. Because of this short time frame, and other limitations of the research studies, we were very uncertain about the results. The current research doesn't tell us whether one blood thinning treatment is better or safer than another for patients during dialysis treatment. Conclusions We still can't be certain about the best way to thin the blood for HD treatment based on existing research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Natale, P; Palmer, SC; Ruospo, M; Longmuir, H; Dodds, B; Prasad, R; Batt, TJ; Jose, MD; Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD011858.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "17383d66-c8c0-46cd-a361-afa49b842077", "pmid": "", "title": "Treatment and prevention of pouchitis after ileal pouch‐anal anastomosis for chronic ulcerative colitis", "imported": false, "abstract": "Abstract - Background Pouchitis occurs in approximately 50% of patients following ileal pouch‐anal anastomosis (IPAA) for chronic ulcerative colitis (UC). Objectives The primary objective was to determine the efficacy and safety of medical therapies for prevention or treatment of acute or chronic pouchitis. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 25 July 2018. We also searched references, trials registers, and conference proceedings. Selection criteria Randomized controlled trials of prevention or treatment of acute or chronic pouchitis in adults who underwent IPAA for UC were considered for inclusion. Data collection and analysis Two authors independently screened studies for eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was evaluated using GRADE. The primary outcome was clinical improvement or remission in participants with acute or chronic pouchitis, or the proportion of participants with no episodes of pouchitis after IPAA. Adverse events (AEs) was a secondary outcome. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for each dichotomous outcome. Main results Fifteen studies (547 participants) were included. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Three studies were low risk of bias. Three studies were high risk of bias and the other studies were unclear. Acute pouchitis: All ciprofloxacin participants (7/7) achieved remission at two weeks compared to 33% (3/9) of metronidazole participants (RR 2.68, 95% CI 1.13 to 6.35, very low certainty evidence). No ciprofloxacin participants (0/7) had an AE compared to 33% (3/9) of metronidazole participants (RR 0.18, 95% CI 0.01 to 2.98; very low certainty evidence). AEs included vomiting, dysgeusia or transient peripheral neuropathy. Forty‐three per cent (6/14) of metronidazole participants achieved remission at 6 weeks compared to 50% (6/12) of budesonide enema participants (RR 0.86, 95% CI 0.37 to 1.96, very low certainty evidence). Fifty per cent (7/14) of metronidazole participants improved clinically at 6 weeks compared to 58% (7/12) of budesonide enema participants (RR 0.86, 95% CI 0.42 to 1.74, very low certainty evidence). Fifty‐seven per cent (8/14) of metronidazole participants had an AE compared to 25% (3/12) of budesonide enema participants (RR 2.29, 95% CI 0.78 to 6.73, very low certainty evidence). AEs included anorexia, nausea, headache, asthenia, metallic taste, vomiting, paraesthesia, and depression. Twenty‐five per cent (2/8) of rifaximin participants achieved remission at 4 weeks compared to 0% (0/10) of placebo participants (RR 6.11, 95% CI 0.33 to 111.71, very low certainty evidence). Thirty‐eight per cent (3/8) of rifaximin participants improved clinically at 4 weeks compared to 30% (3/10) of placebo participants (RR 1.25, 95% CI 0.34 to 4.60, very low certainty evidence). Seventy‐five per cent (6/8) of rifaximin participants had an AE compared to 50% (5/10) of placebo participants (RR 1.50, 95% CI 0.72 to 3.14, very low certainty evidence). AEs included diarrhea, flatulence, nausea, proctalgia, vomiting, thirst, candida, upper respiratory tract infection, increased hepatic enzyme, and cluster headache. Ten per cent (1/10) of Lactobacillus GG participants improved clinically at 12 weeks compared to 0% (0/10) of placebo participants (RR 3.00, 95% CI 0.14 to 65.90, very low certainty evidence). Chronic pouchitis: Eighty‐five per cent (34/40) of De Simone Formulation (a probiotic formulation) participants maintained remission at 9 to 12 months compared to 3% (1/36) of placebo participants (RR 20.24, 95% CI 4.28 to 95.81, 2 studies; low certainty evidence). Two per cent (1/40) of De Simone Formulation participants had an AE compared to 0% (0/36) of placebo participants (RR 2.43, 95% CI 0.11 to 55.89; low certainty evidence). AEs included abdominal cramps, vomiting and diarrhea. Fifty per cent (3/6) of adalimumab patients achieved clinical improvement at 4 weeks compared to 43% (3/7) of placebo participants (RR, 1.17, 95% CI 0.36 to 3.76, low certainty evidence). Sixty per cent (6/10) of glutamine participants maintained remission at 3 weeks compared to 33% (3/9) of butyrate participants (RR 1.80, 95% CI 0.63 to 5.16, very low certainty evidence). Forty‐five per cent (9/20) of patients treated with bismuth carbomer foam enema improved clinically at 3 weeks compared to 45% (9/20) of placebo participants (RR 1.00, 95% CI 0.50 to 1.98, very low certainty evidence). Twenty‐five per cent (5/20) of participants in the bismuth carbomer foam enema group had an AE compared to 35% (7/20) of placebo participants (RR 0.71, 95% CI 0.27 to 1.88, very low certainty evidence). Adverse events included diarrhea, worsening symptoms, cramping, sinusitis, and abdominal pain. Prevention: At 12 months, 90% (18/20) of De Simone Formulation participants had no episodes of acute pouchitis compared to 60% (12/20) of placebo participants (RR 1.50, 95% CI 1.02 to 2.21, low certainty evidence). Another study found 100% (16/16) of De Simone Formulation participants had no episodes of acute pouchitis at 12 months compared to 92% (11/12) of the no treatment control group (RR 1.10, 95% 0.89 to 1.36, very low certainty evidence). Eighty‐six per cent (6/7) of Bifidobacterium longum participants had no episodes of acute pouchitis at 6 months compared to 60% (3/5) of placebo participants (RR 1.43, 95% CI 0.66 to 3.11, very low certainty evidence). Eleven per cent (1/9) of Clostridium butyricum MIYAIRI participants had no episodes of acute pouchitis at 24 months compared to 50% (4/8) of placebo participants (RR 0.22, 95% CI 0.03 to 1.60, very low certainty evidence). Forty‐six per cent (43/94) of allopurinol participants had no episodes of pouchitis at 24 months compared to 43% (39/90) of placebo participants (RR 1.06, 95% CI 0.76 to 1.46; low certainty evidence). Eighty‐one per cent (21/26) of tinidazole participants had no episodes of pouchitis over 12 months compared to 58% (7/12) of placebo participants (RR 1.38, 95% CI 0.83 to 2.31, very low certainty evidence). Authors' conclusions The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. Well designed, adequately powered studies are needed to determine the optimal therapy for the treatment and prevention of pouchitis. Plain language summary Therapy for treatment and prevention of pouchitis What is pouchitis? Some people with ulcerative colitis have their colon and rectum removed with construction of a pouch (made from a loop of small intestine) in place of the rectum ‐ known as ileal pouch‐anal anastomosis (IPAA) surgery. Pouchitis is inflammation of the surgically‐constructed pouch. Symptoms of active pouchitis include diarrhea, increased stool frequency, abdominal cramping, fecal urgency, tenesmus (feeling of constantly needing to pass stools), and incontinence. Acute refers to symptoms that last less than four weeks while chronic refers to symptoms that last more than four weeks. Periods when symptoms stop are called 'remission'. What therapies are used for pouchitis? Therapies used for pouchitis include antibiotics (drugs for bacteria infections), budesonide enemas (a steroid drug), probiotics (helpful bacteria), biologic agents that target tumor necrosis factor, glutamine suppositories (an amino acid), butyrate suppositories (short chain fatty acid), bismuth enemas (diarrhea medication), allopurinol (a purine analogue drug), and tinidazole (an anti‐parasitic drug). What did the researchers investigate? The researchers investigated whether these medications produce remission in people with active pouchitis, maintain remission in people with inactive pouchitis or prevent pouchitis in people who've had IPAA surgery. Side effects were also assessed. The medical literature was searched up to 25 July 2018. What did the researchers find? We found 15 studies with a total of 547 participants. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Acute pouchitis: It is uncertain whether ciprofloxacin is more effective than metronidazole for treatment of acute pouchitis (1 study, 16 participants). Side effects included vomiting, metallic taste and temporary damage to nerves. It is unclear whether there are any differences between metronidazole and budesonide enemas in terms of clinical remission, symptom improvement or side effects (1 study, 26 participants). Side effects included anorexia, nausea, headache, lack of energy and strength, metallic taste, vomiting, pins and needles, and depression. It is uncertain whether there are any differences between rifaximin and placebo in terms of clinical remission, symptom improvement, or side effects (1 study, 18 participants). Side effects included diarrhea, flatulence, nausea, rectal pain, vomiting, thirst, yeast infection, common cold, increased liver enzymes, and cluster headache. It is uncertain whether there is any difference between Lactobacillus GG and placebo in symptom improvement (1 study, 20 participants. The results of these studies are uncertain due to low event numbers caused by the small numbers of people who participated in the studies. Chronic pouchitis: It is uncertain whether De Simone Formulation (a probiotic formulation) is more effective than placebo for maintaining remission in people with inactive disease (2 studies, 76 participants). Side effects included abdominal cramps, vomiting and diarrhea. It is unclear whether there is any difference in effectiveness between adalimumab and placebo for treating chronic pouchitis(1 study, 13 participants). It is unclear whether there is any difference between glutamine and butyrate suppositories for maintenance of remission (1 study, 19 participants). It is unclear whether there are any differences in symptom improvement or side effects between bismuth carbomer foam enemas and placebo (1 study, 40 participants). Side effects included diarrhea, worsening symptoms, cramping, sinus infection, and abdominal pain. The results of these studies are uncertain due to the small number of people who participated in the studies. Prevention of pouchitis: It is uncertain whether De Simone Formulation is more effective than placebo for prevention of pouchitis (1 study, 40 participants). However, it is unclear whether there is any difference in prevention of pouchitis between De Simone Formulation and a no treatment control group (1 study, 28 participants). It is unclear whether there are any differences in prevention of pouchitis between Clostridium butyricum MIYAIRI and placebo (1 study, 17 participants) , Bifidobacterium longum and placebo (1 study, 12 participants) , allopurinol and placebo (1 study, 184 participants) and tinidazole and placebo (1 study, 38 participants). The results of these studies are uncertain due to the small number of people who participated in the studies. The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. More research is needed to determine which of these different medications are best for treatment of pouchitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nguyen, N, Zhang, B, Holubar, SD, Pardi, DS, Singh, S", "articleTypes": [], "doi": "10.1002/14651858.CD001176.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.728Z" }, { "id": "174dfb46-211d-4633-b61d-aacf1e31a3b6", "pmid": "", "title": "Blood pressure lowering efficacy of diuretics as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Diuretics are widely prescribed for hypertension not only as a first‐line drug but also as a second‐line drug. Therefore, it is essential to determine the effects of diuretics on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a second‐line drug. Objectives To quantify the additional reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of diuretic therapy as a second‐line drug in patients with primary hypertension Search methods CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (1966‐July 2008), EMBASE (1988‐July 2008) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized, controlled trials evaluating the BP lowering efficacy of a diuretic in combination therapy with another class of anti‐hypertensive drugs compared with the respective monotherapy (without a diuretic) for a duration of 3 to 12 weeks in patients with primary hypertension. Data collection and analysis Two review authors independently extracted the data and assessed trial quality. Main results Fifty‐three double‐blind RCTs evaluating a thiazide in 15129 hypertensive patients (baseline BP of 156/101 mmHg) were included. Hydrochlorothiazide was the thiazide used in 49/53 (92%) of the included studies. The additional BP reduction caused by the thiazide as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. Thiazides as a second‐line drug reduced BP by 6/3 and 8/4 mmHg at doses of 1 and 2 times the manufacturer's recommended starting dose respectively. The BP lowering effect was dose related. The effect was similar to that obtained when thiazides are used as a single agent. Only 3 double‐blind RCTs evaluating loop diuretics were identified. These RCTs showed a BP lowering effect of a starting dose of about 6/3 mmHg. Authors' conclusions Thiazides when given as a second‐line drug have a dose related effect to lower blood pressure that is similar to when they are added as a first‐line drug. This means that the BP lowering effect of thiazides is additive. Loop diuretics appear to have a similar blood pressure lowering effect as thiazides at 1 times the recommended starting dose. Because of the short duration of the trials and lack of reporting of adverse events, this review does not provide a good estimate of the incidence of adverse effects of diuretics given as a second‐line drug. Plain language summary Diuretics effective in lowering blood pressure when given as a second drug Diuretics are a good first‐line treatment for high blood pressure (BP). Diuretics include loop diuretics and thiazides. We asked how much do diuretics reduce BP when used as the second drug to treat hypertension. We performed a search of the available scientific literature to find all trial evidence to assess this question. Fifty‐six trials were found. Fifty‐three trials involved thiazide diuretics (92% with the drug hydrochlorothiazide) and included a total of 15310 participants. Adding a thiazide to another anti‐hypertensive drug further reduces the BP by an additional 6/3 mmHg when given at the starting dose and reduces BP by 8/4 mmHg at 2 times the starting dose. This is approximately the same effect as when the drugs are used alone. A good estimate of the harms associated with diuretics cannot be estimated in this review because of the lack of reporting and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Chen, JMH; Heran, BS; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "175bd3c2-749f-4b7b-92de-a554e48c7f35", "pmid": "", "title": "Effect of adrenergic agonist oral decongestants on blood pressure", "imported": false, "abstract": "Abstract - Background Adrenergic agonist oral decongestants are commonly taken daily over long periods of time to relieve sinus and nasal congestion. The mechanism of action of decongestants potentially increases blood pressure, and these effects may be acute or chronic. However, no systematic reviews to date have comprehensively assessed the chronic blood pressure effects of adrenergic agonist oral decongestants as a drug class, despite their widespread non‐prescription availability. Objectives Primary objective To assess the effects of adrenergic agonist oral decongestants on systolic and diastolic blood pressure compared to placebo. Secondary objective To assess the effects of adrenergic agonist oral decongestants on heart rate and withdrawals due to adverse effects. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCT) up to July 2024: Cochrane Hypertension Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Register of Studies, Ovid MEDLINE, Ovid Embase, and ClinicalTrials.gov. There were no language, publication year, or publication status restrictions. Selection criteria We included RCTs of at least seven days' duration with parallel groups (intervention and placebo) comparing adrenergic agonist oral decongestants versus placebo on blood pressure in people aged over six years. Data collection and analysis Two review authors (JJC and MC) independently assessed the trials for inclusion, extracted the data, and assessed the risk of bias from the included trials. In cases where there were disagreements, the third review author (JMW) adjudicated. For any missing or unclear information in the studies, we contacted the study author to request the missing information or seek clarification. The primary outcomes were systolic blood pressure and diastolic blood pressure. Secondary outcomes were heart rate and withdrawal due to adverse effects. We used a fixed‐effect model to combine the effect sizes from all studies. We assessed the certainty of the evidence using GRADE. Main results Five RCTs randomizing 882 participants met the inclusion criteria. The shortest study duration was one week, and the longest study duration was 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The largest study included 568 people, and the smallest study included 18 people. The mean age of participants was 20.0 years, with 326 males and 591 females. The studies were conducted in the USA and Europe; most were set in the USA. Pharmaceutical companies funded three of the five included studies. The findings are relevant to all people using adrenergic agonist oral decongestants for seven days or longer regardless of comorbidities or pre‐existing conditions. The adrenergic agonist oral decongestants included were ephedrine (one RCT), pseudoephedrine (one RCT), and phenylpropanolamine (three RCTs). Compared to placebo, adrenergic agonist oral decongestants may have little to no effect on systolic blood pressure , but the evidence is very uncertain (mean difference [MD] 0.91 mmHg, 95% confidence interval [CI] −0.57 to 2.38; 4 RCTs, 784 participants; I 2 = 54%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on diastolic blood pressure (MD 0.44 mmHg, 95% CI −0.59 to 1.48; 5 RCTs, 882 participants; I 2 = 30%; low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on heart rate, but the evidence is very uncertain (MD 1.92 beats per minute, 95% CI −0.62 to 4.47; 2 RCTs, 190 participants; I 2 = 79%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on the number of withdrawals due to adverse effects (risk ratio [RR] 1.20, 95% CI 0.37 to 3.88; 4 RCTs, 806 participants; low‐certainty evidence; note 1 study reported withdrawals due to adverse effects but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 3 studies rather than 4). Four studies were at overall high risk of bias, and one study was at overall low risk of bias. Authors' conclusions In this systematic review, chronic daily intake of adrenergic agonist oral decongestants had little to no effect on blood pressure, heart rate, and withdrawals due to adverse effects. People making decisions about using these medicines should consider the very low certainty of evidence and the theoretical risk of increased blood pressure. Independent trials free from biases that are designed to answer this question are required. The evidence was limited due to the small number of studies, and the blood pressure and heart rate not being measured at the optimal time after drug ingestion. Plain language summary What are the effects of oral decongestants on blood pressure? Key messages – We found no evidence that taking oral decongestants (medicine taken by mouth to relieve a stuffy nose) daily for a week or more changes blood pressure or heart rate or causes people to stop taking them due to unwanted effects. – There were only a few studies, and they were not well designed. More well‐conducted studies are needed. – Given that oral decongestants are sometimes taken daily for weeks or months, and have the potential to increase blood pressure, people should consider this potential risk alongside the limited evidence from this review when deciding whether to use these medicines. What are oral decongestants? Oral decongestants are medications taken by mouth to relieve nasal congestion (stuffy or blocked nose), often caused by colds, allergies, or sinus infections (small, empty spaces behind the cheekbones and forehead that are connected to the nose). They typically include medicines called pseudoephedrine or phenylephrine. How do oral decongestants work? These medicines shrink swollen blood vessels in the nasal passages. This reduces swelling and allows air to flow more freely, helping you breathe easier. What is hypertension? Hypertension (high blood pressure) is when resting blood pressure is consistently above 140/90 mmHg. It can lead to unwanted effects such as stroke (where the blood supply to parts of the brain is reduced or stopped) and heart attack (where the blood supply to the heart is reduced or stopped). Lowering blood pressure is the easiest way to reduce these diseases. How is hypertension treated? Treating hypertension involves lifestyle measures and taking blood pressure‐lowering medicines. Here, we focused on the effects of daily intake of oral decongestants. While these medicines help with nasal congestion, they may also increase blood pressure. What do we want to find out? We wanted to find out whether long‐term use of oral decongestants (for seven days or longer) increases blood pressure and has any unwanted effects. We also evaluated their effectiveness in relieving nasal congestion. This provides essential insights into their benefits and risks to guide informed use. What did we do? We searched for studies that compared the blood pressure effects of oral decongestants with placebo. A placebo is a substance or treatment with no active ingredients that is used in medical research to compare against the effects of real medications. We then compared and summarized the results, and rated our confidence in the evidence depending on the study design and methods. What did we find? We found five studies involving 882 children and adults (326 males and 591 females). The shortest study lasted one week, with the longest study lasting 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The size of the studies ranged from 18 to 568 people, and most were done in the USA. Pharmaceutical companies funded three studies. We found no clear evidence that taking oral decongestants daily changes blood pressure or heart rate, or causes people to stop taking them due to unwanted effects. What are the limitations of the evidence? There was a limited number of studies, and they were not well designed. None of the studies were primarily designed to assess the long‐term effects of oral decongestants on blood pressure. Trials designed to answer this question are needed. How up to date is the evidence? The evidence is up to date to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Chan, JJ, Chan, M, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007895.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.775Z" }, { "id": "17674d16-1cc5-4466-8088-dd3a3387d4d0", "pmid": "", "title": "Triclosan/copolymer containing toothpastes for oral health", "imported": false, "abstract": "Abstract - Background Periodontal disease and dental caries are highly prevalent oral diseases that can lead to pain and discomfort, oral hygiene and aesthetic problems, and eventually tooth loss, all of which can be costly to treat and are a burden to healthcare systems. Triclosan is an antibacterial agent with low toxicity, which, along with a copolymer for aiding retention, can be added to toothpastes to reduce plaque and gingivitis (inflammation of the gums). It is important that these additional ingredients do not interfere with the anticaries effect of the fluoride present in toothpastes, and that they are safe. Objectives To assess the effects of triclosan/copolymer containing fluoride toothpastes, compared with fluoride toothpastes, for the long‐term control of caries, plaque and gingivitis in children and adults. Search methods We searched the Cochrane Oral Health's Trials Register (to 19 August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 7), MEDLINE via OVID (1946 to 19 August 2013), Embase via OVID (1980 to 19 August 2013), and the US National Institutes of Health Trials Register ( clinicaltrials.gov ) (to 19 August 2013). We applied no restrictions regarding language or date of publication in the searches of the electronic databases. Selection criteria We included randomised controlled trials (RCTs) assessing the effects triclosan/copolymer containing toothpastes on oral health. Data collection and analysis Two review authors independently assessed the search results against the inclusion criteria for this review, extracted data and carried out risk of bias assessments. We attempted to contact study authors for missing information or clarification when feasible. We combined sufficiently similar studies in meta‐analyses using random‐effects models when there were at least four studies (fixed‐effect models when fewer than four studies), reporting mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data. Main results We included 30 studies, analysing 14,835 participants, in this review. We assessed 10 studies (33%) as at low risk of bias, nine (30%) as at high risk of bias and 11 (37%) as unclear. Plaque Compared with control, after six to seven months of use, triclosan/copolymer toothpaste reduced plaque by 0.47 on a 0 to 5 scale (MD ‐0.47, 95% confidence interval (CI) ‐0.60 to ‐0.34, 20 studies, 2675 participants, moderate‐quality evidence). The control group mean was 2.17, representing a 22% reduction in plaque. After six to seven months of use, it also reduced the proportion of sites scoring 3 to 5 on a 0 to 5 scale by 0.15 (MD ‐0.15, 95% CI ‐0.20 to ‐0.10, 13 studies, 1850 participants, moderate‐quality evidence). The control group mean was 0.37, representing a 41% reduction in plaque severity. Gingivitis After six to nine months of use, triclosan/copolymer toothpaste reduced inflammation by 0.27 on a 0 to 3 scale (MD ‐0.27, 95% CI ‐0.33 to ‐0.21, 20 studies, 2743 participants, moderate‐quality evidence). The control group mean was 1.22, representing a 22% reduction in inflammation. After six to seven months of use, it reduced the proportion of bleeding sites (i.e. scoring 2 or 3 on the 0 to 3 scale) by 0.13 (MD ‐0.13, 95% CI ‐0.17 to ‐0.08, 15 studies, 1998 participants, moderate‐quality evidence). The control group mean was 0.27, representing a 48% reduction in bleeding. Periodontitis After 36 months of use, there was no evidence of a difference between triclosan/copolymer toothpaste and control in the development of periodontitis (attachment loss) (RR 0.92, 95% CI 0.67 to 1.27, one study, 480 participants, low‐quality evidence). Caries After 24 to 36 months of use, triclosan/copolymer toothpaste slightly reduced coronal caries when using the decayed and filled surfaces (DFS) index (MD ‐0.16, 95% CI ‐0.31 to ‐0.02, four studies, 9692 participants, high‐quality evidence). The control group mean was 3.44, representing a 5% reduction in coronal caries. After 36 months of use, triclosan/copolymer toothpaste probably reduced root caries (MD ‐0.31, 95% CI ‐0.39 to ‐0.23, one study, 1357 participants, moderate‐quality evidence). Calculus After six months of use, triclosan/copolymer toothpaste may have reduced the mean total calculus per participant by 2.12 mm (MD ‐2.12 mm, 95% CI ‐3.39 to ‐0.84, two studies, 415 participants, low‐quality evidence). The control group mean was 14.61 mm, representing a 15% reduction in calculus. Adverse effects There were no data available for meta‐analysis regarding adverse effects, but 22 studies (73%) reported that there were no adverse effects caused by either the experimental or control toothpaste. There was considerable heterogeneity present in the meta‐analyses for plaque, gingivitis and calculus. Plaque and gingivitis showed such consistent results that it did not affect our conclusions, but the reader may wish to interpret the results with more caution. Authors' conclusions There was moderate‐quality evidence showing that toothpastes containing triclosan/copolymer, in addition to fluoride, reduced plaque, gingival inflammation and gingival bleeding when compared with fluoride toothpastes without triclosan/copolymer. These reductions may or may not be clinically important, and are evident regardless of initial plaque and gingivitis levels, or whether a baseline oral prophylaxis had taken place or not. High‐quality evidence showed that triclosan/copolymer toothpastes lead to a small reduction in coronal caries. There was weaker evidence to show that triclosan/copolymer toothpastes may have reduced root caries and calculus, but insufficient evidence to show whether or not they prevented periodontitis. There do not appear to be any serious safety concerns regarding the use of triclosan/copolymer toothpastes in studies up to three years in duration. Plain language summary Triclosan/copolymer containing toothpastes for oral health Review question This Cochrane Review has been conducted to assess the effects of using a toothpaste containing triclosan (an antibacterial ingredient) plus copolymer (an ingredient to reduce the amount of triclosan that is washed away by rinsing or saliva) plus fluoride (a mineral that prevents tooth decay) compared with using a fluoride toothpaste (without triclosan/copolymer) for oral health. Background Gum disease and dental decay are the main reasons for tooth loss. Unless brushed away, plaque (a sticky film containing bacteria) can build up on the teeth. This can lead to gingivitis (a swelling and redness of the gums that affects most adults), which, if not treated, can then lead to a more serious form of gum disease called periodontitis (which affects up to one out of every five adults aged 35 to 44 years worldwide). Periodontitis can cause pain, eating difficulties, an unpleasant facial appearance and eventually tooth loss. Plaque build‐up can also lead to tooth decay, a problem affecting up to 90% of schoolchildren in industrialised countries, and the majority of adults. Vast healthcare resources are used worldwide to treat gum disease and tooth decay, which are both preventable. Currently there is a lot of ongoing research into possible links between periodontitis and other medical conditions such as diabetes, rheumatoid arthritis, heart disease and also to the premature (too early) birth of underweight babies. Adding an effective and safe antibacterial ingredient to toothpastes could be an easy and low‐cost answer to these problems. It is thought that triclosan could fight the harmful bacteria in plaque while also reducing the swelling that leads to serious gum disease. It is important that adding triclosan to fluoride toothpastes does not reduce the beneficial effects that fluoride has on preventing tooth decay. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 19 August 2013. It includes 30 studies published from 1990 to 2012 in which 14,835 participants were randomised to receive a triclosan/copolymer containing fluoride toothpaste or a fluoride toothpaste that did not include triclosan/copolymer. The toothpaste that was used in most of the studies is sold by the manufacturer Colgate. Key results The evidence produced shows benefits in using a triclosan/copolymer fluoride toothpaste when compared with a fluoride toothpaste (without triclosan/copolymer). There was a 22% reduction in plaque, a 22% reduction in gingivitis, a 48% reduction in bleeding gums and a 5% reduction in tooth decay. There was insufficient evidence to show a difference between either toothpaste in preventing periodontitis. There was no evidence of any harmful effects associated with the use of triclosan/copolymer toothpastes in studies up to three years in length. Quality of the evidence The evidence relating to plaque and gingivitis was considered to be of moderate quality. The evidence on tooth decay was high quality, while the evidence on periodontitis was low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Riley, P, Lamont, T", "articleTypes": [], "doi": "10.1002/14651858.CD010514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.769Z" }, { "id": "17688b95-d2ea-447e-9c4b-78bfb99f0cbc", "pmid": "", "title": "Quinine for muscle cramps", "imported": false, "abstract": "Abstract - Background Muscle cramps can occur anywhere and for many reasons. Quinine has been used to treat cramps of all causes. However, controversy continues about its efficacy and safety. This review was first published in 2010 and searches were updated in 2014. Objectives To assess the efficacy and safety of quinine‐based agents in treating muscle cramps. Search methods On 27 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE. We searched reference lists of articles up to 2014. We also searched for ongoing trials in November 2014. Selection criteria Randomised controlled trials of people of all ages with muscle cramps in any location and of any cause, treated with quinine or its derivatives. Data collection and analysis Three review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We contacted study authors for additional information. For comparisons including more than one trial, we assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Main results We identified 23 trials with a total of 1586 participants. Fifty‐eight per cent of these participants were from five unpublished studies. Quinine was compared to placebo (20 trials, n = 1140), vitamin E (four trials, n = 543), a quinine‐vitamin E combination (three trials, n = 510), a quinine‐theophylline combination (one trial, n = 77), and xylocaine injections into the gastrocnemius muscle (one trial, n = 24). The most commonly used quinine dosage was 300 mg/day (range 200 to 500 mg). We found no new trials for inclusion when searches were updated in 2014. The risk of bias in the trials varied considerably. All 23 trials claimed to be randomised, but only a minority described randomisation and allocation concealment adequately. Compared to placebo, quinine significantly reduced cramp number over two weeks by 28%, cramp intensity by 10%, and cramp days by 20%. Cramp duration was not significantly affected. A significantly greater number of people suffered minor adverse events on quinine than placebo (risk difference (RD) 3%, 95% confidence interval (CI) 0% to 6%), mainly gastrointestinal symptoms. Overdoses of quinine have been reported elsewhere to cause potentially fatal adverse effects, but in the included trials there was no significant difference in major adverse events compared with placebo (RD 0%, 95% CI ‐1% to 2%). One participant suffered from thrombocytopenia (0.12% risk) on quinine. A quinine‐vitamin E combination, vitamin E alone, and xylocaine injections into gastrocnemius were not significantly different to quinine across all outcomes, including adverse effects. Based on a single trial comparison, quinine alone was significantly less effective than a quinine‐theophylline combination but with no significant differences in adverse events. Authors' conclusions There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that with use up to 60 days, the incidence of serious adverse events is not significantly greater than for placebo in the identified trials, but because serious adverse events can be rarely fatal, in some countries prescription of quinine is severely restricted. Evidence from single trials suggests that theophylline combined with quinine improves cramps more than quinine alone, and the effects of xylocaine injections into gastrocnemius are not significantly different to quinine across all outcomes. Low or moderate quality evidence shows no significant difference between quinine and vitamin E or quinine and quinine‐vitamin E mixture. Further research into these alternatives, as well other pharmacological and non‐pharmacological treatments, is thus warranted. There is no evidence to judge optimal dosage or duration of quinine treatment. Further studies using different dosages and measurement of serum quinine levels will allow a therapeutic range to be defined for muscle cramp. Because serious adverse events are not common, large population studies are required to more accurately inform incidence. Longer lengths of follow‐up in future trials will help determine the duration of action following cessation of quinine as well as long‐term adverse events. The search for new therapies, pharmacological and nonpharmacological, should continue and further trials should compare vitamin E, quinine‐vitamin E combination, and quinine‐theophylline mixture with quinine. Plain language summary Quinine for muscle cramps Review question We reviewed the evidence about the effect of quinine on muscle cramps. Background Muscle cramps can occur anywhere and in anyone; however, leg cramps are especially common in older people. Quinine is a medicine which has been used to treat cramps for many years. There is conflicting evidence for its ability to reduce cramps. Quinine can cause serious, even fatal adverse events, especially in overdosage. Study characteristics This review includes 23 trials, with 1586 participants. The trials compared quinine or quinine‐based medicines against inactive treatment (placebo) or other active treatments. We found no new studies when we searched the medical literature again and updated the review in 2014. Key results and quality of the evidence The risk of bias in the included trials varied considerably. All 23 trials claimed to be randomised, but many failed to clearly describe how participants were assigned to treatments. There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that there are more minor adverse events with quinine compared to placebo but no increase in major adverse events. However, there are reliable reports from other sources that an overdose of quinine can cause serious harm including death. Low or moderate quality evidence shows there is no significant difference when comparing quinine to vitamin E or to a quinine‐vitamin E mixture. There is evidence from one trial that theophylline combined with quinine improves cramps more than quinine alone. In a single trial there was no significant difference when comparing quinine to xylocaine injections. More research is needed to clarify the best dose and duration of treatment, as well as alternatives to quinine for cramps. The evidence is current to October 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El‐Tawil, S; Al Musa, T; Valli, H; Lunn, MPT; Brassington, R; El‐Tawil, T; Weber, M", "articleTypes": [], "doi": "10.1002/14651858.CD005044.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "17bb9ad1-a193-4a74-aefd-b9777724ba74", "pmid": "", "title": "Antibiotic treatment for the sexual partners of women with bacterial vaginosis", "imported": false, "abstract": "Abstract - Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of BV after antibiotic treatment. Therefore, the treatment of sexual partners could decrease the recurrence of infection and possibly the burden of the disease. Objectives To assess the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for BV. Search methods We searched the Cochrane Sexually Transmitted Infections Group Specialized Register (23 July 2016), CENTRAL (1991 to 23 July 2016), MEDLINE (1946 to 23 July 2016), Embase (1974 to 23 July 2016), LILACS (1982 to 23 July 2016), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (23 July 2016), ClinicalTrials.gov (23 July 2016) and the Web of Science™ (2001 to 23 July 2016). We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) that compared the concurrent use of any antibiotic treatment with placebo, no intervention or any other intervention by the sexual partners of women treated for BV. Data collection and analysis Three review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach. Main results Seven RCTs (1026 participants) met our inclusion criteria, and pharmaceutical industry funded four of these trials. Five trials (854 patients) compared any antibiotic treatment of sexual partners with placebo. Based on high quality evidence, antibiotic treatment does not increase the rate of clinical or symptomatic improvement in women during the first week (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.96 to 1.03; 712 participants, four studies; RR 1.06, 95% CI 1.00 to 1.12; 577 patients, three studies, respectively), between the first and fourth week (RR 1.02, 95% CI 0.94 to 1.11; 590 participants, three studies; RR 0.93, 95% CI 0.84 to 1.03; 444 participants, two studies; respectively) or after the fourth week (RR 0.98, 95% CI 0.90 to 1.07; 572 participants, four studies; RR 1.03, 95% CI 0.90 to 1.17; 296 participants, two studies; respectively). Antibiotic treatment does not led to a lower recurrence during the first and fourth week (RR 1.28, 95% CI 0.68 to 2.43; 218 participants, one study; low quality evidence) or after the fourth week of treatment (RR 1.00, 95% CI 0.67 to 1.52; 372 participants, three studies; low quality evidence) in women, but increases the frequency of adverse events (most frequently gastrointestinal symptoms) reported by sexual partners (RR 2.55, 95% CI 1.55 to 4.18; 477 participants, three studies; low quality evidence).
 
 Two trials (172 participants) compared any antibiotic treatment for sexual partners with no intervention. When we compared it with no intervention, the effects of antibiotic treatment on recurrence rate after the fourth week (RR 1.71, 95% CI 0.65 to 4.55; 51 participants, one study), clinical improvement between the first and fourth week (RR 0.93, 95% CI 0.70 to 1.25; 152 participants, two studies) and symptomatic improvement after the fourth week (RR 0.66, 95% CI 0.39 to 1.11; 70 participants, one study) were imprecise and there were no differences between groups. We downgraded the quality of the evidence to low or very low. Authors' conclusions High quality evidence shows that antibiotic treatment for sexual partners of women with BV, compared with placebo, does not increase the rate of clinical or symptomatic improvement during the first, between the first and fourth or after the fourth week into the women. Low quality evidence suggests that antibiotic treatment does not led to a lower recurrence rate during the first and fourth or after the fourth week of treatment into the women, but increases the frequency of adverse events reported by sexual partners. Finally, compared with no intervention, antibiotic treatment does not decrease the recurrence rate after the fourth week and does not increase the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week into the women, respectively. Plain language summary Antibiotic treatment for the sexual partners of women with bacterial vaginosis Review question We assessed the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for bacterial vaginosis (BV). Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of infection after antibiotic treatment. Therefore, the treatment of sexual partners could offer the advantages of decreasing the recurrence of infection and possibly reducing the burden of the disease. Trial characteristics Cochrane researchers searched the available literature up to the 23 July 2016 and included seven trials with 1026 participants. The trials included sexually‐active non‐pregnant women between 17 and 56 years of age, either single or married, with symptomatic BV. Four studies only included women involved into a monogamous heterosexual relationship and there was no information about this for the remaining trials. Six trials used 5‐nitroimidazoles to treat the sexual partner, four trials used metronidazole and two trials used tinidazole; only one study used a lincosamide for treatment. Five trials compared antibiotic versus placebo (854 participants) and two trials compared antibiotic treatment with no intervention (172 participants). Pharmaceutical companies funded four of the included trials. Key results Compared with placebo, antibiotic treatment for the sexual partners of women treated for BV had no effects on clinical or symptomatic improvement in women, regardless of the time period over which the trials assessed these outcomes (during the first, between the first and fourth, or after the fourth week). Furthermore, antibiotic treatment of the sexual partner may have no effect on the recurrence of BV up to 12 weeks after treatment, but may increase the frequency of minor adverse events reported by sexual partners. Compared with no intervention, treatment of sexual partners of women with BV may have no effect on decreasing the recurrence rate or over the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week, respectively. Quality of evidence The quality of evidence was high for the outcomes of clinical and symptomatic improvement. The quality of evidence was very low for recurrence due to some limitations regarding risk of bias and imprecision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Amaya‐Guio, J; Viveros‐Carreño, DA; Sierra‐Barrios, EM; Martinez‐Velasquez, MY; Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD011701.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "17d34b98-c18e-4e02-995d-68b8c0b67d36", "pmid": "", "title": "Blood pressure lowering efficacy of potassium‐sparing diuretics (that block the epithelial sodium channel) for primary hypertension", "imported": false, "abstract": "Abstract - Background Potassium‐sparing diuretics, which block the epithelial sodium channel (ENaC), are widely prescribed for hypertension as a second‐line drug in patients taking other diuretics (e.g. thiazide diuretics) and much less commonly prescribed as monotherapy. Therefore, it is essential to determine the effects of ENaC blockers on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a first‐line or second‐line therapy. Objectives To quantify the dose‐related reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of ENaC blocker therapy as a first‐line or second‐line drug in patients with primary hypertension. Search methods We searched CENTRAL (The Cochrane Library 2012), MEDLINE (1950 to August 2012), EMBASE (1980 to August 2012) and reference lists of articles. Selection criteria Double‐blind, randomized, controlled trials in patients with primary hypertension that evaluate, for a duration of 3 to 12 weeks, the BP lowering efficacy of: 1) fixed‐dose monotherapy with an ENaC blocker compared with placebo; or 2) an ENaC blocker in combination with another class of anti‐hypertensive drugs compared with the respective monotherapy (without an ENaC blocker). Data collection and analysis Two authors independently assessed the risk of bias and extracted data. Study authors were contacted for additional information. WDAE information was also collected from the trials. Main results No trials evaluating the BP lowering efficacy of ENaC blockers as monotherapy in patients with primary hypertension were identified. Only 6 trials evaluated the BP lowering efficacy of low doses of amiloride and triamterene as a second drug in 496 participants with a baseline BP of 151/102 mm Hg. The additional BP reduction caused by the ENaC blocker as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. The addition of low doses of amiloride and triamterene in these trials did not reduce BP. An estimate of the dose‐related BP lowering efficacy for ENaC blockers was not possible because of a lack of trial data at higher doses. Authors' conclusions ENaC blockers do not have a statistically or clinically significant BP lowering effect at low doses but trials at higher doses are not available. The review did not provide a good estimate of the incidence of harms associated with ENaC blockers. Plain language summary The blood pressure lowering effect of ENaC blockers is not known Potassium‐sparing diuretics, which block the epithelial sodium channel (also called ENaC blockers), are a class of drugs commonly prescribed to prevent loss of potassium but also might help to lower elevated blood pressure. This class includes drugs such as amiloride (Midamor, Amilzide) and triamterene (Dyrenium, Dyazide). We asked how much this class of drugs lowers blood pressure, when used alone or when used as the second drug to treat hypertension. The available scientific literature was searched to find all the trials that had assessed this question. No trials were found studying the blood pressure lowering ability of ENaC blockers when used alone. We found 6 trials studying the blood pressure lowering ability of amiloride and triamterene, when added as a second drug, in 496 participants. All 6 trials studied the ENaC blockers at low doses and there was no blood pressure lowering effect. Trials studying these drugs at higher doses are needed in order to determine if they lower blood pressure. The harms associated with ENaC blockers could not be estimated in this review because of the low doses studied and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Heran, BS; Chen, JMH; Wang, JJ; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD008167.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "17d59ea3-0c65-444d-be2a-4c8d8c16b607", "pmid": "", "title": "New generation antidepressants for depression in children and adolescents: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Major depressive disorders have a significant impact on children and adolescents, including on educational and vocational outcomes, interpersonal relationships, and physical and mental health and well‐being. There is an association between major depressive disorder and suicidal ideation, suicide attempts, and suicide. Antidepressant medication is used in moderate to severe depression; there is now a range of newer generations of these medications. Objectives To investigate, via network meta‐analysis (NMA), the comparative effectiveness and safety of different newer generation antidepressants in children and adolescents with a diagnosed major depressive disorder (MDD) in terms of depression, functioning, suicide‐related outcomes and other adverse outcomes. The impact of age, treatment duration, baseline severity, and pharmaceutical industry funding was investigated on clinician‐rated depression (CDRS‐R) and suicide‐related outcomes. Search methods We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR)), together with Ovid Embase, MEDLINE and PsycINFO till March 2020. Selection criteria Randomised trials of six to 18 year olds of either sex and any ethnicity with clinically diagnosed major depressive disorder were included. Trials that compared the effectiveness of newer generation antidepressants with each other or with a placebo were included. Newer generation antidepressants included: selective serotonin reuptake inhibitors; selective norepinephrine reuptake inhibitors (SNRIs); norepinephrine reuptake inhibitors; norepinephrine dopamine reuptake inhibitors; norepinephrine dopamine disinhibitors (NDDIs); and tetracyclic antidepressants (TeCAs). Data collection and analysis Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed risk of bias. We analysed dichotomous data as Odds Ratios (ORs), and continuous data as Mean Difference (MD) for the following outcomes: depression symptom severity (clinician rated), response or remission of depression symptoms, depression symptom severity (self‐rated), functioning, suicide related outcomes and overall adverse outcomes. Random‐effects network meta‐analyses were conducted in a frequentist framework using multivariate meta‐analysis. Certainty of evidence was assessed using Confidence in Network Meta‐analysis (CINeMA). We used \"informative statements\" to standardise the interpretation and description of the results. Main results Twenty‐six studies were included. There were no data for the two primary outcomes (depressive disorder established via clinical diagnostic interview and suicide), therefore, the results comprise only secondary outcomes. Most antidepressants may be associated with a \"small and unimportant\" reduction in depression symptoms on the CDRS‐R scale (range 17 to 113) compared with placebo (high certainty evidence: paroxetine: MD ‐1.43, 95% CI ‐3.90, 1.04; vilazodone: MD ‐0.84, 95% CI ‐3.03, 1.35; desvenlafaxine MD ‐0.07, 95% CI ‐3.51, 3.36; moderate certainty evidence: sertraline: MD ‐3.51, 95% CI ‐6.99, ‐0.04; fluoxetine: MD ‐2.84, 95% CI ‐4.12, ‐1.56; escitalopram: MD ‐2.62, 95% CI ‐5.29, 0.04; low certainty evidence: duloxetine: MD ‐2.70, 95% CI ‐5.03, ‐0.37; vortioxetine: MD 0.60, 95% CI ‐2.52, 3.72; very low certainty evidence for comparisons between other antidepressants and placebo). There were \"small and unimportant\" differences between most antidepressants in reduction of depression symptoms (high‐ or moderate‐certainty evidence). Results were similar across other outcomes of benefit. In most studies risk of self‐harm or suicide was an exclusion criterion for the study. Proportions of suicide‐related outcomes were low for most included studies and 95% confidence intervals were wide for all comparisons. The evidence is very uncertain about the effects of mirtazapine (OR 0.50, 95% CI 0.03, 8.04), duloxetine (OR 1.15, 95% CI 0.72, 1.82), vilazodone (OR 1.01, 95% CI 0.68, 1.48), desvenlafaxine (OR 0.94, 95% CI 0.59, 1.52), citalopram (OR 1.72, 95% CI 0.76, 3.87) or vortioxetine (OR 1.58, 95% CI 0.29, 8.60) on suicide‐related outcomes compared with placebo. There is low certainty evidence that escitalopram may \"at least slightly\" reduce odds of suicide‐related outcomes compared with placebo (OR 0.89, 95% CI 0.43, 1.84). There is low certainty evidence that fluoxetine (OR 1.27, 95% CI 0.87, 1.86), paroxetine (OR 1.81, 95% CI 0.85, 3.86), sertraline (OR 3.03, 95% CI 0.60, 15.22), and venlafaxine (OR 13.84, 95% CI 1.79, 106.90) may \"at least slightly\" increase odds of suicide‐related outcomes compared with placebo. There is moderate certainty evidence that venlafaxine probably results in an \"at least slightly\" increased odds of suicide‐related outcomes compared with desvenlafaxine (OR 0.07, 95% CI 0.01, 0.56) and escitalopram (OR 0.06, 95% CI 0.01, 0.56). There was very low certainty evidence regarding other comparisons between antidepressants. Authors' conclusions Overall, methodological shortcomings of the randomised trials make it difficult to interpret the findings with regard to the efficacy and safety of newer antidepressant medications. Findings suggest that most newer antidepressants may reduce depression symptoms in a small and unimportant way compared with placebo. Furthermore, there are likely to be small and unimportant differences in the reduction of depression symptoms between the majority of antidepressants. However, our findings reflect the average effects of the antidepressants, and given depression is a heterogeneous condition, some individuals may experience a greater response. Guideline developers and others making recommendations might therefore consider whether a recommendation for the use of newer generation antidepressants is warranted for some individuals in some circumstances. Our findings suggest sertraline, escitalopram, duloxetine, as well as fluoxetine (which is currently the only treatment recommended for first‐line prescribing) could be considered as a first option. Children and adolescents considered at risk of suicide were frequently excluded from trials, so that we cannot be confident about the effects of these medications for these individuals. If an antidepressant is being considered for an individual, this should be done in consultation with the child/adolescent and their family/caregivers and it remains critical to ensure close monitoring of treatment effects and suicide‐related outcomes (combined suicidal ideation and suicide attempt) in those treated with newer generation antidepressants, given findings that some of these medications may be associated with greater odds of these events. Consideration of psychotherapy, particularly cognitive behavioural therapy, as per guideline recommendations, remains important. Plain language summary Newer generation antidepressants for depression in children and adolescents: a network meta‐analysis How well do newer formulations of antidepressants work for children and adolescents with clinical depression? Children and adolescents (6 to 18 years) with depression (also called ‘major depressive disorder’) experience a range of negative impacts in all areas of their lives and have an increased risk of suicide, suicidal thinking and suicide attempts. Antidepressants have been shown to reduce symptoms of depression, but can also increase the risk of suicide‐related outcomes. Who will be interested in this research? The research in this Cochrane Review will interest: ‐ people who decide policy, and influence decisions about the prescription of antidepressant medicines to children and adolescents; ‐ people who prescribe these medicines to children and adolescents; ‐ children and adolescents with depression; and ‐ those who support and care for them (including their parents and caregivers and clinicians who provide treatment). What did we want to find out? We wanted to find out how well newer formulations (called ‘new generation’) antidepressants work to improve depression in children and adolescents aged 6 to 18 years. New generation antidepressants are those that have been developed recently. They are sometimes referred to as ‘second‐‘ and ‘third‐generation’ antidepressants; they do not include older formulations (tricyclic antidepressants or monoamine oxidase inhibitors). We wanted to know how these antidepressants affect: ‐ symptoms of depression; ‐ recovery: no longer meeting diagnostic criteria for major depressive disorder; ‐ response or remission: scores on a scale indicating an important reduction in depression or no longer experiencing depression; ‐ ability to function in daily life; ‐ suicide‐related outcomes; and ‐ whether they cause any unwanted effects in children and adolescents. What did we do? We searched for studies that tested new generation antidepressants on children or adolescents (or both) who had been diagnosed with a major depressive disorder. We identified 26 such studies. We then assessed the trustworthiness of those studies, and synthesized the findings across the studies. What does the evidence from the review tell us? Most newer antidepressants probably reduce depression symptoms better than a placebo (a 'dummy' treatment that does not contain any medicine but looks identical to the medicine being tested). However, the reduction is small and may not be experienced as important by children and adolescents, their parents and caregivers, or clinicians. When different medications are compared against each other, there may be only small and unimportant differences between most of them for the reduction of symptoms. Our findings reflect what happens on average to individuals, but some individuals may experience a greater response. This might lead to recommendations being made for the use of antidepressants for some individuals in some circumstances. Our findings suggest that sertraline, escitalopram, duloxetine and fluoxetine can be used if medication is being considered. The impact of medication on depression symptoms should be closely monitored by those prescribing the medication, especially as suicide‐related thinking and behaviour may be increased in those taking these medications. Close monitoring of suicide‐related behaviours is vital in those treated with new generation antidepressants. What should happen next? The studies that provided this evidence largely excluded children and adolescents who: ‐ were already thinking about suicide and wanting to take their own lives (i.e. had suicidal ideation); ‐ were self‐harming; ‐ had other mental health conditions; and ‐ had psychosocial difficulties. Future research should aim to understand the impacts of these medicines in children and adolescents with these problems, who are more typical of those who request clinical services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Hetrick, SE; McKenzie, JE; Bailey, AP; Sharma, V; Moller, CI; Badcock, PB; Cox, GR; Merry, SN; Meader, N", "articleTypes": [], "doi": "10.1002/14651858.CD013674.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "17d650ab-7b03-4258-8d1e-9ae961244dad", "pmid": "", "title": "External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion). Objectives To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. Search methods We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index‐Science (CPCI‐S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. Selection criteria We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. Data collection and analysis We used standard Cochrane methodology to collect data and performed a network meta‐analysis using the standard frequentist graph‐theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption. Main results We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy‐nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow‐up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low‐certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled. Authors' conclusions Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method. Plain language summary Electrical shocks (electrical cardioversion) and drugs (pharmacological cardioversion) for restoring normal rhythm in patients with atrial fibrillation or atrial flutter Key Messages ‐ Electrical cardioversion and some drugs can be used to restore the normal rhythm in patients with atrial fibrillation (AF) and atrial flutter. While electrical cardioversion is highly effective in dealing with all arrhythmias, the efficacy of drugs varies, with some being only moderately effective or not working at all in persistent AF and atrial flutter. ‐ Electrical cardioversion seems to be a very safe option. The risk of severe complications with cardioversion using drugs was low, but additional precautions are needed. ‐ We need further studies to find out if these treatment options also have a positive effect on quality of life, or if they lead to relevant differences in the duration of hospital stay. What is atrial fibrillation? AF is the most frequent abnormal heart rhythm seen in the world. Patients with this condition may feel their heart beating rapidly and irregularly. This can occur for separate brief or long episodes (paroxysmal AF) or it may become continuous (persistent AF). Atrial flutter is a similar abnormal rhythm that causes similar symptoms, can cause episodes of variable duration and can also become continuous. What is cardioversion? Cardioversion is a treatment to restore the rhythm of the heart back to normal (sinus rhythm). What did we want to find out? We wanted to know if delivering a controlled electrical shock (i.e. electrical cardioversion) and drugs (i.e. pharmacological cardioversion) are effective and safe when restoring heart rhythm back to normal. What did we do? We searched for studies that investigated electrical and pharmacological cardioversion compared to each other or placebo (a medicine that looks like the real medicine but that has no active ingredient). We compared and summarised the results of the studies and rated our trust in these results, based on factors such as study methods and size. What did we find? We found 112 studies. We were able to combine and analyse the results from 72 studies, with 15,968 participants aged between 47 and 72 years. Thirty‐five studies included patients with paroxysmal AF (AF that terminates spontaneously or with intervention within 7 days of onset), 26 studies of patients with persistent AF (AF that is continuously sustained beyond seven days, including episodes terminated by cardioversion after ≥ 7 days), and 14 trials included patients with atrial flutter. The remaining included a mix of paroxysmal, persistent AF and atrial flutter. Main results For patients with paroxysmal AF, electrical cardioversion with biphasic incremental energy, fast‐acting drugs like intravenous vernakalant, flecainide, ibutilide and antazoline, and slower‐acting and/or oral drugs such as quinidine, propafenone, amiodarone and sotalol are effective at restoring sinus rhythm. For patients with persistent AF, electrical cardioversion with biphasic energy seems to be the most effective option; bepridil, quinidine and amiodarone tablets may also be effective in selected cases. For patients with atrial flutter, electrical cardioversion followed by dofetilide are the most effective options. The risk of death and stroke is very low for patients having cardioversion procedures. Malignant arrhythmias (torsade de pointes, sustained ventricular tachycardia or ventricular fibrillation, all of which are associated with high 1‐year mortality rate) were observed for dofetilide, ibutilide, sotalol, quinidine and vernakalant, justifying the need for special care and closer monitoring when using these drugs. Duration of hospitalisation data was available in three studies but, as there were variable timings in these studies, we could not combine them to assess their joint effectiveness. These studies suggest that the duration of hospitalisation may be lower with electrical cardioversion. Heart failure was observed in some patients treated with propafenone, flecainide, sotalol, amiodarone, vernakalant, and placebo, and was not observed in patients receiving electrical cardioversion, suggesting that the latter approach should be the preferred one if concerns exist regarding the occurrence of this outcome. Phlebitis (i.e. inflammation of the vein caused by using injectable drugs) occurred frequently in patients treated with amiodarone, and dysgeusia (i.e. impairment of the sense of taste) and sneezing occurred frequently in patients receiving vernakalant. What are the limitations of the observed results? We are sure or moderately sure of the results for the efficacy of treatments available for persistent AF and atrial flutter. We are less sure about the results for some of the treatment options for paroxysmal AF. Not enough data are available regarding quality of life, and data were limited regarding duration of hospital stay. The risk of stroke or dying was very low. How up to date are the studies and information on this review? The included studies and information are current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Kukendrarajah, K, Ahmad, M, Carrington, M, Ioannou, A, Taylor, J, Razvi, Y, Papageorgiou, N, Mead, GE, Nevis, IF, D'Ascenzo, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013255.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.802Z" }, { "id": "17db3da7-23dc-478f-9505-1a95422b01cb", "pmid": "", "title": "Pharmacological intervention for irritability, aggression, and self‐injury in autism spectrum disorder (ASD)", "imported": false, "abstract": "Abstract - Background Pharmacological interventions are frequently used for people with autism spectrum disorder (ASD) to manage behaviours of concern, including irritability, aggression, and self‐injury. Some pharmacological interventions might help treat some behaviours of concern, but can also have adverse effects (AEs). Objectives To assess the effectiveness and AEs of pharmacological interventions for managing the behaviours of irritability, aggression, and self‐injury in ASD. Search methods We searched CENTRAL, MEDLINE, Embase, 11 other databases and two trials registers up to June 2022. We also searched reference lists of relevant studies, and contacted study authors, experts and pharmaceutical companies. Selection criteria We included randomised controlled trials of participants of any age with a clinical diagnosis of ASD, that compared any pharmacological intervention to an alternative drug, standard care, placebo, or wait‐list control. Data collection and analysis We used standard Cochrane methods. Primary outcomes were behaviours of concern in ASD, (irritability, aggression and self‐injury); and AEs. Secondary outcomes were quality of life, and tolerability and acceptability. Two review authors independently assessed each study for risk of bias, and used GRADE to judge the certainty of the evidence for each outcome. Main results We included 131 studies involving 7014 participants in this review. We identified 26 studies as awaiting classification and 25 as ongoing. Most studies involved children (53 studies involved only children under 13 years), children and adolescents (37 studies), adolescents only (2 studies) children and adults (16 studies), or adults only (23 studies). All included studies compared a pharmacological intervention to a placebo or to another pharmacological intervention. Atypical antipsychotics versus placebo At short‐term follow−up (up to 6 months), atypical antipsychotics probably reduce irritability compared to placebo (standardised mean difference (SMD) −0.90, 95% confidence interval (CI) −1.25 to −0.55, 12 studies, 973 participants; moderate‐certainty evidence), which may indicate a large effect. However, there was no clear evidence of a difference in aggression between groups (SMD −0.44, 95% CI −0.89 to 0.01; 1 study, 77 participants; very low‐certainty evidence). Atypical antipsychotics may also reduce self‐injury (SMD −1.43, 95% CI −2.24 to −0.61; 1 study, 30 participants; low‐certainty evidence), possibly indicating a large effect. There may be higher rates of neurological AEs (dizziness, fatigue, sedation, somnolence, and tremor) in the intervention group (low‐certainty evidence), but there was no clear evidence of an effect on other neurological AEs. Increased appetite may be higher in the intervention group (low‐certainty evidence), but we found no clear evidence of an effect on other metabolic AEs. There was no clear evidence of differences between groups in musculoskeletal or psychological AEs. Neurohormones versus placebo At short‐term follow‐up, neurohormones may have minimal to no clear effect on irritability when compared to placebo (SMD −0.18, 95% CI −0.37 to −0.00; 8 studies; 466 participants; very low‐certainty evidence), although the evidence is very uncertain. No data were reported for aggression or self ‐injury. Neurohormones may reduce the risk of headaches slightly in the intervention group, although the evidence is very uncertain. There was no clear evidence of an effect of neurohormones on any other neurological AEs, nor on any psychological, metabolic, or musculoskeletal AEs (low‐ and very low‐certainty evidence). Attention‐deficit hyperactivity disorder (ADHD)‐related medications versus placebo At short‐term follow‐up, ADHD‐related medications may reduce irritability slightly (SMD −0.20, 95% CI −0.40 to −0.01; 10 studies, 400 participants; low‐certainty evidence), which may indicate a small effect. However, there was no clear evidence that ADHD‐related medications have an effect on self‐injury (SMD −0.62, 95% CI −1.63 to 0.39; 1 study, 16 participants; very low‐certainty evidence). No data were reported for aggression. Rates of neurological AEs (drowsiness, emotional AEs, fatigue, headache, insomnia, and irritability), metabolic AEs (decreased appetite) and psychological AEs (depression) may be higher in the intervention group, although the evidence is very uncertain (very low‐certainty evidence). There was no evidence of a difference between groups for any other metabolic, neurological, or psychological AEs (very low‐certainty evidence). No data were reported for musculoskeletal AEs. Antidepressants versus placebo At short‐term follow‐up, there was no clear evidence that antidepressants have an effect on irritability (SMD −0.06, 95% CI −0.30 to 0.18; 3 studies, 267 participants; low‐certainty evidence). No data for aggression or self‐injury were reported or could be included in the analysis. Rates of metabolic AEs (decreased energy) may be higher in participants receiving antidepressants (very low‐certainty evidence), although no other metabolic AEs showed clear evidence of a difference. Rates of neurological AEs (decreased attention) and psychological AEs (impulsive behaviour and stereotypy) may also be higher in the intervention group (very low‐certainty evidence) although the evidence is very uncertain. There was no clear evidence of any difference in the other metabolic, neurological, or psychological AEs (very low‐certainty evidence), nor between groups in musculoskeletal AEs (very low‐certainty evidence). Risk of bias We rated most of the studies across the four comparisons at unclear overall risk of bias due to having multiple domains rated as unclear, very few rated as low across all domains, and most having at least one domain rated as high risk of bias. Authors' conclusions Evidence suggests that atypical antipsychotics probably reduce irritability, ADHD‐related medications may reduce irritability slightly, and neurohormones may have little to no effect on irritability in the short term in people with ASD. There was some evidence that atypical antipsychotics may reduce self‐injury in the short term, although the evidence is uncertain. There was no clear evidence that antidepressants had an effect on irritability. There was also little to no difference in aggression between atypical antipsychotics and placebo, or self‐injury between ADHD‐related medications and placebo. However, there was some evidence that atypical antipsychotics may result in a large reduction in self‐injury, although the evidence is uncertain. No data were reported (or could be used) for self‐injury or aggression for neurohormones versus placebo. Studies reported a wide range of potential AEs. Atypical antipsychotics and ADHD‐related medications in particular were associated with an increased risk of metabolic and neurological AEs, although the evidence is uncertain for atypical antipsychotics and very uncertain for ADHD‐related medications. The other drug classes had minimal or no associated AEs. Plain language summary Which medications reduce irritability, aggression or self‐harm in people with autism spectrum disorder (ASD)? Key messages • Only 3 classes of medications showed any reduction in irritability, aggression or self‐harm when compared to placebo (a dummy medication). Atypical (second‐generation) antipsychotic medications probably reduce irritability and aggression, but appear to have little to no effect on self‐injury. Attention deficit hyperactivity disorder (ADHD)‐related medications may reduce irritability, although the evidence is uncertain. Neurohormones (oxytocin and secretin) may also reduce irritability, but we are very uncertain about the evidence. • Antidepressants appear to have no effect on irritability. Studies did not report on the effects of antidepressants, ADHD‐related medications and neurohormones on aggression or self‐injury. • Studies reported a wide range of unwanted effects, but only atypical antipsychotics, ADHD‐related medications, and neurohormones showed evidence of a higher risk of any unwanted effects compared to placebo. What is autism spectrum disorder (ASD)? Autism is a disorder that affects a child's physical, mental and behavioural development. It is a lifelong disability that starts in childhood but continues throughout adulthood. People with autism may find it difficult to communicate and interact with the world. However, autism affects each person differently and may be more or less severe in different people, so it is described as a 'spectrum' disorder. Some people with autism spectrum disorder (ASD) may be irritable, angry or aggressive, or hurt themselves physically (self‐injury), which are 'behaviours of concern' that can be difficult to manage and distressing for the person. How are behaviours of concern managed? Behaviours of concern are frequently managed with various types of medications that have been developed to treat other conditions. This means that their effectiveness for behaviours of concern is largely unknown, and they may cause serious and varied unwanted effects that affect all parts of the body. For example: • the heart and lungs; • the stomach and digestive system; • the immune system; • movement, joints and bones; and • mood and emotion. What did we want to find out? We wanted to know which types of medication were effective in reducing behaviours of concern in people with ASD and whether they caused unwanted effects. What did we do? We searched for studies that investigated any medication used to manage behaviours of concern. Studies compared the medication with placebo (a dummy medication) or another medication. People in the studies could be adults or children, but all had ASD with behaviours of concern. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 131 studies with 7014 people. Most studies involved children, although some studies involved both children and adults, or adults only. Studies looked at a wide range of medications, including those usually used to treat schizophrenia or bipolar disorder, depression, attention deficit hyperactivity disorder (ADHD), convulsions, emotional problems, heart and lungs, dementia, Parkinson's, and anxiety. Atypical (second‐generation) antipsychotics are usually used to treat schizophrenia or bipolar disorder. They probably reduce irritability, but they may have little to no effect on aggression and self‐injury. People receiving antipsychotics might be more likely to experience unwanted effects such as increased appetite, dizziness, sedation (slowed thought and movement), sleepiness, tiredness and tremor compared to those receiving no treatment or other medications. People receiving antipsychotics may be no more or less likely than those receiving placebo to experience other unwanted effects. Neurohormones (such as oxytocin and secretin) may have a minimal to small effect on irritability but no studies reported data for the effects of neurohormones on self‐harm or aggression. People receiving neurohormones may be no more or less likely than those receiving placebo to experience unwanted effects. ADHD‐related medications may reduce irritability but may have no effect on self‐injury. No studies reported data for aggression. People receiving ADHD‐related medications might be more likely to experience unwanted effects such as drowsiness, tiredness, headache, difficulties sleeping, and decreased appetite. But they may be no more or less likely than those receiving placebo to experience other unwanted effects. Antidepressants may have little to no effect on irritability. No studies reported useful data for aggression and self‐injury. People receiving antidepressants might be more likely to experience unwanted effects such as impulsive behaviour and making repetitive movements or sounds (stereotypy) compared to placebo. But they may be no more or less likely than those receiving placebo to experience other types of unwanted effects. What are the limitations of the evidence? Most of the studies lasted less than 3 months, and very few studies involved adults. Therefore, we are uncertain if the same effects would be seen over a longer period of time or in adults. How up‐to‐date is the evidence? The review authors searched for studies that had been published up to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Iffland, M; Livingstone, N; Jorgensen, M; Hazell, P; Gillies, D", "articleTypes": [], "doi": "10.1002/14651858.CD011769.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "17ed2e87-0006-430e-9eb1-bcbc2610cea5", "pmid": "", "title": "Dornase alfa for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Dornase alfa is currently used as a mucolytic to treat pulmonary disease (the major cause of morbidity and mortality) in cystic fibrosis. It reduces mucus viscosity in the lungs, promoting improved clearance of secretions. This is an update of a previously published review. Objectives To determine whether the use of dornase alfa in cystic fibrosis is associated with improved mortality and morbidity compared to placebo or other medications that improve airway clearance, and to identify any adverse events associated with its use. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstracts from conferences. Date of the most recent search of the Group's Cystic Fibrosis Register: 12 October 2020. Clinicaltrials.gov and the International Clinical Trials Registry Platform were also searched to identify unpublished or ongoing trials. Date of most recent search: 08 February 2021. Selection criteria All randomised and quasi‐randomised controlled trials comparing dornase alfa to placebo, standard therapy or other medications that improve airway clearance. Data collection and analysis Authors independently assessed trials against the inclusion criteria; two authors carried out analysis of methodological quality and data extraction. GRADE was used to assess the level of evidence. Main results The searches identified 74 trials, of which 19 (2565 participants) met our inclusion criteria. 15 trials compared dornase alfa to placebo or no dornase alfa (2447 participants); two compared daily dornase to hypertonic saline (32 participants); one compared daily dornase alfa to hypertonic saline and alternate day dornase alfa (48 participants); one compared dornase alfa to mannitol and the combination of both drugs (38 participants). Trial duration varied from six days to three years. Dornase alfa compared to placebo or no treatment Dornase alfa probably improved forced expiratory volume at one second (FEV 1 ) at one month (four trials, 248 participants), three months (one trial, 320 participants; moderate‐quality evidence), six months (one trial, 647 participants; high‐quality evidence) and two years (one trial, 410 participants). Limited low‐quality evidence showed treatment may make little or no difference in quality of life. Dornase alfa probably reduced the number of pulmonary exacerbations in trials of up to two years (moderate‐quality evidence). One trial that examined the cost of care, including the cost of dornase alfa, found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa: daily versus alternate day One cross‐over trial (43 children) found little or no difference between treatment regimens for lung function, quality of life or pulmonary exacerbations (low‐quality evidence). Dornase alfa compared to other medications that improve airway clearance Results for these comparisons were mixed. One trial (43 children) showed dornase alfa may lead to a greater improvement in FEV 1 compared to hypertonic saline (low‐quality evidence), and one trial (23 participants) reported little or no differences in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol (low‐quality evidence). One trial (23 participants) found dornase alfa may improve quality of life compared to dornase alfa plus mannitol (low‐quality evidence); other comparisons found little or no difference in this outcome (low‐quality evidence). No trials in any comparison reported any difference between groups in the number of pulmonary exacerbations (low‐quality evidence). When all comparisons are assessed, dornase alfa did not cause significantly more adverse effects than other treatments, except voice alteration and rash. Authors' conclusions There is evidence to show that, compared with placebo, therapy with dornase alfa may improve lung function in people with cystic fibrosis in trials lasting from one month to two years. There was a decrease in pulmonary exacerbations in trials of six months or longer, probably due to treatment. Voice alteration and rash appear to be the only adverse events reported with increased frequency in randomised controlled trials. There is not enough evidence to firmly conclude if dornase alfa is superior to other hyperosmolar agents in improving lung function. Plain language summary Dornase alfa, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of using inhaled dornase alfa for treating lung disease in people with cystic fibrosis. Background Cystic fibrosis is an inherited condition which affects the movement of salt across cells in the body and affects, for example, the sweat glands, airways, pancreas and male reproductive system. Lung disease is the most common cause of death in people with cystic fibrosis and although the average life expectancy has increased over the last 30 years, it is still only 48.5 years in high‐income countries. People with cystic fibrosis develop chronic lung disease because of thick mucus that builds up in the lungs which causes infections and inflammation. Dornase alfa was developed to thin out this mucus, so it is easier for people to cough it up from their lungs; this in turn should decrease the number of infections and amount of inflammation and prevent chronic lung disease. Search date The evidence is current to: 12 October 2020. Study characteristics We included 19 trials with 2565 people with cystic fibrosis; 15 trials (2447 people) compared dornase alfa to placebo (a dummy treatment with no active medication) or no dornase alfa treatment; two trials (32 people) compared daily dornase to hypertonic saline; one trial (48 people) compared daily dornase alfa with hypertonic saline and alternate day dornase alfa; and one trial (38 people) compared dornase alfa to mannitol and the combination of both drugs. People from all age groups (infants through to adults) took part in the trials which lasted from six days to three years. Key results Dornase alfa compared to placebo or no treatment We found that dornase alfa probably improves lung function within one month when compared to a placebo or no treatment and this improvement was also seen in longer trials lasting from six months to two years (eight trials; 1708 participants). There were also fewer pulmonary exacerbations (flare up of lung inflammation) in these longer trials. One trial found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa ‐ daily versus alternate day One trial (43 children) found no differences between treatment schedules for lung function, quality of life or pulmonary exacerbations. Dornase alfa compared to other medications that improve airway clearance The results from trials comparing dornase alfa to hypertonic saline or mannitol were mixed. One trial (43 children) showed a greater improvement in lung function with dornase alfa compared to hypertonic saline and one trial (23 participants) reported no difference in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol. In one trial (23 participants) quality of life scores were better with dornase alfa alone than with dornase alfa plus mannitol; other drug comparisons found no difference between treatments for quality of life. No trials in any comparison of treatments reported any difference between groups in the number of pulmonary exacerbations. Overall, no serious side effects were reported, with only rash and a change in voice seen more frequently in those people taking dornase alfa. However, it is not definitively clear from the current evidence if dornase alfa is better than other medications such as hypertonic saline or mannitol. Quality of the evidence The quality of evidence from the trials comparing dornase alfa to placebo or no treatment was moderate to high for lung function results, but only one trial reported any changes in quality of life so the evidence for this outcome is limited. Also, there were few trials comparing different treatment schedules of dornase alfa (e.g. once a day versus twice a day) or comparing dornase alfa to other medications which help with clearing secretions, so current evidence from these trials is limited and of low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Yang, C; Montgomery, M", "articleTypes": [], "doi": "10.1002/14651858.CD001127.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "17f1defe-8da1-40bd-80af-5707c446149e", "pmid": "", "title": "Vasodilators for primary Raynaud's phenomenon", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Su, KYC, Sharma, M, Kim, HJ, Kaganov, E, Hughes, I, Abdeen, MH, Ng, JH", "articleTypes": [], "doi": "10.1002/14651858.CD006687.pub4 AB - Abstract - Background Numerous agents have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered to be the drugs of choice, evidence of the effects of alternative pharmacological treatments is limited. This is an update of a review first published in 2008. Objectives To assess the effects of drugs with vasodilator effects on primary Raynaud's phenomenon as determined by frequency, severity, and duration of vasospastic attacks; quality of life; adverse events; and Raynauds Condition Score. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trial register to November 16, 2020. Selection criteria We included randomized controlled trials evaluating effects of oral, intravenous, and topical formulations of any drug with vasodilator effects on subjective symptoms, severity scores, and radiological outcomes in primary Raynaud's phenomenon. Treatment with calcium channel blockers was not assessed in this review, nor were these agents compared. Data collection and analysis Two review authors independently selected studies for inclusion, assessed studies using the Cochrane \"Risk of bias\" tool, and extracted study data. Outcomes of interest included frequency, severity, and duration of attacks; quality of life (QoL); adverse events (AEs); and the Raynaud Condition Score (RCS). We assessed the certainty of the evidence using GRADE. Main results We identified seven new studies for this update. In total, we included 15 studies involving 635 participants. These studies compared different vasodilators to placebo. Individual studies used different methods and measures to report different outcomes. Angiotensin‐converting enzyme (ACE) inhibitors Combining data from three studies revealed a possible small increase in the frequency of attacks per week after treatment (captopril or enalapril) compared to placebo (mean difference [MD] 0.79, 95% confidence interval [CI] 0.43 to 1.17; low‐certainty evidence). There was no evidence of a difference between groups in severity of attacks (MD ‐0.17, 95% CI ‐4.66 to 4.31; 34 participants, 2 studies; low‐certainty evidence); duration of attacks (MD 0.54, 95% CI ‐2.42 to 1.34; 14 participants, 1 study; low‐certainty evidence); or AEs (risk ratio [RR] 1.35, 95% CI 0.67 to 2.73; 46 participants, 3 studies; low‐certainty evidence). QoL and RCS were not reported. Alpha blockers Two studies used alpha blockers (buflomedil or moxisylyte). We were unable to combine data due to the way results were presented. Buflomedil probably reduced the frequency of attacks compared to placebo (MD ‐8.82, 95% CI ‐11.04 to ‐6.60; 31 participants, 1 study; moderate‐certainty evidence) and may improve severity scores (MD ‐0.41, 95% CI ‐0.62 to ‐0.30; moderate‐certainty evidence). With moxisylyte, investigators reported fewer attacks (P < 0.02), less severe symptoms (P < 0.01), and shorter duration of attacks, but the clinical relevance of these results is unclear. No evidence of a difference in AEs between buflomedil and placebo groups was noted (RR 1.41, 95% CI 0.27 to 7.28; 31 participants, 1 study; moderate‐certainty evidence). More AEs were observed in participants in the moxisylyte group than in the placebo group. Prostaglandin/prostacyclin analogues One study compared beraprost versus placebo. There was no evidence of benefit for frequency (MD 2.00, 95% CI ‐0.35 to 4.35; 118 participants, low‐certainty evidence) or severity (MD ‐0.06, 95% CI ‐0.34 to 0.22; 118 participants, low‐certainty evidence) of attacks. Overall, more AEs were noted in the beraprost group (RR 1.59, 95% CI 1.05 to 2.42; 125 participants; low‐certainty evidence). This study did not report on duration of attacks, QoL, or RCS. Thromboxane synthase inhibitors One study compared a thromboxane synthase inhibitor (dazoxiben) versus placebo. There was no evidence of benefit for frequency of attacks (MD 0.8, 95% CI ‐1.81 to 3.41; 6 participants; very low‐certainty evidence). Adverse events were not reported in subgroup analyses of participants with primary Raynaud's phenomenon, and the study did not report on duration of attacks, severity of symptoms, QoL, or RCS. Selective serotonin reuptake inhibitors One study compared ketanserin with placebo. There may be a slight reduction in the number of attacks per week with ketanserin compared to placebo (MD ‐14.0, 95% CI ‐27.72 to ‐0.28; 41 participants; very low‐certainty evidence) and reduced severity score (MD ‐133.00, 95% CI ‐162.40 to ‐103.60; 41 participants; very low‐certainty evidence). There was no evidence that ketanserin reduced the duration of attacks (MD ‐4.00, 95% CI ‐14.82 to 6.82; 41 participants; very low‐certainty evidence), or that AEs were increased in either group (RR 1.54, 95% CI 0.89 to 2.65; 41 participants; very low‐certainty evidence). This study did not report on QoL or RCS. Nitrate/nitrate derivatives Four studies compared topical treatments of nitroglycerin or glyceryl trinitrate versus placebo, each reporting on limited outcomes. Meta‐analysis demonstrated no evidence of effect on frequency of attacks per week (MD ‐1.57, 95% CI ‐4.31 to 1.17; 86 participants, 2 studies; very low‐certainty evidence). We were unable to pool any data for the remaining outcomes. Phosphodiesterase inhibitors Three studies compared phosphodiesterase inhibitors (vardenafil, cilostazol or PF‐00489791) to an equivalent placebo. Results showed no evidence of a difference in frequency of attacks (standardized MD [SMD] ‐0.05, 95% CI ‐6.71 to 6.61; 111 participants, 2 studies; low‐certainty evidence), severity of attacks (MD ‐0.03, 95% CI ‐1.04 to 0.97; 111 participants, 2 studies; very low‐certainty evidence), duration of attacks (MD ‐1.60, 95% CI ‐7.51 to 4.31; 73 participants, 1 study; low‐certainty evidence), or RCS (SMD ‐0.8, 95% CI ‐1.74 to 0.13; 79 participants, 2 studies; low‐certainty evidence). Study authors reported that 35% of participants on cilostazol complained of headaches, which were not reported in the placebo group. PF‐00489791 caused 34 of 54 participants to experience AEs versus 43 of 102 participants receiving placebo (RR 1.49). Headache was most common, affecting 14 participants (PF‐00489791) versus nine participants (placebo). Authors' conclusions The included studies investigated several different vasodilators (topical and oral) for treatment of primary Raynaud's phenomenon. Small sample sizes, limited data, and variability in outcome reporting yielded evidence of very low to moderate certainty. Evidence is insufficient to support the use of vasodilators and suggests that vasodilator use may even worsen disease. Plain language summary Vasodilator drugs to reduce the symptoms of primary Raynaud's phenomenon Background Raynaud's phenomenon (RP) is a condition affecting the small blood vessels in the extremities, usually in the fingers but also in the toes and other body parts. It is caused by temporary narrowing of the blood vessels, which leads to color changes with associated numbness, tingling, and pain. Various triggers for this condition are known, such as stress, cold, and use of vibrational hand tools. Conservative measures to control this condition include stopping smoking and maintaining both peripheral and ambient warmth. Medications that dilate the blood vessels such as calcium channel blockers (CCBs) may be used but can have side effects. This review aims to investigate the effectiveness and safety of drugs that dilate the blood vessels other than CCBs. Study characteristics and key results We found seven new studies for this update, bringing the total to 15 (search was good to November 16, 2020). This update now includes other routes of administration such as through the veins (intravenous) and the skin (topical), in contrast to previous reviews, which focused on oral forms of treatment. The studies were published between 1989 and 2013 and involved a total of 635 participants randomly assigned to receive treatment or placebo control. Many studies did not describe various aspects of study methods such as randomization, allocation concealment, and blinding. Treatment duration varied between two weeks and six months.
Angiotensin‐converting enzyme (ACE) inhibitors as a drug class, specifically enalapril and captopril in this review, in general increased the frequency of Raynaud's attacks per week but did not affect the severity of the attacks. Enalapril worsened subjective assessment of improvement, and captopril did not improve subjective outcomes or digital blood flow. Buflomedil showed a small reduction in the frequency and severity of attacks with increased side effects. Beraprost and dazoxiben did not demonstrate any change in frequency or severity of attacks nor in disability score and were associated with increased side effects. Ketanserin did not demonstrate improvement in frequency or duration of attacks nor in digital blood flow but did demonstrate improvement in severity scoring of RP. In a small study, moxisylyte was shown to reduce the frequency and severity of attacks to a small degree but with increased side effects. Topical glyceryl trinitrate did not show any effect on reducing the frequency of attacks per week. One study reported subjective improvement in Raynaud Condition Score (RCS). One small study reported improvements in frequency and severity of attacks as subjective changes. Headaches were the most significant and common side effect of treatment. Phosphodiesterase inhibitors did not cause a reduction in frequency, severity, or duration of attacks and did not improve RCS. One study reported in favor of vardenafil alone to reduce RCS but found that the effect is likely small. One study reported that cilostazol increased the frequency and severity of attacks; more research is needed to confirm this finding. Risk of headache as a side effect of treatment was increased with cilostazol use. PF‐00489791 at a dose of 20 mg was found to slightly improve all subjective outcome measures and RCS. Reliability of the evidence We have very low to moderate confidence in these results, so we cannot make any firm conclusions about the benefit of these drugs for improving symptoms of primary RP. We cannot be confident because of the small numbers of participants involved in studies, issues with how studies were designed, and differences in how they measured whether or not treatments were effective. Therefore, the clinical importance of these results is difficult to assess, especially when placebo response is high. It is also pertinent that the results for each drug class and for individual drugs within each drug class must be interpreted in the context that they may have varying pharmacologic effects in addition to vasodilation. This must be taken into consideration when any conclusions are made about the overall effects of each drug class and/or individual drug.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.809Z" }, { "id": "182c3c50-09b0-490d-be0e-b212c32376bb", "pmid": "", "title": "Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people", "imported": false, "abstract": "Abstract - Background Folate deficiency can result in congenital neural tube defects and megaloblastic anaemia. Low folate levels may be due to insufficient dietary intake or inefficient absorption, but impaired metabolic utilization also occurs. Because B12 deficiency can produce a similar anaemia to folate deficiency, there is a risk that folate supplementation can delay the diagnosis of B12 deficiency, which can cause irreversible neurological damage. Folic acid supplements may sometimes therefore include vitamin B12 supplements with simultaneous administration of vitamin B12. Lesser degrees of folate inadequacy are associated with high blood levels of the amino acid homocysteine which has been linked with the risk of arterial disease, dementia and Alzheimer's disease. There is therefore interest in whether dietary supplementation can improve cognitive function in the elderly. However, any apparent benefit from folic acid which was given in combination with B12 needs to be \"corrected\" for any effect of vitamin B12 alone. A separate Cochrane review of vitamin B12 and cognitive function has therefore been published. Objectives To examine the effects of folic acid supplementation, with or without vitamin B12, on elderly healthy or demented people, in preventing cognitive impairment or retarding its progress. Search methods Trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 10 October 2007 using the terms: folic acid, folate, vitamin B9, leucovorin, methyltetrahydrofolate, vitamin B12, cobalamin and cyanocobalamin. This Register contains references from all major health care databases and many ongoing trials databases. In addition MEDLINE, EMBASE, CINAHL, PsychINFO and LILACS were searched (years 2003‐2007) for additional trials of folate with or without vitamin B12 on healthy elderly people. Selection criteria All double‐blind, placebo‐controlled, randomized trials, in which supplements of folic acid with or without vitamin B12 were compared with placebo for elderly healthy people or people with any type of dementia or cognitive impairment. Data collection and analysis The reviewers independently applied the selection criteria and assessed study quality. One reviewer extracted and analysed the data. In comparing intervention with placebo, weighted mean differences and standardized mean difference or odds ratios were estimated. Main results Eight randomized controlled trials fulfilled the inclusion criteria for this review. Four trials enrolled healthy older people, and four recruited participants with mild to moderate cognitive impairment or dementia with or without diagnosed folate deficiency. Pooling the data was not possible owing to heterogeneity in sample selections, outcomes, trial duration, and dosage. Two studies involved a combination of folic acid and vitamin B12. There is no adequate evidence of benefit from folic acid supplemententation with or without vitamin B12 on cognitive function and mood of unselected healthy elderly people. However, in one trial enrolling a selected group of healthy elderly people with high homocysteine levels, 800 mcg/day folic acid supplementation over three years was associated with significant benefit in terms of global functioning (WMD 0.05, 95% CI 0.004 to 0.096, P = 0.033); memory storage (WMD 0.14, 95% CI 0.04 to 0.24, P = 0.006) and information‐processing speed (WMD 0.09, 95% CI 0.02 to 0.16, P = 0.016). Four trials involved people with cognitive impairment. In one pilot trial enrolling people with Alzheimer's disease, the overall response to cholinesterase inhibitors significantly improved with folic acid at a dose of 1mg/day (odds ratio: 4.06, 95% CI 1.22 to 13.53; P = 0.02) and there was a significant improvement in scores on the Instrumental Activities of Daily Living and the Social Behaviour subscale of the Nurse's Observation Scale for Geriatric Patients (WMD 4.01, 95% CI 0.50 to 7.52, P = 0.02). Other trials involving people with cognitive impairment did not show any benefit in measures of cognitive function from folic acid, with or without vitamin B12. Folic acid plus vitamin B12 was effective in reducing serum homocysteine concentrations (WMD ‐5.90, 95% CI ‐8.43 to ‐3.37, P < 0.00001). Folic acid was well tolerated and no adverse effects were reported. Authors' conclusions The small number of studies which have been done provide no consistent evidence either way that folic acid, with or without vitamin B12, has a beneficial effect on cognitive function of unselected healthy or cognitively impaired older people. In a preliminary study, folic acid was associated with improvement in the response of people with Alzheimer's disease to cholinesterase inhibitors. In another, long‐term use appeared to improve the cognitive function of healthy older people with high homocysteine levels. More studies are needed on this important issue. Plain language summary No evidence that folic acid with or without vitamin B12 improves cognitive function of unselected elderly people with or without dementia. Long‐term supplementation may benefit cognitive function of healthy older people with high homocysteine levels In the economically developed world, folate deficiency is one of the commonest vitamin deficiencies. Several reports suggest a higher prevalence of various psychiatric disorders in elderly people with folate deficiency. There is interest in whether dietary supplements of folic acid (an artificial chemical analogue of naturally occurring folates) can improve cognitive function of people at risk of cognitive decline associated with ageing or dementia, whether by affecting homocysteine metabolism or through other mechanisms. Eight trials met the criteria for inclusion. It was not possible to pool the data because the trials studied different populations, tested folic acid in different doses, and used different outcome measures. There were two trials of folic acid in conjunction with B12. The analysis showed significant benefit of folic acid over placebo in some measures of cognition in a long‐term trial recruiting elderly people with high homocysteine levels from a general population. In one pilot trial, 1 mg/day of folic acid was associated with significant improvement in behavioural response to cholinesterase inhibitors in people with Alzheimer's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Malouf, R, Grimley Evans, J", "articleTypes": [], "doi": "10.1002/14651858.CD004514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.807Z" }, { "id": "183c6235-7a38-4dfc-8386-7731681b4980", "pmid": "", "title": "Systemic interventions for recurrent aphthous stomatitis (mouth ulcers)", "imported": false, "abstract": "Abstract - Background Recurrent aphthous stomatitis (RAS) is the most frequent form of oral ulceration, characterised by recurrent oral mucosal ulceration in an otherwise healthy individual. At its worst RAS can cause significant difficulties in eating and drinking. Treatment is primarily aimed at pain relief and the promotion of healing to reduce the duration of the disease or reduce the rate of recurrence. A variety of topical and systemic therapies have been utilised. Objectives To determine the clinical effect of systemic interventions in the reduction of pain associated with RAS, a reduction in episode duration or frequency. Search methods We undertook electronic searches of: Cochrane Oral Health Group and PaPaS Trials Registers (to 6 June 2012); CENTRAL via The Cochrane Library (to Issue 4, 2012); MEDLINE via OVID (1950 to 6 June 2012); EMBASE via OVID (1980 to 6 June 2012); CINAHL via EBSCO (1980 to 6 June 2012); and AMED via PubMed (1950 to 6 June 2012). We searched reference lists from relevant articles and contacted the authors of eligible trials to identify further trials and obtain additional information. Selection criteria We included randomised controlled trials (RCTs) in which the primary outcome measures assess a reduction of pain associated with RAS, a reduction in episode duration or a reduction in episode frequency. Trials were not restricted by outcome alone. We also included RCTs of a cross‐over design. Data collection and analysis Two review authors independently extracted data in duplicate. We contacted trial authors for details of randomisation, blindness and withdrawals. We carried out risk of bias assessment on six domains. We followed The Cochrane Collaboration statistical guidelines and risk ratio (RR) values were to be calculated using fixed‐effect models (if two or three trials in each meta‐analysis) or random‐effects models (if four or more trials in each meta‐analysis). Main results A total of 25 trials were included, 22 of which were placebo controlled and eight made head‐to‐head comparisons (five trials had more than two treatment arms). Twenty‐one different interventions were assessed. The interventions were grouped into two categories: immunomodulatory/anti‐inflammatory and uncertain. Only one study was assessed as being at low risk of bias. There was insufficient evidence to support or refute the use of any intervention. Authors' conclusions No single treatment was found to be effective and therefore the results remain inconclusive in regard to the best systemic intervention for RAS. This is likely to reflect the poor methodological rigour of trials, and lack of studies for certain drugs, rather than the true effect of the intervention. It is also recognised that in clinical practice, individual drugs appear to work for individual patients and so the interventions are likely to be complex in nature. In addition, it is acknowledged that systemic interventions are often reserved for those patients who have been unresponsive to topical treatments, and therefore may represent a select group of patients. Plain language summary Systemic interventions for recurrent aphthous stomatitis (mouth ulcers) Mouth ulcers (sores) are one of the most common oral problems and many people suffer with them repeatedly. These can be painful and slow to heal. At its worst, this can cause significant difficulties in eating and drinking. This review found that many different treatments were used to manage this condition, although the evidence of their effectiveness remains inconclusive.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Brocklehurst, P, Tickle, M, Glenny, AM, Lewis, MA, Pemberton, MN, Taylor, J, Walsh, T, Riley, P, Yates, JM", "articleTypes": [], "doi": "10.1002/14651858.CD005411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.112Z" }, { "id": "1858c951-9f67-4c07-901f-264c82e7ff80", "pmid": "", "title": "D‐penicillamine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is used for patients with primary biliary cirrhosis due to its hepatic copper decreasing and immunomodulatory potentials. The results from randomised clinical trials have been inconsistent. Objectives To systematically review the beneficial and harmful effects of D‐penicillamine for patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register (September 2003), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2003) , MEDLINE (January 1966 to September 2003) , EMBASE (January 1980 to September 2003) , The Chinese Biomedical CD Database (January 1979 to August 2003) , and LILACS (1982 to 2003); through manual searches of bibliographies; and by contacting authors of the trials and pharmaceutical companies. Selection criteria We included randomised clinical trials comparing D‐penicillamine with placebo/no intervention or other control intervention irrespective of language, year of publication, and publication status. Data collection and analysis Two reviewers independently assessed the methodological quality of the trials and extracted data, validated by a third reviewer. The primary outcomes were 1) mortality and 2) a combination of those who died or underwent liver transplantation. We analysed dichotomous outcomes as relative risk (RR) with 95% confidence interval (CI) by a fixed effect model and a random effects model. We investigated sources of heterogeneity by subgroup analyses and tested the robustness of our findings by sensitivity analyses. Main results We included seven trials randomising 706 patients with primary biliary cirrhosis. D‐penicillamine compared with placebo/no intervention tended to increase mortality (RR 1.34, 95% CI 1.09 to 1.64, fixed; RR 1.46, 95% CI 0.85 to 2.50, random). However, there was substantial heterogeneity. No significant differences were detected regarding the risks of mortality or liver transplantation, pruritus, liver complications, progression of liver histological stage, or the levels of liver biochemical variables (except alanine aminotransferase). D‐penicillamine versus placebo/no intervention significantly increased the risk of adverse events (RR 3.11, 95% CI 2.33 to 4.16, fixed; RR 4.18, 95% CI 1.38 to 12.69, random). Authors' conclusions D‐penicillamine did not appear to reduce the risk of mortality, but significantly increased the occurrences of adverse events in patients with primary biliary cirrhosis. We do not support the use of D‐penicillamine for patients with primary biliary cirrhosis. Plain language summary D‐penicillamine did not reduce the risk of mortality of patients with primary biliary cirrhosis but increased the occurrences of adverse events Primary biliary cirrhosis is an uncommon, chronic liver disease of unknown etiology. D‐penicillamine, a cupruretic drug, has been tested in randomised clinical trials and is used to treat patients with primary biliary cirrhosis. After combining results from seven trials, D‐penicillamine did not appear to improve survival of patients. D‐penicillamine was associated with a four‐time increase of adverse events. There were no significant differences between D‐penicillamine and placebo/no intervention with respect to clinical changes, liver histology, and liver biochemistry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y, Klingenberg, SL, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004789.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.731Z" }, { "id": "185efecf-8006-431e-b46c-f199a9f5b374", "pmid": "", "title": "Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months", "imported": false, "abstract": "Abstract - Background Bronchiolitis is one of the most common respiratory problems in the first year of life. The sputum of infants with bronchiolitis has increased deoxyribonucleic acid (DNA) content, leading to mucous plugging and airway obstruction. Recombinant human deoxyribonuclease (rhDNase), an enzyme that digests extracellular DNA, might aid the clearance of mucus and relieve peripheral airway obstruction. Objectives To determine the effect of nebulised rhDNase on the severity and duration of viral bronchiolitis in children younger than 24 months of age in the hospital setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 7 which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July Week 4, 2012), EMBASE (1974 to August 2012) and LILACS (1982 to August 2012). Selection criteria Randomised controlled trials (RCTs) using nebulised rhDNase alone or with concomitant therapy in children younger than 24 months of age hospitalised with acute bronchiolitis. Data collection and analysis Two review authors independently performed literature searches, assessed trial quality and extracted data. We obtained unpublished data from trial authors. We used Review Manager 5.1 to pool treatment effects expressed as the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI). Main results Three RCTs (333 participants) were identified, two of which were multicentre trials comprising only participants positive for respiratory syncytial virus (RSV). The other trial enrolled participants clinically diagnosed with bronchiolitis from a hospital in Italy. All studies used 2.5 mL (1 mg/mL) of nebulised rhDNase compared with placebo either as a daily or a twice daily dose. Adjunctive therapy included nebulised salbutamol, steroids, supplemental oxygen, intravenous fluids or tube feeding, nasal washing, nasal decongestants and antibiotics. Overall, nebulised rhDNase showed no benefit in clinically meaningful outcomes. Meta‐analysis favoured the control group with a shorter duration of hospital stay (MD 0.50; 95% CI 0.10 to 0.90, P = 0.01) and better clinical score improvement (SMD ‐0.24; 95% CI ‐0.50 to 0.01, P = 0.06). The largest trial showed no difference in supplemental oxygen use or intensive care unit (ICU) admission. In one RCT, four out of 11 patients in the treatment group had atelectasis. Two of these patients showed distinctive clinical improvement after nebulised rhDNase. There was no significant difference in adverse events. These included temporary desaturation, temporary coughing, increased coughing, facial rash, hoarseness, dyspnoea and bad taste, reported in a total of 11 patients from both treatment groups. Authors' conclusions The results based on the three included studies in this review did not support the use of nebulised rhDNase in children under 24 months of age hospitalised with acute bronchiolitis. In these patients, treatment did not shorten the length of hospitalisation or improve clinical outcomes. It might have a role in severe bronchiolitis complicated by atelectasis, but further clinical studies would need to be performed. Plain language summary Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months Bronchiolitis is the most common respiratory illness leading to hospitalisations in infants. Viral infections, particularly respiratory syncytial virus, are the usual cause, which lead to blockage of the small airways of the lungs due to inflammation and increased mucus production. Afflicted children have fever, cough, wheezing and difficulty breathing. Treatment is usually supportive. In bronchiolitis, the mucus produced contains large amounts of DNA, which makes it thicker and stickier. Removal of this DNA facilitates clearance of the mucus. RhDNase is an enzyme that breaks down DNA and hence may improve symptoms. We performed this review to assess the effect of rhDNase delivered through a nebuliser in children under 24 months old hospitalised for bronchiolitis. We identified three randomised controlled trials involving 333 children up to 24 months of age hospitalised with bronchiolitis. All three studies compared nebulised rhDNase with placebo. Any additional treatments were given to both groups. Overall, the studies did not show that nebulised rhDNase shortened the duration of hospital admission, or improved the severity of symptoms. No serious side effects were reported by any of the studies. One study showed that in patients suffering from atelectasis, a severe complication of bronchiolitis wherein the lung does not expand completely, nebulised rhDNase treatment resulted in a distinct improvement within two days. To confirm this beneficial effect, further clinical studies in patients with severe bronchiolitis are needed. Currently, the use of this treatment in young children hospitalised with bronchiolitis is not recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Enriquez, A, Chu, IW, Mellis, C, Lin, WY", "articleTypes": [], "doi": "10.1002/14651858.CD008395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.100Z" }, { "id": "186006aa-bdad-44fd-9f91-039862622ae3", "pmid": "", "title": "Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Chronic obstructive pulmonary disease (COPD) is a chronic lung condition characterised by persistent respiratory symptoms and limited lung airflow, dyspnoea and recurrent exacerbations. Suboptimal therapy or non‐adherence may result in limited effectiveness of pharmacological treatments and subsequently poor health outcomes. Objectives To determine the efficacy and safety of interventions intended to improve adherence to single or combined pharmacological treatments compared with usual care or interventions that are not intended to improve adherence in people with COPD. Search methods We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register, CENTRAL, MEDLINE and Embase (search date 1 May 2020). We also searched web‐based clinical trial registers. Selection criteria RCTs included adults with COPD diagnosed by established criteria (e.g. Global Initiative for Obstructive Lung Disease). Interventions included change to pharmacological treatment regimens, adherence aids, education, behavioural or psychological interventions (e.g. cognitive behavioural therapy), communication or follow‐up by a health professional (e.g. telephone, text message or face‐to‐face), multi‐component interventions, and interventions to improve inhaler technique. Data collection and analysis We used standard Cochrane methodological procedures. Working in pairs, four review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We assessed confidence in the evidence for each primary outcome using GRADE. Primary outcomes were adherence, quality of life and hospital service utilisation. Adherence measures included the Adherence among Patients with Chronic Disease questionnaire (APCD). Quality of life measures included the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). Main results We included 14 trials (2191 participants) in the analysis with follow‐up ranging from six to 52 weeks. Age ranged from 54 to 75 years, and COPD severity ranged from mild to very severe. Trials were conducted in the USA, Spain, Germany, Japan, Jordan, Northern Ireland, Iran, South Korea, China and Belgium. Risk of bias was high due to lack of blinding. Evidence certainty was downgraded due to imprecision and small participant numbers. Single component interventions Six studies (55 to 212 participants) reported single component interventions including changes to pharmacological treatment (different roflumilast doses or different inhaler types), adherence aids (Bluetooth inhaler reminder device), educational (comprehensive verbal instruction), behavioural or psychological (motivational interview). Change in dose of roflumilast may result in little to no difference in adherence (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.22 to 1.99; studies = 1, participants = 55; low certainty). A Bluetooth inhaler reminder device did not improve adherence, but comprehensive verbal instruction from a health professional did improve mean adherence (prescription refills) (mean difference (MD) 1.00, 95% CI 0.46 to 1.54). Motivational interview improved mean adherence scores on the APCD scale (MD 22.22, 95% CI 8.42 to 36.02). Use of a single inhaler compared to two separate inhalers may have little to no impact on quality of life (SGRQ; MD 0.80, 95% CI –3.12 to 4.72; very low certainty). A Bluetooth inhaler monitoring device may provide a small improvement in quality of life on the CCQ (MD 0.40, 95% CI 0.07 to 0.73; very low certainty). Single inhaler use may have little to no impact on the number of people admitted to hospital compared to two separate inhalers (OR 1.47, 95% CI 0.75 to 2.90; very low certainty). Single component interventions may have little to no impact on the number of people expereincing adverse events (very low certainty evidence from studies of a change in pharmacotherapy or use of adherence aids). A change in pharmacotherapy may have little to no impact on exacerbations or deaths (very low certainty). Multi‐component interventions Eight studies (30 to 734 participants) reported multi‐component interventions including tailored care package that included adherence support as a key component or included inhaler technique as a component. A multi‐component intervention may result in more people adhering to pharmacotherapy compared to control at 40.5 weeks (risk ratio (RR) 1.37, 95% CI 1.18 to 1.59; studies = 4, participants = 446; I 2 = 0%; low certainty). There may be little to no impact on quality of life (SGRQ, Chronic Respiratory Disease Questionnaire, CAT) (studies = 3; low to very low certainty). Multi‐component interventions may help to reduce the number of people admitted to hospital for any cause (OR 0.37, 95% CI 0.22 to 0.63; studies = 2, participants = 877; low certainty), or COPD‐related hospitalisations (OR 0.15, 95% CI 0.07 to 0.34; studies = 2, participants = 220; moderate certainty). There may be a small benefit on people experiencing severe exacerbations. There may be little to no effect on adverse events, serious adverse events or deaths, but events were infrequently reported and were rare (low to very low certainty). Authors' conclusions Single component interventions (e.g. education or motivational interviewing provided by a health professional) can help to improve adherence to pharmacotherapy (low to very low certainty). There were slight improvements in quality of life with a Bluetooth inhaler device, but evidence is from one study and very low certainty. Change to pharmacotherapy (e.g. single inhaler instead of two, or different doses of roflumilast) has little impact on hospitalisations or exacerbations (very low certainty). There is no difference in people experiencing adverse events (all‐cause or COPD‐related), or deaths (very low certainty). Multi‐component interventions may improve adherence with education, motivational or behavioural components delivered by health professionals (low certainty). There is little to no impact on quality of life (low to very low certainty). They may help reduce the number of people admitted to hospital overall (specifically pharmacist‐led approaches) (low certainty), and fewer people may have COPD‐related hospital admissions (moderately certainty). There may be a small reduction in people experiencing severe exacerbations, but evidence is from one study (low certainty). Limited evidence found no difference in people experiencing adverse events, serious adverse events or deaths (low to very low certainty). The evidence presented should be interpreted with caution. Larger studies with more intervention types, especially single interventions, are needed. It is unclear which specific COPD subgroups would benefit, therefore discussions between health professionals and patients may help to determine whether they will help to improve health outcomes. Plain language summary Which approaches help people with COPD to maintain taking medication as prescribed? Review question Which approaches help people maintain taking prescribed medication(s), improve quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD)? Background COPD is a lung condition that can cause long‐term breathing problems and includes symptoms such as shortness of breath. Medications do exist that can help but sometimes people do not take them as prescribed. Different approaches could help people to take their medication as prescribed and help improve symptoms or quality of life and reduce hospital admissions. We wanted to find out if any approaches could help people with COPD take their medication(s) as prescribed. Studies identified and selected We searched databases to find the studies. Four people working in pairs looked at the lists of studies separately and agreed on which ones were included. The latest search for studies was conducted in May 2020. Study characteristics We included studies comparing simple ways to help improve medication use (e.g. different medication doses or single inhalers instead of two separate inhalers) to usual COPD care. We also included studies that tested combination approaches (e.g. information or training from nurses or pharmacists and monitoring medication use). What were the key results? We included 14 studies (2191 people) in our analysis. No studies were masked (people knew whether they were receiving an approach to help them with adherence or the alternative). Six studies used simple approaches (e.g. change to medication dosage, change to type of inhaler, or a Bluetooth inhaler reminder device), and eight studies used combined approaches (e.g. nurses or pharmacists giving advice or information about how to improve medication use). We were uncertain about the effects of a different medication dose on people adhering to medication because it was no different to usual care (one study). Two separate studies found that a Bluetooth inhaler reminder device or a change in oral medication dose did not help to improve adherence. Health professionals involved in giving information may help to improve adherence (one study). This was measured by prescription refills. Motivating people to change their behaviour could help to improve adherence their medication (one study). This was measured by people completing a questionnaire about adherence to their medication. One study found that a Bluetooth inhaler device might help to improve quality of life. There may be little to no difference between those using single inhalers in the number of people admitted to hospital compared to those using two separate inhalers (one study). We found no difference between single approaches and usual care on the number of people who had side effects. Combined approaches may help to improve the number of people taking their medication, but we were not confident of this finding (four studies). They may have little to no impact on quality of life (three studies). Combined approaches could be beneficial in reducing the number of people with COPD admitted to hospital for any reason or because of COPD symptoms (two studies). There was no difference between combined approaches and in the number of people who had adverse events. Take home message We could not say for certain that simple approaches are useful to help people with COPD to improve medication use because of very limited information. Combined approaches may help people to take their medication(s) as prescribed and can help to reduce the number of people admitted to hospital, however, more information is needed to help answer this question with confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Janjua, S; Pike, KC; Carr, R; Coles, A; Fortescue, R; Batavia, M", "articleTypes": [], "doi": "10.1002/14651858.CD013381.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "18601631-9d4f-458c-ac61-231c12ffa18d", "pmid": "", "title": "Effect of Fructose and Glucose and TAS1R2 in Glucose, Triglycerides, Uremia, Oxidative Stress, Feelings Related to Food Intake of Individuals With Type 1 Diabetes", "imported": false, "abstract": "- BACKGROUND: Individuals with diabetes report innate preference for sweet foods, possibly due to genetic variants. In addition, studies have shown that ingestion of fructose promotes lower postprandial blood glucose, compared to glucose. However, excessive intake may increase triglycerides, uric acid and oxidative stress, due to oxidative priority.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "18ac7bee-0a25-499e-b3cb-cd1f856fe67f", "pmid": "", "title": "Interventions for preventing osteoradionecrosis of the jaws in adults receiving head and neck radiotherapy", "imported": false, "abstract": "Abstract - Background Osteoradionecrosis (ORN) of the jaws is among the most serious oral complications of head and neck cancer radiotherapy, arising from radiation‐induced fibro‐atrophic tissue injury, manifested by necrosis of osseous tissues and failure to heal, often secondary to operative interventions in the oral cavity. It is associated with considerable morbidity and has important quality of life ramifications. Since ORN is very difficult to treat effectively, preventive measures to limit the onset of this disease are needed; however, the effects of various preventive interventions has not been adequately quantified. Objectives To assess the effects of interventions for preventing ORN of the jaws in adult patients with head and neck cancer undergoing curative or adjuvant (i.e. non‐palliative) radiotherapy. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 5 November 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 10) in the Cochrane Library (searched 5 November 2019), MEDLINE Ovid (1946 to 5 November 2019), Embase Ovid (1980 to 5 November 2019), Allied and Complementary Medicine (AMED) Ovid (1985 to 5 November 2019), Scopus (1966 to 5 November 2019), Proquest Dissertations and Theses International (1861 to 5 November 2019) and Web of Science Conference Proceedings (1990 to 5 November 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We selected randomised controlled trials (RCTs) or quasi‐RCTs of adult patients 18 years or older with head and neck cancer who had undergone curative or adjuvant radiotherapy to the head and neck, who had received an intervention to prevent the onset of ORN. Eligible patients were those subjected to pre‐ or post‐irradiation dental evaluation. Management of these patients was to be with interventions independent of their cancer therapy, including but not limited to local, systemic, or behavioural interventions. Data collection and analysis Two review authors independently selected trials from search results, assessed risk of bias, and extracted relevant data for inclusion in the review. Authors of included studies were contacted to request missing data. We used standard methodological procedures expected by Cochrane. Main results Four studies were identified that met pre‐determined eligibility criteria, evaluating a total of 342 adults. From the four studies, all assessed as at high risk of bias, three broad interventions were identified that may potentially reduce the risk of ORN development: one study showed no reduction in ORN when using platelet‐rich plasma placed in the extraction sockets of prophylactically removed healthy mandibular molar teeth prior to radiotherapy (odds ratio (OR) 3.32, 95% confidence interval (CI) 0.58 to 19.09; one trial, 44 participants; very low‐certainty evidence). Another study involved comparing fluoride gel and high‐content fluoride toothpaste (1350 parts per million (ppm)) in prevention of post‐radiation caries, and found no difference between their use as no cases of ORN were reported (one trial, 220 participants; very low‐certainty evidence). The other two studies involved the use of perioperative hyperbaric oxygen (HBO) therapy and antibiotics. One study showed that treatment with HBO caused a reduction in the development of ORN in comparison to patients treated with antibiotics following dental extractions (risk ratio (RR) 0.18, 95% CI 0.43 to 0.76; one trial, 74 participants; very low‐certainty evidence). Another study found no difference between combined HBO and antibiotics compared to antibiotics alone prior to dental implant placement (RR 3.00, 95% CI 0.14 to 65.16; one trial, 26 participants; very low‐certainty evidence). Adverse effects of the different interventions were not reported clearly or were not important. Authors' conclusions Given the suboptimal reporting and inadequate sample sizes of the included studies, evidence regarding the interventions evaluated by the trials included in this review is uncertain. More well‐designed RCTs with larger samples are required to make conclusive statements regarding the efficacy of these interventions. Plain language summary Dental treatments for preventing damage to the jawbones in people with cancer receiving radiotherapy to the head and neck Review question With this Cochrane Review we tried to find out the best way to prevent the death and exposure of bone in the jaws of people who have had radiotherapy for head and neck cancer. This is a condition called osteoradionecrosis (ORN). Background ORN of the jaws is a serious problem which can happen after people have radiotherapy as part of their treatment for head and neck cancer. ORN refers to the death and exposure of bone that result from damage to the tissues due to being exposed to radiation. ORN is very difficult to treat and it is important that steps are taken to prevent it. In this review, we looked at any treatments that have been used to prevent ORN. Study characteristics This review is up‐to‐date as of 5 November 2019. The review includes four studies involving 342 adults who had received radiotherapy for the treatment of head and neck cancer. The review looks at three different ways to prevent ORN: ‐ the use of platelet‐rich plasma (PRP) in bone after removal of healthy teeth prior to radiotherapy. Plasma is a part of blood that contains special proteins that help the blood to clot, and PRP is concentrated plasma which supports cell growth. Injecting PRP into damaged tissue may stimulate the body to grow new, healthy cells to make it heal more quickly; ‐ taking out teeth because of tooth decay makes the risk of developing ORN greater. Preventing tooth decay in people having radiotherapy is very important. We looked at a study comparing using fluoride gel with a toothpaste with a higher level of fluoride than normal to prevent tooth decay after radiotherapy; ‐ hyperbaric oxygen therapy is breathing oxygen in a pressurized chamber to improve blood supply, which may help heal damaged tissue. Two studies compared the use of hyperbaric oxygen therapy for taking out teeth or placing dental implants with antibiotics. Antibiotics are drugs which stop or slow the growth of bacteria. Key results One study showed no reduction in ORN when using platelet‐rich plasma in bone after the removal of healthy teeth. Another study found no difference between fluoride gel and toothpaste with a higher level of fluoride than normal as no cases of ORN were reported. A third study showed that treatment with hyperbaric oxygen therapy caused a reduction in the development of ORN in comparison to patients treated with antibiotics following the removal of teeth. The fourth study found no difference between combined hyperbaric oxygen therapy and antibiotics compared to antibiotics alone. Harmful effects of the different interventions were not reported clearly or were not important. Certainty of the evidence The level of certainty we have in these findings is very low. This was due to high risk of bias, not all studies mentioning important details, and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to stop ORN of the jaws from happening or making it less severe in adults receiving head and neck radiotherapy. We suggest that more, well‐conducted, and bigger studies including more people, should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "El‐Rabbany, M; Duchnay, M; Raziee, HR; Zych, M; Tenenbaum, H; Shah, PS; Azarpazhooh, A", "articleTypes": [], "doi": "10.1002/14651858.CD011559.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "18bc7d7d-5a28-49fe-bea5-1776455bbb22", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background The anti‐inflammatory effects of n‐3 (omega‐3 fatty acids, fish oil) have been suggested to be beneficial in chronic inflammatory disorders such as inflammatory bowel disease. This review is an update of a previously published Cochrane review. Objectives To systematically review the efficacy and safety of n‐3 for maintenance of remission in Crohn's disease (CD). Search methods The following databases were searched from inception to November 2013 without language restriction: CENTRAL, MEDLINE, EMBASE, HealthSTAR, PubMed, and ACP journal club. Selection criteria Randomized placebo‐controlled trials (RCT) of n‐3 for maintenance of remission in CD were included. Studies must have enrolled patients of any age group, who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil or n‐3 given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. Data collection and analysis The primary outcome was the relapse rate and secondary outcomes included change in disease activity scores, time to first relapse and adverse events. Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality using the Cochrane risk of bias tool. The overall quality of the evidence supporting the primary and selected secondary outcomes was reassessed for the current update using the GRADE system. We used the RevMan software for analyses. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the hazard ratio and 95% CI for time‐to‐event outcomes. Random‐effects or fixed‐effect models were used according to degree of heterogeneity and sensitivity analyses were performed in an attempt to explore possible sources of heterogeneity. Main results Six studies with a total of 1039 patients were eligible for inclusion. The two largest studies were rated as low risk of bias for all assessed items. Four studies were rated as unclear risk of bias for randomization and allocation concealment. Two studies were rated as high risk of bias for incomplete outcome data and selective reporting. There was a marginal significant benefit of n‐3 therapy for maintenance of remission. Thirty‐nine per cent of patients in the n‐3 group relapsed at 12 months compared to 47% of placebo patients (6 studies, 1039 patients; RR 0.77, 95% CI 0.61 to 0.98). A GRADE analysis rated the overall quality of the evidence for the primary outcome (i.e. relapse) as very low due to unexplained heterogeneity (I 2 = 58%), publication bias, and a high or unknown risk of bias in four studies in the pooled analysis. When two large studies at low risk of bias were considered the benefit was no longer statistically significant. Thirty‐seven per cent of patients in the n‐3 group relapsed at 12 months compared to 42% of placebo patients (2 studies, 738 patients; RR 0.88, 95% CI 0.74 to 1.05). No significant heterogeneity was identified for this pooled analysis ( I 2 = 0%). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was moderate due to sparse data (294 events). No serious adverse events were recorded in any of the studies but in a pooled analyses there was a significantly higher rate of diarrhea (4 studies, 862 patients; RR 1.36 95% CI 1.01 to 1.84) and upper gastrointestinal tract symptoms (5 studies, 999 patients; RR 1.65, 95% CI 1.25 to 2.18) in the n‐3 treatment group. Authors' conclusions Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms. Plain language summary Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of Crohn's disease patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of capsules containing omega‐3 fatty acids to maintain remission in Crohn's disease were reviewed. Six studies including 1039 patients were included in the review. A pooled analysis of six studies suggests a marginal benefit for omega 3 fatty acids over placebo (i.e. fake medicine) in preventing relapse of disease at one year. However, these results need to be interpreted with caution due to differences across the studies in terms of induction of remission regimens (e.g. surgical remission versus drug therapy) patients (e.g. adult versus pediatric patients) and medication regimens (e.g. some studies used different placebos), the possibility of publication bias (i.e. only studies with positive results are published) and low methodological quality in four studies in the pooled analysis. When the two largest and highest quality studies were pooled the results showed no benefit to omega‐3 treatment over placebo. There were no serious side effects in any of the studies. Common side effects included unpleasant taste, bad breath, heartburn, nausea and diarrhea. Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Lev‐Tzion, R, Griffiths, AM, Ledder, O, Turner, D", "articleTypes": [], "doi": "10.1002/14651858.CD006320.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.767Z" }, { "id": "18c92893-2bfb-42d1-a2ee-10b238f6c5ad", "pmid": "", "title": "Eplerenone for hypertension", "imported": false, "abstract": "Abstract - Background Eplerenone is an aldosterone receptor blocker that is chemically derived from spironolactone. In Canada, it is indicated for use as adjunctive therapy to reduce mortality for heart failure patients with New York Heart Association (NYHA) class II systolic chronic heart failure and left ventricular systolic dysfunction. It is also used as adjunctive therapy for patients with heart failure following myocardial infarction. Additionally, it is indicated for the treatment of mild and moderate essential hypertension for patients who cannot be treated adequately with other agents. It is important to determine the clinical impact of all antihypertensive medications, including aldosterone antagonists, to support their continued use in essential hypertension. No previous systematic reviews have evaluated the effect of eplerenone on cardiovascular morbidity, mortality, and magnitude of blood pressure lowering in patients with hypertension. Objectives To assess the effects of eplerenone monotherapy versus placebo for primary hypertension in adults. Outcomes of interest were all‐cause mortality, cardiovascular events (fatal or non‐fatal myocardial infarction), cerebrovascular events (fatal or non fatal strokes), adverse events or withdrawals due to adverse events, and systolic and diastolic blood pressure. Search methods We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers up to 3 March 2016. We handsearched references from retrieved studies to identify any studies missed in the initial search. We also searched for unpublished data by contacting the corresponding authors of the included studies and pharmaceutical companies involved in conducting studies on eplerenone monotherapy in primary hypertension. The search had no language restrictions. Selection criteria We selected randomized placebo‐controlled trials studying adult patients with primary hypertension. We excluded studies in people with secondary or gestational hypertension and studies where participants were receiving multiple antihypertensives. Data collection and analysis Three review authors independently reviewed the search results for studies meeting our criteria. Three review authors independently extracted data and assessed trial quality using a standardized data extraction form. A fourth independent review author resolved discrepancies or disagreements. We performed data extraction and synthesis using a standardized format on Covidence. We conducted data analysis using Review Manager 5. Main results A total of 1437 adult patients participated in the five randomized parallel group studies, with treatment durations ranging from 8 to 16 weeks. The daily doses of eplerenone ranged from 25 mg to 400 mg daily. Meta‐analysis of these studies showed a reduction in systolic blood pressure of 9.21 mmHg (95% CI −11.08 to −7.34; I 2 = 58%) and a reduction of diastolic pressure of 4.18 mmHg (95% CI −5.03 to −3.33; I 2 = 0%) (moderate quality evidence). There may be a dose response effect for eplerenone in the reduction in systolic blood pressure at doses of 400 mg/day. However, this finding is uncertain, as it is based on a single included study with low quality evidence. Overall there does not appear to be a clinically important dose response in lowering systolic or diastolic blood pressure at eplerenone doses of 50 mg to 400 mg daily. There did not appear to be any differences in the number of patients who withdrew due to adverse events or the number of patients with at least one adverse event in the eplerenone group compared to placebo. However, only three of the five included studies reported adverse events. Most of the included studies were of moderate quality, as we judged multiple domains as being at unclear risk in the 'Risk of bias' assessment. Authors' conclusions Eplerenone 50 to 200 mg/day lowers blood pressure in people with primary hypertension by 9.21 mmHg systolic and 4.18 mmHg diastolic compared to placebo, with no difference of effect between doses of 50 mg/day to 200 mg/day. A dose of 25 mg/day did not produce a statistically significant reduction in systolic or diastolic blood pressure and there is insufficient evidence for doses above 200 mg/day. There is currently no available evidence to determine the effect of eplerenone on clinically meaningful outcomes such as mortality or morbidity in hypertensive patients. The evidence available on side effects is insufficient and of low quality, which makes it impossible to draw conclusions about potential harm associated with eplerenone treatment in hypertensive patients. Plain language summary Eplerenone for high blood pressure Review question The aim of this review was to determine the effectiveness of eplerenone for reducing blood pressure, its side effect profile, and its impact on clinically meaningful outcomes such as mortality and morbidity. Background Clinicians have used eplerenone to treat high blood pressure since 2002. It is important to determine the clinical impact of all antihypertensive medications used in patients to support their continued use in essential hypertension. We searched multiple databases and found five eligible studies in 1437 people who received either eplerenone or no medication in a random fashion. Study characteristics The doses of eplerenone used in these studies ranged from 25 mg to 400 mg daily. These studies followed patients for 8 to 16 weeks while on therapy. None of the studies reported on the clinically meaningful outcomes of eplerenone, such as whether eplerenone can reduce heart attacks, stroke, or death compared to placebo. Only three of the five studies reported on side effects. Key results There is currently no evidence that eplerenone has a beneficial effect on life expectancy or complications rleated to hypertension (e.g. heart attack, stroke). Evidence for risk of side effects with eplerenone is limited and of poor quality; it is difficult to tell the extent of possible harm with eplerenone versus placebo. This meta‐analysis shows that eplerenone 50 to 200 mg/day reduces systolic blood pressure by approximately 9 mmHg and diastolic blood pressure by 4 mmHg compared to taking no medication. Quality of the evidence We judged the five included trials to be of moderate quality, as authors did not extensively describe portions of their methodology.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tam, TSC; Wu, MHY; Masson, SC; Tsang, MP; Stabler, SN; Kinkade, A; Tung, A; Tejani, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "18e5b03a-8ac0-4061-afc4-e0b05849b5de", "pmid": "", "title": "Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta‐analyses", "imported": false, "abstract": "Abstract - Background Tobacco smoking is the leading preventable cause of death and disease worldwide. Stopping smoking can reduce this harm and many people would like to stop. There are a number of medicines licenced to help people quit globally, and e‐cigarettes are used for this purpose in many countries. Typically treatments work by reducing cravings to smoke, thus aiding initial abstinence and preventing relapse. More information on comparative effects of these treatments is needed to inform treatment decisions and policies. Objectives To investigate the comparative benefits, harms and tolerability of different smoking cessation pharmacotherapies and e‐cigarettes, when used to help people stop smoking tobacco. Search methods We identified studies from recent updates of Cochrane Reviews investigating our interventions of interest. We updated the searches for each review using the Cochrane Tobacco Addiction Group (TAG) specialised register to 29 April 2022. Selection criteria We included randomised controlled trials (RCTs), cluster‐RCTs and factorial RCTs, which measured smoking cessation at six months or longer, recruited adults who smoked combustible cigarettes at enrolment (excluding pregnant people) and randomised them to approved pharmacotherapies and technologies used for smoking cessation worldwide (varenicline, cytisine, nortriptyline, bupropion, nicotine replacement therapy (NRT) and e‐cigarettes) versus no pharmacological intervention, placebo (control) or another approved pharmacotherapy. Studies providing co‐interventions (e.g. behavioural support) were eligible if the co‐intervention was provided equally to study arms. Data collection and analysis We followed standard Cochrane methods for screening, data extraction and risk of bias (RoB) assessment (using the RoB 1 tool). Primary outcome measures were smoking cessation at six months or longer, and the number of people reporting serious adverse events (SAEs). We also measured withdrawals due to treatment. We used Bayesian component network meta‐analyses (cNMA) to examine intervention type, delivery mode, dose, duration, timing in relation to quit day and tapering of nicotine dose, using odds ratios (OR) and 95% credibility intervals (CrIs). We calculated an effect estimate for combination NRT using an additive model. We evaluated the influence of population and study characteristics, provision of behavioural support and control arm rates using meta‐regression. We evaluated certainty using GRADE. Main results Of our 332 eligible RCTs, 319 (835 study arms, 157,179 participants) provided sufficient data to be included in our cNMA. Of these, we judged 51 to be at low risk of bias overall, 104 at high risk and 164 at unclear risk, and 118 reported pharmaceutical or e‐cigarette/tobacco industry funding. Removing studies at high risk of bias did not change our interpretation of the results. Benefits We found high‐certainty evidence that nicotine e‐cigarettes (OR 2.37, 95% CrI 1.73 to 3.24; 16 RCTs, 3828 participants), varenicline (OR 2.33, 95% CrI 2.02 to 2.68; 67 RCTs, 16,430 participants) and cytisine (OR 2.21, 95% CrI 1.66 to 2.97; 7 RCTs, 3848 participants) were associated with higher quit rates than control. In absolute terms, this might lead to an additional eight (95% CrI 4 to 13), eight (95% CrI 6 to 10) and seven additional quitters per 100 (95% CrI 4 to 12), respectively. These interventions appeared to be more effective than the other interventions apart from combination NRT (patch and a fast‐acting form of NRT), which had a lower point estimate (calculated additive effect) but overlapping 95% CrIs (OR 1.93, 95% CrI 1.61 to 2.34). There was also high‐certainty evidence that nicotine patch alone (OR 1.37, 95% CrI 1.20 to 1.56; 105 RCTs, 37,319 participants), fast‐acting NRT alone (OR 1.41, 95% CrI 1.29 to 1.55; 120 RCTs, 31,756 participants) and bupropion (OR 1.43, 95% CrI 1.26 to 1.62; 71 RCTs, 14,759 participants) were more effective than control, resulting in two (95% CrI 1 to 3), three (95% CrI 2 to 3) and three (95% CrI 2 to 4) additional quitters per 100 respectively. Nortriptyline is probably associated with higher quit rates than control (OR 1.35, 95% CrI 1.02 to 1.81; 10 RCTs, 1290 participants; moderate‐certainty evidence), resulting in two (CrI 0 to 5) additional quitters per 100. Non‐nicotine/placebo e‐cigarettes (OR 1.16, 95% CrI 0.74 to 1.80; 8 RCTs, 1094 participants; low‐certainty evidence), equating to one additional quitter (95% CrI ‐2 to 5), had point estimates favouring the intervention over control, but CrIs encompassed the potential for no difference and harm. There was low‐certainty evidence that tapering the dose of NRT prior to stopping treatment may improve effectiveness; however, 95% CrIs also incorporated the null (OR 1.14, 95% CrI 1.00 to 1.29; 111 RCTs, 33,156 participants). This might lead to an additional one quitter per 100 (95% CrI 0 to 2). Harms There were insufficient data to include nortriptyline and non‐nicotine EC in the final SAE model. Overall rates of SAEs for the remaining treatments were low (average 3%). Low‐certainty evidence did not show a clear difference in the number of people reporting SAEs for nicotine e‐cigarettes, varenicline, cytisine or NRT when compared to no pharmacotherapy/e‐cigarettes or placebo. Bupropion may slightly increase rates of SAEs, although the CrI also incorporated no difference (moderate certainty). In absolute terms bupropion may cause one more person in 100 to experience an SAE (95% CrI 0 to 2). Authors' conclusions The most effective interventions were nicotine e‐cigarettes, varenicline and cytisine (all high certainty), as well as combination NRT (additive effect, certainty not rated). There was also high‐certainty evidence for the effectiveness of nicotine patch, fast‐acting NRT and bupropion. Less certain evidence of benefit was present for nortriptyline (moderate certainty), non‐nicotine e‐cigarettes and tapering of nicotine dose (both low certainty). There was moderate‐certainty evidence that bupropion may slightly increase the frequency of SAEs, although there was also the possibility of no increased risk. There was no clear evidence that any other tested interventions increased SAEs. Overall, SAE data were sparse with very low numbers of SAEs, and so further evidence may change our interpretation and certainty. Future studies should report SAEs to strengthen certainty in this outcome. More head‐to‐head comparisons of the most effective interventions are needed, as are tests of combinations of these. Future work should unify data from behavioural and pharmacological interventions to inform approaches to combined support for smoking cessation. Plain language summary How effective are medications and e‐cigarettes for quitting smoking, and what works best? Key messages Some medicines and e‐cigarettes (handheld devices that work by heating liquid that usually contains nicotine and flavourings) can help people to quit smoking for six months or longer. E‐cigarettes, and the medicines cytisine (otherwise known as Tabex) and varenicline (otherwise known as Chantix and Champix), appear to help the most people to quit smoking, followed by using two types of nicotine replacement therapy at once (nicotine patch and another type, such as gum or lozenge). We need more evidence on possible long‐term harms of e‐cigarettes and medicines to help people quit smoking, but there were very low numbers of serious harms found. Stopping smoking Tobacco smoking is bad for people's health and stopping can lead to significant improvements. Most people would like to quit smoking and there are medicines and e‐cigarettes available to help people to do that. These medicines are called nicotine replacement therapy, cytisine, varenicline, bupropion (sometimes known as Zyban or Wellbutrin) and nortriptyline (sometimes known as Norpress). Nortriptyline is only available for quitting smoking in New Zealand, and cytisine is not available in many countries. At time of writing, there are shortages of varenicline due to a manufacturing issue. These medicines and e‐cigarettes can be provided alongside behavioural support, such as counselling. Stop smoking medications and e‐cigarettes are designed to reduce people's craving to smoke. By finding out more information on how these treatments compare to each other, we hope this review will be used to decide the best treatments to help people stop smoking. Why we did this Cochrane Review We wanted to find out: ‐ which treatments (medicines and e‐cigarettes) help people to stop smoking; ‐ how these treatments compare to each other; ‐ whether there are ways of providing these treatments that mean they are more likely to help people stop smoking (e.g. different doses or treatment lengths); ‐ whether these treatments are likely to cause serious harms; and ‐ whether certain treatments are better tolerated, as indicated by fewer people leaving a study due to treatment. What did we do? We searched for studies that looked at these treatments to help adults quit smoking. We looked for randomised controlled trials, where the treatments people received were decided at random. This type of study usually gives the most reliable evidence about the effects of treatments. We compared all treatments with each other using a method called network meta‐analysis. Search date: 29 April 2022 What we found We found 332 studies that met our criteria and 319 of these provided information that we could use in our analyses. These included 157,179 adults who smoked tobacco cigarettes. Most of the studies took place in the USA or Europe. The studies compared the effects of the stop smoking treatments listed above with: ‐ no medicine/e‐cigarettes for stopping smoking; ‐ e‐cigarettes that did not contain nicotine; ‐ placebo (a dummy medication); and ‐ other types of stop smoking medicine or e‐cigarettes. What are the main results of our review? E‐cigarettes, varenicline and cytisine were most likely to help people quit smoking. For every 100 people, 10 to 19 are likely to quit using an e‐cigarette; 12 to 16 using varenicline; and 10 to 18 using cytisine. This is compared to the 6 in 100 people likely to quit when using no medicine/e‐cigarette or placebo. People using two forms of nicotine replacement therapy at the same time, for example, a combination of nicotine patch and nicotine gum, seemed to have similar rates of quitting to people using e‐cigarettes, varenicline and cytisine. Nicotine patches alone, another form of nicotine replacement therapy alone (such as gum, lozenge) and bupropion appeared to help fewer people quit but still work better than no medicine/e‐cigarette or placebo (8, 9 and 9 people per 100, respectively). Nortriptyline appeared to result in the lowest number of people quitting smoking; for every 100 people using nortriptyline 6 to 11 are likely to quit. We are moderately confident that bupropion could rarely cause some serious health effects. The information we have for other treatments does not provide clear evidence of serious harms. For all treatments, findings suggest very few people experience serious harms when using them. How confident are we in our results? We are confident that e‐cigarettes, cytisine, varenicline, nicotine replacement therapy and bupropion help people stop smoking. We do not expect more evidence will change these results. However, more evidence on how these treatments compare to one another, particularly in relation to harms, would be useful. Due to the nature of our analyses we were not able to judge our confidence in the evidence for combination nicotine replacement therapy (two types used together). We are moderately confident that nortriptyline also helps people to stop smoking, but are less confident in our results for non‐nicotine e‐cigarettes and for potential harms of most of the treatments. We still need more evidence on potential harms and hope more studies will report on these in future; however, nicotine replacement therapy has been used since the 1980s with no evidence of serious harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lindson, N; Theodoulou, A; Ordóñez-Mena, JM; Fanshawe, TR; Sutton, AJ; Livingstone-Banks, J; Hajizadeh, A; Zhu, S; Aveyard, P; Freeman, SC; Agrawal, S; Hartmann-Boyce, J", "articleTypes": [], "doi": "10.1002/14651858.CD015226.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "18e6b234-cf33-45d7-b1e4-399a80be70eb", "pmid": "", "title": "Interventions for protecting renal function in the perioperative period", "imported": false, "abstract": "Abstract - Background Various methods have been used to try to protect kidney function in patients undergoing surgery. These most often include pharmacological interventions such as dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants and erythropoietin (EPO). Objectives This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period. We considered the following questions: (1) Are any specific measures known to protect kidney function during the perioperative period? (2) Of measures used to protect the kidneys during the perioperative period, does any one method appear to be more effective than the others? (3) Of measures used to protect the kidneys during the perioperative period,does any one method appear to be safer than the others? Search methods In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 2, 2012), MEDLINE (Ovid SP) (1966 to August 2012) and EMBASE (Ovid SP) (1988 to August 2012). We originally handsearched six journals ( Anesthesia and Analgesi a, Anesthesiology , Annals of Surgery , British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery) (1985 to 2004). However, because these journals are properly indexed in MEDLINE, we decided to rely on electronic searches only without handsearching the journals from 2004 onwards. Selection criteria We selected all randomized controlled trials in adults undergoing surgery for which a treatment measure was used for the purpose of providing renal protection during the perioperative period. Data collection and analysis We selected 72 studies for inclusion in this review. Two review authors extracted data from all selected studies and entered them into RevMan 5.1; then the data were appropriately analysed. We performed subgroup analyses for type of intervention, type of surgical procedure and pre‐existing renal dysfunction. We undertook sensitivity analyses for studies with high and moderately good methodological quality. Main results The updated review included data from 72 studies, comprising a total of 4378 participants. Of these, 2291 received some form of treatment and 2087 acted as controls. The interventions consisted most often of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, NAC, ANP, sodium bicarbonate, antioxidants and EPO or selected hydration fluids. Some clinical heterogeneity and varying risk of bias were noted amongst the studies, although we were able to meaningfully interpret the data. Results showed significant heterogeneity and indicated that most interventions provided no benefit. Data on perioperative mortality were reported in 41 studies and data on acute renal injury in 44 studies (all interventions combined). Because of considerable clinical heterogeneity (different clinical scenarios, as well as considerable methodological variability amongst the studies), we did not perform a meta‐analysis on the combined data. Subgroup analysis of major interventions and surgical procedures showed no significant influence of interventions on reported mortality and acute renal injury. For the subgroup of participants who had pre‐existing renal damage, the risk of mortality from 10 trials (959 participants) was estimated as odds ratio (OR) 0.76, 95% confidence interval (CI) 0.38 to 1.52; the risk of acute renal injury (as reported in the trials) was estimated from 11 trials (979 participants) as OR 0.43, 95% CI 0.23 to 0.80. Subgroup analysis of studies that were rated as having low risk of bias revealed that 19 studies reported mortality numbers (1604 participants); OR was 1.01, 95% CI 0.54 to 1.90. Fifteen studies reported data on acute renal injury (criteria chosen by the individual studies; 1600 participants); OR was 1.03, 95% CI 0.54 to 1.97. Authors' conclusions No reliable evidence from the available literature suggests that interventions during surgery can protect the kidneys from damage. However, the criteria used to diagnose acute renal damage varied in many of the older studies selected for inclusion in this review, many of which suffered from poor methodological quality such as insufficient participant numbers and poor definitions of end points such as acute renal failure and acute renal injury. Recent methods of detecting renal damage such as the use of specific biomarkers and better defined criteria for identifying renal damage (RIFLE (risk, injury, failure, loss of kidney function and end‐stage renal failure) or AKI (acute kidney injury)) may have to be explored further to determine any possible benefit derived from interventions used to protect the kidneys during the perioperative period. Plain language summary No evidence indicates that any of the measures used to protect patients' kidneys during the perioperative period are beneficial The kidneys may be damaged during an operation as a result of direct and indirect insult. The reasons for this are multiple and include changes to physiology brought on by the surgery and by the body’s response to such insult. Damage to kidneys during the perioperative period is associated with significant morbidity and mortality. This updated Cochrane review looked at 72 randomized controlled trials (RCTs) with 4378 participants (search data until August 2012); interventions most often included pharmacological interventions (administration of dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine, atrial natriuretic peptide, sodium bicarbonate, antioxidants and erythropoietin) or selected hydration fluids. We attempted to identify any possible damage to the kidneys by evaluating kidney function up to seven days after the operation. No clear evidence from available RCTs suggests that any of the measures used to protect the kidneys during the perioperative period are beneficial. These findings held true in 14 studies of patients with pre‐existing renal damage and in 24 studies that were considered of good methodological quality. The primary outcomes of these studies were mortality and acute renal injury. Reported mortality in studies with low risk of bias was not different between intervention and control groups (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.52 to 1.97) or for acute renal injury (OR 1.05, 95% CI 0.55 to 2.03). The summary of findings revealed a similar picture. So we conclude that evidence suggests that none of the interventions used currently are helpful in protecting the kidneys during the perioperative period, nor do they cause increased harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zacharias, M; Mugawar, M; Herbison, GP; Walker, RJ; Hovhannisyan, K; Sivalingam, P; Conlon, NP", "articleTypes": [], "doi": "10.1002/14651858.CD003590.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "18f62056-4a45-4ee5-8dd9-95427e19aa0a", "pmid": "", "title": "Statins for children with familial hypercholesterolemia", "imported": false, "abstract": "Abstract - Background Familial hypercholesterolemia is one of the most common inherited metabolic diseases and is an autosomal dominant disorder meaning heterozygotes, or carriers, are affected. Those who are homozygous have severe disease. The average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500, although recent genetic epidemiological data from Denmark and next generation sequencing data suggest the frequency may be closer to 1 in 250. Diagnosis of familial hypercholesterolemia in children is based on elevated total cholesterol and low‐density lipoprotein cholesterol levels or DNA‐based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong treatment, started in childhood, is needed to reduce the risk of cardiovascular disease. In children with the disease, diet was the cornerstone of treatment but the addition of lipid‐lowering medications has resulted in a significant improvement in treatment. Anion exchange resins, such as cholestyramine and colestipol, were found to be effective, but they are poorly tolerated. Since the 1990s studies carried out on children aged 6 to 17 years with heterozygous familial hypercholesterolemia have demonstrated significant reductions in their serum total and low‐density lipoprotein cholesterol levels. While statins seem to be safe and well‐tolerated in children, their long‐term safety in this age group is not firmly established. This is an update of a previously published version of this Cochane Review. Objectives To assess the effectiveness and safety of statins in children with heterozygous familial hypercholesterolemia. Search methods Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline. Date of most recent search: 04 November 2019. Selection criteria Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. Data collection and analysis Two authors independently assessed studies for inclusion and extracted data. Main results We found 26 potentially eligible studies, of which we included nine randomized placebo‐controlled studies (1177 participants). In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). There may be little or no difference in liver function (serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations) between treated and placebo groups at any time point (low‐quality evidence). There may be little or no difference in myopathy (as measured in change in creatinine levels) (low‐quality evidence) or clinical adverse events (moderate‐quality evidence) with statins compared to placebo. One study on simvastatin showed that this may slightly improve flow‐mediated dilatation of the brachial artery (low‐quality evidence), and on pravastatin for two years may have induced a regression in carotid intima media thickness (low‐quality evidence). No studies reported rhabdomyolysis (degeneration of skeletal muscle tissue) or death due to rhabdomyolysis, quality of life or compliance to study medication. Authors' conclusions Statin treatment is an effective lipid‐lowering therapy in children with familial hypercholesterolemia. Few or no safety issues were identified. Statin treatment seems to be safe in the short term, but long‐term safety remains unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians and their care transferred to an adult lipidologist once they reach 18 years of age. Large long‐term randomized controlled trials are needed to establish the long‐term safety issues of statins. Plain language summary Statins for children with inherited high blood cholesterol Review question We reviewed the evidence for the effectiveness and safety of statins in children with inherited high blood cholesterol. Background Familial hypercholesterolemia is an inherited disease in which the blood cholesterol level is high. Vascular disease, i.e. furring up of the blood vessels, often occurs at an earlier age than usual, especially amongst men. Thus lifelong therapies, started in childhood, to reduce blood cholesterol are needed. In children with familial hypercholesterolemia, diet has been the main treatment option. Medications, such as cholestyramine and colestipol, have been used effectively, but due to their unpleasant taste they are poorly tolerated and treatment plans are not followed. The advent of statin therapy for children has improved treatment and this review updates the previous published version. Search date The evidence is current to: 04 November 2019. Study characteristics The review included 9 studies with 1177 people with heterozygous familial hypercholesterolemia aged between 4 and 18 years of age. Studies compared different statin treatments with a substance which contains no medication (termed placebo) and people were selected for one treatment or the other randomly. The studies lasted from 12 weeks to 104 weeks. Key results In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins probably reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). The levels of the liver enzymes, serum aspartate and alanine aminotransferase, and the muscle enzyme, creatinine kinase, did not differ between treated and placebo groups at any time point (low‐quality evidence). The risks of myopathy (disease of muscle tissue) and side‐effects were very low and similar in both groups (low‐quality evidence). Two of the statins, simvastatin and pravastatin may have a positive effect on two of the major blood vessels typically affected by raised cholesterol levels (low‐quality evidence). Quality of the evidence Information regarding blinding (performance bias and detection bias), was available for all nine studies; each was described as double blind, indicating that participants and those participating in treatment procedures were blinded to treatment. In two studies information on how the participants were allocated to treatment groups (selection bias) was clearly presented, but this information was not clearly stated in the remaining seven studies. There is a lack of information whether investigators knew which treatment group participants would be put into (selection bias) and or whether selective reporting (reporting bias) occurred, but it is very unlikely. In conclusion, it can be stated all the studies appeared to be well run and we do not think any of the above‐mentioned factors influenced the results in a negative way. Quality of evidence varied from high (change in serum low‐density lipoprotein (LDL) cholesterol) through moderate (adverse events) to low (change in blood vessel wall (carotid intima‐media) thickness, change in measures if growth and maturation, liver dysfunction, myopathy and change in blood wall (endothelial) function).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Vuorio, A, Kuoppala, J, Kovanen, PT, Humphries, SE, Tonstad, S, Wiegman, A, Drogari, E, Ramaswami, U", "articleTypes": [], "doi": "10.1002/14651858.CD006401.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.739Z" }, { "id": "18fd0dde-df8b-44c6-ae96-e699ad572618", "pmid": "", "title": "Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years", "imported": false, "abstract": "Abstract - Background Zinc deficiency is prevalent in low‐ and middle‐income countries, and is considered a significant risk factor for morbidity, mortality, and linear growth failure. The effectiveness of preventive zinc supplementation in reducing prevalence of zinc deficiency needs to be assessed. Objectives To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged 6 months to 12 years. Search methods A previous version of this review was published in 2014. In this update, we searched CENTRAL, MEDLINE, Embase, five other databases, and one trials register up to February 2022, together with reference checking and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) of preventive zinc supplementation in children aged 6 months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalized children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions. Data collection and analysis Two review authors screened studies, extracted data, and assessed the risk of bias. We contacted study authors for missing information and used GRADE to assess the certainty of evidence. The primary outcomes of this review were all‐cause mortality; and cause‐specific mortality, due to all‐cause diarrhea, lower respiratory tract infection (LRTI, including pneumonia), and malaria. We also collected information on a number of secondary outcomes, such as those related to diarrhea and LRTI morbidity, growth outcomes and serum levels of micronutrients, and adverse events. Main results We included 16 new studies in this review, resulting in a total of 96 RCTs with 219,584 eligible participants. The included studies were conducted in 34 countries; 87 of them in low‐ or middle‐income countries. Most of the children included in this review were under five years of age. The intervention was delivered most commonly in the form of syrup as zinc sulfate, and the most common dose was between 10 mg and 15 mg daily. The median duration of follow‐up was 26 weeks. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes was affected by risk of bias. High‐certainty evidence showed little to no difference in all‐cause mortality with preventive zinc supplementation compared to no zinc (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.84 to 1.03; 16 studies, 17 comparisons, 143,474 participants). Moderate‐certainty evidence showed that preventive zinc supplementation compared to no zinc likely results in little to no difference in mortality due to all‐cause diarrhea (RR 0.95, 95% CI 0.69 to 1.31; 4 studies, 132,321 participants); but probably reduces mortality due to LRTI (RR 0.86, 95% CI 0.64 to 1.15; 3 studies, 132,063 participants) and mortality due to malaria (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 42,818 participants); however, the confidence intervals around the summary estimates for these outcomes were wide, and we could not rule out a possibility of increased risk of mortality. Preventive zinc supplementation likely reduces the incidence of all‐cause diarrhea (RR 0.91, 95% CI 0.90 to 0.93; 39 studies, 19,468 participants; moderate‐certainty evidence) but results in little to no difference in morbidity due to LRTI (RR 1.01, 95% CI 0.95 to 1.08; 19 studies, 10,555 participants; high‐certainty evidence) compared to no zinc. There was moderate‐certainty evidence that preventive zinc supplementation likely leads to a slight increase in height (standardized mean difference (SMD) 0.12, 95% CI 0.09 to 0.14; 74 studies, 20,720 participants). Zinc supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46; 5 studies, 35,192 participants; high‐certainty evidence). We report a number of other outcomes, including the effect of zinc supplementation on weight and serum markers such as zinc, hemoglobin, iron, copper, etc. We also performed a number of subgroup analyses and there was a consistent finding for a number of outcomes that co‐supplementation of zinc with iron decreased the beneficial effect of zinc. Authors' conclusions Even though we included 16 new studies in this update, the overall conclusions of the review remain unchanged. Zinc supplementation might help prevent episodes of diarrhea and improve growth slightly, particularly in children aged 6 months to 12 years of age. The benefits of preventive zinc supplementation may outweigh the harms in regions where the risk of zinc deficiency is relatively high. Plain language summary Is zinc supplementation effective for preventing death and disease, and for promoting growth, in children aged 6 months to 12 years and does it cause unwanted effects? Key messages ‐ Zinc supplementation in children aged 6 months to 12 years makes little to no difference to all‐cause mortality and probably makes no difference to deaths from diarrea. Zinc supplementation probably reduces mortality due to lower respiratory tract infections and malaria but a small possibility of increased risk of mortality cannot be ruled out. ‐ Zinc supplementation in children aged 6 months to 12 years might prevent illness due to diarrhea, but might lead to vomiting after supplementation. It might lead to a small increase in height gain. Why is it important to study zinc supplementation? Zinc is an essential micronutrient. It is important to help children grow normally and to promote a healthy immune system. Lack of zinc may lead to diarrhea, pneumonia, malaria and even death. Low dietary zinc intake is often linked to poverty. As many as half of all children in low‐ and middle‐income countries may have zinc deficiency. Meat, fish, eggs and dairy products are good natural sources of zinc, but are expensive. Lack of clean water and poor sanitation increases exposure to diseases, which zinc might help to fight. The human body cannot produce or store zinc, so giving dietary supplements is important. What did we want to find out? We wanted to find out if giving children zinc supplements helps prevent child death and disease, and promotes growth. What did we do? We searched for studies that randomly assigned children aged 6 months to 12 years to receive zinc supplementation or no zinc. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 96 studies in the review, with 219,584 children. Studies took place in 34, mainly low‐ to middle‐income countries. Most of the children in the studies were under five years old. Zinc was most commonly given as a syrup (zinc sulfate), and the most common dose was between 10 mg and 15 mg daily. We found that giving children zinc supplementation might lead to a small to no reduction in the risk of death for any reason and the risk of death due to diarrhea. The risk of death due to lower respiratory tract infections or malaria may be reduced. Children given zinc experienced less disease due to diarrhea than children not given zinc; however, zinc does not seem to reduce children's risk of respiratory infection. Zinc supplementation may have a small positive effect on growth. Children who take zinc supplementation may experience vomiting as an unwanted effect. What are the limitations of the evidence? We are confident about our results on the effects of zinc supplements on reducing the risk of death due to any cause, illness due to respiratory infection, and occurrence of vomiting after supplementation. Our confidence in the results for our other outcomes was moderate because relatively few studies reported these outcomes and because studies sometimes reported different results from other studies for the same outcomes. How up to date is this evidence? This review updates a previous version published in 2014. The evidence is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Imdad, A; Rogner, J; Sherwani, RN; Sidhu, J; Regan, A; Haykal, MR; Tsistinas, O; Smith, A; Chan, XHS; Mayo-Wilson, E; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD009384.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "1910b4c9-971e-42e8-8663-875ce0ee8b6f", "pmid": "", "title": "Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)", "imported": false, "abstract": "Abstract - Background Idiopathic acute vestibular dysfunction (vestibular neuritis) is the second most common cause of peripheral vertigo after benign paroxysmal positional vertigo (BPPV) and accounts for 7% of the patients who present at outpatient clinics specialising in the treatment of dizziness. The exact aetiology of the condition is unknown and the effects of corticosteroids on the condition and its recovery are uncertain. Objectives To assess the effectiveness of corticosteroids in the management of patients with idiopathic acute vestibular dysfunction (vestibular neuritis). Search methods We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 28 December 2010. Selection criteria Randomised controlled trials comparing corticosteroids with placebo, no treatment or other active treatments, for adults diagnosed with idiopathic acute vestibular dysfunction. Data collection and analysis Two authors independently selected studies from the search results and extracted data. Three authors independently assessed risk of bias. Main results Four trials, involving a total of 149 participants, compared the effectiveness of oral corticosteroids against placebo. All the trials were small and of low methodological quality. Although there was an overall significant effect of corticosteroids compared with placebo medication on complete caloric recovery at one month (risk ratio (RR) of 2.81; 95% confidence interval (CI) 1.32 to 6.00, P = 0.007), no significant effect was seen on complete caloric recovery at 12 months (RR 1.58; 95% CI 0.45 to 5.62, P = 0.48), or on the extent of caloric recovery at either one month (mean difference (MD) 9.60%; 95% CI ‐20.66 to 39.86, P = 0.53) or at 12 months (MD 6.83%; 95% CI ‐27.69 to 41.36, P = 0.70). In addition, there was no significant difference between corticosteroids and placebo medication in the symptomatic recovery of vestibular function following idiopathic acute vestibular dysfunction with respect to vertigo at 24 hours (RR 0.39; 95% CI 0.04 to 3.57, P = 0.40) and use of the Dizziness Handicap Inventory score at one, three, six and 12 months. Authors' conclusions Overall, there is currently insufficient evidence from these trials to support the administration of corticosteroids to patients with idiopathic acute vestibular dysfunction. We found no trials with a low risk of methodological bias that used the highest level of diagnostic criteria and outcome measures. We recommend that future studies should include health‐related quality of life and symptom‐based outcome measures, in addition to objective measures of vestibular improvement, such as caloric testing and electronystagmography. Plain language summary Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis) Idiopathic acute vestibular dysfunction (vestibular neuritis) is a common condition of unknown cause. Patients with the condition often experience dizziness, nausea or vomiting, and trouble with vision, balance or mobility, but have normal hearing and no tinnitus. It has been proposed that a course of corticosteroids, if given early on, may improve recovery from the condition and long‐term patient outcome. However, corticosteroids can cause adverse effects (e.g. bleeding stomach ulcer, mood changes, etc.). This review identified four randomised controlled trials including 149 adult patients with idiopathic acute vestibular dysfunction (vestibular neuritis) treated with either corticosteroids or placebo. The studies were varied in that they used different drugs and different treatment regimens. On the basis of these studies, there is currently insufficient evidence in favour of corticosteroids over placebo medication in the symptomatic recovery and objective testing of vestibular function, both in the short‐term and long‐term. Further studies of higher quality are needed to test the effectiveness of corticosteroids in patients with the condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fishman, JM; Burgess, C; Waddell, A", "articleTypes": [], "doi": "10.1002/14651858.CD008607.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "1925e5c1-2f3f-45c6-a8b8-d92e23993abf", "pmid": "", "title": "Definitive Radiochemotherapy With 5-FU / Cisplatin Plus/Minus Cetuximab in Unresectable Locally Advanced Esophageal Cancer: a Phase II Study", "imported": false, "abstract": "Esophageal cancer is a highly aggressive tumor. Treatment options are various and range from chemotherapy to radiotherapy and several surgical techniques. Nevertheless, the overall survival rates for this disease remain poor.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.269Z" }, { "id": "192840bb-5f9f-42ff-a64e-a4bbd7f29282", "pmid": "", "title": "Using Bitter Taste Receptor Blockers to Improve the Palatability of Pediatric Medicines: Trained Human Sensory Panels", "imported": false, "abstract": "Many people, particularly small children, must take drugs in liquid form because they cannot swallow pills or capsules. The bad taste of some liquid drugs can keep patients from taking drugs they need for their health. Our main goal in this research study is find ingredients that might make drugs taste better.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "1950f45b-33b7-4a8e-a7a1-06b3a12ca8e3", "pmid": "", "title": "Longitudinal Observation of Clinical and Immunological Profiles After SARS-Cov-2 Infection", "imported": false, "abstract": "There are very few long-term studies that analyze the immune responses in patients recovered from COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.245Z" }, { "id": "1956a44d-5c05-49df-bfdb-ec2318b797cb", "pmid": "", "title": "Universal screening for SARS‐CoV‐2 infection: a rapid review", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Viswanathan, M, Kahwati, L, Jahn, B, Giger, K, Dobrescu, AI, Hill, C, Klerings, I, Meixner, J, Persad, E, Teufer, B, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013718 AB - Abstract - Background Coronavirus disease 2019 (COVID‐19) is caused by the novel betacoronavirus, severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2). Most people infected with SARS‐CoV‐2 have mild disease with unspecific symptoms, but about 5% become critically ill with respiratory failure, septic shock and multiple organ failure. An unknown proportion of infected individuals never experience COVID‐19 symptoms although they are infectious, that is, they remain asymptomatic. Those who develop the disease, go through a presymptomatic period during which they are infectious. Universal screening for SARS‐CoV‐2 infections to detect individuals who are infected before they present clinically, could therefore be an important measure to contain the spread of the disease. Objectives We conducted a rapid review to assess (1) the effectiveness of universal screening for SARS‐CoV‐2 infection compared with no screening and (2) the accuracy of universal screening in people who have not presented to clinical care for symptoms of COVID‐19. Search methods An information specialist searched Ovid MEDLINE and the Centers for Disease Control (CDC) COVID‐19 Research Articles Downloadable Database up to 26 May 2020. We searched Embase.com, the CENTRAL, and the Cochrane Covid‐19 Study Register on 14 April 2020. We searched LitCovid to 4 April 2020. The World Health Organization (WHO) provided records from daily searches in Chinese databases and in PubMed up to 15 April 2020. We also searched three model repositories (Covid‐Analytics, Models of Infectious Disease Agent Study [MIDAS], and Society for Medical Decision Making) on 8 April 2020. Selection criteria Trials, observational studies, or mathematical modelling studies assessing screening effectiveness or screening accuracy among general populations in which the prevalence of SARS‐CoV2 is unknown. Data collection and analysis After pilot testing review forms, one review author screened titles and abstracts. Two review authors independently screened the full text of studies and resolved any disagreements by discussion with a third review author. Abstracts excluded by a first review author were dually reviewed by a second review author prior to exclusion. One review author independently extracted data, which was checked by a second review author for completeness and accuracy. Two review authors independently rated the quality of included studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool for diagnostic accuracy studies and a modified form designed originally for economic evaluations for modelling studies. We resolved differences by consensus. We synthesized the evidence in narrative and tabular formats. We rated the certainty of evidence for days to outbreak, transmission, cases missed and detected, diagnostic accuracy (i.e. true positives, false positives, true negatives, false negatives) using the GRADE approach. Main results We included 22 publications. Two modelling studies reported on effectiveness of universal screening. Twenty studies (17 cohort studies and 3 modelling studies) reported on screening test accuracy. Effectiveness of screening We included two modelling studies. One study suggests that symptom screening at travel hubs, such as airports, may slightly slow but not stop the importation of infected cases (assuming 10 or 100 infected travellers per week reduced the delay in a local outbreak to 8 days or 1 day, respectively). We assessed risk of bias as minor or no concerns, and certainty of evidence was low, downgraded for very serious indirectness. The second modelling study provides very low‐certainty evidence that screening of healthcare workers in emergency departments using laboratory tests may reduce transmission to patients and other healthcare workers (assuming a transmission constant of 1.2 new infections per 10,000 people, weekly screening reduced infections by 5.1% within 30 days). The certainty of evidence was very low, downgraded for high risk of bias (major concerns) and indirectness. No modelling studies reported on harms of screening. Screening test accuracy All 17 cohort studies compared an index screening strategy to a reference reverse transcriptase polymerase chain reaction (RT‐PCR) test. All but one study reported on the accuracy of single point‐in‐time screening and varied widely in prevalence of SARS‐CoV‐2, settings, and methods of measurement. We assessed the overall risk of bias as unclear in 16 out of 17 studies, mainly due to limited information on the index test and reference standard. We rated one study as being at high risk of bias due to the inclusion of two separate populations with likely different prevalences. For several screening strategies, the estimates of sensitivity came from small samples. For single point‐in‐time strategies, for symptom assessment, the sensitivity from 12 cohorts (524 people) ranged from 0.00 to 0.60 (very low‐certainty evidence) and the specificity from 12 cohorts (16,165 people) ranged from 0.66 to 1.00 (low‐certainty evidence). For screening using direct temperature measurement (3 cohorts, 822 people), international travel history (2 cohorts, 13,080 people), or exposure to known infected people (3 cohorts, 13,205 people) or suspected infected people (2 cohorts, 954 people), sensitivity ranged from 0.00 to 0.23 (very low‐ to low‐certainty evidence) and specificity ranged from 0.90 to 1.00 (low‐ to moderate‐certainty evidence). For symptom assessment plus direct temperature measurement (2 cohorts, 779 people), sensitivity ranged from 0.12 to 0.69 (very low‐certainty evidence) and specificity from 0.90 to 1.00 (low‐certainty evidence). For rapid PCR test (1 cohort, 21 people), sensitivity was 0.80 (95% confidence interval (CI) 0.44 to 0.96; very low‐certainty evidence) and specificity was 0.73 (95% CI 0.39 to 0.94; very low‐certainty evidence). One cohort (76 people) reported on repeated screening with symptom assessment and demonstrates a sensitivity of 0.44 (95% CI 0.29 to 0.59; very low‐certainty evidence) and specificity of 0.62 (95% CI 0.42 to 0.79; low‐certainty evidence). Three modelling studies evaluated the accuracy of screening at airports. The main outcomes measured were cases missed or detected by entry or exit screening, or both, at airports. One study suggests very low sensitivity at 0.30 (95% CI 0.1 to 0.53), missing 70% of infected travellers. Another study described an unrealistic scenario to achieve a 90% detection rate, requiring 0% asymptomatic infections. The final study provides very uncertain evidence due to low methodological quality. Authors' conclusions The evidence base for the effectiveness of screening comes from two mathematical modelling studies and is limited by their assumptions. Low‐certainty evidence suggests that screening at travel hubs may slightly slow the importation of infected cases. This review highlights the uncertainty and variation in accuracy of screening strategies. A high proportion of infected individuals may be missed and go on to infect others, and some healthy individuals may be falsely identified as positive, requiring confirmatory testing and potentially leading to the unnecessary isolation of these individuals. Further studies need to evaluate the utility of rapid laboratory tests, combined screening, and repeated screening. More research is also needed on reference standards with greater accuracy than RT‐PCR. Given the poor sensitivity of existing approaches, our findings point to the need for greater emphasis on other ways that may prevent transmission such as face coverings, physical distancing, quarantine, and adequate personal protective equipment for frontline workers. Plain language summary How effective is screening for COVID‐19? Why does screening matter? Screening aims to identify a condition in people who may not be showing any symptoms. Some people may have the COVID‐19 virus but appear healthy or have only mild symptoms. It is important to identify infected people so they can stay away from others and seek appropriate care. Incorrectly identifying COVID‐19 in healthy people could lead to unnecessary self‐isolation and further tests. Incorrectly identifying no infection in infected people could spread the virus. Screening for COVID‐19 can include temperature checks, or asking about international travel or contact with COVID‐19 cases, or rapid tests. Screening can occur over the telephone, online, or in person, in homes, clinics, workplaces, airports or schools. What did the review study? We wanted to identify: · the benefits and negative effects of screening apparently healthy people for COVID‐19 infection; · whether screening can identify those with and without the virus correctly. To answer these questions rapidly, we shortened some steps of the normal Cochrane Review process. We are confident these changes do not affect our overall conclusions. What did we do? We looked for studies that screened people who had not sought care for potential COVID‐19 symptoms. This review includes evidence up to May 2020. Key results We found 22 studies; 17 assessed people (cohort studies) and five were computer‐generated models (modelling studies). Studies took place in USA, Europe, and Asia. Benefits and negative effects 
Two modelling studies reported on the benefits and negative effects of screening. One suggested that asking about symptoms at airports may slightly slow, but not stop, the importation of infected people. Another model reported that weekly or biweekly screening of healthcare workers may reduce transmission to patients and other healthcare workers in emergency departments. No studies reported on negative effects of screening. Identification of infected people 
Seventeen cohort studies and three modelling studies reported on whether screening can correctly identify those with and without the virus. Studies varied widely in the baseline level of COVID‐19, settings, and methods. All cohort studies compared screening strategies to a ‘gold standard’ test called RT‐PCR. Cohort studies
All screening strategies (17 studies, 17,574 people), incorrectly identified: · between 20 and 100 out of 100 infected people as healthy; · between 0 and 38 people out of 100 healthy people as infected Asking about symptoms (13 studies, 16,762 people ), incorrectly identified: · between 40 to 100 out of 100 infected people as healthy · between 0 to 34 out of 100 healthy people as infected Temperature measurements , asking about international travel , exposure to known infected people and exposure to known or suspected infected people (6 studies, 14,741 people), incorrectly identified : · between 77 and 100 out of 100 infected people as healthy · between 0 and 10 out of 100 healthy people as infected Asking about symptoms plus temperature measurement (2 studies, 779 people), incorrectly identified: · between 31 and 88 out of 100 infected people as healthy · between 0 to 10 people out of 100 healthy people as infected There was insufficient evidence from two small studies on rapid laboratory tests and repeated symptom assessment to tell how accurate they were in identifying healthy and infected people. Modelling studies 
Three studies modelled entry and exit screening in airports. One study missed 70% of infected travellers. Another detected 90% of infections, but used an unrealistic scenario. The third used very unreliable methods so we cannot use evidence from this study. How confident are we in the results of the studies? Our confidence in these findings is limited because most studies did not describe their screening methods clearly, some found very few cases of infections and the types of participants and settings varied greatly, making it difficult to judge whether the results apply broadly. Authors’ conclusions One‐time screening in apparently healthy people is likely to miss people who are infected. We are unsure whether combined screenings, repeated symptom assessment, or rapid laboratory tests are useful. As more people become infected, screening will identify more cases. However, because screening can miss people who are infected, public health measures such as face coverings, physical distancing, and quarantine for those who are apparently healthy, continue to be very important.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.734Z" }, { "id": "195d604f-1e34-4577-ad00-67f2596866ea", "pmid": "", "title": "Safety, Pharmacokinetics, and Preliminary Efficacy of Tafenoquine for the Treatment of Vivax Malaria in Papua New Guinean Children", "imported": false, "abstract": "Plasmodium vivax is the most geographically widespread malaria species and the second largest contributor to symptomatic malaria worldwide. It accounts for half of all malaria cases outside Africa, with an estimated 14.3 million clinical vivax malaria cases reported annually, contributing to an annual cost of US$359 million. Children are most vulnerable to infection, with P. vivax prevalence peaking between 2 to 6 years of age. In Papua New Guinea (PNG), there are >1.5 million suspected P. vivax cases annually, and while P. falciparum infections are the most prevalent, P. vivax transmission is the most intense in the world. P. vivax in PNG provides a unique epidemiological setting in which to assess innovative treatments in children.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.261Z" }, { "id": "19692548-0fc1-419c-a390-5df5d0d700a4", "pmid": "", "title": "Rinse‐free hand wash for reducing absenteeism among preschool and school children", "imported": false, "abstract": "Abstract - Background Illness‐related absenteeism is an important problem among preschool and school children for low‐, middle‐ and high‐ income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse‐free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness‐related absenteeism in preschool and school children. Objectives 1. To assess the effectiveness of rinse‐free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse‐free hand washing products are the most effective (if head‐to‐head comparisons exist), and what effect additional strategies in combination with rinse‐free hand washing have on the outcomes of interest. Search methods In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied. Selection criteria Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse‐free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions. Data collection and analysis Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings. Main results This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most‐notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse‐free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low‐certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse‐free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse‐free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low‐certainty evidence), which indicates rinse‐free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse‐free' group (eight days absent per 1000). There may be little to no difference between rinse‐free hand washing and 'no rinse‐free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low‐certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very‐low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse‐free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very‐low certainty evidence). Authors' conclusions The findings of this review may have identified a small yet potentially beneficial effect of rinse‐free hand washing regimes on illness‐related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse‐free hand washing regimens in order to provide more conclusive, higher‐certainty evidence regarding its impact. When considering the use of a rinse‐free hand washing program in a local setting, there needs to be consideration of the current rates of illness‐related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings. Plain language summary Rinse‐free hand wash for reducing absenteeism among preschool and school children Background Absenteeism from schooling is costly to parents, schools and governments and sustained absence is detrimental to student learning. Illness‐related absenteeism is a significant contributor to absenteeism from school, but can also result in parents missing work due to catching the illness themselves or having to stay home to care for their children. There are several strategies currently used to reduce illness‐related absenteeism, a common method is the implementation of appropriate hand hygiene practices. However, hand hygiene using soap and water is not always practical, and alternatives may prove to be more effective in reducing the overall rate of illness‐related absenteeism. One such alternative is the use of rinse‐free hand wash. Review question This review was designed to investigate if the use of rinse‐free hand wash can reduce the number of days spent absent from school in preschool and school children compared to no rinse‐free hand wash usage. Study characteristics The searches returned 19 relevant studies with a total of 30,747 participants. Eight studies were conducted in the USA, two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to14 years). These studies were quite varied in the composition and application of the rinse‐free hand washing program. Only two studies included information on the primary outcome (absenteeism due to any reason), whilst for absenteeism for any illness there were six studies that provided information. The evidence presented is up to date to February 2020. Key results The application of, and adherence to a rinse‐free hand wash, hand hygiene program may be associated with small, but potentially beneficial effects in reducing the number of days students were absent from school due to illness compared to no rinse‐free hand wash, hygiene program. However rinse‐free hand washing may be no different to controls at reducing absenteeism for any reason. There may also be no difference in the number of skin irritations between students who received the rinse‐free hand wash compared to those who used soap and water. Most students and teachers responded favorably to using rinse‐free hand wash and complied relatively well with its use. Certainty of the evidence The certainty of the evidence included in this review was low or very low, mainly due to the included studies using poor methods, providing imprecise data, and being very inconsistent from one another. This means that we have low and very‐low certainty, or confidence, in these results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Munn, Z; Tufanaru, C; Lockwood, C; Stern, C; McAneney, H; Barker, TH", "articleTypes": [], "doi": "10.1002/14651858.CD012566.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "196fa4a2-715f-4172-b215-659a48dd4214", "pmid": "", "title": "Interventions for managing taste disturbances", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kumbargere Nagraj, S, George, RP, Shetty, N, Levenson, D, Ferraiolo, DM, Shrestha, A", "articleTypes": [], "doi": "10.1002/14651858.CD010470.pub3 AB - Abstract - Background The sense of taste is very much essential to the overall health of an individual. It is a necessary component to enjoy one's food, which in turn provides nutrition to an individual. Any disturbance in taste perception can hamper quality of life in such patients by influencing their appetite, body weight and psychological well‐being. Taste disorders have been treated using different modalities of treatment and there is no consensus for the best intervention. Hence this Cochrane Review was undertaken. This is an update of the Cochrane Review first published in November 2014. Objectives To assess the effects of interventions for the management of patients with taste disturbances. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 4 July 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017 Issue 6) in the Cochrane Library (searched 4 July 2017); MEDLINE Ovid (1946 to 4 July 2017); Embase Ovid (1980 to 4 July 2017); CINAHL EBSCO (1937 to 4 July 2017); and AMED Ovid (1985 to 4 July 2017). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for trials. Abstracts from scientific meetings and conferences were searched on 25 September 2017. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included all randomised controlled trials (RCTs) comparing any pharmacological agent with a control intervention or any non‐pharmacological agent with a control intervention. We also included cross‐over trials in the review. Data collection and analysis Two pairs of review authors independently, and in duplicate, assessed the quality of trials and extracted data. Wherever possible, we contacted trial authors for additional information. We collected adverse events information from the trials. Main results We included 10 trials (581 participants), nine of which we were able to include in the quantitative analyses (566 participants). We assessed three trials (30%) as having a low risk of bias, four trials (40%) at high risk of bias and three trials (30%) as having an unclear risk of bias. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Of these, nine trials with 544 people compared zinc supplements to placebo for patients with taste disorders. The participants in two trials were children and adolescents with respective mean ages of 10 and 11.2 years and the other seven trials had adult participants. Out of these nine, two trials assessed the patient‐reported outcome for improvement in taste acuity using zinc supplements (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.94 to 2.09; 119 participants, very low‐quality evidence). We meta‐analysed for taste acuity improvement using objective outcome (continuous data) in idiopathic and zinc‐deficient taste disorder patients (standardised mean difference (SMD) 0.44, 95% CI 0.23 to 0.65; 366 participants, three trials, very low‐quality evidence). We also analysed one cross‐over trial separately using the first half of the results for taste detection (mean difference (MD) 2.50, 95% CI 0.93 to 4.07; 14 participants, very low‐quality evidence), and taste recognition (MD 3.00, 95% CI 0.66 to 5.34; 14 participants, very low‐quality evidence). We meta‐analysed taste acuity improvement using objective outcome (dichotomous data) in idiopathic and zinc‐deficient taste disorder patients (RR 1.42, 95% 1.09 to 1.84; 292 participants, two trials, very low‐quality evidence). Out of the nine trials using zinc supplementation, four reported adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase, and minor increase in blood triglycerides. One trial tested taste discrimination using acupuncture (MD 2.80, 95% CI ‐1.18 to 6.78; 37 participants, very low‐quality evidence). No adverse events were reported in the acupuncture trial. None of the included trials could be included in the meta‐analysis for health‐related quality of life in taste disorder patients. Authors' conclusions We found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders. We did not find any evidence to conclude the role of zinc supplements for improving taste discrimination, or any evidence addressing health‐related quality of life due to taste disorders. We found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste). We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. Plain language summary Interventions for managing taste disturbances What is the aim of this review? The aim of this Cochrane Review was to find out what is the best method for the management of zinc‐deficient/idiopathic (of unknown cause) taste disorders and taste disorders secondary to chronic renal failure in children and adults. Key messages Giving zinc supplements or acupuncture may have some benefit in treating taste disorders. However, we still need more high‐quality studies to ascertain the role of zinc supplements and acupuncture in treating taste disorders. What was studied in the review? The sense of taste is essential to the health and psychological well‐being of an individual. Taste disorders can range from lack of taste, to distortion of taste, to reduced ability to taste. Any disorder in taste perception can lead to conditions like malnutrition and consumption of poisonous food substances. The cause may be due to disease, drugs, radiation treatment, or ageing; or it may result from unknown causes. Various treatment methods have been used to improve taste sensation. These include the use of zinc compounds, pilocarpine, alpha lipoic acid, transcranial magnetic stimulation, ginkgo biloba and acupuncture. What are the main results of the review? We collected and analysed all relevant studies to answer this question and found 10 trials in which a total of 581 subjects received different treatments. Nine trials assessed the benefits of zinc compounds and one trial assessed the effects of acupuncture. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Two trials were from Germany, three from Japan, two from the UK, and three from the US. These studies compared zinc with placebo or acupuncture with sham procedure for patients with taste disorders. Two were government funded, three were privately funded, two were funded by a pharmaceutical company and three trials did not mention funding details. When patients with taste disorders are given zinc, compared to placebo: ‐ we found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders;
 ‐ zinc supplementation showed adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase and minor increase in blood triglycerides;
 ‐ no studies were found that looked at improvement in taste discrimination or quality of life. When patients with taste disorders are given acupuncture, compared to sham procedure: ‐ we found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste);
 ‐ acupuncture trial did not show adverse events;
 ‐ no studies were found that looked at improvement in taste acuity or quality of life. We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. How up‐to‐date is this review? We searched for studies that had been published up to 4 July 2017.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.061Z" }, { "id": "19bfd104-100b-4d1d-ac97-25fe6100fd34", "pmid": "", "title": "Eliciting adverse effects data from participants in clinical trials", "imported": false, "abstract": "Abstract - Background Analysis of drug safety in clinical trials involves assessing adverse events (AEs) individually or by aggregate statistical synthesis to provide evidence of likely adverse drug reactions (ADR). While some AEs may be ascertained from physical examinations or tests, there is great reliance on reports from participants to detect subjective symptoms, where he/she is often the only source of information. There is no consensus on how these reports should be elicited, although it is known that questioning methods influence the extent and nature of data detected. This leaves room for measurement error and undermines comparisons between studies and pooled analyses. This review investigated comparisons of methods used in trials to elicit participant‐reported AEs. This should contribute to knowledge about the methodological challenges and possible solutions for achieving better, or more consistent, AE ascertainment in trials. Objectives To systematically review the research that has compared methods used within clinical drug trials (or methods that would be specific for such trials) to elicit information about AEs defined in the protocol or in the planning for the trial. Search methods Databases (searched to March 2015 unless indicated otherwise) included: Embase; MEDLINE; MEDLINE in Process and Other Non‐Indexed Citations; Cochrane Methodology Register (July 2012); Cochrane Central Register of Controlled Trials (February 2015); Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects (January 2015); Health Technology Assessment database (January 2015); CINAHL; CAB Abstracts; BIOSIS (July 2013); Science Citation Index; Social Science Citation Index; Conference Proceedings Citation Index – Science. The search used thesaurus headings and synonyms for the following concepts: (A): Adverse events AND measurement; (B): Participants AND elicitation (also other synonyms for extraction of information about adverse effects from people); (C): Participants AND checklists (also other synonyms as for B). Pragmatic ways were used to limit the results whilst trying to maintain sensitivity. There were no date or sample size restrictions but only reports published in English were included fully, because of resource constraints as regards translation. Selection criteria Two types of studies were included: drug trials comparing two or more methods within‐ or between‐participants to elicit participant‐reported AEs, and research studies performed outside the context of a trial to compare methods which could be used in trials (evidenced by reference to such applicability). Primary outcome data included AEs elicited from participants taking part in any such clinical trial. We included any participant‐reported data relevant for an assessment of drug‐related harm, using the original authors' terminology (and definition, where available), with comment on whether the data were likely to be treatment‐emergent AEs or not. Data collection and analysis Titles and abstracts were independently reviewed for eligibility. Full texts of potentially eligible citations were independently reviewed for final eligibility. Relevant data were extracted and subjected to a 100% check. Disagreements were resolved by discussion, involving a third author. The risk of bias was independently assessed by two authors. The Cochrane 'Risk of bias' tool was used for reports comparing outcomes between participants, while for within‐participant comparisons, each study was critically evaluated in terms of potential impact of the design and conduct on findings using the framework of selection, performance, detection, attrition, reporting, and other biases. An attempt was made to contact authors to retrieve protocols or specific relevant missing information. Reports were not excluded on the basis of quality unless data for outcomes were impossible to compare (e.g. where denominators differed). A narrative synthesis was conducted because differences in study design and presentation meant that a quantitative meta‐analysis was not possible. Main results The 33 eligible studies largely compared open questions with checklist‐type questions or rating scales. Two included participant interviews. Despite different designs, populations and details of questioning methods, the narrative review showed that more specific questioning of participants led to more AEs detected compared to a more general enquiry. A subset of six studies suggested that more severe, bothersome, or otherwise clinically relevant AEs were reported when an initial open enquiry was used, while some less severe, bothersome, or clinically relevant AEs were only reported with a subsequent specific enquiry. However, two studies showed that quite severe or debilitating AEs were only detected by an interview, while other studies did not find a difference in the nature of AEs between elicitation methods. No conclusions could be made regarding the impact of question method on the ability to detect a statistically significant difference between study groups. There was no common statistical rubric, but we were able to represent some effect measures as a risk ratio of the proportion of participants with at least one AE. This showed a lower level of reporting for open questions (O) compared to checklists (CL), with a range for the risk ratios of 0.12 to 0.64. Authors' conclusions This review supports concerns that methods to elicit participant‐reported AEs influence the detection of these data. There was a risk for under‐detection of AEs in studies using a more general elicitation method compared to those using a comprehensive method. These AEs may be important from a clinical perspective or for patients. This under‐detection could compromise ability to pool AE data. However, the impact on the nature of the AE detected by different methods is unclear. The wide variety and low quality of methods to compare elicitation strategies limited this review. Future studies would be improved by using and reporting clear definitions and terminology for AEs (and other important variables), frequency and time period over which they were ascertained, how they were graded, assessed for a relationship to the study drug, coded, and tabulated/reported. While the many potential AE endpoints in a trial may preclude the development of general AE patient‐reported outcome measurement instruments, much could also be learnt from how these employ both quantitative and qualitative methods to better understand data elicited. Any chosen questioning method needs to be feasible for use by both staff and participants. Plain language summary Questioning clinical trial participants about their health in order to collect information on adverse effects of drugs Clinical drug trials or studies are usually conducted to assess how well the drug works but also whether it causes any harm (side effects or adverse effects). Adverse effects can be detected by the trial doctor examining participants or taking some blood samples or doing other kinds of tests. The trial staff can also ask participants about how they are feeling after taking the trial drug. However, the way participants are asked about their health can vary from trial to trial, or even within a trial. In some trials, participants may be asked a simple open question such as 'how have you been feeling?', while in other trials, participants may be asked about whether they have had any of a long list of possible symptoms (such as 'have you had a headache, stomach ache, or sore muscles?'). There has been concern that these different kinds of questions and how they are phrased will impact on what participants report about their health during a trial. This might then affect the trial's results and what we know about the side effects of drugs. We did this review to look at studies that compared different types of participant questioning methods in order to investigate these issues. We found 33 studies comparing mainly open questions with checklist‐type questions, but also some ratings scales and participant interviews. While the studies were all very different in terms of the types of disease, drugs, and patients studied, we found in general that, as would be expected, when a more specific type of question was asked (like a checklist), participants reported more symptoms. What is interesting is that, in those studies that looked more closely at the types of symptoms reported, it seems that an open question picks up the more severe or bothersome symptoms compared to a checklist‐type question. However, some studies found that even quite severe or bothersome symptoms were not reported when a participant is asked an open question and these severe symptoms will only be reported with the more specific question. This makes it difficult to say whether one method is better than any other and the different questioning methods may, in fact, be complementary and therefore should be used together. It is also difficult to say what a specific question should include, as it might take too long for a participant to have to answer a very long list. While more research is needed to resolve the remaining uncertainties, it is very important for trials to be clear about which kind of questioning was used when they publish their results. This will help readers understand the trial's findings about the side effects and make it easier to make accurate comparisons between trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Allen, EN, Chandler, CIR, Mandimika, N, Leisegang, C, Barnes, K", "articleTypes": [], "doi": "10.1002/14651858.MR000039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.130Z" }, { "id": "19c079a0-47a2-4e7b-9ff3-05ec3223ef72", "pmid": "", "title": "Topical benzoyl peroxide for acne", "imported": false, "abstract": "Abstract - Background Acne is a common, economically burdensome condition that can cause psychological harm and, potentially, scarring. Topical benzoyl peroxide (BPO) is a widely used acne treatment; however, its efficacy and safety have not been clearly evaluated. Objectives To assess the effects of BPO for acne. Search methods We searched the following databases up to February 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of relevant randomised controlled trials (RCTs) and systematic reviews. Selection criteria We included RCTs that compared topical BPO used alone (including different formulations and concentrations of BPO) or as part of combination treatment against placebo, no treatment, or other active topical medications for clinically diagnosed acne (used alone or in combination with other topical drugs not containing BPO) on the face or trunk. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Primary outcome measures were 'participant global self‐assessment of acne improvement' and 'withdrawal due to adverse events in the whole course of a trial'. 'Percentage of participants experiencing any adverse event in the whole course of a trial' was a key secondary outcome. Main results We included 120 trials (29,592 participants randomised in 116 trials; in four trials the number of randomised participants was unclear). Ninety‐one studies included males and females. When reported, 72 trials included participants with mild to moderate acne, 26 included participants with severe acne, and the mean age of participants ranged from 18 to 30 years. Our included trials assessed BPO as monotherapy, as add‐on treatment, or combined with other active treatments, as well as BPO of different concentrations and BPO delivered through different vehicles. Comparators included different concentrations or formulations of BPO, placebo, no treatment, or other active treatments given alone or combined. Treatment duration in 80 trials was longer than eight weeks and was only up to 12 weeks in 108 trials. Industry funded 50 trials; 63 trials did not report funding. We commonly found high or unclear risk of performance, detection, or attrition bias. Trial setting was under‐reported but included hospitals, medical centres/departments, clinics, general practices, and student health centres. We reported on outcomes assessed at the end of treatment, and we classified treatment periods as short‐term (two to four weeks), medium‐term (five to eight weeks), or long‐term (longer than eight weeks). For 'participant‐reported acne improvement', BPO may be more effective than placebo or no treatment (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.12 to 1.45; 3 RCTs; 2234 participants; treatment for 10 to 12 weeks; low‐certainty evidence). Based on low‐certainty evidence, there may be little to no difference between BPO and adapalene (RR 0.99, 95% CI 0.90 to 1.10; 5 RCTs; 1472 participants; treatment for 11 to 12 weeks) or between BPO and clindamycin (RR 0.95, 95% CI 0.68 to 1.34; 1 RCT; 240 participants; treatment for 10 weeks) (outcome not reported for BPO versus erythromycin or salicylic acid). For 'withdrawal due to adverse effects', risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment (RR 2.13, 95% CI 1.55 to 2.93; 24 RCTs; 13,744 participants; treatment for 10 to 12 weeks; low‐certainty evidence); the most common causes of withdrawal were erythema, pruritus, and skin burning. Only very low‐certainty evidence was available for the following comparisons: BPO versus adapalene (RR 1.85, 95% CI 0.94 to 3.64; 11 RCTs; 3295 participants; treatment for 11 to 24 weeks; causes of withdrawal not clear), BPO versus clindamycin (RR 1.93, 95% CI 0.90 to 4.11; 8 RCTs; 3330 participants; treatment for 10 to 12 weeks; causes of withdrawal included local hypersensitivity, pruritus, erythema, face oedema, rash, and skin burning), erythromycin (RR 1.00, 95% CI 0.07 to 15.26; 1 RCT; 60 participants; treatment for 8 weeks; withdrawal due to dermatitis), and salicylic acid (no participants had adverse event‐related withdrawal; 1 RCT; 59 participants; treatment for 12 weeks). There may be little to no difference between these groups in terms of withdrawal; however, we are unsure of the results because the evidence is of very low certainty. For 'proportion of participants experiencing any adverse event', very low‐certainty evidence leaves us uncertain about whether BPO increased adverse events when compared with placebo or no treatment (RR 1.40, 95% CI 1.15 to 1.70; 21 RCTs; 11,028 participants; treatment for 10 to 12 weeks), with adapalene (RR 0.71, 95% CI 0.50 to 1.00; 7 RCTs; 2120 participants; treatment for 11 to 24 weeks), with erythromycin (no participants reported any adverse events; 1 RCT; 89 participants; treatment for 10 weeks), or with salicylic acid (RR 4.77, 95% CI 0.24 to 93.67; 1 RCT; 41 participants; treatment for 6 weeks). Moderate‐certainty evidence shows that the risk of adverse events may be increased for BPO versus clindamycin (RR 1.24, 95% CI 0.97 to 1.58; 6 RCTs; 3018 participants; treatment for 10 to 12 weeks); however, the 95% CI indicates that BPO might make little to no difference. Most reported adverse events were mild to moderate, and local dryness, irritation, dermatitis, erythema, application site pain, and pruritus were the most common. Authors' conclusions Current evidence suggests that BPO as monotherapy or add‐on treatment may be more effective than placebo or no treatment for improving acne, and there may be little to no difference between BPO and either adapalene or clindamycin. Our key efficacy evidence is based on participant self‐assessment; trials of BPO versus erythromycin or salicylic acid did not report this outcome. For adverse effects, the evidence is very uncertain regarding BPO compared with adapalene, erythromycin, or salicylic acid. However, risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment. Withdrawal may be linked to tolerability rather than to safety. Risk of mild to moderate adverse events may be higher with BPO compared with clindamycin. Further trials should assess the comparative effects of different preparations or concentrations of BPO and combination BPO versus monotherapy. These trials should fully assess and report adverse effects and patient‐reported outcomes measured on a standardised scale. Plain language summary Topical benzoyl peroxide for acne Review question We reviewed the evidence showing effects and safety of topical benzoyl peroxide (BPO), used alone or in combination. Eligible comparisons included placebo (an identical but inactive treatment), no treatment, or other active (medical) topical medications for treating acne (used alone or in combination with other topical drugs not containing BPO) (evidence is current to February 2019). The main outcomes of interest in this review were participant‐reported acne improvement and withdrawal from the study due to any side effects. More generally, we also considered the percentage of participants experiencing any side effects over the whole course of a trial. Background As a common skin disease, acne vulgaris affects the physical, mental, and social well‐being of millions of adolescents and young adults. A wide range of treatments for acne vulgaris are available, and topical BPO has been recommended as a priority therapy to be used alone or combined with other topical or oral treatments, depending on acne severity. However, the benefits and harms of BPO have yet to be evaluated. Study characteristics We included 120 studies (which comprised 29,592 people randomised in 116 trials; in four trials the number of randomised participants was unclear). Through our search, we found studies assessing different concentrations of BPO, BPO delivered through various means, or BPO used alone or given with other treatments that may or may not be considered as the primary treatment. These studies compared treatments against different concentrations or formulations of BPO, placebo, no treatment, or other medical treatments given alone or in combination. Most of the studies included male and female participants with mild to moderate acne; only 67% of studies reported participant age, which ranged between 18 and 30 years. Participants were treated for over eight weeks in nearly two‐thirds of the trials. Industry financially supported approximately two‐fifths of the trials, and more than half of the trials did not report their funding sources. Few studies reported where they were set, but locations included hospitals, medical centres, national medical institutes, clinics, medical departments, and general practices. Key results We found low‐certainty evidence to suggest that long‐term (i.e. given for longer than eight weeks) BPO treatment may increase self‐reported treatment success compared to placebo or no BPO treatment (three studies), but there may be little to no difference when BPO treatment is compared to adapalene (five studies) or clindamycin (one study). This outcome was not reported by studies comparing BPO treatment to erythromycin or salicylic acid. Long‐term BPO may lead to an increased chance of treatment discontinuation compared to placebo or no treatment (24 studies), with the most common causes being redness, itch, and skin burning (low‐certainty evidence). When medium‐ to long‐term BPO was compared to adapalene (11 studies), clindamycin (eight studies), erythromycin (one study), or salicylic acid (one study), we found only very low‐certainty evidence, meaning that although there may be little to no difference in withdrawal between these groups, we are not sure of the results. It should be noted that participant withdrawal may be linked to issues around treatment acceptability (dermatitis, rash, facial swelling, sensitivity) rather than to safety. Very low‐certainty evidence means that we are uncertain if BPO leads to more side effects among participants receiving medium‐ to long‐term BPO than among those given no treatment/placebo (21 studies), adapalene (seven studies), erythromycin (one study), or salicylic acid (one study). Medium‐term treatment with BPO may lead to increased risk of side effects when compared against clindamycin, but the effects of this treatment vary, so the treatment chosen may make little to no difference (six studies; moderate‐certainty evidence). Side effects reported in these studies were usually mild to moderate, and the most common were local dryness, irritation, eczema, redness, pain at the site of application, and pruritus. Certainty of the evidence For our key comparisons, we rated the certainty of evidence for 'participant‐reported acne improvement' as low. For the outcomes 'withdrawal due to adverse effects' and ‘percentage of participants having any adverse events', the evidence was mainly of very low certainty. Included trials were at high or unclear risk of bias, participant numbers were small, results were not consistent across trials, and we suspected publication bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Yang, Z, Zhang, Y, Lazic Mosler, E, Hu, J, Li, H, Zhang, Y, Liu, J, Zhang, Q", "articleTypes": [], "doi": "10.1002/14651858.CD011154.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.795Z" }, { "id": "19d3c8db-1e0a-4f23-a1af-a8804d81af27", "pmid": "", "title": "Skin‐to‐skin care for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Skin‐to‐skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal‐infant contact, is one non‐pharmacological intervention for pain control in infants. Objectives The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonates The secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants. Search methods For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi‐randomized trials. Selection criteria Studies with randomisation or quasi‐randomisation, double‐ or single‐blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals. Data collection and analysis The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed‐effect model was reported for continuous outcome measures. We included variations on type of tissue‐damaging procedure, provider of care, and duration of SSC. Main results Twenty‐five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes. Seventeen studies (n = 810) compared SSC to a no‐treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of −10.78 beats per minute (95% CI −13.63 to −7.93) favouring SSC. Meta‐analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI −4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta‐analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta‐analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = −34.16, 95% CI −42.86 to −25.45), and two (n = 100) following IM injection (MD = −8.83, 95% CI −14.63 to −3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD −3.21, 95% CI −3.94 to −2.47), at 60 seconds (3 studies; n = 156) (MD −1.64, 95% CI −2.86 to −0.43), and at 90 seconds (n = 156) (MD −1.28, 95% CI −2.53 to −0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI −1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta‐analysis findings. Eight studies compared SSC to another intervention with or without a no‐treatment control. Two cross‐over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no‐treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies. Authors' conclusions SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother‐providers to others, with non‐significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long‐term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions. Plain language summary Skin‐to‐skin care with newborns cuts down procedural pain Review question: Is skin‐to‐skin care effective in cutting down pain from procedures in newborns? Are there any safety issues? Background: Newborns wearing only a diaper being held next to their mother's bare chest is referred to as skin‐to‐skin contact and is also sometimes called 'kangaroo care' because of its similarity to the way kangaroo mothers care for their young. Newborns, especially those who must spend time in a Neonatal Intensive Care Unit, must have various tests and procedures as part of their care, for example heel stick, venous puncture, and injections. Giving analgesic drugs for these procedures can often pose problems so that alternatives to drugs must be found. Study characteristics: Twenty‐eight studies in which newborn babies who were by chance in the kangaroo care group or condition were included from an extensive search of the literature. Skin‐to‐skin care was clearly defined and could have been compared to no pain‐reducing strategies or other pain‐reducing strategies such as sweet taste. Studies were examined which examined well‐established signs of pain, both physiological and behavioural, as well as a combination of physiological and behavioural signs. Different providers of skin‐to‐skin care other than the mother were included. Key results: Kangaroo care appears to reduce the pain response to, and recovery from, these frequent procedures, although few studies could be combined to provide strong evidence. As far as it has been reported, skin‐to‐skin care is safe. Although it appears that skin‐to‐skin care is effective, the size of the benefit remains uncertain. Quality of evidence: The quality of evidence in these studies was generally low for the response to the actual procedure but was moderate for recovery from the procedure.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Johnston, C; Campbell‐Yeo, M; Disher, T; Benoit, B; Fernandes, A; Streiner, D; Inglis, D; Zee, R", "articleTypes": [], "doi": "10.1002/14651858.CD008435.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "19e20a3e-f0bb-476e-86f1-b7748b6ec0a8", "pmid": "", "title": "Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease", "imported": false, "abstract": "Abstract - Background Catheter malfunction, including thrombosis, is associated with reduced dialysis adequacy, as well as an increased risk of catheter‐related bacteraemia and mortality. The role of anticoagulants in the prevention of catheter malfunction remains uncertain. Objectives This review aimed to compare the prophylactic effect of different anticoagulant agents, preparations, doses and administration on the incidence of central venous haemodialysis catheter‐related malfunction and sepsis in patients with end‐stage kidney disease (ESKD). Search methods We searched the Cochrane Renal Group's Specialised Register to 7 January 2016 through contact with the Trials' Search Co‐ordinator using search terms relevant to this review. Selection criteria We included all randomised controlled trials (RCT) assessing anticoagulants compared with conventional care for the prevention of catheter malfunction in adult patients receiving haemodialysis for ESKD. Data collection and analysis The primary outcome was catheter malfunction defined as a catheter blood flow of 200 mL/min or less, or as defined by study authors. Secondary outcomes were catheter‐related bacteraemia, all‐cause mortality and bleeding events. Relative risks (RR) with 95% confidence intervals (CI) for individual studies were pooled using random effects models within treatment classes. Analyses were conducted by class, with subgroup analyses performed of individual agents within classes. Main results We included 27 studies (3003 participants) that were followed up for a median of six months. Study interventions included alternative anticoagulant locking solutions (19 studies, 2216 patients), systemic agents (6 studies, 664 patients) and low or no dose heparin (2 studies, 123 patients). The most common comparison treatment was a locking solution of heparin 5000 IU/mL, used in 17 studies. No significant effect on catheter malfunction was observed for alternative anticoagulant locking solutions (RR 0.96, 95% CI 0.74 to 1.26), systemic agents (RR 0.59, 95% CI 0.28 to 1.23), or low or no dose heparin (RR 0.90, 95% CI 0.10 to 8.31). A significant reduction on incidence of catheter‐related bacteraemia was observed for alternative anticoagulant locking solutions (RR 0.46, 95% CI 0.32 to 0.66) but not systemic agents (RR 2.41, 95% CI 0.89 to 6.55), and could not be assessed in reports of low or no dose heparin studies. No significant effect on all‐cause mortality was observed for alternative anticoagulant locking solutions (RR 0.88, 95% CI 0.54 to 1.43) or systemic agents (RR 0.78, 95% CI 0.37 to 1.65), and was not reported in studies of low or no dose heparin. Bleeding events were only reported in eight studies, including only 2/5 studies of systemic warfarin, with no clear effect demonstrated (RR 1.43, 95% CI 0.86 to 2.39). For individual agents, recombinant tissue plasminogen (rt‐PA) was the only locking solution shown to reduce catheter malfunction (RR 0.58, 95% CI 0.37 to 0.91) based on the results of a single study. No significant on catheter malfunction was observed for other individual classes of alternative anticoagulant locking solutions (citrate: RR 1.14, 95% CI 0.76 to 1.69; antibiotic: RR 1.48, 95% CI 0.79 to 2.77; ethanol: RR 0.88, 95% CI 0.21 to 3.67). On the other hand, all individual classes of alternative anticoagulant locking solutions, except ethanol, reduced catheter‐related bacteraemia (citrate: RR 0.49, 95% CI 0.36 to 0.68; antibiotic: RR 0.27, 95% CI 0.11 to 0.70; rt‐PA: RR 0.35, 95% CI 0.13 to 0.93; ethanol: RR 0.33, 95% CI 0.03 to 4.05). No significant effect on all‐cause mortality was observed for any individual agent within the class of alternative locking solutions. Studies were mainly of low quality and underpowered with an average participant number of 75 and study duration of six months. The interpretation of the study evidence was further limited by the variation in tested interventions and outcome reporting. Authors' conclusions The relative net benefit of anticoagulant therapies for prevention of catheter malfunction remains uncertain. Multiple agents appear to reduce catheter‐related bacteraemia although the lack of clear assessment of harms and the limitations of study quality mean these results should be interpreted with caution. Methodological approaches can be used to avoid methods of reporting unduly affecting on the results of meta‐analyses incorporating studies employed mixed reporting methods. Further high quality randomised studies, including safety outcomes, are needed. Plain language summary Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease Background Patients with end‐stage kidney disease require vascular access during haemodialysis. Central venous haemodialysis catheters are frequently used when permanent vascular access is not available. Catheter problems contribute to greater morbidity and mortality. Catheter malfunction leads to requirements for additional interventions, increased risk of catheter‐related infection and hospitalisation. Standard care for the prevention of catheter malfunction is the use of heparin solutions as a post dialysis ‘lock’ in the catheter ports. The potential impact of heparin treatment on bleeding risk is an acknowledged concern. Therefore newer approaches have been proposed to seek improvements in catheter patency or treatment‐associated harm rates. Study characteristics This review focused on randomised controlled trials (RCTs) of anticoagulants compared with conventional care for the prevention of catheter malfunction patients receiving haemodialysis. Key results We found 27 studies, involving 3003 patients followed for an average six months, which assessed alternative anticoagulant locking solutions, systemic agents and low or no dose heparin. Catheter malfunction were not affected by any of these classes of agents. Subgroup analysis showed that the only agent reducing catheter malfunction was recombinant tissue plasminogen locking solution based on the results of a single study. A significant reduction was observed on the incidence of catheter‐related bacteraemia for alternative anticoagulant locking solutions. There was no evidence to suggest that alternative anticoagulants to heparin locking solutions had an effect on death rates or bleeding events, although only a small proportion of studies reported bleeding events. Quality of the evidence Further high quality information is needed on both potential benefits and safety of alternative approaches to maintaining dialysis access catheter function.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Wang, Y; Ivany, JN; Perkovic, V; Gallagher, MP; Woodward, M; Jardine, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD009631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "19f49857-c2ab-499e-89f1-21486e315bd0", "pmid": "", "title": "Effects of Infant Formula Composition on Infant Feeding Behaviors", "imported": false, "abstract": "There is a paucity of information on whether and how the composition of formulas fed to infants influences their short-term feeding behaviors during the first few months of life. The purpose of this study is to investigate whether the composition of infant formula affects infants' feeding behaviors, in particular, how much formula is consumed within a given feed (i.e., measure of satiation) and how much time elapses after the feed until the infant exhibits signs of hunger (i.e., measure of satiety). The investigators will also examine the relationship between the composition of infant formula consumed and infant temperature, activity, sleep, and mothers' perceptions of infants' intake and regulatory behaviors.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.264Z" }, { "id": "19fbfbcc-1ef1-4260-bfcc-2085ce714997", "pmid": "", "title": "Antibiotics for induction and maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Several antibiotics have been evaluated in Crohn's disease (CD), however randomised controlled trials (RCTs) have produced conflicting results. Objectives To assess the efficacy and safety of antibiotics for induction and maintenance of remission in CD. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and Clinicaltrials.gov database from inception to 28 February 2018. We also searched reference lists and conference proceedings. Selection criteria RCTs comparing antibiotics to placebo or an active comparator in adult (> 15 years) CD patients were considered for inclusion. Data collection and analysis Two authors screened search results and extracted data. Bias was evaluated using the Cochrane risk of bias tool. The primary outcomes were failure to achieve clinical remission and relapse. Secondary outcomes included clinical response, endoscopic response, endoscopic remission, endoscopic relapse, histologic response, histologic remission, adverse events (AEs), serious AEs, withdrawal due to AEs and quality of life. Remission is commonly defined as a Crohn's disease activity index (CDAI) of < 150. Clinical response is commonly defined as a decrease in CDAI from baseline of 70 or 100 points. Relapse is defined as a CDAI > 150. For studies that enrolled participants with fistulizing CD, response was defined as a 50% reduction in draining fistulas. Remission was defined as complete closure of fistulas. We calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for dichotomous outcomes. We calculated the mean difference (MD) and corresponding 95% CI for continuous outcomes. GRADE was used to assess the certainty of the evidence. Main results Thirteen RCTs (N = 1303 participants) were eligible. Two trials were rated as high risk of bias (no blinding). Seven trials were rated as unclear risk of bias and four trials were rated as low risk of bias. Comparisons included ciprofloxacin (500 mg twice daily) versus placebo, rifaximin (800 to 2400 mg daily) versus placebo, metronidazole (400 mg to 500 mg twice daily) versus placebo, clarithromycin (1 g/day) versus placebo, cotrimoxazole (960 mg twice daily) versus placebo, ciprofloxacin (500 mg twice daily) and metronidazole (250 mg four time daily) versus methylprednisolone (0.7 to 1 mg/kg daily), ciprofloxacin (500 mg daily), metronidazole (500 mg daily) and budesonide (9 mg daily) versus placebo with budesonide (9 mg daily), ciprofloxacin (500 mg twice daily) versus mesalazine (2 g twice daily), ciprofloxacin (500 mg twice daily) with adalimumab versus placebo with adalimumab, ciprofloxacin (500 mg twice daily) with infliximab versus placebo with infliximab, clarithromycin (750 mg daily) and antimycobacterial versus placebo, and metronidazole (400 mg twice daily) and cotrimoxazole (960 mg twice daily) versus placebo. We pooled all antibiotics as a class versus placebo and antibiotics with anti‐tumour necrosis factor (anti‐TNF) versus placebo with anti‐TNF. The effect of individual antibiotics on CD was generally uncertain due to imprecision. When we pooled antibiotics as a class, 55% (289/524) of antibiotic participants failed to achieve remission at 6 to 10 weeks compared with 64% (149/231) of placebo participants (RR 0.86, 95% CI 0.76 to 0.98; 7 studies; high certainty evidence). At 10 to 14 weeks, 41% (174/428) of antibiotic participants failed to achieve a clinical response compared to 49% (93/189) of placebo participants (RR 0.77, 95% CI 0.64 to 0.93; 5 studies; moderate certainty evidence). The effect of antibiotics on relapse in uncertain. Forty‐five per cent (37/83) of antibiotic participants relapsed at 52 weeks compared to 57% (41/72) of placebo participants (RR 0.87, 95% CI 0.52 to 1.47; 2 studies; low certainty evidence). Relapse of endoscopic remission was not reported in the included studies. Antibiotics do not appear to increase the risk of AEs. Thirty‐eight per cent (214/568) of antibiotic participants had at least one adverse event compared to 45% (128/284) of placebo participants (RR 0.87, 95% CI 0.75 to 1.02; 9 studies; high certainty evidence). The effect of antibiotics on serious AEs and withdrawal due to AEs was uncertain. Two per cent (6/377) of antibiotic participants had at least one adverse event compared to 0.7% (1/143) of placebo participants (RR 1.70, 95% CI 0.29 to 10.01; 3 studies; low certainty evidence). Nine per cent (53/569) of antibiotic participants withdrew due to AEs compared to 12% (36/289) of placebo participants (RR 0.86, 95% CI 0.57 to 1.29; 9 studies; low certainty evidence) is uncertain. Common adverse events in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation and headache, change in taste and paraesthesia When we pooled antibiotics used with anti‐TNF, 21% (10/48) of patients on combination therapy failed to achieve a clinical response(50% closure of fistulas) or remission (closure of fistulas) at week 12 compared with 36% (19/52) of placebo and anti‐TNF participants (RR 0.57, 95% CI 0.29 to 1.10; 2 studies; low certainty evidence). These studies did not assess the effect of antibiotics and anti‐TNF on clinical or endoscopic relapse. Seventy‐seven per cent (37/48) of antibiotics and anti‐TNF participants had an AE compared to 83% (43/52) of anti‐TNF and placebo participants (RR 0.93, 95% CI 0.76 to 1.12; 2 studies, moderate certainty evidence). The effect of antibiotics and anti‐TNF on withdrawal due to AEs is uncertain. Six per cent (3/48) of antibiotics and anti‐TNF participants withdrew due to an AE compared to 8% (4/52) of anti‐TNF and placebo participants (RR 0.82, 95% CI 0.19 to 3.45; 2 studies, low certainty evidence). Common adverse events included nausea, vomiting, upper respiratory tract infections, change in taste, fatigue and headache Authors' conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be modest and may not be clinically meaningful. High quality evidence suggests that there is no increased risk of adverse events with antibiotics compared to placebo. The effect of antibiotics on the risk of serious adverse events is uncertain. The effect of antibiotics on maintenance of remission in CD is uncertain. Thus, no firm conclusions regarding the efficacy and safety of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the efficacy and safety of antibiotics as therapy in CD Plain language summary Antibiotics for the treatment of Crohn's disease What is Crohn's disease? Crohn's disease (CD) is an inflammatory disorder that can affect any segment of the gastrointestinal tract from the mouth to the anus. Common symptoms of CD include fever, diarrhea, abdominal pain and weight loss. CD is characterized by periods of relapse when people experience symptoms and periods of remission when the symptoms stop. What are antibiotics? Antibiotics are medications used to treat bacterial infections. Antibiotics are designed to target specific bacterial populations and have different mechanisms of action to stop a bacterial population from growing or eradicate the bacteria. What is the purpose this study? Antibiotics are commonly used for managing patients with CD because the inflammatory process in the bowel was believed to be triggered by a specific bacterial pathogen. Elimination of this bacterial target would allow the inflammatory process to resolve. However, current clinical guidelines do not recommend use of antibiotic agents to induce or maintain clinical remission in patients with CD because there is no definitive evidence to suggest a benefit to using antibiotics in this way. How was this study performed? A systematic review of current literature was performed to determine whether antibiotic therapy is effective to induce or maintain remission in CD. An electronic search of several databases was performed and studies that met our inclusion criteria were selected for further evaluation. Statistical analyses were performed to determine which specific antibiotics had an overall benefit. What were the results? Several antibiotics, including ciprofloxacin, metronidazole, clarithromycin, rifaximin and cotrimoxazole, have been studied in CD. Most of the included studies were small in size. When we pooled antibiotics as a class, these drugs provided a modest benefit over placebo (i.e. a fake drug such as a sugar pill) for induction of remission and improvement of CD symptoms. For example, remission rates were 45% (253/542) in participants who received antibiotics compared to 36% (82/231) in participants who received placebo. We rated the quality of evidence supporting this outcome as high. Few studies assessed the use of antibiotics for maintenance of remission in CD. The impact of antibiotics on preventing relapse in CD is uncertain. Antibiotics do not appear to increase the risk of side effects when compared to placebo. Common side effects reported in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation, headache, change in taste and paraesthesia (pins and needles in the extremities). Serious side effects were not well reported in the studies and the impact of antibiotics on the risk of serious side effects is uncertain. Conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be very modest. High quality evidence suggests that there is no increased risk of side effects with antibiotics compared to placebo. The effect of antibiotics on the risk of serious side effects is uncertain. The effect of antibiotics on preventing relapse in CD is uncertain. Thus, no firm conclusions regarding the benefits and harms of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the harms and benefits of antibiotic therapy in CD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Townsend, CM; Parker, CE; MacDonald, JK; Nguyen, TM; Jairath, V; Feagan, BG; Khanna, R", "articleTypes": [], "doi": "10.1002/14651858.CD012730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "1a0ef339-409b-4185-8e76-9188a9ebe9b2", "pmid": "", "title": "Intravenous iron versus oral iron versus no iron with or without erythropoiesis‐ stimulating agents (ESA) for cancer patients with anaemia: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Anaemia is common among cancer patients and they may require red blood cell transfusions. Erythropoiesis‐stimulating agents (ESAs) and iron might help in reducing the need for red blood cell transfusions. However, it remains unclear whether the combination of both drugs is preferable compared to using one drug. Objectives To systematically review the effect of intravenous iron, oral iron or no iron in combination with or without ESAs to prevent or alleviate anaemia in cancer patients and to generate treatment rankings using network meta‐analyses (NMAs). Search methods We identified studies by searching bibliographic databases (CENTRAL, MEDLINE, Embase; until June 2021). We also searched various registries, conference proceedings and reference lists of identified trials. Selection criteria We included randomised controlled trials comparing intravenous, oral or no iron, with or without ESAs for the prevention or alleviation of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in cancer patients. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Outcomes were on‐study mortality, number of patients receiving red blood cell transfusions, number of red blood cell units, haematological response, overall mortality and adverse events. We conducted NMAs and generated treatment rankings. We assessed the certainty of the evidence using GRADE. Main results Ninety‐six trials (25,157 participants) fulfilled our inclusion criteria; 62 trials (24,603 participants) could be considered in the NMA (12 different treatment options). Here we present the comparisons of ESA with or without iron and iron alone versus no treatment. Further results and subgroup analyses are described in the full text. On‐study mortality We estimated that 92 of 1000 participants without treatment for anaemia died up to 30 days after the active study period. Evidence from NMA (55 trials; 15,074 participants) suggests that treatment with ESA and intravenous iron (12 of 1000; risk ratio (RR) 0.13, 95% confidence interval (CI) 0.01 to 2.29; low certainty) or oral iron (34 of 1000; RR 0.37, 95% CI 0.01 to 27.38; low certainty) may decrease or increase and ESA alone (103 of 1000; RR 1.12, 95% CI 0.92 to 1.35; moderate certainty) probably slightly increases on‐study mortality. Additionally, treatment with intravenous iron alone (271 of 1000; RR 2.95, 95% CI 0.71 to 12.34; low certainty) may increase and oral iron alone (24 of 1000; RR 0.26, 95% CI 0.00 to 19.73; low certainty) may increase or decrease on‐study mortality. Haematological response We estimated that 90 of 1000 participants without treatment for anaemia had a haematological response. Evidence from NMA (31 trials; 6985 participants) suggests that treatment with ESA and intravenous iron (604 of 1000; RR 6.71, 95% CI 4.93 to 9.14; moderate certainty), ESA and oral iron (527 of 1000; RR 5.85, 95% CI 4.06 to 8.42; moderate certainty), and ESA alone (467 of 1000; RR 5.19, 95% CI 4.02 to 6.71; moderate certainty) probably increases haematological response. Additionally, treatment with oral iron alone may increase haematological response (153 of 1000; RR 1.70, 95% CI 0.69 to 4.20; low certainty). Red blood cell transfusions We estimated that 360 of 1000 participants without treatment for anaemia needed at least one transfusion. Evidence from NMA (69 trials; 18,684 participants) suggests that treatment with ESA and intravenous iron (158 of 1000; RR 0.44, 95% CI 0.31 to 0.63; moderate certainty), ESA and oral iron (144 of 1000; RR 0.40, 95% CI 0.24 to 0.66; moderate certainty) and ESA alone (212 of 1000; RR 0.59, 95% CI 0.51 to 0.69; moderate certainty) probably decreases the need for transfusions. Additionally, treatment with intravenous iron alone (268 of 1000; RR 0.74, 95% CI 0.43 to 1.28; low certainty) and with oral iron alone (333 of 1000; RR 0.92, 95% CI 0.54 to 1.57; low certainty) may decrease or increase the need for transfusions. Overall mortality We estimated that 347 of 1000 participants without treatment for anaemia died overall. Low‐certainty evidence from NMA (71 trials; 21,576 participants) suggests that treatment with ESA and intravenous iron (507 of 1000; RR 1.46, 95% CI 0.87 to 2.43) or oral iron (482 of 1000; RR 1.39, 95% CI 0.60 to 3.22) and intravenous iron alone (521 of 1000; RR 1.50, 95% CI 0.63 to 3.56) or oral iron alone (534 of 1000; RR 1.54, 95% CI 0.66 to 3.56) may decrease or increase overall mortality. Treatment with ESA alone may lead to little or no difference in overall mortality (357 of 1000; RR 1.03, 95% CI 0.97 to 1.10; low certainty). Thromboembolic events We estimated that 36 of 1000 participants without treatment for anaemia developed thromboembolic events. Evidence from NMA (50 trials; 15,408 participants) suggests that treatment with ESA and intravenous iron (66 of 1000; RR 1.82, 95% CI 0.98 to 3.41; moderate certainty) probably slightly increases and with ESA alone (66 of 1000; RR 1.82, 95% CI 1.34 to 2.47; high certainty) slightly increases the number of thromboembolic events. None of the trials reported results on the other comparisons. Thrombocytopenia or haemorrhage We estimated that 76 of 1000 participants without treatment for anaemia developed thrombocytopenia/haemorrhage. Evidence from NMA (13 trials, 2744 participants) suggests that treatment with ESA alone probably leads to little or no difference in thrombocytopenia/haemorrhage (76 of 1000; RR 1.00, 95% CI 0.67 to 1.48; moderate certainty). None of the trials reported results on other comparisons. Hypertension We estimated that 10 of 1000 participants without treatment for anaemia developed hypertension. Evidence from NMA (24 trials; 8383 participants) suggests that treatment with ESA alone probably increases the number of hypertensions (29 of 1000; RR 2.93, 95% CI 1.19 to 7.25; moderate certainty). None of the trials reported results on the other comparisons. Authors' conclusions When considering ESAs with iron as prevention for anaemia, one has to balance between efficacy and safety. Results suggest that treatment with ESA and iron probably decreases number of blood transfusions, but may increase mortality and the number of thromboembolic events. For most outcomes the different comparisons within the network were not fully connected, so ranking of all treatments together was not possible. More head‐to‐head comparisons including all evaluated treatment combinations are needed to fill the gaps and prove results of this review. Plain language summary Which combinations of medicines are best for the prevention and treatment of anaemia in people with cancer? Key messages • Giving medicines that stimulate the bone marrow to produce red blood cells (ESAs) with iron supplements probably decreases the number of blood transfusions, but may also cause more deaths and increase the number of unwanted effects, such as blood clots. • Because of missing data from the studies we could not compare the different treatment options to each other and rank them. • We need more studies that compare these medicines directly against each other. What is anaemia and why do people with cancer develop it? Anaemia develops when levels of red blood cells are too low. Red blood cells contain a protein called haemoglobin. Iron molecules in the haemoglobin bind to oxygen and carry it around the body. A lack of oxygen to the organs and tissues in the body makes people feel tired and lack energy, and they may be at greater risk of infections. People with cancer are particularly likely to suffer from anaemia. This might be because the cancers cause inflammation and prevent red blood cell production. Or it might be because treatments like chemotherapy slow down production of red blood cells in bone marrow. People suffering from anaemia may need blood transfusions. However, treatment with medicines that stimulate the production of red blood cells in bone marrow (called erythropoiesis‐stimulating agents or ESAs) and iron supplements may reduce the need for transfusions. What did we want to find out? We wanted to identify the most effective treatments for anaemia in people with cancer and whether they cause any unwanted effects. We were interested in whether iron supplements or ESAs given alone or together affect: • deaths; • haemoglobin levels; • blood transfusions; and • unwanted effects. We also wanted to know the best way to give the medicines: by injection (intravenous), or swallowed (oral). What did we do? We searched for studies that compared intravenous, oral or no iron with or without ESAs for the prevention or treatment of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in people with cancer. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and numbers of participants. We used statistical methods to compare multiple treatments against each other and rank them in order of effectiveness and unwanted effects. What did we find? We found 96 relevant studies with 25,157 people. People in the studies were different ages and were receiving a mix of anti‐cancer treatments or no treatment. They had different types of cancer. Ninety‐two studies reported data for our review. They included 24,603 people and compared 12 different treatment options for anaemia. The treatments included combinations of ESAs with intravenous or oral iron and placebo (something that looks, tastes and smells the same as the iron supplement or ESA but with no active ingredient). Not every study reported everything we were interested in, so we did not have enough information to compare each treatment with each of the other treatments. Treatment with ESAs when used on their own or with iron probably increases levels of red blood cells and reduces the need for red blood cell transfusions when compared with no treatment. We cannot rule out an increase in the risk of mortality with ESA in combination with iron, which also appeared to cause more deaths and lead to increased risk of harm caused by the formation of clots in the blood vessels. Our confidence in the findings Overall, we are moderately confident in the evidence that one treatment is better or worse than another. Our confidence is limited because we sometimes found very different results for the same treatments, meaning they could have been both good and bad for patients ‐ we did not have enough evidence to reach firm conclusions. Also, due to a lack of evidence we could not rank the treatments. How up to date is the evidence? The evidence is up‐to‐date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Adams, A, Scheckel, B, Habsaoui, A, Haque, M, Kuhr, K, Monsef, I, Bohlius, J, Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012633.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.141Z" }, { "id": "1a209601-a8e4-48c0-a046-f0bef874397a", "pmid": "", "title": "Intravenous iron versus oral iron versus no iron with or without erythropoiesis‐ stimulating agents (ESA) for cancer patients with anaemia: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Anaemia is common among cancer patients and they may require red blood cell transfusions. Erythropoiesis‐stimulating agents (ESAs) and iron might help in reducing the need for red blood cell transfusions. However, it remains unclear whether the combination of both drugs is preferable compared to using one drug. Objectives To systematically review the effect of intravenous iron, oral iron or no iron in combination with or without ESAs to prevent or alleviate anaemia in cancer patients and to generate treatment rankings using network meta‐analyses (NMAs). Search methods We identified studies by searching bibliographic databases (CENTRAL, MEDLINE, Embase; until June 2021). We also searched various registries, conference proceedings and reference lists of identified trials. Selection criteria We included randomised controlled trials comparing intravenous, oral or no iron, with or without ESAs for the prevention or alleviation of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in cancer patients. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Outcomes were on‐study mortality, number of patients receiving red blood cell transfusions, number of red blood cell units, haematological response, overall mortality and adverse events. We conducted NMAs and generated treatment rankings. We assessed the certainty of the evidence using GRADE. Main results Ninety‐six trials (25,157 participants) fulfilled our inclusion criteria; 62 trials (24,603 participants) could be considered in the NMA (12 different treatment options). Here we present the comparisons of ESA with or without iron and iron alone versus no treatment. Further results and subgroup analyses are described in the full text. On‐study mortality We estimated that 92 of 1000 participants without treatment for anaemia died up to 30 days after the active study period. Evidence from NMA (55 trials; 15,074 participants) suggests that treatment with ESA and intravenous iron (12 of 1000; risk ratio (RR) 0.13, 95% confidence interval (CI) 0.01 to 2.29; low certainty) or oral iron (34 of 1000; RR 0.37, 95% CI 0.01 to 27.38; low certainty) may decrease or increase and ESA alone (103 of 1000; RR 1.12, 95% CI 0.92 to 1.35; moderate certainty) probably slightly increases on‐study mortality. Additionally, treatment with intravenous iron alone (271 of 1000; RR 2.95, 95% CI 0.71 to 12.34; low certainty) may increase and oral iron alone (24 of 1000; RR 0.26, 95% CI 0.00 to 19.73; low certainty) may increase or decrease on‐study mortality. Haematological response We estimated that 90 of 1000 participants without treatment for anaemia had a haematological response. Evidence from NMA (31 trials; 6985 participants) suggests that treatment with ESA and intravenous iron (604 of 1000; RR 6.71, 95% CI 4.93 to 9.14; moderate certainty), ESA and oral iron (527 of 1000; RR 5.85, 95% CI 4.06 to 8.42; moderate certainty), and ESA alone (467 of 1000; RR 5.19, 95% CI 4.02 to 6.71; moderate certainty) probably increases haematological response. Additionally, treatment with oral iron alone may increase haematological response (153 of 1000; RR 1.70, 95% CI 0.69 to 4.20; low certainty). Red blood cell transfusions We estimated that 360 of 1000 participants without treatment for anaemia needed at least one transfusion. Evidence from NMA (69 trials; 18,684 participants) suggests that treatment with ESA and intravenous iron (158 of 1000; RR 0.44, 95% CI 0.31 to 0.63; moderate certainty), ESA and oral iron (144 of 1000; RR 0.40, 95% CI 0.24 to 0.66; moderate certainty) and ESA alone (212 of 1000; RR 0.59, 95% CI 0.51 to 0.69; moderate certainty) probably decreases the need for transfusions. Additionally, treatment with intravenous iron alone (268 of 1000; RR 0.74, 95% CI 0.43 to 1.28; low certainty) and with oral iron alone (333 of 1000; RR 0.92, 95% CI 0.54 to 1.57; low certainty) may decrease or increase the need for transfusions. Overall mortality We estimated that 347 of 1000 participants without treatment for anaemia died overall. Low‐certainty evidence from NMA (71 trials; 21,576 participants) suggests that treatment with ESA and intravenous iron (507 of 1000; RR 1.46, 95% CI 0.87 to 2.43) or oral iron (482 of 1000; RR 1.39, 95% CI 0.60 to 3.22) and intravenous iron alone (521 of 1000; RR 1.50, 95% CI 0.63 to 3.56) or oral iron alone (534 of 1000; RR 1.54, 95% CI 0.66 to 3.56) may decrease or increase overall mortality. Treatment with ESA alone may lead to little or no difference in overall mortality (357 of 1000; RR 1.03, 95% CI 0.97 to 1.10; low certainty). Thromboembolic events We estimated that 36 of 1000 participants without treatment for anaemia developed thromboembolic events. Evidence from NMA (50 trials; 15,408 participants) suggests that treatment with ESA and intravenous iron (66 of 1000; RR 1.82, 95% CI 0.98 to 3.41; moderate certainty) probably slightly increases and with ESA alone (66 of 1000; RR 1.82, 95% CI 1.34 to 2.47; high certainty) slightly increases the number of thromboembolic events. None of the trials reported results on the other comparisons. Thrombocytopenia or haemorrhage We estimated that 76 of 1000 participants without treatment for anaemia developed thrombocytopenia/haemorrhage. Evidence from NMA (13 trials, 2744 participants) suggests that treatment with ESA alone probably leads to little or no difference in thrombocytopenia/haemorrhage (76 of 1000; RR 1.00, 95% CI 0.67 to 1.48; moderate certainty). None of the trials reported results on other comparisons. Hypertension We estimated that 10 of 1000 participants without treatment for anaemia developed hypertension. Evidence from NMA (24 trials; 8383 participants) suggests that treatment with ESA alone probably increases the number of hypertensions (29 of 1000; RR 2.93, 95% CI 1.19 to 7.25; moderate certainty). None of the trials reported results on the other comparisons. Authors' conclusions When considering ESAs with iron as prevention for anaemia, one has to balance between efficacy and safety. Results suggest that treatment with ESA and iron probably decreases number of blood transfusions, but may increase mortality and the number of thromboembolic events. For most outcomes the different comparisons within the network were not fully connected, so ranking of all treatments together was not possible. More head‐to‐head comparisons including all evaluated treatment combinations are needed to fill the gaps and prove results of this review. Plain language summary Which combinations of medicines are best for the prevention and treatment of anaemia in people with cancer? Key messages • Giving medicines that stimulate the bone marrow to produce red blood cells (ESAs) with iron supplements probably decreases the number of blood transfusions, but may also cause more deaths and increase the number of unwanted effects, such as blood clots. • Because of missing data from the studies we could not compare the different treatment options to each other and rank them. • We need more studies that compare these medicines directly against each other. What is anaemia and why do people with cancer develop it? Anaemia develops when levels of red blood cells are too low. Red blood cells contain a protein called haemoglobin. Iron molecules in the haemoglobin bind to oxygen and carry it around the body. A lack of oxygen to the organs and tissues in the body makes people feel tired and lack energy, and they may be at greater risk of infections. People with cancer are particularly likely to suffer from anaemia. This might be because the cancers cause inflammation and prevent red blood cell production. Or it might be because treatments like chemotherapy slow down production of red blood cells in bone marrow. People suffering from anaemia may need blood transfusions. However, treatment with medicines that stimulate the production of red blood cells in bone marrow (called erythropoiesis‐stimulating agents or ESAs) and iron supplements may reduce the need for transfusions. What did we want to find out? We wanted to identify the most effective treatments for anaemia in people with cancer and whether they cause any unwanted effects. We were interested in whether iron supplements or ESAs given alone or together affect: • deaths; • haemoglobin levels; • blood transfusions; and • unwanted effects. We also wanted to know the best way to give the medicines: by injection (intravenous), or swallowed (oral). What did we do? We searched for studies that compared intravenous, oral or no iron with or without ESAs for the prevention or treatment of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in people with cancer. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and numbers of participants. We used statistical methods to compare multiple treatments against each other and rank them in order of effectiveness and unwanted effects. What did we find? We found 96 relevant studies with 25,157 people. People in the studies were different ages and were receiving a mix of anti‐cancer treatments or no treatment. They had different types of cancer. Ninety‐two studies reported data for our review. They included 24,603 people and compared 12 different treatment options for anaemia. The treatments included combinations of ESAs with intravenous or oral iron and placebo (something that looks, tastes and smells the same as the iron supplement or ESA but with no active ingredient). Not every study reported everything we were interested in, so we did not have enough information to compare each treatment with each of the other treatments. Treatment with ESAs when used on their own or with iron probably increases levels of red blood cells and reduces the need for red blood cell transfusions when compared with no treatment. We cannot rule out an increase in the risk of mortality with ESA in combination with iron, which also appeared to cause more deaths and lead to increased risk of harm caused by the formation of clots in the blood vessels. Our confidence in the findings Overall, we are moderately confident in the evidence that one treatment is better or worse than another. Our confidence is limited because we sometimes found very different results for the same treatments, meaning they could have been both good and bad for patients ‐ we did not have enough evidence to reach firm conclusions. Also, due to a lack of evidence we could not rank the treatments. How up to date is the evidence? The evidence is up‐to‐date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Adams, A, Scheckel, B, Habsaoui, A, Haque, M, Kuhr, K, Monsef, I, Bohlius, J, Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012633.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.800Z" }, { "id": "1a35e057-9d47-48ac-8ded-e53a01f8f699", "pmid": "", "title": "Fixed‐dose combinations of drugs versus single‐drug formulations for treating pulmonary tuberculosis", "imported": false, "abstract": "Abstract - Background People who are newly diagnosed with pulmonary tuberculosis (TB) typically receive a standard first‐line treatment regimen that consists of two months of isoniazid, rifampicin, pyrazinamide, and ethambutol followed by four months of isoniazid and rifampicin. Fixed‐dose combinations (FDCs) of these drugs are widely recommended. Objectives To compare the efficacy, safety, and acceptability of anti‐tuberculosis regimens given as fixed‐dose combinations compared to single‐drug formulations for treating people with newly diagnosed pulmonary tuberculosis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL, published in the Cochrane Library, Issue 11 2015); MEDLINE (1966 to 20 November 2015); EMBASE (1980 to 20 November 2015); LILACS (1982 to 20 November 2015); the metaRegister of Controlled Trials; and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), without language restrictions, up to 20 November 2015. Selection criteria Randomized controlled trials that compared the use of FDCs with single‐drug formulations in adults (aged 15 years or more) newly diagnosed with pulmonary TB. Data collection and analysis Two review authors independently assessed studies for inclusion, and assessed the risk of bias and extracted data from the included trials. We used risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data with 95% confidence intervals (CIs). We attempted to assess the effect of treatment for time‐to‐event measures with hazard ratios and their 95% CIs. We used the Cochrane 'Risk of bias' assessment tool to determine the risk of bias in included trials. We used the fixed‐effect model when there was little heterogeneity and the random‐effects model with moderate heterogeneity. We used an I² statistic value of 75% or greater to denote significant heterogeneity, in which case we did not perform a meta‐analysis. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We included 13 randomized controlled trials (RCTs) in the review, which enrolled 5824 participants. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. Overall there is little or no difference detected between FDCs and single‐drug formulations for most outcomes reported. We did not detect a difference in treatment failure between FDCs compared with single‐drug formulations (RR 1.28, 95% CI 0.82 to 2.00; 3606 participants, seven trials, moderate quality evidence ). Relapse may be more frequent in people treated with FDCs compared to single‐drug formulations, although the confidence interval (CI) includes no difference (RR 1.28, 95% CI 1.00 to 1.64; 3621 participants, 10 trials, low quality evidence ). We did not detect any difference in death between fixed‐dose and single‐drug formulation groups (RR 0.96, 95% CI 0.67 to 1.39; 4800 participants, 11 trials, moderate quality evidence ). When we compared FDCs with single‐drug formulations we found little or no difference for sputum smear or culture conversion at the end of treatment (RR 0.99, 95% CI 0.96 to 1.02; 2319 participants, seven trials, high quality evidence ), for serious adverse events (RR 1.45, 95% CI 0.90 to 2.33; 3388 participants, six trials, moderate quality evidence ), and for adverse events that led to discontinuation of therapy (RR 0.96, 95% CI 0.56 to 1.66; 5530 participants, 13 trials, low quality evidence ). We conducted a sensitivity analysis excluding studies at high risk of bias and this did not alter the review findings. Authors' conclusions Fixed‐dose combinations and single‐drug formulations probably have similar effects for treating people with newly diagnosed pulmonary TB. 23 April 2019 No update planned Other This is not a current research question. Plain language summary Fixed‐dose combinations for treating pulmonary tuberculosis What are fixed‐dose combinations and how might they improve care of people with tuberculosis Tuberculosis (TB) is an important health problem, especially in developing countries. The treatment for pulmonary TB in new patients includes four oral medicines taken for six months, sometimes as fixed‐dose combinations (FDCs) that are combined in one tablet, or taken separately as single‐drug formulations. The World Health Organization recommends prescribers use fixed‐dose combinations to reduce the number of tablets that people take. On the supply side, this might reduce prescribing errors and improve drug supply efficiency; on the patient's side, FDCS simplify treatment and improve adherence. We conducted a review to assess the efficacy, safety, and acceptability of FDCs compared with single‐drug formulations for treating people with newly diagnosed pulmonary TB. What the research says We searched for relevant trials up to 20 November 2015, and included 13 randomized controlled trials that enrolled 5824 people. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. There is probably little or no difference in FDCs compared to single‐drug formulations for treatment failure ( moderate quality evidence ); relapse may be more frequent ( low quality evidence ); and the number of deaths were similar ( moderate quality evidence ). There is little or no difference in sputum smear or culture conversion ( high quality evidence ), and no difference was shown for serious adverse events ( moderate quality evidence ) or adverse events that led to discontinuation of therapy ( low quality evidence ). Authors’ conclusions We concluded that fixed‐dose combinations have similar efficacy to single‐drug formulations for treating people with newly diagnosed pulmonary TB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Gallardo, CR; Rigau Comas, D; Valderrama Rodríguez, A; Roqué i Figuls, M; Parker, LA; Caylà, J; Bonfill Cosp, X", "articleTypes": [], "doi": "10.1002/14651858.CD009913.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "1a3c8a2c-4f9c-4ba6-93b2-bb5bc68e1354", "pmid": "", "title": "An Open-label, Non-randomized [11C]Carfentanil PET Study in Healthy Male Subjects to Investigate Brain Mu-opioid Receptor Occupancy, Pharmacokinetics, and Pharmacodynamics of Single Oral Doses of GSK1521498 and Naltrexone.", "imported": false, "abstract": "The purpose of this study is to determine whether GSK1521498 attaches to sites in the brain called mu-opioid receptors that are involved in the liking reactions to palatable high fat and high sugar foods. We hope that blocking these receptors may modify certain behaviours that may lead to obesity.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "1a4461c9-fdeb-4d5f-bd5c-c09a594f422e", "pmid": "", "title": "Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia", "imported": false, "abstract": "Abstract - Background Fibromyalgia is a clinically defined chronic condition of unknown etiology characterized by chronic widespread pain that often co‐exists with sleep disturbances, cognitive dysfunction and fatigue. People with fibromyalgia often report high disability levels and poor quality of life. Drug therapy, for example, with serotonin and noradrenaline reuptake inhibitors (SNRIs), focuses on reducing key symptoms and improving quality of life. This review updates and extends the 2013 version of this systematic review. Objectives To assess the efficacy, tolerability and safety of serotonin and noradrenaline reuptake inhibitors (SNRIs) compared with placebo or other active drug(s) in the treatment of fibromyalgia in adults. Search methods For this update we searched CENTRAL, MEDLINE, Embase, the US National Institutes of Health and the World Health Organization (WHO) International Clinical Trials Registry Platform for published and ongoing trials and examined the reference lists of reviewed articles, to 8 August 2017. Selection criteria We selected randomized, controlled trials of any formulation of SNRIs against placebo or any other active treatment of fibromyalgia in adults. Data collection and analysis Three review authors independently extracted data, examined study quality, and assessed risk of bias. For efficacy, we calculated the number needed to treat for an additional beneficial outcome (NNTB) for pain relief of 50% or greater and of 30% or greater, patient's global impression to be much or very much improved, dropout rates due to lack of efficacy, and the standardized mean differences (SMD) for fatigue, sleep problems, health‐related quality of life, mean pain intensity, depression, anxiety, disability, sexual function, cognitive disturbances and tenderness. For tolerability we calculated number needed to treat for an additional harmful outcome (NNTH) for withdrawals due to adverse events and for nausea, insomnia and somnolence as specific adverse events. For safety we calculated NNTH for serious adverse events. We undertook meta‐analysis using a random‐effects model. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We added eight new studies with 1979 participants for a total of 18 included studies with 7903 participants. Seven studies investigated duloxetine and nine studies investigated milnacipran against placebo. One study compared desvenlafaxine with placebo and pregabalin. One study compared duloxetine with L‐carnitine. The majority of studies were at unclear or high risk of bias in three to five domains. The quality of evidence of all comparisons of desvenlafaxine, duloxetine and milnacipran versus placebo in studies with a parallel design was low due to concerns about publication bias and indirectness, and very low for serious adverse events due to concerns about publication bias, imprecision and indirectness. The quality of evidence of all comparisons of duloxetine and desvenlafaxine with other active drugs was very low due to concerns about publication bias, imprecision and indirectness. Duloxetine and milnacipran had no clinically relevant benefit over placebo for pain relief of 50% or greater: 1274 of 4104 (31%) on duloxetine and milnacipran reported pain relief of 50% or greater compared to 591 of 2814 (21%) participants on placebo (risk difference (RD) 0.09, 95% confidence interval (CI) 0.07 to 0.11; NNTB 11, 95% CI 9 to 14). Duloxetine and milnacipran had a clinically relevant benefit over placebo in patient's global impression to be much or very much improved: 888 of 1710 (52%) on duloxetine and milnacipran (RD 0.19, 95% CI 0.12 to 0.26; NNTB 5, 95% CI 4 to 8) reported to be much or very much improved compared to 354 of 1208 (29%) of participants on placebo. Duloxetine and milnacipran had a clinically relevant benefit compared to placebo for pain relief of 30% or greater. RD was 0.10; 95% CI 0.08 to 0.12; NNTB 10, 95% CI 8 to 12. Duloxetine and milnacipran had no clinically relevant benefit for fatigue (SMD ‐0.13, 95% CI ‐0.18 to ‐0.08; NNTB 18, 95% CI 12 to 29), compared to placebo. There were no differences between either duloxetine or milnacipran and placebo in reducing sleep problems (SMD ‐0.07; 95 % CI ‐0.15 to 0.01). Duloxetine and milnacipran had no clinically relevant benefit compared to placebo in improving health‐related quality of life (SMD ‐0.20, 95% CI ‐0.25 to ‐0.15; NNTB 11, 95% CI 8 to 14). There were 794 of 4166 (19%) participants on SNRIs who dropped out due to adverse events compared to 292 of 2863 (10%) of participants on placebo (RD 0.07, 95% CI 0.04 to 0.10; NNTH 14, 95% CI 10 to 25). There was no difference in serious adverse events between either duloxetine, milnacipran or desvenlafaxine and placebo (RD ‐0.00, 95% CI ‐0.01 to 0.00). There was no difference between desvenlafaxine and placebo in efficacy, tolerability and safety in one small trial. There was no difference between duloxetine and desvenlafaxine in efficacy, tolerability and safety in two trials with active comparators (L‐carnitine, pregabalin). Authors' conclusions The update did not change the major findings of the previous review. Based on low‐ to very low‐quality evidence, the SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in the frequency of pain relief of 50% or greater, but for patient's global impression to be much or very much improved and in the frequency of pain relief of 30% or greater there was a clinically relevant benefit. The SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in improving health‐related quality of life and in reducing fatigue. Duloxetine and milnacipran did not significantly differ from placebo in reducing sleep problems. The dropout rates due to adverse events were higher for duloxetine and milnacipran than for placebo. On average, the potential benefits of duloxetine and milnacipran in fibromyalgia were outweighed by their potential harms. However, a minority of people with fibromyalgia might experience substantial symptom relief without clinically relevant adverse events with duloxetine or milnacipran. We did not find placebo‐controlled studies with other SNRIs than desvenlafaxine, duloxetine and milnacipran. Plain language summary Serotonin and noradrenaline reuptake inhibitors for fibromyalgia Bottom line Duloxetine and milnacipran may reduce pain in people with fibromyalgia. However, some of these people may also experience side effects, such as nausea (feeling sick) and drowsiness. A minority of people with fibromyalgia experience symptom relief without side effects from duloxetine and milnacipran. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as problems with sleep, thinking and exhaustion. They often report poor health‐related quality of life. There is no cure for fibromyalgia at present, so the treatments aim to relieve the symptoms and to improve health‐related quality of life. Serotonin and noradrenaline are chemicals which are produced by the human body, involved in the regulation of pain, sleep and mood. Low concentrations of serotonin have been reported in people with fibromyalgia. Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a class of antidepressants that increase the concentration of serotonin and noradrenaline in the brain. Study characteristics In August 2017, we updated our searches for clinical trials in which SNRIs were used to treat symptoms of fibromyalgia in adults. We found eight new studies since the previous version of the review. In total, we found 18 studies with 7903 participants. The studies were four to 27 weeks long and compared the SNRIs desvenlafaxine, duloxetine and milnacipran against a fake medication (placebo). We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. Key results and quality of the evidence Duloxetine and milnacipran were better than placebo in reducing pain by 50% or more and in improving global well‐being (low‐quality evidence). Duloxetine and milnacipran were better than placebo in improving health‐related quality of life and in reducing fatigue (low‐quality evidence). Duloxetine and milnacipran were not better than placebo in reducing sleep problems (low‐quality evidence). More people dropped out of the trial due to side effects with duloxetine and milnacipran than with placebo (low‐quality evidence). More people reported nausea and drowsiness with duloxetine and milnacipran than with placebo (low‐quality evidence). Duloxetine, milnacipran and placebo did not differ in the frequency of serious side effects experienced (very low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Welsch, P, Üçeyler, N, Klose, P, Walitt, B, Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD010292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.774Z" }, { "id": "1a468266-ef62-430f-bf80-751fcf91ea9e", "pmid": "", "title": "Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people", "imported": false, "abstract": "Abstract - Background There is evidence that water‐loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well‐being are compromised. Objectives To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water‐loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water‐loss dehydration was defined primarily as including everyone with either impending or current water‐loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). Search methods Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases ( The Cochrane Library ), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. Selection criteria Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. Data collection and analysis Diagnostic accuracy of each test was assessed against the best available reference standard for water‐loss dehydration (serum or plasma osmolality cut���off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water‐loss dehydration (including either impending or current water‐loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water‐loss dehydration, but restricted to current dehydration in the final review. We conducted bivariate random‐effects meta‐analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre‐specified cut‐off points investigated. Pre‐set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre‐specifying three cut‐offs for each continuous test may have led to missing a cut‐off with useful sensitivity and specificity, we conducted post‐hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut‐off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. Main results There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water‐loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years. We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut‐offs for each continuous outcome) for diagnostic accuracy of water‐loss dehydration (primary target condition) and of current dehydration (secondary target condition). Only three tests showed any ability to diagnose water‐loss dehydration (including both impending and current water‐loss dehydration) as stand‐alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post‐hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study. Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97). There was sufficient evidence to suggest that several stand‐alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people. No tests were found consistently useful in diagnosing current water‐loss dehydration. Authors' conclusions There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water‐loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated. Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy. Plain language summary Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people Water‐loss dehydration results from drinking too little fluid. It is common in older people and associated with increased risk of many health problems. We wanted to find out whether simple tests (like skin turgor, dry mouth, urine colour and bioelectrical impedance) can usefully tell us whether an older person (aged at least 65 years) is drinking enough. Within the review we assessed 67 different tests, but no tests were consistently useful in telling us whether older people are drinking enough, or are dehydrated. Some tests did appear useful in some studies, and these promising tests should be re‐checked to see whether they are useful in specific older populations. There was sufficient evidence to suggest that some tests should not be used to indicate dehydration. Tests that should not be used include dry mouth, feeling thirsty, heart rate, urine colour, and urine volume.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hooper, L, Abdelhamid, A, Attreed, NJ, Campbell, WW, Channell, AM, Chassagne, P, Culp, KR, Fletcher, SJ, Fortes, MB, Fuller, N, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD009647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.139Z" }, { "id": "1a78e218-5b0d-4715-b1c8-1e04da9b71c8", "pmid": "", "title": "Fish oil for kidney transplant recipients", "imported": false, "abstract": "Abstract - Background Calcineurin inhibitors used in kidney transplantation for immunosuppression have adverse effects that may contribute to nephrotoxicity and increased cardiovascular risk profile. Fish oils are rich in very long chain omega‐3 fatty acids, which may reduce nephrotoxicity by improving endothelial function and reduce rejection rates through their immuno‐modulatory effects. They may also modify the cardiovascular risk profile. Hence, fish oils may potentially prolong graft survival and reduce cardiovascular mortality. Objectives This review aimed to look at the benefits and harms of fish oil treatment in ameliorating the kidney and cardiovascular adverse effects of CNI‐based immunosuppressive therapy in kidney transplant recipients. Search methods We searched the Cochrane Kidney and Transplant Specialised Register (up to 17 March 2016) through contact with the Information Specialist using search terms relevant to this review. Selection criteria All randomised controlled trials (RCTs) and quasi‐RCTs of fish oils in kidney transplant recipients on a calcineurin inhibitor‐based immunosuppressive regimen. RCTs of fish oil versus statins were included. Data collection and analysis Data was extracted and the quality of studies assessed by two authors, with differences resolved by discussion with a third independent author. Dichotomous outcomes were reported as risk ratio (RR) and continuous outcome measures were reported as the mean difference (MD) with 95% confidence intervals using the random effects model. Heterogeneity was assessed using a Chi 2 test on n‐1 degrees of freedom and the I 2 statistic. Data not suitable for pooling were tabulated and described. Main results Fifteen studies (733 patients) were suitable for analysis. All studies were small and had variable methodology. Fish oil did not significantly affect patient or graft survival, acute rejection rates, or calcineurin inhibitor toxicity when compared to placebo. Overall SCr was significantly lower in the fish oil group compared to placebo (5 studies, 237 participants: MD ‐30.63 µmol/L, 95% CI ‐59.74 to ‐1.53; I 2 = 88%). In the subgroup analysis, this was only significant in the long‐course (six months or more) group (4 studies, 157 participants: MD ‐37.41 µmol/L, 95% CI ‐69.89 to ‐4.94; I 2 = 82%). Fish oil treatment was associated with a lower diastolic blood pressure (4 studies, 200 participants: MD ‐4.53 mm Hg, 95% CI ‐7.60 to ‐1.45) compared to placebo. Patients receiving fish oil for more than six months had a modest increase in HDL (5 studies, 178 participants: MD 0.12 mmol/L, 95% CI 0.03 to 0.21; I 2 = 47%) compared to placebo. Fish oil effects on lipids were not significantly different from low‐dose statins. There was insufficient data to analyse cardiovascular outcomes. Fishy aftertaste and gastrointestinal upset were common but did not result in significant patient drop‐out. Authors' conclusions There is insufficient evidence from currently available RCTs to recommend fish oil therapy to improve kidney function, rejection rates, patient survival or graft survival. The improvements in HDL cholesterol and diastolic blood pressure were too modest to recommend routine use. To determine a benefit in clinical outcomes, future RCTs will need to be adequately powered with these outcomes in mind. Plain language summary Fish oil for kidney transplant recipients This review set out to assess any benefit or harm in using fish oil to reduce the risk of kidney damage and heart disease in people who have had a kidney transplant and are receiving standard drugs to prevent rejection. Information from 15 studies was used and showed that fish oils provide a slight improvement in HDL cholesterol and diastolic blood pressure. These studies did not provide enough information on the differences in the risk of death, heart disease, kidney transplant rejection or kidney function between patients receiving fish oils and those receiving placebo. There appeared to be no harmful effects of taking fish oil. The benefits of taking fish oil after a kidney transplant are a mild improvement in some heart disease risk factors. There was not enough information to show any benefit in preventing heart disease or reduction in kidney function. Larger, better studies are needed before regular use of fish oil can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lim, AKH, Manley, KJ, Roberts, MA, Fraenkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD005282.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.736Z" }, { "id": "1a894de0-89e6-4a98-b30e-6e652375d95b", "pmid": "", "title": "Sumatriptan (intranasal route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Intranasal administration may be preferable to oral for individuals experiencing nausea and/or vomiting, although it is primarily absorbed in the gut, not the nasal mucosa. Objectives To determine the efficacy and tolerability of intranasal sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using intranasal sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Twelve studies (4755 participants) compared intranasal sumatriptan with placebo or an active comparator. Most of the data were for the 10 mg and 20 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 10 mg versus placebo the NNTs were 7.3, 7.4, and 5.5 for pain‐free at two hours, and headache relief at one and two hours, respectively. For sumatriptan 20 mg versus placebo the NNTs were 4.7, 4.9, and 3.5, respectively, for the same outcomes. The 20 mg dose was significantly better than the 10 mg dose for each of these three primary efficacy outcomes. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Direct comparison of sumatriptan with active treatments was limited to two studies, one comparing sumatriptan 20 mg and dihydroergotamine (DHE) 1 mg, and one comparing sumatriptan 20 mg with rizatriptan 10 mg. Authors' conclusions Intranasal sumatriptan is effective as an abortive treatment for acute migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events compared with placebo. Plain language summary Sumatriptan (intranasal route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a nasal spray, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, although absorption of the drug occurs primarily in the gut rather than the nasal mucosa. This review found that a single intranasal dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in approximately 2 in 10 people (24%) taking sumatriptan 10 mg, compared with about 1 in 10 (10%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 5 in 10 people (50%) taking sumatriptan 10 mg, compared with approximately 3 in 10 (32%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those who took placebo. The 20 mg dose had greater efficacy, but may be associated with more adverse events, most of which were of short duration and mild or moderate in severity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009663", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "1a9af536-c194-4229-8f22-732f4d0ff604", "pmid": "", "title": "Nebulized and oral thiol derivatives for pulmonary disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is an inherited condition resulting in thickened, sticky respiratory secretions. Respiratory failure, due to recurrent pulmonary infection and inflammation, is the most common cause of mortality. Muco‐active therapies (e.g. dornase alfa and nebulized hypertonic saline) may decrease sputum viscosity, increase airway clearance of sputum, reduce infection and inflammation and improve lung function. Thiol derivatives, either oral or nebulized, have shown benefit in other respiratory diseases. Their mode of action is likely to differ according to the route of administration. There are several thiol derivatives, and it is unclear which of these may be beneficial in cystic fibrosis. Objectives To evaluate the efficacy and safety of nebulized and oral thiol derivatives in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches, hand searches of relevant journals, abstract books and conference proceedings. Most recent search: 13 June 2013. We also conducted a PubMed search on 26 February 2013 for relevant published articles. Selection criteria Randomized and quasi‐randomized controlled trials comparing nebulized or oral thiol derivatives to placebo or another thiol derivative in people with cystic fibrosis. Data collection and analysis The authors independently assessed trials for inclusion, analysed risk of bias and extracted data. Main results Searches identified 23 trials; nine trials (255 participants) are included, of these seven trials are more than 10 years old. Three trials of nebulized thiol derivatives were identified (one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and another compared glutathione to 4% hypertonic saline). Although generally well‐tolerated with no significant adverse effects, there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Six trials of oral thiol derivatives were identified. Three trials compared N‐acetylcysteine to placebo; one compared N‐acetylcysteine, ambroxol and placebo; one compared carbocysteine to ambroxol; and one compared low and high‐dose N‐acetylcysteine. Oral thiol derivatives were generally well‐tolerated with no significant adverse effects, however there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Authors' conclusions We found no evidence to recommend the use of either nebulized or oral thiol derivatives in people with cystic fibrosis. There are very few good quality trials investigating the effect of these medications in cystic fibrosis, and further research is required to investigate the potential role of these medications in improving the outcomes of people with cystic fibrosis. Plain language summary Compounds which can break down the structure of mucus for lung disease in cystic fibrosis Cystic fibrosis is a genetic disorder which mainly affects the lungs. Chest infections recur in people with cystic fibrosis due to a build up of thick sputum (phlegm) in the air passages. Several treatments, including thiol derivatives, aim to loosen this sputum and so improve lung function and reduce the frequency of chest infections. Thiol derivatives may be either nebulized (breathed in) or oral (by mouth). They have been shown to help in other lung conditions, such as chronic obstructive pulmonary disease. This review aims to find out if there is enough evidence to recommend the use of nebulized or oral thiol derivatives for people with cystic fibrosis. We included nine trials; three assessed the effect of nebulized thiol derivatives. Of the nebulized trials, one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and the other compared glutathione to 4% hypertonic saline. Nebulized thiol derivatives were generally well‐tolerated with no major adverse effects. However they showed no significant improvements in any of our outcome measures. Six included trials assessed the effects of oral thiol derivatives.Three of these trials compared oral N‐acetylcysteine to placebo; one compared oral N‐acetylcysteine, oral ambroxol and placebo; and one compared oral carbocysteine and oral ambroxol (no placebo). None of the trials showed an overall significant benefit in any of the outcome measures of this review. Oral thiol derivatives were generally well‐tolerated with no major adverse effects. In summary, the trials included in the review did not provide any evidence that nebulized or oral thiol derivatives were either beneficial or harmful to people with cystic fibrosis. Further research investigating the effects of thiol derivatives in people with cystic fibrosis is required before their use can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Tam, J, Nash, EF, Ratjen, F, Tullis, E, Stephenson, A", "articleTypes": [], "doi": "10.1002/14651858.CD007168.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.767Z" }, { "id": "1aa8394a-154b-43e8-a7d4-83a6aa6bd0c0", "pmid": "", "title": "Honey and lozenges for children with non‐specific cough", "imported": false, "abstract": "Abstract - Background Chronic non‐specific cough is a chronic, dry cough of in the absence of identifiable respiratory disease or known aetiology. Although it is usually not reflective of an underlying severe illness, it does cause significant morbidity, and as such relief from it is often sought. The use of honey and lozenges to soothe upper respiratory tract irritation is common, inexpensive, and potentially more effective in treating the symptoms than pharmacological interventions. Objectives To evaluate the efficacy of honey and/or lozenges in the management of children with chronic non‐specific cough. Search methods The Cochrane Airways Group searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, OLDMEDLINE, and EMBASE databases in October 2010. Selection criteria All randomised controlled trials comparing honey or lozenges with a placebo in treating children with chronic non‐specific cough. Data collection and analysis The results of the searches were assessed according to the pre‐determined criteria. None of the trials identified by the searches were eligible for inclusion, leaving no data available for analysis in this review. Main results The search did not provide any applicable randomised controlled trials that investigated the efficacy of honey and lozenges in treating children with non‐specific chronic cough. Data from acute studies suggest a potential role for honey in relieving cough, but whether this is applicable to chronic cough is unknown. Authors' conclusions Clinically, this review was unable to provide any justifiable recommendation for or against honey and/or lozenges due to the lack of evidence. The absence of applicable studies highlights the need for further research into the area of treating children with chronic non‐specific coughs with honey and/or lozenges. These treatments are not recommended when managing very young children (as lozenges are a potential choking hazard, and honey may cause infant botulism in children under one year of age). Plain language summary Honey and lozenges for children with non‐specific cough Symptomatic relief is often sought for children with chronic non‐specific cough (which is defined as a dry, non‐productive cough with no known cause lasting longer than four consecutive weeks). This review aimed to assess the efficacy of treating children with such coughs using honey or lozenges, as these options are inexpensive. No randomised controlled trials were found to be applicable to this review, primarily due to the participants in the studies not fulfilling the inclusion criteria. However, studies on the efficacy of these treatments in treating acute cough in children showed that honey has the potential to be beneficial in children over a year old. Further research evaluating the efficacy of honey and lozenges in treating chronic non‐specific coughs in children is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Mulholland, S; Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD007523.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "1aa904b8-30f0-44f2-898a-0ea97322a6c1", "pmid": "", "title": "Interventions for pityriasis rosea", "imported": false, "abstract": "Abstract - Background Pityriasis rosea is a scaly, itchy rash that mainly affects young adults and lasts for 2 to 12 weeks. The effects of many available treatments are uncertain. This is an update of a Cochrane Review first published in 2007. Objectives To assess the effects of interventions for the management of pityriasis rosea in any individual diagnosed by a medical practitioner. Search methods We updated our searches of the following databases to October 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched five trials registers. We also checked the reference lists of included and excluded studies, contacted trial authors, scanned the abstracts from major dermatology conference proceedings, and searched the CAB Abstracts database. We searched PubMed for adverse effects to November 2018. Selection criteria Randomised controlled trials of interventions in pityriasis rosea. Treatment could be given in a single therapy or in combination. Eligible comparators were no treatment, placebo, vehicle only, another active compound, or placebo radiation treatment. Data collection and analysis We used standard methodological procedures expected by the Cochrane. Our key outcomes were good or excellent rash improvement within two weeks, rated separately by the participant and medical practitioner; serious adverse events; resolution of itch within two weeks (participant‐rated); reduction in itch score within two weeks (participant‐rated); and minor participant‐reported adverse events not requiring withdrawal of the treatment. Main results We included 14 trials (761 participants). In general, risk of selection bias was unclear or low, but risk of performance bias and reporting bias was high for 21% of the studies. Participant age ranged from 2 to 60 years, and sex ratio was similar. Disease severity was measured by various severity indices, which the included studies did not categorise. Six studies were conducted in India, three in Iran, two in the Philippines, and one each in Pakistan, the USA, and China. The included studies were conducted in dermatology departments and a paediatric clinic. Study duration ranged from 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding source. The included studies assessed macrolide antibiotics, an antiviral agent, phototherapy, steroids and antihistamine, and Chinese medicine. None of the studies measured participant‐rated good or excellent rash improvement. All reported outcomes were assessed within two weeks of treatment, except for adverse effects, which were measured throughout treatment. There is probably no difference between oral clarithromycin and placebo in itch resolution (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.47 to 1.52; 1 study, 28 participants) or rash improvement (medical practitioner‐rated) (RR 1.13, 95% CI 0.89 to 1.44; 1 study, 60 participants). For this comparison, there were no serious adverse events (1 study, 60 participants); minor adverse events and reduction in itch score were not measured; and all evidence was of moderate quality. When compared with placebo, erythromycin may lead to increased rash improvement (medical practitioner‐rated) (RR 4.02, 95% CI 0.28 to 56.61; 2 studies, 86 participants, low‐quality evidence); however, the 95% CI indicates that the result may also be compatible with a benefit of placebo, and there may be little or no difference between treatments. Itch resolution was not measured, but one study measured reduction in itch score, which is probably larger with erythromycin (MD 3.95, 95% CI 3.37 to 4.53; 34 participants, moderate‐quality evidence). In the same single, small trial, none of the participants had a serious adverse event, and there was no clear difference between groups in minor adverse events, which included gastrointestinal upset (RR 2.00, CI 0.20 to 20.04; moderate‐quality evidence). Two trials compared oral azithromycin to placebo or vitamins. There is probably no difference between groups in itch resolution (RR 0.83, 95% CI 0.28 to 2.48) or reduction in itch score (MD 0.04, 95% CI −0.35 to 0.43) (both outcomes based on one study; 70 participants, moderate‐quality evidence). Low‐quality evidence from two studies indicates there may be no difference between groups in rash improvement (medical practitioner‐rated) (RR 1.02, 95% CI 0.52 to 2.00; 119 participants). In these same two studies, no serious adverse events were reported, and there was no clear difference between groups in minor adverse events, specifically mild abdominal pain (RR 5.82, 95% CI 0.72 to 47.10; moderate‐quality evidence). Acyclovir was compared to placebo, vitamins, or no treatment in three trials (all moderate‐quality evidence). Based on one trial (21 participants), itch resolution is probably higher with placebo than with acyclovir (RR 0.34, 95% CI 0.12 to 0.94); reduction in itch score was not measured. However, there is probably a significant difference between groups in rash improvement (medical practitioner‐rated) in favour of acyclovir versus all comparators (RR 2.45, 95% CI 1.33 to 4.53; 3 studies, 141 participants). Based on the same three studies, there were no serious adverse events in either group, and there was probably no difference between groups in minor adverse events (only one participant in the placebo group experienced abdominal pain and diarrhoea). One trial compared acyclovir added to standard care (calamine lotion and oral cetirizine) versus standard care alone (24 participants). The addition of acyclovir may lead to increased itch resolution (RR 4.50, 95% CI 1.22 to 16.62) and reduction in itch score (MD 1.26, 95% CI 0.74 to 1.78) compared to standard care alone. Rash improvement (medical practitioner‐rated) was not measured. The trial reported no serious adverse events in either group, and there may be no difference between groups in minor adverse events, such as headache (RR 7.00, 95% CI 0.40 to 122.44) (all results based on low‐quality evidence). Authors' conclusions When compared with placebo or no treatment, oral acyclovir probably leads to increased good or excellent, medical practitioner‐rated rash improvement. However, evidence for the effect of acyclovir on itch was inconclusive. We found low‐ to moderate‐quality evidence that erythromycin probably reduces itch more than placebo. Small study sizes, heterogeneity, and bias in blinding and selective reporting limited our conclusions. Further research is needed to investigate different dose regimens of acyclovir and the effect of antivirals on pityriasis rosea. Plain language summary Treatments for pityriasis rosea Background Pityriasis rosea is a common scaly rash prevalent in young adults. A patch of redness and scales is followed by widespread rash. Pityriasis rosea usually resolves within 2 to 12 weeks; however, the rash can resemble a serious contagious skin condition, causing concern. Moreover, pityriasis rosea can cause moderate to severe itching, making effective treatment necessary. Review question We wanted to evaluate the effectiveness and safety of treatments for pityriasis rosea. Eligible treatments were topical, systemic (oral or injected medicines that work throughout the entire body), or light therapy, given alone or in combination with another treatment, and compared against no treatment, placebo (an identical but inactive treatment), vehicle (inactive ingredients that help deliver an active treatment) only, or another active treatment. As spontaneous recovery usually occurs between 2 and 12 weeks in cases of untreated pityriasis rosea, we considered outcomes reported at two weeks. Study characteristics The evidence is current to October 2018. We included 14 studies with a total of 761 participants aged between 2 and 60 years (similar numbers of males and females). Most studies were conducted in Asia in dermatology departments and lasted between 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding sources. Disease severity was assessed by various measures, but participants were not categorised into mild, moderate, or severe disease. Important treatments assessed by the studies included various antibiotics and acyclovir (a drug meant to treat herpes infections), which were compared to placebo, no treatment, or standard care. Additional treatments included phototherapy, corticosteroids and antihistamine, and Chinese medicine (potenline). Most studies assessed treatment used for one week. All reported outcomes were assessed within two weeks of treatment, except for side effects, which were measured throughout treatment. None of the included studies reported on the participant's rating of rash improvement. Itch was always participant‐assessed. Rash improvement was rated as good or excellent. There is probably no difference between clarithromycin and placebo in medical practitioner‐rated rash improvement or itch resolution, and no serious adverse events were reported (all moderate‐quality evidence). Reduction in itch score and minor side effects were not measured. Similarly, there may be no difference in medical practitioner‐rated rash improvement between azithromycin and placebo or vitamins, but erythromycin may lead to increased rash improvement when compared to placebo; however, the results show there may be a benefit with placebo or little or no difference between treatments (low‐quality evidence for both outcomes). There is probably no difference between azithromycin and comparators in itch resolution or reduction in itch score; there was no clear difference in minor side effects, such as mild abdominal pain (both moderate‐quality evidence). When comparing erythromycin to placebo, itch resolution was not measured, but there is probably a greater reduction in itch score with erythromycin. There was no clear difference in the likelihood of minor side effects, such as gastrointestinal upset, between groups (moderate‐quality evidence for both outcomes). A single study suggested that acyclovir is probably less effective than placebo in achieving itch resolution (but itch score reduction was not measured). However, results from three studies indicate that acyclovir is probably significantly more beneficial than placebo, no treatment, or vitamin tablets in medical practitioner‐rated rash improvement. There is probably no difference between acyclovir and placebo in the incidence of minor side effects: one participant in the placebo group experienced mild abdominal pain and diarrhoea (all outcomes based on moderate‐quality evidence). A single trial indicated that acyclovir used in combination with standard care (calamine (anti‐itch lotion) and the antihistamine cetirizine) may reduce itch score and increase itch resolution (low‐quality evidence). Medical practitioner‐rated rash improvement was not measured. There may be no difference between groups in minor side effects, such as headache, increased sleep, sickness, and impact on taste. None of the studies reported serious adverse events (low‐ to moderate‐quality evidence). Quality of the evidence The quality of the evidence for the main comparisons was low to moderate. Many of the results were based on a small number of trials, with a low number of participants. There was also some variation amongst the trial results and concerns over study design.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Contreras‐Ruiz, J, Peternel, S, Jiménez Gutiérrez, C, Culav‐Koscak, I, Reveiz, L, Silbermann‐Reynoso, MDL", "articleTypes": [], "doi": "10.1002/14651858.CD005068.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.138Z" }, { "id": "1abcafa9-29ef-41ae-b30d-3b415b43841a", "pmid": "", "title": "Interventions for pityriasis rosea", "imported": false, "abstract": "Abstract - Background Pityriasis rosea is a scaly, itchy rash that mainly affects young adults and lasts for 2 to 12 weeks. The effects of many available treatments are uncertain. This is an update of a Cochrane Review first published in 2007. Objectives To assess the effects of interventions for the management of pityriasis rosea in any individual diagnosed by a medical practitioner. Search methods We updated our searches of the following databases to October 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched five trials registers. We also checked the reference lists of included and excluded studies, contacted trial authors, scanned the abstracts from major dermatology conference proceedings, and searched the CAB Abstracts database. We searched PubMed for adverse effects to November 2018. Selection criteria Randomised controlled trials of interventions in pityriasis rosea. Treatment could be given in a single therapy or in combination. Eligible comparators were no treatment, placebo, vehicle only, another active compound, or placebo radiation treatment. Data collection and analysis We used standard methodological procedures expected by the Cochrane. Our key outcomes were good or excellent rash improvement within two weeks, rated separately by the participant and medical practitioner; serious adverse events; resolution of itch within two weeks (participant‐rated); reduction in itch score within two weeks (participant‐rated); and minor participant‐reported adverse events not requiring withdrawal of the treatment. Main results We included 14 trials (761 participants). In general, risk of selection bias was unclear or low, but risk of performance bias and reporting bias was high for 21% of the studies. Participant age ranged from 2 to 60 years, and sex ratio was similar. Disease severity was measured by various severity indices, which the included studies did not categorise. Six studies were conducted in India, three in Iran, two in the Philippines, and one each in Pakistan, the USA, and China. The included studies were conducted in dermatology departments and a paediatric clinic. Study duration ranged from 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding source. The included studies assessed macrolide antibiotics, an antiviral agent, phototherapy, steroids and antihistamine, and Chinese medicine. None of the studies measured participant‐rated good or excellent rash improvement. All reported outcomes were assessed within two weeks of treatment, except for adverse effects, which were measured throughout treatment. There is probably no difference between oral clarithromycin and placebo in itch resolution (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.47 to 1.52; 1 study, 28 participants) or rash improvement (medical practitioner‐rated) (RR 1.13, 95% CI 0.89 to 1.44; 1 study, 60 participants). For this comparison, there were no serious adverse events (1 study, 60 participants); minor adverse events and reduction in itch score were not measured; and all evidence was of moderate quality. When compared with placebo, erythromycin may lead to increased rash improvement (medical practitioner‐rated) (RR 4.02, 95% CI 0.28 to 56.61; 2 studies, 86 participants, low‐quality evidence); however, the 95% CI indicates that the result may also be compatible with a benefit of placebo, and there may be little or no difference between treatments. Itch resolution was not measured, but one study measured reduction in itch score, which is probably larger with erythromycin (MD 3.95, 95% CI 3.37 to 4.53; 34 participants, moderate‐quality evidence). In the same single, small trial, none of the participants had a serious adverse event, and there was no clear difference between groups in minor adverse events, which included gastrointestinal upset (RR 2.00, CI 0.20 to 20.04; moderate‐quality evidence). Two trials compared oral azithromycin to placebo or vitamins. There is probably no difference between groups in itch resolution (RR 0.83, 95% CI 0.28 to 2.48) or reduction in itch score (MD 0.04, 95% CI −0.35 to 0.43) (both outcomes based on one study; 70 participants, moderate‐quality evidence). Low‐quality evidence from two studies indicates there may be no difference between groups in rash improvement (medical practitioner‐rated) (RR 1.02, 95% CI 0.52 to 2.00; 119 participants). In these same two studies, no serious adverse events were reported, and there was no clear difference between groups in minor adverse events, specifically mild abdominal pain (RR 5.82, 95% CI 0.72 to 47.10; moderate‐quality evidence). Acyclovir was compared to placebo, vitamins, or no treatment in three trials (all moderate‐quality evidence). Based on one trial (21 participants), itch resolution is probably higher with placebo than with acyclovir (RR 0.34, 95% CI 0.12 to 0.94); reduction in itch score was not measured. However, there is probably a significant difference between groups in rash improvement (medical practitioner‐rated) in favour of acyclovir versus all comparators (RR 2.45, 95% CI 1.33 to 4.53; 3 studies, 141 participants). Based on the same three studies, there were no serious adverse events in either group, and there was probably no difference between groups in minor adverse events (only one participant in the placebo group experienced abdominal pain and diarrhoea). One trial compared acyclovir added to standard care (calamine lotion and oral cetirizine) versus standard care alone (24 participants). The addition of acyclovir may lead to increased itch resolution (RR 4.50, 95% CI 1.22 to 16.62) and reduction in itch score (MD 1.26, 95% CI 0.74 to 1.78) compared to standard care alone. Rash improvement (medical practitioner‐rated) was not measured. The trial reported no serious adverse events in either group, and there may be no difference between groups in minor adverse events, such as headache (RR 7.00, 95% CI 0.40 to 122.44) (all results based on low‐quality evidence). Authors' conclusions When compared with placebo or no treatment, oral acyclovir probably leads to increased good or excellent, medical practitioner‐rated rash improvement. However, evidence for the effect of acyclovir on itch was inconclusive. We found low‐ to moderate‐quality evidence that erythromycin probably reduces itch more than placebo. Small study sizes, heterogeneity, and bias in blinding and selective reporting limited our conclusions. Further research is needed to investigate different dose regimens of acyclovir and the effect of antivirals on pityriasis rosea. Plain language summary Treatments for pityriasis rosea Background Pityriasis rosea is a common scaly rash prevalent in young adults. A patch of redness and scales is followed by widespread rash. Pityriasis rosea usually resolves within 2 to 12 weeks; however, the rash can resemble a serious contagious skin condition, causing concern. Moreover, pityriasis rosea can cause moderate to severe itching, making effective treatment necessary. Review question We wanted to evaluate the effectiveness and safety of treatments for pityriasis rosea. Eligible treatments were topical, systemic (oral or injected medicines that work throughout the entire body), or light therapy, given alone or in combination with another treatment, and compared against no treatment, placebo (an identical but inactive treatment), vehicle (inactive ingredients that help deliver an active treatment) only, or another active treatment. As spontaneous recovery usually occurs between 2 and 12 weeks in cases of untreated pityriasis rosea, we considered outcomes reported at two weeks. Study characteristics The evidence is current to October 2018. We included 14 studies with a total of 761 participants aged between 2 and 60 years (similar numbers of males and females). Most studies were conducted in Asia in dermatology departments and lasted between 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding sources. Disease severity was assessed by various measures, but participants were not categorised into mild, moderate, or severe disease. Important treatments assessed by the studies included various antibiotics and acyclovir (a drug meant to treat herpes infections), which were compared to placebo, no treatment, or standard care. Additional treatments included phototherapy, corticosteroids and antihistamine, and Chinese medicine (potenline). Most studies assessed treatment used for one week. All reported outcomes were assessed within two weeks of treatment, except for side effects, which were measured throughout treatment. None of the included studies reported on the participant's rating of rash improvement. Itch was always participant‐assessed. Rash improvement was rated as good or excellent. There is probably no difference between clarithromycin and placebo in medical practitioner‐rated rash improvement or itch resolution, and no serious adverse events were reported (all moderate‐quality evidence). Reduction in itch score and minor side effects were not measured. Similarly, there may be no difference in medical practitioner‐rated rash improvement between azithromycin and placebo or vitamins, but erythromycin may lead to increased rash improvement when compared to placebo; however, the results show there may be a benefit with placebo or little or no difference between treatments (low‐quality evidence for both outcomes). There is probably no difference between azithromycin and comparators in itch resolution or reduction in itch score; there was no clear difference in minor side effects, such as mild abdominal pain (both moderate‐quality evidence). When comparing erythromycin to placebo, itch resolution was not measured, but there is probably a greater reduction in itch score with erythromycin. There was no clear difference in the likelihood of minor side effects, such as gastrointestinal upset, between groups (moderate‐quality evidence for both outcomes). A single study suggested that acyclovir is probably less effective than placebo in achieving itch resolution (but itch score reduction was not measured). However, results from three studies indicate that acyclovir is probably significantly more beneficial than placebo, no treatment, or vitamin tablets in medical practitioner‐rated rash improvement. There is probably no difference between acyclovir and placebo in the incidence of minor side effects: one participant in the placebo group experienced mild abdominal pain and diarrhoea (all outcomes based on moderate‐quality evidence). A single trial indicated that acyclovir used in combination with standard care (calamine (anti‐itch lotion) and the antihistamine cetirizine) may reduce itch score and increase itch resolution (low‐quality evidence). Medical practitioner‐rated rash improvement was not measured. There may be no difference between groups in minor side effects, such as headache, increased sleep, sickness, and impact on taste. None of the studies reported serious adverse events (low‐ to moderate‐quality evidence). Quality of the evidence The quality of the evidence for the main comparisons was low to moderate. Many of the results were based on a small number of trials, with a low number of participants. There was also some variation amongst the trial results and concerns over study design.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Contreras‐Ruiz, J; Peternel, S; Jiménez Gutiérrez, C; Culav‐Koscak, I; Reveiz, L; Silbermann‐Reynoso, MDL", "articleTypes": [], "doi": "10.1002/14651858.CD005068.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "1ad6f7c1-891a-4c4f-9974-855f05cc4480", "pmid": "", "title": "Aminoglycosides, vancomycin, and metronidazole for people with cirrhosis and hepatic encephalopathy", "imported": false, "abstract": "Abstract - Rationale Hepatic encephalopathy is a common complication of cirrhosis. Its development is associated with increased morbidity and mortality. Its exact pathogenesis is unknown, but ammonia, produced by bacterial action in the intestine, plays a key role. Antibiotics modulate the gut flora and may reduce intestinal ammonia production. Aminoglycosides such as neomycin, paromomycin, and ribostamycin have been used to treat hepatic encephalopathy, as have other antibiotics such as vancomycin and metronidazole. Objectives To assess the beneficial and harmful effects of aminoglycosides, vancomycin, and metronidazole versus placebo, no intervention, other antibiotics, or other active pharmacological interventions, for the prevention and treatment of hepatic encephalopathy in people with cirrhosis. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, and three other databases to 15 April 2025. We also searched online trials registries for ongoing and unpublished trials, undertook manual searches of meeting and conference proceedings, checked bibliographies of relevant articles, and corresponded with investigators and pharmaceutical companies. Eligibility criteria We included randomised clinical trials (RCTs) involving participants with cirrhosis and hepatic encephalopathy, or who were at risk of developing hepatic encephalopathy, comparing aminoglycosides, vancomycin, or metronidazole to (1) placebo or no intervention; or (2) other pharmacological agents, including non‐absorbable disaccharides, other antibiotics, or other potentially beneficial agents (e.g. branched‐chain amino acids, L‐ornithine L‐aspartate, nitazoxanide (a broad‐spectrum antiparasitic/antiviral agent), and nicotinohydroxamic acid (a potent urease inhibitor). We included trials irrespective of publication status, outcomes reported, language, or blinding. We excluded trials involving people with hepatic encephalopathy associated with acute liver failure or with non‐cirrhotic portal hypertension. Outcomes The critical outcomes were all‐cause mortality, hepatic encephalopathy, and serious adverse events. The important outcomes were non‐serious adverse events and health‐related quality of life (HRQoL). Our primary time point was the maximum length of follow‐up. Risk of bias We used Cochrane's original risk of bias tool (RoB 1) to assess the risk of bias. Synthesis methods We used standard Cochrane methods. We undertook random‐effects meta‐analyses to calculate risk ratios (RRs) or standardised mean differences (SMDs), with 95% confidence intervals (CIs). We assessed heterogeneity with the I 2 statistic, and the certainty of evidence with the GRADE framework. Included studies We included 24 RCTs, involving 1405 participants experiencing 1418 hepatic encephalopathy events. Twenty‐three trials evaluated the treatment of hepatic encephalopathy and one, the secondary prevention of hepatic encephalopathy; we analysed these trials jointly. The trials assessed three aminoglycosides: neomycin (15 trials), paromomycin (three trials), and ribostamycin (one trial), as well as vancomycin (two trials), and metronidazole (three trials). Overall, 670 participants received these pharmacotherapies while 735 participants received a placebo or other potentially beneficial agents. We classified 22 of the 24 trials to be at an overall high risk of bias based on domain‐level assessments. Synthesis of results The certainty of evidence for all comparisons was low to very low, mainly due to risk of bias, imprecision, and heterogeneity. Twenty‐three of the 24 trials, involving 1383 participants, reported all‐cause mortality data. Aminoglycosides may increase mortality slightly compared to other potentially active agents (RR 1.64, 95% CI 1.03 to 2.62; I² = 0%; 3 studies, 166 participants). The evidence was very uncertain about whether aminoglycosides versus a placebo (RR 1.02, 95% CI 0.62 to 1.69; I² = 0%; 3 studies, 137 participants), non‐absorbable disaccharides (RR 1.21, 95% CI 0.57 to 2.59; I² not applicable; 4 studies, 266 participants), or other antibiotics (RR 1.00, 95% CI 0.24 to 4.23; I² = 83%; 8 studies, 496 participants) result in a difference in mortality risk. The evidence was also very uncertain when comparing vancomycin to non‐absorbable disaccharides (RR 0.94, 95% CI 0.26 to 3.40; I² not applicable; 2 studies, 72 participants), and metronidazole to other active agents (RR 0.97, 95% CI 0.14 to 6.66; I² = 0%; 3 studies, 242 participants). Nineteen trials involving 1281 participants reported data on hepatic encephalopathy. There may be little to no difference in the effects of aminoglycosides versus non‐absorbable disaccharides (RR 0.84, 95% CI 0.67 to 1.05; I² = 0%; 3 studies, 251 participants), aminoglycosides versus other potentially active agents (RR 1.21, 95% CI 0.79 to 1.85; I² = 0%; 3 studies, 166 participants), and metronidazole versus other active agents (RR 1.50, 95% CI 0.89 to 2.54; I² = 48%; 2 studies, 208 participants). The evidence is very uncertain about the effect of aminoglycosides versus placebo, other antibiotics, and vancomycin versus non‐absorbable disaccharides. Twenty trials, involving 1186 participants, reported a total of 328 serious adverse events. Aminoglycosides may slightly increase the risk of serious adverse events compared with other potentially active agents (RR 1.60, 95% CI 1.03 to 2.47; I² = 0%; 3 studies, 166 participants). The evidence is very uncertain when comparing aminoglycosides to placebo and other antibiotics, or when comparing vancomycin to non‐absorbable disaccharides. Eighteen trials, involving 922 participants, reported a total of 96 non‐serious adverse events. There may be a slight increase in the risk of adverse events when comparing aminoglycosides to placebo (RR 2.80, 95% CI 1.11 to 7.04; I² not applicable; 2 studies, 98 participants), and to other antibiotics (RR 3.24, 95% CI 1.08 to 9.70; I² = 0%; 8 studies, 251 participants). The evidence is very uncertain about the effects of aminoglycosides versus non‐absorbable disaccharides or other active agents, and metronidazole versus other active agents. Only one trial assessed HRQoL, but reported the data in a form that precluded meta‐analysis. Eight trials received support from pharmaceutical companies while six did not. Ten trials did not provide this information. Authors' conclusions Due to low‐ or very low‐certainty evidence, we do not know if aminoglycosides benefit hepatic encephalopathy compared to placebo or other potentially active agents. There may be a slight increase in the risks of mortality and serious adverse events with aminoglycosides compared to other agents, and of non‐serious adverse events when compared to placebo and other antibiotics. We do not know if vancomycin or metronidazole improve clinically relevant outcomes. Only one trial assessed health‐related quality of life. Funding This Cochrane review received no specific funding. Registration https://doi.org/10.1002/14651858.CD012734 Plain language summary Do the antibiotics aminoglycosides, vancomycin, and metronidazole help people with cirrhosis and hepatic encephalopathy, a brain disorder associated with chronic liver disease? Key messages Antibiotics previously thought to help people with cirrhosis manage the risk of hepatic encephalopathy do not appear to benefit the condition. These antibiotics possibly cause more side effects than other treatments for this condition. Research is needed to establish whether combining these antibiotics with other treatments may be beneficial. What are cirrhosis and hepatic encephalopathy? Cirrhosis is a long‐term condition in which the liver becomes badly scarred. The liver normally helps clean the blood, process nutrients, and fight infections. When it is repeatedly damaged over time, the scar tissue which develops makes it harder for the liver to work properly. People with cirrhosis may develop hepatic encephalopathy, a condition that results in poor brain functioning. The reason why people develop hepatic encephalopathy is complex, but the build‐up in the blood of toxins from the gut, particularly of a compound called ammonia, plays a key role. Ammonia is produced in the gut mainly as a result of the activities of gut bacteria. How do antibiotics work in hepatic encephalopathy? Antibiotics are medicines used to treat infections caused by bacteria. They work by killing bacteria or stopping them from growing. Certain antibiotics may reduce the levels of ammonia in the blood by interfering with ammonia production in the gut. These antibiotics have been used to treat hepatic encephalopathy for many years, but the evidence that they help is unclear. The antibiotics considered in this review are: aminoglycosides (neomycin, paromomycin, and ribostamycin); vancomycin; metronidazole. What did we want to find out? We wanted to know if these antibiotics help to prevent or treat hepatic encephalopathy in people with cirrhosis. We analysed their effects on the number of people who died, whose symptoms of hepatic encephalopathy improved or failed to improve, and the number who experienced serious or non‐serious complications. What did we do? We searched for studies that compared aminoglycosides, vancomycin, or metronidazole to: placebo – an inactive or 'dummy' medicine; non‐absorbable disaccharides – sugars that mainly act in the gut, and are commonly used to treat some digestive and liver conditions; other antibiotics; other active agents that may help the condition. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 24 studies which involved 1405 participants. Of these, 23 studies evaluated the treatment of hepatic encephalopathy, and one study explored the prevention of hepatic encephalopathy in people at risk. We found evidence for the following comparisons: aminoglycosides versus placebo, non‐absorbable disaccharides, other antibiotics, and other active agents – 19 studies in total; vancomycin versus non‐absorbable disaccharides – 2 studies; metronidazole versus other active agents – 3 studies. Main results Death Aminoglycosides may slightly increase the risk of death compared to other active agents. We do not know if aminoglycosides make any difference to the risk of death compared to placebo, non‐absorbable disaccharides, and other antibiotics. We also do not know if there is any difference in the risk of death between: vancomycin and non‐absorbable disaccharides; metronidazole and other active agents. Hepatic encephalopathy: number of people in whom hepatic encephalopathy failed to improve Aminoglycosides may make little to no difference to the number of people whose condition improves compared to non‐absorbable disaccharides and other active agents. Metronidazole may make little to no difference to the number of people whose condition improves compared to other active agents. We do not know if there is any difference in the number of people whose condition improves when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Serious complications Aminoglycosides may slightly increase the risk of serious complications compared to other active agents. We do not know if there is any difference in serious complications when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Non‐serious complications Aminoglycosides may slightly increase the risk of non‐serious complications compared to placebo or other antibiotics. We do not know if there is any difference in the risk of non‐serious complications when comparing: aminoglycosides to non‐absorbable disaccharides or other active agents; metronidazole to other active agents; vancomycin to non‐absorbable disaccharides. Only one study, using metronidazole, reported on health‐related quality of life, so we were unable to draw any conclusions for this outcome. What are the limitations of the evidence? We had little to no confidence in the results of the review because the participants and researchers in some studies were aware of which treatment the participants received, which may have influenced the results, while some studies did not report on the outcomes we were interested in. The studies were generally small, and differed in how they were conducted. There were also too few studies to be certain about the outcomes. How current is this evidence? The evidence is current to 15 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Jeyaraj, R, Zacharias, HD, Vadera, S, Low, ZY, Gluud, LL, Morgan, MY", "articleTypes": [], "doi": "10.1002/14651858.CD012734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.818Z" }, { "id": "1ad7697e-eb7c-4030-b33f-1874f7645673", "pmid": "", "title": "Combination inhaled steroid and long‐acting beta₂‐agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background The long‐acting bronchodilator tiotropium and single‐inhaler combination therapy of inhaled corticosteroids and long‐acting beta 2 ‐agonists (ICS/LABA) are commonly used for maintenance treatment of patients with chronic obstructive pulmonary disease (COPD). Combining these treatments, which have different mechanisms of action, may be more effective than administering the individual components. Objectives To assess relative effects of the following treatments on markers of exacerbations, symptoms, quality of life and lung function in patients with COPD. • Tiotropium plus LABA/ICS versus tiotropium. • Tiotropium plus LABA/ICS versus LABA/ICS. Search methods We searched the Cochrane Airways Group Specialised Register of Trials (April 2015), ClinicalTrials.gov ( www.ClinicalTrials.gov ), the World Health Organization (WHO) trials portal and reference lists of relevant articles. Selection criteria We included parallel, randomised controlled trials (RCTs) lasting three months or longer conducted to compare ICS and LABA combination therapy in addition to inhaled tiotropium versus tiotropium alone or combination therapy alone. Data collection and analysis We independently assessed trials for inclusion, then extracted data on trial quality and outcome results. We contacted study authors to ask for additional information. We collected trial information on adverse effects. Main results Tiotropium plus LABA/ICS versus tiotropium We included six studies (1902 participants) with low risk of bias that compared tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy versus tiotropium alone. We found no statistically significant differences in mortality between treatments (odds ratio (OR) 1.80, 95% confidence interval (CI) 0.55 to 5.91; two studies; 961 participants) as well as in the all‐cause hospitalisations (OR 0.84, 95% CI 0.53 to 1.33; two studies; 961 participants). The effect on exacerbations was heterogeneous among trials and was not meta‐analysed. Health‐related quality of life measured by St. George’s Respiratory Questionnaire (SGRQ) showed a statistically significant improvement in total scores with use of tiotropium + LABA/ICS compared with tiotropium alone (mean difference (MD) ‐3.46, 95% CI ‐5.05 to ‐1.87; four studies; 1446 participants). Lung function was significantly different in the combined therapy (tiotropium + LABA/ICS) group, although average benefit with this therapy was small. None of the included studies included exercise tolerance as an outcome. A pooled estimate of these studies did not show a statistically significant difference in adverse events (OR 1.16, 95% CI 0.92 to 1.47; four studies; 1363 participants), serious adverse events (OR 0.86, 95% CI 0.57 to 1.30; four studies; 1758 participants) and pneumonia (Peto OR 1.62, 95% CI 0.54 to 4.82; four studies; 1758 participants). Tiotropium plus LABA/ICS versus LABA/ICS One of the six studies (60 participants) also compared combined therapy (tiotropium + LABA/ICS) versus LABA/ICS therapy alone. This study was affected by lack of power; therefore results did not allow us to draw conclusions for this comparison. Authors' conclusions This review update includes three additional studies and provides new low quality evidence supporting the finding that tiotropium + LABA/ICS‐based therapy improves the disease‐specific quality of life. The current evidence is insufficient to support the benefit of tiotropium + LABA/ICS‐based therapy for mortality, hospital admission or exacerbations (moderate and low quality evidence). Compared with use of tiotropium alone, tiotropium + LABA/ICS‐based therapy does not seem to increase undesirable effects nor serious non‐fatal adverse events. Plain language summary Are tiotropium plus combination inhalers better than tiotropium or combination inhalers alone for the treatment of COPD? Background Chronic obstructive pulmonary disease (COPD) is a lung disease that includes the conditions chronic bronchitis and/or emphysema. COPD is characterised by narrowing of the airways and lung tissue destruction. Symptoms include breathlessness and long‐term cough. Symptoms of COPD are treatable, but the condition cannot be reversed or cured. It is usually brought on by airway irritants, such as smoking or inhaled dust. Inhalers with bronchodilators (which allow the airways in the lungs to relax and expand) and/or anti‐inflammatory agents are commonly used to ease symptoms and minimise the long‐term decline in health caused by COPD. Examples of these treatments are tiotropium, which is a bronchodilator, and combination inhalers, which contain another type of bronchodilator (long‐acting beta‐agonists) together with anti‐inflammatory agents (steroids). These treatments work in different ways and therefore might be more beneficial if used together. Study characteristics This review found six studies, involving 1902 participants, comparing the long‐term efficacy and side effects of tiotropium combined with combination inhalers for treatment of patients with COPD. Not all of the people included in these studies had COPD that was severe enough to be recommended for combined therapy according to current guidelines. Key results Current evidence shows potential benefits of treatment with tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy through increased health‐related quality of life and a small improvement i n lung function in patients receiving this combined therapy. However, this evidence does not allow us to draw conclusions about the effects of these treatments on mortality, hospitalisation for all causes and exacerbations. The frequency of serious and non‐serious adverse events was not increased in either of the two groups. Quality of the evidence Overall, we assessed the evidence presented in this review to be of moderate or low quality, which means we are reasonably confident in some of the findings, but less confident in others.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Rojas‐Reyes, MX, García Morales, OM, Dennis, RJ, Karner, C", "articleTypes": [], "doi": "10.1002/14651858.CD008532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.777Z" }, { "id": "1ae9719a-13a5-4d1c-9fb8-fbfaf5cc7df3", "pmid": "", "title": "Zinc supplementation for the promotion of growth and prevention of infections in infants less than six months of age", "imported": false, "abstract": "Abstract - Background Zinc is a vital micronutrient for humans and is essential for protein synthesis, cell growth, and differentiation. Severe zinc deficiency can lead to slower physical, cognitive and sexual growth, cause skin disorders, decrease immunity, increase incidence of acute illnesses in infants and children and contribute to childhood stunting. By estimation, 17.3% of the world population is at risk of inadequate zinc intake. Such nutritional impairment increases the risk of diarrhoea and pneumonia by 20%, as well as leads to a global loss of more than 16 million disability‐adjusted life years in children less than five years of age. Not only does zinc deficiency affect lives, it adds to the considerable financial burden on depleted resources in countries that are most affected. By preventing or curing this deficiency, we can improve childhood mortality, morbidity and growth. Objectives To assess the effectiveness of zinc supplementation for the promotion of growth, reduction in mortality, and the prevention of infections in infants less than six months of age. Search methods We used the standard search strategy of the Cochrane Neonatal Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 4), MEDLINE via PubMed (1966 to 18 May 2018), Embase (1980 to 18 May 2018), and CINAHL (1982 to 18 May 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials . An updated search from 1 January 2018 to 29 January 2020 was run in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria All randomised controlled (individual and cluster randomised) and quasi‐randomised trials of zinc supplementation in healthy, term infants, less than six months of age comparing infant mortality, incidence of diarrhoea or respiratory illnesses, growth and/or serum zinc levels were eligible. Data collection and analysis Two review authors screened search results (title and abstracts) and relevant full texts. Studies fulfilling prespecified inclusion criteria were included with any disagreements resolved by consensus. Extraction and analysis were then conducted. We used the GRADE approach to assess the quality of evidence as indicated by certainty in effect estimates. Main results Eight studies (with 85,629 infants) were included and five studies were meta‐analysed, out of which four studies compared zinc with placebo, and one compared zinc plus riboflavin versus riboflavin. Certain growth outcomes after six months of intervention (Weight for Age Z‐scores (WAZ) (standardised mean difference) (SMD) 0.16, 95% CI 0.03 to 0.29; three studies, n = 955; fixed‐effect; heterogeneity Chi² P = 0.96); I² = 0%); change in WAZ (SMD 0.16, 95% CI 0.07 to 0.25; one study, n = 386; fixed‐effect); (Weight‐for‐Length Z‐score (WLZ) (SMD 0.15, 95% CI 0.02 to 0.28; three studies, n = 955; fixed‐effect; heterogeneity: Chi² P = 0.81); I² = 0%); (change in WLZ (SMD 0.17, 95% CI 0.06 to 0.28; one study, n = 386; fixed‐effect)) were positively affected by zinc supplementation compared to placebo. A single study reported no difference in the incidence of diarrhoea and lower respiratory tract infection with zinc supplementation. Zinc had no effect on mortality in children younger than 12 months. When zinc plus riboflavin was compared to riboflavin only, significant improvement was observed in the incidence of wasting at 24 months (risk ratio (RR) 0.59, 95% CI 0.37 to 0.96; one study, n = 296; fixed‐effect), but significant worsening of incidence of stunting was present at 21 months (RR 1.53, 95% CI 1.09 to 2.16; one study, n = 298; fixed‐effect). Authors' conclusions There was a significant positive impact of zinc supplementation on WAZ and WLZ after six months of intervention in infants compared to placebo. When a combined supplement of zinc and riboflavin was compared to riboflavin, there was a significant reduction in wasting at 24 months, but stunting at 21 months was negatively affected. Although included trials were of good‐to‐moderate quality, evidence that could be meta‐analysed was based on a few studies which affected the overall quality of results. Regardless, there is a need for strong trials conducted in infants younger than six months before a strong recommendation can be made supporting zinc supplementation in this age group. Plain language summary Zinc supplementation for improving the health and survival of infants less than six months old Review question: does zinc supplementation reduce mortality, morbidity and increase growth in infants aged less than six months old? Background: zinc deficiency is prevalent in the world. Adequate zinc levels are linked to decreased deaths, illnesses and improved growth in all populations particularly in developing countries. Zinc supplementation in older children has shown some positive effects. Study characteristics: we searched for studies through January 2020 that enrolled healthy infants aged less than six months old and provided at least six months of zinc supplementation. We included eight studies that covered zinc supplementation compared with placebo, zinc and riboflavin compared with riboflavin only, zinc, riboflavin and B complex vitamins compared with riboflavin and B complex vitamins. Key results and certainty of evidence: zinc had no effect on decreasing deaths or illnesses in children younger than 12 months. Moderate‐ to good‐certainty evidence from three studies suggested an increase in weight‐for‐age Z‐scores and weight‐for‐length Z‐scores after zinc supplementation for six months compared to placebo only. Only one study could be analysed for zinc and riboflavin supplementation compared to riboflavin only, and the results suggested a decrease in wasting after 24 months of supplementation and an increase in stunting after 21 months. Conclusion: with this evidence, we cannot strongly recommend clinicians to prescribe zinc supplements to children under six months of age. We also encourage the development of trials that will provide zinc as well as other micronutrients in this age group and for such trials to evaluate outcomes such as death, disease, side effects and growth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lassi, ZS; Kurji, J; Oliveira, CSD; Moin, A; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD010205.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "1aef9970-bed5-47e6-ae03-182be3516ddc", "pmid": "", "title": "Cannabis‐based medicines and medical cannabis for adults with cancer pain", "imported": false, "abstract": "Abstract - Background Pain is a common symptom in people with cancer; 30% to 50% of people with cancer will experience moderate‐to‐severe pain. This can have a major negative impact on their quality of life. Opioid (morphine‐like) medications are commonly used to treat moderate or severe cancer pain, and are recommended for this purpose in the World Health Organization (WHO) pain treatment ladder. Pain is not sufficiently relieved by opioid medications in 10% to 15% of people with cancer. In people with insufficient relief of cancer pain, new analgesics are needed to effectively and safely supplement or replace opioids. Objectives To evaluate the benefits and harms of cannabis‐based medicines, including medical cannabis, for treating pain and other symptoms in adults with cancer compared to placebo or any other established analgesic for cancer pain. Search methods We used standard, extensive Cochrane search methods. The latest search date was 26 January 2023. Selection criteria We selected double‐blind randomised, controlled trials (RCT) of medical cannabis, plant‐derived and synthetic cannabis‐based medicines against placebo or any other active treatment for cancer pain in adults, with any treatment duration and at least 10 participants per treatment arm. Data collection and analysis We used standard Cochrane methods. The primary outcomes were 1. proportions of participants reporting no worse than mild pain; 2. Patient Global Impression of Change (PGIC) of much improved or very much improved and 3. withdrawals due to adverse events. Secondary outcomes were 4. number of participants who reported pain relief of 30% or greater and overall opioid use reduced or stable; 5. number of participants who reported pain relief of 30% or greater, or 50% or greater; 6. pain intensity; 7. sleep problems; 8. depression and anxiety; 9. daily maintenance and breakthrough opioid dosage; 10. dropouts due to lack of efficacy; 11. all central nervous system adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We identified 14 studies involving 1823 participants. No study assessed the proportions of participants reporting no worse than mild pain on treatment by 14 days after start of treatment. We found five RCTs assessing oromucosal nabiximols (tetrahydrocannabinol (THC) and cannabidiol (CBD)) or THC alone involving 1539 participants with moderate or severe pain despite opioid therapy. The double‐blind periods of the RCTs ranged between two and five weeks. Four studies with a parallel design and 1333 participants were available for meta‐analysis. There was moderate‐certainty evidence that there was no clinically relevant benefit for proportions of PGIC much or very much improved (risk difference (RD) 0.06, 95% confidence interval (CI) 0.01 to 0.12; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 8 to 100). There was moderate‐certainty evidence for no clinically relevant difference in the proportion of withdrawals due to adverse events (RD 0.04, 95% CI 0 to 0.08; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 16 to endless). There was moderate‐certainty evidence for no difference between nabiximols or THC and placebo in the frequency of serious adverse events (RD 0.02, 95% CI −0.03 to 0.07). There was moderate‐certainty evidence that nabiximols and THC used as add‐on treatment for opioid‐refractory cancer pain did not differ from placebo in reducing mean pain intensity (standardised mean difference (SMD) −0.19, 95% CI −0.40 to 0.02). There was low‐certainty evidence that a synthetic THC analogue (nabilone) delivered over eight weeks was not superior to placebo in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and non‐small cell lung cancer (2 studies, 89 participants, qualitative analysis). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that synthetic THC analogues were superior to placebo (SMD −0.98, 95% CI −1.36 to −0.60), but not superior to low‐dose codeine (SMD 0.03, 95% CI −0.25 to 0.32; 5 single‐dose trials; 126 participants) in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours (2 single‐dose trials; 66 participants). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that CBD oil did not add value to specialist palliative care alone in the reduction of pain intensity in people with advanced cancer. There was no difference in the number of dropouts due to adverse events and serious adverse events (1 study, 144 participants, qualitative analysis). We found no studies using herbal cannabis. Authors' conclusions There is moderate‐certainty evidence that oromucosal nabiximols and THC are ineffective in relieving moderate‐to‐severe opioid‐refractory cancer pain. There is low‐certainty evidence that nabilone is ineffective in reducing pain associated with (radio‐) chemotherapy in people with head and neck cancer and non‐small cell lung cancer. There is low‐certainty evidence that a single dose of synthetic THC analogues is not superior to a single low‐dose morphine equivalent in reducing moderate‐to‐severe cancer pain. There is low‐certainty evidence that CBD does not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. Plain language summary Cannabis‐based medicines for cancer pain Do medicines based on cannabis help adults with cancer pain? Key messages Cannabis‐based medicines (CbMs) did not relieve cancer pain that did not respond to morphine‐like medicines. The studies analysed did not allow any statement to be made on the place of these medications in the World Health Organization (WHO) analgesic ladder for cancer pain. Trials with CbMs in cancer need to be very much better designed than those conducted so far. Pain in cancer and its treatment One person in two or three who gets cancer will have pain that becomes moderate or severe in intensity. The pain tends to get worse as the cancer progresses. The WHO recommends taking morphine‐like medicines for moderate‐to‐severe pain from cancer, but 1 in 6 to 10 people with cancer pain do not experience sufficient pain relief from morphine‐like medicines. Several products based on the cannabis plant have been suggested as treatment for cancer pain. These products include inhaled or orally ingested herbal cannabis, and various oils, sprays or tablets containing active cannabis ingredients obtained from the plant, or made synthetically. Some people with cancer pain have reported that CbMs are effective for them, and that is often highlighted in the media. What did we want to find out? If CbMs relieved cancer pain in people living with cancer. If CbMs were associated with any unwanted or harmful effects. What did we do? We searched for clinical trials that examined CbMs compared to other medications to treat cancer pain in adults. We summarised the results of the studies and rated our confidence in the evidence, based on factors such as the methods and size of studies. What did we find? We found 14 studies involving 1823 people. The biggest study included 399 people and the smallest study included 10 people. Studies were conducted in countries around the world; most (six) were based in North America. Five studies used one dose of CbM and lasted less than one day. Other studies lasted between two and eight weeks. Pharmaceutical companies funded seven studies. Six studies compared a mouth spray with a plant‐derived combination of tetrahydrocannabinol (THC), the principal psychoactive constituent of cannabis, and cannabidiol (CBD), an anti‐inflammatory ingredient of cannabis, against a fake medication (placebo). Seven studies compared an artificial cannabinoid mimicking the effects of THC against placebo. Of these seven studies, two studies compared against a morphine‐like medication (codeine), too. One study compared CBD against placebo. We did not find studies with herbal cannabis. Main results Mouth spray with a plant‐derived combination of THC and CBD was probably not better than placebo in reducing pain in people with moderate‐to‐severe cancer pain despite opioid treatment. Thirty‐two out of 100 people reported to be much or very much improved by cannabis‐based mouth spray and 23 out of 100 people with mouth spray with placebo. A total of 19 out of 100 people withdrew early because of side effects by cannabis‐based mouth spray and 16 out of 100 people by mouth spray with placebo. There was no difference in serious side effects between the cannabis‐based mouth spray and a placebo mouth spray. Artificial cannabinoid mimicking the effects of THC may not be better than a fake medication in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and a certain type of lung cancer. A single dose of an artificial cannabinoid mimicking the effects of THC may be better than a single dose of placebo, but may not differ from a single small dose of a morphine‐like medication in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours. CBD may not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. We found no studies with medical cannabis. What are the limitations of the evidence? We are moderately confident in the evidence that a mouth spray with a plant‐derived combination of THC and CBD does not reduce severe cancer pain despite opioid treatment because studies did not provide information about everything that we could have used. We have little confidence in the evidence that an artificial cannabinoid mimicking the effects of THC (nabilone) does not reduce pain associated with chemotherapy or radiochemotherapy because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that artificial cannabinoids mimicking the effects of THC reduce cancer pain after the previous pain‐relieving medication was stopped some hours before because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that CBD added to standard palliative care does not reduce cancer pain because there was only one study available. How up to date is the evidence? The evidence is up to date to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Häuser, W; Welsch, P; Radbruch, L; Fisher, E; Bell, RF; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD014915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "1afdc662-104a-43c4-8457-b2ea3f8e6c26", "pmid": "", "title": "Siponimod for multiple sclerosis", "imported": false, "abstract": "Abstract - Background Multiple sclerosis (MS) is a chronic immune‐mediated disease of the central nervous system, with an unpredictable course. Current MS therapies such as disease‐modifying therapies focus on treating exacerbations, preventing new exacerbations and avoiding the progression of disability. Siponimod (BAF312) is an oral treatment, a selective sphingosine‐1‐phosphate (S1P) receptor modulator, for the treatment of adults with relapsing forms of MS including active, secondary progressive MS with relapses. Objectives To assess the benefits and adverse effects of siponimod as monotherapy or combination therapy versus placebo or any active comparator for people diagnosed with MS. Search methods We searched the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Trials Register, which contains studies from CENTRAL, MEDLINE and Embase, and the trials registry databases ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 10 September 2021. We also handsearched relevant journals and screened the reference lists of published reviews and retrieved articles and searched reports (2004 to September 2021) from the MS societies in Europe and America. Selection criteria We included randomised parallel controlled clinical trials (RCTs) that evaluated siponimod, as monotherapy or combination therapy, versus placebo or any active comparator in people with MS. There were no restrictions on dose or administration frequency. Data collection and analysis We used standard methodological procedures expected by Cochrane. We discussed disagreements and resolved them by consensus among the review authors. Our primary outcomes wereworsening disability , relapse and adverse events, and secondary outcomes were annualised relapse rate, gadolinium‐enhancing lesions, new lesions or enlarged pre‐existing lesions and mean change of brain volume. We independently evaluated the certainty of evidence using the GRADE approach. We contacted principal investigators of included studies for additional data or confirmation of data. Main results Two studies (1948 participants) met our selection criteria, 608 controls and 1334 treated with siponimod. The included studies compared siponimod with placebo. Overall, all studies had a high risk of bias due to selective reporting and attrition bias. Comparing siponimod administered at a dose of 2 mg to placebo, we found that siponimod may reduce the number of participants with disability progression at six months (56 fewer people per 1000; risk ratio (RR) 0.78, 95% confidence interval (CI) 0.65 to 0.94; 1 study, 1641 participants; low‐certainty evidence) and annualised relapse rate (RR 0.43, 95% CI 0.34 to 0.56; 2 studies, 1739 participants; low‐certainty evidence). But it might lead to little reduction in the number of participants with new relapse (166 fewer people per 1000; RR 0.38, 95% CI 0.15 to 1.00; 1 study, 94 participants; very low‐certainty evidence). We observed no evidence of a difference due to adverse events for siponimod at 2 mg compared to placebo (14 more people per 1000; RR 1.52, 95% CI 0.85 to 2.71; 2 studies, 1739 participants, low‐certainty evidence). In addition, due to the high risk of inaccurate magnetic resonance imaging (MRI) data in the two included studies, we could not combine data for active lesions on MRI scans. Both studies had high attrition bias resulting from the unbalanced reasons for dropouts among groups and high risk of bias due to conflicts of interest. Siponimod may reduce the number of gadolinium‐enhancing T1‐weighted lesions at two years of follow‐up (RR 0.14, 95% CI 0.10 to 0.19; P < 0.0001; 1 study, 1641 participants; very low‐certainty evidence). There may be no evidence of a difference between groups in the number of participants with at least one serious adverse event excluding relapses (113 more people per 1000; RR 1.80, 95% CI 0.37 to 8.77; 2 studies, 1739 participants; low‐certainty evidence) at six months. No data were available regarding cardiac adverse events. In terms of safety profile, the most common adverse events associated with siponimod were headache, back pain, bradycardia, dizziness, fatigue, influenza, urinary tract infection, lymphopenia, nausea, alanine amino transferase increase and upper respiratory tract infection. These adverse events have dose‐related effects and rarely led to discontinuation of treatment. Authors' conclusions Based on the findings of the RCTs included in this review, we are uncertain whether siponimod interventions are beneficial for people with MS. There was low‐certainty evidence to support that siponimod at a dose of 2 mg orally once daily as monotherapy compared with placebo may reduce the annualised relapse rate and the number of participants who experienced disability worsening, at 6 months. However, the certainty of the evidence to support the benefit in reducing the number of people with a relapse is very low. The risk of withdrawals due to adverse events requires careful monitoring of participants over time. The duration of all studies was less than 24 months, so the efficacy and safety of siponimod over 24 months are still uncertain, and further exploration is needed in the future. There is no high‐certainty data available to evaluate the benefit on MRI outcomes. We assessed the certainty of the body of evidence for all outcomes was low to very low, downgraded due to serious study limitations, imprecision and indirectness. We are uncertain whether siponimod is beneficial for people with MS. More new studies with robust methodology and longer follow‐up are needed to evaluate the benefit of siponimod for the management of MS and to observe long‐term adverse effects. Also, in addition to comparing with placebo, more new studies are needed to evaluate siponimod versus other therapeutic options. Plain language summary Is siponimod an effective treatment for multiple sclerosis (MS) and does it cause unwanted effects? Key messages · We don’t know whether siponimod is an effective treatment for people with multiple sclerosis (MS). At a dose of 2 mg once a day, siponimod may reduce recurrence of symptoms (relapse, calculated as an annual rate) after six months of treatment and may reduce the number of participants whose disability worsens after three months of treatment. · We don’t know if siponimod causes unwanted effects because studies did not last long enough to fully assess them. · Future studies should last longer in order to monitor unwanted and beneficial effects of siponimod better, and should use more robust methods. They should compare siponimod with other medicines. What is multiple sclerosis? Multiple sclerosis (MS) is a condition caused when the body’s immune system – which defends the body against disease and infection – mistakenly attacks parts of the central nervous system (the brain and spinal cord). Symptoms include problems with balance and walking, and blurred vision. MS is a lifelong condition that can cause serious disability. Some people’s symptoms may develop gradually. However, most people experience ‘attacks’ when new symptoms develop or existing symptoms worsen (called ‘relapse’), followed by periods with no changes to their symptoms (called ‘remittance’). This type of MS is called ‘relapsing remitting’ MS. Eventually, the course of their MS may change. These periods when there are no symptoms, or no worsening of symptoms, may stop and then symptoms may worsen continually. This is called ‘secondary progressive MS’. How does siponimod work? Siponimod is a medicine that attaches to the white blood cells (lymphocytes) that attack the central nervous system. This causes the lymphocytes to stay in the lymph glands instead of circulating in the blood to the brain. Fewer lymphocytes reach the brain so the attack by the immune system is reduced. Siponimod is a tablet taken once a day. What did we want to find out? We wanted to know if siponimod is an effective treatment for MS and whether it causes any unwanted effects. We were interested in the number of people: · who experienced relapses; · whose disability worsened; · who left the studies because of unwanted effects of siponimod; · who developed new or larger brain lesions (damage to the brain); and · who experienced serious unwanted effects, and which unwanted effects they experienced. What did we do? 
We searched for studies that investigated siponimod compared with placebo (a sham medicine that looks and tastes the same as siponimod but with no active ingredients) or another medicine to treat MS. Studies could investigate siponimod alone or combined with another treatment, at any dose over any length of time. Participants had to be aged over 18 years, with confirmed MS. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found two studies with 1948 participants. Both studies compared siponimod with placebo. One study included 1651 people with secondary progressive MS, who were given 2 mg siponimod for up to 3 years. The other study included 297 participants with relapsing remitting MS, who were given siponimod at doses of 10 mg, 2 mg or 0.5 mg for 6 months, or 1.25 mg or 0.25 mg for 3 months. We report the results for 2 mg daily because both studies looked at this dose. At 2 mg a day, compared to placebo: · siponimod may lead to a small reduction (166 fewer people per 1000) in the number of people with a new relapse up to six months after starting treatment, and may also reduce relapses when calculated at an annual rate; · siponimod may reduce the number of people whose disability worsened during the six months after starting treatment (by 56 people per 1000); · there may be no difference to the number of people (14 more per 1000) who left the studies in the six months after starting treatment due to unwanted effects; · siponimod may reduce the number of brain lesions of different types after six months and after two years of follow‐up. · siponimod may make no difference to the number of people with at least one serious unwanted effect in the six months after starting treatment. The most common unwanted effects associated with siponimod were headache, back pain, dizziness, tiredness, influenza, urinary tract infection, reduced white blood cells (lymphopenia), feeling sick, possible liver damage, and infections in the mouth and nose. No information was available about heart‐related unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only 2 studies. They did not provide information about everything we were interested and they included people with different types of MS. Also, they did not last long enough to judge the impact of unwanted effects. Both studies were funded by the company that makes siponimod.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Cao, L; Li, M; Yao, L; Yan, P; Wang, X; Yang, Z; Lao, Y; Li, H; Yang, K; Li, K", "articleTypes": [], "doi": "10.1002/14651858.CD013647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "1b25a299-8642-4dd4-893b-fb8b3e0b323e", "pmid": "", "title": "Interventions to prevent obesity in children aged 2 to 4 years old", "imported": false, "abstract": "Abstract - Rationale Early childhood presents an important opportunity for obesity prevention, an international public health priority. Interventions aiming to prevent obesity typically promote healthy diets or activity levels (physical activity, sedentary behaviour), or both. There is uncertainty over which approaches are more effective. This is one of a suite of three reviews addressing interventions for preventing obesity in children, each focusing on different age groups up to 18 years. These reviews replace and update a 2019 Cochrane review on interventions for preventing obesity in children from birth to 18 years. Objectives To assess the effects of interventions that aimed to prevent obesity in children aged two to four years by changing dietary intake or activity levels, or both, on body mass index (BMI), BMI z‐score (zBMI), BMI percentile, and serious adverse events. Search methods We searched CENTRAL, MEDLINE, Embase, six other databases, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify eligible studies. The latest search date was 7 February 2023. Eligibility criteria We included randomised controlled trials (RCTs) in children aged two to four years, comparing dietary or activity interventions (or both combined) to prevent overweight or obesity versus no intervention, usual care, or another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post‐baseline. There were no language restrictions. Outcomes Our outcomes were BMI, zBMI, BMI percentile, and serious adverse events. Risk of bias We used version 2 of the Cochrane risk of bias tool (RoB 2) to assess included RCTs. Synthesis methods Working independently, two authors screened studies, extracted data, and conducted risk of bias and GRADE assessments. We conducted random‐effects meta‐analyses stratified by type of intervention and follow‐up duration. Included studies We included 67 studies (36,601 participants), with 56 studies (21,404 participants) pooled in the meta‐analyses. Sixty‐three studies were conducted in high‐income countries. Study settings were split between childcare (26 studies; 39%), home (23 studies; 34%), and home plus childcare settings (10 studies; 15%). Few studies were conducted in the community (three studies; 5%) or healthcare settings (five studies; 7%). Most studies compared a combined dietary/activity intervention with a control group. Synthesis of results Dietary interventions versus control Dietary interventions may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0.00, 95% confidence interval (CI) ‐0.28 to 0.28; 1 study, 94 participants; low‐certainty evidence). At medium‐ and long‐term follow‐up, dietary interventions may result in little to no difference in BMI. One study (103 participants; low‐certainty evidence) reported no difference in BMI at medium‐term follow‐up, and one study (2238 participants; low‐certainty evidence) found lower rates of overweight and obesity in the intervention group at long‐term follow‐up. Dietary interventions likely result in little to no difference in zBMI at short‐term (MD 0.03, 95% CI ‐0.13 to 0.19; 2 studies, 145 participants) and medium‐term follow‐up (MD ‐0.17, 95% CI ‐0.44 to 0.10; 1 study, 389 participants), both with moderate‐certainty evidence. None of the included studies reported zBMI at long‐term follow‐up. None of the studies reported serious adverse events. Activity interventions versus control Activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.10, 95% CI ‐0.28 to 0.08; 6 studies, 826 participants; very low‐certainty evidence). They likely reduce BMI at medium‐term follow‐up (MD ‐0.70, 95% CI ‐1.09 to ‐0.31; 1 study, 567 participants; moderate‐certainty evidence). None of the studies reported BMI at long‐term follow‐up. Activity interventions likely result in little to no difference in zBMI at short‐term follow‐up (MD ‐0.06, 95% CI ‐0.19 to 0.07; 3 studies, 635 participants; moderate‐certainty evidence). They may result in little to no difference in zBMI at medium‐term follow‐up, but the evidence is very uncertain (MD ‐0.00, 95% CI ‐0.12 to 0.11; 4 studies, 1083 participants; very low‐certainty evidence). None of the included studies reported zBMI at long‐term follow‐up. Activity interventions may have little to no effect on serious adverse events, but the evidence is very uncertain (2 studies, 773 participants; very low‐certainty evidence). One study found no harms related to the intervention, and one study reported no difference in accident and infection rates between groups. Combined dietary/activity interventions versus control Combined dietary/activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.08, 95% CI ‐0.20 to 0.04; 13 studies, 3867 participants; very low‐certainty evidence). They may result in little to no difference in BMI at medium‐term follow‐up (MD ‐0.05, 95% CI ‐0.18 to 0.08; 9 studies, 7016 participants; low‐certainty evidence), and may result in a slight reduction in BMI at long‐term follow‐up (MD ‐0.20, 95% CI ‐0.39 to ‐0.01; 5 studies, 2074 participants; low‐certainty evidence). Combined interventions may have little to no effect on zBMI at short‐term follow‐up (MD ‐0.03, 95% CI ‐0.07 to 0.01; 14 studies, 5518 participants), and may result in a slight reduction in zBMI at medium‐term follow‐up, but the evidence for both time frames is very uncertain (MD ‐0.07, 95% CI ‐0.11 to ‐0.04; 15 studies; 11,043 participants). Combined interventions may result in a slight reduction in zBMI at long‐term follow‐up (MD ‐0.07, 95% CI ‐0.13 to ‐0.01; 10 studies, 4693 participants; low‐certainty evidence). Combined interventions may result in little to no difference in serious adverse events, but the evidence is very uncertain (4 studies, 1689 participants; very low‐certainty evidence). One study reported that a parent fractured an ankle while roller‐skating at a community centre; the remaining studies reported no adverse events. Authors' conclusions In early childhood, combined dietary/activity interventions may have very modest benefits on BMI and zBMI at long‐term follow‐up. When implemented alone, dietary or activity interventions may have little to no effect on BMI measures. Only six studies reported serious adverse events, with no serious harms resulting directly from the intervention, but the evidence is very uncertain. Funding This review was partly funded by the National Institute for Health Research, School for Public Health Research. Registration Protocol available: DOI: 10.1002/14651858.CD015326 Plain language summary Do dietary and activity strategies help prevent obesity in children aged 2 to 4 years? Key messages Combining strategies for changing diet and physical activity levels in children aged 2 to 4 years to help prevent overweight and obesity may reduce body mass index (BMI) slightly in the long term (after 15 months). There was very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but none of the strategies appeared to result in any serious harm to the children. Future research should carry out obesity prevention strategies in community settings, and target the wider determinants of obesity and obesity prevention. Why is preventing obesity in children important? There is an increasing number of young children living with overweight and obesity worldwide, with evidence of the rates increasing in line with social inequality. Living with overweight during childhood can cause physical and psychological health problems. Children living with overweight are more likely to live with overweight as adults, and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help people change diet or activity (or both) are effective at preventing obesity in children aged 2 to 4 years, and whether they are associated with any serious adverse events. To examine obesity, we used the measure of body mass index (BMI). BMI is calculated by dividing a person's weight (in kg) by their height (in m 2 ). What did we do? We searched for studies that looked at ways to prevent obesity in children aged 2 to 4 years. We did not include studies that only targeted children who were already living with overweight or obesity, but we did include studies involving children at a range of weights. We only included studies if they used methods aimed at changing children's diet, activity level (increasing physical activity or reducing sedentary behaviour), or both. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 67 studies involving 36,601 children aged 2 to 4 years. Most studies (63 of 67) were based in high‐income countries, and four in upper‐middle‐income countries. In 26 studies, the strategies were conducted in childcare settings, 23 studies were primarily home‐based, and 10 were performed in both childcare and home‐based settings. Only 3 studies were conducted in the community, and 5 in healthcare settings. The duration of the programmes varied: 47 ran for fewer than 9 months, with the shortest being 1 visit and the longest lasting 3 years. We analysed results from 56 studies involving 21,404 children. Main findings Children who were helped with a strategy to change their diet and activity levels may have had a reduced BMI, compared with children not given any strategy. This means that these children may have been able to minimise excess weight gain by a small amount, which, for public health, is important. Children who were helped with a strategy to change their diet or activity alone did not have a reduced BMI. Only six of the 67 included studies reported on serious adverse events, and no serious harms were identified. What are the limitations of the evidence? Overall, our confidence in the evidence is very low. However, we do not believe that results from more studies similar in design to those included in this review would produce a higher level of confidence in the results. Four main factors reduced our confidence in the evidence. Results were very inconsistent across different studies. There were not enough studies reporting specific types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons. Results from some studies were not reported in a way that we could include in our analyses and this may have had an impact on the combined results. Studies generally had limitations in how they were conducted, due to the complexity of studies in this age group. This review does not provide enough information to assess how well these strategies work for children with disabilities or those from low‐ and middle‐income countries. How current is this evidence? This review updates a previous review. The evidence is current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Phillips, SM, Spiga, F, Moore, THM, Dawson, S, Stockton, H, Rizk, R, Cheng, HY, Hodder, RK, Gao, Y, Hillier-Brown, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015326.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.818Z" }, { "id": "1b45cce5-3c8f-43e2-9209-bd79e453b922", "pmid": "", "title": "Nutritional supplementation for hip fracture aftercare in older people", "imported": false, "abstract": "Abstract - Background Older people with hip fractures are often malnourished at the time of fracture, and subsequently have poor food intake. This is an update of a Cochrane review first published in 2000, and previously updated in 2010. Objectives To review the effects (benefits and harms) of nutritional interventions in older people recovering from hip fracture. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, MEDLINE In‐Process & Other Non‐Indexed Citations, Embase, CAB Abstracts, CINAHL, trial registers and reference lists. The search was last run in November 2015. Selection criteria Randomised and quasi‐randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture where the interventions were started within the first month after hip fracture. Data collection and analysis Two review authors independently selected trials, extracted data and assessed risk of bias. Where possible, we pooled data for primary outcomes which were: all cause mortality; morbidity; postoperative complications (e.g. wound infections, pressure sores, deep venous thromboses, respiratory and urinary infections, cardiovascular events); and 'unfavourable outcome' defined as the number of trial participants who died plus the number of survivors with complications. We also pooled data for adverse events such as diarrhoea. Main results We included 41 trials involving 3881 participants. Outcome data were limited and risk of bias assessment showed that trials were often methodologically flawed, with less than half of trials at low risk of bias for allocation concealment, incomplete outcome data, or selective reporting of outcomes. The available evidence was judged of either low or very low quality indicating that we were uncertain or very uncertain about the estimates. Eighteen trials evaluated oral multinutrient feeds that provided non‐protein energy, protein, vitamins and minerals. There was low‐quality evidence that oral feeds had little effect on mortality (24/486 versus 31/481; risk ratio (RR) 0.81 favouring supplementation, 95% confidence interval (CI) 0.49 to 1.32; 15 trials). Thirteen trials evaluated the effect of oral multinutrient feeds on complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was low‐quality evidence that the number of participants with complications may be reduced with oral multinutrient feeds (123/370 versus 157/367; RR 0.71, 95% CI 0.59 to 0.86; 11 trials). Based on very low‐quality evidence from six studies (334 participants), oral supplements may result in lower numbers with 'unfavourable outcome' (death or complications): RR 0.67, 95% CI 0.51 to 0.89. There was very low‐quality evidence for six studies (442 participants) that oral supplementation did not result in an increased incidence of vomiting and diarrhoea (RR 0.99, 95% CI 0.47 to 2.05). Only very low‐quality evidence was available from the four trials examining nasogastric multinutrient feeding. Pooled data from three heterogeneous trials showed no evidence of an effect of supplementation on mortality (14/142 versus 14/138; RR 0.99, 95% CI 0.50 to 1.97). One trial (18 participants) found no difference in complications. None reported on unfavourable outcome. Nasogastric feeding was poorly tolerated. One study reported no cases of aspiration pneumonia. There is very low‐quality evidence from one trial (57 participants, mainly men) of no evidence for an effect of tube feeding followed by oral supplementation on mortality or complications. Tube feeding, however, was poorly tolerated. There is very low‐quality evidence from one trial (80 participants) that a combination of intravenous feeding and oral supplements may not affect mortality but could reduce complications. However, this expensive intervention is usually reserved for people with non‐functioning gastrointestinal tracts, which is unlikely in this trial. Four trials tested increasing protein intake in an oral feed. These provided low‐quality evidence for no clear effect of increased protein intake on mortality (30/181 versus 21/180; RR 1.42, 95% CI 0.85 to 2.37; 4 trials) or number of participants with complications but very low‐quality and contradictory evidence of a reduction in unfavourable outcomes (66/113 versus 82/110; RR 0.78, 95% CI 0.65 to 0.95; 2 trials). There was no evidence of an effect on adverse events such as diarrhoea. Trials testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. Based on low‐quality evidence, one trial evaluating the use of dietetic assistants to help with feeding indicated that this intervention may reduce mortality (19/145 versus 36/157; RR 0.57, 95% CI 0.34 to 0.95) but not the number of participants with complications (79/130 versus 84/125). Authors' conclusions There is low‐quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low‐quality evidence that oral supplements may reduce 'unfavourable outcome' (death or complications) and that they do not result in an increased incidence of vomiting and diarrhoea. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding or nasogastric feeding in very malnourished people require further evaluation. Plain language summary Nutritional supplementation for older people after hip fracture Background and aim Older people with hip fractures are often malnourished at the time of their fracture and many have poor food intake while in hospital. Malnutrition may hinder recovery after hip fracture. We reviewed the effects of nutritional interventions in older people recovering from hip fracture. Search results We searched the scientific literature up to November 2015 and include 41 studies including 3881 participants. All nutritional interventions were started within one month of hip fracture. The studies had flaws in their methods that may affect the validity of their results. Some evidence was very low quality which means we are very unsure of the results. Key results Eighteen studies examined the use of additional oral feeds that provided energy from sources other than protein, protein, some vitamins and minerals. There was low‐quality evidence that these multinutrient oral feeds may not reduce mortality but that they may reduce the number of people with complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was very low‐quality evidence that oral multinutrient feeds may reduce unfavourable outcome (death or complications) and that they did not result in increased vomiting and diarrhoea. Four studies examined nasogastric tube feeding, where liquid food is delivered via a tube inserted into the nose and passed down into the stomach, with non‐protein energy, protein, some vitamins and minerals. These studies provided very low‐quality evidence that tube feeding, which was poorly tolerated, did not seem to make a difference to mortality or complications. Unfavourable outcome was not recorded and there was insufficient evidence on adverse events. One study provided very low‐quality evidence that nasogastric tube feeding followed by oral feeds may not affect mortality or complications. It reported that tube feeding was poorly tolerated. One study provided very low‐quality evidence that giving feed into a vein initially and then by mouth may not affect mortality but may reduce complications. However, we were surprised that this intervention was being used in people who seemed to be able to take nutrition orally. Increasing protein intake in an oral feed was tested in four studies. These provided low‐quality evidence of no clear effect on mortality or complications and very low‐quality evidence for a reduction in unfavourable outcome. Studies testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. One study, evaluating the use of dietetic assistants to help with feeding, provided low‐quality evidence that this may reduce mortality but not the numbers of people with complications. Conclusions Oral supplements with non‐protein energy, protein, vitamins and minerals started before or soon after surgery may prevent complications after hip fracture in older people but may not affect mortality. Adequately sized randomised studies with better design are required. We suggest that the role of dietetic assistants, and of peripheral venous feeding or nasogastric feeding in very malnourished patients, require further evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Avenell, A; Smith, TO; Curtain, JP; Mak, JCS; Myint, PK", "articleTypes": [], "doi": "10.1002/14651858.CD001880.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "1b5b6f91-3bef-4d28-b8df-af69c449e741", "pmid": "", "title": "Paroxetine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Paroxetine is the most potent inhibitor of the reuptake of serotonin of all selective serotonin reuptake inhibitors (SSRIs) and has been studied in many randomised controlled trials (RCTs). However, these comparative studies provided contrasting findings and systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to paroxetine alone. The present systematic review assessed the efficacy and tolerability profile of paroxetine in comparison with tricyclics (TCAs), SSRIs and newer or non‐conventional agents. Objectives 1. To determine the efficacy of paroxetine in comparison with other anti‐depressive agents in alleviating the acute symptoms of Major Depressive Disorder. 2. To review acceptability of treatment with paroxetine in comparison with other anti‐depressive agents. 3. To investigate the adverse effects of paroxetine in comparison with other anti‐depressive agents. Search methods We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR, to 30 September 2012), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Reference lists of relevant papers and previous systematic reviews were handsearched. Pharmaceutical companies marketing paroxetine and experts in this field were contacted for supplemental data. Selection criteria All randomised controlled trials allocating participants with major depression to paroxetine versus any other antidepressants (ADs), both conventional (such as TCAs, SSRIs) and newer or non‐conventional (such as hypericum). For trials which had a cross‐over design, only results from the first randomisation period were considered. Data collection and analysis Two review authors independently checked eligibility and extracted data using a standard form. Data were then entered in RevMan 5.2 with a double‐entry procedure. Information extracted included study and participant characteristics, intervention details, settings and efficacy, acceptability and tolerability measures. Main results A total of 115 randomised controlled trials (26,134 participants) were included. In 54 studies paroxetine was compared with older ADs, in 21 studies with another SSRI, and in 40 studies with a newer or non‐conventional antidepressant other than SSRIs. For the primary outcome (patients who responded to treatment), paroxetine was more effective than reboxetine at increasing patients who responded early to treatment (Odds Ratio (OR): 0.66, 95% Confidence Interval (CI) 0.50 to 0.87, number needed to treat to provide benefit (NNTb) = 16, 95% CI 10 to 50, at one to four weeks, 3 RCTs, 1375 participants, moderate quality of evidence), and less effective than mirtazapine (OR: 2.39, 95% CI 1.42 to 4.02, NNTb = 8, 95% CI 5 to 14, at one to four weeks, 3 RCTs, 726 participants, moderate quality of evidence). Paroxetine was less effective than citalopram in improving response to treatment (OR: 1.54, 95% CI 1.04 to 2.28, NNTb = 9, 95% CI 5 to 102, at six to 12 weeks, 1 RCT, 406 participants, moderate quality of evidence). We found no clear evidence that paroxetine was more or less effective compared with other antidepressants at increasing response to treatment at acute (six to 12 weeks), early (one to four weeks), or longer term follow‐up (four to six months). Paroxetine was associated with a lower rate of adverse events than amitriptyline, imipramine and older ADs as a class, but was less well tolerated than agomelatine and hypericum. Included studies were generally at unclear or high risk of bias due to poor reporting of allocation concealment and blinding of outcome assessment, and incomplete reporting of outcomes. Authors' conclusions Some possibly clinically meaningful differences between paroxetine and other ADs exist, but no definitive conclusions can be drawn from these findings. In terms of response, there was a moderate quality of evidence that citalopram was better than paroxetine in the acute phase (six to 12 weeks), although only one study contributed data. In terms of early response to treatment (one to four weeks) there was moderate quality of evidence that mirtazapine was better than paroxetine and that paroxetine was better than reboxetine. However there was no clear evidence that paroxetine was better or worse compared with other antidepressants at increasing response to treatment at any time point. Even if some differences were identified, the findings from this review are better thought as hypothesis forming rather than hypothesis testing and it would be reassuring to see the conclusions replicated in future trials. Finally, most of included studies were at unclear or high risk of bias, and were sponsored by the drug industry. The potential for overestimation of treatment effect due to sponsorship bias should be borne in mind. Plain language summary Paroxetine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms such as appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, inappropriate guilt and morbid thoughts of death. Although medication and psychological treatments are both effective for major depression, antidepressant drugs remain the mainstay of treatment in moderate to severe major depression. However, head‐to‐head comparisons of such drugs provide contrasting findings as to whether they are effective. This review of the research on the effect of an antidepressant drug called paroxetine was conducted to shed light on the field of drug treatment for depression. In September 2012 we searched, in a wide ranging way, for all the useful studies (randomised controlled trials) which had been completed which compared paroxetine with any other antidepressant in treating people with depression. One hundred and fifteen studies were included in this review, with a total of 26,134 people. We grouped the studies according to the types of drug they compared paroxetine against; we then analysed the combined findings of these groups of studies. For the primary outcome (number of people who responded to treatment) paroxetine was more effective than reboxetine, but less effective than mirtazapine (in the early phase: one to four weeks follow‐up) and probably citalopram (at endpoint: six weeks follow‐up). There was some evidence that paroxetine is less well tolerated than agomelatine and St John's Wort, as more patients allocated to paroxetine experienced at least some side effects (though this finding for St John's Wort was only based on one study). In conclusion, some possibly meaningful differences between paroxetine and other antidepressants exist, but no definitive concluions can be drawn due to the limited number of studies per comparison. In addition, most of included studies were sponsored by the drug industry, which means they might potentially have overestimated the effect of paroxetine. Therefore, the results of this review should be interpreted with caution.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Purgato, M; Papola, D; Gastaldon, C; Trespidi, C; Magni, LR; Rizzo, C; Furukawa, TA; Watanabe, N; Cipriani, A; Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006531.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "1b5e8918-8b3b-4156-b36b-dbf4f4a924ad", "pmid": "", "title": "Community‐based supplementary feeding for food insecure, vulnerable and malnourished populations – an overview of systematic reviews", "imported": false, "abstract": "Abstract - Background Supplementary feeding may help food insecure and vulnerable people by optimising the nutritional value and adequacy of the diet, improving quality of life and improving various health parameters of disadvantaged families. In low‐ and middle‐income countries (LMIC), the problems supplementary feeding aims to address are entangled with poverty and deprivation, the programmes are expensive and delivery is complicated. Objectives 1. To summarise the evidence from systematic reviews of supplementary feeding for food insecure, vulnerable and malnourished populations, including children under five years of age, school‐aged children, pregnant and lactating women, people with HIV or tuberculosis (or both), and older populations. 2. To describe and explore the effects of supplementary feeding given to people in these groups, and to describe the range of outcomes between reviews and range of effects in the different groups. Methods In January 2017, we searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase and nine other databases. We included systematic reviews evaluating community‐based supplementary feeding, and concerning food insecure, vulnerable and malnourished populations. Two review authors independently undertook selection of systematic reviews, data extraction and 'Risk of bias' assessment. We assessed review quality using the AMSTAR tool, and used GRADEpro 'Summary of findings' tables from each review to indicate the certainty of the evidence for the main comparisons. We summarised review findings in the text and reported the data for each outcome in additional tables. We also used forest plots to display results graphically. Main results This overview included eight systematic reviews (with last search dates between May 2006 and February 2016). Seven were Cochrane Reviews evaluating interventions in pregnant women; children (aged from birth to five years) from LMIC; disadvantaged infants and young children (aged three months to five years); children with moderate acute malnutrition (MAM); disadvantaged school children; adults and children who were HIV positive or with active tuberculosis (with or without HIV). One was a non‐Cochrane systematic review in older people with Alzheimer's disease. These reviews included 95 trials relevant to this overview, with the majority (74%) of participants from LMIC. The number of included participants varied between 91 and 7940 adults, and 271 and more than 12,595 children. Trials included a wide array of nutritional interventions that varied in duration, frequency and format, with micronutrients often reported as cointerventions. Follow‐up ranged from six weeks to two years; three trials investigated outcomes at four to 17 years of age. All reviews were rated as high quality (AMSTAR score between eight and 11). The GRADE certainty ratings ranged from very low to moderate for individual comparisons, with the evidence often comprising only one or two small trials, thereby resulting in many underpowered analyses (too small to detect small but important differences). The main outcome categories reported across reviews were death, anthropometry (adults and children) and other markers of nutritional status, disease‐related outcomes, neurocognitive development and psychosocial outcomes, and adverse events. Mortality data were limited and underpowered in meta‐analysis in all populations (children with MAM, in children with HIV, and in adults with tuberculosis) with the exception of balanced energy and protein supplementation in pregnancy, which may have reduced the risk of stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94; 5 trials, 3408 women). Supplementation in pregnancy also improved infant birth weight (mean difference (MD) 40.96 g, 95% CI 4.66 to 77.26; 11 trials, 5385 participants) and reduced risk of infants born small‐for‐gestational age (RR 0.79, 95% CI 0.69 to 0.90; 7 trials, 4408 participants). These effects did not translate into demonstrable long‐term benefits for children in terms of growth and neurocognitive development in the one to two trials reporting on longer‐term outcomes. In one study (505 participants), high‐protein supplementation was associated with increased risk of small‐for‐gestational age babies. Effects on growth in children were mixed. In children under five years of age from LMIC, one review found that supplementary feeding had a little or no effect on child growth; however, a more recent review in a similar population found that those who received food supplementation gained an average of 0.12 kg more in weight (MD 0.12 kg, 95% CI 0.05 to 0.18; 9 trials, 1057 participants) and 0.27 cm more in height (MD 0.27 cm, 95% CI 0.07 to 0.48; 9 trials, 1463 participants) than those who were not supplemented. Supplementary food was generally more effective for younger children (younger than two years of age) and for those who were poorer or less well‐nourished. In children with MAM, the provision of specially formulated food improved their weight, weight‐for‐height z scores and other key outcomes such as recovery rate (by 29%), as well as reducing the number of participants dropping out (by 70%). In LMIC, school meals seemed to lead to small benefits for children, including improvements in weight z scores, especially in children from lower‐income countries, height z scores, cognition or intelligence quotient tests, and maths and spelling performance. Supplementary feeding in adults who were HIV positive increased the daily energy and protein intake compared to nutritional counselling alone. Supplementation led to an initial improvement in weight gain or body mass index but did not seem to confer long‐term benefit. In adults with tuberculosis, one small trial found a significant benefit on treatment completion and sputum conversion rate. There were also significant but modest benefits in terms of weight gain (up to 2.60 kg) during active tuberculosis. The one study included in the Alzheimer's disease review found that three months of daily oral nutritional supplements improved nutritional outcomes in the intervention group. There was little or no evidence regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes. Authors' conclusions Considering the current evidence base included, supplementary food effects are modest at best, with inconsistent and limited mortality evidence. The trials reflected in the reviews mostly reported on short‐term outcomes and across the whole of the supplementation trial literature it appears important outcomes, such as quality of life and cost of programmes, are not systematically reported or summarised. Plain language summary Supplementary feeding for groups of people that are food insecure, vulnerable and malnourished What was the aim of this review? To summarise the effect of supplementary feeding on populations that were food insecure, vulnerable and malnourished. The overview authors found eight systematic reviews examining supplementary feeding in a variety of populations. Key messages Across a range of vulnerable populations, supplementary feeding programmes sometimes show modest benefit in nutritional outcomes. In a few studies examining mortality (death), effects were either small or absent, and research mostly looked at short‐term effects. What was studied in the review? Supplementary feeding means providing extra food to people or families over and above their home diet and has been used in populations that are food insecure (limited access to adequate and nutritious food) and vulnerable (including women and young children; school‐aged children; people living with diseases such as tuberculosis, HIV, and Alzheimer's disease; and older people) to improve their health and quality of life. What are the main results of the review? The evidence presented here was current to January 2017. We found eight systematic reviews to include in this summary. These reviews included 95 studies (including up to 7940 adults, and more than 12,595 children in a few studies). Most of the included studies lasted from six weeks to two years, with only three studies following people for longer periods of time (up to 17 years). In these reviews, there were a wide range of different types of supplementary feeding given to vulnerable groups over different periods of time, and often in combination with vitamins or minerals. In pregnancy, we found that energy and protein supplements that were balanced (i.e. providing adequate amounts of energy and nutrients, in this case protein) may have decreased the rate of stillbirth (death or loss of a baby before or during delivery), improved infant birth weight and reduced the risk of infants born small‐for‐gestational age (infants that are smaller than expected). We observed no long‐term benefits for children in terms of growth and cognitive (intellectual) development (although very few studies reported long‐term effects). High‐protein supplements (containing protein in higher amounts) were associated with risk and harm (increased risk of small‐for‐gestational age babies). We found that the effects of supplementary feeding on growth in children were varied. In children under five years of age from low‐ and middle‐income countries, supplementary feeding had a small impact on child growth. We observed some benefits in terms of weight and height gains, especially in younger children (those younger than two years of age) and in those who were poorer or less well‐nourished (or both). Some benefit could be seen in children with moderate acute malnutrition in terms of weight gain, other growth factors and recovery rate. School meals seemed to lead to a number of small benefits in school children (including improvements in weight, height, intelligence tests, and maths and spelling performance). Supplementary feeding in adults who were HIV positive increased the daily intake of energy and protein and led to an early improvement in weight gain or body mass index (measure of whether someone is overweight or underweight), or both, but did not seem to lead to long‐term benefits (although few studies reported long‐term effects). In adults with tuberculosis (serious infectious lung disease), we observed small benefits in terms of weight gain during active tuberculosis. In Alzheimer's disease (a type of dementia), providing a daily oral nutrition supplement for three months improved nutritional outcomes (such as weight and energy intake). There was little or no evidence available regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Visser, J, McLachlan, MH, Maayan, N, Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD010578.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.776Z" }, { "id": "1b6b9120-b7d5-41ee-9b3e-dd7885b106ed", "pmid": "", "title": "Corticosteroids for idiopathic pulmonary fibrosis", "imported": false, "abstract": "Abstract - Background Idiopathic pulmonary fibrosis (IPF) is a disease with significant morbidity and mortality. Patients short survival time, high mortality and generally rapid decline raise the importance of early treatment. Current guidelines suggest a combination of corticosteroids and immunosuppressants as \"gold standard\" for IPF treatment, although the evidence for this recommendation is weak. Based on animal models, it has been hypothesized a central role for aberrant wound healing following repeated epithelial lung injury, weakening the rationale for using corticosteroids in IPF, previously thought to be a chronic inflammatory disease. Objectives The aim of the review is to determine the efficacy of corticosteroids in the treatment of adults with familial and sporadic IPF. Search methods We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2008), MEDLINE (January 1966 to June 2008) and EMBASE (January 1985 to June 2008) and reference lists of articles. We searched reference lists of published articles to identify clinical trials. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) using corticosteroids alone for the treatment of adults with IPF. Data collection and analysis Abstracts of identified articles were retrieved and articles possibly fulfilling inclusion criteria were retrieved in full. Two reviewers would have independently assessed trial quality if there had been any included study. Main results Seventeen articles were selected as potentially eligible for meta‐analysis. After further analysis of full text papers, no RCTs or CCTs were identified as suitable and therefore no data was available for inclusion in any meta‐analysis. All studies were excluded due to inadequate methodologies. Authors' conclusions At present, there is no evidence for an effect of corticosteroid treatment in patients with IPF. On the other hand, other fibrotic lung diseases, such as non‐specific interstitial pneumonia (NSIP), are reported to show a better response to corticosteroids. Making a clear distinction between IPF and other entities grouped under the umbrella term interstitial lung disease is, therefore, essential as this may have therapeutic and prognostic implications. Plain language summary Currently there is no evidence to support the routine use of corticosteroids alone in the management of idiopathic pulmonary fibrosis. Idiopathic pulmonary fibrosis (IPF) is a chronic disorder of unknown cause that is progressive and leads to death. Existing evidence about the treatment of IPF is difficult to interpret because of evolving diagnostic criteria and classification schemes, grouping together diverse entities with markedly different natural histories and responses to therapy. Therefore, because the old studies did not include only IPF patients, their results cannot be extended to IPF as they are currently defined. In addition, methodologic problems mainly related to the lack of randomized placebo‐controlled treatment trials have made evidence‐based conclusions difficult. A systematic search for high quality placebo‐controlled randomised trials comparing corticosteroid treatment with placebo in subjects with a diagnosis of IPF was unable to identify any studies suitable for inclusion in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Richeldi, L; Davies, HRHR; Spagnolo, P; Luppi, F", "articleTypes": [], "doi": "10.1002/14651858.CD002880", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "1bc41a7c-ecdb-46da-ad0e-04081378de1a", "pmid": "", "title": "Anabolic‐androgenic steroids for alcoholic liver disease", "imported": false, "abstract": "Abstract - Background Alcohol is one of the most common causes of liver disease in the Western World. Randomised clinical trials have examined the effects of anabolic‐androgenic steroids for alcoholic liver disease. Objectives To assess the beneficial and harmful effects of anabolic‐androgenic steroids for patients with alcoholic liver disease based on the results of randomised clinical trials. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Controlled Trials Register in The Cochrane Library , MEDLINE , EMBASE, LILACS, and Science Citation Index Expanded until June 2006. Electronic searches were combined with full text searches. Manufacturers and researchers in the field were also contacted. Selection criteria Randomised clinical trials studying patients with alcoholic steatosis, alcoholic fibrosis, alcoholic hepatitis, and/or alcoholic cirrhosis were included. Interventions encompassed anabolic‐androgenic steroids at any dose or duration versus placebo or no intervention. The trials could be double blind, single blind, or unblinded. The trials could be unpublished or published, and no language limitations were applied. Data collection and analysis Outcomes are assessed at maximal follow‐up. All analyses were performed according to the intention‐to‐treat method. The statistical package RevMan Analyses was used. The methodological quality of the randomised clinical trials was assessed. Main results Combining the results of five randomised clinical trials randomising 499 patients with alcoholic hepatitis and/or cirrhosis demonstrated no significant effects of anabolic‐androgenic steroids on mortality (relative risk (RR) 1.01, 95% confidence interval (CI) 0.79 to 1.29), liver‐related mortality (RR 0.83, 95% CI 0.60 to 1.15), complications of liver disease (RR 1.25, 95% CI 0.74 to 2.10), and liver histology. Anabolic‐androgenic steroids did not significantly affect a number of other outcome measures, including sexual function and liver biochemistry. Anabolic‐androgenic steroids were not associated with a significantly increased risk of non‐serious adverse events (RR 1.14, 95% CI 0.50 to 2.59) or with serious adverse events (RR 4.54, 95% CI 0.57 to 36.30). Authors' conclusions This systematic review could not demonstrate any significant beneficial effects of anabolic‐androgenic steroids on any clinically important outcomes (mortality, liver‐related mortality, liver complications, and histology) of patients with alcoholic liver disease. Plain language summary No evidence to support anabolic‐androgenic steroids for alcoholic liver disease Alcohol causes a major part of the liver diseases in the Western World. Several trials have addressed the effects of anabolic‐androgenic steroids for alcoholic liver disease. This systematic review could not demonstrate any significant effects of anabolic‐androgenic steroids on mortality, liver‐related mortality, liver complications, and histology of patients with alcoholic liver disease. Anabolic‐androgenic steroid intervention is not associated with a significant increase in non‐serious adverse events, but with the seldom occurrence of serious adverse events. Accordingly, there is no evidence supporting the use of anabolic‐androgenic steroids for alcoholic liver disease, but further randomised clinical trials may be needed to settle the question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Rambaldi, A, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD003045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.101Z" }, { "id": "1bc8071b-21b4-446b-a146-811fcb4325e5", "pmid": "", "title": "Probiotics for induction of remission in ulcerative colitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Kaur, L, Gordon, M, Baines, PA, Iheozor-Ejiofor, Z, Sinopoulou, V, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD005573.pub3 AB - Abstract - Background Ulcerative colitis is an inflammatory condition affecting the colon, with an annual incidence of approximately 10 to 20 per 100,000 people. The majority of people with ulcerative colitis can be put into remission, leaving a group who do not respond to first‐ or second‐line therapies. There is a significant proportion of people who experience adverse effects with current therapies. Consequently, new alternatives for the treatment of ulcerative colitis are constantly being sought. Probiotics are live microbial feed supplements that may beneficially affect the host by improving intestinal microbial balance, enhancing gut barrier function and improving local immune response. Objectives To assess the efficacy of probiotics compared with placebo or standard medical treatment (5‐aminosalicylates, sulphasalazine or corticosteroids) for the induction of remission in people with active ulcerative colitis. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 31 October 2019. We contacted authors of relevant studies and manufacturers of probiotics regarding ongoing or unpublished trials that may be relevant to the review, and we searched ClinicalTrials.gov. We also searched references of trials for any additional trials. Selection criteria Randomised controlled trials (RCTs) investigating the effectiveness of probiotics compared to standard treatments or placebo in the induction of remission of active ulcerative colitis. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We analysed data using Review Manager 5. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE methodology. Main results In this review, we included 14 studies (865 randomised participants) that met the inclusion criteria. Twelve of the studies looked at adult participants and two studies looked at paediatric participants with mild to moderate ulcerative colitis, the average age was between 12.5 and 47.7 years. The studies compared probiotics to placebo, probiotics to 5‐ASA and a combination of probiotics plus 5‐ASA compared to 5‐ASA alone. Seven studies used a single probiotic strain and seven used a mixture of strains. The studies ranged from two weeks to 52 weeks. The risk of bias was high for all except two studies due to allocation concealment, blinding of participants, incomplete reports of outcome data and selective reporting. This led to GRADE ratings of the evidence ranging from moderate to very low. Probiotics versus placebo 
Probiotics may induce clinical remission when compared to placebo (RR 1.73, 95% CI 1.19 to 2.54; 9 studies, 594 participants; low‐certainty evidence; downgraded due to imprecision and risk of bias, number needed to treat for an additional beneficial outcome (NNTB) 5). Probiotics may lead to an improvement in clinical disease scores (RR 2.29, 95% CI 1.13 to 4.63; 2 studies, 54 participants; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.04, 95% CI 0.42 to 2.59; 7 studies, 520 participants). Reported adverse events included abdominal bloating and discomfort. Probiotics did not lead to any serious adverse events in any of the seven studies that reported on it, however five adverse events were reported in the placebo arm of one study (RR 0.09, CI 0.01 to 1.66; 1 study, 526 participants; very low‐certainty evidence; downgraded due to high risk of bias and imprecision). Probiotics may make little or no difference to withdrawals due to adverse events (RR 0.85, 95% CI 0.42 to 1.72; 4 studies, 401 participants; low‐certainty evidence). Probiotics versus 5‐ASA 
There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (RR 0.92, 95% CI 0.73 to 1.16; 1 study, 116 participants; low‐certainty evidence; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.33, 95% CI 0.53 to 3.33; 1 study, 116 participants). Reported adverse events included abdominal pain, nausea, headache and mouth ulcers. There were no serious adverse events with probiotics, however perforated sigmoid diverticulum and respiratory failure in a patient with severe emphysema were reported in the 5‐ASA arm (RR 0.21, 95% CI 0.01 to 4.22; 1 study, 116 participants; very low‐certainty evidence). Probiotics combined with 5‐ASA versus 5‐ASA alone 
Low‐certainty evidence from a single study shows that when combined with 5‐ASA, probiotics may slightly improve the induction of remission (based on the Sunderland disease activity index) compared to 5‐ASA alone (RR 1.22 CI 1.01 to 1.47; 1 study, 84 participants; low‐certainty evidence; downgraded due to unclear risk of bias and imprecision). No information about adverse events was reported. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes (progression to surgery, need for additional therapy, quality of life scores, or steroid withdrawal) were reported in any of the studies. Authors' conclusions Low‐certainty evidence suggests that probiotics may induce clinical remission in active ulcerative colitis when compared to placebo. There may be little or no difference in clinical remission with probiotics alone compared to 5‐ASA. There is limited evidence from a single study which failed to provide a definition of remission, that probiotics may slightly improve the induction of remission when used in combination with 5‐ASA. There was no evidence to assess whether probiotics are effective in people with severe and more extensive disease, or if specific preparations are superior to others. Further targeted and appropriately designed RCTs are needed to address the gaps in the evidence base. In particular, appropriate powering of studies and the use of standardised participant groups and outcome measures in line with the wider field are needed, as well as reporting to minimise risk of bias. Plain language summary Probiotics for the treatment of active ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can induce remission in people with ulcerative colitis. We analysed data from 14 studies to answer this question. Key messages Probiotics may be better at inducing remission than placebo (dummy treatment). It is unclear whether probiotics are better than 5‐aminosalicylic acid (5‐ASA, an anti‐inflammatory agent used to treat inflammatory bowel disease), however there is limited evidence that when both treatments are used as combined therapy they may be better than 5‐ASA alone in inducing remission. Most studies reported that no serious adverse events took place. For the studies that did report on it, serious adverse events did not occur in the probiotic group. Minor adverse events reported were bloating and diarrhoea. What was studied in the review? Ulcerative colitis is a relapsing and remitting disease which causes inflammation of the large bowel and leads to symptoms such as abdominal pain, diarrhoea and tiredness. There is some evidence to suggest that an imbalance in the bacteria of the gut is the cause of the disease, and therefore probiotics, which are live micro‐organisms, can alter the bacteria and possibly reduce the inflammation. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing probiotics with placebo, probiotics with 5‐ASA, and probiotics in combination with 5‐ASA. We found 14 RCTs looking at 865 participants. The trials looked at adult and paediatric participants. Eight studies allowed additional therapy to continue, whilst the other four studies were unclear about this. 1) Probiotics may improve induction of clinical remission when compared to placebo. 2) It is unclear whether probiotics lead to a difference in adverse events (minor and serious) when compared to placebo. 3) There is limited evidence to determine whether probiotics offer better disease improvement when compared to placebo. 4) There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (low‐certainty evidence). 5) There is limited evidence to suggest that when probiotics plus 5‐ASA are compared to 5‐ASA alone, probiotics may offer a slightly better chance of induction of remission. This is based on low‐certainty evidence from one study, and we are not sure of the type of remission studied. 6) Serious adverse events were reported when probiotics were compared with placebo, but only occurred in the placebo group. Conclusion Whilst the evidence suggests that probiotics may be better at improving induction than placebo, our confidence in the estimate is limited because of the low‐certainty evidence. This is attributed to the small number of participants in each study along with the unreliable methods utilised by the trials. With the evidence presented in these studies, we are unable to make strong conclusions into the effectiveness of probiotics; better designed studies with more participants are needed. How up‐to‐date is this review? This review is up‐to‐date as of October 2019.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.118Z" }, { "id": "1bcefac6-3b82-4661-9cca-22e2308f59e1", "pmid": "", "title": "Sensitivity to 6-n-propylthiouracil (PROP) Association With Gustin (CA6) Gene Polymorphism, Salivary Zinc and BMI in Humans", "imported": false, "abstract": "The investigators evaluate the possible association of PROP taste with gustin gene polymorphism rs2274333 (A/G), salivary zinc ion concentration and BMI. In addition, it has also been evaluated PROP taste sensitivity by recording monophasic potentials from the tongue.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.256Z" }, { "id": "1be4176f-7c7f-467f-99e0-82d0faaec85a", "pmid": "", "title": "Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID‐19", "imported": false, "abstract": "Abstract - Background COVID‐19 illness is highly variable, ranging from infection with no symptoms through to pneumonia and life‐threatening consequences. Symptoms such as fever, cough, or loss of sense of smell (anosmia) or taste (ageusia), can help flag early on if the disease is present. Such information could be used either to rule out COVID‐19 disease, or to identify people who need to go for COVID‐19 diagnostic tests. This is the second update of this review, which was first published in 2020. Objectives To assess the diagnostic accuracy of signs and symptoms to determine if a person presenting in primary care or to hospital outpatient settings, such as the emergency department or dedicated COVID‐19 clinics, has COVID‐19. Search methods We undertook electronic searches up to 10 June 2021 in the University of Bern living search database. In addition, we checked repositories of COVID‐19 publications. We used artificial intelligence text analysis to conduct an initial classification of documents. We did not apply any language restrictions. Selection criteria Studies were eligible if they included people with clinically suspected COVID‐19, or recruited known cases with COVID‐19 and also controls without COVID‐19 from a single‐gate cohort. Studies were eligible when they recruited people presenting to primary care or hospital outpatient settings. Studies that included people who contracted SARS‐CoV‐2 infection while admitted to hospital were not eligible. The minimum eligible sample size of studies was 10 participants. All signs and symptoms were eligible for this review, including individual signs and symptoms or combinations. We accepted a range of reference standards. Data collection and analysis Pairs of review authors independently selected all studies, at both title and abstract, and full‐text stage. They resolved any disagreements by discussion with a third review author. Two review authors independently extracted data and assessed risk of bias using the QUADAS‐2 checklist, and resolved disagreements by discussion with a third review author. Analyses were restricted to prospective studies only. We presented sensitivity and specificity in paired forest plots, in receiver operating characteristic (ROC) space and in dumbbell plots. We estimated summary parameters using a bivariate random‐effects meta‐analysis whenever five or more primary prospective studies were available, and whenever heterogeneity across studies was deemed acceptable. Main results We identified 90 studies; for this update we focused on the results of 42 prospective studies with 52,608 participants. Prevalence of COVID‐19 disease varied from 3.7% to 60.6% with a median of 27.4%. Thirty‐five studies were set in emergency departments or outpatient test centres (46,878 participants), three in primary care settings (1230 participants), two in a mixed population of in‐ and outpatients in a paediatric hospital setting (493 participants), and two overlapping studies in nursing homes (4007 participants). The studies did not clearly distinguish mild COVID‐19 disease from COVID‐19 pneumonia, so we present the results for both conditions together. Twelve studies had a high risk of bias for selection of participants because they used a high level of preselection to decide whether reverse transcription polymerase chain reaction (RT‐PCR) testing was needed, or because they enrolled a non‐consecutive sample, or because they excluded individuals while they were part of the study base. We rated 36 of the 42 studies as high risk of bias for the index tests because there was little or no detail on how, by whom and when, the symptoms were measured. For most studies, eligibility for testing was dependent on the local case definition and testing criteria that were in effect at the time of the study, meaning most people who were included in studies had already been referred to health services based on the symptoms that we are evaluating in this review. The applicability of the results of this review iteration improved in comparison with the previous reviews. This version has more studies of people presenting to ambulatory settings, which is where the majority of assessments for COVID‐19 take place. Only three studies presented any data on children separately, and only one focused specifically on older adults. We found data on 96 symptoms or combinations of signs and symptoms. Evidence on individual signs as diagnostic tests was rarely reported, so this review reports mainly on the diagnostic value of symptoms. Results were highly variable across studies. Most had very low sensitivity and high specificity. RT‐PCR was the most often used reference standard (40/42 studies). Only cough (11 studies) had a summary sensitivity above 50% (62.4%, 95% CI 50.6% to 72.9%)); its specificity was low (45.4%, 95% CI 33.5% to 57.9%)). Presence of fever had a sensitivity of 37.6% (95% CI 23.4% to 54.3%) and a specificity of 75.2% (95% CI 56.3% to 87.8%). The summary positive likelihood ratio of cough was 1.14 (95% CI 1.04 to 1.25) and that of fever 1.52 (95% CI 1.10 to 2.10). Sore throat had a summary positive likelihood ratio of 0.814 (95% CI 0.714 to 0.929), which means that its presence increases the probability of having an infectious disease other than COVID‐19. Dyspnoea (12 studies) and fatigue (8 studies) had a sensitivity of 23.3% (95% CI 16.4% to 31.9%) and 40.2% (95% CI 19.4% to 65.1%) respectively. Their specificity was 75.7% (95% CI 65.2% to 83.9%) and 73.6% (95% CI 48.4% to 89.3%). The summary positive likelihood ratio of dyspnoea was 0.96 (95% CI 0.83 to 1.11) and that of fatigue 1.52 (95% CI 1.21 to 1.91), which means that the presence of fatigue slightly increases the probability of having COVID‐19. Anosmia alone (7 studies), ageusia alone (5 studies), and anosmia or ageusia (6 studies) had summary sensitivities below 50% but summary specificities over 90%. Anosmia had a summary sensitivity of 26.4% (95% CI 13.8% to 44.6%) and a specificity of 94.2% (95% CI 90.6% to 96.5%). Ageusia had a summary sensitivity of 23.2% (95% CI 10.6% to 43.3%) and a specificity of 92.6% (95% CI 83.1% to 97.0%). Anosmia or ageusia had a summary sensitivity of 39.2% (95% CI 26.5% to 53.6%) and a specificity of 92.1% (95% CI 84.5% to 96.2%). The summary positive likelihood ratios of anosmia alone and anosmia or ageusia were 4.55 (95% CI 3.46 to 5.97) and 4.99 (95% CI 3.22 to 7.75) respectively, which is just below our arbitrary definition of a 'red flag', that is, a positive likelihood ratio of at least 5. The summary positive likelihood ratio of ageusia alone was 3.14 (95% CI 1.79 to 5.51). Twenty‐four studies assessed combinations of different signs and symptoms, mostly combining olfactory symptoms. By combining symptoms with other information such as contact or travel history, age, gender, and a local recent case detection rate, some multivariable prediction scores reached a sensitivity as high as 90%. Authors' conclusions Most individual symptoms included in this review have poor diagnostic accuracy. Neither absence nor presence of symptoms are accurate enough to rule in or rule out the disease. The presence of anosmia or ageusia may be useful as a red flag for the presence of COVID‐19. The presence of cough also supports further testing. There is currently no evidence to support further testing with PCR in any individuals presenting only with upper respiratory symptoms such as sore throat, coryza or rhinorrhoea. Combinations of symptoms with other readily available information such as contact or travel history, or the local recent case detection rate may prove more useful and should be further investigated in an unselected population presenting to primary care or hospital outpatient settings. The diagnostic accuracy of symptoms for COVID‐19 is moderate to low and any testing strategy using symptoms as selection mechanism will result in both large numbers of missed cases and large numbers of people requiring testing. Which one of these is minimised, is determined by the goal of COVID‐19 testing strategies, that is, controlling the epidemic by isolating every possible case versus identifying those with clinically important disease so that they can be monitored or treated to optimise their prognosis. The former will require a testing strategy that uses very few symptoms as entry criterion for testing, the latter could focus on more specific symptoms such as fever and anosmia. Plain language summary How accurate are symptoms and medical examination to diagnose COVID‐19? Key messages ‐ The results suggest that a single symptom included in this review cannot accurately diagnose COVID‐19. ‐ Loss of sense of taste or smell could be a 'red flag' for the presence of COVID‐19. Cough or fever might be useful to identify people who might have COVID‐19. These symptoms might be useful to prompt further testing when they are present. ‐ We need more research to investigate combinations of symptoms and signs with other information such as recent contact or travel history, or vaccination status, and in children, and adults aged 65 years and over. What are symptoms or signs of COVID‐19? Symptoms are experienced by patients. COVID‐19 symptoms include cough, sore throat, high temperature, diarrhoea, headache, muscle or joint pain, fatigue, and loss of sense of smell and taste. Signs are measured by healthcare workers during clinical examination. They include lung sounds, blood pressure, blood oxygen level and heart rate. Symptoms and signs of COVID‐19 might be important to help people know whether they and the people they come into contact with should isolate at home, undergo testing with a rapid lateral flow test or PCR (laboratory‐based) test, or be hospitalised. What did we want to find out? Symptoms and signs of COVID‐19 are varied and may indicate other diseases, not just COVID‐19. We wanted to know how accurate diagnosis of COVID‐19 is, based on symptoms and signs from medical examination. We were interested in people with suspected COVID‐19, who go to their doctor, outpatient test centres or hospital. What did we do? We searched for studies that assessed the accuracy of symptoms and signs to diagnose COVID‐19. Studies had to be conducted in general practice, outpatient test centres or hospital outpatient settings only. We only included studies of people in hospital if signs and symptoms were recorded when they were admitted to the hospital, for example through the emergency department. What did we find? We focused on 42 studies with 52,608 participants in this review. The studies assessed 96 separate or combined symptoms and signs. Thirty‐five studies were conducted in emergency departments or outpatient COVID‐19 test centres (46,878 participants), 3 studies in general practice (1230 participants), 2 studies in children’s hospitals (493 in‐ and outpatients), and 2 studies in nursing homes (4007 participants). The studies were conducted in 18 different countries around the world. Twenty‐three studies were conducted in Europe, 8 in North‐America, 5 in Asia, and 3 in South‐America and 3 in Australia. We didn’t find any studies conducted in Africa. Three focused specifically on children, and only 1 focused on adults aged 65 years and over. Most studies did not clearly distinguish between mild and severe COVID‐19, so we present the results for mild, moderate and severe disease together. Few studies reported individual signs as diagnostic tests, so we focus mainly on the diagnostic value of symptoms. The most frequently reported symptoms were cough, fever, shortness of breath and sore throat. According to the studies in our review, in a group of 1000 people with suspected COVID‐19 of whom 270 (27%) would actually have COVID‐19, around 567 people would have a cough. Of these 567, 168 would actually have COVID‐19. Of the 433 who do not have a cough, 102 would have COVID‐19. In the same 1000 people, around 283 people would have a fever. Of these 283, 102 would actually have COVID‐19. Of the 717 people without fever, 168 would have COVID‐19. Someone who has lost their sense of smell or taste is five times more likely to have COVID‐19 than someone who hasn’t. Other symptoms, such as a sore throat or runny nose, are more likely to indicate the presence of an infectious disease other than COVID‐19. In the same 1000 people as described above, around 362 people would have a sore throat. Of these, only 84 would actually have COVID‐19. Of the 638 patients without sore throat, 186 would have COVID‐19. We found similar figures for having a runny nose. What are the limitations of the evidence? The results of this updated review are more reliable than those in previous versions as we included more high‐quality studies. However, the accuracy of individual symptoms varied across studies and the diagnostic value of symptoms such as fever, cough or other respiratory symptoms might still be overestimated, as most studies deliberately included participants because they had these symptoms. The results do not clearly differentiate between people with mild, moderate or severe COVID‐19. Only a few studies investigated the symptom‐based diagnosis of COVID‐19 in children or older adults. How up to date is this review? This review updates our previous review. The evidence is up to date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Struyf, T; Deeks, JJ; Dinnes, J; Takwoingi, Y; Davenport, C; Leeflang, MMG; Spijker, R; Hooft, L; Emperador, D; Domen, J; Tans, A; Janssens, S; Wickramasinghe, D; Lannoy, V; Horn, SR A; Van den Bruel, A", "articleTypes": [], "doi": "10.1002/14651858.CD013665.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "1bfea1ed-c500-4efe-ae61-aecd975fb0f2", "pmid": "", "title": "Chinese medicinal herbs for mumps", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Shu, M, Zhang, YQ, Li, Z, Liu, GJ, Wan, C, Wen, Y", "articleTypes": [], "doi": "10.1002/14651858.CD008578.pub3 AB - Abstract - Background Mumps is an infectious disease caused by the mumps virus. Chinese physicians generally believe that Chinese medicinal herbs are effective in alleviating symptoms and reducing the duration of mumps. Herbalists tend to develop a treatment plan according to the individual's symptoms. Objectives To evaluate the effectiveness and safety of Chinese medicinal herbs combined with routine treatments for mumps. Search methods We searched CENTRAL (2015, Issue 1), MEDLINE (1948 to January week 4, 2015), EMBASE (1974 to February 2015), CINAHL (1981 to February 2015), AMED (1985 to April 2014), the Chinese Biomedical Database (CBM) (1980 to February 2015), China National Knowledge Infrastructure (CNKI) (1979 to February 2015), VIP Information (1989 to February 2015), and relevant databases of ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs for mumps (with or without complications). Data collection and analysis Two review authors independently evaluated trial quality and conducted data extraction. We contacted the trial authors for missing data regarding participant allocation. Some trials allocated participants according to the participants' admission sequence, making it a pseudo‐random allocation. None of the trials concealed participants' allocation or used blinding. Main results We did not identify any eligible trials for inclusion. We identified 108 studies that claimed to use random allocation. We excluded 104 studies because the allocation methods the authors had used were not actually randomised. We were unable to contact the trial authors of the remaining four studies. These trials require further evaluation and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions We did not find any RCTs for or against Chinese herbal medicine used in the treatment of mumps. We hope more high‐quality RCTs will be conducted in the future. Plain language summary Chinese medicinal herbs for mumps Review question 
 We reviewed the evidence about the effect and safety of Chinese medicinal herbs for mumps. Background 
 Mumps (epidemic parotitis) is an infectious illness caused by the multiplication of the mumps virus in the upper respiratory tract. It can range from a mild upper respiratory disease to serious complications. Herbal medicines have been used in traditional Chinese medicine (TCM) as the main therapy to prevent and treat mumps for thousands of years. Many Chinese physicians believe that Chinese medicinal herbs are effective in treating mumps. Study characteristics 
 The evidence is current to February 2015. The review authors did not find any randomised controlled trials (RCTs) to provide reliable evidence for the effectiveness and safety of Chinese medicinal herbs for mumps. Although no trials were included, we reviewed the studies and found no reports of adverse events with Chinese medicinal herbs as a treatment for mumps. Key results 
 High‐quality trials are needed to answer these questions.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.742Z" }, { "id": "1c1abc99-cee0-4c57-84b4-a8a991df8207", "pmid": "", "title": "Nebuliser systems for drug delivery in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Nebuliser systems are used to deliver medications to the lungs, to control the symptoms and the progression of lung disease in people with cystic fibrosis (CF). There are many different nebulised‐medications prescribed for people with CF and there are many different types of nebuliser systems. Some of these nebulised medications are licenced for, and can be taken via only one type of nebuliser system; some are licensed for, and can be taken via more than one type of nebuliser system. This is an update to a previous systematic review. Objectives To assess the time efficiency, effectiveness, safety, cost and impact of use (e.g. burden of care, adherence, quality of life (QoL)) of different nebuliser systems, when used with different inhaled medications for people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching of relevant journals and abstract books containing conference proceedings. We searched the reference lists of each study for additional publications and approached the manufacturers of both nebuliser systems and nebulised medications for published and unpublished data. We also searched online trial registries. Date of the most recent search: 9 August 2023. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing nebuliser systems, including conventional nebulisers, vibrating mesh technology (VMT) systems, adaptive aerosol delivery (AAD) systems and ultrasonic nebuliser systems. Data collection and analysis Two review authors independently assessed studies for inclusion. They also independently extracted data and assessed the risk of bias. A third review author assessed studies where agreement could not be reached. They assessed the certainty of the evidence using GRADE. Main results The search identified 216 studies with 33 of these (2270 participants) included in the review. These studies compared the delivery of tobramycin, colistin, dornase alfa, hypertonic saline and other solutions through the different nebuliser systems in children and adults with CF. This review demonstrates variability in the delivery of medication depending on the nebuliser system used. The certainty of the evidence ranged from low to very low. Some conventional nebuliser systems providing higher flows, higher respirable fractions, and smaller particles decrease treatment time, increase deposition (the amount of drug reaching the lung), and may be preferred by people with CF, as compared to other conventional nebuliser systems providing lower flows, lower respirable fractions and larger particles. Newer nebuliser systems using AAD, or VMT (or both) reduce treatment time compared to conventional systems. Deposition (as a percentage of priming dose) with AAD is greater than with conventional systems. VMT systems may give greater deposition than conventional systems when measuring sputum levels. The available data indicate that these newer systems are safe when used with an appropriate priming dose, which may be different to the priming dose used for conventional systems. There is an indication that adherence is maintained or improved and that individuals prefer AAD or VMT systems, but also that some nebuliser systems using VMT may be subject to increased system failures. There is limited, unclear evidence on the impact of different nebuliser systems on lung function and a lack of data on the impact of different nebuliser systems on our outcomes of quality of life (QoL), adverse effects, respiratory exacerbations and related implications, adherence, satisfaction, cost and device reliability. Authors' conclusions Newer technologies e.g. AAD and VMT have advantages over conventional systems in terms of treatment time, deposition as a percentage of priming dose, preference and adherence. Data are lacking for all varieties of medications which are used in CF care, including different inhaled antibiotics or hypertonic saline, with all delivery (nebuliser system) possibilities. Long‐term RCTs are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as QoL and burden of care), safe and effective dosing levels of a wide variety of medications, clinical outcomes (such as hospitalisations and need for antibiotics), and an economic evaluation of their use. There are insufficient data to establish whether one nebuliser system is better than another overall. Clinicians should be aware of the variability in the performance of different nebuliser systems, compatibility with specific nebulised medication, and they must work with their patients to choose the best nebuliser system for each individual. This is likely to be an ongoing process as the needs and circumstances of each individual change over time. Plain language summary Nebulisers for giving medication for cystic fibrosis Key messages 1. Newer technologies have advantages over conventional systems in terms of treatment time, the amount of drug reaching the lung, preference, and adherence. 2. Not all medications used in treating cystic fibrosis can be delivered by the same nebuliser, and data are lacking for some of the different nebuliser and drug combinations. 3. Long‐term studies are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as quality of life, effective dosing levels, and hospitalisations). What is cystic fibrosis? People with cystic fibrosis have sticky mucus in their lungs which is difficult to get rid of and which can cause infection if it builds up. How are nebulisers used as part of cystic fibrosis treatment? Nebulisers are used to deliver medications to the lungs to control the symptoms and the progression of disease. They change a liquid medication into a mist, so it can be breathed in. Different types of nebuliser systems are used with different medications. 1. Conventional systems ‐ a machine pushes out a constant mist of medication at high speed. 2. Adaptive aerosol delivery systems ‐ like conventional systems, also monitor breathing and only deliver the medication while the person is breathing in. 3. Vibrating mesh technology systems move the liquid medication through a metal mesh to generate a mist with similar‐sized droplets which is delivered constantly. 4. Adaptive aerosol delivery systems with vibrating mesh technology combination between the two systems. 5. Ultrasonic systems use a crystal to vibrate the liquid medication at a high frequency and turn it into a mist which is delivered constantly. What did we want to find out? How well do the different nebuliser systems deliver each inhaled medication (how much medication is delivered into the lungs, and what is the impact on lung function)? Are they safe or do they have any side effects? We also wanted to know how these nebuliser systems affect people with cystic fibrosis in terms of treatment burden, adherence to treatment regimen and their quality of life. What did we do? We assessed 33 studies (2270 adults and children)and compared different types of nebuliser systems for delivering: tobramycin; colistin; dornase alfa; hypertonic saline; and other nebulised medications. What did we find? Conventional systems which have faster air flows and smaller medication droplets decrease treatment time and deliver more medication into the lung than other conventional systems, which have slower air flows and larger medication droplets. Nebulisers use newer technologies, e.g. adaptive aerosol delivery system or vibrating mesh technology, deliver the medication faster and may deliver more of the medication into the lung. These newer systems appear safe when used with the correct amount of medication, which may be different to that used in a conventional system. Some studies suggest that people with cystic fibrosis may prefer these newer systems and may take more of their medication when using them. However, more research is needed into what dose of medication is needed for the different systems, which medications suit which technologies best and how these newer nebuliser technologies affect quality of life, burden of treatment, additional treatment needed (such as oral or intravenous antibiotics) and treatment costs. What are the limitations of the evidence? There were lots of different systems studied, and often we only had a few studies for each comparison. Also, the studies we found were quite small and results varied. We had concerns around at least some aspects of the design of every study which affected our confidence in the results. How up to date is this evidence? We last looked for evidence on 9 August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Stanford, G; Morrison, L; Brown, C", "articleTypes": [], "doi": "10.1002/14651858.CD007639.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "1c27f250-cb49-4bd3-ba95-ab6ce7634220", "pmid": "", "title": "Magnesium for skeletal muscle cramps", "imported": false, "abstract": "Abstract - Background Skeletal muscle cramps are common and often occur in association with pregnancy, advanced age, exercise or motor neuron disorders (such as amyotrophic lateral sclerosis). Typically, such cramps have no obvious underlying pathology, and so are termed idiopathic. Magnesium supplements are marketed for the prophylaxis of cramps but the efficacy of magnesium for this purpose remains unclear. This is an update of a Cochrane Review first published in 2012, and performed to identify and incorporate more recent studies. Objectives To assess the effects of magnesium supplementation compared to no treatment, placebo control or other cramp therapies in people with skeletal muscle cramps. Search methods On 9 September 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, CINAHL Plus, AMED, and SPORTDiscus. We also searched WHO‐ICTRP and ClinicalTrials.gov for registered trials that might be ongoing or unpublished, and ISI Web of Science for studies citing the studies included in this review. Selection criteria Randomized controlled trials (RCTs) of magnesium supplementation (in any form) to prevent skeletal muscle cramps in any patient group (i.e. all clinical presentations of cramp). We considered comparisons of magnesium with no treatment, placebo control, or other therapy. Data collection and analysis Two review authors independently selected trials for inclusion and extracted data. Two review authors assessed risk of bias. We attempted to contact all study authors when questions arose and obtained participant‐level data for four of the included trials, one of which was unpublished. We collected all data on adverse effects from the included RCTs. Main results We identified 11 trials (nine parallel‐group, two cross‐over) enrolling a total of 735 individuals, amongst whom 118 cross‐over participants additionally served as their own controls. Five trials enrolled women with pregnancy‐associated leg cramps (408 participants) and five trials enrolled people with idiopathic cramps (271 participants, with 118 additionally crossed over to control). Another study enrolled 29 people with liver cirrhosis, only some of whom suffered muscle cramps. All trials provided magnesium as an oral supplement, except for one trial which provided magnesium as a series of slow intravenous infusions. Nine trials compared magnesium to placebo, one trial compared magnesium to no treatment, calcium carbonate or vitamin B, and another trial compared magnesium to vitamin E or calcium. We judged the single trial in people with liver cirrhosis and all five trials in participants with pregnancy‐associated leg cramps to be at high risk of bias. In contrast, we rated the risk of bias high in only one of five trials in participants with idiopathic rest cramps. For idiopathic cramps, largely in older adults (mean age 61.6 to 69.3 years) presumed to have nocturnal leg cramps (the commonest presentation), differences in measures of cramp frequency when comparing magnesium to placebo were small, not statistically significant, and showed minimal heterogeneity (I² = 0% to 12%). This includes the primary endpoint, percentage change from baseline in the number of cramps per week at four weeks (mean difference (MD) −9.59%, 95% confidence interval (CI) −23.14% to 3.97%; 3 studies, 177 participants; moderate‐certainty evidence); and the difference in the number of cramps per week at four weeks (MD −0.18 cramps/week, 95% CI −0.84 to 0.49; 5 studies, 307 participants; moderate‐certainty evidence). The percentage of individuals experiencing a 25% or better reduction in cramp rate from baseline was also no different (RR 1.04, 95% CI 0.84 to 1.29; 3 studies, 177 participants; high‐certainty evidence). Similarly, no statistically significant difference was found at four weeks in measures of cramp intensity or cramp duration. This includes the number of participants rating their cramps as moderate or severe at four weeks (RR 1.33, 95% CI 0.81 to 2.21; 2 studies, 91 participants; moderate‐certainty evidence); and the percentage of participants with the majority of cramp durations of one minute or more at four weeks (RR 1.83, 95% CI 0.74 to 4.53, 1 study, 46 participants; low‐certainty evidence). We were unable to perform meta‐analysis for trials of pregnancy‐associated leg cramps. The single study comparing magnesium to no treatment failed to find statistically significant benefit on a three‐point ordinal scale of overall treatment efficacy. Of the three trials comparing magnesium to placebo, one found no benefit on frequency or intensity measures, another found benefit for both, and a third reported inconsistent results for frequency that could not be reconciled. The single study in people with liver cirrhosis was small and had limited reporting of cramps, but found no difference in terms of cramp frequency or cramp intensity. Our analysis of adverse events pooled all studies, regardless of the setting in which cramps occurred. Major adverse events (occurring in 2 out of 72 magnesium recipients and 3 out of 68 placebo recipients), and withdrawals due to adverse events, were not significantly different from placebo. However, in the four studies for which it could be determined, more participants experienced minor adverse events in the magnesium group than in the placebo group (RR 1.51, 95% CI 0.98 to 2.33; 4 studies, 254 participants; low��certainty evidence). Overall, oral magnesium was associated with mostly gastrointestinal adverse events (e.g. diarrhoea), experienced by 11% (10% in control) to 37% (14% in control) of participants. Authors' conclusions It is unlikely that magnesium supplementation provides clinically meaningful cramp prophylaxis to older adults experiencing skeletal muscle cramps. In contrast, for those experiencing pregnancy‐associated rest cramps the literature is conflicting and further research in this population is needed. We found no RCTs evaluating magnesium for exercise‐associated muscle cramps or disease‐state‐associated muscle cramps (for example amyotrophic lateral sclerosis/motor neuron disease) other than a single small (inconclusive) study in people with liver cirrhosis, only some of whom suffered cramps. Plain language summary Magnesium for muscle cramps Review question We reviewed the evidence about the effect of magnesium supplements on muscle cramps, and included the widest possible range of studies. This meant including studies on anyone suffering muscle cramps, regardless of why they suffered them. It also meant including studies where magnesium was given in any of the ways available. This includes being swallowed as a pill or liquid, being injected slowly over a number of hours directly into the blood ('intravenous infusion'), and being injected into muscle ('intramuscular injection'). We included studies comparing magnesium to placebo, comparing magnesium to no treatment, and comparing magnesium to other existing cramp treatments. We found a total of 11 studies. To assess benefit, we examined the effect of magnesium on cramp frequency, cramp pain, and cramp duration, and we examined the number of participants whose cramp rate reduced by 25% or more. To assess for potential harm, we examined how often major and minor adverse health events occurred. Background Muscle cramps are common and occur in a wide range of settings. Older adults and pregnant women commonly complain of leg cramps while they are resting, athletes can cramp when they are pushing the limits of their endurance, and some people develop muscle cramps as a symptom of other medical conditions. One potential treatment that is already being marketed to prevent muscle cramps is magnesium supplementation. Magnesium is a common mineral in our diets and extra oral supplements of this mineral are available either over the Internet or in health food stores and pharmacies (usually in the form of tablets or powders to be dissolved in water). We wanted to combine studies to get the best estimate of magnesium's effect on cramping. We also wanted to examine the effect of magnesium in different categories of cramp sufferers, in case it might work in one setting, and not another. Study characteristics We searched for all high‐quality published studies evaluating the effectiveness of magnesium to prevent muscle cramps and found five studies in older adults, five studies in pregnant women, and one study in people with liver cirrhosis. The studies in older adults included 271 participants (61.6 to 69.3 years of age) and the studies in pregnant women included 408 participants. The single study in people with liver cirrhosis enrolled only 29 people, not all of whom experienced cramping. There were no studies of people who cramp while exercising. Magnesium was compared to placebo in nine of 11 studies, and compared to calcium, vitamin E, vitamins B₁ and B₆, and no treatment, in two studies of pregnant women. The included studies ranged from 14 to 56 days of treatment. Magnesium was given orally in 10 of 11 studies, and by four‐hour intravenous infusion on five consecutive days in one study. Funding for included studies came from a manufacturer of magnesium tablets in two studies, independent sources in three studies, and was not reported in six studies. Key results and certainty of the evidence The combined results of five seemingly reliable studies suggest, with moderate‐certainty, that magnesium is unlikely to reduce the frequency or severity of muscle cramps in older adults. In contrast, the five studies in pregnant women had important limitations to their reliability (both in study design and reporting of results), did not consistently show benefit, and could not be combined. As a result we are very uncertain as to whether pregnant women experiencing muscle cramps would benefit from magnesium. The single study in people with liver cirrhosis reported no difference in cramp frequency or intensity but was too small for conclusions to be drawn. More research on magnesium in pregnant women is needed. The same is true for those who suffer cramps associated with medical conditions, or while exercising. However older adult cramp sufferers appear unlikely to benefit from this therapy. Major side effects were infrequent and participants withdrew from the study at similar rates when given magnesium or placebo. However minor side effects, mostly diarrhoea (as would be expected from magnesium salts) and nausea, were common and affected roughly 11% (10% in control) to 37% (14% in control) of participants. The review is up to date to September 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Garrison, SR; Korownyk, CS; Kolber, MR; Allan, GM; Musini, VM; Sekhon, RK; Dugré, N", "articleTypes": [], "doi": "10.1002/14651858.CD009402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "1c29097d-35ab-4115-80e2-a7439a57f6fc", "pmid": "", "title": "Pharmacological interventions for prevention of weight gain in people with schizophrenia", "imported": false, "abstract": "Abstract - Background Antipsychotic‐induced weight gain is an extremely common problem in people with schizophrenia and is associated with increased morbidity and mortality. Adjunctive pharmacological interventions may be necessary to help manage antipsychotic‐induced weight gain. This review splits and updates a previous Cochrane Review that focused on both pharmacological and behavioural approaches to this problem. Objectives To determine the effectiveness of pharmacological interventions for preventing antipsychotic‐induced weight gain in people with schizophrenia. Search methods The Cochrane Schizophrenia Information Specialist searched Cochrane Schizophrenia's Register of Trials on 10 February 2021. There are no language, date, document type, or publication status limitations for inclusion of records in the register. Selection criteria We included all randomised controlled trials (RCTs) that examined any adjunctive pharmacological intervention for preventing weight gain in people with schizophrenia or schizophrenia‐like illnesses who use antipsychotic medications. Data collection and analysis At least two review authors independently extracted data and assessed the quality of included studies. For continuous outcomes, we combined mean differences (MD) in endpoint and change data in the analysis. For dichotomous outcomes, we calculated risk ratios (RR). We assessed risk of bias for included studies and used GRADE to judge certainty of evidence and create summary of findings tables. The primary outcomes for this review were clinically important change in weight, clinically important change in body mass index (BMI), leaving the study early, compliance with treatment, and frequency of nausea. The included studies rarely reported these outcomes, so, post hoc, we added two new outcomes, average endpoint/change in weight and average endpoint/change in BMI. Main results Seventeen RCTs, with a total of 1388 participants, met the inclusion criteria for the review. Five studies investigated metformin, three topiramate, three H2 antagonists, three monoamine modulators, and one each investigated monoamine modulators plus betahistine, melatonin and samidorphan. The comparator in all studies was placebo or no treatment (i.e. standard care alone). We synthesised all studies in a quantitative meta‐analysis. Most studies inadequately reported their methods of allocation concealment and blinding of participants and personnel. The resulting risk of bias and often small sample sizes limited the overall certainty of the evidence. Only one reboxetine study reported the primary outcome, number of participants with clinically important change in weight. Fewer people in the treatment condition experienced weight gains of more than 5% and more than 7% of their bodyweight than those in the placebo group (> 5% weight gain RR 0.27, 95% confidence interval (CI) 0.11 to 0.65; 1 study, 43 participants; > 7% weight gain RR 0.24, 95% CI 0.07 to 0.83; 1 study, 43 participants; very low‐certainty evidence). No studies reported the primary outcomes, 'clinically important change in BMI', or 'compliance with treatment'. However, several studies reported 'average endpoint/change in body weight' or 'average endpoint/change in BMI'. Metformin may be effective in preventing weight gain (MD −4.03 kg, 95% CI −5.78 to −2.28; 4 studies, 131 participants; low‐certainty evidence); and BMI increase (MD −1.63 kg/m2, 95% CI −2.96 to −0.29; 5 studies, 227 participants; low‐certainty evidence). Other agents that may be slightly effective in preventing weight gain include H2 antagonists such as nizatidine, famotidine and ranitidine (MD −1.32 kg, 95% CI −2.09 to −0.56; 3 studies, 248 participants; low‐certainty evidence) and monoamine modulators such as reboxetine and fluoxetine (weight: MD −1.89 kg, 95% CI −3.31 to −0.47; 3 studies, 103 participants; low‐certainty evidence; BMI: MD −0.66 kg/m2, 95% CI −1.05 to −0.26; 3 studies, 103 participants; low‐certainty evidence). Topiramate did not appear effective in preventing weight gain (MD −4.82 kg, 95% CI −9.99 to 0.35; 3 studies, 168 participants; very low‐certainty evidence ) . For all agents, there was no difference between groups in terms of individuals leaving the study or reports of nausea. However, the results of these outcomes are uncertain given the very low‐certainty evidence. Authors' conclusions There is low‐certainty evidence to suggest that metformin may be effective in preventing weight gain. Interpretation of this result and those for other agents, is limited by the small number of studies, small sample size, and short study duration. In future, we need studies that are adequately powered and with longer treatment durations to further evaluate the efficacy and safety of interventions for managing weight gain. Plain language summary How effective are medications given alongside antipsychotics at preventing weight gain in people with schizophrenia? Key messages ‐ Metformin may be effective in preventing weight gain caused by antipsychotics. ‐ H2 antagonists and monoamine modulators may be slightly effective in preventing weight gain caused by antipsychotics. ‐ Future studies should include more people and evaluate them for longer. What are antipsychotics? Antipsychotics are medications used to treat symptoms of psychosis, such as hallucinations, delusions and agitation. They are often used to treat people with schizophrenia. Examples of antipsychotics are haloperidol (Haldol), chlorpromazine (Thorazine), olanzapine (Zyprexa) and risperidone (Risperdal). Schizophrenia and weight gain People with schizophrenia are twice as likely as the general population to be overweight, perhaps due to a poor diet and an inactive lifestyle. Excess weight can lead to other health conditions, such as heart disease, stroke and diabetes. Unfortunately, an unwanted effect of antipsychotics is weight gain. Sometimes, people with schizophrenia are given medications alongside antipsychotics (‘add‐on’ medications) to prevent this additional weight gain. These add‐on medications may stop people feeling hungry or help them feel full. Usually, they are medications developed for other purposes, such as metformin, which is a medicine to treat diabetes, and fluoxetine, which is an antidepressant. What did we want to find out? We wanted to find out whether add‐on medications to prevent weight gain caused by antipsychotics were effective in people with schizophrenia. What did we do? We searched for studies that examined any medicine given alongside antipsychotics to prevent weight gain in people with schizophrenia. Study participants could be any age or sex but had to have a diagnosis of schizophrenia or a schizophrenia‐like illness. They had to be chosen at random to receive either the weight‐prevention medicine, or a placebo (a dummy medicine) or no add‐on medicine (standard treatment). We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 17 studies with 1388 people that examined the effects of add‐on medications to prevent weight gain caused by antipsychotics. The add‐on medications were metformin, topiramate, H2 antagonists, monoamine modulators, monoamine modulators plus betahistine, melatonin, and samidorphan. Studies were short, lasting between 6 and 24 weeks. And they were small, with only 63 people on average ‐ the smallest included only 14 people, the largest 561 people. Studies done to date suggest that: ‐ metformin may be effective in preventing weight gain and is well‐tolerated compared to standard treatment (5 studies, 232 participants); ‐ H2 antagonists, such as nizatidine, famotidine and ranitidine, or monoamine modulators, such as reboxetine and fluoxetine may be potentially effective in preventing weight gain caused by antipsychotics; ‐ topiramate is probably not effective in preventing weight gain caused by antipsychotics. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only a small number of studies for each add‐on medication. Studies included few people, and lasted only a short time. How up to date is this evidence? The evidence is up to date to February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Agarwal, SM, Stogios, N, Ahsan, ZA, Lockwood, JT, Duncan, MJ, Takeuchi, H, Cohn, T, Taylor, VH, Remington, G, Faulkner, GE J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.123Z" }, { "id": "1c2cd1eb-edfd-4336-af85-f70dfdeff8de", "pmid": "", "title": "Interventions for chronic palmoplantar pustulosis", "imported": false, "abstract": "Abstract - Background Palmoplantar pustulosis is a chronic inflammatory disease in which sterile, relapsing pustules appear on the palms and soles, possibly in conjunction with other symptoms. The previous Cochrane Review on this topic was published in 2006, before biological treatments were extensively used. Objectives To assess the effects of interventions for chronic palmoplantar pustulosis to induce and maintain complete remission. Search methods We searched the following databases up to March 2019: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of the included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria We considered RCTs including people with palmoplantar pustulosis or chronic palmoplantar pustular psoriasis assessing topical therapy, systemic therapy, combinations of topical or systemic therapies, or non‐pharmacological therapies compared with placebo, no intervention, or each other. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our outcomes included 'Proportion of participants cleared or almost cleared', 'Proportion of participants with adverse effects serious or severe enough to cause withdrawal', 'Proportion of participants with at least 50% improvement in disease severity', and 'Proportion of participants with adverse effects'. Main results We included 37 studies (1663 participants; mean age 50 years (range 34 to 63); 24% males). These studies reported condition severity differently. Around half of the included trials stated the setting (hospitals, community clinics, or both). More than half of the studies were at high risk of bias in at least one domain. Our included studies assessed mainly systemic treatments (retinoids, ciclosporin, biologics, etretinate + PUVA (combination of psoralens and long‐wave ultraviolet radiation) therapy combined, and antibiotics), but also topical treatments (dermocorticoids, vitamin D) and phototherapy (PUVA, ultraviolet A1 (UVA1)). Other interventions were assessed by single studies. The most common comparator was placebo. All results presented in this abstract were assessed in the short term (mean treatment duration was 11 weeks (range 8 to 24 weeks)) and are based on participants with chronic palmoplantar pustulosis. All outcome time point measurements were taken from baseline and assessed at the end of treatment. Short‐term and long‐term outcomes were defined as measurement up to 24 weeks after randomisation and between 24 and 104 weeks after randomisation, respectively. One trial (188 participants) assessed the topical vitamin D derivative maxacalcitol versus placebo and found that maxacalcitol may be more effective than placebo in achieving clearance (risk ratio (RR) 7.83, 95% confidence interval (CI) 1.85 to 33.12; low‐quality evidence), and the risk of adverse effects (such as mild local irritation, pruritus, and haematological or urinary test abnormalities) is probably similar in both groups (RR 0.87, 95% CI 0.64 to 1.19; moderate‐quality evidence). Severity was not reported. Two trials (49 participants) assessed PUVA therapy versus placebo or no treatment, providing very low‐quality evidence. Adverse effects were reported with oral PUVA (including nausea, ankle swelling, and non‐purulent conjunctivitis) and with local PUVA (including blistering, erythema, and pruritus). With regard to the systemic retinoid alitretinoin, one trial (33 participants; moderate‐quality evidence) showed that alitretinoin probably makes little or no difference in reducing severity when compared to placebo (RR 0.69, 95% CI 0.36 to 1.30). A similar number of adverse events were reported in both treatment groups, including headache, cheilitis, nausea, arthralgia, and nasopharyngitis (RR 0.84, 95% CI 0.61 to 1.17). Clearance was not reported. There may be little or no difference between etanercept and placebo in achieving clearance (RR 1.64, 95% CI 0.08 to 34.28; 1 study; 15 participants; low‐quality evidence); however, the 95% CI was very wide, showing there may be a difference between groups. Severity was not measured. More patients treated with placebo may achieve reduced severity than those treated with ustekinumab, but the wide 95% CI indicates there might be little or no difference between groups and there might be greater effect with ustekinumab (RR 0.48, 95% CI 0.11 to 2.13; 1 study; 33 participants; low‐quality evidence). Clearance was not reported. It is uncertain whether guselkumab increases clearance when compared to placebo (2 studies; 154 participants) because the quality of evidence is very low, but guselkumab probably better reduces disease severity (RR 2.88, 95% CI 1.24 to 6.69; 1 study; 49 participants; moderate‐quality evidence). Secukinumab is probably superior to placebo in reducing severity (RR 1.55, 95% CI 1.02 to 2.35; 1 study; 157 participants; moderate‐quality evidence), but our clearance outcome was not reported. None of these trials reported on occurrence of adverse effects. Only two of the studies discussed above reported adverse effects serious or severe enough to cause withdrawal. Guselkumab may cause more serious adverse events when compared to placebo, but there is uncertainty due to the very wide 95% CI showing there may be little or no difference and showing more events with placebo (RR 2.88, 95% CI 0.32 to 25.80; 1 study; 49 participants; low‐quality evidence). Secukinumab probably causes more serious adverse events than placebo (RR 3.29, 95% CI 1.40 to 7.75; 1 study; 157 participants; moderate‐quality evidence). Authors' conclusions Evidence is lacking for major chronic palmoplantar pustulosis treatments such as superpotent corticosteroids, phototherapy, acitretin, methotrexate, and ciclosporin. Risk of bias and imprecision limit our confidence. Maxacalcitol may be more effective than placebo in achieving clearance in the short term (low‐quality evidence), and the risk of adverse effects is probably similar (moderate‐quality evidence). Oral alitretinoin is probably no more effective than placebo in reducing severity, with a similar risk of adverse effects (moderate‐quality evidence). Regarding biological treatments, we are uncertain of the effect of etanercept on clearance and the effect of ustekinumab on severity (low‐quality evidence). Secukinumab and guselkumab are probably superior to placebo in reducing severity (moderate‐quality evidence). Adverse events not requiring withdrawal were not reported for these treatments. Reporting of serious adverse effects was incomplete: compared to placebo, secukinumab probably caused more participant withdrawals (moderate‐quality evidence), but we are uncertain of the effect of guselkumab (low‐quality evidence). Future trials should assess commonly used treatments using validated severity and quality of life scales. Plain language summary Treating long‐term palmoplantar pustulosis (pustules on the hands and feet) Review question We wanted to assess treatments for palmoplantar pustulosis (a persistent condition characterised by small, pus‐filled blisters on the hands and feet), when compared to an inactive substance (placebo), no intervention, or each other. We included 37 studies. Background Palmoplantar pustulosis negatively affects a person's life; there is no cure or standard treatment. Over time, the skin becomes thicker and redder, and may develop cracks or flake off as scales. Symptoms are treated with topical medicines (usually corticosteroids), systemic medicines (medicines injected or taken by mouth that work throughout the entire body; usually medicines based on vitamin A or D), or phototherapy (ultraviolet light treatment). Study characteristics The studies involved 1663 adults (mostly women) 34 to 63 years of age (average age 50 years). In 19 studies, participants had had palmoplantar pustulosis from two to 16 years (average 6.4 years). Participants had palmoplantar pustular psoriasis (6 studies), palmoplantar pustulosis (29 studies), or both (2 studies). Study authors reported condition severity differently. The included studies assessed a variety of different treatments: mainly systemic treatments (including biologic medicines, vitamin A medicines, immunosuppressants, antibiotics, and light therapy combined with a vitamin A medicine), but also topical medicines (containing steroids or vitamin D) and light treatments. Single studies assessed other treatments. Treatments were most commonly compared against placebo. Treatment length varied; for our key results, this ranged from 8 to 24 weeks (average 11 weeks). When reported, studies were conducted in hospitals, community clinics, or both. Pharmaceutical companies funded 18 studies. Key results Low‐quality evidence suggests that maxacalcitol (a topical vitamin D derivative) may work better than placebo in achieving clearance; moderate‐quality evidence indicates that the number of side effects is probably similar in both groups (participants experienced itching, irritation, and blood or urine test abnormalities) (1 trial; 188 participants). Severity was not measured. We found very low‐quality evidence for PUVA therapy (i.e. psoralen, a drug to sensitise the skin, and ultraviolet light A) versus placebo or no treatment (2 studies; 49 participants), so we are unable to draw conclusions. Side effects with PUVA included skin blisters, redness, itching, swelling, and feeling sick. Oral alitretinoin probably makes little or no difference in reducing severity when compared to placebo (moderate‐quality evidence; 1 study; 33 participants). A similar result was found for side effects, with headache, sickness, joint pain, high cholesterol, and colds reported in both groups. Clearance was not reported. Five studies assessed biological treatments (etanercept, ustekinumab, guselkumab, secukinumab), which use substances made from living organisms, or synthetic versions, to target the immune system. Low‐quality evidence (1 study; 15 participants) suggests that etanercept may make little or no difference in clearance when compared to placebo, but we are very uncertain of this result. Side effects and severity were not measured. We found low‐quality evidence suggesting that ustekinumab may be worse than placebo in reducing disease severity, but we are very uncertain of this result. Side effects and clearance were not reported (1 study; 33 participants). Compared to placebo, guselkumab probably reduces severity (moderate‐quality evidence; 1 study; 49 participants), but its effects on clearance are uncertain (very low‐quality evidence; 2 studies; 154 participants). Side effects were not measured. Moderate‐quality evidence shows that secukinumab was probably superior to placebo in reducing severity, but skin clearance and side effects were not reported (1 study; 157 participants). Only two studies described above reported withdrawals from treatment due to serious side effects; these are probably more frequent with secukinumab than with placebo (157 participants), and may occur more often with guselkumab than with placebo (49 participants), but we are very uncertain of the guselkumab result. For these key results, outcomes were assessed between 8 and 24 weeks, which we deemed short term. This evidence is current to March 2019. Quality of the evidence The key comparisons reported clearance most often, but evidence quality was mainly very low. Only two key studies reported side effects causing withdrawal (low‐ and moderate‐quality evidence). The evidence underlying our severity and side effects outcomes was variable in quality (very low to moderate). Small participant numbers, results with wide margins of error, and selective reporting have limited our confidence in the evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Obeid, G; Do, G; Kirby, L; Hughes, C; Sbidian, E; Le Cleach, L", "articleTypes": [], "doi": "10.1002/14651858.CD011628.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "1c3a0cef-d7a9-4c60-9996-5cc38aeb29fd", "pmid": "", "title": "Roselle for hypertension in adults", "imported": false, "abstract": "Abstract - Background Hypertension is considered to be a serious health problem worldwide. Controlling and lowering blood pressure are of significant benefit to people with hypertension because hypertension is a risk factor for stroke, heart disease, and cardiovascular disease. Roselle, the tropical plant Hibiscus sabdariffa , also commonly called sour tea or red tea, has been used as both a thirst‐quenching drink and for medicinal purposes. Objectives To assess the effect of Roselle on blood pressure in people with primary hypertension. Search methods For this update, the Cochrane Hypertension Information Specialist searched the following databases and trials registers for randomised controlled trials (RCTs): the Cochrane Hypertension Specialised Register (to 6 August 2021), Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), MEDLINE Ovid (1946 to 5 August 2021), Embase Ovid (1974 to 5 August 2021), ProQuest Dissertations & Theses (to 6 August 2021), Web of Science Clarivate (to 7 August 2021), Food Science and Technology Abstracts Clarivate (to 7 August 2021), the WHO International Clinical Trials Registry Platform (to 6 August 2021), and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (to 6 August 2021). We searched Google Scholar and OpenSIGLE. We also handsearched local and regional Chinese databases: CBM, CMCC, TCMLARS, CNKI, CMAC, and the Index to Chinese Periodical Literature (to 14 September 2020), as well as Thai databases (ThaiJO, CUIR, TDC, CMU e‐Theses, TCTR) (to 3 October 2020). There were no language or publication date restrictions. Selection criteria We sought RCTs evaluating the use of any forms of Roselle with placebo or no treatment in adults with hypertension. Our primary outcome was change in trough and/or peak systolic and diastolic blood pressure (SBP, DBP). Secondary outcomes were withdrawals due to adverse effects, change in pulse pressure, and change in heart rate. Data collection and analysis All search results were managed using Covidence and re‐checked for the number of records, inclusion and exclusion of studies with Mendeley reference management software. We used standard methodological procedures expected by Cochrane. Two review authors worked independently in parallel for screening (titles and abstracts, and full reports), data extraction, risk of bias assessment, and assessment of the certainty of the evidence using the GRADE approach. Any disagreements were resolved by discussion or by consultation with the third review author if necessary. We presented mean difference (MD) of change in SBP and DBP with their corresponding 95% confidence interval (CI). Main results For this update, only one RCT with a parallel‐group design involving 60 participants with type 2 diabetes mellitus fulfilled the inclusion criteria. This study investigated the effect of Roselle extract capsules (total dose of 5600 mg) compared with placebo (lactose) at eight weeks. The study was at low risk of selection bias, performance bias, and detection bias. Conversely, it was at high risk of attrition bias, reporting bias, and other bias (baseline imbalance). We have very little confidence in the effect estimate of Roselle on change‐from‐baseline in both SBP and DBP between the two groups. The MD of change in SBP was 1.65, 95% CI −7.89 to 11.19 mmHg, 52 participants, very low‐certainty evidence. The MD of change in DBP was 4.60, 95% CI −1.38 to 10.58 mmHg, 52 participants, very low‐certainty evidence. Our secondary outcomes of withdrawals due to adverse effects, change in pulse pressure, and change in heart rate were not reported. Due to the limited available data, no secondary analyses were performed (subgroup and sensitivity analysis). Authors' conclusions The evidence is currently insufficient to determine the effectiveness of Roselle compared to placebo for controlling or lowering blood pressure in people with hypertension. The certainty of evidence was very low due to methodological limitations, imprecision, and indirectness. There is a need for rigorous RCTs that address the review question. Plain language summary Red tea (Roselle) for lowering blood pressure in adults Key messages: We don't know if taking Roselle lowers blood pressure in people with hypertension (high blood pressure). We don’t know if Roselle is safe for people with hypertension to consume or if it affects heart rate or pulse pressure. What did we want to find out? We wanted to know if red tea (Roselle) is a safe and effective treatment for lowering blood pressure in adults with high blood pressure when compared to placebo (dummy treatment) or no treatment. Roselle contains substances known as anthocyanins which have been shown to have lowered blood pressure in studies carried out in animals and humans. What did we do? We searched for studies that compared Roselle to placebo or no treatment in people with hypertension. What did we find? We included one study with 60 participants with type 2 diabetes and hypertension. Participants consumed either a capsule of pure Roselle extract or a placebo containing lactose for eight weeks. We are not sure if Roselle has an effect on blood pressure and the study did not report on the safety of Roselle or on changes to heart rate. What are the main limitations of the evidence? We found only one trial which included a small number of participants, all of whom had diabetes. More studies with various types of participants and different ways of taking Roselle (forms, amounts, and time of day, length of use) are needed. How up to date is the evidence? The review updates our previous review. We searched for randomised controlled trials (studies in which participants are randomly assigned to one of two or more treatment groups) in core databases up to August 2021, and searched local and regional Chinese and Thai databases by hand up to October 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Pattanittum, P; Ngamjarus, C; Buttramee, F; Somboonporn, C", "articleTypes": [], "doi": "10.1002/14651858.CD007894.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "1c3c16fd-a716-454d-a754-ea65b8e5718f", "pmid": "", "title": "Sucrose for analgesia in newborn infants undergoing painful procedures", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose with and without non‐nutritive sucking is the most frequently studied non‐pharmacological intervention for procedural pain relief in neonates. Objectives To determine the efficacy, effect of dose, method of administration and safety of sucrose for relieving procedural pain in neonates as assessed by validated composite pain scores, physiological pain indicators (heart rate, respiratory rate, saturation of peripheral oxygen in the blood, transcutaneous oxygen and carbon dioxide (gas exchange measured across the skin ‐ TcpO 2 , TcpCO 2 ), n ear i nfra r ed s pectroscopy (NIRS), e lectro e ncephalo g ram (EEG), or behavioural pain indicators (cry duration, proportion of time crying, proportion of time facial actions (e.g. grimace) are present), or a combination of these and long‐term neurodevelopmental outcomes. Search methods We used the standard methods of the Cochrane Neonatal. We performed electronic and manual literature searches in February 2016 for published randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library , Issue 1, 2016), MEDLINE (1950 to 2016), EMBASE (1980 to 2016), and CINAHL (1982 to 2016) . We did not impose language restrictions. Selection criteria RCTs in which term or preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age), or both, received sucrose for procedural pain. Control interventions included no treatment, water, glucose, breast milk, breastfeeding, local anaesthetic, pacifier, positioning/containing or acupuncture. Data collection and analysis Our main outcome measures were composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We reported a mean difference (MD) or weighted MD (WMD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. For categorical data we used risk ratio (RR) and risk difference. We assessed heterogeneity by the I 2 test. We assessed the risk of bias of included trials using the Cochrane 'Risk of bias' tool, and assessed the quality of the evidence using the GRADE system. Main results Seventy‐four studies enrolling 7049 infants were included. Results from only a few studies could be combined in meta‐analyses and for most analyses the GRADE assessments indicated low‐ or moderate‐quality evidence. There was high‐quality evidence for the beneficial effect of sucrose (24%) with non‐nutritive sucking (pacifier dipped in sucrose) or 0.5 mL of sucrose orally in preterm and term infants: Premature Infant Pain Profile (PIPP) 30 s after heel lance WMD ‐1.70 (95% CI ‐2.13 to ‐1.26; I 2 = 0% (no heterogeneity); 3 studies, n = 278); PIPP 60 s after heel lance WMD ‐2.14 (95% CI ‐3.34 to ‐0.94; I 2 = 0% (no heterogeneity; 2 studies, n = 164). There was high‐quality evidence for the use of 2 mL 24% sucrose prior to venipuncture: PIPP during venipuncture WMD ‐2.79 (95% CI ‐3.76 to ‐1.83; I 2 = 0% (no heterogeneity; 2 groups in 1 study, n = 213); and intramuscular injections: PIPP during intramuscular injection WMD ‐1.05 (95% CI ‐1.98 to ‐0.12; I 2 = 0% (2 groups in 1 study, n = 232). Evidence from studies that could not be included in RevMan‐analyses supported these findings. Reported adverse effects were minor and similar in the sucrose and control groups. Sucrose is not effective in reducing pain from circumcision. The effectiveness of sucrose for reducing pain/stress from other interventions such as arterial puncture, subcutaneous injection, insertion of nasogastric or orogastric tubes, bladder catherization, eye examinations and echocardiography examinations are inconclusive. Most trials indicated some benefit of sucrose use but that the evidence for other painful procedures is of lower quality as it is based on few studies of small sample sizes. The effects of sucrose on long‐term neurodevelopmental outcomes are unknown. Authors' conclusions Sucrose is effective for reducing procedural pain from single events such as heel lance, venipuncture and intramuscular injection in both preterm and term infants. No serious side effects or harms have been documented with this intervention. We could not identify an optimal dose due to inconsistency in effective sucrose dosage among studies. Further investigation of repeated administration of sucrose in neonates is needed. There is some moderate‐quality evidence that sucrose in combination with other non‐pharmacological interventions such as non‐nutritive sucking is more effective than sucrose alone, but more research of this and sucrose in combination with pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing painful procedures Review question Cochrane reviewers investigated how well sucrose (table sugar) works as a reliever of pain in newborn babies who are having painful procedures (e.g. an injection, or heel lance, or insertion of a needle to obtain a blood sample (venipuncture), or eye examinations). The babies' pain responses (e.g. crying, grimacing) were assessed by scoring systems for pain used by health care professionals to measure the pain that babies are experiencing. In addition, the reviewers wanted to investigate whether the level of pain relief is related to the dose of sucrose, or the method of delivery (e.g. as a solution squirted into the mouth, or on a pacifier (also called a soother or dummy), and whether there are any safety concerns about using sucrose to relieve pain. Background Although there are ways to manage the pain of surgery, medical illness and major procedures, ways of preventing or reducing pain from minor medical procedures (e.g. heel lance and venipuncture) have, until relatively recently, been lacking. Sucrose has been examined for its calming effects in crying newborns and its pain‐relieving effects for invasive procedures in full‐term and premature newborns. Study characteristics We searched the medical literature widely up to February 2016 for studies that investigated the pain‐relieving effect of sucrose for minor medical procedures in newborn full‐term and premature babies. We included randomised controlled trials only, as these provide the most reliable medical evidence. We identified 74 studies that reported on a total of more than 7000 infants in this Cochrane Review. Thirty‐eight studies included full‐term babies only, 31 included premature babies only, and five included both full‐term and premature babies. Heel lance was the painful procedure in 38 studies, and venipuncture in nine; the remaining studies investigated a wide variety of other minor painful procedures. The studies used a variety of delivery methods for the sucrose solution (oral syringe, dropper or sucrose‐dipped pacifier), as well as a range of concentrations and volumes of dose. Sucrose treatment was compared with giving the babies a similar volume of water, a pacifier, routine care, breastfeeding, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), laser acupuncture, swaddling, warmth, anaesthetic cream for the skin (EMLA), or a combination of these. The studies used a range of pain assessment scales to measure their results. Study funding sources We did not identify any studies that received funding from the industry. Key results There was high‐quality evidence that sucrose reduces different measures of newborn pain during heel lance, venipuncture and intramuscular injection. However, sucrose does not provide effective pain relief during circumcision. There is conflicting evidence for whether sucrose reduces pain for other minor painful procedures and further research is needed to investigate these more thoroughly. Twenty‐nine studies reported on adverse events (harms of the sucrose and other treatments) and found that the number of minor adverse events (e.g. choking or gagging) was very low, and was similar in the different groups (so not attributable to the sucrose treatment). No major adverse events were reported. Quality of evidence Although sucrose has been widely studied as a pain reliever for newborn babies, most studies have included few babies and have used many different measures of pain to assess its effectiveness. We identified high‐quality evidence that sucrose reduces pain for heel lance, venipuncture and intramuscular injection. The quality of evidence was low or moderate in favour for the use of sucrose for other painful procedures.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stevens, B, Yamada, J, Ohlsson, A, Haliburton, S, Shorkey, A", "articleTypes": [], "doi": "10.1002/14651858.CD001069.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.762Z" }, { "id": "1c53cf0c-b129-4acb-8b7c-91465d120307", "pmid": "", "title": "Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years", "imported": false, "abstract": "Abstract - Background Zinc deficiency is prevalent in low‐ and middle‐income countries, and is considered a significant risk factor for morbidity, mortality, and linear growth failure. The effectiveness of preventive zinc supplementation in reducing prevalence of zinc deficiency needs to be assessed. Objectives To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged 6 months to 12 years. Search methods A previous version of this review was published in 2014. In this update, we searched CENTRAL, MEDLINE, Embase, five other databases, and one trials register up to February 2022, together with reference checking and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) of preventive zinc supplementation in children aged 6 months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalized children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions. Data collection and analysis Two review authors screened studies, extracted data, and assessed the risk of bias. We contacted study authors for missing information and used GRADE to assess the certainty of evidence. The primary outcomes of this review were all‐cause mortality; and cause‐specific mortality, due to all‐cause diarrhea, lower respiratory tract infection (LRTI, including pneumonia), and malaria. We also collected information on a number of secondary outcomes, such as those related to diarrhea and LRTI morbidity, growth outcomes and serum levels of micronutrients, and adverse events. Main results We included 16 new studies in this review, resulting in a total of 96 RCTs with 219,584 eligible participants. The included studies were conducted in 34 countries; 87 of them in low‐ or middle‐income countries. Most of the children included in this review were under five years of age. The intervention was delivered most commonly in the form of syrup as zinc sulfate, and the most common dose was between 10 mg and 15 mg daily. The median duration of follow‐up was 26 weeks. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes was affected by risk of bias. High‐certainty evidence showed little to no difference in all‐cause mortality with preventive zinc supplementation compared to no zinc (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.84 to 1.03; 16 studies, 17 comparisons, 143,474 participants). Moderate‐certainty evidence showed that preventive zinc supplementation compared to no zinc likely results in little to no difference in mortality due to all‐cause diarrhea (RR 0.95, 95% CI 0.69 to 1.31; 4 studies, 132,321 participants); but probably reduces mortality due to LRTI (RR 0.86, 95% CI 0.64 to 1.15; 3 studies, 132,063 participants) and mortality due to malaria (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 42,818 participants); however, the confidence intervals around the summary estimates for these outcomes were wide, and we could not rule out a possibility of increased risk of mortality. Preventive zinc supplementation likely reduces the incidence of all‐cause diarrhea (RR 0.91, 95% CI 0.90 to 0.93; 39 studies, 19,468 participants; moderate‐certainty evidence) but results in little to no difference in morbidity due to LRTI (RR 1.01, 95% CI 0.95 to 1.08; 19 studies, 10,555 participants; high‐certainty evidence) compared to no zinc. There was moderate‐certainty evidence that preventive zinc supplementation likely leads to a slight increase in height (standardized mean difference (SMD) 0.12, 95% CI 0.09 to 0.14; 74 studies, 20,720 participants). Zinc supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46; 5 studies, 35,192 participants; high‐certainty evidence). We report a number of other outcomes, including the effect of zinc supplementation on weight and serum markers such as zinc, hemoglobin, iron, copper, etc. We also performed a number of subgroup analyses and there was a consistent finding for a number of outcomes that co‐supplementation of zinc with iron decreased the beneficial effect of zinc. Authors' conclusions Even though we included 16 new studies in this update, the overall conclusions of the review remain unchanged. Zinc supplementation might help prevent episodes of diarrhea and improve growth slightly, particularly in children aged 6 months to 12 years of age. The benefits of preventive zinc supplementation may outweigh the harms in regions where the risk of zinc deficiency is relatively high. Plain language summary Is zinc supplementation effective for preventing death and disease, and for promoting growth, in children aged 6 months to 12 years and does it cause unwanted effects? Key messages ‐ Zinc supplementation in children aged 6 months to 12 years makes little to no difference to all‐cause mortality and probably makes no difference to deaths from diarrea. Zinc supplementation probably reduces mortality due to lower respiratory tract infections and malaria but a small possibility of increased risk of mortality cannot be ruled out. ‐ Zinc supplementation in children aged 6 months to 12 years might prevent illness due to diarrhea, but might lead to vomiting after supplementation. It might lead to a small increase in height gain. Why is it important to study zinc supplementation? Zinc is an essential micronutrient. It is important to help children grow normally and to promote a healthy immune system. Lack of zinc may lead to diarrhea, pneumonia, malaria and even death. Low dietary zinc intake is often linked to poverty. As many as half of all children in low‐ and middle‐income countries may have zinc deficiency. Meat, fish, eggs and dairy products are good natural sources of zinc, but are expensive. Lack of clean water and poor sanitation increases exposure to diseases, which zinc might help to fight. The human body cannot produce or store zinc, so giving dietary supplements is important. What did we want to find out? We wanted to find out if giving children zinc supplements helps prevent child death and disease, and promotes growth. What did we do? We searched for studies that randomly assigned children aged 6 months to 12 years to receive zinc supplementation or no zinc. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 96 studies in the review, with 219,584 children. Studies took place in 34, mainly low‐ to middle‐income countries. Most of the children in the studies were under five years old. Zinc was most commonly given as a syrup (zinc sulfate), and the most common dose was between 10 mg and 15 mg daily. We found that giving children zinc supplementation might lead to a small to no reduction in the risk of death for any reason and the risk of death due to diarrhea. The risk of death due to lower respiratory tract infections or malaria may be reduced. Children given zinc experienced less disease due to diarrhea than children not given zinc; however, zinc does not seem to reduce children's risk of respiratory infection. Zinc supplementation may have a small positive effect on growth. Children who take zinc supplementation may experience vomiting as an unwanted effect. What are the limitations of the evidence? We are confident about our results on the effects of zinc supplements on reducing the risk of death due to any cause, illness due to respiratory infection, and occurrence of vomiting after supplementation. Our confidence in the results for our other outcomes was moderate because relatively few studies reported these outcomes and because studies sometimes reported different results from other studies for the same outcomes. How up to date is this evidence? This review updates a previous version published in 2014. The evidence is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Imdad, A; Rogner, J; Sherwani, RN; Sidhu, J; Regan, A; Haykal, MR; Tsistinas, O; Smith, A; Chan, XHS; Mayo-Wilson, E; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD009384.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "1c635702-e11f-4d18-ae04-3320691bdac6", "pmid": "", "title": "Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Castillo, M, Scott, NW, Mustafa, MZ, Mustafa, MS, Azuara‐Blanco, A", "articleTypes": [], "doi": "10.1002/14651858.CD009566.pub2 AB - Abstract - Background Seasonal/perennial allergic conjunctivitis is the most common allergic conjunctivitis, usually with acute manifestations when a person is exposed to allergens and with typical signs and symptoms including itching, redness, and tearing. The clinical signs and symptoms of allergic conjunctivitis are mediated by the release of histamine by mast cells. Histamine antagonists (also called antihistamines) inhibit the action of histamine by blocking histamine H1 receptors, antagonising the vasoconstrictor, and to a lesser extent, the vasodilator effects of histamine. Mast cell stabilisers inhibit degranulation and consequently the release of histamine by interrupting the normal chain of intracellular signals.
 
 Topical treatments include eye drops with antihistamines, mast cell stabilisers, non‐steroidal anti‐inflammatory drugs, combinations of the previous treatments, and corticosteroids. Standard treatment is based on topical antihistamines alone or topical mast cell stabilisers alone or a combination of treatments. There is clinical uncertainty about the relative efficacy and safety of topical treatment. Objectives The objective of this review was to assess the effects of topical antihistamines and mast cell stabilisers, alone or in combination, for use in treating seasonal and perennial allergic conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2014, Issue 7), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2014), EMBASE (January 1980 to July 2014), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 July 2014. We also searched the reference lists of review articles and relevant trial reports for details of further relevant publications. Selection criteria We included randomised controlled trials (RCTs) comparing topical antihistamine and mast cell stabilisers, alone or in combination, with placebo, no treatment or to any other antihistamine or mast cell stabiliser, or both, that examined people with seasonal or perennial allergic conjunctivitis, or both. The primary outcome was any participant‐reported evaluation (by questionnaire) of severity of four main ocular symptoms: itching, irritation, watering eye (tearing), and photophobia (dislike of light), both separately and, if possible, by an overall symptom score. We considered any follow‐up time between one week and one year. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Disagreements were resolved by discussion among review authors and the involvement of a third review author. We followed standard methodological approaches used by Cochrane. Main results We identified 30 trials with a total of 4344 participants randomised, with 17 different drugs or treatment comparisons. The following antihistamines and mast cell stabilisers were evaluated in at least one RCT: nedocromil sodium or sodium cromoglycate, olopatadine, ketotifen, azelastine, emedastine, levocabastine (or levocabastine), mequitazine, bepotastine besilate, combination of antazoline and tetryzoline, combination of levocabastine and pemirolast potassium. The most common comparison was azelastine versus placebo (nine studies). We observed a large variability in reporting outcomes. The quality of the studies and reporting was variable, but overall the risk of bias was low. Trials evaluated only short‐term effects, with a range of treatment of one to eight weeks. Meta‐analysis was only possible in one comparison (olopatadine versus ketotifen). There was some evidence to support that topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo. There were no reported serious adverse events related to the use of topical antihistamine and mast cell stabilisers treatment. Authors' conclusions It seems that all reported topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo in the short term. However, there is no long‐term data on their efficacy. Direct comparisons of different antihistamines and mast cell stabilisers need to be interpreted with caution. Overall, topical antihistamines and mast cell stabilisers appear to be safe and well tolerated. We observed a large variability in outcomes reported. Poor quality of reporting challenged the synthesis of evidence. Plain language summary Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis Review question 
 Are treatments with eye drops of antihistamines and mast cell stabilisers, alone or in combination, effective and safe in people with seasonal and allergic conjunctivitis? The main outcome measure was eye symptoms reported by participants, including eye itching, irritation (burning sensation), watering eyes (tearing), and photophobia (dislike of light). We found 30 trials. Background 
 Conjunctivitis refers to inflammation of the conjunctiva, which is the thin tissue that covers the sclera (white part of the eye). Seasonal and perennial allergic conjunctivitis is the most common type of allergic conjunctivitis. Although this condition does not cause sight loss, it can cause intense itching and eye watering. Eye drops with antihistamines or mast cell stabilisers, or both are commonly used. Study characteristics 
 The evidence is current to July 2014. Among the 30 studies reviewed there were 17 different comparisons, including 4344 participants ranging in age between 4 and 85 years. The duration of treatment ranged from one to eight weeks. Ten out of 30 studies were funded by the drug manufacturer (8 totally and 2 partially funded); 20 studies did not report any source of funding. There was inconsistency in the way the effect of treatment was measured and reported. Overall risk of bias was low. Key results 
 Topical antihistamines and mast cell stabilisers, alone or in combination, are safe and effective for reducing symptoms of seasonal and perennial allergic conjunctivitis. We found insufficient evidence to discern which topical antihistamines and mast cell stabilisers are the most effective.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.070Z" }, { "id": "1c8ea108-940e-4ade-9b63-2bceeb412d73", "pmid": "", "title": "Systemic interventions for recurrent aphthous stomatitis (mouth ulcers)", "imported": false, "abstract": "Abstract - Background Recurrent aphthous stomatitis (RAS) is the most frequent form of oral ulceration, characterised by recurrent oral mucosal ulceration in an otherwise healthy individual. At its worst RAS can cause significant difficulties in eating and drinking. Treatment is primarily aimed at pain relief and the promotion of healing to reduce the duration of the disease or reduce the rate of recurrence. A variety of topical and systemic therapies have been utilised. Objectives To determine the clinical effect of systemic interventions in the reduction of pain associated with RAS, a reduction in episode duration or frequency. Search methods We undertook electronic searches of: Cochrane Oral Health Group and PaPaS Trials Registers (to 6 June 2012); CENTRAL via The Cochrane Library (to Issue 4, 2012); MEDLINE via OVID (1950 to 6 June 2012); EMBASE via OVID (1980 to 6 June 2012); CINAHL via EBSCO (1980 to 6 June 2012); and AMED via PubMed (1950 to 6 June 2012). We searched reference lists from relevant articles and contacted the authors of eligible trials to identify further trials and obtain additional information. Selection criteria We included randomised controlled trials (RCTs) in which the primary outcome measures assess a reduction of pain associated with RAS, a reduction in episode duration or a reduction in episode frequency. Trials were not restricted by outcome alone. We also included RCTs of a cross‐over design. Data collection and analysis Two review authors independently extracted data in duplicate. We contacted trial authors for details of randomisation, blindness and withdrawals. We carried out risk of bias assessment on six domains. We followed The Cochrane Collaboration statistical guidelines and risk ratio (RR) values were to be calculated using fixed‐effect models (if two or three trials in each meta‐analysis) or random‐effects models (if four or more trials in each meta‐analysis). Main results A total of 25 trials were included, 22 of which were placebo controlled and eight made head‐to‐head comparisons (five trials had more than two treatment arms). Twenty‐one different interventions were assessed. The interventions were grouped into two categories: immunomodulatory/anti‐inflammatory and uncertain. Only one study was assessed as being at low risk of bias. There was insufficient evidence to support or refute the use of any intervention. Authors' conclusions No single treatment was found to be effective and therefore the results remain inconclusive in regard to the best systemic intervention for RAS. This is likely to reflect the poor methodological rigour of trials, and lack of studies for certain drugs, rather than the true effect of the intervention. It is also recognised that in clinical practice, individual drugs appear to work for individual patients and so the interventions are likely to be complex in nature. In addition, it is acknowledged that systemic interventions are often reserved for those patients who have been unresponsive to topical treatments, and therefore may represent a select group of patients. Plain language summary Systemic interventions for recurrent aphthous stomatitis (mouth ulcers) Mouth ulcers (sores) are one of the most common oral problems and many people suffer with them repeatedly. These can be painful and slow to heal. At its worst, this can cause significant difficulties in eating and drinking. This review found that many different treatments were used to manage this condition, although the evidence of their effectiveness remains inconclusive.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Brocklehurst, P; Tickle, M; Glenny, AM; Lewis, MA; Pemberton, MN; Taylor, J; Walsh, T; Riley, P; Yates, JM", "articleTypes": [], "doi": "10.1002/14651858.CD005411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "1c9500fe-d566-48b1-8d79-f4d627576fb1", "pmid": "", "title": "Blood pressure lowering efficacy of beta‐blockers as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Beta‐blockers are one of the more commonly prescribed classes of anti‐hypertensive drugs, both as first‐line and second‐line. Objectives To quantify the effect on systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and withdrawals due to adverse effects of beta‐blocker therapy when given as a second‐line drug in adult patients with primary hypertension. Search methods CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1966‐Aug 2009), EMBASE (1988‐Aug 2009) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized controlled trials comparing a beta‐blocker in combination with a drug from another class of anti‐hypertensive drugs compared with that drug alone for a duration of 3 to 12 weeks in patients with primary hypertension were included. Data collection and analysis Two reviewers independently extracted the data and assessed trial quality of each included study. Main results 20 double‐blind RCTs evaluated the BP lowering efficacy of beta‐blockers as second‐line drug in 3744 hypertensive patients (baseline BP of 158/102 mmHg; mean duration of 7 weeks). The BP reduction from adding a beta‐blocker as the second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. A reduction in BP was seen with adding a beta‐blocker to thiazide diuretics or calcium channel blockers at doses as low as 0.25 times the manufacturer's recommended starting dose. The BP lowering efficacy of beta‐blockers as a second drug was 6/4 mmHg at 1 times the starting dose and 8/6 mmHg at 2 times the starting dose. Beta‐blockers reduced heart rate by 10 beats/min at 1 to 2 times the starting dose. Beta‐blockers did not statistically significantly increase withdrawals due to adverse effects but this was likely due to the lack of reporting of this outcome in 35% of the included RCTs. Authors' conclusions Addition of a beta‐blocker to diuretics or calcium‐channel blockers reduces BP by 6/4mmHg at 1 times the starting dose and by 8/6 mmHg at 2 times the starting dose. When the blood pressure lowering effect of beta‐blockers from this review was compared to that of thiazide diuretics from our previous review ( Chen 2009 ), second‐line beta‐blockers reduce systolic BP to the same extent as second‐line thiazide diuretics, but reduce diastolic BP to a greater degree. The different effect on diastolic BP means that beta‐blockers have little or no effect on pulse pressure whereas thiazides cause a significant dose‐related decrease in pulse pressure. This difference in the pattern of BP lowering with beta‐blockers as compared to thiazides might be the explanation for the fact that beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than thiazide diuretics, particularly in older individuals. Plain language summary Beta‐blockers lower blood pressure when given as a second drug Beta‐blockers are commonly used in the treatment for high blood pressure (BP). In this review, we asked how much do beta‐blockers reduce BP when used as the second drug to treat hypertension. Twenty trials lasting an average of 7 weeks were found in the world scientific literature to answer this question. The data showed that the addition of a beta‐blocker to thiazide diuretics or calcium channel blockers reduced BP by 8/6 mmHg when given at doses 2 times the recommended starting dose. When we compared these results with our previous review of the blood pressure lowering effect of thiazide diuretics as second line drug, we found that beta‐blockers have a different pattern of BP lowering. This different pattern of effect on blood pressure might explain why first‐line beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than first‐line thiazide diuretics, particularly in older individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, JMH, Heran, BS, Perez, MI, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007185.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.112Z" }, { "id": "1c9d0c70-f57c-49b2-b9e3-b93ba0f20eac", "pmid": "", "title": "Venepuncture versus heel lance for blood sampling in term neonates", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Martins, G, Fiander, M, Taddio, A, Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD001452.pub5 AB - Abstract - Rationale Reducing procedural pain is a key priority in neonatal care, as even routine procedures for blood sampling can cause significant discomfort and pain to the neonate. This systematic review aims to compare venepuncture and heel lance for blood sampling, focusing on pain response, to guide clinical practice. Objectives To evaluate the benefits (degree of pain) and harms (need for more than one skin puncture) of venepuncture compared to heel lance in term neonates. Search methods We searched CENTRAL, MEDLINE, Embase, two trial registries and conference abstracts, and checked references of included studies and related systematic reviews up to 04 July 2025. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs that compared pain response from venepuncture versus heel lance. Neonates could receive a sweet‐tasting solution (such as glucose or sucrose), which is a commonly used analgesic in neonates for pain relief. We excluded studies that reported on pain using physiological parameters in isolation, as they are reflective of overall clinical status and non‐specific arousal. Outcomes Our outcomes of interest were pain reported using validated pain scores (measured using one or more of the following scales: Neonatal Facial Coding System, Neonatal Infant Pain scores, or the Premature Infant Pain Profile) and the need for more than one skin puncture. Risk of bias We used the Risk of bias 1 (RoB) tool to assess bias in the included RCTs. Synthesis methods We conducted a meta‐analysis where possible by calculating standardized mean difference (SMD) and risk ratio (RR) with their 95% confidence intervals (CIs) for continuous and dichotomous outcomes, respectively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included eight studies with 826 neonates. The studies were performed in six high‐, upper‐middle, or low‐income countries. Synthesis of results We judged the overall risk of bias in the eight studies to be high. Most studies had concerns related to blinding and allocation concealment. Venepuncture compared to heel lance (with no sweet‐tasting solution) Pain scores 
Venepuncture probably reduces pain compared to heel lance during the procedure when no sweet‐tasting solution is administered (SMD −1.34, 95% CI −1.55 to −1.14; I² = 94%; 6 studies, 488 participants; moderate‐certainty evidence). Need for more than one skin puncture 
Venepuncture probably reduces the need for more than one skin puncture compared to heel lance when no sweet tasting solution is administered (RR 0.63, 95% CI 0.40 to 0.97; I² = 20%; 6 studies, 397 participants; moderate‐certainty evidence) Venepuncture compared to heel lance (with sweet‐tasting solution) Pain scores 
Venepuncture may reduce pain compared to heel lance during the procedure when a sweet‐tasting solution is administered (SMD −0.38, 95% CI −0.69 to −0.07; I² = 79%; 3 studies, 170 participants; low‐certainty evidence). Need for more than one skin puncture 
The evidence is very uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture when a sweet‐tasting solution is used (RR 7.00, 95% CI 0.38 to 129.93; I² not applicable; 2 studies, 110 participants; very low‐certainty evidence). This is due to the small number of participants in each group. Authors' conclusions Based on moderate‐certainty evidence, venepuncture probably reduces pain during the procedure and the need for more than one skin puncture compared to heel lance when no sweet‐tasting solution is used. When sweet‐tasting solutions are administered, venepuncture may reduce pain during the procedure compared to heel lance, based on low‐certainty evidence. The evidence is very uncertain about the effect of venepuncture compared to heel lance on the number of skin punctures required in the presence of sweet‐tasting solutions. This is due to the small sample size, and hence we could not draw any meaningful conclusions. Further high‐quality studies are needed, particularly in settings where sweet‐tasting solutions are used, to better understand the comparative effectiveness of venepuncture and heel lance for neonatal blood sampling. Funding Cochrane Neonatal editorial support for this review update, as part of a suite of reviews addressing “The infant and family experience in the neonatal intensive care unit”, has been provided by a grant from The Gerber Foundation. The Gerber Foundation is a separately endowed, private, 501(c)(3) foundation not related to Gerber Products Company in any way. Registration Original review (2001): DOI 10.1002/14651858.CD001452
Review update (2004): DOI 10.1002/14651858.CD001452.pub2
Review update (2007): DOI 10.1002/14651858.CD001452.pub3
Review update (2011): DOI 10.1002/14651858.CD001452.pub4 Plain language summary Is using a needle (venepuncture) better than using a device (heel lance) for taking a blood sample from full‐term newborn babies? Key messages Venepuncture (inserting a needle into a vein) may be less painful than heel lance (using a special device to puncture the skin) for newborn babies when having a blood sample taken, with or without sugar water for pain relief, and may reduce the need for more than one skin puncture when no sugar water is given for pain relief. We don’t know whether venepuncture reduces the need for more than one skin puncture compared with heel lance when sugar water is given for pain relief. We need better designed and larger studies that fully report their results to show which method is better for babies. Why do we take blood samples from newborn babies? In most countries, a blood sample from newborn babies is needed for routine screening tests. Blood samples may also be needed for other blood tests to diagnose and manage diseases, such as jaundice or low blood sugar (hypoglycemia). However, taking blood from babies is painful. Untreated pain in newborn babies may affect their physical growth and brain development. A sweet, sugar solution (such as sucrose) can be given to babies before the procedure, which helps to reduce the pain. It is difficult to measure pain in babies, but we rely on things like facial expressions, crying, and changes in heart rate to assess their pain. How are blood samples taken? Venepuncture Venepuncture is a method of taking a blood sample where a person uses a needle to directly puncture the vein. The person who performs this must be well‐trained to help ensure they successfully take a blood sample. This technique is often used when 1 mL or more of blood is required, and to prevent repeated punctures to the skin and associated complications (such as skin infections) from heel lance. Heel lance Heel lance is the standard way of taking a blood sample from newborn babies in hospitals worldwide. It is commonly used when the blood sample required is less than 1 mL. It does not require special training or expertise for successful use. The procedure involves making a small puncture (between 1 mm and 2 mm deep) on the heel of the foot using a lancet, which is usually an automatic device. Following the puncture, the infant's heel is squeezed to collect the required blood sample, which causes further pain. What did we want to find out? We wanted to find out: whether venepuncture is less painful than heel lance for newborn babies; and which procedure works best first time, so a second skin puncture is not needed. What did we do? We searched for studies that compared venepuncture and heel lance for taking blood samples in newborn babies. The studies needed to measure pain responses and the number of skin punctures needed for a successful sample. They also needed to record whether babies were given sugar solution as pain relief. Babies in the studies had to be healthy and born at full term. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included eight studies involving 826 full‐term newborn babies. Three studies took place in Sweden, and one each in Japan, Malaysia, Nepal, Spain, and the UK. When no sweet‐tasting solution was given: venepuncture probably causes less pain compared to heel lance (6 studies, 488 babies); and venepuncture probably reduces the need for more than one skin puncture compared to heel lance (6 studies, 397 babies). When a sweet‐tasting solution was given: venepuncture may cause less pain compared to heel lance (3 studies, 170 babies); and we are uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture (2 studies, 110 babies). What are the limitations of the evidence? Our confidence in the evidence was limited, and ranged from moderate to very low. This is because all the studies had limitations in how they were carried out. These included issues with how babies were assigned to each group, how the studies reported their results, and the number of babies included in the studies. In addition, the people doing the procedures knew which sampling method each baby received, which could have influenced how the studies assessed pain. How up to date is this evidence? This review updates our 2011 Cochrane review. The evidence is up to date to July 2025.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.750Z" }, { "id": "1cadebc1-935d-4f61-b5c8-b2e599ae7c8a", "pmid": "", "title": "Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background It is unclear whether patients with type 2 diabetes who have poor glycaemic control despite maximal oral hypoglycaemic agents (OHAs) should be commenced on insulin as monotherapy, or insulin combined with oral hypoglycaemic agents (insulin‐OHA combination therapy). Objectives To assess the effects of insulin monotherapy versus insulin‐OHA combinations therapy. Search methods Eligible studies were identified by searching MEDLINE, EMBASE, and The Cochrane Library . Selection criteria Randomised controlled trials (RCTs) with 2 months minimum follow‐up duration comparing insulin monotherapy (all schemes) with insulin‐OHA combination therapy. Data collection and analysis Data extraction and assessment of study quality were undertaken by three reviewers in pairs. Main results Twenty RCTs (mean trial duration 10 months) including 1,811 participants, with mean age 59.8 years and mean known duration of diabetes 9.6 years. Overall, study methodological quality was low. Twenty‐eight comparisons in 20 RCTs were ordered according to clinical considerations. No studies assessed diabetes‐related morbidity, mortality or total mortality. From 13 studies (21 comparisons), sufficient data were extracted to calculate pooled effects on glycaemic control. Insulin‐OHA combination therapy had statistically significant benefits on glycaemic control over insulin monotherapy only when the latter was applied as a once‐daily injection of NPH insulin. Conversely, twice‐daily insulin monotherapy (NPH or mixed insulin) provided superior glycaemic control to insulin‐OHA combination therapy regimens where insulin was administered as a single morning injection. In more conventional comparisons, regimens utilising OHAs with bedtime NPH insulin provided comparable glycaemic control to insulin monotherapy (administered as twice daily, or multiple daily injections). Overall, insulin‐OHA combination therapy was associated with a 43% relative reduction in total daily insulin requirement compared to insulin monotherapy. Of the 14 studies (22 comparisons) reporting hypoglycaemia, 13 demonstrated no significant difference in the frequency of symptomatic or biochemical hypoglycaemia between insulin and combination therapy regimens. No significant differences in quality of life related issues were detected. Combination therapy with bedtime NPH insulin resulted in statistically significantly less weight gain compared to insulin monotherapy, provided metformin was used ± sulphonylurea. In all other comparisons no significant differences with respect to weight gain were detected. Authors' conclusions Bedtime NPH insulin combined with oral hypoglycaemic agents provides comparable glycaemic control to insulin monotherapy and is associated with less weight gain if metformin is used. Plain language summary Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus Simple application of a single daily insulin injection in addition to oral hypoglycaemic agents may facilitate the initiation of insulin therapy in type 2 diabetes mellitus.This review examined 20 trials including 1,811 participants which compared insulin monotherapy with insulin in combination with oral hypoglycaemic agents (OHA) in insulin‐requiring patients with type 2 diabetes. The results suggest that a bedtime NPH insulin‐oral hypoglycaemic agent combination therapy regimen provides comparable glycaemic control to insulin monotherapy. Due to lack of studies it remains unclear whether insulin‐OHA combination regimens with metformin alone are superior to those with metformin plus a sulphonylurea. In most cases no significant differences in hypoglycaemic events were observed between insulin mono‐ and OHA combination therapy. No study assessed diabetes‐related morbidity or mortality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Goudswaard, AN; Furlong, NJ; Valk, GD; Stolk, RP; Rutten, GEHM", "articleTypes": [], "doi": "10.1002/14651858.CD003418.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "1cb5482c-685c-4ecd-a307-9e3bcb0856b8", "pmid": "", "title": "Interventions for protecting renal function in the perioperative period", "imported": false, "abstract": "Abstract - Background Various methods have been used to try to protect kidney function in patients undergoing surgery. These most often include pharmacological interventions such as dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants and erythropoietin (EPO). Objectives This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period. We considered the following questions: (1) Are any specific measures known to protect kidney function during the perioperative period? (2) Of measures used to protect the kidneys during the perioperative period, does any one method appear to be more effective than the others? (3) Of measures used to protect the kidneys during the perioperative period,does any one method appear to be safer than the others? Search methods In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 2, 2012), MEDLINE (Ovid SP) (1966 to August 2012) and EMBASE (Ovid SP) (1988 to August 2012). We originally handsearched six journals ( Anesthesia and Analgesi a, Anesthesiology , Annals of Surgery , British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery) (1985 to 2004). However, because these journals are properly indexed in MEDLINE, we decided to rely on electronic searches only without handsearching the journals from 2004 onwards. Selection criteria We selected all randomized controlled trials in adults undergoing surgery for which a treatment measure was used for the purpose of providing renal protection during the perioperative period. Data collection and analysis We selected 72 studies for inclusion in this review. Two review authors extracted data from all selected studies and entered them into RevMan 5.1; then the data were appropriately analysed. We performed subgroup analyses for type of intervention, type of surgical procedure and pre‐existing renal dysfunction. We undertook sensitivity analyses for studies with high and moderately good methodological quality. Main results The updated review included data from 72 studies, comprising a total of 4378 participants. Of these, 2291 received some form of treatment and 2087 acted as controls. The interventions consisted most often of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, NAC, ANP, sodium bicarbonate, antioxidants and EPO or selected hydration fluids. Some clinical heterogeneity and varying risk of bias were noted amongst the studies, although we were able to meaningfully interpret the data. Results showed significant heterogeneity and indicated that most interventions provided no benefit. Data on perioperative mortality were reported in 41 studies and data on acute renal injury in 44 studies (all interventions combined). Because of considerable clinical heterogeneity (different clinical scenarios, as well as considerable methodological variability amongst the studies), we did not perform a meta‐analysis on the combined data. Subgroup analysis of major interventions and surgical procedures showed no significant influence of interventions on reported mortality and acute renal injury. For the subgroup of participants who had pre‐existing renal damage, the risk of mortality from 10 trials (959 participants) was estimated as odds ratio (OR) 0.76, 95% confidence interval (CI) 0.38 to 1.52; the risk of acute renal injury (as reported in the trials) was estimated from 11 trials (979 participants) as OR 0.43, 95% CI 0.23 to 0.80. Subgroup analysis of studies that were rated as having low risk of bias revealed that 19 studies reported mortality numbers (1604 participants); OR was 1.01, 95% CI 0.54 to 1.90. Fifteen studies reported data on acute renal injury (criteria chosen by the individual studies; 1600 participants); OR was 1.03, 95% CI 0.54 to 1.97. Authors' conclusions No reliable evidence from the available literature suggests that interventions during surgery can protect the kidneys from damage. However, the criteria used to diagnose acute renal damage varied in many of the older studies selected for inclusion in this review, many of which suffered from poor methodological quality such as insufficient participant numbers and poor definitions of end points such as acute renal failure and acute renal injury. Recent methods of detecting renal damage such as the use of specific biomarkers and better defined criteria for identifying renal damage (RIFLE (risk, injury, failure, loss of kidney function and end‐stage renal failure) or AKI (acute kidney injury)) may have to be explored further to determine any possible benefit derived from interventions used to protect the kidneys during the perioperative period. Plain language summary No evidence indicates that any of the measures used to protect patients' kidneys during the perioperative period are beneficial The kidneys may be damaged during an operation as a result of direct and indirect insult. The reasons for this are multiple and include changes to physiology brought on by the surgery and by the body’s response to such insult. Damage to kidneys during the perioperative period is associated with significant morbidity and mortality. This updated Cochrane review looked at 72 randomized controlled trials (RCTs) with 4378 participants (search data until August 2012); interventions most often included pharmacological interventions (administration of dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine, atrial natriuretic peptide, sodium bicarbonate, antioxidants and erythropoietin) or selected hydration fluids. We attempted to identify any possible damage to the kidneys by evaluating kidney function up to seven days after the operation. No clear evidence from available RCTs suggests that any of the measures used to protect the kidneys during the perioperative period are beneficial. These findings held true in 14 studies of patients with pre‐existing renal damage and in 24 studies that were considered of good methodological quality. The primary outcomes of these studies were mortality and acute renal injury. Reported mortality in studies with low risk of bias was not different between intervention and control groups (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.52 to 1.97) or for acute renal injury (OR 1.05, 95% CI 0.55 to 2.03). The summary of findings revealed a similar picture. So we conclude that evidence suggests that none of the interventions used currently are helpful in protecting the kidneys during the perioperative period, nor do they cause increased harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zacharias, M, Mugawar, M, Herbison, GP, Walker, RJ, Hovhannisyan, K, Sivalingam, P, Conlon, NP", "articleTypes": [], "doi": "10.1002/14651858.CD003590.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.783Z" }, { "id": "1cce7162-bc13-46fe-a980-16fbb0c2d4ca", "pmid": "", "title": "Zinc supplementation for the treatment of measles in children", "imported": false, "abstract": "Abstract - Background Measles is an important cause of childhood morbidity and mortality globally, despite increasing vaccine coverage. Zinc plays a significant role in the maintenance of normal immunological functions, therefore supplements given to zinc‐deficient children will increase the availability of zinc and could reduce measles‐related morbidity and mortality. This is an update of a review first published in 2015. Objectives To assess the effects of zinc supplementation in reducing morbidity and mortality in children with measles. Search methods We searched CENTRAL (03 February 2017, Issue 2), MEDLINE (1946 to 03 February 2017), Embase (1974 to 03 February 2017), CINAHL (1981 to 03 February 2017), LILACS (1982 to 03 February 2017), Web of Science (1985 to 03 February 2017), and BIOSIS Previews (1985 to 27 June 2014). We also searched ClinicalTrials.gov, the Australian New Zealand Clinical Trials Registry and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 03 February 2017 to identify unpublished and ongoing studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of zinc in reducing morbidity and mortality in children with measles. Data collection and analysis Two review authors independently assessed the studies for inclusion and extracted data on outcomes, details of the interventions, and other study characteristics using a standardised data extraction form. We used risk ratio (RR) and hazard ratio (HR) as measures of effect with 95% confidence intervals (CI). We included only one study, and did not conduct meta‐analysis. Main results We did not identify any new studies for inclusion in this update. One RCT met our inclusion criteria. The study was conducted in India and included 85 children diagnosed with measles and pneumonia. The trial showed no significant difference in mortality between children with measles and pneumonia who received zinc supplements and those who received placebo (RR 0.34, 95% CI 0.01 to 8.14). There was no significant difference in time to absence of fever between children who received zinc supplements and those who did not (HR 1.08, 95% CI 0.67 to 1.74). No treatment‐related side effects were reported in either group. We assessed the overall quality of the evidence as very low. Authors' conclusions We could not draw any definitive conclusions from this review about the effects of zinc supplementation on clinical outcomes of children with measles due to the very low quality of the evidence available. There is insufficient evidence to confirm or refute the effect of zinc supplementation in children with measles. Plain language summary Zinc supplementation for the treatment of measles in children Review question What is the effect of zinc supplementation in the treatment of children with measles? Background Measles infection has reduced globally over the last decade, but large outbreaks still occur, especially in low‐income countries. Zinc is one of the essential micronutrients necessary for the optimal functioning of the immune system. Zinc deficiency is particularly common in children in low‐ and middle‐income countries. It was therefore important to examine the potential role of zinc supplementation in controlling the symptoms of measles infection in children. We aimed to critically assess the current evidence from published studies on the effect of zinc supplementation for the treatment of measles in children. Search date We searched for evidence up to 03 February 2017. This is an update of a review first published in 2015. We did not include any new studies for this update. Study characteristics We found one small randomised trial (involving 85 children) that compared zinc supplements versus placebo administered to children with measles and pneumonia. All 85 children received supportive care and vitamin A. The study was conducted in India and funded by the Child Health Foundation USA and the Nestlé Foundation. Key results The included study was small and did not provide enough data to determine whether zinc had an effect on mortality when compared with placebo. Although no adverse effects were reported, there was insufficient evidence to draw any conclusions about the use of zinc supplements to improve measles symptoms in children. More research is needed to clarify any benefits or harms. Quality of the evidence We assessed the quality of the evidence as very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Awotiwon, AA, Oduwole, O, Sinha, A, Okwundu, CI", "articleTypes": [], "doi": "10.1002/14651858.CD011177.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.740Z" }, { "id": "1ccf8550-0732-474e-8c49-383f4509b2d6", "pmid": "", "title": "Skin‐to‐skin care for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Skin‐to‐skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal‐infant contact, is one non‐pharmacological intervention for pain control in infants. Objectives The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonates The secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants. Search methods For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi‐randomized trials. Selection criteria Studies with randomisation or quasi‐randomisation, double‐ or single‐blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals. Data collection and analysis The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed‐effect model was reported for continuous outcome measures. We included variations on type of tissue‐damaging procedure, provider of care, and duration of SSC. Main results Twenty‐five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes. Seventeen studies (n = 810) compared SSC to a no‐treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of −10.78 beats per minute (95% CI −13.63 to −7.93) favouring SSC. Meta‐analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI −4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta‐analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta‐analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = −34.16, 95% CI −42.86 to −25.45), and two (n = 100) following IM injection (MD = −8.83, 95% CI −14.63 to −3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD −3.21, 95% CI −3.94 to −2.47), at 60 seconds (3 studies; n = 156) (MD −1.64, 95% CI −2.86 to −0.43), and at 90 seconds (n = 156) (MD −1.28, 95% CI −2.53 to −0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI −1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta‐analysis findings. Eight studies compared SSC to another intervention with or without a no‐treatment control. Two cross‐over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no‐treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies. Authors' conclusions SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother‐providers to others, with non‐significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long‐term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions. Plain language summary Skin‐to‐skin care with newborns cuts down procedural pain Review question: Is skin‐to‐skin care effective in cutting down pain from procedures in newborns? Are there any safety issues? Background: Newborns wearing only a diaper being held next to their mother's bare chest is referred to as skin‐to‐skin contact and is also sometimes called 'kangaroo care' because of its similarity to the way kangaroo mothers care for their young. Newborns, especially those who must spend time in a Neonatal Intensive Care Unit, must have various tests and procedures as part of their care, for example heel stick, venous puncture, and injections. Giving analgesic drugs for these procedures can often pose problems so that alternatives to drugs must be found. Study characteristics: Twenty‐eight studies in which newborn babies who were by chance in the kangaroo care group or condition were included from an extensive search of the literature. Skin‐to‐skin care was clearly defined and could have been compared to no pain‐reducing strategies or other pain‐reducing strategies such as sweet taste. Studies were examined which examined well‐established signs of pain, both physiological and behavioural, as well as a combination of physiological and behavioural signs. Different providers of skin‐to‐skin care other than the mother were included. Key results: Kangaroo care appears to reduce the pain response to, and recovery from, these frequent procedures, although few studies could be combined to provide strong evidence. As far as it has been reported, skin‐to‐skin care is safe. Although it appears that skin‐to‐skin care is effective, the size of the benefit remains uncertain. Quality of evidence: The quality of evidence in these studies was generally low for the response to the actual procedure but was moderate for recovery from the procedure.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Johnston, C, Campbell‐Yeo, M, Disher, T, Benoit, B, Fernandes, A, Streiner, D, Inglis, D, Zee, R", "articleTypes": [], "doi": "10.1002/14651858.CD008435.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.732Z" }, { "id": "1cd835e3-22de-4c94-89db-749a05db1402", "pmid": "", "title": "Corticosteroids for treating sepsis in children and adults", "imported": false, "abstract": "Abstract - Background Sepsis occurs when an infection is complicated by organ failure. Sepsis may be complicated by impaired corticosteroid metabolism. Thus, providing corticosteroids may benefit patients. This is an update of a review originally published in 2004 and previously updated in 2010, 2015 and 2019. Objectives To examine the benefits and harms of corticosteroids in children and adults with sepsis. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, ISRCTN and the WHO Clinical Trials Search Portal on 31 December 2023. In addition, we conducted reference checking and citation research, and contacted study authors, to identify additional studies as needed. We updated this search in December 2024, but these results have not yet been incorporated. Selection criteria We included randomised controlled trials (RCTs) of corticosteroids versus placebo or usual care (antimicrobials, fluid replacement and vasopressor therapy as needed) in children and adults with sepsis. We also included RCTs of continuous infusion versus intermittent bolus of corticosteroids. Data collection and analysis We used the same methods in comparisons of corticosteroids versus placebo or usual care, and of continuous infusion versus intermittent bolus administration of corticosteroids. The primary outcome was all‐cause mortality at 28 days. The most critical secondary outcomes were (i) all‐cause mortality in the long term (last follow‐up from 90 days to one year) and in the hospital; (ii) length of stay in the intensive care unit and in hospital; (iii) adverse effects, i.e. superinfection and muscle weakness (within 28 days). All review authors screened and selected studies for inclusion. One review author extracted data, which was checked by the others, and by the lead author of the primary study when possible. For this update, we used Covidence software for screening and selection of studies and abstraction of data by paired review authors, with discrepancies resolved by a third review author. We obtained unpublished data from the authors of some trials. We assessed the risk of bias in trials using the Cochrane risk of bias tool (RoB 1) and applied GRADE to assess the certainty of evidence. The review authors did not contribute to the assessment of eligibility or risk of bias, nor to data extraction, for the trials they had participated in. Main results We included 87 trials (24,336 participants), of which six included only children, two included children and adults, and the remaining trials included only adults. Seventeen additional trials are ongoing and will be considered in future versions of this review. We judged 25 trials as being at low risk of bias. Corticosteroids versus placebo or usual care Compared to placebo or usual care, corticosteroids probably reduce 28‐day mortality (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.84 to 0.95; 72 trials, 22,915 participants; moderate‐certainty evidence). We downgraded the certainty of evidence for this outcome from high to moderate for inconsistency (significant heterogeneity across trial results). Corticosteroids may result in little to no difference in long‐term mortality (RR 0.97, 95% CI 0.91 to 1.03; 12 trials, 8468 participants; low‐certainty evidence) and probably reduce in‐hospital mortality (RR 0.90, 95% CI 0.84 to 0.97; 40 trials, 17,459 participants; moderate‐certainty evidence). Corticosteroids may reduce length of intensive care unit (ICU) stay for all participants (mean difference (MD) ‐0.86 days, 95% CI ‐1.67 to ‐0.05; 25 trials, 8069 participants; low‐certainty evidence) and may reduce length of hospital stay for all participants (MD ‐1.09 days, 95% CI ‐1.85 to ‐0.34; 31 trials, 16,954 participants; low‐certainty evidence). The evidence is uncertain about the effect of corticosteroids on the risk of muscle weakness (RR 1.09, 95% CI 0.78 to 1.53; 7 trials, 6729 participants; very low‐certainty evidence). Corticosteroids may result in little to no difference in the risk of superinfection (RR 0.96, 95% CI 0.86 to 1.07; 36 trials, 7961 participants; low‐certainty evidence). Continuous infusion of corticosteroids versus intermittent bolus Four trials reported data for this comparison, and the certainty of evidence for all outcomes was very low. We are uncertain about the effects of continuous infusion of corticosteroids compared with intermittent bolus administration on 28‐day mortality (RR 1.03, 95% CI 0.81 to 1.32; 3 trials, 310 participants). We downgraded the certainty of evidence to very low due to high risk of bias in all except one trial and due to imprecision. Compared to bolus administration, we are uncertain of the effects of continuous infusion of corticosteroids on long‐term mortality (RR 1.36, 95% CI 1.02 to 1.81; 1 trial, 70 participants; very low‐certainty evidence), in‐hospital mortality (RR 0.92, 95% CI 0.71 to 1.19; 3 trials, 352 participants; very low‐certainty evidence), ICU length of stay amongst all participants (MD ‐0.56 days, 95% CI ‐3.44 to 2.32; 4 trials, 422 participants; very low‐certainty evidence), hospital length of stay amongst all participants (MD ‐0.21 days, 95% CI ‐4.72 to 4.30; 4 trials, 422 participants; very low‐certainty evidence), risk of muscle weakness (RR 0.89, 95% CI 0.13 to 5.98; 1 trial, 70 participants; very low‐certainty evidence) and risk of superinfection (RR 1.12, 95% CI 0.37 to 3.33; 2 trials, 193 participants; very low‐certainty evidence). Authors' conclusions Moderate‐certainty evidence indicates that corticosteroids probably reduce 28‐day, 90‐day and hospital mortality amongst patients with sepsis. Corticosteroids may shorten ICU and hospital length of stay (low‐certainty evidence). There may be little or no difference in the risk of superinfection. The risk of muscle weakness is uncertain. The effects of continuous versus intermittent bolus administration of corticosteroids are uncertain. Plain language summary What are the benefits and harms of corticosteroids in the treatment of children and adults with sepsis? Key messages • Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days and of in‐hospital death, and may have little or no effect on the risk of dying beyond three months. • We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. • Future studies should measure the benefits and harms of corticosteroids for the treatment of specific populations, including children, patients with sepsis without shock or with a mild form of septic shock, patients with acute respiratory distress syndrome (ARDS) and patients with different types of infections. Defining the optimal methods for corticosteroid administration, including the types of molecule ‐ with or without producing sodium and fluid retention and potassium excretion (mineralocorticoid activity), timing of initiation, dose and duration, continuous infusion or intermittent intravenous boluses, and ending of treatment ‐ with or without gradually decreasing the dose to zero, also requires additional studies. Future studies should measure the longer‐term effects, i.e. longer than one year, on survival and complications of sepsis. What is sepsis? Sepsis is present when an infection is complicated by organ failure. People develop rapid breathing, hypotension (low blood pressure) and mental confusion. Sepsis can interfere with the effectiveness of the body’s corticosteroids, which control how your body recognises and defends itself against bacteria, viruses and substances that appear foreign and harmful. What are corticosteroids (medicine)? Corticosteroids are medicines used to stop excessive inflammation. However, these medicines may cause unwanted harms, such as increased blood sugar or salt levels, infections, bleeding in the stomach, agitation or delirium, and weakness of the limbs. Corticosteroids have been given for decades to people with infection resulting from various causes. What did we want to find out? We wanted to find out: • the benefits of using corticosteroids in children and adults with sepsis; and • the best ways to administer this treatment (including the best people to give it to). We also wanted to know if corticosteroids can cause any unwanted effects. What did we do? We searched for studies that compared: • corticosteroids administered intravenously against a 'dummy' treatment, or sham treatment, which does not contain any medicine but looks or tastes identical to corticosteroids, or usual care; or • continuous infusion against intermittent rapid intravenous injections (boluses) of corticosteroids administration. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? This review includes 87 trials (24,336 participants). The biggest study was of 3800 people and the smallest study was of 21 people. Eighty‐three trials compared corticosteroids to no corticosteroids (placebo or usual care in 59 and 24 trials, respectively). Four trials also compared continuous administration versus rapid intravenous injection (i.e. bolus) of corticosteroids given at fixed intervals of six or eight hours. Thirty‐three trials were conducted in Europe, 15 in North America, 22 in Asia, six in the Middle East, six in Africa and three in Latin America; four were multinational trials. Three trials were funded by a drug company, 27 by public organisations or through charitable funding and six by both a drug company and public organisations or charitable funding; 25 did not declare the source of funding. Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days by 10% (72 trials; 22,915 participants), with consistent treatment effects between children and adults. There may be little or no effect of corticosteroids on the risk of dying over the long term (longer than three months), but these results are less certain. Corticosteroids probably reduce the risk of dying in hospital. Corticosteroids may result in a reduction in the length of stay in the intensive care unit (ICU) and in hospital. They may not increase the risk of superinfection (second infection). The evidence is very uncertain about the effect of corticosteroids on the risk of muscle weakness. We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. Four studies reported data for this comparison, and the certainty of evidence for all outcomes was very low. What are the limitations of the evidence? • Corticosteroids versus placebo or usual care We have moderate confidence in our findings that corticosteroids reduced 28‐day mortality. We found some differences amongst the study populations, the types of corticosteroids and how they were given, and the use of additional medicines. • Continuous infusion versus bolus administration of corticosteroids We have very little confidence in our findings about the absence of a difference in 28‐day mortality between the administration of corticosteroids continuously and repeated rapid intravenous injections. We found only four studies that enrolled very few patients. How up‐to‐date is this evidence? The evidence provided in this review is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Annane, D; Briegel, J; Granton, D; Bellissant, E; Bollaert, PE; Keh, D; Kupfer, Y; Pirracchio, R; Rochwerg, B", "articleTypes": [], "doi": "10.1002/14651858.CD002243.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "1cd9f9bc-0372-462d-be7b-2363c0bccf4a", "pmid": "", "title": "A Phase 2, Randomized, Double Blind, Placebo Controlled Study to Evaluate the Efficacy and Safety of Leronlimab in Patients Experiencing Prolonged Coronavirus Disease 2019 (COVID-19) Symptoms [Long-Haulers]", "imported": false, "abstract": "The purpose of this study is to assess the safety and efficacy of leronlimab (PRO 140) administered as weekly subcutaneous injections in subjects experiencing prolonged symptoms (> 12 weeks) of COVID-19.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.243Z" }, { "id": "1ce46798-b11b-4654-8848-5d8d274209b1", "pmid": "", "title": "Immunostimulants for preventing respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are a major cause of childhood morbidity and mortality. Immunostimulants (IS) may reduce the incidence of ARTIs. Objectives To determine the efficacy and safety of IS in preventing ARTIs in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 1, which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to February week 4, 2011), EMBASE (1990 to February 2011), Google Scholar (2009 to February 2011), Scopus (2009 to February 2011), PASCAL (1990 to February 2010), SciSearch (1990 to February 2010) and IPA (1990 to February 2010). Selection criteria We included all comparative randomized controlled trials (RCTs) which enrolled participants less than 18 years of age. The intervention was IS medication, administered by any method, compared to placebo to prevent ARTIs. Data collection and analysis We analyzed the outcome on ARTIs both as the mean number of ARTIs by group and as a percent change in the rate of ARTIs. We undertook meta‐analyses using a random‐effects model and presented results as mean differences (MD) with 95% confidence intervals (CI). Two review authors independently assessed the search results and risk of bias, and extracted data. A funnel plot suggested there may be publication bias in the identified trials. Main results Thirty‐five placebo‐controlled trials (4060 participants) provided data in a form suitable for inclusion in the meta‐analyses. When compared with placebo, the use of IS was shown to reduce ARTIs measured as the total numbers of ARTIs (MD ‐1.24; 95% CI ‐1.54 to ‐0.94) and the difference in ARTI rates (MD ‐38.84%; 95% CI ‐46.37% to ‐31.31%). Trial quality was generally poor and a high level of statistical heterogeneity was evident. The subgroup analysis of bacterial IS, D53 and OM‐85 studies produced similar results, with lower heterogeneity. No difference in adverse events was evident between the placebo and IS groups. Authors' conclusions This review shows that IS reduce the incidence of ARTIs by 40% on average in susceptible children. Studies in healthy children are not available. Although the safety profile in the studies was good, some IS may be unsafe. ARTI‐susceptible children may benefit from IS treatment. Further high‐quality trials are needed and we encourage national health authorities to conduct large, multicentre, double‐blind, placebo‐controlled RCTs on the role of IS in preventing ARTIs in children. Plain language summary Immunostimulants to prevent acute respiratory tract infections in children Acute respiratory tract infections (ARTIs) are responsible for 19% of all deaths in children younger than five years of age, mainly in low‐income countries in Africa, Asia and Latin America. In high‐income countries ARTIs are among the most frequent illnesses, leading to 20% of medical consultations, 30% of days lost from work and 75% of antibiotic prescriptions. In the USA the total cost of non‐influenza‐related viral ARTIs is around $40 billion annually, while the corresponding cost for influenza is US $87.1 billion. The main signs and symptoms of ARTIs include sneezing, runny nose, sore throat, cough and malaise. Children living in rural communities, not attending daycare centres, suffer about seven ARTI episodes in the first year of life; eight ARTIs per year from the ages of one to four; six per year aged five to nine; and five per year aged 10 to 19. Children exposed to risks factors, such as attendance at daycare centres, overcrowding, contact with older siblings, smoking at home and lack of breast feeding, may suffer more ARTIs. Several treatments have been used to reduce the incidence of ARTIs (vitamin A, vitamin C, zinc, antibiotics). Among them are immunostimulants (herbal extracts, bacterial extracts, synthetic compounds), which aim to increase the immune defences of the respiratory tract. We searched for clinical trials of immunostimulants to prevent ARTIs in children compared to placebo. Our review includes 35 studies with 4060 participants. However, the quality of many of the studies was poor and the results were very diverse. By combining results, immunostimulants reduced 1.24 ARTIs in a six‐month period, equivalent to a 39% reduction in ARTIs compared to the placebo group. Only 20 studies provided adequate data on adverse events: the most frequent were rash, nausea, vomiting, abdominal pain and diarrhea. The main limitations of this review were the poor methodological quality and diverse trial results. We conclude that ARTI‐susceptible children may benefit from immunostimulants, but more high‐quality studies are needed. We suggest that national health authorities conduct high‐quality randomized controlled trials to assess the true effects of immunostimulant preparations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Del‐Rio‐Navarro, BE, Espinosa‐Rosales, FJ, Flenady, V, Sienra‐Monge, JJL", "articleTypes": [], "doi": "10.1002/14651858.CD004974.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.767Z" }, { "id": "1d144c6d-f187-4360-948d-f600395f7ad3", "pmid": "", "title": "Corrector therapies (with or without potentiators) for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR variant F508del is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF)). The F508del variant lacks meaningful CFTR function ‐ faulty protein is degraded before reaching the cell membrane, where it needs to be to effect transepithelial salt transport. Corrective therapy could benefit many pwCF. This review evaluates single correctors (monotherapy) and any combination of correctors (most commonly lumacaftor, tezacaftor, elexacaftor, VX‐659, VX‐440 or VX‐152) and a potentiator (e.g. ivacaftor) (dual and triple therapies). Objectives To evaluate the effects of CFTR correctors (with or without potentiators) on clinically important benefits and harms in pwCF of any age with class II CFTR mutations (most commonly F508del). Search methods We searched the Cochrane CF Trials Register (28 November 2022), reference lists of relevant articles and online trials registries (3 December 2022). Selection criteria Randomised controlled trials (RCTs) (parallel design) comparing CFTR correctors to control in pwCF with class II mutations. Data collection and analysis Two authors independently extracted data, assessed risk of bias and judged evidence certainty (GRADE); we contacted investigators for additional data. Main results We included 34 RCTs (4781 participants), lasting between 1 day and 48 weeks; an extension of two lumacaftor‐ivacaftor studies provided additional 96‐week safety data (1029 participants). We assessed eight monotherapy RCTs (344 participants) (4PBA, CPX, lumacaftor, cavosonstat and FDL169), 16 dual‐therapy RCTs (2627 participants) (lumacaftor‐ivacaftor or tezacaftor‐ivacaftor) and 11 triple‐therapy RCTs (1804 participants) (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor). Participants in 21 RCTs had the genotype F508del/F508del, in seven RCTs they had F508del/minimal function (MF), in one RCT F508del/gating genotypes, in one RCT either F508del/F508del genotypes or F508del/residual function genotypes, in one RCT either F508del/gating or F508del/residual function genotypes, and in three RCTs either F508del/F508del genotypes or F508del/MF genotypes. Risk of bias judgements varied across different comparisons. Results from 16 RCTs may not be applicable to all pwCF due to age limits (e.g. adults only) or non‐standard designs (converting from monotherapy to combination therapy). Monotherapy Investigators reported no deaths or clinically relevant improvements in quality of life (QoL). There was insufficient evidence to determine effects on lung function. No placebo‐controlled monotherapy RCT demonstrated differences in mild, moderate or severe adverse effects (AEs); the clinical relevance of these events is difficult to assess due to their variety and few participants (all F508del/F508del). Dual therapy In a tezacaftor‐ivacaftor group there was one death (deemed unrelated to the study drug). QoL scores (respiratory domain) favoured both lumacaftor‐ivacaftor and tezacaftor‐ivacaftor therapy compared to placebo at all time points (moderate‐certainty evidence). At six months, relative change in forced expiratory volume in one second (FEV 1 ) % predicted improved with all dual combination therapies compared to placebo (high‐ to moderate‐certainty evidence). More pwCF reported early transient breathlessness with lumacaftor‐ivacaftor (odds ratio (OR) 2.05, 99% confidence interval (CI) 1.10 to 3.83; I 2 = 0%; 2 studies, 739 participants; high‐certainty evidence). Over 120 weeks (initial study period and follow‐up), systolic blood pressure rose by 5.1 mmHg and diastolic blood pressure by 4.1 mmHg with twice‐daily 400 mg lumacaftor‐ivacaftor (80 participants). The tezacaftor‐ivacaftor RCTs did not report these adverse effects. Pulmonary exacerbation rates decreased in pwCF receiving additional therapies to ivacaftor compared to placebo (all moderate‐certainty evidence): lumacaftor 600 mg (hazard ratio (HR) 0.70, 95% CI 0.57 to 0.87; I 2 = 0%; 2 studies, 739 participants); lumacaftor 400 mg (HR 0.61, 95% CI 0.49 to 0.76; I 2 = 0%; 2 studies, 740 participants); and tezacaftor (HR 0.64, 95% CI 0.46 to 0.89; 1 study, 506 participants). Triple therapy No study reported any deaths (high‐certainty evidence). All other evidence was low‐ to moderate‐certainty. QoL respiratory domain scores probably improved with triple therapy compared to control at six months (six studies). There was probably a greater relative and absolute change in FEV 1 % predicted with triple therapy (four studies each across all combinations). The absolute change in FEV 1 % predicted was probably greater for F508del/MF participants taking elexacaftor‐tezacaftor‐ivacaftor compared to placebo (mean difference 14.30, 95% CI 12.76 to 15.84; 1 study, 403 participants; moderate‐certainty evidence), with similar results for other drug combinations and genotypes. There was little or no difference in adverse events between triple therapy and control (10 studies). No study reported time to next pulmonary exacerbation, but fewer F508del/F508del participants experienced a pulmonary exacerbation with elexacaftor‐tezacaftor‐ivacaftor at four weeks (OR 0.17, 99% CI 0.06 to 0.45; 1 study, 175 participants) and 24 weeks (OR 0.29, 95% CI 0.14 to 0.60; 1 study, 405 participants); similar results were seen across other triple therapy and genotype combinations. Authors' conclusions There is insufficient evidence of clinically important effects from corrector monotherapy in pwCF with F508del/F508del. Additional data in this review reduced the evidence for efficacy of dual therapy; these agents can no longer be considered as standard therapy. Their use may be appropriate in exceptional circumstances (e.g. if triple therapy is not tolerated or due to age). Both dual therapies (lumacaftor‐ivacaftor, tezacaftor‐ivacaftor) result in similar small improvements in QoL and respiratory function with lower pulmonary exacerbation rates. While the effect sizes for QoL and FEV 1 still favour treatment, they have reduced compared to our previous findings. Lumacaftor‐ivacaftor was associated with an increase in early transient shortness of breath and longer‐term increases in blood pressure (not observed for tezacaftor‐ivacaftor). Tezacaftor‐ivacaftor has a better safety profile, although data are lacking in children under 12 years. In this population, lumacaftor‐ivacaftor had an important impact on respiratory function with no apparent immediate safety concerns, but this should be balanced against the blood pressure increase and shortness of breath seen in longer‐term adult data when considering lumacaftor‐ivacaftor. Data from triple therapy trials demonstrate improvements in several key outcomes, including FEV 1 and QoL. There is probably little or no difference in adverse events for triple therapy (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor) in pwCF with one or two F508del variants aged 12 years or older (moderate‐certainty evidence). Further RCTs are required in children under 12 years and those with more severe lung disease. Plain language summary CFTR correctors, a therapy for cystic fibrosis targeted at specific variants (most commonly F508del) Review question How do drugs (or drug combinations) for correcting the basic defect in the most common cystic fibrosis (CF)‐causing gene variant (F508del) impact on outcomes important to people with CF (pwCF), e.g. survival, quality of life (QoL), lung function and safety? Key messages There is a lack of evidence to support monotherapy and limited evidence to support dual therapy for pwCF who have the gene variant F508del. We found important differences across key outcomes, with fewer unwanted side effects in the triple therapy studies when compared to one dual therapy drug combination (lumacaftor plus ivacaftor). More research is needed to assess triple therapy combinations in children and to monitor their safety profiles over the longer term. How would drugs (or drug combinations) correct the basic defect in the most common CF‐causing gene variant (F508del)? The CF gene makes a protein that helps salts move across cells in many parts of the body. Over 80% of pwCF have at least one copy of the genetic variant F508del, meaning they make a full length of this protein, but it cannot move through the cell correctly. Laboratory experiments suggest that if this protein reaches the cell wall, it may be able to function, restore salt movement and correct the chronic problems that pwCF experience. What did we want to find out? How do drugs (or drug combinations) used to treat people of any age who have the genetic variant F508del impact their lives? Are these drugs associated with any unwanted side effects? What did we do? We searched for and included studies that looked at drugs (and drug combinations) used to treat pwCF who had at least one copy of the most common CF‐causing gene variant (F508del) compared to control medications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 34 studies that involved 4781 pwCF and which lasted between 1 day and 48 weeks; all studies compared an active drug treatment to a placebo (drug containing no active treatment). We do not have enough information to decide if 14 studies should be included or not and eight studies have not yet been completed. Eight studies looked at treatment with a single drug (monotherapy). These studies did not report any deaths or clinically relevant improvements in quality of life (QoL) scores. There was not enough evidence to show an effect on lung function. All studies reported side effects; there were a wide range of side effects each reported by a small number of participants in the studies. There were 16 studies assessing a combination of two drugs (dual therapy), either tezacaftor plus ivacaftor or lumacaftor plus ivacaftor. One participant taking tezacaftor plus ivacaftor died, but this was not thought to be related to the treatment. Both dual therapies resulted in improvements in QoL and lung function; rates of pulmonary exacerbations (a flare‐up of symptoms) were also lower. Neither dual therapy was linked to severe side effects, although people starting treatment with lumacaftor plus ivacaftor experienced shortness of breath for one to two weeks; this usually stopped without further treatment . More concerningly, in longer studies some people taking lumacaftor plus ivacaftor experienced a rise in blood pressure. Two people (out of over 500) even stopped lumacaftor plus ivacaftor treatment because of high blood pressure. These side effects were not reported for tezacaftor plus ivacaftor. There were 11 studies assessing different combinations of three drugs (triple therapy). The combinations were based on tezacaftor with ivacaftor (or deutivacaftor, which is a similar but chemically altered version of ivacaftor) and investigators then added either elexacaftor, VX‐659, VX‐440 or VX‐152 and compared these to either triple placebo, or tezacaftor with ivacaftor and one placebo. Some studies split groups by treatment and also by different genetic variants. No study reported any deaths. Triple therapies improved QoL scores and lung function in all comparisons, with no difference in the number or severity of side effects. Fewer people with two copies of F508del taking elexacaftor plus tezacaftor plus ivacaftor experienced a pulmonary exacerbation than those taking the control treatment. What are the limitations of the evidence? Our certainty in the evidence ranged from uncertain to very certain, but we were quite certain of the evidence for most results. While studies generally provided few details about their design, so we could not make clear judgements on potential biases, we had fewer concerns with the larger, more recent studies. Some of our findings are based on studies that were too small to show important effects and for 16 studies the results may not be applicable to all pwCF due to them only including people of certain ages (i.e. only adults or only children). Also, one study had an unusual design where people were given monotherapy and then later a dual therapy. How up‐to‐date is this evidence? This review updates our earlier review. We last looked for evidence on 28 November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Heneghan, M, Southern, KW, Murphy, J, Sinha, IP, Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD010966.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.824Z" }, { "id": "1d36e400-6963-465c-90f3-2ba6a5f2187f", "pmid": "", "title": "Ready‐to‐use therapeutic food (RUTF) for home‐based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age", "imported": false, "abstract": "Abstract - Background Management of severe acute malnutrition (SAM) in children comprises two potential phases: stabilisation and rehabilitation. During the initial stabilisation phase, children receive treatment for dehydration, electrolyte imbalances, intercurrent infections and other complications. In the rehabilitation phase (applicable to children presenting with uncomplicated SAM or those with complicated SAM after complications have been resolved), catch‐up growth is the main focus and the recommended energy and protein requirements are much higher. In‐hospital rehabilitation of children with SAM is not always desirable or practical ‐ especially in rural settings ‐ and home‐based care can offer a better solution. Ready‐to‐use therapeutic food (RUTF) is a widely used option for home‐based rehabilitation, but the findings of our previous review were inconclusive. Objectives To assess the effects of home‐based RUTF used during the rehabilitation phase of SAM in children aged between six months and five years on recovery, relapse, mortality and rate of weight gain. Search methods We searched the following databases in October 2018: CENTRAL, MEDLINE, Embase, six other databases and three trials registers. We ran separate searches for cost‐effectiveness studies, contacted researchers and healthcare professionals in the field, and checked bibliographies of included studies and relevant reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs, where children aged between six months and five years with SAM were, during the rehabilitation phase, treated at home with RUTF compared to an alternative dietary approach, or with different regimens and formulations of RUTF compared to each other. We assessed recovery, deterioration or relapse and mortality as primary outcomes; and rate of weight gain, time to recovery, anthropometrical changes, cognitive development and function, adverse outcomes and acceptability as secondary outcomes. Data collection and analysis We screened for eligible studies, extracted data and assessed risk of bias of those included, independently and in duplicate. Where data allowed, we performed a random‐effects meta‐analysis using Review Manager 5, and investigated substantial heterogeneity through subgroup and sensitivity analyses. For the main outcomes, we evaluated the quality of the evidence using GRADE, and presented results in a 'Summary of findings' table per comparison. Main results We included 15 eligible studies (n = 7976; effective sample size = 6630), four of which were cluster trials. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. Six studies received funding or donations from industry whereas eight did not, and one study did not report the funding source. The overall risk of bias was high for six studies, unclear for three studies, and low for six studies. Among the 14 studies that contributed to meta‐analyses, none (n = 5), some (n = 5) or all (n = 4) children were stabilised in hospital prior to commencement of the study. One small study included only children known to be HIV‐infected, another study stratified the analysis for 'recovery' according to HIV status, while the remaining studies included HIV‐uninfected or untested children. Across all studies, the intervention lasted between 8 and 16 weeks. Only five studies followed up children postintervention (maximum of six months), and generally reported on a limited number of outcomes. We found seven studies with 2261 children comparing home‐based RUTF meeting the World Health Organization (WHO) recommendations for nutritional composition (referred to in this review as standard RUTF) with an alternative dietary approach (effective sample size = 1964). RUTF probably improves recovery (risk ratio (RR) 1.33; 95% confidence interval (CI) 1.16 to 1.54; 6 studies, 1852 children; moderate‐quality evidence), and may increase the rate of weight gain slightly (mean difference (MD) 1.12 g/kg/day, 95% CI 0.27 to 1.96; 4 studies, 1450 children; low‐quality evidence), but we do not know the effects on relapse (RR 0.55, 95% CI 0.30 to 1.01; 4 studies, 1505 children; very low‐quality evidence) and mortality (RR 1.05, 95% CI 0.51 to 2.16; 4 studies, 1505 children; very low‐quality evidence). Two quasi‐randomised cluster trials compared standard, home‐based RUTF meeting total daily nutritional requirements with a similar RUTF but given as a supplement to the usual diet (213 children; effective sample size = 210). Meta‐analysis showed that standard RUTF meeting total daily nutritional requirements may improve recovery (RR 1.41, 95% CI 1.19 to 1.68; low‐quality evidence) and reduce relapse (RR 0.11, 95% CI 0.01 to 0.85; low‐quality evidence), but the effects are unknown for mortality (RR 1.36, 95% CI 0.46 to 4.04; very low‐quality evidence) and rate of weight gain (MD 1.21 g/kg/day, 95% CI ‐ 0.74 to 3.16; very low‐quality evidence). Eight studies randomised 5502 children (effective sample size = 4456) and compared standard home‐based RUTF with RUTFs of alternative formulations (e.g. using locally available ingredients, containing less or no milk powder, containing specific fatty acids, or with added pre‐ and probiotics). For recovery, it made little or no difference whether standard or alternative formulation RUTF was used (RR 1.03, 95% CI 0.99 to 1.08; 6 studies, 4188 children; high‐quality evidence). Standard RUTF decreases relapse (RR 0.84, 95% CI 0.72 to 0.98; 6 studies, 4188 children; high‐quality evidence). However, it probably makes little or no difference to mortality (RR 1.00, 95% CI 0.80 to 1.24; 7 studies, 4309 children; moderate‐quality evidence) and may make little or no difference to the rate of weight gain (MD 0.11 g/kg/day, 95% CI −0.32 to 0.54; 6 studies, 3807 children; low‐quality evidence) whether standard or alternative formulation RUTF is used. Authors' conclusions Compared to alternative dietary approaches, standard RUTF probably improves recovery and may increase rate of weight gain slightly, but the effects on relapse and mortality are unknown. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given as a supplement to the usual diet, but the effects on mortality and rate of weight gain are not clear. When comparing RUTFs with different formulations, the current evidence does not favour a particular formulation, except for relapse, which is reduced with standard RUTF. Well‐designed, adequately powered, pragmatic RCTs with standardised outcome measures, stratified by HIV status, and that include diarrhoea as an outcome, are needed. Plain language summary Ready‐to‐use therapeutic food (RUTF) as home‐based treatment for severely malnourished children between six months and five years Background Malnourished children usually look very thin or wasted and they have a high risk of death and illness. Treating severely malnourished children in hospitals is not always desirable or practical in rural settings, and home‐based treatment may be better. Home‐based treatment can be food prepared by a caregiver (such as flour porridge or energy‐ and nutrient‐dense locally available foods), or ready‐to‐use therapeutic food (RUTF) provided by a clinic. RUTF is usually made according to a standard, energy‐rich composition defined by the World Health Organization (WHO). Typically, the ingredients for standard RUTF include milk powder, sugar, peanut butter, vegetable oil, vitamins and minerals; but ingredients vary depending on local availability, cost and acceptability. Benefits of RUTF include a long shelf life without refrigeration and they require no preparation. This is an update of our previous review, where definite conclusions about the effects of RUTF could not be drawn from the four studies that were available at that time. Review question We assessed standard RUTF compared to an alternative dietary approach (e.g. flour porridge or locally available foods) and examined whether smaller amounts and different formulations of RUTF can achieve similar health outcomes in severely malnourished children aged between six months and five years. The main health outcomes that we investigated were recovery from severe malnutrition, deterioration or relapse, death and the rate of weight gain. Included study characteristics We searched databases for studies up to the October 2018, and found 15 studies with 7976 children. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. One small study included only children infected with HIV, another study analysed children with and without HIV separately for the main outcome (recovery), while the other studies included children who were not infected with HIV or who were untested. Overall, we judged six studies to be at high risk of bias, three studies to be at unclear risk of bias, and six studies to be at low risk of bias. (With 'risk of bias', we mean the extent to which the methods used in a study enable it to determine the truth.) All the studies lasted between 8 and 16 weeks. Only five studies followed up children after the study (for a maximum of six months), and generally reported on a limited number of outcomes. Of our 15 included studies, six were linked to funding or donations from industry, one did not report the source of funding, and eight studies reported funding where sponsors did not include industry. Key findings Compared to alternative dietary approaches, standard RUTF probably improves recovery (moderate‐quality evidence) and may increase the rate of weight gain slightly (low‐quality evidence), but the effects on relapse and death are unknown (very low‐quality evidence). With 'quality of evidence' we mean how confident we are that the particular finding represents the true effect. For example, 'very low‐quality' means we are very uncertain about the finding, 'low‐quality evidence' means the future research is very likely to change the finding, 'moderate‐quality evidence' means that future studies may change this finding, and 'high‐quality evidence' means that it is unlikely that future studies will change the finding. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given supplementary to the usual diet (low‐quality evidence), but for death and the rate of weight gain, the effects are not known (very low‐quality evidence). When comparing RUTFs of different formulations, it makes little or no difference for recovery whether a standard or alternative formulation RUTF is used (high‐quality evidence). For relapse, using standard RUTF decreases relapse (high‐quality evidence). It probably makes little or no difference to death (moderate‐quality evidence) and to the rate of weight gain (low‐quality evidence) whether standard or alternative formulation RUTF is used. Well‐designed, randomised controlled trials (experimental studies where participants meeting the inclusion criteria have an equal chance of being allocated to any of the intervention or control groups) in which analyses have been performed separately for children with and without HIV, and that also measure and report on diarrhoea occurrence, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Schoonees, A, Lombard, MJ, Musekiwa, A, Nel, E, Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD009000.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.775Z" }, { "id": "1d3bee58-b959-4821-ad2f-d121808446e2", "pmid": "", "title": "Cannabinoids for Tourette's Syndrome", "imported": false, "abstract": "Abstract - Background Gilles de la Tourette Syndrome (GTS) is a developmental neuropsychiatric disorder characterised by the presence of chronic motor and phonic tics. Drugs currently used in the treatment of GTS either lack efficacy or are associated with intolerable side effects. There is some anecdotal and experimental evidence that cannabinoids may be effective in treating tics and compulsive behaviour in patients with GTS. There are currently no systematic Cochrane reviews of treatments used in GTS. There is one other Cochrane review being undertaken at present, on the use of fluoxetine for tics in GTS. Objectives To evaluate the efficacy and safety of cannabinoids as compared to placebo or other drugs in treating tics, premonitory urges and obsessive compulsive symptoms (OCS), in patients with GTS. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (in The Cochrane Library Issue 4 2008) , MEDLINE (January 1996 to date), EMBASE (January 1974 to date), PsycINFO (January 1887 to date), CINAHL (January 1982 to date), AMED (January 1985 to date), British Nursing Index (January 1994 to date) and DH DATA (January 1994 to date). 
 
 We also searched the reference lists of located trials and review articles for further information. Selection criteria We included randomised controlled trials (RCTs) comparing any cannabinoid preparation with placebo or other drugs used in the treatment of tics and OCS in patients with GTS. Data collection and analysis Two authors abstracted data independently and settled any differences by discussion. Main results Only two trials were found that met the inclusion criteria. Both compared a cannabinoid, delta‐9‐Tetrahydrocannabinol (Δ 9 THC), either as monotherapy or as adjuvant therapy, with placebo. One was a double blind, single dose crossover trial and the other was a double blind, parallel group study. A total of 28 different patients were studied. Although both trials reported a positive effect from Δ 9 THC, the improvements in tic frequency and severity were small and were only detected by some of the outcome measures. Authors' conclusions Not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome. Plain language summary Cannabinoids for Tourette syndrome Cannabinoid medication might be useful in the treatment of the symptoms in patients with Tourette's syndrome. At the present time only two relevant studies have been conducted. Both studies used tetrahydrocannabinol (Δ 9 THC). In both studies Δ 9 THC was associated with tic reduction. However the sample size was small and a large number of multiple comparisons were made . There were only 28 participants in total, since eight participants took part in both studies. Possibly the patients who derived the greatest benefit and experienced the least adverse effects would be the most inclined to participate in further studies. There were a high number of drop outs/exclusions in the six week study and it is unclear whether intention to treat analysis (ITT) was performed. The results that are reported are analyses done on the patients who remained in the study on the study medication at the correct dose. In reality, patients do opt not to continue treatment if there is limited efficacy or unpalatable side effects. This introduces attrition bias. Whilst there were some significant results, the authors themselves accept that very few of these results are significant if a Bonferroni correction is performed. It is possible that cannabinoid medication has a beneficial effect which is too weak to be detected using ITT and such a small sample size. There is some weak evidence that cannabinoid medication may have an effect on obsessive compulsive behaviour but the measure used was an addition to the TSSL which has not been validated.There were no data on the effect of Δ 9 THC on quality of life.There is not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Curtis, A; Clarke, CE; Rickards, HE", "articleTypes": [], "doi": "10.1002/14651858.CD006565.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "1d614a89-d2ad-4966-8809-d85a1a15c31b", "pmid": "", "title": "Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background It is unclear whether patients with type 2 diabetes who have poor glycaemic control despite maximal oral hypoglycaemic agents (OHAs) should be commenced on insulin as monotherapy, or insulin combined with oral hypoglycaemic agents (insulin‐OHA combination therapy). Objectives To assess the effects of insulin monotherapy versus insulin‐OHA combinations therapy. Search methods Eligible studies were identified by searching MEDLINE, EMBASE, and The Cochrane Library . Selection criteria Randomised controlled trials (RCTs) with 2 months minimum follow‐up duration comparing insulin monotherapy (all schemes) with insulin‐OHA combination therapy. Data collection and analysis Data extraction and assessment of study quality were undertaken by three reviewers in pairs. Main results Twenty RCTs (mean trial duration 10 months) including 1,811 participants, with mean age 59.8 years and mean known duration of diabetes 9.6 years. Overall, study methodological quality was low. Twenty‐eight comparisons in 20 RCTs were ordered according to clinical considerations. No studies assessed diabetes‐related morbidity, mortality or total mortality. From 13 studies (21 comparisons), sufficient data were extracted to calculate pooled effects on glycaemic control. Insulin‐OHA combination therapy had statistically significant benefits on glycaemic control over insulin monotherapy only when the latter was applied as a once‐daily injection of NPH insulin. Conversely, twice‐daily insulin monotherapy (NPH or mixed insulin) provided superior glycaemic control to insulin‐OHA combination therapy regimens where insulin was administered as a single morning injection. In more conventional comparisons, regimens utilising OHAs with bedtime NPH insulin provided comparable glycaemic control to insulin monotherapy (administered as twice daily, or multiple daily injections). Overall, insulin‐OHA combination therapy was associated with a 43% relative reduction in total daily insulin requirement compared to insulin monotherapy. Of the 14 studies (22 comparisons) reporting hypoglycaemia, 13 demonstrated no significant difference in the frequency of symptomatic or biochemical hypoglycaemia between insulin and combination therapy regimens. No significant differences in quality of life related issues were detected. Combination therapy with bedtime NPH insulin resulted in statistically significantly less weight gain compared to insulin monotherapy, provided metformin was used ± sulphonylurea. In all other comparisons no significant differences with respect to weight gain were detected. Authors' conclusions Bedtime NPH insulin combined with oral hypoglycaemic agents provides comparable glycaemic control to insulin monotherapy and is associated with less weight gain if metformin is used. Plain language summary Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus Simple application of a single daily insulin injection in addition to oral hypoglycaemic agents may facilitate the initiation of insulin therapy in type 2 diabetes mellitus.This review examined 20 trials including 1,811 participants which compared insulin monotherapy with insulin in combination with oral hypoglycaemic agents (OHA) in insulin‐requiring patients with type 2 diabetes. The results suggest that a bedtime NPH insulin‐oral hypoglycaemic agent combination therapy regimen provides comparable glycaemic control to insulin monotherapy. Due to lack of studies it remains unclear whether insulin‐OHA combination regimens with metformin alone are superior to those with metformin plus a sulphonylurea. In most cases no significant differences in hypoglycaemic events were observed between insulin mono‐ and OHA combination therapy. No study assessed diabetes‐related morbidity or mortality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Goudswaard, AN, Furlong, NJ, Valk, GD, Stolk, RP, Rutten, GEHM", "articleTypes": [], "doi": "10.1002/14651858.CD003418.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.798Z" }, { "id": "1d80388a-3ad3-4529-b195-de3da8630e8e", "pmid": "", "title": "Interventions for chronic kidney disease in people with sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD), one of the commonest severe monogenic disorders, is caused by the inheritance of two abnormal haemoglobin (beta‐globin) genes. SCD can cause severe pain, significant end‐organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD. Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD. Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, with increased prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end‐stage renal disease. This is an update of a review first published in 2017. Objectives To assess the effectiveness of any intervention for preventing or reducing kidney complications or chronic kidney disease in people with sickle cell disease. Possible interventions include red blood cell transfusions, hydroxyurea, and angiotensin‐converting enzyme inhibitors (ACEIs), either alone or in combination. Search methods We searched for relevant trials in the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, CENTRAL, MEDLINE, Embase, seven other databases, and two other trials registers. Selection criteria Randomised controlled trials (RCTs) comparing interventions to prevent or reduce kidney complications or CKD in people with SCD. We applied no restrictions related to outcomes examined, language, or publication status. Data collection and analysis Two review authors independently assessed trial eligibility, extracted data, assessed the risk of bias, and assessed the certainty of the evidence (GRADE). Main results We included three RCTs with 385 participants. We rated the certainty of the evidence as low to very low across different outcomes according to GRADE methodology, downgrading for risk of bias concerns, indirectness, and imprecision. Hydroxyurea versus placebo One RCT published in 2011 compared hydroxyurea to placebo in 193 children aged nine to 18 months. We are unsure if hydroxyurea compared to placebo reduces or prevents progression of kidney disease assessed by change in glomerular filtration rate (mean difference (MD) 0.58 mL/min /1.73 m 2 , 95% confidence interval (CI) −14.60 to 15.76; 142 participants; very low certainty). Hydroxyurea compared to placebo may improve the ability to concentrate urine (MD 42.23 mOsm/kg, 95% CI 12.14 to 72.32; 178 participants; low certainty), and may make little or no difference to SCD‐related serious adverse events, including acute chest syndrome (risk ratio (RR) 0.39, 99% CI 0.13 to 1.16; 193 participants; low certainty), painful crisis (RR 0.68, 99% CI 0.45 to 1.02; 193 participants; low certainty); and hospitalisations (RR 0.83, 99% CI 0.68 to 1.01; 193 participants; low certainty). No deaths occurred in either trial arm and the RCT did not report quality of life. Angiotensin‐converting enzyme inhibitors versus placebo One RCT published in 1998 compared an ACEI (captopril) to placebo in 22 adults with normal blood pressure and microalbuminuria. We are unsure if captopril compared to placebo reduces proteinuria (MD −49.00 mg/day, 95% CI −124.10 to 26.10; 22 participants; very low certainty). We are unsure if captopril reduces or prevents kidney disease as measured by creatinine clearance; the trial authors stated that creatinine clearance remained constant over six months in both groups, but provided no comparative data (very low certainty). The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Angiotensin‐converting enzyme inhibitors versus vitamin C One RCT published in 2020 compared an ACEI (lisinopril) with vitamin C in 170 children aged one to 18 years with normal blood pressure and microalbuminuria. It reported no data we could analyse. We are unsure if lisinopril compared to vitamin C reduces proteinuria in this population: the large drop in microalbuminuria in both arms of the trial after only one month on treatment may have been due to an overestimation of microalbuminuria at baseline rather than a true effect. The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Authors' conclusions We are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. We are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. We are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria. No RCTs assessed red blood cell transfusions or any combined interventions to prevent or reduce kidney complications. Due to lack of evidence, we cannot comment on the management of children aged over 18 months or adults with any known genotype of SCD. We have identified a lack of adequately designed and powered studies, although we found four ongoing trials since the last version of this review. Only one ongoing trial addresses renal function as a primary outcome in the short term, but such interventions have long‐term effects. Trials of hydroxyurea, ACEIs or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction of kidney complications in people with SCD. Plain language summary Interventions to prevent or reduce kidney complications in people with sickle cell disease Review question Are there any safe and effective interventions that prevent or reduce kidney complications in people with sickle cell disease (SCD)? Background SCD is a serious inherited blood disorder where the red blood cells, which carry oxygen around the body, develop abnormally. Normal red blood cells are flexible and disc‐shaped, but sickled cells are rigid and crescent‐shaped, and stickier than normal red blood cells. This can lead to blockage of blood vessels, resulting in tissue and organ damage and episodes of severe pain. The abnormal cells are fragile and break apart easily, which leads to a decreased number of red blood cells, known as anaemia. Kidney complications can start at an early age in children with SCD and are common in adults with the condition. Kidney complications leading to kidney protein leak and chronic kidney disease can be severe, with serious effects on health. Severe complications include the need for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) or a kidney transplant. Identifying therapies that can prevent or slow down the decline in kidney function in people with SCD is critical for improving health outcomes. Search date The evidence is current to 22 September 2022. Study characteristics We found three randomised controlled trials, which enroled a total of 385 people. One trial, published in 2011, compared the drug hydroxyurea (which helps to maintain the shape and flexibility of red blood cells), to placebo (dummy treatment) in 193 children aged nine to 18 months. The second trial, published in 1998, compared captopril (a drug used to treat high blood pressure) to placebo in 22 adults with normal blood pressure and microalbuminuria (high levels of protein in the urine). The third trial, published in 2020, compared lisinopril (a drug used to treat high blood pressure) to vitamin C in 170 children aged one to 18 years. Two trials received government funding; it was unclear how the third trial was funded. Key results In children aged nine to 18 months, hydroxyurea may increase the ability to produce normal urine, but we are unsure if it has any effect on the glomerular filtration rate (network of filters in the kidney that filter waste from the blood). Hydroxyurea may make little or no difference to the occurrence of serious complications including acute chest syndrome (pain, cough, fever, low oxygen levels, and abnormal substances in the lungs), painful crises, and hospitalisations. We are unsure if giving captopril to adults with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. We are unsure if giving lisinopril to children aged one to 18 years with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. No trials reported quality of life. Limitations of the evidence We have little or very little confidence in the evidence because we only found three trials, and they had specific populations (only children or only adults), few participants, and wide variations in results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Roy, NBA, Carpenter, A, Dale-Harris, I, Dorée, C, Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012380.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.115Z" }, { "id": "1d864527-ecec-46f3-a668-8f10d99cccc1", "pmid": "", "title": "Nutritional interventions for survivors of childhood cancer", "imported": false, "abstract": "Abstract - Background Childhood cancer survivors are at a higher risk of developing health conditions such as osteoporosis, and cardiovascular disease than their peers. Health‐promoting behaviour, such as consuming a healthy diet, could lessen the impact of these chronic issues, yet the prevalence rate of health‐protecting behaviour amongst survivors of childhood cancer is similar to that of the general population. Targeted nutritional interventions may prevent or reduce the incidence of these chronic diseases. Objectives The primary aim of this review was to assess the efficacy of a range of nutritional interventions designed to improve the nutritional intake of childhood cancer survivors, as compared to a control group of childhood cancer survivors who did not receive the intervention. Secondary objectives were to assess metabolic and cardiovascular risk factors, measures of weight and body fat distribution, behavioural change, changes in knowledge regarding disease risk and nutritional intake, participants' views of the intervention, measures of health status and quality of life, measures of harm associated with the process or outcomes of the intervention, and cost‐effectiveness of the intervention Search methods We searched the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 3), MEDLINE/PubMed (from 1945 to April 2013), and Embase/Ovid (from 1980 to April 2013). We ran the search again in August 2015; we have not yet fully assessed these results, but we have identified one ongoing trial. We conducted additional searching of ongoing trial registers ‐ the International Standard Randomised Controlled Trial Number register and the National Institutes of Health register (both screened in the first half of 2013) ‐ reference lists of relevant articles and reviews, and conference proceedings of the International Society for Paediatric Oncology and the International Conference on Long‐Term Complications of Treatment of Children and Adolescents for Cancer (both 2008 to 2012). Selection criteria We included all randomised controlled trials (RCTs) that compared the effects of a nutritional intervention with a control group which did not receive the intervention in this review. Participants were childhood cancer survivors of any age, diagnosed with any type of cancer when less than 18 years of age. Participating childhood cancer survivors had completed their treatment with curative intent prior to the intervention. Data collection and analysis Two review authors independently selected and extracted data from each identified study, using a standardised form. We assessed the validity of each identified study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Intervention s. We used the GRADE criteria to assess the quality of each trial. Main results Three RCTs were eligible for review. A total of 616 participants were included in the analysis. One study included participants who had been treated for acute lymphoblastic leukaemia (ALL) (275 participants). Two studies included participants who had all forms of paediatric malignancies (266 and 75 participants). All participants were less than 21 years of age at study entry. The follow‐up ranged from one month to 36 months from the initial assessment. All intended outcomes were not evaluated by each included study. All studies looked at different interventions, and so we were unable to pool results. We could not rule out the presence of bias in any of the studies. There was no clear evidence of a difference in calcium intake at one month between those who received the single, half‐day, group‐based education that focused on bone health, and those who received standard care (mean difference (MD) 111.60, 95% confidence interval (CI) ‐258.97 to 482.17; P = 0.56, low quality evidence). A regression analysis, adjusting for baseline calcium intake and changes in knowledge and self‐efficacy, showed a significantly greater calcium intake for the intervention as compared with the control group at the one‐month follow‐up (beta coefficient 4.92, 95% CI 0.33 to 9.52; P = 0.04). There was statistically significant higher, self‐reported milk consumption (MD 0.43, 95% CI 0.07 to 0.79; P = 0.02, low quality evidence), number of days on calcium supplementation (MD 11.42, 95% CI 7.11 to 15.73; P < 0.00001, low quality evidence), and use of any calcium supplementation (risk ratio (RR) 3.35, 95% CI 1.86 to 6.04; P < 0.0001, low quality evidence), with those who received this single, face‐to‐face, group‐based, health behaviour session. There was no clear evidence of a difference in bone density Z‐scores measured with a dual‐energy X‐ray absorptiometry (DEXA) scan at 36 months follow‐up (MD ‐0.05, 95% CI ‐0.26 to 0.16; P = 0.64, moderate quality evidence) between those who received calcium and vitamin D supplementation combined with nutrition education and those who received nutrition education alone. There was also no clear evidence of a difference in bone mineral density between the intervention and the control group at the 12‐month (median difference ‐0.17, P = 0.99) and 24‐month follow‐up (median difference ‐0.04, P = 0.54). A single multi‐component health behaviour change intervention, focusing on general healthy eating principles, with two telephone follow‐ups brought about a 0.17 lower score on the four‐point Likert scale of self‐reported junk food intake compared with the control group (MD ‐0.17, 95% CI ‐0.33 to ‐0.01; P = 0.04, low quality evidence); this result was statistically significant. There was no clear evidence of a difference between the groups in the self‐reported use of nutrition as a health protective behaviour (MD ‐0.05, 95% CI ‐0.24 to 0.14; P = 0.60, low quality evidence). Authors' conclusions Due to a paucity of studies, and the heterogeneity of the studies included in this review, we are unable to draw conclusions regarding the effectiveness of nutritional interventions for use with childhood cancer survivors. Although there is low quality evidence for the improvement in health behaviours using health behaviour change interventions, there remains no evidence as to whether this translates into an improvement in dietary intake. There was also no evidence that the studies reduced the risk of cardiovascular and metabolic disorders in childhood cancer survivors, although no evidence of effect is not the same as evidence of no effect. This review highlights the need for further well designed trials to be implemented in this population. Plain language summary Nutritional interventions for survivors of childhood cancer Background Survivors of childhood cancer are at a higher risk of chronic health conditions such as, osteoporosis, metabolic syndrome (including obesity and type II diabetes), and cardiovascular disease. These diseases have the potential to be reduced or prevented with targeted nutritional interventions. Objective This review looks at three randomised controlled trials that studied the effects of interventions designed to improve the dietary intake of children who have completed treatment for cancer. Study Characteristics The three studies included 616 participants who had completed their therapy for childhood cancer. All of the participants were less than 21 years of age at study entry. The interventions ranged from the promotion of health behaviours to vitamin and mineral supplementation. The follow‐up ranged from one month to 36 months from the initial assessment. Key results There was low quality evidence that those who received a health behaviour intervention decreased their self‐reported intake of “junk food”. They also increased their intake of dairy foods, as well as increasing their calcium supplementation. The interventions did not appear to translate to an improvement in their dietary intake, body composition, or bone mineral density. Quality of the evidence The results from this review do not provide enough evidence regarding the effectiveness of nutritional interventions for childhood cancer survivors. There was low quality evidence overall. Further well designed research is needed in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cohen, JE, Wakefield, CE, Cohn, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD009678.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.769Z" }, { "id": "1d86b861-25a0-4f0c-b2cf-8297fc2660d7", "pmid": "", "title": "Sucrose analgesia for venepuncture in neonates", "imported": false, "abstract": "Abstract - Rationale Sucrose is, in general, safe and effective for analgesia during venepuncture in hospitalised neonates. However, there is a lack of evidence on its analgesic effects. Objectives To evaluate the benefits and harms of orally administered sucrose for pain relief from venepuncture in preterm and term neonates compared to no intervention, standard care, and other types of analgesic interventions. Search methods We searched CENTRAL, MEDLINE, Ovid Embase, and trial registries in July 2025, and the China National Knowledge Infrastructure, VIP Chinese Science and Technology Periodicals, and Wanfang Data in August 2024. We checked reference lists of included studies and topic‐related systematic reviews. Eligibility criteria We included randomised controlled trials (RCTs), including cross‐over and cluster‐RCTs, that evaluated the effects of sucrose analgesia in neonates (including term and preterm infants) up to 44 weeks' postmenstrual age undergoing venepuncture. We excluded quasi‐RCTs and studies reported only as conference abstracts. We included studies administering sucrose with or without non‐nutritive sucking (NNS) before, at the time of, or after venepuncture. Sucrose could be of any concentration, volume, or dose. Sucrose was compared to: no intervention, water, or standard care; skin‐to‐skin care; breastfeeding; feeding; NNS alone (e.g. pacifier); glucose; positioning; or topical anaesthetics. Outcomes Outcomes of interest were pain intensity score, as measured by validated pain assessment scales, and adverse events. Risk of bias We used the Cochrane risk of bias tool (RoB 1). Synthesis methods We synthesised results for each outcome using meta‐analysis where possible. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous data (presence or absence of pain). We calculated the standardised mean difference (SMD) or mean difference (MD) for pain intensity scores (continuous outcome), each with its 95% CI. We used a fixed‐effect model to combine data and quantified the impact of heterogeneity using the I² statistic. Where these methods were not feasible due to the nature of the data, we synthesised the results narratively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included a total of 29 studies, accounting for 2764 term and preterm neonates. There was a large variation in sucrose dose and concentration (from 0.1 mL/kg to 0.5 mL/kg or a set volume from 0.1 mL to 2 mL) as well as mode of administration (e.g. oral syringe, pacifier, dropper, in combination with a pacifier). Most of the studies compared sucrose to no intervention, water, or standard care (n = 17). Other comparisons include non‐nutritive sucking, skin‐to‐skin care, breastfeeding, expressed breast milk, and other sweet solutions. Synthesis of results Adverse events (e.g. gagging, apnoea) were not reported for any comparison. Sucrose (with or without NNS) versus no intervention, water, or standard care Sucrose with or without NNS probably reduces pain intensity scores during and 30 seconds after venepuncture compared to no intervention (SMD −0.82, 95% CI −1.02 to −0.63; 7 studies, 477 participants; moderate‐certainty evidence). Sucrose with NNS reduces pain intensity scores one minute after venepuncture compared to no intervention (MD −9.15, 95% CI −9.91 to −8.39; 1 study, 100 participants; high‐certainty evidence). The evidence is uncertain about the effect of sucrose without NNS on pain intensity scores two minutes after venepuncture compared to no intervention (SMD −0.99, 95% CI −1.31 to −0.68; 3 studies, 186 participants; very low‐certainty evidence). Sucrose (with or without NNS) versus skin‐to‐skin care Sucrose without NNS may make little to no difference to pain scores during venepuncture when compared to skin‐to‐skin care (MD 1.49, 95% CI 0.86 to 2.12; 2 studies, 208 participants; low‐certainty evidence). Pain scores after 30 seconds, one minute, and two minutes were not reported. Sucrose (with or without NNS) versus breastfeeding Sucrose probably reduces pain during venepuncture compared to breastfeeding, as measured with the Neonatal Facial Coding System (where 0 = no pain, > 0 = pain) (RR 1.38, 95% CI 1.01 to 1.88; 1 study, 103 participants; moderate‐certainty evidence). Sucrose may result in little to no difference in pain compared to breastfeeding two minutes after venepuncture (RR 1.06, 95% CI 0.94 to 1.19; 1 study, 104 participants; low‐certainty evidence). Pain scores after 30 seconds and one minute were not reported. Sucrose (with or without NNS) versus NNS Sucrose with NNS likely reduces pain during venepuncture compared to NNS (SMD −1.52, 95% CI −1.92 to −1.12; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS may not reduce pain intensity scores during venepuncture compared to NNS (MD 1.37, 95% CI 0.57 to 2.17; 2 studies, 133 participants; low‐certainty evidence). Sucrose with NNS may reduce pain intensity scores one minute after venepuncture compared to NNS (MD −5.81, 95% CI −6.30 to −5.32; 2 studies, 200 participants; low‐certainty evidence). Sucrose with NNS probably reduces pain intensity two minutes after venepuncture compared to NNS alone (SMD −1.30, 95% CI −1.71 to −0.89; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS (MD 0.47, 95% CI −0.14 to 1.08; 1 study, 56 participants; moderate‐certainty evidence). We downgraded the certainty of the evidence in several comparisons, mostly due to unclear or high risk of selection, performance, detection, and reporting bias. High heterogeneity was also detected. Authors' conclusions Current evidence suggests sucrose probably reduces pain scores during and shortly after venepuncture compared to no intervention, water, or standard care. The evidence is very uncertain regarding the effects of sucrose compared to skin‐to‐skin care for analgesia during venepuncture. Compared to breastfeeding, sucrose probably results in a reduction of pain scores during venepuncture, but may result in little difference in pain scores two minutes after venepuncture. The evidence suggests sucrose with NNS probably reduces pain scores during and following venepuncture compared to NNS alone. Sucrose alone probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS. Funding This review had no dedicated funding. Registration Protocol available via doi/10.1002/14651858.CD015221 Plain language summary Does giving newborns sugar water during needle procedures reduce their pain? Key messages Newborn babies given sucrose (sugar water) when undergoing a needle procedure probably have less pain during and shortly after the procedure than babies given nothing, water, or standard comfort measures. Sucrose seems to reduce pain more than pacifiers. We do not have good evidence about the effect of sucrose compared to skin‐to‐skin care. No studies reported on harmful side effects, such as gagging or apnoea (a temporary pause in breathing). What is sucrose analgesia (pain relief)? Sucrose is table sugar. When mixed with water, and in very small amounts, it can be used for pain relief in newborn babies. Sucrose is dropped on a baby's tongue about two minutes before and/or immediately before venepuncture, when a needle is put into a vein to take blood or give treatment. Why is pain relief important for newborn babies who are in hospital? Hospitalised preterm babies (i.e. born early) and term babies (i.e. born at the normal time) are exposed to many painful procedures to give them medicine and to diagnose problems. Pain has many consequences for newborn babies. It can contribute to poor physical growth and affect brain development. Therefore, it is important to reduce babies' experience of pain as much as possible to ensure health as they grow. What did we want to find out? We wanted to find out how well sucrose worked to relieve pain in newborn babies during and shortly after needle punctures. We wanted to know how sucrose compared to other pain relief methods such as pacifier sucking, breastfeeding, or being held next to a mother or father's skin (skin‐to‐skin care). We also wanted to find out if sucrose caused negative effects. What did we do? We searched for studies that investigated the pain‐relief effects of sucrose compared to other methods (e.g. breastfeeding, pacifiers, holding). We summarised the results and rated our confidence in the evidence based on factors such as the number of infants treated and the quality of the methods used in the studies. What did we find? We found 29 studies that included 2764 newborn babies. The studies used different doses of sucrose and gave the sucrose to the babies in different ways. The studies were conducted worldwide. Most were carried out in Asia, with additional studies from Europe, North America, and South America. All the studies were randomised controlled trials, in which infants were assigned randomly to two or more treatment groups. This is the best way to ensure that the infant groups are similar, and that investigators and parents don’t know who is in which group. None of the studies were supported by the pharmaceutical industry. Main results Sucrose probably reduces babies' pain during and shortly after (30 seconds to 1 minute) the needle insertion compared to no pain relief (such as water). Sucrose may make little to no difference to pain during the procedure compared to skin‐to‐skin care. Sucrose probably reduces pain during the needle insertion compared to breastfeeding. Sucrose (with pacifier sucking) likely reduces pain during and shortly after (30 seconds to 2 minutes) the needle insertion compared to pacifier sucking alone. No study reported on harmful effects for any of our comparisons of interest. What are the limitations of the evidence? Sucrose versus no intervention or water We are moderately confident that sucrose probably reduces pain compared to no intervention. However, it is possible that people in the studies were aware of which treatment babies were receiving, and the studies involved small numbers of babies. Sucrose versus skin‐to‐skin care We are not confident that sucrose reduces pain more than skin‐to‐skin care because the two studies reported very different results. Further research is likely to change these results. Sucrose versus breastfeeding We are moderately confident that sucrose probably reduces pain more than breastfeeding. However, the study did not clearly report details of how it was conducted. Sucrose versus pacifier We are moderately confident that sucrose with a pacifier probably reduces pain more than pacifiers alone. The studies differed in how sucrose was given, including the amount of sucrose, how it was administered, and whether it was given with or without a pacifier. How current is this evidence? This evidence is current to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Bueno, M; Candido, L; Hu, J; Fiander, M; Cracknell, J; Xu, E; Kang, J; Yamada, J", "articleTypes": [], "doi": "10.1002/14651858.CD015221.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "1d89c19e-8892-42ff-abbd-d15b09f96b9a", "pmid": "", "title": "Micronutrient supplementation in pregnant women with HIV infection", "imported": false, "abstract": "Abstract - Background Micronutrient deficiencies are widespread and compound the effects of HIV disease; micronutrient supplements may be effective and safe in reducing this burden. Objectives To assess whether micronutrient supplements are effective and safe in reducing mortality and morbidity in pregnant and lactating women with HIV infection and their infants. Search methods The review has been updated three times since publication in 2005. In reviews prior to this update (2011), we searched the CENTRAL, EMBASE, PubMed, and GATEWAY databases to identify randomised controlled trials of micronutrient supplements using the search methods of the Cochrane HIV/AIDS Group. In the 2011 review the PubMed, EMBASE, and CENTRAL databases were searched in July 2011. As the GATEWAY database does not include conference abstracts after 2006, we also searched the AIDS‐specific conference database, www.aegis.org , and contacted researchers and organisations active in the field of research to identify additional unpublished trials. Selection criteria Randomised controlled trials were selected that compared the effects of micronutrient supplements (vitamins, trace elements, and combinations of these) with other supplements, placebo or no treatment on mortality, morbidity, pregnancy outcomes, immunologic indicators, and anthropometric measures in HIV‐positive pregnant and lactating women. Any adverse effects of supplementation were recorded. Data collection and analysis Two reviewer authors independently selected trials, appraised trial quality for risk of bias using standardised criteria, and extracted data using standardised forms. Where disagreements arose, a third author, acted as arbiter. Main results One additional trial is included in this update in addition to the three trials included in the 2010 update of the initial Cochrane review. Four relatively large, well‐conducted randomised controlled trials of the benefits of micronutrient supplementation have been conducted in pregnant and lactating women infected with HIV. Each of the trials evaluated a different micronutrient supplement and no direct comparisons or analyses can be made across the four trials. The four trials were conducted between 1995 and 2006. The trials have all been conducted by the same research team in Dar es Salaam in Tanzania, in an urban setting in hospital‐based antenatal clinics. Pregnant women were recruited with gestational age ranging from 12 to 27 weeks in each of the trials. Sample sizes range from 400 to 1129 with a median of 1000 participants. Three of the trials were placebo‐controlled. Different interventions have been evaluated in each trial, viz.:Vitamin A versus Vitamin A and multivitamins versus Multivitamins versus placebo; Selenium versus placebo; Zinc versus placebo; and Multiple RDA multivitamins versus Single RDA multivitamins. None of the women were receiving antiretrovrial therapy (ART). Multiple micronutrient supplements conferred multiple clinical benefits to pregnant women and their offspring. No significant adverse effects were reported. No significant clinical benefits were found from zinc supplementation of pregnant Tanzanian women. Selenium supplements given during and after pregnancy did not delay maternal HIV disease progression or improve pregnancy outcomes, but may improve child survival and decrease maternal diarrhoeal morbidity. There were no differences in maternal and infant outcomes when women received single RDA multivitamins or multiple RDA multivitamin supplementation. The evidence is lacking for the effects of micronutrient supplementation given concomitantly to pregnant women already initiated on antiretroviral therapy for treatment purposes. GRADE assessments were conducted on outcomes for each trial and included reviewing the data and the potential biases in each trial before grading the level of evidence. None of the trials were graded as providing high quality evidence primarily because there was no replication of results in other trials in other settings. Authors' conclusions In keeping with previous World Health Organization (WHO) recommendations everything possible should be done to promote and support adequate dietary intake of micronutrients, while recognising that this may not be sufficient to correct specific micronutrient deficiencies in all HIV‐infected individuals. Specific recommendations for pregnant and lactating women infected with HIV would be to include the provision of multivitamin supplements in single RDA formulations during the antenatal period and at least for 6 weeks post‐partum, especially for women who are breast‐feeding. There is no conclusive evidence to provide stand‐alone zinc or selenium supplementation to HIV‐infected pregnant and lactating women. Micronutrient supplementation should not be used as a substitute for provision of recommended antiretroviral medication for preventing mother‐to‐child transmission of HIV and treating maternal HIV infection when this is recommended. Further trials of single supplements are required to build the evidence base. The long‐term clinical benefits, adverse effects, and optimal formulation of multiple micronutrient supplements require further investigation in pregnant women at different stages of HIV infection. Plain language summary Micronutrient supplementation interventions to reduce harm in pregnant and lactating women living with HIV Micronutrients are vital components of a person’s daily food intake. Though only a small portion is necessary, a lack of micronutrients has been linked to tiredness, anaemia (low iron in blood), reduced learning ability, weaker immune system, and night blindness. In pregnant women, inadequate micronutrients have been shown to affect the development of the foetus and also the well‐being of the mother. In regions with high HIV prevalence, food availability may be scarce, which could lead to a double burden of disease in vulnerable/at‐risk populations. Specifically, pregnant and lactating women living with HIV may encounter the challenge of adequate food (including micronutrients) consumption, a weakened immune system, and the nutritional demands of a growing foetus or child. In this review, four randomised controlled trials, conducted between 1995 and 2006, assessed the benefits of micronutrient supplementation. The trials took place in an urban setting in hospital‐based antenatal clinics, with participants being pregnant women who ranged between 12‐27 weeks of their pregnancy, and sample sizes ranging from 400 to 1129 participants. Multiple micronutrient supplements improved the health of pregnant women and their offspring. No significant adverse effects were reported. Zinc supplementation did not show any significant beneficcial effects. Although it did not have any effect on the mother's pregnancy or her HIV disease, supplementation with selenium may increase the likelihood of a child surviving, and may reduce the likelihood of the mothers having diarrhoea. However, there is not enough evidence to determine the effect of micronutrient supplementation to pregnant women living with HIV who are being treated with antiretroviral medications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Siegfried, N, Irlam, JH, Visser, ME, Rollins, NN", "articleTypes": [], "doi": "10.1002/14651858.CD009755", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.786Z" }, { "id": "1da884ed-1d6f-45e1-8aaa-8655bc54e881", "pmid": "", "title": "Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common, life‐shortening, genetic disorder in populations of Northern European descent caused by the mutation of a single gene that codes for the production of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. This protein coordinates the transport of salt (and bicarbonate) across cell surfaces, and the mutation most notably affects the airways. In the lungs of people with CF, the defective protein compromises mucociliary clearance and makes the airway prone to chronic infection and inflammation, damaging the structure of the airways and eventually leading to respiratory failure. In addition, abnormalities in the truncated CFTR protein lead to other systemic complications, including malnutrition, diabetes and subfertility. Five classes of mutation have been described, depending on the impact of the mutation on the processing of the CFTR protein in the cell. In class I mutations, premature termination codons prevent the production of any functional protein, resulting in severe CF. Therapies targeting class I mutations aim to enable the normal cellular mechanism to read through the mutation, potentially restoring the production of the CFTR protein. This could, in turn, normalise salt transport in the cells and decrease the chronic infection and inflammation that characterises lung disease in people with CF. This is an update of a previously published review. Objectives To evaluate the benefits and harms of ataluren and similar compounds on clinically important outcomes in people with CF with class I mutations (premature termination codons). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles. The last search of the Cochrane Cystic Fibrosis Trials Register was conducted on 7 March 2022. We searched clinical trial registries maintained by the European Medicines Agency, the US National Institutes of Health and the World Health Organization. The last search of the clinical trials registries was conducted on 4 October 2022. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing ataluren and similar compounds (specific therapies for class I mutations) with placebo in people with CF who have at least one class I mutation. Data collection and analysis For the included trials, the review authors independently extracted data, assessed the risk of bias and evaluated the certainty of the evidence using GRADE; trial authors were contacted for additional data. Main results Our searches identified 56 references to 20 trials; of these, 18 trials were excluded. Both the included parallel RCTs compared ataluren to placebo for 48 weeks in 517 participants (males and females; age range six to 53 years) with CF who had at least one nonsense mutation (a type of class I mutation). The certainty of evidence and risk of bias assessments for the trials were moderate overall. Random sequence generation, allocation concealment and blinding of trial personnel were well documented; participant blinding was less clear. Some participant data were excluded from the analysis in one trial that also had a high risk of bias for selective outcome reporting. PTC Therapeutics Incorporated sponsored both trials with grant support from the Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the National Institutes of Health. The trials reported no difference between treatment groups in terms of quality of life, and no improvement in respiratory function measures. Ataluren was associated with a higher rate of episodes of renal impairment (risk ratio 12.81, 95% confidence interval 2.46 to 66.65; P = 0.002; I 2 = 0%; 2 trials, 517 participants). The trials reported no treatment effect for ataluren for the review's secondary outcomes of pulmonary exacerbation, computed tomography score, weight, body mass index and sweat chloride. No deaths were reported in the trials. The earlier trial performed a post hoc subgroup analysis of participants not receiving concomitant chronic inhaled tobramycin (n = 146). This analysis demonstrated favourable results for ataluren (n = 72) for the relative change in forced expiratory volume in one second (FEV 1 ) per cent (%) predicted and pulmonary exacerbation rate. The later trial aimed to prospectively assess the efficacy of ataluren in participants not concomitantly receiving inhaled aminoglycosides, and found no difference between ataluren and placebo in FEV 1 % predicted and pulmonary exacerbation rate. Authors' conclusions There is currently insufficient evidence to determine the effect of ataluren as a therapy for people with CF with class I mutations. One trial reported favourable results for ataluren in a post hoc subgroup analysis of participants not receiving chronic inhaled aminoglycosides, but these were not reproduced in the later trial, suggesting that the earlier results may have occurred by chance. Future trials should carefully assess for adverse events, notably renal impairment, and consider the possibility of drug interactions. Cross‐over trials should be avoided, given the potential for the treatment to change the natural history of CF. Plain language summary Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis Review question Can ataluren (and similar compounds specifically targeting class I mutations in cystic fibrosis (CF)) improve the quality of life and lung function of people with CF without having adverse effects? Key messages What is CF? In people with CF, the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. This especially affects the airways, causing the airway surface to dry out and making it difficult to clear thick mucus. This leads to progressive infection and damages the lungs, shortening life expectancy. How will ataluren treat CF? In people with certain CF genetic mutations where the genetic instructions for producing the CFTR protein are interrupted (known as premature termination codon or class I mutations), ataluren (and similar medicines) may be able to skip over the break in the faulty gene sequence and allow the body to produce a corrected version of the CFTR protein. By correcting the protein, the airway surface should remain hydrated, allowing people with CF to better clear their mucus and so develop fewer lung infections. What did we want to find out? We wanted to know whether ataluren can improve the quality of life and lung function of people with CF, and whether it can do so without any side effects. We also wanted to measure the effects on lung infections (need for hospital visits or additional antibiotics), survival, nutritional status (weight, body mass index and height) and whether treatment was cost‐effective. What did we do? We searched for trials that directly compared drugs such as ataluren to placebo (treatment not containing an active drug) or to a different treatment for these specific genetic mutations in any people with CF. What did we find? We found two trials including 517 people (males and females between 6 and 53 years of age) comparing ataluren to a placebo. The trials lasted 48 weeks and everyone taking part in the trials had at least one gene with a class I mutation. Key results In people taking ataluren, there was no improvement in clinical outcomes such as quality of life, lung function, exacerbations (flare up of disease), sweat chloride (salt) levels or weight compared with people taking placebo. The trials found that kidney damage was more common in people taking ataluren. The earlier trial analysed their results in a way not originally planned to see whether the effects of ataluren and placebo were different in people using inhaled tobramycin (an antibiotic) on a long‐term basis compared with people not taking the inhaled antibiotic. In people taking ataluren but not using inhaled tobramycin, lung function declined at a slower rate and there were fewer exacerbations than in people in the placebo group also not using inhaled tobramycin. The later trial specifically recruited people not taking tobramycin to see whether this really was an effect of the antibiotic, but the investigators did not find any difference between the ataluren and placebo groups for changes in lung function or exacerbations. This suggests that the earlier results occurred by chance. There were no deaths and we did not find any differences between ataluren and placebo in side effects or nutritional status. Neither trial reported on hospitalisations, extra courses of antibiotics or cost‐effectiveness. We have not found enough high‐quality evidence to determine the effect of ataluren for treating CF. We recommend that future trials are designed and reported clearly so that their results can be included in a systematic review. What are the limitations of the evidence? We are moderately confident in our findings, but there is some uncertainty due to how widely the results varied between participants. We are satisfied that everyone taking part had an equal chance of being in either group (ataluren or placebo) and that no one could work out which group the next person would be put into (so that healthier people did not receive the treatment and make the results seem better). We believe that the clinicians running the trials and those taking part in the trials did not know which treatment each person was receiving. We have some concerns about the emphasis the investigators of one trial placed on the results of a comparison they had not planned (the use of long‐term inhaled tobramycin). Unfortunately, that trial did not report all its results clearly. Sometimes, the results were reported in a way that meant they could not be used in this review, and sometimes the information was not reported at all. This affected our confidence in the overall results. Trial funding sources Both trials were sponsored by PTC Therapeutics Incorporated, who make ataluren. The Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the US National Institutes of Health also supported the trials. How up to date is this evidence? We last searched for evidence on 4 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aslam, AA; Sinha, IP; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD012040.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "1dbbc54b-eed2-428d-a1b8-e715c63c9b06", "pmid": "", "title": "Antitumour antibiotic containing regimens for metastatic breast cancer", "imported": false, "abstract": "Abstract - Background Antitumour antibiotics are used in the management of metastatic breast cancer. Some of these agents have demonstrated higher tumour response rates than non‐antitumour antibiotic regimens, however a survival benefit has not been established in this setting. Objectives To review the randomised evidence comparing antitumour antibiotic containing chemotherapy regimens with regimens not containing an antitumour antibiotic in the management of women with metastatic breast cancer. Search methods The Specialised Register maintained by the Cochrane Breast Cancer Group was searched on 3rd October, 2006 using the codes for 'advanced breast cancer' and 'chemotherapy'. Details of the search strategy and coding applied by the Group to create the register are described in the Group's module on The Cochrane Library. Selection criteria Randomised trials comparing antitumour antibiotic containing regimens with regimens not containing antitumour antibiotics in women with metastatic breast cancer. Data collection and analysis Data were collected from published trials. Studies were assessed for eligibility and quality, and data were extracted by two independent reviewers. Hazard Ratios (HRs) were derived from time‐to‐event outcomes where possible, and a fixed effect model was used for meta‐analysis. Response rates were analysed as dichotomous variables. Quality of life and toxicity data were extracted where present. A primary analysis was conducted for all trials and by class of antitumour antibiotic. Main results Thirty‐four trials reporting on 46 treatment comparisons were identified. All trials published results for tumour response and 27 trials published time‐to‐event data for overall survival. The observed 4244 deaths in 5605 randomised women did not demonstrate a statistically significant difference in survival between regimens that contained antitumour antibiotics and those that did not (HR 0.96, 95% CI 0.90 to 1.02, P = 0.22) and no significant heterogeneity. Antitumour antibiotic regimens were favourably associated with time‐to‐progression (HR 0.84, 95% CI 0.77 to 0.91) and tumour response rates (odds ratio (OR) 1.33, 95% CI 1.21 to 1.48) although statistically significant heterogeneity was observed for these outcomes. These associations were consistent when the analysis was restricted to the 30 trials that reported on anthracyclines. Patients receiving anthracycline containing regimens were also more likely to experience toxic events compared to patients receiving non‐antitumour antibiotic regimens. No statistically significant difference was observed in any outcome between mitoxantrone containing and non‐antitumour antibiotic‐containing regimens. Authors' conclusions Compared to regimens without antitumour antibiotics, regimens that contained these agents showed a statistically significant advantage for tumour response and time to progression in women with metastatic breast cancer but were not associated with an improvement in overall survival. The favourable effect on tumour response and time to progression observed in anthracycline containing regimens was also associated with greater toxicity. Plain language summary Antitumour antibiotic containing regimens for metastatic breast cancer Advanced (metastatic) breast cancer is cancer that has spread beyond the breast. Treatment for metastatic disease usually involves some type of chemotherapy (anti‐cancer drugs) to try to reduce the cancer. Chemotherapy drugs can either be given as a single agent or in combination with other chemotherapy drugs. This is done according to a plan or a course of the drug referred to as a regimen. There are many types of chemotherapy drugs which work in various ways. Antitumour antibiotics work by damaging the cancer cells thereby preventing those cells from multiplying. Chemotherapy in general produces a range of side effects or adverse events related to the treatment. The known side effects of antitumour antibiotics include nausea, vomiting, a reduction in the number of white blood cells (known as leukopenia), and in some cases a toxic reaction which alters the working of the heart (called cardiotoxicity). This review sought to identify and review the randomised evidence comparing courses of chemotherapy containing antitumour antibiotics against courses not containing antitumour antibiotics. This review identified 34 eligible trials involving 5605 women. This review found that for women with advanced breast cancer, taking antitumour antibiotics did not result in better survival than women who took other types of chemotherapy drugs. Despite the lack of evidence of survival benefit, this review demonstrated that women taking these drugs had an advantage in time to progression (the length of time it takes for the cancer to progress after taking the drug) and tumour response (shrinking of the tumour) compared to women who did not take the antitumour antibiotic drugs. In addition however, the risks of side effects including cardiotoxicity, leukopenia and nausea/vomiting were all significantly increased in the women taking the antitumour antibiotics. Given that this review failed to show a benefit in survival for women taking this group of drugs but a higher rate of side effects, the use of these drugs in the management of metastatic breast cancer must be carefully weighed against the risk of these side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Lord, SJ; Ghersi, D; Gattellari, M; Wortley, S; Wilcken, N; Thornton, C; Simes, J", "articleTypes": [], "doi": "10.1002/14651858.CD003367.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "1dbe3b7d-5a29-4482-9bf4-4a8ad47799b2", "pmid": "", "title": "Capsaicin for non‐allergic rhinitis", "imported": false, "abstract": "Abstract - Background There are many forms of rhinitis. Patients are diagnosed with non‐allergic rhinitis when anatomic, infectious and allergic aetiologies have been excluded. The symptoms, including nasal congestion, blockage or obstruction, clear rhinorrhoea, sneezing and, less frequently, nasal itching, can range from mild to debilitating. It affects between 25% and 50% of patients with rhinitis. Several medications are widely used in the treatment of non‐allergic rhinitis, including oral and topical nasal antihistamines, intranasal and (rarely) systemic corticosteroids, and anticholinergics. Capsaicin, the active component of chili peppers, delivered intranasally, is considered a treatment option for non‐allergic rhinitis. Objectives To assess the effectiveness of capsaicin in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications, or two or more of the above therapies in combination, or different capsaicin regimens. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 5); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2015. Selection criteria Randomised controlled trials in adult patients with non‐allergic rhinitis comparing intranasal capsaicin with no therapy, placebo or other topical or systemic medications, or their combinations. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We included four studies (five publications) involving 302 participants with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe, idiopathic non‐allergic rhinitis who were between the ages of 16 and 65. Studies had follow‐up periods ranging from four to 38 weeks. The overall risk of bias in the studies was either high or unclear (two studies had overall high risk of bias, while two others had low to unclear risk of bias). Using the GRADE system we assessed the evidence as being of low to moderate quality. A meta‐analysis was not possible, given lack of similarity of the reported outcomes. Two studies compared capsaicin with placebo. One study reported that capsaicin resulted in an improvement of overall nasal symptoms (a primary outcome) measured on a visual analogue scale (VAS) of 0 to 10. There was a mean difference (MD) of ‐3.34 (95% confidence interval (CI) ‐5.24 to ‐1.44), MD ‐3.73 (95% CI ‐5.45 to ‐2.01) and MD ‐3.52 (95% CI ‐5.55 to ‐1.48) at two, 12 and 36 weeks post‐treatment, respectively. Another study reported that, compared to placebo, capsaicin (at 4 µg/puff) was more likely to produce overall symptom resolution (reduction in nasal blockage, sneezing/itching/coughing and nasal secretion measured with a daily record chart) at four weeks post‐treatment (a primary outcome). The risk ratio (RR) was 3.17 (95% CI 1.38 to 7.29). One study compared capsaicin to budesonide (an intranasal corticosteroid). This study found that patients treated with capsaicin had a better overall symptom score compared to those treated with budesonide (MD 2.50, 95% CI 1.06 to 3.94, VAS of 0 to 10). However, there were no differences in the individual symptom scores for headache, postnasal drip, rhinorrhoea, nasal blockage, sneezing and sore throat assessed during the last three days of a four‐week treatment. One study compared two different regimens of capsaicin administration: five treatments in one day versus five treatments given every two to three days during two weeks. Using daily record charts, the study reported significant improvement of individual symptom scores for rhinorrhoea in patients treated five times per day, however numerical data were not presented. There were no improvements in the other outcomes: rhinorrhoea, nasal obstruction, sneezing and overall nasal symptoms, measured on a VAS. Finally, one of these studies also compared three doses of capsaicin (to placebo). Patients treated with a 1 µg versus 4 µg per puff dose of capsaicin had a worse daily record chart overall symptom score resolution (RR 0.63, 95% CI 0.34 to 1.16). Only one study attempted to measure adverse effects (a primary outcome), however due to methodological issues with the assessment we are unable to draw any conclusions. We sought to include other secondary outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Authors' conclusions Capsaicin may be an option in the treatment of idiopathic non‐allergic rhinitis. It is given in the form of brief treatments, usually during the same day. It appears to have beneficial effects on overall nasal symptoms up to 36 weeks after treatment, based on a few, small studies (low‐quality evidence). Well‐conducted randomised controlled trials are required to further advance our understanding of the effectiveness of capsaicin in non‐allergic rhinitis, especially in patients with non‐allergic rhinitis of different types and severity, and using different methods of capsaicin application. Plain language summary Capsaicin for non‐allergic rhinitis Review question Is capsaicin applied into the nose (intranasal) effective in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications? Background Rhinitis means inflammation of the nose. It affects 30% to 40% of the general population. There are many forms of rhinitis: rhinosinusitis (or simply sinusitis), allergic rhinitis and non‐allergic rhinitis. Non‐allergic rhinitis is diagnosed in patients who have negative tests for allergies and also do not have sinusitis. The symptoms include congestion of the nose, a blocked or obstructed sensation in the nose that causes difficulty breathing, clear nasal discharge (runny nose), sneezing and nasal itching. There are several subtypes of non‐allergic rhinitis: occupational (from exposure to chemicals), smoking, gustatory (related to eating food or drinking fluid), hormonal (from changes in hormone levels in the body), pregnancy, senile or elderly (mostly affecting the older population), medication‐induced (for example, from overuse of decongestant nasal sprays) and local allergic (local allergy in the nose, while skin or blood allergy tests are negative). The most common subtype of non‐allergic rhinitis is 'idiopathic' or 'vasomotor' rhinitis, which results from imbalance of the neural (nerve) system that manages the function of the nose. The mechanisms of many of these subtypes remain unknown. Non‐allergic rhinitis affects about 25% to 50% of patients with rhinitis and is therefore very common. Capsaicin is the active ingredient of chili peppers. It has medicinal properties and is used elsewhere in medicine, for example for neuralgias (nerve pain) and psoriasis (a skin disease). The side effects of using capsaicin in the nose include irritation, burning, sneezing and coughing, however there are no known long‐term side effects of capsaicin use. Capsaicin is given in the form of brief treatments, usually during the same day. It works by down‐regulating transient receptor potential vanilloid (TRPV) receptor expression on C‐sensory fibres. TRPV represents special ion channels involved in the sensations of pain, cold, hotness, tastes, pressure and vision. C fibres help to conduct some of these sensations. There is ongoing research into the effects of capsaicin on these mechanisms and its clinical uses. Study characteristics We included four studies involving 302 patients with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe idiopathic non‐allergic rhinitis, who were between the ages of 16 and 65. The studies had a follow‐up ranging from four to 38 weeks after treatment. Key results Individually, the studies reported that the overall function of the nose in patients with non‐allergic rhinitis improved when treated with capsaicin compared to placebo. Capsaicin also seems to work better than another common type of nasal medication, budesonide (a steroid). The best knowledge that we have on capsaicin treatment supports giving it five times in one day, and to use doses of at least 4 micrograms in each puff. We could not combine the results together. The included studies did not have sufficient information to allow us to draw a conclusion about side effects. We also wanted to include other outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Quality of the evidence Overall, we judged the quality of the evidence to be of low to moderate quality. The evidence is up to date to June 2015. Conclusions Given that many other options do not work well in non‐allergic rhinitis, capsaicin is a reasonable option to try under physician supervision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Gevorgyan, A, Segboer, C, Gorissen, R, van Drunen, CM, Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010591.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.793Z" }, { "id": "1e3953b7-3fa5-40b8-9407-3ccadf9673ab", "pmid": "", "title": "Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non‐hospitalised term infants", "imported": false, "abstract": "Abstract - Background Many women express concern about their ability to produce enough milk, and insufficient milk is frequently cited as the reason for supplementation and early termination of breastfeeding. When addressing this concern, it is important first to consider the influence of maternal and neonatal health, infant suck, proper latch, and feeding frequency on milk production, and that steps be taken to correct or compensate for any contributing issues. Oral galactagogues are substances that stimulate milk production. They may be pharmacological or non‐pharmacological (natural). Natural galactagogues are usually botanical or other food agents. The choice between pharmacological or natural galactagogues is often influenced by familiarity and local customs. Evidence for the possible benefits and harms of galactagogues is important for making an informed decision on their use. Objectives To assess the effect of oral galactagogues for increasing milk production in non‐hospitalised breastfeeding mother‐term infant pairs. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov , the World Health Organization (WHO) International Clinical Trials Registry Platform ( ICTRP ), Health Research and Development Network ‐ Phillippines ( HERDIN ), Natural Products Alert ( Napralert ), the personal reference collection of author LM, and reference lists of retrieved studies (4 November 2019). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs (including published abstracts) comparing oral galactagogues with placebo, no treatment, or another oral galactagogue in mothers breastfeeding healthy term infants. We also included cluster‐randomised trials but excluded cross‐over trials. Data collection and analysis We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two to four review authors independently selected the studies, assessed the risk of bias, extracted data for analysis and checked accuracy. Where necessary, we contacted the study authors for clarification. Main results Forty‐one RCTs involving 3005 mothers and 3006 infants from at least 17 countries met the inclusion criteria. Studies were conducted either in hospitals immediately postpartum or in the community. There was considerable variation in mothers, particularly in parity and whether or not they had lactation insufficiency. Infants' ages at commencement of the studies ranged from newborn to 6 months. The overall certainty of evidence was low to very low because of high risk of biases (mainly due to lack of blinding), substantial clinical and statistical heterogeneity, and imprecision of measurements. Pharmacological galactagogues Nine studies compared a pharmacological galactagogue (domperidone, metoclopramide, sulpiride, thyrotropin‐releasing hormone) with placebo or no treatment. The primary outcome of proportion of mothers who continued breastfeeding at 3, 4 and 6 months was not reported. Only one study (metoclopramide) reported on the outcome of infant weight, finding little or no difference (mean difference (MD) 23.0 grams, 95% confidence interval (CI) ‐47.71 to 93.71; 1 study, 20 participants; low‐certainty evidence). Three studies (metoclopramide, domperidone, sulpiride) reported on milk volume, finding pharmacological galactagogues may increase milk volume (MD 63.82 mL, 95% CI 25.91 to 101.72; I² = 34%; 3 studies, 151 participants; low‐certainty evidence). Subgroup analysis indicates there may be increased milk volume with each drug, but with varying CIs. There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints, such as tiredness, nausea, headache and dry mouth (very low‐certainty evidence). No adverse effects were reported for infants. Natural galactagogues Twenty‐seven studies compared natural oral galactagogues (banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves or other natural mixtures) with placebo or no treatment. One study (Mother's Milk Tea) reported breastfeeding rates at six months with a concluding statement of \"no significant difference\" (no data and no measure of significance provided, 60 participants, very low‐certainty evidence). Three studies (fennel, fenugreek, moringa, mixed botanical tea) reported infant weight but could not be meta‐analysed due to substantial clinical and statistical heterogeneity (I 2 = 60%, 275 participants, very low‐certainty evidence). Subgroup analysis shows we are very uncertain whether fennel or fenugreek improves infant weight, whereas moringa and mixed botanical tea may increase infant weight compared to placebo. Thirteen studies (Bu Xue Sheng Ru, Chanbao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants) reported on milk volume, but meta‐analysis was not possible due to substantial heterogeneity (I 2 = 99%). The subgroup analysis for each intervention suggested either benefit or little or no difference (very low‐certainty evidence). There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints such as mothers with urine that smelled like maple syrup and urticaria in infants (very low‐certainty evidence). Galactagogue versus galactagogue Eight studies (Chanbao; Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one oral galactagogue with another. We were unable to perform meta‐analysis because there was only one small study for each match‐up, so we do not know if one galactagogue is better than another for any outcome. Authors' conclusions Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low‐certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High‐quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used. Plain language summary Milk boosters (galactagogues) for mothers breastfeeding their healthy infants born at term What is the issue? We set out to determine the ability of milk boosters taken by mouth (medicine, herb or food) to increase milk production in breastfeeding mothers of healthy infants born at term. Poor milk supply is often given as the reason for early supplementation and weaning sooner than desired. A range of factors, including mother's and baby's health, baby's sucking skills, proper latch and frequency of feeds, can affect milk production. Every attempt should first be made to identify and correct the causes for low milk production before trying a milk booster. Why is this important? Inadequate milk production can be distressing for mothers and threatening to babies' health. The choice of milk booster is often influenced by familiarity or local customs. Some mothers may prefer medications, while others prefer natural remedies. Evidence for the possible benefits and harms of milk boosters is important to assist mothers in making informed decisions. What evidence did we find? We searched for evidence from randomised controlled studies up to 4 November 2019 and identified 41 eligible studies involving 3005 mothers and 3006 infants from at least 17 countries. The studies varied widely in babies ages, type of milk boosters investigated, how long they were taken, and how outcomes were reported. Medications included sulpiride, metoclopramide, domperidone and thyrotropin‐releasing hormone. Natural interventions included banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves, and a variety of natural mixtures as teas or soups. Milk‐boosting medication Nine studies compared a milk‐boosting medication with placebo or no treatment. None reported exclusive breastfeeding rates at 3. 4 or 6 months and only one (metoclopramide, 20 participants) reported on weight gain in infants receiving only their mothers' own milk, with better results in the milk booster group. Three studies that tracked milk volume (domperidone, metoclopramide, sulpiride; 151 participants) reported more milk in the booster groups, though the certainty of the evidence was low. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as tiredness, nausea, decreased appetite, headache and dry mouth. Natural milk boosters Twenty‐seven studies compared natural milk boosters with placebo or no treatment. Only one (Mother’s Milk Tea; 60 participants) examined the impact on breastfeeding rates, reporting \"no significant difference at 6 months\" without providing any data (very low‐certainty evidence). Three studies (275 participants) reported infant weight, two of which (moringa, mixed botanical tea) reported higher gains in the milk booster group, while the other study (fennel and fenugreek) was inconclusive on whether infant weight gain improved with the milk boosters. In the 13 studies tracking changes in milk volume (Bu Xue Sheng Ru, Chan Bao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants), some showed benefits and others little or no difference, so we are very uncertain about the results for milk volume. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as mothers with urine that smells like maple syrup and rash in infants (very low‐certainty evidence). One milk booster compared with another Eight studies (Chanbao, Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one milk booster with another. There was only one small study for each particular match‐up, hence we cannot be certain if any one milk booster truly worked better than another. What does this mean? There is limited evidence that milk‐boosting medications may increase milk volume and that natural milk boosters may improve milk volume and infants' weight, but we are very uncertain about the supporting evidence. Due to limited information, we are also uncertain if there are any risks to the mother or baby in taking any particular milk booster. More high‐quality studies are needed to increase our certainty about the effects of milk boosters.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Foong, SC; Tan, ML; Foong, WC; Marasco, LA; Ho, JJ; Ong, JH", "articleTypes": [], "doi": "10.1002/14651858.CD011505.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "1e4918c3-6b9a-41c3-bd13-7d9b2020c185", "pmid": "", "title": "Enteral nutritional therapy for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta‐analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review. Objectives To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts. Selection criteria Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review. Data collection and analysis Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random‐effects model was used to pool data. We performed intention‐to‐treat and per‐protocol analyses for the primary outcome. Heterogeneity was explored using the Chi 2 and I 2 statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes. Main results Twenty‐seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non‐elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non‐elemental diets differing in glutamine enrichment. Meta‐analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty‐four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non‐elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per‐protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non‐elemental diets (elemental, semi‐elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non‐elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating. Ten trials compared EN to steroid therapy. Meta‐analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per‐protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per‐protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet. Authors' conclusions Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy Plain language summary Enteral nutritional therapy for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a long‐term inflammation of the gastrointestinal (GI) tract, occurring anywhere from mouth to anus. Common symptoms of this condition include abdominal pain, diarrhea and weight loss. When Crohn's disease patients are experiencing symptoms, it is characterized to be 'active' disease. When the symptoms stop, it is called 'remission'. What is enteral nutrition? Enteral nutrition is a feeding method where all of a person's daily caloric intake is delivered using the GI tract. An example of this is nasogastric tube feeding, where a tube is inserted through a person's nose to deliver their daily nutritional requirements in liquid form. Enteral nutrition can be a form of nutritional therapy for Crohn's disease patients. Enteral nutrition is categorized into elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets come from amino‐acid sources, whereas non‐elemental diets come from oligopeptide or whole protein sources. What are corticosteroids? Corticosteroids are an effective treatment option for active Crohn's disease. These drugs that are taken by mouth and work as immunosuppressants. What did the researchers investigate? The researchers studied whether enteral nutrition is better than steroid therapy at producing remission in Crohn's disease patients. In addition, the investigators looked to see if one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) at producing remission in Crohn's disease. What did the researchers find? The researchers found twenty‐seven studies (1,011 participants) that fulfilled the search criteria. Eleven of these studies, which included 378 patients, compared elemental to non‐elemental diets at producing remission in Crohn's disease. Eight studies, which included 352 patients, investigated enteral nutrition compared to steroid therapy at inducing remission in Crohn's disease. The researchers searched the medical literature extensively up to July 5, 2017. Very low quality evidence suggests that steroids may be more effective than enteral nutrition for induction of remission in adults with active Crohn's disease. Very low quality evidence also suggests that enteral nutrition may be more effective than steroids for induction of remission in children with active Crohn's disease. There was no difference in remission rates between elemental and non‐elemental diets. An increase in side effects was not seen with elemental diets compared to non‐elemental diets, nor with enteral nutrition compared to steroids. Common side effects experienced with enteral nutrition included vomiting, diarrhea, heartburn and flatulence . Common side effects associated with steroid use included acne, moon facies, muscle weakness, hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) . Patients on enteral nutrition were more likely to withdraw from the study due to side effects than those on steroids. The most common reason for study withdrawal was inability to tolerate the taste of the enteral nutrition diet. Enteral nutrition should be considered in pediatric Crohn's patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient compliance with this therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Narula, N; Dhillon, A; Zhang, D; Sherlock, ME; Tondeur, M; Zachos, M", "articleTypes": [], "doi": "10.1002/14651858.CD000542.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "1e5056f8-57fc-495a-9198-7b44a2541253", "pmid": "", "title": "Zolmitriptan for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a common, disabling condition and a burden for the individual, health services, and society. Zolmitriptan is an abortive medication for migraine attacks, belonging to the triptan family. These medicines work in a different way to analgesics such as paracetamol and ibuprofen. Objectives To determine the efficacy and tolerability of zolmitriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, and the Oxford Pain Relief Database, together with three online databases ( www.astrazenecaclinicaltrials.com , www.clinicaltrials.gov , and apps.who.int/trialsearch ) for studies to 12 March 2014. We also searched the reference lists of included studies and relevant reviews. Selection criteria We included randomised, double‐blind, placebo‐ or active‐controlled studies, with at least 10 participants per treatment arm, using zolmitriptan to treat a migraine headache episode. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate risk ratios and numbers needed to treat for an additional beneficial effect (NNT) or harmful effect (NNH) compared with placebo or a different active treatment. Main results Twenty‐five studies (20,162 participants) compared zolmitriptan with placebo or an active comparator. The evidence from placebo‐controlled studies was of high quality for all outcomes except 24 hour outcomes and serious adverse events where only limited data were available. The majority of included studies were at a low risk of performance, detection and attrition biases, but did not adequately describe methods of randomisation and concealment. Most of the data were for the 2.5 mg and 5 mg doses compared with placebo, for treatment of moderate to severe pain. For all efficacy outcomes, zolmitriptan surpassed placebo. For oral zolmitriptan 2.5 mg versus placebo, the NNTs were 5.0, 3.2, 7.7, and 4.1 for pain‐free at two hours, headache relief at two hours, sustained pain‐free during the 24 hours postdose, and sustained headache relief during the 24 hours postdose, respectively. Results for the oral 5 mg dose were similar to the 2.5 mg dose, while zolmitriptan 10 mg was significantly more effective than 5 mg for pain‐free and headache relief at two hours. For headache relief at one and two hours and sustained headache relief during the 24 hours postdose, but not pain‐free at two hours, zolmitriptan 5 mg nasal spray was significantly more effective than the 5 mg oral tablet. For the most part, adverse events were transient and mild and were more common with zolmitriptan than placebo, with a clear dose response relationship (1 mg to 10 mg). High quality evidence from two studies showed that oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people as oral sumatriptan 50 mg (66%, 67%, and 68% respectively), although not necessarily the same individuals. There was no significant difference in numbers experiencing adverse events. Single studies reported on other active treatment comparisons but are not described further because of the small amount of data. Authors' conclusions Zolmitriptan is effective as an abortive treatment for migraine attacks for some people, but is associated with increased adverse events compared to placebo. Zolmitriptan 2.5 mg and 5 mg benefited the same proportion of people as sumatriptan 50 mg, although not necessarily the same individuals, for headache relief at two hours. Plain language summary Zolmitriptan for acute migraine attacks in adults Migraine is a complex condition with a wide variety of symptoms. It affects about 1 person in 8, mainly women aged 30 to 50 years. For many people, the main feature is a painful, and often disabling, headache. Other symptoms include feeling sick, vomiting, disturbed vision, and sensitivity to light, sound, and smells. Zolmitriptan is one of the triptan family of drugs. It is used to treat migraine attacks when they occur, not to prevent attacks occurring. It is available as an oral tablet to swallow whole, an oral tablet to dissolve in the mouth, and a nasal spray. This review looked at 25 studies that involved over 20,000 participants reporting the effects of zolmitriptan on migraine attacks. Most information was for tablets taken by mouth. Overall methodological quality of the included studies was good, and treatment group sizes were large enough to avoid major bias. There were inconsistencies in the way use of rescue medication and adverse events were reported. A single oral dose of zolmitriptan relieved migraine headache pain in some people. Several different pain outcomes were reported. One outcome was pain reduced from moderate or severe to no pain at all two hours after taking treatment. An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 3 in 10 people (30%), compared with about 1 in 10 (10%) taking placebo. Another outcome was pain reduced from moderate or severe to no worse than mild pain two hours after taking treatment (called headache relief). An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 6 in 10 people (61%), compared with 3 in 10 (29%) taking placebo. Slightly better results were obtained with higher doses of 5 mg or 10 mg oral tablets, but the 10 mg dose was associated with more adverse events, most of which were of short duration and mild or moderate in severity. Results for the 5 mg nasal spray were generally similar to those for the oral tablet, but it was significantly better than the tablet at 1 hour. People with migraine want treatment that eliminates the headache and any associated symptoms quickly (maximum two hours) and prevents it returning (within 24 hours). Results indicate that with the 5 mg dose only 14% of those treated were pain‐free at 2 hours with no headache recurrence within 24 hours. Oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people (2 in 3) as oral sumatriptan 50 mg, with no difference in numbers experiencing adverse events. The individuals who respond to each drug may not be the same.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bird, S; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "1e619c36-02d5-4020-8d54-ace1b61bfae5", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: cytokines and growth factors", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulceration can lead to severe pain and difficulty with eating and drinking, which may necessitate opioid analgesics, hospitalisation and supplemental nutrition. These complications may disrupt cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining of the mouth, thus preventing or reducing oral mucositis and its negative effects. Objectives To assess the effects of cytokines and growth factors for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (searched 10 May 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4) in the Cochrane Library (searched 10 May 2017); MEDLINE Ovid (1946 to 10 May 2017); Embase Ovid (7 December 2015 to 10 May 2017); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 10 May 2017); and CANCERLIT PubMed (1950 to 10 May 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of cytokines and growth factors in patients with cancer receiving treatment. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 35 RCTs analysing 3102 participants. Thirteen studies were at low risk of bias, 12 studies were at unclear risk of bias, and 10 studies were at high risk of bias. Our main findings were regarding keratinocyte growth factor (KGF) and are summarised as follows. There might be a reduction in the risk of moderate to severe oral mucositis in adults receiving bone marrow/stem cell transplantation after conditioning therapy for haematological cancers (RR 0.89, 95% CI 0.80 to 0.99; 6 studies; 852 participants; low‐quality evidence). We would need to treat 11 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 6 to 112). There might be a reduction in the risk of severe oral mucositis in this population, but there is also some possibility of an increase in risk (RR 0.85, 95% CI 0.65 to 1.11; 6 studies; 852 participants; low‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to prevent the outcome to 14 to cause the outcome). There is probably a reduction in the risk of moderate to severe oral mucositis in adults receiving radiotherapy to the head and neck with cisplatin or fluorouracil (RR 0.91, 95% CI 0.83 to 1.00; 3 studies; 471 participants; moderate‐quality evidence). We would need to treat 12 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 7 to infinity). It is very likely that there is a reduction in the risk of severe oral mucositis in this population (RR 0.79, 95% CI 0.69 to 0.90; 3 studies; 471 participants; high‐quality evidence). We would need to treat 7 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to 15). It is likely that there is a reduction in the risk of moderate to severe oral mucositis in adults receiving chemotherapy alone for mixed solid and haematological cancers (RR 0.56, 95% CI 0.45 to 0.70; 4 studies; 344 participants; moderate‐quality evidence). We would need to treat 4 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 3 to 6). There might be a reduction in the risk of severe oral mucositis in this population (RR 0.30, 95% CI 0.14 to 0.65; 3 studies; 263 participants; low ‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 8 to 19). Due to the low volume of evidence, single‐study comparisons and insufficient sample sizes, we found no compelling evidence of a benefit for any other cytokines or growth factors and there was no evidence on children. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Authors' conclusions We are confident that KGF is beneficial in the prevention of oral mucositis in adults who are receiving: a) radiotherapy to the head and neck with cisplatin or fluorouracil; or b) chemotherapy alone for mixed solid and haematological cancers. We are less confident about a benefit for KGF in adults receiving bone marrow/stem cell transplant after conditioning therapy for haematological cancers because of multiple factors involved in that population, such as whether or not they received total body irradiation (TBI) and whether the transplant was autologous (the patients' own cells) or allogeneic (cells from a donor). KGF appears to be a relatively safe intervention. Due to limited research, we are not confident that there are any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Plain language summary Can cytokines and growth factors help prevent mouth soreness and ulcers (oral mucositis) in patients being treated for cancer? Review question This review has been produced to assess whether or not the use of cytokines and growth factors during cancer treatment, can help prevent mouth soreness and ulcers. Background Sore mouth and ulcers (oral mucositis) is a side effect of treatment for cancer including chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulcers can lead to severe pain and difficulty with eating and drinking. Sufferers may need strong painkillers, possibly have to go into hospital and even be fed through a tube into their stomach or their veins. These complications may disrupt their cancer therapy, meaning they are not receiving the best treatment, which may reduce survival. Cancer patients have weakened immune systems due to their treatment and are less able to fight infections. An ulcer is an open wound and there is a risk that bacteria can enter the body leading to infection or sepsis (a dangerous inflammatory reaction of the body to infection). Mouth soreness and ulcers can be costly to healthcare systems, yet there are few preventive interventions or treatments proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining the mouth, thus preventing or reducing oral mucositis and its negative effects. Study characteristics Authors from Cochrane Oral Health carried out this review of existing studies and the evidence is current up to 10 May 2017. It includes 35 studies (published between 1993 and 2017) with 3102 participants, all patients being treated for cancer, aged from 1 to 87 years old. Review authors included studies comparing cytokines and growth factors for the prevention of oral mucositis. The studies were carried out all over the world and often featured multiple sites, although most took place in high‐income countries. Main results The main findings were regarding keratinocyte growth factor (KGF). KGF is likely to reduce the risk of oral mucositis in adults who are receiving either radiotherapy to the head and neck with chemotherapy (cisplatin or fluorouracil), or chemotherapy alone for mixed solid and blood cancers. KGF may also reduce the risk of oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, but these results are less clear because of multiple complicating factors. KGF appears to be a relatively safe intervention. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Due to limited research, review authors are uncertain of any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Quality of the evidence For reducing oral mucositis in adults receiving radiotherapy to the head and neck with chemotherapy, review authors rated the evidence for KGF as moderate to high quality. For reducing oral mucositis in adults receiving chemotherapy alone for mixed solid and blood cancers, they rated the evidence for KGF as low to moderate quality. This evidence was downgraded due to there not being enough data and because some results have not yet been published. For reducing oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, they rated the evidence for KGF as low quality because results were not similar across the studies and some results have not yet been published. Evidence on side effects of KGF was poorly reported and inconsistent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P; Glenny, AM; Worthington, HV; Littlewood, A; Fernandez Mauleffinch, LM; Clarkson, JE; McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "1e8bd27b-d679-4868-ab49-773d25eb3e25", "pmid": "", "title": "Interventions for paracetamol (acetaminophen) overdose", "imported": false, "abstract": "Abstract - Background Paracetamol (acetaminophen) is the most widely used non‐prescription analgesic in the world. Paracetamol is commonly taken in overdose either deliberately or unintentionally. In high‐income countries, paracetamol toxicity is a common cause of acute liver injury. There are various interventions to treat paracetamol poisoning, depending on the clinical status of the person. These interventions include inhibiting the absorption of paracetamol from the gastrointestinal tract (decontamination), removal of paracetamol from the vascular system, and antidotes to prevent the formation of, or to detoxify, metabolites. Objectives To assess the benefits and harms of interventions for paracetamol overdosage irrespective of the cause of the overdose. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register (January 2017), CENTRAL (2016, Issue 11), MEDLINE (1946 to January 2017), Embase (1974 to January 2017), and Science Citation Index Expanded (1900 to January 2017). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov database (US National Institute of Health) for any ongoing or completed trials (January 2017). We examined the reference lists of relevant papers identified by the search and other published reviews. Selection criteria Randomised clinical trials assessing benefits and harms of interventions in people who have ingested a paracetamol overdose. The interventions could have been gastric lavage, ipecacuanha, or activated charcoal, or various extracorporeal treatments, or antidotes. The interventions could have been compared with placebo, no intervention, or to each other in differing regimens. Data collection and analysis Two review authors independently extracted data from the included trials. We used fixed‐effect and random‐effects Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of the review outcomes. We used the Cochrane 'Risk of bias' tool to assess the risks of bias (i.e. systematic errors leading to overestimation of benefits and underestimation of harms). We used Trial Sequential Analysis to control risks of random errors (i.e. play of chance) and GRADE to assess the quality of the evidence and constructed 'Summary of findings' tables using GRADE software. Main results We identified 11 randomised clinical trials (of which one acetylcysteine trial was abandoned due to low numbers recruited), assessing several different interventions in 700 participants. The variety of interventions studied included decontamination, extracorporeal measures, and antidotes to detoxify paracetamol's toxic metabolite; which included methionine, cysteamine, dimercaprol, or acetylcysteine. There were no randomised clinical trials of agents that inhibit cytochrome P‐450 to decrease the activation of the toxic metabolite N ‐acetyl‐ p ‐benzoquinone imine. Of the 11 trials, only two had two common outcomes, and hence, we could only meta‐analyse two comparisons. Each of the remaining comparisons included outcome data from one trial only and hence their results are presented as described in the trials. All trial analyses lack power to access efficacy. Furthermore, all the trials were at high risk of bias. Accordingly, the quality of evidence was low or very low for all comparisons. Interventions that prevent absorption, such as gastric lavage, ipecacuanha, or activated charcoal were compared with placebo or no intervention and with each other in one four‐armed randomised clinical trial involving 60 participants with an uncertain randomisation procedure and hence very low quality. The trial presented results on lowering plasma paracetamol levels. Activated charcoal seemed to reduce the absorption of paracetamol, but the clinical benefits were unclear. Activated charcoal seemed to have the best risk:benefit ratio among gastric lavage, ipecacuanha, or supportive treatment if given within four hours of ingestion. There seemed to be no difference between gastric lavage and ipecacuanha, but gastric lavage and ipecacuanha seemed more effective than no treatment (very low quality of evidence). Extracorporeal interventions included charcoal haemoperfusion compared with conventional treatment (supportive care including gastric lavage, intravenous fluids, and fresh frozen plasma) in one trial with 16 participants. The mean cumulative amount of paracetamol removed was 1.4 g. One participant from the haemoperfusion group who had ingested 135 g of paracetamol, died. There were no deaths in the conventional treatment group. Accordingly, we found no benefit of charcoal haemoperfusion (very low quality of evidence). Acetylcysteine appeared superior to placebo and had fewer adverse effects when compared with dimercaprol or cysteamine. Acetylcysteine superiority to methionine was unproven. One small trial (low quality evidence) found that acetylcysteine may reduce mortality in people with fulminant hepatic failure (Peto OR 0.29, 95% CI 0.09 to 0.94). The most recent randomised clinical trials studied different acetylcysteine regimens, with the primary outcome being adverse events. It was unclear which acetylcysteine treatment protocol offered the best efficacy, as most trials were underpowered to look at this outcome. One trial showed that a modified 12‐hour acetylcysteine regimen with a two‐hour acetylcysteine 100 mg/kg bodyweight loading dose was associated with significantly fewer adverse reactions compared with the traditional three‐bag 20.25‐hour regimen (low quality of evidence). All Trial Sequential Analyses showed lack of sufficient power. Children were not included in the majority of trials. Hence, the evidence pertains only to adults. Authors' conclusions These results highlight the paucity of randomised clinical trials comparing different interventions for paracetamol overdose and their routes of administration and the low or very low level quality of the evidence that is available. Evidence from a single trial found activated charcoal seemed the best choice to reduce absorption of paracetamol. Acetylcysteine should be given to people at risk of toxicity including people presenting with liver failure. Further randomised clinical trials with low risk of bias and adequate number of participants are required to determine which regimen results in the fewest adverse effects with the best efficacy. Current management of paracetamol poisoning worldwide involves the administration of intravenous or oral acetylcysteine which is based mainly on observational studies. Results from these observational studies indicate that treatment with acetylcysteine seems to result in a decrease in morbidity and mortality, However, further evidence from randomised clinical trials comparing different treatments are needed. Plain language summary Interventions for paracetamol (acetaminophen) overdose Review question: in this review, we looked at the evidence for the interventions (treatments) used to treat people with paracetamol (acetaminophen) poisoning. Mainly, we tried to assess what effects the interventions had on the number of deaths and the need for a liver transplant. Background: paracetamol is one of the most common drugs taken in overdose. Intentional or accidental poisoning with paracetamol is a common cause of liver injury. Search date: the evidence is current to January 2017. Study characteristics: randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) where participants had come to medical attention because they had taken a paracetamol overdose, intentionally or by accident, regardless of the amount of paracetamol taken or the age, sex, or other medical conditions of the person involved. There are many different interventions that can be used to try to treat people with paracetamol poisoning. These interventions include decreasing the absorption of the paracetamol ingested and hence decreasing the amount absorbed into the bloodstream. The agents include activated charcoal (that binds paracetamol together in the stomach), gastric lavage (stomach washout to remove as much paracetamol as possible), or ipecacuanha (a syrup that is swallowed and causes vomiting (being sick)). Paracetamol once absorbed into the bloodstream goes to the liver where the majority is broken down to harmless products. However, a small amount of the medicine is converted into a toxic product that the liver can normally handle but, when large amounts of paracetamol are taken, the liver is overwhelmed. As a consequence, the toxic product can damage the liver leading to liver failure, kidney failure, and in some cases death. Other interventions to treat paracetamol poisoning include medicines (antidotes) that may decrease the amount of the toxic products (such as a medicine called cimetidine) or breakdown the toxic products (including medicines called methionine, cysteamine, dimercaprol, or acetylcysteine). Finally, attempts can be made to remove paracetamol and its toxic products from the bloodstream using special blood cleansing equipment. All these treatments were examined. We found 11 randomised clinical trials with 700 participants. Most of these trials looked at different treatments. Key results: activated charcoal, gastric lavage, and ipecacuanha may reduce absorption of paracetamol if started within one to two hours of paracetamol ingestion, but the clinical benefit was unclear. Activated charcoal seems to be the best choice if the person is able to take it. People may not be able to take charcoal if they are drowsy and some may dislike its taste or texture (or both). Of the treatments that remove the toxic products of paracetamol, acetylcysteine seems to reduce the rate of liver injury from paracetamol poisoning. Furthermore, it has fewer side effects than some other antidotes such as dimercaprol and cysteamine; its superiority to methionine was unclear. Acetylcysteine should be given to people with paracetamol poisoning at risk of liver damage, risk is determined by the dose ingested, time of ingestion, and investigations. More recent clinical trials have looked at ways to decrease side effects of intravenous (into a vein) acetylcysteine treatment, by altering the way it is given. These trials have shown that by using a slower infusion and lower initial dose of acetylcysteine, the proportion of side effects such as nausea (feeling sick) and vomiting, and allergy (the body's bad reaction to the medicine such as a rash) may be lowered. Quality of the evidence: this review of interventions for paracetamol poisoning found surprisingly few published randomised clinical trials for this very common condition. Furthermore, the majority of trials had few participants and all were at high risk of bias. Accordingly, the quality of the evidence should be considered as low or very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Chiew, AL; Gluud, C; Brok, J; Buckley, NA", "articleTypes": [], "doi": "10.1002/14651858.CD003328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "1e95e74b-b2b8-4284-9800-b29a2423bad6", "pmid": "", "title": "Lamotrigine for chronic neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This is an update of the original Cochrane review entitled Lamotrigine for acute and chronic pain published in Issue 2, 2007, and updated in Issue 2, 2011. Some antiepileptic medicines have a place in the treatment of neuropathic pain (pain due to nerve damage). This updated review adds no new additional studies looking at evidence for lamotrigine as an effective treatment for chronic neuropathic pain or fibromyalgia. The update uses higher standards of evidence than previously. Objectives To assess the analgesic efficacy of lamotrigine in the treatment of chronic neuropathic pain and fibromyalgia, and to evaluate adverse effects reported in the studies. Search methods We identified randomised controlled trials (RCTs) of lamotrigine for chronic neuropathic pain and fibromyalgia (including cancer pain) from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). We ran searches for the original review in 2006, in 2011 for the first update, and subsequent searches in August 2013 for this update. We sought additional studies from the reference lists of the retrieved papers. The original review and first update included acute pain, but no acute pain studies were identified. Selection criteria RCTs investigating the use of lamotrigine (any dose, by any route, and for any study duration) for the treatment of chronic neuropathic pain or fibromyalgia. Assessment of pain intensity or pain relief, or both, using validated scales. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First‐tier studies did not use last observation carried forward (LOCF) or other imputational methods for dropouts. The second tier used data that failed to meet this standard and second‐tier results were therefore subject to potential bias. Main results Twelve included studies in 11 publications (1511 participants), all with chronic neuropathic pain: central post‐stroke pain (1), chemotherapy‐induced neuropathic pain (1), diabetic neuropathy (4), HIV‐related neuropathy (2), mixed neuropathic pain (2), spinal cord injury‐related pain (1), and trigeminal neuralgia (1). We did not identify any additional studies. Participants were aged between 26 and 77 years. Study duration was two weeks in one study and at least six weeks in the remainder; eight were of eight‐week duration or longer. No study provided first‐tier evidence for an efficacy outcome. There was no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of 200 mg to 400 mg daily. Almost 10% of participants taking lamotrigine reported a skin rash. Authors' conclusions Large, high‐quality, long‐duration studies reporting clinically useful levels of pain relief for individual participants provided no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of about 200 to 400 mg daily. Given the availability of more effective treatments including antiepileptics and antidepressant medicines, lamotrigine does not have a significant place in therapy based on the available evidence. The adverse effect profile of lamotrigine is also of concern. Plain language summary Lamotrigine (an antiepileptic drug) for chronic neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our understanding of fibromyalgia (a condition of persistent, widespread pain and tenderness, sleep problems, and fatigue) is lacking, but fibromyalgia can respond to the same medicines as neuropathic pain. Lamotrigine is a medicine used to treat epilepsy, and so might be a useful medicine for neuropathic pain or fibromyalgia. On 26 November 2013 we performed searches to look for clinical trials where lamotrigine was used to treat neuropathic pain or fibromyalgia. We found 12 studies of reasonable quality that tested lamotrigine against placebo for a number of weeks. Almost half of the 1511 people in the studies had painful limbs because of damaged nerves caused by diabetes, and seven different painful neuropathic conditions were examined. No studies looked at fibromyalgia. Lamotrigine did not help the pain, and was no different from placebo except in causing more side effects. Adverse events were more frequent with lamotrigine than placebo, with rash in 1 person in 27.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD006044.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "1ec56df2-2c1e-43a8-a83d-e127bcd1f46a", "pmid": "", "title": "Omega‐3 fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids from oily fish (long‐chain omega‐3 (LCn3)), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha‐linolenic acid (ALA)) may benefit cardiovascular health. Guidelines recommend increasing omega‐3‐rich foods, and sometimes supplementation, but recent trials have not confirmed this. Objectives To assess the effects of increased intake of fish‐ and plant‐based omega‐3 fats for all‐cause mortality, cardiovascular events, adiposity and lipids. Search methods We searched CENTRAL, MEDLINE and Embase to February 2019, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to August 2019, with no language restrictions. We handsearched systematic review references and bibliographies and contacted trial authors. Selection criteria We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation or advice to increase LCn3 or ALA intake, or both, versus usual or lower intake. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed validity. We performed separate random‐effects meta‐analysis for ALA and LCn3 interventions, and assessed dose‐response relationships through meta‐regression. Main results We included 86 RCTs (162,796 participants) in this review update and found that 28 were at low summary risk of bias. Trials were of 12 to 88 months' duration and included adults at varying cardiovascular risk, mainly in high‐income countries. Most trials assessed LCn3 supplementation with capsules, but some used LCn3‐ or ALA‐rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5 g a day to more than 5 g a day (19 RCTs gave at least 3 g LCn3 daily). Meta‐analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all‐cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.93 to 1.01; 143,693 participants; 11,297 deaths in 45 RCTs; high‐certainty evidence), cardiovascular mortality (RR 0.92, 95% CI 0.86 to 0.99; 117,837 participants; 5658 deaths in 29 RCTs; moderate‐certainty evidence), cardiovascular events (RR 0.96, 95% CI 0.92 to 1.01; 140,482 participants; 17,619 people experienced events in 43 RCTs; high‐certainty evidence), stroke (RR 1.02, 95% CI 0.94 to 1.12; 138,888 participants; 2850 strokes in 31 RCTs; moderate‐certainty evidence) or arrhythmia (RR 0.99, 95% CI 0.92 to 1.06; 77,990 participants; 4586 people experienced arrhythmia in 30 RCTs; low‐certainty evidence). Increasing LCn3 may slightly reduce coronary heart disease mortality (number needed to treat for an additional beneficial outcome (NNTB) 334 , RR 0.90, 95% CI 0.81 to 1.00; 127,378 participants; 3598 coronary heart disease deaths in 24 RCTs, low‐certainty evidence) and coronary heart disease events ( NNTB 167 , RR 0.91, 95% CI 0.85 to 0.97; 134,116 participants; 8791 people experienced coronary heart disease events in 32 RCTs, low‐certainty evidence). Overall, effects did not differ by trial duration or LCn3 dose in pre‐planned subgrouping or meta‐regression. There is little evidence of effects of eating fish. Increasing ALA intake probably makes little or no difference to all‐cause mortality (RR 1.01, 95% CI 0.84 to 1.20; 19,327 participants; 459 deaths in 5 RCTs, moderate‐certainty evidence), cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25; 18,619 participants; 219 cardiovascular deaths in 4 RCTs; moderate‐certainty evidence), coronary heart disease mortality (RR 0.95, 95% CI 0.72 to 1.26; 18,353 participants; 193 coronary heart disease deaths in 3 RCTs; moderate‐certainty evidence) and coronary heart disease events (RR 1.00, 95% CI 0.82 to 1.22; 19,061 participants; 397 coronary heart disease events in 4 RCTs; low‐certainty evidence). However, increased ALA may slightly reduce risk of cardiovascular disease events ( NNTB 500 , RR 0.95, 95% CI 0.83 to 1.07; but RR 0.91, 95% CI 0.79 to 1.04 in RCTs at low summary risk of bias; 19,327 participants; 884 cardiovascular disease events in 5 RCTs; low‐certainty evidence), and probably slightly reduces risk of arrhythmia ( NNTB 91 , RR 0.73, 95% CI 0.55 to 0.97; 4912 participants; 173 events in 2 RCTs; moderate‐certainty evidence). Effects on stroke are unclear . Increasing LCn3 and ALA had little or no effect on serious adverse events, adiposity, lipids and blood pressure, except increasing LCn3 reduced triglycerides by ˜15% in a dose‐dependent way (high‐certainty evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐3 fats on cardiovascular health to date. Moderate‐ and low‐certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials). Increasing ALA slightly reduces risk of cardiovascular events and arrhythmia. Plain language summary Omega‐3 intake for cardiovascular disease Review question We reviewed randomised trials (where participants have an equal chance of being assigned to either treatment) examining effects of increasing fish‐ and plant‐based omega‐3 fats on heart and circulatory disease (called cardiovascular diseases, which include heart attacks and stroke), fatness and blood fats (lipids, including cholesterol, triglycerides, high‐density lipoprotein (HDL – 'good' cholesterol) and low‐density lipoprotein (LDL – 'bad' cholesterol)). Background The main types of omega‐3 fats are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), both found in fish, and alpha‐linolenic acid (ALA) found in plant foods. Many people believe that taking omega‐3 supplements reduces risk of heart disease, stroke and death. Trial characteristics The evidence is current to February 2019. The review included 86 trials involving 162,796 people. These trials assessed effects of greater omega‐3 intake versus lower omega‐3 intake for at least a year on heart and circulatory disease. Twenty‐eight trials were very trustworthy (well‐designed so as not to give biased results). Participants were adults, some with existing illness and some healthy, living in North America, Europe, Australia and Asia. Most EPA and DHA trials provided capsules, few gave oily fish. Key results Increasing EPA and DHA has little or no effect on deaths and cardiovascular events (high‐certainty evidence) and probably makes little or no difference to cardiovascular death, stroke, or heart irregularities (moderate‐certainty evidence). However, increasing EPA and DHA may slightly reduce risk of coronary death and coronary events (low‐certainty evidence, coronary events are illnesses of arteries supplying the heart). To prevent one person having a coronary event, 167 people would need to increase their EPA and DHA, and 334 people would need to increase their EPA and DHA to prevent one person dying from coronary disease. EPA and DHA reduce triglycerides by about 15% but do not affect fatness or other lipids (high‐certainty evidence). Eating more ALA (for example, by increasing walnuts or enriched margarine) probably makes little or no difference to all‐cause, cardiovascular or coronary deaths or coronary events but probably slightly reduces cardiovascular events and heart irregularities (moderate‐ or low‐certainty evidence). To prevent one person having a coronary event, 500 people would need to increase their ALA, 91 people to prevent one person having arrhythmia. There is little evidence of effects of eating fish. EPA and DHA reduce triglycerides. EPA, DHA and ALA may be slightly protective of some heart and circulatory diseases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Abdelhamid, AS, Brown, TJ, Brainard, JS, Biswas, P, Thorpe, GC, Moore, HJ, Deane, KHO, Summerbell, CD, Worthington, HV, Song, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD003177.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.143Z" }, { "id": "1ef8b61c-8587-4dc5-bf44-3dda4a8e1ff5", "pmid": "", "title": "Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five‐year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis. Objectives To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions. Search methods We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi‐randomised trials. The reference lists of relevant articles were also searched. Selection criteria All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded. Data collection and analysis Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author. Main results A total of 40 randomised or quasi‐randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials. For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights. Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects. Authors' conclusions There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials. Plain language summary Drug treatment for children with bedwetting (nocturnal enuresis) but not including the drug types desmopressin or tricyclics Bedwetting (nocturnal enuresis) is the involuntary loss of urine at night without an underlying organic disease as the cause. It can result in social problems, sibling teasing and lowered self esteem. It affects around 15% to 20% of five‐year olds, and up to 2% of adults. Many different types of drugs have been used to treat children with bed wetting. There is not enough reliable evidence to show that drugs other than desmopressin or tricyclics reduce bedwetting in children during treatment when used in isolation, despite their risk of unwanted side effects. In other Cochrane reviews, alarms triggered by wetting, desmopressin and tricyclic drugs have been shown to work during treatment. However, alarms have a more sustained effect than desmopressin and tricyclics after treatment has finished. The adverse effects of alarm therapy (tiredness and waking other members of the family) are relatively benign and self limiting compared with the adverse effects of drugs. One class of drugs (anticholinergic drugs) appears to improve the efficacy of other established treatments such as tricyclics, bedwetting alarms and desmopressin. The cost of treating children with bedwetting with alarm therapy or drugs may vary in different countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Deshpande, AV, Caldwell, PHY, Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.772Z" }, { "id": "1f034417-244d-419b-9f32-123c16a86ebd", "pmid": "", "title": "Nitrous oxide‐based techniques versus nitrous oxide‐free techniques for general anaesthesia", "imported": false, "abstract": "Abstract - Background Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise. Objectives To determine if nitrous oxide‐based anaesthesia results in similar outcomes to nitrous oxide‐free anaesthesia in adults undergoing surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites ( http://clinicaltrials.gov/ , http://controlled‐trials.com/ , and http://www.centerwatch.com ). Selection criteria We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol‐based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay. Data collection and analysis Two review authors independently assessed trial quality and extracted the outcome data. We used meta‐analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed‐effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random‐effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Main results We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta‐analyses showed that nitrous oxide‐based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta‐analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide‐based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low. Authors' conclusions Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review. Plain language summary Nitrous oxide (laughing gas)‐based techniques versus nitrous oxide‐free techniques for general anaesthesia Review question We reviewed the evidence about the harmful effects of nitrous oxide on people undergoing general anaesthesia. Background Nitrous oxide is an anaesthetic gas which has been used for more than 160 years for inducing anaesthesia and keeping patients anaesthetized throughout an operation. It is also known as 'laughing gas'. It is a colourless non‐flammable gas with a pleasant, faint sweet odour and taste. Its low cost and low toxicity have made nitrous oxide by far the most commonly used general anaesthetic. However, some studies have reported that adding nitrous oxide may lead to harmful effects. This has led many anaesthetists to question its continued routine use in a variety of operating room settings. We wanted to discover whether using nitrous oxide in general anaesthesia was better or worse than not using nitrous oxide. Study characteristics We examined the evidence available up to 17 October 2014. We included 35 trials involving 13,872 adult participants, all of whom were randomized to either receive nitrous oxide or no nitrous oxide. The trials covered a variety of situations during general anaesthesia. Key results We found that general anaesthesia with nitrous oxide increased the risk of pulmonary atelectasis (i.e. failure of the lungs to expand fully). When we restricted the results to the highest quality studies only, we found evidence that nitrous oxide may potentially increase the risk of pneumonia and severe nausea and vomiting. However, nitrous oxide had no effect on the patients' survival, the incidence of heart attack, stroke, wound infection, the occurrence of blood clots within veins, the length of hospital stay, or the length of intensive care unit stay. Quality of the evidence The evidence related to survival of participants was of moderate quality because we did not have enough data. The evidence related to some harmful effects, such as failure of the lungs to expand fully and heart attack, was of high quality, while for other harmful effects, such as stroke and the occurrence of blood clots within veins, the evidence was of moderate quality. For others, such as pneumonia, severe nausea and vomiting, and wound infection, the evidence was of low quality. The evidence related to the length of time spend in hospital was of moderate quality. Authors conclusions The avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Sun, R, Jia, WQ, Zhang, P, Yang, K, Tian, JH, Ma, B, Liu, Y, Jia, RH, Luo, XF, Kuriyama, A", "articleTypes": [], "doi": "10.1002/14651858.CD008984.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.784Z" }, { "id": "1f0e4748-d4d4-4df6-abb1-c8ff0230f540", "pmid": "", "title": "Honey for acute cough in children", "imported": false, "abstract": "Abstract - Background Cough causes concern for parents and is a major cause of outpatient visits. Cough can impact quality of life, cause anxiety, and affect sleep in children and their parents. Honey has been used to alleviate cough symptoms. This is an update of reviews previously published in 2014, 2012, and 2010. Objectives To evaluate the effectiveness of honey for acute cough in children in ambulatory settings. Search methods We searched CENTRAL (2018, Issue 2), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (2014 to 8 February 2018), Embase (2014 to 8 February 2018), CINAHL (2014 to 8 February 2018), EBSCO (2014 to 8 February 2018), Web of Science (2014 to 8 February 2018), and LILACS (2014 to 8 February 2018). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trial Registry Platform (WHO ICTRP) on 12 February 2018. The 2014 review included searches of AMED and CAB Abstracts, but these were not searched for this update due to lack of institutional access. Selection criteria Randomised controlled trials comparing honey alone, or in combination with antibiotics, versus no treatment, placebo, honey‐based cough syrup, or other over‐the‐counter cough medications for children aged 12 months to 18 years for acute cough in ambulatory settings. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included six randomised controlled trials involving 899 children; we added three studies (331 children) in this update. We assessed two studies as at high risk of performance and detection bias; three studies as at unclear risk of attrition bias; and three studies as at unclear risk of other bias. Studies compared honey with dextromethorphan, diphenhydramine, salbutamol, bromelin (an enzyme from the Bromeliaceae (pineapple) family), no treatment, and placebo. Five studies used 7‐point Likert scales to measure symptomatic relief of cough; one used an unclear 5‐point scale. In all studies, low score indicated better cough symptom relief. Using a 7‐point Likert scale, honey probably reduces cough frequency better than no treatment or placebo (no treatment: mean difference (MD) ‐1.05, 95% confidence interval (CI) ‐1.48 to ‐0.62; I² = 0%; 2 studies; 154 children; moderate‐certainty evidence; placebo: MD ‐1.62, 95% CI ‐3.02 to ‐0.22; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Honey may have a similar effect as dextromethorphan in reducing cough frequency (MD ‐0.07, 95% CI ‐1.07 to 0.94; I² = 87%; 2 studies; 149 children; low‐certainty evidence). Honey may be better than diphenhydramine in reducing cough frequency (MD ‐0.57, 95% CI ‐0.90 to ‐0.24; 1 study; 80 children; low‐certainty evidence). Giving honey for up to three days is probably more effective in relieving cough symptoms compared with placebo or salbutamol. Beyond three days honey probably had no advantage over salbutamol or placebo in reducing cough severity, bothersome cough, and impact of cough on sleep for parents and children (moderate‐certainty evidence). With a 5‐point cough scale, there was probably little or no difference between the effects of honey and bromelin mixed with honey in reducing cough frequency and severity. Adverse events included nervousness, insomnia, and hyperactivity, experienced by seven children (9.3%) treated with honey and two children (2.7%) treated with dextromethorphan (risk ratio (RR) 2.94, 95% Cl 0.74 to 11.71; I² = 0%; 2 studies; 149 children; low‐certainty evidence). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14, 95% Cl 0.01 to 2.68; 1 study; 80 children; low‐certainty evidence). When honey was compared with placebo, 34 children (12%) in the honey group and 13 (11%) in the placebo group complained of gastrointestinal symptoms (RR 1.91, 95% CI 1.12 to 3.24; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Four children who received salbutamol had rashes compared to one child in the honey group (RR 0.19, 95% CI 0.02 to 1.63; 1 study; 100 children; moderate‐certainty evidence). No adverse events were reported in the no‐treatment group. Authors' conclusions Honey probably relieves cough symptoms to a greater extent than no treatment, diphenhydramine, and placebo, but may make little or no difference compared to dextromethorphan. Honey probably reduces cough duration better than placebo and salbutamol. There was no strong evidence for or against using honey. Most of the children received treatment for one night, which is a limitation to the results of this review. There was no difference in occurrence of adverse events between the honey and control arms. Plain language summary Honey for acute cough in children Review question Can honey reduce cough symptoms caused by bacteria and viruses in children? Background Cough causes concern for parents and is a major reason for outpatient visits. Honey is believed to prevent growth of germs and reduce inflammation. Search date We searched databases to 8 February 2018 and trial registers to 12 February 2018. Study characteristics We included six small trials involving 899 children aged 12 months to 18 years conducted in Iran, Israel, the USA, Brazil, and Kenya. This update included three new trials conducted between 2007 and 2016 that involved 331 children. Study funding sources Two studies were supported by pharmaceutical manufacturers; one by a university research centre; one by the Honey Board of Israel and non‐government agencies; and one by USA National Honey Board. One study did not report funding sources. Key results We compared honey to over‐the‐counter cough preparations, bromelin (a pineapple enzyme) mixed with honey, fake treatment (placebo), and no treatment. Honey probably reduces cough symptoms more than placebo and salbutamol (a drug that opens lung airways) when given for up to three days. Honey is probably more effective at providing cough relief and reducing the impact of cough on children's sleep at night than no treatment. There may be little or no difference between the effects of honey and dextromethorphan (an ingredient in over‐the‐counter cough remedies) or honey and bromelin with honey on all cough symptoms. Honey may be better than diphenhydramine (an antihistamine) at relieving and reducing children's cough. The parents of seven children given honey and two given dextromethorphan reported side effects in their children, such as not falling asleep easily, restlessness, and becoming overexcited. The parents of three children in the diphenhydramine group reported that their children were often sleepy. The parents of nine children given salbutamol, seven given honey, and six given placebo reported diarrhoea. The parents of four children who received salbutamol and one child given honey reported rash. We found no evidence for or against the use of honey to relieve cough in children. Using honey for infants aged up to 12 months is not advised because of poor immunity against bacteria that may be present, which can cause paralysis. Most of the children received honey for just one night, which is a limitation to the results of this review. Quality of the evidence Overall, evidence quality was low to moderate. Some studies did not blind participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Oduwole, O; Udoh, EE; Oyo‐Ita, A; Meremikwu, MM", "articleTypes": [], "doi": "10.1002/14651858.CD007094.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "1f10ad83-38da-4329-8503-ea86003b047b", "pmid": "", "title": "N‐acetylcysteine as an adjuvant therapy for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) is one of the most common pathogens to establish and cause infection in human beings, affecting about 50% of the world's population. Prevalence may be as high as 83% in Latin American countries and as low as 17% in North America. Approximately 20% of infected people will manifest disease; people at high risk include those who live in low‐ and middle‐income countries with poor sanitary conditions, since the mechanism of transmission seems to be oral‐oral or faecal‐oral (mostly during infancy). There are several antibiotic regimens to treat the infection, but antibiotic resistance is growing around the world. New adjuvant drugs — such as probiotics, statins, curcumin, and N‐acetylcysteine (NAC) — are being tested to enhance eradication rates. N‐acetylcysteine can destabilise the biofilm structure; it also has synergic action with antibiotics, and bactericidal effects. In addition, NAC has antioxidant properties, and has a primary mucolytic effect by reducing the thickness of the gastric mucus layer, both of which may exert beneficial adjuvant effects on H pylori eradication. Objectives To assess the efficacy and safety of N‐acetylcysteine as an adjuvant therapy to antibiotics for Helicobacter pylori eradication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to April 2018), Embase (1988 to April 2018), CINAHL (1982 to April 2018), LILACS (1982 to April 2018), grey literature databases and trials registries. We handsearched the reference lists of relevant studies. We screened 726 articles and assessed 18 for eligibility. Selection criteria We included randomised controlled trials (RCTs) of any antibiotic regimen plus NAC, in adults infected with H pylori . To be included, trials had to use a control consisting of the same antibiotic regimen with or without placebo. Outcomes of interest were eradication rates, and gastrointestinal, toxic, and allergic adverse events. Reporting of the primary outcomes listed here was not an inclusion criterion for the review. Data collection and analysis Two review authors independently reviewed and extracted data and completed the 'Risk of bias' assessments. A third review author independently confirmed the 'Risk of bias' assessments. We used Review Manager 5 software for data analysis. We contacted study authors if there was missing information. Main results We included eight RCTs (with a total of 559 participants) in this review. The studies recruited outpatients aged between 17 and 76 years who were referred to endoscopy centres in several different countries. The certainty of evidence was reduced for most outcomes due to the poor methodological quality of included studies; issues mainly related to the generation of allocation sequence, allocation concealment, and blinding (this last domain related specifically to adverse outcomes). We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates, compared with the addition of placebo or no NAC (38.8% versus 49.1%, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.51 to 1.08; participants = 559; studies = eight; very low‐certainty evidence). A post‐hoc sensitivity analysis, in which we removed studies that tested antibiotic regimens no longer recommended in clinical practice, showed that the addition of NAC may improve eradication rates compared to control (27.2% versus 37.6%, RR 0.71, 95% CI 0.53 to 0.94; participants = 397; published studies = five). We are uncertain whether NAC is associated with a higher risk of gastrointestinal adverse events compared to control (23.9% versus 18.9%, RR 1.25, 95% CI 0.85 to 1.85; participants = 336; studies = five; very low‐certaintyevidence), or allergic adverse events (2% versus 0%, RR 2.98, 95% CI 0.32 to 27.74; participants = 336; studies = five; very low‐certainty evidence). There were no reports of toxic adverse events amongst included studies. Authors' conclusions We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates compared with the addition of placebo or no NAC. Due to the clinical, statistical and methodological heterogeneity found in included studies, and the uncertainty observed when analysing therapy subgroups, any possible beneficial effect of NAC should be regarded cautiously. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed, randomised clinical studies should be conducted, with good reporting standards and appropriate collection of efficacy and safety outcomes, especially for current recommended antibiotic regimens. Plain language summary N‐acetylcysteine taken with antibiotics for treatment of Helicobacter pylori infection Review question Is the addition of N‐acetylcysteine to antibiotics safe and does it improve cure rates for Helicobacter pylori infection? Background Helicobacter pylori ( H pylori ) is a bacteria that lives in the stomach and might cause several diseases such as gastric cancer, ulcer disease, and others. Colonisation occurs in about one‐half of the world's population and is more common in countries with poor sanitary conditions. People become infected by consuming contaminated water. The infection is treated using antibiotics and a drug which reduces acid production in the stomach. However, rates of antibiotic resistance are rising around the world, which is reducing the cure rates even with treatment. New medications are being tested to improve cure rates. One of these medications is N‐acetylcysteine (NAC). NAC is a drug that helps to dissolve mucus in respiratory diseases. It can be taken by mouth (orally) or injected into a vein (intravenous). NAC can destroy some mechanisms of survival of H pylori and could improve cure rates. Study characteristics We included eight studies (specifically, randomised controlled trials (RCTs)) with a total of 559 people aged between 17 and 76 years old. The evidence is current to April 2018. All studies recruited outpatients from endoscopy centres (centres that specialise in an examination done with a flexible tube with a camera that is inserted into stomach) in several countries. The antibiotic combinations tested were very different in the included studies, as were the doses of NAC (600 mg to 1800 mg per day). NAC was compared with placebo (dummy pill) or nothing. Key results We are uncertain whether the addition of NAC to antibiotics improves H pylori cure rates compared with the addition of placebo or no NAC. Any possible beneficial effect of NAC should be regarded cautiously because the included studies were very different and of low certainty, with some flaws that could have compromised their results and consequently, the results of this review. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed randomised clinical studies, with good reporting standards and appropriate collection of effectiveness and safety outcomes should be done, especially for current recommended antibiotic combinations. Quality of the evidence The overall certainty of the evidence for eradication rates ranged from very low to low. Five studies provided information on adverse events (side effects), and the certainy of evidence was very low. The included studies were poorly conducted and this reduced our confidence in the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fontes, LES; Martimbianco, ALC; Zanin, C; Riera, R", "articleTypes": [], "doi": "10.1002/14651858.CD012357.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "1f2057e0-b509-4b7b-be9f-43f3464115e6", "pmid": "", "title": "Acetylcholinesterase inhibitors for autistic spectrum disorders", "imported": false, "abstract": "Abstract - Background Autism spectrum disorder (autism) is a neurodevelopmental condition characterised by impairments in social communication and interaction, plus restricted, repetitive patterns of behaviour and interests. Whilst some people embrace autism as part of their identity, others struggle with their difficulties, and some seek treatment. There are no current interventions that result in complete reduction of autism features. Acetylcholine is a neurotransmitter for the cholinergic system and has a role in attention, novelty seeking, and memory. Low levels of acetylcholine have been investigated as a potential contributor to autism symptomatology. Donepezil, galantamine, and rivastigmine (commonly referred to as acetylcholinesterase inhibitors) all inhibit acetylcholinesterase, and have slightly different modes of action and biological availability, so their effectiveness and side‐effect profiles may vary. The effect of various acetylcholinesterase inhibitor on core autism features across the lifespan, and possible adverse effects, have not been thoroughly investigated. Objectives To evaluate the efficacy and harms of acetylcholinesterase inhibitors for people with the core features (social interaction, communication, and restrictive and repetitive behaviours) of autism. To assess the effects of acetylcholinesterase inhibitors on non‐core features of autism. Search methods In November 2022, we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the reference lists of included studies and relevant reviews, and contacted authors of relevant studies. Selection criteria Randomised controlled trials (RCTs), comparing acetylcholinesterase inhibitors (e.g. galantamine, donepezil, or rivastigmine) of varying doses, delivered orally or via transdermal patch, either as monotherapy or adjunct therapy, with placebo. People of any age, with a clinical diagnosis of autism were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were core features of autism and adverse effects. Secondary outcomes were language, irritability, hyperactivity, and general health and function. We used GRADE to assess certainty of evidence. Main results We included two RCTs (74 participants). One study was conducted in Iran, the second in the USA, although exact location in the USA is unclear. Galantamine plus risperidone versus placebo plus risperidone One study compared the effects of galantamine plus risperidone to placebo plus risperidone (40 participants, aged 4 years to 12 years). Primary and secondary outcomes of interest were measured postintervention, using subscales of the Aberrant Behavior Checklist (score 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed there was little to no difference between the two groups postintervention for social communication (mean difference (MD) ‐2.75, 95% confidence interval (CI) ‐5.88 to 0.38), and restricted and repetitive behaviour (MD ‐0.55, 95% CI ‐3.47 to 2.37). Overall autism features were not assessed. Adverse events may be higher in the galantamine plus risperidone group (75%) compared with the placebo plus risperidone group (35%): odds ratio 5.57, 95% CI 1.42 to 21.86, low‐certainty evidence. No serious adverse events were reported. Low‐certainty evidence showed a small difference in irritability (MD ‐3.50, 95% CI ‐6.39 to ‐0.61), with the galantamine plus risperidone group showing a greater decline on the irritability subscale than the placebo group postintervention. There was no evidence of a difference between the groups in hyperactivity postintervention (MD ‐5.20, 95% CI ‐10.51 to 0.11). General health and function were not assessed. Donepezil versus placebo One study compared donepezil to placebo (34 participants aged 8 years to 17 years). Primary outcomes of interest were measured postintervention, using subscales of the Modified Version of The Real Life Rating Scale (scored 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed no evidence of group differences immediately postintervention in overall autism features (MD 0.07, 95% CI ‐0.19 to 0.33), or in the autism symptom domains of social communication (MD ‐0.02, 95% CI ‐0.34 to 0.30), and restricted and repetitive behaviours (MD 0.04, 95% CI ‐0.27 to 0.35). Significant adverse events leading to study withdrawal in at least one participant was implied in the data analysis section, but not explicitly reported. The evidence is very uncertain about the effect of donepezil, compared to placebo, on the secondary outcomes of interest, including irritability (MD 1.08, 95% CI ‐0.41 to 2.57), hyperactivity (MD 2.60, 95% CI 0.50 to 4.70), and general health and function (MD 0.03, 95% CI ‐0.48 to 0.54) postintervention. Across all analyses within this comparison, we judged the evidence to be very low‐certainty due to high risk of bias, and very serious imprecision (results based on one small study with wide confidence intervals). The study narratively reported adverse events for the study as a whole, rather than by treatment group. Authors' conclusions Evidence about the effectiveness of acetylcholinesterase inhibitors as a medication to improve outcomes for autistic adults is lacking, and for autistic children is very uncertain. There is a need for more evidence of improvement in outcomes of relevance to clinical care, autistic people, and their families. There are a number of ongoing studies involving acetylcholinesterase inhibitors, and future updates of this review may add to the current evidence. Plain language summary Do acetylcholinesterase inhibitors reduce the core impairments associated with autism spectrum disorder Key messages At present, it is unclear whether acetylcholinesterase inhibitors are effective in treating the core features of autism. This is because very few studies have been carried out. The two we found were small, and did not report the outcomes very well. However, there are a number of ongoing studies in this area. What is autism spectrum disorder? Autism spectrum disorder (autism) is a condition that affects the way a person thinks, feels, interacts with others, and experiences their environment. The core behaviours of autism include reduced sharing of interests, difficulties with nonverbal communication (for example, little eye contact), difficulties forming and maintaining relationships and restricted, or repetitive behaviours or interests. These behaviours can vary in severity, but they still interfere with the person's daily functioning and participation in activities. Medicines, called acetylcholinesterase inhibitors (chemicals that block the normal breakdown of nerve transmitters), have been used to treat Alzheimer's disease (for example, donepezil and galantamine). Recently, it has been suggested that they may also decrease some of the difficulties seen in people with autism. What did we want to find out? Do acetylcholinesterase inhibitors, alone or with other medicines, reduce the core features of autism (social communication and interaction, restrictive and repetitive behaviours) compared with a placebo (a dummy pill). We also wanted to find out if acetylcholinesterase inhibitors were associated with any unwanted side effects. What did we do? We searched for studies that explored whether there were any differences in autistic people's behaviours after they had taken acetylcholinesterase inhibitors compared to people who had taken placebo pills. We compared and summarised the results of the studies, and rated our confidence in the evidence, based on things, such how big and well carried out the studies were. What did we find? We found two relevant studies. One study looked at whether an acetylcholinesterase inhibitor called galantamine, combined with a drug called risperidone (traditionally used to treat psychosis), was better than a placebo combined with risperidone. The study included 40 children, aged between 4 and 12 years, with a diagnosis of autism. it took place over 10 weeks in Iran. A second study compared an acetylcholinesterase inhibitor called donepezil with placebo. It included 34 children, aged between 8 and 17 years, with a diagnosis of autism. It was carried out in the USA. All studies involved children attending outpatient clinics. What are the main results of the review? It is unclear if acetylcholinesterase inhibitors make any difference to the core features of autism in children or adults. Galantamine may cause little to no difference in social interaction and communication skills and irritability levels in children with autism after 10 weeks of treatment. There is no evidence that galantamine reduces difficulties associated with restricted or repetitive behaviours or hyperactivity. Galantamine may also cause some side effects, including nervousness, drowsiness, increased appetite, and tremor. There is no evidence that donepezil reduces difficulties associated with the core features of autism or associated secondary problems. We were unable to find out whether it causes unwanted side effects in children with autism, because the study did not report the results completely. What are the limitations of the evidence? We have little confidence in the evidence for using this medicine to treat problems associated with autism, because the evidence comes from only two small studies that were not very well carried out or reported. Each study looked at a different type of acetylcholinesterase inhibitor and delivered the medicine differently. They did not provide information about all the issues we were interested in, and they measured the side effects differently. If more studies are included in future reviews, these results may change. How up‐to‐date is this review? The evidence in this review is current to November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ure, A; Cox, GR; Haslam, R; Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD013851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "1f26f73c-5b63-45cb-b518-cad8b1ef9e1d", "pmid": "", "title": "Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications", "imported": false, "abstract": "Abstract - Background Radiotherapy as part of head and neck cancer treatment leaves patients requiring much dental rehabilitation in a compromised environment that is difficult for the patient and the dental team to manage. Objectives To assess the effects of maintaining the patient's natural dentition during radiotherapy in comparison to extracting teeth before radiotherapy in areas that are difficult to access by the patient and the dentist, should reduction in mouth opening occur after radiotherapy to the jaws. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 22 November 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 22 November 2012), EMBASE via OVID (1980 to 22 November 2012), CANCERLIT via PubMed (1950 to 22 November 2012), CINAHL via EBSCO (1980 to 22 November 2012) and reference lists of articles. We advertised for currently ongoing studies via the Cochrane Oral Health Group website and the Cochrane Oral Health Group Twitter feed. Selection criteria Randomised controlled trials comparing extraction of teeth prior to radiotherapy with leaving teeth in situ during radiotherapy to the jaws. Data collection and analysis Three review authors independently assessed the results of the searches for inclusion in the review. Main results No randomised controlled trials were found. Authors' conclusions There are no randomised controlled trials to assess the effect of extracting teeth prior to radiotherapy compared to leaving teeth in the mouth during radiotherapy to the jaws. Plain language summary Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications This review aimed to assess if removing the back teeth before radiotherapy would mean that patients had fewer tooth‐related problems after radiotherapy as part of head and neck cancer treatment, when compared to not removing the teeth. Electronic and handsearching found 357 titles of studies but none of them met the inclusion criteria for the review. There is currently no evidence available to answer this complex question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Eliyas, S, Al‐Khayatt, A, Porter, RWJ, Briggs, P", "articleTypes": [], "doi": "10.1002/14651858.CD008857.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.085Z" }, { "id": "1f2fa686-7cd2-4ec7-9c77-12eed0c25789", "pmid": "", "title": "Sumatriptan (oral route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Objectives To determine the efficacy and tolerability of oral sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using oral sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Sixty‐one studies (37,250 participants) compared oral sumatriptan with placebo or an active comparator. Most of the data were for the 50 mg and 100 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 50 mg versus placebo the NNTs were 6.1, 7.5, and 4.0 for pain‐free at two hours and headache relief at one and two hours, respectively. NNTs for sustained pain‐free and sustained headache relief during the 24 hours postdose were 9.5 and 6.0, respectively. For sumatriptan 100 mg versus placebo the NNTs were 4.7, 6.8, 3.5, 6.5, and 5.2, respectively, for the same outcomes. Results for the 25 mg dose were similar to the 50 mg dose, while sumatriptan 100 mg was significantly better than 50 mg for pain‐free and headache relief at two hours, and for sustained pain‐free during 24 hours. Treating early, during the mild pain phase, gave significantly better NNTs for pain‐free at two hours and sustained pain‐free during 24 hours than did treating established attacks with moderate or severe pain intensity. Relief of associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than with placebo. For the most part, adverse events were transient and mild and were more common with the sumatriptan than with placebo, with a clear dose response relationship (25 mg to 100 mg). Sumatriptan was compared directly with a number of active treatments, including other triptans, paracetamol (acetaminophen), acetylsalicylic acid, non‐steroidal anti‐inflammatory drugs (NSAIDs), and ergotamine combinations. Authors' conclusions Oral sumatriptan is effective as an abortive treatment for migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (oral route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is widely available as an oral tablet. This review found that a single dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in about 3 in 10 people (32%) taking sumatriptan 100 mg, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 6 in 10 people (61%) taking sumatriptan 100 mg, compared with about 3 in 10 (32%) taking placebo. Almost a quarter (24%) of people taking sumatriptan 100 mg had freedom from pain at two hours which was sustained during 24 hours without the use of rescue medication, compared with fewer than 1 in 10 (8%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events were mostly of short duration and mild or moderate in severity, and were experienced by about 4 in 10 (43%) of people taking sumatriptan 100 mg, and by 2 in 10 (23%) taking placebo. The 50 mg dose had slightly lower efficacy, but was associated with fewer adverse events. Treating attacks while pain was still mild was more effective than treating established attacks with moderate or severe pain intensity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008615.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "1f31a36e-f5a7-4e7a-93aa-877d8d73455d", "pmid": "", "title": "Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years", "imported": false, "abstract": "Abstract - Background Extensive evidence exists showing analgesic effects of sweet solutions for newborns and infants. It is less certain if the same analgesic effects exist for children one year to 16 years of age. This is an updated version of the original Cochrane review published in Issue 10, 2011 (Harrison 2011) titled Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. Objectives To determine the efficacy of sweet tasting solutions or substances for reducing needle‐related procedural pain in children beyond one year of age. Search methods Searches were run to the end of June 2014. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, the NHS Economic Evaluation Database, MEDLINE, EMBASE, PsycINFO, and ACP Journal Club (all via OvidSP), and CINAH (via EBSCOhost). We applied no language restrictions. Selection criteria Published or unpublished randomised controlled trials (RCT) in which children aged one year to 16 years, received a sweet tasting solution or substance for needle‐related procedural pain. Control conditions included water, non‐sweet tasting substances, pacifier, distraction, positioning/containment, breastfeeding, or no treatment. Data collection and analysis Outcome measures included crying duration, composite pain scores, physiological or behavioral pain indicators, self‐report of pain or parental or healthcare professional‐report of the child's pain. We reported mean differences (MD), weighted mean difference (WMD), or standardized mean difference (SMD) with 95% confidence intervals (CI) using fixed‐effect or random‐effects models as appropriate for continuous outcome measures. We reported risk ratio (RR), risk difference (RD), and the number needed to treat to benefit (NNTB) for dichotomous outcomes. We used the I 2 statistic to assess between‐study heterogeneity. Main results We included one unpublished and seven published studies (total of 808 participants); four more studies and 478 more participants than the 2011 review. Six trials included young children aged one to four years receiving sucrose or candy lollypops for immunisation pain compared with water or no treatment. Usual care included topical anaesthetics, upright parental holding, and distraction. All studies were well designed blinded RCTs, however, five of the six studies had a high risk of bias based on small sample sizes. Two studies included school‐aged children receiving sweet or unsweetened chewing gum before, or before and during, immunisation and blood collection. Both studies, conducted by the same author, had a high risk of bias based on small sample sizes. Results for the toddlers/pre‐school children were conflicting. Duration of cry, using a random‐effects model, was not significantly reduced by sweet taste (six trials, 520 children, WMD ‐15 seconds, 95% CI ‐54 to 24, I 2 = 94%). Composite pain score at time of first needle was reported in four studies (n = 121 children). The scores were not significantly different between the sucrose and control group (SMD ‐0.26, 95% CI ‐1.27 to 0.75, I 2 = 86%). A Children's Hospital of Eastern Ontario Pain Scale score > 4 was significantly less common in the sucrose group compared to the control group in one study (n = 472, RR 0.55, 95% CI 0.45 to 0.67; RD ‐0.29, 95% CI ‐0.37 to ‐0.20; NNTB 3, 95% CI 3 to 5; tests for heterogeneity not applicable. For school‐aged children, chewing sweet gum before needle‐related painful procedures (two studies, n = 111 children) or during the procedures (two studies, n = 103 children) did not significantly reduce pain scores. A comparison of the Faces Pain Scale scores in children chewing sweet gum before the procedures compared with scores of children chewing unsweetened gum revealed a WMD of ‐0.15 (95% CI ‐0.61 to 0.30). Similar results were found when comparing the chewing of sweet gum with unsweetened gum during the procedure (WMD 0.23, 95% CI ‐0.28 to 0.74). The Colored Analogue Scale for children chewing sweet gum compared to unsweetened gum before the procedure was not significantly different (WMD 0.24 (‐0.69 to 1.18)) nor was it different when children chewed the gum during the procedure (WMD 0.86 (95% CI ‐0.12 to 1.83)). There was no heterogeneity for any of these analyses in school‐aged children (I 2 = 0%). Authors' conclusions Based on the eight studies included in this systematic review update, two of which were subgroups of small numbers of eligible toddlers from larger studies, and three of which were pilot RCTs with small numbers of participants, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children between one and four years of age. Further rigorously conducted, adequately powered RCTs are warranted in this population. Based on the two studies by the same author, there was no evidence of analgesic effects of sweet taste in school‐aged children. As there are other effective evidence‐based strategies available to use in this age group, further trials are not warranted. Despite the addition of four studies in this review, conclusions have not changed since the last version of the review. Plain language summary Sweet taste to ease injection needle pain in children aged one to 16 years This is an updated version of the original Cochrane review published in Issue 10, 2011: Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. We re‐ran the search in October 2014. Review question: Do sweet tasting solutions reduce pain during needles in children aged from one to 16 years, compared to no treatment, water, other non‐sweet solutions, or other interventions such as non‐nutritive sucking (babies) or sweet foods or chewing gum (children), topical anaesthetics, music, and distraction? Background: Small amounts of sweet tasting sugar solutions given orally to babies before and during painful needles significantly reduces distress. However it was not known if the same pain‐reducing effects of sweet solutions occurred in children older than one year of age. We therefore examined studies looking at pain‐reducing effects of sweet solutions such as sucrose or glucose for painful needle procedures in children aged one to 16 years. Search date: We searched the literature for published and unpublished studies up to October 2014. Study characteristics : We found six studies focused on young children aged one to four years; two of these studies were included in the original review and four were new studies. The two studies included in the original review used a low concentration of sucrose, just 12%, which is not considered sweet enough for the pain reducing effects. Three of the four new studies were small pilot studies, conducted to inform full trials, and only one study of sweet solutions in young children included large numbers of children. When we compared results of all six studies, only two showed that sugar water (sucrose) reduced pain during injections. However, the four studies that showed no effect all included small numbers of children, therefore they were not considered large enough to detect significant differences in pain. Further well conducted trials with large enough numbers of young children are needed to work out if sweet taste effectively reduces their pain and distress during needles. For older school‐aged children, there were two studies published by the same author, both of which were included in the original review. Neither study showed that sweet taste helped to reduce pain. As other studies show that strategies such as distraction and topical anaesthetics can effectively reduce needle pain in school‐aged children, further studies of sweet taste for pain management in school‐aged children are not warranted. Study funding sources : Of the six studies including young children, two did not acknowledge receipt of research funding. For the remaining four: a state‐wide nursing fund supported two of the pilot studies, an internal research institute provided support for the remaining pilot study and another study was supported in part by a Maternal and Child Health grant. The two studies including school‐aged children, conducted by the same author, were supported by a grant from the Canadian Institutes of Health Research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Harrison, D, Yamada, J, Adams‐Webber, T, Ohlsson, A, Beyene, J, Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD008408.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.061Z" }, { "id": "1f3f5a2c-d1e3-4b5c-9948-9785a6225864", "pmid": "", "title": "Interventions for managing taste disturbances", "imported": false, "abstract": "Abstract - Background The sense of taste is very much essential to the overall health of an individual. It is a necessary component to enjoy one's food, which in turn provides nutrition to an individual. Any disturbance in taste perception can hamper quality of life in such patients by influencing their appetite, body weight and psychological well‐being. Taste disorders have been treated using different modalities of treatment and there is no consensus for the best intervention. Hence this Cochrane Review was undertaken. This is an update of the Cochrane Review first published in November 2014. Objectives To assess the effects of interventions for the management of patients with taste disturbances. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 4 July 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017 Issue 6) in the Cochrane Library (searched 4 July 2017); MEDLINE Ovid (1946 to 4 July 2017); Embase Ovid (1980 to 4 July 2017); CINAHL EBSCO (1937 to 4 July 2017); and AMED Ovid (1985 to 4 July 2017). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for trials. Abstracts from scientific meetings and conferences were searched on 25 September 2017. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included all randomised controlled trials (RCTs) comparing any pharmacological agent with a control intervention or any non‐pharmacological agent with a control intervention. We also included cross‐over trials in the review. Data collection and analysis Two pairs of review authors independently, and in duplicate, assessed the quality of trials and extracted data. Wherever possible, we contacted trial authors for additional information. We collected adverse events information from the trials. Main results We included 10 trials (581 participants), nine of which we were able to include in the quantitative analyses (566 participants). We assessed three trials (30%) as having a low risk of bias, four trials (40%) at high risk of bias and three trials (30%) as having an unclear risk of bias. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Of these, nine trials with 544 people compared zinc supplements to placebo for patients with taste disorders. The participants in two trials were children and adolescents with respective mean ages of 10 and 11.2 years and the other seven trials had adult participants. Out of these nine, two trials assessed the patient‐reported outcome for improvement in taste acuity using zinc supplements (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.94 to 2.09; 119 participants, very low‐quality evidence). We meta‐analysed for taste acuity improvement using objective outcome (continuous data) in idiopathic and zinc‐deficient taste disorder patients (standardised mean difference (SMD) 0.44, 95% CI 0.23 to 0.65; 366 participants, three trials, very low‐quality evidence). We also analysed one cross‐over trial separately using the first half of the results for taste detection (mean difference (MD) 2.50, 95% CI 0.93 to 4.07; 14 participants, very low‐quality evidence), and taste recognition (MD 3.00, 95% CI 0.66 to 5.34; 14 participants, very low‐quality evidence). We meta‐analysed taste acuity improvement using objective outcome (dichotomous data) in idiopathic and zinc‐deficient taste disorder patients (RR 1.42, 95% 1.09 to 1.84; 292 participants, two trials, very low‐quality evidence). Out of the nine trials using zinc supplementation, four reported adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase, and minor increase in blood triglycerides. One trial tested taste discrimination using acupuncture (MD 2.80, 95% CI ‐1.18 to 6.78; 37 participants, very low‐quality evidence). No adverse events were reported in the acupuncture trial. None of the included trials could be included in the meta‐analysis for health‐related quality of life in taste disorder patients. Authors' conclusions We found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders. We did not find any evidence to conclude the role of zinc supplements for improving taste discrimination, or any evidence addressing health‐related quality of life due to taste disorders. We found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste). We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. Plain language summary Interventions for managing taste disturbances What is the aim of this review? The aim of this Cochrane Review was to find out what is the best method for the management of zinc‐deficient/idiopathic (of unknown cause) taste disorders and taste disorders secondary to chronic renal failure in children and adults. Key messages Giving zinc supplements or acupuncture may have some benefit in treating taste disorders. However, we still need more high‐quality studies to ascertain the role of zinc supplements and acupuncture in treating taste disorders. What was studied in the review? The sense of taste is essential to the health and psychological well‐being of an individual. Taste disorders can range from lack of taste, to distortion of taste, to reduced ability to taste. Any disorder in taste perception can lead to conditions like malnutrition and consumption of poisonous food substances. The cause may be due to disease, drugs, radiation treatment, or ageing; or it may result from unknown causes. Various treatment methods have been used to improve taste sensation. These include the use of zinc compounds, pilocarpine, alpha lipoic acid, transcranial magnetic stimulation, ginkgo biloba and acupuncture. What are the main results of the review? We collected and analysed all relevant studies to answer this question and found 10 trials in which a total of 581 subjects received different treatments. Nine trials assessed the benefits of zinc compounds and one trial assessed the effects of acupuncture. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Two trials were from Germany, three from Japan, two from the UK, and three from the US. These studies compared zinc with placebo or acupuncture with sham procedure for patients with taste disorders. Two were government funded, three were privately funded, two were funded by a pharmaceutical company and three trials did not mention funding details. When patients with taste disorders are given zinc, compared to placebo: ‐ we found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders;
 ‐ zinc supplementation showed adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase and minor increase in blood triglycerides;
 ‐ no studies were found that looked at improvement in taste discrimination or quality of life. When patients with taste disorders are given acupuncture, compared to sham procedure: ‐ we found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste);
 ‐ acupuncture trial did not show adverse events;
 ‐ no studies were found that looked at improvement in taste acuity or quality of life. We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. How up‐to‐date is this review? We searched for studies that had been published up to 4 July 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kumbargere Nagraj, S; George, RP; Shetty, N; Levenson, D; Ferraiolo, DM; Shrestha, A", "articleTypes": [], "doi": "10.1002/14651858.CD010470.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "1f532ac1-d32b-4d4a-9f9f-60a017810385", "pmid": "", "title": "Local interventions for the management of alveolar osteitis (dry socket)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Daly, BJM, Sharif, MO, Jones, K, Worthington, HV, Beattie, A", "articleTypes": [], "doi": "10.1002/14651858.CD006968.pub3 AB - Abstract - Background Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012. Objectives To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction. Search methods An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies. Selection criteria We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews. Data collection and analysis We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random‐effects models. For some of the split‐mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence. Main results We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate‐certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively. Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate‐certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low‐certainty evidence). The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low‐certainty evidence). A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) ‐1.40, 95% CI ‐1.75 to ‐1.04; P < 0.00001; 2 studies, 80 participants; very low‐certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects. Authors' conclusions Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate‐certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. Plain language summary What treatments can be used to prevent and treat alveolar osteitis (dry socket)? Key messages ‐ Rinsing with chlorhexidine mouthwash before a dental extraction or beginning 24 hours after may help to prevent a dry socket.
‐ Placing a chlorhexidine gel directly into the socket immediately after tooth extraction may help to prevent a dry socket.
‐ Chlorhexidine rinses cause some minor adverse (unwanted) effects; chlorhexidine intrasocket gels do not appear to cause adverse effects.
‐ Alvogyl reduces the pain of a dry socket when compared to zinc oxide eugenol, but the evidence for this is very uncertain.
‐ Alvogyl does not appear to cause unwanted effects.
‐ We need future studies to strengthen the evidence and investigate the best ways to prevent and treat dry socket in all teeth. What is dry socket? Dry socket is a painful condition that sometimes arises after a tooth has been extracted and is more likely to occur following extraction of wisdom teeth in the lower jaw. What causes dry socket? It is thought to be linked to the loss of some or all of the blood clot that forms at the bottom of a tooth socket after a tooth is taken out. How can we prevent dry socket? An option for prevention of dry socket is to reduce debris and the bacterial load in the mouth, though dry socket is not bacterial in origin. People with poor oral hygiene (food debris and plaque) are at greater risk of dry socket. Improved oral hygiene and rinsing before a dental extraction or beginning 24 hours after may reduce the likelihood of dry socket. How can we treat dry socket ? Options for treating dry socket largely focus on reducing pain locally around the tooth extraction site by placing an obtundent (a soothing medicated dressing). What did we want to find out ? We wanted to find out if antiseptic rinses, gels, or healing patches could help to prevent dry socket. We also wanted to find out if placing a medicated dressing could treat a dry socket and whether any unwanted side effects were produced. What did we do? We searched for studies that compared antiseptic rinses or intrasocket gels with a placebo (dummy) rinse or nothing and a placebo (dummy) intrasocket gel or nothing. To find the best way to treat dry socket we searched for studies that compared different soothing agents with a placebo (dummy) with other soothing agents or with nothing. We compared the results of the studies and summarised the findings. We made an assessment of our confidence in the evidence based on the design of the study and the number of patients recruited. What did we find? We identified 49 trials; 39 trials (6219 participants) investigated prevention of dry socket and 10 trials (552 participants) investigated the treatment of dry socket. We found that: ‐ rinsing both before and after tooth extraction (commencing 24 hours after extraction) with chlorhexidine gluconate rinse (at 0.12% and 0.2% strength) probably results in a reduction in dry socket;
‐ placing chlorhexidine gel (0.2% strength) in the socket of an extracted tooth probably results in a reduction in dry socket;
‐ chlorhexidine rinses and gels are equally effective at reducing dry socket, but the evidence for this comparison is very uncertain;
‐ chlorhexidine rinses produced some minor unwanted effects; chlorhexidine intrasocket gels appeared to produce no unwanted effects;
‐ there was a small amount of evidence of very low certainty from two studies that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. This evidence relates to the old formulation of Alvogyl which is no longer available. It should be noted that the formulation of Alvogyl has changed, it is now called Alveogyl. Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. What are the limitations of the evidence? The main limitation of the evidence are that studies: ‐ reported mostly on tooth extractions involving lower wisdom teeth;
‐ were undertaken in ways that introduced errors in the conduct of the study leading to errors in the results; and
‐ produced imprecise results when they were combined. Due to these errors we have some confidence in the results relating to chlorhexidine rinses and gels but further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. How up to date is this evidence? The search for existing studies was completed by 28 September 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.748Z" }, { "id": "1f5f447b-e7c1-4bb9-9b5b-d91066ff1c15", "pmid": "", "title": "Evaluation of a Nutritional Intervention With Dietary Supplements in People Who Have Recently Lost Weight: Effects on Body Composition, Emotional Health, and Gut Microbiota", "imported": false, "abstract": "This study aims to evaluate the effects of a 12-week nutritional intervention with dietary supplements on individuals who have experienced significant weight loss following the use of GLP-1 receptor agonists or similar weight-loss treatments. The study will investigate whether the combined supplementation protocol can improve body composition, emotional well-being, and gut microbiota diversity after discontinuation of pharmacological treatment.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.242Z" }, { "id": "1f9e4b2e-9dc3-4b6c-9357-68327bc97aff", "pmid": "", "title": "Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Harmful alcohol use is defined as unhealthy alcohol use that results in adverse physical, psychological, social, or societal consequences and is among the leading risk factors for disease, disability and premature mortality globally. The burden of harmful alcohol use is increasing in low‐ and middle‐income countries (LMICs) and there remains a large unmet need for indicated prevention and treatment interventions to reduce harmful alcohol use in these settings. Evidence regarding which interventions are effective and feasible for addressing harmful and other patterns of unhealthy alcohol use in LMICs is limited, which contributes to this gap in services. Objectives To assess the efficacy and safety of psychosocial and pharmacologic treatment and indicated prevention interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs. Search methods We searched for randomized controlled trials (RCTs) indexed in the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, the Cochrane Clinical Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, and the Latin American and Caribbean Health Sciences Literature (LILACS) through 12 December 2021. We searched clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, Web of Science, and Opengrey database to identify unpublished or ongoing studies. We searched the reference lists of included studies and relevant review articles for eligible studies. Selection criteria All RCTs comparing an indicated prevention or treatment intervention (pharmacologic or psychosocial) versus a control condition for people with harmful alcohol use in LMICs were included. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 66 RCTs with 17,626 participants. Sixty‐two of these trials contributed to the meta‐analysis. Sixty‐three studies were conducted in middle‐income countries (MICs), and the remaining three studies were conducted in low‐income countries (LICs). Twenty‐five trials exclusively enrolled participants with alcohol use disorder. The remaining 51 trials enrolled participants with harmful alcohol use, some of which included both cases of alcohol use disorder and people reporting hazardous alcohol use patterns that did not meet criteria for disorder. Fifty‐two RCTs assessed the efficacy of psychosocial interventions; 27 were brief interventions primarily based on motivational interviewing and were compared to brief advice, information, or assessment only. We are uncertain whether a reduction in harmful alcohol use is attributable to brief interventions given the high levels of heterogeneity among included studies (Studies reporting continuous outcomes: Tau² = 0.15, Q =139.64, df =16, P<.001, I² = 89%, 3913 participants, 17 trials, very low certainty; Studies reporting dichotomous outcomes: Tau²=0.18, Q=58.26, df=3, P<.001, I² =95%, 1349 participants, 4 trials, very low certainty). The other types of psychosocial interventions included a range of therapeutic approaches such as behavioral risk reduction, cognitive‐behavioral therapy, contingency management, rational emotive therapy, and relapse prevention. These interventions were most commonly compared to usual care involving varying combinations of psychoeducation, counseling, and pharmacotherapy. We are uncertain whether a reduction in harmful alcohol use is attributable to psychosocial treatments due to high levels of heterogeneity among included studies (Heterogeneity: Tau² = 1.15; Q = 444.32, df = 11, P<.001; I²=98%, 2106 participants, 12 trials, very low certainty). Eight trials compared combined pharmacologic and psychosocial interventions with placebo, psychosocial intervention alone, or another pharmacologic treatment. The active pharmacologic study conditions included disulfiram, naltrexone, ondansetron, or topiramate. The psychosocial components of these interventions included counseling, encouragement to attend Alcoholics Anonymous, motivational interviewing, brief cognitive‐behavioral therapy, or other psychotherapy (not specified). Analysis of studies comparing a combined pharmacologic and psychosocial intervention to psychosocial intervention alone found that the combined approach may be associated with a greater reduction in harmful alcohol use (standardized mean difference (standardized mean difference (SMD))=‐0.43, 95% confidence interval (CI): ‐0.61 to ‐0.24; 475 participants; 4 trials; low certainty). Four trials compared pharmacologic intervention alone with placebo and three with another pharmacotherapy. Drugs assessed were: acamprosate, amitriptyline, baclofen disulfiram, gabapentin, mirtazapine, and naltrexone. None of these trials evaluated the primary clinical outcome of interest, harmful alcohol use. Thirty‐one trials reported rates of retention in the intervention. Meta‐analyses revealed that rates of retention between study conditions did not differ in any of the comparisons (pharmacologic risk ratio (RR) = 1.13, 95% CI: 0.89 to 1.44, 247 participants, 3 trials, low certainty; pharmacologic in addition to psychosocial intervention: RR = 1.15, 95% CI: 0.95 to 1.40, 363 participants, 3 trials, moderate certainty). Due to high levels of heterogeneity, we did not calculate pooled estimates comparing retention in brief (Heterogeneity: Tau² = 0.00; Q = 172.59, df = 11, P<.001; I 2 = 94%; 5380 participants; 12 trials, very low certainty) or other psychosocial interventions (Heterogeneity: Tau² = 0.01; Q = 34.07, df = 8, P<.001; I 2 = 77%; 1664 participants; 9 trials, very low certainty). Two pharmacologic trials and three combined pharmacologic and psychosocial trials reported on side effects. These studies found more side effects attributable to amitriptyline relative to mirtazapine, naltrexone and topiramate relative to placebo, yet no differences in side effects between placebo and either acamprosate or ondansetron. Across all intervention types there was substantial risk of bias. Primary threats to validity included lack of blinding and differential/high rates of attrition. Authors' conclusions In LMICs there is low‐certainty evidence supporting the efficacy of combined psychosocial and pharmacologic interventions on reducing harmful alcohol use relative to psychosocial interventions alone. There is insufficient evidence to determine the efficacy of pharmacologic or psychosocial interventions on reducing harmful alcohol use largely due to the substantial heterogeneity in outcomes, comparisons, and interventions that precluded pooling of these data in meta‐analyses. The majority of studies are brief interventions, primarily among men, and using measures that have not been validated in the target population. Confidence in these results is reduced by the risk of bias and significant heterogeneity among studies as well as the heterogeneity of results on different outcome measures within studies. More evidence on the efficacy of pharmacologic interventions, specific types of psychosocial interventions are needed to increase the certainty of these results. Plain language summary Interventions to reduce harmful alcohol use in low‐ and middle‐income countries Why is this review important? Harmful alcohol use is one of the main contributors to the global burden of disease. In low‐ and middle‐income countries, harmful alcohol use is increasing. However, services to prevent and treat harmful alcohol use are limited. One contributor to the lack of available services is the limited information about which intervention approaches are effective in reducing harmful alcohol use and whether these approaches are feasible and acceptable in low‐resource settings. In order to prevent the physical, psychological, and societal burden of harmful alcohol use, it is important that effective interventions are available to reduce alcohol‐related harm. What is the goal of this review? The goal of this review is to summarize evidence on whether psychosocial and pharmacologic interventions are able to reduce harmful alcohol use in low‐ and middle‐income countries. We also aim to evaluate the safety of treatments and how many people remain in treatment until its completion. What does the research say? We identified 66 randomized controlled trials that evaluated the effect of interventions on reducing harmful alcohol use. Most of these studies assessed psychosocial interventions (n = 52 studies), six assessed pharmacologic interventions alone, and eight assessed combined pharmacologic and psychosocial interventions. The majority of included trials were funded by government agencies (36 trials) followed by multiple public and private funders (8 trials) or private foundations (5 trials). Seventeen trials did not report the funding source. We are uncertain whether brief psychosocial interventions and other psychosocial interventions reduce harmful alcohol use. Combined pharmacologic and psychosocial interventions may reduce harmful alcohol use relative to psychosocial interventions combined with placebo, yet the certainty of the evidence has been assessed as low. No studies were found that looked at the effect of pharmacologic interventions alone on harmful alcohol use. We did not find evidence that rates of retention differed between study conditions for any of the intervention types. Certainty of evidence: The certainty of evidence on the effect of brief and other psychosocial interventions on harmful alcohol use was very low due to lack of masking, differential attrition and missing data, selective outcome reporting, high heterogeneity, and differences in patient populations. The certainty of evidence on the effect of combined pharmacologic and psychosocial interventions on harmful alcohol use was low due to lack of blinding, incomplete outcome data, and heterogeneity in the pharmacologic interventions under investigation. No studies evaluated the effect of pharmacologic interventions alone on harmful alcohol use. The evidence is current to 12 December 2021. What are the next steps? Future research on interventions to reduce harmful alcohol use is needed to address some of the limitations described in this review. Studies evaluating similar interventions across studies and contexts are needed to improve generalizability and understand the necessary characteristics of and conditions for effective intervention. Studies must utilize measurement tools that are valid in the population they are studying. Lastly, studies must be designed to reduce the risk of bias leading to the high degree of uncertainty in the results reported in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, MC, Kane, J, Alto, M, Giusto, A, Lovero, K, Stockton, M, McClendon, J, Nicholson, T, Wainberg, ML., Johnson, RM, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013350.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.114Z" }, { "id": "1fd1c917-c224-48bd-89ff-bb14baf53402", "pmid": "", "title": "Zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance", "imported": false, "abstract": "Abstract - Background Diabetes is associated with long‐term damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity. Insulin resistance is a fundamental aspect of the aetiology of type 2 diabetes. Insulin resistance has been shown to be associated with atherosclerosis, dyslipidaemia, glucose intolerance, hyperuricaemia, hypertension and polycystic ovary syndrome. The mineral zinc plays a key role in the synthesis and action of insulin, both physiologically and in diabetes mellitus. Zinc seems to stimulate insulin action and insulin receptor tyrosine kinase activity. Objectives To assess the effects of zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance. Search methods This review is an update of a previous Cochrane systematic review published in 2007. We searched the Cochrane Library (2015, Issue 3), MEDLINE, EMBASE, LILACS and the ICTRP trial register (from inception to March 2015). There were no language restrictions. We conducted citation searches and screened reference lists of included studies. Selection criteria We included studies if they had a randomised or quasi‐randomised design and if they investigated zinc supplementation compared with placebo or no intervention in adults with insulin resistance living in the community. Data collection and analysis Two review authors selected relevant trials, assessed risk of bias and extracted data. Main results We included three trials with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Risk of bias was unclear for most studies regarding selection bias (random sequence generation, allocation concealment) and detection bias (blinding of outcome assessment). No study reported on our key outcome measures (incidence of type 2 diabetes mellitus, adverse events, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). Evaluation of insulin resistance as measured by the Homeostasis Model Assessment of Insulin Resistance (HOMA‐IR) showed neutral effects when comparing zinc supplementation with control (two trials; 114 participants). There were neutral effects for trials comparing zinc supplementation with placebo for total cholesterol, high‐density lipoprotein (HDL) cholesterol, low‐density lipoprotein (LDL) cholesterol and triglycerides (2 studies, 70 participants). The one trial comparing zinc supplementation with exercise also showed neutral effects for total cholesterol, HDL and LDL cholesterol, and a mean difference in triglycerides of ‐30 mg/dL (95% confidence interval (CI) ‐49 to ‐10) in favour of zinc supplementation (53 participants). Various surrogate laboratory parameters were also analysed in the included trials. Authors' conclusions There is currently no evidence on which to base the use of zinc supplementation for the prevention of type 2 diabetes mellitus. Future trials should investigate patient‐important outcome measures such as incidence of type 2 diabetes mellitus, health‐related quality of life, diabetic complications, all‐cause mortality and socioeconomic effects. Plain language summary Zinc supplementation for the prevention of type 2 diabetes mellitus Review question What are the effects of zinc supplementation compared with placebo or no treatment for the prevention of type 2 diabetes in adults with insulin resistance? Background Some studies have shown that zinc improves glucose levels (glycaemic control) in people with diabetes. As a consequence of diabetes long‐term complications may develop, such as kidney, nerve and eye disease. Also, the risk of cardiovascular complications like heart attacks and strokes is raised. Type 1 diabetes is a form of diabetes where the body cannot produce insulin any more. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity and is characterised by an increasing inability of the body to make good use of insulin (insulin resistance). The mineral zinc plays a key role in the action of insulin and theoretically zinc supplementation used by people with insulin resistance could prevent the onset of diabetes. Study characteristics We included three randomised controlled studies with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Key results No study reported on our patient‐important key outcomes (new onset of type 2 diabetes mellitus, side effects, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). The effects of zinc supplementation are uncertain regarding insulin resistance and lipid levels in the blood (mainly cholesterol and triglycerides). Quality of evidence The overall quality of the included studies was unclear because study authors did not provide important information for us to judge how the studies were performed (unclear risk of bias in most cases). In addition, the number of studies and participants is low and the study authors did not investigate important outcomes such as new onset of type 2 diabetes mellitus or side effects of zinc supplementation. Currentness of evidence This evidence is up to date as of March 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El Dib, R, Gameiro, OLF, Ogata, MSP, Módolo, NSP, Braz, LG, Jorge, EC, do Nascimento Junior, P, Beletate, V", "articleTypes": [], "doi": "10.1002/14651858.CD005525.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.773Z" }, { "id": "1fd231ac-8bc1-4e06-b00c-c7c1651b9ee2", "pmid": "", "title": "Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)", "imported": false, "abstract": "Abstract - Background Idiopathic acute vestibular dysfunction (vestibular neuritis) is the second most common cause of peripheral vertigo after benign paroxysmal positional vertigo (BPPV) and accounts for 7% of the patients who present at outpatient clinics specialising in the treatment of dizziness. The exact aetiology of the condition is unknown and the effects of corticosteroids on the condition and its recovery are uncertain. Objectives To assess the effectiveness of corticosteroids in the management of patients with idiopathic acute vestibular dysfunction (vestibular neuritis). Search methods We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 28 December 2010. Selection criteria Randomised controlled trials comparing corticosteroids with placebo, no treatment or other active treatments, for adults diagnosed with idiopathic acute vestibular dysfunction. Data collection and analysis Two authors independently selected studies from the search results and extracted data. Three authors independently assessed risk of bias. Main results Four trials, involving a total of 149 participants, compared the effectiveness of oral corticosteroids against placebo. All the trials were small and of low methodological quality. Although there was an overall significant effect of corticosteroids compared with placebo medication on complete caloric recovery at one month (risk ratio (RR) of 2.81; 95% confidence interval (CI) 1.32 to 6.00, P = 0.007), no significant effect was seen on complete caloric recovery at 12 months (RR 1.58; 95% CI 0.45 to 5.62, P = 0.48), or on the extent of caloric recovery at either one month (mean difference (MD) 9.60%; 95% CI ‐20.66 to 39.86, P = 0.53) or at 12 months (MD 6.83%; 95% CI ‐27.69 to 41.36, P = 0.70). In addition, there was no significant difference between corticosteroids and placebo medication in the symptomatic recovery of vestibular function following idiopathic acute vestibular dysfunction with respect to vertigo at 24 hours (RR 0.39; 95% CI 0.04 to 3.57, P = 0.40) and use of the Dizziness Handicap Inventory score at one, three, six and 12 months. Authors' conclusions Overall, there is currently insufficient evidence from these trials to support the administration of corticosteroids to patients with idiopathic acute vestibular dysfunction. We found no trials with a low risk of methodological bias that used the highest level of diagnostic criteria and outcome measures. We recommend that future studies should include health‐related quality of life and symptom‐based outcome measures, in addition to objective measures of vestibular improvement, such as caloric testing and electronystagmography. Plain language summary Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis) Idiopathic acute vestibular dysfunction (vestibular neuritis) is a common condition of unknown cause. Patients with the condition often experience dizziness, nausea or vomiting, and trouble with vision, balance or mobility, but have normal hearing and no tinnitus. It has been proposed that a course of corticosteroids, if given early on, may improve recovery from the condition and long‐term patient outcome. However, corticosteroids can cause adverse effects (e.g. bleeding stomach ulcer, mood changes, etc.). This review identified four randomised controlled trials including 149 adult patients with idiopathic acute vestibular dysfunction (vestibular neuritis) treated with either corticosteroids or placebo. The studies were varied in that they used different drugs and different treatment regimens. On the basis of these studies, there is currently insufficient evidence in favour of corticosteroids over placebo medication in the symptomatic recovery and objective testing of vestibular function, both in the short‐term and long‐term. Further studies of higher quality are needed to test the effectiveness of corticosteroids in patients with the condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fishman, JM, Burgess, C, Waddell, A", "articleTypes": [], "doi": "10.1002/14651858.CD008607.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.102Z" }, { "id": "2019dfd6-ba83-482d-aee6-cd2b2432cb7f", "pmid": "", "title": "Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia", "imported": false, "abstract": "Abstract - Background Fibromyalgia is a clinically defined chronic condition of unknown etiology characterized by chronic widespread pain that often co‐exists with sleep disturbances, cognitive dysfunction and fatigue. People with fibromyalgia often report high disability levels and poor quality of life. Drug therapy, for example, with serotonin and noradrenaline reuptake inhibitors (SNRIs), focuses on reducing key symptoms and improving quality of life. This review updates and extends the 2013 version of this systematic review. Objectives To assess the efficacy, tolerability and safety of serotonin and noradrenaline reuptake inhibitors (SNRIs) compared with placebo or other active drug(s) in the treatment of fibromyalgia in adults. Search methods For this update we searched CENTRAL, MEDLINE, Embase, the US National Institutes of Health and the World Health Organization (WHO) International Clinical Trials Registry Platform for published and ongoing trials and examined the reference lists of reviewed articles, to 8 August 2017. Selection criteria We selected randomized, controlled trials of any formulation of SNRIs against placebo or any other active treatment of fibromyalgia in adults. Data collection and analysis Three review authors independently extracted data, examined study quality, and assessed risk of bias. For efficacy, we calculated the number needed to treat for an additional beneficial outcome (NNTB) for pain relief of 50% or greater and of 30% or greater, patient's global impression to be much or very much improved, dropout rates due to lack of efficacy, and the standardized mean differences (SMD) for fatigue, sleep problems, health‐related quality of life, mean pain intensity, depression, anxiety, disability, sexual function, cognitive disturbances and tenderness. For tolerability we calculated number needed to treat for an additional harmful outcome (NNTH) for withdrawals due to adverse events and for nausea, insomnia and somnolence as specific adverse events. For safety we calculated NNTH for serious adverse events. We undertook meta‐analysis using a random‐effects model. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We added eight new studies with 1979 participants for a total of 18 included studies with 7903 participants. Seven studies investigated duloxetine and nine studies investigated milnacipran against placebo. One study compared desvenlafaxine with placebo and pregabalin. One study compared duloxetine with L‐carnitine. The majority of studies were at unclear or high risk of bias in three to five domains. The quality of evidence of all comparisons of desvenlafaxine, duloxetine and milnacipran versus placebo in studies with a parallel design was low due to concerns about publication bias and indirectness, and very low for serious adverse events due to concerns about publication bias, imprecision and indirectness. The quality of evidence of all comparisons of duloxetine and desvenlafaxine with other active drugs was very low due to concerns about publication bias, imprecision and indirectness. Duloxetine and milnacipran had no clinically relevant benefit over placebo for pain relief of 50% or greater: 1274 of 4104 (31%) on duloxetine and milnacipran reported pain relief of 50% or greater compared to 591 of 2814 (21%) participants on placebo (risk difference (RD) 0.09, 95% confidence interval (CI) 0.07 to 0.11; NNTB 11, 95% CI 9 to 14). Duloxetine and milnacipran had a clinically relevant benefit over placebo in patient's global impression to be much or very much improved: 888 of 1710 (52%) on duloxetine and milnacipran (RD 0.19, 95% CI 0.12 to 0.26; NNTB 5, 95% CI 4 to 8) reported to be much or very much improved compared to 354 of 1208 (29%) of participants on placebo. Duloxetine and milnacipran had a clinically relevant benefit compared to placebo for pain relief of 30% or greater. RD was 0.10; 95% CI 0.08 to 0.12; NNTB 10, 95% CI 8 to 12. Duloxetine and milnacipran had no clinically relevant benefit for fatigue (SMD ‐0.13, 95% CI ‐0.18 to ‐0.08; NNTB 18, 95% CI 12 to 29), compared to placebo. There were no differences between either duloxetine or milnacipran and placebo in reducing sleep problems (SMD ‐0.07; 95 % CI ‐0.15 to 0.01). Duloxetine and milnacipran had no clinically relevant benefit compared to placebo in improving health‐related quality of life (SMD ‐0.20, 95% CI ‐0.25 to ‐0.15; NNTB 11, 95% CI 8 to 14). There were 794 of 4166 (19%) participants on SNRIs who dropped out due to adverse events compared to 292 of 2863 (10%) of participants on placebo (RD 0.07, 95% CI 0.04 to 0.10; NNTH 14, 95% CI 10 to 25). There was no difference in serious adverse events between either duloxetine, milnacipran or desvenlafaxine and placebo (RD ‐0.00, 95% CI ‐0.01 to 0.00). There was no difference between desvenlafaxine and placebo in efficacy, tolerability and safety in one small trial. There was no difference between duloxetine and desvenlafaxine in efficacy, tolerability and safety in two trials with active comparators (L‐carnitine, pregabalin). Authors' conclusions The update did not change the major findings of the previous review. Based on low‐ to very low‐quality evidence, the SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in the frequency of pain relief of 50% or greater, but for patient's global impression to be much or very much improved and in the frequency of pain relief of 30% or greater there was a clinically relevant benefit. The SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in improving health‐related quality of life and in reducing fatigue. Duloxetine and milnacipran did not significantly differ from placebo in reducing sleep problems. The dropout rates due to adverse events were higher for duloxetine and milnacipran than for placebo. On average, the potential benefits of duloxetine and milnacipran in fibromyalgia were outweighed by their potential harms. However, a minority of people with fibromyalgia might experience substantial symptom relief without clinically relevant adverse events with duloxetine or milnacipran. We did not find placebo‐controlled studies with other SNRIs than desvenlafaxine, duloxetine and milnacipran. Plain language summary Serotonin and noradrenaline reuptake inhibitors for fibromyalgia Bottom line Duloxetine and milnacipran may reduce pain in people with fibromyalgia. However, some of these people may also experience side effects, such as nausea (feeling sick) and drowsiness. A minority of people with fibromyalgia experience symptom relief without side effects from duloxetine and milnacipran. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as problems with sleep, thinking and exhaustion. They often report poor health‐related quality of life. There is no cure for fibromyalgia at present, so the treatments aim to relieve the symptoms and to improve health‐related quality of life. Serotonin and noradrenaline are chemicals which are produced by the human body, involved in the regulation of pain, sleep and mood. Low concentrations of serotonin have been reported in people with fibromyalgia. Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a class of antidepressants that increase the concentration of serotonin and noradrenaline in the brain. Study characteristics In August 2017, we updated our searches for clinical trials in which SNRIs were used to treat symptoms of fibromyalgia in adults. We found eight new studies since the previous version of the review. In total, we found 18 studies with 7903 participants. The studies were four to 27 weeks long and compared the SNRIs desvenlafaxine, duloxetine and milnacipran against a fake medication (placebo). We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. Key results and quality of the evidence Duloxetine and milnacipran were better than placebo in reducing pain by 50% or more and in improving global well‐being (low‐quality evidence). Duloxetine and milnacipran were better than placebo in improving health‐related quality of life and in reducing fatigue (low‐quality evidence). Duloxetine and milnacipran were not better than placebo in reducing sleep problems (low‐quality evidence). More people dropped out of the trial due to side effects with duloxetine and milnacipran than with placebo (low‐quality evidence). More people reported nausea and drowsiness with duloxetine and milnacipran than with placebo (low‐quality evidence). Duloxetine, milnacipran and placebo did not differ in the frequency of serious side effects experienced (very low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Welsch, P, Üçeyler, N, Klose, P, Walitt, B, Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD010292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.114Z" }, { "id": "2027e367-24db-4669-afa5-7774cc34843d", "pmid": "", "title": "Short‐course oral steroids alone for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of oral corticosteroids compared with placebo/no intervention or other pharmacological interventions (intranasal corticosteroids, antibiotics, antifungals) for chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids with placebo or no treatment or compared with other pharmacological interventions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included eight RCTs (474 randomised participants), which compared oral corticosteroids with placebo or no intervention. All trials only recruited adults with chronic rhinosinusitis with nasal polyps. All trials reported outcomes at two to three weeks, at the end of the short‐course oral steroid treatment period. Three trials additionally reported outcomes at three to six months. Two of these studies prescribed intranasal steroids to patients in both arms of the trial at the end of the oral steroid treatment period. Oral steroids versus placebo or no intervention Disease‐specific health‐related quality of life was reported by one study. This study reported improved quality of life after treatment (two to three weeks) in the group receiving oral steroids compared with the group who received placebo (standardised mean difference (SMD) ‐1.24, 95% confidence interval (CI) ‐1.92 to ‐0.56, 40 participants, modified RSOM‐31), which corresponds to a large effect size. We assessed the evidence to be low quality (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). Disease severity as measured by patient‐reported symptom scores was reported by two studies, which allowed the four key symptoms used to define chronic rhinosinusitis (nasal blockage, nasal discharge, facial pressure, hyposmia) to be combined into one score. The results at the end of treatment (two to three weeks) showed an improvement in patients receiving oral steroids compared to placebo, both when presented as a mean final value (SMD ‐2.84, 95% CI ‐4.09 to ‐1.59, 22 participants) and as a change from baseline (SMD ‐2.28, 95% CI ‐2.76 to ‐1.80, 114 participants). These correspond to large effect sizes but we assessed the evidence to be low quality. One study (114 participants) followed patients for 10 weeks after the two‐week treatment period. All patients in both arms received intranasal steroids at the end of the oral steroid treatment period. The results showed that the initial results after treatment were not sustained (SMD ‐0.22, 95% CI ‐0.59 to 0.15, 114 participants, percentage improvement from baseline). This corresponds to a small effect size and we assessed the evidence to be low quality. There was an increase in adverse events in people receiving orals steroids compared with placebo for gastrointestinal disturbances (risk ratio (RR) 3.45, 95% CI 1.11 to 10.78; 187 participants; three studies) and insomnia (RR 3.63, 95% CI 1.10 to 11.95; 187 participants; three studies). There was no significant impact of oral steroids on mood disturbances at the dosage used in the included study (risk ratio (RR) 2.50, 95% CI 0.55 to 11.41; 40 participants; one study). We assessed the evidence to be low quality due to the lack of definitions of the adverse events and the small number of events or sample size, or both). Other comparisons No studies that compared short‐course oral steroids with other treatment for chronic rhinosinusitis met the inclusion criteria. Authors' conclusions At the end of the treatment course (two to three weeks) there is an improvement in health‐related quality of life and symptom severity in patients with chronic rhinosinusitis with nasal polyps taking oral corticosteroids compared with placebo or no treatment. The quality of the evidence supporting this finding is low. At three to six months after the end of the oral steroid treatment period, there is little or no improvement in health‐related quality of life or symptom severity for patients taking an initial course of oral steroids compared with placebo or no treatment. The data on the adverse effects associated with short courses of oral corticosteroids indicate that there may be an increase in insomnia and gastrointestinal disturbances but it is not clear whether there is an increase in mood disturbances. All of the adverse events results are based on low quality evidence. More research in this area, particularly research evaluating patients with chronic rhinosinusitis without nasal polyps, longer‐term outcomes and adverse effects, is required. There is no evidence for oral steroids compared with other treatments. Plain language summary Short‐term oral corticosteroids compared with no treatment or other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of a short course (typically up to 21 days) of corticosteroid given by mouth to people with chronic rhinosinusitis compared with giving a placebo or no treatment, or another type of treatment. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling the inflammatory response and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included eight randomised controlled trials with a total of 474 participants. All of the patients were adults who had chronic rhinosinusitis with nasal polyps. All of the studies followed patients until the end of treatment (two to three weeks) and three studies (210 participants) followed up people for three to six months after the initial treatment had ended. Five of the eight reports mentioned how the trial was funded. None of the funding sources were pharmaceutical companies. Key results At the end of a two‐ or three‐week treatment course, people who took oral steroids may have had a better quality of life, less severe symptoms and smaller nasal polyps than people who had placebo or did not receive any treatment. After three to six months, there was little or no difference in quality of life, symptom severity or nasal polyps between the people who had oral steroids and the people who had placebo or no intervention. The people who took oral steroids may have had more gastrointestinal disturbances and insomnia than the people who had placebo or no intervention. It is not clear if the people who took oral steroids had more mood disturbances than the people who had placebo or no intervention. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate), as the some of the results are only from one or two studies, which do not have a lot of participants. Most of the trials do not have a high risk of bias, but only people with nasal polyps were included in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K; Chong, LY; Hopkins, C; Philpott, C; Burton, MJ; Schilder, AGM", "articleTypes": [], "doi": "10.1002/14651858.CD011991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "202eafb5-2e0f-43be-a0ff-42693b5fdab7", "pmid": "", "title": "Taste Changes With Bariatric Surgery", "imported": false, "abstract": "It is commonly believed that a link exists between BMI and taste perception. One group of researchers observed that women who are obese experience reduced taste sensitivity when compared to normal-weight controls. Others have compared taste sensitivity between lean and obese subjects and found no significant differences. The inconsistencies in these studies demonstrate how much variation in taste sensitivity is possible when different factors are applied in research. Throughout several studies, one element remains constant - bariatric surgery causes appetite aversions. These changes in appetite and food preference likely have a large influence on the overall magnitude of post-surgical weight loss. Although many studies have investigated the changes in taste preference after bariatric surgery, few, if any, have focused on changes in sweet taste perception.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.143Z" }, { "id": "203d5d71-f8dd-4f78-bf0d-1b600ce65699", "pmid": "", "title": "Pain relief in hysterosalpingography", "imported": false, "abstract": "Abstract - Background Hysterosalpingography (HSG) is a method of testing for tubal patency. However, women struggle to tolerate the procedure, as it is associated with some discomfort. Various pharmacological strategies are available that may reduce pain during the procedure, though there is no consensus as to the best method. Objectives To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing HSG for investigation of subfertility. Search methods This review has drawn on the search strategy developed for the Cochrane Menstrual Disorders and Subfertility Group (MDSG). We searched the following databases to 15 April 2015: MDSG Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO. Selection criteria All identified randomised controlled trials investigating pharmacological interventions for pain relief during HSG were investigated for selection. Data collection and analysis Four review authors independently extracted data. We combined data to calculate mean differences (MDs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I² statistic. We assessed the overall quality of the evidence for the main comparisons using GRADE methods. Main results The search identified 23 trials (1272 women) that were eligible for inclusion into the study. Oral opioid analgesia versus placebo/no treatment There was no evidence of effect for oral opioid analgesia in reducing pain during the procedure (MD −0.91, 95% CI −1.88 to 0.06, 1 study, n = 128, low quality evidence) or more than 30 minutes after the procedure (MD −0.99, 95% CI −1.75 to −0.23, 1 study, n = 128, moderate quality evidence) No studies reported on the effect of oral opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes after the procedure There was insufficient evidence to reach conclusions regarding adverse effects. Intravenous opioid analgesia versus placebo/no treatment There was evidence that intravenous opioids may improve pain relief during the procedure compared to no treatment (MD −3.53, 95% CI −4.29 to −2.77, 1 study, n = 62, moderate quality evidence) No studies reported on the effect of intravenous opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes and more than 30 minutes after the procedure In terms of adverse effects, one trial reported 1/32 participants had apnoea with intravenous remifentanil. Recovery time was nearly 4 minutes longer in the remifentanil group compared to the control. Oral non‐opioid analgesia versus placebo/no treatment There was no evidence of effect for oral non‐opioid analgesia in reducing pain during the procedure (MD −0.13, 95% CI −0.48 to 0.23, 3 studies, n = 133, I² = 61%, low quality evidence), less than 30 minutes after the procedure (MD −0.30, 95% CI −1.03 to 0.43, 2 studies, n = 45, I² = 97%, very low quality evidence), or more than 30 minutes after the procedure (MD −0.36, 95% CI −1.06 to 0.34, 3 studies, n = 133, I² = 58%, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Topical anaesthesia versus placebo/no treatment There was evidence that topical anaesthetics may reduce pain during the procedure (MD −0.63, 95% CI −1.06 to −0.19, 9 studies, n = 613, I² = 66%, low quality evidence). There was no evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD 0.42, 95% CI ‐0.03 to 0.86, 5 studies, n = 373, I² = 59%, very low quality evidence). There was evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain more than 30 minutes after the procedure (MD −1.38, 95% CI ‐3.44 to −0.68, 2 studies, n = 166, I² = 92%, very low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Locally injected anaesthesia versus placebo/no treatment There was evidence of effect that locally injected anaesthetic can reduce pain during the procedure (MD −1.31, 95% CI −1.55 to −1.07, 2 studies, n = 125, I² = 0%, very low quality evidence). There was no evidence of effect for locally injected anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD −1.31, 95% CI −2.14 to −0.49, 2 studies, n = 125, I² = 46%, low quality evidence). No studies were included into the analysis of the effect of locally injected anaesthesia, when injected prior to the procedure, in reducing pain more than 30 minutes after the procedure. There was insufficient evidence to reach conclusions regarding adverse effects. Any analgesic versus any other analgesic There was no evidence of a difference between the groups when oral non‐opioid analgesia was compared to opioid analgesia for pain relief during the procedure (MD 1.10, 95% CI −0.26 to 2.46, 1 study, n = 91, low quality evidence); less than 30 minutes following the procedure (MD −0.30, 95% CI −1.00 to 0.40, 1 study, n = 91, low quality evidence); and more than 30 minutes following the procedure (MD −0.60, 95% CI −1.56 to 0.36, 1 study, n = 91, low quality evidence). Topical anaesthetics were found to be more effective than paracervical block for pain relief during HSG (MD −2.73, 95% CI −3.86 to −1.60, 1 study, n = 20, moderate quality evidence). This benefit did not extend to within 30 minutes following HSG (MD −1.03, 95% CI −2.52 to 0.46, 1 study, n = 20, low quality evidence); or 30 minutes or more after HSG (MD 0.31, 95% CI −0.87 to 1.49, 1 study, n = 20, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Authors' conclusions Topical anaesthetic applied before the procedure may be associated with effective pain relief during HSG, though the quality of this evidence is low. Intravenous opioids may also be effective in pain relief, though this must be weighed against their side effects and their effects on the recovery time. There is insufficient evidence to draw conclusions on the efficacy of other analgesics for HSG, or to reach any other conclusions regarding adverse effects. Plain language summary Drug treatments for pain relief in hysterosalpingography Review question: Which pain‐killers are effective at reducing the discomfort experienced with hysterosalpingography? Background: Hysterosalpingography (HSG) is a test used in investigating infertility in women. HSG involves a dye being introduced into the uterus and the connecting tubes, which enables them to be visualised using an x‐ray, allowing the clinician to assess how open the connecting tubes are. This can be a painful procedure. There is disagreement regarding the best form of pain relief during the procedure. Study characteristics: We identified 19 randomised controlled trials that compared a specific drug treatment to a placebo/no treatment. Four trials compared two different drug treatments to establish if one was better. All studies took place in a clinical setting. Age of participants ranged from 18 to 42 years. Studies took place in India, Australia, United Kingdom, United States of America, Turkey, Israel, Netherlands, Italy, Iran, Nigeria, Spain, Brazil, and Belgium (1272 women in total). We included 15 of these trials in a meta‐analysis. The remaining eight trials, while eligible for inclusion, did not have data in a format that could be entered into meta‐analysis (seven compared a specific drug to a placebo/no treatment, one compared two different drug treatments). The evidence is current to April 2015. Key results : Topical anaesthetic was associated with a mild reduction in the pain experienced during HSG (low quality evidence). However, it has no effect on the discomfort experienced by participants following the procedure (very low quality evidence). Locally injected anaesthetics, on the other hand, were not associated with any benefit. Only one study investigated this (moderate quality evidence). One study directly compared locally injected anaesthetics to topical anaesthetics. This study found that topical anaesthesia was associated with improved pain relief during the procedure (moderate quality evidence) No oral drug was found to be effective in reducing pain experienced during the procedure. This was true for both opioid (low quality evidence) and non‐opioid (low quality evidence) analgesia. One trial however reported that tramadol may be of benefit in reducing the pain experienced more than 30 minutes after the procedure (moderate quality evidence). Quality of the evidence: The quality of the combined results was mainly downgraded for two reasons: 1) studies having methods that may be at risk of bias/inaccuracy; 2) substantially different conclusions between studies that investigate the same drug. The included studies did not report side effects in large enough numbers to make definitive conclusions regarding the side effects of particular drugs during the procedure. Conclusions: Only topical anaesthetics and intravenous opioids were found to be of benefit in reducing pain during the procedure, though the quality of this evidence is low to moderate, and there is no evidence that these are effective at relieving pain following the procedure. There is insufficient evidence for other drug treatments in reducing pain during HSG. There was insufficient evidence to reach any conclusions regarding adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hindocha, A, Beere, L, O'Flynn, H, Watson, A, Ahmad, G", "articleTypes": [], "doi": "10.1002/14651858.CD006106.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.792Z" }, { "id": "20418306-0a15-4442-b3a3-684418885c2e", "pmid": "", "title": "Antibiotics versus topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity. It is characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Antibiotics and antiseptics kill or inhibit the micro‐organisms that may be responsible for the infection. Antibiotics can be applied topically or administered systemically via the oral or injection route. Antiseptics are always directly applied to the ear (topically). Objectives To assess the benefits and harms of antibiotics versus antiseptics for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP). The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving adults and children who had chronic ear discharge of unknown cause or CSOM, where ear discharge had continued for more than two weeks. The intervention was any single, or combination of, antibiotic agent, whether applied topically (without steroids) or systemically. The comparison was any single, or combination of, topical antiseptic agent, applied as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The comparisons were 1. topical antiseptics compared to topical antibiotics, and 2. topical antiseptics compared to systemic antibiotics. We further separated these comparisons into those in which a. both groups of participants received aural toileting in addition to the intervention, or b. both groups received some other add‐on therapy treatment (such as systemic antibiotics) to both arms. Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This updated review included eight new studies. Overall, we identified 15 studies (2371 participants) across seven comparisons with antibiotics compared to acetic acid, aluminium acetate, boric acid, and povidone‐iodine. None of the included studies reported health‐related quality of life or serious complications. 1. Topical antibiotics (quinolones or aminoglycosides) versus topical antiseptic (acetic acid) We included seven studies (835 participants). Acetic acid may increase resolution of ear discharge when compared to aminoglycoside at one to two weeks (low‐certainty evidence). It is very uncertain whether acetic acid may increase resolution of ear discharge at one to two weeks when compared to topical quinolone. Results after four weeks were only presented narratively. It is very uncertain whether acetic acid may cause more ear pain, discomfort, local irritation, or combinations of these compared to topical antibiotics (aminoglycosides and quinolones) (risk ratio (RR) 0.20, 95% confidence interval (CI) 0.03 to 1.12; I 2 = 0%; 3 studies, 277 participants; very low‐certainty evidence). An additional two studies (350 participants) provided narrative results. There may be little to no difference in hearing between groups reported narratively (quinolones; low‐certainty evidence). The evidence is very uncertain for serious complications (aminoglycosides) or suspected ototoxicity (aminoglycosides) (very low‐certainty evidence). 2. Topical antibiotics (quinolones) versus topical antiseptic (boric acid) We included two studies (532 participants). Topical quinolones are likely to increase resolution of ear discharge at one to two weeks compared with boric acid ear drops (RR 1.86, 95% CI 1.48 to 2.35; 1 study, 411 participants; moderate‐certainty evidence). This means that one additional person will have resolution of ear discharge for every four people receiving topical antibiotics (compared with boric acid) at two weeks. No study reported results for ear discharge after four weeks. There may be less ear pain, discomfort, or irritation with quinolones compared with boric acid (RR 0.56, 95% CI 0.32 to 0.98; 2 studies, 510 participants; low‐certainty evidence). Suspected ototoxicity and serious complications were not reported. Topical quinolones may result in a greater improvement in mean hearing from baseline compared to topical boric acid (mean difference (MD) 2.79 decibels, 95% CI 0.48 to 5.10; 1 study, 390 participants; low‐certainty evidence), but this difference may not be clinically significant. 3. Topical antibiotics (quinolones) versus topical antiseptic (povidone‐iodine) We included one study (40 participants). It is very uncertain if there is a difference between quinolones and povidone‐iodine with respect to resolution of ear discharge at one to two weeks (RR 1.02, 95% CI 0.82 to 1.26; 1 RCT, 39 participants; very low‐certainty evidence). The study reported qualitatively that there were no differences between the groups for hearing and no participants developed ototoxic effects (very low‐certainty evidence). There were no results reported for resolution of ear discharge beyond four weeks; ear pain, discomfort, or irritation; or serious complications. 4. Topical antibiotics versus topical antiseptic (aluminium acetate) We included one study (51 participants; 60 ears) that presented results for resolution of ear discharge at two to four weeks results narratively. No other results were reported. 5. Other comparisons Five studies (966 participants) were assessed over an additional three comparisons; however, these results have not been included in the abstract. Authors' conclusions Treatment of CSOM with topical antibiotics (quinolones) likely results in an increase in resolution of ear discharge compared with boric acid at up to two weeks. There was limited evidence for the efficacy of other topical antibiotics or topical antiseptics and so we are unable to draw conclusions. Harmful effects were not well reported. Limitations of the review include lack of recent data, limitations in the quality of included studies, and limited information on certain population groups or interventions. Plain language summary Which are better, antibiotics or topical antiseptics, for treating chronic suppurative otitis media? Key message – There is limited evidence comparing topical antibiotics with topical antiseptics in people with swelling and infection of the middle ear (called chronic suppurative otitis media). The evidence is very uncertain whether antibiotics or topical antiseptics are more effective for reducing ear discharge, except that topical antibiotics are likely to be more effective than boric acid (an antiseptic). What is chronic suppurative otitis media? Chronic suppurative otitis media is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (where the eardrum has a hole or tear in it). The main symptoms of chronic suppurative otitis media are ear discharge (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Antibiotics (which kill bacteria) are the most commonly used treatment for chronic suppurative otitis media. Antibiotics can either be 'topical' (put into the ear canal as ear drops, ointments, sprays, or creams) or 'systemic' (taken either by mouth or by an injection into a muscle or vein). Topical antiseptics (antiseptics put directly into the ear as ear drops or powders) are a possible treatment for chronic suppurative otitis media. Both antibiotics and topical antiseptics kill or stop the growth of the germs that may be responsible for the infection. Antibiotics and topical antiseptics can be used on their own or added to other treatments for chronic suppurative otitis media, such as other antibiotics or ear cleaning (called aural toileting). It was important in this review to examine whether there were any unwanted effects from using antibiotics and antiseptics, such as irritation of the skin within the outer ear, which may cause discomfort, pain, or itching. Some antibiotics and antiseptics (such as alcohol) can also be toxic to the inner ear (called ototoxicity), which means that they may cause permanent hearing loss, dizziness, or ringing in the ear (called tinnitus). What was the aim of this review? We wanted to compare antibiotics and antiseptics for the treatment of chronic suppurative otitis media. In particular, we wanted to know whether they stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found 15 studies, which included 2371 people, that compared antibiotics to a variety of antiseptics (acetic acid, boric acid, povidone‐iodine, and aluminium acetate). One study recruited only children, two studies recruited only adults, and 12 studies included both adults and children. About 40 in every 100 people were females. We presented the main comparisons below. Comparison of antibiotics to acetic acid We included seven studies (835 people). We have little to no confidence in the evidence of whether topical antibiotics or acetic acid improved ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to boric acid We included two studies (532 people). Topical antibiotics (quinolones) are likely to be better than boric acid at reducing ear discharge after one to two weeks. There may also be less ear discomfort (pain, irritation, and bleeding). Topical quinolones may result in a greater improvement in hearing compared to topical boric acid, but this difference may be too small for the person to notice a difference. Comparison of antibiotics to povidone‐iodine We included one study (40 people). We have little to no confidence in the evidence of whether topical or systemic antibiotics or povidone‐iodine improve the resolution of ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to aluminium acetate We included one study (51 people) that stated there was improvement in ear discharge at two to four weeks, but they did not present their results in a way that we could use. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. What are the limitations of the evidence? The studies were small with many being poorly reported, and results varied widely between studies. We also need more information about harmful effects. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K; Chong, LY; Bhutta, MF; Daw, J; Veselinović, T; Morris, PS; Vijayasekaran, S; Schilder, AGM; Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013056.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "2065b446-2cac-4767-904e-1ad0b5d78fa7", "pmid": "", "title": "Preoperative statin therapy for adults undergoing cardiac surgery", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Marques Antunes, M, Nunes-Ferreira, A, Duarte, GS, Gouveia e Melo, R, Sucena Rodrigues, B, Guerra, NC, Nobre, A, Pinto, FJ, Costa, J, Caldeira, D", "articleTypes": [], "doi": "10.1002/14651858.CD008493.pub5 AB - Abstract - Background Despite significant advances in surgical techniques and perioperative care, people undertaking cardiac surgery due to cardiovascular disease are more prone to the development of postoperative adverse events. Statins (5‐hydroxy‐3‐methylglutaryl‐co‐enzyme A (HMG‐CoA) reductase inhibitors) are well‐known for their anti‐inflammatory and antioxidant effects and are established for primary and secondary prevention of coronary artery disease. In addition, statins are thought to have clinical benefits in perioperative outcomes in people undergoing cardiac surgery. This review is an update of a review that was first published in 2012 and updated in 2015. Objectives To evaluate the benefits and harms of preoperative statin therapy in adults undergoing cardiac surgery compared to standard of care or placebo. Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2023), Ovid MEDLINE (1980 to 14 September 2023), and Ovid Embase (1980 to 2023 (week 36)). We applied no language restrictions. Selection criteria We included all randomised controlled trials (RCTs) comparing any statin treatment before cardiac surgery, for any given duration and dose, versus no preoperative statin therapy (standard of care) or placebo. We excluded trials without a registered trial protocol and trials without approval by an institutional ethics committee. Data collection and analysis We used standard Cochrane methodology. Primary outcomes were short‐term mortality and major adverse cardiovascular events. Secondary outcomes were myocardial infarction, atrial fibrillation, stroke, renal failure, length of intensive care unit (ICU) stay, length of hospital stay and adverse effects related to statin therapy. We reported effect measures as risk ratios (RRs) or mean differences (MDs) with corresponding 95% confidence intervals (CIs). We used the RoB 1 tool to assess the risk of bias in included trials, and GRADE to assess the certainty of the evidence. Main results We identified eight RCTs (five new to this review) including 5592 participants. Pooled analysis showed that statin treatment before surgery may result in little to no difference in the risk of postoperative short‐term mortality (RR 1.36, 95% CI 0.72 to 2.59; I 2 = 0%; 6 RCTs, 5260 participants; low‐certainty evidence; note 2 RCTs reported 0 events in both groups so RR calculated from 4 RCTs with 5143 participants). We are very uncertain about the effect of statins on major adverse cardiovascular events (RR 0.93, 95% CI 0.77 to 1.13; 1 RCT, 2406 participants; very low‐certainty evidence). Statins probably result in little to no difference in myocardial infarction (RR 0.88, 95% CI 0.73 to 1.06; I 2 = 0%; 5 RCTs, 4645 participants; moderate‐certainty evidence), may result in little to no difference in atrial fibrillation (RR 0.87, 95% CI 0.72 to 1.05; I 2 = 60%; 8 RCTs, 5592 participants; low‐certainty evidence), and may result in little to no difference in stroke (RR 1.47, 95% CI 0.90 to 2.40; I 2 = 0%; 4 RCTs, 5143 participants; low‐certainty evidence). We are very uncertain about the effect of statins on renal failure (RR 1.04, 95% CI 0.80 to 1.34; I 2 = 57%; 4 RCTs, 4728 participants; very low‐certainty evidence). Additionally, statins probably result in little to no difference in length of ICU stay (MD 1.40 hours, 95% CI −1.62 to 4.41; I 2 = 43%; 3 RCTs, 4528 participants; moderate‐certainty evidence) and overall hospital stay (MD −0.31 days, 95% CI −0.64 to 0.03; I 2 = 84%; 5 RCTs, 4788 participants; moderate‐certainty evidence). No study had any individual risk of bias domain classified as high. However, two studies were at high risk of bias overall given the classification of unclear risk of bias in three domains. Authors' conclusions In this updated Cochrane review, we found no evidence that statin use in the perioperative period of elective cardiac surgery was associated with any clinical benefit or worsening, when compared with placebo or standard of care. Compared with placebo or standard of care, statin use probably results in little to no difference in MIs, length of ICU stay and overall hospital stay; and may make little to no difference to mortality, atrial fibrillation and stroke. We are very uncertain about the effects of statins on major harmful cardiac events and renal failure. The certainty of the evidence validating this finding varied from moderate to very low, depending on the outcome. Future trials should focus on assessing the impact of statin therapy on mortality and major adverse cardiovascular events. Plain language summary Is it better to take statins before undergoing heart‐related surgery? Key messages – Taking statins may make little to no difference to death within 30 days of surgery, irregular heart rhythms and stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off); and probably results in little to no difference in heart attacks, length of intensive care unit stay and overall hospital stay. We are very uncertain about the effects of statins on kidney failure and harmful effects from statin treatment. – Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. What are the dangers of cardiac surgery and how may statins help? Cardiac surgeries can effectively treat people with heart and circulation problems. However, undergoing cardiac surgery also increases the risk of death, heart attack, stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off), irregular heart rhythms and kidney failure. This is partly because more than half of people undergoing cardiac surgery are over 70 years of age. To reduce these risks, we should try to improve recovery rates by preventing these problems from occurring before, during and after surgery. Statins are medications used throughout the world to lower blood cholesterol (a fatty substance found in the blood that may block blood vessels) levels and reduce the chances of cardiovascular issues becoming worse. Studies have shown that fewer people who had built up dangerous amounts of cholesterol in their blood vessels (arteries) died while taking statins. However, the potential benefits of taking statins in people undergoing cardiac surgery are unclear. What did we want to find out? We wanted to find out whether taking statins before undergoing cardiac surgery could help reduce the risk of: – death occurring shortly after surgery; or
– developing other heart or kidney problems. We also wanted to find out if there were any changes in the quality of care associated with cardiac surgeries for people who had been taking statins, such as reducing the length of hospital stay or intensive care unit stay, or if there were any harmful effects from statin treatment. What did we do? We searched for studies published up to September 2023 that compared treatment with statins to treatment with a placebo (a pretend medicine that looks or tastes identical to the medicine being tested) or usual care in people undergoing cardiac surgeries. Contrary to previous versions of this review, we only included trials that we were sure were approved by an ethical review board. What did we find? We found eight studies involving 5592 people with an average age of 63 years and 79% were men. Of these, 2798 people were treated with statins and 2794 people were not treated with statins before cardiac surgery. The smallest study included 57 people and the largest involved 2406 people. All studies were conducted in hospitals affiliated with universities in Asia, Europe and North America. Each study used different statin types (atorvastatin, fluvastatin, simvastatin, pravastatin or rosuvastatin) and doses (between 20 mg and 80 mg). Main results In people undergoing cardiac surgery, compared to no statin treatment, statin treatment: – probably results in little to no difference in heart attacks (5 studies, 4645 people), length of intensive care unit stay (3 studies, 4528 people) and overall hospital stay (5 studies, 4788 people); – may make little to no difference to death within 30 days of surgery (6 studies, 5260 people), irregular heart rhythm (8 studies, 5592 people) and stroke (4 studies, 5143 people). We are very uncertain about the effects of statins on major harmful cardiac events (1 study, 2406 people) and kidney failure (4 studies, 4728 people). What are the limitations of the evidence? We are moderately confident in our findings that there were probably little to no differences in the risk of heart attack, length of hospital and intensive care unit stay. However, we have little to very little confidence about our other findings, namely the most important finding we were looking for, which was a reduction in death. This is because most of the studies had many differences between them, there were fewer comparative cases than expected, and the studies did not always provide information about the statin intervention or treatment outcomes we were interested in. In addition, all studies used a different approach to statin treatment, which made them difficult to compare. Overall, this lowered our confidence in the evidence. Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. How up to date is this evidence? This is an update of a Cochrane review. The evidence is up to date to September 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.816Z" }, { "id": "207042a6-5198-4db2-816f-00b98fba9fef", "pmid": "", "title": "Dietary sodium manipulation and asthma", "imported": false, "abstract": "Abstract - Background There is a wide geographical variation in the prevalence of asthma and observational studies have suggested that dietary sodium may play a role. Objectives To assess the effect of dietary sodium manipulation on asthma control. Search methods We carried out a search using the Cochrane Airways Group asthma register. We searched the bibliographies of included randomised controlled trials (RCTs) for additional studies. We carried out the most recent search in November 2010. Selection criteria We considered only RCTs that involved dietary sodium reduction or increased sodium intake in patients with asthma. Data collection and analysis Both review authors assessed study and extracted data. We conducted data analyses in RevMan 5 using mean differences and random effects. Main results We identified a total of nine studies in relation to sodium manipulation and asthma, of which five were in people with asthma (318 participants), and four in people with exercise‐induced asthma (63 participants). There were no significant benefits of salt restriction on the control of asthma. There was some evidence from the exercise‐induced asthma studies that a low sodium diet may improve lung function after exercise and possibly baseline lung function, but this is based on findings from a very small numbers of participants. Authors' conclusions This review did not find any evidence that dietary sodium reduction significantly improves asthma control. Although dietary sodium reduction may result in improvements in lung function in exercise‐induced asthma, the clinical significance of this effect is unclear. Plain language summary Does reducing the amount of salt in a diet improve asthma symptoms? A review of the current literature suggests that reduction in the amount of dietary sodium consumed has no significant effect on the symptoms of asthma but may be associated with improvements in some lung function measurements in exercise‐induced asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Pogson, Z; McKeever, T", "articleTypes": [], "doi": "10.1002/14651858.CD000436.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "207de82b-768f-4ee1-aa90-60e509928b6a", "pmid": "", "title": "Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Chronic infection with Pseudomonas aeruginosa (PA) in cystic fibrosis (CF) is a source of much morbidity and mortality. Eradication of early PA infection is possible, but can recur in many individuals. We sought to examine strategies to delay the time to PA recurrence in people with CF. Objectives To establish whether secondary prevention strategies, using antibiotics or other therapies, increase the chances of people with CF remaining free from PA infection following successful eradication therapy. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries and the reference lists of relevant articles and reviews. Date of last search: 21 August 2019. Selection criteria Randomised controlled trials (and quasi‐randomised trials where the risk of bias was low) comparing any treatment modality aimed at preventing recurrence of PA infection with placebo, standard therapy or any other treatment modality in people with CF who have undergone successful eradication of PA. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias. Quality of the evidence was assessed using GRADE. Conflicts were resolved by discussion and the opinion of a third review author was sought where necessary. Only a subset of participants in the included trial were eligible, therefore individual participant data were requested and obtained from the trial investigators. Main results We included one trial (n = 306) in the review; however, only 253 participants had undergone successful eradication of PA, so fulfilling the inclusion criteria for our review. Information presented relates only to the included subset of participants. The trial recruited children aged one to 12 years (mean (standard deviation (SD)) age of 5.8 (3.5) years), 129 participants (51.0%) were female and the median follow‐up was 494 days. We compared cycled therapy with tobramycin inhalation solution (TIS), in which participants underwent 28 days of TIS every three months, with culture‐based therapy, in which participants were only prescribed medication when a quarterly sputum sample was positive for PA. Reasons for downgrading the quality of the evidence included applicability (only included children), incomplete outcome data and a small number of participants. The time to next isolation of PA was probably shorter with cycled TIS therapy than with culture‐based therapy, hazard ratio (HR) 2.04 days (95% confidence interval (CI) 1.28 to 3.26) (moderate‐quality evidence). This is in contrast to the main publication of the only included trial, which examined rate of PA positivity rather than time to PA infection and included participants not eligible for inclusion in this review. At the end of the trial, there was no difference between the cycled and culture‐based groups in the change from baseline in forced expiratory volume in one second (FEV 1 ) L, mean difference (MD) 0.0 L (95% CI ‐0.09 to 0.09) or in FEV 1 % predicted, MD 0.70% (95% CI ‐4.33 to 5.73) (both very low‐quality evidence). There was no difference in the change from baseline for FVC between the groups. There was also no difference in the frequency of pulmonary exacerbations between groups, MD ‐0.18 (95% CI ‐0.51 to 0.14) (moderate‐quality evidence). Similarly, there was no difference between groups in the risk of participants developing novel resistant bacteria, RR 1.00 (95% CI 0.67 to 1.5) (moderate‐quality evidence). There were more severe adverse events in the cycled group, but the type of treatment probably makes little or no difference to the results, RR 0.65 (95% CI 0.39 to 1.11) (moderate‐quality evidence). There was no difference between groups in the change in weight or height from baseline or in rates of adherence to tobramycin or all trial medicines. The included trial did not assess changes in quality of life, the time to chronic infection with PA or the cost‐effectiveness of treatment. Authors' conclusions Cycled TIS therapy may be beneficial in prolonging the time to recurrence of PA after successful eradication, but further trials are required, specifically addressing this question and in both adults and children. Plain language summary Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis Review question We reviewed evidence about the effect of treatments given to people with cystic fibrosis (CF) to prevent recurrence of infection with bacteria called Pseudomonas aeruginosa (PA) after it has been successfully treated. Background People with CF experience frequent, severe chest infections. These infections may be caused by bacteria that do not cause disease in healthy people, such as PA. PA is an important infection in CF since if it is not treated early it cannot be cleared from the lungs (termed chronic PA). When it cannot be cleared from the lungs, it causes ongoing damage to the lung tissue as well as worse chest infections. People with CF who have chronic PA may be more unwell than those without it. Early treatment can remove PA from the lungs of people with CF, but infection can happen again and is difficult to prevent. We want to know if giving extra treatment after the PA has been successfully treated, can prolong the time to the next infection. The treatment could be antibiotics or another treatment, for example something that helps the person's immune system fight the PA. Search date The evidence is current to: 21 August 2019. Trial characteristics We included one trial with 306 participants. Only 253 of these people had had successful treatment of PA and so could be included in our review. There were only children in the trial who were aged between one and 12 years old; 51% were girls. The trial compared treatment with one month of an inhaled antibiotic every three months ('cycled treatment') with antibiotic treatment given only when the person was found to have PA ('culture‐based treatment'). People were selected randomly to have either cycled or culture‐based treatment. The trial followed people up for an average of 70 weeks. Key results Taking into the account the certainty of the evidence, we believe that the time to the next isolation of PA was probably shorter with cycled therapy than with culture‐based therapy. We found that PA recurred in a quarter of participants in the culture‐based group by 249 days but in the cycled group it took 505 days; giving cycled treatment doubled the time to a new infection with PA compared with culture‐based treatment. This is in contrast to the main publication of the only included trial, which looked at the rate of positive PA cultures rather than the time to a new infection of PA and included participants not eligible for inclusion in this review. There was no difference between the groups in: pulmonary function (a measure of how well someone's lungs are working); in the number of people having chest infections; in the change in height and weight from the beginning to th end of the trial; in how many people took all the doses of the medications; in how many people developed infections with new bacteria; or in how many people had a serious complication. The trial did not give information about the effect of the two treatments on individuals' quality of life, the time until the development of chronic PA or the cost‐effectiveness of the treatment. Quality of the evidence The quality of most of the evidence was moderate. As the trial only included children, we cannot be sure if the cycled treatment would have the same effect in teenagers or adults with CF. Further trials including both adults and children are needed to help answer the question. Trials designed to specifically answer this question are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Palser, S, Smith, S, Nash, EF, Agarwal, A, Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD012300.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.118Z" }, { "id": "20833e29-9689-40bc-a3a4-835705ccaf06", "pmid": "", "title": "Eliciting adverse effects data from participants in clinical trials", "imported": false, "abstract": "Abstract - Background Analysis of drug safety in clinical trials involves assessing adverse events (AEs) individually or by aggregate statistical synthesis to provide evidence of likely adverse drug reactions (ADR). While some AEs may be ascertained from physical examinations or tests, there is great reliance on reports from participants to detect subjective symptoms, where he/she is often the only source of information. There is no consensus on how these reports should be elicited, although it is known that questioning methods influence the extent and nature of data detected. This leaves room for measurement error and undermines comparisons between studies and pooled analyses. This review investigated comparisons of methods used in trials to elicit participant‐reported AEs. This should contribute to knowledge about the methodological challenges and possible solutions for achieving better, or more consistent, AE ascertainment in trials. Objectives To systematically review the research that has compared methods used within clinical drug trials (or methods that would be specific for such trials) to elicit information about AEs defined in the protocol or in the planning for the trial. Search methods Databases (searched to March 2015 unless indicated otherwise) included: Embase; MEDLINE; MEDLINE in Process and Other Non‐Indexed Citations; Cochrane Methodology Register (July 2012); Cochrane Central Register of Controlled Trials (February 2015); Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects (January 2015); Health Technology Assessment database (January 2015); CINAHL; CAB Abstracts; BIOSIS (July 2013); Science Citation Index; Social Science Citation Index; Conference Proceedings Citation Index – Science. The search used thesaurus headings and synonyms for the following concepts: (A): Adverse events AND measurement; (B): Participants AND elicitation (also other synonyms for extraction of information about adverse effects from people); (C): Participants AND checklists (also other synonyms as for B). Pragmatic ways were used to limit the results whilst trying to maintain sensitivity. There were no date or sample size restrictions but only reports published in English were included fully, because of resource constraints as regards translation. Selection criteria Two types of studies were included: drug trials comparing two or more methods within‐ or between‐participants to elicit participant‐reported AEs, and research studies performed outside the context of a trial to compare methods which could be used in trials (evidenced by reference to such applicability). Primary outcome data included AEs elicited from participants taking part in any such clinical trial. We included any participant‐reported data relevant for an assessment of drug‐related harm, using the original authors' terminology (and definition, where available), with comment on whether the data were likely to be treatment‐emergent AEs or not. Data collection and analysis Titles and abstracts were independently reviewed for eligibility. Full texts of potentially eligible citations were independently reviewed for final eligibility. Relevant data were extracted and subjected to a 100% check. Disagreements were resolved by discussion, involving a third author. The risk of bias was independently assessed by two authors. The Cochrane 'Risk of bias' tool was used for reports comparing outcomes between participants, while for within‐participant comparisons, each study was critically evaluated in terms of potential impact of the design and conduct on findings using the framework of selection, performance, detection, attrition, reporting, and other biases. An attempt was made to contact authors to retrieve protocols or specific relevant missing information. Reports were not excluded on the basis of quality unless data for outcomes were impossible to compare (e.g. where denominators differed). A narrative synthesis was conducted because differences in study design and presentation meant that a quantitative meta‐analysis was not possible. Main results The 33 eligible studies largely compared open questions with checklist‐type questions or rating scales. Two included participant interviews. Despite different designs, populations and details of questioning methods, the narrative review showed that more specific questioning of participants led to more AEs detected compared to a more general enquiry. A subset of six studies suggested that more severe, bothersome, or otherwise clinically relevant AEs were reported when an initial open enquiry was used, while some less severe, bothersome, or clinically relevant AEs were only reported with a subsequent specific enquiry. However, two studies showed that quite severe or debilitating AEs were only detected by an interview, while other studies did not find a difference in the nature of AEs between elicitation methods. No conclusions could be made regarding the impact of question method on the ability to detect a statistically significant difference between study groups. There was no common statistical rubric, but we were able to represent some effect measures as a risk ratio of the proportion of participants with at least one AE. This showed a lower level of reporting for open questions (O) compared to checklists (CL), with a range for the risk ratios of 0.12 to 0.64. Authors' conclusions This review supports concerns that methods to elicit participant‐reported AEs influence the detection of these data. There was a risk for under‐detection of AEs in studies using a more general elicitation method compared to those using a comprehensive method. These AEs may be important from a clinical perspective or for patients. This under‐detection could compromise ability to pool AE data. However, the impact on the nature of the AE detected by different methods is unclear. The wide variety and low quality of methods to compare elicitation strategies limited this review. Future studies would be improved by using and reporting clear definitions and terminology for AEs (and other important variables), frequency and time period over which they were ascertained, how they were graded, assessed for a relationship to the study drug, coded, and tabulated/reported. While the many potential AE endpoints in a trial may preclude the development of general AE patient‐reported outcome measurement instruments, much could also be learnt from how these employ both quantitative and qualitative methods to better understand data elicited. Any chosen questioning method needs to be feasible for use by both staff and participants. Plain language summary Questioning clinical trial participants about their health in order to collect information on adverse effects of drugs Clinical drug trials or studies are usually conducted to assess how well the drug works but also whether it causes any harm (side effects or adverse effects). Adverse effects can be detected by the trial doctor examining participants or taking some blood samples or doing other kinds of tests. The trial staff can also ask participants about how they are feeling after taking the trial drug. However, the way participants are asked about their health can vary from trial to trial, or even within a trial. In some trials, participants may be asked a simple open question such as 'how have you been feeling?', while in other trials, participants may be asked about whether they have had any of a long list of possible symptoms (such as 'have you had a headache, stomach ache, or sore muscles?'). There has been concern that these different kinds of questions and how they are phrased will impact on what participants report about their health during a trial. This might then affect the trial's results and what we know about the side effects of drugs. We did this review to look at studies that compared different types of participant questioning methods in order to investigate these issues. We found 33 studies comparing mainly open questions with checklist‐type questions, but also some ratings scales and participant interviews. While the studies were all very different in terms of the types of disease, drugs, and patients studied, we found in general that, as would be expected, when a more specific type of question was asked (like a checklist), participants reported more symptoms. What is interesting is that, in those studies that looked more closely at the types of symptoms reported, it seems that an open question picks up the more severe or bothersome symptoms compared to a checklist‐type question. However, some studies found that even quite severe or bothersome symptoms were not reported when a participant is asked an open question and these severe symptoms will only be reported with the more specific question. This makes it difficult to say whether one method is better than any other and the different questioning methods may, in fact, be complementary and therefore should be used together. It is also difficult to say what a specific question should include, as it might take too long for a participant to have to answer a very long list. While more research is needed to resolve the remaining uncertainties, it is very important for trials to be clear about which kind of questioning was used when they publish their results. This will help readers understand the trial's findings about the side effects and make it easier to make accurate comparisons between trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Allen, EN, Chandler, CIR, Mandimika, N, Leisegang, C, Barnes, K", "articleTypes": [], "doi": "10.1002/14651858.MR000039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.813Z" }, { "id": "2087f9d8-ddfb-4a86-abe5-7972de8830e4", "pmid": "", "title": "Treatment of periodontitis for glycaemic control in people with diabetes mellitus", "imported": false, "abstract": "Abstract - Background Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontitis. Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus, and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement, or non‐surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe. This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care. Objectives To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis. Search methods An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. Selection criteria We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment or adjunctive antimicrobial therapy or both) to no active intervention or 'usual care' (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least 3 months and have measured HbA1c (glycated haemoglobin). Data collection and analysis At least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials, and assessed included trials for risk of bias. Where necessary and possible, we attempted to contact study authors. Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol). Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index, and probing pocket depth), quality of life, cost implications, and diabetic complications. Main results We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel‐RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 diabetes, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair, or poor. Most studies were carried out in secondary care. We assessed two studies as being at low risk of bias, 14 studies at high risk of bias, and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings. Moderate‐certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) ‐0.59% to ‐0.28%; ‐6.4 mmol/mol to ‐3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI ‐0.52% to ‐0.08%; ‐5.7 mmol/mol to ‐0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI ‐0.55% to ‐0.45%; ‐6.0 mmol/mol to ‐4.9 mmol/mol; 1 study, 264 participants). Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, adverse effects of periodontal treatments were not evaluated in most studies. Authors' conclusions Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate‐certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in this review. Plain language summary Does treatment for gum disease help people with diabetes control blood sugar levels? Review question The main question addressed by this review is: how effective is gum disease (periodontitis) treatment for controlling blood sugar levels (known as glycaemic control) in people with diabetes, compared to no active treatment or usual care? Background The aim of treating periodontitis is to reduce swelling and infection and stabilise the condition of the gums and supporting bone. The level of sugar in the blood is too high in people with diabetes, so keeping blood sugar levels under control is a key issue. Some clinical research suggests a relationship exists between gum disease treatment and glycaemic control. Glycaemic control can be measured in different ways. For this review, we focused on HbA1c, which shows average blood glucose levels over the preceding 3 months. It can be reported as a percentage (of total haemoglobin) or as mmol/mol (millimoles per mole). Excellent glycaemic control in a diabetic person might be around 6.5% or 48 mmol/mol. This review was carried out by authors working with the Cochrane Oral Health and is part one of an update of a review previously published in 2010 and 2015. This review evaluates gum disease treatment versus no active treatment or usual care. Part two of the review will compare different types of periodontal treatment. We carried out this review as it is important to discover if gum disease treatment does improve glycaemic control in order to ensure best use of clinical resources. Study characteristics We searched six research databases and found 35 relevant trials where people with diabetes and periodontitis were randomly allocated to an experimental group or a control group. The experimental groups received gum disease treatment called 'subgingival instrumentation', also known as scaling and root planing or deep cleaning. In some experimental groups, the deep cleaning was supplemented with instructions for cleaning teeth properly ('oral hygiene instruction'), or other gum treatments, for example, antimicrobials, which are used to treat infections. Control groups received no active treatment or 'usual care', which was oral hygiene instruction, support with oral hygiene, and/or removal of plaque above the gumline. The trials randomised 3249 participants in total. Almost all participants had type 2 diabetes, with a mix of good, fair, and poor diabetic control. Most of the studies were carried out in hospitals. The studies followed up participants for between 3 and 12 months. Key results Evidence from 30 trials (results from 2443 participants) showed that periodontitis treatment reduces blood sugar levels (measured by HbA1c) in diabetic patients on average by 0.43 percentage points (e.g. from 7.43% to 7%; 4.7 mmol/mol) 3 to 4 months after receiving the treatment compared with no active treatment or usual care. A difference of 0.30% (3.3 mmol/mol) was seen after 6 months (12 studies), and 0.50% (5.4 mmol/mol) at 12 months (one study). There were not enough studies measuring side effects to be able to evaluate the risk of harm from gum disease treatments. Certainty of the evidence Most of the studies were conducted in a way that meant they were at a high risk of bias or did not provide enough information for us to make a judgement on this. However, the consistency of our findings suggests they are reliable and future research is not likely to change them. In summary, currently there is moderate‐certainty evidence to support gum disease treatment (known as subgingival instrumentation) for controlling blood sugar levels in people with periodontitis (gum disease) and diabetes up to 12 months after the start of the periodontal treatment. Date of the search The evidence is current up to 7 September 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Simpson, TC; Clarkson, JE; Worthington, HV; MacDonald, L; Weldon, JC; Needleman, I; Iheozor-Ejiofor, Z; Wild, SH; Qureshi, A; Walker, A; Patel, VA; Boyers, D; Twigg, J", "articleTypes": [], "doi": "10.1002/14651858.CD004714.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "20b20f63-dff0-4d9f-b54a-6ac20bdde734", "pmid": "", "title": "Enteral nutritional therapy for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta‐analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review. Objectives To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts. Selection criteria Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review. Data collection and analysis Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random‐effects model was used to pool data. We performed intention‐to‐treat and per‐protocol analyses for the primary outcome. Heterogeneity was explored using the Chi 2 and I 2 statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes. Main results Twenty‐seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non‐elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non‐elemental diets differing in glutamine enrichment. Meta‐analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty‐four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non‐elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per‐protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non‐elemental diets (elemental, semi‐elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non‐elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating. Ten trials compared EN to steroid therapy. Meta‐analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per‐protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per‐protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet. Authors' conclusions Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy Plain language summary Enteral nutritional therapy for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a long‐term inflammation of the gastrointestinal (GI) tract, occurring anywhere from mouth to anus. Common symptoms of this condition include abdominal pain, diarrhea and weight loss. When Crohn's disease patients are experiencing symptoms, it is characterized to be 'active' disease. When the symptoms stop, it is called 'remission'. What is enteral nutrition? Enteral nutrition is a feeding method where all of a person's daily caloric intake is delivered using the GI tract. An example of this is nasogastric tube feeding, where a tube is inserted through a person's nose to deliver their daily nutritional requirements in liquid form. Enteral nutrition can be a form of nutritional therapy for Crohn's disease patients. Enteral nutrition is categorized into elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets come from amino‐acid sources, whereas non‐elemental diets come from oligopeptide or whole protein sources. What are corticosteroids? Corticosteroids are an effective treatment option for active Crohn's disease. These drugs that are taken by mouth and work as immunosuppressants. What did the researchers investigate? The researchers studied whether enteral nutrition is better than steroid therapy at producing remission in Crohn's disease patients. In addition, the investigators looked to see if one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) at producing remission in Crohn's disease. What did the researchers find? The researchers found twenty‐seven studies (1,011 participants) that fulfilled the search criteria. Eleven of these studies, which included 378 patients, compared elemental to non‐elemental diets at producing remission in Crohn's disease. Eight studies, which included 352 patients, investigated enteral nutrition compared to steroid therapy at inducing remission in Crohn's disease. The researchers searched the medical literature extensively up to July 5, 2017. Very low quality evidence suggests that steroids may be more effective than enteral nutrition for induction of remission in adults with active Crohn's disease. Very low quality evidence also suggests that enteral nutrition may be more effective than steroids for induction of remission in children with active Crohn's disease. There was no difference in remission rates between elemental and non‐elemental diets. An increase in side effects was not seen with elemental diets compared to non‐elemental diets, nor with enteral nutrition compared to steroids. Common side effects experienced with enteral nutrition included vomiting, diarrhea, heartburn and flatulence . Common side effects associated with steroid use included acne, moon facies, muscle weakness, hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) . Patients on enteral nutrition were more likely to withdraw from the study due to side effects than those on steroids. The most common reason for study withdrawal was inability to tolerate the taste of the enteral nutrition diet. Enteral nutrition should be considered in pediatric Crohn's patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient compliance with this therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Narula, N, Dhillon, A, Zhang, D, Sherlock, ME, Tondeur, M, Zachos, M", "articleTypes": [], "doi": "10.1002/14651858.CD000542.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.128Z" }, { "id": "20b60460-2aa8-4707-b893-23aa651d6e14", "pmid": "", "title": "Sensory stimulation for brain injured individuals in coma or vegetative state", "imported": false, "abstract": "Abstract - Background Coma and vegetative state follow traumatic brain injury in about one out of eight patients, and in patients with non traumatic injury the prognosis is worse. The use of sensory stimulation for coma and vegetative state has gained popularity during the 1980's but beliefs and opinions about its effectiveness vary substantially among health professionals. Objectives To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. Search methods We searched the Injuries Group specialised register, the Cochrane Controlled trials register, EMBASE, MEDLINE, CINAHL and PSYCHLIT from 1966 to January 2002, without language restriction. Reference lists of articles were scanned and we contacted experts in the area to find other relevant studies. Selection criteria Randomised or controlled trials that compared sensory stimulation programmes with standard rehabilitation in patients in coma or vegetative state. Data collection and analysis Abstracts and papers found were screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality resolving disagreement by consensus. Main results Three studies were identified with 68 patients in total. The overall methodological quality was poor and studies differed widely in terms of outcomes measures, study design and conduct. We therefore did not carry out any quantitative synthesis but reviewed results of available studies qualitatively. Authors' conclusions This systematic review indicates that there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state. Plain language summary No strong evidence about the effects of sensory stimulation for a brain‐injured person in a coma About half of people in a coma (deep unconsciousness) because of traumatic brain injury will wake within a year of the accident. Speeding recovery to allow people to wake sooner is a priority for them and their family. One type of treatment uses sensory stimulation to try to keep the person's brain working normally. Sensory stimulation methods vary greatly, from one or two hourly sessions of a day, through to shorter sessions every hour for 12 to 14 hours a day. The review found there is no strong evidence to determine whether sensory stimulation benefits people in comas.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Lombardi, FFL, Taricco, M, De Tanti, A, Telaro, E, Liberati, A", "articleTypes": [], "doi": "10.1002/14651858.CD001427", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.769Z" }, { "id": "20b87921-9532-4a01-8712-fd4a6fc0bb42", "pmid": "", "title": "Cannabis‐based medicines and medical cannabis for adults with cancer pain", "imported": false, "abstract": "Abstract - Background Pain is a common symptom in people with cancer; 30% to 50% of people with cancer will experience moderate‐to‐severe pain. This can have a major negative impact on their quality of life. Opioid (morphine‐like) medications are commonly used to treat moderate or severe cancer pain, and are recommended for this purpose in the World Health Organization (WHO) pain treatment ladder. Pain is not sufficiently relieved by opioid medications in 10% to 15% of people with cancer. In people with insufficient relief of cancer pain, new analgesics are needed to effectively and safely supplement or replace opioids. Objectives To evaluate the benefits and harms of cannabis‐based medicines, including medical cannabis, for treating pain and other symptoms in adults with cancer compared to placebo or any other established analgesic for cancer pain. Search methods We used standard, extensive Cochrane search methods. The latest search date was 26 January 2023. Selection criteria We selected double‐blind randomised, controlled trials (RCT) of medical cannabis, plant‐derived and synthetic cannabis‐based medicines against placebo or any other active treatment for cancer pain in adults, with any treatment duration and at least 10 participants per treatment arm. Data collection and analysis We used standard Cochrane methods. The primary outcomes were 1. proportions of participants reporting no worse than mild pain; 2. Patient Global Impression of Change (PGIC) of much improved or very much improved and 3. withdrawals due to adverse events. Secondary outcomes were 4. number of participants who reported pain relief of 30% or greater and overall opioid use reduced or stable; 5. number of participants who reported pain relief of 30% or greater, or 50% or greater; 6. pain intensity; 7. sleep problems; 8. depression and anxiety; 9. daily maintenance and breakthrough opioid dosage; 10. dropouts due to lack of efficacy; 11. all central nervous system adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We identified 14 studies involving 1823 participants. No study assessed the proportions of participants reporting no worse than mild pain on treatment by 14 days after start of treatment. We found five RCTs assessing oromucosal nabiximols (tetrahydrocannabinol (THC) and cannabidiol (CBD)) or THC alone involving 1539 participants with moderate or severe pain despite opioid therapy. The double‐blind periods of the RCTs ranged between two and five weeks. Four studies with a parallel design and 1333 participants were available for meta‐analysis. There was moderate‐certainty evidence that there was no clinically relevant benefit for proportions of PGIC much or very much improved (risk difference (RD) 0.06, 95% confidence interval (CI) 0.01 to 0.12; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 8 to 100). There was moderate‐certainty evidence for no clinically relevant difference in the proportion of withdrawals due to adverse events (RD 0.04, 95% CI 0 to 0.08; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 16 to endless). There was moderate‐certainty evidence for no difference between nabiximols or THC and placebo in the frequency of serious adverse events (RD 0.02, 95% CI −0.03 to 0.07). There was moderate‐certainty evidence that nabiximols and THC used as add‐on treatment for opioid‐refractory cancer pain did not differ from placebo in reducing mean pain intensity (standardised mean difference (SMD) −0.19, 95% CI −0.40 to 0.02). There was low‐certainty evidence that a synthetic THC analogue (nabilone) delivered over eight weeks was not superior to placebo in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and non‐small cell lung cancer (2 studies, 89 participants, qualitative analysis). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that synthetic THC analogues were superior to placebo (SMD −0.98, 95% CI −1.36 to −0.60), but not superior to low‐dose codeine (SMD 0.03, 95% CI −0.25 to 0.32; 5 single‐dose trials; 126 participants) in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours (2 single‐dose trials; 66 participants). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that CBD oil did not add value to specialist palliative care alone in the reduction of pain intensity in people with advanced cancer. There was no difference in the number of dropouts due to adverse events and serious adverse events (1 study, 144 participants, qualitative analysis). We found no studies using herbal cannabis. Authors' conclusions There is moderate‐certainty evidence that oromucosal nabiximols and THC are ineffective in relieving moderate‐to‐severe opioid‐refractory cancer pain. There is low‐certainty evidence that nabilone is ineffective in reducing pain associated with (radio‐) chemotherapy in people with head and neck cancer and non‐small cell lung cancer. There is low‐certainty evidence that a single dose of synthetic THC analogues is not superior to a single low‐dose morphine equivalent in reducing moderate‐to‐severe cancer pain. There is low‐certainty evidence that CBD does not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. Plain language summary Cannabis‐based medicines for cancer pain Do medicines based on cannabis help adults with cancer pain? Key messages Cannabis‐based medicines (CbMs) did not relieve cancer pain that did not respond to morphine‐like medicines. The studies analysed did not allow any statement to be made on the place of these medications in the World Health Organization (WHO) analgesic ladder for cancer pain. Trials with CbMs in cancer need to be very much better designed than those conducted so far. Pain in cancer and its treatment One person in two or three who gets cancer will have pain that becomes moderate or severe in intensity. The pain tends to get worse as the cancer progresses. The WHO recommends taking morphine‐like medicines for moderate‐to‐severe pain from cancer, but 1 in 6 to 10 people with cancer pain do not experience sufficient pain relief from morphine‐like medicines. Several products based on the cannabis plant have been suggested as treatment for cancer pain. These products include inhaled or orally ingested herbal cannabis, and various oils, sprays or tablets containing active cannabis ingredients obtained from the plant, or made synthetically. Some people with cancer pain have reported that CbMs are effective for them, and that is often highlighted in the media. What did we want to find out? If CbMs relieved cancer pain in people living with cancer. If CbMs were associated with any unwanted or harmful effects. What did we do? We searched for clinical trials that examined CbMs compared to other medications to treat cancer pain in adults. We summarised the results of the studies and rated our confidence in the evidence, based on factors such as the methods and size of studies. What did we find? We found 14 studies involving 1823 people. The biggest study included 399 people and the smallest study included 10 people. Studies were conducted in countries around the world; most (six) were based in North America. Five studies used one dose of CbM and lasted less than one day. Other studies lasted between two and eight weeks. Pharmaceutical companies funded seven studies. Six studies compared a mouth spray with a plant‐derived combination of tetrahydrocannabinol (THC), the principal psychoactive constituent of cannabis, and cannabidiol (CBD), an anti‐inflammatory ingredient of cannabis, against a fake medication (placebo). Seven studies compared an artificial cannabinoid mimicking the effects of THC against placebo. Of these seven studies, two studies compared against a morphine‐like medication (codeine), too. One study compared CBD against placebo. We did not find studies with herbal cannabis. Main results Mouth spray with a plant‐derived combination of THC and CBD was probably not better than placebo in reducing pain in people with moderate‐to‐severe cancer pain despite opioid treatment. Thirty‐two out of 100 people reported to be much or very much improved by cannabis‐based mouth spray and 23 out of 100 people with mouth spray with placebo. A total of 19 out of 100 people withdrew early because of side effects by cannabis‐based mouth spray and 16 out of 100 people by mouth spray with placebo. There was no difference in serious side effects between the cannabis‐based mouth spray and a placebo mouth spray. Artificial cannabinoid mimicking the effects of THC may not be better than a fake medication in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and a certain type of lung cancer. A single dose of an artificial cannabinoid mimicking the effects of THC may be better than a single dose of placebo, but may not differ from a single small dose of a morphine‐like medication in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours. CBD may not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. We found no studies with medical cannabis. What are the limitations of the evidence? We are moderately confident in the evidence that a mouth spray with a plant‐derived combination of THC and CBD does not reduce severe cancer pain despite opioid treatment because studies did not provide information about everything that we could have used. We have little confidence in the evidence that an artificial cannabinoid mimicking the effects of THC (nabilone) does not reduce pain associated with chemotherapy or radiochemotherapy because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that artificial cannabinoids mimicking the effects of THC reduce cancer pain after the previous pain‐relieving medication was stopped some hours before because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that CBD added to standard palliative care does not reduce cancer pain because there was only one study available. How up to date is the evidence? The evidence is up to date to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Häuser, W; Welsch, P; Radbruch, L; Fisher, E; Bell, RF; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD014915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "20c8b31f-d896-4fee-9c73-38d917293c79", "pmid": "", "title": "Blood pressure lowering efficacy of potassium‐sparing diuretics (that block the epithelial sodium channel) for primary hypertension", "imported": false, "abstract": "Abstract - Background Potassium‐sparing diuretics, which block the epithelial sodium channel (ENaC), are widely prescribed for hypertension as a second‐line drug in patients taking other diuretics (e.g. thiazide diuretics) and much less commonly prescribed as monotherapy. Therefore, it is essential to determine the effects of ENaC blockers on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a first‐line or second‐line therapy. Objectives To quantify the dose‐related reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of ENaC blocker therapy as a first‐line or second‐line drug in patients with primary hypertension. Search methods We searched CENTRAL (The Cochrane Library 2012), MEDLINE (1950 to August 2012), EMBASE (1980 to August 2012) and reference lists of articles. Selection criteria Double‐blind, randomized, controlled trials in patients with primary hypertension that evaluate, for a duration of 3 to 12 weeks, the BP lowering efficacy of: 1) fixed‐dose monotherapy with an ENaC blocker compared with placebo; or 2) an ENaC blocker in combination with another class of anti‐hypertensive drugs compared with the respective monotherapy (without an ENaC blocker). Data collection and analysis Two authors independently assessed the risk of bias and extracted data. Study authors were contacted for additional information. WDAE information was also collected from the trials. Main results No trials evaluating the BP lowering efficacy of ENaC blockers as monotherapy in patients with primary hypertension were identified. Only 6 trials evaluated the BP lowering efficacy of low doses of amiloride and triamterene as a second drug in 496 participants with a baseline BP of 151/102 mm Hg. The additional BP reduction caused by the ENaC blocker as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. The addition of low doses of amiloride and triamterene in these trials did not reduce BP. An estimate of the dose‐related BP lowering efficacy for ENaC blockers was not possible because of a lack of trial data at higher doses. Authors' conclusions ENaC blockers do not have a statistically or clinically significant BP lowering effect at low doses but trials at higher doses are not available. The review did not provide a good estimate of the incidence of harms associated with ENaC blockers. Plain language summary The blood pressure lowering effect of ENaC blockers is not known Potassium‐sparing diuretics, which block the epithelial sodium channel (also called ENaC blockers), are a class of drugs commonly prescribed to prevent loss of potassium but also might help to lower elevated blood pressure. This class includes drugs such as amiloride (Midamor, Amilzide) and triamterene (Dyrenium, Dyazide). We asked how much this class of drugs lowers blood pressure, when used alone or when used as the second drug to treat hypertension. The available scientific literature was searched to find all the trials that had assessed this question. No trials were found studying the blood pressure lowering ability of ENaC blockers when used alone. We found 6 trials studying the blood pressure lowering ability of amiloride and triamterene, when added as a second drug, in 496 participants. All 6 trials studied the ENaC blockers at low doses and there was no blood pressure lowering effect. Trials studying these drugs at higher doses are needed in order to determine if they lower blood pressure. The harms associated with ENaC blockers could not be estimated in this review because of the low doses studied and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Heran, BS, Chen, JMH, Wang, JJ, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD008167.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.762Z" }, { "id": "20d652b6-6de2-40fe-9eb7-a688ca7c72ec", "pmid": "", "title": "The Molecular Basis for a Broad Range of Phenotypes Related to hTAS2R38", "imported": false, "abstract": "This single-site, within-subject, experimental study is designed to test the hypothesis that individuals express taste receptors differently and have different sensitivities to bitter taste samples, which results from uneven expression. Subjects will include 100 racially and ethnically diverse, healthy adults. All subjects will provide saliva samples for genetic analysis and undergo taste testing with common psychophysical stimuli. From the pool of 100 subjects, 36 subjects from the common heterozygous group (PAV/AVI) and two from each homozygous group (AVI/AVI, nontaster and PAV/PAV, taster) will be invited to return for two additional sessions. During both sessions the investigators will 1) measure bitterness thresholds for PROP, a common psychophysical stimulus; 2) measure bitterness perception of several vegetables; 3) obtain a saliva sample and 4) collect taste papillae. The investigators will then isolate DNA and RNA from the taste papillae and isolate DNA from saliva to evaluate molecular differences over time and between individuals and how it relates to taste psychophysics. All psychophysical and cellular measurements will be done during both sessions so that the investigators can determine how much variation is observed over a one-week time period in both cellular phenotype and psychophysical phenotype.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.147Z" }, { "id": "20e38b5a-5413-4dc7-825b-826a19e47e7a", "pmid": "", "title": "Cannabis‐based medicines and medical cannabis for adults with cancer pain", "imported": false, "abstract": "Abstract - Background Pain is a common symptom in people with cancer; 30% to 50% of people with cancer will experience moderate‐to‐severe pain. This can have a major negative impact on their quality of life. Opioid (morphine‐like) medications are commonly used to treat moderate or severe cancer pain, and are recommended for this purpose in the World Health Organization (WHO) pain treatment ladder. Pain is not sufficiently relieved by opioid medications in 10% to 15% of people with cancer. In people with insufficient relief of cancer pain, new analgesics are needed to effectively and safely supplement or replace opioids. Objectives To evaluate the benefits and harms of cannabis‐based medicines, including medical cannabis, for treating pain and other symptoms in adults with cancer compared to placebo or any other established analgesic for cancer pain. Search methods We used standard, extensive Cochrane search methods. The latest search date was 26 January 2023. Selection criteria We selected double‐blind randomised, controlled trials (RCT) of medical cannabis, plant‐derived and synthetic cannabis‐based medicines against placebo or any other active treatment for cancer pain in adults, with any treatment duration and at least 10 participants per treatment arm. Data collection and analysis We used standard Cochrane methods. The primary outcomes were 1. proportions of participants reporting no worse than mild pain; 2. Patient Global Impression of Change (PGIC) of much improved or very much improved and 3. withdrawals due to adverse events. Secondary outcomes were 4. number of participants who reported pain relief of 30% or greater and overall opioid use reduced or stable; 5. number of participants who reported pain relief of 30% or greater, or 50% or greater; 6. pain intensity; 7. sleep problems; 8. depression and anxiety; 9. daily maintenance and breakthrough opioid dosage; 10. dropouts due to lack of efficacy; 11. all central nervous system adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We identified 14 studies involving 1823 participants. No study assessed the proportions of participants reporting no worse than mild pain on treatment by 14 days after start of treatment. We found five RCTs assessing oromucosal nabiximols (tetrahydrocannabinol (THC) and cannabidiol (CBD)) or THC alone involving 1539 participants with moderate or severe pain despite opioid therapy. The double‐blind periods of the RCTs ranged between two and five weeks. Four studies with a parallel design and 1333 participants were available for meta‐analysis. There was moderate‐certainty evidence that there was no clinically relevant benefit for proportions of PGIC much or very much improved (risk difference (RD) 0.06, 95% confidence interval (CI) 0.01 to 0.12; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 8 to 100). There was moderate‐certainty evidence for no clinically relevant difference in the proportion of withdrawals due to adverse events (RD 0.04, 95% CI 0 to 0.08; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 16 to endless). There was moderate‐certainty evidence for no difference between nabiximols or THC and placebo in the frequency of serious adverse events (RD 0.02, 95% CI −0.03 to 0.07). There was moderate‐certainty evidence that nabiximols and THC used as add‐on treatment for opioid‐refractory cancer pain did not differ from placebo in reducing mean pain intensity (standardised mean difference (SMD) −0.19, 95% CI −0.40 to 0.02). There was low‐certainty evidence that a synthetic THC analogue (nabilone) delivered over eight weeks was not superior to placebo in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and non‐small cell lung cancer (2 studies, 89 participants, qualitative analysis). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that synthetic THC analogues were superior to placebo (SMD −0.98, 95% CI −1.36 to −0.60), but not superior to low‐dose codeine (SMD 0.03, 95% CI −0.25 to 0.32; 5 single‐dose trials; 126 participants) in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours (2 single‐dose trials; 66 participants). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that CBD oil did not add value to specialist palliative care alone in the reduction of pain intensity in people with advanced cancer. There was no difference in the number of dropouts due to adverse events and serious adverse events (1 study, 144 participants, qualitative analysis). We found no studies using herbal cannabis. Authors' conclusions There is moderate‐certainty evidence that oromucosal nabiximols and THC are ineffective in relieving moderate‐to‐severe opioid‐refractory cancer pain. There is low‐certainty evidence that nabilone is ineffective in reducing pain associated with (radio‐) chemotherapy in people with head and neck cancer and non‐small cell lung cancer. There is low‐certainty evidence that a single dose of synthetic THC analogues is not superior to a single low‐dose morphine equivalent in reducing moderate‐to‐severe cancer pain. There is low‐certainty evidence that CBD does not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. Plain language summary Cannabis‐based medicines for cancer pain Do medicines based on cannabis help adults with cancer pain? Key messages Cannabis‐based medicines (CbMs) did not relieve cancer pain that did not respond to morphine‐like medicines. The studies analysed did not allow any statement to be made on the place of these medications in the World Health Organization (WHO) analgesic ladder for cancer pain. Trials with CbMs in cancer need to be very much better designed than those conducted so far. Pain in cancer and its treatment One person in two or three who gets cancer will have pain that becomes moderate or severe in intensity. The pain tends to get worse as the cancer progresses. The WHO recommends taking morphine‐like medicines for moderate‐to‐severe pain from cancer, but 1 in 6 to 10 people with cancer pain do not experience sufficient pain relief from morphine‐like medicines. Several products based on the cannabis plant have been suggested as treatment for cancer pain. These products include inhaled or orally ingested herbal cannabis, and various oils, sprays or tablets containing active cannabis ingredients obtained from the plant, or made synthetically. Some people with cancer pain have reported that CbMs are effective for them, and that is often highlighted in the media. What did we want to find out? If CbMs relieved cancer pain in people living with cancer. If CbMs were associated with any unwanted or harmful effects. What did we do? We searched for clinical trials that examined CbMs compared to other medications to treat cancer pain in adults. We summarised the results of the studies and rated our confidence in the evidence, based on factors such as the methods and size of studies. What did we find? We found 14 studies involving 1823 people. The biggest study included 399 people and the smallest study included 10 people. Studies were conducted in countries around the world; most (six) were based in North America. Five studies used one dose of CbM and lasted less than one day. Other studies lasted between two and eight weeks. Pharmaceutical companies funded seven studies. Six studies compared a mouth spray with a plant‐derived combination of tetrahydrocannabinol (THC), the principal psychoactive constituent of cannabis, and cannabidiol (CBD), an anti‐inflammatory ingredient of cannabis, against a fake medication (placebo). Seven studies compared an artificial cannabinoid mimicking the effects of THC against placebo. Of these seven studies, two studies compared against a morphine‐like medication (codeine), too. One study compared CBD against placebo. We did not find studies with herbal cannabis. Main results Mouth spray with a plant‐derived combination of THC and CBD was probably not better than placebo in reducing pain in people with moderate‐to‐severe cancer pain despite opioid treatment. Thirty‐two out of 100 people reported to be much or very much improved by cannabis‐based mouth spray and 23 out of 100 people with mouth spray with placebo. A total of 19 out of 100 people withdrew early because of side effects by cannabis‐based mouth spray and 16 out of 100 people by mouth spray with placebo. There was no difference in serious side effects between the cannabis‐based mouth spray and a placebo mouth spray. Artificial cannabinoid mimicking the effects of THC may not be better than a fake medication in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and a certain type of lung cancer. A single dose of an artificial cannabinoid mimicking the effects of THC may be better than a single dose of placebo, but may not differ from a single small dose of a morphine‐like medication in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours. CBD may not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. We found no studies with medical cannabis. What are the limitations of the evidence? We are moderately confident in the evidence that a mouth spray with a plant‐derived combination of THC and CBD does not reduce severe cancer pain despite opioid treatment because studies did not provide information about everything that we could have used. We have little confidence in the evidence that an artificial cannabinoid mimicking the effects of THC (nabilone) does not reduce pain associated with chemotherapy or radiochemotherapy because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that artificial cannabinoids mimicking the effects of THC reduce cancer pain after the previous pain‐relieving medication was stopped some hours before because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that CBD added to standard palliative care does not reduce cancer pain because there was only one study available. How up to date is the evidence? The evidence is up to date to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Häuser, W; Welsch, P; Radbruch, L; Fisher, E; Bell, RF; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD014915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "20e4497b-b5eb-4249-8880-da189c90571a", "pmid": "", "title": "Treatment and prevention of pouchitis after ileal pouch‐anal anastomosis for chronic ulcerative colitis", "imported": false, "abstract": "Abstract - Background Pouchitis occurs in approximately 50% of patients following ileal pouch‐anal anastomosis (IPAA) for chronic ulcerative colitis (UC). Objectives The primary objective was to determine the efficacy and safety of medical therapies for prevention or treatment of acute or chronic pouchitis. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 25 July 2018. We also searched references, trials registers, and conference proceedings. Selection criteria Randomized controlled trials of prevention or treatment of acute or chronic pouchitis in adults who underwent IPAA for UC were considered for inclusion. Data collection and analysis Two authors independently screened studies for eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was evaluated using GRADE. The primary outcome was clinical improvement or remission in participants with acute or chronic pouchitis, or the proportion of participants with no episodes of pouchitis after IPAA. Adverse events (AEs) was a secondary outcome. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for each dichotomous outcome. Main results Fifteen studies (547 participants) were included. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Three studies were low risk of bias. Three studies were high risk of bias and the other studies were unclear. Acute pouchitis: All ciprofloxacin participants (7/7) achieved remission at two weeks compared to 33% (3/9) of metronidazole participants (RR 2.68, 95% CI 1.13 to 6.35, very low certainty evidence). No ciprofloxacin participants (0/7) had an AE compared to 33% (3/9) of metronidazole participants (RR 0.18, 95% CI 0.01 to 2.98; very low certainty evidence). AEs included vomiting, dysgeusia or transient peripheral neuropathy. Forty‐three per cent (6/14) of metronidazole participants achieved remission at 6 weeks compared to 50% (6/12) of budesonide enema participants (RR 0.86, 95% CI 0.37 to 1.96, very low certainty evidence). Fifty per cent (7/14) of metronidazole participants improved clinically at 6 weeks compared to 58% (7/12) of budesonide enema participants (RR 0.86, 95% CI 0.42 to 1.74, very low certainty evidence). Fifty‐seven per cent (8/14) of metronidazole participants had an AE compared to 25% (3/12) of budesonide enema participants (RR 2.29, 95% CI 0.78 to 6.73, very low certainty evidence). AEs included anorexia, nausea, headache, asthenia, metallic taste, vomiting, paraesthesia, and depression. Twenty‐five per cent (2/8) of rifaximin participants achieved remission at 4 weeks compared to 0% (0/10) of placebo participants (RR 6.11, 95% CI 0.33 to 111.71, very low certainty evidence). Thirty‐eight per cent (3/8) of rifaximin participants improved clinically at 4 weeks compared to 30% (3/10) of placebo participants (RR 1.25, 95% CI 0.34 to 4.60, very low certainty evidence). Seventy‐five per cent (6/8) of rifaximin participants had an AE compared to 50% (5/10) of placebo participants (RR 1.50, 95% CI 0.72 to 3.14, very low certainty evidence). AEs included diarrhea, flatulence, nausea, proctalgia, vomiting, thirst, candida, upper respiratory tract infection, increased hepatic enzyme, and cluster headache. Ten per cent (1/10) of Lactobacillus GG participants improved clinically at 12 weeks compared to 0% (0/10) of placebo participants (RR 3.00, 95% CI 0.14 to 65.90, very low certainty evidence). Chronic pouchitis: Eighty‐five per cent (34/40) of De Simone Formulation (a probiotic formulation) participants maintained remission at 9 to 12 months compared to 3% (1/36) of placebo participants (RR 20.24, 95% CI 4.28 to 95.81, 2 studies; low certainty evidence). Two per cent (1/40) of De Simone Formulation participants had an AE compared to 0% (0/36) of placebo participants (RR 2.43, 95% CI 0.11 to 55.89; low certainty evidence). AEs included abdominal cramps, vomiting and diarrhea. Fifty per cent (3/6) of adalimumab patients achieved clinical improvement at 4 weeks compared to 43% (3/7) of placebo participants (RR, 1.17, 95% CI 0.36 to 3.76, low certainty evidence). Sixty per cent (6/10) of glutamine participants maintained remission at 3 weeks compared to 33% (3/9) of butyrate participants (RR 1.80, 95% CI 0.63 to 5.16, very low certainty evidence). Forty‐five per cent (9/20) of patients treated with bismuth carbomer foam enema improved clinically at 3 weeks compared to 45% (9/20) of placebo participants (RR 1.00, 95% CI 0.50 to 1.98, very low certainty evidence). Twenty‐five per cent (5/20) of participants in the bismuth carbomer foam enema group had an AE compared to 35% (7/20) of placebo participants (RR 0.71, 95% CI 0.27 to 1.88, very low certainty evidence). Adverse events included diarrhea, worsening symptoms, cramping, sinusitis, and abdominal pain. Prevention: At 12 months, 90% (18/20) of De Simone Formulation participants had no episodes of acute pouchitis compared to 60% (12/20) of placebo participants (RR 1.50, 95% CI 1.02 to 2.21, low certainty evidence). Another study found 100% (16/16) of De Simone Formulation participants had no episodes of acute pouchitis at 12 months compared to 92% (11/12) of the no treatment control group (RR 1.10, 95% 0.89 to 1.36, very low certainty evidence). Eighty‐six per cent (6/7) of Bifidobacterium longum participants had no episodes of acute pouchitis at 6 months compared to 60% (3/5) of placebo participants (RR 1.43, 95% CI 0.66 to 3.11, very low certainty evidence). Eleven per cent (1/9) of Clostridium butyricum MIYAIRI participants had no episodes of acute pouchitis at 24 months compared to 50% (4/8) of placebo participants (RR 0.22, 95% CI 0.03 to 1.60, very low certainty evidence). Forty‐six per cent (43/94) of allopurinol participants had no episodes of pouchitis at 24 months compared to 43% (39/90) of placebo participants (RR 1.06, 95% CI 0.76 to 1.46; low certainty evidence). Eighty‐one per cent (21/26) of tinidazole participants had no episodes of pouchitis over 12 months compared to 58% (7/12) of placebo participants (RR 1.38, 95% CI 0.83 to 2.31, very low certainty evidence). Authors' conclusions The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. Well designed, adequately powered studies are needed to determine the optimal therapy for the treatment and prevention of pouchitis. Plain language summary Therapy for treatment and prevention of pouchitis What is pouchitis? Some people with ulcerative colitis have their colon and rectum removed with construction of a pouch (made from a loop of small intestine) in place of the rectum ‐ known as ileal pouch‐anal anastomosis (IPAA) surgery. Pouchitis is inflammation of the surgically‐constructed pouch. Symptoms of active pouchitis include diarrhea, increased stool frequency, abdominal cramping, fecal urgency, tenesmus (feeling of constantly needing to pass stools), and incontinence. Acute refers to symptoms that last less than four weeks while chronic refers to symptoms that last more than four weeks. Periods when symptoms stop are called 'remission'. What therapies are used for pouchitis? Therapies used for pouchitis include antibiotics (drugs for bacteria infections), budesonide enemas (a steroid drug), probiotics (helpful bacteria), biologic agents that target tumor necrosis factor, glutamine suppositories (an amino acid), butyrate suppositories (short chain fatty acid), bismuth enemas (diarrhea medication), allopurinol (a purine analogue drug), and tinidazole (an anti‐parasitic drug). What did the researchers investigate? The researchers investigated whether these medications produce remission in people with active pouchitis, maintain remission in people with inactive pouchitis or prevent pouchitis in people who've had IPAA surgery. Side effects were also assessed. The medical literature was searched up to 25 July 2018. What did the researchers find? We found 15 studies with a total of 547 participants. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Acute pouchitis: It is uncertain whether ciprofloxacin is more effective than metronidazole for treatment of acute pouchitis (1 study, 16 participants). Side effects included vomiting, metallic taste and temporary damage to nerves. It is unclear whether there are any differences between metronidazole and budesonide enemas in terms of clinical remission, symptom improvement or side effects (1 study, 26 participants). Side effects included anorexia, nausea, headache, lack of energy and strength, metallic taste, vomiting, pins and needles, and depression. It is uncertain whether there are any differences between rifaximin and placebo in terms of clinical remission, symptom improvement, or side effects (1 study, 18 participants). Side effects included diarrhea, flatulence, nausea, rectal pain, vomiting, thirst, yeast infection, common cold, increased liver enzymes, and cluster headache. It is uncertain whether there is any difference between Lactobacillus GG and placebo in symptom improvement (1 study, 20 participants. The results of these studies are uncertain due to low event numbers caused by the small numbers of people who participated in the studies. Chronic pouchitis: It is uncertain whether De Simone Formulation (a probiotic formulation) is more effective than placebo for maintaining remission in people with inactive disease (2 studies, 76 participants). Side effects included abdominal cramps, vomiting and diarrhea. It is unclear whether there is any difference in effectiveness between adalimumab and placebo for treating chronic pouchitis(1 study, 13 participants). It is unclear whether there is any difference between glutamine and butyrate suppositories for maintenance of remission (1 study, 19 participants). It is unclear whether there are any differences in symptom improvement or side effects between bismuth carbomer foam enemas and placebo (1 study, 40 participants). Side effects included diarrhea, worsening symptoms, cramping, sinus infection, and abdominal pain. The results of these studies are uncertain due to the small number of people who participated in the studies. Prevention of pouchitis: It is uncertain whether De Simone Formulation is more effective than placebo for prevention of pouchitis (1 study, 40 participants). However, it is unclear whether there is any difference in prevention of pouchitis between De Simone Formulation and a no treatment control group (1 study, 28 participants). It is unclear whether there are any differences in prevention of pouchitis between Clostridium butyricum MIYAIRI and placebo (1 study, 17 participants) , Bifidobacterium longum and placebo (1 study, 12 participants) , allopurinol and placebo (1 study, 184 participants) and tinidazole and placebo (1 study, 38 participants). The results of these studies are uncertain due to the small number of people who participated in the studies. The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. More research is needed to determine which of these different medications are best for treatment of pouchitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nguyen, N, Zhang, B, Holubar, SD, Pardi, DS, Singh, S", "articleTypes": [], "doi": "10.1002/14651858.CD001176.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.749Z" }, { "id": "20f35bfb-f037-48ce-8e38-cada8be0dd1f", "pmid": "", "title": "Dual antibiotics for bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is a chronic respiratory disease characterised by abnormal and irreversible dilatation of the smaller airways and associated with a mortality rate greater than twice that of the general population. Antibiotics serve as front‐line therapy for managing bacterial load, but their use is weighed against the development of antibiotic resistance. Dual antibiotic therapy has the potential to suppress infection from multiple strains of bacteria, leading to more successful treatment of exacerbations, reduced symptoms, and improved quality of life. Further evidence is required on the efficacy of dual antibiotics in terms of management of exacerbations and extent of antibiotic resistance. Objectives To evaluate the effects of dual antibiotics in the treatment of adults and children with bronchiectasis. Search methods We identified studies from the Cochrane Airways Group Specialised Register (CAGR), which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED), and PsycINFO, as well as studies obtained by handsearching of journals/abstracts. We also searched the following trial registries: US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. We imposed no restriction on language of publication. We conducted our search in October 2017. Selection criteria We searched for randomised controlled trials comparing dual antibiotics versus a single antibiotic for short‐term (< 4 weeks) or long‐term management of bronchiectasis diagnosed in adults and/or children by bronchography, plain film chest radiography, or high‐resolution computed tomography. Primary outcomes included exacerbations, length of hospitalisation, and serious adverse events. Secondary outcomes were response rates, emergence of resistance to antibiotics, systemic markers of infection, sputum volume and purulence, measures of lung function, adverse events/effects, deaths, exercise capacity, and health‐related quality of life. We did not apply outcome measures as selection criteria. Data collection and analysis Two review authors independently screened the titles and abstracts of 287 records, along with the full text of seven reports. Two studies met review inclusion criteria. Two review authors independently extracted outcome data and assessed risk of bias . We extracted data from only one study and conducted GRADE assessments for the following outcomes: successful treatment of exacerbation; response rates; and serious adverse events. Main results Two randomised trials assessed the effectiveness of oral plus inhaled dual therapy versus oral monotherapy in a total of 118 adults with a mean age of 62.8 years. One multi‐centre trial compared inhaled tobramycin plus oral ciprofloxacin versus ciprofloxacin alone, and one single‐centre trial compared nebulised gentamicin plus systemic antibiotics versus a systemic antibiotic alone. Published papers did not report study funding sources. Effect estimates from one small study with 53 adults showed no evidence of treatment benefit with oral plus inhaled dual therapy for the following primary outcomes at the end of the study: successful management of exacerbation ‐ cure at day 42 (odds ratio (OR) 0.66, 95% confidence interval (CI) 0.22 to 2.01; 53 participants; one study; very low‐quality evidence); number of participants with Pseudomonas aeruginosa eradication at day 21 (OR 2.33, 95% CI 0.66 to 8.24; 53 participants; one study; very low‐quality evidence); and serious adverse events (OR 0.48, 95% CI 0.08 to 2.87; 53 participants; one study; very low‐quality evidence). Similarly, researchers provided no evidence of treatment benefit for the following secondary outcomes: clinical response rates ‐ relapse at day 42 (OR 0.57, 95% CI 0.12 to 2.69; 53 participants; one study; very low‐quality evidence); microbiological response rate at day 21 ‐ eradicated (OR 2.40, 95% CI 0.67 to 8.65; 53 participants; one study; very low‐quality evidence); and adverse events ‐ incidence of wheeze (OR 5.75, 95% CI 1.55 to 21.33). Data show no evidence of benefit in terms of sputum volume, lung function, or antibiotic resistance. Outcomes from a second small study with 65 adults, available only as an abstract, were not included in the quantitative data synthesis. The included studies did not report our other primary outcomes: duration; frequency; and time to next exacerbation; nor our secondary outcomes: systemic markers of infection; exercise capacity; and quality of life. We did not identify any trials that included children. Authors' conclusions A small number of studies in adults have generated high‐quality evidence that is insufficient to inform robust conclusions, and studies in children have provided no evidence. We identified only one dual‐therapy combination of oral and inhaled antibiotics. Results from this single trial of 53 adults that we were able to include in the quantitative synthesis showed no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, serious adverse events, sputum volume, lung function, and antibiotic resistance. Further high‐quality research is required to determine the efficacy and safety of other combinations of dual antibiotics for both adults and children with bronchiectasis, particularly in terms of antibiotic resistance. Plain language summary Dual antibiotics for bronchiectasis Background to the question Bronchiectasis is a lung disease involving abnormal airways, leading to repeated chest infections, and associated with a mortality rate more than twice that of the general population. Although previously considered a relatively rare disease, numbers appear to be increasing, particularly for those over 75 years in low/middle‐income countries. Antibiotics are the main therapy for chest infection, but their use must be weighed against potential side effects and the risk of increasing resistance to antibiotic therapy. One strategy to improve response and/or reduce antibiotic resistance involves giving two antibiotic agents at the same time: dual antibiotic therapy. This review therefore aimed to evaluate the effects of dual antibiotics for treatment of adults and children with bronchiectasis. Study characteristics In October 2017, we identified two relevant studies comparing oral plus inhaled dual therapy versus oral therapy alone. They included a total of 118 adults with an average age of 62.8 years. One study compared inhaled tobramycin plus oral ciprofloxacin with oral ciprofloxacin, and the second study compared inhaled gentamicin plus a systemic (affecting the whole body, rather than just the lungs) antibiotic with a systemic antibiotic alone. Only a research summary was available for the latter. Published papers did not report study funding sources Main results Results from one small trial of 53 adults show no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, the occurrence of serious unwanted events, amount of phlegm, lung function, or resistance to antibiotic treatment. However, we found insufficient evidence to permit confident conclusions about their use. Quality of the evidence The overall quality of the evidence was very poor, largely because one of the studies was not well described and included few participants. Information on exacerbations, exercise ability, and quality of life was not reported. We did not identify any trials that compared other types of dual antibiotic therapy, and we found none that included children. Therefore uncertainty remains concerning the use of dual antibiotics, and further high‐quality studies are needed to examine the role of dual antibiotics in the treatment of adults and children with bronchiectasis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Felix, LM, Grundy, S, Milan, SJ, Armstrong, R, Harrison, H, Lynes, D, Spencer, S", "articleTypes": [], "doi": "10.1002/14651858.CD012514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.093Z" }, { "id": "2102ce05-d4b4-49ca-9ec2-1392c5fb558e", "pmid": "", "title": "Omega‐3 fatty acids supplementation for autism spectrum disorders (ASD)", "imported": false, "abstract": "Abstract - Background It has been suggested that impairments associated with autism spectrum disorders (ASD) may be partially explained by deficits of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. Objectives To review the efficacy of omega‐3 fatty acids for improving core features of ASD (for example, social interaction, communication, and stereotypies) and associated symptoms. Search methods We searched the following databases on 2 June 2010: CENTRAL (2010, Issue 2), MEDLINE (1950 to May Week 3 2010), EMBASE (1980 to 2010 Week 21), PsycINFO (1806 to current), BIOSIS (1985 to current), CINAHL (1982 to current), Science Citation Index (1970 to current), Social Science Citation Index (1970 to current), metaRegister of Controlled Trials (20 November 2008) and ClinicalTrials.gov (10 December 2010). Dissertation Abstracts International was searched on 10 December 2008, but was no longer available to the authors or editorial base in 2010. Selection criteria All randomised controlled trials of omega‐3 fatty acids supplementation compared to placebo in individuals with ASD. Data collection and analysis Three authors independently selected studies, assessed them for risk of bias and extracted relevant data. We conducted meta‐analysis of the included studies for three primary outcomes (social interaction, communication, and stereotypy) and one secondary outcome (hyperactivity). Main results We included two trials with a total of 37 children diagnosed with ASD who were randomised into groups that received either omega‐3 fatty acids supplementation or a placebo. We excluded six trials because they were either non‐randomised controlled trials, did not contain a control group, or the control group did not receive a placebo. Overall, there was no evidence that omega‐3 supplements had an effect on social interaction (mean difference (MD) 0.82, 95% confidence interval (CI) ‐2.84 to 4.48, I 2 = 0%), communication (MD 0.62, 95% CI ‐0.89 to 2.14, I 2 = 0%), stereotypy (MD 0.77, 95% CI ‐0.69 to 2.22, I 2 = 8%), or hyperactivity (MD 3.46, 95% CI ‐0.79 to 7.70, I 2 = 0%). Authors' conclusions To date there is no high quality evidence that omega‐3 fatty acids supplementation is effective for improving core and associated symptoms of ASD. Given the paucity of rigorous studies in this area, there is a need for large well‐conducted randomised controlled trials that examine both high and low functioning individuals with ASD, and that have longer follow‐up periods. Plain language summary Omega‐3 fatty acids for autism spectrum disorders (ASD) It has been suggested that difficulties associated with ASD may be explained in part by lack of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. The purpose of this review was to assess the evidence for the effectiveness of omega‐3 supplementation for core features of ASD and associated symptoms. We found only two small randomised controlled trials that evaluated omega‐3 fatty acids for ASD. There is insufficient evidence that omega‐3 fatty acids supplementation is an effective treatment for ASD. However, high quality large randomised controlled trials are needed before definite recommendations about this treatment can be made.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "James, S, Montgomery, P, Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD007992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.741Z" }, { "id": "211232cd-d49c-45a0-88a9-9158059c518c", "pmid": "", "title": "Alarm interventions for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs. Objectives To assess the effects of enuresis alarms for treating enuresis in children. Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old. Data collection and analysis Two review authors independently assessed risk of bias and extracted data. Main results We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) −2.68, 95% confidence interval (CI) −4.59 to −0.78; 4 trials, 127 children; low‐quality evidence). Low‐quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post‐treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low‐quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD −0.96, 95% CI −2.32 to 0.41; 1 trial, 47 children; very low‐quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low‐quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post‐treatment. Compared with control alarms, code‐word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate‐quality evidence) but there is probably little to no difference in the number of children remaining dry post‐treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate‐quality evidence). Very low‐quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry‐bed training, and star chart plus rewards) (MD ‐0.81, 95% CI ‐2.01 to 0.38; low‐quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low‐quality evidence) and may slightly increase the number of children remaining dry post‐treatment (RR 1.39, 95% CI 0.81 to 2.41; low‐quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD −0.64, 95% CI −1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low‐quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post‐treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate‐quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post‐treatment, because the quality of evidence is very low. Due to very low‐quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD −0.88, 95% CI −0.38 to −1.38; 2 trials, 156 children; low‐quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low‐quality evidence) and the number of children remaining dry post‐treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low‐quality evidence) compared with desmopressin alone. Alarm plus dry‐bed training may increase the number of children achieving a complete response compared to dry‐bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low‐quality evidence). It is unclear if there is any difference in the number of children remaining dry post‐treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low‐quality evidence). Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code‐word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate‐quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate‐quality evidence). Very low‐quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments. Authors' conclusions Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately‐powered trials with robust randomisation are still needed to determine the full effect of alarm therapy. Plain language summary Alarm interventions for nocturnal enuresis (bedwetting) in children Review question Is alarm training an effective treatment for bedwetting in children? Background Bedwetting is common in childhood and affects up to 20% of five‐year‐olds. Although children may spontaneously recover from this, bedwetting can have significant social, emotional and psychological effects on the child and their family. Treatments for bedwetting include alarms (activated by urination), behavioural interventions and drugs. How up‐to‐date is this review? The evidence is current up to 25 June 2018. Study characteristics This review includes 74 trials involving 5983 children. Study funding sources Three of the studies included in the review were funded or supported by a pharmaceutical company. Key results Alarms may be better than no treatment in terms of reducing the number of wet nights a week and increasing the number of children achieving 14 consecutive dry nights. Alarms may increase the number of children remaining dry after stopping treatment, compared to no treatment. We are uncertain if there is any difference between alarms and behavioural interventions (such as bladder training), or between alarms and desmopressin medication in terms of reducing the number of wet nights a week, increasing the number of children achieving 14 consecutive dry nights and increasing the number of children remaining dry after stopping treatment. We are uncertain whether alarms reduce the number of wet nights more than placebo drugs, other types of alarms, tricyclics medication, or various treatments such as hypnotherapy or restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin alone. It may increase the number of children achieving 14 consecutive dry nights and increase the number of children remaining dry after stopping treatment. Alarm plus dry‐bed training may increase the number of children achieving 14 consecutive dry nights compared to dry‐bed training alone, but we are uncertain if the response is maintained after stopping treatment. Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Alarm therapy probably reduces the number of children experiencing adverse events compared with desmopressin. We think there is probably a slight increase in adverse events between code‐word alarms and standard alarms but until we have more evidence from more children we cannot be certain about this. We are uncertain about the safety of alarm therapy compared to other treatments, because the quality of evidence is very low. Quality of the evidence The quality of the evidence means that, in general, the level of certainty in our conclusions is low. Authors' conclusions Alarm therapy may be more effective than no treatment, but due to the low‐quality evidence we do not know how much alarm therapy is more effective than none at all. Adding alarm therapy to desmopressin may be more effective than desmopressin alone. Despite the large number of trials we identified, the low certainty of the evidence means that we cannot tell from these studies whether or not alarm therapy is better than most other therapies for reducing bedwetting in children. We cannot be sure about its effects until there are better‐designed trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Caldwell, PHY; Codarini, M; Stewart, F; Hahn, D; Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002911.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "215aa635-f9a3-4bd7-a93c-a007c3fbd594", "pmid": "", "title": "Post COVID-19 Syndrome: A Pilot Study to Explore the Gut-lung Axis", "imported": false, "abstract": "The outbreak of the novel coronavirus (SARS-CoV-2)-infected disease (COVID-19) began in December 2019, spread throughout China in early 2020 and developed as a pandemic thereafter.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.148Z" }, { "id": "2163c787-c0f8-42e9-bb3d-f56420e5fe85", "pmid": "", "title": "Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non‐hospitalised term infants", "imported": false, "abstract": "Abstract - Background Many women express concern about their ability to produce enough milk, and insufficient milk is frequently cited as the reason for supplementation and early termination of breastfeeding. When addressing this concern, it is important first to consider the influence of maternal and neonatal health, infant suck, proper latch, and feeding frequency on milk production, and that steps be taken to correct or compensate for any contributing issues. Oral galactagogues are substances that stimulate milk production. They may be pharmacological or non‐pharmacological (natural). Natural galactagogues are usually botanical or other food agents. The choice between pharmacological or natural galactagogues is often influenced by familiarity and local customs. Evidence for the possible benefits and harms of galactagogues is important for making an informed decision on their use. Objectives To assess the effect of oral galactagogues for increasing milk production in non‐hospitalised breastfeeding mother‐term infant pairs. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov , the World Health Organization (WHO) International Clinical Trials Registry Platform ( ICTRP ), Health Research and Development Network ‐ Phillippines ( HERDIN ), Natural Products Alert ( Napralert ), the personal reference collection of author LM, and reference lists of retrieved studies (4 November 2019). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs (including published abstracts) comparing oral galactagogues with placebo, no treatment, or another oral galactagogue in mothers breastfeeding healthy term infants. We also included cluster‐randomised trials but excluded cross‐over trials. Data collection and analysis We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two to four review authors independently selected the studies, assessed the risk of bias, extracted data for analysis and checked accuracy. Where necessary, we contacted the study authors for clarification. Main results Forty‐one RCTs involving 3005 mothers and 3006 infants from at least 17 countries met the inclusion criteria. Studies were conducted either in hospitals immediately postpartum or in the community. There was considerable variation in mothers, particularly in parity and whether or not they had lactation insufficiency. Infants' ages at commencement of the studies ranged from newborn to 6 months. The overall certainty of evidence was low to very low because of high risk of biases (mainly due to lack of blinding), substantial clinical and statistical heterogeneity, and imprecision of measurements. Pharmacological galactagogues Nine studies compared a pharmacological galactagogue (domperidone, metoclopramide, sulpiride, thyrotropin‐releasing hormone) with placebo or no treatment. The primary outcome of proportion of mothers who continued breastfeeding at 3, 4 and 6 months was not reported. Only one study (metoclopramide) reported on the outcome of infant weight, finding little or no difference (mean difference (MD) 23.0 grams, 95% confidence interval (CI) ‐47.71 to 93.71; 1 study, 20 participants; low‐certainty evidence). Three studies (metoclopramide, domperidone, sulpiride) reported on milk volume, finding pharmacological galactagogues may increase milk volume (MD 63.82 mL, 95% CI 25.91 to 101.72; I² = 34%; 3 studies, 151 participants; low‐certainty evidence). Subgroup analysis indicates there may be increased milk volume with each drug, but with varying CIs. There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints, such as tiredness, nausea, headache and dry mouth (very low‐certainty evidence). No adverse effects were reported for infants. Natural galactagogues Twenty‐seven studies compared natural oral galactagogues (banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves or other natural mixtures) with placebo or no treatment. One study (Mother's Milk Tea) reported breastfeeding rates at six months with a concluding statement of \"no significant difference\" (no data and no measure of significance provided, 60 participants, very low‐certainty evidence). Three studies (fennel, fenugreek, moringa, mixed botanical tea) reported infant weight but could not be meta‐analysed due to substantial clinical and statistical heterogeneity (I 2 = 60%, 275 participants, very low‐certainty evidence). Subgroup analysis shows we are very uncertain whether fennel or fenugreek improves infant weight, whereas moringa and mixed botanical tea may increase infant weight compared to placebo. Thirteen studies (Bu Xue Sheng Ru, Chanbao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants) reported on milk volume, but meta‐analysis was not possible due to substantial heterogeneity (I 2 = 99%). The subgroup analysis for each intervention suggested either benefit or little or no difference (very low‐certainty evidence). There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints such as mothers with urine that smelled like maple syrup and urticaria in infants (very low‐certainty evidence). Galactagogue versus galactagogue Eight studies (Chanbao; Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one oral galactagogue with another. We were unable to perform meta‐analysis because there was only one small study for each match‐up, so we do not know if one galactagogue is better than another for any outcome. Authors' conclusions Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low‐certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High‐quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used. Plain language summary Milk boosters (galactagogues) for mothers breastfeeding their healthy infants born at term What is the issue? We set out to determine the ability of milk boosters taken by mouth (medicine, herb or food) to increase milk production in breastfeeding mothers of healthy infants born at term. Poor milk supply is often given as the reason for early supplementation and weaning sooner than desired. A range of factors, including mother's and baby's health, baby's sucking skills, proper latch and frequency of feeds, can affect milk production. Every attempt should first be made to identify and correct the causes for low milk production before trying a milk booster. Why is this important? Inadequate milk production can be distressing for mothers and threatening to babies' health. The choice of milk booster is often influenced by familiarity or local customs. Some mothers may prefer medications, while others prefer natural remedies. Evidence for the possible benefits and harms of milk boosters is important to assist mothers in making informed decisions. What evidence did we find? We searched for evidence from randomised controlled studies up to 4 November 2019 and identified 41 eligible studies involving 3005 mothers and 3006 infants from at least 17 countries. The studies varied widely in babies ages, type of milk boosters investigated, how long they were taken, and how outcomes were reported. Medications included sulpiride, metoclopramide, domperidone and thyrotropin‐releasing hormone. Natural interventions included banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves, and a variety of natural mixtures as teas or soups. Milk‐boosting medication Nine studies compared a milk‐boosting medication with placebo or no treatment. None reported exclusive breastfeeding rates at 3. 4 or 6 months and only one (metoclopramide, 20 participants) reported on weight gain in infants receiving only their mothers' own milk, with better results in the milk booster group. Three studies that tracked milk volume (domperidone, metoclopramide, sulpiride; 151 participants) reported more milk in the booster groups, though the certainty of the evidence was low. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as tiredness, nausea, decreased appetite, headache and dry mouth. Natural milk boosters Twenty‐seven studies compared natural milk boosters with placebo or no treatment. Only one (Mother’s Milk Tea; 60 participants) examined the impact on breastfeeding rates, reporting \"no significant difference at 6 months\" without providing any data (very low‐certainty evidence). Three studies (275 participants) reported infant weight, two of which (moringa, mixed botanical tea) reported higher gains in the milk booster group, while the other study (fennel and fenugreek) was inconclusive on whether infant weight gain improved with the milk boosters. In the 13 studies tracking changes in milk volume (Bu Xue Sheng Ru, Chan Bao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants), some showed benefits and others little or no difference, so we are very uncertain about the results for milk volume. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as mothers with urine that smells like maple syrup and rash in infants (very low‐certainty evidence). One milk booster compared with another Eight studies (Chanbao, Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one milk booster with another. There was only one small study for each particular match‐up, hence we cannot be certain if any one milk booster truly worked better than another. What does this mean? There is limited evidence that milk‐boosting medications may increase milk volume and that natural milk boosters may improve milk volume and infants' weight, but we are very uncertain about the supporting evidence. Due to limited information, we are also uncertain if there are any risks to the mother or baby in taking any particular milk booster. More high‐quality studies are needed to increase our certainty about the effects of milk boosters.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Foong, SC, Tan, ML, Foong, WC, Marasco, LA, Ho, JJ, Ong, JH", "articleTypes": [], "doi": "10.1002/14651858.CD011505.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.757Z" }, { "id": "217d5f2b-4b43-4ef3-821b-aff6d5f45cd2", "pmid": "", "title": "Medical interventions for treating anthracycline‐induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer", "imported": false, "abstract": "Abstract - Background Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline‐induced cardiotoxicity. This review is an update of a previously published Cochrane review. Objectives To compare the effect of medical interventions on anthracycline‐induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions, or no treatment. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 8), MEDLINE/PubMed (1949 to September 2015), and EMBASE/Ovid (1980 to September 2015) for potentially relevant articles. In addition, we searched reference lists of relevant articles, conference proceedings of the International Society for Paediatric Oncology (SIOP), the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), the International Conference on Long‐Term Complications of Treatment of Children & Adolescents for Cancer, and the European Symposium on Late Complications from Childhood Cancer (from 2005 to 2015), and ongoing trial databases (the ISRCTN Register, the National Institutes of Health (NIH) Register, and the trials register of the World Health Organization (WHO); all searched in September 2015). Selection criteria Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline‐induced cardiotoxicity with either placebo, other medical interventions, or no treatment. Data collection and analysis Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments, which another review author checked. We performed analyses according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results In the original version of the review we identified two RCTs; in this update we identified no additional studies. One trial (135 participants) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline‐induced cardiac dysfunction. The other trial (68 participants) compared a two‐week treatment of phosphocreatine with a control treatment (vitamin C, adenosine triphosphate, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline‐induced cardiotoxicity. Both studies had methodological limitations. The RCT on enalapril showed no statistically significant differences in overall survival, mortality due to heart failure, development of clinical heart failure, and quality of life between treatment and control groups. A post‐hoc analysis showed a decrease (that is improvement) in one measure of cardiac function (left ventricular end‐systolic wall stress (LVESWS): ‐8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Participants treated with enalapril had a higher risk of dizziness or hypotension (risk ratio 7.17, 95% confidence interval 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013). The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function, and adverse events between treatment and control groups. Authors' conclusions Only one trial evaluated the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side effects of enalapril in childhood cancer survivors with asymptomatic anthracycline‐induced cardiotoxicity. Only one trial evaluated the effect of phosphocreatine in childhood cancer patients with anthracycline‐induced cardiotoxicity. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatments on echocardiographic function and clinical outcomes. We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors. High‐quality studies should be performed. Plain language summary Treatment for cardiac problems caused by anthracycline chemotherapy for childhood cancer Anthracyclines are anticancer drugs used in the treatment of different types of childhood cancer. An important adverse effect of anthracyclines is damage to the heart, which can lead to asymptomatic (without complaints) or symptomatic (with complaints) cardiac problems during and after cancer treatment. While there are several drugs available to treat other types of cardiac problems in adults, it is not known if these drugs are beneficial in treating cardiac problems caused by anthracyclines in childhood cancer patients and survivors. A physician confronted with a childhood cancer patient or survivor with anthracycline‐induced cardiac problems should be able to make an informed decision on how to treat this patient based on high‐quality evidence about the beneficial and adverse effects of the treatment options. We searched for and summarised studies that evaluated drugs for treating anthracycline‐induced cardiac problems in childhood cancer patients and survivors. We identified two randomised studies evaluating two different drugs in two different types of patients. One of these drugs, an angiotensin‐converting enzyme (ACE) inhibitor (enalapril), had a short‐term beneficial effect on heart function in survivors of childhood cancer with asymptomatic cardiac problems caused by anthracyclines compared with placebo. However, the drug had no significant beneficial effect on other important outcomes and was associated with side effects such as dizziness and fatigue. This study was of reasonable/good quality. The other study was of low quality and found no effect of a short treatment with phosphocreatine in childhood leukaemia patients with symptomatic or asymptomatic cardiac problems compared with a control treatment with vitamin C, adenosine triphosphate, vitamin E, and oral coenzyme Q10. We could make no definitive conclusions about treatment options for anthracycline‐induced cardiac problems in childhood cancer patients and survivors. High‐quality studies are needed to determine if there are drugs that improve heart function in these patients.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cheuk, DKL, Sieswerda, E, van Dalen, EC, Postma, A, Kremer, LCM", "articleTypes": [], "doi": "10.1002/14651858.CD008011.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.792Z" }, { "id": "218c9af0-e635-467a-94f1-634c1635ddda", "pmid": "", "title": "Multiple micronutrient powders for home (point‐of‐use) fortification of foods in pregnant women", "imported": false, "abstract": "Abstract - Background It is estimated that 32 million pregnant women suffer from anaemia worldwide. Due to increased metabolic demands, pregnant women are particularly vulnerable to anaemia and vitamin and mineral deficiencies, leading to adverse health effects in both the mother and her baby. Despite the demonstrated benefits of prenatal supplementation with iron and folic acid or multiple micronutrients, poor adherence to routine supplementation has limited the effectiveness of this intervention in many settings. Micronutrient powders for point‐of‐use fortification are packed, single‐dose sachets containing vitamins and minerals that can be added onto prepared food to improve its nutrient profile. The use of multiple micronutrient powders for point‐of‐use fortification of foods in pregnant women could be an alternative intervention to prenatal micronutrient supplementation. Objectives To assess the effects of prenatal home (point‐of‐use) fortification of foods with multiple micronutrient powders on maternal and newborn health. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and the International Clinical Trials Registry Platform ( ICTRP ) (31 January 2015). We also contacted relevant agencies to identify ongoing and unpublished studies. Selection criteria Randomised controlled trials (both individual and cluster randomisation) and quasi‐randomised trials, irrespective of language or publication status. The intervention was micronutrient powders for point‐of‐use fortification of foods, containing at least three micronutrients with one of them being iron, provided to pregnant women of any gestational age and parity. Five comparison groups were considered: no intervention/placebo, iron and folic acid supplements, iron‐only supplements, folic‐acid only supplements, and multiple micronutrients in supplements. Data collection and analysis Two review authors independently assessed the eligibility of studies, extracted and checked data accuracy, and assessed the risk of bias of included studies. Main results Our search identified 12 reports (relating to six studies). We included two cluster‐randomised controlled trials (involving 1172 women) ‐ these trials were considered to be at a moderate to high risk of bias due to methodological limitations. One trial is ongoing, and three studies were excluded. Micronutrient powders for point‐of‐use fortification of foods versus iron and folic acid supplements One trial (involving 478 pregnant women attending 42 antenatal care centres) compared micronutrient powders containing iron, folic acid, vitamin C and zinc with iron and folic acid tablets provided daily from 14 to 22 weeks to 32 weeks' gestation. The trial did not report on any of this review's primary outcomes: maternal anaemia at or near term, maternal iron deficiency, maternal mortality, adverse effects, low birthweight, preterm births. Nor did the trial report on the majority of this review's secondary outcomes, with the exception of maternal adherence. Adherence to micronutrient powders was lower than adherence to iron and folic acid supplements (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.66 to 0.87, one study, n = 405). Micronutrient powders for point‐of‐use fortification of foods versus same multiple micronutrients in supplements One study (involving 694 pregnant women from 18 communities), compared micronutrient powders containing iron, folic acid, vitamin C, zinc, iodine, vitamin E and vitamin B 12 with tablets containing the same seven micronutrients. There was no difference in maternal anaemia at 37 weeks of gestation (RR 0.92, 95% CI 0.53 to 1.59, one study, n = 470, very low quality evidence ). The trial did not report on any of this review's other primary outcomes in relation to maternal iron deficiency, maternal mortality, adverse effects, low birthweight, or preterm birth. In terms of this review's secondary outcomes, the included trial did not report on the majority of this review's prespecified secondary outcomes with one exception ‐ there was no clear difference in maternal haemoglobin Hb or near term (mean difference (MD) 1.0 g/L, 95% CI ‐1.77 to 3.77, one study, n = 470). Authors' conclusions Limited evidence suggests that micronutrient powders for point‐of‐use fortification of foods have no clear difference as multiple micronutrient supplements on maternal anaemia ( very low quality evidence ) and Hb at or near term. There is limited evidence to suggest that women were more likely to adhere to taking tablets than using micronutrient powders. The overall quality of evidence was judged very low (due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes. Therefore, more evidence is needed to assess the potential benefits or harms of the use of micronutrient powders in pregnant women on maternal and infant health outcomes. Future trials should also assess adherence to micronutrient powders and be adequately powered to evaluate the effects on birth outcomes and morbidity. Plain language summary Powders of iron plus other micronutrients for home (point‐of‐use) fortification of foods consumed by pregnant women Pregnant women are particularly vulnerable to nutrient deficiencies due to the requirements of the growing baby during the pregnancy. In low‐income countries, many women have diets with low content of vitamins and minerals, and they participate in long hours of physical labour. They are also exposed to recurrent infections, which make nutritional deficiencies worse. Thus, lack of adequate nutrition can contribute to the poor health of these women their babies. Iron and folic acid supplements in pregnancy are widely recommended. However, getting the supplements to the women and encouraging them to take them is particularly challenging. Micronutrient powders containing iron, vitamin A, zinc and other vitamins and minerals are usually packaged in single‐use sachets and can be sprinkled onto any semi‐solid food at home or in any other place where meals are to be consumed. The use of micronutrient powders to fortify foods may overcome this problem with micronutrient supplements. Micronutrient powders have already been shown to be effective in reducing anaemia and iron deficiency in young children and so may be useful for pregnant women. This review looked at the use of micronutrient powders in pregnancy, compared with micronutrient supplements or with no additional micronutrients. We found only two studies involving a total of 1172 women, undertaken in Bangladesh and Mexico. The overall quality of evidence was judged very low (with a high risk of bias due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes of this review. One trial compared micronutrient powders with iron and folate supplements, and the other trial compared micronutrient powders with the same nutrients but given as supplements. Overall, micronutrient powders fortification of foods had a similar effect as multiple micronutrient supplements on anaemia in mothers at or near term ( very low quality evidence ) or the mother's haemoglobin (Hb) at or near term. The study that compared micronutrient powders with iron and folic acid supplements reported that women were more likely to take iron and folic acid tablets than micronutrient powders. Nearly all of the review's important outcomes were not reported in the included studies. Therefore, more evidence is needed for both mother and infant health outcomes in order to adequately evaluate the use of micronutrient powders in pregnant women.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Suchdev, PS, Peña‐Rosas, JP, De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD011158.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.766Z" }, { "id": "218df0e5-4730-43b1-b1a4-f26253b5e927", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: cytokines and growth factors", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulceration can lead to severe pain and difficulty with eating and drinking, which may necessitate opioid analgesics, hospitalisation and supplemental nutrition. These complications may disrupt cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining of the mouth, thus preventing or reducing oral mucositis and its negative effects. Objectives To assess the effects of cytokines and growth factors for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (searched 10 May 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4) in the Cochrane Library (searched 10 May 2017); MEDLINE Ovid (1946 to 10 May 2017); Embase Ovid (7 December 2015 to 10 May 2017); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 10 May 2017); and CANCERLIT PubMed (1950 to 10 May 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of cytokines and growth factors in patients with cancer receiving treatment. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 35 RCTs analysing 3102 participants. Thirteen studies were at low risk of bias, 12 studies were at unclear risk of bias, and 10 studies were at high risk of bias. Our main findings were regarding keratinocyte growth factor (KGF) and are summarised as follows. There might be a reduction in the risk of moderate to severe oral mucositis in adults receiving bone marrow/stem cell transplantation after conditioning therapy for haematological cancers (RR 0.89, 95% CI 0.80 to 0.99; 6 studies; 852 participants; low‐quality evidence). We would need to treat 11 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 6 to 112). There might be a reduction in the risk of severe oral mucositis in this population, but there is also some possibility of an increase in risk (RR 0.85, 95% CI 0.65 to 1.11; 6 studies; 852 participants; low‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to prevent the outcome to 14 to cause the outcome). There is probably a reduction in the risk of moderate to severe oral mucositis in adults receiving radiotherapy to the head and neck with cisplatin or fluorouracil (RR 0.91, 95% CI 0.83 to 1.00; 3 studies; 471 participants; moderate‐quality evidence). We would need to treat 12 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 7 to infinity). It is very likely that there is a reduction in the risk of severe oral mucositis in this population (RR 0.79, 95% CI 0.69 to 0.90; 3 studies; 471 participants; high‐quality evidence). We would need to treat 7 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to 15). It is likely that there is a reduction in the risk of moderate to severe oral mucositis in adults receiving chemotherapy alone for mixed solid and haematological cancers (RR 0.56, 95% CI 0.45 to 0.70; 4 studies; 344 participants; moderate‐quality evidence). We would need to treat 4 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 3 to 6). There might be a reduction in the risk of severe oral mucositis in this population (RR 0.30, 95% CI 0.14 to 0.65; 3 studies; 263 participants; low ‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 8 to 19). Due to the low volume of evidence, single‐study comparisons and insufficient sample sizes, we found no compelling evidence of a benefit for any other cytokines or growth factors and there was no evidence on children. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Authors' conclusions We are confident that KGF is beneficial in the prevention of oral mucositis in adults who are receiving: a) radiotherapy to the head and neck with cisplatin or fluorouracil; or b) chemotherapy alone for mixed solid and haematological cancers. We are less confident about a benefit for KGF in adults receiving bone marrow/stem cell transplant after conditioning therapy for haematological cancers because of multiple factors involved in that population, such as whether or not they received total body irradiation (TBI) and whether the transplant was autologous (the patients' own cells) or allogeneic (cells from a donor). KGF appears to be a relatively safe intervention. Due to limited research, we are not confident that there are any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Plain language summary Can cytokines and growth factors help prevent mouth soreness and ulcers (oral mucositis) in patients being treated for cancer? Review question This review has been produced to assess whether or not the use of cytokines and growth factors during cancer treatment, can help prevent mouth soreness and ulcers. Background Sore mouth and ulcers (oral mucositis) is a side effect of treatment for cancer including chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulcers can lead to severe pain and difficulty with eating and drinking. Sufferers may need strong painkillers, possibly have to go into hospital and even be fed through a tube into their stomach or their veins. These complications may disrupt their cancer therapy, meaning they are not receiving the best treatment, which may reduce survival. Cancer patients have weakened immune systems due to their treatment and are less able to fight infections. An ulcer is an open wound and there is a risk that bacteria can enter the body leading to infection or sepsis (a dangerous inflammatory reaction of the body to infection). Mouth soreness and ulcers can be costly to healthcare systems, yet there are few preventive interventions or treatments proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining the mouth, thus preventing or reducing oral mucositis and its negative effects. Study characteristics Authors from Cochrane Oral Health carried out this review of existing studies and the evidence is current up to 10 May 2017. It includes 35 studies (published between 1993 and 2017) with 3102 participants, all patients being treated for cancer, aged from 1 to 87 years old. Review authors included studies comparing cytokines and growth factors for the prevention of oral mucositis. The studies were carried out all over the world and often featured multiple sites, although most took place in high‐income countries. Main results The main findings were regarding keratinocyte growth factor (KGF). KGF is likely to reduce the risk of oral mucositis in adults who are receiving either radiotherapy to the head and neck with chemotherapy (cisplatin or fluorouracil), or chemotherapy alone for mixed solid and blood cancers. KGF may also reduce the risk of oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, but these results are less clear because of multiple complicating factors. KGF appears to be a relatively safe intervention. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Due to limited research, review authors are uncertain of any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Quality of the evidence For reducing oral mucositis in adults receiving radiotherapy to the head and neck with chemotherapy, review authors rated the evidence for KGF as moderate to high quality. For reducing oral mucositis in adults receiving chemotherapy alone for mixed solid and blood cancers, they rated the evidence for KGF as low to moderate quality. This evidence was downgraded due to there not being enough data and because some results have not yet been published. For reducing oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, they rated the evidence for KGF as low quality because results were not similar across the studies and some results have not yet been published. Evidence on side effects of KGF was poorly reported and inconsistent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P, Glenny, AM, Worthington, HV, Littlewood, A, Fernandez Mauleffinch, LM, Clarkson, JE, McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.733Z" }, { "id": "21c0162a-490f-43d0-9d8f-8c82150a42b7", "pmid": "", "title": "Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years", "imported": false, "abstract": "Abstract - Background Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health. Objectives To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non‐dietary intervention. Secondary objectives were to assess the impact of ECEC‐based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality‐of‐life outcomes. We also report on cost and adverse consequences of ECEC‐based healthy eating interventions. Search methods We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers. Selection criteria We included randomised controlled trials (RCTs), including cluster‐RCTs, stepped‐wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross‐over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both. Data collection and analysis Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta‐analyses using a random‐effects model; otherwise, we described findings using vote‐counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes. Main results We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster‐RCTs. Twenty‐nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty‐eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC‐based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I 2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I 2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC‐based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI −0.01 to 0.25; P =0.08, I 2 = 70%; 13 studies, 3335 children). There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely result in little to no difference in children's consumption of non‐core (i.e. less healthy/discretionary) foods (SMD −0.05, 95% CI −0.17 to 0.08; P = 0.48, I 2 = 16%; 7 studies, 1369 children) or consumption of sugar‐sweetened beverages (SMD −0.10, 95% CI −0.34 to 0.14; P = 0.41, I 2 = 45%; 3 studies, 522 children). Thirty‐six studies measured BMI, BMI z‐score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC‐based healthy eating interventions may result in little to no difference in child BMI (MD −0.08, 95% CI −0.23 to 0.07; P = 0.30, I 2 = 65%; 15 studies, 3932 children) or in child BMI z‐score (MD −0.03, 95% CI −0.09 to 0.03; P = 0.36, I 2 = 0%; 17 studies; 4766 children). ECEC‐based healthy eating interventions may decrease child weight (MD −0.23, 95% CI −0.49 to 0.03; P = 0.09, I 2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I 2 = 0%; 5 studies, 1070 children). ECEC‐based healthy eating interventions may be cost‐effective but the evidence is very uncertain (6 studies). ECEC‐based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3). Authors' conclusions ECEC‐based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC‐based healthy eating interventions on vegetable consumption. ECEC‐based healthy eating interventions may result in little to no difference in child consumption of non‐core foods and sugar‐sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z‐scores. Future studies exploring the impact of specific intervention components, and describing cost‐effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC‐based healthy eating interventions. Plain language summary How successful are healthy eating programmes in preschools, kindergartens and childcare settings? Key messages • Healthy eating programmes delivered in early childhood education and care (ECEC) settings (e.g. preschools, kindergarten, family day care) may improve child diet quality, likely increase fruit consumption, may have favourable effects on vegetable consumption, and likely have no impact on consumption of less healthy foods and sugar‐sweetened drinks. They may have favourable effects on child weight and may reduce the risk of being overweight or obese. • We don't know if healthy eating interventions save money or cause unwanted effects because very few studies provided information about these points. • We found little evidence from low‐ and middle‐income countries, but healthy eating programmes in high‐income countries may benefit child health. We don't know how to support educators and staff to implement these programmes in practice. We need more research about delivering programmes and about their effect in low‐income countries. Why is it important to improve young children's diet? Having a poor diet puts people at risk of many long‐term diseases including heart disease, type 2 diabetes and certain types of cancers. Research estimates that over 11 million deaths worldwide are caused by having an unhealthy diet. Dietary behaviours and preferences are established early in life and persist into adulthood. What are healthy eating programmes? Healthy eating programmes aim to encourage children to eat a healthier diet. They may involve changes to lessons and the culture in preschools, kindergartens and day care centres (early childhood education and care (ECEC) settings), and working with children's families, teachers and healthcare staff. For example, introducing new fruits and vegetables to children, changing the menu to include healthier options or providing families with information about child healthy eating. Healthy eating programmes may establish lifelong healthy eating patterns, reduce excessive weight gain and improve overall health. What did we want to find out? We wanted to find out what impact healthy eating interventions have on child diet and health. We were interested in changes to diet, weight, language and cognitive performance, social, emotional and quality of life outcomes in children aged six months to six years attending preschool, long day care, nurseries, kindergartens and family day care services. We also wanted to know the cost of interventions and whether they had any potential unwanted effects. What did we do? We searched for studies that compared healthy eating programmes against no action, delayed delivery of the programme, or a programme that did not aim to change child diet. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 52 studies that looked at the effects of 58 healthy eating programmes in ECEC settings for children aged six months to six years. All studies were published in high and high‐middle‐income countries. The programmes were very different from each other. They: • lasted from 4 weeks to 3 years; • were delivered by a range of people including healthcare providers, ECEC staff, and researchers; • used different delivery methods (telephone, face‐to‐face, online, printed materials); and • measured results in a variety of ways (e.g. parent or staff surveys, observations of children's eating, and weighing foods before and after meals). Overall, the programmes aimed to: • change the ECEC environment (e.g. staff demonstrated healthy eating to children, and provided healthier foods); • change the curriculum (e.g. they provided lessons about foods and healthy eating); and • establish partnerships (e.g. they provided educational resources to families); and • increase children's physical activity (e.g. by structured physical activity lessons and encouraging less screen time). Healthy eating programmes may lead to small improvements in child diet quality, increase fruit consumption by 0.11 servings, potentially improve vegetable consumption by 0.12 servings and may have no effect on consumption of less healthy foods and sugar‐sweetened drinks. Further, we found child weight is potentially reduced by 230 g and for every 100 children, 19 would have better weight status. However, we found no evidence of impact on body mass index. The programmes may be cost‐effective and likely to have no unwanted effects, although few studies reported these points. Few studies reported on other learning, social and developmental outcomes. What are the limitations of the evidence? Our confidence in the evidence is low because the healthy eating programmes were conducted, delivered and assessed in different ways. Also, many of the people who received the healthy eating programmes were aware that they were being assessed and this can sometimes influence how they report their effects. For example, parents who reported their child's diet may have been more inclined to give positive answers because they felt they were doing what society expected or because they were grateful for the support and wanted to please the researchers. Also, not all studies provided information about everything we were interested in and there was often missing data when children were followed up after the study. How up‐to‐date is the evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yoong, SL; Lum, M; Wolfenden, L; Jackson, J; Barnes, C; Hall, AE; McCrabb, S; Pearson, N; Lane, C; Jones, JZ; Nolan, E; Dinour, L; McDonnell, T; Booth, D; Grady, A", "articleTypes": [], "doi": "10.1002/14651858.CD013862.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "21c228c4-8b00-4cf9-8ae8-9ed2158af93c", "pmid": "", "title": "Roselle for hypertension in adults", "imported": false, "abstract": "Abstract - Background Hypertension is considered to be a serious health problem worldwide. Controlling and lowering blood pressure are of significant benefit to people with hypertension because hypertension is a risk factor for stroke, heart disease, and cardiovascular disease. Roselle, the tropical plant Hibiscus sabdariffa , also commonly called sour tea or red tea, has been used as both a thirst‐quenching drink and for medicinal purposes. Objectives To assess the effect of Roselle on blood pressure in people with primary hypertension. Search methods For this update, the Cochrane Hypertension Information Specialist searched the following databases and trials registers for randomised controlled trials (RCTs): the Cochrane Hypertension Specialised Register (to 6 August 2021), Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), MEDLINE Ovid (1946 to 5 August 2021), Embase Ovid (1974 to 5 August 2021), ProQuest Dissertations & Theses (to 6 August 2021), Web of Science Clarivate (to 7 August 2021), Food Science and Technology Abstracts Clarivate (to 7 August 2021), the WHO International Clinical Trials Registry Platform (to 6 August 2021), and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (to 6 August 2021). We searched Google Scholar and OpenSIGLE. We also handsearched local and regional Chinese databases: CBM, CMCC, TCMLARS, CNKI, CMAC, and the Index to Chinese Periodical Literature (to 14 September 2020), as well as Thai databases (ThaiJO, CUIR, TDC, CMU e‐Theses, TCTR) (to 3 October 2020). There were no language or publication date restrictions. Selection criteria We sought RCTs evaluating the use of any forms of Roselle with placebo or no treatment in adults with hypertension. Our primary outcome was change in trough and/or peak systolic and diastolic blood pressure (SBP, DBP). Secondary outcomes were withdrawals due to adverse effects, change in pulse pressure, and change in heart rate. Data collection and analysis All search results were managed using Covidence and re‐checked for the number of records, inclusion and exclusion of studies with Mendeley reference management software. We used standard methodological procedures expected by Cochrane. Two review authors worked independently in parallel for screening (titles and abstracts, and full reports), data extraction, risk of bias assessment, and assessment of the certainty of the evidence using the GRADE approach. Any disagreements were resolved by discussion or by consultation with the third review author if necessary. We presented mean difference (MD) of change in SBP and DBP with their corresponding 95% confidence interval (CI). Main results For this update, only one RCT with a parallel‐group design involving 60 participants with type 2 diabetes mellitus fulfilled the inclusion criteria. This study investigated the effect of Roselle extract capsules (total dose of 5600 mg) compared with placebo (lactose) at eight weeks. The study was at low risk of selection bias, performance bias, and detection bias. Conversely, it was at high risk of attrition bias, reporting bias, and other bias (baseline imbalance). We have very little confidence in the effect estimate of Roselle on change‐from‐baseline in both SBP and DBP between the two groups. The MD of change in SBP was 1.65, 95% CI −7.89 to 11.19 mmHg, 52 participants, very low‐certainty evidence. The MD of change in DBP was 4.60, 95% CI −1.38 to 10.58 mmHg, 52 participants, very low‐certainty evidence. Our secondary outcomes of withdrawals due to adverse effects, change in pulse pressure, and change in heart rate were not reported. Due to the limited available data, no secondary analyses were performed (subgroup and sensitivity analysis). Authors' conclusions The evidence is currently insufficient to determine the effectiveness of Roselle compared to placebo for controlling or lowering blood pressure in people with hypertension. The certainty of evidence was very low due to methodological limitations, imprecision, and indirectness. There is a need for rigorous RCTs that address the review question. Plain language summary Red tea (Roselle) for lowering blood pressure in adults Key messages: We don't know if taking Roselle lowers blood pressure in people with hypertension (high blood pressure). We don’t know if Roselle is safe for people with hypertension to consume or if it affects heart rate or pulse pressure. What did we want to find out? We wanted to know if red tea (Roselle) is a safe and effective treatment for lowering blood pressure in adults with high blood pressure when compared to placebo (dummy treatment) or no treatment. Roselle contains substances known as anthocyanins which have been shown to have lowered blood pressure in studies carried out in animals and humans. What did we do? We searched for studies that compared Roselle to placebo or no treatment in people with hypertension. What did we find? We included one study with 60 participants with type 2 diabetes and hypertension. Participants consumed either a capsule of pure Roselle extract or a placebo containing lactose for eight weeks. We are not sure if Roselle has an effect on blood pressure and the study did not report on the safety of Roselle or on changes to heart rate. What are the main limitations of the evidence? We found only one trial which included a small number of participants, all of whom had diabetes. More studies with various types of participants and different ways of taking Roselle (forms, amounts, and time of day, length of use) are needed. How up to date is the evidence? The review updates our previous review. We searched for randomised controlled trials (studies in which participants are randomly assigned to one of two or more treatment groups) in core databases up to August 2021, and searched local and regional Chinese and Thai databases by hand up to October 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Pattanittum, P; Ngamjarus, C; Buttramee, F; Somboonporn, C", "articleTypes": [], "doi": "10.1002/14651858.CD007894.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "21c5de17-ae9f-4a19-ad91-6da069e48c84", "pmid": "", "title": "Pharmacological interventions for prevention of weight gain in people with schizophrenia", "imported": false, "abstract": "Abstract - Background Antipsychotic‐induced weight gain is an extremely common problem in people with schizophrenia and is associated with increased morbidity and mortality. Adjunctive pharmacological interventions may be necessary to help manage antipsychotic‐induced weight gain. This review splits and updates a previous Cochrane Review that focused on both pharmacological and behavioural approaches to this problem. Objectives To determine the effectiveness of pharmacological interventions for preventing antipsychotic‐induced weight gain in people with schizophrenia. Search methods The Cochrane Schizophrenia Information Specialist searched Cochrane Schizophrenia's Register of Trials on 10 February 2021. There are no language, date, document type, or publication status limitations for inclusion of records in the register. Selection criteria We included all randomised controlled trials (RCTs) that examined any adjunctive pharmacological intervention for preventing weight gain in people with schizophrenia or schizophrenia‐like illnesses who use antipsychotic medications. Data collection and analysis At least two review authors independently extracted data and assessed the quality of included studies. For continuous outcomes, we combined mean differences (MD) in endpoint and change data in the analysis. For dichotomous outcomes, we calculated risk ratios (RR). We assessed risk of bias for included studies and used GRADE to judge certainty of evidence and create summary of findings tables. The primary outcomes for this review were clinically important change in weight, clinically important change in body mass index (BMI), leaving the study early, compliance with treatment, and frequency of nausea. The included studies rarely reported these outcomes, so, post hoc, we added two new outcomes, average endpoint/change in weight and average endpoint/change in BMI. Main results Seventeen RCTs, with a total of 1388 participants, met the inclusion criteria for the review. Five studies investigated metformin, three topiramate, three H2 antagonists, three monoamine modulators, and one each investigated monoamine modulators plus betahistine, melatonin and samidorphan. The comparator in all studies was placebo or no treatment (i.e. standard care alone). We synthesised all studies in a quantitative meta‐analysis. Most studies inadequately reported their methods of allocation concealment and blinding of participants and personnel. The resulting risk of bias and often small sample sizes limited the overall certainty of the evidence. Only one reboxetine study reported the primary outcome, number of participants with clinically important change in weight. Fewer people in the treatment condition experienced weight gains of more than 5% and more than 7% of their bodyweight than those in the placebo group (> 5% weight gain RR 0.27, 95% confidence interval (CI) 0.11 to 0.65; 1 study, 43 participants; > 7% weight gain RR 0.24, 95% CI 0.07 to 0.83; 1 study, 43 participants; very low‐certainty evidence). No studies reported the primary outcomes, 'clinically important change in BMI', or 'compliance with treatment'. However, several studies reported 'average endpoint/change in body weight' or 'average endpoint/change in BMI'. Metformin may be effective in preventing weight gain (MD −4.03 kg, 95% CI −5.78 to −2.28; 4 studies, 131 participants; low‐certainty evidence); and BMI increase (MD −1.63 kg/m2, 95% CI −2.96 to −0.29; 5 studies, 227 participants; low‐certainty evidence). Other agents that may be slightly effective in preventing weight gain include H2 antagonists such as nizatidine, famotidine and ranitidine (MD −1.32 kg, 95% CI −2.09 to −0.56; 3 studies, 248 participants; low‐certainty evidence) and monoamine modulators such as reboxetine and fluoxetine (weight: MD −1.89 kg, 95% CI −3.31 to −0.47; 3 studies, 103 participants; low‐certainty evidence; BMI: MD −0.66 kg/m2, 95% CI −1.05 to −0.26; 3 studies, 103 participants; low‐certainty evidence). Topiramate did not appear effective in preventing weight gain (MD −4.82 kg, 95% CI −9.99 to 0.35; 3 studies, 168 participants; very low‐certainty evidence ) . For all agents, there was no difference between groups in terms of individuals leaving the study or reports of nausea. However, the results of these outcomes are uncertain given the very low‐certainty evidence. Authors' conclusions There is low‐certainty evidence to suggest that metformin may be effective in preventing weight gain. Interpretation of this result and those for other agents, is limited by the small number of studies, small sample size, and short study duration. In future, we need studies that are adequately powered and with longer treatment durations to further evaluate the efficacy and safety of interventions for managing weight gain. Plain language summary How effective are medications given alongside antipsychotics at preventing weight gain in people with schizophrenia? Key messages ‐ Metformin may be effective in preventing weight gain caused by antipsychotics. ‐ H2 antagonists and monoamine modulators may be slightly effective in preventing weight gain caused by antipsychotics. ‐ Future studies should include more people and evaluate them for longer. What are antipsychotics? Antipsychotics are medications used to treat symptoms of psychosis, such as hallucinations, delusions and agitation. They are often used to treat people with schizophrenia. Examples of antipsychotics are haloperidol (Haldol), chlorpromazine (Thorazine), olanzapine (Zyprexa) and risperidone (Risperdal). Schizophrenia and weight gain People with schizophrenia are twice as likely as the general population to be overweight, perhaps due to a poor diet and an inactive lifestyle. Excess weight can lead to other health conditions, such as heart disease, stroke and diabetes. Unfortunately, an unwanted effect of antipsychotics is weight gain. Sometimes, people with schizophrenia are given medications alongside antipsychotics (‘add‐on’ medications) to prevent this additional weight gain. These add‐on medications may stop people feeling hungry or help them feel full. Usually, they are medications developed for other purposes, such as metformin, which is a medicine to treat diabetes, and fluoxetine, which is an antidepressant. What did we want to find out? We wanted to find out whether add‐on medications to prevent weight gain caused by antipsychotics were effective in people with schizophrenia. What did we do? We searched for studies that examined any medicine given alongside antipsychotics to prevent weight gain in people with schizophrenia. Study participants could be any age or sex but had to have a diagnosis of schizophrenia or a schizophrenia‐like illness. They had to be chosen at random to receive either the weight‐prevention medicine, or a placebo (a dummy medicine) or no add‐on medicine (standard treatment). We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 17 studies with 1388 people that examined the effects of add‐on medications to prevent weight gain caused by antipsychotics. The add‐on medications were metformin, topiramate, H2 antagonists, monoamine modulators, monoamine modulators plus betahistine, melatonin, and samidorphan. Studies were short, lasting between 6 and 24 weeks. And they were small, with only 63 people on average ‐ the smallest included only 14 people, the largest 561 people. Studies done to date suggest that: ‐ metformin may be effective in preventing weight gain and is well‐tolerated compared to standard treatment (5 studies, 232 participants); ‐ H2 antagonists, such as nizatidine, famotidine and ranitidine, or monoamine modulators, such as reboxetine and fluoxetine may be potentially effective in preventing weight gain caused by antipsychotics; ‐ topiramate is probably not effective in preventing weight gain caused by antipsychotics. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only a small number of studies for each add‐on medication. Studies included few people, and lasted only a short time. How up to date is this evidence? The evidence is up to date to February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Agarwal, SM; Stogios, N; Ahsan, ZA; Lockwood, JT; Duncan, MJ; Takeuchi, H; Cohn, T; Taylor, VH; Remington, G; Faulkner, GE J; Hahn, M", "articleTypes": [], "doi": "10.1002/14651858.CD013337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "22057c2a-d387-4d4a-a526-00b915f152cb", "pmid": "", "title": "Postnatal phenobarbital for the prevention of intraventricular haemorrhage in preterm infants", "imported": false, "abstract": "Abstract - Background Intraventricular haemorrhage (IVH) is a major complication of preterm birth. Large haemorrhages are associated with a high risk of disability and hydrocephalus. Instability of blood pressure and cerebral blood in the newborn flow are postulated as causative factors. Another mechanism may involve reperfusion damage from oxygen free radicals. It has been suggested that phenobarbital stabilises blood pressure and may protect against free radicals. This is an update of a review first published in 2001 and updated in 2007 and 2013. Objectives To assess the benefits and harms of the postnatal administration of phenobarbital in preterm infants at risk of developing IVH compared to control (i.e. no intervention or placebo). Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL and clinical trial registries in January 2022. A new, more sensitive search strategy was developed, and searches were conducted without date limits. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs in which phenobarbital was given within the first 24 hours of life to preterm infants identified as being at risk of IVH because of gestational age below 34 weeks, birth weight below 1500 g or respiratory failure. Phenobarbital was compared to no intervention or placebo. We excluded infants with serious congenital malformations. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were all grades of IVH and severe IVH (i.e. grade III and IV); secondary outcomes were ventricular dilation or hydrocephalus, hypotension, pneumothorax, hypercapnia, acidosis, mechanical ventilation, neurodevelopmental impairment and death. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 10 RCTs (792 infants). The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH of any grade compared with control (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.84 to 1.19; risk difference (RD) 0.00, 95% CI ‐0.06 to 0.07; I² for RD = 65%; 10 RCTs, 792 participants; low certainty evidence) and in severe IVH (RR 0.88, 95% CI 0.64 to 1.21; 10 RCTs, 792 participants; low certainty evidence). The evidence is very uncertain about the effect of phenobarbital on posthaemorrhagic ventricular dilation or hydrocephalus (RR 0.62, 95% CI 0.31 to 1.26; 4 RCTs, 271 participants; very low certainty evidence), mild neurodevelopmental impairment (RR 0.57, 95% CI 0.15 to 2.17; 1RCT, 101 participants; very low certainty evidence), and severe neurodevelopmental impairment (RR 1.12, 95% CI 0.44 to 2.82; 2 RCTs, 153 participants; very low certainty evidence). Phenobarbital may result in little to no difference in death before discharge (RR 0.88, 95% CI 0.64 to 1.21; 9 RCTs, 740 participants; low certainty evidence) and mortality during study period (RR 0.98, 95% CI 0.72 to 1.33; 10 RCTs, 792 participants; low certainty evidence) compared with control. We identified no ongoing trials. Authors' conclusions The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH (any grade or severe) compared with control (i.e. no intervention or placebo). The evidence is very uncertain about the effects of phenobarbital on ventricular dilation or hydrocephalus and on neurodevelopmental impairment. The evidence suggests that phenobarbital results in little to no difference in death before discharge and all deaths during the study period compared with control. Since 1993, no randomised studies have been published on phenobarbital for the prevention of IVH in preterm infants, and no trials are ongoing. The effects of postnatal phenobarbital might be assessed in infants with both neonatal seizures and IVH, in both randomised and observational studies. The assessment of benefits and harms should include long‐term outcomes. Plain language summary What are the benefits and risks of phenobarbital for preventing bleeding to the brain in babies born too early? Key messages • Giving phenobarbital (a medicine used to control seizures) to babies born too early may have little to no effect in preventing intraventricular haemorrhage (bleeding to the brain) and death. • The evidence is very uncertain about the effect of phenobarbital on preventing ventricular dilation (enlarged spaces in the brain) and long‐term brain development. What is bleeding to the brain (intraventricular haemorrhage)? Large bleeds in the centre of the brain can cause disability or death in babies born too early. Unstable blood pressure and blood flow to the brain are believed to cause bleeding into the fluid‐filled cavities of the brain (ventricles). What did we want to find out? Phenobarbital is believed to stabilise blood pressure and therefore potentially help prevent bleeding to the brain. We wanted to find out whether phenobarbital was better than no medicine or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) to prevent bleeding to the brain. What did we do? We searched for studies that compared giving phenobarbital against no medicines. We compared and summarised the results of these studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We included 10 studies (792 babies). The evidence suggests that phenobarbital has little to no effect in preventing bleeding to the brain. The evidence is very uncertain about the effect of phenobarbital on dilation of the ventricles in the brain and long‐term development. The evidence suggests that phenobarbital has little to no effect in preventing deaths. We identified no ongoing trials. What are the limitations of the evidence? It is possible that people conducting the studies were aware of what treatment they were giving. Not all the studies provided data about everything that we were interested in. The studies were very small. How up to date is this evidence? This review updates our previous review. The evidence is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Romantsik, O, Smit, E, Odd, DE, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD001691.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.793Z" }, { "id": "221c6ccb-2258-4e12-8ab4-62c44ebaea48", "pmid": "", "title": "Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors", "imported": false, "abstract": "Abstract - Background Poor diet and insufficient physical activity are major risk factors for non‐communicable diseases. Developing healthy diet and physical activity behaviors early in life is important as these behaviors track between childhood and adulthood. Parents and other adult caregivers have important influences on children's health behaviors, but whether their involvement in children's nutrition and physical activity interventions contributes to intervention effectiveness is not known. Objectives • To assess effects of caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors, including those intended to prevent overweight and obesity • To describe intervention content and behavior change techniques employed, drawing from a behavior change technique taxonomy developed and advanced by Abraham, Michie, and colleagues (Abraham 2008; Michie 2011; Michie 2013; Michie 2015) • To identify content and techniques related to reported outcomes when such information was reported in included studies Search methods In January 2019, we searched CENTRAL, MEDLINE, Embase, 11 other databases, and three trials registers. We also searched the references lists of relevant reports and systematic reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of interventions to improve children's dietary intake or physical activity behavior, or both, with children aged 2 to 18 years as active participants and at least one component involving caregivers versus the same interventions but without the caregiver component(s). We excluded interventions meant as treatment or targeting children with pre‐existing conditions, as well as caregiver‐child units residing in orphanages and school hostel environments. Data collection and analysis We used standard methodological procedures outlined by Cochrane. Main results We included 23 trials with approximately 12,192 children in eligible intervention arms. With the exception of two studies, all were conducted in high‐income countries, with more than half performed in North America. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The specific intervention strategies used were not always reported completely. However, based on available reports, the behavior change techniques used most commonly in the child‐only arm were \"shaping knowledge,\" \"comparison of behavior,\" \"feedback and monitoring,\" and \"repetition and substitution.\" In the child + caregiver arm, the strategies used most commonly included additional \"shaping knowledge\" or \"feedback and monitoring\" techniques, as well as \"social support\" and \"natural consequences.\" We considered all trials to be at high risk of bias for at least one design factor. Seven trials did not contribute any data to analyses. The quality of reporting of intervention content varied between studies, and there was limited scope for meta‐analysis. Both validated and non‐validated instruments were used to measure outcomes of interest. Outcomes measured and reported differed between studies, with 16 studies contributing data to the meta‐analyses. About three‐quarters of studies reported their funding sources; no studies reported industry funding. We assessed the quality of evidence to be low or very low. Dietary behavior change interventions with a caregiver component versus interventions without a caregiver component Seven studies compared dietary behavior change interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (mean difference [MD] −0.42%, 95% confidence interval [CI] −1.25 to 0.41, 1 study, n = 207; low‐quality evidence) or from sodium intake (MD −0.12 g/d, 95% CI −0.36 to 0.12, 1 study, n = 207; low‐quality evidence). No trial in this comparison reported data for children's combined fruit and vegetable intake, sugar‐sweetened beverage (SSB) intake, or physical activity levels, nor for adverse effects of interventions. Physical activity interventions with a caregiver component versus interventions without a caregiver component Six studies compared physical activity interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's total physical activity (MD 0.20 min/h, 95% CI −1.19 to 1.59, 1 study, n = 54; low‐quality evidence) or moderate to vigorous physical activity (MVPA) (standard mean difference [SMD] 0.04, 95% CI −0.41 to 0.49, 2 studies, n = 80; moderate‐quality evidence). No trial in this comparison reported data for percentage of children's total energy intake from saturated fat, sodium intake, fruit and vegetable intake, or SSB intake, nor for adverse effects of interventions. Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component Ten studies compared dietary and physical activity interventions with and without a caregiver component. At the end of the intervention, we detected a small positive impact of a caregiver component on children's SSB intake (SMD −0.28, 95% CI −0.44 to −0.12, 3 studies, n = 651; moderate‐quality evidence). We did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (MD 0.06%, 95% CI −0.67 to 0.80, 2 studies, n = 216; very low‐quality evidence), sodium intake (MD 35.94 mg/d, 95% CI −322.60 to 394.47, 2 studies, n = 315; very low‐quality evidence), fruit and vegetable intake (MD 0.38 servings/d, 95% CI −0.51 to 1.27, 1 study, n = 134; very low‐quality evidence), total physical activity (MD 1.81 min/d, 95% CI −15.18 to 18.80, 2 studies, n = 573; low‐quality evidence), or MVPA (MD −0.05 min/d, 95% CI −18.57 to 18.47, 1 study, n = 622; very low‐quality evidence). One trial indicated that no adverse events were reported by study participants but did not provide data. Authors' conclusions Current evidence is insufficient to support the inclusion of caregiver involvement in interventions to improve children's dietary intake or physical activity behavior, or both. For most outcomes, the quality of the evidence is adversely impacted by the small number of studies with available data, limited effective sample sizes, risk of bias, and imprecision. To establish the value of caregiver involvement, additional studies measuring clinically important outcomes using valid and reliable measures, employing appropriate design and power, and following established reporting guidelines are needed, as is evidence on how such interventions might contribute to health equity. Plain language summary Effects of involving parents and other adult caregivers in children's diet and physical activity interventions Review question Does it make a difference if parents or other adult caregivers are involved in interventions to encourage children to eat healthier or be more physically active? Background Diet and physical activity behaviors are important determinants of health. Parents and other adult caregivers have an essential role in shaping children's health habits by controlling availability of and access to healthy foods and opportunities to be active; supporting, encouraging, and role‐modeling healthy behaviors; and adopting supportive feeding styles and practices. For these reasons, it often is argued that parent and caregiver involvement in children's diet and physical activity interventions is important; however, it remains unclear if involvement of parents and caregivers actually provides benefit. Objectives We assessed the effects of involving parents or other adult caregivers in children's healthy eating and physical activity interventions compared to the effects of the same child interventions without a parent or caregiver component. We were particularly interested in understanding effects on children's dietary intake, children's physical activity levels, and adverse effects of interventions. Study characteristics We found 23 studies, published between 1982 and 2019, that implemented diet interventions, physical activity interventions, or combined diet and physical activity interventions with children or adolescents, and evaluated the effects of adding an intervention component involving parents or other adult caregivers. Approximately 12,192 children aged 2 to 18 years were examined. More than half of studies took place in North America, and all but two were conducted in high‐income countries. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The breadth of information provided about intervention content varied between studies. The most commonly used intervention techniques were those aimed at shaping participants' knowledge, such as providing instruction about how to perform a behavior (e.g. dance, cooking lessons). About three‐quarters of studies reported their funding source; no studies reported industry funding. Key results The findings of this review suggest that adding a parent or caregiver component to dietary behavior change interventions or physical activity interventions may make little or no difference to children's dietary intake or physical activity levels. For interventions that target both diet and physical activity behaviors, involving a parent or caregiver probably slightly reduces children's sugar‐sweetened beverage intake by the end of the intervention. We do not know whether any of these types of interventions result in adverse effects because these data are not available. Quality of evidence Overall, the evidence from studies is of low or very low quality, which means that we are uncertain about study results. Currentness of evidence The evidence is current to January 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Morgan, EH, Schoonees, A, Sriram, U, Faure, M, Seguin‐Fowler, RA", "articleTypes": [], "doi": "10.1002/14651858.CD012547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.803Z" }, { "id": "225b79e1-a6cf-43dd-a1d0-4ca41fa8d278", "pmid": "", "title": "Interventions for the treatment of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "O'Byrne, L, Webster, KE, MacKeith, S, Philpott, C, Hopkins, C, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013876.pub3 AB - Abstract - Background Olfactory dysfunction is a common consequence of COVID‐19 infection and persistent symptoms can have a profound impact on quality of life. At present there is little guidance on how best to treat this condition. A variety of interventions have been suggested to promote recovery, including medication and olfactory training. However, it is uncertain whether any intervention is of benefit. This is an update of the 2021 review with one additional study added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with persisting olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance that had persisted for at least four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the recovery of sense of smell, disease‐related quality of life and serious adverse effects. Secondary outcomes were the change in sense of smell, general quality of life, prevalence of parosmia and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included two studies with 30 participants. The studies evaluated the following interventions: systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant and palmitoylethanolamide plus luteolin. Systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant compared to no intervention We included a single RCT with 18 participants who had anosmia for at least 30 days following COVID‐19 infection. Participants received a 15‐day course of oral corticosteroids combined with nasal irrigation (consisting of an intranasal corticosteroid/mucolytic/decongestant solution) or no intervention. Psychophysical testing was used to assess olfactory function at 40 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Palmitoylethanolamide plus luteolin compared to no intervention We included a single RCT with 12 participants who had anosmia or hyposmia for at least 90 days following COVID‐19 infection. Participants received a 30‐day course of palmitoylethanolamide and luteolin or no intervention. Psychophysical testing was used to assess olfactory function at 30 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the treatment of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important The sense of smell is critical to one's enjoyment of odours and tastes, and is important for safety. During the COVID‐19 pandemic there has been an increasing focus on change in sense of smell as one of the early symptoms associated with infection. This can be a reduction, change or complete loss of the sense of smell. For most people this is temporary, however for some this lasts weeks or even months. If a person has lost their sense of smell for a long time (over four weeks after having COVID‐19), we do not know if there are any treatments that might help it to recover. How we identified and assessed the evidence We searched the medical literature, identifying relevant studies and summarising the results. We assessed the quality of the studies as well as the certainty of the evidence. Factors influencing this included the size of the studies, the methods used to perform them and how results were reported by researchers. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found two small studies to include in the review, including a total of 30 people. All participants had problems with their sense of smell that had lasted for at least four weeks, and started after a COVID‐19 infection. Problems with the sense of smell were identified using special smell identification tests carried out by the research team. The patients were randomly divided into two groups: those who would receive treatment and those who would not. The treatment in one study was a course of corticosteroid tablets ('systemic') and nasal irrigation (with a wash consisting of a mix of corticosteroids, decongestant and an agent that breaks down mucus). The second study used a course of a supplement known as palmitoylethanolamide and luteolin. Systemic corticosteroids and nasal irrigation (intranasal corticosteroids/decongestant/mucolytic) compared to no treatment We do not know whether corticosteroid tablets with nasal irrigation is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 40 days;
 ‐ changing the sense of smell after 40 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. Palmitoylethanolamide and luteolin compared to no treatment We do not know whether palmitoylethanolamide and luteolin is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 30 days;
 ‐ changing the sense of smell after 30 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. We did find a number of other studies that are being carried out, but no results from these studies are yet available to be included in this review. What this means It is unclear whether using corticosteroids with nasal irrigation, or using a palmitoylethanolamide and luteolin supplement, might treat problems with the sense of smell after COVID‐19, or whether these treatments can potentially cause harm. Other treatments are under investigation. This review is a 'living systematic review', meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.743Z" }, { "id": "226741b6-d769-4502-9d08-c582617cf9bb", "pmid": "", "title": "Chinese medicinal herbs for cholelithiasis", "imported": false, "abstract": "Abstract - Background Cholelithiasis is a common disease of the biliary tract. Chinese medicinal herbs are being used widely as an alternative treatment in people with cholelithiasis, but their beneficial or harmful effects have not been assessed systematically. Objectives To assess the beneficial and harmful effects of Chinese medicinal herbs in people with cholelithiasis. Search methods We conducted searches in the Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, Science Citation Index Expanded, Chinese Medicine Conference Disc, and Chinese Bio‐Medicine Disc to January 2013. We handsearched four Chinese journals. No language or year of publication restrictions were applied. Selection criteria Randomised clinical trials studying Chinese medicinal herbs for treatment of cholelithiasis. Data collection and analysis Two review authors (SJ, TG) independently extracted data. For dichotomous data, we estimated the risk ratio (RR), and for continuous data, we calculated the mean difference. We also calculated 95% confidence intervals (CI). Main results Eleven randomised trials with 1205 participants with asymptomatic or mild‐to‐moderate cholelithiasis were included. None of the randomised clinical trials compared a single Chinese medicinal herb with a Western medicine or with surgery. No placebo‐controlled trials were identified. In the trials comparing one Chinese herbal medicine (Gandanxiaoshi tablet) versus another (Aihuodantong tablet), there was no significant difference in the improvement of upper abdominal pain after the end of treatment (RR 1.21; 95% CI 0.71 to 2.05), and the heterogeneity among trials was not substantial. No other outcomes could be assessed. The remaining trials of Chinese medicinal herbs (Qingdan capsule, Danshu capsule, Paishi capsule, Rongdanpaishi capsule), did not offer specific data on symptoms, signs, or change in gallstones that would permit assessment of significant differences in curative effects between the treatment and control groups. No serious adverse events were reported. Authors' conclusions This review reveals no strong evidence that the analysed Chinese medicinal herbs have any beneficial effects on asymptomatic or mild‐to‐moderate cholelithiasis. Definitive conclusions will require much better designed randomised trials to reduce risk of bias and allow detailed assessment of clinical outcomes. Plain language summary Chinese medicinal herbs for cholelithiasis Cholelithiasis (gallstone disease) causes significant morbidity, severe complications, and economic burden worldwide. Though current surgical therapies are effective for gallstones, some types of gallstones (e.g., calcium bilirubinate calculi) cannot easily be eradicated by surgery and they often recur in the bile duct system, putting people at high risk of severe complications. The objective of this review was to evaluate the benefits and harms of Chinese medicinal herbs for people with cholelithiasis. Though some Chinese medicinal herbs appear to be safe for people with asymptomatic, mild, or moderate disease, they have not been conclusively shown to have curative effects on gallstones due to the low methodological quality (high risk of bias) of the included trials. Thus, randomised clinical trials with low risk of bias should be conducted to assess the effects of Chinese medicinal herbs before they can be used widely in the clinic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Gan, T; Chen, J; Jin, SJ; Wang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD004547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "226fd20b-665c-44bf-8dfe-ab3fd82cd64f", "pmid": "", "title": "Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease", "imported": false, "abstract": "Abstract - Background Thyrotropin‐releasing hormones (TRH) added to prenatal corticosteroids has been suggested as a way to further reduce breathing problems and neonatal lung disease in infants born preterm. Objectives To assess the effects of giving prenatal TRH in addition to corticosteroids to women at risk of preterm birth for the prevention of neonatal respiratory disease. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013) and reference lists of retrieved studies. We also contacted trial authors. Selection criteria Randomised controlled trials in women at sufficient risk of preterm birth to warrant the use of prenatal corticosteroids to promote lung maturity. TRH and corticosteroids were compared with corticosteroids, with or without placebo. Data collection and analysis All assessments of trial eligibility, risk of bias and data extractions were independently carried out by at least two review authors. Main results Over 4600 women were recruited into the 15 trials included in the review, however two trials did not contribute any outcome data to the review. The trials had a moderate risk of bias. Overall, prenatal TRH, in addition to corticosteroids, did not reduce the risk of death prior to hospital discharge (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.86 to 1.27, six trials, 3694 infants), neonatal respiratory distress syndrome (average RR 1.05, 95% CI 0.91 to 1.22, nine trials, 3833 infants), or chronic lung disease (RR 1.01, 95% CI 0.85 to 1.19, five trials, 2511 infants), and did not improve any of the secondary fetal, neonatal or childhood outcomes assessed by intention‐to‐treat analyses. Indeed, the data showed prenatal TRH to have adverse effects for women and their infants. All side effects reported (nausea, vomiting, light headedness, urgency of micturition, facial flushing) were significantly more likely to occur in women receiving TRH. In the infants, prenatal TRH increased the risk of needing respiratory support (RR 1.16, 95% CI 1.03 to 1.29, three trials, 1969 infants), and of having a low Apgar score at five minutes (RR 1.48, 95% CI 1.14 to 1.92, three trials, 1969 infants). Only three trials provided data on childhood follow‐up, and while one trial suggested poorer outcomes for infants who were exposed to prenatal TRH, the other two trials, that assessed infants using an established developmental instrument, showed no clear differences between groups in follow‐up outcomes. Sensitivity analyses by trial quality, or subgroups with differing times from entry to birth, or different dose regimens of TRH, did not change these findings. Authors' conclusions Prenatal TRH in addition to corticosteroids, given to women at risk of preterm birth, does not improve infant outcomes and can cause maternal side effects. Plain language summary Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease Thyrotropin‐releasing hormone (TRH) given with corticosteroids does not improve the benefit of corticosteroids on the lungs of babies born too early, and may increase harm. Babies born preterm (before 37 weeks of pregnancy) are at risk of breathing difficulties (such as respiratory distress syndrome). TRH increases thyroid hormones in the baby and it has been thought that adding TRH to corticosteroids for women giving birth early may increase the benefit of corticosteroids on the baby's lungs. This review included 15 trials, of a moderate risk of bias, that involved over 4600 women and their babies. In this review, TRH, given with corticosteroids to women at risk of early birth, was not shown to further reduce the breathing difficulties for the babies. Babies born to mothers who had received TRH with corticosteroids, were more likely to require support for breathing than babies born to mothers who received only corticosteroids. Women receiving TRH were more likely to experience adverse side effects, such as nausea, vomiting and flushing than women who only received corticosteroids. Therefore, based on the current available evidence, TRH is not recommended to be given to women at risk of preterm birth for preventing neonatal respiratory disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Crowther, CA; Alfirevic, Z; Han, S; Haslam, RR", "articleTypes": [], "doi": "10.1002/14651858.CD000019.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "227f6c21-7d51-40c9-aef1-10d48f1ed8a5", "pmid": "", "title": "Complex Effects of Dietary Manipulation on Metabolic Function, Inflammation and Health", "imported": false, "abstract": "The purpose of this research study is to 1) understand how some, but not all people with obesity develop obesity related conditions such as type 2 diabetes and cardiovascular disease, and 2) compare the effects of 3 popular weight loss diets (Mediterranean, low-carbohydrate, or a very-low-fat plant-based diet) in people with obesity.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.157Z" }, { "id": "22820311-47b2-4bef-8fac-9746017aaca2", "pmid": "", "title": "Sensitive Periods in Early Flavor Learning", "imported": false, "abstract": "Flavor is the primary dimension by which young children determine food acceptance. However, children are not merely miniature adults since sensory systems mature postnatally and their responses to certain tastes differ markedly from adults. Moreover, emerging research has revealed that there are sensitive periods during infancy such that early flavor experiences serve to modify later responses to flavors and foods. The proposed study aims to investigate this important issue by using as a model system a class of infant formulas which are hydrolyzed protein based and thus have very pronounced and distinctive flavors which are unpalatable to older-aged infants and adults. This research was initiated because of anecdotal reports by pediatricians that although it is easy to introduce this type of formula to infants during the first months of life, it becomes extremely difficult to do so later in infancy. Indeed, recent studies in the investigators' laboratory provided the first experimental demonstration that infants younger than 4 months of age willingly accept substantial amounts of, and satiate while feeding, a novel, protein hydrolysate formula. In marked contrast, infants older than 4 months reject the protein hydrolysate formula and this rejection occurs within the first minute of a feed, a finding that strongly suggests the sensory qualities of the formula are responsible, at least in part, for this rejection. Moreover, this rejection is not evident when the investigators test older-aged infants with other unfamiliar, but non-hydrolysate, formulas. In other words, the rejection appears to be in response to a particular component or components of protein hydrolysate formulas. This shift in acceptability can be ameliorated by prior exposure. That is, if these formulas are introduced to infants within the first few months of life and are fed continuously, they remain highly acceptable throughout infancy and early childhood. These observations implicate a sensitive period during development, occurring somewhere before 4 months of age, during which exposure to a formula, which is unpalatable to adults and infants over 4 months of age without exposure, renders it acceptable and presumably palatable. To the investigators' knowledge, this is the clearest example of a sensitive period in the development of responses to foods and flavors in humans thus far identified.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.151Z" }, { "id": "228de4b3-78f7-4aad-b81e-23ebb2871011", "pmid": "", "title": "The Effects of GLP-1 Receptor Agonists on Sensory Systems and Ingestive Behavior", "imported": false, "abstract": "The goal of this study is to explore whether of GLP-1 receptor agonist use is associated with differences in taste, smell, food preferences, appetite, food cravings, and responses to food cues in adults. The study includes adults who are not currently taking a GLP-1 receptor agonist but may be eligible to use one, and adults who are already taking a GLP-1 receptor agonist as part of their regular medical care for approximately 1 month or approximately 6 months.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "2299899a-d09b-4e3c-ab6b-4d98dec63f2c", "pmid": "", "title": "Protein substitute for children and adults with phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria is an inherited metabolic disorder characterised by an absence or deficiency of the enzyme phenylalanine hydroxylase. The aim of treatment is to lower blood phenylalanine concentrations to the recommended therapeutic range to prevent developmental delay and support normal growth. Current treatment consists of a low‐phenylalanine diet in combination with a protein substitute which is free from or low in phenylalanine. Guidance regarding the use, dosage, and distribution of dosage of the protein substitute over a 24‐hour period is unclear, and there is variation in recommendations among treatment centres. This is an update of a Cochrane review first published in 2005, and previously updated in 2008. Objectives To assess the benefits and adverse effects of protein substitute, its dosage, and distribution of dose in children and adults with phenylketonuria who are adhering to a low‐phenylalanine diet. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which consists of references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. We also contacted manufacturers of the phenylalanine‐free and low‐phenylalanine protein substitutes for any data from published and unpublished randomised controlled trials. Date of the most recent search of the Group's Inborn Errors of Metabolism Trials Register: 03 April 2014. Selection criteria All randomised or quasi‐randomised controlled trials comparing: any dose of protein substitute with no protein substitute; an alternative dosage; or the same dose, but given as frequent small doses throughout the day compared with the same total daily dose given as larger boluses less frequently. Data collection and analysis Both authors independently extracted data and assessed trial quality. Main results Three trials (69 participants) are included in this review. One trial investigated the use of protein substitute in 16 participants, while a further two trials investigated the dosage of protein substitute in a total of 53 participants. Due to issues with data presentation in each trial, described in full in the review, formal statistical analyses of the data were impossible. Investigators will be contacted for further information. Authors' conclusions No conclusions could be drawn about the short‐ or long‐term use of protein substitute in phenylketonuria due to the lack of adequate or analysable trial data. Additional data and randomised controlled trials are needed to investigate the use of protein substitute in phenylketonuria. Until further evidence is available, current practice in the use of protein substitute should continue to be monitored with care. Plain language summary The impact of protein substitute on the nutrition status, growth, and neuropsychological performance of children and adults with phenylketonuria People with phenylketonuria (PKU) who follow a low‐phenylalanine diet are required to take protein substitute to ensure adequate consumption of protein, energy, and other nutrients. The need for protein substitute has been established through clinical experience and observational data. Randomised, controlled trials are needed to confirm this need as well as its proper dosage and frequency of use. We performed a systematic review of randomised control trials investigating the impact of the use, dosage, and distribution of protein substitute on physical and neuropsychological outcomes in the treatment of PKU. Trials of children and adults diagnosed with PKU in the newborn period who were treated early and continuously were included. We planned to pool the results of the trials to estimate treatment effect. Three trials met the inclusion criteria for the review. One trial evaluated the impact of protein substitute versus no protein substitute on neuropsychological status, plasma amino acid concentrations, and nutrient intake. The remaining two trials investigated the impact of differing dosages of protein substitute on plasma amino acid concentrations and nutrient intake. No trials investigating daily protein substitute distribution were eligible for inclusion in the review. Results are presented in text form only since adequate information for data pooling was not provided. The investigators will be contacted for further information. Currently data are insufficient to reach any conclusions regarding the use, dosage, and distribution of protein substitute in the treatment of PKU. Further randomized or controlled clinical trials are needed to provide evidence for the effectiveness, dosage, and distribution of protein substitute in the treatment of PKU.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Yi, SHL, Singh, RH", "articleTypes": [], "doi": "10.1002/14651858.CD004731.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.085Z" }, { "id": "22a3fd87-a709-408a-8e61-18f9c005920c", "pmid": "", "title": "Blood pressure lowering efficacy of potassium‐sparing diuretics (that block the epithelial sodium channel) for primary hypertension", "imported": false, "abstract": "Abstract - Background Potassium‐sparing diuretics, which block the epithelial sodium channel (ENaC), are widely prescribed for hypertension as a second‐line drug in patients taking other diuretics (e.g. thiazide diuretics) and much less commonly prescribed as monotherapy. Therefore, it is essential to determine the effects of ENaC blockers on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a first‐line or second‐line therapy. Objectives To quantify the dose‐related reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of ENaC blocker therapy as a first‐line or second‐line drug in patients with primary hypertension. Search methods We searched CENTRAL (The Cochrane Library 2012), MEDLINE (1950 to August 2012), EMBASE (1980 to August 2012) and reference lists of articles. Selection criteria Double‐blind, randomized, controlled trials in patients with primary hypertension that evaluate, for a duration of 3 to 12 weeks, the BP lowering efficacy of: 1) fixed‐dose monotherapy with an ENaC blocker compared with placebo; or 2) an ENaC blocker in combination with another class of anti‐hypertensive drugs compared with the respective monotherapy (without an ENaC blocker). Data collection and analysis Two authors independently assessed the risk of bias and extracted data. Study authors were contacted for additional information. WDAE information was also collected from the trials. Main results No trials evaluating the BP lowering efficacy of ENaC blockers as monotherapy in patients with primary hypertension were identified. Only 6 trials evaluated the BP lowering efficacy of low doses of amiloride and triamterene as a second drug in 496 participants with a baseline BP of 151/102 mm Hg. The additional BP reduction caused by the ENaC blocker as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. The addition of low doses of amiloride and triamterene in these trials did not reduce BP. An estimate of the dose‐related BP lowering efficacy for ENaC blockers was not possible because of a lack of trial data at higher doses. Authors' conclusions ENaC blockers do not have a statistically or clinically significant BP lowering effect at low doses but trials at higher doses are not available. The review did not provide a good estimate of the incidence of harms associated with ENaC blockers. Plain language summary The blood pressure lowering effect of ENaC blockers is not known Potassium‐sparing diuretics, which block the epithelial sodium channel (also called ENaC blockers), are a class of drugs commonly prescribed to prevent loss of potassium but also might help to lower elevated blood pressure. This class includes drugs such as amiloride (Midamor, Amilzide) and triamterene (Dyrenium, Dyazide). We asked how much this class of drugs lowers blood pressure, when used alone or when used as the second drug to treat hypertension. The available scientific literature was searched to find all the trials that had assessed this question. No trials were found studying the blood pressure lowering ability of ENaC blockers when used alone. We found 6 trials studying the blood pressure lowering ability of amiloride and triamterene, when added as a second drug, in 496 participants. All 6 trials studied the ENaC blockers at low doses and there was no blood pressure lowering effect. Trials studying these drugs at higher doses are needed in order to determine if they lower blood pressure. The harms associated with ENaC blockers could not be estimated in this review because of the low doses studied and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Heran, BS, Chen, JMH, Wang, JJ, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD008167.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.784Z" }, { "id": "22a4f109-154f-4b7c-84d6-86596f56fde7", "pmid": "", "title": "Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants", "imported": false, "abstract": "Abstract - Background It is important to institute an effective supportive therapy to maintain or recover soft tissue health around dental implants. Different maintenance regimens have been suggested, however it is unclear which are the most effective. Objectives To assess the effects of different interventions for 1) maintaining and 2) recovering soft tissue health around osseointegrated dental implants. Search methods We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and to an Internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 2 June 2010. Selection criteria All randomised controlled trials comparing agents or interventions for maintaining or recovering healthy tissues around dental implants. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random‐effects models using standardised mean differences for continuous data and risk ratios for dichotomous data with 95% confidence intervals. Main results Five trials compared interventions for maintaining soft tissue health around implants and a further six trials compared interventions to recover soft tissue health where there was evidence of peri‐implant mucositis. No statistically significant differences were found between the effectiveness of powered versus manual toothbrushes for either maintaining or recovering soft tissue health. There was no statistically significant difference found between different types of self administered antimicrobials for maintaining soft tissue health (hyaluronic acid gel compared to chlorhexidine gel, amine fluoride/stannous fluoride mouthwash compared to chlorhexidine mouthwash) and triclosan dentifrice compared to sodium fluoride dentifrice showed no statistically significant difference in recovering soft tissue health. However chlorhexidine irrigation was more effective in reducing plaque and marginal bleeding scores compared to chlorhexidine mouthwash and Listerine mouthwash was found to be statistically significantly better than placebo with regard to reducing mean plaque scores and marginal bleeding scores. When interventions administered by dental professional were compared there was no statistically significant difference found between chlorhexidine and physiologic solutions as irrigants at second stage surgery to maintain health of soft tissues. In patients with peri‐implant mucositis two trials evaluated interventions performed by dental professionals. There was no statistically significant difference between mechanical debridement followed by either minocycline or chlorhexidine gel, or between debridement with a titanium curette compared to an ultrasonic debridement tool. Authors' conclusions There was only low quality evidence for which are the most effective interventions for maintaining or recovering health of peri‐implant soft tissues. The included RCTs had short follow‐up periods and few subjects and although overall the risk of bias of the studies was either low or unclear, only single trials were available for each outcome. There was no reliable evidence as to which regimens are most effective for long term maintenance. This should not be interpreted as meaning that current maintenance regimens are ineffective. There was weak evidence that antibacterial mouthrinses are effective in reducing plaque and marginal bleeding around implants. More RCTs should be conducted in this area. In particular, there is a definite need for trials powered to find possible differences, using primary outcome measures and with much longer follow up. Such trials should be reported according to the CONSORT guidelines ( www.consort‐statement.org/ ). Plain language summary Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants Missing teeth can be replaced by dental implants. However, keeping the gums around the implants healthy is important, as they can be negatively affected by dental plaque and its induced inflammation. Prevention of this may include daily implant cleaning techniques by patients and regular cleaning by dental professionals. Antibacterial mouthrinses may help reduce plaque and bleeding around dental implants, but there is no evidence that powered toothbrushes are better than manual toothbrushes or that brushing with a certain gel or dentifrice is better than another. Among the professionally administered treatments there is no evidence that phosphoric acid is more effective than scaling and polishing, that chlorhexidine enclosed in the inner part of implants is superior to physiologic solution or that a topical antibiotic inserted submucosally is better than a chlorhexidine gel.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Grusovin, MG; Coulthard, P; Worthington, HV; George, P; Esposito, M", "articleTypes": [], "doi": "10.1002/14651858.CD003069.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "22bc89fc-f043-465e-8499-40a3b05ba682", "pmid": "", "title": "Nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy", "imported": false, "abstract": "Abstract - Background Across the developed world, an estimated 150,000 to 300,000 people are treated annually with pelvic radiotherapy and 80% will develop gastrointestinal (GI) symptoms during treatment. Acute GI symptoms are associated with a greater risk of chronic, often debilitating, GI symptoms. Up to one‐third of patients are malnourished before pelvic radiotherapy and up to four‐fifths of patients lose weight during treatment. Malnutrition is linked to a higher risk of GI toxicity, which can lead to breaks in radiotherapy and early cessation of chemotherapy, thus compromising the efficacy of the primary cancer treatment. Objectives To assess the effects of nutritional interventions for reducing GI toxicity in adults undergoing radical pelvic radiotherapy. Search methods We searched the Cochrane Gynaecological Cancer Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 4, 2012, MEDLINE and EMBASE to May 2012. We handsearched the citation lists of included studies and previous systematic reviews identified to identify further relevant trials. Selection criteria We included studies if they were randomised controlled trials (RCTs) or non‐randomised studies with concurrent comparison groups including quasi‐randomised trials, cluster RCTs, non‐randomised trials, prospective and retrospective cohort studies, and case series of 30 or more patients. We only included studies if they assessed the effect of a nutritional intervention in adults aged 18 years or over undergoing radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic malignancy. We excluded patients with stomas and a previous history of inflammatory bowel disease. Nutritional support interventions could be provided at any stage before or during pelvic radiotherapy and included dietary counselling; dietary modification of fibre, lactose or fat; supplementary foods or drinks or fortified foods; standard oral nutrition supplements including polymeric‐, peptide‐ or amino acid‐based supplements and those where novel substrates have been added; enteral tube feeds; or parenteral nutrition (partial or total). We excluded probiotics, prebiotics and synbiotics. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors to obtain missing data. We assessed bias for each of the included studies using the bias assessment tables in the Cochrane software Review Manager5. We performed meta‐analysis, when indicated, using the Mantel‐Haenszel fixed‐effect method or inverse variance fixed‐effect method displayed with heterogeneity. We undertook meta‐analyses on trials evaluating dietary modification against standard treatment for diarrhoea at the end of radiotherapy and for change in weight from baseline to end of radiotherapy. Main results The searches identified 7558 titles, and we excluded 7513 during title and abstract searches. We reviewed 45 papers in full, and excluded 39. We identified four studies on handsearching of the references, which, along with the six eligible papers from the database search, led to 10 studies being included. Four studies, three of which were RCTs and one prospective study, investigated the effect of elemental diet on GI symptoms; one RCT investigated the effect of dietary modification and elemental diet; and five RCTs investigated dietary modification. Studies were varied in terms of risk of bias. Data were dichotomised for presence and absence of diarrhoea at the end of radiotherapy for four trials evaluating dietary modification comprising modified fat, lactose, fibre or combinations of these dietary changes. A reduction in diarrhoea was demonstrated with nutritional intervention (risk ratio (RR) 0.66; 95% confidence interval (CI) 0.51 to 0.87, four studies, 413 participants, moderate quality of evidence) with low heterogeneity (Chi 2 = 3.50, I 2 = 14%). Two trials evaluating dietary modification on weight change (comparing baseline and end of radiotherapy) showed no difference between intervention or control (mean difference (MD) ‐0.57 kg; 95% CI ‐1.22 to 0.09) with low heterogeneity (Chi 2 = 1.41, I 2 = 29%). Generally adverse effects were poorly reported in included studies. Elemental diet in particular was poorly tolerated. GI symptoms or toxicity > 6 months after radiotherapy was not reported in included studies Authors' conclusions There have been benefits demonstrated with dietary modification during pelvic radiotherapy to reduce diarrhoea. Those diets included single interventions or combinations of modified fat, lactose‐restriction, fat‐restriction and fibre supplementation. We were unable to meta‐analyse elemental diet, as data were not available. We considered some of the studies to be at high risk of bias. There have been recent advances in novel, more targeted radiotherapy techniques, such that the findings of older studies need to be interpreted with caution. In addition, there were problems with compliance and palatability with some of the interventions, particularly elemental diet, which limits its usefulness in clinical practice. Plain language summary Do nutritional interventions reduce gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy? Background Research has shown that nutrition and radiotherapy have effects on each other. People with malnutrition tend to get more bowel side effects during radiotherapy. It has also been shown that many people lose weight during radiotherapy due to the treatment side effects. These side effects can lead to some people needing gaps in their radiotherapy and sometimes they even need to stop it entirely. This can reduce the chance of cancer cure. This review looked at the literature for providing extra nourishment or changes in diet to patients before or during radiotherapy, to determine whether this is of benefit in terms of reducing bowel symptoms, improving nutritional status and quality of life. Study characteristics Searches of all relevant sources of medical information identified 7558 articles, and, after initial screening of all these articles, we selected 45 as being suitable for this review. On reading the summaries of these 45 trials, 10 were suitable to be included in this review. We included trials that looked at the effects of a nutritional intervention in adults aged 18 years or over having radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic cancer. We excluded patients with stomas and a previous history of inflammatory bowel disease. Key results Results showed that studies evaluating dietary changes, including changes in dietary fat, fibre and lactose, during radiotherapy reduced diarrhoea at the end of treatment. However, these dietary changes did not seem to improve patients' weights. Quality of the evidence While some changes to diet during radiotherapy may benefit patients by reducing diarrhoea, it is important to recognise that some of the studies reviewed were dated and there have been changes in radiotherapy technique since then that may give patients less diarrhoea anyway. In addition, many studies were of poor quality and, therefore, only a small number were able to be included in this review. Some interventions described, for example, having to take a liquid diet, were not acceptable as many patients found them difficult to tolerate and were unable to take them completely.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Henson, CC; Burden, S; Davidson, SE; Lal, S", "articleTypes": [], "doi": "10.1002/14651858.CD009896.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "22d898b1-ec1b-493f-9b8c-c6b224502e1d", "pmid": "", "title": "A Double-Blind, Placebo-Controlled, Randomized, Phase Ib/IIa Clinical Study of ApTOLL for the Treatment of Acute Ischemic Stroke", "imported": false, "abstract": "This is a prospective, multicenter, double-blind, randomized, placebo-controlled, Phase Ib/IIa clinical study to assess the administration of ApTOLL together with endovascular therapy in acute ischemic stroke patients who are candidates to receive reperfusion therapies.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.155Z" }, { "id": "22e9b3e6-d06e-4e87-a868-711013baad72", "pmid": "", "title": "Dietary supplements for dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Dysmenorrhoea refers to painful menstrual cramps and is a common gynaecological complaint. Conventional treatments include non‐steroidal anti‐inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs), which both reduce myometrial activity (contractions of the uterus). A suggested alternative approach is dietary supplements. We used the term 'dietary supplement' to include herbs or other botanical, vitamins, minerals, enzymes, and amino acids. We excluded traditional Chinese medicines. Objectives To determine the efficacy and safety of dietary supplements for treating dysmenorrhoea. Search methods We searched sources including the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, PsycINFO (all from inception to 23 March 2015), trial registries, and the reference lists of relevant articles. Selection criteria We included randomised controlled trials (RCTs) of dietary supplements for moderate or severe primary or secondary dysmenorrhoea. We excluded studies of women with an intrauterine device. Eligible comparators were other dietary supplements, placebo, no treatment, or conventional analgesia. Data collection and analysis Two review authors independently performed study selection, performed data extraction and assessed the risk of bias in the included trials. The primary outcomes were pain intensity and adverse effects. We used a fixed‐effect model to calculate odds ratios (ORs) for dichotomous data, and mean differences (MDs) or standardised mean differences (SMDs) for continuous data, with 95% confidence intervals (CIs). We presented data that were unsuitable for analysis either descriptively or in additional tables. We assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods. Main results We included 27 RCTs (3101 women). Most included studies were conducted amongst cohorts of students with primary dysmenorrhoea in their late teens or early twenties. Twenty‐two studies were conducted in Iran and the rest were performed in other middle‐income countries. Only one study addressed secondary dysmenorrhoea. Interventions included 12 different herbal medicines (German chamomile ( Matricaria chamomilla, M recutita, Chamomilla recutita) , cinnamon ( Cinnamomum zeylanicum, C. verum) , Damask rose ( Rosa damascena), dill ( Anethum graveolens ), fennel ( Foeniculum vulgare ), fenugreek ( Trigonella foenum‐graecum ), ginger ( Zingiber officinale ), guava ( Psidium guajava ), rhubarb ( Rheum emodi ), uzara ( Xysmalobium undulatum ), valerian ( Valeriana officinalis ), and zataria ( Zataria multiflora )) and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Comparators included other supplements, placebo, no treatment, and NSAIDs. We judged all the evidence to be of low or very low quality. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few studies reported adverse effects. Effectiveness of supplements for primary dysmenorrhoea We have presented pain scores (all on a visual analogue scale (VAS) 0 to 10 point scale) or rates of pain relief, or both, at the first post‐treatment follow‐up. Supplements versus placebo or no treatment There was no evidence of effectiveness for vitamin E (MD 0.00 points, 95% CI −0.34 to 0.34; two RCTs, 135 women). There was no consistent evidence of effectiveness for dill (MD ‐1.15 points, 95% CI −2.22 to −0.08, one RCT, 46 women), guava (MD 0.59, 95% CI −0.13 to 1.31; one RCT, 151 women); one RCT, 73 women), or fennel (MD −0.34 points, 95% CI −0.74 to 0.06; one RCT, 43 women). There was very limited evidence of effectiveness for fenugreek (MD −1.71 points, 95% CI −2.35 to −1.07; one RCT, 101 women), fish oil (MD 1.11 points, 95% CI 0.45 to 1.77; one RCT, 120 women), fish oil plus vitamin B1 (MD −1.21 points, 95% CI −1.79 to −0.63; one RCT, 120 women), ginger (MD −1.55 points, 95% CI −2.43 to −0.68; three RCTs, 266 women; OR 5.44, 95% CI 1.80 to 16.46; one RCT, 69 women), valerian (MD −0.76 points, 95% CI −1.44 to −0.08; one RCT, 100 women), vitamin B1 alone (MD −2.70 points, 95% CI −3.32 to −2.08; one RCT, 120 women), zataria (OR 6.66, 95% CI 2.66 to 16.72; one RCT, 99 women), and zinc sulphate (MD −0.95 points, 95% CI −1.54 to −0.36; one RCT, 99 women). Data on chamomile and cinnamon versus placebo were unsuitable for analysis. Supplements versus NSAIDS There was no evidence of any difference between NSAIDs and dill (MD 0.13 points, 95% CI −1.01 to 1.27; one RCT, 47 women), fennel (MD −0.70 points, 95% CI −1.81 to 0.41; one RCT, 59 women), guava (MD 1.19, 95% CI 0.42 to 1.96; one RCT, 155 women), rhubarb (MD −0.20 points, 95% CI −0.44 to 0.04; one RCT, 45 women), or valerian (MD points 0.62 , 95% CI 0.03 to 1.21; one RCT, 99 women), There was no consistent evidence of a difference between Damask rose and NSAIDs (MD −0.15 points, 95% CI −0.55 to 0.25; one RCT, 92 women). There was very limited evidence that chamomile was more effective than NSAIDs (MD −1.42 points, 95% CI −1.69 to −1.15; one RCT, 160 women). Supplements versus other supplements There was no evidence of a difference in effectiveness between ginger and zinc sulphate (MD 0.02 points, 95% CI −0.58 to 0.62; one RCT, 101 women). Vitamin B1 may be more effective than fish oil (MD −1.59 points, 95% CI −2.25 to −0.93; one RCT, 120 women). Effectiveness of supplements for secondary dysmenorrhoea There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis (data were unsuitable for analysis). Safety of supplements Only four of the 27 included studies reported adverse effects in both treatment groups. There was no evidence of a difference between the groups but data were too scanty to reach any conclusions about safety. Authors' conclusions There is no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety is lacking. However for several supplements there was some low quality evidence of effectiveness and more research is justified. Plain language summary Dietary supplements for pain during menstruation Review question Cochrane authors reviewed the evidence of the effect of dietary supplements (e.g. vitamins, minerals, herbs) on period pain (dysmenorrhoea). Background Dietary supplements have been used in the treatment of period pain. It is important to explore their benefits and harms. We investigated the effectiveness of dietary supplements compared to other supplements, placebo, no treatment or conventional analgesics (pain relief) in women with either primary dysmenorrhoea (not related to any other diagnosis) or secondary dysmenorrhoea (related to other causes, such as endometriosis). The evidence is current to 23 March 2015. Study characteristics We included 27 randomised controlled trials (3101 women). Most participants were students in their late teens or early twenties with primary dysmenorrhoea. Most studies were conducted in Iran. Interventions included 12 different herbal medicines (chamomile, cinnamon, Damask rose, dill, fennel, fenugreek, ginger, guava, rhubarb, uzara, valerian, and zataria), and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Supplements were compared with other supplements, placebo, no treatment, and non‐steroidal anti‐inflammatory drugs (NSAIDs). Key results There was no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety was lacking. However, for several supplements there was some low quality evidence of effectiveness. Supplements for which there was some very limited evidence to suggest a potential benefit were fenugreek, ginger, valerian, zataria, zinc sulphate, fish oil, and vitamin B1. There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis. Quality of the evidence The evidence was of low or very low quality for all comparisons. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few included studies reported adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pattanittum, P; Kunyanone, N; Brown, J; Sangkomkamhang, US; Barnes, J; Seyfoddin, V; Marjoribanks, J", "articleTypes": [], "doi": "10.1002/14651858.CD002124.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "233d2ec6-c6d4-4bed-b298-843a2c80525b", "pmid": "", "title": "Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people", "imported": false, "abstract": "Abstract - Background Folate deficiency can result in congenital neural tube defects and megaloblastic anaemia. Low folate levels may be due to insufficient dietary intake or inefficient absorption, but impaired metabolic utilization also occurs. Because B12 deficiency can produce a similar anaemia to folate deficiency, there is a risk that folate supplementation can delay the diagnosis of B12 deficiency, which can cause irreversible neurological damage. Folic acid supplements may sometimes therefore include vitamin B12 supplements with simultaneous administration of vitamin B12. Lesser degrees of folate inadequacy are associated with high blood levels of the amino acid homocysteine which has been linked with the risk of arterial disease, dementia and Alzheimer's disease. There is therefore interest in whether dietary supplementation can improve cognitive function in the elderly. However, any apparent benefit from folic acid which was given in combination with B12 needs to be \"corrected\" for any effect of vitamin B12 alone. A separate Cochrane review of vitamin B12 and cognitive function has therefore been published. Objectives To examine the effects of folic acid supplementation, with or without vitamin B12, on elderly healthy or demented people, in preventing cognitive impairment or retarding its progress. Search methods Trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 10 October 2007 using the terms: folic acid, folate, vitamin B9, leucovorin, methyltetrahydrofolate, vitamin B12, cobalamin and cyanocobalamin. This Register contains references from all major health care databases and many ongoing trials databases. In addition MEDLINE, EMBASE, CINAHL, PsychINFO and LILACS were searched (years 2003‐2007) for additional trials of folate with or without vitamin B12 on healthy elderly people. Selection criteria All double‐blind, placebo‐controlled, randomized trials, in which supplements of folic acid with or without vitamin B12 were compared with placebo for elderly healthy people or people with any type of dementia or cognitive impairment. Data collection and analysis The reviewers independently applied the selection criteria and assessed study quality. One reviewer extracted and analysed the data. In comparing intervention with placebo, weighted mean differences and standardized mean difference or odds ratios were estimated. Main results Eight randomized controlled trials fulfilled the inclusion criteria for this review. Four trials enrolled healthy older people, and four recruited participants with mild to moderate cognitive impairment or dementia with or without diagnosed folate deficiency. Pooling the data was not possible owing to heterogeneity in sample selections, outcomes, trial duration, and dosage. Two studies involved a combination of folic acid and vitamin B12. There is no adequate evidence of benefit from folic acid supplemententation with or without vitamin B12 on cognitive function and mood of unselected healthy elderly people. However, in one trial enrolling a selected group of healthy elderly people with high homocysteine levels, 800 mcg/day folic acid supplementation over three years was associated with significant benefit in terms of global functioning (WMD 0.05, 95% CI 0.004 to 0.096, P = 0.033); memory storage (WMD 0.14, 95% CI 0.04 to 0.24, P = 0.006) and information‐processing speed (WMD 0.09, 95% CI 0.02 to 0.16, P = 0.016). Four trials involved people with cognitive impairment. In one pilot trial enrolling people with Alzheimer's disease, the overall response to cholinesterase inhibitors significantly improved with folic acid at a dose of 1mg/day (odds ratio: 4.06, 95% CI 1.22 to 13.53; P = 0.02) and there was a significant improvement in scores on the Instrumental Activities of Daily Living and the Social Behaviour subscale of the Nurse's Observation Scale for Geriatric Patients (WMD 4.01, 95% CI 0.50 to 7.52, P = 0.02). Other trials involving people with cognitive impairment did not show any benefit in measures of cognitive function from folic acid, with or without vitamin B12. Folic acid plus vitamin B12 was effective in reducing serum homocysteine concentrations (WMD ‐5.90, 95% CI ‐8.43 to ‐3.37, P < 0.00001). Folic acid was well tolerated and no adverse effects were reported. Authors' conclusions The small number of studies which have been done provide no consistent evidence either way that folic acid, with or without vitamin B12, has a beneficial effect on cognitive function of unselected healthy or cognitively impaired older people. In a preliminary study, folic acid was associated with improvement in the response of people with Alzheimer's disease to cholinesterase inhibitors. In another, long‐term use appeared to improve the cognitive function of healthy older people with high homocysteine levels. More studies are needed on this important issue. Plain language summary No evidence that folic acid with or without vitamin B12 improves cognitive function of unselected elderly people with or without dementia. Long‐term supplementation may benefit cognitive function of healthy older people with high homocysteine levels In the economically developed world, folate deficiency is one of the commonest vitamin deficiencies. Several reports suggest a higher prevalence of various psychiatric disorders in elderly people with folate deficiency. There is interest in whether dietary supplements of folic acid (an artificial chemical analogue of naturally occurring folates) can improve cognitive function of people at risk of cognitive decline associated with ageing or dementia, whether by affecting homocysteine metabolism or through other mechanisms. Eight trials met the criteria for inclusion. It was not possible to pool the data because the trials studied different populations, tested folic acid in different doses, and used different outcome measures. There were two trials of folic acid in conjunction with B12. The analysis showed significant benefit of folic acid over placebo in some measures of cognition in a long‐term trial recruiting elderly people with high homocysteine levels from a general population. In one pilot trial, 1 mg/day of folic acid was associated with significant improvement in behavioural response to cholinesterase inhibitors in people with Alzheimer's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Malouf, R, Grimley Evans, J", "articleTypes": [], "doi": "10.1002/14651858.CD004514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.125Z" }, { "id": "2352148d-92e4-4f71-95eb-1982593b83fb", "pmid": "", "title": "Cannabis and cannabinoids for symptomatic treatment for people with multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Filippini, G, Minozzi, S, Borrelli, F, Cinquini, M, Dwan, K", "articleTypes": [], "doi": "10.1002/14651858.CD013444.pub2 AB - Abstract - Background Spasticity and chronic neuropathic pain are common and serious symptoms in people with multiple sclerosis (MS). These symptoms increase with disease progression and lead to worsening disability, impaired activities of daily living and quality of life. Anti‐spasticity medications and analgesics are of limited benefit or poorly tolerated. Cannabinoids may reduce spasticity and pain in people with MS. Demand for symptomatic treatment with cannabinoids is high. A thorough understanding of the current body of evidence regarding benefits and harms of these drugs is required. Objectives To assess benefit and harms of cannabinoids, including synthetic, or herbal and plant‐derived cannabinoids, for reducing symptoms for adults with MS. Search methods We searched the following databases from inception to December 2021: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), CINAHL (EBSCO host), LILACS, the Physiotherapy Evidence Database (PEDro), the World Health Organisation International Clinical Trials Registry Platform, the US National Institutes of Health clinical trial register, the European Union Clinical Trials Register, the International Association for Cannabinoid Medicines databank. We hand searched citation lists of included studies and relevant reviews. Selection criteria We included randomised parallel or cross‐over trials (RCTs) evaluating any cannabinoid (including herbal C annabis, C annabis flowers, plant‐based cannabinoids, or synthetic cannabinoids) irrespective of dose, route, frequency, or duration of use for adults with MS. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane Risk of bias 2 tool for parallel RCTs and crossover trials. We rated the certainty of evidence using the GRADE approach for the following outcomes: reduction of 30% in the spasticity Numeric Rating Scale, pain relief of 50% or greater in the Numeric Rating Scale‐Pain Intensity, much or very much improvement in the Patient Global Impression of Change (PGIC), Health‐Related Quality of Life (HRQoL), withdrawals due to adverse events (AEs) (tolerability), serious adverse events (SAEs), nervous system disorders, psychiatric disorders, physical dependence. Main results We included 25 RCTs with 3763 participants of whom 2290 received cannabinoids. Age ranged from 18 to 60 years, and between 50% and 88% participants across the studies were female. The included studies were 3 to 48 weeks long and compared nabiximols, an oromucosal spray with a plant derived equal (1:1) combination of tetrahydrocannabinol (THC) and cannabidiol (CBD) (13 studies), synthetic cannabinoids mimicking THC (7 studies), an oral THC extract of C annabis sativa (2 studies), inhaled herbal C annabis (1 study) against placebo. One study compared dronabinol, THC extract of C annabis sativa and placebo, one compared inhaled herbal C annabis , dronabinol and placebo. We identified eight ongoing studies. Critical outcomes • Spasticity: nabiximols probably increases the number of people who report an important reduction of perceived severity of spasticity compared with placebo (odds ratio (OR) 2.51, 95% confidence interval (CI) 1.56 to 4.04; 5 RCTs, 1143 participants; I 2 = 67%; moderate‐certainty evidence). The absolute effect was 216 more people (95% CI 99 more to 332 more) per 1000 reporting benefit with cannabinoids than with placebo. • Chronic neuropathic pain: we found only one small trial that measured the number of participants reporting substantial pain relief with a synthetic cannabinoid compared with placebo (OR 4.23, 95% CI 1.11 to 16.17; 1 study, 48 participants; very low‐certainty evidence). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity. • Treatment discontinuation due to AEs: cannabinoids may increase slightly the number of participants who discontinue treatment compared with placebo (OR 2.41, 95% CI 1.51 to 3.84; 21 studies, 3110 participants; I² = 17%; low‐certainty evidence); the absolute effect is 39 more people (95% CI 15 more to 76 more) per 1000 people. Important outcomes • PGIC: cannabinoids probably increase the number of people who report 'very much' or 'much' improvement in health status compared with placebo (OR 1.80, 95% CI 1.37 to 2.36; 8 studies, 1215 participants; I² = 0%; moderate‐certainty evidence). The absolute effect is 113 more people (95% CI 57 more to 175 more) per 1000 people reporting improvement. • HRQoL: cannabinoids may have little to no effect on HRQoL (SMD ‐0.08, 95% CI ‐0.17 to 0.02; 8 studies, 1942 participants; I 2 = 0%; low‐certainty evidence); • SAEs: cannabinoids may result in little to no difference in the number of participants who have SAEs compared with placebo (OR 1.38, 95% CI 0.96 to 1.99; 20 studies, 3124 participants; I² = 0%; low‐certainty evidence); • AEs of the nervous system: cannabinoids may increase nervous system disorders compared with placebo (OR 2.61, 95% CI 1.53 to 4.44; 7 studies, 1154 participants; I² = 63%; low‐certainty evidence); • Psychiatric disorders: cannabinoids may increase psychiatric disorders compared with placebo (OR 1.94, 95% CI 1.31 to 2.88; 6 studies, 1122 participants; I² = 0%; low‐certainty evidence); • Drug tolerance: the evidence is very uncertain about the effect of cannabinoids on drug tolerance (OR 3.07, 95% CI 0.12 to 75.95; 2 studies, 458 participants; very low‐certainty evidence). Authors' conclusions Compared with placebo, nabiximols probably reduces the severity of spasticity in the short‐term in people with MS. We are uncertain about the effect on chronic neurological pain and health‐related quality of life. Cannabinoids may increase slightly treatment discontinuation due to AEs, nervous system and psychiatric disorders compared with placebo. We are uncertain about the effect on drug tolerance. The overall certainty of evidence is limited by short‐term duration of the included studies. Plain language summary Cannabis and cannabinoids for people with multiple sclerosis Key messages 
• Treatment with nabiximols likely results in improvement of spasticity and may not increase serious harmful effects compared with placebo • Compared with placebo, cannabinoids (nabiximols, C annabis extract, synthetic cannabinoids) likely improve well‐being when measured with patient‐reported outcomes • Due to a lack of robust evidence, the benefit of these medicines for treating chronic neuropathic pain is unclear. What is the issue? Many people with multiple sclerosis (MS) experience spasticity that causes also pain and impacts on the ability to carry out daily activities. Spasticity is a form of increased muscle tone. Cannabis ‐based medicines refer to the use of Cannabis , or its ingredients called cannabinoids, as medical therapies to alleviate spasticity, chronic pain and other symptoms in MS. An international survey found that MS was one of the five medical conditions for which C annabis was most often used. Another survey conducted in the UK found that more than one in five people with MS reported they had used C annabis to try to manage their symptoms. What did we want to find out? We wanted to find out if cannabinoids were better than placebo in adults with MS to improve: • spasticity; • chronic neuropathic pain; • well‐being, We also wanted to find out if cannabinoids were associated with: • treatment discontinuation due to unwanted effects; • serious harmful effects; • nervous system disorders or psychiatric disorders; • drug tolerance defined as a condition that occurs when the body gets used to a medicine so that more medicine is needed. What did we do? 
We searched for studies that compared cannabinoids against placebo in adult people with MS. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and certainty of evidence. What did we find? We found 25 studies that involved 3763 people with MS, 2290 of whom received cannabinoids. Fifteen studies were very short term or short‐term studies (two to 12 weeks), seven were intermediate term (12 to 26 weeks), and two were long term (50 and 156 weeks). One study reported results at three days only. The biggest study was conducted in 657 people and the smallest study involved 14 people. Most studies were done in European countries. Thirteen studies evaluated an oral spray (nabiximols) containing two compounds derived from the C annabis plant. The other studies compared different cannabinoids with placebo. Pharmaceutical companies funded 15 of the studies. Main results Compared with placebo, cannabinoids: • probably increase the number of people who report an important reduction of perceived severity of spasticity for up to 14 weeks (evidence from five studies in 1143 people); • may increase the number of people who report an important reduction of perceived severity of chronic neuropathic pain, but the evidence is very uncertain (evidence from one study in 48 people). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity: • probably increase the number of people who perceive their well‐being as 'very much' or 'much' improved (evidence from eight studies in 1215 people); • may increase slightly the number of people who discontinue treatment due to unwanted effects (evidence from 21 studies in 3110 people); • may result in little to no difference in the number of people who have serious harmful effects (evidence from 20 studies in 3124 people); • may increase nervous system disorders (evidence from seven studies in 1154 people) or psychiatric disorders (evidence from six studies in 1122 people); • may have little to no effect on the number of people who have drug tolerance, but the evidence is very uncertain (two studies in 458 people). What are the limitations of the evidence? There is no high‐quality evidence. We are moderately confident that cannabinoids work better versus no cannabinoids to improve severity of spasticity and well‐being in adults with MS. We have little confidence in our results for the effect on chronic neuropathic pain because the available evidence is limited. There is limited evidence to determine the effects of cannabinoids on serious harmful effects, nervous system or psychiatric disorders, and drug tolerance. How up to date is the evidence? 
The evidence is up‐to‐date to December 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.778Z" }, { "id": "235c5ef2-a725-4bab-8793-9f93f40b9704", "pmid": "", "title": "Coblation versus other surgical techniques for tonsillectomy", "imported": false, "abstract": "Abstract - Background Tonsillectomy is a very common operation and is performed using various surgical methods. Coblation is a popular method because it purportedly causes less pain than other surgical methods. However, the superiority of coblation is unproven. Objectives To compare the effects of coblation tonsillectomy for chronic tonsillitis or tonsillar hypertrophy with other surgical techniques, both hot and cold, on intraoperative morbidity, postoperative morbidity and procedural cost. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2017, Issue 3); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 April 2017. Selection criteria Randomised controlled trials (RCTs) of children and adults undergoing tonsillectomy with coblation compared with any other surgical technique. This review is limited to trials of extracapsular (traditional) tonsillectomy and excludes trials of intracapsular tonsil removal (tonsillotomy). Data collection and analysis We used the standard Cochrane methods. Our primary outcomes were: patient‐reported pain using a validated pain scale at postoperative days 1, 3 and 7; intraoperative blood loss; primary postoperative bleeding (within 24 hours) and secondary postoperative bleeding (more than 24 hours after surgery). Secondary outcomes were: time until resumption of normal diet, time until resumption of normal activity, duration of surgery and adverse effects including blood transfusion and the need for reoperation. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 29 studies, with a total of 2561 participants. All studies had moderate or high risk of bias. Sixteen studies used an adequate randomisation technique, however the inability to mask the surgical teams and/or provide adequate methods to mitigate the risk of bias put nearly all studies at moderate or high risk of detection and measurement bias for intraoperative blood loss, and primary and secondary bleeding. In contrast most studies (20) were at low risk of bias for pain assessment. Most studies did not report data in a manner permitting meta‐analysis. Most studies did not clearly report the participant characteristics, surgical indications or whether patients underwent tonsillectomy or adenotonsillectomy. Most studies reported that tonsillitis (infection) and/or tonsillar hypertrophy (obstruction) were the indication for surgery. Seven studies included only adults, 16 studies included only children and six studies included both. Pain At postoperative day 1 there is very low quality evidence that patients in the coblation group had less pain, with a standardised mean difference (SMD) of ‐0.79 (95% confidence interval (CI) ‐1.38 to ‐0.19; 538 participants; six studies). This effect is reduced a SMD of ‐0.44 (95% CI ‐0.97 to 0.09; 401 participants; five studies; very low‐quality evidence ) at day 3, and at day 7 there is low quality evidence of little or no difference in pain (SMD ‐0.01, 95% CI ‐0.22 to 0.19; 420 participants; five studies). Although this suggests that pain may be slightly less in the coblation group between days 1 and 3, the clinical significance is unclear. Intraoperative blood loss Methodological differences between studies in the measurement of intraoperative blood loss precluded meta‐analysis. Primary and secondary bleeding The risk of primary bleeding was similar (risk ratio (RR) 0.99, 95% CI 0.48 to 2.05; 2055 participants; 25 studies; low‐quality evidence ). The risk of secondary bleeding was greater in the coblation group with a risk ratio of 1.36 (95% CI 0.95 to 1.95; 2118 participants; 25 studies; low‐quality evidence ). Using the median of the control group as the baseline risk, the absolute risk in the coblation group was 5% versus 3.6% in the control group. The difference of 1.3% has a 95% CI of 0.2% lower in the coblation group to 3.5% higher. Secondary outcomes Differences in study design and data reporting precluded the identification of differences in the time to resumption of normal diet or activity, or whether there was a difference in the duration of surgery. Although we could not feasibly compare the costs of equipment or operative facility, anaesthetic and surgical fees across different healthcare systems we used duration of surgery as a proxy for cost. Although this outcome was commonly reported in studies, it was not possible to pool the data to determine whether there was a difference. Adverse events other than bleeding were not well reported. It is unclear whether there is a difference in postoperative infections or the need for reoperation. Authors' conclusions The coblation technique may cause less pain on postoperative day 1, but the difference is small and may be clinically meaningless. By postoperative day 3, the difference decreases further and by postoperative day 7 there appears to be little or no difference. We found similar rates of primary bleeding but we cannot rule out a small increased risk of secondary bleeding with coblation. The evidence supporting these findings is of low or very low quality , i.e. there is a very high degree of uncertainty about the results. Moreover, for most outcomes data were only available from a few of the 29 included studies. The current evidence is of very low quality, therefore it is uncertain whether or not the coblation technique has any advantages over traditional tonsillectomy techniques. Despite the large number of studies, failure to use standardised or validated outcome measures precludes the ability to pool data across studies. Therefore, well‐conducted RCTs using consistent, validated outcome measures are needed to establish whether the coblation technique has a benefit over other methods. In the included studies we identified no clear difference in adverse events. However, given the rarity of these events, randomised trials lack the power to detect a difference. Data from large‐scale registries will provide a better estimate of any difference in these rare outcomes. Plain language summary Surgical removal of the tonsils (tonsillectomy) with coblation or another surgical method Review question This review compared the coblation method with other methods of tonsil removal to assess recovery following tonsillectomy or adenotonsillectomy. Background Surgical removal of the tonsils (tonsillectomy) is a very common operation. Patients may have pain for up to two weeks after surgery. Bleeding may occur either immediately after surgery ('primary bleeding' within 24 hours of surgery) or later ('secondary bleeding' more than 24 hours after surgery). There are many methods of tonsillectomy; the traditional method is with metal surgical instruments. Coblation is a new method where the surgeon uses an electrically powered handpiece that 'burns' tissues using low temperatures. Study characteristics This review included evidence available up to April 2017. We included 29 studies, with a total of 2561 participants. All studies had a moderate or high risk of bias. Seven studies included adults, 16 studies included children and six included both adults and children. Most studies measured pain using a patient‐reported scale (for example, asking people to rate their pain on a scale of 1 to 10). Key results The coblation technique may cause slightly less pain one day after surgery and three days after surgery, but it is unlikely that there is a difference in pain seven days after surgery. We are very uncertain whether the amount of pain reduction observed in days 1 to 3 after surgery would be important to patients. There is little or no difference in the risk of bleeding in the first day after surgery, but there may be a small increased risk of bleeding with coblation after the first day. For every 1000 patients having a tonsillectomy, 50 patients would have a bleed with coblation, compared to 36 with traditional surgical techniques. Quality of the evidence The evidence for the difference in pain is of low or very low quality and for the difference in bleeding after surgery it is of low quality . This means that we have little confidence in the results; the true effect may be very different ‐ we simply do not know at this stage.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Pynnonen, M, Brinkmeier, JV, Thorne, MC, Chong, LY, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.783Z" }, { "id": "2387a26b-31b5-41dd-9d21-5f9b3bb7eb5b", "pmid": "", "title": "Nasal decongestants in monotherapy for the common cold", "imported": false, "abstract": "Abstract - Background Many treatments for the common cold exist and are sold over‐the‐counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited. Objectives To assess the efficacy, and short‐ and long‐term safety, of nasal decongestants used in monotherapy to alleviate symptoms of the common cold in adults and children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6, June 2016), which contains the Cochrane Acute Respiratory Infections (ARI) Specialised Register, MEDLINE (1946 to July 2016), Embase (2010 to 15 July 2016), CINAHL (1981 to 15 July 2016), LILACS (1982 to July 2016), Web of Science (1955 to July 2016) and clinical trials registers. Selection criteria Randomised controlled trials (RCTs) and cluster‐RCTs investigating the effectiveness and adverse effects of nasal decongestants compared with placebo for treating the common cold in adults and children. We excluded quasi‐RCTs. Data collection and analysis Three review authors independently extracted and summarised data on subjective measures of nasal congestion, overall patient well‐being score, objective measures of nasal airway resistance, adverse effects and general recovery. One review author acted as arbiter in cases of disagreement. We categorised trials as single and multi‐dose and analysed data both separately and together. We also analysed studies using an oral or topical nasal decongestant separately and together. Main results We included 15 trials with 1838 participants. Fourteen studies included adult participants only (aged 18 years and over). In six studies the intervention was a single dose and in nine studies multiple doses were used. Nine studies used pseudoephedrine and three studies used oxymetazoline. Other decongestants included phenylpropanolamine, norephedrine and xylometazoline. Phenylpropanolamine (or norephedrine) is no longer available on the market therefore we did not include the results of these studies in the meta‐analyses. Eleven studies used oral decongestants; four studies used topical decongestants. Participants were included after contracting the common cold. The duration of symptoms differed among studies; in 10 studies participants had symptoms for less than three days, in three studies symptoms were present for less than five days, one study counted the number of colds over one year, and one study experimentally induced the common cold. In the single‐dose studies, the effectiveness of a nasal decongestant was measured on the same day, whereas the follow‐up in multi‐dose studies ranged between one and 10 days. Most studies were conducted in university settings (N = eight), six at a specific university common cold centre. Three studies were conducted at a university in collaboration with a hospital and two in a hospital only setting. In two studies the setting was unclear. There were large differences in the reporting of outcomes and the reporting of methods in most studies was limited. Therefore, we judged most studies to be at low or unclear risk of bias. Pooling was possible for a limited number of studies only; measures of effect are expressed as standardised mean differences (SMDs). A positive SMD represents an improvement in congestion. There is no defined minimal clinically important difference for measures of subjective improvement in nasal congestion, therefore we used the SMDs as a guide to assess whether an effect was small (0.2 to 0.49), moderate (0.5 to 0.79) or large (≥ 0.8). Single‐dose decongestant versus placebo: 10 studies compared a single dose of nasal decongestant with placebo and their effectiveness was tested between 15 minutes and 10 hours after dosing. Seven of 10 studies reported subjective symptom scores for nasal congestion; none reported overall patient well‐being. However, pooling was not possible due to the large diversity in the measurement and reporting of symptoms of congestion. Two studies recorded adverse events. Both studies used an oral decongestant and each of them showed that there was no statistical difference between the number of adverse events in the treatment group versus the placebo group. Multi‐dose decongestant versus placebo: nine studies compared multiple doses of nasal decongestants with placebo, but only five reported on the primary outcome, subjective symptom scores for nasal congestion. Only one study used a topical decongestant; none reported overall patient well‐being. Subjective measures of congestion were significantly better for the treatment group compared with placebo approximately three hours after the last dose (SMD 0.49, 95% confidence interval (CI) 0.07 to 0.92; P = 0.02; GRADE: low‐quality evidence). However, the SMD of 0.49 only indicates a small clinical effect. Pooling was based on two studies, one oral and one topical, therefore we were unable to assess the effects of oral and topical decongestants separately. Seven studies reported adverse events (six oral and one topical decongestant); meta‐analysis showed that there was no statistical difference between the number of adverse events in the treatment group (125 per 1000) compared to the placebo group (126 per 1000). The odds ratio (OR) for adverse events in the treatment group was 0.98 (95% CI 0.68 to 1.40; P = 0.90; GRADE: low‐quality evidence). The results remained the same when we only considered studies using an oral decongestant (OR 0.95, 95% CI 0.65 to 1.39; P = 0.80; GRADE: low‐quality evidence). Authors' conclusions We were unable to draw conclusions on the effectiveness of single‐dose nasal decongestants due to the limited evidence available. For multiple doses of nasal decongestants, the current evidence suggests that these may have a small positive effect on subjective measures of nasal congestion in adults with the common cold. However, the clinical relevance of this small effect is unknown and there is insufficient good‐quality evidence to draw any firm conclusions. Due to the small number of studies that used a topical nasal decongestant, we were also unable to draw conclusions on the effectiveness of oral versus topical decongestants. Nasal decongestants do not seem to increase the risk of adverse events in adults in the short term. The effectiveness and safety of nasal decongestants in children and the clinical relevance of their small effect in adults is yet to be determined. Plain language summary Do nasal decongestants used alone relieve cold symptoms? Review question We wanted to find out if nasal decongestants used alone can ease nasal congestion symptoms in people with colds. Background Colds, although not serious, are common illnesses responsible for many visits to family doctors and days lost from work and school. Cold symptoms include runny nose, sore throat and sneezing, and they can last up to two weeks. There is no cure for colds; treatments only ease the symptoms. Many people use over‐the‐counter medicines such as nasal decongestants to treat cold symptoms. However, there is little evidence that nasal decongestants actually work. We wanted to find out if nasal decongestants help ease congestion caused by colds. We considered studies that used a nasal decongestant as the only treatment for colds. We looked at subjective symptoms of congestion ‐ this means that symptoms and overall well‐being were self‐rated by patients. Search date We searched for studies in July 2016. Study characteristics We included 15 studies with 1838 participants; 14 included only adults aged 18 years or over. Six studies used a single‐dose nasal decongestant and measured the effects on the day it was administered. Nine studies used multiple doses and the effects were measured between one and 10 days after first administration. Eleven studies used tablets or syrup and four studies used nasal sprays. Eight studies were conducted at universities, three at universities in collaboration with hospitals and two in hospitals. The setting was unclear in two studies. Study funding sources Nine studies were funded by drug manufacturers or agencies with commercial interests in the study results. Funding sources were unclear in six studies. Key results We were unable to draw conclusions about single‐dose nasal decongestants. We found a small benefit in the relief of nasal congestion from multiple doses, but it was unclear if this was beneficial for patients. No studies reported overall patient well‐being. There was no difference in the numbers of adverse events between people who used a nasal decongestant and those who did not. We could not determine if there was a difference in effects between decongestant tablets and nasal sprays. The results relate to adults; there was no evidence on the effectiveness or safety of nasal decongestants for children. Quality of the evidence We assessed the quality of the evidence for subjective cold symptoms as low for the multi‐dose studies ‐ there were few data and reporting was unclear. We also assessed the quality of the evidence for adverse events as low because of unclear reporting and because the estimates were not precise (there were wide confidence intervals ‐ a measure of statistical uncertainty).", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Deckx, L, De Sutter, AIM, Guo, L, Mir, NA, van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009612.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.772Z" }, { "id": "238d79bd-b676-40d3-be98-278c02d0870f", "pmid": "", "title": "Topical lidocaine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Lidocaine is a local anaesthetic that is sometimes used on the skin to treat neuropathic pain. Objectives To assess the analgesic efficacy of topical lidocaine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 1 July 2014, together with the reference lists of retrieved papers and other reviews. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal to identify additional published or unpublished data. Selection criteria We included randomised, double‐blind studies of at least two weeks' duration comparing any formulation of topical lidocaine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts; at least 200 participants in the comparison, 8 to 12 weeks' duration, parallel design); second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison; and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. Main results We included 12 studies (508 participants) in comparisons with placebo or an active control. Six studies enrolled participants with moderate or severe postherpetic neuralgia, and the remaining studies enrolled different, or mixed, neuropathic pain conditions, including trigeminal neuralgia and postsurgical or post‐traumatic neuralgia. Four different formulations were used: 5% medicated patch, 5% cream, 5% gel, and 8% spray. Most studies used a cross‐over design, and two used a parallel‐group design. Two studies used enriched enrolment with randomised withdrawal. Seven studies used multiple doses, with one to four‐week treatment periods, and five used single applications. We judged all of the studies at high risk of bias because of small size or incomplete outcome assessment, or both. There was no first or second tier evidence, and no pooling of data was possible for efficacy outcomes. Only one multiple‐dose study reported our primary outcome of participants with ≥ 50% or ≥ 30% pain intensity reduction. Three single‐dose studies reported participants who were pain‐free at a particular time point, or had a 2‐point (of 10) reduction in pain intensity. The two enriched enrolment, randomised withdrawal studies reported time to loss of efficacy. In all but one study, third tier (very low quality) evidence indicated that lidocaine was better than placebo for some measure of pain relief. Pooling multiple‐dose studies across conditions demonstrated no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals, but there were few events and the withdrawal phase of enriched enrolment designs is not suitable to assess the true impact of adverse events (very low quality evidence). Authors' conclusions This review found no evidence from good quality randomised controlled studies to support the use of topical lidocaine to treat neuropathic pain, although individual studies indicated that it was effective for relief of pain. Clinical experience also supports efficacy in some patients. Several large ongoing studies, of adequate duration, with clinically useful outcomes should provide more robust conclusions about both efficacy and harm. Plain language summary Topical lidocaine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It differs from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are usually not effective in neuropathic pain, while medicines that are sometimes used to treat epilepsy or depression can be very effective in some people with neuropathic pain. Other possible treatments include the use of local anaesthetic applied to the skin. Lidocaine is a local anaesthetic. It is available in plasters (or patches), sprays, and creams, as topical lidocaine. These contain high concentrations of lidocaine because it crosses the skin poorly. Treatment with plasters usually involves applying one, two, or three plasters for up to 12 hours a day. In July 2014 we performed searches to look for clinical trials where topical lidocaine was used to treat neuropathic pain. We found 12 small studies of modest quality that tested topical lidocaine against topical placebo for a number of weeks. One study also tested a cream containing amitriptyline, which is an antidepressant. The 508 people in the studies had different types of neuropathic pain, with pain after herpes zoster infection the most common. There was some indication that topical lidocaine was beneficial in these studies (very low quality evidence). There was no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals (very low quality evidence). A number of studies of topical lidocaine in neuropathic pain are ongoing. Several are large and of long duration. They will be of great help in working out the benefits of topical lidocaine when they are completed and results can be incorporated in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Derry, S; Wiffen, PJ; Moore, RA; Quinlan, J", "articleTypes": [], "doi": "10.1002/14651858.CD010958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "239c5543-8ae9-48ae-bcf0-2eb2c73989da", "pmid": "", "title": "Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Soil‐transmitted helminth (STH) infections are amongst the most common infectious diseases worldwide, with an estimated 24% of the world’s population currently infected. Mass drug administration (MDA) is the periodic medicinal treatment, without prior individual diagnosis, of at‐risk people living in endemic areas. The World Health Organization currently recommends MDA for STHs. MDA programmes are complex health interventions; achieving adherence is important to their success. Adherence is influenced by the target population's perceptions of the drug, the programme, and those delivering it. Objectives To synthesize qualitative research evidence about community experiences and perceptions of mass drug administration programmes for soil‐transmitted helminths. To assess whether our findings confirm, extend, enrich, or conflict with those of a 2022 Cochrane qualitative evidence review of mass drug administration programmes for lymphatic filariasis. Search methods We searched CENTRAL, MEDLINE, Embase, and four other databases up to 11 November 2024, together with reference checking, and citation searching. Selection criteria We synthesized qualitative and mixed‐methods studies. We included studies exploring community experiences and perceptions of MDA programmes for STHs in any country, conducted between 2001 and 2024. We included all participants of MDA programmes, regardless of disease status, individual participation, or other demographic information. We also included lay healthcare workers and formally qualified healthcare workers, if their perspectives were clearly separated from those of the general population. Data collection and analysis We collected data on study characteristics and programme delivery, including country, endemicity, drug regimen, how the drugs were delivered, use of health education and sensitization, and adherence monitoring. We conducted thematic analysis using a 'best‐fit' framework synthesis based on a framework developed in a 2022 Cochrane review exploring community views on mass drug administration for filariasis (a parasitic infection caused by filarial worms). We conducted a deductive phase, accommodating our data within the existing model, followed by an inductive phase, during which we explored data not accommodated by the framework. We used the GRADE‐CERQual approach to assess our confidence in the findings, and updated the filariasis review's conceptual model to display our findings. Main results We included 17 studies, conducted in Bangladesh, Benin, India, Kenya, Malawi, Nigeria, the Philippines, and Turkey. Four themes emerged, three of which were identified in the review of MDA for lymphatic filariasis. People weigh up the benefits and harms in their decision to participate in MDA, though some may not have a choice. Outcomes of individual participation in MDA may be positive, negative, or both. The decision to partake is a careful balance of risk, benefit, and feasibility (high confidence). Unpleasant associations become part of the narrative and spread rapidly through the community (moderate confidence). Physical and social barriers prevent some people from being able to access MDA even if they want to participate (moderate confidence). Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical legacies, rumours, and mistrust of people involved in the programme affect overall trust in drug distribution and influence whether people choose to participate. Past experiences can have a profound effect on people, and negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background and in‐depth training around the drug or the disease itself (moderate confidence). Some community members prefer distribution from people they know or trust (high confidence). However, others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors (CDDs) cannot answer their programme‐related questions (moderate confidence). Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign, which includes improved sanitation, is necessary to tackle STH burden (moderate confidence). One theme that the filariasis review identified was not substantiated by the findings in this review (Programmes expect compliance: this can result in coercion and blame). Authors' conclusions Despite the prevalence and undoubted impact of MDA programmes over the past 10 years, endemic hotspots and continued transmission are common, due in part to poor community adherence. The 2022 Cochrane review outlined several key community concerns and doubts that hinder the effective implementation of MDA for lymphatic filariasis. This review shows that most of these concerns and doubts are shared by communities targeted for MDA for STHs, indicating that there are fundamental challenges in the overall conceptualization and design of MDA programmes that need to be addressed. Funding TF, MT, RK, and the Cochrane Infectious Diseases Group editorial base were funded by UK aid from the UK Government for the benefit of low‐ and middle‐income countries (project number 300342‐104). The views expressed do not necessarily reflect the UK Government’s official policies. Registration The protocol for this review was published in January 2024 on the Cochrane Database of Systematic Reviews. Available at doi.org/10.1002/14651858.CD015794. Plain language summary Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis Key messages People consider several personal, social, and historical factors before deciding to take medicine. Within one community, different individuals will experience benefits and harms associated with treatment, which shape their decision to participate. The decision to adhere depends on the perceived benefits compared to harms, the trust built between communities and the programme, the competency of people delivering the drugs to provide reassurance to the community members, and the perceived organisation of the delivery programme. Our findings are largely consistent with those of a 2022 Cochrane review exploring people's views and experiences of mass drug administration (MDA) programmes for lymphatic filariasis. This evidence overlap suggests that there are key challenges in the design of MDA programmes in general that need to be addressed to increase adherence. What was studied in this synthesis? Mass drug administration (MDA) involves the periodic delivery of drugs to treat entire communities or groups, regardless of whether an individual has a particular disease. This method aims to prevent onward transmission of infection within the population. MDA is currently recommended for some disease‐control programmes in low‐ and middle‐income countries, including for soil‐transmitted helminth (STH) infections. STHs are a group of parasitic worms, including roundworm, hookworm, whipworm, and threadworm. These MDA programmes are usually delivered within a community or as a school‐based programme. Successfully stopping STH infections through MDA depends on community members being willing and able to participate. In this review, we looked for studies that explored how people view and experience mass drug administration programmes for STHs. We identified 17 studies relevant to this synthesis. What was the aim of this synthesis? In this synthesis of qualitative research, we searched for studies that explored people's views on MDA programmes for treating STHs in low‐ and middle‐income countries. We wanted to understand how people view and experience mass drug administration programmes for soil‐transmitted helminths. We were also interested in whether our findings would support, extend, or conflict with findings from a 2022 Cochrane review which looked at MDA programmes for lymphatic filariasis, another infectious disease caused by worms. What were the main findings? We included 17 studies in our analysis. The studies covered several countries in Africa and South‐East Asia, and one country in the Eastern Mediterranean region. The included studies explored the views and experiences of community members and those distributing the medicines in low‐income countries where STH infection is a considerable problem. From the data, four themes emerged. The 2022 Cochrane review of MDA for lymphatic filariasis identified three of these themes, highlighting the similarities between these programmes. One new theme emerged. 1. People weigh up benefits and harms in their decision to participate in MDA, though some may not have a choice. There are many outcomes to participating in the MDA programme, both positive and negative. For community members, several of these may exist at once, and the decision to partake is a careful balance of risk, benefit, and feasibility (we have high confidence in the evidence). Unpleasant experiences can quickly spread through the community (moderate confidence). Physical and social barriers (e.g. travel distance or not attending school, respectively) prevent some people from accessing treatment through the MDA programme (moderate confidence). 2. Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical experiences, rumours, and mistrust of people involved in the programme affect overall trust in the programme. Past experiences can have a strong effect on people; negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). 3. The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background, and in‐depth training around the drug or the disease itself (moderate confidence). Whilst some community members prefer distribution from people who they know or trust (high confidence), others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors cannot answer their questions related to the programme (moderate confidence). 4. (New theme) Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign which includes improved sanitation is necessary to tackle STH burden (moderate confidence). How current is this evidence? The evidence is current to November 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fox, T, Shrestha, S, Kuehn, R, Taylor, M", "articleTypes": [], "doi": "10.1002/14651858.CD015794.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.802Z" }, { "id": "239ca6a0-bf35-4e87-9560-2be09b03ad98", "pmid": "", "title": "Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen‐ultraviolet A photochemotherapy for psoriasis", "imported": false, "abstract": "Abstract - Background The most commonly used types of phototherapy for treating psoriasis are narrow‐band ultraviolet B (NB‐UVB); broad‐band ultraviolet B (BB‐UVB), which includes selective (delivering radiation with a wavelength range of 305 to 325 nm) and conventional BB‐UVB (280 to 320 nm); and psoralen ultraviolet A photochemotherapy (oral or bath PUVA). There is substantial controversy regarding their efficacy when compared with each other. Objectives To assess the effects of narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for psoriasis. Search methods We searched the following databases up to August 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 7), MEDLINE (from 1946), and EMBASE (from 1974). We searched the following databases up to November 2012: CNKI (from 1974) and CBM (from 1978). We also searched trials registers and the OpenGrey database. Selection criteria We included all randomised controlled trials (RCTs) that compared NB‐UVB phototherapy with BB‐UVB or PUVA for treating psoriasis, which included chronic plaque psoriasis (CPP), guttate psoriasis (GP), and palmoplantar psoriasis (PPP). Data collection and analysis Two review authors independently conducted the study selection, 'Risk of bias' assessment, and data extraction. Main results We included 13 RCTs, with a total of 662 participants. We report the results of intention‐to‐treat analyses (ITT) here. Our primary outcomes of interest were as follows: Participant‐rated global improvement, Percentage of participants reaching Psoriasis Area and Severity Index (PASI) 75 (which meant equal to or more than 75% reduction in PASI score), Withdrawal due to side‐effects, and Clearance rate. In one RCT of NB‐UVB compared with oral PUVA in participants with CPP, the difference in PASI 75 was not statistically significant (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.63 to 1.32; N = 51; low quality). In three other RCTs of CPP, the clearance rates were inconsistent because in one, there was no difference between the groups (RR 1.01, 95% CI 0.91 to 1.12; N = 54), and in the other two, the clearance rates were statistically significantly in favour of oral PUVA: RR 0.66, 95% CI 0.47 to 0.93; N = 93 and RR 0.75, 95% CI 0.59 to 0.96; N = 100, respectively. Pooled data from these three studies indicated that withdrawals due to adverse events were not significantly different between either group (RR 0.71, 95% CI 0.20 to 2.54; N = 247; low quality). The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate for CPP was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the NB‐UVB and bath PUVA groups (RR 1.79, 95% CI 0.46 to 6.91; N = 92; low quality), while a parallel RCT favoured bath PUVA (RR 0.18, 95% CI 0.05 to 0.71; N = 36; low quality). In participants with PPP, one RCT found there were no significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate (RR 0.09, 95% CI 0.01 to 1.56; N = 50; low quality). Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or GP in terms of clearance rate (RR 0.93, 95% CI 0.79 to 1.10; N = 90; low quality). One RCT in people with CPP found no significant differences between NB‐UVB and selective BB‐UVB in terms of clearance rate (RR 1.40, 95% CI 0.92 to 2.13; N = 100; low quality) and withdrawals due to adverse events (RR 3.00, 95% CI 0.32 to 27.87; N = 100; low quality). No studies reported our primary outcomes for NB‐UVB compared with conventional BB‐UVB. Authors' conclusions Current evidence is very heterogeneous and needs to be interpreted with caution. The clearance rate between oral PUVA and NB‐UVB is inconsistent among the included studies. Evidence regarding NB‐UVB versus bath PUVA is also inconsistent. Re‐NB‐UVB and re‐PUVA are similarly effective for treating people with CPP or GP. In practice, NB‐UVB may be more convenient to use since exogenous photosensitiser is not required before phototherapy. NB‐UVB is considered ineffective for PPP in clinical practice, and a small RCT did not detect a statistically significant difference between NB‐UVB and topical PUVA for clearing PPP. NB‐UVB seemed to be similar to selective BB‐UVB for clearing CPP. Larger prospective studies are needed to confirm the long‐term safety of NB‐UVB. Plain language summary Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for treating psoriasis Psoriasis is a common, chronic inflammatory skin disease, with an estimated global prevalence ranging from 0.5% to 4.6%. Based on clinical features, psoriasis is generally divided into the following: chronic plaque psoriasis (CPP); psoriasis associated with psoriatic arthritis; and pustular, erythrodermic, or guttate psoriasis. We also considered psoriasis affecting the palms and soles (palmoplantar psoriasis, or PPP). Although psoriasis is rarely life‐threatening, it can affect a person's quality of life significantly. Phototherapy is an essential treatment option for people with psoriasis. The most commonly used types of phototherapy are narrow‐band ultraviolet B (NB‐UVB), broad‐band ultraviolet B (BB‐UVB), and psoralen ultraviolet A photochemotherapy (PUVA). PUVA can be further divided into oral, bath, and topical PUVA according to the administrative route of psoralen. NB‐UVB delivers almost exclusively 311 nm radiation, whereas BB‐UVB can be divided into two types: selective BB‐UVB (305 to 325 nm radiation) and conventional BB‐UVB (280 to 320 nm radiation). This review included 13 small randomised controlled trials (RCT), with a total of 662 participants. Most of these were of poor methodological quality. For treating CPP, the clearance rate between the NB‐UVB and oral PUVA groups were inconsistent in three RCTs. In one, there was no difference between the groups, and in the other two, the clearance rate was in favour of oral PUVA. The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the two groups, while another RCT favoured bath PUVA. Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or guttate psoriasis. One RCT found no significant differences between NB‐UVB and selective BB‐UVB for clearing CPP or in the number of withdrawals due to side‐effects. In participants with PPP, one RCT found there were no statistically significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate. In summary, NB‐UVB may be preferred to oral or bath PUVA because it is more convenient to use. NB‐UVB seemed to be equal to selective BB‐UVB for clearing CPP. Evidence regarding NB‐UVB and conventional BB‐UVB is limited. The long‐term safety of NB‐UVB needs to be confirmed. The efficacy of NB‐UVB for clearing PPP needs to be confirmed in future studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Chen, X; Yang, M; Cheng, Y; Liu, GJ; Zhang, M", "articleTypes": [], "doi": "10.1002/14651858.CD009481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "23a72a3a-1022-4dc8-9990-2f17c21c08cb", "pmid": "", "title": "Sucrose analgesia for heel‐lance procedures in neonates", "imported": false, "abstract": "Abstract - Background Sucrose has been examined for calming and pain‐relieving effects in neonates for invasive procedures such as heel lance. Objectives To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long‐term outcomes Search methods We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries. Selection criteria We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non‐nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin‐to‐skin care. Data collection and analysis We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. We assessed heterogeneity by the I 2 test. We used GRADE to assess certainty of evidence. Main results We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing. Sucrose vs control The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD ‐1.74 (95% CI ‐2.11 to ‐1.37); I 2 = 62%; moderate‐certainty evidence) and 60 seconds after lancing (MD ‐2.14, 95% CI ‐3.34 to ‐0.94; I 2 = 0%; moderate‐certainty evidence). The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD ‐1.90, 95% CI ‐8.58 to 4.78; heterogeneity not applicable (N/A); very low‐certainty evidence). The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD ‐2.00, 95% CI ‐2.42 to ‐1.58; heterogeneity N/A; moderate‐certainty evidence). Sucrose vs NNS The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI ‐0.30 to 1.50; heterogeneity not applicable; very low‐certainty evidence) and on DAN scores at 30 seconds after lancing (MD ‐1.20, 95% CI ‐7.87 to 5.47; heterogeneity N/A; very low‐certainty evidence). Sucrose + NNS vs NNS The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD ‐4.90, 95% CI ‐5.73 to ‐4.07; heterogeneity not applicable; very low‐certainty evidence) and during recovery after lancing (MD ‐3.80, 95% CI ‐4.47 to ‐3.13; heterogeneity N/A; very low‐certainty evidence). The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD ‐0.60, 95% CI ‐1.47 to 0.27; heterogeneity N/A; very low‐certainty evidence). Sucrose vs glucose The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI ‐0.70 to 1.22; heterogeneity not applicable; low‐certainty evidence) and 60 seconds after lancing (MD ‐0.02, 95% CI ‐0.79 to 0.75; heterogeneity N/A; low‐certainty evidence). Sucrose vs breastfeeding The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD ‐0.70, 95% CI ‐0.49 to 1.88; I 2 = 94%; very low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD ‐2.60, 95% CI ‐3.06 to ‐2.14; heterogeneity N/A; very low‐certainty evidence). Sucrose vs expressed breast milk The evidence suggests that sucrose may result in little to no difference in PIPP‐R scores compared to expressed breast milk during (MD 0.3, 95% CI ‐0.24 to 0.84; heterogeneity not applicable; low‐certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI ‐0.11 to 0.71; heterogeneity N/A; low‐certainty evidence). The evidence suggests that sucrose probably may result in slightly increased PIPP‐R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD ‐1.80, 95% CI ‐8.47 to 4.87; heterogeneity N/A; very low‐certainty evidence). Sucrose vs laser acupuncture There was no difference in PIPP‐R scores between sucrose and music groups; however, data were reported as medians and IQRs. The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD ‐0.86, 95% CI ‐1.43 to ‐0.29; heterogeneity N/A; very low‐certainty evidence). Sucrose vs facilitated tucking The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD ‐2.27, 95% CI ‐4.66 to 0.12; heterogeneity N/A; very low‐certainty evidence) and during recovery after lancing (MD ‐0.31, 95% CI ‐1.72 to 1.10; heterogeneity N/A; very low‐certainty evidence). Sucrose vs skin‐to‐skin + water (repeated lancing) The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 30 seconds after 1st (MD 0.13, 95% CI ‐0.70 to 0.96); 2nd (MD ‐0.56, 95% CI ‐1.57 to 0.45); or 3rd lancing (MD‐0.15, 95% CI ‐1.26 to 0.96); heterogeneity N/A, low‐certainty evidence for all comparisons. The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 60 seconds after 1st (MD –0.61, 95% CI ‐1.55 to 0.33); 2nd (MD ‐0.12, 95% CI ‐0.99 to 0.75); or 3rd lancing (MD‐0.40, 95% CI ‐1.48 to 0.68); heterogeneity N/A, low‐certainty evidence for all comparisons. Minor adverse events required no intervention. Authors' conclusions Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate‐certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin‐to‐skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing heel lance Key messages ‐ Sucrose, compared to control interventions, probably reduces pain for a single painful event (heel lance). ‐ There were a few minor immediate adverse events, such as gagging, that resolved without intervention. ‐ We need studies that assess the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. ‐ We need to assess how sucrose affects neonates who are extremely preterm, unstable, or ventilated (or a combination of these factors). What is sucrose analgesia? Sucrose (table sugar) is mixed with water in various concentrations (usually 24%) and is given to babies in very small amounts (e.g. a few drops) about two minutes before a painful procedure. Sucrose is also given with other nondrug pain‐relieving interventions such as a pacifier (non‐nutritive sucking ‐ NNS) or when the baby is receiving skin‐to‐skin care. Why is this important for newborn babies who are undergoing heel lance procedures? Babies who are sick or immature, and require a stay in hospital, have several painful procedures per day and multiple painful procedures throughout the hospital stay; for most babies, the majority of painful procedures are heel lances. If untreated, pain has immediate and long‐term consequences that can impact their brain and behavioural development. It is important to minimise the number of painful procedures and the associated pain and suffering. What did we want to find out? We wanted to know how well sucrose worked to relieve pain in newborn babies who are having heel lance procedures while they were in hospital. We also wanted to know whether there were any safety concerns about using sucrose to relieve pain from single painful events such as heel lance. What did we do? We searched for studies that investigated: ‐ Sucrose compared to no treatment or standard care; ‐ Sucrose compared to water, other sweet solutions (e.g. glucose); ‐ Sucrose compared to another nondrug intervention (e.g. NNS); ‐ Whether sucrose was effective in decreasing the amount and severity of pain that babies experienced as assessed by baby’s pain responses (e.g. crying, grimacing, heart rate) and by using standardised infant pain scales. We also wanted to know if sucrose was associated with any unwanted effects in preterm or term babies. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods. What did we find out? We reviewed 55 studies that included a total of 6273 babies. Twenty‐nine studies had full‐term babies only, 22 had preterm babies only, and four had both full‐term and preterm babies. Heel lance was the painful procedure in 50 studies. Five studies investigated a variety of other minor painful procedures in addition to heel lancing. Main results ‐ Sucrose compared to the control treatment probably reduces pain from single heel lances in babies. ‐ Results are uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, and facilitated tucking, in reducing pain scores. ‐ Results are uncertain about the effect of sucrose + NNS compared to NNS, in reducing pain. ‐ Sucrose does not seem to reduce pain from single heel lances compared to glucose, expressed breast milk, and skin‐to‐skin care. ‐ Reported adverse events were minor and resolved without any intervention. What are the limitations of the evidence? We have moderate‐certainty evidence that sucrose likely reduces pain from heel lance. How up‐to‐date is this evidence? This evidence is up‐to‐date as of February 2022. Study funding sources We did not identify any studies that received funding from industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yamada, J, Bueno, M, Santos, L, Haliburton, S, Campbell-Yeo, M, Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD014806", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.736Z" }, { "id": "23b39adb-e8f5-404d-85c8-3738cfa68c13", "pmid": "", "title": "Modifying the consistency of food and fluids for swallowing difficulties in dementia", "imported": false, "abstract": "Abstract - Background People with dementia can have feeding and swallowing difficulties (dysphagia). Modification of the consistency of food or fluids, or both, is a common management strategy. However, diet modification can affect quality of life and may lead to dehydration and malnutrition. Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia. Objectives To determine the effectiveness and adverse effects associated with modifying the consistency of food and fluids in improving oral intake and eliminating aspiration in adults with dysphagia and dementia. Search methods We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE via Ovid SP, Embase via Ovid SP, PsycINFO via Ovid SP, CINAHL via EBSCOhost, LILACS via BIREME, ClinicalTrials.gov and the World Health Organization (WHO) Portal on 9 May 2018. We also checked the reference lists of relevant articles to identify any additional studies. Selection criteria We included randomised controlled trials (RCTs), quasi‐RCTs and cluster‐RCTs published in any language that measured any of the outcomes of interest. We included trials with adults with a clinical diagnosis of dementia with symptoms and signs of dysphagia confirmed on instrumental assessment. We included participants with all types, stages and severities of dementia. Control groups received either no intervention or interventions not involving diet modification or modification to sensory properties of food. Data collection and analysis Two review authors independently assessed for inclusion all potential studies identified. Data were extracted independently along with assessment of methodological quality using standard Cochrane methods. We contacted study authors for additional unpublished information. Main results No trials on modification of food met the inclusion criteria. We included two studies that examined modification to fluids. Both were part of the same large multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. Participation in the second trial was determined by results from the first trial. With unpublished data supplied by study authors, we examined data from participants with dementia only. The first study, a cross‐over trial, investigated the immediate effects on aspiration of two viscosities of liquids (nectar thick and honey thick) compared to regular liquids in 351 participants with dementia using videofluoroscopy. Regular liquids with a chin down head posture, as well as regular liquids without any intervention were also compared. The sequence of interventions during videofluoroscopy may have influenced response to intervention. The second study, a parallel designed RCT, compared the effect of nectar and honey thick liquids with a chin down head posture over a three‐month period in a subgroup of 260 participants with dementia. Outcomes were pneumonia and adverse intervention effects. Honey thick liquids, which are more consistent with descriptors for 'spoon thick' or 'extremely thick' liquids, showed a more positive impact on immediate elimination of aspiration during videofluoroscopy, but this consistency showed more adverse effects in the second follow‐up study. During the second three‐month follow‐up trial, there were a greater number of incidents of pneumonia in participants receiving honey thick liquids than those receiving nectar thick liquids or taking regular liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of fluids prescribed. Neither trial addressed quality of life. Risk of bias for both studies is high. The overall quality of evidence for outcomes in this review is low. Authors' conclusions We are uncertain about the immediate and long‐term effects of modifying the consistency of fluid for swallowing difficulties in dementia as too few studies have been completed. There may be differences in outcomes depending on the grade of thickness of fluids and the sequence of interventions trialled in videofluoroscopy for people with dementia. Clinicians should be aware that while thickening fluids may have an immediate positive effect on swallowing, the long‐term impact of thickened fluids on the health of the person with dementia should be considered. Further high‐quality clinical trials are required. Plain language summary Modifying the consistency of food and fluids for swallowing difficulties in dementia Background Individuals with dementia often present with swallowing difficulties (dysphagia). The consequences can include choking, dehydration, malnutrition, weight loss, pneumonia and death. Modification of food and liquid is a popular management strategy. It is believed that increasing the viscosity of liquids or altering the consistency of food allows individuals a better opportunity to swallow, with a reduced risk of choking or liquids entering the airway. However, there is growing evidence suggesting that this strategy can lead to dehydration, malnutrition, negative psychological/social consequences, and can affect quality of life for the person with dementia. Review question We wished to find out if changing the viscosity or consistency of food or fluids, or both, makes swallowing safer and has positive outcomes for people with dementia in terms of respiratory status, nutritional status and quality of life. We wanted to examine if modifying food or fluids, or both, also had any adverse effects for the person with dementia. Study characteristics We found two studies, which were both part of the same multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. We included data on people with dementia only. The first of the two studies looked at the immediate effects of two viscosities of liquids compared to regular thin liquids on aspiration (entry of food or fluid into the lungs) in 351 people with dementia. This study also compared drinking regular thin liquids using a chin down head posture as well as drinking regular thin liquids without any changes to head position; the main outcome was fluid entering the lungs. Using a subgroup of 260 people with dementia from the first study, the second study compared the effect of the same liquid viscosities with a chin down head posture. The effectiveness of these interventions on the incidence of pneumonia and adverse effects of these interventions was examined over a three‐month period. Study results Honey thick viscosity liquids, which clinically are similar to descriptions of 'very thick liquids', had a more positive immediate impact on preventing fluid entering the lungs when examined during videofluoroscopy (specialised swallow x‐ray) examination. However, during the three‐month follow‐up period there were a greater number of incidents of pneumonia in the group of people with dementia receiving these honey thick liquids, than those receiving nectar thick liquids and those receiving regular thin liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of liquids that the person with dementia was receiving. Conclusion There were a number of methodological flaws in both studies in this review and these were acknowledged by the authors. While thickening fluids may have an immediate positive effect on swallow function, clinicians should consider the effects of this intervention on the person with dementia in the longer‐term. People with dementia on thickened fluids require long‐term follow‐up. The overall risk of bias of included studies is high. The quality of evidence is low. Further well‐designed research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Flynn, E; Smith, CH; Walsh, CD; Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD011077.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "23b43beb-e55f-4a24-858d-7625fb2215d4", "pmid": "", "title": "Wheat flour fortification with iron and other micronutrients for reducing anaemia and improving iron status in populations", "imported": false, "abstract": "Abstract - Background Anaemia is a condition where the number of red blood cells (and consequently their oxygen‐carrying capacity) is insufficient to meet the body's physiological needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations. Objectives To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health‐related outcomes in populations over two years of age. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, 21 other databases and two trials registers up to 21 July 2020, together with contacting key organisations to identify additional studies. Selection criteria We included cluster‐ or individually‐randomised controlled trials (RCTs) carried out among the general population from any country, aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. We included trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat Data collection and analysis Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risks of bias. We followed Cochrane methods in this review. Main results Our search identified 3538 records, after removing duplicates. We included 10 trials, involving 3319 participants, carried out in Bangladesh, Brazil, India, Kuwait, Philippines, South Africa and Sri Lanka. We identified two ongoing studies and one study is awaiting classification. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, three trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial used various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta‐analyses. Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added may reduce by 27% the risk of anaemia in populations (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.55 to 0.97; 5 studies, 2315 participants; low‐certainty evidence). It is uncertain whether iron‐fortified wheat flour with or without other micronutrients reduces iron deficiency (RR 0.46, 95% CI 0.20 to 1.04; 3 studies, 748 participants; very low‐certainty evidence) or increases haemoglobin concentrations (in g/L) (mean difference MD 2.75, 95% CI 0.71 to 4.80; 8 studies, 2831 participants; very low‐certainty evidence). No trials reported data on adverse effects in children (including constipation, nausea, vomiting, heartburn or diarrhoea), except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to the risk of Infection or inflammation at individual level as measured by C‐reactive protein (CRP) (mean difference (MD) 0.04, 95% CI −0.02 to 0.11; 2 studies, 558 participants; moderate‐certainty evidence). Iron‐fortified wheat flour with other micronutrients added versus unfortified wheat flour (nil micronutrients added) It is unclear whether wheat flour fortified with iron, in combination with other micronutrients decreases anaemia (RR 0.77, 95% CI 0.41 to 1.46; 2 studies, 317 participants; very low‐certainty evidence). The intervention probably reduces the risk of iron deficiency (RR 0.73, 95% CI 0.54 to 0.99; 3 studies, 382 participants; moderate‐certainty evidence) and it is unclear whether it increases average haemoglobin concentrations (MD 2.53, 95% CI −0.39 to 5.45; 4 studies, 532 participants; very low‐certainty evidence). No trials reported data on adverse effects in children. Nine out of 10 trials reported sources of funding, with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials. Authors' conclusions Fortification of wheat flour with iron (in comparison to unfortified flour, or where both groups received the same other micronutrients) may reduce anaemia in the general population above two years of age, but its effects on other outcomes are uncertain. Iron‐fortified wheat flour in combination with other micronutrients, in comparison with unfortified flour, probably reduces iron deficiency, but its effects on other outcomes are uncertain. None of the included trials reported data on adverse side effects except for risk of infection or inflammation at the individual level. The effects of this intervention on other health outcomes are unclear. Future studies at low risk of bias should aim to measure all important outcomes, and to further investigate which variants of fortification, including the role of other micronutrients as well as types of iron fortification, are more effective, and for whom. Plain language summary Does adding iron to wheat flour reduce anaemia and increase iron levels in the general population? Why do we need iron in our diet? Iron is an essential mineral found in every cell of the body. It is needed to make haemoglobin, the oxygen‐carrying protein in the blood. Iron molecules in haemoglobin bind to oxygen and carry it from the lungs to all the cells and tissues in the body. Low levels of haemoglobin means the body does not get enough oxygen. Anaemia develops when haemoglobin levels in the blood fall too low. Symptoms of anaemia include: tiredness and lack of energy, getting out of breath quickly, pale skin and a greater susceptibility to infections. Low haemoglobin levels can be caused by blood loss, pregnancy or not eating enough foods containing iron (iron‐deficiency anaemia). Iron‐deficiency anaemia may be treated by taking iron tablets or eating foods rich in iron. Fortified foods Adding micronutrients (vitamins and minerals) to foods, whether those micronutrients were originally present or not, is called fortification. Fortifying foods is one way to improve nutrition in a population. People living in low‐income countries may not have enough iron in their diet, and may be at risk of anaemia. Adding iron and other nutrients to foods routinely eaten in large quantities, such as flour, is thought to help prevent iron‐deficiency anaemia. Why we did this Cochrane Review We wanted to find out how adding iron, and other minerals and vitamins, to wheat flour affected the blood iron levels of the general population, and whether fewer people developed anaemia or other health conditions. We also wanted to know if adding iron to wheat flour caused any unwanted effects. What did we do? We searched for studies that investigated eating any types of food made with wheat flour containing added iron, or foods made with wheat flour without added iron. We then compared the studies with each other, to find out the effects of adding iron to wheat flour on people's health and the levels of iron and haemoglobin in their blood. Search date: we included evidence published up to 21 July 2020. What we found We found 10 studies in 3319 people (aged 2 years and older). The studies lasted from 3 months to 24 months, and took place in Bangladesh, Brazil, India, Kuwait, the Philippines, Sri Lanka and South Africa. The studies looked at the effects of: · wheat flour containing added iron (with or without other minerals and vitamins) compared with wheat flour without added iron (but with the same other minerals and vitamins); · wheat flour containing added iron and other minerals and vitamins compared with wheat flour without any added minerals or vitamins. The wheat flours used in the studies contained different amounts of iron: from under 40 mg/kg to over 60 mg/kg. We were interested in: · how many people had anaemia (defined by low haemoglobin levels); · how many people had low levels of iron in their blood (iron deficiency; tested using a biomarker); · haemoglobin concentrations in people's blood; · how many children had diarrhoea or respiratory infections; · how many children died (of any cause); · signs of infection or inflammation (the body's response to injury) in children (by testing a biomarker in the blood); and · any unwanted effects. Most studies had multiple sources of funding; some were partly funded by companies involved in the food, chemical or pharmaceutical industries. What are the results of our review? Compared with flour without added iron (but with other minerals and vitamins) Flour containing added iron (with or without other minerals and vitamins): · may reduce anaemia, by 27% (evidence from 5 studies, 2315 people); and · probably makes no difference to children's risk of infection or inflammation (2 studies, 558 children). It was unclear how flour with added iron affected iron deficiency (3 studies, 748 people), or haemoglobin levels (8 studies, 2831 people ). Compared with flour without any added minerals or vitamins Flour containing added iron (with other minerals and vitamins) probably reduced iron deficiency (3 studies, 382 people). It was unclear from the studies how flour containing added iron affected anaemia (2 studies, 317 people) or haemoglobin levels (4 studies, 532 people). No studies reported information about unwanted effects, or how many children died, or had diarrhoea or respiratory infections. Our confidence in our results Our confidence is moderate to low that adding iron to flour probably reduces iron deficiency and anaemia. The studies appeared to show fewer people with iron deficiency and slightly higher haemoglobin levels associated with flour with added iron, but the results varied widely, so we are uncertain about the effect. These results might change if further evidence becomes available. We found limitations in the ways some of the studies were designed and conducted, and this could have affected their results. Key messages Adding iron to wheat flour may lead to fewer people with anaemia or low blood‐iron levels in the general population. We do not know if adding iron to wheat flour causes any unwanted effects, because no studies looked at these.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Field, MS; Mithra, P; Peña-Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD011302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "23b92f48-be54-4de8-8182-463c110f2304", "pmid": "", "title": "Oral nicotine pouches for cessation or reduction of use of other tobacco or nicotine products", "imported": false, "abstract": "Abstract - Rationale Oral nicotine pouches (ONP) emerged in the late 2000s, but have gained popularity since their introduction to the global market in 2016, with claims about their harm reduction potential. Objectives Primary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from combustible tobacco use (smoking). • To evaluate the impact of ONP on the prevalence of combustible tobacco use. Secondary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from other non‐combustible tobacco/commercial nicotine product use. • To evaluate the impact of ONP on the prevalence of use of other non‐combustible tobacco/commercial nicotine products. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO from 2000 to 13 January 2025. We also covered ClinicalTrials.gov and the WHO ICTRP through our search of CENTRAL. Eligibility criteria We included randomised controlled trials (RCTs) of ONP in people using tobacco or other non‐combustible tobacco/non‐pharmaceutical nicotine products. RCTs must have reported tobacco/nicotine use at 4+ weeks or biomarkers or adverse events at 1+ weeks. We also sought interrupted/multiple time‐series studies of ONP's population‐level effects on the prevalence of use of other tobacco/nicotine products. Outcomes Our critical outcomes were: smoking abstinence at 4+ weeks; number of people reporting serious adverse events (SAEs) at 1+ weeks; and change in the prevalence of smoking. Important outcomes included tobacco‐specific nitrosamines (TSNAs), carboxyhaemoglobin (COHb), metals, and inflammatory markers detected in human biosamples. Risk of bias We used the Cochrane RoB 1 tool to assess risk of bias. Synthesis methods We synthesised results using random‐effects meta‐analysis where possible. We used I 2 to quantify statistical heterogeneity. Where meta‐analysis was not possible, we graphically plotted available data in forest plots. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CI). We assessed the certainty of evidence using GRADE. Included studies We included four small studies (n < 150 for each, total n = 284; 3 independent, 1 industry‐funded; 3 at high risk of bias and 1 at unclear risk of bias). All were RCTs in people who smoked combustible cigarettes at baseline. Three were conducted in the USA, and one in New Zealand. Two compared higher‐ versus lower‐nicotine dose ONP. Two compared ONP to instructions to continue smoking as usual. One each compared ONP to electronic cigarettes (e‐cigarettes), snus, and pharmaceutical nicotine replacement therapy (NRT). Synthesis of results Smoking abstinence Smoking abstinence may be slightly higher in people randomised to ONP compared to no intervention at eight‐week follow‐up (RR 1.58, 95% CI 0.07 to 35.32; 1 study, 27 participants; very low‐certainty evidence (risk of bias and imprecision; CI incorporated possibility of no difference)), but the evidence is very uncertain. Low‐certainty evidence (serious imprecision; CI incorporated possibility of no difference) suggests there may be lower abstinence rates in those randomised to ONP compared to e‐cigarettes (RR 0.25, 95% CI 0.03 to 2.02; 1 study, 36 participants). Evidence from one study (n = 30) comparing higher‐ versus lower‐dose ONP found a higher quit rate in the higher‐dose arm, but again with wide CI encompassing the possibility of no difference and of higher quit rates in the lower‐dose arm (RR 5.00, 95% CI 0.26 to 96.13; evidence certainty not assessed). Serious adverse events No SAEs occurred in the three studies reporting this outcome. Data were available for the comparisons ONP versus minimal control (2 studies, 124 participants; very low‐certainty evidence (risk of bias and serious imprecision)) and ONP versus e‐cigarettes (1 study, 26 participants; low‐certainty evidence (serious imprecision)). TSNA One study reported on a TSNA (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol (NNAL)) comparing ONP with instructions to continue smoking. There may be lower levels with ONP (MD −265.30 ng/g creatinine, 95% CI −350.64 to −179.96; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. Data from two studies suggested no difference in NNAL levels between higher‐ and lower‐dose ONP (SMD −0.16, 95% CI −1.87 to 1.56; I 2 = 0%; 77 participants; evidence certainty not assessed). COHb Based on one study, there may be lower levels of COHb with ONP compared to instructions to continue smoking (MD −6.7%, 95% CI −8.33 to −5.07; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. When comparing higher‐ versus lower‐dose ONP, the same study found very slightly lower levels in the higher‐dose group, with the 95% CI incorporating the possibility of no difference (MD −0.40%, 95% CI −1.19 to 0.39; evidence certainty not assessed). No studies reported on prevalence, inflammatory markers, metals, or use of tobacco/nicotine products other than cigarettes. Authors' conclusions There is limited evidence on the use of ONP for cessation or reduction of cigarette use. There is no evidence on the use of ONP for cessation or reduction of other tobacco or nicotine products or on the effects of ONP on prevalence of tobacco use/nicotine vaping. Low‐certainty evidence suggests that people randomised to ONP may be slightly less likely to quit smoking than those randomised to e‐cigarettes, but data were from one small study and therefore imprecise. Limited, short‐term data did not identify any serious health harms from ONP when used to help people transition away from tobacco smoking. More research on the effects of ONP for cessation or reduction of use of other tobacco or non‐pharmaceutical nicotine products is urgently needed. Future trials should prioritise comparing ONP to other active interventions (e.g. NRT and e‐cigarettes). Funding This Cochrane review was funded by the National Cancer Institute of the National Institutes of Health (NIH) and FDA Center for Tobacco Products (CTP) under Award Number 2U54CA229974. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food & Drug Administration. Registration Registration: Cochrane, via protocol available via DOI:10.1002/14651858.CD016220. Plain language summary What are the benefits and risks of oral nicotine pouches when used to help people stop smoking, vaping nicotine, or using other forms of tobacco? Key messages Limited evidence from three small studies found no short‐term serious health harms of oral nicotine pouches in people who smoke. We are uncertain if oral nicotine pouches help people quit smoking compared to instructions to continue smoking as usual or no support to quit. Future research is needed, in particular comparing oral nicotine pouches to other active treatments (e.g. nicotine replacement therapy and e‐cigarettes). What are oral nicotine pouches? Oral nicotine pouches are preportioned pouches containing nicotine, sold in various flavours and nicotine strengths. They are similar in appearance and use to snus. Snus is a form of smokeless tobacco placed between the gum and lip that is popular in Nordic countries, but whose sale is banned in the UK and European Union countries excluding Sweden. Unlike snus, nicotine pouches do not contain tobacco leaf. Like nicotine e‐cigarettes and pharmaceutical forms of nicotine replacement therapy (such as nicotine patches and gums), oral nicotine pouches may be able to help people transition away from harmful forms of tobacco/nicotine product use by replacing them with a product that does not contain tobacco leaf and which, unlike e‐cigarettes, does not involve inhaling vapour into the lungs. Common brand names of oral nicotine pouches include Zyn, Velo, and Nordic Spirit. What did we want to find out? We wanted to find out if oral nicotine pouches can help people transition away from smoking, nicotine vaping, or other forms of tobacco use. We also wanted to know if oral nicotine pouches caused any unwanted effects when used for this purpose. What did we do? We searched for studies where people who smoked, vaped, or used other tobacco products were given oral nicotine pouches as a way to quit. We included studies if they tracked tobacco use or vaping for at least four weeks or looked at unwanted effects or chemical changes in the blood, breath, or urine for at least one week. What did we find? We found four studies including a total of 284 people who were smokers at study start. The studies were conducted between 2006 and 2023, and in those that reported race or ethnicity, were conducted in majority white populations. The average age across studies ranged from 34 to 50 years. The average number of cigarettes smoked by participants at study start was between 14 and 23 per day. The longest study ran for eight weeks. Three studies were independently funded, and one was funded by a tobacco manufacturer. Based on two small studies, it was not clear whether using nicotine pouches helped more people to quit smoking compared to instructions to continue smoking as usual or no support to quit, and there may be lower quit rates in those using nicotine pouches compared to those using a nicotine e‐cigarette (vaping). No serious health harms occurred in any group in the three studies that reported this information, so it is unclear if using nicotine pouches affects the chances of experiencing a serious health harm. We also looked at certain chemicals measured in blood, breath, or urine that can signal exposures to harmful substances. Tobacco use exposes the body to cancer‐causing chemicals. NNAL (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol), a chemical formed when these cancer‐causing chemicals enter the body, measures exposure to harmful ingredients in tobacco smoke. One small study reported lower levels of NNAL in people using oral nicotine pouches compared to those given no specific treatment to stop smoking. Combined evidence from two studies suggested no difference in NNAL levels between people receiving higher‐ versus lower‐dose nicotine pouches. Carbon monoxide is a poisonous gas present in tobacco smoke. When carbon monoxide binds with blood haemoglobin, it forms a substance called carboxyhaemoglobin. Carboxyhaemoglobin measures how much carbon monoxide a person has been exposed to in their blood. One study found lower levels of carboxyhaemoglobin in people using oral nicotine pouches compared to those who continued smoking. When comparing higher‐ versus lower‐dose nicotine pouches, the same study found very slightly lower carboxyhaemoglobin levels in the higher‐dose group. What are the limitations of the evidence? We have little to very low confidence in the evidence because the studies were relatively small, and there are not enough studies to be certain about the results. Also, some studies had issues with the way they were designed that could have affected their results. Many studies are currently underway, and we plan to update this review when their findings become available. How up‐to‐date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hartmann-Boyce, J, Tattan-Birch, H, Brown, J, Shahab, L, Goniewicz, ML, Ma, CL, Wu, AD, Travis, N, Jarman, H, Livingstone-Banks, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD016220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.759Z" }, { "id": "23b93a4c-8458-49b4-9798-653072d46248", "pmid": "", "title": "Sodium channel blockers for cystic fibrosis", "imported": false, "abstract": "Abstract - Background People with cystic fibrosis (CF) have increased transport of the salt, sodium across their airway lining. Over‐absorption of sodium results in the dehydration of the liquid that lines the airway surface and (along with defective chloride secretion) is a primary defect in people with CF. Objectives To determine whether the topical administration of drugs that block sodium transport improves the respiratory condition of people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We contacted principal investigators known to work in the field, previous authors and pharmaceutical companies who manufacture ion transport agents for unpublished or follow‐up data. Most recent search of the Group's register: 19 December 2013. Selection criteria Published or unpublished randomised controlled trials (RCTs) or quasi‐randomised controlled trials of sodium channel blockers compared to placebo or another sodium channel blocker or the same sodium channel blocker at a different dosing regimen. Data collection and analysis Two authors independently extracted data. Meta‐analysis was limited due to differing study designs. Main results Five RCTs, with a total of 226 participants, examining the topical administration of the short‐acting sodium channel blocker, amiloride, compared to placebo were identified as eligible for inclusion in the review. In three studies over six months, there was a significant difference found in the difference in relative change in FVC in favour of placebo (weighted mean difference 1.51% (95% confidence interval ‐2.77 to ‐0.25), although heterogeneity was evident. A two‐week study demonstrated that hypertonic saline with amiloride pre‐treatment did not result in a significant improvement in respiratory function or mucus clearance, in contrast to pre‐treatment with placebo. There were no significant differences identified in other clinically relevant outcomes. Authors' conclusions We found no evidence that the topical administration of a short‐acting sodium channel blocker improves respiratory condition in people with cystic fibrosis and some limited evidence of deterioration in lung function. Plain language summary Drugs to control the movement of salt in the lungs of people with cystic fibrosis Usually salt is absorbed from liquid on the surface of the lungs to stop fluid building up there. In cystic fibrosis too much salt is absorbed and there is little liquid left on the airway surfaces. As a result people with cystic fibrosis have problems clearing their lungs of sticky secretions. Thus the lungs are left open to infection. Drugs applied directly to the lungs may prevent too much salt being absorbed. This may lead to better clearance of mucus and less lung infection and damage. The review includes five studies with a total of 226 participants. All studies looked at short‐acting drugs applied directly to the lungs compared to placebo. When the results from three studies over six months were combined, the placebo group showed a slower rate of decline in forced vital capacity than the treatment group. However, each of these differed in their results. A further study showed that people receiving a sodium channel blocker before receiving hypertonic saline did not achieve better lung function or mucus clearance than those receiving placebo before hypertonic saline. We found no evidence that short‐acting sodium channel blockers administered directly to the lungs improve respiratory status in people with cystic fibrosis. There was even some limited evidence of a decline in lung function. Trials of long‐acting sodium channel blockers are ongoing.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Burrows, EF, Southern, KW, Noone, PG", "articleTypes": [], "doi": "10.1002/14651858.CD005087.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.071Z" }, { "id": "23be259e-6ba5-41e4-b2a1-7edd780ba5c6", "pmid": "", "title": "Effects of opioid, hypnotic and sedating medications on sleep‐disordered breathing in adults with obstructive sleep apnoea", "imported": false, "abstract": "Abstract - Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by partial or complete upper airway occlusion during sleep, leading to intermittent cessation (apnoea) or reduction (hypopnoea) of airflow and dips in arterial oxygen saturation during sleep. Many patients with recognised and unrecognised OSA receive hypnotics, sedatives and opiates/opioids to treat conditions including pain, anxiety and difficulty sleeping. Concerns have been expressed that administration of these drugs to people with co‐existing OSA may worsen OSA. Objectives To investigate whether administration of sedative and hypnotic drugs exacerbates the severity of OSA (as measured by the apnoea‐hypopnoea index (AHI) or the 4% oxygen desaturation index (ODI)) in people with known OSA. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR) of trials. The search was current as of March 2015. Selection criteria Randomised, placebo‐controlled trials including adult participants with confirmed OSA, where participants were randomly assigned to use opiates or opioids, sedatives, hypnotics or placebo. We included participants already using continuous positive airway pressure (CPAP) or a mandibular advancement device. Data collection and analysis We used standard methodological procedures as recommended by The Cochrane Collaboration. Main results Fourteen studies examining the effects of 10 drugs and including a total of 293 participants contributed to this review. Trials were small, with only two trials, which used sodium oxybate, recruiting more than 40 participants, and all but three trials were of only one to three nights in duration. Most participants had mild to moderate OSA with a mean AHI of 11 to 25 events/h, and only two trials recruited patients with severe OSA. Two trials investigating the effects of ramelteon, a treatment option for insomnia, recruited adults over 60 years of age with OSA and concomitant insomnia. The drugs studied in this review included remifentanil (infusion) 0.75 mcg/kg/h, eszopiclone 3 mg, zolpidem 10 and 20 mg, brotizolam 0.25 mg, flurazepam 30 mg, nitrazepam 10 mg to 15 mg, temazepam 10 mg, triazolam 0.25 mg, ramelteon 8 mg and 16 mg and sodium oxybate 4.5 g and 9 g. We were unable to pool most of the data, with the exception of data for eszopiclone and ramelteon. None of the drugs in this review produced a significant increase in AHI or ODI. Two trials have shown a beneficial effect on OSA. One study showed that a single administration of eszopiclone 3 mg significantly decreased AHI compared with placebo (24 ± 4 vs 31 ± 5; P value < 0.05), and a second study of sodium oxybate 4.5 g showed a significant decrease in AHI compared with placebo (mean difference (MD) ‐7.41, 95% confidence interval (CI) ‐14.17 to ‐0.65; N = 48). Only four trials reported outcome data on ODI. No significant increase, in comparison with placebo, was shown with eszopiclone (21 (22 to 37) vs 28.0 (15 to 36); P value = NS), zolpidem (0.81 ± 0.29 vs 1.46 ± 0.53; P value = NS), flurazepam (18.6 ± 19 vs 19.6 ± 15.9; P value = NS) and temazepam (6.53 ± 9.4 vs 6.56 ± 8.3; P value = 0.98). A significant decrease in minimum nocturnal peripheral capillary oxygen saturation (SpO 2 ) was observed with zolpidem 20 mg (76.8 vs 85.2; P value = 0.002), flurazepam 30 mg (81.7 vs 85.2; P value = 0.002), remifentanil infusion (MD ‐7.00, 95% CI ‐11.95 to ‐2.05) and triazolam 0.25 mg in both rapid eye movement (REM) and non‐REM (NREM) sleep (MD ‐14.00, 95% CI ‐21.84 to ‐6.16; MD ‐10.20, 95% CI ‐16.08 to ‐4.32, respectively. One study investigated the effect of an opiate (remifentanil) on patients with moderate OSA. Remifentanil infusion did not significantly change AHI (MD 10.00, 95% CI ‐9.83 to 29.83); however it did significantly decrease the number of obstructive apnoeas (MD ‐9.00, 95% CI ‐17.40 to ‐0.60) and significantly increased the number of central apnoeas (MD 16.00, 95% CI ‐2.21 to 34.21). Similarly, although without significant effect on obstructive apnoeas, central apnoeas were increased in the sodium oxybate 9 g treatment group (MD 7.3 (18); P value = 0.005) in a cross‐over trial. Drugs studied in this review were generally well tolerated, apart from adverse events reported in 19 study participants prescribed remifentanil (n = 1), eszopiclone (n = 6), sodium oxybate (n = 9) or ramelteon (n = 3). Authors' conclusions The findings of this review show that currently no evidence suggests that the pharmacological compounds assessed have a deleterious effect on the severity of OSA as measured by change in AHI or ODI. Significant clinical and statistical decreases in minimum overnight SpO 2 were observed with remifentanil, zolpidem 20 mg and triazolam 0.25 mg. Eszopiclone 3 mg and sodium oxybate 4.5 g showed a beneficial effect on the severity of OSA with a reduction in AHI and may merit further assessment as a potential therapeutic option for a subgroup of patients with OSA. Only one trial assessed the effect of an opioid (remifentanil); some studies included CPAP treatment, whilst in a significant number of participants, previous treatment with CPAP was not stated and thus a residual treatment effect of CPAP could not be excluded. Most studies were small and of short duration, with indiscernible methodological quality.Caution is therefore required when such agents are prescribed for patients with OSA, especially outside the severity of the OSA cohorts and the corresponding dose of compounds given in the particular studies. Larger, longer trials involving patients across a broader spectrum of OSA severity are needed to clarify these results. Plain language summary Effects of opioid, hypnotic and sedating medications on obstructive sleep apnoea (OSA) in adults with known OSA Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by intermittent apnoeas (pauses in breathing) leading to dips in oxygen levels in the blood during sleep. Many people with known or unknown (undiagnosed) OSA receive hypnotics, sedatives and opiate/opioid drugs to treat other conditions including pain, anxiety and difficulty sleeping. Opiates/opioids are commonly prescribed to treat pain after major surgery. These drugs might make sleep apnoea worse ‐ increasing the frequency and duration of apnoeas. Review question We set out to look at evidence derived from randomised placebo‐controlled trials to identify the risks of these drugs for patients with known OSA. What we did We searched and reviewed all randomised placebo‐controlled trials involving adult patients with known OSA who received these drugs. Most of the trials were short at just one or two nights' duration, involved only a small number of patients and used poorly described methodology. Therefore it was difficult to find out the exact effects of these drugs on patients with OSA. Results We found 14 studies examining the effects of 10 drugs in trials including 293 people. Opiates and opioids (treatment of acute and chronic pain) Remifentanil infusion Remifentanil infusion did not significantly change severity of OSA as measured by numbers and duration of pauses in breathing during sleep, but it significantly lowered minimum oxygen levels during the night when compared with placebo. Sedatives and hypnotics 'Z drugs' (a treatment for insomnia, inability to fall asleep or inability to maintain sleep) Eszopiclone and zolpidem Eszopiclone did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, it reduced the severity of OSA, and it might be beneficial in treating this condition, although further studies are needed to assess this effect. Zolpidem did not significantly worsen OSA as measured by the numbers and duration of pauses in breathing during sleep, but in one trial, it significantly lowered minimum oxygen levels during the night when compared with placebo. Benzodiazepines (short‐term relief of severe anxiety, behavioural disturbance or agitation and panic disorders) Brotizolam, flurazepam, nitrazepam, temazepam and triazolam None of the drugs examined had significantly worsened OSA as measured by the numbers and duration of pauses in breathing during sleep. In small, single‐night studies, zolpidem 20 mg, flurazepam 20 mg and triazolam 0.25 mg showed a tendency to increase numbers and duration of pauses during sleep, which was not statistically significant, but these drugs significantly lowered minimum oxygen levels during the night when compared with placebo. Sodium oxybate (a treatment for narcolepsy, a condition causing excessive sleepiness during the day) Sodium oxybate was compared with placebo in two trials. Results showed that sodium oxybate did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, sodium oxybate 4.5 g reduced the severity of OSA and might have proved beneficial in treating this condition, although further studies are needed to assess this effect. Melatonin and melatonin‐related drugs Ramelteon (a treatment drug for insomnia) Ramelteon was assessed in older adults, over 60 years of age, with OSA and insomnia and was found not to worsen OSA. Results of this review show that the drugs studied do not worsen the severity of OSA as measured by the numbers and duration of pauses in breathing during sleep, but significant clinical and statistical decreases in minimum oxygen levels during the night were observed with remifentanil, zolpidem and triazolam; therefore prescribing these drugs for patients with OSA still warrants caution. Sodium oxybate 4.5 g and eszopiclone reduced the severity of OSA and might be beneficial in treating this condition; nonetheless further studies are needed to support these results. Bottom line The long‐term effect and potential side effects of sedative drugs in people with OSA need to be assessed in larger, longer and methodologically robust studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mason, M; Cates, CJ; Smith, I", "articleTypes": [], "doi": "10.1002/14651858.CD011090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "23c8cd78-9e06-44a5-826c-1f0076afdcca", "pmid": "", "title": "Glucocorticoids for croup in children", "imported": false, "abstract": "Abstract - Background Glucocorticoids are the mainstay for the treatment of croup. The existing evidence demonstrates that glucocorticoids are effective in the treatment of croup in children. However, updating the evidence on their clinical relevance in croup is imperative. This is an update to a review first published in 1999, and updated in 2004, 2011, and 2018. Objectives To investigate the effects and safety of glucocorticoids in the treatment of croup in children aged 18 years and below. Search methods We searched the Cochrane Library, which includes the Cochrane Central Register of Controlled Trials (CENTRAL; 2022 Issue 9), Ovid MEDLINE Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations and Ovid MEDLINE (1946 to 4 March 2022), Embase (Ovid) (1974 to 4 March 2022). We also searched the WHO ICTRP and ClinicalTrials.gov on 4 March 2022. Selection criteria We included randomised controlled trials (RCTs) in children (aged 18 years and below) with croup. We assessed the effect of glucocorticoids compared to the following: placebo, any other pharmacologic agents, any other glucocorticoids, any combination of other glucocorticoids, given by different modes of administration, or given in different doses. The included studies must have assessed at least one of our primary outcomes (defined as the change in croup score or return visits, (re)admissions to the hospital or both) or secondary outcomes (defined as the length of stay in hospital or emergency departments, patient improvement, use of additional treatments, or adverse events). Data collection and analysis Review authors independently extracted data, with another review author verified. We entered the data into Review Manager 5 for meta‐analysis. Two review authors independently assessed studies for risk of bias using the Cochrane risk of bias tool. Two review authors assessed the certainty of the evidence for the primary outcomes using the GRADE approach. Main results This updated review includes 45 RCTs with a total of 5888 children, an increase of two RCTs with 1323 children since the last update. We also identified one ongoing study and one study awaiting classification. We assessed most studies (98%) as at high or unclear risk of bias. Any glucocorticoid compared to placebo Compared to placebo, glucocorticoids may result in greater reductions in croup score after two hours (standardised mean difference (SMD) −0.65, 95% confidence interval (CI) −1.13 to −0.18; 7 RCTs, 426 children; low‐certainty evidence); six hours (SMD −0.76, 95% CI −1.12 to −0.40; 11 RCTs, 959 children; low‐certainty evidence); and 12 hours (SMD −1.03, 95% CI −1.53 to ‐0.53; 8 RCTs, 571 children; low‐certainty evidence). The evidence for change in croup score after 24 hours is very uncertain (SMD −0.86, 95% CI −1.40 to −0.31; 8 RCTs, 351 children; very low‐certainty evidence). One glucocorticoid compared to another glucocorticoid There was little to no difference between prednisolone and dexamethasone for reduction in croup score at two‐hour post‐baseline score (SMD 0.06, 95% CI −0.06 to 0.18; 1 RCT, 1231 children; high‐certainty evidence). There was likely little to no difference between prednisolone and dexamethasone for reduction in croup score at six‐hour post‐baseline score (SMD 0.21, 95% CI −0.21 to 0.62; 1 RCT, 99 children; moderate‐certainty evidence). However, dexamethasone probably reduced the return visits or (re)admissions for croup by almost half (risk ratio (RR) 0.55, 95% CI 0.28 to 1.11; 4 RCTs, 1537 children; moderate‐certainty evidence), and showed a 28% reduction in the use of supplemental glucocorticoids as an additional treatment (RR 0.72, 95% CI 0.53 to 0.97; 2 RCTs, 926 children). Dexamethasone given in different doses Compared to 0.15 mg/kg, 0.60 mg/kg dexamethasone probably reduced the severity of croup as assessed by the croup scoring scale at 24‐hour postbaseline score (SMD 0.63, 95% CI 0.16 to 1.10; 1 RCT, 72 children; moderate‐certainty evidence); however, this was not the case at two hours (SMD −0.27, 95% CI −0.76 to 0.22; 2 RCTs, 861 children; high‐certainty evidence). There was probably no reduction at six hours (SMD −0.45, 95% CI −1.26 to 0.35; 3 RCTs, 178 children; moderate‐certainty evidence), and the evidence at 12 hours is very uncertain (SMD −0.60, 95% CI −4.39 to 3.19; 2 RCTs, 113 children; very low‐certainty evidence). There was little to no difference between doses of dexamethasone in return visits or (re)admissions of children or both (RR 0.91, 95% CI 0.71 to 1.17; 3 RCTs, 949 children; high‐certainty evidence) or length of stay in the hospital or emergency department (mean difference 0.12, 95% CI −0.32 to 0.56; 2 RCTs, 892 children). The need for additional treatments, such as epinephrine (RR 0.78, 95% CI 0.34 to 1.75; 2 RCTs, 885 children); intubation (risk difference 0.00, 95% CI −0.00 to 0.00; 2 RCTs, 861 children); or use of supplemental glucocorticoids (RR 0.77, 95% CI 0.51 to 1.15; 2 RCTs, 617 children), also did not differ between doses of dexamethasone. There were moderate to high levels of heterogeneity in the analyses for most comparisons. Adverse events were observed for some of the comparisons reported in the review. Authors' conclusions The evidence that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions has not changed in this update. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg. More RCTs are needed to strengthen the evidence for effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. Plain language summary Glucocorticoids for croup in children Review question What is the effectiveness and safety of glucocorticoids when treating children with croup? Background Respiratory viruses are the main cause of croup in children. Croup leads to a swelling of the throat and airway, which can make breathing difficult. Children also present with a special type of cough called a barking cough. Glucocorticoids are types of steroids that help reduce the swelling, thereby making it easier for children with croup to breathe. This is an update of a review first published in 1999 and updated in 2004, 2011, and 2018. Search date The evidence is current to 4 March 2022. Study characteristics We included 2 new studies with 1323 children, for a total of 45 studies with 5888 children aged 0 to 18 years published between 1964 and 2021. The three types of glucocorticoids used in the new studies were budesonide, dexamethasone, and prednisolone. The most recent study compared the effectiveness of budesonide and dexamethasone. The other new study compared the effectiveness of dexamethasone and prednisolone, as well as a small dose of dexamethasone (0.15 mg/kg) versus 0.60 mg/kg dexamethasone. We added the data from the new study that compared the doses of dexamethasone to previously included studies looking at the same comparison. Study funding sources Funding sources included government (11%), academic or research institute (7%), industry (18%), or foundations (9%). More than half of the studies (55%) did not report funding sources. Key results Compared to prednisolone, dexamethasone showed no improvement in croup score at two and six hours after presenting to the hospital or emergency department, and probably reduced return visits or (re)admissions for croup by almost half. The addition of supplemental glucocorticoid favoured dexamethasone versus prednisolone. Compared to 0.15 mg/kg dexamethasone, the standard dose of 0.60 mg/kg probably reduced the severity of croup as assessed by the croup scoring scale at 24 hours after presenting to the hospital or emergency department. However, we did not find any important difference between groups in croup scoring scale at 2, 6, or 12 hours, return visits or (re)admissions of children, or length of stay in the hospital or emergency department. The need for additional treatments such as the use of other drugs like epinephrine, supplemental glucocorticoid, or the use of a tube to help breathing did not differ between 0.15 mg/kg and 0.60 mg/kg dexamethasone. No serious adverse events from the use of the glucocorticoids were reported in the newly included studies. Conclusions The evidence has not changed that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions compared to placebo (dummy treatment). A small dose of dexamethasone at 0.15 mg/kg may be as effective as the standard dose of 0.60 mg/kg. More studies are needed to strengthen the evidence for the effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. We conclude that glucocorticoids are effective in the treatment of croup in children. Certainty of evidence Most studies (98%) had problems related to their methods, reporting issues, or both. For any glucocorticoid compared to placebo, we downgraded the certainty of the evidence for change in croup score after 2, 6, 12, and 24 hours and return visits or (re)admissions due to study variability, imprecision and inconsistency of study results, and risk of bias. There is little evidence that reporting bias influenced our results for return visits or (re)admissions, or both. Similar threats to the certainty of the evidence were present in the other comparisons in this review, including concerns related to risk of bias and inconsistency and imprecision of study results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aregbesola, A; Tam, CM; Kothari, A; Le, M-L; Ragheb, M; Klassen, TP", "articleTypes": [], "doi": "10.1002/14651858.CD001955.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "24073af2-e894-40cc-8558-cbcc7901fed6", "pmid": "", "title": "Omega‐3 fatty acid supplementation for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Studies suggest that a diet rich in omega‐3 essential fatty acids may have beneficial anti‐inflammatory effects for chronic conditions such as cystic fibrosis. This is an updated version of a previously published review. Objectives To determine whether there is evidence that omega‐3 polyunsaturated fatty acid supplementation reduces morbidity and mortality and to identify any adverse events associated with supplementation. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of last search: 01 April 2020. We also searched online study registries and contacted authors. Date of last search: 12 February 2020. Selection criteria Randomised controlled trials in people with cystic fibrosis comparing omega‐3 fatty acid supplements with placebo. Data collection and analysis Two authors independently selected studies for inclusion, extracted data and assessed the risk of bias of the studies. The quality of the evidence was assessed using GRADE. Main results The searches identified 23 studies; five studies with 106 participants (children and adults) were included; duration of studies and interventions differed. Two studies compared omega‐3 fatty acids to olive oil for six weeks; one study compared omega‐3 fatty acids and omega‐6 fatty acids to control capsules (customised fatty acid blends) for three months; one study compared a liquid dietary supplement containing omega‐3 fatty acids to one without for six months; and one study compared omega‐3 fatty acids to a placebo for 12 months. Three studies had a low risk of bias for randomisation, but the risk was unclear in the remaining two studies; all studies had an unclear risk of bias for allocation concealment. Three of the studies adequately blinded participants; the risk of bias for selective reporting was high in one study and unclear for four studies. Two studies reported the number of respiratory exacerbations. At three months, one study (43 participants) reported no change in antibiotic usage. At 12 months the second study (15 participants) reported a reduction in the number of pulmonary exacerbations and cumulative antibiotic days in the supplement group compared to the previous year (no data for the control group); very low‐quality evidence means we are unsure whether supplementation has any effect on this outcome. With regards to adverse events, one six‐week study (12 participants) reported no difference in diarrhoea between omega‐3 or placebo capsules; the very low‐quality evidence means we are unsure if supplementation has any effect on this outcome. Additionally, one study reported an increase in steatorrhoea requiring participants to increase their daily dose of pancreatic enzymes, but three studies had already increased pancreatic enzyme dose at study begin so as to reduce the incidence of steatorrhoea. One study (43 participants) reported stomach pains at three months (treatment or control group not specified). One six‐week study (19 participants) reported three asthma exacerbations leading to exclusion of participants since corticosteroid treatment could affect affect essential fatty acid metabolism. Four studies reported lung function. One six‐week study (19 participants) reported an increase in forced expiratory volume in one second (FEV 1 ) (L) and forced vital capacity (FVC) (L), but the very low‐quality evidence means we are unsure if supplementation has any effect on lung function. The remaining studies did not report any difference in lung function at three months (unit of measurement not specified) or at six months and one year (FEV 1 % predicted and FVC % predicted). No deaths were reported in any of the five studies. Four studies reported clinical variables. One study reported an increase in Schwachman score and weight alongside a reduction in sputum volume with supplementation compared to placebo at three months (data not analysable). However, three studies reported no differences in either weight at six weeks, in body mass index (BMI) standard deviation (SD) score at six months (very low‐quality evidence) or BMI Z score at 12 months. Three studies reported biochemical markers of fatty acid status. One study showed an increase from baseline in both EPA and DHA content of serum phospholipids in the omega‐3 group compared to placebo at three months and also a significant decrease in n‐6/n‐3 ratio in the supplement group compared to placebo; since the quality of the evidence is very low we are not certain that these changes are due to supplementation. One six‐month cross‐over study showed a higher EPA content of the neutrophil membrane in the supplement group compared to the placebo group, but, no difference in DHA membrane concentration. Furthermore, the leukotriene B 4 to leukotriene B 5 ratio was lower at six months in the omega‐3 group compared to placebo. A one‐year study reported a greater increase in the essential fatty acid profile and a decrease in AA levels in the treatment arm compared to placebo. Authors' conclusions This review found that regular omega‐3 supplements may provide some limited benefits for people with cystic fibrosis with relatively few adverse effects: however, the quality of the evidence across all outcomes was very low. The current evidence is insufficient to draw firm conclusions or recommend routine use of these supplements in people with cystic fibrosis. A large, long‐term, multicentre, randomised controlled study is needed to determine any significant therapeutic effect and to assess the influence of disease severity, dosage and duration of treatment. Future researchers should note the need for additional pancreatic enzymes when providing omega‐3 supplementation or olive oil placebo capsules. More research is required to determine the exact dose of pancreatic enzyme required. Plain language summary The use of omega‐3 supplements in people with cystic fibrosis Review question We reviewed the evidence about the effect of giving omega‐3 supplements to people with cystic fibrosis. Background In people with cystic fibrosis recurring cycles of infection and inflammation are thought to worsen lung function. Studies suggest that omega‐3 fatty acids, such as those derived from fish oils, may work to counter the inflammation and may be of benefit in chronic inflammatory diseases including cystic fibrosis. This is an updated version of the review. Search date The evidence is current to: 01 April 2020. Study characteristics This review includes five small studies which compare omega‐3 supplements to a different supplement without omega‐3. In total there were 106 participants, including both children and adults. The studies lasted between six weeks and 12 months. Key results Due to the very low‐quality evidence, we are uncertain whether the following effects are due to supplementation or not. One 12‐month study reported a reduction in pulmonary exacerbations and antibiotic use when taking omega‐3 supplementation compared to placebo and one three‐month study reported no change in antibiotic use during the study period. Few side effects were reported in any of the studies. One six‐week study reported that lung function and clinical status improved when taking omega‐3 supplements. Sputum levels were also noted to be reduced in this six‐week study. Three studies reported no difference in lung function when taking omega‐3 supplementation compared to placebo. Two longer studies found that people taking omega‐3 supplements showed definite increases in levels of essential fatty acids in their white blood cell membranes and also in levels of phospholipids (molecules that provide structure and protection to cells) measured in blood samples. We are uncertain whether regular omega‐3 supplements benefit people with cystic fibrosis and whether they cause side effects, or not. We are not able to draw firm conclusions or recommend the routine use of these supplements in people with cystic fibrosis. Larger and longer studies are needed to assess the clinical benefit of omega‐3 supplementation and to determine the appropriate dosage. Quality of the evidence We judged the quality of the evidence to be very low due to very low participant numbers, low event rates, limited reporting and poor study design. There was no consistency with regards to the time points when results were reported or the measurements used for the same outcome in different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Watson, H; Stackhouse, C", "articleTypes": [], "doi": "10.1002/14651858.CD002201.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "24271fab-48ba-46aa-844b-89370a345cc7", "pmid": "", "title": "Nutritional interventions for reducing morbidity and mortality in people with HIV", "imported": false, "abstract": "Abstract - Background Adequate nutrition is important for optimal immune and metabolic function. Dietary support may, therefore, improve clinical outcomes in HIV‐infected individuals by reducing the incidence of HIV‐associated complications and attenuating progression of HIV disease, improving quality of life and ultimately reducing disease‐related mortality. Objectives To evaluate the effectiveness of various macronutrient interventions, given orally, in reducing morbidity and mortality in adults and children living with HIV infection. Search methods We searched CENTRAL (up to August 2011), MEDLINE (1966 to August 2011), EMBASE (1988 to August 2011), LILACS (up to February 2012), and Gateway (March 2006‐February 2010). We also scanned reference lists of articles and contacted authors of relevant studies and other researchers. Selection criteria Randomised controlled trials evaluating the effectiveness of macronutrient interventions compared with no nutritional supplements or placebo in the management of adults and children infected with HIV. Data collection and analysis Three reviewers independently applied study selection criteria, assessed study quality, and extracted data. Effects were assessed using mean difference and 95% confidence intervals. Homogenous studies were combined wherever it was clinically meaningful to do so and a meta‐analysis using the random effects model was conducted. Main results Fourteen trials (including 1725 HIV positive adults and 271 HIV positive children), were included in this review. Neither supplementary food nor daily supplement of Spirulina significantly altered the risk of death compared with no supplement or placebo in malnourished, ART naive adult participants in the two studies which reported on this outcome. A nutritional supplement enhanced with protein did not significantly alter the risk of death compared to standard nutritional care in children with prolonged diarrhoea. Supplementation with macronutrient formulas given to provide protein and/or energy and fortified with micronutrients, in conjunction with nutrition counselling, significantly improved energy intake (3 trials; n=131; MD 393.57 kcal/day; 95% CI: 224.66 to 562.47;p<0.00001) and protein intake (2 trials; n=81; MD 23.5 g/day; 95% CI: 12.68, 34.01; p<0.00001) compared with no nutritional supplementation or nutrition counselling alone in adult participants with weight loss. In general supplementation with specific macronutrients such as amino acids, whey protein concentration or Spirulina did not significantly alter clinical, anthropometric or immunological outcomes compared with placebo in HIV‐infected adults and children. Authors' conclusions Given the current evidence base, which is limited to fourteen relatively small trials all evaluating different macronutrient supplements in different populations at different stages of HIV infection and with varying treatment status, no firm conclusions can be drawn about the effects of macronutrient supplementation on morbidity and mortality in people living with HIV. It is, however, promising to see more studies being conducted in low‐income countries, and particularly in children, where macronutrient supplementation both pre‐antiretroviral treatment and in conjunction with antiretroviral treatment might prove to be beneficial. Plain language summary Nutritional interventions for reducing morbidity and mortality in people with HIV Achieving and maintaining optimal nutrition is considered an important adjunct in the clinical care of patients infected with HIV, as good nutrition can improve an individual's immune function, limit disease‐specific complications, and improve quality of life and survival. We sought to determine whether macronutrient interventions, either given to provide protein and/or energy or test the effect of specific macronutrients (i.e. ch as amino acids, whey protein concentrate or Spirulina), given orally, influence morbidity and mortality in adults and children living with HIV infection. Our review, based on fourteen small trials, evaluating different macronutrient supplements, found limited evidence that balanced macronutrient formulas increase protein and energy intake. However, we found no evidence that such supplementation translates into reductions in disease progression or HIV‐related complications, such as opportunistic infections or death.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grobler, L; Siegfried, N; Visser, ME; Mahlungulu, SSN; Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD004536.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "24306b99-5a8f-4de8-8832-bf04f181ff7d", "pmid": "", "title": "A Randomized Double-blinded Placebo-controlled Outpatient Clinical Trial in High Risk Population Confirmed COVID-19 Patients Using Ivermectin and Doxycycline to Prevent COVID-19 Illness-related Hospitalization (COVIVER-OUT PLUS)", "imported": false, "abstract": "The purpose of this Clinical trial is to explore the therapeutic benefits of Ivermectin and Doxycycline in different combinations in high risk patients diagnosed with COVID-19.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "24622149-2571-474d-a6f2-43648b50c3fa", "pmid": "", "title": "Zinc supplementation for the prevention of pneumonia in children aged 2 months to 59 months", "imported": false, "abstract": "Abstract - Background Pneumonia is a leading cause of morbidity and mortality in children younger than five years of age. Most deaths occur during infancy and in low‐income countries. Daily zinc supplements have been reported to prevent acute lower respiratory tract infection (LRTI) and reduce child mortality. This is an update of a review first published in 2010. Objectives To evaluate the effectiveness of zinc supplementation in the prevention of pneumonia in children aged two to 59 months. Search methods We searched CENTRAL (Issue 21 October 2016), MEDLINE (1966 to October 2016), Embase (1974 to October 2016), LILACS (1982 to October 2016), CINAHL (1981 to October 2016), Web of Science (1985 to October 2016) and IMSEAR (1980 to October 2016). Selection criteria Randomised controlled trials (RCTs) evaluating zinc supplementation for the prevention of pneumonia in children aged from 2 months to 59 months. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We did not identify any new studies for inclusion in this update. We included six studies that involved 5193 participants. Analysis showed that zinc supplementation reduced the incidence of pneumonia by 13% (fixed‐effect risk ratio (RR) 0.87; 95% confidence interval (CI) 0.81 to 0.94, six studies, low‐quality evidence) and prevalence of pneumonia by 41% (random‐effects RR 0.59; 95% CI 0.35 to 0.99, one study, n = 609, low‐quality evidence). On subgroup analysis, we found that zinc reduced the incidence of pneumonia defined by specific clinical criteria by 21% (i.e. confirmation by chest examination or chest radiograph) (fixed‐effect RR 0.79; 95% CI 0.71 to 0.88, four studies, n = 3261), but had no effect on lower specificity pneumonia case definition (i.e. age‐specific fast breathing with or without lower chest indrawing) (fixed‐effect RR 0.95; 95% CI 0.86 to 1.06, four studies, n = 1932). Authors' conclusions Zinc supplementation in children is associated with a reduction in the incidence and prevalence of pneumonia. Plain language summary Zinc supplementation for the prevention of pneumonia in children aged two to 59 months Review question We evaluated the effectiveness of zinc supplementation to prevent pneumonia in children aged from two to 59 months. Background Zinc is an essential element for children's growth and development. Too little zinc is associated with increased risk of infection, particularly diarrhoea and pneumonia. Children are more prone to zinc deficiency because they are less able to absorb dietary zinc and some children, especially in low‐income countries, may not have received enough zinc from their mothers before birth. Zinc supplements for children has been reported to prevent pneumonia. Search date We searched the literature up to October 2016. This is an update of a review published in 2010. We did not find any new studies for this update. Study characteristics We included six studies that investigated zinc supplements to prevent pneumonia. The studies were conducted in Bangladesh, India, Peru and South Africa and involved 5193 children aged from two to 59 months. Children received either zinc or a similar‐looking treatment that did not contain zinc. In two studies, children were also given vitamin A. Study funding sources All included studies were funded. Of these, three explicitly mentioned that funding agencies had no role in the design and results of the study. Key results Zinc supplementation was significantly associated with reducing the incidence and prevalence of pneumonia among children aged from two to 59 months. On subgroup analysis, we found that a more stringent diagnosis (radiological examination) increased the reduction in pneumonia incidence. Quality of the evidence Overall, evidence quality was assessed as low on GRADE assessment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lassi, ZS; Moin, A; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD005978.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "24988d98-1da2-42df-8445-24bf03c4ccd0", "pmid": "", "title": "Short‐course oral steroids alone for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of oral corticosteroids compared with placebo/no intervention or other pharmacological interventions (intranasal corticosteroids, antibiotics, antifungals) for chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids with placebo or no treatment or compared with other pharmacological interventions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included eight RCTs (474 randomised participants), which compared oral corticosteroids with placebo or no intervention. All trials only recruited adults with chronic rhinosinusitis with nasal polyps. All trials reported outcomes at two to three weeks, at the end of the short‐course oral steroid treatment period. Three trials additionally reported outcomes at three to six months. Two of these studies prescribed intranasal steroids to patients in both arms of the trial at the end of the oral steroid treatment period. Oral steroids versus placebo or no intervention Disease‐specific health‐related quality of life was reported by one study. This study reported improved quality of life after treatment (two to three weeks) in the group receiving oral steroids compared with the group who received placebo (standardised mean difference (SMD) ‐1.24, 95% confidence interval (CI) ‐1.92 to ‐0.56, 40 participants, modified RSOM‐31), which corresponds to a large effect size. We assessed the evidence to be low quality (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). Disease severity as measured by patient‐reported symptom scores was reported by two studies, which allowed the four key symptoms used to define chronic rhinosinusitis (nasal blockage, nasal discharge, facial pressure, hyposmia) to be combined into one score. The results at the end of treatment (two to three weeks) showed an improvement in patients receiving oral steroids compared to placebo, both when presented as a mean final value (SMD ‐2.84, 95% CI ‐4.09 to ‐1.59, 22 participants) and as a change from baseline (SMD ‐2.28, 95% CI ‐2.76 to ‐1.80, 114 participants). These correspond to large effect sizes but we assessed the evidence to be low quality. One study (114 participants) followed patients for 10 weeks after the two‐week treatment period. All patients in both arms received intranasal steroids at the end of the oral steroid treatment period. The results showed that the initial results after treatment were not sustained (SMD ‐0.22, 95% CI ‐0.59 to 0.15, 114 participants, percentage improvement from baseline). This corresponds to a small effect size and we assessed the evidence to be low quality. There was an increase in adverse events in people receiving orals steroids compared with placebo for gastrointestinal disturbances (risk ratio (RR) 3.45, 95% CI 1.11 to 10.78; 187 participants; three studies) and insomnia (RR 3.63, 95% CI 1.10 to 11.95; 187 participants; three studies). There was no significant impact of oral steroids on mood disturbances at the dosage used in the included study (risk ratio (RR) 2.50, 95% CI 0.55 to 11.41; 40 participants; one study). We assessed the evidence to be low quality due to the lack of definitions of the adverse events and the small number of events or sample size, or both). Other comparisons No studies that compared short‐course oral steroids with other treatment for chronic rhinosinusitis met the inclusion criteria. Authors' conclusions At the end of the treatment course (two to three weeks) there is an improvement in health‐related quality of life and symptom severity in patients with chronic rhinosinusitis with nasal polyps taking oral corticosteroids compared with placebo or no treatment. The quality of the evidence supporting this finding is low. At three to six months after the end of the oral steroid treatment period, there is little or no improvement in health‐related quality of life or symptom severity for patients taking an initial course of oral steroids compared with placebo or no treatment. The data on the adverse effects associated with short courses of oral corticosteroids indicate that there may be an increase in insomnia and gastrointestinal disturbances but it is not clear whether there is an increase in mood disturbances. All of the adverse events results are based on low quality evidence. More research in this area, particularly research evaluating patients with chronic rhinosinusitis without nasal polyps, longer‐term outcomes and adverse effects, is required. There is no evidence for oral steroids compared with other treatments. Plain language summary Short‐term oral corticosteroids compared with no treatment or other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of a short course (typically up to 21 days) of corticosteroid given by mouth to people with chronic rhinosinusitis compared with giving a placebo or no treatment, or another type of treatment. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling the inflammatory response and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included eight randomised controlled trials with a total of 474 participants. All of the patients were adults who had chronic rhinosinusitis with nasal polyps. All of the studies followed patients until the end of treatment (two to three weeks) and three studies (210 participants) followed up people for three to six months after the initial treatment had ended. Five of the eight reports mentioned how the trial was funded. None of the funding sources were pharmaceutical companies. Key results At the end of a two‐ or three‐week treatment course, people who took oral steroids may have had a better quality of life, less severe symptoms and smaller nasal polyps than people who had placebo or did not receive any treatment. After three to six months, there was little or no difference in quality of life, symptom severity or nasal polyps between the people who had oral steroids and the people who had placebo or no intervention. The people who took oral steroids may have had more gastrointestinal disturbances and insomnia than the people who had placebo or no intervention. It is not clear if the people who took oral steroids had more mood disturbances than the people who had placebo or no intervention. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate), as the some of the results are only from one or two studies, which do not have a lot of participants. Most of the trials do not have a high risk of bias, but only people with nasal polyps were included in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K, Chong, LY, Hopkins, C, Philpott, C, Burton, MJ, Schilder, AGM", "articleTypes": [], "doi": "10.1002/14651858.CD011991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.763Z" }, { "id": "24b9f571-2698-4feb-b918-736d54987441", "pmid": "", "title": "Isolation and Establishment of Gustatory Cell Lines in Patients Operated on for Cancer of the Mobile Tongue - ImmortTasteCELL", "imported": false, "abstract": "In terms of incidence, cancer of the tongue is one of the leading cancers in France. Moreover, this cancer is associated with physiological complications ranging from swallowing disorders to loss of taste. Following surgery, impaired perception of food taste may lead to cachexia. It is therefore necessary to carry out research in the field of impaired taste, notably with regard to the regeneration of taste buds. However, there is currently no available functional model of taste bud cells.", "journal": "", "year": "2017", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.236Z" }, { "id": "24cac18b-4511-4da5-9cb4-ea4b57261d93", "pmid": "", "title": "Adjunctive therapies in addition to land‐based exercise therapy for osteoarthritis of the hip or knee", "imported": false, "abstract": "Abstract - Background Land‐based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non‐pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land‐based exercise therapy is lacking. Objectives To evaluate the benefits and harms of adjunctive therapies used in addition to land‐based exercise therapy compared with placebo adjunctive therapy added to land‐based exercise therapy, or land‐based exercise therapy only for people with hip or knee osteoarthritis. Search methods We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land‐based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land‐based exercise therapy, or land‐based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant‐reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short‐term (6 months), medium‐term (6 to 12 months) and long‐term (12 months onwards) effects. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE. Main results We included 62 trials (60 RCTs and 2 quasi‐RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 60 included people with knee osteoarthritis only. Thirty‐six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty‐two trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in 11 (18%) trials. Comparing adjunctive therapies plus land‐based exercise therapy against placebo therapies plus exercise up to six months (short‐term), we found low‐certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate‐certainty evidence indicates that adjunctive therapies did not improve QOL (SF‐36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low‐certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant‐reported global assessment was not measured in any studies. Compared with land‐based exercise therapy, low‐certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short‐term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise‐only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (41 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (41 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low‐certainty evidence). Moderate‐certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant‐reported global assessment (short‐term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI ‐0.32 to ‐0.18 mm); 12% relative improvement (6% better to 18% better). Low‐certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27). Authors' conclusions Moderate‐ to low‐certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant‐reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis. Plain language summary Additional therapies used with exercise therapy for hip or knee osteoarthritis What was the aim of this review? Osteoarthritis, a chronic degenerative condition that commonly affects hip and knee joints, causes pain and difficulty with everyday activities such as walking. Land‐based exercise therapy refers to exercise conducted on land (as opposed to exercise in the water) and is a first‐line treatment. This review aimed to find out if adding additional therapies to land‐based exercise therapy improved pain, function, quality of life, participant‐reported overall change or X‐ray changes in people with hip or knee osteoarthritis. Additional therapies include manual (hands‐on) therapy, psychological or dietary therapies, electrophysical agents (such as heat, cold, nerve stimulation, ultrasound or laser therapy) or acupuncture. We included studies comparing additional therapies plus land‐based exercise therapy to either 1) sham (or dummy) therapy plus land‐based exercise therapy or 2) land‐based exercise therapy only. Search date This systematic review is up‐to‐date to 10 June 2021. What did we find? We found 62 randomised controlled trials with 6508 participants, mostly women, from 24 countries. The average age was between 52 and 83 years, with symptoms present from 9 months to 12 years. Sixty studies enrolled people with knee osteoarthritis, one enrolled people with hip osteoarthritis and one enrolled people with knee or hip osteoarthritis. Twenty‐two trials compared additional therapies plus exercise therapy to sham additional therapies plus exercise therapy, and 41 compared to exercise therapy. Thirty‐eight trials studied electrophysical agents, seven studied manual therapies, four studied acupuncture/dry needling or use of tape, three studied psychological or dietary interventions, whole body vibration (this involves standing on a vibration platform), or spa/mud therapy, and one studied foot orthotics (shoe insoles). Funding source Thirty‐eight studies were funded, four received no funding and funding support was not reported in 20. Main results Eleven trials (18%) measured adverse (unwanted harmful) events, which included both non‐serious and serious adverse events. The most common were increased pain, stiffness or swelling. There was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with sham additional therapies plus exercise therapy (22 studies) Compared with sham additional therapies used with land‐based exercise therapy, additional therapies such as electrophysical agents, acupuncture, dry needling or taping, used with exercise therapy, may not be more effective in improving pain, physical function or quality of life up to six months after treatment. Pain (lower scores mean less pain) Improved by 10% or 0.77 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 12% or 5.03 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 1% or 0.75 points worse on a zero to 100‐point scale. Adverse events Although not commonly reported in studies, there was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with exercise therapy (41 studies) Compared with land‐based exercise therapy, additional therapies (manual therapies, electrotherapy, dietary interventions, psychological therapies, whole body vibration, acupuncture, dry needling, taping, spa/mud therapy or foot orthotics) plus exercise therapy, may not be more effective in improving pain, physical function, quality of life or joint changes measured with X‐rays up to six months after treatment. Pain (lower scores mean less pain) Improved by 7% or 0.41 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 9% or 2.83 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 2%, or 1.04 points worse on a zero to 100‐point scale. Patient‐reported overall change 17% more people rated their treatment a success. X‐ray changes Improved by 12% (based on one study) Adverse effects Although not commonly reported in studies, risks appear no greater for additional therapies used with exercise compared to exercise only. Fewer studies assessed outcomes six or 12 months after treatment. Additional therapies plus land‐based exercise therapy may be no better in reducing pain or improving physical function or quality of life than exercise therapy at 6 or 12 months. In patient‐reported overall assessment, 31% reported improvement at 6 months, and 42% reported improvement at 12 months. Conclusions and certainty of evidence Additional therapies plus exercise therapy do not appear to offer meaningful improvements in pain, function, quality of life or overall change for people with hip or knee osteoarthritis compared with sham additional therapies plus land‐based exercise therapy; or in pain, function, quality of life or changes on X‐rays when compared with exercise therapy only. Compared with exercise therapy there is probably a clinical benefit in patient‐reported overall change for additional therapies plus exercise therapy, based on a small number of studies. Our confidence in the evidence varies between moderate to little or no confidence for different outcomes. Although results indicate no increased adverse events from additional therapies used with exercise therapy, this was poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "French, HP; Abbott, JH; Galvin, R", "articleTypes": [], "doi": "10.1002/14651858.CD011915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "24d78665-8c9e-4949-9749-c3690e223561", "pmid": "", "title": "Corticosteroids for the long‐term treatment in multiple sclerosis", "imported": false, "abstract": "Abstract - Background Short term high dose corticosteroid treatment improves symptoms and short term disability after an acute exacerbation of multiple sclerosis (MS) but it is unknown whether its long‐term use can reduce the accumulation of disability. Objectives To determine the efficacy and safety of long‐term corticosteroid use in MS. Search methods We searched The Cochrane MS Group Trials Register (February 2007),the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to February 2007) and EMBASE (1980 to February 2007). In an effort to identify further published, unpublished and ongoing trials we searched reference lists and contacted trial authors and one pharmaceutical company. Selection criteria We considered controlled, randomised trials (RCTs), with or without blinding, of long term treatment (i.e. longer than 6 months) of any type of corticosteroid in MS, irrespective of disease course. Data collection and analysis Reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Three trials, all classified at high risk of bias, contributed to this review (Miller 1961; BPSM 1995; Zivadinov 2001) resulting in a total of 183 participants (91 treated). Corticosteroid therapy did not reduce the risk of being worse at the end of follow‐up (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.26 to 1.02) but there was a substantial heterogeneity between studies (I 2 : 78.4%). I. v. periodic high dose methylprednisolone (MP) was associated with a significant reduction in the risk of disability progression at 5 years in relapsing‐remitting (RR) MS (OR 0.26, 95% CI 0.10 to 0.66), while oral continuous low dose prednisolone was not associated with any risk reduction in disability progression at 18 months (OR 1.23, 95% CI 0.43 to 3.56). Risk of experiencing at least one exacerbation at end of follow‐up was not significantly reduced with corticosteroid treatment (OR 0.36; 95% CI 0.10 to 1.25). 
 Only one study recorded adverse events: in one patient i. v. MP was discontinued after the fourth pulse when he developed acute glomerulonephritis; a second patient was removed from the study after the fifth i. v. MP pulse because of severe osteoporosis. Authors' conclusions There is no enough evidence that long‐term corticosteroid treatment delays progression of long term disability in patients with MS. Since one study at high risk of bias showed that the administration of pulsed high dose i. v. MP is associated with a significant reduction in the risk of long term disability progression in patients with RR MS, an adequately powered, high quality RCT is needed to investigate this finding. Plain language summary The long‐term use of anti‐inflammatory corticosteroids for treating multiple sclerosis Multiple sclerosis is an inflammatory disease affecting the brain and spinal cord. It results in episodes of neurological deficit which recover (relapses) as well as accumulation of sustained disability with the passage of time. Corticosteroids are potent anti‐inflammatory drugs. It is postulated that long‐term use of steroids may reduce the accumulation of disability. The reviewers found three studies addressing this issue. A meta‐analysis showed a trend towards a beneficial effect of long‐term corticosteroids on accumulation of disability; however only two small studies contributed to this result. It was not possible to reliably comment on the effect of long‐term corticosteroids on the frequency of relapses. Side effects were poorly documented. Therefore rigorous randomised controlled trials of this treatment are warranted.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Ciccone, A; Beretta, S; Brusaferri, F; Galea, I; Protti, A; Spreafico, C", "articleTypes": [], "doi": "10.1002/14651858.CD006264.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "24ea170c-d552-4ad3-b585-0d8107087f16", "pmid": "", "title": "Replacing salt with low‐sodium salt substitutes (LSSS) for cardiovascular health in adults, children and pregnant women", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Brand, A, Visser, ME, Schoonees, A, Naude, CE", "articleTypes": [], "doi": "10.1002/14651858.CD015207 AB - Abstract - Background Elevated blood pressure, or hypertension, is the leading cause of preventable deaths globally. Diets high in sodium (predominantly sodium chloride) and low in potassium contribute to elevated blood pressure. The WHO recommends decreasing mean population sodium intake through effective and safe strategies to reduce hypertension and its associated disease burden. Incorporating low‐sodium salt substitutes (LSSS) into population strategies has increasingly been recognised as a possible sodium reduction strategy, particularly in populations where a substantial proportion of overall sodium intake comes from discretionary salt. The LSSS contain lower concentrations of sodium through its displacement with potassium predominantly, or other minerals. Potassium‐containing LSSS can potentially simultaneously decrease sodium intake and increase potassium intake. Benefits of LSSS include their potential blood pressure‐lowering effect and relatively low cost. However, there are concerns about potential adverse effects of LSSS, such as hyperkalaemia, particularly in people at risk, for example, those with chronic kidney disease (CKD) or taking medications that impair potassium excretion. Objectives To assess the effects and safety of replacing salt with LSSS to reduce sodium intake on cardiovascular health in adults, pregnant women and children. Search methods We searched MEDLINE (PubMed), Embase (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection (Clarivate Analytics), Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCOhost), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) up to 18 August 2021, and screened reference lists of included trials and relevant systematic reviews. No language or publication restrictions were applied. Selection criteria We included randomised controlled trials (RCTs) and prospective analytical cohort studies in participants of any age in the general population, from any setting in any country. This included participants with non‐communicable diseases and those taking medications that impair potassium excretion. Studies had to compare any type and method of implementation of LSSS with the use of regular salt, or no active intervention, at an individual, household or community level, for any duration. Data collection and analysis Two review authors independently screened titles, abstracts and full‐text articles to determine eligibility; and extracted data, assessed risk of bias (RoB) using the Cochrane RoB tool, and assessed the certainty of the evidence using GRADE. We stratified analyses by adults, children (≤ 18 years) and pregnant women. Primary effectiveness outcomes were change in diastolic and systolic blood pressure (DBP and SBP), hypertension and blood pressure control; cardiovascular events and cardiovascular mortality were additionally assessed as primary effectiveness outcomes in adults. Primary safety outcomes were change in blood potassium, hyperkalaemia and hypokalaemia. Main results We included 26 RCTs, 16 randomising individual participants and 10 randomising clusters (families, households or villages). A total of 34,961 adult participants and 92 children were randomised to either LSSS or regular salt, with the smallest trial including 10 and the largest including 20,995 participants. No studies in pregnant women were identified. Studies included only participants with hypertension (11/26), normal blood pressure (1/26), pre‐hypertension (1/26), or participants with and without hypertension (11/26). This was unknown in the remaining studies. The largest study included only participants with an elevated risk of stroke at baseline. Seven studies included adult participants possibly at risk of hyperkalaemia. All 26 trials specifically excluded participants in whom an increased potassium intake is known to be potentially harmful. The majority of trials were conducted in rural or suburban settings, with more than half (14/26) conducted in low‐ and middle‐income countries. The proportion of sodium chloride replacement in the LSSS interventions varied from approximately 3% to 77%. The majority of trials (23/26) investigated LSSS where potassium‐containing salts were used to substitute sodium. In most trials, LSSS implementation was discretionary (22/26). Trial duration ranged from two months to nearly five years. We assessed the overall risk of bias as high in six trials and unclear in 12 trials. LSSS compared to regular salt in adults: LSSS compared to regular salt probably reduce DBP on average (mean difference (MD) ‐2.43 mmHg, 95% confidence interval (CI) ‐3.50 to ‐1.36; 20,830 participants, 19 RCTs, moderate‐certainty evidence) and SBP (MD ‐4.76 mmHg, 95% CI ‐6.01 to ‐3.50; 21,414 participants, 20 RCTs, moderate‐certainty evidence) slightly. On average, LSSS probably reduce non‐fatal stroke (absolute effect (AE) 20 fewer/100,000 person‐years, 95% CI ‐40 to 2; 21,250 participants, 3 RCTs, moderate‐certainty evidence), non‐fatal acute coronary syndrome (AE 150 fewer/100,000 person‐years, 95% CI ‐250 to ‐30; 20,995 participants, 1 RCT, moderate‐certainty evidence) and cardiovascular mortality (AE 180 fewer/100,000 person‐years, 95% CI ‐310 to 0; 23,200 participants, 3 RCTs, moderate‐certainty evidence) slightly, and probably increase blood potassium slightly (MD 0.12 mmol/L, 95% CI 0.07 to 0.18; 784 participants, 6 RCTs, moderate‐certainty evidence), compared to regular salt. LSSS may result in little to no difference, on average, in hypertension (AE 17 fewer/1000, 95% CI ‐58 to 17; 2566 participants, 1 RCT, low‐certainty evidence) and hyperkalaemia (AE 4 more/100,000, 95% CI ‐47 to 121; 22,849 participants, 5 RCTs, moderate‐certainty evidence) compared to regular salt. The evidence is very uncertain about the effects of LSSS on blood pressure control, various cardiovascular events, stroke mortality, hypokalaemia, and other adverse events (very‐low certainty evidence). LSSS compared to regular salt in children: The evidence is very uncertain about the effects of LSSS on DBP and SBP in children. We found no evidence about the effects of LSSS on hypertension, blood pressure control, blood potassium, hyperkalaemia and hypokalaemia in children. Authors' conclusions When compared to regular salt, LSSS probably reduce blood pressure, non‐fatal cardiovascular events and cardiovascular mortality slightly in adults. However, LSSS also probably increase blood potassium slightly in adults. These small effects may be important when LSSS interventions are implemented at the population level. Evidence is limited for adults without elevated blood pressure, and there is a lack of evidence in pregnant women and people in whom an increased potassium intake is known to be potentially harmful, limiting conclusions on the safety of LSSS in the general population. We also cannot draw firm conclusions about effects of non‐discretionary LSSS implementations. The evidence is very uncertain about the effects of LSSS on blood pressure in children. Plain language summary Does using low‐sodium salt substitutes (LSSS) instead of regular salt reduce blood pressure and heart disease risks, and is it safe? Key messages • In adults, using LSSS instead of regular salt in food probably lowers blood pressure slightly. Adults using LSSS instead of regular salt probably have a slightly lower risk of non‐fatal heart conditions, such as stroke or a sudden reduced blood flow to the heart, and death from heart disease. • Using LSSS instead of regular salt probably also slightly increases the level of blood potassium (a mineral that keeps your heart beating at the right pace) in adults. This could be harmful for people who cannot effectively regulate the potassium in their bodies. Other evidence on safety is very limited. • We are not certain about effects of using LSSS instead of regular salt on blood pressure in children, or whether using LSSS is safe in children. • This evidence may not directly apply to people known to be at risk of high blood potassium, such as people with kidney problems or on certain medications. What are low‐sodium salt substitutes (LSSS)? LSSS are products with less sodium than regular salt. Amounts of sodium in LSSS are lowered by replacing some of the sodium with potassium or other minerals. LSSS may help lower risks of using regular salt, since eating lots of sodium and not enough potassium contributes to high blood pressure. Globally, high blood pressure is the largest cause of preventable deaths, mainly because it causes stroke, acute coronary syndrome (ACS; where less blood flows to the heart), and kidney problems. However, LSSS also has potential health risks. Using LSSS may lead to higher than normal blood potassium (hyperkalaemia), which causes problems with the heartbeat speed and rhythm, or can cause the heart to stop. These risks are greater in certain people, for example, those whose kidneys do not work properly to remove potassium. What did we want to find out? We wanted to find out what the effects of using LSSS instead of regular salt are on blood pressure as well as on events (stroke and ACS) and heart disease death. We also wanted to know if using LSSS instead of regular salt is safe, both in the general population and in people who are known to be at risk of high blood potassium levels. We wanted to find this out for adults, children and pregnant women. What did we do? 
We searched five electronic databases and trial registries for studies that compared using LSSS with using regular salt. We compared and summarised the results of the studies and rated our confidence in the combined evidence, based on factors such as study methods and sizes. What did we find? We found 26 trials* involving 34,961 adults and 92 children. No studies in pregnant women were found. Most trials were undertaken in rural or suburban areas, with more than half done in low‐ and middle‐income countries. Most trials included some people with high blood pressure (22); the largest included only people with a high risk of stroke. Seven trials were done in people at possible risk of high blood potassium. All trials excluded people where high potassium intake is known to be harmful, such as people with kidney problems or on certain medications. Nearly all trials (23) examined LSSS types where some sodium was replaced with potassium. The amount of sodium replaced in the various LSSS used in the trials ranged from very small (3%) to large (77%). *Trials are types of studies in which participants are assigned randomly to two or more treatment groups. This is the best way to ensure similar groups of participants. Main results In adults, LSSS probably lowers blood pressure (diastolic and systolic) slightly when compared to regular salt. Using LSSS also probably lowers risk of non‐fatal stroke, non‐fatal ACS and heart disease death slightly when compared to regular salt. However, using LSSS instead of regular salt probably also slightly increases the level of potassium in the blood. Compared to regular salt, LSSS may result in little to no difference in high blood pressure and hyperkalaemia. We could not draw any conclusions about effects of LSSS on blood pressure control, various heart disease events, death caused by stroke, lower than normal blood potassium (hypokalaemia), and other adverse events. We could not draw any conclusions about the effects or safety of using LSSS instead of regular salt in children. What are the limitations of the evidence? We are moderately confident in the evidence. Our confidence was lowered mainly because of concerns about how some trials were conducted, and whether the results apply to the general population. We are not sure about the effects and safety of LSSS in children, pregnant women, people known to have a risk of high blood potassium, or those who do not have high blood pressure. We are also unsure about the effects of LSSS when used in foods not prepared at home. Further research may change these results. How up to date is this evidence? The evidence is up‐to‐date to August 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.091Z" }, { "id": "24ea4027-602b-4808-b8bc-6b2139bbfa95", "pmid": "", "title": "Omega‐3 fatty acids for bipolar disorder", "imported": false, "abstract": "Abstract - Background Bipolar disorder is a complex psychiatric disorder and is amongst the top thirty causes of worldwide disability. Mood stabilisers are the primary pharmacological intervention, both in the treatment of acute episodes and in prophylaxis. There is, however, mounting evidence that dietary supplementation with omega‐3 fatty acids may be beneficial in psychiatric conditions, particularly those involving disturbances of mood. Objectives To review the efficacy of omega‐3 fatty acids as either a monotherapy or an adjunctive treatment for bipolar disorder. Search methods Electronic searches of the following databases were performed: CCDANCTR‐Studies and CCDANCTR‐References were searched on 12/2/2008, Supplementary searches were carried out on Biological Abstracts, CINAHL, The Cochrane Library, CCDAN Register, EMBASE, MEDLINE, and PsycINFO. The search strategy also included cited reference searching, personal contact with all authors of studies initially included and contact with the omega‐3 producing pharmaceutical companies. Selection criteria All relevant randomised controlled trials were included in the review. Studies involving males and females of all ages with a diagnosis of bipolar disorder qualified for inclusion. Studies using any type or dose of omega‐3 fatty acid treatment as monotherapy or in addition to standard pharmacotherapy were eligible. The primary outcome was symptom severity; and secondary outcomes were adverse effects, dropout and satisfaction with treatment. Data collection and analysis Two review authors independently inspected the citations identified from the search. Potentially relevant abstracts were identified and full papers ordered and reassessed for inclusion and methodological quality. All relevant data were extracted. The weighted mean difference (WMD) was used for continuous outcome data, with 95% confidence intervals (CI). Main results Five studies met inclusion criteria for the review, however, methodological quality was highly variable. Only one study, involving 75 participants, provided data for analysis, and showed a benefit of active treatment over control for depression symptom levels (WMD ‐3.93, 95% CI ‐7.00 to ‐0.86)and Clinical Global Impression scores (WMD ‐0.75, 95% CI ‐1.33 to ‐0.17) but not for mania (WMD ‐2.81, 95% CI ‐7.68 to 1.90). No serious adverse effects were reported in the five studies. The pattern of dropout was highly variable between studies. Authors' conclusions Results from one study showed positive effects of omega‐3 as an adjunctive treatment for depressive but not manic symptoms in bipolar disorder. These findings must be regarded with caution owing to the limited data available. There is an acute need for well‐designed and executed randomised controlled trials in this field. Plain language summary Omega‐3 fatty acids for bipolar disorder This systematic review investigated the efficacy of omega‐3 fatty acids for bipolar disorder. Five randomised controlled trials met inclusion criteria for the review. Only one trial provided data that could be analysed, investigating ethyl‐EPA as an adjunctive treatment in a mixed outpatient population. Some positive benefits were found for depressive symptoms but not for mania, and no adverse events were reported. There is currently insufficient evidence on which to base any clear recommendations concerning omega‐3 fatty acids for bipolar disorder. However, given the general health benefits and safety of omega‐3, the preliminary evidence from this review provides a strong case for well‐powered, high‐quality trials in specific index populations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Montgomery, P; Richardson, AJ", "articleTypes": [], "doi": "10.1002/14651858.CD005169.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "24ed7e66-97e9-4fcf-a85d-ca1bf8206956", "pmid": "", "title": "Dornase alfa for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Dornase alfa is currently used as a mucolytic to treat pulmonary disease (the major cause of morbidity and mortality) in cystic fibrosis. It reduces mucus viscosity in the lungs, promoting improved clearance of secretions. This is an update of a previously published review. Objectives To determine whether the use of dornase alfa in cystic fibrosis is associated with improved mortality and morbidity compared to placebo or other medications that improve airway clearance, and to identify any adverse events associated with its use. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstracts from conferences. Date of the most recent search of the Group's Cystic Fibrosis Register: 12 October 2020. Clinicaltrials.gov and the International Clinical Trials Registry Platform were also searched to identify unpublished or ongoing trials. Date of most recent search: 08 February 2021. Selection criteria All randomised and quasi‐randomised controlled trials comparing dornase alfa to placebo, standard therapy or other medications that improve airway clearance. Data collection and analysis Authors independently assessed trials against the inclusion criteria; two authors carried out analysis of methodological quality and data extraction. GRADE was used to assess the level of evidence. Main results The searches identified 74 trials, of which 19 (2565 participants) met our inclusion criteria. 15 trials compared dornase alfa to placebo or no dornase alfa (2447 participants); two compared daily dornase to hypertonic saline (32 participants); one compared daily dornase alfa to hypertonic saline and alternate day dornase alfa (48 participants); one compared dornase alfa to mannitol and the combination of both drugs (38 participants). Trial duration varied from six days to three years. Dornase alfa compared to placebo or no treatment Dornase alfa probably improved forced expiratory volume at one second (FEV 1 ) at one month (four trials, 248 participants), three months (one trial, 320 participants; moderate‐quality evidence), six months (one trial, 647 participants; high‐quality evidence) and two years (one trial, 410 participants). Limited low‐quality evidence showed treatment may make little or no difference in quality of life. Dornase alfa probably reduced the number of pulmonary exacerbations in trials of up to two years (moderate‐quality evidence). One trial that examined the cost of care, including the cost of dornase alfa, found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa: daily versus alternate day One cross‐over trial (43 children) found little or no difference between treatment regimens for lung function, quality of life or pulmonary exacerbations (low‐quality evidence). Dornase alfa compared to other medications that improve airway clearance Results for these comparisons were mixed. One trial (43 children) showed dornase alfa may lead to a greater improvement in FEV 1 compared to hypertonic saline (low‐quality evidence), and one trial (23 participants) reported little or no differences in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol (low‐quality evidence). One trial (23 participants) found dornase alfa may improve quality of life compared to dornase alfa plus mannitol (low‐quality evidence); other comparisons found little or no difference in this outcome (low‐quality evidence). No trials in any comparison reported any difference between groups in the number of pulmonary exacerbations (low‐quality evidence). When all comparisons are assessed, dornase alfa did not cause significantly more adverse effects than other treatments, except voice alteration and rash. Authors' conclusions There is evidence to show that, compared with placebo, therapy with dornase alfa may improve lung function in people with cystic fibrosis in trials lasting from one month to two years. There was a decrease in pulmonary exacerbations in trials of six months or longer, probably due to treatment. Voice alteration and rash appear to be the only adverse events reported with increased frequency in randomised controlled trials. There is not enough evidence to firmly conclude if dornase alfa is superior to other hyperosmolar agents in improving lung function. Plain language summary Dornase alfa, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of using inhaled dornase alfa for treating lung disease in people with cystic fibrosis. Background Cystic fibrosis is an inherited condition which affects the movement of salt across cells in the body and affects, for example, the sweat glands, airways, pancreas and male reproductive system. Lung disease is the most common cause of death in people with cystic fibrosis and although the average life expectancy has increased over the last 30 years, it is still only 48.5 years in high‐income countries. People with cystic fibrosis develop chronic lung disease because of thick mucus that builds up in the lungs which causes infections and inflammation. Dornase alfa was developed to thin out this mucus, so it is easier for people to cough it up from their lungs; this in turn should decrease the number of infections and amount of inflammation and prevent chronic lung disease. Search date The evidence is current to: 12 October 2020. Study characteristics We included 19 trials with 2565 people with cystic fibrosis; 15 trials (2447 people) compared dornase alfa to placebo (a dummy treatment with no active medication) or no dornase alfa treatment; two trials (32 people) compared daily dornase to hypertonic saline; one trial (48 people) compared daily dornase alfa with hypertonic saline and alternate day dornase alfa; and one trial (38 people) compared dornase alfa to mannitol and the combination of both drugs. People from all age groups (infants through to adults) took part in the trials which lasted from six days to three years. Key results Dornase alfa compared to placebo or no treatment We found that dornase alfa probably improves lung function within one month when compared to a placebo or no treatment and this improvement was also seen in longer trials lasting from six months to two years (eight trials; 1708 participants). There were also fewer pulmonary exacerbations (flare up of lung inflammation) in these longer trials. One trial found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa ‐ daily versus alternate day One trial (43 children) found no differences between treatment schedules for lung function, quality of life or pulmonary exacerbations. Dornase alfa compared to other medications that improve airway clearance The results from trials comparing dornase alfa to hypertonic saline or mannitol were mixed. One trial (43 children) showed a greater improvement in lung function with dornase alfa compared to hypertonic saline and one trial (23 participants) reported no difference in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol. In one trial (23 participants) quality of life scores were better with dornase alfa alone than with dornase alfa plus mannitol; other drug comparisons found no difference between treatments for quality of life. No trials in any comparison of treatments reported any difference between groups in the number of pulmonary exacerbations. Overall, no serious side effects were reported, with only rash and a change in voice seen more frequently in those people taking dornase alfa. However, it is not definitively clear from the current evidence if dornase alfa is better than other medications such as hypertonic saline or mannitol. Quality of the evidence The quality of evidence from the trials comparing dornase alfa to placebo or no treatment was moderate to high for lung function results, but only one trial reported any changes in quality of life so the evidence for this outcome is limited. Also, there were few trials comparing different treatment schedules of dornase alfa (e.g. once a day versus twice a day) or comparing dornase alfa to other medications which help with clearing secretions, so current evidence from these trials is limited and of low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Yang, C, Montgomery, M", "articleTypes": [], "doi": "10.1002/14651858.CD001127.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.781Z" }, { "id": "24fe631c-6bfd-4417-83b6-92ea5a3186f0", "pmid": "", "title": "Interventions for treating acute high altitude illness", "imported": false, "abstract": "Abstract - Background Acute high altitude illness is defined as a group of cerebral and pulmonary syndromes that can occur during travel to high altitudes. It is more common above 2500 metres, but can be seen at lower elevations, especially in susceptible people. Acute high altitude illness includes a wide spectrum of syndromes defined under the terms 'acute mountain sickness' (AMS), 'high altitude cerebral oedema' and 'high altitude pulmonary oedema'. There are several interventions available to treat this condition, both pharmacological and non‐pharmacological; however, there is a great uncertainty regarding their benefits and harms. Objectives To assess the clinical effectiveness, and safety of interventions (non‐pharmacological and pharmacological), as monotherapy or in any combination, for treating acute high altitude illness. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science, CINAHL, Wanfang database and the World Health Organization International Clinical Trials Registry Platform for ongoing studies on 10 August 2017. We did not apply any language restriction. Selection criteria We included randomized controlled trials evaluating the effects of pharmacological and non‐pharmacological interventions for individuals suffering from acute high altitude illness: acute mountain sickness, high altitude pulmonary oedema or high altitude cerebral oedema. Data collection and analysis Two review authors independently assessed the eligibility of study reports, the risk of bias for each and performed the data extraction. We resolved disagreements through discussion with a third author. We assessed the quality of evidence with GRADE. Main results We included 13 studies enrolling a total of 468 participants. We identified two ongoing studies. All studies included adults, and two studies included both teenagers and adults. The 13 studies took place in high altitude areas, mostly in the European Alps. Twelve studies included participants with acute mountain sickness, and one study included participants with high altitude pulmonary oedema. Follow‐up was usually less than one day. We downgraded the quality of the evidence in most cases due to risk of bias and imprecision. We report results for the main comparisons as follows. Non‐pharmacological interventions (3 studies, 124 participants) All‐cause mortality and complete relief of AMS symptoms were not reported in the three included trials. One study in 64 participants found that a simulated descent of 193 millibars versus 20 millibars may reduce the average of symptoms to 2.5 vs 3.1 units after 12 hours of treatment (clinical score ranged from 0 to 11 ‒ worse; reduction of 0.6 points on average with the intervention; low quality of evidence). In addition, no complications were found with use of hyperbaric chambers versus supplementary oxygen (one study; 29 participants; low‐quality evidence). Pharmacological interventions (11 trials, 375 participants) All‐cause mortality was not reported in the 11 included trials. One trial found a greater proportion of participants with complete relief of AMS symptoms after 12 and 16 hours when dexamethasone was administered in comparison with placebo (47.1% versus 0%, respectively; one study; 35 participants; low quality of evidence). Likewise, when acetazolamide was compared with placebo, the effects on symptom severity was uncertain (standardized mean difference (SMD) −1.15, 95% CI −2.56 to 0.27; 2 studies, 25 participants; low‐quality evidence). One trial of dexamethasone in comparison with placebo in 35 participants found a reduction in symptom severity (difference on change in the AMS score: 3.7 units reported by authors; moderate quality of evidence). The effects from two additional trials comparing gabapentin with placebo and magnesium with placebo on symptom severity at the end of treatment were uncertain. For gabapentin versus placebo: mean visual analogue scale (VAS) score of 2.92 versus 4.75, respectively; 24 participants; low quality of evidence. For magnesium versus placebo: mean scores of 9 and 10.3 units, respectively; 25 participants; low quality of evidence). The trials did not find adverse events from either treatment (low quality of evidence). One trial comparing magnesium sulphate versus placebo found that flushing was a frequent event in the magnesium sulphate arm (percentage of flushing: 75% versus 7.7%, respectively; one study; 25 participants; low quality of evidence). Authors' conclusions There is limited available evidence to determine the effects of non‐pharmacological and pharmacological interventions in treating acute high altitude illness. Low‐quality evidence suggests that dexamethasone and acetazolamide might reduce AMS score compared to placebo. However, the clinical benefits and harms related to these potential interventions remain unclear. Overall, the evidence is of limited practical significance in the clinical field. High‐quality research in this field is needed, since most trials were poorly conducted and reported. Plain language summary Treatments for high altitude (mountain) illness Background Acute high altitude illness, also known as acute mountain sickness, may present with a variety of symptoms. It is caused by the decreasing level of oxygen at increasingly high altitudes; and it can be experienced when reaching a high altitude when travelling, hiking or climbing mountains or other elevated areas. People going to altitudes over 4000 metres, females, people younger than mid‐adulthood , and people with a history of migraine are at greater risk of suffering from altitude sickness. The most common symptoms are headache, loss of appetite , insomnia, and nausea. However, severe forms can include confusion, difficulty walking, progressive cough, shortness of breath, and even death. Review question What are the benefits and risks of different treatments for people suffering from high altitude illness? Study characteristics We included 13 studies with a total of 468 participants. Most studies included participants with mild or moderate forms of mountain sickness, and only one study included the severe neurological (disorder of the nervous system) form. Follow‐up was usually less than one day. We also identified two ongoing studies. Key results We found studies evaluating the following interventions: simulated descent with a hyperbaric chamber (medical use of oxygen in a special chamber at greater than atmospheric pressure to increase the availability of oxygen in the body); oxygen; medicines: acetazolamide, dexamethasone, ibuprofen, paracetamol, gabapentin, sumatriptan, nitric oxide, and magnesium sulphate. None of the studies reported the effects of these interventions on all‐cause mortality. The report of complete relief from acute mountain sickness symptoms, and adverse events was infrequent. Studies related to simulated descent with the use of a hyperbaric chamber did not find additional benefits or harms related to this intervention (3 studies, 124 participants). In addition, studies related to administration of medicines found some benefits in terms of reduction of symptoms with the use of acetazolamide (2 studies, 25 participants), and dexamethasone (1 study, 35 participants), without an increase in side effects. Quality of the evidence The quality of the evidence we found was low, and thus our certainty in the findings is limited. There was insufficient information on how the studies were conducted, and in some cases there was evidence of tampering at some stages of the trials. Furthermore, the number of persons in each study was very small (< 30 participants), and therefore the results were not clear (imprecise). Some studies were not blinded (that is, participants knew what experimental treatment they were receiving), and this could have affected how the participants evaluated their own symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Simancas‐Racines, D; Arevalo‐Rodriguez, I; Osorio, D; Franco, JVA; Xu, Y; Hidalgo, R", "articleTypes": [], "doi": "10.1002/14651858.CD009567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "25143d03-79a8-4bb9-b87f-0ec9a3ec3180", "pmid": "", "title": "Omega‐3 fatty acid addition during pregnancy", "imported": false, "abstract": "Abstract - Background Higher intakes of foods containing omega‐3 long‐chain polyunsaturated fatty acids (LCPUFA), such as fish, during pregnancy have been associated with longer gestations and improved perinatal outcomes. This is an update of a review that was first published in 2006. Objectives To assess the effects of omega‐3 LCPUFA, as supplements or as dietary additions, during pregnancy on maternal, perinatal, and neonatal outcomes and longer‐term outcomes for mother and child. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (16 August 2018), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing omega‐3 fatty acids (as supplements or as foods, stand‐alone interventions, or with a co‐intervention) during pregnancy with placebo or no omega‐3, and studies or study arms directly comparing omega‐3 LCPUFA doses or types. Trials published in abstract form were eligible for inclusion. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, assessed risk of bias in trials and assessed quality of evidence for prespecified birth/infant, maternal, child/adult and health service outcomes using the GRADE approach. Main results In this update, we included 70 RCTs (involving 19,927 women at low, mixed or high risk of poor pregnancy outcomes) which compared omega‐3 LCPUFA interventions (supplements and food) compared with placebo or no omega‐3. Overall study‐level risk of bias was mixed, with selection and performance bias mostly at low risk, but there was high risk of attrition bias in some trials. Most trials were conducted in upper‐middle or high‐income countries; and nearly half the trials included women at increased/high risk for factors which might increase the risk of adverse maternal and birth outcomes. Preterm birth < 37 weeks (13.4% versus 11.9%; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.81 to 0.97; 26 RCTs, 10,304 participants; high‐quality evidence) and early preterm birth < 34 weeks (4.6% versus 2.7%; RR 0.58, 95% CI 0.44 to 0.77; 9 RCTs, 5204 participants; high‐quality evidence) were both lower in women who received omega‐3 LCPUFA compared with no omega‐3. Prolonged gestation > 42 weeks was probably increased from 1.6% to 2.6% in women who received omega‐3 LCPUFA compared with no omega‐3 (RR 1.61 95% CI 1.11 to 2.33; 5141 participants; 6 RCTs; moderate‐quality evidence ). For infants, there was a possibly reduced risk of perinatal death (RR 0.75, 95% CI 0.54 to 1.03; 10 RCTs, 7416 participants; moderate‐quality evidence: 62/3715 versus 83/3701 infants) and possibly fewer neonatal care admissions (RR 0.92, 95% CI 0.83 to 1.03; 9 RCTs, 6920 participants; moderate‐quality evidence ‐ 483/3475 infants versus 519/3445 infants). There was a reduced risk of low birthweight (LBW) babies (15.6% versus 14%; RR 0.90, 95% CI 0.82 to 0.99; 15 trials, 8449 participants; high‐quality evidence); but a possible small increase in large‐for‐gestational age (LGA) babies (RR 1.15, 95% CI 0.97 to 1.36; 6 RCTs, 3722 participants; moderate‐quality evidence, for omega‐3 LCPUFA compared with no omega‐3. Little or no difference in small‐for‐gestational age or intrauterine growth restriction (RR 1.01, 95% CI 0.90 to 1.13; 8 RCTs, 6907 participants; moderate‐quality evidence) was seen. For the maternal outcomes , there is insufficient evidence to determine the effects of omega‐3 on induction post‐term (average RR 0.82, 95% CI 0.22 to 2.98; 3 trials, 2900 participants; low‐quality evidence), maternal serious adverse events (RR 1.04, 95% CI 0.40 to 2.72; 2 trials, 2690 participants; low‐quality evidence), maternal admission to intensive care (RR 0.56, 95% CI 0.12 to 2.63; 2 trials, 2458 participants; low‐quality evidence), or postnatal depression (average RR 0.99, 95% CI 0.56 to 1.77; 2 trials, 2431 participants; low‐quality evidence). Mean gestational length was greater in women who received omega‐3 LCPUFA (mean difference (MD) 1.67 days, 95% CI 0.95 to 2.39; 41 trials, 12,517 participants; moderate‐quality evidence), and pre‐eclampsia may possibly be reduced with omega‐3 LCPUFA (RR 0.84, 95% CI 0.69 to 1.01; 20 trials, 8306 participants; low‐quality evidence). For the child/adult outcomes, very few differences between antenatal omega‐3 LCPUFA supplementation and no omega‐3 were observed in cognition, IQ, vision, other neurodevelopment and growth outcomes, language and behaviour (mostly low‐quality to very low‐quality evidence). The effect of omega‐3 LCPUFA on body mass index at 19 years (MD 0, 95% CI ‐0.83 to 0.83; 1 trial, 243 participants; very low‐quality evidence) was uncertain. No data were reported for development of diabetes in the children of study participants. Authors' conclusions In the overall analysis, preterm birth < 37 weeks and early preterm birth < 34 weeks were reduced in women receiving omega‐3 LCPUFA compared with no omega‐3. There was a possibly reduced risk of perinatal death and of neonatal care admission , a reduced risk of LBW babies; and possibly a small increased risk of LGA babies with omega‐3 LCPUFA. For our GRADE quality assessments, we assessed most of the important perinatal outcomes as high‐quality (e.g. preterm birth) or moderate‐quality evidence (e.g. perinatal death). For the other outcome domains (maternal, child/adult and health service outcomes) GRADE ratings ranged from moderate to very low, with over half rated as low. Reasons for downgrading across the domain were mostly due to design limitations and imprecision. Omega‐3 LCPUFA supplementation during pregnancy is an effective strategy for reducing the incidence of preterm birth, although it probably increases the incidence of post‐term pregnancies. More studies comparing omega‐3 LCPUFA and placebo (to establish causality in relation to preterm birth) are not needed at this stage. A further 23 ongoing trials are still to report on over 5000 women, so no more RCTs are needed that compare omega‐3 LCPUFA against placebo or no intervention. However, further follow‐up of completed trials is needed to assess longer‐term outcomes for mother and child, to improve understanding of metabolic, growth and neurodevelopment pathways in particular, and to establish if, and how, outcomes vary by different types of omega‐3 LCPUFA, timing and doses; or by characteristics of women. Plain language summary Omega‐3 fatty acid addition during pregnancy What is the issue? Do omega‐3 long chain polyunsaturated fatty acids (LCPUFA) taken during pregnancy ‐ either as supplements or as dietary additions in food (such as some types of fish) ‐ improve health outcomes for babies and their mothers? This is an update of a Cochrane Review that was first published in 2006. Why is this important? Preterm birth (babies born before 37 weeks pregnancy (gestation)) is a leading cause of disability or death in the first five years of life. Fish and fish oil contain omega‐3 LCPUFA (particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)) and have been associated with longer pregnancies. So it is suggested that additional omega‐3 LCPUFAs in pregnancy may reduce the number of babies born preterm and may improve outcomes for children and mothers. However, many pregnant women do not eat fish very often. Encouraging pregnant women to eat fatty fish (which generally have low toxin levels) or to use omega‐3 LCPUFA supplements may improve children’s and women's health. This is an update of a Cochrane Review that was first published in 2006. What evidence did we find? We searched for evidence in August 2018 and found 70 randomised controlled trials (RCTs; this type of trial provides the most reliable results) (involving 19,927 women). Most trials evaluated a group of women who received omega‐3 LCPUFA and compared them with a group of women who received something that looked like omega‐3 LCPUFA but did not contain it (placebo) or received no omega‐3. The trials were mostly undertaken in upper‐middle or high‐income countries. Some studies included women at increased risk of preterm birth. The quality of the evidence from the included studies ranged from high to very low; this affected the certainty of the findings for different outcomes. We found the incidence of preterm birth (before 37 weeks) and very preterm birth (before 34 weeks) was lower in women who received omega‐3 LCPUFA compared with no additional omega‐3. There were also fewer babies with low birthweight. However, omega‐3 LCPUFA probably increased the incidence of pregnancies continuing beyond 42 weeks, although there was no difference identified in induction of labour for post‐term pregnancies. The risk of the baby dying or being very sick and going to neonatal intensive care may be lower with omega‐3 LCPUFA compared with no omega‐3. We did not see any differences between groups for serious adverse events for mothers or in postnatal depression. Very few differences between the omega‐3 LCPUFA groups and no omega‐3 groups were observed in child development and growth. Eleven trials reported that they had received industry funding. When we omitted these trials from the main outcomes (such as preterm birth and very preterm birth) it made very little, or no difference, to the results. What does this mean? Increasing omega‐3 LCPUFA intake during pregnancy, either through supplements or in foods, may reduce the incidence of preterm birth (before 37 weeks and before 34 weeks) and there may be less chance of having a baby with a low birthweight. Women who take omega‐3 LCPUFA supplements during pregnancy may also be more likely to have longer pregnancies. More studies are underway and their results will be included in a further update of this review. Future studies could consider if and how outcomes may vary in different populations of women, and could test different ways of increasing omega‐3 LCPUFA during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Middleton, P, Gomersall, JC, Gould, JF, Shepherd, E, Olsen, SF, Makrides, M", "articleTypes": [], "doi": "10.1002/14651858.CD003402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.125Z" }, { "id": "25147ac8-66d6-4306-8676-1a590b6b7755", "pmid": "", "title": "Drugs for treating giardiasis", "imported": false, "abstract": "Abstract - Background Giardiasis infection may be asymptomatic, or can cause diarrhoea (sometimes severe), weight loss, malabsorption, and, in children, failure to thrive. It is usually treated with metronidazole given three times daily for five to 10 days. Objectives To evaluate the relative effectiveness of alternative antibiotic regimens for treating adults or children with symptomatic giardiasis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6 2012); MEDLINE, EMBASE, LILACS and the International Clinical Trials Registry Platform Search Portal (3 July 2012). Selection criteria We included randomized controlled trials (RCT) comparing metronidazole administered for five to 10 days with any of the following drugs: metronidazole (single dose), tinidazole, albendazole, mebendazole, and nitazoxanide. The primary outcomes were parasitological and clinical cure. Data collection and analysis Two authors independently assessed studies for inclusion, performed the risk of bias assessment, and extracted data. We summarized data using risk ratios and mean differences and we presented the results in forest plots and performed meta‐analyses where possible. We assessed heterogeneity using the Chi 2 test, I 2 statistic and visual inspection; and we explored this by using subgroup analyses.We assessed the quality of evidence by using the GRADE approach. Main results We included 19 trials, involving 1817 participants, of which 1441 were children. Studies were generally small, with poor methods reporting. . Most reported parasitological outcomes rather than clinical improvement. Ten trials, from India, Mexico, Peru, Iran, Cuba, and Turkey, compared albendazole (400 mg once daily for five to 10 days) with metronidazole (250 mg to 500 mg three times daily for five to 10 days). This once‐daily regimen of albendazole is probably equivalent to metronidazole at achieving parasitological cure (RR 0.99, 95% CI 0.95 to 1.03; 932 participants, 10 trials; moderate quality evidence ), and improving symptoms (RR 0.98, 95% confidence interval (CI) 0.93 to 1.04; 483 participants, five trials; moderate quality evidence ), but the duration of follow‐up was short (two to three weeks). Albendazole probably has fewer side effects than metronidazole (gastrointestinal side effects: RR 0.29, 95% CI 0.13 to 0.63; 717 participants, eight trials; moderate quality evidence ; neurological side effects: RR 0.34, 95% CI 0.18 to 0.64; 453 participants, five trials; low quality evidence ). Five trials from Turkey, Spain and the UK compared mebendazole (200 mg three times daily for five to 10 days) with metronidazole (5 mg/kg (or 250 mg) three times daily for five to 10 days). These trials were small in size, and at high risk of bias. Consequently, reliable conclusions on the relative effectiveness cannot be made ( very low quality evidence) . Five further trials, from Iran, Spain and Peru, have evaluated shortened regimens of tinidazole (single dose; 179 participants, three trials), metronidazole (single dose; 55 participants, one trial), and nitazoxanide (three days; 55 participants, one trial). Again, these trials were at high risk of bias and too small to reliably detect or exclude important differences ( very low quality evidence) . Authors' conclusions Albendazole may be of similar effectiveness to metronidazole, may have fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes (such as diarrhoea) will help assess further alternatives. 15 April 2019 Update pending Studies awaiting assessment The CIDG is currently examining a new search conducted in April 2019 for potentially relevant studies. These studies have not yet been incorporated into this Cochrane Review. Plain language summary Drugs for treating giardiasis Giardiasis is an infection of the small intestine caused by a microscopic organism called Giardia lamblia . The infection is passed from person to person by ingesting faecally contaminated water or food. Symptoms frequently include diarrhoea, abdominal pain, flatulence, bloating, vomiting, and weight loss. In this review, we assess alternatives to the most commonly used treatment for giardiasis; metronidazole given orally for five or more days. We identified 19 trials involving 1817 participants, of which 1441 were children. Most trials had a small number of participants and were at high risk of bias. Albendazole is probably of similar effectiveness to metronidazole, probably has fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes are required to assess further alternatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Granados, CE; Reveiz, L; Uribe, LG; Criollo, CP", "articleTypes": [], "doi": "10.1002/14651858.CD007787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "25240faf-cb89-4953-8b70-910b959e07e7", "pmid": "", "title": "Helminth therapy (worms) for induction of remission in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease (IBD) is a chronic, globally‐occurring gastrointestinal disorder and a major cause of illness and disability. It is conventionally classified into Crohn’s disease (CD) and ulcerative colitis (UC). Helminths are parasitic worms with complex life cycles involving tissue‐ or lumen‐dwelling stages in their hosts, and causing long‐lasting or chronic infections that are frequently asymptomatic. Helminths modulate immune responses of their hosts, and many observational and experimental studies support the hypothesis that helminths suppress immune‐mediated chronic inflammation that occurs in asthma, allergy and IBD. Objectives The objective was to evaluate the efficacy and safety of helminth treatment for induction of remission in IBD. Search methods We searched the following databases from inception to 13 July 2013: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Inflammatory Bowel Disease Group Specialized Trials Register. We also searched four online trials registries, and abstracts from major meetings. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) where the intervention was any helminth species or combination of helminth species, administered in any dose and by any route and for any duration of exposure to people with active CD or UC, confirmed through any combination of clinical, endoscopic and histological criteria were eligible for inclusion. Data collection and analysis Two authors independently extracted data and assessed eligibility using a standardized data collection form. We used the RevMan software for analyses. The primary outcome was induction of remission as defined by the included studies. Secondary outcomes included clinical, histologic, or endoscopic improvement as defined by the authors, endoscopic mucosal healing, change in disease activity index score, change in quality of life score, hospital admissions, requirement for intravenous corticosteroids, surgery, study withdrawal and the incidence of adverse events. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. We calculated the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria. Main results Two RCTs (90 participants) were included. One trial assessed the efficacy and safety of Trichuris suis ( T. suis ) ova in patients with UC (n = 54). The other RCT was a phase one that assessed the safety and tolerability of T. suis ova in patients with CD (n = 36). The risk of bias in both studies was judged to be low. In the UC study, during the 12‐week study period, participants in the active arm received 2‐weekly aliquots of 2500 T. suis eggs, added to 0.8 mL of saline; those in the placebo arm received 0.8 mL saline only. There were sparse data available for the outcomes clinical remission and clinical improvement. Ten per cent (3/30) of patients in the T. suis arm entered remission compared to 4% (1/24) of patients in the placebo arm (RR 2.40, 95% CI 0.27 to 21.63). Forty‐three per cent (13/30) of patients in the T. suis group achieved clinical improvement compared to 17% (4/24) of placebo patients (RR 2.60, 95% CI 0.97 to 6.95). The mean ulcerative colitis disease activity index (UCDAI) score was lower in the T. suis group (6.1 +/‐ 0.61) compared to the placebo group (7.5 +/‐ 0.66) after 12 weeks of treatment (MD ‐1.40, 95% CI ‐1.75 to ‐1.05). There was only limited evidence relating to the proportion of patients who experienced an adverse event. Three per cent (1/30) of patients in the T. suis group experienced at least one adverse event compared to 12% (3/24) of placebo patients (RR 0.27, 95% CI 0.03 to 2.40). None of the adverse events reported in this study were judged to be related to the study treatment. GRADE analyses rated the overall quality of the evidence for the primary and secondary outcomes (i.e. clinical remission and improvement) as low due to serious imprecision. In the CD study, participants received a single treatment of T. suis ova at a dosage of 500 (n = 9), 2500 (n = 9), or 7500 (n = 9) embryonated eggs or matching placebo (n = 9). The CD study did not assess clinical remission or improvement as outcomes. There were sparse data on adverse events at two weeks. Thirty‐seven per cent (10/27) of patients in the T. suis group experienced at least one adverse event compared to 44% (4/9) of placebo patients (RR 0.83, 95% CI 0.35 to 2.01). Only one adverse event (dysgeusia) was judged to be possibly related to treatment in this study. Dysgeusia was reported in one patient in the T. suis group and in one patient in the placebo group. Authors' conclusions Currently, there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of helminths used to treat patients with IBD. The evidence for our primary efficacy outcomes in this review comes from one small study and is of low quality due to serious imprecision. We do not have enough evidence to determine whether helminths are safe when used in patients with UC and CD. Further RCTs are required to assess the efficacy and safety of helminth therapy in IBD. Plain language summary Helminth therapy (worms) for induction of remission in inflammatory bowel disease Inflammatory bowel disease (IBD) is comprised of two disorders: ulcerative colitis and Crohn’s disease. These disorders have both distinct and overlapping symptoms, but the underlying cause remains incompletely understood. Standard therapy for IBD includes sulfasalazine, 5‐ASA drugs, steroids, immunosuppressives such as azathioprine, 6‐mercaptopurine and methotrexate and biological agents such as infliximab. Helminths are worm‐like parasites, that inhabit larger organisms. Helminths cause changes in the immune systems of their hosts including an altered immunological response to antigens and this has implications for the treatment of inflammatory bowel disease which is thought to be caused by immune dysregulation. The purpose of this systematic review was to examine the effectiveness and safety of helminth therapy for inducing remission in people with IBD. This review identified two randomised controlled trials including a total of 90 participants. One study compared twice weekly treatment with helminths (an 0.8 mL solution containing 2500 live eggs of the helminth Trichuris suis ) for 12 weeks to a matching placebo (an 0.8 ml identical looking solution with no Trichuris suis eggs) in 54 patients with active ulcerative colitis. Few remissions occurred during the trial and helminth treatment had no detectable effect on these remissions. Ten per cent (3/30) of patients in the helminth group achieved remission compared to four per cent (1/24) of placebo patients. A higher proportion of patients in the helminth group (43% or 13/30) improved clinically compared to the placebo group (17% or 4/24). However, this difference could be a chance effect. We could not determine whether the proportion of patients who had a side effect was higher in either group. No observed side effects were thought to be related to treatment were reported in this study. The other study compared one treatment with various doses of helminths (a solution of 500, 2500 or 7500 Trichuris suis eggs) to a matching placebo in 36 patients with Crohn's disease. This study was designed to assess side effects and did not measure clinical remission or improvement. There amount of information available on side‐effects at two weeks was limited and the results were uncertain due to the small number of participants in the study. The only side effect that was judged to be possibly related to the study treatment was dysgeusia (a distortion of the sense of taste). This was reported in one patient in the helminth group and in one patient in the placebo group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and safety of helminths used to treat patients with IBD. The only information available relating to clinical improvement in patients with active ulcerative colitis comes from one small study. We do not know how safe helminths are when used in patients with ulcerative colitis and Crohn's disease. Further randomised controlled trials are required to assess the efficacy and safety of helminth therapy in IBD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Garg, SK, Croft, AM, Bager, P", "articleTypes": [], "doi": "10.1002/14651858.CD009400.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.787Z" }, { "id": "253269dd-fbe0-48a0-9454-908a887b8349", "pmid": "", "title": "A Randomized, Double-Blind, Placebo-Controlled Phase III Clinical Trial of Pembrolizumab (MK-3475) in Combination With Cisplatin and 5-Fluorouracil Versus Placebo in Combination With Cisplatin and 5-Fluorouracil as First-Line Treatment in Subjects With Advanced/Metastatic Esophageal Carcinoma (KEYNOTE-590)", "imported": false, "abstract": "The purpose of this trial is to evaluate efficacy and safety of pembrolizumab plus standard of care (SOC) chemotherapy with cisplatin and 5-fluorouracil (5-FU) versus placebo plus SOC chemotherapy with cisplatin and 5-FU as first-line treatment in participants with locally advanced or metastatic esophageal carcinoma.", "journal": "", "year": "2017", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.250Z" }, { "id": "25394964-1e91-4558-a180-ac01332587a8", "pmid": "", "title": "Topical silver diamine fluoride (SDF) for preventing and managing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is the world's most prevalent disease. Untreated caries can cause pain and negatively impact psychosocial health, functioning, and nutrition. It is important to identify cost‐effective, easy‐to‐use agents, which can prevent or arrest caries. This review evaluates silver diamine fluoride (SDF). Objectives To assess the effects of silver diamine fluoride for preventing and managing caries in primary and permanent teeth (coronal and root caries) compared to any other intervention including placebo or no treatment. Search methods We searched CENTRAL, MEDLINE, Embase, Cochrane Oral Health's Trial Register and two clinical trials registers in June 2023. Selection criteria We included randomised controlled trials (RCTs), with parallel‐group or split‐mouth design, in children and adults (with or without carious lesions) that compared SDF with placebo or no treatment; different frequencies, concentrations or duration of SDF; or any other intervention. Data collection and analysis We used standard methodological procedures expected by Cochrane, and GRADE to assess the certainty of the evidence. We collected data for primary caries prevention (change in caries increment), arrest of carious lesions, secondary prevention of caries (lesions do not progress from initial classification), adverse effects, dental pain or sensitivity, and aesthetics at the end of study follow‐up. Main results We included 29 RCTs (13,036 participants; 12,020 children, 1016 older adults). We summarise outcome data for the five most clinically relevant comparisons. All studies included high risks of bias, and some findings were imprecise (e.g. because of small sample sizes). SDF versus placebo or no treatment (14 studies; 2695 children, 905 older adults) Compared to placebo or no treatment, SDF may help prevent new caries in the primary dentition (1 study, 373 participants), or on the coronal surfaces of permanent dentition (1 study, 373 participants) but the evidence is very uncertain. SDF likely prevents new root caries (mean difference (MD) −0.79 surfaces, 95% confidence interval (CI) −1.40 to −0.17; 3 studies, 439 participants; moderate‐certainty evidence). SDF may help arrest caries in the primary dentition (MD 0.86 surfaces, 95% CI 0.39 to 1.33; 2 studies, 841 participants; low‐certainty evidence) and the permanent dentition (coronal: 1 study, 373 participants; root: 1 study, 158 participants) but the evidence is very uncertain. The evidence is very uncertain for secondary prevention of caries (primary dentition: 1 study, 128 participants; permanent dentition (coronal): 1 study, 663 participants), for adverse effects (5 studies, 1299 participants), and aesthetics (1 study, 43 participants). Different approaches to SDF application (5 studies, 1808 children) Studies compared different frequencies or intervals of application, different concentrations of SDF, and different durations of treatment. Some studies included multiple comparisons of different approaches. Because of the different approaches, we could not combine findings from these studies. Due to very low‐certainty evidence, we were unsure whether any approach to SDF application was better than another for caries arrest (4 studies, including 8 comparisons of different approaches, 1360 participants); secondary prevention of caries (1 study, 203 participants), or led to differences in adverse effects (3 studies, 1121 children) or aesthetics (1 study, 119 children). SDF versus fluoride varnish (8 studies, 2868 children, 223 older adults) Compared to flouride varnish, SDF may result in little or no difference to the prevention of new caries in the primary dentition (MD 0.00, 95% CI ‐0.26 to 0.26; 1 study, 434 participants; low‐certainty evidence). The evidence is very uncertain for this outcome measure in the permanent dentition (coronal: 1 study, 237 participants; root: 1 study, 100 participants; very low‐certainty evidence). Due to very low‐certainty evidence, we were unsure whether or not there were any differences between flouride varnish (applied weekly for three applications) and SDF for caries arrest and secondary prevention of caries in the primary dentition (1 study, 309 participants). Similarly, we were unsure of adverse effects (3 studies, 980 children), dental pain or sensitivity (1 study, 62 children), or aesthetics (1 study, 263 children). SDF versus sealants and resin infiltration (2 studies, 343 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other for primary prevention of caries in permanent dentition (coronal: 1 study, 242 participants), or adverse effects (2 studies, 336 participants). SDF versus atraumatic restorative treatment (ART) with glass ionomer cement (GIC) or GI material (4 studies, 610 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other at arresting caries in the primary dentition (1 study, 143 participants). We were also unsure whether there were any differences between treatments in adverse effects (3 studies, 482 participants), dental pain or sensitivity (1 study, 234 participants), or aesthetics (2 studies, 248 participants). Authors' conclusions In the primary dentition, evidence remains uncertain whether SDF prevents new caries or progression of existing caries compared to placebo or no treatment, but it may offer benefit over placebo or no treatment in caries arrest. Compared to placebo or no treatment, SDF probably also helps prevent new root caries. However, the evidence is uncertain for other caries outcome measures in this dentition and in all caries outcomes for coronal surfaces of permanent dentition. Compared to flouride varnish, SDF may offer little or no benefit in preventing new caries in the primary dentition, but the evidence is very uncertain for other caries outcome measures in the primary dentition and for preventing new caries in the permanent dentition. We were unable to establish whether one SDF treatment approach was better than another, or how SDF compared to other treatments, because of very low‐certainty evidence. The impact of SDF staining of teeth was poorly reported and the evidence for adverse effects is very uncertain. Additional well‐conducted studies are needed. These should measure the impact of staining and be analysed to take account of clustering issues within participants. Plain language summary Is silver diamine fluoride varnish an effective treatment for preventing and managing tooth decay in children and adults? Key messages ‐ We can't tell if silver diamine fluoride (SDF) is better than no treatment at preventing or treating tooth decay. ‐ We can't tell if SDF is better or worse than other treatments at preventing or treating tooth decay. ‐ New studies could help to find out about the unwanted effects of SDF, whether people are bothered by the staining on the teeth caused by SDF, and the best treatment approach. What is tooth decay? Tooth decay happens when bacteria in your mouth break down sugars from food, producing acids that damage tooth enamel (hard surfaces). This can lead to holes, or cavities, in the teeth. Tooth decay affects the crown of the tooth (the part above the gum) of baby teeth, and the crown and root of permanent teeth. If it is not prevented or treated it can cause toothache, infections and tooth loss. How is tooth decay treated? Treatments for tooth decay include liquids, gels (varnishes) and sealants. These treatments are painted onto the tooth to protect against bacteria. Treatment may also include fillings in larger cavities. Silver diamine fluoride (SDF) is a low‐cost liquid that can be painted on a tooth by a dentist or another trained person. It is suitable for people of all ages, including people with special health needs. However, SDF can permanently stain the treated tooth surface black or dark brown. What did we want to find out? We wanted to find out: ‐ if SDF was better than no treatment or other treatments at preventing new tooth decay, stopping existing tooth decay or preventing tooth decay from progressing; ‐ if there were benefits to applying SDF for different numbers of times, strengths of solution, or durations; ‐ if SDF caused unwanted effects, toothache, or if people were bothered by staining. What did we do? We searched for studies that compared SDF with no treatment or placebo (a dummy treatment), other treatments, or different application approaches. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 29 studies, with 12,020 children and 1016 older adults. Main results Compared with no treatment or placebo, we can't tell if SDF prevents new tooth decay in baby teeth or crown surfaces of permanent teeth. SDF is likely to prevent new tooth decay on root surfaces of permanent teeth. It may also completely stop existing tooth decay in baby teeth. However, we are unsure if it completely stops existing tooth decay on crown and root surfaces of permanent teeth, prevents existing tooth decay from progressing in any types of teeth, increases the risk of unwanted effects, or if people are bothered by the appearance of staining. Studies used different combinations of treatment approaches (number of times SDF is applied and how often, the strength of solution, and duration of treatment). We can't tell if one approach is better than another at stopping or preventing further decay, unwanted effects, or bother with appearance of staining. When SDF is compared with fluoride varnish, neither treatment may be better than the other at preventing new tooth decay in baby teeth. We are unsure about the effect on crown and root surfaces of permanent teeth. We also can't tell if either treatment is better than the other at stopping existing tooth decay or preventing further decay in baby teeth, or if there are any differences in unwanted effects, toothache, or bother with appearance of staining. When SDF is compared with sealants, we can't tell if there are any differences between treatments in preventing new tooth decay on the crown surfaces of permanent teeth, or whether there are any differences between these treatments in unwanted effects. When SDF is compared with fillings (with tooth decay first removed using only hand tools), we can't tell if there were any differences between treatments in stopping existing decay in baby teeth, unwanted effects, toothache, or bother with appearance of staining. What are the limitations of the evidence? Often we were very unsure of the evidence for the following reasons. ‐ SDF stains the teeth. Everyone in the studies would have known what treatment they were given. This might affect their usual teeth‐brushing routine. In most studies, the person checking teeth for new or existing decay would also have known this information. ‐ When we compared different approaches to SDF, the studies were too different from one another to allow us to compare them. ‐ Although we found 29 studies, most evidence was from individual (or few) studies, which were very small. How current is this evidence? The evidence is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Worthington, HV; Lewis, SR; Glenny, A-M; Huang, SS; Innes, NPT; O'Malley, L; Riley, P; Walsh, T; Wong, MC; Clarkson, JE; Veitz-Keenan, A", "articleTypes": [], "doi": "10.1002/14651858.CD012718.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "253e102e-ffcd-49f9-bfa9-c7fa07a98252", "pmid": "", "title": "Alpha‐blockers as medical expulsive therapy for ureteral stones", "imported": false, "abstract": "Abstract - Background Ureteral colic is a common reason for patients to seek medical care. Alpha‐blockers are commonly used to improve stone passage through so‐called medical expulsive therapy (MET), but their effectiveness remains controversial. This is an update of a 2014 Cochrane review; since that time, several large randomised controlled trials (RCTs) have been reported, making this update relevant. Objectives To assess effects of alpha‐blockers compared with standard therapy for ureteral stones 1 cm or smaller confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease. Search methods On 18 November 2017, we searched CENTRAL, MEDLINE Ovid, and Embase. We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials. We checked all references of included and review articles and conference proceedings for articles relevant to this review. We sent letters to investigators to request information about unpublished or incomplete studies. Selection criteria We included RCTs of ureteral stone passage in adult patients that compared alpha‐blockers versus standard therapy. Data collection and analysis Two review authors screened studies for inclusion and extracted data using standard methodological procedures. We performed meta‐analysis using a random‐effects model. Primary outcomes were stone clearance and major adverse events; secondary outcomes were stone expulsion time, number of pain episodes, use of diclofenac, hospitalisation, and surgical intervention. We assessed the quality of evidence on a per‐outcome basis using the GRADE approach. Main results We included 67 studies with 10,509 participants overall. Of these, 15 studies with 5787 participants used a placebo. Stone clearance: Based on the overall analysis, treatment with an alpha‐blocker may result in a large increase in stone clearance (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.36 to 1.55; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that the likely effect is probably smaller (RR 1.16, 95% CI 1.07 to 1.25; moderate‐quality evidence), corresponding to 116 more (95% CI 51 more to 182 more) stone clearances per 1000 participants. Major adverse events: Based on the overall analysis, treatment with an alpha‐blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that alpha‐blockers likely increase the risk of major adverse events slightly (RR 2.09, 95% CI 1.13 to 3.86), corresponding to 29 more (95% CI 3 more to 75 more) major adverse events per 1000 participants. Patients treated with alpha‐blockers may experience shorter stone expulsion times (mean difference (MD) ‐3.40 days, 95% CI ‐4.17 to ‐2.63; low‐quality evidence), may use less diclofenac (MD ‐82.41, 95% CI ‐122.51 to ‐42.31; low‐quality evidence), and likely require fewer hospitalisations (RR 0.51, 95% CI 0.34 to 0.77; moderate‐quality evidence), corresponding to 69 fewer hospitalisations (95% CI 93 fewer to 32 fewer) per 1000 participants. Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI 0.53 to 1.02; low‐quality evidence), corresponding to 28 fewer surgical interventions (95% CI 51 fewer to 2 more) per 1000 participants. A predefined subgroup analysis (test for subgroup differences; P = 0.002) suggests that effects of alpha‐blockers may vary with stone size, with RR of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or smaller versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones larger than 5 mm. We found no evidence suggesting possible subgroup effects based on stone location or alpha‐blocker type. Authors' conclusions For patients with ureteral stones, alpha‐blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha‐blockers may be less effective for smaller (5 mm or smaller) than for larger stones (greater than 5 mm). Plain language summary Alpha‐blockers for ureteral stones in adult patients with symptoms of stone disease Review question Does medical treatment with alpha‐blockers improve the outcomes of patients with stones stuck in their ureter? Background Stones stuck in the ureter, which is the tube that transports urine from the kidney to the bladder, often cause pain and make people see a doctor. Depending on which part of the ureter the stone is stuck in and the size of the stone, it will often pass into the bladder on its own over the course of weeks. If the stone does not come out by itself, people often need to have procedures done to remove the stone. Alpha‐blockers are medications that relax muscles in the urinary tract and may make the stone pass into the bladder faster. However, they can cause unwanted effects. We updated an existing Cochrane Review from 2014 to look into the effects of alpha‐blockers. Study characteristics Based on our latest search of the literature from November 2017, we included 64 studies with 10,509 participants. Of these, 15 studies compared alpha‐blockers with placebo with 5787 participants. A placebo is a pill that looks and tastes exactly like the real medication, so participants did not know what they were getting. These were the higher‐quality studies, which we trusted more. Key results Based on the subset of higher‐quality studies that used a placebo, alpha‐blockers likely resulted in more people passing their stones. However, these patients are likely to experience slightly more serious unwanted effects of this medication. People taking alpha‐blockers may pass their stones in a shorter time, may use less diclofenac (which is a type of pain medication), and are likely to be admitted to the hospital less often. Meanwhile, the need for surgery for their stones was similar. Upon completing additional analyses, we found that effects of alpha‐blockers may be different in people with small (5 mm or smaller) versus larger (larger than 5 mm) stones. It appears that this medication works better in people with larger stones. We could find no difference in how well alpha‐blockers work, no matter where in the ureter the stone is stuck or what type of alpha‐blocker is used. Authors' conclusions For patients with stones stuck in the ureter, alpha‐blockers likely make passing the stone easier but cause slightly more unwanted effects. It appears that alpha‐blockers work better in people with larger (greater than 5 mm) rather than smaller (5 mm or smaller) stones. Quality of the evidence The quality of the evidence for most outcomes was moderate or low, meaning that we have moderate or low confidence in most of the reported results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Campschroer, T; Zhu, X; Vernooij, RWM; Lock, MTWT", "articleTypes": [], "doi": "10.1002/14651858.CD008509.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "25452888-1796-4ecb-9c71-d8651c163183", "pmid": "", "title": "Adhesives for bonded molar tubes during fixed brace treatment", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Millett, DT, Mandall, NA, Mattick, RCR, Hickman, J, Glenny, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008236.pub3 AB - Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. The success of a fixed appliance depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a fixed appliance. It can also be costly in terms of clinical time, materials and time lost from education/work for the patient. This is an update of the Cochrane review first published in 2011. A new full search was conducted on 15 February 2017 but no new studies were identified. We have only updated the search methods section in this new version. The conclusions of this Cochrane review remain the same. Objectives To evaluate the effectiveness of the adhesives used to attach bonded molar tubes, and the relative effectiveness of the adhesives used to attach bonded molar tubes versus adhesives used to attach bands, during fixed appliance treatment, in terms of: (1) how often the tubes (or bands) come off during treatment; and (2) whether they protect the bonded (or banded) teeth against decay. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (to 15 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library (searched 15 February 2017), MEDLINE Ovid (1946 to 15 February 2017), and Embase Ovid (1980 to 15 February 2017). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials of participants with full arch fixed orthodontic appliance(s) with molar tubes, bonded to first or second permanent molars. Trials which compared any type of adhesive used to bond molar tubes (stainless steel or titanium) with any other adhesive, were included. Trials were also included where: (1) a tube was bonded to a molar tooth on one side of an arch and a band cemented to the same tooth type on the opposite side of the same arch;
 (2) molar tubes had been allocated to one tooth type in one patient group and molar bands to the same tooth type in another patient group. Data collection and analysis The selection of papers, decision about eligibility and data extraction were carried out independently and in duplicate without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Two trials (n = 190), at low risk of bias, were included in the review and both presented data on first time failure at the tooth level. Pooling of the data showed a statistically significant difference in favour of molar bands, with a hazard ratio of 2.92 (95% confidence intervals (CI) 1.80 to 4.72). No statistically significant heterogeneity was shown between the two studies. Data on first time failure at the patient level were also available and showed statistically different difference in favour of molar bands (risk ratio 2.30; 95% CI 1.56 to 3.41) (risk of event for molar tubes = 57%; risk of event for molar bands 25%). One trial presented data on decalcification again showing a statistically significant difference in favour of molar bands. No other adverse events identified. Authors' conclusions From the two well‐designed and low risk of bias trials included in this review it was shown that the failure of molar tubes bonded with either a chemically‐cured or light‐cured adhesive was considerably higher than that of molar bands cemented with glass ionomer cement. One trial indicated that there was less decalcification with molar bands cemented with glass ionomer cement than with bonded molar tubes cemented with a light‐cured adhesive. However, given there are limited data for this outcome, further evidence is required to draw more robust conclusions. Plain language summary Adhesives for bonded molar tubes during fixed brace treatment Background Orthodontic treatment involves using fixed or removable dental braces to correct the positions of teeth. The success of dental braces depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a dental brace. Study characteristics The evidence in this review, which was carried out together with Cochrane Oral Health, is up‐to‐date as of 15 February 2017. We included two studies that evaluated 190 participants. Both trials were conducted in the UK and both compared bonded molar tubes with molar bands. Key results From the limited data of two studies at low risk of bias, it would appear that bonded molar tubes are associated with a higher failure rate than with molar bands.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.754Z" }, { "id": "2569dc38-298a-4f28-9f55-2e9960d7f4f0", "pmid": "", "title": "Lifestyle interventions for acute gout", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY, Sriranganathan, MK, Edwards, CJ, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010519.pub2 AB - Abstract - Background Although lifestyle interventions are often recommended in the management of chronic gout, the evidence from trial data of the benefits and safety of using lifestyle interventions for treating acute gout attacks have not previously been examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with acute gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies (up to 5 April 2013). We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials which compared lifestyle interventions to another therapy (active or placebo) in patients with acute gout. Outcomes of interest were the change in participant‐reported pain in the target joint(s), target joint inflammation and function, health‐related quality of life (HRQoL), patient global assessment, study participant withdrawals due to adverse events (AEs) and serious adverse events (SAEs). Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (19 participants) at high risk of bias was included in the review. Patients were randomised to receive oral prednisolone and colchicine with or without concomitant topical ice therapy. Topical ice therapy provided significant additional benefit over oral prednisolone and colchicine alone with respect to pain, but did not significantly reduce swelling during acute gout episodes. Mean pain reduction with standard medical treatment was 4.4 cm on a 0 to 10 cm visual analogue scale (VAS) after one week; the addition of topical ice reduced pain by an additional 3.33 cm (95% CI 5.84 to 0.82), or an absolute reduction of 33% (8% to 58% reduction). Joint swelling was reduced by a mean of 3.8 cm in the standard medical treatment group; the addition of topical ice therapy did not reduce swelling significantly (mean difference (MD) 2.07 cm, 95% CI ‐1.56 to 5.70). Target joint function, HRQoL, patient global assessment, study participant withdrawals due to AEs and SEAs were not reported in this study. Authors' conclusions There is low quality evidence, from a single trial at high risk of bias, that the addition of topical ice therapy to oral prednisolone and colchicine for oligoarticular attacks of acute gout results in significantly greater pain reduction at one week. Plain language summary Lifestyle interventions for treating acute gout attacks This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with acute gout. There was one study included in this review, which looked at the benefits and safety of adding topical ice therapy to medications commonly used for treating acute gout (prednisolone and colchicine). Over a one week period, in addition to prednisolone and colchicine, ice was applied to the skin overlying the joints affected by acute gout, for half‐an‐hour, four times per day, to relieve symptoms of pain and warmth and to reduce signs of redness and swelling. The review shows that in people with acute gout: We are uncertain whether the reduction in pain seen with the addition of topical ice to standard treatment of prednisolone and colchicine, compared to prednisolone and colchicine alone, is a true effect because of the very low quality evidence. Joint function, health‐related quality of life, patient global assessment and side effects and complications were not reported. We often do not have precise information about side effects and complications. Topical ice is likely to be a safe intervention. What is gout and what are lifestyle interventions? Gout is a very common cause of painful joint inflammation (arthritis) and is caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness, warmth and swelling of the affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic make‐up, being overweight, ingesting certain medications (for example cyclosporine), having impaired kidney function, and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Medications are the mainstay of acute gout treatment. Given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as consuming more water, coffee, dairy milk and cherry juice, and having fewer sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout to prevent recurrence of attacks. Best estimate of what happens to people with acute gout using topical ice in addition to medications: Joint pain (lower score means less pain) People who used topical ice (for half‐an‐hour, four times per day for one week) in addition to medical treatment (oral prednisolone and colchicine) rated their pain 3.33 points lower on a 0 to 10 point pain scale (33% absolute improvement).
 ‐ People who used topical ice in addition to medical treatment (prednisolone and colchicine) rated their pain to be 2.25 points on a scale of 0 to 10.
 ‐ People who used medical treatment alone rated their pain to be 5.58 points on a scale of 0 to 10. ‐ Three people would need to be treated with topical ice for one person to benefit from pain relief. Adverse events Side effects or complications of using topical ice in addition to medical therapy were not reported in the study.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.770Z" }, { "id": "256ff59a-e673-48e7-91d5-78e268222c0e", "pmid": "", "title": "Nebuliser systems for drug delivery in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Nebuliser systems are used to deliver medications to the lungs, to control the symptoms and the progression of lung disease in people with cystic fibrosis (CF). There are many different nebulised‐medications prescribed for people with CF and there are many different types of nebuliser systems. Some of these nebulised medications are licenced for, and can be taken via only one type of nebuliser system; some are licensed for, and can be taken via more than one type of nebuliser system. This is an update to a previous systematic review. Objectives To assess the time efficiency, effectiveness, safety, cost and impact of use (e.g. burden of care, adherence, quality of life (QoL)) of different nebuliser systems, when used with different inhaled medications for people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching of relevant journals and abstract books containing conference proceedings. We searched the reference lists of each study for additional publications and approached the manufacturers of both nebuliser systems and nebulised medications for published and unpublished data. We also searched online trial registries. Date of the most recent search: 9 August 2023. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing nebuliser systems, including conventional nebulisers, vibrating mesh technology (VMT) systems, adaptive aerosol delivery (AAD) systems and ultrasonic nebuliser systems. Data collection and analysis Two review authors independently assessed studies for inclusion. They also independently extracted data and assessed the risk of bias. A third review author assessed studies where agreement could not be reached. They assessed the certainty of the evidence using GRADE. Main results The search identified 216 studies with 33 of these (2270 participants) included in the review. These studies compared the delivery of tobramycin, colistin, dornase alfa, hypertonic saline and other solutions through the different nebuliser systems in children and adults with CF. This review demonstrates variability in the delivery of medication depending on the nebuliser system used. The certainty of the evidence ranged from low to very low. Some conventional nebuliser systems providing higher flows, higher respirable fractions, and smaller particles decrease treatment time, increase deposition (the amount of drug reaching the lung), and may be preferred by people with CF, as compared to other conventional nebuliser systems providing lower flows, lower respirable fractions and larger particles. Newer nebuliser systems using AAD, or VMT (or both) reduce treatment time compared to conventional systems. Deposition (as a percentage of priming dose) with AAD is greater than with conventional systems. VMT systems may give greater deposition than conventional systems when measuring sputum levels. The available data indicate that these newer systems are safe when used with an appropriate priming dose, which may be different to the priming dose used for conventional systems. There is an indication that adherence is maintained or improved and that individuals prefer AAD or VMT systems, but also that some nebuliser systems using VMT may be subject to increased system failures. There is limited, unclear evidence on the impact of different nebuliser systems on lung function and a lack of data on the impact of different nebuliser systems on our outcomes of quality of life (QoL), adverse effects, respiratory exacerbations and related implications, adherence, satisfaction, cost and device reliability. Authors' conclusions Newer technologies e.g. AAD and VMT have advantages over conventional systems in terms of treatment time, deposition as a percentage of priming dose, preference and adherence. Data are lacking for all varieties of medications which are used in CF care, including different inhaled antibiotics or hypertonic saline, with all delivery (nebuliser system) possibilities. Long‐term RCTs are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as QoL and burden of care), safe and effective dosing levels of a wide variety of medications, clinical outcomes (such as hospitalisations and need for antibiotics), and an economic evaluation of their use. There are insufficient data to establish whether one nebuliser system is better than another overall. Clinicians should be aware of the variability in the performance of different nebuliser systems, compatibility with specific nebulised medication, and they must work with their patients to choose the best nebuliser system for each individual. This is likely to be an ongoing process as the needs and circumstances of each individual change over time. Plain language summary Nebulisers for giving medication for cystic fibrosis Key messages 1. Newer technologies have advantages over conventional systems in terms of treatment time, the amount of drug reaching the lung, preference, and adherence. 2. Not all medications used in treating cystic fibrosis can be delivered by the same nebuliser, and data are lacking for some of the different nebuliser and drug combinations. 3. Long‐term studies are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as quality of life, effective dosing levels, and hospitalisations). What is cystic fibrosis? People with cystic fibrosis have sticky mucus in their lungs which is difficult to get rid of and which can cause infection if it builds up. How are nebulisers used as part of cystic fibrosis treatment? Nebulisers are used to deliver medications to the lungs to control the symptoms and the progression of disease. They change a liquid medication into a mist, so it can be breathed in. Different types of nebuliser systems are used with different medications. 1. Conventional systems ‐ a machine pushes out a constant mist of medication at high speed. 2. Adaptive aerosol delivery systems ‐ like conventional systems, also monitor breathing and only deliver the medication while the person is breathing in. 3. Vibrating mesh technology systems move the liquid medication through a metal mesh to generate a mist with similar‐sized droplets which is delivered constantly. 4. Adaptive aerosol delivery systems with vibrating mesh technology combination between the two systems. 5. Ultrasonic systems use a crystal to vibrate the liquid medication at a high frequency and turn it into a mist which is delivered constantly. What did we want to find out? How well do the different nebuliser systems deliver each inhaled medication (how much medication is delivered into the lungs, and what is the impact on lung function)? Are they safe or do they have any side effects? We also wanted to know how these nebuliser systems affect people with cystic fibrosis in terms of treatment burden, adherence to treatment regimen and their quality of life. What did we do? We assessed 33 studies (2270 adults and children)and compared different types of nebuliser systems for delivering: tobramycin; colistin; dornase alfa; hypertonic saline; and other nebulised medications. What did we find? Conventional systems which have faster air flows and smaller medication droplets decrease treatment time and deliver more medication into the lung than other conventional systems, which have slower air flows and larger medication droplets. Nebulisers use newer technologies, e.g. adaptive aerosol delivery system or vibrating mesh technology, deliver the medication faster and may deliver more of the medication into the lung. These newer systems appear safe when used with the correct amount of medication, which may be different to that used in a conventional system. Some studies suggest that people with cystic fibrosis may prefer these newer systems and may take more of their medication when using them. However, more research is needed into what dose of medication is needed for the different systems, which medications suit which technologies best and how these newer nebuliser technologies affect quality of life, burden of treatment, additional treatment needed (such as oral or intravenous antibiotics) and treatment costs. What are the limitations of the evidence? There were lots of different systems studied, and often we only had a few studies for each comparison. Also, the studies we found were quite small and results varied. We had concerns around at least some aspects of the design of every study which affected our confidence in the results. How up to date is this evidence? We last looked for evidence on 9 August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Stanford, G, Morrison, L, Brown, C", "articleTypes": [], "doi": "10.1002/14651858.CD007639.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.785Z" }, { "id": "2589ab0c-c8e8-4b01-9fa0-d1b313f9d774", "pmid": "", "title": "Transitional discharge interventions for people with schizophrenia", "imported": false, "abstract": "Abstract - Background Schizophrenia is a chronic mental illness characterized by delusions, hallucinations, and important functional and social disability. Interventions labeled as 'transitional' add to care plans made during the hospital stay in preparation for discharge. They also include interventions developed after discharge to support people with serious mental illness as they make the transition from the hospital to the community. Transitional discharge interventions may anticipate the future needs of the patient after discharge by co‐ordinating the different levels of the health system that can effectively guarantee continuity of care in the community. This occurs through the provision of therapeutic relationships which give a safety net throughout the discharge and community reintegration processes to improve the general condition of users, level of functioning, use of health resources, and satisfaction with care. Objectives To assess the effects of transitional discharge interventions for people with schizophrenia. Search methods On 7 December 2022, we searched the Cochrane Schizophrenia Group's Study‐Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, PubMed, CINAHL, ClinicalTrials.gov, ISRCTN, PsycINFO, and WHO ICTRP. Selection criteria Randomized controlled trials (RCTs) evaluating the effects of transitional discharge interventions in people with schizophrenia and schizophrenia‐related disorders. Eligible interventions included three key elements: predischarge planning, co‐ordination of care and follow‐up, and postdischarge support. Data collection and analysis We used standard Cochrane methods. Outcomes of this review included global state (relapse), service use (hospitalization), general functioning, satisfaction with care, adverse effects/events, quality of life, and direct costs. For binary outcomes, we calculated risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardized mean difference (SMD) and their 95% CIs. We used GRADE to assess certainty of evidence. Main results We found 12 studies with 1748 participants comparing transitional discharge interventions to usual care. All were parallel‐group RCTs. No studies assessed global state (relapse) or reported data about adverse events/effects. All studies had a high risk of bias, mainly due to serious concerns about allocation concealment, deviations from intended interventions, measurement of the outcomes, and missing outcome data. Transitional discharge interventions may make little to no difference in service use (hospitalization) at short‐ and long‐term follow‐ups, but the evidence is very uncertain (RR 1.18, 95% CI 0.55 to 2.50; I 2 = 54%; 4 studies, 462 participants; very low‐certainty evidence). Transitional discharge intervention may increase the levels of functioning after discharge (clinically important change in general functioning) (SMD 0.95, 95% CI −0.06 to 1.97; I² = 95%; 4 studies, 437 participants; very low‐certainty evidence) and may increase the proportion of participants who are satisfied with the intervention (clinically important change in satisfaction) (RR 1.96, 95% CI 1.37 to 2.80; 1 study, 76 participants; very low‐certainty evidence), but for both outcomes the evidence is very uncertain. Transitional discharge intervention may make little to no difference in quality of life compared to treatment as usual (SMD 0.24, 95% CI −0.30 to 0.78; I² = 90%; 4 studies, 748 participants; very low‐certainty evidence), but we are very uncertain. For direct costs, one study with 124 participants did not report full details and thus the results were inconclusive. Authors' conclusions There is currently no clear evidence for or against implementing transitional discharge interventions for people with schizophrenia. Transitional discharge interventions may improve patient satisfaction and functionality, but this evidence is also very uncertain. For future research, it is important to improve the quality of the conduct and reporting of these trials, including using validated tools for measuring their outcomes. Plain language summary What are the benefits of transitional discharge care for people with schizophrenia? Key messages – Transitional discharge care (an intervention that supports a person move from a stay in hospital to the community) may make little to no difference in admissions to hospital and quality of life, and may improve how well a person functions in day‐to‐day life and how happy they are with their treatment when they return home, but we are very uncertain about the results. – The results on costs of running the transitional discharge care program are inconclusive, and the studies provided no information on relapse (a new mental health crisis) or unwanted effects. – We need more and better studies to investigate how to support people with schizophrenia or schizophrenia‐related disorders during the transition from hospital to community. What is schizophrenia? Schizophrenia is a persistent and severe mental health condition where people have hallucinations (where they hear, see, smell, taste, or feel things that appear to be real but only exist in their mind) and delusions (a strong belief in something that is untrue), among other debilitating symptoms, leading to poor quality of life. People with schizophrenia‐related disorders have symptoms that are similar to those of schizophrenia. The illness varies, with people having different symptoms at different times, often with them requiring admission to hospital for treatment. What happens when a person with schizophrenia or schizophrenia‐related disorders is discharged from hospital? People with schizophrenia or schizophrenia‐related disorders are sometimes admitted to hospital to improve their health, and afterward, they are discharged to their homes or other care facilities. This transition might be difficult and frightening for them and their carers, and they may need help to adapt. There are some interventions to support people with schizophrenia or schizophrenia‐related disorders after they leave the hospital, such as case management with an expert guide or continuous care with a nurse. What is transitional discharge care? Transitional discharge care is an intervention which provides support to people leaving hospital to cover their medical, practical, and emotional needs. This starts before hospital discharge and continues until people are confident in their homes or care facilities. This may include help with housing; communicating and co‐ordinating among healthcare staff, patients, and families; planning meetings; sessions with families; visits to the neighborhood; talking therapy sessions; telephone and face‐to‐face support; and support groups focusing on recreation, medication, shopping, cooking, and financial responsibilities. What did we want to find out? We wanted to know whether transitional discharge care helps people with schizophrenia or schizophrenia‐related disorders when leaving the hospital, especially if it reduces the rate of a new mental health crisis (relapse), repeat admissions to hospital, overall functioning in day‐to‐day life, satisfaction with the care they receive, quality of life, unwanted effects, and costs. What did we do? We searched for studies that investigated whether transitional discharge care, compared to no transitional discharge care or usual care, was effective in adults with schizophrenia or schizophrenia‐related disorders. What did we find? We found 12 studies with 1748 people that compared transitional discharge care to usual care. Transitional discharge care may make little to no difference to admissions to hospital (4 studies, 462 people). Transitional discharge care may improve functioning (4 studies, 437 people) and may increase people's satisfaction with care (1 study, 76 people), but we are very uncertain about the results. Transitional discharge care may make little to no difference to quality of life (4 studies, 748 people). The results on costs were inconclusive as the study did not fully report the methods (1 study, 124 people). ​​ None of the included studies provided data for relapse or unwanted effects of transitional discharge care. What are the limitations of the evidence? All 12 studies had problems with their methods and results were inconsistent. Some studies included people with other mental disorders, so the results might not apply directly to people with schizophrenia or schizophrenia‐related disorders. Therefore, we have very low confidence in our findings. How up to date is this evidence? The evidence is up to date to December 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Roson Rodriguez, P, Chen, X, Arancibia, M, Garegnani, L, Escobar Liquitay, CM, Mohammad, HA, Franco, JVA", "articleTypes": [], "doi": "10.1002/14651858.CD009788.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.133Z" }, { "id": "258a8fe9-d814-4bf5-a6e6-f1bc9ccf2c0b", "pmid": "", "title": "Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight", "imported": false, "abstract": "Abstract - Background The global prevalence of childhood and adolescent obesity is high. Lifestyle changes towards a healthy diet, increased physical activity and reduced sedentary activities are recommended to prevent and treat obesity. Evidence suggests that changing these health behaviours can benefit cognitive function and school achievement in children and adolescents in general. There are various theoretical mechanisms that suggest that children and adolescents with excessive body fat may benefit particularly from these interventions. Objectives To assess whether lifestyle interventions (in the areas of diet, physical activity, sedentary behaviour and behavioural therapy) improve school achievement, cognitive function (e.g. executive functions) and/or future success in children and adolescents with obesity or overweight, compared with standard care, waiting‐list control, no treatment, or an attention placebo control group. Search methods In February 2017, we searched CENTRAL, MEDLINE and 15 other databases. We also searched two trials registries, reference lists, and handsearched one journal from inception. We also contacted researchers in the field to obtain unpublished data. Selection criteria We included randomised and quasi‐randomised controlled trials (RCTs) of behavioural interventions for weight management in children and adolescents with obesity or overweight. We excluded studies in children and adolescents with medical conditions known to affect weight status, school achievement and cognitive function. We also excluded self‐ and parent‐reported outcomes. Data collection and analysis Four review authors independently selected studies for inclusion. Two review authors extracted data, assessed quality and risks of bias, and evaluated the quality of the evidence using the GRADE approach. We contacted study authors to obtain additional information. We used standard methodological procedures expected by Cochrane. Where the same outcome was assessed across different intervention types, we reported standardised effect sizes for findings from single‐study and multiple‐study analyses to allow comparison of intervention effects across intervention types. To ease interpretation of the effect size, we also reported the mean difference of effect sizes for single‐study outcomes. Main results We included 18 studies (59 records) of 2384 children and adolescents with obesity or overweight. Eight studies delivered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies delivered dietary interventions. We included five RCTs and 13 cluster‐RCTs. The studies took place in 10 different countries. Two were carried out in children attending preschool, 11 were conducted in primary/elementary school‐aged children, four studies were aimed at adolescents attending secondary/high school and one study included primary/elementary and secondary/high school‐aged children. The number of studies included for each outcome was low, with up to only three studies per outcome. The quality of evidence ranged from high to very low and 17 studies had a high risk of bias for at least one item. None of the studies reported data on additional educational support needs and adverse events. Compared to standard practice, analyses of physical activity‐only interventions suggested high‐quality evidence for improved mean cognitive executive function scores. The mean difference (MD) was 5.00 scale points higher in an after‐school exercise group compared to standard practice (95% confidence interval (CI) 0.68 to 9.32; scale mean 100, standard deviation 15; 116 children, 1 study). There was no statistically significant beneficial effect in favour of the intervention for mathematics, reading, or inhibition control. The standardised mean difference (SMD) for mathematics was 0.49 (95% CI ‐0.04 to 1.01; 2 studies, 255 children, moderate‐quality evidence) and for reading was 0.10 (95% CI ‐0.30 to 0.49; 2 studies, 308 children, moderate‐quality evidence). The MD for inhibition control was ‐1.55 scale points (95% CI ‐5.85 to 2.75; scale range 0 to 100; SMD ‐0.15, 95% CI ‐0.58 to 0.28; 1 study, 84 children, very low‐quality evidence). No data were available for average achievement across subjects taught at school. There was no evidence of a beneficial effect of physical activity interventions combined with healthy lifestyle education on average achievement across subjects taught at school, mathematics achievement, reading achievement or inhibition control. The MD for average achievement across subjects taught at school was 6.37 points lower in the intervention group compared to standard practice (95% CI ‐36.83 to 24.09; scale mean 500, scale SD 70; SMD ‐0.18, 95% CI ‐0.93 to 0.58; 1 study, 31 children, low‐quality evidence). The effect estimate for mathematics achievement was SMD 0.02 (95% CI ‐0.19 to 0.22; 3 studies, 384 children, very low‐quality evidence), for reading achievement SMD 0.00 (95% CI ‐0.24 to 0.24; 2 studies, 284 children, low‐quality evidence), and for inhibition control SMD ‐0.67 (95% CI ‐1.50 to 0.16; 2 studies, 110 children, very low‐quality evidence). No data were available for the effect of combined physical activity and healthy lifestyle education on cognitive executive functions. There was a moderate difference in the average achievement across subjects taught at school favouring interventions targeting the improvement of the school food environment compared to standard practice in adolescents with obesity (SMD 0.46, 95% CI 0.25 to 0.66; 2 studies, 382 adolescents, low‐quality evidence), but not with overweight. Replacing packed school lunch with a nutrient‐rich diet in addition to nutrition education did not improve mathematics (MD ‐2.18, 95% CI ‐5.83 to 1.47; scale range 0 to 69; SMD ‐0.26, 95% CI ‐0.72 to 0.20; 1 study, 76 children, low‐quality evidence) and reading achievement (MD 1.17, 95% CI ‐4.40 to 6.73; scale range 0 to 108; SMD 0.13, 95% CI ‐0.35 to 0.61; 1 study, 67 children, low‐quality evidence). Authors' conclusions Despite the large number of childhood and adolescent obesity treatment trials, we were only able to partially assess the impact of obesity treatment interventions on school achievement and cognitive abilities. School and community‐based physical activity interventions as part of an obesity prevention or treatment programme can benefit executive functions of children with obesity or overweight specifically. Similarly, school‐based dietary interventions may benefit general school achievement in children with obesity. These findings might assist health and education practitioners to make decisions related to promoting physical activity and healthy eating in schools. Future obesity treatment and prevention studies in clinical, school and community settings should consider assessing academic and cognitive as well as physical outcomes. Plain language summary Healthy weight interventions for improving thinking skills and school performance in children and teenagers with obesity What is the aim of this review? The aim of this Cochrane Review was to find out if healthy weight interventions can improve thinking skills and school performance in children and teenagers with obesity. Cochrane researchers collected and analysed all relevant studies to answer this question. What are the key messages? This updated review provides some evidence that school programmes that encourage healthier child weight may also provide ‘co‐benefits’ of thinking skills and school performance. However, we need more high‐quality healthy‐weight interventions that test thinking skills and school performance, as well as health outcomes. What was studied in this review? The number of children and teenagers with obesity is high worldwide. Some children and teenagers with obesity have health issues or are bullied because of their body weight. These experiences have been linked to problems in performing well in school, where they tend to perform less well in thinking tasks such as problem‐solving. Physical activity and healthy eating benefit a healthy body weight and improve thinking skills and school performance in children with a healthy weight. Studies found that healthy‐weight interventions can reduce obesity in children and teenagers, but it is unknown if and how well healthy‐weight interventions can improve thinking skills and school performance in children and teenagers with obesity. What are the main results of this review? The review authors found 18 studies which included a total of 2384 children and teenagers with obesity. Five studies assigned individual children to intervention or control groups. Thirteen studies allocated entire classes, school or school districts to the intervention and control group. Of the 18 studies, 11 involved children at primary/elementary‐school age. Eight studies offered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies offered dietary changes. The studies took place in 10 different countries. Seventeen studies had at least one flaw in how the study was done. This reduces the level of confidence we can have in the findings. Few studies shared the same type of school performance or thinking skills. Only three studies reported the same outcome. None of the studies reported on additional educational support needs and harmful events. We found that, compared with usual routine, physical activity interventions can lead to small improvements in problem‐solving skills. This finding was based on high‐quality evidence. Moderate‐quality findings showed that physical activity interventions do not improve mathematics and reading achievement in children with obesity. Very low‐quality evidence also suggested no benefits of physical activity interventions for improving uncontrolled behavioural responses. General school achievement was not reported in studies comparing physical activity interventions with standard practice. Studies that compared physical activity interventions plus healthy lifestyle education with standard practice were of low to very low quality. They showed no improvement in school achievement or uncontrolled behavioural responses in the intervention group compared to the control group. Problem‐solving skills were not reported in studies comparing physical activity plus healthy lifestyle education with standard practice. Our findings indicate that changing knowledge about nutrition, and changing the food offered in schools can lead to moderate improvements in general school achievement of teenagers with obesity, when compared to standard school practice. Replacing packed school lunch with a nutrient‐rich diet plus nutrition education did not improve mathematics and reading achievement of children with obesity. However, the quality of evidence for general school achievement, mathematics and reading was low. This means that future research is very likely to change the results, because included studies showed some methodological weaknesses (for example, small numbers of children and a high dropout of children from studies). Problem‐solving skills and uncontrolled behavioural responses were not reported for dietary intervention studies. How up‐to‐date is this review? The review authors searched the scientific literature for relevant studies in February 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Martin, A, Booth, JN, Laird, Y, Sproule, J, Reilly, JJ, Saunders, DH", "articleTypes": [], "doi": "10.1002/14651858.CD009728.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.094Z" }, { "id": "258d2d8b-04ef-4367-a543-1cdfaf62aec8", "pmid": "", "title": "Paediatric formulations of artemisinin‐based combination therapies for treating uncomplicated malaria in children", "imported": false, "abstract": "Abstract - Background In endemic malarial areas, young children have high levels of malaria morbidity and mortality. The World Health Organization recommends oral artemisinin‐based combination therapy (ACT) for treating uncomplicated malaria. Paediatric formulations of ACT have been developed to make it easier to treat children. Objectives To evaluate evidence from trials on the efficacy, safety, tolerability, and acceptability of paediatric ACT formulations compared to tablet ACT formulations for uncomplicated P falciparum malaria in children up to 14 years old. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; the Latin American and Caribbean Health Science Information database (LILACS); ISI Web of Science; Google Scholar; Scopus; and the metaRegister of Controlled Trials (mRCT) to 11 December 2019. Selection criteria We included randomised controlled clinical trials (RCTs) of paediatric versus non‐paediatric formulated ACT in children aged 14 years or younger with acute uncomplicated malaria. Data collection and analysis Two authors independently assessed eligibility and risk of bias, and carried out data extraction. We analyzed the primary outcomes of efficacy, safety and tolerability of paediatric versus non‐paediatric ACT using risk ratios (RR) and 95% confidence intervals (CI). Secondary outcomes were: treatment failure on the last day of observation (day 42), fever clearance time, parasite clearance time, pharmacokinetics, and acceptability. Main results Three trials met the inclusion criteria. Two compared a paediatric dispersible tablet formulation against crushed tablets of artemether‐lumefantrine (AL) and dihydroartemisinin‐piperaquine (DHA‐PQ), and one trial assessed artemether‐lumefantrine formulated as powder for suspension compared with crushed tablets. The trials were carried out between 2006 and 2015 in sub‐Saharan Africa (Benin, Mali, Mozambique, Tanzania, Kenya, Democratic Republic of the Congo, Burkina Faso, and The Gambia). In all three trials, the paediatric and control ACT achieved polymerase chain reaction (PCR)‐adjusted treatment failure rates of < 10% on day 28 in the per‐protocol (PP) population. For the comparison of dispersible versus crushed tablets, the two trials did not detect a difference for treatment failure by day 28 (PCR‐adjusted PP population: RR 1.35, 95% CI 0.49 to 3.72; 1061 participants, 2 studies, low‐certainty evidence). Similarly, for the comparison of suspension versus crushed tablet ACT, we did not detect any difference in treatment failure at day 28 (PCR‐adjusted PP population: RR 1.64, 95% CI 0.55 to 4.87; 245 participants, 1 study). We did not detect any difference in serious adverse events for the comparison of dispersible versus crushed tablets (RR 1.05, 95% CI 0.38 to 2.88; 1197 participants, 2 studies, low‐certainty evidence), or for the comparison of suspension versus crushed tablet ACT (RR 0.74, 95% CI 0.17 to 3.26; 267 participants, 1 study). In the dispersible ACT arms, drug‐related adverse events occurred in 9% of children in the AL study and 34% of children in the DHA‐PQ study. In the control arms, drug‐related adverse events occurred in 12% of children in the AL study and in 42% of children in the DHA‐PQ study. Drug‐related adverse events were lower in the dispersible ACT arms (RR 0.78, 95% CI 0.62 to 0.99; 1197 participants, 2 studies, moderate‐certainty evidence). There was no detected difference in the rate of drug‐related adverse events for suspension ACT versus crushed tablet ACT (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study). Drug‐related vomiting appeared to be less common in the dispersible ACT arms (RR 0.75, 95% CI 0.56 to 1.01; 1197 participants, 2 studies, low‐certainty evidence) and in the suspension ACT arm (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study), but both analyses were underpowered. No study assessed acceptability. Authors' conclusions Trials did not demonstrate a difference in efficacy between paediatric dispersible or suspension ACT when compared with the respective crushed tablet ACT for treating uncomplicated P falciparum malaria in children. However, the evidence is of low to moderate certainty due to limited power. There appeared to be fewer drug‐related adverse events with dispersible ACT compared to crushed tablet ACT. None of the included studies assessed acceptability of paediatric ACT formulation. Plain language summary Treating uncomplicated malaria in children: do child‐friendly formulations of medicines work better than usual tablet formulations? What is the aim of this review? We wanted to find out about the potential benefits and harms of child‐friendly formulations of artemisinin‐based combination therapy (ACT) to treat uncomplicated malaria in children. We searched for studies that investigated the use of child‐friendly formulations of ACTs, compared with the usual ACT tablet formulations, to treat uncomplicated malaria in children aged under 14 years. We looked for randomized controlled studies, in which the treatments the children received were decided at random. This type of study usually gives the most reliable evidence about the effects of a treatment. We found three relevant studies of two child‐friendly formulations. Key messages Child‐friendly formulations of ACT probably work as well as crushed tablets to treat uncomplicated malaria in children, and probably cause fewer unwanted effects. What was studied in this review? Malaria is a tropical disease spread by mosquitoes infected with Plasmodium parasites. The most common, and most serious, type of malaria is caused by Plasmodium falciparum . This parasite causes high levels of illness and death, particularly in young children in regions where malaria is widespread. Malaria can be a mild illness, but is sometimes severe and life‐threatening if not treated soon enough or with the right medicines. Medicines based on artemisinin, a compound derived from a plant ( Artemisia annua ), are commonly taken by mouth (orally) to treat malaria in combination with other drugs. The World Health Organization recommends treating uncomplicated malaria with oral artemisinin‐based combination therapy (called ACT). Oral ACT tablets are often crushed to help make them easier for children to swallow. New formulations of oral ACTs have been developed especially for children, such as syrups, and granules, powders or tablets that can be dissolved in water, and which may be flavoured. What are the main results of this review? We found three relevant studies in 1306 children (aged 6 months to 11 years) with uncomplicated malaria. The studies were conducted in sub‐Saharan Africa between 2006 and 2015. All studies were funded by pharmaceutical companies that made child‐friendly formulations of the ACTs. The studies compared crushed ACT tablets to child‐friendly formulations of ACTs: these were dissolvable tablets of artemether‐lumefantrine or dihydroartemisinin‐piperaquine, or artemether‐lumefantrine syrup. We were interested in: · whether children remained cured of malaria after 28 days (measured by absence of Plasmodium parasites in the blood); and · whether the medicines caused any unwanted effects. None of the studies looked at how any of the medicine formulations were accepted by children. There may be little or no difference between the child‐friendly formulations of ACTs (dissolvable tablets or syrup) and the usual crushed tablets for how many children: · were successfully treated after 28 days; or · experienced serious unwanted effects. The crushed ACT tablets and the child‐friendly formulations successfully treated most cases of uncomplicated malaria. After 28 days the rates of treatment failure were similar in both groups. On average, 59 of every 1000 children taking crushed ACT tablets and 62 of every 1000 children taking dissolvable tablets would still have Plasmodium infection (2 studies; 1139 children). Similar numbers of serious unwanted effects were reported for the usual crushed tablets and the dissolvable tablets (2 studies; 1197 children) or syrup (1 study; 267 children), therefore differences as a result of the formulation are unlikely. A dissolvable tablet probably reduces unwanted effects of the medicine, including vomiting (throwing up), compared with the usual crushed tablets. Children taking dissolvable tablets had fewer unwanted effects associated with the medicine (139 of every 1000 children) than those taking crushed tablets (178 of every 1000 children). There was no difference in the number of unwanted effects found in the study with the syrup formulation compared with the usual crushed tablets. Our confidence in our results is low to moderate. The results come from a small number of studies. All studies were supported by manufacturers of the child‐friendly formulations, which could have affected how the studies were designed, conducted, and reported. How up‐to‐date is this review? We searched for studies that had been published up to 11 December 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bélard, S, Ramharter, M, Kurth, F", "articleTypes": [], "doi": "10.1002/14651858.CD009568.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.739Z" }, { "id": "2593c70c-b740-4159-867b-6d647853f645", "pmid": "", "title": "Oral Astragalus (Huang qi) for preventing frequent episodes of acute respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common in children and can involve both upper and lower airways. Many children experience frequent ARTI episodes or recurrent respiratory tract infections (RRTIs) in early life, which creates challenges for paediatricians, primary care physicians, parents and carers of children. In China, Astragalus (Huang qi), alone or in combination with other herbs, is used by Traditional Chinese Medicine (TCM) practitioners in the form of a water extract, to reduce the risk of ARTIs; it is believed to stimulate the immune system. Better understanding of the therapeutic mechanisms of Astragalus may provide insights into ARTI prevention, and consequently reduced antibiotic use. Objectives To assess the effectiveness and safety of oral Astragalus for preventing frequent episodes of acute respiratory tract infections (ARTIs) in children in community settings. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2015), MEDLINE (Ovid) (1946 to 31 December 2015), Embase (Elsevier) (1974 to 31 December 2015), AMED (Ovid) (1985 to 31 December 2015), Chinese National Knowledge Infrastructure (CNKI) (1979 to 31 December 2015) and Chinese Scientific Journals full text database (CQVIP) (1989 to 31 December 2015), China Biology Medicine disc (CBM 1976 to 31 December 2015) and Wanfang Data Knowledge Service Platform (WanFang) (1998 to 31 December 2015). Selection criteria We included randomised controlled trials (RCTs) comparing oral Astragalus as a sole Chinese herbal preparation with placebo to prevent frequent episodes of ARTIs in children. Data collection and analysis We used standard Cochrane methodological procedures for this review. We assessed search results to identify relevant studies. We planned to extract data using standardised forms. Disagreements were to be resolved through discussion. Risk of bias was to be assessed using the Cochrane 'Risk of bias' tool. We planned to use mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) or odds ratio (OR) to analyse dichotomous data, both with 95% confidence intervals (CIs). Main results We identified 6080 records: 3352 from English language databases, 2724 from Chinese databases, and four from other sources. Following initial screening and deduplication, we obtained 120 full‐text papers for assessment. Of these, 21 were not RCTs; 55 did not meet the inclusion criteria because: participants were aged over 14 years; definition was not included for recurrent or frequent episodes; Astragalus preparation was not an intervention; Astragalus preparation was in the formula but was not the sole agent; the Astragalus preparation was not administered orally; or Astragalus was used for treatment rather than prevention of ARTI. A further 44 studies were excluded because they were not placebo‐controlled, although other inclusion criteria were fulfilled. No RCTs met our inclusion criteria. Authors' conclusions We found insufficient evidence to enable assessment of the effectiveness and safety of oral Astragalus as a sole intervention to prevent frequent ARTIs in children aged up to 14 years. Plain language summary Can oral Astragalus (Huang qi) prevent frequent acute respiratory tract infections in children? Review question We assessed evidence for the benefits and harms of oral Astragalus used alone to prevent frequent episodes of acute respiratory infections (ARTIs) in children aged up to 14 years, compared to a dummy treatment. ARTIs include colds, sore throats, laryngitis, influenza, bronchitis and pneumonia. Background Many therapies are used to prevent ARTIs, especially in children. Astragalus, is a widely used and available herbal therapy that has been used for thousands of years in China to help prevent ARTIs. It is thought to boost immunity. Almost one in five children experience frequent ARTIs and treatment accounts for up to 75% of all prescribed antibiotics for children. Because most ARTIs are caused by viruses, antibiotics are not effective in treating these illnesses. Search date We searched the literature up to 31 December 2015. Study characteristics We identified 6080 potentially relevant records. After removing duplicate records, and those that did not meet our inclusion criteria, we obtained 120 full‐text studies. We carefully assessed these studies for possible inclusion. We excluded most studies because: they presented unclear diagnosis criteria; Astragalus preparation was used with other agents; or Astragalus was not compared with a dummy treatment. No studies met our inclusion criteria and so we were unable to analyse any results. Study funding sources We could not assess study funding sources. Key results We did not find any studies that compared use of oral Astragalus alone with a dummy treatment to prevent frequent episodes of ARTI in children aged up to 14 years. Well‐designed, conducted and reported studies investigating this issue are needed to enable assessment in the future. Quality of the evidence We could not assess evidence quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Su, G, Chen, X, Liu, Z, Yang, L, Zhang, L, Stålsby Lundborg, C, Wen, Z, Guo, X, Qin, X, Liang, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.081Z" }, { "id": "259a3df4-e012-4cc7-969e-c6e9c7b0ad16", "pmid": "", "title": "The Role of Bladder Cancer TAS2R38 Expression on Chemotherapy-Induced Bitter Taste", "imported": false, "abstract": "Alteration in the sense of taste is a frequent symptom that is closely linked to chemotherapy exposure, lowering quality of life and nutritional status. Malnutrition is of particular concern in muscle-invasive bladder cancer (MIBC), as malnutrition is associated with many negative outcomes from radical cystectomy (the surgical procedure in MIBC), which include higher morbidity, poor wound healing, and higher rate of infections after surgery.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "25b6e92a-b592-49a4-85d0-18ca01b6013f", "pmid": "", "title": "Lifestyle interventions for acute gout", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY, Sriranganathan, MK, Edwards, CJ, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010519.pub2 AB - Abstract - Background Although lifestyle interventions are often recommended in the management of chronic gout, the evidence from trial data of the benefits and safety of using lifestyle interventions for treating acute gout attacks have not previously been examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with acute gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies (up to 5 April 2013). We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials which compared lifestyle interventions to another therapy (active or placebo) in patients with acute gout. Outcomes of interest were the change in participant‐reported pain in the target joint(s), target joint inflammation and function, health‐related quality of life (HRQoL), patient global assessment, study participant withdrawals due to adverse events (AEs) and serious adverse events (SAEs). Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (19 participants) at high risk of bias was included in the review. Patients were randomised to receive oral prednisolone and colchicine with or without concomitant topical ice therapy. Topical ice therapy provided significant additional benefit over oral prednisolone and colchicine alone with respect to pain, but did not significantly reduce swelling during acute gout episodes. Mean pain reduction with standard medical treatment was 4.4 cm on a 0 to 10 cm visual analogue scale (VAS) after one week; the addition of topical ice reduced pain by an additional 3.33 cm (95% CI 5.84 to 0.82), or an absolute reduction of 33% (8% to 58% reduction). Joint swelling was reduced by a mean of 3.8 cm in the standard medical treatment group; the addition of topical ice therapy did not reduce swelling significantly (mean difference (MD) 2.07 cm, 95% CI ‐1.56 to 5.70). Target joint function, HRQoL, patient global assessment, study participant withdrawals due to AEs and SEAs were not reported in this study. Authors' conclusions There is low quality evidence, from a single trial at high risk of bias, that the addition of topical ice therapy to oral prednisolone and colchicine for oligoarticular attacks of acute gout results in significantly greater pain reduction at one week. Plain language summary Lifestyle interventions for treating acute gout attacks This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with acute gout. There was one study included in this review, which looked at the benefits and safety of adding topical ice therapy to medications commonly used for treating acute gout (prednisolone and colchicine). Over a one week period, in addition to prednisolone and colchicine, ice was applied to the skin overlying the joints affected by acute gout, for half‐an‐hour, four times per day, to relieve symptoms of pain and warmth and to reduce signs of redness and swelling. The review shows that in people with acute gout: We are uncertain whether the reduction in pain seen with the addition of topical ice to standard treatment of prednisolone and colchicine, compared to prednisolone and colchicine alone, is a true effect because of the very low quality evidence. Joint function, health‐related quality of life, patient global assessment and side effects and complications were not reported. We often do not have precise information about side effects and complications. Topical ice is likely to be a safe intervention. What is gout and what are lifestyle interventions? Gout is a very common cause of painful joint inflammation (arthritis) and is caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness, warmth and swelling of the affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic make‐up, being overweight, ingesting certain medications (for example cyclosporine), having impaired kidney function, and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Medications are the mainstay of acute gout treatment. Given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as consuming more water, coffee, dairy milk and cherry juice, and having fewer sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout to prevent recurrence of attacks. Best estimate of what happens to people with acute gout using topical ice in addition to medications: Joint pain (lower score means less pain) People who used topical ice (for half‐an‐hour, four times per day for one week) in addition to medical treatment (oral prednisolone and colchicine) rated their pain 3.33 points lower on a 0 to 10 point pain scale (33% absolute improvement).
 ‐ People who used topical ice in addition to medical treatment (prednisolone and colchicine) rated their pain to be 2.25 points on a scale of 0 to 10.
 ‐ People who used medical treatment alone rated their pain to be 5.58 points on a scale of 0 to 10. ‐ Three people would need to be treated with topical ice for one person to benefit from pain relief. Adverse events Side effects or complications of using topical ice in addition to medical therapy were not reported in the study.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.086Z" }, { "id": "25c29d43-3afd-43cb-a6db-226bcda68585", "pmid": "", "title": "Oral deferiprone for iron chelation in people with thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. A commonly used iron chelator, deferiprone, has been found to be pharmacologically efficacious. However, important questions exist about the efficacy and safety of deferiprone compared to another iron chelator, desferrioxamine. Objectives To summarise data from trials on the clinical efficacy and safety of deferiprone and to compare the clinical efficacy and safety of deferiprone with desferrioxamine for thalassaemia. Search methods We searched the Cochrane Cystic fibrosis and Genetic Disorders Group's Haemoglobinopathies trials Register and MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus registers of ongoing trials and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). We also contacted the manufacturers of deferiprone and desferrioxamine. All searches were updated to 05 March 2013. Selection criteria Randomised controlled trials comparing deferiprone with another iron chelator; or comparing two schedules or doses of deferiprone, in people with transfusion‐dependent thalassaemia. Data collection and analysis Two authors independently assessed trials for risk of bias and extracted data. Missing data were requested from the original investigators. Main results A total of 17 trials involving 1061 participants (range 13 to 213 participants per trial) were included. Of these, 16 trials compared either deferiprone alone with desferrioxamine alone, or a combined therapy of deferiprone and desferrioxamine with either deferiprone alone or desferrioxamine alone; one compared different schedules of deferiprone. There was little consistency between outcomes and limited information to fully assess the risk of bias of most of the included trials. Four trials reported mortality; each reported the death of one individual receiving deferiprone with or without desferrioxamine. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage. Earlier trials measuring the cardiac iron load indirectly by magnetic resonance imaging (MRI) T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, a meta‐analysis of two trials suggested that left ventricular ejection fraction was significantly reduced in patients who received desferrioxamine alone compared with combination therapy. One trial, which planned five years of follow up, was stopped early due to the beneficial effects of combined treatment compared with deferiprone alone in terms of serum ferritin levels reduction. The results of this and three other trials suggest an advantage of combined therapy over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no conclusive or consistent evidence for the improved efficacy of combined deferiprone and desferrioxamine therapy over monotherapy from direct or indirect measures of liver iron. Both deferiprone and desferrioxamine produce a significant reduction in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised controlled trials to suggest that either has a greater reduction of clinically significant end organ damage. Evidence of adverse events were observed in all treatment groups. Occurrence of any adverse event was significantly more likely with deferiprone than desferrioxamine in one trial, RR 2.24 (95% CI 1.19 to 4.23). Meta‐analysis of a further two trials showed a significant increased risk of adverse events associated with combined deferiprone and desferrioxamine compared with desferrioxamine alone, RR 3.04 (95% CI 1.18 to 7.83). The most commonly reported adverse event was joint pain, which occurred significantly more frequently in patients receiving deferiprone than desferrioxamine, RR 2.64 (95% CI 1.21 to 5.77). Other common adverse events included gastrointestinal disturbances as well as neutropenia or leucopenia, or both. Authors' conclusions In the absence of data from randomised controlled trials, there is no evidence to suggest the need for a change in current treatment recommendations; namely that deferiprone is indicated for treating iron overload in people with thalassaemia major when desferrioxamine is contraindicated or inadequate. Intensified desferrioxamine treatment (by either subcutaneous or intravenous route) or use of other oral iron chelators, or both, remains the established treatment to reverse cardiac dysfunction due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently only gave support for deferiprone to be used as a last resort for treating iron overload in thalassaemia, myelodysplasia and sickle cell disease. However, there is evidence that adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcome of deferiprone with desferrioxamine. Plain language summary The use of the iron chelator deferiprone in people with thalassaemia who are dependent on blood transfusions In thalassaemia sometimes the body cannot produce enough haemoglobin. Regular blood transfusions can manage this, but may lead to excess iron in the body, which, if not removed, may damage major organs. Iron chelation therapy removes excess iron; one common chelator is deferiprone. Questions exist about whether deferiprone is as good and safe as the most widely‐used iron chelator, desferrioxamine. Desferrioxamine is administered by a needle under the skin or into a vein, and was the standard monotherapy for 20 years. Seventeen randomised controlled trials compared deferiprone with desferrioxamine. They report little data on death or end organ damage, so we report the effects of therapy using mainly other markers. Removing excess iron was assessed by iron concentration in the blood and liver; heart function; and the amount of iron passed in urine. However, the amount of iron removed with either deferiprone or desferrioxamine was not consistent; one reason being that outcomes were measured differently. This makes it difficult to compare results between trials. Adverse events included joint pain, nausea, stomach upsets and low white blood cell count with deferiprone and pain or skin reactions at the injection site and joint pain with desferrioxamine. In one trial, the risk of an adverse event with deferiprone was twice that of the risk with desferrioxamine. Two further trials showed a three‐fold increased risk of an adverse event with combined deferiprone and desferrioxamine therapy compared with desferrioxamine alone. We found no evidence to change current recommendations to treat iron overload in thalassaemia with deferiprone when desferrioxamine cannot be used or is inadequate. Intensified desferrioxamine treatment or use of other oral iron chelators (or both of these) remains the established treatment to reverse heart problems due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently gave support for deferiprone only to be used as a last resort treatment in patients with thalassaemia, myelodysplasia and sickle cell disease. The danger of raised liver enzymes or a very low white blood cell count with deferiprone means that this treatment should not be used unless close monitoring of full blood counts and liver function is possible. Large trials of chelation therapy with standardised measures of iron stores and end organ damage are needed so valuable trial data can be compared and analysed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA, Brunskill, SJ, Doree, C, Chowdhury, O, Gooding, S, Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004839.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.137Z" }, { "id": "25c2b6dd-c075-4849-a04c-ba925b115683", "pmid": "", "title": "Blood pressure lowering efficacy of beta‐blockers as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Beta‐blockers are one of the more commonly prescribed classes of anti‐hypertensive drugs, both as first‐line and second‐line. Objectives To quantify the effect on systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and withdrawals due to adverse effects of beta‐blocker therapy when given as a second‐line drug in adult patients with primary hypertension. Search methods CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1966‐Aug 2009), EMBASE (1988‐Aug 2009) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized controlled trials comparing a beta‐blocker in combination with a drug from another class of anti‐hypertensive drugs compared with that drug alone for a duration of 3 to 12 weeks in patients with primary hypertension were included. Data collection and analysis Two reviewers independently extracted the data and assessed trial quality of each included study. Main results 20 double‐blind RCTs evaluated the BP lowering efficacy of beta‐blockers as second‐line drug in 3744 hypertensive patients (baseline BP of 158/102 mmHg; mean duration of 7 weeks). The BP reduction from adding a beta‐blocker as the second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. A reduction in BP was seen with adding a beta‐blocker to thiazide diuretics or calcium channel blockers at doses as low as 0.25 times the manufacturer's recommended starting dose. The BP lowering efficacy of beta‐blockers as a second drug was 6/4 mmHg at 1 times the starting dose and 8/6 mmHg at 2 times the starting dose. Beta‐blockers reduced heart rate by 10 beats/min at 1 to 2 times the starting dose. Beta‐blockers did not statistically significantly increase withdrawals due to adverse effects but this was likely due to the lack of reporting of this outcome in 35% of the included RCTs. Authors' conclusions Addition of a beta‐blocker to diuretics or calcium‐channel blockers reduces BP by 6/4mmHg at 1 times the starting dose and by 8/6 mmHg at 2 times the starting dose. When the blood pressure lowering effect of beta‐blockers from this review was compared to that of thiazide diuretics from our previous review ( Chen 2009 ), second‐line beta‐blockers reduce systolic BP to the same extent as second‐line thiazide diuretics, but reduce diastolic BP to a greater degree. The different effect on diastolic BP means that beta‐blockers have little or no effect on pulse pressure whereas thiazides cause a significant dose‐related decrease in pulse pressure. This difference in the pattern of BP lowering with beta‐blockers as compared to thiazides might be the explanation for the fact that beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than thiazide diuretics, particularly in older individuals. Plain language summary Beta‐blockers lower blood pressure when given as a second drug Beta‐blockers are commonly used in the treatment for high blood pressure (BP). In this review, we asked how much do beta‐blockers reduce BP when used as the second drug to treat hypertension. Twenty trials lasting an average of 7 weeks were found in the world scientific literature to answer this question. The data showed that the addition of a beta‐blocker to thiazide diuretics or calcium channel blockers reduced BP by 8/6 mmHg when given at doses 2 times the recommended starting dose. When we compared these results with our previous review of the blood pressure lowering effect of thiazide diuretics as second line drug, we found that beta‐blockers have a different pattern of BP lowering. This different pattern of effect on blood pressure might explain why first‐line beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than first‐line thiazide diuretics, particularly in older individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, JMH, Heran, BS, Perez, MI, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007185.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.794Z" }, { "id": "25e9e37b-3904-4283-96d3-58db1e6051e4", "pmid": "", "title": "Paediatric formulations of artemisinin‐based combination therapies for treating uncomplicated malaria in children", "imported": false, "abstract": "Abstract - Background In endemic malarial areas, young children have high levels of malaria morbidity and mortality. The World Health Organization recommends oral artemisinin‐based combination therapy (ACT) for treating uncomplicated malaria. Paediatric formulations of ACT have been developed to make it easier to treat children. Objectives To evaluate evidence from trials on the efficacy, safety, tolerability, and acceptability of paediatric ACT formulations compared to tablet ACT formulations for uncomplicated P falciparum malaria in children up to 14 years old. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; the Latin American and Caribbean Health Science Information database (LILACS); ISI Web of Science; Google Scholar; Scopus; and the metaRegister of Controlled Trials (mRCT) to 11 December 2019. Selection criteria We included randomised controlled clinical trials (RCTs) of paediatric versus non‐paediatric formulated ACT in children aged 14 years or younger with acute uncomplicated malaria. Data collection and analysis Two authors independently assessed eligibility and risk of bias, and carried out data extraction. We analyzed the primary outcomes of efficacy, safety and tolerability of paediatric versus non‐paediatric ACT using risk ratios (RR) and 95% confidence intervals (CI). Secondary outcomes were: treatment failure on the last day of observation (day 42), fever clearance time, parasite clearance time, pharmacokinetics, and acceptability. Main results Three trials met the inclusion criteria. Two compared a paediatric dispersible tablet formulation against crushed tablets of artemether‐lumefantrine (AL) and dihydroartemisinin‐piperaquine (DHA‐PQ), and one trial assessed artemether‐lumefantrine formulated as powder for suspension compared with crushed tablets. The trials were carried out between 2006 and 2015 in sub‐Saharan Africa (Benin, Mali, Mozambique, Tanzania, Kenya, Democratic Republic of the Congo, Burkina Faso, and The Gambia). In all three trials, the paediatric and control ACT achieved polymerase chain reaction (PCR)‐adjusted treatment failure rates of < 10% on day 28 in the per‐protocol (PP) population. For the comparison of dispersible versus crushed tablets, the two trials did not detect a difference for treatment failure by day 28 (PCR‐adjusted PP population: RR 1.35, 95% CI 0.49 to 3.72; 1061 participants, 2 studies, low‐certainty evidence). Similarly, for the comparison of suspension versus crushed tablet ACT, we did not detect any difference in treatment failure at day 28 (PCR‐adjusted PP population: RR 1.64, 95% CI 0.55 to 4.87; 245 participants, 1 study). We did not detect any difference in serious adverse events for the comparison of dispersible versus crushed tablets (RR 1.05, 95% CI 0.38 to 2.88; 1197 participants, 2 studies, low‐certainty evidence), or for the comparison of suspension versus crushed tablet ACT (RR 0.74, 95% CI 0.17 to 3.26; 267 participants, 1 study). In the dispersible ACT arms, drug‐related adverse events occurred in 9% of children in the AL study and 34% of children in the DHA‐PQ study. In the control arms, drug‐related adverse events occurred in 12% of children in the AL study and in 42% of children in the DHA‐PQ study. Drug‐related adverse events were lower in the dispersible ACT arms (RR 0.78, 95% CI 0.62 to 0.99; 1197 participants, 2 studies, moderate‐certainty evidence). There was no detected difference in the rate of drug‐related adverse events for suspension ACT versus crushed tablet ACT (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study). Drug‐related vomiting appeared to be less common in the dispersible ACT arms (RR 0.75, 95% CI 0.56 to 1.01; 1197 participants, 2 studies, low‐certainty evidence) and in the suspension ACT arm (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study), but both analyses were underpowered. No study assessed acceptability. Authors' conclusions Trials did not demonstrate a difference in efficacy between paediatric dispersible or suspension ACT when compared with the respective crushed tablet ACT for treating uncomplicated P falciparum malaria in children. However, the evidence is of low to moderate certainty due to limited power. There appeared to be fewer drug‐related adverse events with dispersible ACT compared to crushed tablet ACT. None of the included studies assessed acceptability of paediatric ACT formulation. Plain language summary Treating uncomplicated malaria in children: do child‐friendly formulations of medicines work better than usual tablet formulations? What is the aim of this review? We wanted to find out about the potential benefits and harms of child‐friendly formulations of artemisinin‐based combination therapy (ACT) to treat uncomplicated malaria in children. We searched for studies that investigated the use of child‐friendly formulations of ACTs, compared with the usual ACT tablet formulations, to treat uncomplicated malaria in children aged under 14 years. We looked for randomized controlled studies, in which the treatments the children received were decided at random. This type of study usually gives the most reliable evidence about the effects of a treatment. We found three relevant studies of two child‐friendly formulations. Key messages Child‐friendly formulations of ACT probably work as well as crushed tablets to treat uncomplicated malaria in children, and probably cause fewer unwanted effects. What was studied in this review? Malaria is a tropical disease spread by mosquitoes infected with Plasmodium parasites. The most common, and most serious, type of malaria is caused by Plasmodium falciparum . This parasite causes high levels of illness and death, particularly in young children in regions where malaria is widespread. Malaria can be a mild illness, but is sometimes severe and life‐threatening if not treated soon enough or with the right medicines. Medicines based on artemisinin, a compound derived from a plant ( Artemisia annua ), are commonly taken by mouth (orally) to treat malaria in combination with other drugs. The World Health Organization recommends treating uncomplicated malaria with oral artemisinin‐based combination therapy (called ACT). Oral ACT tablets are often crushed to help make them easier for children to swallow. New formulations of oral ACTs have been developed especially for children, such as syrups, and granules, powders or tablets that can be dissolved in water, and which may be flavoured. What are the main results of this review? We found three relevant studies in 1306 children (aged 6 months to 11 years) with uncomplicated malaria. The studies were conducted in sub‐Saharan Africa between 2006 and 2015. All studies were funded by pharmaceutical companies that made child‐friendly formulations of the ACTs. The studies compared crushed ACT tablets to child‐friendly formulations of ACTs: these were dissolvable tablets of artemether‐lumefantrine or dihydroartemisinin‐piperaquine, or artemether‐lumefantrine syrup. We were interested in: · whether children remained cured of malaria after 28 days (measured by absence of Plasmodium parasites in the blood); and · whether the medicines caused any unwanted effects. None of the studies looked at how any of the medicine formulations were accepted by children. There may be little or no difference between the child‐friendly formulations of ACTs (dissolvable tablets or syrup) and the usual crushed tablets for how many children: · were successfully treated after 28 days; or · experienced serious unwanted effects. The crushed ACT tablets and the child‐friendly formulations successfully treated most cases of uncomplicated malaria. After 28 days the rates of treatment failure were similar in both groups. On average, 59 of every 1000 children taking crushed ACT tablets and 62 of every 1000 children taking dissolvable tablets would still have Plasmodium infection (2 studies; 1139 children). Similar numbers of serious unwanted effects were reported for the usual crushed tablets and the dissolvable tablets (2 studies; 1197 children) or syrup (1 study; 267 children), therefore differences as a result of the formulation are unlikely. A dissolvable tablet probably reduces unwanted effects of the medicine, including vomiting (throwing up), compared with the usual crushed tablets. Children taking dissolvable tablets had fewer unwanted effects associated with the medicine (139 of every 1000 children) than those taking crushed tablets (178 of every 1000 children). There was no difference in the number of unwanted effects found in the study with the syrup formulation compared with the usual crushed tablets. Our confidence in our results is low to moderate. The results come from a small number of studies. All studies were supported by manufacturers of the child‐friendly formulations, which could have affected how the studies were designed, conducted, and reported. How up‐to‐date is this review? We searched for studies that had been published up to 11 December 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bélard, S; Ramharter, M; Kurth, F", "articleTypes": [], "doi": "10.1002/14651858.CD009568.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "25f819ba-5c17-41cd-ad00-ca910c1223e3", "pmid": "", "title": "Sucrose analgesia for venepuncture in neonates", "imported": false, "abstract": "Abstract - Rationale Sucrose is, in general, safe and effective for analgesia during venepuncture in hospitalised neonates. However, there is a lack of evidence on its analgesic effects. Objectives To evaluate the benefits and harms of orally administered sucrose for pain relief from venepuncture in preterm and term neonates compared to no intervention, standard care, and other types of analgesic interventions. Search methods We searched CENTRAL, MEDLINE, Ovid Embase, and trial registries in July 2025, and the China National Knowledge Infrastructure, VIP Chinese Science and Technology Periodicals, and Wanfang Data in August 2024. We checked reference lists of included studies and topic‐related systematic reviews. Eligibility criteria We included randomised controlled trials (RCTs), including cross‐over and cluster‐RCTs, that evaluated the effects of sucrose analgesia in neonates (including term and preterm infants) up to 44 weeks' postmenstrual age undergoing venepuncture. We excluded quasi‐RCTs and studies reported only as conference abstracts. We included studies administering sucrose with or without non‐nutritive sucking (NNS) before, at the time of, or after venepuncture. Sucrose could be of any concentration, volume, or dose. Sucrose was compared to: no intervention, water, or standard care; skin‐to‐skin care; breastfeeding; feeding; NNS alone (e.g. pacifier); glucose; positioning; or topical anaesthetics. Outcomes Outcomes of interest were pain intensity score, as measured by validated pain assessment scales, and adverse events. Risk of bias We used the Cochrane risk of bias tool (RoB 1). Synthesis methods We synthesised results for each outcome using meta‐analysis where possible. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous data (presence or absence of pain). We calculated the standardised mean difference (SMD) or mean difference (MD) for pain intensity scores (continuous outcome), each with its 95% CI. We used a fixed‐effect model to combine data and quantified the impact of heterogeneity using the I² statistic. Where these methods were not feasible due to the nature of the data, we synthesised the results narratively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included a total of 29 studies, accounting for 2764 term and preterm neonates. There was a large variation in sucrose dose and concentration (from 0.1 mL/kg to 0.5 mL/kg or a set volume from 0.1 mL to 2 mL) as well as mode of administration (e.g. oral syringe, pacifier, dropper, in combination with a pacifier). Most of the studies compared sucrose to no intervention, water, or standard care (n = 17). Other comparisons include non‐nutritive sucking, skin‐to‐skin care, breastfeeding, expressed breast milk, and other sweet solutions. Synthesis of results Adverse events (e.g. gagging, apnoea) were not reported for any comparison. Sucrose (with or without NNS) versus no intervention, water, or standard care Sucrose with or without NNS probably reduces pain intensity scores during and 30 seconds after venepuncture compared to no intervention (SMD −0.82, 95% CI −1.02 to −0.63; 7 studies, 477 participants; moderate‐certainty evidence). Sucrose with NNS reduces pain intensity scores one minute after venepuncture compared to no intervention (MD −9.15, 95% CI −9.91 to −8.39; 1 study, 100 participants; high‐certainty evidence). The evidence is uncertain about the effect of sucrose without NNS on pain intensity scores two minutes after venepuncture compared to no intervention (SMD −0.99, 95% CI −1.31 to −0.68; 3 studies, 186 participants; very low‐certainty evidence). Sucrose (with or without NNS) versus skin‐to‐skin care Sucrose without NNS may make little to no difference to pain scores during venepuncture when compared to skin‐to‐skin care (MD 1.49, 95% CI 0.86 to 2.12; 2 studies, 208 participants; low‐certainty evidence). Pain scores after 30 seconds, one minute, and two minutes were not reported. Sucrose (with or without NNS) versus breastfeeding Sucrose probably reduces pain during venepuncture compared to breastfeeding, as measured with the Neonatal Facial Coding System (where 0 = no pain, > 0 = pain) (RR 1.38, 95% CI 1.01 to 1.88; 1 study, 103 participants; moderate‐certainty evidence). Sucrose may result in little to no difference in pain compared to breastfeeding two minutes after venepuncture (RR 1.06, 95% CI 0.94 to 1.19; 1 study, 104 participants; low‐certainty evidence). Pain scores after 30 seconds and one minute were not reported. Sucrose (with or without NNS) versus NNS Sucrose with NNS likely reduces pain during venepuncture compared to NNS (SMD −1.52, 95% CI −1.92 to −1.12; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS may not reduce pain intensity scores during venepuncture compared to NNS (MD 1.37, 95% CI 0.57 to 2.17; 2 studies, 133 participants; low‐certainty evidence). Sucrose with NNS may reduce pain intensity scores one minute after venepuncture compared to NNS (MD −5.81, 95% CI −6.30 to −5.32; 2 studies, 200 participants; low‐certainty evidence). Sucrose with NNS probably reduces pain intensity two minutes after venepuncture compared to NNS alone (SMD −1.30, 95% CI −1.71 to −0.89; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS (MD 0.47, 95% CI −0.14 to 1.08; 1 study, 56 participants; moderate‐certainty evidence). We downgraded the certainty of the evidence in several comparisons, mostly due to unclear or high risk of selection, performance, detection, and reporting bias. High heterogeneity was also detected. Authors' conclusions Current evidence suggests sucrose probably reduces pain scores during and shortly after venepuncture compared to no intervention, water, or standard care. The evidence is very uncertain regarding the effects of sucrose compared to skin‐to‐skin care for analgesia during venepuncture. Compared to breastfeeding, sucrose probably results in a reduction of pain scores during venepuncture, but may result in little difference in pain scores two minutes after venepuncture. The evidence suggests sucrose with NNS probably reduces pain scores during and following venepuncture compared to NNS alone. Sucrose alone probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS. Funding This review had no dedicated funding. Registration Protocol available via doi/10.1002/14651858.CD015221 Plain language summary Does giving newborns sugar water during needle procedures reduce their pain? Key messages Newborn babies given sucrose (sugar water) when undergoing a needle procedure probably have less pain during and shortly after the procedure than babies given nothing, water, or standard comfort measures. Sucrose seems to reduce pain more than pacifiers. We do not have good evidence about the effect of sucrose compared to skin‐to‐skin care. No studies reported on harmful side effects, such as gagging or apnoea (a temporary pause in breathing). What is sucrose analgesia (pain relief)? Sucrose is table sugar. When mixed with water, and in very small amounts, it can be used for pain relief in newborn babies. Sucrose is dropped on a baby's tongue about two minutes before and/or immediately before venepuncture, when a needle is put into a vein to take blood or give treatment. Why is pain relief important for newborn babies who are in hospital? Hospitalised preterm babies (i.e. born early) and term babies (i.e. born at the normal time) are exposed to many painful procedures to give them medicine and to diagnose problems. Pain has many consequences for newborn babies. It can contribute to poor physical growth and affect brain development. Therefore, it is important to reduce babies' experience of pain as much as possible to ensure health as they grow. What did we want to find out? We wanted to find out how well sucrose worked to relieve pain in newborn babies during and shortly after needle punctures. We wanted to know how sucrose compared to other pain relief methods such as pacifier sucking, breastfeeding, or being held next to a mother or father's skin (skin‐to‐skin care). We also wanted to find out if sucrose caused negative effects. What did we do? We searched for studies that investigated the pain‐relief effects of sucrose compared to other methods (e.g. breastfeeding, pacifiers, holding). We summarised the results and rated our confidence in the evidence based on factors such as the number of infants treated and the quality of the methods used in the studies. What did we find? We found 29 studies that included 2764 newborn babies. The studies used different doses of sucrose and gave the sucrose to the babies in different ways. The studies were conducted worldwide. Most were carried out in Asia, with additional studies from Europe, North America, and South America. All the studies were randomised controlled trials, in which infants were assigned randomly to two or more treatment groups. This is the best way to ensure that the infant groups are similar, and that investigators and parents don’t know who is in which group. None of the studies were supported by the pharmaceutical industry. Main results Sucrose probably reduces babies' pain during and shortly after (30 seconds to 1 minute) the needle insertion compared to no pain relief (such as water). Sucrose may make little to no difference to pain during the procedure compared to skin‐to‐skin care. Sucrose probably reduces pain during the needle insertion compared to breastfeeding. Sucrose (with pacifier sucking) likely reduces pain during and shortly after (30 seconds to 2 minutes) the needle insertion compared to pacifier sucking alone. No study reported on harmful effects for any of our comparisons of interest. What are the limitations of the evidence? Sucrose versus no intervention or water We are moderately confident that sucrose probably reduces pain compared to no intervention. However, it is possible that people in the studies were aware of which treatment babies were receiving, and the studies involved small numbers of babies. Sucrose versus skin‐to‐skin care We are not confident that sucrose reduces pain more than skin‐to‐skin care because the two studies reported very different results. Further research is likely to change these results. Sucrose versus breastfeeding We are moderately confident that sucrose probably reduces pain more than breastfeeding. However, the study did not clearly report details of how it was conducted. Sucrose versus pacifier We are moderately confident that sucrose with a pacifier probably reduces pain more than pacifiers alone. The studies differed in how sucrose was given, including the amount of sucrose, how it was administered, and whether it was given with or without a pacifier. How current is this evidence? This evidence is current to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Bueno, M; Candido, L; Hu, J; Fiander, M; Cracknell, J; Xu, E; Kang, J; Yamada, J", "articleTypes": [], "doi": "10.1002/14651858.CD015221.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "25fb1809-d44b-4442-8f5f-a264f727fb54", "pmid": "", "title": "Graft interposition for preventing Frey's syndrome in patients undergoing parotidectomy", "imported": false, "abstract": "Abstract - Background Frey's syndrome is characterised by transient flushing and sometimes facial sweating in the area of the auriculotemporal nerve. It most commonly occurs after parotidectomy, but other causes may include submandibular gland surgery, mandibular condylar fracture, obstetric (forceps) trauma, sympathectomy and metabolic disease. Although the pathophysiology of Frey's syndrome remains controversial, the generally accepted hypothesis is that it occurs as the result of injury to the auriculotemporal nerve. There is currently no clear evidence to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome, therefore the prevention of this symptom during surgery is important. The main method used for prevention is the interposition of a graft between the skin flap and the parotid bed during surgery. Biomaterials, allograft or autograft can be used for this purpose. Objectives To evaluate the effects and safety of biomaterial, allograft or autograft interposition for the prevention of Frey's syndrome in patients undergoing parotidectomy, and to identify its effect on prevention and delayed occurrence. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Cochrane Register of Controlled Trials (CENTRAL; 2019, Issue 2); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 5 February 2019. Selection criteria We included randomised controlled trials (RCTs) in patients with parotid disease (including tumours, inflammation, trauma etc.) undergoing parotidectomy with a minimal follow‐up period of six months. We planned to include trials with interventions including biomaterial, allograft or autograft interposition alone or in combination with other surgical techniques. We included trials that compared any graft interposition and no graft interposition, or different graft interpositions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were incidence rate of Frey's syndrome assessed clinically (Minor's starch‐iodine test) and other complications (postoperative infection, subjective painful or restricted cervical movement, scar spread, rejection of the graft, complications related to the donor site such as accessory nerve injury and haematoma). Our secondary outcome measures were incidence rate of Frey's syndrome assessed by participants (by questionnaire) and sweating area assessed by Minor's starch‐iodine test. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included three RCTs (124 participants), two of which we assessed as at high risk of bias and one at unclear risk of bias. All studies were hospital‐based and recruited participants undergoing superficial parotidectomy. Most participants were diagnosed with benign lesions of the parotid gland. Participants were followed up for more than six months. The studies evaluated the two comparisons shown below: Sternocleidomastoid muscle flap versus no flap Two studies assessed this comparison. Both assessed the effects of the sternocleidomastoid muscle flap procedure on the incidence rate of Frey's syndrome assessed clinically but neither showed a significant difference between groups (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.23; 24 participants and RR 1.23, 95% CI 0.88 to 1.73; 36 participants; very low‐certainty evidence). We did not pool the data due to the high heterogeneity (I² = 87%). One study found that the sternocleidomastoid muscle flap may result in little or no difference in other complications including haematoma (RR 2.18, 95% CI 0.09 to 50.16; 36 participants; low‐certainty evidence), subjective painful or restricted cervical movement (RR 0.54, 95% CI 0.14 to 2.05; 36 participants; low‐certainty evidence) and scar spread in the cervical region (RR 0.71, 95% CI 0.05 to 10.54; 36 participants; low‐certainty evidence). Both studies reported the incidence rate of Frey's syndrome assessed by participants, with one reporting no events in either group and the other finding no evidence of a difference (RR 0.63, 95% CI 0.32 to 1.26; 36 participants; low‐certainty evidence). Acellular dermal matrix versus no graft Only one study assessed this comparison. Use of an acellular dermal matrix graft may result in little or no difference to the incidence rate of Frey's syndrome (assessed clinically) in comparison with the no graft group, but the evidence is very uncertain (RR 0.08, 95% CI 0.00 to 1.25; 30 participants; very low‐certainty evidence). Acellular dermal matrix may slightly increase the wound infection rate compared with control (RR 17.00, 95% CI 1.02 to 282.67; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence of seromas or sialoceles (RR 2.33, 95% CI 0.66 to 8.23; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence rate of Frey's syndrome (assessed by participants) in comparison with the no graft group (RR 0.33, 95% CI 0.04 to 3.04; 64 participants; low‐certainty evidence). Authors' conclusions The evidence for the effectiveness of graft interposition in preventing Frey's syndrome is of low or very low certainty. The use of acellular dermal matrix may be associated with an increase in the wound infection rate, and little or no difference in the incidence of seromas or sialoceles. Further studies are needed to draw reliable conclusions. Plain language summary Grafts for preventing Frey's syndrome after surgery to the parotid (salivary) glands Review question Does the use of a graft during surgery to the parotid glands prevent Frey's syndrome? Background The clinical symptoms of Frey's syndrome include sweating and flushing of the cheek when eating and chewing. It results from abnormal regrowth of damaged autonomic nerve fibres of the parotid glands, for example during surgery for parotid gland tumours. It is unclear whether placing a graft between the skin flap and the parotid bed during surgery can prevent this syndrome. Various types of grafts can be used, including biomaterial or skin, muscle or other tissue from the patient. These grafts may possibly hinder the abnormal connections of the nerves controlling the sweat glands and parotid glands when the cut nerves are re‐linking after surgery. Study characteristics We included three studies with 124 participants in this review, but the quality of these studies was not ideal. All of the participants in the studies had tumours of the parotid glands and were undergoing surgery to part of the glands. The studies assessed two types of grafts, tissue obtained from the sternocleidomastoid muscle and a biomaterial (a collagen framework without cells). Key results Two studies compared a tissue graft obtained from the sternocleidomastoid muscle to no graft. It is not known whether this type of tissue graft can prevent Frey's syndrome because the available evidence is very uncertain. One study compared a biomaterial graft to no graft. This type of graft may result in little or no difference to the incidence rate of Frey's syndrome, but the evidence is very uncertain. It may make the patient's wound slightly more likely to become infected. Certainty of the evidence The evidence in this review is mostly of low or very low certainty, because of the small number of studies on this question and the risk of bias in these studies. The findings must therefore be treated with caution and further studies are needed to draw reliable conclusions. The evidence in this review is up to date to 5 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ye, L, Cao, Y, Yang, W, Wu, F, Lin, J, Li, L, Li, C", "articleTypes": [], "doi": "10.1002/14651858.CD012323.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.066Z" }, { "id": "2605a2d7-1e40-46d0-91f6-101ed4245a6a", "pmid": "", "title": "Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common, life‐shortening, genetic disorder in populations of Northern European descent caused by the mutation of a single gene that codes for the production of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. This protein coordinates the transport of salt (and bicarbonate) across cell surfaces, and the mutation most notably affects the airways. In the lungs of people with CF, the defective protein compromises mucociliary clearance and makes the airway prone to chronic infection and inflammation, damaging the structure of the airways and eventually leading to respiratory failure. In addition, abnormalities in the truncated CFTR protein lead to other systemic complications, including malnutrition, diabetes and subfertility. Five classes of mutation have been described, depending on the impact of the mutation on the processing of the CFTR protein in the cell. In class I mutations, premature termination codons prevent the production of any functional protein, resulting in severe CF. Therapies targeting class I mutations aim to enable the normal cellular mechanism to read through the mutation, potentially restoring the production of the CFTR protein. This could, in turn, normalise salt transport in the cells and decrease the chronic infection and inflammation that characterises lung disease in people with CF. This is an update of a previously published review. Objectives To evaluate the benefits and harms of ataluren and similar compounds on clinically important outcomes in people with CF with class I mutations (premature termination codons). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles. The last search of the Cochrane Cystic Fibrosis Trials Register was conducted on 7 March 2022. We searched clinical trial registries maintained by the European Medicines Agency, the US National Institutes of Health and the World Health Organization. The last search of the clinical trials registries was conducted on 4 October 2022. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing ataluren and similar compounds (specific therapies for class I mutations) with placebo in people with CF who have at least one class I mutation. Data collection and analysis For the included trials, the review authors independently extracted data, assessed the risk of bias and evaluated the certainty of the evidence using GRADE; trial authors were contacted for additional data. Main results Our searches identified 56 references to 20 trials; of these, 18 trials were excluded. Both the included parallel RCTs compared ataluren to placebo for 48 weeks in 517 participants (males and females; age range six to 53 years) with CF who had at least one nonsense mutation (a type of class I mutation). The certainty of evidence and risk of bias assessments for the trials were moderate overall. Random sequence generation, allocation concealment and blinding of trial personnel were well documented; participant blinding was less clear. Some participant data were excluded from the analysis in one trial that also had a high risk of bias for selective outcome reporting. PTC Therapeutics Incorporated sponsored both trials with grant support from the Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the National Institutes of Health. The trials reported no difference between treatment groups in terms of quality of life, and no improvement in respiratory function measures. Ataluren was associated with a higher rate of episodes of renal impairment (risk ratio 12.81, 95% confidence interval 2.46 to 66.65; P = 0.002; I 2 = 0%; 2 trials, 517 participants). The trials reported no treatment effect for ataluren for the review's secondary outcomes of pulmonary exacerbation, computed tomography score, weight, body mass index and sweat chloride. No deaths were reported in the trials. The earlier trial performed a post hoc subgroup analysis of participants not receiving concomitant chronic inhaled tobramycin (n = 146). This analysis demonstrated favourable results for ataluren (n = 72) for the relative change in forced expiratory volume in one second (FEV 1 ) per cent (%) predicted and pulmonary exacerbation rate. The later trial aimed to prospectively assess the efficacy of ataluren in participants not concomitantly receiving inhaled aminoglycosides, and found no difference between ataluren and placebo in FEV 1 % predicted and pulmonary exacerbation rate. Authors' conclusions There is currently insufficient evidence to determine the effect of ataluren as a therapy for people with CF with class I mutations. One trial reported favourable results for ataluren in a post hoc subgroup analysis of participants not receiving chronic inhaled aminoglycosides, but these were not reproduced in the later trial, suggesting that the earlier results may have occurred by chance. Future trials should carefully assess for adverse events, notably renal impairment, and consider the possibility of drug interactions. Cross‐over trials should be avoided, given the potential for the treatment to change the natural history of CF. Plain language summary Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis Review question Can ataluren (and similar compounds specifically targeting class I mutations in cystic fibrosis (CF)) improve the quality of life and lung function of people with CF without having adverse effects? Key messages What is CF? In people with CF, the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. This especially affects the airways, causing the airway surface to dry out and making it difficult to clear thick mucus. This leads to progressive infection and damages the lungs, shortening life expectancy. How will ataluren treat CF? In people with certain CF genetic mutations where the genetic instructions for producing the CFTR protein are interrupted (known as premature termination codon or class I mutations), ataluren (and similar medicines) may be able to skip over the break in the faulty gene sequence and allow the body to produce a corrected version of the CFTR protein. By correcting the protein, the airway surface should remain hydrated, allowing people with CF to better clear their mucus and so develop fewer lung infections. What did we want to find out? We wanted to know whether ataluren can improve the quality of life and lung function of people with CF, and whether it can do so without any side effects. We also wanted to measure the effects on lung infections (need for hospital visits or additional antibiotics), survival, nutritional status (weight, body mass index and height) and whether treatment was cost‐effective. What did we do? We searched for trials that directly compared drugs such as ataluren to placebo (treatment not containing an active drug) or to a different treatment for these specific genetic mutations in any people with CF. What did we find? We found two trials including 517 people (males and females between 6 and 53 years of age) comparing ataluren to a placebo. The trials lasted 48 weeks and everyone taking part in the trials had at least one gene with a class I mutation. Key results In people taking ataluren, there was no improvement in clinical outcomes such as quality of life, lung function, exacerbations (flare up of disease), sweat chloride (salt) levels or weight compared with people taking placebo. The trials found that kidney damage was more common in people taking ataluren. The earlier trial analysed their results in a way not originally planned to see whether the effects of ataluren and placebo were different in people using inhaled tobramycin (an antibiotic) on a long‐term basis compared with people not taking the inhaled antibiotic. In people taking ataluren but not using inhaled tobramycin, lung function declined at a slower rate and there were fewer exacerbations than in people in the placebo group also not using inhaled tobramycin. The later trial specifically recruited people not taking tobramycin to see whether this really was an effect of the antibiotic, but the investigators did not find any difference between the ataluren and placebo groups for changes in lung function or exacerbations. This suggests that the earlier results occurred by chance. There were no deaths and we did not find any differences between ataluren and placebo in side effects or nutritional status. Neither trial reported on hospitalisations, extra courses of antibiotics or cost‐effectiveness. We have not found enough high‐quality evidence to determine the effect of ataluren for treating CF. We recommend that future trials are designed and reported clearly so that their results can be included in a systematic review. What are the limitations of the evidence? We are moderately confident in our findings, but there is some uncertainty due to how widely the results varied between participants. We are satisfied that everyone taking part had an equal chance of being in either group (ataluren or placebo) and that no one could work out which group the next person would be put into (so that healthier people did not receive the treatment and make the results seem better). We believe that the clinicians running the trials and those taking part in the trials did not know which treatment each person was receiving. We have some concerns about the emphasis the investigators of one trial placed on the results of a comparison they had not planned (the use of long‐term inhaled tobramycin). Unfortunately, that trial did not report all its results clearly. Sometimes, the results were reported in a way that meant they could not be used in this review, and sometimes the information was not reported at all. This affected our confidence in the overall results. Trial funding sources Both trials were sponsored by PTC Therapeutics Incorporated, who make ataluren. The Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the US National Institutes of Health also supported the trials. How up to date is this evidence? We last searched for evidence on 4 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aslam, AA; Sinha, IP; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD012040.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "2624576c-78b5-4923-9c2c-14d616d611b3", "pmid": "", "title": "Antipsychotics for fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue. It affects approximately 2% of the general population. Up to 70% of patients with fibromyalgia meet the criteria for a depressive or anxiety disorder. People often report high disability levels and poor health‐related quality of life. Drug therapy focuses on reducing key symptoms and disability, and improving health‐related quality of life. Antipsychotics might reduce fibromyalgia and associated mental health symptoms. Objectives To assess the efficacy, tolerability and safety of antipsychotics in fibromyalgia in adults. Search methods We searched CENTRAL (2016, Issue 4), MEDLINE and EMBASE to 20 May 2016, together with reference lists of retrieved papers and reviews and two clinical trial registries. We also contacted trial authors. Selection criteria We selected controlled trials of at least four weeks duration of any formulation of antipsychotics used for the treatment of fibromyalgia in adults. Data collection and analysis We extracted the data from all included studies and two review authors independently assessed study risks of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. We derived first tier evidence from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs, at least 200 participants in the comparison, eight to 12 weeks duration, parallel design), second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison, and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. We rated the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main results We included a total of four studies with 296 participants. Three studies with 206 participants compared quetiapine, an atypical (second‐generation) antipsychotic, with placebo. One study used a cross‐over design and two studies a parallel‐group design. Study duration was eight or 12 weeks. Quetiapine was used in all studies with a bedtime dosage between 50 and 300 mg/day. All studies had one or more sources of potential major bias and we judged them to be at moderate risk of bias overall. The primary outcomes in this review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Second tier evidence indicated that quetiapine was not statistically superior to placebo in the number of participants with a 50% or more pain reduction (very low quality evidence). No study reported data on PGIC. A greater proportion of participants on quetiapine reported a 30% or more pain reduction (risk difference (RD) 0.12, 95% confidence interval (CI) 0.00 to 0.23; number needed to treat for an additional benefit (NNTB) 8, 95% CI 5 to 100) (very low quality evidence). A greater proportion of participants on quetiapine reported a clinically relevant improvement of health‐related quality of life compared to placebo ( RD 0.18, 95% CI 0.05 to 0.31; NNTB 5, 95% CI 3 to 20) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing sleep problems (standardised mean difference (SMD) ‐0.67, 95% CI ‐1.10 to ‐0.23), depression (SMD ‐0.39, 95% CI ‐0.74 to ‐0.04) and anxiety (SMD ‐0.40, 95% CI ‐0.69 to ‐0.11) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing the risk of withdrawing from the study due to a lack of efficacy (RD ‐0.14, 95% CI ‐0.23 to ‐0.05) (very low quality evidence). There was no statistically significant difference between quetiapine and placebo in the proportion of participants withdrawing due to adverse events (tolerability) (very low quality evidence), in the frequency of serious adverse events (safety) (very low quality evidence) and in the proportion of participants reporting dizziness and somnolence as an adverse event (very low quality evidence). In more participants in the quetiapine group a substantial weight gain was noted (RD 0.08, 95% CI 0.02 to 0.15; number needed to treat for an additional harm (NNTH) 12, 95% CI 6 to 50) (very low quality evidence). We downgraded the quality of evidence by three levels to a very low quality rating because of limitations of study design, indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). One parallel design study with 90 participants compared quetiapine (50 to 300 mg/day flexible at bedtime) to amitriptyline (10 to 75 mg/day flexible at bedtime). The study had three major risks of bias and we judged it to be at moderate risk of bias overall. We downgraded the quality of evidence by two levels to a low quality rating because of indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). Third tier evidence indicated no statistically significant differences between the two drugs. Both drugs did not statistically significantly differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life and in the proportion of participants reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared to amitriptyline, more participants left the study due to adverse events (low quality evidence). No serious adverse events were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia. Authors' conclusions Very low quality evidence suggests that quetiapine may be considered for a time‐limited trial (4 to 12 weeks) to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits in shared decision making with the patient. Plain language summary Antipsychotics for fibromyalgia symptoms in adults Bottom line Quetiapine may be considered for 4 to 12 weeks to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as sleep problems, problems with thinking and exhaustion. They often report severe limitations of daily functioning and poor quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. In addition, many patients with fibromyalgia suffer from depression. Medicines used to treat depression can reduce the main symptoms in some people with fibromyalgia. Quetiapine is a drug for the treatment of psychosis (an abnormal condition of the mind described as involving a loss of contact with reality), which is also licensed for the treatment of major depression in some countries. Study characteristics In May 2016, we searched for clinical trials in which antipsychotics were used to treat symptoms of fibromyalgia in adults. We found a total of four studies with 298 participants. We found three studies with 208 participants, which were eight and 12 weeks long and compared quetiapine, an antipsychotic, against a fake medication (placebo). One hundred and sixty‐six participants were diagnosed with major depression. We also found one study comprising 90 patients that compared quetiapine to an antidepressant named amitriptyline, which is frequently used in the treatment of fibromyalgia. Five people in this study were diagnosed with major depression. Key results and quality of the evidence Quetiapine was not better than a fake medication in achieving a pain reduction of 50% or more (very low quality evidence). Quetiapine was better than the fake medication in achieving a pain reduction of 30% or more, reducing sleep problems, and improving depressed mood and anxiety (very low quality evidence). Quetiapine was better than the fake medication in improving health‐related quality of life. Fewer participants dropped out of the trial due to lack of efficacy with quetiapine than with fake medication (very low quality evidence). There was no difference in tolerability and safety between quetiapine and a fake medication (very low quality evidence). For some people, quetiapine led to substantial weight gain and somnolence (sleepiness). Quetiapine and amitriptyline (an antidepressant which is frequently used to improve sleep and reduce pain in people with fibromyalgia) did not differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life. Both drugs did not differ in the proportion of patients reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared with amitriptyline, more people experienced side effects and left the study due to side effects with quetiapine (low quality evidence). No serious side effects with either drug were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B; Klose, P; Üçeyler, N; Phillips, T; Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011804.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "262f6276-c056-4f50-84d3-89362573898e", "pmid": "", "title": "Antibiotics for induction and maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Several antibiotics have been evaluated in Crohn's disease (CD), however randomised controlled trials (RCTs) have produced conflicting results. Objectives To assess the efficacy and safety of antibiotics for induction and maintenance of remission in CD. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and Clinicaltrials.gov database from inception to 28 February 2018. We also searched reference lists and conference proceedings. Selection criteria RCTs comparing antibiotics to placebo or an active comparator in adult (> 15 years) CD patients were considered for inclusion. Data collection and analysis Two authors screened search results and extracted data. Bias was evaluated using the Cochrane risk of bias tool. The primary outcomes were failure to achieve clinical remission and relapse. Secondary outcomes included clinical response, endoscopic response, endoscopic remission, endoscopic relapse, histologic response, histologic remission, adverse events (AEs), serious AEs, withdrawal due to AEs and quality of life. Remission is commonly defined as a Crohn's disease activity index (CDAI) of < 150. Clinical response is commonly defined as a decrease in CDAI from baseline of 70 or 100 points. Relapse is defined as a CDAI > 150. For studies that enrolled participants with fistulizing CD, response was defined as a 50% reduction in draining fistulas. Remission was defined as complete closure of fistulas. We calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for dichotomous outcomes. We calculated the mean difference (MD) and corresponding 95% CI for continuous outcomes. GRADE was used to assess the certainty of the evidence. Main results Thirteen RCTs (N = 1303 participants) were eligible. Two trials were rated as high risk of bias (no blinding). Seven trials were rated as unclear risk of bias and four trials were rated as low risk of bias. Comparisons included ciprofloxacin (500 mg twice daily) versus placebo, rifaximin (800 to 2400 mg daily) versus placebo, metronidazole (400 mg to 500 mg twice daily) versus placebo, clarithromycin (1 g/day) versus placebo, cotrimoxazole (960 mg twice daily) versus placebo, ciprofloxacin (500 mg twice daily) and metronidazole (250 mg four time daily) versus methylprednisolone (0.7 to 1 mg/kg daily), ciprofloxacin (500 mg daily), metronidazole (500 mg daily) and budesonide (9 mg daily) versus placebo with budesonide (9 mg daily), ciprofloxacin (500 mg twice daily) versus mesalazine (2 g twice daily), ciprofloxacin (500 mg twice daily) with adalimumab versus placebo with adalimumab, ciprofloxacin (500 mg twice daily) with infliximab versus placebo with infliximab, clarithromycin (750 mg daily) and antimycobacterial versus placebo, and metronidazole (400 mg twice daily) and cotrimoxazole (960 mg twice daily) versus placebo. We pooled all antibiotics as a class versus placebo and antibiotics with anti‐tumour necrosis factor (anti‐TNF) versus placebo with anti‐TNF. The effect of individual antibiotics on CD was generally uncertain due to imprecision. When we pooled antibiotics as a class, 55% (289/524) of antibiotic participants failed to achieve remission at 6 to 10 weeks compared with 64% (149/231) of placebo participants (RR 0.86, 95% CI 0.76 to 0.98; 7 studies; high certainty evidence). At 10 to 14 weeks, 41% (174/428) of antibiotic participants failed to achieve a clinical response compared to 49% (93/189) of placebo participants (RR 0.77, 95% CI 0.64 to 0.93; 5 studies; moderate certainty evidence). The effect of antibiotics on relapse in uncertain. Forty‐five per cent (37/83) of antibiotic participants relapsed at 52 weeks compared to 57% (41/72) of placebo participants (RR 0.87, 95% CI 0.52 to 1.47; 2 studies; low certainty evidence). Relapse of endoscopic remission was not reported in the included studies. Antibiotics do not appear to increase the risk of AEs. Thirty‐eight per cent (214/568) of antibiotic participants had at least one adverse event compared to 45% (128/284) of placebo participants (RR 0.87, 95% CI 0.75 to 1.02; 9 studies; high certainty evidence). The effect of antibiotics on serious AEs and withdrawal due to AEs was uncertain. Two per cent (6/377) of antibiotic participants had at least one adverse event compared to 0.7% (1/143) of placebo participants (RR 1.70, 95% CI 0.29 to 10.01; 3 studies; low certainty evidence). Nine per cent (53/569) of antibiotic participants withdrew due to AEs compared to 12% (36/289) of placebo participants (RR 0.86, 95% CI 0.57 to 1.29; 9 studies; low certainty evidence) is uncertain. Common adverse events in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation and headache, change in taste and paraesthesia When we pooled antibiotics used with anti‐TNF, 21% (10/48) of patients on combination therapy failed to achieve a clinical response(50% closure of fistulas) or remission (closure of fistulas) at week 12 compared with 36% (19/52) of placebo and anti‐TNF participants (RR 0.57, 95% CI 0.29 to 1.10; 2 studies; low certainty evidence). These studies did not assess the effect of antibiotics and anti‐TNF on clinical or endoscopic relapse. Seventy‐seven per cent (37/48) of antibiotics and anti‐TNF participants had an AE compared to 83% (43/52) of anti‐TNF and placebo participants (RR 0.93, 95% CI 0.76 to 1.12; 2 studies, moderate certainty evidence). The effect of antibiotics and anti‐TNF on withdrawal due to AEs is uncertain. Six per cent (3/48) of antibiotics and anti‐TNF participants withdrew due to an AE compared to 8% (4/52) of anti‐TNF and placebo participants (RR 0.82, 95% CI 0.19 to 3.45; 2 studies, low certainty evidence). Common adverse events included nausea, vomiting, upper respiratory tract infections, change in taste, fatigue and headache Authors' conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be modest and may not be clinically meaningful. High quality evidence suggests that there is no increased risk of adverse events with antibiotics compared to placebo. The effect of antibiotics on the risk of serious adverse events is uncertain. The effect of antibiotics on maintenance of remission in CD is uncertain. Thus, no firm conclusions regarding the efficacy and safety of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the efficacy and safety of antibiotics as therapy in CD Plain language summary Antibiotics for the treatment of Crohn's disease What is Crohn's disease? Crohn's disease (CD) is an inflammatory disorder that can affect any segment of the gastrointestinal tract from the mouth to the anus. Common symptoms of CD include fever, diarrhea, abdominal pain and weight loss. CD is characterized by periods of relapse when people experience symptoms and periods of remission when the symptoms stop. What are antibiotics? Antibiotics are medications used to treat bacterial infections. Antibiotics are designed to target specific bacterial populations and have different mechanisms of action to stop a bacterial population from growing or eradicate the bacteria. What is the purpose this study? Antibiotics are commonly used for managing patients with CD because the inflammatory process in the bowel was believed to be triggered by a specific bacterial pathogen. Elimination of this bacterial target would allow the inflammatory process to resolve. However, current clinical guidelines do not recommend use of antibiotic agents to induce or maintain clinical remission in patients with CD because there is no definitive evidence to suggest a benefit to using antibiotics in this way. How was this study performed? A systematic review of current literature was performed to determine whether antibiotic therapy is effective to induce or maintain remission in CD. An electronic search of several databases was performed and studies that met our inclusion criteria were selected for further evaluation. Statistical analyses were performed to determine which specific antibiotics had an overall benefit. What were the results? Several antibiotics, including ciprofloxacin, metronidazole, clarithromycin, rifaximin and cotrimoxazole, have been studied in CD. Most of the included studies were small in size. When we pooled antibiotics as a class, these drugs provided a modest benefit over placebo (i.e. a fake drug such as a sugar pill) for induction of remission and improvement of CD symptoms. For example, remission rates were 45% (253/542) in participants who received antibiotics compared to 36% (82/231) in participants who received placebo. We rated the quality of evidence supporting this outcome as high. Few studies assessed the use of antibiotics for maintenance of remission in CD. The impact of antibiotics on preventing relapse in CD is uncertain. Antibiotics do not appear to increase the risk of side effects when compared to placebo. Common side effects reported in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation, headache, change in taste and paraesthesia (pins and needles in the extremities). Serious side effects were not well reported in the studies and the impact of antibiotics on the risk of serious side effects is uncertain. Conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be very modest. High quality evidence suggests that there is no increased risk of side effects with antibiotics compared to placebo. The effect of antibiotics on the risk of serious side effects is uncertain. The effect of antibiotics on preventing relapse in CD is uncertain. Thus, no firm conclusions regarding the benefits and harms of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the harms and benefits of antibiotic therapy in CD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Townsend, CM; Parker, CE; MacDonald, JK; Nguyen, TM; Jairath, V; Feagan, BG; Khanna, R", "articleTypes": [], "doi": "10.1002/14651858.CD012730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "263a40ce-f846-4817-be44-5ddf2379667e", "pmid": "", "title": "Preoperative fasting for preventing perioperative complications in children", "imported": false, "abstract": "Abstract - Background Children, like adults, are required to fast before general anaesthesia with the aim of reducing the volume and acidity of their stomach contents. It is thought that fasting reduces the risk of regurgitation and aspiration of gastric contents during surgery. Recent developments have encouraged a shift from the standard 'nil‐by‐mouth‐from‐midnight' fasting policy to more relaxed regimens. Practice has been slow to change due to questions relating to the duration of a total fast, the type and amount of intake permitted. Objectives To systematically assess the effects of different fasting regimens (duration, type and volume of permitted intake) and the impact on perioperative complications and patient well being (aspiration, regurgitation, related morbidity, thirst, hunger, pain, comfort, behaviour, nausea and vomiting) in children. Search methods We searched Cochrane Wounds Group Specialised Register (searched 25/6/09), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 2 2009), Ovid MEDLINE (1950 to June Week 2 2009), Ovid EMBASE (1980 to 2009 Week 25), EBSCO CINAHL (1982 to June Week 3 2009), the National Research Register, relevant conference proceedings and article reference lists and contacted experts. Selection criteria Randomised and quasi randomised controlled trials of preoperative fasting regimens for children were identified. Data collection and analysis Data extraction and trial quality assessment was conducted independently by three authors. Trial authors were contacted for additional information including adverse events. Main results This first update of the review identified two additional eligible studies, bringing the total number of included studies to 25 (forty seven randomised controlled comparisons involving 2543 children considered to be at normal risk of regurgitation or aspiration during anaesthesia). Only one incidence of aspiration and regurgitation was reported. Children permitted fluids up to 120 minutes preoperatively were not found to experience higher gastric volumes or lower gastric pH values than those who fasted. The children permitted fluids were less thirsty and hungry, better behaved and more comfortable than those who fasted. Clear fluids preoperatively did not result in a clinically important difference in children's gastric volume or pH. Evidence relating to the preoperative intake of milk was sparse. The volume of fluid permitted during the preoperative period did not appear to impact on children's intraoperative gastric volume or pH contents. Authors' conclusions There is no evidence that children who are denied oral fluids for more than six hours preoperatively benefit in terms of intraoperative gastric volume and pH compared with children permitted unlimited fluids up to two hours preoperatively. Children permitted fluids have a more comfortable preoperative experience in terms of thirst and hunger. This evidence applies only to children who are considered to be at normal risk of aspiration/regurgitation during anaesthesia. Plain language summary Preoperative fasting for children to prevent complications during surgery General anaesthetics inhibit the protective reflexes that stop the stomach contents reaching the lungs. In order to prevent the inadvertent inhalation of stomach contents, children are often advised to have nothing to eat or drink from the midnight before surgery. However, the review of trials found that drinking clear fluids up to a few hours before surgery did not increase the risk of regurgitation during or after surgery. Indeed there is an added benefit of a more comfortable preoperative experience in terms of thirst and hunger. Some children are considered more likely to regurgitate under anaesthetic, including those who are obese or have stomach disorders. More research is needed to determine whether these children can also safely drink up to a few hours before surgery.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brady, MC; Kinn, S; Ness, V; O'Rourke, K; Randhawa, N; Stuart, P", "articleTypes": [], "doi": "10.1002/14651858.CD005285.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "264b0703-f5f7-4f70-8d51-78c1efa18fdf", "pmid": "", "title": "Multisensory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Multisensory stimulation is a structured, developmentally appropriate intervention that provides simultaneous or sequential stimulation of two or more senses (e.g. tactile, auditory, visual, or vestibular) in a controlled and non‐stressful manner, with the aim of supporting early neurodevelopment in preterm infants. It has the potential to enhance physiological regulation in preterm infants by stabilizing key functions, such as respiratory patterns, heart rate, and oxygen saturation; reducing the need for respiratory support; and improving feeding performance and sleep regulation. Targeted multisensory interventions have also been associated with improved neurodevelopmental outcomes, including enhanced psychomotor development and visual function. Objectives To assess the benefits and harms of multisensory stimulation compared to any single sensory intervention or standard care on major neurodevelopmental disability, mortality, and growth in preterm infants. Search methods We searched CENTRAL, MEDLINE, Embase, Emcare, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 28 November 2025. We checked reference lists of included trials, and systematic reviews on sensory interventions. Eligibility criteria We included 18 randomized controlled trials (RCTs) comparing multisensory stimulation in preterm infants with no intervention (placebo or standard care), and one RCT comparing multisensory stimulation with single‐sense stimulation (tactile stimulation). Outcomes Our critical outcomes were major neurodevelopmental disability at 18 to 24 months: cerebral palsy (CP), developmental delay, intellectual impairment, blindness, sensorineural deafness; death during initial hospitalization; and total weight gain (grams), assessed at discharge. When comparing multisensory stimulation with single‐sense intervention, we also included weight gain during the intervention, an outcome added during the post‐hoc analysis. Important outcomes were duration of hospital stay, of NICU stay, and of respiratory support; and time until full oral feeding. Risk of bias We used the Cochrane tool, RoB 2. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RR) for dichotomous data, and mean differences (MDs) for continuous data, each with its 95% confidence intervals (CIs). We assessed statistical heterogeneity by calculating the I 2 statistic when we included more than two trials in a meta‐analysis. We evaluated the certainty of evidence using GRADE. Included studies We included 19 trials (1554 newborn infants): 18 studies compared multisensory stimulation with standard care; one compared multisensory stimulation with single‐sensory stimulation (tactile). In 10 studies, the primary aim was to assess the neurobehavioral outcomes of multisensory stimulation on preterm neo­nates. The other nine studies aimed to assess the impact of multisensory stimulation on weight gain during the intervention, weight gain until hospital discharge, length of neonatal intensive care unit (NICU) stay, length of hospital stay, time until full oral feeding, length of respiratory support, or a combination. In the abstract we report results for the critical outcomes only. We identified 13 ongoing studies. Four studies are awaiting assessment. Synthesis of results Multisensory stimulation compared to standard care No studies reported on these major neurodevelopmental disabilities, assessed at 18 to 24 months' corrected age (CA): developmental delay, intellectual impairment, blindness, or sensorineural deafness. One study reported on rates of CP at 12 months of age. The evidence is very uncertain about the effect of multisensory stimulation on CP (RR 0.67, 95% CI 0.28 to 1.58; I² not applicable; 1 study, 18 participants; very low‐certainty evidence). The evidence suggests that multisensory stimulation may result in little to no difference in death during initial hospitalization (RR 0.97, 95% CI 0.54 to 1.73; I² not applicable; 1 study, 395 participants; low‐certainty evidence). Multisensory stimulation may increase total weight gain prior to discharge (MD 72.67, 95% CI 68.23 to 77.12; I² = 0%; 3 studies, 474 participants; low‐certainty evidence). Multisensory stimulation compared to single‐sense (tactile) stimulation No studies reported on major neurodevelopmental disability, assessed at 18 to 24 months' CA, or death during initial hospitalization. The evidence is very uncertain about the effect of multisensory stimulation compared to tactile stimulation on weight gain during the intervention (MD −175.00, 95% CI −376.60 to 26.60; I² not applicable; 1 study, 20 participants; very low‐certainty evidence). The certainty of the evidence was low to very low across outcomes, primarily due to risk of bias, imprecision from small sample sizes and wide CIs, and in some cases, inconsistency. The evidence base was also limited by the lack of reporting of relevant outcomes and reliance on surrogate outcomes or shorter follow‐up periods. Authors' conclusions The available evidence on multisensory stimulation in preterm infants is limited and of low to very low certainty. No included studies reported on major neurodevelopmental disabilities at 18 to 24 months’ CA, which represented a critical outcome for this review. Evidence regarding the effect of multisensory stimulation on CP is very uncertain, as it is based on a single small study reporting a surrogate outcome at 12 months. Multisensory stimulation may result in little to no difference in mortality during the initial hospitalization. It may increase total weight gain prior to discharge. However, the clinical significance of this finding is uncertain, particularly given the low certainty of the evidence and the multifactorial nature of growth in preterm infants. The evidence is very uncertain about the effect of multisensory stimulation compared to single‐sense (tactile) stimulation on weight gain during the intervention. The only included study did not report major neurodevelopmental disabilities at 18 to 24 months’ CA, mortality during the initial hospitalization, or total weight gain prior to discharge, which represented the critical outcomes for this review. Overall, the current evidence does not allow firm conclusions about the effectiveness of multisensory stimulation in promoting development or preventing morbidity in preterm infants. Future studies on multisensory stimulation should use more rigorous designs, larger samples, and report interventions using the template for intervention description and replication (TIDieR) checklist to ensure transparency. They should also report essential outcomes, such as neonatal death, major neurodevelopmental disabilities, length of hospital and NICU stay, time to full oral feeding, duration of respiratory support, and weight gain, to better assess the long‑term effects of multisensory stimulation in preterm infants. Funding This Cochrane review had no dedicated funding . Registration Protocol available via DOI: 10.1002/14651858.CD016073 Plain language summary Does stimulating multiple senses (such as hearing, touch, taste, smell) of premature babies improve growth and healthy development or reduce the risk of death? Key messages Multisensory stimulation (the stimulation of more than one sense at a time) may support growth in preterm infants by increasing weight gain before discharge from the hospital. However, it is unclear whether it improves longer‐term developmental outcomes or reduces the risk of death, as the available evidence is limited and uncertain. When compared with stimulation of a single sense (touch alone), it is uncertain whether multisensory stimulation is better than touch alone at increasing weight gain during the intervention. What is multisensory stimulation, and how does it work? Multisensory stimulation means giving premature babies experiences that activate two or more of their senses. The senses involved and the types of stimulation used include the sense of: hearing — a parent’s voice, singing, or calming music; touch — massage or passive movements; smell and taste — a mother’s scent or breast milk; balance — gentle rocking or changing the baby's position; sight — soft, cycled lighting and simple shapes, colors, or moving patterns. During the newborn period, the brain grows very quickly. Providing positive sensory experiences at this time may help premature babies in several ways, such as supporting their memory, helping them regulate emotions, and improving early learning and development. What did we want to find out? We wanted to find out whether multisensory stimulation compared with single‑sense stimulation or standard care helps premature babies survive, grow, stay healthy, and develop well. Specifically, we wanted to find out whether multisensory stimulation might: reduce the number of babies with severe developmental problems at 18 to 24 months' age, such as cerebral palsy, delay in development, limitations in mental abilities, blindness, or deafness; reduce the number of babies who die during the newborn period or before hospital discharge; increase the amount of weight the infants gained by the time they left the hospital. We also looked at other important measures of the babies’ health, including: how long they stayed in the hospital or in the neonatal intensive care unit (NICU); how long it took before they could feed fully by mouth; how many days they needed breathing support. What did we do? We searched for studies in which multisensory stimulation began before the baby was discharged from the hospital after birth, and which compared multisensory stimulation with: no intervention or standard care; single‐sense stimulation. We summarized the results of the studies and rated our confidence in the evidence, based on factors, such as the size of the study (number of babies enrolled) and the methods used. What did we find? We included 19 studies (1544 premature babies). Eighteen of these studies compared multisensory stimulation with standard care, and one study compared multisensory stimulation with a single‑sense intervention (touch only). In 10 studies, the main goal was to examine how multisensory stimulation affects babies’ brain and behavioral development. The remaining nine studies focused on weight gain during the intervention, weight gain prior to hospital discharge, length of stay in the NICU, total length of hospital stay, time until the baby could feed fully by mouth, number of days the baby needed breathing support, or a combination of these measures. We also found 13 ongoing studies and 4 studies that have not yet been fully assessed. They may give us more useful information in the future. Main results None of the studies that compared multisensory stimulation with no intervention reported on the critical outcome major developmental disability at 18 to 24 months' corrected age. Only one study assessed a related outcome, cerebral palsy at 12 months. Because this study was very small, the evidence is very uncertain about whether multisensory stimulation modifies the risk of cerebral palsy. Multisensory stimulation may result in little or no difference in death before hospital discharge, although it was reported in only one large study. It may increase total weight gain prior to discharge, but the observed effect is small, and its clinical significance remains uncertain. Compared with single‐sense stimulation (touch), we could not tell whether multisensory stimulation helped babies gain more weight during the intervention. The only study we found comparing a multi‐ to single‐sensory intervention did not report the critical outcomes, such as major developmental problems at 18 to 24 months' corrected age, death during the first hospital stay, or total weight gain prior to discharge. What are the limitations of the evidence? We have limited confidence in these findings because many of the studies were small or not well‐designed. Several studies did not report the outcomes we were most interested in or did not provide enough data for us to analyze. Because of these limitations, the true effects of multisensory stimulation may be different from what we found. How up‐to‐date is this evidence? The evidence is up‐to‐date to 28 November 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Wróblewska-Seniuk, K; Lenells, M; Prescott, MG; Fiander, M; Soll, RF; Bruschettini, M; supported by Cochrane Sweden and Cochrane Neonatal,", "articleTypes": [], "doi": "10.1002/14651858.CD016073.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "264d013d-98fd-44c9-aadb-b48f453111a0", "pmid": "", "title": "Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy", "imported": false, "abstract": "Abstract - Background In the past women have been advised that lowering their salt intake might reduce their risk of pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of advice to alter dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of dietary advice to alter salt intake compared to continuing a normal diet, on the risk of pre‐eclampsia and its consequences. Search methods We searched the register of trials maintained and updated by the Cochrane Pregnancy and Childbirth Group, and the Cochrane Controlled Trials Register Disc Issue 4, 1998. Selection criteria Studies were included if they were randomised trials of advice to either reduce or to increase dietary salt during pregnancy. Data collection and analysis All data were extracted independently by both reviewers. Main results Two trials were included, with 603 women. They compared advice about a low salt diet with no dietary advice. The confidence intervals for all of the outcomes reported were wide, and cross the no effect line. This includes pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). Even when taken together, these trials are insufficient to provide reliable information about the effects of advice on salt restriction during normal pregnancy. None of the trials included women with pre‐eclampsia, so this review provides no reliable information about changes in salt intake for treatment of pre‐eclampsia. Authors' conclusions Salt consumption during pregnancy should remain a matter of personal preference. Plain language summary Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy To be prepared.", "journal": "Cochrane Database of Systematic Reviews", "year": "1999", "authors": "Duley, L, Henderson‐Smart, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD001687", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.077Z" }, { "id": "264ef961-aa89-4368-a6c2-d3f2026d997b", "pmid": "", "title": "Interventions for perceptual disorders following stroke", "imported": false, "abstract": "Abstract - Background Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non‐invasive brain stimulation, pharmacological and surgical approaches. Objectives To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living. Search methods We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors. Selection criteria We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain. Data collection and analysis One review author assessed titles, with two review authors independently screening abstracts and full‐text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB‐1 tool, and quality of evidence using GRADE. A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update. Main results We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch‐somatosensory disorders. None addressed stroke‐related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non‐invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL): Somatosensory disorders : one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure. Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention. Visual perception disorders : no trials measuring ADL compared an intervention with no treatment or control. In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials). Authors' conclusions Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high‐quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer‐term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines. Plain language summary Interventions for perceptual disorders following stroke Key messages Stroke can affect a person’s ability to process and understand information from their senses, including hearing, smell, somatosensation (sense of body temperature, position, and movement), taste, touch, and vision. Processing and understanding information from these senses is known as perception. Little research has been carried out to find out whether any treatments for stroke‐related problems with perception are helpful. People with stroke‐related problems with hearing, smell, somatosensation, taste, touch, and vision should continue to participate in rehabilitation as recommended by clinical guidelines. Healthcare professionals should continue to offer rehabilitation for stroke‐related perceptual problems in keeping with current clinical guidelines and recommendations. What is a perceptual disorder? Before a stroke, adults gather information about the world through their senses: hearing, smell, somatosensation, taste, touch, and vision. Somatosensation refers to sensation arising from the skin, muscles, or joints, and includes perception of pressure, vibration, temperature, and position. Information gathered might include the colour, shape, and size of objects that they see. Together with memories and cultural experiences, a person can understand how someone is feeling from seeing their facial expression. Other examples are how different odours can be identified through the sense of smell and how different textures can be felt through the sense of touch. A stroke can affect these abilities. How are perceptual disorders treated? Healthcare professionals, including occupational therapists, physiotherapists, and psychologists, may offer different therapies. Treatments might include medicine, stimulation of the brain, or perceptual rehabilitation through activities, puzzles, strategies, or intensive repetition of tasks. What did we want to find out? We wanted to find out whether receiving any perceptual disorder treatment was better than no treatment at all. We measured improvement by looking at how well people could carry out their daily activities. We measured whether treatments also helped other things, such as quality of life, mental health, and perception. We looked for information on when things did not go well. We also explored whether one treatment was more beneficial than another. What did we do? We searched for all relevant research. We assessed the quality of 18 studies and summarised their results. What did we find out? The studies we found were about different perceptual disorders: three studies looked at disorders of touch perception, seven looked at somatosensation, seven studies looked at vision, and one looked at several perceptual problems at the same time. The treatments used in these studies included paper‐and‐pencil copying tasks to improve visual memory and using robots to help improve a person’s sense of where their body is positioned. We found no information to show that any treatment worked. Why are we still uncertain? We found few studies. Each study included a small number of people with a perceptual problem after a stroke. With small numbers of people involved, the results were not clear. Each study looked at different interventions. Less than half the studies (seven) measured the ability to carry out everyday activities. How up to date is this information? Our information is up to date as of August 2021. Based on the information we gathered, we are still unclear about the benefits or harms of treatments for perceptual problems after stroke. People with perceptual problems after stroke should continue to be offered rehabilitation as recommended in clinical guidelines.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hazelton, C; Thomson, K; Todhunter-Brown, A; Campbell, P; Chung, CSY; Dorris, L; Gillespie, DC; Hunter, SM; McGill, K; Nicolson, DJ; Williams, LJ; Brady, MC", "articleTypes": [], "doi": "10.1002/14651858.CD007039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "26550027-f2ce-43ba-94d8-2b6816c7cd2d", "pmid": "", "title": "Complementary therapies for acne vulgaris", "imported": false, "abstract": "Abstract - Background Acne is a chronic skin disease characterised by inflamed spots and blackheads on the face, neck, back, and chest. Cysts and scarring can also occur, especially in more severe disease. People with acne often turn to complementary and alternative medicine (CAM), such as herbal medicine, acupuncture, and dietary modifications, because of their concerns about the adverse effects of conventional medicines. However, evidence for CAM therapies has not been systematically assessed. Objectives To assess the effects and safety of any complementary therapies in people with acne vulgaris. Search methods We searched the following databases from inception up to 22 January 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 , Issue 1 ), MEDLINE (from 1946), Embase (from 1974), PsycINFO (from 1806), AMED (from 1985), CINAHL (from 1981), Scopus (from 1966), and a number of other databases listed in the Methods section of the review. The Cochrane CAM Field Specialised Register was searched up to May 2014. We also searched five trials registers and checked the reference lists of articles for further references to relevant trials. Selection criteria We included parallel‐group randomised controlled trials (or the first phase data of randomised cross‐over trials) of any kind of CAM, compared with no treatment, placebo, or other active therapies, in people with a diagnosis of acne vulgaris. Data collection and analysis Three authors collected data from each included trial and evaluated the methodological quality independently. They resolved disagreements by discussion and, as needed, arbitration by another author. Main results We included 35 studies, with a total of 3227 participants. We evaluated the majority as having unclear risk of selection, attrition, reporting, detection, and other biases. Because of the clinical heterogeneity between trials and the incomplete data reporting, we could only include four trials in two meta‐analyses, with two trials in each meta‐analysis. The categories of CAM included herbal medicine, acupuncture, cupping therapy, diet, purified bee venom (PBV), and tea tree oil. A pharmaceutical company funded one trial; the other trials did not report their funding sources. Our main primary outcome was 'Improvement of clinical signs assessed through skin lesion counts', which we have reported as 'Change in inflammatory and non‐inflammatory lesion counts', 'Change of total skin lesion counts', 'Skin lesion scores', and 'Change of acne severity score'. For 'Change in inflammatory and non‐inflammatory lesion counts', we combined 2 studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD) at 12 weeks and found no clear evidence of a difference between the groups in change in non‐inflammatory lesion counts (mean difference (MD) ‐3.89, 95% confidence interval (CI) ‐10.07 to 2.29, P = 0.10, 75 participants, 2 trials, low quality of evidence). However, although data from 1 of these 2 trials showed benefit of LGLD for reducing inflammatory lesions (MD ‐7.60, 95% CI ‐13.52 to ‐1.68, 43 participants, 1 trial) and total skin lesion counts (MD ‐8.10, 95% CI ‐14.89 to ‐1.31, 43 participants, 1 trial) for people with acne vulgaris, data regarding inflammatory and total lesion counts from the other study were incomplete and unusable in synthesis. Data from a single trial showed potential benefit of tea tree oil compared with placebo in improving total skin lesion counts (MD ‐7.53, 95% CI ‐10.40 to ‐4.66, 60 participants, 1 trial, low quality of evidence) and acne severity scores (MD ‐5.75, 95% CI ‐9.51 to ‐1.99, 60 participants, 1 trial). Another trial showed pollen bee venom to be better than control in reducing numbers of skin lesions (MD ‐1.17, 95% CI ‐2.06 to ‐0.28, 12 participants, 1 trial). Results from the other 31 trials showed inconsistent effects in terms of whether acupuncture, herbal medicine, or wet‐cupping therapy were superior to controls in increasing remission or reducing skin lesions. Twenty‐six of the 35 included studies reported adverse effects; they did not report any severe adverse events, but specific included trials reported mild adverse effects from herbal medicines, wet‐cupping therapy, and tea tree oil gel. Thirty trials measured two of our secondary outcomes, which we combined and expressed as 'Number of participants with remission'. We were able to combine 2 studies (low quality of evidence), which compared Ziyin Qinggan Xiaocuo Granule and the antibiotic, minocycline (100 mg daily) (worst case = risk ratio (RR) 0.49, 95% CI 0.09 to 2.53, 2 trials, 206 participants at 4 weeks; best case = RR 2.82, 95% CI 0.82 to 9.06, 2 trials, 206 participants at 4 weeks), but there was no clear evidence of a difference between the groups. None of the included studies assessed 'Psychosocial function'. Two studies assessed 'Quality of life', and significant differences in favour of the complementary therapy were found in both of them on 'feelings of self‐worth' (MD 1.51, 95% CI 0.88 to 2.14, P < 0.00001, 1 trial, 70 participants; MD 1.26, 95% CI 0.20 to 2.32, 1 trial, 46 participants) and emotional functionality (MD 2.20, 95% CI 1.75 to 2.65, P < 0.00001, 1 trial, 70 participants; MD 0.93, 95% CI 0.17 to 1.69, 1 trial, 46 participants). Because of limitations and concerns about the quality of the included studies, we could not draw a robust conclusion for consistency, size, and direction of outcome effects in this review. Authors' conclusions There is some low‐quality evidence from single trials that LGLD, tea tree oil, and bee venom may reduce total skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs, such as herbal medicine, acupuncture, or wet‐cupping therapy, for the treatment of this condition. There is a potential for adverse effects from herbal medicines; however, future studies need to assess the safety of all of these CAM therapies. Methodological and reporting quality limitations in the included studies weakened any evidence. Future studies should be designed to ensure low risk of bias and meet current reporting standards for clinical trials. Plain language summary Complementary therapies for acne vulgaris Background Acne is a chronic skin disease, which causes spots to occur simultaneously on several areas of the body, including the face, neck, back, and chest. Besides the current commonly used treatments, complementary and alternative medicines (CAM) are of increasing interest to people who often use them in addition to conventional treatments as additive or single therapies to treat acne. The review question Can any complementary therapies improve the clinical symptoms of acne vulgaris? Study characteristics We searched relevant databases and trials registers up to 22 January 2014. We identified 35 randomised controlled trials, with 3227 participants, which used 6 kinds of CAM (herbal medicine, acupuncture, wet cupping, diet, purified bee venom, and tea tree oil). A pharmaceutical company funded one trial; the other trials did not report their funding sources. Key results For our primary outcome, we combined two studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD), but found no clear evidence of a difference between the 2 groups at 12 weeks for a change in non‐inflammatory lesion counts. Only one of these two trials provided usable data to show potential benefit of LGLD for reducing inflammatory and total skin lesion counts. Tea tree oil and pollen bee venom were found to reduce total skin lesion counts in single trials, respectively. The remaining 31 included trials gave mixed results about whether complementary therapies might reduce the total number of skin lesion counts. Twenty‐six trials reported adverse events. The herbal medicine group found some mild side‐effects, such as nausea, diarrhoea, and stomach upset. The acupuncture group found some itch or redness and pain following needle insertion. Participants who used tea tree oil reported itchiness, dryness, and flaking of the skin. None of the trials reported severe adverse effects. For our secondary outcome, there was no clear evidence of a difference in the number of participants with remission between Ziyin Qinggan Xiaocuo Granule and minocycline according to a meta‐analysis of two studies. Quality of the evidence There is some low‐quality evidence from single trials that a low‐glycaemic‐load diet, tea tree oil, and bee venom may reduce skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs. Methodological and reporting quality limitations in the included studies weakened any evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Cao, H, Yang, G, Wang, Y, Liu, JP, Smith, CA, Luo, H, Liu, Y", "articleTypes": [], "doi": "10.1002/14651858.CD009436.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.124Z" }, { "id": "265ce966-1037-46ae-93e8-e2617abbc566", "pmid": "", "title": "Diclofenac for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically cyclo‐oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain. Objectives To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled'). Search methods We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022. Selection criteria We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI). Main results We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low‐certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child‐reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD ‐0.45, 95% CI ‐0.74 to ‐0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD ‐0.64, 95% CI ‐0.89 to ‐0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low‐certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low‐certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results. Authors' conclusions We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non‐pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered. Plain language summary What are the benefits and harms of diclofenac for managing children's pain after they have had an operation? Key messages • Due to a lack of robust evidence, the benefits and harms of diclofenac for managing children's pain after they've had an operation are unclear. • Diclofenac probably reduces nausea and vomiting, but probably increases the risk of bleeding, compared to opioids (such as morphine). • Well‐designed and comprehensively‐reported studies are needed to shed light on the benefits and harms of diclofenac compared to opioids or other medicines, or for different ways of giving diclofenac to children. Postoperative pain management Pain after surgery or a procedure is common and can influence recovery and return to normal activities. There are many ways to reduce pain after an operation, including medicines such as diclofenac. Diclofenac is part of a class of medicines called non‐steroidal anti‐inflammatory drugs (NSAIDs) that can reduce inflammation and pain. They can be given by different routes, such as by mouth or through the anus into the rectum (back passage), and before, during, and after an operation. What did we want to find out? We wanted to find out the benefits and harms of diclofenac compared to other treatments, as well as the most effective way to deliver diclofenac to children. What did we do? We searched for studies that compared (a) diclofenac to other treatments for postoperative pain; or (b) different ways of delivering diclofenac to children. We summarised the results and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 32 studies that included 2250 children with postoperative pain. The largest study included 183 children and the smallest, 31 children. The studies were conducted in many countries around the world; the most common location was the United Kingdom (10 studies). The average age of the children was between 2 and 14 years. Diclofenac was used to manage postoperative pain in 12 different types of surgery; most commonly, ear, nose, and throat surgery (9 studies) or eye surgery (6 studies). Main results It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor and serious harms compared to a placebo (a 'dummy' or sham treatment that does not contain any medicine but looks or tastes identical to the medicine being tested). It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief or pain intensity compared to other medicines, such as opioids, paracetamol, or bupivacaine. Diclofenac probably results in less nausea and vomiting compared to opioids (7 studies involving 463 children), but probably increases the risk of any bleeding (2 studies involving 222 children), but we are very unsure about serious harms (death, long‐term disability, or hospitalisation). It is thus unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor or serious harms compared to placebo or other medicines other than opioids. It is also unclear which route (by mouth or rectal delivery) is the most effective way to manage pain after surgery in children. What are the limitations of the evidence? We are not confident in the evidence because of study design limitations, and none of the studies measured some of our main outcomes of interest. There were also not enough large studies to be certain about the results. How up to date is this evidence? The evidence is current to April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ringsten, M; Kredo, T; Ebrahim, S; Hohlfeld, A; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015087.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "2678c77a-1afa-428d-9fab-e26c9877cee0", "pmid": "", "title": "Pharmaceutical interventions for emotionalism after stroke", "imported": false, "abstract": "Abstract - Background Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2019. Objectives To evaluate the benefits and harms of pharmaceutical treatment in people with emotionalism after stroke. Search methods We searched the Cochrane Stroke Group Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registers (May 2022). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). Data collection and analysis Two review authors independently selected trials, assessed risk of bias, extracted data from all included trials, and used GRADE to assess the certainty of the body of evidence. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I 2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on the Center for Neurologic Study ‐ Lability Scale (CNS‐LS) or Clinician Interview‐Based Impression of Change (CIBIC), or diminished tearfulness. Main results We did not identify any new trials for this update. We included seven trials with a total of 239 participants. Two trials had a cross‐over design, but outcome data were not available from the first phase (precross‐over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with a total of 213 participants. It is uncertain whether fluoxetine increases the number of people who have a 50% reduction in emotionalism when compared to placebo (risk ratio (RR) 0.26, 95% CI 0.09 to 0.77; P = 0.02; 1 trial, 19 participants) because the certainty of evidence is very low. Sertraline may lead to little to no difference in Center for Neurologic Study ‐ Lability Scale (CNS‐LS) scores and Clinician Interview‐Based Impression of Change (CIBIC) scores when compared to placebo (RR 0.20, 95% CI 0.03 to 1.50; P = 0.12; 1 trial, 28 participants; low‐certainty evidence). Antidepressants probably increase the number of people who experience a reduction in tearfulness (RR 0.32, 95% CI 0.12 to 0.86; P = 0.02; 3 trials, 164 participants; moderate‐certainty evidence). No trials were found that evaluated the impact of other pharmaceutical interventions. Only two trial authors systematically recorded and reported adverse events, resulting in limited data on the potential harms of treatment. Six trials reported death as an adverse event and found no difference between the groups (antidepressants versus placebo) in the number of deaths reported (RR 0.59, 95% CI 0.08 to 4.50; P = 0.61; 172 participants; moderate‐certainty evidence). This review provides very low‐ to moderate‐certainty evidence that antidepressants may reduce the frequency and severity of emotionalism. The included trials were small and had some degree of bias. Authors' conclusions Antidepressants may reduce the frequency and severity of crying or laughing episodes when compared to placebo, based on very low‐certainty evidence. Our conclusions must be qualified by several methodological deficiencies in the trials and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post‐stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity, and assess change over time; provide treatment for a sufficient duration and follow‐up to better assess rates of relapse or maintenance; and include careful assessment and complete reporting of adverse events. Plain language summary Medicines for emotionalism after stroke Review question To evaluate the benefits and harms of medicine in people with emotionalism after stroke. Background Emotionalism often occurs after stroke. Emotionalism means that the person has difficulty controlling their emotional behaviour. After stroke, people may suddenly start crying or, less commonly, laughing for no apparent reason. This is distressing for that particular person and their carers. Antidepressants, known to be helpful in people with depression, may be an effective treatment for emotionalism after stroke, but there have been very few randomised controlled trials (RCTs) in this area. (RCTs are studies in which participants are assigned randomly to 2 or more treatment groups. This is the best way to ensure that groups of participants are similar, and that investigators and participants do not know who is in which group.) Search date We identified studies through searches conducted on 26 May 2022. Study characteristics We included 7 randomised controlled trials, involving 239 people with emotionalism, in the review, which reported on the use of antidepressants for treating emotionalism. The numbers of people included in the studies ranged from 10 to 92. The mean/median ages ranged from 57.8 years to 73 years. Studies were from Europe (UK: 1; Denmark: 1; Scotland: 1; and Sweden: 1); Asia (South Korea: 1 and Japan: 1); and the USA (1). Key results We did not identify any new studies in our search update. We included 7 studies involving 239 people. However, 2 studies were not available in the appropriate format to include in the analysis. Therefore, we included only 5 studies, with 213 people, in our analyses. It is uncertain whether antidepressants affect the number of people with at least a 50% reduction in emotional displays, tearfulness, and scores on the questionnaires that measure uncontrollable laughing or crying, but they had no effect on lability (frequency of mood changes) scores and whether a clinician thought there had been an improvement when compared to placebo. No studies of other types of medicine were found. Six studies reported death and found no differences between those who were on antidepressants and those who were not. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low, and the results of further research could differ from the results of this review. Our confidence is limited because the included studies were small, and there was no consistency in how emotionalism was measured across the studies. Conclusion It is uncertain whether antidepressant medicines reduce outbursts of crying or laughing. More studies with systematic assessment and reporting of unwanted or harmful effects of a treatment are needed to ensure that any benefits outweigh the risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Allida, S, House, A, Hackett, ML", "articleTypes": [], "doi": "10.1002/14651858.CD003690.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.769Z" }, { "id": "267d3d3f-b521-4d18-b8e6-8171a202b05d", "pmid": "", "title": "Interventions for treating oral leukoplakia to prevent oral cancer", "imported": false, "abstract": "Abstract - Background Oral leukoplakia is a relatively common oral lesion that, in a small proportion of people, precedes the development of oral cancer. Most leukoplakias are asymptomatic; therefore, the primary objective of treatment should be to prevent onset of cancer. This review updates our previous review, published in 2006. Objectives To assess the effectiveness, safety and acceptability of treatments for leukoplakia in preventing oral cancer. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 16 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) ( the Cochrane Library , 2016, Issue 4), MEDLINE Ovid (1946 to 16 May 2016), Embase Ovid (1980 to 16 May 2016) and CancerLit via PubMed (1950 to 16 May 2016). We searched the metaRegister of Controlled Trials (to 10 February 2015), ClinicalTrials.gov (to 16 May 2016) and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials (to 16 May 2016). We placed no restrictions on the language or date of publication when searching electronic databases. Selection criteria We included randomised controlled trials (RCTs) that enrolled people with a diagnosis of oral leukoplakia and compared any treatment versus placebo or no treatment. Data collection and analysis We collected data using a data extraction form. Oral cancer development, demonstrated by histopathological examination, was our primary outcome. Secondary outcomes were clinical resolution of the lesion, improvement of histological features and adverse events. We contacted trial authors for further details when information was unclear. When valid and relevant data were available, we conducted a meta‐analysis of the data using a fixed‐effect model when we identified fewer than four studies with no heterogeneity. For dichotomous outcomes, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We assessed risk of bias in studies by using the Cochrane tool. We assessed the overall quality of the evidence by using standardised criteria (Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE)). Main results We included 14 studies (909 participants) in this review. Surgical interventions, including laser therapy and cryotherapy, have never been studied by means of an RCT that included a no treatment or placebo arm. The included trials tested a range of medical and complementary treatments, in particular, vitamin A and retinoids (four studies); beta carotene or carotenoids (three studies); non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically ketorolac and celecoxib (two studies); herbal extracts (four studies), including tea components, a Chinese herbal mixture and freeze‐dried black raspberry gel; bleomycin (one study); and Bowman‐Birk inhibitor (one study). We judged one study to be at low risk of bias, seven at unclear risk and six at high risk. In general, we judged the overall quality of the evidence to be low or very low, so findings are uncertain and further research is needed. Five studies recorded cancer incidence, only three of which provided useable data. None of the studies provided evidence that active treatment reduced the risk of oral cancer more than placebo: systemic vitamin A (RR 0.11, 95% CI 0.01 to 2.05; 85 participants, one study); systemic beta carotene (RR 0.71, 95% CI 0.24 to 2.09; 132 participants, two studies); and topical bleomycin (RR 3.00, 95% CI 0.32 to 27.83; 20 participants, one study). Follow‐up ranged between two and seven years. Some individual studies suggested effectiveness of some proposed treatments, namely, systemic vitamin A, beta carotene and lycopene, for achieving clinical resolution of lesions more often than placebo. Similarly, single studies found that systemic retinoic acid and lycopene may provide some benefit in terms of improvement in histological features. Some studies also reported a high rate of relapse. Side effects of varying severity were often described; however, it seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Authors' conclusions Surgical treatment for oral leukoplakia has not been assessed in an RCT that included a no treatment or placebo comparison. Nor has cessation of risk factors such as smoking been assessed. The available evidence on medical and complementary interventions for treating people with leukoplakia is very limited. We do not currently have evidence of a treatment that is effective for preventing the development of oral cancer. Treatments such as vitamin A and beta carotene may be effective in healing oral lesions, but relapses and adverse effects are common. Larger trials of longer duration are required to properly evaluate the effects of leukoplakia treatments on the risk of developing oral cancer. High‐quality research is particularly needed to assess surgical treatment and to assess the effects of risk factor cessation in people with leukoplakia. Plain language summary Interventions for treating oral leukoplakia to prevent oral cancer Review question People with oral leukoplakia are at higher risk of developing oral cancer than those with normal oral mucosa. This review, produced through Cochrane Oral Health , seeks to evaluate whether people affected by leukoplakia can benefit from surgical, medical or complementary treatments, either local or systemic. In particular, we conducted this review to find out which, if any, treatment is able to prevent people with leukoplakia of the mouth from getting oral cancer. This review updates our previous review published in 2006. Background Oral leukoplakia is a white patch formed in the mouth lining that cannot be rubbed off. It often does not hurt and may go unnoticed for years. People with leukoplakia develop oral cancer more often than people without it. Preventing this is critical because rates of oral cancer survival longer than five years after diagnosis are low. Drugs, surgery and other therapies have been tried for treatment of oral leukoplakia. Objectives This review aimed to evaluate whether treatments for oral leukoplakia are effective in preventing oral cancer, and safe and acceptable to patients. Study characteristics The evidence on which this review is based is up‐to‐date as of May 2016. We found 14 randomised controlled trials (RCTs) of medical and complementary treatments, which involved 909 participants in total. Treatments included herbal extracts, anti‐inflammatory drugs, vitamin A, beta carotene supplements and others. Surgical treatment has not been compared with placebo or no treatment in an RCT. Key results Cancer development was measured in studies of three treatments: systemic vitamin A, systemic beta carotene and topical bleomycin. None of these treatments showed effectiveness in preventing cancer development, as measured up to two years for vitamin A and beta carotene, and seven years for bleomycin. Some individual studies of vitamin A and beta carotene suggested that these treatments may be effective for improving or healing oral lesions. However, some studies observed a high rate of relapse in participants whose lesions were initially resolved by treatment. Most treatments caused side effects of differing severity in a high proportion of participants. It seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Quality of the evidence The available evidence is very limited. Most interventions were assessed by only one small study. Most studies had problems in the way they were conducted, making their results unreliable. We judged the quality of evidence for the outcome of cancer development to be very low. Author conclusions Larger, better studies of longer duration are required. As well as further studies of drug treatment and alternative treatments like vitamins, studies are needed to evaluate the effectiveness and safety of surgery, and of stopping risk factor habits such as smoking.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lodi, G; Franchini, R; Warnakulasuriya, S; Varoni, EM; Sardella, A; Kerr, AR; Carrassi, A; MacDonald, LCI; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD001829.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "2680cb32-2db5-43e0-ae13-dc5d320d54fb", "pmid": "", "title": "Momordica charantia for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Momordica charantia (bitter gourd) is not only a nutritious vegetable but it is also used in traditional medical practices to treat type 2 diabetes mellitus. Experimental studies with animals and humans suggested that the vegetable has a possible role in glycaemic control. Objectives To assess the effects of mormodica charantia for type 2 diabetes mellitus. Search methods Several electronic databases were searched, among these were The Cochrane Library (Issue 1, 2012), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2012), combined with handsearches. No language restriction was used. Selection criteria We included randomised controlled trials (RCTs) that compared momordica charantia with placebo or a control intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently extracted data. Risk of bias of the trials was evaluated using the parameters of randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. A meta‐analysis was not performed given the quality of data and the variability of preparations of momordica charantia used in the interventions (no similar preparation was tested twice). Main results Four randomised controlled trials with up to three months duration and investigating 479 participants met the inclusion criteria. Risk of bias of these trials (only two studies were published as a full peer‐reviewed publication) was generally high. Two RCTs compared the effects of preparations from different parts of the momordica charantia plant with placebo on glycaemic control in type 2 diabetes mellitus. There was no statistically significant difference in the glycaemic control with momordica charantia preparations compared to placebo. When momordica charantia was compared to metformin or glibenclamide, there was also no significant change in reliable parameters of glycaemic control. No serious adverse effects were reported in any trial. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions There is insufficient evidence on the effects of momordica charantia for type 2 diabetes mellitus. Further studies are therefore required to address the issues of standardization and the quality control of preparations. For medical nutritional therapy, further observational trials evaluating the effects of momordica charantia are needed before RCTs are established to guide any recommendations in clinical practice. Plain language summary Momordica charantia for type 2 diabetes mellitus Mormordica charantia (bitter gourd or bitter melon) is a climbing perennial that is characterized by elongated, warty fruit‐like gourds or cucumbers and is native to the tropical belt. Although momordica charantia is commonly used in traditional medical practices, along with research suggesting its benefits for people with type 2 diabetes, the current evidence does not warrant using the plant in treating this disease. This review of trials found only four studies which had an overall low quality. Three trials showed no significant differences between momordica charantia and placebo or antidiabetic drugs (glibenclamide and metformin) in the blood sugar response. The duration of treatment ranged from four weeks to three months, and altogether 479 patients with type 2 diabetes mellitus participated. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Adverse effects were mostly moderate, including diarrhoea and abdominal pain. However, reporting of adverse effects was incomplete in the included studies. There are many varieties of preparations of momordica charantia, as well as variations in its use as a vegetable. Further studies are needed to assess the quality of the various momordica charantia preparations as well as to further evaluate its use in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Ooi, CP; Yassin, Z; Hamid, TA", "articleTypes": [], "doi": "10.1002/14651858.CD007845.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "268a1603-0d56-40b8-88b1-3f02d49f7fc0", "pmid": "", "title": "Universal screening for SARS‐CoV‐2 infection: a rapid review", "imported": false, "abstract": "Abstract - Background Coronavirus disease 2019 (COVID‐19) is caused by the novel betacoronavirus, severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2). Most people infected with SARS‐CoV‐2 have mild disease with unspecific symptoms, but about 5% become critically ill with respiratory failure, septic shock and multiple organ failure. An unknown proportion of infected individuals never experience COVID‐19 symptoms although they are infectious, that is, they remain asymptomatic. Those who develop the disease, go through a presymptomatic period during which they are infectious. Universal screening for SARS‐CoV‐2 infections to detect individuals who are infected before they present clinically, could therefore be an important measure to contain the spread of the disease. Objectives We conducted a rapid review to assess (1) the effectiveness of universal screening for SARS‐CoV‐2 infection compared with no screening and (2) the accuracy of universal screening in people who have not presented to clinical care for symptoms of COVID‐19. Search methods An information specialist searched Ovid MEDLINE and the Centers for Disease Control (CDC) COVID‐19 Research Articles Downloadable Database up to 26 May 2020. We searched Embase.com, the CENTRAL, and the Cochrane Covid‐19 Study Register on 14 April 2020. We searched LitCovid to 4 April 2020. The World Health Organization (WHO) provided records from daily searches in Chinese databases and in PubMed up to 15 April 2020. We also searched three model repositories (Covid‐Analytics, Models of Infectious Disease Agent Study [MIDAS], and Society for Medical Decision Making) on 8 April 2020. Selection criteria Trials, observational studies, or mathematical modelling studies assessing screening effectiveness or screening accuracy among general populations in which the prevalence of SARS‐CoV2 is unknown. Data collection and analysis After pilot testing review forms, one review author screened titles and abstracts. Two review authors independently screened the full text of studies and resolved any disagreements by discussion with a third review author. Abstracts excluded by a first review author were dually reviewed by a second review author prior to exclusion. One review author independently extracted data, which was checked by a second review author for completeness and accuracy. Two review authors independently rated the quality of included studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool for diagnostic accuracy studies and a modified form designed originally for economic evaluations for modelling studies. We resolved differences by consensus. We synthesized the evidence in narrative and tabular formats. We rated the certainty of evidence for days to outbreak, transmission, cases missed and detected, diagnostic accuracy (i.e. true positives, false positives, true negatives, false negatives) using the GRADE approach. Main results We included 22 publications. Two modelling studies reported on effectiveness of universal screening. Twenty studies (17 cohort studies and 3 modelling studies) reported on screening test accuracy. Effectiveness of screening We included two modelling studies. One study suggests that symptom screening at travel hubs, such as airports, may slightly slow but not stop the importation of infected cases (assuming 10 or 100 infected travellers per week reduced the delay in a local outbreak to 8 days or 1 day, respectively). We assessed risk of bias as minor or no concerns, and certainty of evidence was low, downgraded for very serious indirectness. The second modelling study provides very low‐certainty evidence that screening of healthcare workers in emergency departments using laboratory tests may reduce transmission to patients and other healthcare workers (assuming a transmission constant of 1.2 new infections per 10,000 people, weekly screening reduced infections by 5.1% within 30 days). The certainty of evidence was very low, downgraded for high risk of bias (major concerns) and indirectness. No modelling studies reported on harms of screening. Screening test accuracy All 17 cohort studies compared an index screening strategy to a reference reverse transcriptase polymerase chain reaction (RT‐PCR) test. All but one study reported on the accuracy of single point‐in‐time screening and varied widely in prevalence of SARS‐CoV‐2, settings, and methods of measurement. We assessed the overall risk of bias as unclear in 16 out of 17 studies, mainly due to limited information on the index test and reference standard. We rated one study as being at high risk of bias due to the inclusion of two separate populations with likely different prevalences. For several screening strategies, the estimates of sensitivity came from small samples. For single point‐in‐time strategies, for symptom assessment, the sensitivity from 12 cohorts (524 people) ranged from 0.00 to 0.60 (very low‐certainty evidence) and the specificity from 12 cohorts (16,165 people) ranged from 0.66 to 1.00 (low‐certainty evidence). For screening using direct temperature measurement (3 cohorts, 822 people), international travel history (2 cohorts, 13,080 people), or exposure to known infected people (3 cohorts, 13,205 people) or suspected infected people (2 cohorts, 954 people), sensitivity ranged from 0.00 to 0.23 (very low‐ to low‐certainty evidence) and specificity ranged from 0.90 to 1.00 (low‐ to moderate‐certainty evidence). For symptom assessment plus direct temperature measurement (2 cohorts, 779 people), sensitivity ranged from 0.12 to 0.69 (very low‐certainty evidence) and specificity from 0.90 to 1.00 (low‐certainty evidence). For rapid PCR test (1 cohort, 21 people), sensitivity was 0.80 (95% confidence interval (CI) 0.44 to 0.96; very low‐certainty evidence) and specificity was 0.73 (95% CI 0.39 to 0.94; very low‐certainty evidence). One cohort (76 people) reported on repeated screening with symptom assessment and demonstrates a sensitivity of 0.44 (95% CI 0.29 to 0.59; very low‐certainty evidence) and specificity of 0.62 (95% CI 0.42 to 0.79; low‐certainty evidence). Three modelling studies evaluated the accuracy of screening at airports. The main outcomes measured were cases missed or detected by entry or exit screening, or both, at airports. One study suggests very low sensitivity at 0.30 (95% CI 0.1 to 0.53), missing 70% of infected travellers. Another study described an unrealistic scenario to achieve a 90% detection rate, requiring 0% asymptomatic infections. The final study provides very uncertain evidence due to low methodological quality. Authors' conclusions The evidence base for the effectiveness of screening comes from two mathematical modelling studies and is limited by their assumptions. Low‐certainty evidence suggests that screening at travel hubs may slightly slow the importation of infected cases. This review highlights the uncertainty and variation in accuracy of screening strategies. A high proportion of infected individuals may be missed and go on to infect others, and some healthy individuals may be falsely identified as positive, requiring confirmatory testing and potentially leading to the unnecessary isolation of these individuals. Further studies need to evaluate the utility of rapid laboratory tests, combined screening, and repeated screening. More research is also needed on reference standards with greater accuracy than RT‐PCR. Given the poor sensitivity of existing approaches, our findings point to the need for greater emphasis on other ways that may prevent transmission such as face coverings, physical distancing, quarantine, and adequate personal protective equipment for frontline workers. Plain language summary How effective is screening for COVID‐19? Why does screening matter? Screening aims to identify a condition in people who may not be showing any symptoms. Some people may have the COVID‐19 virus but appear healthy or have only mild symptoms. It is important to identify infected people so they can stay away from others and seek appropriate care. Incorrectly identifying COVID‐19 in healthy people could lead to unnecessary self‐isolation and further tests. Incorrectly identifying no infection in infected people could spread the virus. Screening for COVID‐19 can include temperature checks, or asking about international travel or contact with COVID‐19 cases, or rapid tests. Screening can occur over the telephone, online, or in person, in homes, clinics, workplaces, airports or schools. What did the review study? We wanted to identify: · the benefits and negative effects of screening apparently healthy people for COVID‐19 infection; · whether screening can identify those with and without the virus correctly. To answer these questions rapidly, we shortened some steps of the normal Cochrane Review process. We are confident these changes do not affect our overall conclusions. What did we do? We looked for studies that screened people who had not sought care for potential COVID‐19 symptoms. This review includes evidence up to May 2020. Key results We found 22 studies; 17 assessed people (cohort studies) and five were computer‐generated models (modelling studies). Studies took place in USA, Europe, and Asia. Benefits and negative effects 
Two modelling studies reported on the benefits and negative effects of screening. One suggested that asking about symptoms at airports may slightly slow, but not stop, the importation of infected people. Another model reported that weekly or biweekly screening of healthcare workers may reduce transmission to patients and other healthcare workers in emergency departments. No studies reported on negative effects of screening. Identification of infected people 
Seventeen cohort studies and three modelling studies reported on whether screening can correctly identify those with and without the virus. Studies varied widely in the baseline level of COVID‐19, settings, and methods. All cohort studies compared screening strategies to a ‘gold standard’ test called RT‐PCR. Cohort studies
All screening strategies (17 studies, 17,574 people), incorrectly identified: · between 20 and 100 out of 100 infected people as healthy; · between 0 and 38 people out of 100 healthy people as infected Asking about symptoms (13 studies, 16,762 people ), incorrectly identified: · between 40 to 100 out of 100 infected people as healthy · between 0 to 34 out of 100 healthy people as infected Temperature measurements , asking about international travel , exposure to known infected people and exposure to known or suspected infected people (6 studies, 14,741 people), incorrectly identified : · between 77 and 100 out of 100 infected people as healthy · between 0 and 10 out of 100 healthy people as infected Asking about symptoms plus temperature measurement (2 studies, 779 people), incorrectly identified: · between 31 and 88 out of 100 infected people as healthy · between 0 to 10 people out of 100 healthy people as infected There was insufficient evidence from two small studies on rapid laboratory tests and repeated symptom assessment to tell how accurate they were in identifying healthy and infected people. Modelling studies 
Three studies modelled entry and exit screening in airports. One study missed 70% of infected travellers. Another detected 90% of infections, but used an unrealistic scenario. The third used very unreliable methods so we cannot use evidence from this study. How confident are we in the results of the studies? Our confidence in these findings is limited because most studies did not describe their screening methods clearly, some found very few cases of infections and the types of participants and settings varied greatly, making it difficult to judge whether the results apply broadly. Authors’ conclusions One‐time screening in apparently healthy people is likely to miss people who are infected. We are unsure whether combined screenings, repeated symptom assessment, or rapid laboratory tests are useful. As more people become infected, screening will identify more cases. However, because screening can miss people who are infected, public health measures such as face coverings, physical distancing, and quarantine for those who are apparently healthy, continue to be very important.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Viswanathan, M; Kahwati, L; Jahn, B; Giger, K; Dobrescu, AI; Hill, C; Klerings, I; Meixner, J; Persad, E; Teufer, B; Gartlehner, G", "articleTypes": [], "doi": "10.1002/14651858.CD013718", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "2698e232-296f-44bf-96a7-f8716c144244", "pmid": "", "title": "Sensory and Gastrointestinal Impact of Taste Receptor Variants on Human Metabolism and Nutrition", "imported": false, "abstract": "We investigate the impact of taste receptors (sweet, bitter and umami) on human metabolism. There ist growing evidence, that components of the taste signalling system, including the taste receptor proteins , have important functions in the regulation of metabolic parameters in non-gustatory tissues.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.252Z" }, { "id": "26c31ccc-6f5e-4afe-bd0a-0f49cb9ab254", "pmid": "", "title": "Interventions for treating iron deficiency anaemia in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease affects approximately seven million people globally. Iron deficiency anaemia can occur as a common systemic manifestation, with a prevalence of up to 90%, which can significantly affect quality of life, both during periods of active disease or in remission. It is important that iron deficiency anaemia is treated effectively and not be assumed to be a normal finding of inflammatory bowel disease. The various routes of iron administration, doses and preparations present varying advantages and disadvantages, and a significant proportion of people experience adverse effects with current therapies. Currently, no consensus has been reached amongst physicians as to which treatment path is most beneficial. Objectives The primary objective was to evaluate the efficacy and safety of the interventions for the treatment of iron deficiency anaemia in people with inflammatory bowel disease. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 21st November 2019. We also contacted experts in the field and searched references of trials for any additional trials. Selection criteria Randomised controlled trials investigating the effectiveness and safety of iron administration interventions compared to other iron administration interventions or placebo in the treatment of iron deficiency anaemia in inflammatory bowel disease. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors. Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We expressed dichotomous and continuous outcomes as risk ratios and mean differences with 95% confidence intervals. We assessed the certainty of the evidence using the GRADE methodology. Main results We included 11 studies (1670 randomised participants) that met the inclusion criteria. The studies compared intravenous iron sucrose vs oral iron sulphate (2 studies); oral iron sulphate vs oral iron hydroxide polymaltose complex (1 study); oral iron fumarate vs intravenous iron sucrose (1 study); intravenous ferric carboxymaltose vs intravenous iron sucrose (1 study); erythropoietin injection + intravenous iron sucrose vs intravenous iron sucrose + injection placebo (1 study); oral ferric maltol vs oral placebo (1 study); oral ferric maltol vs intravenous ferric carboxymaltose (1 study); intravenous ferric carboxymaltose vs oral iron sulphate (1 study); intravenous iron isomaltoside vs oral iron sulphate (1 study); erythropoietin injection vs oral placebo (1 study). All studies compared participants with CD and UC together, as well as considering a range of disease activity states. The primary outcome of number of responders, when defined, was stated to be an increase in haemoglobin of 20 g/L in all but two studies in which an increase in 10g/L was used. In one study comparing intravenous ferric carboxymaltose and intravenous iron sucrose, moderate‐certainty evidence was found that intravenous ferric carboxymaltose was probably superior to intravenous iron sucrose, although there were responders in both groups (150/244 versus 118/239, RR 1.25, 95% CI 1.06 to 1.46, number needed to treat for an additional beneficial outcome (NNTB) = 9). In one study comparing oral ferric maltol to placebo, there was low‐certainty evidence of superiority of the iron (36/64 versus 0/64, RR 73.00, 95% CI 4.58 to 1164.36). There were no other direct comparisons that found any difference in the primary outcomes, although certainty was low and very low for all outcomes, due to imprecision from sparse data and risk of bias varying between moderate and high risk. The reporting of secondary outcomes was inconsistent. The most common was the occurrence of serious adverse events or those requiring withdrawal of therapy. In no comparisons was there a difference seen between any of the intervention agents being studied, although the certainty was very low for all comparisons made, due to risk of bias and significant imprecision due to the low numbers of events. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes were reported in any of the studies. An analysis of all intravenous iron preparations to all oral iron preparations showed that intravenous administration may lead to more responders (368/554 versus 205/373, RR 1.17, 95% CI 1.05 to 1.31, NNTB = 11, low‐certainty due to risk of bias and inconsistency). Withdrawals due to adverse events may be greater in oral iron preparations vs intravenous (15/554 versus 31/373, RR 0.39, 95% CI 0.20 to 0.74, low‐certainty due to risk of bias, inconsistency and imprecision). Authors' conclusions Intravenous ferric carboxymaltose probably leads to more people having resolution of IDA (iron deficiency anaemia) than intravenous iron sucrose. Oral ferric maltol may lead to more people having resolution of IDA than placebo. We are unable to draw conclusions on which of the other treatments is most effective in IDA with IBD (inflammatory bowel disease) due to low numbers of studies in each comparison area and clinical heterogeneity within the studies. Therefore, there are no other conclusions regarding the treatments that can be made and certainty of all findings are low or very low. Overall, intravenous iron delivery probably leads to greater response in patients compared with oral iron, with a NNTB (number needed to treat) of 11. Whilst no serious adverse events were specifically elicited with any of the treatments studied, the numbers of reported events were low and the certainty of these findings very low for all comparisons, so no conclusions can be drawn. There may be more withdrawals due to such events when oral is compared with intravenous iron delivery. Other outcomes were poorly reported and once again no conclusions can be made as to the impact of IDA on any of these outcomes. Given the widespread use of many of these treatments in practice and the only guideline that exists recommending the use of intravenous iron in favour of oral iron, research to investigate this key issue is clearly needed. Considering the current ongoing trials identified in this review, these are more focussed on the impact in specific patient groups (young people) or on other symptoms (such as fatigue). Therefore, there is a need for studies to be performed to fill this evidence gap. Plain language summary Therapies for treating iron deficiency anaemia in Crohn's disease and ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether treatments in people with Crohn's disease and ulcerative colitis can improve iron deficiency anaemia. We analysed data from 11 studies to answer this question. Key messages Iron in the form of ferric carboxymaltose given intravenously is probably better than iron sucrose given intravenously in improving iron deficiency anaemia, although people improved taking both treatments. Oral iron in the form of ferric maltol may be better than placebo (dummy treatment). It is unclear whether any of the other treatments considered are better than each other, however, there is limited evidence due to low numbers of studies and issues due to low quality of the reporting of the research studies. What was studied in the review? People with both ulcerative colitis and Crohn's disease both commonly suffer with low iron levels that in turn lowers their haemoglobin (blood) levels (this is called anaemia). This can lead to a number of symptoms, including tiredness and pain. Several treatments exist to treat iron deficiency anaemia, consisting of delivering extra iron either orally or intravenously (through a vein). An additional treatment, erythropoietin, was also studied which stimulates the body to produce more blood itself. Currently, no consensus has been reached amongst physicians as to which treatment is better. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing any treatment with another or dummy treatment. We found 11 RCTs looking at 1670 participants. The trials looked at adult participants, with none considering children. 1) Intravenous iron in the form of ferric carboxymaltose probably leads to more people having an improvement in iron deficiency anaemia than intravenous iron sucrose (one extra person would improve for every 9 treated and five out of 10 people would improve with either therapy). 2) Oral iron as ferric maltol may lead to more people having resolution of iron deficiency than dummy treatment. 3) It is unclear whether there is any difference between any of the other treatments studied for treating iron deficiency anaemia. 4) It is unclear whether any therapy leads to a difference in adverse events (minor or serious) when compared to any other therapy. Conclusion Iron delivered via a vein as ferric carboxymaltose probably improves anaemia in more people that iron sucrose via a vein, although both groups of people improved. Oral iron as ferric maltol may improve more patients than dummy treatment. No conclusions can be drawn on other treatments due to lack of evidence and quality issues with the studies that were found. Further research is needed, particularly to investigate whether iron delivered through a vein is better than iron delivered orally and also how much treating anaemia in people with IBD makes a difference in terms of the symptoms they may experience. How up‐to‐date is this review? This review is up‐to‐date as of November 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gordon, M; Sinopoulou, V; Iheozor-Ejiofor, Z; Iqbal, T; Allen, P; Hoque, S; Engineer, J; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013529.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "26dfae24-8599-4ddf-b8a9-313ca3a3e359", "pmid": "", "title": "Nirmatrelvir combined with ritonavir for preventing and treating COVID‐19", "imported": false, "abstract": "Abstract - Background Oral nirmatrelvir/ritonavir (Paxlovid) aims to avoid severe COVID‐19 in asymptomatic people or those with mild symptoms, thereby decreasing hospitalization and death. It remains to be evaluated for which indications and patient populations the drug is suitable. Objectives To assess the efficacy and safety of nirmatrelvir/ritonavir plus standard of care (SoC) compared to SoC with or without placebo, or any other intervention for treating COVID‐19 or preventing SARS‐CoV‐2 infection. To explore equity aspects in subgroup analyses. To keep up to date with the evolving evidence base using a living systematic review (LSR) approach and make new relevant studies available to readers in‐between publication of review updates. Search methods We searched the Cochrane COVID‐19 Study Register, Scopus, and World Health Organization COVID‐19 Research Database, identifying completed and ongoing studies without language restrictions and incorporating studies up to 15 May 2023. This is a LSR. We conduct update searches every two months and make them publicly available on the open science framework (OSF) platform. Selection criteria We included randomized controlled trials (RCTs) comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo, or any other intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. We screened all studies for research integrity. Studies were ineligible if they had been retracted, or if they were not prospectively registered including appropriate ethics approval. Data collection and analysis We followed standard Cochrane methodology and used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the following outcomes: 1. to treat outpatients with mild COVID‐19; 2. to treat inpatients with moderate to severe COVID‐19: mortality, clinical worsening or improvement, quality of life, (serious) adverse events, and viral clearance; 3. to prevent SARS‐CoV‐2 infection in postexposure prophylaxis (PEP); and 4. pre‐exposure prophylaxis (PrEP) scenarios: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, mortality, admission to hospital, quality of life, and (serious) adverse events. We explored inequity by subgroup analysis for elderly people, socially‐disadvantaged people with comorbidities, populations from low‐income countries and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. Main results As of 15 May 2023, we included two RCTs with 2510 participants with mild and mild to moderate symptomatic COVID‐19 in outpatient and inpatient settings comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo. All trial participants were without previous confirmed SARS‐CoV‐2 infection and at high risk for progression to severe disease. Randomization coincided with the Delta wave for outpatients and Omicron wave for inpatients. Outpatient trial participants and 73% of inpatients were unvaccinated. Symptom onset in outpatients was no more than five days before randomisation and prior or concomitant therapies including medications highly dependent on CYP3A4 were not allowed. We excluded two studies due to concerns with research integrity. We identified 13 ongoing studies. Three studies are currently awaiting classification. Nirmatrelvir/ritonavir for treating people with asymptomatic or mild COVID‐19 in outpatient settings Nirmatrelvir/ritonavir plus SoC compared to SoC plus placebo may reduce all‐cause mortality at 28 days (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.68; 1 study, 2224 participants; low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.13, 95% CI 0.07 to 0.27; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC may reduce serious adverse events during the study period compared to SoC plus placebo (RR 0.24, 95% CI 0.15 to 0.41; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably has little or no effect on treatment‐emergent adverse events (RR 0.95, 95% CI 0.82 to 1.10; 1 study, 2224 participants; moderate‐certainty evidence), and probably increases treatment‐related adverse events such as dysgeusia and diarrhoea during the study period compared to SoC plus placebo (RR 2.06, 95% CI 1.44 to 2.95; 1 study, 2224 participants; moderate‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably decreases discontinuation of study drug due to adverse events compared to SoC plus placebo (RR 0.49, 95% CI 0.30 to 0.80; 1 study, 2224 participants; moderate‐certainty evidence). No studies reported improvement of clinical status, quality of life, or viral clearance. Nirmatrelvir/ritonavir for treating people with moderate to severe COVID‐19 in inpatient settings We are uncertain whether nirmatrelvir/ritonavir plus SoC compared to SoC reduces all‐cause mortality at 28 days (RR 0.63, 95% CI 0.21 to 1.86; 1 study, 264 participants; very low‐certainty evidence), or increases viral clearance at seven days (RR 1.06, 95% CI 0.71 to 1.58; 1 study, 264 participants; very low‐certainty evidence) and 14 days (RR 1.05, 95% CI 0.92 to 1.20; 1 study, 264 participants; very low‐certainty evidence). No studies reported improvement or worsening of clinical status and quality of life. We did not include data for safety outcomes due to insufficient and inconsistent information. Subgroup analyses for equity For outpatients, the outcome 'admission to hospital or death' was investigated for equity regarding age (less than 65 years versus 65 years or greater) and ethnicity. There were no subgroup differences for age or ethnicity. For inpatients, the outcome 'all‐cause mortality' was investigated for equity regarding age (65 years or less versus greater than 65 years). There was no difference between subgroups of age. No further equity‐related subgroups were reported, and no subgroups were reported for other outcomes. Nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection (PrEP and PEP) No studies available. Authors' conclusions Low‐certainty evidence suggests nirmatrelvir/ritonavir reduces the risk of all‐cause mortality and hospital admission or death in high‐risk, unvaccinated COVID‐19 outpatients infected with the Delta variant of SARS‐CoV‐2. There is low‐ to moderate‐certainty evidence of the safety of nirmatrelvir/ritonavir. Very low‐certainty evidence exists regarding the effects of nirmatrelvir/ritonavir on all‐cause mortality and viral clearance in mildly to moderately affected, mostly unvaccinated COVID‐19 inpatients infected with the Omicron variant of SARS‐CoV‐2. Insufficient and inconsistent information prevents the assessment of safety outcomes. No reliable differences in effect size and direction were found regarding equity aspects. There is no available evidence supporting the use of nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection. We are continually updating our search and making search results available on the OSF platform. Plain language summary Is the combination of nirmatrelvir plus ritonavir effective for treating or preventing COVID‐19? Key messages Nirmatrelvir/ritonavir (Paxlovid) is evaluated for the treatment of coronavirus disease 2019 (COVID‐19). Nirmatrelvir/ritonavir may lead to fewer deaths and improve patient condition, as assessed by need for hospitalization or death within 28 days for unvaccinated outpatients at increased risk for disease progression receiving treatment within five days of symptom onset. We are very uncertain about the effectiveness of nirmatrelvir/ritonavir in inpatients. We excluded two studies due to concerns with research integrity. We found 13 ongoing studies. What is nirmatrelvir/ritonavir? The combination of nirmatrelvir with ritonavir is a new medicine developed to treat infection with the SARS‐CoV‐2 virus and aims to avoid severe COVID‐19 in people without symptoms, or those with mild symptoms. Ritonavir increases the effectiveness of nirmatrelvir but it can interact with many other medicines, which can increase side effects. What did we want to find out? We wanted to know if nirmatrelvir/ritonavir reduces death, illness, and length of infection in people with COVID‐19, or if it is useful in prevention of the disease. We included studies comparing the medicine with placebo (dummy treatment), no treatment, usual care, or any other treatments for COVID‐19. We addressed equity and wanted to know whether there are certain groups of people for which nirmatrelvir/ritonavir works best or is less effective. We looked at elderly people, socially disadvantaged people with other illnesses (comorbidities), people from low‐income and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. We evaluated the effects of nirmatrelvir/ritonavir in people with COVID‐19 regarding: – people dying; – whether COVID‐19 symptoms got better or worse; – quality of life; – unwanted effects of the medicine; – virus elimination. For prevention, we sought the effect on preventing COVID‐19 and SARS‐CoV‐2 infection. What did we do? We searched for randomized controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that investigated nirmatrelvir/ritonavir to prevent or treat COVID‐19. People receiving nirmatrelvir/ritonavir as treatment had to have laboratory‐confirmed COVID‐19 and be treated in hospital or as outpatients. People receiving nirmatrelvir/ritonavir to prevent an infection had to have a high risk of contracting the disease or had to have had a high‐risk contact with a person with confirmed COVID‐19. We summarized the results of the studies and rated our confidence in the evidence, based on common criteria as to how reliable the evidence was. We examined differences with respect to age, level of comorbidity, country according to the World Bank country classification by income level, and ethnicity. What did we find? We found two studies with 2510 participants that investigated nirmatrelvir/ritonavir compared to placebo or standard of care for the treatment of COVID‐19 in people without previous confirmed SARS‐CoV‐2 infection and at increased risk for progression to severe disease due to a comorbidity or risk factor such as current smoking. Included outpatients were enrolled during the Delta wave, unvaccinated, and had a symptom onset of up to five days before starting treatment. Included inpatients were enrolled during the Omicron wave, mostly unvaccinated, and mildly to moderately affected. We found 13 ongoing studies that have not yet been completed, and three studies are currently awaiting classification. Main results Treating outpatients with COVID‐19 For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir may: – lead to fewer deaths; – improve patients' condition assessed by need for admission to hospital or death within 28 days; – reduce serious unwanted events. For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir probably: – has little effect on any unwanted events; – increases any treatment‐related unwanted events (mostly taste disturbance and diarrhoea); – decreases discontinuation of study medicine due to unwanted events. Equity aspects Most study participants were younger than 65 years and of white ethnicity. There was no difference in effectiveness between younger and older participants and participants from different ethnic groups. No subgroups were reported for different levels of comorbidity and World Bank country classification by income level. Treating inpatients with COVID‐19 We are uncertain whether, for the specific population of mildly to moderately affected, high‐risk patients, nirmatrelvir/ritonavir: – leads to fewer deaths; and – increases virus elimination Equity aspects Most study participants were older than 65 years. There was no difference in effectiveness between younger and older participants. No subgroups were reported for different levels of comorbidity, ethnicity, and World Bank country classification by income level. No subgroups were reported for other outcomes. What are the limitations of the evidence? Our confidence in the evidence is low to moderate for outpatients and very low for inpatients. The studies did not report everything we were interested in, such as quality of life and symptom resolution, and had a highly specific population of people at high risk of progression to severe COVID‐19. How up to date is this evidence? The evidence is up to date to 15 May 2023. According to this review's living approach, we will update our search every two months. We are making search results and new relevant studies publicly available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Reis, S, Metzendorf, M-I, Kuehn, R, Popp, M, Gagyor, I, Kranke, P, Meybohm, P, Skoetz, N, Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015395.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.796Z" }, { "id": "26f086ee-04f9-4257-ab5b-553a2e21d0c5", "pmid": "", "title": "Chinese medicinal herbs for measles", "imported": false, "abstract": "Abstract - Background Measles is an infectious disease caused by the Morbillivirus . Chinese physicians believe that medicinal herbs are effective in alleviating symptoms and preventing complications. Chinese herbal medicines are dispensed according to the particular symptoms. This is the second update of a Cochrane Review first published in 2006. Objectives To assess the effectiveness and possible adverse effects of Chinese medicinal herbs for measles. Search methods We searched the Cochrane Central Register of Controlled Clinical Trials (CENTRAL Issue 1, 2011) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to March week 5, 2011), EMBASE (1980 to April 2011), Web of Science (2005 to 30 April 2011), AMED (1985 to 30 April 2011), Chinese Biomedical Database (1976 to 30 June 2011), VIP Information (1989 to 30 June 2011), China National Knowledge Infrastructure (CNKI) (1976 to 30 June 2011), Chinese Journals full‐article database (1994 to 30 June 2011) and the meta Register of Controlled Trials for ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs in patients with measles (without complications). Data collection and analysis Two review authors (SC, TW) independently assessed trial quality and extracted data. We telephone interviewed the trial authors for missing information regarding participant allocation. Some trials allocated participants according to the sequence they were admitted to the trials, that is to say, by using a pseudo‐random allocation method. None of the trials concealed the allocation or used blinding methods. Main results We did not identify any suitable trials for inclusion. In this updated review we identified 80 trials which claimed to use random allocation. We contacted 32 trial authors by telephone and learned that the allocation methods used were not randomised. We excluded 34 studies because the participants experienced complications such as pneumonia. We excluded 10 trials because of non‐random allocation and complications experienced by the participants. We were unable to contact the remaining four trials' authors, so they require further assessment and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions There is no RCT evidence for or against Chinese medicinal herbs as a treatment for measles. We hope high‐quality, robust RCTs in this field will be conducted in the future. Plain language summary Chinese medicinal herbs for measles Measles (rubeola) is an infectious disease caused by multiplication of a single‐strand ribonucleic acid (RNA) virus of the genus Morbillivirus in the upper respiratory tract and conjunctiva. It can lead to serious complications and death. Chinese herbal medicines are believed to be effective in alleviating symptoms and shortening the duration of measles, and are widely used as the main or adjunctive therapy to treat measles in China and other countries. The review authors found a large number of clinical studies providing evidence of Chinese herbal medicines in the treatment of measles. Some of these reports claimed to be randomised controlled trials. However, after telephone interviewing 32 trial authors, we found that none of them used acceptable randomisation procedures to allocate participants and 34 studies included participants with measles complicated with other diseases, for example, pneumonia. Ten trials were non‐randomised controlled studies and four trials require further classification. In this update, we were unable to include any randomised controlled trial for assessment. Although no trials were included, the authors reviewed the articles and found no reports of adverse events in the use of Chinese herbal medicines for treating measles. High‐quality and large trials are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Chen, S, Wu, T, Kong, X, Yuan, H", "articleTypes": [], "doi": "10.1002/14651858.CD005531.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.737Z" }, { "id": "2709d073-0a05-4af0-8175-1220d4985632", "pmid": "", "title": "Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder", "imported": false, "abstract": "Abstract - Background Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. Objectives To assess the effects ‐ and review the acceptability and tolerability ‐ of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. Selection criteria Double‐ or single‐blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. Data collection and analysis Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. Main results Thirty‐one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D‐cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP‐101,606 (1), decoglurant (1), MK‐0657 (1), N‐acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty‐eight studies were placebo‐controlled, and 48 were two‐arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild‐to‐moderate depression. Nineteen studies recruited only patients with treatment‐resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low‐certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) ‐0.87, 95% CI ‐1.26 to ‐0.48; n = 231, studies = 8, very low‐certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low‐certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low‐certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low‐certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and midazolam (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low‐certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate‐certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD ‐0.31, 95% CI ‐0.45 to ‐0.17; n = 824, studies = 4, moderate‐certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low‐certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate‐certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. Authors' conclusions Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta‐analyses for each comparison and the majority of comparisons included only one study. Long term non‐inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real‐world monitoring are needed to establish comprehensive data on safety and efficacy. Plain language summary Ketamine and other glutamate receptor modulators for depression in adults Why is this review important? Depression is one of the most common mental disorders, estimated to affect 350 million people worldwide. Antidepressant medication tends to be given as a first treatment for people with major depression. These drugs are however only effective in about one in four people at one year. Effective alternative medications to treat depression are needed, especially for rapid treatment. A new group of medications is called ‘glutamate receptor modulators’, which act on the glutamergic system. This group includes the medicine ketamine. In this review we examined the evidence for glutamate receptor modulators, including ketamine, as a treatment for depression. Who will be interested in this review? ‐ People with depression, their friends and families. ‐ General practitioners, psychiatrists, psychologists and pharmacists. ‐ Professionals working in adult mental health services. What questions does this review aim to answer? 1. Is treatment with ketamine and other glutamate receptor modulators more effective than treatment with placebo (dummy pill) or other drugs? 2. Is treatment with ketamine and other glutamate receptor modulators more acceptable than placebo or other drugs? Which studies were included in the review? We searched medical databases to find all relevant studies (specifically randomised controlled trials) completed up to 30 July 2020. To be included in the review, studies had to compare ketamine or other glutamate receptor modulators with placebo, other medicines or electroconvulsive therapy (ECT) for depression in adults (aged 18 and over). The studies also had to be single‐blind (the participant does not know which treatment they are receiving) or double‐blind (neither the participant or researcher know which treatment the participant is receiving), to attempt to reduce bias. We included 64 studies in the review, involving a total of 5299 people. The studies investigated16 different glutamate receptor modulator medications. The majority of participants had treatment‐resistant depression (depression which had not responded to two or more medications) at the start of the studies. Most studies were two‐armed, where the glutamate receptor modulator was compared with one other intervention. What does the evidence from the review tell us? Among the 16 drugs included in this review, only ketamine and esketamine were more effective than placebo at reducing symptoms of depression. The effects of ketamine lasted no more than one week after treatment and clearly disappeared after two weeks. Ketamine did, however, cause more side effects than placebo. The effects of esketamine were seen at 24 hours and could last up to four weeks with repeated doses. Esketamine caused a lot more side effects than placebo. The certainty of evidence varied considerably. There was no evidence of a difference between the other glutamate receptor modulators included in this review and placebo or other medications. What should happen next? Ketamine and esketamine appear to reduce the symptoms of depression. However, the trials were all short term so we do not know about the long‐term effects. It is important to note that in some trials attempts to prevent participants and investigators from knowing what medicine was being given were not successful and this may have inflated the positive effects of the active drugs. Future studies should examine what happens when people are repeatedly given the drug, with the aim to mimic the real‐world practice and assess longer‐term effects. More non‐inferiority trials should be conducted, where glutamate receptor modulators are compared with other active medications rather than placebo to find out whether they are better than alternative treatments. In most of the ketamine trials in this review, participants were given the drug by injection into a vein. This restricts the wide‐scale application of ketamine in clinical settings, so trials of ketamine by other routes are needed. Esketamine trials usually used nasal sprays, which are easier to use and could potentially be taken at home if further monitoring and trials found that it was safe to do so. Further studies assessing administration are needed in order to draw more reliable and firm conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Dean, RL, Hurducas, C, Hawton, K, Spyridi, S, Cowen, PJ, Hollingsworth, S, Marquardt, T, Barnes, A, Smith, R, McShane, R, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011612.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.790Z" }, { "id": "27189f86-c679-4147-816f-a21005853f2f", "pmid": "", "title": "Anabolic‐androgenic steroids for alcoholic liver disease", "imported": false, "abstract": "Abstract - Background Alcohol is one of the most common causes of liver disease in the Western World. Randomised clinical trials have examined the effects of anabolic‐androgenic steroids for alcoholic liver disease. Objectives To assess the beneficial and harmful effects of anabolic‐androgenic steroids for patients with alcoholic liver disease based on the results of randomised clinical trials. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Controlled Trials Register in The Cochrane Library , MEDLINE , EMBASE, LILACS, and Science Citation Index Expanded until June 2006. Electronic searches were combined with full text searches. Manufacturers and researchers in the field were also contacted. Selection criteria Randomised clinical trials studying patients with alcoholic steatosis, alcoholic fibrosis, alcoholic hepatitis, and/or alcoholic cirrhosis were included. Interventions encompassed anabolic‐androgenic steroids at any dose or duration versus placebo or no intervention. The trials could be double blind, single blind, or unblinded. The trials could be unpublished or published, and no language limitations were applied. Data collection and analysis Outcomes are assessed at maximal follow‐up. All analyses were performed according to the intention‐to‐treat method. The statistical package RevMan Analyses was used. The methodological quality of the randomised clinical trials was assessed. Main results Combining the results of five randomised clinical trials randomising 499 patients with alcoholic hepatitis and/or cirrhosis demonstrated no significant effects of anabolic‐androgenic steroids on mortality (relative risk (RR) 1.01, 95% confidence interval (CI) 0.79 to 1.29), liver‐related mortality (RR 0.83, 95% CI 0.60 to 1.15), complications of liver disease (RR 1.25, 95% CI 0.74 to 2.10), and liver histology. Anabolic‐androgenic steroids did not significantly affect a number of other outcome measures, including sexual function and liver biochemistry. Anabolic‐androgenic steroids were not associated with a significantly increased risk of non‐serious adverse events (RR 1.14, 95% CI 0.50 to 2.59) or with serious adverse events (RR 4.54, 95% CI 0.57 to 36.30). Authors' conclusions This systematic review could not demonstrate any significant beneficial effects of anabolic‐androgenic steroids on any clinically important outcomes (mortality, liver‐related mortality, liver complications, and histology) of patients with alcoholic liver disease. Plain language summary No evidence to support anabolic‐androgenic steroids for alcoholic liver disease Alcohol causes a major part of the liver diseases in the Western World. Several trials have addressed the effects of anabolic‐androgenic steroids for alcoholic liver disease. This systematic review could not demonstrate any significant effects of anabolic‐androgenic steroids on mortality, liver‐related mortality, liver complications, and histology of patients with alcoholic liver disease. Anabolic‐androgenic steroid intervention is not associated with a significant increase in non‐serious adverse events, but with the seldom occurrence of serious adverse events. Accordingly, there is no evidence supporting the use of anabolic‐androgenic steroids for alcoholic liver disease, but further randomised clinical trials may be needed to settle the question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Rambaldi, A, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD003045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.762Z" }, { "id": "27372e5a-6613-449c-93bb-b4998260b99a", "pmid": "", "title": "Antibiotic strategies for eradicating Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Respiratory tract infections with Pseudomonas aeruginosa occur in most people with cystic fibrosis (CF). Established chronic P aeruginosa infection is virtually impossible to eradicate and is associated with increased mortality and morbidity. Early infection may be easier to eradicate. This is an updated review. Objectives Does giving antibiotics for P aeruginosa infection in people with CF at the time of new isolation improve clinical outcomes (e.g. mortality, quality of life and morbidity), eradicate P aeruginosa infection, and delay the onset of chronic infection, but without adverse effects, compared to usual treatment or an alternative antibiotic regimen? We also assessed cost‐effectiveness. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings. Latest search: 24 March 2022. We searched ongoing trials registries. Latest search: 6 April 2022. Selection criteria We included randomised controlled trials (RCTs) of people with CF, in whom P aeruginosa had recently been isolated from respiratory secretions. We compared combinations of inhaled, oral or intravenous (IV) antibiotics with placebo, usual treatment or other antibiotic combinations. We excluded non‐randomised trials and cross‐over trials. Data collection and analysis Two authors independently selected trials, assessed risk of bias and extracted data. We assessed the certainty of the evidence using GRADE. Main results We included 11 trials (1449 participants) lasting between 28 days and 27 months; some had few participants and most had relatively short follow‐up periods. Antibiotics in this review are: oral – ciprofloxacin and azithromycin; inhaled – tobramycin nebuliser solution for inhalation (TNS), aztreonam lysine (AZLI) and colistin; IV – ceftazidime and tobramycin. There was generally a low risk of bias from missing data. In most trials it was difficult to blind participants and clinicians to treatment. Two trials were supported by the manufacturers of the antibiotic used. TNS versus placebo TNS may improve eradication; fewer participants were still positive for P aeruginosa at one month (odds ratio (OR) 0.06, 95% confidence interval (CI) 0.02 to 0.18; 3 trials, 89 participants; low‐certainty evidence) and two months (OR 0.15, 95% CI 0.03 to 0.65; 2 trials, 38 participants). We are uncertain whether the odds of a positive culture decrease at 12 months (OR 0.02, 95% CI 0.00 to 0.67; 1 trial, 12 participants). TNS (28 days) versus TNS (56 days) One trial (88 participants) comparing 28 days to 56 days TNS treatment found duration of treatment may make little or no difference in time to next isolation (hazard ratio (HR) 0.81, 95% CI 0.37 to 1.76; low‐certainty evidence). Cycled TNS versus culture‐based TNS One trial (304 children, one to 12 years old) compared cycled TNS to culture‐based therapy and also ciprofloxacin to placebo. We found moderate‐certainty evidence of an effect favouring cycled TNS therapy (OR 0.51, 95% CI 0.31 to 0.82), although the trial publication reported age‐adjusted OR and no difference between groups. Ciprofloxacin versus placebo added to cycled and culture‐based TNS therapy One trial (296 participants) examined the effect of adding ciprofloxacin versus placebo to cycled and culture‐based TNS therapy. There is probably no difference between ciprofloxacin and placebo in eradicating P aeruginosa (OR 0.89, 95% CI 0.55 to 1.44; moderate‐certainty evidence). Ciprofloxacin and colistin versus TNS We are uncertain whether there is any difference between groups in eradication of P aeruginosa at up to six months (OR 0.43, 95% CI 0.15 to 1.23; 1 trial, 58 participants) or up to 24 months (OR 0.76, 95% CI 0.24 to 2.42; 1 trial, 47 participants); there was a low rate of short‐term eradication in both groups. Ciprofloxacin plus colistin versus ciprofloxacin plus TNS One trial (223 participants) found there may be no difference in positive respiratory cultures at 16 months between ciprofloxacin with colistin versus TNS with ciprofloxacin (OR 1.28, 95% CI 0.72 to 2.29; low‐certainty evidence). TNS plus azithromycin compared to TNS plus oral placebo Adding azithromycin may make no difference to the number of participants eradicating P aeruginosa after a three‐month treatment phase (risk ratio (RR) 1.01, 95% CI 0.75 to 1.35; 1 trial, 91 participants; low‐certainty evidence); there was also no evidence of any difference in the time to recurrence. Ciprofloxacin and colistin versus no treatment A single trial only reported one of our planned outcomes; there were no adverse effects in either group. AZLI for 14 days plus placebo for 14 days compared to AZLI for 28 days We are uncertain whether giving 14 or 28 days of AZLI makes any difference to the proportion of participants having a negative respiratory culture at 28 days (mean difference (MD) ‐7.50, 95% CI ‐24.80 to 9.80; 1 trial, 139 participants; very low‐certainty evidence). Ceftazidime with IV tobramycin compared with ciprofloxacin (both regimens in conjunction with three months colistin) IV ceftazidime with tobramycin compared with ciprofloxacin may make little or no difference to eradication of P aeruginosa at three months, sustained to 15 months, provided that inhaled antibiotics are also used (RR 0.84, 95 % CI 0.65 to 1.09; P = 0.18; 1 trial, 255 participants; high‐certainty evidence). The results do not support using IV antibiotics over oral therapy to eradicate P aeruginosa , based on both eradication rate and financial cost. Authors' conclusions We found that nebulised antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with P aeruginosa . Eradication may be sustained in the short term. There is insufficient evidence to determine whether these antibiotic strategies decrease mortality or morbidity, improve quality of life, or are associated with adverse effects compared to placebo or standard treatment. Four trials comparing two active treatments have failed to show differences in rates of eradication of P aeruginosa . One large trial showed that intravenous ceftazidime with tobramycin is not superior to oral ciprofloxacin when inhaled antibiotics are also used. There is still insufficient evidence to state which antibiotic strategy should be used for the eradication of early P aeruginosa infection in CF, but there is now evidence that intravenous therapy is not superior to oral antibiotics. Plain language summary Different ways of giving antibiotics to clear Pseudomonas aeruginosa infection in people with cystic fibrosis Key messages ‐ Cystic fibrosis (CF) is an inherited condition where the airways often become blocked with mucus, and people with CF are more likely to get chest infections which cause more damage to the lungs. ‐ Pseudomonas aeruginosa ( P aeruginosa ) is often the cause of infection and is difficult to get rid of; antibiotics are the main treatment, but there are many different antibiotics, and they can be given in different ways. ‐ Inhaled antibiotics may be better than no treatment allowing most people to remain free of P aeruginosa after one month. ‐ There seems to be little difference in the other treatments we compared regarding how well they clear P aeruginosa from the lungs. What is cystic fibrosis? CF is the most common inherited condition that is life‐limiting. Sticky mucus builds up in the lungs of people with CF, which makes it difficult to breathe and can lead to chest infections. These chest infections can cause further lung damage and lead to breathing failure and death. A germ called P aeruginosa is often the cause of infection and is difficult to treat successfully, once it has persisted for longer than six months. What did we want to find out? We wanted to compare different combinations of inhaled, oral and intravenous (IV) antibiotics for clearing P aeruginosa in people with CF, to see if any single treatment works best and is more cost‐effective. What did we find? The review includes 11 studies with a total of 1449 people with CF, of any age or sex, who had mild to severe lung disease. The studies lasted from 28 days to 27 months. We could not combine many results as studies used different treatments. There were 10 different comparisons of antibiotic treatments: three studies compared inhaled antibiotics with a placebo (dummy treatment); two studies compared inhaled antibiotics for different lengths of time; two studies compared inhaled tobramycin with or without oral antibiotics depending on how the infection was detected; two studies compared inhaled antibiotics plus an oral antibiotic with inhaled antibiotics plus a placebo; one study compared two different inhaled antibiotics plus an oral antibiotic; and one study compared IV antibiotics with oral antibiotics. Most of the studies showed how well the treatments got rid of P aeruginosa as well as how they affected lung function, other germs, worsening of flare‐ups, and side effects. Main results Three small studies (of 89 people) treating early infection showed that after one month, inhaled antibiotics were better than no treatment and cleared P aeruginosa in most people, but our confidence in the evidence is low. There is likely to be little difference in the other treatments regarding how well they clear P aeruginosa from the lungs, although we found that inhaled antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with Pseudomonas aeruginosa. A study of IV ceftazidime with tobramycin in comparison with oral ciprofloxacin also showed neither group was better at getting rid of P aeruginosa, but we are more certain of the results and this means that it may be just as effective to treat with oral antibiotics. What are the limitations of the evidence? Some studies were carried out up to 30 years ago and the results may not apply today, and some studies were small. Most studies were quite short, so we could not show whether treatment made people with CF feel better or live longer. Given the treatments used in most of the studies, it would have been easy for people to guess which treatment they were receiving, which might have influenced some of the results. Two studies were supported by the pharmaceutical industry. Further research is needed to see whether clearing the infection completely improves the well‐being and quality of life in people with CF and to establish which antibiotic combination is best at clearing P aeruginosa . Overall our confidence in the evidence was moderate to very low, so further research is likely to change our confidence in the results. However, we have higher confidence in one recently published study, which means we can be more sure of the results. How up to date is this evidence? The studies we have reported on are the most up‐to‐date we could find. We last searched the literature in April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Langton Hewer, SC, Smith, S, Rowbotham, NJ, Yule, A, Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD004197.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.811Z" }, { "id": "27439917-7e36-4b8c-984f-3660f98bb085", "pmid": "", "title": "Vitamin B12 supplementation for growth, development, and cognition in children", "imported": false, "abstract": "Abstract - Rationale Vitamin B 12 deficiency is an important public health problem in children, and has been associated with anaemia and impaired growth, cognition, and development. Vitamin B 12 deficiency may develop in children due to lower content in breast milk, low dietary intake, and as requirements increase with age. Vitamin B 12 supplementation may confer benefits to child growth and development, due to its role in DNA synthesis and methylation, red blood cell formation, and folate metabolism. However, no systematic reviews have been conducted to examine the effects of vitamin B 12 supplementation in children. Objectives To determine the effects of vitamin B 12 supplementation on growth, development, and cognition in children less than 12 years of age. Search methods We searched CENTRAL, MEDLINE, Embase, 12 other databases, and two trial registries on 23 September 2025. We screened reference lists of studies. Eligibility criteria We included randomised controlled trials evaluating the effects of oral vitamin B 12 supplementation, alone or in combination with other micronutrients, in children < 12 years of age. We excluded cross‐over trials, trials targeting pregnant or breastfeeding women, or participants with critical illnesses, and interventions delivered by intravenous/intramuscular injections. Outcomes Critical outcomes were vitamin B 12 status, anaemia, haemoglobin, growth, cognitive function, developmental outcomes, and any adverse effects. Important outcomes included megaloblastic anaemia, body composition, health‐related quality of life, morbidity, and all‐cause mortality. Risk of bias We used Cochrane RoB 2 to evaluate bias. Synthesis methods We conducted meta‐analyses using fixed‐effect models. If there was substantial heterogeneity, we used random‐effect models. When meta‐analyses were not conducted, we described findings from individual trials, and considered synthesis and presentation of findings using other methods. We used GRADE to evaluate the certainty of evidence for critical outcomes. Included studies We included 16 trials (4083 children; 2 days to 11 years) in 10 countries, including India, Japan, Thailand, Nepal, United Kingdom, Italy, Spain, the United States, El Salvador, and Guatemala. Follow‐up periods for outcomes in most studies ranged from five weeks to 31 months, with one study extending follow‐up to nine years. Duration of vitamin B 12 supplementation varied, ranging from 28 days to 31 months, with doses from 0.9 µg/day to 150 µg/day. Nine trials, including 2391 children, contributed data to meta‐analyses. Synthesis of results Supplementation with vitamin B 12 alone versus placebo There may be little to no difference between groups in height/length (mean difference (MD) ‐0.19 cm, 95% confidence interval (CI) ‐2.44 to 2.06; 2 trials, 143 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (standardised mean difference (SMD) 0.09, 95% CI ‐0.10 to 0.28; 2 trials, 438 children, low‐certainty evidence). There may be little to no difference between groups in motor skill development (6 to 9 years, NEuroPSYchological assessment, Second Edition (NEPSY‐II); 1 trial, 403 children, low‐certainty evidence). Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency (absolute risk difference (ARD) 56 fewer per 1000, 95% CI 68 fewer to 24 fewer; 1.8% versus 7.6%; risk ratio (RR) 0.27, 95% CI 0.11 to 0.69; 3 trials, 642 children; high‐certainty evidence), and probably increases total vitamin B 12 concentrations (MD 68.53 pmol/L, 95% CI 41.83 to 95.23; 7 trials, 705 children; moderate‐certainty evidence), compared to placebo, with an average increase of 68.5 pmol/L. There may be little to no difference between groups in anaemia (ARD 21 more per 1000, 95% CI 26 fewer to 191 more; 9.1% versus 4.5%; RR 1.48, 95% CI 0.41 to 5.27; 2 trials, 144 children; low‐certainty evidence). No trials reported the occurrence of any adverse effects. Supplementation with vitamin B 12 alone versus no intervention The evidence is very uncertain about the effects of vitamin B 12 on height/length (2 trials, 70 children; very low‐certainty evidence), compared to no intervention. No trials reported data for the other critical outcomes. Supplementation with vitamin B 12 and other micronutrients, compared to the same formulation without vitamin B 12 There may be little to no difference between groups in height/length (MD ‐0.22 cm, 95% CI ‐0.65 to 0.20; 2 trials, 608 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (SMD 0.00, 95% CI ‐0.13 to 0.13; 3 trials, 956 children; low‐certainty evidence). There may be little to no difference between groups in development outcomes (e.g. motor skill development) (SMD ‐0.05, 95% CI ‐0.18 to 0.08; 2 trials, 960 children; low‐certainty evidence). Children who received vitamin B 12 supplementation and other micronutrients may have little to no difference in vitamin B 12 deficiency (ARD 2 fewer per 1000, 95% CI 7 fewer to 32 more; 0.7% versus 0.8%; RR 0.77, 95% CI 0.12 to 5.16; 2 trials, 534 children; low‐certainty evidence), or total vitamin B 12 concentrations (MD 34.32 pmol/L, 95% CI ‐31.13 to 99.77; 3 trials, 731 children; low‐certainty evidence), compared to supplements without vitamin B 12 . There may be little to no difference between groups in anaemia (21.7% versus 25.0%; 1 trial, 35 children; low‐certainty evidence). There may be little to no difference between groups in any adverse effects (9.2% versus 5.9%; 1 trial, 574 children; low‐certainty evidence). The certainty of evidence for critical outcomes ranged from high to very low; we downgraded for imprecision due to small sample sizes or few events, risk of bias in outcome measurement, randomisation methods, selective reporting bias, or inconsistency due to substantial statistical heterogeneity. Few studies reported growth, cognition, development, anaemia, or any adverse effects. Authors' conclusions Vitamin B 12 supplementation (alone or when supplemented with other micronutrients) in children may have little to no effect on growth (i.e. height/length), cognitive function (e.g. attention), development outcomes (e.g. motor skill development), or anaemia, compared to placebo, no intervention, or the same supplements without vitamin B 12 . Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency and probably improves total vitamin B 12 concentrations, compared to placebo. However, vitamin B 12 supplementation with other micronutrients may result in little to no difference in vitamin B 12 deficiency and total vitamin B 12 concentrations, compared to the same formulation without vitamin B 12 . Funding This review had no dedicated funding. Registration Protocol available via DOI 10.1002/14651858.CD015264. Plain language summary What are the effects of vitamin B 12 supplementation for children less than 12 years of age? Key messages Vitamin B 12 supplementation reduces the risk of vitamin B 12 deficiency, and probably improves vitamin B 12 levels in children less than 12 years of age, compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient) (that is, children who did not take vitamin B 12 supplements). Vitamin B 12 supplements, with other micronutrients (important vitamins and minerals the body needs in small amounts to function), may result in little to no difference in vitamin B 12 deficiency or total vitamin B 12 levels, compared to children who received the same supplements without vitamin B 12 . The impact of vitamin B 12 supplements on other health outcomes in children is less clear. What is vitamin B 12 ? Vitamin B 12 is an important nutrient that helps make red blood cells and keep the body's cells and nerves healthy. Vitamin B 12 deficiency is an important public health problem, including in children and in resource‐poor settings. Lower vitamin B 12 levels in children have been linked to anaemia (lower haemoglobin levels), and poorer growth, development, and cognition (a child's ability to gain knowledge through thought, understanding, and the senses). What did we want to find out? We wanted to find out if taking vitamin B 12 supplements would improve the nutrition and health of children less than 12 years of age. What did we do? We searched for studies that looked at the effects of vitamin B 12 compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient), no intervention, or the same supplements without vitamin B 12 . We summarised the results of the studies and our confidence in the evidence, based on information such as how the study was done. What did we find? We included 16 studies involving 4083 children less than 12 years of age (2 days to 11 years). Nine studies, including 2391 children, had data that we could analyse. The studies were conducted in 10 countries around the world. In most studies, the outcomes were assessed immediately after the intervention from five weeks to 31 months, with one study assessing outcomes after nine years. Vitamin B 12 supplements were provided from 28 days to 31 months in amounts from 0.9 to 150 micrograms a day. Supplementation with vitamin B 12 alone versus placebo There may be little to no difference in height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplements had less vitamin B 12 deficiency, and probably had higher vitamin B 12 levels, compared to placebo. There may be little to no difference between groups in anaemia. No studies provided data on any unwanted (adverse) effects. Vitamin B 12 alone versus no intervention The evidence is very uncertain for height/length. No studies reported data we could analyse for other outcomes. Vitamin B 12 and other micronutrients, compared to supplements with the same supplement without vitamin B 12 There may be little to no difference between groups for height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplementation (with other nutrients) may have little to no difference in vitamin B 12 deficiency, vitamin B 12 levels, anaemia, or any unwanted effects. What are the limitations of the evidence? The small number and the size of studies were limitations of this review. Few studies reported on health outcomes, including growth, cognition, development, anaemia, or any adverse effects. The different ages of children, and differences in the amount of vitamin B 12 and when the outcomes were measured, are also limitations of this review. How up to date is this evidence? The evidence is up to date as of 23 September 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Larvie, DY, Güitrón Leal, CE, Venkatramanan, S, Palma Molina, XE, Steel, LB, Kuriyan, R, Finkelstein, JL", "articleTypes": [], "doi": "10.1002/14651858.CD015264.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.786Z" }, { "id": "274be8e2-34ce-420e-a275-9cce2bd08c5c", "pmid": "", "title": "Vitamin D for the treatment of inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Vitamin D possesses immunomodulatory properties and has been implicated in the pathogenesis and severity of inflammatory bowel disease (IBD). Animal studies and emerging epidemiological evidence have demonstrated an association between vitamin D deficiency and worse disease activity. However, the role of vitamin D for the treatment of IBD is unclear. Objectives To evaluate the benefits and harms of vitamin D supplementation as a treatment for IBD. Search methods We used standard, extensive Cochrane search methods. The latest search date was Jun 2023. Selection criteria We included randomised controlled trials (RCTs) in people of all ages with active or inactive IBD comparing any dose of vitamin D with another dose of vitamin D, another intervention, placebo, or no intervention. We defined doses as: vitamin D (all doses), any‐treatment‐dose vitamin D (greater than 400 IU/day), high‐treatment‐dose vitamin D (greater than 1000 IU/day), low‐treatment‐dose vitamin D (400 IU/day to 1000 IU/day), and supplemental‐dose vitamin D (less than 400 IU/day). Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. clinical response for people with active disease, 2. clinical relapse for people in remission, 3. quality of life, and 4. withdrawals due to adverse events. Our secondary outcomes were 5. disease activity at end of study, 6. normalisation of vitamin D levels at end of study, and 7. total serious adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We included 22 RCTs with 1874 participants. Study duration ranged from four to 52 weeks. Ten studies enroled people with Crohn's disease (CD), five enroled people with ulcerative colitis (UC), and seven enroled people with CD and people with UC. Seventeen studies included adults, three included children, and two included both. Four studies enroled people with active disease, six enroled people in remission, and 12 enroled both. We assessed each study for risk of bias across seven individual domains. Five studies were at low risk of bias across all seven domains. Ten studies were at unclear risk of bias in at least one domain but with no areas of high risk of bias. Seven studies were at high risk of bias for blinding of participants and assessors. Vitamin D (all doses) versus placebo or no treatment Thirteen studies compared vitamin D against placebo or no treatment. We could not draw any conclusions on clinical response for UC as the certainty of the evidence was very low (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.51 to 10.57; 1 study, 60 participants). There were no data on CD. There may be fewer clinical relapses for IBD when using vitamin D compared to placebo or no treatment (RR 0.57, 95% CI 0.34 to 0.96; 3 studies, 310 participants). The certainty of the evidence was low. We could not draw any conclusions on quality of life for IBD (standardised mean difference (SMD) −0.13, 95% CI −3.10 to 2.83 (the SMD value indicates a negligent decrease in quality of life, and the corresponding CIs indicate that the effect can range from a large decrease to a large increase in quality of life); 2 studies, 243 participants) or withdrawals due to adverse events for IBD (RR 1.97, 95% CI 0.18 to 21.27; 12 studies, 1251 participants; note 11 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 12). The certainty of the evidence was very low. High‐treatment‐dose vitamin D versus low‐treatment‐dose vitamin D Five studies compared high treatment vitamin D doses against low treatment vitamin D doses. There were no data on clinical response. There may be no difference in clinical relapse for CD (RR 0.48, 95% CI 0.23 to 1.01; 1 study, 34 participants). The certainty of the evidence was low. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 0.89, 95% CI 0.06 to 13.08; 3 studies, 104 participants; note 2 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 3). The data on quality of life and disease activity could not be meta‐analysed, were of very low certainty, and no conclusions could be drawn. Any‐treatment‐dose vitamin D versus supplemental‐dose vitamin D Four studies compared treatment doses of vitamin D against supplemental doses. There were no data on clinical response and relapse. There were no data on quality of life that could be meta‐analysed. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 3.09, 95% CI 0.13 to 73.17; 4 studies, 233 participants; note 3 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 4). Authors' conclusions There may be fewer clinical relapses when comparing vitamin D with placebo, but we cannot draw any conclusions on differences in clinical response, quality of life, or withdrawals, due to very low‐certainty evidence. When comparing high and low doses of vitamin D, there were no data for clinical response, but there may be no difference in relapse for CD. We cannot draw conclusions on the other outcomes due to very low certainty evidence. Finally, comparing vitamin D (all doses) to supplemental‐dose vitamin D, there were no data on clinical relapse or response, and we could not draw conclusions on other outcomes due to very low certainty evidence or missing data. It is difficult to make any clear recommendations for future research on the basis of the findings of this review. Future studies must be clear on the baseline populations, the purpose of vitamin D treatment, and, therefore, study an appropriate dosing strategy. Stakeholders in the field may wish to reach consensus on such issues prior to new studies. Plain language summary Vitamin D for the treatment of inflammatory bowel disease Key messages The data we presently have for the use of vitamin D for the treatment of inflammatory bowel disease are of very low quality, and we do not know whether it works or if it is safe. What is inflammatory bowel disease? Inflammatory bowel disease is a life‐long disease that affects the gut. Its two main types are ulcerative colitis and Crohn's disease. Ulcerative colitis only affects the large intestine. Crohn's disease can affect any part of the gut, from mouth to bottom. Common symptoms include bloody poo, diarrhoea, stomach ache, fever, weight loss, and fatigue. We do not know exactly what causes it, but it is probably a mix of genes, problems with the immune system, bacteria in the gut, and something in the environment. There is no known cure, but the symptoms are usually managed with medicines, such as steroids and immune system medications, and sometimes surgery. Most people with inflammatory bowel disease have times when they have symptoms (called active disease) and other times when their symptoms are under control (called remission). When symptoms reappear after being in remission, it is called relapse. What did we want to find out? We wanted to find out if vitamin D works for the treatment of inflammatory bowel disease, and whether it is safe to use. Specifically, we looked at improvement of symptoms for people with active disease; relapse for people in remission; quality of life; and withdrawals from the trial because of side effects. What did we do? We searched for randomised controlled trials (studies where people are assigned to one of two or more treatment groups using a random method) comparing vitamin D with any other treatment, standard treatment, or different doses of vitamin D. What did we find? We found 22 trials with 1874 participants with inflammatory bowel disease. The studies lasted from four to 52 weeks. Ten studies were on Crohn's disease, five on ulcerative colitis, and seven on participants who had either of these. Seventeen studies were on adults, three on children, and two on both. Four included people with active disease, six in remission, and 12 on a mix of both. The studies included doses of vitamin D used to treat deficiency and doses given as supplements. Thirteen studies compared vitamin D (all doses) against placebo (dummy treatment) or no other treatment. There was low‐quality evidence that there may be fewer clinical relapses when using vitamin D compared to placebo or no treatment. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Five studies compared high‐treatment‐doses to low‐treatment‐doses of vitamin D. There were no data on improvement of symptoms. There was low‐quality evidence that there may be no difference on relapse in Crohn's disease, but there were no data on ulcerative colitis. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Four studies compared treatment doses to supplement doses of vitamin D. There were no data on improvement of symptoms, relapses, or quality of life changes. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. What are the limitations of the evidence? The evidence is mostly of very low and low quality. This is because of problems with the way the studies were carried out, and problems with how the results were reported. Additionally, the individual studies did not make the same measurements, meaning that we did not have enough numbers of people to strengthen the results of the measures we looked for. How up‐to‐date is this review? This review is up‐to‐date to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wallace, C, Gordon, M, Sinopoulou, V, Limketkai, BN", "articleTypes": [], "doi": "10.1002/14651858.CD011806.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.142Z" }, { "id": "2750c3bc-c56d-45bb-955a-daf452d01872", "pmid": "", "title": "The Acute and Chronic Effects of OliPhenolia® Supplementation on Exercise Induced Inflammation and Functional Movement in Healthy Adult Humans.", "imported": false, "abstract": "This research proposal follows on from previously undertaken work investigating a commercially available olive derived product (OliPhenolia®) on potential exercise / functional benefits for healthy adults. Previous research investigated a dose response bioavailability of the main polyphenol in OliPhenolia® and related metabolites. Based on this data, the current study will aim to investigate, for the first time, whether the polyphenols in the product can positively influence exercise specific inflammation which may be pertinent to improving exercise recovery and is of current scientific interest. As such this research aims to understand the short term (Phase 1) and longer term (Phase 2) use of OliPhenolia® on acute recovery from a standard exercise bout.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "27622a52-a9b5-480f-84b4-07bcc14c71c3", "pmid": "", "title": "Desferrioxamine mesylate for managing transfusional iron overload in people with transfusion‐dependent thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. Desferrioxamine mesylate (desferrioxamine) is one of the most widely used iron chelators. Substantial data have shown the beneficial effects of desferrioxamine, although adherence to desferrioxamine therapy is a challenge. Alternative oral iron chelators, deferiprone and deferasirox, are now commonly used. Important questions exist about whether desferrioxamine, as monotherapy or in combination with an oral iron chelator, is the best treatment for iron chelation therapy. Objectives To determine the effectiveness (dose and method of administration) of desferrioxamine in people with transfusion‐dependent thalassaemia. To summarise data from trials on the clinical efficacy and safety of desferrioxamine for thalassaemia and to compare these with deferiprone and deferasirox. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We also searched MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus ongoing trials registers and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). All searches were updated to 5 March 2013. Selection criteria Randomised controlled trials comparing desferrioxamine with placebo, with another iron chelator, or comparing two schedules or doses of desferrioxamine, in people with transfusion‐dependent thalassaemia. Data collection and analysis Six authors working independently were involved in trial quality assessment and data extraction. For one trial, investigators supplied additional data upon request. Main results A total of 22 trials involving 2187 participants (range 11 to 586 people) were included. These trials included eight comparisons between desferrioxamine alone and deferiprone alone; five comparisons between desferrioxamine combined with deferiprone and deferiprone alone; eight comparisons between desferrioxamine alone and desferrioxamine combined with deferiprone; two comparisons of desferrioxamine with deferasirox; and two comparisons of different routes of desferrioxamine administration (bolus versus continuous infusion). Overall, few trials measured the same or long‐term outcomes. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage; none of these included a comparison with deferasirox. Five trials reported a total of seven deaths; three in patients who received desferrioxamine alone, two in patients who received desferrioxamine and deferiprone. A further death occurred in a patient who received deferiprone in another who received deferasirox alone. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. One trial planned five years of follow up but was stopped early due to the beneficial effects of a reduction in serum ferritin levels in those receiving combined desferrioxamine and deferiprone treatment compared with deferiprone alone. The results of this and three other trials suggest an advantage of combined therapy with desferrioxamine and deferiprone over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no evidence for the improved efficacy of combined desferrioxamine and deferiprone therapy against monotherapy from direct or indirect measures of liver iron. Earlier trials measuring the cardiac iron load indirectly by measurement of the magnetic resonance imaging T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, meta‐analysis of two trials showed a significantly lower left ventricular ejection fraction in patients who received desferrioxamine alone compared with those who received combination therapy using desferrioxamine with deferiprone. Adverse events were recorded by 18 trials. These occurred with all treatments, but were significantly less likely with desferrioxamine than deferiprone in one trial, relative risk 0.45 (95% confidence interval 0.24 to 0.84) and significantly less likely with desferrioxamine alone than desferrioxamine combined with deferiprone in two other trials, relative risk 0.33 (95% confidence interval 0.13 to 0.84). In particular, four studies reported permanent treatment withdrawal due to adverse events from deferiprone; only one of these reported permanent withdrawals associated with desferrioxamine. Adverse events also occurred at a higher frequency in patients who received deferasirox than desferrioxamine in one trial. Eight trials reported local adverse reactions at the site of desferrioxamine infusion including pain and swelling. Adverse events associated with deferiprone included joint pain, gastrointestinal disturbance, increases in liver enzymes and neutropenia; adverse events associated with deferasirox comprised increases in liver enzymes and renal impairment. Regular monitoring of white cell counts has been recommended for deferiprone and monitoring of liver and renal function for deferasirox. In summary, desferrioxamine and the oral iron chelators deferiprone and deferasirox produce significant reductions in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised clinical trials to suggest that any one of these has a greater reduction of clinically significant end organ damage, although in two trials, combination therapy with desferrioxamine and deferiprone showed a greater improvement in left ventricular ejection fraction than desferrioxamine used alone. Authors' conclusions Desferrioxamine is the recommended first‐line therapy for iron overload in people with thalassaemia major and deferiprone or deferasirox are indicated for treating iron overload when desferrioxamine is contraindicated or inadequate. Oral deferasirox has been licensed for use in children aged over six years who receive frequent blood transfusions and in children aged two to five years who receive infrequent blood transfusions. In the absence of randomised controlled trials with long‐term follow up, there is no compelling evidence to change this conclusion. Worsening iron deposition in the myocardium in patients receiving desferrioxamine alone would suggest a change of therapy by intensification of desferrioxamine treatment or the use of desferrioxamine and deferiprone combination therapy. Adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. People treated with all chelators must be kept under close medical supervision and treatment with deferiprone or deferasirox requires regular monitoring of neutrophil counts or renal function respectively. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcomes of deferiprone, deferasirox and desferrioxamine. Plain language summary Desferrioxamine mesylate (desferrioxamine) for managing excess iron levels in the blood of people with thalassaemia who depend on blood transfusions Haemoglobin carries oxygen in the blood. In thalassaemia, a genetic disease, sometimes the body cannot produce enough haemoglobin. This can be managed by receiving regular blood transfusions, but may lead to excess iron in the body which must be removed to prevent organ damage. Iron is removed by iron chelation therapy using a substance called an iron chelator. This works by sticking to excess iron molecules in the body. When patients go to the toilet, this excess iron leaves the body. Three iron chelators are commonly used. One (desferrioxamine) is injected and two (deferiprone and deferasirox) are taken orally. Deferasirox is licensed for use in children. Desferrioxamine is inconvenient and expensive; motivating researchers to find safe, effective oral iron chelators. We found 22 randomised controlled trials comparing iron chelators. These do not provide enough information about death or organ damage. However, they showed all three chelators performed similarly well in removing excess iron. Several trials found combining desferrioxamine and deferiprone removed more excess iron than using just one iron chelator. Trials showing side effects must be considered carefully. Side effects with desferrioxamine included pain or skin reactions at the injection site and joint pain. Side effects with deferiprone included joint pain, nausea, stomach upsets and low white blood cell count. Side effects with deferasirox included skin rashes, increases in liver enzymes and reduced kidney function. Low white blood cell count and reduced kidney function are important side effects and in patients receiving deferiprone or deferasirox these should be monitored regularly. Patients were three times more likely to experience a side effect when deferiprone and desferrioxamine were combined, compared with desferrioxamine alone. Three studies showed that patients using deferiprone were two and a half times more likely to have joint pain compared with using desferrioxamine alone. We have found no evidence for changing current treatment recommendations, which state that deferiprone or deferasirox should be used to remove excess iron when desferrioxamine cannot be used or is inadequate. The Food and Drug Administration in the United States of America have approved deferiprone only as \"last resort treatment of iron overload in thalassemia\". Larger randomised control trials of iron chelation therapy are needed, using standardised agreed measures of iron levels and organ damage to allow comparison of such valuable treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA; Brunskill, SJ; Doree, C; Gooding, S; Chowdhury, O; Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004450.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "27654ad2-0cbf-4d58-b1a8-8c3e82c54359", "pmid": "", "title": "The Effects of Lactobacillus Rhamnosus (JB-1) on Stress and Cognition in Healthy Volunteers", "imported": false, "abstract": "Emerging evidence suggests that microorganisms acting via the Brain-Gut axis may have potential benefits for the management of stress-related conditions. The majority of studies have focused on animal models. Preclinical studies have identified the Lactobacillus Rhamnosus JB-1 strain as a putative psychobiotic with an impact on stress-related behaviours, physiology and cognitive performance. Whether such preclinical effects could be translated to healthy human volunteers remains unknown.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.241Z" }, { "id": "27743145-4f27-499f-841a-19b6413e2c64", "pmid": "", "title": "Fixed‐dose combinations of drugs versus single‐drug formulations for treating pulmonary tuberculosis", "imported": false, "abstract": "Abstract - Background People who are newly diagnosed with pulmonary tuberculosis (TB) typically receive a standard first‐line treatment regimen that consists of two months of isoniazid, rifampicin, pyrazinamide, and ethambutol followed by four months of isoniazid and rifampicin. Fixed‐dose combinations (FDCs) of these drugs are widely recommended. Objectives To compare the efficacy, safety, and acceptability of anti‐tuberculosis regimens given as fixed‐dose combinations compared to single‐drug formulations for treating people with newly diagnosed pulmonary tuberculosis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL, published in the Cochrane Library, Issue 11 2015); MEDLINE (1966 to 20 November 2015); EMBASE (1980 to 20 November 2015); LILACS (1982 to 20 November 2015); the metaRegister of Controlled Trials; and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), without language restrictions, up to 20 November 2015. Selection criteria Randomized controlled trials that compared the use of FDCs with single‐drug formulations in adults (aged 15 years or more) newly diagnosed with pulmonary TB. Data collection and analysis Two review authors independently assessed studies for inclusion, and assessed the risk of bias and extracted data from the included trials. We used risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data with 95% confidence intervals (CIs). We attempted to assess the effect of treatment for time‐to‐event measures with hazard ratios and their 95% CIs. We used the Cochrane 'Risk of bias' assessment tool to determine the risk of bias in included trials. We used the fixed‐effect model when there was little heterogeneity and the random‐effects model with moderate heterogeneity. We used an I² statistic value of 75% or greater to denote significant heterogeneity, in which case we did not perform a meta‐analysis. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We included 13 randomized controlled trials (RCTs) in the review, which enrolled 5824 participants. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. Overall there is little or no difference detected between FDCs and single‐drug formulations for most outcomes reported. We did not detect a difference in treatment failure between FDCs compared with single‐drug formulations (RR 1.28, 95% CI 0.82 to 2.00; 3606 participants, seven trials, moderate quality evidence ). Relapse may be more frequent in people treated with FDCs compared to single‐drug formulations, although the confidence interval (CI) includes no difference (RR 1.28, 95% CI 1.00 to 1.64; 3621 participants, 10 trials, low quality evidence ). We did not detect any difference in death between fixed‐dose and single‐drug formulation groups (RR 0.96, 95% CI 0.67 to 1.39; 4800 participants, 11 trials, moderate quality evidence ). When we compared FDCs with single‐drug formulations we found little or no difference for sputum smear or culture conversion at the end of treatment (RR 0.99, 95% CI 0.96 to 1.02; 2319 participants, seven trials, high quality evidence ), for serious adverse events (RR 1.45, 95% CI 0.90 to 2.33; 3388 participants, six trials, moderate quality evidence ), and for adverse events that led to discontinuation of therapy (RR 0.96, 95% CI 0.56 to 1.66; 5530 participants, 13 trials, low quality evidence ). We conducted a sensitivity analysis excluding studies at high risk of bias and this did not alter the review findings. Authors' conclusions Fixed‐dose combinations and single‐drug formulations probably have similar effects for treating people with newly diagnosed pulmonary TB. 23 April 2019 No update planned Other This is not a current research question. Plain language summary Fixed‐dose combinations for treating pulmonary tuberculosis What are fixed‐dose combinations and how might they improve care of people with tuberculosis Tuberculosis (TB) is an important health problem, especially in developing countries. The treatment for pulmonary TB in new patients includes four oral medicines taken for six months, sometimes as fixed‐dose combinations (FDCs) that are combined in one tablet, or taken separately as single‐drug formulations. The World Health Organization recommends prescribers use fixed‐dose combinations to reduce the number of tablets that people take. On the supply side, this might reduce prescribing errors and improve drug supply efficiency; on the patient's side, FDCS simplify treatment and improve adherence. We conducted a review to assess the efficacy, safety, and acceptability of FDCs compared with single‐drug formulations for treating people with newly diagnosed pulmonary TB. What the research says We searched for relevant trials up to 20 November 2015, and included 13 randomized controlled trials that enrolled 5824 people. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. There is probably little or no difference in FDCs compared to single‐drug formulations for treatment failure ( moderate quality evidence ); relapse may be more frequent ( low quality evidence ); and the number of deaths were similar ( moderate quality evidence ). There is little or no difference in sputum smear or culture conversion ( high quality evidence ), and no difference was shown for serious adverse events ( moderate quality evidence ) or adverse events that led to discontinuation of therapy ( low quality evidence ). Authors’ conclusions We concluded that fixed‐dose combinations have similar efficacy to single‐drug formulations for treating people with newly diagnosed pulmonary TB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Gallardo, CR, Rigau Comas, D, Valderrama Rodríguez, A, Roqué i Figuls, M, Parker, LA, Caylà, J, Bonfill Cosp, X", "articleTypes": [], "doi": "10.1002/14651858.CD009913.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.070Z" }, { "id": "27778ee2-05cc-4224-b7a8-cae35d97517d", "pmid": "", "title": "Pharmacological treatment of gastro‐oesophageal reflux in children", "imported": false, "abstract": "Abstract - Background Gastro‐oesophageal reflux (GOR) is characterised by the regurgitation of gastric contents into the oesophagus. GOR is a common presentation in infancy, both in primary and secondary care, affecting approximately 50% of infants under three months old. The natural history of GOR in infancy is generally of a self‐limiting condition that improves with age, but older children and children with co‐existing medical conditions can have more protracted symptoms. The distinction between gastro‐oesophageal reflux disease (GORD) and GOR is debated. Current National Institute of Health and Care Excellence (NICE) guidelines define GORD as GOR causing symptoms severe enough to merit treatment. This is an update of a review first published in 2014. Objectives To assess the effects of pharmacological treatments for GOR in infants and children. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, and Web of Science up to 17 September 2022. We also searched for ongoing trials in clinical trials registries, contacted experts in the field, and searched the reference lists of trials and reviews for any additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any currently‐available pharmacological treatment for GOR in children with placebo or another medication. We excluded studies assessing dietary management of GORD and studies of thickened feeds. We included studies in infants and children up to 16 years old. Data collection and analysis We used standard methodology expected by Cochrane. Main results We included 36 RCTs involving 2251 children and infants. We were able to extract summary data from 14 RCTs; the remaining trials had insufficient data for extraction. We were unable to pool results in a meta‐analysis due to methodological differences in the included studies (including heterogeneous outcomes, study populations, and study design). We present the results in two groups by age: infants up to 12 months old, and children aged 12 months to 16 years old. Infants Omeprazole versus placebo: there is no clear effect on symptoms from omeprazole. One study (30 infants; very low‐certainty evidence) showed cry/fuss time in infants aged three to 12 months had altered from 246 ± 105 minutes/day at baseline (mean +/‐ standard deviation (SD)) to 191 ± 120 minutes/day in the omeprazole group and from 287 ± 132 minutes/day to 201 ± 100 minutes/day in the placebo group (mean difference (MD) 10 minutes/day lower (95% confidence interval (CI) ‐89.1 to 69.1)). The reflux index changed in the omeprazole group from 9.9 ± 5.8% in 24 hours to 1.0 ± 1.3% and in the placebo group from 7.2 ± 6.0% to 5.3 ± 4.9% in 24 hours (MD 7% lower, 95% CI ‐4.7 to ‐9.3). Omeprazole versus ranitidine: one study (76 infants; very low‐certainty evidence) showed omeprazole may or may not provide symptomatic benefit equivalent to ranitidine. Symptom scores in the omeprazole group changed from 51.9 ± 5.4 to 2.4 ± 1.2, and in the ranitidine group from 47 ± 5.6 to 2.5 ± 0.6 after two weeks: MD ‐4.97 (95% CI ‐7.33 to ‐2.61). Esomeprazole versus placebo: esomeprazole appeared to show no additional reduction in the number of GORD symptoms compared to placebo (1 study, 52 neonates; very low‐certainty evidence): both the esomeprazole group (184.7 ± 78.5 to 156.7 ± 75.1) and placebo group (183.1 ± 77.5 to 158.3 ± 75.9) improved: MD ‐3.2 (95% CI ‐4.6 to ‐1.8). Children Proton pump inhibitors (PPIs) at different doses may provide little to no symptomatic and endoscopic benefit. Rabeprazole given at different doses (0.5 mg/kg and 1 mg/kg) may provide similar symptom improvement (127 children in total; very low‐certainty evidence). In the lower‐dose group (0.5 mg/kg), symptom scores improved in both a low‐weight group of children (< 15 kg) (mean ‐10.6 ± SD 11.13) and a high‐weight group of children (> 15 kg) (mean ‐13.6 ± 13.1). In the higher‐dose groups (1 mg/kg), scores improved in the low‐weight (‐9 ± 11.2) and higher‐weight groups (‐8.3 ± 9.2). For the higher‐weight group, symptom score mean difference between the two different dosing regimens was 2.3 (95% CI ‐2 to 6.6), and for the lower‐weight group, symptom score MD was 4.6 (95% CI ‐2.9 to 12). Pantoprazole: pantoprazole may or may not improve symptom scores at 0.3 mg/kg, 0.6 mg/kg, and 1.2 mg/kg pantoprazole in children aged one to five years by week eight, with no difference between 0.3 mg/kg and 1.2 mg/kg dosing (0.3 mg/kg mean −2.4 ± 1.7; 1.2 mg/kg −1.7 ± 1.2: MD 0.7 (95% CI ‐0.4 to 1.8)) (one study, 60 children; very low‐certainty evidence). There were insufficient summary data to assess other medications. Authors' conclusions There is very low‐certainty evidence about symptom improvements and changes in pH indices for infants. There are no summary data for endoscopic changes. Medications may or may not provide a benefit (based on very low‐certainty evidence) for infants whose symptoms remain bothersome, despite nonmedical interventions or parental reassurance. If a medication is required, there is no clear evidence based on summary data for omeprazole, esomeprazole (in neonates), H₂antagonists, and alginates for symptom improvements (very low‐certainty evidence). Further studies with longer follow‐up are needed. In older children with GORD, in studies with summary data extracted, there is very low‐certainty evidence that PPIs (rabeprazole and pantoprazole) may or may not improve GORD outcomes. No robust data exist for other medications. Further RCT evidence is required in all areas, including subgroups (preterm babies and children with neurodisabilities). Plain language summary Medicines for children with reflux Review question What is the best and safest treatment for babies and children with gastro‐oesophageal reflux? Key messages: ‐ the evidence for medications for babies with gastro‐oesophageal reflux/reflux disease is very uncertain; ‐ for children with gastro‐oesophageal reflux disease, the evidence is very uncertain regarding the effects of proton pump inhibitors. There was no adequate evidence to draw conclusions regarding other medications. What is gastro‐oesophageal reflux? Gastro‐oesophageal reflux happens when stomach contents come back up into the oesophagus (food pipe). Most babies (under 1 year) grow out of reflux symptoms, but does medicine help? Children (older than 1 year) can have reflux just like adults. Reflux can be normal ('physiological reflux'), but in babies and children, it can cause symptoms, including pain or weight loss, as the oesophagus becomes inflamed (oesophagitis). Bothersome symptoms of reflux are called 'gastro‐oesophageal reflux disease' (GORD). How is gastro‐oesophageal reflux treated? Medicines can thicken the stomach contents (alginates), neutralise stomach acid (ranitidine, omeprazole, lansoprazole), or help the stomach to empty faster (domperidone, erythromycin). What did we want to find out? We wanted to learn the best way to reduce reflux in babies and children. We wanted to see if medicines help infants and children to feel better (symptom scores), heal the oesophagus (which is checked by using endoscopy, where a tiny camera is put down the oesophagus), or lower the time the oesophagus is exposed to stomach acid. We also investigated whether the medicines were safe by considering the harmful or unwanted effects reported in the studies. What did we do? We searched for studies testing gastro‐oesophageal reflux medicines in babies and children. We included all studies comparing these medicines, or comparing them to an inactive medicine (placebo). We assessed results which are important to doctors, nurses, and parents, and performed our own analysis of the results. We rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 36 suitable studies (involving 2251 babies and children), conducted worldwide, with most in the USA. The largest study recruited 268 babies, the smallest, 16 children. Fifteen studies compared an active medicine to placebo; 8 compared one active medication to another; and 11 studies gave the same medication at different doses. We found useable outcome information in 14 of the 36 studies. The remaining studies either did not report outcomes we were interested in or did not report them in a way we could analyse. We could not combine the results of any studies because they were too different (in terms of how long they followed participants up and the outcomes they investigated) to use in a meaningful way. Key results Babies. There is no clear effect on symptoms or measured acidity (one measure is reflux index, which is the percentage of time in 24 hours the oesophagus is exposed to stomach acid) between babies given omeprazole or placebo. One study (30 babies) showed cry/fuss time went down from 287 to 201 minutes/day in the placebo group and 246 to 191 minutes/day in the omeprazole group. Reflux index changed in the omeprazole group from 9.9% to 1.0% in 24 hours, and in the placebo group from 7.2% to 5.3%. One study (76 babies) showed that omeprazole and ranitidine may have a similar benefit for symptoms after 2 weeks: symptom scores (higher scores mean worse symptoms) in the omeprazole group dropped from 51.9 to 2.4, and in the ranitidine group, from 47 to 2.5. In one study of 52 newborn babies, esomeprazole appeared to show no reduction in the number of symptoms (184.7 to 156.7) compared to placebo (183.1 to 158.3). None of the studies reported harmful events or results about changes to babies' oesophaguses. Children. In children older than 1 year of age, no studies assessed medical treatment versus placebo. Proton pump inhibitors (PPIs), which block stomach acid production, at different doses may provide little to no improvements in symptoms or oesophagus healing. In one study (127 children), both lower‐weight and higher‐weight children given rabeprazole at lower and higher doses had both minimal – probably unimportant – changes in symptom scores and endoscopic scores (which indicate whether healing of the oesophagus has occurred). Pantoprazole may or may not improve symptom scores in children aged 1 to 5 years by week 8: there was no difference between lower and higher dosing in one study (60 children). Studies investigating other medications did not report enough information for us to assess their results properly. Quality of the evidence We are not confident in the evidence, which was mainly based on single studies with few babies and children. Several studies had pharmaceutical company help with manuscript writing. The question of how best to treat children with disabilities, and whether any PPIs are better than other medicines remain. The evidence is current to 17 September 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Tighe, MP, Andrews, E, Liddicoat, I, Afzal, NA, Hayen, A, Beattie, RM", "articleTypes": [], "doi": "10.1002/14651858.CD008550.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.130Z" }, { "id": "2780b9b0-75b2-43f4-9564-2bbfa39d1058", "pmid": "", "title": "Advice to reduce dietary salt for prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Restricting sodium intake in hypertensive patients over short periods of time reduces blood pressure. Long term effects (on mortality, morbidity or blood pressure) of advice to reduce salt in patients with elevated or normal blood pressure are unclear. Objectives To assess in adults the long term effects (mortality, cardiovascular events, blood pressure, quality of life, weight, urinary sodium excretion, other nutrients and use of anti‐hypertensive medications) of advice to restrict dietary sodium using all relevant randomised controlled trials. Search methods The Cochrane Library, MEDLINE, EMBASE, bibliographies of included studies and related systematic reviews were searched for unconfounded randomised trials in healthy adults aiming to reduce sodium intake over at least 6 months. Attempts were made to trace unpublished or missed studies and authors of all included trials were contacted. There were no language restrictions. Selection criteria Inclusion decisions were independently duplicated and based on the following criteria: 1) randomisation was adequate; 2) there was a usual or control diet group; 3) the intervention aimed to reduce sodium intake; 4) the intervention was not multifactorial; 5) the participants were not children, acutely ill, pregnant or institutionalised; 6) follow‐up was at least 26 weeks; 7) data on any of the outcomes of interest were available. Data collection and analysis Decisions on validity and data extraction were made independently by two reviewers, disagreements were resolved by discussion or if necessary by a third reviewer. Random effects meta‐analysis, sub‐grouping, sensitivity analysis and meta‐regression were performed. Main results Three trials in normotensives (n=2326), five in untreated hypertensives (n=387) and three in treated hypertensives (n=801) were included, with follow up from six months to seven years. The large, high quality (and therefore most informative) studies used intensive behavioural interventions. Deaths and cardiovascular events were inconsistently defined and reported; only 17 deaths equally distributed between intervention and control groups occurred. Systolic and diastolic blood pressures were reduced at 13 to 60 months in those given low sodium advice as compared with controls (systolic by 1.1 mm Hg, 95% CI 1.8 to 0.4, diastolic by 0.6 mm hg, 95% CI 1.5 to ‐0.3), as was urinary 24 hour sodium excretion (by 35.5 mmol/ 24 hours, 95% CI 47.2 to 23.9). Degree of reduction in sodium intake and change in blood pressure were not related. People on anti‐hypertensive medications were able to stop their medication more often on a reduced sodium diet as compared with controls, while maintaining similar blood pressure control. Authors' conclusions Intensive interventions, unsuited to primary care or population prevention programmes, provide only minimal reductions in blood pressure during long‐term trials. Further evaluations to assess effects on morbidity and mortality outcomes are needed for populations as a whole and for patients with elevated blood pressure. A low sodium diet may help in maintenance of lower blood pressure following withdrawal of antihypertensives. If this is confirmed, with no increase in cardiovascular events, then targeting of comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. Plain language summary The long term effects of advice to cut down on salt in food on deaths, cardiovascular disease and blood pressure in adults Intensive support and encouragement to reduce salt intake did lead to reduction in salt eaten. It also lowered blood pressure but only by a small amount (about 1 mmHg for systolic blood pressure, less for diastolic) after more than a year. This reduction was not enough to expect an important health benefit. It was also very hard to keep to a low salt diet. However, the reduction in blood pressure appeared larger for people with higher blood pressure. There was not enough information to assess the effect of these changes in salt intake on health or deaths. Evidence from a large and small trial showed that advice to reduce salt helps to maintain lower blood pressure following withdrawal of antihypertensive medication. If this is confirmed, with no increase in cardiovascular events, then comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. See also the Cochrane review of short‐term salt reduction trials: Jurgens 2003 .", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Hooper, L; Bartlett, C; Davey Smith, G; Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD003656.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "2783a35d-06d1-4a86-a659-3d03ea27de49", "pmid": "", "title": "Neuraminidase inhibitors for preventing and treating influenza in adults and children", "imported": false, "abstract": "Abstract - Background Neuraminidase inhibitors (NIs) are stockpiled and recommended by public health agencies for treating and preventing seasonal and pandemic influenza. They are used clinically worldwide. Objectives To describe the potential benefits and harms of NIs for influenza in all age groups by reviewing all clinical study reports of published and unpublished randomised, placebo‐controlled trials and regulatory comments. Search methods We searched trial registries, electronic databases (to 22 July 2013) and regulatory archives, and corresponded with manufacturers to identify all trials. We also requested clinical study reports. We focused on the primary data sources of manufacturers but we checked that there were no published randomised controlled trials (RCTs) from non‐manufacturer sources by running electronic searches in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE (Ovid), EMBASE, Embase.com, PubMed (not MEDLINE), the Database of Reviews of Effects, the NHS Economic Evaluation Database and the Health Economic Evaluations Database. Selection criteria Randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Data collection and analysis We extracted clinical study reports and assessed risk of bias using purpose‐built instruments. We analysed the effects of zanamivir and oseltamivir on time to first alleviation of symptoms, influenza outcomes, complications, hospitalisations and adverse events in the intention‐to‐treat (ITT) population. All trials were sponsored by the manufacturers. Main results We obtained 107 clinical study reports from the European Medicines Agency (EMA), GlaxoSmithKline and Roche. We accessed comments by the US Food and Drug Administration (FDA), EMA and Japanese regulator. We included 53 trials in Stage 1 (a judgement of appropriate study design) and 46 in Stage 2 (formal analysis), including 20 oseltamivir (9623 participants) and 26 zanamivir trials (14,628 participants). Inadequate reporting put most of the zanamivir studies and half of the oseltamivir studies at a high risk of selection bias. There were inadequate measures in place to protect 11 studies of oseltamivir from performance bias due to non‐identical presentation of placebo. Attrition bias was high across the oseltamivir studies and there was also evidence of selective reporting for both the zanamivir and oseltamivir studies. The placebo interventions in both sets of trials may have contained active substances. Time to first symptom alleviation . For the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.8 hours (95% confidence interval (CI) 8.4 to 25.1 hours, P < 0.0001). This represents a reduction in the time to first alleviation of symptoms from 7 to 6.3 days. There was no effect in asthmatic children, but in otherwise healthy children there was (reduction by a mean difference of 29 hours, 95% CI 12 to 47 hours, P = 0.001). Zanamivir reduced the time to first alleviation of symptoms in adults by 0.60 days (95% CI 0.39 to 0.81 days, P < 0.00001), equating to a reduction in the mean duration of symptoms from 6.6 to 6.0 days. The effect in children was not significant. In subgroup analysis we found no evidence of a difference in treatment effect for zanamivir on time to first alleviation of symptoms in adults in the influenza‐infected and non‐influenza‐infected subgroups (P = 0.53). Hospitalisations . Treatment of adults with oseltamivir had no significant effect on hospitalisations: risk difference (RD) 0.15% (95% CI ‐0.78 to 0.91). There was also no significant effect in children or in prophylaxis. Zanamivir hospitalisation data were unreported. Serious influenza complications or those leading to study withdrawal . In adult treatment trials, oseltamivir did not significantly reduce those complications classified as serious or those which led to study withdrawal (RD 0.07%, 95% CI ‐0.78 to 0.44), nor in child treatment trials; neither did zanamivir in the treatment of adults or in prophylaxis. There were insufficient events to compare this outcome for oseltamivir in prophylaxis or zanamivir in the treatment of children. Pneumonia . Oseltamivir significantly reduced self reported, investigator‐mediated, unverified pneumonia (RD 1.00%, 95% CI 0.22 to 1.49); number needed to treat to benefit (NNTB) = 100 (95% CI 67 to 451) in the treated population. The effect was not significant in the five trials that used a more detailed diagnostic form for pneumonia. There were no definitions of pneumonia (or other complications) in any trial. No oseltamivir treatment studies reported effects on radiologically confirmed pneumonia. There was no significant effect on unverified pneumonia in children. There was no significant effect of zanamivir on either self reported or radiologically confirmed pneumonia. In prophylaxis, zanamivir significantly reduced the risk of self reported, investigator‐mediated, unverified pneumonia in adults (RD 0.32%, 95% CI 0.09 to 0.41); NNTB = 311 (95% CI 244 to 1086), but not oseltamivir. Bronchitis, sinusitis and otitis media . Zanamivir significantly reduced the risk of bronchitis in adult treatment trials (RD 1.80%, 95% CI 0.65 to 2.80); NNTB = 56 (36 to 155), but not oseltamivir. Neither NI significantly reduced the risk of otitis media and sinusitis in both adults and children. Harms of treatment . Oseltamivir in the treatment of adults increased the risk of nausea (RD 3.66%, 95% CI 0.90 to 7.39); number needed to treat to harm (NNTH) = 28 (95% CI 14 to 112) and vomiting (RD 4.56%, 95% CI 2.39 to 7.58); NNTH = 22 (14 to 42). The proportion of participants with four‐fold increases in antibody titre was significantly lower in the treated group compared to the control group (RR 0.92, 95% CI 0.86 to 0.97, I 2 statistic = 0%) (5% absolute difference between arms). Oseltamivir significantly decreased the risk of diarrhoea (RD 2.33%, 95% CI 0.14 to 3.81); NNTB = 43 (95% CI 27 to 709) and cardiac events (RD 0.68%, 95% CI 0.04 to 1.0); NNTB = 148 (101 to 2509) compared to placebo during the on‐treatment period. There was a dose‐response effect on psychiatric events in the two oseltamivir \"pivotal\" treatment trials, WV15670 and WV15671, at 150 mg (standard dose) and 300 mg daily (high dose) (P = 0.038). In the treatment of children, oseltamivir induced vomiting (RD 5.34%, 95% CI 1.75 to 10.29); NNTH = 19 (95% CI 10 to 57). There was a significantly lower proportion of children on oseltamivir with a four‐fold increase in antibodies (RR 0.90, 95% CI 0.80 to 1.00, I 2 = 0%). Prophylaxis . In prophylaxis trials, oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals (oseltamivir: RD 3.05% (95% CI 1.83 to 3.88); NNTB = 33 (26 to 55); zanamivir: RD 1.98% (95% CI 0.98 to 2.54); NNTB = 51 (40 to 103)) and in households (oseltamivir: RD 13.6% (95% CI 9.52 to 15.47); NNTB = 7 (6 to 11); zanamivir: RD 14.84% (95% CI 12.18 to 16.55); NNTB = 7 (7 to 9)). There was no significant effect on asymptomatic influenza (oseltamivir: RR 1.14 (95% CI 0.39 to 3.33); zanamivir: RR 0.97 (95% CI 0.76 to 1.24)). Non‐influenza, influenza‐like illness could not be assessed due to data not being fully reported. In oseltamivir prophylaxis studies, psychiatric adverse events were increased in the combined on‐ and off‐treatment periods (RD 1.06%, 95% CI 0.07 to 2.76); NNTH = 94 (95% CI 36 to 1538) in the study treatment population. Oseltamivir increased the risk of headaches whilst on treatment (RD 3.15%, 95% CI 0.88 to 5.78); NNTH = 32 (95% CI 18 to 115), renal events whilst on treatment (RD 0.67%, 95% CI ‐2.93 to 0.01); NNTH = 150 (NNTH 35 to NNTB > 1000) and nausea whilst on treatment (RD 4.15%, 95% CI 0.86 to 9.51); NNTH = 25 (95% CI 11 to 116). Authors' conclusions Oseltamivir and zanamivir have small, non‐specific effects on reducing the time to alleviation of influenza symptoms in adults, but not in asthmatic children. Using either drug as prophylaxis reduces the risk of developing symptomatic influenza. Treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced, because of a lack of diagnostic definitions. The use of oseltamivir increases the risk of adverse effects, such as nausea, vomiting, psychiatric effects and renal events in adults and vomiting in children. The lower bioavailability may explain the lower toxicity of zanamivir compared to oseltamivir. The balance between benefits and harms should be considered when making decisions about use of both NIs for either the prophylaxis or treatment of influenza. The influenza virus‐specific mechanism of action proposed by the producers does not fit the clinical evidence. Plain language summary Regulatory information on trials of oseltamivir (Tamiflu) and zanamivir (Relenza) for influenza in adults and children Oseltamivir and zanamivir have been stockpiled in many countries to treat and prevent seasonal and pandemic influenza, before an influenza vaccine matched to the circulating virus becomes available. Oseltamivir is classified by the World Health Organization as an essential medicine. How this review has been approached We have updated and combined our reviews on the antiviral drugs zanamivir and oseltamivir for influenza in adults and children on the basis of the manufacturers' reports to regulators (clinical study reports) and the regulators' comments. We have called these comments and reports 'regulatory information'. Clinical study reports are unpublished, extensive documents with great detail on the trials that formed the basis for market approval. They include the protocols, methods and results. Clinical study reports have until now been confidential, seen only by the manufacturers and regulators. Why we have taken this approach In previous versions of this review we identified unresolved discrepancies in the data presented in published trial reports and substantial publication bias. As a consequence, we elected not to use data from journal articles but included the documents generated during licensing processes. We have accessed such data from the UK, USA, European Medicines Agency (EMA), Japanese regulators and clinical study reports from the manufacturers (after a protracted media campaign). This has enabled us to verify information from the randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Based on our assessments of the regulatory documents (in excess of 160,000 pages), we came to the conclusion that there were substantial problems with the design, conduct, reporting and availability of information from many of the trials. What we have found We have used data from 46 trials (20 oseltamivir and 26 zanamivir studies) in this review. We identified problems in the design of many of the studies that we included, which affects our confidence in their results. We found that both drugs shorten the duration of symptoms of influenza‐like illness (unconfirmed influenza or 'the flu') by less than a day. Oseltamivir did not affect the number of hospitalisations, based on the data from all the people enrolled in treatment trials of oseltamivir. Zanamivir trials did not record this outcome. The effects on pneumonia and other complications of influenza, such as bronchitis, middle ear infection (otitis media) and sinusitis, were unreliably reported, as shown by the case report form in the trial documents. Some forms showed limitations in the diagnostic criteria for pneumonia. Regulatory comments noted problems with missing follow‐up diary cards from participants. In children with asthma there was no clear effect on the time to first alleviation of symptoms. Prophylaxis trials showed that oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals and households. There was no evidence of an effect on asymptomatic influenza or on non‐influenza, influenza‐like illness, but trial conduct problems prevent any definitive conclusion. Oseltamivir use was associated with nausea, vomiting, headaches, renal and psychiatric events; these last three were when it was used to prevent influenza (prophylaxis). Its effect on the heart is unclear: it may reduce cardiac symptoms, but may induce serious heart rhythm problems. In adult treatment trials of zanamivir there was no increased risk of reported adverse events. The evidence on the possible harms associated with the treatment of children with zanamivir was sparse. Agreement with other findings The lack of good evidence demonstrating an effect on complications agrees with the conservative conclusions on both drugs drawn by the US Food and Drug Administration (FDA). The FDA only allowed claims of effectiveness of both drugs for the prevention and treatment of symptoms of influenza and not for other effects (including the interruption of person‐to‐person spread of the influenza virus or prevention of pneumonia). The FDA described the overall performance of both drugs as 'modest'. Mechanism of action for beneficial effects These findings all suggest that the low immune response with low levels of pro‐inflammatory cytokines, which is induced by the action of oseltamivir carboxylate, may reduce the symptoms of influenza unrelated to an inhibition of influenza virus replication. The potential hypothermic or antipyretic effect of oseltamivir as a central nervous system depressant may also contribute to the apparent reduction of host symptoms. Statements made on the capacity of oseltamivir to interrupt viral transmission and reduce complications are not supported by any data we have been able to access. The mechanism of action proposed by the producers (influenza virus‐specific) does not fit the clinical evidence which suggests a multi‐system and central action.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Jefferson, T, Jones, MA, Doshi, P, Del Mar, CB, Hama, R, Thompson, MJ, Spencer, EA, Onakpoya, IJ, Mahtani, KR, Nunan, D, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD008965.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.823Z" }, { "id": "278ac81f-99a5-4110-a8c6-a50201360ca1", "pmid": "", "title": "Aminoglycosides, vancomycin, and metronidazole for people with cirrhosis and hepatic encephalopathy", "imported": false, "abstract": "Abstract - Rationale Hepatic encephalopathy is a common complication of cirrhosis. Its development is associated with increased morbidity and mortality. Its exact pathogenesis is unknown, but ammonia, produced by bacterial action in the intestine, plays a key role. Antibiotics modulate the gut flora and may reduce intestinal ammonia production. Aminoglycosides such as neomycin, paromomycin, and ribostamycin have been used to treat hepatic encephalopathy, as have other antibiotics such as vancomycin and metronidazole. Objectives To assess the beneficial and harmful effects of aminoglycosides, vancomycin, and metronidazole versus placebo, no intervention, other antibiotics, or other active pharmacological interventions, for the prevention and treatment of hepatic encephalopathy in people with cirrhosis. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, and three other databases to 15 April 2025. We also searched online trials registries for ongoing and unpublished trials, undertook manual searches of meeting and conference proceedings, checked bibliographies of relevant articles, and corresponded with investigators and pharmaceutical companies. Eligibility criteria We included randomised clinical trials (RCTs) involving participants with cirrhosis and hepatic encephalopathy, or who were at risk of developing hepatic encephalopathy, comparing aminoglycosides, vancomycin, or metronidazole to (1) placebo or no intervention; or (2) other pharmacological agents, including non‐absorbable disaccharides, other antibiotics, or other potentially beneficial agents (e.g. branched‐chain amino acids, L‐ornithine L‐aspartate, nitazoxanide (a broad‐spectrum antiparasitic/antiviral agent), and nicotinohydroxamic acid (a potent urease inhibitor). We included trials irrespective of publication status, outcomes reported, language, or blinding. We excluded trials involving people with hepatic encephalopathy associated with acute liver failure or with non‐cirrhotic portal hypertension. Outcomes The critical outcomes were all‐cause mortality, hepatic encephalopathy, and serious adverse events. The important outcomes were non‐serious adverse events and health‐related quality of life (HRQoL). Our primary time point was the maximum length of follow‐up. Risk of bias We used Cochrane's original risk of bias tool (RoB 1) to assess the risk of bias. Synthesis methods We used standard Cochrane methods. We undertook random‐effects meta‐analyses to calculate risk ratios (RRs) or standardised mean differences (SMDs), with 95% confidence intervals (CIs). We assessed heterogeneity with the I 2 statistic, and the certainty of evidence with the GRADE framework. Included studies We included 24 RCTs, involving 1405 participants experiencing 1418 hepatic encephalopathy events. Twenty‐three trials evaluated the treatment of hepatic encephalopathy and one, the secondary prevention of hepatic encephalopathy; we analysed these trials jointly. The trials assessed three aminoglycosides: neomycin (15 trials), paromomycin (three trials), and ribostamycin (one trial), as well as vancomycin (two trials), and metronidazole (three trials). Overall, 670 participants received these pharmacotherapies while 735 participants received a placebo or other potentially beneficial agents. We classified 22 of the 24 trials to be at an overall high risk of bias based on domain‐level assessments. Synthesis of results The certainty of evidence for all comparisons was low to very low, mainly due to risk of bias, imprecision, and heterogeneity. Twenty‐three of the 24 trials, involving 1383 participants, reported all‐cause mortality data. Aminoglycosides may increase mortality slightly compared to other potentially active agents (RR 1.64, 95% CI 1.03 to 2.62; I² = 0%; 3 studies, 166 participants). The evidence was very uncertain about whether aminoglycosides versus a placebo (RR 1.02, 95% CI 0.62 to 1.69; I² = 0%; 3 studies, 137 participants), non‐absorbable disaccharides (RR 1.21, 95% CI 0.57 to 2.59; I² not applicable; 4 studies, 266 participants), or other antibiotics (RR 1.00, 95% CI 0.24 to 4.23; I² = 83%; 8 studies, 496 participants) result in a difference in mortality risk. The evidence was also very uncertain when comparing vancomycin to non‐absorbable disaccharides (RR 0.94, 95% CI 0.26 to 3.40; I² not applicable; 2 studies, 72 participants), and metronidazole to other active agents (RR 0.97, 95% CI 0.14 to 6.66; I² = 0%; 3 studies, 242 participants). Nineteen trials involving 1281 participants reported data on hepatic encephalopathy. There may be little to no difference in the effects of aminoglycosides versus non‐absorbable disaccharides (RR 0.84, 95% CI 0.67 to 1.05; I² = 0%; 3 studies, 251 participants), aminoglycosides versus other potentially active agents (RR 1.21, 95% CI 0.79 to 1.85; I² = 0%; 3 studies, 166 participants), and metronidazole versus other active agents (RR 1.50, 95% CI 0.89 to 2.54; I² = 48%; 2 studies, 208 participants). The evidence is very uncertain about the effect of aminoglycosides versus placebo, other antibiotics, and vancomycin versus non‐absorbable disaccharides. Twenty trials, involving 1186 participants, reported a total of 328 serious adverse events. Aminoglycosides may slightly increase the risk of serious adverse events compared with other potentially active agents (RR 1.60, 95% CI 1.03 to 2.47; I² = 0%; 3 studies, 166 participants). The evidence is very uncertain when comparing aminoglycosides to placebo and other antibiotics, or when comparing vancomycin to non‐absorbable disaccharides. Eighteen trials, involving 922 participants, reported a total of 96 non‐serious adverse events. There may be a slight increase in the risk of adverse events when comparing aminoglycosides to placebo (RR 2.80, 95% CI 1.11 to 7.04; I² not applicable; 2 studies, 98 participants), and to other antibiotics (RR 3.24, 95% CI 1.08 to 9.70; I² = 0%; 8 studies, 251 participants). The evidence is very uncertain about the effects of aminoglycosides versus non‐absorbable disaccharides or other active agents, and metronidazole versus other active agents. Only one trial assessed HRQoL, but reported the data in a form that precluded meta‐analysis. Eight trials received support from pharmaceutical companies while six did not. Ten trials did not provide this information. Authors' conclusions Due to low‐ or very low‐certainty evidence, we do not know if aminoglycosides benefit hepatic encephalopathy compared to placebo or other potentially active agents. There may be a slight increase in the risks of mortality and serious adverse events with aminoglycosides compared to other agents, and of non‐serious adverse events when compared to placebo and other antibiotics. We do not know if vancomycin or metronidazole improve clinically relevant outcomes. Only one trial assessed health‐related quality of life. Funding This Cochrane review received no specific funding. Registration https://doi.org/10.1002/14651858.CD012734 Plain language summary Do the antibiotics aminoglycosides, vancomycin, and metronidazole help people with cirrhosis and hepatic encephalopathy, a brain disorder associated with chronic liver disease? Key messages Antibiotics previously thought to help people with cirrhosis manage the risk of hepatic encephalopathy do not appear to benefit the condition. These antibiotics possibly cause more side effects than other treatments for this condition. Research is needed to establish whether combining these antibiotics with other treatments may be beneficial. What are cirrhosis and hepatic encephalopathy? Cirrhosis is a long‐term condition in which the liver becomes badly scarred. The liver normally helps clean the blood, process nutrients, and fight infections. When it is repeatedly damaged over time, the scar tissue which develops makes it harder for the liver to work properly. People with cirrhosis may develop hepatic encephalopathy, a condition that results in poor brain functioning. The reason why people develop hepatic encephalopathy is complex, but the build‐up in the blood of toxins from the gut, particularly of a compound called ammonia, plays a key role. Ammonia is produced in the gut mainly as a result of the activities of gut bacteria. How do antibiotics work in hepatic encephalopathy? Antibiotics are medicines used to treat infections caused by bacteria. They work by killing bacteria or stopping them from growing. Certain antibiotics may reduce the levels of ammonia in the blood by interfering with ammonia production in the gut. These antibiotics have been used to treat hepatic encephalopathy for many years, but the evidence that they help is unclear. The antibiotics considered in this review are: aminoglycosides (neomycin, paromomycin, and ribostamycin); vancomycin; metronidazole. What did we want to find out? We wanted to know if these antibiotics help to prevent or treat hepatic encephalopathy in people with cirrhosis. We analysed their effects on the number of people who died, whose symptoms of hepatic encephalopathy improved or failed to improve, and the number who experienced serious or non‐serious complications. What did we do? We searched for studies that compared aminoglycosides, vancomycin, or metronidazole to: placebo – an inactive or 'dummy' medicine; non‐absorbable disaccharides – sugars that mainly act in the gut, and are commonly used to treat some digestive and liver conditions; other antibiotics; other active agents that may help the condition. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 24 studies which involved 1405 participants. Of these, 23 studies evaluated the treatment of hepatic encephalopathy, and one study explored the prevention of hepatic encephalopathy in people at risk. We found evidence for the following comparisons: aminoglycosides versus placebo, non‐absorbable disaccharides, other antibiotics, and other active agents – 19 studies in total; vancomycin versus non‐absorbable disaccharides – 2 studies; metronidazole versus other active agents – 3 studies. Main results Death Aminoglycosides may slightly increase the risk of death compared to other active agents. We do not know if aminoglycosides make any difference to the risk of death compared to placebo, non‐absorbable disaccharides, and other antibiotics. We also do not know if there is any difference in the risk of death between: vancomycin and non‐absorbable disaccharides; metronidazole and other active agents. Hepatic encephalopathy: number of people in whom hepatic encephalopathy failed to improve Aminoglycosides may make little to no difference to the number of people whose condition improves compared to non‐absorbable disaccharides and other active agents. Metronidazole may make little to no difference to the number of people whose condition improves compared to other active agents. We do not know if there is any difference in the number of people whose condition improves when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Serious complications Aminoglycosides may slightly increase the risk of serious complications compared to other active agents. We do not know if there is any difference in serious complications when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Non‐serious complications Aminoglycosides may slightly increase the risk of non‐serious complications compared to placebo or other antibiotics. We do not know if there is any difference in the risk of non‐serious complications when comparing: aminoglycosides to non‐absorbable disaccharides or other active agents; metronidazole to other active agents; vancomycin to non‐absorbable disaccharides. Only one study, using metronidazole, reported on health‐related quality of life, so we were unable to draw any conclusions for this outcome. What are the limitations of the evidence? We had little to no confidence in the results of the review because the participants and researchers in some studies were aware of which treatment the participants received, which may have influenced the results, while some studies did not report on the outcomes we were interested in. The studies were generally small, and differed in how they were conducted. There were also too few studies to be certain about the outcomes. How current is this evidence? The evidence is current to 15 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Jeyaraj, R; Zacharias, HD; Vadera, S; Low, ZY; Gluud, LL; Morgan, MY", "articleTypes": [], "doi": "10.1002/14651858.CD012734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "27942fde-dbcd-48a7-9999-dee5452c7723", "pmid": "", "title": "Antioxidant vitamin supplementation for preventing and slowing the progression of age‐related cataract", "imported": false, "abstract": "Abstract - Background Age‐related cataract is a major cause of visual impairment in the elderly. Oxidative stress has been implicated in its formation and progression. Antioxidant vitamin supplementation has been investigated in this context. Objectives To assess the effectiveness of antioxidant vitamin supplementation in preventing and slowing the progression of age‐related cataract. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 2), MEDLINE (January 1950 to March 2012), EMBASE (January 1980 to March 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to March 2012), Open Grey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 2 March 2012. We also checked the reference lists of included studies and ongoing trials and contacted investigators to identify eligible randomized trials. Selection criteria We included only randomized controlled trials in which supplementation with one or more antioxidant vitamins (beta‐carotene, vitamin C and vitamin E) in any form, dosage or combination for at least one year was compared to another antioxidant vitamin or to placebo. Data collection and analysis Two authors extracted data and assessed trial quality independently. We pooled results for the primary outcomes, i.e., incidence of cataract and incidence of cataract extraction. We did not pool results of the secondary outcomes ‐ progression of cataract and loss of visual acuity, because of differences in definitions of outcomes and data presentation. We pooled results by type of cataract when data were available. We did not perform a sensitivity analysis. Main results Nine trials involving 117,272 individuals of age 35 years or older are included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States, with duration of follow‐up ranging from 2.1 to 12 years. The doses of antioxidant vitamins were higher than the recommended daily allowance. There was no evidence of effect of antioxidant vitamin supplementation in reducing the risk of cataract, cataract extraction, progression of cataract or in slowing the loss of visual acuity. In the pooled analyses, there was no evidence of effect of beta‐carotene supplementation in reducing the risk of cataract (two trials) (relative risk (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.08; n = 57,703) or in reducing the risk of cataract extraction (three trials) (RR 1.00, 95% CI 0.91 to 1.10; n = 86,836) or of vitamin E supplementation in reducing the risk of cataract (three trials) (RR 0.97, 95% CI 0.91 to 1.04; n = 50,059) or of cataract extraction (five trials) (RR 0.98, 95% CI 0.91 to 1.05; n = 83,956). The proportion of participants developing hypercarotenodermia (yellowing of skin) while on beta‐carotene ranged from 7.4% to 15.8%. Authors' conclusions There is no evidence from RCTs that supplementation with antioxidant vitamins (beta‐carotene, vitamin C or vitamin E) prevents or slows the progression of age‐related cataract. We do not recommend any further studies to examine the role of antioxidant vitamins beta‐carotene, vitamin C and vitamin E in preventing or slowing the progression of age‐related cataract. Costs and adverse effects should be weighed carefully with unproven benefits before recommending their intake above recommended daily allowances. Plain language summary Antioxidant vitamins for preventing and slowing the progression of age‐related cataract A cataract occurs when the normally clear lens in the eye becomes cloudy. Cataracts are the leading cause of correctable reduced vision worldwide. Most cataracts develop slowly with normal aging. However, cataracts also may be related to genetic diseases and medical conditions such as diabetes. Other factors such as poor nutrition, sun damage, radiation, corticosteroids, smoking, alcohol, eye trauma or other eye surgery may influence cataract formation. Mild or early cataracts may not impair vision. In some cataracts, new eye‐glass prescriptions, brighter lighting or magnifying lenses may overcome the vision losses. When these interventions fail to improve poor vision due to cataracts, surgical removal (extraction) is the generally accepted effective treatment. However, cataract surgery is associated with some risks. The estimated annual costs for outpatient, inpatient and prescription drug services related to the treatment of cataract is USD 6.8 billion. Antioxidant vitamin supplementation has been studied as a means to prevent the formation or to slow the progression of cataract. Results from observational studies have been inconsistent. The review authors searched for randomized controlled trials in which supplementation with the antioxidant vitamins beta‐carotene (provitamin A), vitamin C and vitamin E was compared to inactive placebo or no supplement. Nine trials involving 117,272 adults of age 35 years or older were included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States and were of high methodological quality. The doses of antioxidants given in each trial were higher than the recommended daily allowances. The trials provided no evidence of effect of the antioxidant vitamins beta‐carotene, vitamin E and vitamin C given alone or in combination on the incidence of cataract, its extraction or progression and on the loss of visual acuity. Some participants (7% to 16%) on beta‐carotene developed yellowing of the skin (hypercarotenodermia).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mathew, MC, Ervin, AM, Tao, J, Davis, RM", "articleTypes": [], "doi": "10.1002/14651858.CD004567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.075Z" }, { "id": "279d977f-1795-4477-911c-379e77e51868", "pmid": "", "title": "Topiramate for neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background Topiramate is an antiepileptic drug with multiple possible mechanisms of action. Antiepileptic drugs are widely used to treat chronic neuropathic pain (pain due to nerve damage) and fibromyalgia, and many guidelines recommend them. Objectives To assess the analgesic efficacy and associated adverse events of topiramate for chronic neuropathic pain and fibromyalgia in adults (aged 18 years and above). Search methods On 8 May 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We reviewed the bibliographies of all randomised trials identified and review articles, and also searched two clinical trial databases, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform, to identify additional published or unpublished data. Selection criteria We included randomised controlled trials (RCTs) with double‐blind assessment of participant outcomes following two weeks of treatment or longer (though the emphasis of the review was on studies of eight weeks or longer) that used a placebo or active comparator. Data collection and analysis We extracted efficacy and adverse event data, and two study authors examined issues of study quality independently. We performed analysis using two tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First tier studies did not use last‐observation‐carried‐forward (LOCF) or other imputation methods for dropouts. The second tier used data that failed to meet this standard; second tier results were therefore subject to potential bias. Main results We included four studies with 1684 participants. Three parallel‐group placebo comparisons were in painful diabetic neuropathy (1643 participants), and one cross‐over study with diphenhydramine as an active placebo (41 participants) was in lumbar radiculopathy. Doses of topiramate were titrated up to 200 mg/day or 400 mg/day. All studies had one or more sources of potential major bias, as they either used LOCF imputation or were of small size. No study provided first tier evidence for an efficacy outcome. There was no convincing evidence for efficacy of topiramate at 200 to 400 mg/day over placebo. Eighty‐two per cent of participants taking topiramate 200 to 400 mg/day experienced at least one adverse event, as did 71% with placebo, and the number needed to treat for an additional harmful effect (NNTH) was 8.6 (95% confidence interval (CI) 4.9 to 35). There was no difference in serious adverse events recorded (6.6% versus 7.5%). Adverse event withdrawals with 400 mg daily were much more common with topiramate (27%) than with placebo (8%), with an NNTH of 5.4 (95% CI 4.3 to 7.1). Lack of efficacy withdrawal was less frequent with topiramate (12%) than placebo (18%). Weight loss was a common event in most studies. No deaths attributable to treatment were reported. Authors' conclusions Topiramate is without evidence of efficacy in diabetic neuropathic pain, the only neuropathic condition in which it has been adequately tested. The data we have includes the likelihood of major bias due to LOCF imputation, where adverse event withdrawals are much higher with active treatment than placebo control. Despite the strong potential for bias, no difference in efficacy between topiramate and placebo was apparent. Plain language summary Topiramate for treating neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (for example from a fall, a cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in treating neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our knowledge about fibromyalgia is even less advanced, but fibromyalgia can respond to the same medicines as neuropathic pain. Topiramate is a medicine used to treat epilepsy, and so it might be a useful medicine for neuropathic pain or fibromyalgia. On 8 May 2013, we performed searches to look for clinical trials on the use of topiramate to treat neuropathic pain or fibromyalgia. We found four studies of reasonable quality that tested topiramate against placebo for a number of weeks. Almost all of the 1684 people in the studies had painful limbs because of damaged nerves caused by diabetes. Topiramate did not help the pain and was no different from placebo except in causing more side‐effects, which made many more people withdraw from the studies early. About 3 people in 10 withdrew because of side‐effects with topiramate compared with 1 in 10 with placebo. Topiramate has not been shown to work as a pain medicine in diabetic neuropathy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ, Derry, S, Lunn, MPT, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008314.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.763Z" }, { "id": "27a63fe9-13c2-43de-936d-069eff992c5c", "pmid": "", "title": "Population‐level interventions in government jurisdictions for dietary sodium reduction", "imported": false, "abstract": "Abstract - Background Excess dietary sodium consumption is a risk factor for high blood pressure, stroke and cardiovascular disease. Currently, dietary sodium consumption in almost every country is too high. Excess sodium intake is associated with high blood pressure, which is common and costly and accounts for significant burden of disease. A large number of jurisdictions worldwide have implemented population‐level dietary sodium reduction initiatives. No systematic review has examined the impact of these initiatives. Objectives • To assess the impact of population‐level interventions for dietary sodium reduction in government jurisdictions worldwide. • To assess the differential impact of those initiatives by social and economic indicators. Search methods We searched the following electronic databases from their start date to 5 January 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); Cochrane Public Health Group Specialised Register; MEDLINE; MEDLINE In Process & Other Non‐Indexed Citations; EMBASE; Effective Public Health Practice Project Database; Web of Science; Trials Register of Promoting Health Interventions (TRoPHI) databases; and Latin American Caribbean Health Sciences Literature (LILACS). We also searched grey literature, other national sources and references of included studies. This review was conducted in parallel with a comprehensive review of national sodium reduction efforts under way worldwide ( Trieu 2015 ), through which we gained additional information directly from country contacts. We imposed no restrictions on language or publication status. Selection criteria We included population‐level initiatives (i.e. interventions that target whole populations, in this case, government jurisdictions, worldwide) for dietary sodium reduction, with at least one pre‐intervention data point and at least one post‐intervention data point of comparable jurisdiction. We included populations of all ages and the following types of study designs: cluster‐randomised, controlled pre‐post, interrupted time series and uncontrolled pre‐post. We contacted study authors at different points in the review to ask for missing information. Data collection and analysis Two review authors extracted data, and two review authors assessed risk of bias for each included initiative. We analysed the impact of initiatives by using estimates of sodium consumption from dietary surveys or urine samples. All estimates were converted to a common metric: salt intake in grams per day. We analysed impact by computing the mean change in salt intake (grams per day) from pre‐intervention to post‐intervention. Main results We reviewed a total of 881 full‐text documents. From these, we identified 15 national initiatives, including more than 260,000 people, that met the inclusion criteria. None of the initiatives were provided in lower‐middle‐income or low‐income countries. All initiatives except one used an uncontrolled pre‐post study design. Because of high levels of study heterogeneity (I 2 > 90%), we focused on individual initiatives rather than on pooled results. Ten initiatives provided sufficient data for quantitative analysis of impact (64,798 participants). As required by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) method, we graded the evidence as very low due to the risk of bias of the included studies, as well as variation in the direction and size of effect across the studies. Five of these showed mean decreases in average daily salt intake per person from pre‐intervention to post‐intervention, ranging from 1.15 grams/day less (Finland) to 0.35 grams/day less (Ireland). Two initiatives showed mean increase in salt intake from pre‐intervention to post‐intervention: Canada (1.66) and Switzerland (0.80 grams/day more per person); however in both countries the pre‐intervention data point was from several years prior to the initiation of the intervention. The remaining initiatives did not show a statistically significant mean change. Seven of the 10 initiatives were multi‐component and incorporated intervention activities of a structural nature (e.g. food product reformulation, food procurement policy in specific settings). Of those seven initiatives, four showed a statistically significant mean decrease in salt intake from pre‐intervention to post‐intervention, ranging from Finland to Ireland (see above), and one showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention (Switzerland; see above). Nine initiatives permitted quantitative analysis of differential impact by sex (men and women separately). For women, three initiatives (China, Finland, France) showed a statistically significant mean decrease, four (Austria, Netherlands, Switzerland, United Kingdom) showed no significant change and two (Canada, United States) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. For men, five initiatives (Austria, China, Finland, France, United Kingdom) showed a statistically significant mean decrease, three (Netherlands, Switzerland, United States) showed no significant change and one (Canada) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. Information was insufficient to indicate whether a differential change in mean salt intake occurred from pre‐intervention to post‐intervention by other axes of equity included in the PROGRESS framework (e.g. education, place of residence). We identified no adverse effects of these initiatives. The number of initiatives was insufficient to permit other subgroup analyses, including stratification by intervention type, economic status of country and duration (or start year) of the initiative. Many studies had methodological strengths, including large, nationally representative samples of the population and rigorous measurement of dietary sodium intake. However, all studies were scored as having high risk of bias, reflecting the observational nature of the research and the use of an uncontrolled study design. The quality of evidence for the main outcome was low. We could perform a sensitivity analysis only for impact. Authors' conclusions Population‐level interventions in government jurisdictions for dietary sodium reduction have the potential to result in population‐wide reductions in salt intake from pre‐intervention to post‐intervention, particularly if they are multi‐component (more than one intervention activity) and incorporate intervention activities of a structural nature (e.g. food product reformulation), and particularly amongst men. Heterogeneity across studies was significant, reflecting different contexts (population and setting) and initiative characteristics. Implementation of future initiatives should embed more effective means of evaluation to help us better understand the variation in the effects. Plain language summary National government initiatives to reduce salt intake in populations The problem 
 In almost all countries worldwide, most people eat too much salt. This is a problem because eating too much salt can cause high blood pressure, which can lead to health problems such as heart disease and stroke. To reduce the amount of salt eaten, governments in many countries have developed national salt reduction initiatives. The review question 
 Our aim was to examine whether national salt reduction initiatives have been effective in reducing the amount of salt consumed in those populations. Study characteristics 
 We searched research papers and government reports and had direct communication with individuals working in salt reduction in their respective countries. The evidence is current as of 5 January 2015, when we last searched electronic databases. Initiatives in 15 countries met the inclusion criteria. Ten of these countries provided sufficient data for quantitative analysis, gathered from studies that included 64,798 participants. Initiatives ranged from one activity (e.g. in Japan, which at the time of writing had a public information campaign) to many activities (e.g. in the United Kingdom, which provided five activities including on‐package nutrition information, restrictions on marketing to children and food product reformulation). Of the 15 countries that met inclusion criteria, seven provided information about funding source, of which six reported non‐industry funding. The other eight countries did not report a funding source for one or more data point(s). Key results and quality of the evidence 
 Five of the 10 countries included in the quantitative analysis (China, Finland, France, Ireland and England) showed a decrease in salt intake after the intervention. Two of the 10 countries (Canada, Switzerland) showed an increase in salt intake after the intervention, however, in both countries the only data available were from several years prior to the intervention starting. Because the initiatives were very different, we cannot present an overall finding of whether these types of initiatives work. When we focused on the subset of seven countries whose salt reduction initiatives included multiple components and were not focused solely on educating the public, we found that more than half (four of seven) showed a decrease in salt intake from pre‐intervention to post‐intervention. When we examined the nine initiatives that analysed men and women separately, we found that amongst men, more than half (five of nine) showed a decrease in salt intake after the intervention. Amongst women, the pattern of findings was less clear, with three of nine interventions showing a decrease, two showing an increase and four showing no change in salt intake. Low‐bias study designs, such as randomised controlled trials, typically are not suitable for evaluating complex initiatives such as these; therefore, we rated all of the studies included in this review as having low methodological quality. Large nationally representative samples of the population and careful measurement of dietary sodium intake were strengths of several studies. However, because of study design limitations, the trustworthiness of study results is not clear. Overall, our results show that national government initiatives have the potential to achieve population‐wide reductions in salt intake, especially amongst men, and particularly if they employ more than one strategy and include structural activities such as food product reformulation (i.e. food companies putting less salt in food products). The wide variation of results across the studies we found presents a challenge in interpreting the current evidence and this warrants more research to help us understand this.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McLaren, L; Sumar, N; Barberio, AM; Trieu, K; Lorenzetti, DL; Tarasuk, V; Webster, J; Campbell, NRC", "articleTypes": [], "doi": "10.1002/14651858.CD010166.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "27b31975-56b2-4b4c-b58a-c84992e49899", "pmid": "", "title": "Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications", "imported": false, "abstract": "Abstract - Background Radiotherapy as part of head and neck cancer treatment leaves patients requiring much dental rehabilitation in a compromised environment that is difficult for the patient and the dental team to manage. Objectives To assess the effects of maintaining the patient's natural dentition during radiotherapy in comparison to extracting teeth before radiotherapy in areas that are difficult to access by the patient and the dentist, should reduction in mouth opening occur after radiotherapy to the jaws. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 22 November 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 22 November 2012), EMBASE via OVID (1980 to 22 November 2012), CANCERLIT via PubMed (1950 to 22 November 2012), CINAHL via EBSCO (1980 to 22 November 2012) and reference lists of articles. We advertised for currently ongoing studies via the Cochrane Oral Health Group website and the Cochrane Oral Health Group Twitter feed. Selection criteria Randomised controlled trials comparing extraction of teeth prior to radiotherapy with leaving teeth in situ during radiotherapy to the jaws. Data collection and analysis Three review authors independently assessed the results of the searches for inclusion in the review. Main results No randomised controlled trials were found. Authors' conclusions There are no randomised controlled trials to assess the effect of extracting teeth prior to radiotherapy compared to leaving teeth in the mouth during radiotherapy to the jaws. Plain language summary Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications This review aimed to assess if removing the back teeth before radiotherapy would mean that patients had fewer tooth‐related problems after radiotherapy as part of head and neck cancer treatment, when compared to not removing the teeth. Electronic and handsearching found 357 titles of studies but none of them met the inclusion criteria for the review. There is currently no evidence available to answer this complex question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Eliyas, S; Al‐Khayatt, A; Porter, RWJ; Briggs, P", "articleTypes": [], "doi": "10.1002/14651858.CD008857.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "27b32cc4-14d6-471c-a25d-df4b79db0ead", "pmid": "", "title": "Smoking Cessation on the Human Airway: Mucus Secretion, Inflammatory and Proteomic Profile in Nasal Lavage and miRNAs in Blood", "imported": false, "abstract": "Smoking cessation improves health conditions with reduction of the risk factors for cardiovascular and respiratory disease, as functional capacity and quality of life. Smoking cessation has positive effects on the miRNAs regulation, however, genomics has been little explored. Smoking and aging induces changes miRNAs. Among the changes in airway epithelial cells, miR-125 called attention because it is enrolled in the suppression of ERBB7 (tirosin kinase receptors), a codified sequence of the growth factor receptor (EGFR) frequently expressed in cancer. The reduction of miR-125 expression may reduce cancer suppression resulting in cancer development. Other miRNA changes can be observed, such as miR-218 that were found in smokers airway epithelial cells as in MiR-15b that were found in lung tissue of COPD smokers. These miRNAs participated in the signalling pathway of TGF-β enrolled in leukocyte migration and cell proliferation. The investigators hypothesize that smoking cessation has a role in the regulation or reduction in the genetic changes smoking-induced. The investigators will assess the subject genomic profile at the baseline, 6 months and 12 months after smoking cessation.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.266Z" }, { "id": "27cd43cd-7669-4674-a724-981d20f78382", "pmid": "", "title": "Chinese medicinal herbs for the common cold", "imported": false, "abstract": "Abstract - Background Chinese medicinal herbs are frequently used to treat the common cold in China. Until now, their efficacy has not been systematically reviewed. Objectives To assess the effectiveness and safety of Chinese medicinal herbs for the common cold. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2008, issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to May 2008); EMBASE (1980 to May 2008); AMED (1985 to May 2008); the Chinese Biomedical Database (CBMdisc) (1978 to May 2008); and China National Knowledge Infrastructure (CNKI) (1994 to May 2008). Selection criteria Randomised controlled trials (RCTs) studying the efficacy of Chinese medicinal herb(s) for the treatment of the common cold. Data collection and analysis Four review authors telephoned the original trial authors of the RCTs identified by our searches to verify the randomisation procedure. Two review authors extracted and analysed data from trials which met the inclusion criteria. Main results We found17 studies involving 3212 patients. The methods of 15 studies were at high risk of bias. In only two studies was the risk of bias low. Trials used \"positive drugs\", of which the efficacy was not known, as controls. Different Chinese herbal preparations were tested in nearly all trials. In only one trial was a Chinese herbal preparation tested twice. In seven trials, six herbal preparations were found to be more effective at enhancing recovery than the control preparations. In the other 10 studies, seven herbal preparations were not shown to be significantly different from the control. One study did not describe the difference between the intervention and control groups. Authors' conclusions Chinese herbal medicines may shorten the symptomatic phase in patients with the common cold. However, the lack of trials of low enough risk of bias, or using a placebo or a drug clearly identified as a control, means that we are uncertain enough to be unable to recommend any kind of Chinese medicinal herbs for the common cold. Plain language summary Chinese medicinal herbs to treat the common cold The common cold is the most widespread acute respiratory tract illness affecting all age groups. Many Chinese herbal medicines are used to treat this illness in China. Although we included 17 trials, involving 3212 patients, in this review, the risk of bias was so high that the evidence did not support using any Chinese herbal preparation(s) for the common cold. Well‐designed clinical trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Zhang, X; Wu, T; Zhang, J; Yan, Q; Xie, L; Liu, GJ", "articleTypes": [], "doi": "10.1002/14651858.CD004782.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "27cdf862-1798-4d47-82fe-3de592e53e20", "pmid": "", "title": "Prognostic models for radiation‐induced complications after radiotherapy in head and neck cancer patients", "imported": false, "abstract": "Abstract - Background Radiotherapy is the mainstay of treatment for head and neck cancer (HNC) but may induce various side effects on surrounding normal tissues. To reach an optimal balance, normal tissue complication probability (NTCP) models have been reported to predict the risk of radiation‐induced side effects in patients with HNC. However, the quality of study design, conduct, and analysis (i.e. risk of bias (ROB)), as well as the predictive performance of these models, remains to be evaluated. Objectives To identify, describe and appraise NTCP models to predict the risk of radiation‐induced side effects in patients with HNC. Search methods We searched Ovid MEDLINE, Embase and the World Health Organization International Clinical Trials Registry Platform from conception to January 2024. In addition, we screened references cited in the retrieved articles. Selection criteria Two review authors independently included articles reporting on the development and external validation of NTCP models to predict any type of radiation‐induced side effects in patients with HNC. Data collection and analysis One reviewer extracted data from each article and assessed their applicability and ROB, while another reviewer carefully verified the results. For models externally validated at least twice for the same outcome as their original developmental study, we performed qualitative analyses of the model performance. The GRADE system was not applied, since it has not been established for reviews of prognostic model studies. Main results Amongst 617 models developed from 152 articles, including 162,527 HNC patients, only 58 (9%) models from seven articles were judged to have low ROB and low concerns for applicability. No external validation was performed for 481 models (78%). For the remaining 136 models and six additional models which were not eligible for the present review, 193 external validations were performed in 48,852 patients with HNC in 39 articles. Models for salivary‐related outcomes Amongst 285 models, two models were externally validated at least twice. The Beetz 2012b model for xerostomia six months after radiotherapy was validated in two studies. C‐statistics ranged from 0.70 to 0.74. Calibration performance was reported in one study. One validation study was rated as having low ROB in all domains, while the other was rated as having high ROB in the analysis domain. The Cavallo 2021 model for acute xerostomia during radiotherapy for patients with nasopharyngeal cancer was externally validated in the same study, using two different types of cohorts. C‐statistics ranged from 0.68 to 0.73 and calibration plots were reported in both cohorts. Both validations were rated as having unclear ROB in the participants' domain because no detailed information about recruiting was provided. Models for swallowing‐related outcomes Amongst 85 models, two models were externally validated at least twice. The Christianen 2012 model for dysphagia six months after radiotherapy was validated in five studies. C‐statistics ranged from 0.66 to 0.75. Calibration performance was assessed in all of them, while four of them were rated as having high ROB in the analysis domain due to the small sample size. The Wopken 2014b model for tube feeding dependence six months after radiotherapy was validated in three external validation studies. C‐statistics ranged from 0.79 to 0.95, while calibration was evaluated in all studies. Due to the small size of the validation datasets, they were judged as having high ROB in the analysis domain. Models for hypothyroidism Of 72 models for hypothyroidism, two models were externally validated at least twice. In addition, there was another model which was not originally developed for patients with HNC, but validated in this domain. The Boomsma 2012 for hypothyroidism within two years after radiotherapy was externally validated in two studies. C‐statistics ranged from 0.64 to 0.74, while only one study reported its calibration performance. Both validation studies were rated as having high ROB in the analysis domain. The Ronjom 2013 model for radiation‐induced hypothyroidism was validated in three studies. C‐statistics ranged from 0.65 to 0.69 and calibration plots were reported in only one study. Two validation studies were judged as having high and the other was rated as having unclear ROB in the analysis domain. The Cella 2012 model was originally developed to predict radiation‐induced hypothyroidism in patients with Hodgkin’s lymphoma. In two validation studies in patients with HNC, c‐statistics ranged from 0.65 to 0.68, but calibration performance was not reported. One validation study was rated as having a high ROB and the other was rated as being unclear in the analysis domain. Models for brain and nerve‐related outcomes Amongst 40 models, three were externally validated at least twice for temporal lobe injury. The OuYang 2023 model, using deep learning in patients with nasopharyngeal cancer, was validated in the same paper using two different cohorts. C‐statistics ranged from 0.80 to 0.82, while calibration performance was assessed in both cohorts. Both validations were judged as having low ROB in all domains. The Wen 2021 model was developed to predict temporal lobe injury in newly diagnosed nasopharyngeal cancer patients. The model was validated by OuYang 2023 using two cohorts and by Yang 2023a using four cohorts. C‐statistics ranged from 0.75 to 0.79, while calibration performance was not reported. The two validations by OuYang 2023 were judged as having unclear ROB in the analysis domain, and the four validations by Yang 2023a were judged as having high ROB in the analysis domain. The Yang 2023a model was validated in the same paper using two cohorts. C‐statistics ranged from 0.79 to 0.81, while calibration performance was assessed in both cohorts. Both validations were judged as having high ROB in the analysis domain. Models for outcomes related to hoarseness, fatigue, nausea‐vomiting, throat pain, aspiration No models were externally validated at least twice. Authors' conclusions Amongst 617 developed models, only one‐fifth were externally validated, of which, ten models at least twice. These ten models showed acceptable discriminative performance at external validation. However, their calibration was not always reported. Furthermore, most validation studies were judged as having high ROB. In conclusion, this review shows the need for more external validation studies and improvement of the quality of conducting and reporting of prediction model studies. Plain language summary Which normal tissue complication probability (NTCP) models are available to predict the risk of radiation‐induced side effects after radiotherapy in patients with head and neck cancer, what is their quality, and what is their predictive performance? Key messages ° Many NTCP models have been developed to predict unwanted effects following radiotherapy in head and neck cancer patients but most of them have not been sufficiently externally validated, that is, tested with patients who were not involved in the original model developmental study, to know how well they really predict the unwanted effects. ° For models tested in two or more studies in addition to their original model development studies, the quality of testing and reporting of their results was generally poor, so it is difficult to know how useful they might be. ° More and better designed studies are required to investigate this issue in the area of head and neck cancer. How can we decide on the likelihood of having unwanted effects as a result of treatment? The likelihood of having unwanted effects as a result of radiotherapy can be calculated by using so‐called NTCP models. NTCP models calculate the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. What did we want to find out? Radiotherapy is the mainstay of treatment of patients with head and neck cancer. However, radiotherapy exposes healthy, sometimes crucial, parts of the head and neck region to radiation. This may result in damage to these normal organs, e.g. disturbed saliva production, which may have important consequences for the quality of life of head and neck cancer patients treated with radiotherapy. To reach an optimal balance between tumour control and preventing radiation‐induced side effects, normal tissue complication probability (NTCP) models can be helpful. These models predict the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. There have been a substantial number of NTCP models for patients with head and neck cancer. We wanted to find out what the quality of study design, conduct, and analysis (i.e. risk of bias) is, and how well these models can predict the risk of radiation‐induced side effects. What did we do? We searched for studies that developed and/or validated NTCP models in patients with head and neck cancer. What did we find? In most of the 617 models developed from 162,527 patients in 152 identified articles, the quality of the models was not sufficient; and it has not been investigated how well they perform in new patients for 78% of these models. For the remaining 22% of the models, 193 external validations were found in 48,852 patients from 39 articles. There were only ten models with two or more external validations. The models were able to distinguish patients with and without the outcome well, but it was often unclear whether their predictions were in line with what was observed, because the latter was not always assessed and/or reported. Overall, the quality of most of these studies was low. How up to date is the review? The evidence is current to 8th January 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Takada, T, Tambas, M, Clementel, E, Leeuwenberg, A, Sharabiani, M, Damen, JAAG, Dunias, ZS, Nauta, JF, Idema, DL, Choi, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014745.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.086Z" }, { "id": "27df2239-e375-4b2b-b098-e5a7daee7b96", "pmid": "", "title": "Long‐acting muscarinic antagonists (LAMA) added to combination long‐acting beta₂‐agonists and inhaled corticosteroids (LABA/ICS) versus LABA/ICS for adults with asthma", "imported": false, "abstract": "Abstract - Background Maintenance treatment with long‐acting beta 2 ‐agonists and inhaled corticosteroids (LABA/ICS) can relieve asthma symptoms and reduce the frequency of exacerbations, but there are limited treatment options for people who do not gain control on combination LABA/ICS. Long‐acting muscarinic antagonists (LAMA) are a class of inhaled drug which have been effective for people with chronic obstructive pulmonary disease and are now becoming available for people with asthma to take alongside their LABA/ICS inhaler. Objectives To assess the effects of adding a long‐acting muscarinic antagonist (LAMA) to combination long‐acting beta 2 ‐agonists (LABA) and inhaled corticosteroids (ICS) in adults whose asthma is not well controlled by LABA/ICS. Search methods We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to January 2016. We also searched ClinicalTrials.gov, the WHO trials portal, and reference lists of other reviews, and we contacted trial authors for additional information. Selection criteria We included parallel randomised controlled trials (RCTs) of at least 12 weeks' duration. Studies met the inclusion criteria if they compared LAMA as an add‐on to LABA/ICS versus LABA/ICS alone for adults with asthma. We included studies reported as full text, those published as abstract only, and unpublished data. Primary outcomes were exacerbations requiring oral corticosteroids (OCS), validated measures of asthma control, and serious adverse events (including mortality). Data collection and analysis Two review authors screened searches and independently extracted details on risk of bias and numerical data. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MD) using a random‐effects model. We rated all outcomes using GRADE. Main results We found four double‐blind, double‐dummy trials comparing LAMA to placebo, including 1197 people with asthma taking combination LABA/ICS. One of the trials was designed to study glycopyrronium bromide but was withdrawn prior to enrolment, and the other three all studied tiotropium bromide (mostly 5 µg once daily via Respimat) over 48 to 52 weeks. People in the trials had a mean forced expiratory volume in one second (FEV 1 ) of 55% of their predicted value, indicating severe asthma. People randomised to take tiotropium add‐on had fewer exacerbations requiring oral corticosteroids than those continuing to take LABA/ICS alone, but the confidence intervals did not rule out no difference (OR 0.76, 95% CI 0.57 to 1.02; moderate quality evidence). Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS would have to take oral corticosteroids for an exacerbation compared with 271 if they took tiotropium as well (95% CI 218 to 333 per 1000). Analyses comparing the number of exacerbations per patient in each group (rate ratio) and the time until first exacerbation (hazard ratio) were in keeping with the main result. Quality of life, as measured by the Asthma Quality of Life Questionnaire (AQLQ) was no better for those taking tiotropium add‐on than for those taking LABA/ICS alone when considered in light of the 0.5 minimal clinically important difference on the scale (MD 0.09, 95% CI − 0.03 to 0.20), and evidence for whether tiotropium increased or decreased serious adverse events in this population was inconsistent (OR 0.60, 95% CI 0.24 to 1.47; I 2 = 76%). Within the secondary outcomes, exacerbations requiring hospital admission were too rare to tell whether tiotropium was beneficial over LABA/ICS alone. There was high quality evidence showing benefits to lung function (trough FEV 1 and forced vital capacity (FVC)) and potentially small benefits to asthma control. People taking tiotropium add‐on were less likely to experience non‐serious adverse events. Authors' conclusions Tiotropium add‐on may have additional benefits over LABA/ICS alone in reducing the need for rescue oral steroids in people with severe asthma. The effect was imprecise, and there was no evidence for other LAMA preparations. Possible benefits on quality of life were negligible, and evidence for the effect on serious adverse events was inconsistent. There are likely to be small added benefits for tiotropium Respimat 5 µg daily on lung function and asthma control over LABA/ICS alone and fewer non‐serious adverse events. The benefit of tiotropium add‐on on the frequency of hospital admission is still unknown, despite year‐long trials. Ongoing and future trials should clearly describe participants' background medications to help clinicians judge how the findings relate to stepwise care. If studies test LAMAs other than tiotropium Respimat for asthma, they should be at least six months long and use accepted and validated outcomes to allow comparisons of the safety and effectiveness between different preparations. Plain language summary Does adding tiotropium, a long‐acting muscarinic antagonist (LAMA), to combination therapy (LABA/ICS) help to control asthma? Adding the LAMA tiotropium Respimat inhaler to combination LABA/ICS inhaler may reduce the need for rescue oral steroids. A noticeable benefit on quality of life is unlikely, and we couldn't tell if it reduced hospital admissions, but adding tiotropium has some benefit on lung function, asthma control, and non‐serious side effects. More detail about the studies and results: Taking a daily inhaler containing a long‐acting beta 2 ‐agonist and an inhaled corticosteroid (LABA/ICS) can improve symptoms and reduce the likelihood of asthma attacks. If this doesn't help, another type of inhaled drug called a long‐acting muscarinic antagonist (LAMA), which has been effective for people with other breathing conditions, is now available for people with asthma to take as well as their LABA/ICS inhaler. We wanted to find out whether adding a LAMA to LABA/ICS is better than continuing LABA/ICS alone for adults with asthma. We found four relevant studies, but one was withdrawn before anyone was signed up. The other three compared a LAMA called tiotropium Respimat to placebo for around a year, with participants in both groups continuing to take their usual LABA/ICS inhaler. People generally had quite poor lung function when they entered the studies, suggesting their asthma was not well controlled ‐ in respiratory medicine, this is known as 'severe asthma'. Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS had to take a course of oral steroids compared with 271 if they took tiotropium as well. However, uncertainty in the results meant that rather than there being 271 people taking oral steroids, there could be anywhere from 218 to 333 people per 1000 who would have to take oral steroids, so we couldn't be sure of the benefit. Quality of life scores were not that different between those who took tiotropium and those who didn't. The studies showed different results for whether people taking tiotropium were more likely to suffer a serious side effect, but fewer people had non‐serious side effects if they took tiotropium. We couldn't tell whether taking tiotropium on top of LABA/ICS reduced the number of people who had to go to hospital for an asthma attack because it didn't happen often enough for us to have confidence in the result. There was high quality evidence that showed benefits to lung function and probably small benefits on measures of asthma control.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Kew, KM; Dahri, K", "articleTypes": [], "doi": "10.1002/14651858.CD011721.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "27e8af05-67d4-4527-a07c-5474526792c9", "pmid": "", "title": "Palliative drug treatments for breathlessness in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is a life‐limiting autosomal recessive genetic illness. A feeling of shortness of breath is common in cystic fibrosis, especially as the disease progresses. Reversing the underlying cause is the priority when treating breathlessness (dyspnoea), but when it is not feasible, palliation (easing) becomes the primary goal to improve an individual's quality of life. A range of drugs administered by various routes have been used, but no definite guidelines are available. A systematic review is needed to evaluate such treatments. Objectives To assess the efficacy and safety of drugs used to ease breathlessness in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 18 November 2019. We searched databases (clinicaltrials.gov, the ISRCTN registry, the Clinical Trials Registry India and WHO ICTRP) for ongoing trials. These searches were last run on 06 March 2020. Selection criteria We planned to include randomised and quasi‐randomised controlled trials in people with cystic fibrosis (diagnosed by a positive sweat chloride test or genetic testing) who have breathlessness. We considered studies comparing any drugs used for easing breathlessness to another drug administered by any route (inhaled (nebulised), intravenous, oral, subcutaneous, transmucosal (including buccal, sublingual and intra‐nasal) and transdermal). Data collection and analysis The authors assessed the search results according to the pre‐defined inclusion criteria. Main results The new searches in 2020 yielded two ongoing studies that were not relevant to the review question. Previous searches had found only one study (cross‐over in design), which did not fulfil the inclusion criteria as no data were available from the first treatment period alone. Authors' conclusions Due to the lack of available evidence, this review cannot provide any information for clinical practice. The authors call for specific research in this area after taking into account relevant ethical considerations. The research should focus on the efficacy and safety of the drugs with efficacy being measured in terms of improvement in quality of life, dyspnoea scores and hospital stay. Plain language summary Drug treatments to ease breathlessness in cystic fibrosis Review question What is the evidence that drug treatments for breathlessness (also known as dyspnoea) in people with cystic fibrosis are effective and safe? Background Cystic fibrosis is a life‐limiting genetic disease. As the disease progresses, thick sticky mucus is formed in the lungs, pancreas and other organs. This thick mucus increases risk of infection, blocks the airways and causes severe breathlessness. Easing of this breathlessness is an important goal for care of people with cystic fibrosis. Many methods have been suggested to address this problem and many drugs have been reported to ease breathlessness. The drugs can be administered through various routes ‐ they might be inhaled, swallowed, injected under the skin, into muscle or into a vein or be absorbed through the skin (either on the body or through membranes inside the mouth or nose). Despite so many drugs being available, there are no defined guidelines for drug treatments aimed at easing breathlessness in people with cystic fibrosis. Search date The evidence from the Cochrane Cystic Fibrosis Trials Register is current to 18 November 2019; the searches of ongoing trial registries are current to 06 March 2020. Study characteristics We had planned to include studies comparing different treatments to ease breathlessness in people with cystic fibrosis where the participants were put into the different treatment groups at random. Our search found only one study in which seven people first received either a drug called hydrocodone or a placebo (dummy treatment) and then swapped to the other treatment; but this study did not report results separately for each treatment arm, so we are not able to include it in the review. Key results No studies fulfilled the inclusion criteria, therefore it is not possible to comment on the outcomes we wished to report on in this review. Until evidence becomes available, the review authors feel that it is advisable for doctors to follow any local or national guidelines. The authors recommend research in this area should take ethical considerations into account and should focus on the safety of the drugs, improvement in quality of life, breathlessness scores and length of hospital stay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Jaiswal, N; Singh, M; Agarwal, A; Chauhan, A; Jaiswal, N", "articleTypes": [], "doi": "10.1002/14651858.CD011855.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "2804575d-bcf7-49d4-8d15-92b3eec6b17f", "pmid": "", "title": "Eradication therapy for peptic ulcer disease in Helicobacter pylori‐positive people", "imported": false, "abstract": "Abstract - Background Peptic ulcer disease is the cause of dyspepsia in about 10% of people. Ninety‐five percent of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori . Eradication of H. pylori reduces the relapse rate of ulcers but the magnitude of this effect is uncertain. This is an update of Ford AC, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori ‐positive patients. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003840. DOI: 10.1002/14651858.CD003840.pub4. Objectives To assess the proportion of peptic ulcers healed and the proportion of participants who remained free from relapse with eradication therapy against placebo or other pharmacological therapies in H. pylori ‐positive people. To assess the proportion of participants that achieved complete relief of symptoms and improvement in quality of life scores. To compare the incidence of adverse effects/drop‐outs (total number for each drug) associated with the different treatments. To assess the proportion of participants in whom successful eradication was achieved. Search methods In this update, we identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1950 to March 2016) and Ovid EMBASE (1980 to March 2016). To identify further relevant trials, we handsearched reference lists from trials selected by electronic searching, and published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ). The search was last updated in March 2016. We contacted members of Cochrane Upper GI and Pancreatic Diseases, and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials of short‐ and long‐term treatment of peptic ulcer disease in H. pylori ‐positive adults. Participants received at least one week of H. pylori eradication compared with ulcer healing drug, placebo or no treatment. Trials were included if they reported assessment from two weeks onwards. Data collection and analysis We collected data on ulcer healing, recurrence, relief of symptoms and adverse effects. We calculated the risk ratio (RR) with 95% confidence intervals (CI) using both fixed‐effect and random‐effects models with Review Manager software (RevMan 5.3) based on intention‐to‐treat analysis as far as possible. Main results A total of 55 trials were included for one or more outcomes for this review. In duodenal ulcer healing, eradication therapy was superior to ulcer healing drug (UHD) (34 trials, 3910 participants, RR of ulcer persisting = 0.66, 95% confidence interval (CI) 0.58 to 0.76; 381/2286 (adjusted proportion: 12.4%) in eradication therapy plus UHD versus 304/1624 (18.7%) in UHD; low quality evidence) and no treatment (two trials, 207 participants, RR 0.37, 95% CI 0.26 to 0.53; 30/125 (adjusted proportion: 21.7%) in eradication therapy versus 48/82 (58.5%) in no treatment; low quality evidence). In gastric ulcer healing, the differences were imprecise between eradication therapy and UHD (15 trials, 1974 participants, RR 1.23, 95% CI 0.90 to 1.68; 220/1192 (adjusted proportion: 16.0%) in eradication therapy plus UHD versus 102/782 (13.0%) in UHD; very low quality evidence). In preventing duodenal ulcer recurrence the differences were imprecise between maintenance therapy with H.pylori eradication therapy and maintenance therapy with UHD (four trials, 319 participants, RR of ulcer recurring 0.73; 95% CI 0.42 to 1.25; 19/159 (adjusted proportion: 11.9%) in eradication therapy versus 26/160 (16.3%) in UHD; very low quality evidence), but eradication therapy was superior to no treatment (27 trials 2509 participants, RR 0.20, 95% CI 0.15 to 0.26; 215/1501 (adjusted proportion: 12.9%) in eradication therapy versus 649/1008 (64.4%) in no treatment; very low quality evidence). In preventing gastric ulcer recurrence, eradication therapy was superior to no treatment (12 trials, 1476 participants, RR 0.31, 95% CI 0.22 to 0.45; 116/697 (adjusted proportion: 16.3%) in eradication therapy versus 356/679 (52.4%) in no treatment; very low quality evidence). None of the trials reported proportion of people with gastric ulcer not healed after initial therapy between H.pylori eradication therapy and no active treatment or the proportion of people with recurrent gastric ulcer or peptic ulcers during maintenance therapy between H.pylori eradication therapy and ulcer healing drug therapy. Authors' conclusions Adding a one to two‐week course of H. pylori eradication therapy is an effective treatment for people with H. pylori‐ positive duodenal ulcer when compared to ulcer healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer healing drug. However, confidence intervals were wide and significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment, and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Plain language summary Antibiotics for people with peptic ulcers caused by Helicobacter pylori infection Review question Are antibiotics useful for the treatment of peptic ulcer (ulcers in the stomach or upper small intestine) in people with Helicobacter pylori ( H. pylori ) infection? Background Peptic ulcers are caused by acidic stomach juices damaging the lining of the stomach (gastric ulcer) or upper small intestine (duodenal ulcer). This causes pain, indigestion and sometimes, bleeding. Ulcers can return after being healed, especially if the person is infected with Helicobacter pylori (a lifelong infection unless treated). H. pylori causes most peptic ulcers. It is not clear whether eradicating H.pylori by treating with antibiotics as part of a combination of drugs ( H.pylori eradication therapy) is helpful in the treatment of people with peptic ulcers compared to no treatment or other medical treatments. This is an update of a previous Cochrane review published in 2006. Study characteristics Fifty‐five studies provided information for the review. Thirty‐four studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of duodenal ulcer. Two studies compared H. pylori eradication therapy against no treatment in the healing of duodenal ulcer. Fifteen studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of gastric ulcer. Three studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of peptic ulcer (gastric or duodenal ulcer). One study compared H. pylori eradication therapy against no treatment in the healing of peptic ulcer (gastric or duodenal ulcer). Four studies compared H. pylori eradication therapy against ulcer‐healing drug in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twenty‐seven studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twelve studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of gastric ulcer after initial ulcer had been healed, while one study compared H. pylori eradication therapy against no treatment in preventing the recurrence of peptic ulcer (gastric or duodenal ulcer) after initial ulcer had been healed. Four studies compared H. pylori eradication therapy plus ulcer‐healing drug versus comparison regimen in the relief of symptoms from peptic ulcer (gastric or duodenal ulcer). There were no studies comparing H. pylori eradication therapy against no treatment in the healing of gastric ulcer, H. pylori eradication therapy against ulcer‐healing drug as maintenance therapy in preventing the recurrence of gastric ulcer after initial ulcer had been healed, or H. pylori eradication therapy plus ulcer‐healing drug against no treatment or ulcer‐healing drug in the relief of symptoms in people with peptic ulcer. Some trials provided information for more than one comparison. The evidence is current until March 2016. Key results Adding a one to two‐week course of H. pylori eradication therapy speeds up ulcer healing for people with H. pylori‐ positive duodenal ulcer when compared to ulcer‐healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer (ulcer returning after initial healing) compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer‐healing drugs. However, because of the small number of studies included for the last two comparisons, significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Quality of the evidence The quality of evidence was low or very low because most of the studies had errors in study design. As a result, there is a lot of uncertainty regarding the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Ford, AC; Gurusamy, KS; Delaney, B; Forman, D; Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD003840.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "28144f55-42da-4665-b8a7-bd1249df4516", "pmid": "", "title": "Interventions for chronic blepharitis", "imported": false, "abstract": "Abstract - Background Blepharitis, an inflammatory condition associated with itchiness, redness, flaking, and crusting of the eyelids, is a common eye condition that affects both children and adults. It is common in all ethnic groups and across all ages. Although infrequent, blepharitis can lead to permanent alterations to the eyelid margin or vision loss from superficial keratopathy (abnormality of the cornea), corneal neovascularization, and ulceration. Most importantly, blepharitis frequently causes significant ocular symptoms such as burning sensation, irritation, tearing, and red eyes as well as visual problems such as photophobia and blurred vision. The exact etiopathogenesis is unknown, but suspected to be multifactorial, including chronic low‐grade infections of the ocular surface with bacteria, infestations with certain parasites such as demodex, and inflammatory skin conditions such as atopy and seborrhea. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. Objectives To examine the effectiveness of interventions in the treatment of chronic blepharitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 1), MEDLINE (January 1950 to February 2012), EMBASE (January 1980 to February 2012), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 9 February 2012. Selection criteria We included randomized controlled trials (RCTs) and quasi‐randomized controlled trials (CCTs) in which participants were adults aged 16 years or older and clinically diagnosed with chronic blepharitis. We also included trials where participants with chronic blepharitis were a subset of the participants included in the study and data were reported separately for these participants. Interventions within the scope of this review included medical treatment and lid hygiene measures. Data collection and analysis Two authors independently assessed search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. Data were meta‐analyzed for studies comparing similar interventions and reporting comparable outcomes with the same timing. Otherwise, results for included studies were summarized in the text. Main results There were 34 studies (2169 participants with blepharitis) included in this review: 20 studies (14 RCTs and 6 CCTs) included 1661 participants with anterior or mixed blepharitis and 14 studies (12 RCTs and 2 CCTs) included 508 participants with posterior blepharitis (MGD). Due to the heterogeneity of study characteristics among the included studies, with respect to follow‐up periods and types of interventions, comparisons, and condition of participants, our ability to perform meta‐analyses was limited. Topical antibiotics were shown to provide some symptomatic relief and were effective in eradicating bacteria from the eyelid margin for anterior blepharitis. Lid hygiene may provide symptomatic relief for anterior and posterior blepharitis. The effectiveness of other treatments for blepharitis, such as topical steroids and oral antibiotics, were inconclusive. Authors' conclusions Despite identifying 34 trials related to treatments for blepharitis, there is no strong evidence for any of the treatments in terms of curing chronic blepharitis. Commercial products are marketed to consumers and prescribed to patients without substantial evidence of effectiveness. Further research is needed to evaluate the effectiveness of such treatments. Any RCT designed for this purpose should separate participants by type of condition (e.g. staphylococcal blepharitis or MGD) in order to minimize imbalances between groups (type I errors) and to achieve statistical power for analyses (prevent type II errors). Medical interventions and commercial products should be compared with conventional lid hygiene measures, such as warm compresses and eyelid margin washing, to determine effectiveness, as well as head‐to‐head to show comparative effectiveness between treatments. Outcomes of interest should be patient‐centered and measured using validated questionnaires or scales. It is important that participants be followed long‐term, at least one year, to assess chronic outcomes properly. Plain language summary Interventions for blepharitis Blepharitis, defined as inflammation of the eyelids, is a common eye condition and affects both children and adults. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. There were 34 studies (2169 participants with blepharitis) included in the review, 20 of which included participants with anterior blepharitis and 14 of which included participants with posterior blepharitis. For anterior blepharitis, topical antibiotics provided some symptomatic relief and were effective in clearing bacteria from the eyelid margins. There was no difference between the types of topical antibiotics used. Topical steroids also provided some symptomatic relief; however, they were ineffective in eliminating bacteria. Lid hygiene, including warm compresses and lid scrubs, showed some symptomatic relief in both anterior and posterior blepharitis. Overall, there was no strong evidence for any of the treatments in terms of curing chronic blepharitis. Further research should be done to evaluate the effectiveness of treatments for blepharitis, with particular attention paid to adequate diagnosis and classification of the disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lindsley, K; Matsumura, S; Hatef, E; Akpek, EK", "articleTypes": [], "doi": "10.1002/14651858.CD005556.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "2836a085-8884-47c2-b6b1-80c40cd8f651", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies for treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). Objectives To assess the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for treating patients with COVID‐19, compared to an active comparator, placebo, or no intervention. To maintain the currency of the evidence, we will use a living systematic review approach. A secondary objective is to track newly developed SARS‐CoV‐2‐targeting mAbs from first tests in humans onwards. Search methods We searched MEDLINE, Embase, the Cochrane COVID‐19 Study Register, and three other databases on 17 June 2021. We also checked references, searched citations, and contacted study authors to identify additional studies. Between submission and publication, we conducted a shortened randomised controlled trial (RCT)‐only search on 30 July 2021. Selection criteria We included studies that evaluated SARS‐CoV‐2‐neutralising mAbs, alone or combined, compared to an active comparator, placebo, or no intervention, to treat people with COVID‐19. We excluded studies on prophylactic use of SARS‐CoV‐2‐neutralising mAbs. Data collection and analysis Two authors independently assessed search results, extracted data, and assessed risk of bias using the Cochrane risk of bias tool (RoB2). Prioritised outcomes were all‐cause mortality by days 30 and 60, clinical progression, quality of life, admission to hospital, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We identified six RCTs that provided results from 17,495 participants with planned completion dates between July 2021 and December 2031. Target sample sizes varied from 1020 to 10,000 participants. Average age was 42 to 53 years across four studies of non‐hospitalised participants, and 61 years in two studies of hospitalised participants. Non‐hospitalised individuals with COVID‐19 Four studies evaluated single agents bamlanivimab (N = 465), sotrovimab (N = 868), regdanvimab (N = 307), and combinations of bamlanivimab/etesevimab (N = 1035), and casirivimab/imdevimab (N = 799). We did not identify data for mortality at 60 days or quality of life. Our certainty of the evidence is low for all outcomes due to too few events (very serious imprecision). Bamlanivimab compared to placebo No deaths occurred in the study by day 29. There were nine people admitted to hospital by day 29 out of 156 in the placebo group compared with one out of 101 in the group treated with 0.7 g bamlanivimab (risk ratio (RR) 0.17, 95% confidence interval (CI) 0.02 to 1.33), 2 from 107 in the group treated with 2.8 g (RR 0.32, 95% CI 0.07 to 1.47) and 2 from 101 in the group treated with 7.0 g (RR 0.34, 95% CI 0.08 to 1.56). Treatment with 0.7 g, 2.8 g and 7.0 g bamlanivimab may have similar rates of AEs as placebo (RR 0.99, 95% CI 0.66 to 1.50; RR 0.90, 95% CI 0.59 to 1.38; RR 0.81, 95% CI 0.52 to 1.27). The effect on SAEs is uncertain. Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Bamlanivimab/etesevimab compared to placebo There were 10 deaths in the placebo group and none in bamlanivimab/etesevimab group by day 30 (RR 0.05, 95% CI 0.00 to 0.81). Bamlanivimab/etesevimab may decrease hospital admission by day 29 (RR 0.30, 95% CI 0.16 to 0.59), may result in a slight increase in any grade AEs (RR 1.15, 95% CI 0.83 to 1.59) and may increase SAEs (RR 1.40, 95% CI 0.45 to 4.37). Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Casirivimab/imdevimab compared to placebo Casirivimab/imdevimab may reduce hospital admissions or death (2.4 g: RR 0.43, 95% CI 0.08 to 2.19; 8.0 g: RR 0.21, 95% CI 0.02 to 1.79). We are uncertain of the effect on grades 3‐4 AEs (2.4 g: RR 0.76, 95% CI 0.17 to 3.37; 8.0 g: RR 0.50, 95% CI 0.09 to 2.73) and SAEs (2.4 g: RR 0.68, 95% CI 0.19 to 2.37; 8.0 g: RR 0.34, 95% CI 0.07 to 1.65). Mortality by day 30 and clinical progression/improvement of symptoms or development of severe symptoms were not reported. Sotrovimab compared to placebo We are uncertain whether sotrovimab has an effect on mortality (RR 0.33, 95% CI 0.01 to 8.18) and invasive mechanical ventilation (IMV) requirement or death (RR 0.14, 95% CI 0.01 to 2.76). Treatment with sotrovimab may reduce the number of participants with oxygen requirement (RR 0.11, 95 % CI 0.02 to 0.45), hospital admission or death by day 30 (RR 0.14, 95% CI 0.04 to 0.48), grades 3‐4 AEs (RR 0.26, 95% CI 0.12 to 0.60), SAEs (RR 0.27, 95% CI 0.12 to 0.63) and may have little or no effect on any grade AEs (RR 0.87, 95% CI 0.66 to 1.16). Regdanvimab compared to placebo Treatment with either dose (40 or 80 mg/kg) compared with placebo may decrease hospital admissions or death (RR 0.45, 95% CI 0.14 to 1.42; RR 0.56, 95% CI 0.19 to 1.60, 206 participants), but may increase grades 3‐4 AEs (RR 2.62, 95% CI 0.52 to 13.12; RR 2.00, 95% CI 0.37 to 10.70). 80 mg/kg may reduce any grade AEs (RR 0.79, 95% CI 0.52 to 1.22) but 40 mg/kg may have little to no effect (RR 0.96, 95% CI 0.64 to 1.43). There were too few events to allow meaningful judgment for the outcomes mortality by 30 days, IMV requirement, and SAEs. Hospitalised individuals with COVID‐19 Two studies evaluating bamlanivimab as a single agent (N = 314) and casirivimab/imdevimab as a combination therapy (N = 9785) were included. Bamlanivimab compared to placebo We are uncertain whether bamlanivimab has an effect on mortality by day 30 (RR 1.39, 95% CI 0.40 to 4.83) and SAEs by day 28 (RR 0.93, 95% CI 0.27 to 3.14). Bamlanivimab may have little to no effect on time to hospital discharge (HR 0.97, 95% CI 0.78 to 1.20) and mortality by day 90 (HR 1.09, 95% CI 0.49 to 2.43). The effect of bamlanivimab on the development of severe symptoms at day 5 (RR 1.17, 95% CI 0.75 to 1.85) is uncertain. Bamlanivimab may increase grades 3‐4 AEs at day 28 (RR 1.27, 95% CI 0.81 to 1.98). We assessed the evidence as low certainty for all outcomes due to serious imprecision, and very low certainty for severe symptoms because of additional concerns about indirectness. Casirivimab/imdevimab with usual care compared to usual care alone Treatment with casirivimab/imdevimab compared to usual care probably has little or no effect on mortality by day 30 (RR 0.94, 95% CI 0.87 to 1.02), IMV requirement or death (RR 0.96, 95% CI 0.90 to 1.04), nor alive at hospital discharge by day 30 (RR 1.01, 95% CI 0.98 to 1.04). We assessed the evidence as moderate certainty due to study limitations (lack of blinding). AEs and SAEs were not reported. Authors' conclusions The evidence for each comparison is based on single studies. None of these measured quality of life. Our certainty in the evidence for all non‐hospitalised individuals is low, and for hospitalised individuals is very low to moderate. We consider the current evidence insufficient to draw meaningful conclusions regarding treatment with SARS‐CoV‐2‐neutralising mAbs. Further studies and long‐term data from the existing studies are needed to confirm or refute these initial findings, and to understand how the emergence of SARS‐CoV‐2 variants may impact the effectiveness of SARS‐CoV‐2‐neutralising mAbs. Publication of the 36 ongoing studies may resolve uncertainties about the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for the treatment of COVID‐19 and possible subgroup differences. Plain language summary Are laboratory‐made, COVID‐19‐specific monoclonal antibodies an effective treatment for COVID‐19? Key messages ‐ We do not know whether antibodies (the body’s natural defence against disease) made in a laboratory and all the same as one another (monoclonal) and designed to target COVID‐19, are an effective treatment for COVID‐19 because we assessed only six studies exploring different treatments in different types of patients. ‐ We identified 36 ongoing studies that will provide more evidence when completed. ‐ We will update this review regularly as more evidence becomes available. What are ‘monoclonal’ antibodies? Antibodies are made by the body as a defence against disease. However, they can also be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that are designed to target only one specific protein – in this case, a protein on the virus that causes COVID‐19 – are ‘monoclonal’. They attach to the COVID‐19 virus and stop it from entering and replicating in human cells, which helps to fight the infection. Monoclonal antibodies have been used successfully to treat other viruses. They are thought to cause fewer unwanted effects than convalescent plasma, which contains a variety of different antibodies. What did we want to find out? We wanted to know if COVID‐19 specific monoclonal antibodies are an effective treatment for COVID‐19. We looked at whether they: ‐ reduced the number of deaths from any cause; ‐ improved symptoms or made them worse; ‐ increased admissions to hospital; and ‐ caused any serious or other unwanted effects. What did we do? We searched for studies that investigated one or more monoclonal antibodies to treat people with confirmed COVID‐19 compared with placebo (sham treatment), another treatment or no treatment. Studies could take place anywhere globally and include participants of any age, gender or ethnicity, with mild, moderate or severe COVID‐19. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found six active studies including a total of 17,495 people. Four studies investigated non‐hospitalised people with no symptoms or mild COVID‐19. Two studies investigated hospitalised people with moderate to severe COVID‐19. Studies took place across the world. Three studies were funded by pharmaceutical companies. The monoclonal antibodies they studied were bamlanivimab, etesevimab, casirivimab and imdevimab, sotrovimab, regdanvimab. We did not identify data for mortality at 60 days and quality of life. Non‐hospitalised people, with no symptoms or mild COVID‐19 (four studies) One study investigated different doses of bamlanivimab (465 people), compared to placebo. We don’t know whether bamlanivimab: ‐ increases or reduces the number of deaths because no participants died within 30 days of treatment; ‐ causes more or fewer serious unwanted effects because there were few events. Bamlanivimab may reduce the number of admissions to hospital within 30 days of treatment compared to placebo. ‐ May cause slightly fewer unwanted effects than placebo. ‐ We did not find data for improved symptoms or worsened symptoms. One study investigated a combination of bamlanivimab and etesevimab (1035 people), compared to placebo. ‐ Bamlanivimab and etesevimab may reduce the number of deaths and admissions to hospital. ‐ May cause slightly more unwanted effects. ‐ May cause more serious unwanted effects. For treatment with bamlanivimab alone or in combination with etesevimab we did not find data for improved symptoms or worsened symptoms. One study (phase 1/2 with 799 people) investigated different doses of casirivimab combined with imdevimab, compared to placebo. ‐ Casirivimab combined with imdevimab may reduce the number of hospital admissions or death. ‐ We don't know whether casirivimab and imdevimab causes more unwanted (grades 3 and 4) and serious unwanted effects than placebo because there were too few deaths to allow us to make a judgment. ‐ We did not find data for the number of people who died at day 30 and development of severe symptoms. ‐ We did not include results from phase 3 (5607 people) of this study, because of high risk of bias, as it was not clear which participants were included in the analysis. One study (583 people) investigated sotrovimab, compared to placebo. We don't know whether sotrovimab: ‐ increases or reduces the number of deaths and people requiring invasive mechanical ventilation or dying, because there were too few deaths to allow us to make a judgment. ‐ Sotrovimab may reduce the number of people requiring oxygen, unwanted (grades 3 to 4) and serious unwanted effects; ‐ may have little or no effect on unwanted effects (all grades). Another study (327 people) investigated different doses of regdanvimab (40 mg/kg and 80 mg/kg), compared to placebo. ‐ Regdanvimab at either dose may reduce the number of admissions to hospital or death. ‐ May increase unwanted events (grades 3 to 4). ‐ Regdanvimab at a dose of 80 mg/kg may reduce unwanted effects (all grades) and 40 mg/kg may have little to no effect. ‐ We don't know whether regdanvimab increases or decreases the number of deaths, requirement for invasive mechanical ventilation, and serious unwanted effects, because there were too few events to allow us to make a judgment. Hospitalised people with moderate to severe COVID‐19 (2 studies) One study (314 people) investigated bamlanivimab compared to placebo. ‐ We don’t know whether bamlanivimab increases or decreases the number of deaths due to any cause up to 30 or 90 days after treatment because there were too few deaths to allow us to make a judgment (6 deaths with bamlanivimab and 4 deaths with placebo in 314 people). ‐ Bamlanivimab may slightly increase the development of severe COVID‐19 symptoms five days after treatment and the number of people with unwanted effects. ‐ Bamlanivimab may have little to no effect on time until discharge from hospital. ‐ We don’t know whether bamlanivimab causes serious unwanted effects by day 30 because the study was small and reported few serious unwanted effects. Another study (9785 people) investigated casirivimab combined with imdevimab, compared to standard of care. ‐ Casirivimab combined with imdevimab has probably little to no effect on the number of deaths, requirement for invasive mechanical ventilation or death, and hospital discharge alive. ‐ We did not find data for unwanted and serious unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is low because we found only six studies, and they did not report everything we were interested in, such as the number of deaths within 60 days and quality of life. We found 36 ongoing studies. When they are published, we will add their results to our review. These results are likely to change our conclusions and will also help us understand how new variants affect how well monoclonal antibodies work. How up to date is this evidence? The evidence is up to date to 17 June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Kreuzberger, N; Hirsch, C; Chai, KL; Tomlinson, E; Khosravi, Z; Popp, M; Neidhardt, M; Piechotta, V; Salomon, S; Valk, SJ; Monsef, I; Schmaderer, C; Wood, EM; So-Osman, C; Roberts, DJ; McQuilten, Z; Estcourt, LJ; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD013825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "2845bce9-8132-4fdb-87bb-7f91e5213bd9", "pmid": "", "title": "Topical medication instillation techniques for glaucoma", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Xu, L, Wang, X, Wu, M", "articleTypes": [], "doi": "10.1002/14651858.CD010520.pub2 AB - Abstract - Background Glaucoma is a leading cause of irreversible blindness worldwide and the second most common cause of blindness after cataracts. The primary treatment for glaucoma aims to lower intraocular pressure (IOP) with the use of topical medicines. Topical medication instillation techniques, such as eyelid closure and nasolacrimal occlusion when instilling drops, have been proposed as potential methods to increase ocular absorption and decrease systemic absorption of the drops. Objectives To investigate the effectiveness of topical medication instillation techniques compared with usual care or another method of instillation of topical medication in the management of glaucoma or ocular hypertension. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 8 December 2016), Embase Ovid (1947 to 8 December 2016), PubMed (1948 to 8 December 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 8 December 2016), International Pharmaceutical Abstracts Database (1970 to 8 December 2016), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ) (last searched 13 May 2013), ClinicalTrials.gov ( www.clinicaltrials.gov ) (searched 8 December 2016) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) (searched 8 December 2016). We did not use any date or language restrictions in the electronic searches for trials. Selection criteria We included randomized controlled trials which had compared any topical medication instillation technique with usual care or a different method of instillation of topical medication. Data collection and analysis Two review authors independently screened records from the searches for eligibility, assessed the risk of bias, and extracted data. We followed methods recommended by Cochrane. Main results We identified two trials (122 eyes of 61 participants) that had evaluated a topical medication instillation technique. We also identified two ongoing trials. Both included trials used a within‐person design and administered prostaglandin monotherapy for glaucoma or ocular hypertension. Because the trials evaluated different instillation techniques and assessed different outcomes, we performed no meta‐analysis. One trial, conducted in the US, evaluated the effect of eyelid closure (one and three minutes) versus no eyelid closure on lowering IOP. At one to two weeks' follow‐up, reduction in IOP was similar in the eyelid closure group and the no eyelid closure group (mean difference (MD) ‐0.33 mmHg, 95% confidence interval (CI) ‐0.8 to 1.5; 51 participants; moderate‐certainty evidence). The second trial, conducted in Italy, evaluated the effect of using an absorbent cloth to wipe excess fluid after instillation (fluid removal) versus not using an absorbent cloth (no removal) on reducing dermatologic adverse events. At four months' follow‐up, eyelashes were shorter among eyes in the fluid removal group compared with the no fluid removal group (MD ‐1.70 mm, 95% CI ‐3.46 to 0.06; 10 participants; low‐certainty evidence). Fewer eyes showed skin hyperpigmentation in the eyelid region towards the nose in the fluid removal group compared with the no removal group (RR 0.07, 95% CI 0.01 to 0.84; 10 participants; low‐certainty evidence); however, the difference was uncertain in the eyelid region towards the temples (RR 0.44, 95% CI 0.07 to 2.66; 10 participants; low‐certainty evidence). The effect hypertrichosis (excessive hair growth) was uncertain between groups (RR 1.00, 95% CI 0.17 to 5.98; 10 participants; low‐certainty evidence). Neither trial reported other outcomes specified for this review, including the proportion of participants with IOP less than 21 mmHg; participant‐reported outcomes related to the ease, convenience, and comfort of instillation techniques; physiologic measurements of systemic absorption; escalation of therapy; mean change in visual fields; optic nerve progression; mean change in best‐corrected visual acuity; proportion in whom glaucoma developed; quality of life outcomes; or cost‐effectiveness outcomes. Neither trial reported data at follow‐up times of more than four months. Authors' conclusions Evidence to evaluate the effectiveness of topical medication instillation techniques for treatment of glaucoma is lacking. It is unclear what, if any, effects instillation techniques have on topical medical therapy for glaucoma. Plain language summary Topical medicine instillation techniques for glaucoma What is the aim of this review? 
 The aim of this Cochrane Review was to find out if the way that people with glaucoma put eye drops in makes a difference in how well the eye drops work. Cochrane researchers collected and analyzed all relevant studies to answer this question and found two studies. Key messages 
 It is unclear if the way that people with glaucoma put their eye drops in makes a difference in how well the drops work. What did this review study? 
 Glaucoma is a leading cause of blindness worldwide. In eyes with glaucoma, the ability to see may be lost because of damage to the optic nerve. The optic nerve is the part of the eye that sends visual information from the eye to the brain. Sometimes such damage occurs when there is too much pressure in the eye (called intraocular pressure or IOP). Sometimes eyes may have too much pressure without damage to the optic nerve (called ocular hypertension). The main goal of glaucoma and ocular hypertension treatment is to lower IOP. Topical medicines, such as eye drops, are most often used as the first treatment. Encouraging specific ways of applying the drops, such as closing your eyes or nasolacrimal occlusion (closing the eye and pressing a finger on the inside corner, by the nose) aims to increase how much medicine is absorbed into the eye and reduce how much medicine is absorbed into the body. What are the main results of the review? 
 We found two studies that compared different ways of putting in eye drops. Both studies used prostaglandin alone for glaucoma or ocular hypertension. One study, in the US, evaluated the effect of closing the eyes for one and three minutes after putting in eye drops on lowering IOP. The second study, in Italy, looked at whether wiping off the excess fluid, after putting in the eye drops, led to fewer changes in the skin surrounding the eye. After one to two weeks in the US study, closing the eyelid for one to three minutes after putting in the eye drops found no difference on IOP compared with not closing the eyelid for a specified amount of time. After four months in the Italian study, eyelashes were shorter when participants had wiped their eyes to remove excess fluid when compared with participants who did not wipe their eyes. We found two ongoing studies that do not have results yet. Based on only two studies and uncertain results, it is unclear if different ways of putting in eye drops have any effect on people with glaucoma. How up‐to‐date is this review? 
 Cochrane researchers searched for studies that had been published up to 8 December 2016.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.793Z" }, { "id": "285739f9-f3d8-4f39-b68b-94dc7582056b", "pmid": "", "title": "Interventions for deliberately altering blood pressure in acute stroke", "imported": false, "abstract": "Abstract - Background It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001 and 2008. Objectives To assess the clinical effectiveness of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke. Search methods We searched the Cochrane Stroke Group Trials Register (last searched in February 2014), the Cochrane Database of Systematic reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 2), MEDLINE (Ovid) (1966 to May 2014), EMBASE (Ovid) (1974 to May 2014), Science Citation Index (ISI, Web of Science, 1981 to May 2014) and the Stroke Trials Registry (searched May 2014). Selection criteria Randomised controlled trials of interventions that aimed to alter blood pressure compared with control in participants within one week of acute ischaemic or haemorrhagic stroke. Data collection and analysis Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data. The review authors cross‐checked data and resolved discrepancies by discussion to reach consensus. We obtained published and unpublished data where available. Main results We included 26 trials involving 17,011 participants (8497 participants were assigned active therapy and 8514 participants received placebo/control). Not all trials contributed to each outcome. Most data came from trials that had a wide time window for recruitment; four trials gave treatment within six hours and one trial within eight hours. The trials tested alpha‐2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide‐like diuretics, and target‐driven blood pressure lowering. One trial tested phenylephrine. At 24 hours after randomisation oral ACEIs reduced systolic blood pressure (SBP, mean difference (MD) ‐8 mmHg, 95% confidence interval (CI) ‐17 to 1) and diastolic blood pressure (DBP, MD ‐3 mmHg, 95% CI ‐9 to 2), sublingual ACEIs reduced SBP (MD ‐12.00 mm Hg, 95% CI ‐26 to 2) and DBP (MD ‐2, 95%CI ‐10 to 6), oral ARA reduced SBP (MD ‐1 mm Hg, 95% CI ‐3 to 2) and DBP (MD ‐1 mm Hg, 95% CI ‐3 to 1), oral beta blockers reduced SBP (MD ‐14 mm Hg; 95% CI ‐27 to ‐1) and DBP (MD ‐1 mm Hg, 95% CI ‐9 to 7), intravenous (iv) beta blockers reduced SBP (MD ‐5 mm Hg, 95% CI ‐18 to 8) and DBP (‐5 mm Hg, 95% CI ‐13 to 3), oral CCBs reduced SBP (MD ‐13 mmHg, 95% CI ‐43 to 17) and DBP (MD ‐6 mmHg, 95% CI ‐14 to 2), iv CCBs reduced SBP (MD ‐32 mmHg, 95% CI ‐65 to 1) and DBP (MD ‐13, 95% CI ‐31 to 6), NO donors reduced SBP (MD ‐12 mmHg, 95% CI ‐19 to ‐5) and DBP (MD ‐3, 95% CI ‐4 to ‐2) while phenylephrine, non‐significantly increased SBP (MD 21 mmHg, 95% CI ‐13 to 55) and DBP (MD 1 mmHg, 95% CI ‐15 to 16). Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05), stroke type (OR 0.98, 95% CI 0.92 to 1.05) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05). Treatment within six hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99) but not death (OR 0.70, 95% CI 0.38 to 1.26) at the end of the trial. Although death or dependency did not differ between people who continued pre‐stroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24), disability scores at the end of the trial were worse in participants randomised to continue treatment (Barthel Index, MD ‐3.2, 95% CI ‐5.8, ‐0.6). Authors' conclusions There is insufficient evidence that lowering blood pressure during the acute phase of stroke improves functional outcome. It is reasonable to withhold blood pressure‐lowering drugs until patients are medically and neurologically stable, and have suitable oral or enteral access, after which drugs can than be reintroduced. In people with acute stroke, CCBs, ACEI, ARA, beta blockers and NO donors each lower blood pressure while phenylephrine probably increases blood pressure. Further trials are needed to identify which people are most likely to benefit from early treatment, in particular whether treatment started very early is beneficial. Plain language summary Drug interventions for deliberately altering blood pressure in acute stroke Background: In people who have just had a stroke (a sudden brain attack due to either blockage or rupture of an artery in the brain), very high and very low blood pressures may be harmful. Therefore, drugs that raise low blood pressure or lower high blood pressure might be beneficial. Up to 50% of people admitted with acute stroke are taking blood pressure tablets on hospital admission and it is not clear whether these medications should be continued or discontinued in the acute situation. This review looked at those trials that deliberately altered blood pressure or compared continuing or stopping blood pressure‐lowering tablets taken before stroke. Study characteristics: This review is up‐to‐date to May 2014. We included 26 trials involving 17,011 participants: 24 trials assessed lowering blood pressure, one trial tested raising blood pressure, and two trials assessed what to do with drugs taken before stroke. All studies took place in hospitals that were used to treating people with stroke. Not all trials contributed information to all outcomes, and we have used data that were available in publications. Key results: There is insufficient evidence to say that lowering blood pressure saves lives or reduces disability in people with acute stroke. Immediately restarting blood pressure‐lowering drugs taken before the stroke may increase disability. Conclusion: More research is needed to identify those people who are most likely to benefit from altering blood pressure in acute stroke, the time window in which the treatment is likely to be of benefit, what types of stroke are likely to respond favourably, and the environment in which such treatment may be best given in routine practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bath, PMW; Krishnan, K", "articleTypes": [], "doi": "10.1002/14651858.CD000039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "2873c3c3-c2c9-41d6-8011-521e7e3d334e", "pmid": "", "title": "Zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance", "imported": false, "abstract": "Abstract - Background Diabetes is associated with long‐term damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity. Insulin resistance is a fundamental aspect of the aetiology of type 2 diabetes. Insulin resistance has been shown to be associated with atherosclerosis, dyslipidaemia, glucose intolerance, hyperuricaemia, hypertension and polycystic ovary syndrome. The mineral zinc plays a key role in the synthesis and action of insulin, both physiologically and in diabetes mellitus. Zinc seems to stimulate insulin action and insulin receptor tyrosine kinase activity. Objectives To assess the effects of zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance. Search methods This review is an update of a previous Cochrane systematic review published in 2007. We searched the Cochrane Library (2015, Issue 3), MEDLINE, EMBASE, LILACS and the ICTRP trial register (from inception to March 2015). There were no language restrictions. We conducted citation searches and screened reference lists of included studies. Selection criteria We included studies if they had a randomised or quasi‐randomised design and if they investigated zinc supplementation compared with placebo or no intervention in adults with insulin resistance living in the community. Data collection and analysis Two review authors selected relevant trials, assessed risk of bias and extracted data. Main results We included three trials with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Risk of bias was unclear for most studies regarding selection bias (random sequence generation, allocation concealment) and detection bias (blinding of outcome assessment). No study reported on our key outcome measures (incidence of type 2 diabetes mellitus, adverse events, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). Evaluation of insulin resistance as measured by the Homeostasis Model Assessment of Insulin Resistance (HOMA‐IR) showed neutral effects when comparing zinc supplementation with control (two trials; 114 participants). There were neutral effects for trials comparing zinc supplementation with placebo for total cholesterol, high‐density lipoprotein (HDL) cholesterol, low‐density lipoprotein (LDL) cholesterol and triglycerides (2 studies, 70 participants). The one trial comparing zinc supplementation with exercise also showed neutral effects for total cholesterol, HDL and LDL cholesterol, and a mean difference in triglycerides of ‐30 mg/dL (95% confidence interval (CI) ‐49 to ‐10) in favour of zinc supplementation (53 participants). Various surrogate laboratory parameters were also analysed in the included trials. Authors' conclusions There is currently no evidence on which to base the use of zinc supplementation for the prevention of type 2 diabetes mellitus. Future trials should investigate patient‐important outcome measures such as incidence of type 2 diabetes mellitus, health‐related quality of life, diabetic complications, all‐cause mortality and socioeconomic effects. Plain language summary Zinc supplementation for the prevention of type 2 diabetes mellitus Review question What are the effects of zinc supplementation compared with placebo or no treatment for the prevention of type 2 diabetes in adults with insulin resistance? Background Some studies have shown that zinc improves glucose levels (glycaemic control) in people with diabetes. As a consequence of diabetes long‐term complications may develop, such as kidney, nerve and eye disease. Also, the risk of cardiovascular complications like heart attacks and strokes is raised. Type 1 diabetes is a form of diabetes where the body cannot produce insulin any more. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity and is characterised by an increasing inability of the body to make good use of insulin (insulin resistance). The mineral zinc plays a key role in the action of insulin and theoretically zinc supplementation used by people with insulin resistance could prevent the onset of diabetes. Study characteristics We included three randomised controlled studies with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Key results No study reported on our patient‐important key outcomes (new onset of type 2 diabetes mellitus, side effects, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). The effects of zinc supplementation are uncertain regarding insulin resistance and lipid levels in the blood (mainly cholesterol and triglycerides). Quality of evidence The overall quality of the included studies was unclear because study authors did not provide important information for us to judge how the studies were performed (unclear risk of bias in most cases). In addition, the number of studies and participants is low and the study authors did not investigate important outcomes such as new onset of type 2 diabetes mellitus or side effects of zinc supplementation. Currentness of evidence This evidence is up to date as of March 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El Dib, R, Gameiro, OLF, Ogata, MSP, Módolo, NSP, Braz, LG, Jorge, EC, do Nascimento Junior, P, Beletate, V", "articleTypes": [], "doi": "10.1002/14651858.CD005525.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.090Z" }, { "id": "28751c91-04f6-48e0-a436-b4f21f0bf073", "pmid": "", "title": "Gut microbiome‐based interventions for the management of obesity in children and adolescents aged up to 19 years", "imported": false, "abstract": "Abstract - Background The epidemic of overweight and obesity affects more than 390 million children and adolescents aged 5 to 19 years and 37 million children under five years of age. Overweight and obesity are associated with both short‐ and long‐term consequences, including chronic inflammation, metabolic diseases, as well as alterations in the gut microbiome composition. Gut microbiome‐based approaches may impact microbiome‐related metrics such as diversity or the abundance of intestinal bacteria, which may be linked to obesity‐related outcomes. However, evidence regarding the effect of gut microbiome‐based interventions for the management of obesity is limited. Objectives To assess the effects of gut microbiome‐based interventions in the management of overweight or obesity in children and adolescents in all their diversity aged 0 to 19 years. Search methods We searched CENTRAL, MEDLINE, CINAHL, Web of Science Core Collection, BIOSIS Previews, Global Index Medicus (all regions), IBECS, SciELO, PAHO, PAHO IRIS, WHO IRIS, WHOLIS, Bibliomap, TRoPHI as well as ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 24 January 2025. We did not apply any language restrictions. Selection criteria We included randomised controlled trials that evaluated gut microbiome‐based interventions [i.e. prebiotics, probiotics, synbiotics, short‐chain fatty acids (SCFAs), and faecal microbiota transplantation (FMT)] compared to standard‐of‐care, placebo, or control interventions in children and adolescents aged 0 to 19 years with overweight or obesity. Data collection and analysis Two review authors independently screened titles and abstracts and full texts, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias 2 tool and certainty of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE), a framework for assessing the certainty of evidence and making recommendations in systematic reviews. Random‐effects meta‐analyses were performed unless only one study per outcome was available, for which fixed‐effect analyses were performed. Main results We found 17 studies (838 participants) from various countries, evaluating the effects of prebiotics, probiotics, synbiotics, SCFAs, and FMT on body mass index (BMI), body weight, waist circumference, total body fat percentage (%TBF), systolic and diastolic blood pressure, and adverse events. Of the 17 studies included, five studies were in adolescents aged 10 to 19 years, and 12 studies were in children and adolescents spanning both age groups, 0 to 19 years. Upon contacting authors for data grouped by age of the participants, no studies provided separate outcomes data for children and adolescents. The included studies were funded by either academic funding sources or grants from the public and private sectors. Additionally, 15 studies were classified as currently being conducted ('ongoing'). The certainty of evidence throughout was very low. In adolescents 10 to 19 years of age, probiotics compared to placebo or no intervention may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events. Similarly, FMT compared to placebo may have little to no effect on waist circumference, %TBF, blood pressure, and adverse events in this age group. According to one study with 41 participants and in children and adolescents 0 to 19 years of age, intervention with prebiotics compared to placebo may result in a small reduction in BMI (mean difference = ‐0.70, 95% CI = ‐1.25 to ‐0.15) and body weight (mean difference = ‐1.5, 95% CI = ‐2.61 to ‐0.39). Prebiotics compared to placebo may have little to no effect on waist circumference, %TBF, systolic blood pressure, and adverse events. No data were available on the effect of prebiotics on diastolic blood pressure. Probiotics compared to placebo may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events in children and adolescents (0 to 19 years). Synbiotics compared to placebo may result in a reduction in systolic blood pressure (mean difference = ‐40.00, 95% CI = ‐50.63 to ‐29.37) in children and adolescents (0 to 19 years); according to one study with 56 participants. The evidence is very uncertain about the effects of synbiotics compared to a placebo on BMI, body weight, waist circumference, blood pressure, and adverse events. No data were available on the effect of synbiotics compared to placebo on %TBF. Synbiotics, compared to probiotics, may have little to no effect on waist circumference, %TBF, and adverse events. No data were available on the effect of synbiotics compared to probiotics on BMI, body weight, and blood pressure. According to one study with 48 participants and very low‐certainty of evidence, SCFAs compared to placebo may result in a reduction in waist circumference (mean difference = ‐5.08, 95% CI = ‐7.40 to ‐2.76) and BMI (mean difference = ‐2.26, 95% CI = ‐3.24 to ‐1.28) in children and adolescents (0–19 years). SCFAs compared to placebo may have little to no effect on adverse events. No data were available on the effect of SCFAs on body weight, %TBF, and blood pressure. Adverse events, i.e. abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine, were reported in the prebiotics group but with very low incidence. Additionally, adverse events such as nausea and headache were reported in the SCFAs group, but with low incidence. Authors' conclusions In adolescents aged 10 to 19 years, gut microbiome‐based interventions may result in little to no difference in obesity‐related outcomes. In children and adolescents aged 0 to 19 years, prebiotics may result in a small reduction in BMI and body weight; synbiotics may result in a reduction in systolic blood pressure, and SCFAs may result in a reduction in BMI and waist circumference, albeit the certainty of evidence was very low. The evidence was of very low certainty due to few studies per comparison, small sample sizes, short intervention durations, and insufficient reporting of adverse events. More rigorous research examining different types of gut microbiome‐based interventions for the management of obesity is required in children and adolescents, both in clinical and community settings. Future trials should also report methods related to randomisation, blinding, and compliance, as well as include prespecified analysis plans. Plain language summary Review question How effective are the gut microbiome‐based interventions for the management of overweight or obesity in children and adolescents in all their diversity, aged 0 to 19 years? Key messages • It is unclear if gut microbiome‐based interventions (nutrition interventions targeting intestinal microbes) have an effect on body mass index (BMI), body weight, waist size, body fat percentage, measures of blood pressure, and adverse events in children and adolescents with overweight and obesity. • Further research, including larger trials, is required to understand the effects of gut microbiome‐based interventions for the management of overweight and obesity in children and adolescents. What is overweight or obesity? Overweight is a condition of excessive fat deposits, and obesity is a chronic disease characterised by excessive fat deposits that can affect most body systems, impair quality of life, and reduce life expectancy. BMI, calculated by dividing a person's weight in kilograms by their height in metres, squared, is often used to define overweight and obesity. How is overweight or obesity managed? Overweight or obesity may be managed through changes in diet, behavioural counselling for lifestyle modifications, medications, or surgery. Despite these approaches, this global epidemic affects more than 390 million children and adolescents aged 5 to 19 years, and 37 million children under five years of age as of 2022. Overweight or obesity is linked to abnormal metabolism and an imbalance in the gut microbiome. Published works have shown that nutrition interventions targeting the \"gut microbiome\" may have beneficial effects on body weight and body fat percentage. The gut microbiome is the community of harmless bacteria and other microorganisms in the human intestine needed for optimal health. What did we want to find out? We wanted to find out the effect of various nutritional interventions targeting the intestinal microbial community on BMI, body weight, waist circumference, total body fat percentage, blood pressure, and adverse events associated with the interventions amongst children and adolescents in all their diversity, aged 0 to 19 years. What did we do? We searched for studies that examined the effects of gut microbiome‐based interventions, including prebiotics (food ingredients that promote beneficial microbes in the gut), probiotics (live microbes that are good for health), synbiotics (a combination of both prebiotics and probiotics), short‐chain fatty acids (i.e. small fat molecules produced by intestinal bacteria by fermenting dietary fibre and non‐digestible carbohydrates), and faecal microbiota transplantation (i.e. a capsule containing stool microbes from a healthy donor), compared to standard‐of‐care (usual care), placebo, control, or no interventions in children and adolescents up to 19 years of age. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 17 studies involving 838 children and adolescents with overweight and obesity. The studies were conducted in different countries, including Spain, China, Taiwan, Canada, Mexico, Italy, Poland, Turkey, Iran, Thailand, Denmark, New Zealand, and the USA. Adolescents aged 10 to 19 years Nutrition interventions targeting intestinal microbes may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. Children and adolescents aged 0 to 19 years It is unclear if prebiotics have an effect on waist size, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that prebiotics compared to a dummy treatment (i.e. an intervention that does not contain any medicine but looks or tastes identical to the intervention being tested) may result in a small reduction in BMI and body weight, but the evidence is very uncertain. Probiotics compared to a dummy treatment may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. It is unclear if synbiotics have an effect on BMI, body weight, waist size, body fat percentage, diastolic blood pressure, and adverse events compared with a dummy treatment. One study found that synbiotics may result in a reduction in systolic blood pressure, but the evidence is very uncertain. It is unclear if short‐chain fatty acids have an effect on body weight, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that short‐chain fatty acids may result in a reduction in BMI and waist circumference, but the evidence is very uncertain. Side effects of the interventions were generally not reported in the included studies, but one study noted potential side effects such as abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine in the prebiotics group; however, the occurrence was very low. Nausea and headache were reported in another study in the short‐chain fatty acids group, but were minimal. What are the limitations of the evidence? The review's findings are limited by the small number of participants, the low number of available studies for each of the comparisons, the lack of long‐term data, and insufficient reporting of adverse effects. How up to date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fahim, SM, Huey, SL, Palma Molina, XE, Agarwal, N, Ridwan, P, Ji, N, Kibbee, M, Kuriyan, R, Finkelstein, JL, Mehta, S", "articleTypes": [], "doi": "10.1002/14651858.CD015875", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.795Z" }, { "id": "288c2d81-aeca-4b7f-b531-4ce539164b3e", "pmid": "", "title": "Pharmacological interventions for the treatment of depression in chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Studies report that up to 80% of individuals with chronic obstructive pulmonary disease (COPD) may struggle with symptoms of depression. However, this major comorbidity in COPD is rarely managed effectively. A number of recent studies indicate that left untreated, COPD‐related depression is associated with worse quality of life, worse compliance with COPD treatment plan, increased exacerbations, hospital admissions, and healthcare costs when compared to individuals with COPD without depression. Regrettably, COPD practice guidelines do not provide conclusive treatment recommendations for the use of antidepressants in patients with COPD, and base their guidelines on findings from trials in the general population. This may be problematic, as there is an elevated risk of respiratory issues associated with antidepressant treatment and COPD. Evaluating effectiveness and safety of pharmacological interventions specifically for patients with COPD and depression was therefore paramount. Objectives To assess the effectiveness and safety of pharmacological interventions for the treatment of depression in patients with COPD. Search methods The last search was performed on 26 November 2018. We initially searched the following databases via the Specialised Trials Registers of the Cochrane Airways and Common Mental Disorders Groups (to June 2016): MEDLINE, Embase, PsycINFO, CINAHL, AMED, and the Cochrane Library trials register (CENTRAL). Searches from June 2016 to November 2018 were performed directly on Ovid MEDLINE, Embase, PsycINFO and the Cochrane Library (Issue 11, 2018). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform to 26 November 2018. We searched the grey literature databases to identify studies not indexed in major databases and the reference lists of studies initially identified for full‐text screening. Selection criteria All published and unpublished randomised controlled trials (RCTs) comparing the efficacy of pharmacological interventions with no intervention, placebo or co‐intervention in adults with diagnosed COPD and depression were eligible for inclusion. Data collection and analysis Two review authors independently assessed articles identified by the search for eligibility. Our primary outcomes were change in depressive symptoms and adverse events. The secondary outcomes were: change in quality of life, change in dyspnoea, change in forced expiratory volume in one second (FEV 1 ), change in exercise tolerance, change in hospital utilisation (length of stay and readmission rates), and cost‐effectiveness. For continuous outcomes, we calculated the pooled mean difference (MD) or standardised mean difference (SMD) with 95% confidence interval (CI) as appropriate. For dichotomous outcomes, we calculated the pooled odds ratio (OR) and corresponding 95% CI using a random‐effects model. We assessed the quality of evidence using the GRADE framework. Main results Of the 1125 records screened for eligibility, four RCTs (N = 201 participants), and one on‐going study, met the inclusion criteria. Two classes of antidepressants were investigated in two separate comparisons with placebo: a tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitors (SSRIs). TCA versus placebo Only one RCT (N = 30 participants) provided results for this comparison. Primary outcomes The TCA (nortriptyline) reduced depressive symptoms post‐treatment compared to placebo (MD ‐10.20, 95% CI ‐16.75 to ‐3.65; P = 0.007; very low‐quality evidence), as measured by the Hamilton Depression Rating Scale (HAM‐D). Three participants withdrew from the trial due to adverse events related to the tested antidepressant (dry mouth, sedation, orthostatic hypotension). Secondary outcomes The overall results post‐treatment indicated that nortriptyline was not effective in improving the quality of life of individuals with COPD, as measured by the Sickness Impact Profile (MD ‐2.80, 95% CI ‐11.02 to 5.42; P = 0.50; very low‐quality evidence). The results for the change in dyspnoea for the domains examined (e.g. dyspnoea scores for 'most day‐to‐day activities') post‐treatment showed no improvement in the intervention group (MD 9.80, 95% CI ‐6.20 to 25.80; P = 0.23; very low‐quality evidence). No data were reported for change in FEV 1 , change in exercise tolerance, change in hospital utilisation, or cost‐effectiveness. The TCA study provided short‐term results, with the last follow‐up data collection at 12 weeks. The quality of the evidence for all the outcomes evaluated was very low due to a small sample size, imprecision, attrition, and selection and reporting bias. SSRIs versus placebo Three RCTs (N = 171 participants) provided results for this comparison. Primary outcomes The pooled results for two studies showed no difference for the change in depressive symptoms post‐intervention (SMD 0.75, 95% CI ‐1.14 to 2.64; 148 participants; 2 studies; P = 0.44; very low‐quality evidence). High heterogeneity was observed (I² = 95%), limiting the reliability of these findings. While it was not possible to meta‐analyse the total adverse events rates across the studies, it was possible to combine the results for two medication‐specific adverse effects: nausea and dizziness. There were no significant post‐treatment group differences for nausea (OR 2.32, 95% CI 0.66 to 8.12; 171 participants; 3 studies; P = 0.19; very low‐quality evidence) or dizziness (OR 0.61, 95% CI 0.09 to 4.06; 143 participants; 2 studies; P = 0.61; very low‐quality evidence). Secondary outcomes The pooled analysis of two trials reporting data for the change in quality of life did not show improvement post‐treatment in the intervention group compared to placebo (SMD 1.17, 95% CI ‐0.80 to 3.15; 148 participants; 2 studies; P = 0.25; very low‐quality evidence). There was no difference between groups in change in FEV 1 post‐treatment (MD 0.01, 95% CI ‐0.03 to 0.05; 148 participants; 2 studies; P = 0.60; low‐quality evidence). However, two trials reported improvement in exercise tolerance in the SSRI group versus the placebo group (MD 13.88, 95% CI 11.73 to 16.03; 148 participants; 2 studies; P < 0.001; very low‐quality evidence). The trials included in this comparison did not report data related to the change in dyspnoea, hospital utilisation rates, or cost‐effectiveness. Authors' conclusions There is insufficient evidence to make definitive statements about the efficacy or safety of antidepressants for treating COPD‐related depression. New RCTs are needed; with better methodological quality and more accurate reporting of the methods used. Moreover, longer‐term follow‐up data collection is needed, including outcomes such as adverse events, hospital utilisation and cost‐effectiveness. Plain language summary Medication for the treatment of depression in chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a term that mainly describes two lung conditions: chronic bronchitis and emphysema. The main symptoms of COPD include shortness of breath, persistent cough, wheezing, and/or frequent chest infections. There is no cure for COPD, but treatment can help slow the disease progress and relieve symptoms. Depression is very common in patients with COPD, but is often untreated. Studies show that untreated depression in patients with COPD can worsen quality of life, increase COPD exacerbations and hospital admissions, and make following a COPD treatment plan difficult. Treatment for depression can include antidepressant medication, psychological therapy, or both. However, evidence‐based recommendations regarding antidepressant medication use specifically for patients with COPD are not currently available. Why is this review important? There is currently no clear overview of existing evidence showing whether antidepressants can effectively and safely reduce depressive symptoms in patients with COPD, therefore it was important to assess the existing experimental studies. Who will be interested in this review? Healthcare professionals, people with COPD and depression, researchers, and policymakers will be interested in the findings of this review. What questions does this review aim to answer? Our main aim was to assess whether pharmacological treatment (e.g. antidepressants) could effectively and safely treat COPD‐related depression. Which studies were included in the review? This review included experimental studies called randomised controlled trials (studies in which participants are assigned to a treatment group based on a random method) that compared the effectiveness of pharmacological interventions (antidepressants) to placebo (inactive treatment in the same form as the active treatment, e.g. a pill). Study participants were adults diagnosed with COPD and depression. What does the evidence from the review tell us? We have identified only four studies worldwide that were eligible for inclusion in our review. This means limited evidence to support the use of antidepressants for the treatment of depression in patients with COPD. Only one study evaluated a tricyclic antidepressant, nortriptyline, finding that it reduced depressive symptoms when compared to a placebo. Three studies evaluated a newer generation class of antidepressants called selective serotonin reuptake inhibitors (SSRIs), finding no evidence for their effectiveness in improving depressive symptoms. Due to the limited evidence, we are unable to make definitive statements about the effectiveness but also safety of antidepressants when used for COPD‐related depression. However, SSRIs may increase exercise capacity in patients with COPD. Given that the current findings were based on only four small studies with evidence rated as of very low quality, it is important to interpret our results with caution. What should happen next? Insufficient evidence prevented us from making clear recommendations for doctors, other healthcare professionals, researchers, or policymakers. More studies with better methodological quality and a larger number of participants are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pollok, J, van Agteren, JEM, Carson‐Chahhoud, KV", "articleTypes": [], "doi": "10.1002/14651858.CD012346.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.795Z" }, { "id": "28953d69-ece5-4cea-9b43-46468044f0a1", "pmid": "", "title": "Antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lassi, ZS, Padhani, ZA, Das, JK, Salam, RA, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD009576.pub3 AB - Abstract - Background Worldwide, pneumonia is the leading cause of death amongst children under five years of age, and accounts for approximately two million deaths annually. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, and the severity of the disease. Treatment is then tailored according to the classification. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. The WHO recommends treating non‐severe pneumonia with oral antibiotics. Pneumonia is more commonly caused by viruses that do not require antibiotic treatment, but pneumonia caused by bacteria needs management with antibiotics to avoid complications. There is no clear way to quickly distinguish between viral and bacterial pneumonia. It is considered safe to give antibiotics, however, this may lead to the development of antibiotic resistance, and thus, limit their use in future infections. Therefore, it is essential to explore the efficacy of antibiotics for children with WHO‐defined non‐severe pneumonia and wheeze. Objectives To evaluate the efficacy of antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze. Search methods We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers (December 2020). Selection criteria We included randomised controlled trials (RCTs) evaluating the efficacy of antibiotic therapy versus no antibiotic therapy for children, aged 2 to 59 months, with non‐severe pneumonia and wheeze. We defined non‐severe pneumonia as 'a cough or difficulty in breathing, with rapid breathing (a respiratory rate of 50 breaths per minute or more for children aged 2 to 12 months, or a respiratory rate of 40 breaths per minute or more for children aged 12 to 59 months), chest indrawing and wheeze'. We excluded trials involving children with severe or very severe pneumonia, and non‐RCTs. Data collection and analysis Our primary outcomes were clinical cure and treatment failure; secondary outcomes were relapse, mortality, and treatment harms. We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Two review authors independently assessed the search results, extracted data, assessed risk of bias and the certainty of the evidence. We contacted the authors of two included trials and the author of the trial awaiting classification to obtain missing numerical outcome data. Main results We included three trials involving 3256 children aged between 2 to 59 months, who exhibited features of non‐severe pneumonia with wheeze. The included trials were multi‐centre, double‐blind, randomised, placebo‐controlled trials carried out in Malawi, Pakistan, and India. The children were treated with a three‐day course of amoxicillin or placebo, and were followed up for a total of two weeks. We assessed the included trials at overall low risk of bias for random sequence generation, allocation concealment, blinding, attrition bias, and selective reporting. Only one trial was assessed to be at high risk for blinding of outcome assessors. One trial is awaiting classification Antibiotic therapy may result in a reduction of treatment failure by 20% (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.68 to 0.94; three trials; 3222 participants; low‐certainty evidence). Antibiotic therapy probably results in little or no difference to clinical cure (RR 1.02, 95% CI 0.96 to 1.08; one trial; 456 participants; moderate‐certainty evidence), and in little or no difference to relapse (RR 1.00, 95% CI 0.74 to 1.34; three trials; 2795 participants; low‐certainty evidence), and treatment harms (RR 0.81, 95% CI 0.60 to 1.09; three trials, 3253 participants; low‐certainty evidence). Two trials (2112 participants ) reported on mortality; no deaths occurred in either group. One trial reported cases of hospitalisation, diarrhoea (with and without dehydration), rash (without itch), tremors, mild nausea and vomiting. Authors' conclusions We do not currently have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. There is a clear need for RCTs to address this question in children aged 2 to 59 months with 2014 WHO‐defined non‐severe pneumonia and wheeze. Plain language summary Comparing treatment of non‐severe pneumonia, in children aged 2 to 59 months, with and without antibiotics Review question 
We tried to identify whether there was a difference in the outcomes for children aged 2 to 59 months with non‐severe pneumonia and wheeze, treated with or without antibiotics. Background 
Pneumonia is an infection of the lungs. In children, it is one of the leading causes of deaths globally. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, severity of the disease and its treatment according to the severity. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. More commonly, pneumonia is caused by viruses that require supportive care rather than antibiotic treatment; however, pneumonia caused by bacteria should be treated with antibiotics to avoid complications. Since there is no clear way to quickly distinguish which organism actually caused the pneumonia, it is considered safe to give antibiotics. However, this may lead to the development of antibiotic resistance, and limit their use in future infections. The question is whether the use of antibiotics is justified in non‐severe pneumonia. Search date Our evidence is current to 23 December 2020. Study characteristics We included three trials (3256 children). They were conducted in four hospitals in three cities in Pakistan (Islamabad, Lahore and Rawalpindi), and in hospital outpatient departments in India and Malawi. The children were treated with a three‐day course of amoxicillin (antibiotic) or placebo, and followed up for two weeks. One trial is awaiting classification. Study funding source The included trials were supported by the USAID through INCLEN and IndiaClen; ARI Research Cell, Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and by a grant from the Bill & Melinda Gates Foundation. Key results Limited data showed a 20% reduction in treatment failure, however, no impact was observed on clinical cure, relapse, and treatment harms. No deaths were reported in either group. Our review did not have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. Certainty of the evidence The certainty of evidence for clinical cure was moderate. The certainty of evidence for treatment failure, relapse, and treatments harms was low, due to downgrading for imprecision and risk of bias.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.766Z" }, { "id": "289e7625-ff08-45fc-9c71-160919aab771", "pmid": "", "title": "Dietary sodium manipulation and asthma", "imported": false, "abstract": "Abstract - Background There is a wide geographical variation in the prevalence of asthma and observational studies have suggested that dietary sodium may play a role. Objectives To assess the effect of dietary sodium manipulation on asthma control. Search methods We carried out a search using the Cochrane Airways Group asthma register. We searched the bibliographies of included randomised controlled trials (RCTs) for additional studies. We carried out the most recent search in November 2010. Selection criteria We considered only RCTs that involved dietary sodium reduction or increased sodium intake in patients with asthma. Data collection and analysis Both review authors assessed study and extracted data. We conducted data analyses in RevMan 5 using mean differences and random effects. Main results We identified a total of nine studies in relation to sodium manipulation and asthma, of which five were in people with asthma (318 participants), and four in people with exercise‐induced asthma (63 participants). There were no significant benefits of salt restriction on the control of asthma. There was some evidence from the exercise‐induced asthma studies that a low sodium diet may improve lung function after exercise and possibly baseline lung function, but this is based on findings from a very small numbers of participants. Authors' conclusions This review did not find any evidence that dietary sodium reduction significantly improves asthma control. Although dietary sodium reduction may result in improvements in lung function in exercise‐induced asthma, the clinical significance of this effect is unclear. Plain language summary Does reducing the amount of salt in a diet improve asthma symptoms? A review of the current literature suggests that reduction in the amount of dietary sodium consumed has no significant effect on the symptoms of asthma but may be associated with improvements in some lung function measurements in exercise‐induced asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Pogson, Z, McKeever, T", "articleTypes": [], "doi": "10.1002/14651858.CD000436.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.762Z" }, { "id": "28a5d568-1583-40a7-ac4e-0a0aad2df16c", "pmid": "", "title": "Pharmacological interventions for promoting smoking cessation during pregnancy", "imported": false, "abstract": "Abstract - Background Tobacco smoking in pregnancy causes serious health problems for the developing fetus and mother. When used by non‐pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion, and varenicline) are effective for increasing smoking cessation, however their efficacy and safety in pregnancy remains unknown. Electronic cigarettes (ECs) are becoming widely used, but their efficacy and safety when used for smoking cessation in pregnancy are also unknown. Objectives To determine the efficacy and safety of smoking cessation pharmacotherapies and ECs used during pregnancy for smoking cessation in later pregnancy and after childbirth, and to determine adherence to smoking cessation pharmacotherapies and ECs for smoking cessation during pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2019), trial registers, and grey literature, and checked references of retrieved studies. Selection criteria Randomised controlled trials (RCTs) conducted in pregnant women, comparing smoking cessation pharmacotherapy or EC use with either placebo or no pharmacotherapy/EC control. We excluded quasi‐randomised, cross‐over, and within‐participant designs, and RCTs with additional intervention components not matched between trial arms. Data collection and analysis We followed standard Cochrane methods. The primary efficacy outcome was smoking cessation in later pregnancy; safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well‐being. We also collated data on adherence to trial treatments. We calculated the risk ratio (RR) or mean difference (MD) and the 95% confidence intervals (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta‐analyses where appropriate. Main results We included 11 trials that enrolled a total of 2412 pregnant women who smoked at enrolment, nine trials of NRT and two trials of bupropion as adjuncts to behavioural support, with comparable behavioural support provided in the control arms. No trials investigated varenicline or ECs. We assessed four trials as at low risk of bias overall. The overall certainty of the evidence was low across outcomes and comparisons as assessed using GRADE, with reductions in confidence due to risk of bias, imprecision, and inconsistency. Compared to placebo and non‐placebo (behavioural support only) controls, there was low‐certainty evidence that NRT increased the likelihood of smoking abstinence in later pregnancy (RR 1.37, 95% CI 1.08 to 1.74; I² = 34%, 9 studies, 2336 women). However, in subgroup analysis by comparator type, there was a subgroup difference between placebo‐controlled and non‐placebo controlled RCTs (test for subgroup differences P = 0.008). There was unclear evidence of an effect in placebo‐controlled RCTs (RR 1.21, 95% CI 0.95 to 1.55; I² = 0%, 6 studies, 2063 women), whereas non‐placebo‐controlled trials showed clearer evidence of a benefit (RR 8.55, 95% CI 2.05 to 35.71; I² = 0%, 3 studies, 273 women). An additional subgroup analysis in which studies were grouped by the type of NRT used found no difference in the effectiveness of NRT in those using patches or fast‐acting NRT (test for subgroup differences P = 0.08). There was no evidence of a difference between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities, or neonatal death. In one study infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' at two years of age compared to the placebo group. Non‐serious adverse effects observed with NRT included headache, nausea, and local reactions (e.g. skin irritation from patches or foul taste from gum), but data could not be pooled. Adherence to NRT treatment regimens was generally low. We identified low‐certainty evidence that there was no difference in smoking abstinence rates observed in later pregnancy in women using bupropion when compared to placebo control (RR 0.74, 95% CI 0.21 to 2.64; I² = 0%, 2 studies, 76 women). Evidence investigating the safety outcomes of bupropion use was sparse, but the existing evidence showed no difference between the bupropion and control group. Authors' conclusions NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy. However, this evidence is of low certainty, as the effect was not evident when potentially biased, non‐placebo‐controlled RCTs were excluded from the analysis. Future studies may therefore change this conclusion. We found no evidence that NRT has either positive or negative impacts on birth outcomes; however, the evidence for some of these outcomes was also judged to be of low certainty due to imprecision and inconsistency. We found no evidence that bupropion may be an effective aid for smoking cessation during pregnancy, and there was little evidence evaluating its safety in this population. Further research evidence on the efficacy and safety of pharmacotherapy and EC use for smoking cessation in pregnancy is needed, ideally from placebo‐controlled RCTs that achieve higher adherence rates and that monitor infants' outcomes into childhood. Future RCTs of NRT should investigate higher doses than those tested in the studies included in this review. Plain language summary Drug treatments and electronic cigarettes for stopping smoking in pregnancy What is the issue? Smoking during pregnancy harms women and infants. However, many women who smoke struggle to stop whilst pregnant. Medication for smoking cessation reduces the intensity of cravings, meaning that people trying to stop smoking are more likely to succeed in the long term. Providing pregnant women who smoke with these treatments could help them to stop smoking and have a positive impact on both their own health and the health of their infants. Why is this important? Medications commonly used to help people to stop smoking include nicotine replacement therapy (NRT), bupropion, and varenicline. Electronic cigarettes containing nicotine are also used by some who smoke to help avoid smoking. However, the safety and effectiveness of smoking cessation drugs and electronic cigarettes in pregnant women is unknown. We searched for studies looking at how good these aids were at helping pregnant women stop smoking and how safe they were when used during pregnancy. What evidence did we find? We searched for evidence on 20 May 2019 and identified 11 randomised studies (studies in which participants are assigned to one of two or more treatment groups using a random method) that enrolled a total of 2412 women. Nine studies tested NRT used alongside counselling to stop smoking, whilst the other two studies tested bupropion. Low‐quality evidence suggests that NRT combined with behavioural support might help women to stop smoking in later pregnancy more than behavioural support alone. Medication trials often use placebos, that is tablets or patches that look like the drug but do not actually include it, so that each comparison group has equal expectation of success and there is a fairer test of the benefits of the medicine itself. When just the higher‐quality, placebo‐controlled trials were analysed, the evidence suggested that NRT was more effective than placebo NRT. There was no evidence that either nicotine patches or fast‐acting NRT (such as gum or lozenge) was more effective than the other. Low‐quality evidence suggests that bupropion may be no more effective than placebo in helping women quit smoking later in pregnancy. We found no trials investigating other smoking cessation pharmacotherapies or electronic cigarettes. There was insufficient evidence to conclude whether NRT had either positive or negative impacts on rates of miscarriage, stillbirth, preterm birth (less than 37 weeks), mean birthweight, low birthweight (less than 2500 g), admissions of babies to neonatal intensive care, or newborn deaths. However, in one trial where infants were followed until two years of age, those infants born to women who had been randomised to NRT were more likely to have healthy development. Similarly, it is unclear whether bupropion had a positive or negative impact on birth outcomes. Studies that looked at whether women used their stop smoking medications as instructed found that use was generally low, and the majority of women used little of the NRT they were given. What does this mean? More research evidence is needed, in particular placebo‐controlled trials that test higher doses of NRT, encourage women to use sufficient medication, and follow infants into childhood. Furthermore, more studies are required investigating the effect and safety of bupropion, electronic cigarettes, and varenicline for giving up smoking during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Claire, R; Chamberlain, C; Davey, MA; Cooper, SE; Berlin, I; Leonardi‐Bee, J; Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD010078.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "28a898e0-c3c2-43ba-af9e-79747cd6fe4a", "pmid": "", "title": "Osmotic therapies added to antibiotics for acute bacterial meningitis", "imported": false, "abstract": "Abstract - Background Every day children and adults die from acute community‐acquired bacterial meningitis, particularly in low‐income countries, and survivors risk deafness, epilepsy and neurological disabilities. Osmotic therapies may attract extra‐vascular fluid and reduce cerebral oedema, and thus reduce death and improve neurological outcomes. This is an update of a Cochrane Review first published in 2013. Objectives To evaluate the effects of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults on mortality, deafness and neurological disability. Search methods We searched CENTRAL (2017, Issue 1), MEDLINE (1950 to 17 February 2017), Embase (1974 to 17 February 2017), CINAHL (1981 to 17 February 2017), LILACS (1982 to 17 February 2017) and registers of ongoing clinical trials (ClinicalTrials.com, WHO ICTRP) (21 February 2017). We also searched conference abstracts and contacted researchers in the field (up to 12 December 2015). Selection criteria Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis. Data collection and analysis Two review authors independently screened the search results and selected trials for inclusion. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not. We used the GRADE approach to assess the certainty of the evidence. Main results We included five trials with 1451 participants. Four trials evaluated glycerol against placebo, and one evaluated glycerol against 50% dextrose; in addition three trials evaluated dexamethasone and one trial evaluated acetaminophen (paracetamol) in a factorial design. Stratified analysis shows no effect modification with steroids; we present aggregate effect estimates. Compared to placebo, glycerol probably has little or no effect on death in people with bacterial meningitis (RR 1.08, 95% CI 0.90 to 1.30; 5 studies, 1272 participants; moderate‐certainty evidence ), but may reduce neurological disability (RR 0.73, 95% CI 0.53 to 1.00; 5 studies, 1270 participants; low‐certainty evidence ). Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30; 4 studies, 1090 participants; low‐certainty evidence ). Glycerol may reduce the risk of subsequent deafness (RR 0.64, 95% CI 0.44 to 0.93; 5 studies, 922 participants; low to moderate‐certainty evidence ). Glycerol probably has little or no effect on gastrointestinal bleeding (RR 0.93, 95% CI 0.39 to 2.19; 3 studies, 607 participants; moderate‐certainty evidence ). The evidence on nausea, vomiting and diarrhoea is uncertain (RR 1.09, 95% CI 0.81 to 1.47; 2 studies, 851 participants; very low‐certainty evidence ). Authors' conclusions Glycerol was the only osmotic therapy evaluated, and data from trials to date have not demonstrated an effect on death. Glycerol may reduce neurological deficiency and deafness. Plain language summary Osmotic therapies added to antibiotics for acute bacterial meningitis What is the aim of this review? The aim of this Cochrane Review is to collect and analyse trials evaluating osmotic therapies given orally or intravenously to people with acute bacterial meningitis. Cochrane authors collected and analysed all relevant studies to answer this question; they found five relevant studies. Key messages Giving glycerol, an osmotic diuretic, probably has little or no effect on death ( moderate‐certainty evidence ), but may reduce subsequent deafness ( moderate‐certainty evidence) or neurological disability ( low‐certainty evidence ). The evidence is current to 17 February 2017. What was studied in the review? In meningitis, the cerebrospinal fluid that surrounds the brain and spinal cord is infected, usually as a result of spread from the blood. Any form of meningitis can result in death or severe disability, but acute bacterial meningitis is rapidly fatal without treatment. Even with antibiotics, 10% to 15% of children with bacterial meningitis die in high‐income countries with much higher rates in low‐income settings. The infection causes the brain to swell, and this is thought to contribute to death and to long‐term brain damage in survivors. Osmotic therapies increase the concentration of the blood by exerting an osmotic pressure across a semi‐permeable membrane (such as a cell wall or blood vessel lining in the brain). This draws water from the brain into the blood, thereby reducing pressure in the brain. Potentially osmotic therapies could increase the rate of survival, or they could do harm. What are the main results of the review? We included five trials that compared glycerol with placebo in a total of 1451 patients with bacterial meningitis. In the studies steroids were often given as well, but this did not appear to modify any of the effects seen with glycerol. This review detected no benefit from glycerol relating to death. There appeared to be marginal protection against deafness and against neurological disability. No effect on epileptic seizures at follow‐up was noted. Glycerol was not associated with any severe adverse effects. The number of trials included was small and only two tested a large number of participants. All trials were from different healthcare settings and examined either adults or children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wall, ECB, Ajdukiewicz, KMB, Bergman, H, Heyderman, RS, Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD008806.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.753Z" }, { "id": "28a9d010-4864-49e4-b491-08076dea6990", "pmid": "", "title": "Snoezelen for dementia", "imported": false, "abstract": "Abstract - Background Snoezelen, multi‐sensory stimulation, provides sensory stimuli to stimulate the primary senses of sight, hearing, touch, taste and smell, through the use of lighting effects, tactile surfaces, meditative music and the odour of relaxing essential oils. The rationale for this lies in the proposition that the provision of a sensory environment for people with dementia places fewer demands on their intellectual abilities but capitalizes on their residual sensorimotor abilities. The clinical application of snoezelen often varies in form, nature, principles and procedures. Such variations not only make the examination of the therapeutic values of snoezelen difficult, but also impede the clinical development of snoezelen in dementia care. A systematic review of evidence for the efficacy of snoezelen in the care of people with dementia is therefore needed to inform future clinical applications and research directions. Objectives To examine the clinical efficacy of snoezelen (or multisensory stimulation) for older people with dementia and their caregivers. Search methods The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 23 March 2008 using the terms: snoezelen OR \"multi‐sensory*\". The CDCIG Specialized Register contains records from all major health care databases ( The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources. The reviewers hand‐searched PubMed and the ISI Web of Science. Selection criteria Randomized controlled trials and quasi‐randomized controlled trials in which snoezelen or multi‐sensory programmes was used as an intervention for older people suffering from any forms of dementia. Data collection and analysis The two reviewers independently reviewed and assessed the quality of the trials. Main results Two new trials were included in this update. Baker 2003 was an expanded study of Baker 2001 reported in the previous version. Both Baker 2003 and van Weert 2005 examined the short‐term and longer‐term effects of snoezelen on behaviour, mood, and communication of people with moderate to severe dementia. The format of implementation was different in the two trials: one was session‐based snoezelen programme (Baker 2003), whilst the other was a 24‐hour integrated snoezelen care (van Weert 2005). Owing to the differences in study methodology, the results of the two trials were not pooled for analysis. The session‐based snoezelen programme (Baker 2003) did not show any effects on behaviour, mood, cognition and communication / interaction in the short term (during or immediately after sessions) or longer term (at post‐intervention or 1‐month post‐intervention follow‐up). Likewise, the 24‐hour integrated snoezelen care (van Weert 2005) failed to demonstrate any significant short‐term and longer term effects on behaviour, mood and interaction. Authors' conclusions A more vigorous review methodology was adopted in this update. The study of Kragt 1997, reported in the previous version, was excluded because the snoezelen programme only consisted of three sessions, which was considered too brief for a therapeutic intervention. Two new trials were reviewed. Meta‐analyses could not be performed because of the limited number of trials and different study methods of the available trials. Overall, there is no evidence showing the efficacy of snoezelen for dementia. There is a need for more reliable and sound research‐based evidence to inform and justify the use of snoezelen in dementia care. Plain language summary No evidence of the efficacy of snoezelen or multi‐sensory stimulation programmes for people with dementia Snoezelen (or multi‐sensory stimulation) has become a commonly used intervention to manage maladaptive behaviours and to promote positive mood of older people with dementia. Originally, two randomised clinical trials were available for this review. Some short‐term benefits were documented in promoting adaptive behaviours in people with dementia during and immediately after their participation in the sessions. In this update, two new trials were included and revealed two different forms of applying snoezelen to dementia care. One is a session‐based snoezelen programme while the other is a 24‐hour integrated snoezelen care programme. Both trials did not show any significant effects on behaviour, interaction, and mood of people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Chung, JCC; Lai, CKY", "articleTypes": [], "doi": "10.1002/14651858.CD003152", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "28aa7b6e-4ee2-44fa-ab88-902db05dce50", "pmid": "", "title": "Different strategies for diagnosing gestational diabetes to improve maternal and infant health", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycaemia with onset or first recognition during pregnancy. If untreated, perinatal morbidity and mortality may be increased. Accurate diagnosis allows appropriate treatment. Use of different tests and different criteria will influence which women are diagnosed with GDM. This is an update of a review published in 2011 and 2015. Objectives To evaluate and compare different testing strategies for diagnosis of gestational diabetes mellitus to improve maternal and infant health while assessing their impact on healthcare service costs. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (9 January 2017) and reference lists of retrieved studies. Selection criteria We included randomised trials if they evaluated tests carried out to diagnose GDM. We excluded studies that used a quasi‐random model, cluster‐randomised or cross‐over trials. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. Main results We included a total of seven small trials, with 1420 women. One trial including 726 women was identified by this update and examined the two step versus one step approach. These trials were assessed as having varying risk of bias, with few outcomes reported. We prespecified six outcomes to be assessed for quality using the GRADE approach for one comparison: 75 g oral glucose tolerance test (OGTT) versus 100 g OGTT; data for only one outcome (diagnosis of gestational diabetes) were available for assessment. One trial compared three different methods of delivering glucose: a candy bar (39 women), a 50 g glucose polymer drink (40 women) and a 50 g glucose monomer drink (43 women). We have included the results reported by this trial as separate comparisons. No trial reported on measures of costs of health services. We examined six main comparisons. 75 g OGTT versus 100 g OGTT (1 trial, 248 women): women who received 75 g OGTT had a higher relative risk of being diagnosed with GDM (risk ratio (RR) 2.55, 95% confidence interval (CI) 0.96 to 6.75; very‐low quality evidence ). No data were reported for the following additional outcomes prespecified for GRADE assessment: caesarean section, macrosomia > 4.5 kg or however defined in the trial, long‐term type 2 diabetes maternal, long‐term type 2 diabetes infant and economic costs. Candy bar versus 50 g glucose monomer drink (1 trial, 60 women): more women receiving the candy bar, rather than glucose monomer, preferred the taste of the candy bar (RR 0.60, 95% CI 0.42 to 0.86) and 1‐hour glucose was less with the candy bar. There were no differences in the other outcomes reported (maternal side effects). No infant outcomes were reported or any review primary outcomes. 50 g glucose polymer drink versus 50 g glucose monomer drink (3 trials, 239 women): mean difference (MD) in gestation at birth was ‐0.80 weeks (1 trial, 100 women; 95% CI ‐1.69 to 0.09). Total side effects were less common with the glucose polymer drink (1 trial, 63 women; RR 0.21, 95% CI 0.07 to 0.59), and no clear difference in taste acceptability was reported (1 trial, 63 women; RR 0.99, 95% CI 0.76 to 1.29). Fewer women reported nausea following the 50 g glucose polymer drink compared with the 50 g glucose monomer drink (1 trial, 66 women; RR 0.29, 95% CI 0.11 to 0.78). No other measures of maternal morbidity or outcomes for the infant were reported. 50 g glucose food versus 50 g glucose drink (1 trial, 30 women): women receiving glucose in their food, rather than as a drink, reported fewer side effects (RR 0.08, 95% CI 0.01 to 0.56). No clear difference was noted in the number of women requiring further testing (RR 0.14, 95% CI 0.01 to 2.55). No other measures of maternal morbidity or outcome were reported for the infant or review primary outcomes. 75 g OGTT World Health Organization (WHO) criteria versus 75 g OGTT American Diabetes Association (ADA) criteria (1 trial, 116 women): no clear differences in included outcomes were observed between women who received the 75 g OGTT and were diagnosed using criteria based on WHO (1999) recommendations and women who received the 75 g OGTT and were diagnosed using criteria recommended by the ADA (1979). Outcomes measured included diagnosis of gestational diabetes (RR 1.47, 95% CI 0.66 to 3.25), caesarean section (RR 1.07, 95% CI 0.85 to 1.35), macrosomia defined as > 90th percentile by ultrasound or birthweight equal to or exceeding 4000 g (RR 0.73, 95% CI 0.19 to 2.79), stillbirth (RR 0.49, 95% CI 0.02 to 11.68) and instrumental birth (RR 0.21, 95% CI 0.01 to 3.94). No other secondary outcomes were reported. Two‐step approach (50 g oral glucose challenge test followed by selective 100 g OGTT Carpenter and Coustan criteria) versus one‐step approach (universal 75 g OGTT ADA criteria) (1 trial, 726 women): women allocated the two‐step approach had a lower risk of being diagnosed with GDM at 11 to 14 weeks' gestation compared to women allocated the one‐step approach (RR 0.51, 95% CI 0.28 to 0.95). No other primary or secondary outcomes were reported. Authors' conclusions There is insufficient evidence to suggest which strategy is best for diagnosing GDM. Large randomised trials are required to establish the best strategy for correctly identifying women with GDM. Plain language summary Different strategies for diagnosing gestational diabetes mellitus (GDM) to improve maternal and infant health What is the issue? We aimed to evaluate and compare different ways of diagnosing gestational diabetes mellitus (GDM). We searched for all relevant studies in January 2017. Why is this important? Between seven and 24 pregnant women in every 100 develop GDM. GDM is when there is an inability to process carbohydrates properly, which leads to high blood sugar (hyperglycaemia). GDM can result in increased risks of problems around the time of birth for the mother and her baby. Treatment can reduce these risks, and therefore diagnosing the condition accurately means that treatment can be given to improve the health of mothers and their babies. Different testing strategies aim to diagnose GDM. We wanted to compare the different strategies, to see how they affected the health of women and their infants, and to assess the cost of the strategies to the healthcare service. What evidence did we find? We found seven trials. A total of 1420 women were included, in settings in Turkey, Mexico, Nigeria, New Zealand, Canada and the USA. Across the trials, different testing approaches and criteria were evaluated as were different diagnostic tests including different oral glucose tolerance test loads; a glucose drink; a candy bar and food high in glucose. Women were given these items to eat/drink, and this was then followed by a blood test to measure blood sugar levels and questionnaires. In some tests, women were required to fast from the night before. The main outcomes we looked for were frequency of diagnosis, incidence of caesarean section, assisted birth and vaginal birth, and incidence of macrosomia in babies (larger than normal weight at birth). Other outcomes spanned a range, including any side effects of the tests, the mothers' preferences, and the health of the babies. There were a number of weaknesses among the studies: the methodology was not clear and there were important gaps in the data. The studies in this review do not provide enough evidence to guide clinical practice and health policy regarding identifying women with GDM. What does this mean? We are uncertain about which strategies to diagnose GDM are better, as we have assessed the quality of evidence as very low. Large randomised trials are needed to establish the best way for identifying women with GDM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Farrar, D, Duley, L, Dowswell, T, Lawlor, DA", "articleTypes": [], "doi": "10.1002/14651858.CD007122.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.068Z" }, { "id": "28bb847b-fea5-4c7d-90a5-4124383426d4", "pmid": "", "title": "Interventions for fatigue in peripheral neuropathy", "imported": false, "abstract": "Abstract - Background Persistent feelings of fatigue (or subjective fatigue), which may be experienced in the absence of physiological factors, affect many people with peripheral neuropathy. A variety of interventions for subjective fatigue are available, but little is known about their efficacy or the likelihood of any adverse effects for people with peripheral neuropathy. Objectives To assess the effects of drugs and physical, psychological or behavioural interventions for fatigue in adults or children with peripheral neuropathy. Search methods On 5 November 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, CINAHL Plus, LILACS and AMED. We also searched reference lists of all studies identified for inclusion and relevant reviews, and contacted the authors of included studies and known experts in the field to identify additional published or unpublished data. We also searched trials registries for ongoing studies. Selection criteria We considered for inclusion randomised controlled trials (RCTs) and quasi‐RCTs comparing any form of intervention for fatigue management in adults with peripheral neuropathy with placebo, no intervention or an alternative form of intervention for fatigue. Interventions considered included drugs, pacing and grading of physical activity, general or specific exercise, compensatory strategies such as orthotics, relaxation, counselling, cognitive and educational strategies. Data collection and analysis Two review authors independently assessed risk of bias and extracted study data. We contacted study authors for additional information. We collected information on adverse events from the included trials. Main results The review includes three trials, which were all at low risk of bias, involving 530 people with peripheral neuropathy. The effects of amantadine from one randomised, double‐blind, placebo‐controlled, cross‐over trial comparing amantadine with placebo for the treatment of fatigue in 80 people with Guillain‐Barré syndrome (GBS) were uncertain for the proportion of people achieving a favourable outcome six weeks post‐intervention (odds ratio (OR) 0.56 (95% confidence interval (CI) 0.22 to 1.35, N = 74, P = 0.16). We assessed the quality of this evidence as low. Two parallel‐group randomised double‐blind, placebo‐controlled trials comparing the effects of two doses of ascorbic acid with placebo for reducing fatigue in adults with Charcot‐Marie‐Tooth disease type 1A (CMT1A) showed that the effects of ascorbic acid at either dose are probably small (standardised mean difference (SMD) ‐0.12 (95% CI ‐0.32 to 0.08, n = 404, P = 0.25)) for change in fatigue after 12 to 24 months (moderate quality evidence). Neither ascorbic acid study measured fatigue at four to 12 weeks, which was our primary outcome measure. No serious adverse events were reported with amantadine. Serious adverse events were reported in the trials of ascorbic acid. However,risk of serious adverse events was similar with ascorbic acid and placebo. Authors' conclusions One small imprecise study in people with GBS showed uncertain effects of amantadine on fatigue. In two studies in people with CMT1A there is moderate‐quality evidence that ascorbic acid has little meaningful benefit on fatigue. Information about adverse effects was limited, although both treatments appear to be well tolerated and safe in these conditions. There was no evidence available from RCTs to evaluate the effect of other drugs or other interventions for fatigue in either GBS, CMT1A or other causes of peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future randomised clinical trials. Plain language summary Treatments for fatigue in peripheral neuropathy Review question To assess the effects of treatments for fatigue in people with peripheral neuropathy. Background Peripheral neuropathy is damage to the nerves outside the brain and spinal cord. Many people with peripheral neuropathy have feelings of severe tiredness (fatigue) that are not necessarily related to physical problems such as muscle weakness. Evidence in other long‐term illnesses where fatigue is a problem suggests that medicines and other forms of treatment may help. The aim of this review was to assess the effect of drugs and other treatments, such as general or specific exercise, orthotics (devices such as braces), relaxation, counselling and cognitive, behavioural and educational strategies on feelings of fatigue in people with peripheral neuropathy. Study characteristics From a wide search, we identified three RCTs that met our selection criteria. The trials involved a total of 530 adults with peripheral neuropathy. Treatments were ascorbic acid (vitamin C) in people with Charcot‐Marie‐Tooth disease in two trials, and amantadine in Guillain‐Barré syndrome in the third. Charcot‐Marie‐Tooth disease is an inherited nerve disease and Guillain‐Barré syndrome is a condition where there is inflammation of the peripheral nerves. We chose measures of fatigue at four to 12 weeks as our preferred measure of the effects of treatment. The amantadine trial but not the ascorbic acid trials provided data at this time point; the ascorbic acid trials provided data more than 12 months after the start of the intervention. Key results and quality of the evidence There was insufficient evidence to determine the effects of amantadine when compared with an inactive treatment (placebo) for fatigue. and there were no major unwanted effects. We found evidence that ascorbic acid probably has little meaningful benefit for fatigue. No major unwanted effects were identified, but the trials were small. We assessed the quality of this evidence as moderate because the results were imprecise, which means they do not rule out the possibility that the drugs could have an effect. We found no evidence from RCTs on other medicines or treatments for fatigue in peripheral neuropathy. There is insufficient evidence to determine the effect of amantadine for fatigue in GBS and ascorbic acid for fatigue in CMT1A. More high‐quality studies are needed to provide evidence on which to base management of feelings of fatigue in peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future RCTs. The evidence in this review is current to November 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "White, CM; van Doorn, PA; Garssen, MPJ; Stockley, RC", "articleTypes": [], "doi": "10.1002/14651858.CD008146.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "28c360ac-bf00-47c0-a39a-e0b583e26b0a", "pmid": "", "title": "A Multiple Ascending Dose Study of Tadalafil to Assess the Pharmacokinetics and Safety in a Pediatric Population With Pulmonary Arterial Hypertension", "imported": false, "abstract": "The purpose of this study is to see how much study drug is in the blood of children with pulmonary arterial hypertension (PAH) after dosing to establish the correct dose for further clinical research.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.244Z" }, { "id": "28d99255-815e-4355-9edf-c12a5265c40b", "pmid": "", "title": "Penicillamine for treating rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is a penicillin derived compound originally used to treat patients with rheumatoid arthritis (RA) in the 1950's. Although frequently used in the past, its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs) such as methotrexate. Objectives To estimate the short‐term effects of D‐penicillamine for the treatment of rheumatoid arthritis (RA). Search methods We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register (issue 3, 2000) and Medline up to and including August 2000 and Embase from 1988‐2000. We also carried out a handsearch of the reference lists of the trials retrieved from the electronic search. Selection criteria All randomized controlled trials and controlled clinical trials comparing D‐penicillamine against placebo in patients with rheumatoid arthritis. Data collection and analysis The methodological quality of the trials was assessed independently by two reviewers (CS, EB) and checked by a third (MS) using a validated quality assessment tool (Jadad 1996). Rheumatoid arthritis outcome measures were extracted from the publications for the six‐month endpoint and stratified according to D‐penicillamine dosages: low (<500mg/day), moderate (500 to <1000mg/day) and high (1000 mg/day or greater). Data was abstracted by one reviewer and checked by a second (CS, MS). The pooled analysis was performed using the standardized mean difference for joint counts, pain and global assessments. The weighted mean difference was used for erythrocyte sedimentation rate (ESR). Toxicity was evaluated with pooled odds ratios for withdrawals and adverse reactions. A chi‐square test was used to assess heterogeneity among trials. Fixed effects models were used throughout, since no statistical heterogeneity was found. Main results Six trials were identified, with 425 patients randomized to D‐penicillamine and 258 to placebo. A statistically significant benefit was observed for D‐penicillamine when compared to placebo for all three‐dose ranges and for most outcome measures including: tender joint counts, pain, physician's global assessments and ESR. The standardized weighted mean differences between treatment and placebo in moderate doses were ‐0.51 [95% CI ‐0.88, ‐0.14] for tender joint counts, ‐0.56 (95% CI ‐0.87, ‐0.26) for pain and ‐0.97 (95% CI ‐1.25, ‐0.70) for global assessment. The difference for ESR was ‐10.6 mm/hr. Similar results were observed for the higher dose group. Total withdrawals were significantly higher in the moderate and high dosage D‐penicillamine groups (OR=1.63 and 2.13 respectively), mostly due to increased adverse reactions (OR = 2.60 and 4.95 respectively), including renal and hematological abnormalities. Authors' conclusions D‐penicillamine appears to have a clinically and statistically significant benefit on the disease activity of patients with rheumatoid arthritis. Its efficacy appears to be similar to that of other disease modifying anti‐rheumatic drugs (DMARDs), but with a significantly higher toxicity. Its effects on long‐term functional status and radiological progression are not clear from this review. Plain language summary Penicillamine for treating rheumatoid arthritis Penicillamine is a penicillin derived compound. Studies showed that this could be used to treat rheumatoid arthritis originally in 1950. It was frequently used in the past, but its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs), such as methotrexate. The purpose of this summary was to find out if penicillamine is helpful in the treatment of rheumatoid arthritis. Penicillamine was seen to be beneficial for all ranges of dosages for disease activity on tender joint pain, physician global assessment and sed rate. No major differences were observed between placebo and low dose penicillamine (<500 mg/day). For higher dosages, patients on penicillamine were twice as likely to withdraw than those receiving placebo 500 to <1000 mg/day. D‐penicillamine appears be have a clinical and statistical benefit on the disease activity of patients with rheumatoid arthritis. Its benefit is similar to that of other such drugs, such as disease modifying anti‐rheumatic drugs (DMARDs). More adverse reactions are seen in patients being treated with D‐penicillamine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Suarez‐Almazor, ME, Belseck, E, Spooner, C", "articleTypes": [], "doi": "10.1002/14651858.CD001460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.728Z" }, { "id": "28e25a15-2702-4368-8c1b-ddd7f202910b", "pmid": "", "title": "Interventions for bullous pemphigoid", "imported": false, "abstract": "Abstract - Background Bullous pemphigoid (BP) is the most common autoimmune blistering disease. Oral steroids are the standard treatment. We have updated this review, which was first published in 2002, because several new treatments have since been tried. Objectives To assess the effects of treatments for bullous pemphigoid. Search methods We updated searches of the following databases to November 2021: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched five trial databases to January 2022, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria RCTs of treatments for immunofluorescence‐confirmed bullous pemphigoid. Data collection and analysis At least two review authors, working independently, evaluated the studies against the review's inclusion criteria and extracted data from included studies. Using GRADE methodology, we assessed the certainty of the evidence for each outcome in each comparison. Our primary outcomes were healing of skin lesions and mortality. Main results We identified 14 RCTs (1442 participants). The main treatment modalities assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Most studies reported mortality but adverse events and quality of life were not well reported. We decided to look at the primary outcomes 'disease control' and 'mortality'. Almost all studies investigated different comparisons; two studies were placebo‐controlled. The results are therefore based on a single study for each comparison except azathioprine. Most studies involved only small numbers of participants. We assessed the risk of bias for all key outcomes as having 'some concerns' or high risk, due to missing data, inappropriate analysis, or insufficient information. Clobetasol propionate cream versus oral prednisone Compared to oral prednisone, clobetasol propionate cream applied over the whole body probably increases skin healing at day 21 (risk ratio (RR 1.08, 95% confidence interval (CI) 1.03 to 1.13; 1 study, 341 participants; moderate‐certainty evidence). Skin healing at 21 days was seen in 99.8% of participants assigned to clobetasol and 92.4% of participants assigned to prednisone. Clobetasol propionate cream applied over the whole body compared to oral prednisone may reduce mortality at one year (RR 0.73, 95% CI 0.53 to 1.01; 1 study, 341 participants; low‐certainty evidence). Death occurred in 26.5% (45/170) of participants assigned to clobetasol and 36.3% (62/171) of participants assigned to oral prednisone. This study did not measure quality of life. Clobetasol propionate cream may reduce risk of severe complications by day 21 compared with oral prednisone (RR 0.65, 95% CI 0.50 to 0.86; 1 study, 341 participants; low‐certainty evidence). Mild clobetasol propionate cream regimen (10 to 30 g/day) versus standard clobetasol propionate cream regimen (40 g/day) A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen probably does not change skin healing at day 21 (RR 1.00, 95% CI 0.97 to 1.03; 1 study, 312 participants; moderate‐certainty evidence). Both groups showed complete healing of lesions at day 21 in 98% participants. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change mortality at one year (RR 1.00, 95% CI 0.75 to 1.32; 1 study, 312 participants; low‐certainty evidence), which occurred in 118/312 (37.9%) participants. This study did not measure quality of life. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change adverse events at one year (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 309 participants; low‐certainty evidence). Doxycycline versus prednisolone Compared to prednisolone (0.5 mg/kg/day), doxycycline (200 mg/day) induces less skin healing at six weeks (RR 0.81, 95% CI 0.72 to 0.92; 1 study, 213 participants; high‐certainty evidence). Complete skin healing was reported in 73.8% of participants assigned to doxycycline and 91.1% assigned to prednisolone. Doxycycline compared to prednisolone probably decreases mortality at one year (RR 0.25, 95% CI 0.07 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 14; 1 study, 234 participants; moderate‐certainty evidence). Mortality occurred in 2.3% (3/132) of participants with doxycycline and 9.1% (11/121) with prednisolone. Compared to prednisolone, doxycycline improved quality of life at one year (mean difference 1.8 points lower, which is more favourable on the Dermatology Life Quality Index, 95% CI 1.02 to 2.58 lower; 1 study, 234 participants; high‐certainty evidence). Doxycycline compared to prednisolone probably reduces severe or life‐threatening treatment‐related adverse events at one year (RR 0.59, 95% CI 0.35 to 0.99; 1 study, 234 participants; moderate‐certainty evidence). Prednisone plus azathioprine versus prednisone It is unclear whether azathioprine plus prednisone compared to prednisone alone affects skin healing or mortality because there was only very low‐certainty evidence from two trials (98 participants). These studies did not measure quality of life. Adverse events were reported in a total of 20/48 (42%) participants assigned to azathioprine plus prednisone and 15/44 (34%) participants assigned to prednisone. Nicotinamide plus tetracycline versus prednisone It is unclear whether nicotinamide plus tetracycline compared to prednisone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (18 participants). This study did not measure quality of life. Fewer adverse events were reported in the nicotinamide group. Methylprednisolone plus azathioprine versus methylprednisolone plus dapsone It is unclear whether azathioprine plus methylprednisolone compared to dapsone plus methylprednisolone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (54 participants). This study did not measure quality of life. A total of 18 adverse events were reported in the azathioprine group and 13 in the dapsone group. Authors' conclusions Clobetasol propionate cream applied over the whole body is probably similarly effective as, and may cause less mortality than, oral prednisone for treating bullous pemphigoid. Lower‐dose clobetasol propionate cream applied over the whole body is probably similarly effective as standard‐dose clobetasol propionate cream and has similar mortality. Doxycycline is less effective but causes less mortality than prednisolone for treating bullous pemphigoid. Other treatments need further investigation. Plain language summary Treatments for bullous pemphigoid Which treatments work best for bullous pemphigoid (a rare, itchy skin disease that causes blisters)? Key messages • A cream, containing topical steroid clobetasol propionate, applied on the entire skin surface is as effective as oral steroids (prednisone), causes less severe unwanted or harmful effects, and may decrease deaths. • Initiating treatment with doxycycline (200 mg/day), an antibiotic with anti‐inflammatory effect, leads to an acceptable short‐term blister control compared to the oral steroid prednisolone (0.5 mg/kg/day), and is superior in long‐term safety aspects, including deaths. What is bullous pemphigoid? Bullous pemphigoid is the most common autoimmune blistering disease. In autoimmune diseases, the body's immune system mistakes its own tissues as foreign and attacks them. In bullous pemphigoid, this causes blisters on the skin. Bullous pemphigoid usually occurs in the elderly, but may also affect younger people. How is bullous pemphigoid treated? Until recently, the leading treatment for bullous pemphigoid was oral steroids which suppress inflammation and the body's own immune system. However, given over a long period of time, oral steroids will cause severe adverse (i.e. harmful) effects. This review assessed studies which investigated the effectiveness of other treatment options for bullous pemphigoid; for example, a steroid cream applied on the skin and the anti‐inflammatory antibiotic medicine, doxycycline. What did we want to find out? We wanted to find out which treatments work best for bullous pemphigoid with respect to the healing of blisters (efficacy) and reduction in adverse effects, such as death. What did we do? We searched for studies that looked at treatments for bullous pemphigoid. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 14 studies including 1442 people with bullous pemphigoid. The main treatments assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Other treatments tested were oral (i.e. taken by mouth) immunosuppressives (medicines that keep your immune system in check) and immunoglobulins (also called antibodies. Antibodies are proteins that your immune system makes to fight germs, for example). ‐ Topical steroid cream, clobetasol propionate, applied over the whole body (40 grams of cream applied per day, with the amount decreased over 12 months) is an effective and safe treatment for bullous pemphigoid. ‐ Treatment with a lower amount of clobetasol propionate cream (10 to 30 grams per day, decreased over 4 months) is equally effective and safe. ‐ Prednisolone, an oral corticosteroid, in the dose of 0.5 mg/kg/day, may be adequate to control disease in most people and reduces adverse effects compared to higher doses of oral corticosteroid. ‐ Initiating treatment with 200 mg/day of doxycycline leads to acceptable blister control compared to oral prednisolone (0.5 mg/kg/day) and is safer. ‐ A study with 20 participants suggests that nicotinamide (a form of vitamin B 3 )and tetracycline (an antibiotic used to treat a wide variety of infections) may be an effective alternative to prednisone and may decrease treatment‐associated death. ‐ Adding azathioprine, a drug which suppresses the immune system, to an oral corticosteroid does not improve disease control; it may lead to a reduced need for oral corticosteroid. ‐ Further research is needed to fully understand the effectiveness of alternatives to oral steroids (such as dapsone or immunoglobulins), as well as the effectiveness of giving other medicines alongside an oral steroid. What are the limitations of the evidence? Except for the studies on topical clobetasol cream and doxycycline, the studies included relatively few participants. The methodological quality of these studies was further limited because of unclear methods of allocating people to different treatment groups; lack of masking (participants and researchers knew which treatments were given to which people, which are not good conditions for fair assessment); and the exclusion of people who dropped out of the studies from treatment analysis. We are confident about the efficacy of initiating treatment with doxycycline and moderately confident about the efficacy of topical clobetasol cream for the treatment of bullous pemphigoid. How up to date is this evidence? The evidence is current to 11 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Singh, S; Kirtschig, G; Anchan, VN; Chi, C-C; Taghipour, K; Boyle, RJ; Murrell, DF", "articleTypes": [], "doi": "10.1002/14651858.CD002292.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "28e25d61-f063-40aa-8931-ba600721c72b", "pmid": "", "title": "Longitudinal Observation of Clinical and Immunological Profiles After SARS-Cov-2 Infection", "imported": false, "abstract": "There are very few long-term studies that analyze the immune responses in patients recovered from COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.156Z" }, { "id": "29041639-45d9-43de-90cd-9c946fc32a7b", "pmid": "", "title": "Chinese medicinal herbs for mumps", "imported": false, "abstract": "Abstract - Background Mumps is an infectious disease caused by the mumps virus. Chinese physicians generally believe that Chinese medicinal herbs are effective in alleviating symptoms and reducing the duration of mumps. Herbalists tend to develop a treatment plan according to the individual's symptoms. Objectives To evaluate the effectiveness and safety of Chinese medicinal herbs combined with routine treatments for mumps. Search methods We searched CENTRAL (2015, Issue 1), MEDLINE (1948 to January week 4, 2015), EMBASE (1974 to February 2015), CINAHL (1981 to February 2015), AMED (1985 to April 2014), the Chinese Biomedical Database (CBM) (1980 to February 2015), China National Knowledge Infrastructure (CNKI) (1979 to February 2015), VIP Information (1989 to February 2015), and relevant databases of ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs for mumps (with or without complications). Data collection and analysis Two review authors independently evaluated trial quality and conducted data extraction. We contacted the trial authors for missing data regarding participant allocation. Some trials allocated participants according to the participants' admission sequence, making it a pseudo‐random allocation. None of the trials concealed participants' allocation or used blinding. Main results We did not identify any eligible trials for inclusion. We identified 108 studies that claimed to use random allocation. We excluded 104 studies because the allocation methods the authors had used were not actually randomised. We were unable to contact the trial authors of the remaining four studies. These trials require further evaluation and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions We did not find any RCTs for or against Chinese herbal medicine used in the treatment of mumps. We hope more high‐quality RCTs will be conducted in the future. Plain language summary Chinese medicinal herbs for mumps Review question 
 We reviewed the evidence about the effect and safety of Chinese medicinal herbs for mumps. Background 
 Mumps (epidemic parotitis) is an infectious illness caused by the multiplication of the mumps virus in the upper respiratory tract. It can range from a mild upper respiratory disease to serious complications. Herbal medicines have been used in traditional Chinese medicine (TCM) as the main therapy to prevent and treat mumps for thousands of years. Many Chinese physicians believe that Chinese medicinal herbs are effective in treating mumps. Study characteristics 
 The evidence is current to February 2015. The review authors did not find any randomised controlled trials (RCTs) to provide reliable evidence for the effectiveness and safety of Chinese medicinal herbs for mumps. Although no trials were included, we reviewed the studies and found no reports of adverse events with Chinese medicinal herbs as a treatment for mumps. Key results 
 High‐quality trials are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Shu, M; Zhang, YQ; Li, Z; Liu, GJ; Wan, C; Wen, Y", "articleTypes": [], "doi": "10.1002/14651858.CD008578.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "2922daee-2147-44a0-a31b-8ec39ff41a9b", "pmid": "", "title": "A Randomized, Active-Controlled, Partially Blinded, Biomarker Select, Phase III Clinical Trial of Pembrolizumab as Monotherapy and in Combination With Cisplatin+5-Fluorouracil Versus Placebo+Cisplatin+5-Fluorouracil as First-Line Treatment in Subjects With Advanced Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma", "imported": false, "abstract": "This is a study of pembrolizumab (MK-3475) as first-line treatment for participants with advanced gastric or gastroesophageal junction (GEJ) adenocarcinoma. Participants whose tumors express programmed death-ligand 1 (PD-L1) will be randomly assigned to one of the three treatment arms of the study: pembrolizumab as monotherapy [pembro mono], pembrolizumab plus standard of care (SOC) chemotherapy with cisplatin plus 5-fluorouracil (5-FU) or capecitabine [pembro combo], or placebo plus SOC chemotherapy with cisplatin plus 5-fluorouracil (5-FU) or capecitabine [SOC].", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "2925c2d4-2694-4312-a125-da969189ddb1", "pmid": "", "title": "Interventions for bullous pemphigoid", "imported": false, "abstract": "Abstract - Background Bullous pemphigoid (BP) is the most common autoimmune blistering disease. Oral steroids are the standard treatment. We have updated this review, which was first published in 2002, because several new treatments have since been tried. Objectives To assess the effects of treatments for bullous pemphigoid. Search methods We updated searches of the following databases to November 2021: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched five trial databases to January 2022, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria RCTs of treatments for immunofluorescence‐confirmed bullous pemphigoid. Data collection and analysis At least two review authors, working independently, evaluated the studies against the review's inclusion criteria and extracted data from included studies. Using GRADE methodology, we assessed the certainty of the evidence for each outcome in each comparison. Our primary outcomes were healing of skin lesions and mortality. Main results We identified 14 RCTs (1442 participants). The main treatment modalities assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Most studies reported mortality but adverse events and quality of life were not well reported. We decided to look at the primary outcomes 'disease control' and 'mortality'. Almost all studies investigated different comparisons; two studies were placebo‐controlled. The results are therefore based on a single study for each comparison except azathioprine. Most studies involved only small numbers of participants. We assessed the risk of bias for all key outcomes as having 'some concerns' or high risk, due to missing data, inappropriate analysis, or insufficient information. Clobetasol propionate cream versus oral prednisone Compared to oral prednisone, clobetasol propionate cream applied over the whole body probably increases skin healing at day 21 (risk ratio (RR 1.08, 95% confidence interval (CI) 1.03 to 1.13; 1 study, 341 participants; moderate‐certainty evidence). Skin healing at 21 days was seen in 99.8% of participants assigned to clobetasol and 92.4% of participants assigned to prednisone. Clobetasol propionate cream applied over the whole body compared to oral prednisone may reduce mortality at one year (RR 0.73, 95% CI 0.53 to 1.01; 1 study, 341 participants; low‐certainty evidence). Death occurred in 26.5% (45/170) of participants assigned to clobetasol and 36.3% (62/171) of participants assigned to oral prednisone. This study did not measure quality of life. Clobetasol propionate cream may reduce risk of severe complications by day 21 compared with oral prednisone (RR 0.65, 95% CI 0.50 to 0.86; 1 study, 341 participants; low‐certainty evidence). Mild clobetasol propionate cream regimen (10 to 30 g/day) versus standard clobetasol propionate cream regimen (40 g/day) A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen probably does not change skin healing at day 21 (RR 1.00, 95% CI 0.97 to 1.03; 1 study, 312 participants; moderate‐certainty evidence). Both groups showed complete healing of lesions at day 21 in 98% participants. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change mortality at one year (RR 1.00, 95% CI 0.75 to 1.32; 1 study, 312 participants; low‐certainty evidence), which occurred in 118/312 (37.9%) participants. This study did not measure quality of life. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change adverse events at one year (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 309 participants; low‐certainty evidence). Doxycycline versus prednisolone Compared to prednisolone (0.5 mg/kg/day), doxycycline (200 mg/day) induces less skin healing at six weeks (RR 0.81, 95% CI 0.72 to 0.92; 1 study, 213 participants; high‐certainty evidence). Complete skin healing was reported in 73.8% of participants assigned to doxycycline and 91.1% assigned to prednisolone. Doxycycline compared to prednisolone probably decreases mortality at one year (RR 0.25, 95% CI 0.07 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 14; 1 study, 234 participants; moderate‐certainty evidence). Mortality occurred in 2.3% (3/132) of participants with doxycycline and 9.1% (11/121) with prednisolone. Compared to prednisolone, doxycycline improved quality of life at one year (mean difference 1.8 points lower, which is more favourable on the Dermatology Life Quality Index, 95% CI 1.02 to 2.58 lower; 1 study, 234 participants; high‐certainty evidence). Doxycycline compared to prednisolone probably reduces severe or life‐threatening treatment‐related adverse events at one year (RR 0.59, 95% CI 0.35 to 0.99; 1 study, 234 participants; moderate‐certainty evidence). Prednisone plus azathioprine versus prednisone It is unclear whether azathioprine plus prednisone compared to prednisone alone affects skin healing or mortality because there was only very low‐certainty evidence from two trials (98 participants). These studies did not measure quality of life. Adverse events were reported in a total of 20/48 (42%) participants assigned to azathioprine plus prednisone and 15/44 (34%) participants assigned to prednisone. Nicotinamide plus tetracycline versus prednisone It is unclear whether nicotinamide plus tetracycline compared to prednisone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (18 participants). This study did not measure quality of life. Fewer adverse events were reported in the nicotinamide group. Methylprednisolone plus azathioprine versus methylprednisolone plus dapsone It is unclear whether azathioprine plus methylprednisolone compared to dapsone plus methylprednisolone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (54 participants). This study did not measure quality of life. A total of 18 adverse events were reported in the azathioprine group and 13 in the dapsone group. Authors' conclusions Clobetasol propionate cream applied over the whole body is probably similarly effective as, and may cause less mortality than, oral prednisone for treating bullous pemphigoid. Lower‐dose clobetasol propionate cream applied over the whole body is probably similarly effective as standard‐dose clobetasol propionate cream and has similar mortality. Doxycycline is less effective but causes less mortality than prednisolone for treating bullous pemphigoid. Other treatments need further investigation. Plain language summary Treatments for bullous pemphigoid Which treatments work best for bullous pemphigoid (a rare, itchy skin disease that causes blisters)? Key messages • A cream, containing topical steroid clobetasol propionate, applied on the entire skin surface is as effective as oral steroids (prednisone), causes less severe unwanted or harmful effects, and may decrease deaths. • Initiating treatment with doxycycline (200 mg/day), an antibiotic with anti‐inflammatory effect, leads to an acceptable short‐term blister control compared to the oral steroid prednisolone (0.5 mg/kg/day), and is superior in long‐term safety aspects, including deaths. What is bullous pemphigoid? Bullous pemphigoid is the most common autoimmune blistering disease. In autoimmune diseases, the body's immune system mistakes its own tissues as foreign and attacks them. In bullous pemphigoid, this causes blisters on the skin. Bullous pemphigoid usually occurs in the elderly, but may also affect younger people. How is bullous pemphigoid treated? Until recently, the leading treatment for bullous pemphigoid was oral steroids which suppress inflammation and the body's own immune system. However, given over a long period of time, oral steroids will cause severe adverse (i.e. harmful) effects. This review assessed studies which investigated the effectiveness of other treatment options for bullous pemphigoid; for example, a steroid cream applied on the skin and the anti‐inflammatory antibiotic medicine, doxycycline. What did we want to find out? We wanted to find out which treatments work best for bullous pemphigoid with respect to the healing of blisters (efficacy) and reduction in adverse effects, such as death. What did we do? We searched for studies that looked at treatments for bullous pemphigoid. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 14 studies including 1442 people with bullous pemphigoid. The main treatments assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Other treatments tested were oral (i.e. taken by mouth) immunosuppressives (medicines that keep your immune system in check) and immunoglobulins (also called antibodies. Antibodies are proteins that your immune system makes to fight germs, for example). ‐ Topical steroid cream, clobetasol propionate, applied over the whole body (40 grams of cream applied per day, with the amount decreased over 12 months) is an effective and safe treatment for bullous pemphigoid. ‐ Treatment with a lower amount of clobetasol propionate cream (10 to 30 grams per day, decreased over 4 months) is equally effective and safe. ‐ Prednisolone, an oral corticosteroid, in the dose of 0.5 mg/kg/day, may be adequate to control disease in most people and reduces adverse effects compared to higher doses of oral corticosteroid. ‐ Initiating treatment with 200 mg/day of doxycycline leads to acceptable blister control compared to oral prednisolone (0.5 mg/kg/day) and is safer. ‐ A study with 20 participants suggests that nicotinamide (a form of vitamin B 3 )and tetracycline (an antibiotic used to treat a wide variety of infections) may be an effective alternative to prednisone and may decrease treatment‐associated death. ‐ Adding azathioprine, a drug which suppresses the immune system, to an oral corticosteroid does not improve disease control; it may lead to a reduced need for oral corticosteroid. ‐ Further research is needed to fully understand the effectiveness of alternatives to oral steroids (such as dapsone or immunoglobulins), as well as the effectiveness of giving other medicines alongside an oral steroid. What are the limitations of the evidence? Except for the studies on topical clobetasol cream and doxycycline, the studies included relatively few participants. The methodological quality of these studies was further limited because of unclear methods of allocating people to different treatment groups; lack of masking (participants and researchers knew which treatments were given to which people, which are not good conditions for fair assessment); and the exclusion of people who dropped out of the studies from treatment analysis. We are confident about the efficacy of initiating treatment with doxycycline and moderately confident about the efficacy of topical clobetasol cream for the treatment of bullous pemphigoid. How up to date is this evidence? The evidence is current to 11 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Singh, S; Kirtschig, G; Anchan, VN; Chi, C-C; Taghipour, K; Boyle, RJ; Murrell, DF", "articleTypes": [], "doi": "10.1002/14651858.CD002292.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "2926003d-bbca-4d58-bcc1-62c5e1e1d18e", "pmid": "", "title": "Adverse events in people taking macrolide antibiotics versus placebo for any indication", "imported": false, "abstract": "Abstract - Background Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment‐specific, rather than disease‐specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases. Objectives To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides. Selection criteria We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups. Data collection and analysis Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide‐resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta‐analysis when three or more included studies reported a specific adverse event. Main results We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events or at least stated that no adverse events were observed. Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low‐quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low‐quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate‐quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate‐quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate‐quality evidence) were also reported more often in participants taking macrolides compared to placebo. The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000. The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting. There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration. Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low‐quality evidence). Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low‐quality evidence). We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low‐quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low‐quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low‐quality evidence) compared to placebo. We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo. Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate‐quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate‐quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate‐quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non‐significant. There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low‐quality evidence). Only 24 studies (13%) provided useful data on macrolide‐resistant bacteria. Macrolide‐resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent. Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials. Authors' conclusions The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as \"none were observed\". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance. Plain language summary Adverse events in people taking macrolide antibiotics Review question We wanted to find out if people treated with a macrolide antibiotic experienced more adverse events than those treated with placebo. Background Macrolide antibiotics are a group of antibiotics that are commonly used to treat both acute and chronic infections. The four most frequently used macrolides are: azithromycin, clarithromycin, erythromycin, and roxithromycin. People taking macrolide antibiotics are at risk of experiencing adverse events such as nausea, diarrhoea, or rash. Search date We searched the literature up to May 2018. Study characteristics We included 183 studies with a total of 252,886 participants. Most studies were conducted in the hospital setting. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events, or at least stated that no adverse events were observed. Study funding sources Drug companies supplied trial medications or funding, or both, in 91 studies. Funding sources were unclear in 59 studies. Key results People treated with a macrolide antibiotic experienced gastrointestinal adverse events such as nausea, vomiting, abdominal pain, and diarrhoea more often than those treated with placebo. Taste disturbances were reported more often by people taking macrolides than those taking a placebo. However, as very few studies reported on these adverse events, these results should be interpreted with caution. Hearing loss was reported more often by people taking macrolide antibiotics, however only four studies reported this outcome. Macrolides caused less cough and fewer respiratory tract infections than placebo. We did not find any evidence that macrolides caused more cardiac disorders, liver disorders, blood infections, skin and soft tissue infections, changes in liver enzymes, appetite loss, dizziness, headache, respiratory symptoms, itching, or rashes than placebo. We did not find more deaths in people treated with macrolides than in those treated with placebo. Very limited information was available to assess if people treated with a macrolide antibiotic were at greater risk of developing resistant bacteria than those treated with placebo. However, bacteria that did not respond to macrolide antibiotics were more commonly identified immediately after treatment in people taking a macrolide than in those taking a placebo, but differences in resistance thereafter were inconsistent. Quality of the evidence The quality of the evidence ranged from very low (cardiac disorders, change in liver enzymes, liver disorders) to low (abdominal pain, death, diarrhoea, dizziness, hearing loss, skin and soft tissue infections, taste disturbance, wheeze) to moderate (appetite loss, blood infection, cough, fever, headache, itching, nausea, rash, respiratory symptoms, respiratory tract infections, vomiting).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hansen, MP; Scott, AM; McCullough, A; Thorning, S; Aronson, JK; Beller, EM; Glasziou, PP; Hoffmann, TC; Clark, J; Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD011825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "2952f797-ffce-49a8-af86-58854d257616", "pmid": "", "title": "Green tea for weight loss and weight maintenance in overweight or obese adults", "imported": false, "abstract": "Abstract - Background Preparations of green tea are used as aids in weight loss and weight maintenance. Catechins and caffeine, both contained in green tea, are each believed to have a role in increasing energy metabolism, which may lead to weight loss. A number of randomised controlled trials (RCTs) evaluating the role of green tea in weight loss have been published; however, the efficacy of green tea preparations in weight loss remains unclear. Objectives To assess the efficacy and safety of green tea preparations for weight loss and weight maintenance in overweight or obese adults. Search methods We searched the following databases from inception to specified date as well as reference lists of relevant articles: The Cochrane Library (Issue 12, 2011), MEDLINE (December 2011), EMBASE (December 2011), CINAHL (January 2012), AMED (January 2012), Biological Abstracts (January 2012), IBIDS (August 2010), Obesity+ (January 2012), IPA (January 2012) and Web of Science (December 2011). Current Controlled Trials with links to other databases of ongoing trials was also searched. Selection criteria RCTs of at least 12 weeks' duration comparing green tea preparations to a control in overweight or obese adults. Data collection and analysis Three authors independently extracted data, assessed studies for risk of bias and quality, with differences resolved by consensus. Heterogeneity of included studies was assessed visually using forest plots and quantified using the I 2 statistic. We synthesised data using meta‐analysis and descriptive analysis as appropriate; subgroup and sensitivity analyses were conducted. Adverse effects reported in studies were recorded. Main results Due to the level of heterogeneity among studies, studies were divided into two groups; those conducted in Japan and those conducted outside Japan. Study length ranged between 12 and 13 weeks. Meta‐analysis of six studies conducted outside Japan showed a mean difference (MD) in weight loss of ‐0.04 kg (95% CI ‐0.5 to 0.4; P = 0.88; I 2 = 18%; 532 participants). The eight studies conducted in Japan were not similar enough to allow pooling of results and MD in weight loss ranged from ‐0.2 kg to ‐3.5 kg (1030 participants) in favour of green tea preparations. Meta‐analysis of studies measuring change in body mass index (BMI) conducted outside Japan showed a MD in BMI of ‐0.2 kg/m 2 (95% CI ‐0.5 to 0.1; P = 0.21; I 2 = 38%; 222 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed a reduction in BMI ranging from no effect to ‐1.3 kg/m 2 (1030 participants), in favour of green tea preparations over control. Meta‐analysis of five studies conducted outside Japan and measuring waist circumference reported a MD of ‐0.2 cm (95% CI ‐1.4 to 0.9; P = 0.70; I 2 = 58%; 404 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed effects on waist circumference ranging from a gain of 1 cm to a loss of 3.3 cm (1030 participants). Meta‐analysis for three weight loss studies, conducted outside Japan, with waist‐to‐hip ratio data (144 participants) yielded no significant change (MD 0; 95% CI ‐0.02 to 0.01). Analysis of two studies conducted to determine if green tea could help to maintain weight after a period of weight loss (184 participants) showed a change in weight loss of 0.6 to ‐1.6 kg, a change in BMI from 0.2 to ‐0.5 kg/m 2 and a change in waist circumference from 0.3 to ‐1.7 cm. In the eight studies that recorded adverse events, four reported adverse events that were mild to moderate, with the exception of two (green tea preparations group) that required hospitalisation (reported as not associated with the intervention). Nine studies reported on compliance/adherence, one study assessed attitude towards eating as part of the health‐related quality of life outcome. No studies reported on patient satisfaction, morbidity or cost. Authors' conclusions Green tea preparations appear to induce a small, statistically non‐significant weight loss in overweight or obese adults. Because the amount of weight loss is small, it is not likely to be clinically important. Green tea had no significant effect on the maintenance of weight loss. Of those studies recording information on adverse events, only two identified an adverse event requiring hospitalisation. The remaining adverse events were judged to be mild to moderate. Plain language summary Green tea for weight loss and weight maintenance in overweight or obese adults Green tea has a long history of many uses, one of which is helping overweight people to lose weight and to maintain weight loss. Believed to be able to increase a person's energy output, green tea weight loss preparations are extracts of green tea that contain a higher concentration of ingredients (catechins and caffeine) than the typical green tea beverage prepared from a tea bag and boiling water. This review looked at 15 weight loss studies and three studies measuring weight maintenance where some form of a green tea preparation was given to one group and results compared to a group receiving a control. Neither group knew whether they were receiving the green tea preparation or the control. A total of 1945 participants completed the studies, ranging in length from 12 to 13 weeks. In summary, the loss in weight in adults who had taken a green tea preparation was statistically not significant, was very small and is not likely to be clinically important. Similar results were found in studies that used other ways to measure loss in weight (body mass index, waist circumference). Studies examining the effect of green tea preparations on weight maintenance did not show any benefit compared to the use of a control preparation. Most adverse effects, such as nausea, constipation, abdominal discomfort and increased blood pressure, were judged to be mild to moderate and to be unrelated to the green tea or control intervention. No deaths were reported, although adverse events required hospitalisation. One study attempted to look at health‐related quality of life by asking participants about their attitudes towards eating. Nine studies tracked participants' compliance with green tea preparations. Studies did not include any information about the effects of green tea preparations on morbidity, costs or patient satisfaction.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Jurgens, TM, Whelan, AM, Killian, L, Doucette, S, Kirk, S, Foy, E", "articleTypes": [], "doi": "10.1002/14651858.CD008650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.789Z" }, { "id": "2958fe04-a8f0-4236-a214-610a4782b5b0", "pmid": "", "title": "Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Nedocromil sodium and sodium cromoglycate inhaled shortly before exercise appear to reduce the severity of exercise‐induced bronchoconstriction. There is some debate over which drug may be more effective. Objectives The objective of this review was to compare the effects on post‐exercise lung function between prophylactic doses of nedocromil sodium (NSG) and sodium cromoglycate (SCG) in persons diagnosed with exercise‐induced bronchoconstriction. Search methods Randomized controlled trials were identified from the Cochrane Airways Review Group Asthma Register. Bibliographies of relevant studies and review articles were searched and primary authors, content experts and manufacturers of drugs were contacted for additional relevant studies. No language restrictions were applied. Searches were current as of December 2007. Selection criteria Randomized controlled trials comparing NCS to SCG in prophylactic treatment of exercise‐induced bronchoconstriction were eligible. Studies were included if: the participants, aged 6 or over, had a confirmed diagnosis of asthma with exercise‐induced bronchoconstriction, were subjected to an exercise challenge sufficient to trigger bronchoconstriction, and the measures of lung function were reported as either changes in forced expiratory volume in one second or peak expiratory flow rate. Data collection and analysis Data extraction and methodological quality assessments were conducted independently by two reviewers using standard forms and validated assessment criteria. In some cases results were extrapolated from graphs. Results from similar studies were pooled and reported as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CI) using the random effects model. Main results Nine studies (162 participants) are included in this review. No significant difference was noted between NCS and SCG with respect to the maximum percent decrease in FEV1 (WMD = ‐0.88; 95% CI: ‐4.50, 2.74), complete protection (i.e. maximum % fall FEV1 still =>10%); OR = 0.95; 95% CI: 0.50 to 1.8, clinical protection (i.e. < 50% improvement over placebo); OR = 0.71; 95% CI: 0.36 to 1.39; unpleasant taste (OR = 6.85; 95% CI: 0.77, 60.73), or sore throat (OR = 3.46; 95% CI: 0.32, 37.48). For these pooled comparisons, no statistically significant heterogeneity was identified. Subgroup analyses based on age, dosage of medications and timing of exercise post‐inhalation were consistent with the overall pooled analyses. Authors' conclusions No significant differences were evident between the effect of NCS and SCG during the immediate post‐exercise period in adults and children with EIB with regards to pulmonary function ‐ specifically maximum percent decrease in FEV1, complete protection, clinical protection, or side effects. Plain language summary Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. Two drugs, nedocromil sodium (Tilade) and sodium cromoglycate are sometimes used before exercise to prevent asthma. The review of trials found that both were similarly effective in relieving exercise‐induced asthma for both children and adults. More people have sore throats and an unpleasant after‐taste after using nedocromil sodium.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Kelly, KD; Spooner, C; Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD002731", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "295a8bdd-2e0f-4c74-810a-2d859d31975d", "pmid": "", "title": "Sucrose analgesia for venepuncture in neonates", "imported": false, "abstract": "Abstract - Rationale Sucrose is, in general, safe and effective for analgesia during venepuncture in hospitalised neonates. However, there is a lack of evidence on its analgesic effects. Objectives To evaluate the benefits and harms of orally administered sucrose for pain relief from venepuncture in preterm and term neonates compared to no intervention, standard care, and other types of analgesic interventions. Search methods We searched CENTRAL, MEDLINE, Ovid Embase, and trial registries in July 2025, and the China National Knowledge Infrastructure, VIP Chinese Science and Technology Periodicals, and Wanfang Data in August 2024. We checked reference lists of included studies and topic‐related systematic reviews. Eligibility criteria We included randomised controlled trials (RCTs), including cross‐over and cluster‐RCTs, that evaluated the effects of sucrose analgesia in neonates (including term and preterm infants) up to 44 weeks' postmenstrual age undergoing venepuncture. We excluded quasi‐RCTs and studies reported only as conference abstracts. We included studies administering sucrose with or without non‐nutritive sucking (NNS) before, at the time of, or after venepuncture. Sucrose could be of any concentration, volume, or dose. Sucrose was compared to: no intervention, water, or standard care; skin‐to‐skin care; breastfeeding; feeding; NNS alone (e.g. pacifier); glucose; positioning; or topical anaesthetics. Outcomes Outcomes of interest were pain intensity score, as measured by validated pain assessment scales, and adverse events. Risk of bias We used the Cochrane risk of bias tool (RoB 1). Synthesis methods We synthesised results for each outcome using meta‐analysis where possible. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous data (presence or absence of pain). We calculated the standardised mean difference (SMD) or mean difference (MD) for pain intensity scores (continuous outcome), each with its 95% CI. We used a fixed‐effect model to combine data and quantified the impact of heterogeneity using the I² statistic. Where these methods were not feasible due to the nature of the data, we synthesised the results narratively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included a total of 29 studies, accounting for 2764 term and preterm neonates. There was a large variation in sucrose dose and concentration (from 0.1 mL/kg to 0.5 mL/kg or a set volume from 0.1 mL to 2 mL) as well as mode of administration (e.g. oral syringe, pacifier, dropper, in combination with a pacifier). Most of the studies compared sucrose to no intervention, water, or standard care (n = 17). Other comparisons include non‐nutritive sucking, skin‐to‐skin care, breastfeeding, expressed breast milk, and other sweet solutions. Synthesis of results Adverse events (e.g. gagging, apnoea) were not reported for any comparison. Sucrose (with or without NNS) versus no intervention, water, or standard care Sucrose with or without NNS probably reduces pain intensity scores during and 30 seconds after venepuncture compared to no intervention (SMD −0.82, 95% CI −1.02 to −0.63; 7 studies, 477 participants; moderate‐certainty evidence). Sucrose with NNS reduces pain intensity scores one minute after venepuncture compared to no intervention (MD −9.15, 95% CI −9.91 to −8.39; 1 study, 100 participants; high‐certainty evidence). The evidence is uncertain about the effect of sucrose without NNS on pain intensity scores two minutes after venepuncture compared to no intervention (SMD −0.99, 95% CI −1.31 to −0.68; 3 studies, 186 participants; very low‐certainty evidence). Sucrose (with or without NNS) versus skin‐to‐skin care Sucrose without NNS may make little to no difference to pain scores during venepuncture when compared to skin‐to‐skin care (MD 1.49, 95% CI 0.86 to 2.12; 2 studies, 208 participants; low‐certainty evidence). Pain scores after 30 seconds, one minute, and two minutes were not reported. Sucrose (with or without NNS) versus breastfeeding Sucrose probably reduces pain during venepuncture compared to breastfeeding, as measured with the Neonatal Facial Coding System (where 0 = no pain, > 0 = pain) (RR 1.38, 95% CI 1.01 to 1.88; 1 study, 103 participants; moderate‐certainty evidence). Sucrose may result in little to no difference in pain compared to breastfeeding two minutes after venepuncture (RR 1.06, 95% CI 0.94 to 1.19; 1 study, 104 participants; low‐certainty evidence). Pain scores after 30 seconds and one minute were not reported. Sucrose (with or without NNS) versus NNS Sucrose with NNS likely reduces pain during venepuncture compared to NNS (SMD −1.52, 95% CI −1.92 to −1.12; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS may not reduce pain intensity scores during venepuncture compared to NNS (MD 1.37, 95% CI 0.57 to 2.17; 2 studies, 133 participants; low‐certainty evidence). Sucrose with NNS may reduce pain intensity scores one minute after venepuncture compared to NNS (MD −5.81, 95% CI −6.30 to −5.32; 2 studies, 200 participants; low‐certainty evidence). Sucrose with NNS probably reduces pain intensity two minutes after venepuncture compared to NNS alone (SMD −1.30, 95% CI −1.71 to −0.89; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS (MD 0.47, 95% CI −0.14 to 1.08; 1 study, 56 participants; moderate‐certainty evidence). We downgraded the certainty of the evidence in several comparisons, mostly due to unclear or high risk of selection, performance, detection, and reporting bias. High heterogeneity was also detected. Authors' conclusions Current evidence suggests sucrose probably reduces pain scores during and shortly after venepuncture compared to no intervention, water, or standard care. The evidence is very uncertain regarding the effects of sucrose compared to skin‐to‐skin care for analgesia during venepuncture. Compared to breastfeeding, sucrose probably results in a reduction of pain scores during venepuncture, but may result in little difference in pain scores two minutes after venepuncture. The evidence suggests sucrose with NNS probably reduces pain scores during and following venepuncture compared to NNS alone. Sucrose alone probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS. Funding This review had no dedicated funding. Registration Protocol available via doi/10.1002/14651858.CD015221 Plain language summary Does giving newborns sugar water during needle procedures reduce their pain? Key messages Newborn babies given sucrose (sugar water) when undergoing a needle procedure probably have less pain during and shortly after the procedure than babies given nothing, water, or standard comfort measures. Sucrose seems to reduce pain more than pacifiers. We do not have good evidence about the effect of sucrose compared to skin‐to‐skin care. No studies reported on harmful side effects, such as gagging or apnoea (a temporary pause in breathing). What is sucrose analgesia (pain relief)? Sucrose is table sugar. When mixed with water, and in very small amounts, it can be used for pain relief in newborn babies. Sucrose is dropped on a baby's tongue about two minutes before and/or immediately before venepuncture, when a needle is put into a vein to take blood or give treatment. Why is pain relief important for newborn babies who are in hospital? Hospitalised preterm babies (i.e. born early) and term babies (i.e. born at the normal time) are exposed to many painful procedures to give them medicine and to diagnose problems. Pain has many consequences for newborn babies. It can contribute to poor physical growth and affect brain development. Therefore, it is important to reduce babies' experience of pain as much as possible to ensure health as they grow. What did we want to find out? We wanted to find out how well sucrose worked to relieve pain in newborn babies during and shortly after needle punctures. We wanted to know how sucrose compared to other pain relief methods such as pacifier sucking, breastfeeding, or being held next to a mother or father's skin (skin‐to‐skin care). We also wanted to find out if sucrose caused negative effects. What did we do? We searched for studies that investigated the pain‐relief effects of sucrose compared to other methods (e.g. breastfeeding, pacifiers, holding). We summarised the results and rated our confidence in the evidence based on factors such as the number of infants treated and the quality of the methods used in the studies. What did we find? We found 29 studies that included 2764 newborn babies. The studies used different doses of sucrose and gave the sucrose to the babies in different ways. The studies were conducted worldwide. Most were carried out in Asia, with additional studies from Europe, North America, and South America. All the studies were randomised controlled trials, in which infants were assigned randomly to two or more treatment groups. This is the best way to ensure that the infant groups are similar, and that investigators and parents don’t know who is in which group. None of the studies were supported by the pharmaceutical industry. Main results Sucrose probably reduces babies' pain during and shortly after (30 seconds to 1 minute) the needle insertion compared to no pain relief (such as water). Sucrose may make little to no difference to pain during the procedure compared to skin‐to‐skin care. Sucrose probably reduces pain during the needle insertion compared to breastfeeding. Sucrose (with pacifier sucking) likely reduces pain during and shortly after (30 seconds to 2 minutes) the needle insertion compared to pacifier sucking alone. No study reported on harmful effects for any of our comparisons of interest. What are the limitations of the evidence? Sucrose versus no intervention or water We are moderately confident that sucrose probably reduces pain compared to no intervention. However, it is possible that people in the studies were aware of which treatment babies were receiving, and the studies involved small numbers of babies. Sucrose versus skin‐to‐skin care We are not confident that sucrose reduces pain more than skin‐to‐skin care because the two studies reported very different results. Further research is likely to change these results. Sucrose versus breastfeeding We are moderately confident that sucrose probably reduces pain more than breastfeeding. However, the study did not clearly report details of how it was conducted. Sucrose versus pacifier We are moderately confident that sucrose with a pacifier probably reduces pain more than pacifiers alone. The studies differed in how sucrose was given, including the amount of sucrose, how it was administered, and whether it was given with or without a pacifier. How current is this evidence? This evidence is current to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Bueno, M, Candido, L, Hu, J, Fiander, M, Cracknell, J, Xu, E, Kang, J, Yamada, J", "articleTypes": [], "doi": "10.1002/14651858.CD015221.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.069Z" }, { "id": "297b4496-db82-4992-bf3a-1ea6055ffccf", "pmid": "", "title": "Ibuprofen, a Phenylpropanoic Acid Nonsteroidal Anti-inflammatory Drug, Inhibits Human Sweet Taste and Glucose Detection", "imported": false, "abstract": "The sweet taste receptor, TAS1R2-TAS1R3, is expressed both orally, where it signals sweet taste, and extraorally in the intestine and pancreas, where it may affect glucose absorption and metabolism. Recently, ibuprofen and naproxen have been identified to inhibit human T1R3 when heterologously expressed in cells. In the present study, the initial objective was to determine if ibuprofen and naproxen inhibit interactions of sugars with human sweet taste receptor under normal, physiological conditions. Ten healthy participants were asked to rate sweetness intensity for a range of sweet stimuli (sucrose, fructose, sucralose) after a prerinse of ibuprofen, naproxen or water. Both ibuprofen and naproxen inhibited sweet taste intensity in a dose-dependent manner. In association studies, ibuprofen use has been linked to preserved metabolic function, as its use is correlated with lower rates of Alzheimer's disease, diabetes and colon cancer. Here the investigators present a potential novel pathway for systemic ibuprofen to impact these metabolic diseases.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "297e41f5-11d0-4e54-93d8-10f8e45c9a19", "pmid": "", "title": "Adhesives for fixed orthodontic bands", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Millett, DT, Glenny, AM, Mattick, RCR, Hickman, J, Mandall, NA", "articleTypes": [], "doi": "10.1002/14651858.CD004485.pub4 AB - Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. It has been shown that the quality of treatment result obtained with fixed appliances is much better than with removable appliances. Fixed appliances are, therefore, favoured by most orthodontists for treatment. The success of a fixed orthodontic appliance depends on the metal attachments (brackets and bands) being attached securely to the teeth so that they do not become loose during treatment. Brackets are usually attached to the front and side teeth, whereas bands (metal rings that go round the teeth) are more commonly used on the back teeth (molars). A number of adhesives are available to attach bands to teeth and it is important to understand which group of adhesives bond most reliably, as well as reducing or preventing dental decay during the treatment period. Objectives To evaluate the effectiveness of the adhesives used to attach bands to teeth during fixed appliance treatment, in terms of:
 (1) how often the bands come off during treatment; and
 (2) whether they protect the banded teeth against decay during fixed appliance treatment. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (searched 2 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 2 June 2016), MEDLINE Ovid (1946 to 2 June 2016) and EMBASE Ovid (1980 to 2 June 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised and controlled clinical trials (RCTs and CCTs) (including split‐mouth studies) of adhesives used to attach orthodontic bands to molar teeth were selected. Patients with full arch fixed orthodontic appliance(s) who had bands attached to molars were included. Data collection and analysis All review authors were involved in study selection, validity assessment and data extraction without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Five RCTs and three CCTs were identified as meeting the review's inclusion criteria. All the included trials were of split‐mouth design. Four trials compared chemically cured zinc phosphate and chemically cured glass ionomer; three trials compared chemically cured glass ionomer cement with light cured compomer; one trial compared chemically cured glass ionomer with a chemically cured glass phosphonate. Data analysis was often inappropriate within the studies meeting the inclusion criteria. Authors' conclusions There is insufficient high quality evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth. Further RCTs are required. Plain language summary Adhesives for fixed orthodontic bands There is insufficient evidence to determine the most effective adhesive for attaching orthodontic bands to molar teeth in patients with full arch fixed orthodontic appliances.
 Orthodontic treatment involves using fixed or removable appliances (braces) on teeth to correct their position. It has been shown that the quality of treatment result obtained with fixed dental appliances is much better than with removable appliances. The success of a fixed dental appliance depends on the metal attachments (brackets and bands) being securely attached to the teeth so that they do not become loose during treatment. Brackets are usually attached to teeth other than molars, where bands (metal rings that go round the teeth) are more commonly used. There is insufficient evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.068Z" }, { "id": "29967989-4674-43f3-9d72-37f6c4df0a8f", "pmid": "", "title": "CFTR modulator monotherapy for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a common, life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR gene variant, F508del, is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF) in some populations). The F508del variant lacks meaningful CFTR function: the faulty protein is degraded before reaching the cell membrane, where it would normally transport salt across the epithelial membrane. Corrective therapy with CFTR modulators could benefit many pwCF. This review evaluates treatment with single modulators (monotherapy). Objectives To evaluate the clinically important benefits and harms of CFTR modulator monotherapy in people of any age with cystic fibrosis with class II CFTR gene variants (most commonly F508del). Search methods We last searched the Cochrane CF Trials Register and online trials registries on 27 June 2025. We also checked the reference lists of relevant articles for additional studies. Eligibility criteria We included parallel‐group randomised controlled trials (RCTs) comparing any single CFTR modulator to placebo or any other single CFTR modulator in pwCF of any age or disease severity with class II variants. Outcomes Our critical outcomes were survival, quality of life (total score and respiratory domain), and forced expiratory volume in one second (FEV 1 % predicted; relative and absolute change from baseline). Our important outcomes included adverse effects and time to first pulmonary exacerbation. We planned to assess outcomes in the immediate term, short term, and longer term. Risk of bias We assessed risk of bias using the original Cochrane tool (RoB 1). Synthesis methods We analysed available data with RevMan using a fixed‐effect model. We reported odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. For adverse events, we reported 99% confidence intervals (CIs); for all other outcomes, we reported 95% CIs. Where we were unable to analyse data, we reported the results narratively. We used GRADE to assess the certainty of the evidence. Included studies We included 10 early‐phase placebo‐controlled RCTs (424 participants) assessing eight different drugs (4PBA, CPX, N6022, cavosonstat, lumacaftor, FDL169, GLPG2222, and riociguat) in adults; one 4PBA study additionally included adolescents (age ≥ 14 years). All participants were homozygous for F508del. The longest study lasted just 29 days, so we could only assess immediate‐term outcomes. Only two studies received no funding from pharmaceutical companies. Our main results are for lumacaftor and cavosonstat, which were the only drugs selected for further investigation in subsequent studies. Synthesis of results Investigators reported no deaths, but also no clinically relevant improvements in quality of life. There was insufficient evidence to determine effects on any measure of lung function. No studies demonstrated differences in the risk of mild, moderate, or severe adverse effects, including pulmonary exacerbations, between CFTR modulator monotherapy and placebo. The clinical relevance of adverse effects is difficult to assess, because each occurred in only a few participants per trial. We assessed the certainty of the evidence for two comparisons (lumacaftor versus placebo and cavosonstat versus placebo), rating the certainty of the evidence to be very low. Authors' conclusions There is a lack of evidence to support monotherapy with a CFTR modulator for pwCF who have two F508del variants (F508del/F508del). Funding This review was completed under a programme of work that is part of the CF Foundation grant funding for Cochrane CF. Registration The protocol was registered on PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/view/CRD420251090914 ). Plain language summary Can single‐medicine treatment with CFTR modulators (medicines that correct the faulty protein in cystic fibrosis) help people who have specific genetic variants of cystic fibrosis (most commonly F508del)? Key messages All the studies only included people with two copies of the most common cystic fibrosis‐causing gene variant (F508del). Most studies were entirely or partly funded by medicine companies. No studies reported any deaths. None of the single medicines we looked at were clearly better than placebo (dummy treatment) for improving quality of life or lung function, and there was no evidence of the medicines causing more harm than placebo. However, we are unsure about these results. The evidence for using a single CFTR modulator is weak, and future research is likely to focus on combination therapies. What is cystic fibrosis and how can it be treated? Cystic fibrosis is a serious inherited illness that shortens life. It damages many organs in the body, particularly the lungs, pancreas, and liver. In the lungs, it causes a build‐up of thick, sticky mucus that leads to repeated infections and progressive damage. Most people with cystic fibrosis experience breathing difficulties, poor nutrition, and a reduced quality of life. Cystic fibrosis is caused by a fault in a gene that makes a protein called CFTR. CFTR regulates the movement of salt and water across cell surfaces, keeping the mucus thin and slippery. The most common CFTR gene variant (found in over 80% of people with cystic fibrosis) is F508del, which is a class II variant. People with two copies of F508del usually have more severe disease than people with one copy. In people with class II variants, the CFTR protein is degraded and cannot move properly through the cell. Laboratory experiments suggest that if the protein reaches the cell wall, it may be able to function, restore salt movement, and correct the chronic problems people with cystic fibrosis experience. CFTR modulators are medicines that help the faulty CFTR protein reach the cell wall. What did we want to find out? We wanted to know if CFTR modulator monotherapy (single‐medicine treatment) can help people of any age with cystic fibrosis who have a class II variant. Specifically, we wanted to know if these medicines can improve survival, quality of life, lung function, and time to the first worsening of lung symptoms. We also wanted to know if this treatment is associated with any unwanted effects. What did we do? We searched for studies that investigated the effects of any single CFTR modulator compared with placebo (dummy treatment) or any other single CFTR modulator in people with cystic fibrosis who had at least one copy of a class II variant. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 10 studies (with 424 participants, all of whom had two copies of F508del) assessing eight different medicines given as monotherapy. Nine studies included only adults, and one study included people from age 14 years. All the studies were small (including between 18 and 89 participants) and lasted between one day and 29 days. They took place in North America (mainly the USA), Europe, and Australia. Our main findings are for two of the eight medicines, lumacaftor and cavosonstat, which have gone on to be evaluated in larger populations. Main findings No studies reported any deaths or meaningful improvements in quality of life. We did not find enough evidence to show any effect of CFTR modulators on lung function. The studies reported a wide range of unwanted effects, but each occurred in only a few participants per study. We did not find enough evidence to support using CFTR modulator monotherapy in people with cystic fibrosis who have two copies of F508del. What are the limitations of the evidence? We are not confident in the evidence, for the following reasons. The studies were small. Most results are based on evidence from a single study. The evidence is not applicable to children. Not all studies provided enough data for us to analyse the results. The evidence related to unwanted effects of treatment was based on very few events. How up‐to‐date is this evidence? This review updates our earlier review of single‐ and multiple‐medicine therapy. The evidence is current to 27 June 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Heneghan, M, Smith, S, Jahnke, N, Nevitt, S, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD016290", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.124Z" }, { "id": "29a4b198-5c94-4764-92a6-93d52e9a5b7a", "pmid": "", "title": "Glutamine for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Crohn's disease is a chronic relapsing condition of the alimentary tract with a high morbidity secondary to bowel inflammation. Glutamine plays a key role in maintaining the integrity of the intestinal mucosa and has been shown to reduce inflammation and disease activity in experimental models of Crohn's disease. Objectives To evaluate the efficacy and safety of glutamine supplementation for induction of remission in Crohn's disease. Search methods We searched the following databases from inception to November 15, 2015: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane IBD Group Specialised Register. Study references were also searched for additional trials. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) that compared glutamine supplementation administered by any route to a placebo, active comparator or no intervention in people with active Crohn's disease were considered for inclusion. Data collection and analysis Two authors independently extracted data and assessed the methodological quality of the included studies. The Cochrane risk of bias tool was used to assess methodological quality. The primary outcome measure was clinical or endoscopic remission. Secondary outcomes included intestinal permeability, clinical response, quality of life, growth in children and adverse events. Risk ratios and 95% confidence intervals were calculated for dichotomous outcomes. The overall quality of the evidence supporting the primary outcome was evaluated using the GRADE criteria. Main results Two small RCTs (total 42 patients) met the inclusion criteria and were included in the review. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. The other study (24 patients) compared glutamine‐supplemented total parenteral nutrition to non‐supplemented total parenteral nutrition in adult patients (> 18 years of age) with acute exacerbation of inflammatory bowel disease. The paediatric study was rated as low risk of bias. The study in adult patients was rated as unclear risk of bias for blinding and low risk of bias for all other items. It was not possible to pool data for meta‐analysis because of significant differences in study populations, nature of interventions, and the way outcomes were assessed. Data from one study showed no statistically significant difference in clinical remission rates at four weeks. Forty‐four per cent (4/9) of patients who received a glutamine‐enriched polymeric diet achieved remission compared to 56% (5/9) of patients who received a standard low‐glutamine polymeric diet (RR 0.80, 95% CI 0.31 to 2.04). A GRADE analysis indicated that the overall quality of evidence for this outcome was low due to serious imprecision (9 events). In both included studies, no statistically significant changes in intestinal permeability were found between patients who received glutamine supplementation and those who did not. Neither study reported on clinical response, quality of life or growth in children. Adverse event data were not well documented. There were no serious adverse events in the paediatric study. The study in adult patients reported three central catheter infections with positive blood cultures in the glutamine group compared to none in the control group (RR 7.00, 95% CI 0.40 to 122.44). Authors' conclusions Currently there is insufficient evidence to allow firm conclusions regarding the efficacy and safety of glutamine for induction of remission in Crohn's disease. Data from two small studies suggest that glutamine supplementation may not be beneficial in active Crohn's disease but these results need to be interpreted with caution as they are based on small numbers of patients. This review highlights the need for adequately powered randomised controlled trials to investigate the efficacy and safety of glutamine for induction of remission in Crohn's disease. Plain language summary Glutamine for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disorder of the intestines which has periods of inactivity and periods when it flares up. Crohn's disease can affect any part of the digestive tract, from the mouth to the anus. The most common symptoms of the disease include abdominal pain, non‐bloody diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms of the disease it is said to be ‘active’; periods when the symptoms stop are called ‘remission’. What is glutamine? Glutamine is an amino acid that plays a key role in maintaining the integrity of the intestinal mucosa (lining of the intestines) and has been shown to reduce inflammation and disease activity in animal models of Crohn's disease. It has therefore been suggested that glutamine may reduce intestinal inflammation in people with Crohn's disease. What did the researchers investigate? The researchers investigated whether glutamine is effective for inducing remission in people with active Crohn's disease and whether this treatment causes any harms (side effects). The researchers searched the medical literature up to November 15, 2015. What did the researchers find? The researchers identified two randomised controlled trials (total 42 participants) that investigated the role of glutamine for the treatment of active Crohn's disease. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. Participants were encouraged to consume the diet orally. If this was not possible the diet was administered via a fine‐bore nasogastric tube. The other study (24 participants) compared glutamine‐supplemented total parenteral nutrition (TPN) to non‐supplemented TPN in adult patients (> 18 years of age) with sudden worsening of inflammatory bowel disease. The TPN diet was administered intravenously via a central catheter (a thin tube) for at least one week. Both studies were generally high quality. Neither study demonstrated any beneficial effects for glutamine. Side effects were not well documented in the two studies. There were no serious side effects noted in the paediatric study. The study in adult patients reported three central catheter‐related blood infections in the glutamine group compared to none in the non‐glutamine control group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and harms of glutamine for the treatment of active Crohn's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Akobeng, AK; Elawad, M; Gordon, M", "articleTypes": [], "doi": "10.1002/14651858.CD007348.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "29af6ce6-232a-4f14-a3c5-6e5e71c03e25", "pmid": "", "title": "Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Rationale Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Alendronate belongs to the bisphosphonate class of drugs, which inhibit bone resorption by interfering with the activity of osteoclasts (bone cells that break down bone tissue). This is an update of a Cochrane review first published in 2008. Objectives To assess the benefits and harms of alendronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched Evidence‐Based Medicine Reviews (which includes CENTRAL), MEDLINE, Embase, two trial registers, drug approval agency websites, and the bibliographies of relevant systematic reviews to identify the studies included in this review. The latest search date was 01 February 2023. We imposed no restrictions on language, date, form of publication, or reported outcomes. Eligibility criteria We included only randomized controlled trials that assessed the effects of alendronate on postmenopausal women. Targeted participants must have received at least one year of alendronate. We classified a study as secondary prevention if its population met one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (‐2.5 or lower), and 75 years old or older. If a study population met none of those criteria, we classified it as a primary prevention study. Outcomes Our major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. Risk of bias We used the Cochrane risk of bias 1 tool. Synthesis methods We used standard methodological procedures expected by Cochrane. Based on the previous review experience, in which the clinical and methodological characteristics in the primary and secondary prevention studies were homogeneous, we used a fixed‐effect model for meta‐analysis and estimated effects using the risk ratio (RR) for dichotomous outcomes. Our base case analyses included all eligible placebo‐controlled studies with usable data. We selected the data available for the longest treatment period. We consider a relative change exceeding 15% as clinically important. Included studies We included 119 studies, of which 102 studies provided data for quantitative synthesis. Of these, we classified 34 studies (15,188 participants) as primary prevention and 68 studies (29,577 participants) as secondary prevention. We had concerns about risks of bias in most studies. Selection bias was the most frequently overlooked domain, with only 20 studies (19%) describing appropriate methods for both sequence generation and allocation concealment. Eight studies (8%) were at low risk of bias in all seven domains. Synthesis of results The base case analyses included 16 primary prevention studies (one to five years in length; 10,057 women) and 20 secondary prevention studies (one to three years in length; 7375 women) which compared alendronate 10 mg/day (or 70 mg/week) to placebo, no treatment, or both. Indirectness, imprecision, and risk of bias emerged as the main factors contributing to the downgrading of the certainty of the evidence. For primary prevention, alendronate may lead to a clinically important reduction in clinical vertebral fractures (16/1190 in the alendronate group versus 24/926 in the placebo group; RR 0.45, 95% confidence interval [CI] 0.25 to 0.84; absolute risk reduction [ARR] 1.4% fewer, 95% CI 1.9% fewer to 0.4% fewer; low‐certainty evidence) and non‐vertebral fractures (RR 0.83, 95% CI 0.72 to 0.97; ARR 1.6% fewer, 95% CI 2.6% fewer to 0.3% fewer; low‐certainty evidence). However, clinically important differences were not observed for the following outcomes: hip fractures (RR 0.76, 95% CI 0.43 to 1.32; ARR 0.2% fewer, 95% CI 0.4% fewer to 0.2% more; low‐certainty evidence); wrist fractures (RR 1.12, 95% CI 0.84 to 1.49; ARR 0.3% more, 95% CI 0.4% fewer to 1.1% more; low‐certainty evidence); withdrawals due to adverse events (RR 1.03, 95% CI 0.89 to 1.18; ARR 0.2% more, 95% CI 0.9% fewer to 1.5% more; low‐certainty evidence); and serious adverse events (RR 1.08, 95% CI 0.82 to 1.43; ARR 0.5% more, 95% CI 1.2% fewer to 2.8% more; low‐certainty evidence). For secondary prevention, alendronate probably results in a clinically important reduction in clinical vertebral fractures (24/1114 in the alendronate group versus 51/1055 in the placebo group; RR 0.45, 95% CI 0.28 to 0.73; ARR 2.7% fewer, 95% CI 3.5% fewer to 1.3% fewer; moderate‐certainty evidence). It may lead to a clinically important reduction in non‐vertebral fractures (RR 0.80, 95% CI 0.64 to 0.99; ARR 2.8% fewer, 95% CI 5.1% fewer to 0.1% fewer; low‐certainty evidence); hip fractures (RR 0.49, 95% CI 0.25 to 0.96; ARR 1.0% fewer, 95% CI 1.5% fewer to 0.1% fewer; low‐certainty evidence); wrist fractures (RR 0.54, 95% CI 0.33 to 0.90; ARR 1.8% fewer, 95% CI 2.6% fewer to 0.4% fewer; low‐certainty evidence); and serious adverse events (RR 0.75, 95% CI 0.59 to 0.96; ARR 3.5% fewer, 95% CI 5.8% fewer to 0.6% fewer; low‐certainty evidence). However, the effects of alendronate for withdrawals due to adverse events are uncertain (RR 0.95, 95% CI 0.78 to 1.16; ARR 0.4% fewer, 95% CI 1.7% fewer to 1.3% more; very low‐certainty evidence). Furthermore, the updated evidence for the safety risks of alendronate suggests that, irrespective of participants' risk of fracture, alendronate may lead to little or no difference for gastrointestinal adverse events. Zero incidents of osteonecrosis of the jaw and atypical femoral fracture were observed. Authors' conclusions For primary prevention, compared to placebo, alendronate 10 mg/day may reduce clinical vertebral and non‐vertebral fractures, but it might make little or no difference to hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. For secondary prevention, alendronate probably reduces clinical vertebral fractures, and may reduce non‐vertebral, hip, and wrist fractures, and serious adverse events, compared to placebo. The evidence is very uncertain about the effect of alendronate on withdrawals due to adverse events. Funding This Cochrane review had no dedicated funding. Registration This review is an update of the previous review (DOI: 10.1002/14651858.CD001155). Plain language summary Does alendronate help prevent fractures caused by osteoporosis in postmenopausal women? Key messages • Alendronate used for up to five years may prevent spinal fractures in women who are at lower risk for fractures, or in those who have not yet had a fracture of the spine. • Alendronate used for up to three years in women diagnosed with osteoporosis, with low bone density, or who have already had a fracture of the spine, probably prevents fractures of the spine. What is osteoporosis? Osteoporosis is a disease which makes bones weak and fragile. Bone is living tissue that is constantly being broken down and replaced. In osteoporosis, old bone breaks down faster than new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones more likely to break even after a minor injury, such as a bump or fall. Women are more likely to get osteoporosis after menopause. What is alendronate? Alendronate is a bisphosphonate, a type of medicine which slows down the cells that break down the old bone. What did we want to find out? We aimed to find out if alendronate is better than placebo (an inactive or 'dummy' medicine) or other medicines in preventing or reducing fractures in postmenopausal women. What did we do? We searched for studies that compared alendronate with placebo or other anti‐osteoporotic medicines for osteoporosis in postmenopausal women. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 119 eligible studies. Of these, 102 studies provided usable data, and 40 studies compared alendronate to placebo (dummy pill). Key findings In women who are at a lower risk for fractures because they have bone density closer to normal, or they may not yet have a fracture in the bones of their spine, alendronate used for up to five years: may prevent clinical spinal fractures – that is, fractures indicated by clinical signs and symptoms, without radiographic evidence; may prevent fractures in bones other than the spine. However, specifically in hip and wrist fractures, alendronate may make no difference; may make no difference to the number of women who withdrew from the study due to adverse events – that is, unwanted, harmful events; may make no difference to the number of women experiencing serious adverse events. In women who are at a higher risk for fractures because they have already been diagnosed with osteoporosis, have low bone density, or have already had a spinal fracture, alendronate used for up to three years: probably prevents clinical spinal fractures; may prevent fractures in bones other than the spine; may prevent hip and wrist fractures; may reduce serious adverse events; We do not know if alendronate reduces withdrawals due to adverse events in this group of women. The best estimates for women at lower fracture risk taking alendronate or placebo are as follows. For clinical spinal fractures, evidence suggests that if 3 out of 100 women taking placebo experience a fracture, only 1 out of 100 women taking alendronate will. If 10 out of 100 women on placebo have a fracture in bones other than the spine, only 8 out of 100 on alendronate are likely to. For hip and wrist fractures, there may be no difference between the two groups in the number of women experiencing fractures. The best estimates for women at higher fracture risk taking alendronate or placebo are as follows. If 5 out of 100 women on placebo have a clinical spinal fracture, only 2 out of 100 women on alendronate are likely to. If 14 out of 100 women on placebo have a fracture in bones other than the spine, only 11 out of 100 on alendronate are likely to. If 2 out of 100 women on placebo have a hip fracture, only 1 out of 100 on alendronate are likely to. If 4 out of 100 women on placebo have a wrist fracture, only 2 out of 100 on alendronate are likely to. What are the limitations of the evidence? For most findings, our confidence in the evidence was low, because it is possible that the women in the studies, and the researchers assessing outcomes, were aware of which treatment the women received. Additionally, some of the evidence focused on specific alendronate doses, whereas the question we wanted to answer was broader. Finally, for some fracture outcomes, the evidence was based on few cases. How current is the evidence? The evidence is current to 1 February 2023. This is an update of a Cochrane review originally published in 2008.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Wells, GA; Hsieh, SC; Peterson, J; Zheng, C; Kelly, SE; Shea, B; Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD001155.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "29b37e65-e16c-4fd6-ae05-249bbb726f1d", "pmid": "", "title": "Chewing gum for postoperative recovery of gastrointestinal function", "imported": false, "abstract": "Abstract - Background Ileus commonly occurs after abdominal surgery, and is associated with complications and increased length of hospital stay (LOHS). Onset of ileus is considered to be multifactorial, and a variety of preventative methods have been investigated. Chewing gum (CG) is hypothesised to reduce postoperative ileus by stimulating early recovery of gastrointestinal (GI) function, through cephalo‐vagal stimulation. There is no comprehensive review of this intervention in abdominal surgery. Objectives To examine whether chewing gum after surgery hastens the return of gastrointestinal function. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), MEDLINE (via PubMed), EMBASE (via Ovid), CINAHL (via EBSCO) and ISI Web of Science (June 2014). We hand‐searched reference lists of identified studies and previous reviews and systematic reviews, and contacted CG companies to ask for information on any studies using their products. We identified proposed and ongoing studies from clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform and meta Register of Controlled Trials. Selection criteria We included completed randomised controlled trials (RCTs) that used postoperative CG as an intervention compared to a control group. Data collection and analysis Two authors independently collected data and assessed study quality using an adapted Cochrane risk of bias (ROB) tool, and resolved disagreements by discussion. We assessed overall quality of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Studies were split into subgroups: colorectal surgery (CRS), caesarean section (CS) and other surgery (OS). We assessed the effect of CG on time to first flatus (TFF), time to bowel movement (TBM), LOHS and time to bowel sounds (TBS) through meta‐analyses using a random‐effects model. We investigated the influence of study quality, reviewers’ methodological estimations and use of Enhanced Recovery After Surgery (ERAS) programmes using sensitivity analyses. We used meta‐regression to explore if surgical site or ROB scores predicted the extent of the effect estimate of the intervention on continuous outcomes. We reported frequency of complications, and descriptions of tolerability of gum and cost. Main results We identified 81 studies that comprised 9072 participants for inclusion in our review. We categorised many studies at high or unclear risk of the bias' assessed. There was statistical evidence that use of CG reduced TFF [overall reduction of 10.4 hours (95% CI: ‐11.9, ‐8.9): 12.5 hours (95% CI: ‐17.2, ‐7.8) in CRS, 7.9 hours (95% CI: –10.0, ‐5.8) in CS, 10.6 hours (95% CI: ‐12.7, ‐8.5) in OS]. There was also statistical evidence that use of CG reduced TBM [overall reduction of 12.7 hours (95% CI: ‐14.5, ‐10.9): 18.1 hours (95% CI: ‐25.3, ‐10.9) in CRS, 9.1 hours (95% CI: ‐11.4, ‐6.7) in CS, 12.3 hours (95% CI: ‐14.9, ‐9.7) in OS]. There was statistical evidence that use of CG slightly reduced LOHS [overall reduction of 0.7 days (95% CI: ‐0.8, ‐0.5): 1.0 days in CRS (95% CI: ‐1.6, ‐0.4), 0.2 days (95% CI: ‐0.3, ‐0.1) in CS, 0.8 days (95% CI: ‐1.1, ‐0.5) in OS]. There was statistical evidence that use of CG slightly reduced TBS [overall reduction of 5.0 hours (95% CI: ‐6.4, ‐3.7): 3.21 hours (95% CI: ‐7.0, 0.6) in CRS, 4.4 hours (95% CI: ‐5.9, ‐2.8) in CS, 6.3 hours (95% CI: ‐8.7, ‐3.8) in OS]. Effect sizes were largest in CRS and smallest in CS. There was statistical evidence of heterogeneity in all analyses other than TBS in CRS. There was little difference in mortality, infection risk and readmission rate between the groups. Some studies reported reduced nausea and vomiting and other complications in the intervention group. CG was generally well‐tolerated by participants. There was little difference in cost between the groups in the two studies reporting this outcome. Sensitivity analyses by quality of studies and robustness of review estimates revealed no clinically important differences in effect estimates. Sensitivity analysis of ERAS studies showed a smaller effect size on TFF, larger effect size on TBM, and no difference between groups for LOHS. Meta‐regression analyses indicated that surgical site is associated with the extent of the effect size on LOHS (all surgical subgroups), and TFF and TBM (CS and CRS subgroups only). There was no evidence that ROB score predicted the extent of the effect size on any outcome. Neither variable explained the identified heterogeneity between studies. Authors' conclusions This review identified some evidence for the benefit of postoperative CG in improving recovery of GI function. However, the research to date has primarily focussed on CS and CRS, and largely consisted of small, poor quality trials. Many components of the ERAS programme also target ileus, therefore the benefit of CG alongside ERAS may be reduced, as we observed in this review. Therefore larger, better quality RCTS in an ERAS setting in wider surgical disciplines would be needed to improve the evidence base for use of CG after surgery. Plain language summary Chewing gum after surgery to help recovery of the digestive system Background When people have surgery on their abdomen, the digestive system can stop working for a few days. This is called ileus, and can be painful and uncomfortable. There are different causes of ileus, and several ways of treating or preventing it. One possible way of preventing ileus is by chewing gum. The idea is that chewing gum tricks the body into thinking it is eating, causing the digestive system to start working again. It is important to do this review because ileus is common: it is estimated that up to a third of people having bowel surgery suffer from ileus. Main Findings This review found 81 relevant studies that recruited over 9000 participants in total. The studies mainly focussed on people having bowel surgery or caesarean section, but there were some studies of other surgery types. There were few studies of children. Most studies were of poor quality, which may mean their results are less reliable. We found some evidence that people who chewed gum after an operation were able to pass wind and have bowel movements sooner than people who did not chew gum. We also found some evidence that people who chewed gum after an operation had bowel sounds (gurgling sounds heard using a stethoscope held to the abdomen) slightly sooner than people who did not chew gum. There was a small difference in how long people stayed in hospital between people who did or did not chew gum. There were no differences in complications (such as infection or death) between people who did or did not chew gum. There was also no difference in the overall cost of treatment between people who did or did not chew gum. Conclusions There is some evidence that chewing gum after surgery may help the digestive system to recover. However, the studies included in this review are generally of poor quality, which meant that their results may not be reliable. We also know that there are many factors affecting ileus, and that modern treatment plans attempt to reduce risk of ileus. Therefore to further explore using chewing gum after surgery, more studies would be needed which are larger, of better quality, include different types of surgery, and consider recent changes in health care systems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Short, V; Herbert, G; Perry, R; Atkinson, C; Ness, AR; Penfold, C; Thomas, S; Andersen, HK; Lewis, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD006506.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "29b98723-0f61-4b53-8db9-e1def7ec530b", "pmid": "", "title": "Venepuncture versus heel lance for blood sampling in term neonates", "imported": false, "abstract": "Abstract - Rationale Reducing procedural pain is a key priority in neonatal care, as even routine procedures for blood sampling can cause significant discomfort and pain to the neonate. This systematic review aims to compare venepuncture and heel lance for blood sampling, focusing on pain response, to guide clinical practice. Objectives To evaluate the benefits (degree of pain) and harms (need for more than one skin puncture) of venepuncture compared to heel lance in term neonates. Search methods We searched CENTRAL, MEDLINE, Embase, two trial registries and conference abstracts, and checked references of included studies and related systematic reviews up to 04 July 2025. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs that compared pain response from venepuncture versus heel lance. Neonates could receive a sweet‐tasting solution (such as glucose or sucrose), which is a commonly used analgesic in neonates for pain relief. We excluded studies that reported on pain using physiological parameters in isolation, as they are reflective of overall clinical status and non‐specific arousal. Outcomes Our outcomes of interest were pain reported using validated pain scores (measured using one or more of the following scales: Neonatal Facial Coding System, Neonatal Infant Pain scores, or the Premature Infant Pain Profile) and the need for more than one skin puncture. Risk of bias We used the Risk of bias 1 (RoB) tool to assess bias in the included RCTs. Synthesis methods We conducted a meta‐analysis where possible by calculating standardized mean difference (SMD) and risk ratio (RR) with their 95% confidence intervals (CIs) for continuous and dichotomous outcomes, respectively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included eight studies with 826 neonates. The studies were performed in six high‐, upper‐middle, or low‐income countries. Synthesis of results We judged the overall risk of bias in the eight studies to be high. Most studies had concerns related to blinding and allocation concealment. Venepuncture compared to heel lance (with no sweet‐tasting solution) Pain scores 
Venepuncture probably reduces pain compared to heel lance during the procedure when no sweet‐tasting solution is administered (SMD −1.34, 95% CI −1.55 to −1.14; I² = 94%; 6 studies, 488 participants; moderate‐certainty evidence). Need for more than one skin puncture 
Venepuncture probably reduces the need for more than one skin puncture compared to heel lance when no sweet tasting solution is administered (RR 0.63, 95% CI 0.40 to 0.97; I² = 20%; 6 studies, 397 participants; moderate‐certainty evidence) Venepuncture compared to heel lance (with sweet‐tasting solution) Pain scores 
Venepuncture may reduce pain compared to heel lance during the procedure when a sweet‐tasting solution is administered (SMD −0.38, 95% CI −0.69 to −0.07; I² = 79%; 3 studies, 170 participants; low‐certainty evidence). Need for more than one skin puncture 
The evidence is very uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture when a sweet‐tasting solution is used (RR 7.00, 95% CI 0.38 to 129.93; I² not applicable; 2 studies, 110 participants; very low‐certainty evidence). This is due to the small number of participants in each group. Authors' conclusions Based on moderate‐certainty evidence, venepuncture probably reduces pain during the procedure and the need for more than one skin puncture compared to heel lance when no sweet‐tasting solution is used. When sweet‐tasting solutions are administered, venepuncture may reduce pain during the procedure compared to heel lance, based on low‐certainty evidence. The evidence is very uncertain about the effect of venepuncture compared to heel lance on the number of skin punctures required in the presence of sweet‐tasting solutions. This is due to the small sample size, and hence we could not draw any meaningful conclusions. Further high‐quality studies are needed, particularly in settings where sweet‐tasting solutions are used, to better understand the comparative effectiveness of venepuncture and heel lance for neonatal blood sampling. Funding Cochrane Neonatal editorial support for this review update, as part of a suite of reviews addressing “The infant and family experience in the neonatal intensive care unit”, has been provided by a grant from The Gerber Foundation. The Gerber Foundation is a separately endowed, private, 501(c)(3) foundation not related to Gerber Products Company in any way. Registration Original review (2001): DOI 10.1002/14651858.CD001452
Review update (2004): DOI 10.1002/14651858.CD001452.pub2
Review update (2007): DOI 10.1002/14651858.CD001452.pub3
Review update (2011): DOI 10.1002/14651858.CD001452.pub4 Plain language summary Is using a needle (venepuncture) better than using a device (heel lance) for taking a blood sample from full‐term newborn babies? Key messages Venepuncture (inserting a needle into a vein) may be less painful than heel lance (using a special device to puncture the skin) for newborn babies when having a blood sample taken, with or without sugar water for pain relief, and may reduce the need for more than one skin puncture when no sugar water is given for pain relief. We don’t know whether venepuncture reduces the need for more than one skin puncture compared with heel lance when sugar water is given for pain relief. We need better designed and larger studies that fully report their results to show which method is better for babies. Why do we take blood samples from newborn babies? In most countries, a blood sample from newborn babies is needed for routine screening tests. Blood samples may also be needed for other blood tests to diagnose and manage diseases, such as jaundice or low blood sugar (hypoglycemia). However, taking blood from babies is painful. Untreated pain in newborn babies may affect their physical growth and brain development. A sweet, sugar solution (such as sucrose) can be given to babies before the procedure, which helps to reduce the pain. It is difficult to measure pain in babies, but we rely on things like facial expressions, crying, and changes in heart rate to assess their pain. How are blood samples taken? Venepuncture Venepuncture is a method of taking a blood sample where a person uses a needle to directly puncture the vein. The person who performs this must be well‐trained to help ensure they successfully take a blood sample. This technique is often used when 1 mL or more of blood is required, and to prevent repeated punctures to the skin and associated complications (such as skin infections) from heel lance. Heel lance Heel lance is the standard way of taking a blood sample from newborn babies in hospitals worldwide. It is commonly used when the blood sample required is less than 1 mL. It does not require special training or expertise for successful use. The procedure involves making a small puncture (between 1 mm and 2 mm deep) on the heel of the foot using a lancet, which is usually an automatic device. Following the puncture, the infant's heel is squeezed to collect the required blood sample, which causes further pain. What did we want to find out? We wanted to find out: whether venepuncture is less painful than heel lance for newborn babies; and which procedure works best first time, so a second skin puncture is not needed. What did we do? We searched for studies that compared venepuncture and heel lance for taking blood samples in newborn babies. The studies needed to measure pain responses and the number of skin punctures needed for a successful sample. They also needed to record whether babies were given sugar solution as pain relief. Babies in the studies had to be healthy and born at full term. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included eight studies involving 826 full‐term newborn babies. Three studies took place in Sweden, and one each in Japan, Malaysia, Nepal, Spain, and the UK. When no sweet‐tasting solution was given: venepuncture probably causes less pain compared to heel lance (6 studies, 488 babies); and venepuncture probably reduces the need for more than one skin puncture compared to heel lance (6 studies, 397 babies). When a sweet‐tasting solution was given: venepuncture may cause less pain compared to heel lance (3 studies, 170 babies); and we are uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture (2 studies, 110 babies). What are the limitations of the evidence? Our confidence in the evidence was limited, and ranged from moderate to very low. This is because all the studies had limitations in how they were carried out. These included issues with how babies were assigned to each group, how the studies reported their results, and the number of babies included in the studies. In addition, the people doing the procedures knew which sampling method each baby received, which could have influenced how the studies assessed pain. How up to date is this evidence? This review updates our 2011 Cochrane review. The evidence is up to date to July 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Martins, G; Fiander, M; Taddio, A; Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD001452.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "29bd6730-b3b7-4d43-ae0e-3c4a2d51a3c1", "pmid": "", "title": "Full‐mouth treatment modalities (within 24 hours) for periodontitis in adults", "imported": false, "abstract": "Abstract - Background Periodontitis is a highly prevalent, chronic inflammation that causes damage to the soft tissues and bones supporting the teeth. Conventional treatment is quadrant scaling and root planing (the second step of periodontal therapy), which comprises scaling and root planing of teeth in one quadrant of the mouth at a time, with the four different sessions separated by at least one week. Alternative protocols for anti‐infective periodontal therapy have been introduced to help enhance treatment outcomes: full‐mouth scaling (subgingival instrumentation of all quadrants within 24 hours), or full‐mouth disinfection (subgingival instrumentation of all quadrants in 24 hours plus adjunctive antiseptic). We use the older term 'scaling and root planing' (SRP) interchangeably with the newer term 'subgingival instrumentation' in this iteration of the review, which updates one originally published in 2008 and first updated in 2015. Objectives To evaluate the clinical effects of full‐mouth scaling or full‐mouth disinfection (within 24 hours) for the treatment of periodontitis compared to conventional quadrant subgingival instrumentation (over a series of visits at least one week apart) and to evaluate whether there was a difference in clinical effects between full‐mouth disinfection and full‐mouth scaling. Search methods An information specialist searched five databases up to 17 June 2021 and used additional search methods to identify published, unpublished and ongoing studies. Selection criteria We included randomised controlled trials (RCTs) lasting at least three months that evaluated full‐mouth scaling and root planing within 24 hours, with or without adjunctive use of an antiseptic, compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of (chronic) periodontitis according to the International Classification of Periodontal Diseases from 1999. A new periodontitis classification was launched in 2018; however, we used the 1999 classification for inclusion or exclusion of studies, as most studies used it. We excluded studies of people with systemic disorders, taking antibiotics or with the older diagnosis of 'aggressive periodontitis'. Data collection and analysis Several review authors independently conducted data extraction and risk of bias assessment (based on randomisation method, allocation concealment, examiner blinding and completeness of follow‐up). Our primary outcomes were tooth loss and change in probing pocket depth (PPD); secondary outcomes were change in probing attachment (i.e. clinical attachment level (CAL)), bleeding on probing (BOP), adverse events and pocket closure (the number/proportion of sites with PPD of 4 mm or less after treatment). We followed Cochrane's methodological guidelines for data extraction and analysis. Main results We included 20 RCTs, with 944 participants, in this updated review. No studies assessed the primary outcome tooth loss. Thirteen trials compared full‐mouth scaling and root planing within 24 hours without the use of antiseptic (FMS) versus control, 13 trials compared full‐mouth scaling and root planing within 24 hours with adjunctive use of an antiseptic (FMD) versus control, and six trials compared FMS with FMD. Of the 13 trials comparing FMS versus control, we assessed three at high risk of bias, six at low risk of bias and four at unclear risk of bias. We assessed our certainty about the evidence as low or very low for the outcomes in this comparison. There was no evidence for a benefit for FMS over control for change in PPD, gain in CAL or reduction in BOP at six to eight months (PPD: mean difference (MD) 0.03 mm, 95% confidence interval (CI) –0.14 to 0.20; 5 trials, 148 participants; CAL: MD 0.10 mm, 95% CI –0.05 to 0.26; 5 trials, 148 participants; BOP: MD 2.64%, 95% CI –8.81 to 14.09; 3 trials, 80 participants). There was evidence of heterogeneity for BOP (I² = 50%), but none for PPD and CAL. Of the 13 trials comparing FMD versus control, we judged four at high risk of bias, one at low risk of bias and eight at unclear risk of bias. At six to eight months, there was no evidence for a benefit for FMD over control for change in PPD or CAL (PPD: MD 0.11 mm, 95% CI –0.04 to 0.27; 6 trials, 224 participants; low‐certainty evidence; CAL: 0.07 mm, 95% CI –0.11 to 0.24; 6 trials, 224 participants; low‐certainty evidence). The analyses found no evidence of a benefit for FMD over control for BOP (very low‐certainty evidence). There was no evidence of heterogeneity for PPD or CAL, but considerable evidence of heterogeneity for BOP, attributed to one study. There were no consistent differences in these outcomes between intervention and control (low‐ to very low‐certainty evidence). Of the six trials comparing FMS and FMD, we judged two trials at high risk of bias, one at low risk of bias and three as unclear. At six to eight months, there was no evidence of a benefit of FMD over FMS for change in PPD or gain in CAL (PPD: MD –0.11 mm, 95% CI –0.30 to 0.07; P = 0.22; 4 trials, 112 participants; low‐certainty evidence; CAL: MD –0.05 mm, 95% CI –0.23 to –0.13; P = 0.58; 4 trials, 112 participants; low‐certainty evidence). There was no evidence of a difference between FMS and FMD for BOP at any time point (P = 0.98; 2 trials, 22 participants; low‐ to very low‐certainty evidence). There was evidence of heterogeneity for BOP (I² = 52%), but not for PPD or CAL. Thirteen studies predefined adverse events as an outcome; three reported an event after FMD or FMS. The most important harm identified was an increase in body temperature. We assessed the certainty of the evidence for most comparisons and outcomes as low because of design limitations leading to risk of bias, and the small number of trials and participants, leading to imprecision in the effect estimates. Authors' conclusions The inclusion of nine new RCTs in this updated review has not changed the conclusions of the previous version of the review. There is still no clear evidence that FMS or FMD approaches provide additional clinical benefit compared to conventional mechanical treatment for adult periodontitis. In practice, the decision to select one approach to non‐surgical periodontal therapy over another should include patient preference and the convenience of the treatment schedule. Plain language summary Treating all teeth (full mouth) within 24 hours for gum disease (periodontitis) in adults Background Long‐lasting gum disease (periodontitis) is a common chronic inflammatory disease that causes damage to soft tissues (gums) and bone around teeth, and can result in tooth loss. Non‐surgical treatments are used to stop and control the disease. These are based on 'subgingival instrumentation', that is, the mechanical removal of bacteria below the gums from the infected root surfaces of the teeth. Conventional treatment is carried out in two to four sessions over several weeks, scaling a different section (or 'quadrant') of the mouth each time. This has traditionally been known as 'scaling and root planing' (SRP). An alternative approach is to treat the whole mouth within 24 hours in one or two sessions (known as full‐mouth scaling (FMS)). When an antiseptic agent (like chlorhexidine) is added to FMS, the intervention is called full‐mouth disinfection (FMD). The rationale for using these full‐mouth approaches is to reduce the likelihood of re‐infection in already treated sites. Review question This review, produced within Cochrane Oral Health, is the second update of one we originally published in 2008. It evaluates the effectiveness of full‐mouth treatments within 24 hours (FMS and FMD) compared to conventional treatment over a number of weeks, and whether there is a difference between FMS and FMD. The evidence is current up to June 2021. Study characteristics The included studies were randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that evaluated a full‐mouth approach to subgingival instrumentation, with at least three months of monitoring (follow‐up). Both FMS and FMD were compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of chronic periodontitis and we excluded studies of people with aggressive periodontitis, systemic disorders (affecting other part of the body) or who were taking antibiotics. We included nine new studies in this update and we excluded one trial that had been included in the previous version of the review. In total, the review now includes 20 studies that involved 944 participants. Key results Treatment effects of FMS and FMD are modest and there are no clear implications for periodontal care. Neither treatment was superior to the usual treatment of scaling and root planing a quarter of the mouth at a time. The most important harm identified was an increased body temperature after FMS or FMD treatments, reported in three out of 13 studies. In practice, the decision to select one approach over another will be based on preference and convenience for patient and dentist. Certainty of the evidence Our confidence in the results is low for most comparisons and outcomes, due to the small number of studies and participants involved, and limitations in study designs. The addition of nine studies has not changed the findings of our previous version of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jervøe-Storm, P-M; Eberhard, J; Needleman, I; Worthington, HV; Jepsen, S", "articleTypes": [], "doi": "10.1002/14651858.CD004622.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "29f0dfe8-dbb5-43d4-ab3a-804f00e2bedb", "pmid": "", "title": "Prolonged Overnight Fasting and/or Exercise on Fatigue and Other Patient Reported Outcomes in Women With Hormone Receptor Positive Advanced Breast Cancer (FastER)", "imported": false, "abstract": "The purpose of this study is to test whether four different supportive care programs can reduce fatigue in women with advanced or metastatic breast cancer who are receiving a medication called a CDK4/6 inhibitor (palbociclib, ribociclib, or abemaciclib) alongwith endocrine therapy with or without a PI3K or AKT inhibitor.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.153Z" }, { "id": "29fb479f-18de-4711-b305-dd61d375c19c", "pmid": "", "title": "Glucocorticoids for croup in children", "imported": false, "abstract": "Abstract - Background Glucocorticoids are the mainstay for the treatment of croup. The existing evidence demonstrates that glucocorticoids are effective in the treatment of croup in children. However, updating the evidence on their clinical relevance in croup is imperative. This is an update to a review first published in 1999, and updated in 2004, 2011, and 2018. Objectives To investigate the effects and safety of glucocorticoids in the treatment of croup in children aged 18 years and below. Search methods We searched the Cochrane Library, which includes the Cochrane Central Register of Controlled Trials (CENTRAL; 2022 Issue 9), Ovid MEDLINE Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations and Ovid MEDLINE (1946 to 4 March 2022), Embase (Ovid) (1974 to 4 March 2022). We also searched the WHO ICTRP and ClinicalTrials.gov on 4 March 2022. Selection criteria We included randomised controlled trials (RCTs) in children (aged 18 years and below) with croup. We assessed the effect of glucocorticoids compared to the following: placebo, any other pharmacologic agents, any other glucocorticoids, any combination of other glucocorticoids, given by different modes of administration, or given in different doses. The included studies must have assessed at least one of our primary outcomes (defined as the change in croup score or return visits, (re)admissions to the hospital or both) or secondary outcomes (defined as the length of stay in hospital or emergency departments, patient improvement, use of additional treatments, or adverse events). Data collection and analysis Review authors independently extracted data, with another review author verified. We entered the data into Review Manager 5 for meta‐analysis. Two review authors independently assessed studies for risk of bias using the Cochrane risk of bias tool. Two review authors assessed the certainty of the evidence for the primary outcomes using the GRADE approach. Main results This updated review includes 45 RCTs with a total of 5888 children, an increase of two RCTs with 1323 children since the last update. We also identified one ongoing study and one study awaiting classification. We assessed most studies (98%) as at high or unclear risk of bias. Any glucocorticoid compared to placebo Compared to placebo, glucocorticoids may result in greater reductions in croup score after two hours (standardised mean difference (SMD) −0.65, 95% confidence interval (CI) −1.13 to −0.18; 7 RCTs, 426 children; low‐certainty evidence); six hours (SMD −0.76, 95% CI −1.12 to −0.40; 11 RCTs, 959 children; low‐certainty evidence); and 12 hours (SMD −1.03, 95% CI −1.53 to ‐0.53; 8 RCTs, 571 children; low‐certainty evidence). The evidence for change in croup score after 24 hours is very uncertain (SMD −0.86, 95% CI −1.40 to −0.31; 8 RCTs, 351 children; very low‐certainty evidence). One glucocorticoid compared to another glucocorticoid There was little to no difference between prednisolone and dexamethasone for reduction in croup score at two‐hour post‐baseline score (SMD 0.06, 95% CI −0.06 to 0.18; 1 RCT, 1231 children; high‐certainty evidence). There was likely little to no difference between prednisolone and dexamethasone for reduction in croup score at six‐hour post‐baseline score (SMD 0.21, 95% CI −0.21 to 0.62; 1 RCT, 99 children; moderate‐certainty evidence). However, dexamethasone probably reduced the return visits or (re)admissions for croup by almost half (risk ratio (RR) 0.55, 95% CI 0.28 to 1.11; 4 RCTs, 1537 children; moderate‐certainty evidence), and showed a 28% reduction in the use of supplemental glucocorticoids as an additional treatment (RR 0.72, 95% CI 0.53 to 0.97; 2 RCTs, 926 children). Dexamethasone given in different doses Compared to 0.15 mg/kg, 0.60 mg/kg dexamethasone probably reduced the severity of croup as assessed by the croup scoring scale at 24‐hour postbaseline score (SMD 0.63, 95% CI 0.16 to 1.10; 1 RCT, 72 children; moderate‐certainty evidence); however, this was not the case at two hours (SMD −0.27, 95% CI −0.76 to 0.22; 2 RCTs, 861 children; high‐certainty evidence). There was probably no reduction at six hours (SMD −0.45, 95% CI −1.26 to 0.35; 3 RCTs, 178 children; moderate‐certainty evidence), and the evidence at 12 hours is very uncertain (SMD −0.60, 95% CI −4.39 to 3.19; 2 RCTs, 113 children; very low‐certainty evidence). There was little to no difference between doses of dexamethasone in return visits or (re)admissions of children or both (RR 0.91, 95% CI 0.71 to 1.17; 3 RCTs, 949 children; high‐certainty evidence) or length of stay in the hospital or emergency department (mean difference 0.12, 95% CI −0.32 to 0.56; 2 RCTs, 892 children). The need for additional treatments, such as epinephrine (RR 0.78, 95% CI 0.34 to 1.75; 2 RCTs, 885 children); intubation (risk difference 0.00, 95% CI −0.00 to 0.00; 2 RCTs, 861 children); or use of supplemental glucocorticoids (RR 0.77, 95% CI 0.51 to 1.15; 2 RCTs, 617 children), also did not differ between doses of dexamethasone. There were moderate to high levels of heterogeneity in the analyses for most comparisons. Adverse events were observed for some of the comparisons reported in the review. Authors' conclusions The evidence that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions has not changed in this update. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg. More RCTs are needed to strengthen the evidence for effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. Plain language summary Glucocorticoids for croup in children Review question What is the effectiveness and safety of glucocorticoids when treating children with croup? Background Respiratory viruses are the main cause of croup in children. Croup leads to a swelling of the throat and airway, which can make breathing difficult. Children also present with a special type of cough called a barking cough. Glucocorticoids are types of steroids that help reduce the swelling, thereby making it easier for children with croup to breathe. This is an update of a review first published in 1999 and updated in 2004, 2011, and 2018. Search date The evidence is current to 4 March 2022. Study characteristics We included 2 new studies with 1323 children, for a total of 45 studies with 5888 children aged 0 to 18 years published between 1964 and 2021. The three types of glucocorticoids used in the new studies were budesonide, dexamethasone, and prednisolone. The most recent study compared the effectiveness of budesonide and dexamethasone. The other new study compared the effectiveness of dexamethasone and prednisolone, as well as a small dose of dexamethasone (0.15 mg/kg) versus 0.60 mg/kg dexamethasone. We added the data from the new study that compared the doses of dexamethasone to previously included studies looking at the same comparison. Study funding sources Funding sources included government (11%), academic or research institute (7%), industry (18%), or foundations (9%). More than half of the studies (55%) did not report funding sources. Key results Compared to prednisolone, dexamethasone showed no improvement in croup score at two and six hours after presenting to the hospital or emergency department, and probably reduced return visits or (re)admissions for croup by almost half. The addition of supplemental glucocorticoid favoured dexamethasone versus prednisolone. Compared to 0.15 mg/kg dexamethasone, the standard dose of 0.60 mg/kg probably reduced the severity of croup as assessed by the croup scoring scale at 24 hours after presenting to the hospital or emergency department. However, we did not find any important difference between groups in croup scoring scale at 2, 6, or 12 hours, return visits or (re)admissions of children, or length of stay in the hospital or emergency department. The need for additional treatments such as the use of other drugs like epinephrine, supplemental glucocorticoid, or the use of a tube to help breathing did not differ between 0.15 mg/kg and 0.60 mg/kg dexamethasone. No serious adverse events from the use of the glucocorticoids were reported in the newly included studies. Conclusions The evidence has not changed that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions compared to placebo (dummy treatment). A small dose of dexamethasone at 0.15 mg/kg may be as effective as the standard dose of 0.60 mg/kg. More studies are needed to strengthen the evidence for the effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. We conclude that glucocorticoids are effective in the treatment of croup in children. Certainty of evidence Most studies (98%) had problems related to their methods, reporting issues, or both. For any glucocorticoid compared to placebo, we downgraded the certainty of the evidence for change in croup score after 2, 6, 12, and 24 hours and return visits or (re)admissions due to study variability, imprecision and inconsistency of study results, and risk of bias. There is little evidence that reporting bias influenced our results for return visits or (re)admissions, or both. Similar threats to the certainty of the evidence were present in the other comparisons in this review, including concerns related to risk of bias and inconsistency and imprecision of study results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aregbesola, A, Tam, CM, Kothari, A, Le, M-L, Ragheb, M, Klassen, TP", "articleTypes": [], "doi": "10.1002/14651858.CD001955.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.724Z" }, { "id": "2a074aca-43ce-412c-a52d-ff498e37c34b", "pmid": "", "title": "WIthdrawal of DUpilumab in Severe Asthma: a Randomized Non-inferiority-controlled Trial", "imported": false, "abstract": "Asthma management has been revolutionised by the development of biological therapies. Dupilumab is an anti-interleukin4 receptor marketed in 2020 for severe asthmatic patients with 2 exacerbations or more within the last 12 months. Although data showed that safety and efficacy of dupilumab are sustained when treatment is extended up to 3 years, no study has emerged regarding dupilumab discontinuation. This study aims to demonstrate the non-inferiority regarding strategy failure at 24 months of stopping dupilumab (intervention group) compared with its continuation (control group) in controlled asthma patients receiving this drug for at least 3 years.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.156Z" }, { "id": "2a11d4d7-27f1-402e-af53-a3ad200c8cf5", "pmid": "", "title": "Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors", "imported": false, "abstract": "Abstract - Background Poor diet and insufficient physical activity are major risk factors for non‐communicable diseases. Developing healthy diet and physical activity behaviors early in life is important as these behaviors track between childhood and adulthood. Parents and other adult caregivers have important influences on children's health behaviors, but whether their involvement in children's nutrition and physical activity interventions contributes to intervention effectiveness is not known. Objectives • To assess effects of caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors, including those intended to prevent overweight and obesity • To describe intervention content and behavior change techniques employed, drawing from a behavior change technique taxonomy developed and advanced by Abraham, Michie, and colleagues (Abraham 2008; Michie 2011; Michie 2013; Michie 2015) • To identify content and techniques related to reported outcomes when such information was reported in included studies Search methods In January 2019, we searched CENTRAL, MEDLINE, Embase, 11 other databases, and three trials registers. We also searched the references lists of relevant reports and systematic reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of interventions to improve children's dietary intake or physical activity behavior, or both, with children aged 2 to 18 years as active participants and at least one component involving caregivers versus the same interventions but without the caregiver component(s). We excluded interventions meant as treatment or targeting children with pre‐existing conditions, as well as caregiver‐child units residing in orphanages and school hostel environments. Data collection and analysis We used standard methodological procedures outlined by Cochrane. Main results We included 23 trials with approximately 12,192 children in eligible intervention arms. With the exception of two studies, all were conducted in high‐income countries, with more than half performed in North America. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The specific intervention strategies used were not always reported completely. However, based on available reports, the behavior change techniques used most commonly in the child‐only arm were \"shaping knowledge,\" \"comparison of behavior,\" \"feedback and monitoring,\" and \"repetition and substitution.\" In the child + caregiver arm, the strategies used most commonly included additional \"shaping knowledge\" or \"feedback and monitoring\" techniques, as well as \"social support\" and \"natural consequences.\" We considered all trials to be at high risk of bias for at least one design factor. Seven trials did not contribute any data to analyses. The quality of reporting of intervention content varied between studies, and there was limited scope for meta‐analysis. Both validated and non‐validated instruments were used to measure outcomes of interest. Outcomes measured and reported differed between studies, with 16 studies contributing data to the meta‐analyses. About three‐quarters of studies reported their funding sources; no studies reported industry funding. We assessed the quality of evidence to be low or very low. Dietary behavior change interventions with a caregiver component versus interventions without a caregiver component Seven studies compared dietary behavior change interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (mean difference [MD] −0.42%, 95% confidence interval [CI] −1.25 to 0.41, 1 study, n = 207; low‐quality evidence) or from sodium intake (MD −0.12 g/d, 95% CI −0.36 to 0.12, 1 study, n = 207; low‐quality evidence). No trial in this comparison reported data for children's combined fruit and vegetable intake, sugar‐sweetened beverage (SSB) intake, or physical activity levels, nor for adverse effects of interventions. Physical activity interventions with a caregiver component versus interventions without a caregiver component Six studies compared physical activity interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's total physical activity (MD 0.20 min/h, 95% CI −1.19 to 1.59, 1 study, n = 54; low‐quality evidence) or moderate to vigorous physical activity (MVPA) (standard mean difference [SMD] 0.04, 95% CI −0.41 to 0.49, 2 studies, n = 80; moderate‐quality evidence). No trial in this comparison reported data for percentage of children's total energy intake from saturated fat, sodium intake, fruit and vegetable intake, or SSB intake, nor for adverse effects of interventions. Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component Ten studies compared dietary and physical activity interventions with and without a caregiver component. At the end of the intervention, we detected a small positive impact of a caregiver component on children's SSB intake (SMD −0.28, 95% CI −0.44 to −0.12, 3 studies, n = 651; moderate‐quality evidence). We did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (MD 0.06%, 95% CI −0.67 to 0.80, 2 studies, n = 216; very low‐quality evidence), sodium intake (MD 35.94 mg/d, 95% CI −322.60 to 394.47, 2 studies, n = 315; very low‐quality evidence), fruit and vegetable intake (MD 0.38 servings/d, 95% CI −0.51 to 1.27, 1 study, n = 134; very low‐quality evidence), total physical activity (MD 1.81 min/d, 95% CI −15.18 to 18.80, 2 studies, n = 573; low‐quality evidence), or MVPA (MD −0.05 min/d, 95% CI −18.57 to 18.47, 1 study, n = 622; very low‐quality evidence). One trial indicated that no adverse events were reported by study participants but did not provide data. Authors' conclusions Current evidence is insufficient to support the inclusion of caregiver involvement in interventions to improve children's dietary intake or physical activity behavior, or both. For most outcomes, the quality of the evidence is adversely impacted by the small number of studies with available data, limited effective sample sizes, risk of bias, and imprecision. To establish the value of caregiver involvement, additional studies measuring clinically important outcomes using valid and reliable measures, employing appropriate design and power, and following established reporting guidelines are needed, as is evidence on how such interventions might contribute to health equity. Plain language summary Effects of involving parents and other adult caregivers in children's diet and physical activity interventions Review question Does it make a difference if parents or other adult caregivers are involved in interventions to encourage children to eat healthier or be more physically active? Background Diet and physical activity behaviors are important determinants of health. Parents and other adult caregivers have an essential role in shaping children's health habits by controlling availability of and access to healthy foods and opportunities to be active; supporting, encouraging, and role‐modeling healthy behaviors; and adopting supportive feeding styles and practices. For these reasons, it often is argued that parent and caregiver involvement in children's diet and physical activity interventions is important; however, it remains unclear if involvement of parents and caregivers actually provides benefit. Objectives We assessed the effects of involving parents or other adult caregivers in children's healthy eating and physical activity interventions compared to the effects of the same child interventions without a parent or caregiver component. We were particularly interested in understanding effects on children's dietary intake, children's physical activity levels, and adverse effects of interventions. Study characteristics We found 23 studies, published between 1982 and 2019, that implemented diet interventions, physical activity interventions, or combined diet and physical activity interventions with children or adolescents, and evaluated the effects of adding an intervention component involving parents or other adult caregivers. Approximately 12,192 children aged 2 to 18 years were examined. More than half of studies took place in North America, and all but two were conducted in high‐income countries. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The breadth of information provided about intervention content varied between studies. The most commonly used intervention techniques were those aimed at shaping participants' knowledge, such as providing instruction about how to perform a behavior (e.g. dance, cooking lessons). About three‐quarters of studies reported their funding source; no studies reported industry funding. Key results The findings of this review suggest that adding a parent or caregiver component to dietary behavior change interventions or physical activity interventions may make little or no difference to children's dietary intake or physical activity levels. For interventions that target both diet and physical activity behaviors, involving a parent or caregiver probably slightly reduces children's sugar‐sweetened beverage intake by the end of the intervention. We do not know whether any of these types of interventions result in adverse effects because these data are not available. Quality of evidence Overall, the evidence from studies is of low or very low quality, which means that we are uncertain about study results. Currentness of evidence The evidence is current to January 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Morgan, EH, Schoonees, A, Sriram, U, Faure, M, Seguin‐Fowler, RA", "articleTypes": [], "doi": "10.1002/14651858.CD012547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.826Z" }, { "id": "2a15e786-975d-4b7f-b9b0-c6559026af7f", "pmid": "", "title": "Fish oil for kidney transplant recipients", "imported": false, "abstract": "Abstract - Background Calcineurin inhibitors used in kidney transplantation for immunosuppression have adverse effects that may contribute to nephrotoxicity and increased cardiovascular risk profile. Fish oils are rich in very long chain omega‐3 fatty acids, which may reduce nephrotoxicity by improving endothelial function and reduce rejection rates through their immuno‐modulatory effects. They may also modify the cardiovascular risk profile. Hence, fish oils may potentially prolong graft survival and reduce cardiovascular mortality. Objectives This review aimed to look at the benefits and harms of fish oil treatment in ameliorating the kidney and cardiovascular adverse effects of CNI‐based immunosuppressive therapy in kidney transplant recipients. Search methods We searched the Cochrane Kidney and Transplant Specialised Register (up to 17 March 2016) through contact with the Information Specialist using search terms relevant to this review. Selection criteria All randomised controlled trials (RCTs) and quasi‐RCTs of fish oils in kidney transplant recipients on a calcineurin inhibitor‐based immunosuppressive regimen. RCTs of fish oil versus statins were included. Data collection and analysis Data was extracted and the quality of studies assessed by two authors, with differences resolved by discussion with a third independent author. Dichotomous outcomes were reported as risk ratio (RR) and continuous outcome measures were reported as the mean difference (MD) with 95% confidence intervals using the random effects model. Heterogeneity was assessed using a Chi 2 test on n‐1 degrees of freedom and the I 2 statistic. Data not suitable for pooling were tabulated and described. Main results Fifteen studies (733 patients) were suitable for analysis. All studies were small and had variable methodology. Fish oil did not significantly affect patient or graft survival, acute rejection rates, or calcineurin inhibitor toxicity when compared to placebo. Overall SCr was significantly lower in the fish oil group compared to placebo (5 studies, 237 participants: MD ‐30.63 µmol/L, 95% CI ‐59.74 to ‐1.53; I 2 = 88%). In the subgroup analysis, this was only significant in the long‐course (six months or more) group (4 studies, 157 participants: MD ‐37.41 µmol/L, 95% CI ‐69.89 to ‐4.94; I 2 = 82%). Fish oil treatment was associated with a lower diastolic blood pressure (4 studies, 200 participants: MD ‐4.53 mm Hg, 95% CI ‐7.60 to ‐1.45) compared to placebo. Patients receiving fish oil for more than six months had a modest increase in HDL (5 studies, 178 participants: MD 0.12 mmol/L, 95% CI 0.03 to 0.21; I 2 = 47%) compared to placebo. Fish oil effects on lipids were not significantly different from low‐dose statins. There was insufficient data to analyse cardiovascular outcomes. Fishy aftertaste and gastrointestinal upset were common but did not result in significant patient drop‐out. Authors' conclusions There is insufficient evidence from currently available RCTs to recommend fish oil therapy to improve kidney function, rejection rates, patient survival or graft survival. The improvements in HDL cholesterol and diastolic blood pressure were too modest to recommend routine use. To determine a benefit in clinical outcomes, future RCTs will need to be adequately powered with these outcomes in mind. Plain language summary Fish oil for kidney transplant recipients This review set out to assess any benefit or harm in using fish oil to reduce the risk of kidney damage and heart disease in people who have had a kidney transplant and are receiving standard drugs to prevent rejection. Information from 15 studies was used and showed that fish oils provide a slight improvement in HDL cholesterol and diastolic blood pressure. These studies did not provide enough information on the differences in the risk of death, heart disease, kidney transplant rejection or kidney function between patients receiving fish oils and those receiving placebo. There appeared to be no harmful effects of taking fish oil. The benefits of taking fish oil after a kidney transplant are a mild improvement in some heart disease risk factors. There was not enough information to show any benefit in preventing heart disease or reduction in kidney function. Larger, better studies are needed before regular use of fish oil can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lim, AKH; Manley, KJ; Roberts, MA; Fraenkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD005282.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "2a174b43-4c65-4b21-9317-a236519da56f", "pmid": "", "title": "Topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antiseptics, a possible treatment for CSOM, inhibit the micro‐organisms that may be responsible for the infection. Antiseptics can be used alone or in addition to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). However, the effects of topical antiseptics for CSOM remain unclear. This is an update of a review last published in 2020, with one new study added. It is one of a suite of seven Cochrane reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To assess the effects of topical antiseptics for people with CSOM. Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The date of the latest search was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antiseptic agent of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antiseptics (a) compared to placebo or no intervention, and (b) compared to another topical antiseptic (e.g. topical antiseptic A versus topical antiseptic B). Within each comparison, we separated studies into (a) those in which both groups of participants had received aural toileting in addition to the topical antiseptics, and those where neither group had received aural toileting, and (b) those in which both groups had received some other concomitant treatment (such as antibiotics) and those with no such concomitant treatment. Data collection and analysis We used standard Cochrane methodological procedures. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results We found one new study (32 participants) in this update, for a total of six included studies with 435 participants (over four studies), plus 222 ears that could not be accounted for in participant numbers (in two studies). Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics (boric acid versus acetic acid, and boric acid versus hydrogen peroxide). The two core comparisons of interest are reported below; other comparisons are described in the Results section of the review. No study measured health‐related quality of life or ear pain. 1. Topical antiseptic versus placebo or no treatment Three studies (297 participants plus 174 ears) compared topical antiseptics with no treatment. Evidence from one study (unclear number of participants, 174 ears) is very uncertain about the effect of a single application of povidone iodine in hydroxypropyl methyl‐cellulose (HPMC) on resolution of ear discharge at one week compared to HPMC alone; however, these results were only provided by ear (rather than by participant) and therefore could not be used quantitatively (very low‐certainty evidence). One study (254 children; cluster‐RCT) found that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge after four weeks compared with dry mopping alone, but the evidence is very uncertain (risk ratio (RR) 1.73, 95% confidence interval (CI) 1.21 to 2.47; 180 participants; very low‐certainty evidence). We made adjustments to the data to account for the intracluster correlation. This study narratively described no clear differences in suspected ototoxicity or hearing outcomes between study arms, but the evidence is very uncertain (very low‐certainty evidence). Evidence from one study (43 children; 58 ears) is very uncertain about the effect of antiseptics on serious complications. The study reported one case of mastoiditis and one of meningitis with focal encephalitis; however, it was unclear whether these were detected pre‐randomisation or during/after treatment. 2. Topical antiseptics versus no treatment/placebo, where both study arms received systemic antibiotics One study (32 participants) compared topical povidone iodine with placebo (saline) in conjunction with oral amoxicillin and dry mopping. Topical povidone iodine with oral amoxicillin and dry mopping may increase resolution of ear discharge at one to two weeks (RR 3.25, 95% CI 1.35 to 7.84; 32 participants; low‐certainty evidence). The study narratively reported no ototoxicity in the topical antiseptic arm; however, this was unclear for the placebo group, so we do not know if povidone iodine increases suspected ototoxicity (low‐certainty evidence). The study did not assess resolution of ear discharge after four weeks, hearing, or serious complications. Authors' conclusions We are very uncertain about the effect of topical antiseptics on improving resolution of ear discharge in people with CSOM given the low and very low certainty of the evidence, which was mostly due to risk of bias and imprecision. However, there is some evidence suggesting that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge compared with dry mopping alone, and that topical povidone iodine may be more effective than placebo (where both arms used systemic beta‐lactam antibiotics and dry mopping). There is insufficient evidence to draw any conclusions about harmful effects. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and risks of topical antiseptics for treating long‐term middle ear infection (chronic suppurative otitis media)? Key messages • Due to a lack of studies, we are very uncertain of the benefits and risks of topical antiseptics in the treatment of chronic suppurative otitis media (long‐term middle ear infection). • We need more information about possible harmful effects of topical antiseptics, as these were not well reported in the studies. What was studied in the review? Chronic suppurative otitis media (CSOM) is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (eardrum). The main symptoms are ear discharge and hearing loss. Topical antiseptics (antiseptics put directly into the ear as ear drops or as a powder) are sometimes used to treat CSOM. Topical antiseptics kill or stop the growth of the micro‐organisms that may be responsible for the infection. Topical antiseptics can be used on their own or added to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). Applying topical antiseptics can cause irritation of the skin within the outer ear, which may result in discomfort, pain, or itching. Some antiseptics (such as alcohol) can be toxic to the inner ear (ototoxicity), which means they may cause irreparable hearing loss (sensorineural), dizziness, or ringing in the ear (tinnitus). What is the aim of this review? The aim of this Cochrane review was to find out the benefits and risks of topical antiseptics compared to placebo (dummy medicine) or no treatment for CSOM. We also wanted to know whether one topical antiseptic was more effective than another. We collected and analysed all relevant studies to answer this question. This is an update of a review last published in 2020, with one new study added. What are the main results of the review? We included a total of six studies in the review. The total number of people in the studies was unclear, as two studies only reported how many ears were treated. However, there were 435 participants plus 222 ears (between 111 and 222 participants) that could not be accounted for in participant numbers. Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics. Different types of antiseptics were used, some in the form of ear drops and others as powders. No study measured health‐related quality of life or ear pain. Topical antiseptic versus placebo or no treatment (with a background treatment of ear cleaning) Three studies (297 participants plus 174 ears) compared topical antiseptics with placebo/no treatment. Based on evidence from one study (unclear number of participants, 174 ears), we do not know if a single application of antiseptic (povidone iodine plus hydroxypropyl methyl‐cellulose) resolves ear discharge at one to two weeks compared with no treatment. Another study (180 children) compared topical antiseptics (boric acid in alcohol ear drops) with no topical antiseptics. All children also had their ears cleaned daily using cotton wool sticks (dry mopping). It is unclear if antiseptics (boric acid) led to an increase in resolution of ear discharge at four weeks or at three to four months compared with no antiseptics. The same study (254 participants) also reported no clear difference between groups in hearing or suspected ototoxicity (hearing or balance problems that develop as a result of taking a medicine), but the evidence is very uncertain. A third study (43 children; 58 ears) found no clear evidence that antiseptics have any effect on serious complications, but it is not known if this was assessed before, during, or after treatment. Topical antiseptic (povidone iodine) versus no treatment/placebo, where both study groups received systemic antibiotics One study (32 participants) compared one antiseptic (povidone iodine) with placebo (saline). All participants also received oral antibiotics (amoxicillin) and ear cleaning. This study found that topical povidone iodine, when given in addition to antibiotics and ear cleaning, may increase the number of people with resolution of ear discharge at between one and two weeks, compared with placebo plus antibiotics and ear cleaning. We do not know if povidone iodine increases suspected ototoxicity. In their report, the study authors stated there was no ototoxicity in participants in the topical antiseptic group, but this was unclear for the placebo group. There was no information on resolution of ear discharge after four weeks, hearing, or serious complications. What are the limitations of the evidence? There is limited information on certain population groups or treatments. Also, the evidence in the review comes from studies that were not conducted recently. How up‐to‐date is the review? The evidence is current to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K, Chong, LY, Bhutta, MF, Daw, J, Veselinović, T, Morris, PS, Vijayasekaran, S, Schilder, AGM, Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013055.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.779Z" }, { "id": "2a1d99e2-e738-4179-8898-7f63c5c43e1d", "pmid": "", "title": "Surgical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Surgical treatment of chronic rhinosinusitis with nasal polyps is an established treatment for medically resistant nasal polyp disease. Whether a nasal polypectomy with additional sinus dissection offers any advantage over an isolated nasal polypectomy has not been systematically reviewed. Objectives To assess the effectiveness of simple polyp surgery versus more extensive surgical clearance in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 1); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised and quasi‐randomised controlled trials in patients over 16 with chronic rhinosinusitis with nasal polyps, who have failed a course of medical management and who have not previously undergone any previous surgical intervention for their nasal disease. Studies compared nasal polypectomy with more extensive sinus clearance in this patient cohort. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no trials which met our inclusion criteria. Six controlled trials (five randomised) met some but not all of the inclusion criteria and were therefore excluded from the review. Authors' conclusions We are unable to reach any conclusions as to whether isolated nasal polypectomy or more extensive sinus surgery is a superior surgical treatment modality for chronic rhinosinusitis with nasal polyps. There is a need for high‐quality randomised controlled trials to assess whether additional sinus surgery confers any benefit when compared to nasal polypectomy performed in isolation. Plain language summary Surgical interventions for chronic rhinosinusitis with nasal polyps Background Benign nasal polyps are abnormal tissue growths inside the nasal passages and sinuses, often on both sides of the nose. They can cause a wide array of symptoms including blocked nose, poor sense of smell that can lead to a loss of taste, runny nose and nasal congestion. Sinuses are air‐filled cavities in the bones of the face, which are in continuity with the nasal passages. The first‐line treatment for nasal polyps is usually medical therapy in the form of steroids ‐ as sprays (topically) or by mouth (orally). In patients where this treatment has failed to relieve the symptoms, the polyps can be removed surgically. These surgical procedures are often not curative and patients may need to continue medical therapy or undergo further surgeries. A number of well‐established surgical techniques can be used to remove polyps. What has not been established is whether removing the nasal polyps and clearing out the sinuses offers any advantage in the control of the disease when compared to simply removing the polyps and leaving the sinuses unchanged. We sought evidence in the literature to establish whether there was any difference in patients who underwent nasal polyp removal alone versus those who had nasal polyps removed as well as opening up of the sinuses. Study characteristics No trials met our inclusion criteria. We did identify six controlled trials (five of which were randomised) in which some but not all of our inclusion criteria were met, but we had to exclude these studies from the review. Key results No trials met our inclusion criteria. Quality of evidence At present, we cannot comment on whether taking nasal polyps out alone or also opening up the sinuses at the same time is a better treatment for patients with this disease. There is a need for high‐quality randomised controlled trials to answer this question. This evidence is current to February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Sharma, R; Lakhani, R; Rimmer, J; Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "2a1fd42c-900e-4e7d-b37b-923cfb15f726", "pmid": "", "title": "Antioxidants for male subfertility", "imported": false, "abstract": "Abstract - Background The inability to have children affects 10% to 15% of couples worldwide. A male factor is estimated to account for up to half of the infertility cases with between 25% to 87% of male subfertility considered to be due to the effect of oxidative stress. Oral supplementation with antioxidants is thought to improve sperm quality by reducing oxidative damage. Antioxidants are widely available and inexpensive when compared to other fertility treatments, however most antioxidants are uncontrolled by regulation and the evidence for their effectiveness is uncertain. We compared the benefits and risks of different antioxidants used for male subfertility. Objectives To evaluate the effectiveness and safety of supplementary oral antioxidants in subfertile men. Search methods The Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, and two trial registers were searched on 15 February 2021, together with reference checking and contact with experts in the field to identify additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any type, dose or combination of oral antioxidant supplement with placebo, no treatment, or treatment with another antioxidant, among subfertile men of a couple attending a reproductive clinic. We excluded studies comparing antioxidants with fertility drugs alone and studies that included men with idiopathic infertility and normal semen parameters or fertile men attending a fertility clinic because of female partner infertility. Data collection and analysis We used standard methodological procedures recommended by Cochrane. The primary review outcome was live birth. Clinical pregnancy, adverse events and sperm parameters were secondary outcomes. Main results We included 90 studies with a total population of 10,303 subfertile men, aged between 18 and 65 years, part of a couple who had been referred to a fertility clinic and some of whom were undergoing medically assisted reproduction (MAR). Investigators compared and combined 20 different oral antioxidants. The evidence was of 'low' to 'very low' certainty: the main limitation was that out of the 67 included studies in the meta‐analysis only 20 studies reported clinical pregnancy, and of those 12 reported on live birth. The evidence is current up to February 2021. Live birth: antioxidants may lead to increased live birth rates (odds ratio (OR) 1.43, 95% confidence interval (CI) 1.07 to 1.91, P = 0.02, 12 RCTs, 1283 men, I 2 = 44%, very low‐certainty evidence). Results in the studies contributing to the analysis of live birth rate suggest that if the baseline chance of live birth following placebo or no treatment is assumed to be 16%, the chance following the use of antioxidants is estimated to be between 17% and 27%. However, this result was based on only 246 live births from 1283 couples in 12 small or medium‐sized studies. When studies at high risk of bias were removed from the analysis, there was no evidence of increased live birth (Peto OR 1.22, 95% CI 0.85 to 1.75, 827 men, 8 RCTs, P = 0.27, I 2 = 32%). Clinical pregnancy rate: antioxidants may lead to increased clinical pregnancy rates (OR 1.89, 95% CI 1.45 to 2.47, P < 0.00001, 20 RCTs, 1706 men, I 2 = 3%, low‐certainty evidence) compared with placebo or no treatment. This suggests that, in the studies contributing to the analysis of clinical pregnancy, if the baseline chance of clinical pregnancy following placebo or no treatment is assumed to be 15%, the chance following the use of antioxidants is estimated to be between 20% and 30%. This result was based on 327 clinical pregnancies from 1706 couples in 20 small studies. Adverse events
Miscarriage: only six studies reported on this outcome and the event rate was very low. No evidence of a difference in miscarriage rate was found between the antioxidant and placebo or no treatment group (OR 1.46, 95% CI 0.75 to 2.83, P = 0.27, 6 RCTs, 664 men, I 2 = 35%, very low‐certainty evidence). The findings suggest that in a population of subfertile couples, with male factor infertility, with an expected miscarriage rate of 5%, the risk of miscarriage following the use of an antioxidant would be between 4% and 13%. Gastrointestinal: antioxidants may lead to an increase in mild gastrointestinal discomfort when compared with placebo or no treatment (OR 2.70, 95% CI 1.46 to 4.99, P = 0.002, 16 RCTs, 1355 men, I 2 = 40%, low‐certainty evidence). This suggests that if the chance of gastrointestinal discomfort following placebo or no treatment is assumed to be 2%, the chance following the use of antioxidants is estimated to be between 2% and 7%. However, this result was based on a low event rate of 46 out of 1355 men in 16 small or medium‐sized studies, and the certainty of the evidence was rated low and heterogeneity was high. We were unable to draw conclusions from the antioxidant versus antioxidant comparison as insufficient studies compared the same interventions. Authors' conclusions In this review, there is very low‐certainty evidence from 12 small or medium‐sized randomised controlled trials suggesting that antioxidant supplementation in subfertile males may improve live birth rates for couples attending fertility clinics. Low‐certainty evidence suggests that clinical pregnancy rates may increase. There is no evidence of increased risk of miscarriage, however antioxidants may give more mild gastrointestinal discomfort, based on very low‐certainty evidence. Subfertile couples should be advised that overall, the current evidence is inconclusive based on serious risk of bias due to poor reporting of methods of randomisation, failure to report on the clinical outcomes live birth rate and clinical pregnancy, often unclear or even high attrition, and also imprecision due to often low event rates and small overall sample sizes. Further large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants. Plain language summary Antioxidants for male subfertility Review question 
Do supplementary oral antioxidants compared with placebo, no treatment or another antioxidant improve fertility outcomes for subfertile men? Background 
A couple may be considered to have fertility problems if they have been trying to conceive for over a year with no success. Many subfertile men undergoing fertility treatment also take dietary supplements in the hope of improving their fertility. Fertility treatment can be a very stressful time for men and their partners. It is important that these couples have access to high‐certainty evidence that will allow them to make informed decisions on whether to take a supplemental antioxidant. This is especially important as most antioxidant supplements are uncontrolled by regulation. This review aimed to assess whether supplements with oral antioxidants, taken by subfertile men, would increase the chances of a couple to achieve a (clinical) pregnancy confirmed by ultrasound and ultimately the birth of a baby (live birth). This review did not examine the use of antioxidants in men with normal sperm. Study characteristics Cochrane authors conducted a review including 90 randomised controlled trials comparing 18 different antioxidants with placebo, no treatment or another antioxidant in a total population of 10,303 subfertile men. The age range of the participants was 18 to 65 years; they were part of a couple who had been referred to a fertility clinic and some were undergoing fertility treatment. The evidence is current to February 2021. Main results 
Antioxidants may be associated with an increased live birth and clinical pregnancy rate. Based on the studied population for live birth, we would expect that out of 100 subfertile men not taking antioxidants, 16 couples would have a baby. In subfertile men taking antioxidants, between 17 and 27 per 100 couples would have a baby. If studies with high risk of bias were removed from the analysis, there was no evidence of increased live birth in the population taking antioxidants. In the people who were studied for clinical pregnancy, we would expect that out of 100 subfertile men not taking antioxidants, 15 couples would have a clinical pregnancy. In subfertile men taking antioxidants, between 20 and 30 per 100 couples would have a clinical pregnancy. Adverse events were poorly reported. Only six studies reported miscarriage. In these studies, miscarriage did not occur more often in the group using antioxidants when compared with the group with placebo or no treatment. However, there is insufficient evidence to draw conclusions about antioxidant use and the risk of miscarriage. The use of antioxidants may be associated with more mild stomach discomfort, with a frequency of 2% in subfertile men not taking antioxidants, and between 2% and 7% in men taking antioxidants. The oral supplements may cause discomforts such as nausea or stomach ache. Authors' conclusion and certainty of the evidence 
Antioxidant supplementation taken by subfertile males of a couple attending a fertility clinic may increase the chance of a live birth, however the overall certainty of evidence was very low from only 12 small to medium‐sized randomised controlled trials. Low‐certainty evidence suggests that clinical pregnancy rates may increase. Overall, there is no evidence of increased risk of miscarriage. Evidence of low certainty suggests that antioxidants may be associated with more gastrointestinal discomfort. Subfertile couples should be advised that overall the current evidence is inconclusive due to the poor reporting of methods, failure to report on live birth and clinical pregnancy rate, imprecision due to low event rates, high number of dropouts and small study group sizes. Large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "de Ligny, W; Smits, RM; Mackenzie-Proctor, R; Jordan, V; Fleischer, K; de Bruin, JP; Showell, MG", "articleTypes": [], "doi": "10.1002/14651858.CD007411.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "2a4bb491-03b5-4e2b-aaf6-24ff847b1323", "pmid": "", "title": "Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment", "imported": false, "abstract": "Abstract - Background Vitamins and minerals have many functions in the nervous system which are important for brain health. It has been suggested that various different vitamin and mineral supplements might be useful in maintaining cognitive function and delaying the onset of dementia. In this review, we sought to examine the evidence for this in people who already had mild cognitive impairment (MCI). Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function and the incidence of dementia in people with mild cognitive impairment. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CENTRAL, CINAHL, LILACs, Web of Science Core Collection, ClinicalTrials.gov, and the WHO Portal/ICTRP, from inception to 25 January 2018. Selection criteria We included randomised or quasi‐randomised, placebo‐controlled trials which evaluated orally administered vitamin or mineral supplements in participants with a diagnosis of mild cognitive impairment and which assessed the incidence of dementia or cognitive outcomes, or both. We were interested in studies applicable to the general population of older people and therefore excluded studies in which participants had severe vitamin or mineral deficiencies. Data collection and analysis We sought data on our primary outcomes of dementia incidence and overall cognitive function and on secondary outcomes of episodic memory, executive function, speed of processing, quality of life, functional performance, clinical global impression, adverse events, and mortality. We conducted data collection and analysis according to standard Cochrane systematic review methods. We assessed the risk of bias of included studies using the Cochrane 'Risk of bias' assessment tool. We grouped vitamins and minerals according to their putative mechanism of action and, where we considered it to be clinically appropriate, we pooled data using random‐effects methods. We used GRADE methods to assess the overall quality of evidence for each comparison and outcome. Main results We included five trials with 879 participants which investigated B vitamin supplements. In four trials, the intervention was a combination of vitamins B6, B12, and folic acid; in one, it was folic acid only. Doses varied. We considered there to be some risks of performance and attrition bias and of selective outcome reporting among these trials. Our primary efficacy outcomes were the incidence of dementia and scores on measures of overall cognitive function. None of the trials reported the incidence of dementia and the evidence on overall cognitive function was of very low‐quality. There was probably little or no effect of B vitamins taken for six to 24 months on episodic memory, executive function, speed of processing, or quality of life. The evidence on our other secondary clinical outcomes, including harms, was very sparse or very low‐quality. There was evidence from one study that there may be a slower rate of brain atrophy over two years in participants taking B vitamins. The same study reported subgroup analyses based on the level of serum homocysteine (tHcy) at baseline and found evidence that B vitamins may improve episodic memory in those with tHcy above the median at baseline. We included one trial (n = 516) of vitamin E supplementation. Vitamin E was given as 1000 IU of alpha‐tocopherol twice daily. We considered this trial to be at risk of attrition and selective reporting bias. There was probably no effect of vitamin E on the probability of progression from MCI to Alzheimer's dementia over three years (HR 1.02; 95% CI 0.74 to 1.41; n = 516; 1 study, moderate‐quality evidence). There was also no evidence of an effect at intermediate time points. The available data did not allow us to conduct analyses, but the authors reported no significant effect of three years of supplementation with vitamin E on overall cognitive function, episodic memory, speed of processing, clinical global impression, functional performance, adverse events, or mortality (five deaths in each group). We considered this to be low‐quality evidence. We included one trial (n = 256) of combined vitamin E and vitamin C supplementation and one trial (n = 26) of supplementation with chromium picolinate. In both cases, there was a single eligible cognitive outcome, but we considered the evidence to be very low‐quality and so could not be sure of any effects. Authors' conclusions The evidence on vitamin and mineral supplements as treatments for MCI is very limited. Three years of treatment with high‐dose vitamin E probably does not reduce the risk of progression to dementia, but we have no data on this outcome for other supplements. Only B vitamins have been assessed in more than one RCT. There is no evidence for beneficial effects on cognition of supplementation with B vitamins for six to 24 months. Evidence from a single study of a reduced rate of brain atrophy in participants taking vitamin B and a beneficial effect of vitamin B on episodic memory in those with higher tHcy at baseline warrants attempted replication. Plain language summary Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment Review question This review investigated whether people with mild cognitive impairment can reduce their risk of developing dementia, or can prevent their memory or other thinking skills from deteriorating further, by taking vitamin or mineral supplements. Background Slight changes in memory and thinking skills are common as people get older. When these changes are worse than can be expected in normal ageing, but are not bad enough to make a person's usual activities difficult to manage, then the person is said to have mild cognitive impairment (MCI). People with MCI are at increased risk of developing dementia in the future. Vitamins and minerals are naturally occurring substances which are needed in the diet to maintain health. They have lots of different functions in the body and many are essential to keep the brain working properly. It has been suggested that supplementing a person's normal diet with extra doses of these vitamins or minerals might help to maintain thinking skills or prevent dementia. Study characteristics We found eight randomised controlled trials (RCTs), which investigated four different types of vitamin or mineral pills by comparing them to a placebo (a dummy pill). The vitamins tested were B vitamins (vitamin B6, vitamin B12 and folic acid), vitamin E, and vitamin E and C given together. The only mineral tested was chromium. Key results and quality of the evidence Vitamin B combination versus placebo Five trials with a total of 879 participants compared B vitamins with placebo. Four used combinations of vitamin B6, vitamin B12, and folic acid; one small study tested folic acid on its own. None of these studies reported whether or not participants developed dementia. These studies did not find that memory or thinking skills differed between the group of people who took vitamin B supplements and those who took placebo after treatment lasting six months to two years. Our confidence in the results on different tests used in the studies varied from moderate to very low. Two years of vitamin B supplements did seem to help memory in a small subgroup of participants in one study who could be identified by a particular blood test at the start of the trial. One study found that there was probably no effect on participants' quality of life. One study scanned the brains of some participants and reported that B vitamins may slow the rate of brain shrinkage. Harmful effects and deaths were reported in very few participants and we cannot conclude whether or not there are harms from taking these or similar combinations of B vitamins. Vitamin E versus placebo. One study with 516 participants compared a relatively high dose of vitamin E (2000 IU a day) to placebo in people who were also taking a multivitamin containing 15 IU of vitamin E (the daily requirement for vitamin E is approximately 30 IU). The risk of developing dementia due to Alzheimer’s disease (the commonest form of dementia) is probably not affected by three years of treatment with high‐dose vitamin E. The quality of the evidence for other outcomes was lower, but there may also be no effect of this dose of vitamin E on specific memory or thinking skills or on how well people could manage their daily activities. Vitamin E and C versus placebo One study with 256 participants compared a combination of vitamins C and E with placebo. It found no effect on overall memory and thinking skills, but we had little confidence in this result because of the quality of the evidence. Chromium picolinate versus placebo Only one very small study with 26 participants investigated the effect of chromium supplements. This study was too small for us to be able to draw any conclusions. Conclusions The amount and quality of research evidence about vitamin and mineral supplements for treating MCI in people without nutritional deficiency is limited. At the moment, it is not possible to identify any supplements which can reduce the risk of people with MCI developing dementia or which can effectively treat their symptoms. More research is needed before we can answer our review question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "McCleery, J, Abraham, RP, Denton, DA, Rutjes, AWS, Chong, LY, Al‐Assaf, AS, Griffith, DJ, Rafeeq, S, Yaman, H, Malik, MA, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011905.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.796Z" }, { "id": "2a4e9820-56f5-4fb7-b494-76dbe027c48d", "pmid": "", "title": "Wheat flour fortification with iron and other micronutrients for reducing anaemia and improving iron status in populations", "imported": false, "abstract": "Abstract - Background Anaemia is a condition where the number of red blood cells (and consequently their oxygen‐carrying capacity) is insufficient to meet the body's physiological needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations. Objectives To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health‐related outcomes in populations over two years of age. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, 21 other databases and two trials registers up to 21 July 2020, together with contacting key organisations to identify additional studies. Selection criteria We included cluster‐ or individually‐randomised controlled trials (RCTs) carried out among the general population from any country, aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. We included trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat Data collection and analysis Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risks of bias. We followed Cochrane methods in this review. Main results Our search identified 3538 records, after removing duplicates. We included 10 trials, involving 3319 participants, carried out in Bangladesh, Brazil, India, Kuwait, Philippines, South Africa and Sri Lanka. We identified two ongoing studies and one study is awaiting classification. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, three trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial used various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta‐analyses. Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added may reduce by 27% the risk of anaemia in populations (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.55 to 0.97; 5 studies, 2315 participants; low‐certainty evidence). It is uncertain whether iron‐fortified wheat flour with or without other micronutrients reduces iron deficiency (RR 0.46, 95% CI 0.20 to 1.04; 3 studies, 748 participants; very low‐certainty evidence) or increases haemoglobin concentrations (in g/L) (mean difference MD 2.75, 95% CI 0.71 to 4.80; 8 studies, 2831 participants; very low‐certainty evidence). No trials reported data on adverse effects in children (including constipation, nausea, vomiting, heartburn or diarrhoea), except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to the risk of Infection or inflammation at individual level as measured by C‐reactive protein (CRP) (mean difference (MD) 0.04, 95% CI −0.02 to 0.11; 2 studies, 558 participants; moderate‐certainty evidence). Iron‐fortified wheat flour with other micronutrients added versus unfortified wheat flour (nil micronutrients added) It is unclear whether wheat flour fortified with iron, in combination with other micronutrients decreases anaemia (RR 0.77, 95% CI 0.41 to 1.46; 2 studies, 317 participants; very low‐certainty evidence). The intervention probably reduces the risk of iron deficiency (RR 0.73, 95% CI 0.54 to 0.99; 3 studies, 382 participants; moderate‐certainty evidence) and it is unclear whether it increases average haemoglobin concentrations (MD 2.53, 95% CI −0.39 to 5.45; 4 studies, 532 participants; very low‐certainty evidence). No trials reported data on adverse effects in children. Nine out of 10 trials reported sources of funding, with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials. Authors' conclusions Fortification of wheat flour with iron (in comparison to unfortified flour, or where both groups received the same other micronutrients) may reduce anaemia in the general population above two years of age, but its effects on other outcomes are uncertain. Iron‐fortified wheat flour in combination with other micronutrients, in comparison with unfortified flour, probably reduces iron deficiency, but its effects on other outcomes are uncertain. None of the included trials reported data on adverse side effects except for risk of infection or inflammation at the individual level. The effects of this intervention on other health outcomes are unclear. Future studies at low risk of bias should aim to measure all important outcomes, and to further investigate which variants of fortification, including the role of other micronutrients as well as types of iron fortification, are more effective, and for whom. Plain language summary Does adding iron to wheat flour reduce anaemia and increase iron levels in the general population? Why do we need iron in our diet? Iron is an essential mineral found in every cell of the body. It is needed to make haemoglobin, the oxygen‐carrying protein in the blood. Iron molecules in haemoglobin bind to oxygen and carry it from the lungs to all the cells and tissues in the body. Low levels of haemoglobin means the body does not get enough oxygen. Anaemia develops when haemoglobin levels in the blood fall too low. Symptoms of anaemia include: tiredness and lack of energy, getting out of breath quickly, pale skin and a greater susceptibility to infections. Low haemoglobin levels can be caused by blood loss, pregnancy or not eating enough foods containing iron (iron‐deficiency anaemia). Iron‐deficiency anaemia may be treated by taking iron tablets or eating foods rich in iron. Fortified foods Adding micronutrients (vitamins and minerals) to foods, whether those micronutrients were originally present or not, is called fortification. Fortifying foods is one way to improve nutrition in a population. People living in low‐income countries may not have enough iron in their diet, and may be at risk of anaemia. Adding iron and other nutrients to foods routinely eaten in large quantities, such as flour, is thought to help prevent iron‐deficiency anaemia. Why we did this Cochrane Review We wanted to find out how adding iron, and other minerals and vitamins, to wheat flour affected the blood iron levels of the general population, and whether fewer people developed anaemia or other health conditions. We also wanted to know if adding iron to wheat flour caused any unwanted effects. What did we do? We searched for studies that investigated eating any types of food made with wheat flour containing added iron, or foods made with wheat flour without added iron. We then compared the studies with each other, to find out the effects of adding iron to wheat flour on people's health and the levels of iron and haemoglobin in their blood. Search date: we included evidence published up to 21 July 2020. What we found We found 10 studies in 3319 people (aged 2 years and older). The studies lasted from 3 months to 24 months, and took place in Bangladesh, Brazil, India, Kuwait, the Philippines, Sri Lanka and South Africa. The studies looked at the effects of: · wheat flour containing added iron (with or without other minerals and vitamins) compared with wheat flour without added iron (but with the same other minerals and vitamins); · wheat flour containing added iron and other minerals and vitamins compared with wheat flour without any added minerals or vitamins. The wheat flours used in the studies contained different amounts of iron: from under 40 mg/kg to over 60 mg/kg. We were interested in: · how many people had anaemia (defined by low haemoglobin levels); · how many people had low levels of iron in their blood (iron deficiency; tested using a biomarker); · haemoglobin concentrations in people's blood; · how many children had diarrhoea or respiratory infections; · how many children died (of any cause); · signs of infection or inflammation (the body's response to injury) in children (by testing a biomarker in the blood); and · any unwanted effects. Most studies had multiple sources of funding; some were partly funded by companies involved in the food, chemical or pharmaceutical industries. What are the results of our review? Compared with flour without added iron (but with other minerals and vitamins) Flour containing added iron (with or without other minerals and vitamins): · may reduce anaemia, by 27% (evidence from 5 studies, 2315 people); and · probably makes no difference to children's risk of infection or inflammation (2 studies, 558 children). It was unclear how flour with added iron affected iron deficiency (3 studies, 748 people), or haemoglobin levels (8 studies, 2831 people ). Compared with flour without any added minerals or vitamins Flour containing added iron (with other minerals and vitamins) probably reduced iron deficiency (3 studies, 382 people). It was unclear from the studies how flour containing added iron affected anaemia (2 studies, 317 people) or haemoglobin levels (4 studies, 532 people). No studies reported information about unwanted effects, or how many children died, or had diarrhoea or respiratory infections. Our confidence in our results Our confidence is moderate to low that adding iron to flour probably reduces iron deficiency and anaemia. The studies appeared to show fewer people with iron deficiency and slightly higher haemoglobin levels associated with flour with added iron, but the results varied widely, so we are uncertain about the effect. These results might change if further evidence becomes available. We found limitations in the ways some of the studies were designed and conducted, and this could have affected their results. Key messages Adding iron to wheat flour may lead to fewer people with anaemia or low blood‐iron levels in the general population. We do not know if adding iron to wheat flour causes any unwanted effects, because no studies looked at these.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Field, MS; Mithra, P; Peña-Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD011302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "2a5605fe-99dc-4af1-b6e0-9e9a6173f27f", "pmid": "", "title": "Chloroquine or hydroxychloroquine for prevention and treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The coronavirus disease 2019 (COVID‐19) pandemic has resulted in substantial mortality. Some specialists proposed chloroquine (CQ) and hydroxychloroquine (HCQ) for treating or preventing the disease. The efficacy and safety of these drugs have been assessed in randomized controlled trials. Objectives To evaluate the effects of chloroquine (CQ) or hydroxychloroquine (HCQ) for 1) treating people with COVID‐19 on death and time to clearance of the virus; 2) preventing infection in people at risk of SARS‐CoV‐2 exposure; 3) preventing infection in people exposed to SARS‐CoV‐2. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Current Controlled Trials (www.controlled‐trials.com), and the COVID‐19‐specific resources www.covid‐nma.com and covid‐19.cochrane.org, for studies of any publication status and in any language. We performed all searches up to 15 September 2020. We contacted researchers to identify unpublished and ongoing studies. Selection criteria We included randomized controlled trials (RCTs) testing chloroquine or hydroxychloroquine in people with COVID‐19, people at risk of COVID‐19 exposure, and people exposed to COVID‐19. Adverse events (any, serious, and QT‐interval prolongation on electrocardiogram) were also extracted. Data collection and analysis Two review authors independently assessed eligibility of search results, extracted data from the included studies, and assessed risk of bias using the Cochrane ‘Risk of bias’ tool. We contacted study authors for clarification and additional data for some studies. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). We performed meta‐analysis using a random‐effects model for outcomes where pooling of effect estimates was appropriate. Main results 1. Treatment of COVID‐19 disease We included 12 trials involving 8569 participants, all of whom were adults. Studies were from China (4); Brazil, Egypt, Iran, Spain, Taiwan, the UK, and North America (each 1 study); and a global study in 30 countries (1 study). Nine were in hospitalized patients, and three from ambulatory care. Disease severity, prevalence of comorbidities, and use of co‐interventions varied substantially between trials. We found potential risks of bias across all domains for several trials. Nine trials compared HCQ with standard care (7779 participants), and one compared HCQ with placebo (491 participants); dosing schedules varied. HCQ makes little or no difference to death due to any cause (RR 1.09, 95% CI 0.99 to 1.19; 8208 participants; 9 trials; high‐certainty evidence). A sensitivity analysis using modified intention‐to‐treat results from three trials did not influence the pooled effect estimate. HCQ may make little or no difference to the proportion of people having negative PCR for SARS‐CoV‐2 on respiratory samples at day 14 from enrolment (RR 1.00, 95% CI 0.91 to 1.10; 213 participants; 3 trials; low‐certainty evidence). HCQ probably results in little to no difference in progression to mechanical ventilation (RR 1.11, 95% CI 0.91 to 1.37; 4521 participants; 3 trials; moderate‐certainty evidence). HCQ probably results in an almost three‐fold increased risk of adverse events (RR 2.90, 95% CI 1.49 to 5.64; 1394 participants; 6 trials; moderate‐certainty evidence), but may make little or no difference to the risk of serious adverse events (RR 0.82, 95% CI 0.37 to 1.79; 1004 participants; 6 trials; low‐certainty evidence). We are very uncertain about the effect of HCQ on time to clinical improvement or risk of prolongation of QT‐interval on electrocardiogram (very low‐certainty evidence). One trial (22 participants) randomized patients to CQ versus lopinavir/ritonavir, a drug with unknown efficacy against SARS‐CoV‐2, and did not report any difference for clinical recovery or adverse events. One trial compared HCQ combined with azithromycin against standard care (444 participants). This trial did not detect a difference in death, requirement for mechanical ventilation, length of hospital admission, or serious adverse events. A higher risk of adverse events was reported in the HCQ‐and‐azithromycin arm; this included QT‐interval prolongation, when measured. One trial compared HCQ with febuxostat, another drug with unknown efficacy against SARS‐CoV‐2 (60 participants). There was no difference detected in risk of hospitalization or change in computed tomography (CT) scan appearance of the lungs; no deaths were reported. 2. Preventing COVID‐19 disease in people at risk of exposure to SARS‐CoV‐2 Ongoing trials are yet to report results for this objective. 3. Preventing COVID‐19 disease in people who have been exposed to SARS‐CoV‐2 One trial (821 participants) compared HCQ with placebo as a prophylactic agent in the USA (around 90% of participants) and Canada. Asymptomatic adults (66% healthcare workers; mean age 40 years; 73% without comorbidity) with a history of exposure to people with confirmed COVID‐19 were recruited. We are very uncertain about the effect of HCQ on the primary outcomes, for which few events were reported: 20/821 (2.4%) developed confirmed COVID‐19 at 14 days from enrolment, and 2/821 (0.2%) were hospitalized due to COVID‐19 (very low‐certainty evidence). HCQ probably increases the risk of adverse events compared with placebo (RR 2.39, 95% CI 1.83 to 3.11; 700 participants; 1 trial; moderate‐certainty evidence). HCQ may result in little or no difference in serious adverse events (no RR: no participants experienced serious adverse events; low‐certainty evidence). One cluster‐randomized trial (2525 participants) compared HCQ with standard care for the prevention of COVID‐19 in people with a history of exposure to SARS‐CoV‐2 in Spain. Most participants were working or residing in nursing homes; mean age was 49 years. There was no difference in the risk of symptomatic confirmed COVID‐19 or production of antibodies to SARS‐CoV‐2 between the two study arms. Authors' conclusions HCQ for people infected with COVID‐19 has little or no effect on the risk of death and probably no effect on progression to mechanical ventilation. Adverse events are tripled compared to placebo, but very few serious adverse events were found. No further trials of hydroxychloroquine or chloroquine for treatment should be carried out. These results make it less likely that the drug is effective in protecting people from infection, although this is not excluded entirely. It is probably sensible to complete trials examining prevention of infection, and ensure these are carried out to a high standard to provide unambiguous results. Plain language summary Is chloroquine or hydroxychloroquine useful in treating people with COVID‐19, or in preventing infection in people who have been exposed to the virus? What is the aim of this review? COVID‐19 is an infectious respiratory disease caused by a coronavirus called SARS‐CoV‐2. If the infection becomes severe, people may need intensive care and support in hospital, including mechanical ventilation. Drugs used for other diseases were tried out in COVID‐19, and this included chloroquine, used for malaria; and hydroxychloroquine used for rheumatic diseases, such as rheumatoid arthritis or systemic lupus erythematosus. We sought evidence of the effects of these drugs in treating people ill with the disease; in preventing the disease in people at risk of getting the disease, such as health workers; and people exposed to the virus developing the disease. Key messages Hydroxychloroquine does not reduce deaths from COVID‐19, and probably does not reduce the number of people needing mechanical ventilation. Hydroxychloroquine caused more unwanted effects than a placebo treatment, though it did not appear to increase the number of serious unwanted effects. We do not think new studies of hydroxychloroquine should be started for treatment of COVID‐19. What was studied in the review? We searched for studies that looked at giving chloroquine and hydroxychloroquine to people with COVID‐19; people at risk of being exposed to the virus; and people who have been exposed to the virus. We found 14 relevant studies: 12 studies of chloroquine or hydroxychloroquine used to treat COVID‐19 in 8569 adults; two studies of hydroxychloroquine to stop COVID‐19 in 3346 adults who had been exposed to the virus but had no symptoms of infection. We did not find any completed studies of these medicines to stop COVID‐19 in people who were at risk of exposure to the virus; studies are still under way. The studies took place in China, Brazil, Egypt, Iran, Taiwan, North America, and Europe; one study was worldwide. Some studies were partly funded by pharmaceutical companies that manufacture hydroxychloroquine. What are the main results of our review? Treating COVID‐19 Compared with usual care or placebo, hydroxychloroquine: · clearly did not affect how many people died (of any cause; 9 studies in 8208 people); · probably did not affect how many people needed mechanical ventilation (3 studies; 4521 people); · may not affect how many people still tested positive for the virus after 14 days (3 studies; 213 people). We are uncertain whether hydroxychloroquine affected the number of people whose symptoms improved after 28 days. Compared with other antiviral treatment (lopinavir plus ritonavir), chloroquine made little or no difference to the time taken for symptoms to improve (1 study; 22 people). Compared with usual care in one study in 444 people, hydroxychloroquine given with azithromycin (an antibiotic) made no difference to: · how many people died; · how many needed mechanical ventilation; or · time spent in hospital. Compared with febuxostat (a medicine to treat gout), hydroxychloroquine made no difference to how many people were admitted to hospital or to changes seen on scans of people's lungs; no deaths were reported (1 study; 60 people). Preventing COVID‐19 in people exposed to it We are uncertain whether hydroxychloroquine affected how many people developed COVID‐19, or how many people were admitted to hospital with COVID‐19, compared with those receiving a placebo treatment (1 study; 821 people). Compared with usual care, hydroxychloroquine made no difference to the risk of developing COVID‐19, or antibodies to the virus, in people exposed to it (1 study; 2525 people). Unwanted effects When used for treating COVID‐19, compared with usual care or placebo, hydroxychloroquine: · probably increases the risk of mild unwanted effects (6 studies; 1394 people); · may not increase the risk of serious harmful effects (6 studies; 1004 people). When given along with azithromycin, hydroxychloroquine increased the risk of any unwanted effects, but made no difference to the risk of serious unwanted effects (1 study; 444 people). Compared with lopinavir plus ritonavir, chloroquine made little or no difference to the risk of unwanted effects (1 study; 22 people). When used for preventing COVID‐19, hydroxychloroquine probably causes more unwanted effects than placebo, but may not increase the risk of serious, harmful unwanted effects (1 study; 700 people). How confident are we in our results? We are confident about our results for how many people died and moderately confident about how many needed mechanical ventilation. We are moderately confident about the unwanted effects of hydroxychloroquine treatment, but less confident about our results for serious unwanted effects; these results might change with further evidence. How up‐to‐date is this review? We included evidence published up to 15 September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Singh, B, Ryan, H, Kredo, T, Chaplin, M, Fletcher, T", "articleTypes": [], "doi": "10.1002/14651858.CD013587.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.804Z" }, { "id": "2a5c888f-a8fa-4659-9365-a63b04defc9f", "pmid": "", "title": "Interventions for the management of dry mouth: non‐pharmacological interventions", "imported": false, "abstract": "Abstract - Background Xerostomia is the subjective sensation of dry mouth. Common causes of xerostomia include adverse effects of many commonly prescribed medications, disease (e.g. Sjogren's Syndrome) and radiotherapy treatment for head and neck cancers. Non‐pharmacological techniques such as acupuncture or mild electrostimulation may be used to improve symptoms. Objectives To assess the effects of non‐pharmacological interventions administered to stimulate saliva production for the relief of dry mouth. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 16th April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 3), MEDLINE via OVID (1948 to 16th April 2013), EMBASE via OVID (1980 to 16th April 2013), AMED via OVID (1985 to 16th April 2013), CINAHL via EBSCO (1981 to 16th April 2013), and CANCERLIT via PubMed (1950 to 16th April 2013). The meta Register of Controlled Clinical Trials ( www.controlled‐trials.com ) and ClinicalTrials.gov ( www.clinicaltrials.gov ) were also searched to identify ongoing and completed trials. References lists of included studies and relevant reviews were also searched. There were no restrictions on the language of publication or publication status. Selection criteria We included parallel group randomised controlled trials of non‐pharmacological interventions to treat dry mouth, where participants had dry mouth symptoms at baseline. Data collection and analysis At least two review authors assessed each of the included studies to confirm eligibility, assess risk of bias and extract data using a piloted data extraction form. We calculated mean difference (MD) and 95% confidence intervals (CI) for continuous outcomes or where different scales were used to assess an outcome, we calculated standardised mean differences (SMD) together with 95% CIs. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information. Main results There were nine studies (total 366 participants randomised) included in this review of non‐pharmacological interventions for dry mouth which were divided into three comparisons. Eight studies were assessed at high risk of bias in at least one domain and the remaining study was at unclear risk of bias. Five small studies (total 153 participants, with dry mouth following radiotherapy treatment) compared acupuncture with placebo. Four were assessed at high risk and one at unclear risk of bias. Two trials reported outcome data for dry mouth in a form suitable for meta‐analysis. The pooled estimate of these two trials (70 participants, low quality evidence) showed no difference between acupuncture and control in dry mouth symptoms (SMD ‐0.34, 95% CI ‐0.81 to 0.14, P value 0.17, I 2 = 39%) with the confidence intervals including both a possible reduction or a possible increase in dry mouth symptoms. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). There was a very small increase in unstimulated whole saliva (UWS) at the end of 4 to 6 weeks of treatment (three trials, 71 participants, low quality evidence) (MD 0.02 ml/minute, 95% CI 0 to 0.04, P value 0.04, I 2 = 57%), and this benefit persisted at the 12‐month follow‐up evaluation (two trials, 54 participants, low quality evidence) (UWS, MD 0.06 ml/minute, 95% CI 0.01 to 0.11, P value 0.03, I 2 = 10%). For the outcome of stimulated whole saliva (SWS, three trials, 71 participants, low quality evidence) there was a benefit favouring acupuncture (MD 0.19 ml/minute, 95% CI 0.07 to 0.31, P value 0.002, I 2 = 1%) an effect which also persisted at the 12‐month follow‐up evaluation (SWS MD 0.28 ml/minute, 95% CI 0.09 to 0.47, P value 0.004, I 2 = 0%) (two trials, 54 participants, low quality evidence). Two small studies, both at high risk of bias, compared the use of an electrostimulation device with a placebo device in participants with Sjögren's Syndrome (total 101 participants). A further study, also at high risk of bias, compared acupuncture‐like electrostimulation of different sets of points in participants who had previously been treated with radiotherapy. None of these studies reported the outcome of dry mouth. There was no difference between electrostimulation and placebo in the outcomes of UWS or SWS at the end of the 4‐week treatment period in the one study (very low that provided data for these outcomes. No adverse effects were reported. A single study at high risk of bias, compared the stimulatory effect of powered versus manual toothbrushing and found no difference for the outcomes of UWS or SWS. Authors' conclusions There is low quality evidence that acupuncture is no different from placebo acupuncture with regard to dry mouth symptoms, which is the most important outcome. This may be because there were insufficient participants included in the two trials to show a possible effect or it may be that there was some benefit due to 'placebo' acupuncture which could have biased the effect to the null. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms. It is well known that dry mouth symptoms may be problematic even when saliva production is increased, yet only two of the trials that evaluated acupuncture reported dry mouth symptoms, a worrying reporting bias. There is some low quality evidence that acupuncture results in a small increase in saliva production in patients with dry mouth following radiotherapy. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms or saliva production in patients with Sjögren's Syndrome. Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation. Plain language summary Non‐drug treatments for dry mouth symptoms Review question This review, carried out by authors of the Cochrane Oral Health Group, has been produced to assess the effects of non‐drug treatments used to stimulate saliva production for the relief of dry mouth (xerostomia) symptoms. Background Dry mouth is a common problem with an estimated incidence of between 10% and 26% in men and between 10% and 33% in women, which may or may not be due to reduced saliva secretion. Common causes of dry mouth include the side effects of many commonly prescribed medications, diseases (such as Sjögren's syndrome where the immune system destroys tissues in the glands which produce saliva) and radiotherapy treatments for head and neck cancers. Saliva moistens the skin in the mouth and helps to maintain oral health. The presence of saliva facilitates speech, acts to wash away food residue from around the teeth, neutralises potentially damaging food and bacterial acids, enhances a person's ability to taste the food, and generally lubricates the mouth. Saliva also acts to soften food, making it easier to chew and swallow. Enzymes in saliva start the digestion of starch and fats, and other substances in saliva, such as epidermal growth factors, promote tissue growth, differentiation and wound healing. The antibacterial, antifungal and antiviral agents in saliva balance the oral flora and help to prevent oral infections, while the minerals in saliva help to maintain tooth enamel. Non‐drug treatments such as acupuncture, mild electrical stimulation, lasers, tooth brushing and other stimulation techniques are used to improve dry mouth symptoms. Study characteristics The evidence on which this review is based was up‐to‐date as of 16 April 2013. Nine studies were included in this review. A total of 366 adult participants took part in these trials, with an average of 40 participants per trial, and an age range from 12 to 77 years. The causes of dry mouth were radiotherapy for oral cancers in four trials, Sjögren's syndrome in three trials, medication‐related in one trial, and in the remaining trial participants had a range of causes of dry mouth. The included studies were divided into three groups, according the interventions evaluated. 1. Five small studies with a total 153 participants evaluated acupuncture. 2. Three studies evaluated electrostimulation devices. 3. One study evaluated a power toothbrush. Key results The five studies evaluating the effects of acupuncture in people who had dry mouth were generally of poor quality. There was no evidence of a difference in dry mouth symptoms, but there was some evidence of a small increase in saliva production which persisted for a year after the end of the acupuncture treatment. There may not have been enough people included in the trials to show a difference in dry mouth, or it may have been that both the real acupuncture and the 'placebo' acupuncture had some beneficial effect. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). The studies evaluating the effects of electrostimulation devices were poorly conducted and reported, and provided insufficient evidence to determine the effects of these devices on either dry mouth or saliva production. The single small study of a powered versus a manual toothbrush also found no difference for either dry mouth or saliva production. None of the included studies reported the outcomes of duration of effectiveness, quality of life, patient satisfaction, or oral health assessment. Quality of the evidence These studies were generally of poor quality (low and very low).", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Furness, S, Bryan, G, McMillan, R, Birchenough, S, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD009603.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.760Z" }, { "id": "2a7189ba-5528-4d13-ac32-42813262e1be", "pmid": "", "title": "Corrector therapies (with or without potentiators) for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR variant F508del is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF)). The F508del variant lacks meaningful CFTR function ‐ faulty protein is degraded before reaching the cell membrane, where it needs to be to effect transepithelial salt transport. Corrective therapy could benefit many pwCF. This review evaluates single correctors (monotherapy) and any combination of correctors (most commonly lumacaftor, tezacaftor, elexacaftor, VX‐659, VX‐440 or VX‐152) and a potentiator (e.g. ivacaftor) (dual and triple therapies). Objectives To evaluate the effects of CFTR correctors (with or without potentiators) on clinically important benefits and harms in pwCF of any age with class II CFTR mutations (most commonly F508del). Search methods We searched the Cochrane CF Trials Register (28 November 2022), reference lists of relevant articles and online trials registries (3 December 2022). Selection criteria Randomised controlled trials (RCTs) (parallel design) comparing CFTR correctors to control in pwCF with class II mutations. Data collection and analysis Two authors independently extracted data, assessed risk of bias and judged evidence certainty (GRADE); we contacted investigators for additional data. Main results We included 34 RCTs (4781 participants), lasting between 1 day and 48 weeks; an extension of two lumacaftor‐ivacaftor studies provided additional 96‐week safety data (1029 participants). We assessed eight monotherapy RCTs (344 participants) (4PBA, CPX, lumacaftor, cavosonstat and FDL169), 16 dual‐therapy RCTs (2627 participants) (lumacaftor‐ivacaftor or tezacaftor‐ivacaftor) and 11 triple‐therapy RCTs (1804 participants) (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor). Participants in 21 RCTs had the genotype F508del/F508del, in seven RCTs they had F508del/minimal function (MF), in one RCT F508del/gating genotypes, in one RCT either F508del/F508del genotypes or F508del/residual function genotypes, in one RCT either F508del/gating or F508del/residual function genotypes, and in three RCTs either F508del/F508del genotypes or F508del/MF genotypes. Risk of bias judgements varied across different comparisons. Results from 16 RCTs may not be applicable to all pwCF due to age limits (e.g. adults only) or non‐standard designs (converting from monotherapy to combination therapy). Monotherapy Investigators reported no deaths or clinically relevant improvements in quality of life (QoL). There was insufficient evidence to determine effects on lung function. No placebo‐controlled monotherapy RCT demonstrated differences in mild, moderate or severe adverse effects (AEs); the clinical relevance of these events is difficult to assess due to their variety and few participants (all F508del/F508del). Dual therapy In a tezacaftor‐ivacaftor group there was one death (deemed unrelated to the study drug). QoL scores (respiratory domain) favoured both lumacaftor‐ivacaftor and tezacaftor‐ivacaftor therapy compared to placebo at all time points (moderate‐certainty evidence). At six months, relative change in forced expiratory volume in one second (FEV 1 ) % predicted improved with all dual combination therapies compared to placebo (high‐ to moderate‐certainty evidence). More pwCF reported early transient breathlessness with lumacaftor‐ivacaftor (odds ratio (OR) 2.05, 99% confidence interval (CI) 1.10 to 3.83; I 2 = 0%; 2 studies, 739 participants; high‐certainty evidence). Over 120 weeks (initial study period and follow‐up), systolic blood pressure rose by 5.1 mmHg and diastolic blood pressure by 4.1 mmHg with twice‐daily 400 mg lumacaftor‐ivacaftor (80 participants). The tezacaftor‐ivacaftor RCTs did not report these adverse effects. Pulmonary exacerbation rates decreased in pwCF receiving additional therapies to ivacaftor compared to placebo (all moderate‐certainty evidence): lumacaftor 600 mg (hazard ratio (HR) 0.70, 95% CI 0.57 to 0.87; I 2 = 0%; 2 studies, 739 participants); lumacaftor 400 mg (HR 0.61, 95% CI 0.49 to 0.76; I 2 = 0%; 2 studies, 740 participants); and tezacaftor (HR 0.64, 95% CI 0.46 to 0.89; 1 study, 506 participants). Triple therapy No study reported any deaths (high‐certainty evidence). All other evidence was low‐ to moderate‐certainty. QoL respiratory domain scores probably improved with triple therapy compared to control at six months (six studies). There was probably a greater relative and absolute change in FEV 1 % predicted with triple therapy (four studies each across all combinations). The absolute change in FEV 1 % predicted was probably greater for F508del/MF participants taking elexacaftor‐tezacaftor‐ivacaftor compared to placebo (mean difference 14.30, 95% CI 12.76 to 15.84; 1 study, 403 participants; moderate‐certainty evidence), with similar results for other drug combinations and genotypes. There was little or no difference in adverse events between triple therapy and control (10 studies). No study reported time to next pulmonary exacerbation, but fewer F508del/F508del participants experienced a pulmonary exacerbation with elexacaftor‐tezacaftor‐ivacaftor at four weeks (OR 0.17, 99% CI 0.06 to 0.45; 1 study, 175 participants) and 24 weeks (OR 0.29, 95% CI 0.14 to 0.60; 1 study, 405 participants); similar results were seen across other triple therapy and genotype combinations. Authors' conclusions There is insufficient evidence of clinically important effects from corrector monotherapy in pwCF with F508del/F508del. Additional data in this review reduced the evidence for efficacy of dual therapy; these agents can no longer be considered as standard therapy. Their use may be appropriate in exceptional circumstances (e.g. if triple therapy is not tolerated or due to age). Both dual therapies (lumacaftor‐ivacaftor, tezacaftor‐ivacaftor) result in similar small improvements in QoL and respiratory function with lower pulmonary exacerbation rates. While the effect sizes for QoL and FEV 1 still favour treatment, they have reduced compared to our previous findings. Lumacaftor‐ivacaftor was associated with an increase in early transient shortness of breath and longer‐term increases in blood pressure (not observed for tezacaftor‐ivacaftor). Tezacaftor‐ivacaftor has a better safety profile, although data are lacking in children under 12 years. In this population, lumacaftor‐ivacaftor had an important impact on respiratory function with no apparent immediate safety concerns, but this should be balanced against the blood pressure increase and shortness of breath seen in longer‐term adult data when considering lumacaftor‐ivacaftor. Data from triple therapy trials demonstrate improvements in several key outcomes, including FEV 1 and QoL. There is probably little or no difference in adverse events for triple therapy (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor) in pwCF with one or two F508del variants aged 12 years or older (moderate‐certainty evidence). Further RCTs are required in children under 12 years and those with more severe lung disease. Plain language summary CFTR correctors, a therapy for cystic fibrosis targeted at specific variants (most commonly F508del) Review question How do drugs (or drug combinations) for correcting the basic defect in the most common cystic fibrosis (CF)‐causing gene variant (F508del) impact on outcomes important to people with CF (pwCF), e.g. survival, quality of life (QoL), lung function and safety? Key messages There is a lack of evidence to support monotherapy and limited evidence to support dual therapy for pwCF who have the gene variant F508del. We found important differences across key outcomes, with fewer unwanted side effects in the triple therapy studies when compared to one dual therapy drug combination (lumacaftor plus ivacaftor). More research is needed to assess triple therapy combinations in children and to monitor their safety profiles over the longer term. How would drugs (or drug combinations) correct the basic defect in the most common CF‐causing gene variant (F508del)? The CF gene makes a protein that helps salts move across cells in many parts of the body. Over 80% of pwCF have at least one copy of the genetic variant F508del, meaning they make a full length of this protein, but it cannot move through the cell correctly. Laboratory experiments suggest that if this protein reaches the cell wall, it may be able to function, restore salt movement and correct the chronic problems that pwCF experience. What did we want to find out? How do drugs (or drug combinations) used to treat people of any age who have the genetic variant F508del impact their lives? Are these drugs associated with any unwanted side effects? What did we do? We searched for and included studies that looked at drugs (and drug combinations) used to treat pwCF who had at least one copy of the most common CF‐causing gene variant (F508del) compared to control medications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 34 studies that involved 4781 pwCF and which lasted between 1 day and 48 weeks; all studies compared an active drug treatment to a placebo (drug containing no active treatment). We do not have enough information to decide if 14 studies should be included or not and eight studies have not yet been completed. Eight studies looked at treatment with a single drug (monotherapy). These studies did not report any deaths or clinically relevant improvements in quality of life (QoL) scores. There was not enough evidence to show an effect on lung function. All studies reported side effects; there were a wide range of side effects each reported by a small number of participants in the studies. There were 16 studies assessing a combination of two drugs (dual therapy), either tezacaftor plus ivacaftor or lumacaftor plus ivacaftor. One participant taking tezacaftor plus ivacaftor died, but this was not thought to be related to the treatment. Both dual therapies resulted in improvements in QoL and lung function; rates of pulmonary exacerbations (a flare‐up of symptoms) were also lower. Neither dual therapy was linked to severe side effects, although people starting treatment with lumacaftor plus ivacaftor experienced shortness of breath for one to two weeks; this usually stopped without further treatment . More concerningly, in longer studies some people taking lumacaftor plus ivacaftor experienced a rise in blood pressure. Two people (out of over 500) even stopped lumacaftor plus ivacaftor treatment because of high blood pressure. These side effects were not reported for tezacaftor plus ivacaftor. There were 11 studies assessing different combinations of three drugs (triple therapy). The combinations were based on tezacaftor with ivacaftor (or deutivacaftor, which is a similar but chemically altered version of ivacaftor) and investigators then added either elexacaftor, VX‐659, VX‐440 or VX‐152 and compared these to either triple placebo, or tezacaftor with ivacaftor and one placebo. Some studies split groups by treatment and also by different genetic variants. No study reported any deaths. Triple therapies improved QoL scores and lung function in all comparisons, with no difference in the number or severity of side effects. Fewer people with two copies of F508del taking elexacaftor plus tezacaftor plus ivacaftor experienced a pulmonary exacerbation than those taking the control treatment. What are the limitations of the evidence? Our certainty in the evidence ranged from uncertain to very certain, but we were quite certain of the evidence for most results. While studies generally provided few details about their design, so we could not make clear judgements on potential biases, we had fewer concerns with the larger, more recent studies. Some of our findings are based on studies that were too small to show important effects and for 16 studies the results may not be applicable to all pwCF due to them only including people of certain ages (i.e. only adults or only children). Also, one study had an unusual design where people were given monotherapy and then later a dual therapy. How up‐to‐date is this evidence? This review updates our earlier review. We last looked for evidence on 28 November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Heneghan, M; Southern, KW; Murphy, J; Sinha, IP; Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD010966.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "2a844423-7291-416c-b3f7-c04ad09ff13f", "pmid": "", "title": "Oral deferiprone for iron chelation in people with thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. A commonly used iron chelator, deferiprone, has been found to be pharmacologically efficacious. However, important questions exist about the efficacy and safety of deferiprone compared to another iron chelator, desferrioxamine. Objectives To summarise data from trials on the clinical efficacy and safety of deferiprone and to compare the clinical efficacy and safety of deferiprone with desferrioxamine for thalassaemia. Search methods We searched the Cochrane Cystic fibrosis and Genetic Disorders Group's Haemoglobinopathies trials Register and MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus registers of ongoing trials and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). We also contacted the manufacturers of deferiprone and desferrioxamine. All searches were updated to 05 March 2013. Selection criteria Randomised controlled trials comparing deferiprone with another iron chelator; or comparing two schedules or doses of deferiprone, in people with transfusion‐dependent thalassaemia. Data collection and analysis Two authors independently assessed trials for risk of bias and extracted data. Missing data were requested from the original investigators. Main results A total of 17 trials involving 1061 participants (range 13 to 213 participants per trial) were included. Of these, 16 trials compared either deferiprone alone with desferrioxamine alone, or a combined therapy of deferiprone and desferrioxamine with either deferiprone alone or desferrioxamine alone; one compared different schedules of deferiprone. There was little consistency between outcomes and limited information to fully assess the risk of bias of most of the included trials. Four trials reported mortality; each reported the death of one individual receiving deferiprone with or without desferrioxamine. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage. Earlier trials measuring the cardiac iron load indirectly by magnetic resonance imaging (MRI) T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, a meta‐analysis of two trials suggested that left ventricular ejection fraction was significantly reduced in patients who received desferrioxamine alone compared with combination therapy. One trial, which planned five years of follow up, was stopped early due to the beneficial effects of combined treatment compared with deferiprone alone in terms of serum ferritin levels reduction. The results of this and three other trials suggest an advantage of combined therapy over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no conclusive or consistent evidence for the improved efficacy of combined deferiprone and desferrioxamine therapy over monotherapy from direct or indirect measures of liver iron. Both deferiprone and desferrioxamine produce a significant reduction in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised controlled trials to suggest that either has a greater reduction of clinically significant end organ damage. Evidence of adverse events were observed in all treatment groups. Occurrence of any adverse event was significantly more likely with deferiprone than desferrioxamine in one trial, RR 2.24 (95% CI 1.19 to 4.23). Meta‐analysis of a further two trials showed a significant increased risk of adverse events associated with combined deferiprone and desferrioxamine compared with desferrioxamine alone, RR 3.04 (95% CI 1.18 to 7.83). The most commonly reported adverse event was joint pain, which occurred significantly more frequently in patients receiving deferiprone than desferrioxamine, RR 2.64 (95% CI 1.21 to 5.77). Other common adverse events included gastrointestinal disturbances as well as neutropenia or leucopenia, or both. Authors' conclusions In the absence of data from randomised controlled trials, there is no evidence to suggest the need for a change in current treatment recommendations; namely that deferiprone is indicated for treating iron overload in people with thalassaemia major when desferrioxamine is contraindicated or inadequate. Intensified desferrioxamine treatment (by either subcutaneous or intravenous route) or use of other oral iron chelators, or both, remains the established treatment to reverse cardiac dysfunction due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently only gave support for deferiprone to be used as a last resort for treating iron overload in thalassaemia, myelodysplasia and sickle cell disease. However, there is evidence that adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcome of deferiprone with desferrioxamine. Plain language summary The use of the iron chelator deferiprone in people with thalassaemia who are dependent on blood transfusions In thalassaemia sometimes the body cannot produce enough haemoglobin. Regular blood transfusions can manage this, but may lead to excess iron in the body, which, if not removed, may damage major organs. Iron chelation therapy removes excess iron; one common chelator is deferiprone. Questions exist about whether deferiprone is as good and safe as the most widely‐used iron chelator, desferrioxamine. Desferrioxamine is administered by a needle under the skin or into a vein, and was the standard monotherapy for 20 years. Seventeen randomised controlled trials compared deferiprone with desferrioxamine. They report little data on death or end organ damage, so we report the effects of therapy using mainly other markers. Removing excess iron was assessed by iron concentration in the blood and liver; heart function; and the amount of iron passed in urine. However, the amount of iron removed with either deferiprone or desferrioxamine was not consistent; one reason being that outcomes were measured differently. This makes it difficult to compare results between trials. Adverse events included joint pain, nausea, stomach upsets and low white blood cell count with deferiprone and pain or skin reactions at the injection site and joint pain with desferrioxamine. In one trial, the risk of an adverse event with deferiprone was twice that of the risk with desferrioxamine. Two further trials showed a three‐fold increased risk of an adverse event with combined deferiprone and desferrioxamine therapy compared with desferrioxamine alone. We found no evidence to change current recommendations to treat iron overload in thalassaemia with deferiprone when desferrioxamine cannot be used or is inadequate. Intensified desferrioxamine treatment or use of other oral iron chelators (or both of these) remains the established treatment to reverse heart problems due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently gave support for deferiprone only to be used as a last resort treatment in patients with thalassaemia, myelodysplasia and sickle cell disease. The danger of raised liver enzymes or a very low white blood cell count with deferiprone means that this treatment should not be used unless close monitoring of full blood counts and liver function is possible. Large trials of chelation therapy with standardised measures of iron stores and end organ damage are needed so valuable trial data can be compared and analysed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA, Brunskill, SJ, Doree, C, Chowdhury, O, Gooding, S, Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004839.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.796Z" }, { "id": "2a8c36e2-183a-4726-8cac-b015f70f047c", "pmid": "", "title": "Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their aetiology is unknown. The management of chronic rhinosinusitis with nasal polyps, aimed at improving these symptoms, includes both surgical and medical treatments, but there is no universally accepted management protocol. Objectives To assess the effectiveness of endonasal/endoscopic surgery versus medical treatment in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised controlled trials of any surgical intervention (e.g. polypectomy, endoscopic sinus surgery) versus any medical treatment (e.g. intranasal and/or systemic steroids), including placebo, in adult patients with chronic rhinosinusitis with nasal polyps. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Meta‐analysis was not possible due to the heterogeneity of the studies and the selective (incomplete) outcome reporting by the studies. Main results Four studies (231 participants randomised) are included in the review. No studies were at low risk of bias. The studies compared different types of surgery versus various types and doses of systemic and topical steroids and antibiotics. There were three comparison pairs: (1) endoscopic sinus surgery (ESS) versus systemic steroids (one study, n = 109), (2) polypectomy versus systemic steroids (two studies, n = 87); (3) ESS plus topical steroid versus antibiotics plus high‐dose topical steroid (one study, n = 35). All participants also received topical steroids but doses and types were the same between the treatment arms of each study, except for the study using antibiotics. In that study, the medical treatment arm had higher doses than the surgical arm. In two of the studies, the authors failed to report the outcomes of interest. Although there were important differences in the types of treatments and comparisons used in these studies, the results were similar. Primary outcomes: symptom scores and quality of life scores There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) failed to find a difference in generic health‐related quality of life scores. The quality of this evidence is low or very low . Endoscopic scores and other secondary outcomes Two studies reported endoscopic scores. One study (ESS versus systemic steroids) reported a large, significant effect size in the surgical group, with a mean difference (MD) in score of ‐1.5 (95% confidence interval (CI) ‐1.78 to ‐1.22, n = 95) on a scale of 0 to 3 (0 = no polyposis, 3 = severe polyposis). In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups (MD 2.3%, 95% CI ‐17.4% to 12.8%, n = 34). None of the included studies reported recurrence rates. No differences were found for any objective measurements or olfactory tests in those studies in which they were measured. Complications Complication rates were not reported in all studies, but rates of up to 21% for medical treatment and 14.3% for surgical treatment are described. Epistaxis was the most commonly reported complication with both medical and surgical treatments, with severe complications reported rarely. Authors' conclusions The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis with nasal polyps is of very low quality. The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. The one positive finding from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. As the overall evidence is of very low quality (serious methodological limitations, reporting bias, indirectness and imprecision) and insufficient to draw firm conclusions, further research to investigate this problem, which has significant implications for quality of life and healthcare service usage, is justified. Plain language summary Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps Background Nasal polyps are common, benign swellings of the lining of the nose. In some people they may cause no symptoms, but in others they may lead to nasal obstruction, congestion, facial pressure and anosmia (loss of sense of smell). The incidence of symptomatic nasal polyps increases with age and they are more common in men than in women. The cause of nasal polyps is not fully understood but they may be a result of chronic (long‐term) inflammation of the lining of the nose (termed 'chronic rhinosinusitis with nasal polyps'). Chronic rhinosinusitis with nasal polyps can be treated medically, for example with drugs such as topical (intranasal) steroid sprays, or with surgery (for example, nasal polypectomy with or without endoscopic sinus surgery (ESS)). However, it is unclear what is the most effective management strategy. Study characteristics Four randomised controlled trials, involving a total of 231 patients with chronic rhinosinusitis with nasal polyps, are included in this review. The number of patients in each study ranged from 34 to 109. The studies took place in ENT departments in several European countries. All patients were adults and most of the studies enrolled more men than women. In all studies the patients were randomly assigned to either surgery or medical treatment (such as antibiotics or steroid tablets or injections) in addition to topical steroids given as nasal sprays or drops. Both the type of surgery performed and the medical treatments used varied widely between the studies, and did not allow all of the studies to be looked at together. Rather, we considered the treatment groups in the four studies as three separate pairs of comparisons instead of simply 'surgical' versus 'medical' treatments. Key results The main outcome measures were patient‐reported disease‐specific symptom scores and health‐related quality of life scores, as well as generic health‐related quality of life scores. There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) did not find a difference in general health‐related quality of life scores. Two studies reported changes in polyp size (when looked at with an endoscope) using a score. One study (ESS versus systemic steroids) reported a significantly better score in the surgery group than in the steroids group at 12 months. In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups. There were no reported differences between the different medical and surgical treatment groups in any study for any other objective (clinician‐based) measurements. Complication rates were not reported in all studies, but nosebleeds (epistaxis) were the most commonly described complication with both medical and surgical treatment; severe complications were reported rarely in either group. Conclusion The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. One positive finding (polyps size scores) from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. There is not enough evidence to draw firm conclusions regarding the most appropriate treatment for this condition. Chronic rhinosinusitis with nasal polyps has significant implications for quality of life and the use of healthcare services. Further research to investigate this problem is justified. Quality of the evidence Overall, we found this evidence to be of low or very low quality. We have low confidence in the estimates of these studies; further research will very likely change these estimates. There were serious limitations in how the studies were carried out or reported (or both), and the number of participants involved was small. In addition, some of the treatment regimens used in the trials are no longer current standards of therapy for patients with chronic rhinosinusitis with nasal polyps. This evidence is up to date to 20 February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Rimmer, J, Fokkens, W, Chong, LY, Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.778Z" }, { "id": "2a8f932f-62bd-4dc7-814c-bc41b92d49f9", "pmid": "", "title": "A Pilot Study of Facial Recognition Software to Assess Palatability in Pediatric Patients", "imported": false, "abstract": "The study is designed to see if, after tasting specific things, whether a child's facial pattern and voice pattern can determine the difference in something that has a sweet taste, no taste, and a bitter taste. The investigators will do this by comparing video recordings of a child's facial expression and voice to the child's response to follow-up questions after tasting three (3) different substances.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "2a9382cd-02f2-47b0-8a6b-00c802113985", "pmid": "", "title": "Folic acid for fragile X syndrome", "imported": false, "abstract": "Abstract - Background It has been argued that individuals with fragile X syndrome could have low folate levels in their bodies and that supplementing their dietary intake might remediate the adverse developmental and behavioural effects of the condition. Objectives To review the efficacy and safety of folic acid in the treatment of people with fragile X syndrome. Search methods We searched four databases in November 2010: CENTRAL, PubMed, EMBASE and PsycINFO. Selection criteria Randomised controlled trials. Data collection and analysis Two review authors independently extracted data and assessed risk of bias using the Cochrane 'Risk of bias' tool. Main results We included five trials, which were published between 1986 and 1992. Overall, they included 67 patients, all male, with ages ranging from one to 54 years. Intellectual disability in participants varied from borderline to severe and some studies included patients with an additional diagnosis of autism or autistic behaviour. Four of the studies were placebo‐controlled cross‐over trials and one study was a parallel design. The duration of follow‐up ranged from two months to 12 months and the period on folic acid or placebo ranged from two to eight months. Doses of folic acid ranged from 10 mg to 250 mg per day, 10 mg per day being the most common. Most of the younger patients involved were also taking part in special education programmes (usually involving language and occupational therapy). We were not able to perform meta‐analysis to combine results but none of the individual studies found evidence of clinical benefit with the use of folic acid medication in fragile X syndrome patients on any of the areas of interest, either psychological and learning capabilities or behaviour and social performance, as measured with standardised tools. Separate analysis of evidence for patients of different age groups, i.e. prepubertal children and postpubertal young people, found some statistically significant results, but did not show clear evidence of benefit for either group. Adverse effects of folic acid treatment were rare, not serious and transient. Studies were generally poorly reported and we classified only one study as being at low risk of bias. Authors' conclusions The quality of available evidence is low and not suitable for drawing conclusions about the effect of folic acid on fragile X syndrome patients. It consists of few studies with small samples of patients, all of them male, with little statistical power to detect anything other than huge effects. Plain language summary Folic acid for fragile X syndrome People with fragile X syndrome (or FXS) have intellectual limitations that can range from mild to severe. Fragile X syndrome is considered the most common form of inherited intellectual disability and it has been estimated that it affects approximately 1 in 4000 males and 1 in 8000 females. Folate is particularly important during the early development of the brain and in later life is involved in methylation processes that are essential for the maintenance of normal brain function. It was observed that cells from patients with fragile X syndrome cultured in solutions deficient in folic acid revealed a fragile site at the X chromosome; consequently it was thought that individuals with fragile X syndrome had low folate levels in their bodies, which may be due to insufficient dietary intake, inefficient absorption or impaired metabolic utilisation. It was argued that supplementing their dietary intake might help improve the adverse developmental and behavioural effects of the condition. This review asks whether folic acid helps improve symptoms in people with fragile X syndrome and whether it has any side effects. We found five randomised controlled trials, all of which were published between 1986 and 1992. These studies included 69 people, all male. One of the studies compared a folic acid group with a control group; the other four used a cross‐over design (i.e. participants received first one treatment and then the other). The quality of reporting of the trials was generally poor, particularly the methods used, which made it difficult to assess the risk of bias in the studies. The results of the few published studies did not find significant differences in the effects of folic acid or placebo on psychological or learning capabilities, behaviour or social performance, as measured by standardised tools. There is therefore no evidence to support the recommendation of supplementing dietary intake with folic acid medication for people with fragile X syndrome. However, due to the number and quality of the studies, it is not possible to conclude with any certainty that folic acid does not help. Given that intellectual, behavioural, emotional and/or learning performance in people with fragile X syndrome are strongly influenced by different social factors, future studies should also pay attention to the evaluation of non‐pharmacological interventions, such as modifications in the home environment, tailored behavioural interventions and classroom environments, or language and occupational therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Rueda, JR; Ballesteros, J; Guillen, V; Tejada, MI; Solà, I", "articleTypes": [], "doi": "10.1002/14651858.CD008476.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "2a9b092b-f1b2-4cc2-a602-4377ce8e0d4e", "pmid": "", "title": "Breastfeeding or breast milk for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Pain in the neonate is associated with acute behavioural and physiological changes. Cumulative pain is associated with morbidities, including adverse neurodevelopmental outcomes. Studies have shown a reduction in changes in physiological parameters and pain score measurements following pre‐emptive analgesic administration in neonates experiencing pain or stress. Non‐pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for analgesia. This is an update of a review first published in 2006 and updated in 2012. Objectives The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries (ICTRP, ISRCTN and clinicaltrials.gov) in August 2022; searches were limited from 2011 forwards. We checked the reference lists of included studies and relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates. We included both term (≥ 37 completed weeks postmenstrual age) and preterm infants (< 37 completed weeks' postmenstrual age) up to a maximum of 44 weeks' postmenstrual age. The study must have reported on either physiological markers of pain or validated pain scores. Data collection and analysis We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a mean difference (MD). We used the GRADE approach to assess the certainty of evidence. Main results Of the 66 included studies, 36 evaluated breastfeeding, 29 evaluated supplemental breast milk and one study compared them against each other. The procedures conducted in the studies were: heel lance (39), venipuncture (11), intramuscular vaccination (nine), eye examination for retinopathy of prematurity (four), suctioning (four) and adhesive tape removal as procedure (one). We noted marked heterogeneity in the control interventions and pain assessment measures amongst the studies. Since many studies included multiple arms with breastfeeding/supplemental breast milk as the main comparator, we were not able to synthesise all interventions together. Individual interventions are compared to breastfeeding/supplemental breast milk and reported. The numbers of studies/participants presented with the findings are not taken from pooled analyses (as is usual in Cochrane Reviews), but are the overall totals in each comparison. Overall, the included studies were at low risk of bias except for masking of intervention and outcome assessment, where nearly one‐third of studies were at high risk of bias. Breastfeeding versus control Breastfeeding may reduce the increase in heart rate compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration of sucrose/glucose (20% to 33%) with skin‐to‐skin contact (low‐certainty evidence, 8 studies, 784 participants). Breastfeeding likely reduces the duration of crying compared to no intervention, lying on table, rocking, heel warming, holding by mother, skin‐to‐skin contact, bottle feeding mother's milk and moderate concentration of glucose (moderate‐certainty evidence, 16 studies, 1866 participants). Breastfeeding may reduce percentage time crying compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration sucrose and moderate concentration of sucrose with skin‐to‐skin contact (low‐certainty evidence, 4 studies, 359 participants). Breastfeeding likely reduces the Neonatal Infant Pain Scale (NIPS) score compared to no intervention, holding by mother, heel warming, music, EMLA cream, moderate glucose concentration, swaddling, swaddling and holding (moderate‐certainty evidence, 12 studies, 1432 participants). Breastfeeding may reduce the Neonatal Facial Coding System (NFCS) score compared to no intervention, holding, pacifier and moderate concentration of glucose (low‐certainty evidence, 2 studies, 235 participants). Breastfeeding may reduce the Douleur Aigue Nouveau‐né (DAN) score compared to positioning, holding or placebo (low‐certainty evidence, 4 studies, 709 participants). In the majority of the other comparisons there was little or no difference between the breastfeeding and control group in any of the outcome measures. Supplemental breast milk versus control Supplemental breast milk may reduce the increase in heart rate compared to water or no intervention (low‐certainty evidence, 5 studies, 336 participants). Supplemental breast milk likely reduces the duration of crying compared to positioning, massage or placebo (moderate‐certainty evidence, 11 studies, 1283 participants). Supplemental breast milk results in little or no difference in percentage time crying compared to placebo or glycine (low‐certainty evidence, 1 study, 70 participants). Supplemental breast milk results in little or no difference in NIPS score compared to no intervention, pacifier, moderate concentration of sucrose, eye drops, gentle touch and verbal comfort, and breast milk odour and verbal comfort (low‐certainty evidence, 3 studies, 291 participants). Supplemental breast milk may reduce NFCS score compared to glycine (overall low‐certainty evidence, 1 study, 40 participants). DAN scores were lower when compared to massage and water; no different when compared to no intervention, EMLA and moderate concentration of sucrose; and higher when compared to rocking or pacifier (low‐certainty evidence, 2 studies, 224 participants). Due to the high number of comparator interventions, other measures of pain were assessed in a very small number of studies in both comparisons, rendering the evidence of low certainty. The majority of studies did not report on adverse events, considering the benign nature of the intervention. Those that reported on adverse events identified none in any participants. Subgroup analyses were not conducted due to the small number of studies. Authors' conclusions Moderate‐/low‐certainty evidence suggests that breastfeeding or supplemental breast milk may reduce pain in neonates undergoing painful procedures compared to no intervention/positioning/holding or placebo or non‐pharmacological interventions. Low‐certainty evidence suggests that moderate concentration (20% to 33%) glucose/sucrose may lead to little or no difference in reducing pain compared to breastfeeding. The effectiveness of breast milk for painful procedures should be studied in the preterm population, as there are currently a limited number of studies that have assessed its effectiveness in this population. Plain language summary Breastfeeding or breast milk for procedural pain in newborn babies Review question We investigated how well breastfeeding or supplemental breast milk (expressed breast milk given via feeding tube or by placing breast milk in baby's mouth) works as a pain reliever in newborn babies while they undergo painful procedures (e.g. vaccination, heel prick, blood sampling for tests or eye examinations). The babies' pain responses (e.g. changes in heart rate, oxygen level, blood pressure, percentages of crying time, duration of crying etc.) were assessed by health care professionals to measure the pain that babies are experiencing. Background Breastfeeding may provide pain relief for newborn babies undergoing painful procedures. Medication for pain relief is commonly given for major painful procedures, but may not be given for minor painful procedures such as blood sampling (by heel prick or taking a sample from a vein). There are different forms of non‐drug strategies that can be used to reduce pain in babies, such as holding or swaddling them, sucking on a pacifier, or giving sweet solutions (such as sucrose or glucose). Different studies done in newborn babies have shown that breastfeeding may be a good way to reduce the pain they feel when subjected to minor painful procedures. These studies have been done in full‐term babies, and they have shown that breastfeeding may be effective by demonstrating that it reduces babies' crying time and various pain scores that have been validated for babies. Breast milk given by syringe has not shown the same efficacy as breastfeeding itself. Very few studies have been done in preterm babies, and so new studies are needed to determine if the use of supplemental breast milk in these small babies is effective in reducing their pain. Study characteristics We searched the medical literature thoroughly up to 1 August 2022 for studies that investigated the pain‐relieving effect of breastfeeding or supplemental breast milk for minor medical procedures in newborn full‐term and preterm neonates We included randomised trials only, as they provide the most reliable medical evidence. We identified 66 studies that reported on a total of more than 6200 infants in this Cochrane Review. Thirty‐six studies evaluated breastfeeding, 29 studies evaluated supplemental breast milk, while one study compared both against each other. In over half of the studies, pain relief was during a heel prick procedure. In others, it was during vaccination, drawing blood from a vein or other procedures. The studies used a variety of comparative groups, for example, placebo, no intervention, maternal holding, skin‐to‐skin contact, similar volume of water, a pacifier, routine care, various concentrations of sucrose or glucose, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), swaddling, heel warmth, anaesthetic cream for the skin, or a combination of these. The studies used a wide variety of pain scales as well as changes in heart rate and blood pressure and cry duration to assess pain. Study funding sources The studies included in the review were not externally funded according to information given in the reports. Key results Newborn babies in the breastfeeding group experienced a lower heart rate, shorter duration of cry, lower percentage of cry time and lower scores on the Neonatal Infant Pain Scale than babies who received no intervention. Moderate concentrations of glucose/sucrose may have similar effectiveness to breastfeeding. Studies of supplemental breast milk showed variable results. Supplemental breast milk was found to have a lower increase in heart rate when compared to water, and a lower duration of crying when compared to placebo. What are the limitations of the evidence We are moderately confident that breastfeeding reduces pain as assessed by heart rate, cry duration or validated pain scale compared to no intervention. Supplemental breast milk for painful procedures may reduce pain when compared to no intervention or placebo. Due to the high number of comparator groups, other measures of pain were assessed in a very small number of studies. The majority of the studies did not report on any unwanted or harmful effects of treatment. Those that did this identified no unwanted or harmful effects of treatment in any infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Shah, PS; Torgalkar, R; Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD004950.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "2aa8a165-8d4c-4477-83d8-53ad975f27e3", "pmid": "", "title": "Adverse events in people taking macrolide antibiotics versus placebo for any indication", "imported": false, "abstract": "Abstract - Background Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment‐specific, rather than disease‐specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases. Objectives To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides. Selection criteria We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups. Data collection and analysis Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide‐resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta‐analysis when three or more included studies reported a specific adverse event. Main results We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events or at least stated that no adverse events were observed. Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low‐quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low‐quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate‐quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate‐quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate‐quality evidence) were also reported more often in participants taking macrolides compared to placebo. The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000. The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting. There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration. Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low‐quality evidence). Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low‐quality evidence). We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low‐quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low‐quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low‐quality evidence) compared to placebo. We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo. Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate‐quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate‐quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate‐quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non‐significant. There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low‐quality evidence). Only 24 studies (13%) provided useful data on macrolide‐resistant bacteria. Macrolide‐resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent. Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials. Authors' conclusions The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as \"none were observed\". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance. Plain language summary Adverse events in people taking macrolide antibiotics Review question We wanted to find out if people treated with a macrolide antibiotic experienced more adverse events than those treated with placebo. Background Macrolide antibiotics are a group of antibiotics that are commonly used to treat both acute and chronic infections. The four most frequently used macrolides are: azithromycin, clarithromycin, erythromycin, and roxithromycin. People taking macrolide antibiotics are at risk of experiencing adverse events such as nausea, diarrhoea, or rash. Search date We searched the literature up to May 2018. Study characteristics We included 183 studies with a total of 252,886 participants. Most studies were conducted in the hospital setting. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events, or at least stated that no adverse events were observed. Study funding sources Drug companies supplied trial medications or funding, or both, in 91 studies. Funding sources were unclear in 59 studies. Key results People treated with a macrolide antibiotic experienced gastrointestinal adverse events such as nausea, vomiting, abdominal pain, and diarrhoea more often than those treated with placebo. Taste disturbances were reported more often by people taking macrolides than those taking a placebo. However, as very few studies reported on these adverse events, these results should be interpreted with caution. Hearing loss was reported more often by people taking macrolide antibiotics, however only four studies reported this outcome. Macrolides caused less cough and fewer respiratory tract infections than placebo. We did not find any evidence that macrolides caused more cardiac disorders, liver disorders, blood infections, skin and soft tissue infections, changes in liver enzymes, appetite loss, dizziness, headache, respiratory symptoms, itching, or rashes than placebo. We did not find more deaths in people treated with macrolides than in those treated with placebo. Very limited information was available to assess if people treated with a macrolide antibiotic were at greater risk of developing resistant bacteria than those treated with placebo. However, bacteria that did not respond to macrolide antibiotics were more commonly identified immediately after treatment in people taking a macrolide than in those taking a placebo, but differences in resistance thereafter were inconsistent. Quality of the evidence The quality of the evidence ranged from very low (cardiac disorders, change in liver enzymes, liver disorders) to low (abdominal pain, death, diarrhoea, dizziness, hearing loss, skin and soft tissue infections, taste disturbance, wheeze) to moderate (appetite loss, blood infection, cough, fever, headache, itching, nausea, rash, respiratory symptoms, respiratory tract infections, vomiting).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hansen, MP; Scott, AM; McCullough, A; Thorning, S; Aronson, JK; Beller, EM; Glasziou, PP; Hoffmann, TC; Clark, J; Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD011825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "2ab217e7-ad04-4989-80e8-6175cc80e537", "pmid": "", "title": "Zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance", "imported": false, "abstract": "Abstract - Background Diabetes is associated with long‐term damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity. Insulin resistance is a fundamental aspect of the aetiology of type 2 diabetes. Insulin resistance has been shown to be associated with atherosclerosis, dyslipidaemia, glucose intolerance, hyperuricaemia, hypertension and polycystic ovary syndrome. The mineral zinc plays a key role in the synthesis and action of insulin, both physiologically and in diabetes mellitus. Zinc seems to stimulate insulin action and insulin receptor tyrosine kinase activity. Objectives To assess the effects of zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance. Search methods This review is an update of a previous Cochrane systematic review published in 2007. We searched the Cochrane Library (2015, Issue 3), MEDLINE, EMBASE, LILACS and the ICTRP trial register (from inception to March 2015). There were no language restrictions. We conducted citation searches and screened reference lists of included studies. Selection criteria We included studies if they had a randomised or quasi‐randomised design and if they investigated zinc supplementation compared with placebo or no intervention in adults with insulin resistance living in the community. Data collection and analysis Two review authors selected relevant trials, assessed risk of bias and extracted data. Main results We included three trials with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Risk of bias was unclear for most studies regarding selection bias (random sequence generation, allocation concealment) and detection bias (blinding of outcome assessment). No study reported on our key outcome measures (incidence of type 2 diabetes mellitus, adverse events, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). Evaluation of insulin resistance as measured by the Homeostasis Model Assessment of Insulin Resistance (HOMA‐IR) showed neutral effects when comparing zinc supplementation with control (two trials; 114 participants). There were neutral effects for trials comparing zinc supplementation with placebo for total cholesterol, high‐density lipoprotein (HDL) cholesterol, low‐density lipoprotein (LDL) cholesterol and triglycerides (2 studies, 70 participants). The one trial comparing zinc supplementation with exercise also showed neutral effects for total cholesterol, HDL and LDL cholesterol, and a mean difference in triglycerides of ‐30 mg/dL (95% confidence interval (CI) ‐49 to ‐10) in favour of zinc supplementation (53 participants). Various surrogate laboratory parameters were also analysed in the included trials. Authors' conclusions There is currently no evidence on which to base the use of zinc supplementation for the prevention of type 2 diabetes mellitus. Future trials should investigate patient‐important outcome measures such as incidence of type 2 diabetes mellitus, health‐related quality of life, diabetic complications, all‐cause mortality and socioeconomic effects. Plain language summary Zinc supplementation for the prevention of type 2 diabetes mellitus Review question What are the effects of zinc supplementation compared with placebo or no treatment for the prevention of type 2 diabetes in adults with insulin resistance? Background Some studies have shown that zinc improves glucose levels (glycaemic control) in people with diabetes. As a consequence of diabetes long‐term complications may develop, such as kidney, nerve and eye disease. Also, the risk of cardiovascular complications like heart attacks and strokes is raised. Type 1 diabetes is a form of diabetes where the body cannot produce insulin any more. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity and is characterised by an increasing inability of the body to make good use of insulin (insulin resistance). The mineral zinc plays a key role in the action of insulin and theoretically zinc supplementation used by people with insulin resistance could prevent the onset of diabetes. Study characteristics We included three randomised controlled studies with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Key results No study reported on our patient‐important key outcomes (new onset of type 2 diabetes mellitus, side effects, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). The effects of zinc supplementation are uncertain regarding insulin resistance and lipid levels in the blood (mainly cholesterol and triglycerides). Quality of evidence The overall quality of the included studies was unclear because study authors did not provide important information for us to judge how the studies were performed (unclear risk of bias in most cases). In addition, the number of studies and participants is low and the study authors did not investigate important outcomes such as new onset of type 2 diabetes mellitus or side effects of zinc supplementation. Currentness of evidence This evidence is up to date as of March 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El Dib, R; Gameiro, OLF; Ogata, MSP; Módolo, NSP; Braz, LG; Jorge, EC; do Nascimento Junior, P; Beletate, V", "articleTypes": [], "doi": "10.1002/14651858.CD005525.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "2ab83c82-d349-4e56-a0c2-00fb06e4a801", "pmid": "", "title": "Oral protein‐based supplements versus placebo or no treatment for people with chronic kidney disease requiring dialysis", "imported": false, "abstract": "Abstract - Background Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein‐based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein‐based nutritional supplements in this population is limited. Objectives The aims of this review were to determine the benefits and harms of using oral protein‐based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein‐based nutritional supplements to no oral protein‐based nutritional supplements or placebo. Data collection and analysis Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes. Main results Twenty‐two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow‐up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self‐reported outcomes. Oral protein‐based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I 2 = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein‐based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I 2 = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein‐based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid‐arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein‐based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI ‐0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD ‐0.04 kg/m 2 , 95% CI ‐0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI ‐1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein‐based nutritional supplements affect triceps skinfold thickness, mid‐arm circumference, C‐reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein‐based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies. Authors' conclusions Overall, it is likely that oral protein‐based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid‐arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well‐designed RCTs in this population are required. Plain language summary Oral protein‐based nutritional supplement in people with chronic kidney disease requiring dialysis What is the issue? People with chronic kidney disease requiring dialysis are at risk of developing malnutrition for many reasons and often do not eat enough because their appetite is poor. Oral nutritional supplements are commonly provided to people who do not eat enough to meet their needs. Provision of nutritional supplements to dialysis patients requires careful consideration of potassium, phosphate and fluid limits. What did we do? We aimed to determine if giving oral protein‐based nutritional supplements improved serum albumin levels and other measures of nutrition. What did we find? A total of 1278 people took part in 22 studies that were included in this review to investigate the effects of oral protein‐based nutritional supplements. All participants were adults on maintenance dialysis (79% haemodialysis and 21% peritoneal dialysis). The studies lasted from one to 12 months. The findings suggest that giving oral protein‐based nutritional supplementation probably results in a slightly greater increase in albumin level and may improve prealbumin level and mid‐arm muscle circumference. The increase in albumin level was more evident in participants who were on haemodialysis and in those who were malnourished. It is uncertain whether oral protein‐based nutritional supplementation affects potassium and phosphate levels. Oral protein‐based nutritional supplements may result in little or no difference in the risk of developing abdominal symptoms.There were some differences between the quality of the studies and their designs. Conclusions The authors conclude that oral protein‐based nutritional supplements appear to be effective in improving some nutritional markers in people who need dialysis; however, it remains uncertain whether these results translate to meaningful outcomes for this population. More research is required to determine the cost‐effectiveness of this treatment, and if it can bring benefit to patients such as feeling better and living longer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Mah, JY, Choy, SW, Roberts, MA, Desai, AM, Corken, M, Gwini, SM, McMahon, LP", "articleTypes": [], "doi": "10.1002/14651858.CD012616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.099Z" }, { "id": "2ac0e1e9-58ab-45aa-9c16-78814c3dc6c5", "pmid": "", "title": "Interventions for fatigue in peripheral neuropathy", "imported": false, "abstract": "Abstract - Background Persistent feelings of fatigue (or subjective fatigue), which may be experienced in the absence of physiological factors, affect many people with peripheral neuropathy. A variety of interventions for subjective fatigue are available, but little is known about their efficacy or the likelihood of any adverse effects for people with peripheral neuropathy. Objectives To assess the effects of drugs and physical, psychological or behavioural interventions for fatigue in adults or children with peripheral neuropathy. Search methods On 5 November 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, CINAHL Plus, LILACS and AMED. We also searched reference lists of all studies identified for inclusion and relevant reviews, and contacted the authors of included studies and known experts in the field to identify additional published or unpublished data. We also searched trials registries for ongoing studies. Selection criteria We considered for inclusion randomised controlled trials (RCTs) and quasi‐RCTs comparing any form of intervention for fatigue management in adults with peripheral neuropathy with placebo, no intervention or an alternative form of intervention for fatigue. Interventions considered included drugs, pacing and grading of physical activity, general or specific exercise, compensatory strategies such as orthotics, relaxation, counselling, cognitive and educational strategies. Data collection and analysis Two review authors independently assessed risk of bias and extracted study data. We contacted study authors for additional information. We collected information on adverse events from the included trials. Main results The review includes three trials, which were all at low risk of bias, involving 530 people with peripheral neuropathy. The effects of amantadine from one randomised, double‐blind, placebo‐controlled, cross‐over trial comparing amantadine with placebo for the treatment of fatigue in 80 people with Guillain‐Barré syndrome (GBS) were uncertain for the proportion of people achieving a favourable outcome six weeks post‐intervention (odds ratio (OR) 0.56 (95% confidence interval (CI) 0.22 to 1.35, N = 74, P = 0.16). We assessed the quality of this evidence as low. Two parallel‐group randomised double‐blind, placebo‐controlled trials comparing the effects of two doses of ascorbic acid with placebo for reducing fatigue in adults with Charcot‐Marie‐Tooth disease type 1A (CMT1A) showed that the effects of ascorbic acid at either dose are probably small (standardised mean difference (SMD) ‐0.12 (95% CI ‐0.32 to 0.08, n = 404, P = 0.25)) for change in fatigue after 12 to 24 months (moderate quality evidence). Neither ascorbic acid study measured fatigue at four to 12 weeks, which was our primary outcome measure. No serious adverse events were reported with amantadine. Serious adverse events were reported in the trials of ascorbic acid. However,risk of serious adverse events was similar with ascorbic acid and placebo. Authors' conclusions One small imprecise study in people with GBS showed uncertain effects of amantadine on fatigue. In two studies in people with CMT1A there is moderate‐quality evidence that ascorbic acid has little meaningful benefit on fatigue. Information about adverse effects was limited, although both treatments appear to be well tolerated and safe in these conditions. There was no evidence available from RCTs to evaluate the effect of other drugs or other interventions for fatigue in either GBS, CMT1A or other causes of peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future randomised clinical trials. Plain language summary Treatments for fatigue in peripheral neuropathy Review question To assess the effects of treatments for fatigue in people with peripheral neuropathy. Background Peripheral neuropathy is damage to the nerves outside the brain and spinal cord. Many people with peripheral neuropathy have feelings of severe tiredness (fatigue) that are not necessarily related to physical problems such as muscle weakness. Evidence in other long‐term illnesses where fatigue is a problem suggests that medicines and other forms of treatment may help. The aim of this review was to assess the effect of drugs and other treatments, such as general or specific exercise, orthotics (devices such as braces), relaxation, counselling and cognitive, behavioural and educational strategies on feelings of fatigue in people with peripheral neuropathy. Study characteristics From a wide search, we identified three RCTs that met our selection criteria. The trials involved a total of 530 adults with peripheral neuropathy. Treatments were ascorbic acid (vitamin C) in people with Charcot‐Marie‐Tooth disease in two trials, and amantadine in Guillain‐Barré syndrome in the third. Charcot‐Marie‐Tooth disease is an inherited nerve disease and Guillain‐Barré syndrome is a condition where there is inflammation of the peripheral nerves. We chose measures of fatigue at four to 12 weeks as our preferred measure of the effects of treatment. The amantadine trial but not the ascorbic acid trials provided data at this time point; the ascorbic acid trials provided data more than 12 months after the start of the intervention. Key results and quality of the evidence There was insufficient evidence to determine the effects of amantadine when compared with an inactive treatment (placebo) for fatigue. and there were no major unwanted effects. We found evidence that ascorbic acid probably has little meaningful benefit for fatigue. No major unwanted effects were identified, but the trials were small. We assessed the quality of this evidence as moderate because the results were imprecise, which means they do not rule out the possibility that the drugs could have an effect. We found no evidence from RCTs on other medicines or treatments for fatigue in peripheral neuropathy. There is insufficient evidence to determine the effect of amantadine for fatigue in GBS and ascorbic acid for fatigue in CMT1A. More high‐quality studies are needed to provide evidence on which to base management of feelings of fatigue in peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future RCTs. The evidence in this review is current to November 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "White, CM, van Doorn, PA, Garssen, MPJ, Stockley, RC", "articleTypes": [], "doi": "10.1002/14651858.CD008146.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.099Z" }, { "id": "2ac5de19-f425-4f5d-83cc-b839c8752182", "pmid": "", "title": "Pharmacological interventions for the treatment of depression in chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Studies report that up to 80% of individuals with chronic obstructive pulmonary disease (COPD) may struggle with symptoms of depression. However, this major comorbidity in COPD is rarely managed effectively. A number of recent studies indicate that left untreated, COPD‐related depression is associated with worse quality of life, worse compliance with COPD treatment plan, increased exacerbations, hospital admissions, and healthcare costs when compared to individuals with COPD without depression. Regrettably, COPD practice guidelines do not provide conclusive treatment recommendations for the use of antidepressants in patients with COPD, and base their guidelines on findings from trials in the general population. This may be problematic, as there is an elevated risk of respiratory issues associated with antidepressant treatment and COPD. Evaluating effectiveness and safety of pharmacological interventions specifically for patients with COPD and depression was therefore paramount. Objectives To assess the effectiveness and safety of pharmacological interventions for the treatment of depression in patients with COPD. Search methods The last search was performed on 26 November 2018. We initially searched the following databases via the Specialised Trials Registers of the Cochrane Airways and Common Mental Disorders Groups (to June 2016): MEDLINE, Embase, PsycINFO, CINAHL, AMED, and the Cochrane Library trials register (CENTRAL). Searches from June 2016 to November 2018 were performed directly on Ovid MEDLINE, Embase, PsycINFO and the Cochrane Library (Issue 11, 2018). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform to 26 November 2018. We searched the grey literature databases to identify studies not indexed in major databases and the reference lists of studies initially identified for full‐text screening. Selection criteria All published and unpublished randomised controlled trials (RCTs) comparing the efficacy of pharmacological interventions with no intervention, placebo or co‐intervention in adults with diagnosed COPD and depression were eligible for inclusion. Data collection and analysis Two review authors independently assessed articles identified by the search for eligibility. Our primary outcomes were change in depressive symptoms and adverse events. The secondary outcomes were: change in quality of life, change in dyspnoea, change in forced expiratory volume in one second (FEV 1 ), change in exercise tolerance, change in hospital utilisation (length of stay and readmission rates), and cost‐effectiveness. For continuous outcomes, we calculated the pooled mean difference (MD) or standardised mean difference (SMD) with 95% confidence interval (CI) as appropriate. For dichotomous outcomes, we calculated the pooled odds ratio (OR) and corresponding 95% CI using a random‐effects model. We assessed the quality of evidence using the GRADE framework. Main results Of the 1125 records screened for eligibility, four RCTs (N = 201 participants), and one on‐going study, met the inclusion criteria. Two classes of antidepressants were investigated in two separate comparisons with placebo: a tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitors (SSRIs). TCA versus placebo Only one RCT (N = 30 participants) provided results for this comparison. Primary outcomes The TCA (nortriptyline) reduced depressive symptoms post‐treatment compared to placebo (MD ‐10.20, 95% CI ‐16.75 to ‐3.65; P = 0.007; very low‐quality evidence), as measured by the Hamilton Depression Rating Scale (HAM‐D). Three participants withdrew from the trial due to adverse events related to the tested antidepressant (dry mouth, sedation, orthostatic hypotension). Secondary outcomes The overall results post‐treatment indicated that nortriptyline was not effective in improving the quality of life of individuals with COPD, as measured by the Sickness Impact Profile (MD ‐2.80, 95% CI ‐11.02 to 5.42; P = 0.50; very low‐quality evidence). The results for the change in dyspnoea for the domains examined (e.g. dyspnoea scores for 'most day‐to‐day activities') post‐treatment showed no improvement in the intervention group (MD 9.80, 95% CI ‐6.20 to 25.80; P = 0.23; very low‐quality evidence). No data were reported for change in FEV 1 , change in exercise tolerance, change in hospital utilisation, or cost‐effectiveness. The TCA study provided short‐term results, with the last follow‐up data collection at 12 weeks. The quality of the evidence for all the outcomes evaluated was very low due to a small sample size, imprecision, attrition, and selection and reporting bias. SSRIs versus placebo Three RCTs (N = 171 participants) provided results for this comparison. Primary outcomes The pooled results for two studies showed no difference for the change in depressive symptoms post‐intervention (SMD 0.75, 95% CI ‐1.14 to 2.64; 148 participants; 2 studies; P = 0.44; very low‐quality evidence). High heterogeneity was observed (I² = 95%), limiting the reliability of these findings. While it was not possible to meta‐analyse the total adverse events rates across the studies, it was possible to combine the results for two medication‐specific adverse effects: nausea and dizziness. There were no significant post‐treatment group differences for nausea (OR 2.32, 95% CI 0.66 to 8.12; 171 participants; 3 studies; P = 0.19; very low‐quality evidence) or dizziness (OR 0.61, 95% CI 0.09 to 4.06; 143 participants; 2 studies; P = 0.61; very low‐quality evidence). Secondary outcomes The pooled analysis of two trials reporting data for the change in quality of life did not show improvement post‐treatment in the intervention group compared to placebo (SMD 1.17, 95% CI ‐0.80 to 3.15; 148 participants; 2 studies; P = 0.25; very low‐quality evidence). There was no difference between groups in change in FEV 1 post‐treatment (MD 0.01, 95% CI ‐0.03 to 0.05; 148 participants; 2 studies; P = 0.60; low‐quality evidence). However, two trials reported improvement in exercise tolerance in the SSRI group versus the placebo group (MD 13.88, 95% CI 11.73 to 16.03; 148 participants; 2 studies; P < 0.001; very low‐quality evidence). The trials included in this comparison did not report data related to the change in dyspnoea, hospital utilisation rates, or cost‐effectiveness. Authors' conclusions There is insufficient evidence to make definitive statements about the efficacy or safety of antidepressants for treating COPD‐related depression. New RCTs are needed; with better methodological quality and more accurate reporting of the methods used. Moreover, longer‐term follow‐up data collection is needed, including outcomes such as adverse events, hospital utilisation and cost‐effectiveness. Plain language summary Medication for the treatment of depression in chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a term that mainly describes two lung conditions: chronic bronchitis and emphysema. The main symptoms of COPD include shortness of breath, persistent cough, wheezing, and/or frequent chest infections. There is no cure for COPD, but treatment can help slow the disease progress and relieve symptoms. Depression is very common in patients with COPD, but is often untreated. Studies show that untreated depression in patients with COPD can worsen quality of life, increase COPD exacerbations and hospital admissions, and make following a COPD treatment plan difficult. Treatment for depression can include antidepressant medication, psychological therapy, or both. However, evidence‐based recommendations regarding antidepressant medication use specifically for patients with COPD are not currently available. Why is this review important? There is currently no clear overview of existing evidence showing whether antidepressants can effectively and safely reduce depressive symptoms in patients with COPD, therefore it was important to assess the existing experimental studies. Who will be interested in this review? Healthcare professionals, people with COPD and depression, researchers, and policymakers will be interested in the findings of this review. What questions does this review aim to answer? Our main aim was to assess whether pharmacological treatment (e.g. antidepressants) could effectively and safely treat COPD‐related depression. Which studies were included in the review? This review included experimental studies called randomised controlled trials (studies in which participants are assigned to a treatment group based on a random method) that compared the effectiveness of pharmacological interventions (antidepressants) to placebo (inactive treatment in the same form as the active treatment, e.g. a pill). Study participants were adults diagnosed with COPD and depression. What does the evidence from the review tell us? We have identified only four studies worldwide that were eligible for inclusion in our review. This means limited evidence to support the use of antidepressants for the treatment of depression in patients with COPD. Only one study evaluated a tricyclic antidepressant, nortriptyline, finding that it reduced depressive symptoms when compared to a placebo. Three studies evaluated a newer generation class of antidepressants called selective serotonin reuptake inhibitors (SSRIs), finding no evidence for their effectiveness in improving depressive symptoms. Due to the limited evidence, we are unable to make definitive statements about the effectiveness but also safety of antidepressants when used for COPD‐related depression. However, SSRIs may increase exercise capacity in patients with COPD. Given that the current findings were based on only four small studies with evidence rated as of very low quality, it is important to interpret our results with caution. What should happen next? Insufficient evidence prevented us from making clear recommendations for doctors, other healthcare professionals, researchers, or policymakers. More studies with better methodological quality and a larger number of participants are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pollok, J; van Agteren, JEM; Carson‐Chahhoud, KV", "articleTypes": [], "doi": "10.1002/14651858.CD012346.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "2ac9593f-3309-4203-b22b-74f9636822c6", "pmid": "", "title": "Chinese herbal medicine for menopausal symptoms", "imported": false, "abstract": "Abstract - Background Chinese herbal medicine (CHM) usage is expected to increase as women suffering from menopausal symptoms are seeking alternative therapy due to concerns from the adverse effects (AEs) associated with hormone therapy (HT). Scientific evidence for their effectiveness and safety is needed. Objectives To evaluate the effectiveness and safety of CHM in the treatment of menopausal symptoms. Search methods We searched the Gynaecology and Fertility Group's Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), MEDLINE, Embase, CINAHL, AMED, and PsycINFO (from inception to March 2015). Others included Current Control Trials, Citation Indexes, conference abstracts in the ISI Web of Knowledge, LILACS database, PubMed, OpenSIGLE database, and China National Knowledge Infrastructure database (CNKI, 1999 to 2015). Other resources included reference lists of articles as well as direct contact with authors. Selection criteria Randomised controlled trials (RCTs) comparing the effectiveness of CHM with placebo, HT, pharmaceutical drugs, acupuncture, or another CHM formula in women over 18 years of age, and suffering from menopausal symptoms. Data collection and analysis Two review authors independently assessed 864 studies for eligibility. Data extractions were performed by them with disagreements resolved through group discussion and clarification of data or direct contact with the study authors. Data analyses were performed in accordance with Cochrane Collaboration guidelines. Main results We included 22 RCTs (2902 women). Participants were from different ethnic backgrounds with the majority of Chinese origin. When CHM was compared with placebo (eight RCTs), there was little or no evidence of a difference between the groups for the following pooled outcomes: hot flushes per day (MD 0.00, 95% CI ‐0.88 to 0.89; 2 trials, 199 women; moderate quality evidence); hot flushes per day assessed by an overall hot flush score in which a difference of one point equates to one mild hot flush per day (MD ‐0.81 points, 95% CI ‐2.08 to 0.45; 3 RCTs, 263 women; low quality evidence); and overall vasomotor symptoms per month measured by the Menopause‐Specific Quality of Life questionnaire (MENQOL, scale 0 to 6) (MD ‐0.42 points; 95% CI ‐1.52 to 0.68; 3 RCTs, 256 women; low quality evidence). In addition, results from individual studies suggested there was no evidence of a difference between the groups for daily hot flushes assessed by severity (MD ‐0.70 points, 95% CI ‐1.00, ‐0.40; 1 RCT, 108 women; moderate quality evidence); or overall monthly hot flushes scores (MD ‐2.80 points, 95% CI ‐8.93 to 3.33; 1 RCT, 84 women; very low quality evidence); or overall daily night sweats scores (MD 0.07 points, 95% CI ‐0.19 to 0.33, 1 RCT, 64 women; low quality evidence); or overall monthly night sweats scores (MD 1.30 points, 95% CI ‐1.76 to 4.36, 1 RCT, 84 women; very low quality evidence). However one study using the Kupperman Index reported that overall monthly vasomotor symptom scores were lower in the CHM group (MD ‐4.79 points, 95% CI ‐5.52 to ‐4.06; 1 RCT, 69 women; low quality evidence). When CHM was compared with hormone therapy (HT) (10 RCTs), only two RCTs reported monthly vasomotor symptoms using MENQOL. It was uncertain whether CHM reduces vasomotor symptoms (MD 0.47 points, 95% CI ‐0.50 to 1.44; 2 RCTs, 127 women; very low quality evidence). Adverse effects were not fully reported in the included studies. Adverse events reported by women taking CHM included mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects were inconclusive because of imprecise estimates of effects: CHM versus placebo (RR 1.51; 95% CI 0.69 to 3.33; 7 trials, 705 women; I² = 40%); CHM versus HT (RR 0.96; 95% CI 0.66 to 1.39; 2 RCTs, 864 women; I² = 0%); and CHM versus specific conventional medications (such as Fluoxetine and Estazolam) (RR 0.20; 95% CI 0.03 to 1.17; 2 RCTs, 139 women; I² = 61%). Authors' conclusions We found insufficient evidence that Chinese herbal medicines were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Effects on safety were inconclusive. The quality of the evidence ranged from very low to moderate; there is a need for well‐designed randomised controlled studies. Plain language summary Title: Chinese herbal medicines for menopausal symptoms Review Question: Are Chinese herbal medicines effective and safe for relieving menopausal symptoms? Background: Menopause usually takes place when a woman is around 51 years of age. Women can experience symptoms such as hot flushes, sweats, poor sleep, joint pains, anxiousness, dry skin and vagina when the organs which produce female hormones slow down. Usually hormone therapy (HT) is prescribed to reduce the symptoms. Due to concerns on long term use of HT resulting in adverse effects, women have been looking for alternative treatments to relieve their symptoms. Chinese herbal medicines (CHM) is one of the popular choices. Although CHM has been used for a very long time clinically, its effectiveness and long‐term safety remained unanswered from a scientific perspective. Study characteristics: This review examined 22 randomised clinical trials where 2902 women took part in the studies; 1499 in the CHM group and 1403 in the control group which might include a placebo (non‐active compound made to look, taste and smell the same as the study compound) or a drug or HT or another CHM formula (different from the one being tested). Most of the studies had a trial period for 12 weeks. The data are current to March 2015. Key results: We found insufficient evidence that CHM were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Adverse effects were not well reported, some women taking CHM reported mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects on safety were inconclusive. Quality of the evidence: The quality of the evidence ranged from very low to moderate. The studies did not produce good quality evidence to allow the authors to draw a conclusive statement regarding the effectiveness or safety of CHM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Zhu, X, Liew, Y, Liu, ZL", "articleTypes": [], "doi": "10.1002/14651858.CD009023.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.758Z" }, { "id": "2ad8b1ea-3ad9-4524-8bfa-4fe498e2f319", "pmid": "", "title": "Interventions for managing taste disturbances", "imported": false, "abstract": "Abstract - Background The sense of taste is very much essential to the overall health of an individual. It is a necessary component to enjoy one's food, which in turn provides nutrition to an individual. Any disturbance in taste perception can hamper quality of life in such patients by influencing their appetite, body weight and psychological well‐being. Taste disorders have been treated using different modalities of treatment and there is no consensus for the best intervention. Hence this Cochrane Review was undertaken. This is an update of the Cochrane Review first published in November 2014. Objectives To assess the effects of interventions for the management of patients with taste disturbances. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 4 July 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017 Issue 6) in the Cochrane Library (searched 4 July 2017); MEDLINE Ovid (1946 to 4 July 2017); Embase Ovid (1980 to 4 July 2017); CINAHL EBSCO (1937 to 4 July 2017); and AMED Ovid (1985 to 4 July 2017). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for trials. Abstracts from scientific meetings and conferences were searched on 25 September 2017. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included all randomised controlled trials (RCTs) comparing any pharmacological agent with a control intervention or any non‐pharmacological agent with a control intervention. We also included cross‐over trials in the review. Data collection and analysis Two pairs of review authors independently, and in duplicate, assessed the quality of trials and extracted data. Wherever possible, we contacted trial authors for additional information. We collected adverse events information from the trials. Main results We included 10 trials (581 participants), nine of which we were able to include in the quantitative analyses (566 participants). We assessed three trials (30%) as having a low risk of bias, four trials (40%) at high risk of bias and three trials (30%) as having an unclear risk of bias. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Of these, nine trials with 544 people compared zinc supplements to placebo for patients with taste disorders. The participants in two trials were children and adolescents with respective mean ages of 10 and 11.2 years and the other seven trials had adult participants. Out of these nine, two trials assessed the patient‐reported outcome for improvement in taste acuity using zinc supplements (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.94 to 2.09; 119 participants, very low‐quality evidence). We meta‐analysed for taste acuity improvement using objective outcome (continuous data) in idiopathic and zinc‐deficient taste disorder patients (standardised mean difference (SMD) 0.44, 95% CI 0.23 to 0.65; 366 participants, three trials, very low‐quality evidence). We also analysed one cross‐over trial separately using the first half of the results for taste detection (mean difference (MD) 2.50, 95% CI 0.93 to 4.07; 14 participants, very low‐quality evidence), and taste recognition (MD 3.00, 95% CI 0.66 to 5.34; 14 participants, very low‐quality evidence). We meta‐analysed taste acuity improvement using objective outcome (dichotomous data) in idiopathic and zinc‐deficient taste disorder patients (RR 1.42, 95% 1.09 to 1.84; 292 participants, two trials, very low‐quality evidence). Out of the nine trials using zinc supplementation, four reported adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase, and minor increase in blood triglycerides. One trial tested taste discrimination using acupuncture (MD 2.80, 95% CI ‐1.18 to 6.78; 37 participants, very low‐quality evidence). No adverse events were reported in the acupuncture trial. None of the included trials could be included in the meta‐analysis for health‐related quality of life in taste disorder patients. Authors' conclusions We found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders. We did not find any evidence to conclude the role of zinc supplements for improving taste discrimination, or any evidence addressing health‐related quality of life due to taste disorders. We found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste). We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. Plain language summary Interventions for managing taste disturbances What is the aim of this review? The aim of this Cochrane Review was to find out what is the best method for the management of zinc‐deficient/idiopathic (of unknown cause) taste disorders and taste disorders secondary to chronic renal failure in children and adults. Key messages Giving zinc supplements or acupuncture may have some benefit in treating taste disorders. However, we still need more high‐quality studies to ascertain the role of zinc supplements and acupuncture in treating taste disorders. What was studied in the review? The sense of taste is essential to the health and psychological well‐being of an individual. Taste disorders can range from lack of taste, to distortion of taste, to reduced ability to taste. Any disorder in taste perception can lead to conditions like malnutrition and consumption of poisonous food substances. The cause may be due to disease, drugs, radiation treatment, or ageing; or it may result from unknown causes. Various treatment methods have been used to improve taste sensation. These include the use of zinc compounds, pilocarpine, alpha lipoic acid, transcranial magnetic stimulation, ginkgo biloba and acupuncture. What are the main results of the review? We collected and analysed all relevant studies to answer this question and found 10 trials in which a total of 581 subjects received different treatments. Nine trials assessed the benefits of zinc compounds and one trial assessed the effects of acupuncture. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Two trials were from Germany, three from Japan, two from the UK, and three from the US. These studies compared zinc with placebo or acupuncture with sham procedure for patients with taste disorders. Two were government funded, three were privately funded, two were funded by a pharmaceutical company and three trials did not mention funding details. When patients with taste disorders are given zinc, compared to placebo: ‐ we found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders;
 ‐ zinc supplementation showed adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase and minor increase in blood triglycerides;
 ‐ no studies were found that looked at improvement in taste discrimination or quality of life. When patients with taste disorders are given acupuncture, compared to sham procedure: ‐ we found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste);
 ‐ acupuncture trial did not show adverse events;
 ‐ no studies were found that looked at improvement in taste acuity or quality of life. We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. How up‐to‐date is this review? We searched for studies that had been published up to 4 July 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kumbargere Nagraj, S; George, RP; Shetty, N; Levenson, D; Ferraiolo, DM; Shrestha, A", "articleTypes": [], "doi": "10.1002/14651858.CD010470.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "2ada5249-c73e-4ef2-96b7-bc3098b91579", "pmid": "", "title": "Oral immunotherapy for milk allergy", "imported": false, "abstract": "Abstract - Background The mainstay of treatment of IgE‐mediated cow milk allergy (IMCMA) is an avoidance diet, which is especially difficult with a ubiquitous food like milk. Milk oral immunotherapy (MOIT) may be an alternative treatment, through desensitization or induction of tolerance. Objectives We aim to assess the clinical efficacy and safety of MOIT in children and adults with IMCMA as compared to a placebo treatment or avoidance strategy. Search methods We searched 13 databases for journal articles, conference proceedings, theses and unpublished trials, without language or date restrictions, using a combination of subject headings and text words. The search is up‐to‐date as of October 1, 2012. Selection criteria Only randomised controlled trials (RCT) were considered for inclusion. Blinded and open trial designs were included. Children and adults with IMCMA were included. MOIT administered by any protocol were included. Data collection and analysis A total of 2111 unique records were identified and screened for potential inclusion. Studies were selected, data extracted and methodological quality assessed independently by two reviewers. We attempted to contact the study investigators to inquire about data not published that was required for the analysis. Statistical heterogeneity was assessed using the I² test. We estimated a pooled risk ratio (RR) for each outcome using a Mantel‐Haenzel fixed‐effect model if statistical heterogeneity was low as evaluated by an I² value less than 50%. Main results Of 157 records reviewed, 16 were included, representing five trials. In general, the studies were small and had inconsistent methodological rigor. Overall, the quality of evidence was rated as low. Each study used a different MOIT protocol. A total of 196 patients were studied (106 MOIT, 90 control) and all were children. Three studies were blinded and two used an avoidance diet control. Sixty‐six patients (62%) in the MOIT group were able to tolerate a full serving of milk (about 200 mL) compared to seven (8%) of the control group (RR 6.61, 95% CI 3.51 to 12.44). In addition, 27 (25%) in the MOIT group could ingest a partial serving of milk (10 to 184 mL) while none could in the control group (RR 9.34, 95% CI 2.72 to 32.09). None of the studies assessed the patients following a period off immunotherapy. Adverse reactions were common (97 of 106 MOIT patients had at least one symptom), although most were local and mild. Because of variability in reporting methods, adverse effects could not be combined quantitatively. For every 11 patients receiving MOIT, one required intramuscular epinephrine. One patient required it on two occasions. Authors' conclusions Studies to date have involved small numbers of patients and the quality of evidence is generally low. The current evidence shows that MOIT can lead to desensitization in the majority of individuals with IMCMA although the development of long‐term tolerance has not been established. A major drawback of MOIT is the frequency of adverse effects, although most are mild and self‐limited. The use of parenteral epinephrine is not infrequent. Because there are no standardized protocols, guidelines would be required prior to incorporating desensitization into clinical practice. Plain language summary Repetitive, increasing doses of daily milk for treatment of milk allergy To date, the only option to treat food allergy is strict avoidance of the food and carrying an epinephrine injector (Epipen/Twinject) in case of an allergic reaction. For a food like cow's milk, avoidance is very difficult because it is found in many foods. The constant fear of accidentally eating or drinking cow's milk and anxiety related to carrying an injector has negative effects on quality of life. Accidentally having milk can cause life‐threatening reactions. Oral immunotherapy involves initially taking a very small amount of the allergen, in the case of milk allergy, cow's milk, and slowly increasing the amount each day until a full serving is reached. This may change the way the body's immune system sees the allergen, thereby increasing the amount of milk that can be eaten or drunk with no reaction. We identified randomized controlled trials that compared oral immunotherapy to placebo or continued avoidance diet in children and adults with cow's milk allergy. Five studies satisfied our inclusion criteria. In total there were 196 participants (106 in the treatment group and 90 in the control), all of whom were children. In general, the quality of the studies was low. Because the trials involved small numbers and there were problems with the way they were done, further research is needed. The current evidence shows that oral immunotherapy can help a majority of allergic children tolerate a full serving of milk, as long as they continue drinking this amount each day. However, it is not known if this protection is continued if the immunotherapy is stopped for some time. Side effects during oral immunotherapy are frequent and most patients will have at least some mild symptoms. In the studies we included, for every 11 patients who received oral immunotherapy, one needed to be treated with epinephrine injection at some point for a serious allergic reaction to the therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Yeung, JP; Kloda, LA; McDevitt, J; Ben‐Shoshan, M; Alizadehfar, R", "articleTypes": [], "doi": "10.1002/14651858.CD009542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "2b05560a-3b1a-4df1-a5e1-60aaac6f79f9", "pmid": "", "title": "Pharmacological interventions for promoting smoking cessation during pregnancy", "imported": false, "abstract": "Abstract - Background Tobacco smoking in pregnancy causes serious health problems for the developing fetus and mother. When used by non‐pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion, and varenicline) are effective for increasing smoking cessation, however their efficacy and safety in pregnancy remains unknown. Electronic cigarettes (ECs) are becoming widely used, but their efficacy and safety when used for smoking cessation in pregnancy are also unknown. Objectives To determine the efficacy and safety of smoking cessation pharmacotherapies and ECs used during pregnancy for smoking cessation in later pregnancy and after childbirth, and to determine adherence to smoking cessation pharmacotherapies and ECs for smoking cessation during pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2019), trial registers, and grey literature, and checked references of retrieved studies. Selection criteria Randomised controlled trials (RCTs) conducted in pregnant women, comparing smoking cessation pharmacotherapy or EC use with either placebo or no pharmacotherapy/EC control. We excluded quasi‐randomised, cross‐over, and within‐participant designs, and RCTs with additional intervention components not matched between trial arms. Data collection and analysis We followed standard Cochrane methods. The primary efficacy outcome was smoking cessation in later pregnancy; safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well‐being. We also collated data on adherence to trial treatments. We calculated the risk ratio (RR) or mean difference (MD) and the 95% confidence intervals (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta‐analyses where appropriate. Main results We included 11 trials that enrolled a total of 2412 pregnant women who smoked at enrolment, nine trials of NRT and two trials of bupropion as adjuncts to behavioural support, with comparable behavioural support provided in the control arms. No trials investigated varenicline or ECs. We assessed four trials as at low risk of bias overall. The overall certainty of the evidence was low across outcomes and comparisons as assessed using GRADE, with reductions in confidence due to risk of bias, imprecision, and inconsistency. Compared to placebo and non‐placebo (behavioural support only) controls, there was low‐certainty evidence that NRT increased the likelihood of smoking abstinence in later pregnancy (RR 1.37, 95% CI 1.08 to 1.74; I² = 34%, 9 studies, 2336 women). However, in subgroup analysis by comparator type, there was a subgroup difference between placebo‐controlled and non‐placebo controlled RCTs (test for subgroup differences P = 0.008). There was unclear evidence of an effect in placebo‐controlled RCTs (RR 1.21, 95% CI 0.95 to 1.55; I² = 0%, 6 studies, 2063 women), whereas non‐placebo‐controlled trials showed clearer evidence of a benefit (RR 8.55, 95% CI 2.05 to 35.71; I² = 0%, 3 studies, 273 women). An additional subgroup analysis in which studies were grouped by the type of NRT used found no difference in the effectiveness of NRT in those using patches or fast‐acting NRT (test for subgroup differences P = 0.08). There was no evidence of a difference between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities, or neonatal death. In one study infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' at two years of age compared to the placebo group. Non‐serious adverse effects observed with NRT included headache, nausea, and local reactions (e.g. skin irritation from patches or foul taste from gum), but data could not be pooled. Adherence to NRT treatment regimens was generally low. We identified low‐certainty evidence that there was no difference in smoking abstinence rates observed in later pregnancy in women using bupropion when compared to placebo control (RR 0.74, 95% CI 0.21 to 2.64; I² = 0%, 2 studies, 76 women). Evidence investigating the safety outcomes of bupropion use was sparse, but the existing evidence showed no difference between the bupropion and control group. Authors' conclusions NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy. However, this evidence is of low certainty, as the effect was not evident when potentially biased, non‐placebo‐controlled RCTs were excluded from the analysis. Future studies may therefore change this conclusion. We found no evidence that NRT has either positive or negative impacts on birth outcomes; however, the evidence for some of these outcomes was also judged to be of low certainty due to imprecision and inconsistency. We found no evidence that bupropion may be an effective aid for smoking cessation during pregnancy, and there was little evidence evaluating its safety in this population. Further research evidence on the efficacy and safety of pharmacotherapy and EC use for smoking cessation in pregnancy is needed, ideally from placebo‐controlled RCTs that achieve higher adherence rates and that monitor infants' outcomes into childhood. Future RCTs of NRT should investigate higher doses than those tested in the studies included in this review. Plain language summary Drug treatments and electronic cigarettes for stopping smoking in pregnancy What is the issue? Smoking during pregnancy harms women and infants. However, many women who smoke struggle to stop whilst pregnant. Medication for smoking cessation reduces the intensity of cravings, meaning that people trying to stop smoking are more likely to succeed in the long term. Providing pregnant women who smoke with these treatments could help them to stop smoking and have a positive impact on both their own health and the health of their infants. Why is this important? Medications commonly used to help people to stop smoking include nicotine replacement therapy (NRT), bupropion, and varenicline. Electronic cigarettes containing nicotine are also used by some who smoke to help avoid smoking. However, the safety and effectiveness of smoking cessation drugs and electronic cigarettes in pregnant women is unknown. We searched for studies looking at how good these aids were at helping pregnant women stop smoking and how safe they were when used during pregnancy. What evidence did we find? We searched for evidence on 20 May 2019 and identified 11 randomised studies (studies in which participants are assigned to one of two or more treatment groups using a random method) that enrolled a total of 2412 women. Nine studies tested NRT used alongside counselling to stop smoking, whilst the other two studies tested bupropion. Low‐quality evidence suggests that NRT combined with behavioural support might help women to stop smoking in later pregnancy more than behavioural support alone. Medication trials often use placebos, that is tablets or patches that look like the drug but do not actually include it, so that each comparison group has equal expectation of success and there is a fairer test of the benefits of the medicine itself. When just the higher‐quality, placebo‐controlled trials were analysed, the evidence suggested that NRT was more effective than placebo NRT. There was no evidence that either nicotine patches or fast‐acting NRT (such as gum or lozenge) was more effective than the other. Low‐quality evidence suggests that bupropion may be no more effective than placebo in helping women quit smoking later in pregnancy. We found no trials investigating other smoking cessation pharmacotherapies or electronic cigarettes. There was insufficient evidence to conclude whether NRT had either positive or negative impacts on rates of miscarriage, stillbirth, preterm birth (less than 37 weeks), mean birthweight, low birthweight (less than 2500 g), admissions of babies to neonatal intensive care, or newborn deaths. However, in one trial where infants were followed until two years of age, those infants born to women who had been randomised to NRT were more likely to have healthy development. Similarly, it is unclear whether bupropion had a positive or negative impact on birth outcomes. Studies that looked at whether women used their stop smoking medications as instructed found that use was generally low, and the majority of women used little of the NRT they were given. What does this mean? More research evidence is needed, in particular placebo‐controlled trials that test higher doses of NRT, encourage women to use sufficient medication, and follow infants into childhood. Furthermore, more studies are required investigating the effect and safety of bupropion, electronic cigarettes, and varenicline for giving up smoking during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Claire, R, Chamberlain, C, Davey, MA, Cooper, SE, Berlin, I, Leonardi‐Bee, J, Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD010078.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.764Z" }, { "id": "2b196d13-00e0-47e9-8bbf-adfb0358f37d", "pmid": "", "title": "Vitamin C for preventing and treating pneumonia", "imported": false, "abstract": "Abstract - Background Pneumonia is one of the most common serious infections, causing two million deaths annually among young children in low‐income countries. In high‐income countries pneumonia is most significantly a problem of the elderly. Objectives To assess the prophylactic and therapeutic effects of vitamin C on pneumonia. Search methods We searched CENTRAL 2013, Issue 3, MEDLINE (1950 to March week 4, 2013), EMBASE (1974 to April 2013) and Web of Science (1955 to April 2013). Selection criteria To assess the therapeutic effects of vitamin C, we selected placebo‐controlled trials. To assess prophylactic effects, we selected controlled trials with or without a placebo. Data collection and analysis Two review authors independently read the trial reports and extracted data. Main results We identified three prophylactic trials which recorded 37 cases of community‐acquired pneumonia in 2335 people. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. Two trials examined military recruits and the third studied boys from \"lower wage‐earning classes\" attending a boarding school in the UK during World War II. Each of these three trials found a statistically significant (80% or greater) reduction in pneumonia incidence in the vitamin C group. We identified two therapeutic trials involving 197 community‐acquired pneumonia patients. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. That trial studied elderly patients in the UK and found lower mortality and reduced severity in the vitamin C group; however, the benefit was restricted to the most ill patients. The other therapeutic trial studied adults with a wide age range in the former Soviet Union and found a dose‐dependent reduction in the duration of pneumonia with two vitamin C doses. We identified one prophylactic trial recording 13 cases of hospital‐acquired pneumonia in 37 severely burned patients; one‐day administration of vitamin C had no effect on pneumonia incidence. The identified studies are clinically heterogeneous which limits their comparability. The included studies did not find adverse effects of vitamin C. Authors' conclusions The prophylactic use of vitamin C to prevent pneumonia should be further investigated in populations who have a high incidence of pneumonia, especially if dietary vitamin C intake is low. Similarly, the therapeutic effects of vitamin C should be studied, especially in patients with low plasma vitamin C levels. The current evidence is too weak to advocate prophylactic use of vitamin C to prevent pneumonia in the general population. Nevertheless, therapeutic vitamin C supplementation may be reasonable for pneumonia patients who have low vitamin C plasma levels because its cost and risks are low. Plain language summary Vitamin C for preventing and treating pneumonia Pneumonia is an infection of the lungs usually caused by bacteria and viruses. Its clinical diagnosis is sometimes difficult. Pneumonia is more common in young children and in the aged. In low‐income countries it causes two million deaths annually among young children. In the USA it is the most common cause of death from infection. Vitamin C was identified in the early 1900s and suggestions that one of its biological roles may be to resist infections are supported by numerous animal studies. We looked for studies in humans and found three trials with a total of 2335 participants that looked at whether vitamin C prevents pneumonia in the community. Two of these preventive trials studied soldiers while the third studied boys in a UK boarding school in the 1940s. Two therapeutic trials with a total of 197 pneumonia patients looked at whether vitamin C might be beneficial for pneumonia patients. One studied patients aged 66 to 94 years in the UK with pneumonia. The other therapeutic trial was conducted in the former Soviet Union but the social and nutritional backgrounds of the patients were not described. One study with 37 burns patients examined the effect of vitamin C on hospital‐acquired pneumonia. Our searches were up‐date‐as of April 2013. Five of the identified trials found preventive or therapeutic benefits of vitamin C against pneumonia but the study on hospital‐acquired pneumonia found no effect. The overall quality of the studies was good. However, the five trials with positive findings were carried out in such extraordinary conditions that the results should not be extrapolated to the general population. Therefore, more research is needed. In the meantime, supplementing pneumonia patients who have low plasma vitamin C levels may be reasonable because of its safety and low cost. None of the five trials reported noteworthy adverse effects of vitamin C.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H; Louhiala, P", "articleTypes": [], "doi": "10.1002/14651858.CD005532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "2b2ab84f-63c6-4e23-bf69-e3bdb2716221", "pmid": "", "title": "Oral versus intravenous steroids for treatment of relapses in multiple sclerosis", "imported": false, "abstract": "Abstract - Background This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD006921. DOI: 10.1002/14651858.CD006921.pub2). Multiple sclerosis (MS), a chronic inflammatory and neurodegenerative disease of the central nervous system (CNS), is characterized by recurrent relapses of CNS inflammation ranging from mild to severely disabling. Relapses have long been treated with steroids to reduce inflammation and hasten recovery. However, the commonly used intravenous methylprednisolone (IVMP) requires repeated infusions with the added costs of homecare or hospitalization, and may interfere with daily responsibilities. Oral steroids have been used in place of intravenous steroids, with lower direct and indirect costs. Objectives The primary objective was to compare efficacy of oral versus intravenous steroids in promoting disability recovery in MS relapses <= six weeks. Secondary objectives included subsequent relapse rate, disability, ambulation, hospitalization, immunological markers, radiological markers, and quality of life. Search methods A literature search was performed using Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group's Trials Register (January 2012), abstracts from meetings of the American Academy of Neurology (2008‐2012), the European Federation of Neurological Sciences (2008‐2012), the European Committee for Treatment and Research in Multiple Sclerosis and American Committee for Treatment and Research in Multiple Sclerosis (2008‐2012) handsearching. No language restrictions were applied. Selection criteria Randomized or quasi‐randomized trials comparing oral versus intravenous steroids for acute relapses (<= six weeks) in patients with clinically definite MSover age 16 were eligible. Data collection and analysis Three review authors (JB, PO and MH) participated in the independent assessment of all published articles as potentially relevant to the review. Any disagreement was resolved by discussion among review authors. We contacted study authors for additional information. Methodological quality was assessed by the same three review authors. Relevant data were extracted, and effect size was reported as mean difference (MD), mean difference (MD), odds ratio (OR) and absolute risk difference (ARD). Main results With this current update, a total of five eligible studies (215 patients) were identified. Only one outcome, the proportion of patients with Expanded Disability Status Scale (EDSS) improvement at four weeks, was common to three trials, while two trials examined magnetic resonance imaging (MRI) outcomes. The results of this review shows there is no significant difference in relapse recovery at week four (MD ‐0.22, 95% confidence interval (95% CI), 0.71 to 0.26, P = 0.20) nor differences in magnetic resonance imaging (MRI) gadolinium enhancement activity based on oral versus intravenous steroid treatment. However, only two of the five studies employed more current and rigorous methodological techniques, so these results must be taken with some caution. The Oral Megadose Corticosteroid Therapy of Acute Exacerbations of Multiple Sclerosis (OMEGA) trial and the \"Efficacy and Safety of Methylprednisolone Per os Versus IV for the Treatment of Multiple Sclerosis (MS) Relapses\" (COPOUSEP) trial, designed to address such limitations, are currently underway. Authors' conclusions The analysis of the five included trials comparing intravenous versus oral steroid therapy for MS relapses do not demonstrate any significant differences in clinical (benefits and adverse events), radiological or pharmacological outcomes. Based on the evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy in the treatment of MS relapses. Plain language summary A comparison of the efficacy of oral versus intravenous steroids in relapsing‐remitting multiple sclerosis (RRMS) RRMS is characterized by periods of disability (relapse) due to inflammation in the central nervous system. All research has shown that a \"speeding up\" of recovery is obtained by use of corticosteroids, given most often in intravenous form. If oral steroids worked as well as intravenous ones for relapse events, they would be easier to take and are more affordable. 
 
 The objective of this review was to assess if oral and intravenous steroids are equally effective and safe in aiding in the recovery from relapses. Among the pertinent literature, only five studies met the inclusion criteria, comprising a total of 215 participants. Despite some limitations in the methods used to conduct the studies (i.e. incomplete reporting of the participants who dropped out the studies and appropriateness of the sample size) and in the analysis of the data, all five studies found that there were no significant differences in term of benefits and adverse events and in the pharmacological and radiological outcomes in patients taking oral or intravenous steroids. Both treatments appear to be equally effective and safe. Based on this evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy for the treatment of MS relapses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Burton, JM; O'Connor, PW; Hohol, M; Beyene, J", "articleTypes": [], "doi": "10.1002/14651858.CD006921.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "2b3aa8b0-419f-4c27-a007-0ae4087c7a78", "pmid": "", "title": "Probiotic treatment for women with gestational diabetes to improve maternal and infant health and well‐being", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance first recognised during pregnancy and associated with complications for mothers and babies. Probiotics are naturally occurring micro‐organisms, which when ingested in adequate amounts, may confer health benefits. Evidence of the role of probiotics as treatment for GDM is limited. Objectives To evaluate the safety and effectiveness of probiotics in treating women with GDM on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth’s Trials Register ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (24 July 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing the use of probiotics versus placebo/standard care for the treatment of GDM. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, checked data accuracy, and assessed risk of bias of included trials. The certainty of evidence for selected maternal and infant/child outcomes was assessed using GRADE. Main results Nine RCTs (695 pregnant women with GDM) comparing probiotics versus placebo were identified. The overall risk of bias in the nine RCTs was low to unclear and the evidence was downgraded for imprecision due to the small numbers of women participating in the trials. The trials were carried out in hospitals and universities in Iran (seven trials), Thailand (one trial) and Ireland (one trial). All trials compared probiotics with placebo. Maternal outcomes We are uncertain if probiotics have any effect compared with placebo on hypertensive disorders of pregnancy, (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.64 to 3.53; participants = 256; studies = 3; low‐certainty evidence) and mode of birth as caesareans (average RR 0.64, 95% CI 0.30 to 1.35; participants = 267; studies = 3; low‐certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm . No trials reported primary outcomes of: mode of birth as vaginal/assisted and subsequent development of type 2 diabetes. We are uncertain if probiotics have any effect compared with placebo on induction of labour (RR 1.33, 95% CI 0.74 to 2.37; participants = 127; studies = 1; very low‐certainty evidence). For other secondary maternal outcomes, we are uncertain if there are differences between probiotics and placebo for: postpartum haemorrhage; weight gain during pregnancy intervention and total gestational weight gain; fasting plasma glucose and need for extra pharmacotherapy (insulin). Probiotics may be associated with a slight reduction in triglycerides and total cholesterol. In probiotics compared with placebo, there was evidence of reduction in markers for insulin resistance (HOMA‐IR) and HOMA‐B; and insulin secretion. There was also an increase in quantitative insulin sensitivity check index (QUICKI). Probiotics were associated with minor benefits in relevant bio‐markers with evidence of a reduction in inflammatory markers high‐sensitivity C‐reactive protein (hs‐CRP), interleukin 6 (IL‐6), and marker of oxidative stress malondialdehyde; and an increase in antioxidant total glutathione, but we are uncertain if there is any difference in total antioxidant capacity. No trials reported secondary outcomes: perineal trauma, postnatal weight retention or return to pre‐pregnancy weight and postnatal depression. Infant/child/adult outcomes We are uncertain if probiotics have any effect, compared with placebo, on the risk of large‐for‐gestational‐age babies (RR 0.73, 95% CI 0.35 to 1.52; participants = 174; studies = 2; low‐certainty evidence) or infant hypoglycaemia (RR 0.85, 95% CI 0.39 to 1.84; participants = 177; studies = 3; low ‐ certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm. No trials reported primary outcomes of: perinatal (fetal/neonatal) mortality; or neurosensory disability. For other secondary outcomes, we are uncertain if there is any difference between probiotics and placebo in gestational age at birth, preterm birth, macrosomia, birthweight, head circumference, length, infant hypoglycaemia, and neonatal intensive care unit (NICU) admissions. There was evidence of a reduction in infant hyperbilirubinaemia with probiotics compared with placebo. No trials reported secondary outcomes: infant adiposity, and later childhood adiposity. There were no adverse events reported by any of the trials. Authors' conclusions Low‐certainty evidence means we are not certain if there is any difference between probiotic and placebo groups in maternal hypertensive disorders of pregnancy, caesareans; and large‐for‐gestational‐age babies . There were no adverse events reported by the trials. Due to the variability of probiotics used and small sample sizes of trials, evidence from this review has limited ability to inform practice. Well‐designed adequately‐powered trials are needed to identify whether probiotics may improve maternal blood glucose levels and/or infant/child/adult outcomes; and whether they can be used to treat GDM. Plain language summary Probiotics as an added treatment for gestational diabetes to improve mother and baby outcomes What is the issue? Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in high blood glucose levels, first recognised during pregnancy. Pregnant women with GDM are at risk of high blood pressure, labour induction, and caesareans. Their babies are at risk of being born large, birth difficulties, respiratory distress, low blood glucose at birth and jaundice that can cause brain injury. There is increased risks of having long‐term diabetes in the mother, and the baby being overweight. Probiotics are micro‐organisms naturally in food and are in fermented milk, yogurt, or capsules. There are many different probiotics; the two most used are Lactobacillus and Bifidobacterium, and if consumed in adequate amounts may confer health benefits. Why is this important? Probiotics need to be safe and maternal blood glucose levels carefully managed during pregnancy. Women with GDM may receive dietary and physical activity education with monitoring blood glucose levels as initial management. When blood glucose levels are above a certain threshold, women with GDM are prescribed glucose‐lowering medications including metformin and/or insulin. This review aimed to determine the safety and effectiveness of probiotics in treating women with GDM. What evidence did we find? We searched for evidence for randomised controlled trials (latest July 2019). We identified nine studies, involving 695 women with GDM. All trials compared probiotics with placebo. The certainty of the evidence was assessed as very low or low. The overall risk of bias was low to unclear. Seven trials were conducted in Iran; one in Thailand, and one in Ireland. Trials took place in hospitals and universities. We are uncertain if there is any difference between probiotic and placebo in rates of: high blood‐pressure disorders (three studies, 256 participants, low‐certainty evidence); caesarean section (three studies, 267 women, low‐certainty evidence ); and large‐for‐gestational‐age babies (two studies, 174 participants, low‐certainty evidence). We are uncertain if there is any difference between probiotic and placebo for induction of labour (one study, 127 participants, very low‐certainty evidence) and low blood glucose levels in the newborn (three studies, 177 participants, low‐certainty evidence). We are also uncertain if there is any difference between probiotics and placebo for heavy bleeding immediately after birth, weight gain during pregnancy or total gestational weight gain. We are uncertain if there is any difference in fasting blood glucose between probiotics and placebo (seven studies, 554 participants). Probiotics may be assoicated with a slight reduction in triglycerides and total cholesterol (four studies, 320 participants). There was reduction in insulin secretion with probiotics (seven studies, 505 participants). One trial (60 participants) showed no difference between groups in need for insulin. Biomarkers, did show a reduction in insulin resistance (HOMA‐IR), (seven studies, 505 participants) and insulin resistance and β cell function (HOMA‐B) (two studies,130 participants) with probiotics. Quantitative insulin sensitivity check index (QUICKI) increased (four studies, 276 participants) with probiotics. Inflammatory markers, hs‐CRP (four studies, 248 participants) and interleukin 6 (two studies, 128 participants) were reduced with probiotics. Antioxidant total glutathione was increased (two studies, 120 participants) and the oxidative stress biomarker malondialdehyde was reduced with probiotics (three studies, 176 participants). We are uncertain if there is any difference in total antioxidant capacity (four studies 266 participants). For the newborn baby, we are uncertain if there is any difference between groups for: birthweight, gestational age at birth, preterm births, large babies, head circumference and length scores, or need for admission to the neonatal intensive care unit. The number of babies with high levels of bilirubin was reduced with probiotics. No adverse events were reported by the trials. What does this mean? Based on the clinical trials available, the evidence is limited to support the use of probiotics as treatment for women with GDM to improve pregnancy outcomes for mothers and their babies. Larger well‐designed randomised controlled trials are needed to assess the effects of probiotics on management of glucose levels and when available, they can be included in the update of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Okesene-Gafa, KAM, Moore, AE, Jordan, V, McCowan, L, Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD012970.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.108Z" }, { "id": "2b535026-14a2-4766-9a48-4824914d6ef0", "pmid": "", "title": "Probiotics for induction of remission in ulcerative colitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Kaur, L, Gordon, M, Baines, PA, Iheozor-Ejiofor, Z, Sinopoulou, V, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD005573.pub3 AB - Abstract - Background Ulcerative colitis is an inflammatory condition affecting the colon, with an annual incidence of approximately 10 to 20 per 100,000 people. The majority of people with ulcerative colitis can be put into remission, leaving a group who do not respond to first‐ or second‐line therapies. There is a significant proportion of people who experience adverse effects with current therapies. Consequently, new alternatives for the treatment of ulcerative colitis are constantly being sought. Probiotics are live microbial feed supplements that may beneficially affect the host by improving intestinal microbial balance, enhancing gut barrier function and improving local immune response. Objectives To assess the efficacy of probiotics compared with placebo or standard medical treatment (5‐aminosalicylates, sulphasalazine or corticosteroids) for the induction of remission in people with active ulcerative colitis. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 31 October 2019. We contacted authors of relevant studies and manufacturers of probiotics regarding ongoing or unpublished trials that may be relevant to the review, and we searched ClinicalTrials.gov. We also searched references of trials for any additional trials. Selection criteria Randomised controlled trials (RCTs) investigating the effectiveness of probiotics compared to standard treatments or placebo in the induction of remission of active ulcerative colitis. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We analysed data using Review Manager 5. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE methodology. Main results In this review, we included 14 studies (865 randomised participants) that met the inclusion criteria. Twelve of the studies looked at adult participants and two studies looked at paediatric participants with mild to moderate ulcerative colitis, the average age was between 12.5 and 47.7 years. The studies compared probiotics to placebo, probiotics to 5‐ASA and a combination of probiotics plus 5‐ASA compared to 5‐ASA alone. Seven studies used a single probiotic strain and seven used a mixture of strains. The studies ranged from two weeks to 52 weeks. The risk of bias was high for all except two studies due to allocation concealment, blinding of participants, incomplete reports of outcome data and selective reporting. This led to GRADE ratings of the evidence ranging from moderate to very low. Probiotics versus placebo 
Probiotics may induce clinical remission when compared to placebo (RR 1.73, 95% CI 1.19 to 2.54; 9 studies, 594 participants; low‐certainty evidence; downgraded due to imprecision and risk of bias, number needed to treat for an additional beneficial outcome (NNTB) 5). Probiotics may lead to an improvement in clinical disease scores (RR 2.29, 95% CI 1.13 to 4.63; 2 studies, 54 participants; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.04, 95% CI 0.42 to 2.59; 7 studies, 520 participants). Reported adverse events included abdominal bloating and discomfort. Probiotics did not lead to any serious adverse events in any of the seven studies that reported on it, however five adverse events were reported in the placebo arm of one study (RR 0.09, CI 0.01 to 1.66; 1 study, 526 participants; very low‐certainty evidence; downgraded due to high risk of bias and imprecision). Probiotics may make little or no difference to withdrawals due to adverse events (RR 0.85, 95% CI 0.42 to 1.72; 4 studies, 401 participants; low‐certainty evidence). Probiotics versus 5‐ASA 
There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (RR 0.92, 95% CI 0.73 to 1.16; 1 study, 116 participants; low‐certainty evidence; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.33, 95% CI 0.53 to 3.33; 1 study, 116 participants). Reported adverse events included abdominal pain, nausea, headache and mouth ulcers. There were no serious adverse events with probiotics, however perforated sigmoid diverticulum and respiratory failure in a patient with severe emphysema were reported in the 5‐ASA arm (RR 0.21, 95% CI 0.01 to 4.22; 1 study, 116 participants; very low‐certainty evidence). Probiotics combined with 5‐ASA versus 5‐ASA alone 
Low‐certainty evidence from a single study shows that when combined with 5‐ASA, probiotics may slightly improve the induction of remission (based on the Sunderland disease activity index) compared to 5‐ASA alone (RR 1.22 CI 1.01 to 1.47; 1 study, 84 participants; low‐certainty evidence; downgraded due to unclear risk of bias and imprecision). No information about adverse events was reported. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes (progression to surgery, need for additional therapy, quality of life scores, or steroid withdrawal) were reported in any of the studies. Authors' conclusions Low‐certainty evidence suggests that probiotics may induce clinical remission in active ulcerative colitis when compared to placebo. There may be little or no difference in clinical remission with probiotics alone compared to 5‐ASA. There is limited evidence from a single study which failed to provide a definition of remission, that probiotics may slightly improve the induction of remission when used in combination with 5‐ASA. There was no evidence to assess whether probiotics are effective in people with severe and more extensive disease, or if specific preparations are superior to others. Further targeted and appropriately designed RCTs are needed to address the gaps in the evidence base. In particular, appropriate powering of studies and the use of standardised participant groups and outcome measures in line with the wider field are needed, as well as reporting to minimise risk of bias. Plain language summary Probiotics for the treatment of active ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can induce remission in people with ulcerative colitis. We analysed data from 14 studies to answer this question. Key messages Probiotics may be better at inducing remission than placebo (dummy treatment). It is unclear whether probiotics are better than 5‐aminosalicylic acid (5‐ASA, an anti‐inflammatory agent used to treat inflammatory bowel disease), however there is limited evidence that when both treatments are used as combined therapy they may be better than 5‐ASA alone in inducing remission. Most studies reported that no serious adverse events took place. For the studies that did report on it, serious adverse events did not occur in the probiotic group. Minor adverse events reported were bloating and diarrhoea. What was studied in the review? Ulcerative colitis is a relapsing and remitting disease which causes inflammation of the large bowel and leads to symptoms such as abdominal pain, diarrhoea and tiredness. There is some evidence to suggest that an imbalance in the bacteria of the gut is the cause of the disease, and therefore probiotics, which are live micro‐organisms, can alter the bacteria and possibly reduce the inflammation. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing probiotics with placebo, probiotics with 5‐ASA, and probiotics in combination with 5‐ASA. We found 14 RCTs looking at 865 participants. The trials looked at adult and paediatric participants. Eight studies allowed additional therapy to continue, whilst the other four studies were unclear about this. 1) Probiotics may improve induction of clinical remission when compared to placebo. 2) It is unclear whether probiotics lead to a difference in adverse events (minor and serious) when compared to placebo. 3) There is limited evidence to determine whether probiotics offer better disease improvement when compared to placebo. 4) There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (low‐certainty evidence). 5) There is limited evidence to suggest that when probiotics plus 5‐ASA are compared to 5‐ASA alone, probiotics may offer a slightly better chance of induction of remission. This is based on low‐certainty evidence from one study, and we are not sure of the type of remission studied. 6) Serious adverse events were reported when probiotics were compared with placebo, but only occurred in the placebo group. Conclusion Whilst the evidence suggests that probiotics may be better at improving induction than placebo, our confidence in the estimate is limited because of the low‐certainty evidence. This is attributed to the small number of participants in each study along with the unreliable methods utilised by the trials. With the evidence presented in these studies, we are unable to make strong conclusions into the effectiveness of probiotics; better designed studies with more participants are needed. How up‐to‐date is this review? This review is up‐to‐date as of October 2019.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.777Z" }, { "id": "2b60ea1b-b4c2-4e8a-9fec-8a5b11a46d5d", "pmid": "", "title": "Pharmacological and non‐pharmacological strategies for obese women with subfertility", "imported": false, "abstract": "Abstract - Background Clinicians primarily recommend weight loss for obese women seeking pregnancy. The effectiveness of interventions aimed at weight loss in obese women with subfertility is unclear. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for achieving weight loss in obese women with subfertility. Search methods We searched the CGF Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and AMED from inception to 18 August 2020. We also checked reference lists and contacted experts in the field for additional relevant papers. Selection criteria We included published and unpublished randomised controlled trials in which weight loss was the main goal of the intervention. Our primary effectiveness outcomes were live birth or ongoing pregnancy and primary safety outcomes were miscarriage and adverse events. Secondary outcomes included clinical pregnancy, weight change, quality of life, and mental health outcome. Data collection and analysis Review authors followed standard Cochrane methodology. Main results This review includes 10 trials. Evidence was of very low to low quality: the main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision. Non‐pharmacological intervention versus no intervention or placebo Evidence is insufficient to determine whether a diet or lifestyle intervention compared to no intervention affects live birth (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.65 to 1.11; 918 women, 3 studies; I² = 78%; low‐quality evidence). This suggests that if the chance of live birth following no intervention is assumed to be 43%, the chance following diet or lifestyle changes would be 33% to 46%. We are uncertain if lifestyle change compared with no intervention affects miscarriage rate (OR 1.54, 95% CI 0.99 to 2.39; 917 women, 3 studies; I² = 0%; very low‐quality evidence). Evidence is insufficient to determine whether lifestyle change compared with no intervention affects clinical pregnancy (OR 1.06, 95% CI 0.81 to 1.40; 917 women, 3 studies; I² = 73%; low‐quality evidence). Lifestyle intervention resulted in a decrease in body mass index (BMI), but data were not pooled due to heterogeneity in effect (mean difference (MD) ‐3.70, 95% CI ‐4.10 to ‐3.30; 305 women, 1 study; low‐quality evidence; and MD ‐1.80, 95% CI ‐2.67 to ‐0.93; 43 women, 1 study; very low‐quality evidence). Non‐pharmacological versus non‐pharmacological intervention We are uncertain whether intensive weight loss interventions compared to standard care nutrition counselling affects live birth (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), BMI (MD ‐3.00, 95% CI ‐5.37 to ‐0.63; 11 women, 1 study; very low‐quality evidence), weight change (MD ‐9.00, 95% CI ‐15.50 to ‐2.50; 11 women, 1 study; very low‐quality evidence), quality of life (MD 0.06, 95% CI ‐0.03 to 0.15; 11 women, 1 study; very low‐quality evidence), or mental health (MD ‐7.00, 95% CI ‐13.92 to ‐0.08; 11 women, 1 study; very low‐quality evidence). No study reported on adverse events . Pharmacological versus pharmacological intervention For metformin plus liraglutide compared to metformin we are uncertain of an effect on the adverse events nausea (OR 7.22, 95% CI 0.72 to 72.7; 28 women, 1 study; very low‐quality evidence), diarrhoea (OR 0.31, 95% CI 0.01 to 8.3; 28 women, 1 study; very low‐quality evidence), and headache (OR 5.80, 95% CI 0.25 to 133; 28 women, 1 study; very low‐quality evidence). We are uncertain if a combination of metformin plus liraglutide vs metformin affects BMI (MD 2.1, 95% CI ‐0.42 to 2.62; 28 women, 1 study; very low‐quality evidence) and total body fat (MD ‐0.50, 95% CI ‐4.65 to 3.65; 28 women, 1 study; very low‐quality evidence). For metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo, we are uncertain of an effect on miscarriage (OR 3.58, 95% CI 0.73 to 17.55; 274 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 5.56, 95% CI 2.57 to 12.02; 274 women, 1 study; very low‐quality evidence) or BMI (MD ‐0.3, 95% CI 1.17 to 0.57, 274 women, 1 study, very low‐quality evidence). We are uncertain if dexfenfluramine versus placebo affects weight loss in kilograms (MD ‐0.10, 95% CI ‐2.77 to 2.57; 21 women, 1 study; very low‐quality evidence). No study reported on live birth, quality of life, or mental health outcomes. Pharmacological intervention versus no intervention or placebo We are uncertain if metformin compared with placebo affects live birth (OR 1.57, 95% CI 0.44 to 5.57; 65 women, 1 study; very low‐quality evidence). This suggests that if the chance of live birth following placebo is assumed to be 15%, the chance following metformin would be 7% to 50%. We are uncertain if metformin compared with placebo affects gastrointestinal adverse events (OR 0.91, 95% CI 0.32 to 2.57; 65 women, 1 study; very low‐quality evidence) or miscarriage (OR 0.50, 95% CI 0.04 to 5.80; 65 women, 1 study; very low‐quality evidence) or clinical pregnancy (OR 2.67, 95% CI 0.90 to 7.93; 96 women, 2 studies; I² = 48%; very low‐quality evidence). We are also uncertain if diet combined with metformin versus diet and placebo affects BMI (MD ‐0.30, 95% CI ‐2.16 to 1.56; 143 women, 1 study; very low‐quality evidence) or waist‐to‐hip ratio (WHR) (MD 2.00, 95% CI ‐2.21 to 6.21; 143 women, 1 study; very low‐quality evidence). Pharmacological versus non‐pharmacological intervention No study undertook this comparison. Authors' conclusions Evidence is insufficient to support the use of pharmacological and non‐pharmacological strategies for obese women with subfertility. No data are available for the comparison of pharmacological versus non‐pharmacological strategies. We are uncertain whether pharmacological or non‐pharmacological strategies effect live birth, ongoing pregnancy, adverse events, clinical pregnancy, quality of life, or mental health outcomes. However, for obese women with subfertility, a lifestyle intervention may reduce BMI. Future studies should compare a combination of pharmacological and lifestyle interventions for obese women with subfertility. Plain language summary Do pharmacological and non‐pharmacological strategies reduce weight in obese women with subfertility? To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for weight reduction in obese women with subfertility. Background To prevent the adverse effects of obesity, weight loss is recommended as the first line of treatment for obese women seeking pregnancy. The effectiveness of pharmacological and non‐pharmacological interventions for obese women with subfertility is unclear. Study characteristics We found 10 randomised trials comparing pharmacological and non‐pharmacological strategies in 1490 obese women with subfertility. Key results Lack of data is a major concern in interpretation of these data. Only 10 studies were included in the analysis. Three studies compared non‐pharmacological intervention versus no intervention or placebo. We are uncertain whether diet versus no intervention improves live birth, ongoing pregnancy, clinical pregnancy, or adverse events. A diet or lifestyle intervention may result in body mass index (BMI) weight change. Evidence was insufficient to show a difference in waist‐to‐hip ratio (WHR) with diet or lifestyle change compared to no intervention. No study reported on quality of life, or mental health outcomes for this comparison. One study compared non‐pharmacological interventions ‐ intensive weight loss intervention versus standard of care nutrition counselling; however due to the very low quality of evidence, we are uncertain whether intensive weight loss interventions improve live birth, clinical pregnancy, quality of life, or mental health outcomes. No study reported on adverse events, or weight changes, for this comparison. Three studies reported on pharmacological versus pharmacological interventions. Evidence was insufficient to show a difference in adverse events between metformin compared to metformin plus liraglutide. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for miscarriage. Evidence was insufficient to reveal a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo or metformin plus liraglutide versus metformin in clinical pregnancy. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for weight change using BMI. Moreover, evidence was insufficient to reveal a difference between dexfenfluramine versus placebo or metformin plus liraglutide versus metformin for weight loss in kilograms, or per cent of total body fat. No study reported on live birth and change in quality of life or mental health outcomes for this comparison. In the comparison of pharmacological intervention versus no intervention or placebo, three studies were included. Evidence was insufficient to show a difference between metformin and control groups related to live birth. Evidence was insufficient to reveal a difference between metformin compared to placebo in live birth, clinical pregnancy, or adverse events. Evidence was insufficient to demonstrate a difference between diet combined with metformin versus diet combined with placebo for weight change using BMI or WHR. No study reported on quality of life or mental health outcomes for this comparison. We found no study comparing non‐pharmacological with pharmacological interventions. Quality of the evidence The evidence was of very low to low quality. The main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading of evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Taghavi, SA; van Wely, M; Jahanfar, S; Bazarganipour, F", "articleTypes": [], "doi": "10.1002/14651858.CD012650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "2b6e60f0-54e7-4665-936a-fd6b583f0d41", "pmid": "", "title": "Interventions for treating oral leukoplakia to prevent oral cancer", "imported": false, "abstract": "Abstract - Background Oral leukoplakia is a relatively common oral lesion that, in a small proportion of people, precedes the development of oral cancer. Most leukoplakias are asymptomatic; therefore, the primary objective of treatment should be to prevent onset of cancer. This review updates our previous review, published in 2006. Objectives To assess the effectiveness, safety and acceptability of treatments for leukoplakia in preventing oral cancer. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 16 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) ( the Cochrane Library , 2016, Issue 4), MEDLINE Ovid (1946 to 16 May 2016), Embase Ovid (1980 to 16 May 2016) and CancerLit via PubMed (1950 to 16 May 2016). We searched the metaRegister of Controlled Trials (to 10 February 2015), ClinicalTrials.gov (to 16 May 2016) and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials (to 16 May 2016). We placed no restrictions on the language or date of publication when searching electronic databases. Selection criteria We included randomised controlled trials (RCTs) that enrolled people with a diagnosis of oral leukoplakia and compared any treatment versus placebo or no treatment. Data collection and analysis We collected data using a data extraction form. Oral cancer development, demonstrated by histopathological examination, was our primary outcome. Secondary outcomes were clinical resolution of the lesion, improvement of histological features and adverse events. We contacted trial authors for further details when information was unclear. When valid and relevant data were available, we conducted a meta‐analysis of the data using a fixed‐effect model when we identified fewer than four studies with no heterogeneity. For dichotomous outcomes, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We assessed risk of bias in studies by using the Cochrane tool. We assessed the overall quality of the evidence by using standardised criteria (Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE)). Main results We included 14 studies (909 participants) in this review. Surgical interventions, including laser therapy and cryotherapy, have never been studied by means of an RCT that included a no treatment or placebo arm. The included trials tested a range of medical and complementary treatments, in particular, vitamin A and retinoids (four studies); beta carotene or carotenoids (three studies); non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically ketorolac and celecoxib (two studies); herbal extracts (four studies), including tea components, a Chinese herbal mixture and freeze‐dried black raspberry gel; bleomycin (one study); and Bowman‐Birk inhibitor (one study). We judged one study to be at low risk of bias, seven at unclear risk and six at high risk. In general, we judged the overall quality of the evidence to be low or very low, so findings are uncertain and further research is needed. Five studies recorded cancer incidence, only three of which provided useable data. None of the studies provided evidence that active treatment reduced the risk of oral cancer more than placebo: systemic vitamin A (RR 0.11, 95% CI 0.01 to 2.05; 85 participants, one study); systemic beta carotene (RR 0.71, 95% CI 0.24 to 2.09; 132 participants, two studies); and topical bleomycin (RR 3.00, 95% CI 0.32 to 27.83; 20 participants, one study). Follow‐up ranged between two and seven years. Some individual studies suggested effectiveness of some proposed treatments, namely, systemic vitamin A, beta carotene and lycopene, for achieving clinical resolution of lesions more often than placebo. Similarly, single studies found that systemic retinoic acid and lycopene may provide some benefit in terms of improvement in histological features. Some studies also reported a high rate of relapse. Side effects of varying severity were often described; however, it seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Authors' conclusions Surgical treatment for oral leukoplakia has not been assessed in an RCT that included a no treatment or placebo comparison. Nor has cessation of risk factors such as smoking been assessed. The available evidence on medical and complementary interventions for treating people with leukoplakia is very limited. We do not currently have evidence of a treatment that is effective for preventing the development of oral cancer. Treatments such as vitamin A and beta carotene may be effective in healing oral lesions, but relapses and adverse effects are common. Larger trials of longer duration are required to properly evaluate the effects of leukoplakia treatments on the risk of developing oral cancer. High‐quality research is particularly needed to assess surgical treatment and to assess the effects of risk factor cessation in people with leukoplakia. Plain language summary Interventions for treating oral leukoplakia to prevent oral cancer Review question People with oral leukoplakia are at higher risk of developing oral cancer than those with normal oral mucosa. This review, produced through Cochrane Oral Health , seeks to evaluate whether people affected by leukoplakia can benefit from surgical, medical or complementary treatments, either local or systemic. In particular, we conducted this review to find out which, if any, treatment is able to prevent people with leukoplakia of the mouth from getting oral cancer. This review updates our previous review published in 2006. Background Oral leukoplakia is a white patch formed in the mouth lining that cannot be rubbed off. It often does not hurt and may go unnoticed for years. People with leukoplakia develop oral cancer more often than people without it. Preventing this is critical because rates of oral cancer survival longer than five years after diagnosis are low. Drugs, surgery and other therapies have been tried for treatment of oral leukoplakia. Objectives This review aimed to evaluate whether treatments for oral leukoplakia are effective in preventing oral cancer, and safe and acceptable to patients. Study characteristics The evidence on which this review is based is up‐to‐date as of May 2016. We found 14 randomised controlled trials (RCTs) of medical and complementary treatments, which involved 909 participants in total. Treatments included herbal extracts, anti‐inflammatory drugs, vitamin A, beta carotene supplements and others. Surgical treatment has not been compared with placebo or no treatment in an RCT. Key results Cancer development was measured in studies of three treatments: systemic vitamin A, systemic beta carotene and topical bleomycin. None of these treatments showed effectiveness in preventing cancer development, as measured up to two years for vitamin A and beta carotene, and seven years for bleomycin. Some individual studies of vitamin A and beta carotene suggested that these treatments may be effective for improving or healing oral lesions. However, some studies observed a high rate of relapse in participants whose lesions were initially resolved by treatment. Most treatments caused side effects of differing severity in a high proportion of participants. It seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Quality of the evidence The available evidence is very limited. Most interventions were assessed by only one small study. Most studies had problems in the way they were conducted, making their results unreliable. We judged the quality of evidence for the outcome of cancer development to be very low. Author conclusions Larger, better studies of longer duration are required. As well as further studies of drug treatment and alternative treatments like vitamins, studies are needed to evaluate the effectiveness and safety of surgery, and of stopping risk factor habits such as smoking.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lodi, G; Franchini, R; Warnakulasuriya, S; Varoni, EM; Sardella, A; Kerr, AR; Carrassi, A; MacDonald, LCI; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD001829.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "2b9867bd-540c-49b2-996c-5cf141f35630", "pmid": "", "title": "Enteral tube feeding for people with severe dementia", "imported": false, "abstract": "Abstract - Background The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing. Objectives To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021. Selection criteria We included randomised controlled trials (RCTs), or controlled non‐randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post‐pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers. Data collection and analysis Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non‐randomised Studies of Interventions' (ROBINS‐I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre‐agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta‐analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study. Main results We found no eligible RCTs. We included fourteen controlled, non‐randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low‐certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate‐certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very‐low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low‐certainty evidence. Five studies reported a variety of harm‐related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia. Authors' conclusions We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here. Plain language summary Enteral tube feeding for people with severe dementia What are the advantages and problems of tube feeding people with severe dementia? Key messages Tube feeding may not increase the length of time people with severe dementia live compared to no tube feeding. The risk of developing a pressure sore is probably higher with a feeding tube than with no tube. No studies looked at quality of life.We need more and better studies to investigate tube feeding people with severe dementia. Future studies should focus on a broader range of outcomes including, pain, quality of life and the impact on carers What is tube feeding? Somebody who can’t eat or drink through their mouth may be given liquid food through a tube into their stomach. This is called enteral tube feeding. The tube passes through their nose into their stomach (a nasogastric tube), or is inserted into the stomach through a small cut in their belly (percutaneous endoscopic gastrostomy or PEG). Why is this important for people with dementia? People with dementia often have difficulties eating and drinking. During the early stages of dementia, they may forget to eat, chew food without swallowing, or be confused at mealtimes. Some people experience changes in the taste and smell of food. In the later stages of dementia, people often have difficulties swallowing. It can be difficult to ensure they receive appropriate food and fluids. People with severe dementia need full‐time care, and it is often their families who care for them. It is difficult to decide whether or not to tube‐feed someone with dementia because the feeding tube can be uncomfortable or even painful, and may cause other unwanted effects such as pneumonia, worsen bowel or bladder control, as well as bleeding, swelling and infection. People with severe dementia may be confused or distressed by the tube and may try to remove it. What did we want to find out? We wanted to know whether tube feeding helps people with severe dementia who have problems with eating and swallowing. We were interested in the effect of tube feeding on: how long people lived; their quality of life (well‐being); and the development or healing of pressure sores (also known as bed sores). What did we do? 
We searched for studies that investigated whether: PEG compared to no tube; a nasogastric tube compared to no tube; orPEG, nasogastric and other types of tube feeding compared to no tube was effective and whether tube feeding caused any unwanted effects in adults of any age with severe dementia and poor intake of food and drink. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 14 studies that included 49,714 participants. Of these, 6203 were tube‐fed and 43,511 were not. Participants with no feeding tube were given standard care or standard care with extra treatments to encourage eating and drinking. Main results In people with severe dementia, compared to no tube feeding: PEG may make no difference to how long people live (4 studies, 36,816 people), and leads to a small increase in the chance of developing pressure sores (1 study, 4421 people). we don’t know if nasogastric tube feeding increases the length of time people live or increases their chance of developing pressure sores, because none of our included studies gave information about these points. Studies of people with either PEG or nasogastric tubes showed tube feeding may increase the length of time people live (4 studies, 1696 people), and may slightly increase the chance of developing pressure sores (3 studies, 351 people). None of our included studies reported quality of life. What are the limitations of the evidence? We have moderate confidence in our finding that pressure ulcers were more common in people who were fed with a PEG tube. However, we have little to very little confidence for our other findings. Three main factors reduced our confidence in the evidence. Firstly, people in the studies were not randomly placed into different treatment groups. This means that differences between the groups could be due to differences between people rather than between the treatments. However, due to ethical considerations it would be very difficult to do this in future studies. Secondly, results were very inconsistent across the different studies. Finally, some studies were very small. The results of further research could differ from the results of this review. How up to date is this evidence? The evidence is up to date to 14 April 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Davies, N; Barrado-Martín, Y; Vickerstaff, V; Rait, G; Fukui, A; Candy, B; Smith, CH; Manthorpe, J; Moore, KJ; Sampson, EL", "articleTypes": [], "doi": "10.1002/14651858.CD013503.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "2b9bd508-8b72-40e9-b464-7cccc66aa88f", "pmid": "", "title": "Interventions for dysphagia in oesophageal cancer", "imported": false, "abstract": "Abstract - Background Most patients with oesophageal and gastro‐oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009. Objectives The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro‐oesophageal carcinoma. Search methods To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Selection criteria Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, self‐expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head‐to‐head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30‐day mortality, adverse effects and quality of life. Data collection and analysis Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group. Main results We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re‐interventions and for adverse effects. Anti‐reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti‐reflux stents might have reduced gastro‐oesophageal reflux and complications. Newly‐designed double‐layered nitinol (Niti‐S) stents were preferable due to longer survival time and fewer complications compared to simple Niti‐S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy. Authors' conclusions Self‐expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high‐dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti‐reflux stents and newly‐designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self‐expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re‐interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia. Plain language summary Interventions for reducing difficulty in swallowing in people with oesophageal cancer Review question For most patients with unresectable or inoperable oesophageal cancer, providing clinical benefit with palliative treatment is highly desirable. However, the optimal palliative technique for dysphagia improvement and better quality of life is not established. Background Dysphagia (difficulty or discomfort in swallowing) is common among patients with unresectable or inoperable oesophageal cancer. There are five levels of dysphagia, ranging from the ability to eat a normal diet to some solids, semisolids, liquids and to complete dysphagia. Study characteristics The review included randomised controlled studies comparing the use of different interventions to improve dysphagia among patients with inoperable or unresectable primary oesophageal cancer. To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Key results The review updates the previous version but still fails to present any obvious superiority of one technique over another among the different kinds of interventions. Self‐expanding metal stents provided safer and more effective relief of dysphagia compared to rigid plastic stents. Other techniques like radiotherapy or brachytherapy were also suitable alternatives and might be favourable in improving quality of life and prolonging survival. Individual differences should be emphasised when the intervention type was determined. Quality of the evidence Half of the studies included in this review were of high quality. Most studies did not state the methods used to seek and report quality of life outcomes and adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Yang, C, Li, J, Fu, W, Xu, W, Yang, S", "articleTypes": [], "doi": "10.1002/14651858.CD005048.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.794Z" }, { "id": "2b9c2e4f-9704-4330-adea-f154e953b2ad", "pmid": "", "title": "", "imported": false, "abstract": "The study aims at evaluating in normal weight and obese subjects those factors such as taste sensitivity and circulating endocannabinoids in influencing dietary choice and thereby lipid and energy metabolism in order to design personalized nutritional strategies.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.145Z" }, { "id": "2ba42462-2528-483c-8523-bdb4f8ba58e2", "pmid": "", "title": "The Role of Sweet Taste Receptor Blockade on Intragastric Liquid Meal-stimulated Secretion of Satiation Peptides in Healthy Humans", "imported": false, "abstract": "The purpose of this study is to determine the functional significance of sweet taste receptors in the secretion of gastrointestinal (GI) satiation peptides by using a specific sweet taste receptor antagonist to block sweet taste perception in the gastrointestinal tract.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.143Z" }, { "id": "2ba4cfb6-fae6-4b01-b5ba-762a5644338e", "pmid": "", "title": "Interventions for treating burning mouth syndrome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McMillan, R, Forssell, H, Buchanan, JAG, Glenny, AM, Weldon, JC, Zakrzewska, JM", "articleTypes": [], "doi": "10.1002/14651858.CD002779.pub3 AB - Abstract - Background Burning mouth syndrome (BMS) is a term used for oral mucosal pain (burning pain or discomfort in the tongue, lips or entire oral cavity) without identifiable cause. General population prevalence varies from 0.1% to 3.9%. Many BMS patients indicate anxiety, depression, personality disorders and impaired quality of life (QoL). This review updates the previous versions published in 2000 and 2005. Objectives To determine the effectiveness and safety of any intervention versus placebo for symptom relief and changes in QoL, taste, and feeling of dryness in people with BMS. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 31 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 11) in the Cochrane Library (searched 31 December 2015), MEDLINE Ovid (1946 to 31 December 2015), and Embase Ovid (1980 to 31 December 2015). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching the electronic databases Selection criteria Randomised controlled trials (RCTs) comparing any treatment against placebo in people with BMS. The primary outcomes were symptom relief (pain/burning) and change in QoL. Secondary outcomes included change in taste, feeling of dryness, and adverse effects. Data collection and analysis We used standard methodological procedures expected by Cochrane. Outcome data were analysed as short‐term (up to three months) or long‐term (three to six months). Main results We included 23 RCTs (1121 analysed participants; 83% female). Interventions were categorised as: antidepressants and antipsychotics, anticonvulsants, benzodiazepines, cholinergics, dietary supplements, electromagnetic radiation, physical barriers, psychological therapies, and topical treatments. Only one RCT was assessed at low risk of bias overall, four RCTs' risk of bias was unclear, and 18 studies were at high risk of bias. Overall quality of the evidence for effectiveness was very low for all interventions and all outcomes. Twenty‐one RCTs assessed short‐term symptom relief. There is very low‐quality evidence of benefit from electromagnetic radiation (one RCT, 58 participants), topical benzodiazepines (two RCTs, 111 participants), physical barriers (one RCT, 50 participants), and anticonvulsants (one RCT, 100 participants). We found insufficient/contradictory evidence regarding the effectiveness of antidepressants, cholinergics, systemic benzodiazepines, dietary supplements or topical treatments. No RCT assessing psychological therapies evaluated short‐term symptom relief. Four studies assessed long‐term symptom relief. There is very low‐quality evidence of a benefit from psychological therapies (one RCT, 30 participants), capsaicin oral rinse (topical treatment) (one RCT, 18 participants), and topical benzodiazepines (one RCT, 66 participants). We found no evidence of a difference for dietary supplements or lactoperoxidase oral rinse. No studies assessing antidepressants, anticonvulsants, cholinergics, electromagnetic radiation or physical barriers evaluated long‐term symptom relief. Short‐term change in QoL was assessed by seven studies (none long‐term).The quality of evidence was very low. A benefit was found for electromagnetic radiation (one RCT, 58 participants), however findings were inconclusive for antidepressants, benzodiazepines, dietary supplements and physical barriers. Secondary outcomes (change in taste and feeling of dryness) were only assessed short‐term, and the findings for both were also inconclusive. With regard to adverse effects, there is very low‐quality evidence that antidepressants increase dizziness and drowsiness (one RCT, 37 participants), and that alpha lipoic acid increased headache (two RCTs, 118 participants) and gastrointestinal complaints (3 RCTs, 138 participants). We found insufficient/contradictory evidence regarding adverse events for anticonvulsants or benzodiazepines. Adverse events were poorly reported or unreported for cholinergics, electromagnetic radiation, and psychological therapies. No adverse events occurred from physical barriers or topical therapy use. Authors' conclusions Given BMS' potentially disabling nature, the need to identify effective modes of treatment for sufferers is vital. Due to the limited number of clinical trials at low risk of bias, there is insufficient evidence to support or refute the use of any interventions in managing BMS. Further clinical trials, with improved methodology and standardised outcome sets are required in order to establish which treatments are effective. Future studies are encouraged to assess the role of treatments used in other neuropathic pain conditions and psychological therapies in the treatment of BMS. Plain language summary Interventions for treating burning mouth syndrome Review question Which treatments help to relieve symptoms for people with burning mouth syndrome (BMS)? Background BMS is a common painful condition. Symptoms include burning, dryness or uncomfortable sensations in the mouth and changes to taste, with no obvious underlying medical or dental cause. BMS is usually persistent and suffered long term, and can lead to a reduced quality of life (QoL). Currently, scientific research suggests that BMS is caused by underlying damage to the nerves. There are many treatments available including drugs for anxiety, other psychological conditions and increasing saliva production, protective barriers and treatments applied to the mouth surface amongst others. Study characteristics This review of studies was carried out through Cochrane Oral Health, and the evidence is current up to 31 December 2015. We found 23 studies (assessing 1121 people; 83% were women), published between 1995 and 2015 to include in this review. Twenty‐one studies assessed short‐term (up to three months) symptom relief, and four studies assessed long‐term (from three to six months) symptom relief. Seventeen studies provided information about side effect occurrence, seven studies assessed a measure of QoL, and two studies assessed changes in taste and feeling of dryness. All of the 23 treatments included in this review were compared to a placebo (fake treatment): antidepressants and antipsychotics (two studies), antiseizure drugs (one study), types of tranquillisers (four studies), saliva stimulants (one study), dietary supplements (12 studies), directed energy waves (one study), physical barriers (one study), psychological therapies (one study), and treatments applied to the mouth surface (five studies). Key results Short‐term symptom relief We found evidence of short‐term symptom relief for directed energy waves (one study, 58 participants), a type of tranquilliser used topically (that is held in the mouth before being removed, and which also acts as an antiseizure drug) called clonazepam (two studies, 111 participants), thin plastic tongue covers (one study, 50 participants), and an antiseizure drug called gabapentin (one study, 100 participants). There was no difference in short‐term symptom relief found for antidepressants, saliva stimulants, and another type of tranquilliser used systemically (one that is swallowed) also called clonazepam. We were unable to show whether dietary supplements or treatments applied to the mouth surface provide symptom relief in the short term or not. Short‐term relief was not reported for the single study that assessed a psychological therapy. Long‐term symptom relief We found evidence of long‐term symptom relief for psychological therapy (one study, 30 participants), chili pepper mouthrinse (one study, 18 participants) and the topical tranquilliser called clonazepam (one study, 66 participants). We found there was no difference in long‐term symptom relief for dietary supplements or treatments applied to the mouth surface. Studies which assessed antidepressants, directed energy waves, saliva stimulants, antiseizure drugs, or physical barriers did not evaluate long‐term symptom relief. Change in QoL There was evidence of short‐term improvement in QoL for directed energy waves (one study, 58 patients), although no difference was found for antidepressants, tranquillisers, dietary supplements and physical barriers. No study assessed long‐term QoL changes. Change in taste or feeling of dryness A few studies assessed short‐term change in taste or feeling of dryness (none evaluated these outcomes long‐term), but there was not enough evidence to judge the effects of treatment on these outcomes. Side effects Side effects were more likely to be experienced with antidepressants (dizziness and drowsiness more likely: one study, 37 people), and with a dietary supplement called alpha lipoic acid (also known as ALA) with or without other ingredients (headaches more likely: two studies, 118 people; and upset stomachs more likely: three studies, 138 people). Quality of the evidence 
 Overall, we found very low‐quality evidence for each short‐ and long‐term outcome we investigated (symptom relief; changes in QoL, taste and feeling of dryness; and side effects) in all types of assessed treatment: antidepressants and antipsychotics, antiseizure drugs, types of tranquillisers, saliva stimulants, dietary supplements, directed energy waves, physical barriers (except side effects, which was assessed as low quality), psychological therapies, and treatments applied to the mouth surface. As we found so few studies at low risk of bias, we are currently unable to prove or disprove the effectiveness of any treatments for managing BMS.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.062Z" }, { "id": "2bc0a5b2-b8c1-437e-809f-8a15940fca2f", "pmid": "", "title": "Lasers for caries removal in deciduous and permanent teeth", "imported": false, "abstract": "Abstract - Background Despite considerable improvements in oral health, dental caries continue to be a public health issue. The most frequently used, and universally accepted technique, to remove caries is through mechanical ablation of decayed tissues by means of rotating drills (diamond or tungsten carbide, or both). In the past few decades, the introduction of adhesive filling materials (resin composites) has affected cavity filling procedures by reducing its retention needs, with advantages for dental tissue conservation. Consequently, new minimally invasive strategies were introduced into dental practice, such as the use of lasers to perform highly controlled tissue ablation. Laser use has also raised expectations of limiting pain and discomfort compared to using drills, as well as overcoming drill phobia. Objectives The main objective of the review was to compare the effects of laser‐based methods to conventional mechanical methods for removing dental caries in deciduous and permanent teeth. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (searched 22 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 22 June 2016), MEDLINE Ovid (1946 to 22 June 2016), Embase Ovid (1980 to 22 June 2016), ProQuest Dissertations and Theses (1980 to 22 June 2016), Zetoc (limited to conference proceedings) (1993 to 22 June 2016), and ISI Web of Knowledge (limited to conference proceedings) (1990 to 22 June 2016). We checked the reference lists of relevant articles to identify additional studies. We searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. Selection criteria We included randomised controlled trials, split‐mouth trials and cluster‐randomised trials (irrespective of their language) comparing laser therapy to drill ablation of caries. We included participants of any age (children, adolescents and adults). Data collection and analysis Two review authors independently screened titles and abstracts of citations identified by the review search strategy. Two review authors independently evaluated the full text of relevant primary studies, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. Main results We included nine randomised trials, published between 1998 and 2014, involving 662 participants. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Four studies examined only permanent teeth, and five studies evaluated both deciduous and permanent teeth. Six trials used Er:YAG (erbium‐doped yttrium aluminium garnet) lasers, two trials employed Er,Cr:YSGG (erbium, chromium: yttrium‐scandium‐gallium‐garnet) lasers, and one trial used Nd:YAG (neodymium‐doped yttrium aluminium garnet) laser. Overall, the trials had small sample sizes, and the majority were at unclear or high risk of bias. The primary outcomes were evaluated in a limited number of trials (removal of caries (four trials (but only two reported quantitative data)); episodes of pain (five studies)). There was insufficient evidence to suggest that either lasers or drill were better at caries removal (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.99 to 1.01; 2 studies; 256 treated caries; P = 0.75; I 2 = 0%; low‐quality evidence). The incidence of moderate or high pain was greater in the drill group compared to the laser group (RR 0.40, 95% CI 0.28 to 0.57; 2 studies; 143 participants; P < 0.001; I 2 = 50%). Similarly, the need for anaesthesia was significantly higher in the drill group than in the laser group (RR 0.25, 95% CI 0.10 to 0.65; 3 studies; 217 children/adolescents; P = 0.004; I 2 = 0%). In terms of marginal integrity of restoration, there was no evidence of a difference between laser and drill comparisons evaluated at 6 months (RR 1.00, 95% CI 0.21 to 4.78; 3 studies), 1 year (RR 1.59, 95% CI 0.34 to 7.38; 2 studies), or 2 years (RR 1.00, 95% CI 0.21 to 4.74; 1 study). There was no evidence of a difference for durability of restoration between laser therapy or drill at 6 months' follow‐up (RR 2.40, 95% CI 0.65 to 8.77; 4 studies), at 1 year (RR 1.40, 95% CI 0.29 to 6.78; 2 studies) or at 2 years' follow‐up (RR 0.50, 95% CI 0.02 to 14.60; 1 study). Only two trials investigated the recurrence of caries, but no events occurred during 6 months' follow‐up. There was insufficient evidence of a difference between laser or drill in terms of pulpal inflammation or necrosis at 1 week (RR 1.51, 95% CI 0.26 to 8.75; 3 studies) and at 6 months (RR 0.99, 95% CI 0.10 to 9.41; 2 studies). Authors' conclusions Given the low quality of the body of evidence, we concluded that evidence was insufficient to support the use of laser as an alternative to traditional drill therapy for caries removal. We found some evidence in favour of laser therapy for pain control, need of anaesthesia and patient discomfort, but, again, the body of evidence was of low quality. Additional well‐designed, randomised trials investigating the most relevant outcomes are needed. Plain language summary Lasers for the removal of decay in first and permanent teeth Review question This review addressed the issue of whether there is an advantage to laser therapy for the removal of decay in teeth and patient pain, compared to a traditional drill, in children, adolescents and adults. Background Dental decay is a cavity formation in teeth resulting from the destruction of dental tissue caused by bacteria under certain conditions, including poor oral hygiene and excessive sugar intake. Symptoms may include pain and difficulty with eating, and complications may include tooth loss, infection or inflammation of the gum. Rotating drills are traditionally used to remove decay. However, this mechanical tool may have unexpected side effects, such as the removal of too much or too little decay, in addition to discomfort due to pain, noise and vibration. Laser therapy is a potential alternative to a mechanical drill. Study characteristics Cochrane Oral Health provided the search strategies and carried out the search in several electronic databases. We selected nine randomised trials for inclusion in this review that were conducted between 1998 and 2014. The evidence in the review is up to date as of 22 June 2016. The trials involved a total of 662 participants, with 1498 teeth treated. Three studies were conducted in the USA, one in Taiwan, one in China, one in Bulgaria, one in Germany, one in Turkey and one in the UK. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Key results Despite the number of included studies, only a few trials adequately and completely reported information on the primary outcomes. Two trials reported on removal of decay, and there was not enough evidence to conclude that either lasers or drills were better at decay removal. Only five trials reported on episodes of pain, which was significantly reduced in people treated with lasers. There was no difference in terms of side effects, such as inflammation or death of dental pulp, between the two interventions. Quality of the evidence The overall quality of the evidence for the nine studies was low. Only one study adequately randomised participants, and none of the included studies was at low risk of bias. This review highlights the need for high‐quality studies comparing laser therapy and mechanical drills in the treatment of dental decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Montedori, A; Abraha, I; Orso, M; D'Errico, PG; Pagano, S; Lombardo, G", "articleTypes": [], "doi": "10.1002/14651858.CD010229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "2bccf74b-6ad1-44a5-96c5-5c0e250aea57", "pmid": "", "title": "Omega‐3 fatty acid supplementation for depression in children and adolescents", "imported": false, "abstract": "Abstract - Background Mental health disorders including major depressive disorder (MDD) are well recognized as major contributors to the global burden of disease among adolescents. The prevalence of adolescent depression is estimated to have increased by at least 25% during the COVID‐19 pandemic, compounding the already challenging problem of insufficient mental health service and service accessibility that existed prepandemic. Omega‐3 polyunsaturated fatty acid (PUFA) supplementation is currently recommended as a preventive treatment for depression in high‐risk adults as well as a second‐line monotherapy for adults with mild to moderate MDD, and adjunctive to antidepressants for adults with moderate to severe MDD. The benefits of omega‐3 PUFA intake on depressive illness have been hypothesized to occur as a result of their effect on neurotransmission, maintenance of membrane fluidity, and anti‐inflammatory action. A comprehensive synthesis and quantification of the existing evidence on omega‐3 PUFA's efficacy in treating depression among children and adolescents is essential for clinicians to provide informed guidance to young people and their families, especially considering the absence of current guidelines for this age group. Objectives Primary objective To determine the impact of omega‐3 PUFA supplementation versus a comparator (e.g. placebo, wait list controls, no treatment/supplementation, or standard care) on clinician‐diagnosed depression or self‐reported depression symptoms in children and adolescents. Secondary objectives To estimate the size of the effect of omega‐3 PUFAs on depression symptoms. To estimate the effect of each type of omega‐3 PUFA (EPA or DHA), compared with placebo, on depression. To determine if the effect is modified by dosage, format (capsule or liquid), sex, or age. To determine compliance and attrition for omega‐3 PUFAs as an intervention for depression in children and adolescents. To determine the safety of omega‐3 PUFAs as an intervention for depression in children and adolescents. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases, reference lists of included studies, grey literature, and relevant reviews. The latest search date was 18 May 2023. Selection criteria We included randomized controlled trials (RCTs) involving males and females aged 19 years or younger with diagnosed depression comparing omega‐3 PUFA supplementation to placebo, wait list control, no treatment/supplementation, or standard care. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were self‐reported depression symptoms and clinically diagnosed resolution of depression. Our secondary outcomes were attrition, adverse effects, and compliance with the intervention. We used GRADE to assess the certainty of evidence for key outcomes. Main results We included five trials with 228 participants in our meta‐analysis. All trials used a placebo comparator; intervention duration ranged from 10 to 16 weeks (median: 12 weeks). Omega‐3 PUFA supplementation compared to placebo may reduce self‐reported depression symptoms, but the evidence is very uncertain (standardized mean difference [SMD] −0.34, 95% confidence interval [CI] −0.85 to 0.17; lower SMD means greater improvement in depression due to omega‐3 PUFA; 5 trials, 185 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may have little to no effect on remission of depression symptoms compared to placebo, but the evidence is very uncertain (omega‐3 PUFA versus placebo: 50% versus 48%; odds ratio [OR] 1.11, 95% CI 0.45 to 2.75; 4 trials, 127 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in attrition (dropouts) compared to placebo (omega‐3 PUFA versus placebo: 18% versus 19%; OR 0.94, 95% CI 0.46 to 1.90; 5 trials, 228 participants; low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in adverse effects, with one study reporting more muscle cramps in the fish oil group (13/27 participants) compared to the placebo group (6/29 participants); one study reported more frequent defecation in the omega‐3 group (1/29 participants) and one study identified mild skin rash and unusual/manic behavior in the placebo group (2/27 participants). None of the included studies reported serious adverse effects. Authors' conclusions Based on five small studies, omega‐3 PUFA supplementation may reduce self‐reported depression symptoms, but the evidence is very uncertain. Omega‐3 PUFA supplementation may have little to no effect on depression remission compared to placebo, but the evidence is very uncertain. Omega‐3 PUFA supplementation may result in little to no difference in attrition or adverse effects. The studies observed no serious adverse effects. This review highlights early‐stage research on omega‐3 PUFA and depression in young people. The evidence on the effects of omega‐3 PUFA supplementation in improving self‐reported depression symptoms or achieving depression remission in children and adolescents is very uncertain. While no harms are evident, more data are needed to confirm potential risks. Addressing current limitations in the evidence base through the design and conduct of methodologically rigorous studies — larger sample sizes, varied dosages, eicosapentaenoic acid/docosahexaenoic acid ratios, treatment durations, and safety profiles — is crucial to advance our understanding of the role of omega‐3 PUFA supplementation for depression in children and adolescents. Plain language summary Is omega‐3 polyunsaturated fatty acid supplementation better than a placebo for treating depression among children and adolescents? Key messages – Due to a lack of robust evidence, the benefits and unwanted effects of omega‐3 polyunsaturated fatty acids (which are important fats that you must obtain from your diet) supplementation for treating depression among children and adolescents are unclear. – Larger, well‐designed studies are needed to give better estimates of the potential benefits and harms of omega‐3 polyunsaturated fatty acid supplementation for child and adolescent depression. Why is it important to find treatments for children and adolescents with depression? People with depression have a low mood or lose pleasure or interest in usual activities. It is a long‐lasting (chronic) disorder that is both serious and recurrent (it can return after periods of feeling well). It often begins during childhood and adolescence, affecting up to eight in every 100 children. Unfortunately, response to current treatments for depression in children and adolescents is poor, and relieving symptoms (remission) can be challenging. In recent studies, supplements of omega‐3 polyunsaturated fatty acids have shown promise as a potential treatment for depression in adults. Our body cannot make these beneficial fats, but they are naturally present in oily fish, marine sources, and certain nuts and seeds. They can also be given as daily supplements in capsule or liquid forms (for example, as cod liver oil capsules). What did we want to find out? We wanted to find out: – if omega‐3 polyunsaturated fatty acids supplementation works to decrease symptoms of depression in children and adolescents; and – if omega‐3 polyunsaturated fatty acids supplementation helps children and adolescents achieve remission from depression. We also wanted to know if omega‐3 polyunsaturated fatty acids supplementation can cause any unwanted effects. What did we do? We searched for studies in which children and adolescents were assigned randomly to two or more treatment groups that compared omega‐3 polyunsaturated fatty acids supplementation with a placebo (pretend treatment with the same appearance), on a waiting list, no treatment/supplementation, or usual care. This is the best way to ensure that groups of people are similar and that investigators do not know who is in which group. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found five studies that involved 228 children and adolescents ranging from 10 to 16 years of age with depression. The largest study included 60 people, and the smallest study included 28 people. Three studies were conducted in the USA, one in Israel, and one in Slovakia. Four studies lasted for around 12 weeks and one study lasted for 16 weeks. We found that omega‐3 polyunsaturated fatty acids supplementation may reduce self‐reported depression symptoms, but the results are very uncertain. If omega‐3 PUFA supplements and placebos were given to a group of 100 children and adolescents with depression, then 50 children receiving omega‐3 polyunsaturated fatty acids would achieve remission and 48 receiving the placebo would achieve remission. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results, and the studies were very small. To date, there is insufficient evidence to determine if omega‐3 polyunsaturated fatty acids supplementation improves depression for children and adolescents. How up to date is this evidence? The evidence is up to date to 18 May 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Campisi, SC, Zasowski, C, Bradley-Ridout, G, Schumacher, A, Szatmari, P, Korczak, D", "articleTypes": [], "doi": "10.1002/14651858.CD014803.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.114Z" }, { "id": "2bce88d1-b169-4161-9746-a921f0c45a7c", "pmid": "", "title": "Drugs for treating giardiasis", "imported": false, "abstract": "Abstract - Background Giardiasis infection may be asymptomatic, or can cause diarrhoea (sometimes severe), weight loss, malabsorption, and, in children, failure to thrive. It is usually treated with metronidazole given three times daily for five to 10 days. Objectives To evaluate the relative effectiveness of alternative antibiotic regimens for treating adults or children with symptomatic giardiasis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6 2012); MEDLINE, EMBASE, LILACS and the International Clinical Trials Registry Platform Search Portal (3 July 2012). Selection criteria We included randomized controlled trials (RCT) comparing metronidazole administered for five to 10 days with any of the following drugs: metronidazole (single dose), tinidazole, albendazole, mebendazole, and nitazoxanide. The primary outcomes were parasitological and clinical cure. Data collection and analysis Two authors independently assessed studies for inclusion, performed the risk of bias assessment, and extracted data. We summarized data using risk ratios and mean differences and we presented the results in forest plots and performed meta‐analyses where possible. We assessed heterogeneity using the Chi 2 test, I 2 statistic and visual inspection; and we explored this by using subgroup analyses.We assessed the quality of evidence by using the GRADE approach. Main results We included 19 trials, involving 1817 participants, of which 1441 were children. Studies were generally small, with poor methods reporting. . Most reported parasitological outcomes rather than clinical improvement. Ten trials, from India, Mexico, Peru, Iran, Cuba, and Turkey, compared albendazole (400 mg once daily for five to 10 days) with metronidazole (250 mg to 500 mg three times daily for five to 10 days). This once‐daily regimen of albendazole is probably equivalent to metronidazole at achieving parasitological cure (RR 0.99, 95% CI 0.95 to 1.03; 932 participants, 10 trials; moderate quality evidence ), and improving symptoms (RR 0.98, 95% confidence interval (CI) 0.93 to 1.04; 483 participants, five trials; moderate quality evidence ), but the duration of follow‐up was short (two to three weeks). Albendazole probably has fewer side effects than metronidazole (gastrointestinal side effects: RR 0.29, 95% CI 0.13 to 0.63; 717 participants, eight trials; moderate quality evidence ; neurological side effects: RR 0.34, 95% CI 0.18 to 0.64; 453 participants, five trials; low quality evidence ). Five trials from Turkey, Spain and the UK compared mebendazole (200 mg three times daily for five to 10 days) with metronidazole (5 mg/kg (or 250 mg) three times daily for five to 10 days). These trials were small in size, and at high risk of bias. Consequently, reliable conclusions on the relative effectiveness cannot be made ( very low quality evidence) . Five further trials, from Iran, Spain and Peru, have evaluated shortened regimens of tinidazole (single dose; 179 participants, three trials), metronidazole (single dose; 55 participants, one trial), and nitazoxanide (three days; 55 participants, one trial). Again, these trials were at high risk of bias and too small to reliably detect or exclude important differences ( very low quality evidence) . Authors' conclusions Albendazole may be of similar effectiveness to metronidazole, may have fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes (such as diarrhoea) will help assess further alternatives. 15 April 2019 Update pending Studies awaiting assessment The CIDG is currently examining a new search conducted in April 2019 for potentially relevant studies. These studies have not yet been incorporated into this Cochrane Review. Plain language summary Drugs for treating giardiasis Giardiasis is an infection of the small intestine caused by a microscopic organism called Giardia lamblia . The infection is passed from person to person by ingesting faecally contaminated water or food. Symptoms frequently include diarrhoea, abdominal pain, flatulence, bloating, vomiting, and weight loss. In this review, we assess alternatives to the most commonly used treatment for giardiasis; metronidazole given orally for five or more days. We identified 19 trials involving 1817 participants, of which 1441 were children. Most trials had a small number of participants and were at high risk of bias. Albendazole is probably of similar effectiveness to metronidazole, probably has fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes are required to assess further alternatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Granados, CE; Reveiz, L; Uribe, LG; Criollo, CP", "articleTypes": [], "doi": "10.1002/14651858.CD007787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "2bd9be48-5c9a-42ac-a6e1-306f2460e4ed", "pmid": "", "title": "Lactobacillus Reuteri Versus Placebo in the Treatment and Prevention of Infantile Colic: a Clinical and Microbiological, Double-blind, Prospective, Randomised, Controlled Study", "imported": false, "abstract": "The purpose of this study is:", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.240Z" }, { "id": "2be3cfbc-6804-49fe-86bd-fc7a54e3c1e0", "pmid": "", "title": "Hydroxyurea (hydroxycarbamide) for sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and a reduced life expectancy. Hydroxyurea (hydroxycarbamide), an oral chemotherapeutic drug, ameliorates some of the clinical problems of SCD, in particular that of pain, by raising foetal haemoglobin (HbF). This is an update of a previously published Cochrane Review. Objectives The aims of this review are to determine through a review of randomised or quasi‐randomised studies whether the use of hydroxyurea in people with SCD alters the pattern of acute events, including pain; prevents, delays or reverses organ dysfunction; alters mortality and quality of life; or is associated with adverse effects. In addition, we hoped to assess whether the response to hydroxyurea in SCD varies with the type of SCD, age of the individual, duration and dose of treatment, and healthcare setting. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Haemoglobinopathies Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. The date of the most recent search was 17 February 2022. Selection criteria Randomised and quasi‐randomised controlled trials (RCTs and quasi‐RCTs), of one month or longer, comparing hydroxyurea with placebo or standard therapy in people with SCD. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction, assessed the risk of bias and assessed the quality of the evidence using GRADE. Main results We included nine RCTs recruiting 1104 adults and children with SCD (haemoglobin SS (HbSS), haemoglobin SC (HbSC) or haemoglobin Sβºthalassaemia (HbSβºthal) genotypes). Studies lasted from six to 30 months. We judged the quality of the evidence for the first two comparisons below as moderate to low as the studies contributing to these comparisons were mostly large and well‐designed (and at low risk of bias); however, the evidence was limited and imprecise for some outcomes such as quality of life, deaths during the studies and adverse events, and the results are applicable only to individuals with HbSS and HbSβºthal genotypes. We judged the quality of the evidence for the third and fourth comparisons to be very low due to the limited number of participants, the lack of statistical power (both studies were terminated early with approximately only 20% of their target sample size recruited) and the lack of applicability to all age groups and genotypes. Hydroxyurea versus placebo Five studies (784 adults and children with HbSS or HbSβºthal) compared hydroxyurea to placebo; four recruited individuals with only severe disease and one recruited individuals with all disease severities. Hydroxyurea probably improves pain alteration (using measures such as pain crisis frequency, duration, intensity, hospital admissions and opoid use) and life‐threatening illness, but we found no difference in death rates (10 deaths occurred during the studies, but the rates did not differ by treatment group) (all moderate‐quality evidence). Hydroxyurea may improve measures of HbF (low‐quality evidence) and probably decreases neutrophil counts (moderate‐quality evidence). There were no consistent differences in terms of quality of life and adverse events (including serious or life‐threatening events) (low‐quality evidence). There were fewer occurrences of acute chest syndrome and blood transfusions in the hydroxyurea groups. Hydroxyurea and phlebotomy versus transfusion and chelation Two studies (254 children with HbSS or HbSβºthal also with risk of primary or secondary stroke) contributed to this comparison. There were no consistent differences in terms of pain alteration, death or adverse events (low‐quality evidence) or life‐threatening illness (moderate‐quality evidence). Hydroxyurea with phlebotomy probably increased HbF and decreased neutrophil counts (moderate‐quality evidence), but there were more occurrences of acute chest syndrome and infections. Quality of life was not reported. In the primary prevention study, no strokes occurred in either treatment group but in the secondary prevention study, seven strokes occurred in the hydroxyurea and phlebotomy group (none in the transfusion and chelation group) and the study was terminated early. Hydroxyurea versus observation One study (22 children with HbSS or HbSβºthal also at risk of stoke) compared hydroxyurea to observation. Pain alteration and quality of life were not reported. There were no differences in life‐threatening illness, death (no deaths reported in either group) or adverse events (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF or decreases neutrophil counts (very low‐quality evidence). Treatment regimens with and without hydroxyurea One study (44 adults and children with HbSC) compared treatment regimens with and without hydroxyurea. Pain alteration, life‐threatening illness and quality of life were not reported. There were no differences in death rates (no deaths reported in either group), adverse events or neutrophil levels (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF (very low‐quality evidence). Authors' conclusions There is evidence to suggest that hydroxyurea may be effective in decreasing the frequency of pain episodes and other acute complications in adults and children with sickle cell anaemia of HbSS or HbSβºthal genotypes and in preventing life‐threatening neurological events in those with sickle cell anaemia at risk of primary stroke by maintaining transcranial Doppler velocities. However, there is still insufficient evidence on the long‐term benefits of hydroxyurea, particularly with regard to preventing chronic complications of SCD, or recommending a standard dose or dose escalation to maximum tolerated dose. There is also insufficient evidence about the long‐term risks of hydroxyurea, including its effects on fertility and reproduction. Evidence is also limited on the effects of hydroxyurea on individuals with the HbSC genotype. Future studies should be designed to address such uncertainties. Plain language summary Hydroxyurea (also known as hydroxycarbamide) for people with sickle cell disease Review question What is the effect of hydroxyurea on clinical outcomes (changes in pain crises, life‐threatening illnesses, survival, haemoglobin levels, quality of life and side effects) in people with sickle cell disease (SCD) of any genotype? Background Sickle cell disease (SCD) is an inherited genetic disorder that creates problems with haemoglobin (the substance in red blood cells that carries oxygen around the body). The disease can be inherited in different ways; people can inherit two sickle genes (HbSS genotype) or they can inherit the sickle gene from one parent and a different haemoglobin gene such as haemoglobin C, resulting in the HbSC genotype, or a beta thalassaemia gene from the second parent, which gives rise to HbSβ+ or HbSβºthal. In people with SCD the abnormal sickle haemoglobin forms long polymers (chains) within the red blood cells when they become de‐oxygenated. This damages the red blood cells and makes them stickier, leading to blockages and reduced blood flow, causing pain and organ damage. Foetal haemoglobin (HbF) stops these polymers forming in the sickle haemoglobin within the red blood cell. The drug hydroxyurea is used to increase HbF and can reduce the effects of the disease. This is an update of a previously published Cochrane Review. Search date The evidence is current to 17 February 2022. Study characteristics We included nine randomised studies (1104 adults and children with SCD (HbSS, HbSC or HbSβºthal genotypes)). Studies lasted from six to 30 months. Key results and quality of the evidence In five studies, 784 adults and children with SCD were randomly selected to receive hydroxyurea or placebo. In two studies, 254 children with SCD, who were also at an increased risk of having a first or second stroke, were randomly selected to receive hydroxyurea and phlebotomy (collection of blood) or blood transfusion and chelation (administration of agents to remove excess iron from the body). These seven studies only recruited people with HbSS or HbSβºthal genotypes so the results do not apply to people with the HbSC genotype. There was moderate‐quality evidence from these seven studies that hydroxyurea may reduce the frequency of pain crises, may increase HbF and may decrease neutrophil (white blood cell) counts compared to the comparator treatment. We found no difference between people receiving hydroxyurea or other treatments in terms of quality of life, deaths during the studies and adverse effects (including serious and life‐threatening effects). However, there is less information about these outcomes in the studies, so the quality of this evidence is low. Two further studies were included in the review. In one study, 22 children with SCD, who were also at increased risk of having a stroke, were randomly selected to receive hydroxyurea or no treatment (observation only) and in one study 44 adults and children were randomly selected to receive treatments with or without adding hydroxyurea. In both studies we are unsure if hydroxyurea led to an increase in HbF compared to the comparator treatment. There were no deaths during the studies. There was no difference between people receiving hydroxyurea or other treatments in terms of pain crises and adverse effects (including serious or life‐threatening effects) and neither study measured quality of life. The quality of the evidence from these studies is very low, given the studies were very small and only recruited around 20% of the intended number of people, and the results do not apply to all people with SCD (different genotypes). Conclusions The evidence shows that hydroxyurea is likely to be effective in the short term at decreasing the frequency of painful episodes and raising HbF levels in the blood in people with SCD. Hydroxyurea is also likely to be effective in preventing first strokes for those at an increased risk of stroke and does not seem to be associated with an increase in any adverse effects (including serious and life‐threatening effects). There is currently little evidence from the studies that we examined on whether hydroxyurea is beneficial over a long period of time, what the best dose to take is, or whether treatment causes any long‐term or serious side effects. More studies are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Rankine-Mullings, AE; Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD002202.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "2c053869-5826-49d8-b2e5-c311afed0b72", "pmid": "", "title": "Bitter Taste and Allele-specific Expression of the Human TAS2R38 Gene", "imported": false, "abstract": "This single-site, within-subject experimental basic research study is designed to analyze the hypothesis that allele-specific expression of the bitter taste receptor T2R38 in taste tissue of individuals heterozygous for the taste receptor gene TAS2R38 correlates with that in nasal epithelium, and is responsible for differences in acyl-homoserine lactone-induced respiratory defenses. Subjects will include 100 predominantly European adults without chronic rhinosinusitis who will be undergoing a sinonasal procedure for reconstructive purposes. All subjects will provide saliva samples for genotyping, from which 25 subjects heterozygous for TAS2R38 (AVI/PAV) will be identified. These individuals will be asked to complete a beverage frequency questionnaire and taste test prior to the procedure that will evaluate for a number of compounds, among them bitter ligands specific to T2R38. Their tongue will also be photographed to evaluate the anatomy of their fungiform papillae, the mushroom-like structures on the tongue which contain taste buds. Subjects will subsequently provide nasal epithelium and taste tissue, which will be processed to 1) evaluate for allele-specific expression of TAS2R38 mRNA in both the taste and nasal tissue, with the nasal tissue concurrently being cultured in an air-liquid interface system to 2) assess the AHL-induced respiratory defenses of ciliary beat frequency (CBF) and nitric oxide (NO) production. Should subjects require a subsequent sinonasal procedure for clinically-determined reasons, taste and nasal tissue will again be obtained and analyzed for TAS2R38 mRNA, allowing for 3) longitudinal evaluation of mRNA expression level.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "2c073451-3257-4970-9439-6bd4a5141c66", "pmid": "", "title": "Could Docosahexaenoic Acid (DHA), Contained in Breast Milk and Artificial Baby Milks, Protect Infants and Children From COVID-19 and Make Them Less Prone to COVID-19-related Severe Illness Than Adults?", "imported": false, "abstract": "Could Docosahexaenoic Acid (DHA) Protect Infants and Children From COVID-19 and Make Them Less Susceptible to COVID-19-related Severe Illness Than Adults?", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.161Z" }, { "id": "2c0c9600-3a7f-40f4-b7b0-733c4c6b95e6", "pmid": "", "title": "A Double-Blind, Placebo-Controlled, Randomized, Phase Ib/IIa Clinical Study of ApTOLL for the Treatment of Acute Ischemic Stroke", "imported": false, "abstract": "This is a prospective, multicenter, double-blind, randomized, placebo-controlled, Phase Ib/IIa clinical study to assess the administration of ApTOLL together with endovascular therapy in acute ischemic stroke patients who are candidates to receive reperfusion therapies.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.244Z" }, { "id": "2c0ec262-f84a-4cee-a945-9d6784033ee9", "pmid": "", "title": "Breastfeeding or breast milk for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Pain in the neonate is associated with acute behavioural and physiological changes. Cumulative pain is associated with morbidities, including adverse neurodevelopmental outcomes. Studies have shown a reduction in changes in physiological parameters and pain score measurements following pre‐emptive analgesic administration in neonates experiencing pain or stress. Non‐pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for analgesia. This is an update of a review first published in 2006 and updated in 2012. Objectives The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries (ICTRP, ISRCTN and clinicaltrials.gov) in August 2022; searches were limited from 2011 forwards. We checked the reference lists of included studies and relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates. We included both term (≥ 37 completed weeks postmenstrual age) and preterm infants (< 37 completed weeks' postmenstrual age) up to a maximum of 44 weeks' postmenstrual age. The study must have reported on either physiological markers of pain or validated pain scores. Data collection and analysis We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a mean difference (MD). We used the GRADE approach to assess the certainty of evidence. Main results Of the 66 included studies, 36 evaluated breastfeeding, 29 evaluated supplemental breast milk and one study compared them against each other. The procedures conducted in the studies were: heel lance (39), venipuncture (11), intramuscular vaccination (nine), eye examination for retinopathy of prematurity (four), suctioning (four) and adhesive tape removal as procedure (one). We noted marked heterogeneity in the control interventions and pain assessment measures amongst the studies. Since many studies included multiple arms with breastfeeding/supplemental breast milk as the main comparator, we were not able to synthesise all interventions together. Individual interventions are compared to breastfeeding/supplemental breast milk and reported. The numbers of studies/participants presented with the findings are not taken from pooled analyses (as is usual in Cochrane Reviews), but are the overall totals in each comparison. Overall, the included studies were at low risk of bias except for masking of intervention and outcome assessment, where nearly one‐third of studies were at high risk of bias. Breastfeeding versus control Breastfeeding may reduce the increase in heart rate compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration of sucrose/glucose (20% to 33%) with skin‐to‐skin contact (low‐certainty evidence, 8 studies, 784 participants). Breastfeeding likely reduces the duration of crying compared to no intervention, lying on table, rocking, heel warming, holding by mother, skin‐to‐skin contact, bottle feeding mother's milk and moderate concentration of glucose (moderate‐certainty evidence, 16 studies, 1866 participants). Breastfeeding may reduce percentage time crying compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration sucrose and moderate concentration of sucrose with skin‐to‐skin contact (low‐certainty evidence, 4 studies, 359 participants). Breastfeeding likely reduces the Neonatal Infant Pain Scale (NIPS) score compared to no intervention, holding by mother, heel warming, music, EMLA cream, moderate glucose concentration, swaddling, swaddling and holding (moderate‐certainty evidence, 12 studies, 1432 participants). Breastfeeding may reduce the Neonatal Facial Coding System (NFCS) score compared to no intervention, holding, pacifier and moderate concentration of glucose (low‐certainty evidence, 2 studies, 235 participants). Breastfeeding may reduce the Douleur Aigue Nouveau‐né (DAN) score compared to positioning, holding or placebo (low‐certainty evidence, 4 studies, 709 participants). In the majority of the other comparisons there was little or no difference between the breastfeeding and control group in any of the outcome measures. Supplemental breast milk versus control Supplemental breast milk may reduce the increase in heart rate compared to water or no intervention (low‐certainty evidence, 5 studies, 336 participants). Supplemental breast milk likely reduces the duration of crying compared to positioning, massage or placebo (moderate‐certainty evidence, 11 studies, 1283 participants). Supplemental breast milk results in little or no difference in percentage time crying compared to placebo or glycine (low‐certainty evidence, 1 study, 70 participants). Supplemental breast milk results in little or no difference in NIPS score compared to no intervention, pacifier, moderate concentration of sucrose, eye drops, gentle touch and verbal comfort, and breast milk odour and verbal comfort (low‐certainty evidence, 3 studies, 291 participants). Supplemental breast milk may reduce NFCS score compared to glycine (overall low‐certainty evidence, 1 study, 40 participants). DAN scores were lower when compared to massage and water; no different when compared to no intervention, EMLA and moderate concentration of sucrose; and higher when compared to rocking or pacifier (low‐certainty evidence, 2 studies, 224 participants). Due to the high number of comparator interventions, other measures of pain were assessed in a very small number of studies in both comparisons, rendering the evidence of low certainty. The majority of studies did not report on adverse events, considering the benign nature of the intervention. Those that reported on adverse events identified none in any participants. Subgroup analyses were not conducted due to the small number of studies. Authors' conclusions Moderate‐/low‐certainty evidence suggests that breastfeeding or supplemental breast milk may reduce pain in neonates undergoing painful procedures compared to no intervention/positioning/holding or placebo or non‐pharmacological interventions. Low‐certainty evidence suggests that moderate concentration (20% to 33%) glucose/sucrose may lead to little or no difference in reducing pain compared to breastfeeding. The effectiveness of breast milk for painful procedures should be studied in the preterm population, as there are currently a limited number of studies that have assessed its effectiveness in this population. Plain language summary Breastfeeding or breast milk for procedural pain in newborn babies Review question We investigated how well breastfeeding or supplemental breast milk (expressed breast milk given via feeding tube or by placing breast milk in baby's mouth) works as a pain reliever in newborn babies while they undergo painful procedures (e.g. vaccination, heel prick, blood sampling for tests or eye examinations). The babies' pain responses (e.g. changes in heart rate, oxygen level, blood pressure, percentages of crying time, duration of crying etc.) were assessed by health care professionals to measure the pain that babies are experiencing. Background Breastfeeding may provide pain relief for newborn babies undergoing painful procedures. Medication for pain relief is commonly given for major painful procedures, but may not be given for minor painful procedures such as blood sampling (by heel prick or taking a sample from a vein). There are different forms of non‐drug strategies that can be used to reduce pain in babies, such as holding or swaddling them, sucking on a pacifier, or giving sweet solutions (such as sucrose or glucose). Different studies done in newborn babies have shown that breastfeeding may be a good way to reduce the pain they feel when subjected to minor painful procedures. These studies have been done in full‐term babies, and they have shown that breastfeeding may be effective by demonstrating that it reduces babies' crying time and various pain scores that have been validated for babies. Breast milk given by syringe has not shown the same efficacy as breastfeeding itself. Very few studies have been done in preterm babies, and so new studies are needed to determine if the use of supplemental breast milk in these small babies is effective in reducing their pain. Study characteristics We searched the medical literature thoroughly up to 1 August 2022 for studies that investigated the pain‐relieving effect of breastfeeding or supplemental breast milk for minor medical procedures in newborn full‐term and preterm neonates We included randomised trials only, as they provide the most reliable medical evidence. We identified 66 studies that reported on a total of more than 6200 infants in this Cochrane Review. Thirty‐six studies evaluated breastfeeding, 29 studies evaluated supplemental breast milk, while one study compared both against each other. In over half of the studies, pain relief was during a heel prick procedure. In others, it was during vaccination, drawing blood from a vein or other procedures. The studies used a variety of comparative groups, for example, placebo, no intervention, maternal holding, skin‐to‐skin contact, similar volume of water, a pacifier, routine care, various concentrations of sucrose or glucose, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), swaddling, heel warmth, anaesthetic cream for the skin, or a combination of these. The studies used a wide variety of pain scales as well as changes in heart rate and blood pressure and cry duration to assess pain. Study funding sources The studies included in the review were not externally funded according to information given in the reports. Key results Newborn babies in the breastfeeding group experienced a lower heart rate, shorter duration of cry, lower percentage of cry time and lower scores on the Neonatal Infant Pain Scale than babies who received no intervention. Moderate concentrations of glucose/sucrose may have similar effectiveness to breastfeeding. Studies of supplemental breast milk showed variable results. Supplemental breast milk was found to have a lower increase in heart rate when compared to water, and a lower duration of crying when compared to placebo. What are the limitations of the evidence We are moderately confident that breastfeeding reduces pain as assessed by heart rate, cry duration or validated pain scale compared to no intervention. Supplemental breast milk for painful procedures may reduce pain when compared to no intervention or placebo. Due to the high number of comparator groups, other measures of pain were assessed in a very small number of studies. The majority of the studies did not report on any unwanted or harmful effects of treatment. Those that did this identified no unwanted or harmful effects of treatment in any infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Shah, PS; Torgalkar, R; Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD004950.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "2c1b1244-b64f-49e1-8c94-e5f7436f0342", "pmid": "", "title": "Mechanisms Underlying Predictors of Success From Obesity Surgery", "imported": false, "abstract": "The goal of this project is to identify predictors of success in the treatment of obesity after bariatric surgery. The specific aims of this proposal are to:", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.159Z" }, { "id": "2c2004ad-422b-4ef5-a488-c8cca163899f", "pmid": "", "title": "Omega 3 fatty acids for preventing or slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Evidence from animal models and observational studies in humans has suggested that there is an inverse relationship between dietary intake of omega 3 long‐chain polyunsaturated fatty acids (LCPUFA) and risk of developing age‐related macular degeneration (AMD) or progression to advanced AMD. Objectives To review the evidence that increasing the levels of omega 3 LCPUFA in the diet (either by eating more foods rich in omega 3 or by taking nutritional supplements) prevents AMD or slows the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 1), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2015), EMBASE (January 1980 to February 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to February 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 February 2015. Selection criteria We included randomised controlled trials (RCTs) where increased dietary intake of omega 3 LCPUFA was compared to placebo or no intervention with the aim of preventing the development of AMD, or slowing its progression. Data collection and analysis Both authors independently selected studies, assessed them for risk of bias and extracted data. One author entered data into RevMan 5 and the other author checked the data entry. We conducted a meta‐analysis for one primary outcome, progression of AMD, using a fixed‐effect inverse variance model. Main results We included two RCTs in this review, in which 2343 participants with AMD were randomised to receive either omega 3 fatty acid supplements or a placebo. The trials, which had a low risk of bias, were conducted in the USA and France. Overall, there was no evidence that people who took omega 3 fatty acid supplements were at decreased (or increased risk) of progression to advanced AMD (pooled hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.84 to 1.10, high quality evidence). Similarly, people taking these supplements were no more (or less) likely to lose 15 or more letters of visual acuity (USA study HR 0.96, 95% CI 0.84 to 1.10; French study at 36 months risk ratio (RR) 1.25, 95% CI 0.69 to 2.26, participants = 230). The number of adverse events was similar in the intervention and placebo groups (USA study participants with one or more serious adverse event RR 1.00, 95% CI 0.91 to 1.09, participants = 2080; French study total adverse events RR 1.05, 95% CI 0.97 to 1.13, participants = 263). Authors' conclusions This review found that omega 3 LCPUFA supplementation in people with AMD for periods up to five years does not reduce the risk of progression to advanced AMD or the development of moderate to severe visual loss. No published randomised trials were identified on dietary omega 3 fatty acids for primary prevention of AMD. Currently available evidence does not support increasing dietary intake of omega 3 LCPUFA for the explicit purpose of preventing or slowing the progression of AMD. Plain language summary Omega 3 fatty acids for preventing and slowing the progression of age‐related macular degeneration Review question 
 We asked the question whether increased dietary intake of omega 3 fatty acids prevented or slowed the progression of age‐related macular degeneration. Background 
 Age‐related macular degeneration (AMD) is an eye condition that affects the central area of the retina (light‐sensitive tissue at the back of the eye). AMD is associated with a loss of detailed vision and adversely affects tasks such as reading, driving and face recognition. In the absence of a cure, there has been considerable interest in the role of modifiable risk factors to prevent or slow down the progression of AMD. Evidence from population studies suggests that people who have a diet with relatively high levels of omega 3 fatty acids (such as those derived from fish oils) are less likely to develop AMD. Study characteristics 
 We searched for studies up to 2 February 2015. We identified two trials with a total of 2343 participants. The trials were conducted in the USA and France and investigated the use of fish oil supplements in people with AMD who were at high risk of progressing to advanced disease. We judged the studies to be at low risk of bias. One study was funded by government grants and the other study was funded by the manufacturer of the dietary supplement. Key results 
 These studies found that omega 3 supplementation for periods up to five years did not reduce the rate of progression to advanced AMD or reduce significant visual loss compared to a placebo. The incidence of adverse effects was similar in the intervention and placebo groups. Quality of the evidence 
 We judged the quality of the evidence on rate of progression to AMD to be high, and the quality of the evidence for other outcomes to be moderate because the estimates were imprecise.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Lawrenson, JG; Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD010015.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "2c2948bf-4490-44f5-8d0d-02ec9af71eca", "pmid": "", "title": "Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "van den Bosch, CH, van Woensel, J, van de Wetering, MD", "articleTypes": [], "doi": "10.1002/14651858.CD003295.pub4 AB - Abstract - Background This is an updated version of a Cochrane Review last published in 2013. Long‐term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating people with cancer. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infections remain a common complication. These infections are mainly caused by gram‐positive bacteria. Antimicrobial prevention strategies aimed at these micro‐organisms could potentially decrease the majority of CVC‐related infections. The aim of this review was to evaluate the efficacy of prophylactic antibiotics for the prevention of gram‐positive infections in people with cancer who have long‐term CVCs. Objectives To assess the effects of administering antibiotics prior to the insertion of long‐term CVCs or as a flush/lock solution, or both during long‐term CVC access to prevent gram‐positive CVC‐related infections in adults and children receiving treatment for cancer. Search methods The search for this updated review was conducted on 19 November 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE via Ovid and Embase via Ovid. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform portal for additional articles. Selection criteria We included randomised controlled trials (RCTs) that compared either the administration of prophylactic antibiotics prior to long‐term CVC insertion versus no administration of antibiotics, or the use of an antibiotic versus a non‐antibiotic flush/lock solution in long‐term CVCs, in adults and children receiving treatment for cancer. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two authors independently selected studies, classified them and extracted data onto a predesigned data collection form. The outcomes of interest were gram‐positive catheter‐related infection events and total number of CVCs and CVC days. We pooled the data using a random‐effects model for meta‐analyses. We used the GRADE approach to assess the certainty of the evidence. Main results For this update, we identified 310 potentially relevant studies and screened them for eligibility. We included one additional RCT with 404 participants. The original review included 11 RCTs with a total of 840 people with cancer (adults and children). In total this review included 12 RCTs with 1244 participants. Antibiotics prior to insertion of the CVC 
Six trials compared the use of antibiotics (vancomycin, teicoplanin, ceftazidime or cefazolin) versus no antibiotics given before the insertion of a long‐term CVC. One study did not observe any CVC‐related infection events in either group was not included in the quantitative analysis as it was not possible to calculate a risk ratio. Administering an antibiotic prior to insertion of the CVC may not reduce gram‐positive CVC‐related infections (pooled risk ratio 0.67, confidence interval (CI) 95% 0.32 to 1.43; control versus intervention group risk 10.4% versus 7.3% of the participants; 5 studies, 648 participants; moderate‐certainty evidence). We sought adverse event data, but these were not described by the authors. The overall risk of bias was deemed low. Antibiotics as a flushing or locking solution 
Six trials compared a combined antibiotic (vancomycin, amikacin or taurolidine) and heparin solution with a heparin‐only solution for flushing or locking the long‐term CVC after use. One study did not observe any CVC‐related sepsis events (CRS) and was not included in this study in the quantitative analysis as it was not possible to calculate a risk ratio. Flushing and locking long‐term CVCs with a combined antibiotic and heparin solution likely reduced the risk of gram‐positive CVC‐related infections compared to a heparin‐only solution (pooled rate ratio 0.47, CI 95% 0.26 to 0.85; control versus intervention group rate ratio 0.66 versus 0.27 per 1000 CVC‐days; 5 studies, 443 participants; moderate‐certainty evidence). One trial reported a higher incidence of occlusions and participants in one trial reported an unpleasant taste after flushing associated with a combined antibiotic and heparin solution. The overall risk of bias was deemed low. Authors' conclusions Since the last version of this review, we included one additional study. There was no observed benefit of administering antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing or locking long‐term CVCs with an antibiotic solution likely reduces gram‐positive CVC‐related infections experienced in people at risk of neutropenia through chemotherapy or disease. However, a limitation of this review is heterogeneity between the studies for both outcomes. Insufficient data were available to evaluate if the conclusions apply equally for different CVC types and for adults versus children. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if the baseline CVC‐related infection rates are high. Further research is needed to identify high‐risk groups most likely to benefit from these antibiotic flush/lock solutions. Plain language summary Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer The issue 
People undergoing anti‐cancer treatment (chemotherapy) often have a catheter (tube) inserted into a large vein, through which their chemotherapy is given. This is known as a central venous catheter (CVC). As chemotherapy is usually administered over several months to years, long‐term CVCs are used. Despite sterile insertion and care afterwards, these CVCs often become infected by a type of bacteria called gram‐positive bacteria. Giving antibiotics as a preventive (prophylactic antibiotics) before the catheter is inserted, or using the antibiotics as a lock or flush solution, or both, may prevent these infections. A lock/flush solution is instilled in the catheter when it is not in use. This solution often contains heparin, saline, or both, to prevent a clot forming in the catheter. The aim of the review 
The aim of this review was to determine whether giving antibiotics before catheter insertion or as a lock/flush solution can prevent gram‐positive CVC‐related infections. What are the main findings? 
We searched databases to identify randomised controlled trials (RCTs ‐ clinical studies where people are randomly put into one of two or more treatment groups). We identified 12 relevant studies, which included a total of 1244 adults and children with cancer. We included six studies (756 people) that compared giving antibiotics before the insertion of the CVC against not giving antibiotics. We found that giving an antibiotic before CVC insertion did not prevent infections. The studies authors' did not describe side‐effects. We included six studies (488 people) that compared an antibiotic solution with a heparin‐only solution to flush/lock a CVC. We found that an antibiotic lock/flush solution reduced the number of CVC‐related infections. People in one study reported an unpleasant taste after flushing, and one study found there were fewer CVC obstructions (e.g. a clot) in people who received the combined antibiotic and anticoagulant solution. Certainty of the evidence 
We have moderate confidence in the evidence for giving antibiotics prior to CVC insertion and antibiotic lock/flush solutions since the studies were done in different people, used different types of catheters and antibiotics, and measured their results in different ways. What are the conclusions? 
We did not observe any benefit of giving antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing/locking long‐term CVCs with an antibiotic appeared to reduce gram‐positive CVC‐related infections in people with cancer. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if baseline CVC‐related infection rates are high. This review updates our previous review. The evidence is up to date to 19 November 2020.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.736Z" }, { "id": "2c3152b2-32d7-455e-9b1e-617114f79259", "pmid": "", "title": "Inhaled anti‐pseudomonal antibiotics for long‐term therapy in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review. Objectives To evaluate the effects of long‐term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug‐sensitivity reactions and survival). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022. Selection criteria We selected trials where people with cystic fibrosis received inhaled anti‐pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi‐randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). Data collection and analysis Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system. Main results The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta‐analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low‐certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) ‐5.30 days, 95% CI ‐8.59 to ‐2.01; 1 trial, 245 participants; low‐certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta‐analyses. We are uncertain of the effect of the intervention on adverse events (very low‐certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEV 1 ) % predicted compared to tobramycin (MD ‐3.40%, 95% CI ‐6.63 to ‐0.17; 1 trial, 273 participants; moderate‐certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate‐certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high‐certainty evidence). Important treatment‐related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high. Authors' conclusions Long‐term treatment with inhaled anti‐pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer‐term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes. Plain language summary Inhaling antibiotics to treat lung infection in people with cystic fibrosis Review question Are inhaled antibiotics helpful against persistent infection with Pseudomonas aeruginosa in people with cystic fibrosis (CF)? Key messages As people with CF get older, they are more likely to become infected on a long‐term basis with Pseudomonas aeruginosa. This is the most common cause of chronic lung infection in people with CF . We wanted to find out whether antibiotics targeting Pseudomonas aeruginosa would reduce the effects of infection when they are breathed into the lungs. We wanted to learn whether this treatment would improve lung function, quality of life and survival. We also looked for any harmful effects. What is CF? Cystic fibrosis is an inherited disease which results in abnormal mucus in several parts of the body and mainly affects the lungs, which are susceptible to infection by certain bacteria. Infection causes inflammation which results in progressive damage to the lungs. What did we find? The review includes 18 trials with 3042 people with CF aged between five and 45 years of age . The trials lasted from three to 33 months. In 11 trials investigators compared inhaled antibiotics with a placebo (an inhaled substance without the medication in it) and people were selected for one treatment or the other randomly. Eight trials compared one inhaled antibiotic with either a different inhaled antibiotic or a different schedule of the same inhaled antibiotic. One of the trials compared an antibiotic both to placebo and to a different antibiotic and so fell into both groups. Main results Results from four trials showed that when compared to placebo, inhaled antibiotics may improve lung function and reduce the number of times the people with CF had a worsening of symptoms (exacerbation). Inhaled antibiotics may also mean fewer days off school or work (a measure of quality of life). They did not seem to have an effect on survival. We are not sure of the side effects of inhaled antibiotics, but tinnitus and changes in voice were reported more often in people inhaling antibiotics rather than the placebo. We did not find enough evidence to be able to comment on how inhaled antibiotics affect height and weight. Where the trials compared different inhaled antibiotics or schedules, there was only one trial in each of the eight different comparisons. The only differences we found in all these comparisons were for two outcomes. In one trial we found that aztreonam lysine probably improved lung function more than tobramycin, but no important differences were found in the other trials with regard to lung function. Aztreonam lysine also probably led to fewer people needing additional courses of antibiotics than tobramycin and there were fewer hospitalisations after levofloxacin compared to placebo. We noted that important side effects that were related to the treatment were not very common in the trials, but they were less common with tobramycin than with other antibiotics. What are the limitations of the evidence? The trials that we included in this review measured lung function in different ways and also how often people experienced a sudden worsening of symptoms. That made it difficult for us to combine the results of different trials to strengthen our evidence. We thought the overall certainty of evidence was low for most outcomes, mainly due to risks of bias within the trials and low event rates meaning results were not precise. How up to date is this evidence? The evidence is current to: 28 June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Smith, S; Rowbotham, NJ", "articleTypes": [], "doi": "10.1002/14651858.CD001021.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "2c379de8-2bf6-4fae-8823-865537a3dd47", "pmid": "", "title": "Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease", "imported": false, "abstract": "Abstract - Background Thyrotropin‐releasing hormones (TRH) added to prenatal corticosteroids has been suggested as a way to further reduce breathing problems and neonatal lung disease in infants born preterm. Objectives To assess the effects of giving prenatal TRH in addition to corticosteroids to women at risk of preterm birth for the prevention of neonatal respiratory disease. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013) and reference lists of retrieved studies. We also contacted trial authors. Selection criteria Randomised controlled trials in women at sufficient risk of preterm birth to warrant the use of prenatal corticosteroids to promote lung maturity. TRH and corticosteroids were compared with corticosteroids, with or without placebo. Data collection and analysis All assessments of trial eligibility, risk of bias and data extractions were independently carried out by at least two review authors. Main results Over 4600 women were recruited into the 15 trials included in the review, however two trials did not contribute any outcome data to the review. The trials had a moderate risk of bias. Overall, prenatal TRH, in addition to corticosteroids, did not reduce the risk of death prior to hospital discharge (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.86 to 1.27, six trials, 3694 infants), neonatal respiratory distress syndrome (average RR 1.05, 95% CI 0.91 to 1.22, nine trials, 3833 infants), or chronic lung disease (RR 1.01, 95% CI 0.85 to 1.19, five trials, 2511 infants), and did not improve any of the secondary fetal, neonatal or childhood outcomes assessed by intention‐to‐treat analyses. Indeed, the data showed prenatal TRH to have adverse effects for women and their infants. All side effects reported (nausea, vomiting, light headedness, urgency of micturition, facial flushing) were significantly more likely to occur in women receiving TRH. In the infants, prenatal TRH increased the risk of needing respiratory support (RR 1.16, 95% CI 1.03 to 1.29, three trials, 1969 infants), and of having a low Apgar score at five minutes (RR 1.48, 95% CI 1.14 to 1.92, three trials, 1969 infants). Only three trials provided data on childhood follow‐up, and while one trial suggested poorer outcomes for infants who were exposed to prenatal TRH, the other two trials, that assessed infants using an established developmental instrument, showed no clear differences between groups in follow‐up outcomes. Sensitivity analyses by trial quality, or subgroups with differing times from entry to birth, or different dose regimens of TRH, did not change these findings. Authors' conclusions Prenatal TRH in addition to corticosteroids, given to women at risk of preterm birth, does not improve infant outcomes and can cause maternal side effects. Plain language summary Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease Thyrotropin‐releasing hormone (TRH) given with corticosteroids does not improve the benefit of corticosteroids on the lungs of babies born too early, and may increase harm. Babies born preterm (before 37 weeks of pregnancy) are at risk of breathing difficulties (such as respiratory distress syndrome). TRH increases thyroid hormones in the baby and it has been thought that adding TRH to corticosteroids for women giving birth early may increase the benefit of corticosteroids on the baby's lungs. This review included 15 trials, of a moderate risk of bias, that involved over 4600 women and their babies. In this review, TRH, given with corticosteroids to women at risk of early birth, was not shown to further reduce the breathing difficulties for the babies. Babies born to mothers who had received TRH with corticosteroids, were more likely to require support for breathing than babies born to mothers who received only corticosteroids. Women receiving TRH were more likely to experience adverse side effects, such as nausea, vomiting and flushing than women who only received corticosteroids. Therefore, based on the current available evidence, TRH is not recommended to be given to women at risk of preterm birth for preventing neonatal respiratory disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Crowther, CA, Alfirevic, Z, Han, S, Haslam, RR", "articleTypes": [], "doi": "10.1002/14651858.CD000019.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.769Z" }, { "id": "2c3900c3-427d-40dc-82b7-e580225fbbf0", "pmid": "", "title": "Antioxidant vitamin and mineral supplements for slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Age‐related macular degeneration (AMD) is a degenerative condition of the back of the eye that occurs in people over the age of 50 years. Antioxidants may prevent cellular damage in the retina by reacting with free radicals that are produced in the process of light absorption. Higher dietary levels of antioxidant vitamins and minerals may reduce the risk of progression of AMD. This is the third update of the review. Objectives To assess the effects of antioxidant vitamin and mineral supplements on the progression of AMD in people with AMD. Search methods We searched CENTRAL, MEDLINE, Embase, one other database, and three trials registers, most recently on 29 November 2022. Selection criteria We included randomised controlled trials (RCTs) that compared antioxidant vitamin or mineral supplementation to placebo or no intervention, in people with AMD. Data collection and analysis We used standard methods expected by Cochrane. Main results We included 26 studies conducted in the USA, Europe, China, and Australia. These studies enroled 11,952 people aged 65 to 75 years and included slightly more women (on average 56% women). We judged the studies that contributed data to the review to be at low or unclear risk of bias. Thirteen studies compared multivitamins with control in people with early and intermediate AMD. Most evidence came from the Age‐Related Eye Disease Study (AREDS) in the USA. People taking antioxidant vitamins were less likely to progress to late AMD (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.58 to 0.90; 3 studies, 2445 participants; moderate‐certainty evidence). In people with early AMD, who are at low risk of progression, this means there would be approximately four fewer cases of progression to late AMD for every 1000 people taking vitamins (one fewer to six fewer cases). In people with intermediate AMD at higher risk of progression, this corresponds to approximately 78 fewer cases of progression for every 1000 people taking vitamins (26 fewer to 126 fewer). AREDS also provided evidence of a lower risk of progression for both neovascular AMD (OR 0.62, 95% CI 0.47 to 0.82; moderate‐certainty evidence) and geographic atrophy (OR 0.75, 95% CI 0.51 to 1.10; moderate‐certainty evidence), and a lower risk of losing 3 or more lines of visual acuity (OR 0.77, 95% CI 0.62 to 0.96; moderate‐certainty evidence). Low‐certainty evidence from one study of 110 people suggested higher quality of life scores (measured with the Visual Function Questionnaire) in treated compared with non‐treated people after 24 months (mean difference (MD) 12.30, 95% CI 4.24 to 20.36). In exploratory subgroup analyses in the follow‐on study to AREDS (AREDS2), replacing beta‐carotene with lutein/zeaxanthin gave hazard ratios (HR) of 0.82 (95% CI 0.69 to 0.96), 0.78 (95% CI 0.64 to 0.94), 0.94 (95% CI 0.70 to 1.26), and 0.88 (95% CI 0.75 to 1.03) for progression to late AMD, neovascular AMD, geographic atrophy, and vision loss, respectively. Six studies compared lutein (with or without zeaxanthin) with placebo and one study compared a multivitamin including lutein/zeaxanthin with multivitamin alone. The duration of supplementation and follow‐up ranged from six months to five years. Most evidence came from the AREDS2 study in the USA; almost all participants in AREDS2 also took the original AREDS supplementation formula. People taking lutein/zeaxanthin may have similar or slightly reduced risk of progression to late AMD (RR 0.94, 95% CI 0.87 to 1.01), neovascular AMD (RR 0.92, 95% CI 0.84 to 1.02), and geographic atrophy (RR 0.92, 95% CI 0.80 to 1.05) compared with control (1 study, 4176 participants, 6891 eyes; low‐certainty evidence). A similar risk of progression to visual loss of 15 or more letters was seen in the lutein/zeaxanthin and control groups (RR 0.98, 95% CI 0.91 to 1.05; 6656 eyes; low‐certainty evidence). Quality of life (Visual Function Questionnaire) was similar between groups (MD 1.21, 95% CI ‐2.59 to 5.01; 2 studies, 308 participants; moderate‐certainty evidence).
One study in Australia randomised 1204 people to vitamin E or placebo with four years of follow‐up; 19% of participants had AMD. The number of late AMD events was low (N = 7) and the estimate of effect was uncertain (RR 1.36, 95% CI 0.31 to 6.05; very low‐certainty evidence). There was no evidence of any effect of treatment on visual loss (RR 1.04, 95% CI 0.74 to 1.47; low‐certainty evidence). There were no data on neovascular AMD, geographic atrophy, or quality of life.
Five studies compared zinc with placebo. Evidence largely drawn from the largest study (AREDS) found a lower progression to late AMD over six years (OR 0.83, 95% CI 0.70 to 0.98; 3 studies, 3790 participants; moderate‐certainty evidence), neovascular AMD (OR 0.76, 95% CI 0.62 to 0.93; moderate‐certainty evidence), geographic atrophy (OR 0.84, 95% CI 0.64 to 1.10; moderate‐certainty evidence), or visual loss (OR 0.87, 95% CI 0.75 to 1.00; 2 studies, 3791 participants; moderate‐certainty evidence). There were no data on quality of life. Gastrointestinal symptoms were the main reported adverse effect. In AREDS, zinc was associated with a higher risk of genitourinary problems in men, but no difference was seen between high‐ and low‐dose zinc groups in AREDS2. Most studies were too small to detect rare adverse effects. Data from larger studies (AREDS/AREDS2) suggested there may be little or no effect on mortality with multivitamin (HR 0.87, 95% CI 0.60 to 1.25; low‐certainty evidence) or lutein/zeaxanthin supplementation (HR 1.06, 95% CI 0.87 to 1.31; very low‐certainty evidence), but confirmed the increased risk of lung cancer with beta‐carotene, mostly in former smokers. Authors' conclusions Moderate‐certainty evidence suggests that antioxidant vitamin and mineral supplementation (AREDS: vitamin C, E, beta‐carotene, and zinc) probably slows down progression to late AMD. People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than people with early AMD. Although low‐certainty evidence suggested little effect with lutein/zeaxanthin alone compared with placebo, exploratory subgroup analyses from one large American study support the view that lutein/zeaxanthin may be a suitable replacement for the beta‐carotene used in the original AREDS formula. Plain language summary Do antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD)? Key messages 
‐ Taking an antioxidant multivitamin supplement may slow down the progression of age‐related macular degeneration (AMD), an eye disease that blurs your central vision. ‐ People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than for people with early AMD. ‐ Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence as to safety as they were generally too small. What is age‐related macular degeneration? Age‐related macular degeneration (AMD) is an eye disease that blurs your central vision. It is usually only diagnosed in people aged 50 years and above. AMD affects the central area (macula) of the back of the eye (retina), as the macula degenerates with age. In early AMD, yellow spots (called drusen) can be seen under the retina by an eye health professional. The affected person will probably be unaware that they have a problem. As the disease progresses, the drusen become larger (intermediate AMD). In the later stages of the disease, there may be loss of the cells – needed for vision – in the back of the eye. This is known as geographic atrophy. Sometimes, new (harmful) blood vessels grow in the macula. These new blood vessels may bleed and cause scarring. This is known as neovascular AMD. Neovascular AMD and geographic atrophy are known as late AMD. Why might antioxidant vitamins and minerals be helpful? Antioxidant vitamins and minerals may help to protect the macula against this deterioration and loss of vision. Antioxidants are natural molecules that may prevent or delay some types of cell damage. Vitamins C and E, beta‐carotene, lutein, zeaxanthin, and zinc are examples of antioxidants commonly found in dietary supplements. What did we want to find out? 
We wanted to find out whether antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD) and prevent visual loss. What did we do? We searched for studies that compared antioxidant vitamin and mineral supplements with placebo (a ‘dummy’ treatment not containing any supplements) or no treatment. We only looked at the effects of these supplements in people with AMD. There is another Cochrane Review on the effects of these supplements in people who do not already have AMD. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 26 studies from the USA, Europe, China, and Australia that enroled 11,952 people with AMD. These studies compared multivitamin supplements, zinc, vitamin E, lutein (with or without zeaxanthin) with placebo. Participants were aged 65 to 75 years and there were slightly more women than men in the studies. Main findings • Taking an antioxidant multivitamin supplement (AREDS formula containing vitamins E and C, beta‐carotene plus zinc) probably slows down the progression of AMD to late AMD and vision loss. This may result in a small improvement in quality of life. • People with intermediate AMD have a higher risk of progression to late AMD and so may be more likely to benefit from supplements (78 fewer cases of progression for every 1000 people taking supplements). People with early AMD have a low risk of progression and so may be less likely to benefit (4 fewer cases of progression to late AMD for every 1000 people taking supplements). • Lutein with or without zeaxanthin may have little or no effect on progression to late AMD but may be a suitable replacement for beta‐carotene in the AREDS formula. Beta‐carotene may increase the chance of lung cancer in people who have smoked. • The effects of vitamin E alone on the progression to late AMD and vision loss are uncertain. Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence about safety because most of the studies were small and reported on harmful effects inconsistently. What are the limitations of the evidence? Our confidence in the evidence ranged from moderate to very low. This is because most of the included studies were small, and they did not cover all the comparisons and outcomes we were interested in. How up to date is this review? 
This review updates our previous version. The evidence is up to date to 29 November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Evans, JR; Lawrenson, JG", "articleTypes": [], "doi": "10.1002/14651858.CD000254.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "2c458698-6b48-4d46-ba9e-eff8343b4b65", "pmid": "", "title": "Listening to music for insomnia in adults", "imported": false, "abstract": "Abstract - Background Insomnia is a common problem in modern society. It is associated with reduced quality of life and impairments in physical and mental health. Listening to music is widely used as a sleep aid, but it remains unclear if it can actually improve insomnia in adults. This Cochrane Review is an update of a review published in 2015. Objectives To assess the effects of listening to music on sleep in adults with insomnia and to assess the influence of specific variables that may moderate the effect . Search methods For this update, we searched CENTRAL, MEDLINE, Embase, nine other databases and two trials registers up to December 2021. In addition, we handsearched reference lists of included studies, and contacted authors of published studies to identify additional studies eligible for inclusion, including any unpublished or ongoing trials. Selection criteria Randomised controlled trials comparing the effects of listening to music with no treatment or treatment as usual (TAU) in adults complaining of sleep difficulties. Data collection and analysis Two review authors independently screened records for eligibility, selected studies for inclusion, extracted data and assessed risk of bias of the included studies. We assessed the certainty of the evidence using GRADE. The primary outcomes were sleep quality, insomnia severity, sleep‐onset latency, total sleep time, sleep interruption, sleep efficiency and adverse events. Data on the predefined outcome measures were included in meta‐analyses when consistently reported by at least two studies that were homogeneous in terms of participants, interventions and outcomes. We undertook meta‐analyses using random‐effects models. Main results We included 13 studies (eight studies new to this update) comprising 1007 participants. The studies examined the effect of listening to prerecorded music daily, for 25 to 60 minutes, for a period of three days to three months. The risk of bias within the studies varied, with all studies being at high risk of performance bias, because of limited possibilities to blind participants to the music intervention. Some studies were at high risk of detection bias or other bias. Four studies reported funding from national research councils, three studies reported financial support from university sources and one study reported a grant from a private foundation. Five studies did not report any financial support. At the end of the intervention, we found moderate‐certainty evidence for improved sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI) in themusic groups compared to no intervention or TAU (mean difference (MD) −2.79, 95% confidence interval (CI) −3.86 to −1.72; 10 studies, 708 participants). The PSQI scale ranges from 0 to 21 with higher scores indicating poorer sleep. The size of the effect indicates an increase in sleep quality of the size of about one standard deviation in favour of the intervention. We found no clear evidence of a difference in the effects of listening to music compared to no treatment or TAU on insomnia severity (MD −6.96, 95% CI −15.21 to 1.28; 2 studies, 63 participants; very low‐certainty evidence). We found low‐certainty evidence that, compared to no treatment or TAU, listening to music may reduce problems with sleep‐onset latency (MD −0.60, 95% CI −0.83 to −0.37; 3 studies, 197 participants), total sleep time (MD −0.69, 95% CI −1.16 to −0.23; 3 studies, 197 participants) and sleep efficiency (MD −0.96, 95% CI −1.38 to −0.54; 3 studies, 197 participants), but may have no effect on perceived sleep interruption (MD −0.53, 95% CI −1.47 to 0.40; 3 studies, 197 participants). In addition, three studies (136 participants) included objective measures of sleep‐onset latency, total sleep time, sleep efficiency and sleep interruption and showed that listening to music may not improve these outcomes compared to no treatment or TAU. None of the included studies reported any adverse events. Authors' conclusions The findings of this review provide evidence that music may be effective for improving subjective sleep quality in adults with symptoms of insomnia. More research is needed to establish the effect of listening to music on other aspects of sleep as well as the daytime consequences of insomnia. Plain language summary Music for insomnia in adults Review question This review assessed the effects of listening to music on insomnia (sleep problems) in adults and the impact of factors that may influence the effect. Key messages We found a beneficial effect of music on sleep quality. For all the other outcomes, we did not find enough good‐quality evidence as there were too few participants and the people doing the scoring of the data were aware of the treatment. What is insomnia? Worldwide, millions of people experience insomnia. People can have difficulties getting to sleep, staying asleep or may experience poor sleep quality. Poor sleep affects people's physical and mental health. The consequences of poor sleep are costly, for both individuals and society. Many people listen to music to improve their sleep, but the effect of listening to music is unclear. What did we do? We searched electronic databases to identify relevant studies. We included 13 studies with 1007 participants. The studies compared the effect of listening to music to treatment as usual or no treatment. Treatment as usual could be sleep hygiene education (learning a set of rituals to help with sleep) or standard care for participants with insomnia related to chronic medical conditions. The studies examined the effect of listening to prerecorded music daily, for 25 to 50 minutes, for three days to three months. Seven of the included studies reported funding from national research councils or university sources, and one study reported funding from a private foundation. Five studies did not report any funding sources. What did we find? Ten studies measured sleep quality, and the results showed that music probably facilitates a large improvement in the quality of sleep compared to no treatment or treatment as usual. We do not know if listening to music has an effect on the severity of insomnia (difficulty in falling or staying asleep) or the number of times a person wakes up (broken sleep) compared to no treatment or treatment as usual. Listening to music may improve slightly sleep‐onset latency (how quickly a person falls asleep), sleep duration (length of time a person is asleep) and sleep efficiency (amount of a time a person is asleep compared to the total time spent in bed), compared to no treatment or treatment as usual. None of the studies reported any negative effects caused by listening to music. What are the limitations of the evidence? The quality of evidence from the 10 studies that examined sleep quality was moderate. Our confidence in the evidence for the quality of sleep is only moderate because the people in the studies were aware of which treatment they were getting and the people scoring the data were also sometimes aware of which treatment the participants were getting, which could introduce bias. We have little confidence in the evidence for the severity of insomnia because the studies were very small and were done in different types of people who knew which treatment they were getting. Our confidence in the evidence on sleep‐onset latency, sleep duration and sleep efficiency is low because the studies used very different methods to measure these outcomes, and the people in the studies were aware of the nature of the treatment. We have little confidence in the evidence on sleep interruption because the studies used different methods and showed different results. Furthermore, the participants in the studies knew which treatment they were getting. Future studies should assess other aspects of sleep as well as measures of daytime functioning, such as mood, fatigue, concentration, and quality of life. How up to date is this evidence? The evidence is current to 31 December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jespersen, KV, Pando-Naude, V, Koenig, J, Jennum, P, Vuust, P", "articleTypes": [], "doi": "10.1002/14651858.CD010459.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.782Z" }, { "id": "2c467125-a847-4408-a48a-b17b3fbb896d", "pmid": "", "title": "Sustained‐release naltrexone for opioid dependence", "imported": false, "abstract": "Abstract - Background Opioid dependence is a severe and often lifelong disorder with a high risk of overdose and premature death, as well as severe psychosocial difficulties. Sustained‐release naltrexone is a treatment option that works by blocking the euphoric and overdose effects of opioids. When injected intramuscularly, naltrexone provides blockade for one month, while the blocking effects with implants can last for up to six months. Objectives To assess the benefits and harms of sustained‐release naltrexone for the treatment of opioid dependence. Search methods For this update, we searched the following databases from 2007 up to 20 December 2023: the Cochrane Drugs and Alcohol Specialised Register of Trials, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, ISI Web of Science, LILACS, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We manually searched the reference lists of identified studies, published reviews and relevant websites. Selection criteria Randomised controlled trials comparing the effects of injectable or implantable naltrexone with other treatment, no treatment or placebo in adults with opioid dependence. Data collection and analysis Primary outcomes were illicit opioid use, retention in treatment, treatment acceptability and adverse events. Secondary outcomes were opioid craving, recreational use of substances other than opioids, mental health, quality of life and criminal activity. We assessed the risk of bias using the Cochrane risk of bias tool (RoB 1). We combined the results of individual trials through meta‐analysis where possible using a random‐effects model. Two review authors independently assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We identified 22 studies (3416 participants) that met our inclusion criteria. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. Sustained‐release naltrexone compared with opioid agonist treatment We found moderate‐certainty evidence that sustained‐release naltrexone probably increases in‐treatment illicit opioid use slightly (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.01 to 1.31; 1 study, 570 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 1.17, 95% CI 0.78 to 1.76; 3 studies, 773 participants) and treatment acceptability (RR 0.92, 95% CI 0.73 to 1.16; 3 studies, 773 participants). There was low‐certainty evidence that sustained‐release naltrexone may increase serious adverse events slightly in comparison with opioid agonist treatment for serious adverse events (RR 1.40, 95% CI 0.92 to 2.11; 2 studies, 713 participants). Sustained‐release naltrexone compared with oral naltrexone treatment We found low‐certainty evidence that sustained‐release naltrexone may reduce in‐treatment illicit opioid use (RR 0.65, 95% CI 0.45 to 0.93; 1 study, 69 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 2.40, 95% CI 1.64 to 3.52; 3 studies, 464 participants) and on serious adverse events (RR 1.25, 95% CI 0.46 to 3.36; 2 studies, 260 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in treatment acceptability in comparison with oral naltrexone treatment (RR 1.00, 95% CI 0.99 to 1.01; 3 studies, 474 participants). Sustained‐release naltrexone compared with placebo We found low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in in‐treatment illicit opioid use (RR 0.83, 95% CI 0.66 to 1.03; 3 studies, 443 participants), treatment acceptability (RR 1.00, 95% CI 0.98 to 1.02; 1 study, 204 participants) and serious adverse events (RR 0.74, 95% CI 0.17 to 3.23; 3 studies, 443 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment in comparison with placebo (RR 2.10, 95% CI 1.23 to 3.60; 4 studies, 594 participants). Sustained‐release naltrexone compared with treatment as usual We found high‐certainty evidence that sustained‐release naltrexone reduces in‐treatment illicit opioid use (RR 0.72, 95% CI 0.57 to 0.90; 4 studies, 479 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little or no difference in retention in treatment (RR 1.20, 95% CI 0.79 to 1.82; 3 studies, 126 participants) and that it may result in a slight reduction in treatment acceptability (RR 0.79, 95% CI 0.69 to 0.90; 8 studies, 1094 participants). There was moderate‐certainty evidence that sustained‐release naltrexone probably reduces serious adverse events in comparison with treatment as usual (RR 0.59, 95% CI 0.36 to 0.95; 6 studies, 1009 participants). Our primary outcome measures were not reported for sustained‐release naltrexone compared with psychosocial treatments. Amongst the most common methodological weaknesses were the risk of performance bias and imprecision due to few studies and small sample size for many outcomes. Authors' conclusions Sustained‐release naltrexone may slightly increase illicit opioid use and serious adverse events compared to opioid agonists, with uncertain effects on retention and acceptability. It may reduce illicit opioid use compared to oral naltrexone but has uncertain effects on other outcomes. Compared to placebo, it may have little to no impact on key outcomes. Compared to treatment as usual, it reduces illicit opioid use and may reduce serious adverse events but has little effect on retention and slightly reduces acceptability. Significant gaps remain in the evidence on sustained‐release naltrexone for opioid dependence. Future research should include comparisons with psychosocial treatments, larger and higher‐quality studies, and analyses of differences between formulations and comparator treatments. Improved study designs are needed to reduce bias, and more inclusive research should address under‐represented populations and synthetic opioid users. The lack of long‐term outcome data limits understanding of sustained effects, highlighting the need for extended follow‐up and exploration of diverse treatment settings and populations. Plain language summary What are the benefits and risks of sustained‐release (long‐acting) naltrexone for the treatment of dependence on opioid drugs (addiction)? Key messages • It is unclear whether people treated with sustained‐release naltrexone use illicit opioids, such as heroin, less frequently than people treated with opioid agonists, such as buprenorphine or methadone. • People treated with sustained‐release naltrexone may use illicit opioids less frequently than people treated with oral naltrexone, placebo or treatment as usual. • Treatment with sustained‐release naltrexone may be less safe than opioid agonist treatment, but safer than treatment as usual. • Clinicians and patients should weigh the availability and characteristics of treatment options, noting that sustained‐release naltrexone aids abstinence without restricting freedom but requires detoxification; more evidence is needed on long‐term safety and retention. What is dependence on opioid drugs? Opioid drugs, including heroin and prescription painkillers like oxycodone, carry the risk of addiction and serious health consequences. Treatment often involves replacing these opioids with safer alternatives such as methadone or buprenorphine, although other options like therapy or naltrexone are available. However, overcoming opioid dependence remains a persistent challenge due to its complex nature and the associated risks of relapse and overdose. What did we want to find out? In this review we sought to compare sustained‐release naltrexone treatment with other treatments or no treatment for opioid dependence. Naltrexone should not be confused with naloxone, which is a short‐acting drug used for opioid overdose reversal. Other treatments include opioid agonist treatment (such as methadone or buprenorphine), oral naltrexone (taken by mouth, tablets), placebo (sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested), treatment as usual and psychosocial treatments (therapeutic approaches that address both psychological and social aspects of mental health conditions, e.g. psychotherapy, psychoeducation and support groups). What did we do? We searched scientific databases for studies up to December 2023. We identified 22 randomised controlled trials (studies where people were allocated at random to one of two or more treatment or control conditions) involving 3416 adults and adolescents with opioid dependence. Seventy‐four per cent of the people in the studies were male, and they had an average age of 40 years. Twelve of the 22 studies were conducted in the USA or Canada, five in Russia, three in Norway, and one in the UK and Australia, respectively. The main outcomes we examined were opioid use and treatment safety. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. What did we find? We found that when comparing sustained‐release naltrexone to opioid agonist treatment, illicit opioid use probably increases slightly. On the other hand, when comparing sustained‐release naltrexone to treatment as usual, sustained‐release naltrexone reduces illicit opioid use. Compared to oral naltrexone, illicit opioid use may decrease, and compared to placebo, there may be little or no difference. We found no studies comparing sustained‐release naltrexone with psychosocial treatments for any of our primary outcomes. It is generally unclear whether people remain longer in sustained‐release naltrexone treatment than in other treatments or placebo. We do not know whether more people will initiate sustained‐release naltrexone treatment than opioid agonist treatment. When compared to oral naltrexone or placebo, there may be little or no difference in the proportion of people who will initiate treatment. Compared to treatment as usual, it may be that fewer people will initiate sustained‐release naltrexone treatment. Compared to opioid agonist treatment, sustained‐release naltrexone may increase serious adverse (unwanted or harmful) events slightly. It is unclear whether sustained‐release naltrexone results in more or fewer serious adverse events than oral naltrexone. When compared to placebo, there may be little or no difference in the proportion of people who will experience serious adverse events. Sustained‐release naltrexone probably reduces serious adverse events in comparison to treatment as usual. What were the limitations of the evidence? Overall, we have limited confidence in the evidence. One of the reasons is that it is very likely that participants knew which treatments they were assigned to, even if the researchers in many cases tried to conceal the assigned treatment condition for participants and treatment providers. Opioid dependence comes with strong drug cravings and an increased risk of relapse during any treatment. Therefore, participants experiencing cravings and those who maybe even tried to use drugs like heroin would have understood what type of treatment they were assigned to. Another major reason for our limited confidence in the evidence was that the number of studies, and people participating in them, was often too small to obtain precise results. Other reasons for lowering our confidence were inconsistencies in study results and national treatment policies in some studies that make it difficult to apply the results in other countries. How up‐to‐date is this evidence? The evidence is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kornør, H, Lobmaier, PPK, Kunøe, N", "articleTypes": [], "doi": "10.1002/14651858.CD006140.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.821Z" }, { "id": "2c5ad828-3649-4638-bac4-1d55bf9ad4bd", "pmid": "", "title": "Pine bark (Pinus spp.) extract for treating chronic disorders", "imported": false, "abstract": "Abstract - Background Pine bark ( Pinus spp.) extract is rich in bioflavonoids, predominantly proanthocyanidins, which are antioxidants. Commercially‐available extract supplements are marketed for preventing or treating various chronic conditions associated with oxidative stress. This is an update of a previously published review. Objectives To assess the efficacy and safety of pine bark extract supplements for treating chronic disorders. Search methods We searched three databases and three trial registries; latest search: 30 September 2019. We contacted the manufacturers of pine bark extracts to identify additional studies and hand‐searched bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) evaluating pine bark extract supplements in adults or children with any chronic disorder. Data collection and analysis Two authors independently assessed trial eligibility, extracted data and assessed risk of bias. Where possible, we pooled data in meta‐analyses. We used GRADE to evaluate the certainty of evidence. Primary outcomes were participant‐ and investigator‐reported clinical outcomes directly related to each disorder and all‐cause mortality. We also assessed adverse events and biomarkers of oxidative stress. Main results This review included 27 RCTs (22 parallel and five cross‐over designs; 1641 participants) evaluating pine bark extract supplements across 10 chronic disorders: asthma (two studies; 86 participants); attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), cardiovascular disease (CVD) and risk factors (seven studies; 338 participants), chronic venous insufficiency (CVI) (two studies; 60 participants), diabetes mellitus (DM) (six studies; 339 participants), erectile dysfunction (three studies; 277 participants), female sexual dysfunction (one study; 83 participants), osteoarthritis (three studies; 293 participants), osteopenia (one study; 44 participants) and traumatic brain injury (one study; 60 participants). Two studies exclusively recruited children; the remainder recruited adults. Trials lasted between four weeks and six months. Placebo was the control in 24 studies. Overall risk of bias was low for four, high for one and unclear for 22 studies. In adults with asthma, we do not know whether pine bark extract increases change in forced expiratory volume in one second (FEV 1 ) % predicted/forced vital capacity (FVC) (mean difference (MD) 7.70, 95% confidence interval (CI) 3.19 to 12.21; one study; 44 participants; very low‐certainty evidence), increases change in FEV 1 % predicted (MD 7.00, 95% CI 0.10 to 13.90; one study; 44 participants; very low‐certainty evidence), improves asthma symptoms (risk ratio (RR) 1.85, 95% CI 1.32 to 2.58; one study; 60 participants; very low‐certainty evidence) or increases the number of people able to stop using albuterol inhalers (RR 6.00, 95% CI 1.97 to 18.25; one study; 60 participants; very low‐certainty evidence). In children with ADHD, we do not know whether pine bark extract decreases inattention and hyperactivity assessed by parent‐ and teacher‐rating scales (narrative synthesis; one study; 57 participants; very low‐certainty evidence) or increases the change in visual‐motoric coordination and concentration (MD 3.37, 95% CI 2.41 to 4.33; one study; 57 participants; very low‐certainty evidence). In participants with CVD, we do not know whether pine bark extract decreases diastolic blood pressure (MD ‐3.00 mm Hg, 95% CI ‐4.51 to ‐1.49; one study; 61 participants; very low‐certainty evidence); increases HDL cholesterol (MD 0.05 mmol/L, 95% CI ‐0.01 to 0.11; one study; 61 participants; very low‐certainty evidence) or decreases LDL cholesterol (MD ‐0.03 mmol/L, 95% CI ‐0.05 to 0.00; one study; 61 participants; very low‐certainty evidence). In participants with CVI, we do not know whether pine bark extract decreases pain scores (MD ‐0.59, 95% CI ‐1.02 to ‐0.16; one study; 40 participants; very low‐certainty evidence), increases the disappearance of pain (RR 25.0, 95% CI 1.58 to 395.48; one study; 40 participants; very low‐certainty evidence) or increases physician‐judged treatment efficacy (RR 4.75, 95% CI 1.97 to 11.48; 1 study; 40 participants; very low‐certainty evidence). In type 2 DM, we do not know whether pine bark extract leads to a greater reduction in fasting blood glucose (MD 1.0 mmol/L, 95% CI 0.91 to 1.09; one study; 48 participants;very low‐certainty evidence) or decreases HbA1c (MD ‐0.90 %, 95% CI ‐1.78 to ‐0.02; 1 study; 48 participants; very low‐certainty evidence). In a mixed group of participants with type 1 and type 2 DM we do not know whether pine bark extract decreases HbA1c (MD ‐0.20 %, 95% CI ‐1.83 to 1.43; one study; 67 participants; very low‐certainty evidence). In men with erectile dysfunction, we do not know whether pine bark extract supplements increase International Index of Erectile Function‐5 scores (not pooled; two studies; 147 participants; very low‐certainty evidence). In women with sexual dysfunction, we do not know whether pine bark extract increases satisfaction as measured by the Female Sexual Function Index (MD 5.10, 95% CI 3.49 to 6.71; one study; 75 participants; very low‐certainty evidence) or leads to a greater reduction of pain scores (MD 4.30, 95% CI 2.69 to 5.91; one study; 75 participants; very low‐certainty evidence). In adults with osteoarthritis of the knee, we do not know whether pine bark extract decreases composite Western Ontario and McMaster Universities Osteoarthritis Index scores (MD ‐730.00, 95% CI ‐1011.95 to ‐448.05; one study; 37 participants; very low‐certainty evidence) or the use of non‐steroidal anti‐inflammatory medication (MD ‐18.30, 95% CI ‐25.14 to ‐11.46; one study; 35 participants; very low‐certainty evidence). We do not know whether pine bark extract increases bone alkaline phosphatase in post‐menopausal women with osteopenia (MD 1.16 ug/L, 95% CI ‐2.37 to 4.69; one study; 40 participants; very low‐certainty evidence). In individuals with traumatic brain injury, we do not know whether pine bark extract decreases cognitive failure scores (MD ‐2.24, 95% CI ‐11.17 to 6.69; one study; 56 participants; very low‐certainty evidence) or post‐concussion symptoms (MD ‐0.76, 95% CI ‐5.39 to 3.87; one study; 56 participants; very low‐certainty evidence). For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. Authors' conclusions Small sample sizes, limited numbers of RCTs per condition, variation in outcome measures, and poor reporting of the included RCTs mean no definitive conclusions regarding the efficacy or safety of pine bark extract supplements are possible. Plain language summary Using pine bark supplements to help treat a variety of chronic diseases Review question Can pine bark antioxidant supplements help to treat chronic diseases? Background The main ingredients in pine bark extract supplements are proanthocyanidins, which are antioxidants. These supplements are marketed to prevent or treat a wide range of chronic diseases. This is an update of a previously published review, where we assessed how well these supplements work for treating chronic diseases, as well as their safety. Search date The evidence is current to 30 September 2019. Study characteristics We included 27 studies (1641 participants) across 10 chronic diseases. These included: asthma (two studies; 86 participants), attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), heart disease and risk factors (seven studies; 332 participants), chronic venous insufficiency (leg veins not working effectively; two studies; 60 participants), diabetes (six studies; 336 participants), erectile dysfunction (three studies; 227 participants), female sexual dysfunction (one study; 75 participants), osteoarthritis (cartilage damage in joints; three studies; 293 participants), osteopenia (beginning of bone mass loss; one study; 44 participants) and traumatic brain injury (one study; 56 participants). Two of the studies were conducted exclusively in children; the others were in adults. Studies compared pine bark supplements with placebo (i.e. a dummy supplement) or non‐antioxidant interventions and participants were randomly selected for one treatment or the other. The duration of treatment ranged from four weeks to six months. Key results For most outcomes across the different chronic diseases we only included one study with a small number of participants. In adults with asthma, we do not know whether pine bark extract increases lung function, improves asthma symptoms or increases the number of people able to stop using albuterol inhalers (a specific type of asthma pump).
In children with ADHD, we do not know whether pine bark supplements decrease inattention and hyperactivity (assessed by parents and teachers) or whether it increases co‐ordination and concentration.
In people with heart disease we do not know if pine bark supplements decrease blood pressure and LDL cholesterol (the bad type) or whether it increases HDL cholesterol (the good type).
In adults with chronic venous insufficiency we do not know whether pine bark supplements decrease pain, increase the number of people free of pain, or how well doctors think the treatment works. In people with type 2 diabetes, we do not know whether pine bark supplements improve blood sugar levels or HbA1c levels (the long‐term marker for measuring blood sugar control); we also do not know if pine bark supplements decrease HbA1c in people with type 1 or type 2 diabetes.
In men with erectile dysfunction, we do not know if pine bark supplements increase erectile function. Similarly, in women with sexual dysfunction, we do not know if pine bark supplements increase sexual satisfaction or reduce pain.
In adults with osteoarthritis, it is not clear if pine bark supplements improve pain, swelling or stiffness in the knee, or whether it decreases the use of anti‐inflammatory drugs. We also do not know if pine bark supplements increase bone formation in postmenopausal women with weakened bones. Lastly, in people with a traumatic brain injury, it is not clear if pine bark supplements improve memory and post‐concussion symptoms . For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. With the available studies, we cannot clearly say how well (or not) pine bark supplements work and whether they are safe. Quality of the evidence The overall risk of bias was low for four studies, high for one and unclear for 22 studies. By this we mean the extent to which the methods used in a study enable it to determine the truth. The certainty of evidence was very low for all outcomes across all chronic diseases in the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Robertson, NU; Schoonees, A; Brand, A; Visser, J", "articleTypes": [], "doi": "10.1002/14651858.CD008294.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "2c5d32df-9d4c-4469-9d0a-b85e5be778ea", "pmid": "", "title": "Interventions for deliberately altering blood pressure in acute stroke", "imported": false, "abstract": "Abstract - Background It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001 and 2008. Objectives To assess the clinical effectiveness of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke. Search methods We searched the Cochrane Stroke Group Trials Register (last searched in February 2014), the Cochrane Database of Systematic reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 2), MEDLINE (Ovid) (1966 to May 2014), EMBASE (Ovid) (1974 to May 2014), Science Citation Index (ISI, Web of Science, 1981 to May 2014) and the Stroke Trials Registry (searched May 2014). Selection criteria Randomised controlled trials of interventions that aimed to alter blood pressure compared with control in participants within one week of acute ischaemic or haemorrhagic stroke. Data collection and analysis Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data. The review authors cross‐checked data and resolved discrepancies by discussion to reach consensus. We obtained published and unpublished data where available. Main results We included 26 trials involving 17,011 participants (8497 participants were assigned active therapy and 8514 participants received placebo/control). Not all trials contributed to each outcome. Most data came from trials that had a wide time window for recruitment; four trials gave treatment within six hours and one trial within eight hours. The trials tested alpha‐2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide‐like diuretics, and target‐driven blood pressure lowering. One trial tested phenylephrine. At 24 hours after randomisation oral ACEIs reduced systolic blood pressure (SBP, mean difference (MD) ‐8 mmHg, 95% confidence interval (CI) ‐17 to 1) and diastolic blood pressure (DBP, MD ‐3 mmHg, 95% CI ‐9 to 2), sublingual ACEIs reduced SBP (MD ‐12.00 mm Hg, 95% CI ‐26 to 2) and DBP (MD ‐2, 95%CI ‐10 to 6), oral ARA reduced SBP (MD ‐1 mm Hg, 95% CI ‐3 to 2) and DBP (MD ‐1 mm Hg, 95% CI ‐3 to 1), oral beta blockers reduced SBP (MD ‐14 mm Hg; 95% CI ‐27 to ‐1) and DBP (MD ‐1 mm Hg, 95% CI ‐9 to 7), intravenous (iv) beta blockers reduced SBP (MD ‐5 mm Hg, 95% CI ‐18 to 8) and DBP (‐5 mm Hg, 95% CI ‐13 to 3), oral CCBs reduced SBP (MD ‐13 mmHg, 95% CI ‐43 to 17) and DBP (MD ‐6 mmHg, 95% CI ‐14 to 2), iv CCBs reduced SBP (MD ‐32 mmHg, 95% CI ‐65 to 1) and DBP (MD ‐13, 95% CI ‐31 to 6), NO donors reduced SBP (MD ‐12 mmHg, 95% CI ���19 to ‐5) and DBP (MD ‐3, 95% CI ‐4 to ‐2) while phenylephrine, non‐significantly increased SBP (MD 21 mmHg, 95% CI ‐13 to 55) and DBP (MD 1 mmHg, 95% CI ‐15 to 16). Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05), stroke type (OR 0.98, 95% CI 0.92 to 1.05) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05). Treatment within six hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99) but not death (OR 0.70, 95% CI 0.38 to 1.26) at the end of the trial. Although death or dependency did not differ between people who continued pre‐stroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24), disability scores at the end of the trial were worse in participants randomised to continue treatment (Barthel Index, MD ‐3.2, 95% CI ‐5.8, ‐0.6). Authors' conclusions There is insufficient evidence that lowering blood pressure during the acute phase of stroke improves functional outcome. It is reasonable to withhold blood pressure‐lowering drugs until patients are medically and neurologically stable, and have suitable oral or enteral access, after which drugs can than be reintroduced. In people with acute stroke, CCBs, ACEI, ARA, beta blockers and NO donors each lower blood pressure while phenylephrine probably increases blood pressure. Further trials are needed to identify which people are most likely to benefit from early treatment, in particular whether treatment started very early is beneficial. Plain language summary Drug interventions for deliberately altering blood pressure in acute stroke Background: In people who have just had a stroke (a sudden brain attack due to either blockage or rupture of an artery in the brain), very high and very low blood pressures may be harmful. Therefore, drugs that raise low blood pressure or lower high blood pressure might be beneficial. Up to 50% of people admitted with acute stroke are taking blood pressure tablets on hospital admission and it is not clear whether these medications should be continued or discontinued in the acute situation. This review looked at those trials that deliberately altered blood pressure or compared continuing or stopping blood pressure‐lowering tablets taken before stroke. Study characteristics: This review is up‐to‐date to May 2014. We included 26 trials involving 17,011 participants: 24 trials assessed lowering blood pressure, one trial tested raising blood pressure, and two trials assessed what to do with drugs taken before stroke. All studies took place in hospitals that were used to treating people with stroke. Not all trials contributed information to all outcomes, and we have used data that were available in publications. Key results: There is insufficient evidence to say that lowering blood pressure saves lives or reduces disability in people with acute stroke. Immediately restarting blood pressure‐lowering drugs taken before the stroke may increase disability. Conclusion: More research is needed to identify those people who are most likely to benefit from altering blood pressure in acute stroke, the time window in which the treatment is likely to be of benefit, what types of stroke are likely to respond favourably, and the environment in which such treatment may be best given in routine practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bath, PMW, Krishnan, K", "articleTypes": [], "doi": "10.1002/14651858.CD000039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.065Z" }, { "id": "2c63ec35-5710-49de-bc8d-ad53b4cc4064", "pmid": "", "title": "A Randomized Cross-Over Study to Investigate the Effect of the Non-Nutritive Sweetener Sucralose on Glucose Metabolism in Patients with Type 1 Diabetes", "imported": false, "abstract": "The goal of this randomized crossover study is to test the prediction that consuming carbohydrates will affect insulin release differently depending on whether Non-Nutritive Sweeteners (NNSs) are consumed simultaneously. We aim to determine whether the predicted effects are associated with oral or post-oral sweet taste receptor signaling,. Our study will focus on patients diagnosed with type 1 diabetes (T1D) who are using an artificial pancreas (AP) system, as it allows us to monitor glucose and insulin levels over time.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.233Z" }, { "id": "2c8415cb-2496-44eb-9e29-0ee3647cceb1", "pmid": "", "title": "Oral Astragalus (Huang qi) for preventing frequent episodes of acute respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common in children and can involve both upper and lower airways. Many children experience frequent ARTI episodes or recurrent respiratory tract infections (RRTIs) in early life, which creates challenges for paediatricians, primary care physicians, parents and carers of children. In China, Astragalus (Huang qi), alone or in combination with other herbs, is used by Traditional Chinese Medicine (TCM) practitioners in the form of a water extract, to reduce the risk of ARTIs; it is believed to stimulate the immune system. Better understanding of the therapeutic mechanisms of Astragalus may provide insights into ARTI prevention, and consequently reduced antibiotic use. Objectives To assess the effectiveness and safety of oral Astragalus for preventing frequent episodes of acute respiratory tract infections (ARTIs) in children in community settings. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2015), MEDLINE (Ovid) (1946 to 31 December 2015), Embase (Elsevier) (1974 to 31 December 2015), AMED (Ovid) (1985 to 31 December 2015), Chinese National Knowledge Infrastructure (CNKI) (1979 to 31 December 2015) and Chinese Scientific Journals full text database (CQVIP) (1989 to 31 December 2015), China Biology Medicine disc (CBM 1976 to 31 December 2015) and Wanfang Data Knowledge Service Platform (WanFang) (1998 to 31 December 2015). Selection criteria We included randomised controlled trials (RCTs) comparing oral Astragalus as a sole Chinese herbal preparation with placebo to prevent frequent episodes of ARTIs in children. Data collection and analysis We used standard Cochrane methodological procedures for this review. We assessed search results to identify relevant studies. We planned to extract data using standardised forms. Disagreements were to be resolved through discussion. Risk of bias was to be assessed using the Cochrane 'Risk of bias' tool. We planned to use mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) or odds ratio (OR) to analyse dichotomous data, both with 95% confidence intervals (CIs). Main results We identified 6080 records: 3352 from English language databases, 2724 from Chinese databases, and four from other sources. Following initial screening and deduplication, we obtained 120 full‐text papers for assessment. Of these, 21 were not RCTs; 55 did not meet the inclusion criteria because: participants were aged over 14 years; definition was not included for recurrent or frequent episodes; Astragalus preparation was not an intervention; Astragalus preparation was in the formula but was not the sole agent; the Astragalus preparation was not administered orally; or Astragalus was used for treatment rather than prevention of ARTI. A further 44 studies were excluded because they were not placebo‐controlled, although other inclusion criteria were fulfilled. No RCTs met our inclusion criteria. Authors' conclusions We found insufficient evidence to enable assessment of the effectiveness and safety of oral Astragalus as a sole intervention to prevent frequent ARTIs in children aged up to 14 years. Plain language summary Can oral Astragalus (Huang qi) prevent frequent acute respiratory tract infections in children? Review question We assessed evidence for the benefits and harms of oral Astragalus used alone to prevent frequent episodes of acute respiratory infections (ARTIs) in children aged up to 14 years, compared to a dummy treatment. ARTIs include colds, sore throats, laryngitis, influenza, bronchitis and pneumonia. Background Many therapies are used to prevent ARTIs, especially in children. Astragalus, is a widely used and available herbal therapy that has been used for thousands of years in China to help prevent ARTIs. It is thought to boost immunity. Almost one in five children experience frequent ARTIs and treatment accounts for up to 75% of all prescribed antibiotics for children. Because most ARTIs are caused by viruses, antibiotics are not effective in treating these illnesses. Search date We searched the literature up to 31 December 2015. Study characteristics We identified 6080 potentially relevant records. After removing duplicate records, and those that did not meet our inclusion criteria, we obtained 120 full‐text studies. We carefully assessed these studies for possible inclusion. We excluded most studies because: they presented unclear diagnosis criteria; Astragalus preparation was used with other agents; or Astragalus was not compared with a dummy treatment. No studies met our inclusion criteria and so we were unable to analyse any results. Study funding sources We could not assess study funding sources. Key results We did not find any studies that compared use of oral Astragalus alone with a dummy treatment to prevent frequent episodes of ARTI in children aged up to 14 years. Well‐designed, conducted and reported studies investigating this issue are needed to enable assessment in the future. Quality of the evidence We could not assess evidence quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Su, G; Chen, X; Liu, Z; Yang, L; Zhang, L; Stålsby Lundborg, C; Wen, Z; Guo, X; Qin, X; Liang, J; Liu, X", "articleTypes": [], "doi": "10.1002/14651858.CD011958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "2c8ef32b-096b-467f-a7cb-8fae8753740e", "pmid": "", "title": "Chloroquine or hydroxychloroquine for prevention and treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The coronavirus disease 2019 (COVID‐19) pandemic has resulted in substantial mortality. Some specialists proposed chloroquine (CQ) and hydroxychloroquine (HCQ) for treating or preventing the disease. The efficacy and safety of these drugs have been assessed in randomized controlled trials. Objectives To evaluate the effects of chloroquine (CQ) or hydroxychloroquine (HCQ) for 1) treating people with COVID‐19 on death and time to clearance of the virus; 2) preventing infection in people at risk of SARS‐CoV‐2 exposure; 3) preventing infection in people exposed to SARS‐CoV‐2. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Current Controlled Trials (www.controlled‐trials.com), and the COVID‐19‐specific resources www.covid‐nma.com and covid‐19.cochrane.org, for studies of any publication status and in any language. We performed all searches up to 15 September 2020. We contacted researchers to identify unpublished and ongoing studies. Selection criteria We included randomized controlled trials (RCTs) testing chloroquine or hydroxychloroquine in people with COVID‐19, people at risk of COVID‐19 exposure, and people exposed to COVID‐19. Adverse events (any, serious, and QT‐interval prolongation on electrocardiogram) were also extracted. Data collection and analysis Two review authors independently assessed eligibility of search results, extracted data from the included studies, and assessed risk of bias using the Cochrane ‘Risk of bias’ tool. We contacted study authors for clarification and additional data for some studies. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). We performed meta‐analysis using a random‐effects model for outcomes where pooling of effect estimates was appropriate. Main results 1. Treatment of COVID‐19 disease We included 12 trials involving 8569 participants, all of whom were adults. Studies were from China (4); Brazil, Egypt, Iran, Spain, Taiwan, the UK, and North America (each 1 study); and a global study in 30 countries (1 study). Nine were in hospitalized patients, and three from ambulatory care. Disease severity, prevalence of comorbidities, and use of co‐interventions varied substantially between trials. We found potential risks of bias across all domains for several trials. Nine trials compared HCQ with standard care (7779 participants), and one compared HCQ with placebo (491 participants); dosing schedules varied. HCQ makes little or no difference to death due to any cause (RR 1.09, 95% CI 0.99 to 1.19; 8208 participants; 9 trials; high‐certainty evidence). A sensitivity analysis using modified intention‐to‐treat results from three trials did not influence the pooled effect estimate. HCQ may make little or no difference to the proportion of people having negative PCR for SARS‐CoV‐2 on respiratory samples at day 14 from enrolment (RR 1.00, 95% CI 0.91 to 1.10; 213 participants; 3 trials; low‐certainty evidence). HCQ probably results in little to no difference in progression to mechanical ventilation (RR 1.11, 95% CI 0.91 to 1.37; 4521 participants; 3 trials; moderate‐certainty evidence). HCQ probably results in an almost three‐fold increased risk of adverse events (RR 2.90, 95% CI 1.49 to 5.64; 1394 participants; 6 trials; moderate‐certainty evidence), but may make little or no difference to the risk of serious adverse events (RR 0.82, 95% CI 0.37 to 1.79; 1004 participants; 6 trials; low‐certainty evidence). We are very uncertain about the effect of HCQ on time to clinical improvement or risk of prolongation of QT‐interval on electrocardiogram (very low‐certainty evidence). One trial (22 participants) randomized patients to CQ versus lopinavir/ritonavir, a drug with unknown efficacy against SARS‐CoV‐2, and did not report any difference for clinical recovery or adverse events. One trial compared HCQ combined with azithromycin against standard care (444 participants). This trial did not detect a difference in death, requirement for mechanical ventilation, length of hospital admission, or serious adverse events. A higher risk of adverse events was reported in the HCQ‐and‐azithromycin arm; this included QT‐interval prolongation, when measured. One trial compared HCQ with febuxostat, another drug with unknown efficacy against SARS‐CoV‐2 (60 participants). There was no difference detected in risk of hospitalization or change in computed tomography (CT) scan appearance of the lungs; no deaths were reported. 2. Preventing COVID‐19 disease in people at risk of exposure to SARS‐CoV‐2 Ongoing trials are yet to report results for this objective. 3. Preventing COVID‐19 disease in people who have been exposed to SARS‐CoV‐2 One trial (821 participants) compared HCQ with placebo as a prophylactic agent in the USA (around 90% of participants) and Canada. Asymptomatic adults (66% healthcare workers; mean age 40 years; 73% without comorbidity) with a history of exposure to people with confirmed COVID‐19 were recruited. We are very uncertain about the effect of HCQ on the primary outcomes, for which few events were reported: 20/821 (2.4%) developed confirmed COVID‐19 at 14 days from enrolment, and 2/821 (0.2%) were hospitalized due to COVID‐19 (very low‐certainty evidence). HCQ probably increases the risk of adverse events compared with placebo (RR 2.39, 95% CI 1.83 to 3.11; 700 participants; 1 trial; moderate‐certainty evidence). HCQ may result in little or no difference in serious adverse events (no RR: no participants experienced serious adverse events; low‐certainty evidence). One cluster‐randomized trial (2525 participants) compared HCQ with standard care for the prevention of COVID‐19 in people with a history of exposure to SARS‐CoV‐2 in Spain. Most participants were working or residing in nursing homes; mean age was 49 years. There was no difference in the risk of symptomatic confirmed COVID‐19 or production of antibodies to SARS‐CoV‐2 between the two study arms. Authors' conclusions HCQ for people infected with COVID‐19 has little or no effect on the risk of death and probably no effect on progression to mechanical ventilation. Adverse events are tripled compared to placebo, but very few serious adverse events were found. No further trials of hydroxychloroquine or chloroquine for treatment should be carried out. These results make it less likely that the drug is effective in protecting people from infection, although this is not excluded entirely. It is probably sensible to complete trials examining prevention of infection, and ensure these are carried out to a high standard to provide unambiguous results. Plain language summary Is chloroquine or hydroxychloroquine useful in treating people with COVID‐19, or in preventing infection in people who have been exposed to the virus? What is the aim of this review? COVID‐19 is an infectious respiratory disease caused by a coronavirus called SARS‐CoV‐2. If the infection becomes severe, people may need intensive care and support in hospital, including mechanical ventilation. Drugs used for other diseases were tried out in COVID‐19, and this included chloroquine, used for malaria; and hydroxychloroquine used for rheumatic diseases, such as rheumatoid arthritis or systemic lupus erythematosus. We sought evidence of the effects of these drugs in treating people ill with the disease; in preventing the disease in people at risk of getting the disease, such as health workers; and people exposed to the virus developing the disease. Key messages Hydroxychloroquine does not reduce deaths from COVID‐19, and probably does not reduce the number of people needing mechanical ventilation. Hydroxychloroquine caused more unwanted effects than a placebo treatment, though it did not appear to increase the number of serious unwanted effects. We do not think new studies of hydroxychloroquine should be started for treatment of COVID‐19. What was studied in the review? We searched for studies that looked at giving chloroquine and hydroxychloroquine to people with COVID‐19; people at risk of being exposed to the virus; and people who have been exposed to the virus. We found 14 relevant studies: 12 studies of chloroquine or hydroxychloroquine used to treat COVID‐19 in 8569 adults; two studies of hydroxychloroquine to stop COVID‐19 in 3346 adults who had been exposed to the virus but had no symptoms of infection. We did not find any completed studies of these medicines to stop COVID‐19 in people who were at risk of exposure to the virus; studies are still under way. The studies took place in China, Brazil, Egypt, Iran, Taiwan, North America, and Europe; one study was worldwide. Some studies were partly funded by pharmaceutical companies that manufacture hydroxychloroquine. What are the main results of our review? Treating COVID‐19 Compared with usual care or placebo, hydroxychloroquine: · clearly did not affect how many people died (of any cause; 9 studies in 8208 people); · probably did not affect how many people needed mechanical ventilation (3 studies; 4521 people); · may not affect how many people still tested positive for the virus after 14 days (3 studies; 213 people). We are uncertain whether hydroxychloroquine affected the number of people whose symptoms improved after 28 days. Compared with other antiviral treatment (lopinavir plus ritonavir), chloroquine made little or no difference to the time taken for symptoms to improve (1 study; 22 people). Compared with usual care in one study in 444 people, hydroxychloroquine given with azithromycin (an antibiotic) made no difference to: · how many people died; · how many needed mechanical ventilation; or · time spent in hospital. Compared with febuxostat (a medicine to treat gout), hydroxychloroquine made no difference to how many people were admitted to hospital or to changes seen on scans of people's lungs; no deaths were reported (1 study; 60 people). Preventing COVID‐19 in people exposed to it We are uncertain whether hydroxychloroquine affected how many people developed COVID‐19, or how many people were admitted to hospital with COVID‐19, compared with those receiving a placebo treatment (1 study; 821 people). Compared with usual care, hydroxychloroquine made no difference to the risk of developing COVID‐19, or antibodies to the virus, in people exposed to it (1 study; 2525 people). Unwanted effects When used for treating COVID‐19, compared with usual care or placebo, hydroxychloroquine: · probably increases the risk of mild unwanted effects (6 studies; 1394 people); · may not increase the risk of serious harmful effects (6 studies; 1004 people). When given along with azithromycin, hydroxychloroquine increased the risk of any unwanted effects, but made no difference to the risk of serious unwanted effects (1 study; 444 people). Compared with lopinavir plus ritonavir, chloroquine made little or no difference to the risk of unwanted effects (1 study; 22 people). When used for preventing COVID‐19, hydroxychloroquine probably causes more unwanted effects than placebo, but may not increase the risk of serious, harmful unwanted effects (1 study; 700 people). How confident are we in our results? We are confident about our results for how many people died and moderately confident about how many needed mechanical ventilation. We are moderately confident about the unwanted effects of hydroxychloroquine treatment, but less confident about our results for serious unwanted effects; these results might change with further evidence. How up‐to‐date is this review? We included evidence published up to 15 September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Singh, B, Ryan, H, Kredo, T, Chaplin, M, Fletcher, T", "articleTypes": [], "doi": "10.1002/14651858.CD013587.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.782Z" }, { "id": "2cabf9e5-20d3-449d-95f2-333612aec986", "pmid": "", "title": "Antiviral treatment for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gagyor, I, Madhok, VB, Daly, F, Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001869.pub9 AB - Abstract - Background Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. This review was first published in 2001 and most recently updated in 2015. Since a significant benefit of corticosteroids for the early management of Bell's palsy has been demonstrated, the main focus of this update, as in the previous version, was to determine the effect of adding antivirals to corticosteroid treatment. We undertook this update to integrate additional evidence and to better assess the robustness of findings, taking risk of bias fully into account. Objectives To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy. Search methods We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS in July 2019. We reviewed the bibliographies of the identified trials and contacted trial authors to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies. Selection criteria We considered randomised controlled trials (RCTs) or quasi‐RCTs of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that followed‐up participants for less than three months. Data collection and analysis We independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures. We performed sensitivity analyses excluding trials at high or unclear risk of bias in at least five domains, and reported these data as the primary analyses. Main results Fourteen trials, including 2488 participants, met the inclusion criteria. Most were small, and most were at high or unclear risk of bias in multiple domains. We included four new studies at this update. Incomplete recovery A combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in people with Bell's palsy compared to corticosteroids alone (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.38 to 1.74; 3 trials, N = 766; random‐effects; low‐certainty evidence). We excluded 10 trials that were at high or unclear risk of bias in several domains from this analysis and limited all analyses to studies at lower risk of bias. Recovery rates were better in participants receiving corticosteroids alone than antivirals alone (RR 2.69, 95% CI 0.73 to 10.01; 2 trials, N = 667; random‐effects), but the result was imprecise and allowed for the possibility of no effect. The rate of incomplete recovery was lower with antivirals plus corticosteroids than with placebo or no treatment (RR 0.56, 95% CI 0.42 to 0.76; 2 trials, N = 658; random‐effects). Antivirals alone had no clear effect on incomplete recovery rates compared with placebo, but the result was imprecise (RR 1.10, 95% CI 0.87 to 1.40; 2 trials, N = 658; fixed‐effect). For people with severe Bell's palsy (House‐Brackmann score of 5 and 6, or equivalent on other scales), we found that the combination of antivirals and corticosteroids had no clear effect on incomplete recovery at month six compared to corticosteroids alone, although the result was again imprecise (RR 0.82, 95% CI 0.57 to 1.17; 2 trials, N = 98; random‐effects). Motor synkinesis or crocodile tears Antivirals plus corticosteroids reduced the proportion of participants who experienced these long‐term sequelae from Bell's palsy compared to placebo plus corticosteroids (RR 0.56, 95% CI 0.36 to 0.87; 2 trials, N = 469; fixed‐effect; moderate‐certainty evidence). Antivirals plus corticosteroids reduced long‐term sequelae compared to placebo but there was no clear difference in this outcome with antivirals alone compared to placebo. Adverse events Adverse event data were available in four studies providing data on 1592 participants. None of the four comparisons showed clear differences in adverse events between treatment and comparison arms (very low‐certainty evidence); for the comparison of antivirals plus corticosteroids and corticosteroids alone in studies at lower risk of bias, the RR was 1.17 (95% CI 0.81 to 1.69; 2 trials, N = 656; fixed‐effect; very low‐certainty evidence). Authors' conclusions The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, or in people with severe Bell's palsy, but the results were very imprecise. Corticosteroids alone were probably more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no clear benefit from antivirals alone over placebo. The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone. Studies also showed fewer episodes of long‐term sequelae in corticosteroid‐treated participants than antiviral‐treated participants. We found no clear difference in adverse events from the use of antivirals compared with either placebo or corticosteroids, but the evidence is too uncertain for us to draw conclusions. An adequately powered RCT in people with Bell’s palsy that compares different antiviral agents may be indicated. Plain language summary Antiviral treatment for Bell's palsy Review question We reviewed the evidence about the effect of antiviral therapy (drugs used specifically to treat viral infections), alone or in combination with any other therapy, on Bell's palsy. Our focus in this updated review was combined therapy with antiviral drugs and corticosteroids (which are drugs used to reduce inflammation) as there is already good evidence that corticosteroids can reduce rates of incomplete recovery from Bell's palsy. Background Bell's palsy is a disease of the facial nerve that causes one side of the face to be paralysed. Some studies have suggested that it is caused by the same viral infections that cause cold sores or shingles and investigated the effect of antiviral therapy. Earlier versions of this review have found that antivirals alone are not helpful compared to a dummy pill, and are less effective than corticosteroids alone. However, studies of antiviral treatment in combination with corticosteroids have conflicting results. Study characteristics We identified 14 trials, which included 2488 participants with mild, moderate, or severe one‐sided Bell's palsy of unknown cause. Participants were aged from 14 to 84 years. The trials compared:
 ‐ antivirals plus corticosteroids to corticosteroids alone or in combination with placebo;
 ‐ antivirals alone or in combination with placebo to placebo or no treatment;
 ‐ antivirals alone or in combination with placebo to corticosteroid treatment alone or in combination with placebo; or
 ‐ antivirals plus corticosteroids to placebo or no treatment. For the majority of the studies, no information on funding was given. The remaining were mostly partly public funded, and one trial was funded by a pharmaceutical company. Eleven studies had high or uncertain risk of bias from various factors that can systematically affect trial results. We chose to base our conclusions only on data from three studies at a lower risk of bias. Key results and certainty of the evidence The review showed that there may be no clear difference in rates of incomplete recovery from Bell's palsy after treatment with the combination of antivirals and corticosteroids, compared to corticosteroids alone. This finding was of low certainty and was based on data from three trials involving 766 people with Bell's palsy of various degrees of severity. We excluded data from 10 trials with multiple potential sources of bias. However, we can be moderately confident that the combined therapy reduced the number of people left with long‐term effects of Bell's palsy (excessive tearing of the eyes or an abnormal facial movement) compared to corticosteroid treatment alone. Data from two studies (98 participants) showed that in people with severe Bell's palsy (complete or almost complete facial paralysis), combined antivirals and corticosteroids had no clear effect on recovery compared with corticosteroid treatment alone. Corticosteroids alone were more effective than antivirals alone on rates of incomplete recovery (667 participants, 2 trials); antivirals and corticosteroids combined were more effective than placebo or no treatment (658 participants, 2 trials); and there was no clear benefit from antivirals alone over placebo (658 participants, 2 trials). Although, based on data from two trials (656 participants), we found no clear difference in the occurrence of side effects between people receiving both antivirals and corticosteroids, compared to those receiving corticosteroids alone, this evidence is too uncertain for us to draw conclusions. Large studies in people with Bell's palsy comparing additional antiviral agents may be indicated in the future.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.759Z" }, { "id": "2cda7e6f-5f81-40d6-b2b4-026eaebb9ea6", "pmid": "", "title": "Brexpiprazole versus placebo or other antidepressive agents for treating depression", "imported": false, "abstract": "Abstract - Background Brexpiprazole is the newest antipsychotic drug approved as an adjunctive for treatment‐resistant depression. This systematic review provides comprehensive, high‐quality evidence for the effects of brexpiprazole in major depressive disorder (MDD) based on existing and emerging randomised controlled trials (RCTs). Objectives To evaluate the benefits and harms of brexpiprazole as monotherapy or adjunct treatment in the acute and longer‐term treatment of MDD compared to placebo or other antidepressive agents. Search methods We used standard, extensive Cochrane search methods. The latest search date was November 2021. Selection criteria We included RCTs in people with a history of non‐response to one or more antidepressant monotherapies comparing brexpiprazole as monotherapy or adjunct treatment with placebo or other antidepressive agents. Data collection and analysis We used standard Cochrane methods. Primary outcomes were 1. response to treatment, measured as number of participants who achieved 50% or more reduction of the score on a validated scale for depression, 2. dropouts due to any reason, and 3. dropouts due to adverse effects, all measured at eight weeks (acute treatment). Our secondary outcomes were 4. number of participants who responded to treatment after two and 18 weeks, number of participants who achieved remission after eight weeks, 5. total number of participants with any adverse events, 6. social functioning or adjustment, and 7. health‐related quality of life. We used GRADE to assess certainty of evidence for each outcome. Main results We retrieved nine studies with 3424 participants with treatment‐resistant depression, defined as lack of response to at least two trials of antidepressant monotherapy. The age of participants was 18 to 65 years in seven studies, 18 to 75 years in one study, and older than 65 years in one study. Inclusion criteria for all studies required a diagnosis of MDD with a current major depressive episode per Diagnostic and Statistical Manual of Mental Disorders Text Revision Fourth Edition criteria and additional criteria on minimal scores on Montgomery–Åsberg Depression Rating Scale (MADRS) and Hamilton Depression Rating Scale which varied across studies. Eight studies compared brexpiprazole as adjunctive treatment to an antidepressant versus placebo as adjunctive treatment to an antidepressant. One study added brexpiprazole or placebo to a combination of antidepressant and ketamine. Four studies used fixed dosages and five studies used flexible dosages of brexpiprazole. The manufacturer sponsored eight studies and one study was independently funded. Brexpiprazole was superior in achieving response at eight weeks (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.23 to 1.75; 8 studies, 3409 participants; high‐certainty evidence). More participants randomised to brexpiprazole dropped out due to any cause at eight weeks (OR 1.37, 95% CI 1.02 to 1.83; 7 studies, 2523 participants; high‐certainty evidence) or due to adverse effects (OR 2.88, 95% CI 1.37 to 6.05; 6 studies, 2472 participants; high‐certainty evidence). Brexpiprazole was superior to placebo when added to an antidepressant for achieving remission at eight weeks (OR 1.46, 95% CI 1.19 to 1.79; 7 studies, 3358 participants; high‐certainty evidence). When response was defined based on a change in the score on MADRS, brexpiprazole also demonstrated better efficacy than placebo (mean difference (MD) –1.39, 95% CI –1.96 to –0.82; 8 studies, 3263 participants; high‐certainty evidence). Compared to placebo, add‐on brexpiprazole is probably more likely to result in akathisia (OR 2.95, 95% CI 2.06 to 4.21; 7 studies, 3358 participants; moderate‐certainty evidence) and weight gain (OR 3.14, 95% CI 2.19 to 4.49; 9 studies, 3424 participants; moderate‐certainty evidence). The risk of bias varied between low and unclear for most studies. Only one study was at high risk of selective reporting bias and other bias; however, this study had a small sample size and its impact on overall risk of bias was not considered significant. The certainty of the evidence on five of the main outcomes (response to treatment, measured as number of participants who achieved response and change in depressive symptoms, remission, dropouts due to any cause, dropouts due to adverse effects) was high. The certainty of evidence for akathisia and weight gain was downgraded one level to moderate due to indirectness. Authors' conclusions Our review supports the superior efficacy of add‐on brexpiprazole in comparison to placebo in adults with treatment‐resistant depression for the short‐term and acute treatment of depression. Our findings were limited by the small number of studies and the moderate‐certainty evidence for the most common adverse effects (akathisia and weight gain). There was insufficient evidence for the effects of brexpiprazole for depression in older people or children. In addition, we found no studies that compared brexpiprazole to other antidepressants or where brexpiprazole was added after lack of response to only one antidepressant. We also lacked sufficient data to establish the long‐term efficacy of brexpiprazole as adjunctive treatment. Active comparators, long‐term studies in different age groups and cost‐effect analyses are needed to more precisely establish the clinical role of brexpiprazole in the treatment of MDD. Plain language summary What are the benefits and harms of brexpiprazole, a new antipsychotic medication, for the treatment of depression when compared to dummy tablets or antidepressants? Key messages – Brexpiprazole added to an antidepressant is better at reducing the symptoms of depression than placebo (dummy tablet) added to an antidepressant. – Brexpiprazole might be more commonly associated with weight gain and akathisia (a feeling of restlessness that causes a compelling need to move all the time). What is depression? Depression is a common mental health condition which leads to low mood, inability to experience pleasure, sleep disruption, weight loss, fatigue or low energy, slower speech and movements, feeling worthless or excessively guilty, being unable to concentrate and having thoughts of committing suicide. To be diagnosed with depression, a person should experience five or more of these symptoms, including low mood or loss of sense of pleasure for at least two weeks. How is the condition treated? Unless the symptoms of depression are mild, the first option for treatment is an antidepressant medication, but antidepressants only help in half of cases when prescribed for the first time. When an antidepressant is not enough to treat depression, one available option is to add another medication to help the effects of the antidepressant. Other options include changing the antidepressant to another antidepressant, talking therapy or stimulation of the brain through electrical pulses. Brexpiprazole is a new medication which can be added to an antidepressant that has not worked by itself. Brexpiprazole can be prescribed in doses from 0.5 mg to 3 mg for the treatment of depression. It has also been approved for the treatment of schizophrenia. What did we want to find out? We wanted to examine the effects of brexpiprazole in the treatment of depression when prescribed by itself or when added to another antidepressant and how its effects compare to the effects of antidepressants or placebo. To do so we explored several effects. First, we looked into how well brexpiprazole decreased the symptoms of depression. Second, we explored how many participants gave up taking part in the studies for any reason. Third, we investigated how many stopped participating because of the unwanted effects they experienced. Fourth, we explored what unwanted effects emerged with the use of brexpiprazole. We also wanted to know how brexpiprazole affected the quality of life of the participants and how it affected the way they functioned in their everyday lives. What did we do? We searched scientific databases for studies that reported the effects of brexpiprazole versus placebo or antidepressants for depression. We included only studies in which the participants were assigned randomly to one or the other treatment. Neither them nor the team that was evaluating the effects of the treatment knew what was prescribed and this helped to objectively evaluate the results without the knowledge of what was prescribed impacting on the outcome. We compared and summarised the results and evaluated how confident we were that the results of the studies represented the real effects of the medication. We based our confidence on different factors such as the size of the effects, the methods used, and what and how the results were reported. What did we find and what were the limitations of our findings? We found nine studies, which included 3424 participants; two‐thirds of them were women and one‐third were men. We only found studies in which brexpiprazole was added after the participants had tried treatment with two or more antidepressants on their own. We have a high level of confidence that brexpiprazole added to an antidepressant reduced the symptoms of depression more after eight weeks of treatment than placebo added to an antidepressant. Brexpiprazole was also more likely to lead to no symptoms of depression than placebo when either of them was added to an antidepressant. We are moderately confident that brexpiprazole caused weight gain or subjective feelings of restlessness more often than placebo. We are less confident about the results around these unwanted effects as we could not find information about how they were measured and whether all studies used the same methods to measure them. What did we fail to find? We found no studies that explored how brexpiprazole would work for children or older people who have depression. We wanted to find how brexpiprazole would work when given for depression for longer periods of time, such as 18 to 24 weeks, but we found only one study and its results were not enough to draw a conclusion. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 1 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ralovska, S; Koychev, I; Marinov, P; Furukawa, TA; Mulsant, B; Cipriani, A", "articleTypes": [], "doi": "10.1002/14651858.CD013866.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "2cdefa8e-4f1a-48a9-af21-94d5e62c548d", "pmid": "", "title": "Oral anti‐diabetic pharmacological therapies for the treatment of women with gestational diabetes", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is a major public health issue with rates increasing globally. Gestational diabetes, glucose intolerance first recognised during pregnancy, usually resolves after birth and is associated with short‐ and long‐term complications for the mother and her infant. Treatment options can include oral anti‐diabetic pharmacological therapies. Objectives To evaluate the effects of oral anti‐diabetic pharmacological therapies for treating women with GDM. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (14 May 2016), ClinicalTrials.gov , WHO ICTRP (14 May 2016) and reference lists of retrieved studies. Selection criteria We included published and unpublished randomised controlled trials assessing the effects of oral anti‐diabetic pharmacological therapies for treating pregnant women with GDM. We included studies comparing oral anti‐diabetic pharmacological therapies with 1) placebo/standard care, 2) another oral anti‐diabetic pharmacological therapy, 3) combined oral anti‐diabetic pharmacological therapies. Trials using insulin as the comparator were excluded as they are the subject of a separate Cochrane systematic review. Women with pre‐existing type 1 or type 2 diabetes were excluded. Data collection and analysis Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and data were checked for accuracy. Main results We included 11 studies (19 publications) (1487 women and their babies). Eight studies had data that could be included in meta‐analyses. Studies were conducted in Brazil, India, Israel, UK, South Africa and USA. The studies varied in diagnostic criteria and treatment targets for glycaemic control for GDM. The overall risk of bias was 'unclear' due to inadequate reporting of methodology. Using GRADE the quality of the evidence ranged from moderate to very low quality . Evidence was downgraded for risk of bias (reporting bias, lack of blinding), inconsistency, indirectness, imprecision and for oral anti‐diabetic therapy versus placebo for generalisability. Oral anti‐diabetic pharmacological therapies versus placebo/standard care There was no evidence of a difference between glibenclamide and placebo groups for hypertensive disorders of pregnancy (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.81 to 1.90; one study, 375 women, very low‐quality evidence), birth by caesarean section (RR 1.03, 95% CI 0.79 to 1.34; one study, 375 women, very low‐quality evidence), perineal trauma (RR 0.98, 95% CI 0.06 to 15.62; one study, 375 women, very low‐quality evidence) or induction of labour (RR 1.18, 95% CI 0.79 to 1.76; one study, 375 women; very low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant, there was no evidence of a difference in the risk of being born large‐for‐gestational age (LGA) between infants whose mothers had been treated with glibenclamide and those in the placebo group (RR 0.89, 95% CI 0.51 to 1.58; one study, 375, low‐quality evidence). No data were reported for other infant primary or GRADE outcomes (perinatal mortality, death or serious morbidity composite, neurosensory disability in later childhood, neonatal hypoglycaemia, adiposity, diabetes). Metformin versus glibenclamide There was no evidence of a difference between metformin‐ and glibenclamide‐treated groups for the risk of hypertensive disorders of pregnancy (RR 0.70, 95% CI 0.38 to 1.30; three studies, 508 women, moderate‐quality evidence), birth by caesarean section (average RR 1.20, 95% CI 1.20; 95% CI 0.83 to 1.72, four studies, 554 women, I 2 = 61%, Tau 2 = 0.07 low‐quality evidence), induction of labour (0.81, 95% CI 0.61 to 1.07; one study, 159 women; low‐quality evidence) or perineal trauma (RR 1.67, 95% CI 0.22 to 12.52; two studies, 158 women; low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant there was no evidence of a difference between the metformin‐ and glibenclamide‐exposed groups for the risk of being born LGA (average RR 0.67, 95% CI 0.24 to 1.83; two studies, 246 infants, I 2 = 54%, Tau 2 = 0.30 low‐quality evidence). Metformin was associated with a decrease in a death or serious morbidity composite (RR 0.54, 95% CI 0.31 to 0.94; one study, 159 infants, low‐quality evidence). There was no clear difference between groups for neonatal hypoglycaemia (RR 0.86, 95% CI 0.42 to 1.77; four studies, 554 infants, low‐quality evidence) or perinatal mortality (RR 0.92, 95% CI 0.06 to 14.55, two studies, 359 infants). No data were reported for neurosensory disability in later childhood or for adiposity or diabetes. Glibenclamide versus acarbose There was no evidence of a difference between glibenclamide and acarbose from one study (43 women) for any of their maternal or infant primary outcomes (caesarean section, RR 0.95, 95% CI 0.53 to 1.70; low‐quality evidence; perinatal mortality ‐ no events; low‐quality evidence; LGA , RR 2.38, 95% CI 0.54 to 10.46; low‐quality evidence). There was no evidence of a difference between glibenclamide and acarbose for neonatal hypoglycaemia (RR 6.33, 95% CI 0.87 to 46.32; low‐quality evidence). There were no data reported for other pre‐specified GRADE or primary maternal outcomes (hypertensive disorders of pregnancy, development of type 2 diabetes, perineal trauma, return to pre‐pregnancy weight, postnatal depression, induction of labour) or neonatal outcomes (death or serious morbidity composite, adiposity or diabetes). Authors' conclusions There were insufficient data comparing oral anti‐diabetic pharmacological therapies with placebo/standard care (lifestyle advice) to inform clinical practice. There was insufficient high‐quality evidence to be able to draw any meaningful conclusions as to the benefits of one oral anti‐diabetic pharmacological therapy over another due to limited reporting of data for the primary and secondary outcomes in this review. Short‐ and long‐term clinical outcomes for this review were inadequately reported or not reported. Current choice of oral anti‐diabetic pharmacological therapy appears to be based on clinical preference, availability and national clinical practice guidelines. The benefits and potential harms of one oral anti‐diabetic pharmacological therapy compared with another, or compared with placebo/standard care remains unclear and requires further research. Future trials should attempt to report on the core outcomes suggested in this review, in particular long‐term outcomes for the woman and the infant that have been poorly reported to date, women's experiences and cost benefit. Plain language summary Oral medication for the treatment of women with gestational diabetes What is the issue? Globally the number of women being diagnosed with gestational diabetes mellitus (GDM) is increasing. GDM is an intolerance to glucose leading to high blood sugars, first recognised during pregnancy and usually resolving after birth. Standard care involves lifestyle advice on diet and exercise. Treatment for some women includes oral anti‐diabetic medications, such as metformin and glibenclamide, which are an alternative to, or can be used alongside, insulin to control the blood sugar. This review aimed to investigate benefits of taking oral medication to treat GDM in pregnant women. Another Cochrane Review compares the effects of insulin with oral anti‐diabetic pharmacological therapies ( Brown 2016 ). Why is this important? Women diagnosed with GDM are at a greater risk of experiencing complications such as high blood pressure during pregnancy and at birth. They have an increased risk of developing diabetes later in life. The babies of women who have been diagnosed with GDM can be larger than normal and this can cause injuries to the mother and the baby at birth. The birth is more likely to be induced or the baby born by caesarean section. These babies are at risk of developing diabetes as children or young adults. Finding the best medications to treat the women and prevent the complications that are linked to GDM is therefore important. What evidence did we find? We searched for studies on 14 May 2016. We included 11 randomised controlled trials involving 1487 mothers and their babies (but only eight trials contributed data to our analyses). The evidence was limited by the quality and number of studies and we advise caution when looking at the results. The criteria for diagnosis of GDM and treatment targets varied between studies, and each outcome is based on few studies with low numbers of women. Three studies compared oral medication with placebo/standard care but the following findings are from a single study (375 women). The quality of the evidence was very low or low. We found no differences between the oral medication and placebo group for the risk of high blood pressure, birth by caesarean section, induction of labour or perineal trauma. The number of babies born large‐for‐gestational age, with low blood sugars or dying at birth was not clearly different between the groups. Two studies (434 women) reported no difference in the need for insulin between the oral medication and placebo group. Six studies compared metformin with glibenclamide. The quality of the evidence was very low to moderate. We found no difference between metformin and glibenclamide for the risk of high blood pressure (three studies, 508 women, moderate‐quality evidence), birth by caesarean section (four studies, 554 women, low‐quality evidence), perineal trauma (two studies, 308 women, low‐quality evidence) or induction of labour (one study, 159 women, low‐quality evidence). We found no difference between metformin and glibenclamide for the baby having low blood sugars (four studies, 554 infants, low‐quality evidence), being born large‐for‐gestational age (two studies, 246 infants) or dying at birth (all low‐ or very low‐quality evidence). In one study, the babies of the mothers taking metformin were at reduced risk of having any serious outcome (low blood sugar, jaundice, being born large, breathing problems, injury at birth or death combined) (low‐quality evidence). One small study (43 women) comparing glibenclamide with acarbose reported no differences in outcomes for mothers or their babies. None of the included studies provided any data on many of the outcomes pre‐specified in this review, including long‐term outcomes for the mother or for the baby as a child or an adult. What does this mean? There is not enough high‐quality evidence available to guide us on if oral medication has better outcomes for women with gestational diabetes, and their babies, compared with a placebo or if one oral medication has better health outcomes than another oral medication. Because we are still unclear, further research is needed. Future studies should be encouraged to report on the outcomes suggested in this review and in particular the long‐term outcomes for the woman and the infant that have been poorly reported to date.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Brown, J; Martis, R; Hughes, B; Rowan, J; Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD011967.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "2ce08be6-6ff4-49a9-b77a-54a2627584d9", "pmid": "", "title": "Probiotics for treatment of chronic constipation in children", "imported": false, "abstract": "Abstract - Background Functional constipation is defined as chronic constipation with no identifiable underlying cause. It is a significant cause of morbidity in children, accounting for up to 25% of visits to paediatric gastroenterologists. Probiotic preparations may sufficiently alter the gut microbiome and promote normal gut physiology in a way that helps relieve functional constipation. Several studies have sought to address this hypothesis, as well as the role of probiotics in other functional gut disorders. Therefore, it is important to have a focused review to assess the evidence to date. Objectives To evaluate the efficacy and safety of probiotics for the management of chronic constipation without a physical explanation in children. Search methods On 28 June 2021, we searched CENTRAL, MEDLINE, Embase, CINAHL, AMED, WHO ICTR, and ClinicalTrials.gov, with no language, date, publication status, or document type limitations. Selection criteria We included randomised controlled trials (RCTs) that assessed probiotic preparations (including synbiotics) compared to placebo, no treatment or any other interventional preparation in people aged between 0 and 18 years old with a diagnosis of functional constipation according to consensus criteria (such as Rome IV). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 14 studies (1127 randomised participants): 12 studies assessed probiotics in the treatment of functional constipation, whilst two studies investigated synbiotic preparations. Three studies compared probiotics to placebo in relation to the frequency of defecation at study end, but we did not pool them as there was very significant unexplained heterogeneity. Four studies compared probiotics to placebo in relation to treatment success. There may be no difference in global improvement/treatment success (RR 1.29, 95% CI 0.73 to 2.26; 313 participants; low‐certainty evidence). Five studies compared probiotics to placebo in relation to withdrawals due to adverse events, with the pooled effect suggesting there may be no difference (RR 0.64, 95% CI 0.21 to 1.95; 357 participants; low‐certainty evidence). The pooled estimate from three studies that compared probiotics plus an osmotic laxative to osmotic laxative alone found there may be no difference in frequency of defecation (MD ‐0.01, 95% CI ‐0.57 to 0.56; 268 participants; low‐certainty evidence). Two studies compared probiotics plus an osmotic laxative to osmotic laxative alone in relation to global improvement/treatment success, and found there may be no difference between the treatments (RR 0.95, 95% CI 0.79 to 1.15; 139 participants; low‐certainty evidence). Three studies compared probiotics plus osmotic laxative to osmotic laxative alone in relation to withdrawals due to adverse events, but it is unclear if there is a difference between them (RR 2.86, 95% CI 0.12 to 68.35; 268 participants; very low‐certainty evidence). Two studies compared probiotics versus magnesium oxide. It is unclear if there is a difference in frequency of defecation (MD 0.28, 95% CI ‐0.58 to 1.14; 36 participants), treatment success (RR 1.08, 95% CI 0.74 to 1.57; 36 participants) or withdrawals due to adverse events (RR 0.50, 95% CI 0.05 to 5.04; 77 participants). The certainty of the evidence is very low for these outcomes. One study assessed the role of a synbiotic preparation in comparison to placebo. There may be higher treatment success in favour of synbiotics compared to placebo (RR 2.32, 95% CI 1.54 to 3.47; 155 participants; low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study assessed a synbiotic plus paraffin compared to paraffin alone. It is uncertain if there is a difference in frequency of defecation (MD 0.74, 95% CI ‐0.96, 2.44; 66 participants; very low‐certainty evidence), or treatment success (RR 0.91, 95% CI 0.71 to 1.17; 66 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study compared a synbiotic preparation to paraffin. It is uncertain if there is a difference in frequency of defecation (MD ‐1.53, 95% CI ‐3.00, ‐0.06; 60 participants; very low‐certainty evidence) or in treatment success (RR 0.86, 95% CI 0.65, 1.13; 60 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. All secondary outcomes were either not reported or reported in a way that did not allow for analysis. Authors' conclusions There is insufficient evidence to conclude whether probiotics are efficacious in successfully treating chronic constipation without a physical explanation in children or changing the frequency of defecation, or whether there is a difference in withdrawals due to adverse events when compared with placebo. There is limited evidence from one study to suggest a synbiotic preparation may be more likely than placebo to lead to treatment success, with no difference in withdrawals due to adverse events. There is insufficient evidence to draw efficacy or safety conclusions about the use of probiotics in combination with or in comparison to any of the other interventions reported. The majority of the studies that presented data on serious adverse events reported that no events occurred. Two studies did not report this outcome. Future studies are needed to confirm efficacy, but the research community requires guidance on the best context for probiotics in such studies, considering where they should be best considered in a potential treatment hierarchy and should align with core outcome sets to support future interpretation of findings. Plain language summary Probiotics for treatment of chronic constipation in children What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can be used to treat chronic constipation without a physical explanation in children (aged 0 to 18 years). We analysed data from 14 studies to answer this question. Key messages We were unable to draw conclusions when comparing probiotics to placebo for frequency of defecation in children treated for chronic constipation without a physical explanation. There may be no difference in treatment success between the two groups. There may not be a difference in frequency of defecation or treatment success when comparing probiotics and laxatives to using laxatives alone. We were unable to draw conclusions when comparing probiotics to magnesium oxide for frequency of defecation or treatment success. There may be a higher frequency of defecation in children treated with synbiotic preparations compared to placebo. There may not be a difference in participants withdrawing from the studies due to adverse events when comparing probiotic preparations to placebo. We were unable to draw conclusions on the safety of any of the other comparisons due to the low number of people who withdrew from the studies. What was studied in the review? Children often suffer from constipation for long periods of time, and when there is no underlying physical cause that can be found we call it 'functional constipation'. It has been suggested that probiotic and synbiotic preparations might help improve symptoms in these children. Probiotics are preparations that contain living bacteria that have been proposed to be beneficial to the digestive system. Synbiotics also include food substances that support the growth of these bacteria. There is currently no consensus about whether this is the case, or how these preparations are best used. What are the main results of the review? We searched for randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) comparing any probiotic or synbiotic treatment with any other treatment (such as dummy/placebo treatments) in children with chronic constipation without a physical explanation. We found 14 trials including a total of 1127 participants who were aged under 18. We made the following conclusions.
• There may be no difference in treatment success when comparing probiotics to placebo.
• We were unable to draw conclusions on whether there is a difference in the frequency of defecation.
• There may be no difference in treatment success when comparing probiotics and laxatives to laxatives alone.
• We were unable to draw conclusions on frequency of defecation or treatment success when comparing probiotics to magnesium oxide.
• Synbiotics may be better than placebo in improving the frequency of defection.
• There may be no difference in how many people withdrew from the trials because of side effects when comparing probiotics to placebo, or probiotics and laxative to laxative alone.
• We have limited confidence in the evidence because the studies only included a small number of children, and due to lack of detail on some of the methods used. All analyses were limited due to differences in the specific probiotics or the treatments they were compared with, low numbers of children included in the studies and, most importantly, the use of a range of different measures of success. This meant that combining studies was difficult, so the overall ability of this review to answer its core questions was limited. What next? Future studies are needed to find out how helpful probiotics are for childhood constipation. Researchers need to agree whether probiotics should be a first option therapy, an add‐on to other therapies, a second option after other therapies have failed, or a combination of all the above. Future research should measure the same items (known as a core outcome set) to ensure these results can support future reviews. How up‐to‐date is this review? This review is current to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wallace, C; Sinopoulou, V; Gordon, M; Akobeng, AK; Llanos-Chea, A; Hungria, G; Febo-Rodriguez, L; Fifi, A; Fernandez Valdes, L; Langshaw, A; Saps, M", "articleTypes": [], "doi": "10.1002/14651858.CD014257.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "2cfa4fbc-ed1d-471f-b2cd-f92293719c51", "pmid": "", "title": "Translational Health Research Into Vascular and Neurocognitive Effects of Weight Loss", "imported": false, "abstract": "The goal of this clinical trial is to learn about the nature of brain abnormalities associated with excess body fat in healthy adults aged 35-55. The main questions it aims to answer are:", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.246Z" }, { "id": "2d17a3a1-8313-4eec-856d-db87ca2e1a97", "pmid": "", "title": "Lactobacillus Reuteri Versus Placebo in the Treatment and Prevention of Infantile Colic: a Clinical and Microbiological, Double-blind, Prospective, Randomised, Controlled Study", "imported": false, "abstract": "The purpose of this study is:", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.151Z" }, { "id": "2d1e9761-c828-4fdc-b8bb-dd73b31b1dd5", "pmid": "", "title": "Breastfeeding for procedural pain in infants beyond the neonatal period", "imported": false, "abstract": "Abstract - Background Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin‐to‐skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk. Objectives To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin‐to‐skin contact, expressed breast milk, formula milk, bottle feeding, sweet‐tasting solutions (e.g. sucrose or glucose), distraction, or other interventions. Search methods We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In‐Process & Other Non‐Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials. Selection criteria We included RCTs and quasi‐RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet‐tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin‐to‐skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random‐effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information. Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38‐second reduction in cry time (MD ‐38, 95% CI ‐50 to ‐26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12‐month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7‐point reduction in standardised pain scores (SMD ‐1.7, 95% CI ‐2.2 to ‐1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD ‐3.6, ‐23 to 16). Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage. No included studies reported adverse events. Authors' conclusions We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin‐breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted. Plain language summary Does breastfeeding reduce vaccination pain in babies aged 1 to 12 months? Bottom line We found that breastfeeding before and during vaccination injections helped to reduce pain in most babies up to the age of one year. Background Needles are used for babies' early childhood vaccinations and medical care during childhood illnesses. These are essential, but painful. They cause distress for the babies and often their parents/caregivers, and can result in future anxiety and fear about needles. Breastfeeding during blood tests in newborn babies reduces pain. Breastfeeding when possible and feasible may also help to comfort babies and reduce their pain beyond the newborn period and throughout infancy. Study characteristics In February 2016 we searched the medical literature for studies examining the effectiveness of breastfeeding babies 1 to 12 months old during the use of needles. We compared effectiveness of breastfeeding in reducing pain (as scored by crying time and pain scores), to holding, babies lying flat, or the giving of water or sweet solutions. We found 10 studies with a total of 1066 infants. All studies examined if breastfeeding reduced pain during vaccinations. Key results Breastfeeding reduced crying in young babies having vaccinations. On average, breastfed babies cried for 38 seconds less than babies who were not breastfed (6 studies; 547 infants; moderate‐quality evidence), and pain scores were significantly lower (5 studies; 310 infants; moderate‐quality evidence). No studies reported on any harm (very low‐quality evidence). We could draw no conclusions on risk of harm while breastfeeding healthy babies during vaccination. Going forward: if mothers are breastfeeding, it could be considered when possible for babies during vaccinations. More evidence is needed to learn if breastfeeding helps older babies and babies in hospital during blood work or procedures such as insertion of drips. Quality of the evidence The quality of the evidence was moderate for crying time and pain scores. Most studies included younger infants aged 1 to 6 months. Further research including older infants up to 12 months of age may change our conclusions. In addition, the studies evaluated the effects of breastfeeding during vaccination. We do not know whether breastfeeding helps sick babies aged 1 to 12 months in hospital during blood sampling or drip insertion.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Harrison, D, Reszel, J, Bueno, M, Sampson, M, Shah, VS, Taddio, A, Larocque, C, Turner, L", "articleTypes": [], "doi": "10.1002/14651858.CD011248.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.736Z" }, { "id": "2d1f5243-0d9d-4486-a354-8b3a7e668e1d", "pmid": "", "title": "Aspirin with or without an antiemetic for acute migraine headaches in adults", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010). Migraine is a common, disabling condition and a burden for the individual, health services and society. Many sufferers choose not to, or are unable to, seek professional help and rely on over‐the‐counter analgesics. Co‐therapy with an antiemetic should help to reduce nausea and vomiting commonly associated with migraine headaches. Objectives To determine the efficacy and tolerability of aspirin, alone or in combination with an antiemetic, compared to placebo and other active interventions in the treatment of acute migraine headaches in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, ClinicalTrials.gov, and reference lists for studies through 10 March 2010 for the original review and to 31 January 2013 for the update. Selection criteria We included randomised, double‐blind, placebo‐controlled or active‐controlled studies, or both, using aspirin to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and numbers needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment. Main results No new studies were found for this update. Thirteen studies (4222 participants) compared aspirin 900 mg or 1000 mg, alone or in combination with metoclopramide 10 mg, with placebo or other active comparators, mainly sumatriptan 50 mg or 100 mg. For all efficacy outcomes, all active treatments were superior to placebo, with NNTs of 8.1, 4.9 and 6.6 for 2‐hour pain‐free, 2‐hour headache relief, and 24‐hour headache relief with aspirin alone versus placebo, and 8.8, 3.3 and 6.2 with aspirin plus metoclopramide versus placebo. Sumatriptan 50 mg did not differ from aspirin alone for 2‐hour pain‐free and headache relief, while sumatriptan 100 mg was better than the combination of aspirin plus metoclopramide for 2‐hour pain‐free, but not headache relief; there were no data for 24‐hour headache relief. Adverse events were mostly mild and transient, occurring slightly more often with aspirin than placebo. Additional metoclopramide significantly reduced nausea (P < 0.00006) and vomiting (P = 0.002) compared with aspirin alone. Authors' conclusions We found no new studies since the last version of this review. Aspirin 1000 mg is an effective treatment for acute migraine headaches, similar to sumatriptan 50 mg or 100 mg. Addition of metoclopramide 10 mg improves relief of nausea and vomiting. Adverse events were mainly mild and transient, and were slightly more common with aspirin than placebo, but less common than with sumatriptan 100 mg. Plain language summary Aspirin with or without an antiemetic for acute migraine headaches in adults This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010); no new studies were found. A single oral dose of 1000 mg of aspirin reduced pain from moderate or severe to none by two hours in approximately 1 in 4 people (24%) taking aspirin, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (52%) taking aspirin compared with approximately 1 in 3 (32%) taking placebo. Of those who experienced effective headache relief at two hours, more had that relief sustained over 24 hours with aspirin than with placebo. Addition of 10 mg of the antiemetic metoclopramide substantially increased relief of nausea and vomiting compared with aspirin alone, but made little difference to pain. Oral sumatriptan 100 mg was better than aspirin plus metoclopramide for pain‐free response at two hours, but otherwise there were no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short‐term use were mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Kirthi, V; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008041.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "2d2b0bad-3c53-4904-841d-d438d8e03ceb", "pmid": "", "title": "Fluoride toothpastes of different concentrations for preventing dental caries", "imported": false, "abstract": "Abstract - Background Caries (dental decay) is a disease of the hard tissues of the teeth caused by an imbalance, over time, in the interactions between cariogenic bacteria in dental plaque and fermentable carbohydrates (mainly sugars). Regular toothbrushing with fluoride toothpaste is the principal non‐professional intervention to prevent caries, but the caries‐preventive effect varies according to different concentrations of fluoride in toothpaste, with higher concentrations associated with increased caries control. Toothpastes with higher fluoride concentration increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Objectives To determine and compare the effects of toothpastes of different fluoride concentrations (parts per million (ppm)) in preventing dental caries in children, adolescents, and adults. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 August 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7) in the Cochrane Library (searched 15 August 2018); MEDLINE Ovid (1946 to 15 August 2018); and Embase Ovid (1980 to 15 August 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 August 2018). No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials that compared toothbrushing with fluoride toothpaste with toothbrushing with a non‐fluoride toothpaste or toothpaste of a different fluoride concentration, with a follow‐up period of at least 1 year. The primary outcome was caries increment measured by the change from baseline in the decayed, (missing), and filled surfaces or teeth index in all permanent or primary teeth (D(M)FS/T or d(m)fs/t). Data collection and analysis Two members of the review team, independently and in duplicate, undertook the selection of studies, data extraction, and risk of bias assessment. We graded the certainty of the evidence through discussion and consensus. The primary effect measure was the mean difference (MD) or standardised mean difference (SMD) caries increment. Where it was appropriate to pool data, we used random‐effects pairwise or network meta‐analysis. Main results We included 96 studies published between 1955 and 2014 in this updated review. Seven studies with 11,356 randomised participants (7047 evaluated) reported the effects of fluoride toothpaste up to 1500 ppm on the primary dentition; one study with 2500 randomised participants (2008 evaluated) reported the effects of 1450 ppm fluoride toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants (40,066 evaluated) reported the effects of toothpaste up to 2400 ppm on the immature permanent dentition; and three studies with 2675 randomised participants (2162 evaluated) reported the effects of up to 1100 ppm fluoride toothpaste on the mature permanent dentition. Follow‐up in most studies was 36 months. In the primary dentition of young children, 1500 ppm fluoride toothpaste reduces caries increment when compared with non‐fluoride toothpaste (MD ‐1.86 dfs, 95% confidence interval (CI) ‐2.51 to ‐1.21; 998 participants, one study, moderate‐certainty evidence); the caries‐preventive effects for the head‐to‐head comparison of 1055 ppm versus 550 ppm fluoride toothpaste are similar (MD ‐0.05, dmfs, 95% CI ‐0.38 to 0.28; 1958 participants, two studies, moderate‐certainty evidence), but toothbrushing with 1450 ppm fluoride toothpaste slightly reduces decayed, missing, filled teeth (dmft) increment when compared with 440 ppm fluoride toothpaste (MD ‐0.34, dmft, 95%CI ‐0.59 to ‐0.09; 2362 participants, one study, moderate‐certainty evidence). The certainty of the remaining evidence for this comparison was judged to be low. We included 81 studies in the network meta‐analysis of D(M)FS increment in the permanent dentition of children and adolescents. The network included 21 different comparisons of seven fluoride concentrations. The certainty of the evidence was judged to be low with the following exceptions: there was high‐ and moderate‐certainty evidence that 1000 to 1250 ppm or 1450 to 1500 ppm fluoride toothpaste reduces caries increments when compared with non‐fluoride toothpaste (SMD ‐0.28, 95% CI ‐0.32 to ‐0.25, 55 studies; and SMD ‐0.36, 95% CI ‐0.43 to ‐0.29, four studies); there was moderate‐certainty evidence that 1450 to 1500 ppm fluoride toothpaste slightly reduces caries increments when compared to 1000 to 1250 ppm (SMD ‐0.08, 95% CI ‐0.14 to ‐0.01, 10 studies); and moderate‐certainty evidence that the caries increments are similar for 1700 to 2200 ppm and 2400 to 2800 ppm fluoride toothpaste when compared to 1450 to 1500 ppm (SMD 0.04, 95% CI ‐0.07 to 0.15, indirect evidence only; SMD ‐0.05, 95% CI ‐0.14 to 0.05, two studies). In the adult permanent dentition, 1000 or 1100 ppm fluoride toothpaste reduces DMFS increment when compared with non‐fluoride toothpaste in adults of all ages (MD ‐0.53, 95% CI ‐1.02 to ‐0.04; 2162 participants, three studies, moderate‐certainty evidence). The evidence for DMFT was low certainty. Only a minority of studies assessed adverse effects of toothpaste. When reported, effects such as soft tissue damage and tooth staining were minimal. Authors' conclusions This Cochrane Review supports the benefits of using fluoride toothpaste in preventing caries when compared to non‐fluoride toothpaste. Evidence for the effects of different fluoride concentrations is more limited, but a dose‐response effect was observed for D(M)FS in children and adolescents. For many comparisons of different concentrations the caries‐preventive effects and our confidence in these effect estimates are uncertain and could be challenged by further research. The choice of fluoride toothpaste concentration for young children should be balanced against the risk of fluorosis. Plain language summary Fluoride toothpastes of different strengths for preventing tooth decay Review question 
 This review has been produced to assess the effects of toothpastes of different fluoride strengths on preventing tooth decay in children, adolescents and adults. Background 
 Tooth decay (caries) is a widespread disease, affecting billions of people worldwide. Fluoride has long been used to prevent decay, through a variety of different methods including toothpaste, water, milk, mouthrinses, tooth gels and varnish. Regular toothbrushing is recommended to prevent decay and other oral diseases, and toothbrushing for 2 minutes twice daily with a fluoride toothpaste is generally recommended. The typical strength of regular or family toothpaste is around 1000 to 1500 parts per million (ppm) fluoride, but many other strengths are available worldwide. There is no minimum fluoride concentration, but the maximum permissible fluoride concentration for a toothpaste varies according to age and country. Higher concentrations are rarely available over the counter, and are classed as a prescription‐only medicine. Stronger fluoride toothpaste may offer greater protection against decay but also increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Study characteristics 
 Authors from Cochrane Oral Health carried out this review and the evidence is current up to 15 August 2018. It includes 96 studies published between 1955 and 2014: seven studies with 11,356 randomised participants reported the effects of fluoride toothpaste up to 1500 ppm on the primary teeth; one study with 2500 randomised participants reported the effects of 1450 ppm toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants reported the effects of toothpaste up to 2400 ppm on the permanent teeth of children up to 18 years of age; and three studies with 2675 randomised participants reported the effects of up to 1100 ppm toothpaste on the permanent teeth of adults. Most studies assessed decay after participants had been using the toothpastes for 36 months. Main results 
 We present below findings for which there is moderate‐ or high‐certainty evidence. In primary teeth of young children, brushing teeth with a toothpaste containing 1500 ppm fluoride reduced the amount of new decay when compared with non‐fluoride toothpaste; the amount of new decay was similar with 1055 ppm compared with 550 ppm fluoride toothpaste; and there was a slight reduction in the amount of new decay with 1450 ppm toothpaste compared with 440 ppm fluoride toothpaste. Eighty‐one studies assessed the effects of different strengths of fluoride toothpaste compared against each other (seven different strengths in 21 combinations) in permanent teeth of children and adolescents. We found that there was less new decay when toothbrushing with toothpaste containing 1000 to 1250 ppm or 1450 to 1500 ppm fluoride compared with non‐fluoride toothpaste, and that toothbrushing with 1450 to 1500 ppm fluoride toothpaste reduced the amount of new decay more than 1000 to 1250 ppm toothpaste. We found that there was a similar amount of new decay when children and adolescents used a toothpaste of 1700 to 2200 ppm or 2400 to 2800 ppm fluoride compared to 1450 to 1500 ppm toothpaste. The evidence for the effects of other strengths of toothpaste was less certain. In permanent teeth of adults of all ages, 1000 or 1100 ppm toothpaste reduced decay compared with non‐fluoride toothpaste. Most studies did not measure harmful effects of toothpaste use, but when reported, effects such as soft tissue damage and tooth staining were minimal. Certainty of the evidence 
 There is high‐certainty evidence that toothpaste containing 1000 to 1250 ppm fluoride is more effective than non‐fluoride toothpaste. There is moderate‐certainty evidence for the other findings reported in 'Main results' above. For other toothpaste strengths compared against each other or against non‐fluoride toothpaste, there are too few studies with too few participants to have any clarity about the effects. Authors conclusions 
 There are benefits of using fluoride toothpaste at certain strengths to prevent tooth decay when compared with non‐fluoride toothpaste. The stronger the fluoride concentration, the more decay is prevented. For many of the comparisons of different strengths of toothpaste, the findings are uncertain and could be challenged by further research. The choice of fluoride toothpaste for young children should be balanced against the risk of fluorosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Walsh, T; Worthington, HV; Glenny, AM; Marinho, VCC; Jeroncic, A", "articleTypes": [], "doi": "10.1002/14651858.CD007868.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "2d303d96-3707-4911-8e97-bb88c348c1d5", "pmid": "", "title": "Antiemetics for adults for prevention of nausea and vomiting caused by moderately or highly emetogenic chemotherapy: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background About 70% to 80% of adults with cancer experience chemotherapy‐induced nausea and vomiting (CINV). CINV remains one of the most distressing symptoms associated with cancer therapy and is associated with decreased adherence to chemotherapy. Combining 5‐hydroxytryptamine‐3 (5‐HT₃) receptor antagonists with corticosteroids or additionally with neurokinin‐1 (NK₁) receptor antagonists is effective in preventing CINV among adults receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Various treatment options are available, but direct head‐to‐head comparisons do not allow comparison of all treatments versus another. Objectives • In adults with solid cancer or haematological malignancy receiving HEC ‐ To compare the effects of antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids on prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting in network meta‐analysis (NMA) ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy • In adults with solid cancer or haematological malignancy receiving MEC ‐ To compare whether antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids are superior for prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting to treatment combinations including 5‐HT₃ receptor antagonists and corticosteroids solely, in network meta‐analysis ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy Search methods We searched CENTRAL, MEDLINE, Embase, conference proceedings, and study registries from 1988 to February 2021 for randomised controlled trials (RCTs). Selection criteria We included RCTs including adults with any cancer receiving HEC or MEC (according to the latest definition) and comparing combination therapies of NK₁ and 5‐HT₃ inhibitors and corticosteroids for prevention of CINV. Data collection and analysis We used standard methodological procedures expected by Cochrane. We expressed treatment effects as risk ratios (RRs). Prioritised outcomes were complete control of vomiting during delayed and overall phases, complete control of nausea during the overall phase, quality of life, serious adverse events (SAEs), and on‐study mortality. We assessed GRADE and developed 12 'Summary of findings' tables. We report results of most crucial outcomes in the abstract, that is, complete control of vomiting during the overall phase and SAEs. For a comprehensive illustration of results, we randomly chose aprepitant plus granisetron as exemplary reference treatment for HEC, and granisetron as exemplary reference treatment for MEC. Main results Highly emetogenic chemotherapy ( HEC) We included 73 studies reporting on 25,275 participants and comparing 14 treatment combinations with NK₁ and 5‐HT₃ inhibitors. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 704 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with aprepitant + granisetron. Evidence from NMA (39 RCTs, 21,642 participants; 12 treatment combinations with NK₁ and 5‐HT₃ inhibitors) suggests that the following drug combinations are more efficacious than aprepitant + granisetron for completely controlling vomiting during the overall treatment phase (one to five days): fosnetupitant + palonosetron (810 of 1000; RR 1.15, 95% confidence interval (CI) 0.97 to 1.37; moderate certainty), aprepitant + palonosetron (753 of 1000; RR 1.07, 95% CI 1.98 to 1.18; low‐certainty), aprepitant + ramosetron (753 of 1000; RR 1.07, 95% CI 0.95 to 1.21; low certainty), and fosaprepitant + palonosetron (746 of 1000; RR 1.06, 95% CI 0.96 to 1.19; low certainty). Netupitant + palonosetron (704 of 1000; RR 1.00, 95% CI 0.93 to 1.08; high‐certainty) and fosaprepitant + granisetron (697 of 1000; RR 0.99, 95% CI 0.93 to 1.06; high‐certainty) have little to no impact on complete control of vomiting during the overall treatment phase (one to five days) when compared to aprepitant + granisetron, respectively. Evidence further suggests that the following drug combinations are less efficacious than aprepitant + granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): aprepitant + ondansetron (676 of 1000; RR 0.96, 95% CI 0.88 to 1.05; low certainty), fosaprepitant + ondansetron (662 of 1000; RR 0.94, 95% CI 0.85 to 1.04; low certainty), casopitant + ondansetron (634 of 1000; RR 0.90, 95% CI 0.79 to 1.03; low certainty), rolapitant + granisetron (627 of 1000; RR 0.89, 95% CI 0.78 to 1.01; moderate certainty), and rolapitant + ondansetron (598 of 1000; RR 0.85, 95% CI 0.65 to 1.12; low certainty). We could not include two treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 35 of 1000 participants experience any SAEs when treated with aprepitant + granisetron. Evidence from NMA (23 RCTs, 16,065 participants; 11 treatment combinations) suggests that fewer participants may experience SAEs when treated with the following drug combinations than with aprepitant + granisetron: fosaprepitant + ondansetron (8 of 1000; RR 0.23, 95% CI 0.05 to 1.07; low certainty), casopitant + ondansetron (8 of 1000; RR 0.24, 95% CI 0.04 to 1.39; low certainty), netupitant + palonosetron (9 of 1000; RR 0.27, 95% CI 0.05 to 1.58; low certainty), fosaprepitant + granisetron (13 of 1000; RR 0.37, 95% CI 0.09 to 1.50; low certainty), and rolapitant + granisetron (20 of 1000; RR 0.57, 95% CI 0.19 to 1.70; low certainty). Evidence is very uncertain about the effects of aprepitant + ondansetron (8 of 1000; RR 0.22, 95% CI 0.04 to 1.14; very low certainty), aprepitant + ramosetron (11 of 1000; RR 0.31, 95% CI 0.05 to 1.90; very low certainty), fosaprepitant + palonosetron (12 of 1000; RR 0.35, 95% CI 0.04 to 2.95; very low certainty), fosnetupitant + palonosetron (13 of 1000; RR 0.36, 95% CI 0.06 to 2.16; very low certainty), and aprepitant + palonosetron (17 of 1000; RR 0.48, 95% CI 0.05 to 4.78; very low certainty) on the risk of SAEs when compared to aprepitant + granisetron, respectively. We could not include three treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron, rolapitant + ondansetron) in NMA for this outcome because of missing direct comparisons. Moderately emetogenic chemotherapy (MEC) We included 38 studies reporting on 12,038 participants and comparing 15 treatment combinations with NK₁ and 5‐HT₃ inhibitors, or 5‐HT₃ inhibitors solely. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 555 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with granisetron. Evidence from NMA (22 RCTs, 7800 participants; 11 treatment combinations) suggests that the following drug combinations are more efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days): aprepitant + palonosetron (716 of 1000; RR 1.29, 95% CI 1.00 to 1.66; low certainty), netupitant + palonosetron (694 of 1000; RR 1.25, 95% CI 0.92 to 1.70; low certainty), and rolapitant + granisetron (660 of 1000; RR 1.19, 95% CI 1.06 to 1.33; high certainty). Palonosetron (588 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) and aprepitant + granisetron (577 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) may or may not increase complete response in the overall treatment phase (one to five days) when compared to granisetron, respectively. Azasetron (560 of 1000; RR 1.01, 95% CI 0.76 to 1.34; low certainty) may result in little to no difference in complete response in the overall treatment phase (one to five days) when compared to granisetron. Evidence further suggests that the following drug combinations are less efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): fosaprepitant + ondansetron (500 of 1000; RR 0.90, 95% CI 0.66 to 1.22; low certainty), aprepitant + ondansetron (477 of 1000; RR 0.86, 95% CI 0.64 to 1.17; low certainty), casopitant + ondansetron (461 of 1000; RR 0.83, 95% CI 0.62 to 1.12; low certainty), and ondansetron (433 of 1000; RR 0.78, 95% CI 0.59 to 1.04; low certainty). We could not include five treatment combinations (fosaprepitant + granisetron, azasetron, dolasetron, ramosetron, tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 153 of 1000 participants experience any SAEs when treated with granisetron. Evidence from pair‐wise comparison (1 RCT, 1344 participants) suggests that more participants may experience SAEs when treated with rolapitant + granisetron (176 of 1000; RR 1.15, 95% CI 0.88 to 1.50; low certainty). NMA was not feasible for this outcome because of missing direct comparisons. Certainty of evidence Our main reason for downgrading was serious or very serious imprecision (e.g. due to wide 95% CIs crossing or including unity, few events leading to wide 95% CIs, or small information size). Additional reasons for downgrading some comparisons or whole networks were serious study limitations due to high risk of bias or moderate inconsistency within networks. Authors' conclusions This field of supportive cancer care is very well researched. However, new drugs or drug combinations are continuously emerging and need to be systematically researched and assessed. For people receiving HEC, synthesised evidence does not suggest one superior treatment for prevention and control of chemotherapy‐induced nausea and vomiting. For people receiving MEC, synthesised evidence does not suggest superiority for treatments including both NK₁ and 5‐HT₃ inhibitors when compared to treatments including 5‐HT₃ inhibitors only. Rather, the results of our NMA suggest that the choice of 5‐HT₃ inhibitor may have an impact on treatment efficacy in preventing CINV. When interpreting the results of this systematic review, it is important for the reader to understand that NMAs are no substitute for direct head‐to‐head comparisons, and that results of our NMA do not necessarily rule out differences that could be clinically relevant for some individuals. Plain language summary Which drug combinations are best for prevention of nausea and vomiting caused by chemotherapy in adults with cancer? The burden of nausea and vomiting caused by chemotherapy and what helps to prevent it? In about 70% to 80% of adults with cancer, chemotherapy induces nausea and vomiting (CINV). Depending on the type of chemotherapy, treatment can cause strong or moderate sickness (hereafter referred to as HEC (highly emetogenic chemotherapy) and MEC (moderately emetogenic chemotherapy)). Multiple drug combinations have showed high benefit for CINV among adults receiving HEC or MEC. What was the aim of our review? Using a network meta‐analysis, we aimed to compare the benefits and harms of different drug combinations for prevention of CINV among people receiving HEC or MEC, and to identify treatment ranking. A network meta‐analysis is a technique used to compare different treatments described in already published trials, even when the original individual trial does not describe such comparisons. What studies did we look at? We searched selected medical databases and trial registries until February 2021. We included studies comparing multiple drug combinations for prevention of CINV among adults with any type of cancer receiving HEC or MEC that is commonly used in clinical practice. In particular, we looked at drugs inhibiting two specific biochemical receptors (neurokinin receptor and serotonin receptor) that trigger nausea and vomiting after chemotherapy. We looked at the preventative effects of these treatments over five days. This is the period during which the maximum intensity of CINV and further peaks of intensity are expected, after the start of chemotherapy. Our key results... ...for people receiving HEC We found 73 studies that reported on the experience of 25,275 participants and compared 14 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped to prevent any vomiting in 60% to 81% of people on average. Those individuals also had no need for rescue medicines, which are used in case nausea and vomiting occur even though prophylactic treatment has been given. The results of our analysis suggest some differences in effectiveness of different treatments, but overall we had little confidence that those differences would be reflected in real‐world observations. Harms. We estimated that 1% to 4% of people experience serious side effects. The differences between treatments were small. ...for people receiving MEC We found 38 studies that reported on the experience of 12,038 participants and compared 15 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped prevent any vomiting in 43% to 72% of people on average. Those individuals also had no need for rescue medicines. The results of our analysis suggest some differences in the effectiveness of different treatments, but overall, we had little confidence that those differences would be reflected in real‐world observations. Harms. Few studies reported serious side effects. The ones that did suggest that on average 15% to 18% of people experience such events. Differences between treatments were small. However, we think that future research is needed to rule out potential differences between treatments. Our confidence in the findings We assessed how confident we were that there are differences between compared treatments. We had low or very low confidence that one treatment is better or worse than another in preventing CINV. Our confidence in differences between statistical results was mainly limited because measures of variation were wide apart and included both potential advantages and disadvantages, although measures of precision showed no or little effect. We also identified limitations in some of the included studies, which further limited our confidence in the effects. This was mainly the case when study personnel and participants knew which treatments were given and therefore may not adhere to the planned intervention, or may perceive or report effects differently. Our conclusions The results of our analysis suggest that there is no superior drug combination for prevention of CINV for people receiving HEC or MEC. However, results suggest that the choice of drugs targeting the serotonin receptor may impact effectiveness, irrespective of whether given with or without a drug targeting the neurokinin receptor. However, when interpreting these results, it is important for the reader to understand that these kinds of multiple‐comparison analyses are no substitute for head‐to‐head comparisons, and that the results do not necessarily rule out differences that could be clinically relevant for some individuals. How up‐to‐date is this evidence? Evidence is up‐to‐date to 2 February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Piechotta, V; Adams, A; Haque, M; Scheckel, B; Kreuzberger, N; Monsef, I; Jordan, K; Kuhr, K; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "2d389b3b-6e63-4f66-8e18-a8451333c447", "pmid": "", "title": "Optimizing Naltrexone for Individuals of East Asian Descent", "imported": false, "abstract": "This study will elucidate the pharmacogenetic effects of the Asn40Asp SNP of the OPRM1 gene on biobehavioral and neural markers of response to naltrexone in individuals of East Asian descent, an ethnic group most likely to express the positive predictive allele.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.243Z" }, { "id": "2d4e340a-c5fe-49a9-9ed7-51b13cf20eed", "pmid": "", "title": "Interventions for recurrent idiopathic epistaxis (nosebleeds) in children", "imported": false, "abstract": "Abstract - Background Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified. Although nosebleeds are very common in children, and most cases are self limiting or settle with simple measures (such as pinching the nose), more severe recurrent cases can require treatment from a healthcare professional. However, there is no consensus on the effectiveness of the different clinical interventions currently used in managing this condition. Objectives To assess the effects of different interventions for the management of recurrent idiopathic epistaxis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 5 March 2012. Selection criteria We identified all randomised controlled trials (RCTs) (with or without blinding) in which any surgical or medical intervention for the treatment of recurrent idiopathic epistaxis in children was evaluated in comparison with either no treatment, a placebo or another intervention, and in which the frequency and severity of episodes of nasal bleeding following treatment was stated or calculable. The two authors reviewed the full‐text articles of all retrieved trials of possible relevance and applied the inclusion criteria independently. Data collection and analysis We graded trials for risk of bias using the Cochrane approach. One author performed data extraction in a standardised manner and this was rechecked by the other author. Where necessary we contacted investigators to obtain missing information. We did not undertake a meta‐analysis because of the heterogeneity of the treatments, procedures and quality of the included trials. A narrative overview of the results is therefore presented. Main results Five studies (four RCTs and one quasi‐randomised controlled trial) involving 468 participants satisfied the inclusion criteria. The identified RCTs compared 0.5% neomycin + 0.1% chlorhexidine (Naseptin®) cream with no treatment, Vaseline® petroleum jelly with no treatment, 75% with 95% silver nitrate nasal cautery, and silver nitrate cautery combined with Naseptin® against Naseptin® alone; the quasi‐randomised controlled trial compared Naseptin® antiseptic cream with silver nitrate cautery. Overall results were inconclusive, with no statistically significant difference found between the compared treatments upon completion of the trials, however 75% silver nitrate was more effective than 95% silver nitrate at two weeks following application. The group treated with 75% silver nitrate had 88% complete resolution of epistaxis compared to 65% in the group treated with 95% silver nitrate (P = 0.01). No serious adverse effects were reported from any of the interventions, although children receiving silver nitrate cautery reported that it was a painful experience (despite the use of local anaesthetic). The pain scores were significantly less in those treated with 75% silver nitrate, the mean score being 1 compared to a mean score of 5 in those treated with 95% silver nitrate; this was statistically significant (P = 0.001). We carried out a 'Risk of bias' assessment of each study according to the Cochrane methodology and judged that two randomised controlled trials had a low risk of bias, two had an unclear risk of bias and the quasi‐randomised controlled trial had a high risk of bias. Authors' conclusions The optimal management of children with recurrent idiopathic epistaxis is unknown, however if silver nitrate nasal cautery is undertaken 75% is preferable to 95% as it is more effective in the short term and causes less pain. High‐quality randomised controlled trials comparing interventions either with placebo or no treatment, and with a follow‐up period of at least a year, are needed to assess the relative merits of the various treatments currently in use. Plain language summary Interventions for recurrent nosebleeds of unknown cause in children Nosebleeds in children usually just stop by themselves or after pinching the nose. However, some children get repeated nosebleeds with no specific cause (recurrent idiopathic epistaxis). The most common treatments are cautery or antiseptic cream, or both. Cautery (a method of sealing) can be painful even with local anaesthetic, and usually involves using a silver nitrate stick to seal off a visible blood vessel inside the nose that may be rupturing. Other options include ointments and nasal sprays. The review of trials found that there is not enough evidence to compare the effectiveness of different treatment options, however using a lower concentration of silver nitrate cautery is more effective in the short term and less painful. More research is needed to show the best options for reducing recurrent nosebleeds of unknown cause in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Qureishi, A, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004461.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.770Z" }, { "id": "2d4e458f-b7f9-4511-a2e6-651e8cbb13ad", "pmid": "", "title": "Probiotics for the prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer", "imported": false, "abstract": "Abstract - Background Treament‐related diarrhoea is one of the most common and troublesome adverse effects related to chemotherapy or radiotherapy in people with cancer. Its reported incidence has been as high as 50% to 80%. Severe treatment‐related diarrhoea can lead to fluid and electrolyte losses and nutritional deficiencies and could adversely affect quality of life (QoL). It is also associated with increased risk of infection in people with neutropenia due to anticancer therapy and often leads to treatment delays, dose reductions, or treatment discontinuation. Probiotics may be effective in preventing or treating chemotherapy‐ or radiotherapy‐induced diarrhoea. Objectives To evaluate the clinical effectiveness and side effects of probiotics used alone or combined with other agents for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 7), MEDLINE (1946 to July week 2, 2017), and Embase (1980 to 2017, week 30). We also searched prospective clinical trial registers and the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) investigating the effects of probiotics for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Data collection and analysis Two review authors independently selected studies, extracted data, and assessed risk of bias. We used random‐effects models for all meta‐analyses. If meta‐analysis was not possible, we summarised the results narratively. Main results We included 12 studies involving 1554 participants. Eleven studies were prevention studies, of which seven compared probiotics with placebo (887 participants), one compared two doses of probiotics with each other and with placebo (246 participants), and three compared probiotics with another active agent (216 participants).The remaining study assessed the effectiveness of probiotics compared with placebo for treatment of radiotherapy‐related diarrhoea (205 participants). For prevention of radiotherapy (with or without chemotherapy)‐induced diarrhoea, review authors identified five heterogeneous placebo‐controlled studies (with 926 participants analysed). Owing to heterogeneity, we could not carry out a meta‐analysis, except for two outcomes. For occurrence of any diarrhoea, risk ratios (RRs) ranged from 0.35 (95% confidence interval (CI) 0.26 to 0.47) to 1.0 (95% CI 0.94 to 1.06) (three studies; low‐certainty evidence). A beneficial effect of probiotics on quality of life could neither be demonstrated nor refuted (two studies; low‐certainty evidence). For occurrence of grade 2 or higher diarrhoea, the pooled RR was 0.75 (95% CI 0.55 to 1.03; four studies; 420 participants; low‐certainty evidence), and for grade 3 or higher diarrhoea, RRs ranged from 0.11 (95% CI 0.06 to 0.23) to 1.24 (95% CI 0.74 to 2.08) (three studies; low‐certainty evidence). For probiotic users, time to rescue medication was 36 hours longer in one study (95% CI 34.7 to 37.3), but another study reported no difference (moderate‐certainty evidence). For the need for rescue medication, the pooled RR was 0.50 (95% CI 0.15 to 1.66; three studies; 194 participants; very low‐certainty evidence). No study reported major differences between groups with respect to adverse effects. Although not mentioned explicitly, no studies reported deaths, except one in which one participant in the probiotics group died of myocardial infarction after three sessions of radiotherapy. Three placebo‐controlled studies, with 128 analysed participants, addressed prevention of chemotherapy‐induced diarrhoea. For occurrence of any diarrhoea, the pooled RR was 0.59 (95% CI 0.36 to 0.96; two studies; 106 participants; low‐certainty evidence). For all other outcomes, a beneficial effect of probiotics could be neither demonstrated nor refuted (one to two studies; 46 to 106 participants; all low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. Three studies compared probiotics with another intervention in 213 participants treated with radiotherapy (with or without chemotherapy). One very small study (21 participants) reported less diarrhoea six weeks after treatment when dietary counselling was provided (RR 0.30, 95% CI 0.11 to 0.81; very low‐certainty evidence). In another study (148 participants), grade 3 or 4 diarrhoea occurred less often in the probiotics group than in the control group (guar gum containing nutritional supplement) (odds ratio (OR) 0.38, 95% CI 0.16 to 0.89; low‐certainty evidence), and two studies (63 participants) found less need for rescue medication of probiotics versus another active treatment (RR 0.44, 95% CI 0.22 to 0.86; very low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. One placebo‐controlled study with 205 participants addressed treatment for radiotherapy‐induced diarrhoea and could not demonstrate or refute a beneficial effect of probiotics on average diarrhoea grade, time to rescue medication for diarrhoea (13 hours longer in the probiotics group; 95% CI ‐0.9 to 26.9 hours), or need for rescue medication (RR 0.74, 95% CI 0.53 to 1.03; moderate‐certainty evidence). This study did not address quality of life. No studies reported serious adverse events or diarrhoea‐related deaths. Authors' conclusions This review presents limited low‐ or very low‐certainty evidence supporting the effects of probiotics for prevention and treatment of diarrhoea related to radiotherapy (with or without chemotherapy) or chemotherapy alone, need for rescue medication, or occurrence of adverse events. All studies were underpowered and heterogeneous. Severe side effects were absent from all studies. Robust evidence on this topic must be provided by future methodologically well‐designed trials. Plain language summary Live micro‐organisms for prevention or treatment of diarrhoea in people with cancer who are treated with chemotherapy or radiotherapy Background 
 Up to 80% of people treated with chemotherapy or radiotherapy for cancer suffer from diarrhoea ‐ one of the most common and troublesome side effects. Severe diarrhoea can lead to dehydration (fluid and salts loss) and malnutrition from changes to digestion and bowel habits and could adversely affect quality of life. It is also associated with increased risk of infection in people with low white cell blood count related to cancer treatment. Diarrhoea often leads to delays in cancer treatment or the need to lower the dose or even discontinue cancer treatment. Foods containing live bacteria or yeast (probiotics) might have a beneficial effect on the occurrence and severity of diarrhoea. Aim of the review 
 To evaluate the effects of live micro‐organisms (probiotics) in preventing the occurrence or reducing the severity of diarrhoea in people with cancer who are receiving chemotherapy or radiotherapy. Main findings 
 Overall, the studies we found do not give a clear answer on whether probiotics reduce the occurrence or severity of diarrhoea, improve quality of life, or reduce the need for other medication. However, an analysis of only well‐performed studies demonstrated a beneficial effect for some outcomes. With regard to prevention of diarrhoea compared with placebo in participants treated with radiotherapy with or without chemotherapy, we are not able to conclude whether use of probiotics would be beneficial based on the five relevant studies. For prevention of diarrhoea due to chemotherapy alone, three studies suggested that use of probiotics may not reduce diarrhoea, and one study reported use of less rescue medication for diarrhoea. Three studies that compared probiotics with another agent for preventing diarrhoea in patients treated with radiotherapy with or without chemotherapy found beneficial effects of probiotics for the occurrence and severity of diarrhoea and the need for rescue medication. With respect to treatment of diarrhoea due to radiotherapy, we found only one study that did not demonstrate a clear effect of probiotics compared with placebo. No study reported serious adverse events nor deaths related to diarrhoea. Certainty of the evidence 
 The quality (certainty) of the evidence in prevention studies was low to very low. For the only study that assessed the effects of probiotics on treatment for diarrhoea, the certainty of the evidence was moderate. What are the conclusions? 
 Evidence supporting the effects of probiotics in preventing or treating diarrhoea related to cancer treatment is insufficient. However, probiotics appear to be safe, as no studies have found severe side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wei, D; Heus, P; van de Wetering, FT; van Tienhoven, G; Verleye, L; Scholten, RJPM", "articleTypes": [], "doi": "10.1002/14651858.CD008831.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "2d524caa-869a-43ff-9986-92295f950ebe", "pmid": "", "title": "Lamotrigine for chronic neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This is an update of the original Cochrane review entitled Lamotrigine for acute and chronic pain published in Issue 2, 2007, and updated in Issue 2, 2011. Some antiepileptic medicines have a place in the treatment of neuropathic pain (pain due to nerve damage). This updated review adds no new additional studies looking at evidence for lamotrigine as an effective treatment for chronic neuropathic pain or fibromyalgia. The update uses higher standards of evidence than previously. Objectives To assess the analgesic efficacy of lamotrigine in the treatment of chronic neuropathic pain and fibromyalgia, and to evaluate adverse effects reported in the studies. Search methods We identified randomised controlled trials (RCTs) of lamotrigine for chronic neuropathic pain and fibromyalgia (including cancer pain) from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). We ran searches for the original review in 2006, in 2011 for the first update, and subsequent searches in August 2013 for this update. We sought additional studies from the reference lists of the retrieved papers. The original review and first update included acute pain, but no acute pain studies were identified. Selection criteria RCTs investigating the use of lamotrigine (any dose, by any route, and for any study duration) for the treatment of chronic neuropathic pain or fibromyalgia. Assessment of pain intensity or pain relief, or both, using validated scales. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First‐tier studies did not use last observation carried forward (LOCF) or other imputational methods for dropouts. The second tier used data that failed to meet this standard and second‐tier results were therefore subject to potential bias. Main results Twelve included studies in 11 publications (1511 participants), all with chronic neuropathic pain: central post‐stroke pain (1), chemotherapy‐induced neuropathic pain (1), diabetic neuropathy (4), HIV‐related neuropathy (2), mixed neuropathic pain (2), spinal cord injury‐related pain (1), and trigeminal neuralgia (1). We did not identify any additional studies. Participants were aged between 26 and 77 years. Study duration was two weeks in one study and at least six weeks in the remainder; eight were of eight‐week duration or longer. No study provided first‐tier evidence for an efficacy outcome. There was no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of 200 mg to 400 mg daily. Almost 10% of participants taking lamotrigine reported a skin rash. Authors' conclusions Large, high‐quality, long‐duration studies reporting clinically useful levels of pain relief for individual participants provided no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of about 200 to 400 mg daily. Given the availability of more effective treatments including antiepileptics and antidepressant medicines, lamotrigine does not have a significant place in therapy based on the available evidence. The adverse effect profile of lamotrigine is also of concern. Plain language summary Lamotrigine (an antiepileptic drug) for chronic neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our understanding of fibromyalgia (a condition of persistent, widespread pain and tenderness, sleep problems, and fatigue) is lacking, but fibromyalgia can respond to the same medicines as neuropathic pain. Lamotrigine is a medicine used to treat epilepsy, and so might be a useful medicine for neuropathic pain or fibromyalgia. On 26 November 2013 we performed searches to look for clinical trials where lamotrigine was used to treat neuropathic pain or fibromyalgia. We found 12 studies of reasonable quality that tested lamotrigine against placebo for a number of weeks. Almost half of the 1511 people in the studies had painful limbs because of damaged nerves caused by diabetes, and seven different painful neuropathic conditions were examined. No studies looked at fibromyalgia. Lamotrigine did not help the pain, and was no different from placebo except in causing more side effects. Adverse events were more frequent with lamotrigine than placebo, with rash in 1 person in 27.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD006044.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.090Z" }, { "id": "2d5fd169-054c-4b27-93a0-482345cc1791", "pmid": "", "title": "Blood pressure lowering efficacy of beta‐blockers as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Beta‐blockers are one of the more commonly prescribed classes of anti‐hypertensive drugs, both as first‐line and second‐line. Objectives To quantify the effect on systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and withdrawals due to adverse effects of beta‐blocker therapy when given as a second‐line drug in adult patients with primary hypertension. Search methods CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1966‐Aug 2009), EMBASE (1988‐Aug 2009) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized controlled trials comparing a beta‐blocker in combination with a drug from another class of anti‐hypertensive drugs compared with that drug alone for a duration of 3 to 12 weeks in patients with primary hypertension were included. Data collection and analysis Two reviewers independently extracted the data and assessed trial quality of each included study. Main results 20 double‐blind RCTs evaluated the BP lowering efficacy of beta‐blockers as second‐line drug in 3744 hypertensive patients (baseline BP of 158/102 mmHg; mean duration of 7 weeks). The BP reduction from adding a beta‐blocker as the second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. A reduction in BP was seen with adding a beta‐blocker to thiazide diuretics or calcium channel blockers at doses as low as 0.25 times the manufacturer's recommended starting dose. The BP lowering efficacy of beta‐blockers as a second drug was 6/4 mmHg at 1 times the starting dose and 8/6 mmHg at 2 times the starting dose. Beta‐blockers reduced heart rate by 10 beats/min at 1 to 2 times the starting dose. Beta‐blockers did not statistically significantly increase withdrawals due to adverse effects but this was likely due to the lack of reporting of this outcome in 35% of the included RCTs. Authors' conclusions Addition of a beta‐blocker to diuretics or calcium‐channel blockers reduces BP by 6/4mmHg at 1 times the starting dose and by 8/6 mmHg at 2 times the starting dose. When the blood pressure lowering effect of beta‐blockers from this review was compared to that of thiazide diuretics from our previous review ( Chen 2009 ), second‐line beta‐blockers reduce systolic BP to the same extent as second‐line thiazide diuretics, but reduce diastolic BP to a greater degree. The different effect on diastolic BP means that beta‐blockers have little or no effect on pulse pressure whereas thiazides cause a significant dose‐related decrease in pulse pressure. This difference in the pattern of BP lowering with beta‐blockers as compared to thiazides might be the explanation for the fact that beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than thiazide diuretics, particularly in older individuals. Plain language summary Beta‐blockers lower blood pressure when given as a second drug Beta‐blockers are commonly used in the treatment for high blood pressure (BP). In this review, we asked how much do beta‐blockers reduce BP when used as the second drug to treat hypertension. Twenty trials lasting an average of 7 weeks were found in the world scientific literature to answer this question. The data showed that the addition of a beta‐blocker to thiazide diuretics or calcium channel blockers reduced BP by 8/6 mmHg when given at doses 2 times the recommended starting dose. When we compared these results with our previous review of the blood pressure lowering effect of thiazide diuretics as second line drug, we found that beta‐blockers have a different pattern of BP lowering. This different pattern of effect on blood pressure might explain why first‐line beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than first‐line thiazide diuretics, particularly in older individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, JMH, Heran, BS, Perez, MI, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007185.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.772Z" }, { "id": "2d63759a-26a3-4c21-a5da-771e96190365", "pmid": "", "title": "Enteral nutrition for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Prevention of relapse is a major issue in the management of quiescent Crohn's disease (CD). Current therapies (e.g. methotrexate, biologics, 6‐mercaptopurine and azathioprine) may be effective for maintaining remission in CD, but these drugs may cause significant adverse events. Interventions that are effective and safe for maintenance of remission in CD are desirable. Objectives The primary objectives were to evaluate the efficacy and safety of enteral nutrition for the maintenance of remission in CD and to assess the impact of formula composition on effectiveness. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and clinicaltrials.gov from inception to 27 July 2018. We also searched references of retrieved studies and reviews. Selection criteria Randomised controlled trials (RCTs) including participants of any age with quiescent CD were considered for inclusion. Studies that compared enteral nutrition with no intervention, placebo or any other intervention were selected for review. Data collection and analysis Two authors independently screened studies for inclusion, extracted data and assessed methodological quality using the Cochrane risk of bias tool. The primary outcome was clinical or endoscopic relapse as defined by the primary studies. Secondary outcomes included anthropometric measures (i.e. height and weight), quality of life (QoL), adverse events, serious adverse events and withdrawal due to adverse events. We calculated the risk ratio and 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated the mean difference and 95% CI. A random‐effects model was used for the statistical analysis. We used the GRADE criteria to assess the overall certainty of the evidence supporting the primary outcome and selected secondary outcomes. Main results Four RCTs (262 adult participants) met the inclusion criteria. One study (N = 33) compared an elemental diet to a non‐elemental (polymeric) diet. One study (N = 51) compared a half elemental diet to a regular free diet. Another study (N = 95) compared an elemental diet to 6‐mercaptopurine (6‐MP) or a no treatment control group. One study (N= 83) compared a polymeric diet to mesalamine. Two studies were rated as high risk of bias due to lack of blinding or incomplete outcome data. The other two studies were judged to have an unclear risk of bias. The studies were not pooled due to differences in control interventions and the way outcomes were assessed. The effect of an elemental diet compared to a polymeric diet on remission rates or withdrawal due to adverse events is uncertain. Fifty‐eight per cent (11/19) of participants in the elemental diet group relapsed at 12 months compared to 57% (8/14) of participants in the polymeric diet group (RR 1.01, 95% CI 0.56 to 1.84; very low certainty evidence). Thirty‐two per cent (6/19) of participants in the elemental diet group were intolerant to the enteral nutritional formula because of taste or smell and were withdrawn from the study in the first 2 weeks compared to zero participants (0/14) in the polymeric diet group (RR 9.75, 95% CI 0.59 to 159.93; low certainty evidence). Anthropometric measures, QoL, adverse events and serious adverse events were not reported as outcomes. The effect of an elemental diet (half of total daily calorie requirements) compared to a normal free diet on relapse rates is uncertain. Thirty‐five per cent (9/26) of participants in the elemental diet group relapsed at 12 months compared to 64% (16/25) of participants in the free diet group (RR 0.54, 95% CI 0.30 to 0.99; very low certainty evidence). No adverse events were reported. This study reported no differences in weight change between the two diet groups. Height and QoL were not reported as outcomes. The effect of an elemental diet compared to 6‐MP on relapse rates or adverse events is uncertain. Thirty‐eight per cent (12/32) of participants in the elemental diet group relapsed at 12 months compared to 23% (7/30) of participants in the 6‐MP group (RR 1.61; 95% CI 0.73 to 3.53; very low certainty evidence). Three per cent (1/32) of participants in the elemental diet group had an adverse event compared to 13% (4/30) of participants in the 6‐MP group (RR 0.23, 95% CI 0.03 to 1.98; low certainty evidence). Adverse events in the elemental diet group included surgery due to worsening CD. Adverse events in the 6‐MP group included liver injury (n = 2), hair loss (n = 1) and surgery due to an abscess (n = 1). No serious adverse events or withdrawals due to adverse events were reported. Weight, height and QoL were not reported as outcomes The effect of a polymeric diet compared to mesalamine on relapse rates and weight is uncertain. Forty‐two per cent (18/43) of participants in the polymeric diet group relapsed at 6 months compared to 55% (22/40) of participants in the mesalamine group (RR 0.76; 95% CI 0.49 to 1.19; low certainty evidence). The mean difference in weight gain over the study period was 1.9 kg higher in the polymeric diet group compared to mesalamine (95% CI ‐4.62 to 8.42; low certainty evidence). Two participants in the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had an adverse event. Height, QoL, serious adverse events and withdrawal due to adverse events were not reported as outcomes. Authors' conclusions The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the efficacy and safety of enteral nutrition in quiescent CD can be drawn. More research is needed to determine the efficacy and safety of using enteral nutrition as maintenance therapy in CD. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available. Plain language summary Enteral nutrition (liquid feeds) for maintenance of remission in Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disease of the intestines that frequently occurs in the lower part of the small intestine (ileum). Symptoms include abdominal pain, diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms the disease is considered 'active'. When the symptoms stop, it is called 'remission'. When people in remission experience symptoms it is called a 'relapse'. What is enteral nutrition? Enteral nutrition is a feeding method where a person's daily caloric intake is delivered via a liquid diet using the GI tract. Enteral nutrition can be administered by mouth or by tube feeding, where a tube is inserted through the nose or abdomen into the stomach to deliver the liquid feed. Enteral nutrition is a form of nutritional therapy for Crohn's disease patients. The mechanism by which enteral nutrition may influence inflammation is unknown and is being studied. Enteral nutrition can be classified as elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets are composed of amino‐acids (organic compounds), fats, sugars, vitamins and minerals. Elemental diets are easily absorbed and digested. Non‐elemental diets are based on oligopeptide (organic compounds composed of 2 to 20 amino‐acids) or whole protein sources. Non‐elemental diets are best for people who can digest and absorb nutrients without difficulty. What is 6‐mercaptopurine? 6‐Mercaptopurine is an immunosuppressive drug that is thought to reduce inflammation in people with Crohn's disease by blocking the immune system. What is mesalamine? Mesalamine is a 5‐aminosalicylic acid drug. 5‐Aminosalicylic drugs are thought to treat Crohn's disease by reducing inflammation in the gastrointestinal tract. These drugs are usually taken by mouth. What did the researchers investigate? The researchers studied whether enteral nutrition helps to maintain remission in people with Crohn's disease. The researchers also investigated whether one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) for maintaining remission in people with Crohn's disease. What did the researchers find? Four studies including 262 adult participants with Crohn's disease in remission were included. One study (33 participants) compared an elemental diet to a non‐elemental (polymeric) diet. One study (51 participants) compared an elemental diet to a normal diet (no supplements). One study (95 participants) compared an elemental diet to 6‐mercaptopurine or a no treatment control group. One study (83 participants) compared a non‐elemental polymeric diet to mesalamine. The researchers searched the medical literature extensively up to 27 July 2018. The study comparing an elemental diet to a polymeric diet found no difference in remission rates at 12 months. Six elemental diet participants were not able to tolerate the enteral nutritional formula because of taste or smell and were withdrawn from the study. Participants who received half of their total daily calorie requirements as elemental diet and the remaining half by normal diet had a lower chance of relapse at 12 months compared to participants who received a free diet. No side effects were reported in this study. The study comparing an elemental diet to 6‐mercaptopurine did not show any difference in relapse rates at 12 months. There was no difference in side effect rates. The only side effect reported in the elemental diet group was surgery due to worsening Crohn's disease. Side effects in the 6‐mercaptopurine group included liver injury in two participants, hair loss in one participant and surgery to treat an abscess in one participant. The study comparing a polymeric diet to mesalamine found no difference in relapse rates at six months. Two participants the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had side effects. No serious side effects were reported in any of the studies. The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the effectiveness and safety of enteral nutrition for maintenance of remission in Crohn's disease can be drawn. More research is needed to determine the effectiveness and safety of using enteral nutrition as maintenance therapy in Crohn's disease. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Akobeng, AK, Zhang, D, Gordon, M, MacDonald, JK", "articleTypes": [], "doi": "10.1002/14651858.CD005984.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.064Z" }, { "id": "2d7453ea-7185-470b-a17e-64d1024bea10", "pmid": "", "title": "Paracetamol (acetaminophen) for prevention or treatment of pain in newborns", "imported": false, "abstract": "Abstract - Background Newborn infants have the ability to experience pain. Hospitalised infants are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Objectives To determine the efficacy and safety of paracetamol for the prevention or treatment of procedural/postoperative pain or pain associated with clinical conditions in neonates. To review the effects of various doses and routes of administration (enteral, intravenous or rectal) of paracetamol for the prevention or treatment of pain in neonates. Search methods We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 4), MEDLINE via PubMed (1966 to 9 May 2016), Embase (1980 to 9 May 2016), and CINAHL (1982 to 9 May 2016). We searched clinical trials' databases, Google Scholar, conference proceedings, and the reference lists of retrieved articles. Selection criteria We included randomised and quasi‐randomised controlled trials of paracetamol for the prevention/treatment of pain in neonates (≤ 28 days of age). Data collection and analysis Two review authors independently extracted data from the articles using pre‐designed forms. We used this form to decide trial inclusion/exclusion, to extract data from eligible trials and to request additional published information from authors of the original reports. We entered and cross‐checked data using RevMan 5 software. When noted, we resolved differences by mutual discussion and consensus. We used the GRADE approach to assess the quality of evidence. Main results We included nine trials with low risk of bias, which assessed paracetamol for the treatment of pain in 728 infants. Painful procedures studied included heel lance, assisted vaginal birth, eye examination for retinopathy of prematurity assessment and postoperative care. Results of individual studies could not be combined in meta‐analyses as the painful conditions, the use of paracetamol and comparison interventions and the outcome measures differed. Paracetamol compared with water, cherry elixir or EMLA cream (eutectic mixture of lidocaine and prilocaine) did not significantly reduce pain following heel lance. The Premature Infant Pain Profile score (PIPP) within three minutes following lancing was higher in the paracetamol group than in the oral glucose group (mean difference (MD) 2.21, 95% confidence interval (CI) 0.72 to 3.70; one study, 38 infants). Paracetamol did not reduce \"modified facies scores\" after assisted vaginal birth (one study, 119 infants). In another study (n = 123), the Échelle de Douleur et d'Inconfort du Nouveau‐Né score at two hours of age was significantly higher in the group that received paracetamol suppositories than in the placebo suppositories group (MD 1.00, 95% CI 0.60 to 1.40). In that study, when infants were subjected to a heel lance at two to three days of age, Bernese Pain Scale for Neonates scores were higher in the paracetamol group than in the placebo group, and infants spent a longer time crying (MD 19 seconds, 95% CI 14 to 24). For eye examinations, no significant reduction in PIPP scores in the first or last 45 seconds of eye examination was reported, nor at five minutes after the eye examination. In one study (n = 81), the PIPP score was significantly higher in the paracetamol group than in the 24% sucrose group (MD 3.90, 95% CI 2.92 to 4.88). In one study (n = 114) the PIPP score during eye examination was significantly lower in the paracetamol group than in the water group (MD −2.70, 95% CI −3.55 to 1.85). For postoperative care following major surgery, the total amount of morphine (µg/kg) administered over 48 hours was significantly less among infants assigned to the paracetamol group than to the morphine group (MD −157 µg/kg, 95% CI −27 to −288). No adverse events were noted in any study. The quality of evidence according to GRADE was low. Authors' conclusions The paucity and low quality of existing data do not provide sufficient evidence to establish the role of paracetamol in reducing the effects of painful procedures in neonates. Paracetamol given after assisted vaginal birth may increase the response to later painful exposures. Paracetamol may reduce the total need for morphine following major surgery, and for this aspect of paracetamol use, further research is needed. Plain language summary Paracetamol (acetaminophen) for prevention or treatment of pain in newborns Review question: Is paracetamol effective and safe for the prevention or treatment of procedural or postoperative pain or pain associated with clinical conditions in newborn infants? Background: Newborn infants have the ability to experience pain. Newborns treated in neonatal intensive care units are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Study characteristics: We identified nine studies that reported comparisons in 728 infants of paracetamol versus placebo or other pain‐reducing interventions. The literature search was updated in May 2016. Key results: Paracetamol for heel lance did not reduce pain compared with placebo (water or cherry elixir) or compared with EMLA cream (eutectic mixture of lidocaine and prilocaine). Paracetamol use was associated with a stronger response to pain than was seen with glucose. Paracetamol did not reduce pain in infants exposed to vacuum extraction or forceps at birth, and their response to a subsequent heel lance at two to three days of life was increased compared with placebo. For eye examination, paracetamol was effective in reducing pain compared with water in one study, but the pain response was stronger among paracetamol‐treated infants than in infants given 24% sucrose. In infants treated with paracetamol and morphine compared with morphine alone, the total amount of morphine required during the first 48 hours following major surgery to the chest or the abdomen was less in the paracetamol group. Paracetamol did not significantly reduce pain during heel lance. Paracetamol following assisted birth may increase the response to later exposure to painful interventions. Paraetamol may reduce the total need for morphine following major surgery, and further research is needed into this aspect of paracetamol use. Quality of evidence: In general the studies were of good quality but the numbers of infants enrolled in the different studies were small. The overall quality of evidence was low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ohlsson, A, Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD011219.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.800Z" }, { "id": "2d823b91-2450-4501-b256-38224d9aa364", "pmid": "", "title": "Pharmacological treatments for Friedreich ataxia", "imported": false, "abstract": "Abstract - Rationale Friedreich ataxia (FRDA) is a rare inherited autosomal recessive neurological disorder, characterised initially by unsteadiness in standing and walking, and slowly progressing to wheelchair dependency, usually in the late teens or early twenties. Scoliosis, pes cavus and cardiomyopathy are often present at diagnosis. As the disease progresses, individuals usually develop slurred speech, auditory impairment (especially in a noisy environment), urinary tract morbidity, diabetes, anxiety, depression, muscle spasticity and visual disturbances. Cardiac abnormalities cause premature death in 60% of people with FRDA. There is no easily defined clinical or biochemical marker to assess progression and no known curative treatment. This is the third update of a review published in 2009 and updated in 2012 and 2016. Objectives To assess the effects of pharmacological treatments for people with Friedreich ataxia (FRDA) after 12 months of treatment. Search methods To identify studies for inclusion in this review, we searched CENTRAL, MEDLINE, Embase, CINAHL Plus, TRIP, Orphanet, WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. We also checked reference lists of relevant studies and contacted study authors. The most recent search was on 4 February 2025. Eligibility criteria We were interested in randomised controlled trials (RCTs) and quasi‐RCTs of pharmacological treatments (including vitamins) in people with genetically‐confirmed FRDA. To be included in the review, studies had to last at least 12 months. Outcomes We assessed the following outcomes after 12 months of treatment: change in score on a validated ataxia rating scale; change in interventricular septal thickness in diastole (IVSTd) by cardiac magnetic resonance imaging or echocardiogram; change in activities of daily living (ADL) using a validated questionnaire; change in upper limb dexterity; and change in cardiopulmonary exercise testing (CPET). We also assessed treatment‐related adverse events with medication continued for the study period, and treatment‐emergent adverse events leading to cessation of medication or death during the study period. Risk of bias Using the Cochrane risk of bias tool RoB 2, we assessed the risk of bias in the seven outcomes reported in our summary of findings tables. Synthesis methods We synthesised the results of the studies for each outcome using meta‐analysis, where possible. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and the risk ratio (RR) for dichotomous outcomes, all with 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for our prespecified outcomes as high, moderate, low or very low. Included studies We included eight RCTs in this updated review. We included seven of them in meta‐analysis, and these studies enroled a total of 574 participants, with sample sizes ranging from 29 to 232 participants per study. One study was international, with centres in North America, Europe and Australia. There were four other multicentre studies (three in Europe and one in North America). Single‐centre studies were conducted in the UK, Italy and France. Participants in the studies ranged from eight to 70 years of age at enrolment, with the mean age in each study being between 18 years and 35 years (with an unweighted pooled mean age across studies of 25.9 years). All of the studies enroled both males and females, with the proportion of female participants ranging from 21% to 58%. Sixty‐eight per cent of participants had severe ataxia, while the other 32% had moderate ataxia. The studies tested epoetin alpha, CoQ10 and vitamin E, idebenone, leriglitazone, omaveloxolone, and RT001. One study tested pioglitazone but has not published any results. Four of the studies were pharmaceutical‐industry‐controlled. Synthesis of results Meta‐analysis of seven studies demonstrated that pharmacological treatment probably makes little or no difference to scores on the ataxia rating scale after 12 months of treatment (SMD 0.02, 95% CI −0.23 to 0.26; I² = 42%; 7 studies, 513 participants; moderate‐certainty evidence). The evidence was very uncertain about the effects of treatment on IVSTd (MD −0.51, 95% CI −1.10 to 0.09; I² = 80%; 2 studies, 72 participants; very low‐certainty evidence) and on ADL (MD −0.59, 95% CI −1.39 to 0.21; I² = 24%; 3 studies, 167 participants; very low‐certainty evidence). Meta‐analysis of three studies showed that treatment probably improves upper limb dexterity (SMD −0.42, 95% CI −0.73 to −0.11; I² = 0%; 3 studies, 166 participants; moderate‐certainty evidence). We are very uncertain about the effect of pharmacological treatment on CPET (SMD −0.16, 95% CI −0.46 to 0.13; I² = 0%; 3 studies, 181 participants; very low‐certainty evidence). We are very uncertain whether pharmacological treatment has any effect on treatment‐related adverse events (RR 0.88, 95% CI 0.63 to 1.22; I² = 0%; 2 studies, 104 participants; very low‐certainty evidence). There were only 104 participants in this analysis out of a total of 545 participants, so the result may have little relevance. Meta‐analysis of six studies found that there may be little to no difference between pharmacological treatment and placebo in treatment‐emergent adverse events leading to cessation of medication or death (RR 1.24, 95% CI 0.44 to 3.48; I² = 0%; 6 studies, 313 participants; low‐certainty evidence). Our certainty in the evidence ranged from very low to moderate. We downgraded all outcomes by one or two levels for imprecision, with further downgrades for inconsistency (for the outcomes of IVSTd, ADL, CPET) and suspected publication bias (for the outcomes of IVSTd, ADL, CPET and adverse events). Authors' conclusions In this updated Cochrane systematic review, meta‐analysis of results on the ataxia rating scale showed that pharmacological treatments probably make little or no difference compared with placebo after 12 months of treatment. Given this result, the probable improvement that we found in upper limb dexterity was unexpected. Treatment‐emergent adverse events leading to cessation of medication or death may be no more common in treatment groups than placebo groups as there were few adverse events detected in the treated groups. However, the studies may not have detected all rare and serious adverse events. Funding The authors in this review received no funding. Registration Protocol (2009) DOI: 10.1002/14651858.CD007791 Original review (2009) DOI: 10.1002/14651858.CD99791.pub2 Update (2012) DOI: 10.1002/14651858.CD007791.pub3 Update (2016) DOI: 10.1002/14651858.CD007791.pub4 Plain language summary Does taking medicine help people with Friedreich ataxia? Key messages For people with a progressive genetic condition called Friedreich ataxia, which affects nerves and muscles, taking medicine for a year probably has little to no effect on measures of ataxia (problems with co‐ordination and balance) or speech, although it probably improves upper limb dexterity (the ability to co‐ordinate the action of the arms, hands and fingers). We are uncertain whether taking medicine has any effect on heart health, the ability to perform daily tasks, or the body's response to exercise in people with Friedreich ataxia. From the available evidence, it is very uncertain whether the medicines cause any unwanted effects. What is Friedreich ataxia? Friedreich ataxia is a rare inherited condition affecting the nerves and muscles, which usually appears in childhood, at between 5 and 15 years of age. It causes clumsiness of movement, which progresses to unsteadiness in standing and walking, and to being dependent on a wheelchair by the late teens or early twenties. It can be associated with a curved spine (scoliosis), foot deformity (a high arch) and heart problems. As the disease progresses, slurred speech, hearing difficulties, problems going to the toilet, muscle spasticity, depression, anxiety and visual disturbances are common. Heart problems are a cause of early death in nearly two‐thirds of people with Friedreich ataxia. Clinical examination and laboratory tests are not very useful for judging the progression of the disease, which makes it difficult to understand the results of studies with Friedreich ataxia patients. What are the possible options for treating Friedreich ataxia? There is currently no cure for Friedreich ataxia. Various medicines have been tried. A new medicine, omaveloxolone, was recently approved in the USA and Europe for people over 16 years of age with Friedreich ataxia. What did we want to find out? We wanted to know if any of the medicines tested in randomised clinical trials help improve the lives of people with Friedreich ataxia. Randomised clinical trials are studies where some people take medicine and others take placebo, which is a substance that has no medical benefit but looks the same as the active medicine. No‐one involved with the study knows who is taking medicine and who is taking placebo. This is the third update of a Cochrane review that was first published in 2009. What did we do? We searched for randomised clinical trials that compared medicine to placebo in people with Friedreich ataxia and lasted at least 12 months. We combined the results of the studies and rated our confidence in this evidence, based on factors such as study methods and the number of people involved. What did we find? We found eight studies, seven of which reported results after taking medicine or placebo for 12 months. The studies included a total of 574 people, whose average ages were between 18 and 35 years. Most of the participants (68%) had severe ataxia, while 32% had moderate ataxia. The studies took place in Europe, North America and Australia. Four of them were carried out by the pharmaceutical industry (i.e. by companies who make the medicines). Two studies used a medicine called idebenone, and each of the others used a different medicine: co‐Q10 with vitamin E, epoetin alpha, omaveloxolone, leriglitazone, pioglitazone, and RT001. We found that, after one year, there was probably little to no difference in the level of ataxia that people experienced, regardless of whether they took medicine or placebo (7 studies, 513 people). We are very uncertain whether medicine has any effect on heart health (based on measuring the thickness of the heart muscle) or the ability to do daily tasks or how people score on special tests designed to measure the body's response to exercise. We found that medicine probably improves upper limb dexterity after one year (3 studies (testing leriglitazone, epoetin alpha and omaveloxolone), 166 people). With regard to safety, we are very uncertain whether the medicines cause any more unwanted effects than placebo. We found that there may be little to no difference between people taking medicine and people taking placebo in terms of the number of who either stopped taking the medicine or placebo, or the number of who died during the study years (6 studies, 313 people). What are the limitations of the evidence? Our confidence in the effect of medicine on ataxia is only moderate. This is because the results were not very precise. We are only moderately confident about the effect of medicine on upper limb dexterity because this was only reported in small studies. We had very little confidence in the other outcomes because of the small numbers of people in the studies. The studies reported varied results, and some studies did not publish the results for all the assessments that were carried out. It is difficult to measure an individual's perceptions of the positive effects of any new medicine, which may vary depending on their expectations prior to starting the medicine and whether their illness is early or advanced. How up to date is this evidence? The evidence is current to 4 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lyons, S, Kearney, M, Fahey, MC, Janjal, P, Pandolfo, M, Patton, P", "articleTypes": [], "doi": "10.1002/14651858.CD007791.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.801Z" }, { "id": "2dae47cf-9342-49e6-a64b-772888605468", "pmid": "", "title": "Acupuncture for acute management and rehabilitation of traumatic brain injury", "imported": false, "abstract": "Abstract - Background Traumatic brain injury (TBI) can be life threatening depending on the severity of the insult to the brain. It can also cause a range of debilitating sequelae which require cognitive, motor, communication, emotional, or behavioral rehabilitation of varying intensity and duration. A number of studies conducted and published in China have suggested that acupuncture may be beneficial in the acute treatment and rehabilitation of TBI. Objectives To determine the efficacy and safety of acupuncture in the acute management or rehabilitation (or both) of patients with a TBI, including cognitive, neurological, motor, communication, emotional, or behavioral complications, or a combination of such complications. Search methods We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials ( The Cochrane Library ), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO and others. We also searched the Chinese Acupuncture Studies Register, the Studies Register of the Cochrane Complementary Medicine Field, NCCAM, and NIH Clinical Studies Database. Three major Mainland Chinese academic literature databases (CNKI, VIP and Wang Fang Data) were also searched using keywords in simplified Chinese. We searched all databases through December 2009, and some searches have been updated to October 2012. Selection criteria Randomized controlled studies evaluating different variants of acupuncture and involving participants of any age who had suffered a TBI. Included trials compared acupuncture with placebo or sham treatment, or acupuncture plus other treatments compared with the same other treatments. We excluded trials that only compared different variants of acupuncture or compared acupuncture alone against other treatments alone, as they did not yield the net effect of acupuncture. Data collection and analysis Two review authors identified potential articles from the literature search and extracted data independently using a data extraction form. We performed methodological assessment of included studies using the Cochrane Collaboration's tool for assessing risk of bias. We were unable to perform quantitative data analysis due to insufficient included studies and available data. Main results Four RCTs, including 294 participants, reported outcomes specified by this review. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The results seem to suggest that acupuncture is efficacious for these indications, however the low methodological quality of these studies renders the results questionable. No adverse effects of acupuncture were reported in any of the studies. Authors' conclusions The low methodological quality of the included studies does not allow us to make conclusive judgments on the efficacy and safety of acupuncture in either the acute treatment and/or rehabilitation of TBI. Its beneficial role for these indications remains uncertain. Further research with high quality trials is required. Plain language summary Acupuncture for acute management and rehabilitation of traumatic brain injury Acupuncture used for the acute treatment, rehabilitation (or both) of traumatic brain injury (TBI) has been studied in China. We conducted a systematic review to evaluate the efficacy and safety of acupuncture for these conditions. Four randomized controlled trials were eligible for inclusion in this review, involving 294 patients. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The studies were of low methodological quality and were diverse in their objectives, participant characteristics, acupuncture modalities and strategies, and outcome measures. The small number of studies together with their low methodological quality means that they are inadequate to allow any conclusion to be drawn about the efficacy and safety of acupuncture in the treatment of TBI. Further methodologically robust studies are needed to generate evidence‐based conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wong, V, Cheuk, DKL, Lee, S, Chu, V", "articleTypes": [], "doi": "10.1002/14651858.CD007700.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.773Z" }, { "id": "2db9b98e-daa7-4b33-a028-98b76aa2d28b", "pmid": "", "title": "Vitamin and mineral supplementation for maintaining cognitive function in cognitively healthy people in mid and late life", "imported": false, "abstract": "Abstract - Background Vitamins and minerals play multiple functions within the central nervous system which may help to maintain brain health and optimal cognitive functioning. Supplementation of the diet with various vitamins and minerals has been suggested as a means of maintaining cognitive function, or even of preventing dementia, in later life. Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function in cognitively healthy people aged 40 years or more. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov and the WHO Portal/ICTRP from inception to 26th January 2018. Selection criteria We included randomised controlled trials that evaluated the cognitive effects on people aged 40 years or more of any vitamin or mineral supplements taken by mouth for at least three months. Data collection and analysis Study selection, data extraction, and quality assessments were done in duplicate. Vitamins were considered broadly in the categories of B vitamins, antioxidant vitamins, and combinations of both. Minerals were considered separately, where possible. If interventions and outcomes were considered sufficiently similar, then data were pooled. In order to separate short‐term cognitive effects from possible longer‐term effects on the trajectory of cognitive decline, data were pooled for various treatment durations from 3 months to 12 months and up to 10 years or more. Main results In total, we included 28 studies with more than 83,000 participants. There were some general limitations of the evidence. Most participants were enrolled in studies which were not designed primarily to assess cognition. These studies often had no baseline cognitive assessment and used only brief cognitive assessments at follow‐up. Very few studies assessed the incidence of dementia. Most study reports did not mention adverse events or made only very general statements about them. Only 10 studies had a mean follow‐up > 5 years. Only two studies had participants whose mean age was < 60 years at baseline. The risk of bias in the included studies was generally low, other than a risk of attrition bias for longer‐term outcomes. We considered the certainty of the evidence behind almost all results to be moderate or low. We included 14 studies with 27,882 participants which compared folic acid, vitamin B12, vitamin B6, or a combination of these to placebo. The majority of participants were aged over 60 years and had a history of cardio‐ or cerebrovascular disease. We found that giving B vitamin supplements to cognitively healthy adults, mainly in their 60s and 70s, probably has little or no effect on global cognitive function at any time point up to 5 years (SMD values from ‐0.03 to 0.06) and may also have no effect at 5‐10 years (SMD ‐0.01). There were very sparse data on adverse effects or on incidence of cognitive impairment or dementia. We included 8 studies with 47,840 participants in which the active intervention was one or more of the antioxidant vitamins: ß‐carotene, vitamin C or vitamin E. Results were mixed. For overall cognitive function, there was low‐certainty evidence of benefit associated with ß‐carotene after a mean of 18 years of treatment (MD 0.18 TICS points, 95% CI 0.01 to 0.35) and of vitamin C after 5 years to 10 years (MD 0.46 TICS points, 95% CI 0.14 to 0.78), but not at earlier time points. From two studies which reported on dementia incidence, there was low‐certainty evidence of no effect of an antioxidant vitamin combination or of vitamin E, either alone or combined with selenium. One of the included studies had been designed to look for effects on the incidence of prostate cancer; it found a statistically significant increase in prostate cancer diagnoses among men taking vitamin E. One trial with 4143 participants compared vitamin D3 (400 IU/day) and calcium supplements to placebo. We found low‐ to moderate‐certainty evidence of no effect of vitamin D3 and calcium supplements at any time‐point up to 10 years on overall cognitive function (MD after a mean of 7.8 years ‐0.1 MMSE points, 95% CI ‐0.81 to 0.61) or the incidence of dementia (HR 0.94, 95% CI 0.72 to 1.24). A pilot study with 60 participants used a higher dose of vitamin D3 (4000 IU on alternate days) and found preliminary evidence that this dose probably has no effect on cognitive function over six months. We included data from one trial of zinc and copper supplementation with 1072 participants. There was moderate‐certainty evidence of little or no effect on overall cognitive function (MD 0.6 MMSE points, 95% CI ‐0.19 to 1.39) or on the incidence of cognitive impairment after 5 years to 10 years. A second smaller trial provided no usable data, but reported no cognitive effects of six months of supplementation with zinc gluconate. From one study with 3711 participants, there was low‐certainty evidence of no effect of approximately five years of selenium supplementation on the incidence of dementia (HR 0.83, 95% CI 0.61 to 1.13). Finally, we included three trials of complex supplements (combinations of B vitamins, antioxidant vitamins, and minerals) with 6306 participants. From the one trial which assessed overall cognitive function, there was low‐certainty evidence of little or no effect on the TICS (MD after a mean of 8.5 years 0.12, 95% CI ‐0.14 to 0.38). Authors' conclusions We did not find evidence that any vitamin or mineral supplementation strategy for cognitively healthy adults in mid or late life has a meaningful effect on cognitive decline or dementia, although the evidence does not permit definitive conclusions. There were very few data on supplementation starting in midlife (< 60 years); studies designed to assess cognitive outcomes tended to be too short to assess maintenance of cognitive function; longer studies often had other primary outcomes and used cognitive measures which may have lacked sensitivity. The only positive signals of effect came from studies of long‐term supplementation with antioxidant vitamins. These may be the most promising for further research. Plain language summary Vitamin and mineral supplementation for preventing cognitive deterioration in cognitively healthy people in mid and late life Review question This review aimed to find out whether people aged 40 years or older could maintain their mental abilities or reduce their risk of dementia by taking vitamin or mineral supplements. Background There is great interest in anything people might do to keep themselves mentally healthy as they age and, especially, to reduce their risk of developing dementia. Various vitamin and mineral supplements have been suggested as ways to do this. Vitamins and minerals have many functions in the body and the ways they might affect brain health are not well understood. Therefore, we were interested in the effects of any vitamins or minerals, either alone or in combination. What we did We searched up to January 2018 for all trials which had studied the effect on cognition (thinking and remembering) of any vitamin or mineral supplements in people aged 40 years or more who had no cognitive problems at the beginning of the study. The studies had to include a comparison group which had not taken the supplement being studied and, to be sure the comparison was fair, it should have been decided at random whether people got the supplement or not. What we found We grouped the 28 included trials according to the kind of supplement they used and how it might work. Most of the trials were not originally designed to study cognition or dementia and used only simple measures of cognition. Very few studies investigated whether participants developed dementia. Long‐term studies are probably needed to find effects on the risk of dementia or cognitive decline but only 10 studies had an average length of follow‐up longer than five years. The studies were generally well‐conducted although the longer trials had difficulty following up all of the participants and this could have biased some of the longer‐term results. There were 14 trials of B vitamins (folic acid, vitamin B6, vitamin B12) with nearly 28,000 participants, mainly in their 60s and 70s. Most of these trials were quite short (less than two years). We found no evidence that B vitamins had any effect on cognition. There were 8 trials of antioxidant vitamins (beta‐carotene/vitamin A, vitamin C, vitamin E) with approximately 47,000 participants. These trials tended to be longer than the B vitamin trials so may have had more chance of detecting effects on dementia and cognitive decline. The results were mixed. We found low‐certainty evidence of better overall cognitive function after an average of 18 years taking beta‐carotene and after five years to 10 years taking vitamin C, but no effects after shorter periods of treatment. There were also small benefits of beta‐carotene, vitamin C, and antioxidant combinations on memory at some time points but not others. There was no evidence of any benefits from vitamin E alone. Two studies examined the risk of developing dementia. One found no effect of a combination of antioxidant vitamins and the other found no effect of vitamin E, either alone or combined with the mineral selenium. Most of the studies did not report any information about harmful effects. One included trial was designed to look for an effect on the risk of prostate cancer; it found a higher risk among the men taking vitamin E. There was a small trial of vitamin D supplements which found they probably had no effect on cognition over six months. There were longer trials of vitamin D with calcium (one trial), zinc and copper (one trial), and complex multivitamins (three trials). All lasted between five and 10 years, but none of them found any evidence of beneficial effects on cognition. One trial found no effect of selenium taken for approximately five years on the risk of developing dementia. Conclusions We found no good evidence to suggest that middle‐aged or older people can preserve cognitive function or prevent dementia by taking vitamin or mineral supplements. There were a few positive results associated with long‐term use of antioxidant vitamins, particularly beta‐carotene and vitamin C, although the effects were small. Further research into the effects of these vitamins may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rutjes, AWS; Denton, DA; Di Nisio, M; Chong, LY; Abraham, RP; Al‐Assaf, AS; Anderson, JL; Malik, MA; Vernooij, RWM; Martínez, G; Tabet, N; McCleery, J", "articleTypes": [], "doi": "10.1002/14651858.CD011906.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "2de08525-deae-4468-b2c4-f57485f50d5c", "pmid": "", "title": "Lamotrigine for chronic neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This is an update of the original Cochrane review entitled Lamotrigine for acute and chronic pain published in Issue 2, 2007, and updated in Issue 2, 2011. Some antiepileptic medicines have a place in the treatment of neuropathic pain (pain due to nerve damage). This updated review adds no new additional studies looking at evidence for lamotrigine as an effective treatment for chronic neuropathic pain or fibromyalgia. The update uses higher standards of evidence than previously. Objectives To assess the analgesic efficacy of lamotrigine in the treatment of chronic neuropathic pain and fibromyalgia, and to evaluate adverse effects reported in the studies. Search methods We identified randomised controlled trials (RCTs) of lamotrigine for chronic neuropathic pain and fibromyalgia (including cancer pain) from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). We ran searches for the original review in 2006, in 2011 for the first update, and subsequent searches in August 2013 for this update. We sought additional studies from the reference lists of the retrieved papers. The original review and first update included acute pain, but no acute pain studies were identified. Selection criteria RCTs investigating the use of lamotrigine (any dose, by any route, and for any study duration) for the treatment of chronic neuropathic pain or fibromyalgia. Assessment of pain intensity or pain relief, or both, using validated scales. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First‐tier studies did not use last observation carried forward (LOCF) or other imputational methods for dropouts. The second tier used data that failed to meet this standard and second‐tier results were therefore subject to potential bias. Main results Twelve included studies in 11 publications (1511 participants), all with chronic neuropathic pain: central post‐stroke pain (1), chemotherapy‐induced neuropathic pain (1), diabetic neuropathy (4), HIV‐related neuropathy (2), mixed neuropathic pain (2), spinal cord injury‐related pain (1), and trigeminal neuralgia (1). We did not identify any additional studies. Participants were aged between 26 and 77 years. Study duration was two weeks in one study and at least six weeks in the remainder; eight were of eight‐week duration or longer. No study provided first‐tier evidence for an efficacy outcome. There was no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of 200 mg to 400 mg daily. Almost 10% of participants taking lamotrigine reported a skin rash. Authors' conclusions Large, high‐quality, long‐duration studies reporting clinically useful levels of pain relief for individual participants provided no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of about 200 to 400 mg daily. Given the availability of more effective treatments including antiepileptics and antidepressant medicines, lamotrigine does not have a significant place in therapy based on the available evidence. The adverse effect profile of lamotrigine is also of concern. Plain language summary Lamotrigine (an antiepileptic drug) for chronic neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our understanding of fibromyalgia (a condition of persistent, widespread pain and tenderness, sleep problems, and fatigue) is lacking, but fibromyalgia can respond to the same medicines as neuropathic pain. Lamotrigine is a medicine used to treat epilepsy, and so might be a useful medicine for neuropathic pain or fibromyalgia. On 26 November 2013 we performed searches to look for clinical trials where lamotrigine was used to treat neuropathic pain or fibromyalgia. We found 12 studies of reasonable quality that tested lamotrigine against placebo for a number of weeks. Almost half of the 1511 people in the studies had painful limbs because of damaged nerves caused by diabetes, and seven different painful neuropathic conditions were examined. No studies looked at fibromyalgia. Lamotrigine did not help the pain, and was no different from placebo except in causing more side effects. Adverse events were more frequent with lamotrigine than placebo, with rash in 1 person in 27.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD006044.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "2de3e8cd-dcbe-4774-824d-f0975050aeca", "pmid": "", "title": "Topiramate for essential tremor", "imported": false, "abstract": "Abstract - Background Essential tremor (ET) is one of the most common movement disorders. The management is primarily based on pharmacological agents and in clinical practice propranolol and primidone are considered the first‐line therapy. However, these treatments can be ineffective in 25% to 55% of people and are frequently associated with serious adverse events (AEs). For these reasons, it is worthwhile evaluating other treatments for ET. Topiramate has been suggested as a potentially useful agent for the treatment of ET but there is uncertainty about its efficacy and safety. Objectives To assess the efficacy and safety of topiramate in the treatment of ET. Search methods We carried out a systematic search without language restrictions to identify all relevant trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to January 2017), Embase (January 1988 to January 2017), National Institute for Health and Care Excellence (1999 to January 2017), ClinicalTrials.gov (1997 to January 2017) and World Health Organization International Clinical Trials Registry Platform (ICTRP; 2004 to January 2017). We searched BIOSIS Citation Index (2000 to January 2017) for conference proceedings. We handsearched grey literature and the reference lists of identified studies and reviews. Selection criteria We included all randomised controlled trials (RCTs) of topiramate versus placebo/open control or any other treatments. We included studies in which the diagnosis of ET was made according to accepted and validated diagnostic criteria. We excluded studies conducted in people presenting with secondary forms of tremor or reporting only neurophysiological parameters to assess outcomes. Data collection and analysis Two review authors independently collected and extracted data using a data collection form. We assessed the risk of bias and the quality of evidence. We used a fixed‐effect meta‐analysis for data synthesis. Main results This review included three trials comparing topiramate to placebo (309 participants). They were all at high overall risk of bias. The quality of evidence ranged from very low to low. Compared to placebo, participants treated with topiramate showed a significant improvement in functional disability and an increased risk of withdrawal (risk ratio (RR) 1.78, 95% confidence interval (CI) 1.23 to 2.60). There were more AEs for topiramate‐treated participants, particularly paraesthesia, weight loss, appetite decrease and memory difficulty. Authors' conclusions This systematic review highlighted the presence of limited data and very low to low quality evidence to support the apparent efficacy and the occurrence of treatment‐limiting AEs in people with ET treated with topiramate. Further research to assess topiramate efficacy and safety on ET is needed. Plain language summary Use of topiramate for the treatment of essential tremor Review question The authors of this review tried to assess the effectiveness and safety of topiramate in people with essential tremor. Background Essential tremor is a type of uncontrollable shaking or trembling of parts of the body. Although it is not harmful in terms of its effect on life expectancy, it generally gets worse and may be disabling. Treatment is usually with medicines (called propranolol and primidone), which may not work in a quarter to a half of people with essential tremor. Some specialists have suggested that another medicine, topiramate, could be useful for treating the condition. Study characteristics We searched medical databases for studies of topiramate compared with placebo (a pretend tablet) or any other medicine in adults with essential tremor. We found three studies comparing topiramate versus placebo, involving 309 participants with moderate to severe essential tremor. Key results The effect of topiramate on daily activities, risk of stopping treatment and side effects was uncertain because the quality of evidence was very low to low. Quality of evidence We only found a few studies that had problems with their methods so we could not make firm conclusions about how well topiramate works and if it has side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Bruno, E, Nicoletti, A, Quattrocchi, G, Allegra, R, Filippini, G, Colosimo, C, Zappia, M", "articleTypes": [], "doi": "10.1002/14651858.CD009683.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.777Z" }, { "id": "2e108262-60b8-4ae1-a0dc-828221e73389", "pmid": "", "title": "Antiviral treatment for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. This review was first published in 2001 and most recently updated in 2015. Since a significant benefit of corticosteroids for the early management of Bell's palsy has been demonstrated, the main focus of this update, as in the previous version, was to determine the effect of adding antivirals to corticosteroid treatment. We undertook this update to integrate additional evidence and to better assess the robustness of findings, taking risk of bias fully into account. Objectives To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy. Search methods We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS in July 2019. We reviewed the bibliographies of the identified trials and contacted trial authors to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies. Selection criteria We considered randomised controlled trials (RCTs) or quasi‐RCTs of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that followed‐up participants for less than three months. Data collection and analysis We independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures. We performed sensitivity analyses excluding trials at high or unclear risk of bias in at least five domains, and reported these data as the primary analyses. Main results Fourteen trials, including 2488 participants, met the inclusion criteria. Most were small, and most were at high or unclear risk of bias in multiple domains. We included four new studies at this update. Incomplete recovery A combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in people with Bell's palsy compared to corticosteroids alone (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.38 to 1.74; 3 trials, N = 766; random‐effects; low‐certainty evidence). We excluded 10 trials that were at high or unclear risk of bias in several domains from this analysis and limited all analyses to studies at lower risk of bias. Recovery rates were better in participants receiving corticosteroids alone than antivirals alone (RR 2.69, 95% CI 0.73 to 10.01; 2 trials, N = 667; random‐effects), but the result was imprecise and allowed for the possibility of no effect. The rate of incomplete recovery was lower with antivirals plus corticosteroids than with placebo or no treatment (RR 0.56, 95% CI 0.42 to 0.76; 2 trials, N = 658; random‐effects). Antivirals alone had no clear effect on incomplete recovery rates compared with placebo, but the result was imprecise (RR 1.10, 95% CI 0.87 to 1.40; 2 trials, N = 658; fixed‐effect). For people with severe Bell's palsy (House‐Brackmann score of 5 and 6, or equivalent on other scales), we found that the combination of antivirals and corticosteroids had no clear effect on incomplete recovery at month six compared to corticosteroids alone, although the result was again imprecise (RR 0.82, 95% CI 0.57 to 1.17; 2 trials, N = 98; random‐effects). Motor synkinesis or crocodile tears Antivirals plus corticosteroids reduced the proportion of participants who experienced these long‐term sequelae from Bell's palsy compared to placebo plus corticosteroids (RR 0.56, 95% CI 0.36 to 0.87; 2 trials, N = 469; fixed‐effect; moderate‐certainty evidence). Antivirals plus corticosteroids reduced long‐term sequelae compared to placebo but there was no clear difference in this outcome with antivirals alone compared to placebo. Adverse events Adverse event data were available in four studies providing data on 1592 participants. None of the four comparisons showed clear differences in adverse events between treatment and comparison arms (very low‐certainty evidence); for the comparison of antivirals plus corticosteroids and corticosteroids alone in studies at lower risk of bias, the RR was 1.17 (95% CI 0.81 to 1.69; 2 trials, N = 656; fixed‐effect; very low‐certainty evidence). Authors' conclusions The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, or in people with severe Bell's palsy, but the results were very imprecise. Corticosteroids alone were probably more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no clear benefit from antivirals alone over placebo. The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone. Studies also showed fewer episodes of long‐term sequelae in corticosteroid‐treated participants than antiviral‐treated participants. We found no clear difference in adverse events from the use of antivirals compared with either placebo or corticosteroids, but the evidence is too uncertain for us to draw conclusions. An adequately powered RCT in people with Bell’s palsy that compares different antiviral agents may be indicated. Plain language summary Antiviral treatment for Bell's palsy Review question We reviewed the evidence about the effect of antiviral therapy (drugs used specifically to treat viral infections), alone or in combination with any other therapy, on Bell's palsy. Our focus in this updated review was combined therapy with antiviral drugs and corticosteroids (which are drugs used to reduce inflammation) as there is already good evidence that corticosteroids can reduce rates of incomplete recovery from Bell's palsy. Background Bell's palsy is a disease of the facial nerve that causes one side of the face to be paralysed. Some studies have suggested that it is caused by the same viral infections that cause cold sores or shingles and investigated the effect of antiviral therapy. Earlier versions of this review have found that antivirals alone are not helpful compared to a dummy pill, and are less effective than corticosteroids alone. However, studies of antiviral treatment in combination with corticosteroids have conflicting results. Study characteristics We identified 14 trials, which included 2488 participants with mild, moderate, or severe one‐sided Bell's palsy of unknown cause. Participants were aged from 14 to 84 years. The trials compared:
 ‐ antivirals plus corticosteroids to corticosteroids alone or in combination with placebo;
 ‐ antivirals alone or in combination with placebo to placebo or no treatment;
 ‐ antivirals alone or in combination with placebo to corticosteroid treatment alone or in combination with placebo; or
 ‐ antivirals plus corticosteroids to placebo or no treatment. For the majority of the studies, no information on funding was given. The remaining were mostly partly public funded, and one trial was funded by a pharmaceutical company. Eleven studies had high or uncertain risk of bias from various factors that can systematically affect trial results. We chose to base our conclusions only on data from three studies at a lower risk of bias. Key results and certainty of the evidence The review showed that there may be no clear difference in rates of incomplete recovery from Bell's palsy after treatment with the combination of antivirals and corticosteroids, compared to corticosteroids alone. This finding was of low certainty and was based on data from three trials involving 766 people with Bell's palsy of various degrees of severity. We excluded data from 10 trials with multiple potential sources of bias. However, we can be moderately confident that the combined therapy reduced the number of people left with long‐term effects of Bell's palsy (excessive tearing of the eyes or an abnormal facial movement) compared to corticosteroid treatment alone. Data from two studies (98 participants) showed that in people with severe Bell's palsy (complete or almost complete facial paralysis), combined antivirals and corticosteroids had no clear effect on recovery compared with corticosteroid treatment alone. Corticosteroids alone were more effective than antivirals alone on rates of incomplete recovery (667 participants, 2 trials); antivirals and corticosteroids combined were more effective than placebo or no treatment (658 participants, 2 trials); and there was no clear benefit from antivirals alone over placebo (658 participants, 2 trials). Although, based on data from two trials (656 participants), we found no clear difference in the occurrence of side effects between people receiving both antivirals and corticosteroids, compared to those receiving corticosteroids alone, this evidence is too uncertain for us to draw conclusions. Large studies in people with Bell's palsy comparing additional antiviral agents may be indicated in the future.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gagyor, I; Madhok, VB; Daly, F; Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001869.pub9", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "2e21979f-a1e0-4fe5-b225-f4cde0c52597", "pmid": "", "title": "Calcitonin for metastatic bone pain", "imported": false, "abstract": "Abstract - Background Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastases. The hormone calcitonin has the potential to relieve pain and also retain bone density, thus reducing the risk of fractures. This review is an update of a previously published review in the Cochrane Library (2003, Issue 3) which was also updated in 2006 (Issue 3) and in 2011 (Issue 9). Objectives The main objective of the review is to determine the effectiveness of calcitonin to reduce metastatic bone pain in patients with painful bone metastases. Secondary objectives are to assess the benefits of calcitonin in reducing the incidence of bone complications (hypercalcemia, fractures and nervous compression) and improving patient survival, and to report any adverse effects of the treatment. Search methods We updated the electronic searches in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2015. We also searched registers of clinical trials in progress up to February 2015. Selection criteria We included studies if they were randomised, double‐blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. Data collection and analysis Two independent review authors performed study selection and data extraction. Only two studies (90 participants) were eligible for inclusion in the review and therefore meta‐analysis of the data was not possible. We performed intention‐to‐treat (ITT) analysis by imputing all missing values as adverse effects. Main results The overall quality of the evidence was very low. In this update no new studies were identified for inclusion; one additional study was excluded. Of the two small included studies, one study showed a non‐significant effect of calcitonin on the number of patients with complete pain relief (risk ratio (RR) 2.50; 95% confidence interval (CI) 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; 95% CI 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases, for improving quality of life or for patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.50; 95% CI 0.77 to 15.88). Authors' conclusions Current available research evidence is of very low quality and there is a lack of evidence to support the use of calcitonin for managing bone pain from bone metastases. Since the last version of this review, we did not identify any additional studies. Plain language summary Calcitonin used to treat metastatic bone pain People who have cancer which has spread to their bones and the nerves adjacent to the bones often suffer severe pain. There are several treatments to help relieve this pain: radiotherapy, analgesic drugs (pain killers) such as opioids, and bone‐modulating drugs such as bisphosphonates and calcitonin. Calcitonin has the potential to relieve pain and maintain bone strength, thus reducing the risk of broken bones. This review looked at the effectiveness of calcitonin for controlling pain from bone metastases. However, only two studies were found with very low quality evidence to support the use of calcitonin for patients suffering from bone pain. We updated the review in 2015 and did not find any more studies. There were slightly more side effects for the patients given calcitonin. Unless new studies provide additional relevant information about this treatment, other therapeutic approaches should be considered.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Martinez-Zapata, MJ; Roqué i Figuls, M; Català, E; Roman, Y; Alonso Coello, P", "articleTypes": [], "doi": "10.1002/14651858.CD003223.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "2e34f84b-b0a5-4dac-8509-15006539903c", "pmid": "", "title": "Aversive smoking for smoking cessation", "imported": false, "abstract": "Abstract - Background Aversion therapy pairs the pleasurable stimulus of smoking a cigarette with some unpleasant stimulus. The objective is to extinguish the urge to smoke. Objectives This review has two aims: First, to determine the efficacy of rapid smoking and other aversive methods in helping smokers to stop smoking; Second, to determine whether there is a dose‐response effect on smoking cessation at different levels of aversive stimulation. Search methods We searched the Cochrane Tobacco Addiction Group specialised register (latest search date October 2009) for studies which evaluated any technique of aversive smoking. Selection criteria Randomized trials which compared aversion treatments with 'inactive' procedures or which compared aversion treatments of different intensity for smoking cessation. Trials must have reported follow up of least six months from beginning of treatment. Data collection and analysis We extracted data in duplicate on the study population, the type of aversion treatment, the outcome measure, method of randomization and completeness of follow up. The outcome measure was abstinence from smoking at maximum follow up, using the strictest measure reported by the authors. Subjects lost to follow up were regarded as smokers. Where appropriate, we performed meta‐analysis using a fixed effect model. Main results Twenty‐five trials met the inclusion criteria. Twelve included rapid smoking and nine used other aversion methods. Ten trials included two or more conditions allowing assessment of a dose‐response to aversive stimulation. The odds ratio (OR) for abstinence following rapid smoking compared to control was 2.01 (95% confidence intervals (CI): 1.36 to 2.95). Several factors suggest that this finding should be interpreted cautiously. A funnel plot of included studies was asymmetric, due to the relative absence of small studies with negative results. Most trials had a number of serious methodological problems likely to lead to spurious positive results. The only trial using biochemical validation of all self reported cessation gave a non‐significant result. Other aversion methods were not shown to be effective (OR 1.15, 95% CI 0.73 to 1.82). There was a borderline dose‐response to the level of aversive stimulation (OR 1.67, 95% CI 0.99 to 2.81). Authors' conclusions The existing studies provide insufficient evidence to determine the efficacy of rapid smoking, or whether there is a dose‐response to aversive stimulation. Milder versions of aversive smoking seem to lack specific efficacy. Rapid smoking is an unproven method with sufficient indications of promise to warrant evaluation using modern rigorous methodology. Plain language summary Does smoking in a way that is unpleasant help smokers to quit Aversion treatments pair undesirable behaviours with negative sensations. In smoking cessation, several approaches have been suggested such as rapid smoking, which requires smokers to take a puff every few seconds to make smoking unpleasant. The results of the existing trials suggest that this may be effective, but the evidence is not conclusive because most of the studies of this approach have methodological problems. A recent laboratory study also suggests that the method has an active ingredient. Further research may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Hajek, P; Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "2e5a5d80-4ec5-460f-955f-570e87d67e5d", "pmid": "", "title": "Protein substitute for children and adults with phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria is an inherited metabolic disorder characterised by an absence or deficiency of the enzyme phenylalanine hydroxylase. The aim of treatment is to lower blood phenylalanine concentrations to the recommended therapeutic range to prevent developmental delay and support normal growth. Current treatment consists of a low‐phenylalanine diet in combination with a protein substitute which is free from or low in phenylalanine. Guidance regarding the use, dosage, and distribution of dosage of the protein substitute over a 24‐hour period is unclear, and there is variation in recommendations among treatment centres. This is an update of a Cochrane review first published in 2005, and previously updated in 2008. Objectives To assess the benefits and adverse effects of protein substitute, its dosage, and distribution of dose in children and adults with phenylketonuria who are adhering to a low‐phenylalanine diet. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which consists of references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. We also contacted manufacturers of the phenylalanine‐free and low‐phenylalanine protein substitutes for any data from published and unpublished randomised controlled trials. Date of the most recent search of the Group's Inborn Errors of Metabolism Trials Register: 03 April 2014. Selection criteria All randomised or quasi‐randomised controlled trials comparing: any dose of protein substitute with no protein substitute; an alternative dosage; or the same dose, but given as frequent small doses throughout the day compared with the same total daily dose given as larger boluses less frequently. Data collection and analysis Both authors independently extracted data and assessed trial quality. Main results Three trials (69 participants) are included in this review. One trial investigated the use of protein substitute in 16 participants, while a further two trials investigated the dosage of protein substitute in a total of 53 participants. Due to issues with data presentation in each trial, described in full in the review, formal statistical analyses of the data were impossible. Investigators will be contacted for further information. Authors' conclusions No conclusions could be drawn about the short‐ or long‐term use of protein substitute in phenylketonuria due to the lack of adequate or analysable trial data. Additional data and randomised controlled trials are needed to investigate the use of protein substitute in phenylketonuria. Until further evidence is available, current practice in the use of protein substitute should continue to be monitored with care. Plain language summary The impact of protein substitute on the nutrition status, growth, and neuropsychological performance of children and adults with phenylketonuria People with phenylketonuria (PKU) who follow a low‐phenylalanine diet are required to take protein substitute to ensure adequate consumption of protein, energy, and other nutrients. The need for protein substitute has been established through clinical experience and observational data. Randomised, controlled trials are needed to confirm this need as well as its proper dosage and frequency of use. We performed a systematic review of randomised control trials investigating the impact of the use, dosage, and distribution of protein substitute on physical and neuropsychological outcomes in the treatment of PKU. Trials of children and adults diagnosed with PKU in the newborn period who were treated early and continuously were included. We planned to pool the results of the trials to estimate treatment effect. Three trials met the inclusion criteria for the review. One trial evaluated the impact of protein substitute versus no protein substitute on neuropsychological status, plasma amino acid concentrations, and nutrient intake. The remaining two trials investigated the impact of differing dosages of protein substitute on plasma amino acid concentrations and nutrient intake. No trials investigating daily protein substitute distribution were eligible for inclusion in the review. Results are presented in text form only since adequate information for data pooling was not provided. The investigators will be contacted for further information. Currently data are insufficient to reach any conclusions regarding the use, dosage, and distribution of protein substitute in the treatment of PKU. Further randomized or controlled clinical trials are needed to provide evidence for the effectiveness, dosage, and distribution of protein substitute in the treatment of PKU.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Yi, SHL, Singh, RH", "articleTypes": [], "doi": "10.1002/14651858.CD004731.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.747Z" }, { "id": "2e5a7b26-ccc5-433e-b1ec-d5fbffccffad", "pmid": "", "title": "Vitamin and mineral supplementation for maintaining cognitive function in cognitively healthy people in mid and late life", "imported": false, "abstract": "Abstract - Background Vitamins and minerals play multiple functions within the central nervous system which may help to maintain brain health and optimal cognitive functioning. Supplementation of the diet with various vitamins and minerals has been suggested as a means of maintaining cognitive function, or even of preventing dementia, in later life. Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function in cognitively healthy people aged 40 years or more. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov and the WHO Portal/ICTRP from inception to 26th January 2018. Selection criteria We included randomised controlled trials that evaluated the cognitive effects on people aged 40 years or more of any vitamin or mineral supplements taken by mouth for at least three months. Data collection and analysis Study selection, data extraction, and quality assessments were done in duplicate. Vitamins were considered broadly in the categories of B vitamins, antioxidant vitamins, and combinations of both. Minerals were considered separately, where possible. If interventions and outcomes were considered sufficiently similar, then data were pooled. In order to separate short‐term cognitive effects from possible longer‐term effects on the trajectory of cognitive decline, data were pooled for various treatment durations from 3 months to 12 months and up to 10 years or more. Main results In total, we included 28 studies with more than 83,000 participants. There were some general limitations of the evidence. Most participants were enrolled in studies which were not designed primarily to assess cognition. These studies often had no baseline cognitive assessment and used only brief cognitive assessments at follow‐up. Very few studies assessed the incidence of dementia. Most study reports did not mention adverse events or made only very general statements about them. Only 10 studies had a mean follow‐up > 5 years. Only two studies had participants whose mean age was < 60 years at baseline. The risk of bias in the included studies was generally low, other than a risk of attrition bias for longer‐term outcomes. We considered the certainty of the evidence behind almost all results to be moderate or low. We included 14 studies with 27,882 participants which compared folic acid, vitamin B12, vitamin B6, or a combination of these to placebo. The majority of participants were aged over 60 years and had a history of cardio‐ or cerebrovascular disease. We found that giving B vitamin supplements to cognitively healthy adults, mainly in their 60s and 70s, probably has little or no effect on global cognitive function at any time point up to 5 years (SMD values from ‐0.03 to 0.06) and may also have no effect at 5‐10 years (SMD ‐0.01). There were very sparse data on adverse effects or on incidence of cognitive impairment or dementia. We included 8 studies with 47,840 participants in which the active intervention was one or more of the antioxidant vitamins: ß‐carotene, vitamin C or vitamin E. Results were mixed. For overall cognitive function, there was low‐certainty evidence of benefit associated with ß‐carotene after a mean of 18 years of treatment (MD 0.18 TICS points, 95% CI 0.01 to 0.35) and of vitamin C after 5 years to 10 years (MD 0.46 TICS points, 95% CI 0.14 to 0.78), but not at earlier time points. From two studies which reported on dementia incidence, there was low‐certainty evidence of no effect of an antioxidant vitamin combination or of vitamin E, either alone or combined with selenium. One of the included studies had been designed to look for effects on the incidence of prostate cancer; it found a statistically significant increase in prostate cancer diagnoses among men taking vitamin E. One trial with 4143 participants compared vitamin D3 (400 IU/day) and calcium supplements to placebo. We found low‐ to moderate‐certainty evidence of no effect of vitamin D3 and calcium supplements at any time‐point up to 10 years on overall cognitive function (MD after a mean of 7.8 years ‐0.1 MMSE points, 95% CI ‐0.81 to 0.61) or the incidence of dementia (HR 0.94, 95% CI 0.72 to 1.24). A pilot study with 60 participants used a higher dose of vitamin D3 (4000 IU on alternate days) and found preliminary evidence that this dose probably has no effect on cognitive function over six months. We included data from one trial of zinc and copper supplementation with 1072 participants. There was moderate‐certainty evidence of little or no effect on overall cognitive function (MD 0.6 MMSE points, 95% CI ‐0.19 to 1.39) or on the incidence of cognitive impairment after 5 years to 10 years. A second smaller trial provided no usable data, but reported no cognitive effects of six months of supplementation with zinc gluconate. From one study with 3711 participants, there was low‐certainty evidence of no effect of approximately five years of selenium supplementation on the incidence of dementia (HR 0.83, 95% CI 0.61 to 1.13). Finally, we included three trials of complex supplements (combinations of B vitamins, antioxidant vitamins, and minerals) with 6306 participants. From the one trial which assessed overall cognitive function, there was low‐certainty evidence of little or no effect on the TICS (MD after a mean of 8.5 years 0.12, 95% CI ‐0.14 to 0.38). Authors' conclusions We did not find evidence that any vitamin or mineral supplementation strategy for cognitively healthy adults in mid or late life has a meaningful effect on cognitive decline or dementia, although the evidence does not permit definitive conclusions. There were very few data on supplementation starting in midlife (< 60 years); studies designed to assess cognitive outcomes tended to be too short to assess maintenance of cognitive function; longer studies often had other primary outcomes and used cognitive measures which may have lacked sensitivity. The only positive signals of effect came from studies of long‐term supplementation with antioxidant vitamins. These may be the most promising for further research. Plain language summary Vitamin and mineral supplementation for preventing cognitive deterioration in cognitively healthy people in mid and late life Review question This review aimed to find out whether people aged 40 years or older could maintain their mental abilities or reduce their risk of dementia by taking vitamin or mineral supplements. Background There is great interest in anything people might do to keep themselves mentally healthy as they age and, especially, to reduce their risk of developing dementia. Various vitamin and mineral supplements have been suggested as ways to do this. Vitamins and minerals have many functions in the body and the ways they might affect brain health are not well understood. Therefore, we were interested in the effects of any vitamins or minerals, either alone or in combination. What we did We searched up to January 2018 for all trials which had studied the effect on cognition (thinking and remembering) of any vitamin or mineral supplements in people aged 40 years or more who had no cognitive problems at the beginning of the study. The studies had to include a comparison group which had not taken the supplement being studied and, to be sure the comparison was fair, it should have been decided at random whether people got the supplement or not. What we found We grouped the 28 included trials according to the kind of supplement they used and how it might work. Most of the trials were not originally designed to study cognition or dementia and used only simple measures of cognition. Very few studies investigated whether participants developed dementia. Long‐term studies are probably needed to find effects on the risk of dementia or cognitive decline but only 10 studies had an average length of follow‐up longer than five years. The studies were generally well‐conducted although the longer trials had difficulty following up all of the participants and this could have biased some of the longer‐term results. There were 14 trials of B vitamins (folic acid, vitamin B6, vitamin B12) with nearly 28,000 participants, mainly in their 60s and 70s. Most of these trials were quite short (less than two years). We found no evidence that B vitamins had any effect on cognition. There were 8 trials of antioxidant vitamins (beta‐carotene/vitamin A, vitamin C, vitamin E) with approximately 47,000 participants. These trials tended to be longer than the B vitamin trials so may have had more chance of detecting effects on dementia and cognitive decline. The results were mixed. We found low‐certainty evidence of better overall cognitive function after an average of 18 years taking beta‐carotene and after five years to 10 years taking vitamin C, but no effects after shorter periods of treatment. There were also small benefits of beta‐carotene, vitamin C, and antioxidant combinations on memory at some time points but not others. There was no evidence of any benefits from vitamin E alone. Two studies examined the risk of developing dementia. One found no effect of a combination of antioxidant vitamins and the other found no effect of vitamin E, either alone or combined with the mineral selenium. Most of the studies did not report any information about harmful effects. One included trial was designed to look for an effect on the risk of prostate cancer; it found a higher risk among the men taking vitamin E. There was a small trial of vitamin D supplements which found they probably had no effect on cognition over six months. There were longer trials of vitamin D with calcium (one trial), zinc and copper (one trial), and complex multivitamins (three trials). All lasted between five and 10 years, but none of them found any evidence of beneficial effects on cognition. One trial found no effect of selenium taken for approximately five years on the risk of developing dementia. Conclusions We found no good evidence to suggest that middle‐aged or older people can preserve cognitive function or prevent dementia by taking vitamin or mineral supplements. There were a few positive results associated with long‐term use of antioxidant vitamins, particularly beta‐carotene and vitamin C, although the effects were small. Further research into the effects of these vitamins may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rutjes, AWS, Denton, DA, Di Nisio, M, Chong, LY, Abraham, RP, Al‐Assaf, AS, Anderson, JL, Malik, MA, Vernooij, RWM, Martínez, G, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011906.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.773Z" }, { "id": "2e5c27bd-c2bc-40ce-b8ff-e131e05624b0", "pmid": "", "title": "The Effects of Semaglutide on Modulation of Taste Sensitivity, Tongue Tissue Transcriptome, Gastric Emptying and Central Neural Responses in Women With PCOS and Obesity: a Randomized, Single-blind, Placebo-controlled Clinical Trial", "imported": false, "abstract": "The purpose of the study is to explore the effects of GLP-1 receptor agonist (GLP-1 RA) semaglutide on modulation of taste sensitivity, tongue tissue transcriptome, modulation of neural response in central reward processing regions and gastric emptying rate. In addition, we aim to investigate the associations between semaglutide induced modulation of taste sensitivity, neural responses and gastric emptying with changes in body mass, eating- behavioural pattern, food perception and food intake.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.256Z" }, { "id": "2e6bdd0a-47f1-4554-995a-41102d65ee8b", "pmid": "", "title": "Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults", "imported": false, "abstract": "Abstract - Background Acetylcholinesterase inhibitors, such as neostigmine, have traditionally been used for reversal of non‐depolarizing neuromuscular blocking agents. However, these drugs have significant limitations, such as indirect mechanisms of reversal, limited and unpredictable efficacy, and undesirable autonomic responses. Sugammadex is a selective relaxant‐binding agent specifically developed for rapid reversal of non‐depolarizing neuromuscular blockade induced by rocuronium. Its potential clinical benefits include fast and predictable reversal of any degree of block, increased patient safety, reduced incidence of residual block on recovery, and more efficient use of healthcare resources. Objectives The main objective of this review was to compare the efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade caused by non‐depolarizing neuromuscular agents in adults. Search methods We searched the following databases on 2 May 2016: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (WebSPIRS Ovid SP), Embase (WebSPIRS Ovid SP), and the clinical trials registries www.controlled‐trials.com , clinicaltrials.gov , and www.centerwatch.com . We re‐ran the search on 10 May 2017. Selection criteria We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published, or language. We included adults, classified as American Society of Anesthesiologists (ASA) I to IV, who received non‐depolarizing neuromuscular blocking agents for an elective in‐patient or day‐case surgical procedure. We included all trials comparing sugammadex versus neostigmine that reported recovery times or adverse events. We included any dose of sugammadex and neostigmine and any time point of study drug administration. Data collection and analysis Two review authors independently screened titles and abstracts to identify trials for eligibility, examined articles for eligibility, abstracted data, assessed the articles, and excluded obviously irrelevant reports. We resolved disagreements by discussion between review authors and further disagreements through consultation with the last review author. We assessed risk of bias in 10 methodological domains using the Cochrane risk of bias tool and examined risk of random error through trial sequential analysis. We used the principles of the GRADE approach to prepare an overall assessment of the quality of evidence. For our primary outcomes (recovery times to train‐of‐four ratio (TOFR) > 0.9), we presented data as mean differences (MDs) with 95 % confidence intervals (CIs), and for our secondary outcomes (risk of adverse events and risk of serious adverse events), we calculated risk ratios (RRs) with CIs. Main results We included 41 studies (4206 participants) in this updated review, 38 of which were new studies. Twelve trials were eligible for meta‐analysis of primary outcomes (n = 949), 28 trials were eligible for meta‐analysis of secondary outcomes (n = 2298), and 10 trials (n = 1647) were ineligible for meta‐analysis. We compared sugammadex 2 mg/kg and neostigmine 0.05 mg/kg for reversal of rocuronium‐induced moderate neuromuscular blockade (NMB). Sugammadex 2 mg/kg was 10.22 minutes (6.6 times) faster then neostigmine 0.05 mg/kg (1.96 vs 12.87 minutes) in reversing NMB from the second twitch (T2) to TOFR > 0.9 (MD 10.22 minutes, 95% CI 8.48 to 11.96; I 2 = 84%; 10 studies, n = 835; GRADE: moderate quality). We compared sugammadex 4 mg/kg and neostigmine 0.07 mg/kg for reversal of rocuronium‐induced deep NMB. Sugammadex 4 mg/kg was 45.78 minutes (16.8 times) faster then neostigmine 0.07 mg/kg (2.9 vs 48.8 minutes) in reversing NMB from post‐tetanic count (PTC) 1 to 5 to TOFR > 0.9 (MD 45.78 minutes, 95% CI 39.41 to 52.15; I 2 = 0%; two studies, n = 114; GRADE: low quality). For our secondary outcomes, we compared sugammadex, any dose, and neostigmine, any dose, looking at risk of adverse and serious adverse events. We found significantly fewer composite adverse events in the sugammadex group compared with the neostigmine group (RR 0.60, 95% CI 0.49 to 0.74; I 2 = 40%; 28 studies, n = 2298; GRADE: moderate quality). Risk of adverse events was 28% in the neostigmine group and 16% in the sugammadex group, resulting in a number needed to treat for an additional beneficial outcome (NNTB) of 8. When looking at specific adverse events, we noted significantly less risk of bradycardia (RR 0.16, 95% CI 0.07 to 0.34; I 2 = 0%; 11 studies, n = 1218; NNTB 14; GRADE: moderate quality), postoperative nausea and vomiting (PONV) (RR 0.52, 95% CI 0.28 to 0.97; I 2 = 0%; six studies, n = 389; NNTB 16; GRADE: low quality) and overall signs of postoperative residual paralysis (RR 0.40, 95% CI 0.28 to 0.57; I 2 = 0%; 15 studies, n = 1474; NNTB 13; GRADE: moderate quality) in the sugammadex group when compared with the neostigmine group. Finally, we found no significant differences between sugammadex and neostigmine regarding risk of serious adverse events (RR 0.54, 95% CI 0.13 to 2.25; I 2 = 0%; 10 studies, n = 959; GRADE: low quality). Application of trial sequential analysis (TSA) indicates superiority of sugammadex for outcomes such as recovery time from T2 to TOFR > 0.9, adverse events, and overall signs of postoperative residual paralysis. Authors' conclusions Review results suggest that in comparison with neostigmine, sugammadex can more rapidly reverse rocuronium‐induced neuromuscular block regardless of the depth of the block. Sugammadex 2 mg/kg is 10.22 minutes (˜ 6.6 times) faster in reversing moderate neuromuscular blockade (T2) than neostigmine 0.05 mg/kg (GRADE: moderate quality), and sugammadex 4 mg/kg is 45.78 minutes (˜ 16.8 times) faster in reversing deep neuromuscular blockade (PTC 1 to 5) than neostigmine 0.07 mg/kg (GRADE: low quality). With an NNTB of 8 to avoid an adverse event, sugammadex appears to have a better safety profile than neostigmine. Patients receiving sugammadex had 40% fewer adverse events compared with those given neostigmine. Specifically, risks of bradycardia (RR 0.16, NNTB 14; GRADE: moderate quality), PONV (RR 0.52, NNTB 16; GRADE: low quality), and overall signs of postoperative residual paralysis (RR 0.40, NNTB 13; GRADE: moderate quality) were reduced. Both sugammadex and neostigmine were associated with serious adverse events in less than 1% of patients, and data showed no differences in risk of serious adverse events between groups (RR 0.54; GRADE: low quality). Plain language summary Benefits and harms of sugammadex versus neostigmine in reversing induced paralysis Background Different levels of induced paralysis are sometimes necessary when patients are put to sleep or are prepared for operations. When the operation is finished, paralysis should be reversed in a fast, reliable, and safe way. Neostigmine is a medication that is traditionally used to reverse induced paralysis. However, its use can be associated with incomplete or slow reversal as well as changes in lung function, heart function, and vomiting and nausea. Sugammadex is a relatively new medication specifically designed to reverse rocuronium‐induced paralysis in a faster, more reliable, and safer way when compared with neostigmine. Objective This review systematically sets out to compare the benefits and harms of sugammadex and neostigmine. The evidence is current up to May 2017. Study characteristics We identified 41 randomized controlled trials comparing sugammadex with neostigmine that provided suitable data on efficacy and safety. All of these trials included adults undergoing surgery and involved a total of 4206 participants. Key results Data indicate that sugammadex was 10.22 minutes (6.6 times) faster than neostigmine (1.96 vs 12.87 minutes) in reversing moderate induced paralysis. Sugammadex was 45.78 minutes (16.8 times) faster than neostigmine (2.9 vs 48.8 minutes) in reversing deep induced paralysis. Participants receiving sugammadex appeared to have a 40% reduced risk of experiencing harmful events than those given neostigmine. Statistically, eight persons can be treated with sugammadex as opposed to neostigmine to avoid one person experiencing a single random harmful event. The occurrence of serious harmful events was nearly non‐existent and data show no differences between compared groups. Conclusion Sugammadex is more efficient and safer than neostigmine for reversing moderate and deep induced paralysis. Quality of evidence We consider our overall findings on benefits and harms to provide evidence of moderate quality in favour of sugammadex.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Hristovska, AM, Duch, P, Allingstrup, M, Afshari, A", "articleTypes": [], "doi": "10.1002/14651858.CD012763", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.799Z" }, { "id": "2e97a726-4eb7-416c-8ed3-c831ced8bc09", "pmid": "", "title": "The Functional Significance of Gut-expressed Taste Receptors in the Secretion of Glucagon-like Peptide-1 and Peptide YY", "imported": false, "abstract": "The purpose of this study is to determine the functional significance of sweet taste receptors in the secretion of GI satiety peptides by using a specific sweet taste receptor antagonist to block sweet taste perception in the gut.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.142Z" }, { "id": "2e9911e5-d24b-44ba-8d9a-cb58a1b53ad9", "pmid": "", "title": "Interventions to prevent obesity in children aged 2 to 4 years old", "imported": false, "abstract": "Abstract - Rationale Early childhood presents an important opportunity for obesity prevention, an international public health priority. Interventions aiming to prevent obesity typically promote healthy diets or activity levels (physical activity, sedentary behaviour), or both. There is uncertainty over which approaches are more effective. This is one of a suite of three reviews addressing interventions for preventing obesity in children, each focusing on different age groups up to 18 years. These reviews replace and update a 2019 Cochrane review on interventions for preventing obesity in children from birth to 18 years. Objectives To assess the effects of interventions that aimed to prevent obesity in children aged two to four years by changing dietary intake or activity levels, or both, on body mass index (BMI), BMI z‐score (zBMI), BMI percentile, and serious adverse events. Search methods We searched CENTRAL, MEDLINE, Embase, six other databases, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify eligible studies. The latest search date was 7 February 2023. Eligibility criteria We included randomised controlled trials (RCTs) in children aged two to four years, comparing dietary or activity interventions (or both combined) to prevent overweight or obesity versus no intervention, usual care, or another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post‐baseline. There were no language restrictions. Outcomes Our outcomes were BMI, zBMI, BMI percentile, and serious adverse events. Risk of bias We used version 2 of the Cochrane risk of bias tool (RoB 2) to assess included RCTs. Synthesis methods Working independently, two authors screened studies, extracted data, and conducted risk of bias and GRADE assessments. We conducted random‐effects meta‐analyses stratified by type of intervention and follow‐up duration. Included studies We included 67 studies (36,601 participants), with 56 studies (21,404 participants) pooled in the meta‐analyses. Sixty‐three studies were conducted in high‐income countries. Study settings were split between childcare (26 studies; 39%), home (23 studies; 34%), and home plus childcare settings (10 studies; 15%). Few studies were conducted in the community (three studies; 5%) or healthcare settings (five studies; 7%). Most studies compared a combined dietary/activity intervention with a control group. Synthesis of results Dietary interventions versus control Dietary interventions may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0.00, 95% confidence interval (CI) ‐0.28 to 0.28; 1 study, 94 participants; low‐certainty evidence). At medium‐ and long‐term follow‐up, dietary interventions may result in little to no difference in BMI. One study (103 participants; low‐certainty evidence) reported no difference in BMI at medium‐term follow‐up, and one study (2238 participants; low‐certainty evidence) found lower rates of overweight and obesity in the intervention group at long‐term follow‐up. Dietary interventions likely result in little to no difference in zBMI at short‐term (MD 0.03, 95% CI ‐0.13 to 0.19; 2 studies, 145 participants) and medium‐term follow‐up (MD ‐0.17, 95% CI ‐0.44 to 0.10; 1 study, 389 participants), both with moderate‐certainty evidence. None of the included studies reported zBMI at long‐term follow‐up. None of the studies reported serious adverse events. Activity interventions versus control Activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.10, 95% CI ‐0.28 to 0.08; 6 studies, 826 participants; very low‐certainty evidence). They likely reduce BMI at medium‐term follow‐up (MD ‐0.70, 95% CI ‐1.09 to ‐0.31; 1 study, 567 participants; moderate‐certainty evidence). None of the studies reported BMI at long‐term follow‐up. Activity interventions likely result in little to no difference in zBMI at short‐term follow‐up (MD ‐0.06, 95% CI ‐0.19 to 0.07; 3 studies, 635 participants; moderate‐certainty evidence). They may result in little to no difference in zBMI at medium‐term follow‐up, but the evidence is very uncertain (MD ‐0.00, 95% CI ‐0.12 to 0.11; 4 studies, 1083 participants; very low‐certainty evidence). None of the included studies reported zBMI at long‐term follow‐up. Activity interventions may have little to no effect on serious adverse events, but the evidence is very uncertain (2 studies, 773 participants; very low‐certainty evidence). One study found no harms related to the intervention, and one study reported no difference in accident and infection rates between groups. Combined dietary/activity interventions versus control Combined dietary/activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.08, 95% CI ‐0.20 to 0.04; 13 studies, 3867 participants; very low‐certainty evidence). They may result in little to no difference in BMI at medium‐term follow‐up (MD ‐0.05, 95% CI ‐0.18 to 0.08; 9 studies, 7016 participants; low‐certainty evidence), and may result in a slight reduction in BMI at long‐term follow‐up (MD ‐0.20, 95% CI ‐0.39 to ‐0.01; 5 studies, 2074 participants; low‐certainty evidence). Combined interventions may have little to no effect on zBMI at short‐term follow‐up (MD ‐0.03, 95% CI ‐0.07 to 0.01; 14 studies, 5518 participants), and may result in a slight reduction in zBMI at medium‐term follow‐up, but the evidence for both time frames is very uncertain (MD ‐0.07, 95% CI ‐0.11 to ‐0.04; 15 studies; 11,043 participants). Combined interventions may result in a slight reduction in zBMI at long‐term follow‐up (MD ‐0.07, 95% CI ‐0.13 to ‐0.01; 10 studies, 4693 participants; low‐certainty evidence). Combined interventions may result in little to no difference in serious adverse events, but the evidence is very uncertain (4 studies, 1689 participants; very low‐certainty evidence). One study reported that a parent fractured an ankle while roller‐skating at a community centre; the remaining studies reported no adverse events. Authors' conclusions In early childhood, combined dietary/activity interventions may have very modest benefits on BMI and zBMI at long‐term follow‐up. When implemented alone, dietary or activity interventions may have little to no effect on BMI measures. Only six studies reported serious adverse events, with no serious harms resulting directly from the intervention, but the evidence is very uncertain. Funding This review was partly funded by the National Institute for Health Research, School for Public Health Research. Registration Protocol available: DOI: 10.1002/14651858.CD015326 Plain language summary Do dietary and activity strategies help prevent obesity in children aged 2 to 4 years? Key messages Combining strategies for changing diet and physical activity levels in children aged 2 to 4 years to help prevent overweight and obesity may reduce body mass index (BMI) slightly in the long term (after 15 months). There was very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but none of the strategies appeared to result in any serious harm to the children. Future research should carry out obesity prevention strategies in community settings, and target the wider determinants of obesity and obesity prevention. Why is preventing obesity in children important? There is an increasing number of young children living with overweight and obesity worldwide, with evidence of the rates increasing in line with social inequality. Living with overweight during childhood can cause physical and psychological health problems. Children living with overweight are more likely to live with overweight as adults, and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help people change diet or activity (or both) are effective at preventing obesity in children aged 2 to 4 years, and whether they are associated with any serious adverse events. To examine obesity, we used the measure of body mass index (BMI). BMI is calculated by dividing a person's weight (in kg) by their height (in m 2 ). What did we do? We searched for studies that looked at ways to prevent obesity in children aged 2 to 4 years. We did not include studies that only targeted children who were already living with overweight or obesity, but we did include studies involving children at a range of weights. We only included studies if they used methods aimed at changing children's diet, activity level (increasing physical activity or reducing sedentary behaviour), or both. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 67 studies involving 36,601 children aged 2 to 4 years. Most studies (63 of 67) were based in high‐income countries, and four in upper‐middle‐income countries. In 26 studies, the strategies were conducted in childcare settings, 23 studies were primarily home‐based, and 10 were performed in both childcare and home‐based settings. Only 3 studies were conducted in the community, and 5 in healthcare settings. The duration of the programmes varied: 47 ran for fewer than 9 months, with the shortest being 1 visit and the longest lasting 3 years. We analysed results from 56 studies involving 21,404 children. Main findings Children who were helped with a strategy to change their diet and activity levels may have had a reduced BMI, compared with children not given any strategy. This means that these children may have been able to minimise excess weight gain by a small amount, which, for public health, is important. Children who were helped with a strategy to change their diet or activity alone did not have a reduced BMI. Only six of the 67 included studies reported on serious adverse events, and no serious harms were identified. What are the limitations of the evidence? Overall, our confidence in the evidence is very low. However, we do not believe that results from more studies similar in design to those included in this review would produce a higher level of confidence in the results. Four main factors reduced our confidence in the evidence. Results were very inconsistent across different studies. There were not enough studies reporting specific types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons. Results from some studies were not reported in a way that we could include in our analyses and this may have had an impact on the combined results. Studies generally had limitations in how they were conducted, due to the complexity of studies in this age group. This review does not provide enough information to assess how well these strategies work for children with disabilities or those from low‐ and middle‐income countries. How current is this evidence? This review updates a previous review. The evidence is current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Phillips, SM; Spiga, F; Moore, THM; Dawson, S; Stockton, H; Rizk, R; Cheng, HY; Hodder, RK; Gao, Y; Hillier-Brown, F; Rai, K; Yu, CB; O'Brien, KM; Summerbell, CD", "articleTypes": [], "doi": "10.1002/14651858.CD015326.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "2ea17985-682b-4e42-9308-7fab9ed2fd24", "pmid": "", "title": "Enteral tube feeding for people with severe dementia", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Davies, N, Barrado-Martín, Y, Vickerstaff, V, Rait, G, Fukui, A, Candy, B, Smith, CH, Manthorpe, J, Moore, KJ, Sampson, EL", "articleTypes": [], "doi": "10.1002/14651858.CD013503.pub2 AB - Abstract - Background The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing. Objectives To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021. Selection criteria We included randomised controlled trials (RCTs), or controlled non‐randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post‐pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers. Data collection and analysis Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non‐randomised Studies of Interventions' (ROBINS‐I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre‐agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta‐analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study. Main results We found no eligible RCTs. We included fourteen controlled, non‐randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low‐certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate‐certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very‐low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low‐certainty evidence. Five studies reported a variety of harm‐related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia. Authors' conclusions We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here. Plain language summary Enteral tube feeding for people with severe dementia What are the advantages and problems of tube feeding people with severe dementia? Key messages Tube feeding may not increase the length of time people with severe dementia live compared to no tube feeding. The risk of developing a pressure sore is probably higher with a feeding tube than with no tube. No studies looked at quality of life.We need more and better studies to investigate tube feeding people with severe dementia. Future studies should focus on a broader range of outcomes including, pain, quality of life and the impact on carers What is tube feeding? Somebody who can’t eat or drink through their mouth may be given liquid food through a tube into their stomach. This is called enteral tube feeding. The tube passes through their nose into their stomach (a nasogastric tube), or is inserted into the stomach through a small cut in their belly (percutaneous endoscopic gastrostomy or PEG). Why is this important for people with dementia? People with dementia often have difficulties eating and drinking. During the early stages of dementia, they may forget to eat, chew food without swallowing, or be confused at mealtimes. Some people experience changes in the taste and smell of food. In the later stages of dementia, people often have difficulties swallowing. It can be difficult to ensure they receive appropriate food and fluids. People with severe dementia need full‐time care, and it is often their families who care for them. It is difficult to decide whether or not to tube‐feed someone with dementia because the feeding tube can be uncomfortable or even painful, and may cause other unwanted effects such as pneumonia, worsen bowel or bladder control, as well as bleeding, swelling and infection. People with severe dementia may be confused or distressed by the tube and may try to remove it. What did we want to find out? We wanted to know whether tube feeding helps people with severe dementia who have problems with eating and swallowing. We were interested in the effect of tube feeding on: how long people lived; their quality of life (well‐being); and the development or healing of pressure sores (also known as bed sores). What did we do? 
We searched for studies that investigated whether: PEG compared to no tube; a nasogastric tube compared to no tube; orPEG, nasogastric and other types of tube feeding compared to no tube was effective and whether tube feeding caused any unwanted effects in adults of any age with severe dementia and poor intake of food and drink. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 14 studies that included 49,714 participants. Of these, 6203 were tube‐fed and 43,511 were not. Participants with no feeding tube were given standard care or standard care with extra treatments to encourage eating and drinking. Main results In people with severe dementia, compared to no tube feeding: PEG may make no difference to how long people live (4 studies, 36,816 people), and leads to a small increase in the chance of developing pressure sores (1 study, 4421 people). we don’t know if nasogastric tube feeding increases the length of time people live or increases their chance of developing pressure sores, because none of our included studies gave information about these points. Studies of people with either PEG or nasogastric tubes showed tube feeding may increase the length of time people live (4 studies, 1696 people), and may slightly increase the chance of developing pressure sores (3 studies, 351 people). None of our included studies reported quality of life. What are the limitations of the evidence? We have moderate confidence in our finding that pressure ulcers were more common in people who were fed with a PEG tube. However, we have little to very little confidence for our other findings. Three main factors reduced our confidence in the evidence. Firstly, people in the studies were not randomly placed into different treatment groups. This means that differences between the groups could be due to differences between people rather than between the treatments. However, due to ethical considerations it would be very difficult to do this in future studies. Secondly, results were very inconsistent across the different studies. Finally, some studies were very small. The results of further research could differ from the results of this review. How up to date is this evidence? The evidence is up to date to 14 April 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.781Z" }, { "id": "2ea699e2-54ff-478a-af13-3d6ed926222f", "pmid": "", "title": "Nicotine replacement therapy versus control for smoking cessation", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence. Objectives To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long‐term smoking cessation, compared to placebo or 'no NRT' interventions. Search methods We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017. Selection criteria Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow‐up of less than six months. We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews. Data collection and analysis Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow‐up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta‐analysis using a Mantel‐Haenszel fixed‐effect model. Main results We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non‐NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare. Authors' conclusions There is high‐quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non‐ischaemic chest pain and palpitations. Plain language summary Can nicotine replacement therapy (NRT) help people quit smoking? Background We reviewed the evidence about whether NRT helps people who want to quit smoking to stop smoking at six months or longer. NRT aims to reduce withdrawal symptoms associated with stopping smoking by replacing the nicotine from cigarettes. NRT is available as skin patches that deliver nicotine slowly, and chewing gum, nasal and oral sprays, inhalators, and lozenges/tablets, all of which deliver nicotine to the brain more quickly than skin patches, but less rapidly than from smoking cigarettes. Study characteristics This review includes 136 trials of NRT, with 64,640 people in the main analysis. All studies were conducted in people who wanted to quit smoking. Most studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. The evidence is current to July 2017. Trials lasted for at least six months. Key results We found evidence that all forms of NRT made it more likely that a person's attempt to quit smoking would succeed. The chances of stopping smoking were increased by 50% to 60%. NRT works with or without additional counselling, and does not need to be prescribed by a doctor. Side effects from using NRT are related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. There is no evidence that NRT increases the risk of heart attacks. Quality of evidence The overall quality of the evidence is high, meaning that further research is very unlikely to change our conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hartmann‐Boyce, J; Chepkin, SC; Ye, W; Bullen, C; Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD000146.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "2eb8c208-6d0f-4f3c-9ec7-42b190865243", "pmid": "", "title": "The Effects of Lactobacillus Rhamnosus (JB-1) on Stress and Cognition in Healthy Volunteers", "imported": false, "abstract": "Emerging evidence suggests that microorganisms acting via the Brain-Gut axis may have potential benefits for the management of stress-related conditions. The majority of studies have focused on animal models. Preclinical studies have identified the Lactobacillus Rhamnosus JB-1 strain as a putative psychobiotic with an impact on stress-related behaviours, physiology and cognitive performance. Whether such preclinical effects could be translated to healthy human volunteers remains unknown.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.152Z" }, { "id": "2ebf971f-4c58-4c08-bb4a-c9bb89871928", "pmid": "", "title": "Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)", "imported": false, "abstract": "Abstract - Background Idiopathic acute vestibular dysfunction (vestibular neuritis) is the second most common cause of peripheral vertigo after benign paroxysmal positional vertigo (BPPV) and accounts for 7% of the patients who present at outpatient clinics specialising in the treatment of dizziness. The exact aetiology of the condition is unknown and the effects of corticosteroids on the condition and its recovery are uncertain. Objectives To assess the effectiveness of corticosteroids in the management of patients with idiopathic acute vestibular dysfunction (vestibular neuritis). Search methods We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 28 December 2010. Selection criteria Randomised controlled trials comparing corticosteroids with placebo, no treatment or other active treatments, for adults diagnosed with idiopathic acute vestibular dysfunction. Data collection and analysis Two authors independently selected studies from the search results and extracted data. Three authors independently assessed risk of bias. Main results Four trials, involving a total of 149 participants, compared the effectiveness of oral corticosteroids against placebo. All the trials were small and of low methodological quality. Although there was an overall significant effect of corticosteroids compared with placebo medication on complete caloric recovery at one month (risk ratio (RR) of 2.81; 95% confidence interval (CI) 1.32 to 6.00, P = 0.007), no significant effect was seen on complete caloric recovery at 12 months (RR 1.58; 95% CI 0.45 to 5.62, P = 0.48), or on the extent of caloric recovery at either one month (mean difference (MD) 9.60%; 95% CI ‐20.66 to 39.86, P = 0.53) or at 12 months (MD 6.83%; 95% CI ‐27.69 to 41.36, P = 0.70). In addition, there was no significant difference between corticosteroids and placebo medication in the symptomatic recovery of vestibular function following idiopathic acute vestibular dysfunction with respect to vertigo at 24 hours (RR 0.39; 95% CI 0.04 to 3.57, P = 0.40) and use of the Dizziness Handicap Inventory score at one, three, six and 12 months. Authors' conclusions Overall, there is currently insufficient evidence from these trials to support the administration of corticosteroids to patients with idiopathic acute vestibular dysfunction. We found no trials with a low risk of methodological bias that used the highest level of diagnostic criteria and outcome measures. We recommend that future studies should include health‐related quality of life and symptom‐based outcome measures, in addition to objective measures of vestibular improvement, such as caloric testing and electronystagmography. Plain language summary Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis) Idiopathic acute vestibular dysfunction (vestibular neuritis) is a common condition of unknown cause. Patients with the condition often experience dizziness, nausea or vomiting, and trouble with vision, balance or mobility, but have normal hearing and no tinnitus. It has been proposed that a course of corticosteroids, if given early on, may improve recovery from the condition and long‐term patient outcome. However, corticosteroids can cause adverse effects (e.g. bleeding stomach ulcer, mood changes, etc.). This review identified four randomised controlled trials including 149 adult patients with idiopathic acute vestibular dysfunction (vestibular neuritis) treated with either corticosteroids or placebo. The studies were varied in that they used different drugs and different treatment regimens. On the basis of these studies, there is currently insufficient evidence in favour of corticosteroids over placebo medication in the symptomatic recovery and objective testing of vestibular function, both in the short‐term and long‐term. Further studies of higher quality are needed to test the effectiveness of corticosteroids in patients with the condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fishman, JM; Burgess, C; Waddell, A", "articleTypes": [], "doi": "10.1002/14651858.CD008607.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "2ecf82ed-fb8b-449d-babb-d99516997551", "pmid": "", "title": "Lifestyle interventions for acute gout", "imported": false, "abstract": "Abstract - Background Although lifestyle interventions are often recommended in the management of chronic gout, the evidence from trial data of the benefits and safety of using lifestyle interventions for treating acute gout attacks have not previously been examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with acute gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies (up to 5 April 2013). We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials which compared lifestyle interventions to another therapy (active or placebo) in patients with acute gout. Outcomes of interest were the change in participant‐reported pain in the target joint(s), target joint inflammation and function, health‐related quality of life (HRQoL), patient global assessment, study participant withdrawals due to adverse events (AEs) and serious adverse events (SAEs). Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (19 participants) at high risk of bias was included in the review. Patients were randomised to receive oral prednisolone and colchicine with or without concomitant topical ice therapy. Topical ice therapy provided significant additional benefit over oral prednisolone and colchicine alone with respect to pain, but did not significantly reduce swelling during acute gout episodes. Mean pain reduction with standard medical treatment was 4.4 cm on a 0 to 10 cm visual analogue scale (VAS) after one week; the addition of topical ice reduced pain by an additional 3.33 cm (95% CI 5.84 to 0.82), or an absolute reduction of 33% (8% to 58% reduction). Joint swelling was reduced by a mean of 3.8 cm in the standard medical treatment group; the addition of topical ice therapy did not reduce swelling significantly (mean difference (MD) 2.07 cm, 95% CI ‐1.56 to 5.70). Target joint function, HRQoL, patient global assessment, study participant withdrawals due to AEs and SEAs were not reported in this study. Authors' conclusions There is low quality evidence, from a single trial at high risk of bias, that the addition of topical ice therapy to oral prednisolone and colchicine for oligoarticular attacks of acute gout results in significantly greater pain reduction at one week. Plain language summary Lifestyle interventions for treating acute gout attacks This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with acute gout. There was one study included in this review, which looked at the benefits and safety of adding topical ice therapy to medications commonly used for treating acute gout (prednisolone and colchicine). Over a one week period, in addition to prednisolone and colchicine, ice was applied to the skin overlying the joints affected by acute gout, for half‐an‐hour, four times per day, to relieve symptoms of pain and warmth and to reduce signs of redness and swelling. The review shows that in people with acute gout: We are uncertain whether the reduction in pain seen with the addition of topical ice to standard treatment of prednisolone and colchicine, compared to prednisolone and colchicine alone, is a true effect because of the very low quality evidence. Joint function, health‐related quality of life, patient global assessment and side effects and complications were not reported. We often do not have precise information about side effects and complications. Topical ice is likely to be a safe intervention. What is gout and what are lifestyle interventions? Gout is a very common cause of painful joint inflammation (arthritis) and is caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness, warmth and swelling of the affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic make‐up, being overweight, ingesting certain medications (for example cyclosporine), having impaired kidney function, and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Medications are the mainstay of acute gout treatment. Given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as consuming more water, coffee, dairy milk and cherry juice, and having fewer sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout to prevent recurrence of attacks. Best estimate of what happens to people with acute gout using topical ice in addition to medications: Joint pain (lower score means less pain) People who used topical ice (for half‐an‐hour, four times per day for one week) in addition to medical treatment (oral prednisolone and colchicine) rated their pain 3.33 points lower on a 0 to 10 point pain scale (33% absolute improvement).
 ‐ People who used topical ice in addition to medical treatment (prednisolone and colchicine) rated their pain to be 2.25 points on a scale of 0 to 10.
 ‐ People who used medical treatment alone rated their pain to be 5.58 points on a scale of 0 to 10. ‐ Three people would need to be treated with topical ice for one person to benefit from pain relief. Adverse events Side effects or complications of using topical ice in addition to medical therapy were not reported in the study.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY; Sriranganathan, MK; Edwards, CJ; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010519.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "2ed09d95-7bed-4ee8-8d1f-db059fbceab7", "pmid": "", "title": "Adjunctive systemic antimicrobials for the non‐surgical treatment of periodontitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Khattri, S, Kumbargere Nagraj, S, Arora, A, Eachempati, P, Kusum, CK, Bhat, KG, Johnson, TM, Lodi, G", "articleTypes": [], "doi": "10.1002/14651858.CD012568.pub2 AB - Abstract - Background Systemic antimicrobials can be used as an adjunct to mechanical debridement (scaling and root planing (SRP)) as a non‐surgical treatment approach to manage periodontitis. A range of antibiotics with different dosage and combinations are documented in the literature. The review follows the previous classification of periodontitis as all included studies used this classification. Objectives To assess the effects of systemic antimicrobials as an adjunct to SRP for the non‐surgical treatment of patients with periodontitis. Search methods Cochrane Oral Health's Information Specialist searched the following databases to 9 March 2020: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, and Embase. The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included randomized controlled trials (RCTs) which involved individuals with clinically diagnosed untreated periodontitis. Trials compared SRP with systemic antibiotics versus SRP alone/placebo, or with other systemic antibiotics. Data collection and analysis We selected trials, extracted data, and assessed risk of bias in duplicate. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE. Main results We included 45 trials conducted worldwide involving 2664 adult participants. 14 studies were at low, 8 at high, and the remaining 23 at unclear overall risk of bias. Seven trials did not contribute data to the analysis. We assessed the certainty of the evidence for the 10 comparisons which reported long‐term follow‐up (≥ 1 year). None of the studies reported data on antimicrobial resistance and patient‐reported quality of life changes. Amoxicillin + metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐16.20%, 95% CI ‐25.87 to ‐6.53; 1 study, 44 participants); clinical attachment level (CAL) (MD ‐0.47 mm, 95% CI ‐0.90 to ‐0.05; 2 studies, 389 participants); probing pocket depth (PD) (MD ‐0.30 mm, 95% CI ‐0.42 to ‐0.18; 2 studies, 389 participants); and percentage of bleeding on probing (BOP) (MD ‐8.06%, 95% CI ‐14.26 to ‐1.85; 2 studies, 389 participants) was of very low certainty. Only the results for closed pockets and BOP showed a minimally important clinical difference (MICD) favouring amoxicillin + metronidazole + SRP. Metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐12.20%, 95% CI ‐29.23 to 4.83; 1 study, 22 participants); CAL (MD ‐1.12 mm, 95% CI ‐2.24 to 0; 3 studies, 71 participants); PD (MD ‐1.11 mm, 95% CI ‐2.84 to 0.61; 2 studies, 47 participants); and percentage of BOP (MD ‐6.90%, 95% CI ‐22.10 to 8.30; 1 study, 22 participants) was of very low certainty. Only the results for CAL and PD showed an MICD favouring the MTZ + SRP group. Azithromycin + SRP versus SRP for chronic/aggressive periodontitis: we found no evidence of a difference in percentage of closed pockets (MD 2.50%, 95% CI ‐10.19 to 15.19; 1 study, 40 participants); CAL (MD ‐0.59 mm, 95% CI ‐1.27 to 0.08; 2 studies, 110 participants); PD (MD ‐0.77 mm, 95% CI ‐2.33 to 0.79; 2 studies, 110 participants); and percentage of BOP (MD ‐1.28%, 95% CI ‐4.32 to 1.76; 2 studies, 110 participants) (very low‐certainty evidence for all outcomes). Amoxicillin + clavulanate + SRP versus SRP for chronic periodontitis: the evidence from 1 study, 21 participants for CAL (MD 0.10 mm, 95% CI ‐0.51 to 0.71); PD (MD 0.10 mm, 95% CI ‐0.17 to 0.37); and BOP (MD 0%, 95% CI ‐0.09 to 0.09) was of very low certainty and did not show a difference between the groups. Doxycycline + SRP versus SRP in aggressive periodontitis: the evidence from 1 study, 22 participants for CAL (MD ‐0.80 mm, 95% CI ‐1.49 to ‐0.11); and PD (MD ‐1.00 mm, 95% CI ‐1.78 to ‐0.22) was of very low certainty, with the doxycycline + SRP group showing an MICD in PD only. Tetracycline + SRP versus SRP for aggressive periodontitis: we found very low‐certainty evidence of a difference in long‐term improvement in CAL for the tetracycline group (MD ‐2.30 mm, 95% CI ‐2.50 to ‐2.10; 1 study, 26 participants). Clindamycin + SRP versus SRP in aggressive periodontitis: we found very low‐certainty evidence from 1 study, 21 participants of a difference in long‐term improvement in CAL (MD ‐1.70 mm, 95% CI ‐2.40 to ‐1.00); and PD (MD ‐1.80 mm, 95% CI ‐2.47 to ‐1.13) favouring clindamycin + SRP. Doxycycline + SRP versus metronidazole + SRP for aggressive periodontitis: there was very low‐certainty evidence from 1 study, 27 participants of a difference in long‐term CAL (MD 1.10 mm, 95% CI 0.36 to 1.84); and PD (MD 1.00 mm, 95% CI 0.30 to 1.70) favouring metronidazole + SRP. Clindamycin + SRP versus metronidazole + SRP for aggressive periodontitis: the evidence from 1 study, 26 participants for CAL (MD 0.20 mm, 95% CI ‐0.55 to 0.95); and PD (MD 0.20 mm, 95% CI ‐0.38 to 0.78) was of very low certainty and did not show a difference between the groups. Clindamycin + SRP versus doxycycline + SRP for aggressive periodontitis: the evidence from 1 study, 23 participants for CAL (MD ‐0.90 mm, 95% CI ‐1.62 to ‐0.18); and PD (MD ‐0.80 mm, 95% CI ‐1.58 to ‐0.02) was of very low certainty and did not show a difference between the groups. Most trials testing amoxicillin, metronidazole, and azithromycin reported adverse events such as nausea, vomiting, diarrhoea, mild gastrointestinal disturbances, and metallic taste. No serious adverse events were reported. Authors' conclusions There is very low‐certainty evidence (for long‐term follow‐up) to inform clinicians and patients if adjunctive systemic antimicrobials are of any help for the non‐surgical treatment of periodontitis. There is insufficient evidence to decide whether some antibiotics are better than others when used alongside SRP. None of the trials reported serious adverse events but patients should be made aware of the common adverse events related to these drugs. Well‐planned RCTs need to be conducted clearly defining the minimally important clinical difference for the outcomes closed pockets, CAL, PD, and BOP. Plain language summary What are the benefits and risks of using antibiotics as well as cleaning by a dental care professional to treat gum disease? Why is this question important? Gum disease is a common condition in which the gums become swollen, sore or infected. It is caused by bacteria that accumulate on gums and teeth. Diseased gums may bleed when people brush their teeth, and may cause bad breath. If gum disease is not treated, teeth can become loose and eventually fall out. This can affect a person’s ability to chew and speak. It can also make people feel self‐conscious about their appearance. Dental‐care professionals can clean teeth and gums to remove excess bacteria from the mouth. They use special instruments – typically, an ultrasound scraper followed by specialised hand‐held instruments – to scrape bacteria from the teeth, and stop these from affecting the gums. Antibiotics (medicines that kill bacteria) taken by mouth (orally) can be used alongside professional cleaning, to remove bacteria from the area between the teeth and gums. However, there are potential risks associated with antibiotics, such as allergic reactions and antibiotic resistance (changes in bacteria after exposure to antibiotics, that allow the bacteria to survive future antibiotic treatment). We conducted a review of the evidence from research studies to find out about the benefits and risks of using antibiotics alongside professional dental cleaning to treat gum disease. We also wanted to know if some antibiotics work better than others in this situation. How did we identify and evaluate the evidence? First, we searched for randomized controlled studies (clinical studies where people are randomly put into one of two or more treatment groups), because these studies provide the most robust evidence about the effects of a treatment. We then compared the results, and summarized the evidence from all the studies. Finally, we rated our confidence in the evidence, based on factors such as study methods and sizes, and the consistency of findings across studies. What did we find? We found 45 studies that involved a total of 2664 people over the age of 18 who had gum disease. The studies compared professional cleaning plus antibiotics against professional cleaning alone, or compared different antibiotics used alongside professional cleaning against one another. We cannot tell whether antibiotics reduce gum disease in the long term (one year or more after treatment), or whether some antibiotics are better than others. This is because we have very little confidence in the evidence we found. We cannot tell whether antibiotics are associated with unwanted effects, because we have too little confidence in the evidence. The most commonly reported unwanted effects were temporary, mild gastrointestinal disturbances, such as nausea, vomiting, diarrhoea, or a metallic taste in the mouth. No serious unwanted effects were reported. No studies reported on antimicrobial resistance or changes in people’s quality of life. What does this mean? We do not know whether: ‐ using antibiotics alongside professional cleaning is beneficial for treating gum disease in the long term (more than one year after treatment);
‐ using antibiotics alongside professional cleaning is associated with unwanted effects; or
‐ some antibiotics are better than others for treating gum disease alongside professional cleaning. Our confidence in the available evidence is very low. The results of our review are likely to change if more evidence becomes available. Future studies should clearly define what qualifies as a minimally important improvement in gum disease. How‐up‐to date is this review? The evidence in this Cochrane Review is current to March 2020.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.757Z" }, { "id": "2eedb5a0-29ef-4a4e-a993-764553a2f37e", "pmid": "", "title": "Pharmacological and non‐pharmacological strategies for obese women with subfertility", "imported": false, "abstract": "Abstract - Background Clinicians primarily recommend weight loss for obese women seeking pregnancy. The effectiveness of interventions aimed at weight loss in obese women with subfertility is unclear. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for achieving weight loss in obese women with subfertility. Search methods We searched the CGF Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and AMED from inception to 18 August 2020. We also checked reference lists and contacted experts in the field for additional relevant papers. Selection criteria We included published and unpublished randomised controlled trials in which weight loss was the main goal of the intervention. Our primary effectiveness outcomes were live birth or ongoing pregnancy and primary safety outcomes were miscarriage and adverse events. Secondary outcomes included clinical pregnancy, weight change, quality of life, and mental health outcome. Data collection and analysis Review authors followed standard Cochrane methodology. Main results This review includes 10 trials. Evidence was of very low to low quality: the main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision. Non‐pharmacological intervention versus no intervention or placebo Evidence is insufficient to determine whether a diet or lifestyle intervention compared to no intervention affects live birth (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.65 to 1.11; 918 women, 3 studies; I² = 78%; low‐quality evidence). This suggests that if the chance of live birth following no intervention is assumed to be 43%, the chance following diet or lifestyle changes would be 33% to 46%. We are uncertain if lifestyle change compared with no intervention affects miscarriage rate (OR 1.54, 95% CI 0.99 to 2.39; 917 women, 3 studies; I² = 0%; very low‐quality evidence). Evidence is insufficient to determine whether lifestyle change compared with no intervention affects clinical pregnancy (OR 1.06, 95% CI 0.81 to 1.40; 917 women, 3 studies; I² = 73%; low‐quality evidence). Lifestyle intervention resulted in a decrease in body mass index (BMI), but data were not pooled due to heterogeneity in effect (mean difference (MD) ‐3.70, 95% CI ‐4.10 to ‐3.30; 305 women, 1 study; low‐quality evidence; and MD ‐1.80, 95% CI ‐2.67 to ‐0.93; 43 women, 1 study; very low‐quality evidence). Non‐pharmacological versus non‐pharmacological intervention We are uncertain whether intensive weight loss interventions compared to standard care nutrition counselling affects live birth (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), BMI (MD ‐3.00, 95% CI ‐5.37 to ‐0.63; 11 women, 1 study; very low‐quality evidence), weight change (MD ‐9.00, 95% CI ‐15.50 to ‐2.50; 11 women, 1 study; very low‐quality evidence), quality of life (MD 0.06, 95% CI ‐0.03 to 0.15; 11 women, 1 study; very low‐quality evidence), or mental health (MD ‐7.00, 95% CI ‐13.92 to ‐0.08; 11 women, 1 study; very low‐quality evidence). No study reported on adverse events . Pharmacological versus pharmacological intervention For metformin plus liraglutide compared to metformin we are uncertain of an effect on the adverse events nausea (OR 7.22, 95% CI 0.72 to 72.7; 28 women, 1 study; very low‐quality evidence), diarrhoea (OR 0.31, 95% CI 0.01 to 8.3; 28 women, 1 study; very low‐quality evidence), and headache (OR 5.80, 95% CI 0.25 to 133; 28 women, 1 study; very low‐quality evidence). We are uncertain if a combination of metformin plus liraglutide vs metformin affects BMI (MD 2.1, 95% CI ‐0.42 to 2.62; 28 women, 1 study; very low‐quality evidence) and total body fat (MD ‐0.50, 95% CI ‐4.65 to 3.65; 28 women, 1 study; very low‐quality evidence). For metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo, we are uncertain of an effect on miscarriage (OR 3.58, 95% CI 0.73 to 17.55; 274 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 5.56, 95% CI 2.57 to 12.02; 274 women, 1 study; very low‐quality evidence) or BMI (MD ‐0.3, 95% CI 1.17 to 0.57, 274 women, 1 study, very low‐quality evidence). We are uncertain if dexfenfluramine versus placebo affects weight loss in kilograms (MD ‐0.10, 95% CI ‐2.77 to 2.57; 21 women, 1 study; very low‐quality evidence). No study reported on live birth, quality of life, or mental health outcomes. Pharmacological intervention versus no intervention or placebo We are uncertain if metformin compared with placebo affects live birth (OR 1.57, 95% CI 0.44 to 5.57; 65 women, 1 study; very low‐quality evidence). This suggests that if the chance of live birth following placebo is assumed to be 15%, the chance following metformin would be 7% to 50%. We are uncertain if metformin compared with placebo affects gastrointestinal adverse events (OR 0.91, 95% CI 0.32 to 2.57; 65 women, 1 study; very low‐quality evidence) or miscarriage (OR 0.50, 95% CI 0.04 to 5.80; 65 women, 1 study; very low‐quality evidence) or clinical pregnancy (OR 2.67, 95% CI 0.90 to 7.93; 96 women, 2 studies; I² = 48%; very low‐quality evidence). We are also uncertain if diet combined with metformin versus diet and placebo affects BMI (MD ‐0.30, 95% CI ‐2.16 to 1.56; 143 women, 1 study; very low‐quality evidence) or waist‐to‐hip ratio (WHR) (MD 2.00, 95% CI ‐2.21 to 6.21; 143 women, 1 study; very low‐quality evidence). Pharmacological versus non‐pharmacological intervention No study undertook this comparison. Authors' conclusions Evidence is insufficient to support the use of pharmacological and non‐pharmacological strategies for obese women with subfertility. No data are available for the comparison of pharmacological versus non‐pharmacological strategies. We are uncertain whether pharmacological or non‐pharmacological strategies effect live birth, ongoing pregnancy, adverse events, clinical pregnancy, quality of life, or mental health outcomes. However, for obese women with subfertility, a lifestyle intervention may reduce BMI. Future studies should compare a combination of pharmacological and lifestyle interventions for obese women with subfertility. Plain language summary Do pharmacological and non‐pharmacological strategies reduce weight in obese women with subfertility? To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for weight reduction in obese women with subfertility. Background To prevent the adverse effects of obesity, weight loss is recommended as the first line of treatment for obese women seeking pregnancy. The effectiveness of pharmacological and non‐pharmacological interventions for obese women with subfertility is unclear. Study characteristics We found 10 randomised trials comparing pharmacological and non‐pharmacological strategies in 1490 obese women with subfertility. Key results Lack of data is a major concern in interpretation of these data. Only 10 studies were included in the analysis. Three studies compared non‐pharmacological intervention versus no intervention or placebo. We are uncertain whether diet versus no intervention improves live birth, ongoing pregnancy, clinical pregnancy, or adverse events. A diet or lifestyle intervention may result in body mass index (BMI) weight change. Evidence was insufficient to show a difference in waist‐to‐hip ratio (WHR) with diet or lifestyle change compared to no intervention. No study reported on quality of life, or mental health outcomes for this comparison. One study compared non‐pharmacological interventions ‐ intensive weight loss intervention versus standard of care nutrition counselling; however due to the very low quality of evidence, we are uncertain whether intensive weight loss interventions improve live birth, clinical pregnancy, quality of life, or mental health outcomes. No study reported on adverse events, or weight changes, for this comparison. Three studies reported on pharmacological versus pharmacological interventions. Evidence was insufficient to show a difference in adverse events between metformin compared to metformin plus liraglutide. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for miscarriage. Evidence was insufficient to reveal a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo or metformin plus liraglutide versus metformin in clinical pregnancy. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for weight change using BMI. Moreover, evidence was insufficient to reveal a difference between dexfenfluramine versus placebo or metformin plus liraglutide versus metformin for weight loss in kilograms, or per cent of total body fat. No study reported on live birth and change in quality of life or mental health outcomes for this comparison. In the comparison of pharmacological intervention versus no intervention or placebo, three studies were included. Evidence was insufficient to show a difference between metformin and control groups related to live birth. Evidence was insufficient to reveal a difference between metformin compared to placebo in live birth, clinical pregnancy, or adverse events. Evidence was insufficient to demonstrate a difference between diet combined with metformin versus diet combined with placebo for weight change using BMI or WHR. No study reported on quality of life or mental health outcomes for this comparison. We found no study comparing non‐pharmacological with pharmacological interventions. Quality of the evidence The evidence was of very low to low quality. The main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading of evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Taghavi, SA, van Wely, M, Jahanfar, S, Bazarganipour, F", "articleTypes": [], "doi": "10.1002/14651858.CD012650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.108Z" }, { "id": "2ef61c79-7248-483f-adb3-79a94c9fffcc", "pmid": "", "title": "Donepezil for dementia due to Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Alzheimer's disease is the most common cause of dementia in older people. One approach to symptomatic treatment of Alzheimer's disease is to enhance cholinergic neurotransmission in the brain by blocking the action of the enzyme responsible for the breakdown of the neurotransmitter acetylcholine. This can be done by a group of drugs known as cholinesterase inhibitors. Donepezil is a cholinesterase inhibitor. This review is an updated version of a review first published in 1998. Objectives To assess the clinical efficacy and safety of donepezil in people with mild, moderate or severe dementia due to Alzheimer's disease; to compare the efficacy and safety of different doses of donepezil; and to assess the effect of donepezil on healthcare resource use and costs. Search methods We searched Cochrane Dementia and Cognitive Improvement’s Specialized Register, MEDLINE, Embase, PsycINFO and a number of other sources on 20 May 2017 to ensure that the search was as comprehensive and up‐to‐date as possible. In addition, we contacted members of the Donepezil Study Group and Eisai Inc. Selection criteria We included all double‐blind, randomised controlled trials in which treatment with donepezil was administered to people with mild, moderate or severe dementia due to Alzheimer's disease for 12 weeks or more and its effects compared with those of placebo in a parallel group of patients, or where two different doses of donepezil were compared. Data collection and analysis One reviewer (JSB) extracted data on cognitive function, activities of daily living, behavioural symptoms, global clinical state, quality of life, adverse events, deaths and healthcare resource costs. Where appropriate and possible, we estimated pooled treatment effects. We used GRADE methods to assess the quality of the evidence for each outcome. Main results Thirty studies involving 8257 participants met the inclusion criteria of the review, of which 28 studies reported results in sufficient detail for the meta‐analyses. Most studies were of six months' duration or less. Only one small trial lasted 52 weeks. The studies tested mainly donepezil capsules at a dose of 5 mg/day or 10 mg/day. Two studies tested a slow‐release oral formulation that delivered 23 mg/day. Participants in 21 studies had mild to moderate disease, in five studies moderate to severe, and in four severe disease. Seventeen studies were industry funded or sponsored, four studies were funded independently of industry and for nine studies there was no information on source of funding. Our main analysis compared the safety and efficacy of donepezil 10 mg/day with placebo at 24 to 26 weeks of treatment. Thirteen studies contributed data from 3396 participants to this analysis. Eleven of these studies were multicentre studies. Seven studies recruited patients with mild to moderate Alzheimer's disease, two with moderate to severe, and four with severe Alzheimer's disease, with a mean age of about 75 years. Almost all evidence was of moderate quality, downgraded due to study limitations. After 26 weeks of treatment, donepezil compared with placebo was associated with better outcomes for cognitive function measured with the Alzheimer's Disease Assessment Scale‐Cognitive (ADAS‐Cog, range 0 to 70) (mean difference (MD) ‐2.67, 95% confidence interval (CI) ‐3.31 to ‐2.02, 1130 participants, 5 studies), the Mini‐Mental State Examination (MMSE) score (MD 1.05, 95% CI 0.73 to 1.37, 1757 participants, 7 studies) and the Severe Impairment Battery (SIB, range 0 to 100) (MD 5.92, 95% CI 4.53 to 7.31, 1348 participants, 5 studies). Donepezil was also associated with better function measured with the Alzheimer's Disease Cooperative Study activities of daily living score for severe Alzheimer's disease (ADCS‐ADL‐sev) (MD 1.03, 95% CI 0.21 to 1.85, 733 participants, 3 studies). A higher proportion of participants treated with donepezil experienced improvement on the clinician‐rated global impression of change scale (odds ratio (OR) 1.92, 95% CI 1.54 to 2.39, 1674 participants, 6 studies). There was no difference between donepezil and placebo for behavioural symptoms measured by the Neuropsychiatric Inventory (NPI) (MD ‐1.62, 95% CI ‐3.43 to 0.19, 1035 participants, 4 studies) or by the Behavioural Pathology in Alzheimer's Disease (BEHAVE‐AD) scale (MD 0.4, 95% CI ‐1.28 to 2.08, 194 participants, 1 study). There was also no difference between donepezil and placebo for Quality of Life (QoL) (MD ‐2.79, 95% CI ‐8.15 to 2.56, 815 participants, 2 studies). Participants receiving donepezil were more likely to withdraw from the studies before the end of treatment (24% versus 20%, OR 1.25, 95% CI 1.05 to 1.50, 2846 participants, 12 studies) or to experience an adverse event during the studies (72% vs 65%, OR 1.59, 95% 1.31 to 1.95, 2500 participants, 10 studies). There was no evidence of a difference between donepezil and placebo for patient total healthcare resource utilisation. Three studies compared donepezil 10 mg/day to donepezil 5 mg/day over 26 weeks. The 5 mg dose was associated with slightly worse cognitive function on the ADAS‐Cog, but not on the MMSE or SIB, with slightly better QoL and with fewer adverse events and withdrawals from treatment. Two studies compared donepezil 10 mg/day to donepezil 23 mg/day. There were no differences on efficacy outcomes, but fewer participants on 10 mg/day experienced adverse events or withdrew from treatment. Authors' conclusions There is moderate‐quality evidence that people with mild, moderate or severe dementia due to Alzheimer's disease treated for periods of 12 or 24 weeks with donepezil experience small benefits in cognitive function, activities of daily living and clinician‐rated global clinical state. There is some evidence that use of donepezil is neither more nor less expensive compared with placebo when assessing total healthcare resource costs. Benefits on 23 mg/day were no greater than on 10 mg/day, and benefits on the 10 mg/day dose were marginally larger than on the 5 mg/day dose, but the rates of withdrawal and of adverse events before end of treatment were higher the higher the dose. Plain language summary Donepezil for people with dementia due to Alzheimer's disease Review question What effects (benefits or harms) does donepezil have on people with dementia due to Alzheimer's disease? Background Alzheimer's disease is the most common cause of dementia. As the disease progresses, people lose the ability to remember, communicate, think clearly and perform the activities of daily living. Their behaviour may also change. In severe Alzheimer's disease people lose the ability to care for themselves. The most commonly used treatment for Alzheimer's disease are medicines known as acetylcholinesterase inhibitors. Donepezil is one of these medicines. It is taken as a pill once a day. In Alzheimer's disease, one of the changes in the brain is a reduced number of nerve cells called cholinergic neurones. These are nerve cells that signal to other cells using a chemical called acetylcholine. Acetylcholinesterase inhibitors, such as donepezil, work by preventing acetylcholine from being broken down. This may improve the symptoms of dementia. However, acetylcholine is also found elsewhere in the body and so drugs of this type may have unwanted effects. Review methods In this review we examined evidence about benefits and harms from studies that compared donepezil, taken for at least 12 weeks, to placebo (a dummy pill), or that compared different doses of donepezil. The studies had to be double‐blind and randomised, that is, the decision whether people taking part got donepezil or placebo had to be made randomly and neither they nor the researchers should have known which treatment they were getting while the trial was going on. This was to make the comparison as unbiased, or fair, as possible. We searched for studies up to May 2017. We assessed the quality of all the studies we included. When it was sensible to do so, we analysed the results of studies together to get an overall result. Key results We included 30 studies with 8257 participants. Most of the people in the studies had mild or moderate dementia due to Alzheimer's disease, but in nine studies they had moderate or severe dementia. Almost all of the studies lasted six months or less. The majority of the studies were known to have been funded by the manufacturer of donepezil. We found that people with Alzheimer's disease who took 10 mg of donepezil a day for six months did slightly better than people taking placebo, on scales measuring their cognitive function (e.g. thinking and remembering), how well they could manage their daily activities, and the overall impression of a trained researcher. We did not find any effect on behaviour or quality of life. People taking donepezil were more likely than those taking placebo to report side effects and to drop out of the studies. Most side effects were described as mild. Nausea, vomiting and diarrhoea were most common. Comparing 5 mg of donepezil a day with 10 mg/day, people on 5 mg had fewer side effects, but did slightly less well on cognitive function tests. A higher dose (23 mg/day) offered no advantages and was associated with more side effects. There is some evidence that use of donepezil is neither more nor less expensive than placebo when total health care costs are taken into account. Quality of the evidence In general, we thought that the quality of the evidence was moderate. The main factor reducing our confidence was concern that the results of some studies might have been biased by the way they were done. We cannot be sure that the results apply to treatment longer than six months. Conclusions After six months of treatment, there are benefits of donepezil that are large enough to measure in studies. It is associated with side effects that are mainly mild, but that may cause people to stop treatment. Being able to stabilise cognitive performance or ability to maintain activities of daily living may be important clinically. In terms of total healthcare costs the use of donepezil appears cost neutral. However, there does not appear to be an effect on quality of life. More data are still required from longer‐term clinical studies examining measures of disease progression or time to needing full time care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Birks, JS; Harvey, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD001190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "2ef91cd3-35ee-4fc6-b3e8-9a23bc866edd", "pmid": "", "title": "Non‐immunosuppressive treatment for IgA nephropathy", "imported": false, "abstract": "Abstract - Background IgA nephropathy (IgAN) is the most common primary glomerular disease, with approximately 20% to 40% of patients progressing to kidney failure within 25 years. Non‐immunosuppressive treatment has become a mainstay in the management of IgAN by improving blood pressure (BP) management, decreasing proteinuria, and avoiding the risks of long‐term immunosuppressive management. Due to the slowly progressive nature of the disease, clinical trials are often underpowered, and conflicting information about management with non‐immunosuppressive treatment is common. This is an update of a Cochrane review, first published in 2011. Objectives To assess the benefits and harms of non‐immunosuppressive treatment for treating IgAN in adults and children. We aimed to examine all non‐immunosuppressive therapies (e.g. anticoagulants, antihypertensives, dietary restriction and supplementation, tonsillectomy, and herbal medicines) in the management of IgAN. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to December 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs of non‐immunosuppressive agents in adults and children with biopsy‐proven IgAN were included. Data collection and analysis Two authors independently reviewed search results, extracted data and assessed study quality. Results were expressed as mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI) using random‐effects meta‐analysis. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results This review includes 80 studies (4856 participants), of which 24 new studies (2018 participants) were included in this review update. The risk of bias within the included studies was mostly high or unclear for many of the assessed methodological domains, with poor reporting of important key clinical trial methods in most studies. Antihypertensive therapies were the most examined non‐immunosuppressive therapy (37 studies, 1799 participants). Compared to placebo or no treatment, renin‐angiotensin system (RAS) inhibition probably decreases proteinuria (3 studies, 199 participants: MD ‐ 0.71 g/24 h, 95% CI ‐1.04 to ‐0.39; moderate certainty evidence) but may result in little or no difference to kidney failure or doubling of serum creatinine (SCr), or complete remission of proteinuria (low certainty evidence). Death, remission of haematuria, relapse of proteinuria or > 50% increase in SCr were not reported. Compared to symptomatic treatment, RAS inhibition (3 studies, 168 participants) probably decreases proteinuria (MD ‐1.16 g/24 h, 95% CI ‐1.52 to ‐0.81) and SCr (MD ‐9.37 µmol/L, 95% CI ‐71.95 to ‐6.80) and probably increases creatinine clearance (2 studies, 127 participants: MD 23.26 mL/min, 95% CI 10.40 to 36.12) (all moderate certainty evidence); however, the risk of kidney failure is uncertain (1 study, 34 participants: RR 0.20, 95% CI 0.01 to 3.88; very low certainty evidence). Death, remission of proteinuria or haematuria, or relapse of proteinuria were not reported. The risk of adverse events may be no different with RAS inhibition compared to either placebo or symptomatic treatment (low certainty evidence). In low certainty evidence, tonsillectomy in people with IgAN in addition to standard care may increase remission of proteinuria compared to standard care alone (2 studies, 143 participants: RR 1.90, 95% CI 1.45 to 2.47) and remission of microscopic haematuria (2 studies, 143 participants: RR 1.93, 95% CI 1.47 to 2.53) and may decrease relapse of proteinuria (1 study, 73 participants: RR 0.70, 95% CI 0.57 to 0.85) and relapse of haematuria (1 study, 72 participants: RR 0.70, 95% CI 0.51 to 0.98). Death, kidney failure and a > 50% increase in SCr were not reported. These trials have only been conducted in Japanese people with IgAN, and the findings' generalisability is unclear. Anticoagulant therapy, fish oil, and traditional Chinese medicines exhibited small benefits to kidney function in patients with IgAN when compared to placebo or no treatment. However, compared to standard care, the kidney function benefits are no longer evident. Antimalarial therapy compared to placebo in one study reported an increase in a > 50% reduction of proteinuria (53 participants: RR 3.13 g/24 h, 95% CI 1.17 to 8.36; low certainty evidence). Although, there was uncertainty regarding adverse events from this study due to very few events. Authors' conclusions Available RCTs focused on a diverse range of interventions. They were few, small, and of insufficient duration to determine potential long‐term benefits on important kidney and cardiovascular outcomes and harms of treatment. Antihypertensive agents appear to be the most beneficial non‐immunosuppressive intervention for IgAN. The antihypertensives examined were predominantly angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers. The benefits of RAS inhibition appear to outweigh the harms in patients with IgAN. The certainty of the evidence of RCTs demonstrating a benefit of tonsillectomy to patients with Japanese patients with IgAN was low. In addition, these findings are inconsistent across observational studies in people with IgAN of other ethnicities; hence, tonsillectomy is not widely recommended, given the potential harm of therapy. The RCT evidence is insufficiently robust to demonstrate efficacy for the other non‐immunosuppressive treatments evaluated here. Plain language summary Non‐immunosuppressive treatment for IgA nephropathy Key messages Treatment with renin‐angiotensin system (RAS) inhibition, namely angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, is the most common first‐line, non‐immunosuppressive therapy used for managing patients with IgA nephropathy (IgAN). The role of other non‐immunosuppressive treatments in managing IgAN is unclear and warrants further clinical studies. Why treat IgA nephropathy with non‐immunosuppressive therapies? IgAN is one of the most common kidney diseases, leading to reduced kidney function and kidney failure for about 20% to 40% of patients within 20 to 25 years. The cause of IgAN is not widely understood, but most people have an abnormality in their immune system that leads to damage to the kidney. However, other non‐immune functions play a role in the disease's impact on the kidney. What did we want to find out? We wanted to find out if non‐immunosuppressive treatments (e.g. antihypertensive agents, anticoagulants, fish oil, tonsillectomy, herbal medicine) improved kidney function in adults and children with IgAN. What did we do? We searched for all trials that assessed the benefits and harms of randomly allocated non‐immunosuppressive treatment in people with IgAN. We compared and summarised the results of the trials and rated our confidence in the information based on factors such as trial methods and sizes. What did we find? We included 80 studies involving 4856 people with IgAN treated with a diverse collection of non‐immunosuppressive treatments. Patients in studies were given various therapies, including blood pressure lowering agents (antihypertensives), removal of participant's tonsils (tonsillectomy), antimalarials, traditional Chinese medicine, dietary supplements (e.g. fish oil), and vitamin D receptor agonists. Antihypertensive medication aimed at inhibiting the RAS appears to slow damage to the kidney with minimal side effects. However, its impact in preventing people from progressing to kidney failure is unclear. Other interventions, such as tonsillectomy, antimalarial medication, and low‐calorie restricted diets role in treating patients are still unclear. What are the limitations of the evidence? The small number of studies per comparison and the small size of the studies were limitations in this review. Not all the studies provided data about the outcomes we were interested in. We are unsure about the results. How up to date is the evidence? The evidence is up to date as of December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Tunnicliffe, DJ; Reid, S; Craig, JC; Samuels, JA; Molony, DA; Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD003962.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "2f1a3c6a-d018-43ff-a47a-222995b5185f", "pmid": "", "title": "Over the counter (OTC) artificial tear drops for dry eye syndrome", "imported": false, "abstract": "Abstract - Background Over the counter (OTC) artificial tears historically have been the first line of treatment for dry eye syndrome and dry eye‐related conditions like contact lens discomfort, yet currently we know little regarding the overall efficacy of individual, commercially available artificial tears. This review provides a much needed meta‐analytical look at all randomized and quasi‐randomized clinical trials that have analyzed head‐to‐head comparisons of OTC artificial tears. Objectives To evaluate the effectiveness and toxicity of OTC artificial tear applications in the treatment of dry eye syndrome compared with another class of OTC artificial tears, no treatment, or placebo. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 12), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2015), EMBASE (January 1980 to December 2015), Latin American and Caribbean Health Sciences (LILACS) (January 1982 to December 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) and the US Food and Drugs Administration (FDA) website ( www.fda.gov ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 December 2015. We searched reference lists of included trials for any additional trials not identified by the electronic searches. Selection criteria This review includes randomized controlled trials with adult participants who were diagnosed with dry eye, regardless of race and gender. We included trials in which the age of participants was not reported, and clinical trials comparing OTC artificial tears with another class of OTC artificial tears, placebo, or no treatment. This review did not consider head‐to‐head comparisons of artificial tears with another type of dry‐eye therapy. Data collection and analysis We followed the standard methodological procedures expected by Cochrane. Two authors independently screened the search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. We performed meta‐analysis for trials that compared similar interventions and reported comparable outcomes with sufficient data. We summarized all other included trial results in the text. Main results We included 43 randomized controlled trials (3497 participants with dry eye). Due to the heterogeneity of study characteristics among the included trials with respect to types of diagnostic criteria, interventions, comparisons, and measurements taken, our ability to perform meta‐analyses was limited. The review found that, in general, there was uncertainty whether different OTC artificial tears provide similar relief of signs and symptoms when compared with each other or placebo. Nevertheless, we found that 0.2% polyacrylic acid‐based artificial tears were consistently more effective at treating dry eye symptoms than 1.4% polyvinyl alcohol‐based artificial tears in two trials assessing this comparison (175 participants). All other included artificial tears produced contradictory between‐group results or found no between‐group differences. Our review also found that OTC artificial tears may be generally safe, but not without adverse events. Overall, we assessed the quality of evidence as low due to high risks of bias among included trials and poor reporting of outcome measures which were insufficient for quantitative analysis. Furthermore, we identified an additional 18 potentially eligible trials that were reported only in clinical trial registers with no associated results or publications. These trials reportedly enrolled 2079 total participants for whom no data are available. Such lack of reporting of trial results represents a high risk of publication bias. Authors' conclusions OTC artificial tears may be safe and effective means for treating dry eye syndrome; the literature indicates that the majority of OTC artificial tears may have similar efficacies. This conclusion could be greatly skewed by the inconsistencies in study designs and inconsistencies in reporting trial results. Additional research is therefore needed before we can draw robust conclusions about the effectiveness of individual OTC artificial tear formulations. Plain language summary Efficacy of over the counter (OTC) artificial tears for dry eye syndrome Research question What is the effect of over the counter (OTC) artificial tears on dry eye syndrome? Background 
 Dry eye syndrome is a long‐term condition that is known to cause eye discomfort and visual disturbances like blurred vision. This condition affects millions of people around the world, and the first‐line treatment for dry eye is typically over the counter (OTC) artificial tears. OTC artificial tears are meant to replace or supplement the tears (fluid) that naturally cover the eye’s front surface (cornea and conjunctiva). There are a great number of commercially available artificial tears, yet there is currently no agreement about whether one formulation works better than another at treating dry eye. Our review attempts to bridge this knowledge gap. Study characteristics 
 This review included 43 randomized controlled trials (3497 people with dry eye) that compared OTC artificial tears with other OTC artificial tears, with no treatment, or with placebo. We considered participant symptoms to be the primary outcome for this review. We recorded other commonly performed dry eye tests as secondary outcomes (e.g. vision, tear stability). We measured primary and secondary outcomes at two and four weeks, although we also considered other time points in this review. We searched for trials up to December 2015. Key results 
 This review analyzed many OTC artificial tear formulations, and most of the literature indicates uncertainty as to which OTC artificial tear works best. The literature also shows that OTC artificial tears may be effective at treating dry eye symptoms and that OTC artificial tears are generally safe, although not without side effects. We also identified an additional 18 potentially eligible trials that were registered, but did not provide any results or publications. These trials may have enrolled 2079 total participants for whom no data are available. Without the results of these trials, the effects of the OTC artificial tears that they evaluated are unknown. Quality of the evidence The overall quality of the evidence was low for the various OTC artificial tear formulations compared in this review. This finding indicates that future published research may have an important impact on the conclusions currently provided in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pucker, AD; Ng, SM; Nichols, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD009729.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "2f1c0ce7-9d24-4902-bb1f-5eb2f1a74870", "pmid": "", "title": "Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants)", "imported": false, "abstract": "Abstract - Background 'Immediate' implants are placed in dental sockets just after tooth extraction. 'Immediate‐delayed' implants are those implants inserted after weeks up to about a couple of months to allow for soft tissue healing. 'Delayed' implants are those placed thereafter in partially or completely healed bone. The potential advantages of immediate implants are that treatment time can be shortened and that bone volumes might be partially maintained thus possibly providing good aesthetic results. The potential disadvantages are an increased risk of infection and failures. After implant placement in postextractive sites, gaps can be present between the implant and the bony walls. It is possible to fill these gaps and to augment bone simultaneously to implant placement. There are many techniques to achieve this but it is unclear when augmentation is needed and which could be the best augmentation technique. Objectives To evaluate success, complications, aesthetics and patient satisfaction between 'immediate', 'immediate‐delayed' and 'delayed' implants. To evaluate whether and when augmentation procedures are necessary and which is the most effective technique. Search methods The Cochrane Oral Health Group's Trials Register (to 2 June 2010), CENTRAL ( The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 ‐ 2 June 2010) and EMBASE via OVID (1980 ‐ 2 June 2010) were searched. Several dental journals were handsearched. Selection criteria Randomised controlled trials (RCTs) comparing immediate, immediate‐delayed, and delayed implants, or comparing various bone augmentation procedures around the inserted implants, reporting the outcome of the interventions to at least 1 year after functional loading. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Trial authors were contacted for any missing information. Results were expressed as random‐effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). The statistical unit of the analysis was the patient. Main results Fourteen eligible RCTs were identified but only seven trials could be included. Four RCTs evaluated implant placement timing. Two RCTs compared immediate versus delayed implants in 126 patients and found no statistically significant differences. One RCT compared immediate‐delayed versus delayed implants in 46 patients. After 2 years patients in the immediate‐delayed group perceived the time to functional loading significantly shorter, were more satisfied and independent blinded assessor judged the level of the perimplant marginal mucosa in relation to that of the adjacent teeth as more appropriate (RR = 1.68; 95% CI 1.04 to 2.72). These differences disappeared 5 years after loading but significantly more complications occurred in the immediate‐delayed group (RR = 4.20; 95% CI 1.01 to 17.43). One RCT compared immediate with immediately delayed implants in 16 patients for 2 years and found no differences. Three RCTs evaluated different techniques of bone grafting for implants immediately placed in extraction sockets. No statistically significant difference was observed when evaluating whether autogenous bone is needed in postextractive sites (1 trial with 26 patients) or which was the most effective augmentation technique (2 trials with 56 patients). Authors' conclusions There is insufficient evidence to determine possible advantages or disadvantages of immediate, immediate‐delayed or delayed implants, therefore these preliminary conclusions are based on few underpowered trials often judged to be at high risk of bias. There is a suggestion that immediate and immediate‐delayed implants may be at higher risks of implant failures and complications than delayed implants on the other hand the aesthetic outcome might be better when placing implants just after teeth extraction. There is not enough reliable evidence supporting or refuting the need for augmentation procedures at immediate implants placed in fresh extraction sockets or whether any of the augmentation techniques is superior to the others. Plain language summary Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants) Dental implants can be placed in sockets just after tooth extraction (immediate implants) or after a couple of weeks up to a couple of months (immediate‐delayed implants) or thereafter (delayed implants). This review looked at which was the best time to place dental implants and whether it would be advantageous to augment sites with gaps present at implant placement. It also tried to determine the most effective bone augmentation procedure. The seven identified studies included too few patients to answer the questions. Four studies evaluated which is the best time to place implants. One study evaluated whether bone grafting is advantageous at implant placement and two studies evaluated which are the best grafting techniques. There is currently too little evidence to draw any reliable conclusions, however, the aesthetic outcome could be slightly better when placing implants early after tooth extraction, though early placed implants might be at a higher risk of failure. There is not enough evidence supporting or refusing the need of bone augmentation when extracted teeth are immediately replaced with dental implants, nor it is known whether any augmentation procedure is better than the others. Bone substitutes (anorganic bovine bone) can be used instead of self generated (autogenous) bone graft.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Esposito, M, Grusovin, MG, Polyzos, IP, Felice, P, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD005968.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.772Z" }, { "id": "2f206469-a266-4d47-81e2-3a8816ce4ec0", "pmid": "", "title": "Effects on Sleep Quality and Bioelectrical Parameters of Cellular Health After Administration of a Plant Protein Supplement Combined With Ashwagandha and Rhodiola", "imported": false, "abstract": "This study evaluates whether a combination of plant protein with adaptogenic herbs (ashwagandha and rhodiola) can improve sleep quality in middle-aged adults with sleep disturbances.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.267Z" }, { "id": "2f21d688-d006-437f-b6ae-7ddc86fe5fbf", "pmid": "", "title": "Interventions for acute otitis externa", "imported": false, "abstract": "Abstract - Background Acute otitis externa is an inflammatory condition of the ear canal, with or without infection. Symptoms include ear discomfort, itchiness, discharge and impaired hearing. It is also known as 'swimmer's ear' and can usually be treated successfully with a course of ear drops. Objectives To assess the effectiveness of interventions for acute otitis externa. Search methods Our search for published and unpublished trials included the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources. The date of the most recent search was 6 January 2009. Selection criteria Randomised controlled trials evaluating ear cleaning, topical medication or systemic therapy in the treatment of acute otitis externa were eligible. We excluded complicated acute otitis externa; otitis externa secondary to otitis media or chronic suppurative otitis media; chronic otitis externa; fungal otitis externa (otomycosis); eczematous otitis externa; viral otitis externa and furunculosis. Data collection and analysis Two authors assessed eligibility and quality. Main results Nineteen randomised controlled trials with a total of 3382 participants were included. Three meta‐analyses were possible. The overall quality of studies was low. Topical antimicrobials containing steroids were significantly more effective than placebo drops: OR 11 (95% CI 2.00 to 60.57; one trial). In general, no clinically meaningful differences were noted in clinical cure rates between the various topical interventions reviewed. One notable exception involved a trial of high quality which showed that acetic acid was significantly less effective when compared with antibiotic/steroid drops in terms of cure rate at two and three weeks (OR 0.29 (95% CI 0.13 to 0.62) and OR 0.25 (95% CI 0.11 to 0.58) respectively). One trial of low quality comparing quinolone with non‐quinolone antibiotics did not find any difference in clinical cure rate. No trials evaluated the effectiveness of ear cleaning. Only two trials evaluated steroid‐only drops. One trial of low quality suggested no significant difference between steroid and antibiotic/steroid but did not report the magnitude or precision of the result. Another trial of moderate quality comparing an oral antihistamine with topical steroid against topical steroid alone found that cure rates in both groups were high and comparable (100% (15/15) and 94% (14/15) respectively at three weeks). Authors' conclusions There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available: Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow‐up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid. The evidence for steroid‐only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed. Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision. Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated. Plain language summary Interventions to treat acute otitis externa, a specific form of ear canal inflammation also known as swimmer's ear Acute otitis externa causes inflammation of the ear canal. It is a common clinical problem encountered in general practice. This review assesses the various forms of medication used to treat the condition. Nineteen randomised controlled trials were included (3382 participants). Most were of low quality. The findings of the review may not be wholly relevant to primary care as most of the trials were conducted in a hospital setting and over half involved ear cleaning as part of the treatment (this is generally not available in primary care). However, the review does demonstrate that topical treatments alone are effective at treating acute otitis externa. There was little to choose between them in terms of effectiveness. However, when treatment needs to be extended beyond one week acetic acid drops appear to be less effective than antibiotic/steroid drops. In addition, symptoms persist for two days longer in those treated with acetic acid. More research is needed to determine the effectiveness of steroid‐only drops. Patients treated with antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Kaushik, V, Malik, T, Saeed, SR", "articleTypes": [], "doi": "10.1002/14651858.CD004740.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.131Z" }, { "id": "2f24a1ec-ff24-4b23-a956-7b02d87557ee", "pmid": "", "title": "Altered dietary salt for preventing pre‐eclampsia, and its complications", "imported": false, "abstract": "Abstract - Background In the past, women have been advised that lowering their salt intake might reduce their risk of developing pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of altered dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of altered dietary salt during pregnancy on the risk of developing pre‐eclampsia and its complications. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (8 April 2005), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2005), and EMBASE (2002 to May 2005). We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 1 October 2009 and added the results to the awaiting classification section. Selection criteria Randomised trials evaluating either reduced or increased dietary salt intake during pregnancy. Data collection and analysis Two review authors selected trials for inclusion and extracted data independently. Data were entered on Review Manager software for analysis, and double‐checked for accuracy. Main results Two trials were included, with 603 women. Both compared advice to reduce dietary salt intake with advice to continue a normal diet. The confidence intervals were wide and crossed the no‐effect line for all the reported outcomes, including pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). In other words, there was insufficient evidence for reliable conclusions about the effects of advice to reduce dietary salt. Authors' conclusions In the absence of evidence that advice to alter salt intake during pregnancy has any beneficial effect for prevention of pre‐eclampsia or any other outcome, salt consumption during pregnancy should remain a matter of personal preference. [Note: The citation in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Altered dietary salt for preventing pre‐eclampsia, and its complications Low salt intake in pregnancy is unlikely to prevent pre‐eclampsia. Pre‐eclampsia is a serious complication of pregnancy associated with poor health, or even death, for the mother and baby. Pre‐eclampsia is identified by raised blood pressure and protein in the urine during the second half of pregnancy. In the past, a low‐salt diet was often recommended, in the belief that it would help to prevent pre‐eclampsia. However, the review found just two trials that did not show any evidence of benefit for the mother or baby. Salt intake in pregnancy should be a matter of personal preference.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Duley, L; Henderson‐Smart, DJ; Meher, S", "articleTypes": [], "doi": "10.1002/14651858.CD005548", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "2f590b1e-b046-4adb-827b-f3a14c2aee34", "pmid": "", "title": "Systemic antifungal therapy for tinea capitis in children", "imported": false, "abstract": "Abstract - Background Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread. This is an update of the original Cochrane review. Objectives To assess the effects of systemic antifungal drugs for tinea capitis in children. Search methods We updated our searches of the following databases to November 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and CINAHL (from 1981). We searched five trial registers and checked the reference lists of studies for references to relevant randomised controlled trials (RCTs). We obtained unpublished, ongoing trials and grey literature via correspondence with experts in the field and from pharmaceutical companies. Selection criteria RCTs of systemic antifungal therapy in children with normal immunity under the age of 18 with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 25 studies (N = 4449); 4 studies (N = 2637) were new to this update. Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy for the primary outcome of complete (i.e. clinical and mycological) cure in three studies involving 328 participants with Trichophyton species infections (84.2% versus 79.0%; risk ratio (RR) 1.06, 95% confidence interval (CI) 0.98 to 1.15; low quality evidence). Complete cure with itraconazole (two to six weeks) and griseofulvin (six weeks) was similar in two studies (83.6% versus 91.0%; RR 0.92, 95% CI 0.81 to 1.05; N = 134; very low quality evidence). In two studies, there was no difference between itraconazole and terbinafine for two to three weeks treatment (73.8% versus 78.8%; RR 0.93, 95% CI 0.72 to 1.19; N = 160; low quality evidence). In three studies, there was a similar proportion achieving complete cured with two to four weeks of fluconazole or six weeks of griseofulvin (41.4% versus 52.7%; RR 0.92, 95% CI 0.81 to 1.05; N = 615; moderate quality evidence). Current evidence for ketoconazole versus griseofulvin was limited. One study favoured griseofulvin (12 weeks) because ketoconazole (12 weeks) appeared less effective for complete cure (RR 0.76, 95% CI 0.62 to 0.94; low quality evidence). However, their effects appeared to be similar when the treatment lasted 26 weeks (RR 0.95, 95% CI 0.83 to 1.07; low quality evidence). Another study indicated that complete cure was similar for ketoconazole (12 weeks) and griseofulvin (12 weeks) (RR 0.89, 95% CI 0.57 to 1.39; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole (for two to three weeks) and terbinafine (for two to three weeks) (82.0% versus 94.0%; RR 0.87, 95% CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, we did not find a significant difference between fluconazole (for two to three weeks) and itraconazole (for two to three weeks) (82.0% versus 82.0%; RR 1.00, 95% CI 0.83 to 1.20; low quality evidence). This update provides new data: in children with Microsporum infections, a meta‐analysis of two studies found that the complete cure was lower for terbinafine (6 weeks) than for griseofulvin (6‐12 weeks) (34.7% versus 50.9%; RR 0.68, 95% CI 0.53 to 0.86; N = 334; moderate quality evidence). In the original review, there was no significant difference in complete cure between terbinafine (four weeks) and griseofulvin (eight weeks) in children with Microsporum infections in one small study (27.2% versus 60.0%; RR 0.45, 95% CI 0.15 to 1.35; N = 21; low quality evidence). One study provides new evidence that terbinafine and griseofulvin for six weeks show similar efficacy (49.5% versus 37.8%; RR 1.18, 95% CI 0.74 to 1.88; N = 1006; low quality evidence). However, in children infected with T. tonsurans , terbinafine was better than griseofulvin (52.1% versus 35.4%; RR 1.47, 95% CI 1.22 to 1.77; moderate quality evidence). For children infected with T. violaceum, these two regimens have similar effects (41.3% versus 45.1%; RR 0.91, 95% CI 0.68 to 1.24; low quality evidence). Additionally, three weeks of fluconazole was similar to six weeks of fluconazole in one study in 491 participants infected with T. tonsurans and M. canis (30.2% versus 34.1%; RR 0.88, 95% CI 0.68 to 1.14; low quality evidence). The frequency of adverse events attributed to the study drugs was similar for terbinafine and griseofulvin (9.2% versus 8.3%; RR 1.11, 95% CI 0.79 to 1.57; moderate quality evidence), and severe adverse events were rare (0.6% versus 0.6%; RR 0.97, 95% CI 0.24 to 3.88; moderate quality evidence). Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible. All of the included studies were at either high or unclear risk of bias in at least one domain. Using GRADE to rate the overall quality of the evidence, lower quality evidence resulted in lower confidence in the estimate of effect. Authors' conclusions Newer treatments including terbinafine, itraconazole and fluconazole are at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Limited evidence suggests that terbinafine, itraconazole and fluconazole have similar effects, whereas ketoconazole may be less effective than griseofulvin in children infected with Trichophyton . With some interventions the proportion achieving complete clinical cure was in excess of 90% (e.g. one study of terbinafine or griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. New evidence from this update suggests that terbinafine is more effective than griseofulvin in children with T. tonsurans infection. However, in children with Microsporum infections, new evidence suggests that the effect of griseofulvin is better than terbinafine. We did not find any evidence to support a difference in terms of adherence between four weeks of terbinafine versus eight weeks of griseofulvin. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles. Plain language summary Antifungal medicines for treating children with ringworm Background Tinea capitis, or ringworm, is a fungal infection of the scalp caused mainly by two species of fungi called Trichophyton and Microsporum . It is common in children. Most fungal infections can be treated with antifungal creams applied directly to the skin (topical treatments). However, because the fungal infection is found at the root of the hair follicles, where topical treatments cannot reach, tinea capitis always requires medication administered by mouth so that the treatment spreads throughout the entire body (systemic treatments). There are several different types of antifungal medicines available. Review question Which antifungal medicine is best for treating ringworm on the scalp in children? Study characteristics In November 2015, we searched for studies that used the gold standard design for clinical trials (randomised controlled trials) of antifungal treatments taken by mouth. We found 25 studies in which 4449 children under 18 years (4 studies with 2637 children were new to this update) had taken part. Key results With respect to complete cure (both cure of the infection and visible cure (i.e. fungal and clinical cure) low to moderate quality evidence suggests that newer treatments such as terbinafine, itraconazole and fluconazole are at least as good as griseofulvin, the usual treatment in children with tinea capitis caused by Trichophyton infections. However, new evidence in this update suggests that terbinafine may have better effects than griseofulvin for completely curing children with T. tonsurans infection. By contrast, in children with Microsporum infections, new evidence seems to indicate that griseofulvin is more effective than terbinafine. Terbinafine, itraconazole and fluconazole appear to have similar effects in terms of the proportion of participants achieving complete cure, whereas ketoconazole appears to be less effective than griseofulvin for children with tinea capitis caused by Trichophyton species. However, the quality of this evidence is low. With some interventions, the proportion with complete clinical cure was in excess of 90% (e.g. one study of terbinafine versus griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. The included studies reported on negative side effects, which were similarly mild and reversible for terbinafine, griseofulvin, itraconazole, ketoconazole and fluconazole. They included skin‐specific effects such as itching as well as abdominal discomfort, headache and nausea. Quality of the evidence The quality of the evidence in this review was generally low to moderate, so further research is likely to have an important effect on our confidence in these results. Some evidence was even of very low quality. We still need more and better evidence to help us understand the effectiveness and adverse events of systemic antifungal drugs for tinea capitis in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chen, X, Jiang, X, Yang, M, González, U, Lin, X, Hua, X, Xue, S, Zhang, M, Bennett, C", "articleTypes": [], "doi": "10.1002/14651858.CD004685.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.776Z" }, { "id": "2f8ebfeb-55fb-40c2-86ec-6b560c83a7d8", "pmid": "", "title": "Activation and Inhibition of the Sweet Taste Receptor T1R2-T1R3 Differentially Affect Glucose Tolerance in Humans", "imported": false, "abstract": "In the present study, our objective was to determine whether T1R2-T1R3 influences glucose metabolism bidirectionally via hyperactivation with sucralose and inhibition with sodium lactisole in mixture with glucose loads during tolerance tests in humans. In 12 healthy participants we conducted oral glucose tolerance tests (OGTTs) of 75 g glucose with and without the addition of the T1R2-T1R3 agonist, sucralose (5 mM). We also conducted OGTTs in 10 healthy participants with and without the addition of a T1R2-T1R3 antagonist, sodium lactisole (2 mM). Plasma glucose, insulin, and glucagon were measured before, during, and after OGTTs up to 120 minutes post-prandially. We also assessed individual participants' sweet taste responses to sucralose, their sensitivities to sweetness inhibition by lactisole, and their BMIs.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "2fbdb347-c398-4b72-8cdb-4c5f3aa84b9b", "pmid": "", "title": "The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents", "imported": false, "abstract": "Abstract - Background Erythropoiesis‐stimulating agents (ESAs) are commonly used to treat chemotherapy‐induced anemia (CIA). However, about half of patients do not benefit. Objectives To evaluate the benefits and harms related to the use of iron as a supplement to ESA and iron alone compared with ESA alone in the management of CIA. Search methods We searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1 January 2016), MEDLINE (1950 to February 2016), and www.clinicaltrials.gov without using any language limits. Selection criteria All randomized controlled trials (RCTs) comparing 'iron plus ESA' or 'iron alone' versus 'ESA alone' in people with CIA were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included eight RCTs (12 comparisons) comparing ESA plus iron versus ESA alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone in people with CIA. None of the included RCTs reported overall survival. There was a beneficial effect of iron supplementation to ESAs compared with ESAs alone on hematopoietic response (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.09 to 1.26; P < 0.0001; 1712 participants; 11 comparisons; high‐quality evidence). Assuming a baseline risk of 35% to 80% for hematopoietic response without iron supplementation, between seven and 16 patients should be treated to achieve hematopoietic response in one patient. In subgroup analyses, RCTs that used intravenous (IV) iron favored ESAs and iron (RR 1.20 (95% CI 1.10 to 1.31); P < 0.00001; 1321 participants; eight comparisons), whereas we found no evidence for a difference in hematopoietic response in RCTs using oral iron (RR 1.04 (95% CI 0.87 to 1.24); P = 0.68; 391 participants; three comparisons). There was no evidence for a difference between the subgroups of IV and oral iron (P = 0.16). There was no evidence for a difference between the subgroups of types of iron (P = 0.31) and types of ESAs (P = 0.16) for hematopoietic response. The iron supplementation to ESAs might be beneficial as fewer participants treated with iron supplementation required red blood cell (RBC) transfusions compared to the number of participants treated with ESAs alone (RR 0.74 (95% CI 0.60 to 0.92); P = 0.007; 1719 participants; 11 comparisons; moderate‐quality evidence). Assuming a baseline risk of 7% to 40% for RBC transfusion without iron supplementation, between 10 and 57 patients should be treated to avoid RBC transfusion in one patient. We found no evidence for a difference in the median time to hematopoietic response with addition of iron to ESAs (hazard ratio (HR) 0.93 (95% CI 0.67 to 1.28); P = 0.65; 1042 participants; seven comparisons; low‐quality evidence). In subgroup analyses, RCTs in which dextran (HR 0.95 (95% CI 0.36 to 2.52); P = 0.92; 340 participants; three comparisons), sucrose iron (HR 1.15 (95% CI 0.60 to 2.21); P = 0.67; 102 participants; one comparison) and sulfate iron (HR 1.24 (95% CI 0.99 to 1.56); P = 0.06; 55 participants; one comparison) were used showed no evidence for difference between iron supplementation versus ESAs alone compared with RCTs in which gluconate (HR 0.78 (95% CI 0.65 to 0.94); P = 0.01; 464 participants; two comparisons) was used for median time to hematopoietic response (P = 0.02). There was no evidence for a difference between the subgroups of route of iron administration (P = 0.13) and types of ESAs (P = 0.46) for median time to hematopoietic response. Our results indicated that there could be improvement in the hemoglobin (Hb) levels with addition of iron to ESAs (mean difference (MD) 0.48 (95% CI 0.10 to 0.86); P = 0.01; 827 participants; seven comparisons; low‐quality evidence). In RCTs in which IV iron was used there was evidence for a difference (MD 0.84 (95% CI 0.21 to 1.46); P = 0.009; 436 participants; four comparisons) compared with oral iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) for mean change in Hb level (P = 0.03). RCTs in which dextran (MD 1.55 (95% CI 0.62 to 2.47); P = 0.001; 102 participants; two comparisons) was used showed evidence for a difference with iron supplementation versus ESAs alone compared with RCTs in which gluconate (MD 0.54 (95% CI ‐0.15 to 1.22); P = 0.12; 334 participants; two comparisons) and sulfate iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) were used for mean change in Hb level (P = 0.007). RCTs in which epoetin was used showed evidence for a difference with iron supplementation versus ESAs alone (MD 0.77 (95% CI 0.25 to 1.29); P = 0.004; 337 participants; five comparisons) compared with darbepoetin use (MD 0.10 (95% CI ‐0.13 to 0.33); P = 0.38; 490 participants; two comparisons) for mean change in Hb level (P = 0.02). We found no evidence for a difference in quality of life with addition of iron to ESAs (standardized mean difference 0.01 (95% CI ‐0.10 to 0.12); P = 0.88; 1124 participants; three RCTs; high‐quality evidence). We found no evidence for a difference in risk of grade III‐IV thromboembolic events (RR 0.95 (95% CI 0.54 to 1.65); P = 0.85; 783 participants; three RCTs; moderate‐quality evidence). The incidence of treatment‐related mortality (TRM) was 0% (997 participants; four comparisons; high‐quality evidence). Other common adverse events included vomiting, asthenia, and leukopenia, and were similar in both arms. Overall the risk of bias across outcomes was high to low. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown. Our main reasons for downgrading the quality of evidence were inconsistency across the included studies and imprecision of results. Authors' conclusions Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation. Plain language summary The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents Review question: Is iron alone or iron as a supplement to erythropoiesis‐stimulating agents (ESAs) superior to ESAs alone in the management of people diagnosed with chemotherapy‐induced anemia (CIA)? Background: The current treatment of CIA is ESAs, which increase the production of red blood cells (erythropoiesis), and in some cases ESAs and iron. In some cases, strategies such as no therapy or wait and watch with clinical oversight and red blood cell transfusion may be safe and suitable options. We conducted a systematic review to evaluate the benefits and harms of iron in the management of CIA. Search date: The evidence is current to February 2016. Study characteristics: We included eight industry‐funded randomized controlled trials (RCTs) comparing ESAs plus iron versus ESAs alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone. Study funding source: All the included trials were industry funded. Key results: Adding iron to ESAs improves the hematopoietic response in people with CIA. Use of iron with ESAs might reduce the risk of blood transfusions and improve hemoglobin. We found no improvement in quality of life with addition of iron. We found no evidence for a difference in time to hematopoietic response and risk of development of blood clot in veins of people with CIA treated with iron and ESAs compared with ESAs alone. There were zero treatment‐related deaths among 997 participants in the four trials that reported this outcome. Other harms included constipation, vomiting, and diarrhea, and were similar with ESAs and iron compared with ESAs alone. None of the trials reported data on survival. Quality of evidence: The quality of evidence for hematopoietic response was high. The quality of evidence for red blood cell transfusion was moderate, as the pooled estimate had large variation. The quality of evidence for change in hemoglobin and time to hematopoietic response was low, as the pooled estimates had large variation and results were not similar across studies. The quality of evidence for quality of life was high. The quality of evidence for risk of blood clots in veins was moderate due to variation in pooled estimate. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Mhaskar, R, Wao, H, Miladinovic, B, Kumar, A, Djulbegovic, B", "articleTypes": [], "doi": "10.1002/14651858.CD009624.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.756Z" }, { "id": "2fbf6727-9d86-4b5f-9bb8-8c36ed876fdc", "pmid": "", "title": "Statins for asthma", "imported": false, "abstract": "Abstract - Background Asthma is a common chronic respiratory disease. People with asthma have inflammation of their airways that causes recurrent episodes of wheezing, breathlessness and chest tightness, with or without a cough. Statins possess multiple therapeutic effects, including lowering lipid levels in the blood. Statins are reported to have a potential role as an adjunct treatment in asthma. However, comprehensive evidence of the benefits and harms of using statins is required to facilitate decision making. Objectives To assess the benefits and harms of statins as an adjunct therapy for asthma in adults and children. Search methods We searched for studies in the Cochrane Airways Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid SP and Embase Ovid SP, from their inception dates We handsearched the proceedings of major respiratory conferences. We also searched clinical trials registries for completed, ongoing and unpublished studies, and scanned the reference lists of included studies and relevant reviews to identify additional studies. The search is current to 7 February 2020. Selection criteria We included randomised controlled trials (RCTs) with a parallel‐group design that assessed statins for at least 12 weeks' duration. We considered all participants with a clinical diagnosis of asthma to be eligible, regardless of age, sex, disease severity and previous or current treatment. We planned to include studies reported as full text, those published as abstract only, and unpublished data. Data collection and analysis Two review authors independently screened and selected the studies, extracted outcome data and intervention characteristics from included studies, and assessed risk of bias according to standard Cochrane methodological procedures. We resolved any disagreement through discussion. Main results We found only one trial involving a total of 60 people living with asthma. The trial compared the effect of atorvastatin with a placebo (dummy treatment containing lactose) in treating people with chronic asthma. The trial did not report data for the primary outcomes or adverse events. There was uncertainty about the relative effect on forced expiratory volume in one second (FEV 1 ) and peak expiratory flow (PEF) in the atorvastatin group compared with the placebo group. The study did not report serious adverse effects for the interventions. The included study had internal discrepancies in its reported data. Authors' conclusions The evidence was of very low certainty, so we are unable to draw conclusions about the effectiveness and safety of statins to treat asthma. High‐quality RCTs are needed to assess the effect of statins on people with asthma. Well‐designed multicentre trials with larger samples and longer duration of treatment are required, which assess outcomes such as adverse events, hospital utilisation and costs, to provide better quality evidence. Future studies that include subgroups of obese people with asthma are also required. Plain language summary Statins for asthma Review question We reviewed the evidence about the effect of statins in people with asthma. Background Asthma is a common chronic (persistent) airway disease. Asthma is caused by inflammation in the lungs and bronchoconstriction (tightening of the small tubes in the lungs in response to a trigger such as pollen or cold air). Inflammation and bronchoconstriction cause airflow obstruction (narrowing and blockage). People with asthma experience recurrent attacks of wheezing, difficultly in breathing, and chest tightness, with or without a cough. Statins are anti‐inflammatory medicines. We wanted to review the evidence for statins because the theory is that their anti‐inflammatory properties will help people with asthma. We wanted to discover whether using statin therapy was better or worse than other alternatives, such as usual care alone or different types of statins (atorvastatin, simvastatin). Study characteristics We found only one trial that assessed atorvastatin (a type of statin drug) and placebo (dummy treatment) in 60 adults with asthma over a period of 12 weeks. These people had chronic asthma (persistent airway disease) when they started treatment. Key results We found that the statin (atorvastatin) did not result in any clear improvement in lung function in people with asthma, but may be better in asthma control than the dummy drug. However, because there is only one trial, we cannot draw firm conclusions. The trial did not report on adverse effects or severe adverse effects (harms). We are uncertain whether statins may have beneficial effects on relieving asthma or whether they may increase the risk of adverse events or non‐serious adverse events. Quality of the evidence The evidence was of very low certainty, so we cannot draw firm conclusions about whether statins are helpful and safe to be used by people with asthma. The evidence is current to 7 February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Naing, C; Ni, H", "articleTypes": [], "doi": "10.1002/14651858.CD013268.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "2fceaafc-bf43-43f9-a4d7-a274e7e21dd2", "pmid": "", "title": "Vitamin C for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Vitamin C (ascorbic acid) for preventing and treating the common cold has been a subject of controversy for 70 years. Objectives To find out whether vitamin C reduces the incidence, the duration or severity of the common cold when used either as a continuous regular supplementation every day or as a therapy at the onset of cold symptoms. Search methods We searched CENTRAL 2012, Issue 11, MEDLINE (1966 to November week 3, 2012), EMBASE (1990 to November 2012), CINAHL (January 2010 to November 2012), LILACS (January 2010 to November 2012) and Web of Science (January 2010 to November 2012). We also searched the U.S. National Institutes of Health trials register and WHO ICTRP on 29 November 2012. Selection criteria We excluded trials which used less than 0.2 g per day of vitamin C and trials without a placebo comparison. We restricted our review to placebo‐controlled trials. Data collection and analysis Two review authors independently extracted data. We assessed 'incidence' of colds during regular supplementation as the proportion of participants experiencing one or more colds during the study period. 'Duration' was the mean number of days of illness of cold episodes. Main results Twenty‐nine trial comparisons involving 11,306 participants contributed to the meta‐analysis on the risk ratio (RR) of developing a cold whilst taking vitamin C regularly over the study period. In the general community trials involving 10,708 participants, the pooled RR was 0.97 (95% confidence interval (CI) 0.94 to 1.00). Five trials involving a total of 598 marathon runners, skiers and soldiers on subarctic exercises yielded a pooled RR of 0.48 (95% CI 0.35 to 0.64). Thirty‐one comparisons examined the effect of regular vitamin C on common cold duration (9745 episodes). In adults the duration of colds was reduced by 8% (3% to 12%) and in children by 14% (7% to 21%). In children, 1 to 2 g/day vitamin C shortened colds by 18%. The severity of colds was also reduced by regular vitamin C administration. Seven comparisons examined the effect of therapeutic vitamin C (3249 episodes). No consistent effect of vitamin C was seen on the duration or severity of colds in the therapeutic trials. The majority of included trials were randomised, double‐blind trials. The exclusion of trials that were either not randomised or not double‐blind had no effect on the conclusions. Authors' conclusions The failure of vitamin C supplementation to reduce the incidence of colds in the general population indicates that routine vitamin C supplementation is not justified, yet vitamin C may be useful for people exposed to brief periods of severe physical exercise. Regular supplementation trials have shown that vitamin C reduces the duration of colds, but this was not replicated in the few therapeutic trials that have been carried out. Nevertheless, given the consistent effect of vitamin C on the duration and severity of colds in the regular supplementation studies, and the low cost and safety, it may be worthwhile for common cold patients to test on an individual basis whether therapeutic vitamin C is beneficial for them. Further therapeutic RCTs are warranted. Plain language summary Vitamin C for preventing and treating the common cold The common cold is a major cause of visits to a doctor in high‐income countries and of absenteeism from work and school. There are over 200 viruses which can cause the common cold symptoms including runny nose, congestion, sneezing, sore throat, cough, and sometimes headache, fever and red eyes. Symptoms vary from person to person and cold to cold. Since the common cold is usually caused by one of the respiratory viruses, antibiotics are useless and therefore other potential treatment options are of substantial public health interest. Vitamin C has been proposed for treating respiratory infections since it was isolated in the 1930s. It became particularly popular in the 1970s when Nobel laureate Linus Pauling concluded from earlier placebo‐controlled trials that vitamin C would prevent and alleviate the common cold. Over two dozen new trials were undertaken thereafter. Vitamin C has been widely sold and used as a preventive and therapeutic agent. This review is restricted to placebo‐controlled trials testing 0.2 g/day or more of vitamin C. Regular ingestion of vitamin C had no effect on common cold incidence in the ordinary population, based on 29 trial comparisons involving 11,306 participants. However, regular supplementation had a modest but consistent effect in reducing the duration of common cold symptoms, which is based on 31 study comparisons with 9745 common cold episodes. In five trials with 598 participants exposed to short periods of extreme physical stress (including marathon runners and skiers) vitamin C halved the common cold risk. The published trials have not reported adverse effects of vitamin C. Trials of high doses of vitamin C administered therapeutically, starting after the onset of symptoms, showed no consistent effect on the duration or severity of common cold symptoms. However, only a few therapeutic trials have been carried out and none have examined children, although the effect of prophylactic vitamin C has been greater in children. One large trial with adults reported benefit from an 8 g therapeutic dose at the onset of symptoms, and two therapeutic trials using five‐day supplementation reported benefit. More trials are necessary to settle the possible role of therapeutic vitamin C, meaning administration immediately after the onset of symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H, Chalker, E", "articleTypes": [], "doi": "10.1002/14651858.CD000980.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.071Z" }, { "id": "2fdd722c-d20b-4f4f-863a-d18f074cee4b", "pmid": "", "title": "Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy", "imported": false, "abstract": "Abstract - Background In the past women have been advised that lowering their salt intake might reduce their risk of pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of advice to alter dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of dietary advice to alter salt intake compared to continuing a normal diet, on the risk of pre‐eclampsia and its consequences. Search methods We searched the register of trials maintained and updated by the Cochrane Pregnancy and Childbirth Group, and the Cochrane Controlled Trials Register Disc Issue 4, 1998. Selection criteria Studies were included if they were randomised trials of advice to either reduce or to increase dietary salt during pregnancy. Data collection and analysis All data were extracted independently by both reviewers. Main results Two trials were included, with 603 women. They compared advice about a low salt diet with no dietary advice. The confidence intervals for all of the outcomes reported were wide, and cross the no effect line. This includes pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). Even when taken together, these trials are insufficient to provide reliable information about the effects of advice on salt restriction during normal pregnancy. None of the trials included women with pre‐eclampsia, so this review provides no reliable information about changes in salt intake for treatment of pre‐eclampsia. Authors' conclusions Salt consumption during pregnancy should remain a matter of personal preference. Plain language summary Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy To be prepared.", "journal": "Cochrane Database of Systematic Reviews", "year": "1999", "authors": "Duley, L, Henderson‐Smart, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD001687", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.761Z" }, { "id": "2fef8c29-6107-455f-b9f7-dec359b17e51", "pmid": "", "title": "Antioxidant vitamin and mineral supplements for slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Evans, JR, Lawrenson, JG", "articleTypes": [], "doi": "10.1002/14651858.CD000254.pub5 AB - Abstract - Background Age‐related macular degeneration (AMD) is a degenerative condition of the back of the eye that occurs in people over the age of 50 years. Antioxidants may prevent cellular damage in the retina by reacting with free radicals that are produced in the process of light absorption. Higher dietary levels of antioxidant vitamins and minerals may reduce the risk of progression of AMD. This is the third update of the review. Objectives To assess the effects of antioxidant vitamin and mineral supplements on the progression of AMD in people with AMD. Search methods We searched CENTRAL, MEDLINE, Embase, one other database, and three trials registers, most recently on 29 November 2022. Selection criteria We included randomised controlled trials (RCTs) that compared antioxidant vitamin or mineral supplementation to placebo or no intervention, in people with AMD. Data collection and analysis We used standard methods expected by Cochrane. Main results We included 26 studies conducted in the USA, Europe, China, and Australia. These studies enroled 11,952 people aged 65 to 75 years and included slightly more women (on average 56% women). We judged the studies that contributed data to the review to be at low or unclear risk of bias. Thirteen studies compared multivitamins with control in people with early and intermediate AMD. Most evidence came from the Age‐Related Eye Disease Study (AREDS) in the USA. People taking antioxidant vitamins were less likely to progress to late AMD (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.58 to 0.90; 3 studies, 2445 participants; moderate‐certainty evidence). In people with early AMD, who are at low risk of progression, this means there would be approximately four fewer cases of progression to late AMD for every 1000 people taking vitamins (one fewer to six fewer cases). In people with intermediate AMD at higher risk of progression, this corresponds to approximately 78 fewer cases of progression for every 1000 people taking vitamins (26 fewer to 126 fewer). AREDS also provided evidence of a lower risk of progression for both neovascular AMD (OR 0.62, 95% CI 0.47 to 0.82; moderate‐certainty evidence) and geographic atrophy (OR 0.75, 95% CI 0.51 to 1.10; moderate‐certainty evidence), and a lower risk of losing 3 or more lines of visual acuity (OR 0.77, 95% CI 0.62 to 0.96; moderate‐certainty evidence). Low‐certainty evidence from one study of 110 people suggested higher quality of life scores (measured with the Visual Function Questionnaire) in treated compared with non‐treated people after 24 months (mean difference (MD) 12.30, 95% CI 4.24 to 20.36). In exploratory subgroup analyses in the follow‐on study to AREDS (AREDS2), replacing beta‐carotene with lutein/zeaxanthin gave hazard ratios (HR) of 0.82 (95% CI 0.69 to 0.96), 0.78 (95% CI 0.64 to 0.94), 0.94 (95% CI 0.70 to 1.26), and 0.88 (95% CI 0.75 to 1.03) for progression to late AMD, neovascular AMD, geographic atrophy, and vision loss, respectively. Six studies compared lutein (with or without zeaxanthin) with placebo and one study compared a multivitamin including lutein/zeaxanthin with multivitamin alone. The duration of supplementation and follow‐up ranged from six months to five years. Most evidence came from the AREDS2 study in the USA; almost all participants in AREDS2 also took the original AREDS supplementation formula. People taking lutein/zeaxanthin may have similar or slightly reduced risk of progression to late AMD (RR 0.94, 95% CI 0.87 to 1.01), neovascular AMD (RR 0.92, 95% CI 0.84 to 1.02), and geographic atrophy (RR 0.92, 95% CI 0.80 to 1.05) compared with control (1 study, 4176 participants, 6891 eyes; low‐certainty evidence). A similar risk of progression to visual loss of 15 or more letters was seen in the lutein/zeaxanthin and control groups (RR 0.98, 95% CI 0.91 to 1.05; 6656 eyes; low‐certainty evidence). Quality of life (Visual Function Questionnaire) was similar between groups (MD 1.21, 95% CI ‐2.59 to 5.01; 2 studies, 308 participants; moderate‐certainty evidence).
One study in Australia randomised 1204 people to vitamin E or placebo with four years of follow‐up; 19% of participants had AMD. The number of late AMD events was low (N = 7) and the estimate of effect was uncertain (RR 1.36, 95% CI 0.31 to 6.05; very low‐certainty evidence). There was no evidence of any effect of treatment on visual loss (RR 1.04, 95% CI 0.74 to 1.47; low‐certainty evidence). There were no data on neovascular AMD, geographic atrophy, or quality of life.
Five studies compared zinc with placebo. Evidence largely drawn from the largest study (AREDS) found a lower progression to late AMD over six years (OR 0.83, 95% CI 0.70 to 0.98; 3 studies, 3790 participants; moderate‐certainty evidence), neovascular AMD (OR 0.76, 95% CI 0.62 to 0.93; moderate‐certainty evidence), geographic atrophy (OR 0.84, 95% CI 0.64 to 1.10; moderate‐certainty evidence), or visual loss (OR 0.87, 95% CI 0.75 to 1.00; 2 studies, 3791 participants; moderate‐certainty evidence). There were no data on quality of life. Gastrointestinal symptoms were the main reported adverse effect. In AREDS, zinc was associated with a higher risk of genitourinary problems in men, but no difference was seen between high‐ and low‐dose zinc groups in AREDS2. Most studies were too small to detect rare adverse effects. Data from larger studies (AREDS/AREDS2) suggested there may be little or no effect on mortality with multivitamin (HR 0.87, 95% CI 0.60 to 1.25; low‐certainty evidence) or lutein/zeaxanthin supplementation (HR 1.06, 95% CI 0.87 to 1.31; very low‐certainty evidence), but confirmed the increased risk of lung cancer with beta‐carotene, mostly in former smokers. Authors' conclusions Moderate‐certainty evidence suggests that antioxidant vitamin and mineral supplementation (AREDS: vitamin C, E, beta‐carotene, and zinc) probably slows down progression to late AMD. People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than people with early AMD. Although low‐certainty evidence suggested little effect with lutein/zeaxanthin alone compared with placebo, exploratory subgroup analyses from one large American study support the view that lutein/zeaxanthin may be a suitable replacement for the beta‐carotene used in the original AREDS formula. Plain language summary Do antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD)? Key messages 
‐ Taking an antioxidant multivitamin supplement may slow down the progression of age‐related macular degeneration (AMD), an eye disease that blurs your central vision. ‐ People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than for people with early AMD. ‐ Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence as to safety as they were generally too small. What is age‐related macular degeneration? Age‐related macular degeneration (AMD) is an eye disease that blurs your central vision. It is usually only diagnosed in people aged 50 years and above. AMD affects the central area (macula) of the back of the eye (retina), as the macula degenerates with age. In early AMD, yellow spots (called drusen) can be seen under the retina by an eye health professional. The affected person will probably be unaware that they have a problem. As the disease progresses, the drusen become larger (intermediate AMD). In the later stages of the disease, there may be loss of the cells – needed for vision – in the back of the eye. This is known as geographic atrophy. Sometimes, new (harmful) blood vessels grow in the macula. These new blood vessels may bleed and cause scarring. This is known as neovascular AMD. Neovascular AMD and geographic atrophy are known as late AMD. Why might antioxidant vitamins and minerals be helpful? Antioxidant vitamins and minerals may help to protect the macula against this deterioration and loss of vision. Antioxidants are natural molecules that may prevent or delay some types of cell damage. Vitamins C and E, beta‐carotene, lutein, zeaxanthin, and zinc are examples of antioxidants commonly found in dietary supplements. What did we want to find out? 
We wanted to find out whether antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD) and prevent visual loss. What did we do? We searched for studies that compared antioxidant vitamin and mineral supplements with placebo (a ‘dummy’ treatment not containing any supplements) or no treatment. We only looked at the effects of these supplements in people with AMD. There is another Cochrane Review on the effects of these supplements in people who do not already have AMD. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 26 studies from the USA, Europe, China, and Australia that enroled 11,952 people with AMD. These studies compared multivitamin supplements, zinc, vitamin E, lutein (with or without zeaxanthin) with placebo. Participants were aged 65 to 75 years and there were slightly more women than men in the studies. Main findings • Taking an antioxidant multivitamin supplement (AREDS formula containing vitamins E and C, beta‐carotene plus zinc) probably slows down the progression of AMD to late AMD and vision loss. This may result in a small improvement in quality of life. • People with intermediate AMD have a higher risk of progression to late AMD and so may be more likely to benefit from supplements (78 fewer cases of progression for every 1000 people taking supplements). People with early AMD have a low risk of progression and so may be less likely to benefit (4 fewer cases of progression to late AMD for every 1000 people taking supplements). • Lutein with or without zeaxanthin may have little or no effect on progression to late AMD but may be a suitable replacement for beta‐carotene in the AREDS formula. Beta‐carotene may increase the chance of lung cancer in people who have smoked. • The effects of vitamin E alone on the progression to late AMD and vision loss are uncertain. Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence about safety because most of the studies were small and reported on harmful effects inconsistently. What are the limitations of the evidence? Our confidence in the evidence ranged from moderate to very low. This is because most of the included studies were small, and they did not cover all the comparisons and outcomes we were interested in. How up to date is this review? 
This review updates our previous version. The evidence is up to date to 29 November 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.782Z" }, { "id": "2ffe3487-df8f-40e7-9587-3f059f67172f", "pmid": "", "title": "Running Performance in Response to Different Forms of Carbohydrate", "imported": false, "abstract": "Carbohydrates serve as the body's primary energy source during intense exercise, and consuming carbohydrates during exercise has been shown to improve exercise performance. Previous research has shown that the presence of carbohydrates in the mouth activates sweet taste receptors on the tongue, which signal the brain to increase neural activation in areas associated with motor functioning, sensory perception, and reward centers during exercise through this CPR. The primary objective of this intervention is to establish how carbohydrates delivered in different forms (MR versus dissolvable strip (DS)) affect running performance during a 12.8km running TT.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.149Z" }, { "id": "30159051-ef32-4d39-9e7d-bcfe0c973522", "pmid": "", "title": "Interventions for treating oro‐antral communications and fistulae due to dental procedures", "imported": false, "abstract": "Abstract - Background An oro‐antral communication is an unnatural opening between the oral cavity and maxillary sinus. When it fails to close spontaneously, it remains patent and is epithelialized to develop into an oro‐antral fistula. Various surgical and non‐surgical techniques have been used for treating the condition. Surgical procedures include flaps, grafts and other techniques like re‐implantation of third molars. Non‐surgical techniques include allogenic materials and xenografts. This is an update of a review first published in May 2016. Objectives To assess the effectiveness and safety of various interventions for the treatment of oro‐antral communications and fistulae due to dental procedures. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 23 May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 4), MEDLINE Ovid (1946 to 23 May 2018), and Embase Ovid (1980 to 23 May 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the reference lists of included and excluded trials for any randomised controlled trials (RCTs). Selection criteria We included RCTs evaluating any intervention for treating oro‐antral communications or oro‐antral fistulae due to dental procedures. We excluded quasi‐RCTs and cross‐over trials. We excluded studies on participants who had oro‐antral communications, fistulae or both related to Caldwell‐Luc procedure or surgical excision of tumours. Data collection and analysis Two review authors independently selected trials. Two review authors assessed trial risk of bias and extracted data independently. We estimated risk ratios (RR) for dichotomous data, with 95% confidence intervals (CI). We assessed the overall quality of the evidence using the GRADE approach. Main results We included only one study in this review, which compared two surgical interventions: pedicled buccal fat pad flap and buccal flap for the treatment of oro‐antral communications. The study involved 20 participants. The risk of bias was unclear. The relevant outcome reported in this trial was successful (complete) closure of oro‐antral communication. The quality of the evidence for the primary outcome was very low. The study did not find evidence of a difference between interventions for the successful (complete) closure of an oro‐antral communication (RR 1.00, 95% Cl 0.83 to 1.20) one month after the surgery. All oro‐antral communications in both groups were successfully closed so there were no adverse effects due to treatment failure. We did not find trials evaluating any other intervention for treating oro‐antral communications or fistulae due to dental procedures. Authors' conclusions We found very low quality evidence from a single small study that compared pedicled buccal fat pad and buccal flap. The evidence was insufficient to judge whether there is a difference in the effectiveness of these interventions as all oro‐antral communications in the study were successfully closed by one month after surgery. Large, well‐conducted RCTs investigating different interventions for the treatment of oro‐antral communications and fistulae caused by dental procedures are needed to inform clinical practice. Plain language summary Treatment of communications between the oral cavity and the maxillary sinus due to dental procedures Review question What evidence is available for the safe and effective treatment of openings between the mouth and main sinus caused by dental procedures? Background The floor of the main sinus near the nose is thin and lies directly above the roots of the teeth at the back of the mouth. Sometimes following infection or dental treatment, this structure becomes damaged and openings or channels between the mouth and the sinus are formed. These are known as oro‐antral communications (OAC). If the OAC is left open (then described as an oro‐antral fistula (OAF), it may become permanent, leading to long‐lasting sinus infections. This condition can be treated surgically by using flaps, grafts and other techniques; or non‐surgically using a variety of methods and materials. There is little evidence for the most effective and safe treatments for closing OACs and OAFs and clinicians who treat these conditions have identified an urgent need for this. This is an update of a review first published in May 2016. Study characteristics We searched various databases until 23 May 2018. Only one study, which was conducted in Iran, is included in our review. The study ran for two years and involved 20 people with OAC aged between 25 and 56 years. Participants were divided into two groups and two surgical treatments were compared for treating oro‐antral communications; one group was treated with pedicled buccal fat pad flap (PBFPF) and the other with buccal flap (BF). Key results and quality of evidence The study did not find evidence of a difference between PBFPF and BF in terms of successful (complete) closure of OAC. Both interventions resulted in successful closure by one month after surgery. The study did not therefore report any adverse effects of treatment failure. It may not be possible to generalise these findings because the quality of the evidence was very low, due to unclear risk of bias and the small numbers studied in the single included trial. Conclusion The evidence currently available is insufficient to draw reliable conclusions regarding the effects of interventions used to treat OAC or fistulae due to dental procedures. More well‐designed and well‐reported trials evaluating different interventions are needed to provide reliable evidence to inform clinical decisions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Kiran Kumar Krishanappa, S; Eachempati, P; Kumbargere Nagraj, S; Shetty, NY; Moe, S; Aggarwal, H; Mathew, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD011784.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "3015a56a-bb79-46de-a968-660e7a6e6a9d", "pmid": "", "title": "Chinese medicinal herbs for asymptomatic carriers of hepatitis B virus infection", "imported": false, "abstract": "Abstract - Background About 350 million people are chronically infected carriers of hepatitis B virus and are at a higher risk of serious illness and death from cirrhosis of the liver and liver cancer. Chinese medicinal herbs have been used widely for more than 2000 years to treat chronic liver disease. Objectives To assess whether Chinese medicinal herbs are effective and safe for treating asymptomatic carriers of hepatitis B virus. Search methods The trials registers of The Cochrane Hepato‐Biliary Group , The Cochrane Library , and The Cochrane Complementary Medicine Field were searched in combination with MEDLINE , EMBASE , and handsearches of Chinese journals and conference proceedings (October 2000). Selection criteria Randomised or quasi‐randomised trials (minimum follow‐up three months) in asymptomatic carriers of hepatitis B virus. Chinese medicinal herbs (single herb or compound of herbs) compared with placebo, no intervention, general non‐specific treatment, or interferon treatment. Trials of Chinese medicinal herbs plus interferon versus interferon alone were also included. Data collection and analysis Data were extracted independently by two authors. Analysis was performed by intention‐to‐treat where possible. Pre‐specified subgroup analyses were: ethnic origin, age at time of infection, and single herb or compound of herbs. Main results Three randomised clinical trials (307 patients) that followed patients for three months or more after the end of treatment were included. The methodological quality was poor. The herbal compound 'Jianpi Wenshen recipe' had significant effects on viral markers compared to interferon: relative risk 2.40 (95% CI 1.01 to 5.72) for clearance of serum HBsAg, 2.03 (95% CI 0.98 to 4.20) for clearance of HBeAg, and 2.54 (95% CI 1.13 to 5.70) for seroconversion of HBeAg to anti‐HBe. Phyllanthus amarus and Astragalus membranaceus showed no significant antiviral effect compared with placebo. Analysis of pooling eight randomised clinical trials with less than three months follow‐up did not show a significant benefit of Chinese medicinal herbs on viral markers. Data on long‐term clinical outcomes and quality of life were lacking. Authors' conclusions Based on one low quality trial, the medicinal herb 'Jianpi Wenshen recipe' may have an antiviral activity in asymptomatic carriers of hepatitis B virus. However, rigorous randomised, double‐blind, placebo‐controlled trials are needed before herbs should be used for this condition. Plain language summary Firm evidence for effect of Chinese medicinal herbs for asymptomatic hepatitis B virus carriers is still awaited Chinese medicinal herbs have a long history in the treatment of liver diseases. Three randomised clinical trials were included. Due to their poor methodologic quality and the existing small number of trials, there is currently insufficient evidence for treating asymptomatic hepatitis B virus carriers with Chinese medicinal herbs like the herbal compound 'Jianpi Wenshen recipe', Phyllanthus amarus and Astragalus membranaceus. Methodologically better and larger randomised trials are needed comparing medicinal herbs versus placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Liu, JP, McIntosh, H, Lin, H", "articleTypes": [], "doi": "10.1002/14651858.CD002231", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.775Z" }, { "id": "3046e8cf-6348-45de-9a00-c8634761179e", "pmid": "", "title": "Antibiotics to prevent complications following tooth extractions", "imported": false, "abstract": "Abstract - Background The most frequent indications for tooth extractions, generally performed by general dental practitioners, are dental caries and periodontal infections. Systemic antibiotics may be prescribed to patients undergoing extractions to prevent complications due to infection. This is an update of a review first published in 2012. Objectives To determine the effect of systemic antibiotic prophylaxis on the prevention of infectious complications following tooth extractions. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 16 April 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 3), MEDLINE Ovid (1946 to 16 April 2020), Embase Ovid (1980 to 16 April 2020), and LILACS (1982 to 16 April 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised, double‐blind, placebo‐controlled trials of systemic antibiotic prophylaxis in patients undergoing tooth extraction(s) for any indication. Data collection and analysis At least two review authors independently performed data extraction and 'Risk of bias' assessment for the included studies. We contacted trial authors for further details where these were unclear. For dichotomous outcomes, we calculated risk ratios (RR) and 95% confidence intervals (CI) using random‐effects models. For continuous outcomes, we used mean differences (MD) with 95% CI using random‐effects models. We examined potential sources of heterogeneity. We assessed the certainty of the body of evidence for key outcomes as high, moderate, low, or very low, using the GRADE approach. Main results We included 23 trials that randomised approximately 3206 participants (2583 analysed) to prophylactic antibiotics or placebo. Although general dentists perform dental extractions because of severe dental caries or periodontal infection, only one of the trials evaluated the role of antibiotic prophylaxis in groups of patients affected by those clinical conditions. We assessed 16 trials as being at high risk of bias, three at low risk, and four as unclear. Compared to placebo, antibiotics may reduce the risk of postsurgical infectious complications in patients undergoing third molar extractions by approximately 66% (RR 0.34, 95% CI 0.19 to 0.64; 1728 participants; 12 studies; low‐certainty evidence), which means that 19 people (95% CI 15 to 34) need to be treated with antibiotics to prevent one infection following extraction of impacted wisdom teeth. Antibiotics may also reduce the risk of dry socket by 34% (RR 0.66, 95% CI 0.45 to 0.97; 1882 participants; 13 studies; low‐certainty evidence), which means that 46 people (95% CI 29 to 62) need to take antibiotics to prevent one case of dry socket following extraction of impacted wisdom teeth. The evidence for our other outcomes is uncertain: pain, whether measured dichotomously as presence or absence (RR 0.59, 95% CI 0.31 to 1.12; 675 participants; 3 studies) or continuously using a visual analogue scale (0‐to‐10‐centimetre scale, where 0 is no pain) (MD −0.26, 95% CI −0.59 to 0.07; 422 participants; 4 studies); fever (RR 0.66, 95% CI 0.24 to 1.79; 475 participants; 4 studies); and adverse effects, which were mild and transient (RR 1.46, 95% CI 0.81 to 2.64; 1277 participants; 8 studies) (very low‐certainty evidence). We found no clear evidence that the timing of antibiotic administration (preoperative, postoperative, or both) was important. The included studies enrolled a subset of patients undergoing dental extractions, that is healthy people who had surgical extraction of third molars. Consequently, the results of this review may not be generalisable to all people undergoing tooth extractions. Authors' conclusions The vast majority (21 out of 23) of the trials included in this review included only healthy patients undergoing extraction of impacted third molars, often performed by oral surgeons. None of the studies evaluated tooth extraction in immunocompromised patients. We found low‐certainty evidence that prophylactic antibiotics may reduce the risk of infection and dry socket following third molar extraction when compared to placebo, and very low‐certainty evidence of no increase in the risk of adverse effects. On average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection. It is unclear whether the evidence in this review is generalisable to patients with concomitant illnesses or patients at a higher risk of infection. Due to the increasing prevalence of bacteria that are resistant to antibiotic treatment, clinicians should evaluate if and when to prescribe prophylactic antibiotic therapy before a dental extraction for each patient on the basis of the patient's clinical conditions (healthy or affected by systemic pathology) and level of risk from infective complications. Immunocompromised patients, in particular, need an individualised approach in consultation with their treating medical specialist. Plain language summary Are antibiotics an effective way to prevent infection following tooth removal? What is the problem? Teeth that are affected by decay or gum disease or painful wisdom teeth are often removed (extracted) by dentists. Tooth extraction is a surgical procedure that leaves a wound in the mouth that can become infected. Infection can lead to swelling, pain, development of pus, fever, as well as ‘dry socket’ (where the tooth socket is not filled by a blood clot, and there is severe pain and bad odour). These complications are unpleasant for patients and may cause difficulty with chewing, speaking, and teeth cleaning, and may even result in days off work or study. Treatment of infection is generally simple and involves drainage of the infection from the wound and patients receiving antibiotics. Why is this question important? Antibiotics work by killing the bacteria that cause infections, or by slowing their growth. However, some infections clear up by themselves. Taking antibiotics unnecessarily may stop them working effectively in future. This ‘antimicrobial resistance’ is a growing problem throughout the world. Antibiotics may also cause unwanted effects such as diarrhoea and nausea. Some patients may be allergic to antibiotics, and antibiotics may not mix well with other medicines. Dentists frequently give patients antibiotics at the time of the extraction as a precaution in order to prevent infection occurring in the first place. This may be unnecessary and may lead to unwanted effects. What did we want to find out? We wanted to know whether giving antibiotics as a preventive measure reduces infection and other complications after tooth extraction. We also wanted to understand whether antibiotics work differently in healthy people compared with people with health conditions such as diabetes or HIV. What did we do? We searched for studies that assessed the effectiveness of antibiotics compared to placebo (sham medicine), given when no infection was present in order to prevent infection following tooth extraction. Studies could include people of any age undergoing tooth extraction. Where possible, we pooled the studies’ results and analysed them together. We also assessed the quality of each study to judge the reliability (certainty) of evidence of individual studies and the body of evidence. What we found We found 23 included studies with a total of more than 3200 participants, who received either antibiotics (of different kinds and dosages) or placebo immediately before or just after tooth extraction, or both. Four studies were conducted in Spain, three each in Brazil, Sweden, and the UK, two in India, and one each in Colombia, Denmark, Finland, France, Poland, New Zealand, Nigeria, and the USA. All but one study included healthy patients in their 20s. Twenty‐one studies assessed the removal of wisdom teeth in hospital dental departments, one assessed the removal of other teeth and one assessed complex oral surgery. None of the included studies assessed tooth extraction in general dental practice for the removal of decayed teeth. Main results Antibiotics given just before or just after surgery (or both) may reduce the risk of infection and dry socket after the removal of wisdom teeth by oral surgeons. However, antibiotics may cause more (generally brief and minor) unwanted effects for these patients. We found no evidence that antibiotics prevent pain, fever, swelling, or problems with restricted mouth opening in patients who have had wisdom teeth removed. There was no evidence to judge the effects of preventive antibiotics for extractions of severely decayed teeth, teeth in diseased gums, or extractions in patients who are sick or have low immunity to infection. How reliable are the results? Our confidence in the results is limited because we had concerns about aspects of the design and reporting of all of the included studies. What does this mean? We did not find studies in patients with depressed immune systems, other illnesses, or in young children or older patients, therefore the results of our review probably do not apply to people who may be at high risk of infection. Also, extractions were mainly carried out by oral surgeons, so the review may not apply to dentists working in general practice. Another concern, which cannot be assessed by clinical studies (i.e. studies testing new medical approaches in people), is that widespread use of antibiotics by people who do not have an infection is likely to contribute to the development of antimicrobial resistance. We concluded that antibiotics given to healthy people when they are having teeth extracted may help prevent infection, but the decision to use an antibiotic should be judged on an individual patient basis based on their state of health and possible complications of getting an infection. How up‐to‐date is this review? This is an updated review. The evidence is current to April 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lodi, G; Azzi, L; Varoni, EM; Pentenero, M; Del Fabbro, M; Carrassi, A; Sardella, A; Manfredi, M", "articleTypes": [], "doi": "10.1002/14651858.CD003811.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "307a80b1-675c-432f-9e6b-76183a01d26d", "pmid": "", "title": "Pimozide for schizophrenia or related psychoses", "imported": false, "abstract": "Abstract - Background Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been associated with cardiotoxicity and sudden unexplained death. Electrocardiogram monitoring is now required before and during use. Objectives To review the effects of pimozide for people with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medication. A secondary objective was to examine the effects of pimozide for people with delusional disorder. Search methods We searched the Cochrane Schizophrenia Group's Register (28 January 2013). Selection criteria We sought all relevant randomised clinical trials (RCTs) comparing pimozide with other treatments. Data collection and analysis Working independently, we inspected citations, ordered papers and then re‐inspected and assessed the quality of the studies and of extracted data. For homogeneous dichotomous data, we calculated the relative risk (RR), the 95% confidence interval (CI) and mean differences (MDs) for continuous data. We excluded data if loss to follow‐up was greater than 50%. We assessed risk of bias for included studies and used GRADE to rate the quality of the evidence. Main results We included 32 studies in total: Among the five studies that compared pimozide versus placebo, only one study provided data for global state relapse, for which no difference between groups was noted at medium term (1 RCT n = 20, RR 0.22 CI 0.03 to 1.78, very low quality of evidence ). None of the five studies provided data for no improvement or first‐rank symptoms in mental state. Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (1 RCT, n = 19, RR 5.50 CI 0.30 to 101.28, very low quality of evidence ) or at medium term (1 RCT n = 25, RR 1.33 CI 0.14 to 12.82, very low quality of evidence ), or for Parkinsonism (tremor) at medium term (1 RCT n = 25, RR 1 CI 0.2 to 4.95, very low quality of evidence ). No data were reported for quality of life at medium term. Of the 26 studies comparing pimozide versus any antipsychotic, seven studies provided data for global state relapse at medium term, for which no difference was noted (7 RCTs n = 227, RR 0.82 CI 0.57 to 1.17, moderate quality of evidence ). Data from one study demonstrated no difference in mental state (no improvement) at medium term (1 RCT n = 23, RR 1.09 CI 0.08 to 15.41, very low quality evidence ); another study demonstrated no difference in the presence of first‐rank symptoms at medium term (1 RCT n = 44, RR 0.53 CI 0.25 to 1.11, low quality of evidence ). Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (6 RCTs n = 186, RR 1.21 CI 0.71 to 2.05, low quality of evidence ) or medium term (5 RCTs n = 219, RR 1.12 CI 0.24 to 5.25, low quality of evidence ), or for Parkinsonism (tremor) at medium term (4 RCTs n = 174, RR 1.46 CI 0.68 to 3.11, very low quality of evidence ). No data were reported for quality of life at medium term. In the one study that compared pimozide plus any antipsychotic versus the same antipsychotic, significantly fewer relapses were noted in the augmented pimozide group at medium term (1 RCT n = 69, RR 0.28 CI 0.15 to 0.50, low quality evidence ). No data were reported for mental state outcomes or for extrapyramidal symptoms (EPS). Data were skewed for quality of life scores, which were not included in the meta‐analysis but were presented separately. Two studies compared pimozide plus any antipsychotics versus antipsychotic plus placebo; neither study reported data for outcomes of interest, apart from Parkinsonism at medium term and quality of life using the Specific Level of Functioning scale (SLOF); however, data were skewed. Only one study compared pimozide plus any antipsychotic versus antipsychotics plus antipsychotic; no data were reported for global state and mental state outcomes of interest. Data were provided for Parkinsonism (rigidity and tremor) using the Extrapyramidal Symptom Rating Scale (ESRS); however, these data were skewed. Authors' conclusions Although shortcomings in the data are evident, enough overall consistency over different outcomes and time scales is present to confirm that pimozide is a drug with efficacy similar to that of other, more commonly used antipsychotic drugs such as chlorpromazine for people with schizophrenia. No data support or refute its use for those with delusional disorder. Plain language summary Pimozide for schizophrenia or related psychoses People with schizophrenia have ‘positive symptoms’ such as hearing voices and seeing things (hallucinations) and fixed strange beliefs (delusions). People with schizophrenia also have ‘negative symptoms’ such as tiredness, apathy and loss of emotion. Antipsychotic drugs are the main treatment for the symptoms of schizophrenia and can be grouped into older drugs (first generation or ‘typical’) and newer drugs (second generation or ‘atypical’). Pimozide is a ‘typical’ antipsychotic drug that was first introduced in the late 1960s and was given to people with schizophrenia. Pimozide is thought to be effective in treating the positive and negative symptoms of schizophrenia or similar mental health problems such as delusional disorder, but it produces serious side effects such as muscle stiffness, tremors and slow body movements. Pimozide may also cause heart problems and has been linked to sudden unexplained death. Monitoring the heart via electrocardiogram is now required before and during treatment with pimozide. It is well known that people with mental health problems suffer from physical illnesses such as heart disease and diabetes and can die on average twenty years younger than those in the general population.
 An update search for this review was carried out 28 January 2013; the review now includes 32 studies that assess the effects of pimozide for people with schizophrenia or similar mental health problems. Pimozide was compared with other antipsychotic drugs, placebo (‘dummy’ treatment) or no treatment. Results suggest that pimozide is probably just as effective as other commonly used ‘typical’ antipsychotic drugs (for outcomes such as treating mental state, relapse, leaving the study early). No studies included delusional disorders, so no information is available on this group of people. No evidence was found to support the concern that pimozide causes heart problems (although this may be result of the fact that the studies were small and short term and the participants did not receive doses above recommended limits of 20 mg/d). Pimozide may cause less sleepiness than other typical antipsychotic drugs, but it may cause more tremors and uncontrollable shaking. The claim that pimozide is useful for treating people with negative symptoms also is not supported and proven. However, the quality of evidence in the main was low or very low quality, studies were small and of short duration and were poorly reported. Large‐scale, well‐conducted and well‐reported studies are required to assess the effectiveness of pimozide in the treatment of schizophrenia and other mental health problems such as delusional disorder. This plain language summary has been written by a consumer, Benjamin Gray (Service User and Service User Expert, Rethink Mental Illness).", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Mothi, M; Sampson, S", "articleTypes": [], "doi": "10.1002/14651858.CD001949.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "309664c7-d57a-4a04-9f52-e9be90dedea3", "pmid": "", "title": "Nedocromil sodium for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Exercise‐induced bronchoconstriction (EIB) following strenuous physical exertion afflicts many people. It can be the cause of sub‐optimal performance, symptoms such as cough, dyspnea, wheeze and chest tightness, and can lead people to avoid physical activity. Management of EIB focuses on prevention through pharmacotherapy and alternate strategies. Single use, pre‐exercise, beta‐agonists and non‐steroidal antiinflammatory agents are recommended. Objectives Bronchodilator medications have been commonly used to prevent narrowing of airways after exercise, but anti‐inflammatory drugs such as nedocromil sodium have also been used. The objective of this review was to assess the effects of a single dose of nedocromil sodium to prevent exercise‐induced bronchoconstriction. Search methods We searched the Cochrane Airways Group Specialised Regsiter, the Cochrane Central Register of Controlled Trials, Current Contents, review articles, textbooks and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. Searches have been updated to August 2008. Selection criteria Randomised trials comparing a single dose of nedocromil sodium with placebo to prevent exercise‐induced bronchoconstriction in patients with EIB over six years of age. Data collection and analysis Trial quality assessment and data extraction were conducted independently by two reviewers. Study authors were contacted for confirmation of data. No new studies were identified in an update search conducted in August 2008. Main results The combined results from 20 randomised controlled trials involving 280 participants, show that 4 mg, of nedocromil sodium inhaled 15 to 60 minutes prior to exercise significantly reduce the severity and duration of EIB in both adults and children, when compared to placebo. The maximum percentage fall in FEV1 was improved significantly compared to placebo (weighted mean difference 15.5 %; 95% confidence interval:13.2 to 18.1). For the maximum percentage fall in peak expiratory flow rate (PEFR) the improvement was similar: WMD 15.0%, (95% CI 8.3 to 21.6). Nedocromil shortened the time to recover lung normal function from more than 30 minutes with placebo to less than 10 minutes with the drug. It had a greater effect on those patients with more severe exercise‐induced bronchoconstriction (defined as an exercise‐induced fall in lung function > 30% from baseline). There were no significant adverse effects reported with the short term use of nedocromil. A further search conducted in August 2005 did not yield any further studies. Authors' conclusions Nedocromil sodium used before exercise reduces the severity and duration of exercise‐induced bronchoconstriction. This effect appears to be more pronounced in people with severe exercise‐induced bronchoconstriction. Plain language summary Nedocromil sodium for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. The review of trials found that nedocromil sodium (Tilade) inhaled 15 to 60 minutes before exercise may reduce the severity and length of this kind of asthma for both adults and children, particularly those who have severe episodes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Spooner, C; Saunders, LD; Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD001183", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "30acde25-3e2b-4a40-863d-17137b99cccc", "pmid": "", "title": "Misoprostol for intrauterine device placement", "imported": false, "abstract": "Abstract - Rationale Identifying effective approaches to reduce pain and improve providers' ease of intrauterine device (IUD) placement may reduce barriers to IUD access and use. The cervical softening and dilation effects of misoprostol might make IUD placement less painful for women and technically easier for providers. However, evidence suggests that misoprostol does not improve many outcomes and may only be helpful for some patients (e.g. those with a recent failed IUD placement). Objectives To examine the effect of misoprostol for routine IUD placement on patient and provider outcomes compared to placebo or no treatment. Search methods In November 2021 we searched CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ClinicalTrials.gov. We conducted update searches in July 2022 and September 2024. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in July 2025. Eligibility criteria We included randomized controlled trials (RCTs) of women undergoing interval IUD placement (i.e. placement outside the postabortion or postpartum period) that compared misoprostol to placebo or no treatment. We included trials that examined the placement of currently available levonorgestrel (LNG)‐releasing IUDs, or any copper T IUD, for women of any age, of any parity, and for any indication. Outcomes Our core critical and important outcomes were pain (during tenaculum placement, during IUD placement, and after IUD placement before clinic discharge); providers' ease of placement; need for cervical dilation; placement success; patient satisfaction; misoprostol side effects (preplacement abdominal pain or cramping, and diarrhea); and adverse events (vasovagal reaction). Risk of bias We used the Risk of Bias 2 tool (RoB 2) to assess the risk of bias for outcomes. Synthesis methods We synthesized results for each outcome using meta‐analysis. We calculated mean differences (MD) for continuous outcomes using inverse variance estimation and random‐effects models. We calculated risk ratios (RR) for dichotomous outcomes using Mantel‐Haenszel estimation and random‐effects models. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included 14 RCTs with a total of 1972 women. The trials were conducted in North America, South America, Europe and Africa, and were published between 2007 and 2022. Synthesis of results The results below summarize the effect of misoprostol on outcomes compared to placebo or no treatment. Pain: misoprostol results in little to no difference in pain during tenaculum placement (MD −0.73, 95% confidence interval [CI] −1.19 to −0.28; 3 RCTs, 261 women; high‐certainty evidence) and after IUD placement before clinic discharge (MD −0.01, 95% CI −0.45 to 0.43; 5 RCTs, 448 women; high‐certainty evidence). Misoprostol may result in little to no difference in pain during IUD placement (MD −0.47, 95% CI −1.23 to 0.29; 7 RCTs, 766 women; low‐certainty evidence). Providers' ease of placement: misoprostol may result in little to no difference in a clinically meaningful effect on ease of IUD placement for providers (MD −0.89, 95% CI −1.55 to −0.22; 8 RCTs, 848 women; low‐certainty evidence). Need for cervical dilation: misoprostol may result in little to no difference in need for cervical dilation for women without a recent failed placement attempt (RR 0.84, 95% CI 0.38 to 1.85; 6 RCTs, 562 women; low‐certainty evidence). Misoprostol probably results in little to no difference in need for cervical dilation for women with a recent failed placement attempt (RR 0.88, 95% CI 0.56 to 1.36; 1 RCT, 90 women; moderate‐certainty evidence). Placement success: misoprostol probably results in little to no difference in placement success for women without a recent failed placement attempt (RR 1.01, 95% CI 0.98 to 1.04; 12 RCTs, 1579 women; moderate‐certainty evidence) but probably results in a slight increase in placement success for women with a recent failed placement attempt (RR 1.41, 95% CI 1.09 to 1.83; 1 RCT, 90 women; moderate‐certainty evidence). Patient satisfaction: misoprostol may increase women's satisfaction with the IUD placement procedure, but the evidence is very uncertain (MD 2.00, 95% CI −0.05 to 4.06; 2 RCTs, 226 women; very low‐certainty evidence) Misoprostol side effects before clinic discharge: misoprostol probably results in an increase in preplacement abdominal pain or cramping (RR 2.14, 95% CI 1.42 to 3.23; 7 RCTs, 781 women; moderate‐certainty evidence)and probably results in a slight increase in diarrhea (RR 1.76, 95% CI 1.01 to 3.06; 9 RCTs, 940 women; moderate‐certainty evidence). Adverse events before clinic discharge: misoprostol may result in little to no difference in vasovagal reaction (RR 0.94, 95% CI 0.37 to 2.37; 6 RCTs [3 RCTs had 0 events], 780 women; low‐certainty evidence). We downgraded the evidence due to serious concerns about inconsistency and serious or very serious concerns about imprecision. Authors' conclusions Evidence from RCTs of women seeking routine IUD placement suggests that receiving misoprostol compared to placebo or no treatment makes little to no difference to pain during tenaculum placement or after IUD placement; and may make little to no difference to pain during IUD placement. Misoprostol may make little to no difference to reduced vasovagal reaction, improved providers' ease of placement, or reduced need for cervical dilation; and probably makes little to no difference to placement success, except for women with a recent failed IUD placement attempt, where misoprostol probably leads to a clinically meaningful increase in placement success. Misoprostol use probably leads to clinically important increases in harms, specifically preplacement abdominal pain or cramping and diarrhea. Misoprostol may increase patient satisfaction with the IUD placement procedure, but the evidence is very uncertain. The number of available RCTs did not support examining effect modifiers such as prior vaginal delivery status, misoprostol dose, or IUD type. Funding This review was supported in part by an appointment to the Research Participation Program at the Centers for Disease Control and Prevention (CDC) administered by the Oak Ridge Institute for Science and Education. Registration Protocol (2022): doi.org/10.1002/14651858.CD015584 Plain language summary Is misoprostol an effective treatment for routine intrauterine device (IUD) placement and does it cause unwanted effects? Key messages Using misoprostol (a medication that softens and widens the cervix ‐ the neck of the womb) before placing an intrauterine device (IUD ‐ a contraceptive device placed inside the womb) makes little to no difference to pain when a tool (a tenaculum) is used to hold the cervix in place during IUD placement or pain after IUD placement. It may make little to no difference to pain during placement, ease of placement for providers, or need for cervical widening; and probably makes little to no difference to placement success, except for women who recently tried unsuccessfully to have an IUD placed. Misoprostol‐related unwanted effects like stomach cramps and diarrhea probably increase, but it may make little to no difference to other unwanted events. We don't know whether misoprostol use affects women's satisfaction with the procedure. What is an intrauterine device? An intrauterine device (IUD) is a small t‐shaped device inserted through the cervix (the neck of the womb) into the womb to prevent pregnancy. IUDs need to be placed by a trained doctor, nurse, or healthcare provider. IUD placement may be a painful procedure, and it may be more difficult for women who have not had a baby or who have already tried unsuccessfully to have an IUD placed. Serious unwanted events are rare with IUD placement but women may experience non‐serious unwanted effects similar to period pain (cramps) or light bleeding. What is misoprostol? Misoprostol is a medication that is commonly used to start labor and to treat bleeding following birth. It causes the cervix to soften and widen, and so might make IUD placement less painful for women and easier for providers. Misoprostol may cause some unwanted effects like cramps, sickness or diarrhea. Sometimes women may feel dizzy, sweaty or light‐headed. An IUD is an effective and reversible contraceptive method, so identifying ways to reduce pain and improve ease of placement for providers may reduce barriers to IUD access and use. What did we want to find out? We wanted to find out if misoprostol reduces pain, makes IUD placement easier for providers, reduces the need for other methods to widen the cervix, improves placement success and women's satisfaction with the procedure, and whether it causes unwanted effects. What did we do? We searched for studies that examined misoprostol for routine IUD placement compared to placebo (a sham medication) or no treatment. We combined and analyzed the studies' results and rated our confidence in the evidence, based on factors such as study methods. What did we find? We found 14 RCTs with 1972 women. The studies took place in North America, South America, Europe, and Africa. All the studies compared misoprostol with placebo or no treatment. Main results Pain. Misoprostol: results in little to no difference in pain during tenaculum placement (a tenaculum is a tool that holds the cervix in place during IUD placement) (3 studies, 261 women); may result in little to no difference in pain during IUD placement (7 studies, 766 women); results in little to no difference in pain after IUD placement before leaving the clinic (5 studies, 448 women). Providers' ease of placing the IUD Misoprostol may result in little to no difference in ease of IUD placement for providers (8 studies, 848 women). Need for cervical dilation. Misoprostol: may result in little to no difference in the need for cervical widening for women without a recent failed placement attempt (6 studies, 562 women); probably results in little to no difference in the need for cervical widening for women with a recent failed placement attempt (1 study, 90 women). Placement success. Misoprostol: probably results in little to no difference in placement success for women without a recent failed placement attempt (12 studies, 1579 women); probably results in a slight increase in placement success for women with a recent failed placement attempt (1 study, 90 women). Patient satisfaction We are not sure whether misoprostol increases patient satisfaction with the IUD placement procedure (2 studies, 226 women). Unwanted effects. Misoprostol: probably results in an increase in stomach cramps (7 studies, 781 women); probably results in a slight increase in diarrhea (9 studies, 940 women); may result in little to no difference in dizziness or light‐headedness (6 studies, 780 women). What are the limitations of the evidence? Some studies did not report key information about what we wanted to know, and some studies were different from each other, so we couldn't include them in our analyses. We had planned to examine whether certain factors affected the results, such as whether women had previously given birth vaginally, the dose of misoprostol used, or the type of IUD placed, but there were not enough studies to do this in a meaningful way. How up to date is this evidence? The evidence is up to date to 23 September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Zapata, LB; Snyder, E; Nguyen, AT; Kapp, N; Ti, A; Whiteman, MK; Curtis, KM", "articleTypes": [], "doi": "10.1002/14651858.CD015584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "30ce61eb-924a-4af8-8fe3-4872d27d7d64", "pmid": "", "title": "Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months", "imported": false, "abstract": "Abstract - Background Bronchiolitis is one of the most common respiratory problems in the first year of life. The sputum of infants with bronchiolitis has increased deoxyribonucleic acid (DNA) content, leading to mucous plugging and airway obstruction. Recombinant human deoxyribonuclease (rhDNase), an enzyme that digests extracellular DNA, might aid the clearance of mucus and relieve peripheral airway obstruction. Objectives To determine the effect of nebulised rhDNase on the severity and duration of viral bronchiolitis in children younger than 24 months of age in the hospital setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 7 which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July Week 4, 2012), EMBASE (1974 to August 2012) and LILACS (1982 to August 2012). Selection criteria Randomised controlled trials (RCTs) using nebulised rhDNase alone or with concomitant therapy in children younger than 24 months of age hospitalised with acute bronchiolitis. Data collection and analysis Two review authors independently performed literature searches, assessed trial quality and extracted data. We obtained unpublished data from trial authors. We used Review Manager 5.1 to pool treatment effects expressed as the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI). Main results Three RCTs (333 participants) were identified, two of which were multicentre trials comprising only participants positive for respiratory syncytial virus (RSV). The other trial enrolled participants clinically diagnosed with bronchiolitis from a hospital in Italy. All studies used 2.5 mL (1 mg/mL) of nebulised rhDNase compared with placebo either as a daily or a twice daily dose. Adjunctive therapy included nebulised salbutamol, steroids, supplemental oxygen, intravenous fluids or tube feeding, nasal washing, nasal decongestants and antibiotics. Overall, nebulised rhDNase showed no benefit in clinically meaningful outcomes. Meta‐analysis favoured the control group with a shorter duration of hospital stay (MD 0.50; 95% CI 0.10 to 0.90, P = 0.01) and better clinical score improvement (SMD ‐0.24; 95% CI ‐0.50 to 0.01, P = 0.06). The largest trial showed no difference in supplemental oxygen use or intensive care unit (ICU) admission. In one RCT, four out of 11 patients in the treatment group had atelectasis. Two of these patients showed distinctive clinical improvement after nebulised rhDNase. There was no significant difference in adverse events. These included temporary desaturation, temporary coughing, increased coughing, facial rash, hoarseness, dyspnoea and bad taste, reported in a total of 11 patients from both treatment groups. Authors' conclusions The results based on the three included studies in this review did not support the use of nebulised rhDNase in children under 24 months of age hospitalised with acute bronchiolitis. In these patients, treatment did not shorten the length of hospitalisation or improve clinical outcomes. It might have a role in severe bronchiolitis complicated by atelectasis, but further clinical studies would need to be performed. Plain language summary Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months Bronchiolitis is the most common respiratory illness leading to hospitalisations in infants. Viral infections, particularly respiratory syncytial virus, are the usual cause, which lead to blockage of the small airways of the lungs due to inflammation and increased mucus production. Afflicted children have fever, cough, wheezing and difficulty breathing. Treatment is usually supportive. In bronchiolitis, the mucus produced contains large amounts of DNA, which makes it thicker and stickier. Removal of this DNA facilitates clearance of the mucus. RhDNase is an enzyme that breaks down DNA and hence may improve symptoms. We performed this review to assess the effect of rhDNase delivered through a nebuliser in children under 24 months old hospitalised for bronchiolitis. We identified three randomised controlled trials involving 333 children up to 24 months of age hospitalised with bronchiolitis. All three studies compared nebulised rhDNase with placebo. Any additional treatments were given to both groups. Overall, the studies did not show that nebulised rhDNase shortened the duration of hospital admission, or improved the severity of symptoms. No serious side effects were reported by any of the studies. One study showed that in patients suffering from atelectasis, a severe complication of bronchiolitis wherein the lung does not expand completely, nebulised rhDNase treatment resulted in a distinct improvement within two days. To confirm this beneficial effect, further clinical studies in patients with severe bronchiolitis are needed. Currently, the use of this treatment in young children hospitalised with bronchiolitis is not recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Enriquez, A, Chu, IW, Mellis, C, Lin, WY", "articleTypes": [], "doi": "10.1002/14651858.CD008395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.761Z" }, { "id": "30edad58-59f7-4a7e-b17b-58acf2ecf761", "pmid": "", "title": "Silver acetate for smoking cessation", "imported": false, "abstract": "Abstract - Background Silver acetate produces an unpleasant taste when combined with cigarettes, thereby producing an aversive stimulus. It has been marketed in various forms with the aim of extinguishing the urge to smoke, by pairing the urge with an unpleasant stimulus. Objectives The aim of this review was to determine the effectiveness of silver acetate products (gum, lozenge, spray) in promoting smoking cessation. Search methods We searched the Cochrane Tobacco Addiction Group specialised trials register. Most recent search was in July 2012. Selection criteria We included randomised trials of silver acetate for smoking cessation with reports of smoking status at least six months after the beginning of treatment. Data collection and analysis We extracted data in duplicate on the type of subjects, the dose and form of silver acetate, the outcome measures, method of randomisation, and completeness of follow‐up. The main outcome measure was biochemically validated abstinence from smoking after at least six months follow‐up in patients smoking at baseline. Subjects lost to follow‐up were counted as continuing smokers. Where appropriate, we performed meta‐analysis using a fixed effects model. Main results Two studies provided long‐term follow‐up data on patients randomised to silver acetate or placebo. In one of these studies, there was a third arm, randomised to 2mg nicotine gum. The pooled risk ratio for quitting for silver acetate vs placebo was 1.04 (95% confidence interval 0.69 to 1.57). Authors' conclusions Existing trials show little evidence for a specific effect of silver acetate in promoting smoking cessation. The confidence intervals for the ratio are quite wide. However, the upper limit of the confidence intervals for a positive effect equates to an absolute increase in the smoking cessation rate of about 4%. Any effect of this agent is therefore likely to be smaller than nicotine replacement therapy. The lack of effect of silver acetate may reflect poor compliance with a treatment whose rationale is to create an unpleasant stimulus. Plain language summary Does silver acetate help people stop smoking Silver acetate products (gum, lozenge, and spray) produce an unpleasant metallic taste when combined with cigarettes, so they are used as a form of aversion therapy for smoking. However, the review of trials found little evidence to show that silver acetate helps smokers quit. Any beneficial effect of silver acetate is likely to be very small, and less than the effect already proven for nicotine replacement therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lancaster, T; Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000191.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "31296fec-3d56-4498-8642-b323d719e422", "pmid": "", "title": "Fixed‐dose combinations of drugs versus single‐drug formulations for treating pulmonary tuberculosis", "imported": false, "abstract": "Abstract - Background People who are newly diagnosed with pulmonary tuberculosis (TB) typically receive a standard first‐line treatment regimen that consists of two months of isoniazid, rifampicin, pyrazinamide, and ethambutol followed by four months of isoniazid and rifampicin. Fixed‐dose combinations (FDCs) of these drugs are widely recommended. Objectives To compare the efficacy, safety, and acceptability of anti‐tuberculosis regimens given as fixed‐dose combinations compared to single‐drug formulations for treating people with newly diagnosed pulmonary tuberculosis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL, published in the Cochrane Library, Issue 11 2015); MEDLINE (1966 to 20 November 2015); EMBASE (1980 to 20 November 2015); LILACS (1982 to 20 November 2015); the metaRegister of Controlled Trials; and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), without language restrictions, up to 20 November 2015. Selection criteria Randomized controlled trials that compared the use of FDCs with single‐drug formulations in adults (aged 15 years or more) newly diagnosed with pulmonary TB. Data collection and analysis Two review authors independently assessed studies for inclusion, and assessed the risk of bias and extracted data from the included trials. We used risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data with 95% confidence intervals (CIs). We attempted to assess the effect of treatment for time‐to‐event measures with hazard ratios and their 95% CIs. We used the Cochrane 'Risk of bias' assessment tool to determine the risk of bias in included trials. We used the fixed‐effect model when there was little heterogeneity and the random‐effects model with moderate heterogeneity. We used an I² statistic value of 75% or greater to denote significant heterogeneity, in which case we did not perform a meta‐analysis. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We included 13 randomized controlled trials (RCTs) in the review, which enrolled 5824 participants. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. Overall there is little or no difference detected between FDCs and single‐drug formulations for most outcomes reported. We did not detect a difference in treatment failure between FDCs compared with single‐drug formulations (RR 1.28, 95% CI 0.82 to 2.00; 3606 participants, seven trials, moderate quality evidence ). Relapse may be more frequent in people treated with FDCs compared to single‐drug formulations, although the confidence interval (CI) includes no difference (RR 1.28, 95% CI 1.00 to 1.64; 3621 participants, 10 trials, low quality evidence ). We did not detect any difference in death between fixed‐dose and single‐drug formulation groups (RR 0.96, 95% CI 0.67 to 1.39; 4800 participants, 11 trials, moderate quality evidence ). When we compared FDCs with single‐drug formulations we found little or no difference for sputum smear or culture conversion at the end of treatment (RR 0.99, 95% CI 0.96 to 1.02; 2319 participants, seven trials, high quality evidence ), for serious adverse events (RR 1.45, 95% CI 0.90 to 2.33; 3388 participants, six trials, moderate quality evidence ), and for adverse events that led to discontinuation of therapy (RR 0.96, 95% CI 0.56 to 1.66; 5530 participants, 13 trials, low quality evidence ). We conducted a sensitivity analysis excluding studies at high risk of bias and this did not alter the review findings. Authors' conclusions Fixed‐dose combinations and single‐drug formulations probably have similar effects for treating people with newly diagnosed pulmonary TB. 23 April 2019 No update planned Other This is not a current research question. Plain language summary Fixed‐dose combinations for treating pulmonary tuberculosis What are fixed‐dose combinations and how might they improve care of people with tuberculosis Tuberculosis (TB) is an important health problem, especially in developing countries. The treatment for pulmonary TB in new patients includes four oral medicines taken for six months, sometimes as fixed‐dose combinations (FDCs) that are combined in one tablet, or taken separately as single‐drug formulations. The World Health Organization recommends prescribers use fixed‐dose combinations to reduce the number of tablets that people take. On the supply side, this might reduce prescribing errors and improve drug supply efficiency; on the patient's side, FDCS simplify treatment and improve adherence. We conducted a review to assess the efficacy, safety, and acceptability of FDCs compared with single‐drug formulations for treating people with newly diagnosed pulmonary TB. What the research says We searched for relevant trials up to 20 November 2015, and included 13 randomized controlled trials that enrolled 5824 people. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. There is probably little or no difference in FDCs compared to single‐drug formulations for treatment failure ( moderate quality evidence ); relapse may be more frequent ( low quality evidence ); and the number of deaths were similar ( moderate quality evidence ). There is little or no difference in sputum smear or culture conversion ( high quality evidence ), and no difference was shown for serious adverse events ( moderate quality evidence ) or adverse events that led to discontinuation of therapy ( low quality evidence ). Authors’ conclusions We concluded that fixed‐dose combinations have similar efficacy to single‐drug formulations for treating people with newly diagnosed pulmonary TB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Gallardo, CR, Rigau Comas, D, Valderrama Rodríguez, A, Roqué i Figuls, M, Parker, LA, Caylà, J, Bonfill Cosp, X", "articleTypes": [], "doi": "10.1002/14651858.CD009913.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.755Z" }, { "id": "31399a2e-d2d5-4957-943f-c00db19d55f9", "pmid": "", "title": "Metformin for endometrial hyperplasia", "imported": false, "abstract": "Abstract - Background Endometrial cancer is one of the most common gynaecological cancers in the world. Rates of endometrial cancer are rising, in part because of rising obesity rates. Endometrial hyperplasia is a precancerous condition in women that can lead to endometrial cancer if left untreated. Endometrial hyperplasia occurs more commonly than endometrial cancer. Progesterone tablets that are currently used to treat women with endometrial hyperplasia are associated with adverse effects in up to 84% of women. A levonorgestrel intrauterine device may improve compliance, but it is invasive, is not acceptable to all women, and is associated with irregular vaginal bleeding in 82% of cases. Therefore, an alternative treatment for women with endometrial hyperplasia is needed. Metformin, a drug that is often used to treat people with diabetes, has been shown, in some human studies, to reverse endometrial hyperplasia. However, the effectiveness and safety of metformin for treatment of endometrial hyperplasia remain uncertain. This is an update of a review first published in 2017. Objectives To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia. Search methods We searched the Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, PubMed, Embase, Google Scholar, OpenGrey, LILACS, and two trials registers from inception to 5 September 2022. We searched the bibliographies of all relevant studies, and contacted experts in the field for any additional trials. Selection criteria We included randomised controlled trials (RCTs) and cross‐over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo, no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type. Data collection and analysis Two review authors independently assessed studies for eligibility, extracted data from included studies, assessed the risk of bias in the included studies, and assessed the certainty of the evidence for each outcome. We resolved disagreements by discussion or by deferring to a third review author. When study details were missing, review authors contacted the study authors. The primary outcome of this review was regression of endometrial hyperplasia histology (with or without atypia) towards normal histology. Main results We included seven RCTs, in which a total of 387 women took part. In the comparison, Metformin plus megestrol versus megestrol alone, we rated the certainty of the evidence as low for the outcome, regression of endometrial hyperplasia. We rated the quality of the evidence as very low for the rest of the outcomes, in all three comparisons. Although there was a low risk of selection bias, there was a high risk of bias in the blinding of personnel and outcome assessment (performance bias and detection bias) in many studies. This update identified four new RCTs and six ongoing RCTs. Metformin versus megestrol We are uncertain whether metformin increases the regression of endometrial hyperplasia towards normal histology over megestrol (odds ratio (OR) 4.89, 95% confidence interval (CI) 1.56 to 15.32; P = 0.006; 2 RCTs, 83 participants; I² = 7%; very low‐certainty evidence). This evidence suggests that if the rate of regression with megestrol is 61%, the rate of regression with metformin would be between 71% and 96%. It is unresolved whether metformin results in different rates of abnormal uterine bleeding or hysterectomy compared to megestrol. No study in this comparison reported progression of hyperplasia to endometrial cancer, recurrence of endometrial hyperplasia, health‐related quality of life, or adverse effects during treatment. Metformin plus megestrol versus megestrol monotherapy The combination of metformin and megestrol may enhance the regression of endometrial hyperplasia towards normal histology more than megestrol alone (OR 3.27, 95% CI 1.65 to 6.51; P = 0.0007; 4 RCTs, 258 participants; I² = 0%, low‐certainty evidence). This suggests that if the rate of regression with megestrol monotherapy is 54%, the rate of regression with the addition of metformin would be between 66% and 84%. In one study, 3/8 (37.5%) of participants who took metformin had nausea that settled without further treatment. It is unresolved whether the combination of metformin and megestrol results in different rates of recurrence of endometrial hyperplasia, progression of endometrial hyperplasia to endometrial cancer, or hysterectomy compared to megestrol monotherapy. No study in this comparison reported abnormal uterine bleeding, or health‐related quality of life. Metformin plus levonorgestrel (intrauterine system) versus levonorgestrel (intrauterine system) monotherapy We are uncertain whether there is a difference between groups in the regression of endometrial hyperplasia towards normal histology (OR 0.29, 95% CI 0.01 to 7.56; 1 RCT, 46 participants; very low‐certainty evidence). This evidence suggests that if the rate of regression with levonorgestrel monotherapy is 96%, the rate of regression with the addition of metformin would be between 73% and 100%. It is unresolved whether the combination of metformin and levonorgestrel results in different rates of abnormal uterine bleeding, hysterectomy, or the development of adverse effects during treatment compared to levonorgestrel monotherapy. No study in this comparison reported recurrence of endometrial hyperplasia, progression of hyperplasia to endometrial cancer, or health‐related quality of life. Authors' conclusions Review authors found insufficient evidence to either support or refute the use of metformin, specifically megestrol acetate, given alone or in combination with standard therapy, for the treatment of women with endometrial hyperplasia. Robustly designed and adequately powered randomised controlled trials, yielding long‐term outcome data are still needed to address this clinical question. Plain language summary Metformin for endometrial hyperplasia Review question Is metformin an effective and safe treatment for women with endometrial hyperplasia? Background Endometrial cancer (cancer of the lining of the womb) is a common cancer that affects the reproductive organs in women worldwide. Endometrial hyperplasia (thickening of the lining of the womb) is a precancerous condition in women that can lead to endometrial cancer if left untreated. Successful treatment of women with endometrial hyperplasia can prevent endometrial cancer. Endometrial hyperplasia is usually treated by providing progesterone hormone tablets, inserting a levonorgestrel‐releasing intrauterine system (LNG‐IUS) into the womb, advising women with extra weight to lose weight, or performing a hysterectomy for women who do not want a future pregnancy. However, progesterone tablets are associated with side effects in up to 84% of women, and this can prevent women from completing treatment. Also, progesterone tablets do not always work, and endometrial hyperplasia can return in up to 14% to 30% of women after treatment. The LNG‐IUS is associated with irregular vaginal bleeding in up to 82% of women. Many women find it painful to use, or find it otherwise unacceptable. Therefore, an alternative treatment for endometrial hyperplasia is required. Metformin, an oral tablet that is usually used to treat diabetes, has been shown to cure endometrial hyperplasia in some human studies. Although women taking metformin may experience side effects, treatment is usually well tolerated. If women experience fewer side effects when taking metformin rather than progesterone tablets, and if metformin effectively treats endometrial hyperplasia, women would be more willing to complete treatment, and the cure rate would improve. This could reduce the number of women who end up with endometrial cancer. However, the effectiveness and safety of metformin used to treat women with endometrial hyperplasia remain uncertain. Study characteristics We included seven randomised controlled trials in which a total of 387 women took part. Five studies compared metformin to megestrol (a form of progesterone), and one study compared metformin plus megestrol to megestrol alone. Women in all studies received treatment for three to six months. The evidence is current to 5 September 2022. Key results Studies on metformin alone versus megestrol alone provided insufficient evidence to show differences in effectiveness for curing endometrial hyperplasia. Studies on metformin plus megestrol versus megestrol alone found that metformin may improve the thickened walls of the womb, but the evidence is uncertain about other outcomes. One small study provided insufficient evidence to support or refute the use of metformin plus the LNG‐IUS or the LNG‐IUS alone. Certainty of the evidence We rated the certainty of the evidence as low to very‐low for all outcomes, because of limitations in the way the studies were designed, and small sample sizes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Shiwani, H; Clement, NS; Daniels, JP; Atiomo, W", "articleTypes": [], "doi": "10.1002/14651858.CD012214.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "313e2a61-03ad-4c58-9beb-2de0c5f9620b", "pmid": "", "title": "Oral zinc for the prevention of hyperbilirubinaemia in neonates", "imported": false, "abstract": "Abstract - Background Between 6% and 15% of neonates develop hyperbilirubinaemia requiring treatment. Successful management of neonatal hyperbilirubinaemia relies on prevention and early treatment, with phototherapy being the mainstay of treatment. Oral zinc has been reported to decrease the serum total bilirubin (STB), presumably by decreasing the enterohepatic circulation. Objectives To determine the effect of oral zinc supplementation compared to placebo or no treatment on the incidence of hyperbilirubinaemia in neonates during the first week of life and to assess the safety of oral zinc in enrolled neonates. Search methods We searched CENTRAL (The Cochrane Library 2014, Issue 1), MEDLINE (1966 to November 30, 2014), and EMBASE (1990 to November 30, 2014). Selection criteria Randomised controlled trials were eligible for inclusion if they enrolled neonates (term and preterm) to whom oral zinc, in a dose of 10 to 20 mg/day, was initiated within the first 96 hours of life, for any duration until day seven, compared with no treatment or placebo. Data collection and analysis We used the standard methods of The Cochrane Collaboration and its Neonatal Review Group for data collection and analysis. Main results Only one study met the criteria of inclusion in the review. This study compared oral zinc with placebo. Oral zinc was administered in a dose of 5 mL twice daily from day 2 to day 7 postpartum. The drug was administered into the mouth of the infant by the plastic measure provided with the bottle or with a spoon. Incidence of hyperbilirubinaemia, defined as serum total bilirubin (STB) ≥ 15 mg/dL, was similar between groups (N = 286; risk ratio (RR) 0.94, 95% confidence interval (CI) 0.58 to 1.52). Mean STB levels, mg/dL, at 72 ± 12 hours were comparable in both the groups (N = 286; mean difference (MD) ‐0.20; 95% CI ‐1.03 to 0.63). Although the duration of phototherapy in the zinc group was significantly shorter compared to the placebo group (N = 286; MD ‐12.80, 95% CI ‐16.93 to ‐8.67), the incidence of need for phototherapy was comparable across both the groups (N = 286; RR 1.20; 95% CI 0.66 to 2.18). Incidences of side effects like vomiting (N = 286; RR 0.65, 95% CI 0.19 to 2.25), diarrhoea (N = 286; RR 2.92, 95% CI 0.31 to 27.71), and rash (N = 286; RR 2.92, 95% CI 0.12 to 71.03) were found to be rare and statistically comparable between groups. Authors' conclusions The limited evidence available has not shown that oral zinc supplementation given to infants up to one week old reduces the incidence of hyperbilirubinaemia or need for phototherapy. Plain language summary Oral zinc for the prevention of hyperbilirubinaemia in neonates Review question In newborn infants less than one week old, does oral zinc salt supplementation compared to placebo or no treatment decrease the incidence of hyperbilirubinaemia (jaundice)? Background Jaundice, or yellowish discolouration of the skin, can occur due to an increased amount of bilirubin pigment in the blood. It is a commonly observed and usually harmless condition in newborn infants during the first week after birth. However, in some babies, the amount of bilirubin pigment can increase to dangerous levels and necessitate treatment. Bilirubin is metabolised in the liver and is excreted via the intestine in faeces. Increased reabsorption of bilirubin from the intestine is one of the major factors inducing hyperbilirubinaemia in newborn infants. Oral zinc salt, a relatively harmless medicine, can reduce the bilirubin level in newborn infants by decreasing its reabsorption from the intestine. Study characteristics Researchers from Cochrane searched for all available literature up to 30 November 2014. One randomised controlled trial met our inclusion criteria. Results In this review, the efficacy of oral zinc salt was compared with placebo. One study enrolling 294 infants was identified. This study evaluated oral zinc salt, given in a dose of 5 mg twice daily to infants between 25 and 168 hours old. The administration of oral zinc salt did not affect the incidence of jaundice (hyperbilirubinaemia) in these infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mishra, S, Cheema, A, Agarwal, R, Deorari, A, Paul, V", "articleTypes": [], "doi": "10.1002/14651858.CD008432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.747Z" }, { "id": "316162c6-b6b8-4160-9062-10617c38e42f", "pmid": "", "title": "The Effects of Genetic Variation in the Bitter and Fat Taste Receptor Genes on Taste Perception, Dietary Behaviour and Obesity Status", "imported": false, "abstract": "Obesity is an increasing problem for adults in the UK. Diets high in fat and sugar are the major contributors to weight gain. Individual differences in taste perception are a crucial factor in determining the investigator's choice of foods and an individual's sensitivity to the either bitter or fat taste compounds has been linked to a preference for different foods including sweet and high fat foods. Previous research has not comprehensively explored the effect of both fat and bitter taste sensitivity on dietary intake and obesity status. Therefore, the aim of this study is to explore the associations between genetics, fat and bitter taste sensitivity, food preference, dietary intake and obesity measures in the adult UK population.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.142Z" }, { "id": "316219e6-98f9-42f2-8749-0f4cb624c23d", "pmid": "", "title": "Metabolic and bariatric surgery in adults with obesity and diabetes mellitus: a network meta‐analysis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E, Gorenflo, L, Schwarzer, G, Stadelmaier, J, Wallerer, S, Marjanovic, G, Fink, JM, Lehane, C, Metzendorf, MI, Meerpohl, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015622.pub2 AB - Abstract - Rationale Obesity and its associated comorbidities, particularly type 2 diabetes (T2D), have reached epidemic dimensions globally. Both conditions are related to an increased risk of serious health outcomes and impose a substantial burden on those affected. Metabolic and bariatric surgery (MBS) may offer a therapeutic option for achieving sustained weight loss, improving comorbidities and thereby enhancing long���term quality of life. Objectives To investigate the medium‐ and long‐term benefits and harms of different MBS procedures compared with each other and to non‐surgical treatment on outcomes relevant to adults with obesity and T2D, and to obtain a clinically meaningful ranking of these interventions by considering both randomised controlled trials (RCTs) and cohort studies. Search methods We searched MEDLINE, Cochrane CENTRAL, CINAHL, LILACS, BASE as well as the WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 25 June 2024. We did not apply any language restrictions. Eligibility criteria We included RCTs and both prospective and retrospective cohort studies with a minimum follow‐up of three years in adults (≥ 18 years) with obesity (body mass index ≥ 30 kg/m² or ethnic‐specific cut‐off values) and T2D. Eligible interventions include MBS procedures (i.e. laparoscopic adjustable gastric banding [LAGB], sleeve gastrectomy [SG], Roux‐en‐Y gastric bypass [RYGB], one‐anastomosis gastric bypass [OAGB], gastric plication [GCP], biliopancreatic diversion with duodenal switch, and their variations) or non‐surgical treatment (i.e. lifestyle intervention, medical treatment [LI/MT]). Outcomes Critical outcomes were medium‐ (≥ 3 to < 5 years) and long‐term (≥ 5 years) weight loss (%), waist circumference (cm), T2D remission (complete, partial), and serious adverse events (SAE). Important outcomes included all‐cause mortality, T2D complications, glycaemic control (glycated haemoglobin (HbA1c) in %) and health‐related quality of life (HRQoL). Risk of bias We used the Risk of Bias 2 (RoB 2) tool for RCTs and Risk Of Bias In Non‐randomized Studies – of Interventions (ROBINS‐I) for cohort studies. Synthesis methods We performed random‐effects network meta‐analyses based on the frequentist approach and ranked treatments by P scores. We rated the certainty of evidence according to the GRADE approach for long‐term outcomes (≥ 5 years). Included studies We included 18 studies (with 70 reports) with 15,282 participants in this review. Of these, 13 studies were RCTs (n = 911) and five were cohort studies (n = 14,371). Two RCTs compared MBS with LI/MT, ten compared two or three different MBS procedures and one with a 3‐arm design investigated two different MBS procedures as well as LI/MT. All cohort studies compared different MBS procedures. The networks were based on the following MBS procedures: RYGB, SG, OAGB, LAGB, GCP, and LI/MT. Synthesis of results NMA results (8 RCTs; n = 491) suggest greater long‐term weight loss after RYGB compared to LI/MT (MD ‐16.95%; 95% CI ‐24.19 to ‐9.71). OAGB (MD ‐12.10%; 95% CI ‐22.85 to ‐1.34) and SG (MD ‐9.40 %; 95% CI ‐17.45 to ‐1.34) may also result in greater weight loss compared to LI/MT, but the evidence is very uncertain. A reduction in waist circumference at long‐term follow‐up (6 RCTs; n = 348) is likely higher after RYGB compared to LI/MT (MD ‐12.34 cm; 95% CI ‐17.88 to ‐6.81). OAGB (MD: ‐13.28 cm; 95% CI ‐22.04 to ‐4.53) and SG (MD‐9.08 cm; 95% CI ‐15.74 to ‐2.43) may also lead to a higher reduction in waist circumference compared to LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effects of MBS procedures compared to LI/MT on long‐term complete T2D remission (9 RCTs; n = 536). All MBS procedures (8 RCTs; n = 588) may result more often in partial T2D remissions than LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effect of all MBS procedures compared to LI/MT on SAE (9 RCTs; n = 598) and all‐cause mortality in the long term (7 RCTs; n = 520). RYGB may reduce total long‐term T2D complications compared to LI/MT (Rate ratio (RaR) 0.17; 95% CI 0.03 to 0.89; 5 RCTs; n = 356), but the evidence is very uncertain. Based on NMA results (10 RCTs; n = 612), RYGB may reduce HbA1c compared to LI/MT (MD ‐1.44%; 95% CI ‐2.26 to ‐0.63). OAGB (MD ‐2.01%; 95%CI ‐3.42 to ‐0.60) and SG (MD ‐1.01%; 95%CI ‐1.94 to ‐0.08) may also reduce HbA1c compared to LI/MT, but the evidence is every uncertain. Both RYGB and SG may increase mental and physical components of HRQoL compared to LI/MT (both 2 RCTs; n = 118), but evidence is very uncertain. The inclusion of cohort studies in the analyses of percentage weight loss, partial type 2 diabetes remission, SAE, and all‐cause mortality confirmed the main findings. For most outcomes, the main reasons for downgrading certainty of evidence were related to risk of bias and imprecision. Authors' conclusions In people with obesity and T2D, RYGB, OAGB and, to a lesser extent, SG may lead to long‐term improvements in body weight, waist circumference, partial T2D remission, and HbA1c compared with LI/MT. However, due to imprecise results, the magnitude of the effects often remains uncertain or very uncertain. For other outcomes, especially complete T2D remission, SAE, all‐cause mortality and T2D complications, the evidence is mainly very uncertain, due to a low numbers of participants and events. When interpreting these findings, it should be noted that cohort studies were not, as originally planned, included in the certainty of evidence assessment, as these studies were judged to have a high or critical risk of bias. Larger and well‐designed studies may contribute to diminishing the existing uncertainties and enhancing our confidence in the findings. Funding This Cochrane review was funded by the German Federal Ministry of Education and Research (BMBF) (grant number: 01KG2201). Registration Protocol (2024) DOI: https://doi.org/10.1002/14651858.CD015622 PROSPERO ID: CRD42023457363 Plain language summary Review question What are the long‐term benefits and risks of different types of weight loss surgery (also called metabolic and bariatric surgery) to treat obesity and type 2 diabetes in adults? Key messages In people with obesity and type 2 diabetes, gastric (stomach) bypass (i.e. Roux‐en‐Y gastric bypass and one‐anastomosis gastric bypass) may be most beneficial for improving body weight, waist circumference, type 2 diabetes status and long‐term blood sugar levels at least five years after surgery, but for one‐anastomosis gastric bypass, we are very uncertain about the results. It is unclear whether the different surgical procedures have an effect on risks such as serious unwanted health effects and death from any cause at least five years after surgery. Larger and well‐designed studies may help reduce the existing uncertainties and increase our confidence in the findings. What are obesity and type 2 diabetes? 
Obesity is a condition with too many fat deposits that can damage health. In type 2 diabetes, the body has difficulty controlling blood sugar levels because the hormone insulin does not work properly. Type 2 diabetes often occurs in people with obesity, and both conditions increase the risk of premature death and other health problems, such as cardiovascular disease. How are obesity and type 2 diabetes treated? Lifestyle interventions such as nutrition, exercise, and behavioural programmes, along with medicines, are often used first for weight loss and improvement of diabetes status. When these do not work well, metabolic and bariatric surgery may be considered as an additional treatment option. There are a number of different types of bariatric surgery: gastric (stomach) banding; gastric sleeve (removal of a part of the stomach); Roux‐en‐Y gastric bypass (RYGB); one‐anastomosis gastric bypass, or mini‐gastric bypass; gastric plication (folding to make the stomach smaller); biliopancreatic diversion with duodenal switch. What did we want to find out? Which of the different types of surgery are the safest and most beneficial ones by comparing them with each other and with lifestyle and medication therapy regarding their long‐term (at least 5 years follow‐up) benefits and risks. Whether these surgical procedures improve body weight, waist circumference, type 2 diabetes status, long‐term blood sugar levels, and quality of life at least five years after surgery. Whether surgery affects serious unwanted health effects, death from any cause, and type 2 diabetes complications over this period. What did we do? 
We searched for studies involving people with obesity and type 2 diabetes. We included studies that compared at least two different surgical procedures, or surgery with lifestyle and medication treatment. We summarised and compared all treatments using a method called network meta‐analysis, and we rated our confidence in the results based on factors such as study methods and sample size. What did we find? 
We found 18 studies, including 15,282 people with obesity and type 2 diabetes. In 13 of these studies (including 911 people), participants were assigned randomly to two or more treatment groups. This is the best way to ensure that groups of people are similar. Five studies (with 14,371 people) used ‘real‐life’ observational data. The studies investigated surgical procedures such as gastric band, gastric sleeve, Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, and gastric plication. We found that: Roux‐en‐Y gastric bypass, may improve body weight and likely reduce waist circumference compared with lifestyle and medication treatment in the long term. One‐anastomosis gastric bypass and, to a lesser extent, gastric sleeve, may also improve body weight and waist circumference, but we are very uncertain about the results. Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, gastric sleeve, and gastric band may improve type 2 diabetes status, but we are very uncertain about the results. It is unclear whether the types of surgery have an effect on serious unwanted health effects or death from any cause. Roux‐en‐Y gastric bypass may reduce type 2 diabetes complications in the long term compared to non‐surgical treatments, but we are very uncertain about the results. Roux‐en‐Y gastric bypass may improve blood sugar levels compared to non‐surgical treatments. One‐anastomosis gastric bypass and gastric sleeve may also improve blood sugar levels, but we are very uncertain about the results. RYGB and SG may lead to a greater increase in health‐related quality of life than non‐surgical treatments, but again, we are very uncertain about the results. What are the limitations of the evidence? 
Our confidence in the evidence is often low to very low because the studies included only small numbers of people, and the results for some outcomes, especially serious unwanted health effects, death from any cause, and type 2 diabetes complications, were based on very few events. Moreover, for several surgical procedures, there were not enough studies to be certain about the outcomes. It is important to note that rating our confidence in findings was based only on studies in which participants were randomly assigned to groups and did not include observational studies. How up to date is this evidence? 
This evidence is up to date as of June 2024.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.820Z" }, { "id": "317ddcf3-e3cb-4e6c-a26f-e8cc6cd55f52", "pmid": "", "title": "Probiotics for the prevention of pediatric antibiotic‐associated diarrhea", "imported": false, "abstract": "Abstract - Background Antibiotics alter the microbial balance commonly resulting in antibiotic‐associated diarrhea (AAD). Probiotics may prevent AAD via providing gut barrier, restoration of the gut microflora, and other potential mechanisms of action. Objectives The primary objectives were to assess the efficacy and safety of probiotics (any specified strain or dose) used for the prevention of AAD in children. Search methods MEDLINE, Embase, CENTRAL, CINAHL, and the Web of Science (inception to 28 May 2018) were searched along with registers including the ISRCTN and Clinicaltrials.gov. We also searched the NICE Evidence Services database as well as reference lists from relevant articles. Selection criteria Randomized, parallel, controlled trials in children (0 to 18 years) receiving antibiotics, that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhea secondary to antibiotic use were considered for inclusion. Data collection and analysis Study selection, data extraction, and risk of bias assessment were conducted independently by two authors. Dichotomous data (incidence of AAD, adverse events) were combined using a pooled risk ratio (RR) or risk difference (RD), and continuous data (mean duration of diarrhea) as mean difference (MD), along with corresponding 95% confidence interval (95% CI). We calculated the number needed to treat for an additional beneficial outcome (NNTB) where appropriate. For studies reporting on microbiome characteristics using heterogeneous outcomes, we describe the results narratively. The certainty of the evidence was evaluated using GRADE. Main results Thirty‐three studies (6352 participants) were included. Probiotics assessed included Bacillus spp., Bifidobacterium spp., Clostridium butyricum , Lactobacilli spp. , Lactococcus spp., Leuconostoc cremoris , Saccharomyces spp., or Streptococcus spp., alone or in combination. The risk of bias was determined to be high in 20 studies and low in 13 studies. Complete case (patients who did not complete the studies were not included in the analysis) results from 33 trials reporting on the incidence of diarrhea show a precise benefit from probiotics compared to active, placebo or no treatment control. After 5 days to 12 weeks of follow‐up, the incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group (RR 0.45, 95% CI 0.36 to 0.56; I² = 57%, 6352 participants; NNTB 9, 95% CI 7 to 13; moderate certainty evidence). Nineteen studies had loss to follow‐up ranging from 1% to 46%. After making assumptions for those lost, the observed benefit was still statistically significant using an extreme plausible intention‐to‐treat (ITT) analysis, wherein the incidence of AAD in the probiotic group was 12% (436/3551) compared to 19% (664/3468) in the control group (7019 participants; RR 0.61; 95% CI 0.49 to 0.77; P <0.00001; I² = 70%). An a priori available case subgroup analysis exploring heterogeneity indicated that high dose (≥ 5 billion CFUs per day) is more effective than low probiotic dose (< 5 billion CFUs per day), interaction P value = 0.01. For the high dose studies the incidence of AAD in the probiotic group was 8% (162/2029) compared to 23% (462/2009) in the control group (4038 participants; RR 0.37; 95% CI 0.30 to 0.46; P = 0.06; moderate certainty evidence). For the low dose studies the incidence of AAD in the probiotic group was 8% (97/1155) compared to 13% (133/1059) in the control group (2214 participants; RR 0.68; 95% CI 0.46 to 1.01; P = 0.02). Again, assumptions for loss to follow‐up using an extreme plausible ITT analysis was statistically significant. For high dose studies the incidence of AAD in the probiotic group was 13% (278/2218) compared to 23% (503/2207) in control group (4425 participants; RR 0.54; 95% CI 0.42 to 0.70; P <0.00001; I² = 68%; moderate certainty evidence). None of the 24 trials (4415 participants) that reported on adverse events reported any serious adverse events attributable to probiotics. Adverse event rates were low. After 5 days to 4 weeks follow‐up, 4% (86/2229) of probiotics participants had an adverse event compared to 6% (121/2186) of control participants (RD 0.00; 95% CI ‐0.01 to 0.01; P < 0.00001; I² = 75%; low certainty evidence). Common adverse events included rash, nausea, gas, flatulence, abdominal bloating, and constipation. After 10 days to 12 weeks of follow‐up, eight studies recorded data on our secondary outcome, the mean duration of diarrhea; with probiotics reducing diarrhea duration by almost one day (MD ‐0.91; 95% CI ‐1.38 to ‐0.44; P <0.00001; low certainty evidence). One study reported on microbiome characteristics, reporting no difference in changes with concurrent antibiotic and probiotic use. Authors' conclusions The overall evidence suggests a moderate protective effect of probiotics for preventing AAD (NNTB 9, 95% CI 7 to 13). Using five criteria to evaluate the credibility of the subgroup analysis on probiotic dose, the results indicate the subgroup effect based on high dose probiotics (≥ 5 billion CFUs per day) was credible. Based on high‐dose probiotics, the NNTB to prevent one case of diarrhea is 6 (95% CI 5 to 9). The overall certainty of the evidence for the primary endpoint, incidence of AAD, based on high dose probiotics was moderate due to the minor issues with risk of bias and inconsistency related to a diversity of probiotic agents used. Evidence also suggests that probiotics may moderately reduce the duration of diarrhea, a reduction by almost one day. The benefit of high dose probiotics (e.g. Lactobacillus rhamnosus or Saccharomyces boulardii ) needs to be confirmed by a large well‐designed multi‐centered randomized trial. It is premature to draw firm conclusions about the efficacy and safety of 'other' probiotic agents as an adjunct to antibiotics in children. Adverse event rates were low and no serious adverse events were attributable to probiotics. Although no serious adverse events were observed among inpatient and outpatient children, including small studies conducted in the intensive care unit and in the neonatal unit, observational studies not included in this review have reported serious adverse events in severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter use and disorders associated with bacterial/fungal translocation. Plain language summary Probiotics for the prevention of antibiotic‐associated diarrhea in children What is antibiotic‐associated diarrhea? Antibiotic‐associated diarrhea (AAD) occurs when antibiotics disturb the natural balance of \"good\" and \"bad\" bacteria in the intestinal tract causing harmful bacteria to multiply beyond their normal numbers. The symptoms of AAD include frequent watery bowel movements and crampy abdominal pain. What are probiotics? Probiotics are found in dietary supplements or yogurts and contain potentially beneficial bacteria or yeast. Probiotics may restore the natural balance of bacteria in the intestinal tract. What did the researchers investigate? The researchers investigated whether probiotics prevent AAD in children receiving antibiotic therapy and whether probiotics causes any harms (side effects). The researchers searched the medical literature extensively up to May 28, 2018. What did the researchers find? Thirty‐three studies were reviewed and provide the best available evidence. The studies tested 6352 children (3 days to 17 years of age) who were receiving probiotics co‐administered with antibiotics to prevent AAD. The participants received probiotics ( Lactobacilli spp., Bifidobacterium spp., Streptococcus spp. , or Saccharomyces boulardii alone or in combination), placebo (pills not including probiotics), other treatments thought to prevent AAD (i.e. diosmectite or infant formula) or no treatment. The studies were short‐term, ranging in length from 5 days to 12 weeks. Analyses showed that probiotics are effective for preventing AAD. The incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group, demonstrating a moderate reduction (11% fewer will suffer diarrhea). For every 9 children treated, probiotics will prevent one case of diarrhea. Further, evidence suggests that higher dose probiotics (≥ 5 billion CFUs per day) reduce the incidence of AAD. Eight per cent (162/2029) of the high dose probiotics group had AAD compared to 23% (462/2009) in the control group, demonstrating a moderate to large reduction (15% fewer suffer diarrhea). Probiotics were generally well tolerated, and minor side effects (e.g. rash, nausea, gas, flatulence, abdominal bloating, constipation) occurred infrequently. . Evidence suggested that probiotics are effective for a moderate reduction in duration of diarrhea (almost one day). Among the various probiotics evaluated, Lactobacillus rhamnosus or Saccharomyces boulardii at 5 to 40 billion colony forming units/day appear most appropriate for preventing AAD in children receiving antibiotics. It is premature to draw conclusions about the effectiveness and safety of 'other' probiotic agents for preventing AAD. Although no serious probiotic‐related side effects were observed among the mostly otherwise healthy children who participated in the studies, serious side effects have been reported in observational studies not included in this review, including severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter (a flexible tube used to give medicines) use and disorders associated with bacterial or fungal translocation (the passage of bacteria from the gut to other areas of the body).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Guo, Q; Goldenberg, JZ; Humphrey, C; El Dib, R; Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD004827.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "31973d83-476f-4861-8d80-b45981e49413", "pmid": "", "title": "Anticholinergic agents for chronic asthma in adults", "imported": false, "abstract": "Abstract - Background Anticholinergic agents such as ipratropium bromide are sometimes used in the treatment of chronic asthma. They effect bronchodilation and have also been used in combination with ß2 ‐agonists in the management of chronic asthma. Objectives To examine the effectiveness of anticholinergic agents versus placebo and in comparison with ß2 ‐agonists or as adjunctive therapy to ß2 ‐agonists. Search methods The Cochrane Airways Group asthma and wheeze database was searched with a pre‐defined search strategy. Searches were current as of August 2008. Reference lists of articles were also examined. Selection criteria Randomised trials or quasi‐randomised trials were considered for inclusion. Studies assessing an anticholinergic agent versus placebo or in combination/comparison with ß2 ‐agonists were included. In practice, all ß2 ‐agonists were short acting. Short‐term (less than 24 hours duration) were not considered for this review. Data collection and analysis Two reviewers independently assessed abstracts for retrieval of full text articles. Papers were then assessed for suitability for inclusion in the review. Data from included studies were extracted by two reviewers and entered into the software package (RevMan 4.2). We contacted authors for missing data and some responded. Adverse effect data were analysed if reported in the included studies. Main results The studies analysed were in two groups: those comparing anticholinergics with placebo and those comparing the combination of anticholinergics with short acting ß2 ‐agonists versus short acting ß2 ‐agonists alone. The former group had 13 studies involving 205 participants included in this review, and the latter 9 studies involving 440 patients. Generally methodological quality was poorly reported, and there were some reservations with respect to the quality of the studies. Despite the limited number of studies that could be combined, anticholinergic agents in comparison with placebo resulted in more favourable symptom scores particularly in respect of daytime dyspnoea (WMD ‐0.09 (95%CI ‐0.14, ‐0.04, 3 studies, 59 patients). Daily peak flow measurements also showed a statistically significant improvement for the anticholinergic (e.g. morning PEF: WMD =14.38 litres/min (95%CI 7.69, 21.08; 3 studies, 59 patients). However the clinical significance is small and in terms of peak flow measurements equates to approximately a 7% increase over placebo. The more clinically relevant comparison of a combination of anticholinergic plus short acting ß2 ‐agonist versus short acting ß2 ‐agonist alone gave no evidence in respect of symptom scores or peak flow rates of any significant differences between the two regimes. Again there are reservations with respect to the quality of the information from which these conclusions are drawn. An update search in August 2004 did not identify any new studies. Authors' conclusions Overall this review provides no justification for routinely introducing anticholinergics as part of add‐on treatment for patients whose asthma is not well controlled on standard therapies. This does not exclude the possibility that there may be a sub‐group of patients who derive some benefit and a trial of treatment in individual patients may still be justified. The role of long term anticholinergics such as tiotropium bromide has yet to be established in patients with asthma and any future trials might draw on the messages derived from this review. Plain language summary Anticholinergic agents for chronic asthma in adults Anticholinergic agents such as Atrovent are sometimes used to treat people with asthma as a bronchodilator that opens up the airways in the lungs. This review found that although this treatment was better than placebo, the size of the effect was rather small. When the drug was used in combination with more widely used bronchodilators (beta‐agonists such as fenoterol), it did not appear to add much benefit. However, there are concerns about the quality of the studies that have been analysed. It could be that there are some adults with chronic asthma who respond to treatment with anticholinergic drugs, but the review has not been able to identify their common characteristics.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Westby, MJ; Benson, MK; Gibson, PG", "articleTypes": [], "doi": "10.1002/14651858.CD003269.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "319b3eb7-c0b7-498c-b762-bfba0e5181ae", "pmid": "", "title": "Environmental enrichment for stroke and other non‐progressive brain injury", "imported": false, "abstract": "Abstract - Background Rehabilitation is effective for recovery after stroke and other non‐progressive brain injuries but it is unclear if the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. Environmental enrichment is a relatively new concept within rehabilitation for humans. In this review, this is defined as an intervention designed to facilitate physical (motor and sensory), cognitive and social activity by the provision of equipment and organisation of a structured, stimulating environment. The environment should be designed to encourage (but not force) activities without additional specialised rehabilitation input. Objectives To assess the effects of environmental enrichment on well‐being, functional recovery, activity levels and quality of life in people who have stroke or non‐progressive brain injury. Search methods We conducted the search on 26 October 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers. Selection criteria We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services. Data collection and analysis Two review authors independently assessed eligible studies, extracted data, and assessed study quality. Any disagreements were resolved through discussion with a third review author. We determined the risk of bias for the included study and performed a 'best evidence' synthesis using the GRADE approach. Main results We identified one RCT, involving 53 participants with stroke, comparing environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. We excluded five studies, found two studies awaiting classification and one ongoing study which described environmental enrichment in their interventions. Of the excluded studies, three were non‐RCTs and two described co‐interventions with a significant component of rehabilitation. Based on the single small included RCT at high risk of bias, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the provision of environmental enrichment. Authors' conclusions The gap in current research should not, however, be interpreted as proof that environmental enrichment is ineffective. Further research is needed with robust study designs, such as cluster RCTs, and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (inpatient versus outpatient), the relative effectiveness of various components of environmental enrichment, cost‐effectiveness, and safety of the intervention in people following stroke or other non‐progressive brain injuries. It should be noted, however, that it is challenging to randomise or double‐blind trials of environmental enrichment given the nature of the intervention. Plain language summary Treatment using environmental enrichment for supporting rehabilitation following stroke and other brain injuries which do not get worse over time (non‐progressive brain injury) Background Rehabilitation helps with recovery after stroke and other non‐progressive brain injuries through therapy. However, outside of therapy hours, people may have very little to keep them stimulated. Environmental enrichment is a relatively new concept in rehabilitation where the environment itself is designed to be engaging and to include physical, thinking, and social activities like exercises and games. For example, a nursery for babies may be interesting and stimulating but a hospital environment for adults is generally not. The design of the environment alone should encourage (but not force) activities without additional specialised rehabilitation. Review question 
We wanted to find out whether treatment with environmental enrichment is better or worse than alternatives. Search date 
The evidence is current to 26 October 2020. Study characteristics 
Population: we planned to include studies in which participants were adults who had had a stroke or a non‐progressive brain injury (such as traumatic brain injury but not dementia, Alzheimer's diease, or multiple sclerosis). Intervention: environmental enrichment interventions will usually include multiple activities, such as computers plus gaming technology plus music and reading. Comparison: we planned to compare environmental interventions with usual care (regular physiotherapy, speech therapy, occupational therapy) or alternative treatment. Outcomes: we divided outcomes into primary and secondary outcomes. Primary outcomes focused on psychological well‐being (anxiety, depression, stress) and coping. Secondary outcomes focused on quality of life, physical function, communication and cognitive function, and activity levels. We also planned to report adverse events. Key results 
We found one trial that compared environmental intervention alone with usual care or alternative treatment. The trial included 53 participants who had had a stroke and was based in a hospital rehabilitation ward. The trial compared environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services. The main outcomes related to psychological well‐being and coping. We were uncertain of the results because the trial was very small and highly prone to bias. Conclusion 
The gap in current research does not mean that environmental enrichment is ineffective. Further research is needed with strong study designs and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (in hospital versus out of hospital), which components of environmental enrichment are effective, whether environmental enrichment is cost‐effective, and if it is safe for people following stroke or other non‐progressive brain injuries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Qin, H; Reid, I; Gorelik, A; Ng, L", "articleTypes": [], "doi": "10.1002/14651858.CD011879.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "31aed2ff-8385-4c54-9a49-7fffa070d495", "pmid": "", "title": "Environmental and behavioural modifications for improving food and fluid intake in people with dementia", "imported": false, "abstract": "Abstract - Background Weight loss, malnutrition and dehydration are common problems for people with dementia. Environmental modifications such as, change of routine, context or ambience at mealtimes, or behavioural modifications, such as education or training of people with dementia or caregivers, may be considered to try to improve food and fluid intake and nutritional status of people with dementia. Objectives Primary: To assess the effects of environmental or behavioural modifications on food and fluid intake and nutritional status in people with dementia. Secondary: To assess the effects of environmental or behavioural modifications in connection with nutrition on mealtime behaviour, cognitive and functional outcomes and quality of life, in specific settings (i.e. home care, residential care and nursing home care) for different stages of dementia. To assess the adverse consequences or effects of the included interventions. Search methods We searched the Specialized Register of Cochrane Dementia and Cognitive Improvement (ALOIS), MEDLINE, Eembase, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 17 January 2018. We scanned reference lists of other reviews and of included articles. Selection criteria We included randomised controlled trials (RCTs) investigating interventions designed to modify the mealtime environment of people with dementia, to modify the mealtime behaviour of people with dementia or their caregivers, or both, with the intention of improving food and fluid intake. We included people with any common dementia subtype. Data collection and analysis Two review authors independently selected studies, extracted data and assessed the risk of bias of included trials. We assessed the quality of evidence for each outcome using the GRADE approach. Main results We included nine studies, investigating 1502 people. Three studies explicitly investigated participants with Alzheimer's disease; six did not specify the type of dementia. Five studies provided clear measures to identify the severity of dementia at baseline, and overall very mild to severe stages were covered. The interventions and outcome measures were diverse. The overall quality of evidence was mainly low to very low. One study implemented environmental as well as behavioural modifications by providing additional food items between meals and personal encouragement to consume them. The control group received no intervention. Differences between groups were very small and the quality of the evidence from this study was very low, so we are very uncertain of any effect of this intervention. The remaining eight studies implemented behavioural modifications. Three studies provided nutritional education and nutrition promotion programmes. Control groups did not receive these programmes. After 12 months, the intervention group showed slightly higher protein intake per day (mean difference (MD) 0.11 g/kg, 95% confidence interval (CI) ‐0.01 to 0.23; n = 78, 1 study; low‐quality evidence), but there was no clear evidence of a difference in nutritional status assessed with body mass index (BMI) (MD ‐0.26 kg/m² favouring control, 95% CI ‐0.70 to 0.19; n = 734, 2 studies; moderate‐quality evidence), body weight (MD ‐1.60 kg favouring control, 95% CI ‐3.47 to 0.27; n = 656, 1 study; moderate‐quality evidence), or score on Mini Nutritional Assessment (MNA) (MD ‐0.10 favouring control, 95% CI ‐0.67 to 0.47; n = 656, 1 study; low‐quality evidence). After six months, the intervention group in one study had slightly lower BMI (MD ‐1.79 kg/m² favouring control, 95% CI ‐1.28 to ‐2.30; n = 52, 1 study; moderate‐quality evidence) and body weight (MD ‐8.11 kg favouring control, 95% CI ‐2.06 to ‐12.56; n = 52, 1 study; moderate‐quality evidence). This type of intervention may have a small positive effect on food intake, but little or no effect, or a negative effect, on nutritional status. Two studies compared self‐feeding skills training programmes. In one study, the control group received no training and in the other study the control group received a different self‐feeding skills training programme. For both comparisons the quality of the evidence was very low and we are very uncertain whether these interventions have any effect. One study investigated general training of nurses to impart knowledge on how to feed people with dementia and improve attitudes towards people with dementia. Again, the quality of the evidence was very low so that we cannot be certain of any effect. Two studies investigated vocal or tactile positive feedback provided by caregivers while feeding participants. After three weeks, the intervention group showed an increase in calories consumed per meal (MD 200 kcal, 95% CI 119.81 to 280.19; n = 42, 1 study; low‐quality evidence) and protein consumed per meal (MD 15g, 95% CI 7.74 to 22.26; n = 42, 1 study; low‐quality evidence). This intervention may increase the intake of food and liquids slightly; nutritional status was not assessed. Authors' conclusions Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia. Plain language summary Environmental and behavioural modifications for improving food and fluid intake in people with dementia What we wanted to know Weight loss, malnutrition and dehydration are common problems for people with dementia and can occur at any stage of the illness. People with dementia often develop psychological symptoms or behaviours which cause them to eat or drink less. In the later stages of the illness, they become dependent on others to help them eat or drink. We wanted to investigate how to keep people with dementia eating and drinking as well as possible. We looked for studies which changed the way food and drink are presented to people with dementia, and for studies which attempted to change the behaviour of people with dementia or of those helping them to eat. We called these environmental and behavioural modifications respectively, though some interventions include aspects of both. We were mainly interested in the effect on how much people with dementia ate and drank and on measures of how well‐nourished they were (e.g. body weight or body mass index (BMI)), but we also looked for effects on eating behaviour, symptoms of dementia and quality of life. How we tried to answer the question We searched for all the randomised controlled trials (RCTs) which were relevant to our question. In these trials, some people with dementia got an environmental or behavioural modification intended to improve their eating and drinking and were then compared with other people who had not had the intervention (the control group). Whether someone got the intervention or not was decided at random. We found nine RCTs to include in our review. In total, there were 1502 people in these trials. They had varying degrees of dementia, probably mostly due to Alzheimer's disease. Seven of the trials took place in care homes. In one trial, people were given extra snacks between meals and encouraged to eat them. In three trials, people with dementia were given education about diet and eating. In two trials, people with dementia were taught skills to help them to eat independently. In three trials, training was given to the carers responsible for helping people with dementia to eat. What we found out All the trials we found tested different interventions and measured their effects in different ways. Generally, the trials were small and there were problems with the way they were done, which reduced our confidence in the results. For some interventions, the quality of the evidence was so low that we could not draw any conclusions. For others, there was a mixture of positive and negative effects. What we concluded Because of the amount and quality of the evidence we found, we cannot at the moment, identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Herke, M; Fink, A; Langer, G; Wustmann, T; Watzke, S; Hanff, AM; Burckhardt, M", "articleTypes": [], "doi": "10.1002/14651858.CD011542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "31d12317-502b-4a3b-97b2-ecf998f38dc5", "pmid": "", "title": "Probiotics for the prevention of Clostridioides difficile‐associated diarrhea in adults and children", "imported": false, "abstract": "Abstract - Rationale Antibiotics can disturb gastrointestinal microbiota, which may lead to reduced resistance to pathogens such as Clostridioides difficile . Probiotics are live microbial preparations that, when administered in adequate amounts, may confer a health benefit to the host, and are a potential C difficile infection prevention strategy. Objectives To assess the benefits and harms of probiotics for preventing C difficile ‐associated diarrhea (CDAD) in adults and children receiving an antibiotic for any reason. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, and Ovid Embase from 18 March 2017 (search date of the previous version of the review) to 3 March 2025. Eligibility criteria We included randomized controlled trials with a placebo, alternative prophylaxis, or no‐treatment control investigating probiotics (any strain or dose) for the prevention of CDAD in adults and children receiving an antibiotic for any reason. Outcomes The critical outcome was incidence of CDAD. Important outcomes included detection of C difficile in stool (i.e. colonization in absence of symptoms), adverse events, antibiotic‐associated diarrhea (AAD), and length of hospital stay. Risk of bias Two review authors independently assessed risk of bias using Cochrane's RoB 1 tool. Synthesis methods We pooled dichotomous outcomes (e.g . incidence of CDAD) using a random‐effects complete‐case model to calculate the risk ratio (RR) and absolute risk reduction (ARR) and corresponding 95% confidence interval (95% CI). We pooled continuous outcomes (e.g. length of hospital stay) using a random‐effects model to calculate the mean difference (MD) and corresponding 95% CI. We conducted sensitivity analyses to explore the impact of missing outcome data on benefits and harms outcomes. To investigate heterogeneity, we conducted a priori subgroup analyses on risk of bias, probiotic dose, probiotic species, adults versus children, inpatients versus outpatients, and the event rate in the control group for developing CDAD (low 0% to 2%; moderate 3% to 5%; high > 5%). The certainty of the evidence for each outcome was independently assessed using the GRADE approach. Included studies Eight new studies (n = 4595) met our inclusion criteria, for a total of 47 included studies (n = 15,260). Although we noted a high risk of bias in individual studies for sequence generation or allocation concealment, this did not impact our findings. Around 30% of studies lacked a published protocol or clinical trial registration, and in some cases there were inconsistencies between the reported methods and published results. We noted authors' affiliation with a probiotic company and financial support received from probiotic companies in 28 studies. Synthesis of results Evidence from 38 trials (13,179 participants) suggests that probiotics may result in a small absolute risk reduction (ARR) of 1.6% (incidence of 1.6% [110/6787] in the probiotic group versus 3.2% [203/6392] in the control group), and a relative risk reduction (RRR) of 50% (RR 0.50, 95% CI 0.38 to 0.64; P < 0.001; low‐certainty evidence) in incidence of CDAD. Twenty‐seven of 38 trials had missing CDAD data, ranging from 2% to 45%. Our complete‐case CDAD results proved robust to sensitivity analyses of plausible and worst‐plausible assumptions regarding missing outcome data. Pooled results from 16 trials (1302 participants) suggest that probiotics may result in a small absolute reduction in C difficile in stool (i.e. colonization in absence of symptoms) (ARR 2.1%; incidence of 14.9% [101/677] in the probiotic group versus 16.2% [101/625] in the control group; RR 0.87, 95% CI 0.68 to 1.11; P = 0.27; low‐certainty evidence). Thirty‐seven studies (11,911 participants) reported on adverse events. Our pooled analysis indicates that probiotics probably result in a small ARR of 1.7% (incidence of 10.9% [669/6148] in the probiotic group versus 12.2% [701/5763] in the control group), and an RRR of 14.0% (RR 0.86, 95% CI 0.72 to 1.01; P = 0.074; moderate‐certainty evidence). The most common adverse events in both the treatment and control groups were abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. Pooled results from 40 studies (13,419 participants) suggest that probiotics may result in a large ARR of 9% (incidence of 23% [1592/6901] in the probiotic group versus 27.4% [1787/6518] in the control group), and an RRR of 33% (RR 0.67, 95% CI 0.57 to 0.78; P < 0.001; low‐certainty evidence) in incidence of AAD. Only seven trials (6553 participants) investigated length of hospital stay. There is likely little to no difference in length of hospital stay between treatment and control groups (MD −0.07, 95% CI −0.35 to 0.21; P = 0.63; moderate‐certainty evidence). We downgraded the certainty of evidence for CDAD and AAD due to the low number of events or publication bias. We observed some variability in CDAD control group event rate (< 2% to > 5%) that may impact the applicability of evidence depending on clinical setting. We downgraded the certainty of evidence for adverse events due to variation between the results of the studies and for hospital stay due to selective reporting. Authors' conclusions The currently available evidence suggests that probiotics may be effective for preventing CDAD, suggesting that for every 65 people taking probiotics, one case of CDAD may be prevented (number needed to treat for an additional beneficial outcome of 65, 95% CI 48 to 97). There are probably fewer adverse events in the probiotic group. The short‐term use of probiotics may have a small absolute benefit, and is likely not associated with adverse effects when used in patient populations receiving systemic antibiotics who are not immunocompromised. Large trials comparing probiotics with placebo in people with a low baseline risk of CDAD are needed. Funding There was no source of funding for this update. Registration The original review was done in 2013 by Johnston and colleagues, for which the protocol was developed. We followed the methods specified in the 2017 review, while modifying the search strategy and risk of bias assessment for selective reporting for this update. Plain language summary What are the benefits and harms of probiotics for preventing Clostridioides difficile‐ associated diarrhea in adults and children receiving antibiotics for any reason? Key messages In people prescribed antibiotics, probiotics may be effective in preventing Clostridioides difficile ‐associated diarrhea (CDAD), and may reduce the risk of antibiotic‐associated diarrhea. Probiotics probably do not result in harm when taken with an antibiotic, with fewer mild to moderate unwanted effects in the group receiving probiotic than the group receiving placebo (dummy treatment) or no treatment. In those taking antibiotics who do not have a weakened immune system, the short‐term use of probiotics may offer a small benefit, and are likely not harmful. However, additional large studies comparing probiotics with placebo in people with a low risk of CDAD are needed. What is Clostridioides difficile ‐associated diarrhea (CDAD) ? Antibiotics are among the most prescribed medications worldwide. Antibiotic treatment may disturb the balance of organisms that normally populate the gut. This can result in a range of symptoms, most notably diarrhea. C difficile is a particularly dangerous organism that may colonize and infect the gut if the microbial balance has been disrupted. The effects of C difficile infection can vary, with some people having no symptoms, and others suffering diarrhea, severe inflammation, enlargement of the colon, or even death. The cost of treatment is expensive, and the financial burden on the medical system is substantial. What are probiotics? Probiotics are live microorganisms (bacteria or yeast) that provide health benefits when given in adequate amounts. They help to prevent potential disturbances to the gut microbial balance that are associated with antibiotic use, and to reduce the risk of growing harmful bacteria. Probiotics can be found in dietary supplements or yogurts and are widely available as capsules sold in health food stores and supermarkets. As 'functional food' or 'good bacteria,' probiotics have been suggested as a means of both preventing and treating CDAD. What did we want to find out? We wanted to know if probiotics prevent CDAD in adults and children receiving antibiotic therapy, and whether probiotics cause any unwanted effects. The researchers searched the medical literature extensively up to 3 March 2025. What did we do? We searched for studies that compared probiotics (any strain or dose) versus placebo (dummy treatment), alternative preventive treatment, or no treatment for the prevention of CDAD in adults and children receiving antibiotic therapy for any reason. We compared and summarized the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included 47 studies with a total of 15,260 adults and children who received antibiotic therapy along with probiotics, assessing CDAD or C difficile growth. Thirty‐eight studies (13,179 participants) assessed the effectiveness of probiotics for preventing CDAD. Our results suggest that probiotics may result in a small reduction in the risk of CDAD compared to placebo or no treatment. Probiotics may result in a small reduction in C difficile growth (16 studies, 1302 participants). Thirty‐seven studies (11,911 participants) looked at unwanted effects. Our results show that probiotics probably result in a small reduction in the risk of developing unwanted effects compared to placebo or no treatment. The most commonly reported unwanted effects included abdominal cramping, nausea, fever, soft stools, flatulence (gas), and taste disturbance, and were more common in the placebo or no‐treatment group. Forty studies (13,419 participants) reported on antibiotic‐associated diarrhea (AAD); probiotics may result in a large reduction in the risk of AAD compared to placebo or no treatment. Seven studies (6553 participants) reporting on length of hospital stay showed likely little to no difference between probiotics and placebo or no treatment. What are the limitations of the evidence? The studies we reviewed used different types of probiotics, but they didn't directly compare one probiotic to another. This lack of direct comparisons makes it harder to determine which probiotic works best. We have moderate to little confidence in the available evidence. Our confidence is limited because in some studies, people who dropped out of the study or were not followed up on resulted in missing information. The two largest studies in our analysis did not show a clear benefit of probiotics for preventing CDAD. How up‐to‐date is this evidence? The evidence is current to 3 March 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Esmaeilinezhad, Z, Ghosh, NR, Walsh, CM, Steen, JP, Burgman, AM, Mertz, D, Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD006095.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.771Z" }, { "id": "31f131c8-d5ca-473a-a7f0-17e0974541a4", "pmid": "", "title": "Pharmaceutical interventions for emotionalism after stroke", "imported": false, "abstract": "Abstract - Background Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2019. Objectives To evaluate the benefits and harms of pharmaceutical treatment in people with emotionalism after stroke. Search methods We searched the Cochrane Stroke Group Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registers (May 2022). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). Data collection and analysis Two review authors independently selected trials, assessed risk of bias, extracted data from all included trials, and used GRADE to assess the certainty of the body of evidence. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I 2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on the Center for Neurologic Study ‐ Lability Scale (CNS‐LS) or Clinician Interview‐Based Impression of Change (CIBIC), or diminished tearfulness. Main results We did not identify any new trials for this update. We included seven trials with a total of 239 participants. Two trials had a cross‐over design, but outcome data were not available from the first phase (precross‐over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with a total of 213 participants. It is uncertain whether fluoxetine increases the number of people who have a 50% reduction in emotionalism when compared to placebo (risk ratio (RR) 0.26, 95% CI 0.09 to 0.77; P = 0.02; 1 trial, 19 participants) because the certainty of evidence is very low. Sertraline may lead to little to no difference in Center for Neurologic Study ‐ Lability Scale (CNS‐LS) scores and Clinician Interview‐Based Impression of Change (CIBIC) scores when compared to placebo (RR 0.20, 95% CI 0.03 to 1.50; P = 0.12; 1 trial, 28 participants; low‐certainty evidence). Antidepressants probably increase the number of people who experience a reduction in tearfulness (RR 0.32, 95% CI 0.12 to 0.86; P = 0.02; 3 trials, 164 participants; moderate‐certainty evidence). No trials were found that evaluated the impact of other pharmaceutical interventions. Only two trial authors systematically recorded and reported adverse events, resulting in limited data on the potential harms of treatment. Six trials reported death as an adverse event and found no difference between the groups (antidepressants versus placebo) in the number of deaths reported (RR 0.59, 95% CI 0.08 to 4.50; P = 0.61; 172 participants; moderate‐certainty evidence). This review provides very low‐ to moderate‐certainty evidence that antidepressants may reduce the frequency and severity of emotionalism. The included trials were small and had some degree of bias. Authors' conclusions Antidepressants may reduce the frequency and severity of crying or laughing episodes when compared to placebo, based on very low‐certainty evidence. Our conclusions must be qualified by several methodological deficiencies in the trials and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post‐stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity, and assess change over time; provide treatment for a sufficient duration and follow‐up to better assess rates of relapse or maintenance; and include careful assessment and complete reporting of adverse events. Plain language summary Medicines for emotionalism after stroke Review question To evaluate the benefits and harms of medicine in people with emotionalism after stroke. Background Emotionalism often occurs after stroke. Emotionalism means that the person has difficulty controlling their emotional behaviour. After stroke, people may suddenly start crying or, less commonly, laughing for no apparent reason. This is distressing for that particular person and their carers. Antidepressants, known to be helpful in people with depression, may be an effective treatment for emotionalism after stroke, but there have been very few randomised controlled trials (RCTs) in this area. (RCTs are studies in which participants are assigned randomly to 2 or more treatment groups. This is the best way to ensure that groups of participants are similar, and that investigators and participants do not know who is in which group.) Search date We identified studies through searches conducted on 26 May 2022. Study characteristics We included 7 randomised controlled trials, involving 239 people with emotionalism, in the review, which reported on the use of antidepressants for treating emotionalism. The numbers of people included in the studies ranged from 10 to 92. The mean/median ages ranged from 57.8 years to 73 years. Studies were from Europe (UK: 1; Denmark: 1; Scotland: 1; and Sweden: 1); Asia (South Korea: 1 and Japan: 1); and the USA (1). Key results We did not identify any new studies in our search update. We included 7 studies involving 239 people. However, 2 studies were not available in the appropriate format to include in the analysis. Therefore, we included only 5 studies, with 213 people, in our analyses. It is uncertain whether antidepressants affect the number of people with at least a 50% reduction in emotional displays, tearfulness, and scores on the questionnaires that measure uncontrollable laughing or crying, but they had no effect on lability (frequency of mood changes) scores and whether a clinician thought there had been an improvement when compared to placebo. No studies of other types of medicine were found. Six studies reported death and found no differences between those who were on antidepressants and those who were not. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low, and the results of further research could differ from the results of this review. Our confidence is limited because the included studies were small, and there was no consistency in how emotionalism was measured across the studies. Conclusion It is uncertain whether antidepressant medicines reduce outbursts of crying or laughing. More studies with systematic assessment and reporting of unwanted or harmful effects of a treatment are needed to ensure that any benefits outweigh the risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Allida, S; House, A; Hackett, ML", "articleTypes": [], "doi": "10.1002/14651858.CD003690.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "322d9103-46e2-42a1-bb37-f229c1eae93f", "pmid": "", "title": "Oncology, Undernutrition and Sensoriality: Links, Mechanisms and Levers for Action - Study ONDES", "imported": false, "abstract": "Cancers of the upper aerodigestive tract account for around 4% of all malignant tumours worldwide. Colon and liver cancer are the most common digestive cancers. The epidemiology of liver cancer is changing, and the number of deaths from liver cancer has increased by 25% worldwide (Huang 2022). In France, around 19,000 cancers of the upper aerodigestive tract and 88,000 new cases of digestive cancer are diagnosed each year (colon cancer remains the most common) (Globocan 2020). Patients with these two types of cancer are at particularly high risk of undernutrition (Pressoir 2010; Gyan 2018).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "3267c9d9-49f9-4282-a053-83b3e717d80c", "pmid": "", "title": "Prostaglandins for management of retained placenta", "imported": false, "abstract": "Abstract - Background Retained placenta affects 0.5% to 3% of women following delivery and it is a major cause of maternal death due to postpartum haemorrhage. Usually, retained placenta has been managed by manual removal or curettage under anaesthesia, which may be associated with haemorrhage, infection and uterine perforation. Medical management to facilitate the delivery of the retained placenta could be a safe alternative avoiding surgical intervention. Objectives To assess the effectiveness and safety of prostaglandins for the management of retained placenta. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013), LILACS (1982 to 1 December 2013), SciELO (1998 to 1 December 2013), Web of Science (2001 to 1 December 2013), openSIGLE (1997 to 1 December 2013 ) , World Health Organization International Clinical Trials Registry Platform ( ICTRP ) (1 December 2013) and the metaRegister of Controlled Trials ( mRCT ) (1 December 2013) . We also contacted authors of included studies and reviewed the reference lists of retrieved studies. Selection criteria Randomised controlled clinical trials comparing the use of prostaglandins (or prostaglandin analogues) with placebo, expectant management, tocolytic drugs, any other prostaglandins or surgical interventions for the management of retained placenta after vaginal delivery of singleton live infants of 20 or more weeks of gestation. Data collection and analysis Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. Any disagreements were resolved through consensus or consultation with a third review author when required. Authors of the included studies were contacted for additional information. Main results We included three trials, involving 244 women. The studies were considered to be at high risk of bias. The prostaglandins used were PG E2 analogue (sulprostone) in 50 participants and PG E1 analogue (misoprostol) in 194 participants at a dose of 250 mcg and 800 mcg respectively. The prostaglandins compared with placebo, were not superior in reducing the rate of manual removal of placenta (average risk ratio (RR) 0.82; 95% confidence interval (CI) 0.54 to 1.27), severe postpartum haemorrhage (RR 0.80; 95% CI 0.55 to 1.15), need for blood transfusion (RR 0.72; 95% CI 0.43 to 1.22), mean blood loss (mean difference (MD) ‐205.26 mL; 95% CI ‐536.31 to 125.79, random‐effects) and the mean time from injection to placental removal (MD ‐7.00 minutes; 95% CI ‐21.20 to 7.20). Side‐effects were no different between groups (vomiting, headache, pain and nausea between injection and discharge from the labour ward), with the exception of shivering, which was more frequent in women receiving prostaglandins (RR 10.00; 95% CI 1.40 to 71.49). We did not obtain any data for the primary outcomes of maternal mortality and the need to add another therapeutic uterotonic. Authors' conclusions Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes) or side‐effects (vomiting, headache, pain and nausea between injection and discharge from the labour ward) except for 'shivering' which was more frequent in women who received prostaglandin. The included studies were of poor quality and there is little confidence in the effect estimates; the true effect is likely to be substantially different. We can not make any recommendations about changes to clinical practice. More high‐quality research in this area is needed. Plain language summary Prostaglandins for management of retained placenta Medical research evidence is sparse and insufficient to support the routine use of the prostaglandins for the management of retained placenta. Retained placenta affects 0.5% to 3% of women following delivery and is a major cause of maternal death caused by postpartum haemorrhage. A retained placenta is usually managed by manual removal or curettage under anaesthesia (which is not always immediately available). Surgical procedures themselves can be associated with haemorrhage and also infection and uterine perforation. Prostaglandins or their analogues, administered by any route, could be an alternative treatment especially in developing countries. Such medical management may facilitate the delivery of the retained placenta and be a safer alternative to surgery. The review identified three randomised controlled studies (involving 244 women) that compared the use of prostaglandins with placebo. Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and need for blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes). The prostaglandin was administered by intravenous infusion (E2 analogue sulprostone) in one study including 50 women and was orally or sublingually administered (E1 analogue misoprostol) in the other two studies including 194 women. Shivering was more frequent in women receiving the prostaglandin but there were no clear differences in vomiting, headache, maternal pain or nausea compared with placebo. The trials were small and of poor methodological quality. The quality of evidence is very low due to study limitations, inconsistency and imprecise results (few women and outcome events with wide confidence intervals). Two studies were stopped early due to an apparent benefit.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Grillo‐Ardila, CF; Ruiz‐Parra, AI; Gaitán, HG; Rodriguez‐Malagon, N", "articleTypes": [], "doi": "10.1002/14651858.CD010312.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "32c796c1-077e-45b9-883f-e03bebbb32b6", "pmid": "", "title": "The Effects of Taste Receptors Regulation in Upper Airway Innate Immunity of CF Patients", "imported": false, "abstract": "The project is intended to be realised in two phases. In the first stage, a case control study will be performed. In the second phase, double-blind, placebo controlled cross-over study will be conducted. The first stage it to compare innate immunity activation and Pseudomonas aeruginosa (Pa) expression between Pa positive and negative patients. In the second phase the effects of inhaled lactizole- TAS3R inhibitor will be assessed.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.230Z" }, { "id": "32cef4a7-0500-460b-92cf-f9b4e555ad28", "pmid": "", "title": "The Acute and Chronic Effects of OliPhenolia® Supplementation on Exercise Induced Inflammation and Functional Movement in Healthy Adult Humans.", "imported": false, "abstract": "This research proposal follows on from previously undertaken work investigating a commercially available olive derived product (OliPhenolia®) on potential exercise / functional benefits for healthy adults. Previous research investigated a dose response bioavailability of the main polyphenol in OliPhenolia® and related metabolites. Based on this data, the current study will aim to investigate, for the first time, whether the polyphenols in the product can positively influence exercise specific inflammation which may be pertinent to improving exercise recovery and is of current scientific interest. As such this research aims to understand the short term (Phase 1) and longer term (Phase 2) use of OliPhenolia® on acute recovery from a standard exercise bout.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.147Z" }, { "id": "32d182ee-6559-4b7e-8b5f-73184a8e4f95", "pmid": "", "title": "A Phase 2, Randomized, Double Blind, Placebo Controlled Study to Evaluate the Efficacy and Safety of Leronlimab in Patients Experiencing Prolonged Coronavirus Disease 2019 (COVID-19) Symptoms [Long-Haulers]", "imported": false, "abstract": "The purpose of this study is to assess the safety and efficacy of leronlimab (PRO 140) administered as weekly subcutaneous injections in subjects experiencing prolonged symptoms (> 12 weeks) of COVID-19.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "33021bc7-f119-4c2c-a8e9-81d34a45c566", "pmid": "", "title": "Omega‐3 fatty acid supplementation for depression in children and adolescents", "imported": false, "abstract": "Abstract - Background Mental health disorders including major depressive disorder (MDD) are well recognized as major contributors to the global burden of disease among adolescents. The prevalence of adolescent depression is estimated to have increased by at least 25% during the COVID‐19 pandemic, compounding the already challenging problem of insufficient mental health service and service accessibility that existed prepandemic. Omega‐3 polyunsaturated fatty acid (PUFA) supplementation is currently recommended as a preventive treatment for depression in high‐risk adults as well as a second‐line monotherapy for adults with mild to moderate MDD, and adjunctive to antidepressants for adults with moderate to severe MDD. The benefits of omega‐3 PUFA intake on depressive illness have been hypothesized to occur as a result of their effect on neurotransmission, maintenance of membrane fluidity, and anti‐inflammatory action. A comprehensive synthesis and quantification of the existing evidence on omega‐3 PUFA's efficacy in treating depression among children and adolescents is essential for clinicians to provide informed guidance to young people and their families, especially considering the absence of current guidelines for this age group. Objectives Primary objective To determine the impact of omega‐3 PUFA supplementation versus a comparator (e.g. placebo, wait list controls, no treatment/supplementation, or standard care) on clinician‐diagnosed depression or self‐reported depression symptoms in children and adolescents. Secondary objectives To estimate the size of the effect of omega‐3 PUFAs on depression symptoms. To estimate the effect of each type of omega‐3 PUFA (EPA or DHA), compared with placebo, on depression. To determine if the effect is modified by dosage, format (capsule or liquid), sex, or age. To determine compliance and attrition for omega‐3 PUFAs as an intervention for depression in children and adolescents. To determine the safety of omega‐3 PUFAs as an intervention for depression in children and adolescents. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases, reference lists of included studies, grey literature, and relevant reviews. The latest search date was 18 May 2023. Selection criteria We included randomized controlled trials (RCTs) involving males and females aged 19 years or younger with diagnosed depression comparing omega‐3 PUFA supplementation to placebo, wait list control, no treatment/supplementation, or standard care. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were self‐reported depression symptoms and clinically diagnosed resolution of depression. Our secondary outcomes were attrition, adverse effects, and compliance with the intervention. We used GRADE to assess the certainty of evidence for key outcomes. Main results We included five trials with 228 participants in our meta‐analysis. All trials used a placebo comparator; intervention duration ranged from 10 to 16 weeks (median: 12 weeks). Omega‐3 PUFA supplementation compared to placebo may reduce self‐reported depression symptoms, but the evidence is very uncertain (standardized mean difference [SMD] −0.34, 95% confidence interval [CI] −0.85 to 0.17; lower SMD means greater improvement in depression due to omega‐3 PUFA; 5 trials, 185 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may have little to no effect on remission of depression symptoms compared to placebo, but the evidence is very uncertain (omega‐3 PUFA versus placebo: 50% versus 48%; odds ratio [OR] 1.11, 95% CI 0.45 to 2.75; 4 trials, 127 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in attrition (dropouts) compared to placebo (omega‐3 PUFA versus placebo: 18% versus 19%; OR 0.94, 95% CI 0.46 to 1.90; 5 trials, 228 participants; low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in adverse effects, with one study reporting more muscle cramps in the fish oil group (13/27 participants) compared to the placebo group (6/29 participants); one study reported more frequent defecation in the omega‐3 group (1/29 participants) and one study identified mild skin rash and unusual/manic behavior in the placebo group (2/27 participants). None of the included studies reported serious adverse effects. Authors' conclusions Based on five small studies, omega‐3 PUFA supplementation may reduce self‐reported depression symptoms, but the evidence is very uncertain. Omega‐3 PUFA supplementation may have little to no effect on depression remission compared to placebo, but the evidence is very uncertain. Omega‐3 PUFA supplementation may result in little to no difference in attrition or adverse effects. The studies observed no serious adverse effects. This review highlights early‐stage research on omega‐3 PUFA and depression in young people. The evidence on the effects of omega‐3 PUFA supplementation in improving self‐reported depression symptoms or achieving depression remission in children and adolescents is very uncertain. While no harms are evident, more data are needed to confirm potential risks. Addressing current limitations in the evidence base through the design and conduct of methodologically rigorous studies — larger sample sizes, varied dosages, eicosapentaenoic acid/docosahexaenoic acid ratios, treatment durations, and safety profiles — is crucial to advance our understanding of the role of omega‐3 PUFA supplementation for depression in children and adolescents. Plain language summary Is omega‐3 polyunsaturated fatty acid supplementation better than a placebo for treating depression among children and adolescents? Key messages – Due to a lack of robust evidence, the benefits and unwanted effects of omega‐3 polyunsaturated fatty acids (which are important fats that you must obtain from your diet) supplementation for treating depression among children and adolescents are unclear. – Larger, well‐designed studies are needed to give better estimates of the potential benefits and harms of omega‐3 polyunsaturated fatty acid supplementation for child and adolescent depression. Why is it important to find treatments for children and adolescents with depression? People with depression have a low mood or lose pleasure or interest in usual activities. It is a long‐lasting (chronic) disorder that is both serious and recurrent (it can return after periods of feeling well). It often begins during childhood and adolescence, affecting up to eight in every 100 children. Unfortunately, response to current treatments for depression in children and adolescents is poor, and relieving symptoms (remission) can be challenging. In recent studies, supplements of omega‐3 polyunsaturated fatty acids have shown promise as a potential treatment for depression in adults. Our body cannot make these beneficial fats, but they are naturally present in oily fish, marine sources, and certain nuts and seeds. They can also be given as daily supplements in capsule or liquid forms (for example, as cod liver oil capsules). What did we want to find out? We wanted to find out: – if omega‐3 polyunsaturated fatty acids supplementation works to decrease symptoms of depression in children and adolescents; and – if omega‐3 polyunsaturated fatty acids supplementation helps children and adolescents achieve remission from depression. We also wanted to know if omega‐3 polyunsaturated fatty acids supplementation can cause any unwanted effects. What did we do? We searched for studies in which children and adolescents were assigned randomly to two or more treatment groups that compared omega‐3 polyunsaturated fatty acids supplementation with a placebo (pretend treatment with the same appearance), on a waiting list, no treatment/supplementation, or usual care. This is the best way to ensure that groups of people are similar and that investigators do not know who is in which group. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found five studies that involved 228 children and adolescents ranging from 10 to 16 years of age with depression. The largest study included 60 people, and the smallest study included 28 people. Three studies were conducted in the USA, one in Israel, and one in Slovakia. Four studies lasted for around 12 weeks and one study lasted for 16 weeks. We found that omega‐3 polyunsaturated fatty acids supplementation may reduce self‐reported depression symptoms, but the results are very uncertain. If omega‐3 PUFA supplements and placebos were given to a group of 100 children and adolescents with depression, then 50 children receiving omega‐3 polyunsaturated fatty acids would achieve remission and 48 receiving the placebo would achieve remission. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results, and the studies were very small. To date, there is insufficient evidence to determine if omega‐3 polyunsaturated fatty acids supplementation improves depression for children and adolescents. How up to date is this evidence? The evidence is up to date to 18 May 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Campisi, SC; Zasowski, C; Bradley-Ridout, G; Schumacher, A; Szatmari, P; Korczak, D", "articleTypes": [], "doi": "10.1002/14651858.CD014803.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "3304c3a0-cfba-4c04-9d36-d5a92c62627e", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies to prevent COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as potential prophylaxis to prevent coronavirus disease 2019 (COVID‐19). Objectives To assess the effects of SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, to prevent infection with SARS‐CoV‐2 causing COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register, MEDLINE, Embase, and three other databases on 27 April 2022. We checked references, searched citations, and contacted study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that evaluated SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, alone or combined, versus an active comparator, placebo, or no intervention, for pre‐exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) of COVID‐19. We excluded studies of SARS‐CoV‐2‐neutralising mAbs to treat COVID‐19, as these are part of another review. Data collection and analysis Two review authors independently assessed search results, extracted data, and assessed risk of bias using Cochrane RoB 2. Prioritised outcomes were infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, all‐cause mortality, admission to hospital, quality of life, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We included four RCTs of 9749 participants who were previously uninfected and unvaccinated at baseline. Median age was 42 to 76 years. Around 20% to 77.5% of participants in the PrEP studies and 35% to 100% in the PEP studies had at least one risk factor for severe COVID‐19. At baseline, 72.8% to 82.2% were SARS‐CoV‐2 antibody seronegative. We identified four ongoing studies, and two studies awaiting classification. Pre‐exposure prophylaxis Tixagevimab/cilgavimab versus placebo One study evaluated tixagevimab/cilgavimab versus placebo in participants exposed to SARS‐CoV‐2 wild‐type, Alpha, Beta, and Delta variant. About 39.3% of participants were censored for efficacy due to unblinding and 13.8% due to vaccination. Within six months, tixagevimab/cilgavimab probably decreases infection with SARS‐CoV‐2 (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.29 to 0.70; 4685 participants; moderate‐certainty evidence), decreases development of clinical COVID‐19 symptoms (RR 0.18, 95% CI 0.09 to 0.35; 5172 participants; high‐certainty evidence), and may decrease admission to hospital (RR 0.03, 95% CI 0 to 0.59; 5197 participants; low‐certainty evidence). Tixagevimab/cilgavimab may result in little to no difference on mortality within six months, all‐grade AEs, and SAEs (low‐certainty evidence). Quality of life was not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and Delta variant. About 36.5% of participants opted for SARS‐CoV‐2 vaccination and had a mean of 66.1 days between last dose of intervention and vaccination. Within six months, casirivimab/imdevimab may decrease infection with SARS‐CoV‐2 (RR 0.01, 95% CI 0 to 0.14; 825 seronegative participants; low‐certainty evidence) and may decrease development of clinical COVID‐19 symptoms (RR 0.02, 95% CI 0 to 0.27; 969 participants; low‐certainty evidence). We are uncertain whether casirivimab/imdevimab affects mortality regardless of the SARS‐CoV‐2 antibody serostatus. Casirivimab/imdevimab may increase all‐grade AEs slightly (RR 1.14, 95% CI 0.98 to 1.31; 969 participants; low‐certainty evidence). The evidence is very uncertain about the effects on grade 3 to 4 AEs and SAEs within six months. Admission to hospital and quality of life were not reported. Postexposure prophylaxis Bamlanivimab versus placebo One study evaluated bamlanivimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type. Bamlanivimab probably decreases infection with SARS‐CoV‐2 versus placebo by day 29 (RR 0.76, 95% CI 0.59 to 0.98; 966 participants; moderate‐certainty evidence), may result in little to no difference on all‐cause mortality by day 60 (R 0.83, 95% CI 0.25 to 2.70; 966 participants; low‐certainty evidence), may increase all‐grade AEs by week eight (RR 1.12, 95% CI 0.86 to 1.46; 966 participants; low‐certainty evidence), and may increase slightly SAEs (RR 1.46, 95% CI 0.73 to 2.91; 966 participants; low‐certainty evidence). Development of clinical COVID‐19 symptoms, admission to hospital within 30 days, and quality of life were not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and potentially, but less likely to Delta variant. Within 30 days, casirivimab/imdevimab decreases infection with SARS‐CoV‐2 (RR 0.34, 95% CI 0.23 to 0.48; 1505 participants; high‐certainty evidence), development of clinical COVID‐19 symptoms (broad‐term definition) (RR 0.19, 95% CI 0.10 to 0.35; 1505 participants; high‐certainty evidence), may result in little to no difference on mortality (RR 3.00, 95% CI 0.12 to 73.43; 1505 participants; low‐certainty evidence), and may result in little to no difference in admission to hospital. Casirivimab/imdevimab may slightly decrease grade 3 to 4 AEs (RR 0.50, 95% CI 0.24 to 1.02; 2617 participants; low‐certainty evidence), decreases all‐grade AEs (RR 0.70, 95% CI 0.61 to 0.80; 2617 participants; high‐certainty evidence), and may result in little to no difference on SAEs in participants regardless of SARS‐CoV‐2 antibody serostatus. Quality of life was not reported. Authors' conclusions For PrEP, there is a decrease in development of clinical COVID‐19 symptoms (high certainty), infection with SARS‐CoV‐2 (moderate certainty), and admission to hospital (low certainty) with tixagevimab/cilgavimab. There is low certainty of a decrease in infection with SARS‐CoV‐2, and development of clinical COVID‐19 symptoms; and a higher rate for all‐grade AEs with casirivimab/imdevimab. For PEP, there is moderate certainty of a decrease in infection with SARS‐CoV‐2 and low certainty for a higher rate for all‐grade AEs with bamlanivimab. There is high certainty of a decrease in infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, and a higher rate for all‐grade AEs with casirivimab/imdevimab. Although there is high‐to‐moderate certainty evidence for some outcomes, it is insufficient to draw meaningful conclusions. These findings only apply to people unvaccinated against COVID‐19. They are only applicable to the variants prevailing during the study and not other variants (e.g. Omicron). In vitro, tixagevimab/cilgavimab is effective against Omicron, but there are no clinical data. Bamlanivimab and casirivimab/imdevimab are ineffective against Omicron in vitro. Further studies are needed and publication of four ongoing studies may resolve the uncertainties. Plain language summary Are laboratory‐made COVID‐19‐specific monoclonal antibodies effective to prevent COVID‐19 in adults? Key messages Pre‐exposure prophylaxis of COVID‐19: – tixagevimab/cilgavimab probably reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may reduce number of people admitted to hospital; – casirivimab/imdevimab may reduce number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may increase number of unwanted effects (any severity) slightly. Postexposure prophylaxis of COVID‐19: – bamlanivimab probably reduces number of people infected with COVID‐19; – casirivimab/imdevimab reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and reduces number of unwanted effects (any severity). What are 'monoclonal' antibodies? The body makes antibodies to defend against disease. However, they may be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that target only one specific protein – in this case, a protein on the SARS‐CoV‐2 virus (that causes COVID‐19) – are 'monoclonal'. They attach to the virus and stop it from entering and replicating in human cells to prevent and fight infection. They are relevant for people who do not respond or respond poorly to vaccinations. What did we want to find out? We wanted to know if COVID‐19‐specific monoclonal antibodies are effective at preventing COVID‐19 in people exposed to the virus or are at high risk of being exposed to the virus. We looked at: – confirmed COVID‐19 infections; – development of COVID‐19 symptoms; – death from any cause; – hospital admission; – quality of life; – unwanted effects, such as infections and cardiac disorders; – serious unwanted effects, such as life‐threatening, hospitalisation, disability, or death. What did we do? We searched for studies comparing monoclonal antibodies (e.g. bamlanivimab, tixagevimab/cilgavimab, and casirivimab/imdevimab) with placebo (sham treatment), another treatment, or no treatment to prevent COVID‐19 in people of any age, gender, or ethnicity. We summarised data and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? Four studies including 9749 people; two investigated people before being exposed to SARS‐CoV‐2 (pre‐exposure prophylaxis) and two investigated people who were in contact with an infected person (postexposure prophylaxis). Studies were conducted before the emergence of the Omicron variant and before or during widespread vaccine roll‐out. Participants were unvaccinated at baseline. Pre‐exposure prophylaxis One study (5197 people) compared tixagevimab/cilgavimab to placebo. Participants had been exposed to wild‐type, Alpha, Beta, and Delta variants. Tixagevimab/cilgavimab: – reduces development of symptoms; – probably reduces number of people infected; – may reduce number of hospital admissions; – may have little or no effect on deaths from any cause, unwanted effects (any severity), and serious unwanted effect. We found no data for quality of life, or mild and severe unwanted effects. One study (969 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and Delta variants. Casirivimab/imdevimab: – may reduce number of people infected and development of symptoms; – resulted in no deaths; – may increase unwanted effects (any severity) slightly; – we are uncertain whether casirivimab/imdevimab may have an effect on severe and serious unwanted effects. We found no data for number of people with COVID‐19 within 30 days, development of symptoms within 30 days, hospital admissions within 30 days, quality of life, and mild unwanted effects. Postexposure prophylaxis (two studies) One study (966 people) compared bamlanivimab to placebo. Participants may have been exposed to wild‐type variants. Bamlanivimab: – probably reduces number of people infected; – may have little or no effect on deaths from any cause; – may increase unwanted effects (any severity) and serious unwanted effects slightly. We found no data for number of people who developed symptoms, hospital admissions, quality of life, mild, and severe unwanted effects. One study (2617 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and potentially, but unlikely Delta variants. Casirivimab/ imdevimab: – reduces number of people infected, development of symptoms, and unwanted effects (any severity); – may slightly reduce severe unwanted effects; – may have little or no effect on deaths, hospital admissions, and serious unwanted effects. We found no data for quality of life and mild unwanted effects. What are the limitations of the evidence? One study reported each comparison. All participants were unvaccinated at the beginning of the studies, which were conducted prior to the occurrence of Omicron. Our confidence in the evidence is high to very low. Although we have high confidence in the evidence found for relevant outcomes, the findings are not transferable to vaccinated people and variants that occurred outside the study periods, such as Omicron. Although laboratory studies have shown that tixagevimab/cilgavimab is effective against Omicron, there are no data from clinical studies. The other monoclonal antibodies included in this review were ineffective against Omicron in laboratory studies. Four ongoing studies are likely to change our conclusions and may help us understand how new variants and COVID‐19 vaccines affect the effectiveness of monoclonal antibodies in preventing COVID‐19. How up to date is this evidence? The evidence is up‐to‐date to 27 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hirsch, C; Park, YS; Piechotta, V; Chai, KL; Estcourt, LJ; Monsef, I; Salomon, S; Wood, EM; So-Osman, C; McQuilten, Z; Spinner, CD; Malin, JJ; Stegemann, M; Skoetz, N; Kreuzberger, N", "articleTypes": [], "doi": "10.1002/14651858.CD014945.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "330785b5-a865-4ca8-aedd-6ae1e3a2c3f0", "pmid": "", "title": "Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders", "imported": false, "abstract": "Abstract - Background About 5% of school children have a specific learning disorder, defined as unexpected failure to acquire adequate abilities in reading, writing or mathematics that is not a result of reduced intellectual ability, inadequate teaching or social deprivation. Of these events, 80% are reading disorders. Polyunsaturated fatty acids (PUFAs), in particular, omega‐3 and omega‐6 fatty acids, which normally are abundant in the brain and in the retina, are important for learning. Some children with specific learning disorders have been found to be deficient in these PUFAs, and it is argued that supplementation of PUFAs may help these children improve their learning abilities. Objectives 1. To assess effects on learning outcomes of supplementation of polyunsaturated fatty acids (PUFAs) for children with specific learning disorders.
 2. To determine whether adverse effects of supplementation of PUFAs are reported in these children. Search methods In November 2015, we searched CENTRAL, Ovid MEDLINE, Embase, PsycINFO, 10 other databases and two trials registers. We also searched the reference lists of relevant articles. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing PUFAs with placebo or no treatment in children younger than 18 years with specific learning disabilities, as diagnosed in accordance with the fifth (or earlier) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5), or the 10th (or earlier) revision of the International Classification of Diseases (ICD‐10) or equivalent criteria. We included children with coexisting developmental disorders such as attention deficit hyperactivity disorder (ADHD) or autism. Data collection and analysis Two review authors (MLT and KHT) independently screened the titles and abstracts of articles identified by the search and eliminated all studies that did not meet the inclusion criteria. We contacted study authors to ask for missing information and clarification, when needed. We used the GRADE approach to assess the quality of evidence. Main results Two small studies involving 116 children, mainly boys between 10 and 18 years of age, met the inclusion criteria. One study was conducted in a school setting, the other at a specialised clinic. Both studies used three months of a combination of omega‐3 and omega‐6 supplements as the intervention compared with placebo. Although both studies had generally low risk of bias, we judged the risk of reporting bias as unclear in one study, and as high in the other study. In addition, one of the studies was funded by industry and reported active company involvement in the study. None of the studies reported data on the primary outcomes of reading, writing, spelling and mathematics scores, as assessed by standardised tests. Evidence of low quality indicates that supplementation of PUFAs did not increase the risk of gastrointestinal disturbances (risk ratio 1.43, 95% confidence interval 0.25 to 8.15; two studies, 116 children). Investigators reported no other adverse effects. Both studies reported attention deficit hyperactivity disorder (ADHD)‐related behaviour outcomes. We were unable to combine the results in a meta‐analysis because one study reported findings as a continuous outcome, and the other as a dichotomous outcome. No other secondary outcomes were reported. We excluded one study because it used a cointervention (carnosine), and five other studies because they did not provide a robust diagnosis of a specific learning disorder. We identified one ongoing study and found three studies awaiting classification. Authors' conclusions Evidence is insufficient to permit any conclusions about the effect of PUFAs on the learning abilities of children with specific learning disorders. Well‐designed RCTs with clearly defined populations of children with specific learning disorders who have been diagnosed by standardised diagnostic criteria are needed. Plain language summary Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders Review question We reviewed the evidence on the effects of polyunsaturated fatty acids (PUFAs), compared with placebo or no treatment, on reading, writing or mathematical abilities of children up to 18 years of age who have specific learning disorders. Background Children with specific learning disorders are those whose abilities in reading, spelling, writing and mathematics are considerably below what is expected for their age, and whose problems are not a result of lower intelligence, inadequate teaching or social deprivation. A child may have a single disorder, such as a reading disorder, or a combined disorder, such as a reading and mathematics disorder. Children may have other problems too, such as attention deficit hyperactivity disorder (ADHD), along with a specific learning disorder. Polyunsaturated fatty acids are known to be necessary for normal brain development and function. The best known PUFAs are the omega‐3 fatty acids, which include docosahexaenoic acid (commonly known as DHA), but the omega‐6 fatty acids are also well known. Polyunsaturated fatty acids must be obtained from foods or supplements, as the human body cannot make them from other types of fat. Because they are needed for normal brain growth and development, PUFAs might help children with specific learning disorders. Study characteristics The evidence is current to November 2015. We found two small studies involving 116 children that met our inclusion criteria. Both studies gave children a combination of omega‐3 and omega‐6 capsules as the intervention for three months. Most of these studies involved boys between 10 and 18 years of age ‐ one was conducted in a school setting, and the other at a specialised clinic. One of the studies was funded by the company that supplied the omega‐3 and omega‐6 supplements. Another study could not be included in this review because investigators added carnosine (an amino acid that is highly concentrated in the brain) to the PUFAs. Carnosine and PUFAs might have similar effects, so it would not be possible to separate the effects of the two ingredients. Review authors excluded five studies because it was not confirmed that a specific learning disorder was diagnosed in these children. Key results None of the included studies reported effects of PUFAs on reading, writing, spelling or mathematical abilities of children. Evidence of low quality (because studies included few participants and showed evidence of bias) suggests that using PUFAs did not increase the risk of minor disturbances to the digestive system. Included studies reported no other types of adverse effects. Both studies reported on ADHD‐related behaviour. However, the format of available data did not allow us to readily combine them or to reach any conclusions. Included studies reported no other secondary outcomes. Conclusion Evidence is not sufficient to support or refute the use of PUFAs in children with specific learning disorders.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Tan, ML; Ho, JJ; Teh, KH", "articleTypes": [], "doi": "10.1002/14651858.CD009398.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "331f42ce-18c9-43ef-be3c-f5eee68799e4", "pmid": "", "title": "Vitamin D for the treatment of inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Vitamin D possesses immunomodulatory properties and has been implicated in the pathogenesis and severity of inflammatory bowel disease (IBD). Animal studies and emerging epidemiological evidence have demonstrated an association between vitamin D deficiency and worse disease activity. However, the role of vitamin D for the treatment of IBD is unclear. Objectives To evaluate the benefits and harms of vitamin D supplementation as a treatment for IBD. Search methods We used standard, extensive Cochrane search methods. The latest search date was Jun 2023. Selection criteria We included randomised controlled trials (RCTs) in people of all ages with active or inactive IBD comparing any dose of vitamin D with another dose of vitamin D, another intervention, placebo, or no intervention. We defined doses as: vitamin D (all doses), any‐treatment‐dose vitamin D (greater than 400 IU/day), high‐treatment‐dose vitamin D (greater than 1000 IU/day), low‐treatment‐dose vitamin D (400 IU/day to 1000 IU/day), and supplemental‐dose vitamin D (less than 400 IU/day). Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. clinical response for people with active disease, 2. clinical relapse for people in remission, 3. quality of life, and 4. withdrawals due to adverse events. Our secondary outcomes were 5. disease activity at end of study, 6. normalisation of vitamin D levels at end of study, and 7. total serious adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We included 22 RCTs with 1874 participants. Study duration ranged from four to 52 weeks. Ten studies enroled people with Crohn's disease (CD), five enroled people with ulcerative colitis (UC), and seven enroled people with CD and people with UC. Seventeen studies included adults, three included children, and two included both. Four studies enroled people with active disease, six enroled people in remission, and 12 enroled both. We assessed each study for risk of bias across seven individual domains. Five studies were at low risk of bias across all seven domains. Ten studies were at unclear risk of bias in at least one domain but with no areas of high risk of bias. Seven studies were at high risk of bias for blinding of participants and assessors. Vitamin D (all doses) versus placebo or no treatment Thirteen studies compared vitamin D against placebo or no treatment. We could not draw any conclusions on clinical response for UC as the certainty of the evidence was very low (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.51 to 10.57; 1 study, 60 participants). There were no data on CD. There may be fewer clinical relapses for IBD when using vitamin D compared to placebo or no treatment (RR 0.57, 95% CI 0.34 to 0.96; 3 studies, 310 participants). The certainty of the evidence was low. We could not draw any conclusions on quality of life for IBD (standardised mean difference (SMD) −0.13, 95% CI −3.10 to 2.83 (the SMD value indicates a negligent decrease in quality of life, and the corresponding CIs indicate that the effect can range from a large decrease to a large increase in quality of life); 2 studies, 243 participants) or withdrawals due to adverse events for IBD (RR 1.97, 95% CI 0.18 to 21.27; 12 studies, 1251 participants; note 11 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 12). The certainty of the evidence was very low. High‐treatment‐dose vitamin D versus low‐treatment‐dose vitamin D Five studies compared high treatment vitamin D doses against low treatment vitamin D doses. There were no data on clinical response. There may be no difference in clinical relapse for CD (RR 0.48, 95% CI 0.23 to 1.01; 1 study, 34 participants). The certainty of the evidence was low. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 0.89, 95% CI 0.06 to 13.08; 3 studies, 104 participants; note 2 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 3). The data on quality of life and disease activity could not be meta‐analysed, were of very low certainty, and no conclusions could be drawn. Any‐treatment‐dose vitamin D versus supplemental‐dose vitamin D Four studies compared treatment doses of vitamin D against supplemental doses. There were no data on clinical response and relapse. There were no data on quality of life that could be meta‐analysed. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 3.09, 95% CI 0.13 to 73.17; 4 studies, 233 participants; note 3 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 4). Authors' conclusions There may be fewer clinical relapses when comparing vitamin D with placebo, but we cannot draw any conclusions on differences in clinical response, quality of life, or withdrawals, due to very low‐certainty evidence. When comparing high and low doses of vitamin D, there were no data for clinical response, but there may be no difference in relapse for CD. We cannot draw conclusions on the other outcomes due to very low certainty evidence. Finally, comparing vitamin D (all doses) to supplemental‐dose vitamin D, there were no data on clinical relapse or response, and we could not draw conclusions on other outcomes due to very low certainty evidence or missing data. It is difficult to make any clear recommendations for future research on the basis of the findings of this review. Future studies must be clear on the baseline populations, the purpose of vitamin D treatment, and, therefore, study an appropriate dosing strategy. Stakeholders in the field may wish to reach consensus on such issues prior to new studies. Plain language summary Vitamin D for the treatment of inflammatory bowel disease Key messages The data we presently have for the use of vitamin D for the treatment of inflammatory bowel disease are of very low quality, and we do not know whether it works or if it is safe. What is inflammatory bowel disease? Inflammatory bowel disease is a life‐long disease that affects the gut. Its two main types are ulcerative colitis and Crohn's disease. Ulcerative colitis only affects the large intestine. Crohn's disease can affect any part of the gut, from mouth to bottom. Common symptoms include bloody poo, diarrhoea, stomach ache, fever, weight loss, and fatigue. We do not know exactly what causes it, but it is probably a mix of genes, problems with the immune system, bacteria in the gut, and something in the environment. There is no known cure, but the symptoms are usually managed with medicines, such as steroids and immune system medications, and sometimes surgery. Most people with inflammatory bowel disease have times when they have symptoms (called active disease) and other times when their symptoms are under control (called remission). When symptoms reappear after being in remission, it is called relapse. What did we want to find out? We wanted to find out if vitamin D works for the treatment of inflammatory bowel disease, and whether it is safe to use. Specifically, we looked at improvement of symptoms for people with active disease; relapse for people in remission; quality of life; and withdrawals from the trial because of side effects. What did we do? We searched for randomised controlled trials (studies where people are assigned to one of two or more treatment groups using a random method) comparing vitamin D with any other treatment, standard treatment, or different doses of vitamin D. What did we find? We found 22 trials with 1874 participants with inflammatory bowel disease. The studies lasted from four to 52 weeks. Ten studies were on Crohn's disease, five on ulcerative colitis, and seven on participants who had either of these. Seventeen studies were on adults, three on children, and two on both. Four included people with active disease, six in remission, and 12 on a mix of both. The studies included doses of vitamin D used to treat deficiency and doses given as supplements. Thirteen studies compared vitamin D (all doses) against placebo (dummy treatment) or no other treatment. There was low‐quality evidence that there may be fewer clinical relapses when using vitamin D compared to placebo or no treatment. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Five studies compared high‐treatment‐doses to low‐treatment‐doses of vitamin D. There were no data on improvement of symptoms. There was low‐quality evidence that there may be no difference on relapse in Crohn's disease, but there were no data on ulcerative colitis. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Four studies compared treatment doses to supplement doses of vitamin D. There were no data on improvement of symptoms, relapses, or quality of life changes. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. What are the limitations of the evidence? The evidence is mostly of very low and low quality. This is because of problems with the way the studies were carried out, and problems with how the results were reported. Additionally, the individual studies did not make the same measurements, meaning that we did not have enough numbers of people to strengthen the results of the measures we looked for. How up‐to‐date is this review? This review is up‐to‐date to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wallace, C; Gordon, M; Sinopoulou, V; Limketkai, BN", "articleTypes": [], "doi": "10.1002/14651858.CD011806.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "332e5353-0401-41e3-9197-f2e8175f9b11", "pmid": "", "title": "A Randomized Double-blinded Placebo-controlled Outpatient Clinical Trial in High Risk Population Confirmed COVID-19 Patients Using Ivermectin and Doxycycline to Prevent COVID-19 Illness-related Hospitalization (COVIVER-OUT PLUS)", "imported": false, "abstract": "The purpose of this Clinical trial is to explore the therapeutic benefits of Ivermectin and Doxycycline in different combinations in high risk patients diagnosed with COVID-19.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.251Z" }, { "id": "333a11d4-281a-4ca1-a749-b8d6487a7a7c", "pmid": "", "title": "Statins for asthma", "imported": false, "abstract": "Abstract - Background Asthma is a common chronic respiratory disease. People with asthma have inflammation of their airways that causes recurrent episodes of wheezing, breathlessness and chest tightness, with or without a cough. Statins possess multiple therapeutic effects, including lowering lipid levels in the blood. Statins are reported to have a potential role as an adjunct treatment in asthma. However, comprehensive evidence of the benefits and harms of using statins is required to facilitate decision making. Objectives To assess the benefits and harms of statins as an adjunct therapy for asthma in adults and children. Search methods We searched for studies in the Cochrane Airways Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid SP and Embase Ovid SP, from their inception dates We handsearched the proceedings of major respiratory conferences. We also searched clinical trials registries for completed, ongoing and unpublished studies, and scanned the reference lists of included studies and relevant reviews to identify additional studies. The search is current to 7 February 2020. Selection criteria We included randomised controlled trials (RCTs) with a parallel‐group design that assessed statins for at least 12 weeks' duration. We considered all participants with a clinical diagnosis of asthma to be eligible, regardless of age, sex, disease severity and previous or current treatment. We planned to include studies reported as full text, those published as abstract only, and unpublished data. Data collection and analysis Two review authors independently screened and selected the studies, extracted outcome data and intervention characteristics from included studies, and assessed risk of bias according to standard Cochrane methodological procedures. We resolved any disagreement through discussion. Main results We found only one trial involving a total of 60 people living with asthma. The trial compared the effect of atorvastatin with a placebo (dummy treatment containing lactose) in treating people with chronic asthma. The trial did not report data for the primary outcomes or adverse events. There was uncertainty about the relative effect on forced expiratory volume in one second (FEV 1 ) and peak expiratory flow (PEF) in the atorvastatin group compared with the placebo group. The study did not report serious adverse effects for the interventions. The included study had internal discrepancies in its reported data. Authors' conclusions The evidence was of very low certainty, so we are unable to draw conclusions about the effectiveness and safety of statins to treat asthma. High‐quality RCTs are needed to assess the effect of statins on people with asthma. Well‐designed multicentre trials with larger samples and longer duration of treatment are required, which assess outcomes such as adverse events, hospital utilisation and costs, to provide better quality evidence. Future studies that include subgroups of obese people with asthma are also required. Plain language summary Statins for asthma Review question We reviewed the evidence about the effect of statins in people with asthma. Background Asthma is a common chronic (persistent) airway disease. Asthma is caused by inflammation in the lungs and bronchoconstriction (tightening of the small tubes in the lungs in response to a trigger such as pollen or cold air). Inflammation and bronchoconstriction cause airflow obstruction (narrowing and blockage). People with asthma experience recurrent attacks of wheezing, difficultly in breathing, and chest tightness, with or without a cough. Statins are anti‐inflammatory medicines. We wanted to review the evidence for statins because the theory is that their anti‐inflammatory properties will help people with asthma. We wanted to discover whether using statin therapy was better or worse than other alternatives, such as usual care alone or different types of statins (atorvastatin, simvastatin). Study characteristics We found only one trial that assessed atorvastatin (a type of statin drug) and placebo (dummy treatment) in 60 adults with asthma over a period of 12 weeks. These people had chronic asthma (persistent airway disease) when they started treatment. Key results We found that the statin (atorvastatin) did not result in any clear improvement in lung function in people with asthma, but may be better in asthma control than the dummy drug. However, because there is only one trial, we cannot draw firm conclusions. The trial did not report on adverse effects or severe adverse effects (harms). We are uncertain whether statins may have beneficial effects on relieving asthma or whether they may increase the risk of adverse events or non‐serious adverse events. Quality of the evidence The evidence was of very low certainty, so we cannot draw firm conclusions about whether statins are helpful and safe to be used by people with asthma. The evidence is current to 7 February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Naing, C, Ni, H", "articleTypes": [], "doi": "10.1002/14651858.CD013268.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.094Z" }, { "id": "3352d799-6332-4c1c-a920-a10f258fd0db", "pmid": "", "title": "Effect of adrenergic agonist oral decongestants on blood pressure", "imported": false, "abstract": "Abstract - Background Adrenergic agonist oral decongestants are commonly taken daily over long periods of time to relieve sinus and nasal congestion. The mechanism of action of decongestants potentially increases blood pressure, and these effects may be acute or chronic. However, no systematic reviews to date have comprehensively assessed the chronic blood pressure effects of adrenergic agonist oral decongestants as a drug class, despite their widespread non‐prescription availability. Objectives Primary objective To assess the effects of adrenergic agonist oral decongestants on systolic and diastolic blood pressure compared to placebo. Secondary objective To assess the effects of adrenergic agonist oral decongestants on heart rate and withdrawals due to adverse effects. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCT) up to July 2024: Cochrane Hypertension Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Register of Studies, Ovid MEDLINE, Ovid Embase, and ClinicalTrials.gov. There were no language, publication year, or publication status restrictions. Selection criteria We included RCTs of at least seven days' duration with parallel groups (intervention and placebo) comparing adrenergic agonist oral decongestants versus placebo on blood pressure in people aged over six years. Data collection and analysis Two review authors (JJC and MC) independently assessed the trials for inclusion, extracted the data, and assessed the risk of bias from the included trials. In cases where there were disagreements, the third review author (JMW) adjudicated. For any missing or unclear information in the studies, we contacted the study author to request the missing information or seek clarification. The primary outcomes were systolic blood pressure and diastolic blood pressure. Secondary outcomes were heart rate and withdrawal due to adverse effects. We used a fixed‐effect model to combine the effect sizes from all studies. We assessed the certainty of the evidence using GRADE. Main results Five RCTs randomizing 882 participants met the inclusion criteria. The shortest study duration was one week, and the longest study duration was 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The largest study included 568 people, and the smallest study included 18 people. The mean age of participants was 20.0 years, with 326 males and 591 females. The studies were conducted in the USA and Europe; most were set in the USA. Pharmaceutical companies funded three of the five included studies. The findings are relevant to all people using adrenergic agonist oral decongestants for seven days or longer regardless of comorbidities or pre‐existing conditions. The adrenergic agonist oral decongestants included were ephedrine (one RCT), pseudoephedrine (one RCT), and phenylpropanolamine (three RCTs). Compared to placebo, adrenergic agonist oral decongestants may have little to no effect on systolic blood pressure , but the evidence is very uncertain (mean difference [MD] 0.91 mmHg, 95% confidence interval [CI] −0.57 to 2.38; 4 RCTs, 784 participants; I 2 = 54%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on diastolic blood pressure (MD 0.44 mmHg, 95% CI −0.59 to 1.48; 5 RCTs, 882 participants; I 2 = 30%; low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on heart rate, but the evidence is very uncertain (MD 1.92 beats per minute, 95% CI −0.62 to 4.47; 2 RCTs, 190 participants; I 2 = 79%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on the number of withdrawals due to adverse effects (risk ratio [RR] 1.20, 95% CI 0.37 to 3.88; 4 RCTs, 806 participants; low‐certainty evidence; note 1 study reported withdrawals due to adverse effects but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 3 studies rather than 4). Four studies were at overall high risk of bias, and one study was at overall low risk of bias. Authors' conclusions In this systematic review, chronic daily intake of adrenergic agonist oral decongestants had little to no effect on blood pressure, heart rate, and withdrawals due to adverse effects. People making decisions about using these medicines should consider the very low certainty of evidence and the theoretical risk of increased blood pressure. Independent trials free from biases that are designed to answer this question are required. The evidence was limited due to the small number of studies, and the blood pressure and heart rate not being measured at the optimal time after drug ingestion. Plain language summary What are the effects of oral decongestants on blood pressure? Key messages – We found no evidence that taking oral decongestants (medicine taken by mouth to relieve a stuffy nose) daily for a week or more changes blood pressure or heart rate or causes people to stop taking them due to unwanted effects. – There were only a few studies, and they were not well designed. More well‐conducted studies are needed. – Given that oral decongestants are sometimes taken daily for weeks or months, and have the potential to increase blood pressure, people should consider this potential risk alongside the limited evidence from this review when deciding whether to use these medicines. What are oral decongestants? Oral decongestants are medications taken by mouth to relieve nasal congestion (stuffy or blocked nose), often caused by colds, allergies, or sinus infections (small, empty spaces behind the cheekbones and forehead that are connected to the nose). They typically include medicines called pseudoephedrine or phenylephrine. How do oral decongestants work? These medicines shrink swollen blood vessels in the nasal passages. This reduces swelling and allows air to flow more freely, helping you breathe easier. What is hypertension? Hypertension (high blood pressure) is when resting blood pressure is consistently above 140/90 mmHg. It can lead to unwanted effects such as stroke (where the blood supply to parts of the brain is reduced or stopped) and heart attack (where the blood supply to the heart is reduced or stopped). Lowering blood pressure is the easiest way to reduce these diseases. How is hypertension treated? Treating hypertension involves lifestyle measures and taking blood pressure‐lowering medicines. Here, we focused on the effects of daily intake of oral decongestants. While these medicines help with nasal congestion, they may also increase blood pressure. What do we want to find out? We wanted to find out whether long‐term use of oral decongestants (for seven days or longer) increases blood pressure and has any unwanted effects. We also evaluated their effectiveness in relieving nasal congestion. This provides essential insights into their benefits and risks to guide informed use. What did we do? We searched for studies that compared the blood pressure effects of oral decongestants with placebo. A placebo is a substance or treatment with no active ingredients that is used in medical research to compare against the effects of real medications. We then compared and summarized the results, and rated our confidence in the evidence depending on the study design and methods. What did we find? We found five studies involving 882 children and adults (326 males and 591 females). The shortest study lasted one week, with the longest study lasting 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The size of the studies ranged from 18 to 568 people, and most were done in the USA. Pharmaceutical companies funded three studies. We found no clear evidence that taking oral decongestants daily changes blood pressure or heart rate, or causes people to stop taking them due to unwanted effects. What are the limitations of the evidence? There was a limited number of studies, and they were not well designed. None of the studies were primarily designed to assess the long‐term effects of oral decongestants on blood pressure. Trials designed to answer this question are needed. How up to date is the evidence? The evidence is up to date to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Chan, JJ, Chan, M, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007895.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.115Z" }, { "id": "3355c6af-8b7b-4fa5-bfc3-5d7c2a5e3c09", "pmid": "", "title": "Adhesives for fixed orthodontic bands", "imported": false, "abstract": "Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. It has been shown that the quality of treatment result obtained with fixed appliances is much better than with removable appliances. Fixed appliances are, therefore, favoured by most orthodontists for treatment. The success of a fixed orthodontic appliance depends on the metal attachments (brackets and bands) being attached securely to the teeth so that they do not become loose during treatment. Brackets are usually attached to the front and side teeth, whereas bands (metal rings that go round the teeth) are more commonly used on the back teeth (molars). A number of adhesives are available to attach bands to teeth and it is important to understand which group of adhesives bond most reliably, as well as reducing or preventing dental decay during the treatment period. Objectives To evaluate the effectiveness of the adhesives used to attach bands to teeth during fixed appliance treatment, in terms of:
 (1) how often the bands come off during treatment; and
 (2) whether they protect the banded teeth against decay during fixed appliance treatment. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (searched 2 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 2 June 2016), MEDLINE Ovid (1946 to 2 June 2016) and EMBASE Ovid (1980 to 2 June 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised and controlled clinical trials (RCTs and CCTs) (including split‐mouth studies) of adhesives used to attach orthodontic bands to molar teeth were selected. Patients with full arch fixed orthodontic appliance(s) who had bands attached to molars were included. Data collection and analysis All review authors were involved in study selection, validity assessment and data extraction without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Five RCTs and three CCTs were identified as meeting the review's inclusion criteria. All the included trials were of split‐mouth design. Four trials compared chemically cured zinc phosphate and chemically cured glass ionomer; three trials compared chemically cured glass ionomer cement with light cured compomer; one trial compared chemically cured glass ionomer with a chemically cured glass phosphonate. Data analysis was often inappropriate within the studies meeting the inclusion criteria. Authors' conclusions There is insufficient high quality evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth. Further RCTs are required. Plain language summary Adhesives for fixed orthodontic bands There is insufficient evidence to determine the most effective adhesive for attaching orthodontic bands to molar teeth in patients with full arch fixed orthodontic appliances.
 Orthodontic treatment involves using fixed or removable appliances (braces) on teeth to correct their position. It has been shown that the quality of treatment result obtained with fixed dental appliances is much better than with removable appliances. The success of a fixed dental appliance depends on the metal attachments (brackets and bands) being securely attached to the teeth so that they do not become loose during treatment. Brackets are usually attached to teeth other than molars, where bands (metal rings that go round the teeth) are more commonly used. There is insufficient evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Millett, DT; Glenny, AM; Mattick, RCR; Hickman, J; Mandall, NA", "articleTypes": [], "doi": "10.1002/14651858.CD004485.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "33618842-cd3c-44f2-8b32-c6f31a01fcb9", "pmid": "", "title": "Aspirin with or without an antiemetic for acute migraine headaches in adults", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010). Migraine is a common, disabling condition and a burden for the individual, health services and society. Many sufferers choose not to, or are unable to, seek professional help and rely on over‐the‐counter analgesics. Co‐therapy with an antiemetic should help to reduce nausea and vomiting commonly associated with migraine headaches. Objectives To determine the efficacy and tolerability of aspirin, alone or in combination with an antiemetic, compared to placebo and other active interventions in the treatment of acute migraine headaches in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, ClinicalTrials.gov, and reference lists for studies through 10 March 2010 for the original review and to 31 January 2013 for the update. Selection criteria We included randomised, double‐blind, placebo‐controlled or active‐controlled studies, or both, using aspirin to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and numbers needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment. Main results No new studies were found for this update. Thirteen studies (4222 participants) compared aspirin 900 mg or 1000 mg, alone or in combination with metoclopramide 10 mg, with placebo or other active comparators, mainly sumatriptan 50 mg or 100 mg. For all efficacy outcomes, all active treatments were superior to placebo, with NNTs of 8.1, 4.9 and 6.6 for 2‐hour pain‐free, 2‐hour headache relief, and 24‐hour headache relief with aspirin alone versus placebo, and 8.8, 3.3 and 6.2 with aspirin plus metoclopramide versus placebo. Sumatriptan 50 mg did not differ from aspirin alone for 2‐hour pain‐free and headache relief, while sumatriptan 100 mg was better than the combination of aspirin plus metoclopramide for 2‐hour pain‐free, but not headache relief; there were no data for 24‐hour headache relief. Adverse events were mostly mild and transient, occurring slightly more often with aspirin than placebo. Additional metoclopramide significantly reduced nausea (P < 0.00006) and vomiting (P = 0.002) compared with aspirin alone. Authors' conclusions We found no new studies since the last version of this review. Aspirin 1000 mg is an effective treatment for acute migraine headaches, similar to sumatriptan 50 mg or 100 mg. Addition of metoclopramide 10 mg improves relief of nausea and vomiting. Adverse events were mainly mild and transient, and were slightly more common with aspirin than placebo, but less common than with sumatriptan 100 mg. Plain language summary Aspirin with or without an antiemetic for acute migraine headaches in adults This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010); no new studies were found. A single oral dose of 1000 mg of aspirin reduced pain from moderate or severe to none by two hours in approximately 1 in 4 people (24%) taking aspirin, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (52%) taking aspirin compared with approximately 1 in 3 (32%) taking placebo. Of those who experienced effective headache relief at two hours, more had that relief sustained over 24 hours with aspirin than with placebo. Addition of 10 mg of the antiemetic metoclopramide substantially increased relief of nausea and vomiting compared with aspirin alone, but made little difference to pain. Oral sumatriptan 100 mg was better than aspirin plus metoclopramide for pain‐free response at two hours, but otherwise there were no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short‐term use were mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Kirthi, V, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008041.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.775Z" }, { "id": "336e0b8c-5207-4cd5-a730-c6b4acd645fd", "pmid": "", "title": "Omega‐3 fatty acids supplementation for autism spectrum disorders (ASD)", "imported": false, "abstract": "Abstract - Background It has been suggested that impairments associated with autism spectrum disorders (ASD) may be partially explained by deficits of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. Objectives To review the efficacy of omega‐3 fatty acids for improving core features of ASD (for example, social interaction, communication, and stereotypies) and associated symptoms. Search methods We searched the following databases on 2 June 2010: CENTRAL (2010, Issue 2), MEDLINE (1950 to May Week 3 2010), EMBASE (1980 to 2010 Week 21), PsycINFO (1806 to current), BIOSIS (1985 to current), CINAHL (1982 to current), Science Citation Index (1970 to current), Social Science Citation Index (1970 to current), metaRegister of Controlled Trials (20 November 2008) and ClinicalTrials.gov (10 December 2010). Dissertation Abstracts International was searched on 10 December 2008, but was no longer available to the authors or editorial base in 2010. Selection criteria All randomised controlled trials of omega‐3 fatty acids supplementation compared to placebo in individuals with ASD. Data collection and analysis Three authors independently selected studies, assessed them for risk of bias and extracted relevant data. We conducted meta‐analysis of the included studies for three primary outcomes (social interaction, communication, and stereotypy) and one secondary outcome (hyperactivity). Main results We included two trials with a total of 37 children diagnosed with ASD who were randomised into groups that received either omega‐3 fatty acids supplementation or a placebo. We excluded six trials because they were either non‐randomised controlled trials, did not contain a control group, or the control group did not receive a placebo. Overall, there was no evidence that omega‐3 supplements had an effect on social interaction (mean difference (MD) 0.82, 95% confidence interval (CI) ‐2.84 to 4.48, I 2 = 0%), communication (MD 0.62, 95% CI ‐0.89 to 2.14, I 2 = 0%), stereotypy (MD 0.77, 95% CI ‐0.69 to 2.22, I 2 = 8%), or hyperactivity (MD 3.46, 95% CI ‐0.79 to 7.70, I 2 = 0%). Authors' conclusions To date there is no high quality evidence that omega‐3 fatty acids supplementation is effective for improving core and associated symptoms of ASD. Given the paucity of rigorous studies in this area, there is a need for large well‐conducted randomised controlled trials that examine both high and low functioning individuals with ASD, and that have longer follow‐up periods. Plain language summary Omega‐3 fatty acids for autism spectrum disorders (ASD) It has been suggested that difficulties associated with ASD may be explained in part by lack of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. The purpose of this review was to assess the evidence for the effectiveness of omega‐3 supplementation for core features of ASD and associated symptoms. We found only two small randomised controlled trials that evaluated omega‐3 fatty acids for ASD. There is insufficient evidence that omega‐3 fatty acids supplementation is an effective treatment for ASD. However, high quality large randomised controlled trials are needed before definite recommendations about this treatment can be made.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "James, S, Montgomery, P, Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD007992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.078Z" }, { "id": "3384c342-2ecd-45e9-87ec-84b266c0b3bc", "pmid": "", "title": "Colchicine for pericarditis", "imported": false, "abstract": "Abstract - Background Pericarditis is the inflammation of the pericardium, the membranous sac surrounding the heart. Recurrent pericarditis is the most common complication of acute pericarditis, causing severe and disabling chest pains. Recurrent pericarditis affects one in three patients with acute pericarditis within the first 18 months. Colchicine has been suggested to be beneficial in preventing recurrent pericarditis. Objectives To review all randomised controlled trials (RCTs) that assess the effects of colchicine alone or combined, compared to any other intervention to prevent further recurrences of pericarditis, in people with acute or recurrent pericarditis. Search methods We searched the following bibliographic databases on 4 August 2014: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2014 on The Cochrane Library ), MEDLINE (OVID, 1946 to July week 4, 2014), EMBASE (OVID, 1947 to 2014 week 31), and the Conference Proceedings Citation Index ‐ Science on Web of Science (Thomson Reuters) 1990 to 1 Aug 2014. We did not apply any language or time restrictions. Selection criteria RCTs of people with acute or recurrent pericarditis who are receiving colchicine compared to any other treatment, in order to prevent recurrences. Data collection and analysis Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The first primary outcome was the time to recurrence, measured by calculating the hazard ratios (HRs). The second primary outcome was the adverse effects of colchicine. Secondary outcomes were the rate of recurrences at 6, 12 and 18 months, and symptom relief. Main results We included four RCTs, involving 564 participants in this review. We compared the effects of colchicine in addition to a non‐steroidal anti‐inflammatory drug (NSAID) such as ibuprofen, aspirin or indomethacin to the effects of the NSAID alone. Two comparable trials studied the effects of colchicine in 204 participants with recurrent pericarditis and two trials studied 360 people with acute pericarditis. All trials had a moderate quality for the primary outcomes. We identified two on‐going trials; one of these trials examines acute pericarditis and the other assesses recurrent pericarditis. There was moderate quality evidence that colchicine reduces episodes of pericarditis in people with recurrent pericarditis over 18 months follow‐up (HR 0.37; 95% confidence interval (CI) 0.24 to 0.58). It is expected that at 18 months, the number needed to treat (NNT) is 4. In people with acute pericarditis, there was moderate quality evidence that colchicine reduces recurrence (HR 0.40; 95% CI 0.27 to 0.61) at 18 months follow‐up. Colchicine led to a greater chance of symptom relief at 72 hours (risk ratio (RR) 1.4; 95% CI 1.26 to 1.56; low quality evidence). Adverse effects were mainly gastrointestinal and included abdominal pain and diarrhoea. The pooled RR for adverse events was 1.26 (95% CI 0.75 to 2.12). While the number of people experiencing adverse effects was higher in the colchicine than the control groups (9% versus 7%), the quality of evidence was low owing to imprecision, and there was no statistically significant difference between the treatment groups (P = 0.42). There was moderate quality evidence that treatment with colchicine led to more people stopping treatment due to adverse events (RR 1.87; 95% CI 1.02 to 3.41). Authors' conclusions Colchicine, as adjunctive therapy to NSAIDs, is effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis. However, evidence is based on a limited number of small trials. Patients with multiple resistant recurrences were not represented in any published or on‐going trials, and it is these patients that are in the most need for treatment. Plain language summary Systematic review of randomised controlled trials about the efficacy and safety of colchicine in people with pericarditis Pericarditis is the inflammation and swelling of the tissue covering the outer layer of the heart. Pericarditis causes severe and disabling chest pain and fever, however the main issue is the repeated recurrence of pericarditis attacks. Colchicine is an ancient medication that has been used in the treatment of other inflammatory diseases such as gout. We wanted to discover whether colchicine alone or added to other medications is better or worse than alternative therapies in preventing pericarditis. We have reviewed all randomised controlled trials about the effect of colchicine in preventing recurrence of pericarditis in people with pericarditis. We found four trials involving 564 participants, who were followed up for at least 18 months. Two studies examined the use of colchicine in people with recurrent pericarditis and two examined the use of colchicine in people with a first episode of pericarditis. The evidence is current to August 2014. The trials showed that people taking colchicine have a lower risk of developing pericarditis recurrence and a higher proportion experience symptom relief. It is expected that at 18 months, one pericarditis recurrence can be avoided for every four people receiving colchicine with NSAIDs rather than NSAIDs alone. Adverse effects were reported in all trials and affected 15 people (9%) of the 162 taking colchicine. Adverse effects included abdominal pain, nausea and vomiting. Two studies were designed so that participants knew the type of intervention they were taking and people in the comparison group had no dummy pill. The results of these studies could exaggerate the effects of the drug. The evidence suggests beneficial effects of colchicine in preventing recurrence of pericarditis, however this is based on a limited number of small trials. More trials are currently being done and we await their results to see if the benefits of colchicine can be further confirmed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Alabed, S; Cabello, JB; Irving, GJ; Qintar, M; Burls, A", "articleTypes": [], "doi": "10.1002/14651858.CD010652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "338e76ac-a413-4cb5-8cf3-c4cdbb9c89b6", "pmid": "", "title": "Vitamin C for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Vitamin C (ascorbic acid) for preventing and treating the common cold has been a subject of controversy for 70 years. Objectives To find out whether vitamin C reduces the incidence, the duration or severity of the common cold when used either as a continuous regular supplementation every day or as a therapy at the onset of cold symptoms. Search methods We searched CENTRAL 2012, Issue 11, MEDLINE (1966 to November week 3, 2012), EMBASE (1990 to November 2012), CINAHL (January 2010 to November 2012), LILACS (January 2010 to November 2012) and Web of Science (January 2010 to November 2012). We also searched the U.S. National Institutes of Health trials register and WHO ICTRP on 29 November 2012. Selection criteria We excluded trials which used less than 0.2 g per day of vitamin C and trials without a placebo comparison. We restricted our review to placebo‐controlled trials. Data collection and analysis Two review authors independently extracted data. We assessed 'incidence' of colds during regular supplementation as the proportion of participants experiencing one or more colds during the study period. 'Duration' was the mean number of days of illness of cold episodes. Main results Twenty‐nine trial comparisons involving 11,306 participants contributed to the meta‐analysis on the risk ratio (RR) of developing a cold whilst taking vitamin C regularly over the study period. In the general community trials involving 10,708 participants, the pooled RR was 0.97 (95% confidence interval (CI) 0.94 to 1.00). Five trials involving a total of 598 marathon runners, skiers and soldiers on subarctic exercises yielded a pooled RR of 0.48 (95% CI 0.35 to 0.64). Thirty‐one comparisons examined the effect of regular vitamin C on common cold duration (9745 episodes). In adults the duration of colds was reduced by 8% (3% to 12%) and in children by 14% (7% to 21%). In children, 1 to 2 g/day vitamin C shortened colds by 18%. The severity of colds was also reduced by regular vitamin C administration. Seven comparisons examined the effect of therapeutic vitamin C (3249 episodes). No consistent effect of vitamin C was seen on the duration or severity of colds in the therapeutic trials. The majority of included trials were randomised, double‐blind trials. The exclusion of trials that were either not randomised or not double‐blind had no effect on the conclusions. Authors' conclusions The failure of vitamin C supplementation to reduce the incidence of colds in the general population indicates that routine vitamin C supplementation is not justified, yet vitamin C may be useful for people exposed to brief periods of severe physical exercise. Regular supplementation trials have shown that vitamin C reduces the duration of colds, but this was not replicated in the few therapeutic trials that have been carried out. Nevertheless, given the consistent effect of vitamin C on the duration and severity of colds in the regular supplementation studies, and the low cost and safety, it may be worthwhile for common cold patients to test on an individual basis whether therapeutic vitamin C is beneficial for them. Further therapeutic RCTs are warranted. Plain language summary Vitamin C for preventing and treating the common cold The common cold is a major cause of visits to a doctor in high‐income countries and of absenteeism from work and school. There are over 200 viruses which can cause the common cold symptoms including runny nose, congestion, sneezing, sore throat, cough, and sometimes headache, fever and red eyes. Symptoms vary from person to person and cold to cold. Since the common cold is usually caused by one of the respiratory viruses, antibiotics are useless and therefore other potential treatment options are of substantial public health interest. Vitamin C has been proposed for treating respiratory infections since it was isolated in the 1930s. It became particularly popular in the 1970s when Nobel laureate Linus Pauling concluded from earlier placebo‐controlled trials that vitamin C would prevent and alleviate the common cold. Over two dozen new trials were undertaken thereafter. Vitamin C has been widely sold and used as a preventive and therapeutic agent. This review is restricted to placebo‐controlled trials testing 0.2 g/day or more of vitamin C. Regular ingestion of vitamin C had no effect on common cold incidence in the ordinary population, based on 29 trial comparisons involving 11,306 participants. However, regular supplementation had a modest but consistent effect in reducing the duration of common cold symptoms, which is based on 31 study comparisons with 9745 common cold episodes. In five trials with 598 participants exposed to short periods of extreme physical stress (including marathon runners and skiers) vitamin C halved the common cold risk. The published trials have not reported adverse effects of vitamin C. Trials of high doses of vitamin C administered therapeutically, starting after the onset of symptoms, showed no consistent effect on the duration or severity of common cold symptoms. However, only a few therapeutic trials have been carried out and none have examined children, although the effect of prophylactic vitamin C has been greater in children. One large trial with adults reported benefit from an 8 g therapeutic dose at the onset of symptoms, and two therapeutic trials using five‐day supplementation reported benefit. More trials are necessary to settle the possible role of therapeutic vitamin C, meaning administration immediately after the onset of symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H; Chalker, E", "articleTypes": [], "doi": "10.1002/14651858.CD000980.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "33973610-9cfa-4aff-8f0f-eec58406d25a", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 2. Less commonly‐used drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of mainly cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres (˜ 8200 feet). Acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude ascent. In this second review, in a series of three about preventive strategies for HAI, we assessed the effectiveness of five of the less commonly used classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of five of the less commonly used pharmacological interventions for preventing acute HAI in participants who are at risk of developing high altitude illness in any setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in May 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text search terms. We scanned the reference lists and citations of included trials and any relevant systematic reviews that we identified for further references to additional trials. Selection criteria We included randomized controlled trials conducted in any setting where one of five classes of drugs was employed to prevent acute HAI: selective 5‐hydroxytryptamine(1) receptor agonists; N‐methyl‐D‐aspartate (NMDA) antagonist; endothelin‐1 antagonist; anticonvulsant drugs; and spironolactone. We included trials involving participants who are at risk of developing high altitude illness (AMS or HACE, or HAPE, or both). We included participants with and without a history of high altitude illness. We applied no age or gender restrictions. We included trials where the relevant medication was administered before the beginning of ascent. We excluded trials using these drugs during ascent or after ascent. Data collection and analysis We used the standard methodological procedures employed by Cochrane. Main results We included eight studies (334 participants, 9 references) in this review. Twelve studies are ongoing and will be considered in future versions of this review as appropriate. We have been unable to obtain full‐text versions of a further 12 studies and have designated them as 'awaiting classification'. Four studies were at a low risk of bias for randomization; two at a low risk of bias for allocation concealment. Four studies were at a low risk of bias for blinding of participants and personnel. We considered three studies at a low risk of bias for blinding of outcome assessors. We considered most studies at a high risk of selective reporting bias. We report results for the following four main comparisons. Sumatriptan versus placebo (1 parallel study; 102 participants) Data on sumatriptan showed a reduction of the risk of AMS when compared with a placebo (risk ratio (RR) = 0.43, CI 95% 0.21 to 0.84; 1 study, 102 participants; low quality of evidence). The one included study did not report events of HAPE, HACE or adverse events related to administrations of sumatriptan. Magnesium citrate versus placebo (1 parallel study; 70 participants) The estimated RR for AMS, comparing magnesium citrate tablets versus placebo, was 1.09 (95% CI 0.55 to 2.13; 1 study; 70 participants; low quality of evidence). In addition, the estimated RR for loose stools was 3.25 (95% CI 1.17 to 8.99; 1 study; 70 participants; low quality of evidence). The one included study did not report events of HAPE or HACE. Spironolactone versus placebo (2 parallel studies; 205 participants) Pooled estimation of RR for AMS was not performed due to considerable heterogeneity between the included studies (I² = 72%). RR from individual studies was 0.40 (95% CI 0.12 to 1.31) and 1.44 (95% CI 0.79 to 2.01; very low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Acetazolamide versus spironolactone (1 parallel study; 232 participants) Data on acetazolamide compared with spironolactone showed a reduction of the risk of AMS with the administration of acetazolamide (RR = 0.36, 95% CI 0.18 to 0.70; 232 participants; low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Authors' conclusions This Cochrane Review is the second in a series of three providing relevant information to clinicians and other interested parties on how to prevent high altitude illness. The assessment of five of the less commonly used classes of drugs suggests that there is a scarcity of evidence related to these interventions. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Overall, the evidence is limited due to the low number of studies identified (for most of the comparison only one study was identified); limitations in the quality of the evidence (moderate to low); and the number of studies pending classification (24 studies awaiting classification or ongoing). We lack the large and methodologically sound studies required to establish or refute the efficacy and safety of most of the pharmacological agents evaluated in this review. Plain language summary Medicines less commonly used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and lung conditions that can occur during travel to altitudes above 2500 metres (˜ 8200 feet). HAI‐related conditions are generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but primarily affect the brain (drowsiness, confusion or unconsciousness) or the lungs (cough, breathlessness) in different individuals. We assessed five classes of medicines less commonly used to prevent the onset of this illness in this review. Study characteristics The evidence is current to May 2017. We included eight studies and 334 participants related to five different classes of medicines sometimes recommended for HAI prevention. These medicines included those that mimic the action of serotonin at selected sites (selective 5‐hydroxytryptamine(1) receptor agonists), medicines that regulate the action of calcium (N‐methyl‐D‐aspartate (NMDA) antagonist), medicines that promote dilation of the blood vessels (endothelin‐1 antagonist), medicines that prevent a neuron (nerve cell) from 'firing' (initiating an action) and convulsions from developing (anticonvulsant medicines), as well as medicines that regulate the body´s sodium and water levels (spironolactone). All studies were undertaken in high altitude mountain areas. The participants ranged between 16 and 65 years of age. Only one study included people at a high risk of this condition due to their history of HAI. Four trials provided the intervention between one to three days prior to the ascent (50%), and three trials less than 24 hours prior (37.5%). The participants in all these studies reached a final altitude of between 3500 and 5895 metres above sea level. Only one of the eight included studies did not provide clear information about the source of funding (12.5%). Twenty‐four additional studies were classified as ongoing (12), or awaiting classification (12; unable to obtain full texts). Key results The assessment of the less commonly used pharmacological interventions suggest that there is a scarcity of evidence related to these interventions. For most of the assessed comparisons, we only found evidence from a single study. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Quality of the evidence The quality of the evidence was rated from low to very low. Several studies had quality shortcomings such as only having small sample sizes and therefore generating uncertain results. For most of the medicines evaluated, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Gonzalez Garay, AG; Molano Franco, D; Nieto Estrada, VH; Martí‐Carvajal, AJ; Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD012983", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "33aca02b-399d-47ab-ae2f-97dd7b90234c", "pmid": "", "title": "Omega‐3 fatty acid supplementation for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Studies suggest that a diet rich in omega‐3 essential fatty acids may have beneficial anti‐inflammatory effects for chronic conditions such as cystic fibrosis. This is an updated version of a previously published review. Objectives To determine whether there is evidence that omega‐3 polyunsaturated fatty acid supplementation reduces morbidity and mortality and to identify any adverse events associated with supplementation. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of last search: 01 April 2020. We also searched online study registries and contacted authors. Date of last search: 12 February 2020. Selection criteria Randomised controlled trials in people with cystic fibrosis comparing omega‐3 fatty acid supplements with placebo. Data collection and analysis Two authors independently selected studies for inclusion, extracted data and assessed the risk of bias of the studies. The quality of the evidence was assessed using GRADE. Main results The searches identified 23 studies; five studies with 106 participants (children and adults) were included; duration of studies and interventions differed. Two studies compared omega‐3 fatty acids to olive oil for six weeks; one study compared omega‐3 fatty acids and omega‐6 fatty acids to control capsules (customised fatty acid blends) for three months; one study compared a liquid dietary supplement containing omega‐3 fatty acids to one without for six months; and one study compared omega‐3 fatty acids to a placebo for 12 months. Three studies had a low risk of bias for randomisation, but the risk was unclear in the remaining two studies; all studies had an unclear risk of bias for allocation concealment. Three of the studies adequately blinded participants; the risk of bias for selective reporting was high in one study and unclear for four studies. Two studies reported the number of respiratory exacerbations. At three months, one study (43 participants) reported no change in antibiotic usage. At 12 months the second study (15 participants) reported a reduction in the number of pulmonary exacerbations and cumulative antibiotic days in the supplement group compared to the previous year (no data for the control group); very low‐quality evidence means we are unsure whether supplementation has any effect on this outcome. With regards to adverse events, one six‐week study (12 participants) reported no difference in diarrhoea between omega‐3 or placebo capsules; the very low‐quality evidence means we are unsure if supplementation has any effect on this outcome. Additionally, one study reported an increase in steatorrhoea requiring participants to increase their daily dose of pancreatic enzymes, but three studies had already increased pancreatic enzyme dose at study begin so as to reduce the incidence of steatorrhoea. One study (43 participants) reported stomach pains at three months (treatment or control group not specified). One six‐week study (19 participants) reported three asthma exacerbations leading to exclusion of participants since corticosteroid treatment could affect affect essential fatty acid metabolism. Four studies reported lung function. One six‐week study (19 participants) reported an increase in forced expiratory volume in one second (FEV 1 ) (L) and forced vital capacity (FVC) (L), but the very low‐quality evidence means we are unsure if supplementation has any effect on lung function. The remaining studies did not report any difference in lung function at three months (unit of measurement not specified) or at six months and one year (FEV 1 % predicted and FVC % predicted). No deaths were reported in any of the five studies. Four studies reported clinical variables. One study reported an increase in Schwachman score and weight alongside a reduction in sputum volume with supplementation compared to placebo at three months (data not analysable). However, three studies reported no differences in either weight at six weeks, in body mass index (BMI) standard deviation (SD) score at six months (very low‐quality evidence) or BMI Z score at 12 months. Three studies reported biochemical markers of fatty acid status. One study showed an increase from baseline in both EPA and DHA content of serum phospholipids in the omega‐3 group compared to placebo at three months and also a significant decrease in n‐6/n‐3 ratio in the supplement group compared to placebo; since the quality of the evidence is very low we are not certain that these changes are due to supplementation. One six‐month cross‐over study showed a higher EPA content of the neutrophil membrane in the supplement group compared to the placebo group, but, no difference in DHA membrane concentration. Furthermore, the leukotriene B 4 to leukotriene B 5 ratio was lower at six months in the omega‐3 group compared to placebo. A one‐year study reported a greater increase in the essential fatty acid profile and a decrease in AA levels in the treatment arm compared to placebo. Authors' conclusions This review found that regular omega‐3 supplements may provide some limited benefits for people with cystic fibrosis with relatively few adverse effects: however, the quality of the evidence across all outcomes was very low. The current evidence is insufficient to draw firm conclusions or recommend routine use of these supplements in people with cystic fibrosis. A large, long‐term, multicentre, randomised controlled study is needed to determine any significant therapeutic effect and to assess the influence of disease severity, dosage and duration of treatment. Future researchers should note the need for additional pancreatic enzymes when providing omega‐3 supplementation or olive oil placebo capsules. More research is required to determine the exact dose of pancreatic enzyme required. Plain language summary The use of omega‐3 supplements in people with cystic fibrosis Review question We reviewed the evidence about the effect of giving omega‐3 supplements to people with cystic fibrosis. Background In people with cystic fibrosis recurring cycles of infection and inflammation are thought to worsen lung function. Studies suggest that omega‐3 fatty acids, such as those derived from fish oils, may work to counter the inflammation and may be of benefit in chronic inflammatory diseases including cystic fibrosis. This is an updated version of the review. Search date The evidence is current to: 01 April 2020. Study characteristics This review includes five small studies which compare omega‐3 supplements to a different supplement without omega‐3. In total there were 106 participants, including both children and adults. The studies lasted between six weeks and 12 months. Key results Due to the very low‐quality evidence, we are uncertain whether the following effects are due to supplementation or not. One 12‐month study reported a reduction in pulmonary exacerbations and antibiotic use when taking omega‐3 supplementation compared to placebo and one three‐month study reported no change in antibiotic use during the study period. Few side effects were reported in any of the studies. One six‐week study reported that lung function and clinical status improved when taking omega‐3 supplements. Sputum levels were also noted to be reduced in this six‐week study. Three studies reported no difference in lung function when taking omega‐3 supplementation compared to placebo. Two longer studies found that people taking omega‐3 supplements showed definite increases in levels of essential fatty acids in their white blood cell membranes and also in levels of phospholipids (molecules that provide structure and protection to cells) measured in blood samples. We are uncertain whether regular omega‐3 supplements benefit people with cystic fibrosis and whether they cause side effects, or not. We are not able to draw firm conclusions or recommend the routine use of these supplements in people with cystic fibrosis. Larger and longer studies are needed to assess the clinical benefit of omega‐3 supplementation and to determine the appropriate dosage. Quality of the evidence We judged the quality of the evidence to be very low due to very low participant numbers, low event rates, limited reporting and poor study design. There was no consistency with regards to the time points when results were reported or the measurements used for the same outcome in different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Watson, H, Stackhouse, C", "articleTypes": [], "doi": "10.1002/14651858.CD002201.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.772Z" }, { "id": "33cd591c-7e03-4211-80a3-19b4dbab8223", "pmid": "", "title": "Smectite for acute infectious diarrhoea in children", "imported": false, "abstract": "Abstract - Background As mortality secondary to acute infectious diarrhoea has decreased worldwide, the focus shifts to adjuvant therapies to lessen the burden of disease. Smectite, a medicinal clay, could offer a complementary intervention to reduce the duration of diarrhoea. Objectives To assess the effects of smectite for treating acute infectious diarrhoea in children. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Pubmed), Embase (Ovid), LILACS, reference lists from studies and previous reviews, and conference abstracts, up to 27 June 2017. Selection criteria Randomized and quasi‐randomized trials comparing smectite to a control group in children aged one month to 18 years old with acute infectious diarrhoea. Data collection and analysis Two review authors independently screened abstracts and the full texts for inclusion, extracted data, and assessed risk of bias. Our primary outcomes were duration of diarrhoea and clinical resolution at day 3. We summarized continuous outcomes using mean differences (MD) and dichotomous outcomes using risk ratios (RR), with 95% confidence intervals (CI). Where appropriate, we pooled data in meta‐analyses and assessed heterogeneity. We explored publication bias using a funnel plot. Main results Eighteen trials with 2616 children met our inclusion criteria. Studies were conducted in both ambulatory and in‐hospital settings, and in both high‐income and low‐ or middle‐income countries. Most studies included children with rotavirus infections, and half included breastfed children. Smectite may reduce the duration of diarrhoea by approximately a day (MD ‐24.38 hours, 95% CI ‐30.91 to ‐17.85; 14 studies; 2209 children; low‐certainty evidence); may increase clinical resolution at day 3 (risk ratio (RR) 2.10, 95% CI 1.30 to 3.39; 5 trials; 312 children; low‐certainty evidence); and may reduce stool output (MD ‐11.37, 95% CI ‐21.94 to ‐0.79; 3 studies; 634 children; low‐certainty evidence). We are uncertain whether smectite reduces stool frequency, measured as depositions per day (MD ‐1.33, 95% CI ‐2.28 to ‐0.38; 3 studies; 954 children; very low‐certainty evidence). There was no evidence of an effect on need for hospitalization (RR 0.93, 95% CI 0.75 to 1.15; 2 studies; 885 children; low‐certainty evidence) and need for intravenous rehydration (RR 0.77, 95% CI 0.54 to 1.11; 1 study; 81 children; moderate‐certainty evidence). The most frequently reported side effect was constipation, which did not differ between groups (RR 4.71, 95% CI 0.56 to 39.19; 2 studies; 128 children; low‐certainty evidence). No deaths or serious adverse effects were reported. Authors' conclusions Based on low‐certainty evidence, smectite used as an adjuvant to rehydration therapy may reduce the duration of diarrhoea in children with acute infectious diarrhoea by a day; may increase cure rate by day 3; and may reduce stool output, but has no effect on hospitalization rates or need for intravenous therapy. 2 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (27 Jun, 2017) were included Plain language summary Smectite for treating children with acute diarrhoea What is the aim of this review? The aim of this Cochrane Review was to find out if smectite (or diosmectite), a medicinal clay commonly prescribed to people who have diarrhoea in order to reduce their stool output, helps children with acute diarrhoea. We collected and analysed all relevant studies to answer this question and found 18 relevant studies. Key messages Giving smectite to children with acute diarrhoea may reduce its duration. However, more high‐quality studies are still needed, including studies that assess different causes of diarrhoea and the economic effects of this treatment. What was studied in the review? Acute diarrhoea is one of the most common diseases in children. It is usually caused by a viral infection. The main aim of treatment is to maintain a good level of hydration. This is achieved with oral rehydration solutions, and few children need to be hospitalized or require intravenous rehydration. Still, even with proper hydration, having loose stools is a burden for both parents and patients. Smectite may help by reducing inflammation in the gut; by acting as a barrier to reduce the penetration of toxins; or by increasing water absorption. What are the main results? We found 18 relevant studies with 2616 children that were conducted in both high‐income and low‐ or middle‐income countries. These studies compared children receiving smectite with children receiving routine care or a placebo (a pill or liquid that contains no medicine). Eight studies were funded by the manufacturer. Smectite may reduce the duration of diarrhoea by one day (low‐certainty evidence); may increase the number of children cured by day 3 (low‐certainty evidence); and may slightly reduce the quantity of loose stools (low‐certainty evidence). We are uncertain whether smectite has an effect on how many stools children have (very low‐certainty evidence). It may not have an effect on how many children need to be hospitalized (low‐certainty evidence), and probably does not have an effect on how many children need intravenous rehydration (moderate‐certainty evidence). We found no reports of serious adverse effects. Minor adverse effects included constipation, vomiting, and bad taste, but these did not differ between groups. How up‐to‐date is this review? We searched for studies published up to 27 June 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pérez‐Gaxiola, G; Cuello‐García, CA; Florez, ID; Pérez‐Pico, VM", "articleTypes": [], "doi": "10.1002/14651858.CD011526.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "33dec61d-b312-424a-96e9-b95fcae648b1", "pmid": "", "title": "Nicotine replacement therapy versus control for smoking cessation", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence. Objectives To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long‐term smoking cessation, compared to placebo or 'no NRT' interventions. Search methods We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017. Selection criteria Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow‐up of less than six months. We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews. Data collection and analysis Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow‐up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta‐analysis using a Mantel‐Haenszel fixed‐effect model. Main results We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non‐NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare. Authors' conclusions There is high‐quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non‐ischaemic chest pain and palpitations. Plain language summary Can nicotine replacement therapy (NRT) help people quit smoking? Background We reviewed the evidence about whether NRT helps people who want to quit smoking to stop smoking at six months or longer. NRT aims to reduce withdrawal symptoms associated with stopping smoking by replacing the nicotine from cigarettes. NRT is available as skin patches that deliver nicotine slowly, and chewing gum, nasal and oral sprays, inhalators, and lozenges/tablets, all of which deliver nicotine to the brain more quickly than skin patches, but less rapidly than from smoking cigarettes. Study characteristics This review includes 136 trials of NRT, with 64,640 people in the main analysis. All studies were conducted in people who wanted to quit smoking. Most studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. The evidence is current to July 2017. Trials lasted for at least six months. Key results We found evidence that all forms of NRT made it more likely that a person's attempt to quit smoking would succeed. The chances of stopping smoking were increased by 50% to 60%. NRT works with or without additional counselling, and does not need to be prescribed by a doctor. Side effects from using NRT are related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. There is no evidence that NRT increases the risk of heart attacks. Quality of evidence The overall quality of the evidence is high, meaning that further research is very unlikely to change our conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hartmann‐Boyce, J, Chepkin, SC, Ye, W, Bullen, C, Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD000146.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.060Z" }, { "id": "33e271e5-f746-4e96-b1b6-db30b183d435", "pmid": "", "title": "Topical silver diamine fluoride (SDF) for preventing and managing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is the world's most prevalent disease. Untreated caries can cause pain and negatively impact psychosocial health, functioning, and nutrition. It is important to identify cost‐effective, easy‐to‐use agents, which can prevent or arrest caries. This review evaluates silver diamine fluoride (SDF). Objectives To assess the effects of silver diamine fluoride for preventing and managing caries in primary and permanent teeth (coronal and root caries) compared to any other intervention including placebo or no treatment. Search methods We searched CENTRAL, MEDLINE, Embase, Cochrane Oral Health's Trial Register and two clinical trials registers in June 2023. Selection criteria We included randomised controlled trials (RCTs), with parallel‐group or split‐mouth design, in children and adults (with or without carious lesions) that compared SDF with placebo or no treatment; different frequencies, concentrations or duration of SDF; or any other intervention. Data collection and analysis We used standard methodological procedures expected by Cochrane, and GRADE to assess the certainty of the evidence. We collected data for primary caries prevention (change in caries increment), arrest of carious lesions, secondary prevention of caries (lesions do not progress from initial classification), adverse effects, dental pain or sensitivity, and aesthetics at the end of study follow‐up. Main results We included 29 RCTs (13,036 participants; 12,020 children, 1016 older adults). We summarise outcome data for the five most clinically relevant comparisons. All studies included high risks of bias, and some findings were imprecise (e.g. because of small sample sizes). SDF versus placebo or no treatment (14 studies; 2695 children, 905 older adults) Compared to placebo or no treatment, SDF may help prevent new caries in the primary dentition (1 study, 373 participants), or on the coronal surfaces of permanent dentition (1 study, 373 participants) but the evidence is very uncertain. SDF likely prevents new root caries (mean difference (MD) −0.79 surfaces, 95% confidence interval (CI) −1.40 to −0.17; 3 studies, 439 participants; moderate‐certainty evidence). SDF may help arrest caries in the primary dentition (MD 0.86 surfaces, 95% CI 0.39 to 1.33; 2 studies, 841 participants; low‐certainty evidence) and the permanent dentition (coronal: 1 study, 373 participants; root: 1 study, 158 participants) but the evidence is very uncertain. The evidence is very uncertain for secondary prevention of caries (primary dentition: 1 study, 128 participants; permanent dentition (coronal): 1 study, 663 participants), for adverse effects (5 studies, 1299 participants), and aesthetics (1 study, 43 participants). Different approaches to SDF application (5 studies, 1808 children) Studies compared different frequencies or intervals of application, different concentrations of SDF, and different durations of treatment. Some studies included multiple comparisons of different approaches. Because of the different approaches, we could not combine findings from these studies. Due to very low‐certainty evidence, we were unsure whether any approach to SDF application was better than another for caries arrest (4 studies, including 8 comparisons of different approaches, 1360 participants); secondary prevention of caries (1 study, 203 participants), or led to differences in adverse effects (3 studies, 1121 children) or aesthetics (1 study, 119 children). SDF versus fluoride varnish (8 studies, 2868 children, 223 older adults) Compared to flouride varnish, SDF may result in little or no difference to the prevention of new caries in the primary dentition (MD 0.00, 95% CI ‐0.26 to 0.26; 1 study, 434 participants; low‐certainty evidence). The evidence is very uncertain for this outcome measure in the permanent dentition (coronal: 1 study, 237 participants; root: 1 study, 100 participants; very low‐certainty evidence). Due to very low‐certainty evidence, we were unsure whether or not there were any differences between flouride varnish (applied weekly for three applications) and SDF for caries arrest and secondary prevention of caries in the primary dentition (1 study, 309 participants). Similarly, we were unsure of adverse effects (3 studies, 980 children), dental pain or sensitivity (1 study, 62 children), or aesthetics (1 study, 263 children). SDF versus sealants and resin infiltration (2 studies, 343 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other for primary prevention of caries in permanent dentition (coronal: 1 study, 242 participants), or adverse effects (2 studies, 336 participants). SDF versus atraumatic restorative treatment (ART) with glass ionomer cement (GIC) or GI material (4 studies, 610 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other at arresting caries in the primary dentition (1 study, 143 participants). We were also unsure whether there were any differences between treatments in adverse effects (3 studies, 482 participants), dental pain or sensitivity (1 study, 234 participants), or aesthetics (2 studies, 248 participants). Authors' conclusions In the primary dentition, evidence remains uncertain whether SDF prevents new caries or progression of existing caries compared to placebo or no treatment, but it may offer benefit over placebo or no treatment in caries arrest. Compared to placebo or no treatment, SDF probably also helps prevent new root caries. However, the evidence is uncertain for other caries outcome measures in this dentition and in all caries outcomes for coronal surfaces of permanent dentition. Compared to flouride varnish, SDF may offer little or no benefit in preventing new caries in the primary dentition, but the evidence is very uncertain for other caries outcome measures in the primary dentition and for preventing new caries in the permanent dentition. We were unable to establish whether one SDF treatment approach was better than another, or how SDF compared to other treatments, because of very low‐certainty evidence. The impact of SDF staining of teeth was poorly reported and the evidence for adverse effects is very uncertain. Additional well‐conducted studies are needed. These should measure the impact of staining and be analysed to take account of clustering issues within participants. Plain language summary Is silver diamine fluoride varnish an effective treatment for preventing and managing tooth decay in children and adults? Key messages ‐ We can't tell if silver diamine fluoride (SDF) is better than no treatment at preventing or treating tooth decay. ‐ We can't tell if SDF is better or worse than other treatments at preventing or treating tooth decay. ‐ New studies could help to find out about the unwanted effects of SDF, whether people are bothered by the staining on the teeth caused by SDF, and the best treatment approach. What is tooth decay? Tooth decay happens when bacteria in your mouth break down sugars from food, producing acids that damage tooth enamel (hard surfaces). This can lead to holes, or cavities, in the teeth. Tooth decay affects the crown of the tooth (the part above the gum) of baby teeth, and the crown and root of permanent teeth. If it is not prevented or treated it can cause toothache, infections and tooth loss. How is tooth decay treated? Treatments for tooth decay include liquids, gels (varnishes) and sealants. These treatments are painted onto the tooth to protect against bacteria. Treatment may also include fillings in larger cavities. Silver diamine fluoride (SDF) is a low‐cost liquid that can be painted on a tooth by a dentist or another trained person. It is suitable for people of all ages, including people with special health needs. However, SDF can permanently stain the treated tooth surface black or dark brown. What did we want to find out? We wanted to find out: ‐ if SDF was better than no treatment or other treatments at preventing new tooth decay, stopping existing tooth decay or preventing tooth decay from progressing; ‐ if there were benefits to applying SDF for different numbers of times, strengths of solution, or durations; ‐ if SDF caused unwanted effects, toothache, or if people were bothered by staining. What did we do? We searched for studies that compared SDF with no treatment or placebo (a dummy treatment), other treatments, or different application approaches. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 29 studies, with 12,020 children and 1016 older adults. Main results Compared with no treatment or placebo, we can't tell if SDF prevents new tooth decay in baby teeth or crown surfaces of permanent teeth. SDF is likely to prevent new tooth decay on root surfaces of permanent teeth. It may also completely stop existing tooth decay in baby teeth. However, we are unsure if it completely stops existing tooth decay on crown and root surfaces of permanent teeth, prevents existing tooth decay from progressing in any types of teeth, increases the risk of unwanted effects, or if people are bothered by the appearance of staining. Studies used different combinations of treatment approaches (number of times SDF is applied and how often, the strength of solution, and duration of treatment). We can't tell if one approach is better than another at stopping or preventing further decay, unwanted effects, or bother with appearance of staining. When SDF is compared with fluoride varnish, neither treatment may be better than the other at preventing new tooth decay in baby teeth. We are unsure about the effect on crown and root surfaces of permanent teeth. We also can't tell if either treatment is better than the other at stopping existing tooth decay or preventing further decay in baby teeth, or if there are any differences in unwanted effects, toothache, or bother with appearance of staining. When SDF is compared with sealants, we can't tell if there are any differences between treatments in preventing new tooth decay on the crown surfaces of permanent teeth, or whether there are any differences between these treatments in unwanted effects. When SDF is compared with fillings (with tooth decay first removed using only hand tools), we can't tell if there were any differences between treatments in stopping existing decay in baby teeth, unwanted effects, toothache, or bother with appearance of staining. What are the limitations of the evidence? Often we were very unsure of the evidence for the following reasons. ‐ SDF stains the teeth. Everyone in the studies would have known what treatment they were given. This might affect their usual teeth‐brushing routine. In most studies, the person checking teeth for new or existing decay would also have known this information. ‐ When we compared different approaches to SDF, the studies were too different from one another to allow us to compare them. ‐ Although we found 29 studies, most evidence was from individual (or few) studies, which were very small. How current is this evidence? The evidence is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Worthington, HV, Lewis, SR, Glenny, A-M, Huang, SS, Innes, NPT, O'Malley, L, Riley, P, Walsh, T, Wong, MC, Clarkson, JE, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012718.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.753Z" }, { "id": "3412ccd8-c36d-4e0c-b30e-234b5615cc3c", "pmid": "", "title": "Interventions for preventing osteoradionecrosis of the jaws in adults receiving head and neck radiotherapy", "imported": false, "abstract": "Abstract - Background Osteoradionecrosis (ORN) of the jaws is among the most serious oral complications of head and neck cancer radiotherapy, arising from radiation‐induced fibro‐atrophic tissue injury, manifested by necrosis of osseous tissues and failure to heal, often secondary to operative interventions in the oral cavity. It is associated with considerable morbidity and has important quality of life ramifications. Since ORN is very difficult to treat effectively, preventive measures to limit the onset of this disease are needed; however, the effects of various preventive interventions has not been adequately quantified. Objectives To assess the effects of interventions for preventing ORN of the jaws in adult patients with head and neck cancer undergoing curative or adjuvant (i.e. non‐palliative) radiotherapy. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 5 November 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 10) in the Cochrane Library (searched 5 November 2019), MEDLINE Ovid (1946 to 5 November 2019), Embase Ovid (1980 to 5 November 2019), Allied and Complementary Medicine (AMED) Ovid (1985 to 5 November 2019), Scopus (1966 to 5 November 2019), Proquest Dissertations and Theses International (1861 to 5 November 2019) and Web of Science Conference Proceedings (1990 to 5 November 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We selected randomised controlled trials (RCTs) or quasi‐RCTs of adult patients 18 years or older with head and neck cancer who had undergone curative or adjuvant radiotherapy to the head and neck, who had received an intervention to prevent the onset of ORN. Eligible patients were those subjected to pre‐ or post‐irradiation dental evaluation. Management of these patients was to be with interventions independent of their cancer therapy, including but not limited to local, systemic, or behavioural interventions. Data collection and analysis Two review authors independently selected trials from search results, assessed risk of bias, and extracted relevant data for inclusion in the review. Authors of included studies were contacted to request missing data. We used standard methodological procedures expected by Cochrane. Main results Four studies were identified that met pre‐determined eligibility criteria, evaluating a total of 342 adults. From the four studies, all assessed as at high risk of bias, three broad interventions were identified that may potentially reduce the risk of ORN development: one study showed no reduction in ORN when using platelet‐rich plasma placed in the extraction sockets of prophylactically removed healthy mandibular molar teeth prior to radiotherapy (odds ratio (OR) 3.32, 95% confidence interval (CI) 0.58 to 19.09; one trial, 44 participants; very low‐certainty evidence). Another study involved comparing fluoride gel and high‐content fluoride toothpaste (1350 parts per million (ppm)) in prevention of post‐radiation caries, and found no difference between their use as no cases of ORN were reported (one trial, 220 participants; very low‐certainty evidence). The other two studies involved the use of perioperative hyperbaric oxygen (HBO) therapy and antibiotics. One study showed that treatment with HBO caused a reduction in the development of ORN in comparison to patients treated with antibiotics following dental extractions (risk ratio (RR) 0.18, 95% CI 0.43 to 0.76; one trial, 74 participants; very low‐certainty evidence). Another study found no difference between combined HBO and antibiotics compared to antibiotics alone prior to dental implant placement (RR 3.00, 95% CI 0.14 to 65.16; one trial, 26 participants; very low‐certainty evidence). Adverse effects of the different interventions were not reported clearly or were not important. Authors' conclusions Given the suboptimal reporting and inadequate sample sizes of the included studies, evidence regarding the interventions evaluated by the trials included in this review is uncertain. More well‐designed RCTs with larger samples are required to make conclusive statements regarding the efficacy of these interventions. Plain language summary Dental treatments for preventing damage to the jawbones in people with cancer receiving radiotherapy to the head and neck Review question With this Cochrane Review we tried to find out the best way to prevent the death and exposure of bone in the jaws of people who have had radiotherapy for head and neck cancer. This is a condition called osteoradionecrosis (ORN). Background ORN of the jaws is a serious problem which can happen after people have radiotherapy as part of their treatment for head and neck cancer. ORN refers to the death and exposure of bone that result from damage to the tissues due to being exposed to radiation. ORN is very difficult to treat and it is important that steps are taken to prevent it. In this review, we looked at any treatments that have been used to prevent ORN. Study characteristics This review is up‐to‐date as of 5 November 2019. The review includes four studies involving 342 adults who had received radiotherapy for the treatment of head and neck cancer. The review looks at three different ways to prevent ORN: ‐ the use of platelet‐rich plasma (PRP) in bone after removal of healthy teeth prior to radiotherapy. Plasma is a part of blood that contains special proteins that help the blood to clot, and PRP is concentrated plasma which supports cell growth. Injecting PRP into damaged tissue may stimulate the body to grow new, healthy cells to make it heal more quickly; ‐ taking out teeth because of tooth decay makes the risk of developing ORN greater. Preventing tooth decay in people having radiotherapy is very important. We looked at a study comparing using fluoride gel with a toothpaste with a higher level of fluoride than normal to prevent tooth decay after radiotherapy; ‐ hyperbaric oxygen therapy is breathing oxygen in a pressurized chamber to improve blood supply, which may help heal damaged tissue. Two studies compared the use of hyperbaric oxygen therapy for taking out teeth or placing dental implants with antibiotics. Antibiotics are drugs which stop or slow the growth of bacteria. Key results One study showed no reduction in ORN when using platelet‐rich plasma in bone after the removal of healthy teeth. Another study found no difference between fluoride gel and toothpaste with a higher level of fluoride than normal as no cases of ORN were reported. A third study showed that treatment with hyperbaric oxygen therapy caused a reduction in the development of ORN in comparison to patients treated with antibiotics following the removal of teeth. The fourth study found no difference between combined hyperbaric oxygen therapy and antibiotics compared to antibiotics alone. Harmful effects of the different interventions were not reported clearly or were not important. Certainty of the evidence The level of certainty we have in these findings is very low. This was due to high risk of bias, not all studies mentioning important details, and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to stop ORN of the jaws from happening or making it less severe in adults receiving head and neck radiotherapy. We suggest that more, well‐conducted, and bigger studies including more people, should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "El‐Rabbany, M; Duchnay, M; Raziee, HR; Zych, M; Tenenbaum, H; Shah, PS; Azarpazhooh, A", "articleTypes": [], "doi": "10.1002/14651858.CD011559.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "34463b97-0066-4b72-965a-fbe17cf48855", "pmid": "", "title": "Clonidine for pain in non‐ventilated infants", "imported": false, "abstract": "Abstract - Background Critically ill newborn infants undergo a variety of painful procedures or experience a variety of painful conditions during their early life in the neonatal unit. In the critically ill paediatric and neonatal population, clonidine is prescribed as an adjunct to opioids or benzodiazepines aiming to reduce the doses of these drugs that are required for analgesia or sedation, or to facilitate weaning from mechanical ventilation. It has been shown that clonidine premedication might have a positive effect on postoperative pain in children. Objectives To assess the benefit and harms of clonidine for the prevention or treatment of procedural pain; postoperative pain; or pain associated with clinical conditions in non‐ventilated neonates. Search methods We used the standard search strategy of Cochrane Neonatal to search the CENTRAL, MEDLINE via PubMed, Embase, and CINAHL to December 2018. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials. We ran an updated search from 1 January 2018 to 11 March 2020 in CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials, and cluster trials comparing clonidine to placebo or no treatment, opioids, paracetamol, dexmedetomidine, or non‐pharmacological pain‐reducing interventions for the management of procedural pain, postoperative pain, and pain associated with clinical conditions in preterm and term newborns. Data collection and analysis Two review authors independently planned to extract data (e.g. number of participants, birth weight, gestational age, modality of administration, and dose of clonidine) and assess the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow‐up). The primary outcome considered was pain: for procedural pain, the mean values of each analgesia scale assessed during the procedure and at one to two hours after the procedure; for postoperative pain and for pain associated with clinical conditions, the mean values of each analgesia scale assessed at 30 minutes, three hours, and 12 hours after the administration of the intervention. We planned to use the GRADE approach to assess the quality of evidence. Main results Our search strategy yielded 3383 references. Two review authors independently assessed all references for inclusion. We did not find any completed studies for inclusion. We excluded three trials where clonidine was administered for spinal anaesthesia. Authors' conclusions We did not find any studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of clonidine for the prevention or treatment of procedural or postoperative pain, or pain associated with clinical conditions in neonates. Plain language summary Clonidine for painful procedures and conditions in infants Review question: does clonidine administration reduce pain in newborns exposed to painful procedures or conditions? Background: newborns admitted to the hospital are exposed to a number of painful procedures which might include blood sampling, lumbar puncture (a medical procedure where a needle is inserted into the spinal canal, usually to collect cerebrospinal fluid for testing), tubes in the stomach, different types of catheters, and minor surgical procedures such as neonatal circumcision. In addition, newborns might have pain because of clinical conditions, such as, fractured bone, pain following traumatic vaginal birth, disease of the skin (open skin lesions from an inherited skin disorder), or intestines (necrotising enterocolitis (inflammation)). All babies, and especially those born too early (preterm), are very sensitive to pain. Moreover, the experience of repeated episodes of pain might cause problems, such as an altered development of the nervous system, in early life and an increased pain sensitivity when they grow up. Most of the medicines to manage pain and stress in babies have side effects, and might also harm the immature developing brain by inducing death of cells (apoptosis) in the brain. Study characteristics: we searched for studies up to 11 March 2020. The aim of this review was to assess if clonidine could reduce pain in newborns. This medicine can be given through injections, using a tube in the stomach (nasogastric tube), through the skin, and as spinal anaesthesia. However, the latter is not in the focus of this review as it is used for babies undergoing specific surgical procedures. Clonidine works on the brain modifying responses and reducing stress and agitation. Furthermore, clonidine may reduce pain, especially if used in combination with other medicines. Key results: we found no studies for our review. Three studies were excluded because clonidine was given for spinal anaesthesia, whereas our review focuses on other indications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Romantsik, O; Calevo, MG; Norman, E; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD013104.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "3469e298-6056-4186-bab9-beb6dd97a6c9", "pmid": "", "title": "Probiotics for the prevention of Clostridioides difficile‐associated diarrhea in adults and children", "imported": false, "abstract": "Abstract - Rationale Antibiotics can disturb gastrointestinal microbiota, which may lead to reduced resistance to pathogens such as Clostridioides difficile . Probiotics are live microbial preparations that, when administered in adequate amounts, may confer a health benefit to the host, and are a potential C difficile infection prevention strategy. Objectives To assess the benefits and harms of probiotics for preventing C difficile ‐associated diarrhea (CDAD) in adults and children receiving an antibiotic for any reason. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, and Ovid Embase from 18 March 2017 (search date of the previous version of the review) to 3 March 2025. Eligibility criteria We included randomized controlled trials with a placebo, alternative prophylaxis, or no‐treatment control investigating probiotics (any strain or dose) for the prevention of CDAD in adults and children receiving an antibiotic for any reason. Outcomes The critical outcome was incidence of CDAD. Important outcomes included detection of C difficile in stool (i.e. colonization in absence of symptoms), adverse events, antibiotic‐associated diarrhea (AAD), and length of hospital stay. Risk of bias Two review authors independently assessed risk of bias using Cochrane's RoB 1 tool. Synthesis methods We pooled dichotomous outcomes (e.g . incidence of CDAD) using a random‐effects complete‐case model to calculate the risk ratio (RR) and absolute risk reduction (ARR) and corresponding 95% confidence interval (95% CI). We pooled continuous outcomes (e.g. length of hospital stay) using a random‐effects model to calculate the mean difference (MD) and corresponding 95% CI. We conducted sensitivity analyses to explore the impact of missing outcome data on benefits and harms outcomes. To investigate heterogeneity, we conducted a priori subgroup analyses on risk of bias, probiotic dose, probiotic species, adults versus children, inpatients versus outpatients, and the event rate in the control group for developing CDAD (low 0% to 2%; moderate 3% to 5%; high > 5%). The certainty of the evidence for each outcome was independently assessed using the GRADE approach. Included studies Eight new studies (n = 4595) met our inclusion criteria, for a total of 47 included studies (n = 15,260). Although we noted a high risk of bias in individual studies for sequence generation or allocation concealment, this did not impact our findings. Around 30% of studies lacked a published protocol or clinical trial registration, and in some cases there were inconsistencies between the reported methods and published results. We noted authors' affiliation with a probiotic company and financial support received from probiotic companies in 28 studies. Synthesis of results Evidence from 38 trials (13,179 participants) suggests that probiotics may result in a small absolute risk reduction (ARR) of 1.6% (incidence of 1.6% [110/6787] in the probiotic group versus 3.2% [203/6392] in the control group), and a relative risk reduction (RRR) of 50% (RR 0.50, 95% CI 0.38 to 0.64; P < 0.001; low‐certainty evidence) in incidence of CDAD. Twenty‐seven of 38 trials had missing CDAD data, ranging from 2% to 45%. Our complete‐case CDAD results proved robust to sensitivity analyses of plausible and worst‐plausible assumptions regarding missing outcome data. Pooled results from 16 trials (1302 participants) suggest that probiotics may result in a small absolute reduction in C difficile in stool (i.e. colonization in absence of symptoms) (ARR 2.1%; incidence of 14.9% [101/677] in the probiotic group versus 16.2% [101/625] in the control group; RR 0.87, 95% CI 0.68 to 1.11; P = 0.27; low‐certainty evidence). Thirty‐seven studies (11,911 participants) reported on adverse events. Our pooled analysis indicates that probiotics probably result in a small ARR of 1.7% (incidence of 10.9% [669/6148] in the probiotic group versus 12.2% [701/5763] in the control group), and an RRR of 14.0% (RR 0.86, 95% CI 0.72 to 1.01; P = 0.074; moderate‐certainty evidence). The most common adverse events in both the treatment and control groups were abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. Pooled results from 40 studies (13,419 participants) suggest that probiotics may result in a large ARR of 9% (incidence of 23% [1592/6901] in the probiotic group versus 27.4% [1787/6518] in the control group), and an RRR of 33% (RR 0.67, 95% CI 0.57 to 0.78; P < 0.001; low‐certainty evidence) in incidence of AAD. Only seven trials (6553 participants) investigated length of hospital stay. There is likely little to no difference in length of hospital stay between treatment and control groups (MD −0.07, 95% CI −0.35 to 0.21; P = 0.63; moderate‐certainty evidence). We downgraded the certainty of evidence for CDAD and AAD due to the low number of events or publication bias. We observed some variability in CDAD control group event rate (< 2% to > 5%) that may impact the applicability of evidence depending on clinical setting. We downgraded the certainty of evidence for adverse events due to variation between the results of the studies and for hospital stay due to selective reporting. Authors' conclusions The currently available evidence suggests that probiotics may be effective for preventing CDAD, suggesting that for every 65 people taking probiotics, one case of CDAD may be prevented (number needed to treat for an additional beneficial outcome of 65, 95% CI 48 to 97). There are probably fewer adverse events in the probiotic group. The short‐term use of probiotics may have a small absolute benefit, and is likely not associated with adverse effects when used in patient populations receiving systemic antibiotics who are not immunocompromised. Large trials comparing probiotics with placebo in people with a low baseline risk of CDAD are needed. Funding There was no source of funding for this update. Registration The original review was done in 2013 by Johnston and colleagues, for which the protocol was developed. We followed the methods specified in the 2017 review, while modifying the search strategy and risk of bias assessment for selective reporting for this update. Plain language summary What are the benefits and harms of probiotics for preventing Clostridioides difficile‐ associated diarrhea in adults and children receiving antibiotics for any reason? Key messages In people prescribed antibiotics, probiotics may be effective in preventing Clostridioides difficile ‐associated diarrhea (CDAD), and may reduce the risk of antibiotic‐associated diarrhea. Probiotics probably do not result in harm when taken with an antibiotic, with fewer mild to moderate unwanted effects in the group receiving probiotic than the group receiving placebo (dummy treatment) or no treatment. In those taking antibiotics who do not have a weakened immune system, the short‐term use of probiotics may offer a small benefit, and are likely not harmful. However, additional large studies comparing probiotics with placebo in people with a low risk of CDAD are needed. What is Clostridioides difficile ‐associated diarrhea (CDAD) ? Antibiotics are among the most prescribed medications worldwide. Antibiotic treatment may disturb the balance of organisms that normally populate the gut. This can result in a range of symptoms, most notably diarrhea. C difficile is a particularly dangerous organism that may colonize and infect the gut if the microbial balance has been disrupted. The effects of C difficile infection can vary, with some people having no symptoms, and others suffering diarrhea, severe inflammation, enlargement of the colon, or even death. The cost of treatment is expensive, and the financial burden on the medical system is substantial. What are probiotics? Probiotics are live microorganisms (bacteria or yeast) that provide health benefits when given in adequate amounts. They help to prevent potential disturbances to the gut microbial balance that are associated with antibiotic use, and to reduce the risk of growing harmful bacteria. Probiotics can be found in dietary supplements or yogurts and are widely available as capsules sold in health food stores and supermarkets. As 'functional food' or 'good bacteria,' probiotics have been suggested as a means of both preventing and treating CDAD. What did we want to find out? We wanted to know if probiotics prevent CDAD in adults and children receiving antibiotic therapy, and whether probiotics cause any unwanted effects. The researchers searched the medical literature extensively up to 3 March 2025. What did we do? We searched for studies that compared probiotics (any strain or dose) versus placebo (dummy treatment), alternative preventive treatment, or no treatment for the prevention of CDAD in adults and children receiving antibiotic therapy for any reason. We compared and summarized the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included 47 studies with a total of 15,260 adults and children who received antibiotic therapy along with probiotics, assessing CDAD or C difficile growth. Thirty‐eight studies (13,179 participants) assessed the effectiveness of probiotics for preventing CDAD. Our results suggest that probiotics may result in a small reduction in the risk of CDAD compared to placebo or no treatment. Probiotics may result in a small reduction in C difficile growth (16 studies, 1302 participants). Thirty‐seven studies (11,911 participants) looked at unwanted effects. Our results show that probiotics probably result in a small reduction in the risk of developing unwanted effects compared to placebo or no treatment. The most commonly reported unwanted effects included abdominal cramping, nausea, fever, soft stools, flatulence (gas), and taste disturbance, and were more common in the placebo or no‐treatment group. Forty studies (13,419 participants) reported on antibiotic‐associated diarrhea (AAD); probiotics may result in a large reduction in the risk of AAD compared to placebo or no treatment. Seven studies (6553 participants) reporting on length of hospital stay showed likely little to no difference between probiotics and placebo or no treatment. What are the limitations of the evidence? The studies we reviewed used different types of probiotics, but they didn't directly compare one probiotic to another. This lack of direct comparisons makes it harder to determine which probiotic works best. We have moderate to little confidence in the available evidence. Our confidence is limited because in some studies, people who dropped out of the study or were not followed up on resulted in missing information. The two largest studies in our analysis did not show a clear benefit of probiotics for preventing CDAD. How up‐to‐date is this evidence? The evidence is current to 3 March 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Esmaeilinezhad, Z; Ghosh, NR; Walsh, CM; Steen, JP; Burgman, AM; Mertz, D; Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD006095.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "34809e79-7dae-45b3-9c07-422416b81d48", "pmid": "", "title": "Replacing salt with low‐sodium salt substitutes (LSSS) for cardiovascular health in adults, children and pregnant women", "imported": false, "abstract": "Abstract - Background Elevated blood pressure, or hypertension, is the leading cause of preventable deaths globally. Diets high in sodium (predominantly sodium chloride) and low in potassium contribute to elevated blood pressure. The WHO recommends decreasing mean population sodium intake through effective and safe strategies to reduce hypertension and its associated disease burden. Incorporating low‐sodium salt substitutes (LSSS) into population strategies has increasingly been recognised as a possible sodium reduction strategy, particularly in populations where a substantial proportion of overall sodium intake comes from discretionary salt. The LSSS contain lower concentrations of sodium through its displacement with potassium predominantly, or other minerals. Potassium‐containing LSSS can potentially simultaneously decrease sodium intake and increase potassium intake. Benefits of LSSS include their potential blood pressure‐lowering effect and relatively low cost. However, there are concerns about potential adverse effects of LSSS, such as hyperkalaemia, particularly in people at risk, for example, those with chronic kidney disease (CKD) or taking medications that impair potassium excretion. Objectives To assess the effects and safety of replacing salt with LSSS to reduce sodium intake on cardiovascular health in adults, pregnant women and children. Search methods We searched MEDLINE (PubMed), Embase (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection (Clarivate Analytics), Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCOhost), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) up to 18 August 2021, and screened reference lists of included trials and relevant systematic reviews. No language or publication restrictions were applied. Selection criteria We included randomised controlled trials (RCTs) and prospective analytical cohort studies in participants of any age in the general population, from any setting in any country. This included participants with non‐communicable diseases and those taking medications that impair potassium excretion. Studies had to compare any type and method of implementation of LSSS with the use of regular salt, or no active intervention, at an individual, household or community level, for any duration. Data collection and analysis Two review authors independently screened titles, abstracts and full‐text articles to determine eligibility; and extracted data, assessed risk of bias (RoB) using the Cochrane RoB tool, and assessed the certainty of the evidence using GRADE. We stratified analyses by adults, children (≤ 18 years) and pregnant women. Primary effectiveness outcomes were change in diastolic and systolic blood pressure (DBP and SBP), hypertension and blood pressure control; cardiovascular events and cardiovascular mortality were additionally assessed as primary effectiveness outcomes in adults. Primary safety outcomes were change in blood potassium, hyperkalaemia and hypokalaemia. Main results We included 26 RCTs, 16 randomising individual participants and 10 randomising clusters (families, households or villages). A total of 34,961 adult participants and 92 children were randomised to either LSSS or regular salt, with the smallest trial including 10 and the largest including 20,995 participants. No studies in pregnant women were identified. Studies included only participants with hypertension (11/26), normal blood pressure (1/26), pre‐hypertension (1/26), or participants with and without hypertension (11/26). This was unknown in the remaining studies. The largest study included only participants with an elevated risk of stroke at baseline. Seven studies included adult participants possibly at risk of hyperkalaemia. All 26 trials specifically excluded participants in whom an increased potassium intake is known to be potentially harmful. The majority of trials were conducted in rural or suburban settings, with more than half (14/26) conducted in low‐ and middle‐income countries. The proportion of sodium chloride replacement in the LSSS interventions varied from approximately 3% to 77%. The majority of trials (23/26) investigated LSSS where potassium‐containing salts were used to substitute sodium. In most trials, LSSS implementation was discretionary (22/26). Trial duration ranged from two months to nearly five years. We assessed the overall risk of bias as high in six trials and unclear in 12 trials. LSSS compared to regular salt in adults: LSSS compared to regular salt probably reduce DBP on average (mean difference (MD) ‐2.43 mmHg, 95% confidence interval (CI) ‐3.50 to ‐1.36; 20,830 participants, 19 RCTs, moderate‐certainty evidence) and SBP (MD ‐4.76 mmHg, 95% CI ‐6.01 to ‐3.50; 21,414 participants, 20 RCTs, moderate‐certainty evidence) slightly. On average, LSSS probably reduce non‐fatal stroke (absolute effect (AE) 20 fewer/100,000 person‐years, 95% CI ‐40 to 2; 21,250 participants, 3 RCTs, moderate‐certainty evidence), non‐fatal acute coronary syndrome (AE 150 fewer/100,000 person‐years, 95% CI ‐250 to ‐30; 20,995 participants, 1 RCT, moderate‐certainty evidence) and cardiovascular mortality (AE 180 fewer/100,000 person‐years, 95% CI ‐310 to 0; 23,200 participants, 3 RCTs, moderate‐certainty evidence) slightly, and probably increase blood potassium slightly (MD 0.12 mmol/L, 95% CI 0.07 to 0.18; 784 participants, 6 RCTs, moderate‐certainty evidence), compared to regular salt. LSSS may result in little to no difference, on average, in hypertension (AE 17 fewer/1000, 95% CI ‐58 to 17; 2566 participants, 1 RCT, low‐certainty evidence) and hyperkalaemia (AE 4 more/100,000, 95% CI ‐47 to 121; 22,849 participants, 5 RCTs, moderate‐certainty evidence) compared to regular salt. The evidence is very uncertain about the effects of LSSS on blood pressure control, various cardiovascular events, stroke mortality, hypokalaemia, and other adverse events (very‐low certainty evidence). LSSS compared to regular salt in children: The evidence is very uncertain about the effects of LSSS on DBP and SBP in children. We found no evidence about the effects of LSSS on hypertension, blood pressure control, blood potassium, hyperkalaemia and hypokalaemia in children. Authors' conclusions When compared to regular salt, LSSS probably reduce blood pressure, non‐fatal cardiovascular events and cardiovascular mortality slightly in adults. However, LSSS also probably increase blood potassium slightly in adults. These small effects may be important when LSSS interventions are implemented at the population level. Evidence is limited for adults without elevated blood pressure, and there is a lack of evidence in pregnant women and people in whom an increased potassium intake is known to be potentially harmful, limiting conclusions on the safety of LSSS in the general population. We also cannot draw firm conclusions about effects of non‐discretionary LSSS implementations. The evidence is very uncertain about the effects of LSSS on blood pressure in children. Plain language summary Does using low‐sodium salt substitutes (LSSS) instead of regular salt reduce blood pressure and heart disease risks, and is it safe? Key messages • In adults, using LSSS instead of regular salt in food probably lowers blood pressure slightly. Adults using LSSS instead of regular salt probably have a slightly lower risk of non‐fatal heart conditions, such as stroke or a sudden reduced blood flow to the heart, and death from heart disease. • Using LSSS instead of regular salt probably also slightly increases the level of blood potassium (a mineral that keeps your heart beating at the right pace) in adults. This could be harmful for people who cannot effectively regulate the potassium in their bodies. Other evidence on safety is very limited. • We are not certain about effects of using LSSS instead of regular salt on blood pressure in children, or whether using LSSS is safe in children. • This evidence may not directly apply to people known to be at risk of high blood potassium, such as people with kidney problems or on certain medications. What are low‐sodium salt substitutes (LSSS)? LSSS are products with less sodium than regular salt. Amounts of sodium in LSSS are lowered by replacing some of the sodium with potassium or other minerals. LSSS may help lower risks of using regular salt, since eating lots of sodium and not enough potassium contributes to high blood pressure. Globally, high blood pressure is the largest cause of preventable deaths, mainly because it causes stroke, acute coronary syndrome (ACS; where less blood flows to the heart), and kidney problems. However, LSSS also has potential health risks. Using LSSS may lead to higher than normal blood potassium (hyperkalaemia), which causes problems with the heartbeat speed and rhythm, or can cause the heart to stop. These risks are greater in certain people, for example, those whose kidneys do not work properly to remove potassium. What did we want to find out? We wanted to find out what the effects of using LSSS instead of regular salt are on blood pressure as well as on events (stroke and ACS) and heart disease death. We also wanted to know if using LSSS instead of regular salt is safe, both in the general population and in people who are known to be at risk of high blood potassium levels. We wanted to find this out for adults, children and pregnant women. What did we do? 
We searched five electronic databases and trial registries for studies that compared using LSSS with using regular salt. We compared and summarised the results of the studies and rated our confidence in the combined evidence, based on factors such as study methods and sizes. What did we find? We found 26 trials* involving 34,961 adults and 92 children. No studies in pregnant women were found. Most trials were undertaken in rural or suburban areas, with more than half done in low‐ and middle‐income countries. Most trials included some people with high blood pressure (22); the largest included only people with a high risk of stroke. Seven trials were done in people at possible risk of high blood potassium. All trials excluded people where high potassium intake is known to be harmful, such as people with kidney problems or on certain medications. Nearly all trials (23) examined LSSS types where some sodium was replaced with potassium. The amount of sodium replaced in the various LSSS used in the trials ranged from very small (3%) to large (77%). *Trials are types of studies in which participants are assigned randomly to two or more treatment groups. This is the best way to ensure similar groups of participants. Main results In adults, LSSS probably lowers blood pressure (diastolic and systolic) slightly when compared to regular salt. Using LSSS also probably lowers risk of non‐fatal stroke, non‐fatal ACS and heart disease death slightly when compared to regular salt. However, using LSSS instead of regular salt probably also slightly increases the level of potassium in the blood. Compared to regular salt, LSSS may result in little to no difference in high blood pressure and hyperkalaemia. We could not draw any conclusions about effects of LSSS on blood pressure control, various heart disease events, death caused by stroke, lower than normal blood potassium (hypokalaemia), and other adverse events. We could not draw any conclusions about the effects or safety of using LSSS instead of regular salt in children. What are the limitations of the evidence? We are moderately confident in the evidence. Our confidence was lowered mainly because of concerns about how some trials were conducted, and whether the results apply to the general population. We are not sure about the effects and safety of LSSS in children, pregnant women, people known to have a risk of high blood potassium, or those who do not have high blood pressure. We are also unsure about the effects of LSSS when used in foods not prepared at home. Further research may change these results. How up to date is this evidence? The evidence is up‐to‐date to August 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Brand, A; Visser, ME; Schoonees, A; Naude, CE", "articleTypes": [], "doi": "10.1002/14651858.CD015207", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "3495cbc5-b295-4a34-b6c0-c5d5e9446cd7", "pmid": "", "title": "Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID‐19", "imported": false, "abstract": "Abstract - Background COVID‐19 illness is highly variable, ranging from infection with no symptoms through to pneumonia and life‐threatening consequences. Symptoms such as fever, cough, or loss of sense of smell (anosmia) or taste (ageusia), can help flag early on if the disease is present. Such information could be used either to rule out COVID‐19 disease, or to identify people who need to go for COVID‐19 diagnostic tests. This is the second update of this review, which was first published in 2020. Objectives To assess the diagnostic accuracy of signs and symptoms to determine if a person presenting in primary care or to hospital outpatient settings, such as the emergency department or dedicated COVID‐19 clinics, has COVID‐19. Search methods We undertook electronic searches up to 10 June 2021 in the University of Bern living search database. In addition, we checked repositories of COVID‐19 publications. We used artificial intelligence text analysis to conduct an initial classification of documents. We did not apply any language restrictions. Selection criteria Studies were eligible if they included people with clinically suspected COVID‐19, or recruited known cases with COVID‐19 and also controls without COVID‐19 from a single‐gate cohort. Studies were eligible when they recruited people presenting to primary care or hospital outpatient settings. Studies that included people who contracted SARS‐CoV‐2 infection while admitted to hospital were not eligible. The minimum eligible sample size of studies was 10 participants. All signs and symptoms were eligible for this review, including individual signs and symptoms or combinations. We accepted a range of reference standards. Data collection and analysis Pairs of review authors independently selected all studies, at both title and abstract, and full‐text stage. They resolved any disagreements by discussion with a third review author. Two review authors independently extracted data and assessed risk of bias using the QUADAS‐2 checklist, and resolved disagreements by discussion with a third review author. Analyses were restricted to prospective studies only. We presented sensitivity and specificity in paired forest plots, in receiver operating characteristic (ROC) space and in dumbbell plots. We estimated summary parameters using a bivariate random‐effects meta‐analysis whenever five or more primary prospective studies were available, and whenever heterogeneity across studies was deemed acceptable. Main results We identified 90 studies; for this update we focused on the results of 42 prospective studies with 52,608 participants. Prevalence of COVID‐19 disease varied from 3.7% to 60.6% with a median of 27.4%. Thirty‐five studies were set in emergency departments or outpatient test centres (46,878 participants), three in primary care settings (1230 participants), two in a mixed population of in‐ and outpatients in a paediatric hospital setting (493 participants), and two overlapping studies in nursing homes (4007 participants). The studies did not clearly distinguish mild COVID‐19 disease from COVID‐19 pneumonia, so we present the results for both conditions together. Twelve studies had a high risk of bias for selection of participants because they used a high level of preselection to decide whether reverse transcription polymerase chain reaction (RT‐PCR) testing was needed, or because they enrolled a non‐consecutive sample, or because they excluded individuals while they were part of the study base. We rated 36 of the 42 studies as high risk of bias for the index tests because there was little or no detail on how, by whom and when, the symptoms were measured. For most studies, eligibility for testing was dependent on the local case definition and testing criteria that were in effect at the time of the study, meaning most people who were included in studies had already been referred to health services based on the symptoms that we are evaluating in this review. The applicability of the results of this review iteration improved in comparison with the previous reviews. This version has more studies of people presenting to ambulatory settings, which is where the majority of assessments for COVID‐19 take place. Only three studies presented any data on children separately, and only one focused specifically on older adults. We found data on 96 symptoms or combinations of signs and symptoms. Evidence on individual signs as diagnostic tests was rarely reported, so this review reports mainly on the diagnostic value of symptoms. Results were highly variable across studies. Most had very low sensitivity and high specificity. RT‐PCR was the most often used reference standard (40/42 studies). Only cough (11 studies) had a summary sensitivity above 50% (62.4%, 95% CI 50.6% to 72.9%)); its specificity was low (45.4%, 95% CI 33.5% to 57.9%)). Presence of fever had a sensitivity of 37.6% (95% CI 23.4% to 54.3%) and a specificity of 75.2% (95% CI 56.3% to 87.8%). The summary positive likelihood ratio of cough was 1.14 (95% CI 1.04 to 1.25) and that of fever 1.52 (95% CI 1.10 to 2.10). Sore throat had a summary positive likelihood ratio of 0.814 (95% CI 0.714 to 0.929), which means that its presence increases the probability of having an infectious disease other than COVID‐19. Dyspnoea (12 studies) and fatigue (8 studies) had a sensitivity of 23.3% (95% CI 16.4% to 31.9%) and 40.2% (95% CI 19.4% to 65.1%) respectively. Their specificity was 75.7% (95% CI 65.2% to 83.9%) and 73.6% (95% CI 48.4% to 89.3%). The summary positive likelihood ratio of dyspnoea was 0.96 (95% CI 0.83 to 1.11) and that of fatigue 1.52 (95% CI 1.21 to 1.91), which means that the presence of fatigue slightly increases the probability of having COVID‐19. Anosmia alone (7 studies), ageusia alone (5 studies), and anosmia or ageusia (6 studies) had summary sensitivities below 50% but summary specificities over 90%. Anosmia had a summary sensitivity of 26.4% (95% CI 13.8% to 44.6%) and a specificity of 94.2% (95% CI 90.6% to 96.5%). Ageusia had a summary sensitivity of 23.2% (95% CI 10.6% to 43.3%) and a specificity of 92.6% (95% CI 83.1% to 97.0%). Anosmia or ageusia had a summary sensitivity of 39.2% (95% CI 26.5% to 53.6%) and a specificity of 92.1% (95% CI 84.5% to 96.2%). The summary positive likelihood ratios of anosmia alone and anosmia or ageusia were 4.55 (95% CI 3.46 to 5.97) and 4.99 (95% CI 3.22 to 7.75) respectively, which is just below our arbitrary definition of a 'red flag', that is, a positive likelihood ratio of at least 5. The summary positive likelihood ratio of ageusia alone was 3.14 (95% CI 1.79 to 5.51). Twenty‐four studies assessed combinations of different signs and symptoms, mostly combining olfactory symptoms. By combining symptoms with other information such as contact or travel history, age, gender, and a local recent case detection rate, some multivariable prediction scores reached a sensitivity as high as 90%. Authors' conclusions Most individual symptoms included in this review have poor diagnostic accuracy. Neither absence nor presence of symptoms are accurate enough to rule in or rule out the disease. The presence of anosmia or ageusia may be useful as a red flag for the presence of COVID‐19. The presence of cough also supports further testing. There is currently no evidence to support further testing with PCR in any individuals presenting only with upper respiratory symptoms such as sore throat, coryza or rhinorrhoea. Combinations of symptoms with other readily available information such as contact or travel history, or the local recent case detection rate may prove more useful and should be further investigated in an unselected population presenting to primary care or hospital outpatient settings. The diagnostic accuracy of symptoms for COVID‐19 is moderate to low and any testing strategy using symptoms as selection mechanism will result in both large numbers of missed cases and large numbers of people requiring testing. Which one of these is minimised, is determined by the goal of COVID‐19 testing strategies, that is, controlling the epidemic by isolating every possible case versus identifying those with clinically important disease so that they can be monitored or treated to optimise their prognosis. The former will require a testing strategy that uses very few symptoms as entry criterion for testing, the latter could focus on more specific symptoms such as fever and anosmia. Plain language summary How accurate are symptoms and medical examination to diagnose COVID‐19? Key messages ‐ The results suggest that a single symptom included in this review cannot accurately diagnose COVID‐19. ‐ Loss of sense of taste or smell could be a 'red flag' for the presence of COVID‐19. Cough or fever might be useful to identify people who might have COVID‐19. These symptoms might be useful to prompt further testing when they are present. ‐ We need more research to investigate combinations of symptoms and signs with other information such as recent contact or travel history, or vaccination status, and in children, and adults aged 65 years and over. What are symptoms or signs of COVID‐19? Symptoms are experienced by patients. COVID‐19 symptoms include cough, sore throat, high temperature, diarrhoea, headache, muscle or joint pain, fatigue, and loss of sense of smell and taste. Signs are measured by healthcare workers during clinical examination. They include lung sounds, blood pressure, blood oxygen level and heart rate. Symptoms and signs of COVID‐19 might be important to help people know whether they and the people they come into contact with should isolate at home, undergo testing with a rapid lateral flow test or PCR (laboratory‐based) test, or be hospitalised. What did we want to find out? Symptoms and signs of COVID‐19 are varied and may indicate other diseases, not just COVID‐19. We wanted to know how accurate diagnosis of COVID‐19 is, based on symptoms and signs from medical examination. We were interested in people with suspected COVID‐19, who go to their doctor, outpatient test centres or hospital. What did we do? We searched for studies that assessed the accuracy of symptoms and signs to diagnose COVID‐19. Studies had to be conducted in general practice, outpatient test centres or hospital outpatient settings only. We only included studies of people in hospital if signs and symptoms were recorded when they were admitted to the hospital, for example through the emergency department. What did we find? We focused on 42 studies with 52,608 participants in this review. The studies assessed 96 separate or combined symptoms and signs. Thirty‐five studies were conducted in emergency departments or outpatient COVID‐19 test centres (46,878 participants), 3 studies in general practice (1230 participants), 2 studies in children’s hospitals (493 in‐ and outpatients), and 2 studies in nursing homes (4007 participants). The studies were conducted in 18 different countries around the world. Twenty‐three studies were conducted in Europe, 8 in North‐America, 5 in Asia, and 3 in South‐America and 3 in Australia. We didn’t find any studies conducted in Africa. Three focused specifically on children, and only 1 focused on adults aged 65 years and over. Most studies did not clearly distinguish between mild and severe COVID‐19, so we present the results for mild, moderate and severe disease together. Few studies reported individual signs as diagnostic tests, so we focus mainly on the diagnostic value of symptoms. The most frequently reported symptoms were cough, fever, shortness of breath and sore throat. According to the studies in our review, in a group of 1000 people with suspected COVID‐19 of whom 270 (27%) would actually have COVID‐19, around 567 people would have a cough. Of these 567, 168 would actually have COVID‐19. Of the 433 who do not have a cough, 102 would have COVID‐19. In the same 1000 people, around 283 people would have a fever. Of these 283, 102 would actually have COVID‐19. Of the 717 people without fever, 168 would have COVID‐19. Someone who has lost their sense of smell or taste is five times more likely to have COVID‐19 than someone who hasn’t. Other symptoms, such as a sore throat or runny nose, are more likely to indicate the presence of an infectious disease other than COVID‐19. In the same 1000 people as described above, around 362 people would have a sore throat. Of these, only 84 would actually have COVID‐19. Of the 638 patients without sore throat, 186 would have COVID‐19. We found similar figures for having a runny nose. What are the limitations of the evidence? The results of this updated review are more reliable than those in previous versions as we included more high‐quality studies. However, the accuracy of individual symptoms varied across studies and the diagnostic value of symptoms such as fever, cough or other respiratory symptoms might still be overestimated, as most studies deliberately included participants because they had these symptoms. The results do not clearly differentiate between people with mild, moderate or severe COVID‐19. Only a few studies investigated the symptom‐based diagnosis of COVID‐19 in children or older adults. How up to date is this review? This review updates our previous review. The evidence is up to date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Struyf, T; Deeks, JJ; Dinnes, J; Takwoingi, Y; Davenport, C; Leeflang, MMG; Spijker, R; Hooft, L; Emperador, D; Domen, J; Tans, A; Janssens, S; Wickramasinghe, D; Lannoy, V; Horn, SR A; Van den Bruel, A", "articleTypes": [], "doi": "10.1002/14651858.CD013665.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "34cdf996-9658-4369-8e62-68980a30faae", "pmid": "", "title": "Treatments for intractable constipation in childhood", "imported": false, "abstract": "Abstract - Background Constipation that is prolonged and does not resolve with conventional therapeutic measures is called intractable constipation. The treatment of intractable constipation is challenging, involving pharmacological or non‐pharmacological therapies, as well as surgical approaches. Unresolved constipation can negatively impact quality of life, with additional implications for health systems. Consequently, there is an urgent need to identify treatments that are efficacious and safe. Objectives To evaluate the efficacy and safety of treatments used for intractable constipation in children. Search methods We searched CENTRAL, MEDLINE, Embase, and two trials registers up to 23 June 2023. We also searched reference lists of included studies for relevant studies. Selection criteria We included randomised controlled trials (RCTs) comparing any pharmacological, non‐pharmacological, or surgical treatment to placebo or another active comparator, in participants aged between 0 and 18 years with functional constipation who had not responded to conventional medical therapy. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were symptom resolution, frequency of defecation, treatment success, and adverse events; secondary outcomes were stool consistency, painful defecation, quality of life, faecal incontinence frequency, abdominal pain, hospital admission for disimpaction, and school absence. We used GRADE to assess the certainty of evidence for each primary outcome. Main results This review included 10 RCTs with 1278 children who had intractable constipation. We assessed one study as at low risk of bias across all domains. There were serious concerns about risk of bias in six studies. One study compared the injection of 160 units botulinum toxin A (n = 44) to unspecified oral stool softeners (n = 44). We are very uncertain whether botulinum toxin A injection improves treatment success (risk ratio (RR) 37.00, 95% confidence interval (CI) 5.31 to 257.94; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Frequency of defecation was reported only for the botulinum toxin A injection group (mean interval of 2.6 days). The study reported no data for the other primary outcomes. One study compared erythromycin estolate (n = 6) to placebo (n = 8). The only primary outcome reported was adverse events , which were 0 in both groups. The evidence is of very low certainty due to concerns with risk of bias and serious imprecision. One study compared 12 or 24 μg oral lubiprostone (n = 404) twice a day to placebo (n = 202) over 12 weeks. There may be little to no difference in treatment success (RR 1.29, 95% CI 0.87 to 1.92; low certainty evidence). We also found that lubiprostone probably results in little to no difference in adverse events (RR 1.05, 95% CI 0.91 to 1.21; moderate certainty evidence). The study reported no data for the other primary outcomes. One study compared three‐weekly rectal sodium dioctyl sulfosuccinate and sorbitol enemas (n = 51) to 0.5 g/kg/day polyethylene glycol laxatives (n = 51) over a 52‐week period. We are very uncertain whether rectal sodium dioctyl sulfosuccinate and sorbitol enemas improve treatment success (RR 1.33, 95% CI 0.83 to 2.14; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Results of defecation frequency per week was reported only as modelled means using a linear mixed model. The study reported no data for the other primary outcomes. One study compared biofeedback therapy (n = 12) to no intervention (n = 12). We are very uncertain whether biofeedback therapy improves symptom resolution (RR 2.50, 95% CI 1.08 to 5.79; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). The study reported no data for the other primary outcomes. One study compared 20 minutes of intrarectal electromotive botulinum toxin A using 2800 Hz frequency and botulinum toxin A dose 10 international units/kg (n = 30) to 10 international units/kg botulinum toxin A injection (n = 30). We are very uncertain whether intrarectal electromotive botulinum toxin A improves symptom resolution (RR 0.96, 95% CI 0.76 to 1.22; very low certainty evidence) or if it increases the frequency of defecation (mean difference (MD) 0.00, 95% CI −1.87 to 1.87; very low certainty evidence). We are also very uncertain whether intrarectal electromotive botulinum toxin A has an improved safety profile (RR 0.20, 95% CI 0.01 to 4.00; very low certainty evidence). The evidence for these results is of very low certainty due to serious concerns with risk of bias and imprecision. The study did not report data on treatment success. One study compared the injection of 60 units botulinum toxin A (n = 21) to myectomy of the internal anal sphincter (n = 21). We are very uncertain whether botulinum toxin A injection improves treatment success (RR 1.00, 95% CI 0.75 to 1.34; very low certainty evidence). No adverse events were recorded. The study reported no data for the other primary outcomes. One study compared 0.04 mg/kg oral prucalopride (n = 107) once daily to placebo (n = 108) over eight weeks. Oral prucalopride probably results in little or no difference in defecation frequency (MD 0.50, 95% CI −0.06 to 1.06; moderate certainty evidence); treatment success (RR 0.96, 95% CI 0.53 to 1.72; moderate certainty evidence); and adverse events (RR 1.15, 95% CI 0.94 to 1.39; moderate certainty evidence). The study did not report data on symptom resolution. One study compared transcutaneous electrical stimulation to sham stimulation, and another study compared dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. These studies did not report any of our predefined primary outcomes. Authors' conclusions We identified low to moderate certainty evidence that oral lubiprostone may result in little to no difference in treatment success and adverse events compared to placebo. Based on moderate certainty evidence, there is probably little or no difference between oral prucalopride and placebo in defecation frequency, treatment success, or adverse events. For all other comparisons, the certainty of the evidence for our predefined primary outcomes is very low due to serious concerns with study limitations and imprecision. Consequently, no robust conclusions could be drawn. Plain language summary Management of intractable constipation in children Key messages • There may be little to no difference between lubiprostone and placebo (dummy treatment) in achieving treatment success in children with intractable constipation. We also found that lubiprostone is probably as safe as placebo. • There is probably little or no difference between prucalopride, also a laxative, and placebo in frequency of defecation per day, treatment success, and safety. • It is unclear whether any of the other treatments we looked at are helpful. The evidence is uncertain because of the very low number of study participants and problems with how the research was reported. • Currently, there is not an agreed‐upon definition for intractable constipation. To develop further evidence on therapies for intractable constipation, researchers must use the same definition. We would encourage further work to come up with an agreed‐upon definition. What is intractable constipation? Constipation in children is a common problem. If doctors cannot find an underlying cause for the symptoms, it is called functional constipation. The symptoms of constipation include lower frequency of defecation, bowel incontinence or soiling, and stomach pain. Constipation can be mild and respond well to standard treatments, such as behavioural changes or laxatives. However, it can also be more severe or last for a long time. We defined intractable constipation as constipation that persists despite standard treatments. What did we want to find out? We wanted to find out which treatments are helpful and safe for treating children (between 0 and 18 years of age) with constipation that has not responded to standard medical treatments (intractable constipation). This extreme level of constipation can impact a child's life in very negative ways, such as keeping them away from school and other daily activities; causing them pain, discomfort, and general distress; and requiring hospital visits for treatment. Consequently, there is a need to investigate if the tested therapies can help resolve the problem. What did we do? We considered any medication, surgical procedure, or therapy to help children with intractable constipation. Each study compared a specific treatment to placebo, no treatment, or another treatment. We were interested in whether the treatments increased the frequency of defecation, improved symptoms, or led to treatment success. We also wanted to know if the treatments were safe, so we looked at whether they caused side effects. We searched for randomised controlled trials (studies in which people are randomly assigned to one of two or more treatment groups) comparing any medical, surgical, or complementary therapy versus no treatment, placebo, or another treatment in children with intractable constipation. What did we find? We found 10 studies involving a total of 1278 children. The average age of study participants ranged from around 5 to 10 years. The studies were conducted in Iran, Brazil, Colombia, the USA, Canada, Australia, and several European countries. Studies lasted from one to six months. The studies made the following comparisons: • botox injection versus stool softeners; • erythromycin versus placebo; • lubiprostone versus placebo; • rectal sodium dioctyl sulfosuccinate and sorbitol versus oral polyethylene glycol laxatives; • biofeedback therapy versus no treatment; • intrarectal electromotive botox injection versus a usual botox injection; • botox injection versus myectomy of the internal anal sphincter; • prucalopride versus placebo; • transcutaneous electrical stimulation versus sham stimulation; and • dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. Main results • There may be little to no difference between lubiprostone and placebo in achieving treatment success, and there is probably little to no difference in adverse events for this comparison. • There is probably little or no difference between prucalopride and placebo in defecation frequency, treatment success, and adverse events. • We do not know whether any of the other treatments looked at in this review are safer or more beneficial than others. What are the limitations of the evidence? The evidence is limited due to small participant numbers in the included studies, and because each study looked at a different comparison, both of which resulted in the evidence being imprecise. There were also issues with the way the studies were conducted, which led to concerns that study results might be biased. How up‐to‐date is this evidence? This review is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gordon, M, Grafton-Clarke, C, Rajindrajith, S, Benninga, M, Sinopoulou, V, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD014580.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.084Z" }, { "id": "34dd3e70-8393-4dec-8fb9-1f2dfb77f244", "pmid": "", "title": "Intranasal steroids for acute sinusitis", "imported": false, "abstract": "Abstract - Background Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school. Objectives We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis in adults and children. Search methods We searched CENTRAL 2013, Issue 4, MEDLINE (January 1966 to May week 2, 2013), EMBASE (1990 to May 2013) and bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) comparing INCS treatment to placebo or no intervention in adults and children with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop‐outs before the end of the study, rates of relapse, complications and return to school or work. Data collection and analysis Two review authors independently extracted data, assessed trial quality and resolved discrepancies by consensus. Main results No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well‐designed and double‐blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow‐up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta‐analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% confidence interval (CI) 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop‐out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS. Authors' conclusions Current evidence is limited for acute sinusitis confirmed by radiology or nasal endoscopy but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy. Plain language summary Steroids for acute sinusitis in adults and children Acute sinusitis is a common reason for primary care visits; it is one of the 10 most common diagnoses in outpatient clinics, presenting with various symptoms and signs that include purulent nasal discharge and congestion and cough lasting beyond the typical seven to 10 days of a viral upper respiratory infection. There have been suggestions, based on studies of allergic rhinitis and chronic sinusitis, that intranasal corticosteroids (INCS) may relieve symptoms and hasten recovery in acute sinusitis due to their anti‐inflammatory properties. A critical systematic review of the literature found four well‐conducted, randomised, placebo‐controlled intervention studies, involving 1943 participants treated for 15 or 21 days. The results suggest that there may be a modest effect with INCS in the resolution or improvement of symptoms. Only minor adverse events such as epistaxis, headache and nasal itching were reported. Given the small number of studies included in this review, it is recommended that further randomised controlled trials be conducted. The evidence is up to date as of May 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zalmanovici Trestioreanu, A, Yaphe, J", "articleTypes": [], "doi": "10.1002/14651858.CD005149.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.742Z" }, { "id": "34e0ce9f-89ad-4629-b354-5b1835df820b", "pmid": "", "title": "Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults", "imported": false, "abstract": "Abstract - Background The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non‐opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. Objectives To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. Selection criteria We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. Data collection and analysis We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. Main results We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after). The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies. IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) −0.50, 95% confidence interval (CI) −0.72 to −0.28; 29 studies, 1656 participants; very low‐quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD −0.14, 95% CI −0.25 to −0.04; 33 studies, 1847 participants; moderate‐quality evidence), and at late time points (48 hours) (SMD −0.11, 95% CI −0.25 to 0.04; 24 studies, 1404 participants; moderate‐quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures. We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) −7.92 hours, 95% CI −12.71 to −3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD −4.52 mg morphine equivalents , 95% CI −6.25 to −2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes. The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low‐quality evidence). IV Lidocaine compared to TEA The effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI −0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI −1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD −1.66, 95% CI −10.88 to 7.56; 2 studies, 102 participants); all very low‐quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low‐quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low‐quality evidence). Authors' conclusions We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review. Plain language summary Intravenous infusion of lidocaine starting at the time of surgery for reduction of pain and improvement of recovery after surgery Background The most common problems immediately following surgery under general anaesthesia are pain, nausea and vomiting, delirium and slow or no movement of food through the digestive system. Opioid medications given to reduce postoperative pain may also be associated with nausea and constipation, also preventing a smooth recovery. It is of interest for patients and clinicians to reduce or prevent these complications leading to an early recovery so that patients can leave hospital earlier. One option for pain relief after surgery is epidural analgesia, where an opioid or local anaesthetic such as lidocaine is injected into the space surrounding the spinal cord. Not all patients may be suited to epidural analgesia, and so additional options such as intravenous non‐opioid analgesic medications that enable a rapid recovery are required. The aim of this review was to assess the benefits and risks of intravenous infusion of lidocaine in patients undergoing various surgical procedures. Lidocaine is a medication used to numb tissue in a specific area. Study characteristics This review was published in 2015, and updated in 2017. We found 68 randomized controlled studies (RCTs), (clinical studies where people are randomly put into one of two or more treatment groups), with results from a total of 4525 participants. RCTs are used because they provide the most reliable evidence. Intravenous lidocaine was compared with placebo or standard care in 66 of the studies, and with thoracic (chest area of spine) epidural analgesia in two studies. (A placebo is an inactive substance or procedure given to a participant in a medical trial to compare its effects with those of a real drug or other intervention). Lidocaine infusion was started during the surgery, before the first cut, and continued to at least the end of surgery. The included studies were moderately well conducted. Key results We are uncertain whether lidocaine infusion reduces pain, one to four hours after surgery when compared to placebo or usual care (29 studies, over 1600 participants). There was probably no difference in pain at 24 hours (33 studies, 1847 participants) and at 48 hours (24 studies, 1404 participants) between participants in the lidocaine and the placebo group. We are uncertain whether lidocaine infusion improves recovery of bowel function, with a reduction in the time to first defaecation or bowel movements (12 studies, 684 participants), and reduced risk of stopping the passage of food in the gut (4 studies, 273 participants). We are also uncertain whether lidocaine reduces postoperative nausea (35 studies, 1903 participants), and the requirement for opioids for pain relief (40 studies, 2201 participants). Only a limited number of studies systematically analysed adverse effects of intravenous lidocaine infusion. The side effects of intravenous lidocaine were unclear. In the two studies that investigated intravenous lidocaine compared to epidural analgesia (102 participants), the effect on pain at 24 and 48 hours, and on the time to first bowel movement, remains unclear. The effect of lidocaine on the risk of stopping the passage of food in the gut and for postoperative nausea is also unclear, as only one small trial assessed these outcomes. Neither study investigated the effect on pain immediately after surgery, or on opioid consumption. Both studies looked at adverse effects associated with lidocaine, but the effect is uncertain. Quality of the evidence We rated the quality of evidence for most outcomes as very low. This was because of inconsistent findings across studies and the fact that the evidence came from small studies that were of moderate design quality or a limited number of studies. The quality of the evidence for minimal or no effect on pain at 24 and 48 hours was moderate quality. The studies involved a variety of surgical procedures. The dose of lidocaine used, and how long it was delivered for after the end of surgery, also varied between studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Weibel, S; Jelting, Y; Pace, NL; Helf, A; Eberhart, LHJ; Hahnenkamp, K; Hollmann, MW; Poepping, DM; Schnabel, A; Kranke, P", "articleTypes": [], "doi": "10.1002/14651858.CD009642.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "34f4b8f5-a29f-446e-9f89-75bdcbc5aa4d", "pmid": "", "title": "Expression of Bitter Taste Receptors in Oropharynx Carcinoma", "imported": false, "abstract": "The aim of this work is to investigate the expression of the bitter taste receptors in p16-positive and negative oropharyngeal carcinomas (in comparison to healthy, local tissue).", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "350b800a-174a-4670-9e3c-1dc9658b52a2", "pmid": "", "title": "Synbiotics, prebiotics and probiotics for people with chronic kidney disease", "imported": false, "abstract": "Abstract - Background Chronic kidney disease (CKD) is a major public health problem affecting 13% of the global population. Prior research has indicated that CKD is associated with gut dysbiosis. Gut dysbiosis may lead to the development and/or progression of CKD, which in turn may in turn lead to gut dysbiosis as a result of uraemic toxins, intestinal wall oedema, metabolic acidosis, prolonged intestinal transit times, polypharmacy (frequent antibiotic exposures) and dietary restrictions used to treat CKD. Interventions such as synbiotics, prebiotics, and probiotics may improve the balance of the gut flora by altering intestinal pH, improving gut microbiota balance and enhancing gut barrier function (i.e. reducing gut permeability). Objectives This review aimed to evaluate the benefits and harms of synbiotics, prebiotics, and probiotics for people with CKD. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria We included randomised controlled trials (RCTs) measuring and reporting the effects of synbiotics, prebiotics, or probiotics in any combination and any formulation given to people with CKD (CKD stages 1 to 5, including dialysis and kidney transplant). Two authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. Data collection and analysis Data extraction was independently carried out by two authors using a standard data extraction form. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross‐checked by another. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Forty‐five studies (2266 randomised participants) were included in this review. Study participants were adults (two studies in children) with CKD ranging from stages 1 to 5, with patients receiving and not receiving dialysis, of whom half also had diabetes and hypertension. No studies investigated the same synbiotic, prebiotic or probiotic of similar strains, doses, or frequencies. Most studies were judged to be low risk for selection bias, performance bias and reporting bias, unclear risk for detection bias and for control of confounding factors, and high risk for attrition and other biases. Compared to prebiotics, it is uncertain whether synbiotics improve estimated glomerular filtration rate (eGFR) at four weeks (1 study, 34 participants: MD ‐3.80 mL/min/1.73 m², 95% CI ‐17.98 to 10.38), indoxyl sulfate at four weeks (1 study, 42 participants: MD 128.30 ng/mL, 95% CI ‐242.77 to 499.37), change in gastrointestinal (GI) upset (borborymgi) at four weeks (1 study, 34 participants: RR 15.26, 95% CI 0.99 to 236.23), or change in GI upset (Gastrointestinal Symptom Rating Scale) at 12 months (1 study, 56 participants: MD 0.00, 95% CI ‐0.27 to 0.27), because the certainty of the evidence was very low. Compared to certain strains of prebiotics, it is uncertain whether a different strain of prebiotics improves eGFR at 12 weeks (1 study, 50 participants: MD 0.00 mL/min, 95% CI ‐1.73 to 1.73), indoxyl sulfate at six weeks (2 studies, 64 participants: MD ‐0.20 μg/mL, 95% CI ‐1.01 to 0.61; I² = 0%) or change in any GI upset, intolerance or microbiota composition, because the certainty of the evidence was very low. Compared to certain strains of probiotics, it is uncertain whether a different strain of probiotic improves eGFR at eight weeks (1 study, 30 participants: MD ‐0.64 mL/min, 95% CI ‐9.51 to 8.23; very low certainty evidence). Compared to placebo or no treatment, it is uncertain whether synbiotics improve eGFR at six or 12 weeks (2 studies, 98 participants: MD 1.42 mL/min, 95% CI 0.65 to 2.2) or change in any GI upset or intolerance at 12 weeks because the certainty of the evidence was very low. Compared to placebo or no treatment, it is uncertain whether prebiotics improves indoxyl sulfate at eight weeks (2 studies, 75 participants: SMD ‐0.14 mg/L, 95% CI ‐0.60 to 0.31; very low certainty evidence) or microbiota composition because the certainty of the evidence is very low. Compared to placebo or no treatment, it is uncertain whether probiotics improve eGFR at eight, 12 or 15 weeks (3 studies, 128 participants: MD 2.73 mL/min, 95% CI ‐2.28 to 7.75; I² = 78%), proteinuria at 12 or 24 weeks (1 study, 60 participants: MD ‐15.60 mg/dL, 95% CI ‐34.30 to 3.10), indoxyl sulfate at 12 or 24 weeks (2 studies, 83 participants: MD ‐4.42 mg/dL, 95% CI ‐9.83 to 1.35; I² = 0%), or any change in GI upset or intolerance because the certainty of the evidence was very low. Probiotics may have little or no effect on albuminuria at 12 or 24 weeks compared to placebo or no treatment (4 studies, 193 participants: MD 0.02 g/dL, 95% CI ‐0.08 to 0.13; I² = 0%; low certainty evidence). For all comparisons, adverse events were poorly reported and were minimal (flatulence, nausea, diarrhoea, abdominal pain) and non‐serious, and withdrawals were not related to the study treatment. Authors' conclusions We found very few studies that adequately test biotic supplementation as alternative treatments for improving kidney function, GI symptoms, dialysis outcomes, allograft function, patient‐reported outcomes, CVD, cancer, reducing uraemic toxins, and adverse effects. We are not certain whether synbiotics, prebiotics, or probiotics are more or less effective compared to one another, antibiotics, or standard care for improving patient outcomes in people with CKD. Adverse events were uncommon and mild. Plain language summary Prebiotics (dietary fibre), probiotics (good bacteria) or synbiotics (prebiotics plus probiotics) for people with chronic kidney disease Key messages Chronic kidney disease (CKD) is a serious health problem that affects over 850 million people worldwide. People with kidney disease have an unhealthy balance of good and bad bacteria in their guts, called 'gut dysbiosis'. This imbalance arises because of the effects of reduced kidney function (retained toxic waste products, fluid retention causing the gut wall to swell), drugs frequently used in people with CKD (especially antibiotics), and dietary restrictions placed on people with CKD. Gut dysbiosis can, in turn, cause or worsen CKD because bacteria can produce toxins that cross the bowel wall and damage the kidneys. Gut dysbiosis can also cause stomach problems (like bloating, cramping, constipation and diarrhoea) and reduce quality of life. To improve the balance of the gut flora, good bacteria can be taken in tablets of high doses of prebiotics and probiotics. Prebiotics, or indigestible plant fibre, can encourage the growth of good bacteria. Synbiotics are a combination of prebiotics and probiotics. Some research suggests that taking high doses of the good bacteria can re‐balance the good bacteria in people's gut, thereby improving bowel symptoms and the conditions that lead to worsening of CKD. What did we do? We reviewed all of the evidence on synbiotics, prebiotics and probiotics to see whether they can improve outcomes in people who have CKD (all stages 1 to 5). What did we find? We found 45 studies randomising 2266 participants. Half of these looked at participants receiving dialysis (mostly haemodialysis), and the other half not receiving dialysis. Half also had diabetes and hypertension. We are uncertain whether synbiotics, prebiotics, or probiotics improve bowel outcomes, quality of life, kidney toxin levels or kidney function. The quality of the evidence that we found is low quality and very low certainty. All studies were conducted using moderate to poor‐quality methods with too few patients. Summary Currently, we do not have enough information from trials to know whether synbiotics, prebiotics or probiotics work to improve bowel symptoms, quality of life, kidney toxin levels, or kidney function in people with CKD. Ten studies are currently ongoing; therefore, it is possible that findings may change with the inclusion of these studies in future updates. The evidence is up to date to 9 October 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Cooper, TE; Khalid, R; Chan, S; Craig, JC; Hawley, CM; Howell, M; Johnson, DW; Jaure, A; Teixeira-Pinto, A; Wong, G", "articleTypes": [], "doi": "10.1002/14651858.CD013631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "35371e81-071e-452c-bde3-81ab185ca565", "pmid": "", "title": "Desmopressin for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐old children and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Desmopressin has been used to treat bedwetting since the 1970s. This is an update of a Cochrane review first published in 2000 and last updated in 2006. Objectives To assess the effects of desmopressin on treating nocturnal enuresis in children. Search methods We searched Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched January 2023) and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of desmopressin or desmopressin combined with another intervention for treating nocturnal enuresis in children between five and 16 years old. Data collection and analysis Three review authors independently extracted data and assessed the risk of bias in the eligible trials. We used standard methodological procedures expected by Cochrane. Main results We identified 50 new studies for this review, which now includes 95 studies (8473) participants, of whom 5434 received desmopressin. In this review we continued the assessment of the effect of combination therapy involving desmopressin. The majority of the trials were in children between the ages of five to 16 years in an outpatient setting. The quality of the evidence was assessed as low or very low. The first comparison was desmopressin versus placebo. Desmopressin may reduce the mean number of wet nights per week compared with placebo (MD ‐1.81, 95% CI ‐2.24 to ‐1.39; participants = 1267; studies = 16; low‐certainty evidence). Desmopressin probably leads to more children achieving 14 consecutive dry nights by the end of treatment compared with placebo (RR 3.18, 95% CI 1.75 to 5.80; participants = 922: studies = 11; moderate‐certainty evidence). There may be little to no difference in children experiencing adverse effects with desmopressin compared to placebo (RR 1.11, 95% CI 0.81 to 1.52; participants = 269; studies = 3; low‐certainty evidence). Desmopressin was compared with alarm therapy. It is uncertain if there is any difference between desmopressin compared with alarm training in reducing the number of wet nights per week (MD 0.63, 95% CI ‐0.49 to 1.75; participants = 285; studies = 4; I 2 = 82%; very low‐certainty evidence). There may be little or no difference between desmopressin and alarm therapy in the number of children achieving 14 consecutive dry nights (RR 0.98, 95% CI 0.88 to 1.09; participants = 1530; studies = 15; low‐certainty evidence). There may be little to no difference in children experiencing side effects with desmopressin therapy compared with alarm therapy (RR 1.50, 95% CI 0.33 to 6.78; participants = 461, studies = 4; low‐certainty evidence). We compared desmopressin with other medications, including tricyclics and anticholinergics. It is uncertain if there is any difference between desmopressin compared to tricyclics in reducing the mean number of wet nights per week (MD 0.23, 95% CI ‐ 0.88 to 1.33; participants = 331; studies = 4; I 2 = 79%; very low‐certainty evidence) or in the number of children achieving 14 consecutive dry nights at the end of treatment (RR 0.94, 95% CI 0.63 to 1.38; participants = 371; studies = 7; I 2 = 71%; very low‐certainty evidence). It is uncertain whether children experience more side effects with desmopressin compared with tricyclics (RR 0.29, 95%CI 0.06 to 1.39; participants = 351; studies = 4, very low‐certainty evidence). This review included studies with combination therapies. It is uncertain if desmopressin combined with alarm therapy reduces the mean number of wet nights at the end of treatment compared with alarm monotherapy (MD ‐0.80, 95% CI ‐1.34 to ‐0.25; participants = 528; studies = 6; I 2 = 84%; very low‐certainty evidence); or if it increases the number of children achieving 14 consecutive dry nights (RR 1.25, 95% CI 0.96 to 1.63; participants = 822; studies = 10; very low‐certainty evidence). Desmopressin plus alarm therapy may make little to no difference in children experiencing side effects compared with alarm therapy alone (RR 1.05 95% CI 0.07 to 16.56; participants = 207; studies = 1; low‐certainty evidence). Combining desmopressin with alarm therapy probably reduces the number of wet nights at the end of treatment (MD ‐0.88; 95%CI ‐1.38 to ‐0.38; participants = 156; studies = 2; moderate‐certainty evidence), and may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin monotherapy (RR 1.26, 95% CI 1.06 to 1.51; participants = 370; studies = 5; low‐certainty evidence). It is uncertain if combined desmopressin and anticholinergic therapy versus desmopressin monotherapy reduces the mean number of wet nights at the end of therapy (MD ‐0.50; 95% CI ‐1.05 to 0.06; participants = 188; studies = 3; I 2 = 66%; very low‐certainty evidence); or if it may increase the number of children achieving 14 consecutive dry nights at the end of treatment (RR 1.53, 95% CI 1.10 to 2.11; participants = 611; studies = 8; low‐certainty evidence). There may be little to no difference in adverse events between desmopressin plus anticholinergics and desmopressin monotherapy (RR 1.51 95% CI 0.73 to 3.09, participants = 187; studies =2; low‐certainty evidence). Minor adverse effects were common for desmopressin, including dizziness, headache, mood changes, gastrointestinal discomfort, nasal discomfort, hyponatraemia and one report of a convulsion. Authors' conclusions Desmopressin compared with placebo may increase the number of dry nights per week at the end of treatment in children. Desmopressin therapy may be as effective as alarm therapy at the end of treatment. However, the quality of evidence was assessed as low or very low. Alarm therapy compared to desmopressin may improve the number of children who are dry at follow‐up (moderate‐certainty evidence). Plain language summary Desmopressin for bedwetting in children Review question Is desmopressin an effective treatment for bedwetting in children? Key messages: Desmopressin may improve bedwetting. Only one study assessed quality of life. Further studies with good patient numbers are required. What is enuresis? What does desmopressin do ? Enuresis or bedwetting is involuntary wetting during sleep at an age when a child should be dry, usually at age five. The generally quoted prevalence rates (that is the proportion of a population with bedwetting in a given time period) are 15% to 20% of five‐year‐olds, 7% of seven‐year‐olds, 5% of 10‐year‐old children, and 2% to 3% of teenagers. Various treatments have been used to treat bedwetting. Desmopressin is a man‐made form of vasopressin, a chemical released from the brain that helps control the amount of urine made by the kidneys. Desmopressin is used to control bedwetting at night and reduces the number of bedwetting episodes. Why was it important to do this review? Although bedwetting is not a harmful condition and, with time, stops spontaneously, it is stigmatising and can impact the child’s quality of life, emotional and psychological wellbeing. It is a condition that unsettles the whole family and the affected children may suffer parental discontentment, teasing and may be at risk of physical or emotional abuse. Successful therapies that reduce bedwetting improve the child's self‐esteem and, therefore, it is important to see if desmopressin is as effective as other known treatments. How is the condition treated ? • Desmopressin therapy • Alarm therapy • Anticholinergic medications • Combination therapy – such as desmopressin and alarm therapy compared to desmopressin therapy There are several other therapies, such as behavioural therapies and laser therapy, though we have concentrated on the main therapies utilised. What did we want to find out? We wanted to see if desmopressin: • was effective in reducing the episodes of wet nights children may have; • was as effective as other treatments such as alarm therapy in treating bedwetting; • worked in combination with other treatments; • was associated with any unwanted effects. What did we do? We searched for studies where people were randomly placed into different treatment groups. We searched for and included studies that compared: • desmopressin with no treatment or placebo; • desmopressin and alarm therapy; • combination treatments of desmopressin and alarm. We compared and analysed our results, then rated our confidence in the evidence based on factors such as study methods and size of the studies. What did we find? We found 98 studies with 8699 participants, of whom 5616 received desmopressin. Main results • We found the use of desmopressin compared with placebo may improve wetting by giving children one more dry night a week while receiving treatment. This suggests that more children may stop wetting while using desmopressin (28% versus 1% who are given placebo or no treatment). • More children who received desmopressin therapy compared with placebo probably achieved 14 consecutive dry nights at the end of treatment. • We found that, when desmopressin was compared with alarm therapy, there was little to no difference in the number of children achieving 14 dry nights in a row. The evidence is also uncertain if desmopressin versus alarm therapy reduces the number of dry nights per week. • We found that combining desmopressin with alarm therapy may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin alone. • We found that side effects were commonly reported for desmopressin. These included dizziness, headache, mood changes, abdominal discomfort, nasal discomfort, hyponatraemia (low sodium level) and one report of a seizure. Thirty‐two studies reported no adverse effects occurring, and 25 studies omitted to report or mention adverse effects. What are the limitations of the evidence? We, however, have little confidence in the evidence as, in several studies, participants were aware of the therapy they were receiving, and several studies were very small. How up‐to‐date is this review? The evidence is current up to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hahn, D; Stewart, F; Raman, G", "articleTypes": [], "doi": "10.1002/14651858.CD002112.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "354245bb-aeb7-4347-afe1-1bfc81e0cf75", "pmid": "", "title": "Open versus closed surgical exposure of canine teeth that are displaced in the roof of the mouth", "imported": false, "abstract": "Abstract - Background Palatally displaced canines or PDCs are upper permanent canines, commonly known as 'eye' teeth, that are displaced in the roof of the mouth. This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. PDCs are a frequent dental anomaly, present in 2% to 3% of young people. Management of this problem is both time consuming and expensive. It involves surgical exposure (uncovering) followed by fixed braces for two to three years to bring the canine into alignment within the dental arch. Two techniques for exposing palatal canines are routinely used in the UK: the closed technique and the open technique. The closed technique involves uncovering the canine, attaching an eyelet and gold chain and then suturing the palatal mucosa back over the tooth. The tooth is then moved into position covered by the palatal mucosa. The open technique involves uncovering the canine tooth and removing the overlying palatal tissue to leave it uncovered. The orthodontist can then see the crown of the canine to align it. Objectives To assess the effects of using either an open or closed surgical method to expose canines that have become displaced in the roof of the mouth, in terms of success and other clinical and patient‐reported outcomes. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 24 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (in the Cochrane Library, 2017, Issue 1), MEDLINE Ovid (1946 to 24 February 2017), and Embase Ovid (1980 to 24 February 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised and quasi‐randomised controlled trials assessing young people receiving surgical treatment to correct upper PDCs. There was no restriction on age, presenting malocclusion or type of active orthodontic treatment undertaken. We included unilaterally and bilaterally displaced canines. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias in the included studies. We attempted to contact study authors for missing data or clarification where feasible. We followed statistical guidelines from the Cochrane Handbook for Systematic Reviews of Interventions for data synthesis. Main results We included three studies, involving 146 participants. Two studies were assessed as being at high risk of bias. The main finding of the review was that the two techniques may be equally successful at exposing PDCs (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.93 to 1.06; three studies, 141 participants analysed, low‐quality evidence). One surgical failure was due to detachment of the gold chain (closed group). One study reported on complications following surgery and found two in the closed group: a post‐operative infection requiring antibiotics and pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to pool data for dental aesthetics, patient‐reported pain and discomfort, periodontal health and treatment time; however, individual studies did not find any differences between the surgical techniques (low‐ to very low‐quality evidence). Authors' conclusions Currently, the evidence suggests that neither the open or closed surgical technique for exposing palatally displaced maxillary canine teeth is superior for any of the outcomes included in this review; however, we considered the evidence to be low quality, with two of the three included studies being at high risk of bias. This suggests the need for more high‐quality studies. Three ongoing clinical trials have been identified and it is hoped that these will produce data that can be pooled to increase the degree of certainty in these findings. Plain language summary Open versus closed surgical exposure of eye teeth that are displaced in the roof of the mouth Review question Is it better to use an open or closed surgical method to expose eye teeth ('canines') that have become displaced in the roof of the mouth? Background Permanent canine teeth in the upper jaw usually erupt into the mouth between the ages of 11 to 12 years. In 2% to 3% of young people, the canine teeth fail to erupt (grow down) and become displaced in the roof of the mouth (palate).This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. Management of this problem is both time consuming and expensive. It usually involves surgical exposure (uncovering), followed by fixed orthodontic braces for two to three years, to move the canine into the correct position. Two surgical techniques are routinely used in the UK: the closed technique involves uncovering the buried tooth, gluing an attachment onto the exposed tooth and repositioning the palatal flap. Shortly after surgery, an orthodontic brace is used to apply gentle forces to bring the canine into its correct position within the dental arch. The canine moves into position beneath the gum. An alternative method is the open technique, which involves surgically uncovering the canine tooth as before, but instead of placing an attachment onto the exposed tooth, a window of gum from around the tooth is removed and a dressing (pack) placed to cover the exposed area. Approximately 10 days later, this pack is removed and the canine is allowed to erupt naturally. Once the tooth has erupted sufficiently for an orthodontic attachment to be glued onto its surface, orthodontic braces are used to bring the tooth in line with the other teeth. Study characteristics The evidence in this review is up‐to‐date as of February 2017. Authors with Cochrane Oral Health found three relevant studies, involving 146 participants who had eye teeth displaced in the roof of the mouth, either on one or both sides. The majority of participants were female and the average age in the studies ranged from 14 to 17 years. Two studies were designed in a way that made them likely to be biased. Key results We combined results from three studies and found that one technique did not seem to have an advantage over the other for ensuring the movement of the tooth into the correct position without the need for repeat surgery. Five out of 141 participants analysed were surgical failures, one of which was due to the complication of detachment of the gold chain during surgery. One study reported complications after surgery and found one participant in the closed group had a post‐operative infection requiring antibiotics and another participant in the closed group experienced pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to combine results from studies for any other outcomes, but individual studies did not show evidence of a difference between the two techniques for pain, discomfort, appearance, gum health, length of treatment time or cost (low to very low quality evidence). Quality of the evidence Overall, we assessed the quality of the evidence as low, which means we cannot be certain of the findings. Author conclusions It does not seem that one surgical technique is better than the other for moving displaced eye teeth into the correct position, or for other outcomes, but this finding is uncertain because the quality of the evidence is low. This suggests the need for more high‐quality studies. Three studies are currently in process. When they are completed, we will include them in an update of this review and may be able to reach firmer conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Parkin, N; Benson, PE; Thind, B; Shah, A; Khalil, I; Ghafoor, S", "articleTypes": [], "doi": "10.1002/14651858.CD006966.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "355e04a9-c119-4640-bc87-2fb37676606a", "pmid": "", "title": "Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common, life‐shortening, genetic disorder in populations of Northern European descent caused by the mutation of a single gene that codes for the production of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. This protein coordinates the transport of salt (and bicarbonate) across cell surfaces, and the mutation most notably affects the airways. In the lungs of people with CF, the defective protein compromises mucociliary clearance and makes the airway prone to chronic infection and inflammation, damaging the structure of the airways and eventually leading to respiratory failure. In addition, abnormalities in the truncated CFTR protein lead to other systemic complications, including malnutrition, diabetes and subfertility. Five classes of mutation have been described, depending on the impact of the mutation on the processing of the CFTR protein in the cell. In class I mutations, premature termination codons prevent the production of any functional protein, resulting in severe CF. Therapies targeting class I mutations aim to enable the normal cellular mechanism to read through the mutation, potentially restoring the production of the CFTR protein. This could, in turn, normalise salt transport in the cells and decrease the chronic infection and inflammation that characterises lung disease in people with CF. This is an update of a previously published review. Objectives To evaluate the benefits and harms of ataluren and similar compounds on clinically important outcomes in people with CF with class I mutations (premature termination codons). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles. The last search of the Cochrane Cystic Fibrosis Trials Register was conducted on 7 March 2022. We searched clinical trial registries maintained by the European Medicines Agency, the US National Institutes of Health and the World Health Organization. The last search of the clinical trials registries was conducted on 4 October 2022. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing ataluren and similar compounds (specific therapies for class I mutations) with placebo in people with CF who have at least one class I mutation. Data collection and analysis For the included trials, the review authors independently extracted data, assessed the risk of bias and evaluated the certainty of the evidence using GRADE; trial authors were contacted for additional data. Main results Our searches identified 56 references to 20 trials; of these, 18 trials were excluded. Both the included parallel RCTs compared ataluren to placebo for 48 weeks in 517 participants (males and females; age range six to 53 years) with CF who had at least one nonsense mutation (a type of class I mutation). The certainty of evidence and risk of bias assessments for the trials were moderate overall. Random sequence generation, allocation concealment and blinding of trial personnel were well documented; participant blinding was less clear. Some participant data were excluded from the analysis in one trial that also had a high risk of bias for selective outcome reporting. PTC Therapeutics Incorporated sponsored both trials with grant support from the Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the National Institutes of Health. The trials reported no difference between treatment groups in terms of quality of life, and no improvement in respiratory function measures. Ataluren was associated with a higher rate of episodes of renal impairment (risk ratio 12.81, 95% confidence interval 2.46 to 66.65; P = 0.002; I 2 = 0%; 2 trials, 517 participants). The trials reported no treatment effect for ataluren for the review's secondary outcomes of pulmonary exacerbation, computed tomography score, weight, body mass index and sweat chloride. No deaths were reported in the trials. The earlier trial performed a post hoc subgroup analysis of participants not receiving concomitant chronic inhaled tobramycin (n = 146). This analysis demonstrated favourable results for ataluren (n = 72) for the relative change in forced expiratory volume in one second (FEV 1 ) per cent (%) predicted and pulmonary exacerbation rate. The later trial aimed to prospectively assess the efficacy of ataluren in participants not concomitantly receiving inhaled aminoglycosides, and found no difference between ataluren and placebo in FEV 1 % predicted and pulmonary exacerbation rate. Authors' conclusions There is currently insufficient evidence to determine the effect of ataluren as a therapy for people with CF with class I mutations. One trial reported favourable results for ataluren in a post hoc subgroup analysis of participants not receiving chronic inhaled aminoglycosides, but these were not reproduced in the later trial, suggesting that the earlier results may have occurred by chance. Future trials should carefully assess for adverse events, notably renal impairment, and consider the possibility of drug interactions. Cross‐over trials should be avoided, given the potential for the treatment to change the natural history of CF. Plain language summary Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis Review question Can ataluren (and similar compounds specifically targeting class I mutations in cystic fibrosis (CF)) improve the quality of life and lung function of people with CF without having adverse effects? Key messages What is CF? In people with CF, the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. This especially affects the airways, causing the airway surface to dry out and making it difficult to clear thick mucus. This leads to progressive infection and damages the lungs, shortening life expectancy. How will ataluren treat CF? In people with certain CF genetic mutations where the genetic instructions for producing the CFTR protein are interrupted (known as premature termination codon or class I mutations), ataluren (and similar medicines) may be able to skip over the break in the faulty gene sequence and allow the body to produce a corrected version of the CFTR protein. By correcting the protein, the airway surface should remain hydrated, allowing people with CF to better clear their mucus and so develop fewer lung infections. What did we want to find out? We wanted to know whether ataluren can improve the quality of life and lung function of people with CF, and whether it can do so without any side effects. We also wanted to measure the effects on lung infections (need for hospital visits or additional antibiotics), survival, nutritional status (weight, body mass index and height) and whether treatment was cost‐effective. What did we do? We searched for trials that directly compared drugs such as ataluren to placebo (treatment not containing an active drug) or to a different treatment for these specific genetic mutations in any people with CF. What did we find? We found two trials including 517 people (males and females between 6 and 53 years of age) comparing ataluren to a placebo. The trials lasted 48 weeks and everyone taking part in the trials had at least one gene with a class I mutation. Key results In people taking ataluren, there was no improvement in clinical outcomes such as quality of life, lung function, exacerbations (flare up of disease), sweat chloride (salt) levels or weight compared with people taking placebo. The trials found that kidney damage was more common in people taking ataluren. The earlier trial analysed their results in a way not originally planned to see whether the effects of ataluren and placebo were different in people using inhaled tobramycin (an antibiotic) on a long‐term basis compared with people not taking the inhaled antibiotic. In people taking ataluren but not using inhaled tobramycin, lung function declined at a slower rate and there were fewer exacerbations than in people in the placebo group also not using inhaled tobramycin. The later trial specifically recruited people not taking tobramycin to see whether this really was an effect of the antibiotic, but the investigators did not find any difference between the ataluren and placebo groups for changes in lung function or exacerbations. This suggests that the earlier results occurred by chance. There were no deaths and we did not find any differences between ataluren and placebo in side effects or nutritional status. Neither trial reported on hospitalisations, extra courses of antibiotics or cost‐effectiveness. We have not found enough high‐quality evidence to determine the effect of ataluren for treating CF. We recommend that future trials are designed and reported clearly so that their results can be included in a systematic review. What are the limitations of the evidence? We are moderately confident in our findings, but there is some uncertainty due to how widely the results varied between participants. We are satisfied that everyone taking part had an equal chance of being in either group (ataluren or placebo) and that no one could work out which group the next person would be put into (so that healthier people did not receive the treatment and make the results seem better). We believe that the clinicians running the trials and those taking part in the trials did not know which treatment each person was receiving. We have some concerns about the emphasis the investigators of one trial placed on the results of a comparison they had not planned (the use of long‐term inhaled tobramycin). Unfortunately, that trial did not report all its results clearly. Sometimes, the results were reported in a way that meant they could not be used in this review, and sometimes the information was not reported at all. This affected our confidence in the overall results. Trial funding sources Both trials were sponsored by PTC Therapeutics Incorporated, who make ataluren. The Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the US National Institutes of Health also supported the trials. How up to date is this evidence? We last searched for evidence on 4 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aslam, AA, Sinha, IP, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD012040.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.744Z" }, { "id": "355f3ea2-fd2c-4cbf-981c-6f998e99fae6", "pmid": "", "title": "Omega‐3 fatty acids for depression in adults", "imported": false, "abstract": "Abstract - Background Major depressive disorder (MDD) is highly debilitating, difficult to treat, has a high rate of recurrence, and negatively impacts the individual and society as a whole. One potential treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, some other seafood, and some nuts and seeds. Various lines of evidence suggest a role for n‐3PUFAs in MDD, but the evidence is far from conclusive. Reviews and meta‐analyses clearly demonstrate heterogeneity between studies. Investigations of heterogeneity suggest different effects of n‐3PUFAs, depending on the severity of depressive symptoms, where no effects of n‐3PUFAs are found in studies of individuals with mild depressive symptomology, but possible benefit may be suggested in studies of individuals with more severe depressive symptomology. Hence it is important to establish their effectiveness in treating MDD. This review updates and incorporates an earlier review with the same research objective (Appleton 2015). Objectives To assess the effects of n‐3 polyunsaturated fatty acids (also known as omega‐3 fatty acids) versus a comparator (e.g. placebo, antidepressant treatment, standard care, no treatment, wait‐list control) for major depressive disorder (MDD) in adults. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO together with trial registries and grey literature sources (to 9 January 2021). We checked reference lists and contacted authors of included studies for additional information when necessary. Selection criteria We included studies in the review if they: used a randomised controlled trial design; provided n‐3PUFAs as an intervention; used a comparator; measured depressive symptomology as an outcome; and were conducted in adults with MDD. Primary outcomes were depressive symptomology (continuous data collected using a validated rating scale) and adverse events. Secondary outcomes were depressive symptomology (dichotomous data on remission and response), quality of life, and non‐completion of studies. Data collection and analysis We used standard methodological procedures as expected by Cochrane. We assessed the certainty of the evidence using GRADE criteria. Main results The review includes 35 relevant studies: 34 studies involving a total of 1924 participants investigated the impact of n‐3PUFA supplementation compared to placebo, and one study involving 40 participants investigated the impact of n‐3PUFA supplementation compared to antidepressant treatment. For the placebo comparison, n‐3PUFA supplementation resulted in a small to modest benefit for depressive symptomology, compared to placebo: standardised mean difference (SMD) (random‐effects model) −0.40 (95% confidence interval (CI) −0.64 to −0.16; 33 studies, 1848 participants; very low‐certainty evidence), but this effect is unlikely to be clinically meaningful. An SMD of 0.40 represents a difference between groups in scores on the HDRS (17‐item) of approximately 2.5 points (95% CI 1.0 to 4.0), where the minimal clinically important change score on this scale is 3.0 points. The confidence intervals include both a possible clinically important effect and a possible negligible effect, and there is considerable heterogeneity between studies. Sensitivity analyses, funnel plot inspection and comparison of our results with those of large well‐conducted trials also suggest that this effect estimate may be biased towards a positive finding for n‐3PUFAs. Although the numbers of individuals experiencing adverse events were similar in intervention and placebo groups (odds ratio (OR) 1.27, 95% CI 0.99 to 1.64; 24 studies, 1503 participants; very low‐certainty evidence), the confidence intervals include a small decrease to a modest increase in adverse events with n‐3PUFAs. There was no evidence for a difference between n‐3PUFA and placebo groups in remission rates (OR 1.13, 95% CI 0.74 to 1.72; 8 studies, 609 participants, low‐certainty evidence), response rates (OR 1.20, 95% CI 0.80 to 1.79; 17 studies, 794 participants; low‐certainty evidence), quality of life (SMD −0.38 (95% CI −0.82 to 0.06), 12 studies, 476 participants, very low‐certainty evidence), or trial non‐completion (OR 0.92, 95% CI 0.70 to 1.22; 29 studies, 1777 participants, very low‐certainty evidence). The evidence on which these results are based was also very limited, highly heterogeneous, and potentially biased. Only one study, involving 40 participants, was available for the antidepressant comparison. This study found no differences between treatment with n‐3PUFAs and treatment with antidepressants in depressive symptomology (mean difference (MD) −0.70, 95% CI −5.88 to 4.48), rates of response to treatment (OR 1.23, 95% CI 0.35 to 4.31), or trial non‐completion (OR 1.00, 95% CI 0.21 to 4.71). Confidence intervals are however very wide in all analyses, and do not rule out important beneficial or detrimental effects of n‐3PUFAs compared to antidepressants. Adverse events were not reported in a manner suitable for analysis, and rates of depression remission and quality of life were not reported. Authors' conclusions At present, we do not have sufficient high‐certainty evidence to determine the effects of n‐3PUFAs as a treatment for MDD. Our primary analyses may suggest a small‐to‐modest, non‐clinically beneficial effect of n‐3PUFAs on depressive symptomology compared to placebo; however the estimate is imprecise, and we judged the certainty of the evidence on which this result is based to be low to very low. Our data may also suggest similar rates of adverse events and trial non‐completion in n‐3PUFA and placebo groups, but again our estimates are very imprecise. Effects of n‐3PUFAs compared to antidepressants are very imprecise and uncertain. More complete evidence is required for both the potential positive and negative effects of n‐3PUFAs for MDD. Plain language summary Omega‐3 fatty acids for depression in adults Why is this review important? Major depressive disorder (MDD) is characterised by depressed mood or a markedly decreased pleasure or interest in all activities, or both. It has negative impacts on the individual and on society, often over the long term. One possible treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, in some other seafood and in some nuts and seeds. Various lines of evidence suggest that n‐3PUFAs may impact on depressive symptoms, but a lot of studies have different findings, making it difficult to draw conclusions. Who will be interested in this review? Health professionals, including general practitioners, mental health and psychiatric specialists; individuals with MDD; and the people around them. What questions does this review aim to answer? Do n‐3PUFAs, compared to an alternative, have an effect on depressive symptoms, negative side effects, rates of recovery, quality of life, and rates of study non‐completion, in individuals with MDD? Which studies were included in the review? This review is an update of earlier work (Appleton 2015), using the same methods. We searched scientific databases for all randomised controlled trials in adults with MDD, where individuals received either n‐3PUFAs or an alternative, that were completed up to January 2021. We have included 35 relevant studies: 34 of them involving 1924 people compared the effects of n‐3PUFAs with those of placebo, and one study involving 40 people compared the effects of n‐3PUFAs with those of antidepressants. All studies were of direct relevance to our review, but we considered the certainty of the evidence to be low to very low. What does the evidence from the review tell us? At present, we do not have enough high quality evidence to determine the effects of n‐3PUFAs as a treatment for MDD. We found a small‐to‐modest positive effect of n‐3PUFAs compared to placebo, but the size of this effect is unlikely to be meaningful to people with MDD, and we considered the evidence to be of low or very low certainty, with many differences between studies. There was also insufficient high quality evidence to determine the effects of n‐3PUFAs on negative side effects or numbers not completing studies. What should happen next? We need more evidence, particularly to explain the differences between study findings, e.g. by looking at individuals who may or may not benefit from n‐3PUFAs. Future studies should also compare n‐3PUFAs with usual antidepressant treatment, and investigate the way these treatments may work.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Appleton, KM; Voyias, PD; Sallis, HM; Dawson, S; Ness, AR; Churchill, R; Perry, R", "articleTypes": [], "doi": "10.1002/14651858.CD004692.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "3563086a-be6a-4260-9da4-3a8616e749fa", "pmid": "", "title": "Benperidol for schizophrenia", "imported": false, "abstract": "Abstract - Background Benperidol is a relatively old antipsychotic drug that has been marketed since 1966. It has been used in Germany for 30 years but is also available in Belgium, Greece, Italy, the Netherlands and the UK. Benperidol is a butyrophenone antipsychotic, with the highest neuroleptic potency in terms of D2 receptor blockade. Those taking it are therefore reputed to be at high risk of extrapyramidal side‐effects, but benperidol's unusual profile may render it valuable to certain subgroups of people with schizophrenia. Objectives To examine the clinical effects and safety of benperidol for those with schizophrenia and schizophrenia‐like psychoses. Search methods We searched the Cochrane Schizophrenia Group's register (March 2009) for this update. Selection criteria We included all randomised controlled trials that compared benperidol with other treatments for people with schizophrenia, or schizophrenia‐like psychoses. Data collection and analysis We reliably selected studies, quality rated them and extracted data. We independently extracted data but excluded data if loss to follow up was greater than 50%. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results The update yielded no further studies for inclusion in the review. We identified only one unpublished poorly randomised controlled trial (N=40, duration 30 days, comparison perphenazine). Although benperidol was inferior to perphenazine (1 RCT, N=40, global state no better or worse RR 8.0 CI 2.1 to 30, NNH 1.4 CI 1 to 2) poor reporting suggests that an overestimate of effect is likely. It was not possible to report other outcomes. Authors' conclusions Currently, there are insufficient data from randomised trials to assess the clinical effects of benperidol. This compound merits further research interest. Plain language summary Benperidol for schizophrenia Benperidol is a relatively old drug that is used for the treatment of schizophrenia in several European countries. We identified only one small, poorly reported, unpublished, randomised trial comparing benperidol with another antipsychotic. Unfortunately the quality of reporting is so poor that the results cannot be considered reliable. Although benperidol was first marketed in 1966, more trials on this drug are justified as with the advent of new compounds there is a danger that inexpensive drugs such as benperidol remain under‐researched and overlooked.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Schwarz, C, Hartung, B, Leucht, S", "articleTypes": [], "doi": "10.1002/14651858.CD003083.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.754Z" }, { "id": "35631b07-0ecb-4aee-b378-5adb0b02d69f", "pmid": "", "title": "Honey for acute cough in children", "imported": false, "abstract": "Abstract - Background Cough causes concern for parents and is a major cause of outpatient visits. Cough can impact quality of life, cause anxiety, and affect sleep in children and their parents. Honey has been used to alleviate cough symptoms. This is an update of reviews previously published in 2014, 2012, and 2010. Objectives To evaluate the effectiveness of honey for acute cough in children in ambulatory settings. Search methods We searched CENTRAL (2018, Issue 2), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (2014 to 8 February 2018), Embase (2014 to 8 February 2018), CINAHL (2014 to 8 February 2018), EBSCO (2014 to 8 February 2018), Web of Science (2014 to 8 February 2018), and LILACS (2014 to 8 February 2018). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trial Registry Platform (WHO ICTRP) on 12 February 2018. The 2014 review included searches of AMED and CAB Abstracts, but these were not searched for this update due to lack of institutional access. Selection criteria Randomised controlled trials comparing honey alone, or in combination with antibiotics, versus no treatment, placebo, honey‐based cough syrup, or other over‐the‐counter cough medications for children aged 12 months to 18 years for acute cough in ambulatory settings. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included six randomised controlled trials involving 899 children; we added three studies (331 children) in this update. We assessed two studies as at high risk of performance and detection bias; three studies as at unclear risk of attrition bias; and three studies as at unclear risk of other bias. Studies compared honey with dextromethorphan, diphenhydramine, salbutamol, bromelin (an enzyme from the Bromeliaceae (pineapple) family), no treatment, and placebo. Five studies used 7‐point Likert scales to measure symptomatic relief of cough; one used an unclear 5‐point scale. In all studies, low score indicated better cough symptom relief. Using a 7‐point Likert scale, honey probably reduces cough frequency better than no treatment or placebo (no treatment: mean difference (MD) ‐1.05, 95% confidence interval (CI) ‐1.48 to ‐0.62; I² = 0%; 2 studies; 154 children; moderate‐certainty evidence; placebo: MD ‐1.62, 95% CI ‐3.02 to ‐0.22; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Honey may have a similar effect as dextromethorphan in reducing cough frequency (MD ‐0.07, 95% CI ‐1.07 to 0.94; I² = 87%; 2 studies; 149 children; low‐certainty evidence). Honey may be better than diphenhydramine in reducing cough frequency (MD ‐0.57, 95% CI ‐0.90 to ‐0.24; 1 study; 80 children; low‐certainty evidence). Giving honey for up to three days is probably more effective in relieving cough symptoms compared with placebo or salbutamol. Beyond three days honey probably had no advantage over salbutamol or placebo in reducing cough severity, bothersome cough, and impact of cough on sleep for parents and children (moderate‐certainty evidence). With a 5‐point cough scale, there was probably little or no difference between the effects of honey and bromelin mixed with honey in reducing cough frequency and severity. Adverse events included nervousness, insomnia, and hyperactivity, experienced by seven children (9.3%) treated with honey and two children (2.7%) treated with dextromethorphan (risk ratio (RR) 2.94, 95% Cl 0.74 to 11.71; I² = 0%; 2 studies; 149 children; low‐certainty evidence). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14, 95% Cl 0.01 to 2.68; 1 study; 80 children; low‐certainty evidence). When honey was compared with placebo, 34 children (12%) in the honey group and 13 (11%) in the placebo group complained of gastrointestinal symptoms (RR 1.91, 95% CI 1.12 to 3.24; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Four children who received salbutamol had rashes compared to one child in the honey group (RR 0.19, 95% CI 0.02 to 1.63; 1 study; 100 children; moderate‐certainty evidence). No adverse events were reported in the no‐treatment group. Authors' conclusions Honey probably relieves cough symptoms to a greater extent than no treatment, diphenhydramine, and placebo, but may make little or no difference compared to dextromethorphan. Honey probably reduces cough duration better than placebo and salbutamol. There was no strong evidence for or against using honey. Most of the children received treatment for one night, which is a limitation to the results of this review. There was no difference in occurrence of adverse events between the honey and control arms. Plain language summary Honey for acute cough in children Review question Can honey reduce cough symptoms caused by bacteria and viruses in children? Background Cough causes concern for parents and is a major reason for outpatient visits. Honey is believed to prevent growth of germs and reduce inflammation. Search date We searched databases to 8 February 2018 and trial registers to 12 February 2018. Study characteristics We included six small trials involving 899 children aged 12 months to 18 years conducted in Iran, Israel, the USA, Brazil, and Kenya. This update included three new trials conducted between 2007 and 2016 that involved 331 children. Study funding sources Two studies were supported by pharmaceutical manufacturers; one by a university research centre; one by the Honey Board of Israel and non‐government agencies; and one by USA National Honey Board. One study did not report funding sources. Key results We compared honey to over‐the‐counter cough preparations, bromelin (a pineapple enzyme) mixed with honey, fake treatment (placebo), and no treatment. Honey probably reduces cough symptoms more than placebo and salbutamol (a drug that opens lung airways) when given for up to three days. Honey is probably more effective at providing cough relief and reducing the impact of cough on children's sleep at night than no treatment. There may be little or no difference between the effects of honey and dextromethorphan (an ingredient in over‐the‐counter cough remedies) or honey and bromelin with honey on all cough symptoms. Honey may be better than diphenhydramine (an antihistamine) at relieving and reducing children's cough. The parents of seven children given honey and two given dextromethorphan reported side effects in their children, such as not falling asleep easily, restlessness, and becoming overexcited. The parents of three children in the diphenhydramine group reported that their children were often sleepy. The parents of nine children given salbutamol, seven given honey, and six given placebo reported diarrhoea. The parents of four children who received salbutamol and one child given honey reported rash. We found no evidence for or against the use of honey to relieve cough in children. Using honey for infants aged up to 12 months is not advised because of poor immunity against bacteria that may be present, which can cause paralysis. Most of the children received honey for just one night, which is a limitation to the results of this review. Quality of the evidence Overall, evidence quality was low to moderate. Some studies did not blind participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Oduwole, O, Udoh, EE, Oyo‐Ita, A, Meremikwu, MM", "articleTypes": [], "doi": "10.1002/14651858.CD007094.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.098Z" }, { "id": "35675687-2864-41f2-9908-bf15fc1db439", "pmid": "", "title": "Chinese medicinal herbs for measles", "imported": false, "abstract": "Abstract - Background Measles is an infectious disease caused by the Morbillivirus . Chinese physicians believe that medicinal herbs are effective in alleviating symptoms and preventing complications. Chinese herbal medicines are dispensed according to the particular symptoms. This is the second update of a Cochrane Review first published in 2006. Objectives To assess the effectiveness and possible adverse effects of Chinese medicinal herbs for measles. Search methods We searched the Cochrane Central Register of Controlled Clinical Trials (CENTRAL Issue 1, 2011) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to March week 5, 2011), EMBASE (1980 to April 2011), Web of Science (2005 to 30 April 2011), AMED (1985 to 30 April 2011), Chinese Biomedical Database (1976 to 30 June 2011), VIP Information (1989 to 30 June 2011), China National Knowledge Infrastructure (CNKI) (1976 to 30 June 2011), Chinese Journals full‐article database (1994 to 30 June 2011) and the meta Register of Controlled Trials for ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs in patients with measles (without complications). Data collection and analysis Two review authors (SC, TW) independently assessed trial quality and extracted data. We telephone interviewed the trial authors for missing information regarding participant allocation. Some trials allocated participants according to the sequence they were admitted to the trials, that is to say, by using a pseudo‐random allocation method. None of the trials concealed the allocation or used blinding methods. Main results We did not identify any suitable trials for inclusion. In this updated review we identified 80 trials which claimed to use random allocation. We contacted 32 trial authors by telephone and learned that the allocation methods used were not randomised. We excluded 34 studies because the participants experienced complications such as pneumonia. We excluded 10 trials because of non‐random allocation and complications experienced by the participants. We were unable to contact the remaining four trials' authors, so they require further assessment and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions There is no RCT evidence for or against Chinese medicinal herbs as a treatment for measles. We hope high‐quality, robust RCTs in this field will be conducted in the future. Plain language summary Chinese medicinal herbs for measles Measles (rubeola) is an infectious disease caused by multiplication of a single‐strand ribonucleic acid (RNA) virus of the genus Morbillivirus in the upper respiratory tract and conjunctiva. It can lead to serious complications and death. Chinese herbal medicines are believed to be effective in alleviating symptoms and shortening the duration of measles, and are widely used as the main or adjunctive therapy to treat measles in China and other countries. The review authors found a large number of clinical studies providing evidence of Chinese herbal medicines in the treatment of measles. Some of these reports claimed to be randomised controlled trials. However, after telephone interviewing 32 trial authors, we found that none of them used acceptable randomisation procedures to allocate participants and 34 studies included participants with measles complicated with other diseases, for example, pneumonia. Ten trials were non‐randomised controlled studies and four trials require further classification. In this update, we were unable to include any randomised controlled trial for assessment. Although no trials were included, the authors reviewed the articles and found no reports of adverse events in the use of Chinese herbal medicines for treating measles. High‐quality and large trials are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Chen, S; Wu, T; Kong, X; Yuan, H", "articleTypes": [], "doi": "10.1002/14651858.CD005531.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "35a8db95-73dd-442c-876e-be7f9a3d861a", "pmid": "", "title": "Interventions to improve adherence to antiretroviral therapy in children with HIV infection", "imported": false, "abstract": "Abstract - Background Achieving and maintaining high levels of medication adherence are required to achieve the full benefits of antiretroviral therapy (ART), yet suboptimal adherence among children is common in both developed and developing countries. Objectives To conduct a systematic review of the literature of evaluations of interventions for improving paediatric ART adherence. Search methods We created a comprehensive search strategy in order to identify all studies relevant to this topic. In July 2010, we searched the following electronic databases: EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, LILACS, Web of Science, Web of Social Science, NLM Gateway (supplemented by a manual search of the most recent abstracts not included in the Gateway database). We searched abstracts from the International AIDS Conference from 2002 to 2010, the International AIDS Society Conference on Pathogenesis, Treatment and Prevention from 2003 to 2009, and from the Conference on Retroviruses and Opportunistic Infections from 1997 to 2010. We used search strategies determined by the Cochrane Review Group on HIV/AIDS. We also contacted researchers who work in this field and checked reference lists of related systematic reviews and of all included studies. Selection criteria Randomised and non‐randomised controlled trials of interventions to improve adherence to ART among children and adolescents (age ≤18 years) were included. Studies had to report adherence to ART as an outcome. Data collection and analysis After one author performed an initial screening to exclude citations that did not meet the inclusion criteria, two authors did a second screening of those citations that likely met the criteria. For all articles that passed the second screening, full articles were pulled in order to make a final determination. Two authors then extracted data and graded methodological quality independently. Differences were resolved through discussion. Main results Four studies met the inclusion criteria. No single intervention was evaluated by more than one trial. Two studies were conducted in low‐income countries. Two studies were randomised controlled trials (RCT), and two were non‐randomised trials. An RCT of a home‐based nursing programme showed a positive effect of the intervention on knowledge and medication refills (p=.002), but no effect on CD4 count and viral load. A second RCT of caregiver medication diaries showed that the intervention group had fewer participants reporting no missed doses compared to the control group (85% vs. 92%, respectively), although this difference was not statistically significant (p=.08). The intervention had no effect on CD4 percentage or viral load. A non‐randomised trial of peer support group therapy for adolescents demonstrated no change in self‐reported adherence, yet the percentage of participants with suppressed viral load increased from 30% to 80% (p=.06). The second non‐randomised trial found that the percentage of children achieving >80% adherence was no different between children on a lopinavir‐ritonavir (LPV/r) regimen compared to children on a non‐nucleoside reverse transcriptase regimen (p=.781). However, the proportion of children achieving virological suppression was significantly greater for children on the LPV/r regimen than for children on the NNRTI‐containing regimen (p=.002). Authors' conclusions A home‐based nursing intervention has the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence or disease outcomes. Two interventions, an LPV/r‐containing regimen and peer support therapy for adolescents, did not demonstrate improvements in adherence, yet demonstrated greater viral load suppression compared to control groups, suggesting a different mechanism for improved health outcomes. Well‐designed evaluations of interventions to improve paediatric adherence to ART are needed. Plain language summary Interventions to improve adherence to ART in children and adolescents Achieving and maintaining high levels of medication adherence are required to realise the full benefits of antiretroviral therapy (ART). We identified four studies that evaluated interventions designed to improve adherence to ART among children and adolescents age 18 years and younger. These studies showed that home‐based nursing, peer support for adolescents and LPV/r‐containing regimens have the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence. There is a need for well‐designed evaluations of interventions to improve paediatric adherence to ART.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Bain‐Brickley, D, Butler, LM, Kennedy, GE, Rutherford, GW", "articleTypes": [], "doi": "10.1002/14651858.CD009513", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.760Z" }, { "id": "35cb3989-9580-4c43-b3e7-6910a275d478", "pmid": "", "title": "The Role of Sweet Taste Receptor Blockade on Intragastric Liquid Meal-stimulated Secretion of Satiation Peptides in Healthy Humans", "imported": false, "abstract": "The purpose of this study is to determine the functional significance of sweet taste receptors in the secretion of gastrointestinal (GI) satiation peptides by using a specific sweet taste receptor antagonist to block sweet taste perception in the gastrointestinal tract.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "35e9a4e4-6ee6-450f-a476-681d5db5d1e2", "pmid": "", "title": "Pharmacological and non‐pharmacological strategies for obese women with subfertility", "imported": false, "abstract": "Abstract - Background Clinicians primarily recommend weight loss for obese women seeking pregnancy. The effectiveness of interventions aimed at weight loss in obese women with subfertility is unclear. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for achieving weight loss in obese women with subfertility. Search methods We searched the CGF Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and AMED from inception to 18 August 2020. We also checked reference lists and contacted experts in the field for additional relevant papers. Selection criteria We included published and unpublished randomised controlled trials in which weight loss was the main goal of the intervention. Our primary effectiveness outcomes were live birth or ongoing pregnancy and primary safety outcomes were miscarriage and adverse events. Secondary outcomes included clinical pregnancy, weight change, quality of life, and mental health outcome. Data collection and analysis Review authors followed standard Cochrane methodology. Main results This review includes 10 trials. Evidence was of very low to low quality: the main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision. Non‐pharmacological intervention versus no intervention or placebo Evidence is insufficient to determine whether a diet or lifestyle intervention compared to no intervention affects live birth (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.65 to 1.11; 918 women, 3 studies; I² = 78%; low‐quality evidence). This suggests that if the chance of live birth following no intervention is assumed to be 43%, the chance following diet or lifestyle changes would be 33% to 46%. We are uncertain if lifestyle change compared with no intervention affects miscarriage rate (OR 1.54, 95% CI 0.99 to 2.39; 917 women, 3 studies; I² = 0%; very low‐quality evidence). Evidence is insufficient to determine whether lifestyle change compared with no intervention affects clinical pregnancy (OR 1.06, 95% CI 0.81 to 1.40; 917 women, 3 studies; I² = 73%; low‐quality evidence). Lifestyle intervention resulted in a decrease in body mass index (BMI), but data were not pooled due to heterogeneity in effect (mean difference (MD) ‐3.70, 95% CI ‐4.10 to ‐3.30; 305 women, 1 study; low‐quality evidence; and MD ‐1.80, 95% CI ‐2.67 to ‐0.93; 43 women, 1 study; very low‐quality evidence). Non‐pharmacological versus non‐pharmacological intervention We are uncertain whether intensive weight loss interventions compared to standard care nutrition counselling affects live birth (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), BMI (MD ‐3.00, 95% CI ‐5.37 to ‐0.63; 11 women, 1 study; very low‐quality evidence), weight change (MD ‐9.00, 95% CI ‐15.50 to ‐2.50; 11 women, 1 study; very low‐quality evidence), quality of life (MD 0.06, 95% CI ‐0.03 to 0.15; 11 women, 1 study; very low‐quality evidence), or mental health (MD ‐7.00, 95% CI ‐13.92 to ‐0.08; 11 women, 1 study; very low‐quality evidence). No study reported on adverse events . Pharmacological versus pharmacological intervention For metformin plus liraglutide compared to metformin we are uncertain of an effect on the adverse events nausea (OR 7.22, 95% CI 0.72 to 72.7; 28 women, 1 study; very low‐quality evidence), diarrhoea (OR 0.31, 95% CI 0.01 to 8.3; 28 women, 1 study; very low‐quality evidence), and headache (OR 5.80, 95% CI 0.25 to 133; 28 women, 1 study; very low‐quality evidence). We are uncertain if a combination of metformin plus liraglutide vs metformin affects BMI (MD 2.1, 95% CI ‐0.42 to 2.62; 28 women, 1 study; very low‐quality evidence) and total body fat (MD ‐0.50, 95% CI ‐4.65 to 3.65; 28 women, 1 study; very low‐quality evidence). For metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo, we are uncertain of an effect on miscarriage (OR 3.58, 95% CI 0.73 to 17.55; 274 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 5.56, 95% CI 2.57 to 12.02; 274 women, 1 study; very low‐quality evidence) or BMI (MD ‐0.3, 95% CI 1.17 to 0.57, 274 women, 1 study, very low‐quality evidence). We are uncertain if dexfenfluramine versus placebo affects weight loss in kilograms (MD ‐0.10, 95% CI ‐2.77 to 2.57; 21 women, 1 study; very low‐quality evidence). No study reported on live birth, quality of life, or mental health outcomes. Pharmacological intervention versus no intervention or placebo We are uncertain if metformin compared with placebo affects live birth (OR 1.57, 95% CI 0.44 to 5.57; 65 women, 1 study; very low‐quality evidence). This suggests that if the chance of live birth following placebo is assumed to be 15%, the chance following metformin would be 7% to 50%. We are uncertain if metformin compared with placebo affects gastrointestinal adverse events (OR 0.91, 95% CI 0.32 to 2.57; 65 women, 1 study; very low‐quality evidence) or miscarriage (OR 0.50, 95% CI 0.04 to 5.80; 65 women, 1 study; very low‐quality evidence) or clinical pregnancy (OR 2.67, 95% CI 0.90 to 7.93; 96 women, 2 studies; I² = 48%; very low‐quality evidence). We are also uncertain if diet combined with metformin versus diet and placebo affects BMI (MD ‐0.30, 95% CI ‐2.16 to 1.56; 143 women, 1 study; very low‐quality evidence) or waist‐to‐hip ratio (WHR) (MD 2.00, 95% CI ‐2.21 to 6.21; 143 women, 1 study; very low‐quality evidence). Pharmacological versus non‐pharmacological intervention No study undertook this comparison. Authors' conclusions Evidence is insufficient to support the use of pharmacological and non‐pharmacological strategies for obese women with subfertility. No data are available for the comparison of pharmacological versus non‐pharmacological strategies. We are uncertain whether pharmacological or non‐pharmacological strategies effect live birth, ongoing pregnancy, adverse events, clinical pregnancy, quality of life, or mental health outcomes. However, for obese women with subfertility, a lifestyle intervention may reduce BMI. Future studies should compare a combination of pharmacological and lifestyle interventions for obese women with subfertility. Plain language summary Do pharmacological and non‐pharmacological strategies reduce weight in obese women with subfertility? To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for weight reduction in obese women with subfertility. Background To prevent the adverse effects of obesity, weight loss is recommended as the first line of treatment for obese women seeking pregnancy. The effectiveness of pharmacological and non‐pharmacological interventions for obese women with subfertility is unclear. Study characteristics We found 10 randomised trials comparing pharmacological and non‐pharmacological strategies in 1490 obese women with subfertility. Key results Lack of data is a major concern in interpretation of these data. Only 10 studies were included in the analysis. Three studies compared non‐pharmacological intervention versus no intervention or placebo. We are uncertain whether diet versus no intervention improves live birth, ongoing pregnancy, clinical pregnancy, or adverse events. A diet or lifestyle intervention may result in body mass index (BMI) weight change. Evidence was insufficient to show a difference in waist‐to‐hip ratio (WHR) with diet or lifestyle change compared to no intervention. No study reported on quality of life, or mental health outcomes for this comparison. One study compared non‐pharmacological interventions ‐ intensive weight loss intervention versus standard of care nutrition counselling; however due to the very low quality of evidence, we are uncertain whether intensive weight loss interventions improve live birth, clinical pregnancy, quality of life, or mental health outcomes. No study reported on adverse events, or weight changes, for this comparison. Three studies reported on pharmacological versus pharmacological interventions. Evidence was insufficient to show a difference in adverse events between metformin compared to metformin plus liraglutide. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for miscarriage. Evidence was insufficient to reveal a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo or metformin plus liraglutide versus metformin in clinical pregnancy. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for weight change using BMI. Moreover, evidence was insufficient to reveal a difference between dexfenfluramine versus placebo or metformin plus liraglutide versus metformin for weight loss in kilograms, or per cent of total body fat. No study reported on live birth and change in quality of life or mental health outcomes for this comparison. In the comparison of pharmacological intervention versus no intervention or placebo, three studies were included. Evidence was insufficient to show a difference between metformin and control groups related to live birth. Evidence was insufficient to reveal a difference between metformin compared to placebo in live birth, clinical pregnancy, or adverse events. Evidence was insufficient to demonstrate a difference between diet combined with metformin versus diet combined with placebo for weight change using BMI or WHR. No study reported on quality of life or mental health outcomes for this comparison. We found no study comparing non‐pharmacological with pharmacological interventions. Quality of the evidence The evidence was of very low to low quality. The main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading of evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Taghavi, SA, van Wely, M, Jahanfar, S, Bazarganipour, F", "articleTypes": [], "doi": "10.1002/14651858.CD012650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.768Z" }, { "id": "35fed866-ea91-413b-855d-603ca6ab3231", "pmid": "", "title": "Celiac Disease and Vitamin Status: Evaluation of the Effect of Supplementation With a Probiotic (VIVOMIXX®) on Vitamin B6, B12, 25'OH D, Folic Acid and Omocystein Levels, Metabolic and Inflammatory Status, and Gut Microbiota Metabolomics in a Cohoort of Celiac Patients", "imported": false, "abstract": "Celiac disease is a disorder caused by a disregulation of the immune system which leads to immune response to gluten. Diet therapy is the gold standard of treatment, and the only effective one. Macronutrients and micronutrients deficiency (vitamin D, folic acid, vitamin B12, vitamin B6, iron and zinc), which is in any case far more common in patients who don't follow gluten free diet, can persist in a subset of patients who follow gluten-free diet. Supplementation of vitamins in these patients may have a beneficial role. A recent study in a murine model showed that supplementation with probiotic VIVOMIXX® leads to an increase in expression of vitamin D receptors in proximal and distal colon.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "360e3945-4743-4390-bb60-4d5953993a28", "pmid": "", "title": "Acupuncture for Bell's palsy", "imported": false, "abstract": "Abstract - Background Bell's palsy or idiopathic facial palsy is an acute facial paralysis due to inflammation of the facial nerve. A number of studies published in China have suggested acupuncture is beneficial for facial palsy. Objectives The objective of this review was to examine the efficacy of acupuncture in hastening recovery and reducing long‐term morbidity from Bell's palsy. Search methods We updated the searches of the Cochrane Neuromuscular Disease Group Trials Specialized Register (24 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2010), MEDLINE (January 1966 to May 2010), EMBASE (January 1980 to May 2010), AMED (January 1985 to May 2010), LILACS (from January 1982 to May 2010) and the Chinese Biomedical Retrieval System (January 1978 to May 2010) for randomised controlled trials using 'Bell's palsy' and its synonyms, 'idiopathic facial paralysis' or 'facial palsy' as well as search terms including 'acupuncture'. Chinese journals in which we thought we might find randomised controlled trials relevant to our study were handsearched. We reviewed the bibliographies of the randomised trials and contacted the authors and known experts in the field to identify additional published or unpublished data. Selection criteria We included all randomised controlled trials involving acupuncture by needle insertion in the treatment of Bell's palsy irrespective of any language restrictions. Data collection and analysis Two review authors identified potential articles from the literature search, extracted data and assessed quality of each trial independently. All disagreements were resolved by discussion between the review authors. Main results The literature search and handsearching identified 49 potentially relevant articles. Of these, six RCTs were included involving 537 participants with Bell's palsy. Two more possible trials were identified in the update than the previous version of this systematic review, but both were excluded because they were not real RCTs. Of the six included trials, five used acupuncture while the other one used acupuncture combined with drugs. No trial reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. Authors' conclusions The quality of the included trials was inadequate to allow any conclusion about the efficacy of acupuncture. More research with high quality trials is needed. Plain language summary Acupuncture for Bell's palsy Bell's palsy or idiopathic facial palsy is the most common disorder affecting the facial nerves and results in weakness or paralysis on one side of the face. The paralysis causes distortion of the face and interferes with normal functions, such as closing the eye and eating. It is thought to be caused by inflammation of the facial nerve. According to Traditional Chinese Medicine, facial paralysis is known as 'deviated mouth'. It was attributed to 'wind' by past dynasties. 'Qi' refers to the vital substances comprising the human body and the physiological functions of viscera and bowels, channels and collaterals. It maintains life activities and reflects the resistance of the human body. Deficiency of 'qi' allows the invasion of exogenous pathogenic wind. Acupuncture is part of Traditional Chinese Medicine and dates back thousands of years. It involves inserting fine needles into specific points on the skin or applying various other techniques to the acupuncture points to bring about healing. In Bell's palsy, acupuncture treatment might have numerous beneficial effects. This review aimed to review systematically all randomised controlled trials and controlled clinical trials, which examined the effectiveness of acupuncture by needle insertion for Bell's palsy. Six studies including a total of 537 participants met the inclusion criteria. Five studies used acupuncture while the other used acupuncture combined with drugs. No trials reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. More research with high quality trials is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, N, Zhou, M, He, L, Zhou, D, Li, N", "articleTypes": [], "doi": "10.1002/14651858.CD002914.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.762Z" }, { "id": "360fb074-51df-4ed9-9e43-80563fa4218d", "pmid": "", "title": "Relief of pain due to uterine cramping/involution after birth", "imported": false, "abstract": "Abstract - Background Women may experience differing types of pain and discomfort following birth, including cramping pain (often called after‐birth pain) associated with uterine involution, where the uterus contracts to reduce blood loss and return the uterus to its non‐pregnant size. This is an update of a review first published in 2011. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological pain relief/analgesia for the relief of after‐birth pains following vaginal birth. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (31 October 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials comparing two different types of analgesia or analgesia versus placebo or analgesia versus no treatment, for the relief of after‐birth pains following vaginal birth. Types of analgesia included pharmacological and non‐pharmacological. Quasi‐randomised trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed trials for inclusion, conducted 'Risk of bias' assessment, extracted data and assessed the certainty of the evidence using the GRADE approach. Main results In this update, we include 28 studies (involving 2749 women). The evidence identified in this review comes from middle‐ to high‐income countries. Generally the trials were at low risk of selection bias, performance bias and attrition bias, but some trials were at high risk of bias due to selective reporting and lack of blinding. Our GRADE certainty of evidence assessments ranged from moderate to very low certainty, with downgrading decisions based on study limitations, imprecision, and (for one comparison) indirectness. Most studies reported our primary outcome of adequate pain relief as reported by the women. No studies reported data relating to neonatal adverse events, duration of hospital stay, or breastfeeding rates. Almost half of the included studies (11/28) excluded breastfeeding women from participating, making the evidence less generalisable to a broader group of women. Non‐steroidal anti‐inflammatory drugs (NSAIDs) compared to placebo NSAIDs are probably better than placebo for adequate pain relief as reported by the women (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.45 to 1.91; 11 studies, 946 women; moderate‐certainty evidence). NSAIDs may reduce the need for additional pain relief compared to placebo (RR 0.15, 95% CI 0.07 to 0.33; 4 studies, 375 women; low‐certainty evidence). There may be a similar risk of maternal adverse events (RR 1.05, 95% CI 0.78 to 1.41; 9 studies, 598 women; low‐certainty evidence). NSAIDs compared to opioids NSAIDs are probably better than opioids for adequate pain relief as reported by the women (RR 1.33, 95% CI 1.13 to 1.57; 5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of maternal adverse events (RR 0.62, 95% CI 0.43 to 0.89; 3 studies, 255 women; low‐certainty evidence). NSAIDs may be better than opioids for the need for additional pain relief, but the wide CIs include the possibility that the two classes of drugs are similarly effective or that opioids are better (RR 0.37, 95% CI 0.12 to 1.12; 2 studies, 232 women; low‐certainty evidence). Opioids compared to placebo Opioids may be better than placebo for adequate pain relief as reported by the women (RR 1.26, 95% CI 0.99 to 1.61; 5 studies, 299 women; low‐certainty evidence). Opioids may reduce the need for additional pain relief compared to placebo (RR 0.48, 95% CI 0.28 to 0.82; 3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of maternal adverse events compared with placebo, although the certainty of evidence is low (RR 1.59, 95% CI 0.99 to 2.55; 3 studies, 188 women; low‐certainty evidence). Paracetamol compared to placebo Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events (2 studies, 123 women). Paracetamol compared to NSAIDs Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events. No data were reported about the need for additional pain relief comparing paracetamol and NSAIDs (2 studies, 112 women). NSAIDs compared to herbal analgesia We are uncertain if there are any differences between NSAIDs and herbal analgesia for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events, because the certainty of evidence is very low (4 studies, 394 women). Transcutaneous nerve stimulation (TENS) compared to no TENS Very low‐certainty evidence means we are uncertain if TENS is better than no TENS for adequate pain relief as reported by the women. No other data were reported comparing TENS with no TENS (1 study, 32 women). Authors' conclusions NSAIDs may be better than placebo and are probably better than opioids at relieving pain from uterine cramping/involution following vaginal birth. NSAIDs and paracetamol may be as effective as each other, whereas opioids may be more effective than placebo. Due to low‐certainty evidence, we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater generalisability by including breastfeeding women. In addition, further research is required, including a survey of postpartum women to describe appropriately their experience of uterine cramping and involution. We identified nine ongoing studies, which may help to increase the level of certainty of the evidence around pain relief due to uterine cramping in future updates of this review. Plain language summary Relief of pain caused by uterine cramping or involution after giving birth This updated review investigates the effectiveness and safety of drug and non‐drug pain relief in women experiencing after‐birth pains following vaginal birth. Giving an agent for pain relief was compared to an inactive placebo, to no treatment, or to a different type of agent in randomised controlled trials. What is the issue? Women may experience cramping pain and discomfort following the birth of their baby, as the uterus contracts and returns to its normal pre‐pregnancy size. These pains usually last for two to three days after the birth. Women who have previously had a baby are more likely to experience after‐birth pains. Breastfeeding stimulates the uterus to contract and increases the severity of the pains. Types of pain relief used to treat the pain include paracetamol, non‐steroidal anti‐inflammatory drugs (NSAIDs) ibuprofen and naproxen, opioids including codeine, and non‐medicine methods such as herbal preparations and transcutaneous electrical nerve stimulation (TENS). Why is this important? Management of pain after birth is important, as the pain can affect a mother carrying out her normal activities as well as bonding with and caring for her baby. After‐pains can interfere with establishing breastfeeding. What evidence did we find? We searched for evidence from randomised controlled trials (October 2019) and identified 28 studies (2749 mothers) who were in hospital after uncomplicated single births. Most of the evidence is low‐certainty because the studies did not include sufficient numbers of women. Many of the studies excluded breastfeeding women.This makes the evidence less relevant to a broader group of women. No studies reported evidence on adverse events in the newborn infants. NSAIDs are probably better than placebo (a dummy treatment) in giving adequate pain relief as reported by the women (11 studies, 946 women; moderate‐certainty evidence), and they may reduce the need for additional pain relief (4 studies, 375 women; low‐certainty evidence). There may be little difference between NSAIDs and placebo in the risk of adverse events in the mother (9 studies, 598 women; low‐certainty evidence). NSAIDs are probably better than opioids in providing adequate pain relief as reported by the women (5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of adverse events in the mother (3 studies, 255 women; low‐certainty evidence). NSAIDs may slightly reduce the need for additional pain relief compared with opioids (2 studies, 232 women; low‐certainty evidence). Opioids may be better than placebo for adequate pain relief as reported by the women (5 studies, 299 women; low‐certainty evidence) and for the need for additional pain relief (3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of adverse events in the mother compared with placebo (3 studies, 188 women; low‐certainty evidence). Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional analgesia, or risk of maternal adverse events (2 studies, 123 women). Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events (2 studies, 112 women). Very low‐certainty evidence means we are uncertain if NSAIDs are better than herbal pain relief for adequate pain relief as reported by the women (4 studies, 394 women), the need for additional pain relief (1 study, 90 women) or risk of maternal adverse events (1 study, 108 women). Very low‐certainty evidence means we are uncertain if there is any difference between TENS and no TENS for adequate pain relief as reported by the women (1 study, 32 women). What does this mean? NSAIDs may be better than placebo and are probably better than opioids at relieving after‐birth pains following vaginal birth. The quality of the evidence was poor and we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater relevance by including breastfeeding women. Further research could also include a survey of women after delivery to capture their experience of after‐birth pains following vaginal birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Deussen, AR, Ashwood, P, Martis, R, Stewart, F, Grzeskowiak, LE", "articleTypes": [], "doi": "10.1002/14651858.CD004908.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.804Z" }, { "id": "3627cc0d-bf13-4a60-a15b-f95c71c3b7eb", "pmid": "", "title": "Community‐based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries", "imported": false, "abstract": "Abstract - Background Supplementary feeding is defined as the provision of extra food to children or families beyond the normal ration of their home diets. The impact of food supplementation on child growth merits careful evaluation in view of the reliance of many states and non‐governmental organisations on this intervention to improve child health in low and middle income countries (LMIC). This is an update of a Cochrane review first published in 2005. Objectives To evaluate the effectiveness of community‐based supplementary feeding for promoting the physical growth of children under five years of age in LMIC. Search methods For this updated review we searched the following databases on 31 January 2011: CENTRAL ( The Cochrane Library ), MEDLINE (1948 to January week 3, 2011), EMBASE (1980 to week 3, 2011), CINAHL (1937 to 27 January 2011), LILACS (all years), WorldCat for dissertations and theses (all years) and ClinicalTrials.gov (all years). Selection criteria Randomised controlled trials (RCTs) evaluating supplementary feeding in comparison to a control group (no intervention or a placebo such as food with a very low number of nutrients and calories) in children from birth to five years of age in LMIC. Data collection and analysis Two review authors independently extracted and analysed the data. Main results We included eight RCTs (n = 1243 children) that were at relatively high risk of bias. We found high levels of clinical heterogeneity in the participants, interventions and outcome measures across studies. Nevertheless, in order to quantify pooled effects of supplementary feeding, we decided to combine studies according to prespecified characteristics. These were the children's age (younger or older than 24 months), their nutritional status at baseline (stunted or wasted, or not stunted or wasted) and the duration of the intervention (less or more than 12 months). A statistically significant difference of effect was only found for length during the intervention in children aged less than 12 months (two studies; 795 children; mean difference 0.19 cm; 95% confidence interval (CI) 0.07 to 0.31). Based on the summary statistic calculated for each study, the mean difference (MD) between intervention and control groups ranged from 0.48 cm (95% CI 0.07 to 0.89) to 1.3 cm (95% CI 0.03 to 2.57) after 3 and 12 months of intervention, respectively. Data on potential adverse effects were lacking. Authors' conclusions The scarcity of available studies and their heterogeneity makes it difficult to reach any firm conclusions. The review findings suggest supplementary feeding has a negligible impact on child growth; however, the pooled results should be interpreted with great caution because the studies included in the review are clinically diverse. Future studies should address issues of research design, including sample size calculation, to detect meaningful clinical effects and adequate intervention allocation concealment. In the meantime, families and children in need should be provided appropriate feeding, health care and sanitation without waiting for new RCTs to establish a research basis for feeding children. Plain language summary Providing extra food for children under five years of age in low and middle income countries Undernutrition is one of the underlying causes of childhood illness and death in low‐ and middle‐income countries. Providing extra food to children or families beyond what they normally have at home is an intervention aimed at supporting the nutritional wellbeing of the target population. We included eight studies where the participants were randomly assigned to two groups: one group received the extra food and the other group was a control, either receiving no food or food with very low nutritional content. Although the impact of supplementary feeding on child growth appeared to be negligible, it is not possible to draw any conclusions until we have studies that involve larger numbers and do not allow assessors to know who is receiving the intervention. Although it is difficult to determine whether community‐based supplementary feeding helps to promote the growth of children from birth to five years in low‐ and middle‐income countries, it is obviously vital to continue to provide food, health care and sanitation to those who need them.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Sguassero, Y; de Onis, M; Bonotti, AM; Carroli, G", "articleTypes": [], "doi": "10.1002/14651858.CD005039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "36283684-fbdc-4189-8f33-d7a3ea4531f8", "pmid": "", "title": "Interventions for hyperthyroidism pre‐pregnancy and during pregnancy", "imported": false, "abstract": "Abstract - Background Women with hyperthyroidism in pregnancy have increased risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction; and they can develop severe pre‐eclampsia or placental abruption. Objectives To identify interventions used in the management of hyperthyroidism pre‐pregnancy or during pregnancy and to ascertain the impact of these interventions on important maternal, fetal, neonatal and childhood outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 September 2013). Selection criteria We planned to include randomised controlled trials, quasi‐randomised controlled trials, and cluster‐randomised trials comparing antithyroid interventions for hyperthyroidism pre‐pregnancy or during pregnancy with another intervention or no intervention (placebo or no treatment). Data collection and analysis Two review authors assessed trial eligibility and planned to assess trial quality and extract the data independently. Main results No trials were included in the review. Authors' conclusions As we did not identify any eligible trials, we are unable to comment on implications for practice, although early identification of hyperthyroidism before pregnancy may allow a woman to choose radioactive iodine therapy or surgery before planning to have a child. Designing and conducting a trial of antithyroid interventions for pregnant women with hyperthyroidism presents formidable challenges. Not only is hyperthyroidism a relatively rare condition, both of the two main drugs used have potential for harm, one for the mother and the other for the child. More observational research is required about the potential harms of methimazole in early pregnancy and about the potential liver damage from propylthiouracil. Plain language summary No evidence found from randomised trials for drugs to treat pregnant women with hyperthyroidism Hyperthyroidism in pregnancy is a rare, serious condition which can increase the risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction. Pregnant women who are hyperthyroid may also develop severe pre‐eclampsia or placental abruption. Most of these women have Graves' disease, an autoimmune disease most common in women aged 20 to 40 years. Most pregnant women with hyperthyroidism are diagnosed with thyroid disease prior to conception and will have previously received treatment for the condition. Generally only drug therapy is considered for treating pregnant women with hyperthyroidism. Radioiodine treatment is not used in pregnancy because it destroys the fetal thyroid gland, resulting in permanent hypothyroidism in the newborn. The main antithyroid drugs used are the thionamides, propylthiouracil (PTU), methimazole and carbimazole. PTU is currently the favoured drug for use in pregnancy, as it is associated with fewer teratogenic effects (scalp lesions) than methimazole. However, since there have been reports of liver damage in people taking PTU, it may be reasonable for pregnant hyperthyroid women to be treated with PTU in the first trimester (to reduce any teratogenic effects of methimazole) and then to change to methimazole. We did not identify any randomised trials to help inform women and their doctors about which antithyroid drugs are most effective, with the lowest potential for harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Earl, R, Crowther, CA, Middleton, P", "articleTypes": [], "doi": "10.1002/14651858.CD008633.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.087Z" }, { "id": "3628d217-42d5-4903-a93d-f39c71cee78a", "pmid": "", "title": "Effect of alcohol on blood pressure", "imported": false, "abstract": "Abstract - Background Alcohol is consumed by over 2 billion people worldwide. It is a common substance of abuse and its use can lead to more than 200 disorders including hypertension. Alcohol has both acute and chronic effects on blood pressure. This review aimed to quantify the acute effects of different doses of alcohol over time on blood pressure and heart rate in an adult population. Objectives Primary objective To determine short‐term dose‐related effects of alcohol versus placebo on systolic blood pressure and diastolic blood pressure in healthy and hypertensive adults over 18 years of age. Secondary objective To determine short‐term dose‐related effects of alcohol versus placebo on heart rate in healthy and hypertensive adults over 18 years of age. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to March 2019: the Cochrane Hypertension Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2), in the Cochrane Library; MEDLINE (from 1946); Embase (from 1974); the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. We also contacted authors of relevant articles regarding further published and unpublished work. These searches had no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing effects of a single dose of alcohol versus placebo on blood pressure (BP) or heart rate (HR) in adults (≥ 18 years of age). Data collection and analysis Two review authors (ST and CT) independently extracted data and assessed the quality of included studies. We also contacted trial authors for missing or unclear information. Mean difference (MD) from placebo with 95% confidence interval (CI) was the outcome measure, and a fixed‐effect model was used to combine effect sizes across studies. Main results We included 32 RCTs involving 767 participants. Most of the study participants were male (N = 642) and were healthy. The mean age of participants was 33 years, and mean body weight was 78 kilograms. Low‐dose alcohol (< 14 g) within six hours (2 RCTs, N = 28) did not affect BP but did increase HR by 5.1 bpm (95% CI 1.9 to 8.2) (moderate‐certainty evidence). Medium‐dose alcohol (14 to 28 g) within six hours (10 RCTs, N = 149) decreased systolic blood pressure (SBP) by 5.6 mmHg (95% CI ‐8.3 to ‐3.0) and diastolic blood pressure (DBP) by 4.0 mmHg (95% CI ‐6.0 to ‐2.0) and increased HR by 4.6 bpm (95% CI 3.1 to 6.1) (moderate‐certainty evidence for all). Medium‐dose alcohol within 7 to 12 hours (4 RCTs, N = 54) did not affect BP or HR. Medium‐dose alcohol > 13 hours after consumption (4 RCTs, N = 66) did not affect BP or HR. High‐dose alcohol (> 30 g) within six hours (16 RCTs, N = 418) decreased SBP by 3.5 mmHg (95% CI ‐6.0 to ‐1.0), decreased DBP by 1.9 mmHg (95% CI‐3.9 to 0.04), and increased HR by 5.8 bpm (95% CI 4.0 to 7.5). The certainty of evidence was moderate for SBP and HR, and was low for DBP. High‐dose alcohol within 7 to 12 hours of consumption (3 RCTs, N = 54) decreased SBP by 3.7 mmHg (95% CI ‐7.0 to ‐0.5) and DBP by 1.7 mmHg (95% CI –4.6 to 1.8) and increased HR by 6.2 bpm (95% CI 3.0 to 9.3). The certainty of evidence was moderate for SBP and HR, and low for DBP. High‐dose alcohol ≥ 13 hours after consumption (4 RCTs, N = 154) increased SBP by 3.7 mmHg (95% CI 2.3 to 5.1), DBP by 2.4 mmHg (95% CI 0.2 to 4.5), and HR by 2.7 bpm (95% CI 0.8 to 4.6) (moderate‐certainty evidence for all). Authors' conclusions High‐dose alcohol has a biphasic effect on BP; it decreases BP up to 12 hours after consumption and increases BP > 13 hours after consumption. High‐dose alcohol increases HR at all times up to 24 hours. Findings of this review are relevant mainly to healthy males, as only small numbers of women were included in the included trials. Plain language summary Alcohol has a biphasic effect on blood pressure and increases heart rate Review question We reviewed available evidence about the short‐term effects of different doses of alcoholic drinks compared to non‐alcoholic drinks on blood pressure and heart rate in adults (≥ 18 years) with both normal and raised blood pressure. Background Drinking excessive alcohol is considered one of the most common causes of raised blood pressure. We wanted to quantify the effects of a single dose of alcohol on blood pressure and heart rate within 24 hours of consumption. Study characteristics We included 32 randomised controlled trials involving 767 participants published up to March 2019. Although these trials included adults from 18 to 96 years of age with various health conditions, most study participants were young healthy males. The source of funding was not reported for a majority of the studies. Key results For low doses of alcohol, we found that one glass of alcohol had little to no effect on blood pressure and increased heart rate within six hours of drinking. We are moderately certain that medium‐dose alcohol decreased blood pressure and increased heart rate within six hours of consumption. We did not see any significant change in blood pressure or heart rate after that, but the evidence was limited. We are also moderately certain that high‐dose alcohol decreased blood pressure within six hours, and the effect lasted up to 12 hours. After that, blood pressure was found to be increased. Heart rate increased significantly after alcohol consumption and remained increased at all times measured. Thus alcohol decreases blood pressure initially (up to 12 hours after ingestion) and increases blood pressure after that. Alcohol consistently increases heart rate at all times within 24 hours of consumption.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Tasnim, S, Tang, C, Musini, VM, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD012787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.790Z" }, { "id": "3630c52a-8da2-4875-859b-2f8078814883", "pmid": "", "title": "Colchicine for acute gout", "imported": false, "abstract": "Abstract - Background This is an updated Cochrane Review, first published in 2006 and updated in 2014. Gout is one of the most common rheumatic diseases worldwide. Despite the use of colchicine as one of the first‐line therapies for the treatment of acute gout, evidence for its benefits and harms is relatively limited. Objectives To update the available evidence of the benefits and harms of colchicine for the treatment of acute gout. Search methods We updated the search of CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICTRP registries to 28 August 2020. We did not impose any date or language restrictions in the search. Selection criteria We considered published randomised controlled trials (RCTs) and quasi‐randomised controlled trials (quasi‐RCTs) evaluating colchicine therapy compared with another therapy (placebo or active) in acute gout; low‐dose colchicine at clinically relevant doses compared with placebo was the primary comparison. The major outcomes were pain, participant global assessment of treatment success (proportion with 50% or greater decrease in pain from baseline up to 32 to 36 hours), reduction of inflammation, function of target joint, serious adverse events, total adverse events and withdrawals due to adverse events. Data collection and analysis We used standard methodological procedures as expected by Cochrane in this review update. Main results We included four trials (803 randomised participants), including two new trials, in this updated review. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We did not identify any trials comparing colchicine to glucocorticoids (by any route). The mean age of participants ranged from 51.2 to 70 years, and trial duration from 48 hours to 12 weeks. Two trials were at low risk of bias, one was possibly susceptible to selection bias (random sequence generation), reporting bias and other bias, and one open‐label trial was at high risk of performance and detection bias. For the primary comparison, low‐quality evidence from one trial (103 participants, downgraded for imprecision and bias) suggests low‐dose colchicine may improve treatment outcome compared to placebo with little or no increased risk of adverse events. The number of people who reported treatment success (50% or greater pain reduction) at 32 to 36 hours was slightly larger with low‐dose colchicine (418 per 1000) compared with placebo (172 per 1000; risk ratio (RR) 2.43, 95% confidence interval (CI) 1.05 to 5.64; absolute improvement 25% more reported success (7% more to 42% more, the 95% CIs include both a clinically important and unimportant benefit); relative change of 143% more people reported treatment success (5% more to 464% more). The incidence of total adverse events was 364 per 1000 with low‐dose colchicine compared with 276 per 1000 with placebo: RR 1.32, 95% CI 0.68 to 2.56; absolute difference 9% more events with low‐dose colchicine (9% fewer to 43% more, the 95% CIs include both a clinically important effect and no effect); relative change of 32% more events (32% fewer to 156% more). No participants withdrew due to adverse events or reported any serious adverse events. Pain, inflammation and function were not reported. Low‐quality evidence (downgraded for imprecision and bias) from two trials (124 participants) suggests that high‐dose colchicine compared to placebo may improve symptoms, but with increased risk of harms. More participants reported treatment success at 32 to 36 hours with high‐dose colchicine (518 per 1000) compared with placebo (240 per 1000): RR 2.16, 95% CI 1.28 to 3.65, absolute improvement 28% (8% more to 46% more); more also had reduced inflammation at this time point with high‐dose colchicine (504 per 1000) compared with placebo (48 per 1000): RR 10.50, 95% CI 1.48 to 74.38; absolute improvement 45% greater (22% greater to 68% greater); but more adverse events were reported with high‐dose colchicine (829 per 1000 compared with 260 per 1000): RR 3.21, 95% CI 2.01 to 5.11, absolute difference 57% (26% more to 74% more). Pain and function were not reported. Low‐quality evidence from a single trial comparing high‐dose to low‐dose colchicine indicates there may be little or no difference in benefit in terms of treatment success at 32 to 36 hours but more adverse events associated with the higher dose. Similarly, low‐quality evidence from a single trial indicates there may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction at seven days, with a similar number of adverse events reported at four weeks follow‐up. Reduction of inflammation, function of target joint and withdrawals due to adverse events were not reported in either of these trials, and pain was not reported in the high‐dose versus low‐dose colchicine trial. We were unable to estimate the risk of serious adverse events for most comparisons as there were few events reported in the trials. One trial (399 participants) reported three serious adverse (one in a participant receiving low‐dose colchicine and two in participants receiving NSAIDs), due to reasons unrelated to the trial (low‐quality evidence downgraded for bias and imprecision). Authors' conclusions We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve pain when compared to placebo, low‐quality evidence suggests that high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo, while low‐quality evidence indicates that the number of adverse events may be similar with low‐dose colchicine and NSAIDs. Further trials comparing colchicine to placebo or other treatment will likely have an important impact on our confidence in the effect estimates and may change the conclusions of this review. There are no trials reporting the effect of colchicine in populations with comorbidities or in comparison with other commonly used treatments, such as glucocorticoids. Plain language summary Colchicine for treating acute gout flares Background Gout is a very common cause of inflammatory arthritis (pain, redness, warmth and swelling of affected joints) and is caused by urate crystals forming either within or around joints. Uric acid is a normal waste product that is usually excreted with urine. However, in the case of gout, there is either excessive production of uric acid, or the body is not able to excrete it quickly enough, or a combination of both. An attack of gout usually occurs rapidly and usually resolves within 7 to 10 days. Colchicine is a drug that is used mainly in gout to treat an acute attack or to prevent an attack while starting uric acid‐lowering therapy. Study characteristics This Cochrane Review is current to August 2020. We included four trials (803 randomised participants) in this updated review, including two new trials. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (fake medicine) (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We selected low‐dose colchicine compared with placebo as the primary comparison; the low dose is consistent with doses used in practice. Trials were performed in hospital and multicentre settings in four countries, the majority of participants were male, and mean age ranged between 51.2 and 70 years. One trial received funding from a pharmaceutical company that was involved in the study design, data collection, data analysis, and manuscript writing. Key results Compared with placebo medication, low‐dose colchicine for people with acute gout may slightly improve treatment outcomes with little or no increased risk of adverse events at 32 to 36 hours. Proportion of participants reporting treatment success (defined as 50% or more reduction in pain) 25% more people (7% more to 42% more) reported success, or 25 more out of 100 ‐ 42 people out of 100 reported treatment success with colchicine ‐ 17 people out of 100 reported treatment success with placebo Total adverse events (diarrhoea, vomiting or nausea) 6% more people reported adverse events (13% more to 23% more), or 6 more out of 100 ‐ 26 people out of 100 reported side effects with colchicine ‐ 20 people out of 100 reported side effects with placebo Pain, reduction of inflammation, function of target joint, serious adverse events or withdrawals due to adverse events were not reported for this comparison. Other comparisons are briefly summarised here: High‐dose colchicine may improve symptoms compared with placebo, but with more adverse events. High‐dose may have little or no benefit over low‐dose colchicine but more adverse events. There may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction, with a similar number of adverse events. There were no trials that compared colchicine to glucocorticoids. Quality of the evidence We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve treatment success when compared to placebo, high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo while the number of adverse events may be similar with low‐dose colchicine compared with NSAIDs. Further research is very likely to have an important impact on our confidence in the estimate of effect and may change the estimate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "McKenzie, BJ; Wechalekar, MD; Johnston, RV; Schlesinger, N; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD006190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "36411414-c176-4e9e-9d53-442743ac7cfb", "pmid": "", "title": "Vitamin D supplementation for chronic liver diseases in adults", "imported": false, "abstract": "Abstract - Background Vitamin D deficiency is often reported in people with chronic liver diseases. Improving vitamin D status could therefore be beneficial for people with chronic liver diseases. Objectives To assess the beneficial and harmful effects of vitamin D supplementation in adults with chronic liver diseases. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index‐Science. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We scanned bibliographies of relevant publications and enquired experts and pharmaceutical companies as to additional trials. All searches were up to November 2020. Selection criteria Randomised clinical trials that compared vitamin D at any dose, duration, and route of administration versus placebo or no intervention in adults with chronic liver diseases. Vitamin D could have been administered as supplemental vitamin D (vitamin D 3 (cholecalciferol) or vitamin D 2 (ergocalciferol)), or an active form of vitamin D (1α‐hydroxyvitamin D (alfacalcidol), 25‐hydroxyvitamin D (calcidiol), or 1,25‐dihydroxyvitamin D (calcitriol)). Data collection and analysis We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of evidence. Main results We included 27 randomised clinical trials with 1979 adult participants. This review update added 12 trials with 945 participants. We assessed all trials at high risk of bias. All trials had a parallel‐group design. Eleven trials were conducted in high‐income countries and 16 trials in middle‐income countries. Ten trials included participants with chronic hepatitis C, five trials participants with liver cirrhosis, 11 trials participants with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. All of the included trials reported the baseline vitamin D status of participants. Participants in nine trials had baseline serum 25‐hydroxyvitamin D levels at or above vitamin D adequacy (20 ng/mL), whilst participants in the remaining 18 trials were vitamin D insufficient (less than 20 ng/mL). Twenty‐four trials administered vitamin D orally, two trials intramuscularly, and one trial intramuscularly and orally. In all 27 trials, the mean duration of vitamin D supplementation was 6 months, and the mean follow‐up of participants from randomisation was 7 months. Twenty trials (1592 participants; 44% women; mean age 48 years) tested vitamin D 3 (cholecalciferol); three trials (156 participants; 28% women; mean age 54 years) tested vitamin D 2 ; four trials (291 participants; 60% women; mean age 52 years) tested 1,25‐dihydroxyvitamin D; and one trial (18 participants; 0% women; mean age 52 years) tested 25‐hydroxyvitamin D. One trial did not report the form of vitamin D. Twelve trials used a placebo, whilst the other 15 trials used no intervention in the control group. Fourteen trials appeared to be free of vested interest. Eleven trials did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on all‐cause mortality (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.51 to 1.45; 27 trials; 1979 participants). The mean follow‐up was 7 months (range 1 to 18 months). We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on liver‐related mortality (RR 1.62, 95% CI 0.08 to 34.66; 1 trial; 18 participants) (follow‐up: 12 months); serious adverse events such as hypercalcaemia (RR 5.00, 95% CI 0.25 to 100.8; 1 trial; 76 participants); myocardial infarction (RR 0.75, 95% CI 0.08 to 6.81; 2 trials; 86 participants); thyroiditis (RR 0.33, 95% CI 0.01 to 7.91; 1 trial; 68 participants); circular haemorrhoidal prolapse (RR 3.00, 95% CI 0.14 to 65.9; 1 trial; 20 participants); bronchopneumonia (RR 0.33, 95% CI 0.02 to 7.32; 1 trial 20 participants); and non‐serious adverse events. The certainty of evidence for all outcomes is very low. We found no data on liver‐related morbidity such as gastrointestinal bleeding, hepatic encephalopathy, hepatorenal syndrome, ascites, or liver cancer. There were also no data on health‐related quality of life. The evidence is also very uncertain regarding the effect of vitamin D versus placebo or no intervention on rapid, early, and sustained virological response in people with chronic hepatitis C. Authors' conclusions Given the high risk of bias and insufficient power of the included trials and the very low certainty of the available evidence, vitamin D supplementation versus placebo or no intervention may increase or reduce all‐cause mortality, liver‐related mortality, serious adverse events, or non‐serious adverse events in adults with chronic liver diseases. There is a lack of data on liver‐related morbidity and health‐related quality of life. Further evidence on clinically important outcomes analysed in this review is needed. Plain language summary Vitamin D supplementation for chronic liver diseases Review question Is vitamin D supplementation beneficial or harmful for adults with chronic liver diseases? Background The available evidence on vitamin D and chronic liver diseases in adults is inconclusive. The aim of this systematic review (a summary of results of available healthcare trials) was to analyse the benefits and harms of the different forms of vitamin D in people with chronic liver diseases. Study characteristics Twenty‐seven trials with 1979 adult participants provided data for this review. This review update added 12 trials with 945 participants. The 1979 trial participants were randomly assigned to vitamin D compared with placebo (dummy pill) or no treatment. Eleven trials were conducted in high‐income countries, and 16 trials in middle‐income countries. The age range of the participants was 28 years to 61 years, and on average 44% were women. Ten trials included people with chronic hepatitis C, five trials people with liver cirrhosis, 11 trials people with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. There were no trials including people with chronic hepatitis B or inherited liver diseases. All of the included trials reported the baseline vitamin D status of participants. Vitamin D administration lasted on average six months, and most trials used the cholecalciferol (vitamin D 3 ) form. Funding Fourteen trials appeared to be free of vested interest that could bias the trial results. Eleven trials may not have been free of vested interest, as they did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We found no difference between trials without industry support compared to trials at risk of industry support in our analysis. Key results There is not enough evidence to determine whether vitamin D has beneficial or harmful effects, or has little to no effect on chronic liver diseases in adults. There were too few participants in the individual trials as well as in our evidence synthesis. The trials were at high risk of bias so we lack fair assessments of the benefits and harms of vitamin D in this population. Neither benefits nor harms of vitamin D supplementation in people with chronic liver diseases can be excluded. There were no trials including people with chronic hepatitis B and inherited liver diseases. Quality of the evidence We judged all trials to be at high risk of bias (that is an underestimation or overestimation of the true intervention effect). The certainty of evidence is very low. Currentness of evidence The evidence is current to November 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Bjelakovic, M, Nikolova, D, Bjelakovic, G, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD011564.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.107Z" }, { "id": "365c2872-3eec-4bf1-9073-fe4b7d926153", "pmid": "", "title": "Antioxidant supplementation for lung disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Airway infection leads to progressive damage of the lungs in cystic fibrosis (CF) and oxidative stress has been implicated in the etiology. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, beta‐carotene and selenium) or N‐acetylcysteine (NAC) as a source of glutathione, may therefore potentially help maintain an oxidant‐antioxidant balance. Glutathione or NAC can also be inhaled and if administered in this way can also have a mucolytic effect besides the antioxidant effect. Current literature suggests a relationship between oxidative status and lung function. This is an update of a previously published review. Objectives To synthesise existing knowledge on the effect of antioxidants such as vitamin C, vitamin E, beta‐carotene, selenium and glutathione (or NAC as precursor of glutathione) on lung function through inflammatory and oxidative stress markers in people with CF. Search methods The Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and PubMed were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies. We also searched online trials registries. Last search of Cystic Fibrosis Trials Register: 08 January 2019. Selection criteria Randomised and quasi‐randomised controlled studies comparing antioxidants as listed above (individually or in combination) in more than a single administration to placebo or standard care in people with CF. Data collection and analysis Two authors independently selected studies, extracted data and assessed the risk of bias in the included studies. We contacted study investigators to obtain missing information. If meta‐analysed, studies were subgrouped according to supplement, method of administration and the duration of supplementation. We assessed the quality of the evidence using GRADE. Main results One quasi‐randomised and 19 randomised controlled studies (924 children and adults) were included; 16 studies (n = 639) analysed oral antioxidant supplementation and four analysed inhaled supplements (n = 285). Only one of the 20 included studies was judged to be free of bias. Oral supplements versus control The change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted at three months and six months was only reported for the comparison of NAC to control. Four studies (125 participants) reported at three months; we are uncertain whether NAC improved FEV 1 % predicted as the quality of the evidence was very low, mean difference (MD) 2.83% (95% confidence interval (CI) ‐2.16 to 7.83). However, at six months two studies (109 participants) showed that NAC probably increased FEV 1 % predicted from baseline (moderate‐quality evidence), MD 4.38% (95% CI 0.89 to 7.87). A study of a combined vitamin and selenium supplement (46 participants) reported a greater change from baseline in FEV 1 % predicted in the control group at two months, MD ‐4.30% (95% CI ‐5.64 to ‐2.96). One study (61 participants) found that NAC probably makes little or no difference in the change from baseline in quality of life (QoL) at six months (moderate‐quality evidence), standardised mean difference (SMD) ‐0.03 (95% CI ‐0.53 to 0.47), but the two‐month combined vitamin and selenium study reported a small difference in QoL in favour of the control group, SMD ‐0.66 (95% CI ‐1.26 to ‐0.07). The NAC study reported on the change from baseline in body mass index (BMI) (62 participants) and similarly found that NAC probably made no difference between groups (moderate‐quality evidence). One study (69 participants) found that a mixed vitamin and mineral supplement may lead to a slightly lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) provided information on adverse events, but did not find any clear and consistent evidence of differences between treatment or control groups with the quality of the evidence ranging from low to moderate. Studies of β‐carotene and vitamin E consistently reported greater plasma levels of the respective antioxidants. Inhaled supplements versus control Two studies (258 participants) showed inhaled glutathione probably improves FEV 1 % predicted at three months, MD 3.50% (95% CI 1.38 to 5.62), but not at six months compared to placebo, MD 2.30% (95% CI ‐0.12 to 4.71) (moderate‐quality evidence). The same studies additionally reported an improvement in FEV 1 L in the treated group compared to placebo at both three and six months. One study (153 participants) reported inhaled glutathione probably made little or no difference to the change in QoL from baseline, MD 0.80 (95% CI ‐1.63 to 3.23) (moderate‐quality evidence). No study reported on the change from baseline in BMI at six months, but one study (16 participants) reported at two months and a further study (105 participants) at 12 months; neither study found any difference at either time point. One study (153 participants) reported no difference in the time to the first pulmonary exacerbation at six months. Two studies (223 participants) reported treatment may make little or no difference in adverse events (low‐quality evidence), a further study (153 participants) reported that the number of serious adverse events were similar across groups. Authors' conclusions With regards to micronutrients, there does not appear to be a positive treatment effect of antioxidant micronutrients on clinical end‐points; however, oral supplementation with glutathione showed some benefit to lung function and nutritional status. Based on the available evidence, inhaled and oral glutathione appear to improve lung function, while oral administration decreases oxidative stress; however, due to the very intensive antibiotic treatment and other concurrent treatments that people with CF take, the beneficial effect of antioxidants remains difficult to assess in those with chronic infection without a very large population sample and a long‐term study period. Further studies, especially in very young children, using outcome measures such as lung clearance index and the bronchiectasis scores derived from chest scans, with improved focus on study design variables (such as dose levels and timing), and elucidating clear biological pathways by which oxidative stress is involved in CF, are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn. The benefit of antioxidants in people with CF who receive CFTR modulators therapies should also be assessed in the future. Plain language summary How do vitamins E and C, beta‐carotene, selenium and glutathione affect lung disease in people with cystic fibrosis? Background Frequent chest infections cause long‐term lung inflammation; inflammation‐causing cells produce an oxygen molecule (reactive oxygen species (ROS)), which may harm body tissue (oxidative damage); the body uses antioxidants to protect itself. People with cystic fibrosis (CF) have high levels of ROS compared to low levels of antioxidants. Antioxidant supplements might reduce oxidative damage and build up levels of antioxidants. Given difficulties in absorbing fat, people with CF have low levels of fat‐soluble antioxidants (vitamin E and beta‐carotene). Water‐soluble vitamin C decreases with age in people with CF. Glutathione, one of the most abundant antioxidants in cells, is not released properly into the lungs of people with CF. Some enzymes that help antioxidants work depend on the mineral selenium, so selenium supplements aim to stimulate antioxidant action. Most supplements are swallowed, but glutathione and N‐acetylcysteine (NAC) (which the body uses to make glutathione) can also be inhaled; these may affect lung function as antioxidants, but also due to thinning mucus when inhaled (allowing easier mucus clearance). Search date Last search for this updated review: 08 January 2019. Study characteristics We included 20 studies (924 people with CF, almost equal gender split, aged six months to 59 years); 16 studies compared oral supplements to placebo ('dummy' treatment) and four compared inhaled supplements to placebo. Key results Oral supplements We are uncertain whether NAC changes lung function (forced expiratory volume in one second (FEV 1 ) % predicted) at three months (four studies, 125 participants, very low‐quality evidence), but at six months two studies (109 participants) reported NAC probably improved FEV 1 % predicted (moderate‐quality evidence). One study (46 participants) reported a greater change in FEV 1 % predicted with placebo than with a combined vitamin and selenium supplement after two months. One study (61 participants) reported little or no difference in quality of life (QoL) scores between NAC and control after six months (moderate‐quality evidence), but the two‐month combined vitamin and selenium study reported slightly better QoL scores in the control group. NAC probably made no difference to body mass index (BMI) (one study, 62 participants, moderate‐quality evidence). One study (69 participants) reported that a mixed vitamin and mineral supplement may lead to a lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) did not find any clear and consistent differences in side effects between groups (evidence ranged from low to moderate quality). Vitamin E and β‐carotene studies consistently reported greater levels of these antioxidants in blood samples. Inhaled supplements In two studies (258 participants), inhaled glutathione probably improved FEV 1 % predicted compared to placebo at three months but not at six months (moderate‐quality evidence); these studies also reported a greater improvement in FEV 1 litres with glutathione compared to placebo at both time points. Two studies (258 participants) found little or no difference in the change in QoL scores (moderate‐quality evidence). One two‐month study (16 participants) and a 12‐month study (105 participants) reported no difference between groups in the change in BMI. There was no difference in the time to the first pulmonary exacerbation in one six‐month study. Two studies (223 participants) reported no difference between groups in side effects (low‐quality evidence) and another study (153 participants) reported that the number of serious side effects were similar across groups. Conclusions Vitamin and mineral supplements do not seem to improve clinical outcomes. Inhaled glutathione appears to improve lung function, while oral administration lowers oxidative stress, with benefits to lung function and nutritional measures. Intensive antibiotic and other concurrent treatments for people with CF and chronic infection mean it is difficult to assess the effect of antioxidants without a very large and long study. Future research should look at how antioxidants affect people with CF taking CFTR modulator therapies. Quality of the evidence Evidence ranged from very low to moderate quality. All but one study had some bias; mostly because data were not fully reported (likely to affect our results). We were also largely unsure if participants knew which treatment they received, both in advance and once the studies started (unsure how this might affect our results).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ciofu, O; Smith, S; Lykkesfeldt, J", "articleTypes": [], "doi": "10.1002/14651858.CD007020.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "3676e8e3-bedb-4233-81e8-8eb72f3d0619", "pmid": "", "title": "Adjunctive systemic antimicrobials for the non‐surgical treatment of periodontitis", "imported": false, "abstract": "Abstract - Background Systemic antimicrobials can be used as an adjunct to mechanical debridement (scaling and root planing (SRP)) as a non‐surgical treatment approach to manage periodontitis. A range of antibiotics with different dosage and combinations are documented in the literature. The review follows the previous classification of periodontitis as all included studies used this classification. Objectives To assess the effects of systemic antimicrobials as an adjunct to SRP for the non‐surgical treatment of patients with periodontitis. Search methods Cochrane Oral Health's Information Specialist searched the following databases to 9 March 2020: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, and Embase. The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included randomized controlled trials (RCTs) which involved individuals with clinically diagnosed untreated periodontitis. Trials compared SRP with systemic antibiotics versus SRP alone/placebo, or with other systemic antibiotics. Data collection and analysis We selected trials, extracted data, and assessed risk of bias in duplicate. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE. Main results We included 45 trials conducted worldwide involving 2664 adult participants. 14 studies were at low, 8 at high, and the remaining 23 at unclear overall risk of bias. Seven trials did not contribute data to the analysis. We assessed the certainty of the evidence for the 10 comparisons which reported long‐term follow‐up (≥ 1 year). None of the studies reported data on antimicrobial resistance and patient‐reported quality of life changes. Amoxicillin + metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐16.20%, 95% CI ‐25.87 to ‐6.53; 1 study, 44 participants); clinical attachment level (CAL) (MD ‐0.47 mm, 95% CI ‐0.90 to ‐0.05; 2 studies, 389 participants); probing pocket depth (PD) (MD ‐0.30 mm, 95% CI ‐0.42 to ‐0.18; 2 studies, 389 participants); and percentage of bleeding on probing (BOP) (MD ‐8.06%, 95% CI ‐14.26 to ‐1.85; 2 studies, 389 participants) was of very low certainty. Only the results for closed pockets and BOP showed a minimally important clinical difference (MICD) favouring amoxicillin + metronidazole + SRP. Metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐12.20%, 95% CI ‐29.23 to 4.83; 1 study, 22 participants); CAL (MD ‐1.12 mm, 95% CI ‐2.24 to 0; 3 studies, 71 participants); PD (MD ‐1.11 mm, 95% CI ‐2.84 to 0.61; 2 studies, 47 participants); and percentage of BOP (MD ‐6.90%, 95% CI ‐22.10 to 8.30; 1 study, 22 participants) was of very low certainty. Only the results for CAL and PD showed an MICD favouring the MTZ + SRP group. Azithromycin + SRP versus SRP for chronic/aggressive periodontitis: we found no evidence of a difference in percentage of closed pockets (MD 2.50%, 95% CI ‐10.19 to 15.19; 1 study, 40 participants); CAL (MD ‐0.59 mm, 95% CI ‐1.27 to 0.08; 2 studies, 110 participants); PD (MD ‐0.77 mm, 95% CI ‐2.33 to 0.79; 2 studies, 110 participants); and percentage of BOP (MD ‐1.28%, 95% CI ‐4.32 to 1.76; 2 studies, 110 participants) (very low‐certainty evidence for all outcomes). Amoxicillin + clavulanate + SRP versus SRP for chronic periodontitis: the evidence from 1 study, 21 participants for CAL (MD 0.10 mm, 95% CI ‐0.51 to 0.71); PD (MD 0.10 mm, 95% CI ‐0.17 to 0.37); and BOP (MD 0%, 95% CI ‐0.09 to 0.09) was of very low certainty and did not show a difference between the groups. Doxycycline + SRP versus SRP in aggressive periodontitis: the evidence from 1 study, 22 participants for CAL (MD ‐0.80 mm, 95% CI ‐1.49 to ‐0.11); and PD (MD ‐1.00 mm, 95% CI ‐1.78 to ‐0.22) was of very low certainty, with the doxycycline + SRP group showing an MICD in PD only. Tetracycline + SRP versus SRP for aggressive periodontitis: we found very low‐certainty evidence of a difference in long‐term improvement in CAL for the tetracycline group (MD ‐2.30 mm, 95% CI ‐2.50 to ‐2.10; 1 study, 26 participants). Clindamycin + SRP versus SRP in aggressive periodontitis: we found very low‐certainty evidence from 1 study, 21 participants of a difference in long‐term improvement in CAL (MD ‐1.70 mm, 95% CI ‐2.40 to ‐1.00); and PD (MD ‐1.80 mm, 95% CI ‐2.47 to ‐1.13) favouring clindamycin + SRP. Doxycycline + SRP versus metronidazole + SRP for aggressive periodontitis: there was very low‐certainty evidence from 1 study, 27 participants of a difference in long‐term CAL (MD 1.10 mm, 95% CI 0.36 to 1.84); and PD (MD 1.00 mm, 95% CI 0.30 to 1.70) favouring metronidazole + SRP. Clindamycin + SRP versus metronidazole + SRP for aggressive periodontitis: the evidence from 1 study, 26 participants for CAL (MD 0.20 mm, 95% CI ‐0.55 to 0.95); and PD (MD 0.20 mm, 95% CI ‐0.38 to 0.78) was of very low certainty and did not show a difference between the groups. Clindamycin + SRP versus doxycycline + SRP for aggressive periodontitis: the evidence from 1 study, 23 participants for CAL (MD ‐0.90 mm, 95% CI ‐1.62 to ‐0.18); and PD (MD ‐0.80 mm, 95% CI ‐1.58 to ‐0.02) was of very low certainty and did not show a difference between the groups. Most trials testing amoxicillin, metronidazole, and azithromycin reported adverse events such as nausea, vomiting, diarrhoea, mild gastrointestinal disturbances, and metallic taste. No serious adverse events were reported. Authors' conclusions There is very low‐certainty evidence (for long‐term follow‐up) to inform clinicians and patients if adjunctive systemic antimicrobials are of any help for the non‐surgical treatment of periodontitis. There is insufficient evidence to decide whether some antibiotics are better than others when used alongside SRP. None of the trials reported serious adverse events but patients should be made aware of the common adverse events related to these drugs. Well‐planned RCTs need to be conducted clearly defining the minimally important clinical difference for the outcomes closed pockets, CAL, PD, and BOP. Plain language summary What are the benefits and risks of using antibiotics as well as cleaning by a dental care professional to treat gum disease? Why is this question important? Gum disease is a common condition in which the gums become swollen, sore or infected. It is caused by bacteria that accumulate on gums and teeth. Diseased gums may bleed when people brush their teeth, and may cause bad breath. If gum disease is not treated, teeth can become loose and eventually fall out. This can affect a person’s ability to chew and speak. It can also make people feel self‐conscious about their appearance. Dental‐care professionals can clean teeth and gums to remove excess bacteria from the mouth. They use special instruments – typically, an ultrasound scraper followed by specialised hand‐held instruments – to scrape bacteria from the teeth, and stop these from affecting the gums. Antibiotics (medicines that kill bacteria) taken by mouth (orally) can be used alongside professional cleaning, to remove bacteria from the area between the teeth and gums. However, there are potential risks associated with antibiotics, such as allergic reactions and antibiotic resistance (changes in bacteria after exposure to antibiotics, that allow the bacteria to survive future antibiotic treatment). We conducted a review of the evidence from research studies to find out about the benefits and risks of using antibiotics alongside professional dental cleaning to treat gum disease. We also wanted to know if some antibiotics work better than others in this situation. How did we identify and evaluate the evidence? First, we searched for randomized controlled studies (clinical studies where people are randomly put into one of two or more treatment groups), because these studies provide the most robust evidence about the effects of a treatment. We then compared the results, and summarized the evidence from all the studies. Finally, we rated our confidence in the evidence, based on factors such as study methods and sizes, and the consistency of findings across studies. What did we find? We found 45 studies that involved a total of 2664 people over the age of 18 who had gum disease. The studies compared professional cleaning plus antibiotics against professional cleaning alone, or compared different antibiotics used alongside professional cleaning against one another. We cannot tell whether antibiotics reduce gum disease in the long term (one year or more after treatment), or whether some antibiotics are better than others. This is because we have very little confidence in the evidence we found. We cannot tell whether antibiotics are associated with unwanted effects, because we have too little confidence in the evidence. The most commonly reported unwanted effects were temporary, mild gastrointestinal disturbances, such as nausea, vomiting, diarrhoea, or a metallic taste in the mouth. No serious unwanted effects were reported. No studies reported on antimicrobial resistance or changes in people’s quality of life. What does this mean? We do not know whether: ‐ using antibiotics alongside professional cleaning is beneficial for treating gum disease in the long term (more than one year after treatment);
‐ using antibiotics alongside professional cleaning is associated with unwanted effects; or
‐ some antibiotics are better than others for treating gum disease alongside professional cleaning. Our confidence in the available evidence is very low. The results of our review are likely to change if more evidence becomes available. Future studies should clearly define what qualifies as a minimally important improvement in gum disease. How‐up‐to date is this review? The evidence in this Cochrane Review is current to March 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Khattri, S; Kumbargere Nagraj, S; Arora, A; Eachempati, P; Kusum, CK; Bhat, KG; Johnson, TM; Lodi, G", "articleTypes": [], "doi": "10.1002/14651858.CD012568.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "368cdf74-ac68-4e89-bf1a-b993513e1900", "pmid": "", "title": "Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer", "imported": false, "abstract": "Abstract - Background Radioactive iodine treatment for differentiated thyroid cancer possibly results in xerostomia. Amifostine has been used to prevent the effects of irradiation to salivary glands. To date, the effects of amifostine on salivary glands in radioactive iodine treated differentiated thyroid cancer remain uncertain. Objectives To assess the effects of amifostine on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer. Search methods Studies were obtained from computerized searches of MEDLINE, EMBASE, The Cochrane Library and paper collections of conferences held in Chinese. Selection criteria Randomised controlled clinical trials and quasi‐randomised controlled clinical trials comparing the effects of amifostine on salivary glands after radioactive iodine treatment for differentiated thyroid cancer with placebo and a duration of follow up of at least three months. Data collection and analysis Two authors independently assessed risk of bias and extracted data. Main results Two trials with 130 patients (67 and 63 patients randomised to intervention versus control) were included. Both studies had a low risk of bias. Amifostine versus placebo showed no statistically significant differences in the incidence of xerostomia (130 patients, two studies), the decrease of scintigraphically measured uptake of technetium‐99m by salivary or submandibular glands at twelve months (80 patients, one study), and the reduction of blood pressure (130 patients, two studies). Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Meta‐analysis was not performed on the function of salivary glands measured by technetium‐99m scintigraphy at three months after high dose radioactive iodine treatment due to the highly inconsistent findings across studies (I 2 statistic 99%). None of the included trials investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions Results from two randomised controlled clinical trials suggest that the amifostine has no significant radioprotective effects on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer patients. Moreover, no health‐related quality of life and other patient‐oriented outcomes were evaluated in the two included trials. Randomised controlled clinical trials with low risk of bias investigating patient‐oriented outcomes are needed to guide treatment choice. Plain language summary Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer Thyroid cancer is the most common malignancy of the endocrine system consisting of several subtypes like papillary carcinoma (accounting for 80% of cases) and follicular carcinoma (accounting for 11% of cases). These are collectively referred to as 'differentiated thyroid cancer'. Treatment with radioactive iodine after surgery (ablation of the thyroid gland or 'thyroidectomy') is important for the detection of metastatic disease and for the destruction of the remaining thyroid tissue with microscopic cancer. After radioactive iodine treatment, adverse effects may happen in the salivary glands and cause salivary gland swelling and pain, usually involving the parotid. The symptoms may develop immediately after a therapeutic dose of radioactive iodine or months later and progress in intensity with time. Secondary complications reported include dry mouth ('xerostomia') and taste alterations. Amifostine is thought to be a radioprotector of salivary glands used in conjunction with radioiodine therapy. This medication is administered intravenously and was reported to ameliorate the damage of salivary glands caused by radioactive iodine therapy. We found only two randomised controlled trials in which the effects of amifostine were compared with placebo. The two randomised clinical trials investigated 130 patients treated with high dose radioactive iodine for thyroid cancer. Altogether data from the two trials suggest that amifostine has no obvious protective effects on the salivary glands in these patients. Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Until better data become available, the use of sour candy or lemon juice to increase salivation might be more appropriate during radioactive iodine treatment for patients with differentiated thyroid cancer. Patients should be well informed of the importance of hydration, acid stimulation and glandular massage after radioactive iodine treatment. In addition, early recognition and treatment of xerostomia may improve outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Ma, C; Xie, J; Chen, Q; Wang, G; Zuo, S", "articleTypes": [], "doi": "10.1002/14651858.CD007956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "36a66b71-2b39-429f-865b-e59b1064fa67", "pmid": "", "title": "Topical medication instillation techniques for glaucoma", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Xu, L, Wang, X, Wu, M", "articleTypes": [], "doi": "10.1002/14651858.CD010520.pub2 AB - Abstract - Background Glaucoma is a leading cause of irreversible blindness worldwide and the second most common cause of blindness after cataracts. The primary treatment for glaucoma aims to lower intraocular pressure (IOP) with the use of topical medicines. Topical medication instillation techniques, such as eyelid closure and nasolacrimal occlusion when instilling drops, have been proposed as potential methods to increase ocular absorption and decrease systemic absorption of the drops. Objectives To investigate the effectiveness of topical medication instillation techniques compared with usual care or another method of instillation of topical medication in the management of glaucoma or ocular hypertension. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 8 December 2016), Embase Ovid (1947 to 8 December 2016), PubMed (1948 to 8 December 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 8 December 2016), International Pharmaceutical Abstracts Database (1970 to 8 December 2016), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ) (last searched 13 May 2013), ClinicalTrials.gov ( www.clinicaltrials.gov ) (searched 8 December 2016) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) (searched 8 December 2016). We did not use any date or language restrictions in the electronic searches for trials. Selection criteria We included randomized controlled trials which had compared any topical medication instillation technique with usual care or a different method of instillation of topical medication. Data collection and analysis Two review authors independently screened records from the searches for eligibility, assessed the risk of bias, and extracted data. We followed methods recommended by Cochrane. Main results We identified two trials (122 eyes of 61 participants) that had evaluated a topical medication instillation technique. We also identified two ongoing trials. Both included trials used a within‐person design and administered prostaglandin monotherapy for glaucoma or ocular hypertension. Because the trials evaluated different instillation techniques and assessed different outcomes, we performed no meta‐analysis. One trial, conducted in the US, evaluated the effect of eyelid closure (one and three minutes) versus no eyelid closure on lowering IOP. At one to two weeks' follow‐up, reduction in IOP was similar in the eyelid closure group and the no eyelid closure group (mean difference (MD) ‐0.33 mmHg, 95% confidence interval (CI) ‐0.8 to 1.5; 51 participants; moderate‐certainty evidence). The second trial, conducted in Italy, evaluated the effect of using an absorbent cloth to wipe excess fluid after instillation (fluid removal) versus not using an absorbent cloth (no removal) on reducing dermatologic adverse events. At four months' follow‐up, eyelashes were shorter among eyes in the fluid removal group compared with the no fluid removal group (MD ‐1.70 mm, 95% CI ‐3.46 to 0.06; 10 participants; low‐certainty evidence). Fewer eyes showed skin hyperpigmentation in the eyelid region towards the nose in the fluid removal group compared with the no removal group (RR 0.07, 95% CI 0.01 to 0.84; 10 participants; low‐certainty evidence); however, the difference was uncertain in the eyelid region towards the temples (RR 0.44, 95% CI 0.07 to 2.66; 10 participants; low‐certainty evidence). The effect hypertrichosis (excessive hair growth) was uncertain between groups (RR 1.00, 95% CI 0.17 to 5.98; 10 participants; low‐certainty evidence). Neither trial reported other outcomes specified for this review, including the proportion of participants with IOP less than 21 mmHg; participant‐reported outcomes related to the ease, convenience, and comfort of instillation techniques; physiologic measurements of systemic absorption; escalation of therapy; mean change in visual fields; optic nerve progression; mean change in best‐corrected visual acuity; proportion in whom glaucoma developed; quality of life outcomes; or cost‐effectiveness outcomes. Neither trial reported data at follow‐up times of more than four months. Authors' conclusions Evidence to evaluate the effectiveness of topical medication instillation techniques for treatment of glaucoma is lacking. It is unclear what, if any, effects instillation techniques have on topical medical therapy for glaucoma. Plain language summary Topical medicine instillation techniques for glaucoma What is the aim of this review? 
 The aim of this Cochrane Review was to find out if the way that people with glaucoma put eye drops in makes a difference in how well the eye drops work. Cochrane researchers collected and analyzed all relevant studies to answer this question and found two studies. Key messages 
 It is unclear if the way that people with glaucoma put their eye drops in makes a difference in how well the drops work. What did this review study? 
 Glaucoma is a leading cause of blindness worldwide. In eyes with glaucoma, the ability to see may be lost because of damage to the optic nerve. The optic nerve is the part of the eye that sends visual information from the eye to the brain. Sometimes such damage occurs when there is too much pressure in the eye (called intraocular pressure or IOP). Sometimes eyes may have too much pressure without damage to the optic nerve (called ocular hypertension). The main goal of glaucoma and ocular hypertension treatment is to lower IOP. Topical medicines, such as eye drops, are most often used as the first treatment. Encouraging specific ways of applying the drops, such as closing your eyes or nasolacrimal occlusion (closing the eye and pressing a finger on the inside corner, by the nose) aims to increase how much medicine is absorbed into the eye and reduce how much medicine is absorbed into the body. What are the main results of the review? 
 We found two studies that compared different ways of putting in eye drops. Both studies used prostaglandin alone for glaucoma or ocular hypertension. One study, in the US, evaluated the effect of closing the eyes for one and three minutes after putting in eye drops on lowering IOP. The second study, in Italy, looked at whether wiping off the excess fluid, after putting in the eye drops, led to fewer changes in the skin surrounding the eye. After one to two weeks in the US study, closing the eyelid for one to three minutes after putting in the eye drops found no difference on IOP compared with not closing the eyelid for a specified amount of time. After four months in the Italian study, eyelashes were shorter when participants had wiped their eyes to remove excess fluid when compared with participants who did not wipe their eyes. We found two ongoing studies that do not have results yet. Based on only two studies and uncertain results, it is unclear if different ways of putting in eye drops have any effect on people with glaucoma. How up‐to‐date is this review? 
 Cochrane researchers searched for studies that had been published up to 8 December 2016.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.111Z" }, { "id": "36aa8716-d88b-4f05-aacb-8ece14acf786", "pmid": "", "title": "Desipramine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Antidepressants are widely used to treat chronic neuropathic pain (pain due to nerve damage), usually in doses below those at which they exert antidepressant effects. An earlier review that included all antidepressants for neuropathic pain is being replaced by new reviews of individual drugs examining individual neuropathic pain conditions. Desipramine is a tricyclic antidepressant that is occasionally used for treating neuropathic pain. Objectives To assess the analgesic efficacy of desipramine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 29 April 2014, and the reference lists of retrieved papers and other reviews. We also used our own hand searched database to identify older studies, and two clinical trials databases for ongoing or unpublished studies. Selection criteria We included randomised, double‐blind studies of at least two weeks duration comparing desipramine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 years and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted the efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts, at least 200 participants in the comparison, 8 to 12 weeks duration, parallel design); second tier from data that failed to meet one or more of these criteria and were considered at some risk of bias but with adequate numbers in the comparison; and third tier from data involving small numbers of participants and considered very likely to be biased or that used outcomes of limited clinical utility, or both. Main results Five studies treated 177 participants with painful diabetic neuropathy (104) or postherpetic neuralgia (73). The mean or median ages in the studies were 55 to 72 years. Four studies used a cross‐over, and one a parallel group design; 145 participants were randomised to receive desipramine 12.5 mg to 250 mg daily, with most taking 100 mg to 150 mg daily following titration. Comparators were placebo in three studies (an 'active placebo' in two studies), fluoxetine, clomipramine (one study each), and amitriptyline (two studies), and treatment was for two to six weeks. All studies had one or more sources of potential major bias. No study provided first or second tier evidence for any outcome. No data were available on the proportion of people with at least 50% or 30% reduction in pain, but data were available from three studies for our other primary outcome of Patient Global Impression of Change, reported as patient evaluation of pain relief that was 'complete' or 'a lot'. No pooling of data was possible, but third tier evidence in individual studies indicated some improvement in pain relief with desipramine compared with placebo, although this was very low quality evidence, derived mainly from group mean data and completer analyses in small, short duration studies where major bias was possible. There were too few participants in comparisons of desipramine with another active treatment to draw any conclusions. All studies reported some information about adverse events, but reporting was inconsistent and fragmented. Participants taking desipramine experienced more adverse events, and a higher rate of withdrawal due to adverse events, than did participants taking placebo (very low quality evidence). Authors' conclusions This review found little evidence to support the use of desipramine to treat neuropathic pain. There was very low quality evidence of benefit and harm, but this came from studies that were methodologically flawed and potentially subject to major bias. Effective medicines with much greater supportive evidence are available. There may be a role for desipramine in patients who have not obtained pain relief from other treatments. Plain language summary Desipramine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not usually effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Desipramine is a tricyclic antidepressant from the same class of medicines as amitriptyline, which is widely recommended for treating neuropathic pain. Desipramine may also be useful in these painful conditions. In 2014, we performed searches to look for clinical trials where desipramine was used to treat neuropathic pain. Five small studies, each with 24 to 54 participants, included 177 participants in total with painful diabetic neuropathy or postherpetic neuralgia. Studies were randomised and double‐blind, but all had one or more sources of potential major bias that could lead to overestimation of efficacy. It was not possible to combine information from the different studies, but individually they indicated some benefit from desipramine (usually at a dose between 100 mg and 150 mg daily), compared with placebo, at the expense of increased adverse events. There was not enough information about other comparators to draw any conclusions. There was too little information, which was of inadequate quality, to be sure that desipramine works as a pain medicine in painful diabetic neuropathy or postherpetic neuralgia, and no information about other types of neuropathic pain. Other medicines have been shown to be effective as treatments of first choice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hearn, L, Moore, RA, Derry, S, Wiffen, PJ, Phillips, T", "articleTypes": [], "doi": "10.1002/14651858.CD011003.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.078Z" }, { "id": "36edd1a8-0663-4425-99a1-d2d6854b6d1d", "pmid": "", "title": "Probiotics for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Trivedi, A, Teo, E, Walker, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012265.pub2 AB - Abstract - Background The intestinal microflora has an essential role in providing a barrier against colonisation of pathogens, facilitating important metabolic functions, stimulating the development of the immune system, and maintaining intestinal motility. Probiotics are live microorganisms that can be administered to supplement the gut flora. Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be partly due to a disruption of the integrity of the gut and its intestinal microflora. There may be a role for probiotics in reducing the incidence of sepsis and improving intestinal motility, thus reducing morbidity and mortality and improving enteral feeding in neonates in the postoperative period. Objectives To evaluate the efficacy and safety of administering probiotics after gastrointestinal surgery for the postoperative management of neonates born from 35 weeks of gestation. Search methods We searched CENTRAL, MEDLINE, Embase, and trial registries in August 2023. We checked reference lists of included studies and relevant systematic reviews for additional studies. Selection criteria We included randomised controlled trials (RCTs) that investigated the postoperative administration of oral probiotics versus placebo or no treatment in neonates born from 35 weeks of gestation who had one or more gastrointestinal surgical procedures. We applied no restrictions regarding the type or dosage of probiotics or the duration of treatment. Data collection and analysis We used standard Cochrane methods, and we used GRADE to assess the certainty of evidence. Main results We identified one RCT that recruited 61 neonates with a gestational age of 35 weeks or more. All infants were admitted to a neonatal intensive care unit and had surgery for gastrointestinal pathologies. There may be little or no difference in proven sepsis (positive bacterial culture, local or systemic) between infants who receive probiotics compared with those who receive placebo (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.16 to 2.55; 61 infants; low‐certainty evidence). Probiotics compared to placebo may have little or no effect on time to full enteral feeds (mean difference (MD) 0.63 days, 95% CI −4.02 to 5.28; 61 infants; low‐certainty evidence). There were no reported deaths prior to discharge from hospital in either study arm. Two weeks after supplementation, the infants who received probiotics had a substantially higher relative abundance of non‐pathogenic intestinal microflora (Bifidobacteriaceae) than those who received placebo (MD 38.22, 95% CI 28.40 to 48.04; 39 infants; low‐certainty evidence). Authors' conclusions This review provides low‐certainty evidence from one small RCT that probiotics compared to placebo have little or no effect on the risk of proven sepsis (positive bacterial culture, local or systemic) or time to full‐enteral feeds in neonates who have undergone gastrointestinal surgery. Probiotics may substantially increase the abundance of beneficial bacterial in the intestine of these neonates, but the clinical implications of this finding are unknown. There is a need for adequately powered RCTs to assess the role of probiotics in this population. We identified two ongoing studies. As neither reported the gestational age of prospective study participants, we are unsure if they will be eligible for inclusion in this review. Plain language summary Benefits and harms of giving probiotics to newborns after digestive tract surgery Key message • Probiotics may have little or no effect on the risk of blood infection in infants born from 35 weeks of pregnancy who have undergone surgery of the digestive tract (food pipe, stomach, or bowel).
• Probiotics may increase the proportion of 'good' bacteria in the bowel, but we do not know if this has any real benefit for the infant. What are probiotics? Probiotics are live bacteria that may offer health benefits when consumed. There is evidence that probiotics can prevent an inflammatory disease of the bowel (necrotising enterocolitis) and infection in premature babies. What are some of the risks of bowel surgery in babies? Surgery of the digestive tract increases the risk of infection, and infection can increase the length of hospital stay. Treatment with antibiotics (medicines that treat bacterial infection) and the stress of surgery can diminish the 'good' bacteria in the bowel. What did we want to find out? We wanted to find out if giving probiotics to babies born from 35 weeks of pregnancy who underwent stomach or bowel surgery could improve rates of infection, length of hospital stay, rates of death, feeding, and the proportion of 'good' bacteria in the stomach and bowel. What did we do? We searched for studies that randomly assigned babies to experimental treatment (probiotics) or a control, which could be placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested) or no treatment. What did we find? We found one small study of 61 babies born from 35 weeks of pregnancy who had digestive tract surgery. Thirty babies received probiotics after the surgery, and 30 received a placebo. In the probiotics group, 13% of babies had a blood infection, compared with 19% in the placebo group. This difference is too small to be significant. On average, the babies in the probiotic group were receiving food into their stomach about 15 hours sooner than those in the placebo group. Again, this difference is not important. Among 39 infants who were tested, those in the probiotics group had considerably more 'good' bacteria in their bowel compared to the placebo group. What are the limitations of the evidence? We have little confidence in the evidence because it is based on a single study with few participants. The evidence is not strong enough to support giving probiotics routinely. Well‐designed and large studies are needed to determine the benefits and harms of giving probiotics to newborns after digestive tract surgery. How up to date is this evidence? The evidence is up to date to August 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.788Z" }, { "id": "36efe10e-bff7-46e5-bb43-af7652c618c3", "pmid": "", "title": "Evaluation of the Perception of Freshness and Swallowing Safety in Stroke Patients With Dysphagia Receiving a Specially Designed Thickened Oral Nutritional Supplement: the Cooling Sensation Safe Deglution Study", "imported": false, "abstract": "Dysphagia is a common complication in patients who have suffered a cerebrovascular accident (CVA), with an incidence ranging from 29% to 81%. Rehabilitation improves dysphagia in 47% of cases within the first few weeks and in 17% within 2-4 months. However, dysphagia can lead to nutritional and respiratory complications, affecting recovery and increasing healthcare costs due to the need for prolonged hospitalizations and readmissions.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.265Z" }, { "id": "370cc5b1-89bc-4985-8728-c817f1df6a14", "pmid": "", "title": "Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age‐inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long‐term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega‐3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents. Objectives To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents. Search methods We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references. Selection criteria We included randomised and quasi‐randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD. Data collection and analysis We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow‐up; and cost. We used GRADE to assess the certainty of evidence for each outcome. Main results We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross‐over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega‐3 PUFA, six used a combined omega‐3/omega‐6 supplement, and two used an omega‐6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co‐intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega‐3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega‐3 PUFA plus atomoxetine to atomoxetine; omega‐3 PUFA plus physical training to physical training; and an omega‐3 or omega‐6 supplement plus methylphenidate to methylphenidate; and two trials compared omega‐3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months. Although we found low‐certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high‐certainty evidence that PUFA had no effect on parent‐rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) −0.08, 95% CI −0.24 to 0.07; 16 studies, 1166 participants). There was also high‐certainty evidence that parent‐rated inattention (medium‐term: SMD −0.01, 95% CI −0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium‐term: SMD 0.09, 95% CI −0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo. There was moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate‐certainty evidence that medium‐term loss to follow‐up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants). Authors' conclusions Although we found low‐certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high‐certainty evidence that PUFA had no effect on total parent‐rated ADHD symptoms. There was also high‐certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups. We found moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate‐certainty evidence that follow‐up was similar between groups. It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times. Plain language summary Polyunsaturated fatty acids (PUFA) supplements for attention deficit hyperactivity disorder (ADHD) in children and adolescents What is ADHD? Attention deficit hyperactivity disorder (ADHD) is a common problem in children and adolescents. Those affected may struggle to concentrate, feel restless, or act on impulse. As a result of these difficulties, ADHD can cause long‐term social, academic, and mental health problems. Medicines are the most frequently used treatments for ADHD, but they are not always effective and can cause unwanted side effects. What are polyunsaturated fatty acids (PUFA)? Polyunsaturated fatty acids (PUFA) are a type of fat. They are necessary for normal brain development and are found in foods such as fish (omega‐3 PUFA) and vegetable oils (omega‐6 PUFA). How could PUFA be useful in ADHD? There is some evidence that ADHD could be related to low levels of PUFA, in particular omega‐3 PUFA. PUFA supplements may therefore improve ADHD symptoms, behavioural problems, and related mental health symptoms such as anxiety and depression. What did we want to find out? We wanted to know whether PUFA supplements improve ADHD symptoms in children and adolescents with ADHD. Although there were some limited data in the original review that suggested PUFA improved symptoms of ADHD, there is currently little evidence that PUFA supplementation is beneficial. It was important to update the evidence to incorporate new studies that have been published since the original review. What did we do? We searched for all trials that compared PUFA to placebo (dummy pill), medicines, or psychological or medical therapies in children or adolescents with ADHD. We searched 13 databases and two trials registers up to October 2021. What did we find? We found 24 new studies in this update, bringing the total number of studies included in the review to 37, which involved more than 2374 children and adolescents with ADHD. Seven studies were conducted in Iran; four each in the USA and Israel; two each in Australia, Canada, New Zealand, Sweden, and the UK; and one each in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Thirty‐six studies compared PUFA to placebo. Treatment with PUFA lasted between two weeks and six months. Although there was some evidence that PUFA could improve ADHD symptoms in children and adolescents, most of the evidence indicated that PUFA did not improve ADHD symptoms such as inattention or hyperactivity‐impulsivity. PUFA probably makes little to no difference to overall side effects or whether a person drops out of a study (i.e. does not complete it). How confident are we about what we found? We are confident that PUFA has no effect on ADHD symptoms when compared to placebo. Although there was some evidence that ADHD symptoms may be more likely to improve in children and adolescents receiving PUFA compared to those receiving placebo, we have little confidence in this finding. We are fairly confident that there are no differences between PUFA and placebo groups in overall side effects or dropout. Limitations of the analyses included small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Gillies, D; Leach, MJ; Perez Algorta, G", "articleTypes": [], "doi": "10.1002/14651858.CD007986.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "371c944d-2a70-4ec5-8f5b-f7ea4d8e470f", "pmid": "", "title": "Diclofenac for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically cyclo‐oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain. Objectives To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled'). Search methods We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022. Selection criteria We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI). Main results We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low‐certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child‐reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD ‐0.45, 95% CI ‐0.74 to ‐0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD ‐0.64, 95% CI ‐0.89 to ‐0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low‐certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low‐certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results. Authors' conclusions We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non‐pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered. Plain language summary What are the benefits and harms of diclofenac for managing children's pain after they have had an operation? Key messages • Due to a lack of robust evidence, the benefits and harms of diclofenac for managing children's pain after they've had an operation are unclear. • Diclofenac probably reduces nausea and vomiting, but probably increases the risk of bleeding, compared to opioids (such as morphine). • Well‐designed and comprehensively‐reported studies are needed to shed light on the benefits and harms of diclofenac compared to opioids or other medicines, or for different ways of giving diclofenac to children. Postoperative pain management Pain after surgery or a procedure is common and can influence recovery and return to normal activities. There are many ways to reduce pain after an operation, including medicines such as diclofenac. Diclofenac is part of a class of medicines called non‐steroidal anti‐inflammatory drugs (NSAIDs) that can reduce inflammation and pain. They can be given by different routes, such as by mouth or through the anus into the rectum (back passage), and before, during, and after an operation. What did we want to find out? We wanted to find out the benefits and harms of diclofenac compared to other treatments, as well as the most effective way to deliver diclofenac to children. What did we do? We searched for studies that compared (a) diclofenac to other treatments for postoperative pain; or (b) different ways of delivering diclofenac to children. We summarised the results and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 32 studies that included 2250 children with postoperative pain. The largest study included 183 children and the smallest, 31 children. The studies were conducted in many countries around the world; the most common location was the United Kingdom (10 studies). The average age of the children was between 2 and 14 years. Diclofenac was used to manage postoperative pain in 12 different types of surgery; most commonly, ear, nose, and throat surgery (9 studies) or eye surgery (6 studies). Main results It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor and serious harms compared to a placebo (a 'dummy' or sham treatment that does not contain any medicine but looks or tastes identical to the medicine being tested). It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief or pain intensity compared to other medicines, such as opioids, paracetamol, or bupivacaine. Diclofenac probably results in less nausea and vomiting compared to opioids (7 studies involving 463 children), but probably increases the risk of any bleeding (2 studies involving 222 children), but we are very unsure about serious harms (death, long‐term disability, or hospitalisation). It is thus unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor or serious harms compared to placebo or other medicines other than opioids. It is also unclear which route (by mouth or rectal delivery) is the most effective way to manage pain after surgery in children. What are the limitations of the evidence? We are not confident in the evidence because of study design limitations, and none of the studies measured some of our main outcomes of interest. There were also not enough large studies to be certain about the results. How up to date is this evidence? The evidence is current to April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ringsten, M, Kredo, T, Ebrahim, S, Hohlfeld, A, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015087.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.141Z" }, { "id": "372e5090-cd7c-4352-ad19-52c51436664e", "pmid": "", "title": "Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide and its prevalence among children has significantly increased over the last two decades. Prevalence and severity are related to age, with children of school age most commonly affected. Objectives To assess the effectiveness and adverse event profile of antihistamines (oral or topical) used as an adjunct to topical nasal steroids for intermittent and persistent allergic rhinitis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 21 September 2009. Selection criteria Randomised controlled trials (RCTs) in children under the age of 18 with a history of allergic rhinitis, with or without allergic conjunctivitis or asthma, comparing topical nasal steroids with antihistamines to topical nasal steroids only. Data collection and analysis Two review authors independently screened studies, extracted data and assessed risk of bias. Main results One study including 24 participants met the inclusion criteria for this review. This study compared the administration of topical nasal steroids with oral antihistamines to topical nasal steroids only in children, but it did not provide sufficient data to address the clinical question of this review. Authors' conclusions In view of the lack of evidence for the benefit or lack of benefit of antihistamine add‐on therapy with topical nasal steroids for children with intermittent or persistent allergic rhinitis, it is important that clinicians are mindful of the adverse effects of antihistamines and the additional costs that may be incurred. Plain language summary Antihistamines as an addition to topical nasal steroids for allergic rhinitis in children Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide. Seasonal allergic rhinitis (hay fever) is most common around springtime. The symptoms are mostly sneezing, a runny nose and watery eyes. We looked for trials that compared antihistamines (either oral or topical) in addition to a topical nasal steroid with a topical nasal steroid alone in children who had allergic rhinitis. We wanted to know whether adding antihistamines (oral or topical) in the therapy of children with allergic rhinitis who already use topical nasal steroids would have additional benefits for them. We found one trial that had been carried out in children comparing oral antihistamines in addition to topical nasal steroids with topical nasal steroids alone but it did not provide sufficient data to draw any conclusions. Most of the trials focused only on adults or included a small number of children. Unfortunately, the trials which included children along with adults did not report whether there were any differences in the effect of treatment or adverse effects in children in comparison with adults. We are therefore unable to draw a conclusion as to whether or not this combination therapy has beneficial effect in children with allergic rhinitis or whether the benefits are acceptable in terms of the adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Nasser, M, Fedorowicz, Z, Aljufairi, H, McKerrow, W", "articleTypes": [], "doi": "10.1002/14651858.CD006989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.139Z" }, { "id": "372f44c5-12f4-4679-a472-fa17a587d5c0", "pmid": "", "title": "Different strategies for diagnosing gestational diabetes to improve maternal and infant health", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycaemia with onset or first recognition during pregnancy. If untreated, perinatal morbidity and mortality may be increased. Accurate diagnosis allows appropriate treatment. Use of different tests and different criteria will influence which women are diagnosed with GDM. This is an update of a review published in 2011 and 2015. Objectives To evaluate and compare different testing strategies for diagnosis of gestational diabetes mellitus to improve maternal and infant health while assessing their impact on healthcare service costs. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (9 January 2017) and reference lists of retrieved studies. Selection criteria We included randomised trials if they evaluated tests carried out to diagnose GDM. We excluded studies that used a quasi‐random model, cluster‐randomised or cross‐over trials. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. Main results We included a total of seven small trials, with 1420 women. One trial including 726 women was identified by this update and examined the two step versus one step approach. These trials were assessed as having varying risk of bias, with few outcomes reported. We prespecified six outcomes to be assessed for quality using the GRADE approach for one comparison: 75 g oral glucose tolerance test (OGTT) versus 100 g OGTT; data for only one outcome (diagnosis of gestational diabetes) were available for assessment. One trial compared three different methods of delivering glucose: a candy bar (39 women), a 50 g glucose polymer drink (40 women) and a 50 g glucose monomer drink (43 women). We have included the results reported by this trial as separate comparisons. No trial reported on measures of costs of health services. We examined six main comparisons. 75 g OGTT versus 100 g OGTT (1 trial, 248 women): women who received 75 g OGTT had a higher relative risk of being diagnosed with GDM (risk ratio (RR) 2.55, 95% confidence interval (CI) 0.96 to 6.75; very‐low quality evidence ). No data were reported for the following additional outcomes prespecified for GRADE assessment: caesarean section, macrosomia > 4.5 kg or however defined in the trial, long‐term type 2 diabetes maternal, long‐term type 2 diabetes infant and economic costs. Candy bar versus 50 g glucose monomer drink (1 trial, 60 women): more women receiving the candy bar, rather than glucose monomer, preferred the taste of the candy bar (RR 0.60, 95% CI 0.42 to 0.86) and 1‐hour glucose was less with the candy bar. There were no differences in the other outcomes reported (maternal side effects). No infant outcomes were reported or any review primary outcomes. 50 g glucose polymer drink versus 50 g glucose monomer drink (3 trials, 239 women): mean difference (MD) in gestation at birth was ‐0.80 weeks (1 trial, 100 women; 95% CI ‐1.69 to 0.09). Total side effects were less common with the glucose polymer drink (1 trial, 63 women; RR 0.21, 95% CI 0.07 to 0.59), and no clear difference in taste acceptability was reported (1 trial, 63 women; RR 0.99, 95% CI 0.76 to 1.29). Fewer women reported nausea following the 50 g glucose polymer drink compared with the 50 g glucose monomer drink (1 trial, 66 women; RR 0.29, 95% CI 0.11 to 0.78). No other measures of maternal morbidity or outcomes for the infant were reported. 50 g glucose food versus 50 g glucose drink (1 trial, 30 women): women receiving glucose in their food, rather than as a drink, reported fewer side effects (RR 0.08, 95% CI 0.01 to 0.56). No clear difference was noted in the number of women requiring further testing (RR 0.14, 95% CI 0.01 to 2.55). No other measures of maternal morbidity or outcome were reported for the infant or review primary outcomes. 75 g OGTT World Health Organization (WHO) criteria versus 75 g OGTT American Diabetes Association (ADA) criteria (1 trial, 116 women): no clear differences in included outcomes were observed between women who received the 75 g OGTT and were diagnosed using criteria based on WHO (1999) recommendations and women who received the 75 g OGTT and were diagnosed using criteria recommended by the ADA (1979). Outcomes measured included diagnosis of gestational diabetes (RR 1.47, 95% CI 0.66 to 3.25), caesarean section (RR 1.07, 95% CI 0.85 to 1.35), macrosomia defined as > 90th percentile by ultrasound or birthweight equal to or exceeding 4000 g (RR 0.73, 95% CI 0.19 to 2.79), stillbirth (RR 0.49, 95% CI 0.02 to 11.68) and instrumental birth (RR 0.21, 95% CI 0.01 to 3.94). No other secondary outcomes were reported. Two‐step approach (50 g oral glucose challenge test followed by selective 100 g OGTT Carpenter and Coustan criteria) versus one‐step approach (universal 75 g OGTT ADA criteria) (1 trial, 726 women): women allocated the two‐step approach had a lower risk of being diagnosed with GDM at 11 to 14 weeks' gestation compared to women allocated the one‐step approach (RR 0.51, 95% CI 0.28 to 0.95). No other primary or secondary outcomes were reported. Authors' conclusions There is insufficient evidence to suggest which strategy is best for diagnosing GDM. Large randomised trials are required to establish the best strategy for correctly identifying women with GDM. Plain language summary Different strategies for diagnosing gestational diabetes mellitus (GDM) to improve maternal and infant health What is the issue? We aimed to evaluate and compare different ways of diagnosing gestational diabetes mellitus (GDM). We searched for all relevant studies in January 2017. Why is this important? Between seven and 24 pregnant women in every 100 develop GDM. GDM is when there is an inability to process carbohydrates properly, which leads to high blood sugar (hyperglycaemia). GDM can result in increased risks of problems around the time of birth for the mother and her baby. Treatment can reduce these risks, and therefore diagnosing the condition accurately means that treatment can be given to improve the health of mothers and their babies. Different testing strategies aim to diagnose GDM. We wanted to compare the different strategies, to see how they affected the health of women and their infants, and to assess the cost of the strategies to the healthcare service. What evidence did we find? We found seven trials. A total of 1420 women were included, in settings in Turkey, Mexico, Nigeria, New Zealand, Canada and the USA. Across the trials, different testing approaches and criteria were evaluated as were different diagnostic tests including different oral glucose tolerance test loads; a glucose drink; a candy bar and food high in glucose. Women were given these items to eat/drink, and this was then followed by a blood test to measure blood sugar levels and questionnaires. In some tests, women were required to fast from the night before. The main outcomes we looked for were frequency of diagnosis, incidence of caesarean section, assisted birth and vaginal birth, and incidence of macrosomia in babies (larger than normal weight at birth). Other outcomes spanned a range, including any side effects of the tests, the mothers' preferences, and the health of the babies. There were a number of weaknesses among the studies: the methodology was not clear and there were important gaps in the data. The studies in this review do not provide enough evidence to guide clinical practice and health policy regarding identifying women with GDM. What does this mean? We are uncertain about which strategies to diagnose GDM are better, as we have assessed the quality of evidence as very low. Large randomised trials are needed to establish the best way for identifying women with GDM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Farrar, D; Duley, L; Dowswell, T; Lawlor, DA", "articleTypes": [], "doi": "10.1002/14651858.CD007122.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "373b017a-1653-4e47-a43c-5502d693bab0", "pmid": "", "title": "Topical anaesthetic or vasoconstrictor preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy", "imported": false, "abstract": "Abstract - Background Nasal pharyngolaryngoscopy (NPL) is performed as an outpatient and inpatient procedure on a daily basis, for a variety of indications. It frequently causes some degree of discomfort to the patient. Various different topical agents, which are intended to reduce this discomfort, are in common use. This review aimed to assess the effectiveness of the various agents. Objectives To assess the effectiveness of topical preparations used to reduce discomfort and facilitate NPL in adults. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 14 April 2010. Selection criteria Randomised controlled trials (RCTs) looking at the effect of topical anaesthetic or vasoconstrictor agents used reduce discomfort and facilitate NPL in adult patients. Data collection and analysis Two review authors independently selected studies, extracted data and assessed risk of bias. We contacted trial authors for further information where necessary. The primary outcome measured was pain/discomfort. Secondary outcomes that were looked at included side effects of the topical medications, ease of the procedure and the quality of the view from the operator's perspective. Main results We included eight RCTs (746 participants) in the review. The risk of bias in the studies was generally low. Five studies did not demonstrate any advantage in using a topical treatment prior to endoscopy. One study suggested that a vasoconstrictor alone should be used to reduce the general level of unpleasantness. Two studies did not compare treatment against placebo or no treatment, so it was not possible to draw meaningful conclusions from them. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. There was variation in the format of the outcome data and a lack of complete data; none of the included studies reported their results in a way that would allow pooling and we could not therefore perform meta‐analysis. Authors' conclusions The included studies do not demonstrate any evidence to support the use of topical treatments prior to the use of a fibre‐optic nasal endoscope. Some go as far as to suggest that these agents should not be used due to cost and unpleasant side effects. Five studies did not demonstrate any advantage in terms of reducing pain or discomfort when using a topical treatment prior to endoscopy. The absence of demonstrable effect may be due to relatively small patient groups. It is therefore possible that there is a small effect of using these sprays. Further research using standardised reporting methods is needed. Plain language summary Topical anaesthetic or vasoconstrictor (blood vessel narrowing) preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy Topical medications are often applied to the inside of a patient's nose prior to examining the nose, sinuses and throat with a flexible nasopharyngolaryngoscope. The aim of this is to reduce any discomfort the patient may feel and also to improve the adequacy of the examination. Types of preparation include lidocaine, phenylephrine and lidocaine, oxymetazoline, xylometazoline and cocaine and they are usually administered as a spray, although they may also be in the form of a solution which can be applied to cotton wool and placed in the nasal cavity, or as gels, pastes or creams. We looked for randomised controlled trials comparing any of these topical treatments with placebo, no treatment or another topical treatment in adult patients undergoing nasal pharyngolaryngoscopy (NPL). We included eight studies in the review (with a total of 746 patients). It was not possible to combine data from any of the studies, therefore we assessed the individual study results. Five of the studies did not demonstrate any advantage, in terms of reducing pain or discomfort, of using a topical treatment prior to endoscopy. One of these suggested that a vasoconstrictor (xylometazoline) alone reduced the level of \"general unpleasantness\". Two studies did not compare the treatment against placebo or no treatment. A final study actually suggested an increase in pain with the use of topical agents. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. Further standardised research is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Sunkaraneni, VS, Jones, SEM", "articleTypes": [], "doi": "10.1002/14651858.CD005606.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.727Z" }, { "id": "373b01c7-a488-459c-b5e8-4de7faeadc6b", "pmid": "", "title": "Adjunctive therapies in addition to land‐based exercise therapy for osteoarthritis of the hip or knee", "imported": false, "abstract": "Abstract - Background Land‐based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non‐pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land‐based exercise therapy is lacking. Objectives To evaluate the benefits and harms of adjunctive therapies used in addition to land‐based exercise therapy compared with placebo adjunctive therapy added to land‐based exercise therapy, or land‐based exercise therapy only for people with hip or knee osteoarthritis. Search methods We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land‐based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land‐based exercise therapy, or land‐based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant‐reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short‐term (6 months), medium‐term (6 to 12 months) and long‐term (12 months onwards) effects. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE. Main results We included 62 trials (60 RCTs and 2 quasi‐RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 60 included people with knee osteoarthritis only. Thirty‐six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty‐two trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in 11 (18%) trials. Comparing adjunctive therapies plus land‐based exercise therapy against placebo therapies plus exercise up to six months (short‐term), we found low‐certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate‐certainty evidence indicates that adjunctive therapies did not improve QOL (SF‐36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low‐certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant‐reported global assessment was not measured in any studies. Compared with land‐based exercise therapy, low‐certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short‐term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise‐only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (41 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (41 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low‐certainty evidence). Moderate‐certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant‐reported global assessment (short‐term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI ‐0.32 to ‐0.18 mm); 12% relative improvement (6% better to 18% better). Low‐certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27). Authors' conclusions Moderate‐ to low‐certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant‐reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis. Plain language summary Additional therapies used with exercise therapy for hip or knee osteoarthritis What was the aim of this review? Osteoarthritis, a chronic degenerative condition that commonly affects hip and knee joints, causes pain and difficulty with everyday activities such as walking. Land‐based exercise therapy refers to exercise conducted on land (as opposed to exercise in the water) and is a first‐line treatment. This review aimed to find out if adding additional therapies to land‐based exercise therapy improved pain, function, quality of life, participant‐reported overall change or X‐ray changes in people with hip or knee osteoarthritis. Additional therapies include manual (hands‐on) therapy, psychological or dietary therapies, electrophysical agents (such as heat, cold, nerve stimulation, ultrasound or laser therapy) or acupuncture. We included studies comparing additional therapies plus land‐based exercise therapy to either 1) sham (or dummy) therapy plus land‐based exercise therapy or 2) land‐based exercise therapy only. Search date This systematic review is up‐to‐date to 10 June 2021. What did we find? We found 62 randomised controlled trials with 6508 participants, mostly women, from 24 countries. The average age was between 52 and 83 years, with symptoms present from 9 months to 12 years. Sixty studies enrolled people with knee osteoarthritis, one enrolled people with hip osteoarthritis and one enrolled people with knee or hip osteoarthritis. Twenty‐two trials compared additional therapies plus exercise therapy to sham additional therapies plus exercise therapy, and 41 compared to exercise therapy. Thirty‐eight trials studied electrophysical agents, seven studied manual therapies, four studied acupuncture/dry needling or use of tape, three studied psychological or dietary interventions, whole body vibration (this involves standing on a vibration platform), or spa/mud therapy, and one studied foot orthotics (shoe insoles). Funding source Thirty‐eight studies were funded, four received no funding and funding support was not reported in 20. Main results Eleven trials (18%) measured adverse (unwanted harmful) events, which included both non‐serious and serious adverse events. The most common were increased pain, stiffness or swelling. There was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with sham additional therapies plus exercise therapy (22 studies) Compared with sham additional therapies used with land‐based exercise therapy, additional therapies such as electrophysical agents, acupuncture, dry needling or taping, used with exercise therapy, may not be more effective in improving pain, physical function or quality of life up to six months after treatment. Pain (lower scores mean less pain) Improved by 10% or 0.77 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 12% or 5.03 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 1% or 0.75 points worse on a zero to 100‐point scale. Adverse events Although not commonly reported in studies, there was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with exercise therapy (41 studies) Compared with land‐based exercise therapy, additional therapies (manual therapies, electrotherapy, dietary interventions, psychological therapies, whole body vibration, acupuncture, dry needling, taping, spa/mud therapy or foot orthotics) plus exercise therapy, may not be more effective in improving pain, physical function, quality of life or joint changes measured with X‐rays up to six months after treatment. Pain (lower scores mean less pain) Improved by 7% or 0.41 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 9% or 2.83 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 2%, or 1.04 points worse on a zero to 100‐point scale. Patient‐reported overall change 17% more people rated their treatment a success. X‐ray changes Improved by 12% (based on one study) Adverse effects Although not commonly reported in studies, risks appear no greater for additional therapies used with exercise compared to exercise only. Fewer studies assessed outcomes six or 12 months after treatment. Additional therapies plus land‐based exercise therapy may be no better in reducing pain or improving physical function or quality of life than exercise therapy at 6 or 12 months. In patient‐reported overall assessment, 31% reported improvement at 6 months, and 42% reported improvement at 12 months. Conclusions and certainty of evidence Additional therapies plus exercise therapy do not appear to offer meaningful improvements in pain, function, quality of life or overall change for people with hip or knee osteoarthritis compared with sham additional therapies plus land‐based exercise therapy; or in pain, function, quality of life or changes on X‐rays when compared with exercise therapy only. Compared with exercise therapy there is probably a clinical benefit in patient‐reported overall change for additional therapies plus exercise therapy, based on a small number of studies. Our confidence in the evidence varies between moderate to little or no confidence for different outcomes. Although results indicate no increased adverse events from additional therapies used with exercise therapy, this was poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "French, HP, Abbott, JH, Galvin, R", "articleTypes": [], "doi": "10.1002/14651858.CD011915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.803Z" }, { "id": "3753bb4f-5618-488d-9a11-b84e880147fd", "pmid": "", "title": "Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment", "imported": false, "abstract": "Abstract - Background Vitamins and minerals have many functions in the nervous system which are important for brain health. It has been suggested that various different vitamin and mineral supplements might be useful in maintaining cognitive function and delaying the onset of dementia. In this review, we sought to examine the evidence for this in people who already had mild cognitive impairment (MCI). Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function and the incidence of dementia in people with mild cognitive impairment. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CENTRAL, CINAHL, LILACs, Web of Science Core Collection, ClinicalTrials.gov, and the WHO Portal/ICTRP, from inception to 25 January 2018. Selection criteria We included randomised or quasi‐randomised, placebo‐controlled trials which evaluated orally administered vitamin or mineral supplements in participants with a diagnosis of mild cognitive impairment and which assessed the incidence of dementia or cognitive outcomes, or both. We were interested in studies applicable to the general population of older people and therefore excluded studies in which participants had severe vitamin or mineral deficiencies. Data collection and analysis We sought data on our primary outcomes of dementia incidence and overall cognitive function and on secondary outcomes of episodic memory, executive function, speed of processing, quality of life, functional performance, clinical global impression, adverse events, and mortality. We conducted data collection and analysis according to standard Cochrane systematic review methods. We assessed the risk of bias of included studies using the Cochrane 'Risk of bias' assessment tool. We grouped vitamins and minerals according to their putative mechanism of action and, where we considered it to be clinically appropriate, we pooled data using random‐effects methods. We used GRADE methods to assess the overall quality of evidence for each comparison and outcome. Main results We included five trials with 879 participants which investigated B vitamin supplements. In four trials, the intervention was a combination of vitamins B6, B12, and folic acid; in one, it was folic acid only. Doses varied. We considered there to be some risks of performance and attrition bias and of selective outcome reporting among these trials. Our primary efficacy outcomes were the incidence of dementia and scores on measures of overall cognitive function. None of the trials reported the incidence of dementia and the evidence on overall cognitive function was of very low‐quality. There was probably little or no effect of B vitamins taken for six to 24 months on episodic memory, executive function, speed of processing, or quality of life. The evidence on our other secondary clinical outcomes, including harms, was very sparse or very low‐quality. There was evidence from one study that there may be a slower rate of brain atrophy over two years in participants taking B vitamins. The same study reported subgroup analyses based on the level of serum homocysteine (tHcy) at baseline and found evidence that B vitamins may improve episodic memory in those with tHcy above the median at baseline. We included one trial (n = 516) of vitamin E supplementation. Vitamin E was given as 1000 IU of alpha‐tocopherol twice daily. We considered this trial to be at risk of attrition and selective reporting bias. There was probably no effect of vitamin E on the probability of progression from MCI to Alzheimer's dementia over three years (HR 1.02; 95% CI 0.74 to 1.41; n = 516; 1 study, moderate‐quality evidence). There was also no evidence of an effect at intermediate time points. The available data did not allow us to conduct analyses, but the authors reported no significant effect of three years of supplementation with vitamin E on overall cognitive function, episodic memory, speed of processing, clinical global impression, functional performance, adverse events, or mortality (five deaths in each group). We considered this to be low‐quality evidence. We included one trial (n = 256) of combined vitamin E and vitamin C supplementation and one trial (n = 26) of supplementation with chromium picolinate. In both cases, there was a single eligible cognitive outcome, but we considered the evidence to be very low‐quality and so could not be sure of any effects. Authors' conclusions The evidence on vitamin and mineral supplements as treatments for MCI is very limited. Three years of treatment with high‐dose vitamin E probably does not reduce the risk of progression to dementia, but we have no data on this outcome for other supplements. Only B vitamins have been assessed in more than one RCT. There is no evidence for beneficial effects on cognition of supplementation with B vitamins for six to 24 months. Evidence from a single study of a reduced rate of brain atrophy in participants taking vitamin B and a beneficial effect of vitamin B on episodic memory in those with higher tHcy at baseline warrants attempted replication. Plain language summary Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment Review question This review investigated whether people with mild cognitive impairment can reduce their risk of developing dementia, or can prevent their memory or other thinking skills from deteriorating further, by taking vitamin or mineral supplements. Background Slight changes in memory and thinking skills are common as people get older. When these changes are worse than can be expected in normal ageing, but are not bad enough to make a person's usual activities difficult to manage, then the person is said to have mild cognitive impairment (MCI). People with MCI are at increased risk of developing dementia in the future. Vitamins and minerals are naturally occurring substances which are needed in the diet to maintain health. They have lots of different functions in the body and many are essential to keep the brain working properly. It has been suggested that supplementing a person's normal diet with extra doses of these vitamins or minerals might help to maintain thinking skills or prevent dementia. Study characteristics We found eight randomised controlled trials (RCTs), which investigated four different types of vitamin or mineral pills by comparing them to a placebo (a dummy pill). The vitamins tested were B vitamins (vitamin B6, vitamin B12 and folic acid), vitamin E, and vitamin E and C given together. The only mineral tested was chromium. Key results and quality of the evidence Vitamin B combination versus placebo Five trials with a total of 879 participants compared B vitamins with placebo. Four used combinations of vitamin B6, vitamin B12, and folic acid; one small study tested folic acid on its own. None of these studies reported whether or not participants developed dementia. These studies did not find that memory or thinking skills differed between the group of people who took vitamin B supplements and those who took placebo after treatment lasting six months to two years. Our confidence in the results on different tests used in the studies varied from moderate to very low. Two years of vitamin B supplements did seem to help memory in a small subgroup of participants in one study who could be identified by a particular blood test at the start of the trial. One study found that there was probably no effect on participants' quality of life. One study scanned the brains of some participants and reported that B vitamins may slow the rate of brain shrinkage. Harmful effects and deaths were reported in very few participants and we cannot conclude whether or not there are harms from taking these or similar combinations of B vitamins. Vitamin E versus placebo. One study with 516 participants compared a relatively high dose of vitamin E (2000 IU a day) to placebo in people who were also taking a multivitamin containing 15 IU of vitamin E (the daily requirement for vitamin E is approximately 30 IU). The risk of developing dementia due to Alzheimer’s disease (the commonest form of dementia) is probably not affected by three years of treatment with high‐dose vitamin E. The quality of the evidence for other outcomes was lower, but there may also be no effect of this dose of vitamin E on specific memory or thinking skills or on how well people could manage their daily activities. Vitamin E and C versus placebo One study with 256 participants compared a combination of vitamins C and E with placebo. It found no effect on overall memory and thinking skills, but we had little confidence in this result because of the quality of the evidence. Chromium picolinate versus placebo Only one very small study with 26 participants investigated the effect of chromium supplements. This study was too small for us to be able to draw any conclusions. Conclusions The amount and quality of research evidence about vitamin and mineral supplements for treating MCI in people without nutritional deficiency is limited. At the moment, it is not possible to identify any supplements which can reduce the risk of people with MCI developing dementia or which can effectively treat their symptoms. More research is needed before we can answer our review question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "McCleery, J; Abraham, RP; Denton, DA; Rutjes, AWS; Chong, LY; Al‐Assaf, AS; Griffith, DJ; Rafeeq, S; Yaman, H; Malik, MA; Di Nisio, M; Martínez, G; Vernooij, RWM; Tabet, N", "articleTypes": [], "doi": "10.1002/14651858.CD011905.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "375d7fe4-98fe-43a9-a837-36ffc34405fd", "pmid": "", "title": "Combination inhaled steroid and long‐acting beta₂‐agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background The long‐acting bronchodilator tiotropium and single‐inhaler combination therapy of inhaled corticosteroids and long‐acting beta 2 ‐agonists (ICS/LABA) are commonly used for maintenance treatment of patients with chronic obstructive pulmonary disease (COPD). Combining these treatments, which have different mechanisms of action, may be more effective than administering the individual components. Objectives To assess relative effects of the following treatments on markers of exacerbations, symptoms, quality of life and lung function in patients with COPD. • Tiotropium plus LABA/ICS versus tiotropium. • Tiotropium plus LABA/ICS versus LABA/ICS. Search methods We searched the Cochrane Airways Group Specialised Register of Trials (April 2015), ClinicalTrials.gov ( www.ClinicalTrials.gov ), the World Health Organization (WHO) trials portal and reference lists of relevant articles. Selection criteria We included parallel, randomised controlled trials (RCTs) lasting three months or longer conducted to compare ICS and LABA combination therapy in addition to inhaled tiotropium versus tiotropium alone or combination therapy alone. Data collection and analysis We independently assessed trials for inclusion, then extracted data on trial quality and outcome results. We contacted study authors to ask for additional information. We collected trial information on adverse effects. Main results Tiotropium plus LABA/ICS versus tiotropium We included six studies (1902 participants) with low risk of bias that compared tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy versus tiotropium alone. We found no statistically significant differences in mortality between treatments (odds ratio (OR) 1.80, 95% confidence interval (CI) 0.55 to 5.91; two studies; 961 participants) as well as in the all‐cause hospitalisations (OR 0.84, 95% CI 0.53 to 1.33; two studies; 961 participants). The effect on exacerbations was heterogeneous among trials and was not meta‐analysed. Health‐related quality of life measured by St. George’s Respiratory Questionnaire (SGRQ) showed a statistically significant improvement in total scores with use of tiotropium + LABA/ICS compared with tiotropium alone (mean difference (MD) ‐3.46, 95% CI ‐5.05 to ‐1.87; four studies; 1446 participants). Lung function was significantly different in the combined therapy (tiotropium + LABA/ICS) group, although average benefit with this therapy was small. None of the included studies included exercise tolerance as an outcome. A pooled estimate of these studies did not show a statistically significant difference in adverse events (OR 1.16, 95% CI 0.92 to 1.47; four studies; 1363 participants), serious adverse events (OR 0.86, 95% CI 0.57 to 1.30; four studies; 1758 participants) and pneumonia (Peto OR 1.62, 95% CI 0.54 to 4.82; four studies; 1758 participants). Tiotropium plus LABA/ICS versus LABA/ICS One of the six studies (60 participants) also compared combined therapy (tiotropium + LABA/ICS) versus LABA/ICS therapy alone. This study was affected by lack of power; therefore results did not allow us to draw conclusions for this comparison. Authors' conclusions This review update includes three additional studies and provides new low quality evidence supporting the finding that tiotropium + LABA/ICS‐based therapy improves the disease‐specific quality of life. The current evidence is insufficient to support the benefit of tiotropium + LABA/ICS‐based therapy for mortality, hospital admission or exacerbations (moderate and low quality evidence). Compared with use of tiotropium alone, tiotropium + LABA/ICS‐based therapy does not seem to increase undesirable effects nor serious non‐fatal adverse events. Plain language summary Are tiotropium plus combination inhalers better than tiotropium or combination inhalers alone for the treatment of COPD? Background Chronic obstructive pulmonary disease (COPD) is a lung disease that includes the conditions chronic bronchitis and/or emphysema. COPD is characterised by narrowing of the airways and lung tissue destruction. Symptoms include breathlessness and long‐term cough. Symptoms of COPD are treatable, but the condition cannot be reversed or cured. It is usually brought on by airway irritants, such as smoking or inhaled dust. Inhalers with bronchodilators (which allow the airways in the lungs to relax and expand) and/or anti‐inflammatory agents are commonly used to ease symptoms and minimise the long‐term decline in health caused by COPD. Examples of these treatments are tiotropium, which is a bronchodilator, and combination inhalers, which contain another type of bronchodilator (long‐acting beta‐agonists) together with anti‐inflammatory agents (steroids). These treatments work in different ways and therefore might be more beneficial if used together. Study characteristics This review found six studies, involving 1902 participants, comparing the long‐term efficacy and side effects of tiotropium combined with combination inhalers for treatment of patients with COPD. Not all of the people included in these studies had COPD that was severe enough to be recommended for combined therapy according to current guidelines. Key results Current evidence shows potential benefits of treatment with tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy through increased health‐related quality of life and a small improvement i n lung function in patients receiving this combined therapy. However, this evidence does not allow us to draw conclusions about the effects of these treatments on mortality, hospitalisation for all causes and exacerbations. The frequency of serious and non‐serious adverse events was not increased in either of the two groups. Quality of the evidence Overall, we assessed the evidence presented in this review to be of moderate or low quality, which means we are reasonably confident in some of the findings, but less confident in others.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Rojas‐Reyes, MX; García Morales, OM; Dennis, RJ; Karner, C", "articleTypes": [], "doi": "10.1002/14651858.CD008532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "37740cb7-9566-43d8-9a73-7856cf9f92f4", "pmid": "", "title": "Pain relief in hysterosalpingography", "imported": false, "abstract": "Abstract - Background Hysterosalpingography (HSG) is a method of testing for tubal patency. However, women struggle to tolerate the procedure, as it is associated with some discomfort. Various pharmacological strategies are available that may reduce pain during the procedure, though there is no consensus as to the best method. Objectives To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing HSG for investigation of subfertility. Search methods This review has drawn on the search strategy developed for the Cochrane Menstrual Disorders and Subfertility Group (MDSG). We searched the following databases to 15 April 2015: MDSG Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO. Selection criteria All identified randomised controlled trials investigating pharmacological interventions for pain relief during HSG were investigated for selection. Data collection and analysis Four review authors independently extracted data. We combined data to calculate mean differences (MDs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I² statistic. We assessed the overall quality of the evidence for the main comparisons using GRADE methods. Main results The search identified 23 trials (1272 women) that were eligible for inclusion into the study. Oral opioid analgesia versus placebo/no treatment There was no evidence of effect for oral opioid analgesia in reducing pain during the procedure (MD −0.91, 95% CI −1.88 to 0.06, 1 study, n = 128, low quality evidence) or more than 30 minutes after the procedure (MD −0.99, 95% CI −1.75 to −0.23, 1 study, n = 128, moderate quality evidence) No studies reported on the effect of oral opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes after the procedure There was insufficient evidence to reach conclusions regarding adverse effects. Intravenous opioid analgesia versus placebo/no treatment There was evidence that intravenous opioids may improve pain relief during the procedure compared to no treatment (MD −3.53, 95% CI −4.29 to −2.77, 1 study, n = 62, moderate quality evidence) No studies reported on the effect of intravenous opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes and more than 30 minutes after the procedure In terms of adverse effects, one trial reported 1/32 participants had apnoea with intravenous remifentanil. Recovery time was nearly 4 minutes longer in the remifentanil group compared to the control. Oral non‐opioid analgesia versus placebo/no treatment There was no evidence of effect for oral non‐opioid analgesia in reducing pain during the procedure (MD −0.13, 95% CI −0.48 to 0.23, 3 studies, n = 133, I² = 61%, low quality evidence), less than 30 minutes after the procedure (MD −0.30, 95% CI −1.03 to 0.43, 2 studies, n = 45, I² = 97%, very low quality evidence), or more than 30 minutes after the procedure (MD −0.36, 95% CI −1.06 to 0.34, 3 studies, n = 133, I² = 58%, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Topical anaesthesia versus placebo/no treatment There was evidence that topical anaesthetics may reduce pain during the procedure (MD −0.63, 95% CI −1.06 to −0.19, 9 studies, n = 613, I² = 66%, low quality evidence). There was no evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD 0.42, 95% CI ‐0.03 to 0.86, 5 studies, n = 373, I² = 59%, very low quality evidence). There was evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain more than 30 minutes after the procedure (MD −1.38, 95% CI ‐3.44 to −0.68, 2 studies, n = 166, I² = 92%, very low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Locally injected anaesthesia versus placebo/no treatment There was evidence of effect that locally injected anaesthetic can reduce pain during the procedure (MD −1.31, 95% CI −1.55 to −1.07, 2 studies, n = 125, I² = 0%, very low quality evidence). There was no evidence of effect for locally injected anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD −1.31, 95% CI −2.14 to −0.49, 2 studies, n = 125, I² = 46%, low quality evidence). No studies were included into the analysis of the effect of locally injected anaesthesia, when injected prior to the procedure, in reducing pain more than 30 minutes after the procedure. There was insufficient evidence to reach conclusions regarding adverse effects. Any analgesic versus any other analgesic There was no evidence of a difference between the groups when oral non‐opioid analgesia was compared to opioid analgesia for pain relief during the procedure (MD 1.10, 95% CI −0.26 to 2.46, 1 study, n = 91, low quality evidence); less than 30 minutes following the procedure (MD −0.30, 95% CI −1.00 to 0.40, 1 study, n = 91, low quality evidence); and more than 30 minutes following the procedure (MD −0.60, 95% CI −1.56 to 0.36, 1 study, n = 91, low quality evidence). Topical anaesthetics were found to be more effective than paracervical block for pain relief during HSG (MD −2.73, 95% CI −3.86 to −1.60, 1 study, n = 20, moderate quality evidence). This benefit did not extend to within 30 minutes following HSG (MD −1.03, 95% CI −2.52 to 0.46, 1 study, n = 20, low quality evidence); or 30 minutes or more after HSG (MD 0.31, 95% CI −0.87 to 1.49, 1 study, n = 20, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Authors' conclusions Topical anaesthetic applied before the procedure may be associated with effective pain relief during HSG, though the quality of this evidence is low. Intravenous opioids may also be effective in pain relief, though this must be weighed against their side effects and their effects on the recovery time. There is insufficient evidence to draw conclusions on the efficacy of other analgesics for HSG, or to reach any other conclusions regarding adverse effects. Plain language summary Drug treatments for pain relief in hysterosalpingography Review question: Which pain‐killers are effective at reducing the discomfort experienced with hysterosalpingography? Background: Hysterosalpingography (HSG) is a test used in investigating infertility in women. HSG involves a dye being introduced into the uterus and the connecting tubes, which enables them to be visualised using an x‐ray, allowing the clinician to assess how open the connecting tubes are. This can be a painful procedure. There is disagreement regarding the best form of pain relief during the procedure. Study characteristics: We identified 19 randomised controlled trials that compared a specific drug treatment to a placebo/no treatment. Four trials compared two different drug treatments to establish if one was better. All studies took place in a clinical setting. Age of participants ranged from 18 to 42 years. Studies took place in India, Australia, United Kingdom, United States of America, Turkey, Israel, Netherlands, Italy, Iran, Nigeria, Spain, Brazil, and Belgium (1272 women in total). We included 15 of these trials in a meta‐analysis. The remaining eight trials, while eligible for inclusion, did not have data in a format that could be entered into meta‐analysis (seven compared a specific drug to a placebo/no treatment, one compared two different drug treatments). The evidence is current to April 2015. Key results : Topical anaesthetic was associated with a mild reduction in the pain experienced during HSG (low quality evidence). However, it has no effect on the discomfort experienced by participants following the procedure (very low quality evidence). Locally injected anaesthetics, on the other hand, were not associated with any benefit. Only one study investigated this (moderate quality evidence). One study directly compared locally injected anaesthetics to topical anaesthetics. This study found that topical anaesthesia was associated with improved pain relief during the procedure (moderate quality evidence) No oral drug was found to be effective in reducing pain experienced during the procedure. This was true for both opioid (low quality evidence) and non‐opioid (low quality evidence) analgesia. One trial however reported that tramadol may be of benefit in reducing the pain experienced more than 30 minutes after the procedure (moderate quality evidence). Quality of the evidence: The quality of the combined results was mainly downgraded for two reasons: 1) studies having methods that may be at risk of bias/inaccuracy; 2) substantially different conclusions between studies that investigate the same drug. The included studies did not report side effects in large enough numbers to make definitive conclusions regarding the side effects of particular drugs during the procedure. Conclusions: Only topical anaesthetics and intravenous opioids were found to be of benefit in reducing pain during the procedure, though the quality of this evidence is low to moderate, and there is no evidence that these are effective at relieving pain following the procedure. There is insufficient evidence for other drug treatments in reducing pain during HSG. There was insufficient evidence to reach any conclusions regarding adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hindocha, A, Beere, L, O'Flynn, H, Watson, A, Ahmad, G", "articleTypes": [], "doi": "10.1002/14651858.CD006106.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.815Z" }, { "id": "37776d4b-ba37-4cfe-94cf-bbd5a1e34440", "pmid": "", "title": "Antibiotics for acute rhinosinusitis in adults", "imported": false, "abstract": "Abstract - Background Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear. We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging. Objectives To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings. Search methods We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines. Selection criteria Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis‐like signs or symptoms or sinusitis confirmed by imaging. Data collection and analysis Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required. Main results We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I² = 0%; 8 trials; high‐quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I² = 0%; 3 trials; moderate‐quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate‐quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I² = 0%; 3 trials; high‐quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I² = 16%; 10 trials; high‐quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I² = 21%; 12 trials; high‐quality evidence). A disease‐related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group). Authors' conclusions The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high‐quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate‐quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials. Plain language summary Antibiotics for sinus infection of short duration in adults Review question Do antibiotics cure sinus infection faster than no antibiotics in adults? Background A sinus is a cavity situated in the head. Adults with short‐duration sinus infection experience stuffy nose and thick, yellow discharge from the nose. People with sinus infection can feel slime in the back of the throat, facial pain, pain when bending forward, and pain in the upper teeth or when chewing. A short‐duration sinus infection may be suspected following physical examination and questions about symptoms. Blood examination or images of the sinuses can support diagnosis, but are not routinely recommended in most countries. Short‐duration sinus infections are mostly caused by viruses. Nevertheless, physicians tend to prescribe antibiotics, which should only be used to treat bacterial infections. Taking antibiotics unnecessarily results in antibiotic resistance against bacterial infections. We investigated whether antibiotics cure adults with short‐duration sinus infection faster than a dummy drug (placebo) or no treatment. Search date 18 January 2018. Study characteristics We included 15 studies in which adults with short‐duration sinus infection, whether or not confirmed by imaging, randomly received antibiotics, or a dummy drug or no treatment, in ambulatory care settings. The studies included a total of 3057 adults whose average age was 36 years; about 60% were female. Participants were followed until they were cured. Trial duration ranged from 8 to 28 days. Study funding sources Seven studies received financial support from government or academic institutions; six received grants from the pharmaceutical industry; and five did not state sources of support. Key results Without antibiotics, almost half of all participants were cured after one week, and two out of three were cured after 14 days. Five (diagnosis based on symptoms described to a doctor) to 11 (diagnosis confirmed by x‐ray) more people per 100 were cured faster with antibiotics. A computed tomography (CT) scan could better predict who would benefit from antibiotics, but routine use would cause health problems related to radiation exposure. Ten more people per 100 were relieved faster of thick, yellow discharge from the nose with antibiotics compared to a dummy drug or no treatment. Thirteen more people per 100 experienced side effects (mostly concerning stomach or intestines) with antibiotics compared to a dummy drug or no treatment. Compared with people who initially started antibiotics, five more people per 100 in the dummy drug or no treatment group had to start antibiotics because their condition worsened. Serious complications (e.g. brain abscess) were rare. We found that antibiotics are not a first‐choice treatment for adults with short‐duration sinus infection. We found no evidence relating to adults with severe sinusitis or with reduced immunity, or to children. Quality of evidence We found high‐quality evidence when the diagnosis was based on symptoms described to a doctor. We downgraded evidence quality to moderate when diagnosis was confirmed by x‐ray or CT scan because the number of participants was small, which makes the estimates less reliable.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Lemiengre, MB; van Driel, ML; Merenstein, D; Liira, H; Mäkelä, M; De Sutter, AIM", "articleTypes": [], "doi": "10.1002/14651858.CD006089.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "37925781-9012-4629-aa67-6acec116398c", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies for treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). Objectives To assess the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for treating patients with COVID‐19, compared to an active comparator, placebo, or no intervention. To maintain the currency of the evidence, we will use a living systematic review approach. A secondary objective is to track newly developed SARS‐CoV‐2‐targeting mAbs from first tests in humans onwards. Search methods We searched MEDLINE, Embase, the Cochrane COVID‐19 Study Register, and three other databases on 17 June 2021. We also checked references, searched citations, and contacted study authors to identify additional studies. Between submission and publication, we conducted a shortened randomised controlled trial (RCT)‐only search on 30 July 2021. Selection criteria We included studies that evaluated SARS‐CoV‐2‐neutralising mAbs, alone or combined, compared to an active comparator, placebo, or no intervention, to treat people with COVID‐19. We excluded studies on prophylactic use of SARS‐CoV‐2‐neutralising mAbs. Data collection and analysis Two authors independently assessed search results, extracted data, and assessed risk of bias using the Cochrane risk of bias tool (RoB2). Prioritised outcomes were all‐cause mortality by days 30 and 60, clinical progression, quality of life, admission to hospital, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We identified six RCTs that provided results from 17,495 participants with planned completion dates between July 2021 and December 2031. Target sample sizes varied from 1020 to 10,000 participants. Average age was 42 to 53 years across four studies of non‐hospitalised participants, and 61 years in two studies of hospitalised participants. Non‐hospitalised individuals with COVID‐19 Four studies evaluated single agents bamlanivimab (N = 465), sotrovimab (N = 868), regdanvimab (N = 307), and combinations of bamlanivimab/etesevimab (N = 1035), and casirivimab/imdevimab (N = 799). We did not identify data for mortality at 60 days or quality of life. Our certainty of the evidence is low for all outcomes due to too few events (very serious imprecision). Bamlanivimab compared to placebo No deaths occurred in the study by day 29. There were nine people admitted to hospital by day 29 out of 156 in the placebo group compared with one out of 101 in the group treated with 0.7 g bamlanivimab (risk ratio (RR) 0.17, 95% confidence interval (CI) 0.02 to 1.33), 2 from 107 in the group treated with 2.8 g (RR 0.32, 95% CI 0.07 to 1.47) and 2 from 101 in the group treated with 7.0 g (RR 0.34, 95% CI 0.08 to 1.56). Treatment with 0.7 g, 2.8 g and 7.0 g bamlanivimab may have similar rates of AEs as placebo (RR 0.99, 95% CI 0.66 to 1.50; RR 0.90, 95% CI 0.59 to 1.38; RR 0.81, 95% CI 0.52 to 1.27). The effect on SAEs is uncertain. Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Bamlanivimab/etesevimab compared to placebo There were 10 deaths in the placebo group and none in bamlanivimab/etesevimab group by day 30 (RR 0.05, 95% CI 0.00 to 0.81). Bamlanivimab/etesevimab may decrease hospital admission by day 29 (RR 0.30, 95% CI 0.16 to 0.59), may result in a slight increase in any grade AEs (RR 1.15, 95% CI 0.83 to 1.59) and may increase SAEs (RR 1.40, 95% CI 0.45 to 4.37). Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Casirivimab/imdevimab compared to placebo Casirivimab/imdevimab may reduce hospital admissions or death (2.4 g: RR 0.43, 95% CI 0.08 to 2.19; 8.0 g: RR 0.21, 95% CI 0.02 to 1.79). We are uncertain of the effect on grades 3‐4 AEs (2.4 g: RR 0.76, 95% CI 0.17 to 3.37; 8.0 g: RR 0.50, 95% CI 0.09 to 2.73) and SAEs (2.4 g: RR 0.68, 95% CI 0.19 to 2.37; 8.0 g: RR 0.34, 95% CI 0.07 to 1.65). Mortality by day 30 and clinical progression/improvement of symptoms or development of severe symptoms were not reported. Sotrovimab compared to placebo We are uncertain whether sotrovimab has an effect on mortality (RR 0.33, 95% CI 0.01 to 8.18) and invasive mechanical ventilation (IMV) requirement or death (RR 0.14, 95% CI 0.01 to 2.76). Treatment with sotrovimab may reduce the number of participants with oxygen requirement (RR 0.11, 95 % CI 0.02 to 0.45), hospital admission or death by day 30 (RR 0.14, 95% CI 0.04 to 0.48), grades 3‐4 AEs (RR 0.26, 95% CI 0.12 to 0.60), SAEs (RR 0.27, 95% CI 0.12 to 0.63) and may have little or no effect on any grade AEs (RR 0.87, 95% CI 0.66 to 1.16). Regdanvimab compared to placebo Treatment with either dose (40 or 80 mg/kg) compared with placebo may decrease hospital admissions or death (RR 0.45, 95% CI 0.14 to 1.42; RR 0.56, 95% CI 0.19 to 1.60, 206 participants), but may increase grades 3‐4 AEs (RR 2.62, 95% CI 0.52 to 13.12; RR 2.00, 95% CI 0.37 to 10.70). 80 mg/kg may reduce any grade AEs (RR 0.79, 95% CI 0.52 to 1.22) but 40 mg/kg may have little to no effect (RR 0.96, 95% CI 0.64 to 1.43). There were too few events to allow meaningful judgment for the outcomes mortality by 30 days, IMV requirement, and SAEs. Hospitalised individuals with COVID‐19 Two studies evaluating bamlanivimab as a single agent (N = 314) and casirivimab/imdevimab as a combination therapy (N = 9785) were included. Bamlanivimab compared to placebo We are uncertain whether bamlanivimab has an effect on mortality by day 30 (RR 1.39, 95% CI 0.40 to 4.83) and SAEs by day 28 (RR 0.93, 95% CI 0.27 to 3.14). Bamlanivimab may have little to no effect on time to hospital discharge (HR 0.97, 95% CI 0.78 to 1.20) and mortality by day 90 (HR 1.09, 95% CI 0.49 to 2.43). The effect of bamlanivimab on the development of severe symptoms at day 5 (RR 1.17, 95% CI 0.75 to 1.85) is uncertain. Bamlanivimab may increase grades 3‐4 AEs at day 28 (RR 1.27, 95% CI 0.81 to 1.98). We assessed the evidence as low certainty for all outcomes due to serious imprecision, and very low certainty for severe symptoms because of additional concerns about indirectness. Casirivimab/imdevimab with usual care compared to usual care alone Treatment with casirivimab/imdevimab compared to usual care probably has little or no effect on mortality by day 30 (RR 0.94, 95% CI 0.87 to 1.02), IMV requirement or death (RR 0.96, 95% CI 0.90 to 1.04), nor alive at hospital discharge by day 30 (RR 1.01, 95% CI 0.98 to 1.04). We assessed the evidence as moderate certainty due to study limitations (lack of blinding). AEs and SAEs were not reported. Authors' conclusions The evidence for each comparison is based on single studies. None of these measured quality of life. Our certainty in the evidence for all non‐hospitalised individuals is low, and for hospitalised individuals is very low to moderate. We consider the current evidence insufficient to draw meaningful conclusions regarding treatment with SARS‐CoV‐2‐neutralising mAbs. Further studies and long‐term data from the existing studies are needed to confirm or refute these initial findings, and to understand how the emergence of SARS‐CoV‐2 variants may impact the effectiveness of SARS‐CoV‐2‐neutralising mAbs. Publication of the 36 ongoing studies may resolve uncertainties about the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for the treatment of COVID‐19 and possible subgroup differences. Plain language summary Are laboratory‐made, COVID‐19‐specific monoclonal antibodies an effective treatment for COVID‐19? Key messages ‐ We do not know whether antibodies (the body’s natural defence against disease) made in a laboratory and all the same as one another (monoclonal) and designed to target COVID‐19, are an effective treatment for COVID‐19 because we assessed only six studies exploring different treatments in different types of patients. ‐ We identified 36 ongoing studies that will provide more evidence when completed. ‐ We will update this review regularly as more evidence becomes available. What are ‘monoclonal’ antibodies? Antibodies are made by the body as a defence against disease. However, they can also be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that are designed to target only one specific protein – in this case, a protein on the virus that causes COVID‐19 – are ‘monoclonal’. They attach to the COVID‐19 virus and stop it from entering and replicating in human cells, which helps to fight the infection. Monoclonal antibodies have been used successfully to treat other viruses. They are thought to cause fewer unwanted effects than convalescent plasma, which contains a variety of different antibodies. What did we want to find out? We wanted to know if COVID‐19 specific monoclonal antibodies are an effective treatment for COVID‐19. We looked at whether they: ‐ reduced the number of deaths from any cause; ‐ improved symptoms or made them worse; ‐ increased admissions to hospital; and ‐ caused any serious or other unwanted effects. What did we do? We searched for studies that investigated one or more monoclonal antibodies to treat people with confirmed COVID‐19 compared with placebo (sham treatment), another treatment or no treatment. Studies could take place anywhere globally and include participants of any age, gender or ethnicity, with mild, moderate or severe COVID‐19. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found six active studies including a total of 17,495 people. Four studies investigated non‐hospitalised people with no symptoms or mild COVID‐19. Two studies investigated hospitalised people with moderate to severe COVID‐19. Studies took place across the world. Three studies were funded by pharmaceutical companies. The monoclonal antibodies they studied were bamlanivimab, etesevimab, casirivimab and imdevimab, sotrovimab, regdanvimab. We did not identify data for mortality at 60 days and quality of life. Non‐hospitalised people, with no symptoms or mild COVID‐19 (four studies) One study investigated different doses of bamlanivimab (465 people), compared to placebo. We don’t know whether bamlanivimab: ‐ increases or reduces the number of deaths because no participants died within 30 days of treatment; ‐ causes more or fewer serious unwanted effects because there were few events. Bamlanivimab may reduce the number of admissions to hospital within 30 days of treatment compared to placebo. ‐ May cause slightly fewer unwanted effects than placebo. ‐ We did not find data for improved symptoms or worsened symptoms. One study investigated a combination of bamlanivimab and etesevimab (1035 people), compared to placebo. ‐ Bamlanivimab and etesevimab may reduce the number of deaths and admissions to hospital. ‐ May cause slightly more unwanted effects. ‐ May cause more serious unwanted effects. For treatment with bamlanivimab alone or in combination with etesevimab we did not find data for improved symptoms or worsened symptoms. One study (phase 1/2 with 799 people) investigated different doses of casirivimab combined with imdevimab, compared to placebo. ‐ Casirivimab combined with imdevimab may reduce the number of hospital admissions or death. ‐ We don't know whether casirivimab and imdevimab causes more unwanted (grades 3 and 4) and serious unwanted effects than placebo because there were too few deaths to allow us to make a judgment. ‐ We did not find data for the number of people who died at day 30 and development of severe symptoms. ‐ We did not include results from phase 3 (5607 people) of this study, because of high risk of bias, as it was not clear which participants were included in the analysis. One study (583 people) investigated sotrovimab, compared to placebo. We don't know whether sotrovimab: ‐ increases or reduces the number of deaths and people requiring invasive mechanical ventilation or dying, because there were too few deaths to allow us to make a judgment. ‐ Sotrovimab may reduce the number of people requiring oxygen, unwanted (grades 3 to 4) and serious unwanted effects; ‐ may have little or no effect on unwanted effects (all grades). Another study (327 people) investigated different doses of regdanvimab (40 mg/kg and 80 mg/kg), compared to placebo. ‐ Regdanvimab at either dose may reduce the number of admissions to hospital or death. ‐ May increase unwanted events (grades 3 to 4). ‐ Regdanvimab at a dose of 80 mg/kg may reduce unwanted effects (all grades) and 40 mg/kg may have little to no effect. ‐ We don't know whether regdanvimab increases or decreases the number of deaths, requirement for invasive mechanical ventilation, and serious unwanted effects, because there were too few events to allow us to make a judgment. Hospitalised people with moderate to severe COVID‐19 (2 studies) One study (314 people) investigated bamlanivimab compared to placebo. ‐ We don’t know whether bamlanivimab increases or decreases the number of deaths due to any cause up to 30 or 90 days after treatment because there were too few deaths to allow us to make a judgment (6 deaths with bamlanivimab and 4 deaths with placebo in 314 people). ‐ Bamlanivimab may slightly increase the development of severe COVID‐19 symptoms five days after treatment and the number of people with unwanted effects. ‐ Bamlanivimab may have little to no effect on time until discharge from hospital. ‐ We don’t know whether bamlanivimab causes serious unwanted effects by day 30 because the study was small and reported few serious unwanted effects. Another study (9785 people) investigated casirivimab combined with imdevimab, compared to standard of care. ‐ Casirivimab combined with imdevimab has probably little to no effect on the number of deaths, requirement for invasive mechanical ventilation or death, and hospital discharge alive. ‐ We did not find data for unwanted and serious unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is low because we found only six studies, and they did not report everything we were interested in, such as the number of deaths within 60 days and quality of life. We found 36 ongoing studies. When they are published, we will add their results to our review. These results are likely to change our conclusions and will also help us understand how new variants affect how well monoclonal antibodies work. How up to date is this evidence? The evidence is up to date to 17 June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Kreuzberger, N; Hirsch, C; Chai, KL; Tomlinson, E; Khosravi, Z; Popp, M; Neidhardt, M; Piechotta, V; Salomon, S; Valk, SJ; Monsef, I; Schmaderer, C; Wood, EM; So-Osman, C; Roberts, DJ; McQuilten, Z; Estcourt, LJ; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD013825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "37964331-541d-4ec3-a66f-23990f1582ce", "pmid": "", "title": "Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease", "imported": false, "abstract": "Abstract - Background Catheter malfunction, including thrombosis, is associated with reduced dialysis adequacy, as well as an increased risk of catheter‐related bacteraemia and mortality. The role of anticoagulants in the prevention of catheter malfunction remains uncertain. Objectives This review aimed to compare the prophylactic effect of different anticoagulant agents, preparations, doses and administration on the incidence of central venous haemodialysis catheter‐related malfunction and sepsis in patients with end‐stage kidney disease (ESKD). Search methods We searched the Cochrane Renal Group's Specialised Register to 7 January 2016 through contact with the Trials' Search Co‐ordinator using search terms relevant to this review. Selection criteria We included all randomised controlled trials (RCT) assessing anticoagulants compared with conventional care for the prevention of catheter malfunction in adult patients receiving haemodialysis for ESKD. Data collection and analysis The primary outcome was catheter malfunction defined as a catheter blood flow of 200 mL/min or less, or as defined by study authors. Secondary outcomes were catheter‐related bacteraemia, all‐cause mortality and bleeding events. Relative risks (RR) with 95% confidence intervals (CI) for individual studies were pooled using random effects models within treatment classes. Analyses were conducted by class, with subgroup analyses performed of individual agents within classes. Main results We included 27 studies (3003 participants) that were followed up for a median of six months. Study interventions included alternative anticoagulant locking solutions (19 studies, 2216 patients), systemic agents (6 studies, 664 patients) and low or no dose heparin (2 studies, 123 patients). The most common comparison treatment was a locking solution of heparin 5000 IU/mL, used in 17 studies. No significant effect on catheter malfunction was observed for alternative anticoagulant locking solutions (RR 0.96, 95% CI 0.74 to 1.26), systemic agents (RR 0.59, 95% CI 0.28 to 1.23), or low or no dose heparin (RR 0.90, 95% CI 0.10 to 8.31). A significant reduction on incidence of catheter‐related bacteraemia was observed for alternative anticoagulant locking solutions (RR 0.46, 95% CI 0.32 to 0.66) but not systemic agents (RR 2.41, 95% CI 0.89 to 6.55), and could not be assessed in reports of low or no dose heparin studies. No significant effect on all‐cause mortality was observed for alternative anticoagulant locking solutions (RR 0.88, 95% CI 0.54 to 1.43) or systemic agents (RR 0.78, 95% CI 0.37 to 1.65), and was not reported in studies of low or no dose heparin. Bleeding events were only reported in eight studies, including only 2/5 studies of systemic warfarin, with no clear effect demonstrated (RR 1.43, 95% CI 0.86 to 2.39). For individual agents, recombinant tissue plasminogen (rt‐PA) was the only locking solution shown to reduce catheter malfunction (RR 0.58, 95% CI 0.37 to 0.91) based on the results of a single study. No significant on catheter malfunction was observed for other individual classes of alternative anticoagulant locking solutions (citrate: RR 1.14, 95% CI 0.76 to 1.69; antibiotic: RR 1.48, 95% CI 0.79 to 2.77; ethanol: RR 0.88, 95% CI 0.21 to 3.67). On the other hand, all individual classes of alternative anticoagulant locking solutions, except ethanol, reduced catheter‐related bacteraemia (citrate: RR 0.49, 95% CI 0.36 to 0.68; antibiotic: RR 0.27, 95% CI 0.11 to 0.70; rt‐PA: RR 0.35, 95% CI 0.13 to 0.93; ethanol: RR 0.33, 95% CI 0.03 to 4.05). No significant effect on all‐cause mortality was observed for any individual agent within the class of alternative locking solutions. Studies were mainly of low quality and underpowered with an average participant number of 75 and study duration of six months. The interpretation of the study evidence was further limited by the variation in tested interventions and outcome reporting. Authors' conclusions The relative net benefit of anticoagulant therapies for prevention of catheter malfunction remains uncertain. Multiple agents appear to reduce catheter‐related bacteraemia although the lack of clear assessment of harms and the limitations of study quality mean these results should be interpreted with caution. Methodological approaches can be used to avoid methods of reporting unduly affecting on the results of meta‐analyses incorporating studies employed mixed reporting methods. Further high quality randomised studies, including safety outcomes, are needed. Plain language summary Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease Background Patients with end‐stage kidney disease require vascular access during haemodialysis. Central venous haemodialysis catheters are frequently used when permanent vascular access is not available. Catheter problems contribute to greater morbidity and mortality. Catheter malfunction leads to requirements for additional interventions, increased risk of catheter‐related infection and hospitalisation. Standard care for the prevention of catheter malfunction is the use of heparin solutions as a post dialysis ‘lock’ in the catheter ports. The potential impact of heparin treatment on bleeding risk is an acknowledged concern. Therefore newer approaches have been proposed to seek improvements in catheter patency or treatment‐associated harm rates. Study characteristics This review focused on randomised controlled trials (RCTs) of anticoagulants compared with conventional care for the prevention of catheter malfunction patients receiving haemodialysis. Key results We found 27 studies, involving 3003 patients followed for an average six months, which assessed alternative anticoagulant locking solutions, systemic agents and low or no dose heparin. Catheter malfunction were not affected by any of these classes of agents. Subgroup analysis showed that the only agent reducing catheter malfunction was recombinant tissue plasminogen locking solution based on the results of a single study. A significant reduction was observed on the incidence of catheter‐related bacteraemia for alternative anticoagulant locking solutions. There was no evidence to suggest that alternative anticoagulants to heparin locking solutions had an effect on death rates or bleeding events, although only a small proportion of studies reported bleeding events. Quality of the evidence Further high quality information is needed on both potential benefits and safety of alternative approaches to maintaining dialysis access catheter function.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Wang, Y, Ivany, JN, Perkovic, V, Gallagher, MP, Woodward, M, Jardine, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD009631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.791Z" }, { "id": "379e3869-4610-4047-b75f-34a1b758ae0a", "pmid": "", "title": "Zinc for prevention and treatment of the common cold", "imported": false, "abstract": "Abstract - Background The common cold is an acute, self‐limiting viral respiratory illness. Symptoms include nasal congestion and mucus discharge, sneezing, sore throat, cough, and general malaise. Given the frequency of colds, they are a public health burden and a significant cause of lost work productivity and school absenteeism. There are no established interventions to prevent colds or shorten their duration. However, zinc supplements are commonly recommended and taken for this purpose. Objectives To assess the effectiveness and safety of zinc for the prevention and treatment of the common cold. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and LILACS to 22 May 2023, and searched Web of Science Core Collection and two trials registries to 14 June 2023. We also used reference checking, citation searching, and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) in children or adults that tested any form of zinc against placebo to prevent or treat the common cold or upper respiratory infection (URTI). We excluded zinc interventions in which zinc was combined with other minerals, vitamins, or herbs (e.g. a multivitamin, or mineral supplement containing zinc). Data collection and analysis We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We independently extracted data. When necessary, we contacted study authors for additional information. We assessed zinc (type and route) with placebo in the prevention and treatment of the common cold. Primary outcomes included the proportion of participants developing colds (for analyses of prevention trials only), duration of cold (measured in days from start to resolution of the cold), adverse events potentially due to zinc supplements (e.g. unpleasant taste, loss of smell, vomiting, stomach cramps, and diarrhoea), and adverse events considered to be potential complications of the common cold (e.g. respiratory bacterial infections). Main results We included 34 studies (15 prevention, 19 treatment) involving 8526 participants. Twenty‐two studies were conducted on adults and 12 studies were conducted on children. Most trials were conducted in the USA (n = 18), followed by India, Indonesia, Iran, and Turkey (two studies each), and Australia, Burkina Faso, Colombia, Denmark, Finland, Tanzania, Thailand, and the UK (one study each). The 15 prevention studies identified the condition as either common cold (n = 8) or URTI (n = 7). However, almost all therapeutic studies (17/19) focused on the common cold. Most studies (17/34) evaluated the effectiveness of zinc administered as lozenges (3 prevention; 14 treatment) in acetate, gluconate, and orotate forms; gluconate lozenges were the most common (9/17). Zinc gluconate was given at doses between 45 and 276 mg/day for between 4.5 and 21 days. Five (5/17) lozenge studies gave acetate lozenges and two (2/17) gave both acetate and gluconate lozenges. One (1/17) lozenge study administered intranasal ( gluconate ) and lozenge ( orotate ) zinc in tandem for cold treatment. Of the 17/34 studies that did not use lozenges, 1/17 gave capsules, 3/17 administered dissolved powders, 5/17 gave tablets, 4/17 used syrups, and 4/17 used intranasal administration. Most studies were at unclear or high risk of bias in at least one domain. There may be little or no reduction in the risk of developing a cold with zinc compared to placebo (risk ratio (RR) 0.93, 95% CI 0.85 to 1.01; I 2 = 20%; 9 studies, 1449 participants; low‐certainty evidence). There may be little or no reduction in the mean number of colds that occur over five to 18 months of follow‐up (mean difference (MD) ‐0.90, 95% CI ‐1.93 to 0.12; I 2 = 96%; 2 studies, 1284 participants; low‐certainty evidence). When colds occur, there is probably little or no difference in the duration of colds in days (MD ‐0.63, 95% CI ‐1.29 to 0.04; I² = 77%; 3 studies, 740 participants; moderate‐certainty evidence), and there may be little or no difference in global symptom severity (standardised mean difference (SMD) 0.04, 95% CI ‐0.35 to 0.43; I² = 0%; 2 studies, 101 participants; low‐certainty evidence). When zinc is used for cold treatment, there may be a reduction in the mean duration of the cold in days (MD ‐2.37, 95% CI ‐4.21 to ‐0.53; I² = 97%; 8 studies, 972 participants; low‐certainty evidence), although it is uncertain whether there is a reduction in the risk of having an ongoing cold at the end of follow‐up (RR 0.52, 95% CI 0.21 to 1.27; I² = 65%; 5 studies, 357 participants; very low‐certainty evidence), or global symptom severity (SMD ‐0.03, 95% CI ‐0.56 to 0.50; I² = 78%; 2 studies, 261 participants; very low‐certainty evidence), and there may be little or no difference in the risk of a change in global symptom severity (RR 1.02, 95% CI 0.85 to 1.23; 1 study, 114 participants; low‐certainty evidence). Thirty‐one studies reported non‐serious adverse events (2422 participants). It is uncertain whether there is a difference in the risk of adverse events with zinc used for cold prevention (RR 1.11, 95% CI 0.84 to 1.47; I 2 = 0%; 7 studies, 1517 participants; very low‐certainty evidence) or an increase in the risk of serious adverse events (RR 1.67, 95% CI 0.78 to 3.57; I 2 = 0%; 3 studies, 1563 participants; low‐certainty evidence). There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment (RR 1.34, 95% CI 1.15 to 1.55; I 2 = 44%; 2084 participants, 16 studies; moderate‐certainty evidence); no treatment study provided information on serious adverse events. No study provided clear information about adverse events considered to be potential complications of the common cold. Authors' conclusions The findings suggest that zinc supplementation may have little or no effect on the prevention of colds but may reduce the duration of ongoing colds, with an increase in non‐serious adverse events. Overall, there was wide variation in interventions (including concomitant therapy) and outcomes across the studies, as well as incomplete reporting of several domains, which should be considered when making conclusions about the efficacy of zinc for the common cold. Plain language summary Zinc for the prevention and treatment of the common cold Key messages 
‐ There may be little or no reduction in the risk of developing a cold with zinc supplements compared to placebo. ‐ For people who already have a cold, there may be a reduction in how long the cold lasts with zinc supplements compared to placebo. ‐ There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment. What is the common cold? 
The common cold is primarily a viral infection of the upper respiratory tract. There is no specific combination of symptoms that defines a cold, but symptoms can include nasal congestion, sneezing, sore throat, cough, fatigue, and runny nose, with or without fever. Most people usually recover from this illness without medical treatment; however, there are no definitive treatments to prevent colds or shorten their duration. Given the frequency of colds in adults and children, they are a public health burden and a significant cause of lost work productivity and school absenteeism. Prevention and treatment for the common cold with zinc is an ongoing interest. What did we want to find out? 
We wanted to find out if zinc was better than placebo at reducing the risk of developing a cold and shortening the duration of existing colds. A placebo is a substance similar in appearance to a treatment, but that has no known therapeutic effect. Placebos help assess the effects of the belief that a treatment has been received versus treatment actually being received. We also wanted to find out if zinc was associated with any adverse effects (e.g. harms), especially harms considered to be potential complications of the common cold. Additionally, we looked at self‐reported overall cold severity, individual symptom severity, individual symptom duration, and days missed from work or school. What did we do? 
We searched six databases and two clinical trials registers for studies comparing zinc with placebo for the treatment or prevention of the common cold in adults and children. We compared and summarised the results of the studies, and we found and rated our confidence in the evidence based on specific factors such as risk of bias and study methods. What did we find? 
We found 34 studies of cold prevention or treatment. The studies were conducted in 13 countries, a majority taking place in the USA. Twelve studies were conducted on children (aged under 18 years) and 22 studies were conducted on adults. Most treatments ended with self‐reported resolution of symptoms, and the minimum treatment period was five days with a maximum period of 540 days. Most of the studies were funded by an organisation with ties to related commerce/industry or did not report their funding. The remainder were funded by private clinics, non‐government foundations, universities, or governmental entities. We assessed the effects of: ‐ zinc as a preventative measure; and ‐ zinc as a treatment measure. We obtained the following results: Zinc for prevention Compared with placebo, taking zinc may make little to no difference in preventing people from catching a cold (9 studies, 1449 people). Preventative zinc also probably makes little to no difference to the length of the cold if one has been caught (3 studies, 740 participants) and may make little to no difference to the severity of the symptoms experienced (2 studies, 101 people). Negative side effects were reported by people taking either zinc or placebo; irregularities in taste and stomach upset were the most common. Zinc for treatment Zinc taken for treatment of a cold may reduce the length of time that symptoms are present, by approximately two days, when compared with placebo (8 studies, 972 people). However, we have little confidence in the evidence supporting this conclusion. It is unclear whether zinc makes a difference to the severity of the cold symptoms experienced (2 studies, 261 people). Negative side effects were reported more frequently for those taking zinc as a cold treatment when compared to those taking placebo; irregularities in taste and stomach upset were the most common. Studies administering intranasal zinc did not report any cases of anosmia (loss of sense of smell) but information about specific side effects is uncertain. What are the limitations of the evidence? 
Our confidence in the evidence is mostly low to very low, and the results of further research could differ from the results of this review. Several factors reduced our confidence in the evidence. Firstly, some studies did not report adequately on how people in the studies were randomly placed into treatment groups, meaning that differences between the study groups could be due to differences between the participants and not the treatments. Secondly, some studies used widely different ways of delivering treatments. Finally, due to the large differences between studies in the approaches used to test the effectiveness of zinc, it is likely that additional studies are required before any firm conclusions can be drawn. How up‐to‐date is this evidence? 
The evidence is current to 22 May 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Nault, D; Machingo, TA; Shipper, AG; Antiporta, DA; Hamel, C; Nourouzpour, S; Konstantinidis, M; Phillips, E; Lipski, EA; Wieland, LS", "articleTypes": [], "doi": "10.1002/14651858.CD014914.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "37a6f688-ef52-482b-93e8-c9ac5b70300f", "pmid": "", "title": "Silver acetate for smoking cessation", "imported": false, "abstract": "Abstract - Background Silver acetate produces an unpleasant taste when combined with cigarettes, thereby producing an aversive stimulus. It has been marketed in various forms with the aim of extinguishing the urge to smoke, by pairing the urge with an unpleasant stimulus. Objectives The aim of this review was to determine the effectiveness of silver acetate products (gum, lozenge, spray) in promoting smoking cessation. Search methods We searched the Cochrane Tobacco Addiction Group specialised trials register. Most recent search was in July 2012. Selection criteria We included randomised trials of silver acetate for smoking cessation with reports of smoking status at least six months after the beginning of treatment. Data collection and analysis We extracted data in duplicate on the type of subjects, the dose and form of silver acetate, the outcome measures, method of randomisation, and completeness of follow‐up. The main outcome measure was biochemically validated abstinence from smoking after at least six months follow‐up in patients smoking at baseline. Subjects lost to follow‐up were counted as continuing smokers. Where appropriate, we performed meta‐analysis using a fixed effects model. Main results Two studies provided long‐term follow‐up data on patients randomised to silver acetate or placebo. In one of these studies, there was a third arm, randomised to 2mg nicotine gum. The pooled risk ratio for quitting for silver acetate vs placebo was 1.04 (95% confidence interval 0.69 to 1.57). Authors' conclusions Existing trials show little evidence for a specific effect of silver acetate in promoting smoking cessation. The confidence intervals for the ratio are quite wide. However, the upper limit of the confidence intervals for a positive effect equates to an absolute increase in the smoking cessation rate of about 4%. Any effect of this agent is therefore likely to be smaller than nicotine replacement therapy. The lack of effect of silver acetate may reflect poor compliance with a treatment whose rationale is to create an unpleasant stimulus. Plain language summary Does silver acetate help people stop smoking Silver acetate products (gum, lozenge, and spray) produce an unpleasant metallic taste when combined with cigarettes, so they are used as a form of aversion therapy for smoking. However, the review of trials found little evidence to show that silver acetate helps smokers quit. Any beneficial effect of silver acetate is likely to be very small, and less than the effect already proven for nicotine replacement therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lancaster, T; Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000191.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "37bb0218-01bc-45c0-8722-054d6ea11664", "pmid": "", "title": "Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis", "imported": false, "abstract": "Abstract - Background Seasonal/perennial allergic conjunctivitis is the most common allergic conjunctivitis, usually with acute manifestations when a person is exposed to allergens and with typical signs and symptoms including itching, redness, and tearing. The clinical signs and symptoms of allergic conjunctivitis are mediated by the release of histamine by mast cells. Histamine antagonists (also called antihistamines) inhibit the action of histamine by blocking histamine H1 receptors, antagonising the vasoconstrictor, and to a lesser extent, the vasodilator effects of histamine. Mast cell stabilisers inhibit degranulation and consequently the release of histamine by interrupting the normal chain of intracellular signals.
 
 Topical treatments include eye drops with antihistamines, mast cell stabilisers, non‐steroidal anti‐inflammatory drugs, combinations of the previous treatments, and corticosteroids. Standard treatment is based on topical antihistamines alone or topical mast cell stabilisers alone or a combination of treatments. There is clinical uncertainty about the relative efficacy and safety of topical treatment. Objectives The objective of this review was to assess the effects of topical antihistamines and mast cell stabilisers, alone or in combination, for use in treating seasonal and perennial allergic conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2014, Issue 7), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2014), EMBASE (January 1980 to July 2014), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 July 2014. We also searched the reference lists of review articles and relevant trial reports for details of further relevant publications. Selection criteria We included randomised controlled trials (RCTs) comparing topical antihistamine and mast cell stabilisers, alone or in combination, with placebo, no treatment or to any other antihistamine or mast cell stabiliser, or both, that examined people with seasonal or perennial allergic conjunctivitis, or both. The primary outcome was any participant‐reported evaluation (by questionnaire) of severity of four main ocular symptoms: itching, irritation, watering eye (tearing), and photophobia (dislike of light), both separately and, if possible, by an overall symptom score. We considered any follow‐up time between one week and one year. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Disagreements were resolved by discussion among review authors and the involvement of a third review author. We followed standard methodological approaches used by Cochrane. Main results We identified 30 trials with a total of 4344 participants randomised, with 17 different drugs or treatment comparisons. The following antihistamines and mast cell stabilisers were evaluated in at least one RCT: nedocromil sodium or sodium cromoglycate, olopatadine, ketotifen, azelastine, emedastine, levocabastine (or levocabastine), mequitazine, bepotastine besilate, combination of antazoline and tetryzoline, combination of levocabastine and pemirolast potassium. The most common comparison was azelastine versus placebo (nine studies). We observed a large variability in reporting outcomes. The quality of the studies and reporting was variable, but overall the risk of bias was low. Trials evaluated only short‐term effects, with a range of treatment of one to eight weeks. Meta‐analysis was only possible in one comparison (olopatadine versus ketotifen). There was some evidence to support that topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo. There were no reported serious adverse events related to the use of topical antihistamine and mast cell stabilisers treatment. Authors' conclusions It seems that all reported topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo in the short term. However, there is no long‐term data on their efficacy. Direct comparisons of different antihistamines and mast cell stabilisers need to be interpreted with caution. Overall, topical antihistamines and mast cell stabilisers appear to be safe and well tolerated. We observed a large variability in outcomes reported. Poor quality of reporting challenged the synthesis of evidence. Plain language summary Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis Review question 
 Are treatments with eye drops of antihistamines and mast cell stabilisers, alone or in combination, effective and safe in people with seasonal and allergic conjunctivitis? The main outcome measure was eye symptoms reported by participants, including eye itching, irritation (burning sensation), watering eyes (tearing), and photophobia (dislike of light). We found 30 trials. Background 
 Conjunctivitis refers to inflammation of the conjunctiva, which is the thin tissue that covers the sclera (white part of the eye). Seasonal and perennial allergic conjunctivitis is the most common type of allergic conjunctivitis. Although this condition does not cause sight loss, it can cause intense itching and eye watering. Eye drops with antihistamines or mast cell stabilisers, or both are commonly used. Study characteristics 
 The evidence is current to July 2014. Among the 30 studies reviewed there were 17 different comparisons, including 4344 participants ranging in age between 4 and 85 years. The duration of treatment ranged from one to eight weeks. Ten out of 30 studies were funded by the drug manufacturer (8 totally and 2 partially funded); 20 studies did not report any source of funding. There was inconsistency in the way the effect of treatment was measured and reported. Overall risk of bias was low. Key results 
 Topical antihistamines and mast cell stabilisers, alone or in combination, are safe and effective for reducing symptoms of seasonal and perennial allergic conjunctivitis. We found insufficient evidence to discern which topical antihistamines and mast cell stabilisers are the most effective.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Castillo, M; Scott, NW; Mustafa, MZ; Mustafa, MS; Azuara‐Blanco, A", "articleTypes": [], "doi": "10.1002/14651858.CD009566.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "37cb4e79-843c-43b2-a06d-01dbcc44290f", "pmid": "", "title": "Coblation versus other surgical techniques for tonsillectomy", "imported": false, "abstract": "Abstract - Background Tonsillectomy is a very common operation and is performed using various surgical methods. Coblation is a popular method because it purportedly causes less pain than other surgical methods. However, the superiority of coblation is unproven. Objectives To compare the effects of coblation tonsillectomy for chronic tonsillitis or tonsillar hypertrophy with other surgical techniques, both hot and cold, on intraoperative morbidity, postoperative morbidity and procedural cost. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2017, Issue 3); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 April 2017. Selection criteria Randomised controlled trials (RCTs) of children and adults undergoing tonsillectomy with coblation compared with any other surgical technique. This review is limited to trials of extracapsular (traditional) tonsillectomy and excludes trials of intracapsular tonsil removal (tonsillotomy). Data collection and analysis We used the standard Cochrane methods. Our primary outcomes were: patient‐reported pain using a validated pain scale at postoperative days 1, 3 and 7; intraoperative blood loss; primary postoperative bleeding (within 24 hours) and secondary postoperative bleeding (more than 24 hours after surgery). Secondary outcomes were: time until resumption of normal diet, time until resumption of normal activity, duration of surgery and adverse effects including blood transfusion and the need for reoperation. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 29 studies, with a total of 2561 participants. All studies had moderate or high risk of bias. Sixteen studies used an adequate randomisation technique, however the inability to mask the surgical teams and/or provide adequate methods to mitigate the risk of bias put nearly all studies at moderate or high risk of detection and measurement bias for intraoperative blood loss, and primary and secondary bleeding. In contrast most studies (20) were at low risk of bias for pain assessment. Most studies did not report data in a manner permitting meta‐analysis. Most studies did not clearly report the participant characteristics, surgical indications or whether patients underwent tonsillectomy or adenotonsillectomy. Most studies reported that tonsillitis (infection) and/or tonsillar hypertrophy (obstruction) were the indication for surgery. Seven studies included only adults, 16 studies included only children and six studies included both. Pain At postoperative day 1 there is very low quality evidence that patients in the coblation group had less pain, with a standardised mean difference (SMD) of ‐0.79 (95% confidence interval (CI) ‐1.38 to ‐0.19; 538 participants; six studies). This effect is reduced a SMD of ‐0.44 (95% CI ‐0.97 to 0.09; 401 participants; five studies; very low‐quality evidence ) at day 3, and at day 7 there is low quality evidence of little or no difference in pain (SMD ‐0.01, 95% CI ‐0.22 to 0.19; 420 participants; five studies). Although this suggests that pain may be slightly less in the coblation group between days 1 and 3, the clinical significance is unclear. Intraoperative blood loss Methodological differences between studies in the measurement of intraoperative blood loss precluded meta‐analysis. Primary and secondary bleeding The risk of primary bleeding was similar (risk ratio (RR) 0.99, 95% CI 0.48 to 2.05; 2055 participants; 25 studies; low‐quality evidence ). The risk of secondary bleeding was greater in the coblation group with a risk ratio of 1.36 (95% CI 0.95 to 1.95; 2118 participants; 25 studies; low‐quality evidence ). Using the median of the control group as the baseline risk, the absolute risk in the coblation group was 5% versus 3.6% in the control group. The difference of 1.3% has a 95% CI of 0.2% lower in the coblation group to 3.5% higher. Secondary outcomes Differences in study design and data reporting precluded the identification of differences in the time to resumption of normal diet or activity, or whether there was a difference in the duration of surgery. Although we could not feasibly compare the costs of equipment or operative facility, anaesthetic and surgical fees across different healthcare systems we used duration of surgery as a proxy for cost. Although this outcome was commonly reported in studies, it was not possible to pool the data to determine whether there was a difference. Adverse events other than bleeding were not well reported. It is unclear whether there is a difference in postoperative infections or the need for reoperation. Authors' conclusions The coblation technique may cause less pain on postoperative day 1, but the difference is small and may be clinically meaningless. By postoperative day 3, the difference decreases further and by postoperative day 7 there appears to be little or no difference. We found similar rates of primary bleeding but we cannot rule out a small increased risk of secondary bleeding with coblation. The evidence supporting these findings is of low or very low quality , i.e. there is a very high degree of uncertainty about the results. Moreover, for most outcomes data were only available from a few of the 29 included studies. The current evidence is of very low quality, therefore it is uncertain whether or not the coblation technique has any advantages over traditional tonsillectomy techniques. Despite the large number of studies, failure to use standardised or validated outcome measures precludes the ability to pool data across studies. Therefore, well‐conducted RCTs using consistent, validated outcome measures are needed to establish whether the coblation technique has a benefit over other methods. In the included studies we identified no clear difference in adverse events. However, given the rarity of these events, randomised trials lack the power to detect a difference. Data from large‐scale registries will provide a better estimate of any difference in these rare outcomes. Plain language summary Surgical removal of the tonsils (tonsillectomy) with coblation or another surgical method Review question This review compared the coblation method with other methods of tonsil removal to assess recovery following tonsillectomy or adenotonsillectomy. Background Surgical removal of the tonsils (tonsillectomy) is a very common operation. Patients may have pain for up to two weeks after surgery. Bleeding may occur either immediately after surgery ('primary bleeding' within 24 hours of surgery) or later ('secondary bleeding' more than 24 hours after surgery). There are many methods of tonsillectomy; the traditional method is with metal surgical instruments. Coblation is a new method where the surgeon uses an electrically powered handpiece that 'burns' tissues using low temperatures. Study characteristics This review included evidence available up to April 2017. We included 29 studies, with a total of 2561 participants. All studies had a moderate or high risk of bias. Seven studies included adults, 16 studies included children and six included both adults and children. Most studies measured pain using a patient‐reported scale (for example, asking people to rate their pain on a scale of 1 to 10). Key results The coblation technique may cause slightly less pain one day after surgery and three days after surgery, but it is unlikely that there is a difference in pain seven days after surgery. We are very uncertain whether the amount of pain reduction observed in days 1 to 3 after surgery would be important to patients. There is little or no difference in the risk of bleeding in the first day after surgery, but there may be a small increased risk of bleeding with coblation after the first day. For every 1000 patients having a tonsillectomy, 50 patients would have a bleed with coblation, compared to 36 with traditional surgical techniques. Quality of the evidence The evidence for the difference in pain is of low or very low quality and for the difference in bleeding after surgery it is of low quality . This means that we have little confidence in the results; the true effect may be very different ‐ we simply do not know at this stage.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Pynnonen, M, Brinkmeier, JV, Thorne, MC, Chong, LY, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.100Z" }, { "id": "37d9fa8d-da84-46b4-b906-283959144407", "pmid": "", "title": "Interventions for perceptual disorders following stroke", "imported": false, "abstract": "Abstract - Background Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non‐invasive brain stimulation, pharmacological and surgical approaches. Objectives To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living. Search methods We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors. Selection criteria We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain. Data collection and analysis One review author assessed titles, with two review authors independently screening abstracts and full‐text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB‐1 tool, and quality of evidence using GRADE. A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update. Main results We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch‐somatosensory disorders. None addressed stroke‐related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non‐invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL): Somatosensory disorders : one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure. Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention. Visual perception disorders : no trials measuring ADL compared an intervention with no treatment or control. In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials). Authors' conclusions Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high‐quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer‐term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines. Plain language summary Interventions for perceptual disorders following stroke Key messages Stroke can affect a person’s ability to process and understand information from their senses, including hearing, smell, somatosensation (sense of body temperature, position, and movement), taste, touch, and vision. Processing and understanding information from these senses is known as perception. Little research has been carried out to find out whether any treatments for stroke‐related problems with perception are helpful. People with stroke‐related problems with hearing, smell, somatosensation, taste, touch, and vision should continue to participate in rehabilitation as recommended by clinical guidelines. Healthcare professionals should continue to offer rehabilitation for stroke‐related perceptual problems in keeping with current clinical guidelines and recommendations. What is a perceptual disorder? Before a stroke, adults gather information about the world through their senses: hearing, smell, somatosensation, taste, touch, and vision. Somatosensation refers to sensation arising from the skin, muscles, or joints, and includes perception of pressure, vibration, temperature, and position. Information gathered might include the colour, shape, and size of objects that they see. Together with memories and cultural experiences, a person can understand how someone is feeling from seeing their facial expression. Other examples are how different odours can be identified through the sense of smell and how different textures can be felt through the sense of touch. A stroke can affect these abilities. How are perceptual disorders treated? Healthcare professionals, including occupational therapists, physiotherapists, and psychologists, may offer different therapies. Treatments might include medicine, stimulation of the brain, or perceptual rehabilitation through activities, puzzles, strategies, or intensive repetition of tasks. What did we want to find out? We wanted to find out whether receiving any perceptual disorder treatment was better than no treatment at all. We measured improvement by looking at how well people could carry out their daily activities. We measured whether treatments also helped other things, such as quality of life, mental health, and perception. We looked for information on when things did not go well. We also explored whether one treatment was more beneficial than another. What did we do? We searched for all relevant research. We assessed the quality of 18 studies and summarised their results. What did we find out? The studies we found were about different perceptual disorders: three studies looked at disorders of touch perception, seven looked at somatosensation, seven studies looked at vision, and one looked at several perceptual problems at the same time. The treatments used in these studies included paper‐and‐pencil copying tasks to improve visual memory and using robots to help improve a person’s sense of where their body is positioned. We found no information to show that any treatment worked. Why are we still uncertain? We found few studies. Each study included a small number of people with a perceptual problem after a stroke. With small numbers of people involved, the results were not clear. Each study looked at different interventions. Less than half the studies (seven) measured the ability to carry out everyday activities. How up to date is this information? Our information is up to date as of August 2021. Based on the information we gathered, we are still unclear about the benefits or harms of treatments for perceptual problems after stroke. People with perceptual problems after stroke should continue to be offered rehabilitation as recommended in clinical guidelines.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hazelton, C; Thomson, K; Todhunter-Brown, A; Campbell, P; Chung, CSY; Dorris, L; Gillespie, DC; Hunter, SM; McGill, K; Nicolson, DJ; Williams, LJ; Brady, MC", "articleTypes": [], "doi": "10.1002/14651858.CD007039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "37de10c1-b079-487f-9439-f69164faf156", "pmid": "", "title": "Interventions to reduce harm from continued tobacco use", "imported": false, "abstract": "Abstract - Background Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced‐exposure tobacco products (PREPs), as an alternative to cigarettes. Objectives To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long‐term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco? Search methods We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free‐text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. Selection criteria Randomized or quasi‐randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention. Data collection and analysis We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long‐term smoking abstinence), using fixed‐effect models. Where it was not possible to meta‐analyse data, we summarized findings narratively. Main results Twenty‐four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically‐heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as ‘low’ or ‘very low’, due to imprecision and indirectness. A ‘low’ grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A ‘very low’ grade means we are very uncertain about the estimate. Authors' conclusions People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high‐quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high‐quality RCTs are conducted, and that these also measure the long‐term health effects of treatments. Plain language summary Can smokers be helped to reduce the harm caused by cigarette smoking by smoking fewer cigarettes or using different tobacco products? Background The best thing to do to reduce the harms caused by smoking is to quit, but some people may not want to do this or may feel that they are unable to stop smoking completely. Cutting down the number of cigarettes smoked daily or using different tobacco products, such as chewing tobacco or low‐tar cigarettes, may reduce some of the harm caused by smoking. It may also help people to stop smoking completely in the long term. On the other hand, reducing smoking or using other tobacco products may not improve health and could reduce a person's motivation to quit smoking altogether. It is important that we review the evidence to find out whether these approaches could help smokers who do not want to or cannot quit to reduce the harm caused by their smoking. We were mainly interested in whether these approaches improved the health of smokers, but also looked at smoking reduction and quitting rates. Study characteristics We found 20 randomised controlled trials that tested ways to help people to cut down the number of cigarettes they smoked. Some of these just advised smokers to smoke less, but most also provided them with a product to help them cut down: nicotine replacement therapy (NRT), varenicline, bupropion, electronic cigarettes (ecigs), or snus (a form of smokeless, oral tobacco). We also found four randomized controlled trials that tested the effects of using cigarettes designed to reduce the damage caused by smoking: reduced tar, carbon or nicotine cigarettes. Most of the studies used NRT to help people to reduce their smoking. All of the studies included people who were not planning to quit smoking soon. The research is current to October 2015. Key results Eight studies (with 3081 smokers) found that using NRT roughly doubled the likelihood of halving the number of cigarettes smoked each day, compared to using a placebo. Using NRT in this way also nearly doubled the likelihood of quitting completely. One trial each tested bupropion, varenicline, ecigs and snus to help reduce the harms caused by smoking, and there was no evidence that any of these treatments helped smokers to reduce the number of cigarettes they were smoking each day. This may be because there has not yet been enough research into these methods. Only one of the trials testing cigarettes designed to reduce risk measured their effect on the number of people quitting smoking. It found that people were not more likely to quit smoking if they used reduced‐nicotine cigarettes than if they smoked their usual cigarettes. We did not find any trials which reported the long‐term health effects of the treatments, and so it remains uncertain how much health benefit there is from reducing the number of cigarettes smoked each day or smoking cigarettes designed to be less harmful. Quality of evidence The tobacco industry funded three of the included studies of cigarettes designed to reduce risk. None of the studies looked at whether there had been a long‐term change in the health of the users. We rate the quality of the evidence looking at how many people quit smoking as 'low' or 'very low', generally because the findings are based on a small number of studies. We need more studies to investigate methods of reducing the harm caused by continued smoking. These need to measure the health of the users over a long period.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lindson‐Hawley, N, Hartmann‐Boyce, J, Fanshawe, TR, Begh, R, Farley, A, Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD005231.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.092Z" }, { "id": "37ecc2b4-7832-4f81-a450-aadc9d1261e2", "pmid": "", "title": "Intranasal fentanyl for the management of acute pain in children", "imported": false, "abstract": "Abstract - Background Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula. Objectives We identified and evaluated all randomized controlled trials (RCTs) and quasi‐randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of \"rescue analgesia,\" patient/parental satisfaction and patient mortality. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014). Selection criteria We included RCTs comparing INF versus any other pharmacological/non‐pharmacological intervention for the treatment of children in acute pain (aged < 18 years). Data collection and analysis Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions. Main results Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a “bad taste” and vomiting with INF. Overall the risk of bias in all studies was considered low. Authors' conclusions INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non‐inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause. Plain language summary Intranasal fentanyl for the treatment of children in acute pain Background Pain is the most common reason why patients are seen in emergency departments (EDs). The challenging nature of treating children in acute severe pain is reflected in the medical literature by poor pain management in this population. We reviewed evidence on the effect of intranasal fentanyl (INF) (a strong pain relief drug, similar to morphine) compared with any other pain‐relieving technique for treatment of children in acute severe pain. Study characteristics We included studies with children (younger than 18 years of age) suffering from acute severe pain as a result of injury or medical illness. The target intervention was INF administered for pain relief compared with any other drug intervention for pain relief (e.g. intravenous morphine) or non‐drug intervention (e.g. limb splinting, wound dressing) provided in the emergency setting. The evidence is current to January 2014. Key results We identified three studies that included 313 children with acute severe pain resulting from broken bones of the upper and lower limbs. These trials compared INF versus morphine administered by a needle into a muscle (intramuscular morphine) or via a drip into a vein (intravenous morphine), as well as standard concentration INF versus high concentration INF. The collective study population in these trials consisted of children three to 15 years of age. Males accounted for approximately two‐thirds of the overall study population. The review concluded that INF may be an effective analgesic for the treatment of children in acute moderate to severe pain, and its administration appears to cause minimal distress to children; however, the evidence is insufficient to permit judgement of the effects of INF compared with intramuscular or intravenous morphine. No serious adverse events (e.g. opiate toxicity, death) were reported. Limitations Limitations of this review include the following: Few studies (three) were eligible for inclusion; no study examined the use of INF in children younger than three years of age; no study included children with pain resulting from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Murphy, A, O'Sullivan, R, Wakai, A, Grant, TS, Barrett, MJ, Cronin, J, McCoy, SC, Hom, J, Kandamany, N", "articleTypes": [], "doi": "10.1002/14651858.CD009942.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.731Z" }, { "id": "37fbd9a1-7f0c-4463-a9d1-9c9de30d6102", "pmid": "", "title": "Paracetamol (acetaminophen) for prevention or treatment of pain in newborns", "imported": false, "abstract": "Abstract - Background Newborn infants have the ability to experience pain. Hospitalised infants are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Objectives To determine the efficacy and safety of paracetamol for the prevention or treatment of procedural/postoperative pain or pain associated with clinical conditions in neonates. To review the effects of various doses and routes of administration (enteral, intravenous or rectal) of paracetamol for the prevention or treatment of pain in neonates. Search methods We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 4), MEDLINE via PubMed (1966 to 9 May 2016), Embase (1980 to 9 May 2016), and CINAHL (1982 to 9 May 2016). We searched clinical trials' databases, Google Scholar, conference proceedings, and the reference lists of retrieved articles. Selection criteria We included randomised and quasi‐randomised controlled trials of paracetamol for the prevention/treatment of pain in neonates (≤ 28 days of age). Data collection and analysis Two review authors independently extracted data from the articles using pre‐designed forms. We used this form to decide trial inclusion/exclusion, to extract data from eligible trials and to request additional published information from authors of the original reports. We entered and cross‐checked data using RevMan 5 software. When noted, we resolved differences by mutual discussion and consensus. We used the GRADE approach to assess the quality of evidence. Main results We included nine trials with low risk of bias, which assessed paracetamol for the treatment of pain in 728 infants. Painful procedures studied included heel lance, assisted vaginal birth, eye examination for retinopathy of prematurity assessment and postoperative care. Results of individual studies could not be combined in meta‐analyses as the painful conditions, the use of paracetamol and comparison interventions and the outcome measures differed. Paracetamol compared with water, cherry elixir or EMLA cream (eutectic mixture of lidocaine and prilocaine) did not significantly reduce pain following heel lance. The Premature Infant Pain Profile score (PIPP) within three minutes following lancing was higher in the paracetamol group than in the oral glucose group (mean difference (MD) 2.21, 95% confidence interval (CI) 0.72 to 3.70; one study, 38 infants). Paracetamol did not reduce \"modified facies scores\" after assisted vaginal birth (one study, 119 infants). In another study (n = 123), the Échelle de Douleur et d'Inconfort du Nouveau‐Né score at two hours of age was significantly higher in the group that received paracetamol suppositories than in the placebo suppositories group (MD 1.00, 95% CI 0.60 to 1.40). In that study, when infants were subjected to a heel lance at two to three days of age, Bernese Pain Scale for Neonates scores were higher in the paracetamol group than in the placebo group, and infants spent a longer time crying (MD 19 seconds, 95% CI 14 to 24). For eye examinations, no significant reduction in PIPP scores in the first or last 45 seconds of eye examination was reported, nor at five minutes after the eye examination. In one study (n = 81), the PIPP score was significantly higher in the paracetamol group than in the 24% sucrose group (MD 3.90, 95% CI 2.92 to 4.88). In one study (n = 114) the PIPP score during eye examination was significantly lower in the paracetamol group than in the water group (MD −2.70, 95% CI −3.55 to 1.85). For postoperative care following major surgery, the total amount of morphine (µg/kg) administered over 48 hours was significantly less among infants assigned to the paracetamol group than to the morphine group (MD −157 µg/kg, 95% CI −27 to −288). No adverse events were noted in any study. The quality of evidence according to GRADE was low. Authors' conclusions The paucity and low quality of existing data do not provide sufficient evidence to establish the role of paracetamol in reducing the effects of painful procedures in neonates. Paracetamol given after assisted vaginal birth may increase the response to later painful exposures. Paracetamol may reduce the total need for morphine following major surgery, and for this aspect of paracetamol use, further research is needed. Plain language summary Paracetamol (acetaminophen) for prevention or treatment of pain in newborns Review question: Is paracetamol effective and safe for the prevention or treatment of procedural or postoperative pain or pain associated with clinical conditions in newborn infants? Background: Newborn infants have the ability to experience pain. Newborns treated in neonatal intensive care units are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Study characteristics: We identified nine studies that reported comparisons in 728 infants of paracetamol versus placebo or other pain‐reducing interventions. The literature search was updated in May 2016. Key results: Paracetamol for heel lance did not reduce pain compared with placebo (water or cherry elixir) or compared with EMLA cream (eutectic mixture of lidocaine and prilocaine). Paracetamol use was associated with a stronger response to pain than was seen with glucose. Paracetamol did not reduce pain in infants exposed to vacuum extraction or forceps at birth, and their response to a subsequent heel lance at two to three days of life was increased compared with placebo. For eye examination, paracetamol was effective in reducing pain compared with water in one study, but the pain response was stronger among paracetamol‐treated infants than in infants given 24% sucrose. In infants treated with paracetamol and morphine compared with morphine alone, the total amount of morphine required during the first 48 hours following major surgery to the chest or the abdomen was less in the paracetamol group. Paracetamol did not significantly reduce pain during heel lance. Paracetamol following assisted birth may increase the response to later exposure to painful interventions. Paraetamol may reduce the total need for morphine following major surgery, and further research is needed into this aspect of paracetamol use. Quality of evidence: In general the studies were of good quality but the numbers of infants enrolled in the different studies were small. The overall quality of evidence was low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ohlsson, A; Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD011219.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "38050caa-5c2f-4d63-96fb-ea9f31439787", "pmid": "", "title": "Oral versus intravenous steroids for treatment of relapses in multiple sclerosis", "imported": false, "abstract": "Abstract - Background This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD006921. DOI: 10.1002/14651858.CD006921.pub2). Multiple sclerosis (MS), a chronic inflammatory and neurodegenerative disease of the central nervous system (CNS), is characterized by recurrent relapses of CNS inflammation ranging from mild to severely disabling. Relapses have long been treated with steroids to reduce inflammation and hasten recovery. However, the commonly used intravenous methylprednisolone (IVMP) requires repeated infusions with the added costs of homecare or hospitalization, and may interfere with daily responsibilities. Oral steroids have been used in place of intravenous steroids, with lower direct and indirect costs. Objectives The primary objective was to compare efficacy of oral versus intravenous steroids in promoting disability recovery in MS relapses <= six weeks. Secondary objectives included subsequent relapse rate, disability, ambulation, hospitalization, immunological markers, radiological markers, and quality of life. Search methods A literature search was performed using Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group's Trials Register (January 2012), abstracts from meetings of the American Academy of Neurology (2008‐2012), the European Federation of Neurological Sciences (2008‐2012), the European Committee for Treatment and Research in Multiple Sclerosis and American Committee for Treatment and Research in Multiple Sclerosis (2008‐2012) handsearching. No language restrictions were applied. Selection criteria Randomized or quasi‐randomized trials comparing oral versus intravenous steroids for acute relapses (<= six weeks) in patients with clinically definite MSover age 16 were eligible. Data collection and analysis Three review authors (JB, PO and MH) participated in the independent assessment of all published articles as potentially relevant to the review. Any disagreement was resolved by discussion among review authors. We contacted study authors for additional information. Methodological quality was assessed by the same three review authors. Relevant data were extracted, and effect size was reported as mean difference (MD), mean difference (MD), odds ratio (OR) and absolute risk difference (ARD). Main results With this current update, a total of five eligible studies (215 patients) were identified. Only one outcome, the proportion of patients with Expanded Disability Status Scale (EDSS) improvement at four weeks, was common to three trials, while two trials examined magnetic resonance imaging (MRI) outcomes. The results of this review shows there is no significant difference in relapse recovery at week four (MD ‐0.22, 95% confidence interval (95% CI), 0.71 to 0.26, P = 0.20) nor differences in magnetic resonance imaging (MRI) gadolinium enhancement activity based on oral versus intravenous steroid treatment. However, only two of the five studies employed more current and rigorous methodological techniques, so these results must be taken with some caution. The Oral Megadose Corticosteroid Therapy of Acute Exacerbations of Multiple Sclerosis (OMEGA) trial and the \"Efficacy and Safety of Methylprednisolone Per os Versus IV for the Treatment of Multiple Sclerosis (MS) Relapses\" (COPOUSEP) trial, designed to address such limitations, are currently underway. Authors' conclusions The analysis of the five included trials comparing intravenous versus oral steroid therapy for MS relapses do not demonstrate any significant differences in clinical (benefits and adverse events), radiological or pharmacological outcomes. Based on the evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy in the treatment of MS relapses. Plain language summary A comparison of the efficacy of oral versus intravenous steroids in relapsing‐remitting multiple sclerosis (RRMS) RRMS is characterized by periods of disability (relapse) due to inflammation in the central nervous system. All research has shown that a \"speeding up\" of recovery is obtained by use of corticosteroids, given most often in intravenous form. If oral steroids worked as well as intravenous ones for relapse events, they would be easier to take and are more affordable. 
 
 The objective of this review was to assess if oral and intravenous steroids are equally effective and safe in aiding in the recovery from relapses. Among the pertinent literature, only five studies met the inclusion criteria, comprising a total of 215 participants. Despite some limitations in the methods used to conduct the studies (i.e. incomplete reporting of the participants who dropped out the studies and appropriateness of the sample size) and in the analysis of the data, all five studies found that there were no significant differences in term of benefits and adverse events and in the pharmacological and radiological outcomes in patients taking oral or intravenous steroids. Both treatments appear to be equally effective and safe. Based on this evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy for the treatment of MS relapses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Burton, JM; O'Connor, PW; Hohol, M; Beyene, J", "articleTypes": [], "doi": "10.1002/14651858.CD006921.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "3807caa0-7388-447b-b2cf-e4944b9fc6ae", "pmid": "", "title": "Topical medication instillation techniques for glaucoma", "imported": false, "abstract": "Abstract - Background Glaucoma is a leading cause of irreversible blindness worldwide and the second most common cause of blindness after cataracts. The primary treatment for glaucoma aims to lower intraocular pressure (IOP) with the use of topical medicines. Topical medication instillation techniques, such as eyelid closure and nasolacrimal occlusion when instilling drops, have been proposed as potential methods to increase ocular absorption and decrease systemic absorption of the drops. Objectives To investigate the effectiveness of topical medication instillation techniques compared with usual care or another method of instillation of topical medication in the management of glaucoma or ocular hypertension. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 8 December 2016), Embase Ovid (1947 to 8 December 2016), PubMed (1948 to 8 December 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 8 December 2016), International Pharmaceutical Abstracts Database (1970 to 8 December 2016), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ) (last searched 13 May 2013), ClinicalTrials.gov ( www.clinicaltrials.gov ) (searched 8 December 2016) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) (searched 8 December 2016). We did not use any date or language restrictions in the electronic searches for trials. Selection criteria We included randomized controlled trials which had compared any topical medication instillation technique with usual care or a different method of instillation of topical medication. Data collection and analysis Two review authors independently screened records from the searches for eligibility, assessed the risk of bias, and extracted data. We followed methods recommended by Cochrane. Main results We identified two trials (122 eyes of 61 participants) that had evaluated a topical medication instillation technique. We also identified two ongoing trials. Both included trials used a within‐person design and administered prostaglandin monotherapy for glaucoma or ocular hypertension. Because the trials evaluated different instillation techniques and assessed different outcomes, we performed no meta‐analysis. One trial, conducted in the US, evaluated the effect of eyelid closure (one and three minutes) versus no eyelid closure on lowering IOP. At one to two weeks' follow‐up, reduction in IOP was similar in the eyelid closure group and the no eyelid closure group (mean difference (MD) ‐0.33 mmHg, 95% confidence interval (CI) ‐0.8 to 1.5; 51 participants; moderate‐certainty evidence). The second trial, conducted in Italy, evaluated the effect of using an absorbent cloth to wipe excess fluid after instillation (fluid removal) versus not using an absorbent cloth (no removal) on reducing dermatologic adverse events. At four months' follow‐up, eyelashes were shorter among eyes in the fluid removal group compared with the no fluid removal group (MD ‐1.70 mm, 95% CI ‐3.46 to 0.06; 10 participants; low‐certainty evidence). Fewer eyes showed skin hyperpigmentation in the eyelid region towards the nose in the fluid removal group compared with the no removal group (RR 0.07, 95% CI 0.01 to 0.84; 10 participants; low‐certainty evidence); however, the difference was uncertain in the eyelid region towards the temples (RR 0.44, 95% CI 0.07 to 2.66; 10 participants; low‐certainty evidence). The effect hypertrichosis (excessive hair growth) was uncertain between groups (RR 1.00, 95% CI 0.17 to 5.98; 10 participants; low‐certainty evidence). Neither trial reported other outcomes specified for this review, including the proportion of participants with IOP less than 21 mmHg; participant‐reported outcomes related to the ease, convenience, and comfort of instillation techniques; physiologic measurements of systemic absorption; escalation of therapy; mean change in visual fields; optic nerve progression; mean change in best‐corrected visual acuity; proportion in whom glaucoma developed; quality of life outcomes; or cost‐effectiveness outcomes. Neither trial reported data at follow‐up times of more than four months. Authors' conclusions Evidence to evaluate the effectiveness of topical medication instillation techniques for treatment of glaucoma is lacking. It is unclear what, if any, effects instillation techniques have on topical medical therapy for glaucoma. Plain language summary Topical medicine instillation techniques for glaucoma What is the aim of this review? 
 The aim of this Cochrane Review was to find out if the way that people with glaucoma put eye drops in makes a difference in how well the eye drops work. Cochrane researchers collected and analyzed all relevant studies to answer this question and found two studies. Key messages 
 It is unclear if the way that people with glaucoma put their eye drops in makes a difference in how well the drops work. What did this review study? 
 Glaucoma is a leading cause of blindness worldwide. In eyes with glaucoma, the ability to see may be lost because of damage to the optic nerve. The optic nerve is the part of the eye that sends visual information from the eye to the brain. Sometimes such damage occurs when there is too much pressure in the eye (called intraocular pressure or IOP). Sometimes eyes may have too much pressure without damage to the optic nerve (called ocular hypertension). The main goal of glaucoma and ocular hypertension treatment is to lower IOP. Topical medicines, such as eye drops, are most often used as the first treatment. Encouraging specific ways of applying the drops, such as closing your eyes or nasolacrimal occlusion (closing the eye and pressing a finger on the inside corner, by the nose) aims to increase how much medicine is absorbed into the eye and reduce how much medicine is absorbed into the body. What are the main results of the review? 
 We found two studies that compared different ways of putting in eye drops. Both studies used prostaglandin alone for glaucoma or ocular hypertension. One study, in the US, evaluated the effect of closing the eyes for one and three minutes after putting in eye drops on lowering IOP. The second study, in Italy, looked at whether wiping off the excess fluid, after putting in the eye drops, led to fewer changes in the skin surrounding the eye. After one to two weeks in the US study, closing the eyelid for one to three minutes after putting in the eye drops found no difference on IOP compared with not closing the eyelid for a specified amount of time. After four months in the Italian study, eyelashes were shorter when participants had wiped their eyes to remove excess fluid when compared with participants who did not wipe their eyes. We found two ongoing studies that do not have results yet. Based on only two studies and uncertain results, it is unclear if different ways of putting in eye drops have any effect on people with glaucoma. How up‐to‐date is this review? 
 Cochrane researchers searched for studies that had been published up to 8 December 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Xu, L; Wang, X; Wu, M", "articleTypes": [], "doi": "10.1002/14651858.CD010520.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "380d5400-ebd4-449d-b11f-140b7a0c0d57", "pmid": "", "title": "Pharmacological and nutritional treatment for McArdle disease (Glycogen Storage Disease type V)", "imported": false, "abstract": "Abstract - Background McArdle disease (Glycogen Storage Disease type V) is caused by an absence of muscle phosphorylase leading to exercise intolerance, myoglobinuria rhabdomyolysis and acute renal failure. This is an update of a review first published in 2004. Objectives To review systematically the evidence from randomised controlled trials (RCTs) of pharmacological or nutritional treatments for improving exercise performance and quality of life in McArdle disease. Search methods We searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE on 11 August 2014. Selection criteria We included RCTs (including cross‐over studies) and quasi‐RCTs. We included unblinded open trials and individual patient studies in the discussion. Interventions included any pharmacological agent or nutritional supplement. Primary outcome measures included any objective assessment of exercise endurance (for example aerobic capacity (VO 2 ) max, walking speed, muscle force or power and fatigability). Secondary outcome measures included metabolic changes (such as reduced plasma creatine kinase and a reduction in the frequency of myoglobinuria), subjective measures (including quality of life scores and indices of disability) and serious adverse events. Data collection and analysis Three review authors checked the titles and abstracts identified by the search and reviewed the manuscripts. Two review authors independently assessed the risk of bias of relevant studies, with comments from a third author. Two authors extracted data onto a specially designed form. Main results We identified 31 studies, and 13 fulfilled the criteria for inclusion. We described trials that were not eligible for the review in the Discussion. The included studies involved a total of 85 participants, but the number in each individual trial was small; the largest treatment trial included 19 participants and the smallest study included only one participant. There was no benefit with: D‐ribose, glucagon, verapamil, vitamin B 6 , branched chain amino acids, dantrolene sodium, and high‐dose creatine. Minimal subjective benefit was found with low dose creatine and ramipril only for patients with a polymorphism known as the D/D angiotensin converting enzyme (ACE) phenotype. A carbohydrate‐rich diet resulted in better exercise performance compared with a protein‐rich diet. Two studies of oral sucrose given at different times and in different amounts before exercise showed an improvement in exercise performance. Four studies reported adverse effects. Oral ribose caused diarrhoea and symptoms suggestive of hypoglycaemia including light‐headedness and hunger. In one study, branched chain amino acids caused a deterioration of functional outcomes. Dantrolene was reported to cause a number of adverse effects including tiredness, somnolence, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of myalgia. Authors' conclusions Although there was low quality evidence of improvement in some parameters with creatine, oral sucrose, ramipril and a carbohydrate‐rich diet, none was sufficiently strong to indicate significant clinical benefit. Plain language summary Drug and nutritional treatment for McArdle disease Review question We reviewed the evidence about the effects of drug and nutritional treatment for McArdle disease. Background McArdle disease (also known as glycogen storage disease type V) is a disorder affecting muscle metabolism. The condition is caused by the lack of an enzyme called muscle phosphorylase. This results in an inability to break down glycogen 'fuel' stores. McArdle disease leads to pain and fatigue with strenuous exercise. Sometimes severe muscle damage develops and occasionally this results in acute reversible kidney failure. Study characteristics After a wide search, we identified 13 randomised studies that included 85 participants with McArdle disease. This is an update of a review first published in 2004. We found no new trials at this update. Key results and quality of the evidence The review found no benefit compared with placebo with the following treatments: D‐ribose, glucagon, verapamil, vitamin B 6 , oral branched chain amino acids, dantrolene sodium, high‐dose creatine and ramipril. Low dose creatine and ramipril produced minimal benefit for patients who also have the D/D angiotensin converting enzyme (ACE) phenotype. Taking low dose creatine supplements had a minor benefit in improving exercise tolerance in a small number of people with the condition. Taking a sugary drink before planned strenuous exercise can improve performance but this treatment is not practical for day‐to‐day living. A diet rich in carbohydrate may be superior to a diet rich in protein. Adverse effects were reported in four studies. Oral ribose caused symptoms suggestive of a low blood sugar including light‐headedness, hunger and diarrhoea. One study of branched chain amino acids resulted in a deterioration in participants. Dantrolene was reported to cause a number of side‐effects including tiredness, sleepiness, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause any side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of muscle pain. The quality of these studies was low due to the small number of participants; the largest number in one trial was 19 and one trial had only one participant. The evidence is current to August 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Quinlivan, R; Martinuzzi, A; Schoser, B", "articleTypes": [], "doi": "10.1002/14651858.CD003458.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "38146d6c-2dbc-47e6-93ef-8f30509da1e0", "pmid": "", "title": "Thoracic imaging tests for the diagnosis of COVID‐19", "imported": false, "abstract": "Abstract - Background Our March 2021 edition of this review showed thoracic imaging computed tomography (CT) to be sensitive and moderately specific in diagnosing COVID‐19 pneumonia. This new edition is an update of the review. Objectives Our objectives were to evaluate the diagnostic accuracy of thoracic imaging in people with suspected COVID‐19; assess the rate of positive imaging in people who had an initial reverse transcriptase polymerase chain reaction (RT‐PCR) negative result and a positive RT‐PCR result on follow‐up; and evaluate the accuracy of thoracic imaging for screening COVID‐19 in asymptomatic individuals. The secondary objective was to assess threshold effects of index test positivity on accuracy. Search methods We searched the COVID‐19 Living Evidence Database from the University of Bern, the Cochrane COVID‐19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID‐19 publications through to 17 February 2021. We did not apply any language restrictions. Selection criteria We included diagnostic accuracy studies of all designs, except for case‐control, that recruited participants of any age group suspected to have COVID‐19. Studies had to assess chest CT, chest X‐ray, or ultrasound of the lungs for the diagnosis of COVID‐19, use a reference standard that included RT‐PCR, and report estimates of test accuracy or provide data from which we could compute estimates. We excluded studies that used imaging as part of the reference standard and studies that excluded participants with normal index test results. Data collection and analysis The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using QUADAS‐2. We presented sensitivity and specificity per study on paired forest plots, and summarized pooled estimates in tables. We used a bivariate meta‐analysis model where appropriate. Main results We included 98 studies in this review. Of these, 94 were included for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eight studies were included for assessing the rate of positive imaging in individuals with initial RT‐PCR negative results and positive RT‐PCR results on follow‐up, and 10 studies were included for evaluating the accuracy of thoracic imaging for imagining asymptomatic individuals. For all 98 included studies, risk of bias was high or unclear in 52 (53%) studies with respect to participant selection, in 64 (65%) studies with respect to reference standard, in 46 (47%) studies with respect to index test, and in 48 (49%) studies with respect to flow and timing. Concerns about the applicability of the evidence to: participants were high or unclear in eight (8%) studies; index test were high or unclear in seven (7%) studies; and reference standard were high or unclear in seven (7%) studies. Imaging in people with suspected COVID‐19 We included 94 studies. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All studies used RT‐PCR alone or in combination with other criteria (for example, clinical signs and symptoms, positive contacts) as the reference standard for the diagnosis of COVID‐19. For chest CT (69 studies, 28285 participants, 14,342 (51%) cases), sensitivities ranged from 45% to 100%, and specificities from 10% to 99%. The pooled sensitivity of chest CT was 86.9% (95% confidence interval (CI) 83.6 to 89.6), and pooled specificity was 78.3% (95% CI 73.7 to 82.3). Definition for index test positivity was a source of heterogeneity for sensitivity, but not specificity. Reference standard was not a source of heterogeneity. For chest X‐ray (17 studies, 8529 participants, 5303 (62%) cases), the sensitivity ranged from 44% to 94% and specificity from 24 to 93%. The pooled sensitivity of chest X‐ray was 73.1% (95% CI 64.1 to 80.5), and pooled specificity was 73.3% (95% CI 61.9 to 82.2). Definition for index test positivity was not found to be a source of heterogeneity. Definition for index test positivity and reference standard were not found to be sources of heterogeneity. For ultrasound of the lungs (15 studies, 2410 participants, 1158 (48%) cases), the sensitivity ranged from 73% to 94% and the specificity ranged from 21% to 98%. The pooled sensitivity of ultrasound was 88.9% (95% CI 84.9 to 92.0), and the pooled specificity was 72.2% (95% CI 58.8 to 82.5). Definition for index test positivity and reference standard were not found to be sources of heterogeneity. Indirect comparisons of modalities evaluated across all 94 studies indicated that chest CT and ultrasound gave higher sensitivity estimates than X‐ray (P = 0.0003 and P = 0.001, respectively). Chest CT and ultrasound gave similar sensitivities (P = 0.42). All modalities had similar specificities (CT versus X‐ray P = 0.36; CT versus ultrasound P = 0.32; X‐ray versus ultrasound P = 0.89). Imaging in PCR‐negative people who subsequently became positive For rate of positive imaging in individuals with initial RT‐PCR negative results, we included 8 studies (7 CT, 1 ultrasound) with a total of 198 participants suspected of having COVID‐19, all of whom had a final diagnosis of COVID‐19. Most studies (7/8) evaluated CT. Of 177 participants with initially negative RT‐PCR who had positive RT‐PCR results on follow‐up testing, 75.8% (95% CI 45.3 to 92.2) had positive CT findings. Imaging in asymptomatic PCR‐positive people For imaging asymptomatic individuals, we included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with a total of 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. For chest CT (7 studies, 3134 participants, 315 (10%) cases), the pooled sensitivity was 55.7% (95% CI 35.4 to 74.3) and the pooled specificity was 91.1% (95% CI 82.6 to 95.7). Authors' conclusions Chest CT and ultrasound of the lungs are sensitive and moderately specific in diagnosing COVID‐19. Chest X‐ray is moderately sensitive and moderately specific in diagnosing COVID‐19. Thus, chest CT and ultrasound may have more utility for ruling out COVID‐19 than for differentiating SARS‐CoV‐2 infection from other causes of respiratory illness. The uncertainty resulting from high or unclear risk of bias and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results. Plain language summary How accurate is chest imaging for diagnosing COVID‐19? Why is this question important? People with suspected COVID‐19 need to know quickly whether they are infected, so they can receive appropriate treatment, self‐isolate, and inform close contacts. Currently, a formal diagnosis of COVID‐19 requires a laboratory test (RT‐PCR) of nose and throat samples. RT‐PCR requires specialist equipment and takes at least 24 hours to produce a result. It is not completely accurate, and may require a second RT‐PCR or a different test to confirm diagnosis. Clinicians may use chest imaging to diagnose people who have COVID‐19 symptoms, while awaiting RT‐PCR results or when RT‐PCR results are negative, and the person has COVID‐19 symptoms. This is the fourth version of this review. What did we want to find out? We wanted to know whether chest imaging is accurate enough to diagnose COVID‐19 in people with suspected infection; we included studies in people with suspected COVID‐19 only and excluded studies in people with confirmed COVID‐19. We also wanted to assess the accuracy of chest imaging for screening asymptomatic people. The evidence is up to date to 17 February 2021. What are chest imaging tests? X‐rays or scans produce an image of the organs and structures in the chest. ‐ X‐rays (radiography) use radiation to produce a 2‐D image. Usually done in hospitals, using fixed equipment by a radiographer; they can also be done on portable machines. ‐ Computed tomography (CT) scans use a computer to merge 2‐D X‐ray images and convert them to a 3‐D image. They require highly‐specialized equipment and are done in hospital by a specialist radiographer. ‐ Ultrasound scans use high‐frequency sound waves to produce an image. They can be done in hospitals or other healthcare settings, such as a doctor’s office. What did we do? We searched for studies that assessed the accuracy of chest imaging to diagnose COVID‐19 in people of any age with suspected COVID‐19. We included studies with ‘symptomatic' or 'mixed populations'. What did we find? We found 94 studies with 37,631 participants (of whom 19,768 (53%) had a final diagnosis of COVID‐19) for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All 94 studies used RT‐PCR either alone or in combination with other criteria (such as clinical signs and symptoms, or positive contacts) as the reference standard for the diagnosis of COVID‐19. Chest CT: suspected people Pooled results showed that chest CT (69 studies) correctly diagnosed COVID‐19 in 87% of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 21% of people who did not have COVID‐19. Chest X‐ray: suspected people Pooled results showed that chest X‐ray (17 studies) correctly diagnosed COVID‐19 in 73 % of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 27% of people who did not have COVID‐19. Lung ultrasound: suspected people Pooled results showed that lung ultrasound (15 studies) correctly diagnosed COVID‐19 in 87% of people with COVID‐19. However, it incorrectly diagnosed COVID‐19 in 24% of people who did not have COVID‐19. Screening asymptomatic people We included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. Pooled results of seven studies, showed that CT correctly diagnosed COVID‐19 in 56% of people who had COVID‐19, and incorrectly identified COVID‐19 in 8% of people who did not have COVID‐19. How reliable are the results? The studies differed from each other and used different methods to report their results. Very few studies directly compared one type of imaging test with another. Also, the risk of bias was high or unclear in about half of all included studies. Therefore, it is difficult to draw confident conclusions. What does this mean? The evidence suggests that chest CT and ultrasound are better at ruling out COVID‐19 infection than distinguishing it from other respiratory problems. So, their usefulness may be limited to excluding COVID‐19 infection rather than differentiating it from other causes of lung infection. In addition, chest CT imaging had poor sensitivity and high specificity for detecting asymptomatic individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ebrahimzadeh, S; Islam, N; Dawit, H; Salameh, J-P; Kazi, S; Fabiano, N; Treanor, L; Absi, M; Ahmad, F; Rooprai, P; Al Khalil, A; Harper, K; Kamra, N; Leeflang, MMG; Hooft, L; van der Pol, CB; Prager, R; Hare, SS; Dennie, C; Spijker, R; Deeks, JJ; Dinnes, J; Jenniskens, K; Korevaar, DA; Cohen, JF; Van den Bruel, A; Takwoingi, Y; van de Wijgert, J; Wang, J; Pena, E; Sabongui, S; McInnes, MDF", "articleTypes": [], "doi": "10.1002/14651858.CD013639.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "38188dbf-d619-49db-a0a3-3b5054bf134c", "pmid": "", "title": "Sucrose analgesia for heel‐lance procedures in neonates", "imported": false, "abstract": "Abstract - Background Sucrose has been examined for calming and pain‐relieving effects in neonates for invasive procedures such as heel lance. Objectives To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long‐term outcomes Search methods We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries. Selection criteria We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non‐nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin‐to‐skin care. Data collection and analysis We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. We assessed heterogeneity by the I 2 test. We used GRADE to assess certainty of evidence. Main results We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing. Sucrose vs control The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD ‐1.74 (95% CI ‐2.11 to ‐1.37); I 2 = 62%; moderate‐certainty evidence) and 60 seconds after lancing (MD ‐2.14, 95% CI ‐3.34 to ‐0.94; I 2 = 0%; moderate‐certainty evidence). The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD ‐1.90, 95% CI ‐8.58 to 4.78; heterogeneity not applicable (N/A); very low‐certainty evidence). The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD ‐2.00, 95% CI ‐2.42 to ‐1.58; heterogeneity N/A; moderate‐certainty evidence). Sucrose vs NNS The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI ‐0.30 to 1.50; heterogeneity not applicable; very low‐certainty evidence) and on DAN scores at 30 seconds after lancing (MD ‐1.20, 95% CI ‐7.87 to 5.47; heterogeneity N/A; very low‐certainty evidence). Sucrose + NNS vs NNS The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD ‐4.90, 95% CI ‐5.73 to ‐4.07; heterogeneity not applicable; very low‐certainty evidence) and during recovery after lancing (MD ‐3.80, 95% CI ‐4.47 to ‐3.13; heterogeneity N/A; very low‐certainty evidence). The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD ‐0.60, 95% CI ‐1.47 to 0.27; heterogeneity N/A; very low‐certainty evidence). Sucrose vs glucose The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI ‐0.70 to 1.22; heterogeneity not applicable; low‐certainty evidence) and 60 seconds after lancing (MD ‐0.02, 95% CI ‐0.79 to 0.75; heterogeneity N/A; low‐certainty evidence). Sucrose vs breastfeeding The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD ‐0.70, 95% CI ‐0.49 to 1.88; I 2 = 94%; very low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD ‐2.60, 95% CI ‐3.06 to ‐2.14; heterogeneity N/A; very low‐certainty evidence). Sucrose vs expressed breast milk The evidence suggests that sucrose may result in little to no difference in PIPP‐R scores compared to expressed breast milk during (MD 0.3, 95% CI ‐0.24 to 0.84; heterogeneity not applicable; low‐certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI ‐0.11 to 0.71; heterogeneity N/A; low‐certainty evidence). The evidence suggests that sucrose probably may result in slightly increased PIPP‐R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD ‐1.80, 95% CI ‐8.47 to 4.87; heterogeneity N/A; very low‐certainty evidence). Sucrose vs laser acupuncture There was no difference in PIPP‐R scores between sucrose and music groups; however, data were reported as medians and IQRs. The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD ‐0.86, 95% CI ‐1.43 to ‐0.29; heterogeneity N/A; very low‐certainty evidence). Sucrose vs facilitated tucking The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD ‐2.27, 95% CI ‐4.66 to 0.12; heterogeneity N/A; very low‐certainty evidence) and during recovery after lancing (MD ‐0.31, 95% CI ‐1.72 to 1.10; heterogeneity N/A; very low‐certainty evidence). Sucrose vs skin‐to‐skin + water (repeated lancing) The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 30 seconds after 1st (MD 0.13, 95% CI ‐0.70 to 0.96); 2nd (MD ‐0.56, 95% CI ‐1.57 to 0.45); or 3rd lancing (MD‐0.15, 95% CI ‐1.26 to 0.96); heterogeneity N/A, low‐certainty evidence for all comparisons. The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 60 seconds after 1st (MD –0.61, 95% CI ‐1.55 to 0.33); 2nd (MD ‐0.12, 95% CI ‐0.99 to 0.75); or 3rd lancing (MD‐0.40, 95% CI ‐1.48 to 0.68); heterogeneity N/A, low‐certainty evidence for all comparisons. Minor adverse events required no intervention. Authors' conclusions Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate‐certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin‐to‐skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing heel lance Key messages ‐ Sucrose, compared to control interventions, probably reduces pain for a single painful event (heel lance). ‐ There were a few minor immediate adverse events, such as gagging, that resolved without intervention. ‐ We need studies that assess the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. ‐ We need to assess how sucrose affects neonates who are extremely preterm, unstable, or ventilated (or a combination of these factors). What is sucrose analgesia? Sucrose (table sugar) is mixed with water in various concentrations (usually 24%) and is given to babies in very small amounts (e.g. a few drops) about two minutes before a painful procedure. Sucrose is also given with other nondrug pain‐relieving interventions such as a pacifier (non‐nutritive sucking ‐ NNS) or when the baby is receiving skin‐to‐skin care. Why is this important for newborn babies who are undergoing heel lance procedures? Babies who are sick or immature, and require a stay in hospital, have several painful procedures per day and multiple painful procedures throughout the hospital stay; for most babies, the majority of painful procedures are heel lances. If untreated, pain has immediate and long‐term consequences that can impact their brain and behavioural development. It is important to minimise the number of painful procedures and the associated pain and suffering. What did we want to find out? We wanted to know how well sucrose worked to relieve pain in newborn babies who are having heel lance procedures while they were in hospital. We also wanted to know whether there were any safety concerns about using sucrose to relieve pain from single painful events such as heel lance. What did we do? We searched for studies that investigated: ‐ Sucrose compared to no treatment or standard care; ‐ Sucrose compared to water, other sweet solutions (e.g. glucose); ‐ Sucrose compared to another nondrug intervention (e.g. NNS); ‐ Whether sucrose was effective in decreasing the amount and severity of pain that babies experienced as assessed by baby’s pain responses (e.g. crying, grimacing, heart rate) and by using standardised infant pain scales. We also wanted to know if sucrose was associated with any unwanted effects in preterm or term babies. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods. What did we find out? We reviewed 55 studies that included a total of 6273 babies. Twenty‐nine studies had full‐term babies only, 22 had preterm babies only, and four had both full‐term and preterm babies. Heel lance was the painful procedure in 50 studies. Five studies investigated a variety of other minor painful procedures in addition to heel lancing. Main results ‐ Sucrose compared to the control treatment probably reduces pain from single heel lances in babies. ‐ Results are uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, and facilitated tucking, in reducing pain scores. ‐ Results are uncertain about the effect of sucrose + NNS compared to NNS, in reducing pain. ‐ Sucrose does not seem to reduce pain from single heel lances compared to glucose, expressed breast milk, and skin‐to‐skin care. ‐ Reported adverse events were minor and resolved without any intervention. What are the limitations of the evidence? We have moderate‐certainty evidence that sucrose likely reduces pain from heel lance. How up‐to‐date is this evidence? This evidence is up‐to‐date as of February 2022. Study funding sources We did not identify any studies that received funding from industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yamada, J, Bueno, M, Santos, L, Haliburton, S, Campbell-Yeo, M, Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD014806", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.757Z" }, { "id": "382e52df-8327-44ee-8713-de8d7fb65ece", "pmid": "", "title": "Ready‐to‐use therapeutic food (RUTF) for home‐based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age", "imported": false, "abstract": "Abstract - Background Management of severe acute malnutrition (SAM) in children comprises two potential phases: stabilisation and rehabilitation. During the initial stabilisation phase, children receive treatment for dehydration, electrolyte imbalances, intercurrent infections and other complications. In the rehabilitation phase (applicable to children presenting with uncomplicated SAM or those with complicated SAM after complications have been resolved), catch‐up growth is the main focus and the recommended energy and protein requirements are much higher. In‐hospital rehabilitation of children with SAM is not always desirable or practical ‐ especially in rural settings ‐ and home‐based care can offer a better solution. Ready‐to‐use therapeutic food (RUTF) is a widely used option for home‐based rehabilitation, but the findings of our previous review were inconclusive. Objectives To assess the effects of home‐based RUTF used during the rehabilitation phase of SAM in children aged between six months and five years on recovery, relapse, mortality and rate of weight gain. Search methods We searched the following databases in October 2018: CENTRAL, MEDLINE, Embase, six other databases and three trials registers. We ran separate searches for cost‐effectiveness studies, contacted researchers and healthcare professionals in the field, and checked bibliographies of included studies and relevant reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs, where children aged between six months and five years with SAM were, during the rehabilitation phase, treated at home with RUTF compared to an alternative dietary approach, or with different regimens and formulations of RUTF compared to each other. We assessed recovery, deterioration or relapse and mortality as primary outcomes; and rate of weight gain, time to recovery, anthropometrical changes, cognitive development and function, adverse outcomes and acceptability as secondary outcomes. Data collection and analysis We screened for eligible studies, extracted data and assessed risk of bias of those included, independently and in duplicate. Where data allowed, we performed a random‐effects meta‐analysis using Review Manager 5, and investigated substantial heterogeneity through subgroup and sensitivity analyses. For the main outcomes, we evaluated the quality of the evidence using GRADE, and presented results in a 'Summary of findings' table per comparison. Main results We included 15 eligible studies (n = 7976; effective sample size = 6630), four of which were cluster trials. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. Six studies received funding or donations from industry whereas eight did not, and one study did not report the funding source. The overall risk of bias was high for six studies, unclear for three studies, and low for six studies. Among the 14 studies that contributed to meta‐analyses, none (n = 5), some (n = 5) or all (n = 4) children were stabilised in hospital prior to commencement of the study. One small study included only children known to be HIV‐infected, another study stratified the analysis for 'recovery' according to HIV status, while the remaining studies included HIV‐uninfected or untested children. Across all studies, the intervention lasted between 8 and 16 weeks. Only five studies followed up children postintervention (maximum of six months), and generally reported on a limited number of outcomes. We found seven studies with 2261 children comparing home‐based RUTF meeting the World Health Organization (WHO) recommendations for nutritional composition (referred to in this review as standard RUTF) with an alternative dietary approach (effective sample size = 1964). RUTF probably improves recovery (risk ratio (RR) 1.33; 95% confidence interval (CI) 1.16 to 1.54; 6 studies, 1852 children; moderate‐quality evidence), and may increase the rate of weight gain slightly (mean difference (MD) 1.12 g/kg/day, 95% CI 0.27 to 1.96; 4 studies, 1450 children; low‐quality evidence), but we do not know the effects on relapse (RR 0.55, 95% CI 0.30 to 1.01; 4 studies, 1505 children; very low‐quality evidence) and mortality (RR 1.05, 95% CI 0.51 to 2.16; 4 studies, 1505 children; very low‐quality evidence). Two quasi‐randomised cluster trials compared standard, home‐based RUTF meeting total daily nutritional requirements with a similar RUTF but given as a supplement to the usual diet (213 children; effective sample size = 210). Meta‐analysis showed that standard RUTF meeting total daily nutritional requirements may improve recovery (RR 1.41, 95% CI 1.19 to 1.68; low‐quality evidence) and reduce relapse (RR 0.11, 95% CI 0.01 to 0.85; low‐quality evidence), but the effects are unknown for mortality (RR 1.36, 95% CI 0.46 to 4.04; very low‐quality evidence) and rate of weight gain (MD 1.21 g/kg/day, 95% CI ‐ 0.74 to 3.16; very low‐quality evidence). Eight studies randomised 5502 children (effective sample size = 4456) and compared standard home‐based RUTF with RUTFs of alternative formulations (e.g. using locally available ingredients, containing less or no milk powder, containing specific fatty acids, or with added pre‐ and probiotics). For recovery, it made little or no difference whether standard or alternative formulation RUTF was used (RR 1.03, 95% CI 0.99 to 1.08; 6 studies, 4188 children; high‐quality evidence). Standard RUTF decreases relapse (RR 0.84, 95% CI 0.72 to 0.98; 6 studies, 4188 children; high‐quality evidence). However, it probably makes little or no difference to mortality (RR 1.00, 95% CI 0.80 to 1.24; 7 studies, 4309 children; moderate‐quality evidence) and may make little or no difference to the rate of weight gain (MD 0.11 g/kg/day, 95% CI −0.32 to 0.54; 6 studies, 3807 children; low‐quality evidence) whether standard or alternative formulation RUTF is used. Authors' conclusions Compared to alternative dietary approaches, standard RUTF probably improves recovery and may increase rate of weight gain slightly, but the effects on relapse and mortality are unknown. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given as a supplement to the usual diet, but the effects on mortality and rate of weight gain are not clear. When comparing RUTFs with different formulations, the current evidence does not favour a particular formulation, except for relapse, which is reduced with standard RUTF. Well‐designed, adequately powered, pragmatic RCTs with standardised outcome measures, stratified by HIV status, and that include diarrhoea as an outcome, are needed. Plain language summary Ready‐to‐use therapeutic food (RUTF) as home‐based treatment for severely malnourished children between six months and five years Background Malnourished children usually look very thin or wasted and they have a high risk of death and illness. Treating severely malnourished children in hospitals is not always desirable or practical in rural settings, and home‐based treatment may be better. Home‐based treatment can be food prepared by a caregiver (such as flour porridge or energy‐ and nutrient‐dense locally available foods), or ready‐to‐use therapeutic food (RUTF) provided by a clinic. RUTF is usually made according to a standard, energy‐rich composition defined by the World Health Organization (WHO). Typically, the ingredients for standard RUTF include milk powder, sugar, peanut butter, vegetable oil, vitamins and minerals; but ingredients vary depending on local availability, cost and acceptability. Benefits of RUTF include a long shelf life without refrigeration and they require no preparation. This is an update of our previous review, where definite conclusions about the effects of RUTF could not be drawn from the four studies that were available at that time. Review question We assessed standard RUTF compared to an alternative dietary approach (e.g. flour porridge or locally available foods) and examined whether smaller amounts and different formulations of RUTF can achieve similar health outcomes in severely malnourished children aged between six months and five years. The main health outcomes that we investigated were recovery from severe malnutrition, deterioration or relapse, death and the rate of weight gain. Included study characteristics We searched databases for studies up to the October 2018, and found 15 studies with 7976 children. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. One small study included only children infected with HIV, another study analysed children with and without HIV separately for the main outcome (recovery), while the other studies included children who were not infected with HIV or who were untested. Overall, we judged six studies to be at high risk of bias, three studies to be at unclear risk of bias, and six studies to be at low risk of bias. (With 'risk of bias', we mean the extent to which the methods used in a study enable it to determine the truth.) All the studies lasted between 8 and 16 weeks. Only five studies followed up children after the study (for a maximum of six months), and generally reported on a limited number of outcomes. Of our 15 included studies, six were linked to funding or donations from industry, one did not report the source of funding, and eight studies reported funding where sponsors did not include industry. Key findings Compared to alternative dietary approaches, standard RUTF probably improves recovery (moderate‐quality evidence) and may increase the rate of weight gain slightly (low‐quality evidence), but the effects on relapse and death are unknown (very low‐quality evidence). With 'quality of evidence' we mean how confident we are that the particular finding represents the true effect. For example, 'very low‐quality' means we are very uncertain about the finding, 'low‐quality evidence' means the future research is very likely to change the finding, 'moderate‐quality evidence' means that future studies may change this finding, and 'high‐quality evidence' means that it is unlikely that future studies will change the finding. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given supplementary to the usual diet (low‐quality evidence), but for death and the rate of weight gain, the effects are not known (very low‐quality evidence). When comparing RUTFs of different formulations, it makes little or no difference for recovery whether a standard or alternative formulation RUTF is used (high‐quality evidence). For relapse, using standard RUTF decreases relapse (high‐quality evidence). It probably makes little or no difference to death (moderate‐quality evidence) and to the rate of weight gain (low‐quality evidence) whether standard or alternative formulation RUTF is used. Well‐designed, randomised controlled trials (experimental studies where participants meeting the inclusion criteria have an equal chance of being allocated to any of the intervention or control groups) in which analyses have been performed separately for children with and without HIV, and that also measure and report on diarrhoea occurrence, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Schoonees, A; Lombard, MJ; Musekiwa, A; Nel, E; Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD009000.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "384e324d-3fcc-4ae2-83b0-714304851248", "pmid": "", "title": "Nitrous oxide‐based techniques versus nitrous oxide‐free techniques for general anaesthesia", "imported": false, "abstract": "Abstract - Background Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise. Objectives To determine if nitrous oxide‐based anaesthesia results in similar outcomes to nitrous oxide‐free anaesthesia in adults undergoing surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites ( http://clinicaltrials.gov/ , http://controlled‐trials.com/ , and http://www.centerwatch.com ). Selection criteria We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol‐based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay. Data collection and analysis Two review authors independently assessed trial quality and extracted the outcome data. We used meta‐analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed‐effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random‐effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Main results We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta‐analyses showed that nitrous oxide‐based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta‐analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide‐based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low. Authors' conclusions Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review. Plain language summary Nitrous oxide (laughing gas)‐based techniques versus nitrous oxide‐free techniques for general anaesthesia Review question We reviewed the evidence about the harmful effects of nitrous oxide on people undergoing general anaesthesia. Background Nitrous oxide is an anaesthetic gas which has been used for more than 160 years for inducing anaesthesia and keeping patients anaesthetized throughout an operation. It is also known as 'laughing gas'. It is a colourless non‐flammable gas with a pleasant, faint sweet odour and taste. Its low cost and low toxicity have made nitrous oxide by far the most commonly used general anaesthetic. However, some studies have reported that adding nitrous oxide may lead to harmful effects. This has led many anaesthetists to question its continued routine use in a variety of operating room settings. We wanted to discover whether using nitrous oxide in general anaesthesia was better or worse than not using nitrous oxide. Study characteristics We examined the evidence available up to 17 October 2014. We included 35 trials involving 13,872 adult participants, all of whom were randomized to either receive nitrous oxide or no nitrous oxide. The trials covered a variety of situations during general anaesthesia. Key results We found that general anaesthesia with nitrous oxide increased the risk of pulmonary atelectasis (i.e. failure of the lungs to expand fully). When we restricted the results to the highest quality studies only, we found evidence that nitrous oxide may potentially increase the risk of pneumonia and severe nausea and vomiting. However, nitrous oxide had no effect on the patients' survival, the incidence of heart attack, stroke, wound infection, the occurrence of blood clots within veins, the length of hospital stay, or the length of intensive care unit stay. Quality of the evidence The evidence related to survival of participants was of moderate quality because we did not have enough data. The evidence related to some harmful effects, such as failure of the lungs to expand fully and heart attack, was of high quality, while for other harmful effects, such as stroke and the occurrence of blood clots within veins, the evidence was of moderate quality. For others, such as pneumonia, severe nausea and vomiting, and wound infection, the evidence was of low quality. The evidence related to the length of time spend in hospital was of moderate quality. Authors conclusions The avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Sun, R; Jia, WQ; Zhang, P; Yang, K; Tian, JH; Ma, B; Liu, Y; Jia, RH; Luo, XF; Kuriyama, A", "articleTypes": [], "doi": "10.1002/14651858.CD008984.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "385b4fcb-3869-4bfb-adab-a2d778f78bcc", "pmid": "", "title": "A Randomised Controlled Trial of a Duodenal Sleeve Bypass Device (EndoBarrier)Compared With Standard Medical Therapy for the Management of Obese Subjects With Type 2 Diabetes", "imported": false, "abstract": "The management of obesity is challenging and obesity surgery is by far the most effective treatment currently available. Recent medical research indicates that it also improves the management of blood glucose levels in people with type 2 diabetes. Obesity surgery carries different risks and benefits and it is important to balance these by choosing the right procedure for each patient. Therefore new effective strategies to prevent and reduce obesity and its complications such as type 2 diabetes mellitus are needed. This study is designed to see whether a new device called the EndoBarrier Gastrointestinal Liner helps patients manage their blood sugar levels and lose weight. It is a randomised, placebo controlled trial which compares the potential of the EndoBarrier device with conventional drug therapy, diet and exercise for obesity related type 2 diabetes, and their effectiveness on metabolic state (HbA1c reduced by 20% and blood pressure below 135/85), weight loss, and quality of life. It will further evaluate whether any other conditions that may be related to obesity could become less severe and collect information about complications to determine the safety of the device. The study will also perform various measurements and tests to understand the underlying mechanism of the device. After an initial screening visit to determine patients eligibility, they will be invited for 14 subsequent visits. Patients will be randomised into either having the EndoBarrier device or standard medical therapy treatment for 12 months followed by another 12 months follow-up period. They will also be routinely seen by specialist dietitian who will provide dietetic support throughout the study.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.250Z" }, { "id": "386d6f77-5d2a-4eec-834e-e2bee73a4dc1", "pmid": "", "title": "Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery", "imported": false, "abstract": "Abstract - Background Postoperative pain may lead to adverse effects on the body, which might result in an increase in morbidity. Its management therefore poses a unique challenge for the clinician. Major shoulder surgery is associated with severe postoperative pain, and different modalities are available to manage such pain, including opioid and non‐opioid analgesics, local anaesthetics infiltrated into and around the shoulder joint and regional anaesthesia. All of these techniques, alone or in combination, have been used to treat the postoperative pain of major shoulder surgery but with varying success. Objectives The objective of this review was to compare the analgesic efficacy of continuous interscalene brachial plexus block (ISBPB) with parenteral opioid analgesia for pain relief after major shoulder surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12), MEDLINE (1950 to December 2012), EMBASE (1980 to December 2012), Web of Science (1954 to December 2012), CINAHL (1982 to December 2012) and bibliographies of published studies. Selection criteria We included randomized controlled trials assessing the effectiveness of continuous ISBPB compared with different forms of parenteral opioid analgesia in relieving pain in adult participants undergoing elective major shoulder surgery. Data collection and analysis Two review authors independently assessed trial quality and extracted outcome data. Main results We included two randomized controlled trials (147 participants). A total of 17 participants were excluded from one trial because of complications related to continuous ISBPB (16) or parenteral opioid analgesia (one). Thus we have information on 130 participants (66 in the continuous ISBPB group and 64 in the parenteral opioid group). The studies were clinically heterogeneous. No meta‐analysis was undertaken. However, results of the two included studies showed better pain relief with continuous ISBPB following major shoulder surgery and a lower incidence of complications when interscalene block is performed under ultrasound guidance rather than without it. Authors' conclusions Because of the small number of studies (two) relevant to the subject and the high risk of bias of the selected studies, no reasonable conclusion can be drawn. Plain language summary Comparison of an upper limb nerve block using local anaesthetic with opioid analgesia for pain relief following major shoulder surgery Pain following surgical procedures can sometimes increase the incidence of complications in the body. It is important to manage this pain effectively. Major shoulder surgery can cause severe pain. Effectively treating this pain will help reduce complications and will promote early mobilization. A wide range of methods are used to treat pain after major shoulder surgery, including administration of opioid (derived from opium) and non‐opioid pain killers and administration of drugs that produce numbness and hence pain relief in and around the shoulder joint or around the nerves supplying the upper limb. We compared the usefulness of a continuous upper limb nerve block performed by injecting local anaesthetic into the neck close to where the nerves originate (interscalene brachial plexus block—ISBPB group) with the administration of opioid pain killers into a vein, into a muscle or under the skin (any route other than by mouth)—the parenteral opioid group. Evidence obtained is current to December 2012. We included two studies involving 147 participants. Seventeen participants were excluded (16 from the ISBPB group and one from the other), leaving 130 participants: 66 in the ISBPB group and 64 in the parenteral opioid group. The studies were of medium to low quality because of issues with study design, and one of the trials was sponsored by a drug company. The severity of pain was assessed by the patient using a numerical scale on which zero was considered as no pain and 10 or 100 as the worst imaginable pain for 72 hours in one study and 48 hours in the other. The severity of postoperative pain was significantly less for the ISBPB group at all time points in one study and at all but one time point in the other study. No concrete conclusions can be drawn because of the small number of studies, which were not of high quality. However, from the available evidence, it can be seen that in one of the trials, the requirement for additional painkiller (piritramide) was significantly higher in the parenteral opioid group, whereas the other trial did not mention this. The incidence of nausea and vomiting was significantly less in the ISBPB group when compared with the parenteral opioid group. Complications related to ISBPB were virtually eliminated when ultrasound was used to perform ISBPB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ullah, H, Samad, K, Khan, FA", "articleTypes": [], "doi": "10.1002/14651858.CD007080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.071Z" }, { "id": "386d966b-0f76-45ab-9ac7-1b3fe7c4083f", "pmid": "", "title": "Pharmacological interventions for self‐harm in adults", "imported": false, "abstract": "Abstract - Background Self‐harm (SH; intentional self‐poisoning or self‐injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm. Objectives To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta‐analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients. Search methods For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co‐ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013. Selection criteria We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services. Data collection and analysis We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta‐analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow‐up. For this analysis, we pooled data using a random‐effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach. Main results We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low‐dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported. Authors' conclusions Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment. Plain language summary Drugs and natural products for self‐harm in adults We have reviewed the international literature regarding pharmacological (drug) and natural product (dietary supplementation) treatment trials in this field. A total of seven trials meeting our inclusion criteria were identified. There is little evidence of beneficial effects of either pharmacological or natural product treatments. However, few trials have been conducted and those that have are small, meaning that possible beneficial effects of some therapies cannot be ruled out. Why is this review important? Self‐harm (SH), which includes intentional self‐poisoning/overdose and self‐injury, is a major problem in many countries and is strongly linked to suicide. It is therefore important that effective treatments for SH patients are developed. Whilst there has been an increase in the use of psychosocial interventions for SH in adults (which is the focus of a separate review), drug treatments are frequently used in clinical practice. It is therefore important to assess the evidence for their effectiveness. Who will be interested in this review? Clinicians working with patients who engage in SH, patients themselves, and their relatives. What questions does this review aim to answer? This review is an update of a previous Cochrane review from 1999 which found little evidence of beneficial effects of drug treatments on repetition of SH apart from for flupenthixol. This update aims to further evaluate the evidence for effectiveness of drugs and natural products for patients with SH with a broader range of outcomes. Which studies were included in the review? To be included in the review, studies had to be randomised controlled trials of drug treatments for adults who had recently engaged in SH. What does the evidence from the review tell us? There is currently no clear evidence for the effectiveness of antidepressants, antipsychotics, mood stabilisers, or natural products in preventing repetition of SH. What should happen next? We recommend further trials of drugs for SH patients, possibly in combination with psychological treatment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hawton, K, Witt, KG, Taylor Salisbury, TL, Arensman, E, Gunnell, D, Hazell, P, Townsend, E, van Heeringen, K", "articleTypes": [], "doi": "10.1002/14651858.CD011777", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.116Z" }, { "id": "387f09a5-7502-4baa-a995-fe16a1c51c37", "pmid": "", "title": "Echinacea for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Echinacea plant preparations (family Asteraceae ) are widely used in Europe and North America for common colds. Most consumers and physicians are not aware that products available under the term Echinacea differ appreciably in their composition, mainly due to the use of variable plant material, extraction methods and the addition of other components. Objectives To assess whether there is evidence that Echinacea preparations are effective and safe compared to placebo in the prevention and treatment of the common cold. Search methods We searched CENTRAL 2013, Issue 5, MEDLINE (1946 to May week 5, 2013), EMBASE (1991 to June 2013), CINAHL (1981 to June 2013), AMED (1985 to February 2012), LILACS (1981 to June 2013), Web of Science (1955 to June 2013), CAMBASE (no time limits), the Centre for Complementary Medicine Research (1988 to September 2007), WHO ICTRP and clinicaltrials.gov (last searched 5 June 2013), screened references and asked experts in the field about published and unpublished studies. Selection criteria Randomized controlled trials (RCTs) comparing mono‐preparations of Echinacea with placebo. Data collection and analysis At least two review authors independently assessed eligibility and trial quality and extracted data. The primary efficacy outcome was the number of individuals with at least one cold in prevention trials and the duration of colds in treatment trials. For all included trials the primary safety and acceptability outcome was the number of participants dropping out due to adverse events. We assessed trial quality using the Cochrane 'Risk of bias' tool. Main results Twenty‐four double‐blind trials with 4631 participants including a total of 33 comparisons of Echinacea preparations and placebo met the inclusion criteria. A variety of different Echinacea preparations based on different species and parts of plant were used. Evidence from seven trials was available for preparations based on the aerial parts of Echinacea purpurea. Ten trials were considered to have a low risk of bias, six to have an unclear risk of bias and eight to have a high risk of bias. Ten trials with 13 comparisons investigated prevention and 15 trials with 20 comparisons investigated treatment of colds (one trial addressed both prevention and treatment). Due to the strong clinical heterogeneity of the studies we refrained from pooling for the main analysis. None of the 12 prevention comparisons reporting the number of patients with at least one cold episode found a statistically significant difference. However a post hoc pooling of their results, suggests a relative risk reduction of 10% to 20%. Of the six treatment trials reporting data on the duration of colds, only two showed a significant effect of Echinacea over placebo. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. Authors' conclusions Echinacea products have not here been shown to provide benefits for treating colds, although, it is possible there is a weak benefit from some Echinacea products : the results of individual prophylaxis trials consistently show positive (if non‐significant) trends, although potential effects are of questionable clinical relevance. Plain language summary Echinacea for preventing and treating the common cold Preparations of the plant Echinacea are widely used in some European countries and in North America for common colds. Echinacea preparations available on the market differ greatly as different types (species) and parts (herb, root or both) of the plant are used, different manufacturing methods (drying, alcoholic extraction or pressing out the juice from fresh plants) are used and sometimes also other herbs are added. We reviewed 24 controlled clinical trials with 4631 participants investigating the effectiveness of several different Echinacea preparations for preventing and treating common colds or induced rhinovirus infections. Our review shows that a variety of products prepared from different Echinacea species, different plant parts and in a different form have been compared to placebo in randomized trials. Due to the significant differences in the preparations tested, it was difficult to draw strong conclusions. Five trials were rated as having a low risk of bias in all five categories of the Cochrane 'Risk of bias' tool. Five more trials were rated as low risk of bias, having an unclear risk of bias in only one category. Eight trials were rated as having a high risk of bias in at least one category and the remaining six as having an unclear risk of bias. The majority of trials investigated whether taking Echinacea preparations after the onset of cold symptoms shortens the duration, compared with placebo. Although it seems possible that some Echinacea products are more effective than a placebo for treating colds, the overall evidence for clinically relevant treatment effects is weak. In general, trials investigating Echinacea for preventing colds did not show statistically significant reductions in illness occurrence. However, nearly all prevention trials pointed in the direction of small preventive effects. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. The evidence is current to July 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Karsch‐Völk, M; Barrett, B; Kiefer, D; Bauer, R; Ardjomand‐Woelkart, K; Linde, K", "articleTypes": [], "doi": "10.1002/14651858.CD000530.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "388fbefc-bbdf-4954-adeb-2e0f9b32f60b", "pmid": "", "title": "Endometrial preparation for women undergoing embryo transfer with frozen embryos or embryos derived from donor oocytes", "imported": false, "abstract": "Abstract - Background A frozen embryo transfer (FET) cycle is when one or more embryos (frozen during a previous treatment cycle) are thawed and transferred to the uterus. Some women undergo fresh embryo transfer (ET) cycles with embryos derived from donated oocytes. In both situations, the endometrium is primed with oestrogen and progestogen in different doses and routes of administration. Objectives To evaluate the most effective endometrial preparation for women undergoing transfer with frozen embryos or embryos from donor oocytes with regard to the subsequent live birth rate (LBR). Search methods The Cochrane Gynaecology and Fertility Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, LILACS, trials registers and abstracts of reproductive societies' meetings were searched in June 2020 together with reference checking and contact with study authors and experts in the field to identify additional studies. Selection criteria Randomised controlled trials (RCTs) evaluating endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. Data collection and analysis We used standard methodological procedures recommended by Cochrane. We analysed all available interventions versus placebo, no treatment, or between each other. The primary review outcome was live birth rate. Secondary outcomes were clinical and multiple pregnancy, miscarriage, cycle cancellation, endometrial thickness and adverse effects. Main results Thirty‐one RCTs (5426 women) were included. Evidence was moderate to very low‐quality: the main limitations were serious risk of bias due to poor reporting of methods, and serious imprecision. Stimulated versus programmed cycle We are uncertain whether a letrozole‐stimulated cycle compared to a programmed cycle, for endometrial preparation, improves LBR (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.49 to 3.26; 100 participants; one study; very low‐quality evidence). Stimulating with follicle stimulating hormone (FSH), letrozole or clomiphene citrate may improve clinical pregnancy rate (CPR) (OR 1.63, 95% CI 1.12 to 2.38; 656 participants; five studies; I 2 = 11%; low‐quality evidence). We are uncertain if they reduce miscarriage rate (MR) (OR 0.79, 95% CI 0.36 to 1.71; 355 participants; three studies; I 2 = 0%; very low‐quality evidence). Endometrial thickness (ET) may be reduced with clomiphene citrate (mean difference(MD) ‐1.04, 95% CI ‐1.59 to ‐0.49; 92 participants; one study; low‐quality evidence). Other outcomes were not reported. Natural versus programmed cycle We are uncertain of the effect from a natural versus programmed cycle for LBR (OR 0.97, 95% CI 0.74 to 1.28; 1285 participants; four studies; I 2 = 0%; very low‐quality evidence) and CPR (OR 0.79, 95% CI 0.62 to 1.01; 1249 participants; five studies; I 2 = 60%; very low‐quality evidence), while a natural cycle probably reduces the cycle cancellation rate (CCR) (OR 0.60, 95% CI 0.44 to 0.82; 734 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and ET. No study reported other outcomes. Transdermal versus oral oestrogens From low‐quality evidence we are uncertain of the effect transdermal compared to oral oestrogens has on CPR (OR 0.86, 95% CI 0.59 to 1.25; 504 participants; three studies; I 2 = 58%) or MR (OR 0.55, 95% CI 0.27 to 1.09; 414 participants; two studies; I 2 = 0%). Other outcomes were not reported. Day of starting administration of progestogen When doing a fresh ET using donated oocytes in a synchronised cycle starting progestogen on the day of oocyte pick‐up (OPU) or the day after OPU, in comparison with recipients that start progestogen the day prior to OPU, probably increases the CPR (OR 1.87, 95% CI 1.13 to 3.08; 282 participants; one study, moderate‐quality evidence). We are uncertain of the effect on multiple pregnancy rate (MPR) or MR. It probably reduces the CCR (OR 0.28, 95% CI 0.11 to 0.74; 282 participants; one study; moderate‐quality evidence). No study reported other outcomes. Gonadotropin‐releasing hormone (GnRH) agonist versus control A cycle with GnRH agonist compared to without may improve LBR (OR 2.62, 95% CI 1.19 to 5.78; 234 participants; one study; low‐quality evidence). From low‐quality evidence we are uncertain of the effect on CPR (OR 1.08, 95% CI 0.82 to 1.43; 1289 participants; eight studies; I 2 = 20%), MR (OR 0.85, 95% CI 0.36 to 2.00; 828 participants; four studies; I 2 = 0%), CCR (OR 0.49, 95% CI 0.21 to 1.17; 530 participants; two studies; I 2 = 0%) and ET (MD ‐0.08, 95% CI ‐0.33 to 0.16; 697 participants; four studies; I 2 = 4%). No study reported other outcomes. Among different GnRH agonists From very low‐quality evidence we are uncertain if cycles among different GnRH agonists improves CPR or MR. No study reported other outcomes. GnRH agonists versus GnRH antagonists GnRH antagonists compared to agonists probably improves CPR (OR 0.62, 95% CI 0.42 to 0.90; 473 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and MPR. No study reported other outcomes. Aspirin versus control From very low‐quality evidence we are uncertain whether a cycle with aspirin versus without improves LBR, CPR, or ET. Steroids versus control From very low‐quality evidence we are uncertain whether a cycle with steroids compared to without improves LBR, CPR or MR. No study reported other outcomes. Authors' conclusions There is insufficient evidence on the use of any particular intervention for endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. In frozen embryo transfers, low‐quality evidence showed that clinical pregnancy rates may be improved in a stimulated cycle compared to a programmed one, and we are uncertain of the effect when comparing a programmed cycle to a natural cycle. Cycle cancellation rates are probably reduced in a natural cycle. Although administering a GnRH agonist, compared to without, may improve live birth rates, clinical pregnancy rates will probably be improved in a GnRH antagonist cycle over an agonist cycle. In fresh synchronised oocyte donor cycles, the clinical pregnancy rate is probably improved and cycle cancellation rates are probably reduced when starting progestogen the day of or day after donor oocyte retrieval. Adequately powered studies are needed to evaluate each treatment more accurately. Plain language summary Endometrial preparation for egg donor recipients or for frozen embryo transfers Review question What is the most effective method for endometrial preparation in women undergoing embryo transfers with frozen embryos or embryos derived from donor oocytes? Background Couples undergo infertility treatments due to male factor, female factors or unexplained infertility. After an unsuccessful fresh embryo transfer cycle, a frozen‐thawed embryo transfer can be performed when frozen embryos are available. Adequate hormonal preparation of the endometrium is of utmost importance for both egg donor and frozen embryo replacement cycles to provide the optimal chances of pregnancy. Many drugs and various modes of administration have been tried by several investigators in order to optimise implantation rates and consequently improve the success rates of the embryo transfer procedures: stimulated cycles (to generate endogenous oestradiol), programmed cycles (administering exogenous oestradiol) or natural cycles (allowing the ovaries to produce oestradiol without stimulation) are some of the options; avoiding spontaneous ovulation with gonadotropin‐releasing hormone (GnRH) agonists and antagonists could have some impact; or using some other drugs such as aspirin or steroids that could potentially enhance the endometrial receptivity were also evaluated. Study characteristics We found 31 randomised controlled trials comparing different interventions such as the dose and route of administration of oestrogens and progestogen, the use of drugs that stop the patient from ovulating prematurely (GnRH agonists), and the use of other medications to improve the endometrium in a total of 5426 women. The evidence is current to June 2020. Key results We are uncertain whether a stimulated cycle (with letrozole) compared to a programmed cycle, for endometrial preparation, improves live birth. The evidence suggests that if the chance of live birth following a programmed cycle is assumed to be 24%, the chance following a stimulated cycle would be between 13% and 51%. We are also uncertain of the impact on miscarriage rate and endometrial thickness. A stimulated cycle may improve clinical pregnancy rate. Data were lacking on multiple pregnancy, cycle cancellation and other adverse effects. We are uncertain whether a natural cycle improves the live birth rate, pregnancy rate, miscarriage rate and endometrial thickness in comparison with a programmed cycle. Data were lacking for all other outcomes. We are uncertain if transdermal (delivered via the skin) oestrogens compared with oral (by mouth) oestrogens improve clinical pregnancy rate and miscarriage rate. Data were lacking for all other outcomes in this comparison. Starting progestogen on the day of the donor oocyte retrieval or the day after probably increases the clinical pregnancy rate and probably reduces the cycle cancellation rate. We are uncertain if it reduces the miscarriage rate. Data were lacking for all other outcomes. A cycle with GnRH agonist compared to without may improve live birth rate. We are uncertain of the effect of a GnRH cycle compared to no GnRH for the outcomes of clinical pregnancy rate, miscarriage rate, and endometrial thickness. No study reported on the other outcomes for this comparison. We are uncertain if any GnRH agonist is better than other: a cycle with daily leuprolide or with deposit tryptorelin improves clinical pregnancy rate, or if daily acetate leuprolide or daily nafarelin reduces the miscarriage rate. Other outcomes were not reported. GnRH antagonists compared to agonists probably improve clinical pregnancy rate. We are uncertain of the effect on miscarriage rate and multiple pregnancy rate. No study reported the other outcomes. We are uncertain whether a cycle with aspirin compared to a cycle without improves live birth, clinical pregnancy rate or endometrial thickness. Data were lacking for all other outcomes. We are also uncertain whether a cycle with steroids compared to a cycle without steroids improves live birth rate, clinical pregnancy rate or miscarriage rate. No study reported on the other outcomes. Quality of the evidence The evidence was of moderate to very low‐quality. The main limitations in the evidence were poor reporting of study methods, and lack of precision in the findings for live birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Glujovsky, D; Pesce, R; Sueldo, C; Quinteiro Retamar, AM; Hart, RJ; Ciapponi, A", "articleTypes": [], "doi": "10.1002/14651858.CD006359.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "389da5e1-b5ec-4a3e-80b4-a8240fddf9d6", "pmid": "", "title": "Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection", "imported": false, "abstract": "Abstract - Background Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted infections. The majority of women with genital herpes will have a recurrence during pregnancy. Transmission of the virus from mother to fetus typically occurs by direct contact with virus in the genital tract during birth. Objectives To assess the effectiveness of antenatal antiviral prophylaxis for recurrent genital herpes on neonatal herpes and maternal recurrences at delivery. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2006, Issue 4), MEDLINE (January 1966 to February 2007) and EMBASE (January 1974 to February 2007; handsearched conference proceedings; reviewed bibliographies of all relevant articles for further references; and contacted experts in the field. Selection criteria Randomized controlled trials which assessed the effectiveness of antivirals compared to placebo or no therapy, on neonatal herpes and maternal disease endpoints among pregnant women with genital herpes. Data collection and analysis Two authors independently applied study selection criteria and extracted data. Main results Seven randomized controlled trials (1249 participants) which met our inclusion criteria compared acyclovir to placebo or no treatment (five trials) and valacyclovir to placebo (two trials). The effect of antepartum antiviral prophylaxis on neonatal herpes could not be estimated. There were no cases of symptomatic neonatal herpes in the included studies in either the treatment or placebo groups. Women who received antiviral prophylaxis were significantly less likely to have a recurrence of genital herpes at delivery (relative risk (RR) 0.28, 95% confidence interval (CI) 0.18 to 0.43, I 2 = 0%). Women who received antiviral prophylaxis were also significantly less likely to have a cesarean delivery for genital herpes (RR 0.30, 95% CI 0.20 to 0.45, I 2 = 27.3%). Women who received antiviral prophylaxis were significantly less likely to have HSV detected at delivery (RR 0.14, 95% CI 0.05 to 0.39, I 2 = 0%). Authors' conclusions Women with recurrent genital herpes simplex virus should be informed that the risk of neonatal herpes is low. There is insufficient evidence to determine if antiviral prophylaxis reduces the incidence of neonatal herpes. Antenatal antiviral prophylaxis reduces viral shedding and recurrences at delivery and reduces the need for cesarean delivery for genital herpes. Limited information exists regarding the neonatal safety of prophylaxis. The risks, benefits, and alternatives to antenatal prophylaxis should be discussed with women who have a history and prophylaxis initiated for women who desire intervention. Plain language summary Use of antiviral drugs in late pregnancy for reducing the recurrence of genital herpes at labor and birth and reducing the risk of newborn HSV infection The incidence of herpes, a sexually transmitted disease, varies across the world. Among pregnant women with herpes, nearly 75% can expect at least one flare‐up during their pregnancy. Transmission of the virus from mother to baby typically occurs by direct contact with the virus during birth. It is often recommended that a cesarean should be offered to women with active lesions to reduce the risk of transmission to the baby. In addition, several antiviral agents are available for use both for therapy and for preventing a flare‐up. These antiviral drugs include acyclovir, penciclovir, valacyclovir, and famciclovir. The review assessed whether antiviral drugs given to pregnant women with herpes before a recurrence might be effective in reducing transmission to the baby. Seven studies were identified involving 1249 women. Giving antiviral drugs reduces viral shedding and recurrences at labor and birth. They also reduced the use of cesarean, but there is no evidence of reduction in neonatal herpes. Women should also be informed that the risk of the baby getting herpes during birth is low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Hollier, LM; Wendel, GD", "articleTypes": [], "doi": "10.1002/14651858.CD004946.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "38cf1af1-b962-4b2c-b04f-f910e69a98bd", "pmid": "", "title": "Intranasal fentanyl for the management of acute pain in children", "imported": false, "abstract": "Abstract - Background Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula. Objectives We identified and evaluated all randomized controlled trials (RCTs) and quasi‐randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of \"rescue analgesia,\" patient/parental satisfaction and patient mortality. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014). Selection criteria We included RCTs comparing INF versus any other pharmacological/non‐pharmacological intervention for the treatment of children in acute pain (aged < 18 years). Data collection and analysis Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions. Main results Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a “bad taste” and vomiting with INF. Overall the risk of bias in all studies was considered low. Authors' conclusions INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non‐inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause. Plain language summary Intranasal fentanyl for the treatment of children in acute pain Background Pain is the most common reason why patients are seen in emergency departments (EDs). The challenging nature of treating children in acute severe pain is reflected in the medical literature by poor pain management in this population. We reviewed evidence on the effect of intranasal fentanyl (INF) (a strong pain relief drug, similar to morphine) compared with any other pain‐relieving technique for treatment of children in acute severe pain. Study characteristics We included studies with children (younger than 18 years of age) suffering from acute severe pain as a result of injury or medical illness. The target intervention was INF administered for pain relief compared with any other drug intervention for pain relief (e.g. intravenous morphine) or non‐drug intervention (e.g. limb splinting, wound dressing) provided in the emergency setting. The evidence is current to January 2014. Key results We identified three studies that included 313 children with acute severe pain resulting from broken bones of the upper and lower limbs. These trials compared INF versus morphine administered by a needle into a muscle (intramuscular morphine) or via a drip into a vein (intravenous morphine), as well as standard concentration INF versus high concentration INF. The collective study population in these trials consisted of children three to 15 years of age. Males accounted for approximately two‐thirds of the overall study population. The review concluded that INF may be an effective analgesic for the treatment of children in acute moderate to severe pain, and its administration appears to cause minimal distress to children; however, the evidence is insufficient to permit judgement of the effects of INF compared with intramuscular or intravenous morphine. No serious adverse events (e.g. opiate toxicity, death) were reported. Limitations Limitations of this review include the following: Few studies (three) were eligible for inclusion; no study examined the use of INF in children younger than three years of age; no study included children with pain resulting from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Murphy, A; O'Sullivan, R; Wakai, A; Grant, TS; Barrett, MJ; Cronin, J; McCoy, SC; Hom, J; Kandamany, N", "articleTypes": [], "doi": "10.1002/14651858.CD009942.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "38d0308b-b93b-4f04-a838-b8bdd7841f92", "pmid": "", "title": "Cannabinoids for Tourette's Syndrome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Curtis, A, Clarke, CE, Rickards, HE", "articleTypes": [], "doi": "10.1002/14651858.CD006565.pub2 AB - Abstract - Background Gilles de la Tourette Syndrome (GTS) is a developmental neuropsychiatric disorder characterised by the presence of chronic motor and phonic tics. Drugs currently used in the treatment of GTS either lack efficacy or are associated with intolerable side effects. There is some anecdotal and experimental evidence that cannabinoids may be effective in treating tics and compulsive behaviour in patients with GTS. There are currently no systematic Cochrane reviews of treatments used in GTS. There is one other Cochrane review being undertaken at present, on the use of fluoxetine for tics in GTS. Objectives To evaluate the efficacy and safety of cannabinoids as compared to placebo or other drugs in treating tics, premonitory urges and obsessive compulsive symptoms (OCS), in patients with GTS. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (in The Cochrane Library Issue 4 2008) , MEDLINE (January 1996 to date), EMBASE (January 1974 to date), PsycINFO (January 1887 to date), CINAHL (January 1982 to date), AMED (January 1985 to date), British Nursing Index (January 1994 to date) and DH DATA (January 1994 to date). 
 
 We also searched the reference lists of located trials and review articles for further information. Selection criteria We included randomised controlled trials (RCTs) comparing any cannabinoid preparation with placebo or other drugs used in the treatment of tics and OCS in patients with GTS. Data collection and analysis Two authors abstracted data independently and settled any differences by discussion. Main results Only two trials were found that met the inclusion criteria. Both compared a cannabinoid, delta‐9‐Tetrahydrocannabinol (Δ 9 THC), either as monotherapy or as adjuvant therapy, with placebo. One was a double blind, single dose crossover trial and the other was a double blind, parallel group study. A total of 28 different patients were studied. Although both trials reported a positive effect from Δ 9 THC, the improvements in tic frequency and severity were small and were only detected by some of the outcome measures. Authors' conclusions Not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome. Plain language summary Cannabinoids for Tourette syndrome Cannabinoid medication might be useful in the treatment of the symptoms in patients with Tourette's syndrome. At the present time only two relevant studies have been conducted. Both studies used tetrahydrocannabinol (Δ 9 THC). In both studies Δ 9 THC was associated with tic reduction. However the sample size was small and a large number of multiple comparisons were made . There were only 28 participants in total, since eight participants took part in both studies. Possibly the patients who derived the greatest benefit and experienced the least adverse effects would be the most inclined to participate in further studies. There were a high number of drop outs/exclusions in the six week study and it is unclear whether intention to treat analysis (ITT) was performed. The results that are reported are analyses done on the patients who remained in the study on the study medication at the correct dose. In reality, patients do opt not to continue treatment if there is limited efficacy or unpalatable side effects. This introduces attrition bias. Whilst there were some significant results, the authors themselves accept that very few of these results are significant if a Bonferroni correction is performed. It is possible that cannabinoid medication has a beneficial effect which is too weak to be detected using ITT and such a small sample size. There is some weak evidence that cannabinoid medication may have an effect on obsessive compulsive behaviour but the measure used was an addition to the TSSL which has not been validated.There were no data on the effect of Δ 9 THC on quality of life.There is not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.735Z" }, { "id": "38d0eca3-dc5b-4bf4-b6b2-3010a48d12cd", "pmid": "", "title": "Childhood adversity and 5-HTTLPR across mental health outcomes: A transdiagnostic meta-analysis", "imported": false, "abstract": "Background Childhood maltreatment is associated with increased risk for various psychiatric disorders, although individual responses to early adversity vary. The serotonin transporter-linked polymorphic region (5-HTTLPR) has been examined as a potential moderator of sensitivity to environmental stress, but findings across studies have been inconsistent. Objective This meta-analysis examined whether 5-HTTLPR polymorphisms moderate the association between childhood adversity and clinically diagnosed psychiatric disorders. Participants and settings Fourteen studies (N = 3479) were included, representing community, population-based, and clinical samples from multiple regions. Childhood adversity was assessed using validated interviews, questionnaires, or official electronic records. Methods Systematic searches of eight databases (last updated 3 December 2025) identified studies reporting 5-HTTLPR genotype, childhood adversity, and psychiatric diagnoses. Ratio-of-odds-ratios (ROR) quantifies differences in adversity effects between S-allele carriers and LL homozygotes. Multilevel random-effects models generated pooled estimates. Sensitivity, moderator, and publication-bias analyses were performed. Study quality was assessed using the Newcastle–Ottawa Scale, and certainty of evidence using GRADE. Results Pooled analyses indicated no statistically significant interaction between childhood adversity and 5-HTTLPR genotype (ROR = 1.11, 95% CI 0.89–1.37). Analyses restricted to SS-only or SL-only groups and sexual abuse-specific subgroups produced similar results. Heterogeneity was moderate, and small-study effects were borderline. Moderator analyses did not identify consistent influences of diagnosis or ancestry. Conclusion Across available studies, evidence for an interaction between childhood adversity and 5-HTTLPR genotype was limited. Unlike previous meta-analyses that focused primarily on symptom-level or trait-based measures, the present study evaluates clinically diagnosed outcomes, offering evidence that 5-HTTLPR is unlikely to represent a robust moderator of adversity effects. These findings may suggest that, within current research parameters, 5-HTTLPR does not show a consistent moderating role in clinically diagnosed psychiatric outcomes.", "journal": "Child Abuse & Neglect", "year": "2026", "authors": "Shivam, Vishnu", "articleTypes": [], "doi": "https://doi.org/10.1016/j.chiabu.2026.107901", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:16.478Z" }, { "id": "38d924c6-fdc8-4e51-a68a-062fdc3dbe9e", "pmid": "", "title": "Chelation therapy for atherosclerotic cardiovascular disease", "imported": false, "abstract": "Abstract - Background Chelation therapy is promoted and practiced around the world as a form of alternative medicine in the treatment of atherosclerotic cardiovascular disease. It has been suggested as a safe, relatively inexpensive, non‐surgical method of restoring blood flow in atherosclerotic vessels. However, there is currently limited high‐quality, adequately‐powered research informing evidence‐based medicine on the topic, specifically regarding clinical outcomes. Due to this limited evidence, the benefit of chelation therapy remains controversial at present. This is an update of a review first published in 2002. Objectives To assess the effects of ethylene diamine tetra‐acetic acid (EDTA) chelation therapy versus placebo or no treatment on clinical outcomes among people with atherosclerotic cardiovascular disease. Search methods For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 6 August 2019. We searched the bibliographies of the studies retrieved by the literature searches for further trials. Selection criteria We included studies if they were randomised controlled trials of EDTA chelation therapy versus placebo or no treatment in participants with atherosclerotic cardiovascular disease. The main outcome measures we considered include all‐cause or cause‐specific mortality, non‐fatal cardiovascular events, direct or indirect measurement of disease severity, and subjective measures of improvement or adverse events. Data collection and analysis Two review authors independently extracted data and assessed trial quality using standard Cochrane procedures. A third author considered any unresolved issues, and we discussed any discrepancies until a consensus was reached. We contacted study authors for additional information. Main results We included five studies with a total of 1993 randomised participants. Three studies enrolled participants with peripheral vascular disease and two studies included participants with coronary artery disease, one of which specifically recruited people who had had a myocardial infarction. The number of participants in each study varied widely (from 10 to 1708 participants), but all studies compared EDTA chelation to a placebo. Risk of bias for the included studies was generally moderate to low, but one study had high risk of bias because the study investigators broke their randomisation code halfway through the study and rolled the placebo participants over to active treatment. Certainty of the evidence, as assessed by GRADE, was generally low to very low, which was mostly due to a paucity of data in each outcome's meta‐analysis. This limited our ability to draw any strong conclusions. We also had concerns about one study's risk of bias regarding blinding and outcome assessment that may have biased the results. Two studies with coronary artery disease participants reported no evidence of a difference in all‐cause mortality between chelation therapy and placebo (risk ratio (RR) 0.97, 95% CI 0.73 to 1.28; 1792 participants; low‐certainty). One study with coronary artery disease participants reported no evidence of a difference in coronary heart disease deaths between chelation therapy and placebo (RR 1.02, 95% CI 0.70 to 1.48; 1708 participants; very low‐certainty). Two studies with coronary artery disease participants reported no evidence of a difference in myocardial infarction (RR 0.81, 95% CI 0.57 to 1.14; 1792 participants; moderate‐certainty), angina (RR 0.95, 95% CI 0.55 to 1.67; 1792 participants; very low‐certainty), and coronary revascularisation (RR 0.46, 95% CI 0.07 to 3.25; 1792 participants). Two studies (one with coronary artery disease participants and one with peripheral vascular disease participants) reported no evidence of a difference in stroke (RR 0.88, 95% CI 0.40 to 1.92; 1867 participants; low‐certainty). Ankle‐brachial pressure index (ABPI; also known as ankle brachial index) was measured in three studies, all including participants with peripheral vascular disease; two studies found no evidence of a difference in the treatment groups after three months after treatment (mean difference (MD) 0.02, 95% CI ‐0.03 to 0.06; 181 participants; low‐certainty). A third study reported an improvement in ABPI in the EDTA chelation group, but this study was at high risk of bias. Meta‐analysis of maximum and pain‐free walking distances three months after treatment included participants with peripheral vascular disease and showed no evidence of a difference between the treatment groups (MD ‐31.46, 95% CI ‐87.63 to 24.71; 165 participants; 2 studies; low‐certainty). Quality of life outcomes were reported by two studies that included participants with coronary artery disease, but we were unable to pool the data due to different methods of reporting and varied criteria. However, there did not appear to be any major differences between the treatment groups. None of the included studies reported on vascular deaths. Overall, there was no evidence of major or minor adverse events associated with EDTA chelation treatment. Authors' conclusions There is currently insufficient evidence to determine the effectiveness or ineffectiveness of chelation therapy in improving clinical outcomes of people with atherosclerotic cardiovascular disease. More high‐quality, randomised controlled trials are needed that assess the effects of chelation therapy on longevity and quality of life among people with atherosclerotic cardiovascular disease. Plain language summary Chelation therapy for atherosclerotic cardiovascular (heart and circulation) disease Background Atherosclerosis is caused by fatty deposits that cause a narrowing of people's arteries and restrict blood flow. People with blocked arteries are more likely to have strokes, heart attacks, and narrow blood vessels in their feet. Chelation therapy involves infusions into the bloodstream of substances believed to remove metals from the blood. This treatment is offered to people with atherosclerotic cardiovascular disease as a way of breaking down the blockages in their blood vessels. Chelation therapy is practiced in several places around the world as an alternative form of medicine, but there is currently a lack of knowledge surrounding this treatment. More information is needed to understand if this treatment should be more widely recommended. Key results This review included evidence from five studies with a total of 1993 participants (current until August 2019). Three studies enrolled participants with peripheral vascular disease, and two of the studies included participants with coronary artery disease, one of which specifically recruited people who had had a heart attack. All five studies compared chelation therapy with no treatment or placebo. Only two of the studies (both of which included participants with coronary artery disease) reported death from any cause, and these reported no difference in overall deaths between those that received chelation therapy and those who did not. Ony one study (in people with coronary artery disease) reported cardiovascular death, and this study found no difference between in risk between those who had chelation therapy and those who did not. Two studies of people with coronary artery disease reported rates of heart attack and angina, and found no difference in the risk of these between participants who had chelation treatment and those who did not. Similarly, two studies (one in people with coronary artery disease and one in people with peripheral vascular disease) reported the chance of having a stroke, and found no clear difference in the chance of this between people who did or did not received chelation treatment. Two studies in people with peripheral vascular disease used an indirect measure of blood flow known as the ankle‐brachial pressure index (ABPI), or ankle brachial index. These studies did not show any differences in this measure between people who received chelation therapy for three or six months and those who did not get the treatment. There was also no clear differences in the distance participants could walk. We could not combine specific measures of quality of life in a single analysis. Looking at the two studies in people with coronary artery disease that reported this outcome, there was no difference in the quality of life reported by people who received chelation therapy and those who did not get the treatment. Two studies reported information about adverse events, but we could not combine this in a single analysis because they reported them in different ways and the events were different. However, the people who had chelation therapy did not appear to have any increase in either minor or major adverse events, compared with people who did not have the therapy. Certainty of the evidence We considered most of the data we found to be of low certainty, mostly because there were very few studies that provided data. Even though we included five studies, not all of them reported on each outcome. There is currently not enough evidence about the effects of chelation therapy on blockages in the blood vessels of people with atherosclerotic cardiovascular (heart and circulation) disease. Conclusions Overall, this review did not find any clear differences between people treated with chelation and people given the control, for the outcomes we evaluated. None of the outcomes included more than two studies, therefore it is difficult at this time to determine if these are true findings or just because there is not enough data. Further high‐quality trials that focus on clinical outcomes are necessary.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Villarruz-Sulit, MVanessa; Forster, R; Dans, AL; Tan, FN; Sulit, DV", "articleTypes": [], "doi": "10.1002/14651858.CD002785.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "38dd42b2-3924-4f74-ba02-fc6a70f59c45", "pmid": "", "title": "Drugs for the acute treatment of migraine in children and adolescents", "imported": false, "abstract": "Abstract - Background Numerous medications are available for the acute treatment of migraine in adults, and some have now been approved for use in children and adolescents in the ambulatory setting. A systematic review of acute treatment of migraine medication trials in children and adolescents will help clinicians make evidence‐informed management choices. Objectives To assess the effects of pharmacological interventions by any route of administration versus placebo for migraine in children and adolescents 17 years of age or less. For the purposes of this review, children were defined as under 12 years of age and adolescents 12 to 17 years of age. Search methods We searched seven bibliographic databases and four clinical trial registers as well as gray literature for studies through February 2016. Selection criteria We included prospective randomized controlled clinical trials of children and adolescents with migraine, comparing acute symptom relieving migraine medications with placebo in the ambulatory setting. Data collection and analysis Two reviewers screened titles and abstracts and reviewed the full text of potentially eligible studies. Two independent reviewers extracted data for studies meeting inclusion criteria. We calculated the risk ratios (RRs) and number needed to treat for an additional beneficial outcome (NNTB) for dichotomous data. We calculated the risk difference (RD) and number needed to treat for an additional harmful outcome (NNTH) for proportions of adverse events. The percentage of pain‐free patients at two hours was the primary efficacy outcome measure. We used adverse events to evaluate safety and tolerability. Secondary outcome measures included headache relief, use of rescue medication, headache recurrence, presence of nausea, and presence of vomiting. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables. Main results We identified a total of 27 randomized controlled trials (RCTs) of migraine symptom‐relieving medications, in which 9158 children and adolescents were enrolled and 7630 (range of mean age between 8.2 and 14.7 years) received medication. Twenty‐four studies focused on drugs in the triptan class, including almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, sumatriptan + naproxen sodium, and zolmitriptan. Other medications studied included paracetamol (acetaminophen), ibuprofen, and dihydroergotamine (DHE). More than half of the studies evaluated sumatriptan. All but one study reported adverse event data. Most studies presented a low or unclear risk of bias, and the overall quality of evidence, according to GRADE criteria, was low to moderate, downgraded mostly due to imprecision and inconsistency. Ibuprofen was more effective than placebo for producing pain freedom at two hours in two small studies that included 162 children (RR 1.87, 95% confidence interval (CI) 1.15 to 3.04) with low quality evidence (due to imprecision). Paracetamol was not superior to placebo in one small study of 80 children. Triptans as a class of medication were superior to placebo in producing pain freedom in 3 studies involving 273 children (RR 1.67, 95% CI 1.06 to 2.62, NNTB 13) (moderate quality evidence) and 21 studies involving 7026 adolescents (RR 1.32, 95% CI 1.19 to 1.47, NNTB 6) (moderate quality evidence). There was no significant difference in the effect sizes between studies involving children versus adolescents. Triptans were associated with an increased risk of minor (non‐serious) adverse events in adolescents (RD 0.13, 95% CI 0.08 to 0.18, NNTH 8), but studies did not report any serious adverse events. The risk of minor adverse events was not significant in children (RD 0.06, 95% CI − 0.04 to 0.17, NNTH 17). Sumatriptan plus naproxen sodium was superior to placebo in one study involving 490 adolescents (RR 3.25, 95% CI 1.78 to 5.94, NNTB 6) (moderate quality evidence). Oral dihydroergotamine was not superior to placebo in one small study involving 13 children. Authors' conclusions Low quality evidence from two small trials shows that ibuprofen appears to improve pain freedom for the acute treatment of children with migraine. We have only limited information on adverse events associated with ibuprofen in the trials included in this review. Triptans as a class are also effective at providing pain freedom in children and adolescents but are associated with higher rates of minor adverse events. Sumatriptan plus naproxen sodium is also effective in treating adolescents with migraine. Plain language summary Drugs for the acute treatment of migraine in children and adolescents Background and review question Migraine is a painful and debilitating disorder that is common in children (under 12 years of age) and adolescents (12 to 17 years of age). Common symptoms reported during a migraine attack are headache, nausea, vomiting, and sensitivity to light and sound. Many treatments for migraine are available, of which the most common are paracetamol (also known as acetaminophen), ibuprofen and other anti‐inflammatories, and triptans. Not all triptan medications are approved for use in children or adolescents, and approvals vary from country to country. Study characteristics In our review, we looked at 27 randomized controlled trials of drugs compared to placebo to find out which treatments were effective at providing pain freedom two hours after treatment. We also wanted to know what side effects might be caused by the treatments. A total of 7630 children received medication in the studies. The evidence is current to February 2016. Each study had between 13 and 888 participants. Their average age was 12.9 years and ranged from 8.2 to 14.7 years. Nineteen of the studies were funded by the drug manufacturer. Key results Ibuprofen appears to be effective in treating children with migraine, but the evidence is limited to only two small trials. Ibuprofen is readily available and inexpensive, making it an excellent first choice for migraine treatment. Paracetamol was not shown to be effective in providing pain freedom in children, but we only found one small study. Triptans are a type of medication designed specifically to treat migraine and are often effective at providing greater pain freedom in children and adolescents. The triptans examined in children included rizatriptan and sumatriptan, while almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan were examined in adolescents. The combination of sumatriptan plus naproxen sodium is also effective at treating adolescents with migraine. Overall, there is a risk that the triptan medications may cause minor unwanted side effects like taste disturbance, nasal symptoms, dizziness, fatigue, low energy, nausea, or vomiting. The studies did not report any serious side effects. Quality of the evidence The overall quality of the evidence provided by the review was moderate for the triptans, but low for paracetamol and ibuprofen, as we only identified a few studies. More studies need to look at the effects of each of the migraine treatments in children and adolescents separately.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Richer, L; Billinghurst, L; Linsdell, MA; Russell, K; Vandermeer, B; Crumley, ET; Durec, T; Klassen, TP; Hartling, L", "articleTypes": [], "doi": "10.1002/14651858.CD005220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "38dd6529-6116-4111-bca6-59343ddf1c46", "pmid": "", "title": "Fluoride toothpastes of different concentrations for preventing dental caries", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Walsh, T, Worthington, HV, Glenny, AM, Marinho, VCC, Jeroncic, A", "articleTypes": [], "doi": "10.1002/14651858.CD007868.pub3 AB - Abstract - Background Caries (dental decay) is a disease of the hard tissues of the teeth caused by an imbalance, over time, in the interactions between cariogenic bacteria in dental plaque and fermentable carbohydrates (mainly sugars). Regular toothbrushing with fluoride toothpaste is the principal non‐professional intervention to prevent caries, but the caries‐preventive effect varies according to different concentrations of fluoride in toothpaste, with higher concentrations associated with increased caries control. Toothpastes with higher fluoride concentration increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Objectives To determine and compare the effects of toothpastes of different fluoride concentrations (parts per million (ppm)) in preventing dental caries in children, adolescents, and adults. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 August 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7) in the Cochrane Library (searched 15 August 2018); MEDLINE Ovid (1946 to 15 August 2018); and Embase Ovid (1980 to 15 August 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 August 2018). No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials that compared toothbrushing with fluoride toothpaste with toothbrushing with a non‐fluoride toothpaste or toothpaste of a different fluoride concentration, with a follow‐up period of at least 1 year. The primary outcome was caries increment measured by the change from baseline in the decayed, (missing), and filled surfaces or teeth index in all permanent or primary teeth (D(M)FS/T or d(m)fs/t). Data collection and analysis Two members of the review team, independently and in duplicate, undertook the selection of studies, data extraction, and risk of bias assessment. We graded the certainty of the evidence through discussion and consensus. The primary effect measure was the mean difference (MD) or standardised mean difference (SMD) caries increment. Where it was appropriate to pool data, we used random‐effects pairwise or network meta‐analysis. Main results We included 96 studies published between 1955 and 2014 in this updated review. Seven studies with 11,356 randomised participants (7047 evaluated) reported the effects of fluoride toothpaste up to 1500 ppm on the primary dentition; one study with 2500 randomised participants (2008 evaluated) reported the effects of 1450 ppm fluoride toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants (40,066 evaluated) reported the effects of toothpaste up to 2400 ppm on the immature permanent dentition; and three studies with 2675 randomised participants (2162 evaluated) reported the effects of up to 1100 ppm fluoride toothpaste on the mature permanent dentition. Follow‐up in most studies was 36 months. In the primary dentition of young children, 1500 ppm fluoride toothpaste reduces caries increment when compared with non‐fluoride toothpaste (MD ‐1.86 dfs, 95% confidence interval (CI) ‐2.51 to ‐1.21; 998 participants, one study, moderate‐certainty evidence); the caries‐preventive effects for the head‐to‐head comparison of 1055 ppm versus 550 ppm fluoride toothpaste are similar (MD ‐0.05, dmfs, 95% CI ‐0.38 to 0.28; 1958 participants, two studies, moderate‐certainty evidence), but toothbrushing with 1450 ppm fluoride toothpaste slightly reduces decayed, missing, filled teeth (dmft) increment when compared with 440 ppm fluoride toothpaste (MD ‐0.34, dmft, 95%CI ‐0.59 to ‐0.09; 2362 participants, one study, moderate‐certainty evidence). The certainty of the remaining evidence for this comparison was judged to be low. We included 81 studies in the network meta‐analysis of D(M)FS increment in the permanent dentition of children and adolescents. The network included 21 different comparisons of seven fluoride concentrations. The certainty of the evidence was judged to be low with the following exceptions: there was high‐ and moderate‐certainty evidence that 1000 to 1250 ppm or 1450 to 1500 ppm fluoride toothpaste reduces caries increments when compared with non‐fluoride toothpaste (SMD ‐0.28, 95% CI ‐0.32 to ‐0.25, 55 studies; and SMD ‐0.36, 95% CI ‐0.43 to ‐0.29, four studies); there was moderate‐certainty evidence that 1450 to 1500 ppm fluoride toothpaste slightly reduces caries increments when compared to 1000 to 1250 ppm (SMD ‐0.08, 95% CI ‐0.14 to ‐0.01, 10 studies); and moderate‐certainty evidence that the caries increments are similar for 1700 to 2200 ppm and 2400 to 2800 ppm fluoride toothpaste when compared to 1450 to 1500 ppm (SMD 0.04, 95% CI ‐0.07 to 0.15, indirect evidence only; SMD ‐0.05, 95% CI ‐0.14 to 0.05, two studies). In the adult permanent dentition, 1000 or 1100 ppm fluoride toothpaste reduces DMFS increment when compared with non‐fluoride toothpaste in adults of all ages (MD ‐0.53, 95% CI ‐1.02 to ‐0.04; 2162 participants, three studies, moderate‐certainty evidence). The evidence for DMFT was low certainty. Only a minority of studies assessed adverse effects of toothpaste. When reported, effects such as soft tissue damage and tooth staining were minimal. Authors' conclusions This Cochrane Review supports the benefits of using fluoride toothpaste in preventing caries when compared to non‐fluoride toothpaste. Evidence for the effects of different fluoride concentrations is more limited, but a dose‐response effect was observed for D(M)FS in children and adolescents. For many comparisons of different concentrations the caries‐preventive effects and our confidence in these effect estimates are uncertain and could be challenged by further research. The choice of fluoride toothpaste concentration for young children should be balanced against the risk of fluorosis. Plain language summary Fluoride toothpastes of different strengths for preventing tooth decay Review question 
 This review has been produced to assess the effects of toothpastes of different fluoride strengths on preventing tooth decay in children, adolescents and adults. Background 
 Tooth decay (caries) is a widespread disease, affecting billions of people worldwide. Fluoride has long been used to prevent decay, through a variety of different methods including toothpaste, water, milk, mouthrinses, tooth gels and varnish. Regular toothbrushing is recommended to prevent decay and other oral diseases, and toothbrushing for 2 minutes twice daily with a fluoride toothpaste is generally recommended. The typical strength of regular or family toothpaste is around 1000 to 1500 parts per million (ppm) fluoride, but many other strengths are available worldwide. There is no minimum fluoride concentration, but the maximum permissible fluoride concentration for a toothpaste varies according to age and country. Higher concentrations are rarely available over the counter, and are classed as a prescription‐only medicine. Stronger fluoride toothpaste may offer greater protection against decay but also increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Study characteristics 
 Authors from Cochrane Oral Health carried out this review and the evidence is current up to 15 August 2018. It includes 96 studies published between 1955 and 2014: seven studies with 11,356 randomised participants reported the effects of fluoride toothpaste up to 1500 ppm on the primary teeth; one study with 2500 randomised participants reported the effects of 1450 ppm toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants reported the effects of toothpaste up to 2400 ppm on the permanent teeth of children up to 18 years of age; and three studies with 2675 randomised participants reported the effects of up to 1100 ppm toothpaste on the permanent teeth of adults. Most studies assessed decay after participants had been using the toothpastes for 36 months. Main results 
 We present below findings for which there is moderate‐ or high‐certainty evidence. In primary teeth of young children, brushing teeth with a toothpaste containing 1500 ppm fluoride reduced the amount of new decay when compared with non‐fluoride toothpaste; the amount of new decay was similar with 1055 ppm compared with 550 ppm fluoride toothpaste; and there was a slight reduction in the amount of new decay with 1450 ppm toothpaste compared with 440 ppm fluoride toothpaste. Eighty‐one studies assessed the effects of different strengths of fluoride toothpaste compared against each other (seven different strengths in 21 combinations) in permanent teeth of children and adolescents. We found that there was less new decay when toothbrushing with toothpaste containing 1000 to 1250 ppm or 1450 to 1500 ppm fluoride compared with non‐fluoride toothpaste, and that toothbrushing with 1450 to 1500 ppm fluoride toothpaste reduced the amount of new decay more than 1000 to 1250 ppm toothpaste. We found that there was a similar amount of new decay when children and adolescents used a toothpaste of 1700 to 2200 ppm or 2400 to 2800 ppm fluoride compared to 1450 to 1500 ppm toothpaste. The evidence for the effects of other strengths of toothpaste was less certain. In permanent teeth of adults of all ages, 1000 or 1100 ppm toothpaste reduced decay compared with non‐fluoride toothpaste. Most studies did not measure harmful effects of toothpaste use, but when reported, effects such as soft tissue damage and tooth staining were minimal. Certainty of the evidence 
 There is high‐certainty evidence that toothpaste containing 1000 to 1250 ppm fluoride is more effective than non‐fluoride toothpaste. There is moderate‐certainty evidence for the other findings reported in 'Main results' above. For other toothpaste strengths compared against each other or against non‐fluoride toothpaste, there are too few studies with too few participants to have any clarity about the effects. Authors conclusions 
 There are benefits of using fluoride toothpaste at certain strengths to prevent tooth decay when compared with non‐fluoride toothpaste. The stronger the fluoride concentration, the more decay is prevented. For many of the comparisons of different strengths of toothpaste, the findings are uncertain and could be challenged by further research. The choice of fluoride toothpaste for young children should be balanced against the risk of fluorosis.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.074Z" }, { "id": "38fb5aaa-72c3-4962-8255-ced976f034aa", "pmid": "", "title": "Xylitol for preventing acute otitis media in children up to 12 years of age", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Azarpazhooh, A, Lawrence, HP, Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD007095.pub3 AB - Abstract - Background Acute otitis media (AOM) is the most common bacterial infection among young children in the United States. There are limitations and concerns over its treatment with antibiotics and surgery and so effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk of dental decay. Xylitol can reduce the adherence of Streptococcus pneumoniae ( S pneumoniae ) and Haemophilus influenzae ( H influenzae ) to nasopharyngeal cells in vitro. This is an update of a review first published in 2011. Objectives To assess the efficacy and safety of xylitol to prevent AOM in children aged up to 12 years. Search methods We searched CENTRAL (to Issue 12, 2015), MEDLINE (1950 to January 2016), Embase (1974 to January 2016), CINAHL (1981 to January 2016), LILACS (1982 to January 2016), Web of Science (2011 to January 2016) and International Pharmaceutical Abstracts (2000 to January 2016). Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs of children aged 12 years or younger where xylitol supplementation was compared with placebo or no treatment to prevent AOM. Data collection and analysis Two review authors independently selected trials from search results, assessed and rated study quality and extracted relevant data for inclusion in the review. We contacted trial authors to request missing data. We noted data on any adverse events of xylitol. We extracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR), risk difference (RD) and associated 95% confidence intervals (CI). Main results We identified five clinical trials that involved 3405 children for inclusion. For this 2016 update, we identified one new trial for inclusion. This trial was systematically reviewed but due to several sources of heterogeneity, was not included in the meta‐analysis. The remaining four trials were of adequate methodological quality. In three RCTs that involved a total of 1826 healthy Finnish children attending daycare, there is moderate quality evidence that xylitol (in any form) can reduce the risk of AOM from 30% to around 22% compared with the control group (RR 0.75, 95% CI 0.65 to 0.88). Among the reasons for dropouts, there were no significant differences in abdominal discomfort and rash between the xylitol and the control groups. Xylitol was not effective in reducing AOM among healthy children during a respiratory infection (RR 1.13, 95% CI 0.83 to 1.53; moderate quality evidence) or among otitis‐prone healthy children (RR 0.90, 95% CI 0.67 to 1.21; low‐quality evidence). Authors' conclusions There is moderate quality evidence showing that the prophylactic administration of xylitol among healthy children attending daycare centres can reduce the occurrence of AOM. There is inconclusive evidence with regard to the efficacy of xylitol in preventing AOM among children with respiratory infection, or among otitis‐prone children. The meta‐analysis was limited because data came from a small number of studies, and most were from the same research group. Plain language summary Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age Review question 
 We reviewed the evidence about the effectiveness and safety of xylitol to prevent acute middle ear infection (acute otitis media; AOM) in children up to 12 years old. Background 
 AOM is the most common bacterial infection among young children in the United States. Although serious complications are rare, this common childhood ailment imposes a huge impact on the healthcare system. In the United States, it accounted for almost 20 million office visits. Antibiotic treatment of AOM is costly and raises concerns about the development of antibiotic‐resistant strains of bacteria. Surgery is invasive and costly, and because of these factors, effective measures for preventing AOM are sought. An alternative treatment is xylitol or birch sugar. Xylitol has been used for decades as a natural non‐sugar sweetener principally in chewing gums, confectionery, toothpaste and medicines, and can reduce the risk of tooth decay. Search date We searched the literature up to January 2016. This is an update of a review that was last published in 2011. Study characteristics 
 We identified five clinical trials that involved 3405 children, mostly from the same research group. Four trials were conducted in Finland and enrolled healthy children (three trials) or children with an acute respiratory infection (one trial). The fifth trial was conducted in the USA and enrolled otitis‐prone children who were recruited from attendance at general medical practices. Study funding sources All five trials received governmental funding; and the Finnish study investigators have a US patent for the use of xylitol to treat respiratory infections. Key results Xylitol, administered in chewing gum, lozenges or syrup, can reduce the occurrence of AOM among healthy children with no acute upper respiratory infection from 30% to 22%. There is no difference in side effects (namely, abdominal discomfort and rash). Based on these results we would expect that out of 1000 children up to 12 years of age, 299 would experience an AOM compared with between 194 and 263 children who would experience an AOM if they are provided with xylitol chewing gum. The preventive effect among healthy children with respiratory infection or among otitis‐prone children is inconclusive. Quality of the evidence 
 The quality of evidence was moderate for healthy children and children with respiratory infections but low for otitis‐prone children.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.076Z" }, { "id": "38fbfb2c-56b1-4499-b559-435d481f631b", "pmid": "", "title": "Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background It is unclear whether patients with type 2 diabetes who have poor glycaemic control despite maximal oral hypoglycaemic agents (OHAs) should be commenced on insulin as monotherapy, or insulin combined with oral hypoglycaemic agents (insulin‐OHA combination therapy). Objectives To assess the effects of insulin monotherapy versus insulin‐OHA combinations therapy. Search methods Eligible studies were identified by searching MEDLINE, EMBASE, and The Cochrane Library . Selection criteria Randomised controlled trials (RCTs) with 2 months minimum follow‐up duration comparing insulin monotherapy (all schemes) with insulin‐OHA combination therapy. Data collection and analysis Data extraction and assessment of study quality were undertaken by three reviewers in pairs. Main results Twenty RCTs (mean trial duration 10 months) including 1,811 participants, with mean age 59.8 years and mean known duration of diabetes 9.6 years. Overall, study methodological quality was low. Twenty‐eight comparisons in 20 RCTs were ordered according to clinical considerations. No studies assessed diabetes‐related morbidity, mortality or total mortality. From 13 studies (21 comparisons), sufficient data were extracted to calculate pooled effects on glycaemic control. Insulin‐OHA combination therapy had statistically significant benefits on glycaemic control over insulin monotherapy only when the latter was applied as a once‐daily injection of NPH insulin. Conversely, twice‐daily insulin monotherapy (NPH or mixed insulin) provided superior glycaemic control to insulin‐OHA combination therapy regimens where insulin was administered as a single morning injection. In more conventional comparisons, regimens utilising OHAs with bedtime NPH insulin provided comparable glycaemic control to insulin monotherapy (administered as twice daily, or multiple daily injections). Overall, insulin‐OHA combination therapy was associated with a 43% relative reduction in total daily insulin requirement compared to insulin monotherapy. Of the 14 studies (22 comparisons) reporting hypoglycaemia, 13 demonstrated no significant difference in the frequency of symptomatic or biochemical hypoglycaemia between insulin and combination therapy regimens. No significant differences in quality of life related issues were detected. Combination therapy with bedtime NPH insulin resulted in statistically significantly less weight gain compared to insulin monotherapy, provided metformin was used ± sulphonylurea. In all other comparisons no significant differences with respect to weight gain were detected. Authors' conclusions Bedtime NPH insulin combined with oral hypoglycaemic agents provides comparable glycaemic control to insulin monotherapy and is associated with less weight gain if metformin is used. Plain language summary Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus Simple application of a single daily insulin injection in addition to oral hypoglycaemic agents may facilitate the initiation of insulin therapy in type 2 diabetes mellitus.This review examined 20 trials including 1,811 participants which compared insulin monotherapy with insulin in combination with oral hypoglycaemic agents (OHA) in insulin‐requiring patients with type 2 diabetes. The results suggest that a bedtime NPH insulin‐oral hypoglycaemic agent combination therapy regimen provides comparable glycaemic control to insulin monotherapy. Due to lack of studies it remains unclear whether insulin‐OHA combination regimens with metformin alone are superior to those with metformin plus a sulphonylurea. In most cases no significant differences in hypoglycaemic events were observed between insulin mono‐ and OHA combination therapy. No study assessed diabetes‐related morbidity or mortality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Goudswaard, AN, Furlong, NJ, Valk, GD, Stolk, RP, Rutten, GEHM", "articleTypes": [], "doi": "10.1002/14651858.CD003418.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.116Z" }, { "id": "3914d948-9353-4e4d-8728-9d68136d3c85", "pmid": "", "title": "Oral water soluble contrast for malignant bowel obstruction", "imported": false, "abstract": "Abstract - Background Malignant bowel obstruction (MBO) is a common problem in patients with intra‐abdominal cancer. Oral water soluble contrast (OWSC) has been shown to be useful in the management of adhesive small bowel obstruction in identifying patients who will recover with conservative management alone and also in reducing the length of hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in patients with MBO. Objectives To determine the reliability of OWSC media and follow‐up abdominal radiographs in predicting the success of conservative treatment in resolving inoperable MBO with conservative management. To determine the efficacy and safety of OWSC media in reducing the duration of obstruction and reducing hospital stay in people with MBO. Search methods We identified studies from searching Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in Process, Embase, CINAHL, Science Citation Index (Web of Science) and Conference Proceedings Citation Index ‐ Science (Web of Science). We also searched registries of clinical trials and the CareSearch Grey Literature database. The date of the search was the 6 June 2017. Selection criteria Randomised controlled trials (RCTs), or prospective controlled studies, that evaluated the diagnostic potential of OWSC in predicting which malignant bowel obstructions will resolve with conservative treatment. RCTs, or prospective controlled studies, that assessed the therapeutic potential of OWSC in managing MBO at any level compared with placebo, no intervention or usual treatment or supportive care. Data collection and analysis We used standard methodological procedures expected by Cochrane. We assessed risk of bias and assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We found only one RCT meeting the selection criteria for the second objective (therapeutic potential) of this review. This study recruited nine participants. It compared the use of gastrografin versus placebo in adult patients with MBO with no indication for further intervention (surgery, endoscopy) apart from standardised conservative management. The overall risk of bias for the study was high due to issues with low numbers of participants, selective reporting of outcomes and a high attrition rate for the intervention arm. Primary outcomes The included trial was a pilot study whose primary outcome was to test the feasibility for a large study. The authors reported specifically on the number of patients screened, the number recruited and reasons for exclusion; this was not the focus of our review. Due to the low number of participants, the authors of the study decided not to report on our primary outcome of assessing the ability of OWSC to predict the likelihood of malignant small bowel obstruction resolving with conservative treatment alone (diagnostic effect). It also did not report on our primary outcome of rate of resolution of MBO in patients receiving OWSC compared with those not receiving it (therapeutic effect). The study reported that no issues regarding safety or tolerability of either gastrografin or placebo were identified. The overall quality of the evidence for the incidence of adverse events with OWSC was very low, downgraded twice for serious limitations to study quality (high risk of selective reporting and attrition bias) and downgraded once for imprecision (sparse data). Secondary outcomes The study planned to report on this review’s secondary outcome measures of length of hospital stay and time from administration of OWSC to resolution of MBO. However the authors of the study decided not to do so due to the low numbers of patients recruited. The study did not report on our secondary outcome measure of survival times from onset of inoperable MBO until death. Authors' conclusions There is insufficient evidence from RCTs to determine the place of OWSC in predicting which patients with inoperable MBO will respond with conservative treatment alone. There is also insufficient evidence from RCTs to determine the therapeutic effects and safety of OWSC in patients with malignant small bowel obstruction. Plain language summary Oral water soluble contrast for cancer‐related bowel obstruction Background Intra‐abdominal cancer is where the cancer has either started elsewhere in the body and spread into the stomach area or started in the bowel itself. It can commonly grow and block the movement of food or faeces through the bowel. A blockage of the bowel caused by cancer is known as malignant bowel obstruction (MBO). Some patients with MBO benefit from surgery to reverse the blockage. In others it is not possible to reverse the MBO and it either resolves or becomes permanent (limiting prognosis to days or weeks). Scar tissue around the bowel (called adhesions) can also cause a blockage, this is known as adhesive small bowel obstruction. Adhesive obstructions often resolve with conservative management in hospital (allowing the bowel to \"rest\" and recover). However in some, the obstruction requires surgery to remove the scar tissue and fix the blockage. Oral water soluble contrast (OWSC) is often prepared in liquid form and when swallowed before an x‐ray or computed tomography (CT) scan will show up clearly in the bowel. It can predict which people with adhesive small bowel obstruction will require surgery. In some patients it may also speed recovery leading to reduced hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in MBO. Study characteristics We searched for evidence that OWSC could be used to identify which patients with inoperable MBO would recover with conservative management. We also wanted to know if OWSC increased the likelihood of recovery from MBO, reduced hospital stay or improved prognosis. Finally, we wished to know what side effects OWSC might cause for patients with MBO. We conducted the search in June 2017 and found one study. It only recruited nine participants and did not fully report on the outcomes of using OWSC in MBO. Key Findings We found insufficient evidence that OWSC can identify which patients with MBO will recover with conservative management. We found insufficient evidence that patients with MBO benefit from OWSC in terms of length of hospital stay, recovery time or survival. No conclusions could be made about side effects from OWSC. Quality of Evidence We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. We rated the quality of the evidence as very low due to the lack of studies reporting on the benefits of using OWSC in MBO and the only study we found reporting on side effects recruited very few participants (nine). The low quality of the evidence means that we are very uncertain about the use of OWSC in the management of MBO and cannot confirm its benefits or harms in patients with this condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Syrmis, W, Richard, R, Jenkins-Marsh, S, Chia, SC, Good, P", "articleTypes": [], "doi": "10.1002/14651858.CD012014.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.752Z" }, { "id": "391d706e-de9a-4032-ad91-23417f955310", "pmid": "", "title": "Supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults", "imported": false, "abstract": "Abstract - Background Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy. Objectives To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults. Search methods We identified publications from comprehensive searches of the Cochrane Library , MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016. Selection criteria Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care. Data collection and analysis Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta‐analyses for the outcome measures, 'all‐cause mortality', 'hospitalisation' and 'nutritional status (weight change)'. Main results Forty‐one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow‐up ranged from ‘duration of hospital stay’ to 12 months. The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all‐cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate‐quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low‐quality evidence). Only five trials (4451 participants) investigated health‐related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of ‐0.5 days (95% CI ‐2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low‐quality evidence. Only three of 41 included trials (4108 participants; very low‐quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta‐analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate‐quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low‐quality evidence). Authors' conclusions There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all‐cause mortality for supportive interventions comes from hospital‐based trials and more research is needed to confirm this effect. There is very low‐quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient‐important outcomes in future research. Plain language summary Supportive interventions for improving dietary intake in nutritionally vulnerable groups Review question Are supportive interventions for improving dietary intake in nutritionally vulnerable groups (malnourished or nutritionally at‐risk individuals) effective? Background Serving meals in a dining room, or the use of assistance to help feed people in need and other similar methods are often recommended to help especially sick and elderly people who have lost or are likely to lose weight (nutritionally vulnerable groups). Such supportive interventions are implemented in the health care in many countries but their effects are not well investigated. Study characteristics We included 41 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 10,681 people in our review. There were five different interventions which we call 'supportive interventions': changes to the organisation of nutritional care (13 studies, 3456 people), changes to the feeding environment (5 studies, 351 people), modification of the meal profile or pattern (12 studies, 649 people), additional supplementation of meals (10 studies, 6022 people) and home meal delivery systems (1 study, 203 people). Monitoring participants over time (follow‐up) ranged from ‘duration of hospital stay’ to 12 months. The comparator groups received 'usual' care. More than half of all participants took part in studies investigating the additional supplementation of meals (for example a protein‐energy oral nutritional supplement in addition to the usual diet). Key results It is possible that supportive interventions for enhancing dietary intake in nutritionally vulnerable groups reduce death from any cause (approximately 23 fewer cases of death per 1000 participants in favour of supportive interventions). However, this has to be confirmed by more evidence from high‐quality randomised controlled studies. The number of participants experiencing any medical complication did not differ substantially between the supportive interventions and the comparator groups. The same was found for health‐related quality of life (which is physical, mental, emotional and social health attributed to health), patient satisfaction, nutritional or energy intake and days spent in hospital. Economic costs were not well investigated. Only three studies reported on side effects, describing intolerance to the nutritional supplement (such as diarrhoea or vomiting in 5 of 34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567 of 2017 participants). After analysing 15 studies in 1945 participants we found a beneficial effect of supportive interventions compared with comparators on weight: on average people in the supportive interventions groups increased their weight 0.6 kg more than people in the comparator groups. This evidence is up to date as of September 2016. Quality of evidence The overall quality of evidence ranged between moderate to very low, mainly because for most of our outcomes there was only a small number of studies and participants to achieve reliable information, or because risk of bias made results uncertain. However, if some randomised controlled studies with low risk of bias for our patient‐important outcomes and a good number of participants were performed, this review could quickly provide good guidance for better health care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Baldwin, C; Kimber, KL; Gibbs, M; Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD009840.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "39217546-c8b1-47fb-bdbf-d5a4ad24d3cb", "pmid": "", "title": "Iodised salt for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency is the main cause for potentially preventable mental retardation in childhood, as well as causing goitre and hypothyroidism in people of all ages. It is still prevalent in large parts of the world. Objectives To assess the effects of iodised salt in comparison with other forms of iodine supplementation or placebo in the prevention of iodine deficiency disorders. Search methods We searched The Cochrane Library , MEDLINE, the Register of Chinese trials developed by the Chinese Cochrane Centre, and the Chinese Med Database, China National knowledge Infrastructure, and searched reference lists, databases of ongoing trials and the Internet. Selection criteria We included prospective controlled studies of iodised salt versus other forms of iodine supplementation or placebo in people living in areas of iodine deficiency. Studies reported mainly goitre rates and urinary iodine excretion as outcome measures. Data collection and analysis The initial data selection and quality assessment of trials was done independently by two reviewers. Subsequently, after the scope of the review was slightly widened from including only randomised controlled trials to including non‐randomised prospective comparative studies, a third reviewer repeated the trials selection and quality assessment. As the studies identified were not sufficiently similar and not of sufficient quality, we did not do a meta‐analysis but summarised the data in a narrative format. Main results We found six prospective controlled trials relating to our question. Four of these were described as randomised controlled trials, one was a prospective controlled trial that did not specify allocation to comparison groups, and one was a repeated cross‐sectional study comparing different interventions. Comparison interventions included non‐iodised salt, iodised water, iodised oil, and salt iodisation with potassium iodide versus potassium iodate. Numbers of participants in the trials ranged from 35 to 334; over 20,000 people were included in the cross‐sectional study. Three studies were in children only, two investigated both groups of children and adults and one investigated pregnant women. There was a tendency towards goitre reduction with iodised salt, although this was not significant in all studies. There was also an improved iodine status in most studies (except in small children in one of the studies), although urinary iodine excretion did not always reach the levels recommended by the WHO. None of the studies observed any adverse effects of iodised salt. Authors' conclusions The results suggest that iodised salt is an effective means of improving iodine status. No conclusions can be made about improvements in other, more patient‐oriented outcomes, such as physical and mental development in children and mortality. None of the studies specifically investigated development of iodine‐induced hyperthyroidism, which can be easily overlooked if just assessed on the basis of symptoms. High quality controlled studies investigating relevant long term outcome measures are needed to address questions of dosage and best means of iodine supplementation in different population groups and settings. Plain language summary Iodised salt for preventing iodine deficiency disorders Iodine deficiency causes mental retardation in children as well as enlarged thyroid glands (goitre) and deficiencies in thyroid hormones in people of all ages. It still exists in large parts of the world. This review looked at studies of iodised salt in the diet that included a comparison group. Six studies, most of them in children but some also in adults, were included. Iodine in the urine increased in all but one studies, but there was some concern that small children did not eat enough salt to achieve adequate iodine status. Some studies, but not all, also showed a reduction in the enlargement of the thyroid gland (goitre) that can accompany lack of iodine in the diet. Adverse effects were not reported, but these may not have been studied adequately. More high quality long term studies measuring outcomes related to child development, to deaths associated with iodine‐deficiency and to adverse effects are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Wu, T, Liu, GJ, Li, P, Clar, C", "articleTypes": [], "doi": "10.1002/14651858.CD003204", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.099Z" }, { "id": "394421d9-3cac-4720-9296-e17131691b40", "pmid": "", "title": "A Phase III Randomized, Double-blind, Placebo-controlled Multicenter Study in Adults, to Determine the Safety, Efficacy, and Immunogenicity of AZD1222, a Non-replicating ChAdOx1 Vector Vaccine, for the Prevention of COVID-19", "imported": false, "abstract": "The aim of the study is to assess the safety, efficacy, and immunogenicity of AZD1222 for the prevention of COVID-19.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.162Z" }, { "id": "3973f320-5e0b-426a-a63a-1e161c81cdfa", "pmid": "", "title": "Polyunsaturated fatty acid supplementation for schizophrenia", "imported": false, "abstract": "Abstract - Background Limited evidence supports a hypothesis suggesting that the symptoms of schizophrenia may be the result of altered neuronal membrane structure and metabolism. The structure and metabolism is dependent on blood plasma levels of certain essential fatty acids and their metabolites. Objectives To assess the effects of polyunsaturated fatty acids for people with schizophrenia. Search methods We have updated the initial searches of 1998, 2002 and 2005 with a search of the Cochrane Schizophrenia Group's Register, November 2008, which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. Where necessary, we contacted authors and relevant pharmaceutical companies for additional information. Selection criteria We included all randomised controlled trials of polyunsaturated fatty acid treatment for schizophrenia. Data collection and analysis Working independently, we selected studies for quality assessment and extracted relevant data. We analysed on an intention‐to‐treat basis. Where possible and appropriate we calculated the Relative Risk (RR) and their 95% confidence intervals (CI) and estimated the number needed to treat (NNT). For continuous data we calculated weighted mean differences (WMD) and their 95% confidence intervals. We also inspected the data for heterogeneity. Main results Eight studies are now included in this review. When any dose omega‐3 (E‐EPA or EPA) is compared with placebo, small short trials suggest that the need for neuroleptics appears to be reduced for people allocated omega‐3 supplementation (n=30, 1 RCT, RR 0.73 CI 0.54 to 1.00) and mental state may improve (n=30, 1 RCT, RR not gaining 25% change in PANSS scores 0.54 CI 0.30 to 0.96, NNT 3 CI 2 to 29). There are no differences in the number of people leaving the study early (n=595, 6 RCTs, RR 0.86 CI 0.50 to 1.48). There are few data on the comparison of any dose omega‐6 (GLA) with placebo. For movement disorder outcomes, the one small study we found does not show any difference for average short‐term endpoint AIMS score (n=16, 1 RCT, WMD 1.30 CI ‐1.96 to 4.56). When any dose omega‐3 (E‐EPA or EPA) is compared with any dose omega‐3 (DHA) there is no significant difference for mental state outcome of not gaining 25% change in PANSS scores (n=31, 1 RCT, RR 0.66 CI 0.39 to 1.11). When different doses of omega‐3 (E‐EPA) are compared with placebo there are no differences in measures of global and mental state between the studies. For the outcome of 'experiencing at least one adverse effect' no differences between groups are found for any dose (1 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.97 CI 0.60 to 1.56; 2 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.67 CI 0.37 to 1.20; 4 g/day E‐EPA vs placebo n=58, 1 RCT, RR 1.15 CI 0.72 to 1.82). Authors' conclusions Three updates of this review have resulted in more included studies and more people randomised but still relatively little useful additional data. The results remain inconclusive. The new trials all compare the omega‐3 polyunsaturated fatty acids, in particular eicosapentaenoic acid and its ester, ethyl‐eicosapentaenoic acid. The use of omega‐3 polyunsaturated fatty acids for schizophrenia still remains experimental and this review highlights the need for large, well designed, conducted and reported studies. Plain language summary Polyunsaturated fatty acid supplementation for schizophrenia Schizophrenia is a serious mental health problem that affects about one percent of any population. For some people it can become an illness that they have to live with for their entire life. Early research has suggested that supplementing the diet with omega 3 or omega 6 fatty acids may have a positive effect on the symptoms of schizophrenia. This review looks at randomised control trials where omega 3 or omega 6 were used in combination with antipsychotic medication, or as a treatment in their own right for schizophrenia. Eight studies were found which included a total of 517 people who had a diagnosis of schizophrenia or schizoaffective disorder (combined symptoms of schizophrenia and a mood disorder). They ranged from six to 16 weeks in length and were in both hospital and community settings. The majority of the trials compared two different types of omega 3 fatty acids, EPA (usually as E‐EPA) and DHA with placebo, in people with schizophrenia who are stable on antipsychotic medication. Some of these trials show some improvement in general functioning and in mental state but not to a statistically significant degree. In the longest trial there was no difference between the two groups at the end of the study. One trial compared E‐EPA with DHA and found a suggestion that E‐EPA works better than DHA, but again it was not statistically significant. Where EPA was compared to placebo as a first line treatment for schizophrenia (30 people), those taking EPA had a better overall outcome and improvement in mental state. However, this was a short trial with few people. Finally, one trial compared a type of omega 6 with placebo in men who had the movement disorder tardive dykinesia (16 people). There was no improvement in the symptoms of movement adverse effects in either group at the end of six weeks. These trials were both small and short. In addition most of the data they reported were not able to be used, and half of the trials were funded by the group supplying the trial medication. Therefore it is still not clear whether taking manufactured omega 3 or 6 improves overall functioning or mental state in people with schizophrenia. (Plain language summary prepared for this review by Janey Antoniou of RETHINK, UK www.rethink.org )", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Irving, CB; Mumby‐Croft, R; Joy, LA", "articleTypes": [], "doi": "10.1002/14651858.CD001257.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "397f30fb-78d9-4777-8e72-0ec57a9df898", "pmid": "", "title": "Interventions for the eradication of meticillin‐resistant Staphylococcus aureus (MRSA) in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a genetic disorder characterised by recurrent and persistent pulmonary infections from resistant organisms, resulting in deterioration of lung function and early mortality. Meticillin‐resistant Staphylococcus aureus (MRSA) is an important infection in hospital patients and harmful to people with CF (pwCF). Chronic pulmonary MRSA infection may confer a worse clinical outcome on pwCF and result in a faster decline in lung function. Robust evidence clearly guiding MRSA eradication in CF is urgently needed. This is an updated review. Objectives To evaluate the effectiveness of antibiotic treatment designed to eradicate MRSA, to determine whether eradication confers better clinical and microbiological outcomes for pwCF, and to ascertain whether attempts at eradicating MRSA lead to increased acquisition of other resistant organisms (including Pseudomonas aeruginosa ), increased adverse effects from drugs, or both. Search methods We searched the Cochrane CF's Trials Register, PubMed, MEDLINE and three trials registries; handsearched article reference lists; and contacted experts in the field. We last searched Cochrane CF's Trials Register and the trials registries on 28 April 2026. Eligibility criteria Randomised controlled trials (RCTs) or quasi‐RCTs of any combination of topical, inhaled, oral or intravenous antibiotics for treating MRSA compared with placebo, standard treatment or no treatment in pwCF, regardless of age or disease severity. Outcomes We planned to assess these outcomes at up to 12 months following therapy: eradication of MRSA from respiratory cultures, time until next positive MRSA isolate, quality of life (QoL), change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted, change in weight (kg), frequency of pulmonary exacerbations and adverse effects of treatment. Risk of bias Using the original Cochrane risk of bias tool, we assessed individual domains and produced an overall risk of bias for each trial. Synthesis methods We followed Cochrane's standard methodology, conducting fixed‐effect meta‐analyses or reporting narratively. We assessed evidence certainty using GRADE. Included studies We included five RCTs (410 participants). Synthesis of results Oral antibiotics versus no treatment Two trials (106 participants) compared observation to oral trimethoprim plus sulfamethoxazole combined with rifampicin; in one trial for two weeks alongside topical decontamination and a three‐week environmental decontamination, and in a second for 21 days alongside intranasal mupirocin (five days); 29 participants withdrew from the second trial by the end of follow‐up. Oral antibiotics have little or no effect on any outcome reported below, in contrast to one study (45 participants) which was terminated early due to results clearly favouring treatment. In one trial defining eradication as negative MRSA respiratory cultures at day 28 and remaining so at day 168 (45 participants), treatment may result in more negative cultures than observation (odds ratio (OR) 12.6 (95% confidence interval (CI) 2.84 to 55.84; low‐certainty). There may be little to no difference between groups by day 168 of follow‐up (OR 1.17, 95% CI 0.31 to 4.42), and also in one trial defining successful eradication as no MRSA in at least three cultures over six months follow‐up (OR 2.74, 95% CI 0.64 to 11.75; low‐certainty). Treatment may result in an increase in FEV 1 % predicted from baseline (MD 5.67%, 95% CI 1.43 to 9.90; 2 trials, 58 participants; low‐certainty evidence). There may be little to no differences between groups in QoL, frequency of pulmonary exacerbations (although one study reported a lower hospitalisation rate through day 168 with treatment (P = 0.01)), adverse effects, or weight (all low‐certainty evidence). Nebulised antibiotics versus placebo Two trials (275 participants randomised, 251 analysed) compared a standard dose of vancomycin (one trial additionally compared a high dose) to placebo. The multi‐arm trial reported a decrease in MRSA colony forming units (CFUs) at each time point, up to one month. There were no differences in most lung function results in either trial, but treatment probably increased FEV 1 % predicted at 20 weeks (MD 3.55%, 95% CI 0.33 to 6.77; P = 0.03; 1 trial, 133 participants; moderate‐certainty evidence). This trial also reported no difference in pulmonary exacerbation frequency, while the multi‐arm trial reported a longer time to the next exacerbation with the lower vancomycin dose (no placebo data available). Evidence from both trials suggests that nebulised antibiotics may make little or no difference in QoL (high to low‐certainty), or frequency of adverse outcomes or of exacerbations (low‐to‐moderate‐certainty evidence). Oral antibiotics plus nebulised antibiotics (vancomycin) versus oral antibiotics plus placebo One trial (29 participants randomised, 25 participants analysed) compared combination antibiotic treatment (inhaled plus oral) to oral antibiotics plus inhaled placebo, defining eradication as a negative MRSA respiratory sample at one month following treatment. Combination antibiotic treatment may result in little or no difference in MRSA eradication at three months (OR 1.63, 95% CI 0.19 to 13.93; low‐certainty evidence), lung function (no data available for analysis) or adverse effects (low‐certainty evidence), in QoL (very low‐certainty evidence) or nasal colonisation with MRSA. Authors' conclusions Early eradication of MRSA is possible in pwCF; evidence from one trial suggested active MRSA treatment may result in a higher proportion of MRSA‐negative respiratory cultures after one month compared with observation. However, longer follow‐up showed treatment may make little or no difference in the proportion of participants remaining MRSA‐negative. One trial of nebulised antibiotics alone compared to placebo reported a decrease in MRSA CFUs with a higher antibiotic dose. The longer‐term clinical consequences of any treatment option – in terms of lung function, mortality and cost of care – remain unclear. We judged the evidence to range from high to very low‐certainty, due to potential biases from trial design, high attrition rates and small sample sizes. While early eradication of respiratory MRSA in pwCF may be possible, the currently available evidence does not demonstrate that routine treatment of respiratory MRSA in pwCF is effective. Research is needed to assess MRSA infection and treatment in the age of modulator therapies. Funding The 2025 update was undertaken as part of Cochrane CF funding from the UK CF Trust and the CF Foundation. Registration Protocol (2012) DOI: 10.1002/14651858.CD009650. Original review (2013) DOI: 10.1002/14651858.CD009650.pub2. Review updates: (2015) DOI: 10.1002/14651858.CD009650.pub3; (2018) DOI: 10.1002/14651858.CD123456.pub4; (2022) DOI: 10.1002/14651858.CD009650.pub5. Plain language summary Can treatment with antibiotics clear the 'superbug' MRSA from the lungs of people with cystic fibrosis? Key messages Early treatment of meticillin‐resistant Staphylococcus aureus (MRSA) (a type of bacteria which are resistant to some antibiotics) infection in people with cystic fibrosis (CF) seems possible, but we are unsure about the effectiveness of current routine treatment. Longer‐term implications of treatment are not clear. Research is needed to assess MRSA infection and treatment in the age of cystic fibrosis transmembrane conductance regulator (CFTR) modulators (drugs that fix the broken protein made by the CF gene so salt and water can move correctly across cells and help move mucus from the lungs). What is cystic fibrosis (CF)? CF is an inherited condition which causes thick mucus to build up in the lungs and other organs. It is very difficult for people with CF to cough up this thick mucus, making it an ideal breeding ground for germs (including MRSA), and making them more prone to chest infections. CF worsens over time. Although there is currently no cure, many people with CF can lead active and full lives. What is MRSA and how is it treated? MRSA (meticillin‐resistant Staphyloccocus aureus) are bacteria which cause infection that is treated with antibiotics. However, MRSA are resistant to some types of antibiotics, making the infection hard to treat. They are sometimes called 'superbugs' and infection with MRSA is particularly worrying for people with CF, as it is thought that MRSA can cause more damage than other bacteria which are not resistant to antibiotics. MRSA is usually treated with a combination of antibiotics, taken orally (by mouth) or inhaled, alongside decontamination treatment (antibiotic creams applied to the skin and nasal cavities). What did we want to find out? We wanted to know whether treatment with antibiotics: can get rid of MRSA infection in the lungs of children or adults with CF; does not cause infection with other resistant bacteria; does not cause unwanted effects. What did we do? We looked for studies that investigated antibiotics (oral or inhaled) to treat MRSA infections in people with CF. Studies had to compare antibiotic treatment with either no treatment, placebo (sham treatment) or other type of antibiotics. People had to have CF and current infection with MRSA. What did we find? We found five studies which recruited 410 people with CF and a diagnosed MRSA infection. Studies took place in Italy or North America and lasted from eight weeks to six months. People in the studies (equal numbers of males and females) were young (average age ranged from 11 to 25 years). Oral antibiotics compared to no treatment (2 studies, 106 people) One group of people with CF were treated with oral antibiotics (trimethoprim, sulfamethoxazole and rifampicin or co‐trimoxazole and rifampicin), plus decontamination treatment; the other group received no treatment. Oral antibiotics may clear MRSA. One trial stopped early due to clear benefits of antibiotics, but some people cleared the infection with no treatment. In six months, there was no difference between groups in the number of people who still had MRSA. Antibiotics may increase lung function. There may be little to no difference between groups in quality of life, frequency of flare‐ups of the disease (although one study reported fewer people taking antibiotics were admitted to hospital in the first six months), unwanted effects of treatment, or changes in weight. Inhaled antibiotics compared to placebo (2 studies, 251 people) Both studies compared a standard dose of vancomycin (an inhaled antibiotic) to placebo (a dummy drug) and one study also compared a standard dose of vancomycin to a high dose. Inhaled antibiotics probably make no difference to lung function compared to placebo (2 studies), but results from one study indicated that inhaled antibiotics probably lead to a small increase after 20 weeks. A standard dose of vancomycin probably makes no difference to the frequency of flare‐ups compared to placebo (2 studies); One study reported a longer time to the next flare‐up with the lower dose of vancomycin; One study reported a decrease in MRSA bacteria levels with a higher dose of vancomycin for up to one month; Neither study reported any differences in quality of life or unwanted effects. Oral plus inhaled antibiotics compared to oral antibiotics plus placebo (1 study, 25 people) One study compared a combination of oral plus inhaled antibiotics to inhaled antibiotics plus placebo. We are uncertain if either treatment made any difference to MRSA clearance; There may be few or no differences between groups in lung function, quality of life or unwanted effects; The study did not report changes in weight or frequency of flare‐ups. What are the limitations of the evidence? Our confidence in the results ranged from high to very low. This was due to potential issues with the trial designs (people knew which treatment they were receiving), or because there were small numbers of people in each trial and many of them dropped out. How up to date is this evidence? This review updates our previous review published in 2022. The evidence is current to 28 April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lo, DKH; Jahnke, N; Smith, S; Muhlebach, MS; Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD009650.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "398a0038-be0f-40e2-a18e-f3acfea34791", "pmid": "", "title": "Omega‐3 fatty acids for depression in adults", "imported": false, "abstract": "Abstract - Background Major depressive disorder (MDD) is highly debilitating, difficult to treat, has a high rate of recurrence, and negatively impacts the individual and society as a whole. One potential treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, some other seafood, and some nuts and seeds. Various lines of evidence suggest a role for n‐3PUFAs in MDD, but the evidence is far from conclusive. Reviews and meta‐analyses clearly demonstrate heterogeneity between studies. Investigations of heterogeneity suggest different effects of n‐3PUFAs, depending on the severity of depressive symptoms, where no effects of n‐3PUFAs are found in studies of individuals with mild depressive symptomology, but possible benefit may be suggested in studies of individuals with more severe depressive symptomology. Hence it is important to establish their effectiveness in treating MDD. This review updates and incorporates an earlier review with the same research objective (Appleton 2015). Objectives To assess the effects of n‐3 polyunsaturated fatty acids (also known as omega‐3 fatty acids) versus a comparator (e.g. placebo, antidepressant treatment, standard care, no treatment, wait‐list control) for major depressive disorder (MDD) in adults. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO together with trial registries and grey literature sources (to 9 January 2021). We checked reference lists and contacted authors of included studies for additional information when necessary. Selection criteria We included studies in the review if they: used a randomised controlled trial design; provided n‐3PUFAs as an intervention; used a comparator; measured depressive symptomology as an outcome; and were conducted in adults with MDD. Primary outcomes were depressive symptomology (continuous data collected using a validated rating scale) and adverse events. Secondary outcomes were depressive symptomology (dichotomous data on remission and response), quality of life, and non‐completion of studies. Data collection and analysis We used standard methodological procedures as expected by Cochrane. We assessed the certainty of the evidence using GRADE criteria. Main results The review includes 35 relevant studies: 34 studies involving a total of 1924 participants investigated the impact of n‐3PUFA supplementation compared to placebo, and one study involving 40 participants investigated the impact of n‐3PUFA supplementation compared to antidepressant treatment. For the placebo comparison, n‐3PUFA supplementation resulted in a small to modest benefit for depressive symptomology, compared to placebo: standardised mean difference (SMD) (random‐effects model) −0.40 (95% confidence interval (CI) −0.64 to −0.16; 33 studies, 1848 participants; very low‐certainty evidence), but this effect is unlikely to be clinically meaningful. An SMD of 0.40 represents a difference between groups in scores on the HDRS (17‐item) of approximately 2.5 points (95% CI 1.0 to 4.0), where the minimal clinically important change score on this scale is 3.0 points. The confidence intervals include both a possible clinically important effect and a possible negligible effect, and there is considerable heterogeneity between studies. Sensitivity analyses, funnel plot inspection and comparison of our results with those of large well‐conducted trials also suggest that this effect estimate may be biased towards a positive finding for n‐3PUFAs. Although the numbers of individuals experiencing adverse events were similar in intervention and placebo groups (odds ratio (OR) 1.27, 95% CI 0.99 to 1.64; 24 studies, 1503 participants; very low‐certainty evidence), the confidence intervals include a small decrease to a modest increase in adverse events with n‐3PUFAs. There was no evidence for a difference between n‐3PUFA and placebo groups in remission rates (OR 1.13, 95% CI 0.74 to 1.72; 8 studies, 609 participants, low‐certainty evidence), response rates (OR 1.20, 95% CI 0.80 to 1.79; 17 studies, 794 participants; low‐certainty evidence), quality of life (SMD −0.38 (95% CI −0.82 to 0.06), 12 studies, 476 participants, very low‐certainty evidence), or trial non‐completion (OR 0.92, 95% CI 0.70 to 1.22; 29 studies, 1777 participants, very low‐certainty evidence). The evidence on which these results are based was also very limited, highly heterogeneous, and potentially biased. Only one study, involving 40 participants, was available for the antidepressant comparison. This study found no differences between treatment with n‐3PUFAs and treatment with antidepressants in depressive symptomology (mean difference (MD) −0.70, 95% CI −5.88 to 4.48), rates of response to treatment (OR 1.23, 95% CI 0.35 to 4.31), or trial non‐completion (OR 1.00, 95% CI 0.21 to 4.71). Confidence intervals are however very wide in all analyses, and do not rule out important beneficial or detrimental effects of n‐3PUFAs compared to antidepressants. Adverse events were not reported in a manner suitable for analysis, and rates of depression remission and quality of life were not reported. Authors' conclusions At present, we do not have sufficient high‐certainty evidence to determine the effects of n‐3PUFAs as a treatment for MDD. Our primary analyses may suggest a small‐to‐modest, non‐clinically beneficial effect of n‐3PUFAs on depressive symptomology compared to placebo; however the estimate is imprecise, and we judged the certainty of the evidence on which this result is based to be low to very low. Our data may also suggest similar rates of adverse events and trial non‐completion in n‐3PUFA and placebo groups, but again our estimates are very imprecise. Effects of n‐3PUFAs compared to antidepressants are very imprecise and uncertain. More complete evidence is required for both the potential positive and negative effects of n‐3PUFAs for MDD. Plain language summary Omega‐3 fatty acids for depression in adults Why is this review important? Major depressive disorder (MDD) is characterised by depressed mood or a markedly decreased pleasure or interest in all activities, or both. It has negative impacts on the individual and on society, often over the long term. One possible treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, in some other seafood and in some nuts and seeds. Various lines of evidence suggest that n‐3PUFAs may impact on depressive symptoms, but a lot of studies have different findings, making it difficult to draw conclusions. Who will be interested in this review? Health professionals, including general practitioners, mental health and psychiatric specialists; individuals with MDD; and the people around them. What questions does this review aim to answer? Do n‐3PUFAs, compared to an alternative, have an effect on depressive symptoms, negative side effects, rates of recovery, quality of life, and rates of study non‐completion, in individuals with MDD? Which studies were included in the review? This review is an update of earlier work (Appleton 2015), using the same methods. We searched scientific databases for all randomised controlled trials in adults with MDD, where individuals received either n‐3PUFAs or an alternative, that were completed up to January 2021. We have included 35 relevant studies: 34 of them involving 1924 people compared the effects of n‐3PUFAs with those of placebo, and one study involving 40 people compared the effects of n‐3PUFAs with those of antidepressants. All studies were of direct relevance to our review, but we considered the certainty of the evidence to be low to very low. What does the evidence from the review tell us? At present, we do not have enough high quality evidence to determine the effects of n‐3PUFAs as a treatment for MDD. We found a small‐to‐modest positive effect of n‐3PUFAs compared to placebo, but the size of this effect is unlikely to be meaningful to people with MDD, and we considered the evidence to be of low or very low certainty, with many differences between studies. There was also insufficient high quality evidence to determine the effects of n‐3PUFAs on negative side effects or numbers not completing studies. What should happen next? We need more evidence, particularly to explain the differences between study findings, e.g. by looking at individuals who may or may not benefit from n‐3PUFAs. Future studies should also compare n‐3PUFAs with usual antidepressant treatment, and investigate the way these treatments may work.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Appleton, KM; Voyias, PD; Sallis, HM; Dawson, S; Ness, AR; Churchill, R; Perry, R", "articleTypes": [], "doi": "10.1002/14651858.CD004692.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "399ca0a9-8fc1-4341-b6d7-e5501a8952a2", "pmid": "", "title": "Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia", "imported": false, "abstract": "Abstract - Background In a review and meta‐analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion‐focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect. Objectives To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic. Search methods We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the `awaiting classification' section of this review. Selection criteria We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion‐focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post‐surgery. Data collection and analysis One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion. Where possible we used random‐effects meta‐analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges' g) to combine data from different outcome measures. If data were not available in a form suitable for meta‐analysis we performed a narrative review. Main results Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty‐one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta‐analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD ‐0.20, 95% confidence interval (CI) ‐0.35 to ‐0.06), length of stay (mean difference ‐0.52 days, 95% CI ‐0.82 to ‐0.22) and negative affect (SMD ‐0.35, 95% CI ‐0.54 to ‐0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached. Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall,we rated the quality of evidence for each outcome as ‘low’ because of the high level of heterogeneity in meta‐analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta‐analysis, so we rated the quality of evidence as `very low'. Authors' conclusions The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well‐conducted and clearly reported research. Plain language summary The effect of psychological preparation on pain, behavioural recovery, negative emotion and length of stay after surgery Background The way people think and feel before surgery can affect how they feel and what they do after surgery. For example, research shows that people who feel more anxious before their surgery experience more pain after it. A review conducted in 1993 looked at the impact of psychological preparation on outcomes after surgery. The term `psychological preparation' includes a range of techniques that aim to change what people think, how they feel or what they do. This 1993 review found that psychological preparation techniques reduced pain after surgery, improved behavioural recovery (how quickly people return to activities), decreased length of stay in hospital and reduced negative emotion (e.g. feelings of anxiety or depression). We aimed to carry out an up‐to‐date review using Cochrane methodology to learn whether there are helpful (or harmful) effects of psychological preparation for people undergoing surgery, and which outcomes (pain after surgery, behavioural recovery, negative emotion or length of stay) are improved. Study characteristics We included studies of adults who received planned surgery with general anaesthesia. We looked at seven psychological preparation techniques: procedural information (information about what, when and how processes will happen); sensory information (what the experience will feel like and what other sensations they may have, e.g. taste, smell); behavioural instruction (telling patients what they need to do); cognitive intervention (techniques that aim to change how people think); relaxation techniques; hypnosis; and emotion‐focused interventions (techniques that aim to help people to manage their feelings). The psychological preparation had to be delivered before surgery for the study to be included in the review. We included studies that looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion after surgery (within one month). Studies were included in the review up to the search date of 4 May 2014. We updated the search on 7 July 2015 and will incorporate the 38 studies found in this later search when the review is updated. We included 105 studies from 115 papers, with 10,302 participants taking part. Sixty‐one studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative emotion. In accordance with the review protocol, we did not record details about funding sources. Key results In this review we included 105 studies, which were reported in 115 papers. A total of 10,302 participants were randomized in these studies. For pain, length of stay and negative emotion we combined numerical findings from the studies. We found that psychological preparation before surgery seemed to reduce pain and negative emotion after the operation and may reduce the time spent in hospital by around half a day but the quality of the evidence was low. Also, the studies used many different psychological preparation techniques (often in different combinations) so it was not possible to discover which techniques were better. We could not statistically combine numerical findings for behavioural recovery because few studies provided sufficient details and studies used different ways of measuring how quickly people returned to usual activities. In reviewing the studies, we found that psychological preparation, in particular behavioural instruction, may have the potential to improve behavioural recovery. However, the quality of this evidence was very low. We looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion in this review and did not find evidence to suggest that psychological preparation might lead to harm in these outcomes. However, as we did not look at other outcomes it is possible that we did not identify potential harm. Quality of the evidence Many studies were poorly reported, so we could not be confident that findings were reliable. For this reason and because of the large variation in psychological techniques, types of surgery and measures used, we graded the quality of the evidence as `low' for the outcomes pain, negative emotion and length of stay; we cannot be confident that these techniques help patients to recover from surgery. For behavioural recovery, we further downgraded the quality of the evidence to `very low' because of problems with measurement and reporting of the outcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, R; Scott, NW; Manyande, A; Bruce, J; Vögele, C; Byrne‐Davis, LMT; Unsworth, M; Osmer, C; Johnston, M", "articleTypes": [], "doi": "10.1002/14651858.CD008646.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "39ac370d-2822-4252-944b-054fe22941d9", "pmid": "", "title": "Rituximab for people with multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Filippini, G, Kruja, J, Del Giovane, C", "articleTypes": [], "doi": "10.1002/14651858.CD013874.pub3 AB - Abstract - Background Multiple sclerosis (MS) is the most common neurological cause of disability in young adults. Off‐label rituximab for MS is used in most countries surveyed by the International Federation of MS, including high‐income countries where on‐label disease‐modifying treatments (DMTs) are available. This updates the 2021 version of the review. Objectives To assess the benefits and harms of rituximab as 'first choice' and 'switching' treatment for adults with any form of MS. Search methods We searched CENTRAL , MEDLINE, Embase, CINAHL, and three trials registers on 31 December 2023, together with reference checking and contacting study authors to identify unpublished studies. Selection criteria We included randomised controlled trials (RCTs) and controlled non‐randomised studies of interventions (NRSIs) comparing rituximab with placebo or another DMT for adults with any form of MS. Data collection and analysis We followed standard Cochrane methods. We used RoB 1 to assess risk of bias in RCTs and ROBINS‐I in NRSIs. We assessed the certainty of evidence for critical and important prioritised outcomes using GRADE: disability worsening, relapse, serious adverse events (SAEs), health‐related quality of life (HRQoL), common infections, cancer, and mortality. We conducted separate analyses for rituximab as 'first choice' or as 'switching' treatment, relapsing or progressive MS, comparison with placebo or another DMT, and RCTs or NRSIs. Main results In this update, the number of study participants increased from 16,429 (15 studies) to 37,443 (28 studies; 13 new studies: 1 RCT and 12 NRSIs). The studies were conducted worldwide; most originated from high‐income countries (25 studies). Public institutions funded 22 (79%) of the studies. Most studies investigated the effects of rituximab on people with relapsing MS (19 studies; 27,500 (73%) participants). We identified 12 ongoing studies. Rituximab as 'first choice' for active relapsing MS None of the included studies compared rituximab to placebo. One RCT compared rituximab to dimethyl fumarate, with 24 months' follow‐up. Rituximab may reduce the recurrence of relapse (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.04 to 0.57; 195 participants; low‐certainty evidence). The evidence is very uncertain on disability worsening and SAEs. Rituximab may result in little to no difference in upper respiratory tract infections (rate ratio (RR) 1.03, 95% CI 0.79 to 1.34; low‐certainty evidence). The evidence is very uncertain for urinary tract, skin, and viral infections. HRQoL, cancer, and mortality were not reported. One NRSI compared rituximab to other DMTs, with 24 months' follow‐up. Disability worsening was not reported. Compared with interferon beta or glatiramer acetate, rituximab likely delays relapse (hazard ratio (HR) 0.14, 95% CI 0.05 to 0.39; 1 study, 335 participants; moderate‐certainty evidence). Compared with dimethyl fumarate and natalizumab, rituximab may delay relapse (dimethyl fumarate: HR 0.29, 95% CI 0.08 to 1.00; 1 study, 206 participants; low‐certainty evidence; natalizumab: HR 0.24, 95% CI 0.06 to 1.00; 1 study, 170 participants; low‐certainty evidence). The evidence for relapse is very uncertain when comparing rituximab to fingolimod. The effect on SAEs is uncertain due to very few events in all the comparison groups. No deaths were reported. HRQoL, common infections, and cancer were not reported. Rituximab as 'first choice' for primary progressive MS One RCT compared rituximab to placebo, with 24 months' follow‐up. Rituximab likely results in little or no difference in disability worsening (OR 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate‐certainty evidence). The evidence is very uncertain on relapse, SAEs, common infections, cancer, and mortality. HRQoL was not reported. None of the included studies compared rituximab as 'first choice' treatment to other DMTs for primary or secondary progressive MS. Rituximab as 'switching' treatment for relapsing MS One small RCT compared rituximab to placebo, with 12 months' follow‐up. Disability worsening was not reported. Rituximab may reduce recurrence of relapses (OR 0.38, 95% CI 0.16 to 0.93; 1 study, 104 participants; low‐certainty evidence). The evidence is very uncertain regarding SAEs, common infections, cancer, and mortality. HRQoL was not reported. Twelve NRSIs compared rituximab to other DMTs, with 24 months' follow‐up. The evidence on disability worsening is very uncertain in comparison with interferons or glatiramer acetate, natalizumab, alemtuzumab, and ocrelizumab. Rituximab likely delays time to relapse in comparison with interferons or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 study, 1383 participants; moderate‐certainty evidence), fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 study, 256 participants; moderate‐certainty evidence), and may result in little or no difference compared with natalizumab (HR 0.96, 95% CI 0.83 to 1.10; 3 studies, 1922 participants; low‐certainty evidence). The evidence is very uncertain on relapse in comparison with alemtuzumab. There is uncertainty regarding SAEs when comparing rituximab to natalizumab and fingolimod. Rituximab likely increases serious common infections when compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 study, 5477 participants; moderate‐certainty evidence) and natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 studies, 5001 participants; moderate‐certainty evidence). The evidence for common infections is very uncertain when comparing rituximab to fingolimod and ocrelizumab. Rituximab may slightly reduce the risk of cancer compared with natalizumab (HR 0.79, 95% CI 0.62 to 0.99; 2 studies, 6202 participants; low‐certainty evidence), whereas the evidence is very uncertain in comparison with fingolimod. The effect of rituximab on mortality is very uncertain due to very few events in all the comparison groups. HRQoL was not reported. Authors' conclusions For preventing relapses in relapsing MS, rituximab as 'first choice' and 'switching' treatment compares favourably with a wide range of approved DMTs. The protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab on primary progressive MS. There is limited evidence for long‐term adverse events of rituximab in people with MS. Evidence for serious adverse events, cancer, and mortality was of very low certainty due to few events. There is an increased risk of serious (hospital‐treated) infections with rituximab compared with other DMTs, although the absolute risk is low. High‐quality (prospectively registered) NRSIs should be conducted to draw more reliable conclusions about the potential benefits and harms of rituximab in people with MS. Plain language summary Is rituximab better for people with multiple sclerosis than other disease‐modifying medicines? Key messages • We are uncertain whether rituximab prevents disability worsening in people with any form of multiple sclerosis (MS). 
• Rituximab may offer moderate‐to‐large benefit against a range of other medicines in preventing relapses in relapsing MS, both in people treated with rituximab for the first time and in those given rituximab after other medicines failed to work or became unsuitable.
• Very few people given rituximab in the studies had serious unwanted/harmful events, developed cancer, or died over 24 months' follow‐up. What is multiple sclerosis (MS)? MS is a disease affecting the central nervous system, in which the body’s immune system mistakenly attacks the protective covering of nerve fibres, which leads to inflammation and damage. Communication between the brain and the rest of the body is affected, resulting in a wide range of symptoms. There are two main types: (1) relapsing MS, where someone has periods of relapse (worsening of symptoms) followed by remissions (improvement or complete recovery); and (2) progressive MS, where symptoms worsen over time, without distinct periods of improvement. Relapsing MS is more common. How is MS treated? There is no cure for MS, so the goal of treatment is to manage symptoms, reduce disease activity, slow progression, and improve quality of life. This involves giving people with MS disease‐modifying treatments (DMTs), in contrast to treatments which only manage symptoms. There are different kinds of disease‐modifying treatments for MS, including rituximab. Rituximab is: • a medicine given slowly via a needle in a vein (intravenous infusion) that can suppress certain immune cells;
• included in the World Health Organization (WHO) Model List of Essential Medicines for MS, which makes rituximab available worldwide. Rituximab is not always reimbursed by health systems because it is not licensed for MS by marketing authorities;
• a highly effective treatment. It's cheaper and is given less often than other approved medicines for MS. Treatment with rituximab requires specialist care and infusion facilities, but other approved medicines do too. What did we want to find out? We wanted to find out the effects of rituximab on people with any form of MS on: • disability worsening, relapse, and quality of life;
• unwanted effects, such as serious harmful effects, serious common infections, cancer, and death. What did we do? We searched for studies that compared rituximab with other infused medicines (e.g. natalizumab), injectable medicines (e.g. interferon beta, glatiramer acetate), and oral medicines (e.g. fingolimod, dimethyl fumarate). We compared and summarised the results of the included studies, and rated our confidence in the evidence, based on factors such as study methods and quality. What did we find? We found 28 studies that involved 37,443 people with MS and lasted one or two years. The biggest study involved 8600 people and the smallest, 27 people. Most people (27,500, 73% of all participants) had a relapsing form of MS, while only 813 (2%) had a progressive form. Three studies included 9130 (24%) people with all forms of MS. Most studies originated from high‐income countries. Public institutions funded 22 (79%) of the studies. MAIN RESULTS Relapsing forms of MS • We do not know if rituximab has an effect on long‐term disability worsening due to the short follow‐up period of the studies.
• For people treated with rituximab for the first time as well as those given rituximab after other medicines failed to work or became unsuitable, rituximab may reduce the risk of relapses compared with interferon beta or glatiramer acetate, dimethyl fumarate, fingolimod, and natalizumab (evidence from 16 studies). 
• Serious unwanted effects of rituximab are very few. However, we do not know if rituximab has an effect on long‐term serious unwanted effects due to the short follow‐up period of the studies.
• Rituximab likely increases serious common infections (i.e. hospital‐treated infections) compared with other approved medicines for MS. However, the likelihood of serious common infections occurring is low in terms of the total number of people being considered. Progressive forms of MS We do not know if rituximab has benefits for people with primary progressive MS. What are the main limitations of the evidence? Our confidence in the evidence is limited because of three main factors. First, people were not randomly placed into different treatment groups in most of the studies. This means that differences between the groups could be due to differences between participants rather than between the comparison treatments. Second, we found few studies in which participants were assigned randomly to different treatment groups. These studies were small and used methods likely to introduce errors in their results. Third, results originated from short‐term studies. This is an important issue for people with a lifelong disease such as MS, who need to know the long‐term benefits and unwanted effects of a medicine. How current is the evidence? This review updates our previous review. The evidence is current to 31 December 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.818Z" }, { "id": "39b840f6-49c7-4336-a0ec-c66bcf08c7e2", "pmid": "", "title": "Modafinil for people with schizophrenia or related disorders", "imported": false, "abstract": "Abstract - Background People with schizophrenia have a range of different symptoms, including positive symptoms (hallucinations and delusions), negative symptoms (such as social withdrawal and lack of affect), and cognitive impairment. The standard medication for people with schizophrenia is antipsychotics. However, these medications may not be effective for all symptoms of schizophrenia, as cognitive and negative symptoms are usually hard to treat. Additional therapies or medications are available for the management of these symptoms. Modafinil, a wakefulness‐promoting agent most frequently used in narcolepsy or shift work sleep disorder, is one intervention that is theorised to have an effect of these symptoms. Objectives The primary objective of this review was to assess the effects of modafinil for people with schizophrenia or related disorders. Search methods On 27 April 2015, 24 May 2017, and 31 October 2019, we searched the Cochrane Schizophrenia Group's register of trials, which is based on regular searches of CENTRAL, MEDLINE, Embase, AMED, BIOSIS, CINAHL, PsycINFO, PubMed, and registries of clinical trials. There are no language, time, document type, or publication status limitations for the inclusion of records in the register. Selection criteria We selected all randomised controlled trials comparing modafinil with placebo or other treatments for people with schizophrenia or schizophrenia‐spectrum disorders. Data collection and analysis We independently extracted data from the included studies. We analysed dichotomous data using risk ratios (RR) and 95% confidence intervals (CI). We analysed continuous data using mean difference (MD) with a 95% CI. We used a random‐effects model for the meta‐analysis. We used GRADE to complete a 'Summary of findings' table and assessed risk of bias for the included studies. Main results Eleven studies including a total of 422 participants contributed to data analyses. Most studies had a small population size (average 38 people per study) and were of short duration. We also detected a high risk of bias for selective outcome reporting in just under 50% of the trials. We therefore rated the overall methodological quality of the included studies as low. We considered seven main outcomes of interest: clinically important change in overall mental state, clinically important change in cognitive functioning, incidence of a clinically important adverse effect/event, clinically important change in global state, leaving the study early for any reason, clinically important change in quality of life, and hospital admission. All studies assessed the effects of adding modafinil to participants' usual antipsychotic treatment compared to adding placebo to usual antipsychotic treatment. Six studies found that adding modafinil to antipsychotic treatment may have little or no effect on overall mental state of people with schizophrenia, specifically the risk of worsening psychosis (RR 0.91, 95% CI 0.28 to 2.98; participants = 209; studies = 6, low‐quality evidence ). Regarding the effect of modafinil on cognitive function, the trials did not report clinically important change data, but one study reported endpoint scores on the MATRICS Consensus Cognitive Battery (MCCB): in this study we found no clear difference in scores between modafinil and placebo treatment groups (MD −3.10, 95% CI −10.9 to 4.7; participants = 48; studies = 1, very low‐quality evidence ). Only one study (N = 35) reported adverse effect/event data. In this study one serious adverse event occurred in each group (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). One study measured change in global state using the Clinical Global Impression ‐ Improvement Scale. This study found that adding modafinil to antipsychotic treatment may have little or no effect on global state (RR 6.36, 95% CI 0.94 to 43.07, participants = 21; studies = 1, very low‐quality evidence ). Nine studies found that modafinil has no effect on numbers of participants leaving the study early (RR 1.26, 95% CI 0.63 to 2.52 participants = 357; studies = 9, moderate‐quality evidence ). None of the trials reported clinically important change in quality of life, but one study did report quality of life using endpoint scores on the Quality of Life Inventory, finding no clear difference between treatment groups (MD −0.2, 95% CI −1.18 to 0.78; participants = 20; studies = 1, very low‐quality evidence ). Finally, one study reported data for number of participants needing hospitalisation: one participant in each group was hospitalised (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). Authors' conclusions Due to methodological issues, low sample size, and short duration of the clinical trials as well as high risk of bias for outcome reporting, most of the evidence available for this review is of very low or low quality. For results where quality is low or very low, we are uncertain or very uncertain if the effect estimates are true effects, limiting our conclusions. Specifically, we found that modafinil is no better or worse than placebo at preventing worsening of psychosis; however, we are uncertain about this result. We have more confidence that participants receiving modafinil are no more likely to leave a trial early than participants receiving placebo. However, we are very uncertain about the remaining equivocal results between modafinil and placebo for outcomes such as improvement in global state or cognitive function, incidence of adverse events, and changes in quality of life. More high‐quality data are needed before firm conclusions regarding the effects of modafinil for people with schizophrenia or related disorders can be made. Plain language summary Modafinil for schizophrenia Review question: Is adding modafinil to antipsychotic treatment effective and safe for people with schizophrenia? Background Schizophrenia is a complicated and chronic mental disorder that usually presents with a wide range of symptoms. The standard treatment (antipsychotics) is considered to be effective for the positive symptoms (such as delusions and hallucinations or bizarre thoughts). However, there are negative and cognitive symptoms (such as social withdrawal, lack of affect, problems with memory) that are not adequately treated with these medications. These symptoms tend to be chronic and can therefore have a long‐term impact on an individual's quality of life. Additional treatments are often added to antipsychotic treatment, of which one is modafinil, a wakefulness‐promoting medication usually used for sleep disorders. Searching for evidence We ran an electronic search of Cochrane Schizophrenia's register of trials in April 2015, May 2017, and October 2019 for trials that randomised (allocated participants to treatment groups using a random method) people with schizophrenia to receive add‐on modafinil (modafinil added to their standard care) or to receive add‐on placebo. We identified 67 records that referred to 25 studies. Evidence found Eleven studies met the review requirements and reported data that could be used in analyses. However, the trials included small numbers of participants and were of short duration; schizophrenia is a long‐term health problem that ideally requires studies of longer duration. Our analysis of the data showed there is no clear difference between add‐on modafinil and add‐on placebo for improving mental state or global state, changing cognitive functioning, causing participants to leave a study early, producing adverse effects, or affecting rates of hospitalisation. However, most of these results were based on very low‐ or low‐quality data, therefore it is uncertain if these statistical effect sizes found by our data analyses are true effects. Conclusions The results of this review indicate no clear difference in effectiveness and safety between add‐on modafinil and add‐on placebo, however these results are not conclusive as they are based low‐ or very low‐quality evidence. Based on the current evidence we were unable to provide an answer to our review question as to whether modafinil is better than placebo for improving the symptoms of schizophrenia, or if it is safe to use for people with schizophrenia. More high‐quality research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ortiz-Orendain, J, Covarrubias-Castillo, SA, Vazquez-Alvarez, AO, Castiello-de Obeso, S, Arias Quiñones, GE, Seegers, M, Colunga-Lozano, LE", "articleTypes": [], "doi": "10.1002/14651858.CD008661.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.124Z" }, { "id": "39ba90c9-3b3a-4127-8a09-f9d78bc81db6", "pmid": "", "title": "Interventions for drooling in children with cerebral palsy", "imported": false, "abstract": "Abstract - Background Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation ( Blasco 1992 ; Van der Burg 2006 ). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP. Objectives (1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning. Search methods We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts. We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled‐trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts. Selection criteria Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included. Data collection and analysis Data were extracted independently by MW, MS and LP and differences resolved through discussion. Main results Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin‐A (BoNT‐A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro‐motor and oro‐sensory therapies, behavioural interventions, intra‐oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta‐analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies. Authors' conclusions It was not possible to reach a conclusion on the effectiveness and safety of either BoNT‐A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided. Plain language summary Interventions for drooling in children with cerebral palsy Many children with CP have difficulty controlling saliva. Drooling varies in severity and can be distressing for the children, families and caregivers. Excessive drooling can cause constant damp soiled clothing, unpleasant odour, irritated, chapped or sore skin around the mouth and chin, skin and mouth infections, dehydration, difficulties chewing, interference with speech, damage to books, communication aids, computer and audio equipment. There is also risk of social rejection and social isolation for these children. Many interventions are used to reduce or eliminate drooling. These include surgery, medications, botulinum toxin (BoNT‐A and BoNT‐B)), physical therapies, therapies to improve sensory function, behavioural therapies to assist the child in managing his/her own drooling, appliances placed in the mouth, and acupuncture. There is no clear consensus on which interventions are safe and effective in managing drooling in children with CP. This makes it hard to decide which intervention will be safest and most effective. Only RCTs and CCTs were included in this review. Trials were identified by electronic searches of databases, searches of clinical trials registers, peer reviewed journals, published conference proceedings and reference lists of relevant articles. Six trials were found. Four examined the safety and efficacy of BoNT‐A and two examined benztropine and glycopyrrolate. No trials were found on other interventions. The quality of trials was variable. The trials all differed in the children recruited, the product used, how the product was delivered and how its effectiveness was measured. All trials reported a positive reduction in drooling and all showed some statistically significant change for treatment groups up to 1 month post intervention. Few studies examined client and/or carer satisfaction with the intervention. Some looked at side effects of the intervention but no study examined the effect of interventions on the child's quality of life or psychological well being. There is insufficient evidence to support the use of one intervention over another. As trials on just two kinds of interventions were retrieved, and given the variation and quality of these studies, it is not possible to conclude that one intervention is more effective than another. The lack of trials on other interventions does not suggest that these interventions are ineffective. Adequately powered well designed trials are required across all interventions. In addition to using sensitive measures looking at change in salivary flow, measures are needed that examine client and carer satisfaction, changes in quality of life, psychological well being and in unwanted symptoms associated with drooling.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Walshe, M; Smith, M; Pennington, L", "articleTypes": [], "doi": "10.1002/14651858.CD008624.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "39c83b96-1e61-4e24-adc3-dec39445e748", "pmid": "", "title": "Full‐mouth treatment modalities (within 24 hours) for periodontitis in adults", "imported": false, "abstract": "Abstract - Background Periodontitis is a highly prevalent, chronic inflammation that causes damage to the soft tissues and bones supporting the teeth. Conventional treatment is quadrant scaling and root planing (the second step of periodontal therapy), which comprises scaling and root planing of teeth in one quadrant of the mouth at a time, with the four different sessions separated by at least one week. Alternative protocols for anti‐infective periodontal therapy have been introduced to help enhance treatment outcomes: full‐mouth scaling (subgingival instrumentation of all quadrants within 24 hours), or full‐mouth disinfection (subgingival instrumentation of all quadrants in 24 hours plus adjunctive antiseptic). We use the older term 'scaling and root planing' (SRP) interchangeably with the newer term 'subgingival instrumentation' in this iteration of the review, which updates one originally published in 2008 and first updated in 2015. Objectives To evaluate the clinical effects of full‐mouth scaling or full‐mouth disinfection (within 24 hours) for the treatment of periodontitis compared to conventional quadrant subgingival instrumentation (over a series of visits at least one week apart) and to evaluate whether there was a difference in clinical effects between full‐mouth disinfection and full‐mouth scaling. Search methods An information specialist searched five databases up to 17 June 2021 and used additional search methods to identify published, unpublished and ongoing studies. Selection criteria We included randomised controlled trials (RCTs) lasting at least three months that evaluated full‐mouth scaling and root planing within 24 hours, with or without adjunctive use of an antiseptic, compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of (chronic) periodontitis according to the International Classification of Periodontal Diseases from 1999. A new periodontitis classification was launched in 2018; however, we used the 1999 classification for inclusion or exclusion of studies, as most studies used it. We excluded studies of people with systemic disorders, taking antibiotics or with the older diagnosis of 'aggressive periodontitis'. Data collection and analysis Several review authors independently conducted data extraction and risk of bias assessment (based on randomisation method, allocation concealment, examiner blinding and completeness of follow‐up). Our primary outcomes were tooth loss and change in probing pocket depth (PPD); secondary outcomes were change in probing attachment (i.e. clinical attachment level (CAL)), bleeding on probing (BOP), adverse events and pocket closure (the number/proportion of sites with PPD of 4 mm or less after treatment). We followed Cochrane's methodological guidelines for data extraction and analysis. Main results We included 20 RCTs, with 944 participants, in this updated review. No studies assessed the primary outcome tooth loss. Thirteen trials compared full‐mouth scaling and root planing within 24 hours without the use of antiseptic (FMS) versus control, 13 trials compared full‐mouth scaling and root planing within 24 hours with adjunctive use of an antiseptic (FMD) versus control, and six trials compared FMS with FMD. Of the 13 trials comparing FMS versus control, we assessed three at high risk of bias, six at low risk of bias and four at unclear risk of bias. We assessed our certainty about the evidence as low or very low for the outcomes in this comparison. There was no evidence for a benefit for FMS over control for change in PPD, gain in CAL or reduction in BOP at six to eight months (PPD: mean difference (MD) 0.03 mm, 95% confidence interval (CI) –0.14 to 0.20; 5 trials, 148 participants; CAL: MD 0.10 mm, 95% CI –0.05 to 0.26; 5 trials, 148 participants; BOP: MD 2.64%, 95% CI –8.81 to 14.09; 3 trials, 80 participants). There was evidence of heterogeneity for BOP (I² = 50%), but none for PPD and CAL. Of the 13 trials comparing FMD versus control, we judged four at high risk of bias, one at low risk of bias and eight at unclear risk of bias. At six to eight months, there was no evidence for a benefit for FMD over control for change in PPD or CAL (PPD: MD 0.11 mm, 95% CI –0.04 to 0.27; 6 trials, 224 participants; low‐certainty evidence; CAL: 0.07 mm, 95% CI –0.11 to 0.24; 6 trials, 224 participants; low‐certainty evidence). The analyses found no evidence of a benefit for FMD over control for BOP (very low‐certainty evidence). There was no evidence of heterogeneity for PPD or CAL, but considerable evidence of heterogeneity for BOP, attributed to one study. There were no consistent differences in these outcomes between intervention and control (low‐ to very low‐certainty evidence). Of the six trials comparing FMS and FMD, we judged two trials at high risk of bias, one at low risk of bias and three as unclear. At six to eight months, there was no evidence of a benefit of FMD over FMS for change in PPD or gain in CAL (PPD: MD –0.11 mm, 95% CI –0.30 to 0.07; P = 0.22; 4 trials, 112 participants; low‐certainty evidence; CAL: MD –0.05 mm, 95% CI –0.23 to –0.13; P = 0.58; 4 trials, 112 participants; low‐certainty evidence). There was no evidence of a difference between FMS and FMD for BOP at any time point (P = 0.98; 2 trials, 22 participants; low‐ to very low‐certainty evidence). There was evidence of heterogeneity for BOP (I² = 52%), but not for PPD or CAL. Thirteen studies predefined adverse events as an outcome; three reported an event after FMD or FMS. The most important harm identified was an increase in body temperature. We assessed the certainty of the evidence for most comparisons and outcomes as low because of design limitations leading to risk of bias, and the small number of trials and participants, leading to imprecision in the effect estimates. Authors' conclusions The inclusion of nine new RCTs in this updated review has not changed the conclusions of the previous version of the review. There is still no clear evidence that FMS or FMD approaches provide additional clinical benefit compared to conventional mechanical treatment for adult periodontitis. In practice, the decision to select one approach to non‐surgical periodontal therapy over another should include patient preference and the convenience of the treatment schedule. Plain language summary Treating all teeth (full mouth) within 24 hours for gum disease (periodontitis) in adults Background Long‐lasting gum disease (periodontitis) is a common chronic inflammatory disease that causes damage to soft tissues (gums) and bone around teeth, and can result in tooth loss. Non‐surgical treatments are used to stop and control the disease. These are based on 'subgingival instrumentation', that is, the mechanical removal of bacteria below the gums from the infected root surfaces of the teeth. Conventional treatment is carried out in two to four sessions over several weeks, scaling a different section (or 'quadrant') of the mouth each time. This has traditionally been known as 'scaling and root planing' (SRP). An alternative approach is to treat the whole mouth within 24 hours in one or two sessions (known as full‐mouth scaling (FMS)). When an antiseptic agent (like chlorhexidine) is added to FMS, the intervention is called full‐mouth disinfection (FMD). The rationale for using these full‐mouth approaches is to reduce the likelihood of re‐infection in already treated sites. Review question This review, produced within Cochrane Oral Health, is the second update of one we originally published in 2008. It evaluates the effectiveness of full‐mouth treatments within 24 hours (FMS and FMD) compared to conventional treatment over a number of weeks, and whether there is a difference between FMS and FMD. The evidence is current up to June 2021. Study characteristics The included studies were randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that evaluated a full‐mouth approach to subgingival instrumentation, with at least three months of monitoring (follow‐up). Both FMS and FMD were compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of chronic periodontitis and we excluded studies of people with aggressive periodontitis, systemic disorders (affecting other part of the body) or who were taking antibiotics. We included nine new studies in this update and we excluded one trial that had been included in the previous version of the review. In total, the review now includes 20 studies that involved 944 participants. Key results Treatment effects of FMS and FMD are modest and there are no clear implications for periodontal care. Neither treatment was superior to the usual treatment of scaling and root planing a quarter of the mouth at a time. The most important harm identified was an increased body temperature after FMS or FMD treatments, reported in three out of 13 studies. In practice, the decision to select one approach over another will be based on preference and convenience for patient and dentist. Certainty of the evidence Our confidence in the results is low for most comparisons and outcomes, due to the small number of studies and participants involved, and limitations in study designs. The addition of nine studies has not changed the findings of our previous version of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jervøe-Storm, P-M; Eberhard, J; Needleman, I; Worthington, HV; Jepsen, S", "articleTypes": [], "doi": "10.1002/14651858.CD004622.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "39e354d6-339e-4c68-9669-097ef02e4fe6", "pmid": "", "title": "Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight", "imported": false, "abstract": "Abstract - Background The global prevalence of childhood and adolescent obesity is high. Lifestyle changes towards a healthy diet, increased physical activity and reduced sedentary activities are recommended to prevent and treat obesity. Evidence suggests that changing these health behaviours can benefit cognitive function and school achievement in children and adolescents in general. There are various theoretical mechanisms that suggest that children and adolescents with excessive body fat may benefit particularly from these interventions. Objectives To assess whether lifestyle interventions (in the areas of diet, physical activity, sedentary behaviour and behavioural therapy) improve school achievement, cognitive function (e.g. executive functions) and/or future success in children and adolescents with obesity or overweight, compared with standard care, waiting‐list control, no treatment, or an attention placebo control group. Search methods In February 2017, we searched CENTRAL, MEDLINE and 15 other databases. We also searched two trials registries, reference lists, and handsearched one journal from inception. We also contacted researchers in the field to obtain unpublished data. Selection criteria We included randomised and quasi‐randomised controlled trials (RCTs) of behavioural interventions for weight management in children and adolescents with obesity or overweight. We excluded studies in children and adolescents with medical conditions known to affect weight status, school achievement and cognitive function. We also excluded self‐ and parent‐reported outcomes. Data collection and analysis Four review authors independently selected studies for inclusion. Two review authors extracted data, assessed quality and risks of bias, and evaluated the quality of the evidence using the GRADE approach. We contacted study authors to obtain additional information. We used standard methodological procedures expected by Cochrane. Where the same outcome was assessed across different intervention types, we reported standardised effect sizes for findings from single‐study and multiple‐study analyses to allow comparison of intervention effects across intervention types. To ease interpretation of the effect size, we also reported the mean difference of effect sizes for single‐study outcomes. Main results We included 18 studies (59 records) of 2384 children and adolescents with obesity or overweight. Eight studies delivered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies delivered dietary interventions. We included five RCTs and 13 cluster‐RCTs. The studies took place in 10 different countries. Two were carried out in children attending preschool, 11 were conducted in primary/elementary school‐aged children, four studies were aimed at adolescents attending secondary/high school and one study included primary/elementary and secondary/high school‐aged children. The number of studies included for each outcome was low, with up to only three studies per outcome. The quality of evidence ranged from high to very low and 17 studies had a high risk of bias for at least one item. None of the studies reported data on additional educational support needs and adverse events. Compared to standard practice, analyses of physical activity‐only interventions suggested high‐quality evidence for improved mean cognitive executive function scores. The mean difference (MD) was 5.00 scale points higher in an after‐school exercise group compared to standard practice (95% confidence interval (CI) 0.68 to 9.32; scale mean 100, standard deviation 15; 116 children, 1 study). There was no statistically significant beneficial effect in favour of the intervention for mathematics, reading, or inhibition control. The standardised mean difference (SMD) for mathematics was 0.49 (95% CI ‐0.04 to 1.01; 2 studies, 255 children, moderate‐quality evidence) and for reading was 0.10 (95% CI ‐0.30 to 0.49; 2 studies, 308 children, moderate‐quality evidence). The MD for inhibition control was ‐1.55 scale points (95% CI ‐5.85 to 2.75; scale range 0 to 100; SMD ‐0.15, 95% CI ‐0.58 to 0.28; 1 study, 84 children, very low‐quality evidence). No data were available for average achievement across subjects taught at school. There was no evidence of a beneficial effect of physical activity interventions combined with healthy lifestyle education on average achievement across subjects taught at school, mathematics achievement, reading achievement or inhibition control. The MD for average achievement across subjects taught at school was 6.37 points lower in the intervention group compared to standard practice (95% CI ‐36.83 to 24.09; scale mean 500, scale SD 70; SMD ‐0.18, 95% CI ‐0.93 to 0.58; 1 study, 31 children, low‐quality evidence). The effect estimate for mathematics achievement was SMD 0.02 (95% CI ‐0.19 to 0.22; 3 studies, 384 children, very low‐quality evidence), for reading achievement SMD 0.00 (95% CI ‐0.24 to 0.24; 2 studies, 284 children, low‐quality evidence), and for inhibition control SMD ‐0.67 (95% CI ‐1.50 to 0.16; 2 studies, 110 children, very low‐quality evidence). No data were available for the effect of combined physical activity and healthy lifestyle education on cognitive executive functions. There was a moderate difference in the average achievement across subjects taught at school favouring interventions targeting the improvement of the school food environment compared to standard practice in adolescents with obesity (SMD 0.46, 95% CI 0.25 to 0.66; 2 studies, 382 adolescents, low‐quality evidence), but not with overweight. Replacing packed school lunch with a nutrient‐rich diet in addition to nutrition education did not improve mathematics (MD ‐2.18, 95% CI ‐5.83 to 1.47; scale range 0 to 69; SMD ‐0.26, 95% CI ‐0.72 to 0.20; 1 study, 76 children, low‐quality evidence) and reading achievement (MD 1.17, 95% CI ‐4.40 to 6.73; scale range 0 to 108; SMD 0.13, 95% CI ‐0.35 to 0.61; 1 study, 67 children, low‐quality evidence). Authors' conclusions Despite the large number of childhood and adolescent obesity treatment trials, we were only able to partially assess the impact of obesity treatment interventions on school achievement and cognitive abilities. School and community‐based physical activity interventions as part of an obesity prevention or treatment programme can benefit executive functions of children with obesity or overweight specifically. Similarly, school‐based dietary interventions may benefit general school achievement in children with obesity. These findings might assist health and education practitioners to make decisions related to promoting physical activity and healthy eating in schools. Future obesity treatment and prevention studies in clinical, school and community settings should consider assessing academic and cognitive as well as physical outcomes. Plain language summary Healthy weight interventions for improving thinking skills and school performance in children and teenagers with obesity What is the aim of this review? The aim of this Cochrane Review was to find out if healthy weight interventions can improve thinking skills and school performance in children and teenagers with obesity. Cochrane researchers collected and analysed all relevant studies to answer this question. What are the key messages? This updated review provides some evidence that school programmes that encourage healthier child weight may also provide ‘co‐benefits’ of thinking skills and school performance. However, we need more high‐quality healthy‐weight interventions that test thinking skills and school performance, as well as health outcomes. What was studied in this review? The number of children and teenagers with obesity is high worldwide. Some children and teenagers with obesity have health issues or are bullied because of their body weight. These experiences have been linked to problems in performing well in school, where they tend to perform less well in thinking tasks such as problem‐solving. Physical activity and healthy eating benefit a healthy body weight and improve thinking skills and school performance in children with a healthy weight. Studies found that healthy‐weight interventions can reduce obesity in children and teenagers, but it is unknown if and how well healthy‐weight interventions can improve thinking skills and school performance in children and teenagers with obesity. What are the main results of this review? The review authors found 18 studies which included a total of 2384 children and teenagers with obesity. Five studies assigned individual children to intervention or control groups. Thirteen studies allocated entire classes, school or school districts to the intervention and control group. Of the 18 studies, 11 involved children at primary/elementary‐school age. Eight studies offered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies offered dietary changes. The studies took place in 10 different countries. Seventeen studies had at least one flaw in how the study was done. This reduces the level of confidence we can have in the findings. Few studies shared the same type of school performance or thinking skills. Only three studies reported the same outcome. None of the studies reported on additional educational support needs and harmful events. We found that, compared with usual routine, physical activity interventions can lead to small improvements in problem‐solving skills. This finding was based on high‐quality evidence. Moderate‐quality findings showed that physical activity interventions do not improve mathematics and reading achievement in children with obesity. Very low‐quality evidence also suggested no benefits of physical activity interventions for improving uncontrolled behavioural responses. General school achievement was not reported in studies comparing physical activity interventions with standard practice. Studies that compared physical activity interventions plus healthy lifestyle education with standard practice were of low to very low quality. They showed no improvement in school achievement or uncontrolled behavioural responses in the intervention group compared to the control group. Problem‐solving skills were not reported in studies comparing physical activity plus healthy lifestyle education with standard practice. Our findings indicate that changing knowledge about nutrition, and changing the food offered in schools can lead to moderate improvements in general school achievement of teenagers with obesity, when compared to standard school practice. Replacing packed school lunch with a nutrient‐rich diet plus nutrition education did not improve mathematics and reading achievement of children with obesity. However, the quality of evidence for general school achievement, mathematics and reading was low. This means that future research is very likely to change the results, because included studies showed some methodological weaknesses (for example, small numbers of children and a high dropout of children from studies). Problem‐solving skills and uncontrolled behavioural responses were not reported for dietary intervention studies. How up‐to‐date is this review? The review authors searched the scientific literature for relevant studies in February 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Martin, A, Booth, JN, Laird, Y, Sproule, J, Reilly, JJ, Saunders, DH", "articleTypes": [], "doi": "10.1002/14651858.CD009728.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.776Z" }, { "id": "39f990c1-ed33-45be-813c-59bd53262cef", "pmid": "", "title": "Gut microbiome‐based interventions for the management of obesity in children and adolescents aged up to 19 years", "imported": false, "abstract": "Abstract - Background The epidemic of overweight and obesity affects more than 390 million children and adolescents aged 5 to 19 years and 37 million children under five years of age. Overweight and obesity are associated with both short‐ and long‐term consequences, including chronic inflammation, metabolic diseases, as well as alterations in the gut microbiome composition. Gut microbiome‐based approaches may impact microbiome‐related metrics such as diversity or the abundance of intestinal bacteria, which may be linked to obesity‐related outcomes. However, evidence regarding the effect of gut microbiome‐based interventions for the management of obesity is limited. Objectives To assess the effects of gut microbiome‐based interventions in the management of overweight or obesity in children and adolescents in all their diversity aged 0 to 19 years. Search methods We searched CENTRAL, MEDLINE, CINAHL, Web of Science Core Collection, BIOSIS Previews, Global Index Medicus (all regions), IBECS, SciELO, PAHO, PAHO IRIS, WHO IRIS, WHOLIS, Bibliomap, TRoPHI as well as ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 24 January 2025. We did not apply any language restrictions. Selection criteria We included randomised controlled trials that evaluated gut microbiome‐based interventions [i.e. prebiotics, probiotics, synbiotics, short‐chain fatty acids (SCFAs), and faecal microbiota transplantation (FMT)] compared to standard‐of‐care, placebo, or control interventions in children and adolescents aged 0 to 19 years with overweight or obesity. Data collection and analysis Two review authors independently screened titles and abstracts and full texts, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias 2 tool and certainty of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE), a framework for assessing the certainty of evidence and making recommendations in systematic reviews. Random‐effects meta‐analyses were performed unless only one study per outcome was available, for which fixed‐effect analyses were performed. Main results We found 17 studies (838 participants) from various countries, evaluating the effects of prebiotics, probiotics, synbiotics, SCFAs, and FMT on body mass index (BMI), body weight, waist circumference, total body fat percentage (%TBF), systolic and diastolic blood pressure, and adverse events. Of the 17 studies included, five studies were in adolescents aged 10 to 19 years, and 12 studies were in children and adolescents spanning both age groups, 0 to 19 years. Upon contacting authors for data grouped by age of the participants, no studies provided separate outcomes data for children and adolescents. The included studies were funded by either academic funding sources or grants from the public and private sectors. Additionally, 15 studies were classified as currently being conducted ('ongoing'). The certainty of evidence throughout was very low. In adolescents 10 to 19 years of age, probiotics compared to placebo or no intervention may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events. Similarly, FMT compared to placebo may have little to no effect on waist circumference, %TBF, blood pressure, and adverse events in this age group. According to one study with 41 participants and in children and adolescents 0 to 19 years of age, intervention with prebiotics compared to placebo may result in a small reduction in BMI (mean difference = ‐0.70, 95% CI = ‐1.25 to ‐0.15) and body weight (mean difference = ‐1.5, 95% CI = ‐2.61 to ‐0.39). Prebiotics compared to placebo may have little to no effect on waist circumference, %TBF, systolic blood pressure, and adverse events. No data were available on the effect of prebiotics on diastolic blood pressure. Probiotics compared to placebo may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events in children and adolescents (0 to 19 years). Synbiotics compared to placebo may result in a reduction in systolic blood pressure (mean difference = ‐40.00, 95% CI = ‐50.63 to ‐29.37) in children and adolescents (0 to 19 years); according to one study with 56 participants. The evidence is very uncertain about the effects of synbiotics compared to a placebo on BMI, body weight, waist circumference, blood pressure, and adverse events. No data were available on the effect of synbiotics compared to placebo on %TBF. Synbiotics, compared to probiotics, may have little to no effect on waist circumference, %TBF, and adverse events. No data were available on the effect of synbiotics compared to probiotics on BMI, body weight, and blood pressure. According to one study with 48 participants and very low‐certainty of evidence, SCFAs compared to placebo may result in a reduction in waist circumference (mean difference = ‐5.08, 95% CI = ‐7.40 to ‐2.76) and BMI (mean difference = ‐2.26, 95% CI = ‐3.24 to ‐1.28) in children and adolescents (0–19 years). SCFAs compared to placebo may have little to no effect on adverse events. No data were available on the effect of SCFAs on body weight, %TBF, and blood pressure. Adverse events, i.e. abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine, were reported in the prebiotics group but with very low incidence. Additionally, adverse events such as nausea and headache were reported in the SCFAs group, but with low incidence. Authors' conclusions In adolescents aged 10 to 19 years, gut microbiome‐based interventions may result in little to no difference in obesity‐related outcomes. In children and adolescents aged 0 to 19 years, prebiotics may result in a small reduction in BMI and body weight; synbiotics may result in a reduction in systolic blood pressure, and SCFAs may result in a reduction in BMI and waist circumference, albeit the certainty of evidence was very low. The evidence was of very low certainty due to few studies per comparison, small sample sizes, short intervention durations, and insufficient reporting of adverse events. More rigorous research examining different types of gut microbiome‐based interventions for the management of obesity is required in children and adolescents, both in clinical and community settings. Future trials should also report methods related to randomisation, blinding, and compliance, as well as include prespecified analysis plans. Plain language summary Review question How effective are the gut microbiome‐based interventions for the management of overweight or obesity in children and adolescents in all their diversity, aged 0 to 19 years? Key messages • It is unclear if gut microbiome‐based interventions (nutrition interventions targeting intestinal microbes) have an effect on body mass index (BMI), body weight, waist size, body fat percentage, measures of blood pressure, and adverse events in children and adolescents with overweight and obesity. • Further research, including larger trials, is required to understand the effects of gut microbiome‐based interventions for the management of overweight and obesity in children and adolescents. What is overweight or obesity? Overweight is a condition of excessive fat deposits, and obesity is a chronic disease characterised by excessive fat deposits that can affect most body systems, impair quality of life, and reduce life expectancy. BMI, calculated by dividing a person's weight in kilograms by their height in metres, squared, is often used to define overweight and obesity. How is overweight or obesity managed? Overweight or obesity may be managed through changes in diet, behavioural counselling for lifestyle modifications, medications, or surgery. Despite these approaches, this global epidemic affects more than 390 million children and adolescents aged 5 to 19 years, and 37 million children under five years of age as of 2022. Overweight or obesity is linked to abnormal metabolism and an imbalance in the gut microbiome. Published works have shown that nutrition interventions targeting the \"gut microbiome\" may have beneficial effects on body weight and body fat percentage. The gut microbiome is the community of harmless bacteria and other microorganisms in the human intestine needed for optimal health. What did we want to find out? We wanted to find out the effect of various nutritional interventions targeting the intestinal microbial community on BMI, body weight, waist circumference, total body fat percentage, blood pressure, and adverse events associated with the interventions amongst children and adolescents in all their diversity, aged 0 to 19 years. What did we do? We searched for studies that examined the effects of gut microbiome‐based interventions, including prebiotics (food ingredients that promote beneficial microbes in the gut), probiotics (live microbes that are good for health), synbiotics (a combination of both prebiotics and probiotics), short‐chain fatty acids (i.e. small fat molecules produced by intestinal bacteria by fermenting dietary fibre and non‐digestible carbohydrates), and faecal microbiota transplantation (i.e. a capsule containing stool microbes from a healthy donor), compared to standard‐of‐care (usual care), placebo, control, or no interventions in children and adolescents up to 19 years of age. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 17 studies involving 838 children and adolescents with overweight and obesity. The studies were conducted in different countries, including Spain, China, Taiwan, Canada, Mexico, Italy, Poland, Turkey, Iran, Thailand, Denmark, New Zealand, and the USA. Adolescents aged 10 to 19 years Nutrition interventions targeting intestinal microbes may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. Children and adolescents aged 0 to 19 years It is unclear if prebiotics have an effect on waist size, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that prebiotics compared to a dummy treatment (i.e. an intervention that does not contain any medicine but looks or tastes identical to the intervention being tested) may result in a small reduction in BMI and body weight, but the evidence is very uncertain. Probiotics compared to a dummy treatment may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. It is unclear if synbiotics have an effect on BMI, body weight, waist size, body fat percentage, diastolic blood pressure, and adverse events compared with a dummy treatment. One study found that synbiotics may result in a reduction in systolic blood pressure, but the evidence is very uncertain. It is unclear if short‐chain fatty acids have an effect on body weight, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that short‐chain fatty acids may result in a reduction in BMI and waist circumference, but the evidence is very uncertain. Side effects of the interventions were generally not reported in the included studies, but one study noted potential side effects such as abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine in the prebiotics group; however, the occurrence was very low. Nausea and headache were reported in another study in the short‐chain fatty acids group, but were minimal. What are the limitations of the evidence? The review's findings are limited by the small number of participants, the low number of available studies for each of the comparisons, the lack of long‐term data, and insufficient reporting of adverse effects. How up to date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fahim, SM; Huey, SL; Palma Molina, XE; Agarwal, N; Ridwan, P; Ji, N; Kibbee, M; Kuriyan, R; Finkelstein, JL; Mehta, S", "articleTypes": [], "doi": "10.1002/14651858.CD015875", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "3a306eaf-b79d-4d4e-971c-c516488f445a", "pmid": "", "title": "External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion). Objectives To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. Search methods We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index‐Science (CPCI‐S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. Selection criteria We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. Data collection and analysis We used standard Cochrane methodology to collect data and performed a network meta‐analysis using the standard frequentist graph‐theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption. Main results We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy‐nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow‐up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low‐certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled. Authors' conclusions Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method. Plain language summary Electrical shocks (electrical cardioversion) and drugs (pharmacological cardioversion) for restoring normal rhythm in patients with atrial fibrillation or atrial flutter Key Messages ‐ Electrical cardioversion and some drugs can be used to restore the normal rhythm in patients with atrial fibrillation (AF) and atrial flutter. While electrical cardioversion is highly effective in dealing with all arrhythmias, the efficacy of drugs varies, with some being only moderately effective or not working at all in persistent AF and atrial flutter. ‐ Electrical cardioversion seems to be a very safe option. The risk of severe complications with cardioversion using drugs was low, but additional precautions are needed. ‐ We need further studies to find out if these treatment options also have a positive effect on quality of life, or if they lead to relevant differences in the duration of hospital stay. What is atrial fibrillation? AF is the most frequent abnormal heart rhythm seen in the world. Patients with this condition may feel their heart beating rapidly and irregularly. This can occur for separate brief or long episodes (paroxysmal AF) or it may become continuous (persistent AF). Atrial flutter is a similar abnormal rhythm that causes similar symptoms, can cause episodes of variable duration and can also become continuous. What is cardioversion? Cardioversion is a treatment to restore the rhythm of the heart back to normal (sinus rhythm). What did we want to find out? We wanted to know if delivering a controlled electrical shock (i.e. electrical cardioversion) and drugs (i.e. pharmacological cardioversion) are effective and safe when restoring heart rhythm back to normal. What did we do? We searched for studies that investigated electrical and pharmacological cardioversion compared to each other or placebo (a medicine that looks like the real medicine but that has no active ingredient). We compared and summarised the results of the studies and rated our trust in these results, based on factors such as study methods and size. What did we find? We found 112 studies. We were able to combine and analyse the results from 72 studies, with 15,968 participants aged between 47 and 72 years. Thirty‐five studies included patients with paroxysmal AF (AF that terminates spontaneously or with intervention within 7 days of onset), 26 studies of patients with persistent AF (AF that is continuously sustained beyond seven days, including episodes terminated by cardioversion after ≥ 7 days), and 14 trials included patients with atrial flutter. The remaining included a mix of paroxysmal, persistent AF and atrial flutter. Main results For patients with paroxysmal AF, electrical cardioversion with biphasic incremental energy, fast‐acting drugs like intravenous vernakalant, flecainide, ibutilide and antazoline, and slower‐acting and/or oral drugs such as quinidine, propafenone, amiodarone and sotalol are effective at restoring sinus rhythm. For patients with persistent AF, electrical cardioversion with biphasic energy seems to be the most effective option; bepridil, quinidine and amiodarone tablets may also be effective in selected cases. For patients with atrial flutter, electrical cardioversion followed by dofetilide are the most effective options. The risk of death and stroke is very low for patients having cardioversion procedures. Malignant arrhythmias (torsade de pointes, sustained ventricular tachycardia or ventricular fibrillation, all of which are associated with high 1‐year mortality rate) were observed for dofetilide, ibutilide, sotalol, quinidine and vernakalant, justifying the need for special care and closer monitoring when using these drugs. Duration of hospitalisation data was available in three studies but, as there were variable timings in these studies, we could not combine them to assess their joint effectiveness. These studies suggest that the duration of hospitalisation may be lower with electrical cardioversion. Heart failure was observed in some patients treated with propafenone, flecainide, sotalol, amiodarone, vernakalant, and placebo, and was not observed in patients receiving electrical cardioversion, suggesting that the latter approach should be the preferred one if concerns exist regarding the occurrence of this outcome. Phlebitis (i.e. inflammation of the vein caused by using injectable drugs) occurred frequently in patients treated with amiodarone, and dysgeusia (i.e. impairment of the sense of taste) and sneezing occurred frequently in patients receiving vernakalant. What are the limitations of the observed results? We are sure or moderately sure of the results for the efficacy of treatments available for persistent AF and atrial flutter. We are less sure about the results for some of the treatment options for paroxysmal AF. Not enough data are available regarding quality of life, and data were limited regarding duration of hospital stay. The risk of stroke or dying was very low. How up to date are the studies and information on this review? The included studies and information are current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Kukendrarajah, K, Ahmad, M, Carrington, M, Ioannou, A, Taylor, J, Razvi, Y, Papageorgiou, N, Mead, GE, Nevis, IF, D'Ascenzo, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013255.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.142Z" }, { "id": "3a3c9751-62f3-4fe7-87a4-5ac88fe78ac6", "pmid": "", "title": "Ondansetron Pharmacotherapy for Hazardous Drinking in HIV+, African-American Women", "imported": false, "abstract": "The proposed randomized clinical trial will investigate a novel pharmacotherapy for hazardous drinking, HIV-infected men and women, using the serotonin receptor (5-HT3) antagonist ondansetron. The investigators predict that participants who are treated with active doses of ondansetron will reduce their drinking more and show better HIV treatment participation and progress compared to participants who are treated with placebo. This study will provide important new safety and efficacy results on drinking and HIV outcomes following alcohol pharmacotherapy in HIV-infected persons.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.240Z" }, { "id": "3a5d8310-5d23-48d4-8062-5464987029cd", "pmid": "", "title": "Honey for acute cough in children", "imported": false, "abstract": "Abstract - Background Cough causes concern for parents and is a major cause of outpatient visits. Cough can impact quality of life, cause anxiety, and affect sleep in children and their parents. Honey has been used to alleviate cough symptoms. This is an update of reviews previously published in 2014, 2012, and 2010. Objectives To evaluate the effectiveness of honey for acute cough in children in ambulatory settings. Search methods We searched CENTRAL (2018, Issue 2), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (2014 to 8 February 2018), Embase (2014 to 8 February 2018), CINAHL (2014 to 8 February 2018), EBSCO (2014 to 8 February 2018), Web of Science (2014 to 8 February 2018), and LILACS (2014 to 8 February 2018). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trial Registry Platform (WHO ICTRP) on 12 February 2018. The 2014 review included searches of AMED and CAB Abstracts, but these were not searched for this update due to lack of institutional access. Selection criteria Randomised controlled trials comparing honey alone, or in combination with antibiotics, versus no treatment, placebo, honey‐based cough syrup, or other over‐the‐counter cough medications for children aged 12 months to 18 years for acute cough in ambulatory settings. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included six randomised controlled trials involving 899 children; we added three studies (331 children) in this update. We assessed two studies as at high risk of performance and detection bias; three studies as at unclear risk of attrition bias; and three studies as at unclear risk of other bias. Studies compared honey with dextromethorphan, diphenhydramine, salbutamol, bromelin (an enzyme from the Bromeliaceae (pineapple) family), no treatment, and placebo. Five studies used 7‐point Likert scales to measure symptomatic relief of cough; one used an unclear 5‐point scale. In all studies, low score indicated better cough symptom relief. Using a 7‐point Likert scale, honey probably reduces cough frequency better than no treatment or placebo (no treatment: mean difference (MD) ‐1.05, 95% confidence interval (CI) ‐1.48 to ‐0.62; I² = 0%; 2 studies; 154 children; moderate‐certainty evidence; placebo: MD ‐1.62, 95% CI ‐3.02 to ‐0.22; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Honey may have a similar effect as dextromethorphan in reducing cough frequency (MD ‐0.07, 95% CI ‐1.07 to 0.94; I² = 87%; 2 studies; 149 children; low‐certainty evidence). Honey may be better than diphenhydramine in reducing cough frequency (MD ‐0.57, 95% CI ‐0.90 to ‐0.24; 1 study; 80 children; low‐certainty evidence). Giving honey for up to three days is probably more effective in relieving cough symptoms compared with placebo or salbutamol. Beyond three days honey probably had no advantage over salbutamol or placebo in reducing cough severity, bothersome cough, and impact of cough on sleep for parents and children (moderate‐certainty evidence). With a 5‐point cough scale, there was probably little or no difference between the effects of honey and bromelin mixed with honey in reducing cough frequency and severity. Adverse events included nervousness, insomnia, and hyperactivity, experienced by seven children (9.3%) treated with honey and two children (2.7%) treated with dextromethorphan (risk ratio (RR) 2.94, 95% Cl 0.74 to 11.71; I² = 0%; 2 studies; 149 children; low‐certainty evidence). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14, 95% Cl 0.01 to 2.68; 1 study; 80 children; low‐certainty evidence). When honey was compared with placebo, 34 children (12%) in the honey group and 13 (11%) in the placebo group complained of gastrointestinal symptoms (RR 1.91, 95% CI 1.12 to 3.24; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Four children who received salbutamol had rashes compared to one child in the honey group (RR 0.19, 95% CI 0.02 to 1.63; 1 study; 100 children; moderate‐certainty evidence). No adverse events were reported in the no‐treatment group. Authors' conclusions Honey probably relieves cough symptoms to a greater extent than no treatment, diphenhydramine, and placebo, but may make little or no difference compared to dextromethorphan. Honey probably reduces cough duration better than placebo and salbutamol. There was no strong evidence for or against using honey. Most of the children received treatment for one night, which is a limitation to the results of this review. There was no difference in occurrence of adverse events between the honey and control arms. Plain language summary Honey for acute cough in children Review question Can honey reduce cough symptoms caused by bacteria and viruses in children? Background Cough causes concern for parents and is a major reason for outpatient visits. Honey is believed to prevent growth of germs and reduce inflammation. Search date We searched databases to 8 February 2018 and trial registers to 12 February 2018. Study characteristics We included six small trials involving 899 children aged 12 months to 18 years conducted in Iran, Israel, the USA, Brazil, and Kenya. This update included three new trials conducted between 2007 and 2016 that involved 331 children. Study funding sources Two studies were supported by pharmaceutical manufacturers; one by a university research centre; one by the Honey Board of Israel and non‐government agencies; and one by USA National Honey Board. One study did not report funding sources. Key results We compared honey to over‐the‐counter cough preparations, bromelin (a pineapple enzyme) mixed with honey, fake treatment (placebo), and no treatment. Honey probably reduces cough symptoms more than placebo and salbutamol (a drug that opens lung airways) when given for up to three days. Honey is probably more effective at providing cough relief and reducing the impact of cough on children's sleep at night than no treatment. There may be little or no difference between the effects of honey and dextromethorphan (an ingredient in over‐the‐counter cough remedies) or honey and bromelin with honey on all cough symptoms. Honey may be better than diphenhydramine (an antihistamine) at relieving and reducing children's cough. The parents of seven children given honey and two given dextromethorphan reported side effects in their children, such as not falling asleep easily, restlessness, and becoming overexcited. The parents of three children in the diphenhydramine group reported that their children were often sleepy. The parents of nine children given salbutamol, seven given honey, and six given placebo reported diarrhoea. The parents of four children who received salbutamol and one child given honey reported rash. We found no evidence for or against the use of honey to relieve cough in children. Using honey for infants aged up to 12 months is not advised because of poor immunity against bacteria that may be present, which can cause paralysis. Most of the children received honey for just one night, which is a limitation to the results of this review. Quality of the evidence Overall, evidence quality was low to moderate. Some studies did not blind participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Oduwole, O; Udoh, EE; Oyo‐Ita, A; Meremikwu, MM", "articleTypes": [], "doi": "10.1002/14651858.CD007094.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "3a60fdb8-7226-427e-975e-6dcf2329e2ca", "pmid": "", "title": "Definitive Radiochemotherapy With 5-FU / Cisplatin Plus/Minus Cetuximab in Unresectable Locally Advanced Esophageal Cancer: a Phase II Study", "imported": false, "abstract": "Esophageal cancer is a highly aggressive tumor. Treatment options are various and range from chemotherapy to radiotherapy and several surgical techniques. Nevertheless, the overall survival rates for this disease remain poor.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.160Z" }, { "id": "3a6121e6-b644-4038-b3e8-dbff69266425", "pmid": "", "title": "Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people", "imported": false, "abstract": "Abstract - Background Folate deficiency can result in congenital neural tube defects and megaloblastic anaemia. Low folate levels may be due to insufficient dietary intake or inefficient absorption, but impaired metabolic utilization also occurs. Because B12 deficiency can produce a similar anaemia to folate deficiency, there is a risk that folate supplementation can delay the diagnosis of B12 deficiency, which can cause irreversible neurological damage. Folic acid supplements may sometimes therefore include vitamin B12 supplements with simultaneous administration of vitamin B12. Lesser degrees of folate inadequacy are associated with high blood levels of the amino acid homocysteine which has been linked with the risk of arterial disease, dementia and Alzheimer's disease. There is therefore interest in whether dietary supplementation can improve cognitive function in the elderly. However, any apparent benefit from folic acid which was given in combination with B12 needs to be \"corrected\" for any effect of vitamin B12 alone. A separate Cochrane review of vitamin B12 and cognitive function has therefore been published. Objectives To examine the effects of folic acid supplementation, with or without vitamin B12, on elderly healthy or demented people, in preventing cognitive impairment or retarding its progress. Search methods Trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 10 October 2007 using the terms: folic acid, folate, vitamin B9, leucovorin, methyltetrahydrofolate, vitamin B12, cobalamin and cyanocobalamin. This Register contains references from all major health care databases and many ongoing trials databases. In addition MEDLINE, EMBASE, CINAHL, PsychINFO and LILACS were searched (years 2003‐2007) for additional trials of folate with or without vitamin B12 on healthy elderly people. Selection criteria All double‐blind, placebo‐controlled, randomized trials, in which supplements of folic acid with or without vitamin B12 were compared with placebo for elderly healthy people or people with any type of dementia or cognitive impairment. Data collection and analysis The reviewers independently applied the selection criteria and assessed study quality. One reviewer extracted and analysed the data. In comparing intervention with placebo, weighted mean differences and standardized mean difference or odds ratios were estimated. Main results Eight randomized controlled trials fulfilled the inclusion criteria for this review. Four trials enrolled healthy older people, and four recruited participants with mild to moderate cognitive impairment or dementia with or without diagnosed folate deficiency. Pooling the data was not possible owing to heterogeneity in sample selections, outcomes, trial duration, and dosage. Two studies involved a combination of folic acid and vitamin B12. There is no adequate evidence of benefit from folic acid supplemententation with or without vitamin B12 on cognitive function and mood of unselected healthy elderly people. However, in one trial enrolling a selected group of healthy elderly people with high homocysteine levels, 800 mcg/day folic acid supplementation over three years was associated with significant benefit in terms of global functioning (WMD 0.05, 95% CI 0.004 to 0.096, P = 0.033); memory storage (WMD 0.14, 95% CI 0.04 to 0.24, P = 0.006) and information‐processing speed (WMD 0.09, 95% CI 0.02 to 0.16, P = 0.016). Four trials involved people with cognitive impairment. In one pilot trial enrolling people with Alzheimer's disease, the overall response to cholinesterase inhibitors significantly improved with folic acid at a dose of 1mg/day (odds ratio: 4.06, 95% CI 1.22 to 13.53; P = 0.02) and there was a significant improvement in scores on the Instrumental Activities of Daily Living and the Social Behaviour subscale of the Nurse's Observation Scale for Geriatric Patients (WMD 4.01, 95% CI 0.50 to 7.52, P = 0.02). Other trials involving people with cognitive impairment did not show any benefit in measures of cognitive function from folic acid, with or without vitamin B12. Folic acid plus vitamin B12 was effective in reducing serum homocysteine concentrations (WMD ‐5.90, 95% CI ‐8.43 to ‐3.37, P < 0.00001). Folic acid was well tolerated and no adverse effects were reported. Authors' conclusions The small number of studies which have been done provide no consistent evidence either way that folic acid, with or without vitamin B12, has a beneficial effect on cognitive function of unselected healthy or cognitively impaired older people. In a preliminary study, folic acid was associated with improvement in the response of people with Alzheimer's disease to cholinesterase inhibitors. In another, long‐term use appeared to improve the cognitive function of healthy older people with high homocysteine levels. More studies are needed on this important issue. Plain language summary No evidence that folic acid with or without vitamin B12 improves cognitive function of unselected elderly people with or without dementia. Long‐term supplementation may benefit cognitive function of healthy older people with high homocysteine levels In the economically developed world, folate deficiency is one of the commonest vitamin deficiencies. Several reports suggest a higher prevalence of various psychiatric disorders in elderly people with folate deficiency. There is interest in whether dietary supplements of folic acid (an artificial chemical analogue of naturally occurring folates) can improve cognitive function of people at risk of cognitive decline associated with ageing or dementia, whether by affecting homocysteine metabolism or through other mechanisms. Eight trials met the criteria for inclusion. It was not possible to pool the data because the trials studied different populations, tested folic acid in different doses, and used different outcome measures. There were two trials of folic acid in conjunction with B12. The analysis showed significant benefit of folic acid over placebo in some measures of cognition in a long‐term trial recruiting elderly people with high homocysteine levels from a general population. In one pilot trial, 1 mg/day of folic acid was associated with significant improvement in behavioural response to cholinesterase inhibitors in people with Alzheimer's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Malouf, R; Grimley Evans, J", "articleTypes": [], "doi": "10.1002/14651858.CD004514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "3a6b29a9-2be4-4e48-b975-304b295e840c", "pmid": "", "title": "Medical interventions for treating anthracycline‐induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer", "imported": false, "abstract": "Abstract - Background Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline‐induced cardiotoxicity. This review is an update of a previously published Cochrane review. Objectives To compare the effect of medical interventions on anthracycline‐induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions, or no treatment. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 8), MEDLINE/PubMed (1949 to September 2015), and EMBASE/Ovid (1980 to September 2015) for potentially relevant articles. In addition, we searched reference lists of relevant articles, conference proceedings of the International Society for Paediatric Oncology (SIOP), the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), the International Conference on Long‐Term Complications of Treatment of Children & Adolescents for Cancer, and the European Symposium on Late Complications from Childhood Cancer (from 2005 to 2015), and ongoing trial databases (the ISRCTN Register, the National Institutes of Health (NIH) Register, and the trials register of the World Health Organization (WHO); all searched in September 2015). Selection criteria Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline‐induced cardiotoxicity with either placebo, other medical interventions, or no treatment. Data collection and analysis Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments, which another review author checked. We performed analyses according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results In the original version of the review we identified two RCTs; in this update we identified no additional studies. One trial (135 participants) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline‐induced cardiac dysfunction. The other trial (68 participants) compared a two‐week treatment of phosphocreatine with a control treatment (vitamin C, adenosine triphosphate, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline‐induced cardiotoxicity. Both studies had methodological limitations. The RCT on enalapril showed no statistically significant differences in overall survival, mortality due to heart failure, development of clinical heart failure, and quality of life between treatment and control groups. A post‐hoc analysis showed a decrease (that is improvement) in one measure of cardiac function (left ventricular end‐systolic wall stress (LVESWS): ‐8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Participants treated with enalapril had a higher risk of dizziness or hypotension (risk ratio 7.17, 95% confidence interval 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013). The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function, and adverse events between treatment and control groups. Authors' conclusions Only one trial evaluated the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side effects of enalapril in childhood cancer survivors with asymptomatic anthracycline‐induced cardiotoxicity. Only one trial evaluated the effect of phosphocreatine in childhood cancer patients with anthracycline‐induced cardiotoxicity. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatments on echocardiographic function and clinical outcomes. We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors. High‐quality studies should be performed. Plain language summary Treatment for cardiac problems caused by anthracycline chemotherapy for childhood cancer Anthracyclines are anticancer drugs used in the treatment of different types of childhood cancer. An important adverse effect of anthracyclines is damage to the heart, which can lead to asymptomatic (without complaints) or symptomatic (with complaints) cardiac problems during and after cancer treatment. While there are several drugs available to treat other types of cardiac problems in adults, it is not known if these drugs are beneficial in treating cardiac problems caused by anthracyclines in childhood cancer patients and survivors. A physician confronted with a childhood cancer patient or survivor with anthracycline‐induced cardiac problems should be able to make an informed decision on how to treat this patient based on high‐quality evidence about the beneficial and adverse effects of the treatment options. We searched for and summarised studies that evaluated drugs for treating anthracycline‐induced cardiac problems in childhood cancer patients and survivors. We identified two randomised studies evaluating two different drugs in two different types of patients. One of these drugs, an angiotensin‐converting enzyme (ACE) inhibitor (enalapril), had a short‐term beneficial effect on heart function in survivors of childhood cancer with asymptomatic cardiac problems caused by anthracyclines compared with placebo. However, the drug had no significant beneficial effect on other important outcomes and was associated with side effects such as dizziness and fatigue. This study was of reasonable/good quality. The other study was of low quality and found no effect of a short treatment with phosphocreatine in childhood leukaemia patients with symptomatic or asymptomatic cardiac problems compared with a control treatment with vitamin C, adenosine triphosphate, vitamin E, and oral coenzyme Q10. We could make no definitive conclusions about treatment options for anthracycline‐induced cardiac problems in childhood cancer patients and survivors. High‐quality studies are needed to determine if there are drugs that improve heart function in these patients.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cheuk, DKL; Sieswerda, E; van Dalen, EC; Postma, A; Kremer, LCM", "articleTypes": [], "doi": "10.1002/14651858.CD008011.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "3a7bd15e-6c3b-4bec-8f2b-284f568ef76a", "pmid": "", "title": "Aversive smoking for smoking cessation", "imported": false, "abstract": "Abstract - Background Aversion therapy pairs the pleasurable stimulus of smoking a cigarette with some unpleasant stimulus. The objective is to extinguish the urge to smoke. Objectives This review has two aims: First, to determine the efficacy of rapid smoking and other aversive methods in helping smokers to stop smoking; Second, to determine whether there is a dose‐response effect on smoking cessation at different levels of aversive stimulation. Search methods We searched the Cochrane Tobacco Addiction Group specialised register (latest search date October 2009) for studies which evaluated any technique of aversive smoking. Selection criteria Randomized trials which compared aversion treatments with 'inactive' procedures or which compared aversion treatments of different intensity for smoking cessation. Trials must have reported follow up of least six months from beginning of treatment. Data collection and analysis We extracted data in duplicate on the study population, the type of aversion treatment, the outcome measure, method of randomization and completeness of follow up. The outcome measure was abstinence from smoking at maximum follow up, using the strictest measure reported by the authors. Subjects lost to follow up were regarded as smokers. Where appropriate, we performed meta‐analysis using a fixed effect model. Main results Twenty‐five trials met the inclusion criteria. Twelve included rapid smoking and nine used other aversion methods. Ten trials included two or more conditions allowing assessment of a dose‐response to aversive stimulation. The odds ratio (OR) for abstinence following rapid smoking compared to control was 2.01 (95% confidence intervals (CI): 1.36 to 2.95). Several factors suggest that this finding should be interpreted cautiously. A funnel plot of included studies was asymmetric, due to the relative absence of small studies with negative results. Most trials had a number of serious methodological problems likely to lead to spurious positive results. The only trial using biochemical validation of all self reported cessation gave a non‐significant result. Other aversion methods were not shown to be effective (OR 1.15, 95% CI 0.73 to 1.82). There was a borderline dose‐response to the level of aversive stimulation (OR 1.67, 95% CI 0.99 to 2.81). Authors' conclusions The existing studies provide insufficient evidence to determine the efficacy of rapid smoking, or whether there is a dose‐response to aversive stimulation. Milder versions of aversive smoking seem to lack specific efficacy. Rapid smoking is an unproven method with sufficient indications of promise to warrant evaluation using modern rigorous methodology. Plain language summary Does smoking in a way that is unpleasant help smokers to quit Aversion treatments pair undesirable behaviours with negative sensations. In smoking cessation, several approaches have been suggested such as rapid smoking, which requires smokers to take a puff every few seconds to make smoking unpleasant. The results of the existing trials suggest that this may be effective, but the evidence is not conclusive because most of the studies of this approach have methodological problems. A recent laboratory study also suggests that the method has an active ingredient. Further research may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Hajek, P, Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.756Z" }, { "id": "3a99b1fb-08fe-41e1-8fa3-2ec27f931745", "pmid": "", "title": "Pharmacotherapy for hypertension‐induced left ventricular hypertrophy", "imported": false, "abstract": "Abstract - Background Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension‐induced LVH. Objectives To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension‐induced LVH. Search methods Cochrane Hypertension’s Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) with at least 12 months’ follow‐up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension‐induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all‐cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. Data collection and analysis Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. Main results We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow‐up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention‐to‐treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add‐on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low‐certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low‐certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low‐certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low‐certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low‐certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. Authors' conclusions We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low‐certainty evidence requires that caution be used when interpreting the findings. High‐quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension‐induced LVH are warranted. Plain language summary What are the main benefits and risks of drugs for reducing blood pressure in the treatment of people with thickening of the heart muscle caused by high blood pressure? Key messages Given the lack of robust evidence, the benefits and risks of adding additional drugs for reducing blood pressure to treat people with thickening of the heart muscle and high blood pressure are unclear. It is unclear if adding drugs for reducing blood pressure causes more serious harms in patients than placebo (dummy treatment) or no treatment; however, it may increase treatment discontinuation due to unwanted effects. There is a need for future studies to better understand the benefits and harms of adding drugs for reducing blood pressure in people with thickening of the heart muscle caused by high blood pressure. What is thickening of the heart muscle? Thickening of the heart muscle is a condition where the muscle gets bigger and affects the function of the heart. This can happen when the heart has worked too hard over time and is mainly caused by high blood pressure. People with thickening of the heart muscle can experience shortness of breath, fatigue, chest pain, heart palpitations, and dizziness or fainting. How is thickening of the heart muscle treated? Thickening of the heart muscle can be treated with drugs for reducing blood pressure. What did we want to find out? We wanted to find out if adding drugs for reducing blood pressure was better than placebo or no drug treatment at preventing illness and death in people with thickening of the heart muscle and high blood pressure. We also wanted to learn if the addition of drugs for reducing blood pressure was associated with any unwanted or harmful effects. What did we do? We searched for studies that investigated the addition of drugs for reducing blood pressure compared with placebo or no drug treatment. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as methods and sizes of participant groups. What did we find? We found 3 studies that involved 930 people with thickening of the heart muscle and high blood pressure. The largest study was in 692 people, and the smallest study was in 15 people. Study participants were of both genders and on average between 66 and 75 years old. Participants were followed for between three and four years. The studies were conducted in several countries in Europe, Asia, and North and South America. One study received pharmaceutical industry funding. It is uncertain if adding drugs for reducing blood pressure has an effect on death, development of heart and blood vessel diseases, or on hospitalisation for heart failure. It is unclear if adding drugs for reducing blood pressure causes more serious harms than placebo or no drug treatment, but it may increase treatment discontinuations due to unwanted effects. It is unclear if adding drugs for reducing blood pressure has an effect on heart muscle mass. What are the limitations of the evidence? Our confidence in the evidence is lacking because of the small number of identified studies. The available evidence is based on a small percentage of people with thickening of the heart muscle and high blood pressure identified from larger populations in the included studies. Further evidence may change our results. How up‐to‐date is the evidence? The evidence is current to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Leache, L; Gutiérrez-Valencia, M; Finizola, RM; Infante, E; Finizola, B; Pardo Pardo, J; Flores, Y; Granero, R; Arai, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD012039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "3ac3710d-d8d5-4f09-8938-c8e8263e7cc9", "pmid": "", "title": "Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wells, GA, Hsieh, S-C, Zheng, C, Peterson, J, Liu, W, Kelly, SE, Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD004523.pub4 AB - Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration leading to increased fracture risk. Risedronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts. This is an update of a Cochrane Review that was originally published in 2003. Objectives We assessed the benefits and harms of risedronate in the primary and secondary prevention of osteoporotic fractures for postmenopausal women at lower and higher risk for fractures, respectively. Search methods With broader and updated strategies, we searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE and Embase. A grey literature search, including the online databases ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), and drug approval agencies, as well as bibliography checks of relevant systematic reviews was also performed. Eligible trials published between 1966 to 24 March 2021 were identified. Selection criteria We included randomised controlled trials that assessed the benefits and harms of risedronate in the prevention of fractures for postmenopausal women. Participants must have received at least one year of risedronate, placebo or other anti‐osteoporotic drugs, with or without concurrent calcium/vitamin D. Major outcomes were clinical vertebral, non‐vertebral, hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. In the interest of clinical relevance and applicability, we classified a study as secondary prevention if its population fulfilled more than one of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, low bone mineral density (BMD)T score ≤ ‐2.5, and age ≥ 75 years old. If none of these criteria was met, the study was considered to be primary prevention. Data collection and analysis We used standard methodology expected by Cochrane. We pooled the relative risk (RR) of fractures using a fixed‐effect model based on the expectation that the clinical and methodological characteristics of the respective primary and secondary prevention studies would be homogeneous, and the experience from the previous review suggesting that there would be a small number of studies. The base case included the data available for the longest treatment period in each placebo‐controlled trial and a >15% relative change was considered clinically important. The main findings of the review were presented in summary of findings tables, using the GRADE approach. In addition, we looked at benefit and harm comparisons between different dosage regimens for risedronate and between risedronate and other anti‐osteoporotic drugs. Main results Forty‐three trials fulfilled the eligibility criteria, among which 33 studies (27,348 participants) reported data that could be extracted and quantitatively synthesized. We had concerns about particular domains of risk of bias in each trial. Selection bias was the most frequent concern, with only 24% of the studies describing appropriate methods for both sequence generation and allocation concealment. Fifty per cent and 39% of the studies reporting benefit and harm outcomes, respectively, were subject to high risk. None of the studies included in the quantitative syntheses were judged to be at low risk of bias in all seven domains. The results described below pertain to the comparisons for daily risedronate 5 mg versus placebo which reported major outcomes. Other comparisons are described in the full text. For primary prevention, low‐ to very low‐certainty evidence was collected from four studies (one to two years in length) including 989 postmenopausal women at lower risk of fractures. Risedronate 5 mg/day may make little or no difference to wrist fractures [RR 0.48 ( 95% CI 0.03 to 7.50; two studies, 243 participants); absolute risk reduction (ARR) 0.6% fewer (95% CI 1% fewer to 7% more)] and withdrawals due to adverse events [RR 0.67 (95% CI 0.38 to 1.18; three studies, 748 participants); ARR 2% fewer (95% CI 5% fewer to 1% more)], based on low‐certainty evidence. However, its preventive effects on non‐vertebral fractures and serious adverse events are not known due to the very low‐certainty evidence. There were zero clinical vertebral and hip fractures reported therefore the effects of risedronate for these outcomes are not estimable. For secondary prevention, nine studies (one to three years in length) including 14,354 postmenopausal women at higher risk of fractures provided evidence. Risedronate 5 mg/day probably prevents non‐vertebral fractures [RR 0.80 (95% CI 0.72 to 0.90; six studies, 12,173 participants); RRR 20% (95% CI 10% to 28%) and ARR 2% fewer (95% CI 1% fewer to 3% fewer), moderate certainty], and may reduce hip fractures [RR 0.73 (95% CI 0.56 to 0.94); RRR 27% (95% CI 6% to 44%) and ARR 1% fewer (95% CI 0.2% fewer to 1% fewer), low certainty]. Both of these effects are probably clinically important. However, risedronate's effects are not known for wrist fractures [RR 0.64 (95% CI 0.33 to 1.24); three studies,1746 participants); ARR 1% fewer (95% CI 2% fewer to 1% more), very‐low certainty] and not estimable for clinical vertebral fractures due to zero events reported (low certainty). Risedronate results in little to no difference in withdrawals due to adverse events [RR 0.98 (95% CI 0.90 to 1.07; eight studies, 9529 participants); ARR 0.3% fewer (95% CI 2% fewer to 1% more); 16.9% in risedronate versus 17.2% in control, high certainty] and probably results in little to no difference in serious adverse events [RR 1.00 (95% CI 0.94 to 1.07; six studies, 9435 participants); ARR 0% fewer (95% CI 2% fewer to 2% more; 29.2% in both groups, moderate certainty). Authors' conclusions This update recaps the key findings from our previous review that, for secondary prevention, risedronate 5 mg/day probably prevents non‐vertebral fracture, and may reduce the risk of hip fractures. We are uncertain on whether risedronate 5mg/day reduces clinical vertebral and wrist fractures. Compared to placebo, risedronate probably does not increase the risk of serious adverse events. For primary prevention, the benefit and harms of risedronate were supported by limited evidence with high uncertainty. Plain language summary Risedronate for preventing fractures caused by osteoporosis in postmenopausal women This summary of a Cochrane Review presents what we know from the evidence up to 24 March 2021 about the effect of risedronate for preventing fractures (broken bones) caused by osteoporosis. What is osteoporosis and what is risedronate? 
Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow and old bone cells break down to make room for the new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break even after a minor injury, like a little bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. Risedronate belongs to the class of drugs called bisphosphonates. It is a type of medication that slows down the cells that break down the old bone. In postmenopausal women whose bone density is closer to normal or who may not yet have had a fracture in the bones of their spine therefore putting them at lower risk for fractures: ‐ there is insufficient evidence to tell us if risedronate leads to any reduction in the number of women sustaining bone fractures; ‐ based on limited data there is no evidence of an increase in adverse events for postmenopausal women at lower risk for fractures. In postmenopausal women who have already been diagnosed with osteoporosis (who have low bone density, or who have already had a fracture in the bones of their spine) putting them at higher risk for fractures, risedronate: ‐ probably prevents fractures in the bones of the hip and in bones other than in the spine; ‐ may not lead to any difference in preventing wrist fractures; ‐ does not have enough evidence to show if it may prevent fractures in the bones of the spine suggested by clinical signs and symptoms; ‐ might make little or no difference in adverse events for postmenopausal women at higher risk for fractures. Best estimate of what happens to postmenopausal women at lower risk for fractures who take risedronate or placebo: ‐ for spine fractures suggested by clinical signs and symptoms and hip fractures, it was not possible to calculate the effect because none of these fractures were reported in any of the studies; ‐ compared to placebo, there is not enough information to tell if risedronate prevents fractures in wrist and bones other than in the spine. Best estimate of what happens to postmenopausal women at higher risk for fractures who take risedronate or placebo: Fractures of the spine suggested by clinical signs and symptoms were not reported in any of the studies. Fractures in bones other than the spine: ‐ 10 out of 100 women had a fracture when taking a placebo; ‐ 8 out of 100 women had a fracture when taking risedronate; Fractures of the hip ‐ 3 out of 100 women had a fracture when taking a placebo; ‐ 2 out of 100 women had a fracture when taking risedronate. Fractures of the wrist: ‐ there is not enough information to tell if risedronate prevents wrist fractures.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.129Z" }, { "id": "3adaa783-ae03-468b-9070-f4b17b01e2be", "pmid": "", "title": "Interventions for treating oral leukoplakia to prevent oral cancer", "imported": false, "abstract": "Abstract - Background Oral leukoplakia is a relatively common oral lesion that, in a small proportion of people, precedes the development of oral cancer. Most leukoplakias are asymptomatic; therefore, the primary objective of treatment should be to prevent onset of cancer. This review updates our previous review, published in 2006. Objectives To assess the effectiveness, safety and acceptability of treatments for leukoplakia in preventing oral cancer. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 16 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) ( the Cochrane Library , 2016, Issue 4), MEDLINE Ovid (1946 to 16 May 2016), Embase Ovid (1980 to 16 May 2016) and CancerLit via PubMed (1950 to 16 May 2016). We searched the metaRegister of Controlled Trials (to 10 February 2015), ClinicalTrials.gov (to 16 May 2016) and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials (to 16 May 2016). We placed no restrictions on the language or date of publication when searching electronic databases. Selection criteria We included randomised controlled trials (RCTs) that enrolled people with a diagnosis of oral leukoplakia and compared any treatment versus placebo or no treatment. Data collection and analysis We collected data using a data extraction form. Oral cancer development, demonstrated by histopathological examination, was our primary outcome. Secondary outcomes were clinical resolution of the lesion, improvement of histological features and adverse events. We contacted trial authors for further details when information was unclear. When valid and relevant data were available, we conducted a meta‐analysis of the data using a fixed‐effect model when we identified fewer than four studies with no heterogeneity. For dichotomous outcomes, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We assessed risk of bias in studies by using the Cochrane tool. We assessed the overall quality of the evidence by using standardised criteria (Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE)). Main results We included 14 studies (909 participants) in this review. Surgical interventions, including laser therapy and cryotherapy, have never been studied by means of an RCT that included a no treatment or placebo arm. The included trials tested a range of medical and complementary treatments, in particular, vitamin A and retinoids (four studies); beta carotene or carotenoids (three studies); non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically ketorolac and celecoxib (two studies); herbal extracts (four studies), including tea components, a Chinese herbal mixture and freeze‐dried black raspberry gel; bleomycin (one study); and Bowman‐Birk inhibitor (one study). We judged one study to be at low risk of bias, seven at unclear risk and six at high risk. In general, we judged the overall quality of the evidence to be low or very low, so findings are uncertain and further research is needed. Five studies recorded cancer incidence, only three of which provided useable data. None of the studies provided evidence that active treatment reduced the risk of oral cancer more than placebo: systemic vitamin A (RR 0.11, 95% CI 0.01 to 2.05; 85 participants, one study); systemic beta carotene (RR 0.71, 95% CI 0.24 to 2.09; 132 participants, two studies); and topical bleomycin (RR 3.00, 95% CI 0.32 to 27.83; 20 participants, one study). Follow‐up ranged between two and seven years. Some individual studies suggested effectiveness of some proposed treatments, namely, systemic vitamin A, beta carotene and lycopene, for achieving clinical resolution of lesions more often than placebo. Similarly, single studies found that systemic retinoic acid and lycopene may provide some benefit in terms of improvement in histological features. Some studies also reported a high rate of relapse. Side effects of varying severity were often described; however, it seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Authors' conclusions Surgical treatment for oral leukoplakia has not been assessed in an RCT that included a no treatment or placebo comparison. Nor has cessation of risk factors such as smoking been assessed. The available evidence on medical and complementary interventions for treating people with leukoplakia is very limited. We do not currently have evidence of a treatment that is effective for preventing the development of oral cancer. Treatments such as vitamin A and beta carotene may be effective in healing oral lesions, but relapses and adverse effects are common. Larger trials of longer duration are required to properly evaluate the effects of leukoplakia treatments on the risk of developing oral cancer. High‐quality research is particularly needed to assess surgical treatment and to assess the effects of risk factor cessation in people with leukoplakia. Plain language summary Interventions for treating oral leukoplakia to prevent oral cancer Review question People with oral leukoplakia are at higher risk of developing oral cancer than those with normal oral mucosa. This review, produced through Cochrane Oral Health , seeks to evaluate whether people affected by leukoplakia can benefit from surgical, medical or complementary treatments, either local or systemic. In particular, we conducted this review to find out which, if any, treatment is able to prevent people with leukoplakia of the mouth from getting oral cancer. This review updates our previous review published in 2006. Background Oral leukoplakia is a white patch formed in the mouth lining that cannot be rubbed off. It often does not hurt and may go unnoticed for years. People with leukoplakia develop oral cancer more often than people without it. Preventing this is critical because rates of oral cancer survival longer than five years after diagnosis are low. Drugs, surgery and other therapies have been tried for treatment of oral leukoplakia. Objectives This review aimed to evaluate whether treatments for oral leukoplakia are effective in preventing oral cancer, and safe and acceptable to patients. Study characteristics The evidence on which this review is based is up‐to‐date as of May 2016. We found 14 randomised controlled trials (RCTs) of medical and complementary treatments, which involved 909 participants in total. Treatments included herbal extracts, anti‐inflammatory drugs, vitamin A, beta carotene supplements and others. Surgical treatment has not been compared with placebo or no treatment in an RCT. Key results Cancer development was measured in studies of three treatments: systemic vitamin A, systemic beta carotene and topical bleomycin. None of these treatments showed effectiveness in preventing cancer development, as measured up to two years for vitamin A and beta carotene, and seven years for bleomycin. Some individual studies of vitamin A and beta carotene suggested that these treatments may be effective for improving or healing oral lesions. However, some studies observed a high rate of relapse in participants whose lesions were initially resolved by treatment. Most treatments caused side effects of differing severity in a high proportion of participants. It seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Quality of the evidence The available evidence is very limited. Most interventions were assessed by only one small study. Most studies had problems in the way they were conducted, making their results unreliable. We judged the quality of evidence for the outcome of cancer development to be very low. Author conclusions Larger, better studies of longer duration are required. As well as further studies of drug treatment and alternative treatments like vitamins, studies are needed to evaluate the effectiveness and safety of surgery, and of stopping risk factor habits such as smoking.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lodi, G, Franchini, R, Warnakulasuriya, S, Varoni, EM, Sardella, A, Kerr, AR, Carrassi, A, MacDonald, LCI, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD001829.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.099Z" }, { "id": "3aee01a2-653f-4886-8e23-4f65317cd384", "pmid": "", "title": "Macrolide antibiotics (including azithromycin) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a life‐limiting genetic condition, affecting over 90,000 people worldwide. CF affects several organs in the body, but airway damage has the most profound impact on quality of life (QoL) and survival. Causes of lower airway infection in people with CF are, most notably, Staphylococcus aureus in the early course of the disease and Pseudomonas aeruginosa at a later stage. Macrolide antibiotics, e.g. azithromycin and clarithromycin, are usually taken orally, have a broad spectrum of action against gram‐positive (e.g. S aureus ) and some gram‐negative bacteria (e.g. Haemophilus influenzae ), and may have a modifying role in diseases involving airway infection and inflammation such as CF. They are well‐tolerated and relatively inexpensive, but widespread use has resulted in the emergence of resistant bacteria. This is an updated review. Objectives To assess the potential effects of macrolide antibiotics on clinical status in terms of benefit and harm in people with CF. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals, and abstract books of conference proceedings. We last searched the Group's Cystic Fibrosis Trials Register on 2 November 2022. We last searched the trial registries WHO ICTRP and clinicaltrials.gov on 9 November 2022. We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow‐up data, where possible. Selection criteria We included randomised controlled trials of macrolide antibiotics in adults and children with CF. We compared them to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose or type of administration. Data collection and analysis Two authors independently extracted data and assessed risk of bias. We assessed the certainty of evidence using GRADE. Main results We included 14 studies (1467 participants) lasting 28 days to 36 months. All the studies assessed azithromycin: 11 compared oral azithromycin to placebo (1167 participants); one compared a high dose to a low dose (47 participants); one compared nebulised to oral azithromycin (45 participants); and one looked at weekly versus daily dose (208 participants). Oral azithromycin versus placebo There is a slight improvement in forced expiratory volume (FEV 1 % predicted) in one second in the azithromycin group at up to six months compared to placebo (mean difference (MD) 3.97, 95% confidence interval (CI) 1.74 to 6.19; high‐certainty evidence), although there is probably no difference at three months, (MD 2.70%, 95% CI ‐0.12 to 5.52), or 12 months (MD ‐0.13, 95% CI ‐4.96 to 4.70). Participants in the azithromycin group are probably at a decreased risk of pulmonary exacerbation with a longer time to exacerbation (hazard ratio (HR) 0.61, 95% CI 0.50 to 0.75; moderate‐certainty evidence). Mild side effects were common, but there was no difference between groups (moderate‐certainty evidence). There is no difference in hospital admissions at six months (odds ratio (OR) 0.61, 95% CI 0.36 to 1.04; high‐certainty evidence), or in new acquisition of P aeruginosa at 12 months (HR 1.00, 95% CI 0.64 to 1.55; moderate‐certainty evidence). High‐dose versus low‐dose azithromycin We are uncertain whether there is any difference in FEV 1 % predicted at six months between the two groups (no data available) or in the rate of exacerbations per child per month (MD ‐0.05 (95% CI ‐0.20 to 0.10)); very low‐certainty evidence for both outcomes. Only children were included in the study and the study did not report on any of our other clinically important outcomes. Nebulised azithromycin versus oral azithromycin We were unable to include any of the data into our analyses and have reported findings directly from the paper; we graded all evidence as being of very low certainty. The authors reported that there was a greater mean change in FEV 1 % predicted at one month in the nebulised azithromycin group (P < 0.001). We are uncertain whether there was a change in P aeruginosa count. Weekly azithromycin versus daily azithromycin There is probably a lower mean change in FEV 1 % predicted at six months in the weekly group compared to the daily group (MD ‐0.70, 95% CI ‐0.95 to ‐0.45) and probably also a longer period of time until first exacerbation in the weekly group (MD 17.30 days, 95% CI 4.32 days to 30.28 days). Gastrointestinal side effects are probably more common in the weekly group and there is likely no difference in admissions to hospital or QoL. We graded all evidence as moderate certainty. Authors' conclusions Azithromycin therapy is associated with a small but consistent improvement in respiratory function, a decreased risk of exacerbation and longer time to exacerbation at six months; but evidence for treatment efficacy beyond six months remains limited. Azithromycin appears to have a good safety profile (although a weekly dose was associated with more gastrointestinal side effects, which makes it less acceptable for long‐term therapy), with a relatively minimal treatment burden for people with CF, and it is inexpensive. A wider concern may be the emergence of macrolide resistance reported in the most recent study which, combined with the lack of long‐term data, means we do not feel that the current evidence is strong enough to support azithromycin therapy for all people with CF. Future research should report over longer time frames using validated tools and consistent reporting, to allow for easier synthesis of data. In particular, future trials should report important adverse events such as hearing impairment or liver disease. More data on the effects of azithromycin given in different ways and reporting on our primary outcomes would benefit decision‐making on whether and how to give macrolide antibiotics. Finally, it is important to assess azithromycin therapy for people with CF who are established on the relatively new cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies which correct the underlying molecular defect associated with CF (none of the trials included in the review are relevant to this population). Plain language summary Treatment with macrolide antibiotics (including azithromycin) for people with cystic fibrosis Review question What are the effects of macrolide antibiotics in people with cystic fibrosis (CF) and infection of their airways? Key messages ‐ People with CF are more prone to chest infections caused by bacteria that can be hard to treat. ‐ Macrolide antibiotics (such as azithromycin and clarithromycin) may lessen the effects of bacteria. ‐ One macrolide antibiotic, azithromycin, can improve lung function at six months compared to a placebo (treatment with no active ingredient) and may reduce the risk of getting a flare‐up of lung infection. We are not sure whether a higher dose of azithromycin is any better than a lower dose, or if azithromycin when inhaled is any better than azithromycin when swallowed (oral). Oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. ‐ Current evidence does not support longer‐term use of azithromycin for all people with CF. Introduction People with CF suffer from infections in their airways, often caused by the bug Pseudomonas aeruginosa , which is resistant to nearly all antibiotics that can be swallowed (oral). Macrolide antibiotics, e.g. azithromycin and clarithromycin, have no direct killing effect on Pseudomonas aeruginosa , but they may reduce the activity of these bacteria. What did we want to find out? We wanted to discover whether the use of macrolide antibiotics (usually taken orally) affected the health of people with CF and whether these drugs have any side effects. What did we do? We searched for studiesthat looked at the effects of macrolide antibiotics in children and adults with CF and summarised the evidence. What did we find? We found 14 studies, which put the total of 1467 children and adults into different treatment groups at random, which we included in this review. Eleven studies compared azithromycin to placebo, one compared two different doses of azithromycin (high versus low dose), one compared inhaled azithromycin to oral azithromycin, and one compared oral azithromycin once a week to once a day. Main results We found that there was a slight improvement in lung function in people that were given azithromycin compared to a placebo at six months and also that the risk of a flare‐up of infection was lower. The risk of side effects (such as vomiting, diarrhoea and headache) was similar in both groups, as was the chance of a new infection with Pseudomonas aeruginosa. In terms of lung function and flare‐up of infection, we were unsure whether a higher dose of azithromycin is better than a lower dose (but only one study in children examined dose), or whether inhaled azithromycin is better than oral azithromycin. Taking oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. What are the limitations of the evidence? We were unable to combine all the study results because they were measured in different ways and at different time points; future trials should address this issue. Also, now that many people with CF are being treated with the new modulator therapies (e.g. elexacaftor‐tezacaftor‐ivacaftor), it is important to assess how macrolide antibiotics affect the health of these people. In the studies we found for this review, none of the people taking part were being treated with modulator therapies. We are able to report the results of the studies that compared azithromycin to placebo with certainty as the studies were well conducted and included a larger number of participants. The evidence from the studies comparing high and low doses or nebulised and oral azithromycin was much less certain because the studies were small and there was risk of bias in the way they were carried out. We were moderately certain of the results of the study comparing weekly azithromycin to daily azithromycin. How up to date is this evidence? The studies we have reported are the most up to date we could find. We last searched for studies in November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Southern, KW, Solis-Moya, A, Kurz, D, Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD002203.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.803Z" }, { "id": "3af7570d-f9b4-4e66-a848-d399bdbbd50e", "pmid": "", "title": "CBD/THC Solution as a Pharmacological Strategy for Patients With Fibromyalgia. Single-center, Double-blind, Randomized, Placebo-controlled Clinical Trial Protocol (FibroCann)", "imported": false, "abstract": "Fibromyalgia is considered a chronic pain syndrome, non-inflammatory, of unknown etiology, which manifests itself in the musculoskeletal system in up to 2.5% of the general population, predominantly in females, mainly between 35 and 44 years old, having a direct impact on the quality of life of their patients (JUNIOR; GOLDENFUM; SIENA, 2012; HEYMANN et al., 2017). In 1990, eighteen (18) specific sites were defined as tender points which are used to better diagnose fibromyalgia (WOLFE et al., 2010). Due to its clinical and exclusion diagnosis, treatment usually starts late, which allows the progression of symptoms and corroborates its low efficiency in the long term (DE SOUSA BRAZ et al., 2011). Due to the ineffective results and significant side effects that conventional treatment with drugs such as antidepressants, analgesics and anti-inflammatory drugs can provide, patients, physicians and researchers are looking for new main or adjuvant treatments, pharmacological and non-pharmacological (DE SOUSA BRAZ et al. al., 2011). In this context, it has been seen that the use of Cannabis sativa as a therapeutic option in fibromyalgia is promising, especially in reducing the pain caused by the disease and also the adjuvant symptoms, such as depression and sleep disorders (YASSIN; ORON; ROBINSON, 2019). This result must occur due to the action of cannabinoids, such as CBD and THC, on cannabinoid receptors distributed in peripheral nerves, spinal cord and supraspinal region, sites responsible for the reception, transmission and perception of pain (STE-MARIE et al., 2012). Currently, cannabinoids are considered safe analgesics with considerable efficacy, which demonstrates potential as a therapeutic option in the treatment of chronic pain, particularly in patients refractory to other treatments (HAUSER et al., 2018). In addition to its action on the painful mechanisms of fibromyalgia, the antidepressant effects of Cannabis are of great value in the treatment of fibromyalgia. These effects are explained by the modulation on serotonin 5-HT1A receptors, which has its effect exerted especially by CBD (ESPEJO-PORRAS et al., 2013).", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.244Z" }, { "id": "3b0295cb-77e7-49a4-a163-8b642f609883", "pmid": "", "title": "Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy", "imported": false, "abstract": "Abstract - Background In the past women have been advised that lowering their salt intake might reduce their risk of pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of advice to alter dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of dietary advice to alter salt intake compared to continuing a normal diet, on the risk of pre‐eclampsia and its consequences. Search methods We searched the register of trials maintained and updated by the Cochrane Pregnancy and Childbirth Group, and the Cochrane Controlled Trials Register Disc Issue 4, 1998. Selection criteria Studies were included if they were randomised trials of advice to either reduce or to increase dietary salt during pregnancy. Data collection and analysis All data were extracted independently by both reviewers. Main results Two trials were included, with 603 women. They compared advice about a low salt diet with no dietary advice. The confidence intervals for all of the outcomes reported were wide, and cross the no effect line. This includes pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). Even when taken together, these trials are insufficient to provide reliable information about the effects of advice on salt restriction during normal pregnancy. None of the trials included women with pre‐eclampsia, so this review provides no reliable information about changes in salt intake for treatment of pre‐eclampsia. Authors' conclusions Salt consumption during pregnancy should remain a matter of personal preference. Plain language summary Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy To be prepared.", "journal": "Cochrane Database of Systematic Reviews", "year": "1999", "authors": "Duley, L; Henderson‐Smart, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD001687", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "3b02d9b4-2ffa-4f84-894a-d3fa29198737", "pmid": "", "title": "Interventions for the prevention and management of oropharyngeal candidiasis associated with HIV infection in adults and children", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Pienaar, ED, Young, T, Holmes, H", "articleTypes": [], "doi": "10.1002/14651858.CD003940.pub3 AB - Abstract - Background Oral candidiasis (OC) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Left untreated, these lesions contribute considerably to the morbidity associated with HIV infection. Interventions aimed at preventing and treating HIV‐associated oral candidal lesions form an integral component of maintaining the quality of life for affected individuals. Objectives To determine the effects of any intervention in preventing or treating OC in children and adults with HIV infection. Search methods The search strategy was based on that of the Cochrane HIV/AIDS Review Group. The following electronic databases were searched for randomised controlled trials for the years 1982 to 2005: Medline, AIDSearch, EMBASE and CINAHL. The Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectiveness, and the Cochrane Central Register of Controlled Trials (CENTRAL) were also searched through May 2005. The abstracts of relevant conferences, including the International Conferences on AIDS and the Conference on Retroviruses and Opportunistic Infections, as indexed by AIDSLINE, were also reviewed. The strategy was iterative, in that references of included studies were searched for additional references. All languages were included. The updated database search was done for the period 2005 up to 2009. The following databases were searched: Medline, EMBASE, the Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectivenes s and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library. AIDSearch was not searched for the updated search as it ceased publication during 2008. Selection criteria Randomised controlled trials (RCTs) of palliative, preventative or curative therapy were considered, irrespective of whether the control group received a placebo. Participants were HIV positive adults and children. Data collection and analysis Two authors independently assessed the methodological quality of the trials and extracted data. Study authors were contacted for additional data where necessary. Main results For the first publication of the review in 2006, forty studies were retrieved. Twenty eight trials (n=3225) met inclusion criteria. During the update search for the review a, further six studies were identified. Of these, five met the inclusion criteria and were included in the review. The review now includes 33 studies (n=3445): 22 assessing treatment and 11 assessing prevention of oropharyngeal candidiasis. Six studies were done in developing countries, 16 in the United States of America and the remainder in Europe. Treatment 
 Treatment was assessed in the majority of trials looking at both clinical and mycological cures. In the majority of comparisons there was only one trial. Compared to nystatin, fluconazole favoured clinical cure in adults (1 RCT; n=167; RR 1.69; 95% CI 1.27 to 2.23). There was no difference with regard to clinical cure between fluconazole compared to ketoconazole (2 RCTs; n=83; RR 1.27; 95% CI 0.97 to 1.66), itraconazole (2 RCTs; n=434; RR 1.05; 95% CI 0.94 to 1.16), clotrimazole (2 RCTs; n=358; RR 1.14; 95% CI 0.92 to 1.42) or posaconazole (1 RCT; n=366; RR1.32; 95% CI 0.36 to 4.83). Two trials compared different dosages of fluconazole with no difference in clinical cure. When compared with clotrimazole, both fluconazole (2 RCTs; n=358; RR 1.47; 95% CI 1.16 to 1.87) and itraconazole (1 RCT; n=123; RR 2.20; 95% CI 1.43 to3.39) proved to be better for mycological cure. Both gentian violet (1 RCT; n=96; RR 5.28; 95% CI 1.23 to 22.55) and ketoconazole (1 RCT; n=92; RR 5.22; 95% CI 1.21 to 22.53) were superior to nystatin in bringing about clinical cure. A single trial compared gentian violet with lemon juice and lemon grass with no significant difference in clinical cure between the groups. 
 
 Prevention 
 Successful prevention was defined as the prevention of a relapse while receiving prophylaxis. Fluconazole was compared with placebo in five studies (5 RCTs; n=599; RR 0.61; 95% CI 0.5 to 0.74) and with no treatment in another (1 RCT; n=65; RR 0.16; 95% CI 0.08 to 0.34). In both instances the prevention of clinical episodes was favoured by fluconazole. Comparing continuous fluconazole treatment with intermittent treatment (2 RCTs; n=891; RR 0.65; 95% CI 0.23 to 1.83), there was no significant difference between the two treatment arms. Chlorhexidine was compared with normal saline in a single study with no significant difference between the treatment arms. Authors' conclusions Five new studies were added to the review, but their results do not alter the final conclusion of the review. Implications for practice 
 Due to there being only one study in children, it is not possible to make recommendations for treatment or prevention of OC in children. Amongst adults, there were few studies per comparison. Due to insufficient evidence, no conclusion could be made about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole or ketoconazole with regard to OC prophylaxis. In comparison to placebo, fluconazole is an effective preventative intervention. However, the potential for resistant Candida organisms to develop, as well as the cost of prophylaxis, might impact the feasibility of implementation. No studies were found comparing fluconazole with other interventions. The direction of findings suggests that ketoconazole, fluconazole, itraconazole and clotrimazole improved the treatment outcomes. Implications for research 
 It is encouraging that low‐cost alternatives are being tested, but more research needs to be on in this area and on interventions like gentian violet and other less expensive anti‐fungal drugs to treat OC. More well‐designed treatment trials with larger samples are needed to allow for sufficient power to detect differences in not only clinical, but also mycological, response and relapse rates. There is also a strong need for more research to be done on the treatment and prevention of OC in children as it is reported that OC is the most frequent fungal infection in children and adolescents who are HIV positive. More research on the effectiveness of less expensive interventions also needs to be done in resource‐poor settings. Currently few trials report outcomes related to quality of life, nutrition, or survival. Future researchers should consider measuring these when planning trials. Development of resistance remains under‐studied and more work must be done in this area. It is recommended that trials be more standardised and conform more closely to CONSORT. Plain language summary Interventions for the prevention and management of oral thrush associated with HIV infection in adults and children Oral candidiasis (thrush) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Interventions aimed at preventing and treating HIV‐associated oral thrush form an integral component of maintaining the quality of life for affected individuals. This review evaluated the effects of interventions in preventing or treating oral thrush in children and adults with HIV infection. Thirty three trials (n=3445) were included. Twenty two trials investigated treatment and eleven trials investigate prevention. There was no difference with regard to clinical cure between fluconazole compared to ketoconazole, itraconazole, clotrimazole and posaconazole. Fluconazole, gentian violet and ketoconazole were superior to nystatin. Compared to placebo and no treatment, fluconazole was effective in preventing clinical episodes from occurring. Continuous fluconazole was better than intermittent treatment. Insufficient evidence was found to come to any conclusion about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole, ketoconazole or chlorhexidine with regard to OC prophylaxis.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.094Z" }, { "id": "3b042482-48e9-4309-8873-9666dddbda9f", "pmid": "", "title": "Drugs for preventing malaria in pregnant women in endemic areas: any drug regimen versus placebo or no treatment", "imported": false, "abstract": "Abstract - Background Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. To reduce these effects, the World Health Organization recommends that pregnant women living in malaria endemic areas sleep under insecticide‐treated bednets, are treated for malaria illness and anaemia, and receive chemoprevention with an effective antimalarial drug during the second and third trimesters. Objectives To assess the effects of malaria chemoprevention given to pregnant women living in malaria endemic areas on substantive maternal and infant health outcomes. We also summarised the effects of intermittent preventive treatment with sulfadoxine‐pyrimethamine (SP) alone, and preventive regimens for Plasmodium vivax. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and reference lists up to 1 June 2014. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs of any antimalarial drug regimen for preventing malaria in pregnant women living in malaria‐endemic areas compared to placebo or no intervention. In the mother, we sought outcomes that included mortality, severe anaemia, and severe malaria; anaemia, haemoglobin values, and malaria episodes; indicators of malaria infection, and adverse events. In the baby, we sought foetal loss, perinatal, neonatal and infant mortality; preterm birth and birthweight measures; and indicators of malaria infection. We included regimens that were known to be effective against the malaria parasite at the time but may no longer be used because of parasite drug resistance. Data collection and analysis Two review authors applied inclusion criteria, assessed risk of bias and extracted data. Dichotomous outcomes were compared using risk ratios (RR), and continuous outcomes using mean differences (MD); both are presented with 95% confidence intervals (CI). We assessed the quality of evidence using the GRADE approach. Main results Seventeen trials enrolling 14,481 pregnant women met our inclusion criteria. These trials were conducted between 1957 and 2008, in Nigeria (three trials), The Gambia (three trials), Kenya (three trials), Mozambique (two trials), Uganda (two trials), Cameroon (one trial), Burkina Faso (one trial), and Thailand (two trials). Six different antimalarials were evaluated against placebo or no intervention; chloroquine (given weekly), pyrimethamine (weekly or monthly), proguanil (daily), pyrimethamine‐dapsone (weekly or fortnightly), and mefloquine (weekly), or intermittent preventive therapy with SP (given twice, three times or monthly). Trials recruited women in their first or second pregnancy (eight trials); only multigravid women (one trial); or all women (eight trials). Only six trials had adequate allocation concealment. For women in their first or second pregnancy, malaria chemoprevention reduces the risk of moderate to severe anaemia by around 40% (RR 0.60, 95% CI 0.47 to 0.75; three trials, 2503 participants, high quality evidence ), and the risk of any anaemia by around 17% (RR 0.83, 95% CI 0.74 to 0.93; five trials,, 3662 participants, high quality evidence ). Malaria chemoprevention reduces the risk of antenatal parasitaemia by around 61% (RR 0.39, 95% CI 0.26 to 0.58; seven trials, 3663 participants, high quality evidence ), and two trials reported a reduction in febrile illness ( low quality evidence ). There were only 16 maternal deaths and these trials were underpowered to detect an effect on maternal mortality ( very low quality evidence ). For infants of women in their first and second pregnancies, malaria chemoprevention probably increases mean birthweight by around 93 g (MD 92.72 g, 95% CI 62.05 to 123.39; nine trials, 3936 participants, moderate quality evidence ), reduces low birthweight by around 27% (RR 0.73, 95% CI 0.61 to 0.87; eight trials, 3619 participants, moderate quality evidence ), and reduces placental parasitaemia by around 46% (RR 0.54, 95% CI 0.43 to 0.69; seven trials, 2830 participants, high quality evidence ). Fewer trials evaluated spontaneous abortions, still births, perinatal deaths, or neonatal deaths, and these analyses were underpowered to detect clinically important differences. In multigravid women, chemoprevention has similar effects on antenatal parasitaemia (RR 0.38, 95% CI 0.28 to 0.50; three trials, 977 participants, high quality evidence )but there are too few trials to evaluate effects on other outcomes. In trials giving chemoprevention to all pregnant women irrespective of parity, the average effects of chemoprevention measured in all women indicated it may prevent severe anaemia (defined by authors, but at least < 8 g/L: RR 0.19, 95% CI 0.05 to 0.75; two trials, 1327 participants, low quality evidence), but consistent benefits have not been shown for other outcomes. In an analysis confined only to intermittent preventive therapy with SP, the estimates of effect and the quality of the evidence were similar. A summary of a single trial in Thailand of prophylaxis against P. vivax showed chloroquine prevented vivax infection (RR 0.01, 95% CI 0.00 to 0.20; one trial, 942 participants). Authors' conclusions Routine chemoprevention to prevent malaria and its consequences has been extensively tested in RCTs, with clinically important benefits on anaemia and parasitaemia in the mother, and on birthweight in infants. 8 May 2019 No update planned Review superseded The intervention is clearly effective. The questions now are around head‐to‐head comparisons not included in this review. Plain language summary The effect of taking antimalarial drugs routinely to prevent malaria in pregnancy Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. For this reason, women are encouraged to try and prevent malaria infection during pregnancy by sleeping under mosquito bed‐nets, and by taking drugs effective against malaria throughout pregnancy as chemoprevention. This Cochrane Review looked at all drug regimens compared to placebo. The review authors sought to summarise and quantify the overall effects of chemoprevention. Seventeen trials were included, all conducted between 1957 and 2008, and all but two in countries of Africa. For women in their first or second pregnancy, malaria chemoprevention prevents moderate to severe anaemia ( high quality evidence ); and prevents malaria parasites being detected in the blood ( high quality evidence ). It may also prevent malaria illness. We don't know if it prevents maternal deaths, as this would require very large studies to detect an effect. In their infants, malaria chemoprevention improves the average birthweight ( moderate quality evidence ), and reduces the number of low birthweight infants ( moderate quality evidence ). We are not sure if chemoprevention reduces mortality of babies in the first week, month and year, as again studies would need to be very large to show these effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Radeva‐Petrova, D; Kayentao, K; ter Kuile, FO; Sinclair, D; Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD000169.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "3b0827aa-a41c-48cc-854c-718289e53d2e", "pmid": "", "title": "Pharmacological interventions for preventing dry mouth and salivary gland dysfunction following radiotherapy", "imported": false, "abstract": "Abstract - Background Salivary gland dysfunction is an 'umbrella' term for the presence of either xerostomia (subjective sensation of dryness), or salivary gland hypofunction (reduction in saliva production). It is a predictable side effect of radiotherapy to the head and neck region, and is associated with a significant impairment of quality of life. A wide range of pharmacological interventions, with varying mechanisms of action, have been used for the prevention of radiation‐induced salivary gland dysfunction. Objectives To assess the effects of pharmacological interventions for the prevention of radiation‐induced salivary gland dysfunction. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 14 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 14 September 2016); MEDLINE Ovid (1946 to 14 September 2016); Embase Ovid (1980 to 14 September 2016); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 14 September 2016); LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 14 September 2016); Zetoc Conference Proceedings (1993 to 14 September 2016); and OpenGrey (1997 to 14 September 2016). We searched the US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials, irrespective of their language of publication or publication status. Trials included participants of all ages, ethnic origin and gender, scheduled to receive radiotherapy on its own or in addition to chemotherapy to the head and neck region. Participants could be outpatients or inpatients. We included trials comparing any pharmacological agent regimen, prescribed prophylactically for salivary gland dysfunction prior to or during radiotherapy, with placebo, no intervention or an alternative pharmacological intervention. Comparisons of radiation techniques were excluded. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 39 studies that randomised 3520 participants; the number of participants analysed varied by outcome and time point. The studies were ordered into 14 separate comparisons with meta‐analysis only being possible in three of those. We found low‐quality evidence to show that amifostine, when compared to a placebo or no treatment control, might reduce the risk of moderate to severe xerostomia (grade 2 or higher on a 0 to 4 scale) at the end of radiotherapy (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.19 to 0.67; P = 0.001, 3 studies, 119 participants), and up to three months after radiotherapy (RR 0.66, 95% CI 0.48 to 0.92; P = 0.01, 5 studies, 687 participants), but there is insufficient evidence that the effect is sustained up to 12 months after radiotherapy (RR 0.70, 95% CI 0.40 to 1.23; P = 0.21, 7 studies, 682 participants). We found very low‐quality evidence that amifostine increased unstimulated salivary flow rate up to 12 months after radiotherapy, both in terms of mg of saliva per 5 minutes (mean difference (MD) 0.32, 95% CI 0.09 to 0.55; P = 0.006, 1 study, 27 participants), and incidence of producing greater than 0.1 g of saliva over 5 minutes (RR 1.45, 95% CI 1.13 to 1.86; P = 0.004, 1 study, 175 participants). However, there was insufficient evidence to show a difference when looking at stimulated salivary flow rates. There was insufficient (very low‐quality) evidence to show that amifostine compromised the effects of cancer treatment when looking at survival measures. There was some very low‐quality evidence of a small benefit for amifostine in terms of quality of life (10‐point scale) at 12 months after radiotherapy (MD 0.70, 95% CI 0.20 to 1.20; P = 0.006, 1 study, 180 participants), but insufficient evidence at the end of and up to three months postradiotherapy. A further study showed no evidence of a difference at 6, 12, 18 and 24 months postradiotherapy. There was low‐quality evidence that amifostine is associated with increases in: vomiting (RR 4.90, 95% CI 2.87 to 8.38; P < 0.00001, 5 studies, 601 participants); hypotension (RR 9.20, 95% CI 2.84 to 29.83; P = 0.0002, 3 studies, 376 participants); nausea (RR 2.60, 95% CI 1.81 to 3.74; P < 0.00001, 4 studies, 556 participants); and allergic response (RR 7.51, 95% CI 1.40 to 40.39; P = 0.02, 3 studies, 524 participants). We found insufficient evidence (that was of very low quality) to determine whether or not pilocarpine performed better or worse than a placebo or no treatment control for the outcomes: xerostomia, salivary flow rate, survival, and quality of life. There was some low‐quality evidence that pilocarpine was associated with an increase in sweating (RR 2.98, 95% CI 1.43 to 6.22; P = 0.004, 5 studies, 389 participants). We found insufficient evidence to determine whether or not palifermin performed better or worse than placebo for: xerostomia (low quality); survival (moderate quality); and any adverse effects. There was also insufficient evidence to determine the effects of the following interventions: biperiden plus pilocarpine, Chinese medicines, bethanechol, artificial saliva, selenium, antiseptic mouthrinse, antimicrobial lozenge, polaprezinc, azulene rinse, and Venalot Depot (coumarin plus troxerutin). Authors' conclusions There is some low‐quality evidence to suggest that amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months postradiotherapy). However, it is less clear whether or not this effect is sustained to 12 months postradiotherapy. The benefits of amifostine should be weighed against its high cost and side effects. There was insufficient evidence to show that any other intervention is beneficial. Plain language summary Drugs for preventing dry mouth and problems with saliva after radiotherapy Review question To assess the effects of treatment with drugs in order to prevent damage to salivary glands following radiotherapy to the head and neck Background Problems with saliva production and salivary glands are a significant and mostly permanent side effect for people after radiotherapy treatment to the head and neck. When this occurs the condition is known as dry mouth or xerostomia. Dry mouth is not measurable and is a subjective or personal expression of how the mouth feels. It can have other causes and is a consequence of the production of less saliva or by the consistency of saliva. The rate of flow of saliva in an individual's mouth however can be measured. People who have dry mouth have a reduced quality of life. They can experience issues with taste and general discomfort, difficulties chewing, swallowing and speaking as well as tooth decay, thrush and other infections of the mouth. A wide range of drugs that work in different ways have been used to try and prevent problems with salivary glands caused by radiotherapy. Unfortunately there is currently not enough evidence to show which drugs or which type of drugs are most effective. Study characteristics The evidence in this review is current up to 14 September 2016. 39 studies were included with a total of 3520 participants. Participants were male and female, all ages and ethnic origins, out patients or in patients, who were scheduled to have radiation therapy with or without chemotherapy to the head and neck. Drugs included were any prescribed to prevent salivary gland problems and given before or during radiotherapy. Information was collected from the end of radiotherapy except for that about adverse effects. Different techniques for giving radiation treatment that might reduce damage were not included. The main outcomes measured were participant's own assessment of dry mouth and the measurement of salivary flow. Secondary outcomes measured included adverse or unwanted effects such as sweating, crying, watery discharge from the nose, diarrhoea and nausea. Key results There is some low‐quality evidence to suggest that the drug amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months after radiotherapy). However it is less clear whether or not this effect is sustained to 12 months after radiotherapy. The benefits of amifostine should be weighed against its high costs and side effects. Adverse effects of vomiting, low blood pressure, feeling of sickness and allergic response were all more frequent in those receiving amifostine. There was insufficient evidence to show that any other treatment is beneficial. Quality of the evidence The quality of evidence for amifostine was found to be low because of risk of bias, inconsistency and imprecision caused by the small number of studies in the comparison or sample size. A standardized scale for measuring participant's experience of dry mouth would in future allow comparison and pooling together of results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P, Glenny, AM, Hua, F, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD012744", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.071Z" }, { "id": "3b1139b2-7fbc-4153-8edb-65d498370932", "pmid": "", "title": "Antihypertensive Effects of Rosmarinus Officinalis L. Infusion Supplements in Male Patients With Mild Hypertension : A Randomized Double-Blind Placebo-Controlled Study", "imported": false, "abstract": "This study assessed the antihypertensive effect of rosemary tea through a placebo-controlled clinical study, angiotensin-converting enzyme (ACE) inhibition analysis, and in silico evaluation of interactions between rosemary bioactive compounds and the AT1R (Angiotensin II Type 1 Receptor).", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.239Z" }, { "id": "3b153730-dfc8-4601-b4a2-aaf6da62bd7b", "pmid": "", "title": "Treatments for intractable constipation in childhood", "imported": false, "abstract": "Abstract - Background Constipation that is prolonged and does not resolve with conventional therapeutic measures is called intractable constipation. The treatment of intractable constipation is challenging, involving pharmacological or non‐pharmacological therapies, as well as surgical approaches. Unresolved constipation can negatively impact quality of life, with additional implications for health systems. Consequently, there is an urgent need to identify treatments that are efficacious and safe. Objectives To evaluate the efficacy and safety of treatments used for intractable constipation in children. Search methods We searched CENTRAL, MEDLINE, Embase, and two trials registers up to 23 June 2023. We also searched reference lists of included studies for relevant studies. Selection criteria We included randomised controlled trials (RCTs) comparing any pharmacological, non‐pharmacological, or surgical treatment to placebo or another active comparator, in participants aged between 0 and 18 years with functional constipation who had not responded to conventional medical therapy. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were symptom resolution, frequency of defecation, treatment success, and adverse events; secondary outcomes were stool consistency, painful defecation, quality of life, faecal incontinence frequency, abdominal pain, hospital admission for disimpaction, and school absence. We used GRADE to assess the certainty of evidence for each primary outcome. Main results This review included 10 RCTs with 1278 children who had intractable constipation. We assessed one study as at low risk of bias across all domains. There were serious concerns about risk of bias in six studies. One study compared the injection of 160 units botulinum toxin A (n = 44) to unspecified oral stool softeners (n = 44). We are very uncertain whether botulinum toxin A injection improves treatment success (risk ratio (RR) 37.00, 95% confidence interval (CI) 5.31 to 257.94; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Frequency of defecation was reported only for the botulinum toxin A injection group (mean interval of 2.6 days). The study reported no data for the other primary outcomes. One study compared erythromycin estolate (n = 6) to placebo (n = 8). The only primary outcome reported was adverse events , which were 0 in both groups. The evidence is of very low certainty due to concerns with risk of bias and serious imprecision. One study compared 12 or 24 μg oral lubiprostone (n = 404) twice a day to placebo (n = 202) over 12 weeks. There may be little to no difference in treatment success (RR 1.29, 95% CI 0.87 to 1.92; low certainty evidence). We also found that lubiprostone probably results in little to no difference in adverse events (RR 1.05, 95% CI 0.91 to 1.21; moderate certainty evidence). The study reported no data for the other primary outcomes. One study compared three‐weekly rectal sodium dioctyl sulfosuccinate and sorbitol enemas (n = 51) to 0.5 g/kg/day polyethylene glycol laxatives (n = 51) over a 52‐week period. We are very uncertain whether rectal sodium dioctyl sulfosuccinate and sorbitol enemas improve treatment success (RR 1.33, 95% CI 0.83 to 2.14; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Results of defecation frequency per week was reported only as modelled means using a linear mixed model. The study reported no data for the other primary outcomes. One study compared biofeedback therapy (n = 12) to no intervention (n = 12). We are very uncertain whether biofeedback therapy improves symptom resolution (RR 2.50, 95% CI 1.08 to 5.79; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). The study reported no data for the other primary outcomes. One study compared 20 minutes of intrarectal electromotive botulinum toxin A using 2800 Hz frequency and botulinum toxin A dose 10 international units/kg (n = 30) to 10 international units/kg botulinum toxin A injection (n = 30). We are very uncertain whether intrarectal electromotive botulinum toxin A improves symptom resolution (RR 0.96, 95% CI 0.76 to 1.22; very low certainty evidence) or if it increases the frequency of defecation (mean difference (MD) 0.00, 95% CI −1.87 to 1.87; very low certainty evidence). We are also very uncertain whether intrarectal electromotive botulinum toxin A has an improved safety profile (RR 0.20, 95% CI 0.01 to 4.00; very low certainty evidence). The evidence for these results is of very low certainty due to serious concerns with risk of bias and imprecision. The study did not report data on treatment success. One study compared the injection of 60 units botulinum toxin A (n = 21) to myectomy of the internal anal sphincter (n = 21). We are very uncertain whether botulinum toxin A injection improves treatment success (RR 1.00, 95% CI 0.75 to 1.34; very low certainty evidence). No adverse events were recorded. The study reported no data for the other primary outcomes. One study compared 0.04 mg/kg oral prucalopride (n = 107) once daily to placebo (n = 108) over eight weeks. Oral prucalopride probably results in little or no difference in defecation frequency (MD 0.50, 95% CI −0.06 to 1.06; moderate certainty evidence); treatment success (RR 0.96, 95% CI 0.53 to 1.72; moderate certainty evidence); and adverse events (RR 1.15, 95% CI 0.94 to 1.39; moderate certainty evidence). The study did not report data on symptom resolution. One study compared transcutaneous electrical stimulation to sham stimulation, and another study compared dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. These studies did not report any of our predefined primary outcomes. Authors' conclusions We identified low to moderate certainty evidence that oral lubiprostone may result in little to no difference in treatment success and adverse events compared to placebo. Based on moderate certainty evidence, there is probably little or no difference between oral prucalopride and placebo in defecation frequency, treatment success, or adverse events. For all other comparisons, the certainty of the evidence for our predefined primary outcomes is very low due to serious concerns with study limitations and imprecision. Consequently, no robust conclusions could be drawn. Plain language summary Management of intractable constipation in children Key messages • There may be little to no difference between lubiprostone and placebo (dummy treatment) in achieving treatment success in children with intractable constipation. We also found that lubiprostone is probably as safe as placebo. • There is probably little or no difference between prucalopride, also a laxative, and placebo in frequency of defecation per day, treatment success, and safety. • It is unclear whether any of the other treatments we looked at are helpful. The evidence is uncertain because of the very low number of study participants and problems with how the research was reported. • Currently, there is not an agreed‐upon definition for intractable constipation. To develop further evidence on therapies for intractable constipation, researchers must use the same definition. We would encourage further work to come up with an agreed‐upon definition. What is intractable constipation? Constipation in children is a common problem. If doctors cannot find an underlying cause for the symptoms, it is called functional constipation. The symptoms of constipation include lower frequency of defecation, bowel incontinence or soiling, and stomach pain. Constipation can be mild and respond well to standard treatments, such as behavioural changes or laxatives. However, it can also be more severe or last for a long time. We defined intractable constipation as constipation that persists despite standard treatments. What did we want to find out? We wanted to find out which treatments are helpful and safe for treating children (between 0 and 18 years of age) with constipation that has not responded to standard medical treatments (intractable constipation). This extreme level of constipation can impact a child's life in very negative ways, such as keeping them away from school and other daily activities; causing them pain, discomfort, and general distress; and requiring hospital visits for treatment. Consequently, there is a need to investigate if the tested therapies can help resolve the problem. What did we do? We considered any medication, surgical procedure, or therapy to help children with intractable constipation. Each study compared a specific treatment to placebo, no treatment, or another treatment. We were interested in whether the treatments increased the frequency of defecation, improved symptoms, or led to treatment success. We also wanted to know if the treatments were safe, so we looked at whether they caused side effects. We searched for randomised controlled trials (studies in which people are randomly assigned to one of two or more treatment groups) comparing any medical, surgical, or complementary therapy versus no treatment, placebo, or another treatment in children with intractable constipation. What did we find? We found 10 studies involving a total of 1278 children. The average age of study participants ranged from around 5 to 10 years. The studies were conducted in Iran, Brazil, Colombia, the USA, Canada, Australia, and several European countries. Studies lasted from one to six months. The studies made the following comparisons: • botox injection versus stool softeners; • erythromycin versus placebo; • lubiprostone versus placebo; • rectal sodium dioctyl sulfosuccinate and sorbitol versus oral polyethylene glycol laxatives; • biofeedback therapy versus no treatment; • intrarectal electromotive botox injection versus a usual botox injection; • botox injection versus myectomy of the internal anal sphincter; • prucalopride versus placebo; • transcutaneous electrical stimulation versus sham stimulation; and • dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. Main results • There may be little to no difference between lubiprostone and placebo in achieving treatment success, and there is probably little to no difference in adverse events for this comparison. • There is probably little or no difference between prucalopride and placebo in defecation frequency, treatment success, and adverse events. • We do not know whether any of the other treatments looked at in this review are safer or more beneficial than others. What are the limitations of the evidence? The evidence is limited due to small participant numbers in the included studies, and because each study looked at a different comparison, both of which resulted in the evidence being imprecise. There were also issues with the way the studies were conducted, which led to concerns that study results might be biased. How up‐to‐date is this evidence? This review is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gordon, M, Grafton-Clarke, C, Rajindrajith, S, Benninga, M, Sinopoulou, V, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD014580.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.768Z" }, { "id": "3b2d6388-4cfd-47a9-b511-ce32536cc05f", "pmid": "", "title": "Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Subcutaneous administration may be preferable to oral for individuals experiencing nausea and/or vomiting Objectives To determine the efficacy and tolerability of subcutaneous sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using subcutaneous sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Thirty‐five studies (9365 participants) compared subcutaneous sumatriptan with placebo or an active comparator. Most of the data were for the 6 mg dose. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 6 mg versus placebo the NNTs were 2.9, 2.3, 2.2, and 2.1 for pain‐free at one and two hours, and headache relief at one and two hours, respectively, and 6.1 for sustained pain‐free at 24 hours. Results for the 4 mg and 8 mg doses were similar to the 6 mg dose, with 6 mg significantly better than 4 mg only for pain‐free at one hour, and 8 mg significantly better than 6 mg only for headache relief at one hour. There was no evidence of increased migraine relief if a second dose of sumatriptan 6 mg was given after an inadequate response to the first. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Sumatriptan was compared directly with a number of active treatments, including other triptans, acetylsalicylic acid plus metoclopramide, and dihydroergotamine, but there were insufficient data for any pooled analyses. Authors' conclusions Subcutaneous sumatriptan is effective as an abortive treatment for acute migraine attacks, quickly relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a subcutaneous injection, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, or needing fast relief. This review found that a single subcutaneous dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in almost 6 in 10 people (59%) taking sumatriptan 6 mg, compared with about 1 in 7 (15%) taking placebo, and reduced from moderate or severe to no worse than mild pain by two hours in almost 8 in 10 people (79%) taking sumatriptan compared with about 3 in 10 (31%) taking placebo. Subcutaneous sumatriptan was fast‐acting, and the majority of people experiencing pain relief had done so by one hour. About 3 in 10 (31%) people had freedom from pain at two hours which was sustained during the 24 hours postdose without the use of rescue medication, compared with about 1 in 7 (15%) with placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events, most of which were of short duration and mild or moderate in severity, were more frequent with sumatriptan than with placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009665", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "3b316100-1c7b-4a44-ac06-da69969e1d66", "pmid": "", "title": "Non‐nutritive sweeteners for diabetes mellitus", "imported": false, "abstract": "Abstract - Background Products sweetened with non‐nutritive sweeteners (NNS) are widely available. Many people with type 1 or type 2 diabetes use NNS as a replacement for nutritive sweeteners to control their carbohydrate and energy intake. Health outcomes associated with NNS use in diabetes are unknown. Objectives To assess the effects of non‐nutritive sweeteners in people with diabetes mellitus. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Scopus, the WHO ICTRP, and ClinicalTrials.gov. The date of the last search of all databases (except for Scopus) was May 2019. We last searched Scopus in January 2019. We did not apply any language restrictions. Selection criteria We included randomised controlled trials (RCTs) with a duration of four weeks or more comparing any type of NNS with usual diet, no intervention, placebo, water, a different NNS, or a nutritive sweetener in individuals with type 1 or type 2 diabetes. Trials with concomitant behaviour‐changing interventions, such as diet, exercise, or both, were eligible for inclusion, given that the concomitant interventions were the same in the intervention and comparator groups. Data collection and analysis Two review authors independently screened abstracts, full texts, and records retrieved from trials registries, assessed the certainty of the evidence, and extracted data. We used a random‐effects model to perform meta‐analysis, and calculated effect estimates as risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs). We assessed risk of bias using the Cochrane 'Risk of bias' tool and the certainty of evidence using the GRADE approach. Main results We included nine RCTs that randomised a total of 979 people with type 1 or type 2 diabetes. The intervention duration ranged from 4 to 10 months. We judged none of these trials as at low risk of bias for all ’Risk of bias’ domains; most of the included trials did not report the method of randomisation. Three trials compared the effects of a dietary supplement containing NNS with sugar: glycosylated haemoglobin A1c (HbA1c) was 0.4% higher in the NNS group (95% CI −0.5 to 1.2; P = 0.44; 3 trials; 72 participants; very low‐certainty evidence). The MD in weight change was −0.1 kg (95% CI −2.7 to 2.6; P = 0.96; 3 trials; 72 participants; very low‐certainty evidence). None of the trials with sugar as comparator reported on adverse events. Five trials compared NNS with placebo. The MD for HbA1c was 0%, 95% CI −0.1 to 0.1; P = 0.99; 4 trials; 360 participants; very low‐certainty evidence. The 95% prediction interval ranged between −0.3% and 0.3%. The comparison of NNS versus placebo showed a MD in body weight of −0.2 kg, 95% CI −1 to 0.6; P = 0.64; 2 trials; 184 participants; very low‐certainty evidence. Three trials reported the numbers of participants experiencing at least one non‐serious adverse event: 36/113 participants (31.9%) in the NNS group versus 42/118 participants (35.6%) in the placebo group (RR 0.78, 95% CI 0.39 to 1.56; P = 0.48; 3 trials; 231 participants; very low‐certainty evidence). One trial compared NNS with a nutritive low‐calorie sweetener (tagatose). HbA1c was 0.3% higher in the NNS group (95% CI 0.1 to 0.4; P = 0.01; 1 trial; 354 participants; very low‐certainty evidence). This trial did not report body weight data and adverse events. The included trials did not report data on health‐related quality of life, diabetes complications, all‐cause mortality, or socioeconomic effects. Authors' conclusions There is inconclusive evidence of very low certainty regarding the effects of NNS consumption compared with either sugar, placebo, or nutritive low‐calorie sweetener consumption on clinically relevant benefit or harm for HbA1c, body weight, and adverse events in people with type 1 or type 2 diabetes. Data on health‐related quality of life, diabetes complications, all‐cause mortality, and socioeconomic effects are lacking. Plain language summary Non‐nutritive sweeteners for diabetes mellitus Review question Are non‐nutritive sweeteners beneficial or harmful in people with diabetes? Background Non‐nutritive sweeteners are sweetening agents having higher sweetening intensity and lower calorie content per gram compared to caloric sweeteners like sucrose or corn syrups. Both the general population and diabetic people use non‐nutritive sweeteners as a caloric sweetener replacement to control their carbohydrate and energy intake. Most of the non‐nutritive sweeteners approved for human consumption are synthetic (artificial sweeteners); however, increasing numbers of natural non‐caloric sweeteners are becoming available for human consumption. Products sweetened with non‐nutritive sweeteners are widely available on the market: diet beverages, diet yoghourts, desserts, and chewing gums are the most common products containing non‐nutritive sweeteners. Non‐nutritive sweeteners are also available as table‐top sweeteners for use by consumers at home as a sweetening agent for beverages and for cooking and baking. There is very little information about the health consequences of this intensified non‐nutritive sweeteners consumption in people with diabetes. We wanted to find out whether non‐nutritive sweeteners consumption in people with diabetes has an effect on long‐term average blood sugar levels (glycosylated haemoglobin A1c ‐ HbA1c), body weight, side effects, diabetes complications (such as heart attack, eye or kidney disease), and health‐related quality of life. Study characteristics We found nine randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) that allocated people with diabetes to either a group that received a non‐nutritive sweetener or a comparator group. The comparator was usual diet with additional sugar in three studies; placebo (a dummy pill) in five studies; and tagatose (a nutritive low‐calorie sweetener) in one study. The studies included a total of 979 participants; most of the studies were small, with fewer than 100 participants. The length of the studies varied from 4 to 10 months. This evidence is up‐to‐date as of May 2019. Key results Data on health‐related quality of life, diabetes complications, death from any cause, and socioeconomic effects (such as absence from work, visits to general practitioner, medication consumption) were lacking, and data were generally sparse for all comparisons. The available data did not show a clear difference between non‐nutritive sweeteners and sugar, placebo, or the nutritive low‐calorie sweetener tagatose for HbA1c, body weight, and side effects. Certainty of the evidence We rated the overall certainty of the evidence as very low, mainly due to the small numbers of included studies and participants and methodological limitations of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lohner, S, Kuellenberg de Gaudry, D, Toews, I, Ferenci, T, Meerpohl, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD012885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.749Z" }, { "id": "3b497d35-b73b-41a1-bf58-474a05c6acab", "pmid": "", "title": "Community‐based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries", "imported": false, "abstract": "Abstract - Background Supplementary feeding is defined as the provision of extra food to children or families beyond the normal ration of their home diets. The impact of food supplementation on child growth merits careful evaluation in view of the reliance of many states and non‐governmental organisations on this intervention to improve child health in low and middle income countries (LMIC). This is an update of a Cochrane review first published in 2005. Objectives To evaluate the effectiveness of community‐based supplementary feeding for promoting the physical growth of children under five years of age in LMIC. Search methods For this updated review we searched the following databases on 31 January 2011: CENTRAL ( The Cochrane Library ), MEDLINE (1948 to January week 3, 2011), EMBASE (1980 to week 3, 2011), CINAHL (1937 to 27 January 2011), LILACS (all years), WorldCat for dissertations and theses (all years) and ClinicalTrials.gov (all years). Selection criteria Randomised controlled trials (RCTs) evaluating supplementary feeding in comparison to a control group (no intervention or a placebo such as food with a very low number of nutrients and calories) in children from birth to five years of age in LMIC. Data collection and analysis Two review authors independently extracted and analysed the data. Main results We included eight RCTs (n = 1243 children) that were at relatively high risk of bias. We found high levels of clinical heterogeneity in the participants, interventions and outcome measures across studies. Nevertheless, in order to quantify pooled effects of supplementary feeding, we decided to combine studies according to prespecified characteristics. These were the children's age (younger or older than 24 months), their nutritional status at baseline (stunted or wasted, or not stunted or wasted) and the duration of the intervention (less or more than 12 months). A statistically significant difference of effect was only found for length during the intervention in children aged less than 12 months (two studies; 795 children; mean difference 0.19 cm; 95% confidence interval (CI) 0.07 to 0.31). Based on the summary statistic calculated for each study, the mean difference (MD) between intervention and control groups ranged from 0.48 cm (95% CI 0.07 to 0.89) to 1.3 cm (95% CI 0.03 to 2.57) after 3 and 12 months of intervention, respectively. Data on potential adverse effects were lacking. Authors' conclusions The scarcity of available studies and their heterogeneity makes it difficult to reach any firm conclusions. The review findings suggest supplementary feeding has a negligible impact on child growth; however, the pooled results should be interpreted with great caution because the studies included in the review are clinically diverse. Future studies should address issues of research design, including sample size calculation, to detect meaningful clinical effects and adequate intervention allocation concealment. In the meantime, families and children in need should be provided appropriate feeding, health care and sanitation without waiting for new RCTs to establish a research basis for feeding children. Plain language summary Providing extra food for children under five years of age in low and middle income countries Undernutrition is one of the underlying causes of childhood illness and death in low‐ and middle‐income countries. Providing extra food to children or families beyond what they normally have at home is an intervention aimed at supporting the nutritional wellbeing of the target population. We included eight studies where the participants were randomly assigned to two groups: one group received the extra food and the other group was a control, either receiving no food or food with very low nutritional content. Although the impact of supplementary feeding on child growth appeared to be negligible, it is not possible to draw any conclusions until we have studies that involve larger numbers and do not allow assessors to know who is receiving the intervention. Although it is difficult to determine whether community‐based supplementary feeding helps to promote the growth of children from birth to five years in low‐ and middle‐income countries, it is obviously vital to continue to provide food, health care and sanitation to those who need them.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Sguassero, Y, de Onis, M, Bonotti, AM, Carroli, G", "articleTypes": [], "doi": "10.1002/14651858.CD005039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.125Z" }, { "id": "3b4cb545-e3ba-42d6-97ff-77dc91d1bcc0", "pmid": "", "title": "Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is the most common life‐limiting autosomal recessive genetic disorder in white populations. Distal intestinal obstruction syndrome (DIOS) is an important morbidity in cystic fibrosis. It is the result of the accumulation of viscid faecal material within the bowel which combines with thick, sticky mucus produced in the intestines of people with cystic fibrosis. The intestine may be completely blocked (complete DIOS) or only partially blocked (incomplete DIOS). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the acute complete or incomplete faecal obstruction and ultimately prevent the need for surgical intervention . Objectives This review aimed to evaluate the effectiveness and safety of different treatment regimens for the treatment of DIOS (complete and incomplete) in children and adults with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials (including cross‐over trials (to be judged on an individual basis)) comparing the use of laxative agents or surgery for treating DIOS in children, young people and adults with cystic fibrosis to each other, placebo or no intervention. Data collection and analysis Two authors independently screened papers, extracted trial details and assessed for risk of bias. The authors assessed the quality of evidence using GRADE. Main results There was one trial with 20 participants (16 females) included in the review. The mean age of participants was 13.1 years. The trial was a double‐blinded, randomised cross‐over trial which had a duration of 12 months in total and compared high‐dose and low‐dose pancreatic enzyme therapy. As only the abstract of the trial was available, the overall risk of bias was judged to be unclear. The trial did not address either of our primary outcomes (time until resolution of DIOS and treatment failure rate), but reported episodes of acute DIOS, presence of abdominal mass and abdominal pain. There were no numerical data available for these outcomes, but the authors stated that there was no difference between treatment with high‐dose or low‐dose pancreatic enzymes. The overall certainty of the evidence was found to be very low. Authors' conclusions There is a clear lack of evidence for the treatment of DIOS in people with cystic fibrosis. The included abstract did not address our primary outcome measures and did not provide numerical data for the two secondary outcomes it did address. Therefore, we cannot justify the use of high‐dose pancreatic enzymes for treating DIOS, nor can we comment on the efficacy and safety of other laxative agents. From our findings, it is clear that more randomised controlled trials need to be conducted in this area. Plain language summary Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis Review question We reviewed the evidence about the effectiveness and safety of different treatments for distal intestinal obstruction syndrome (DIOS) in children and adults with cystic fibrosis. Background Cystic fibrosis is a common, life‐limiting, inherited disease. One of the main features of cystic fibrosis is the thick, sticky mucus produced by many organs including the lungs, pancreas and intestine. DIOS occurs when mucus in the intestine combines with faeces and builds up to produce a mass. This mass can partially or completely block the intestine and cause symptoms such as vomiting, severe abdominal pain and a swollen stomach (abdominal distension). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the complete or partial blockage and ultimately prevent the need for any surgical intervention. Search date The evidence is current to: 12 October 2021. Trial characteristics The review included one trial with 20 people with cystic fibrosis who were aged between 7.1 and 23.2 years of age (average 13.1 years old). The 12‐month trial compared a high dose of pancreatic enzymes with a low dose of pancreatic enzymes for treating chronic DIOS. Key results The trial did not report on our primary outcomes (time until DIOS successfully treated and treatment failure rate), but addressed two of our secondary outcomes; episodes of acute DIOS and the harmful effects that might occur in participants (the presence of an abdominal mass and abdominal pain). There were no numerical data available for these results, but the authors reported that there was no difference between high‐dose or low‐dose pancreatic enzymes. Certainty of the evidence We found the overall certainty of the evidence to be very low. The trial itself was only published as an abstract from a conference which did not include numerical data and it was not published as a full report. This meant that we do not know many details about the trial. We thought that the overall risk of bias was unclear, as the trial authors did not describe how participants were put into the treatment groups, whether any participants dropped out or whether the planned outcomes were the same as the reported outcomes. The trial also had a very small number of participants and a limited age range, making it difficult to draw conclusions about the relevance of the treatment for all people with cystic fibrosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gilchrist, FJ; Green, J; Carroll, W", "articleTypes": [], "doi": "10.1002/14651858.CD012798.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "3b4e744a-40b3-437e-aa2b-c844b5bb80fb", "pmid": "", "title": "Omega‐3 fatty acid addition during pregnancy", "imported": false, "abstract": "Abstract - Background Higher intakes of foods containing omega‐3 long‐chain polyunsaturated fatty acids (LCPUFA), such as fish, during pregnancy have been associated with longer gestations and improved perinatal outcomes. This is an update of a review that was first published in 2006. Objectives To assess the effects of omega‐3 LCPUFA, as supplements or as dietary additions, during pregnancy on maternal, perinatal, and neonatal outcomes and longer‐term outcomes for mother and child. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (16 August 2018), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing omega‐3 fatty acids (as supplements or as foods, stand‐alone interventions, or with a co‐intervention) during pregnancy with placebo or no omega‐3, and studies or study arms directly comparing omega‐3 LCPUFA doses or types. Trials published in abstract form were eligible for inclusion. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, assessed risk of bias in trials and assessed quality of evidence for prespecified birth/infant, maternal, child/adult and health service outcomes using the GRADE approach. Main results In this update, we included 70 RCTs (involving 19,927 women at low, mixed or high risk of poor pregnancy outcomes) which compared omega‐3 LCPUFA interventions (supplements and food) compared with placebo or no omega‐3. Overall study‐level risk of bias was mixed, with selection and performance bias mostly at low risk, but there was high risk of attrition bias in some trials. Most trials were conducted in upper‐middle or high‐income countries; and nearly half the trials included women at increased/high risk for factors which might increase the risk of adverse maternal and birth outcomes. Preterm birth < 37 weeks (13.4% versus 11.9%; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.81 to 0.97; 26 RCTs, 10,304 participants; high‐quality evidence) and early preterm birth < 34 weeks (4.6% versus 2.7%; RR 0.58, 95% CI 0.44 to 0.77; 9 RCTs, 5204 participants; high‐quality evidence) were both lower in women who received omega‐3 LCPUFA compared with no omega‐3. Prolonged gestation > 42 weeks was probably increased from 1.6% to 2.6% in women who received omega‐3 LCPUFA compared with no omega‐3 (RR 1.61 95% CI 1.11 to 2.33; 5141 participants; 6 RCTs; moderate‐quality evidence ). For infants, there was a possibly reduced risk of perinatal death (RR 0.75, 95% CI 0.54 to 1.03; 10 RCTs, 7416 participants; moderate‐quality evidence: 62/3715 versus 83/3701 infants) and possibly fewer neonatal care admissions (RR 0.92, 95% CI 0.83 to 1.03; 9 RCTs, 6920 participants; moderate‐quality evidence ‐ 483/3475 infants versus 519/3445 infants). There was a reduced risk of low birthweight (LBW) babies (15.6% versus 14%; RR 0.90, 95% CI 0.82 to 0.99; 15 trials, 8449 participants; high‐quality evidence); but a possible small increase in large‐for‐gestational age (LGA) babies (RR 1.15, 95% CI 0.97 to 1.36; 6 RCTs, 3722 participants; moderate‐quality evidence, for omega‐3 LCPUFA compared with no omega‐3. Little or no difference in small‐for‐gestational age or intrauterine growth restriction (RR 1.01, 95% CI 0.90 to 1.13; 8 RCTs, 6907 participants; moderate‐quality evidence) was seen. For the maternal outcomes , there is insufficient evidence to determine the effects of omega‐3 on induction post‐term (average RR 0.82, 95% CI 0.22 to 2.98; 3 trials, 2900 participants; low‐quality evidence), maternal serious adverse events (RR 1.04, 95% CI 0.40 to 2.72; 2 trials, 2690 participants; low‐quality evidence), maternal admission to intensive care (RR 0.56, 95% CI 0.12 to 2.63; 2 trials, 2458 participants; low‐quality evidence), or postnatal depression (average RR 0.99, 95% CI 0.56 to 1.77; 2 trials, 2431 participants; low‐quality evidence). Mean gestational length was greater in women who received omega‐3 LCPUFA (mean difference (MD) 1.67 days, 95% CI 0.95 to 2.39; 41 trials, 12,517 participants; moderate‐quality evidence), and pre‐eclampsia may possibly be reduced with omega‐3 LCPUFA (RR 0.84, 95% CI 0.69 to 1.01; 20 trials, 8306 participants; low‐quality evidence). For the child/adult outcomes, very few differences between antenatal omega‐3 LCPUFA supplementation and no omega‐3 were observed in cognition, IQ, vision, other neurodevelopment and growth outcomes, language and behaviour (mostly low‐quality to very low‐quality evidence). The effect of omega‐3 LCPUFA on body mass index at 19 years (MD 0, 95% CI ‐0.83 to 0.83; 1 trial, 243 participants; very low‐quality evidence) was uncertain. No data were reported for development of diabetes in the children of study participants. Authors' conclusions In the overall analysis, preterm birth < 37 weeks and early preterm birth < 34 weeks were reduced in women receiving omega‐3 LCPUFA compared with no omega‐3. There was a possibly reduced risk of perinatal death and of neonatal care admission , a reduced risk of LBW babies; and possibly a small increased risk of LGA babies with omega‐3 LCPUFA. For our GRADE quality assessments, we assessed most of the important perinatal outcomes as high‐quality (e.g. preterm birth) or moderate‐quality evidence (e.g. perinatal death). For the other outcome domains (maternal, child/adult and health service outcomes) GRADE ratings ranged from moderate to very low, with over half rated as low. Reasons for downgrading across the domain were mostly due to design limitations and imprecision. Omega‐3 LCPUFA supplementation during pregnancy is an effective strategy for reducing the incidence of preterm birth, although it probably increases the incidence of post‐term pregnancies. More studies comparing omega‐3 LCPUFA and placebo (to establish causality in relation to preterm birth) are not needed at this stage. A further 23 ongoing trials are still to report on over 5000 women, so no more RCTs are needed that compare omega‐3 LCPUFA against placebo or no intervention. However, further follow‐up of completed trials is needed to assess longer‐term outcomes for mother and child, to improve understanding of metabolic, growth and neurodevelopment pathways in particular, and to establish if, and how, outcomes vary by different types of omega‐3 LCPUFA, timing and doses; or by characteristics of women. Plain language summary Omega‐3 fatty acid addition during pregnancy What is the issue? Do omega‐3 long chain polyunsaturated fatty acids (LCPUFA) taken during pregnancy ‐ either as supplements or as dietary additions in food (such as some types of fish) ‐ improve health outcomes for babies and their mothers? This is an update of a Cochrane Review that was first published in 2006. Why is this important? Preterm birth (babies born before 37 weeks pregnancy (gestation)) is a leading cause of disability or death in the first five years of life. Fish and fish oil contain omega‐3 LCPUFA (particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)) and have been associated with longer pregnancies. So it is suggested that additional omega‐3 LCPUFAs in pregnancy may reduce the number of babies born preterm and may improve outcomes for children and mothers. However, many pregnant women do not eat fish very often. Encouraging pregnant women to eat fatty fish (which generally have low toxin levels) or to use omega‐3 LCPUFA supplements may improve children’s and women's health. This is an update of a Cochrane Review that was first published in 2006. What evidence did we find? We searched for evidence in August 2018 and found 70 randomised controlled trials (RCTs; this type of trial provides the most reliable results) (involving 19,927 women). Most trials evaluated a group of women who received omega‐3 LCPUFA and compared them with a group of women who received something that looked like omega‐3 LCPUFA but did not contain it (placebo) or received no omega‐3. The trials were mostly undertaken in upper‐middle or high‐income countries. Some studies included women at increased risk of preterm birth. The quality of the evidence from the included studies ranged from high to very low; this affected the certainty of the findings for different outcomes. We found the incidence of preterm birth (before 37 weeks) and very preterm birth (before 34 weeks) was lower in women who received omega‐3 LCPUFA compared with no additional omega‐3. There were also fewer babies with low birthweight. However, omega‐3 LCPUFA probably increased the incidence of pregnancies continuing beyond 42 weeks, although there was no difference identified in induction of labour for post‐term pregnancies. The risk of the baby dying or being very sick and going to neonatal intensive care may be lower with omega‐3 LCPUFA compared with no omega‐3. We did not see any differences between groups for serious adverse events for mothers or in postnatal depression. Very few differences between the omega‐3 LCPUFA groups and no omega‐3 groups were observed in child development and growth. Eleven trials reported that they had received industry funding. When we omitted these trials from the main outcomes (such as preterm birth and very preterm birth) it made very little, or no difference, to the results. What does this mean? Increasing omega‐3 LCPUFA intake during pregnancy, either through supplements or in foods, may reduce the incidence of preterm birth (before 37 weeks and before 34 weeks) and there may be less chance of having a baby with a low birthweight. Women who take omega‐3 LCPUFA supplements during pregnancy may also be more likely to have longer pregnancies. More studies are underway and their results will be included in a further update of this review. Future studies could consider if and how outcomes may vary in different populations of women, and could test different ways of increasing omega‐3 LCPUFA during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Middleton, P; Gomersall, JC; Gould, JF; Shepherd, E; Olsen, SF; Makrides, M", "articleTypes": [], "doi": "10.1002/14651858.CD003402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "3b64acb0-d33e-43af-b9a9-ef6e8f510039", "pmid": "", "title": "Nedocromil sodium for chronic asthma in children", "imported": false, "abstract": "Abstract - Background Currently inhaled corticosteroids are the main stay in the maintenance treatment of chronic asthma in children. Although inhaled corticosteroids play a crucial role in the management of childhood asthma, the long‐term side effects of inhaled corticosteroids used in the management of chronic asthma in children are not clearly known. Objectives The objective of this review is to compare the safety and efficacy of inhaled nedocromil sodium with placebo in the treatment of chronic asthma in children. Search methods We searched the Cochrane Airway Group trials register, review articles, and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. We also searched abstracts of major respiratory society meetings. The last search was carried out in November 2009. Selection criteria Randomised placebo controlled trials comparing nedocromil sodium to placebo in the treatment of chronic asthma in children (0 to 18 years). Data collection and analysis Both authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Fifteen trials (twelve parallel group studies; three crossover trials recruiting 1422 children (837 males and 585 females)) were included. The studies were generally of good methodological quality. Two large long term studies used nedocromil for six months and four to six years and showed conflicting results in symptom free days. Short term studies (duration between 4 weeks to 12 weeks) showed that nedocromil sodium produced some improvement in a number of efficacy measures compared to placebo including FEV 1 , FVC, FEV 1 % predicted, PC20 FEV 1 , evening PEF and symptom scores. The parent's assessment of efficacy was in favour of nedocromil (odds ratio (OR) 0.5 (95% CI 0.3 to 0.8). Nedocromil sodium has a good safety profile. The only significant side effect observed was unpleasant taste. There was little evidence for a clinically dose response effect and only a few studies recruited participants with severe asthma. Authors' conclusions A limited number of small studies have shown that nedocromil is of benefit in improving lung function and some measures of symptoms, but the evidence with regard to the primary outcome of the review was conflicting. Two long‐term trials did not show consistent effects on lung function outcomes, whereas several small short‐term trials have shown benefit in these outcomes. Differing severities at baseline may explain this difference with milder participants experiencing less benefit, although the discrepancy between study findings may also reflect publication bias. Nedocromil sodium is associated with a very good safety profile with no significant short term or long‐ term adverse side effects. Although nedocromil may have advantages over inhaled corticosteroids in terms of side effects, there is a need for head to head trials of nedocromil and inhaled corticosteroids to establish whether asthma control is similar, especially in mild asthma. It is not yet clear where nedocromil should sit in relation to other therapies in the treatment of asthma in children. Plain language summary Nedocromil sodium for chronic asthma in children Nedocromil (or Tilade) is a 'preventer' therapy used to treat chronic asthma in children. It is thought to be safer than inhaled steroids and can be used for the management of mild to moderate asthma. The review of studies including 15 trials and 1422 children found that there were some encouraging results in short term studies when nedocromil was compared on its own with placebo, particularly with regard to lung function tests. However, these results were not confirmed in one large, longer term study of four to six years duration, which did not show significant difference in the primary outcome of symptom free days. This study was conducted in children who had mild asthma. There may be a role for nedocromil in the management of moderate asthma, but it should be assessed in relation to inhaled steroids, whose efficacy is well‐established. This particularly important in symptomatic asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Sridhar, AV; McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD004108.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "3b6bc885-3082-4502-b8f7-e270cac29db8", "pmid": "", "title": "Surgical techniques for the removal of mandibular wisdom teeth", "imported": false, "abstract": "Abstract - Background Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short‐term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity. Objectives To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication. Selection criteria Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth. Data collection and analysis Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel‐group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross‐over or split‐mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split‐mouth studies in our analyses, and combined parallel‐group and split‐mouth studies using the generic inverse‐variance method. We used the fixed‐effect model for three studies or fewer, and random‐effects model for more than three studies. Main results We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low‐certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low‐certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low‐certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low‐certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand‐piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low‐certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low‐certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low‐certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low‐certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low‐certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported. Authors' conclusions In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future. Plain language summary Comparing different surgical techniques used to remove wisdom teeth from the lower jaw Background The removal of wisdom teeth is a common operation, but it can cause short‐ and long‐term side effects. People may have their wisdom teeth removed if they are causing pain or infection, or if they are damaging other teeth or not breaking through the gum properly. Surgery has a risk of complications. One of the most common is dry socket (also known as alveolar osteitis). This is when a blood clot fails to form in the socket that the tooth has come out of, or the clot is disturbed before the socket has properly healed. Because the bones and nerves underlying the socket are exposed, it can be a very painful condition. Review question We aimed to find out the benefits and harms of different surgical techniques used to remove wisdom teeth from the lower jaw, specifically how surgeons can reduce the risk of complications following surgery. We considered the most important outcomes to be: dry socket, wound infection, long‐term damage to the nerves supplying sensation to the tongue and skin of the lower lip and chin, and problems such as excessive bleeding or a broken jaw. Study characteristics We searched for relevant studies up to 8 July 2019. We included 62 studies with 4643 participants. Many studies excluded people who were not in excellent health so the participants in the trials may not be truly representative. Key results The available evidence is inconclusive. It is unclear if the position of the cut into the gum makes any difference to the outcomes. It is unclear whether it is possible to avoid damaging a nerve to the tongue by using a surgical instrument called a lingual retractor. It is unclear as to whether the type of surgical tool (a chisel or a rotating drill) used to remove bone from the jaw makes a difference to the likelihood of the wound becoming infected. It is unclear if the amount and method of delivering saltwater to clean the tooth socket after the extraction makes any difference to the outcomes. It is unclear whether different methods to stitch the gum after the tooth is removed makes any difference to the outcomes. Placing products that are derived from the patient’s own blood into the tooth socket may help to reduce the occurrence of dry socket (a condition that causes intense pain a few days after extraction). Another three surgical approaches were tested in the studies, but they did not measure the important outcomes. Certainty of the evidence None of the included studies were at low risk of bias. All of the studies were quite small. The quality of the studies varied, with most having flaws that could have biased their results. In addition, some of the results were very imprecise, with variation between them that could not be explained. For these reasons, we consider the available evidence to be uncertain. Future research may be able to provide dental surgeons and patients with clearer conclusions than those listed above.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bailey, E; Kashbour, W; Shah, N; Worthington, HV; Renton, TF; Coulthard, P", "articleTypes": [], "doi": "10.1002/14651858.CD004345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "3b6e32c1-d3dc-48d3-ace2-887bfc70c3e7", "pmid": "", "title": "Echinacea for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Echinacea plant preparations (family Asteraceae ) are widely used in Europe and North America for common colds. Most consumers and physicians are not aware that products available under the term Echinacea differ appreciably in their composition, mainly due to the use of variable plant material, extraction methods and the addition of other components. Objectives To assess whether there is evidence that Echinacea preparations are effective and safe compared to placebo in the prevention and treatment of the common cold. Search methods We searched CENTRAL 2013, Issue 5, MEDLINE (1946 to May week 5, 2013), EMBASE (1991 to June 2013), CINAHL (1981 to June 2013), AMED (1985 to February 2012), LILACS (1981 to June 2013), Web of Science (1955 to June 2013), CAMBASE (no time limits), the Centre for Complementary Medicine Research (1988 to September 2007), WHO ICTRP and clinicaltrials.gov (last searched 5 June 2013), screened references and asked experts in the field about published and unpublished studies. Selection criteria Randomized controlled trials (RCTs) comparing mono‐preparations of Echinacea with placebo. Data collection and analysis At least two review authors independently assessed eligibility and trial quality and extracted data. The primary efficacy outcome was the number of individuals with at least one cold in prevention trials and the duration of colds in treatment trials. For all included trials the primary safety and acceptability outcome was the number of participants dropping out due to adverse events. We assessed trial quality using the Cochrane 'Risk of bias' tool. Main results Twenty‐four double‐blind trials with 4631 participants including a total of 33 comparisons of Echinacea preparations and placebo met the inclusion criteria. A variety of different Echinacea preparations based on different species and parts of plant were used. Evidence from seven trials was available for preparations based on the aerial parts of Echinacea purpurea. Ten trials were considered to have a low risk of bias, six to have an unclear risk of bias and eight to have a high risk of bias. Ten trials with 13 comparisons investigated prevention and 15 trials with 20 comparisons investigated treatment of colds (one trial addressed both prevention and treatment). Due to the strong clinical heterogeneity of the studies we refrained from pooling for the main analysis. None of the 12 prevention comparisons reporting the number of patients with at least one cold episode found a statistically significant difference. However a post hoc pooling of their results, suggests a relative risk reduction of 10% to 20%. Of the six treatment trials reporting data on the duration of colds, only two showed a significant effect of Echinacea over placebo. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. Authors' conclusions Echinacea products have not here been shown to provide benefits for treating colds, although, it is possible there is a weak benefit from some Echinacea products : the results of individual prophylaxis trials consistently show positive (if non‐significant) trends, although potential effects are of questionable clinical relevance. Plain language summary Echinacea for preventing and treating the common cold Preparations of the plant Echinacea are widely used in some European countries and in North America for common colds. Echinacea preparations available on the market differ greatly as different types (species) and parts (herb, root or both) of the plant are used, different manufacturing methods (drying, alcoholic extraction or pressing out the juice from fresh plants) are used and sometimes also other herbs are added. We reviewed 24 controlled clinical trials with 4631 participants investigating the effectiveness of several different Echinacea preparations for preventing and treating common colds or induced rhinovirus infections. Our review shows that a variety of products prepared from different Echinacea species, different plant parts and in a different form have been compared to placebo in randomized trials. Due to the significant differences in the preparations tested, it was difficult to draw strong conclusions. Five trials were rated as having a low risk of bias in all five categories of the Cochrane 'Risk of bias' tool. Five more trials were rated as low risk of bias, having an unclear risk of bias in only one category. Eight trials were rated as having a high risk of bias in at least one category and the remaining six as having an unclear risk of bias. The majority of trials investigated whether taking Echinacea preparations after the onset of cold symptoms shortens the duration, compared with placebo. Although it seems possible that some Echinacea products are more effective than a placebo for treating colds, the overall evidence for clinically relevant treatment effects is weak. In general, trials investigating Echinacea for preventing colds did not show statistically significant reductions in illness occurrence. However, nearly all prevention trials pointed in the direction of small preventive effects. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. The evidence is current to July 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Karsch‐Völk, M; Barrett, B; Kiefer, D; Bauer, R; Ardjomand‐Woelkart, K; Linde, K", "articleTypes": [], "doi": "10.1002/14651858.CD000530.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "3b8516b2-e476-4a1e-8639-4e2ed322ac08", "pmid": "", "title": "The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement", "imported": false, "abstract": "Abstract - Background The World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework is an holistic, settings‐based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed. Objectives To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well‐being of students and their academic achievement. Search methods We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov , Current controlled trials , and WHO International Clinical Trials Registry Platform . We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles. Selection criteria We included cluster‐randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school’s ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements. Data collection and analysis At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random‐effects meta‐analyses to provide a summary of results across studies. Main results We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand‐washing (2), multiple risk behaviours (7), cycle‐helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self‐reported data and high attrition rates for some studies. In addition, there was a lack of long‐term follow‐up data for most studies. We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta‐analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school‐related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement. Authors' conclusions The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well‐designed research is required to establish the effectiveness of this approach for other health topics and academic achievement. Plain language summary The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement Background Health and education are strongly connected: healthy children achieve better results at school, which in turn are associated with improved health later in life. This relationship between health and education forms the basis of the World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework, an approach to promoting health in schools that addresses the whole school environment. Although the HPS framework is used in many schools, we currently do not know if it is effective. This review aimed to assess whether the HPS framework can improve students’ health and well‐being and their performance at school. Study characteristics We searched 20 health, education, and social science databases, as well as trials registries and relevant websites, for cluster‐randomised controlled trials of school‐based interventions aiming to improve the health of young people aged four to 18 years. We only included trials of programmes that addressed all three points in the HPS framework: including health education in the curriculum; changing the school’s social or physical environment, or both; and involving students’ families or the local community, or both. Key results We found 67 trials, comprising 1345 schools and 98 districts, that fulfilled our criteria. These focused on a wide range of health topics, including physical activity, nutrition, substance use (tobacco, alcohol, and drugs), bullying, violence, mental health, sexual health, hand‐washing, cycle‐helmet use, sun protection, eating disorders, and oral health. For each study, two review authors independently extracted relevant data and assessed the risk of the study being biased. We grouped together studies according to the health topic(s) they focused on. We found that interventions using the HPS approach were able to reduce students’ body mass index (BMI), increase physical activity and fitness levels, improve fruit and vegetable consumption, decrease cigarette use, and reduce reports of being bullied. However, we found little evidence of an effect on BMI when age and gender were taken into account (zBMI), and no evidence of effectiveness on fat intake, alcohol and drug use, mental health, violence, and bullying others. We did not have enough data to draw conclusions about the effectiveness of the HPS approach for sexual health, hand‐washing, cycle‐helmet use, eating disorders, sun protection, oral health or academic outcomes. Few studies discussed whether the health promotion activities, or the collection of data relating to these, could have caused any harm to the students involved. Quality of the evidence Overall, the quality of evidence was low to moderate. We identified some problems with the way studies were conducted, which may have introduced bias, including many studies relying on students’ accounts of their own behaviours (rather than these being measured objectively) and high numbers of students dropping out of studies. These problems, and the small number of studies included in our analysis, limit our ability to draw clear conclusions about the effectiveness of the HPS framework in general. Conclusions Overall, we found some evidence to suggest the HPS approach can produce improvements in certain areas of health, but there are not enough data to draw conclusions about its effectiveness for others. We need more studies to find out if this approach can improve other aspects of health and how students perform at school.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Langford, R, Bonell, CP, Jones, HE, Pouliou, T, Murphy, SM, Waters, E, Komro, KA, Gibbs, LF, Magnus, D, Campbell, R", "articleTypes": [], "doi": "10.1002/14651858.CD008958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.140Z" }, { "id": "3b91c782-5b62-49f5-b818-15a1bf0eedb5", "pmid": "", "title": "Manipulating Tobacco Constituents in Male Menthol Smokers", "imported": false, "abstract": "This study examines the potential effect of reducing nicotine content or menthol or both in men. It will also examine whether there are gender differences in manipulating tobacco flavors and nicotine concentrations in cigarettes on smoking behavior.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.155Z" }, { "id": "3b9b3bb9-4840-4d82-8933-eb01f0cd2df0", "pmid": "", "title": "Interventions for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is the most common, life‐limiting, genetically inherited disease. It affects multiple organs, particularly the respiratory system. However, gastrointestinal problems such as constipation and distal intestinal obstruction syndrome (DIOS) are also important and well‐recognised complications in CF. They share similar symptoms e.g. bloating, abdominal pain, but are distinct conditions. Constipation occurs when there is gradual faecal impaction of the colon, but DIOS occurs when there is an accumulation of faeces and sticky mucus, forming a mass in the distal part of the small intestine. The mass may partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). Symptoms of DIOS can affect quality of life and other aspects of CF health, such as airway clearance, exercise, sleep and nutritional status. Treatment of constipation and prevention of complete bowel obstruction are required for gastrointestinal management in CF. However, many different strategies are used in clinical practice and there is a lack of consensus. The importance of this topic was highlighted in a recent research priority setting exercise by the James Lind Alliance. Objectives To evaluate the effectiveness and safety of laxative agents of differing types for preventing DIOS (complete and incomplete) in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised and quasi‐randomised controlled parallel trials comparing laxative therapy for preventing DIOS (including osmotic agents, stimulants, mucolytics and substances with more than one action) at any dose to placebo, no treatment or an alternative laxative therapy, in people of any age with pancreatic sufficient or insufficient CF and any stage of lung disease. Randomised cross‐over trials were judged on an individual basis. Data collection and analysis Two authors independently assessed trials for inclusion, extracted outcome data and performed a risk of bias assessment for the included data. We judged the certainty of the evidence using GRADE criteria. Main results We included one cross‐over trial (17 participants) with a duration of 12 months, in which participants were randomly allocated to either cisapride (a gastro‐prokinetic agent) or placebo for six months each. The trial had an unclear risk of bias for most domains but had a high risk of reporting bias. Radiograph scores revealed no difference in occurrence of DIOS between cisapride and placebo (narrative report, no data provided). There were no adverse effects. Symptom scores were the only secondary outcome within the review that were reported. Total gastrointestinal symptom scores favoured cisapride with a statistically significant mean difference (MD) of ‐7.60 (95% confidence interval (CI) ‐14.73 to ‐0.47). There was no significant difference at six months between cisapride and placebo for abdominal distension, MD ‐0.90 (95% CI ‐2.39 to 0.59) or abdominal pain, MD ‐0.4 (95% CI ‐2.05 to 1.25). The global symptom scores (whether individuals felt better or worse) were reported in the paper to favour cisapride and be statistically significant (P < 0.05). We assessed the available data to be very low certainty. There was a great deal of missing data from the included trial and the investigators failed to report numerical data for many outcomes. The overall risk of bias of the trial was unclear and it had a high risk for reporting bias. There was also indirectness; the trial drug (cisapride) has since been removed from the market in several countries due to adverse effects, thus it has no current applicability for preventing DIOS. The included trial also had very few participants, which downgraded the certainty a further level for precision. Authors' conclusions There is an absence of evidence for interventions for the prevention of DIOS. As there was only one included trial, we could not perform a meta‐analysis of the data. Furthermore, the included trial compared a prokinetic agent (cisapride) that is no longer licensed for use in a number of countries due to the risk of serious cardiac events, a finding that came to light after the trial was conducted. Therefore, the limited findings from the trial are not applicable in current clinical practice. Overall, a great deal more research needs to be undertaken on gastrointestinal complications in CF, as this is a very poorly studied area compared to respiratory complications in CF. Plain language summary Which interventions are effective and safe for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis? Background Cystic fibrosis (CF) is an inherited, life‐long condition that causes organ systems in the body to produce large amounts of thick and sticky mucus. The most commonly affected area is the lungs, in which thick mucus leads to recurrent chest infections and breathing difficulties. Another commonly affected area is the digestive system. Many people with CF suffer from bloating and abdominal pain which may be caused by constipation or distal intestinal obstruction syndrome (DIOS). In DIOS, overproduction of thick mucus combines with stool and sticks to the intestinal wall. This mass can partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). The latter causes severe pain, vomiting and is treated as a medical emergency. As part of effective care for people with CF, constipation should therefore be treated and complete bowel obstruction be prevented. It is also important to recognise that constipation and DIOS impact on other aspects of CF health. Bloating, abdominal pain and nausea may affect airway clearance, exercise and sleep. Nutritional status may also be affected due to decreased appetite and malabsorption. DIOS may affect the absorption of other medications taken by people with CF. Overall, DIOS can significantly impair quality of life. Different laxatives are currently used in clinics, but prescribing practices differ and there is no consensus on optimal treatment strategies. Hence, this review aimed to analyse the evidence for the preventing DIOS. Search date We last searched for evidence: 12 October 2021. Trial characteristics We included one trial in the review, which included 17 people aged between 13 to 35 years. These people were randomly put into groups to take either a placebo drug (with no active medication) or cisapride for six months each and then to cross over and take the alternative treatment for a further six months. Key results The trial used radiography to diagnose DIOS, but did not provide any data and only stated that there was no difference between cisapride and placebo. The trial also stated that there were no adverse effects from the cisapride. The trial assessed participant‐reported total and individual gastrointestinal symptom scores. People in the cisapride group reported an improvement in total gastrointestinal symptom scores compared to those in the placebo group. However, there were no differences reported between groups for the individual symptom scores of abdominal pain and abdominal distension (swelling). Participants also reported global symptom scores, which showed that most people felt better taking cisapride compared to placebo. Certainty of the evidence The overall certainty of the evidence was very low. With one trial in this review, we could not combine data from different trials. The trial did not provide enough information about the methods used for allocating participants or about missing data and did not fully report certain results. The small number of participants also lowered the precision of the results. Since this trial was conducted, cisapride has been removed from the market in a number of countries due to rare but serious heart complications, therefore it has no applicability to current clinical practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carroll, W; Green, J; Gilchrist, FJ", "articleTypes": [], "doi": "10.1002/14651858.CD012619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "3bc78b3c-e196-456c-bc2b-1829fe652062", "pmid": "", "title": "Interventions for acute otitis externa", "imported": false, "abstract": "Abstract - Background Acute otitis externa is an inflammatory condition of the ear canal, with or without infection. Symptoms include ear discomfort, itchiness, discharge and impaired hearing. It is also known as 'swimmer's ear' and can usually be treated successfully with a course of ear drops. Objectives To assess the effectiveness of interventions for acute otitis externa. Search methods Our search for published and unpublished trials included the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources. The date of the most recent search was 6 January 2009. Selection criteria Randomised controlled trials evaluating ear cleaning, topical medication or systemic therapy in the treatment of acute otitis externa were eligible. We excluded complicated acute otitis externa; otitis externa secondary to otitis media or chronic suppurative otitis media; chronic otitis externa; fungal otitis externa (otomycosis); eczematous otitis externa; viral otitis externa and furunculosis. Data collection and analysis Two authors assessed eligibility and quality. Main results Nineteen randomised controlled trials with a total of 3382 participants were included. Three meta‐analyses were possible. The overall quality of studies was low. Topical antimicrobials containing steroids were significantly more effective than placebo drops: OR 11 (95% CI 2.00 to 60.57; one trial). In general, no clinically meaningful differences were noted in clinical cure rates between the various topical interventions reviewed. One notable exception involved a trial of high quality which showed that acetic acid was significantly less effective when compared with antibiotic/steroid drops in terms of cure rate at two and three weeks (OR 0.29 (95% CI 0.13 to 0.62) and OR 0.25 (95% CI 0.11 to 0.58) respectively). One trial of low quality comparing quinolone with non‐quinolone antibiotics did not find any difference in clinical cure rate. No trials evaluated the effectiveness of ear cleaning. Only two trials evaluated steroid‐only drops. One trial of low quality suggested no significant difference between steroid and antibiotic/steroid but did not report the magnitude or precision of the result. Another trial of moderate quality comparing an oral antihistamine with topical steroid against topical steroid alone found that cure rates in both groups were high and comparable (100% (15/15) and 94% (14/15) respectively at three weeks). Authors' conclusions There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available: Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow‐up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid. The evidence for steroid‐only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed. Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision. Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated. Plain language summary Interventions to treat acute otitis externa, a specific form of ear canal inflammation also known as swimmer's ear Acute otitis externa causes inflammation of the ear canal. It is a common clinical problem encountered in general practice. This review assesses the various forms of medication used to treat the condition. Nineteen randomised controlled trials were included (3382 participants). Most were of low quality. The findings of the review may not be wholly relevant to primary care as most of the trials were conducted in a hospital setting and over half involved ear cleaning as part of the treatment (this is generally not available in primary care). However, the review does demonstrate that topical treatments alone are effective at treating acute otitis externa. There was little to choose between them in terms of effectiveness. However, when treatment needs to be extended beyond one week acetic acid drops appear to be less effective than antibiotic/steroid drops. In addition, symptoms persist for two days longer in those treated with acetic acid. More research is needed to determine the effectiveness of steroid‐only drops. Patients treated with antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Kaushik, V; Malik, T; Saeed, SR", "articleTypes": [], "doi": "10.1002/14651858.CD004740.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "3bcde1f5-b282-4064-88a0-05e8b7b4417c", "pmid": "", "title": "Progestin‐only pills for contraception", "imported": false, "abstract": "Abstract - Background The introduction of a new progestin‐only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. Objectives This review examined randomized controlled trials of progestin‐only pills for differences in efficacy, acceptability, and continuation rates. Search methods Through October 2013, we searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, and LILACS for studies of progestin‐only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. Selection criteria We included all randomized controlled trials in any language that included progestin‐only pills for contraception. We incorporated any comparison with a progestin‐only pill; this could include different doses, other progestin‐only pills, combined oral contraceptives, or other contraceptives. Data collection and analysis The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry. We attempted to extract life‐table rates (actuarial or continuous) and used the rate difference as the effect measure. Where life‐table rates were not published, we used the incidence rate ratio (ratio of Pearl rates). Where only the crude number of events was published, we calculated the Peto odds ratio with 95% confidence interval (CI) using a fixed‐effect model. For continuous variables, the mean difference (MD) was computed with 95% CI. Because of disparate exposures, we were not able to combine studies in meta‐analysis. Main results Six trials met the inclusion criteria. We have not found any new studies since the initial review. In the trial comparing the desogestrel versus levonorgestrel progestin‐only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin‐only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low‐dose mifepristone versus a levonorgestrel progestin‐only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin‐only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin‐only and two combined oral contraceptives, the progestin‐only pill containing levonorgestrel 30 μg had higher efficacy than did the pill containing norethisterone 350 μg. An early trial found megestrol acetate inferior to other progestin‐only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. Authors' conclusions Evidence is insufficient to compare progestin‐only pills to each other or to combined oral contraceptives. Plain language summary Progestin‐only pills for contraception Progestin‐only pills, as their name implies, contain just one hormone. The more common birth control pills combine two hormones. How these one‐hormone pills compare to each other or to two‐hormone pills is not clear. Hence, we did this review to compare progestin‐only pills to other similar pills or to combined (two‐hormone) pills. Through October 2013, we did a computer search and literature search to find randomized trials of progestin‐only pills. We found six trials for the initial review. We have not found any more studies since then. Some studies are several decades old and not very relevant to pills available today. A newer pill containing the progestin desogestrel may work better to prevent pregnancy than an older pill with levonorgestrel. The newer pill caused more bleeding problems. Pills with levonorgestrel may be more effective than pills with other progestins that are no longer used. These studies are not adequate to tell how progestin‐only pills compare to each other or to combined (two‐hormone) pills. Larger studies with currently used pills are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grimes, DA, Lopez, LM, O'Brien, PA, Raymond, EG", "articleTypes": [], "doi": "10.1002/14651858.CD007541.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.102Z" }, { "id": "3bdfd9f8-6ac6-4b2a-bf79-680703a8a462", "pmid": "", "title": "Drug interventions for the treatment of obesity in children and adolescents", "imported": false, "abstract": "Abstract - Background Child and adolescent obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. Objectives To assess the efficacy of drug interventions for the treatment of obesity in children and adolescents. Search methods We searched CENTRAL , MEDLINE, Embase, PubMed (subsets not available on Ovid), LILACS as well as the trial registers ICTRP (WHO) and ClinicalTrials.gov. Searches were undertaken from inception to March 2016. We checked references and applied no language restrictions. Selection criteria We selected randomised controlled trials (RCTs) of pharmacological interventions for treating obesity (licensed and unlicensed for this indication) in children and adolescents (mean age under 18 years) with or without support of family members, with a minimum of three months' pharmacological intervention and six months' follow‐up from baseline. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. In addition, we excluded trials which included growth hormone therapies and pregnant participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data following standard Cochrane methodology. Where necessary we contacted authors for additional information. Main results We included 21 trials and identified eight ongoing trials. The included trials evaluated metformin (11 trials), sibutramine (six trials), orlistat (four trials), and one trial arm investigated the combination of metformin and fluoxetine. The ongoing trials evaluated metformin (four trials), topiramate (two trials) and exenatide (two trials). A total of 2484 people participated in the included trials, 1478 participants were randomised to drug intervention and 904 to comparator groups (91 participants took part in two cross‐over trials; 11 participants not specified). Eighteen trials used a placebo in the comparator group. Two trials had a cross‐over design while the remaining 19 trials were parallel RCTs. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up from baseline ranged from six months to 100 weeks. Trials generally had a low risk of bias for random sequence generation, allocation concealment and blinding (participants, personnel and assessors) for subjective and objective outcomes. We judged approximately half of the trials as having a high risk of bias in one or more domain such as selective reporting. The primary outcomes of this review were change in body mass index (BMI), change in weight and adverse events. All 21 trials measured these outcomes. The secondary outcomes were health‐related quality of life (only one trial reported results showing no marked differences; very low certainty evidence), body fat distribution (measured in 18 trials), behaviour change (measured in six trials), participants' views of the intervention (not reported), morbidity associated with the intervention (measured in one orlistat trial only reporting more new gallstones following the intervention; very low certainty evidence), all‐cause mortality (one suicide in the orlistat intervention group; low certainty evidence) and socioeconomic effects (not reported). Intervention versus comparator for mean difference (MD) in BMI change was ‐1.3 kg/m 2 (95% confidence interval (CI) ‐1.9 to ‐0.8; P < 0.00001; 16 trials; 1884 participants; low certainty evidence). When split by drug type, sibutramine, metformin and orlistat all showed reductions in BMI in favour of the intervention. Intervention versus comparator for change in weight showed a MD of ‐3.9 kg (95% CI ‐5.9 to ‐1.9; P < 0.00001; 11 trials; 1180 participants; low certainty evidence). As with BMI, when the trials were split by drug type, sibutramine, metformin and orlistat all showed reductions in weight in favour of the intervention. Five trials reported serious adverse events: 24/878 (2.7%) participants in the intervention groups versus 8/469 (1.7%) participants in the comparator groups (risk ratio (RR) 1.43, 95% CI 0.63 to 3.25; 1347 participants; low certainty evidence). A total 52/1043 (5.0%) participants in the intervention groups versus 17/621 (2.7%) in the comparator groups discontinued the trial because of adverse events (RR 1.45, 95% CI 0.83 to 2.52; 10 trials; 1664 participants; low certainty evidence). The most common adverse events in orlistat and metformin trials were gastrointestinal (such as diarrhoea, mild abdominal pain or discomfort, fatty stools). The most frequent adverse events in sibutramine trials included tachycardia, constipation and hypertension. The single fluoxetine trial reported dry mouth and loose stools. No trial investigated drug treatment for overweight children. Authors' conclusions This systematic review is part of a series of associated Cochrane reviews on interventions for obese children and adolescents and has shown that pharmacological interventions (metformin, sibutramine, orlistat and fluoxetine) may have small effects in reduction in BMI and bodyweight in obese children and adolescents. However, many of these drugs are not licensed for the treatment of obesity in children and adolescents, or have been withdrawn. Trials were generally of low quality with many having a short or no post‐intervention follow‐up period and high dropout rates (overall dropout of 25%). Future research should focus on conducting trials with sufficient power and long‐term follow‐up, to ensure the long‐term effects of any pharmacological intervention are comprehensively assessed. Adverse events should be reported in a more standardised manner specifying amongst other things the number of participants experiencing at least one adverse event. The requirement of regulatory authorities (US Food and Drug Administration and European Medicines Agency) for trials of all new medications to be used in children and adolescents should drive an increase in the number of high quality trials. Plain language summary Drug interventions for the treatment of obesity in children and adolescents Review question Do drug (medicine) interventions reduce weight in obese children and adolescents and are they safe? Background Across the world more children and adolescents are becoming overweight and obese. These children and adolescents are more likely to have health problems, both while as children or adolescents and in later life. More information is needed about what works best for treating this problem recognising that so‐called lifestyle changes (diet, exercise and counselling) have limited efficacy. Study characteristics We found 21 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) comparing various drugs plus a behaviour changing intervention such as diet, exercise or both (= intervention groups) usually with placebo (a pretend drug) plus a behaviour changing intervention (= control groups). We also identified eight ongoing studies (studies which are currently running but not completed yet). A total of 2484 children and adolescents took part in the included studies. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up ranged from six months to 100 weeks. Key results The included studies investigated metformin (10 studies), sibutramine (six studies), orlistat (four studies) and one study group evaluated the combination of metformin and fluoxetine. The ongoing studies are investigating metformin (four studies), topiramate (two studies) and exenatide (two studies). Most studies reported on body mass index (BMI) and bodyweight: BMI is a measure of body fat and is calculated from weight and height measurements (kg/m 2 ). In children, BMI is often measured in a way that takes into account sex, weight and height as children grow older (BMI z score). The average change in BMI across control groups was between a 1.8 kg/m 2 reduction to a 0.9 kg/m 2 increase, while across all intervention groups the average reduction was more pronounced (1.3 kg/m 2 reduction). The same effect was observed for weight change: on average, children and adolescents in the intervention groups lost 3.9 kg more weight than the children and adolescents in the control groups. Study authors reported an average of serious side effects in 24 per 1000 participants in the intervention groups compared with an average of 17 per 1000 participants in the control groups. The numbers of participants dropping out of the study because of side effects were 40 per 1000 in the intervention groups and 27 per 1000 in the control groups. The most common side effects in the orlistat and metformin studies were gut (such as diarrhoea and mild tummy pain). Common side effects in the sibutramine trials included increased heart rate (tachycardia), constipation and high blood pressure. The fluoxetine study reported dry mouth and loose stools. One study reported health‐related quality of life (a measure of physical, mental, emotional and social functioning) and found no marked differences between intervention and control. No study reported the participants' views of the intervention or socioeconomic effects. Only one study reported on morbidity (how often a disease occurs in a specific area) associated with the intervention, where there were more gallstones after the orlistat treatment. Study authors reported one suicide in the orlistat intervention group. However, studies were not long enough to reliably investigate death from any cause. No study investigated drug treatment for children who were only overweight (obese children have a much higher weight, BMI or BMI z score than children being overweight). This evidence is up to date to March 2016. Quality of the evidence The overall certainty of the evidence was low or very low, mainly because there were only a few studies per outcome measurement, the number of included children or adolescents was small, and due to variation in the results of the studies. In addition, many children or adolescents left the studies before the study had finished.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Axon, E; Atkinson, G; Richter, B; Metzendorf, MI; Baur, L; Finer, N; Corpeleijn, E; O'Malley, C; Ells, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012436", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "3be46033-4bfb-4ebd-aee7-0e5a1e9f334c", "pmid": "", "title": "Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia", "imported": false, "abstract": "Abstract - Background Fibromyalgia is a clinically defined chronic condition of unknown etiology characterized by chronic widespread pain that often co‐exists with sleep disturbances, cognitive dysfunction and fatigue. People with fibromyalgia often report high disability levels and poor quality of life. Drug therapy, for example, with serotonin and noradrenaline reuptake inhibitors (SNRIs), focuses on reducing key symptoms and improving quality of life. This review updates and extends the 2013 version of this systematic review. Objectives To assess the efficacy, tolerability and safety of serotonin and noradrenaline reuptake inhibitors (SNRIs) compared with placebo or other active drug(s) in the treatment of fibromyalgia in adults. Search methods For this update we searched CENTRAL, MEDLINE, Embase, the US National Institutes of Health and the World Health Organization (WHO) International Clinical Trials Registry Platform for published and ongoing trials and examined the reference lists of reviewed articles, to 8 August 2017. Selection criteria We selected randomized, controlled trials of any formulation of SNRIs against placebo or any other active treatment of fibromyalgia in adults. Data collection and analysis Three review authors independently extracted data, examined study quality, and assessed risk of bias. For efficacy, we calculated the number needed to treat for an additional beneficial outcome (NNTB) for pain relief of 50% or greater and of 30% or greater, patient's global impression to be much or very much improved, dropout rates due to lack of efficacy, and the standardized mean differences (SMD) for fatigue, sleep problems, health‐related quality of life, mean pain intensity, depression, anxiety, disability, sexual function, cognitive disturbances and tenderness. For tolerability we calculated number needed to treat for an additional harmful outcome (NNTH) for withdrawals due to adverse events and for nausea, insomnia and somnolence as specific adverse events. For safety we calculated NNTH for serious adverse events. We undertook meta‐analysis using a random‐effects model. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We added eight new studies with 1979 participants for a total of 18 included studies with 7903 participants. Seven studies investigated duloxetine and nine studies investigated milnacipran against placebo. One study compared desvenlafaxine with placebo and pregabalin. One study compared duloxetine with L‐carnitine. The majority of studies were at unclear or high risk of bias in three to five domains. The quality of evidence of all comparisons of desvenlafaxine, duloxetine and milnacipran versus placebo in studies with a parallel design was low due to concerns about publication bias and indirectness, and very low for serious adverse events due to concerns about publication bias, imprecision and indirectness. The quality of evidence of all comparisons of duloxetine and desvenlafaxine with other active drugs was very low due to concerns about publication bias, imprecision and indirectness. Duloxetine and milnacipran had no clinically relevant benefit over placebo for pain relief of 50% or greater: 1274 of 4104 (31%) on duloxetine and milnacipran reported pain relief of 50% or greater compared to 591 of 2814 (21%) participants on placebo (risk difference (RD) 0.09, 95% confidence interval (CI) 0.07 to 0.11; NNTB 11, 95% CI 9 to 14). Duloxetine and milnacipran had a clinically relevant benefit over placebo in patient's global impression to be much or very much improved: 888 of 1710 (52%) on duloxetine and milnacipran (RD 0.19, 95% CI 0.12 to 0.26; NNTB 5, 95% CI 4 to 8) reported to be much or very much improved compared to 354 of 1208 (29%) of participants on placebo. Duloxetine and milnacipran had a clinically relevant benefit compared to placebo for pain relief of 30% or greater. RD was 0.10; 95% CI 0.08 to 0.12; NNTB 10, 95% CI 8 to 12. Duloxetine and milnacipran had no clinically relevant benefit for fatigue (SMD ‐0.13, 95% CI ‐0.18 to ‐0.08; NNTB 18, 95% CI 12 to 29), compared to placebo. There were no differences between either duloxetine or milnacipran and placebo in reducing sleep problems (SMD ‐0.07; 95 % CI ‐0.15 to 0.01). Duloxetine and milnacipran had no clinically relevant benefit compared to placebo in improving health‐related quality of life (SMD ‐0.20, 95% CI ‐0.25 to ‐0.15; NNTB 11, 95% CI 8 to 14). There were 794 of 4166 (19%) participants on SNRIs who dropped out due to adverse events compared to 292 of 2863 (10%) of participants on placebo (RD 0.07, 95% CI 0.04 to 0.10; NNTH 14, 95% CI 10 to 25). There was no difference in serious adverse events between either duloxetine, milnacipran or desvenlafaxine and placebo (RD ‐0.00, 95% CI ‐0.01 to 0.00). There was no difference between desvenlafaxine and placebo in efficacy, tolerability and safety in one small trial. There was no difference between duloxetine and desvenlafaxine in efficacy, tolerability and safety in two trials with active comparators (L‐carnitine, pregabalin). Authors' conclusions The update did not change the major findings of the previous review. Based on low‐ to very low‐quality evidence, the SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in the frequency of pain relief of 50% or greater, but for patient's global impression to be much or very much improved and in the frequency of pain relief of 30% or greater there was a clinically relevant benefit. The SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in improving health‐related quality of life and in reducing fatigue. Duloxetine and milnacipran did not significantly differ from placebo in reducing sleep problems. The dropout rates due to adverse events were higher for duloxetine and milnacipran than for placebo. On average, the potential benefits of duloxetine and milnacipran in fibromyalgia were outweighed by their potential harms. However, a minority of people with fibromyalgia might experience substantial symptom relief without clinically relevant adverse events with duloxetine or milnacipran. We did not find placebo‐controlled studies with other SNRIs than desvenlafaxine, duloxetine and milnacipran. Plain language summary Serotonin and noradrenaline reuptake inhibitors for fibromyalgia Bottom line Duloxetine and milnacipran may reduce pain in people with fibromyalgia. However, some of these people may also experience side effects, such as nausea (feeling sick) and drowsiness. A minority of people with fibromyalgia experience symptom relief without side effects from duloxetine and milnacipran. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as problems with sleep, thinking and exhaustion. They often report poor health‐related quality of life. There is no cure for fibromyalgia at present, so the treatments aim to relieve the symptoms and to improve health‐related quality of life. Serotonin and noradrenaline are chemicals which are produced by the human body, involved in the regulation of pain, sleep and mood. Low concentrations of serotonin have been reported in people with fibromyalgia. Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a class of antidepressants that increase the concentration of serotonin and noradrenaline in the brain. Study characteristics In August 2017, we updated our searches for clinical trials in which SNRIs were used to treat symptoms of fibromyalgia in adults. We found eight new studies since the previous version of the review. In total, we found 18 studies with 7903 participants. The studies were four to 27 weeks long and compared the SNRIs desvenlafaxine, duloxetine and milnacipran against a fake medication (placebo). We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. Key results and quality of the evidence Duloxetine and milnacipran were better than placebo in reducing pain by 50% or more and in improving global well‐being (low‐quality evidence). Duloxetine and milnacipran were better than placebo in improving health‐related quality of life and in reducing fatigue (low‐quality evidence). Duloxetine and milnacipran were not better than placebo in reducing sleep problems (low‐quality evidence). More people dropped out of the trial due to side effects with duloxetine and milnacipran than with placebo (low‐quality evidence). More people reported nausea and drowsiness with duloxetine and milnacipran than with placebo (low‐quality evidence). Duloxetine, milnacipran and placebo did not differ in the frequency of serious side effects experienced (very low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Welsch, P; Üçeyler, N; Klose, P; Walitt, B; Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD010292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "3bea0726-de0f-45a5-8d7e-9fe2478daad7", "pmid": "", "title": "Models for delivery and co‐ordination of primary or secondary health care (or both) to older adults living in aged care facilities", "imported": false, "abstract": "Abstract - Background The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co‐ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost‐effectiveness of alternative models of providing health care to ACF residents. Objectives Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost‐effectiveness of the alternative models. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included individual and cluster‐randomised trials, and cost/cost‐effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co‐ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co‐ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline‐recommended care, health‐related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work‐related satisfaction and work‐related stress of ACF staff. Data collection and analysis Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. Main results We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co‐ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low‐certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I 2 = 53%; 8 trials, 1263 participants; low‐certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low‐certainty evidence) and adherence to guideline‐recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health‐related quality of life of ACF residents (MD ‐0.016, 95% CI ‐0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low‐certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate‐certainty evidence). We did not pool the cost‐effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co‐ordination of care), we are uncertain of the cost‐effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. Authors' conclusions Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health‐related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost‐effectiveness of alternative models of care due to the limited, disparate data available. Plain language summary Alternative ways to organise delivery of health care to older adults living in aged care facilities What is the aim of this review? This Cochrane review set out to determine if providing residents of aged care facilities (ACF) with the same care as usual care, just delivered in a different way (alternative models of care), is better in terms of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs. For example, are multidisciplinary teams (alternative model) a better way of delivering care to residents of ACFs compared to providing care through individual practitioners (usual care)? Key messages Compared to usual care, alternative models of care may reduce unplanned hospital admissions, but may make little or no difference to the number of emergency department visits and the health‐related quality of life of ACF residents, and probably make little or no difference to mortality. We are uncertain of the effect of alternative models of care on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guideline‐recommended care. Importantly, we are uncertain whether alternative models of care are cost‐effective due to the limited, conflicting data available. Studies differed widely in terms of intervention characteristics, health care settings and descriptions of usual care and this hindered many analyses in this review. Future studies should provide a detailed description of what intervention and usual care constitutes in their setting. What was studied in this review? The world's population is ageing and the number of persons living in residential ACFs is growing worldwide. ACF residents are often frail, elderly people with multiple health conditions that require intensive medical care. When an ACF is not able to deliver appropriate health care, residents are often transferred to a hospital for treatment. Such transfers are often burdensome and traumatic for ACF residents and their families and may lead to increased costs. Alternative models of care, designed to provide care that is better co‐ordinated and more timely, aim to reduce unnecessary hospital transfers and improve residents' well‐being. Alternative models of care may be more expensive to implement (e.g. employ more healthcare personnel) but may lead to cost savings down the line (e.g. more residents receive care in ACF, avoiding costly hospital transfers). The synthesised evidence in this review compares the effect of alternative models of care with usual care on the number of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs (i.e. does the model deliver better value for money compared to usual care). What are the main results of this review? We identified 40 studies (with in total 21,787 participants; three studies did not provide number of participants) conducted in 15 countries. The study participants differed with respect to their health needs. In 11 studies, the alternative model of care was aimed at all ACF residents (with mixed health needs/conditions). Other studies included residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers; 13 studies) or residents requiring a specific type of care (e.g. residents after discharge from a hospital; four studies). In most (31) of the studies, the alternative model of care focused on 'co‐ordination of care'. In three studies, the alternative models of care focused on 'who provides care' (e.g. nurse practitioner‐led care using best practice guide instead of GP‐led care) and in two studies, alternative models of care focused on 'where care is provided' (i.e. investigating alternative locations for the provision of care, for example within ACF versus outside of ACF). In four studies, the alternative models of care focused on the use of information and communications technology for the provision of care to ACF residents. In all studies, the alternative model of care was compared with usual care. We found that, compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits; however, the number of unplanned hospital admissions may be reduced. We are uncertain of the effect of alternative models of care on adverse events and adherence to clinical guideline‐recommended care compared with usual care. Alternative models of care may have little or no effect on ACF residents' health‐related quality of life and probably make little or no difference to mortality. Based on the findings of five studies that provided full economic evaluations (all alternative models of care focused on 'co‐ordination of care'), we are uncertain whether alternative models of care are more cost‐effective than usual care. What are the limitations of the evidence? Our confidence in the evidence is limited because participants in the studies were aware of which treatment they were getting. Usual care was poorly described by most of the studies. Usual care differs across countries and regions, so this lack of information limits our interpretation, contextualisation and generalisation of the comparisons. Not all of the studies provided data about outcomes we were looking to assess. How up‐to‐date is this review? The review authors searched for studies published up to October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Putrik, P, Grobler, L, Lalor, A, Ramsay, H, Gorelik, A, Karnon, J, Parker, D, Morgan, M, Buchbinder, R, O'Connor, D", "articleTypes": [], "doi": "10.1002/14651858.CD013880.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.824Z" }, { "id": "3bea5561-0707-4b2b-8d49-be7cfe059eed", "pmid": "", "title": "Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010. For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established. Objectives To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications. Search methods Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012. Selection criteria Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Data collection and analysis Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information. Main results One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012. Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study. Weight loss was greater for the NG group at six weeks post‐treatment than for the PEG group (P = 0.001). At six months post‐treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post‐treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively. We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review. Authors' conclusions There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required. Plain language summary Artificial tube feeding methods for use with patients with head and neck cancer who are receiving treatment with radiotherapy, chemotherapy or both Patients with cancer of the head and neck are at risk of malnutrition during radiotherapy treatment due to the side effects of this treatment and they may need tube feeding to meet their nutritional needs. Tube feeding can either be delivered via a nasogastric feeding tube, which is a fine tube inserted through the nose into the stomach, or a gastrostomy tube which is inserted through the skin of the abdomen directly into the stomach. Both of these methods allow the delivery of nutrients directly into the stomach. Tube feeding is essential to meet the nutritional needs of head and neck cancer patients as malnutrition can lead to a poorer prognosis for this patient group. There is debate over which method of tube feeding provides the most benefit to the patient for outcomes such as nutritional benefit and quality of life, as well as avoiding delays in radiotherapy treatment. Following our analysis of the available literature, only one clinical trial was eligible to be included in this review. The authors of this review found no evidence to support the use of any one method of tube feeding over another.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Nugent, B, Lewis, S, O'Sullivan, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007904.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.763Z" }, { "id": "3bf1b4d8-4b57-415d-8743-57d2e8a3849b", "pmid": "", "title": "Folic acid for fragile X syndrome", "imported": false, "abstract": "Abstract - Background It has been argued that individuals with fragile X syndrome could have low folate levels in their bodies and that supplementing their dietary intake might remediate the adverse developmental and behavioural effects of the condition. Objectives To review the efficacy and safety of folic acid in the treatment of people with fragile X syndrome. Search methods We searched four databases in November 2010: CENTRAL, PubMed, EMBASE and PsycINFO. Selection criteria Randomised controlled trials. Data collection and analysis Two review authors independently extracted data and assessed risk of bias using the Cochrane 'Risk of bias' tool. Main results We included five trials, which were published between 1986 and 1992. Overall, they included 67 patients, all male, with ages ranging from one to 54 years. Intellectual disability in participants varied from borderline to severe and some studies included patients with an additional diagnosis of autism or autistic behaviour. Four of the studies were placebo‐controlled cross‐over trials and one study was a parallel design. The duration of follow‐up ranged from two months to 12 months and the period on folic acid or placebo ranged from two to eight months. Doses of folic acid ranged from 10 mg to 250 mg per day, 10 mg per day being the most common. Most of the younger patients involved were also taking part in special education programmes (usually involving language and occupational therapy). We were not able to perform meta‐analysis to combine results but none of the individual studies found evidence of clinical benefit with the use of folic acid medication in fragile X syndrome patients on any of the areas of interest, either psychological and learning capabilities or behaviour and social performance, as measured with standardised tools. Separate analysis of evidence for patients of different age groups, i.e. prepubertal children and postpubertal young people, found some statistically significant results, but did not show clear evidence of benefit for either group. Adverse effects of folic acid treatment were rare, not serious and transient. Studies were generally poorly reported and we classified only one study as being at low risk of bias. Authors' conclusions The quality of available evidence is low and not suitable for drawing conclusions about the effect of folic acid on fragile X syndrome patients. It consists of few studies with small samples of patients, all of them male, with little statistical power to detect anything other than huge effects. Plain language summary Folic acid for fragile X syndrome People with fragile X syndrome (or FXS) have intellectual limitations that can range from mild to severe. Fragile X syndrome is considered the most common form of inherited intellectual disability and it has been estimated that it affects approximately 1 in 4000 males and 1 in 8000 females. Folate is particularly important during the early development of the brain and in later life is involved in methylation processes that are essential for the maintenance of normal brain function. It was observed that cells from patients with fragile X syndrome cultured in solutions deficient in folic acid revealed a fragile site at the X chromosome; consequently it was thought that individuals with fragile X syndrome had low folate levels in their bodies, which may be due to insufficient dietary intake, inefficient absorption or impaired metabolic utilisation. It was argued that supplementing their dietary intake might help improve the adverse developmental and behavioural effects of the condition. This review asks whether folic acid helps improve symptoms in people with fragile X syndrome and whether it has any side effects. We found five randomised controlled trials, all of which were published between 1986 and 1992. These studies included 69 people, all male. One of the studies compared a folic acid group with a control group; the other four used a cross‐over design (i.e. participants received first one treatment and then the other). The quality of reporting of the trials was generally poor, particularly the methods used, which made it difficult to assess the risk of bias in the studies. The results of the few published studies did not find significant differences in the effects of folic acid or placebo on psychological or learning capabilities, behaviour or social performance, as measured by standardised tools. There is therefore no evidence to support the recommendation of supplementing dietary intake with folic acid medication for people with fragile X syndrome. However, due to the number and quality of the studies, it is not possible to conclude with any certainty that folic acid does not help. Given that intellectual, behavioural, emotional and/or learning performance in people with fragile X syndrome are strongly influenced by different social factors, future studies should also pay attention to the evaluation of non‐pharmacological interventions, such as modifications in the home environment, tailored behavioural interventions and classroom environments, or language and occupational therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Rueda, JR, Ballesteros, J, Guillen, V, Tejada, MI, Solà, I", "articleTypes": [], "doi": "10.1002/14651858.CD008476.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.782Z" }, { "id": "3c2d0c12-2633-4b18-9342-d7ec0d29f806", "pmid": "", "title": "Sweet potato for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Sweet potato ( Ipomoea batatas ) is among the most nutritious subtropical and tropical vegetables. It is also used in traditional medicine practices for type 2 diabetes mellitus. Research in animal and human models suggests a possible role of sweet potato in glycaemic control. Objectives To assess the effects of sweet potato for type 2 diabetes mellitus. Search methods We searched several electronic databases, including The Cochrane Library (2013, Issue 1), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2013), combined with handsearches. No language restrictions were used. Selection criteria We included randomised controlled trials (RCTs) that compared sweet potato with a placebo or a comparator intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently selected the trials and extracted the data. We evaluated risk of bias by assessing randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. Main results Three RCTs met our inclusion criteria: these investigated a total of 140 participants and ranged from six weeks to five months in duration. All three studies were performed by the same trialist. Overall, the risk of bias of these trials was unclear or high. All RCTs compared the effect of sweet potato preparations with placebo on glycaemic control in type 2 diabetes mellitus. There was a statistically significant improvement in glycosylated haemoglobin A1c (HbA1c) at three to five months with 4 g/day sweet potato preparation compared to placebo (mean difference ‐0.3% (95% confidence interval ‐0.6 to ‐0.04); P = 0.02; 122 participants; 2 trials). No serious adverse effects were reported. Diabetic complications and morbidity, death from any cause, health‐related quality of life, well‐being, functional outcomes and costs were not investigated. Authors' conclusions There is insufficient evidence about the use of sweet potato for type 2 diabetes mellitus. In addition to improvement in trial methodology, issues of standardization and quality control of preparations ‐ including other varieties of sweet potato ‐ need to be addressed. Further observational trials and RCTs evaluating the effects of sweet potato are needed to guide any recommendations in clinical practice. Plain language summary Sweet potato for type 2 diabetes mellitus Sweet potato ( Ipomoea batatas ) is a plant found in the tropical and subtropical belts and is one of the most nutritious tropical and subtropical vegetables. As well as being popular in cooking in countries in Asia‐Pacific, Africa and North America, sweet potato is also used in traditional medicine for the treatment of diabetes mellitus. We decided to investigate whether there is enough evidence from medical trials to show whether sweet potato works as a treatment for diabetes. This review of randomised controlled trials found only three studies (with a total of 140 participants) that evaluated the effects of sweet potato for type 2 diabetes mellitus compared with a fake medicine (placebo). All these trials were of very low quality. Two studies with 122 participants showed improved long‐term metabolic control of blood sugar levels as measured by glycosylated haemoglobin A1c (HbA1c) which was moderately lowered by 0.3% in participants who were given 4 g sweet potato tablets a day for three to five months. The duration of treatment ranged from six weeks to five months. No study investigated diabetic complications, death from any cause, health‐related quality of life, well‐being, functional outcomes or costs. Adverse effects were mostly mild, and included abdominal distension and pain. There are many varieties of sweet potatoes and sweet potato preparations. More trials are needed to assess the quality of the various sweet potato preparations as well as to evaluate further the use of different varieties of sweet potato in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Ooi, CP; Loke, SC", "articleTypes": [], "doi": "10.1002/14651858.CD009128.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "3c3f8780-f255-4cfc-a841-b6dc9d56e5e9", "pmid": "", "title": "Chlorhexidine treatment for the prevention of dental caries in children and adolescents", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) is a common disease that is preventable by reducing the dietary intake of free sugars and using topical sodium fluoride products. An antibacterial agent known as chlorhexidine may also help prevent caries. A number of over‐the‐counter and professionally administered chlorhexidine‐based preparations are available in a variety of formulations and in a range of strengths. Although previous reviews have concluded that some formulations of chlorhexidine may be effective in inhibiting the progression of established caries in children, there is currently a lack of evidence to either claim or refute a benefit for its use in preventing dental caries. Objectives To assess the effects of chlorhexidine‐containing oral products (toothpastes, mouthrinses, varnishes, gels, gums and sprays) on the prevention of dental caries in children and adolescents. Search methods We searched the Cochrane Oral Health Group Trials Register (25 February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 12), MEDLINE via OVID (1946 to 25 February 2015), EMBASE via OVID (1980 to 25 February 2015) and CINAHL via EBSCO (1937 to 25 February 2015). We handsearched several journals placed no language restrictions on our search. After duplicate citations were removed, the electronic searches retrieved 1075 references to studies. Selection criteria We included parallel‐group, randomised controlled trials (RCTs) that compared the caries preventive effects of chlorhexidine gels, toothpastes, varnishes, mouthrinses, chewing gums or sprays with each other, placebo or no intervention in children and adolescents. We excluded trials with combined interventions of chlorhexidine and fluoride or comparisons between chlorhexidine and fluoride interventions. Data collection and analysis Two review authors independently extracted trial data and assessed risk of bias. We resolved disagreements by consensus. We contacted trial authors for clarification or additional study details when necessary. The number of included studies that were suitable for meta‐analysis was limited due to the clinical diversity of the included studies with respect to age, composition of intervention, and variation in outcome measures and follow‐up. Where we were unable to conduct meta‐analysis, we elected to present a narrative synthesis of the results. Main results We included eight RCTs that evaluated the effects of chlorhexidine varnishes (1%, 10% or 40% concentration) and chlorhexidine gel (0.12%) on the primary or permanent teeth, or both, of children from birth to 15 years of age at the start of the study. The studies randomised a total of 2876 participants, of whom 2276 (79%) were evaluated. We assessed six studies as being at high risk of bias overall and two studies as being at unclear risk of bias overall. Follow‐up assessment ranged from 6 to 36 months. Six trials compared chlorhexidine varnish with placebo or no treatment. It was possible to pool the data from two trials in the permanent dentition (one study using 10% chlorhexidine and the other, 40%). This led to an increase in the DMFS increment in the varnish group of 0.53 (95% confidence interval (CI) ‐0.47 to 1.53; two trials, 690 participants; very low quality evidence). Only one trial (10% concentration chlorhexidine varnish) provided usable data for elevated mutans streptococci levels > 4 with RR 0.93 (95% CI 0.80 to 1.07, 496 participants; very low quality evidence). One trial measured adverse effects (for example, ulcers or tooth staining) and reported that there were none; another trial reported that no side effects of the treatment were noted. No trials reported on pain, quality of life, patient satisfaction or costs. Two trials compared chlorhexidine gel (0.12% concentration) with no treatment in the primary dentition. The presence of new caries gave rise to a 95% confidence interval that was compatible with either an increase or a decrease in caries incidence (RR 1.00, 95% CI 0.36 to 2.77; 487 participants; very low quality evidence). Similarly, data for the effects of chlorhexidine gel on the prevalence of mutans streptococci were inconclusive (RR 1.26, 95% CI 0.95 to 1.66; two trials, 490 participants; very low quality evidence). Both trials measured adverse effects and did not observe any. Neither of these trials reported on the other secondary outcomes such as measures of pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Authors' conclusions We found little evidence from the eight trials on varnishes and gels included in this review to either support or refute the assertion that chlorhexidine is more effective than placebo or no treatment in the prevention of caries or the reduction of mutans streptococci levels in children and adolescents. There were no trials on other products containing chlorhexidine such as sprays, toothpastes, chewing gums or mouthrinses. Further high quality research is required, in particular evaluating the effects on both the primary and permanent dentition and using other chlorhexidine‐containing oral products. Plain language summary Antiseptic treatment (chlorhexidine) to prevent tooth decay in children and young people Review question This review examined the effectiveness of varnishes and gels containing chlorhexidine in preventing tooth decay in children and young people. Background Tooth decay is a very common disease that over time destroys the tooth surface. It has been estimated to affect up to 80% of people in high‐income countries and, despite being preventable through oral hygiene and dietary measures and the use of agents such as fluoride that reduce risk of decay, it is likely to remain a problem, especially in low‐income countries. Tooth decay can result in pain and infection, and in young children may require treatment in hospital under a general anaesthetic. As well as causing anxiety and pain, this may mean the child or young person missing time at school and their parents or carers having to take time off work, possibly losing income and incurring extra costs. Prevention of tooth decay is simpler and possibly cheaper than waiting until it occurs and then requires extensive treatment. Tooth decay is largely preventable, and a range of things may assist this: twice‐daily toothbrushing with a fluoride toothpaste, reducing both the amount of and number of times per day sugar is eaten, and drinking water that contains fluoride (bottled or tap, depending on where you live). Tooth decay occurs when certain types of bacteria (germs) in the mouth, such as Streptococcus mutans, produce acids from the sugar we eat, which dissolve the hard enamel coating on our teeth. The chemical antiseptic treatment chlorhexidine is highly successful at destroying these bacteria and can be used safely at home in the form of a gel, spray, chewing gum, toothpaste or mouthrinse. Alternatively, chlorhexidine can be applied as a varnish to the surface of teeth by a dentist. Study characteristics The evidence in this review, carried out through the Cochrane Oral Health Group, is up‐to‐date at 25 February 2015. We found eight studies that were suitable to include in this review. The studies involved a total of 2876 children from birth to 15 years of age who were at moderate to high risk of tooth decay. Six of the studies looked at the effects of dental professionals applying different strengths of chlorhexidine varnishes to the baby teeth, permanent teeth or both types of teeth in children and adolescents. The other two studies looked at the effects of parents placing chlorhexidine gel on their children's baby teeth. There were no studies that examined other products containing chlorhexidine, such as sprays, toothpastes, chewing gums or mouthrinses. Key results The results did not provide evidence that chlorhexidine varnish or gel reduces tooth decay or reduces the bacteria that encourage tooth decay. The studies did not evaluate other outcomes such as pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Four studies measured side effects and found none were observed. Quality of the evidence Due to the lack of suitable studies and concerns about possible bias in the included studies, the evidence is very low quality. As a result, we are not able to conclude whether or not chlorhexidine is effective in preventing tooth decay in children or adolescents, when compared to placebo (an inactive substitute for chlorhexidine) or no treatment. Future research on the use of chlorhexidine to prevent tooth decay is needed and should consider both primary and permanent teeth and should assess other chlorhexidine‐containing products that can be used at home, such as toothpastes or mouthrinses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Walsh, T; Oliveira‐Neto, JM; Moore, D", "articleTypes": [], "doi": "10.1002/14651858.CD008457.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "3c44bf9e-020d-4c07-9bac-08faf8c6c0a0", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies to prevent COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as potential prophylaxis to prevent coronavirus disease 2019 (COVID‐19). Objectives To assess the effects of SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, to prevent infection with SARS‐CoV‐2 causing COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register, MEDLINE, Embase, and three other databases on 27 April 2022. We checked references, searched citations, and contacted study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that evaluated SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, alone or combined, versus an active comparator, placebo, or no intervention, for pre‐exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) of COVID‐19. We excluded studies of SARS‐CoV‐2‐neutralising mAbs to treat COVID‐19, as these are part of another review. Data collection and analysis Two review authors independently assessed search results, extracted data, and assessed risk of bias using Cochrane RoB 2. Prioritised outcomes were infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, all‐cause mortality, admission to hospital, quality of life, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We included four RCTs of 9749 participants who were previously uninfected and unvaccinated at baseline. Median age was 42 to 76 years. Around 20% to 77.5% of participants in the PrEP studies and 35% to 100% in the PEP studies had at least one risk factor for severe COVID‐19. At baseline, 72.8% to 82.2% were SARS‐CoV‐2 antibody seronegative. We identified four ongoing studies, and two studies awaiting classification. Pre‐exposure prophylaxis Tixagevimab/cilgavimab versus placebo One study evaluated tixagevimab/cilgavimab versus placebo in participants exposed to SARS‐CoV‐2 wild‐type, Alpha, Beta, and Delta variant. About 39.3% of participants were censored for efficacy due to unblinding and 13.8% due to vaccination. Within six months, tixagevimab/cilgavimab probably decreases infection with SARS‐CoV‐2 (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.29 to 0.70; 4685 participants; moderate‐certainty evidence), decreases development of clinical COVID‐19 symptoms (RR 0.18, 95% CI 0.09 to 0.35; 5172 participants; high‐certainty evidence), and may decrease admission to hospital (RR 0.03, 95% CI 0 to 0.59; 5197 participants; low‐certainty evidence). Tixagevimab/cilgavimab may result in little to no difference on mortality within six months, all‐grade AEs, and SAEs (low‐certainty evidence). Quality of life was not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and Delta variant. About 36.5% of participants opted for SARS‐CoV‐2 vaccination and had a mean of 66.1 days between last dose of intervention and vaccination. Within six months, casirivimab/imdevimab may decrease infection with SARS‐CoV‐2 (RR 0.01, 95% CI 0 to 0.14; 825 seronegative participants; low‐certainty evidence) and may decrease development of clinical COVID‐19 symptoms (RR 0.02, 95% CI 0 to 0.27; 969 participants; low‐certainty evidence). We are uncertain whether casirivimab/imdevimab affects mortality regardless of the SARS‐CoV‐2 antibody serostatus. Casirivimab/imdevimab may increase all‐grade AEs slightly (RR 1.14, 95% CI 0.98 to 1.31; 969 participants; low‐certainty evidence). The evidence is very uncertain about the effects on grade 3 to 4 AEs and SAEs within six months. Admission to hospital and quality of life were not reported. Postexposure prophylaxis Bamlanivimab versus placebo One study evaluated bamlanivimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type. Bamlanivimab probably decreases infection with SARS‐CoV‐2 versus placebo by day 29 (RR 0.76, 95% CI 0.59 to 0.98; 966 participants; moderate‐certainty evidence), may result in little to no difference on all‐cause mortality by day 60 (R 0.83, 95% CI 0.25 to 2.70; 966 participants; low‐certainty evidence), may increase all‐grade AEs by week eight (RR 1.12, 95% CI 0.86 to 1.46; 966 participants; low‐certainty evidence), and may increase slightly SAEs (RR 1.46, 95% CI 0.73 to 2.91; 966 participants; low‐certainty evidence). Development of clinical COVID‐19 symptoms, admission to hospital within 30 days, and quality of life were not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and potentially, but less likely to Delta variant. Within 30 days, casirivimab/imdevimab decreases infection with SARS‐CoV‐2 (RR 0.34, 95% CI 0.23 to 0.48; 1505 participants; high‐certainty evidence), development of clinical COVID‐19 symptoms (broad‐term definition) (RR 0.19, 95% CI 0.10 to 0.35; 1505 participants; high‐certainty evidence), may result in little to no difference on mortality (RR 3.00, 95% CI 0.12 to 73.43; 1505 participants; low‐certainty evidence), and may result in little to no difference in admission to hospital. Casirivimab/imdevimab may slightly decrease grade 3 to 4 AEs (RR 0.50, 95% CI 0.24 to 1.02; 2617 participants; low‐certainty evidence), decreases all‐grade AEs (RR 0.70, 95% CI 0.61 to 0.80; 2617 participants; high‐certainty evidence), and may result in little to no difference on SAEs in participants regardless of SARS‐CoV‐2 antibody serostatus. Quality of life was not reported. Authors' conclusions For PrEP, there is a decrease in development of clinical COVID‐19 symptoms (high certainty), infection with SARS‐CoV‐2 (moderate certainty), and admission to hospital (low certainty) with tixagevimab/cilgavimab. There is low certainty of a decrease in infection with SARS‐CoV‐2, and development of clinical COVID‐19 symptoms; and a higher rate for all‐grade AEs with casirivimab/imdevimab. For PEP, there is moderate certainty of a decrease in infection with SARS‐CoV‐2 and low certainty for a higher rate for all‐grade AEs with bamlanivimab. There is high certainty of a decrease in infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, and a higher rate for all‐grade AEs with casirivimab/imdevimab. Although there is high‐to‐moderate certainty evidence for some outcomes, it is insufficient to draw meaningful conclusions. These findings only apply to people unvaccinated against COVID‐19. They are only applicable to the variants prevailing during the study and not other variants (e.g. Omicron). In vitro, tixagevimab/cilgavimab is effective against Omicron, but there are no clinical data. Bamlanivimab and casirivimab/imdevimab are ineffective against Omicron in vitro. Further studies are needed and publication of four ongoing studies may resolve the uncertainties. Plain language summary Are laboratory‐made COVID‐19‐specific monoclonal antibodies effective to prevent COVID‐19 in adults? Key messages Pre‐exposure prophylaxis of COVID‐19: – tixagevimab/cilgavimab probably reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may reduce number of people admitted to hospital; – casirivimab/imdevimab may reduce number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may increase number of unwanted effects (any severity) slightly. Postexposure prophylaxis of COVID‐19: – bamlanivimab probably reduces number of people infected with COVID‐19; – casirivimab/imdevimab reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and reduces number of unwanted effects (any severity). What are 'monoclonal' antibodies? The body makes antibodies to defend against disease. However, they may be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that target only one specific protein – in this case, a protein on the SARS‐CoV‐2 virus (that causes COVID‐19) – are 'monoclonal'. They attach to the virus and stop it from entering and replicating in human cells to prevent and fight infection. They are relevant for people who do not respond or respond poorly to vaccinations. What did we want to find out? We wanted to know if COVID‐19‐specific monoclonal antibodies are effective at preventing COVID‐19 in people exposed to the virus or are at high risk of being exposed to the virus. We looked at: – confirmed COVID‐19 infections; – development of COVID‐19 symptoms; – death from any cause; – hospital admission; – quality of life; – unwanted effects, such as infections and cardiac disorders; – serious unwanted effects, such as life‐threatening, hospitalisation, disability, or death. What did we do? We searched for studies comparing monoclonal antibodies (e.g. bamlanivimab, tixagevimab/cilgavimab, and casirivimab/imdevimab) with placebo (sham treatment), another treatment, or no treatment to prevent COVID‐19 in people of any age, gender, or ethnicity. We summarised data and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? Four studies including 9749 people; two investigated people before being exposed to SARS‐CoV‐2 (pre‐exposure prophylaxis) and two investigated people who were in contact with an infected person (postexposure prophylaxis). Studies were conducted before the emergence of the Omicron variant and before or during widespread vaccine roll‐out. Participants were unvaccinated at baseline. Pre‐exposure prophylaxis One study (5197 people) compared tixagevimab/cilgavimab to placebo. Participants had been exposed to wild‐type, Alpha, Beta, and Delta variants. Tixagevimab/cilgavimab: – reduces development of symptoms; – probably reduces number of people infected; – may reduce number of hospital admissions; – may have little or no effect on deaths from any cause, unwanted effects (any severity), and serious unwanted effect. We found no data for quality of life, or mild and severe unwanted effects. One study (969 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and Delta variants. Casirivimab/imdevimab: – may reduce number of people infected and development of symptoms; – resulted in no deaths; – may increase unwanted effects (any severity) slightly; – we are uncertain whether casirivimab/imdevimab may have an effect on severe and serious unwanted effects. We found no data for number of people with COVID‐19 within 30 days, development of symptoms within 30 days, hospital admissions within 30 days, quality of life, and mild unwanted effects. Postexposure prophylaxis (two studies) One study (966 people) compared bamlanivimab to placebo. Participants may have been exposed to wild‐type variants. Bamlanivimab: – probably reduces number of people infected; – may have little or no effect on deaths from any cause; – may increase unwanted effects (any severity) and serious unwanted effects slightly. We found no data for number of people who developed symptoms, hospital admissions, quality of life, mild, and severe unwanted effects. One study (2617 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and potentially, but unlikely Delta variants. Casirivimab/ imdevimab: – reduces number of people infected, development of symptoms, and unwanted effects (any severity); – may slightly reduce severe unwanted effects; – may have little or no effect on deaths, hospital admissions, and serious unwanted effects. We found no data for quality of life and mild unwanted effects. What are the limitations of the evidence? One study reported each comparison. All participants were unvaccinated at the beginning of the studies, which were conducted prior to the occurrence of Omicron. Our confidence in the evidence is high to very low. Although we have high confidence in the evidence found for relevant outcomes, the findings are not transferable to vaccinated people and variants that occurred outside the study periods, such as Omicron. Although laboratory studies have shown that tixagevimab/cilgavimab is effective against Omicron, there are no data from clinical studies. The other monoclonal antibodies included in this review were ineffective against Omicron in laboratory studies. Four ongoing studies are likely to change our conclusions and may help us understand how new variants and COVID‐19 vaccines affect the effectiveness of monoclonal antibodies in preventing COVID‐19. How up to date is this evidence? The evidence is up‐to‐date to 27 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hirsch, C, Park, YS, Piechotta, V, Chai, KL, Estcourt, LJ, Monsef, I, Salomon, S, Wood, EM, So-Osman, C, McQuilten, Z, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014945.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.789Z" }, { "id": "3c4a31c1-4c5d-4c81-b8d8-1ca774dddb7c", "pmid": "", "title": "CFTR modulator monotherapy for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a common, life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR gene variant, F508del, is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF) in some populations). The F508del variant lacks meaningful CFTR function: the faulty protein is degraded before reaching the cell membrane, where it would normally transport salt across the epithelial membrane. Corrective therapy with CFTR modulators could benefit many pwCF. This review evaluates treatment with single modulators (monotherapy). Objectives To evaluate the clinically important benefits and harms of CFTR modulator monotherapy in people of any age with cystic fibrosis with class II CFTR gene variants (most commonly F508del). Search methods We last searched the Cochrane CF Trials Register and online trials registries on 27 June 2025. We also checked the reference lists of relevant articles for additional studies. Eligibility criteria We included parallel‐group randomised controlled trials (RCTs) comparing any single CFTR modulator to placebo or any other single CFTR modulator in pwCF of any age or disease severity with class II variants. Outcomes Our critical outcomes were survival, quality of life (total score and respiratory domain), and forced expiratory volume in one second (FEV 1 % predicted; relative and absolute change from baseline). Our important outcomes included adverse effects and time to first pulmonary exacerbation. We planned to assess outcomes in the immediate term, short term, and longer term. Risk of bias We assessed risk of bias using the original Cochrane tool (RoB 1). Synthesis methods We analysed available data with RevMan using a fixed‐effect model. We reported odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. For adverse events, we reported 99% confidence intervals (CIs); for all other outcomes, we reported 95% CIs. Where we were unable to analyse data, we reported the results narratively. We used GRADE to assess the certainty of the evidence. Included studies We included 10 early‐phase placebo‐controlled RCTs (424 participants) assessing eight different drugs (4PBA, CPX, N6022, cavosonstat, lumacaftor, FDL169, GLPG2222, and riociguat) in adults; one 4PBA study additionally included adolescents (age ≥ 14 years). All participants were homozygous for F508del. The longest study lasted just 29 days, so we could only assess immediate‐term outcomes. Only two studies received no funding from pharmaceutical companies. Our main results are for lumacaftor and cavosonstat, which were the only drugs selected for further investigation in subsequent studies. Synthesis of results Investigators reported no deaths, but also no clinically relevant improvements in quality of life. There was insufficient evidence to determine effects on any measure of lung function. No studies demonstrated differences in the risk of mild, moderate, or severe adverse effects, including pulmonary exacerbations, between CFTR modulator monotherapy and placebo. The clinical relevance of adverse effects is difficult to assess, because each occurred in only a few participants per trial. We assessed the certainty of the evidence for two comparisons (lumacaftor versus placebo and cavosonstat versus placebo), rating the certainty of the evidence to be very low. Authors' conclusions There is a lack of evidence to support monotherapy with a CFTR modulator for pwCF who have two F508del variants (F508del/F508del). Funding This review was completed under a programme of work that is part of the CF Foundation grant funding for Cochrane CF. Registration The protocol was registered on PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/view/CRD420251090914 ). Plain language summary Can single‐medicine treatment with CFTR modulators (medicines that correct the faulty protein in cystic fibrosis) help people who have specific genetic variants of cystic fibrosis (most commonly F508del)? Key messages All the studies only included people with two copies of the most common cystic fibrosis‐causing gene variant (F508del). Most studies were entirely or partly funded by medicine companies. No studies reported any deaths. None of the single medicines we looked at were clearly better than placebo (dummy treatment) for improving quality of life or lung function, and there was no evidence of the medicines causing more harm than placebo. However, we are unsure about these results. The evidence for using a single CFTR modulator is weak, and future research is likely to focus on combination therapies. What is cystic fibrosis and how can it be treated? Cystic fibrosis is a serious inherited illness that shortens life. It damages many organs in the body, particularly the lungs, pancreas, and liver. In the lungs, it causes a build‐up of thick, sticky mucus that leads to repeated infections and progressive damage. Most people with cystic fibrosis experience breathing difficulties, poor nutrition, and a reduced quality of life. Cystic fibrosis is caused by a fault in a gene that makes a protein called CFTR. CFTR regulates the movement of salt and water across cell surfaces, keeping the mucus thin and slippery. The most common CFTR gene variant (found in over 80% of people with cystic fibrosis) is F508del, which is a class II variant. People with two copies of F508del usually have more severe disease than people with one copy. In people with class II variants, the CFTR protein is degraded and cannot move properly through the cell. Laboratory experiments suggest that if the protein reaches the cell wall, it may be able to function, restore salt movement, and correct the chronic problems people with cystic fibrosis experience. CFTR modulators are medicines that help the faulty CFTR protein reach the cell wall. What did we want to find out? We wanted to know if CFTR modulator monotherapy (single‐medicine treatment) can help people of any age with cystic fibrosis who have a class II variant. Specifically, we wanted to know if these medicines can improve survival, quality of life, lung function, and time to the first worsening of lung symptoms. We also wanted to know if this treatment is associated with any unwanted effects. What did we do? We searched for studies that investigated the effects of any single CFTR modulator compared with placebo (dummy treatment) or any other single CFTR modulator in people with cystic fibrosis who had at least one copy of a class II variant. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 10 studies (with 424 participants, all of whom had two copies of F508del) assessing eight different medicines given as monotherapy. Nine studies included only adults, and one study included people from age 14 years. All the studies were small (including between 18 and 89 participants) and lasted between one day and 29 days. They took place in North America (mainly the USA), Europe, and Australia. Our main findings are for two of the eight medicines, lumacaftor and cavosonstat, which have gone on to be evaluated in larger populations. Main findings No studies reported any deaths or meaningful improvements in quality of life. We did not find enough evidence to show any effect of CFTR modulators on lung function. The studies reported a wide range of unwanted effects, but each occurred in only a few participants per study. We did not find enough evidence to support using CFTR modulator monotherapy in people with cystic fibrosis who have two copies of F508del. What are the limitations of the evidence? We are not confident in the evidence, for the following reasons. The studies were small. Most results are based on evidence from a single study. The evidence is not applicable to children. Not all studies provided enough data for us to analyse the results. The evidence related to unwanted effects of treatment was based on very few events. How up‐to‐date is this evidence? This review updates our earlier review of single‐ and multiple‐medicine therapy. The evidence is current to 27 June 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Heneghan, M; Smith, S; Jahnke, N; Nevitt, S; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD016290", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "3c6bcaf5-028c-4904-81e9-02ff29870827", "pmid": "", "title": "Bile acids for liver‐transplanted patients", "imported": false, "abstract": "Abstract - Background Liver transplantation has become a widely accepted form of treatment for numerous end‐stage liver diseases. Bile acids may decrease allograft rejection after liver transplantation by changing the expression of major histocompatibility complex class molecules in bile duct epithelium and central vein endothelium. Objectives To assess the beneficial and harmful effects of bile acids for liver‐transplanted patients. Search methods We performed searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials in The Cochrane Library , MEDLINE , EMBASE , and Science Citation Expanded to September, 2009. Selection criteria Randomised clinical trials comparing any dose of bile acids or duration of treatment in liver‐transplanted patients versus placebo, no intervention, or another intervention. We included randomised clinical trials irrespective of blinding, language, and publication status. Data collection and analysis Two review authors extracted and checked data independently. We evaluated the risk of bias of the trials from the method of allocation sequence generation, allocation concealment, blinding, outcome data analysis, outcome data reporting, and other potential sources of bias. We used the intention‐to‐treat principle to perform meta‐analyses and presented the outcomes as relative risks (RR) or mean differences (MD), both with 95% confidence intervals (CI). Main results The updated search resulted in no new trials meeting the inclusion criteria of this review, thus leaving it to the seven already included randomised trials (six evaluating ursodeoxycholic acid versus placebo or no intervention, and one evaluating tauro‐ursodeoxycholic acid versus no intervention) enrolling a total of 335 participants. The administration of bile acids began one day or more after liver transplantation. All patients received the standard triple‐drug immunosuppressive regimen (steroids, azathioprine, and cyclosporine or tacrolimus) to suppress the allograft rejection response after liver transplantation. Bile acids compared with placebo or no intervention did not significantly change all‐cause mortality (RR 0.85, 95% CI 0.53 to 1.36), mortality related to allograft rejection (RR 0.30, 95% CI 0.01 to 7.12), retransplantation (RR 0.76, 95% CI 0.20 to 2.86), acute cellular rejection, or number of patients with steroid‐resistant rejection. Bile acids significantly reduced the number of patients who had chronic rejection in a fixed‐effect model but not in a random‐effects model meta‐analysis. Bile acids were safe and well tolerated by liver‐transplanted patients. However, this observation is based on data analysis from three trials with only 187 patients. Authors' conclusions We did not find evidence to support or refute bile acids for liver‐transplanted patients. Further randomised trials are necessary before bile acids can be recommended to liver‐transplanted patients. Plain language summary Bile acids for liver‐transplanted patients Liver transplantation is a major surgical procedure that has been practiced for more than forty years and has nowadays become a generally accepted treatment option in patients with end‐stage liver disease. The most common cause for liver transplantation in adults is cirrhosis caused by various types of liver injuries such as infections (hepatitis B and C), alcohol, autoimmune liver diseases, early‐stage liver cancer, metabolic and hereditary disorders, but also diseases of unknown aetiology. All transplant recipients need lifetime immunosuppressive therapy to prevent transplant rejection. Bile acids are being used for a variety of chronic liver diseases, mainly primary biliary cirrhosis and primary sclerosing cholangitis. However, their mechanisms of action and beneficial and harmful effects are poorly understood. This has led to the idea of the potential use of bile acids to prevent rejection in liver‐transplanted patients. Results of the seven randomised clinical trials included in the review in which patients received standard immunosuppressive treatment (steroids, azathioprine, and cyclosporine or tacrolimus) with or without bile acids after liver transplantation, did not show any significant effects of bile acids on all‐cause mortality, mortality related to rejection, acute cellular rejection, steroid resistant rejection, or need for retransplantation. One analysis suggested that bile acids might beneficially influence number of patients with chronic rejection, but was contradicted by the analyses. The evidence that the use of ursodeoxycholic acid might have beneficial effects on chronic rejection and length of hospitalisation is weak as it is produced from trials with high risk of bias and insufficient number of included patients. That bile acids seemed well tolerated, with no reports of serious adverse events, is good knowledge, but much more research is needed before their use is acquitted. None of the randomised clinical trials assessed the effects of bile acids on quality of life or cost‐effectiveness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Poropat, G; Giljaca, V; Stimac, D; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005442.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "3c6c54f3-e172-4a72-b526-290af912f357", "pmid": "", "title": "Inhaled corticosteroids for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Inhaled corticosteroids are well established for the long‐term treatment of inflammatory respiratory diseases such as asthma or chronic obstructive pulmonary disease. They have been investigated for the treatment of coronavirus disease 2019 (COVID‐19). The anti‐inflammatory action of inhaled corticosteroids might have the potential to reduce the risk of severe illness resulting from hyperinflammation in COVID‐19. Objectives To assess whether inhaled corticosteroids are effective and safe in the treatment of COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (which includes CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO ICTRP, and medRxiv), Web of Science (Science Citation Index, Emerging Citation Index), and the WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies to 7 October 2021. Selection criteria We included randomised controlled trials (RCTs) evaluating inhaled corticosteroids for COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We included the following interventions: any type or dose of inhaled corticosteroids. We included the following comparison: inhaled corticosteroids plus standard care versus standard care (with or without placebo). We excluded studies examining nasal or topical steroids. Data collection and analysis We followed standard Cochrane methodology. For risk of bias assessment, we used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the outcomes of mortality, admission to hospital or death, symptom resolution, time to symptom resolution, serious adverse events, adverse events, and infections. Main results Inhaled corticosteroids plus standard care versus standard care (with/without placebo) People with a confirmed diagnosis of moderate‐to‐severe COVID‐19 We found no studies that included people with a confirmed diagnosis of moderate‐to‐severe COVID‐19. People with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included three RCTs allocating 3607 participants, of whom 2490 had confirmed mild COVID���19. We analysed a subset of the total number of participants recruited to the studies (2171, 52% female) as some trials had a platform design where not all participants were allocated to treatment groups simultaneously. The included studies were community‐based, recruiting people who were able to use inhaler devices to deliver steroids and relied on remote assessment and self‐reporting of outcomes. Most people were older than 50 years and had co‐morbidities such as hypertension, lung disease, or diabetes. The studies were conducted in high‐income countries prior to wide‐scale vaccination programmes. A total of 1057 participants were analysed in the inhaled corticosteroid arm (budesonide: 860 participants; ciclesonide: 197 participants), and 1075 participants in the control arm. No studies included people with asymptomatic SARS‐CoV‐2 infection. With respect to the following outcomes, inhaled corticosteroids compared to standard care: – may result in little to no difference in all‐cause mortality (at up to day 30) (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.22 to 1.67; 2132 participants; low‐certainty evidence). In absolute terms, this means that for every nine deaths per 1000 people not receiving inhaled corticosteroids, there were six deaths per 1000 people who did receive the intervention (95% CI 2 to 16 per 1000 people); – probably reduces admission to hospital or death (at up to 30 days) (RR 0.72, 95% CI 0.51 to 0.99; 2025 participants; moderate‐certainty evidence); – probably increases resolution of all initial symptoms at day 14 (RR 1.19, 95% CI 1.09 to 1.30; 1986 participants; moderate‐certainty evidence); – may reduce the duration to symptom resolution (at up to day 30) (by −4.00 days, 95% CI −6.22 to −1.78 less than control group rate of 12 days; 139 participants; low‐certainty evidence); – the evidence is very uncertain about the effect on serious adverse events (during study period) (RR 0.51, 95% CI 0.09 to 2.76; 1586 participants; very low‐certainty evidence); – may result in little to no difference in adverse events (at up to day 30) (RR 0.78, 95% CI 0.47 to 1.31; 400 participants; low‐certainty evidence); – may result in little to no difference in infections (during study period) (RR 0.88, 95% CI 0.30 to 2.58; 400 participants; low‐certainty evidence). As studies did not report outcomes for subgroups (e.g. age, ethnicity, sex), we did not perform subgroup analyses. Authors' conclusions In people with confirmed COVID‐19 and mild symptoms who are able to use inhaler devices, we found moderate‐certainty evidence that inhaled corticosteroids probably reduce the combined endpoint of admission to hospital or death and increase the resolution of all initial symptoms at day 14. Low‐certainty evidence suggests that corticosteroids make little to no difference in all‐cause mortality up to day 30 and may decrease the duration to symptom resolution. We do not know whether inhaled corticosteroids increase or decrease serious adverse events due to heterogeneity in the way they were reported across the studies. There is low‐certainty evidence that inhaled corticosteroids may decrease infections. The evidence we identified came from studies in high‐income settings using budesonide and ciclesonide prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, serious adverse events, and people with asymptomatic infection or with moderate‐to‐severe COVID‐19. The 10 ongoing and four completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. We monitor newly published results of RCTs on inhaled corticosteroids on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Are inhaled corticosteroids an effective treatment for people with mild COVID‐19? Key messages Inhaled corticosteroids (anti‐inflammatory medicines) given via the oral inhaled route are evaluated for treatment of coronavirus disease 2019 (COVID‐19). We identified three published studies for people with mild disease. Inhaled corticosteroids probably reduce the risk of people going to hospital or death (admission to hospital or death before hospital admission). Inhaled corticosteroids may lower the number of days people have symptoms of mild COVID‐19 and probably increase resolution of COVID‐19 symptoms at day 14. They may make little to no difference in death from any cause, and we do not have enough evidence to know whether they cause serious harms. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with moderate‐to‐severe COVID‐19. We found 10 ongoing and four completed unpublished studies. We will update this review when their results become available. What are inhaled corticosteroids? Inhaled corticosteroids are medicines that are breathed into the lower airways through an inhaler where they reduce inflammation in the lungs. They are commonly used to treat respiratory diseases like asthma and chronic obstructive pulmonary disease. Long‐term use and incorrect inhaler technique may lead to side effects that include a mouth infection called thrush, a change in voice, and an increased risk of lung infections. Good inhaler technique means the medicine does not stay in the mouth and throat. Why are inhaled corticosteroids possible treatments for COVID‐19? COVID‐19 mainly affects the lungs and airways. When the immune system fights the virus, the lungs and airways become inflamed. This inflammation causes breathing difficulties, and the lungs cannot easily move oxygen into the blood and remove carbon dioxide from the blood. What did we want to find out? People need more and better treatment options for asymptomatic SARS‐CoV‐2 infection (the virus that causes COVID‐19) or mild, moderate, or severe COVID‐19. We wanted to know if inhaled corticosteroids are an effective and helpful treatment option for COVID‐19 in any setting (for example, home or hospital) and whether they cause unwanted effects. We were interested in: – death from any cause up to day 30, day 60, or longer if reported; – admission to hospital or death within 30 days; – whether symptoms resolved and how fast; – quality of life; – unwanted effects. What did we do? We looked for studies where the investigators compared inhaled corticosteroids and usual care to usual care only, sometimes in addition to a dummy medicine that did not contain any active ingredients (placebo) but was given in the same way. To make the comparison least skewed and more fair, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the inhaled corticosteroids or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Three studies compared inhaled corticosteroids plus usual care compared to usual care with or without placebo in people with a confirmed diagnosis of mild COVID‐19. These studies analysed 2171 participants mostly older than 50 years and with other medical problems, 52% of them were female, of whom 1057 received inhaled corticosteroids in our analyses. We found no studies that included people with asymptomatic infection or confirmed diagnosis of moderate‐to‐severe COVID‐19. We also found 10 ongoing studies, and four completed studies without published results. Main results All studies compared inhaled corticosteroids with usual care or placebo. The studies included only people with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease. No studies looked at hospitalised people or people with asymptomatic SARS‐CoV‐2 infection. Inhaled corticosteroids – may make little to no difference in death from any cause up to day 30; – probably reduce the risk of admission to hospital or occurrence of death up to day 30; – probably increase resolution of COVID‐19 symptoms at day 14 and may reduce time to symptom resolution. We are very uncertain about a possible difference in serious unwanted effects. Moreover, inhaled corticosteroids may result in little to no difference in the number of any unwanted effects or additional infections. What are the limitations of the evidence? The studies were conducted in populations from wealthy countries, prior to the roll‐out of COVID‐19 vaccination programmes. We have moderate confidence in the evidence for the outcomes of symptom resolution at day 14 and hospital admission. We have low confidence in the evidence for the effects on deaths from any cause for people with mild COVID‐19 and time to symptom resolution. The confidence in the unwanted or serious unwanted effects and infections is low or very low, because of the differences in the way investigators recorded and reported results. There was no evidence for people with asymptomatic infection or moderate‐to‐severe COVID‐19 who were hospitalised. How up to date is this evidence? Our evidence is up‐to‐date to 7 October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Griesel, M; Wagner, C; Mikolajewska, A; Stegemann, M; Fichtner, F; Metzendorf, M-I; Nair, AAnil; Daniel, J; Fischer, A-L; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015125", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "3c6d23cc-1aca-4613-b74c-4e1ae6cd66fc", "pmid": "", "title": "Neuraminidase inhibitors for preventing and treating influenza in adults and children", "imported": false, "abstract": "Abstract - Background Neuraminidase inhibitors (NIs) are stockpiled and recommended by public health agencies for treating and preventing seasonal and pandemic influenza. They are used clinically worldwide. Objectives To describe the potential benefits and harms of NIs for influenza in all age groups by reviewing all clinical study reports of published and unpublished randomised, placebo‐controlled trials and regulatory comments. Search methods We searched trial registries, electronic databases (to 22 July 2013) and regulatory archives, and corresponded with manufacturers to identify all trials. We also requested clinical study reports. We focused on the primary data sources of manufacturers but we checked that there were no published randomised controlled trials (RCTs) from non‐manufacturer sources by running electronic searches in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE (Ovid), EMBASE, Embase.com, PubMed (not MEDLINE), the Database of Reviews of Effects, the NHS Economic Evaluation Database and the Health Economic Evaluations Database. Selection criteria Randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Data collection and analysis We extracted clinical study reports and assessed risk of bias using purpose‐built instruments. We analysed the effects of zanamivir and oseltamivir on time to first alleviation of symptoms, influenza outcomes, complications, hospitalisations and adverse events in the intention‐to‐treat (ITT) population. All trials were sponsored by the manufacturers. Main results We obtained 107 clinical study reports from the European Medicines Agency (EMA), GlaxoSmithKline and Roche. We accessed comments by the US Food and Drug Administration (FDA), EMA and Japanese regulator. We included 53 trials in Stage 1 (a judgement of appropriate study design) and 46 in Stage 2 (formal analysis), including 20 oseltamivir (9623 participants) and 26 zanamivir trials (14,628 participants). Inadequate reporting put most of the zanamivir studies and half of the oseltamivir studies at a high risk of selection bias. There were inadequate measures in place to protect 11 studies of oseltamivir from performance bias due to non‐identical presentation of placebo. Attrition bias was high across the oseltamivir studies and there was also evidence of selective reporting for both the zanamivir and oseltamivir studies. The placebo interventions in both sets of trials may have contained active substances. Time to first symptom alleviation . For the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.8 hours (95% confidence interval (CI) 8.4 to 25.1 hours, P < 0.0001). This represents a reduction in the time to first alleviation of symptoms from 7 to 6.3 days. There was no effect in asthmatic children, but in otherwise healthy children there was (reduction by a mean difference of 29 hours, 95% CI 12 to 47 hours, P = 0.001). Zanamivir reduced the time to first alleviation of symptoms in adults by 0.60 days (95% CI 0.39 to 0.81 days, P < 0.00001), equating to a reduction in the mean duration of symptoms from 6.6 to 6.0 days. The effect in children was not significant. In subgroup analysis we found no evidence of a difference in treatment effect for zanamivir on time to first alleviation of symptoms in adults in the influenza‐infected and non‐influenza‐infected subgroups (P = 0.53). Hospitalisations . Treatment of adults with oseltamivir had no significant effect on hospitalisations: risk difference (RD) 0.15% (95% CI ‐0.78 to 0.91). There was also no significant effect in children or in prophylaxis. Zanamivir hospitalisation data were unreported. Serious influenza complications or those leading to study withdrawal . In adult treatment trials, oseltamivir did not significantly reduce those complications classified as serious or those which led to study withdrawal (RD 0.07%, 95% CI ‐0.78 to 0.44), nor in child treatment trials; neither did zanamivir in the treatment of adults or in prophylaxis. There were insufficient events to compare this outcome for oseltamivir in prophylaxis or zanamivir in the treatment of children. Pneumonia . Oseltamivir significantly reduced self reported, investigator‐mediated, unverified pneumonia (RD 1.00%, 95% CI 0.22 to 1.49); number needed to treat to benefit (NNTB) = 100 (95% CI 67 to 451) in the treated population. The effect was not significant in the five trials that used a more detailed diagnostic form for pneumonia. There were no definitions of pneumonia (or other complications) in any trial. No oseltamivir treatment studies reported effects on radiologically confirmed pneumonia. There was no significant effect on unverified pneumonia in children. There was no significant effect of zanamivir on either self reported or radiologically confirmed pneumonia. In prophylaxis, zanamivir significantly reduced the risk of self reported, investigator‐mediated, unverified pneumonia in adults (RD 0.32%, 95% CI 0.09 to 0.41); NNTB = 311 (95% CI 244 to 1086), but not oseltamivir. Bronchitis, sinusitis and otitis media . Zanamivir significantly reduced the risk of bronchitis in adult treatment trials (RD 1.80%, 95% CI 0.65 to 2.80); NNTB = 56 (36 to 155), but not oseltamivir. Neither NI significantly reduced the risk of otitis media and sinusitis in both adults and children. Harms of treatment . Oseltamivir in the treatment of adults increased the risk of nausea (RD 3.66%, 95% CI 0.90 to 7.39); number needed to treat to harm (NNTH) = 28 (95% CI 14 to 112) and vomiting (RD 4.56%, 95% CI 2.39 to 7.58); NNTH = 22 (14 to 42). The proportion of participants with four‐fold increases in antibody titre was significantly lower in the treated group compared to the control group (RR 0.92, 95% CI 0.86 to 0.97, I 2 statistic = 0%) (5% absolute difference between arms). Oseltamivir significantly decreased the risk of diarrhoea (RD 2.33%, 95% CI 0.14 to 3.81); NNTB = 43 (95% CI 27 to 709) and cardiac events (RD 0.68%, 95% CI 0.04 to 1.0); NNTB = 148 (101 to 2509) compared to placebo during the on‐treatment period. There was a dose‐response effect on psychiatric events in the two oseltamivir \"pivotal\" treatment trials, WV15670 and WV15671, at 150 mg (standard dose) and 300 mg daily (high dose) (P = 0.038). In the treatment of children, oseltamivir induced vomiting (RD 5.34%, 95% CI 1.75 to 10.29); NNTH = 19 (95% CI 10 to 57). There was a significantly lower proportion of children on oseltamivir with a four‐fold increase in antibodies (RR 0.90, 95% CI 0.80 to 1.00, I 2 = 0%). Prophylaxis . In prophylaxis trials, oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals (oseltamivir: RD 3.05% (95% CI 1.83 to 3.88); NNTB = 33 (26 to 55); zanamivir: RD 1.98% (95% CI 0.98 to 2.54); NNTB = 51 (40 to 103)) and in households (oseltamivir: RD 13.6% (95% CI 9.52 to 15.47); NNTB = 7 (6 to 11); zanamivir: RD 14.84% (95% CI 12.18 to 16.55); NNTB = 7 (7 to 9)). There was no significant effect on asymptomatic influenza (oseltamivir: RR 1.14 (95% CI 0.39 to 3.33); zanamivir: RR 0.97 (95% CI 0.76 to 1.24)). Non‐influenza, influenza‐like illness could not be assessed due to data not being fully reported. In oseltamivir prophylaxis studies, psychiatric adverse events were increased in the combined on‐ and off‐treatment periods (RD 1.06%, 95% CI 0.07 to 2.76); NNTH = 94 (95% CI 36 to 1538) in the study treatment population. Oseltamivir increased the risk of headaches whilst on treatment (RD 3.15%, 95% CI 0.88 to 5.78); NNTH = 32 (95% CI 18 to 115), renal events whilst on treatment (RD 0.67%, 95% CI ‐2.93 to 0.01); NNTH = 150 (NNTH 35 to NNTB > 1000) and nausea whilst on treatment (RD 4.15%, 95% CI 0.86 to 9.51); NNTH = 25 (95% CI 11 to 116). Authors' conclusions Oseltamivir and zanamivir have small, non‐specific effects on reducing the time to alleviation of influenza symptoms in adults, but not in asthmatic children. Using either drug as prophylaxis reduces the risk of developing symptomatic influenza. Treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced, because of a lack of diagnostic definitions. The use of oseltamivir increases the risk of adverse effects, such as nausea, vomiting, psychiatric effects and renal events in adults and vomiting in children. The lower bioavailability may explain the lower toxicity of zanamivir compared to oseltamivir. The balance between benefits and harms should be considered when making decisions about use of both NIs for either the prophylaxis or treatment of influenza. The influenza virus‐specific mechanism of action proposed by the producers does not fit the clinical evidence. Plain language summary Regulatory information on trials of oseltamivir (Tamiflu) and zanamivir (Relenza) for influenza in adults and children Oseltamivir and zanamivir have been stockpiled in many countries to treat and prevent seasonal and pandemic influenza, before an influenza vaccine matched to the circulating virus becomes available. Oseltamivir is classified by the World Health Organization as an essential medicine. How this review has been approached We have updated and combined our reviews on the antiviral drugs zanamivir and oseltamivir for influenza in adults and children on the basis of the manufacturers' reports to regulators (clinical study reports) and the regulators' comments. We have called these comments and reports 'regulatory information'. Clinical study reports are unpublished, extensive documents with great detail on the trials that formed the basis for market approval. They include the protocols, methods and results. Clinical study reports have until now been confidential, seen only by the manufacturers and regulators. Why we have taken this approach In previous versions of this review we identified unresolved discrepancies in the data presented in published trial reports and substantial publication bias. As a consequence, we elected not to use data from journal articles but included the documents generated during licensing processes. We have accessed such data from the UK, USA, European Medicines Agency (EMA), Japanese regulators and clinical study reports from the manufacturers (after a protracted media campaign). This has enabled us to verify information from the randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Based on our assessments of the regulatory documents (in excess of 160,000 pages), we came to the conclusion that there were substantial problems with the design, conduct, reporting and availability of information from many of the trials. What we have found We have used data from 46 trials (20 oseltamivir and 26 zanamivir studies) in this review. We identified problems in the design of many of the studies that we included, which affects our confidence in their results. We found that both drugs shorten the duration of symptoms of influenza‐like illness (unconfirmed influenza or 'the flu') by less than a day. Oseltamivir did not affect the number of hospitalisations, based on the data from all the people enrolled in treatment trials of oseltamivir. Zanamivir trials did not record this outcome. The effects on pneumonia and other complications of influenza, such as bronchitis, middle ear infection (otitis media) and sinusitis, were unreliably reported, as shown by the case report form in the trial documents. Some forms showed limitations in the diagnostic criteria for pneumonia. Regulatory comments noted problems with missing follow‐up diary cards from participants. In children with asthma there was no clear effect on the time to first alleviation of symptoms. Prophylaxis trials showed that oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals and households. There was no evidence of an effect on asymptomatic influenza or on non‐influenza, influenza‐like illness, but trial conduct problems prevent any definitive conclusion. Oseltamivir use was associated with nausea, vomiting, headaches, renal and psychiatric events; these last three were when it was used to prevent influenza (prophylaxis). Its effect on the heart is unclear: it may reduce cardiac symptoms, but may induce serious heart rhythm problems. In adult treatment trials of zanamivir there was no increased risk of reported adverse events. The evidence on the possible harms associated with the treatment of children with zanamivir was sparse. Agreement with other findings The lack of good evidence demonstrating an effect on complications agrees with the conservative conclusions on both drugs drawn by the US Food and Drug Administration (FDA). The FDA only allowed claims of effectiveness of both drugs for the prevention and treatment of symptoms of influenza and not for other effects (including the interruption of person‐to‐person spread of the influenza virus or prevention of pneumonia). The FDA described the overall performance of both drugs as 'modest'. Mechanism of action for beneficial effects These findings all suggest that the low immune response with low levels of pro‐inflammatory cytokines, which is induced by the action of oseltamivir carboxylate, may reduce the symptoms of influenza unrelated to an inhibition of influenza virus replication. The potential hypothermic or antipyretic effect of oseltamivir as a central nervous system depressant may also contribute to the apparent reduction of host symptoms. Statements made on the capacity of oseltamivir to interrupt viral transmission and reduce complications are not supported by any data we have been able to access. The mechanism of action proposed by the producers (influenza virus‐specific) does not fit the clinical evidence which suggests a multi‐system and central action.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Jefferson, T; Jones, MA; Doshi, P; Del Mar, CB; Hama, R; Thompson, MJ; Spencer, EA; Onakpoya, IJ; Mahtani, KR; Nunan, D; Howick, J; Heneghan, CJ", "articleTypes": [], "doi": "10.1002/14651858.CD008965.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "3c81b25d-0f88-440f-a24a-e23456544d6b", "pmid": "", "title": "Interventions for cleaning dentures in adults", "imported": false, "abstract": "Abstract - Background Removing denture plaque may be essential for maintaining the oral health of edentulous people. Brushing and soaking in chemical products are two of the most commonly used methods of cleaning dentures. Objectives To evaluate the effectiveness and safety of different methods for cleansing removable dentures. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to May 2009); CENTRAL ( The Cochrane Library 2009, Issue 2); MEDLINE (1965 to May 2009); EMBASE (1980 to May 2009); LILACS (1980 to May 2009); and CINAHL (1997 to May 2009). There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing any mechanical method (e.g. brushing or ultrasound) or chemical (e.g. enzymes, sodium hypochlorite, oral rinses or peroxide solutions) in adults over the age of 18 wearing removable partial dentures or complete dentures. The primary outcomes considered were the health of denture bearing areas (soft tissues, periodontal tissues and teeth) and participants' satisfaction and preference. Secondary outcomes included denture plaque coverage area, indicators of halitosis and microbial counts on abutment teeth, soft tissues or denture base or saliva. Data collection and analysis Two independent review authors screened and extracted information from, and independently assessed the risk of bias in the included trials. Main results Although six RCTs were included in this review, the wide range of different interventions and outcome variables did not permit pooling of data in a meta‐analysis. Isolated reports indicated that chemicals and brushing appear to be more effective than placebo in the reduction of plaque coverage and microbial counts of anaerobes and aerobes on complete denture bases. Authors' conclusions There is a lack of evidence about the comparative effectiveness of the different denture cleaning methods considered in this review. Few well designed RCTs were found. Future research should focus on comparisons between mechanical and chemical methods; the assessment of the association of methods, primary variables and costs should also receive future attention. Plain language summary Interventions for cleaning dentures in adults Plaque formed on the surfaces of removable dentures can have a significant impact on oral health, as long as it can lead to infection of denture‐supporting mucosa (stomatitis), gum inflammation (gingivitis) and tooth decay. Denture plaque can be removed by several different methods which include: brushing with paste, soaking in chemicals (e.g. effervescent tablets or bleach) and using special devices (a microwave oven or ultrasonic device). This review found weak evidence in support of soaking of dentures in effervescent tablets or enzymatic solutions and that brushing with paste can remove plaque and kill microbes better than inactive treatments. It is, however, unclear which is the most effective and there is a paucity of data on the use of alternative methods. Futures studies should aim to provide reliable information about which method is more effective in maintaining oral health of removable denture wearers. The scarce data found was restricted to the cleansing of complete dentures made from an acrylic resin base. Further research should also investigate how removable partial dentures can be cleaned, and in particular on the corrosive effects of cleaners on their metallic components.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "de Souza, RF, de Freitas Oliveira Paranhos, H, Lovato da Silva, CH, Abu‐Naba'a, L, Fedorowicz, Z, Gurgan, CA", "articleTypes": [], "doi": "10.1002/14651858.CD007395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.082Z" }, { "id": "3c8f271a-1057-4f85-bc41-1668113f5b1c", "pmid": "", "title": "Interventions for oropharyngeal dysphagia in children with neurological impairment", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Morgan, AT, Dodrill, P, Ward, EC", "articleTypes": [], "doi": "10.1002/14651858.CD009456.pub2 AB - Abstract - Background Oropharyngeal dysphagia encompasses problems with the oral preparatory phase of swallowing (chewing and preparing the food), oral phase (moving the food or fluid posteriorly through the oral cavity with the tongue into the back of the throat) and pharyngeal phase (swallowing the food or fluid and moving it through the pharynx to the oesophagus). Populations of children with neurological impairment who commonly experience dysphagia include, but are not limited to, those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). Objectives To examine the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. Search methods We searched the following electronic databases in October 2011: CENTRAL 2011(3), MEDLINE (1948 to September Week 4 2011), EMBASE (1980 to 2011 Week 40)
, CINAHL (1937 to current)
, ERIC (1966 to current), PsycINFO (1806 to October Week 1 2011), Science Citation Index (1970 to 7 October 2011), Social Science Citation Index (1970 to 7 October 2011), Cochrane Database of Systematic Reviews, 2011(3), DARE 2011(3), Current Controlled Trials (ISRCTN Register) (15 October 2011), ClinicalTrials.gov (15 October 2011) and WHO ICTRP (15 October 2011). We searched for dissertations and theses using Networked Digital Library of Theses and Dissertations, Australasian Digital Theses Program and DART‐Europe E‐theses Portal (11 October 2011). Finally, additional references were also obtained from reference lists from articles. Selection criteria The review included randomised controlled trials and quasi‐randomised controlled trials for children with oropharyngeal dysphagia and neurological impairment. Data collection and analysis All three review authors (AM, PD and EW) independently screened titles and abstracts for inclusion and discussed results. In cases of uncertainty over whether an abstract met inclusion criterion, review authors obtained the full‐text article and independently evaluated each paper for inclusion. The data were categorised for comparisons depending on the nature of the control group (for example, oral sensorimotor treatment versus no treatment). Effectiveness of the oropharyngeal dysphagia intervention was assessed by considering primary outcomes of physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency a child is able to consume. Secondary outcomes were changes in growth, child’s level of participation in the mealtime routine and the level of parent or carer stress associated with feeding. Main results Three studies met the inclusion criteria for the review. Two studies were based on oral sensorimotor interventions for participants with cerebral palsy compared to standard care and a third study trialled lip strengthening exercises for children with myotonic dystrophy type 1 compared to no treatment ( Sjogreen 2010 ). A meta‐analysis combining results across the three studies was not possible because one of the studies had participants with a different condition, and the remaining two, although using oral sensorimotor treatments, used vastly different approaches with different intensities and durations. The decision not to combine these was in line with our protocol. In this review, we present the results from individual studies for four outcomes: physiological functions of the oropharyngeal mechanism for swallowing, the presence of chest infection and pneumonia, diet consistency, and changes in growth. However, it is not possible to reach definitive conclusions on the effectiveness of particular interventions for oropharyngeal dysphagia based on these studies. One study had a high risk of attrition bias owing to missing data, had statistically significant differences (in weight) across experimental and control groups at baseline, and did not describe other aspects of the trial sufficiently to enable assessment of other potential risks of bias. Another study was at high risk of detection bias as some outcomes were assessed by parents who knew whether their child was in the intervention or control group. The third study overall seemed to be at low risk of bias, but like the other two studies, suffered from a small sample size. Authors' conclusions The review demonstrates that there is currently insufficient high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials to provide conclusive results about the effectiveness of any particular type of oral‐motor therapy for children with neurological impairment. There is an urgent need for larger‐scale (appropriately statistically powered), randomised trials to evaluate the efficacy of interventions for oropharyngeal dysphagia. Plain language summary Interventions for swallowing difficulty in children with neurological impairment Oropharyngeal dysphagia, or swallowing difficulty, can be defined as problems with chewing and preparing food, difficulty moving food through the mouth to the back of the tongue, and difficulty with swallowing and movement of food through the 'throat' or pharynx. Many children with neurological impairment experience swallowing difficulties, including those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). This review examined the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. The three studies included in the review examined oral sensorimotor treatments and lip strengthening interventions. We were interested in three primary outcomes, which were physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency, and three secondary outcomes, which were changes in growth, child's level of participation in the mealtime routine, and the level of parent or carer stress associated with feeding. We concluded that there is currently not enough high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials for any particular type of oropharyngeal dysphagia intervention in this population of children. There is a need for larger‐scale randomised controlled trials to evaluate the effects of interventions for oropharyngeal dysphagia in children with neurological impairment.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.117Z" }, { "id": "3caac629-5017-4b7b-9126-3519958cfa65", "pmid": "", "title": "Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Castillo, M, Scott, NW, Mustafa, MZ, Mustafa, MS, Azuara‐Blanco, A", "articleTypes": [], "doi": "10.1002/14651858.CD009566.pub2 AB - Abstract - Background Seasonal/perennial allergic conjunctivitis is the most common allergic conjunctivitis, usually with acute manifestations when a person is exposed to allergens and with typical signs and symptoms including itching, redness, and tearing. The clinical signs and symptoms of allergic conjunctivitis are mediated by the release of histamine by mast cells. Histamine antagonists (also called antihistamines) inhibit the action of histamine by blocking histamine H1 receptors, antagonising the vasoconstrictor, and to a lesser extent, the vasodilator effects of histamine. Mast cell stabilisers inhibit degranulation and consequently the release of histamine by interrupting the normal chain of intracellular signals.
 
 Topical treatments include eye drops with antihistamines, mast cell stabilisers, non‐steroidal anti‐inflammatory drugs, combinations of the previous treatments, and corticosteroids. Standard treatment is based on topical antihistamines alone or topical mast cell stabilisers alone or a combination of treatments. There is clinical uncertainty about the relative efficacy and safety of topical treatment. Objectives The objective of this review was to assess the effects of topical antihistamines and mast cell stabilisers, alone or in combination, for use in treating seasonal and perennial allergic conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2014, Issue 7), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2014), EMBASE (January 1980 to July 2014), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 July 2014. We also searched the reference lists of review articles and relevant trial reports for details of further relevant publications. Selection criteria We included randomised controlled trials (RCTs) comparing topical antihistamine and mast cell stabilisers, alone or in combination, with placebo, no treatment or to any other antihistamine or mast cell stabiliser, or both, that examined people with seasonal or perennial allergic conjunctivitis, or both. The primary outcome was any participant‐reported evaluation (by questionnaire) of severity of four main ocular symptoms: itching, irritation, watering eye (tearing), and photophobia (dislike of light), both separately and, if possible, by an overall symptom score. We considered any follow‐up time between one week and one year. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Disagreements were resolved by discussion among review authors and the involvement of a third review author. We followed standard methodological approaches used by Cochrane. Main results We identified 30 trials with a total of 4344 participants randomised, with 17 different drugs or treatment comparisons. The following antihistamines and mast cell stabilisers were evaluated in at least one RCT: nedocromil sodium or sodium cromoglycate, olopatadine, ketotifen, azelastine, emedastine, levocabastine (or levocabastine), mequitazine, bepotastine besilate, combination of antazoline and tetryzoline, combination of levocabastine and pemirolast potassium. The most common comparison was azelastine versus placebo (nine studies). We observed a large variability in reporting outcomes. The quality of the studies and reporting was variable, but overall the risk of bias was low. Trials evaluated only short‐term effects, with a range of treatment of one to eight weeks. Meta‐analysis was only possible in one comparison (olopatadine versus ketotifen). There was some evidence to support that topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo. There were no reported serious adverse events related to the use of topical antihistamine and mast cell stabilisers treatment. Authors' conclusions It seems that all reported topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo in the short term. However, there is no long‐term data on their efficacy. Direct comparisons of different antihistamines and mast cell stabilisers need to be interpreted with caution. Overall, topical antihistamines and mast cell stabilisers appear to be safe and well tolerated. We observed a large variability in outcomes reported. Poor quality of reporting challenged the synthesis of evidence. Plain language summary Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis Review question 
 Are treatments with eye drops of antihistamines and mast cell stabilisers, alone or in combination, effective and safe in people with seasonal and allergic conjunctivitis? The main outcome measure was eye symptoms reported by participants, including eye itching, irritation (burning sensation), watering eyes (tearing), and photophobia (dislike of light). We found 30 trials. Background 
 Conjunctivitis refers to inflammation of the conjunctiva, which is the thin tissue that covers the sclera (white part of the eye). Seasonal and perennial allergic conjunctivitis is the most common type of allergic conjunctivitis. Although this condition does not cause sight loss, it can cause intense itching and eye watering. Eye drops with antihistamines or mast cell stabilisers, or both are commonly used. Study characteristics 
 The evidence is current to July 2014. Among the 30 studies reviewed there were 17 different comparisons, including 4344 participants ranging in age between 4 and 85 years. The duration of treatment ranged from one to eight weeks. Ten out of 30 studies were funded by the drug manufacturer (8 totally and 2 partially funded); 20 studies did not report any source of funding. There was inconsistency in the way the effect of treatment was measured and reported. Overall risk of bias was low. Key results 
 Topical antihistamines and mast cell stabilisers, alone or in combination, are safe and effective for reducing symptoms of seasonal and perennial allergic conjunctivitis. We found insufficient evidence to discern which topical antihistamines and mast cell stabilisers are the most effective.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.734Z" }, { "id": "3cad5ec0-c660-469e-8b75-aa11980ca38e", "pmid": "", "title": "Environmental enrichment for stroke and other non‐progressive brain injury", "imported": false, "abstract": "Abstract - Background Rehabilitation is effective for recovery after stroke and other non‐progressive brain injuries but it is unclear if the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. Environmental enrichment is a relatively new concept within rehabilitation for humans. In this review, this is defined as an intervention designed to facilitate physical (motor and sensory), cognitive and social activity by the provision of equipment and organisation of a structured, stimulating environment. The environment should be designed to encourage (but not force) activities without additional specialised rehabilitation input. Objectives To assess the effects of environmental enrichment on well‐being, functional recovery, activity levels and quality of life in people who have stroke or non‐progressive brain injury. Search methods We conducted the search on 26 October 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers. Selection criteria We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services. Data collection and analysis Two review authors independently assessed eligible studies, extracted data, and assessed study quality. Any disagreements were resolved through discussion with a third review author. We determined the risk of bias for the included study and performed a 'best evidence' synthesis using the GRADE approach. Main results We identified one RCT, involving 53 participants with stroke, comparing environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. We excluded five studies, found two studies awaiting classification and one ongoing study which described environmental enrichment in their interventions. Of the excluded studies, three were non‐RCTs and two described co‐interventions with a significant component of rehabilitation. Based on the single small included RCT at high risk of bias, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the provision of environmental enrichment. Authors' conclusions The gap in current research should not, however, be interpreted as proof that environmental enrichment is ineffective. Further research is needed with robust study designs, such as cluster RCTs, and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (inpatient versus outpatient), the relative effectiveness of various components of environmental enrichment, cost‐effectiveness, and safety of the intervention in people following stroke or other non‐progressive brain injuries. It should be noted, however, that it is challenging to randomise or double‐blind trials of environmental enrichment given the nature of the intervention. Plain language summary Treatment using environmental enrichment for supporting rehabilitation following stroke and other brain injuries which do not get worse over time (non‐progressive brain injury) Background Rehabilitation helps with recovery after stroke and other non‐progressive brain injuries through therapy. However, outside of therapy hours, people may have very little to keep them stimulated. Environmental enrichment is a relatively new concept in rehabilitation where the environment itself is designed to be engaging and to include physical, thinking, and social activities like exercises and games. For example, a nursery for babies may be interesting and stimulating but a hospital environment for adults is generally not. The design of the environment alone should encourage (but not force) activities without additional specialised rehabilitation. Review question 
We wanted to find out whether treatment with environmental enrichment is better or worse than alternatives. Search date 
The evidence is current to 26 October 2020. Study characteristics 
Population: we planned to include studies in which participants were adults who had had a stroke or a non‐progressive brain injury (such as traumatic brain injury but not dementia, Alzheimer's diease, or multiple sclerosis). Intervention: environmental enrichment interventions will usually include multiple activities, such as computers plus gaming technology plus music and reading. Comparison: we planned to compare environmental interventions with usual care (regular physiotherapy, speech therapy, occupational therapy) or alternative treatment. Outcomes: we divided outcomes into primary and secondary outcomes. Primary outcomes focused on psychological well‐being (anxiety, depression, stress) and coping. Secondary outcomes focused on quality of life, physical function, communication and cognitive function, and activity levels. We also planned to report adverse events. Key results 
We found one trial that compared environmental intervention alone with usual care or alternative treatment. The trial included 53 participants who had had a stroke and was based in a hospital rehabilitation ward. The trial compared environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services. The main outcomes related to psychological well‐being and coping. We were uncertain of the results because the trial was very small and highly prone to bias. Conclusion 
The gap in current research does not mean that environmental enrichment is ineffective. Further research is needed with strong study designs and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (in hospital versus out of hospital), which components of environmental enrichment are effective, whether environmental enrichment is cost‐effective, and if it is safe for people following stroke or other non‐progressive brain injuries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Qin, H; Reid, I; Gorelik, A; Ng, L", "articleTypes": [], "doi": "10.1002/14651858.CD011879.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "3cbbdc91-92ae-4c4a-98a6-dfe1f0805c43", "pmid": "", "title": "Probiotic Modulation of Gut Microflora in Cirrhosis: Influence on Immune Function and Infections", "imported": false, "abstract": "Liver cirrhosis is the 10th most common cause of death in the western world. Infection is the most common precipitant of deterioration of liver function in cirrhosis. Endotoxin, derived from gram-negative organisms in the gut, can enter the circulation due to increased gut permeability and contributes to neutrophil dysfunction, infection risk and mortality in alcoholic cirrhotics. As probiotics decrease gram-negative organisms in the gut and/or decrease gut permeability, the investigators hypothesize that probiotic treatment would restore neutrophil function and prevent infection in alcoholic cirrhosis.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "3cc442a0-941f-421e-a651-98a742aa7cbb", "pmid": "", "title": "Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years", "imported": false, "abstract": "Abstract - Background Zinc deficiency is prevalent in low‐ and middle‐income countries, and is considered a significant risk factor for morbidity, mortality, and linear growth failure. The effectiveness of preventive zinc supplementation in reducing prevalence of zinc deficiency needs to be assessed. Objectives To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged 6 months to 12 years. Search methods A previous version of this review was published in 2014. In this update, we searched CENTRAL, MEDLINE, Embase, five other databases, and one trials register up to February 2022, together with reference checking and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) of preventive zinc supplementation in children aged 6 months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalized children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions. Data collection and analysis Two review authors screened studies, extracted data, and assessed the risk of bias. We contacted study authors for missing information and used GRADE to assess the certainty of evidence. The primary outcomes of this review were all‐cause mortality; and cause‐specific mortality, due to all‐cause diarrhea, lower respiratory tract infection (LRTI, including pneumonia), and malaria. We also collected information on a number of secondary outcomes, such as those related to diarrhea and LRTI morbidity, growth outcomes and serum levels of micronutrients, and adverse events. Main results We included 16 new studies in this review, resulting in a total of 96 RCTs with 219,584 eligible participants. The included studies were conducted in 34 countries; 87 of them in low‐ or middle‐income countries. Most of the children included in this review were under five years of age. The intervention was delivered most commonly in the form of syrup as zinc sulfate, and the most common dose was between 10 mg and 15 mg daily. The median duration of follow‐up was 26 weeks. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes was affected by risk of bias. High‐certainty evidence showed little to no difference in all‐cause mortality with preventive zinc supplementation compared to no zinc (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.84 to 1.03; 16 studies, 17 comparisons, 143,474 participants). Moderate‐certainty evidence showed that preventive zinc supplementation compared to no zinc likely results in little to no difference in mortality due to all‐cause diarrhea (RR 0.95, 95% CI 0.69 to 1.31; 4 studies, 132,321 participants); but probably reduces mortality due to LRTI (RR 0.86, 95% CI 0.64 to 1.15; 3 studies, 132,063 participants) and mortality due to malaria (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 42,818 participants); however, the confidence intervals around the summary estimates for these outcomes were wide, and we could not rule out a possibility of increased risk of mortality. Preventive zinc supplementation likely reduces the incidence of all‐cause diarrhea (RR 0.91, 95% CI 0.90 to 0.93; 39 studies, 19,468 participants; moderate‐certainty evidence) but results in little to no difference in morbidity due to LRTI (RR 1.01, 95% CI 0.95 to 1.08; 19 studies, 10,555 participants; high‐certainty evidence) compared to no zinc. There was moderate‐certainty evidence that preventive zinc supplementation likely leads to a slight increase in height (standardized mean difference (SMD) 0.12, 95% CI 0.09 to 0.14; 74 studies, 20,720 participants). Zinc supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46; 5 studies, 35,192 participants; high‐certainty evidence). We report a number of other outcomes, including the effect of zinc supplementation on weight and serum markers such as zinc, hemoglobin, iron, copper, etc. We also performed a number of subgroup analyses and there was a consistent finding for a number of outcomes that co‐supplementation of zinc with iron decreased the beneficial effect of zinc. Authors' conclusions Even though we included 16 new studies in this update, the overall conclusions of the review remain unchanged. Zinc supplementation might help prevent episodes of diarrhea and improve growth slightly, particularly in children aged 6 months to 12 years of age. The benefits of preventive zinc supplementation may outweigh the harms in regions where the risk of zinc deficiency is relatively high. Plain language summary Is zinc supplementation effective for preventing death and disease, and for promoting growth, in children aged 6 months to 12 years and does it cause unwanted effects? Key messages ‐ Zinc supplementation in children aged 6 months to 12 years makes little to no difference to all‐cause mortality and probably makes no difference to deaths from diarrea. Zinc supplementation probably reduces mortality due to lower respiratory tract infections and malaria but a small possibility of increased risk of mortality cannot be ruled out. ‐ Zinc supplementation in children aged 6 months to 12 years might prevent illness due to diarrhea, but might lead to vomiting after supplementation. It might lead to a small increase in height gain. Why is it important to study zinc supplementation? Zinc is an essential micronutrient. It is important to help children grow normally and to promote a healthy immune system. Lack of zinc may lead to diarrhea, pneumonia, malaria and even death. Low dietary zinc intake is often linked to poverty. As many as half of all children in low‐ and middle‐income countries may have zinc deficiency. Meat, fish, eggs and dairy products are good natural sources of zinc, but are expensive. Lack of clean water and poor sanitation increases exposure to diseases, which zinc might help to fight. The human body cannot produce or store zinc, so giving dietary supplements is important. What did we want to find out? We wanted to find out if giving children zinc supplements helps prevent child death and disease, and promotes growth. What did we do? We searched for studies that randomly assigned children aged 6 months to 12 years to receive zinc supplementation or no zinc. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 96 studies in the review, with 219,584 children. Studies took place in 34, mainly low‐ to middle‐income countries. Most of the children in the studies were under five years old. Zinc was most commonly given as a syrup (zinc sulfate), and the most common dose was between 10 mg and 15 mg daily. We found that giving children zinc supplementation might lead to a small to no reduction in the risk of death for any reason and the risk of death due to diarrhea. The risk of death due to lower respiratory tract infections or malaria may be reduced. Children given zinc experienced less disease due to diarrhea than children not given zinc; however, zinc does not seem to reduce children's risk of respiratory infection. Zinc supplementation may have a small positive effect on growth. Children who take zinc supplementation may experience vomiting as an unwanted effect. What are the limitations of the evidence? We are confident about our results on the effects of zinc supplements on reducing the risk of death due to any cause, illness due to respiratory infection, and occurrence of vomiting after supplementation. Our confidence in the results for our other outcomes was moderate because relatively few studies reported these outcomes and because studies sometimes reported different results from other studies for the same outcomes. How up to date is this evidence? This review updates a previous version published in 2014. The evidence is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Imdad, A; Rogner, J; Sherwani, RN; Sidhu, J; Regan, A; Haykal, MR; Tsistinas, O; Smith, A; Chan, XHS; Mayo-Wilson, E; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD009384.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "3cd5a74d-1e4f-402e-b7d4-6a95f70ea8c2", "pmid": "", "title": "Tobacco packaging design for reducing tobacco use", "imported": false, "abstract": "Abstract - Background Tobacco use is the largest single preventable cause of death and disease worldwide. Standardised tobacco packaging is an intervention intended to reduce the promotional appeal of packs and can be defined as packaging with a uniform colour (and in some cases shape and size) with no logos or branding, apart from health warnings and other government‐mandated information, and the brand name in a prescribed uniform font, colour and size. Australia was the first country to implement standardised tobacco packaging between October and December 2012, France implemented standardised tobacco packaging on 1 January 2017 and several other countries are implementing, or intending to implement, standardised tobacco packaging. Objectives To assess the effect of standardised tobacco packaging on tobacco use uptake, cessation and reduction. Search methods We searched MEDLINE, Embase, PsycINFO and six other databases from 1980 to January 2016. We checked bibliographies and contacted study authors to identify additional peer‐reviewed studies. Selection criteria Primary outcomes included changes in tobacco use prevalence incorporating tobacco use uptake, cessation, consumption and relapse prevention. Secondary outcomes covered intermediate outcomes that can be measured and are relevant to tobacco use uptake, cessation or reduction. We considered multiple study designs: randomised controlled trials, quasi‐experimental and experimental studies, observational cross‐sectional and cohort studies. The review focused on all populations and people of any age; to be included, studies had to be published in peer‐reviewed journals. We examined studies that assessed the impact of changes in tobacco packaging such as colour, design, size and type of health warnings on the packs in relation to branded packaging. In experiments, the control condition was branded tobacco packaging but could include variations of standardised packaging. Data collection and analysis Screening and data extraction followed standard Cochrane methods. We used different 'Risk of bias' domains for different study types. We have summarised findings narratively. Main results Fifty‐one studies met our inclusion criteria, involving approximately 800,000 participants. The studies included were diverse, including observational studies, between‐ and within‐participant experimental studies, cohort and cross‐sectional studies, and time‐series analyses. Few studies assessed behavioural outcomes in youth and non‐smokers. Five studies assessed the primary outcomes: one observational study assessed smoking prevalence among 700,000 participants until one year after standardised packaging in Australia; four studies assessed consumption in 9394 participants, including a series of Australian national cross‐sectional surveys of 8811 current smokers, in addition to three smaller studies. No studies assessed uptake, cessation, or relapse prevention. Two studies assessed quit attempts. Twenty studies examined other behavioural outcomes and 45 studies examined non‐behavioural outcomes (e.g. appeal, perceptions of harm). In line with the challenges inherent in evaluating standardised tobacco packaging, a number of methodological imitations were apparent in the included studies and overall we judged most studies to be at high or unclear risk of bias in at least one domain. The one included study assessing the impact of standardised tobacco packaging on smoking prevalence in Australia found a 3.7% reduction in odds when comparing before to after the packaging change, or a 0.5 percentage point drop in smoking prevalence, when adjusting for confounders. Confidence in this finding is limited, due to the nature of the evidence available, and is therefore rated low by GRADE standards. Findings were mixed amongst the four studies assessing consumption, with some studies finding no difference and some studies finding evidence of a decrease; certainty in this outcome was rated very low by GRADE standards due to the limitations in study design. One national study of Australian adult smoker cohorts (5441 participants) found that quit attempts increased from 20.2% prior to the introduction of standardised packaging to 26.6% one year post‐implementation. A second study of calls to quitlines provides indirect support for this finding, with a 78% increase observed in the number of calls after the implementation of standardised packaging. Here again, certainty is low. Studies of other behavioural outcomes found evidence of increased avoidance behaviours when using standardised packs, reduced demand for standardised packs and reduced craving. Evidence from studies measuring eye‐tracking showed increased visual attention to health warnings on standardised compared to branded packs. Corroborative evidence for the latter finding came from studies assessing non‐behavioural outcomes, which in general found greater warning salience when viewing standardised, than branded packs. There was mixed evidence for quitting cognitions, whereas findings with youth generally pointed towards standardised packs being less likely to motivate smoking initiation than branded packs. We found the most consistent evidence for appeal, with standardised packs rating lower than branded packs. Tobacco in standardised packs was also generally perceived as worse‐tasting and lower quality than tobacco in branded packs. Standardised packaging also appeared to reduce misperceptions that some cigarettes are less harmful than others, but only when dark colours were used for the uniform colour of the pack. Authors' conclusions The available evidence suggests that standardised packaging may reduce smoking prevalence. Only one country had implemented standardised packaging at the time of this review, so evidence comes from one large observational study that provides evidence for this effect. A reduction in smoking behaviour is supported by routinely collected data by the Australian government. Data on the effects of standardised packaging on non‐behavioural outcomes (e.g. appeal) are clearer and provide plausible mechanisms of effect consistent with the observed decline in prevalence. As standardised packaging is implemented in different countries, research programmes should be initiated to capture long term effects on tobacco use prevalence, behaviour, and uptake. We did not find any evidence suggesting standardised packaging may increase tobacco use. Plain language summary Can the use of standardised packaging for tobacco products reduce the use of tobacco? Background Tobacco use kills more people worldwide than any other preventable cause of death. The best way to reduce tobacco use is by stopping people from starting to use tobacco and encouraging and helping existing users to stop. This can be done by introducing policies that can reach a wide number of people in a country, together with offering individual treatment and support to individuals who are already using tobacco to help them to stop. Many countries have introduced bans on tobacco advertising but have not controlled the look of the tobacco pack itself. Tobacco packs can be colourful and attractive, with exciting new shapes and sizes. Standardised tobacco packaging is a government policy which removes these bright designs by, for example, only allowing tobacco packs to be in one colour, shape or size. Standardised packaging generally involves the use of the same uniform colour on all tobacco packs, with no brand imagery, and the brand name written in a specified font, colour and size. Health warnings and other information that governments wish to put on the packs can remain. Australia was the first country to introduce standardised tobacco packaging by December 2012. France was the second by January 2017. Several other countries are introducing standardised packaging or planning to do so. We examined whether standardised packaging reduces tobacco use. Study characteristics We searched nine databases for articles evaluating standardised packaging that had been already reviewed by academics and published before January 2016. We also checked references in those papers to other studies and contacted the authors where necessary. Key results We found 51 studies involving approximately 800,000 participants. These studies varied considerably. Some studies focused on the effect of standardised packaging in Australia, and included looking at overall smoking levels, whether smokers altered their behaviour such as by cutting down the number of cigarettes they smoked, and whether smokers were making more quit attempts. We also included experiments in which people used or viewed standardised tobacco packs and examined their responses, compared to when they were viewing branded packs. We also included studies that assessed people’s eye movements when they looked at different packs and how willing people were to buy, and how much they were willing to pay for, standardised compared to branded packs. Only five studies looked at our key outcomes. One study in Australia looked at data from 700,000 people before and after standardised packaging was introduced. This study found that there was a half a percentage point drop in the proportion of people who used tobacco after the introduction of standardised packaging, compared to before, when adjusting for other factors which could affect this. Four other studies looked at whether current smokers changed the number of cigarettes they smoked. Two studies from Australia looked at this, one using surveys which included 8811 current smokers, and found no change in the number of cigarettes smoked. The three smaller studies found mixed results. Two further studies looked at quit attempts and observed increases in these in Australia after standardised packaging was introduced. The remainder of the studies looked at other outcomes, and the most consistent finding was that standardised packaging reduced how appealing people found the packs compared with branded packs. No studies reported the number of people who quit using tobacco, the number of people who started using tobacco, or the number of people who returned to using tobacco after quitting. Quality of the evidence Certainty in these findings is limited for several reasons, including the difficulties involved in studying national policies like standardised packaging. However, findings suggesting standardised packaging may decrease tobacco use are supported by routine data from the Australian government and studies looking at other outcomes. For example, in our included studies people consistently found standardised packs less appealing than branded packs. We did not find any evidence suggesting standardised packaging may increase tobacco use.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "McNeill, A; Gravely, S; Hitchman, SC; Bauld, L; Hammond, D; Hartmann‐Boyce, J", "articleTypes": [], "doi": "10.1002/14651858.CD011244.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "3cee000f-e7f9-4b15-98e9-c67483797f6f", "pmid": "", "title": "Chewing gum for postoperative recovery of gastrointestinal function", "imported": false, "abstract": "Abstract - Background Ileus commonly occurs after abdominal surgery, and is associated with complications and increased length of hospital stay (LOHS). Onset of ileus is considered to be multifactorial, and a variety of preventative methods have been investigated. Chewing gum (CG) is hypothesised to reduce postoperative ileus by stimulating early recovery of gastrointestinal (GI) function, through cephalo‐vagal stimulation. There is no comprehensive review of this intervention in abdominal surgery. Objectives To examine whether chewing gum after surgery hastens the return of gastrointestinal function. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), MEDLINE (via PubMed), EMBASE (via Ovid), CINAHL (via EBSCO) and ISI Web of Science (June 2014). We hand‐searched reference lists of identified studies and previous reviews and systematic reviews, and contacted CG companies to ask for information on any studies using their products. We identified proposed and ongoing studies from clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform and meta Register of Controlled Trials. Selection criteria We included completed randomised controlled trials (RCTs) that used postoperative CG as an intervention compared to a control group. Data collection and analysis Two authors independently collected data and assessed study quality using an adapted Cochrane risk of bias (ROB) tool, and resolved disagreements by discussion. We assessed overall quality of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Studies were split into subgroups: colorectal surgery (CRS), caesarean section (CS) and other surgery (OS). We assessed the effect of CG on time to first flatus (TFF), time to bowel movement (TBM), LOHS and time to bowel sounds (TBS) through meta‐analyses using a random‐effects model. We investigated the influence of study quality, reviewers’ methodological estimations and use of Enhanced Recovery After Surgery (ERAS) programmes using sensitivity analyses. We used meta‐regression to explore if surgical site or ROB scores predicted the extent of the effect estimate of the intervention on continuous outcomes. We reported frequency of complications, and descriptions of tolerability of gum and cost. Main results We identified 81 studies that comprised 9072 participants for inclusion in our review. We categorised many studies at high or unclear risk of the bias' assessed. There was statistical evidence that use of CG reduced TFF [overall reduction of 10.4 hours (95% CI: ‐11.9, ‐8.9): 12.5 hours (95% CI: ‐17.2, ‐7.8) in CRS, 7.9 hours (95% CI: –10.0, ‐5.8) in CS, 10.6 hours (95% CI: ‐12.7, ‐8.5) in OS]. There was also statistical evidence that use of CG reduced TBM [overall reduction of 12.7 hours (95% CI: ‐14.5, ‐10.9): 18.1 hours (95% CI: ‐25.3, ‐10.9) in CRS, 9.1 hours (95% CI: ‐11.4, ‐6.7) in CS, 12.3 hours (95% CI: ‐14.9, ‐9.7) in OS]. There was statistical evidence that use of CG slightly reduced LOHS [overall reduction of 0.7 days (95% CI: ‐0.8, ‐0.5): 1.0 days in CRS (95% CI: ‐1.6, ‐0.4), 0.2 days (95% CI: ‐0.3, ‐0.1) in CS, 0.8 days (95% CI: ‐1.1, ‐0.5) in OS]. There was statistical evidence that use of CG slightly reduced TBS [overall reduction of 5.0 hours (95% CI: ‐6.4, ‐3.7): 3.21 hours (95% CI: ‐7.0, 0.6) in CRS, 4.4 hours (95% CI: ‐5.9, ‐2.8) in CS, 6.3 hours (95% CI: ‐8.7, ‐3.8) in OS]. Effect sizes were largest in CRS and smallest in CS. There was statistical evidence of heterogeneity in all analyses other than TBS in CRS. There was little difference in mortality, infection risk and readmission rate between the groups. Some studies reported reduced nausea and vomiting and other complications in the intervention group. CG was generally well‐tolerated by participants. There was little difference in cost between the groups in the two studies reporting this outcome. Sensitivity analyses by quality of studies and robustness of review estimates revealed no clinically important differences in effect estimates. Sensitivity analysis of ERAS studies showed a smaller effect size on TFF, larger effect size on TBM, and no difference between groups for LOHS. Meta‐regression analyses indicated that surgical site is associated with the extent of the effect size on LOHS (all surgical subgroups), and TFF and TBM (CS and CRS subgroups only). There was no evidence that ROB score predicted the extent of the effect size on any outcome. Neither variable explained the identified heterogeneity between studies. Authors' conclusions This review identified some evidence for the benefit of postoperative CG in improving recovery of GI function. However, the research to date has primarily focussed on CS and CRS, and largely consisted of small, poor quality trials. Many components of the ERAS programme also target ileus, therefore the benefit of CG alongside ERAS may be reduced, as we observed in this review. Therefore larger, better quality RCTS in an ERAS setting in wider surgical disciplines would be needed to improve the evidence base for use of CG after surgery. Plain language summary Chewing gum after surgery to help recovery of the digestive system Background When people have surgery on their abdomen, the digestive system can stop working for a few days. This is called ileus, and can be painful and uncomfortable. There are different causes of ileus, and several ways of treating or preventing it. One possible way of preventing ileus is by chewing gum. The idea is that chewing gum tricks the body into thinking it is eating, causing the digestive system to start working again. It is important to do this review because ileus is common: it is estimated that up to a third of people having bowel surgery suffer from ileus. Main Findings This review found 81 relevant studies that recruited over 9000 participants in total. The studies mainly focussed on people having bowel surgery or caesarean section, but there were some studies of other surgery types. There were few studies of children. Most studies were of poor quality, which may mean their results are less reliable. We found some evidence that people who chewed gum after an operation were able to pass wind and have bowel movements sooner than people who did not chew gum. We also found some evidence that people who chewed gum after an operation had bowel sounds (gurgling sounds heard using a stethoscope held to the abdomen) slightly sooner than people who did not chew gum. There was a small difference in how long people stayed in hospital between people who did or did not chew gum. There were no differences in complications (such as infection or death) between people who did or did not chew gum. There was also no difference in the overall cost of treatment between people who did or did not chew gum. Conclusions There is some evidence that chewing gum after surgery may help the digestive system to recover. However, the studies included in this review are generally of poor quality, which meant that their results may not be reliable. We also know that there are many factors affecting ileus, and that modern treatment plans attempt to reduce risk of ileus. Therefore to further explore using chewing gum after surgery, more studies would be needed which are larger, of better quality, include different types of surgery, and consider recent changes in health care systems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Short, V, Herbert, G, Perry, R, Atkinson, C, Ness, AR, Penfold, C, Thomas, S, Andersen, HK, Lewis, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD006506.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.092Z" }, { "id": "3cfba107-4597-434b-967a-7c953fc10560", "pmid": "", "title": "Beclomethasone versus placebo for chronic asthma", "imported": false, "abstract": "Abstract - Background Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti‐inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane‐134a (HFA) propellant which is free from chlorofluorocarbon (CFC). Objectives The objectives of this review were to: 
 (1) Compare the efficacy of BDP with placebo with both CFC and HFA propellants in the treatment of chronic asthma. 
 (2) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. 
 (3) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies. Search methods Electronic searches were current as of January 2003. Selection criteria Randomised parallel group design trials for a minimum period of four weeks, in children and adults comparing CFC‐BDP or HFA‐BDP with placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality. Data collection and analysis One reviewer extracted data; authors were contacted to clarify missing information. We analysed data with RevMan Analyses 1.0.2. Main results 60 studies recruiting 6542 participants met the inclusion criteria. CFC‐BDP (57 studies): In non‐oral steroid treated patients, at doses of 400mcg/day or less CFC‐BDP produced significant improvements from baseline in a number of efficacy measures compared with placebo, including forced expiratory volume in one second (FEV1) 360 ml (95% CI 260 to 460); FEV1 (% predicted) WMD 12.41% (95% CI 8.18 to 16.64) and morning peak expiratory flow rate (am PEF) WMD 35.95 L/min (95% CI 27.85 to 44.04). BDP also led to reductions in rescue beta‐2 agonist use compared with placebo of ‐2.32 puffs/d (95% CI ‐2.55 to ‐2.09) and reduced the relative risk (RR) of trial withdrawal due to an asthma exacerbation 0.25 (95% CI 0.12 to 0.51). Subgroup analyses based on treatment duration provide support to the proposal that a treatment period of greater than four weeks is required to realise a fuller treatment effect. In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD ‐4.91 mg/d (95% CI ‐5.88 to ‐3.94 mg/d) and greater likelihood of withdrawing oral steroid treatment RR 8.02 (95% CI 3.23 to 19.92). HFA‐BDP (3 studies): In non‐oral steroid‐treated patients, HFA‐BDP was significantly more effective than placebo in improving FEV1, morning and evening PEF, FEF25 to 75%, reduced asthma symptoms and beta2‐agonists daily consumption. Significant effects for such outcomes were apparent after six weeks of treatment. In oral steroid treated patients, HFA‐BDP improved significantly FEV1 and am PEF. The summary estimates for these outcomes suggested a high level of heterogeneity, and divergent aims of the studies may contribute to the variation we observed. Limited data on adverse events were reported. Authors' conclusions This review has quantified the efficacy of CFC‐BDP and HFA‐BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose‐response in people with severe asthma. Plain language summary Inhaled beclomethasone compared with placebo for chronic asthma During an asthma attack, the airways narrow, causing breathing problems, wheezing and coughing. Inhaled corticosteroids (ICS) are used to reduce swelling of the airways. Inhaled beclomethasone dipropionate (BDP) is commonly used. There is now a new formulation of the drug which uses a new propellant (HFA‐BDP). This review of trials found that BDP delivered with the old and new propellant is effective in helping people with chronic asthma. BDP at all doses improves airflow, reduces symptoms and the need for rescue bronchodilators. The review only included studies conducted for more than 4 weeks. The drug was well tolerated and the safety profile was comparable with placebo. The findings apply to both children and adults. The effects of the new propellant suggest that it could be more effective than the older version, although a different review will address that particular question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Adams, NP; Bestall, JC; Malouf, R; Lasserson, TJ; Jones, P", "articleTypes": [], "doi": "10.1002/14651858.CD002738.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "3cfc82eb-e940-4aa6-b2f8-3c537105ccff", "pmid": "", "title": "Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery", "imported": false, "abstract": "Abstract - Background In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete. Objectives To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Date of the last search: 20 November 2014. Selection criteria Randomised and quasi‐randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention. Data collection and analysis Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta‐analyses were performed on available and relevant data. Main results Of the 16 identified trials, four (112 participants) were eligible for inclusion. Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon‐aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post‐operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re‐intervention was not reported by either trial. Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re‐intervention). In one trial a high‐dose rFVIIa regimen (90 μg/kg) was compared with a low‐dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety. Authors' conclusions There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well‐designed randomised controlled trials would be needed, in particular to address the cost‐effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies. Plain language summary Preventing bleeding in people with congenital bleeding disorders during and after surgery In haemophilia and other congenital bleeding disorders blood does not clot properly, which can cause excessive bleeding. This is particularly relevant during surgery, when the risk of bleeding depends on the type and severity of the clotting disorder and on the type of surgery. Therefore, during and after surgery, these individuals should receive treatment to improve the ability of their blood to clot and so prevent bleeding. Clotting factor concentrates (when available and appropriate in those individuals missing specific clotting proteins) or other non‐specific drugs for clotting, or a combination of both, are administered. It is not known what is the optimal dose or duration or method of administration of these treatments in these circumstances. We searched for randomised controlled trials comparing the efficacy (mortality, blood loss, need for re‐intervention, subjective assessment of efficacy, duration and dose of therapy) and the safety of any type of treatment given to people with congenital bleeding disorders during any type of surgery. We found four trials to be included in this review. Two trials evaluated 59 people with haemophilia A or B receiving antifibrinolytic drugs (agents that reduce the breakdown of clots) or placebo in addition to the initial standard treatment before dental extractions. The remaining two trials evaluated 53 people with haemophilia A or B and inhibitors (antibodies that act against the factor concentrate therapy) receiving an different clotting concentrate, recombinant activated factor VII, both during and after surgery. These two trials evaluated different treatment options: high‐dose compared with low‐dose and a single large (bolus) infusion compared with continuous infusion. The trials included in this review provide some information in two specific situations in people with congenital bleeding disorders undergoing surgery. However, on the whole, there is not enough evidence from trials to define the best treatments for the various types of disease and types of surgery. Further trials would be useful to improve our knowledge but are difficult to carry out and currently do not appear to be a clinical priority. Indeed, both major and minor surgery are safely performed in clinical practice in these individuals based on local experience and data from uncontrolled studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Coppola, A; Windyga, J; Tufano, A; Yeung, C; Di Minno, MND", "articleTypes": [], "doi": "10.1002/14651858.CD009961.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "3d2ad885-baff-42ee-b3bb-d75b674e2ffb", "pmid": "", "title": "Interventions for perceptual disorders following stroke", "imported": false, "abstract": "Abstract - Background Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non‐invasive brain stimulation, pharmacological and surgical approaches. Objectives To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living. Search methods We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors. Selection criteria We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain. Data collection and analysis One review author assessed titles, with two review authors independently screening abstracts and full‐text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB‐1 tool, and quality of evidence using GRADE. A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update. Main results We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch‐somatosensory disorders. None addressed stroke‐related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non‐invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL): Somatosensory disorders : one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure. Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention. Visual perception disorders : no trials measuring ADL compared an intervention with no treatment or control. In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials). Authors' conclusions Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high‐quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer‐term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines. Plain language summary Interventions for perceptual disorders following stroke Key messages Stroke can affect a person’s ability to process and understand information from their senses, including hearing, smell, somatosensation (sense of body temperature, position, and movement), taste, touch, and vision. Processing and understanding information from these senses is known as perception. Little research has been carried out to find out whether any treatments for stroke‐related problems with perception are helpful. People with stroke‐related problems with hearing, smell, somatosensation, taste, touch, and vision should continue to participate in rehabilitation as recommended by clinical guidelines. Healthcare professionals should continue to offer rehabilitation for stroke‐related perceptual problems in keeping with current clinical guidelines and recommendations. What is a perceptual disorder? Before a stroke, adults gather information about the world through their senses: hearing, smell, somatosensation, taste, touch, and vision. Somatosensation refers to sensation arising from the skin, muscles, or joints, and includes perception of pressure, vibration, temperature, and position. Information gathered might include the colour, shape, and size of objects that they see. Together with memories and cultural experiences, a person can understand how someone is feeling from seeing their facial expression. Other examples are how different odours can be identified through the sense of smell and how different textures can be felt through the sense of touch. A stroke can affect these abilities. How are perceptual disorders treated? Healthcare professionals, including occupational therapists, physiotherapists, and psychologists, may offer different therapies. Treatments might include medicine, stimulation of the brain, or perceptual rehabilitation through activities, puzzles, strategies, or intensive repetition of tasks. What did we want to find out? We wanted to find out whether receiving any perceptual disorder treatment was better than no treatment at all. We measured improvement by looking at how well people could carry out their daily activities. We measured whether treatments also helped other things, such as quality of life, mental health, and perception. We looked for information on when things did not go well. We also explored whether one treatment was more beneficial than another. What did we do? We searched for all relevant research. We assessed the quality of 18 studies and summarised their results. What did we find out? The studies we found were about different perceptual disorders: three studies looked at disorders of touch perception, seven looked at somatosensation, seven studies looked at vision, and one looked at several perceptual problems at the same time. The treatments used in these studies included paper‐and‐pencil copying tasks to improve visual memory and using robots to help improve a person’s sense of where their body is positioned. We found no information to show that any treatment worked. Why are we still uncertain? We found few studies. Each study included a small number of people with a perceptual problem after a stroke. With small numbers of people involved, the results were not clear. Each study looked at different interventions. Less than half the studies (seven) measured the ability to carry out everyday activities. How up to date is this information? Our information is up to date as of August 2021. Based on the information we gathered, we are still unclear about the benefits or harms of treatments for perceptual problems after stroke. People with perceptual problems after stroke should continue to be offered rehabilitation as recommended in clinical guidelines.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hazelton, C, Thomson, K, Todhunter-Brown, A, Campbell, P, Chung, CSY, Dorris, L, Gillespie, DC, Hunter, SM, McGill, K, Nicolson, DJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD007039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.062Z" }, { "id": "3d3980b5-a9eb-4533-a267-95f7f35ee5e6", "pmid": "", "title": "Sucrose for analgesia in newborn infants undergoing painful procedures", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose with and without non‐nutritive sucking is the most frequently studied non‐pharmacological intervention for procedural pain relief in neonates. Objectives To determine the efficacy, effect of dose, method of administration and safety of sucrose for relieving procedural pain in neonates as assessed by validated composite pain scores, physiological pain indicators (heart rate, respiratory rate, saturation of peripheral oxygen in the blood, transcutaneous oxygen and carbon dioxide (gas exchange measured across the skin ‐ TcpO 2 , TcpCO 2 ), n ear i nfra r ed s pectroscopy (NIRS), e lectro e ncephalo g ram (EEG), or behavioural pain indicators (cry duration, proportion of time crying, proportion of time facial actions (e.g. grimace) are present), or a combination of these and long‐term neurodevelopmental outcomes. Search methods We used the standard methods of the Cochrane Neonatal. We performed electronic and manual literature searches in February 2016 for published randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library , Issue 1, 2016), MEDLINE (1950 to 2016), EMBASE (1980 to 2016), and CINAHL (1982 to 2016) . We did not impose language restrictions. Selection criteria RCTs in which term or preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age), or both, received sucrose for procedural pain. Control interventions included no treatment, water, glucose, breast milk, breastfeeding, local anaesthetic, pacifier, positioning/containing or acupuncture. Data collection and analysis Our main outcome measures were composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We reported a mean difference (MD) or weighted MD (WMD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. For categorical data we used risk ratio (RR) and risk difference. We assessed heterogeneity by the I 2 test. We assessed the risk of bias of included trials using the Cochrane 'Risk of bias' tool, and assessed the quality of the evidence using the GRADE system. Main results Seventy‐four studies enrolling 7049 infants were included. Results from only a few studies could be combined in meta‐analyses and for most analyses the GRADE assessments indicated low‐ or moderate‐quality evidence. There was high‐quality evidence for the beneficial effect of sucrose (24%) with non‐nutritive sucking (pacifier dipped in sucrose) or 0.5 mL of sucrose orally in preterm and term infants: Premature Infant Pain Profile (PIPP) 30 s after heel lance WMD ‐1.70 (95% CI ‐2.13 to ‐1.26; I 2 = 0% (no heterogeneity); 3 studies, n = 278); PIPP 60 s after heel lance WMD ‐2.14 (95% CI ‐3.34 to ‐0.94; I 2 = 0% (no heterogeneity; 2 studies, n = 164). There was high‐quality evidence for the use of 2 mL 24% sucrose prior to venipuncture: PIPP during venipuncture WMD ‐2.79 (95% CI ‐3.76 to ‐1.83; I 2 = 0% (no heterogeneity; 2 groups in 1 study, n = 213); and intramuscular injections: PIPP during intramuscular injection WMD ‐1.05 (95% CI ‐1.98 to ‐0.12; I 2 = 0% (2 groups in 1 study, n = 232). Evidence from studies that could not be included in RevMan‐analyses supported these findings. Reported adverse effects were minor and similar in the sucrose and control groups. Sucrose is not effective in reducing pain from circumcision. The effectiveness of sucrose for reducing pain/stress from other interventions such as arterial puncture, subcutaneous injection, insertion of nasogastric or orogastric tubes, bladder catherization, eye examinations and echocardiography examinations are inconclusive. Most trials indicated some benefit of sucrose use but that the evidence for other painful procedures is of lower quality as it is based on few studies of small sample sizes. The effects of sucrose on long‐term neurodevelopmental outcomes are unknown. Authors' conclusions Sucrose is effective for reducing procedural pain from single events such as heel lance, venipuncture and intramuscular injection in both preterm and term infants. No serious side effects or harms have been documented with this intervention. We could not identify an optimal dose due to inconsistency in effective sucrose dosage among studies. Further investigation of repeated administration of sucrose in neonates is needed. There is some moderate‐quality evidence that sucrose in combination with other non‐pharmacological interventions such as non‐nutritive sucking is more effective than sucrose alone, but more research of this and sucrose in combination with pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing painful procedures Review question Cochrane reviewers investigated how well sucrose (table sugar) works as a reliever of pain in newborn babies who are having painful procedures (e.g. an injection, or heel lance, or insertion of a needle to obtain a blood sample (venipuncture), or eye examinations). The babies' pain responses (e.g. crying, grimacing) were assessed by scoring systems for pain used by health care professionals to measure the pain that babies are experiencing. In addition, the reviewers wanted to investigate whether the level of pain relief is related to the dose of sucrose, or the method of delivery (e.g. as a solution squirted into the mouth, or on a pacifier (also called a soother or dummy), and whether there are any safety concerns about using sucrose to relieve pain. Background Although there are ways to manage the pain of surgery, medical illness and major procedures, ways of preventing or reducing pain from minor medical procedures (e.g. heel lance and venipuncture) have, until relatively recently, been lacking. Sucrose has been examined for its calming effects in crying newborns and its pain‐relieving effects for invasive procedures in full‐term and premature newborns. Study characteristics We searched the medical literature widely up to February 2016 for studies that investigated the pain‐relieving effect of sucrose for minor medical procedures in newborn full‐term and premature babies. We included randomised controlled trials only, as these provide the most reliable medical evidence. We identified 74 studies that reported on a total of more than 7000 infants in this Cochrane Review. Thirty‐eight studies included full‐term babies only, 31 included premature babies only, and five included both full‐term and premature babies. Heel lance was the painful procedure in 38 studies, and venipuncture in nine; the remaining studies investigated a wide variety of other minor painful procedures. The studies used a variety of delivery methods for the sucrose solution (oral syringe, dropper or sucrose‐dipped pacifier), as well as a range of concentrations and volumes of dose. Sucrose treatment was compared with giving the babies a similar volume of water, a pacifier, routine care, breastfeeding, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), laser acupuncture, swaddling, warmth, anaesthetic cream for the skin (EMLA), or a combination of these. The studies used a range of pain assessment scales to measure their results. Study funding sources We did not identify any studies that received funding from the industry. Key results There was high‐quality evidence that sucrose reduces different measures of newborn pain during heel lance, venipuncture and intramuscular injection. However, sucrose does not provide effective pain relief during circumcision. There is conflicting evidence for whether sucrose reduces pain for other minor painful procedures and further research is needed to investigate these more thoroughly. Twenty‐nine studies reported on adverse events (harms of the sucrose and other treatments) and found that the number of minor adverse events (e.g. choking or gagging) was very low, and was similar in the different groups (so not attributable to the sucrose treatment). No major adverse events were reported. Quality of evidence Although sucrose has been widely studied as a pain reliever for newborn babies, most studies have included few babies and have used many different measures of pain to assess its effectiveness. We identified high‐quality evidence that sucrose reduces pain for heel lance, venipuncture and intramuscular injection. The quality of evidence was low or moderate in favour for the use of sucrose for other painful procedures.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stevens, B, Yamada, J, Ohlsson, A, Haliburton, S, Shorkey, A", "articleTypes": [], "doi": "10.1002/14651858.CD001069.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.740Z" }, { "id": "3d472849-9a38-4989-a29c-78a2e2b868b8", "pmid": "", "title": "Isolation and Establishment of Gustatory Cell Lines in Patients Operated on for Cancer of the Mobile Tongue - ImmortTasteCELL", "imported": false, "abstract": "In terms of incidence, cancer of the tongue is one of the leading cancers in France. Moreover, this cancer is associated with physiological complications ranging from swallowing disorders to loss of taste. Following surgery, impaired perception of food taste may lead to cachexia. It is therefore necessary to carry out research in the field of impaired taste, notably with regard to the regeneration of taste buds. However, there is currently no available functional model of taste bud cells.", "journal": "", "year": "2017", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.148Z" }, { "id": "3d514351-10fb-4f29-9717-60b41d313d3a", "pmid": "", "title": "Interventions for the management of dry mouth: topical therapies", "imported": false, "abstract": "Abstract - Background Xerostomia (the feeling of dry mouth) is a common symptom especially in older adults. Causes of dry mouth include medications, autoimmune disease (Sjögren's Syndrome), radiotherapy or chemotherapy for cancer, hormone disorders and infections. Objectives To determine which topical treatments for dry mouth are effective in reducing this symptom. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (28 October 2011), The Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 4 2011), MEDLINE via OVID (1950 to 28 October 2011), EMBASE via OVID (1980 to 28 October 2011), CINAHL via EBSCO (1980 to 28 October 2011), AMED via OVID (1985 to 28 October 2011), CANCERLIT via PubMed (1950 to 28 October 2011). Selection criteria We included randomised controlled trials of topical interventions such as lozenges, sprays, mouthrinses, gels, oils, chewing gum or toothpastes for the treatment of dry mouth symptom. We classified interventions into two broad categories, saliva stimulants and saliva substitutes, and these were compared with either placebo or another intervention. We included both parallel group and crossover trials. Data collection and analysis Two or more review authors independently carried out data extraction and assessed risk of bias. Trial authors were contacted for additional information as required. Main results Thirty‐six randomised controlled trials involving 1597 participants met the inclusion criteria. Two trials compared saliva stimulants to placebo, nine trials compared saliva substitutes to placebo, five trials compared saliva stimulants directly with saliva substitutes, 18 trials directly compared two or more saliva substitutes, and two trials directly compared two or more saliva stimulants. Only one trial was at low risk of bias and 17 were at high risk of bias. Due to the range of interventions, comparisons and outcome measures in the trials, meta‐analysis was possible for only a few comparisons. Oxygenated glycerol triester (OGT) saliva substitute spray shows evidence of effectiveness compared to an electrolyte spray (standardised mean difference (SMD) 0.77, 95% confidence interval (CI) 0.38 to 1.15) which corresponds to approximately a mean difference of 2 points on a 10‐point visual analogue scale (VAS) for mouth dryness. Both integrated mouthcare systems (toothpaste + gel + mouthwash) and oral reservoir devices show promising results but there is insufficient evidence at present to recommend their use. Although chewing gum is associated with increased saliva production in the majority of those with residual capacity, there is no evidence that gum is more or less effective than saliva substitutes. Authors' conclusions There is no strong evidence from this review that any topical therapy is effective for relieving the symptom of dry mouth. OGT spray is more effective than an aqueous electrolyte spray (SMD 0.77, 95% CI 0.38 to 1.15) which is approximately equivalent to a mean difference of 2 points on a 10‐point VAS scale for mouth dryness. Chewing gums appear to increase saliva production in those with residual secretory capacity and may be preferred by patients, but there is no evidence that gum is better or worse than saliva substitutes. Integrated mouthcare systems and oral reservoir devices may be helpful but further research is required to confirm this. Well designed, adequately powered randomised controlled trials of topical interventions for dry mouth, which are designed and reported according to CONSORT guidelines, are required to provide evidence to guide clinical care. For many people the symptom of dry mouth is a chronic problem and trials should evaluate whether treatments are palatable, effective in reducing xerostomia, as well as the long‐term effects of treatments on quality of life of those with chronic dry mouth symptoms. Plain language summary Interventions for the management of dry mouth: topical therapies Dry mouth is a common problem with a range of causes. The symptom may be due to a reduction in the quantity of saliva produced, or a change in the composition of saliva, but a feeling of dry mouth may also be present in people with normal saliva production. Radiotherapy or chemotherapy for head and neck cancers, and diseases such as Sjögren's Syndrome, may result in reduced saliva production. Many commonly prescribed medications are associated with a feeling of dry mouth, despite normal saliva production. As well as difficulty in speaking, chewing and swallowing, prolonged dry mouth may result in increased risk of tooth decay and reduced quality of life. In many sufferers dry mouth cannot be cured, but effective ways for people to manage dry mouth symptoms are available. Many topical treatments (applied directly to the inside of the mouth) such as sprays, lozenges, mouthrinses, gels, oils, chewing gum or toothpastes have been evaluated in this review, but there is no strong evidence that any topical treatment is effective for relieving the sensation of dry mouth. Oxygenated glycerol triester (OGT) saliva substitute spray is more effective than a water based electrolyte spray. A gel‐releasing device worn in the mouth, or a mouthcare system might be effective but more research is needed. Chewing gum increases saliva production but there is no evidence that gum is better or worse than saliva substitutes. Acidic products and those containing sugar should be avoided.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Furness, S; Worthington, HV; Bryan, G; Birchenough, S; McMillan, R", "articleTypes": [], "doi": "10.1002/14651858.CD008934.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "3d58f9f7-e8b9-4ec9-8209-21fb792b4030", "pmid": "", "title": "Colchicine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Colchicine has been used for patients with primary biliary cirrhosis because of its immunomodulatory and antifibrotic potential. The therapeutical responses to colchicine in randomised clinical trials were inconsistent. Objectives To evaluate the beneficial and harmful effects of colchicine in patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials on The Cochrane Library , MEDLINE, EMBASE (September 2003) , and manual searches of bibliographies. We contacted authors of trials and pharmaceutical companies. Selection criteria Randomised clinical trials comparing colchicine with any kind of control therapy were included irrespective of language, year of publication, and publication status. Data collection and analysis The primary outcomes were the number of deaths and the number of death and/or patients who underwent liver transplantation. Dichotomous outcomes were reported as relative risk (RR) with 95% confidence interval (CI). We examined intervention effects by using both a fixed effect model and a random effects model. Heterogeneity was investigated by subgroup analyses and sensitivity analyses. Main results Eleven randomised clinical trials involving 716 patients with primary biliary cirrhosis fulfilled the inclusion criteria. No significant differences were detected between colchicine and placebo/no intervention on the number of deaths (RR 1.21, 95% CI 0.71 to 2.06), the number of deaths and/or patients who underwent liver transplantation (RR 1.00, 95% CI 0.67 to 1.49), liver complications, liver biochemical variables, liver histological measurements, and adverse events. Trial methodology was generally low and some trials had high drop‐out rate. A best‐worst‐case‐scenario analysis showed no significant effect of colchicine on mortality (RR 0.59, 95%CI 0.30 to 1.15), while a worst‐best‐case‐scenario analysis showed a significant detrimental effect of colchicine on mortality (RR 2.28, 95% CI 1.17 to 4.44). Colchicine significantly decreased the number of patients without improvement of pruritus (RR 0.75, 95% CI 0.65 to 0.87). However, this estimate was based on only 156 patients from three trials. The effect of the combined treatment with ursodeoxycholic acid was not significantly different from that of colchicine alone. Authors' conclusions We did not find evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis. As we are not able to exclude a detrimental effect of colchicine, we suggest that it is only used in randomised clinical trials. Plain language summary No convincing evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis Primary biliary cirrhosis is a rare, chronic liver disease of unknown etiology. Colchicine, a plant alkaloid, has been used to treat patients with primary biliary cirrhosis and was tested in randomised clinical trials. When all identified trials were combined, colchicine appeared to be not significantly different from placebo/no intervention in respect to mortality, mortality and/or patients who underwent liver transplantation, liver complications, liver biochemistry, liver histology, and the occurrences of adverse events. Colchicine may reduce pruritus, but this finding may be due to bias. The addition of ursodeoxycholic acid did not significantly influence the effect of colchicine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.777Z" }, { "id": "3d8009af-47e3-49da-a946-712ba329833f", "pmid": "", "title": "Citalopram versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Recent US and UK clinical practice guidelines recommend that second‐generation antidepressants should be considered amongst the best first‐line options when drug therapy is indicated for a depressive episode. Systematic reviews have already highlighted some differences in efficacy between second‐generation antidepressants. Citalopram, one of the first selective serotonin reuptake inhibitors (SSRI) introduced in the market, is one of these antidepressant drugs that clinicians use for routine depression care. Objectives To assess the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with tricyclics, heterocyclics, other SSRIs and other conventional and non‐conventional antidepressants in the acute‐phase treatment of major depression. Search methods We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to February 2012. No language restriction was applied. We contacted pharmaceutical companies and experts in this field for supplemental data. Selection criteria Randomised controlled trials allocating patients with major depression to citalopram versus any other antidepressants. Data collection and analysis Two reviewers independently extracted data. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (the number of patients who responded or remitted), patient acceptability (the number of patients who failed to complete the study) and tolerability (side‐effects). Main results Thirty‐seven trials compared citalopram with other antidepressants (such as tricyclics, heterocyclics, SSRIs and other antidepressants, either conventional ones, such as mirtazapine, venlafaxine and reboxetine, or non‐conventional, like hypericum ). Citalopram was shown to be significantly less effective than escitalopram in achieving acute response (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.08 to 2.02), but more effective than paroxetine (OR 0.65, 95% CI 0.44 to 0.96) and reboxetine (OR 0.63, 95% CI 0.43 to 0.91). Significantly fewer patients allocated to citalopram withdrew from trials due to adverse events compared with patients allocated to tricyclics (OR 0.54, 95% CI 0.38 to 0.78) and fewer patients allocated to citalopram reported at least one side effect than reboxetine or venlafaxine (OR 0.64, 95% CI 0.42 to 0.97 and OR 0.46, 95% CI 0.24 to 0.88, respectively). Authors' conclusions Some statistically significant differences between citalopram and other antidepressants for the acute phase treatment of major depression were found in terms of efficacy, tolerability and acceptability. Citalopram was more efficacious than paroxetine and reboxetine and more acceptable than tricyclics, reboxetine and venlafaxine, however, it seemed to be less efficacious than escitalopram. As with most systematic reviews in psychopharmacology, the potential for overestimation of treatment effect due to sponsorship bias and publication bias should be borne in mind when interpreting review findings. Economic analyses were not reported in the included studies, however, cost effectiveness information is needed in the field of antidepressant trials. Plain language summary Citalopram versus other antidepressants for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Antidepressant drugs remain the mainstay of treatment in moderate‐to‐severe major depression. During the last 20 years, selective serotonin reuptake inhibitors (SSRIs) have progressively become the most commonly prescribed antidepressants. Citalopram, one of the first SSRIs introduced in the market, is the racemic mixture of S‐ and R‐enantiomer. In the present review we assessed the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with all other antidepressants in the acute‐phase treatment of major depression. Thirty‐seven randomised controlled trials (more than 6000 participants) were included in the present review. In terms of efficacy, citalopram was more efficacious than other reference compounds like paroxetine or reboxetine, but worse than escitalopram. In terms of side effects, citalopram was more acceptable than older antidepressants, like tricyclics. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including differences in efficacy and side‐effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cipriani, A; Purgato, M; Furukawa, TA; Trespidi, C; Imperadore, G; Signoretti, A; Churchill, R; Watanabe, N; Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006534.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "3d86f7c1-e57a-4064-a47f-8695a0b59c25", "pmid": "", "title": "Fortification of maize flour with iron for controlling anaemia and iron deficiency in populations", "imported": false, "abstract": "Abstract - Background Approximately 800 million women and children have anaemia, a condition thought to cause almost 9% of the global burden of years lived with disability. Around half this burden could be amenable to interventions that involve the provision of iron. Maize (corn) is one of the world's most important cereal grains and is cultivated across most of the globe. Several programmes around the world have fortified maize flour and other maize‐derived foodstuffs with iron and other vitamins and minerals to combat anaemia and iron deficiency. Objectives To assess the effects of iron fortification of maize flour, corn meal and fortified maize flour products for anaemia and iron status in the general population. Search methods We searched the following international and regional sources in December 2017 and January 2018: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE (R) In Process; Embase; Web of Science (both the Social Science Citation Index and the Science Citation Index); CINAHL Ebsco; POPLINE; AGRICOLA ( agricola.nal.usda.gov ); BIOSIS (ISI); Bibliomap and TRoPHI; IBECS; Scielo; Global Index Medicus ‐ AFRO (includes African Index Medicus); EMRO (includes Index Medicus for the Eastern Mediterranean Region); LILACS; PAHO (Pan American Health Library); WHOLIS (WHO Library); WPRO (includes Western Pacific Region Index Medicus); IMSEAR, Index Medicus for the South‐East Asian Region; IndMED, Indian medical journals; and the Native Health Research Database. We searched clinicaltrials.gov and the International Clinical Trials Registry Platform ( ICTRP ) for any ongoing or planned studies on 17 January 2018 and contacted authors of such studies to obtain further information or eligible data if available. For assistance in identifying ongoing or unpublished studies, we also contacted relevant international organisations and agencies working in food fortification on 9 August 2016. Selection criteria We included cluster‐ or individually randomised controlled trials and observational studies. Interventions included (central/industrial) fortification of maize flour or corn meal with iron alone or with other vitamins and minerals and provided to individuals over 2 years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies and assessed the risk of bias of the included studies. Trial designs with a comparison group were included to assess the effects of interventions. Trial designs without a control or comparison group (uncontrolled before‐and‐after studies) were included for completeness but were not considered in assessments of the overall effectiveness of interventions or used to draw conclusions regarding the effects of interventions in the review. Main results Our search yielded 4529 records. After initial screening of titles and abstracts, we reviewed the full text of 75 studies (80 records). We included 5 studies and excluded 70. All the included studies assessed the effects of providing maize products fortified with iron plus other vitamins and minerals versus unfortified maize flour. No studies compared this intervention to no intervention or looked at the relative effect of flour and products fortified with iron alone (without other vitamins and minerals). Three were randomised trials involving 2610 participants, and two were uncontrolled before‐and‐after studies involving 849 participants. Only three studies contributed data for the meta‐analysis and included children aged 2 to 11.9 years and women. Compared to unfortified maize flour, it is uncertain whether fortifying maize flour or corn meal with iron and other vitamins and minerals has any effect on anaemia (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.58 to 1.40; 2 studies; 1027 participants; very low‐certainty evidence), or on the risk of iron deficiency (RR 0.75, 95% CI 0.49 to 1.15; 2 studies; 1102 participants; very low‐certainty evidence), haemoglobin concentration (mean difference (MD) 1.25 g/L, 95% CI −2.36 to 4.86 g/L; 3 studies; 1144 participants; very low‐certainty evidence) or ferritin concentrations (MD 0.48 µg/L, 95% CI −0.37 to 1.33 µg/L; 1 study; 584 participants; very low‐certainty evidence). None of the studies reported on any adverse effects. We judged the certainty of the evidence to be very low based on GRADE, so we are uncertain whether the results reflect the true effect of the intervention. We downgraded evidence due to high risk of selection bias and unclear risk of performance bias in one of two included studies, high heterogeneity and wide CIs crossing the line of no effect for anaemia prevalence and haemoglobin concentration. Authors' conclusions It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of anaemia or iron deficiency in children aged over 2 years or in adults. Moreover, the evidence is too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population, as the certainty of the evidence is very low. No studies reported on any adverse effects. Public organisations funded three of the five included studies, while the private sector gave grants to universities to perform the other two. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. The reduced number of studies, including only two age groups (children and women of reproductive age), as well as the limited number of comparisons (only one out of the four planned) constitute the main limitations of this review. Plain language summary Fortification of maize flour with iron for preventing anaemia and iron deficiency What is the aim of this review? The aim of this Cochrane Review was to determine the effects of fortifying maize flour, corn meal and fortified‐maize flour products with iron for anaemia and iron status in the general population. We searched for relevant published studies to answer this question and analysed all relevant information. Key messages It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We do not know whether fortifying maize flour with iron reduces anaemia in the general population, as the evidence was very unreliable. No studies reported on any harmful effects. What was studied in the review? Approximately 496 million non‐pregnant women, 32 million pregnant women, and 273 million children were thought to be anaemic as of 2011. Iron deficiency is considered to be the single most prevalent nutrient deficiency worldwide, but at least half this burden is considered responsive to interventions that involve providing people with iron. Fortification means adding vitamins and minerals to foods to increase their nutritional value. In public health, fortifying staple foods is considered one way of reducing micronutrient deficiencies without changing usual and culturally acceptable diets. Maize (corn) is one of the world's most important cereal grains. In sub‐Saharan Africa, some parts of Southeast Asia and Latin America, where iron deficiency is endemic, maize is a dietary staple for more than 200 million people. Fortification of maize flour with iron (and in some cases, other nutrients) is mandatory in Brazil, Costa Rica, El Salvador, Kenya, Mexico, Nigeria, Rwanda, South Africa, Tanzania, Uganda, the USA and Venezuela. What are the main results of the review? We found five relevant studies, but none looked at the effects of maize flour or maize flour products fortified with iron alone. Five studies compared the effects of maize flour or maize‐flour products fortified with iron plus other vitamins and minerals versus unfortified maize flours or maize‐flour products (not containing iron or any other vitamin and minerals). Three of these five studies randomly divided a collective total of 2302 children aged 2 to 12 years and 130 indigenous women into groups receiving fortified versus unfortified maize flour or corn flour. One study was from Kenya and the other two took place in Mexico. The remaining two studies did not provide data to assess the effects of fortification relative to a comparison group. Three of five of the included studies were funded by public organisations and two by funds granted by private sector to universities. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency in the general population. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population. How up‐to‐date is this review? We searched for studies that had been published up to 17 January 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Garcia‐Casal, MN; Peña‐Rosas, JP; De‐Regil, LM; Gwirtz, JA; Pasricha, SR", "articleTypes": [], "doi": "10.1002/14651858.CD010187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "3d8b58f1-16b7-4bb1-9813-49ade0ba5344", "pmid": "", "title": "Synbiotics, prebiotics and probiotics for people with chronic kidney disease", "imported": false, "abstract": "Abstract - Background Chronic kidney disease (CKD) is a major public health problem affecting 13% of the global population. Prior research has indicated that CKD is associated with gut dysbiosis. Gut dysbiosis may lead to the development and/or progression of CKD, which in turn may in turn lead to gut dysbiosis as a result of uraemic toxins, intestinal wall oedema, metabolic acidosis, prolonged intestinal transit times, polypharmacy (frequent antibiotic exposures) and dietary restrictions used to treat CKD. Interventions such as synbiotics, prebiotics, and probiotics may improve the balance of the gut flora by altering intestinal pH, improving gut microbiota balance and enhancing gut barrier function (i.e. reducing gut permeability). Objectives This review aimed to evaluate the benefits and harms of synbiotics, prebiotics, and probiotics for people with CKD. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria We included randomised controlled trials (RCTs) measuring and reporting the effects of synbiotics, prebiotics, or probiotics in any combination and any formulation given to people with CKD (CKD stages 1 to 5, including dialysis and kidney transplant). Two authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. Data collection and analysis Data extraction was independently carried out by two authors using a standard data extraction form. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross‐checked by another. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Forty‐five studies (2266 randomised participants) were included in this review. Study participants were adults (two studies in children) with CKD ranging from stages 1 to 5, with patients receiving and not receiving dialysis, of whom half also had diabetes and hypertension. No studies investigated the same synbiotic, prebiotic or probiotic of similar strains, doses, or frequencies. Most studies were judged to be low risk for selection bias, performance bias and reporting bias, unclear risk for detection bias and for control of confounding factors, and high risk for attrition and other biases. Compared to prebiotics, it is uncertain whether synbiotics improve estimated glomerular filtration rate (eGFR) at four weeks (1 study, 34 participants: MD ‐3.80 mL/min/1.73 m², 95% CI ‐17.98 to 10.38), indoxyl sulfate at four weeks (1 study, 42 participants: MD 128.30 ng/mL, 95% CI ‐242.77 to 499.37), change in gastrointestinal (GI) upset (borborymgi) at four weeks (1 study, 34 participants: RR 15.26, 95% CI 0.99 to 236.23), or change in GI upset (Gastrointestinal Symptom Rating Scale) at 12 months (1 study, 56 participants: MD 0.00, 95% CI ‐0.27 to 0.27), because the certainty of the evidence was very low. Compared to certain strains of prebiotics, it is uncertain whether a different strain of prebiotics improves eGFR at 12 weeks (1 study, 50 participants: MD 0.00 mL/min, 95% CI ‐1.73 to 1.73), indoxyl sulfate at six weeks (2 studies, 64 participants: MD ‐0.20 μg/mL, 95% CI ‐1.01 to 0.61; I² = 0%) or change in any GI upset, intolerance or microbiota composition, because the certainty of the evidence was very low. Compared to certain strains of probiotics, it is uncertain whether a different strain of probiotic improves eGFR at eight weeks (1 study, 30 participants: MD ‐0.64 mL/min, 95% CI ‐9.51 to 8.23; very low certainty evidence). Compared to placebo or no treatment, it is uncertain whether synbiotics improve eGFR at six or 12 weeks (2 studies, 98 participants: MD 1.42 mL/min, 95% CI 0.65 to 2.2) or change in any GI upset or intolerance at 12 weeks because the certainty of the evidence was very low. Compared to placebo or no treatment, it is uncertain whether prebiotics improves indoxyl sulfate at eight weeks (2 studies, 75 participants: SMD ‐0.14 mg/L, 95% CI ‐0.60 to 0.31; very low certainty evidence) or microbiota composition because the certainty of the evidence is very low. Compared to placebo or no treatment, it is uncertain whether probiotics improve eGFR at eight, 12 or 15 weeks (3 studies, 128 participants: MD 2.73 mL/min, 95% CI ‐2.28 to 7.75; I² = 78%), proteinuria at 12 or 24 weeks (1 study, 60 participants: MD ‐15.60 mg/dL, 95% CI ‐34.30 to 3.10), indoxyl sulfate at 12 or 24 weeks (2 studies, 83 participants: MD ‐4.42 mg/dL, 95% CI ‐9.83 to 1.35; I² = 0%), or any change in GI upset or intolerance because the certainty of the evidence was very low. Probiotics may have little or no effect on albuminuria at 12 or 24 weeks compared to placebo or no treatment (4 studies, 193 participants: MD 0.02 g/dL, 95% CI ‐0.08 to 0.13; I² = 0%; low certainty evidence). For all comparisons, adverse events were poorly reported and were minimal (flatulence, nausea, diarrhoea, abdominal pain) and non‐serious, and withdrawals were not related to the study treatment. Authors' conclusions We found very few studies that adequately test biotic supplementation as alternative treatments for improving kidney function, GI symptoms, dialysis outcomes, allograft function, patient‐reported outcomes, CVD, cancer, reducing uraemic toxins, and adverse effects. We are not certain whether synbiotics, prebiotics, or probiotics are more or less effective compared to one another, antibiotics, or standard care for improving patient outcomes in people with CKD. Adverse events were uncommon and mild. Plain language summary Prebiotics (dietary fibre), probiotics (good bacteria) or synbiotics (prebiotics plus probiotics) for people with chronic kidney disease Key messages Chronic kidney disease (CKD) is a serious health problem that affects over 850 million people worldwide. People with kidney disease have an unhealthy balance of good and bad bacteria in their guts, called 'gut dysbiosis'. This imbalance arises because of the effects of reduced kidney function (retained toxic waste products, fluid retention causing the gut wall to swell), drugs frequently used in people with CKD (especially antibiotics), and dietary restrictions placed on people with CKD. Gut dysbiosis can, in turn, cause or worsen CKD because bacteria can produce toxins that cross the bowel wall and damage the kidneys. Gut dysbiosis can also cause stomach problems (like bloating, cramping, constipation and diarrhoea) and reduce quality of life. To improve the balance of the gut flora, good bacteria can be taken in tablets of high doses of prebiotics and probiotics. Prebiotics, or indigestible plant fibre, can encourage the growth of good bacteria. Synbiotics are a combination of prebiotics and probiotics. Some research suggests that taking high doses of the good bacteria can re‐balance the good bacteria in people's gut, thereby improving bowel symptoms and the conditions that lead to worsening of CKD. What did we do? We reviewed all of the evidence on synbiotics, prebiotics and probiotics to see whether they can improve outcomes in people who have CKD (all stages 1 to 5). What did we find? We found 45 studies randomising 2266 participants. Half of these looked at participants receiving dialysis (mostly haemodialysis), and the other half not receiving dialysis. Half also had diabetes and hypertension. We are uncertain whether synbiotics, prebiotics, or probiotics improve bowel outcomes, quality of life, kidney toxin levels or kidney function. The quality of the evidence that we found is low quality and very low certainty. All studies were conducted using moderate to poor‐quality methods with too few patients. Summary Currently, we do not have enough information from trials to know whether synbiotics, prebiotics or probiotics work to improve bowel symptoms, quality of life, kidney toxin levels, or kidney function in people with CKD. Ten studies are currently ongoing; therefore, it is possible that findings may change with the inclusion of these studies in future updates. The evidence is up to date to 9 October 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Cooper, TE, Khalid, R, Chan, S, Craig, JC, Hawley, CM, Howell, M, Johnson, DW, Jaure, A, Teixeira-Pinto, A, Wong, G", "articleTypes": [], "doi": "10.1002/14651858.CD013631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.802Z" }, { "id": "3d9e4d90-1223-4c3b-b307-78c19155f7bb", "pmid": "", "title": "Drugs for the acute treatment of migraine in children and adolescents", "imported": false, "abstract": "Abstract - Background Numerous medications are available for the acute treatment of migraine in adults, and some have now been approved for use in children and adolescents in the ambulatory setting. A systematic review of acute treatment of migraine medication trials in children and adolescents will help clinicians make evidence‐informed management choices. Objectives To assess the effects of pharmacological interventions by any route of administration versus placebo for migraine in children and adolescents 17 years of age or less. For the purposes of this review, children were defined as under 12 years of age and adolescents 12 to 17 years of age. Search methods We searched seven bibliographic databases and four clinical trial registers as well as gray literature for studies through February 2016. Selection criteria We included prospective randomized controlled clinical trials of children and adolescents with migraine, comparing acute symptom relieving migraine medications with placebo in the ambulatory setting. Data collection and analysis Two reviewers screened titles and abstracts and reviewed the full text of potentially eligible studies. Two independent reviewers extracted data for studies meeting inclusion criteria. We calculated the risk ratios (RRs) and number needed to treat for an additional beneficial outcome (NNTB) for dichotomous data. We calculated the risk difference (RD) and number needed to treat for an additional harmful outcome (NNTH) for proportions of adverse events. The percentage of pain‐free patients at two hours was the primary efficacy outcome measure. We used adverse events to evaluate safety and tolerability. Secondary outcome measures included headache relief, use of rescue medication, headache recurrence, presence of nausea, and presence of vomiting. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables. Main results We identified a total of 27 randomized controlled trials (RCTs) of migraine symptom‐relieving medications, in which 9158 children and adolescents were enrolled and 7630 (range of mean age between 8.2 and 14.7 years) received medication. Twenty‐four studies focused on drugs in the triptan class, including almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, sumatriptan + naproxen sodium, and zolmitriptan. Other medications studied included paracetamol (acetaminophen), ibuprofen, and dihydroergotamine (DHE). More than half of the studies evaluated sumatriptan. All but one study reported adverse event data. Most studies presented a low or unclear risk of bias, and the overall quality of evidence, according to GRADE criteria, was low to moderate, downgraded mostly due to imprecision and inconsistency. Ibuprofen was more effective than placebo for producing pain freedom at two hours in two small studies that included 162 children (RR 1.87, 95% confidence interval (CI) 1.15 to 3.04) with low quality evidence (due to imprecision). Paracetamol was not superior to placebo in one small study of 80 children. Triptans as a class of medication were superior to placebo in producing pain freedom in 3 studies involving 273 children (RR 1.67, 95% CI 1.06 to 2.62, NNTB 13) (moderate quality evidence) and 21 studies involving 7026 adolescents (RR 1.32, 95% CI 1.19 to 1.47, NNTB 6) (moderate quality evidence). There was no significant difference in the effect sizes between studies involving children versus adolescents. Triptans were associated with an increased risk of minor (non‐serious) adverse events in adolescents (RD 0.13, 95% CI 0.08 to 0.18, NNTH 8), but studies did not report any serious adverse events. The risk of minor adverse events was not significant in children (RD 0.06, 95% CI − 0.04 to 0.17, NNTH 17). Sumatriptan plus naproxen sodium was superior to placebo in one study involving 490 adolescents (RR 3.25, 95% CI 1.78 to 5.94, NNTB 6) (moderate quality evidence). Oral dihydroergotamine was not superior to placebo in one small study involving 13 children. Authors' conclusions Low quality evidence from two small trials shows that ibuprofen appears to improve pain freedom for the acute treatment of children with migraine. We have only limited information on adverse events associated with ibuprofen in the trials included in this review. Triptans as a class are also effective at providing pain freedom in children and adolescents but are associated with higher rates of minor adverse events. Sumatriptan plus naproxen sodium is also effective in treating adolescents with migraine. Plain language summary Drugs for the acute treatment of migraine in children and adolescents Background and review question Migraine is a painful and debilitating disorder that is common in children (under 12 years of age) and adolescents (12 to 17 years of age). Common symptoms reported during a migraine attack are headache, nausea, vomiting, and sensitivity to light and sound. Many treatments for migraine are available, of which the most common are paracetamol (also known as acetaminophen), ibuprofen and other anti‐inflammatories, and triptans. Not all triptan medications are approved for use in children or adolescents, and approvals vary from country to country. Study characteristics In our review, we looked at 27 randomized controlled trials of drugs compared to placebo to find out which treatments were effective at providing pain freedom two hours after treatment. We also wanted to know what side effects might be caused by the treatments. A total of 7630 children received medication in the studies. The evidence is current to February 2016. Each study had between 13 and 888 participants. Their average age was 12.9 years and ranged from 8.2 to 14.7 years. Nineteen of the studies were funded by the drug manufacturer. Key results Ibuprofen appears to be effective in treating children with migraine, but the evidence is limited to only two small trials. Ibuprofen is readily available and inexpensive, making it an excellent first choice for migraine treatment. Paracetamol was not shown to be effective in providing pain freedom in children, but we only found one small study. Triptans are a type of medication designed specifically to treat migraine and are often effective at providing greater pain freedom in children and adolescents. The triptans examined in children included rizatriptan and sumatriptan, while almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan were examined in adolescents. The combination of sumatriptan plus naproxen sodium is also effective at treating adolescents with migraine. Overall, there is a risk that the triptan medications may cause minor unwanted side effects like taste disturbance, nasal symptoms, dizziness, fatigue, low energy, nausea, or vomiting. The studies did not report any serious side effects. Quality of the evidence The overall quality of the evidence provided by the review was moderate for the triptans, but low for paracetamol and ibuprofen, as we only identified a few studies. More studies need to look at the effects of each of the migraine treatments in children and adolescents separately.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Richer, L, Billinghurst, L, Linsdell, MA, Russell, K, Vandermeer, B, Crumley, ET, Durec, T, Klassen, TP, Hartling, L", "articleTypes": [], "doi": "10.1002/14651858.CD005220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.769Z" }, { "id": "3dab341d-bab5-418d-a5a0-865e2b67f08a", "pmid": "", "title": "Ibuprofen, a Phenylpropanoic Acid Nonsteroidal Anti-inflammatory Drug, Inhibits Human Sweet Taste and Glucose Detection", "imported": false, "abstract": "The sweet taste receptor, TAS1R2-TAS1R3, is expressed both orally, where it signals sweet taste, and extraorally in the intestine and pancreas, where it may affect glucose absorption and metabolism. Recently, ibuprofen and naproxen have been identified to inhibit human T1R3 when heterologously expressed in cells. In the present study, the initial objective was to determine if ibuprofen and naproxen inhibit interactions of sugars with human sweet taste receptor under normal, physiological conditions. Ten healthy participants were asked to rate sweetness intensity for a range of sweet stimuli (sucrose, fructose, sucralose) after a prerinse of ibuprofen, naproxen or water. Both ibuprofen and naproxen inhibited sweet taste intensity in a dose-dependent manner. In association studies, ibuprofen use has been linked to preserved metabolic function, as its use is correlated with lower rates of Alzheimer's disease, diabetes and colon cancer. Here the investigators present a potential novel pathway for systemic ibuprofen to impact these metabolic diseases.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.230Z" }, { "id": "3dbb5cdf-871b-46d6-83af-4fbda57ea02f", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high risk patients. Ulceration can lead to severe pain and difficulty eating and drinking, which may necessitate opioid analgesics, hospitalisation and nasogastric or intravenous nutrition. These complications may lead to interruptions or alterations to cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Oral cryotherapy is a low‐cost, simple intervention which is unlikely to cause side‐effects. It has shown promise in clinical trials and warrants an up‐to‐date Cochrane review to assess and summarise the international evidence. Objectives To assess the effects of oral cryotherapy for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to 17 June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) ( Cochrane Library 2015, Issue 5), MEDLINE via Ovid (1946 to 17 June 2015), EMBASE via Ovid (1980 to 17 June 2015), CANCERLIT via PubMed (1950 to 17 June 2015) and CINAHL via EBSCO (1937 to 17 June 2015). We searched the US National Institutes of Health Trials Registry, and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching databases. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of oral cryotherapy in patients with cancer receiving treatment. We used outcomes from a published core outcome set registered on the COMET website. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. We contacted study authors for information where feasible. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 14 RCTs analysing 1280 participants. The vast majority of participants did not receive radiotherapy to the head and neck, so this review primarily assesses prevention of chemotherapy‐induced oral mucositis. All studies were at high risk of bias. The following results are for the main comparison: oral cryotherapy versus control (standard care or no treatment). Adults receiving fluorouracil‐based (5FU) chemotherapy for solid cancers Oral cryotherapy probably reduces oral mucositis of any severity (RR 0.61, 95% CI 0.52 to 0.72, 5 studies, 444 analysed, moderate quality evidence). In a population where 728 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 444 (95% CI 379 to 524). The number needed to treat to benefit one additional person (NNTB), i.e. to prevent them from developing oral mucositis, is 4 people (95% CI 3 to 5). The results were similar for moderate to severe oral mucositis (RR 0.52, 95% CI 0.41 to 0.65, 5 studies, 444 analysed, moderate quality evidence). NNTB 4 (95% CI 4 to 6). Severe oral mucositis is probably reduced (RR 0.40, 95% CI 0.27 to 0.61, 5 studies, 444 analysed, moderate quality evidence). Where 300 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 120 (95% CI 81 to 183), NNTB 6 (95% CI 5 to 9). Adults receiving high‐dose melphalan‐based chemotherapy before haematopoietic stem cell transplantation (HSCT) Oral cryotherapy may reduce oral mucositis of any severity (RR 0.59, 95% CI 0.35 to 1.01, 5 studies, 270 analysed, low quality evidence). Where 824 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 486 (95% CI reduced to 289 to increased to 833). The NNTB is 3, although the uncertainty surrounding the effect estimate means that the 95% CI ranges from 2 NNTB, to 111 NNTH (number needed to treat in order to harm one additional person, i.e. for one additional person to develop oral mucositis). The results were similar for moderate to severe oral mucositis (RR 0.43, 95% CI 0.17 to 1.09, 5 studies, 270 analysed, low quality evidence). NNTB 3 (95% CI 2 NNTB to 17 NNTH). Severe oral mucositis is probably reduced (RR 0.38, 95% CI 0.20 to 0.72, 5 studies, 270 analysed, moderate quality evidence). Where 427 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 162 (95% CI 85 to 308), NNTB 4 (95% CI 3 to 9). Oral cryotherapy was shown to be safe, with very low rates of minor adverse effects, such as headaches, chills, numbness/taste disturbance, and tooth pain. This appears to contribute to the high rates of compliance seen in the included studies. There was limited or no evidence on the secondary outcomes of this review, or on patients undergoing other chemotherapies, radiotherapy, targeted therapy, or on comparisons of oral cryotherapy with other interventions or different oral cryotherapy regimens. Therefore no further robust conclusions can be made. There was also no evidence on the effects of oral cryotherapy in children undergoing cancer treatment. Authors' conclusions We are confident that oral cryotherapy leads to large reductions in oral mucositis of all severities in adults receiving 5FU for solid cancers. We are less confident in the ability of oral cryotherapy to reduce oral mucositis in adults receiving high‐dose melphalan before HSCT. Evidence suggests that it does reduce oral mucositis in these adults, but we are less certain about the size of the reduction, which could be large or small. However, we are confident that there is an appreciable reduction in severe oral mucositis in these adults. This Cochrane review includes some very recent and currently unpublished data, and strengthens international guideline statements for adults receiving the above cancer treatments. Plain language summary Can keeping the mouth cold during cancer treatment help to prevent mouth soreness and ulcers in children and adults? Review question This review has been produced to assess whether or not keeping the mouth cold during cancer treatment, by using ice, ice‐cold water, ice cream or ice lollies/popsicles, can help prevent mouth soreness and ulcers in children and adults. Background People receiving treatment for cancer are at risk of developing a sore mouth and ulcers as a side effect. This side effect is called oral mucositis and affects over 75% of high‐risk patients (those receiving radiotherapy to the head and neck or high‐dose chemotherapy). The pain caused by this condition can be severe and can stop the person's ability to eat and drink, which may mean they need to take strong pain killers, stay in hospital and be fed through a tube into their stomach, or even into their veins. This in turn can lead to disruption to their cancer treatment, meaning they are not receiving the best possible treatment. The results may be a reduction in the patient's chances of survival, and increased costs to the healthcare system. Cancer patients have weakened immune systems due to their treatment, meaning that their bodies are less able to fight infections. This can be a problem if bacteria enter the body through the ulcer, which is an open wound. This can lead to sepsis (a dangerous inflammatory reaction of the body to infection), which requires antibiotics and hospitalisation, and can cause death. Oral cryotherapy is the cooling of the mouth using ice, ice‐cold water, ice cream or ice lollies/popsicles. It is thought to help prevent oral mucositis in people receiving certain types of chemotherapy because the coldness makes the blood vessels in the mouth more narrow, and this reduces the amount of blood containing chemotherapy drugs from reaching the mouth and causing oral mucositis. It is a low‐cost, natural treatment without serious side effects. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 17 June 2015. It includes 14 studies published from 1991 to 2015 in which 1316 participants were randomised (1280 of whom were included in the analyses) to receive oral cryotherapy versus standard care (usually saline mouthrinses) or no treatment or a different treatment or a different method of oral cryotherapy, and the number of people developing oral mucositis of different severities was compared. Nearly all the evidence was on adults receiving oral cryotherapy versus standard care or no treatment. This evidence fell into two main groups: 1) adults receiving fluorouracil‐based (5FU) treatment for solid cancers; or 2) adults receiving high‐dose melphalan‐based cancer treatment before haematopoietic stem cell transplantation (HSCT). HSCT is given to help the body to produce all types of blood cells, which are destroyed during cancer treatment. Key results There is evidence showing that oral cryotherapy can lead to large reductions in the numbers of adults who get oral mucositis of all severities after receiving 5FU‐based treatment for solid cancers. There is less certain evidence to suggest that oral cryotherapy may reduce the numbers of adults who get oral mucositis after receiving high‐dose melphalan‐based cancer treatment prior to HSCT. The evidence suggests that it does reduce oral mucositis in these adults, but the size of the reduction is much less certain. However, there is more certain evidence that there is a large reduction in severe oral mucositis in these adults. Oral cryotherapy did not cause any serious side effects in any of the participants of these studies, and most people seemed able to carry it out properly and complete it. Quality of the evidence The evidence presented, on the main outcome of whether or not people developed oral mucositis of all severities, is of moderate (because the nature of the oral cryotherapy treatment meant that the studies could not be 'blinded' which is a desirable characteristic of these studies) to low quality (because in addition to the above problem, the results of the individual studies were too different to give a precise result when they were combined).", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P, Glenny, AM, Worthington, HV, Littlewood, A, Clarkson, JE, McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011552.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.084Z" }, { "id": "3dfc3d05-5978-4138-b1db-440a0ab9e996", "pmid": "", "title": "Treatment of periodontitis for glycaemic control in people with diabetes mellitus", "imported": false, "abstract": "Abstract - Background Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontitis. Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus, and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement, or non‐surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe. This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care. Objectives To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis. Search methods An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. Selection criteria We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment or adjunctive antimicrobial therapy or both) to no active intervention or 'usual care' (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least 3 months and have measured HbA1c (glycated haemoglobin). Data collection and analysis At least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials, and assessed included trials for risk of bias. Where necessary and possible, we attempted to contact study authors. Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol). Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index, and probing pocket depth), quality of life, cost implications, and diabetic complications. Main results We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel‐RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 diabetes, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair, or poor. Most studies were carried out in secondary care. We assessed two studies as being at low risk of bias, 14 studies at high risk of bias, and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings. Moderate‐certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) ‐0.59% to ‐0.28%; ‐6.4 mmol/mol to ‐3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI ‐0.52% to ‐0.08%; ‐5.7 mmol/mol to ‐0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI ‐0.55% to ‐0.45%; ‐6.0 mmol/mol to ‐4.9 mmol/mol; 1 study, 264 participants). Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, adverse effects of periodontal treatments were not evaluated in most studies. Authors' conclusions Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate‐certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in this review. Plain language summary Does treatment for gum disease help people with diabetes control blood sugar levels? Review question The main question addressed by this review is: how effective is gum disease (periodontitis) treatment for controlling blood sugar levels (known as glycaemic control) in people with diabetes, compared to no active treatment or usual care? Background The aim of treating periodontitis is to reduce swelling and infection and stabilise the condition of the gums and supporting bone. The level of sugar in the blood is too high in people with diabetes, so keeping blood sugar levels under control is a key issue. Some clinical research suggests a relationship exists between gum disease treatment and glycaemic control. Glycaemic control can be measured in different ways. For this review, we focused on HbA1c, which shows average blood glucose levels over the preceding 3 months. It can be reported as a percentage (of total haemoglobin) or as mmol/mol (millimoles per mole). Excellent glycaemic control in a diabetic person might be around 6.5% or 48 mmol/mol. This review was carried out by authors working with the Cochrane Oral Health and is part one of an update of a review previously published in 2010 and 2015. This review evaluates gum disease treatment versus no active treatment or usual care. Part two of the review will compare different types of periodontal treatment. We carried out this review as it is important to discover if gum disease treatment does improve glycaemic control in order to ensure best use of clinical resources. Study characteristics We searched six research databases and found 35 relevant trials where people with diabetes and periodontitis were randomly allocated to an experimental group or a control group. The experimental groups received gum disease treatment called 'subgingival instrumentation', also known as scaling and root planing or deep cleaning. In some experimental groups, the deep cleaning was supplemented with instructions for cleaning teeth properly ('oral hygiene instruction'), or other gum treatments, for example, antimicrobials, which are used to treat infections. Control groups received no active treatment or 'usual care', which was oral hygiene instruction, support with oral hygiene, and/or removal of plaque above the gumline. The trials randomised 3249 participants in total. Almost all participants had type 2 diabetes, with a mix of good, fair, and poor diabetic control. Most of the studies were carried out in hospitals. The studies followed up participants for between 3 and 12 months. Key results Evidence from 30 trials (results from 2443 participants) showed that periodontitis treatment reduces blood sugar levels (measured by HbA1c) in diabetic patients on average by 0.43 percentage points (e.g. from 7.43% to 7%; 4.7 mmol/mol) 3 to 4 months after receiving the treatment compared with no active treatment or usual care. A difference of 0.30% (3.3 mmol/mol) was seen after 6 months (12 studies), and 0.50% (5.4 mmol/mol) at 12 months (one study). There were not enough studies measuring side effects to be able to evaluate the risk of harm from gum disease treatments. Certainty of the evidence Most of the studies were conducted in a way that meant they were at a high risk of bias or did not provide enough information for us to make a judgement on this. However, the consistency of our findings suggests they are reliable and future research is not likely to change them. In summary, currently there is moderate‐certainty evidence to support gum disease treatment (known as subgingival instrumentation) for controlling blood sugar levels in people with periodontitis (gum disease) and diabetes up to 12 months after the start of the periodontal treatment. Date of the search The evidence is current up to 7 September 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Simpson, TC; Clarkson, JE; Worthington, HV; MacDonald, L; Weldon, JC; Needleman, I; Iheozor-Ejiofor, Z; Wild, SH; Qureshi, A; Walker, A; Patel, VA; Boyers, D; Twigg, J", "articleTypes": [], "doi": "10.1002/14651858.CD004714.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "3e042f6b-11a0-46f9-8ce1-27e33c57847e", "pmid": "", "title": "Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery", "imported": false, "abstract": "Abstract - Background Postoperative pain may lead to adverse effects on the body, which might result in an increase in morbidity. Its management therefore poses a unique challenge for the clinician. Major shoulder surgery is associated with severe postoperative pain, and different modalities are available to manage such pain, including opioid and non‐opioid analgesics, local anaesthetics infiltrated into and around the shoulder joint and regional anaesthesia. All of these techniques, alone or in combination, have been used to treat the postoperative pain of major shoulder surgery but with varying success. Objectives The objective of this review was to compare the analgesic efficacy of continuous interscalene brachial plexus block (ISBPB) with parenteral opioid analgesia for pain relief after major shoulder surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12), MEDLINE (1950 to December 2012), EMBASE (1980 to December 2012), Web of Science (1954 to December 2012), CINAHL (1982 to December 2012) and bibliographies of published studies. Selection criteria We included randomized controlled trials assessing the effectiveness of continuous ISBPB compared with different forms of parenteral opioid analgesia in relieving pain in adult participants undergoing elective major shoulder surgery. Data collection and analysis Two review authors independently assessed trial quality and extracted outcome data. Main results We included two randomized controlled trials (147 participants). A total of 17 participants were excluded from one trial because of complications related to continuous ISBPB (16) or parenteral opioid analgesia (one). Thus we have information on 130 participants (66 in the continuous ISBPB group and 64 in the parenteral opioid group). The studies were clinically heterogeneous. No meta‐analysis was undertaken. However, results of the two included studies showed better pain relief with continuous ISBPB following major shoulder surgery and a lower incidence of complications when interscalene block is performed under ultrasound guidance rather than without it. Authors' conclusions Because of the small number of studies (two) relevant to the subject and the high risk of bias of the selected studies, no reasonable conclusion can be drawn. Plain language summary Comparison of an upper limb nerve block using local anaesthetic with opioid analgesia for pain relief following major shoulder surgery Pain following surgical procedures can sometimes increase the incidence of complications in the body. It is important to manage this pain effectively. Major shoulder surgery can cause severe pain. Effectively treating this pain will help reduce complications and will promote early mobilization. A wide range of methods are used to treat pain after major shoulder surgery, including administration of opioid (derived from opium) and non‐opioid pain killers and administration of drugs that produce numbness and hence pain relief in and around the shoulder joint or around the nerves supplying the upper limb. We compared the usefulness of a continuous upper limb nerve block performed by injecting local anaesthetic into the neck close to where the nerves originate (interscalene brachial plexus block—ISBPB group) with the administration of opioid pain killers into a vein, into a muscle or under the skin (any route other than by mouth)—the parenteral opioid group. Evidence obtained is current to December 2012. We included two studies involving 147 participants. Seventeen participants were excluded (16 from the ISBPB group and one from the other), leaving 130 participants: 66 in the ISBPB group and 64 in the parenteral opioid group. The studies were of medium to low quality because of issues with study design, and one of the trials was sponsored by a drug company. The severity of pain was assessed by the patient using a numerical scale on which zero was considered as no pain and 10 or 100 as the worst imaginable pain for 72 hours in one study and 48 hours in the other. The severity of postoperative pain was significantly less for the ISBPB group at all time points in one study and at all but one time point in the other study. No concrete conclusions can be drawn because of the small number of studies, which were not of high quality. However, from the available evidence, it can be seen that in one of the trials, the requirement for additional painkiller (piritramide) was significantly higher in the parenteral opioid group, whereas the other trial did not mention this. The incidence of nausea and vomiting was significantly less in the ISBPB group when compared with the parenteral opioid group. Complications related to ISBPB were virtually eliminated when ultrasound was used to perform ISBPB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ullah, H, Samad, K, Khan, FA", "articleTypes": [], "doi": "10.1002/14651858.CD007080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.756Z" }, { "id": "3e098fb4-3a6a-4213-b46c-2dc99c0f48d5", "pmid": "", "title": "Rituximab for people with multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Filippini, G, Kruja, J, Del Giovane, C", "articleTypes": [], "doi": "10.1002/14651858.CD013874.pub3 AB - Abstract - Background Multiple sclerosis (MS) is the most common neurological cause of disability in young adults. Off‐label rituximab for MS is used in most countries surveyed by the International Federation of MS, including high‐income countries where on‐label disease‐modifying treatments (DMTs) are available. This updates the 2021 version of the review. Objectives To assess the benefits and harms of rituximab as 'first choice' and 'switching' treatment for adults with any form of MS. Search methods We searched CENTRAL , MEDLINE, Embase, CINAHL, and three trials registers on 31 December 2023, together with reference checking and contacting study authors to identify unpublished studies. Selection criteria We included randomised controlled trials (RCTs) and controlled non‐randomised studies of interventions (NRSIs) comparing rituximab with placebo or another DMT for adults with any form of MS. Data collection and analysis We followed standard Cochrane methods. We used RoB 1 to assess risk of bias in RCTs and ROBINS‐I in NRSIs. We assessed the certainty of evidence for critical and important prioritised outcomes using GRADE: disability worsening, relapse, serious adverse events (SAEs), health‐related quality of life (HRQoL), common infections, cancer, and mortality. We conducted separate analyses for rituximab as 'first choice' or as 'switching' treatment, relapsing or progressive MS, comparison with placebo or another DMT, and RCTs or NRSIs. Main results In this update, the number of study participants increased from 16,429 (15 studies) to 37,443 (28 studies; 13 new studies: 1 RCT and 12 NRSIs). The studies were conducted worldwide; most originated from high‐income countries (25 studies). Public institutions funded 22 (79%) of the studies. Most studies investigated the effects of rituximab on people with relapsing MS (19 studies; 27,500 (73%) participants). We identified 12 ongoing studies. Rituximab as 'first choice' for active relapsing MS None of the included studies compared rituximab to placebo. One RCT compared rituximab to dimethyl fumarate, with 24 months' follow‐up. Rituximab may reduce the recurrence of relapse (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.04 to 0.57; 195 participants; low‐certainty evidence). The evidence is very uncertain on disability worsening and SAEs. Rituximab may result in little to no difference in upper respiratory tract infections (rate ratio (RR) 1.03, 95% CI 0.79 to 1.34; low‐certainty evidence). The evidence is very uncertain for urinary tract, skin, and viral infections. HRQoL, cancer, and mortality were not reported. One NRSI compared rituximab to other DMTs, with 24 months' follow‐up. Disability worsening was not reported. Compared with interferon beta or glatiramer acetate, rituximab likely delays relapse (hazard ratio (HR) 0.14, 95% CI 0.05 to 0.39; 1 study, 335 participants; moderate‐certainty evidence). Compared with dimethyl fumarate and natalizumab, rituximab may delay relapse (dimethyl fumarate: HR 0.29, 95% CI 0.08 to 1.00; 1 study, 206 participants; low‐certainty evidence; natalizumab: HR 0.24, 95% CI 0.06 to 1.00; 1 study, 170 participants; low‐certainty evidence). The evidence for relapse is very uncertain when comparing rituximab to fingolimod. The effect on SAEs is uncertain due to very few events in all the comparison groups. No deaths were reported. HRQoL, common infections, and cancer were not reported. Rituximab as 'first choice' for primary progressive MS One RCT compared rituximab to placebo, with 24 months' follow‐up. Rituximab likely results in little or no difference in disability worsening (OR 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate‐certainty evidence). The evidence is very uncertain on relapse, SAEs, common infections, cancer, and mortality. HRQoL was not reported. None of the included studies compared rituximab as 'first choice' treatment to other DMTs for primary or secondary progressive MS. Rituximab as 'switching' treatment for relapsing MS One small RCT compared rituximab to placebo, with 12 months' follow‐up. Disability worsening was not reported. Rituximab may reduce recurrence of relapses (OR 0.38, 95% CI 0.16 to 0.93; 1 study, 104 participants; low‐certainty evidence). The evidence is very uncertain regarding SAEs, common infections, cancer, and mortality. HRQoL was not reported. Twelve NRSIs compared rituximab to other DMTs, with 24 months' follow‐up. The evidence on disability worsening is very uncertain in comparison with interferons or glatiramer acetate, natalizumab, alemtuzumab, and ocrelizumab. Rituximab likely delays time to relapse in comparison with interferons or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 study, 1383 participants; moderate‐certainty evidence), fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 study, 256 participants; moderate‐certainty evidence), and may result in little or no difference compared with natalizumab (HR 0.96, 95% CI 0.83 to 1.10; 3 studies, 1922 participants; low‐certainty evidence). The evidence is very uncertain on relapse in comparison with alemtuzumab. There is uncertainty regarding SAEs when comparing rituximab to natalizumab and fingolimod. Rituximab likely increases serious common infections when compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 study, 5477 participants; moderate‐certainty evidence) and natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 studies, 5001 participants; moderate‐certainty evidence). The evidence for common infections is very uncertain when comparing rituximab to fingolimod and ocrelizumab. Rituximab may slightly reduce the risk of cancer compared with natalizumab (HR 0.79, 95% CI 0.62 to 0.99; 2 studies, 6202 participants; low‐certainty evidence), whereas the evidence is very uncertain in comparison with fingolimod. The effect of rituximab on mortality is very uncertain due to very few events in all the comparison groups. HRQoL was not reported. Authors' conclusions For preventing relapses in relapsing MS, rituximab as 'first choice' and 'switching' treatment compares favourably with a wide range of approved DMTs. The protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab on primary progressive MS. There is limited evidence for long‐term adverse events of rituximab in people with MS. Evidence for serious adverse events, cancer, and mortality was of very low certainty due to few events. There is an increased risk of serious (hospital‐treated) infections with rituximab compared with other DMTs, although the absolute risk is low. High‐quality (prospectively registered) NRSIs should be conducted to draw more reliable conclusions about the potential benefits and harms of rituximab in people with MS. Plain language summary Is rituximab better for people with multiple sclerosis than other disease‐modifying medicines? Key messages • We are uncertain whether rituximab prevents disability worsening in people with any form of multiple sclerosis (MS). 
• Rituximab may offer moderate‐to‐large benefit against a range of other medicines in preventing relapses in relapsing MS, both in people treated with rituximab for the first time and in those given rituximab after other medicines failed to work or became unsuitable.
• Very few people given rituximab in the studies had serious unwanted/harmful events, developed cancer, or died over 24 months' follow‐up. What is multiple sclerosis (MS)? MS is a disease affecting the central nervous system, in which the body’s immune system mistakenly attacks the protective covering of nerve fibres, which leads to inflammation and damage. Communication between the brain and the rest of the body is affected, resulting in a wide range of symptoms. There are two main types: (1) relapsing MS, where someone has periods of relapse (worsening of symptoms) followed by remissions (improvement or complete recovery); and (2) progressive MS, where symptoms worsen over time, without distinct periods of improvement. Relapsing MS is more common. How is MS treated? There is no cure for MS, so the goal of treatment is to manage symptoms, reduce disease activity, slow progression, and improve quality of life. This involves giving people with MS disease‐modifying treatments (DMTs), in contrast to treatments which only manage symptoms. There are different kinds of disease‐modifying treatments for MS, including rituximab. Rituximab is: • a medicine given slowly via a needle in a vein (intravenous infusion) that can suppress certain immune cells;
• included in the World Health Organization (WHO) Model List of Essential Medicines for MS, which makes rituximab available worldwide. Rituximab is not always reimbursed by health systems because it is not licensed for MS by marketing authorities;
• a highly effective treatment. It's cheaper and is given less often than other approved medicines for MS. Treatment with rituximab requires specialist care and infusion facilities, but other approved medicines do too. What did we want to find out? We wanted to find out the effects of rituximab on people with any form of MS on: • disability worsening, relapse, and quality of life;
• unwanted effects, such as serious harmful effects, serious common infections, cancer, and death. What did we do? We searched for studies that compared rituximab with other infused medicines (e.g. natalizumab), injectable medicines (e.g. interferon beta, glatiramer acetate), and oral medicines (e.g. fingolimod, dimethyl fumarate). We compared and summarised the results of the included studies, and rated our confidence in the evidence, based on factors such as study methods and quality. What did we find? We found 28 studies that involved 37,443 people with MS and lasted one or two years. The biggest study involved 8600 people and the smallest, 27 people. Most people (27,500, 73% of all participants) had a relapsing form of MS, while only 813 (2%) had a progressive form. Three studies included 9130 (24%) people with all forms of MS. Most studies originated from high‐income countries. Public institutions funded 22 (79%) of the studies. MAIN RESULTS Relapsing forms of MS • We do not know if rituximab has an effect on long‐term disability worsening due to the short follow‐up period of the studies.
• For people treated with rituximab for the first time as well as those given rituximab after other medicines failed to work or became unsuitable, rituximab may reduce the risk of relapses compared with interferon beta or glatiramer acetate, dimethyl fumarate, fingolimod, and natalizumab (evidence from 16 studies). 
• Serious unwanted effects of rituximab are very few. However, we do not know if rituximab has an effect on long‐term serious unwanted effects due to the short follow‐up period of the studies.
• Rituximab likely increases serious common infections (i.e. hospital‐treated infections) compared with other approved medicines for MS. However, the likelihood of serious common infections occurring is low in terms of the total number of people being considered. Progressive forms of MS We do not know if rituximab has benefits for people with primary progressive MS. What are the main limitations of the evidence? Our confidence in the evidence is limited because of three main factors. First, people were not randomly placed into different treatment groups in most of the studies. This means that differences between the groups could be due to differences between participants rather than between the comparison treatments. Second, we found few studies in which participants were assigned randomly to different treatment groups. These studies were small and used methods likely to introduce errors in their results. Third, results originated from short‐term studies. This is an important issue for people with a lifelong disease such as MS, who need to know the long‐term benefits and unwanted effects of a medicine. How current is the evidence? This review updates our previous review. The evidence is current to 31 December 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.795Z" }, { "id": "3e2a6897-cb91-4052-ae41-76dd38b25266", "pmid": "", "title": "Antioxidant supplementation for lung disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Airway infection leads to progressive damage of the lungs in cystic fibrosis (CF) and oxidative stress has been implicated in the etiology. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, beta‐carotene and selenium) or N‐acetylcysteine (NAC) as a source of glutathione, may therefore potentially help maintain an oxidant‐antioxidant balance. Glutathione or NAC can also be inhaled and if administered in this way can also have a mucolytic effect besides the antioxidant effect. Current literature suggests a relationship between oxidative status and lung function. This is an update of a previously published review. Objectives To synthesise existing knowledge on the effect of antioxidants such as vitamin C, vitamin E, beta‐carotene, selenium and glutathione (or NAC as precursor of glutathione) on lung function through inflammatory and oxidative stress markers in people with CF. Search methods The Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and PubMed were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies. We also searched online trials registries. Last search of Cystic Fibrosis Trials Register: 08 January 2019. Selection criteria Randomised and quasi‐randomised controlled studies comparing antioxidants as listed above (individually or in combination) in more than a single administration to placebo or standard care in people with CF. Data collection and analysis Two authors independently selected studies, extracted data and assessed the risk of bias in the included studies. We contacted study investigators to obtain missing information. If meta‐analysed, studies were subgrouped according to supplement, method of administration and the duration of supplementation. We assessed the quality of the evidence using GRADE. Main results One quasi‐randomised and 19 randomised controlled studies (924 children and adults) were included; 16 studies (n = 639) analysed oral antioxidant supplementation and four analysed inhaled supplements (n = 285). Only one of the 20 included studies was judged to be free of bias. Oral supplements versus control The change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted at three months and six months was only reported for the comparison of NAC to control. Four studies (125 participants) reported at three months; we are uncertain whether NAC improved FEV 1 % predicted as the quality of the evidence was very low, mean difference (MD) 2.83% (95% confidence interval (CI) ‐2.16 to 7.83). However, at six months two studies (109 participants) showed that NAC probably increased FEV 1 % predicted from baseline (moderate‐quality evidence), MD 4.38% (95% CI 0.89 to 7.87). A study of a combined vitamin and selenium supplement (46 participants) reported a greater change from baseline in FEV 1 % predicted in the control group at two months, MD ‐4.30% (95% CI ‐5.64 to ‐2.96). One study (61 participants) found that NAC probably makes little or no difference in the change from baseline in quality of life (QoL) at six months (moderate‐quality evidence), standardised mean difference (SMD) ‐0.03 (95% CI ‐0.53 to 0.47), but the two‐month combined vitamin and selenium study reported a small difference in QoL in favour of the control group, SMD ‐0.66 (95% CI ‐1.26 to ‐0.07). The NAC study reported on the change from baseline in body mass index (BMI) (62 participants) and similarly found that NAC probably made no difference between groups (moderate‐quality evidence). One study (69 participants) found that a mixed vitamin and mineral supplement may lead to a slightly lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) provided information on adverse events, but did not find any clear and consistent evidence of differences between treatment or control groups with the quality of the evidence ranging from low to moderate. Studies of β‐carotene and vitamin E consistently reported greater plasma levels of the respective antioxidants. Inhaled supplements versus control Two studies (258 participants) showed inhaled glutathione probably improves FEV 1 % predicted at three months, MD 3.50% (95% CI 1.38 to 5.62), but not at six months compared to placebo, MD 2.30% (95% CI ‐0.12 to 4.71) (moderate‐quality evidence). The same studies additionally reported an improvement in FEV 1 L in the treated group compared to placebo at both three and six months. One study (153 participants) reported inhaled glutathione probably made little or no difference to the change in QoL from baseline, MD 0.80 (95% CI ‐1.63 to 3.23) (moderate‐quality evidence). No study reported on the change from baseline in BMI at six months, but one study (16 participants) reported at two months and a further study (105 participants) at 12 months; neither study found any difference at either time point. One study (153 participants) reported no difference in the time to the first pulmonary exacerbation at six months. Two studies (223 participants) reported treatment may make little or no difference in adverse events (low‐quality evidence), a further study (153 participants) reported that the number of serious adverse events were similar across groups. Authors' conclusions With regards to micronutrients, there does not appear to be a positive treatment effect of antioxidant micronutrients on clinical end‐points; however, oral supplementation with glutathione showed some benefit to lung function and nutritional status. Based on the available evidence, inhaled and oral glutathione appear to improve lung function, while oral administration decreases oxidative stress; however, due to the very intensive antibiotic treatment and other concurrent treatments that people with CF take, the beneficial effect of antioxidants remains difficult to assess in those with chronic infection without a very large population sample and a long‐term study period. Further studies, especially in very young children, using outcome measures such as lung clearance index and the bronchiectasis scores derived from chest scans, with improved focus on study design variables (such as dose levels and timing), and elucidating clear biological pathways by which oxidative stress is involved in CF, are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn. The benefit of antioxidants in people with CF who receive CFTR modulators therapies should also be assessed in the future. Plain language summary How do vitamins E and C, beta‐carotene, selenium and glutathione affect lung disease in people with cystic fibrosis? Background Frequent chest infections cause long‐term lung inflammation; inflammation‐causing cells produce an oxygen molecule (reactive oxygen species (ROS)), which may harm body tissue (oxidative damage); the body uses antioxidants to protect itself. People with cystic fibrosis (CF) have high levels of ROS compared to low levels of antioxidants. Antioxidant supplements might reduce oxidative damage and build up levels of antioxidants. Given difficulties in absorbing fat, people with CF have low levels of fat‐soluble antioxidants (vitamin E and beta‐carotene). Water‐soluble vitamin C decreases with age in people with CF. Glutathione, one of the most abundant antioxidants in cells, is not released properly into the lungs of people with CF. Some enzymes that help antioxidants work depend on the mineral selenium, so selenium supplements aim to stimulate antioxidant action. Most supplements are swallowed, but glutathione and N‐acetylcysteine (NAC) (which the body uses to make glutathione) can also be inhaled; these may affect lung function as antioxidants, but also due to thinning mucus when inhaled (allowing easier mucus clearance). Search date Last search for this updated review: 08 January 2019. Study characteristics We included 20 studies (924 people with CF, almost equal gender split, aged six months to 59 years); 16 studies compared oral supplements to placebo ('dummy' treatment) and four compared inhaled supplements to placebo. Key results Oral supplements We are uncertain whether NAC changes lung function (forced expiratory volume in one second (FEV 1 ) % predicted) at three months (four studies, 125 participants, very low‐quality evidence), but at six months two studies (109 participants) reported NAC probably improved FEV 1 % predicted (moderate‐quality evidence). One study (46 participants) reported a greater change in FEV 1 % predicted with placebo than with a combined vitamin and selenium supplement after two months. One study (61 participants) reported little or no difference in quality of life (QoL) scores between NAC and control after six months (moderate‐quality evidence), but the two‐month combined vitamin and selenium study reported slightly better QoL scores in the control group. NAC probably made no difference to body mass index (BMI) (one study, 62 participants, moderate‐quality evidence). One study (69 participants) reported that a mixed vitamin and mineral supplement may lead to a lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) did not find any clear and consistent differences in side effects between groups (evidence ranged from low to moderate quality). Vitamin E and β‐carotene studies consistently reported greater levels of these antioxidants in blood samples. Inhaled supplements In two studies (258 participants), inhaled glutathione probably improved FEV 1 % predicted compared to placebo at three months but not at six months (moderate‐quality evidence); these studies also reported a greater improvement in FEV 1 litres with glutathione compared to placebo at both time points. Two studies (258 participants) found little or no difference in the change in QoL scores (moderate‐quality evidence). One two‐month study (16 participants) and a 12‐month study (105 participants) reported no difference between groups in the change in BMI. There was no difference in the time to the first pulmonary exacerbation in one six‐month study. Two studies (223 participants) reported no difference between groups in side effects (low‐quality evidence) and another study (153 participants) reported that the number of serious side effects were similar across groups. Conclusions Vitamin and mineral supplements do not seem to improve clinical outcomes. Inhaled glutathione appears to improve lung function, while oral administration lowers oxidative stress, with benefits to lung function and nutritional measures. Intensive antibiotic and other concurrent treatments for people with CF and chronic infection mean it is difficult to assess the effect of antioxidants without a very large and long study. Future research should look at how antioxidants affect people with CF taking CFTR modulator therapies. Quality of the evidence Evidence ranged from very low to moderate quality. All but one study had some bias; mostly because data were not fully reported (likely to affect our results). We were also largely unsure if participants knew which treatment they received, both in advance and once the studies started (unsure how this might affect our results).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ciofu, O, Smith, S, Lykkesfeldt, J", "articleTypes": [], "doi": "10.1002/14651858.CD007020.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.742Z" }, { "id": "3e2d381b-5189-45ed-858a-c3277065560b", "pmid": "", "title": "Interventions for the cessation of non‐nutritive sucking habits in children", "imported": false, "abstract": "Abstract - Background Comforting behaviours, such as the use of pacifiers (dummies, soothers), blankets and finger or thumb sucking, are common in babies and young children. These comforting habits, which can be referred to collectively as 'non‐nutritive sucking habits' (NNSHs), tend to stop as children get older, under their own impetus or with support from parents and carers. However, if the habit continues whilst the permanent dentition is becoming established, it can contribute to, or cause, development of a malocclusion (abnormal bite). A diverse variety of approaches has been used to help children with stopping a NNSH. These include advice, removal of the comforting object, fitting an orthodontic appliance to interfere with the habit, application of an aversive taste to the digit or behaviour modification techniques. Some of these interventions are easier to apply than others and less disturbing for the child and their parent; some are more applicable to a particular type of habit. Objectives The primary objective of the review was to evaluate the effects of different interventions for cessation of NNSHs in children. The secondary objectives were to determine which interventions work most quickly and are the most effective in terms of child and parent‐ or carer‐centred outcomes of least discomfort and psychological distress from the intervention, as well as the dental measures of malocclusion (reduction in anterior open bite, overjet and correction of posterior crossbite) and cost‐effectiveness. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 8 October 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 9), MEDLINE via OVID (1946 to 8 October 2014), EMBASE via OVID (1980 to 8 October 2014), PsycINFO via OVID (1980 to 8 October 2014) and CINAHL via EBSCO (1937 to 8 October 2014), the US National Institutes of Health Trials Register (Clinical Trials.gov) (to 8 October 2014) and the WHO International Clinical Trials Registry Platform (to 8 October 2014). There were no restrictions regarding language or date of publication in the searches of the electronic databases. We screened reference lists from relevant articles and contacted authors of eligible studies for further information where necessary. Selection criteria Randomised or quasi‐randomised controlled trials in children with a non‐nutritive sucking habit that compared one intervention with another intervention or a no‐intervention control group. The primary outcome of interest was cessation of the habit. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Three review authors were involved in screening the records identified; two undertook data extraction, two assessed risk of bias and two assessed overall quality of the evidence base. Most of the data could not be combined and only one meta‐analysis could be carried out. Main results We included six trials, which recruited 252 children (aged 2 and a half to 18 years), but presented follow‐up data on only 246 children. Digit sucking was the only NNSH assessed in the studies. Five studies compared single or multiple interventions with a no‐intervention or waiting list control group and one study made a head‐to‐head comparison. All the studies were at high risk of bias due to major limitations in methodology and reporting. There were small numbers of participants in the studies (20 to 38 participants per study) and follow‐up times ranged from 1 to 36 months. Short‐term outcomes were observed under one year post‐intervention and long‐term outcomes were observed at one year or more post‐intervention. Orthodontics appliance (with or without psychological intervention) versus no treatment Two trials that assessed this comparison evaluated our primary outcome of cessation of habit. One of the trials evaluated palatal crib and one used a mix of palatal cribs and arches. Both trials were at high risk of bias. The orthodontic appliance was more likely to stop digit sucking than no treatment, whether it was used over the short term (risk ratio (RR) 6.53, 95% confidence interval (CI) 1.67 to 25.53; 2 trials, 70 participants) or long term (RR 5.81, 95% CI 1.49 to 22.66; 1 trial, 37 participants) or used in combination with a psychological intervention (RR 6.36, 95% CI 0.97 to 41.96; 1 trial, 32 participants). Psychological intervention versus no treatment Two trials (78 participants) at high risk of bias evaluated positive reinforcement (alone or in combination with gaining the child's co‐operation) or negative reinforcement compared with no treatment. Pooling of data showed a statistically significant difference in favour of the psychological interventions in the short term (RR 6.16, 95% CI 1.18 to 32.10; I 2 = 0%). One study, with data from 57 participants, reported on the long‐term effect of positive and negative reinforcement on sucking cessation and found a statistically significant difference in favour of the psychological interventions (RR 6.25, 95% CI 1.65 to 23.65). Head‐to‐head comparisons Only one trial demonstrated a clear difference in effectiveness between different active interventions. This trial, which had only 22 participants, found a higher likelihood of cessation of habit with palatal crib than palatal arch (RR 0.13, 95% CI 0.03 to 0.59). Authors' conclusions This review found low‐quality evidence that orthodontic appliances (palatal arch and palatal crib) and psychological interventions (including positive and negative reinforcement) are effective at improving sucking cessation in children. There is very low‐quality evidence that palatal crib is more effective than palatal arch. This review has highlighted the need for high‐quality trials evaluating interventions to stop non‐nutritive sucking habits to be conducted and the need for a consolidated, standardised approach to reporting outcomes in these trials. Plain language summary Interventions for stopping dummy or finger or thumb sucking habits in children Review question This review has been produced to assess the effects of interventions to stop sucking habits in children, which are not linked to food. Important considerations are: which treatment or combination of treatments work most effectively, when should treatment be started, what is the optimum length of time for the intervention and what causes least upset to children and their parents? Background Often babies and children develop a habit of sucking objects to comfort and calm them. They frequently suck dummies (known as pacifiers in the USA), fingers, thumbs or other items like blankets. Eventually, most children grow out of the habit, or stop due to encouragement from their parents. Some children, however, continue sucking as a habit. If they continue to do so as their adult teeth start to grow through (around the age of six), there is a risk that these adult teeth will grow into the wrong position causing them to stick out too far or not meet properly when biting. As a result these children often need dental treatment to fix the problems caused by their sucking habit. Possible treatments to help children break their sucking habits examined in studies in this review include the use of two different braces in the mouth; giving advice and incentives for changing behaviour (known as psychological advice/treatment); applying a bitter, nasty tasting substance to the children’s thumbs/fingers or combinations of these treatments. None of the studies included looked at barrier methods, for example the use of gloves or plasters or withdrawal of dummies. Study characteristics Review authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 8 October 2014. The review includes six studies published from 1967 to 1997, which involved 252 children as participants (although data were supplied on only 246 of the children). Three of the studies were carried out in the USA, one in Canada, one in Sweden and one in Australia. Not all of the studies gave the ages of children involved; in four of the studies children were aged from two and a half to 18 years old, in one study they were aged four years and over and in another nine years and over. Results Use of an orthodontic brace (such as a palatal crib or arch) or a psychological intervention (such as use of positive or negative reinforcement), or both, was more likely to lead to cessation of the habit than no treatment. Most of the trials that compared two different interventions were inconclusive but one study suggested that, of two different types of braces,a palatal crib is more effective than a palatal arch design. Quality of the evidence The evidence presented is of low quality due to the small number of participants in the few available studies and problems with the way in which the studies were conducted. There was a high risk of bias across the studies. Conclusion Orthodontic braces or psychological intervention seems to be effective to help children stop sucking that does not have a feeding purpose but the evidence is low quality. Further high quality clinical trials are required to guide decision making for what is a common problem that can require lengthy and expensive dental treatment to correct.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Borrie, FRP, Bearn, DR, Innes, NPT, Iheozor-Ejiofor, Z", "articleTypes": [], "doi": "10.1002/14651858.CD008694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.065Z" }, { "id": "3e2e9bb3-2ef5-42a6-89f6-ece2649f6dbe", "pmid": "", "title": "Interventions to prevent obesity in children aged 12 to 18 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or ‘activity’ levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review. Objectives To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta‐analyses. Sixty studies were based in high‐income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty‐one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short‐term follow‐up (mean difference (MD) ‐0.18, 95% confidence interval (CI) ‐0.41 to 0.06; 3 studies, 605 participants), medium‐term follow‐up (MD ‐0.65, 95% CI ‐1.18 to ‐0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long‐term follow‐up (MD ‐0.14, 95% CI ‐0.38 to 0.10; 2 studies, 1089 participants); all very low‐certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long‐term follow‐up (MD ‐0.30, 95% CI ‐1.67 to 1.07; 1 study, 44 participants); zBMI at short‐term (MD ‐0.06, 95% CI ‐0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium‐term (MD 0.02, 95% CI ‐0.17 to 0.21; 1 study, 112 participants) follow‐up; all low‐certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low‐certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short‐term follow‐up (MD ‐0.64, 95% CI ‐1.86 to 0.58; 6 studies, 1780 participants; low‐certainty evidence) and probably do not reduce zBMI at medium‐ (MD 0, 95% CI ‐0.04 to 0.05; 6 studies, 5335 participants) or long‐term (MD ‐0.05, 95% CI ‐0.12 to 0.02; 1 study, 985 participants) follow‐up; both moderate‐certainty evidence. Activity interventions do not reduce zBMI at short‐term follow‐up (MD 0.02, 95% CI ‐0.01 to 0.05; 7 studies, 4718 participants; high‐certainty evidence), but may reduce BMI slightly at medium‐term (MD ‐0.32, 95% CI ‐0.53 to ‐0.11; 3 studies, 2143 participants) and long‐term (MD ‐0.28, 95% CI ‐0.51 to ‐0.05; 1 study, 985 participants) follow‐up; both low‐certainty evidence. Seven studies (5428 participants; low‐certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short‐term follow‐up (MD 0.03, 95% CI ‐0.07 to 0.13; 11 studies, 3429 participants; high‐certainty evidence), and probably do not reduce BMI at medium‐term (MD 0.01, 95% CI ‐0.09 to 0.11; 8 studies, 5612 participants; moderate‐certainty evidence) or long‐term (MD 0.06, 95% CI ‐0.04 to 0.16; 6 studies, 8736 participants; moderate‐certainty evidence) follow‐up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD ‐0.09, 95% CI ‐0.2 to 0.02; 3 studies, 515 participants; very low‐certainty evidence), and they may not reduce zBMI at medium‐term (MD ‐0.05, 95% CI ‐0.1 to 0.01; 6 studies, 3511 participants; low‐certainty evidence) or long‐term (MD ‐0.02, 95% CI ‐0.05 to 0.01; 7 studies, 8430 participants; low‐certainty evidence) follow‐up. Four studies (2394 participants) reported data on serious adverse events (very low‐certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect. Authors' conclusions The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low‐certainty evidence that activity interventions may have a small beneficial effect on BMI at medium‐ and long‐term follow‐up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples. Plain language summary Do dietary and activity strategies help prevent obesity in children and young people aged 12 to 18 years? Key messages ‐ Strategies to encourage adolescents to change their diet or activity levels (or both), to prevent them becoming overweight or developing obesity make no or very little difference to their body mass index (BMI; an estimate of the amount of body fat according to height and weight). ‐ Based on the very little information available about serious adverse events, there appears to be little or no effect of dietary or activity strategies, or both, to results in serious harms (e.g. injuries). ‐ Due to a lack of evidence, future research should focus on community settings (e.g. in youth clubs) and research involving adolescents with disabilities. Why is preventing obesity in children and young people important? More adolescents are developing overweight and obesity worldwide. Being overweight as an adolescent can cause health problems, and people may be affected psychologically and in their social life. Puberty and moving into adulthood is a challenging time, and many struggle with their mental health. Overweight adolescents are likely to be overweight or obese as adults and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help adolescents modify their diet or activity (or both) were effective at preventing obesity. We also wanted to know if these strategies were associated with any serious harms. What did we do? We searched scientific databases for studies that looked at ways of preventing obesity in children aged 12 to 18 years. We excluded studies aimed at adolescents who were already overweight or living with obesity. However, we included studies where the sample was a whole group (e.g. a school), which may have included those living with overweight or obesity. We only included studies if the methods they used aimed to change the children's diet, their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed children into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 74 studies involving 83,407 children and young people. Sixty studies were based in high‐income countries (e.g. USA and in Europe). In 57 studies, the strategies were tried in schools, although 12 were based at home or other places like community settings (five studies) such as youth groups. Fifty‐one strategies were implemented for fewer than nine months; the shortest intervention lasted one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five studies were partly funded by industry (food suppliers, a PlayStation manufacturer, a gym equipment supplier, a healthcare device manufacturer and a private healthcare facility). Our analyses included results from 54 studies of 46,358 adolescents (20 studies did not report their results in a way that could be included in our analyses). We found that adolescents who were helped with a strategy to change their diet or activity levels (or both) either did not reduce their BMI, or any reduction was meagre, compared to adolescents who were not given a strategy. Only a few studies reported any possible harms of the interventions, and none identified serious harms. What are the limitations of the evidence? Overall, we have limited confidence in the beneficial effects of these interventions in preventing obesity in children and adolescents. It is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. Many studies had limitations in how they were done (e.g. in some studies, the methods used to randomly place people into groups were not adequate or the results of some of the studies were not analysed correctly). 3. There were not enough studies reporting particular types of outcomes, such as BMI (an estimate of the amount of body fat according to height and weight) or zBMI (comparison of a child’s BMI with other children of the same age and sex) for a particular duration of follow‐up to be certain about the results for some comparisons. Also, certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way that we could include them in our analyses (e.g. without any detail of the difference in change between the intervention and control groups) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for adolescents with disabilities, or whether those implemented in community settings are effective. How up to date is this evidence? This review supersedes our previous review. The evidence is up‐to‐date until February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F; Tomlinson, E; Davies, AL; Moore, THM; Dawson, S; Breheny, K; Savović, J; Hodder, RK; Wolfenden, L; Higgins, JPT; Summerbell, CD", "articleTypes": [], "doi": "10.1002/14651858.CD015330.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "3e435aca-3369-414b-8eaa-b7239be571ca", "pmid": "", "title": "Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions", "imported": false, "abstract": "Abstract - Background Individuals on continuous treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) are at increased risk of bleeding complications during and after oral or dental procedures. Anticoagulant treatment is preferably continued at the same dose, since dose reduction or discontinuation of treatment is associated with an increased risk of thromboembolism. The use of haemostatic measures during or after the procedure (or both) could enable continuation of the oral anticoagulant treatment. Objectives We aimed to assess the efficacy of antifibrinolytic agents for preventing bleeding complications in people on oral anticoagulants undergoing minor oral surgery or dental extractions. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and the Cochrane Library. Additional searches were performed using ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), the CINAHL database of nursing and allied health services, the open access ProQuest dissertation database, papers and reports from the American College of Clinical Pharmacy (ACCP) and abstract books from annual scientific conferences. Date of last search: 04 January 2018. Selection criteria Randomised and quasi‐randomised controlled trials in people on continuous treatment with VKAs or DOACs undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid (TXA) or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. Data collection and analysis Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained from potentially relevant abstracts and two authors independently assessed these for inclusion based of the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. The quality of the evidence was assessed using GRADE. Main results No eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures were identified. Three randomised trials and one quasi‐randomised trial (follow‐up in all was seven days) in people on continuous treatment with VKAs were included with a total of 253 participants (mean age 60 years). Two trials published in 1989 and 1993 compared the antifibrinolytic agent TXA with placebo in people using VKAs. Two other trials were published in 1999 and 2015 and compared TXA with gelatin sponge and sutures, and dry gauze compression, respectively. In all included trials, those who were treated with VKAs had international normalised ratio (INR) values within the therapeutic range and TXA was applied locally, not systemically. The two trials from 1989 and 1993 comparing TXA with placebo showed a statistically significant beneficial effect regarding the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) of ‐0.25 (95% confidence interval (CI) ‐0.36 to ‐0.14) (128 participants) (moderate‐quality evidence). For the two trials that compared TXA with either gelatin sponge and sutures or with dry gauze compression, there was no difference between the TXA and the standard care group, RD 0.02 (95% CI ‐0.07 to 0.11) (125 participants) (moderate‐quality evidence). The combined RD of all included trials was ‐0.13 (95% CI ‐0.30 to 0.05) (moderate‐quality evidence). There were no side effects of antifibrinolytic therapy that required treatment withdrawal (128 participants) (moderate‐quality evidence). Despite heterogeneity between trials with respect to the different haemostatic measures used in the control groups, the trials were comparable regarding design and baseline participant characteristics. Overall, we considered the risk of bias to be low in the trials comparing TXA with placebo and moderate in the trials comparing TXA with alternative haemostatic measures. Authors' conclusions Based on the results of this Cochrane Review, there seems to be a beneficial effect of locally applied TXA in preventing oral bleeding in people on continuous treatment with VKAs undergoing minor oral surgery or dental extractions. However, the small number of identified randomised controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population. We were unable to identify any eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures. Therefore, a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs. Plain language summary Drugs that prevent oral bleeding in people using oral anticoagulants undergoing minor oral surgery or dental extractions Review question We reviewed the evidence about whether antifibrinolytic medicine (drugs that prevent breakdown of a blood clot), such as tranexamic acid or epsilon aminocaproic acid, can prevent oral bleeding after minor oral surgery or dental extractions in people using oral anticoagulants (blood thinners that are taken by mouth) without interruption during the procedure. Background People on continuous oral anticoagulant treatment are at an increased risk of bleeding complications during and after oral surgery or dental extractions. There are two types of oral anticoagulant treatment: vitamin K antagonists (VKAs) (e.g. warfarin and coumarin) and direct oral anticoagulants (DOACs) (e.g. dabigatran, rivaroxaban, apixaban, edoxaban). DOACs are becoming an increasingly popular alternative for VKAs, traditionally used for preventing blood clotting in people at risk of thrombosis. The number of bleeds and the severity of each bleed depend on medication‐related factors (such as the degree of anticoagulation, measured by the international normalised ratio (INR)), surgery‐related factors (such as the size of the wound or the number of roots extracted), as well as patient‐related factors (such as inflammation of the gums or blood vessel diseases). The INR level is important to determine how well the anticoagulant treatment is preventing blood clots. Within the desired range of the INR level, a person has both the least risk of blood clotting complications and the least risk of excessive bleeding. In routine practice antifibrinolytic medicine is often used before, during and after minor oral surgery or dental extractions for people using oral anticoagulants. The question is whether there is reliable scientific evidence for this practice. Search date The evidence is current to: 04 January 2018. Study characteristics We did not find any trials of antifibrinolytic medicine for preventing bleeding after minor oral surgery or dental extractions in people using DOACs. This review includes four trials (253 participants) in people continuously treated with VKAs during minor oral surgery or dental extractions. The earliest included trial was published in 1989 and the most recent one in 2015. The mean age of all participants was 60 years. The follow‐up time in all trials was seven days. Key results Overall, the included trials showed a reduction in the number of bleeds after dental extraction when using tranexamic acid solution in the mouth. Combining the results of the separate trials it appeared that antifibrinolytic medication reduces the bleeding rate after dental extractions by 25% when compared to placebo ('dummy' treatment). However, there was no difference in bleeding rate between people treated with tranexamic acid and those treated with standard care (e.g. gauze compression or stitches). Side effects of the antifibrinolytic medication rarely occurred and did not lead to individuals discontinuing tranexamic acid treatment. No evidence was found for people being treated with DOACs. It could, however, be argued that, if antifibrinolytic medicine is effective in people on continuous treatment with VKAs, it might also work for people receiving other comparable anticoagulant drugs. Quality of evidence In relation to the review's two primary outcomes of number of postoperative bleeds and side effects of therapy, we judged there to be moderate‐quality evidence. In the two trials comparing tranexamic acid with placebo, the risk of bias, in relation to trial design, was considered to be low, in the two trials comparing tranexamic acid to standard care (gelatin sponge and sutures; or dry gauze compression) the risk of bias was considered to be moderate. This was mainly due to the lack of blinding (a way of making sure that the people involved in the trial do not know which trial arm they are assigned to) and inadequate allocation concealment (using the play of chance to assign participants to comparison groups to prevent selection bias) in two of these trials. There were differences between the trials with regards to different standard care treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Engelen, ET; Schutgens, REG; Mauser‐Bunschoten, EP; van Es, RJJ; van Galen, KPM", "articleTypes": [], "doi": "10.1002/14651858.CD012293.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "3e462970-762a-4585-a6a6-1dc1153079e5", "pmid": "", "title": "Omega‐3 fatty acids for bipolar disorder", "imported": false, "abstract": "Abstract - Background Bipolar disorder is a complex psychiatric disorder and is amongst the top thirty causes of worldwide disability. Mood stabilisers are the primary pharmacological intervention, both in the treatment of acute episodes and in prophylaxis. There is, however, mounting evidence that dietary supplementation with omega‐3 fatty acids may be beneficial in psychiatric conditions, particularly those involving disturbances of mood. Objectives To review the efficacy of omega‐3 fatty acids as either a monotherapy or an adjunctive treatment for bipolar disorder. Search methods Electronic searches of the following databases were performed: CCDANCTR‐Studies and CCDANCTR‐References were searched on 12/2/2008, Supplementary searches were carried out on Biological Abstracts, CINAHL, The Cochrane Library, CCDAN Register, EMBASE, MEDLINE, and PsycINFO. The search strategy also included cited reference searching, personal contact with all authors of studies initially included and contact with the omega‐3 producing pharmaceutical companies. Selection criteria All relevant randomised controlled trials were included in the review. Studies involving males and females of all ages with a diagnosis of bipolar disorder qualified for inclusion. Studies using any type or dose of omega‐3 fatty acid treatment as monotherapy or in addition to standard pharmacotherapy were eligible. The primary outcome was symptom severity; and secondary outcomes were adverse effects, dropout and satisfaction with treatment. Data collection and analysis Two review authors independently inspected the citations identified from the search. Potentially relevant abstracts were identified and full papers ordered and reassessed for inclusion and methodological quality. All relevant data were extracted. The weighted mean difference (WMD) was used for continuous outcome data, with 95% confidence intervals (CI). Main results Five studies met inclusion criteria for the review, however, methodological quality was highly variable. Only one study, involving 75 participants, provided data for analysis, and showed a benefit of active treatment over control for depression symptom levels (WMD ‐3.93, 95% CI ‐7.00 to ‐0.86)and Clinical Global Impression scores (WMD ‐0.75, 95% CI ‐1.33 to ‐0.17) but not for mania (WMD ‐2.81, 95% CI ‐7.68 to 1.90). No serious adverse effects were reported in the five studies. The pattern of dropout was highly variable between studies. Authors' conclusions Results from one study showed positive effects of omega‐3 as an adjunctive treatment for depressive but not manic symptoms in bipolar disorder. These findings must be regarded with caution owing to the limited data available. There is an acute need for well‐designed and executed randomised controlled trials in this field. Plain language summary Omega‐3 fatty acids for bipolar disorder This systematic review investigated the efficacy of omega‐3 fatty acids for bipolar disorder. Five randomised controlled trials met inclusion criteria for the review. Only one trial provided data that could be analysed, investigating ethyl‐EPA as an adjunctive treatment in a mixed outpatient population. Some positive benefits were found for depressive symptoms but not for mania, and no adverse events were reported. There is currently insufficient evidence on which to base any clear recommendations concerning omega‐3 fatty acids for bipolar disorder. However, given the general health benefits and safety of omega‐3, the preliminary evidence from this review provides a strong case for well‐powered, high‐quality trials in specific index populations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Montgomery, P, Richardson, AJ", "articleTypes": [], "doi": "10.1002/14651858.CD005169.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.082Z" }, { "id": "3e506d71-d772-447a-99d4-f19dd1c5d244", "pmid": "", "title": "Cannabinoids for fibromyalgia", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue affecting approximately 2% of the general population. People often report high disability levels and poor health‐related quality of life (HRQoL). Drug therapy focuses on reducing key symptoms and disability, and improving HRQoL. Cannabis has been used for millennia to reduce pain and other somatic and psychological symptoms. Objectives To assess the efficacy, tolerability and safety of cannabinoids for fibromyalgia symptoms in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE to April 2016, together with reference lists of retrieved papers and reviews, three clinical trial registries, and contact with trial authors. Selection criteria We selected randomised controlled trials of at least four weeks' duration of any formulation of cannabis products used for the treatment of adults with fibromyalgia. Data collection and analysis Two review authors independently extracted the data of all included studies and assessed risk of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs; at least 200 participants in the comparison, eight to 12 weeks' duration, parallel design), second tier evidence from data that did not meet one or more of these criteria and were considered at some risk of bias but with adequate numbers (i.e. data from at least 200 participants) in the comparison, and third tier evidence from data involving small numbers of participants that were considered very likely to be biased or used outcomes of limited clinical utility, or both. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Main results We included two studies with 72 participants. Overall, the two studies were at moderate risk of bias. The evidence was derived from group mean data and completer analysis (very low quality evidence overall). We rated the quality of all outcomes according to GRADE as very low due to indirectness, imprecision and potential reporting bias. The primary outcomes in our review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Nabilone was compared to placebo and to amitriptyline in one study each. Study sizes were 32 and 40 participants. One study used a cross‐over design and one used a parallel group design; study duration was four or six weeks. Both studies used nabilone, a synthetic cannabinoid, with a bedtime dosage of 1 mg/day. No study reported the proportion of participants experiencing at least 30% or 50% pain relief or who were very much improved. No study provided first or second tier (high to moderate quality) evidence for an outcome of efficacy, tolerability and safety. Third tier (very low quality) evidence indicated greater reduction of pain and limitations of HRQoL compared to placebo in one study. There were no significant differences to placebo noted for fatigue and depression (very low quality evidence). Third tier evidence indicated better effects of nabilone on sleep than amitriptyline (very low quality evidence). There were no significant differences between the two drugs noted for pain, mood and HRQoL (very low quality evidence). More participants dropped out due to adverse events in the nabilone groups (4/52 participants) than in the control groups (1/20 in placebo and 0/32 in amitriptyline group). The most frequent adverse events were dizziness, nausea, dry mouth and drowsiness (six participants with nabilone). Neither study reported serious adverse events during the period of both studies. We planned to create a GRADE 'Summary of findings' table, but due to the scarcity of data we were unable to do this. We found no relevant study with herbal cannabis, plant‐based cannabinoids or synthetic cannabinoids other than nabilone in fibromyalgia. Authors' conclusions We found no convincing, unbiased, high quality evidence suggesting that nabilone is of value in treating people with fibromyalgia. The tolerability of nabilone was low in people with fibromyalgia. Plain language summary Cannabis products for people with fibromyalgia Background Fibromyalgia is characterised by chronic (longer than three months) widespread pain that often co‐exists with sleep problems, problems with thinking and fatigue (exhaustion). People often report severe limitations of daily functioning and poor health‐related quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. Cannabis has been used for 3000 years to reduce pain and other symptoms, such as loss of appetite and anxiety. Key results and quality of the evidence In April 2016 we searched for reports of clinical trials that used cannabis products to treat symptoms in adults with fibromyalgia. We found two small, moderate quality studies, of four and six weeks long, including 72 participants. Both studies tested nabilone, a synthetic (man‐made) cannabis product, comparing it with placebo (a dummy pill) or amitriptyline (an antidepressant frequently used in the treatment of fibromyalgia). Nabilone did not convincingly relieve fibromyalgia symptoms (pain, sleep, fatigue) better than placebo or amitriptyline (very low quality evidence). Compared with placebo and amitriptyline, more people experienced side effects and left the study due to side effects (very low quality evidence). There were no serious side effects reported. We found no relevant study with herbal cannabis, plant‐based cannabinoids or other synthetic cannabinoids than nabilone in fibromyalgia. There was not enough high quality evidence available to draw any robust conclusions. We found no studies on medical cannabis in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B, Klose, P, Fitzcharles, M-A, Phillips, T, Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.105Z" }, { "id": "3e51f23b-7fc3-47a2-b404-1bd8f7452fe1", "pmid": "", "title": "Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women", "imported": false, "abstract": "Abstract - Background Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions, particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia. However, its long‐term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teeth staining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation for preventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent. Objectives To assess the effects of intermittent oral iron supplementation, alone or in combination with other nutrients, on anaemia and its associated impairments among menstruating women, compared with no intervention, a placebo, or daily supplementation. Search methods In February 2018, we searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers. In March 2018, we also searched LILACS, IBECS and IMBIOMED. In addition, we examined reference lists, and contacted authors and known experts to identify additional studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs with either individual or cluster randomisation. Participants were menstruating women; that is, women beyond menarche and prior to menopause who were not pregnant or lactating and did not have a known condition that impeded the presence of menstrual periods. The intervention was the use of iron supplements intermittently (one, two or three times a week on non‐consecutive days) compared with placebo, no intervention, or the same supplements provided on a daily basis. Data collection and analysis Both review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy, assessed the risk of bias of the included studies, and rated the quality of the evidence using GRADE. Main results We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessing risk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one third of the included studies did not provide a funding source. Although quality across studies was variable, the results consistently showed that intermittent iron supplementation (alone or with any other vitamins and minerals) compared with no intervention or a placebo, reduced the risk of having anaemia (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.49 to 0.87; 11 studies, 3135 participants; low‐quality evidence), and improved the concentration of haemoglobin (mean difference (MD) 5.19 g/L, 95% CI 3.07 to 7.32; 15 studies, 2886 participants; moderate‐quality evidence), and ferritin (MD 7.46 μg/L, 95% CI 5.02 to 9.90; 7 studies, 1067 participants; low‐quality evidence). Intermittent regimens may also reduce the risk of having iron deficiency (RR 0.50, 95% CI 0.24 to 1.04; 3 studies, 624 participants; low‐quality evidence), but evidence was inconclusive regarding iron deficiency anaemia (RR 0.07, 95% CI 0.00 to 1.16; 1 study, 97 participants; very low‐quality evidence) and all‐cause morbidity (RR 1.12, 95% CI 0.82 to 1.52; 1 study, 119 participants; very low‐quality evidence). Women in the control group were less likely to have any adverse side effects than those receiving intermittent iron supplements (RR 1.98, 95% CI 0.31 to 12.72; 3 studies, 630 participants; moderate‐quality evidence). In comparison with daily supplementation, results showed that intermittent supplementation (alone or with any other vitamins and minerals) produced similar effects to daily supplementation (alone or with any other vitamins and minerals) on anaemia (RR 1.09, 95% CI 0.93 to 1.29; 8 studies, 1749 participants; moderate‐quality evidence). Intermittent supplementation may produce similar haemoglobin concentrations (MD 0.43 g/L, 95% CI −1.44 to 2.31; 10 studies, 2127 participants; low‐quality evidence) but lower ferritin concentrations on average (MD −6.07 μg/L, 95% CI −10.66 to −1.48; 4 studies, 988 participants; low‐quality evidence) compared to daily supplementation. Compared to daily regimens, intermittent regimens may also reduce the risk of having iron deficiency (RR 4.30, 95% CI 0.56 to 33.20; 1 study, 198 participants; very low‐quality evidence). Women receiving iron supplements intermittently were less likely to have any adverse side effects than those receiving iron supplements daily (RR 0.41, 95% CI 0.21 to 0.82; 6 studies, 1166 participants; moderate‐quality evidence). No studies reported on the effect of intermittent regimens versus daily regimens on iron deficiency anaemia and all‐cause morbidity. Information on disease outcomes, adherence, economic productivity, and work performance was scarce, and evidence about the effects of intermittent supplementation on these outcomes unclear. Overall, whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline did not seem to affect the findings. Furthermore, the response did not differ in areas where malaria was frequent, although very few trials were conducted in these settings. Authors' conclusions Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations with different anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittently is probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base ranged from very low to moderate quality, suggesting that we are uncertain about these effects. Plain language summary Iron supplements taken one, two or three times a week for preventing anaemia, and its consequences in menstruating women What is the issue? Across the globe, approximately one out of three non‐pregnant women of reproductive age are anaemic; i.e. have fewer red blood cells or less haemoglobin (a red substance that combines with oxygen and carries it around the body) in each red blood cell than normal. Although there are several causes of anaemia, it very often results from sustained iron deficiency. The standard practice to prevent or treat anaemia in women has been daily iron supplementation (sometimes combined with folic acid and other vitamins and minerals) for three months. However, it is frequently associated with side effects such as nausea or constipation. Intermittent supplementation (that is, the consumption of supplements one, two or three times a week on non‐consecutive days) has been proposed as an effective and safer alternative to daily supplementation. Why is this important? Women with anaemia may have less energy for physical work and become more prone to infections. Most women throughout the world enter pregnancy with anaemia, putting them at greater risk of having low birth‐weight babies and other complications during delivery. Some scientists believe that taking iron a few times a week – instead of every day – can help women with anaemia to feel better and improve their haemoglobin without giving them as many side effects. If women have fewer side effects, they may be more likely to take iron supplements more regularly and for longer periods. What evidence did we find? We reviewed the evidence in February 2018. We included 25 randomised controlled trials (a type of experiment in which participants are randomly assigned to one or more treatment groups) involving 10,996 women. We included studies examining the administration of intermittent iron supplements versus no intervention, a placebo (dummy pill) or the same supplements given on a daily basis. Most studies were implemented in school settings and were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one‐third of the included studies did not provide a funding source. The findings show that women receiving intermittent supplementation with iron alone, or in combination with folic acid or other nutrients, were less likely to be anaemic or iron deficient than those women who received no iron supplements or a placebo. They also had higher concentrations of haemoglobin and ferritin (a protein that carries iron) but reported more side effects. In addition, the findings indicate that intermittent supplementation was as effective as daily supplementation in reducing the prevalence of anaemia and increasing haemoglobin concentrations, with fewer side effects. It may have reduced the risk of having iron deficiency also, but it had no effect on raising ferritin concentrations more than the daily dose. We found scarce evidence on the effect of intermittent supplementation compared to placebo or daily supplementation on iron deficiency anaemia, all‐cause morbidity, disease outcomes, adherence, economic productivity, and work performance. What does this mean? Intermittent iron supplementation in menstruating women may be an effective intervention for reducing anaemia and improving haemoglobin concentrations compared to no treatment, placebo or daily supplementation. Intermittent supplementation may be associated with fewer side effects compared to daily supplementation. The findings were not affected by whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline (starting point for comparisons). The evidence base was of overall low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fernández-Gaxiola, AC; De-Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD009218.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "3e6db5a6-1bdc-4804-a765-c4952c975c58", "pmid": "", "title": "Anticholinergic agents for chronic asthma in adults", "imported": false, "abstract": "Abstract - Background Anticholinergic agents such as ipratropium bromide are sometimes used in the treatment of chronic asthma. They effect bronchodilation and have also been used in combination with ß2 ‐agonists in the management of chronic asthma. Objectives To examine the effectiveness of anticholinergic agents versus placebo and in comparison with ß2 ‐agonists or as adjunctive therapy to ß2 ‐agonists. Search methods The Cochrane Airways Group asthma and wheeze database was searched with a pre‐defined search strategy. Searches were current as of August 2008. Reference lists of articles were also examined. Selection criteria Randomised trials or quasi‐randomised trials were considered for inclusion. Studies assessing an anticholinergic agent versus placebo or in combination/comparison with ß2 ‐agonists were included. In practice, all ß2 ‐agonists were short acting. Short‐term (less than 24 hours duration) were not considered for this review. Data collection and analysis Two reviewers independently assessed abstracts for retrieval of full text articles. Papers were then assessed for suitability for inclusion in the review. Data from included studies were extracted by two reviewers and entered into the software package (RevMan 4.2). We contacted authors for missing data and some responded. Adverse effect data were analysed if reported in the included studies. Main results The studies analysed were in two groups: those comparing anticholinergics with placebo and those comparing the combination of anticholinergics with short acting ß2 ‐agonists versus short acting ß2 ‐agonists alone. The former group had 13 studies involving 205 participants included in this review, and the latter 9 studies involving 440 patients. Generally methodological quality was poorly reported, and there were some reservations with respect to the quality of the studies. Despite the limited number of studies that could be combined, anticholinergic agents in comparison with placebo resulted in more favourable symptom scores particularly in respect of daytime dyspnoea (WMD ‐0.09 (95%CI ‐0.14, ‐0.04, 3 studies, 59 patients). Daily peak flow measurements also showed a statistically significant improvement for the anticholinergic (e.g. morning PEF: WMD =14.38 litres/min (95%CI 7.69, 21.08; 3 studies, 59 patients). However the clinical significance is small and in terms of peak flow measurements equates to approximately a 7% increase over placebo. The more clinically relevant comparison of a combination of anticholinergic plus short acting ß2 ‐agonist versus short acting ß2 ‐agonist alone gave no evidence in respect of symptom scores or peak flow rates of any significant differences between the two regimes. Again there are reservations with respect to the quality of the information from which these conclusions are drawn. An update search in August 2004 did not identify any new studies. Authors' conclusions Overall this review provides no justification for routinely introducing anticholinergics as part of add‐on treatment for patients whose asthma is not well controlled on standard therapies. This does not exclude the possibility that there may be a sub‐group of patients who derive some benefit and a trial of treatment in individual patients may still be justified. The role of long term anticholinergics such as tiotropium bromide has yet to be established in patients with asthma and any future trials might draw on the messages derived from this review. Plain language summary Anticholinergic agents for chronic asthma in adults Anticholinergic agents such as Atrovent are sometimes used to treat people with asthma as a bronchodilator that opens up the airways in the lungs. This review found that although this treatment was better than placebo, the size of the effect was rather small. When the drug was used in combination with more widely used bronchodilators (beta‐agonists such as fenoterol), it did not appear to add much benefit. However, there are concerns about the quality of the studies that have been analysed. It could be that there are some adults with chronic asthma who respond to treatment with anticholinergic drugs, but the review has not been able to identify their common characteristics.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Westby, MJ, Benson, MK, Gibson, PG", "articleTypes": [], "doi": "10.1002/14651858.CD003269.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.073Z" }, { "id": "3e8ba5b4-bb34-4c6a-8a91-faecc48a1841", "pmid": "", "title": "Serotonin-receptor Agonism in Reward Processing", "imported": false, "abstract": "There is growing animal and human evidence for role of 5HT1A receptor agonism in treating depression and reward deficits. The next step is to translate this evidence directly into humans by characterising the effects of buspirone, as a 5HT1A agonist, on cognitive models of reward and emotional processing.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.235Z" }, { "id": "3e904027-2c37-462f-9488-a489c5bcea3f", "pmid": "", "title": "Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults", "imported": false, "abstract": "Abstract - Background Chancroid is a genital ulcerative disease caused by Haemophilus ducreyi . This microorganism is endemic in Africa, where it can cause up to 10% of genital ulcers. Macrolides may be an effective alternative to treat chancroid and, based on their oral administration and duration of therapy, could be considered as first line therapy. Objectives To assess the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults. Search methods We searched the Cochrane STI Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, WHO ICTRP, ClinicalTrials.gov and Web of Science to 30 October 2017. We also handsearched conference proceedings and reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) comparing macrolides in different regimens or with other therapeutic alternatives for chancroid. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We resolved disagreements through consensus. We used the GRADE approach to assess the quality of the evidence. Main results Seven RCTs (875 participants) met our inclusion criteria, of which four were funded by industry. Five studies (664 participants) compared macrolides with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Low quality evidence suggested there was no difference between the groups after treatment in terms of clinical cure (risk ratio (RR) 1.09, 95% confidence interval (CI) 0.97 to 1.21; 2 studies, 340 participants with syndromic approach and RR 1.06, 95% CI 0.98 to 1.15; 5 studies, 348 participants with aetiological diagnosis) or improvement (RR 0.89, 95% CI 0.52 to 1.52; 2 studies, 340 participants with syndromic approach and RR 0.80, 95% CI 0.42 to 1.51; 3 studies, 187 participants with aetiological diagnosis). Based on low and very low quality evidence, there was no difference between macrolides and any other antibiotic treatments for microbiological cure (RR 0.93, 95% CI 0.74 to 1.16; 1 study, 45 participants) and minor adverse effects (RR 1.34, 95% CI 0.24 to 7.51; 3 studies, 412 participants). Two trials (269 participants) compared erythromycin with any other macrolide type. Low quality evidence suggested that, compared with azithromycin or rosaramicin, long courses of erythromycin did not increase clinical cure (RR 1.00, 95% CI 0.91 to 1.10; 2 studies, 269 participants with syndromic approach and RR 1.04, 95% CI 0.93 to 1.16; 2 studies, 211 participants with aetiological diagnosis), with a similar frequency of minor adverse effects between the groups (RR 1.14, 95% CI 0.63 to 2.06; 1 trial, 101 participants). For this comparison, subgroup analysis found no difference between HIV‐positive participants (RR 1.02, 95% CI 0.73 to 1.43; 1 study, 38 participants) and HIV‐negative participants (RR 1.04, 95% CI 0.94 to 1.14; 1 study, 89 participants). We downgraded the quality of evidence to low, because of imprecision, some limitations on risk of bias and heterogeneity. None of the trials reported serious adverse events, cost effectiveness and participant satisfaction. Authors' conclusions At present, the quality of the evidence on the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults is low, implying that we are uncertain about the estimated treatment effect. There is no statistically significant difference between the available therapeutic alternatives for the treatment of sexually active adults with genital ulcers compatible with chancroid. Low quality evidence suggests that azithromycin could be considered as the first therapeutic alternative, based on their mono‐dose oral administration, with a similar safety and effectiveness profile, when it is compared with long‐term erythromycin use. Due to sparse available evidence about the safety and effectiveness of macrolides to treat H ducreyi infection in people with HIV, these results should be taken with caution. Plain language summary Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults Review question 
 In this Cochrane Review, we assess the effectiveness and safety of macrolides in different regimens or with other treatments for H ducreyi infection in adults. Background Chancroid is a sexually transmitted infection (STI) caused by infection with a bacteria called Haemophilus ducreyi . It causes ulcers in the genital area and is endemic in some low‐income countries. Control and eradication of chancroid could reduce transmission of the STI from one sexual partner to another. Macrolides are antibiotics that could be effective and safe for treating H ducreyi infection. Trial characteristics We searched the available literature up to 30 October 2017 and we included seven trials with 875 participants. The trials recruited men and non‐pregnant women over the age of 16 years who presented with genital ulcers compatible with chancroid. Three studies included people with high‐risk sexual behaviour as migrant mine workers, sex workers and men with prostitute contact. All the trials tested for other STIs, and discarded people who were also infected with syphilis and herpes simple virus. One study included people with HIV. The most frequent antibiotic treatment was erythromycin with azithromycin as an alternative. They were compared with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Five studies compared two types of antibiotic and two studies compared different ways of treating with macrolides. Four trials were funded by pharmaceutical companies. Key results There was no difference between the types of antibiotics in sexually active adults with genital ulcers compatible with chancroid. Erythromycin is usually the first choice for treatment but low quality evidence suggested that azithromycin (as a single dose, oral (by mouth) administration) had similar safety and effectiveness. Because of sparse evidence about the safety and effectiveness of macrolides to treat Haemophilus ducreyi infection in people with HIV, these results should be taken with caution. Quality of evidence The quality of evidence was low as there was a risk of bias due to poor methods, people dropping out of the study and pharmaceutical companies sponsored four studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Romero, L; Huerfano, C; Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD012492.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "3e990727-b662-49d5-bf66-645e112b5f2d", "pmid": "", "title": "Nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy", "imported": false, "abstract": "Abstract - Background Across the developed world, an estimated 150,000 to 300,000 people are treated annually with pelvic radiotherapy and 80% will develop gastrointestinal (GI) symptoms during treatment. Acute GI symptoms are associated with a greater risk of chronic, often debilitating, GI symptoms. Up to one‐third of patients are malnourished before pelvic radiotherapy and up to four‐fifths of patients lose weight during treatment. Malnutrition is linked to a higher risk of GI toxicity, which can lead to breaks in radiotherapy and early cessation of chemotherapy, thus compromising the efficacy of the primary cancer treatment. Objectives To assess the effects of nutritional interventions for reducing GI toxicity in adults undergoing radical pelvic radiotherapy. Search methods We searched the Cochrane Gynaecological Cancer Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 4, 2012, MEDLINE and EMBASE to May 2012. We handsearched the citation lists of included studies and previous systematic reviews identified to identify further relevant trials. Selection criteria We included studies if they were randomised controlled trials (RCTs) or non‐randomised studies with concurrent comparison groups including quasi‐randomised trials, cluster RCTs, non‐randomised trials, prospective and retrospective cohort studies, and case series of 30 or more patients. We only included studies if they assessed the effect of a nutritional intervention in adults aged 18 years or over undergoing radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic malignancy. We excluded patients with stomas and a previous history of inflammatory bowel disease. Nutritional support interventions could be provided at any stage before or during pelvic radiotherapy and included dietary counselling; dietary modification of fibre, lactose or fat; supplementary foods or drinks or fortified foods; standard oral nutrition supplements including polymeric‐, peptide‐ or amino acid‐based supplements and those where novel substrates have been added; enteral tube feeds; or parenteral nutrition (partial or total). We excluded probiotics, prebiotics and synbiotics. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors to obtain missing data. We assessed bias for each of the included studies using the bias assessment tables in the Cochrane software Review Manager5. We performed meta‐analysis, when indicated, using the Mantel‐Haenszel fixed‐effect method or inverse variance fixed‐effect method displayed with heterogeneity. We undertook meta‐analyses on trials evaluating dietary modification against standard treatment for diarrhoea at the end of radiotherapy and for change in weight from baseline to end of radiotherapy. Main results The searches identified 7558 titles, and we excluded 7513 during title and abstract searches. We reviewed 45 papers in full, and excluded 39. We identified four studies on handsearching of the references, which, along with the six eligible papers from the database search, led to 10 studies being included. Four studies, three of which were RCTs and one prospective study, investigated the effect of elemental diet on GI symptoms; one RCT investigated the effect of dietary modification and elemental diet; and five RCTs investigated dietary modification. Studies were varied in terms of risk of bias. Data were dichotomised for presence and absence of diarrhoea at the end of radiotherapy for four trials evaluating dietary modification comprising modified fat, lactose, fibre or combinations of these dietary changes. A reduction in diarrhoea was demonstrated with nutritional intervention (risk ratio (RR) 0.66; 95% confidence interval (CI) 0.51 to 0.87, four studies, 413 participants, moderate quality of evidence) with low heterogeneity (Chi 2 = 3.50, I 2 = 14%). Two trials evaluating dietary modification on weight change (comparing baseline and end of radiotherapy) showed no difference between intervention or control (mean difference (MD) ‐0.57 kg; 95% CI ‐1.22 to 0.09) with low heterogeneity (Chi 2 = 1.41, I 2 = 29%). Generally adverse effects were poorly reported in included studies. Elemental diet in particular was poorly tolerated. GI symptoms or toxicity > 6 months after radiotherapy was not reported in included studies Authors' conclusions There have been benefits demonstrated with dietary modification during pelvic radiotherapy to reduce diarrhoea. Those diets included single interventions or combinations of modified fat, lactose‐restriction, fat‐restriction and fibre supplementation. We were unable to meta‐analyse elemental diet, as data were not available. We considered some of the studies to be at high risk of bias. There have been recent advances in novel, more targeted radiotherapy techniques, such that the findings of older studies need to be interpreted with caution. In addition, there were problems with compliance and palatability with some of the interventions, particularly elemental diet, which limits its usefulness in clinical practice. Plain language summary Do nutritional interventions reduce gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy? Background Research has shown that nutrition and radiotherapy have effects on each other. People with malnutrition tend to get more bowel side effects during radiotherapy. It has also been shown that many people lose weight during radiotherapy due to the treatment side effects. These side effects can lead to some people needing gaps in their radiotherapy and sometimes they even need to stop it entirely. This can reduce the chance of cancer cure. This review looked at the literature for providing extra nourishment or changes in diet to patients before or during radiotherapy, to determine whether this is of benefit in terms of reducing bowel symptoms, improving nutritional status and quality of life. Study characteristics Searches of all relevant sources of medical information identified 7558 articles, and, after initial screening of all these articles, we selected 45 as being suitable for this review. On reading the summaries of these 45 trials, 10 were suitable to be included in this review. We included trials that looked at the effects of a nutritional intervention in adults aged 18 years or over having radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic cancer. We excluded patients with stomas and a previous history of inflammatory bowel disease. Key results Results showed that studies evaluating dietary changes, including changes in dietary fat, fibre and lactose, during radiotherapy reduced diarrhoea at the end of treatment. However, these dietary changes did not seem to improve patients' weights. Quality of the evidence While some changes to diet during radiotherapy may benefit patients by reducing diarrhoea, it is important to recognise that some of the studies reviewed were dated and there have been changes in radiotherapy technique since then that may give patients less diarrhoea anyway. In addition, many studies were of poor quality and, therefore, only a small number were able to be included in this review. Some interventions described, for example, having to take a liquid diet, were not acceptable as many patients found them difficult to tolerate and were unable to take them completely.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Henson, CC; Burden, S; Davidson, SE; Lal, S", "articleTypes": [], "doi": "10.1002/14651858.CD009896.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "3e9bc76f-1b8b-4749-baf4-36c460017c34", "pmid": "", "title": "Interventions to prevent obesity in children aged 5 to 11 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well‐being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review. Objectives To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta‐analyses. One hundred forty‐six studies were based in high‐income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0, 95% confidence interval (CI) ‐0.10 to 0.10; 5 studies, 2107 participants; low‐certainty evidence) and at medium‐term follow‐up (MD ‐0.01, 95% CI ‐0.15 to 0.12; 9 studies, 6815 participants; low‐certainty evidence) or zBMI at long‐term follow‐up (MD ‐0.05, 95% CI ‐0.10 to 0.01; 7 studies, 5285 participants; low‐certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long‐term follow‐up (MD ‐0.17, 95% CI ‐0.48 to 0.13; 2 studies, 945 participants; moderate‐certainty evidence) and zBMI at short‐ or medium‐term follow‐up (MD ‐0.06, 95% CI ‐0.13 to 0.01; 8 studies, 3695 participants; MD ‐0.04, 95% CI ‐0.10 to 0.02; 9 studies, 7048 participants; moderate‐certainty evidence). Five studies (1913 participants; very low‐certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short‐term or long‐term follow‐up (BMI short‐term: MD ‐0.02, 95% CI ‐0.17 to 0.13; 14 studies, 4069 participants; zBMI short‐term: MD ‐0.02, 95% CI ‐0.07 to 0.02; 6 studies, 3580 participants; low‐certainty evidence; BMI long‐term: MD ‐0.07, 95% CI ‐0.24 to 0.10; 8 studies, 8302 participants; zBMI long‐term: MD ‐0.02, 95% CI ‐0.09 to 0.04; 6 studies, 6940 participants; low‐certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.18 to ‐0.05; 16 studies, 21,286 participants; zBMI: MD ‐0.05, 95% CI ‐0.09 to ‐0.02; 13 studies, 20,600 participants; moderate‐certainty evidence). Eleven studies (21,278 participants; low‐certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to ‐0.01; 27 studies, 16,066 participants; zBMI: MD ‐0.03, 95% CI ‐0.06 to 0.00; 26 studies, 12,784 participants; low‐certainty evidence) and likely result in a reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD ‐0.05, 95% CI ‐0.07 to ‐0.02; 24 studies, 20,998 participants; moderate‐certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long‐term follow‐up (BMI: MD 0.03, 95% CI ‐0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD ‐0.02, 95% CI ‐0.06 to 0.01; 22 studies, 23,594 participants; low‐certainty evidence). Nineteen studies (27,882 participants; low‐certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow‐up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high‐income versus non‐high‐income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability. Authors' conclusions The body of evidence in this review demonstrates that a range of school‐based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short‐ and medium‐term, but not at long‐term follow‐up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community‐based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities. Plain language summary Do dietary and activity strategies help prevent obesity in children aged 5 to 11 years? Key messages ‐ Strategies for changing activity levels, or both activity levels and diet, of children to help prevent them developing overweight or obesity might be effective in making small reductions in body mass index (BMI) in children aged 5 to 11 years. ‐ There is very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but from what we found there appears to be little or no effect. ‐ This change in BMI, when provided to many children across a whole population, is useful for parents concerned about their children becoming overweight as they move into adulthood and for governments in trying to tackle the problems of obesity through the life course. Why is preventing obesity in children important? More children are developing overweight and obesity worldwide. Being overweight as a child can cause health problems, and people may be affected psychologically and in their social life. Children that are overweight are likely to be overweight as adults and continue to experience poor physical and mental health. Indeed, childhood obesity is associated with type 2 diabetes and heart disease in adulthood and middle‐age mortality. What did we want to find out? We wanted to find out if strategies to help people modify their diet or activity (or both) are effective at preventing obesity in children aged 5 to 11 years. We also wanted to find out if these strategies were associated with any serious adverse events. What did we do? We searched many scientific databases to find studies that looked at ways of preventing obesity in children. We included studies aimed at children aged 5 to 11 years. We did not include studies only aimed at children who were already overweight or were already living with obesity. However, we included studies in which children who were overweight or living with obesity were included in the analysis. We only included studies if the methods they used were aimed at changing children's diet, or their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed people into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 172 studies that involved 189,707 children. One hundred forty‐six studies were based in high‐income countries (e.g. the USA and in Europe). In 111 studies, the strategies were tried in schools, though 15 were based in the community, eight in the home and seven in clinical settings; one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six strategies were implemented for less than nine months, with the shortest being conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry (e.g. food suppliers, pharmaceutical industry and private healthcare services). Our statistical analyses included results from 149 studies of 160,267 children. We found that children who were helped with a strategy to change their activity levels alone or in combination with a strategy to change their diet may have their BMI reduced, compared with children who were not given any strategy. This means that these children may have been able to minimise their excess weight gain by a small amount which, for public health, is important. In contrast, children who were helped with a strategy to change their diet only did not have their BMI reduced. Only a few studies reported any possible harms of the strategies, and no serious harms were identified in these. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low. However, it is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. A lot of the studies had limitations in how they were done. 3. There were not enough studies reporting particular types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons, and also certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way such that we could include them in our analyses (e.g. without any detail of the difference between the strategies examined) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for children with disabilities, or whether those implemented in community settings are effective. How up‐to‐date is this evidence? This review updates our previous review. The evidence is up‐to‐date to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F, Davies, AL, Tomlinson, E, Moore, THM, Dawson, S, Breheny, K, Savović, J, Gao, Y, Phillips, SM, Hillier-Brown, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015328.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.789Z" }, { "id": "3ea0811f-0320-4e3b-9f0d-7ed7232446d9", "pmid": "", "title": "Pimozide for schizophrenia or related psychoses", "imported": false, "abstract": "Abstract - Background Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been associated with cardiotoxicity and sudden unexplained death. Electrocardiogram monitoring is now required before and during use. Objectives To review the effects of pimozide for people with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medication. A secondary objective was to examine the effects of pimozide for people with delusional disorder. Search methods We searched the Cochrane Schizophrenia Group's Register (28 January 2013). Selection criteria We sought all relevant randomised clinical trials (RCTs) comparing pimozide with other treatments. Data collection and analysis Working independently, we inspected citations, ordered papers and then re‐inspected and assessed the quality of the studies and of extracted data. For homogeneous dichotomous data, we calculated the relative risk (RR), the 95% confidence interval (CI) and mean differences (MDs) for continuous data. We excluded data if loss to follow‐up was greater than 50%. We assessed risk of bias for included studies and used GRADE to rate the quality of the evidence. Main results We included 32 studies in total: Among the five studies that compared pimozide versus placebo, only one study provided data for global state relapse, for which no difference between groups was noted at medium term (1 RCT n = 20, RR 0.22 CI 0.03 to 1.78, very low quality of evidence ). None of the five studies provided data for no improvement or first‐rank symptoms in mental state. Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (1 RCT, n = 19, RR 5.50 CI 0.30 to 101.28, very low quality of evidence ) or at medium term (1 RCT n = 25, RR 1.33 CI 0.14 to 12.82, very low quality of evidence ), or for Parkinsonism (tremor) at medium term (1 RCT n = 25, RR 1 CI 0.2 to 4.95, very low quality of evidence ). No data were reported for quality of life at medium term. Of the 26 studies comparing pimozide versus any antipsychotic, seven studies provided data for global state relapse at medium term, for which no difference was noted (7 RCTs n = 227, RR 0.82 CI 0.57 to 1.17, moderate quality of evidence ). Data from one study demonstrated no difference in mental state (no improvement) at medium term (1 RCT n = 23, RR 1.09 CI 0.08 to 15.41, very low quality evidence ); another study demonstrated no difference in the presence of first‐rank symptoms at medium term (1 RCT n = 44, RR 0.53 CI 0.25 to 1.11, low quality of evidence ). Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (6 RCTs n = 186, RR 1.21 CI 0.71 to 2.05, low quality of evidence ) or medium term (5 RCTs n = 219, RR 1.12 CI 0.24 to 5.25, low quality of evidence ), or for Parkinsonism (tremor) at medium term (4 RCTs n = 174, RR 1.46 CI 0.68 to 3.11, very low quality of evidence ). No data were reported for quality of life at medium term. In the one study that compared pimozide plus any antipsychotic versus the same antipsychotic, significantly fewer relapses were noted in the augmented pimozide group at medium term (1 RCT n = 69, RR 0.28 CI 0.15 to 0.50, low quality evidence ). No data were reported for mental state outcomes or for extrapyramidal symptoms (EPS). Data were skewed for quality of life scores, which were not included in the meta‐analysis but were presented separately. Two studies compared pimozide plus any antipsychotics versus antipsychotic plus placebo; neither study reported data for outcomes of interest, apart from Parkinsonism at medium term and quality of life using the Specific Level of Functioning scale (SLOF); however, data were skewed. Only one study compared pimozide plus any antipsychotic versus antipsychotics plus antipsychotic; no data were reported for global state and mental state outcomes of interest. Data were provided for Parkinsonism (rigidity and tremor) using the Extrapyramidal Symptom Rating Scale (ESRS); however, these data were skewed. Authors' conclusions Although shortcomings in the data are evident, enough overall consistency over different outcomes and time scales is present to confirm that pimozide is a drug with efficacy similar to that of other, more commonly used antipsychotic drugs such as chlorpromazine for people with schizophrenia. No data support or refute its use for those with delusional disorder. Plain language summary Pimozide for schizophrenia or related psychoses People with schizophrenia have ‘positive symptoms’ such as hearing voices and seeing things (hallucinations) and fixed strange beliefs (delusions). People with schizophrenia also have ‘negative symptoms’ such as tiredness, apathy and loss of emotion. Antipsychotic drugs are the main treatment for the symptoms of schizophrenia and can be grouped into older drugs (first generation or ‘typical’) and newer drugs (second generation or ‘atypical’). Pimozide is a ‘typical’ antipsychotic drug that was first introduced in the late 1960s and was given to people with schizophrenia. Pimozide is thought to be effective in treating the positive and negative symptoms of schizophrenia or similar mental health problems such as delusional disorder, but it produces serious side effects such as muscle stiffness, tremors and slow body movements. Pimozide may also cause heart problems and has been linked to sudden unexplained death. Monitoring the heart via electrocardiogram is now required before and during treatment with pimozide. It is well known that people with mental health problems suffer from physical illnesses such as heart disease and diabetes and can die on average twenty years younger than those in the general population.
 An update search for this review was carried out 28 January 2013; the review now includes 32 studies that assess the effects of pimozide for people with schizophrenia or similar mental health problems. Pimozide was compared with other antipsychotic drugs, placebo (‘dummy’ treatment) or no treatment. Results suggest that pimozide is probably just as effective as other commonly used ‘typical’ antipsychotic drugs (for outcomes such as treating mental state, relapse, leaving the study early). No studies included delusional disorders, so no information is available on this group of people. No evidence was found to support the concern that pimozide causes heart problems (although this may be result of the fact that the studies were small and short term and the participants did not receive doses above recommended limits of 20 mg/d). Pimozide may cause less sleepiness than other typical antipsychotic drugs, but it may cause more tremors and uncontrollable shaking. The claim that pimozide is useful for treating people with negative symptoms also is not supported and proven. However, the quality of evidence in the main was low or very low quality, studies were small and of short duration and were poorly reported. Large‐scale, well‐conducted and well‐reported studies are required to assess the effectiveness of pimozide in the treatment of schizophrenia and other mental health problems such as delusional disorder. This plain language summary has been written by a consumer, Benjamin Gray (Service User and Service User Expert, Rethink Mental Illness).", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Mothi, M; Sampson, S", "articleTypes": [], "doi": "10.1002/14651858.CD001949.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "3eadcae8-c2fd-403f-bacc-34ab6dbc860c", "pmid": "", "title": "Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years", "imported": false, "abstract": "Abstract - Background Child and adolescent overweight and obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages. Objectives To assess the effects of diet, physical activity and behavioural interventions (behaviour‐changing interventions) for the treatment of overweight or obese children aged 6 to 11 years. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases. Selection criteria We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour‐changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow‐up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. Data collection and analysis Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta‐analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty‐five trials compared a behaviour‐changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour‐changing intervention. Sixty‐four trials were parallel RCTs, and four were cluster RCTs. Sixty‐four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2. Primary analyses demonstrated that behaviour‐changing interventions compared to no treatment/usual care control at longest follow‐up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was ‐0.53 kg/m 2 (95% confidence interval (CI) ‐0.82 to ‐0.24); P < 0.00001; 24 trials; 2785 participants; low‐quality evidence. MD in BMI z score was ‐0.06 units (95% CI ‐0.10 to ‐0.02); P = 0.001; 37 trials; 4019 participants; low‐quality evidence and MD in weight was ‐1.45 kg (95% CI ‐1.88 to ‐1.02); P < 0.00001; 17 trials; 1774 participants; low‐quality evidence. Thirty‐one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health‐related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI ‐12.88 to ‐0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all‐cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta‐analysed. As the meta‐analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post‐intervention follow‐up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post‐intervention was no longer evident at follow‐up at less than six months, which has to be investigated in further trials. Authors' conclusions Multi‐component behaviour‐changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short‐term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour‐changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour‐changing interventions on health‐related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer‐term follow‐up and further research on the most appropriate forms of post‐intervention maintenance in order to ensure intervention benefits are sustained over the longer term. Plain language summary Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years Review question How effective are diet, physical activity and behavioural interventions in reducing the weight of overweight or obese children aged 6 to 11 years? Background Across the world more children are becoming overweight and obese. These children are more likely to suffer from health problems, both while as children and in later life. More information is needed about what works best for treating this problem. Study characteristics We found 70 randomised controlled trials (clinical trials where people are randomly put into one of two or more treatment groups) comparing diet, physical activity, and behavioural (where habits are changed or improved) treatments to a variety of control groups delivered to 8461 overweight or obese children aged 6 to 11 years. We reported on the effects of 64 multicomponent interventions (different combinations of diet and physical activity and behaviour change), four physical activity interventions and two dietary interventions compared with no intervention, 'usual care’ or some other therapy if it was also delivered in the intervention arm. The children in the included studies were followed up between six months and three years. Key results The average age of the children was 10 years. Most studies reported the body mass index (BMI) z score: BMI is a measure of body fat and is calculated by dividing weight (in kilograms) by the square of the body height measured in metres (kg/m²). In children, BMI is often measured in a way that takes into account sex and age, weight, and height changes as children grow older (BMI z score). We summarised the results of 37 trials in 4019 children reporting the BMI z score, which on average was 0.06 units lower in the intervention groups compared with the control groups. We summarised the results of 24 trials in 2785 children reporting BMI, which on average was 0.53 kg/m 2 lower in the intervention groups compared with the control groups. We summarised the results of 17 trials in 1774 children reporting weight, which on average was 1.45 kg lower in the intervention groups compared with the control groups. Other effects of the interventions, such as improvements in health‐related quality of life were less clear. No study investigated death from any cause, morbidity or socioeconomic effects. Serious adverse events were rare: only two of 31 trials with data reported any serious adverse events (4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). This evidence is up to date as of July 2016. Quality of the evidence The overall quality of the evidence was low or very low, mainly because of limited confidence in how studies were performed, and the results were inconsistent between the studies. Also there were just a few studies for some outcomes, with small numbers of included children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Mead, E; Brown, T; Rees, K; Azevedo, LB; Whittaker, V; Jones, D; Olajide, J; Mainardi, GM; Corpeleijn, E; O'Malley, C; Beardsmore, E; Al‐Khudairy, L; Baur, L; Metzendorf, MI; Demaio, A; Ells, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012651", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "3ebf4cb1-9e39-43fd-882b-4651c2e04d80", "pmid": "", "title": "Pharmacological interventions for people with borderline personality disorder", "imported": false, "abstract": "Abstract - Background Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off‐label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods. Objectives To assess the effects of pharmacological treatment for people with BPD. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. Selection criteria Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events. Data collection and analysis At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. Main results We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty‐nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD ‐0.18, 95% confidence interval (CI) ‐0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD −0.27, 95% CI −0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD −0.07, 95% CI −0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self‐harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale‐Modified‐Self‐Injury item (0‐5 points), 95% CI −10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide‐related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI −0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD −0.26, 95% CI −1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD −0.36, 95% CI −1.96 to 1.25; 2 trials, 44 participants). Very low‐certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD −0.16, 95% CI −0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD −0.25, 95% CI ‐0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD −0.01, 95% CI ‐0.28 to 0.26; 2 trials, 214 participants). Low‐certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD −0.21, 95% CI −0.34 to ‐0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD −0.58, 95% CI ‐1.14 to ‐0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD −0.07, 95% CI ‐0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low‐certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non‐standardised. The available evidence on non‐serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified. Authors' conclusions This review included 18 more trials than the 2010 version, so larger meta‐analyses with more statistical power were feasible. We found mostly very low‐certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma‐related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples. Plain language summary What are the benefits and risks of medication for people with borderline personality disorder? Key messages This review is an update of a previous review on the same topic published in 2010. Although this review includes an additional 18 studies, the conclusions remain the same: there are probably no benefits and risks of medications for borderline personality disorder (BDP), but the evidence is unclear. Better and larger studies comparing the effects of medication with placebo are needed. Such studies should focus on men, adolescents and those with additional psychiatric diagnoses. What is BPD? BPD affects how a person interacts with others and understands one's self. Although its exact causes are unclear, it is thought to result from a combination of genetic and environmental factors (e.g. stressful or traumatic life events when growing up). Approximately 2% of adults and 3% of adolescents are affected. The symptoms of BPD can be grouped into four categories. Instability in mood: People with BPD may experience intense feelings that change rapidly and are difficult to control. They may also feel empty and abandoned much of the time. Cognitive distortions (disturbed patterns of thinking): People with BPD often have upsetting thoughts (e.g. they may think that they are a terrible person). They can have brief episodes of strange experiences (e.g. paranoid ideations or stress‐induced dissociative experiences (i.e. feeling detached from the world around them). Impulsive behaviour: People with BPD may act impulsively and do things that could harm themselves (e.g. when sad and depressed, they may self‐harm or have suicidal feelings). They might also engage in reckless behaviour (e.g. drug misuse). Intense but unstable relationships: People with BPD may find it difficult to keep stable relationships (e.g. they may feel very worried about being abandoned and might constantly text or call, or make threats to harm or kill themselves if the person leaves them). A person only needs to experience five out of nine criteria across these categories to be given a diagnosis of BPD. How is BPD treated? No medication has been approved for the treatment of BPD. Nonetheless, a large proportion of people with BPD are given medications for sustained periods of time to alleviate their symptoms. The type of medication given is chosen based on its known effects on other disorders with similar symptoms. Review question We wanted to find out whether medications to treat BPD work better or worse than placebo; whether one medication works better than another; or whether one combination of medications work better than another combination of medications. We wanted to look at how well medications worked on BPD severity, self‐harm, suicide‐related outcomes, and functioning (how well a person performs in everyday life). We also wanted to find out if medications are associated with any unwanted side effects. What did we do? We searched for studies that compared the effects of different medications with placebo, another medication, or a combination of medications, in people diagnosed with BPD. We compared and summarised the results and rated our confidence in the evidence based on factors such as sample size and methods used. Below, we present the findings from our key comparison: medication versus placebo. What did we find? We found 46 studies that involved 2769 people with BPD. The smallest study had 13 participants and the largest 451 participants. There were four studies with more than 100 participants. Except for one study that included men only, all studies included women. The average age of the participants ranged from 16 years to 39 years. Most studies were conducted in outpatient settings (31 studies) in Europe (20 studies) and lasted between four and 52 weeks. Pharmaceutical companies fully or partially funded 16 studies. The studies looked at the effects of 27 different medications, mostly classified as: 1) antipsychotics (drugs to treat psychosis where a person’s thoughts and mood are so impaired that the person has lost contact with reality); 2) antidepressants (drugs to treat depression); or 3) mood stabilisers (drugs to control and even out mood swings, reducing both high moods (mania) and low moods (depression)). Compared with placebo, medications seem to make little to no difference to BPD severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. They may make little to no difference as to whether a person continues in a study or drops out. Compared to placebo, antipsychotics and mood stabilisers may make little to no difference to the occurrence of unwanted or harmful effects. No study reported on the side effects of antidepressants. What are the limitations of the evidence? Our confidence in the evidence varied between very low and low. The results of future research could differ from the results of this review. Four main factors reduced our confidence in the evidence. First, not all of the studies provided data about everything that we were interested in. Second, the results were very inconsistent across the different studies. Third, there were not enough studies to be certain about the results of our outcomes. Fourth, many studies did not clearly report how they were conducted. How up‐to‐date is this evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Stoffers-Winterling, JM, Storebø, OJ, Pereira Ribeiro, J, Kongerslev, MT, Völlm, BA, Mattivi, JT, Faltinsen, E, Todorovac, A, Jørgensen, MS, Callesen, HE, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.800Z" }, { "id": "3ecafe0e-2fbf-4d0b-95bd-bb7ec4fea9b2", "pmid": "", "title": "Antidepressants for pain management in adults with chronic pain: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well‐being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients’ global impression of change for certain chronic pain conditions. However, there has not been a network meta‐analysis (NMA) examining all antidepressants across all chronic pain conditions. Objectives To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache). Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022. Selection criteria We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double‐blind. We included RCTs with active comparators that were unable to be double‐blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow‐up was less than two weeks and those with fewer than 10 participants in each arm. Data collection and analysis Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta‐analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta‐Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta‐analysis (ROB‐MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB‐MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal. Main results This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo‐controlled (83), and parallel−armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short‐term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest‐ranked antidepressant with moderate‐ to high‐certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate‐certainty evidence) and continuous pain intensity (standardised mean difference (SMD) −0.31, 95% CI −0.39 to −0.24; 18 studies, 4959 participants; moderate‐certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD −0.22, 95% CI −0.39 to 0.06; 4 studies, 1866 participants; moderate‐certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD −0.5, 95% CI −0.78 to −0.22; 1 study, 406 participants; low‐certainty evidence), while duloxetine showed a small effect (SMD −0.16, 95% CI −0.22 to −0.1; 26 studies, 7952 participants; moderate‐certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest‐ranked antidepressants with moderate‐certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low‐certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes. Authors' conclusions Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high‐quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long‐term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point. Plain language summary How effective are antidepressants used to treat chronic pain and do they cause unwanted effects? Key messages • We are only confident in the effectiveness of one antidepressant: duloxetine. We found that a standard dose (60 mg) was effective, and that there is no benefit to using a higher dose. • We are uncertain about unwanted effects for any antidepressant as the data for this were very poor. Future research should address this. • In clinical practice for chronic pain, a standard dose of duloxetine may be considered before trying other antidepressants. • Adopting a person‐centred approach is critical. Pain is a very individual experience and certain medications may work for people even while the research evidence is inconclusive or unavailable. Future studies should last longer and focus on unwanted effects of antidepressants. What is chronic pain? Chronic pain is pain of any kind that lasts for more than three months. Over one‐third of people across the world experience chronic pain. This often affects people's mood and well‐being, and their ability to work and carry out daily tasks. How do antidepressants treat chronic pain? Antidepressants are medications originally developed to treat depression. Different types of antidepressants work in different ways. Antidepressants that work in the same way are grouped into classes. The most common classes are selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and serotonin‐noradrenalin reuptake inhibitors (SNRIs). Research suggests that antidepressants may be effective for pain because the same chemicals that affect mood might also affect pain. What did we want to find out? We wanted to find out if antidepressants were effective for managing chronic pain and whether they cause unwanted effects. What did we do? We searched for studies that compared any antidepressant with any other treatment for any type of chronic pain (except headache). We compared all the treatments against each other using a statistical method called network meta‐analysis. This method allows us to rank the effectiveness of the different antidepressants from best to worst. What did we find? We found 176 studies including 28,664 people with chronic pain. These studies investigated 89 different types or combinations of treatment. Studies mainly investigated the effect of antidepressants on three different types of pain: fibromyalgia (59 studies), nerve pain (49 studies), and musculoskeletal pain (e.g. osteoarthritis or low back pain; 40 studies). The most common antidepressant classes investigated were SNRIs (74 studies), TCAs (72 studies), and SSRIs (34 studies). The most common antidepressants investigated were: amitriptyline (a TCA; 43 studies); duloxetine (an SNRI; 43 studies), and milnacipran (an SNRI; 18 studies). Of the 146 studies that reported where their funding came from, pharmaceutical companies funded 72 studies. The average study lasted 10 weeks. Most of the studies compared an antidepressant with a placebo (which looks like the real medicine but doesn’t have any medicine in it), but some studies compared an antidepressant against a different type of medicine, a different antidepressant, a different type of treatment (like physiotherapy), or different doses of the same antidepressant. Most of the studies in this review reported information on pain relief and unwanted effects. Fewer studies reported on quality of life, sleep, and physical function. Main results • Duloxetine probably has a moderate effect on reducing pain and improving physical function. It was the antidepressant that we have the most confidence in. Higher doses of duloxetine probably provided no extra benefits than standard doses. For every 1000 people taking standard‐dose duloxetine, 435 will experience 50% pain relief compared with 287 who will experience 50% pain relief taking placebo. • Milnacipran may reduce pain, but we are not as confident in this result as duloxetine because there were fewer studies with fewer people involved. • Most studies excluded people with mental health conditions, meaning that participants were already in the 'normal' ranges for anxiety and depression at the beginning of studies. This limited our analysis for mood. Mirtazapine and duloxetine may improve mood, but we are very uncertain about the results. • We do not know about unwanted effects of using antidepressants for chronic pain; there are not enough data to be certain about the results. What are the limitations of the evidence? There are still a number of questions that we were unable to answer: • Aside from duloxetine and milnacipran, we do not have confidence in the results from any other antidepressant included in this review because there are not enough studies. • We do not know whether antidepressants are effective at treating pain in the long term. The average length of studies was 10 weeks. • There was no reliable evidence on the safety of taking antidepressants for chronic pain, both short‐ and long‐term. • We do not know how effective antidepressants are for people with both chronic pain and depression as the most studies excluded participants with depression and anxiety. How up to date is this evidence? This review is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Birkinshaw, H, Friedrich, CM, Cole, P, Eccleston, C, Serfaty, M, Stewart, G, White, S, Moore, RA, Phillippo, D, Pincus, T", "articleTypes": [], "doi": "10.1002/14651858.CD014682.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.813Z" }, { "id": "3ed8e480-6276-4ade-83cd-654504cf339f", "pmid": "", "title": "Glutamatergic drugs for schizophrenia", "imported": false, "abstract": "Abstract - Background It has been shown that central nervous system dopamine can play a major role in the pathophysiology of schizophrenia. Brain glutamate is thought to mediate symptoms in schizophrenia due to the influence of glutamate neurons on the dopaminergic transmission in the brain. It might be possible to decrease negative symptoms and the cognitive impairment of people with schizophrenia by treatment with glutamatergic drugs. Objectives To determine the efficacy of glutamatergic drugs in the treatment of schizophrenia. Search methods We searched the Cochrane Schizophrenia Group's Trials Register (May 2002 and October 2003), inspected references of all identified studies and contacted relevant authors. Selection criteria We included all randomised controlled trials in which glutamatergic medication was administered to people with schizophrenia. Data collection and analysis We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results We included eighteen short‐term trials with 358 randomised participants. The single studies were small with numbers of participants ranging between six and 51. All trials were short‐term trials with a maximum duration of 12 weeks. In all of these trials, glycine, D‐serine, D‐cycloserine, or ampakine CX516 was used to augment the effect of antipsychotic drugs. D‐cycloserine, a partial agonist of NMDA receptors' glycine site, seemed ineffective towards the symptoms of schizophrenia. NMDA receptor co‐agonists glycine and D‐serine showed some effects in reducing the negative symptoms of schizophrenia (n=132, SMD ‐0.66, CI ‐1.0 to ‐0.3, p=0.0004), but the magnitude of the effect was moderate. Furthermore, when responder rates rather than mean scores of negative symptoms were analysed the data were inconsistent: There was no difference in responder rates between glycine and the control in terms of more than 20% improvement of negative symptoms (n=62, RR 0.70, CI 0.3 to 1.71) and only a borderline significant superiority in terms of more than 50% improvement (n=62, RR 0.87, CI 0.8 to 1.00). There were also some effects in favour of glycine and/or D‐serine in terms of overall and general symptoms, but the results were again inconsistent and depended on the response definition applied. Available rating scale data on positive symptoms and cognitive functioning did not indicate a statistically significant effect of glycine or D‐serine. Authors' conclusions In general, all glutamatergic drugs appeared to be ineffective in further reducing positive symptoms of the disease when added to the existing antipsychotic treatment. Glycine and D‐serine may somewhat improve negative symptoms when added to regular antipsychotic medication, but the results were not fully consistent and data are too few to allow any firm conclusions. Many participants in the included trials were treatment‐resistant which may have reduced treatment response. Additional research on glutamatergic mechanisms of schizophrenia is needed. Plain language summary Glutamatergic drugs for schizophrenia Schizophrenia is a severe psychiatric disease characterised by positive symptoms such as hallucinations and delusions and negative symptoms such as blunted affect and emotional withdrawal. People with schizophrenia may also suffer from cognitive deficits. Current medication is effective in reducing positive symptoms, but negative and cognitive symptoms are fairly resistant to treatment. Antipsychotic drugs act mainly on the dopamine system in the brain, although other neurotransmitter systems may also play a role in schizophrenia. We sought to review all randomised trials that used glutamatergic drugs in the treatment of schizophrenia. This review shows that substances acting on the glutamate system may improve symptoms when added to regular antipsychotic medication, although the available evidence base is too limited to allow for any firm conclusions. Presently, glutamatergic drugs are not available for clinical use. Additional research is needed to determine their ultimate role in the treatment of schizophrenia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Tiihonen, J, Wahlbeck, K", "articleTypes": [], "doi": "10.1002/14651858.CD003730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.102Z" }, { "id": "3eeca34d-bfff-447f-aa5f-a8979b22c72a", "pmid": "", "title": "Topiramate for essential tremor", "imported": false, "abstract": "Abstract - Background Essential tremor (ET) is one of the most common movement disorders. The management is primarily based on pharmacological agents and in clinical practice propranolol and primidone are considered the first‐line therapy. However, these treatments can be ineffective in 25% to 55% of people and are frequently associated with serious adverse events (AEs). For these reasons, it is worthwhile evaluating other treatments for ET. Topiramate has been suggested as a potentially useful agent for the treatment of ET but there is uncertainty about its efficacy and safety. Objectives To assess the efficacy and safety of topiramate in the treatment of ET. Search methods We carried out a systematic search without language restrictions to identify all relevant trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to January 2017), Embase (January 1988 to January 2017), National Institute for Health and Care Excellence (1999 to January 2017), ClinicalTrials.gov (1997 to January 2017) and World Health Organization International Clinical Trials Registry Platform (ICTRP; 2004 to January 2017). We searched BIOSIS Citation Index (2000 to January 2017) for conference proceedings. We handsearched grey literature and the reference lists of identified studies and reviews. Selection criteria We included all randomised controlled trials (RCTs) of topiramate versus placebo/open control or any other treatments. We included studies in which the diagnosis of ET was made according to accepted and validated diagnostic criteria. We excluded studies conducted in people presenting with secondary forms of tremor or reporting only neurophysiological parameters to assess outcomes. Data collection and analysis Two review authors independently collected and extracted data using a data collection form. We assessed the risk of bias and the quality of evidence. We used a fixed‐effect meta‐analysis for data synthesis. Main results This review included three trials comparing topiramate to placebo (309 participants). They were all at high overall risk of bias. The quality of evidence ranged from very low to low. Compared to placebo, participants treated with topiramate showed a significant improvement in functional disability and an increased risk of withdrawal (risk ratio (RR) 1.78, 95% confidence interval (CI) 1.23 to 2.60). There were more AEs for topiramate‐treated participants, particularly paraesthesia, weight loss, appetite decrease and memory difficulty. Authors' conclusions This systematic review highlighted the presence of limited data and very low to low quality evidence to support the apparent efficacy and the occurrence of treatment‐limiting AEs in people with ET treated with topiramate. Further research to assess topiramate efficacy and safety on ET is needed. Plain language summary Use of topiramate for the treatment of essential tremor Review question The authors of this review tried to assess the effectiveness and safety of topiramate in people with essential tremor. Background Essential tremor is a type of uncontrollable shaking or trembling of parts of the body. Although it is not harmful in terms of its effect on life expectancy, it generally gets worse and may be disabling. Treatment is usually with medicines (called propranolol and primidone), which may not work in a quarter to a half of people with essential tremor. Some specialists have suggested that another medicine, topiramate, could be useful for treating the condition. Study characteristics We searched medical databases for studies of topiramate compared with placebo (a pretend tablet) or any other medicine in adults with essential tremor. We found three studies comparing topiramate versus placebo, involving 309 participants with moderate to severe essential tremor. Key results The effect of topiramate on daily activities, risk of stopping treatment and side effects was uncertain because the quality of evidence was very low to low. Quality of evidence We only found a few studies that had problems with their methods so we could not make firm conclusions about how well topiramate works and if it has side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Bruno, E, Nicoletti, A, Quattrocchi, G, Allegra, R, Filippini, G, Colosimo, C, Zappia, M", "articleTypes": [], "doi": "10.1002/14651858.CD009683.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.755Z" }, { "id": "3eedef10-d1b5-488f-8c35-5cf86df293d9", "pmid": "", "title": "A Randomized, Double Blinded, Placebo-controlled, Multicenter, Phase III Study to Evaluate the Efficacy and Safety of Losartan in Early Immunoglobulin A Nephropathy (IgAN) Patients", "imported": false, "abstract": "Immunoglobulin A nephropathy (IgAN) is the most common glomerulonephritis worldwide. IgAN is progressive, particularly when patients have a significant proteinuria (proteinuria >1g/g creatinine), impaired kidney function, or elevated blood pressure. In 10 years, nearly 20-40% of these IgAN patients progress to end-stage renal disease (ESRD). Early IgAN is tentatively defined when proteinuria is insignificant and kidney function and blood pressure are normal. Patients with early IgAN rarely progress to ESRD. However, 30-40% of patients with early IgAN ultimately developed a significant proteinuria and hypertension in 10 years. Therefore, earlier intervention may be needed if it can prevent the development of a significant proteinuria and hypertension. Since angiotensin ll receptor blocker (ARB) is drug of choice in reducing proteinuria and controlling blood pressure, the investigators hypothesized that early introduction of ARB may be beneficial in preventing the significant proteinuria development in early IgAN patients. To prove the hypothesis, the investigators plan the current interventional study.", "journal": "", "year": "2017", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.241Z" }, { "id": "3eef9108-1345-4474-be7f-6c536af8aa12", "pmid": "", "title": "Environmental interventions to reduce the consumption of sugar‐sweetened beverages and their effects on health", "imported": false, "abstract": "Abstract - Background Frequent consumption of excess amounts of sugar‐sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB. Objectives To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar‐sweetened beverages and sugar‐sweetened milk, diet‐related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes. Search methods We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors. Selection criteria We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet‐related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) and interrupted‐time‐series (ITS) studies, implemented in real‐world settings with a combined length of intervention and follow‐up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB‐specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review. Data collection and analysis Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta‐analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented ‘Summary of findings’ tables. Main results We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow‐up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non‐randomised designs. The studies examine a broad range of interventions, and we present results for these separately. Labelling interventions (8 studies): We found moderate‐certainty evidence that traffic‐light labelling is associated with decreasing sales of SSBs, and low‐certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu‐board calorie labelling reported effects on SSB sales varied. Nutrition standards in public institutions (16 studies): We found low‐certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low‐certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied. Economic tools (7 studies): We found moderate‐certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low‐calorie beverages reported effects on SSB sales varied. Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied. Retail and food service interventions (7 studies): We found low‐certainty evidence that healthier default beverages in children’s menus in chain restaurants are associated with decreasing SSB sales, and moderate‐certainty evidence that in‐store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low‐certainty evidence that urban planning restrictions on new fast‐food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied. Intersectoral approaches (8 studies): We found moderate‐certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate‐certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied. Home‐based interventions (7 studies): We found moderate‐certainty evidence that improved availability of low‐calorie beverages in the home environment is associated with decreased SSB intake, and high‐certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs. Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low‐calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes. We analysed interventions targeting sugar‐sweetened milk separately, and found low‐ to moderate‐certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar‐sweetened milk. We found low‐certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar‐sweetened milk consumption. Authors' conclusions The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high‐quality evaluations using appropriate study designs, with a particular focus on the long‐term effects of approaches suitable for large‐scale implementation. Plain language summary Cutting back on sugar‐sweetened beverages: What works? What are sugar‐sweetened beverages? Sugar‐sweetened beverages (SSBs) are cold and hot drinks with added sugar. Common SSBs are non‐diet soft drinks, regular soda, iced tea, sports drinks, energy drinks, fruit punches, sweetened waters, and sweetened tea and coffee. Why are SSBs an important health topic? Research shows that people who drink a lot of SSBs often gain weight. Drinking a lot of SSBs can also increase the risk of diabetes, heart disease, and dental decay. Doctors therefore recommend that children, teenagers and adults drink fewer SSBs. Governments, businesses, schools and workplaces have taken various measures to support healthier beverage choices. What is the aim of this review? We wanted to find out whether the measures taken so far have been successful in helping people to drink fewer SSBs to improve their health. We focused on measures that change the environment in which people make beverage choices. We did not look at studies on educational programmes or on SSB taxes, as these are examined in separate reviews. (We did, however, examine price increases on SSB which were not due to taxes.) We searched for all available studies meeting clearly‐defined criteria to answer this question. This review reflects the state of the evidence up until January 2018. What studies did we find? We found 58 studies, which included more than one million adults, teenagers and children. Most studies lasted about one year, and were done in schools, stores or restaurants. Some studies used methods that are not very reliable. For example, in some studies participants were simply asked how much SSB they drank, which is not very reliable, as people sometimes forget how much SSB they drank. Some of the findings of our review may therefore change when more and better studies become available. What do these studies tell us? We have found some evidence that some of the measures implemented to help people drink fewer SSBs have been successful, including the following: ▪ Labels which are easy to understand, such as traffic‐light labels, and labels which rate the healthfulness of beverages with stars or numbers. ▪ Limits to the availability of SSB in schools (e.g. replacing SSBs with water in school cafeterias). ▪ Price increases on SSBs in restaurants, stores and leisure centres. ▪ Children’s menus in chain restaurants which include healthier beverages as their standard beverage. ▪ Promotion of healthier beverages in supermarkets. ▪ Government food benefits (e.g. food stamps) which cannot be used to buy SSBs. ▪ Community campaigns focused on SSBs. ▪ Measures that improve the availability of low‐calorie beverages at home, e.g. through home deliveries of bottled water and diet beverages. We have also found some evidence that improved availability of drinking water and diet beverages at home can help people lose weight. There are also other measures which may influence how much SSB people drink, but for these the available evidence is less certain. Some, but not all studies found that such measures can have effects which were not intended and which may be negative. Some studies reported that profits of stores and restaurants decreased when the measures were implemented, but other studies showed that profits increased or stayed the same. Children who get free drinking water in schools may drink less milk. Some studies reported that people were unhappy with the measures. We also looked at studies on sugar‐sweetened milk. We found that small prizes for children who chose plain milk in their school cafeteria, as well as emoticon labels, may help children drink less sugar‐sweetened milk. However, this may also drive up the share of milk which is wasted because children choose but do not drink it. What does this mean in practice? Our review shows that measures which change the environment in which people make beverage choices can help people drink less SSB. Based on our findings we suggest that such measures may be used more widely. Government officials, business people and health professionals implementing such measures should work together with researchers to find out more about their effects in the short and long term.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "von Philipsborn, P; Stratil, JM; Burns, J; Busert, LK; Pfadenhauer, LM; Polus, S; Holzapfel, C; Hauner, H; Rehfuess, E", "articleTypes": [], "doi": "10.1002/14651858.CD012292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "3f03ec89-3b19-4094-82eb-9b1847d7464b", "pmid": "", "title": "Statins for children with familial hypercholesterolemia", "imported": false, "abstract": "Abstract - Background Familial hypercholesterolemia is one of the most common inherited metabolic diseases and is an autosomal dominant disorder meaning heterozygotes, or carriers, are affected. Those who are homozygous have severe disease. The average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500, although recent genetic epidemiological data from Denmark and next generation sequencing data suggest the frequency may be closer to 1 in 250. Diagnosis of familial hypercholesterolemia in children is based on elevated total cholesterol and low‐density lipoprotein cholesterol levels or DNA‐based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong treatment, started in childhood, is needed to reduce the risk of cardiovascular disease. In children with the disease, diet was the cornerstone of treatment but the addition of lipid‐lowering medications has resulted in a significant improvement in treatment. Anion exchange resins, such as cholestyramine and colestipol, were found to be effective, but they are poorly tolerated. Since the 1990s studies carried out on children aged 6 to 17 years with heterozygous familial hypercholesterolemia have demonstrated significant reductions in their serum total and low‐density lipoprotein cholesterol levels. While statins seem to be safe and well‐tolerated in children, their long‐term safety in this age group is not firmly established. This is an update of a previously published version of this Cochane Review. Objectives To assess the effectiveness and safety of statins in children with heterozygous familial hypercholesterolemia. Search methods Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline. Date of most recent search: 04 November 2019. Selection criteria Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. Data collection and analysis Two authors independently assessed studies for inclusion and extracted data. Main results We found 26 potentially eligible studies, of which we included nine randomized placebo‐controlled studies (1177 participants). In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). There may be little or no difference in liver function (serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations) between treated and placebo groups at any time point (low‐quality evidence). There may be little or no difference in myopathy (as measured in change in creatinine levels) (low‐quality evidence) or clinical adverse events (moderate‐quality evidence) with statins compared to placebo. One study on simvastatin showed that this may slightly improve flow‐mediated dilatation of the brachial artery (low‐quality evidence), and on pravastatin for two years may have induced a regression in carotid intima media thickness (low‐quality evidence). No studies reported rhabdomyolysis (degeneration of skeletal muscle tissue) or death due to rhabdomyolysis, quality of life or compliance to study medication. Authors' conclusions Statin treatment is an effective lipid‐lowering therapy in children with familial hypercholesterolemia. Few or no safety issues were identified. Statin treatment seems to be safe in the short term, but long‐term safety remains unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians and their care transferred to an adult lipidologist once they reach 18 years of age. Large long‐term randomized controlled trials are needed to establish the long‐term safety issues of statins. Plain language summary Statins for children with inherited high blood cholesterol Review question We reviewed the evidence for the effectiveness and safety of statins in children with inherited high blood cholesterol. Background Familial hypercholesterolemia is an inherited disease in which the blood cholesterol level is high. Vascular disease, i.e. furring up of the blood vessels, often occurs at an earlier age than usual, especially amongst men. Thus lifelong therapies, started in childhood, to reduce blood cholesterol are needed. In children with familial hypercholesterolemia, diet has been the main treatment option. Medications, such as cholestyramine and colestipol, have been used effectively, but due to their unpleasant taste they are poorly tolerated and treatment plans are not followed. The advent of statin therapy for children has improved treatment and this review updates the previous published version. Search date The evidence is current to: 04 November 2019. Study characteristics The review included 9 studies with 1177 people with heterozygous familial hypercholesterolemia aged between 4 and 18 years of age. Studies compared different statin treatments with a substance which contains no medication (termed placebo) and people were selected for one treatment or the other randomly. The studies lasted from 12 weeks to 104 weeks. Key results In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins probably reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). The levels of the liver enzymes, serum aspartate and alanine aminotransferase, and the muscle enzyme, creatinine kinase, did not differ between treated and placebo groups at any time point (low‐quality evidence). The risks of myopathy (disease of muscle tissue) and side‐effects were very low and similar in both groups (low‐quality evidence). Two of the statins, simvastatin and pravastatin may have a positive effect on two of the major blood vessels typically affected by raised cholesterol levels (low‐quality evidence). Quality of the evidence Information regarding blinding (performance bias and detection bias), was available for all nine studies; each was described as double blind, indicating that participants and those participating in treatment procedures were blinded to treatment. In two studies information on how the participants were allocated to treatment groups (selection bias) was clearly presented, but this information was not clearly stated in the remaining seven studies. There is a lack of information whether investigators knew which treatment group participants would be put into (selection bias) and or whether selective reporting (reporting bias) occurred, but it is very unlikely. In conclusion, it can be stated all the studies appeared to be well run and we do not think any of the above‐mentioned factors influenced the results in a negative way. Quality of evidence varied from high (change in serum low‐density lipoprotein (LDL) cholesterol) through moderate (adverse events) to low (change in blood vessel wall (carotid intima‐media) thickness, change in measures if growth and maturation, liver dysfunction, myopathy and change in blood wall (endothelial) function).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Vuorio, A; Kuoppala, J; Kovanen, PT; Humphries, SE; Tonstad, S; Wiegman, A; Drogari, E; Ramaswami, U", "articleTypes": [], "doi": "10.1002/14651858.CD006401.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "3f1ee90f-5575-4d73-8c6c-c46e1f93d265", "pmid": "", "title": "Pharmacological treatment of gastro‐oesophageal reflux in children", "imported": false, "abstract": "Abstract - Background Gastro‐oesophageal reflux (GOR) is characterised by the regurgitation of gastric contents into the oesophagus. GOR is a common presentation in infancy, both in primary and secondary care, affecting approximately 50% of infants under three months old. The natural history of GOR in infancy is generally of a self‐limiting condition that improves with age, but older children and children with co‐existing medical conditions can have more protracted symptoms. The distinction between gastro‐oesophageal reflux disease (GORD) and GOR is debated. Current National Institute of Health and Care Excellence (NICE) guidelines define GORD as GOR causing symptoms severe enough to merit treatment. This is an update of a review first published in 2014. Objectives To assess the effects of pharmacological treatments for GOR in infants and children. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, and Web of Science up to 17 September 2022. We also searched for ongoing trials in clinical trials registries, contacted experts in the field, and searched the reference lists of trials and reviews for any additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any currently‐available pharmacological treatment for GOR in children with placebo or another medication. We excluded studies assessing dietary management of GORD and studies of thickened feeds. We included studies in infants and children up to 16 years old. Data collection and analysis We used standard methodology expected by Cochrane. Main results We included 36 RCTs involving 2251 children and infants. We were able to extract summary data from 14 RCTs; the remaining trials had insufficient data for extraction. We were unable to pool results in a meta‐analysis due to methodological differences in the included studies (including heterogeneous outcomes, study populations, and study design). We present the results in two groups by age: infants up to 12 months old, and children aged 12 months to 16 years old. Infants Omeprazole versus placebo: there is no clear effect on symptoms from omeprazole. One study (30 infants; very low‐certainty evidence) showed cry/fuss time in infants aged three to 12 months had altered from 246 ± 105 minutes/day at baseline (mean +/‐ standard deviation (SD)) to 191 ± 120 minutes/day in the omeprazole group and from 287 ± 132 minutes/day to 201 ± 100 minutes/day in the placebo group (mean difference (MD) 10 minutes/day lower (95% confidence interval (CI) ‐89.1 to 69.1)). The reflux index changed in the omeprazole group from 9.9 ± 5.8% in 24 hours to 1.0 ± 1.3% and in the placebo group from 7.2 ± 6.0% to 5.3 ± 4.9% in 24 hours (MD 7% lower, 95% CI ‐4.7 to ‐9.3). Omeprazole versus ranitidine: one study (76 infants; very low‐certainty evidence) showed omeprazole may or may not provide symptomatic benefit equivalent to ranitidine. Symptom scores in the omeprazole group changed from 51.9 ± 5.4 to 2.4 ± 1.2, and in the ranitidine group from 47 ± 5.6 to 2.5 ± 0.6 after two weeks: MD ‐4.97 (95% CI ‐7.33 to ‐2.61). Esomeprazole versus placebo: esomeprazole appeared to show no additional reduction in the number of GORD symptoms compared to placebo (1 study, 52 neonates; very low‐certainty evidence): both the esomeprazole group (184.7 ± 78.5 to 156.7 ± 75.1) and placebo group (183.1 ± 77.5 to 158.3 ± 75.9) improved: MD ‐3.2 (95% CI ‐4.6 to ‐1.8). Children Proton pump inhibitors (PPIs) at different doses may provide little to no symptomatic and endoscopic benefit. Rabeprazole given at different doses (0.5 mg/kg and 1 mg/kg) may provide similar symptom improvement (127 children in total; very low‐certainty evidence). In the lower‐dose group (0.5 mg/kg), symptom scores improved in both a low‐weight group of children (< 15 kg) (mean ‐10.6 ± SD 11.13) and a high‐weight group of children (> 15 kg) (mean ‐13.6 ± 13.1). In the higher‐dose groups (1 mg/kg), scores improved in the low‐weight (‐9 ± 11.2) and higher‐weight groups (‐8.3 ± 9.2). For the higher‐weight group, symptom score mean difference between the two different dosing regimens was 2.3 (95% CI ‐2 to 6.6), and for the lower‐weight group, symptom score MD was 4.6 (95% CI ‐2.9 to 12). Pantoprazole: pantoprazole may or may not improve symptom scores at 0.3 mg/kg, 0.6 mg/kg, and 1.2 mg/kg pantoprazole in children aged one to five years by week eight, with no difference between 0.3 mg/kg and 1.2 mg/kg dosing (0.3 mg/kg mean −2.4 ± 1.7; 1.2 mg/kg −1.7 ± 1.2: MD 0.7 (95% CI ‐0.4 to 1.8)) (one study, 60 children; very low‐certainty evidence). There were insufficient summary data to assess other medications. Authors' conclusions There is very low‐certainty evidence about symptom improvements and changes in pH indices for infants. There are no summary data for endoscopic changes. Medications may or may not provide a benefit (based on very low‐certainty evidence) for infants whose symptoms remain bothersome, despite nonmedical interventions or parental reassurance. If a medication is required, there is no clear evidence based on summary data for omeprazole, esomeprazole (in neonates), H₂antagonists, and alginates for symptom improvements (very low‐certainty evidence). Further studies with longer follow‐up are needed. In older children with GORD, in studies with summary data extracted, there is very low‐certainty evidence that PPIs (rabeprazole and pantoprazole) may or may not improve GORD outcomes. No robust data exist for other medications. Further RCT evidence is required in all areas, including subgroups (preterm babies and children with neurodisabilities). Plain language summary Medicines for children with reflux Review question What is the best and safest treatment for babies and children with gastro‐oesophageal reflux? Key messages: ‐ the evidence for medications for babies with gastro‐oesophageal reflux/reflux disease is very uncertain; ‐ for children with gastro‐oesophageal reflux disease, the evidence is very uncertain regarding the effects of proton pump inhibitors. There was no adequate evidence to draw conclusions regarding other medications. What is gastro‐oesophageal reflux? Gastro‐oesophageal reflux happens when stomach contents come back up into the oesophagus (food pipe). Most babies (under 1 year) grow out of reflux symptoms, but does medicine help? Children (older than 1 year) can have reflux just like adults. Reflux can be normal ('physiological reflux'), but in babies and children, it can cause symptoms, including pain or weight loss, as the oesophagus becomes inflamed (oesophagitis). Bothersome symptoms of reflux are called 'gastro‐oesophageal reflux disease' (GORD). How is gastro‐oesophageal reflux treated? Medicines can thicken the stomach contents (alginates), neutralise stomach acid (ranitidine, omeprazole, lansoprazole), or help the stomach to empty faster (domperidone, erythromycin). What did we want to find out? We wanted to learn the best way to reduce reflux in babies and children. We wanted to see if medicines help infants and children to feel better (symptom scores), heal the oesophagus (which is checked by using endoscopy, where a tiny camera is put down the oesophagus), or lower the time the oesophagus is exposed to stomach acid. We also investigated whether the medicines were safe by considering the harmful or unwanted effects reported in the studies. What did we do? We searched for studies testing gastro‐oesophageal reflux medicines in babies and children. We included all studies comparing these medicines, or comparing them to an inactive medicine (placebo). We assessed results which are important to doctors, nurses, and parents, and performed our own analysis of the results. We rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 36 suitable studies (involving 2251 babies and children), conducted worldwide, with most in the USA. The largest study recruited 268 babies, the smallest, 16 children. Fifteen studies compared an active medicine to placebo; 8 compared one active medication to another; and 11 studies gave the same medication at different doses. We found useable outcome information in 14 of the 36 studies. The remaining studies either did not report outcomes we were interested in or did not report them in a way we could analyse. We could not combine the results of any studies because they were too different (in terms of how long they followed participants up and the outcomes they investigated) to use in a meaningful way. Key results Babies. There is no clear effect on symptoms or measured acidity (one measure is reflux index, which is the percentage of time in 24 hours the oesophagus is exposed to stomach acid) between babies given omeprazole or placebo. One study (30 babies) showed cry/fuss time went down from 287 to 201 minutes/day in the placebo group and 246 to 191 minutes/day in the omeprazole group. Reflux index changed in the omeprazole group from 9.9% to 1.0% in 24 hours, and in the placebo group from 7.2% to 5.3%. One study (76 babies) showed that omeprazole and ranitidine may have a similar benefit for symptoms after 2 weeks: symptom scores (higher scores mean worse symptoms) in the omeprazole group dropped from 51.9 to 2.4, and in the ranitidine group, from 47 to 2.5. In one study of 52 newborn babies, esomeprazole appeared to show no reduction in the number of symptoms (184.7 to 156.7) compared to placebo (183.1 to 158.3). None of the studies reported harmful events or results about changes to babies' oesophaguses. Children. In children older than 1 year of age, no studies assessed medical treatment versus placebo. Proton pump inhibitors (PPIs), which block stomach acid production, at different doses may provide little to no improvements in symptoms or oesophagus healing. In one study (127 children), both lower‐weight and higher‐weight children given rabeprazole at lower and higher doses had both minimal – probably unimportant – changes in symptom scores and endoscopic scores (which indicate whether healing of the oesophagus has occurred). Pantoprazole may or may not improve symptom scores in children aged 1 to 5 years by week 8: there was no difference between lower and higher dosing in one study (60 children). Studies investigating other medications did not report enough information for us to assess their results properly. Quality of the evidence We are not confident in the evidence, which was mainly based on single studies with few babies and children. Several studies had pharmaceutical company help with manuscript writing. The question of how best to treat children with disabilities, and whether any PPIs are better than other medicines remain. The evidence is current to 17 September 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Tighe, MP; Andrews, E; Liddicoat, I; Afzal, NA; Hayen, A; Beattie, RM", "articleTypes": [], "doi": "10.1002/14651858.CD008550.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "3f22b7ac-2972-45aa-9b59-2c450bd6bf43", "pmid": "", "title": "Oral protein‐based supplements versus placebo or no treatment for people with chronic kidney disease requiring dialysis", "imported": false, "abstract": "Abstract - Background Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein‐based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein‐based nutritional supplements in this population is limited. Objectives The aims of this review were to determine the benefits and harms of using oral protein‐based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein‐based nutritional supplements to no oral protein‐based nutritional supplements or placebo. Data collection and analysis Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes. Main results Twenty‐two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow‐up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self‐reported outcomes. Oral protein‐based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I 2 = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein‐based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I 2 = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein‐based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid‐arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein‐based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI ‐0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD ‐0.04 kg/m 2 , 95% CI ‐0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI ‐1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein‐based nutritional supplements affect triceps skinfold thickness, mid‐arm circumference, C‐reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein‐based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies. Authors' conclusions Overall, it is likely that oral protein‐based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid‐arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well‐designed RCTs in this population are required. Plain language summary Oral protein‐based nutritional supplement in people with chronic kidney disease requiring dialysis What is the issue? People with chronic kidney disease requiring dialysis are at risk of developing malnutrition for many reasons and often do not eat enough because their appetite is poor. Oral nutritional supplements are commonly provided to people who do not eat enough to meet their needs. Provision of nutritional supplements to dialysis patients requires careful consideration of potassium, phosphate and fluid limits. What did we do? We aimed to determine if giving oral protein‐based nutritional supplements improved serum albumin levels and other measures of nutrition. What did we find? A total of 1278 people took part in 22 studies that were included in this review to investigate the effects of oral protein‐based nutritional supplements. All participants were adults on maintenance dialysis (79% haemodialysis and 21% peritoneal dialysis). The studies lasted from one to 12 months. The findings suggest that giving oral protein‐based nutritional supplementation probably results in a slightly greater increase in albumin level and may improve prealbumin level and mid‐arm muscle circumference. The increase in albumin level was more evident in participants who were on haemodialysis and in those who were malnourished. It is uncertain whether oral protein‐based nutritional supplementation affects potassium and phosphate levels. Oral protein‐based nutritional supplements may result in little or no difference in the risk of developing abdominal symptoms.There were some differences between the quality of the studies and their designs. Conclusions The authors conclude that oral protein‐based nutritional supplements appear to be effective in improving some nutritional markers in people who need dialysis; however, it remains uncertain whether these results translate to meaningful outcomes for this population. More research is required to determine the cost‐effectiveness of this treatment, and if it can bring benefit to patients such as feeling better and living longer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Mah, JY; Choy, SW; Roberts, MA; Desai, AM; Corken, M; Gwini, SM; McMahon, LP", "articleTypes": [], "doi": "10.1002/14651858.CD012616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "3f449351-1f75-4021-830b-bec0cd4e9f06", "pmid": "", "title": "Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age", "imported": false, "abstract": "Abstract - Background According to global prevalence analysis studies, acute upper respiratory tract infections (URTIs) are the most common acute infectious disease in children, especially in preschool children. Acute URTIs lead to an economic burden on families and society. Vitamin A refers to the fat‐soluble compound all‐trans‐retinol and also represents retinol and its active metabolites. Vitamin A interacts with both the innate immune system and the adaptive immune system and improves the host's defences against infections. Correlation studies show that serum retinol deficiency was associated with a higher risk of respiratory tract infections. Therefore, vitamin A supplementation may be important in preventing acute URTIs. Objectives To assess the effectiveness and safety of vitamin A supplements for preventing acute upper respiratory tract infections in children up to seven years of age. Search methods We searched CENTRAL, MEDLINE, Embase, the Chinese Biomedical Literature Database, and two trial registration platforms to 8 June 2023. We also checked the reference lists of all primary studies and reviewed relevant systematic reviews and trials for additional references. We imposed no language or publication restrictions. Selection criteria We included randomised controlled trials (RCTs), which evaluated the role of vitamin A supplementation in the prevention of acute URTIs in children up to seven years of age. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Main results We included six studies (27,351 participants). Four studies were RCTs and two were cluster‐RCTs. The included studies were all conducted in lower‐middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas with a high local prevalence of malnutrition and xerophthalmia. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. We judged the included studies to be at either a high or unclear risk of bias for random sequence generation, incomplete outcome data, and blinding. Primary outcomes Six studies reported the incidence of acute URTIs during the study period. Five studies reported the number of acute URTIs over a period of time, but there was population heterogeneity and the results were presented in different forms, therefore only three studies were meta‐analysed. We are uncertain of the effect of vitamin A supplementation on the number of acute URTIs over two weeks (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.92 to 1.09; I 2 = 44%; 3 studies, 22,668 participants; low‐certainty evidence). Two studies reported the proportion of participants with an acute URTI. We are uncertain of the effect of vitamin A supplementation on the proportion of participants with an acute URTI (2 studies, 15,535 participants; low‐certainty evidence). Only one study (116 participants) reported adverse events. No infant in either the placebo or vitamin A group was found to have feeding difficulties (failure to feed or vomiting), a bulging fontanelle, or neurological signs before or after vitamin A administration (very low‐certainty evidence). Secondary outcomes Two studies (296 participants) reported the severity of subjective symptoms, presented by the mean duration of acute URTI. Vitamin A may have little to no effect on the mean duration of acute URTI (very low‐certainty evidence). Authors' conclusions The evidence for the use of vitamin A supplementation to prevent acute URTI is uncertain, because population, dose and duration of interventions, and outcomes vary between studies. From generally very low‐ to low‐certainty evidence, we found that there may be no benefit in the use of vitamin A supplementation to prevent acute URTI in children up to seven years of age. More RCTs are needed to strengthen the current evidence. Future research should report over longer time frames using validated tools and consistent reporting, and ensure adequate power calculations, to allow for easier synthesis of data. Finally, it is important to assess vitamin A supplementation for preschool children with vitamin A deficiency. Plain language summary Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age Background Acute upper respiratory tract infections (URTIs) are the most common acute infectious diseases in children, especially in preschool children. Vitamin A has a positive role in the immune system and may improve the host's defences against infections. Studies show that children with vitamin deficiency are more likely to suffer from respiratory tract infections. Therefore, we assessed the role of vitamin A supplementation in the prevention of acute upper respiratory tract infections in preschool children (up to seven years of age). Review question What is the role of vitamin A supplementation in the prevention of acute URTIs in preschool children (up to seven years of age), compared to no supplementation? Search date We searched for evidence up to 8 June 2023. Study characteristics All included studies were conducted in lower‐ and middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas more likely to experience malnutrition and dry eye. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. Key results We included six studies involving 27,351 participants. We have very low to low confidence in the evidence provided by the studies. Five studies reported the number of acute URTIs over a period of time. The included studies varied by population and the results were presented in different forms, so we could only combine three studies together (meta‐analysis). We are uncertain if vitamin A supplementation lowers the number of acute URTIs over a two‐week period (three studies, 22,668 participants). Two studies reported the proportion of participants with acute URTI. The effect of vitamin A supplementation on the proportion of participants with acute URTI is uncertain (two studies, 15,535 participants). Only one study (116 participants) reported adverse events and none occurred in infants in the placebo or vitamin A groups. Two studies (296 participants) reported the severity of subjective symptoms, presented by the average duration of acute URTIs. Vitamin A may have little to no effect on the average duration of acute URTIs. Authors' conclusions From evidence in which we have very low to low confidence, we found that there may be no benefit in using vitamin A supplementation to prevent acute URTIs in children up to seven years of age. High‐quality studies focusing on preschool children with vitamin A deficiency are needed to identify whether vitamin A supplementation may be effective.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Cheng, X; Li, D; Yang, C; Chen, B; Xu, P; Zhang, L", "articleTypes": [], "doi": "10.1002/14651858.CD015306.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "3f5391f2-281a-410b-94c7-e9eb57750460", "pmid": "", "title": "Interventions for acute otitis externa", "imported": false, "abstract": "Abstract - Background Acute otitis externa is an inflammatory condition of the ear canal, with or without infection. Symptoms include ear discomfort, itchiness, discharge and impaired hearing. It is also known as 'swimmer's ear' and can usually be treated successfully with a course of ear drops. Objectives To assess the effectiveness of interventions for acute otitis externa. Search methods Our search for published and unpublished trials included the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources. The date of the most recent search was 6 January 2009. Selection criteria Randomised controlled trials evaluating ear cleaning, topical medication or systemic therapy in the treatment of acute otitis externa were eligible. We excluded complicated acute otitis externa; otitis externa secondary to otitis media or chronic suppurative otitis media; chronic otitis externa; fungal otitis externa (otomycosis); eczematous otitis externa; viral otitis externa and furunculosis. Data collection and analysis Two authors assessed eligibility and quality. Main results Nineteen randomised controlled trials with a total of 3382 participants were included. Three meta‐analyses were possible. The overall quality of studies was low. Topical antimicrobials containing steroids were significantly more effective than placebo drops: OR 11 (95% CI 2.00 to 60.57; one trial). In general, no clinically meaningful differences were noted in clinical cure rates between the various topical interventions reviewed. One notable exception involved a trial of high quality which showed that acetic acid was significantly less effective when compared with antibiotic/steroid drops in terms of cure rate at two and three weeks (OR 0.29 (95% CI 0.13 to 0.62) and OR 0.25 (95% CI 0.11 to 0.58) respectively). One trial of low quality comparing quinolone with non‐quinolone antibiotics did not find any difference in clinical cure rate. No trials evaluated the effectiveness of ear cleaning. Only two trials evaluated steroid‐only drops. One trial of low quality suggested no significant difference between steroid and antibiotic/steroid but did not report the magnitude or precision of the result. Another trial of moderate quality comparing an oral antihistamine with topical steroid against topical steroid alone found that cure rates in both groups were high and comparable (100% (15/15) and 94% (14/15) respectively at three weeks). Authors' conclusions There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available: Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow‐up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid. The evidence for steroid‐only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed. Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision. Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated. Plain language summary Interventions to treat acute otitis externa, a specific form of ear canal inflammation also known as swimmer's ear Acute otitis externa causes inflammation of the ear canal. It is a common clinical problem encountered in general practice. This review assesses the various forms of medication used to treat the condition. Nineteen randomised controlled trials were included (3382 participants). Most were of low quality. The findings of the review may not be wholly relevant to primary care as most of the trials were conducted in a hospital setting and over half involved ear cleaning as part of the treatment (this is generally not available in primary care). However, the review does demonstrate that topical treatments alone are effective at treating acute otitis externa. There was little to choose between them in terms of effectiveness. However, when treatment needs to be extended beyond one week acetic acid drops appear to be less effective than antibiotic/steroid drops. In addition, symptoms persist for two days longer in those treated with acetic acid. More research is needed to determine the effectiveness of steroid‐only drops. Patients treated with antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Kaushik, V; Malik, T; Saeed, SR", "articleTypes": [], "doi": "10.1002/14651858.CD004740.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "3f55acfa-2215-435f-8d2b-756ee556a364", "pmid": "", "title": "Effects of Low-dose B-vitamins Supplementation on Plasma Homocysteine and Framingham Risk Score: Double Blind Randomized Controlled Trial in Healthy Chinese Elderly", "imported": false, "abstract": "The purpose of this study is to evaluate whether low dose complex B-vitamins (folic acid,vitamin B6 and vitamin B12) can lower the risk of developing hyperhomocysteinemia in an apparently healthy population with low folate/B12 and high Hcy status.", "journal": "", "year": "2008", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.267Z" }, { "id": "3f574b2d-e4c8-4b26-b834-3fbe4f45e3fe", "pmid": "", "title": "Efficacy of Bitter Taste Blockers on Flavor Acceptance in Pediatric Populations", "imported": false, "abstract": "This proposal describes 2 basic research studies that will be conducted sequentially. Study 1 will test the efficacy of both classic and newly developed \"generally recognized as a safe\" (GRAS) bitter blockers on the perceived bitterness and acceptance of different classes of bitter-tasting compounds by children and compare their responses to adults. Because variations among and between children and adults in terms of sensitivity to different bitter compounds are due in part to genetically determined receptor variation, the investigators will consider genotype when assessing how well bitter blockers perform. In Study 2, the investigators aim to evaluate different methods (forced-choice procedures, hedonic face scales) used for testing children to determine their reliability and reproducibility.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.233Z" }, { "id": "3f7d8b91-d5db-4506-ba71-6f8d0ca440e2", "pmid": "", "title": "Chinese herbal medicine for menopausal symptoms", "imported": false, "abstract": "Abstract - Background Chinese herbal medicine (CHM) usage is expected to increase as women suffering from menopausal symptoms are seeking alternative therapy due to concerns from the adverse effects (AEs) associated with hormone therapy (HT). Scientific evidence for their effectiveness and safety is needed. Objectives To evaluate the effectiveness and safety of CHM in the treatment of menopausal symptoms. Search methods We searched the Gynaecology and Fertility Group's Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), MEDLINE, Embase, CINAHL, AMED, and PsycINFO (from inception to March 2015). Others included Current Control Trials, Citation Indexes, conference abstracts in the ISI Web of Knowledge, LILACS database, PubMed, OpenSIGLE database, and China National Knowledge Infrastructure database (CNKI, 1999 to 2015). Other resources included reference lists of articles as well as direct contact with authors. Selection criteria Randomised controlled trials (RCTs) comparing the effectiveness of CHM with placebo, HT, pharmaceutical drugs, acupuncture, or another CHM formula in women over 18 years of age, and suffering from menopausal symptoms. Data collection and analysis Two review authors independently assessed 864 studies for eligibility. Data extractions were performed by them with disagreements resolved through group discussion and clarification of data or direct contact with the study authors. Data analyses were performed in accordance with Cochrane Collaboration guidelines. Main results We included 22 RCTs (2902 women). Participants were from different ethnic backgrounds with the majority of Chinese origin. When CHM was compared with placebo (eight RCTs), there was little or no evidence of a difference between the groups for the following pooled outcomes: hot flushes per day (MD 0.00, 95% CI ‐0.88 to 0.89; 2 trials, 199 women; moderate quality evidence); hot flushes per day assessed by an overall hot flush score in which a difference of one point equates to one mild hot flush per day (MD ‐0.81 points, 95% CI ‐2.08 to 0.45; 3 RCTs, 263 women; low quality evidence); and overall vasomotor symptoms per month measured by the Menopause‐Specific Quality of Life questionnaire (MENQOL, scale 0 to 6) (MD ‐0.42 points; 95% CI ‐1.52 to 0.68; 3 RCTs, 256 women; low quality evidence). In addition, results from individual studies suggested there was no evidence of a difference between the groups for daily hot flushes assessed by severity (MD ‐0.70 points, 95% CI ‐1.00, ‐0.40; 1 RCT, 108 women; moderate quality evidence); or overall monthly hot flushes scores (MD ‐2.80 points, 95% CI ‐8.93 to 3.33; 1 RCT, 84 women; very low quality evidence); or overall daily night sweats scores (MD 0.07 points, 95% CI ‐0.19 to 0.33, 1 RCT, 64 women; low quality evidence); or overall monthly night sweats scores (MD 1.30 points, 95% CI ‐1.76 to 4.36, 1 RCT, 84 women; very low quality evidence). However one study using the Kupperman Index reported that overall monthly vasomotor symptom scores were lower in the CHM group (MD ‐4.79 points, 95% CI ‐5.52 to ‐4.06; 1 RCT, 69 women; low quality evidence). When CHM was compared with hormone therapy (HT) (10 RCTs), only two RCTs reported monthly vasomotor symptoms using MENQOL. It was uncertain whether CHM reduces vasomotor symptoms (MD 0.47 points, 95% CI ‐0.50 to 1.44; 2 RCTs, 127 women; very low quality evidence). Adverse effects were not fully reported in the included studies. Adverse events reported by women taking CHM included mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects were inconclusive because of imprecise estimates of effects: CHM versus placebo (RR 1.51; 95% CI 0.69 to 3.33; 7 trials, 705 women; I² = 40%); CHM versus HT (RR 0.96; 95% CI 0.66 to 1.39; 2 RCTs, 864 women; I² = 0%); and CHM versus specific conventional medications (such as Fluoxetine and Estazolam) (RR 0.20; 95% CI 0.03 to 1.17; 2 RCTs, 139 women; I² = 61%). Authors' conclusions We found insufficient evidence that Chinese herbal medicines were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Effects on safety were inconclusive. The quality of the evidence ranged from very low to moderate; there is a need for well‐designed randomised controlled studies. Plain language summary Title: Chinese herbal medicines for menopausal symptoms Review Question: Are Chinese herbal medicines effective and safe for relieving menopausal symptoms? Background: Menopause usually takes place when a woman is around 51 years of age. Women can experience symptoms such as hot flushes, sweats, poor sleep, joint pains, anxiousness, dry skin and vagina when the organs which produce female hormones slow down. Usually hormone therapy (HT) is prescribed to reduce the symptoms. Due to concerns on long term use of HT resulting in adverse effects, women have been looking for alternative treatments to relieve their symptoms. Chinese herbal medicines (CHM) is one of the popular choices. Although CHM has been used for a very long time clinically, its effectiveness and long‐term safety remained unanswered from a scientific perspective. Study characteristics: This review examined 22 randomised clinical trials where 2902 women took part in the studies; 1499 in the CHM group and 1403 in the control group which might include a placebo (non‐active compound made to look, taste and smell the same as the study compound) or a drug or HT or another CHM formula (different from the one being tested). Most of the studies had a trial period for 12 weeks. The data are current to March 2015. Key results: We found insufficient evidence that CHM were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Adverse effects were not well reported, some women taking CHM reported mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects on safety were inconclusive. Quality of the evidence: The quality of the evidence ranged from very low to moderate. The studies did not produce good quality evidence to allow the authors to draw a conclusive statement regarding the effectiveness or safety of CHM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Zhu, X; Liew, Y; Liu, ZL", "articleTypes": [], "doi": "10.1002/14651858.CD009023.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "3f82f7c2-ee87-4334-8f69-48306ec00410", "pmid": "", "title": "Donepezil for dementia due to Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Alzheimer's disease is the most common cause of dementia in older people. One approach to symptomatic treatment of Alzheimer's disease is to enhance cholinergic neurotransmission in the brain by blocking the action of the enzyme responsible for the breakdown of the neurotransmitter acetylcholine. This can be done by a group of drugs known as cholinesterase inhibitors. Donepezil is a cholinesterase inhibitor. This review is an updated version of a review first published in 1998. Objectives To assess the clinical efficacy and safety of donepezil in people with mild, moderate or severe dementia due to Alzheimer's disease; to compare the efficacy and safety of different doses of donepezil; and to assess the effect of donepezil on healthcare resource use and costs. Search methods We searched Cochrane Dementia and Cognitive Improvement’s Specialized Register, MEDLINE, Embase, PsycINFO and a number of other sources on 20 May 2017 to ensure that the search was as comprehensive and up‐to‐date as possible. In addition, we contacted members of the Donepezil Study Group and Eisai Inc. Selection criteria We included all double‐blind, randomised controlled trials in which treatment with donepezil was administered to people with mild, moderate or severe dementia due to Alzheimer's disease for 12 weeks or more and its effects compared with those of placebo in a parallel group of patients, or where two different doses of donepezil were compared. Data collection and analysis One reviewer (JSB) extracted data on cognitive function, activities of daily living, behavioural symptoms, global clinical state, quality of life, adverse events, deaths and healthcare resource costs. Where appropriate and possible, we estimated pooled treatment effects. We used GRADE methods to assess the quality of the evidence for each outcome. Main results Thirty studies involving 8257 participants met the inclusion criteria of the review, of which 28 studies reported results in sufficient detail for the meta‐analyses. Most studies were of six months' duration or less. Only one small trial lasted 52 weeks. The studies tested mainly donepezil capsules at a dose of 5 mg/day or 10 mg/day. Two studies tested a slow‐release oral formulation that delivered 23 mg/day. Participants in 21 studies had mild to moderate disease, in five studies moderate to severe, and in four severe disease. Seventeen studies were industry funded or sponsored, four studies were funded independently of industry and for nine studies there was no information on source of funding. Our main analysis compared the safety and efficacy of donepezil 10 mg/day with placebo at 24 to 26 weeks of treatment. Thirteen studies contributed data from 3396 participants to this analysis. Eleven of these studies were multicentre studies. Seven studies recruited patients with mild to moderate Alzheimer's disease, two with moderate to severe, and four with severe Alzheimer's disease, with a mean age of about 75 years. Almost all evidence was of moderate quality, downgraded due to study limitations. After 26 weeks of treatment, donepezil compared with placebo was associated with better outcomes for cognitive function measured with the Alzheimer's Disease Assessment Scale‐Cognitive (ADAS‐Cog, range 0 to 70) (mean difference (MD) ‐2.67, 95% confidence interval (CI) ‐3.31 to ‐2.02, 1130 participants, 5 studies), the Mini‐Mental State Examination (MMSE) score (MD 1.05, 95% CI 0.73 to 1.37, 1757 participants, 7 studies) and the Severe Impairment Battery (SIB, range 0 to 100) (MD 5.92, 95% CI 4.53 to 7.31, 1348 participants, 5 studies). Donepezil was also associated with better function measured with the Alzheimer's Disease Cooperative Study activities of daily living score for severe Alzheimer's disease (ADCS‐ADL‐sev) (MD 1.03, 95% CI 0.21 to 1.85, 733 participants, 3 studies). A higher proportion of participants treated with donepezil experienced improvement on the clinician‐rated global impression of change scale (odds ratio (OR) 1.92, 95% CI 1.54 to 2.39, 1674 participants, 6 studies). There was no difference between donepezil and placebo for behavioural symptoms measured by the Neuropsychiatric Inventory (NPI) (MD ‐1.62, 95% CI ‐3.43 to 0.19, 1035 participants, 4 studies) or by the Behavioural Pathology in Alzheimer's Disease (BEHAVE‐AD) scale (MD 0.4, 95% CI ‐1.28 to 2.08, 194 participants, 1 study). There was also no difference between donepezil and placebo for Quality of Life (QoL) (MD ‐2.79, 95% CI ‐8.15 to 2.56, 815 participants, 2 studies). Participants receiving donepezil were more likely to withdraw from the studies before the end of treatment (24% versus 20%, OR 1.25, 95% CI 1.05 to 1.50, 2846 participants, 12 studies) or to experience an adverse event during the studies (72% vs 65%, OR 1.59, 95% 1.31 to 1.95, 2500 participants, 10 studies). There was no evidence of a difference between donepezil and placebo for patient total healthcare resource utilisation. Three studies compared donepezil 10 mg/day to donepezil 5 mg/day over 26 weeks. The 5 mg dose was associated with slightly worse cognitive function on the ADAS‐Cog, but not on the MMSE or SIB, with slightly better QoL and with fewer adverse events and withdrawals from treatment. Two studies compared donepezil 10 mg/day to donepezil 23 mg/day. There were no differences on efficacy outcomes, but fewer participants on 10 mg/day experienced adverse events or withdrew from treatment. Authors' conclusions There is moderate‐quality evidence that people with mild, moderate or severe dementia due to Alzheimer's disease treated for periods of 12 or 24 weeks with donepezil experience small benefits in cognitive function, activities of daily living and clinician‐rated global clinical state. There is some evidence that use of donepezil is neither more nor less expensive compared with placebo when assessing total healthcare resource costs. Benefits on 23 mg/day were no greater than on 10 mg/day, and benefits on the 10 mg/day dose were marginally larger than on the 5 mg/day dose, but the rates of withdrawal and of adverse events before end of treatment were higher the higher the dose. Plain language summary Donepezil for people with dementia due to Alzheimer's disease Review question What effects (benefits or harms) does donepezil have on people with dementia due to Alzheimer's disease? Background Alzheimer's disease is the most common cause of dementia. As the disease progresses, people lose the ability to remember, communicate, think clearly and perform the activities of daily living. Their behaviour may also change. In severe Alzheimer's disease people lose the ability to care for themselves. The most commonly used treatment for Alzheimer's disease are medicines known as acetylcholinesterase inhibitors. Donepezil is one of these medicines. It is taken as a pill once a day. In Alzheimer's disease, one of the changes in the brain is a reduced number of nerve cells called cholinergic neurones. These are nerve cells that signal to other cells using a chemical called acetylcholine. Acetylcholinesterase inhibitors, such as donepezil, work by preventing acetylcholine from being broken down. This may improve the symptoms of dementia. However, acetylcholine is also found elsewhere in the body and so drugs of this type may have unwanted effects. Review methods In this review we examined evidence about benefits and harms from studies that compared donepezil, taken for at least 12 weeks, to placebo (a dummy pill), or that compared different doses of donepezil. The studies had to be double‐blind and randomised, that is, the decision whether people taking part got donepezil or placebo had to be made randomly and neither they nor the researchers should have known which treatment they were getting while the trial was going on. This was to make the comparison as unbiased, or fair, as possible. We searched for studies up to May 2017. We assessed the quality of all the studies we included. When it was sensible to do so, we analysed the results of studies together to get an overall result. Key results We included 30 studies with 8257 participants. Most of the people in the studies had mild or moderate dementia due to Alzheimer's disease, but in nine studies they had moderate or severe dementia. Almost all of the studies lasted six months or less. The majority of the studies were known to have been funded by the manufacturer of donepezil. We found that people with Alzheimer's disease who took 10 mg of donepezil a day for six months did slightly better than people taking placebo, on scales measuring their cognitive function (e.g. thinking and remembering), how well they could manage their daily activities, and the overall impression of a trained researcher. We did not find any effect on behaviour or quality of life. People taking donepezil were more likely than those taking placebo to report side effects and to drop out of the studies. Most side effects were described as mild. Nausea, vomiting and diarrhoea were most common. Comparing 5 mg of donepezil a day with 10 mg/day, people on 5 mg had fewer side effects, but did slightly less well on cognitive function tests. A higher dose (23 mg/day) offered no advantages and was associated with more side effects. There is some evidence that use of donepezil is neither more nor less expensive than placebo when total health care costs are taken into account. Quality of the evidence In general, we thought that the quality of the evidence was moderate. The main factor reducing our confidence was concern that the results of some studies might have been biased by the way they were done. We cannot be sure that the results apply to treatment longer than six months. Conclusions After six months of treatment, there are benefits of donepezil that are large enough to measure in studies. It is associated with side effects that are mainly mild, but that may cause people to stop treatment. Being able to stabilise cognitive performance or ability to maintain activities of daily living may be important clinically. In terms of total healthcare costs the use of donepezil appears cost neutral. However, there does not appear to be an effect on quality of life. More data are still required from longer‐term clinical studies examining measures of disease progression or time to needing full time care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Birks, JS, Harvey, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD001190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.782Z" }, { "id": "3fae18cb-484e-4018-94ac-2dc1e1818230", "pmid": "", "title": "Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease", "imported": false, "abstract": "Abstract - Background Thyrotropin‐releasing hormones (TRH) added to prenatal corticosteroids has been suggested as a way to further reduce breathing problems and neonatal lung disease in infants born preterm. Objectives To assess the effects of giving prenatal TRH in addition to corticosteroids to women at risk of preterm birth for the prevention of neonatal respiratory disease. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013) and reference lists of retrieved studies. We also contacted trial authors. Selection criteria Randomised controlled trials in women at sufficient risk of preterm birth to warrant the use of prenatal corticosteroids to promote lung maturity. TRH and corticosteroids were compared with corticosteroids, with or without placebo. Data collection and analysis All assessments of trial eligibility, risk of bias and data extractions were independently carried out by at least two review authors. Main results Over 4600 women were recruited into the 15 trials included in the review, however two trials did not contribute any outcome data to the review. The trials had a moderate risk of bias. Overall, prenatal TRH, in addition to corticosteroids, did not reduce the risk of death prior to hospital discharge (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.86 to 1.27, six trials, 3694 infants), neonatal respiratory distress syndrome (average RR 1.05, 95% CI 0.91 to 1.22, nine trials, 3833 infants), or chronic lung disease (RR 1.01, 95% CI 0.85 to 1.19, five trials, 2511 infants), and did not improve any of the secondary fetal, neonatal or childhood outcomes assessed by intention‐to‐treat analyses. Indeed, the data showed prenatal TRH to have adverse effects for women and their infants. All side effects reported (nausea, vomiting, light headedness, urgency of micturition, facial flushing) were significantly more likely to occur in women receiving TRH. In the infants, prenatal TRH increased the risk of needing respiratory support (RR 1.16, 95% CI 1.03 to 1.29, three trials, 1969 infants), and of having a low Apgar score at five minutes (RR 1.48, 95% CI 1.14 to 1.92, three trials, 1969 infants). Only three trials provided data on childhood follow‐up, and while one trial suggested poorer outcomes for infants who were exposed to prenatal TRH, the other two trials, that assessed infants using an established developmental instrument, showed no clear differences between groups in follow‐up outcomes. Sensitivity analyses by trial quality, or subgroups with differing times from entry to birth, or different dose regimens of TRH, did not change these findings. Authors' conclusions Prenatal TRH in addition to corticosteroids, given to women at risk of preterm birth, does not improve infant outcomes and can cause maternal side effects. Plain language summary Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease Thyrotropin‐releasing hormone (TRH) given with corticosteroids does not improve the benefit of corticosteroids on the lungs of babies born too early, and may increase harm. Babies born preterm (before 37 weeks of pregnancy) are at risk of breathing difficulties (such as respiratory distress syndrome). TRH increases thyroid hormones in the baby and it has been thought that adding TRH to corticosteroids for women giving birth early may increase the benefit of corticosteroids on the baby's lungs. This review included 15 trials, of a moderate risk of bias, that involved over 4600 women and their babies. In this review, TRH, given with corticosteroids to women at risk of early birth, was not shown to further reduce the breathing difficulties for the babies. Babies born to mothers who had received TRH with corticosteroids, were more likely to require support for breathing than babies born to mothers who received only corticosteroids. Women receiving TRH were more likely to experience adverse side effects, such as nausea, vomiting and flushing than women who only received corticosteroids. Therefore, based on the current available evidence, TRH is not recommended to be given to women at risk of preterm birth for preventing neonatal respiratory disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Crowther, CA; Alfirevic, Z; Han, S; Haslam, RR", "articleTypes": [], "doi": "10.1002/14651858.CD000019.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "4011769f-aa81-4236-9cd1-ff3771844976", "pmid": "", "title": "Antibiotics versus topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity. It is characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Antibiotics and antiseptics kill or inhibit the micro‐organisms that may be responsible for the infection. Antibiotics can be applied topically or administered systemically via the oral or injection route. Antiseptics are always directly applied to the ear (topically). Objectives To assess the benefits and harms of antibiotics versus antiseptics for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP). The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving adults and children who had chronic ear discharge of unknown cause or CSOM, where ear discharge had continued for more than two weeks. The intervention was any single, or combination of, antibiotic agent, whether applied topically (without steroids) or systemically. The comparison was any single, or combination of, topical antiseptic agent, applied as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The comparisons were 1. topical antiseptics compared to topical antibiotics, and 2. topical antiseptics compared to systemic antibiotics. We further separated these comparisons into those in which a. both groups of participants received aural toileting in addition to the intervention, or b. both groups received some other add‐on therapy treatment (such as systemic antibiotics) to both arms. Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This updated review included eight new studies. Overall, we identified 15 studies (2371 participants) across seven comparisons with antibiotics compared to acetic acid, aluminium acetate, boric acid, and povidone‐iodine. None of the included studies reported health‐related quality of life or serious complications. 1. Topical antibiotics (quinolones or aminoglycosides) versus topical antiseptic (acetic acid) We included seven studies (835 participants). Acetic acid may increase resolution of ear discharge when compared to aminoglycoside at one to two weeks (low‐certainty evidence). It is very uncertain whether acetic acid may increase resolution of ear discharge at one to two weeks when compared to topical quinolone. Results after four weeks were only presented narratively. It is very uncertain whether acetic acid may cause more ear pain, discomfort, local irritation, or combinations of these compared to topical antibiotics (aminoglycosides and quinolones) (risk ratio (RR) 0.20, 95% confidence interval (CI) 0.03 to 1.12; I 2 = 0%; 3 studies, 277 participants; very low‐certainty evidence). An additional two studies (350 participants) provided narrative results. There may be little to no difference in hearing between groups reported narratively (quinolones; low‐certainty evidence). The evidence is very uncertain for serious complications (aminoglycosides) or suspected ototoxicity (aminoglycosides) (very low‐certainty evidence). 2. Topical antibiotics (quinolones) versus topical antiseptic (boric acid) We included two studies (532 participants). Topical quinolones are likely to increase resolution of ear discharge at one to two weeks compared with boric acid ear drops (RR 1.86, 95% CI 1.48 to 2.35; 1 study, 411 participants; moderate‐certainty evidence). This means that one additional person will have resolution of ear discharge for every four people receiving topical antibiotics (compared with boric acid) at two weeks. No study reported results for ear discharge after four weeks. There may be less ear pain, discomfort, or irritation with quinolones compared with boric acid (RR 0.56, 95% CI 0.32 to 0.98; 2 studies, 510 participants; low‐certainty evidence). Suspected ototoxicity and serious complications were not reported. Topical quinolones may result in a greater improvement in mean hearing from baseline compared to topical boric acid (mean difference (MD) 2.79 decibels, 95% CI 0.48 to 5.10; 1 study, 390 participants; low‐certainty evidence), but this difference may not be clinically significant. 3. Topical antibiotics (quinolones) versus topical antiseptic (povidone‐iodine) We included one study (40 participants). It is very uncertain if there is a difference between quinolones and povidone‐iodine with respect to resolution of ear discharge at one to two weeks (RR 1.02, 95% CI 0.82 to 1.26; 1 RCT, 39 participants; very low‐certainty evidence). The study reported qualitatively that there were no differences between the groups for hearing and no participants developed ototoxic effects (very low‐certainty evidence). There were no results reported for resolution of ear discharge beyond four weeks; ear pain, discomfort, or irritation; or serious complications. 4. Topical antibiotics versus topical antiseptic (aluminium acetate) We included one study (51 participants; 60 ears) that presented results for resolution of ear discharge at two to four weeks results narratively. No other results were reported. 5. Other comparisons Five studies (966 participants) were assessed over an additional three comparisons; however, these results have not been included in the abstract. Authors' conclusions Treatment of CSOM with topical antibiotics (quinolones) likely results in an increase in resolution of ear discharge compared with boric acid at up to two weeks. There was limited evidence for the efficacy of other topical antibiotics or topical antiseptics and so we are unable to draw conclusions. Harmful effects were not well reported. Limitations of the review include lack of recent data, limitations in the quality of included studies, and limited information on certain population groups or interventions. Plain language summary Which are better, antibiotics or topical antiseptics, for treating chronic suppurative otitis media? Key message – There is limited evidence comparing topical antibiotics with topical antiseptics in people with swelling and infection of the middle ear (called chronic suppurative otitis media). The evidence is very uncertain whether antibiotics or topical antiseptics are more effective for reducing ear discharge, except that topical antibiotics are likely to be more effective than boric acid (an antiseptic). What is chronic suppurative otitis media? Chronic suppurative otitis media is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (where the eardrum has a hole or tear in it). The main symptoms of chronic suppurative otitis media are ear discharge (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Antibiotics (which kill bacteria) are the most commonly used treatment for chronic suppurative otitis media. Antibiotics can either be 'topical' (put into the ear canal as ear drops, ointments, sprays, or creams) or 'systemic' (taken either by mouth or by an injection into a muscle or vein). Topical antiseptics (antiseptics put directly into the ear as ear drops or powders) are a possible treatment for chronic suppurative otitis media. Both antibiotics and topical antiseptics kill or stop the growth of the germs that may be responsible for the infection. Antibiotics and topical antiseptics can be used on their own or added to other treatments for chronic suppurative otitis media, such as other antibiotics or ear cleaning (called aural toileting). It was important in this review to examine whether there were any unwanted effects from using antibiotics and antiseptics, such as irritation of the skin within the outer ear, which may cause discomfort, pain, or itching. Some antibiotics and antiseptics (such as alcohol) can also be toxic to the inner ear (called ototoxicity), which means that they may cause permanent hearing loss, dizziness, or ringing in the ear (called tinnitus). What was the aim of this review? We wanted to compare antibiotics and antiseptics for the treatment of chronic suppurative otitis media. In particular, we wanted to know whether they stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found 15 studies, which included 2371 people, that compared antibiotics to a variety of antiseptics (acetic acid, boric acid, povidone‐iodine, and aluminium acetate). One study recruited only children, two studies recruited only adults, and 12 studies included both adults and children. About 40 in every 100 people were females. We presented the main comparisons below. Comparison of antibiotics to acetic acid We included seven studies (835 people). We have little to no confidence in the evidence of whether topical antibiotics or acetic acid improved ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to boric acid We included two studies (532 people). Topical antibiotics (quinolones) are likely to be better than boric acid at reducing ear discharge after one to two weeks. There may also be less ear discomfort (pain, irritation, and bleeding). Topical quinolones may result in a greater improvement in hearing compared to topical boric acid, but this difference may be too small for the person to notice a difference. Comparison of antibiotics to povidone‐iodine We included one study (40 people). We have little to no confidence in the evidence of whether topical or systemic antibiotics or povidone‐iodine improve the resolution of ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to aluminium acetate We included one study (51 people) that stated there was improvement in ear discharge at two to four weeks, but they did not present their results in a way that we could use. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. What are the limitations of the evidence? The studies were small with many being poorly reported, and results varied widely between studies. We also need more information about harmful effects. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K, Chong, LY, Bhutta, MF, Daw, J, Veselinović, T, Morris, PS, Vijayasekaran, S, Schilder, AGM, Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013056.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.087Z" }, { "id": "40441df1-1880-4321-b699-3f65cba0b07e", "pmid": "", "title": "Convalescent plasma for people with COVID‐19", "imported": false, "abstract": "Abstract - Rationale Convalescent plasma (CP) may reduce mortality in people with viral respiratory diseases, and is being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). A thorough understanding of the current body of evidence regarding the benefits and risks of this intervention is required. Objectives To assess the effectiveness and safety of convalescent plasma transfusion in the treatment of people with COVID‐19. Search methods To identify completed and ongoing studies, we searched CENTRAL, MEDLINE, Embase, the Epistemonikos COVID‐19 L*OVE Platform, and clinical trial registries to October 2024. Eligibility criteria We included randomised controlled trials (RCTs) evaluating convalescent plasma for people with COVID‐19, irrespective of disease severity, age, gender, or ethnicity. We excluded studies investigating other coronavirus diseases or standard immunoglobulin. Outcomes We used the GRADE approach to rate the certainty of evidence for the following outcomes: all‐cause mortality (up to day 28), worsening and improvement of clinical status (for individuals with moderate to severe disease), hospital admission or death, COVID‐19 symptoms resolution (for individuals with mild disease), quality of life (QoL), grade 3/4 adverse events, and serious adverse events. Risk of bias We used RoB 2 to assess bias in included studies. Synthesis methods We followed standard Cochrane methodology. Included studies We included 48 RCTs (24,518 participants), 15 of which were added in this update. We also identified 36 new ongoing studies and 33 completed studies awaiting classification. Synthesis of results Individuals with a confirmed diagnosis of COVID‐19 and moderate to severe disease Forty‐two RCTs investigated the use of CP for 21,393 participants with moderate to severe disease. Of these, 36 RCTs (20,798 participants) compared CP to placebo or standard care, five (604 participants) to standard plasma, and one (190 participants) to human immunoglobulin. In the full review, we performed subgroup analyses by antibody detection, time since symptom onset, country income level, and key comorbidities. Convalescent plasma versus placebo or standard care alone CP does not reduce all‐cause mortality at up to day 28 (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.90 to 1.03; 31 RCTs, 20,798 participants; high‐certainty evidence). It has little to no impact on the need for invasive mechanical ventilation, or death (RR 1.03, 95% CI 0.98 to 1.08; 8 RCTs, 15,189 participants; high‐certainty evidence) and has no impact on whether participants are discharged from hospital (RR 1.00, 95% CI 0.97 to 1.02; 9 RCTs, 13,930 participants; high‐certainty evidence). CP may have little to no impact on QoL (MD 1.00, 95% CI −2.14 to 4.14; 1 RCT, 483 participants; low‐certainty evidence). CP may have little to no impact on the risk of grade 3/4 adverse events (RR 1.17, 95% CI 0.96 to 1.42; 6 RCTs, 2392 participants; low‐certainty evidence). It probably has little to no effect on the risk of serious adverse events (RR 1.19, 95% CI 1.02 to 1.38; 11 studies, 5298 participants; moderate‐certainty evidence). Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.77, 95% CI 0.53 to 1.10; 5 RCTs, 604 participants; very low‐certainty evidence) and whether it increases the need for invasive mechanical ventilation, or death (RR 5.59, 95% CI 0.29 to 108.38; 1 study, 34 participants; very low‐certainty evidence). The evidence is uncertain about whether convalescent plasma reduces or increases the risk of grade 3/4 adverse events (1 RCT, 248 participants). The evidence is also uncertain about whether CP reduces the risk of serious adverse events (RR 0.82, 95% CI 0.57 to 1.17; 4 RCTs, 447 participants; very low‐certainty evidence). No studies in this comparison reported clinical improvement or QoL. Individuals with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease Six RCTs investigated the use of CP for 2761 participants with mild disease. Four RCTs (1164 participants) compared CP to placebo or standard care alone, and two (1597 participants) to standard plasma. Convalescent plasma versus placebo or standard care alone The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (odds ratio (OR) 1.24, 95% CI 0.33 to 4.60; 3 RCTs, 1004 participants; very low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.45, 95% CI 0.04 to 4.81; 2 RCTs, 493 participants; very low‐certainty evidence). It may have little to no impact on time to COVID‐19 symptom resolution (hazard ratio (HR) 1.05, 95% CI 0.85 to 1.30; 1 RCT, 376 participants) and on the risk of grade 3/4 adverse events (RR 1.29, 95% CI 0.75 to 2.19; 1 RCT, 376 participants), both with low‐certainty evidence. The evidence is uncertain about whether CP has an impact on the risk of serious adverse events (RR 0.84, 95% CI 0.56 to 1.26; 2 RCTs, 494 participants; very low‐certainty evidence). No studies in this comparison reported other critical outcomes. Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.41, 95% CI 0.05 to 3.06; 2 RCTs, 1597 participants; very low‐certainty evidence). It probably reduces admission to hospital or death within 28 days (RR 0.50, 95% CI 0.32 to 0.78; 2 RCTs, 1597 participants; moderate‐certainty evidence). CP may have little to no effect on initial symptom resolution at up to day 28 (RR 1.12, 95% CI 0.82 to 1.54; 1 RCT, 416 participants; low‐certainty evidence). Neither study in this comparison reported other critical outcomes. Authors' conclusions Compared with placebo or standard care, high‐certainty evidence shows that CP does not reduce mortality in individuals with moderate to severe disease and has little to no effect on clinical improvement or worsening. CP probably has little to no effect on serious adverse events. Publication of ongoing studies might resolve some of the uncertainties around CP therapy for people with asymptomatic or mild disease. This review was previously a living systematic review, from the first version published in 2020 until our last search in October 2024. The research question is no longer a priority for decision‐making, new studies are less frequently published, and research that might impact the conclusions of the review is no longer emerging. Funding The European Commission, Belgium SUPorting high quality evaluation of COVID‐19 convalescent plasma thrOughouT Europe (SUPPORT‐E, grant number 101015756) supported this review. Registration Protocol registered with the Center for Open Science on 17 April 2020 (DOI: 10.17605/OSF.IO/DWF53). Access the 2023 version of this review here: DOI: 10.1002/14651858.CD013600.pub6. Plain language summary Does plasma (a blood product) from people who have recovered from COVID‐19 help treat COVID‐19? Key messages We are very confident that plasma from the blood of people who have recovered from COVID‐19 (convalescent plasma) does not help people with moderate to severe COVID‐19. Convalescent plasma may make little or no difference to people with mild COVID‐19. We still need more evidence about people with mild COVID‐19, those with no symptoms, and those with a weaker immune system. What is convalescent plasma? The body produces antibodies as one of its defences against infection. Antibodies are found in part of the blood called plasma. Plasma from people who have recovered from the COVID‐19 virus contains COVID‐19 antibodies. It can be used to make convalescent plasma, which is plasma that contains these antibodies. Convalescent plasma has been used successfully to treat some viruses. This treatment (given by a drip or injection) is generally well‐tolerated, but can cause unwanted effects. What did we want to find out? We wanted to find out whether convalescent plasma helps people with confirmed COVID‐19. We looked at: deaths from any cause; worsening of people's condition, measured by the number of people who needed a ventilator (a machine that helps people breathe) or died; improvement in people's condition, measured by the number of people discharged from hospital; quality of life; unwanted effects. What did we do? We searched for studies that investigated convalescent plasma to treat people with COVID‐19. Studies could take place anywhere in the world and include people with mild, moderate, or severe COVID‐19. Where possible, we combined the studies’ results to analyse them. We rated our confidence in the evidence, based on factors such as study methods and the number of people included. What did we find? We found 48 studies with 24,518 participants. Of these, 42 studies included people with moderate to severe COVID‐19, and six studies included people with mild COVID‐19. The following findings compare convalescent plasma with placebo (a 'dummy' treatment that does not contain any medicine but is given in the same way as the medicine being tested) or the standard care given to people with COVID‐19. People with moderate to severe COVID‐19 In people with moderate to severe COVID‐19, convalescent plasma: makes no difference to deaths from any cause up to 28 days after treatment. About 230 of 1000 people given placebo or standard care died, compared to 220 of 1000 people given convalescent plasma (31 studies, 20,798 people). makes little to no difference to needing support from a ventilator or dying . About 291 of 1000 people given placebo or standard care needed a ventilator or died, compared to 300 of 1000 people given convalescent plasma (8 studies, 15,189 people). makes no difference to people being discharged from hospital. About 670 of 1000 people in both groups were discharged from hospital (9 studies, 13,930 people). may result in no difference in people's quality of life (1 study, 483 people). probably makes no difference to serious unwanted effects. About 109 of 1000 people given placebo or standard care had serious unwanted effects, compared to 129 of 1000 people given convalescent plasma (11 studies, 5298 people). People with mild COVID‐19 We are uncertain whether convalescent plasma reduces deaths from any cause up to 28 days after treatment. About 8 of 1000 people given placebo or standard care died, compared to 10 of 1000 people given convalescent plasma (3 studies, 1004 people). We are uncertain whether convalescent plasma reduces admission to hospital or death within 28 days after treatment. About 106 of 1000 people given placebo or standard care were admitted to hospital or died, compared to 48 of 1000 people given convalescent plasma (2 studies, 493 people). Convalescent plasma may result in no difference in the time until COVID‐19 symptoms resolved (1 study, 376 people). None of the studies measured people's quality of life. We are uncertain whether convalescent plasma has an impact on serious unwanted effects. About 174 of 1000 people given placebo or standard care had serious unwanted effects, compared to 150 of 1000 people given convalescent plasma (2 studies, 494 people). What are the limitations of the evidence? For people with moderate to severe COVID‐19, we are very confident in the evidence about the number of deaths from any cause, and whether people's condition worsened or improved, because the results are drawn from many high‐quality studies with consistent results. We are only moderately confident about the evidence for serious unwanted effects because studies often reported these effects only for people treated with convalescent plasma, or did not report them. For people with mild COVID‐19, we have little to no confidence in the evidence because we could not identify enough consistent results from many of the studies. We still have little evidence about quality of life and about the effects of convalescent plasma for people with mild disease. How up to date is this evidence? This updates our previous review published in 2023. The evidence is current to October 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Iannizzi, C, Chai, KL, Piechotta, V, Monsef, I, Wood, EM, Lamikanra, AA, Roberts, DJ, McQuilten, Z, So-Osman, C, Jindal, A, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013600.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.138Z" }, { "id": "408c9d58-6cb8-4248-8ac7-40680c371942", "pmid": "", "title": "Thoracic imaging tests for the diagnosis of COVID‐19", "imported": false, "abstract": "Abstract - Background Our March 2021 edition of this review showed thoracic imaging computed tomography (CT) to be sensitive and moderately specific in diagnosing COVID‐19 pneumonia. This new edition is an update of the review. Objectives Our objectives were to evaluate the diagnostic accuracy of thoracic imaging in people with suspected COVID‐19; assess the rate of positive imaging in people who had an initial reverse transcriptase polymerase chain reaction (RT‐PCR) negative result and a positive RT‐PCR result on follow‐up; and evaluate the accuracy of thoracic imaging for screening COVID‐19 in asymptomatic individuals. The secondary objective was to assess threshold effects of index test positivity on accuracy. Search methods We searched the COVID‐19 Living Evidence Database from the University of Bern, the Cochrane COVID‐19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID‐19 publications through to 17 February 2021. We did not apply any language restrictions. Selection criteria We included diagnostic accuracy studies of all designs, except for case‐control, that recruited participants of any age group suspected to have COVID‐19. Studies had to assess chest CT, chest X‐ray, or ultrasound of the lungs for the diagnosis of COVID‐19, use a reference standard that included RT‐PCR, and report estimates of test accuracy or provide data from which we could compute estimates. We excluded studies that used imaging as part of the reference standard and studies that excluded participants with normal index test results. Data collection and analysis The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using QUADAS‐2. We presented sensitivity and specificity per study on paired forest plots, and summarized pooled estimates in tables. We used a bivariate meta‐analysis model where appropriate. Main results We included 98 studies in this review. Of these, 94 were included for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eight studies were included for assessing the rate of positive imaging in individuals with initial RT‐PCR negative results and positive RT‐PCR results on follow‐up, and 10 studies were included for evaluating the accuracy of thoracic imaging for imagining asymptomatic individuals. For all 98 included studies, risk of bias was high or unclear in 52 (53%) studies with respect to participant selection, in 64 (65%) studies with respect to reference standard, in 46 (47%) studies with respect to index test, and in 48 (49%) studies with respect to flow and timing. Concerns about the applicability of the evidence to: participants were high or unclear in eight (8%) studies; index test were high or unclear in seven (7%) studies; and reference standard were high or unclear in seven (7%) studies. Imaging in people with suspected COVID‐19 We included 94 studies. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All studies used RT‐PCR alone or in combination with other criteria (for example, clinical signs and symptoms, positive contacts) as the reference standard for the diagnosis of COVID‐19. For chest CT (69 studies, 28285 participants, 14,342 (51%) cases), sensitivities ranged from 45% to 100%, and specificities from 10% to 99%. The pooled sensitivity of chest CT was 86.9% (95% confidence interval (CI) 83.6 to 89.6), and pooled specificity was 78.3% (95% CI 73.7 to 82.3). Definition for index test positivity was a source of heterogeneity for sensitivity, but not specificity. Reference standard was not a source of heterogeneity. For chest X‐ray (17 studies, 8529 participants, 5303 (62%) cases), the sensitivity ranged from 44% to 94% and specificity from 24 to 93%. The pooled sensitivity of chest X‐ray was 73.1% (95% CI 64.1 to 80.5), and pooled specificity was 73.3% (95% CI 61.9 to 82.2). Definition for index test positivity was not found to be a source of heterogeneity. Definition for index test positivity and reference standard were not found to be sources of heterogeneity. For ultrasound of the lungs (15 studies, 2410 participants, 1158 (48%) cases), the sensitivity ranged from 73% to 94% and the specificity ranged from 21% to 98%. The pooled sensitivity of ultrasound was 88.9% (95% CI 84.9 to 92.0), and the pooled specificity was 72.2% (95% CI 58.8 to 82.5). Definition for index test positivity and reference standard were not found to be sources of heterogeneity. Indirect comparisons of modalities evaluated across all 94 studies indicated that chest CT and ultrasound gave higher sensitivity estimates than X‐ray (P = 0.0003 and P = 0.001, respectively). Chest CT and ultrasound gave similar sensitivities (P = 0.42). All modalities had similar specificities (CT versus X‐ray P = 0.36; CT versus ultrasound P = 0.32; X‐ray versus ultrasound P = 0.89). Imaging in PCR‐negative people who subsequently became positive For rate of positive imaging in individuals with initial RT‐PCR negative results, we included 8 studies (7 CT, 1 ultrasound) with a total of 198 participants suspected of having COVID‐19, all of whom had a final diagnosis of COVID‐19. Most studies (7/8) evaluated CT. Of 177 participants with initially negative RT‐PCR who had positive RT‐PCR results on follow‐up testing, 75.8% (95% CI 45.3 to 92.2) had positive CT findings. Imaging in asymptomatic PCR‐positive people For imaging asymptomatic individuals, we included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with a total of 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. For chest CT (7 studies, 3134 participants, 315 (10%) cases), the pooled sensitivity was 55.7% (95% CI 35.4 to 74.3) and the pooled specificity was 91.1% (95% CI 82.6 to 95.7). Authors' conclusions Chest CT and ultrasound of the lungs are sensitive and moderately specific in diagnosing COVID‐19. Chest X‐ray is moderately sensitive and moderately specific in diagnosing COVID‐19. Thus, chest CT and ultrasound may have more utility for ruling out COVID‐19 than for differentiating SARS‐CoV‐2 infection from other causes of respiratory illness. The uncertainty resulting from high or unclear risk of bias and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results. Plain language summary How accurate is chest imaging for diagnosing COVID‐19? Why is this question important? People with suspected COVID‐19 need to know quickly whether they are infected, so they can receive appropriate treatment, self‐isolate, and inform close contacts. Currently, a formal diagnosis of COVID‐19 requires a laboratory test (RT‐PCR) of nose and throat samples. RT‐PCR requires specialist equipment and takes at least 24 hours to produce a result. It is not completely accurate, and may require a second RT‐PCR or a different test to confirm diagnosis. Clinicians may use chest imaging to diagnose people who have COVID‐19 symptoms, while awaiting RT‐PCR results or when RT‐PCR results are negative, and the person has COVID‐19 symptoms. This is the fourth version of this review. What did we want to find out? We wanted to know whether chest imaging is accurate enough to diagnose COVID‐19 in people with suspected infection; we included studies in people with suspected COVID‐19 only and excluded studies in people with confirmed COVID‐19. We also wanted to assess the accuracy of chest imaging for screening asymptomatic people. The evidence is up to date to 17 February 2021. What are chest imaging tests? X‐rays or scans produce an image of the organs and structures in the chest. ‐ X‐rays (radiography) use radiation to produce a 2‐D image. Usually done in hospitals, using fixed equipment by a radiographer; they can also be done on portable machines. ‐ Computed tomography (CT) scans use a computer to merge 2‐D X‐ray images and convert them to a 3‐D image. They require highly‐specialized equipment and are done in hospital by a specialist radiographer. ‐ Ultrasound scans use high‐frequency sound waves to produce an image. They can be done in hospitals or other healthcare settings, such as a doctor’s office. What did we do? We searched for studies that assessed the accuracy of chest imaging to diagnose COVID‐19 in people of any age with suspected COVID‐19. We included studies with ‘symptomatic' or 'mixed populations'. What did we find? We found 94 studies with 37,631 participants (of whom 19,768 (53%) had a final diagnosis of COVID‐19) for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All 94 studies used RT‐PCR either alone or in combination with other criteria (such as clinical signs and symptoms, or positive contacts) as the reference standard for the diagnosis of COVID‐19. Chest CT: suspected people Pooled results showed that chest CT (69 studies) correctly diagnosed COVID‐19 in 87% of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 21% of people who did not have COVID‐19. Chest X‐ray: suspected people Pooled results showed that chest X‐ray (17 studies) correctly diagnosed COVID‐19 in 73 % of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 27% of people who did not have COVID‐19. Lung ultrasound: suspected people Pooled results showed that lung ultrasound (15 studies) correctly diagnosed COVID‐19 in 87% of people with COVID‐19. However, it incorrectly diagnosed COVID‐19 in 24% of people who did not have COVID‐19. Screening asymptomatic people We included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. Pooled results of seven studies, showed that CT correctly diagnosed COVID‐19 in 56% of people who had COVID‐19, and incorrectly identified COVID‐19 in 8% of people who did not have COVID‐19. How reliable are the results? The studies differed from each other and used different methods to report their results. Very few studies directly compared one type of imaging test with another. Also, the risk of bias was high or unclear in about half of all included studies. Therefore, it is difficult to draw confident conclusions. What does this mean? The evidence suggests that chest CT and ultrasound are better at ruling out COVID‐19 infection than distinguishing it from other respiratory problems. So, their usefulness may be limited to excluding COVID‐19 infection rather than differentiating it from other causes of lung infection. In addition, chest CT imaging had poor sensitivity and high specificity for detecting asymptomatic individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ebrahimzadeh, S, Islam, N, Dawit, H, Salameh, J-P, Kazi, S, Fabiano, N, Treanor, L, Absi, M, Ahmad, F, Rooprai, P, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013639.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.783Z" }, { "id": "40903ca0-028c-45d1-886e-8c4c8c2dccd0", "pmid": "", "title": "Chlorambucil for patients with primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. But it is unknown whether it benefits or harms these patients. Objectives To evaluate the beneficial and any harmful effects of chlorambucil for primary biliary cirrhosis patients. Search methods Eligible trials were identified by searching the Cochrane Hepato‐Biliary Group Controlled Trials Register (March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2012, Issue 2), MEDLINE (1946 to March 2012), EMBASE (1974 to March 2012), Science Citation Index EXPANDED (1900 to March 2012), The Chinese Biomedical Database (1976 to March 2012), The Chinese Medical Current Contents (1994 to March 2012), The China Hospital Knowledge Database (1994 to March 2012), and a database of ongoing trials (http://www.controlled‐trials.com/mrct/) (accessed 6 March 2012). The reference lists of the retrieved publications and review articles were also read through, and pharmaceutical companies known to produce chlorambucil were contacted. Selection criteria Randomised clinical trials, irrespective of language, year of publication, and publication status, comparing chlorambucil at any dose versus placebo, no intervention, another active drug, or one dose of chlorambucil with another dose. Data collection and analysis We planned to assess continuous data with mean differences (MD), and dichotomous outcomes with relative risk (RR), both with 95% confidence intervals (CI). As we only identified one trial, Fisher's exact tests were employed. Main results Only one randomised trial was identified and included in the review. The bias risk in the trial was high. The trial compared chlorambucil versus no intervention in 24 patients with primary biliary cirrhosis. Fisher's exact test did not show a significant reduction of mortality when comparing chlorambucil with no treatment (0/13 (0%) versus (2/11 (18.2%); P = 0.20). There was no significant difference regarding adverse events for chlorambucil compared with no treatment, but all patients receiving chlorambucil experienced adverse events (13/13 (100%) versus (3/11 (27%); P = 0.1). According to the authors of the trial, chlorambucil led to a significant improvement in mean serum levels of bilirubin (P < 0.05), albumin (P < 0.05), immunoglobulin M (P < 0.01), serum aspartate aminotransferase activity (P < 0.01), and hepatic inflammatory infiltrates (P < 0.01). Authors' conclusions There is not sufficient evidence to support or reject the use of chlorambucil for patients with primary biliary cirrhosis. Chlorambucil may show benefit in some unvalidated surrogate outcome measures (for example, serum bilirubin and immunoglobulin M levels). Chlorambucil is, however, connected with a number of adverse events. Bone marrow suppression should be noted in particular. Further randomised clinical trials are necessary to assess the benefits and harms of chlorambucil in this indication. Plain language summary Chlorambucil for patients with primary biliary cirrhosis Primary biliary cirrhosis is an autoimmune disease of the liver. Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. This review aimed to assess the beneficial or harmful effects of chlorambucil for primary biliary cirrhosis. The authors identified only one randomised trial, with 24 participants included. This trial compared chlorambucil with no intervention. The trial is small and at a high risk of bias, which suggests that the results may not be reliable. Meta‐analyses were not possible because of the inclusion of one trial only. Fisher's exact test and t‐test were used instead. Chlorambucil was not associated with significantly lower mortality when compared with no intervention. All patients on chlorambucil experienced adverse events, especially bone marrow suppression. Chlorambucil led to a significant improvement in mean serum levels of bilirubin, albumin, immunoglobulin M, serum aspartate aminotransferase activity, and hepatic inflammatory infiltrates. However, these outcomes are unvalidated surrogate outcomes for patient‐relevant outcomes. This means that improvement of these biochemistry measures cannot be taken as proof of improvement of patient‐relevant outcomes. It remains unclear whether chlorambucil can be supported or rejected for use in patients with primary biliary cirrhosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Li, WX, Yan, X, Shi, CR, Zhang, AP", "articleTypes": [], "doi": "10.1002/14651858.CD008714.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.779Z" }, { "id": "4093eb4c-4e3b-4dce-9e58-38076bae6262", "pmid": "", "title": "Breastfeeding or breast milk for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Pain in the neonate is associated with acute behavioural and physiological changes. Cumulative pain is associated with morbidities, including adverse neurodevelopmental outcomes. Studies have shown a reduction in changes in physiological parameters and pain score measurements following pre‐emptive analgesic administration in neonates experiencing pain or stress. Non‐pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for analgesia. This is an update of a review first published in 2006 and updated in 2012. Objectives The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries (ICTRP, ISRCTN and clinicaltrials.gov) in August 2022; searches were limited from 2011 forwards. We checked the reference lists of included studies and relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates. We included both term (≥ 37 completed weeks postmenstrual age) and preterm infants (< 37 completed weeks' postmenstrual age) up to a maximum of 44 weeks' postmenstrual age. The study must have reported on either physiological markers of pain or validated pain scores. Data collection and analysis We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a mean difference (MD). We used the GRADE approach to assess the certainty of evidence. Main results Of the 66 included studies, 36 evaluated breastfeeding, 29 evaluated supplemental breast milk and one study compared them against each other. The procedures conducted in the studies were: heel lance (39), venipuncture (11), intramuscular vaccination (nine), eye examination for retinopathy of prematurity (four), suctioning (four) and adhesive tape removal as procedure (one). We noted marked heterogeneity in the control interventions and pain assessment measures amongst the studies. Since many studies included multiple arms with breastfeeding/supplemental breast milk as the main comparator, we were not able to synthesise all interventions together. Individual interventions are compared to breastfeeding/supplemental breast milk and reported. The numbers of studies/participants presented with the findings are not taken from pooled analyses (as is usual in Cochrane Reviews), but are the overall totals in each comparison. Overall, the included studies were at low risk of bias except for masking of intervention and outcome assessment, where nearly one‐third of studies were at high risk of bias. Breastfeeding versus control Breastfeeding may reduce the increase in heart rate compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration of sucrose/glucose (20% to 33%) with skin‐to‐skin contact (low‐certainty evidence, 8 studies, 784 participants). Breastfeeding likely reduces the duration of crying compared to no intervention, lying on table, rocking, heel warming, holding by mother, skin‐to‐skin contact, bottle feeding mother's milk and moderate concentration of glucose (moderate‐certainty evidence, 16 studies, 1866 participants). Breastfeeding may reduce percentage time crying compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration sucrose and moderate concentration of sucrose with skin‐to‐skin contact (low‐certainty evidence, 4 studies, 359 participants). Breastfeeding likely reduces the Neonatal Infant Pain Scale (NIPS) score compared to no intervention, holding by mother, heel warming, music, EMLA cream, moderate glucose concentration, swaddling, swaddling and holding (moderate‐certainty evidence, 12 studies, 1432 participants). Breastfeeding may reduce the Neonatal Facial Coding System (NFCS) score compared to no intervention, holding, pacifier and moderate concentration of glucose (low‐certainty evidence, 2 studies, 235 participants). Breastfeeding may reduce the Douleur Aigue Nouveau‐né (DAN) score compared to positioning, holding or placebo (low‐certainty evidence, 4 studies, 709 participants). In the majority of the other comparisons there was little or no difference between the breastfeeding and control group in any of the outcome measures. Supplemental breast milk versus control Supplemental breast milk may reduce the increase in heart rate compared to water or no intervention (low‐certainty evidence, 5 studies, 336 participants). Supplemental breast milk likely reduces the duration of crying compared to positioning, massage or placebo (moderate‐certainty evidence, 11 studies, 1283 participants). Supplemental breast milk results in little or no difference in percentage time crying compared to placebo or glycine (low‐certainty evidence, 1 study, 70 participants). Supplemental breast milk results in little or no difference in NIPS score compared to no intervention, pacifier, moderate concentration of sucrose, eye drops, gentle touch and verbal comfort, and breast milk odour and verbal comfort (low‐certainty evidence, 3 studies, 291 participants). Supplemental breast milk may reduce NFCS score compared to glycine (overall low‐certainty evidence, 1 study, 40 participants). DAN scores were lower when compared to massage and water; no different when compared to no intervention, EMLA and moderate concentration of sucrose; and higher when compared to rocking or pacifier (low‐certainty evidence, 2 studies, 224 participants). Due to the high number of comparator interventions, other measures of pain were assessed in a very small number of studies in both comparisons, rendering the evidence of low certainty. The majority of studies did not report on adverse events, considering the benign nature of the intervention. Those that reported on adverse events identified none in any participants. Subgroup analyses were not conducted due to the small number of studies. Authors' conclusions Moderate‐/low‐certainty evidence suggests that breastfeeding or supplemental breast milk may reduce pain in neonates undergoing painful procedures compared to no intervention/positioning/holding or placebo or non‐pharmacological interventions. Low‐certainty evidence suggests that moderate concentration (20% to 33%) glucose/sucrose may lead to little or no difference in reducing pain compared to breastfeeding. The effectiveness of breast milk for painful procedures should be studied in the preterm population, as there are currently a limited number of studies that have assessed its effectiveness in this population. Plain language summary Breastfeeding or breast milk for procedural pain in newborn babies Review question We investigated how well breastfeeding or supplemental breast milk (expressed breast milk given via feeding tube or by placing breast milk in baby's mouth) works as a pain reliever in newborn babies while they undergo painful procedures (e.g. vaccination, heel prick, blood sampling for tests or eye examinations). The babies' pain responses (e.g. changes in heart rate, oxygen level, blood pressure, percentages of crying time, duration of crying etc.) were assessed by health care professionals to measure the pain that babies are experiencing. Background Breastfeeding may provide pain relief for newborn babies undergoing painful procedures. Medication for pain relief is commonly given for major painful procedures, but may not be given for minor painful procedures such as blood sampling (by heel prick or taking a sample from a vein). There are different forms of non‐drug strategies that can be used to reduce pain in babies, such as holding or swaddling them, sucking on a pacifier, or giving sweet solutions (such as sucrose or glucose). Different studies done in newborn babies have shown that breastfeeding may be a good way to reduce the pain they feel when subjected to minor painful procedures. These studies have been done in full‐term babies, and they have shown that breastfeeding may be effective by demonstrating that it reduces babies' crying time and various pain scores that have been validated for babies. Breast milk given by syringe has not shown the same efficacy as breastfeeding itself. Very few studies have been done in preterm babies, and so new studies are needed to determine if the use of supplemental breast milk in these small babies is effective in reducing their pain. Study characteristics We searched the medical literature thoroughly up to 1 August 2022 for studies that investigated the pain‐relieving effect of breastfeeding or supplemental breast milk for minor medical procedures in newborn full‐term and preterm neonates We included randomised trials only, as they provide the most reliable medical evidence. We identified 66 studies that reported on a total of more than 6200 infants in this Cochrane Review. Thirty‐six studies evaluated breastfeeding, 29 studies evaluated supplemental breast milk, while one study compared both against each other. In over half of the studies, pain relief was during a heel prick procedure. In others, it was during vaccination, drawing blood from a vein or other procedures. The studies used a variety of comparative groups, for example, placebo, no intervention, maternal holding, skin‐to‐skin contact, similar volume of water, a pacifier, routine care, various concentrations of sucrose or glucose, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), swaddling, heel warmth, anaesthetic cream for the skin, or a combination of these. The studies used a wide variety of pain scales as well as changes in heart rate and blood pressure and cry duration to assess pain. Study funding sources The studies included in the review were not externally funded according to information given in the reports. Key results Newborn babies in the breastfeeding group experienced a lower heart rate, shorter duration of cry, lower percentage of cry time and lower scores on the Neonatal Infant Pain Scale than babies who received no intervention. Moderate concentrations of glucose/sucrose may have similar effectiveness to breastfeeding. Studies of supplemental breast milk showed variable results. Supplemental breast milk was found to have a lower increase in heart rate when compared to water, and a lower duration of crying when compared to placebo. What are the limitations of the evidence We are moderately confident that breastfeeding reduces pain as assessed by heart rate, cry duration or validated pain scale compared to no intervention. Supplemental breast milk for painful procedures may reduce pain when compared to no intervention or placebo. Due to the high number of comparator groups, other measures of pain were assessed in a very small number of studies. The majority of the studies did not report on any unwanted or harmful effects of treatment. Those that did this identified no unwanted or harmful effects of treatment in any infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Shah, PS; Torgalkar, R; Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD004950.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "4094aea2-07bb-4cdd-9cb1-e4e1f8c9b52e", "pmid": "", "title": "Sumatriptan (oral route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Objectives To determine the efficacy and tolerability of oral sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using oral sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Sixty‐one studies (37,250 participants) compared oral sumatriptan with placebo or an active comparator. Most of the data were for the 50 mg and 100 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 50 mg versus placebo the NNTs were 6.1, 7.5, and 4.0 for pain‐free at two hours and headache relief at one and two hours, respectively. NNTs for sustained pain‐free and sustained headache relief during the 24 hours postdose were 9.5 and 6.0, respectively. For sumatriptan 100 mg versus placebo the NNTs were 4.7, 6.8, 3.5, 6.5, and 5.2, respectively, for the same outcomes. Results for the 25 mg dose were similar to the 50 mg dose, while sumatriptan 100 mg was significantly better than 50 mg for pain‐free and headache relief at two hours, and for sustained pain‐free during 24 hours. Treating early, during the mild pain phase, gave significantly better NNTs for pain‐free at two hours and sustained pain‐free during 24 hours than did treating established attacks with moderate or severe pain intensity. Relief of associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than with placebo. For the most part, adverse events were transient and mild and were more common with the sumatriptan than with placebo, with a clear dose response relationship (25 mg to 100 mg). Sumatriptan was compared directly with a number of active treatments, including other triptans, paracetamol (acetaminophen), acetylsalicylic acid, non‐steroidal anti‐inflammatory drugs (NSAIDs), and ergotamine combinations. Authors' conclusions Oral sumatriptan is effective as an abortive treatment for migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (oral route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is widely available as an oral tablet. This review found that a single dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in about 3 in 10 people (32%) taking sumatriptan 100 mg, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 6 in 10 people (61%) taking sumatriptan 100 mg, compared with about 3 in 10 (32%) taking placebo. Almost a quarter (24%) of people taking sumatriptan 100 mg had freedom from pain at two hours which was sustained during 24 hours without the use of rescue medication, compared with fewer than 1 in 10 (8%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events were mostly of short duration and mild or moderate in severity, and were experienced by about 4 in 10 (43%) of people taking sumatriptan 100 mg, and by 2 in 10 (23%) taking placebo. The 50 mg dose had slightly lower efficacy, but was associated with fewer adverse events. Treating attacks while pain was still mild was more effective than treating established attacks with moderate or severe pain intensity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008615.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "40dcd27d-591e-4ba3-8384-4a4bca347347", "pmid": "", "title": "Treatment for recurrent vulvovaginal candidiasis (thrush)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Cooke, G, Watson, C, Deckx, L, Pirotta, M, Smith, J, van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009151.pub2 AB - Abstract - Background Recurrent vulvovaginal candidiasis (RVVC) affects up to 5% of women. No comprehensive systematic review of treatments for RVVC has been published. Objectives The primary objective was to assess the effectiveness and safety of pharmacological and non‐pharmacological treatments for RVVC. The secondary objective was to assess patient preference of treatment options. Search methods We conducted electronic searches of bibliographic databases, including CENTRAL, MEDLINE, Embase, and CINAHL (search date 6 October 2021). We also handsearched reference lists of identified trials and contacted authors of identified trials, experts in RVVC, and manufacturers of products for vulvovaginal candidiasis. Selection criteria We considered all published and unpublished randomised controlled trials evaluating RVVC treatments for at least six months, in women with four or more symptomatic episodes of vulvovaginal candidiasis in the past year. We excluded women with immunosuppressive disorders or taking immunosuppressant medication. We included women with diabetes mellitus and pregnant women. Diagnosis of RVVC must have been confirmed by presence of symptoms and a positive culture and/or microscopy. We included all drug and non‐drug therapies and partner treatment, assessing the following primary outcomes: • number of clinical recurrences per participant per year (recurrence defined as clinical signs and positive culture/microscopy);
• proportion of participants with at least one clinical recurrence during the treatment and follow‐up period; and
• adverse events. Data collection and analysis Two authors independently reviewed titles and abstracts to identify eligible trials. Duplicate data extraction was completed independently by two authors. We assessed risk of bias as described in the Cochrane Handbook for Systematic Reviews of Interventions . We used the fixed‐effects model for pooling and expressed the results as risk ratio (RR) with 95% confidence intervals (CI). Where important statistical heterogeneity was present we either did not pool data (I 2 > 70%) or used a random‐effects model (I 2 40‐70%). We used the GRADE tool to assess overall certainty of the evidence for the pooled primary outcomes. Main results Studies: Twenty‐three studies involving 2212 women aged 17 to 67 years met the inclusion criteria. Most studies excluded pregnant women and women with diabetes or immunosuppression. The predominant species found on culture at study entry was Candida albicans . Overall, the included studies were small (<100 participants). Six studies compared antifungal treatment with placebo (607 participants); four studies compared oral versus topical antifungals (543 participants); one study compared different oral antifungals (45 participants); two studies compared different dosing regimens for antifungals (100 participants); one study compared two different dosing regimens of the same topical agent (23 participants); one study compared short versus longer treatment duration (26 participants); two studies assessed the effect of partner treatment (98 participants); one study compared a complementary treatment (Lactobacillus vaginal tablets and probiotic oral tablets) with placebo (34 participants); three studies compared complementary medicine with antifungals (354 participants); two studies compared 'dermasilk' briefs with cotton briefs (130 participants); one study examined Lactobacillus vaccination versus heliotherapy versus ciclopyroxolamine (90 participants); one study compared CAM treatments to an antifungal treatment combined with CAM treatments (68 participants). We did not find any studies comparing different topical antifungals. Nine studies reported industry funding, three were funded by an independent source and eleven did not report their funding source. Risk of bias: Overall, the risk of bias was high or unclear due to insufficient blinding of allocation and participants and poor reporting. Primary outcomes: Meta‐analyses comparing drug treatments (oral and topical) with placebo or no treatment showed there may be a clinically relevant reduction in clinical recurrence at 6 months (RR 0.36, 95% CI 0.21 to 0.63; number needed to treat for an additional beneficial outcome (NNTB) = 2; participants = 607; studies = 6; I² = 82%; low‐certainty evidence) and 12 months (RR 0.80, 95% CI 0.72 to 0.89; NNTB = 6; participants = 585; studies = 6; I² = 21%; low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. We are very uncertain whether oral drug treatment compared to topical treatment increases the risk of clinical recurrence at 6 months (RR 1.66, 95% CI 0.83 to 3.31; participants = 206; studies = 3; I² = 0%; very low‐certainty evidence) and reduces the risk of clinical recurrence at 12 months (RR 0.95, 95% CI 0.71 to 1.27; participants = 206; studies = 3; I² = 10%; very low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. Adverse events were scarce across both treatment and control groups in both comparisons. The reporting of adverse events varied amongst studies, was generally of very low quality and could not be pooled. Overall the adverse event rate was low for both placebo and treatment arms and ranged from less than 5% to no side effects or complications. Authors' conclusions In women with RVVC, treatment with oral or topical antifungals may reduce symptomatic clinical recurrences when compared to placebo or no treatment. We were unable to find clear differences between different treatment options (e.g. oral versus topical treatment, different doses and durations). These findings are not applicable to pregnant or immunocompromised women and women with diabetes as the studies did not include or report on them. More research is needed to determine the optimal medication, dose and frequency. Plain language summary The effectiveness and safety of treatments for recurrent vulvovaginal candidiasis (thrush) Review question Cochrane authors set out to investigate the effectiveness and safety of drug treatments or non‐drug treatments (such as complementary and alternative medicines) for women with recurrent vulvovaginal candidiasis (thrush). Background Thrush of the vaginal/vulvar area is caused by Candida , a form of yeast that is commonly found in the vagina as part of normal flora without causing symptoms. For unknown reasons, Candida can start growing and cause symptoms of vulvovaginal candidiasis (commonly named thrush). Symptoms of vulvovaginal thrush include itching, swelling, and irritation of the vaginal and vulval areas. It is estimated that uncomplicated vulvovaginal thrush affects up to 75% of women at some time during their reproductive years. Recurrent vulvovaginal candidiasis (RVVC) occurs when a woman has four or more fungal infections during a 12‐month period. Up to 5% of women suffer from RVVC. Some doctors advise taking antifungals as a prevention, but there are no clear evidence‐based guidelines. Study characteristics We identified 23 studies involving 2212 participants between 17 and 67 years old with a diagnosis of RVVC confirmed by a positive test. The studies compared a range of antifungal medicines (taken by mouth or inserted into the vagina), and some complementary or alternative treatments (such as Lactobacillus vaccines or probiotics and special underwear). The studies reported the effects on recurrence of thrush after 6 and 12 months. Only one study reported the number of clinical recurrences at 12 months. Nine studies reported industry funding, three were funded by an independent source and nine studies did not report their funding source. The evidence is current to October 2021. Key results Six studies (607 participants) compared antifungal medication with placebo or no treatment. Based on low certainty evidence antifungal treatments may give a clinically relevant reduction in clinical recurrence at 6 and 12 months. We are uncertain if oral treatments are better than topical treatments (very low certainty evidence for no difference). Adverse effects of taking antifungal medication to prevent recurrence of thrush were not common. Studies reported on adverse effects differently, making comparisons difficult. More research is needed to determine the optimal medication, dose and frequency. We were unable to determine the effects in women who are pregnant or have diabetes. Certainty of the evidence Our confidence in the evidence was low to very low due to serious concerns about risk of bias, unclear reporting and the limited number of studies that could be combined. This means that new studies might change our confidence in the effects of treatments and our conclusions.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.803Z" }, { "id": "40e9e5e2-b63d-448e-b314-4c65e4449fba", "pmid": "", "title": "Cannabinoids for Tourette's Syndrome", "imported": false, "abstract": "Abstract - Background Gilles de la Tourette Syndrome (GTS) is a developmental neuropsychiatric disorder characterised by the presence of chronic motor and phonic tics. Drugs currently used in the treatment of GTS either lack efficacy or are associated with intolerable side effects. There is some anecdotal and experimental evidence that cannabinoids may be effective in treating tics and compulsive behaviour in patients with GTS. There are currently no systematic Cochrane reviews of treatments used in GTS. There is one other Cochrane review being undertaken at present, on the use of fluoxetine for tics in GTS. Objectives To evaluate the efficacy and safety of cannabinoids as compared to placebo or other drugs in treating tics, premonitory urges and obsessive compulsive symptoms (OCS), in patients with GTS. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (in The Cochrane Library Issue 4 2008) , MEDLINE (January 1996 to date), EMBASE (January 1974 to date), PsycINFO (January 1887 to date), CINAHL (January 1982 to date), AMED (January 1985 to date), British Nursing Index (January 1994 to date) and DH DATA (January 1994 to date). 
 
 We also searched the reference lists of located trials and review articles for further information. Selection criteria We included randomised controlled trials (RCTs) comparing any cannabinoid preparation with placebo or other drugs used in the treatment of tics and OCS in patients with GTS. Data collection and analysis Two authors abstracted data independently and settled any differences by discussion. Main results Only two trials were found that met the inclusion criteria. Both compared a cannabinoid, delta‐9‐Tetrahydrocannabinol (Δ 9 THC), either as monotherapy or as adjuvant therapy, with placebo. One was a double blind, single dose crossover trial and the other was a double blind, parallel group study. A total of 28 different patients were studied. Although both trials reported a positive effect from Δ 9 THC, the improvements in tic frequency and severity were small and were only detected by some of the outcome measures. Authors' conclusions Not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome. Plain language summary Cannabinoids for Tourette syndrome Cannabinoid medication might be useful in the treatment of the symptoms in patients with Tourette's syndrome. At the present time only two relevant studies have been conducted. Both studies used tetrahydrocannabinol (Δ 9 THC). In both studies Δ 9 THC was associated with tic reduction. However the sample size was small and a large number of multiple comparisons were made . There were only 28 participants in total, since eight participants took part in both studies. Possibly the patients who derived the greatest benefit and experienced the least adverse effects would be the most inclined to participate in further studies. There were a high number of drop outs/exclusions in the six week study and it is unclear whether intention to treat analysis (ITT) was performed. The results that are reported are analyses done on the patients who remained in the study on the study medication at the correct dose. In reality, patients do opt not to continue treatment if there is limited efficacy or unpalatable side effects. This introduces attrition bias. Whilst there were some significant results, the authors themselves accept that very few of these results are significant if a Bonferroni correction is performed. It is possible that cannabinoid medication has a beneficial effect which is too weak to be detected using ITT and such a small sample size. There is some weak evidence that cannabinoid medication may have an effect on obsessive compulsive behaviour but the measure used was an addition to the TSSL which has not been validated.There were no data on the effect of Δ 9 THC on quality of life.There is not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Curtis, A; Clarke, CE; Rickards, HE", "articleTypes": [], "doi": "10.1002/14651858.CD006565.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "40f2b25a-aaff-4358-8f65-581422a494ed", "pmid": "", "title": "Lifestyle interventions for acute gout", "imported": false, "abstract": "Abstract - Background Although lifestyle interventions are often recommended in the management of chronic gout, the evidence from trial data of the benefits and safety of using lifestyle interventions for treating acute gout attacks have not previously been examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with acute gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies (up to 5 April 2013). We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials which compared lifestyle interventions to another therapy (active or placebo) in patients with acute gout. Outcomes of interest were the change in participant‐reported pain in the target joint(s), target joint inflammation and function, health‐related quality of life (HRQoL), patient global assessment, study participant withdrawals due to adverse events (AEs) and serious adverse events (SAEs). Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (19 participants) at high risk of bias was included in the review. Patients were randomised to receive oral prednisolone and colchicine with or without concomitant topical ice therapy. Topical ice therapy provided significant additional benefit over oral prednisolone and colchicine alone with respect to pain, but did not significantly reduce swelling during acute gout episodes. Mean pain reduction with standard medical treatment was 4.4 cm on a 0 to 10 cm visual analogue scale (VAS) after one week; the addition of topical ice reduced pain by an additional 3.33 cm (95% CI 5.84 to 0.82), or an absolute reduction of 33% (8% to 58% reduction). Joint swelling was reduced by a mean of 3.8 cm in the standard medical treatment group; the addition of topical ice therapy did not reduce swelling significantly (mean difference (MD) 2.07 cm, 95% CI ‐1.56 to 5.70). Target joint function, HRQoL, patient global assessment, study participant withdrawals due to AEs and SEAs were not reported in this study. Authors' conclusions There is low quality evidence, from a single trial at high risk of bias, that the addition of topical ice therapy to oral prednisolone and colchicine for oligoarticular attacks of acute gout results in significantly greater pain reduction at one week. Plain language summary Lifestyle interventions for treating acute gout attacks This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with acute gout. There was one study included in this review, which looked at the benefits and safety of adding topical ice therapy to medications commonly used for treating acute gout (prednisolone and colchicine). Over a one week period, in addition to prednisolone and colchicine, ice was applied to the skin overlying the joints affected by acute gout, for half‐an‐hour, four times per day, to relieve symptoms of pain and warmth and to reduce signs of redness and swelling. The review shows that in people with acute gout: We are uncertain whether the reduction in pain seen with the addition of topical ice to standard treatment of prednisolone and colchicine, compared to prednisolone and colchicine alone, is a true effect because of the very low quality evidence. Joint function, health‐related quality of life, patient global assessment and side effects and complications were not reported. We often do not have precise information about side effects and complications. Topical ice is likely to be a safe intervention. What is gout and what are lifestyle interventions? Gout is a very common cause of painful joint inflammation (arthritis) and is caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness, warmth and swelling of the affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic make‐up, being overweight, ingesting certain medications (for example cyclosporine), having impaired kidney function, and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Medications are the mainstay of acute gout treatment. Given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as consuming more water, coffee, dairy milk and cherry juice, and having fewer sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout to prevent recurrence of attacks. Best estimate of what happens to people with acute gout using topical ice in addition to medications: Joint pain (lower score means less pain) People who used topical ice (for half‐an‐hour, four times per day for one week) in addition to medical treatment (oral prednisolone and colchicine) rated their pain 3.33 points lower on a 0 to 10 point pain scale (33% absolute improvement).
 ‐ People who used topical ice in addition to medical treatment (prednisolone and colchicine) rated their pain to be 2.25 points on a scale of 0 to 10.
 ‐ People who used medical treatment alone rated their pain to be 5.58 points on a scale of 0 to 10. ‐ Three people would need to be treated with topical ice for one person to benefit from pain relief. Adverse events Side effects or complications of using topical ice in addition to medical therapy were not reported in the study.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY; Sriranganathan, MK; Edwards, CJ; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010519.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "4125991b-9369-45b0-bb93-ddda9f4899d0", "pmid": "", "title": "Statins for Smith‐Lemli‐Opitz syndrome", "imported": false, "abstract": "Abstract - Background Smith‐Lemli‐Opitz syndrome (SLOS) is a multiple congenital malformations syndrome caused by defective cholesterol biosynthesis. Affected individuals show cholesterol deficiency and accumulation of various precursor molecules, mainly 7‐dehydrocholesterol and 8‐dehydrocholesterol. There is currently no cure for SLOS, with cholesterol supplementation being primarily a biochemical therapy of limited evidence. However, several anecdotal reports and preclinical studies have highlighted statins as a potential therapy for SLOS. Objectives To evaluate the effects of statins, either alone or in combination with other non‐statin therapies (e.g. cholesterol, bile acid, or vitamin co‐supplementation), compared to cholesterol supplementation alone or in combination with other non‐statin therapies (e.g. bile acid or vitamin supplementation) on several important outcomes including overall survival, neurobehavioral features, and adverse effects in individuals with SLOS. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and three trials registers on 15 February 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs with parallel or cross‐over designs, and non‐randomized studies of interventions (NRSIs) including non‐randomized trials, cohort studies, and controlled before‐and‐after studies, were eligible for inclusion in this review if they met our prespecified inclusion criteria, i.e. involved human participants with biochemically or genetically diagnosed SLOS receiving statin therapy or cholesterol supplementation, or both. Data collection and analysis Two authors screened titles and abstracts and subsequently full‐texts for all potentially‐relevant references. Both authors independently extracted relevant data from included studies and assessed the risks of bias. We analyzed the data extracted from the included NRSIs and cohort studies separately from the data extracted from the single included RCT. We used a random‐effects model to account for the inherent heterogeneity and methodological variation between these different study designs. We used GRADE to assess the certainty of evidence. Main results We included six studies (61 participants with SLOS); one RCT (N = 18), three prospective NRSIs (N = 20), and two retrospective NRSIs (N = 22). Five studies included only children, and two limited their participant inclusion by disease severity. Overall, there were nearly twice as many males as females. All six studies compared add‐on statin therapy to cholesterol supplementation alone. However, the dosages, formulations, and durations of treatment were highly variable across studies. We judged the RCT as having a high risk of bias due to missing data and selective reporting. All included NRSIs had a serious or critical overall risk of bias assessed by the Risk Of Bias In Non‐randomized Studies of Interventions tool (ROBINS‐I). None of the included studies evaluated survival or reported quality of life (QoL). Only the included RCT formally assessed changes in the neurobehavioral manifestations of SLOS, and we are uncertain whether statin therapy improves this outcome (very low‐certainty evidence). We are also uncertain whether the adverse events reported in the RCT were statin‐related (very low‐certainty evidence). In contrast, the adverse events reported in the NRSIs seem to be possibly due to statin therapy (risk ratio 13.00, 95% confidence interval 1.85 to 91.49; P = 0.01; low‐certainty evidence), with only one of the NRSIs retrospectively mentioning changes in the irritability of two of their participants. We are uncertain whether statins affect growth based on the RCT or NRSI results (very low‐certainty evidence). The RCT showed that statins may make little or no difference to plasma biomarker levels (low‐certainty evidence), while we are uncertain of their effects on such parameters in the NRSIs (very low‐certainty evidence). Authors' conclusions Currently, there is no evidence on the potential effects of statin therapy in people with SLOS regarding survival or QoL, and very limited evidence on the effects on neurobehavioral manifestations. Likewise, current evidence is insufficient and of very low certainty regarding the effects of statins on growth parameters in children with SLOS and plasma or cerebrospinal fluid (CSF) levels of various disease biomarkers. Despite these limitations, current evidence seemingly suggests that statins may increase the risk of adverse reactions in individuals with SLOS receiving statins compared to those who are not. Given the insufficient evidence on potential benefits of statins in individuals with SLOS, and their potential for causing adverse reactions, anyone considering this therapy should take these findings into consideration. Future studies should address the highlighted gaps in evidence on the use of statins in individuals with SLOS by collecting prospective data on survival and performing serial standardized assessments of neurobehavioral features, QoL, anthropometric measures, and plasma and CSF biomarker levels after statin introduction. Future studies should also attempt to use consistent dosages, formulations and durations of cholesterol and statin therapy. Plain language summary Statins for Smith‐Lemli‐Opitz syndrome Review question Is statin therapy, either alone or combined with cholesterol therapy, linked to better outcomes (e.g. survival, quality of life, severity or frequency of neurobehavioral abnormalities, changes in growth parameters or biomarker levels) compared to cholesterol therapy alone for people with Smith‐Lemli‐Opitz syndrome (SLOS), and what are the risks of harmful effects for either option? Background Smith‐Lemli‐Opitz syndrome is a genetic malformation syndrome, which occurs when cholesterol is not able to be produced by the body and there is a build up of several toxic molecules that would, under normal circumstances, go on to become cholesterol, such as 7DHC and 8DHC. This means that people with SLOS may fail to achieve normal physical growth, show various degrees of intellectual disability or developmental delay (or both), and show a range of possible behavioral abnormalities (e.g. irritability, aggressiveness, anxiety, attention‐deficit hyperactivity disorder (ADHD), impulsivity and sleep disturbances, among others). It is also notable that SLOS may cause various possible physical abnormalities and disability. There is currently no cure for SLOS, but cholesterol supplementation remains common practice among clinicians caring for people with SLOS. This is based solely on our current understanding of the underlying biochemistry of the disease itself. However, there has been evidence from studies in the laboratory and in single individuals suggesting that statins may be helpful for treating people with SLOS. Search date We conducted our latest search on 15 February 2022. Study characteristics In this review, we included six studies of different designs that included a total of 61 people with SLOS, mostly males. Five of the studies only included children (18 years old or younger). All studies compared a combination of statin and cholesterol therapy to cholesterol supplementation alone. However, the studies used different doses and formulations of statin or cholesterol therapy (or both), as well as different durations of treatment. Key results We found no evidence for the effects of combined statin and cholesterol supplementation, compared to cholesterol supplementation alone, on survival or quality of life in people with SLOS. We are also not sure if combined statin and cholesterol therapy has positive effects on neurobehavioral manifestations or growth in individuals with SLOS compared with cholesterol therapy alone, as we have low confidence in the evidence. We think people with SLOS receiving statin therapy in addition to cholesterol supplementation are more likely to experience adverse events that are usually associated with using statins, compared to those who are only receiving cholesterol supplementation. Finally, we are uncertain about the effects of statin therapy on the levels of various biomarkers usually measured in the blood of people with SLOS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ballout, RA; Livinski, A; Fu, Y-P; Steiner, RD; Remaley, AT", "articleTypes": [], "doi": "10.1002/14651858.CD013521.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "412c94df-5626-4638-ba42-2a67f6fbe439", "pmid": "", "title": "A PHASE 2, NON RANDOMIZED, OPEN LABEL, SINGLE ARM, MULTI CENTER STUDY OF TALAZOPARIB FOR NEOADJUVANT TREATMENT OF GERMLINE BRCA1/2 MUTATION PATIENTS WITH EARLY HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR 2 NEGATIVE BREAST CANCER", "imported": false, "abstract": "A PHASE 2, NON RANDOMIZED, OPEN LABEL, SINGLE ARM, MULTI CENTER STUDY OF TALAZOPARIB FOR NEOADJUVANT TREATMENT OF GERMLINE BRCA1/2 MUTATION PATIENTS WITH EARLY HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR 2 NEGATIVE BREAST CANCER", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.157Z" }, { "id": "413c4408-deeb-4339-8902-8414487ded64", "pmid": "", "title": "Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Rationale Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Alendronate belongs to the bisphosphonate class of drugs, which inhibit bone resorption by interfering with the activity of osteoclasts (bone cells that break down bone tissue). This is an update of a Cochrane review first published in 2008. Objectives To assess the benefits and harms of alendronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched Evidence‐Based Medicine Reviews (which includes CENTRAL), MEDLINE, Embase, two trial registers, drug approval agency websites, and the bibliographies of relevant systematic reviews to identify the studies included in this review. The latest search date was 01 February 2023. We imposed no restrictions on language, date, form of publication, or reported outcomes. Eligibility criteria We included only randomized controlled trials that assessed the effects of alendronate on postmenopausal women. Targeted participants must have received at least one year of alendronate. We classified a study as secondary prevention if its population met one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (‐2.5 or lower), and 75 years old or older. If a study population met none of those criteria, we classified it as a primary prevention study. Outcomes Our major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. Risk of bias We used the Cochrane risk of bias 1 tool. Synthesis methods We used standard methodological procedures expected by Cochrane. Based on the previous review experience, in which the clinical and methodological characteristics in the primary and secondary prevention studies were homogeneous, we used a fixed‐effect model for meta‐analysis and estimated effects using the risk ratio (RR) for dichotomous outcomes. Our base case analyses included all eligible placebo‐controlled studies with usable data. We selected the data available for the longest treatment period. We consider a relative change exceeding 15% as clinically important. Included studies We included 119 studies, of which 102 studies provided data for quantitative synthesis. Of these, we classified 34 studies (15,188 participants) as primary prevention and 68 studies (29,577 participants) as secondary prevention. We had concerns about risks of bias in most studies. Selection bias was the most frequently overlooked domain, with only 20 studies (19%) describing appropriate methods for both sequence generation and allocation concealment. Eight studies (8%) were at low risk of bias in all seven domains. Synthesis of results The base case analyses included 16 primary prevention studies (one to five years in length; 10,057 women) and 20 secondary prevention studies (one to three years in length; 7375 women) which compared alendronate 10 mg/day (or 70 mg/week) to placebo, no treatment, or both. Indirectness, imprecision, and risk of bias emerged as the main factors contributing to the downgrading of the certainty of the evidence. For primary prevention, alendronate may lead to a clinically important reduction in clinical vertebral fractures (16/1190 in the alendronate group versus 24/926 in the placebo group; RR 0.45, 95% confidence interval [CI] 0.25 to 0.84; absolute risk reduction [ARR] 1.4% fewer, 95% CI 1.9% fewer to 0.4% fewer; low‐certainty evidence) and non‐vertebral fractures (RR 0.83, 95% CI 0.72 to 0.97; ARR 1.6% fewer, 95% CI 2.6% fewer to 0.3% fewer; low‐certainty evidence). However, clinically important differences were not observed for the following outcomes: hip fractures (RR 0.76, 95% CI 0.43 to 1.32; ARR 0.2% fewer, 95% CI 0.4% fewer to 0.2% more; low‐certainty evidence); wrist fractures (RR 1.12, 95% CI 0.84 to 1.49; ARR 0.3% more, 95% CI 0.4% fewer to 1.1% more; low‐certainty evidence); withdrawals due to adverse events (RR 1.03, 95% CI 0.89 to 1.18; ARR 0.2% more, 95% CI 0.9% fewer to 1.5% more; low‐certainty evidence); and serious adverse events (RR 1.08, 95% CI 0.82 to 1.43; ARR 0.5% more, 95% CI 1.2% fewer to 2.8% more; low‐certainty evidence). For secondary prevention, alendronate probably results in a clinically important reduction in clinical vertebral fractures (24/1114 in the alendronate group versus 51/1055 in the placebo group; RR 0.45, 95% CI 0.28 to 0.73; ARR 2.7% fewer, 95% CI 3.5% fewer to 1.3% fewer; moderate‐certainty evidence). It may lead to a clinically important reduction in non‐vertebral fractures (RR 0.80, 95% CI 0.64 to 0.99; ARR 2.8% fewer, 95% CI 5.1% fewer to 0.1% fewer; low‐certainty evidence); hip fractures (RR 0.49, 95% CI 0.25 to 0.96; ARR 1.0% fewer, 95% CI 1.5% fewer to 0.1% fewer; low‐certainty evidence); wrist fractures (RR 0.54, 95% CI 0.33 to 0.90; ARR 1.8% fewer, 95% CI 2.6% fewer to 0.4% fewer; low‐certainty evidence); and serious adverse events (RR 0.75, 95% CI 0.59 to 0.96; ARR 3.5% fewer, 95% CI 5.8% fewer to 0.6% fewer; low‐certainty evidence). However, the effects of alendronate for withdrawals due to adverse events are uncertain (RR 0.95, 95% CI 0.78 to 1.16; ARR 0.4% fewer, 95% CI 1.7% fewer to 1.3% more; very low‐certainty evidence). Furthermore, the updated evidence for the safety risks of alendronate suggests that, irrespective of participants' risk of fracture, alendronate may lead to little or no difference for gastrointestinal adverse events. Zero incidents of osteonecrosis of the jaw and atypical femoral fracture were observed. Authors' conclusions For primary prevention, compared to placebo, alendronate 10 mg/day may reduce clinical vertebral and non‐vertebral fractures, but it might make little or no difference to hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. For secondary prevention, alendronate probably reduces clinical vertebral fractures, and may reduce non‐vertebral, hip, and wrist fractures, and serious adverse events, compared to placebo. The evidence is very uncertain about the effect of alendronate on withdrawals due to adverse events. Funding This Cochrane review had no dedicated funding. Registration This review is an update of the previous review (DOI: 10.1002/14651858.CD001155). Plain language summary Does alendronate help prevent fractures caused by osteoporosis in postmenopausal women? Key messages • Alendronate used for up to five years may prevent spinal fractures in women who are at lower risk for fractures, or in those who have not yet had a fracture of the spine. • Alendronate used for up to three years in women diagnosed with osteoporosis, with low bone density, or who have already had a fracture of the spine, probably prevents fractures of the spine. What is osteoporosis? Osteoporosis is a disease which makes bones weak and fragile. Bone is living tissue that is constantly being broken down and replaced. In osteoporosis, old bone breaks down faster than new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones more likely to break even after a minor injury, such as a bump or fall. Women are more likely to get osteoporosis after menopause. What is alendronate? Alendronate is a bisphosphonate, a type of medicine which slows down the cells that break down the old bone. What did we want to find out? We aimed to find out if alendronate is better than placebo (an inactive or 'dummy' medicine) or other medicines in preventing or reducing fractures in postmenopausal women. What did we do? We searched for studies that compared alendronate with placebo or other anti‐osteoporotic medicines for osteoporosis in postmenopausal women. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 119 eligible studies. Of these, 102 studies provided usable data, and 40 studies compared alendronate to placebo (dummy pill). Key findings In women who are at a lower risk for fractures because they have bone density closer to normal, or they may not yet have a fracture in the bones of their spine, alendronate used for up to five years: may prevent clinical spinal fractures – that is, fractures indicated by clinical signs and symptoms, without radiographic evidence; may prevent fractures in bones other than the spine. However, specifically in hip and wrist fractures, alendronate may make no difference; may make no difference to the number of women who withdrew from the study due to adverse events – that is, unwanted, harmful events; may make no difference to the number of women experiencing serious adverse events. In women who are at a higher risk for fractures because they have already been diagnosed with osteoporosis, have low bone density, or have already had a spinal fracture, alendronate used for up to three years: probably prevents clinical spinal fractures; may prevent fractures in bones other than the spine; may prevent hip and wrist fractures; may reduce serious adverse events; We do not know if alendronate reduces withdrawals due to adverse events in this group of women. The best estimates for women at lower fracture risk taking alendronate or placebo are as follows. For clinical spinal fractures, evidence suggests that if 3 out of 100 women taking placebo experience a fracture, only 1 out of 100 women taking alendronate will. If 10 out of 100 women on placebo have a fracture in bones other than the spine, only 8 out of 100 on alendronate are likely to. For hip and wrist fractures, there may be no difference between the two groups in the number of women experiencing fractures. The best estimates for women at higher fracture risk taking alendronate or placebo are as follows. If 5 out of 100 women on placebo have a clinical spinal fracture, only 2 out of 100 women on alendronate are likely to. If 14 out of 100 women on placebo have a fracture in bones other than the spine, only 11 out of 100 on alendronate are likely to. If 2 out of 100 women on placebo have a hip fracture, only 1 out of 100 on alendronate are likely to. If 4 out of 100 women on placebo have a wrist fracture, only 2 out of 100 on alendronate are likely to. What are the limitations of the evidence? For most findings, our confidence in the evidence was low, because it is possible that the women in the studies, and the researchers assessing outcomes, were aware of which treatment the women received. Additionally, some of the evidence focused on specific alendronate doses, whereas the question we wanted to answer was broader. Finally, for some fracture outcomes, the evidence was based on few cases. How current is the evidence? The evidence is current to 1 February 2023. This is an update of a Cochrane review originally published in 2008.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Wells, GA; Hsieh, SC; Peterson, J; Zheng, C; Kelly, SE; Shea, B; Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD001155.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "413ea854-f043-4069-98a0-4d22e96934c6", "pmid": "", "title": "Omega‐3 fatty acids for the treatment of dementia", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) from fish and plant sources are commonly considered as a promising non‐medical alternative to improve brain functions and slow down the progression of dementia. This assumption is mostly based on findings of preclinical studies and epidemiological research. Resulting explanatory models aim at the role omega‐3 PUFAs play in the development and integrity of the brain's neurons, their protective antioxidative effect on cell membranes and potential neurochemical mechanisms directly related to Alzheimer‐specific pathology. Epidemiological research also found evidence of malnutrition in people with dementia. Considering this and the fact that omega‐3 PUFA cannot be synthesised by humans, omega‐3 PUFAs might be a promising treatment option for dementia. Objectives To assess the efficacy and safety of omega‐3 polyunsaturated fatty acid (PUFA) supplementation for the treatment of people with dementia. Search methods We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 10 December 2015. We contacted manufacturers of omega‐3 supplements and scanned reference lists of landmark papers and included articles. Selection criteria We included randomised controlled trials (RCTs) in which omega‐3 PUFA in the form of supplements or enriched diets were administered to people with Alzheimer's disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), Parkinson's disease dementia (PDD) or frontotemporal dementia (FTD). Data collection and analysis The primary outcome measures of interest were changes in global and specific cognitive functions, functional performance, dementia severity and adverse effects. Two review authors independently selected studies, extracted data and assessed the quality of trials according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We received unpublished data from the trial authors and collected adverse effects information from the published articles. We conducted meta‐analyses for available outcome measures at six months. Main results We included three comparable randomised, placebo‐controlled trials investigating omega‐3 PUFA supplements in 632 participants with mild to moderate AD over six, 12 and 18 months. We found no studies investigating other types of dementia. All trials were of high methodological quality. The overall quality of evidence for most of the outcomes was high. There was no evidence of a benefit from omega‐3 PUFAs on cognitive function when measured at six months with the Alzheimer's Disease Assessment Scale ‐ Cognitive subscale (standardised mean difference (SMD) ‐0.02, 95% confidence interval (CI) ‐0.19 to 0.15; 566 participants; 3 studies; high quality evidence) or Mini‐Mental State Examination (mean difference (MD) 0.18, 95% CI ‐1.05 to 1.41; 202 participants; 2 studies; high quality evidence) or on activities of daily living (SMD ‐0.02, 95% CI ‐0.19 to 0.16; 544 participants; 2 studies; high quality evidence). There was also no effect at six months of treatment on severity of dementia measured with the Clinical Dementia Rating ‐ Sum of Boxes (MD ‐0.00, 95% CI ‐0.58 to 0.57; 542 participants; 2 studies; high quality evidence) or on quality of life measured with the Quality of Life Alzheimer's Disease scale (MD ‐0.10, 95% CI ‐1.28 to 1.08; 322 participants; 1 study; high quality evidence). There was no difference at six months on mental health measured with the Montgomery‐Åsberg Depression Rating Scale (MD ‐0.10, 95% CI ‐0.74 to 0.54; 178 participants: 1 study; high quality of evidence) or the Neuropsychiatric Inventory (SMD 0.10, 95% CI ‐0.07 to 0.27; 543 participants; 2 studies; high quality of evidence). One very small study showed a benefit for omega‐3 PUFAs in instrumental activities of daily living after 12 months of treatment (MD ‐3.50, 95% CI ‐4.30 to ‐2.70; 22 participants; moderate quality evidence). The included studies did not measure specific cognitive function. The studies did not report adverse events well. Two studies stated that all adverse events were mild and that they did not differ in overall frequency between omega‐3 PUFA and placebo groups. Data from one study showed no difference between groups in frequency of any adverse event (risk ratio (RR) 1.02, 95% CI 0.95 to 1.10; 402 participants; 1 study; moderate quality evidence) or any serious adverse event (RR 1.05, 95% CI 0.78 to 1.41; 402 participants; 1 study; high quality evidence) at 18 months of treatment. Authors' conclusions We found no convincing evidence for the efficacy of omega‐3 PUFA supplements in the treatment of mild to moderate AD. This result was consistent for all outcomes relevant for people with dementia. Adverse effects of omega‐3 PUFAs seemed to be low, but based on the evidence synthesised in this review, we cannot make a final statement on tolerability. The effects on other populations remain unclear. Plain language summary Omega‐3 fatty acids for the treatment of dementia Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) are assumed to have a beneficial effect on the function of the brain. It has been suggested that they might improve or delay decline in memory and ability to carry out everyday tasks in people with dementia. In this review, we investigated randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) comparing omega‐3 PUFAs, given in the form of supplements or enriched diets, with placebo (a pretend treatment) in people with the most common types of dementia. Included trials We included three trials that investigated 632 people with Alzheimer's disease of mild to moderate severity. We found no trials on other types of dementia. In all trials participants took either placebo or omega‐3 PUFA supplements. The quality of the trials was good. The participants were allocated to the groups randomly. The participants and most of the investigators did not know which treatment was given. Results When we combined the results of the trials, we found that taking omega‐3 PUFA supplements for six months had no effect on cognition (learning and understanding), everyday functioning, quality of life or mental health. One very small study observed that omega‐3 PUFAs improved cognitively complex daily activities, such as shopping, when taken for a longer period of time. However, the quality of the evidence was only moderate, so this should be confirmed in further trials. Omega‐3 PUFAs also had no effect on ratings of the overall severity of the illness. The trials did not report side effects very well, but none of the studies reported significant harmful effects on health. Conclusion Altogether, the quality of the evidence was moderate or high for most of the effects that we measured, but we found no evidence for either benefit or harm from omega‐3 PUFA supplements in people with mild to moderate Alzheimer's disease. The effects on people with other types of dementia remain unclear.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Burckhardt, M, Herke, M, Wustmann, T, Watzke, S, Langer, G, Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD009002.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.759Z" }, { "id": "413f8195-f874-4647-a4eb-613e08efaee7", "pmid": "", "title": "Inhaled corticosteroids for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Inhaled corticosteroids are well established for the long‐term treatment of inflammatory respiratory diseases such as asthma or chronic obstructive pulmonary disease. They have been investigated for the treatment of coronavirus disease 2019 (COVID‐19). The anti‐inflammatory action of inhaled corticosteroids might have the potential to reduce the risk of severe illness resulting from hyperinflammation in COVID‐19. Objectives To assess whether inhaled corticosteroids are effective and safe in the treatment of COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (which includes CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO ICTRP, and medRxiv), Web of Science (Science Citation Index, Emerging Citation Index), and the WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies to 7 October 2021. Selection criteria We included randomised controlled trials (RCTs) evaluating inhaled corticosteroids for COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We included the following interventions: any type or dose of inhaled corticosteroids. We included the following comparison: inhaled corticosteroids plus standard care versus standard care (with or without placebo). We excluded studies examining nasal or topical steroids. Data collection and analysis We followed standard Cochrane methodology. For risk of bias assessment, we used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the outcomes of mortality, admission to hospital or death, symptom resolution, time to symptom resolution, serious adverse events, adverse events, and infections. Main results Inhaled corticosteroids plus standard care versus standard care (with/without placebo) People with a confirmed diagnosis of moderate‐to‐severe COVID‐19 We found no studies that included people with a confirmed diagnosis of moderate‐to‐severe COVID‐19. People with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included three RCTs allocating 3607 participants, of whom 2490 had confirmed mild COVID���19. We analysed a subset of the total number of participants recruited to the studies (2171, 52% female) as some trials had a platform design where not all participants were allocated to treatment groups simultaneously. The included studies were community‐based, recruiting people who were able to use inhaler devices to deliver steroids and relied on remote assessment and self‐reporting of outcomes. Most people were older than 50 years and had co‐morbidities such as hypertension, lung disease, or diabetes. The studies were conducted in high‐income countries prior to wide‐scale vaccination programmes. A total of 1057 participants were analysed in the inhaled corticosteroid arm (budesonide: 860 participants; ciclesonide: 197 participants), and 1075 participants in the control arm. No studies included people with asymptomatic SARS‐CoV‐2 infection. With respect to the following outcomes, inhaled corticosteroids compared to standard care: – may result in little to no difference in all‐cause mortality (at up to day 30) (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.22 to 1.67; 2132 participants; low‐certainty evidence). In absolute terms, this means that for every nine deaths per 1000 people not receiving inhaled corticosteroids, there were six deaths per 1000 people who did receive the intervention (95% CI 2 to 16 per 1000 people); – probably reduces admission to hospital or death (at up to 30 days) (RR 0.72, 95% CI 0.51 to 0.99; 2025 participants; moderate‐certainty evidence); – probably increases resolution of all initial symptoms at day 14 (RR 1.19, 95% CI 1.09 to 1.30; 1986 participants; moderate‐certainty evidence); – may reduce the duration to symptom resolution (at up to day 30) (by −4.00 days, 95% CI −6.22 to −1.78 less than control group rate of 12 days; 139 participants; low‐certainty evidence); – the evidence is very uncertain about the effect on serious adverse events (during study period) (RR 0.51, 95% CI 0.09 to 2.76; 1586 participants; very low‐certainty evidence); – may result in little to no difference in adverse events (at up to day 30) (RR 0.78, 95% CI 0.47 to 1.31; 400 participants; low‐certainty evidence); – may result in little to no difference in infections (during study period) (RR 0.88, 95% CI 0.30 to 2.58; 400 participants; low‐certainty evidence). As studies did not report outcomes for subgroups (e.g. age, ethnicity, sex), we did not perform subgroup analyses. Authors' conclusions In people with confirmed COVID‐19 and mild symptoms who are able to use inhaler devices, we found moderate‐certainty evidence that inhaled corticosteroids probably reduce the combined endpoint of admission to hospital or death and increase the resolution of all initial symptoms at day 14. Low‐certainty evidence suggests that corticosteroids make little to no difference in all‐cause mortality up to day 30 and may decrease the duration to symptom resolution. We do not know whether inhaled corticosteroids increase or decrease serious adverse events due to heterogeneity in the way they were reported across the studies. There is low‐certainty evidence that inhaled corticosteroids may decrease infections. The evidence we identified came from studies in high‐income settings using budesonide and ciclesonide prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, serious adverse events, and people with asymptomatic infection or with moderate‐to‐severe COVID‐19. The 10 ongoing and four completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. We monitor newly published results of RCTs on inhaled corticosteroids on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Are inhaled corticosteroids an effective treatment for people with mild COVID‐19? Key messages Inhaled corticosteroids (anti‐inflammatory medicines) given via the oral inhaled route are evaluated for treatment of coronavirus disease 2019 (COVID‐19). We identified three published studies for people with mild disease. Inhaled corticosteroids probably reduce the risk of people going to hospital or death (admission to hospital or death before hospital admission). Inhaled corticosteroids may lower the number of days people have symptoms of mild COVID‐19 and probably increase resolution of COVID‐19 symptoms at day 14. They may make little to no difference in death from any cause, and we do not have enough evidence to know whether they cause serious harms. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with moderate‐to‐severe COVID‐19. We found 10 ongoing and four completed unpublished studies. We will update this review when their results become available. What are inhaled corticosteroids? Inhaled corticosteroids are medicines that are breathed into the lower airways through an inhaler where they reduce inflammation in the lungs. They are commonly used to treat respiratory diseases like asthma and chronic obstructive pulmonary disease. Long‐term use and incorrect inhaler technique may lead to side effects that include a mouth infection called thrush, a change in voice, and an increased risk of lung infections. Good inhaler technique means the medicine does not stay in the mouth and throat. Why are inhaled corticosteroids possible treatments for COVID‐19? COVID‐19 mainly affects the lungs and airways. When the immune system fights the virus, the lungs and airways become inflamed. This inflammation causes breathing difficulties, and the lungs cannot easily move oxygen into the blood and remove carbon dioxide from the blood. What did we want to find out? People need more and better treatment options for asymptomatic SARS‐CoV‐2 infection (the virus that causes COVID‐19) or mild, moderate, or severe COVID‐19. We wanted to know if inhaled corticosteroids are an effective and helpful treatment option for COVID‐19 in any setting (for example, home or hospital) and whether they cause unwanted effects. We were interested in: – death from any cause up to day 30, day 60, or longer if reported; – admission to hospital or death within 30 days; – whether symptoms resolved and how fast; – quality of life; – unwanted effects. What did we do? We looked for studies where the investigators compared inhaled corticosteroids and usual care to usual care only, sometimes in addition to a dummy medicine that did not contain any active ingredients (placebo) but was given in the same way. To make the comparison least skewed and more fair, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the inhaled corticosteroids or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Three studies compared inhaled corticosteroids plus usual care compared to usual care with or without placebo in people with a confirmed diagnosis of mild COVID‐19. These studies analysed 2171 participants mostly older than 50 years and with other medical problems, 52% of them were female, of whom 1057 received inhaled corticosteroids in our analyses. We found no studies that included people with asymptomatic infection or confirmed diagnosis of moderate‐to‐severe COVID‐19. We also found 10 ongoing studies, and four completed studies without published results. Main results All studies compared inhaled corticosteroids with usual care or placebo. The studies included only people with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease. No studies looked at hospitalised people or people with asymptomatic SARS‐CoV‐2 infection. Inhaled corticosteroids – may make little to no difference in death from any cause up to day 30; – probably reduce the risk of admission to hospital or occurrence of death up to day 30; – probably increase resolution of COVID‐19 symptoms at day 14 and may reduce time to symptom resolution. We are very uncertain about a possible difference in serious unwanted effects. Moreover, inhaled corticosteroids may result in little to no difference in the number of any unwanted effects or additional infections. What are the limitations of the evidence? The studies were conducted in populations from wealthy countries, prior to the roll‐out of COVID‐19 vaccination programmes. We have moderate confidence in the evidence for the outcomes of symptom resolution at day 14 and hospital admission. We have low confidence in the evidence for the effects on deaths from any cause for people with mild COVID‐19 and time to symptom resolution. The confidence in the unwanted or serious unwanted effects and infections is low or very low, because of the differences in the way investigators recorded and reported results. There was no evidence for people with asymptomatic infection or moderate‐to‐severe COVID‐19 who were hospitalised. How up to date is this evidence? Our evidence is up‐to‐date to 7 October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Griesel, M; Wagner, C; Mikolajewska, A; Stegemann, M; Fichtner, F; Metzendorf, M-I; Nair, AAnil; Daniel, J; Fischer, A-L; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015125", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "416391f2-865b-49a3-b334-b450f3ec0f3e", "pmid": "", "title": "Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is the most common life‐limiting autosomal recessive genetic disorder in white populations. Distal intestinal obstruction syndrome (DIOS) is an important morbidity in cystic fibrosis. It is the result of the accumulation of viscid faecal material within the bowel which combines with thick, sticky mucus produced in the intestines of people with cystic fibrosis. The intestine may be completely blocked (complete DIOS) or only partially blocked (incomplete DIOS). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the acute complete or incomplete faecal obstruction and ultimately prevent the need for surgical intervention . Objectives This review aimed to evaluate the effectiveness and safety of different treatment regimens for the treatment of DIOS (complete and incomplete) in children and adults with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials (including cross‐over trials (to be judged on an individual basis)) comparing the use of laxative agents or surgery for treating DIOS in children, young people and adults with cystic fibrosis to each other, placebo or no intervention. Data collection and analysis Two authors independently screened papers, extracted trial details and assessed for risk of bias. The authors assessed the quality of evidence using GRADE. Main results There was one trial with 20 participants (16 females) included in the review. The mean age of participants was 13.1 years. The trial was a double‐blinded, randomised cross‐over trial which had a duration of 12 months in total and compared high‐dose and low‐dose pancreatic enzyme therapy. As only the abstract of the trial was available, the overall risk of bias was judged to be unclear. The trial did not address either of our primary outcomes (time until resolution of DIOS and treatment failure rate), but reported episodes of acute DIOS, presence of abdominal mass and abdominal pain. There were no numerical data available for these outcomes, but the authors stated that there was no difference between treatment with high‐dose or low‐dose pancreatic enzymes. The overall certainty of the evidence was found to be very low. Authors' conclusions There is a clear lack of evidence for the treatment of DIOS in people with cystic fibrosis. The included abstract did not address our primary outcome measures and did not provide numerical data for the two secondary outcomes it did address. Therefore, we cannot justify the use of high‐dose pancreatic enzymes for treating DIOS, nor can we comment on the efficacy and safety of other laxative agents. From our findings, it is clear that more randomised controlled trials need to be conducted in this area. Plain language summary Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis Review question We reviewed the evidence about the effectiveness and safety of different treatments for distal intestinal obstruction syndrome (DIOS) in children and adults with cystic fibrosis. Background Cystic fibrosis is a common, life‐limiting, inherited disease. One of the main features of cystic fibrosis is the thick, sticky mucus produced by many organs including the lungs, pancreas and intestine. DIOS occurs when mucus in the intestine combines with faeces and builds up to produce a mass. This mass can partially or completely block the intestine and cause symptoms such as vomiting, severe abdominal pain and a swollen stomach (abdominal distension). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the complete or partial blockage and ultimately prevent the need for any surgical intervention. Search date The evidence is current to: 12 October 2021. Trial characteristics The review included one trial with 20 people with cystic fibrosis who were aged between 7.1 and 23.2 years of age (average 13.1 years old). The 12‐month trial compared a high dose of pancreatic enzymes with a low dose of pancreatic enzymes for treating chronic DIOS. Key results The trial did not report on our primary outcomes (time until DIOS successfully treated and treatment failure rate), but addressed two of our secondary outcomes; episodes of acute DIOS and the harmful effects that might occur in participants (the presence of an abdominal mass and abdominal pain). There were no numerical data available for these results, but the authors reported that there was no difference between high‐dose or low‐dose pancreatic enzymes. Certainty of the evidence We found the overall certainty of the evidence to be very low. The trial itself was only published as an abstract from a conference which did not include numerical data and it was not published as a full report. This meant that we do not know many details about the trial. We thought that the overall risk of bias was unclear, as the trial authors did not describe how participants were put into the treatment groups, whether any participants dropped out or whether the planned outcomes were the same as the reported outcomes. The trial also had a very small number of participants and a limited age range, making it difficult to draw conclusions about the relevance of the treatment for all people with cystic fibrosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gilchrist, FJ; Green, J; Carroll, W", "articleTypes": [], "doi": "10.1002/14651858.CD012798.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "4166f42a-322c-41c7-89db-24331e6a53c6", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background The anti‐inflammatory effects of n‐3 (omega‐3 fatty acids, fish oil) have been suggested to be beneficial in chronic inflammatory disorders such as inflammatory bowel disease. This review is an update of a previously published Cochrane review. Objectives To systematically review the efficacy and safety of n‐3 for maintenance of remission in Crohn's disease (CD). Search methods The following databases were searched from inception to November 2013 without language restriction: CENTRAL, MEDLINE, EMBASE, HealthSTAR, PubMed, and ACP journal club. Selection criteria Randomized placebo‐controlled trials (RCT) of n‐3 for maintenance of remission in CD were included. Studies must have enrolled patients of any age group, who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil or n‐3 given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. Data collection and analysis The primary outcome was the relapse rate and secondary outcomes included change in disease activity scores, time to first relapse and adverse events. Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality using the Cochrane risk of bias tool. The overall quality of the evidence supporting the primary and selected secondary outcomes was reassessed for the current update using the GRADE system. We used the RevMan software for analyses. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the hazard ratio and 95% CI for time‐to‐event outcomes. Random‐effects or fixed‐effect models were used according to degree of heterogeneity and sensitivity analyses were performed in an attempt to explore possible sources of heterogeneity. Main results Six studies with a total of 1039 patients were eligible for inclusion. The two largest studies were rated as low risk of bias for all assessed items. Four studies were rated as unclear risk of bias for randomization and allocation concealment. Two studies were rated as high risk of bias for incomplete outcome data and selective reporting. There was a marginal significant benefit of n‐3 therapy for maintenance of remission. Thirty‐nine per cent of patients in the n‐3 group relapsed at 12 months compared to 47% of placebo patients (6 studies, 1039 patients; RR 0.77, 95% CI 0.61 to 0.98). A GRADE analysis rated the overall quality of the evidence for the primary outcome (i.e. relapse) as very low due to unexplained heterogeneity (I 2 = 58%), publication bias, and a high or unknown risk of bias in four studies in the pooled analysis. When two large studies at low risk of bias were considered the benefit was no longer statistically significant. Thirty‐seven per cent of patients in the n‐3 group relapsed at 12 months compared to 42% of placebo patients (2 studies, 738 patients; RR 0.88, 95% CI 0.74 to 1.05). No significant heterogeneity was identified for this pooled analysis ( I 2 = 0%). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was moderate due to sparse data (294 events). No serious adverse events were recorded in any of the studies but in a pooled analyses there was a significantly higher rate of diarrhea (4 studies, 862 patients; RR 1.36 95% CI 1.01 to 1.84) and upper gastrointestinal tract symptoms (5 studies, 999 patients; RR 1.65, 95% CI 1.25 to 2.18) in the n‐3 treatment group. Authors' conclusions Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms. Plain language summary Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of Crohn's disease patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of capsules containing omega‐3 fatty acids to maintain remission in Crohn's disease were reviewed. Six studies including 1039 patients were included in the review. A pooled analysis of six studies suggests a marginal benefit for omega 3 fatty acids over placebo (i.e. fake medicine) in preventing relapse of disease at one year. However, these results need to be interpreted with caution due to differences across the studies in terms of induction of remission regimens (e.g. surgical remission versus drug therapy) patients (e.g. adult versus pediatric patients) and medication regimens (e.g. some studies used different placebos), the possibility of publication bias (i.e. only studies with positive results are published) and low methodological quality in four studies in the pooled analysis. When the two largest and highest quality studies were pooled the results showed no benefit to omega‐3 treatment over placebo. There were no serious side effects in any of the studies. Common side effects included unpleasant taste, bad breath, heartburn, nausea and diarrhea. Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Lev‐Tzion, R, Griffiths, AM, Ledder, O, Turner, D", "articleTypes": [], "doi": "10.1002/14651858.CD006320.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.082Z" }, { "id": "4180cf7c-1eca-4f14-a9cc-8f712e8aaf7c", "pmid": "", "title": "Corticosteroids for hospitalised children with acute asthma", "imported": false, "abstract": "Abstract - Background Systemic corticosteroids are used routinely in the management of children with severe acute asthma. There is a lack of consensus regarding the agent, dose and route of corticosteroid administration. Objectives To determine the benefit of systemic corticosteroids (oral, intravenous, or intramuscular) compared to placebo and inhaled steroids in acute paediatric asthma. Search methods All controlled trials were identified from the Cochrane Airways Review Group Register, hand searching of respiratory journals, reference lists and contacts with experts and pharmaceutical companies. Selection criteria Studies were included if they described a randomised controlled trial (RCT) involving children aged 1‐18 years with severe acute asthma who received oral, inhaled, intravenous or intramuscular corticosteroids. Only studies in which patients required hospital admission were included. Data collection and analysis Two reviewers using a standard form extracted all data. All data, numeric calculations and graphic extrapolations were independently confirmed. Main results Seven trials were included with a total of 426 children studied (274 with oral prednisone vs. placebo, 106 with intravenous steroids vs placebo and 46 with nebulised budesonide vs prednisolone). A significant number of steroid treated children were discharged early after admission (>4 hours) with an OR of 7.00 (95% CI: 2.98 to 16.45) and NNT of 3 (95%CI: 2 to 8). The length of stay was shorter in the steroid groups with a WMD of ‐8.75 hours (95% CI: ‐19.23 to 1.74). There were no significant differences between groups in pulmonary function or oxygen saturation measurements. Children treated with steroids in hospital were less likely to relapse within one to three months with OR 0.19 (95%CI: 0.07 to 0.55) and NNT of 3 (95%CI: 2 to 7). The single small study that compared nebulised budesonide to oral prednisone failed to demonstrate equivalence or a difference between each therapy. Authors' conclusions Systemic corticosteroids produce some improvements for children admitted to hospital with acute asthma. The benefits may include earlier discharge and fewer relapses. Inhaled or nebulised corticosteroids cannot be recommended as equivalent to systemic steroids at this time. Further studies examining differing doses and routes of administration for corticosteroids will clarify the optimal therapy. Plain language summary Corticosteroids for hospitalised children with acute asthma An acute asthma attack in a child often results in a trip to the hospital. In the emergency department steroid drugs are given which may improve the child's condition and allow them to be sent home after a few hours observation. However, some children require continued treatment in hospital. This review asked the question \"do steroid drugs help children admitted to hospital with asthma?\" We found that steroids given by mouth or through an intravenous tube help children recover from acute asthma. The benefits may include earlier discharge or a shorter stay in hospital. Children were less likely to come back to hospital in the one to three months following the admission. However, the evidence was not overwhelming due to the limited number of studies available and different medicines used. Further research needs to concentrate on the best medications to use and the best route of administration.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Smith, M; Iqbal, SMSI; Rowe, BH; N'Diaye, T", "articleTypes": [], "doi": "10.1002/14651858.CD002886", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "41905581-b22f-4b4e-b1cd-2888851f89dc", "pmid": "", "title": "Pharmaceutical interventions for emotionalism after stroke", "imported": false, "abstract": "Abstract - Background Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2019. Objectives To evaluate the benefits and harms of pharmaceutical treatment in people with emotionalism after stroke. Search methods We searched the Cochrane Stroke Group Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registers (May 2022). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). Data collection and analysis Two review authors independently selected trials, assessed risk of bias, extracted data from all included trials, and used GRADE to assess the certainty of the body of evidence. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I 2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on the Center for Neurologic Study ‐ Lability Scale (CNS‐LS) or Clinician Interview‐Based Impression of Change (CIBIC), or diminished tearfulness. Main results We did not identify any new trials for this update. We included seven trials with a total of 239 participants. Two trials had a cross‐over design, but outcome data were not available from the first phase (precross‐over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with a total of 213 participants. It is uncertain whether fluoxetine increases the number of people who have a 50% reduction in emotionalism when compared to placebo (risk ratio (RR) 0.26, 95% CI 0.09 to 0.77; P = 0.02; 1 trial, 19 participants) because the certainty of evidence is very low. Sertraline may lead to little to no difference in Center for Neurologic Study ‐ Lability Scale (CNS‐LS) scores and Clinician Interview‐Based Impression of Change (CIBIC) scores when compared to placebo (RR 0.20, 95% CI 0.03 to 1.50; P = 0.12; 1 trial, 28 participants; low‐certainty evidence). Antidepressants probably increase the number of people who experience a reduction in tearfulness (RR 0.32, 95% CI 0.12 to 0.86; P = 0.02; 3 trials, 164 participants; moderate‐certainty evidence). No trials were found that evaluated the impact of other pharmaceutical interventions. Only two trial authors systematically recorded and reported adverse events, resulting in limited data on the potential harms of treatment. Six trials reported death as an adverse event and found no difference between the groups (antidepressants versus placebo) in the number of deaths reported (RR 0.59, 95% CI 0.08 to 4.50; P = 0.61; 172 participants; moderate‐certainty evidence). This review provides very low‐ to moderate‐certainty evidence that antidepressants may reduce the frequency and severity of emotionalism. The included trials were small and had some degree of bias. Authors' conclusions Antidepressants may reduce the frequency and severity of crying or laughing episodes when compared to placebo, based on very low‐certainty evidence. Our conclusions must be qualified by several methodological deficiencies in the trials and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post‐stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity, and assess change over time; provide treatment for a sufficient duration and follow‐up to better assess rates of relapse or maintenance; and include careful assessment and complete reporting of adverse events. Plain language summary Medicines for emotionalism after stroke Review question To evaluate the benefits and harms of medicine in people with emotionalism after stroke. Background Emotionalism often occurs after stroke. Emotionalism means that the person has difficulty controlling their emotional behaviour. After stroke, people may suddenly start crying or, less commonly, laughing for no apparent reason. This is distressing for that particular person and their carers. Antidepressants, known to be helpful in people with depression, may be an effective treatment for emotionalism after stroke, but there have been very few randomised controlled trials (RCTs) in this area. (RCTs are studies in which participants are assigned randomly to 2 or more treatment groups. This is the best way to ensure that groups of participants are similar, and that investigators and participants do not know who is in which group.) Search date We identified studies through searches conducted on 26 May 2022. Study characteristics We included 7 randomised controlled trials, involving 239 people with emotionalism, in the review, which reported on the use of antidepressants for treating emotionalism. The numbers of people included in the studies ranged from 10 to 92. The mean/median ages ranged from 57.8 years to 73 years. Studies were from Europe (UK: 1; Denmark: 1; Scotland: 1; and Sweden: 1); Asia (South Korea: 1 and Japan: 1); and the USA (1). Key results We did not identify any new studies in our search update. We included 7 studies involving 239 people. However, 2 studies were not available in the appropriate format to include in the analysis. Therefore, we included only 5 studies, with 213 people, in our analyses. It is uncertain whether antidepressants affect the number of people with at least a 50% reduction in emotional displays, tearfulness, and scores on the questionnaires that measure uncontrollable laughing or crying, but they had no effect on lability (frequency of mood changes) scores and whether a clinician thought there had been an improvement when compared to placebo. No studies of other types of medicine were found. Six studies reported death and found no differences between those who were on antidepressants and those who were not. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low, and the results of further research could differ from the results of this review. Our confidence is limited because the included studies were small, and there was no consistency in how emotionalism was measured across the studies. Conclusion It is uncertain whether antidepressant medicines reduce outbursts of crying or laughing. More studies with systematic assessment and reporting of unwanted or harmful effects of a treatment are needed to ensure that any benefits outweigh the risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Allida, S, House, A, Hackett, ML", "articleTypes": [], "doi": "10.1002/14651858.CD003690.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.109Z" }, { "id": "419083ae-dad4-4752-85e9-21b263c86bd4", "pmid": "", "title": "Oral treatments for fungal infections of the skin of the foot", "imported": false, "abstract": "Abstract - Background About 15% of the world population have fungal infections of the feet (tinea pedis or athlete's foot). There are many clinical presentations of tinea pedis, and most commonly, tinea pedis is seen between the toes (interdigital) and on the soles, heels, and sides of the foot (plantar). Plantar tinea pedis is known as moccasin foot. Once acquired, the infection can spread to other sites including the nails, which can be a source of re‐infection. Oral therapy is usually used for chronic conditions or when topical treatment has failed. Objectives To assess the effects of oral treatments for fungal infections of the skin of the foot (tinea pedis). Search methods For this update we searched the following databases to July 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library , MEDLINE (from 1946), EMBASE (from 1974), and CINAHL (from 1981). We checked the bibliographies of retrieved trials for further references to relevant trials, and we searched online trials registers. Selection criteria Randomised controlled trials of oral treatments in participants who have a clinically diagnosed tinea pedis, confirmed by microscopy and growth of dermatophytes (fungi) in culture. Data collection and analysis Two review authors independently undertook study selection, 'Risk of bias' assessment, and data extraction. Main results We included 15 trials, involving 1438 participants. The 2 trials (71 participants) comparing terbinafine and griseofulvin produced a pooled risk ratio (RR) of 2.26 (95% confidence interval (CI) 1.49 to 3.44) in favour of terbinafine's ability to cure infection. No significant difference was detected between terbinafine and itraconazole, fluconazole and itraconazole, fluconazole and ketoconazole, or between griseofulvin and ketoconazole, although the trials were generally small. Two trials showed that terbinafine and itraconazole were effective compared with placebo: terbinafine (31 participants, RR 24.54, 95% CI 1.57 to 384.32) and itraconazole (72 participants, RR 6.67, 95% CI 2.17 to 20.48). All drugs reported adverse effects, with gastrointestinal effects most commonly reported. Ten of the trials were published over 15 years ago, and this is reflected by the poor reporting of information from which to make a clear 'Risk of bias' assessment. Only one trial was at low risk of bias overall. The majority of the remaining trials were judged as 'unclear' risk of bias because of the lack of clear statements with respect to methods of generating the randomisation sequence and allocation concealment. More trials achieved blinding of participants and personnel than blinding of the outcome assessors, which was again poorly reported. Authors' conclusions The evidence suggests that terbinafine is more effective than griseofulvin, and terbinafine and itraconazole are more effective than no treatment. In order to produce more reliable data, a rigorous evaluation of different drug therapies needs to be undertaken with larger sample sizes to ensure they are large enough to show any real difference when two treatments are being compared. It is also important to continue to follow up and collect data, preferably for six months after the end of the intervention period, to establish whether or not the infection recurred. Plain language summary Oral antifungal drugs for treating athlete's foot (tinea pedis) Athlete's foot (tinea pedis) is a fungal infection of the feet that is easily spread and difficult to get rid of. This review compared different oral antifungal drugs (i.e. drugs taken by mouth), and it included 15 trials, involving 1438 participants. There are several different kinds of oral treatments, and the trials we found considered all the oral drugs used to treat athlete's foot. We found terbinafine and itraconazole to be more effective than placebo. And we found terbinafine to be more effective than griseofulvin. Griseofulvin is a treatment that was developed much earlier than the new treatments, such as terbinafine and itraconazole; these newer treatments tend to be most evaluated. Trials of other drugs were not large enough to show differences between them. All drugs had side‐effects; gastrointestinal effects were the most common. In future clinical trials, larger numbers of participants are needed to test different treatments in order to produce more reliable data. Also, future research should consider the costs of the different treatment approaches.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Bell‐Syer, SEM, Khan, SM, Torgerson, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD003584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.101Z" }, { "id": "41aecf03-d484-46c8-96d9-f7b741eb1f88", "pmid": "", "title": "Changes in Gut Microbiota and Postprandial GLP-1 Concentration Due to Sucralose Consumption", "imported": false, "abstract": "Recently, it has been proposed that the consumption of non-nutritive sweeteners, including sucralose, it's not harmless and is related with metabolic effects. Some studies have reported that sucralose produces alterations in glucose homeostasis. In vitro studies indicate that sucralose can interact with sweet taste receptors (T1R2 and T1R3) in the intestine, thus increasing the expression of glucose transporters including the sodium-glucose cotransporter type 1 (SGLT1) and the glucose transporter 2 (GLUT2), increasing glucose absorption. This interaction with intestinal sweet taste receptors also generates an increase in the secretion of the incretins glucagon-like peptide type 1 (GLP-1) and the glucose-dependent insulinotropic polypeptide (GIP), which might enhance the postprandial insulin release. However, these results are preliminary and it's desirable to confirm if sucralose consumption is associated with glucose metabolism modifications using an appropriate methodological design and with gold standard methods. The aim of this triple-blind, placebo-controlled, parallel, randomized clinical trial is to confirm the changes in insulin sensitivity associated with sucralose consumption in humans, to identify whether these changes are in the liver or skeletal muscle and to investigate the pathophysiological mechanisms generating these changes. Specifically, we will investigate if sucralose generates a dysbiosis in the gut microbiota that could be related to insulin resistance by increasing concentrations of lipopolysaccharide, a toxin found in Gram-negative bacteria that triggers a low-grade inflammation known as metabolic endotoxemia. In addition, the changes in postprandial concentrations of GLP-1, glucose, insulin, and C-peptide due to the combination of sucralose with a mixed meal will be investigated. The results of this study will determine if sucralose consumption, frequently used as a non-nutritive sweetener, is associated to significant changes in glucose homeostasis in humans.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "41c4da9b-8e48-4fcc-a8a1-bcde2ed9f13d", "pmid": "", "title": "Glucocorticoids for croup in children", "imported": false, "abstract": "Abstract - Background Glucocorticoids are the mainstay for the treatment of croup. The existing evidence demonstrates that glucocorticoids are effective in the treatment of croup in children. However, updating the evidence on their clinical relevance in croup is imperative. This is an update to a review first published in 1999, and updated in 2004, 2011, and 2018. Objectives To investigate the effects and safety of glucocorticoids in the treatment of croup in children aged 18 years and below. Search methods We searched the Cochrane Library, which includes the Cochrane Central Register of Controlled Trials (CENTRAL; 2022 Issue 9), Ovid MEDLINE Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations and Ovid MEDLINE (1946 to 4 March 2022), Embase (Ovid) (1974 to 4 March 2022). We also searched the WHO ICTRP and ClinicalTrials.gov on 4 March 2022. Selection criteria We included randomised controlled trials (RCTs) in children (aged 18 years and below) with croup. We assessed the effect of glucocorticoids compared to the following: placebo, any other pharmacologic agents, any other glucocorticoids, any combination of other glucocorticoids, given by different modes of administration, or given in different doses. The included studies must have assessed at least one of our primary outcomes (defined as the change in croup score or return visits, (re)admissions to the hospital or both) or secondary outcomes (defined as the length of stay in hospital or emergency departments, patient improvement, use of additional treatments, or adverse events). Data collection and analysis Review authors independently extracted data, with another review author verified. We entered the data into Review Manager 5 for meta‐analysis. Two review authors independently assessed studies for risk of bias using the Cochrane risk of bias tool. Two review authors assessed the certainty of the evidence for the primary outcomes using the GRADE approach. Main results This updated review includes 45 RCTs with a total of 5888 children, an increase of two RCTs with 1323 children since the last update. We also identified one ongoing study and one study awaiting classification. We assessed most studies (98%) as at high or unclear risk of bias. Any glucocorticoid compared to placebo Compared to placebo, glucocorticoids may result in greater reductions in croup score after two hours (standardised mean difference (SMD) −0.65, 95% confidence interval (CI) −1.13 to −0.18; 7 RCTs, 426 children; low‐certainty evidence); six hours (SMD −0.76, 95% CI −1.12 to −0.40; 11 RCTs, 959 children; low‐certainty evidence); and 12 hours (SMD −1.03, 95% CI −1.53 to ‐0.53; 8 RCTs, 571 children; low‐certainty evidence). The evidence for change in croup score after 24 hours is very uncertain (SMD −0.86, 95% CI −1.40 to −0.31; 8 RCTs, 351 children; very low‐certainty evidence). One glucocorticoid compared to another glucocorticoid There was little to no difference between prednisolone and dexamethasone for reduction in croup score at two‐hour post‐baseline score (SMD 0.06, 95% CI −0.06 to 0.18; 1 RCT, 1231 children; high‐certainty evidence). There was likely little to no difference between prednisolone and dexamethasone for reduction in croup score at six‐hour post‐baseline score (SMD 0.21, 95% CI −0.21 to 0.62; 1 RCT, 99 children; moderate‐certainty evidence). However, dexamethasone probably reduced the return visits or (re)admissions for croup by almost half (risk ratio (RR) 0.55, 95% CI 0.28 to 1.11; 4 RCTs, 1537 children; moderate‐certainty evidence), and showed a 28% reduction in the use of supplemental glucocorticoids as an additional treatment (RR 0.72, 95% CI 0.53 to 0.97; 2 RCTs, 926 children). Dexamethasone given in different doses Compared to 0.15 mg/kg, 0.60 mg/kg dexamethasone probably reduced the severity of croup as assessed by the croup scoring scale at 24‐hour postbaseline score (SMD 0.63, 95% CI 0.16 to 1.10; 1 RCT, 72 children; moderate‐certainty evidence); however, this was not the case at two hours (SMD −0.27, 95% CI −0.76 to 0.22; 2 RCTs, 861 children; high‐certainty evidence). There was probably no reduction at six hours (SMD −0.45, 95% CI −1.26 to 0.35; 3 RCTs, 178 children; moderate‐certainty evidence), and the evidence at 12 hours is very uncertain (SMD −0.60, 95% CI −4.39 to 3.19; 2 RCTs, 113 children; very low‐certainty evidence). There was little to no difference between doses of dexamethasone in return visits or (re)admissions of children or both (RR 0.91, 95% CI 0.71 to 1.17; 3 RCTs, 949 children; high‐certainty evidence) or length of stay in the hospital or emergency department (mean difference 0.12, 95% CI −0.32 to 0.56; 2 RCTs, 892 children). The need for additional treatments, such as epinephrine (RR 0.78, 95% CI 0.34 to 1.75; 2 RCTs, 885 children); intubation (risk difference 0.00, 95% CI −0.00 to 0.00; 2 RCTs, 861 children); or use of supplemental glucocorticoids (RR 0.77, 95% CI 0.51 to 1.15; 2 RCTs, 617 children), also did not differ between doses of dexamethasone. There were moderate to high levels of heterogeneity in the analyses for most comparisons. Adverse events were observed for some of the comparisons reported in the review. Authors' conclusions The evidence that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions has not changed in this update. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg. More RCTs are needed to strengthen the evidence for effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. Plain language summary Glucocorticoids for croup in children Review question What is the effectiveness and safety of glucocorticoids when treating children with croup? Background Respiratory viruses are the main cause of croup in children. Croup leads to a swelling of the throat and airway, which can make breathing difficult. Children also present with a special type of cough called a barking cough. Glucocorticoids are types of steroids that help reduce the swelling, thereby making it easier for children with croup to breathe. This is an update of a review first published in 1999 and updated in 2004, 2011, and 2018. Search date The evidence is current to 4 March 2022. Study characteristics We included 2 new studies with 1323 children, for a total of 45 studies with 5888 children aged 0 to 18 years published between 1964 and 2021. The three types of glucocorticoids used in the new studies were budesonide, dexamethasone, and prednisolone. The most recent study compared the effectiveness of budesonide and dexamethasone. The other new study compared the effectiveness of dexamethasone and prednisolone, as well as a small dose of dexamethasone (0.15 mg/kg) versus 0.60 mg/kg dexamethasone. We added the data from the new study that compared the doses of dexamethasone to previously included studies looking at the same comparison. Study funding sources Funding sources included government (11%), academic or research institute (7%), industry (18%), or foundations (9%). More than half of the studies (55%) did not report funding sources. Key results Compared to prednisolone, dexamethasone showed no improvement in croup score at two and six hours after presenting to the hospital or emergency department, and probably reduced return visits or (re)admissions for croup by almost half. The addition of supplemental glucocorticoid favoured dexamethasone versus prednisolone. Compared to 0.15 mg/kg dexamethasone, the standard dose of 0.60 mg/kg probably reduced the severity of croup as assessed by the croup scoring scale at 24 hours after presenting to the hospital or emergency department. However, we did not find any important difference between groups in croup scoring scale at 2, 6, or 12 hours, return visits or (re)admissions of children, or length of stay in the hospital or emergency department. The need for additional treatments such as the use of other drugs like epinephrine, supplemental glucocorticoid, or the use of a tube to help breathing did not differ between 0.15 mg/kg and 0.60 mg/kg dexamethasone. No serious adverse events from the use of the glucocorticoids were reported in the newly included studies. Conclusions The evidence has not changed that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions compared to placebo (dummy treatment). A small dose of dexamethasone at 0.15 mg/kg may be as effective as the standard dose of 0.60 mg/kg. More studies are needed to strengthen the evidence for the effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. We conclude that glucocorticoids are effective in the treatment of croup in children. Certainty of evidence Most studies (98%) had problems related to their methods, reporting issues, or both. For any glucocorticoid compared to placebo, we downgraded the certainty of the evidence for change in croup score after 2, 6, 12, and 24 hours and return visits or (re)admissions due to study variability, imprecision and inconsistency of study results, and risk of bias. There is little evidence that reporting bias influenced our results for return visits or (re)admissions, or both. Similar threats to the certainty of the evidence were present in the other comparisons in this review, including concerns related to risk of bias and inconsistency and imprecision of study results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aregbesola, A; Tam, CM; Kothari, A; Le, M-L; Ragheb, M; Klassen, TP", "articleTypes": [], "doi": "10.1002/14651858.CD001955.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "41c8a898-173a-407e-aefb-baa78091fa25", "pmid": "", "title": "Alarm interventions for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs. Objectives To assess the effects of enuresis alarms for treating enuresis in children. Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old. Data collection and analysis Two review authors independently assessed risk of bias and extracted data. Main results We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) −2.68, 95% confidence interval (CI) −4.59 to −0.78; 4 trials, 127 children; low‐quality evidence). Low‐quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post‐treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low‐quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD −0.96, 95% CI −2.32 to 0.41; 1 trial, 47 children; very low‐quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low‐quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post‐treatment. Compared with control alarms, code‐word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate‐quality evidence) but there is probably little to no difference in the number of children remaining dry post‐treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate‐quality evidence). Very low‐quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry‐bed training, and star chart plus rewards) (MD ‐0.81, 95% CI ‐2.01 to 0.38; low‐quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low‐quality evidence) and may slightly increase the number of children remaining dry post‐treatment (RR 1.39, 95% CI 0.81 to 2.41; low‐quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD −0.64, 95% CI −1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low‐quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post‐treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate‐quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post‐treatment, because the quality of evidence is very low. Due to very low‐quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD −0.88, 95% CI −0.38 to −1.38; 2 trials, 156 children; low‐quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low‐quality evidence) and the number of children remaining dry post‐treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low‐quality evidence) compared with desmopressin alone. Alarm plus dry‐bed training may increase the number of children achieving a complete response compared to dry‐bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low‐quality evidence). It is unclear if there is any difference in the number of children remaining dry post‐treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low‐quality evidence). Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code‐word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate‐quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate‐quality evidence). Very low‐quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments. Authors' conclusions Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately‐powered trials with robust randomisation are still needed to determine the full effect of alarm therapy. Plain language summary Alarm interventions for nocturnal enuresis (bedwetting) in children Review question Is alarm training an effective treatment for bedwetting in children? Background Bedwetting is common in childhood and affects up to 20% of five‐year‐olds. Although children may spontaneously recover from this, bedwetting can have significant social, emotional and psychological effects on the child and their family. Treatments for bedwetting include alarms (activated by urination), behavioural interventions and drugs. How up‐to‐date is this review? The evidence is current up to 25 June 2018. Study characteristics This review includes 74 trials involving 5983 children. Study funding sources Three of the studies included in the review were funded or supported by a pharmaceutical company. Key results Alarms may be better than no treatment in terms of reducing the number of wet nights a week and increasing the number of children achieving 14 consecutive dry nights. Alarms may increase the number of children remaining dry after stopping treatment, compared to no treatment. We are uncertain if there is any difference between alarms and behavioural interventions (such as bladder training), or between alarms and desmopressin medication in terms of reducing the number of wet nights a week, increasing the number of children achieving 14 consecutive dry nights and increasing the number of children remaining dry after stopping treatment. We are uncertain whether alarms reduce the number of wet nights more than placebo drugs, other types of alarms, tricyclics medication, or various treatments such as hypnotherapy or restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin alone. It may increase the number of children achieving 14 consecutive dry nights and increase the number of children remaining dry after stopping treatment. Alarm plus dry‐bed training may increase the number of children achieving 14 consecutive dry nights compared to dry‐bed training alone, but we are uncertain if the response is maintained after stopping treatment. Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Alarm therapy probably reduces the number of children experiencing adverse events compared with desmopressin. We think there is probably a slight increase in adverse events between code‐word alarms and standard alarms but until we have more evidence from more children we cannot be certain about this. We are uncertain about the safety of alarm therapy compared to other treatments, because the quality of evidence is very low. Quality of the evidence The quality of the evidence means that, in general, the level of certainty in our conclusions is low. Authors' conclusions Alarm therapy may be more effective than no treatment, but due to the low‐quality evidence we do not know how much alarm therapy is more effective than none at all. Adding alarm therapy to desmopressin may be more effective than desmopressin alone. Despite the large number of trials we identified, the low certainty of the evidence means that we cannot tell from these studies whether or not alarm therapy is better than most other therapies for reducing bedwetting in children. We cannot be sure about its effects until there are better‐designed trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Caldwell, PHY; Codarini, M; Stewart, F; Hahn, D; Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002911.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "41d0debc-52bb-4168-ae97-fbd0db93a97f", "pmid": "", "title": "Corticosteroids for hospitalised children with acute asthma", "imported": false, "abstract": "Abstract - Background Systemic corticosteroids are used routinely in the management of children with severe acute asthma. There is a lack of consensus regarding the agent, dose and route of corticosteroid administration. Objectives To determine the benefit of systemic corticosteroids (oral, intravenous, or intramuscular) compared to placebo and inhaled steroids in acute paediatric asthma. Search methods All controlled trials were identified from the Cochrane Airways Review Group Register, hand searching of respiratory journals, reference lists and contacts with experts and pharmaceutical companies. Selection criteria Studies were included if they described a randomised controlled trial (RCT) involving children aged 1‐18 years with severe acute asthma who received oral, inhaled, intravenous or intramuscular corticosteroids. Only studies in which patients required hospital admission were included. Data collection and analysis Two reviewers using a standard form extracted all data. All data, numeric calculations and graphic extrapolations were independently confirmed. Main results Seven trials were included with a total of 426 children studied (274 with oral prednisone vs. placebo, 106 with intravenous steroids vs placebo and 46 with nebulised budesonide vs prednisolone). A significant number of steroid treated children were discharged early after admission (>4 hours) with an OR of 7.00 (95% CI: 2.98 to 16.45) and NNT of 3 (95%CI: 2 to 8). The length of stay was shorter in the steroid groups with a WMD of ‐8.75 hours (95% CI: ‐19.23 to 1.74). There were no significant differences between groups in pulmonary function or oxygen saturation measurements. Children treated with steroids in hospital were less likely to relapse within one to three months with OR 0.19 (95%CI: 0.07 to 0.55) and NNT of 3 (95%CI: 2 to 7). The single small study that compared nebulised budesonide to oral prednisone failed to demonstrate equivalence or a difference between each therapy. Authors' conclusions Systemic corticosteroids produce some improvements for children admitted to hospital with acute asthma. The benefits may include earlier discharge and fewer relapses. Inhaled or nebulised corticosteroids cannot be recommended as equivalent to systemic steroids at this time. Further studies examining differing doses and routes of administration for corticosteroids will clarify the optimal therapy. Plain language summary Corticosteroids for hospitalised children with acute asthma An acute asthma attack in a child often results in a trip to the hospital. In the emergency department steroid drugs are given which may improve the child's condition and allow them to be sent home after a few hours observation. However, some children require continued treatment in hospital. This review asked the question \"do steroid drugs help children admitted to hospital with asthma?\" We found that steroids given by mouth or through an intravenous tube help children recover from acute asthma. The benefits may include earlier discharge or a shorter stay in hospital. Children were less likely to come back to hospital in the one to three months following the admission. However, the evidence was not overwhelming due to the limited number of studies available and different medicines used. Further research needs to concentrate on the best medications to use and the best route of administration.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Smith, M, Iqbal, SMSI, Rowe, BH, N'Diaye, T", "articleTypes": [], "doi": "10.1002/14651858.CD002886", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.783Z" }, { "id": "41df9bbd-c789-4610-9610-9532e108807a", "pmid": "", "title": "Alarm interventions for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs. Objectives To assess the effects of enuresis alarms for treating enuresis in children. Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old. Data collection and analysis Two review authors independently assessed risk of bias and extracted data. Main results We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) −2.68, 95% confidence interval (CI) −4.59 to −0.78; 4 trials, 127 children; low‐quality evidence). Low‐quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post‐treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low‐quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD −0.96, 95% CI −2.32 to 0.41; 1 trial, 47 children; very low‐quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low‐quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post‐treatment. Compared with control alarms, code‐word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate‐quality evidence) but there is probably little to no difference in the number of children remaining dry post‐treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate‐quality evidence). Very low‐quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry‐bed training, and star chart plus rewards) (MD ‐0.81, 95% CI ‐2.01 to 0.38; low‐quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low‐quality evidence) and may slightly increase the number of children remaining dry post‐treatment (RR 1.39, 95% CI 0.81 to 2.41; low‐quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD −0.64, 95% CI −1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low‐quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post‐treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate‐quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post‐treatment, because the quality of evidence is very low. Due to very low‐quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD −0.88, 95% CI −0.38 to −1.38; 2 trials, 156 children; low‐quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low‐quality evidence) and the number of children remaining dry post‐treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low‐quality evidence) compared with desmopressin alone. Alarm plus dry‐bed training may increase the number of children achieving a complete response compared to dry‐bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low‐quality evidence). It is unclear if there is any difference in the number of children remaining dry post‐treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low‐quality evidence). Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code‐word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate‐quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate‐quality evidence). Very low‐quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments. Authors' conclusions Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately‐powered trials with robust randomisation are still needed to determine the full effect of alarm therapy. Plain language summary Alarm interventions for nocturnal enuresis (bedwetting) in children Review question Is alarm training an effective treatment for bedwetting in children? Background Bedwetting is common in childhood and affects up to 20% of five‐year‐olds. Although children may spontaneously recover from this, bedwetting can have significant social, emotional and psychological effects on the child and their family. Treatments for bedwetting include alarms (activated by urination), behavioural interventions and drugs. How up‐to‐date is this review? The evidence is current up to 25 June 2018. Study characteristics This review includes 74 trials involving 5983 children. Study funding sources Three of the studies included in the review were funded or supported by a pharmaceutical company. Key results Alarms may be better than no treatment in terms of reducing the number of wet nights a week and increasing the number of children achieving 14 consecutive dry nights. Alarms may increase the number of children remaining dry after stopping treatment, compared to no treatment. We are uncertain if there is any difference between alarms and behavioural interventions (such as bladder training), or between alarms and desmopressin medication in terms of reducing the number of wet nights a week, increasing the number of children achieving 14 consecutive dry nights and increasing the number of children remaining dry after stopping treatment. We are uncertain whether alarms reduce the number of wet nights more than placebo drugs, other types of alarms, tricyclics medication, or various treatments such as hypnotherapy or restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin alone. It may increase the number of children achieving 14 consecutive dry nights and increase the number of children remaining dry after stopping treatment. Alarm plus dry‐bed training may increase the number of children achieving 14 consecutive dry nights compared to dry‐bed training alone, but we are uncertain if the response is maintained after stopping treatment. Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Alarm therapy probably reduces the number of children experiencing adverse events compared with desmopressin. We think there is probably a slight increase in adverse events between code‐word alarms and standard alarms but until we have more evidence from more children we cannot be certain about this. We are uncertain about the safety of alarm therapy compared to other treatments, because the quality of evidence is very low. Quality of the evidence The quality of the evidence means that, in general, the level of certainty in our conclusions is low. Authors' conclusions Alarm therapy may be more effective than no treatment, but due to the low‐quality evidence we do not know how much alarm therapy is more effective than none at all. Adding alarm therapy to desmopressin may be more effective than desmopressin alone. Despite the large number of trials we identified, the low certainty of the evidence means that we cannot tell from these studies whether or not alarm therapy is better than most other therapies for reducing bedwetting in children. We cannot be sure about its effects until there are better‐designed trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Caldwell, PHY; Codarini, M; Stewart, F; Hahn, D; Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002911.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "41e03b89-cb15-434e-99f0-9ec81a28446a", "pmid": "", "title": "Genital ulcer disease treatment for reducing sexual acquisition of HIV", "imported": false, "abstract": "Abstract - Background Genital ulcer disease by virtue of disruption of the mucosal surfaces may enhance HIV acquisition. Genital ulcer disease treatment with resolution of the ulcers may therefore contribute in reducing the sexual acquisition of HIV. Objectives To determine the effects of treatment of genital ulcer disease on sexual acquisition of HIV. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, LILACS, NLM Gateway, Web of Science, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and reference lists of relevant publications for eligible studies published between 1980 and August 2011. Selection criteria Randomized controlled trials of any treatment intervention aimed at curing genital ulcer disease compared with an alternative treatment, placebo, or no treatment. We included only trials whose unit of randomization was the individual with confirmed genital ulcer. Data collection and analysis We independently selected studies and extracted data in duplicate; resolving discrepancies by discussion, consensus, and arbitration by third review author. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI). Main results There were three randomized controlled trials that met our inclusion criteria recruited HIV‐negative participants with chancroid (two trials with 143 participants) and primary syphilis (one trial with 30 participants). The syphilis study, carried out in the US between 1995 and 1997, randomized participants to receive a single 2.0 g oral dose of azithromycin (11 participants); two 2.0 g oral doses of azithromycin administered six to eight days apart (eight participants); or benzathine penicillin G administered as either 2.4 million units intramuscular injection once or twice seven days apart (11 participants). No participant in the trial seroconverted during 12 months of follow‐up. The chancroid trials, conducted in Kenya by 1990, found no significant differences in HIV seroconversion rates during four to 12 weeks of follow‐up between 400 and 200 mg single oral doses of fleroxacin (one trial, 45 participants; RR 3.00; 95% CI 0.29 to 30.69), or between 400 mg fleroxacin and 800 mg sulfamethoxazole plus 160 mg trimethoprim (one trial, 98 participants; RR 0.33; 95% CI 0.04 to 3.09). Adverse events reported were mild to moderate in severity, and included Jarisch‐Herxheimer reactions and gastrointestinal symptoms. The differences between the treatment arms in the incidence of adverse events were not significant. The quality of this evidence on the effectiveness of genital ulcer disease treatment in reducing sexual acquisition of HIV, according to GRADE methodology, is of very low quality. Authors' conclusions At present, there is insufficient evidence to determine whether curative treatment of genital ulcer disease would reduce the risk of HIV acquisition. The very low quality of the evidence implies that the true effect of genital ulcer disease treatment on sexual acquisition of HIV may be substantially different from the effect estimated from currently available data. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not. Plain language summary Genital ulcer disease treatment for reducing sexual acquisition of HIV The presence of a genital ulcer would provide an entry point for the HIV virus if an HIV‐negative individual with an ulcer has unprotected sexual intercourse with an HIV‐infected person. Treatment of the condition causing the genital ulcer would allow the ulcer to heal and therefore reduce the chances of HIV acquisition. This review assessed whether giving treatment for diseases that present with ulcers in the genital region would reduce sexual acquisition of HIV. Three studies were identified involving 173 HIV‐negative patients with genital ulcers. These studies did not provide sufficient evidence that treatment of genital ulcer diseases reduces sexual acquisition of HIV infection. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mutua, FM; M'Imunya, JM; Wiysonge, CS", "articleTypes": [], "doi": "10.1002/14651858.CD007933.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "41e6b2e8-561a-48fe-9375-59a09b8b549c", "pmid": "", "title": "Interventions for hirsutism (excluding laser and photoepilation therapy alone)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "van Zuuren, EJ, Fedorowicz, Z, Carter, B, Pandis, N", "articleTypes": [], "doi": "10.1002/14651858.CD010334.pub2 AB - Abstract - Background Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen‐sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective. Objectives To assess the effects of interventions (except laser and light‐based therapies alone) for hirsutism. Search methods We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014. Selection criteria Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism. Data collection and analysis Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses. Main results We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty‐eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow‐up above 40%. Primary outcomes, 'participant‐reported improvement of hirsutism' and 'change in health‐related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin‐releasing hormone (GnRH) analogues)). Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one‐third of studies. The quality of evidence was moderate to very low for most outcomes. There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman‐Gallwey scores. The mean difference (MD) was ‐1.84 (95% confidence interval (CI) ‐3.86 to 0.18). There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman‐Gallwey scores more effectively than placebo (MD ‐7.60, 95% CI ‐10.53 to ‐4.67 and MD ‐7.20, 95% CI ‐10.15 to ‐4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87). Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman‐Gallwey scores (MD ‐7.69, 95% CI ‐10.12 to ‐5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD ‐1.90, 95% CI ‐5.01 to 1.21 and MD 0.49, 95% CI ‐1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI ‐0.58 to 3.56 and MD 0.40, 95% CI ‐1.18 to 1.98) (low quality evidence). Although there was very low quality evidence of a difference in reduction of Ferriman‐Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD ‐5.73, 95% CI ‐6.87 to ‐4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached. Metformin demonstrated no benefit over placebo in reduction of Ferriman‐Gallwey scores (MD 0.05, 95% CI ‐1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements. We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman‐Gallwey scores. Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman‐Gallwey scores (low quality evidence). Ferriman‐Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD ‐6.30, 95% CI ‐9.83 to ‐2.77) (very low quality evidence). Data showing reductions in Ferriman‐Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%). Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman‐Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs. Authors' conclusions Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision‐making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects. Further research should consist of well‐designed, rigorously reported, head‐to‐head trials examining OCPs combined with antiandrogens or 5α‐reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α‐reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment. Plain language summary Treatments for unwanted male pattern hair growth in women Background 
 Up to 5% to 10% of women are hirsute (hair in areas where normally only men have hairs such as moustache, beard area, chest, belly, back etc). The most common cause is polycystic ovary syndrome. Hirsutism can lead to psychological distress, low self esteem, decreased self image, depression, feelings of shame and social difficulties. Review question 
 Which treatments (except laser and light‐based therapies alone) work best for hirsutism? Study characteristics 
 We included 157 studies published up to June 2014, which examined 10,550 people. Participants included women with a mean age of 25 years. There was considerable variation in the quality of how the studies were conducted; more than half were not blinded and this may have had an impact on the reporting of the outcomes. Most studies were carried out in single centres in Europe and lasted six to 12 months. A range of treatments were evaluated, mostly in single studies. These included a few topical treatments, lifestyle modification, oral contraceptive pills (OCPs), medication to inhibit the effect of hormones that are responsible for male traits, and combination therapies. Participant‐assessed improvement and impact on quality of life were evaluated in a minority of the studies, whilst the majority of the studies measured physician‐assessed reduction in hirsutism, as well as androgen levels in the blood. Half of the studies reported adverse events and around one‐third other signs and symptoms, e.g. oily skin and menstrual irregularities that might be due to an increase of androgen levels in the blood. Key results 
 Oral contraceptive pills reduced the amount of hairs, but the reduction was not consistent across the studies, although two OCPs (ethinyl estradiol 35 µg + cyproterone acetate 2 mg compared to ethinyl estradiol 30 µg + desogestrel 0.15 mg) appeared to be effective in a way that can be considered important for women with hirsutism. Of the antiandrogen drugs, flutamide was considered to be more effective than placebo by both the women and the doctors. Spironolactone was also effective, but data were only available for the physicians' assessments. Finasteride did not show convincing effectiveness based on the evaluations of the hirsute women and those made by the investigators. The addition of cyproterone acetate (an antiandrogen) to OCP seemed to enhance the beneficial effect of OCPs on hair reduction. Insulin sensitisers (antidiabetic drugs) and lifestyle modification did not have any demonstrable benefit in terms of the severity of hirsutism. Unfortunately, the self assessments by the women, as well as the impact of hirsutism on their quality of life, were outcomes that were insufficiently addressed in the studies. The adverse events reported with the different drugs are well known, i.e. pain in the stomach and intestines, breast tenderness, reduced libido and dry skin with flutamide and finasteride; irregular bleeding with spironolactone; nausea, diarrhoea and abdominal bloating with metformin; and hot flushes, decreased libido, vaginal dryness, breast tenderness and headaches with the GnRH analogues. There were no important differences in blood androgen levels between the different treatment groups, OCPs had a positive effect on acne, and similarly insulin sensitisers improved the menstrual pattern. We were expecting to find evidence that combined therapies of an OCP with an antiandrogen were more effective than, for example, OCPs alone, but the lack of studies did not allow us to draw these conclusions. Overall we concluded that OCPs (especially with antiandrogenic activity), OCPs combined with cyproterone acetate, flutamide and spironolactone are effective in treating hirsutism. However, additional cosmetic measures (epilating, waxing, bleaching, electrolysis, laser and photoepilation) are generally required because all treatments need at least six to 12 months to reach the optimum effect. In addition, because of the distress associated with hirsutism and its impact on quality of life psychological support should be part of the treatment approach. Quality of the evidence 
 The overall quality of the evidence for the different outcomes was on average rated as moderate to very low. Important reasons for this were that studies were not blinded, or had a small sample size.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.825Z" }, { "id": "420d5b6c-3d21-4e70-8df6-720e5a47cf6c", "pmid": "", "title": "Xiao Chai Hu Tang, a herbal medicine, for chronic hepatitis B", "imported": false, "abstract": "Abstract - Background Chronic hepatitis B is associated with high morbidity and mortality. Chronic hepatitis B requires long‐term management aiming at reduction of the risks of hepatocellular inflammatory necrosis, liver fibrosis, decompensated liver cirrhosis, liver failure, and liver cancer, and improving health‐related quality of life. The Chinese herbal medicine formula Xiao Chai Hu Tang has been used to decrease discomfort and replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established with rigorous review methodology. Objectives To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and seven other databases to 1 March 2019. We also searched the World Health Organization International Clinical Trials Registry Platform ( www.who.int/ictrp ), ClinicalTrials.gov ( www.clinicaltrials.gov/ ), and the Chinese Clinical Trial Registry for ongoing or unpublished trials to 1 March 2019. Selection criteria We included randomised clinical trials, irrespective of publication status, language, and blinding, comparing Xiao Chai Hu Tang formula versus no intervention or placebo in people with chronic hepatitis B. We included participants of any sex and age, diagnosed with chronic hepatitis B according to guidelines or as defined by the trialists. We allowed co‐interventions when the co‐interventions were administered equally to all the intervention groups. Data collection and analysis Review authors independently retrieved data from reports and after correspondence with investigators. Our primary outcomes were all‐cause mortality, serious adverse events, and health‐related quality of life. Our secondary outcomes were hepatitis B‐related mortality, hepatitis B‐related morbidity, and adverse events considered 'not to be serious'. We presented the meta‐analysed results as risk ratios (RR) with 95% confidence intervals (CI). We assessed the risks of bias using risk of bias domains with predefined definitions. We used GRADE methodology to evaluate our certainty in the evidence. Main results We included 10 randomised clinical trials with 934 participants, but only five trials with 490 participants provided data for analysis. All the trials compared Xiao Chai Hu Tang formula with no intervention. All trials appeared to have been conducted and published only in China. The included trials assessed heterogeneous forms of Xiao Chai Hu Tang formula, administered for three to eight months. One trial included participants with hepatitis B and comorbid tuberculosis, and one trial included participants with hepatitis B and liver cirrhosis. The remaining trials included participants with hepatitis B only. All the trials were at high risk of bias, and the certainty of evidence for all outcomes that provided data for analyses was very low. We downgraded the evidence by one or two levels because of outcome risk of bias, inconsistency or heterogeneity of results (opposite direction of effect), indirectness of evidence (use of surrogate outcomes instead of clinically relevant outcomes), imprecision of results (the CIs were wide), and publication bias (small sample size of the trials). Additionally, 47 trials lacked the necessary methodological information needed to ensure the inclusion of these trials in our review. None of the included trials aimed to assess clinically relevant outcomes such as all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, or hepatitis B‐related morbidity. The effects of Xiao Chai Hu Tang formula on the proportion of participants with adverse events considered 'not to be serious' is uncertain (RR 0.43, 95% CI 0.02 to 11.98; I 2 = 69%; very low‐certainty evidence). Only three trials with 222 participants reported the proportion of people with detectable hepatitis B virus DNA (HBV‐DNA), but the evidence that Xiao Chai Hu Tang formula reduces the presence of HBV‐DNA in the blood (a surrogate outcome) is uncertain (RR 0.62, 95% CI 0.45 to 0.85; I 2 = 0%; very low‐certainty evidence). Only two trials with 160 participants reported the proportion of people with detectable hepatitis B virus e‐antigen (HBeAg; a surrogate outcome) (RR 0.72, 95% CI 0.50 to 1.02; I 2 = 38%; very low‐certainty evidence) and the evidence is uncertain. The evidence is also uncertain for separately reported adverse events considered 'not to be serious'. Funding: two of the 10 included trials received academic funding from government or hospital. None of the remaining eight trials reported information on funding. Authors' conclusions The clinical effects of Xiao Chai Hu Tang formula for chronic hepatitis B remain unclear. The included trials were small and of low methodological quality. Despite the wide use of Xiao Chai Hu Tang formula, we lack data on all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, and hepatitis B‐related morbidity. The evidence in this systematic review comes from data obtained from a maximum three trials. We graded the certainty of evidence as very low for adverse events considered not to be serious and the surrogate outcomes HBeAg and HBV‐DNA. We found a large number of trials which lacked clear description of their design and conduct, and hence, these trials are not included in the present review. As all identified trials were conducted in China, there might be a concern about the applicability of this review outside China. Large‐sized, high‐quality randomised sham‐controlled trials with homogeneous groups of participants and transparent funding are lacking. Plain language summary Xiao Chai Hu Tang, a Chinese herbal medicine formula, for chronic hepatitis B Review question To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B virus infection. Background Chronic hepatitis B virus infection is a common liver disease, associated with high morbidity (illness) and death. It causes psychological stress and is a burden to people with chronic hepatitis B and their families. Xiao Chai Hu Tang formula has been used for treating people with chronic hepatitis B as it is believed that it decreases discomfort and prevents the replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established in reviews with rigorous review methodology. Search date The review includes trials published up to 1 March 2019. Study characteristics We included 10 randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) with 934 participants. All trials compared Xiao Chai Hu Tang formula with no treatment. The trials assessed different formulas and doses for three to eight months. One trial included participants with tuberculosis (a disease of the lungs that can make you cough mucous), and one trial included participants with liver cirrhosis (scarring). Only five trials with 490 participants provided data for analysis Study funding sources Two of the 10 included trials reported receiving academic funding. None of the remaining eight trials reported information of support or funding. Key results None of the 10 included trials reported data on all‐cause mortality (death from any cause), serious side effects (untoward medical occurrences that result in serious outcomes such as death or disability), health‐related quality of life (a measure of physical, mental, emotional, and social functioning a measure of a person's satisfaction with their life and health), hepatitis B‐related death, and hepatitis B‐related morbidity. We are uncertain whether Xiao Chai Hu Tang formula versus no intervention has a positive or negative effect regarding side effects considered 'not to be serious', the proportion of people with detectable HBeAg (a hepatitis B viral protein that indicates active viral replication), and separately reported side effects considered 'not to be serious'. Xiao Chai Hu Tang formula compared with no intervention seems to reduce the proportion of people with detectable HBV‐DNA (which is used to indicate how much hepatitis B virus is in the blood) but the reliability of this finding is low. Surrogate outcomes are markers that are used in research as a substitute for a clinically meaningful measure that directly measures patient outcomes. We cannot always be certain that such surrogate outcomes are reliable substitutes for important outcomes as they need to be officially examined. Caution is needed with this beneficial finding as the trials are at high risk of bias, and this outcome has not yet been proven relevant to patients. We identified an additional 47 studies as potential randomised clinical trials, but the data they reported were of no use. Accordingly, properly designed randomised clinical trials are needed before the benefits and harms of Xiao Chai Hu Tang formula for chronic hepatitis B can be determined. Reliability of the evidence The reliability of the evidence on the use of Xiao Chai Hu Tang formula in people with chronic hepatitis B virus in terms of its beneficial or harmful effects on death, health‐related quality of life, risk of dying due to hepatitis B virus infection, and serious side effects cannot be determined as no trials aimed to explore these. The reliability of the evidence that Xiao Chai Hu Tang formula, when compared with no intervention, in terms of side effects considered 'not to be serious', the proportion of people with detectable HBV‐DNA, and the proportion of people with detectable HBeAg is very low. These assessments of the reliability of the evidence are due to the poor design and reporting of the included trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kong, DZ; Liang, N; Yang, GL; Zhang, Z; Liu, Y; Li, J; Liu, X; Liang, S; Nikolova, D; Jakobsen, JC; Gluud, C; Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD013090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "4225caec-4cfb-4b55-b137-527375288ad3", "pmid": "", "title": "Adhesives for bonded molar tubes during fixed brace treatment", "imported": false, "abstract": "Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. The success of a fixed appliance depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a fixed appliance. It can also be costly in terms of clinical time, materials and time lost from education/work for the patient. This is an update of the Cochrane review first published in 2011. A new full search was conducted on 15 February 2017 but no new studies were identified. We have only updated the search methods section in this new version. The conclusions of this Cochrane review remain the same. Objectives To evaluate the effectiveness of the adhesives used to attach bonded molar tubes, and the relative effectiveness of the adhesives used to attach bonded molar tubes versus adhesives used to attach bands, during fixed appliance treatment, in terms of: (1) how often the tubes (or bands) come off during treatment; and (2) whether they protect the bonded (or banded) teeth against decay. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (to 15 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library (searched 15 February 2017), MEDLINE Ovid (1946 to 15 February 2017), and Embase Ovid (1980 to 15 February 2017). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials of participants with full arch fixed orthodontic appliance(s) with molar tubes, bonded to first or second permanent molars. Trials which compared any type of adhesive used to bond molar tubes (stainless steel or titanium) with any other adhesive, were included. Trials were also included where: (1) a tube was bonded to a molar tooth on one side of an arch and a band cemented to the same tooth type on the opposite side of the same arch;
 (2) molar tubes had been allocated to one tooth type in one patient group and molar bands to the same tooth type in another patient group. Data collection and analysis The selection of papers, decision about eligibility and data extraction were carried out independently and in duplicate without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Two trials (n = 190), at low risk of bias, were included in the review and both presented data on first time failure at the tooth level. Pooling of the data showed a statistically significant difference in favour of molar bands, with a hazard ratio of 2.92 (95% confidence intervals (CI) 1.80 to 4.72). No statistically significant heterogeneity was shown between the two studies. Data on first time failure at the patient level were also available and showed statistically different difference in favour of molar bands (risk ratio 2.30; 95% CI 1.56 to 3.41) (risk of event for molar tubes = 57%; risk of event for molar bands 25%). One trial presented data on decalcification again showing a statistically significant difference in favour of molar bands. No other adverse events identified. Authors' conclusions From the two well‐designed and low risk of bias trials included in this review it was shown that the failure of molar tubes bonded with either a chemically‐cured or light‐cured adhesive was considerably higher than that of molar bands cemented with glass ionomer cement. One trial indicated that there was less decalcification with molar bands cemented with glass ionomer cement than with bonded molar tubes cemented with a light‐cured adhesive. However, given there are limited data for this outcome, further evidence is required to draw more robust conclusions. Plain language summary Adhesives for bonded molar tubes during fixed brace treatment Background Orthodontic treatment involves using fixed or removable dental braces to correct the positions of teeth. The success of dental braces depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a dental brace. Study characteristics The evidence in this review, which was carried out together with Cochrane Oral Health, is up‐to‐date as of 15 February 2017. We included two studies that evaluated 190 participants. Both trials were conducted in the UK and both compared bonded molar tubes with molar bands. Key results From the limited data of two studies at low risk of bias, it would appear that bonded molar tubes are associated with a higher failure rate than with molar bands.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Millett, DT; Mandall, NA; Mattick, RCR; Hickman, J; Glenny, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008236.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "422edec7-286e-4461-83a3-e201441ceb14", "pmid": "", "title": "A Multiple Ascending Dose Study of Tadalafil to Assess the Pharmacokinetics and Safety in a Pediatric Population With Pulmonary Arterial Hypertension", "imported": false, "abstract": "The purpose of this study is to see how much study drug is in the blood of children with pulmonary arterial hypertension (PAH) after dosing to establish the correct dose for further clinical research.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "424afa9d-10eb-48b0-823a-c470edf30108", "pmid": "", "title": "Acute Effects of the Two Alternative Sweeteners D-allulose and Erythritol on Gastrointestinal Hormone Secretion and Glycemic Control", "imported": false, "abstract": "The aim of this project is to investigate the effect of intragastric (ig) D-allulose on metabolic parameters in general and to investigate the effect of sweet taste receptor blockade on GI hormone responses, glycemic control, gastric emptying (GE) rates and appetite-related sensations to ig administration of erythritol and D-allulose.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.148Z" }, { "id": "425e25bb-8c08-47f7-96fa-778302c09a02", "pmid": "", "title": "Full‐mouth treatment modalities (within 24 hours) for periodontitis in adults", "imported": false, "abstract": "Abstract - Background Periodontitis is a highly prevalent, chronic inflammation that causes damage to the soft tissues and bones supporting the teeth. Conventional treatment is quadrant scaling and root planing (the second step of periodontal therapy), which comprises scaling and root planing of teeth in one quadrant of the mouth at a time, with the four different sessions separated by at least one week. Alternative protocols for anti‐infective periodontal therapy have been introduced to help enhance treatment outcomes: full‐mouth scaling (subgingival instrumentation of all quadrants within 24 hours), or full‐mouth disinfection (subgingival instrumentation of all quadrants in 24 hours plus adjunctive antiseptic). We use the older term 'scaling and root planing' (SRP) interchangeably with the newer term 'subgingival instrumentation' in this iteration of the review, which updates one originally published in 2008 and first updated in 2015. Objectives To evaluate the clinical effects of full‐mouth scaling or full‐mouth disinfection (within 24 hours) for the treatment of periodontitis compared to conventional quadrant subgingival instrumentation (over a series of visits at least one week apart) and to evaluate whether there was a difference in clinical effects between full‐mouth disinfection and full‐mouth scaling. Search methods An information specialist searched five databases up to 17 June 2021 and used additional search methods to identify published, unpublished and ongoing studies. Selection criteria We included randomised controlled trials (RCTs) lasting at least three months that evaluated full‐mouth scaling and root planing within 24 hours, with or without adjunctive use of an antiseptic, compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of (chronic) periodontitis according to the International Classification of Periodontal Diseases from 1999. A new periodontitis classification was launched in 2018; however, we used the 1999 classification for inclusion or exclusion of studies, as most studies used it. We excluded studies of people with systemic disorders, taking antibiotics or with the older diagnosis of 'aggressive periodontitis'. Data collection and analysis Several review authors independently conducted data extraction and risk of bias assessment (based on randomisation method, allocation concealment, examiner blinding and completeness of follow‐up). Our primary outcomes were tooth loss and change in probing pocket depth (PPD); secondary outcomes were change in probing attachment (i.e. clinical attachment level (CAL)), bleeding on probing (BOP), adverse events and pocket closure (the number/proportion of sites with PPD of 4 mm or less after treatment). We followed Cochrane's methodological guidelines for data extraction and analysis. Main results We included 20 RCTs, with 944 participants, in this updated review. No studies assessed the primary outcome tooth loss. Thirteen trials compared full‐mouth scaling and root planing within 24 hours without the use of antiseptic (FMS) versus control, 13 trials compared full‐mouth scaling and root planing within 24 hours with adjunctive use of an antiseptic (FMD) versus control, and six trials compared FMS with FMD. Of the 13 trials comparing FMS versus control, we assessed three at high risk of bias, six at low risk of bias and four at unclear risk of bias. We assessed our certainty about the evidence as low or very low for the outcomes in this comparison. There was no evidence for a benefit for FMS over control for change in PPD, gain in CAL or reduction in BOP at six to eight months (PPD: mean difference (MD) 0.03 mm, 95% confidence interval (CI) –0.14 to 0.20; 5 trials, 148 participants; CAL: MD 0.10 mm, 95% CI –0.05 to 0.26; 5 trials, 148 participants; BOP: MD 2.64%, 95% CI –8.81 to 14.09; 3 trials, 80 participants). There was evidence of heterogeneity for BOP (I² = 50%), but none for PPD and CAL. Of the 13 trials comparing FMD versus control, we judged four at high risk of bias, one at low risk of bias and eight at unclear risk of bias. At six to eight months, there was no evidence for a benefit for FMD over control for change in PPD or CAL (PPD: MD 0.11 mm, 95% CI –0.04 to 0.27; 6 trials, 224 participants; low‐certainty evidence; CAL: 0.07 mm, 95% CI –0.11 to 0.24; 6 trials, 224 participants; low‐certainty evidence). The analyses found no evidence of a benefit for FMD over control for BOP (very low‐certainty evidence). There was no evidence of heterogeneity for PPD or CAL, but considerable evidence of heterogeneity for BOP, attributed to one study. There were no consistent differences in these outcomes between intervention and control (low‐ to very low‐certainty evidence). Of the six trials comparing FMS and FMD, we judged two trials at high risk of bias, one at low risk of bias and three as unclear. At six to eight months, there was no evidence of a benefit of FMD over FMS for change in PPD or gain in CAL (PPD: MD –0.11 mm, 95% CI –0.30 to 0.07; P = 0.22; 4 trials, 112 participants; low‐certainty evidence; CAL: MD –0.05 mm, 95% CI –0.23 to –0.13; P = 0.58; 4 trials, 112 participants; low‐certainty evidence). There was no evidence of a difference between FMS and FMD for BOP at any time point (P = 0.98; 2 trials, 22 participants; low‐ to very low‐certainty evidence). There was evidence of heterogeneity for BOP (I² = 52%), but not for PPD or CAL. Thirteen studies predefined adverse events as an outcome; three reported an event after FMD or FMS. The most important harm identified was an increase in body temperature. We assessed the certainty of the evidence for most comparisons and outcomes as low because of design limitations leading to risk of bias, and the small number of trials and participants, leading to imprecision in the effect estimates. Authors' conclusions The inclusion of nine new RCTs in this updated review has not changed the conclusions of the previous version of the review. There is still no clear evidence that FMS or FMD approaches provide additional clinical benefit compared to conventional mechanical treatment for adult periodontitis. In practice, the decision to select one approach to non‐surgical periodontal therapy over another should include patient preference and the convenience of the treatment schedule. Plain language summary Treating all teeth (full mouth) within 24 hours for gum disease (periodontitis) in adults Background Long‐lasting gum disease (periodontitis) is a common chronic inflammatory disease that causes damage to soft tissues (gums) and bone around teeth, and can result in tooth loss. Non‐surgical treatments are used to stop and control the disease. These are based on 'subgingival instrumentation', that is, the mechanical removal of bacteria below the gums from the infected root surfaces of the teeth. Conventional treatment is carried out in two to four sessions over several weeks, scaling a different section (or 'quadrant') of the mouth each time. This has traditionally been known as 'scaling and root planing' (SRP). An alternative approach is to treat the whole mouth within 24 hours in one or two sessions (known as full‐mouth scaling (FMS)). When an antiseptic agent (like chlorhexidine) is added to FMS, the intervention is called full‐mouth disinfection (FMD). The rationale for using these full‐mouth approaches is to reduce the likelihood of re‐infection in already treated sites. Review question This review, produced within Cochrane Oral Health, is the second update of one we originally published in 2008. It evaluates the effectiveness of full‐mouth treatments within 24 hours (FMS and FMD) compared to conventional treatment over a number of weeks, and whether there is a difference between FMS and FMD. The evidence is current up to June 2021. Study characteristics The included studies were randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that evaluated a full‐mouth approach to subgingival instrumentation, with at least three months of monitoring (follow‐up). Both FMS and FMD were compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of chronic periodontitis and we excluded studies of people with aggressive periodontitis, systemic disorders (affecting other part of the body) or who were taking antibiotics. We included nine new studies in this update and we excluded one trial that had been included in the previous version of the review. In total, the review now includes 20 studies that involved 944 participants. Key results Treatment effects of FMS and FMD are modest and there are no clear implications for periodontal care. Neither treatment was superior to the usual treatment of scaling and root planing a quarter of the mouth at a time. The most important harm identified was an increased body temperature after FMS or FMD treatments, reported in three out of 13 studies. In practice, the decision to select one approach over another will be based on preference and convenience for patient and dentist. Certainty of the evidence Our confidence in the results is low for most comparisons and outcomes, due to the small number of studies and participants involved, and limitations in study designs. The addition of nine studies has not changed the findings of our previous version of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jervøe-Storm, P-M, Eberhard, J, Needleman, I, Worthington, HV, Jepsen, S", "articleTypes": [], "doi": "10.1002/14651858.CD004622.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.104Z" }, { "id": "42733377-f6af-44bf-8f2b-037714f30f77", "pmid": "", "title": "Pharmacological interventions for cognitive decline in people with Down syndrome", "imported": false, "abstract": "Abstract - Background People with Down syndrome are vulnerable to developing dementia at an earlier age than the general population. Alzheimer's disease and cognitive decline in people with Down syndrome can place a significant burden on both the person with Down syndrome and their family and carers. Various pharmacological interventions, including donepezil, galantamine, memantine and rivastigmine, appear to have some effect in treating cognitive decline in people without Down syndrome, but their effectiveness for those with Down syndrome remains unclear. Objectives To assess the effectiveness of anti‐dementia pharmacological interventions and nutritional supplements for treating cognitive decline in people with Down syndrome. Search methods In January 2015, we searched CENTRAL, ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), Ovid MEDLINE, Embase, PsycINFO, seven other databases, and two trials registers. In addition, we checked the references of relevant reviews and studies and contacted study authors, other researchers and relevant drug manufacturers to identify additional studies. Selection criteria Randomised controlled trials (RCTs) of anti‐dementia pharmacological interventions or nutritional supplements for adults (aged 18 years and older) with Down syndrome, in which treatment was administered and compared with either placebo or no treatment. Data collection and analysis Two review authors independently assessed the risk of bias of included trials and extracted the relevant data. Review authors contacted study authors to obtain missing information where necessary. Main results Only nine studies (427 participants) met the inclusion criteria for this review. Four of these (192 participants) assessed the effectiveness of donepezil, two (139 participants) assessed memantine, one (21 participants) assessed simvastatin, one study (35 participants) assessed antioxidants, and one study (40 participants) assessed acetyl‐L‐carnitine. Five studies focused on adults aged 45 to 55 years, while the remaining four studies focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one between Norway and the UK, and one in Japan. Follow‐up periods in studies ranged from four weeks to two years. The reviewers judged all included studies to be at low or unclear risk of bias. Analyses indicate that for participants who received donepezil, scores in measures of cognitive functioning (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) ‐0.27 to 1.13) and measures of behaviour (SMD 0.42, 95% CI ‐0.06 to 0.89) were similar to those who received placebo. However, participants who received donepezil were significantly more likely to experience an adverse event (odds ratio (OR) 0.32, 95% CI 0.16 to 0.62). The quality of this body of evidence was low. None of the included donepezil studies reported data for carer stress, institutional/home care, or death. For participants who received memantine, scores in measures of cognitive functioning (SMD 0.05, 95% CI ‐0.43 to 0.52), behaviour (SMD ‐0.17, 95% CI ‐0.46 to 0.11), and occurrence of adverse events (OR 0.45, 95% CI 0.18 to 1.17) were similar to those who received placebo. The quality of this body of evidence was low. None of the included memantine studies reported data for carer stress, institutional/home care, or death. Due to insufficient data, it was possible to provide a narrative account only of the outcomes for simvastatin, antioxidants, and acetyl‐L‐carnitine. Results from one pilot study suggest that participants who received simvastatin may have shown a slight improvement in cognitive measures. Authors' conclusions Due to the low quality of the body of evidence in this review, it is difficult to draw conclusions about the effectiveness of any pharmacological intervention for cognitive decline in people with Down syndrome. Plain language summary Medications for cognitive decline in people with Down syndrome People with Down syndrome often experience cognitive decline (a deterioration in memory, language, thinking and judgment that are greater than normal age‐related changes) at a younger age and in greater numbers than the general population. Various medicines have been shown to improve, or at least slow down the progression of these symptoms in people without Down syndrome. Review question Do adults (18 years and older) with Down syndrome benefit from treatment with medicine to prevent cognitive decline, compared with other adults with Down syndrome who receive either fake medicine (placebos) or no medicine? Study characteristics In January 2015, we, a team of Cochrane researchers, searched for all medical studies that investigated the effect of any medicine or nutritional supplement on cognitive decline in adults with Down syndrome. We found nine relevant randomised controlled trials (this design produces the most reliable results) that we could include in this overview. These studies tested: ‐ donepezil, a medicine used to treat Alzheimer's disease (four studies); ‐ memantine, a medicine used to treat Alzheimer's disease (two studies); ‐ simvastatin, a (statin) medicine used to prevent heart disease (one study); ‐ a mixture of antioxidants, including forms of vitamins C and E, and alpha‐lipoic acid (one study); and ‐ acetyl‐L‐carnitine, a dietary supplement that has previously been used to treat dementia (one study). Five of the studies focused on adults aged 45 to 55 years and four focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one took place in Norway and the UK, and one study was conducted in Japan. Key results The nine studies we found examined the effects of five medicines that are, or have been, used to prevent cognitive decline. All the studies compared the medicine being tested with a placebo (a tablet or capsule that looked and tasted like the medicine, but which contained no medicine). Generally, those who received the medicine did no better than those who received the placebo in any of the areas assessed in the studies. The areas assessed included general functioning (including memory and thinking, speech, mood and behaviour); cognitive functioning (including memory, following what’s going on around you); adaptive behaviours (being able to do day‐to‐day tasks); or behaviour problems (such as being irritable or aggressive). The only medicine to show any positive effect was the statin, simvastatin. Preliminary findings from a very small study showed that simvastin had some benefit on improving memory compared to placebo. In the four donepezil studies, those participants given donepezil reported more headaches, dizziness, and nausea than participants given placebo. In the two memantine studies, there was no difference between participants given memantine or placebo for reports of headaches, dizziness, and nausea. Quality of the evidence Although the included studies were well conducted, most involved small numbers of participants and for many of the areas assessed we could not combine results from two or more studies. Overall, the quality of this evidence is low. We cannot be certain whether any of these medicines are effective. Running more trials with more people over a longer period of time would allow us answer this question with greater certainty. We could not find any trials that investigated many of the medicines used to prevent cognitive decline, and so research is needed to explore the effectiveness of these medications in the Down syndrome population.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Livingstone, N, Hanratty, J, McShane, R, Macdonald, G", "articleTypes": [], "doi": "10.1002/14651858.CD011546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.793Z" }, { "id": "4276e51e-3a33-4ea4-bc37-4b06edd412b2", "pmid": "", "title": "Vitamin B12 supplementation for growth, development, and cognition in children", "imported": false, "abstract": "Abstract - Rationale Vitamin B 12 deficiency is an important public health problem in children, and has been associated with anaemia and impaired growth, cognition, and development. Vitamin B 12 deficiency may develop in children due to lower content in breast milk, low dietary intake, and as requirements increase with age. Vitamin B 12 supplementation may confer benefits to child growth and development, due to its role in DNA synthesis and methylation, red blood cell formation, and folate metabolism. However, no systematic reviews have been conducted to examine the effects of vitamin B 12 supplementation in children. Objectives To determine the effects of vitamin B 12 supplementation on growth, development, and cognition in children less than 12 years of age. Search methods We searched CENTRAL, MEDLINE, Embase, 12 other databases, and two trial registries on 23 September 2025. We screened reference lists of studies. Eligibility criteria We included randomised controlled trials evaluating the effects of oral vitamin B 12 supplementation, alone or in combination with other micronutrients, in children < 12 years of age. We excluded cross‐over trials, trials targeting pregnant or breastfeeding women, or participants with critical illnesses, and interventions delivered by intravenous/intramuscular injections. Outcomes Critical outcomes were vitamin B 12 status, anaemia, haemoglobin, growth, cognitive function, developmental outcomes, and any adverse effects. Important outcomes included megaloblastic anaemia, body composition, health‐related quality of life, morbidity, and all‐cause mortality. Risk of bias We used Cochrane RoB 2 to evaluate bias. Synthesis methods We conducted meta‐analyses using fixed‐effect models. If there was substantial heterogeneity, we used random‐effect models. When meta‐analyses were not conducted, we described findings from individual trials, and considered synthesis and presentation of findings using other methods. We used GRADE to evaluate the certainty of evidence for critical outcomes. Included studies We included 16 trials (4083 children; 2 days to 11 years) in 10 countries, including India, Japan, Thailand, Nepal, United Kingdom, Italy, Spain, the United States, El Salvador, and Guatemala. Follow‐up periods for outcomes in most studies ranged from five weeks to 31 months, with one study extending follow‐up to nine years. Duration of vitamin B 12 supplementation varied, ranging from 28 days to 31 months, with doses from 0.9 µg/day to 150 µg/day. Nine trials, including 2391 children, contributed data to meta‐analyses. Synthesis of results Supplementation with vitamin B 12 alone versus placebo There may be little to no difference between groups in height/length (mean difference (MD) ‐0.19 cm, 95% confidence interval (CI) ‐2.44 to 2.06; 2 trials, 143 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (standardised mean difference (SMD) 0.09, 95% CI ‐0.10 to 0.28; 2 trials, 438 children, low‐certainty evidence). There may be little to no difference between groups in motor skill development (6 to 9 years, NEuroPSYchological assessment, Second Edition (NEPSY‐II); 1 trial, 403 children, low‐certainty evidence). Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency (absolute risk difference (ARD) 56 fewer per 1000, 95% CI 68 fewer to 24 fewer; 1.8% versus 7.6%; risk ratio (RR) 0.27, 95% CI 0.11 to 0.69; 3 trials, 642 children; high‐certainty evidence), and probably increases total vitamin B 12 concentrations (MD 68.53 pmol/L, 95% CI 41.83 to 95.23; 7 trials, 705 children; moderate‐certainty evidence), compared to placebo, with an average increase of 68.5 pmol/L. There may be little to no difference between groups in anaemia (ARD 21 more per 1000, 95% CI 26 fewer to 191 more; 9.1% versus 4.5%; RR 1.48, 95% CI 0.41 to 5.27; 2 trials, 144 children; low‐certainty evidence). No trials reported the occurrence of any adverse effects. Supplementation with vitamin B 12 alone versus no intervention The evidence is very uncertain about the effects of vitamin B 12 on height/length (2 trials, 70 children; very low‐certainty evidence), compared to no intervention. No trials reported data for the other critical outcomes. Supplementation with vitamin B 12 and other micronutrients, compared to the same formulation without vitamin B 12 There may be little to no difference between groups in height/length (MD ‐0.22 cm, 95% CI ‐0.65 to 0.20; 2 trials, 608 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (SMD 0.00, 95% CI ‐0.13 to 0.13; 3 trials, 956 children; low‐certainty evidence). There may be little to no difference between groups in development outcomes (e.g. motor skill development) (SMD ‐0.05, 95% CI ‐0.18 to 0.08; 2 trials, 960 children; low‐certainty evidence). Children who received vitamin B 12 supplementation and other micronutrients may have little to no difference in vitamin B 12 deficiency (ARD 2 fewer per 1000, 95% CI 7 fewer to 32 more; 0.7% versus 0.8%; RR 0.77, 95% CI 0.12 to 5.16; 2 trials, 534 children; low‐certainty evidence), or total vitamin B 12 concentrations (MD 34.32 pmol/L, 95% CI ‐31.13 to 99.77; 3 trials, 731 children; low‐certainty evidence), compared to supplements without vitamin B 12 . There may be little to no difference between groups in anaemia (21.7% versus 25.0%; 1 trial, 35 children; low‐certainty evidence). There may be little to no difference between groups in any adverse effects (9.2% versus 5.9%; 1 trial, 574 children; low‐certainty evidence). The certainty of evidence for critical outcomes ranged from high to very low; we downgraded for imprecision due to small sample sizes or few events, risk of bias in outcome measurement, randomisation methods, selective reporting bias, or inconsistency due to substantial statistical heterogeneity. Few studies reported growth, cognition, development, anaemia, or any adverse effects. Authors' conclusions Vitamin B 12 supplementation (alone or when supplemented with other micronutrients) in children may have little to no effect on growth (i.e. height/length), cognitive function (e.g. attention), development outcomes (e.g. motor skill development), or anaemia, compared to placebo, no intervention, or the same supplements without vitamin B 12 . Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency and probably improves total vitamin B 12 concentrations, compared to placebo. However, vitamin B 12 supplementation with other micronutrients may result in little to no difference in vitamin B 12 deficiency and total vitamin B 12 concentrations, compared to the same formulation without vitamin B 12 . Funding This review had no dedicated funding. Registration Protocol available via DOI 10.1002/14651858.CD015264. Plain language summary What are the effects of vitamin B 12 supplementation for children less than 12 years of age? Key messages Vitamin B 12 supplementation reduces the risk of vitamin B 12 deficiency, and probably improves vitamin B 12 levels in children less than 12 years of age, compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient) (that is, children who did not take vitamin B 12 supplements). Vitamin B 12 supplements, with other micronutrients (important vitamins and minerals the body needs in small amounts to function), may result in little to no difference in vitamin B 12 deficiency or total vitamin B 12 levels, compared to children who received the same supplements without vitamin B 12 . The impact of vitamin B 12 supplements on other health outcomes in children is less clear. What is vitamin B 12 ? Vitamin B 12 is an important nutrient that helps make red blood cells and keep the body's cells and nerves healthy. Vitamin B 12 deficiency is an important public health problem, including in children and in resource‐poor settings. Lower vitamin B 12 levels in children have been linked to anaemia (lower haemoglobin levels), and poorer growth, development, and cognition (a child's ability to gain knowledge through thought, understanding, and the senses). What did we want to find out? We wanted to find out if taking vitamin B 12 supplements would improve the nutrition and health of children less than 12 years of age. What did we do? We searched for studies that looked at the effects of vitamin B 12 compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient), no intervention, or the same supplements without vitamin B 12 . We summarised the results of the studies and our confidence in the evidence, based on information such as how the study was done. What did we find? We included 16 studies involving 4083 children less than 12 years of age (2 days to 11 years). Nine studies, including 2391 children, had data that we could analyse. The studies were conducted in 10 countries around the world. In most studies, the outcomes were assessed immediately after the intervention from five weeks to 31 months, with one study assessing outcomes after nine years. Vitamin B 12 supplements were provided from 28 days to 31 months in amounts from 0.9 to 150 micrograms a day. Supplementation with vitamin B 12 alone versus placebo There may be little to no difference in height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplements had less vitamin B 12 deficiency, and probably had higher vitamin B 12 levels, compared to placebo. There may be little to no difference between groups in anaemia. No studies provided data on any unwanted (adverse) effects. Vitamin B 12 alone versus no intervention The evidence is very uncertain for height/length. No studies reported data we could analyse for other outcomes. Vitamin B 12 and other micronutrients, compared to supplements with the same supplement without vitamin B 12 There may be little to no difference between groups for height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplementation (with other nutrients) may have little to no difference in vitamin B 12 deficiency, vitamin B 12 levels, anaemia, or any unwanted effects. What are the limitations of the evidence? The small number and the size of studies were limitations of this review. Few studies reported on health outcomes, including growth, cognition, development, anaemia, or any adverse effects. The different ages of children, and differences in the amount of vitamin B 12 and when the outcomes were measured, are also limitations of this review. How up to date is this evidence? The evidence is up to date as of 23 September 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Larvie, DY, Güitrón Leal, CE, Venkatramanan, S, Palma Molina, XE, Steel, LB, Kuriyan, R, Finkelstein, JL", "articleTypes": [], "doi": "10.1002/14651858.CD015264.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.103Z" }, { "id": "427a45e8-65f5-4466-8254-deb9f5557555", "pmid": "", "title": "Convalescent plasma for people with COVID‐19", "imported": false, "abstract": "Abstract - Rationale Convalescent plasma (CP) may reduce mortality in people with viral respiratory diseases, and is being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). A thorough understanding of the current body of evidence regarding the benefits and risks of this intervention is required. Objectives To assess the effectiveness and safety of convalescent plasma transfusion in the treatment of people with COVID‐19. Search methods To identify completed and ongoing studies, we searched CENTRAL, MEDLINE, Embase, the Epistemonikos COVID‐19 L*OVE Platform, and clinical trial registries to October 2024. Eligibility criteria We included randomised controlled trials (RCTs) evaluating convalescent plasma for people with COVID‐19, irrespective of disease severity, age, gender, or ethnicity. We excluded studies investigating other coronavirus diseases or standard immunoglobulin. Outcomes We used the GRADE approach to rate the certainty of evidence for the following outcomes: all‐cause mortality (up to day 28), worsening and improvement of clinical status (for individuals with moderate to severe disease), hospital admission or death, COVID‐19 symptoms resolution (for individuals with mild disease), quality of life (QoL), grade 3/4 adverse events, and serious adverse events. Risk of bias We used RoB 2 to assess bias in included studies. Synthesis methods We followed standard Cochrane methodology. Included studies We included 48 RCTs (24,518 participants), 15 of which were added in this update. We also identified 36 new ongoing studies and 33 completed studies awaiting classification. Synthesis of results Individuals with a confirmed diagnosis of COVID‐19 and moderate to severe disease Forty‐two RCTs investigated the use of CP for 21,393 participants with moderate to severe disease. Of these, 36 RCTs (20,798 participants) compared CP to placebo or standard care, five (604 participants) to standard plasma, and one (190 participants) to human immunoglobulin. In the full review, we performed subgroup analyses by antibody detection, time since symptom onset, country income level, and key comorbidities. Convalescent plasma versus placebo or standard care alone CP does not reduce all‐cause mortality at up to day 28 (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.90 to 1.03; 31 RCTs, 20,798 participants; high‐certainty evidence). It has little to no impact on the need for invasive mechanical ventilation, or death (RR 1.03, 95% CI 0.98 to 1.08; 8 RCTs, 15,189 participants; high‐certainty evidence) and has no impact on whether participants are discharged from hospital (RR 1.00, 95% CI 0.97 to 1.02; 9 RCTs, 13,930 participants; high‐certainty evidence). CP may have little to no impact on QoL (MD 1.00, 95% CI −2.14 to 4.14; 1 RCT, 483 participants; low‐certainty evidence). CP may have little to no impact on the risk of grade 3/4 adverse events (RR 1.17, 95% CI 0.96 to 1.42; 6 RCTs, 2392 participants; low‐certainty evidence). It probably has little to no effect on the risk of serious adverse events (RR 1.19, 95% CI 1.02 to 1.38; 11 studies, 5298 participants; moderate‐certainty evidence). Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.77, 95% CI 0.53 to 1.10; 5 RCTs, 604 participants; very low‐certainty evidence) and whether it increases the need for invasive mechanical ventilation, or death (RR 5.59, 95% CI 0.29 to 108.38; 1 study, 34 participants; very low‐certainty evidence). The evidence is uncertain about whether convalescent plasma reduces or increases the risk of grade 3/4 adverse events (1 RCT, 248 participants). The evidence is also uncertain about whether CP reduces the risk of serious adverse events (RR 0.82, 95% CI 0.57 to 1.17; 4 RCTs, 447 participants; very low‐certainty evidence). No studies in this comparison reported clinical improvement or QoL. Individuals with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease Six RCTs investigated the use of CP for 2761 participants with mild disease. Four RCTs (1164 participants) compared CP to placebo or standard care alone, and two (1597 participants) to standard plasma. Convalescent plasma versus placebo or standard care alone The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (odds ratio (OR) 1.24, 95% CI 0.33 to 4.60; 3 RCTs, 1004 participants; very low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.45, 95% CI 0.04 to 4.81; 2 RCTs, 493 participants; very low‐certainty evidence). It may have little to no impact on time to COVID‐19 symptom resolution (hazard ratio (HR) 1.05, 95% CI 0.85 to 1.30; 1 RCT, 376 participants) and on the risk of grade 3/4 adverse events (RR 1.29, 95% CI 0.75 to 2.19; 1 RCT, 376 participants), both with low‐certainty evidence. The evidence is uncertain about whether CP has an impact on the risk of serious adverse events (RR 0.84, 95% CI 0.56 to 1.26; 2 RCTs, 494 participants; very low‐certainty evidence). No studies in this comparison reported other critical outcomes. Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.41, 95% CI 0.05 to 3.06; 2 RCTs, 1597 participants; very low‐certainty evidence). It probably reduces admission to hospital or death within 28 days (RR 0.50, 95% CI 0.32 to 0.78; 2 RCTs, 1597 participants; moderate‐certainty evidence). CP may have little to no effect on initial symptom resolution at up to day 28 (RR 1.12, 95% CI 0.82 to 1.54; 1 RCT, 416 participants; low‐certainty evidence). Neither study in this comparison reported other critical outcomes. Authors' conclusions Compared with placebo or standard care, high‐certainty evidence shows that CP does not reduce mortality in individuals with moderate to severe disease and has little to no effect on clinical improvement or worsening. CP probably has little to no effect on serious adverse events. Publication of ongoing studies might resolve some of the uncertainties around CP therapy for people with asymptomatic or mild disease. This review was previously a living systematic review, from the first version published in 2020 until our last search in October 2024. The research question is no longer a priority for decision‐making, new studies are less frequently published, and research that might impact the conclusions of the review is no longer emerging. Funding The European Commission, Belgium SUPorting high quality evaluation of COVID‐19 convalescent plasma thrOughouT Europe (SUPPORT‐E, grant number 101015756) supported this review. Registration Protocol registered with the Center for Open Science on 17 April 2020 (DOI: 10.17605/OSF.IO/DWF53). Access the 2023 version of this review here: DOI: 10.1002/14651858.CD013600.pub6. Plain language summary Does plasma (a blood product) from people who have recovered from COVID‐19 help treat COVID‐19? Key messages We are very confident that plasma from the blood of people who have recovered from COVID‐19 (convalescent plasma) does not help people with moderate to severe COVID‐19. Convalescent plasma may make little or no difference to people with mild COVID‐19. We still need more evidence about people with mild COVID‐19, those with no symptoms, and those with a weaker immune system. What is convalescent plasma? The body produces antibodies as one of its defences against infection. Antibodies are found in part of the blood called plasma. Plasma from people who have recovered from the COVID‐19 virus contains COVID‐19 antibodies. It can be used to make convalescent plasma, which is plasma that contains these antibodies. Convalescent plasma has been used successfully to treat some viruses. This treatment (given by a drip or injection) is generally well‐tolerated, but can cause unwanted effects. What did we want to find out? We wanted to find out whether convalescent plasma helps people with confirmed COVID‐19. We looked at: deaths from any cause; worsening of people's condition, measured by the number of people who needed a ventilator (a machine that helps people breathe) or died; improvement in people's condition, measured by the number of people discharged from hospital; quality of life; unwanted effects. What did we do? We searched for studies that investigated convalescent plasma to treat people with COVID‐19. Studies could take place anywhere in the world and include people with mild, moderate, or severe COVID‐19. Where possible, we combined the studies’ results to analyse them. We rated our confidence in the evidence, based on factors such as study methods and the number of people included. What did we find? We found 48 studies with 24,518 participants. Of these, 42 studies included people with moderate to severe COVID‐19, and six studies included people with mild COVID‐19. The following findings compare convalescent plasma with placebo (a 'dummy' treatment that does not contain any medicine but is given in the same way as the medicine being tested) or the standard care given to people with COVID‐19. People with moderate to severe COVID‐19 In people with moderate to severe COVID‐19, convalescent plasma: makes no difference to deaths from any cause up to 28 days after treatment. About 230 of 1000 people given placebo or standard care died, compared to 220 of 1000 people given convalescent plasma (31 studies, 20,798 people). makes little to no difference to needing support from a ventilator or dying . About 291 of 1000 people given placebo or standard care needed a ventilator or died, compared to 300 of 1000 people given convalescent plasma (8 studies, 15,189 people). makes no difference to people being discharged from hospital. About 670 of 1000 people in both groups were discharged from hospital (9 studies, 13,930 people). may result in no difference in people's quality of life (1 study, 483 people). probably makes no difference to serious unwanted effects. About 109 of 1000 people given placebo or standard care had serious unwanted effects, compared to 129 of 1000 people given convalescent plasma (11 studies, 5298 people). People with mild COVID‐19 We are uncertain whether convalescent plasma reduces deaths from any cause up to 28 days after treatment. About 8 of 1000 people given placebo or standard care died, compared to 10 of 1000 people given convalescent plasma (3 studies, 1004 people). We are uncertain whether convalescent plasma reduces admission to hospital or death within 28 days after treatment. About 106 of 1000 people given placebo or standard care were admitted to hospital or died, compared to 48 of 1000 people given convalescent plasma (2 studies, 493 people). Convalescent plasma may result in no difference in the time until COVID‐19 symptoms resolved (1 study, 376 people). None of the studies measured people's quality of life. We are uncertain whether convalescent plasma has an impact on serious unwanted effects. About 174 of 1000 people given placebo or standard care had serious unwanted effects, compared to 150 of 1000 people given convalescent plasma (2 studies, 494 people). What are the limitations of the evidence? For people with moderate to severe COVID‐19, we are very confident in the evidence about the number of deaths from any cause, and whether people's condition worsened or improved, because the results are drawn from many high‐quality studies with consistent results. We are only moderately confident about the evidence for serious unwanted effects because studies often reported these effects only for people treated with convalescent plasma, or did not report them. For people with mild COVID‐19, we have little to no confidence in the evidence because we could not identify enough consistent results from many of the studies. We still have little evidence about quality of life and about the effects of convalescent plasma for people with mild disease. How up to date is this evidence? This updates our previous review published in 2023. The evidence is current to October 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Iannizzi, C, Chai, KL, Piechotta, V, Monsef, I, Wood, EM, Lamikanra, AA, Roberts, DJ, McQuilten, Z, So-Osman, C, Jindal, A, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013600.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.797Z" }, { "id": "427c182f-ecc6-437a-b7b4-028be291df20", "pmid": "", "title": "Ondansetron Pharmacotherapy for Hazardous Drinking in HIV+, African-American Women", "imported": false, "abstract": "The proposed randomized clinical trial will investigate a novel pharmacotherapy for hazardous drinking, HIV-infected men and women, using the serotonin receptor (5-HT3) antagonist ondansetron. The investigators predict that participants who are treated with active doses of ondansetron will reduce their drinking more and show better HIV treatment participation and progress compared to participants who are treated with placebo. This study will provide important new safety and efficacy results on drinking and HIV outcomes following alcohol pharmacotherapy in HIV-infected persons.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "4280ed75-f3f9-436a-b5bb-84c59c27b0de", "pmid": "", "title": "CBD/THC Solution as a Pharmacological Strategy for Patients With Fibromyalgia. Single-center, Double-blind, Randomized, Placebo-controlled Clinical Trial Protocol (FibroCann)", "imported": false, "abstract": "Fibromyalgia is considered a chronic pain syndrome, non-inflammatory, of unknown etiology, which manifests itself in the musculoskeletal system in up to 2.5% of the general population, predominantly in females, mainly between 35 and 44 years old, having a direct impact on the quality of life of their patients (JUNIOR; GOLDENFUM; SIENA, 2012; HEYMANN et al., 2017). In 1990, eighteen (18) specific sites were defined as tender points which are used to better diagnose fibromyalgia (WOLFE et al., 2010). Due to its clinical and exclusion diagnosis, treatment usually starts late, which allows the progression of symptoms and corroborates its low efficiency in the long term (DE SOUSA BRAZ et al., 2011). Due to the ineffective results and significant side effects that conventional treatment with drugs such as antidepressants, analgesics and anti-inflammatory drugs can provide, patients, physicians and researchers are looking for new main or adjuvant treatments, pharmacological and non-pharmacological (DE SOUSA BRAZ et al. al., 2011). In this context, it has been seen that the use of Cannabis sativa as a therapeutic option in fibromyalgia is promising, especially in reducing the pain caused by the disease and also the adjuvant symptoms, such as depression and sleep disorders (YASSIN; ORON; ROBINSON, 2019). This result must occur due to the action of cannabinoids, such as CBD and THC, on cannabinoid receptors distributed in peripheral nerves, spinal cord and supraspinal region, sites responsible for the reception, transmission and perception of pain (STE-MARIE et al., 2012). Currently, cannabinoids are considered safe analgesics with considerable efficacy, which demonstrates potential as a therapeutic option in the treatment of chronic pain, particularly in patients refractory to other treatments (HAUSER et al., 2018). In addition to its action on the painful mechanisms of fibromyalgia, the antidepressant effects of Cannabis are of great value in the treatment of fibromyalgia. These effects are explained by the modulation on serotonin 5-HT1A receptors, which has its effect exerted especially by CBD (ESPEJO-PORRAS et al., 2013).", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.154Z" }, { "id": "4282540c-ec4b-4eac-abf8-b540bac6f1f3", "pmid": "", "title": "Benperidol for schizophrenia", "imported": false, "abstract": "Abstract - Background Benperidol is a relatively old antipsychotic drug that has been marketed since 1966. It has been used in Germany for 30 years but is also available in Belgium, Greece, Italy, the Netherlands and the UK. Benperidol is a butyrophenone antipsychotic, with the highest neuroleptic potency in terms of D2 receptor blockade. Those taking it are therefore reputed to be at high risk of extrapyramidal side‐effects, but benperidol's unusual profile may render it valuable to certain subgroups of people with schizophrenia. Objectives To examine the clinical effects and safety of benperidol for those with schizophrenia and schizophrenia‐like psychoses. Search methods We searched the Cochrane Schizophrenia Group's register (March 2009) for this update. Selection criteria We included all randomised controlled trials that compared benperidol with other treatments for people with schizophrenia, or schizophrenia‐like psychoses. Data collection and analysis We reliably selected studies, quality rated them and extracted data. We independently extracted data but excluded data if loss to follow up was greater than 50%. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results The update yielded no further studies for inclusion in the review. We identified only one unpublished poorly randomised controlled trial (N=40, duration 30 days, comparison perphenazine). Although benperidol was inferior to perphenazine (1 RCT, N=40, global state no better or worse RR 8.0 CI 2.1 to 30, NNH 1.4 CI 1 to 2) poor reporting suggests that an overestimate of effect is likely. It was not possible to report other outcomes. Authors' conclusions Currently, there are insufficient data from randomised trials to assess the clinical effects of benperidol. This compound merits further research interest. Plain language summary Benperidol for schizophrenia Benperidol is a relatively old drug that is used for the treatment of schizophrenia in several European countries. We identified only one small, poorly reported, unpublished, randomised trial comparing benperidol with another antipsychotic. Unfortunately the quality of reporting is so poor that the results cannot be considered reliable. Although benperidol was first marketed in 1966, more trials on this drug are justified as with the advent of new compounds there is a danger that inexpensive drugs such as benperidol remain under‐researched and overlooked.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Schwarz, C, Hartung, B, Leucht, S", "articleTypes": [], "doi": "10.1002/14651858.CD003083.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.093Z" }, { "id": "428e9eca-dd03-4926-84ec-1c58cc3593a5", "pmid": "", "title": "Pharmacological intervention for irritability, aggression, and self‐injury in autism spectrum disorder (ASD)", "imported": false, "abstract": "Abstract - Background Pharmacological interventions are frequently used for people with autism spectrum disorder (ASD) to manage behaviours of concern, including irritability, aggression, and self‐injury. Some pharmacological interventions might help treat some behaviours of concern, but can also have adverse effects (AEs). Objectives To assess the effectiveness and AEs of pharmacological interventions for managing the behaviours of irritability, aggression, and self‐injury in ASD. Search methods We searched CENTRAL, MEDLINE, Embase, 11 other databases and two trials registers up to June 2022. We also searched reference lists of relevant studies, and contacted study authors, experts and pharmaceutical companies. Selection criteria We included randomised controlled trials of participants of any age with a clinical diagnosis of ASD, that compared any pharmacological intervention to an alternative drug, standard care, placebo, or wait‐list control. Data collection and analysis We used standard Cochrane methods. Primary outcomes were behaviours of concern in ASD, (irritability, aggression and self‐injury); and AEs. Secondary outcomes were quality of life, and tolerability and acceptability. Two review authors independently assessed each study for risk of bias, and used GRADE to judge the certainty of the evidence for each outcome. Main results We included 131 studies involving 7014 participants in this review. We identified 26 studies as awaiting classification and 25 as ongoing. Most studies involved children (53 studies involved only children under 13 years), children and adolescents (37 studies), adolescents only (2 studies) children and adults (16 studies), or adults only (23 studies). All included studies compared a pharmacological intervention to a placebo or to another pharmacological intervention. Atypical antipsychotics versus placebo At short‐term follow−up (up to 6 months), atypical antipsychotics probably reduce irritability compared to placebo (standardised mean difference (SMD) −0.90, 95% confidence interval (CI) −1.25 to −0.55, 12 studies, 973 participants; moderate‐certainty evidence), which may indicate a large effect. However, there was no clear evidence of a difference in aggression between groups (SMD −0.44, 95% CI −0.89 to 0.01; 1 study, 77 participants; very low‐certainty evidence). Atypical antipsychotics may also reduce self‐injury (SMD −1.43, 95% CI −2.24 to −0.61; 1 study, 30 participants; low‐certainty evidence), possibly indicating a large effect. There may be higher rates of neurological AEs (dizziness, fatigue, sedation, somnolence, and tremor) in the intervention group (low‐certainty evidence), but there was no clear evidence of an effect on other neurological AEs. Increased appetite may be higher in the intervention group (low‐certainty evidence), but we found no clear evidence of an effect on other metabolic AEs. There was no clear evidence of differences between groups in musculoskeletal or psychological AEs. Neurohormones versus placebo At short‐term follow‐up, neurohormones may have minimal to no clear effect on irritability when compared to placebo (SMD −0.18, 95% CI −0.37 to −0.00; 8 studies; 466 participants; very low‐certainty evidence), although the evidence is very uncertain. No data were reported for aggression or self ‐injury. Neurohormones may reduce the risk of headaches slightly in the intervention group, although the evidence is very uncertain. There was no clear evidence of an effect of neurohormones on any other neurological AEs, nor on any psychological, metabolic, or musculoskeletal AEs (low‐ and very low‐certainty evidence). Attention‐deficit hyperactivity disorder (ADHD)‐related medications versus placebo At short‐term follow‐up, ADHD‐related medications may reduce irritability slightly (SMD −0.20, 95% CI −0.40 to −0.01; 10 studies, 400 participants; low‐certainty evidence), which may indicate a small effect. However, there was no clear evidence that ADHD‐related medications have an effect on self‐injury (SMD −0.62, 95% CI −1.63 to 0.39; 1 study, 16 participants; very low‐certainty evidence). No data were reported for aggression. Rates of neurological AEs (drowsiness, emotional AEs, fatigue, headache, insomnia, and irritability), metabolic AEs (decreased appetite) and psychological AEs (depression) may be higher in the intervention group, although the evidence is very uncertain (very low‐certainty evidence). There was no evidence of a difference between groups for any other metabolic, neurological, or psychological AEs (very low‐certainty evidence). No data were reported for musculoskeletal AEs. Antidepressants versus placebo At short‐term follow‐up, there was no clear evidence that antidepressants have an effect on irritability (SMD −0.06, 95% CI −0.30 to 0.18; 3 studies, 267 participants; low‐certainty evidence). No data for aggression or self‐injury were reported or could be included in the analysis. Rates of metabolic AEs (decreased energy) may be higher in participants receiving antidepressants (very low‐certainty evidence), although no other metabolic AEs showed clear evidence of a difference. Rates of neurological AEs (decreased attention) and psychological AEs (impulsive behaviour and stereotypy) may also be higher in the intervention group (very low‐certainty evidence) although the evidence is very uncertain. There was no clear evidence of any difference in the other metabolic, neurological, or psychological AEs (very low‐certainty evidence), nor between groups in musculoskeletal AEs (very low‐certainty evidence). Risk of bias We rated most of the studies across the four comparisons at unclear overall risk of bias due to having multiple domains rated as unclear, very few rated as low across all domains, and most having at least one domain rated as high risk of bias. Authors' conclusions Evidence suggests that atypical antipsychotics probably reduce irritability, ADHD‐related medications may reduce irritability slightly, and neurohormones may have little to no effect on irritability in the short term in people with ASD. There was some evidence that atypical antipsychotics may reduce self‐injury in the short term, although the evidence is uncertain. There was no clear evidence that antidepressants had an effect on irritability. There was also little to no difference in aggression between atypical antipsychotics and placebo, or self‐injury between ADHD‐related medications and placebo. However, there was some evidence that atypical antipsychotics may result in a large reduction in self‐injury, although the evidence is uncertain. No data were reported (or could be used) for self‐injury or aggression for neurohormones versus placebo. Studies reported a wide range of potential AEs. Atypical antipsychotics and ADHD‐related medications in particular were associated with an increased risk of metabolic and neurological AEs, although the evidence is uncertain for atypical antipsychotics and very uncertain for ADHD‐related medications. The other drug classes had minimal or no associated AEs. Plain language summary Which medications reduce irritability, aggression or self‐harm in people with autism spectrum disorder (ASD)? Key messages • Only 3 classes of medications showed any reduction in irritability, aggression or self‐harm when compared to placebo (a dummy medication). Atypical (second‐generation) antipsychotic medications probably reduce irritability and aggression, but appear to have little to no effect on self‐injury. Attention deficit hyperactivity disorder (ADHD)‐related medications may reduce irritability, although the evidence is uncertain. Neurohormones (oxytocin and secretin) may also reduce irritability, but we are very uncertain about the evidence. • Antidepressants appear to have no effect on irritability. Studies did not report on the effects of antidepressants, ADHD‐related medications and neurohormones on aggression or self‐injury. • Studies reported a wide range of unwanted effects, but only atypical antipsychotics, ADHD‐related medications, and neurohormones showed evidence of a higher risk of any unwanted effects compared to placebo. What is autism spectrum disorder (ASD)? Autism is a disorder that affects a child's physical, mental and behavioural development. It is a lifelong disability that starts in childhood but continues throughout adulthood. People with autism may find it difficult to communicate and interact with the world. However, autism affects each person differently and may be more or less severe in different people, so it is described as a 'spectrum' disorder. Some people with autism spectrum disorder (ASD) may be irritable, angry or aggressive, or hurt themselves physically (self‐injury), which are 'behaviours of concern' that can be difficult to manage and distressing for the person. How are behaviours of concern managed? Behaviours of concern are frequently managed with various types of medications that have been developed to treat other conditions. This means that their effectiveness for behaviours of concern is largely unknown, and they may cause serious and varied unwanted effects that affect all parts of the body. For example: • the heart and lungs; • the stomach and digestive system; • the immune system; • movement, joints and bones; and • mood and emotion. What did we want to find out? We wanted to know which types of medication were effective in reducing behaviours of concern in people with ASD and whether they caused unwanted effects. What did we do? We searched for studies that investigated any medication used to manage behaviours of concern. Studies compared the medication with placebo (a dummy medication) or another medication. People in the studies could be adults or children, but all had ASD with behaviours of concern. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 131 studies with 7014 people. Most studies involved children, although some studies involved both children and adults, or adults only. Studies looked at a wide range of medications, including those usually used to treat schizophrenia or bipolar disorder, depression, attention deficit hyperactivity disorder (ADHD), convulsions, emotional problems, heart and lungs, dementia, Parkinson's, and anxiety. Atypical (second‐generation) antipsychotics are usually used to treat schizophrenia or bipolar disorder. They probably reduce irritability, but they may have little to no effect on aggression and self‐injury. People receiving antipsychotics might be more likely to experience unwanted effects such as increased appetite, dizziness, sedation (slowed thought and movement), sleepiness, tiredness and tremor compared to those receiving no treatment or other medications. People receiving antipsychotics may be no more or less likely than those receiving placebo to experience other unwanted effects. Neurohormones (such as oxytocin and secretin) may have a minimal to small effect on irritability but no studies reported data for the effects of neurohormones on self‐harm or aggression. People receiving neurohormones may be no more or less likely than those receiving placebo to experience unwanted effects. ADHD‐related medications may reduce irritability but may have no effect on self‐injury. No studies reported data for aggression. People receiving ADHD‐related medications might be more likely to experience unwanted effects such as drowsiness, tiredness, headache, difficulties sleeping, and decreased appetite. But they may be no more or less likely than those receiving placebo to experience other unwanted effects. Antidepressants may have little to no effect on irritability. No studies reported useful data for aggression and self‐injury. People receiving antidepressants might be more likely to experience unwanted effects such as impulsive behaviour and making repetitive movements or sounds (stereotypy) compared to placebo. But they may be no more or less likely than those receiving placebo to experience other types of unwanted effects. What are the limitations of the evidence? Most of the studies lasted less than 3 months, and very few studies involved adults. Therefore, we are uncertain if the same effects would be seen over a longer period of time or in adults. How up‐to‐date is the evidence? The review authors searched for studies that had been published up to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Iffland, M; Livingstone, N; Jorgensen, M; Hazell, P; Gillies, D", "articleTypes": [], "doi": "10.1002/14651858.CD011769.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "42932370-aaee-4eec-980b-1445774c8773", "pmid": "", "title": "N‐acetylcysteine as an adjuvant therapy for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) is one of the most common pathogens to establish and cause infection in human beings, affecting about 50% of the world's population. Prevalence may be as high as 83% in Latin American countries and as low as 17% in North America. Approximately 20% of infected people will manifest disease; people at high risk include those who live in low‐ and middle‐income countries with poor sanitary conditions, since the mechanism of transmission seems to be oral‐oral or faecal‐oral (mostly during infancy). There are several antibiotic regimens to treat the infection, but antibiotic resistance is growing around the world. New adjuvant drugs — such as probiotics, statins, curcumin, and N‐acetylcysteine (NAC) — are being tested to enhance eradication rates. N‐acetylcysteine can destabilise the biofilm structure; it also has synergic action with antibiotics, and bactericidal effects. In addition, NAC has antioxidant properties, and has a primary mucolytic effect by reducing the thickness of the gastric mucus layer, both of which may exert beneficial adjuvant effects on H pylori eradication. Objectives To assess the efficacy and safety of N‐acetylcysteine as an adjuvant therapy to antibiotics for Helicobacter pylori eradication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to April 2018), Embase (1988 to April 2018), CINAHL (1982 to April 2018), LILACS (1982 to April 2018), grey literature databases and trials registries. We handsearched the reference lists of relevant studies. We screened 726 articles and assessed 18 for eligibility. Selection criteria We included randomised controlled trials (RCTs) of any antibiotic regimen plus NAC, in adults infected with H pylori . To be included, trials had to use a control consisting of the same antibiotic regimen with or without placebo. Outcomes of interest were eradication rates, and gastrointestinal, toxic, and allergic adverse events. Reporting of the primary outcomes listed here was not an inclusion criterion for the review. Data collection and analysis Two review authors independently reviewed and extracted data and completed the 'Risk of bias' assessments. A third review author independently confirmed the 'Risk of bias' assessments. We used Review Manager 5 software for data analysis. We contacted study authors if there was missing information. Main results We included eight RCTs (with a total of 559 participants) in this review. The studies recruited outpatients aged between 17 and 76 years who were referred to endoscopy centres in several different countries. The certainty of evidence was reduced for most outcomes due to the poor methodological quality of included studies; issues mainly related to the generation of allocation sequence, allocation concealment, and blinding (this last domain related specifically to adverse outcomes). We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates, compared with the addition of placebo or no NAC (38.8% versus 49.1%, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.51 to 1.08; participants = 559; studies = eight; very low‐certainty evidence). A post‐hoc sensitivity analysis, in which we removed studies that tested antibiotic regimens no longer recommended in clinical practice, showed that the addition of NAC may improve eradication rates compared to control (27.2% versus 37.6%, RR 0.71, 95% CI 0.53 to 0.94; participants = 397; published studies = five). We are uncertain whether NAC is associated with a higher risk of gastrointestinal adverse events compared to control (23.9% versus 18.9%, RR 1.25, 95% CI 0.85 to 1.85; participants = 336; studies = five; very low‐certaintyevidence), or allergic adverse events (2% versus 0%, RR 2.98, 95% CI 0.32 to 27.74; participants = 336; studies = five; very low‐certainty evidence). There were no reports of toxic adverse events amongst included studies. Authors' conclusions We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates compared with the addition of placebo or no NAC. Due to the clinical, statistical and methodological heterogeneity found in included studies, and the uncertainty observed when analysing therapy subgroups, any possible beneficial effect of NAC should be regarded cautiously. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed, randomised clinical studies should be conducted, with good reporting standards and appropriate collection of efficacy and safety outcomes, especially for current recommended antibiotic regimens. Plain language summary N‐acetylcysteine taken with antibiotics for treatment of Helicobacter pylori infection Review question Is the addition of N‐acetylcysteine to antibiotics safe and does it improve cure rates for Helicobacter pylori infection? Background Helicobacter pylori ( H pylori ) is a bacteria that lives in the stomach and might cause several diseases such as gastric cancer, ulcer disease, and others. Colonisation occurs in about one‐half of the world's population and is more common in countries with poor sanitary conditions. People become infected by consuming contaminated water. The infection is treated using antibiotics and a drug which reduces acid production in the stomach. However, rates of antibiotic resistance are rising around the world, which is reducing the cure rates even with treatment. New medications are being tested to improve cure rates. One of these medications is N‐acetylcysteine (NAC). NAC is a drug that helps to dissolve mucus in respiratory diseases. It can be taken by mouth (orally) or injected into a vein (intravenous). NAC can destroy some mechanisms of survival of H pylori and could improve cure rates. Study characteristics We included eight studies (specifically, randomised controlled trials (RCTs)) with a total of 559 people aged between 17 and 76 years old. The evidence is current to April 2018. All studies recruited outpatients from endoscopy centres (centres that specialise in an examination done with a flexible tube with a camera that is inserted into stomach) in several countries. The antibiotic combinations tested were very different in the included studies, as were the doses of NAC (600 mg to 1800 mg per day). NAC was compared with placebo (dummy pill) or nothing. Key results We are uncertain whether the addition of NAC to antibiotics improves H pylori cure rates compared with the addition of placebo or no NAC. Any possible beneficial effect of NAC should be regarded cautiously because the included studies were very different and of low certainty, with some flaws that could have compromised their results and consequently, the results of this review. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed randomised clinical studies, with good reporting standards and appropriate collection of effectiveness and safety outcomes should be done, especially for current recommended antibiotic combinations. Quality of the evidence The overall certainty of the evidence for eradication rates ranged from very low to low. Five studies provided information on adverse events (side effects), and the certainy of evidence was very low. The included studies were poorly conducted and this reduced our confidence in the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fontes, LES, Martimbianco, ALC, Zanin, C, Riera, R", "articleTypes": [], "doi": "10.1002/14651858.CD012357.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.101Z" }, { "id": "42a030a0-6079-4b4d-967f-e9355cbd5ac1", "pmid": "", "title": "Triptans for acute cluster headache", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 ( Law 2010 ). Cluster headache is an uncommon, severely painful, and disabling condition, with rapid onset. Validated treatment options are limited; first‐line therapy includes inhaled oxygen. Other therapies such as intranasal lignocaine and ergotamine are not as commonly used and are less well studied. Triptans are successfully used to treat migraine attacks and they may also be useful for cluster headache. Objectives To assess the efficacy and tolerability of the triptan class of drugs compared to placebo and other active interventions in the acute treatment of episodic and chronic cluster headache in adult patients. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ClinicalTrials.gov, and reference lists for studies from inception to 22 January 2010 for the original review, and from 2009 to 4 April 2013 for this update. Selection criteria Randomised, double‐blind, placebo‐controlled studies of triptans for acute treatment of cluster headache episodes. Data collection and analysis Two review authors independently assessed study quality and extracted data. Numbers of participants with different levels of pain relief, requiring rescue medication, and experiencing adverse events and headache‐associated symptoms in treatment and control groups were used to calculate relative risk and numbers needed to treat for benefit (NNT) and harm (NNH). Main results New searches in 2013 did not identify any relevant new studies. All six included studies used a single dose of triptan to treat an attack of moderate to severe pain intensity. Subcutaneous sumatriptan was given to 131 participants at a 6 mg dose, and 88 at a 12 mg dose. Oral or intranasal zolmitriptan was given to 231 participants at a 5 mg dose, and 223 at a 10 mg dose. Placebo was given to 326 participants. Triptans were more effective than placebo for headache relief and pain‐free responses. By 15 minutes after treatment with subcutaneous sumatriptan 6 mg, 48% of participants were pain‐free and 75% had no pain or mild pain (17% and 32% respectively with placebo). NNTs for subcutaneous sumatriptan 6 mg were 3.3 (95% CI 2.4 to 5.0) and 2.4 (1.9 to 3.2) respectively. Intranasal zolmitriptan 10 mg was of less benefit, with 12% of participants pain‐free and 28% with no or mild pain (3% and 7% respectively with placebo). NNTs for intranasal zolmitriptan 10 mg were 11 (6.4 to 49) and 4.9 (3.3 to 9.2) respectively. Authors' conclusions Based on limited data, subcutaneous sumatriptan 6 mg was superior to intranasal zolmitriptan 5 mg or 10 mg for rapid (15 minute) responses, which are important in this condition. Oral routes of administration are not appropriate. Plain language summary Triptans for acute cluster headache Cluster headaches are excruciating headaches of extreme intensity. They can last for several hours, are usually on one side of the head only, and affect men more than women. Multiple headaches can occur over several days. Fast pain relief is important because of the intense nature of the pain with cluster headache. Triptans are a type of drug used to treat migraine. Although migraine is different from cluster headache, there are reasons to believe that some forms of these drugs could be useful in cluster headache. Triptans can be given by injection under the skin (subcutaneously) or by a spray into the nose (intranasally) to produce fast pain relief. The review found six studies examining two different triptans. The number of people in the studies was limited. Within 15 minutes of using subcutaneous sumatriptan 6 mg, almost 8 in 10 participants had no worse than mild pain, and 5 in 10 were pain‐free. Within 15 minutes of using intranasal zolmitriptan 5 mg, about 3 in 10 had no worse than mild pain, and 1 in 10 was pain‐free. Adverse events were more common with a triptan than with placebo but they were generally of mild to moderate severity. Cluster headache is an awful thing to have. More research on how to get better pain relief faster, and to more patients, would be welcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Law, S, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008042.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.767Z" }, { "id": "42adb67a-4138-406d-b50f-8cf26bdbfe72", "pmid": "", "title": "Taste Physiology in Healthy, Normal-weight Volunteers", "imported": false, "abstract": "Taste physiology describes five main taste qualities in humans: sweet, sour, salty, umami and bitter. The receptors found on the tongue are also found in the entire gut. The correlation of stimulation of these gut receptors and brain activity has not yet been examined. The objectives are to investigate the effect of different taste substances on i) regional brain activity and ii) satiation peptide release.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.232Z" }, { "id": "42cfa537-bb02-4629-80ef-18071ecee5e3", "pmid": "", "title": "Nicotine replacement therapy versus control for smoking cessation", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence. Objectives To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long‐term smoking cessation, compared to placebo or 'no NRT' interventions. Search methods We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017. Selection criteria Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow‐up of less than six months. We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews. Data collection and analysis Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow‐up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta‐analysis using a Mantel‐Haenszel fixed‐effect model. Main results We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non‐NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare. Authors' conclusions There is high‐quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non‐ischaemic chest pain and palpitations. Plain language summary Can nicotine replacement therapy (NRT) help people quit smoking? Background We reviewed the evidence about whether NRT helps people who want to quit smoking to stop smoking at six months or longer. NRT aims to reduce withdrawal symptoms associated with stopping smoking by replacing the nicotine from cigarettes. NRT is available as skin patches that deliver nicotine slowly, and chewing gum, nasal and oral sprays, inhalators, and lozenges/tablets, all of which deliver nicotine to the brain more quickly than skin patches, but less rapidly than from smoking cigarettes. Study characteristics This review includes 136 trials of NRT, with 64,640 people in the main analysis. All studies were conducted in people who wanted to quit smoking. Most studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. The evidence is current to July 2017. Trials lasted for at least six months. Key results We found evidence that all forms of NRT made it more likely that a person's attempt to quit smoking would succeed. The chances of stopping smoking were increased by 50% to 60%. NRT works with or without additional counselling, and does not need to be prescribed by a doctor. Side effects from using NRT are related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. There is no evidence that NRT increases the risk of heart attacks. Quality of evidence The overall quality of the evidence is high, meaning that further research is very unlikely to change our conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hartmann‐Boyce, J; Chepkin, SC; Ye, W; Bullen, C; Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD000146.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "42db6285-f368-4ae8-b22d-328c5693fe6b", "pmid": "", "title": "Misoprostol for intrauterine device placement", "imported": false, "abstract": "Abstract - Rationale Identifying effective approaches to reduce pain and improve providers' ease of intrauterine device (IUD) placement may reduce barriers to IUD access and use. The cervical softening and dilation effects of misoprostol might make IUD placement less painful for women and technically easier for providers. However, evidence suggests that misoprostol does not improve many outcomes and may only be helpful for some patients (e.g. those with a recent failed IUD placement). Objectives To examine the effect of misoprostol for routine IUD placement on patient and provider outcomes compared to placebo or no treatment. Search methods In November 2021 we searched CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ClinicalTrials.gov. We conducted update searches in July 2022 and September 2024. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in July 2025. Eligibility criteria We included randomized controlled trials (RCTs) of women undergoing interval IUD placement (i.e. placement outside the postabortion or postpartum period) that compared misoprostol to placebo or no treatment. We included trials that examined the placement of currently available levonorgestrel (LNG)‐releasing IUDs, or any copper T IUD, for women of any age, of any parity, and for any indication. Outcomes Our core critical and important outcomes were pain (during tenaculum placement, during IUD placement, and after IUD placement before clinic discharge); providers' ease of placement; need for cervical dilation; placement success; patient satisfaction; misoprostol side effects (preplacement abdominal pain or cramping, and diarrhea); and adverse events (vasovagal reaction). Risk of bias We used the Risk of Bias 2 tool (RoB 2) to assess the risk of bias for outcomes. Synthesis methods We synthesized results for each outcome using meta‐analysis. We calculated mean differences (MD) for continuous outcomes using inverse variance estimation and random‐effects models. We calculated risk ratios (RR) for dichotomous outcomes using Mantel‐Haenszel estimation and random‐effects models. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included 14 RCTs with a total of 1972 women. The trials were conducted in North America, South America, Europe and Africa, and were published between 2007 and 2022. Synthesis of results The results below summarize the effect of misoprostol on outcomes compared to placebo or no treatment. Pain: misoprostol results in little to no difference in pain during tenaculum placement (MD −0.73, 95% confidence interval [CI] −1.19 to −0.28; 3 RCTs, 261 women; high‐certainty evidence) and after IUD placement before clinic discharge (MD −0.01, 95% CI −0.45 to 0.43; 5 RCTs, 448 women; high‐certainty evidence). Misoprostol may result in little to no difference in pain during IUD placement (MD −0.47, 95% CI −1.23 to 0.29; 7 RCTs, 766 women; low‐certainty evidence). Providers' ease of placement: misoprostol may result in little to no difference in a clinically meaningful effect on ease of IUD placement for providers (MD −0.89, 95% CI −1.55 to −0.22; 8 RCTs, 848 women; low‐certainty evidence). Need for cervical dilation: misoprostol may result in little to no difference in need for cervical dilation for women without a recent failed placement attempt (RR 0.84, 95% CI 0.38 to 1.85; 6 RCTs, 562 women; low‐certainty evidence). Misoprostol probably results in little to no difference in need for cervical dilation for women with a recent failed placement attempt (RR 0.88, 95% CI 0.56 to 1.36; 1 RCT, 90 women; moderate‐certainty evidence). Placement success: misoprostol probably results in little to no difference in placement success for women without a recent failed placement attempt (RR 1.01, 95% CI 0.98 to 1.04; 12 RCTs, 1579 women; moderate‐certainty evidence) but probably results in a slight increase in placement success for women with a recent failed placement attempt (RR 1.41, 95% CI 1.09 to 1.83; 1 RCT, 90 women; moderate‐certainty evidence). Patient satisfaction: misoprostol may increase women's satisfaction with the IUD placement procedure, but the evidence is very uncertain (MD 2.00, 95% CI −0.05 to 4.06; 2 RCTs, 226 women; very low‐certainty evidence) Misoprostol side effects before clinic discharge: misoprostol probably results in an increase in preplacement abdominal pain or cramping (RR 2.14, 95% CI 1.42 to 3.23; 7 RCTs, 781 women; moderate‐certainty evidence)and probably results in a slight increase in diarrhea (RR 1.76, 95% CI 1.01 to 3.06; 9 RCTs, 940 women; moderate‐certainty evidence). Adverse events before clinic discharge: misoprostol may result in little to no difference in vasovagal reaction (RR 0.94, 95% CI 0.37 to 2.37; 6 RCTs [3 RCTs had 0 events], 780 women; low‐certainty evidence). We downgraded the evidence due to serious concerns about inconsistency and serious or very serious concerns about imprecision. Authors' conclusions Evidence from RCTs of women seeking routine IUD placement suggests that receiving misoprostol compared to placebo or no treatment makes little to no difference to pain during tenaculum placement or after IUD placement; and may make little to no difference to pain during IUD placement. Misoprostol may make little to no difference to reduced vasovagal reaction, improved providers' ease of placement, or reduced need for cervical dilation; and probably makes little to no difference to placement success, except for women with a recent failed IUD placement attempt, where misoprostol probably leads to a clinically meaningful increase in placement success. Misoprostol use probably leads to clinically important increases in harms, specifically preplacement abdominal pain or cramping and diarrhea. Misoprostol may increase patient satisfaction with the IUD placement procedure, but the evidence is very uncertain. The number of available RCTs did not support examining effect modifiers such as prior vaginal delivery status, misoprostol dose, or IUD type. Funding This review was supported in part by an appointment to the Research Participation Program at the Centers for Disease Control and Prevention (CDC) administered by the Oak Ridge Institute for Science and Education. Registration Protocol (2022): doi.org/10.1002/14651858.CD015584 Plain language summary Is misoprostol an effective treatment for routine intrauterine device (IUD) placement and does it cause unwanted effects? Key messages Using misoprostol (a medication that softens and widens the cervix ‐ the neck of the womb) before placing an intrauterine device (IUD ‐ a contraceptive device placed inside the womb) makes little to no difference to pain when a tool (a tenaculum) is used to hold the cervix in place during IUD placement or pain after IUD placement. It may make little to no difference to pain during placement, ease of placement for providers, or need for cervical widening; and probably makes little to no difference to placement success, except for women who recently tried unsuccessfully to have an IUD placed. Misoprostol‐related unwanted effects like stomach cramps and diarrhea probably increase, but it may make little to no difference to other unwanted events. We don't know whether misoprostol use affects women's satisfaction with the procedure. What is an intrauterine device? An intrauterine device (IUD) is a small t‐shaped device inserted through the cervix (the neck of the womb) into the womb to prevent pregnancy. IUDs need to be placed by a trained doctor, nurse, or healthcare provider. IUD placement may be a painful procedure, and it may be more difficult for women who have not had a baby or who have already tried unsuccessfully to have an IUD placed. Serious unwanted events are rare with IUD placement but women may experience non‐serious unwanted effects similar to period pain (cramps) or light bleeding. What is misoprostol? Misoprostol is a medication that is commonly used to start labor and to treat bleeding following birth. It causes the cervix to soften and widen, and so might make IUD placement less painful for women and easier for providers. Misoprostol may cause some unwanted effects like cramps, sickness or diarrhea. Sometimes women may feel dizzy, sweaty or light‐headed. An IUD is an effective and reversible contraceptive method, so identifying ways to reduce pain and improve ease of placement for providers may reduce barriers to IUD access and use. What did we want to find out? We wanted to find out if misoprostol reduces pain, makes IUD placement easier for providers, reduces the need for other methods to widen the cervix, improves placement success and women's satisfaction with the procedure, and whether it causes unwanted effects. What did we do? We searched for studies that examined misoprostol for routine IUD placement compared to placebo (a sham medication) or no treatment. We combined and analyzed the studies' results and rated our confidence in the evidence, based on factors such as study methods. What did we find? We found 14 RCTs with 1972 women. The studies took place in North America, South America, Europe, and Africa. All the studies compared misoprostol with placebo or no treatment. Main results Pain. Misoprostol: results in little to no difference in pain during tenaculum placement (a tenaculum is a tool that holds the cervix in place during IUD placement) (3 studies, 261 women); may result in little to no difference in pain during IUD placement (7 studies, 766 women); results in little to no difference in pain after IUD placement before leaving the clinic (5 studies, 448 women). Providers' ease of placing the IUD Misoprostol may result in little to no difference in ease of IUD placement for providers (8 studies, 848 women). Need for cervical dilation. Misoprostol: may result in little to no difference in the need for cervical widening for women without a recent failed placement attempt (6 studies, 562 women); probably results in little to no difference in the need for cervical widening for women with a recent failed placement attempt (1 study, 90 women). Placement success. Misoprostol: probably results in little to no difference in placement success for women without a recent failed placement attempt (12 studies, 1579 women); probably results in a slight increase in placement success for women with a recent failed placement attempt (1 study, 90 women). Patient satisfaction We are not sure whether misoprostol increases patient satisfaction with the IUD placement procedure (2 studies, 226 women). Unwanted effects. Misoprostol: probably results in an increase in stomach cramps (7 studies, 781 women); probably results in a slight increase in diarrhea (9 studies, 940 women); may result in little to no difference in dizziness or light‐headedness (6 studies, 780 women). What are the limitations of the evidence? Some studies did not report key information about what we wanted to know, and some studies were different from each other, so we couldn't include them in our analyses. We had planned to examine whether certain factors affected the results, such as whether women had previously given birth vaginally, the dose of misoprostol used, or the type of IUD placed, but there were not enough studies to do this in a meaningful way. How up to date is this evidence? The evidence is up to date to 23 September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Zapata, LB; Snyder, E; Nguyen, AT; Kapp, N; Ti, A; Whiteman, MK; Curtis, KM", "articleTypes": [], "doi": "10.1002/14651858.CD015584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "42e8a570-923e-4612-ac86-0a9ccdf69cb3", "pmid": "", "title": "A Placebo-Controlled, Randomized, Double-Blind Study to Assess the Safety, Tolerability and Efficacy of Folinic Acid Administered to Pediatric Subjects With Autism Spectrum Disorder (ASD)", "imported": false, "abstract": "Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by difficulties in social communication and the presence of restricted or repetitive behaviors. Although behavioral and educational interventions can be helpful, there is currently no established medication for the core symptoms of ASD. Medications approved for associated irritability may be effective in some children but are often associated with significant adverse effects.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.246Z" }, { "id": "42fe0ac0-9073-4c29-b504-fedfdbae2538", "pmid": "", "title": "Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries", "imported": false, "abstract": "Abstract - Background Protein Energy Malnutrition is an important cause of child morbidity and mortality in middle‐ and low‐income countries. It has been suggested that excessive free radical activity may be responsible for the clinical manifestation of kwashiorkor. Antioxidants may be able to curb excessive free radical activity and prevent the development of kwashiorkor in susceptible children. Objectives To evaluate the benefits of supplementation of vitamin E, selenium, cysteine and riboflavin (alone or in combination) in preventing kwashiorkor. Search methods We conducted searches of CENTRAL 2009 ( The Cochrane Library 2009 Issue 2), MEDLINE 1966 to 2009, EMBASE 1980 to 2009, CINAHL 1982 to 2009, LILACS 1982 to 2009, Meta register of Controlled trials, Open Sigle, African Index Medicus. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating vitamin E, selenium, cysteine and riboflavin alone or in combination in healthy pre‐school children in middle‐ and low‐income countries. Data collection and analysis Two authors extracted and independently analysed data. Main results One cluster‐RCT including 2372 children met our inclusion criteria. Children were randomised, based on household, either to a supplement containing all four micronutrients or to placebo. No statistically significant difference in the incidence of kwashiorkor between the intervention and control groups could be demonstrated at 20 weeks (RR 1.70; 95% CI 0.98 to 2.42). Nor could any statistically significant difference in all‐cause mortality be demonstrated (RR 0.75; 95% CI 0.17 to 3.36). Authors' conclusions Based on the one available trial, we could draw no firm conclusion for the effectiveness of supplementary antioxidant micronutrients for the prevention of kwashiorkor in pre‐school children. Plain language summary Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries Undernutrition is one of the leading underlying causes of childhood morbidity and mortality in developing countries. Providing antioxidants that would help curb excess free radicals in the body may help prevent the development of kwashiorkor. We identified one cluster‐RCT that attempted to investigate this. Based on the published evidence reviewed, we could draw no firm conclusions of the benefits of supplementary antioxidants for the prevention of kwashiorkor in pre‐school children. There is a need for further research in this area to be certain if antioxidant supplementation can help prevent kwashiorkor in young children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Odigwe, CC; Smedslund, G; Ejemot‐Nwadiaro, RI; Anyanechi, CC; Krawinkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD008147.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "4304d405-4232-492a-a3df-2e387b023052", "pmid": "", "title": "Non‐immunosuppressive treatment for IgA nephropathy", "imported": false, "abstract": "Abstract - Background IgA nephropathy (IgAN) is the most common primary glomerular disease, with approximately 20% to 40% of patients progressing to kidney failure within 25 years. Non‐immunosuppressive treatment has become a mainstay in the management of IgAN by improving blood pressure (BP) management, decreasing proteinuria, and avoiding the risks of long‐term immunosuppressive management. Due to the slowly progressive nature of the disease, clinical trials are often underpowered, and conflicting information about management with non‐immunosuppressive treatment is common. This is an update of a Cochrane review, first published in 2011. Objectives To assess the benefits and harms of non‐immunosuppressive treatment for treating IgAN in adults and children. We aimed to examine all non‐immunosuppressive therapies (e.g. anticoagulants, antihypertensives, dietary restriction and supplementation, tonsillectomy, and herbal medicines) in the management of IgAN. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to December 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs of non‐immunosuppressive agents in adults and children with biopsy‐proven IgAN were included. Data collection and analysis Two authors independently reviewed search results, extracted data and assessed study quality. Results were expressed as mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI) using random‐effects meta‐analysis. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results This review includes 80 studies (4856 participants), of which 24 new studies (2018 participants) were included in this review update. The risk of bias within the included studies was mostly high or unclear for many of the assessed methodological domains, with poor reporting of important key clinical trial methods in most studies. Antihypertensive therapies were the most examined non‐immunosuppressive therapy (37 studies, 1799 participants). Compared to placebo or no treatment, renin‐angiotensin system (RAS) inhibition probably decreases proteinuria (3 studies, 199 participants: MD ‐ 0.71 g/24 h, 95% CI ‐1.04 to ‐0.39; moderate certainty evidence) but may result in little or no difference to kidney failure or doubling of serum creatinine (SCr), or complete remission of proteinuria (low certainty evidence). Death, remission of haematuria, relapse of proteinuria or > 50% increase in SCr were not reported. Compared to symptomatic treatment, RAS inhibition (3 studies, 168 participants) probably decreases proteinuria (MD ‐1.16 g/24 h, 95% CI ‐1.52 to ‐0.81) and SCr (MD ‐9.37 µmol/L, 95% CI ‐71.95 to ‐6.80) and probably increases creatinine clearance (2 studies, 127 participants: MD 23.26 mL/min, 95% CI 10.40 to 36.12) (all moderate certainty evidence); however, the risk of kidney failure is uncertain (1 study, 34 participants: RR 0.20, 95% CI 0.01 to 3.88; very low certainty evidence). Death, remission of proteinuria or haematuria, or relapse of proteinuria were not reported. The risk of adverse events may be no different with RAS inhibition compared to either placebo or symptomatic treatment (low certainty evidence). In low certainty evidence, tonsillectomy in people with IgAN in addition to standard care may increase remission of proteinuria compared to standard care alone (2 studies, 143 participants: RR 1.90, 95% CI 1.45 to 2.47) and remission of microscopic haematuria (2 studies, 143 participants: RR 1.93, 95% CI 1.47 to 2.53) and may decrease relapse of proteinuria (1 study, 73 participants: RR 0.70, 95% CI 0.57 to 0.85) and relapse of haematuria (1 study, 72 participants: RR 0.70, 95% CI 0.51 to 0.98). Death, kidney failure and a > 50% increase in SCr were not reported. These trials have only been conducted in Japanese people with IgAN, and the findings' generalisability is unclear. Anticoagulant therapy, fish oil, and traditional Chinese medicines exhibited small benefits to kidney function in patients with IgAN when compared to placebo or no treatment. However, compared to standard care, the kidney function benefits are no longer evident. Antimalarial therapy compared to placebo in one study reported an increase in a > 50% reduction of proteinuria (53 participants: RR 3.13 g/24 h, 95% CI 1.17 to 8.36; low certainty evidence). Although, there was uncertainty regarding adverse events from this study due to very few events. Authors' conclusions Available RCTs focused on a diverse range of interventions. They were few, small, and of insufficient duration to determine potential long‐term benefits on important kidney and cardiovascular outcomes and harms of treatment. Antihypertensive agents appear to be the most beneficial non‐immunosuppressive intervention for IgAN. The antihypertensives examined were predominantly angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers. The benefits of RAS inhibition appear to outweigh the harms in patients with IgAN. The certainty of the evidence of RCTs demonstrating a benefit of tonsillectomy to patients with Japanese patients with IgAN was low. In addition, these findings are inconsistent across observational studies in people with IgAN of other ethnicities; hence, tonsillectomy is not widely recommended, given the potential harm of therapy. The RCT evidence is insufficiently robust to demonstrate efficacy for the other non‐immunosuppressive treatments evaluated here. Plain language summary Non‐immunosuppressive treatment for IgA nephropathy Key messages Treatment with renin‐angiotensin system (RAS) inhibition, namely angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, is the most common first‐line, non‐immunosuppressive therapy used for managing patients with IgA nephropathy (IgAN). The role of other non‐immunosuppressive treatments in managing IgAN is unclear and warrants further clinical studies. Why treat IgA nephropathy with non‐immunosuppressive therapies? IgAN is one of the most common kidney diseases, leading to reduced kidney function and kidney failure for about 20% to 40% of patients within 20 to 25 years. The cause of IgAN is not widely understood, but most people have an abnormality in their immune system that leads to damage to the kidney. However, other non‐immune functions play a role in the disease's impact on the kidney. What did we want to find out? We wanted to find out if non‐immunosuppressive treatments (e.g. antihypertensive agents, anticoagulants, fish oil, tonsillectomy, herbal medicine) improved kidney function in adults and children with IgAN. What did we do? We searched for all trials that assessed the benefits and harms of randomly allocated non‐immunosuppressive treatment in people with IgAN. We compared and summarised the results of the trials and rated our confidence in the information based on factors such as trial methods and sizes. What did we find? We included 80 studies involving 4856 people with IgAN treated with a diverse collection of non‐immunosuppressive treatments. Patients in studies were given various therapies, including blood pressure lowering agents (antihypertensives), removal of participant's tonsils (tonsillectomy), antimalarials, traditional Chinese medicine, dietary supplements (e.g. fish oil), and vitamin D receptor agonists. Antihypertensive medication aimed at inhibiting the RAS appears to slow damage to the kidney with minimal side effects. However, its impact in preventing people from progressing to kidney failure is unclear. Other interventions, such as tonsillectomy, antimalarial medication, and low‐calorie restricted diets role in treating patients are still unclear. What are the limitations of the evidence? The small number of studies per comparison and the small size of the studies were limitations in this review. Not all the studies provided data about the outcomes we were interested in. We are unsure about the results. How up to date is the evidence? The evidence is up to date as of December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Tunnicliffe, DJ; Reid, S; Craig, JC; Samuels, JA; Molony, DA; Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD003962.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "430fd80a-25c3-4d31-9744-fb80dd6a9e36", "pmid": "", "title": "Interventions for the eradication of meticillin‐resistant Staphylococcus aureus (MRSA) in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a genetic disorder characterised by recurrent and persistent pulmonary infections from resistant organisms, resulting in deterioration of lung function and early mortality. Meticillin‐resistant Staphylococcus aureus (MRSA) is an important infection in hospital patients and harmful to people with CF (pwCF). Chronic pulmonary MRSA infection may confer a worse clinical outcome on pwCF and result in a faster decline in lung function. Robust evidence clearly guiding MRSA eradication in CF is urgently needed. This is an updated review. Objectives To evaluate the effectiveness of antibiotic treatment designed to eradicate MRSA, to determine whether eradication confers better clinical and microbiological outcomes for pwCF, and to ascertain whether attempts at eradicating MRSA lead to increased acquisition of other resistant organisms (including Pseudomonas aeruginosa ), increased adverse effects from drugs, or both. Search methods We searched the Cochrane CF's Trials Register, PubMed, MEDLINE and three trials registries; handsearched article reference lists; and contacted experts in the field. We last searched Cochrane CF's Trials Register and the trials registries on 28 April 2026. Eligibility criteria Randomised controlled trials (RCTs) or quasi‐RCTs of any combination of topical, inhaled, oral or intravenous antibiotics for treating MRSA compared with placebo, standard treatment or no treatment in pwCF, regardless of age or disease severity. Outcomes We planned to assess these outcomes at up to 12 months following therapy: eradication of MRSA from respiratory cultures, time until next positive MRSA isolate, quality of life (QoL), change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted, change in weight (kg), frequency of pulmonary exacerbations and adverse effects of treatment. Risk of bias Using the original Cochrane risk of bias tool, we assessed individual domains and produced an overall risk of bias for each trial. Synthesis methods We followed Cochrane's standard methodology, conducting fixed‐effect meta‐analyses or reporting narratively. We assessed evidence certainty using GRADE. Included studies We included five RCTs (410 participants). Synthesis of results Oral antibiotics versus no treatment Two trials (106 participants) compared observation to oral trimethoprim plus sulfamethoxazole combined with rifampicin; in one trial for two weeks alongside topical decontamination and a three‐week environmental decontamination, and in a second for 21 days alongside intranasal mupirocin (five days); 29 participants withdrew from the second trial by the end of follow‐up. Oral antibiotics have little or no effect on any outcome reported below, in contrast to one study (45 participants) which was terminated early due to results clearly favouring treatment. In one trial defining eradication as negative MRSA respiratory cultures at day 28 and remaining so at day 168 (45 participants), treatment may result in more negative cultures than observation (odds ratio (OR) 12.6 (95% confidence interval (CI) 2.84 to 55.84; low‐certainty). There may be little to no difference between groups by day 168 of follow‐up (OR 1.17, 95% CI 0.31 to 4.42), and also in one trial defining successful eradication as no MRSA in at least three cultures over six months follow‐up (OR 2.74, 95% CI 0.64 to 11.75; low‐certainty). Treatment may result in an increase in FEV 1 % predicted from baseline (MD 5.67%, 95% CI 1.43 to 9.90; 2 trials, 58 participants; low‐certainty evidence). There may be little to no differences between groups in QoL, frequency of pulmonary exacerbations (although one study reported a lower hospitalisation rate through day 168 with treatment (P = 0.01)), adverse effects, or weight (all low‐certainty evidence). Nebulised antibiotics versus placebo Two trials (275 participants randomised, 251 analysed) compared a standard dose of vancomycin (one trial additionally compared a high dose) to placebo. The multi‐arm trial reported a decrease in MRSA colony forming units (CFUs) at each time point, up to one month. There were no differences in most lung function results in either trial, but treatment probably increased FEV 1 % predicted at 20 weeks (MD 3.55%, 95% CI 0.33 to 6.77; P = 0.03; 1 trial, 133 participants; moderate‐certainty evidence). This trial also reported no difference in pulmonary exacerbation frequency, while the multi‐arm trial reported a longer time to the next exacerbation with the lower vancomycin dose (no placebo data available). Evidence from both trials suggests that nebulised antibiotics may make little or no difference in QoL (high to low‐certainty), or frequency of adverse outcomes or of exacerbations (low‐to‐moderate‐certainty evidence). Oral antibiotics plus nebulised antibiotics (vancomycin) versus oral antibiotics plus placebo One trial (29 participants randomised, 25 participants analysed) compared combination antibiotic treatment (inhaled plus oral) to oral antibiotics plus inhaled placebo, defining eradication as a negative MRSA respiratory sample at one month following treatment. Combination antibiotic treatment may result in little or no difference in MRSA eradication at three months (OR 1.63, 95% CI 0.19 to 13.93; low‐certainty evidence), lung function (no data available for analysis) or adverse effects (low‐certainty evidence), in QoL (very low‐certainty evidence) or nasal colonisation with MRSA. Authors' conclusions Early eradication of MRSA is possible in pwCF; evidence from one trial suggested active MRSA treatment may result in a higher proportion of MRSA‐negative respiratory cultures after one month compared with observation. However, longer follow‐up showed treatment may make little or no difference in the proportion of participants remaining MRSA‐negative. One trial of nebulised antibiotics alone compared to placebo reported a decrease in MRSA CFUs with a higher antibiotic dose. The longer‐term clinical consequences of any treatment option – in terms of lung function, mortality and cost of care – remain unclear. We judged the evidence to range from high to very low‐certainty, due to potential biases from trial design, high attrition rates and small sample sizes. While early eradication of respiratory MRSA in pwCF may be possible, the currently available evidence does not demonstrate that routine treatment of respiratory MRSA in pwCF is effective. Research is needed to assess MRSA infection and treatment in the age of modulator therapies. Funding The 2025 update was undertaken as part of Cochrane CF funding from the UK CF Trust and the CF Foundation. Registration Protocol (2012) DOI: 10.1002/14651858.CD009650. Original review (2013) DOI: 10.1002/14651858.CD009650.pub2. Review updates: (2015) DOI: 10.1002/14651858.CD009650.pub3; (2018) DOI: 10.1002/14651858.CD123456.pub4; (2022) DOI: 10.1002/14651858.CD009650.pub5. Plain language summary Can treatment with antibiotics clear the 'superbug' MRSA from the lungs of people with cystic fibrosis? Key messages Early treatment of meticillin‐resistant Staphylococcus aureus (MRSA) (a type of bacteria which are resistant to some antibiotics) infection in people with cystic fibrosis (CF) seems possible, but we are unsure about the effectiveness of current routine treatment. Longer‐term implications of treatment are not clear. Research is needed to assess MRSA infection and treatment in the age of cystic fibrosis transmembrane conductance regulator (CFTR) modulators (drugs that fix the broken protein made by the CF gene so salt and water can move correctly across cells and help move mucus from the lungs). What is cystic fibrosis (CF)? CF is an inherited condition which causes thick mucus to build up in the lungs and other organs. It is very difficult for people with CF to cough up this thick mucus, making it an ideal breeding ground for germs (including MRSA), and making them more prone to chest infections. CF worsens over time. Although there is currently no cure, many people with CF can lead active and full lives. What is MRSA and how is it treated? MRSA (meticillin‐resistant Staphyloccocus aureus) are bacteria which cause infection that is treated with antibiotics. However, MRSA are resistant to some types of antibiotics, making the infection hard to treat. They are sometimes called 'superbugs' and infection with MRSA is particularly worrying for people with CF, as it is thought that MRSA can cause more damage than other bacteria which are not resistant to antibiotics. MRSA is usually treated with a combination of antibiotics, taken orally (by mouth) or inhaled, alongside decontamination treatment (antibiotic creams applied to the skin and nasal cavities). What did we want to find out? We wanted to know whether treatment with antibiotics: can get rid of MRSA infection in the lungs of children or adults with CF; does not cause infection with other resistant bacteria; does not cause unwanted effects. What did we do? We looked for studies that investigated antibiotics (oral or inhaled) to treat MRSA infections in people with CF. Studies had to compare antibiotic treatment with either no treatment, placebo (sham treatment) or other type of antibiotics. People had to have CF and current infection with MRSA. What did we find? We found five studies which recruited 410 people with CF and a diagnosed MRSA infection. Studies took place in Italy or North America and lasted from eight weeks to six months. People in the studies (equal numbers of males and females) were young (average age ranged from 11 to 25 years). Oral antibiotics compared to no treatment (2 studies, 106 people) One group of people with CF were treated with oral antibiotics (trimethoprim, sulfamethoxazole and rifampicin or co‐trimoxazole and rifampicin), plus decontamination treatment; the other group received no treatment. Oral antibiotics may clear MRSA. One trial stopped early due to clear benefits of antibiotics, but some people cleared the infection with no treatment. In six months, there was no difference between groups in the number of people who still had MRSA. Antibiotics may increase lung function. There may be little to no difference between groups in quality of life, frequency of flare‐ups of the disease (although one study reported fewer people taking antibiotics were admitted to hospital in the first six months), unwanted effects of treatment, or changes in weight. Inhaled antibiotics compared to placebo (2 studies, 251 people) Both studies compared a standard dose of vancomycin (an inhaled antibiotic) to placebo (a dummy drug) and one study also compared a standard dose of vancomycin to a high dose. Inhaled antibiotics probably make no difference to lung function compared to placebo (2 studies), but results from one study indicated that inhaled antibiotics probably lead to a small increase after 20 weeks. A standard dose of vancomycin probably makes no difference to the frequency of flare‐ups compared to placebo (2 studies); One study reported a longer time to the next flare‐up with the lower dose of vancomycin; One study reported a decrease in MRSA bacteria levels with a higher dose of vancomycin for up to one month; Neither study reported any differences in quality of life or unwanted effects. Oral plus inhaled antibiotics compared to oral antibiotics plus placebo (1 study, 25 people) One study compared a combination of oral plus inhaled antibiotics to inhaled antibiotics plus placebo. We are uncertain if either treatment made any difference to MRSA clearance; There may be few or no differences between groups in lung function, quality of life or unwanted effects; The study did not report changes in weight or frequency of flare‐ups. What are the limitations of the evidence? Our confidence in the results ranged from high to very low. This was due to potential issues with the trial designs (people knew which treatment they were receiving), or because there were small numbers of people in each trial and many of them dropped out. How up to date is this evidence? This review updates our previous review published in 2022. The evidence is current to 28 April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lo, DKH; Jahnke, N; Smith, S; Muhlebach, MS; Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD009650.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "4322650a-a8a8-4c75-b8be-dc0a74bac118", "pmid": "", "title": "The Effect of Lactobacillus Reuteri ATCC PTA 6475 on Volumetric Bone Mineral Density in Patients With Osteopenia", "imported": false, "abstract": "Lactobacillus reuteri (L. reuteri) has been widely studied in clinical trials and has probiotic, health-promoting effects in both adults and children, and is safe for human consumption. Animal models indicate that treatment with L. reuteri has positive effects on bone metabolism and bone density. In other animal models of diabetes and the metabolic syndrome, positive effects on blood glucose and weight have been reported. The present double-blind, placebo-controlled, randomized study is designed to investigate if dietary supplementation with L. reuteri twice daily for 12 months has any effect on bone density, body composition, inflammation, or metabolic and endocrine markers in elderly women with osteopenia.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.261Z" }, { "id": "432da62a-8428-454b-a7be-a62b750690d3", "pmid": "", "title": "Supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults", "imported": false, "abstract": "Abstract - Background Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy. Objectives To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults. Search methods We identified publications from comprehensive searches of the Cochrane Library , MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016. Selection criteria Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care. Data collection and analysis Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta‐analyses for the outcome measures, 'all‐cause mortality', 'hospitalisation' and 'nutritional status (weight change)'. Main results Forty‐one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow‐up ranged from ‘duration of hospital stay’ to 12 months. The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all‐cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate‐quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low‐quality evidence). Only five trials (4451 participants) investigated health‐related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of ‐0.5 days (95% CI ‐2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low‐quality evidence. Only three of 41 included trials (4108 participants; very low‐quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta‐analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate‐quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low‐quality evidence). Authors' conclusions There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all‐cause mortality for supportive interventions comes from hospital‐based trials and more research is needed to confirm this effect. There is very low‐quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient‐important outcomes in future research. Plain language summary Supportive interventions for improving dietary intake in nutritionally vulnerable groups Review question Are supportive interventions for improving dietary intake in nutritionally vulnerable groups (malnourished or nutritionally at‐risk individuals) effective? Background Serving meals in a dining room, or the use of assistance to help feed people in need and other similar methods are often recommended to help especially sick and elderly people who have lost or are likely to lose weight (nutritionally vulnerable groups). Such supportive interventions are implemented in the health care in many countries but their effects are not well investigated. Study characteristics We included 41 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 10,681 people in our review. There were five different interventions which we call 'supportive interventions': changes to the organisation of nutritional care (13 studies, 3456 people), changes to the feeding environment (5 studies, 351 people), modification of the meal profile or pattern (12 studies, 649 people), additional supplementation of meals (10 studies, 6022 people) and home meal delivery systems (1 study, 203 people). Monitoring participants over time (follow‐up) ranged from ‘duration of hospital stay’ to 12 months. The comparator groups received 'usual' care. More than half of all participants took part in studies investigating the additional supplementation of meals (for example a protein‐energy oral nutritional supplement in addition to the usual diet). Key results It is possible that supportive interventions for enhancing dietary intake in nutritionally vulnerable groups reduce death from any cause (approximately 23 fewer cases of death per 1000 participants in favour of supportive interventions). However, this has to be confirmed by more evidence from high‐quality randomised controlled studies. The number of participants experiencing any medical complication did not differ substantially between the supportive interventions and the comparator groups. The same was found for health‐related quality of life (which is physical, mental, emotional and social health attributed to health), patient satisfaction, nutritional or energy intake and days spent in hospital. Economic costs were not well investigated. Only three studies reported on side effects, describing intolerance to the nutritional supplement (such as diarrhoea or vomiting in 5 of 34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567 of 2017 participants). After analysing 15 studies in 1945 participants we found a beneficial effect of supportive interventions compared with comparators on weight: on average people in the supportive interventions groups increased their weight 0.6 kg more than people in the comparator groups. This evidence is up to date as of September 2016. Quality of evidence The overall quality of evidence ranged between moderate to very low, mainly because for most of our outcomes there was only a small number of studies and participants to achieve reliable information, or because risk of bias made results uncertain. However, if some randomised controlled studies with low risk of bias for our patient‐important outcomes and a good number of participants were performed, this review could quickly provide good guidance for better health care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Baldwin, C; Kimber, KL; Gibbs, M; Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD009840.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "435abf48-bfc1-46fa-9704-2d06221fb0b0", "pmid": "", "title": "Triclosan/copolymer containing toothpastes for oral health", "imported": false, "abstract": "Abstract - Background Periodontal disease and dental caries are highly prevalent oral diseases that can lead to pain and discomfort, oral hygiene and aesthetic problems, and eventually tooth loss, all of which can be costly to treat and are a burden to healthcare systems. Triclosan is an antibacterial agent with low toxicity, which, along with a copolymer for aiding retention, can be added to toothpastes to reduce plaque and gingivitis (inflammation of the gums). It is important that these additional ingredients do not interfere with the anticaries effect of the fluoride present in toothpastes, and that they are safe. Objectives To assess the effects of triclosan/copolymer containing fluoride toothpastes, compared with fluoride toothpastes, for the long‐term control of caries, plaque and gingivitis in children and adults. Search methods We searched the Cochrane Oral Health's Trials Register (to 19 August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 7), MEDLINE via OVID (1946 to 19 August 2013), Embase via OVID (1980 to 19 August 2013), and the US National Institutes of Health Trials Register ( clinicaltrials.gov ) (to 19 August 2013). We applied no restrictions regarding language or date of publication in the searches of the electronic databases. Selection criteria We included randomised controlled trials (RCTs) assessing the effects triclosan/copolymer containing toothpastes on oral health. Data collection and analysis Two review authors independently assessed the search results against the inclusion criteria for this review, extracted data and carried out risk of bias assessments. We attempted to contact study authors for missing information or clarification when feasible. We combined sufficiently similar studies in meta‐analyses using random‐effects models when there were at least four studies (fixed‐effect models when fewer than four studies), reporting mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data. Main results We included 30 studies, analysing 14,835 participants, in this review. We assessed 10 studies (33%) as at low risk of bias, nine (30%) as at high risk of bias and 11 (37%) as unclear. Plaque Compared with control, after six to seven months of use, triclosan/copolymer toothpaste reduced plaque by 0.47 on a 0 to 5 scale (MD ‐0.47, 95% confidence interval (CI) ‐0.60 to ‐0.34, 20 studies, 2675 participants, moderate‐quality evidence). The control group mean was 2.17, representing a 22% reduction in plaque. After six to seven months of use, it also reduced the proportion of sites scoring 3 to 5 on a 0 to 5 scale by 0.15 (MD ‐0.15, 95% CI ‐0.20 to ‐0.10, 13 studies, 1850 participants, moderate‐quality evidence). The control group mean was 0.37, representing a 41% reduction in plaque severity. Gingivitis After six to nine months of use, triclosan/copolymer toothpaste reduced inflammation by 0.27 on a 0 to 3 scale (MD ‐0.27, 95% CI ‐0.33 to ‐0.21, 20 studies, 2743 participants, moderate‐quality evidence). The control group mean was 1.22, representing a 22% reduction in inflammation. After six to seven months of use, it reduced the proportion of bleeding sites (i.e. scoring 2 or 3 on the 0 to 3 scale) by 0.13 (MD ‐0.13, 95% CI ‐0.17 to ‐0.08, 15 studies, 1998 participants, moderate‐quality evidence). The control group mean was 0.27, representing a 48% reduction in bleeding. Periodontitis After 36 months of use, there was no evidence of a difference between triclosan/copolymer toothpaste and control in the development of periodontitis (attachment loss) (RR 0.92, 95% CI 0.67 to 1.27, one study, 480 participants, low‐quality evidence). Caries After 24 to 36 months of use, triclosan/copolymer toothpaste slightly reduced coronal caries when using the decayed and filled surfaces (DFS) index (MD ‐0.16, 95% CI ‐0.31 to ‐0.02, four studies, 9692 participants, high‐quality evidence). The control group mean was 3.44, representing a 5% reduction in coronal caries. After 36 months of use, triclosan/copolymer toothpaste probably reduced root caries (MD ‐0.31, 95% CI ‐0.39 to ‐0.23, one study, 1357 participants, moderate‐quality evidence). Calculus After six months of use, triclosan/copolymer toothpaste may have reduced the mean total calculus per participant by 2.12 mm (MD ‐2.12 mm, 95% CI ‐3.39 to ‐0.84, two studies, 415 participants, low‐quality evidence). The control group mean was 14.61 mm, representing a 15% reduction in calculus. Adverse effects There were no data available for meta‐analysis regarding adverse effects, but 22 studies (73%) reported that there were no adverse effects caused by either the experimental or control toothpaste. There was considerable heterogeneity present in the meta‐analyses for plaque, gingivitis and calculus. Plaque and gingivitis showed such consistent results that it did not affect our conclusions, but the reader may wish to interpret the results with more caution. Authors' conclusions There was moderate‐quality evidence showing that toothpastes containing triclosan/copolymer, in addition to fluoride, reduced plaque, gingival inflammation and gingival bleeding when compared with fluoride toothpastes without triclosan/copolymer. These reductions may or may not be clinically important, and are evident regardless of initial plaque and gingivitis levels, or whether a baseline oral prophylaxis had taken place or not. High‐quality evidence showed that triclosan/copolymer toothpastes lead to a small reduction in coronal caries. There was weaker evidence to show that triclosan/copolymer toothpastes may have reduced root caries and calculus, but insufficient evidence to show whether or not they prevented periodontitis. There do not appear to be any serious safety concerns regarding the use of triclosan/copolymer toothpastes in studies up to three years in duration. Plain language summary Triclosan/copolymer containing toothpastes for oral health Review question This Cochrane Review has been conducted to assess the effects of using a toothpaste containing triclosan (an antibacterial ingredient) plus copolymer (an ingredient to reduce the amount of triclosan that is washed away by rinsing or saliva) plus fluoride (a mineral that prevents tooth decay) compared with using a fluoride toothpaste (without triclosan/copolymer) for oral health. Background Gum disease and dental decay are the main reasons for tooth loss. Unless brushed away, plaque (a sticky film containing bacteria) can build up on the teeth. This can lead to gingivitis (a swelling and redness of the gums that affects most adults), which, if not treated, can then lead to a more serious form of gum disease called periodontitis (which affects up to one out of every five adults aged 35 to 44 years worldwide). Periodontitis can cause pain, eating difficulties, an unpleasant facial appearance and eventually tooth loss. Plaque build‐up can also lead to tooth decay, a problem affecting up to 90% of schoolchildren in industrialised countries, and the majority of adults. Vast healthcare resources are used worldwide to treat gum disease and tooth decay, which are both preventable. Currently there is a lot of ongoing research into possible links between periodontitis and other medical conditions such as diabetes, rheumatoid arthritis, heart disease and also to the premature (too early) birth of underweight babies. Adding an effective and safe antibacterial ingredient to toothpastes could be an easy and low‐cost answer to these problems. It is thought that triclosan could fight the harmful bacteria in plaque while also reducing the swelling that leads to serious gum disease. It is important that adding triclosan to fluoride toothpastes does not reduce the beneficial effects that fluoride has on preventing tooth decay. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 19 August 2013. It includes 30 studies published from 1990 to 2012 in which 14,835 participants were randomised to receive a triclosan/copolymer containing fluoride toothpaste or a fluoride toothpaste that did not include triclosan/copolymer. The toothpaste that was used in most of the studies is sold by the manufacturer Colgate. Key results The evidence produced shows benefits in using a triclosan/copolymer fluoride toothpaste when compared with a fluoride toothpaste (without triclosan/copolymer). There was a 22% reduction in plaque, a 22% reduction in gingivitis, a 48% reduction in bleeding gums and a 5% reduction in tooth decay. There was insufficient evidence to show a difference between either toothpaste in preventing periodontitis. There was no evidence of any harmful effects associated with the use of triclosan/copolymer toothpastes in studies up to three years in length. Quality of the evidence The evidence relating to plaque and gingivitis was considered to be of moderate quality. The evidence on tooth decay was high quality, while the evidence on periodontitis was low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Riley, P; Lamont, T", "articleTypes": [], "doi": "10.1002/14651858.CD010514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "436c6159-cbe2-4dd3-88b2-a0b7c6c3f67f", "pmid": "", "title": "WIthdrawal of DUpilumab in Severe Asthma: a Randomized Non-inferiority-controlled Trial", "imported": false, "abstract": "Asthma management has been revolutionised by the development of biological therapies. Dupilumab is an anti-interleukin4 receptor marketed in 2020 for severe asthmatic patients with 2 exacerbations or more within the last 12 months. Although data showed that safety and efficacy of dupilumab are sustained when treatment is extended up to 3 years, no study has emerged regarding dupilumab discontinuation. This study aims to demonstrate the non-inferiority regarding strategy failure at 24 months of stopping dupilumab (intervention group) compared with its continuation (control group) in controlled asthma patients receiving this drug for at least 3 years.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.265Z" }, { "id": "439a1b16-5253-4491-a7b4-ec3ad3914fdc", "pmid": "", "title": "Short- and Long-term Effects of Once Weekly Semaglutide 2.4 mg on Appetite, Eating Behavior, and Psychosocial Status", "imported": false, "abstract": "This study will evaluate the effect of semaglutide on eating behavior, appetite (hunger/fullness), and food liking in the long-term, as compared to placebo. All participants will receive lifestyle modification (diet and exercise) counseling, and will be prescribed the FDA-approved weight loss medication, semaglutide, or placebo (an inactive saline solution) for 72 weeks.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.162Z" }, { "id": "439b04ba-7081-4d1e-b287-928d9ef57686", "pmid": "", "title": "Desmopressin for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐old children and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Desmopressin has been used to treat bedwetting since the 1970s. This is an update of a Cochrane review first published in 2000 and last updated in 2006. Objectives To assess the effects of desmopressin on treating nocturnal enuresis in children. Search methods We searched Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched January 2023) and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of desmopressin or desmopressin combined with another intervention for treating nocturnal enuresis in children between five and 16 years old. Data collection and analysis Three review authors independently extracted data and assessed the risk of bias in the eligible trials. We used standard methodological procedures expected by Cochrane. Main results We identified 50 new studies for this review, which now includes 95 studies (8473) participants, of whom 5434 received desmopressin. In this review we continued the assessment of the effect of combination therapy involving desmopressin. The majority of the trials were in children between the ages of five to 16 years in an outpatient setting. The quality of the evidence was assessed as low or very low. The first comparison was desmopressin versus placebo. Desmopressin may reduce the mean number of wet nights per week compared with placebo (MD ‐1.81, 95% CI ‐2.24 to ‐1.39; participants = 1267; studies = 16; low‐certainty evidence). Desmopressin probably leads to more children achieving 14 consecutive dry nights by the end of treatment compared with placebo (RR 3.18, 95% CI 1.75 to 5.80; participants = 922: studies = 11; moderate‐certainty evidence). There may be little to no difference in children experiencing adverse effects with desmopressin compared to placebo (RR 1.11, 95% CI 0.81 to 1.52; participants = 269; studies = 3; low‐certainty evidence). Desmopressin was compared with alarm therapy. It is uncertain if there is any difference between desmopressin compared with alarm training in reducing the number of wet nights per week (MD 0.63, 95% CI ‐0.49 to 1.75; participants = 285; studies = 4; I 2 = 82%; very low‐certainty evidence). There may be little or no difference between desmopressin and alarm therapy in the number of children achieving 14 consecutive dry nights (RR 0.98, 95% CI 0.88 to 1.09; participants = 1530; studies = 15; low‐certainty evidence). There may be little to no difference in children experiencing side effects with desmopressin therapy compared with alarm therapy (RR 1.50, 95% CI 0.33 to 6.78; participants = 461, studies = 4; low‐certainty evidence). We compared desmopressin with other medications, including tricyclics and anticholinergics. It is uncertain if there is any difference between desmopressin compared to tricyclics in reducing the mean number of wet nights per week (MD 0.23, 95% CI ‐ 0.88 to 1.33; participants = 331; studies = 4; I 2 = 79%; very low‐certainty evidence) or in the number of children achieving 14 consecutive dry nights at the end of treatment (RR 0.94, 95% CI 0.63 to 1.38; participants = 371; studies = 7; I 2 = 71%; very low‐certainty evidence). It is uncertain whether children experience more side effects with desmopressin compared with tricyclics (RR 0.29, 95%CI 0.06 to 1.39; participants = 351; studies = 4, very low‐certainty evidence). This review included studies with combination therapies. It is uncertain if desmopressin combined with alarm therapy reduces the mean number of wet nights at the end of treatment compared with alarm monotherapy (MD ‐0.80, 95% CI ‐1.34 to ‐0.25; participants = 528; studies = 6; I 2 = 84%; very low‐certainty evidence); or if it increases the number of children achieving 14 consecutive dry nights (RR 1.25, 95% CI 0.96 to 1.63; participants = 822; studies = 10; very low‐certainty evidence). Desmopressin plus alarm therapy may make little to no difference in children experiencing side effects compared with alarm therapy alone (RR 1.05 95% CI 0.07 to 16.56; participants = 207; studies = 1; low‐certainty evidence). Combining desmopressin with alarm therapy probably reduces the number of wet nights at the end of treatment (MD ‐0.88; 95%CI ‐1.38 to ‐0.38; participants = 156; studies = 2; moderate‐certainty evidence), and may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin monotherapy (RR 1.26, 95% CI 1.06 to 1.51; participants = 370; studies = 5; low‐certainty evidence). It is uncertain if combined desmopressin and anticholinergic therapy versus desmopressin monotherapy reduces the mean number of wet nights at the end of therapy (MD ‐0.50; 95% CI ‐1.05 to 0.06; participants = 188; studies = 3; I 2 = 66%; very low‐certainty evidence); or if it may increase the number of children achieving 14 consecutive dry nights at the end of treatment (RR 1.53, 95% CI 1.10 to 2.11; participants = 611; studies = 8; low‐certainty evidence). There may be little to no difference in adverse events between desmopressin plus anticholinergics and desmopressin monotherapy (RR 1.51 95% CI 0.73 to 3.09, participants = 187; studies =2; low‐certainty evidence). Minor adverse effects were common for desmopressin, including dizziness, headache, mood changes, gastrointestinal discomfort, nasal discomfort, hyponatraemia and one report of a convulsion. Authors' conclusions Desmopressin compared with placebo may increase the number of dry nights per week at the end of treatment in children. Desmopressin therapy may be as effective as alarm therapy at the end of treatment. However, the quality of evidence was assessed as low or very low. Alarm therapy compared to desmopressin may improve the number of children who are dry at follow‐up (moderate‐certainty evidence). Plain language summary Desmopressin for bedwetting in children Review question Is desmopressin an effective treatment for bedwetting in children? Key messages: Desmopressin may improve bedwetting. Only one study assessed quality of life. Further studies with good patient numbers are required. What is enuresis? What does desmopressin do ? Enuresis or bedwetting is involuntary wetting during sleep at an age when a child should be dry, usually at age five. The generally quoted prevalence rates (that is the proportion of a population with bedwetting in a given time period) are 15% to 20% of five‐year‐olds, 7% of seven‐year‐olds, 5% of 10‐year‐old children, and 2% to 3% of teenagers. Various treatments have been used to treat bedwetting. Desmopressin is a man‐made form of vasopressin, a chemical released from the brain that helps control the amount of urine made by the kidneys. Desmopressin is used to control bedwetting at night and reduces the number of bedwetting episodes. Why was it important to do this review? Although bedwetting is not a harmful condition and, with time, stops spontaneously, it is stigmatising and can impact the child’s quality of life, emotional and psychological wellbeing. It is a condition that unsettles the whole family and the affected children may suffer parental discontentment, teasing and may be at risk of physical or emotional abuse. Successful therapies that reduce bedwetting improve the child's self‐esteem and, therefore, it is important to see if desmopressin is as effective as other known treatments. How is the condition treated ? • Desmopressin therapy • Alarm therapy • Anticholinergic medications • Combination therapy – such as desmopressin and alarm therapy compared to desmopressin therapy There are several other therapies, such as behavioural therapies and laser therapy, though we have concentrated on the main therapies utilised. What did we want to find out? We wanted to see if desmopressin: • was effective in reducing the episodes of wet nights children may have; • was as effective as other treatments such as alarm therapy in treating bedwetting; • worked in combination with other treatments; • was associated with any unwanted effects. What did we do? We searched for studies where people were randomly placed into different treatment groups. We searched for and included studies that compared: • desmopressin with no treatment or placebo; • desmopressin and alarm therapy; • combination treatments of desmopressin and alarm. We compared and analysed our results, then rated our confidence in the evidence based on factors such as study methods and size of the studies. What did we find? We found 98 studies with 8699 participants, of whom 5616 received desmopressin. Main results • We found the use of desmopressin compared with placebo may improve wetting by giving children one more dry night a week while receiving treatment. This suggests that more children may stop wetting while using desmopressin (28% versus 1% who are given placebo or no treatment). • More children who received desmopressin therapy compared with placebo probably achieved 14 consecutive dry nights at the end of treatment. • We found that, when desmopressin was compared with alarm therapy, there was little to no difference in the number of children achieving 14 dry nights in a row. The evidence is also uncertain if desmopressin versus alarm therapy reduces the number of dry nights per week. • We found that combining desmopressin with alarm therapy may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin alone. • We found that side effects were commonly reported for desmopressin. These included dizziness, headache, mood changes, abdominal discomfort, nasal discomfort, hyponatraemia (low sodium level) and one report of a seizure. Thirty‐two studies reported no adverse effects occurring, and 25 studies omitted to report or mention adverse effects. What are the limitations of the evidence? We, however, have little confidence in the evidence as, in several studies, participants were aware of the therapy they were receiving, and several studies were very small. How up‐to‐date is this review? The evidence is current up to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hahn, D; Stewart, F; Raman, G", "articleTypes": [], "doi": "10.1002/14651858.CD002112.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "43a55d2c-2ef6-4918-868f-377a9b13ce80", "pmid": "", "title": "Interventions for managing halitosis", "imported": false, "abstract": "Abstract - Background Halitosis or bad breath is a symptom in which a noticeably unpleasant breath odour is present due to an underlying oral or systemic disease. 50% to 60% of the world population has experienced this problem which can lead to social stigma and loss of self‐confidence. Multiple interventions have been tried to control halitosis ranging from mouthwashes and toothpastes to lasers. This new Cochrane Review incorporates Cochrane Reviews previously published on tongue scraping and mouthrinses for halitosis. Objectives The objectives of this review were to assess the effects of various interventions used to control halitosis due to oral diseases only. We excluded studies including patients with halitosis secondary to systemic disease and halitosis‐masking interventions. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 April 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3) in the Cochrane Library (searched 8 April 2019), MEDLINE Ovid (1946 to 8 April 2019), and Embase Ovid (1980 to 8 April 2019). We also searched LILACS BIREME (1982 to 19 April 2019), the National Database of Indian Medical Journals (1985 to 19 April 2019), OpenGrey (1992 to 19 April 2019), and CINAHL EBSCO (1937 to 19 April 2019). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (8 April 2019), the World Health Organization International Clinical Trials Registry Platform (8 April 2019), the ISRCTN Registry (19 April 2019), the Clinical Trials Registry ‐ India (19 April 2019), were searched for ongoing trials. We also searched the cross‐references of included studies and systematic reviews published on the topic. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs) which involved adults over the age of 16, and any intervention for managing halitosis compared to another or placebo, or no intervention. The active interventions or controls were administered over a minimum of one week and with no upper time limit. We excluded quasi‐randomised trials, trials comparing the results for less than one week follow‐up, and studies including advanced periodontitis. Data collection and analysis Two pairs of review authors independently selected trials, extracted data, and assessed risk of bias. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach. Main results We included 44 trials in the review with 1809 participants comparing an intervention with a placebo or a control. The age of participants ranged from 17 to 77 years. Most of the trials reported on short‐term follow‐up (ranging from one week to four weeks). Only one trial reported long‐term follow‐up (three months). Three studies were at low overall risk of bias, 16 at high overall risk of bias, and the remaining 25 at unclear overall risk of bias. We compared different types of interventions which were categorised as mechanical debridement, chewing gums, systemic deodorising agents, topical agents, toothpastes, mouthrinse/mouthwash, tablets, and combination methods. Mechanical debridement: for mechanical tongue cleaning versus no tongue cleaning, the evidence was very uncertain for the outcome dentist‐reported organoleptic test (OLT) scores (MD ‐0.20, 95% CI ‐0.34 to ‐0.07; 2 trials, 46 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Chewing gums: for 0.6% eucalyptus chewing gum versus placebo chewing gum, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.10, 95% CI ‐0.31 to 0.11; 1 trial, 65 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Systemic deodorising agents: for 1000 mg champignon versus placebo, the evidence was very uncertain for the outcome patient‐reported visual analogue scale (VAS) scores (MD ‐1.07, 95% CI ‐14.51 to 12.37; 1 trial, 40 participants; very low‐certainty evidence). No data were reported for dentist‐reported OLT score or adverse events. Topical agents: for hinokitiol gel versus placebo gel, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.27, 95% CI ‐1.26 to 0.72; 1 trial, 18 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Toothpastes: for 0.3% triclosan toothpaste versus control toothpaste, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐3.48, 95% CI ‐3.77 to ‐3.19; 1 trial, 81 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Mouthrinse/mouthwash: for mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.20, 95% CI ‐0.58 to 0.18; 1 trial, 44 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Tablets: no data were reported on key outcomes for this comparison. Combination methods: for brushing plus cetylpyridium mouthwash versus brushing, the evidence was uncertain for the outcome dentist‐reported OLT scores (MD ‐0.48, 95% CI ‐0.72 to ‐0.24; 1 trial, 70 participants; low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Authors' conclusions We found low‐ to very low‐certainty evidence to support the effectiveness of interventions for managing halitosis compared to placebo or control for the OLT and patient‐reported outcomes tested. We were unable to draw any conclusions regarding the superiority of any intervention or concentration. Well‐planned RCTs need to be conducted by standardising the interventions and concentrations. Plain language summary Interventions for managing bad breath Review question With this Cochrane Review we tried to find out the best way to control bad breath, also called halitosis, due to a disease within the mouth in adults. Background Bad breath or halitosis is caused by too much bacteria or small food parts left inside the mouth, most commonly at the back of the tongue. It can be a sign of a disease within the mouth or other body diseases. People with bad breath can have low self‐esteem and feel embarrassed. It can affect their personal relationships and work. In this review, we looked at treatments for bad breath due to a disease within the mouth and at treatments that aim to control not just mask bad breath. Study characteristics This review is up‐to‐date as of 8 April 2019. The review includes 44 studies involving 1809 people who were 17 to 77 years old. The review compared an intervention with another intervention, a placebo or a control. It looked at eight different ways to control bad breath: mechanical cleaning (e.g. tongue cleaners and toothbrushes), chewing gums, systemic deodorising agents (e.g. mushroom extract that you eat), topical agents (e.g. gel that you apply), toothpastes, mouthrinse/mouthwash, tablets, and combination of different treatments. Key results The evidence was very uncertain for mechanical tongue cleaning versus no tongue cleaning, 0.6% eucalyptus chewing gum versus placebo chewing gum, 1000 mg mushroom extract versus placebo, hinokitiol gel versus placebo gel, 0.3% triclosan toothpaste versus control toothpaste, mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, and brushing plus cetylpyridium mouthwash versus brushing. Harmful effects of the different interventions were not reported or were not important. Certainty of the evidence The level of certainty we have in these findings is low to very low. This was due mainly to risk of bias and the small number of people studied in the included trials. Conclusion We do not have enough evidence to say which intervention works better to control bad breath.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kumbargere Nagraj, S, Eachempati, P, Uma, E, Singh, VP, Ismail, NM, Varghese, E", "articleTypes": [], "doi": "10.1002/14651858.CD012213.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.079Z" }, { "id": "43ab80ee-71f9-45d6-86d3-d778cc7929f0", "pmid": "", "title": "Prognostic models for radiation‐induced complications after radiotherapy in head and neck cancer patients", "imported": false, "abstract": "Abstract - Background Radiotherapy is the mainstay of treatment for head and neck cancer (HNC) but may induce various side effects on surrounding normal tissues. To reach an optimal balance, normal tissue complication probability (NTCP) models have been reported to predict the risk of radiation‐induced side effects in patients with HNC. However, the quality of study design, conduct, and analysis (i.e. risk of bias (ROB)), as well as the predictive performance of these models, remains to be evaluated. Objectives To identify, describe and appraise NTCP models to predict the risk of radiation‐induced side effects in patients with HNC. Search methods We searched Ovid MEDLINE, Embase and the World Health Organization International Clinical Trials Registry Platform from conception to January 2024. In addition, we screened references cited in the retrieved articles. Selection criteria Two review authors independently included articles reporting on the development and external validation of NTCP models to predict any type of radiation‐induced side effects in patients with HNC. Data collection and analysis One reviewer extracted data from each article and assessed their applicability and ROB, while another reviewer carefully verified the results. For models externally validated at least twice for the same outcome as their original developmental study, we performed qualitative analyses of the model performance. The GRADE system was not applied, since it has not been established for reviews of prognostic model studies. Main results Amongst 617 models developed from 152 articles, including 162,527 HNC patients, only 58 (9%) models from seven articles were judged to have low ROB and low concerns for applicability. No external validation was performed for 481 models (78%). For the remaining 136 models and six additional models which were not eligible for the present review, 193 external validations were performed in 48,852 patients with HNC in 39 articles. Models for salivary‐related outcomes Amongst 285 models, two models were externally validated at least twice. The Beetz 2012b model for xerostomia six months after radiotherapy was validated in two studies. C‐statistics ranged from 0.70 to 0.74. Calibration performance was reported in one study. One validation study was rated as having low ROB in all domains, while the other was rated as having high ROB in the analysis domain. The Cavallo 2021 model for acute xerostomia during radiotherapy for patients with nasopharyngeal cancer was externally validated in the same study, using two different types of cohorts. C‐statistics ranged from 0.68 to 0.73 and calibration plots were reported in both cohorts. Both validations were rated as having unclear ROB in the participants' domain because no detailed information about recruiting was provided. Models for swallowing‐related outcomes Amongst 85 models, two models were externally validated at least twice. The Christianen 2012 model for dysphagia six months after radiotherapy was validated in five studies. C‐statistics ranged from 0.66 to 0.75. Calibration performance was assessed in all of them, while four of them were rated as having high ROB in the analysis domain due to the small sample size. The Wopken 2014b model for tube feeding dependence six months after radiotherapy was validated in three external validation studies. C‐statistics ranged from 0.79 to 0.95, while calibration was evaluated in all studies. Due to the small size of the validation datasets, they were judged as having high ROB in the analysis domain. Models for hypothyroidism Of 72 models for hypothyroidism, two models were externally validated at least twice. In addition, there was another model which was not originally developed for patients with HNC, but validated in this domain. The Boomsma 2012 for hypothyroidism within two years after radiotherapy was externally validated in two studies. C‐statistics ranged from 0.64 to 0.74, while only one study reported its calibration performance. Both validation studies were rated as having high ROB in the analysis domain. The Ronjom 2013 model for radiation‐induced hypothyroidism was validated in three studies. C‐statistics ranged from 0.65 to 0.69 and calibration plots were reported in only one study. Two validation studies were judged as having high and the other was rated as having unclear ROB in the analysis domain. The Cella 2012 model was originally developed to predict radiation‐induced hypothyroidism in patients with Hodgkin’s lymphoma. In two validation studies in patients with HNC, c‐statistics ranged from 0.65 to 0.68, but calibration performance was not reported. One validation study was rated as having a high ROB and the other was rated as being unclear in the analysis domain. Models for brain and nerve‐related outcomes Amongst 40 models, three were externally validated at least twice for temporal lobe injury. The OuYang 2023 model, using deep learning in patients with nasopharyngeal cancer, was validated in the same paper using two different cohorts. C‐statistics ranged from 0.80 to 0.82, while calibration performance was assessed in both cohorts. Both validations were judged as having low ROB in all domains. The Wen 2021 model was developed to predict temporal lobe injury in newly diagnosed nasopharyngeal cancer patients. The model was validated by OuYang 2023 using two cohorts and by Yang 2023a using four cohorts. C‐statistics ranged from 0.75 to 0.79, while calibration performance was not reported. The two validations by OuYang 2023 were judged as having unclear ROB in the analysis domain, and the four validations by Yang 2023a were judged as having high ROB in the analysis domain. The Yang 2023a model was validated in the same paper using two cohorts. C‐statistics ranged from 0.79 to 0.81, while calibration performance was assessed in both cohorts. Both validations were judged as having high ROB in the analysis domain. Models for outcomes related to hoarseness, fatigue, nausea‐vomiting, throat pain, aspiration No models were externally validated at least twice. Authors' conclusions Amongst 617 developed models, only one‐fifth were externally validated, of which, ten models at least twice. These ten models showed acceptable discriminative performance at external validation. However, their calibration was not always reported. Furthermore, most validation studies were judged as having high ROB. In conclusion, this review shows the need for more external validation studies and improvement of the quality of conducting and reporting of prediction model studies. Plain language summary Which normal tissue complication probability (NTCP) models are available to predict the risk of radiation‐induced side effects after radiotherapy in patients with head and neck cancer, what is their quality, and what is their predictive performance? Key messages ° Many NTCP models have been developed to predict unwanted effects following radiotherapy in head and neck cancer patients but most of them have not been sufficiently externally validated, that is, tested with patients who were not involved in the original model developmental study, to know how well they really predict the unwanted effects. ° For models tested in two or more studies in addition to their original model development studies, the quality of testing and reporting of their results was generally poor, so it is difficult to know how useful they might be. ° More and better designed studies are required to investigate this issue in the area of head and neck cancer. How can we decide on the likelihood of having unwanted effects as a result of treatment? The likelihood of having unwanted effects as a result of radiotherapy can be calculated by using so‐called NTCP models. NTCP models calculate the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. What did we want to find out? Radiotherapy is the mainstay of treatment of patients with head and neck cancer. However, radiotherapy exposes healthy, sometimes crucial, parts of the head and neck region to radiation. This may result in damage to these normal organs, e.g. disturbed saliva production, which may have important consequences for the quality of life of head and neck cancer patients treated with radiotherapy. To reach an optimal balance between tumour control and preventing radiation‐induced side effects, normal tissue complication probability (NTCP) models can be helpful. These models predict the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. There have been a substantial number of NTCP models for patients with head and neck cancer. We wanted to find out what the quality of study design, conduct, and analysis (i.e. risk of bias) is, and how well these models can predict the risk of radiation‐induced side effects. What did we do? We searched for studies that developed and/or validated NTCP models in patients with head and neck cancer. What did we find? In most of the 617 models developed from 162,527 patients in 152 identified articles, the quality of the models was not sufficient; and it has not been investigated how well they perform in new patients for 78% of these models. For the remaining 22% of the models, 193 external validations were found in 48,852 patients from 39 articles. There were only ten models with two or more external validations. The models were able to distinguish patients with and without the outcome well, but it was often unclear whether their predictions were in line with what was observed, because the latter was not always assessed and/or reported. Overall, the quality of most of these studies was low. How up to date is the review? The evidence is current to 8th January 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Takada, T; Tambas, M; Clementel, E; Leeuwenberg, A; Sharabiani, M; Damen, JAAG; Dunias, ZS; Nauta, JF; Idema, DL; Choi, J; Meijerink, LM; Langendijk, JA; Moons, KG; Schuit, E", "articleTypes": [], "doi": "10.1002/14651858.CD014745.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "43ad9fbf-bf74-4ee6-9421-41abc69b592b", "pmid": "", "title": "Enteral nutritional therapy for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta‐analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review. Objectives To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts. Selection criteria Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review. Data collection and analysis Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random‐effects model was used to pool data. We performed intention‐to‐treat and per‐protocol analyses for the primary outcome. Heterogeneity was explored using the Chi 2 and I 2 statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes. Main results Twenty‐seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non‐elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non‐elemental diets differing in glutamine enrichment. Meta‐analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty‐four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non‐elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per‐protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non‐elemental diets (elemental, semi‐elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non‐elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating. Ten trials compared EN to steroid therapy. Meta‐analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per‐protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per‐protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet. Authors' conclusions Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy Plain language summary Enteral nutritional therapy for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a long‐term inflammation of the gastrointestinal (GI) tract, occurring anywhere from mouth to anus. Common symptoms of this condition include abdominal pain, diarrhea and weight loss. When Crohn's disease patients are experiencing symptoms, it is characterized to be 'active' disease. When the symptoms stop, it is called 'remission'. What is enteral nutrition? Enteral nutrition is a feeding method where all of a person's daily caloric intake is delivered using the GI tract. An example of this is nasogastric tube feeding, where a tube is inserted through a person's nose to deliver their daily nutritional requirements in liquid form. Enteral nutrition can be a form of nutritional therapy for Crohn's disease patients. Enteral nutrition is categorized into elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets come from amino‐acid sources, whereas non‐elemental diets come from oligopeptide or whole protein sources. What are corticosteroids? Corticosteroids are an effective treatment option for active Crohn's disease. These drugs that are taken by mouth and work as immunosuppressants. What did the researchers investigate? The researchers studied whether enteral nutrition is better than steroid therapy at producing remission in Crohn's disease patients. In addition, the investigators looked to see if one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) at producing remission in Crohn's disease. What did the researchers find? The researchers found twenty‐seven studies (1,011 participants) that fulfilled the search criteria. Eleven of these studies, which included 378 patients, compared elemental to non‐elemental diets at producing remission in Crohn's disease. Eight studies, which included 352 patients, investigated enteral nutrition compared to steroid therapy at inducing remission in Crohn's disease. The researchers searched the medical literature extensively up to July 5, 2017. Very low quality evidence suggests that steroids may be more effective than enteral nutrition for induction of remission in adults with active Crohn's disease. Very low quality evidence also suggests that enteral nutrition may be more effective than steroids for induction of remission in children with active Crohn's disease. There was no difference in remission rates between elemental and non‐elemental diets. An increase in side effects was not seen with elemental diets compared to non‐elemental diets, nor with enteral nutrition compared to steroids. Common side effects experienced with enteral nutrition included vomiting, diarrhea, heartburn and flatulence . Common side effects associated with steroid use included acne, moon facies, muscle weakness, hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) . Patients on enteral nutrition were more likely to withdraw from the study due to side effects than those on steroids. The most common reason for study withdrawal was inability to tolerate the taste of the enteral nutrition diet. Enteral nutrition should be considered in pediatric Crohn's patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient compliance with this therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Narula, N; Dhillon, A; Zhang, D; Sherlock, ME; Tondeur, M; Zachos, M", "articleTypes": [], "doi": "10.1002/14651858.CD000542.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "43e1148e-d85b-45a0-b8fc-d5f3756fecbb", "pmid": "", "title": "Tartrazine exclusion for allergic asthma", "imported": false, "abstract": "Abstract - Background Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There has been conflicting evidence as to whether tartrazine causes exacerbations of asthma with some studies finding a positive association especially in individuals with cross‐sensitivity to aspirin. Objectives To assess the overall effect of tartrazine (exclusion or challenge) in the management of asthma. Search methods A search was carried out on the Cochrane Airways Group Specialised Register. Bibliographies of each RCT was searched for additional papers. Authors of identified RCTs were contacted for further information. Searches are updated annually and are current as of February 2006. Selection criteria RCTs of oral administration of tartrazine (as a challenge) versus placebo or dietary avoidance of tartrazine versus normal diet were considered. Studies which focused upon allergic asthma, were also included. Studies of tartrazine exclusion for other allergic conditions such as hay fever, allergic rhinitis and eczema were only considered if the results for subjects with asthma were separately identified. Trials could be in either adults or children with asthma or allergic asthma (e.g. sensitivity to aspirin or food items known to contain tartrazine). Data collection and analysis Study quality was assessed and data abstracted by two reviewers independently. Outcomes were analysed using RevMan 4.1.1. Main results Ninety four abstracts were found, of which 20 were potentially relevant. Six? met the inclusion criteria, but only three presented results in a format that permitted analysis and none could be combined in a meta‐analysis. In none of the studies did tartrazine challenge or avoidance in diet significantly alter asthma outcomes. Authors' conclusions Due to the paucity of available evidence, it is not possible to provide firm conclusions as to the effects of tartrazine on asthma control. However, the six RCTs that could be included in this review all arrived at the same conclusion. Routine tartrazine exclusion may not benefit most patients, except those very few individuals with proven sensitivity. Plain language summary Tartrazine exclusion for allergic asthma Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There is no evidence that tartrazine makes asthma worse or avoiding it makes asthma patients any better.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Ardern, K", "articleTypes": [], "doi": "10.1002/14651858.CD000460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "43f13b88-11b9-4da2-8221-b2665596a10c", "pmid": "", "title": "Interventions for managing halitosis", "imported": false, "abstract": "Abstract - Background Halitosis or bad breath is a symptom in which a noticeably unpleasant breath odour is present due to an underlying oral or systemic disease. 50% to 60% of the world population has experienced this problem which can lead to social stigma and loss of self‐confidence. Multiple interventions have been tried to control halitosis ranging from mouthwashes and toothpastes to lasers. This new Cochrane Review incorporates Cochrane Reviews previously published on tongue scraping and mouthrinses for halitosis. Objectives The objectives of this review were to assess the effects of various interventions used to control halitosis due to oral diseases only. We excluded studies including patients with halitosis secondary to systemic disease and halitosis‐masking interventions. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 April 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3) in the Cochrane Library (searched 8 April 2019), MEDLINE Ovid (1946 to 8 April 2019), and Embase Ovid (1980 to 8 April 2019). We also searched LILACS BIREME (1982 to 19 April 2019), the National Database of Indian Medical Journals (1985 to 19 April 2019), OpenGrey (1992 to 19 April 2019), and CINAHL EBSCO (1937 to 19 April 2019). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (8 April 2019), the World Health Organization International Clinical Trials Registry Platform (8 April 2019), the ISRCTN Registry (19 April 2019), the Clinical Trials Registry ‐ India (19 April 2019), were searched for ongoing trials. We also searched the cross‐references of included studies and systematic reviews published on the topic. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs) which involved adults over the age of 16, and any intervention for managing halitosis compared to another or placebo, or no intervention. The active interventions or controls were administered over a minimum of one week and with no upper time limit. We excluded quasi‐randomised trials, trials comparing the results for less than one week follow‐up, and studies including advanced periodontitis. Data collection and analysis Two pairs of review authors independently selected trials, extracted data, and assessed risk of bias. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach. Main results We included 44 trials in the review with 1809 participants comparing an intervention with a placebo or a control. The age of participants ranged from 17 to 77 years. Most of the trials reported on short‐term follow‐up (ranging from one week to four weeks). Only one trial reported long‐term follow‐up (three months). Three studies were at low overall risk of bias, 16 at high overall risk of bias, and the remaining 25 at unclear overall risk of bias. We compared different types of interventions which were categorised as mechanical debridement, chewing gums, systemic deodorising agents, topical agents, toothpastes, mouthrinse/mouthwash, tablets, and combination methods. Mechanical debridement: for mechanical tongue cleaning versus no tongue cleaning, the evidence was very uncertain for the outcome dentist‐reported organoleptic test (OLT) scores (MD ‐0.20, 95% CI ‐0.34 to ‐0.07; 2 trials, 46 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Chewing gums: for 0.6% eucalyptus chewing gum versus placebo chewing gum, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.10, 95% CI ‐0.31 to 0.11; 1 trial, 65 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Systemic deodorising agents: for 1000 mg champignon versus placebo, the evidence was very uncertain for the outcome patient‐reported visual analogue scale (VAS) scores (MD ‐1.07, 95% CI ‐14.51 to 12.37; 1 trial, 40 participants; very low‐certainty evidence). No data were reported for dentist‐reported OLT score or adverse events. Topical agents: for hinokitiol gel versus placebo gel, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.27, 95% CI ‐1.26 to 0.72; 1 trial, 18 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Toothpastes: for 0.3% triclosan toothpaste versus control toothpaste, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐3.48, 95% CI ‐3.77 to ‐3.19; 1 trial, 81 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Mouthrinse/mouthwash: for mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.20, 95% CI ‐0.58 to 0.18; 1 trial, 44 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Tablets: no data were reported on key outcomes for this comparison. Combination methods: for brushing plus cetylpyridium mouthwash versus brushing, the evidence was uncertain for the outcome dentist‐reported OLT scores (MD ‐0.48, 95% CI ‐0.72 to ‐0.24; 1 trial, 70 participants; low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Authors' conclusions We found low‐ to very low‐certainty evidence to support the effectiveness of interventions for managing halitosis compared to placebo or control for the OLT and patient‐reported outcomes tested. We were unable to draw any conclusions regarding the superiority of any intervention or concentration. Well‐planned RCTs need to be conducted by standardising the interventions and concentrations. Plain language summary Interventions for managing bad breath Review question With this Cochrane Review we tried to find out the best way to control bad breath, also called halitosis, due to a disease within the mouth in adults. Background Bad breath or halitosis is caused by too much bacteria or small food parts left inside the mouth, most commonly at the back of the tongue. It can be a sign of a disease within the mouth or other body diseases. People with bad breath can have low self‐esteem and feel embarrassed. It can affect their personal relationships and work. In this review, we looked at treatments for bad breath due to a disease within the mouth and at treatments that aim to control not just mask bad breath. Study characteristics This review is up‐to‐date as of 8 April 2019. The review includes 44 studies involving 1809 people who were 17 to 77 years old. The review compared an intervention with another intervention, a placebo or a control. It looked at eight different ways to control bad breath: mechanical cleaning (e.g. tongue cleaners and toothbrushes), chewing gums, systemic deodorising agents (e.g. mushroom extract that you eat), topical agents (e.g. gel that you apply), toothpastes, mouthrinse/mouthwash, tablets, and combination of different treatments. Key results The evidence was very uncertain for mechanical tongue cleaning versus no tongue cleaning, 0.6% eucalyptus chewing gum versus placebo chewing gum, 1000 mg mushroom extract versus placebo, hinokitiol gel versus placebo gel, 0.3% triclosan toothpaste versus control toothpaste, mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, and brushing plus cetylpyridium mouthwash versus brushing. Harmful effects of the different interventions were not reported or were not important. Certainty of the evidence The level of certainty we have in these findings is low to very low. This was due mainly to risk of bias and the small number of people studied in the included trials. Conclusion We do not have enough evidence to say which intervention works better to control bad breath.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kumbargere Nagraj, S; Eachempati, P; Uma, E; Singh, VP; Ismail, NM; Varghese, E", "articleTypes": [], "doi": "10.1002/14651858.CD012213.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "43ffd8ca-ea06-4f87-bd32-74923482d6d2", "pmid": "", "title": "Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Chronic obstructive pulmonary disease (COPD) is a chronic lung condition characterised by persistent respiratory symptoms and limited lung airflow, dyspnoea and recurrent exacerbations. Suboptimal therapy or non‐adherence may result in limited effectiveness of pharmacological treatments and subsequently poor health outcomes. Objectives To determine the efficacy and safety of interventions intended to improve adherence to single or combined pharmacological treatments compared with usual care or interventions that are not intended to improve adherence in people with COPD. Search methods We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register, CENTRAL, MEDLINE and Embase (search date 1 May 2020). We also searched web‐based clinical trial registers. Selection criteria RCTs included adults with COPD diagnosed by established criteria (e.g. Global Initiative for Obstructive Lung Disease). Interventions included change to pharmacological treatment regimens, adherence aids, education, behavioural or psychological interventions (e.g. cognitive behavioural therapy), communication or follow‐up by a health professional (e.g. telephone, text message or face‐to‐face), multi‐component interventions, and interventions to improve inhaler technique. Data collection and analysis We used standard Cochrane methodological procedures. Working in pairs, four review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We assessed confidence in the evidence for each primary outcome using GRADE. Primary outcomes were adherence, quality of life and hospital service utilisation. Adherence measures included the Adherence among Patients with Chronic Disease questionnaire (APCD). Quality of life measures included the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). Main results We included 14 trials (2191 participants) in the analysis with follow‐up ranging from six to 52 weeks. Age ranged from 54 to 75 years, and COPD severity ranged from mild to very severe. Trials were conducted in the USA, Spain, Germany, Japan, Jordan, Northern Ireland, Iran, South Korea, China and Belgium. Risk of bias was high due to lack of blinding. Evidence certainty was downgraded due to imprecision and small participant numbers. Single component interventions Six studies (55 to 212 participants) reported single component interventions including changes to pharmacological treatment (different roflumilast doses or different inhaler types), adherence aids (Bluetooth inhaler reminder device), educational (comprehensive verbal instruction), behavioural or psychological (motivational interview). Change in dose of roflumilast may result in little to no difference in adherence (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.22 to 1.99; studies = 1, participants = 55; low certainty). A Bluetooth inhaler reminder device did not improve adherence, but comprehensive verbal instruction from a health professional did improve mean adherence (prescription refills) (mean difference (MD) 1.00, 95% CI 0.46 to 1.54). Motivational interview improved mean adherence scores on the APCD scale (MD 22.22, 95% CI 8.42 to 36.02). Use of a single inhaler compared to two separate inhalers may have little to no impact on quality of life (SGRQ; MD 0.80, 95% CI –3.12 to 4.72; very low certainty). A Bluetooth inhaler monitoring device may provide a small improvement in quality of life on the CCQ (MD 0.40, 95% CI 0.07 to 0.73; very low certainty). Single inhaler use may have little to no impact on the number of people admitted to hospital compared to two separate inhalers (OR 1.47, 95% CI 0.75 to 2.90; very low certainty). Single component interventions may have little to no impact on the number of people expereincing adverse events (very low certainty evidence from studies of a change in pharmacotherapy or use of adherence aids). A change in pharmacotherapy may have little to no impact on exacerbations or deaths (very low certainty). Multi‐component interventions Eight studies (30 to 734 participants) reported multi‐component interventions including tailored care package that included adherence support as a key component or included inhaler technique as a component. A multi‐component intervention may result in more people adhering to pharmacotherapy compared to control at 40.5 weeks (risk ratio (RR) 1.37, 95% CI 1.18 to 1.59; studies = 4, participants = 446; I 2 = 0%; low certainty). There may be little to no impact on quality of life (SGRQ, Chronic Respiratory Disease Questionnaire, CAT) (studies = 3; low to very low certainty). Multi‐component interventions may help to reduce the number of people admitted to hospital for any cause (OR 0.37, 95% CI 0.22 to 0.63; studies = 2, participants = 877; low certainty), or COPD‐related hospitalisations (OR 0.15, 95% CI 0.07 to 0.34; studies = 2, participants = 220; moderate certainty). There may be a small benefit on people experiencing severe exacerbations. There may be little to no effect on adverse events, serious adverse events or deaths, but events were infrequently reported and were rare (low to very low certainty). Authors' conclusions Single component interventions (e.g. education or motivational interviewing provided by a health professional) can help to improve adherence to pharmacotherapy (low to very low certainty). There were slight improvements in quality of life with a Bluetooth inhaler device, but evidence is from one study and very low certainty. Change to pharmacotherapy (e.g. single inhaler instead of two, or different doses of roflumilast) has little impact on hospitalisations or exacerbations (very low certainty). There is no difference in people experiencing adverse events (all‐cause or COPD‐related), or deaths (very low certainty). Multi‐component interventions may improve adherence with education, motivational or behavioural components delivered by health professionals (low certainty). There is little to no impact on quality of life (low to very low certainty). They may help reduce the number of people admitted to hospital overall (specifically pharmacist‐led approaches) (low certainty), and fewer people may have COPD‐related hospital admissions (moderately certainty). There may be a small reduction in people experiencing severe exacerbations, but evidence is from one study (low certainty). Limited evidence found no difference in people experiencing adverse events, serious adverse events or deaths (low to very low certainty). The evidence presented should be interpreted with caution. Larger studies with more intervention types, especially single interventions, are needed. It is unclear which specific COPD subgroups would benefit, therefore discussions between health professionals and patients may help to determine whether they will help to improve health outcomes. Plain language summary Which approaches help people with COPD to maintain taking medication as prescribed? Review question Which approaches help people maintain taking prescribed medication(s), improve quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD)? Background COPD is a lung condition that can cause long‐term breathing problems and includes symptoms such as shortness of breath. Medications do exist that can help but sometimes people do not take them as prescribed. Different approaches could help people to take their medication as prescribed and help improve symptoms or quality of life and reduce hospital admissions. We wanted to find out if any approaches could help people with COPD take their medication(s) as prescribed. Studies identified and selected We searched databases to find the studies. Four people working in pairs looked at the lists of studies separately and agreed on which ones were included. The latest search for studies was conducted in May 2020. Study characteristics We included studies comparing simple ways to help improve medication use (e.g. different medication doses or single inhalers instead of two separate inhalers) to usual COPD care. We also included studies that tested combination approaches (e.g. information or training from nurses or pharmacists and monitoring medication use). What were the key results? We included 14 studies (2191 people) in our analysis. No studies were masked (people knew whether they were receiving an approach to help them with adherence or the alternative). Six studies used simple approaches (e.g. change to medication dosage, change to type of inhaler, or a Bluetooth inhaler reminder device), and eight studies used combined approaches (e.g. nurses or pharmacists giving advice or information about how to improve medication use). We were uncertain about the effects of a different medication dose on people adhering to medication because it was no different to usual care (one study). Two separate studies found that a Bluetooth inhaler reminder device or a change in oral medication dose did not help to improve adherence. Health professionals involved in giving information may help to improve adherence (one study). This was measured by prescription refills. Motivating people to change their behaviour could help to improve adherence their medication (one study). This was measured by people completing a questionnaire about adherence to their medication. One study found that a Bluetooth inhaler device might help to improve quality of life. There may be little to no difference between those using single inhalers in the number of people admitted to hospital compared to those using two separate inhalers (one study). We found no difference between single approaches and usual care on the number of people who had side effects. Combined approaches may help to improve the number of people taking their medication, but we were not confident of this finding (four studies). They may have little to no impact on quality of life (three studies). Combined approaches could be beneficial in reducing the number of people with COPD admitted to hospital for any reason or because of COPD symptoms (two studies). There was no difference between combined approaches and in the number of people who had adverse events. Take home message We could not say for certain that simple approaches are useful to help people with COPD to improve medication use because of very limited information. Combined approaches may help people to take their medication(s) as prescribed and can help to reduce the number of people admitted to hospital, however, more information is needed to help answer this question with confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Janjua, S, Pike, KC, Carr, R, Coles, A, Fortescue, R, Batavia, M", "articleTypes": [], "doi": "10.1002/14651858.CD013381.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.801Z" }, { "id": "4403ec27-7387-4761-a44b-c6f0c91ede8b", "pmid": "", "title": "Snoezelen for dementia", "imported": false, "abstract": "Abstract - Background Snoezelen, multi‐sensory stimulation, provides sensory stimuli to stimulate the primary senses of sight, hearing, touch, taste and smell, through the use of lighting effects, tactile surfaces, meditative music and the odour of relaxing essential oils. The rationale for this lies in the proposition that the provision of a sensory environment for people with dementia places fewer demands on their intellectual abilities but capitalizes on their residual sensorimotor abilities. The clinical application of snoezelen often varies in form, nature, principles and procedures. Such variations not only make the examination of the therapeutic values of snoezelen difficult, but also impede the clinical development of snoezelen in dementia care. A systematic review of evidence for the efficacy of snoezelen in the care of people with dementia is therefore needed to inform future clinical applications and research directions. Objectives To examine the clinical efficacy of snoezelen (or multisensory stimulation) for older people with dementia and their caregivers. Search methods The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 23 March 2008 using the terms: snoezelen OR \"multi‐sensory*\". The CDCIG Specialized Register contains records from all major health care databases ( The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources. The reviewers hand‐searched PubMed and the ISI Web of Science. Selection criteria Randomized controlled trials and quasi‐randomized controlled trials in which snoezelen or multi‐sensory programmes was used as an intervention for older people suffering from any forms of dementia. Data collection and analysis The two reviewers independently reviewed and assessed the quality of the trials. Main results Two new trials were included in this update. Baker 2003 was an expanded study of Baker 2001 reported in the previous version. Both Baker 2003 and van Weert 2005 examined the short‐term and longer‐term effects of snoezelen on behaviour, mood, and communication of people with moderate to severe dementia. The format of implementation was different in the two trials: one was session‐based snoezelen programme (Baker 2003), whilst the other was a 24‐hour integrated snoezelen care (van Weert 2005). Owing to the differences in study methodology, the results of the two trials were not pooled for analysis. The session‐based snoezelen programme (Baker 2003) did not show any effects on behaviour, mood, cognition and communication / interaction in the short term (during or immediately after sessions) or longer term (at post‐intervention or 1‐month post‐intervention follow‐up). Likewise, the 24‐hour integrated snoezelen care (van Weert 2005) failed to demonstrate any significant short‐term and longer term effects on behaviour, mood and interaction. Authors' conclusions A more vigorous review methodology was adopted in this update. The study of Kragt 1997, reported in the previous version, was excluded because the snoezelen programme only consisted of three sessions, which was considered too brief for a therapeutic intervention. Two new trials were reviewed. Meta‐analyses could not be performed because of the limited number of trials and different study methods of the available trials. Overall, there is no evidence showing the efficacy of snoezelen for dementia. There is a need for more reliable and sound research‐based evidence to inform and justify the use of snoezelen in dementia care. Plain language summary No evidence of the efficacy of snoezelen or multi‐sensory stimulation programmes for people with dementia Snoezelen (or multi‐sensory stimulation) has become a commonly used intervention to manage maladaptive behaviours and to promote positive mood of older people with dementia. Originally, two randomised clinical trials were available for this review. Some short‐term benefits were documented in promoting adaptive behaviours in people with dementia during and immediately after their participation in the sessions. In this update, two new trials were included and revealed two different forms of applying snoezelen to dementia care. One is a session‐based snoezelen programme while the other is a 24‐hour integrated snoezelen care programme. Both trials did not show any significant effects on behaviour, interaction, and mood of people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Chung, JCC, Lai, CKY", "articleTypes": [], "doi": "10.1002/14651858.CD003152", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.763Z" }, { "id": "4413e784-0ee9-4199-ae7e-ea3a48d33609", "pmid": "", "title": "Non‐nutritive sweeteners for diabetes mellitus", "imported": false, "abstract": "Abstract - Background Products sweetened with non‐nutritive sweeteners (NNS) are widely available. Many people with type 1 or type 2 diabetes use NNS as a replacement for nutritive sweeteners to control their carbohydrate and energy intake. Health outcomes associated with NNS use in diabetes are unknown. Objectives To assess the effects of non‐nutritive sweeteners in people with diabetes mellitus. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Scopus, the WHO ICTRP, and ClinicalTrials.gov. The date of the last search of all databases (except for Scopus) was May 2019. We last searched Scopus in January 2019. We did not apply any language restrictions. Selection criteria We included randomised controlled trials (RCTs) with a duration of four weeks or more comparing any type of NNS with usual diet, no intervention, placebo, water, a different NNS, or a nutritive sweetener in individuals with type 1 or type 2 diabetes. Trials with concomitant behaviour‐changing interventions, such as diet, exercise, or both, were eligible for inclusion, given that the concomitant interventions were the same in the intervention and comparator groups. Data collection and analysis Two review authors independently screened abstracts, full texts, and records retrieved from trials registries, assessed the certainty of the evidence, and extracted data. We used a random‐effects model to perform meta‐analysis, and calculated effect estimates as risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs). We assessed risk of bias using the Cochrane 'Risk of bias' tool and the certainty of evidence using the GRADE approach. Main results We included nine RCTs that randomised a total of 979 people with type 1 or type 2 diabetes. The intervention duration ranged from 4 to 10 months. We judged none of these trials as at low risk of bias for all ’Risk of bias’ domains; most of the included trials did not report the method of randomisation. Three trials compared the effects of a dietary supplement containing NNS with sugar: glycosylated haemoglobin A1c (HbA1c) was 0.4% higher in the NNS group (95% CI −0.5 to 1.2; P = 0.44; 3 trials; 72 participants; very low‐certainty evidence). The MD in weight change was −0.1 kg (95% CI −2.7 to 2.6; P = 0.96; 3 trials; 72 participants; very low‐certainty evidence). None of the trials with sugar as comparator reported on adverse events. Five trials compared NNS with placebo. The MD for HbA1c was 0%, 95% CI −0.1 to 0.1; P = 0.99; 4 trials; 360 participants; very low‐certainty evidence. The 95% prediction interval ranged between −0.3% and 0.3%. The comparison of NNS versus placebo showed a MD in body weight of −0.2 kg, 95% CI −1 to 0.6; P = 0.64; 2 trials; 184 participants; very low‐certainty evidence. Three trials reported the numbers of participants experiencing at least one non‐serious adverse event: 36/113 participants (31.9%) in the NNS group versus 42/118 participants (35.6%) in the placebo group (RR 0.78, 95% CI 0.39 to 1.56; P = 0.48; 3 trials; 231 participants; very low‐certainty evidence). One trial compared NNS with a nutritive low‐calorie sweetener (tagatose). HbA1c was 0.3% higher in the NNS group (95% CI 0.1 to 0.4; P = 0.01; 1 trial; 354 participants; very low‐certainty evidence). This trial did not report body weight data and adverse events. The included trials did not report data on health‐related quality of life, diabetes complications, all‐cause mortality, or socioeconomic effects. Authors' conclusions There is inconclusive evidence of very low certainty regarding the effects of NNS consumption compared with either sugar, placebo, or nutritive low‐calorie sweetener consumption on clinically relevant benefit or harm for HbA1c, body weight, and adverse events in people with type 1 or type 2 diabetes. Data on health‐related quality of life, diabetes complications, all‐cause mortality, and socioeconomic effects are lacking. Plain language summary Non‐nutritive sweeteners for diabetes mellitus Review question Are non‐nutritive sweeteners beneficial or harmful in people with diabetes? Background Non‐nutritive sweeteners are sweetening agents having higher sweetening intensity and lower calorie content per gram compared to caloric sweeteners like sucrose or corn syrups. Both the general population and diabetic people use non‐nutritive sweeteners as a caloric sweetener replacement to control their carbohydrate and energy intake. Most of the non‐nutritive sweeteners approved for human consumption are synthetic (artificial sweeteners); however, increasing numbers of natural non‐caloric sweeteners are becoming available for human consumption. Products sweetened with non‐nutritive sweeteners are widely available on the market: diet beverages, diet yoghourts, desserts, and chewing gums are the most common products containing non‐nutritive sweeteners. Non‐nutritive sweeteners are also available as table‐top sweeteners for use by consumers at home as a sweetening agent for beverages and for cooking and baking. There is very little information about the health consequences of this intensified non‐nutritive sweeteners consumption in people with diabetes. We wanted to find out whether non‐nutritive sweeteners consumption in people with diabetes has an effect on long‐term average blood sugar levels (glycosylated haemoglobin A1c ‐ HbA1c), body weight, side effects, diabetes complications (such as heart attack, eye or kidney disease), and health‐related quality of life. Study characteristics We found nine randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) that allocated people with diabetes to either a group that received a non‐nutritive sweetener or a comparator group. The comparator was usual diet with additional sugar in three studies; placebo (a dummy pill) in five studies; and tagatose (a nutritive low‐calorie sweetener) in one study. The studies included a total of 979 participants; most of the studies were small, with fewer than 100 participants. The length of the studies varied from 4 to 10 months. This evidence is up‐to‐date as of May 2019. Key results Data on health‐related quality of life, diabetes complications, death from any cause, and socioeconomic effects (such as absence from work, visits to general practitioner, medication consumption) were lacking, and data were generally sparse for all comparisons. The available data did not show a clear difference between non‐nutritive sweeteners and sugar, placebo, or the nutritive low‐calorie sweetener tagatose for HbA1c, body weight, and side effects. Certainty of the evidence We rated the overall certainty of the evidence as very low, mainly due to the small numbers of included studies and participants and methodological limitations of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lohner, S; Kuellenberg de Gaudry, D; Toews, I; Ferenci, T; Meerpohl, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD012885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "44288b69-c2e6-4a9b-8990-6b622c6f7378", "pmid": "", "title": "Zinc supplements for preventing otitis media", "imported": false, "abstract": "Abstract - Background Otitis media is inflammation of the middle ear and is usually caused by infection. It affects people of all ages but is particularly common in young children. Around 164 million people worldwide have long‐term hearing loss caused by this condition, 90% of them in low‐income countries. As zinc supplements prevent pneumonia in disadvantaged children, we wanted to investigate whether zinc supplements could also prevent otitis media. Objectives To evaluate whether zinc supplements prevent otitis media in adults and children of different ages. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (1950 to February week 4, 2014) and EMBASE (1974 to March 2014). Selection criteria Randomised, placebo‐controlled trials of zinc supplements given at least once a week for at least a month for preventing otitis media. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of the included trials and extracted and analysed data. We summarised results using risk ratios (RRs) or rate ratios for dichotomous data and mean differences (MDs) for continuous data. We combined trial results where appropriate. Main results No new trials were identified for inclusion in this update. We identified 12 trials for inclusion, 10 of which contributed outcomes data. There were a total of 6820 participants. In trials of healthy children living in low‐income communities, two trials did not demonstrate a significant difference between the zinc‐supplemented and placebo groups in the numbers of participants experiencing an episode of definite otitis media during follow‐up (3191 participants); another trial showed a significantly lower incidence rate of otitis media in the zinc group (rate ratio 0.69, 95% confidence interval (CI) 0.61 to 0.79, n = 1621). A small trial of 39 infants undergoing treatment for severe malnutrition suggested a benefit of zinc for the mean number of episodes of otitis media (mean difference (MD) ‐1.12 episodes, 95% CI ‐2.21 to ‐0.03). Zinc supplements did not seem to cause any serious adverse events but a small minority of children were reported to have vomited shortly after ingestion of the supplements. The trial evidence included is generally of good quality, with a low risk of bias. Authors' conclusions Evidence on whether zinc supplementation can reduce the incidence of otitis media in healthy children under the age of five years living in low‐ and middle‐income countries is mixed. There is some evidence of benefit in children being treated for marasmus (severe malnutrition), but this is based on one small trial and should therefore be treated with caution. Plain language summary Zinc supplements for preventing middle ear infections Background Middle ear infections are common, especially among young children, usually causing earache and some temporary (occasionally permanent) hearing loss. Zinc is an essential micronutrient, which has a role in the optimal functioning of the immune system and resistance to infection. It must be consumed regularly as it cannot be stored in the body. Some people, especially children in low‐ and middle‐income countries, may not have adequate zinc intake from food alone. Researchers have examined the potential role of zinc supplements in preventing infective illnesses. Therefore we wanted to discover whether zinc supplements have any role in preventing middle ear infections. Study characteristics The review authors searched the medical literature for studies up to March 2014. We searched for trials which compared middle ear infections in people randomly selected to receive zinc supplements or who did not receive supplements. We found 10 eligible studies, all conducted amongst young children. The total number of participants was 6820. Nine trials were conducted in low‐ and middle‐income countries. Seven trials were conducted on healthy children. Participants included both males and females. Results The results of the trials provided no convincing evidence that zinc supplements reduce the occurrence of middle ear infections in healthy children. However, in one small study of severely malnourished children, those receiving zinc supplements had fewer middle ear infections. The only adverse effect was vomiting. Quality of evidence The trial evidence included is generally of good quality, with a low risk of bias. All the included trials included otitis media only as a secondary outcome. Therefore, there was a potential to miss trials which were less publicised or less well indexed within the electronic databases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Gulani, A; Sachdev, HS", "articleTypes": [], "doi": "10.1002/14651858.CD006639.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "44298cb4-61f3-4065-b62a-c497966c9c82", "pmid": "", "title": "Point‐of‐use fortification of foods with micronutrient powders containing iron in children of preschool and school‐age", "imported": false, "abstract": "Abstract - Background Approximately 600 million children of preschool and school age are anaemic worldwide. It is estimated that at least half of the cases are due to iron deficiency. Point‐of‐use fortification of foods with micronutrient powders (MNP) has been proposed as a feasible intervention to prevent and treat anaemia. It refers to the addition of iron alone or in combination with other vitamins and minerals in powder form, to energy‐containing foods (excluding beverages) at home or in any other place where meals are to be consumed. MNPs can be added to foods either during or after cooking or immediately before consumption without the explicit purpose of improving the flavour or colour. Objectives To assess the effects of point‐of‐use fortification of foods with iron‐containing MNP alone, or in combination with other vitamins and minerals on nutrition, health and development among children at preschool (24 to 59 months) and school (five to 12 years) age, compared with no intervention, a placebo or iron‐containing supplements. Search methods In December 2016, we searched the following databases: CENTRAL, MEDLINE, Embase, BIOSIS, Science Citation Index, Social Science Citation Index, CINAHL, LILACS, IBECS, Popline and SciELO. We also searched two trials registers in April 2017, and contacted relevant organisations to identify ongoing and unpublished trials. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs trials with either individual or cluster randomisation. Participants were children aged between 24 months and 12 years at the time of intervention. For trials with children outside this age range, we included studies where we were able to disaggregate the data for children aged 24 months to 12 years, or when more than half of the participants were within the requisite age range. We included trials with apparently healthy children; however, we included studies carried out in settings where anaemia and iron deficiency are prevalent, and thus participants may have had these conditions at baseline. Data collection and analysis Two review authors independently assessed the eligibility of trials against the inclusion criteria, extracted data from included trials, assessed the risk of bias of the included trials and graded the quality of the evidence. Main results We included 13 studies involving 5810 participants from Latin America, Africa and Asia. We excluded 38 studies and identified six ongoing/unpublished trials. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. No trials compared the effects of MNP versus iron‐containing supplements (as drops, tablets or syrup). The sample sizes in the included trials ranged from 90 to 2193 participants. Six trials included participants younger than 59 months of age only, four included only children aged 60 months or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. The iron doses varied from 2.5 mg to 30 mg of elemental iron. Four trials reported giving 10 mg of elemental iron as sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), chelated ferrous sulphate or microencapsulated ferrous fumarate. Three trials gave 12.5 mg of elemental iron as microencapsulated ferrous fumarate. Three trials gave 2.5 mg or 2.86 mg of elemental iron as NaFeEDTA. One trial gave 30 mg and one trial provided 14 mg of elemental iron as microencapsulated ferrous fumarate, while one trial gave 28 mg of iron as ferrous glycine phosphate. In comparison with receiving no intervention or a placebo, children receiving iron‐containing MNP for point‐of‐use fortification of foods had lower risk of anaemia prevalence ratio (PR) 0.66, 95% confidence interval (CI) 0.49 to 0.88, 10 trials, 2448 children; moderate‐quality evidence) and iron deficiency (PR 0.35, 95% CI 0.27 to 0.47, 5 trials, 1364 children; moderate‐quality evidence) and had higher haemoglobin (mean difference (MD) 3.37 g/L, 95% CI 0.94 to 5.80, 11 trials, 2746 children; low‐quality evidence). Only one trial with 115 children reported on all‐cause mortality (zero cases; low‐quality evidence). There was no effect on diarrhoea (risk ratio (RR) 0.97, 95% CI 0.53 to 1.78, 2 trials, 366 children; low‐quality evidence). Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children. However, information on mortality, morbidity, developmental outcomes and adverse effects is still scarce. Plain language summary Powdered vitamins and minerals added to foods at the point‐of‐use reduces anaemia and iron deficiency in preschool‐ and school‐age children Background to the question Approximately one billion people worldwide are deficient in at least one vitamin or mineral (also known of micronutrients). Iron, vitamin A, zinc and iodine deficiencies are very frequent among children of preschool (aged 24 months to less than 5 years) and school age (5 to 12 years of age), limiting their health and daily physical performance. Anaemia, the condition in which red blood cells have limited capacity to carry oxygen, frequently results after prolonged iron deficiency. Point‐of‐use fortification with powdered vitamins and minerals has been proposed as a public health intervention to reduce micronutrient deficiencies in children. In this process, a powdered premix containing iron, and possibly other vitamins and minerals, is added to foods either during or after cooking, or immediately before consumption to improve their nutritious value but not their flavour or colour. In some cases, point‐of‐use fortification is also known as home fortification. Review question What are the effects of point‐of‐use fortification of foods with iron‐containing micronutrient powders (MNP) alone, or in combination with other vitamins and minerals, on nutrition, health and development among children of preschool and school age (24 months to 12 years of age) compared with no intervention, a placebo (dummy pill) or regular iron‐containing supplements (as drops, tablets or syrup)? Study characteristics This review included 13 trials with 5810 participants from Latin America, Africa and Asia. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. Six trials included participants younger than 59 months of age only, four included only children aged 60 months of age or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. We searched existing clinical trials in December 2016 and ongoing trials in April 2017. We also contacted relevant institutions for additional information upon publication of the protocol and in April 2017. Key results The review found that children receiving iron‐containing MNP for point‐of‐use fortification of foods were at significantly lower risk of having anaemia and iron deficiency and had higher haemoglobin concentrations. We did not find any positive or negative effect on diarrhoea or mortality, but the data on these two outcomes were very limited. Quality of the evidence We rated the overall quality of the evidence for the provision of multiple MNP versus no intervention or placebo as moderate for anaemia, iron deficiency and adverse effects. We judged the evidence to be of low quality for haemoglobin, mortality and diarrhoea, and to be very low‐quality for ferritin. In general, the most common risk of bias in the studies was the lack of blinding for participants, personnel and outcome assessors. Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children and seems feasible for public health purposes. However, future research should aim to increase the body of evidence on mortality, morbidity, developmental outcomes and adverse effects. Due to the lack of trials, we were unable to determine at this time if this intervention has comparable effects to those observed with iron supplements (provided as drops, tablets or syrup).", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "De‐Regil, LM; Jefferds, MED; Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009666.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "44379049-4eec-46f9-af96-162739c25950", "pmid": "", "title": "A Phase 1, Randomised, Single-blind, Placebo-controlled, Single-centre Study to Investigate the Safety, Tolerability and Pharmacokinetics of Single and Multiple Doses of Elarekibep Given Twice Daily as Inhaled or a Single IV Formulation in Healthy Japanese Subjects", "imported": false, "abstract": "This study will assess the safety, tolerability and pharmacokinetics (PK) of elarekibep after single and multiple doses given twice daily (BID) by inhalation or intravenous (IV) in healthy Japanese subjects compared with placebo.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.239Z" }, { "id": "443b45d3-288d-40b1-8b1e-6c9985713de7", "pmid": "", "title": "Chinese herbal medicine for primary dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Conventional treatment for primary dysmenorrhoea has a failure rate of 20% to 25% and may be contraindicated or not tolerated by some women. Chinese herbal medicine may be a suitable alternative. Objectives To determine the efficacy and safety of Chinese herbal medicine for primary dysmenorrhoea when compared with placebo, no treatment, and other treatment. Search methods The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007), EMBASE (1980 to January 2007), CINAHL (1982 to January 2007), AMED (1985 to January 2007), CENTRAL (The Cochrane Library issue 4, 2006), China National Knowledge Infrastructure (CNKI, 1990 to January 2007), Traditional Chinese Medicine Database System (TCMDS, 1990 to December 2006), and the Chinese BioMedicine Database (CBM, 1990 to December 2006) were searched. Citation lists of included trials were also reviewed. Selection criteria Any randomised controlled trials involving Chinese herbal medicine versus placebo, no treatment, conventional therapy, heat compression, another type of Chinese herbal medicine, acupuncture or massage. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra‐uterine contraceptive device. Data collection and analysis Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Data were combined for meta‐analysis using either Peto odds ratios or relative risk (RR) for dichotomous data or weighted mean difference for continuous data. A fixed‐effect statistical model was used, where suitable. If data were not suitable for meta‐analysis, any available data from the trial were extracted and presented as descriptive data. Main results Thirty‐nine randomised controlled trials involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for Chinese herbal medicine compared to placebo were unclear as data could not be combined (3 RCTs). Chinese herbal medicine resulted in significant improvements in pain relief (14 RCTs; RR 1.99, 95% CI 1.52 to 2.60), overall symptoms (6 RCTs; RR 2.17, 95% CI 1.73 to 2.73) and use of additional medication (2 RCTs; RR 1.58, 95% CI 1.30 to 1.93) when compared to use of pharmaceutical drugs. Self‐designed Chinese herbal formulae resulted in significant improvements in pain relief (18 RCTs; RR 2.06, 95% CI 1.80 to 2.36), overall symptoms (14 RCTs; RR 1.99, 95% CI 1.65 to 2.40) and use of additional medication (5 RCTs; RR 1.58, 95% CI 1.34 to 1.87) after up to three months of follow‐up when compared to commonly used Chinese herbal health products. Chinese herbal medicine also resulted in better pain relief than acupuncture (2 RCTs; RR 1.75, 95% CI 1.09 to 2.82) and heat compression (1 RCT; RR 2.08, 95% CI 2.06 to 499.18). Authors' conclusions The review found promising evidence supporting the use of Chinese herbal medicine for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials. Plain language summary Chinese herbal medicine may help reduce menstrual pain. Dysmenorrhoea is a very common complaint that refers to painful menstrual cramps in abdomen. Primary dysmenorrhoea refers to pain of an unknown cause (i.e. no medical condition is identified). Nonsteroidal anti‐inflammatory drugs or the contraceptive pill have been used successfully for treatment but more women are looking for non‐drug therapies. Chinese herbal medicine has been used for centuries in China and it is currently used in public hospitals in China for the treatment of primary dysmenorrhoea. The review found promising evidence for the use of Chinese herbal medicine in reducing menstrual pain in the treatment of primary dysmenorrhoea, compared to conventional medicine such as NSAIDs and the oral contraceptive pill, acupuncture and heat compression. No significant adverse effects were identified in this review. However the findings should be interpreted with caution due to the generally low methodological quality of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Zhu, X; Proctor, M; Bensoussan, A; Wu, E; Smith, CA", "articleTypes": [], "doi": "10.1002/14651858.CD005288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "44557661-43c2-4901-aca5-3b99051095aa", "pmid": "", "title": "Probiotics for induction of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Ulcerative colitis is an inflammatory condition affecting the colon, with an annual incidence of approximately 10 to 20 per 100,000 people. The majority of people with ulcerative colitis can be put into remission, leaving a group who do not respond to first‐ or second‐line therapies. There is a significant proportion of people who experience adverse effects with current therapies. Consequently, new alternatives for the treatment of ulcerative colitis are constantly being sought. Probiotics are live microbial feed supplements that may beneficially affect the host by improving intestinal microbial balance, enhancing gut barrier function and improving local immune response. Objectives To assess the efficacy of probiotics compared with placebo or standard medical treatment (5‐aminosalicylates, sulphasalazine or corticosteroids) for the induction of remission in people with active ulcerative colitis. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 31 October 2019. We contacted authors of relevant studies and manufacturers of probiotics regarding ongoing or unpublished trials that may be relevant to the review, and we searched ClinicalTrials.gov. We also searched references of trials for any additional trials. Selection criteria Randomised controlled trials (RCTs) investigating the effectiveness of probiotics compared to standard treatments or placebo in the induction of remission of active ulcerative colitis. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We analysed data using Review Manager 5. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE methodology. Main results In this review, we included 14 studies (865 randomised participants) that met the inclusion criteria. Twelve of the studies looked at adult participants and two studies looked at paediatric participants with mild to moderate ulcerative colitis, the average age was between 12.5 and 47.7 years. The studies compared probiotics to placebo, probiotics to 5‐ASA and a combination of probiotics plus 5‐ASA compared to 5‐ASA alone. Seven studies used a single probiotic strain and seven used a mixture of strains. The studies ranged from two weeks to 52 weeks. The risk of bias was high for all except two studies due to allocation concealment, blinding of participants, incomplete reports of outcome data and selective reporting. This led to GRADE ratings of the evidence ranging from moderate to very low. Probiotics versus placebo 
Probiotics may induce clinical remission when compared to placebo (RR 1.73, 95% CI 1.19 to 2.54; 9 studies, 594 participants; low‐certainty evidence; downgraded due to imprecision and risk of bias, number needed to treat for an additional beneficial outcome (NNTB) 5). Probiotics may lead to an improvement in clinical disease scores (RR 2.29, 95% CI 1.13 to 4.63; 2 studies, 54 participants; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.04, 95% CI 0.42 to 2.59; 7 studies, 520 participants). Reported adverse events included abdominal bloating and discomfort. Probiotics did not lead to any serious adverse events in any of the seven studies that reported on it, however five adverse events were reported in the placebo arm of one study (RR 0.09, CI 0.01 to 1.66; 1 study, 526 participants; very low‐certainty evidence; downgraded due to high risk of bias and imprecision). Probiotics may make little or no difference to withdrawals due to adverse events (RR 0.85, 95% CI 0.42 to 1.72; 4 studies, 401 participants; low‐certainty evidence). Probiotics versus 5‐ASA 
There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (RR 0.92, 95% CI 0.73 to 1.16; 1 study, 116 participants; low‐certainty evidence; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.33, 95% CI 0.53 to 3.33; 1 study, 116 participants). Reported adverse events included abdominal pain, nausea, headache and mouth ulcers. There were no serious adverse events with probiotics, however perforated sigmoid diverticulum and respiratory failure in a patient with severe emphysema were reported in the 5‐ASA arm (RR 0.21, 95% CI 0.01 to 4.22; 1 study, 116 participants; very low‐certainty evidence). Probiotics combined with 5‐ASA versus 5‐ASA alone 
Low‐certainty evidence from a single study shows that when combined with 5‐ASA, probiotics may slightly improve the induction of remission (based on the Sunderland disease activity index) compared to 5‐ASA alone (RR 1.22 CI 1.01 to 1.47; 1 study, 84 participants; low‐certainty evidence; downgraded due to unclear risk of bias and imprecision). No information about adverse events was reported. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes (progression to surgery, need for additional therapy, quality of life scores, or steroid withdrawal) were reported in any of the studies. Authors' conclusions Low‐certainty evidence suggests that probiotics may induce clinical remission in active ulcerative colitis when compared to placebo. There may be little or no difference in clinical remission with probiotics alone compared to 5‐ASA. There is limited evidence from a single study which failed to provide a definition of remission, that probiotics may slightly improve the induction of remission when used in combination with 5‐ASA. There was no evidence to assess whether probiotics are effective in people with severe and more extensive disease, or if specific preparations are superior to others. Further targeted and appropriately designed RCTs are needed to address the gaps in the evidence base. In particular, appropriate powering of studies and the use of standardised participant groups and outcome measures in line with the wider field are needed, as well as reporting to minimise risk of bias. Plain language summary Probiotics for the treatment of active ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can induce remission in people with ulcerative colitis. We analysed data from 14 studies to answer this question. Key messages Probiotics may be better at inducing remission than placebo (dummy treatment). It is unclear whether probiotics are better than 5‐aminosalicylic acid (5‐ASA, an anti‐inflammatory agent used to treat inflammatory bowel disease), however there is limited evidence that when both treatments are used as combined therapy they may be better than 5‐ASA alone in inducing remission. Most studies reported that no serious adverse events took place. For the studies that did report on it, serious adverse events did not occur in the probiotic group. Minor adverse events reported were bloating and diarrhoea. What was studied in the review? Ulcerative colitis is a relapsing and remitting disease which causes inflammation of the large bowel and leads to symptoms such as abdominal pain, diarrhoea and tiredness. There is some evidence to suggest that an imbalance in the bacteria of the gut is the cause of the disease, and therefore probiotics, which are live micro‐organisms, can alter the bacteria and possibly reduce the inflammation. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing probiotics with placebo, probiotics with 5‐ASA, and probiotics in combination with 5‐ASA. We found 14 RCTs looking at 865 participants. The trials looked at adult and paediatric participants. Eight studies allowed additional therapy to continue, whilst the other four studies were unclear about this. 1) Probiotics may improve induction of clinical remission when compared to placebo. 2) It is unclear whether probiotics lead to a difference in adverse events (minor and serious) when compared to placebo. 3) There is limited evidence to determine whether probiotics offer better disease improvement when compared to placebo. 4) There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (low‐certainty evidence). 5) There is limited evidence to suggest that when probiotics plus 5‐ASA are compared to 5‐ASA alone, probiotics may offer a slightly better chance of induction of remission. This is based on low‐certainty evidence from one study, and we are not sure of the type of remission studied. 6) Serious adverse events were reported when probiotics were compared with placebo, but only occurred in the placebo group. Conclusion Whilst the evidence suggests that probiotics may be better at improving induction than placebo, our confidence in the estimate is limited because of the low‐certainty evidence. This is attributed to the small number of participants in each study along with the unreliable methods utilised by the trials. With the evidence presented in these studies, we are unable to make strong conclusions into the effectiveness of probiotics; better designed studies with more participants are needed. How up‐to‐date is this review? This review is up‐to‐date as of October 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Kaur, L; Gordon, M; Baines, PA; Iheozor-Ejiofor, Z; Sinopoulou, V; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD005573.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "44629171-6011-4ae0-b99d-16b0e83f6fe2", "pmid": "", "title": "Prophylactic TCM for Mitigation of EGFR-TKI Related Dermatological Adverse Effect", "imported": false, "abstract": "Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have become standard practice for advanced non-small cell lung cancer (NSCLC) with EGFR gene mutation. EGFR-TKIs involving Afatinib, Erlotinib, and Gefitinib were Food and Drug Administration (FDA) approved since 2006 and given payment continuously for lung adenocarcinoma with EGFR mutation in Taiwan.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.249Z" }, { "id": "4463c648-63db-4a43-ad05-29e6bd0e80e0", "pmid": "", "title": "Taste Preferences for Nutritive and Non Nutritive Sweeteners Among Children and Adults", "imported": false, "abstract": "The goal of the study is to determine whether there are age-, diet- and genetically-related differences in the perception of sweeteners, both nutritive and non-nutritive.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.145Z" }, { "id": "446e67a6-65ba-4793-a45d-77cec1a9c6a5", "pmid": "", "title": "Pharmacological interventions for smoking cessation: an overview and network meta‐analysis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Cahill, K, Stevens, S, Perera, R, Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD009329.pub2 AB - Abstract - Background Smoking is the leading preventable cause of illness and premature death worldwide. Some medications have been proven to help people to quit, with three licensed for this purpose in Europe and the USA: nicotine replacement therapy (NRT), bupropion, and varenicline. Cytisine (a treatment pharmacologically similar to varenicline) is also licensed for use in Russia and some of the former socialist economy countries. Other therapies, including nortriptyline, have also been tested for effectiveness. Objectives How do NRT, bupropion and varenicline compare with placebo and with each other in achieving long‐term abstinence (six months or longer)?
 How do the remaining treatments compare with placebo in achieving long‐term abstinence?
 How do the risks of adverse and serious adverse events (SAEs) compare between the treatments, and are there instances where the harms may outweigh the benefits? Methods The overview is restricted to Cochrane reviews, all of which include randomised trials. Participants are usually adult smokers, but we exclude reviews of smoking cessation for pregnant women and in particular disease groups or specific settings. We cover nicotine replacement therapy (NRT), antidepressants (bupropion and nortriptyline), nicotine receptor partial agonists (varenicline and cytisine), anxiolytics, selective type 1 cannabinoid receptor antagonists (rimonabant), clonidine, lobeline, dianicline, mecamylamine, Nicobrevin, opioid antagonists, nicotine vaccines, and silver acetate. Our outcome for benefit is continuous or prolonged abstinence at least six months from the start of treatment. Our outcome for harms is the incidence of serious adverse events associated with each of the treatments.
 We searched the Cochrane Database of Systematic Reviews (CDSR) in The Cochrane Library , for any reviews with 'smoking' in the title, abstract or keyword fields. The last search was conducted in November 2012. We assessed methodological quality using a revised version of the AMSTAR scale. For NRT, bupropion and varenicline we conducted network meta‐analyses, comparing each with the others and with placebo for benefit, and varenicline and bupropion for risks of serious adverse events. Main results We identified 12 treatment‐specific reviews. The analyses covered 267 studies, involving 101,804 participants. Both NRT and bupropion were superior to placebo (odds ratios (OR) 1.84; 95% credible interval (CredI) 1.71 to 1.99, and 1.82; 95% CredI 1.60 to 2.06 respectively). Varenicline increased the odds of quitting compared with placebo (OR 2.88; 95% CredI 2.40 to 3.47). Head‐to‐head comparisons between bupropion and NRT showed equal efficacy (OR 0.99; 95% CredI 0.86 to 1.13). Varenicline was superior to single forms of NRT (OR 1.57; 95% CredI 1.29 to 1.91), and to bupropion (OR 1.59; 95% CredI 1.29 to 1.96).
 Varenicline was more effective than nicotine patch (OR 1.51; 95% CredI 1.22 to 1.87), than nicotine gum (OR 1.72; 95% CredI 1.38 to 2.13), and than 'other' NRT (inhaler, spray, tablets, lozenges; OR 1.42; 95% CredI 1.12 to 1.79), but was not more effective than combination NRT (OR 1.06; 95% CredI 0.75 to 1.48). Combination NRT also outperformed single formulations. The four categories of NRT performed similarly against each other, apart from 'other' NRT, which was marginally more effective than NRT gum (OR 1.21; 95% CredI 1.01 to 1.46).
 Cytisine (a nicotine receptor partial agonist) returned positive findings (risk ratio (RR) 3.98; 95% CI 2.01 to 7.87), without significant adverse events or SAEs.
 Across the 82 included and excluded bupropion trials, our estimate of six seizures in the bupropion arms versus none in the placebo arms was lower than the expected rate (1:1000), at about 1:1500. SAE meta‐analysis of the bupropion studies demonstrated no excess of neuropsychiatric (RR 0.88; 95% CI 0.31 to 2.50) or cardiovascular events (RR 0.77; 95% CI 0.37 to 1.59). SAE meta‐analysis of 14 varenicline trials found no difference between the varenicline and placebo arms (RR 1.06; 95% CI 0.72 to 1.55), and subgroup analyses detected no significant excess of neuropsychiatric events (RR 0.53; 95% CI 0.17 to 1.67), or of cardiac events (RR 1.26; 95% CI 0.62 to 2.56).
 Nortriptyline increased the chances of quitting (RR 2.03; 95% CI 1.48 to 2.78). Neither nortriptyline nor bupropion were shown to enhance the effect of NRT compared with NRT alone. Clonidine increased the chances of quitting (RR 1.63; 95% CI 1.22 to 2.18), but this was offset by a dose‐dependent rise in adverse events. Mecamylamine in combination with NRT may increase the chances of quitting, but the current evidence is inconclusive. Other treatments failed to demonstrate a benefit compared with placebo. Nicotine vaccines are not yet licensed for use as an aid to smoking cessation or relapse prevention. Nicobrevin's UK license is now revoked, and the manufacturers of rimonabant, taranabant and dianicline are no longer supporting the development or testing of these treatments. Authors' conclusions NRT, bupropion, varenicline and cytisine have been shown to improve the chances of quitting. Combination NRT and varenicline are equally effective as quitting aids. Nortriptyline also improves the chances of quitting. On current evidence, none of the treatments appear to have an incidence of adverse events that would mitigate their use.
 Further research is warranted into the safety of varenicline and into cytisine's potential as an effective and affordable treatment, but not into the efficacy and safety of NRT. Plain language summary Medications to help people to stop smoking: an overview of reviews Background 
 Smoking is a main cause of early death throughout the world. There are a number of medications which can help people to quit smoking. Three of these, nicotine replacement therapy (NRT), bupropion and varenicline, are licensed for this purpose in the USA and Europe. Cytisine (similar to varenicline) is licensed for use in Russia and Eastern Europe. We reviewed studies of these and other treatments, including nortriptyline, to compare their benefits and risks.
 Methods 
 We found 12 Cochrane reviews of different treatments. The treatments include nicotine replacement therapy (NRT); antidepressants (bupropion and nortriptyline); nicotine receptor partial agonists (varenicline and cytisine); anxiolytics; selective type 1 cannabinoid receptor antagonists (rimonabant); clonidine; lobeline; dianicline; mecamylamine; Nicobrevin; opioid antagonists; nicotine vaccines; and silver acetate. The reviews were conducted between 2008 and 2012, and analysed 267 trials, covering more than 101,000 smokers. All the reviews used randomised controlled trials, and compared the active treatment with a placebo, and sometimes with other treatments. The outcomes were measured at least six months from the start of treatment, and the results were usually checked by testing breath, blood or urine. We also assessed the risk of harms from each treatment. We then compared NRT, bupropion and varenicline with each other, using a network meta‐analysis.
 Results 
 NRT and bupropion helped about 80% more people to quit than placebo; this means that for every 10 people who quit with placebo about 18 could be expected to quit with NRT or with bupropion. Varenicline more than doubled the chances of quitting compared with placebo, so that for every 10 who quit with placebo about 28 could be expected to quit with varenicline.
 Varenicline helped about 50% more people to quit than nicotine patch and 'other' NRT (tablets, sprays, lozenges and inhalers), and about 70% more people than nicotine gum. So for every 10 people who quit with NRT patch or with 'other' NRT, about 15 could be expected to quit with varenicline, and for every 10 who quit with NRT gum about 17 could be expected to quit with varenicline. Combining two type of NRT was as effective as using varenicline, and helped more people to quit than single types of NRT. There was little to choose between different types of NRT, apart from 'other' NRT, which helped slightly more people than nicotine gum; for every 10 people who quit with NRT gum, about 12 could be expected to quit with 'other' NRT.
 NRT combined with nortriptyline or with bupropion was not more effective than NRT alone.
 Both cytisine and nortriptyline compared with placebo improved the chances of quitting, with minimal risk of harms.
 
 Bupropion carries a known risk of seizures (about 1 per 1000 users), but we found fewer than expected in the included and excluded trials, at about 1 in 1500. Although there may be a marginal increase in the likelihood of any serious adverse event while taking bupropion, we did not find increased risks of neuropsychiatric or heart and circulatory problems in the bupropion studies. The evidence for the safety of varenicline is still under investigation; we found no evidence from the trials that it is linked to an increase in neuropsychiatric problems, or with increased heart and circulatory problems.
 
 Clonidine helped people to quit, but caused side effects. It is not clear whether or not mecamylamine used with NRT helps people to quit. Other treatments did not seem to help. So far, nicotine vaccines are not licensed for use anywhere in the world. Nicobrevin is no longer available in the UK, and rimonabant, taranabant and dianicline have all been withdrawn from the market.
 Conclusions 
 NRT, bupropion and varenicline all improve the chances of quitting, with a low risk of harms.
 Combination use of NRT is as effective as varenicline, and more effective than single types of NRT.
 Cytisine has potential as a safe, effective and affordable treatment.
 Nortriptyline improves the chances of quitting, with little evidence of harmful events.
 We need continued monitoring of the safety of varenicline.
 More research into NRT versus placebo is unlikely to change our understanding of the treatment.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.770Z" }, { "id": "4493f112-d367-4caa-837a-f31b149fa9a8", "pmid": "", "title": "Eplerenone for hypertension", "imported": false, "abstract": "Abstract - Background Eplerenone is an aldosterone receptor blocker that is chemically derived from spironolactone. In Canada, it is indicated for use as adjunctive therapy to reduce mortality for heart failure patients with New York Heart Association (NYHA) class II systolic chronic heart failure and left ventricular systolic dysfunction. It is also used as adjunctive therapy for patients with heart failure following myocardial infarction. Additionally, it is indicated for the treatment of mild and moderate essential hypertension for patients who cannot be treated adequately with other agents. It is important to determine the clinical impact of all antihypertensive medications, including aldosterone antagonists, to support their continued use in essential hypertension. No previous systematic reviews have evaluated the effect of eplerenone on cardiovascular morbidity, mortality, and magnitude of blood pressure lowering in patients with hypertension. Objectives To assess the effects of eplerenone monotherapy versus placebo for primary hypertension in adults. Outcomes of interest were all‐cause mortality, cardiovascular events (fatal or non‐fatal myocardial infarction), cerebrovascular events (fatal or non fatal strokes), adverse events or withdrawals due to adverse events, and systolic and diastolic blood pressure. Search methods We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers up to 3 March 2016. We handsearched references from retrieved studies to identify any studies missed in the initial search. We also searched for unpublished data by contacting the corresponding authors of the included studies and pharmaceutical companies involved in conducting studies on eplerenone monotherapy in primary hypertension. The search had no language restrictions. Selection criteria We selected randomized placebo‐controlled trials studying adult patients with primary hypertension. We excluded studies in people with secondary or gestational hypertension and studies where participants were receiving multiple antihypertensives. Data collection and analysis Three review authors independently reviewed the search results for studies meeting our criteria. Three review authors independently extracted data and assessed trial quality using a standardized data extraction form. A fourth independent review author resolved discrepancies or disagreements. We performed data extraction and synthesis using a standardized format on Covidence. We conducted data analysis using Review Manager 5. Main results A total of 1437 adult patients participated in the five randomized parallel group studies, with treatment durations ranging from 8 to 16 weeks. The daily doses of eplerenone ranged from 25 mg to 400 mg daily. Meta‐analysis of these studies showed a reduction in systolic blood pressure of 9.21 mmHg (95% CI −11.08 to −7.34; I 2 = 58%) and a reduction of diastolic pressure of 4.18 mmHg (95% CI −5.03 to −3.33; I 2 = 0%) (moderate quality evidence). There may be a dose response effect for eplerenone in the reduction in systolic blood pressure at doses of 400 mg/day. However, this finding is uncertain, as it is based on a single included study with low quality evidence. Overall there does not appear to be a clinically important dose response in lowering systolic or diastolic blood pressure at eplerenone doses of 50 mg to 400 mg daily. There did not appear to be any differences in the number of patients who withdrew due to adverse events or the number of patients with at least one adverse event in the eplerenone group compared to placebo. However, only three of the five included studies reported adverse events. Most of the included studies were of moderate quality, as we judged multiple domains as being at unclear risk in the 'Risk of bias' assessment. Authors' conclusions Eplerenone 50 to 200 mg/day lowers blood pressure in people with primary hypertension by 9.21 mmHg systolic and 4.18 mmHg diastolic compared to placebo, with no difference of effect between doses of 50 mg/day to 200 mg/day. A dose of 25 mg/day did not produce a statistically significant reduction in systolic or diastolic blood pressure and there is insufficient evidence for doses above 200 mg/day. There is currently no available evidence to determine the effect of eplerenone on clinically meaningful outcomes such as mortality or morbidity in hypertensive patients. The evidence available on side effects is insufficient and of low quality, which makes it impossible to draw conclusions about potential harm associated with eplerenone treatment in hypertensive patients. Plain language summary Eplerenone for high blood pressure Review question The aim of this review was to determine the effectiveness of eplerenone for reducing blood pressure, its side effect profile, and its impact on clinically meaningful outcomes such as mortality and morbidity. Background Clinicians have used eplerenone to treat high blood pressure since 2002. It is important to determine the clinical impact of all antihypertensive medications used in patients to support their continued use in essential hypertension. We searched multiple databases and found five eligible studies in 1437 people who received either eplerenone or no medication in a random fashion. Study characteristics The doses of eplerenone used in these studies ranged from 25 mg to 400 mg daily. These studies followed patients for 8 to 16 weeks while on therapy. None of the studies reported on the clinically meaningful outcomes of eplerenone, such as whether eplerenone can reduce heart attacks, stroke, or death compared to placebo. Only three of the five studies reported on side effects. Key results There is currently no evidence that eplerenone has a beneficial effect on life expectancy or complications rleated to hypertension (e.g. heart attack, stroke). Evidence for risk of side effects with eplerenone is limited and of poor quality; it is difficult to tell the extent of possible harm with eplerenone versus placebo. This meta‐analysis shows that eplerenone 50 to 200 mg/day reduces systolic blood pressure by approximately 9 mmHg and diastolic blood pressure by 4 mmHg compared to taking no medication. Quality of the evidence We judged the five included trials to be of moderate quality, as authors did not extensively describe portions of their methodology.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tam, TSC, Wu, MHY, Masson, SC, Tsang, MP, Stabler, SN, Kinkade, A, Tung, A, Tejani, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.770Z" }, { "id": "449abdc3-8afd-434f-a04b-166fb3cd52ba", "pmid": "", "title": "Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, rhinorrhoea, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. The use of topical (intranasal) corticosteroids has been widely advocated for the treatment of chronic rhinosinusitis given the belief that inflammation is a major component of this condition. Objectives To assess the effects of intranasal corticosteroids in people with chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) with a follow‐up period of at least three months comparing intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) against placebo or no treatment in patients with chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity and the commonest adverse event ‐ epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation or other systemic adverse events. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 18 RCTs with a total of 2738 participants. Fourteen studies had participants with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. Intranasal corticosteroids versus placebo or no intervention Only one study (20 adult participants without polyps) measured our primary outcome disease‐specific HRQL using the Rhinosinusitis Outcome Measures‐31 (RSOM‐31). They reported no significant difference (numerical data not available) ( very low quality evidence). Our second primary outcome, disease severity , was measured using the Chronic Sinusitis Survey in a second study (134 participants without polyps), which found no important difference (mean difference (MD) 2.84, 95% confidence interval (CI) ‐5.02 to 10.70; scale 0 to 100). Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group (RR 2.78, 95% CI 1.76 to 4.40; 109 participants). The quality of the evidence was low . Six studies provided data on at least two of the individual symptoms used in the EPOS 2012 criteria to define chronic rhinosinusitis (nasal blockage, rhinorrhoea, loss of sense of smell and facial pain/pressure). When all four symptoms in the EPOS criteria were available on a scale of 0 to 3 (higher = more severe symptoms), the average MD in change from baseline was ‐0.26 (95% CI ‐0.37 to ‐0.15; 243 participants; two studies; low quality evidence). Although there were more studies and participants when only nasal blockage and rhinorrhoea were considered (MD ‐0.31, 95% CI ‐0.38 to ‐0.24; 1702 participants; six studies), the MD was almost identical to when loss of sense of smell was also considered (1345 participants, four studies; moderate quality evidence). When considering the results for the individual symptoms, benefit was shown in the intranasal corticosteroids group. The effect size was larger for nasal blockage (MD ‐0.40, 95% CI ‐0.52 to ‐0.29; 1702 participants; six studies) than for rhinorrhoea (MD ‐0.25, 95% CI ‐0.33 to ‐0.17; 1702 participants; six studies) or loss of sense of smell (MD ‐0.19, 95% CI ‐0.28 to ‐0.11; 1345 participants; four studies). There was heterogeneity in the analysis for facial pain/pressure (MD ‐0.27, 95% CI ‐0.56 to 0.02; 243 participants; two studies). The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure. There was an increased risk of epistaxis with intranasal corticosteroids (risk ratio (RR) 2.74, 95% CI 1.88 to 4.00; 2508 participants; 13 studies; high quality evidence). Considering our secondary outcome, general HRQL, one study (134 participants without polyps) measured this using the SF‐36 and reported a statistically significant benefit only on the general health subscale. The quality of the evidence was very low . It is unclear whether there is a difference in the risk of local irritation (RR 0.94, 95% CI 0.53 to 1.64; 2124 participants; 11 studies) ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis or stunted growth (children). Other comparisons We identified no other studies that compared intranasal corticosteroids plus co‐intervention A versus placebo plus co‐intervention A. Authors' conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life ( very low quality evidence). For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of epistaxis is increased ( high quality evidence), but these data included all levels of severity; small streaks of blood may not be a major concern for patients. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) . Plain language summary Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of intranasal (in the nose) steroids given to people with chronic rhinosinusitis. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose (rhinorrhoea), pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation in order to improve patient symptoms. Study characteristics We included 18 randomised controlled trials (RCTs) with a total of 2738 participants in this review. Most studies were relatively small, with as few as 9 or 10 patients per intervention arm. The largest study had 748 patients in total. Most were conducted in tertiary referral centres in northern Europe, the US and Canada. Fourteen studies only included participants with chronic rhinosinusitis with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Key results and quality of the evidence One study (20 participants) reported no statistically significant difference in disease‐specific health‐related quality of life. Another measured general health‐related quality of life and reported a statistically significant benefit only on a subscale for general health. Both studies recruited participants with chronic rhinosinusitis without nasal polyps. The quality of the evidence was very low (we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect). Disease severity was measured in one study (chronic rhinosinusitis without nasal polyps, 134 participants), which found no important difference. Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group. The quality of the evidence was low (our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect). When each type of symptom was measured separately (nasal blockage, rhinorrhoea, loss of sense of smell, facial pain/pressure), benefit was shown in the intranasal corticosteroids group. The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure (moderate quality evidence means we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different). There was an increased risk of nosebleeds (epistaxis) with intranasal corticosteroids ( high quality evidence). However, it was unclear whether there was a difference in the risk of local (nose or throat) irritation ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis (fragile bones) or stunted growth (in children). Conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life and the quality of this evidence is very low . For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of nosebleeds is increased ( high quality evidence), but this included all levels of severity; for some patients small streaks of blood may not be a major concern. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) .", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chong, LY; Head, K; Hopkins, C; Philpott, C; Schilder, AGM; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "449d12e4-2cf9-49c2-8aa7-ef6d2909ddb9", "pmid": "", "title": "Pharmacological interventions for smoking cessation: an overview and network meta‐analysis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Cahill, K, Stevens, S, Perera, R, Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD009329.pub2 AB - Abstract - Background Smoking is the leading preventable cause of illness and premature death worldwide. Some medications have been proven to help people to quit, with three licensed for this purpose in Europe and the USA: nicotine replacement therapy (NRT), bupropion, and varenicline. Cytisine (a treatment pharmacologically similar to varenicline) is also licensed for use in Russia and some of the former socialist economy countries. Other therapies, including nortriptyline, have also been tested for effectiveness. Objectives How do NRT, bupropion and varenicline compare with placebo and with each other in achieving long‐term abstinence (six months or longer)?
 How do the remaining treatments compare with placebo in achieving long‐term abstinence?
 How do the risks of adverse and serious adverse events (SAEs) compare between the treatments, and are there instances where the harms may outweigh the benefits? Methods The overview is restricted to Cochrane reviews, all of which include randomised trials. Participants are usually adult smokers, but we exclude reviews of smoking cessation for pregnant women and in particular disease groups or specific settings. We cover nicotine replacement therapy (NRT), antidepressants (bupropion and nortriptyline), nicotine receptor partial agonists (varenicline and cytisine), anxiolytics, selective type 1 cannabinoid receptor antagonists (rimonabant), clonidine, lobeline, dianicline, mecamylamine, Nicobrevin, opioid antagonists, nicotine vaccines, and silver acetate. Our outcome for benefit is continuous or prolonged abstinence at least six months from the start of treatment. Our outcome for harms is the incidence of serious adverse events associated with each of the treatments.
 We searched the Cochrane Database of Systematic Reviews (CDSR) in The Cochrane Library , for any reviews with 'smoking' in the title, abstract or keyword fields. The last search was conducted in November 2012. We assessed methodological quality using a revised version of the AMSTAR scale. For NRT, bupropion and varenicline we conducted network meta‐analyses, comparing each with the others and with placebo for benefit, and varenicline and bupropion for risks of serious adverse events. Main results We identified 12 treatment‐specific reviews. The analyses covered 267 studies, involving 101,804 participants. Both NRT and bupropion were superior to placebo (odds ratios (OR) 1.84; 95% credible interval (CredI) 1.71 to 1.99, and 1.82; 95% CredI 1.60 to 2.06 respectively). Varenicline increased the odds of quitting compared with placebo (OR 2.88; 95% CredI 2.40 to 3.47). Head‐to‐head comparisons between bupropion and NRT showed equal efficacy (OR 0.99; 95% CredI 0.86 to 1.13). Varenicline was superior to single forms of NRT (OR 1.57; 95% CredI 1.29 to 1.91), and to bupropion (OR 1.59; 95% CredI 1.29 to 1.96).
 Varenicline was more effective than nicotine patch (OR 1.51; 95% CredI 1.22 to 1.87), than nicotine gum (OR 1.72; 95% CredI 1.38 to 2.13), and than 'other' NRT (inhaler, spray, tablets, lozenges; OR 1.42; 95% CredI 1.12 to 1.79), but was not more effective than combination NRT (OR 1.06; 95% CredI 0.75 to 1.48). Combination NRT also outperformed single formulations. The four categories of NRT performed similarly against each other, apart from 'other' NRT, which was marginally more effective than NRT gum (OR 1.21; 95% CredI 1.01 to 1.46).
 Cytisine (a nicotine receptor partial agonist) returned positive findings (risk ratio (RR) 3.98; 95% CI 2.01 to 7.87), without significant adverse events or SAEs.
 Across the 82 included and excluded bupropion trials, our estimate of six seizures in the bupropion arms versus none in the placebo arms was lower than the expected rate (1:1000), at about 1:1500. SAE meta‐analysis of the bupropion studies demonstrated no excess of neuropsychiatric (RR 0.88; 95% CI 0.31 to 2.50) or cardiovascular events (RR 0.77; 95% CI 0.37 to 1.59). SAE meta‐analysis of 14 varenicline trials found no difference between the varenicline and placebo arms (RR 1.06; 95% CI 0.72 to 1.55), and subgroup analyses detected no significant excess of neuropsychiatric events (RR 0.53; 95% CI 0.17 to 1.67), or of cardiac events (RR 1.26; 95% CI 0.62 to 2.56).
 Nortriptyline increased the chances of quitting (RR 2.03; 95% CI 1.48 to 2.78). Neither nortriptyline nor bupropion were shown to enhance the effect of NRT compared with NRT alone. Clonidine increased the chances of quitting (RR 1.63; 95% CI 1.22 to 2.18), but this was offset by a dose‐dependent rise in adverse events. Mecamylamine in combination with NRT may increase the chances of quitting, but the current evidence is inconclusive. Other treatments failed to demonstrate a benefit compared with placebo. Nicotine vaccines are not yet licensed for use as an aid to smoking cessation or relapse prevention. Nicobrevin's UK license is now revoked, and the manufacturers of rimonabant, taranabant and dianicline are no longer supporting the development or testing of these treatments. Authors' conclusions NRT, bupropion, varenicline and cytisine have been shown to improve the chances of quitting. Combination NRT and varenicline are equally effective as quitting aids. Nortriptyline also improves the chances of quitting. On current evidence, none of the treatments appear to have an incidence of adverse events that would mitigate their use.
 Further research is warranted into the safety of varenicline and into cytisine's potential as an effective and affordable treatment, but not into the efficacy and safety of NRT. Plain language summary Medications to help people to stop smoking: an overview of reviews Background 
 Smoking is a main cause of early death throughout the world. There are a number of medications which can help people to quit smoking. Three of these, nicotine replacement therapy (NRT), bupropion and varenicline, are licensed for this purpose in the USA and Europe. Cytisine (similar to varenicline) is licensed for use in Russia and Eastern Europe. We reviewed studies of these and other treatments, including nortriptyline, to compare their benefits and risks.
 Methods 
 We found 12 Cochrane reviews of different treatments. The treatments include nicotine replacement therapy (NRT); antidepressants (bupropion and nortriptyline); nicotine receptor partial agonists (varenicline and cytisine); anxiolytics; selective type 1 cannabinoid receptor antagonists (rimonabant); clonidine; lobeline; dianicline; mecamylamine; Nicobrevin; opioid antagonists; nicotine vaccines; and silver acetate. The reviews were conducted between 2008 and 2012, and analysed 267 trials, covering more than 101,000 smokers. All the reviews used randomised controlled trials, and compared the active treatment with a placebo, and sometimes with other treatments. The outcomes were measured at least six months from the start of treatment, and the results were usually checked by testing breath, blood or urine. We also assessed the risk of harms from each treatment. We then compared NRT, bupropion and varenicline with each other, using a network meta‐analysis.
 Results 
 NRT and bupropion helped about 80% more people to quit than placebo; this means that for every 10 people who quit with placebo about 18 could be expected to quit with NRT or with bupropion. Varenicline more than doubled the chances of quitting compared with placebo, so that for every 10 who quit with placebo about 28 could be expected to quit with varenicline.
 Varenicline helped about 50% more people to quit than nicotine patch and 'other' NRT (tablets, sprays, lozenges and inhalers), and about 70% more people than nicotine gum. So for every 10 people who quit with NRT patch or with 'other' NRT, about 15 could be expected to quit with varenicline, and for every 10 who quit with NRT gum about 17 could be expected to quit with varenicline. Combining two type of NRT was as effective as using varenicline, and helped more people to quit than single types of NRT. There was little to choose between different types of NRT, apart from 'other' NRT, which helped slightly more people than nicotine gum; for every 10 people who quit with NRT gum, about 12 could be expected to quit with 'other' NRT.
 NRT combined with nortriptyline or with bupropion was not more effective than NRT alone.
 Both cytisine and nortriptyline compared with placebo improved the chances of quitting, with minimal risk of harms.
 
 Bupropion carries a known risk of seizures (about 1 per 1000 users), but we found fewer than expected in the included and excluded trials, at about 1 in 1500. Although there may be a marginal increase in the likelihood of any serious adverse event while taking bupropion, we did not find increased risks of neuropsychiatric or heart and circulatory problems in the bupropion studies. The evidence for the safety of varenicline is still under investigation; we found no evidence from the trials that it is linked to an increase in neuropsychiatric problems, or with increased heart and circulatory problems.
 
 Clonidine helped people to quit, but caused side effects. It is not clear whether or not mecamylamine used with NRT helps people to quit. Other treatments did not seem to help. So far, nicotine vaccines are not licensed for use anywhere in the world. Nicobrevin is no longer available in the UK, and rimonabant, taranabant and dianicline have all been withdrawn from the market.
 Conclusions 
 NRT, bupropion and varenicline all improve the chances of quitting, with a low risk of harms.
 Combination use of NRT is as effective as varenicline, and more effective than single types of NRT.
 Cytisine has potential as a safe, effective and affordable treatment.
 Nortriptyline improves the chances of quitting, with little evidence of harmful events.
 We need continued monitoring of the safety of varenicline.
 More research into NRT versus placebo is unlikely to change our understanding of the treatment.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.110Z" }, { "id": "44c0e164-fb8b-444d-afc7-438c88792b54", "pmid": "", "title": "Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015. Objectives To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate. Selection criteria We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non‐serious, general behaviour, and quality of life. Data collection and analysis Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel‐group trials and first‐period data from cross‐over trials formed the basis of our primary analyses. We undertook separate analyses using end‐of‐last period data from cross‐over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach. Main results We included 212 trials (16,302 participants randomised); 55 parallel‐group trials (8104 participants randomised), and 156 cross‐over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross‐over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male‐female ratio was 3:1. Most trials were carried out in high‐income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias. Primary outcomes: methylphenidate versus placebo or no intervention may improve teacher‐rated ADHD symptoms (standardised mean difference (SMD) −0.74, 95% confidence interval (CI) −0.88 to −0.61; I² = 38%; 21 trials; 1728 participants; very low‐certainty evidence). This corresponds to a mean difference (MD) of −10.58 (95% CI −12.58 to −8.72) on the ADHD Rating Scale (ADHD‐RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD‐RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68). Secondary outcomes: methylphenidate may cause more adverse events considered non‐serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher‐rated general behaviour versus placebo (SMD −0.62, 95% CI −0.91 to −0.33; I² = 68%; 7 trials 792 participants; very low‐certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI −0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low‐certainty evidence). Authors' conclusions The majority of our conclusions from the 2015 version of this review still apply. Our updated meta‐analyses suggest that methylphenidate versus placebo or no‐intervention may improve teacher‐rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non‐serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non‐serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes. Plain language summary Is methylphenidate an effective treatment for children and adolescents with attention deficit hyperactivity disorder (ADHD) and does it cause unwanted effects? Key messages ‐ Methylphenidate might reduce hyperactivity and impulsivity and might help children to concentrate. Methylphenidate might also help to improve general behaviour, but does not seem to affect quality of life. ‐ Methylphenidate does not seem to increase the risk of serious (life‐threatening) unwanted effects when used for periods of up to six months. However, it is associated with an increased risk of non‐serious unwanted effects like sleeping problems and decreased appetite. ‐ Future studies should focus more on reporting unwanted effects and should take place over longer periods of time. What is attention deficit hyperactivity disorder (ADHD)? ADHD is one of the most commonly diagnosed and treated childhood psychiatric disorders. Children with ADHD find it hard to concentrate. They are often hyperactive (fidgety, unable to sit still for long periods) and impulsive (doing things without stopping to think). ADHD can make it difficult for children to do well at school, because they find it hard to follow instructions and to concentrate. Their behavioural problems can interfere with their ability to get on well with family and friends, and they often get into more trouble than other children. How is ADHD treated? Methylphenidate (for example, Ritalin) is the medication most often prescribed to children and adolescents with ADHD. Methylphenidate is a stimulant that helps to increase activity in parts of the brain, such as those involved with concentration. Methylphenidate can be taken as a tablet or given as a skin patch. It can be formulated to have an immediate effect, or be delivered slowly, over a period of hours. Methylphenidate may cause unwanted effects, such as headaches, stomachaches and problems sleeping. It sometimes causes serious unwanted effects like heart problems, hallucinations, or facial 'tics' (twitches). What did we want to find out? We wanted to find out if methylphenidate improves children's ADHD symptoms (attention, hyperactivity) based mainly on teachers' ratings using various scales, and whether it causes serious unwanted effects, like death, hospitalisation, or disability. We were also interested in less serious unwanted effects like sleep problems and loss of appetite, and its effects on children's general behaviour and quality of life. What did we do? We searched for studies that investigated the use of methylphenidate in children and adolescents with ADHD. Participants in the studies had to be aged 18 years or younger and have a diagnosis of ADHD. They could have other disorders or illnesses and be taking other medication or undergoing behavioural treatments. They had to have a normal IQ (intelligence quotient). Studies could compare methylphenidate with placebo (something designed to look and taste the same as methylphenidate but with no active ingredient) or no treatment. Participants had to be randomly chosen to receive methylphenidate or not. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 212 studies with 16,302 children or adolescents with ADHD. Most of the trials compared methylphenidate with placebo. Most studies were small with around 70 children, with an average age of 10 years (ages ranged from 3 to 18 years). Most studies were short, lasting an average of around a month; the shortest study lasted just one day and the longest 425 days. Most studies were in the USA. Based on teachers' ratings, compared with placebo or no treatment, methylphenidate: ‐ may improve ADHD symptoms (21 studies, 1728 children) ‐ may make no difference to serious unwanted effects (26 studies, 3673 participants) ‐ may cause more non‐serious unwanted effects (35 studies, 5342 participants) ‐ may improve general behaviour (7 trials 792 participants) ‐ may not affect quality of life (4 trials, 608 participants) Limitations of the evidence Our confidence in the results of the review is limited for several reasons. It was often possible for people in the studies to know which treatment the children were taking, which could influence the results. The reporting of the results was not complete in many studies and for some outcomes the results varied across studies. Studies were small and they used different scales for measuring symptoms. And most of the studies only lasted for a short period of time, making it impossible to assess the long‐term effects of methylphenidate. Around 41% of studies were funded or partly funded by the pharmaceutical industry. How up to date is this evidence? This is an update of a review conducted in 2015. The evidence is current to March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Storebø, OJ; Storm, MR; Pereira Ribeiro, J; Skoog, M; Groth, C; Callesen, HE; Schaug, JP; Darling, P; Huus, C-ML; Zwi, M; Kirubakaran, R; Simonsen, E; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD009885.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "44c3760a-0db9-4327-b696-210519e7ebb2", "pmid": "", "title": "Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega‐3 PUFA and plant oils in omega‐6 PUFA. Evidence suggests that increasing PUFA‐rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear. Objectives To assess effects of increasing total PUFA intake on cardiovascular disease and all‐cause mortality, lipids and adiposity in adults. Search methods We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all‐cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions. Data collection and analysis Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta‐analyses used random‐effects analysis, sensitivity analyses included fixed‐effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence. Main results We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA. Increasing PUFA intake probably has little or no effect on all‐cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate‐quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) and stroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low‐quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality. Increasing PUFA intake probably slightly decreases triglycerides (by 15%, MD ‐0.12 mmol/L, 95% CI ‐0.20 to ‐0.04, 20 trials, 3905 participants), but has little or no effect on total cholesterol (mean difference (MD) ‐0.12 mmol/L, 95% CI ‐0.23 to ‐0.02, 26 trials, 8072 participants), high‐density lipoprotein (HDL) (MD ‐0.01 mmol/L, 95% CI ‐0.02 to 0.01, 18 trials, 4674 participants) or low‐density lipoprotein (LDL) (MD ‐0.01 mmol/L, 95% CI ‐0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably has little or no effect on adiposity (body weight MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants). Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality. Authors' conclusions This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all‐cause or cardiovascular disease mortality. The mechanism may be via TG reduction. Plain language summary Polyunsaturated fatty acids for prevention and treatment of diseases of the heart and circulation Review question We reviewed randomised trials (participants have an equal chance to be assigned to either treatment) examining effects of increasing intake of polyunsaturated fatty acids (PUFA) on deaths and diseases of the heart and circulation (cardiovascular diseases), including heart attacks and stroke. Background We eat PUFA in our usual food, but quantities of PUFA eaten vary. There is some evidence that increasing the amount of PUFA we eat can reduce our blood cholesterol and make us less likely to develop cardiovascular disease, particularly if PUFAs are eaten instead of saturated fats (fats from animal sources such as meat and cheese). But eating more PUFA may increase our body weight, and omega‐6 fats (one component of PUFA) may worsen cardiovascular risk by increasing inflammation. Evidence on the benefits or harms of increasing PUFA intake on diseases of the heart and circulation, or on other health outcomes, is inconclusive. Trial characteristics Evidence in this Cochrane Review is current to 27 April 2017. We included 49 trials randomising 24,272 participants, for one to eight years. These trials assessed effects of eating more, compared to less PUFA, on diseases of the heart and circulation, and deaths. Twelve trials were very trustworthy (had low risk of bias overall). Participants were men and women, some with existing illnesses and some not. Trials took place in North America, Asia, Europe and Australia, and sixteen were funded only by national or charitable agencies. Key results Increasing PUFA probably makes little or no difference (neither benefit nor harm) to our risk of death (moderate‐quality evidence), and may make little or no difference to our risk of dying from cardiovascular disease (low‐quality evidence). However, increasing PUFA probably slightly reduces our risk of heart disease events and of combined heart and stroke events (moderate‐quality evidence). Fifty three people would need to eat more PUFA to prevent one person experiencing a heart disease event, and 63 people to prevent one person experiencing a heart or stroke event. Increasing PUFA may very slightly reduce risk of death due to heart disease, as well as stroke, but harm is possible (low‐quality evidence). PUFA probably slightly reduces fats circulating in the blood (triglycerides, moderate‐quality evidence but without effects on other lipids or adiposity). The evidence mainly comes from dietary‐advice trials of men living in high‐income countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abdelhamid, AS; Martin, N; Bridges, C; Brainard, JS; Wang, X; Brown, TJ; Hanson, S; Jimoh, OF; Ajabnoor, SM; Deane, KHO; Song, F; Hooper, L", "articleTypes": [], "doi": "10.1002/14651858.CD012345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "4508e080-0f6f-403b-a398-46a0fa6a1cac", "pmid": "", "title": "Oral water soluble contrast for malignant bowel obstruction", "imported": false, "abstract": "Abstract - Background Malignant bowel obstruction (MBO) is a common problem in patients with intra‐abdominal cancer. Oral water soluble contrast (OWSC) has been shown to be useful in the management of adhesive small bowel obstruction in identifying patients who will recover with conservative management alone and also in reducing the length of hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in patients with MBO. Objectives To determine the reliability of OWSC media and follow‐up abdominal radiographs in predicting the success of conservative treatment in resolving inoperable MBO with conservative management. To determine the efficacy and safety of OWSC media in reducing the duration of obstruction and reducing hospital stay in people with MBO. Search methods We identified studies from searching Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in Process, Embase, CINAHL, Science Citation Index (Web of Science) and Conference Proceedings Citation Index ‐ Science (Web of Science). We also searched registries of clinical trials and the CareSearch Grey Literature database. The date of the search was the 6 June 2017. Selection criteria Randomised controlled trials (RCTs), or prospective controlled studies, that evaluated the diagnostic potential of OWSC in predicting which malignant bowel obstructions will resolve with conservative treatment. RCTs, or prospective controlled studies, that assessed the therapeutic potential of OWSC in managing MBO at any level compared with placebo, no intervention or usual treatment or supportive care. Data collection and analysis We used standard methodological procedures expected by Cochrane. We assessed risk of bias and assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We found only one RCT meeting the selection criteria for the second objective (therapeutic potential) of this review. This study recruited nine participants. It compared the use of gastrografin versus placebo in adult patients with MBO with no indication for further intervention (surgery, endoscopy) apart from standardised conservative management. The overall risk of bias for the study was high due to issues with low numbers of participants, selective reporting of outcomes and a high attrition rate for the intervention arm. Primary outcomes The included trial was a pilot study whose primary outcome was to test the feasibility for a large study. The authors reported specifically on the number of patients screened, the number recruited and reasons for exclusion; this was not the focus of our review. Due to the low number of participants, the authors of the study decided not to report on our primary outcome of assessing the ability of OWSC to predict the likelihood of malignant small bowel obstruction resolving with conservative treatment alone (diagnostic effect). It also did not report on our primary outcome of rate of resolution of MBO in patients receiving OWSC compared with those not receiving it (therapeutic effect). The study reported that no issues regarding safety or tolerability of either gastrografin or placebo were identified. The overall quality of the evidence for the incidence of adverse events with OWSC was very low, downgraded twice for serious limitations to study quality (high risk of selective reporting and attrition bias) and downgraded once for imprecision (sparse data). Secondary outcomes The study planned to report on this review’s secondary outcome measures of length of hospital stay and time from administration of OWSC to resolution of MBO. However the authors of the study decided not to do so due to the low numbers of patients recruited. The study did not report on our secondary outcome measure of survival times from onset of inoperable MBO until death. Authors' conclusions There is insufficient evidence from RCTs to determine the place of OWSC in predicting which patients with inoperable MBO will respond with conservative treatment alone. There is also insufficient evidence from RCTs to determine the therapeutic effects and safety of OWSC in patients with malignant small bowel obstruction. Plain language summary Oral water soluble contrast for cancer‐related bowel obstruction Background Intra‐abdominal cancer is where the cancer has either started elsewhere in the body and spread into the stomach area or started in the bowel itself. It can commonly grow and block the movement of food or faeces through the bowel. A blockage of the bowel caused by cancer is known as malignant bowel obstruction (MBO). Some patients with MBO benefit from surgery to reverse the blockage. In others it is not possible to reverse the MBO and it either resolves or becomes permanent (limiting prognosis to days or weeks). Scar tissue around the bowel (called adhesions) can also cause a blockage, this is known as adhesive small bowel obstruction. Adhesive obstructions often resolve with conservative management in hospital (allowing the bowel to \"rest\" and recover). However in some, the obstruction requires surgery to remove the scar tissue and fix the blockage. Oral water soluble contrast (OWSC) is often prepared in liquid form and when swallowed before an x‐ray or computed tomography (CT) scan will show up clearly in the bowel. It can predict which people with adhesive small bowel obstruction will require surgery. In some patients it may also speed recovery leading to reduced hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in MBO. Study characteristics We searched for evidence that OWSC could be used to identify which patients with inoperable MBO would recover with conservative management. We also wanted to know if OWSC increased the likelihood of recovery from MBO, reduced hospital stay or improved prognosis. Finally, we wished to know what side effects OWSC might cause for patients with MBO. We conducted the search in June 2017 and found one study. It only recruited nine participants and did not fully report on the outcomes of using OWSC in MBO. Key Findings We found insufficient evidence that OWSC can identify which patients with MBO will recover with conservative management. We found insufficient evidence that patients with MBO benefit from OWSC in terms of length of hospital stay, recovery time or survival. No conclusions could be made about side effects from OWSC. Quality of Evidence We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. We rated the quality of the evidence as very low due to the lack of studies reporting on the benefits of using OWSC in MBO and the only study we found reporting on side effects recruited very few participants (nine). The low quality of the evidence means that we are very uncertain about the use of OWSC in the management of MBO and cannot confirm its benefits or harms in patients with this condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Syrmis, W, Richard, R, Jenkins-Marsh, S, Chia, SC, Good, P", "articleTypes": [], "doi": "10.1002/14651858.CD012014.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.773Z" }, { "id": "450e16fe-9cf7-4c5d-b846-1041ea87918a", "pmid": "", "title": "Interventions for hirsutism (excluding laser and photoepilation therapy alone)", "imported": false, "abstract": "Abstract - Background Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen‐sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective. Objectives To assess the effects of interventions (except laser and light‐based therapies alone) for hirsutism. Search methods We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014. Selection criteria Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism. Data collection and analysis Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses. Main results We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty‐eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow‐up above 40%. Primary outcomes, 'participant‐reported improvement of hirsutism' and 'change in health‐related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin‐releasing hormone (GnRH) analogues)). Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one‐third of studies. The quality of evidence was moderate to very low for most outcomes. There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman‐Gallwey scores. The mean difference (MD) was ‐1.84 (95% confidence interval (CI) ‐3.86 to 0.18). There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman‐Gallwey scores more effectively than placebo (MD ‐7.60, 95% CI ‐10.53 to ‐4.67 and MD ‐7.20, 95% CI ‐10.15 to ‐4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87). Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman‐Gallwey scores (MD ‐7.69, 95% CI ‐10.12 to ‐5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD ‐1.90, 95% CI ‐5.01 to 1.21 and MD 0.49, 95% CI ‐1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI ‐0.58 to 3.56 and MD 0.40, 95% CI ‐1.18 to 1.98) (low quality evidence). Although there was very low quality evidence of a difference in reduction of Ferriman‐Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD ‐5.73, 95% CI ‐6.87 to ‐4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached. Metformin demonstrated no benefit over placebo in reduction of Ferriman‐Gallwey scores (MD 0.05, 95% CI ‐1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements. We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman‐Gallwey scores. Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman‐Gallwey scores (low quality evidence). Ferriman‐Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD ‐6.30, 95% CI ‐9.83 to ‐2.77) (very low quality evidence). Data showing reductions in Ferriman‐Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%). Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman‐Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs. Authors' conclusions Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision‐making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects. Further research should consist of well‐designed, rigorously reported, head‐to‐head trials examining OCPs combined with antiandrogens or 5α‐reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α‐reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment. Plain language summary Treatments for unwanted male pattern hair growth in women Background 
 Up to 5% to 10% of women are hirsute (hair in areas where normally only men have hairs such as moustache, beard area, chest, belly, back etc). The most common cause is polycystic ovary syndrome. Hirsutism can lead to psychological distress, low self esteem, decreased self image, depression, feelings of shame and social difficulties. Review question 
 Which treatments (except laser and light‐based therapies alone) work best for hirsutism? Study characteristics 
 We included 157 studies published up to June 2014, which examined 10,550 people. Participants included women with a mean age of 25 years. There was considerable variation in the quality of how the studies were conducted; more than half were not blinded and this may have had an impact on the reporting of the outcomes. Most studies were carried out in single centres in Europe and lasted six to 12 months. A range of treatments were evaluated, mostly in single studies. These included a few topical treatments, lifestyle modification, oral contraceptive pills (OCPs), medication to inhibit the effect of hormones that are responsible for male traits, and combination therapies. Participant‐assessed improvement and impact on quality of life were evaluated in a minority of the studies, whilst the majority of the studies measured physician‐assessed reduction in hirsutism, as well as androgen levels in the blood. Half of the studies reported adverse events and around one‐third other signs and symptoms, e.g. oily skin and menstrual irregularities that might be due to an increase of androgen levels in the blood. Key results 
 Oral contraceptive pills reduced the amount of hairs, but the reduction was not consistent across the studies, although two OCPs (ethinyl estradiol 35 µg + cyproterone acetate 2 mg compared to ethinyl estradiol 30 µg + desogestrel 0.15 mg) appeared to be effective in a way that can be considered important for women with hirsutism. Of the antiandrogen drugs, flutamide was considered to be more effective than placebo by both the women and the doctors. Spironolactone was also effective, but data were only available for the physicians' assessments. Finasteride did not show convincing effectiveness based on the evaluations of the hirsute women and those made by the investigators. The addition of cyproterone acetate (an antiandrogen) to OCP seemed to enhance the beneficial effect of OCPs on hair reduction. Insulin sensitisers (antidiabetic drugs) and lifestyle modification did not have any demonstrable benefit in terms of the severity of hirsutism. Unfortunately, the self assessments by the women, as well as the impact of hirsutism on their quality of life, were outcomes that were insufficiently addressed in the studies. The adverse events reported with the different drugs are well known, i.e. pain in the stomach and intestines, breast tenderness, reduced libido and dry skin with flutamide and finasteride; irregular bleeding with spironolactone; nausea, diarrhoea and abdominal bloating with metformin; and hot flushes, decreased libido, vaginal dryness, breast tenderness and headaches with the GnRH analogues. There were no important differences in blood androgen levels between the different treatment groups, OCPs had a positive effect on acne, and similarly insulin sensitisers improved the menstrual pattern. We were expecting to find evidence that combined therapies of an OCP with an antiandrogen were more effective than, for example, OCPs alone, but the lack of studies did not allow us to draw these conclusions. Overall we concluded that OCPs (especially with antiandrogenic activity), OCPs combined with cyproterone acetate, flutamide and spironolactone are effective in treating hirsutism. However, additional cosmetic measures (epilating, waxing, bleaching, electrolysis, laser and photoepilation) are generally required because all treatments need at least six to 12 months to reach the optimum effect. In addition, because of the distress associated with hirsutism and its impact on quality of life psychological support should be part of the treatment approach. Quality of the evidence 
 The overall quality of the evidence for the different outcomes was on average rated as moderate to very low. Important reasons for this were that studies were not blinded, or had a small sample size.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "van Zuuren, EJ; Fedorowicz, Z; Carter, B; Pandis, N", "articleTypes": [], "doi": "10.1002/14651858.CD010334.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "451c179f-9a2b-4ffb-addd-a771de074b61", "pmid": "", "title": "The Role of Sweet Taste Receptor Blockade on Intraduodenal Glucose- and Liquid Meal-stimulated Secretion of Satiation Peptides in Healthy Humans", "imported": false, "abstract": "The purpose of this study is to determine the functional significance of sweet taste receptors in the secretion of GI satiation peptides by using a specific sweet taste receptor antagonist to block sweet taste perception in the gastrointestinal tract.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "452be544-b68b-42b6-a62a-121c03c76438", "pmid": "", "title": "Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age‐inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long‐term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega‐3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents. Objectives To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents. Search methods We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references. Selection criteria We included randomised and quasi‐randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD. Data collection and analysis We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow‐up; and cost. We used GRADE to assess the certainty of evidence for each outcome. Main results We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross‐over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega‐3 PUFA, six used a combined omega‐3/omega‐6 supplement, and two used an omega‐6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co‐intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega‐3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega‐3 PUFA plus atomoxetine to atomoxetine; omega‐3 PUFA plus physical training to physical training; and an omega‐3 or omega‐6 supplement plus methylphenidate to methylphenidate; and two trials compared omega‐3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months. Although we found low‐certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high‐certainty evidence that PUFA had no effect on parent‐rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) −0.08, 95% CI −0.24 to 0.07; 16 studies, 1166 participants). There was also high‐certainty evidence that parent‐rated inattention (medium‐term: SMD −0.01, 95% CI −0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium‐term: SMD 0.09, 95% CI −0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo. There was moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate‐certainty evidence that medium‐term loss to follow‐up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants). Authors' conclusions Although we found low‐certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high‐certainty evidence that PUFA had no effect on total parent‐rated ADHD symptoms. There was also high‐certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups. We found moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate‐certainty evidence that follow‐up was similar between groups. It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times. Plain language summary Polyunsaturated fatty acids (PUFA) supplements for attention deficit hyperactivity disorder (ADHD) in children and adolescents What is ADHD? Attention deficit hyperactivity disorder (ADHD) is a common problem in children and adolescents. Those affected may struggle to concentrate, feel restless, or act on impulse. As a result of these difficulties, ADHD can cause long‐term social, academic, and mental health problems. Medicines are the most frequently used treatments for ADHD, but they are not always effective and can cause unwanted side effects. What are polyunsaturated fatty acids (PUFA)? Polyunsaturated fatty acids (PUFA) are a type of fat. They are necessary for normal brain development and are found in foods such as fish (omega‐3 PUFA) and vegetable oils (omega‐6 PUFA). How could PUFA be useful in ADHD? There is some evidence that ADHD could be related to low levels of PUFA, in particular omega‐3 PUFA. PUFA supplements may therefore improve ADHD symptoms, behavioural problems, and related mental health symptoms such as anxiety and depression. What did we want to find out? We wanted to know whether PUFA supplements improve ADHD symptoms in children and adolescents with ADHD. Although there were some limited data in the original review that suggested PUFA improved symptoms of ADHD, there is currently little evidence that PUFA supplementation is beneficial. It was important to update the evidence to incorporate new studies that have been published since the original review. What did we do? We searched for all trials that compared PUFA to placebo (dummy pill), medicines, or psychological or medical therapies in children or adolescents with ADHD. We searched 13 databases and two trials registers up to October 2021. What did we find? We found 24 new studies in this update, bringing the total number of studies included in the review to 37, which involved more than 2374 children and adolescents with ADHD. Seven studies were conducted in Iran; four each in the USA and Israel; two each in Australia, Canada, New Zealand, Sweden, and the UK; and one each in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Thirty‐six studies compared PUFA to placebo. Treatment with PUFA lasted between two weeks and six months. Although there was some evidence that PUFA could improve ADHD symptoms in children and adolescents, most of the evidence indicated that PUFA did not improve ADHD symptoms such as inattention or hyperactivity‐impulsivity. PUFA probably makes little to no difference to overall side effects or whether a person drops out of a study (i.e. does not complete it). How confident are we about what we found? We are confident that PUFA has no effect on ADHD symptoms when compared to placebo. Although there was some evidence that ADHD symptoms may be more likely to improve in children and adolescents receiving PUFA compared to those receiving placebo, we have little confidence in this finding. We are fairly confident that there are no differences between PUFA and placebo groups in overall side effects or dropout. Limitations of the analyses included small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Gillies, D; Leach, MJ; Perez Algorta, G", "articleTypes": [], "doi": "10.1002/14651858.CD007986.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "453ba227-0628-426b-94fa-f4a976b20d9c", "pmid": "", "title": "Chinese herbal medicine for schizophrenia", "imported": false, "abstract": "Abstract - Background Traditional Chinese medicine (TCM) was the main form of treatment in China for psychiatric illnesses until the development of antipsychotic drugs in the 1950's. Antipsychotic drugs have become the primary intervention for schizophrenia, although herbal medicines can still form part of the treatment. Objectives To review Chinese herbal medicine, used alone or as part of a TCM approach, for people with schizophrenia and related psychoses. Search methods We undertook electronic searches of the Cochrane Schizophrenia Group's register (December 2003), the Traditional Chinese Medical Literature Analysis and Retrieval Database (TCMLARS) (October 2003), Chinese Biomedical Database (CBM) (December 2003), China National Knowledge Infrastructure Database (May 2004), Complementary Medicine Database (AMED) (December 2003). We contacted the Chinese Cochrane Centre, the Cochrane Complementary Medicine Field and first authors of included studies and inspected reference lists for additional studies. Selection criteria We included all relevant randomised controlled trials involving people with schizophrenia‐like illnesses, allocated to Chinese herbal medicine, including any Chinese herbs (single or mixture), compared with placebo/no treatment or antipsychotic drugs. We updated this search July 2012 and added 45 new trials to the awaiting classification section. Data collection and analysis We independently extracted data and calculated fixed effects relative risk (RR), the 95% confidence intervals (CI) for homogeneous dichotomous data, and, where appropriate, the number needed to treat (NNT) on an intention‐to‐treat basis. For continuous data, we calculated weighted mean differences (WMD). Main results Only one small trial of the seven included studies truly evaluated TCM for schizophrenia. The other trials evaluated Chinese herbs for schizophrenia. We found one study comparing Chinese herbal medicine with antipsychotic drugs. Data for the global state outcome 'no change/worse' favoured people allocated to antipsychotic medication (n=90, RR 1.88 CI 1.2 to 2.9, NNH 4 CI 2 to 12). Six trials compared Chinese herbal medicine in combination with antipsychotic with antipsychotic drugs alone. One trial found global state 'not improved/worse' favoured the herbal medicine/antipsychotic combination (n=123, RR 0.19 CI 0.1 to 0.6, NNT 6 CI 5 to 11). Two studies (n=103) also found short‐term data from the Clinical Global Impression scale favoured the herbal medicine plus antipsychotic group (WMD ‐0.46 CI ‐0.9 to ‐0.1) compared with those given only antipsychotics. Significantly fewer people in the experimental group left the study early compared with those given antipsychotics alone (n=1004, 6 RCTs, RR 0.30 CI 0.16 to 0.58, NNT 21 CI 18 to 35). Reports of constipation were significantly lower in the treatment group compared to those receiving antipsychotics (n=67, 1 RCT, RR 0.03 CI 0.0 to 0.5, NNH 2 CI 2 to 4). Authors' conclusions Chinese herbal medicines, given in a Western biomedical context, may be beneficial for people with schizophrenia when combined with antipsychotics. Traditional Chinese medicine is also under‐evaluated, but results from one pioneering study that attempted to evaluate TCM should encourage further trials. Note: the 45 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed. Plain language summary Chinese herbal medicine for schizophrenia Antipsychotic medication is the mainstay of treatment for people with schizophrenia, and although effective, still leaves some people with distressing symptoms and/or disabling adverse effects. Safer and more effective health care interventions are needed. Traditional Chinese medicine (TCM) has been used to treat mental health disorders, including schizophrenia, for more than 2000 years. Chinese herbs may also have antipsychotic properties when used in a Western biomedical context. In this review we sought and found trials relevant to the effects of both approaches for schizophrenia. Traditional Chinese medicine methodology has been evaluated for schizophrenia, but the one included study was too limited in terms of sample size and study length to guide good practice. However, this pioneering study does show that TCM can be evaluated for its efficacy for people with schizophrenia , and should encourage trialists to undertake further, more comprehensive trials in this area. The use of Chinese herbs in a Western medicine context, without incorporating TCM methodology, has been evaluated in six trials, although again these are limited by their sample size and study length. The results of these six trials suggest that using Chinese herbs alone for psychotic symptoms may not be indicated, but if used in conjunction with Western antipsychotic drugs, they may be beneficial in terms of mental state, global functioning and decrease of adverse effects. However, further trials are needed before the effects of TCM for people with schizophrenia can be evaluated with any real confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Rathbone, J; Zhang, L; Zhang, M; Xia, J; Liu, X; Yang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD003444.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "4565ef01-3b08-41d5-9cea-0f181ff65e02", "pmid": "", "title": "Fortification of staple foods with vitamin A for vitamin A deficiency", "imported": false, "abstract": "Abstract - Background Vitamin A deficiency is a significant public health problem in many low‐ and middle‐income countries, especially affecting young children, women of reproductive age, and pregnant women. Fortification of staple foods with vitamin A has been used to increase vitamin A consumption among these groups. Objectives To assess the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving health‐related outcomes in the general population older than two years of age. Search methods We searched the following international databases with no language or date restrictions: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library; MEDLINE and MEDLINE In Process OVID; Embase OVID; CINAHL Ebsco; Web of Science (ISI) SCI, SSCI, CPCI‐exp and CPCI‐SSH; BIOSIS (ISI); POPLINE; Bibliomap; TRoPHI; ASSIA (Proquest); IBECS; SCIELO; Global Index Medicus ‐ AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched clinicaltrials.gov and the International Clinical Trials Registry Platform to identify ongoing and unpublished studies. The date of the last search was 19 July 2018. Selection criteria We included individually or cluster‐randomised controlled trials (RCTs) in this review. The intervention included fortification of staple foods (sugar, edible oils, edible fats, maize flour or corn meal, wheat flour, milk and dairy products, and condiments and seasonings) with vitamin A alone or in combination with other vitamins and minerals. We included the general population older than two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two authors independently screened and assessed eligibility of studies for inclusion, extracted data from included studies and assessed their risk of bias. We used standard Cochrane methodology to carry out the review. Main results We included 10 randomised controlled trials involving 4455 participants. All the studies were conducted in low‐ and upper‐middle income countries where vitamin A deficiency was a public health issue. One of the included trials did not contribute data to the outcomes of interest. Three trials compared provision of staple foods fortified with vitamin A versus unfortified staple food, five trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus unfortified staple foods, and two trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus no intervention. No studies compared staple foods fortified with vitamin A alone versus no intervention. The duration of interventions ranged from three to nine months. We assessed six studies at high risk of bias overall. Government organisations, non‐governmental organisations, the private sector, and academic institutions funded the included studies; funding source does not appear to have distorted the results. Staple food fortified with vitamin A versus unfortified staple food We are uncertain whether fortifying staple foods with vitamin A alone makes little or no difference for serum retinol concentration (mean difference (MD) 0.03 μmol/L, 95% CI −0.06 to 0.12; 3 studies, 1829 participants; I² = 90%, very low‐certainty evidence ). It is uncertain whether vitamin A alone reduces the risk of subclinical vitamin A deficiency (risk ratio (RR) 0.45, 95% CI 0.19 to 1.05; 2 studies; 993 participants; I² = 33%, very low‐certainty evidence ). The certainty of the evidence was mainly affected by risk of bias, imprecision and inconsistency. It is uncertain whether vitamin A fortification reduces clinical vitamin A deficiency, defined as night blindness (RR 0.11, 95% CI 0.01 to 1.98; 1 study, 581 participants, very low‐certainty evidence ). The certainty of the evidence was mainly affected by imprecision, inconsistency, and risk of bias. Staple foods fortified with vitamin A versus no intervention No studies provided data for this comparison. Staple foods fortified with vitamin A plus other micronutrients versus same unfortified staple foods Fortifying staple foods with vitamin A plus other micronutrients may not increase the serum retinol concentration (MD 0.08 μmol/L, 95% CI ‐0.06 to 0.22; 4 studies; 1009 participants; I² = 95%, low‐certainty evidence ). The certainty of the evidence was mainly affected by serious inconsistency and risk of bias. In comparison to unfortified staple foods, fortification with vitamin A plus other micronutrients probably reduces the risk of subclinical vitamin A deficiency (RR 0.27, 95% CI 0.16 to 0.49; 3 studies; 923 participants; I² = 0%; moderate‐certainty evidence ). The certainty of the evidence was mainly affected by serious risk of bias. Staple foods fortified with vitamin A plus other micronutrients versus no intervention Fortification of staple foods with vitamin A plus other micronutrients may increase serum retinol concentration (MD 0.22 μmol/L, 95% CI 0.15 to 0.30; 2 studies; 318 participants; I² = 0%; low‐certainty evidence ). When compared to no intervention, it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency (RR 0.71, 95% CI 0.52 to 0.98; 2 studies; 318 participants; I² = 0%; very low‐certainty evidence ) . The certainty of the evidence was affected mainly by serious imprecision and risk of bias. No trials reported on the outcomes of all‐cause morbidity, all‐cause mortality, adverse effects, food intake, congenital anomalies (for pregnant women), or breast milk concentration (for lactating women). Authors' conclusions Fortifying staple foods with vitamin A alone may make little or no difference to serum retinol concentrations or the risk of subclinical vitamin A deficiency. In comparison with provision of unfortified foods, provision of staple foods fortified with vitamin A plus other micronutrients may not increase serum retinol concentration but probably reduces the risk of subclinical vitamin A deficiency. Compared to no intervention, staple foods fortified with vitamin A plus other micronutrients may increase serum retinol concentration, although it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency as the certainty of the evidence has been assessed as very low. It was not possible to estimate the effect of staple food fortification on outcomes such as mortality, morbidity, adverse effects, congenital anomalies, or breast milk vitamin A, as no trials included these outcomes. The type of funding source for the studies did not appear to distort the results from the analysis. Plain language summary Fortification of staple foods with vitamin A for vitamin A deficiency What is the aim of the review? We wanted to investigate the effects of fortifying common staple foods with vitamin A, with or without other micronutrients, in populations two years of age and older. Staple foods used in public health fortification programmes have included refined sugar, edible vegetable oils and fats, rice, wheat flour, maize flours and corn meals, condiments and seasonings, and powdered or liquid milk. We searched for all the possible information on this question and found 10 eligible studies. Key messages Fortifiying staple foods with vitamin A plus other micronutrients may increase the serum retinol concentrations (an indicator of vitamin A stores in the body) and reduce the risk of subclinical vitamin A deficiency (those without clinical eye signs for risk of blinding undernutrition, detected through a serum/plasma retinol 70 μmol/L or less). However, adding vitamin A alone to the staple foods may have little or no effect on vitamin A status or deficiency. What was studied in this review? Vitamin A is an essential nutrient vital for good vision, cell growth, and immunity. Many people in low‐ and middle‐income countries have vitamin A deficiency, especially young children, pregnant women, and women of reproductive age, who may not get enough to eat to cover their increased nutritional demands. Long‐term deprivation of vitamin A could lead to visual impairment, blindness, common infections of the upper respiratory tract, diarrhoea, and measles. There are several strategies to combat the vitamin A deficiency, such as supplementing the diet with vitamin A capsules, adding vitamins and minerals in powder form to energy‐containing foods, eating more vitamin A‐rich foods, and fortifying staple foods with vitamin A during processing. This review focused on the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving the health of the general population older than two years of age. What are the main results of the review? We found 10 relevant studies (involving 4455 participants) from China, India, the Philippines, Bangladesh, Thailand, and Mexico. Three studies provided one study group with staple foods fortified with vitamin A alone, and another group with the same unfortified staple foods. Five studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus the same unfortified staple food, and two studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus no intervention. No studies compared staple foods fortified with vitamin A versus no intervention. Government agencies, private agencies, non‐governmental organisations, the private sector, and academic institutions funded the studies. The source of funding does not appear to have distorted the results. The effect of fortification of staple foods with vitamin A alone on vitamin A stores and on subclinical vitamin A deficiency is uncertain. It is uncertain whether this intervention might reduce clinical vitamin A deficiency (night blindness). We are moderately confident that fortifying staple foods with vitamin A and other micronutrients may not improve vitamin A status. However, children and adolescents in low‐ and middle‐income populations who eat foods fortified with vitamin A and other micronutrients may have a lower risk of subclinical vitamin A deficiency compared to those receiving unfortified staple foods. We do not know how vitamin A fortification affects other health indicators, such as the rate of disease in the population, mortality, adverse effects, food intake, birth defects (for pregnant women), or breast milk concentration for lactating women. We considered six of the included studies to be of poor methodological quality. The review authors searched for published studies up to July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hombali, AS; Solon, JA; Venkatesh, BT; Nair, NS; Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010068.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "457b8eae-c21a-4206-b69d-8b15b0674ed0", "pmid": "", "title": "Pharmacological and nutritional treatment for McArdle disease (Glycogen Storage Disease type V)", "imported": false, "abstract": "Abstract - Background McArdle disease (Glycogen Storage Disease type V) is caused by an absence of muscle phosphorylase leading to exercise intolerance, myoglobinuria rhabdomyolysis and acute renal failure. This is an update of a review first published in 2004. Objectives To review systematically the evidence from randomised controlled trials (RCTs) of pharmacological or nutritional treatments for improving exercise performance and quality of life in McArdle disease. Search methods We searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE on 11 August 2014. Selection criteria We included RCTs (including cross‐over studies) and quasi‐RCTs. We included unblinded open trials and individual patient studies in the discussion. Interventions included any pharmacological agent or nutritional supplement. Primary outcome measures included any objective assessment of exercise endurance (for example aerobic capacity (VO 2 ) max, walking speed, muscle force or power and fatigability). Secondary outcome measures included metabolic changes (such as reduced plasma creatine kinase and a reduction in the frequency of myoglobinuria), subjective measures (including quality of life scores and indices of disability) and serious adverse events. Data collection and analysis Three review authors checked the titles and abstracts identified by the search and reviewed the manuscripts. Two review authors independently assessed the risk of bias of relevant studies, with comments from a third author. Two authors extracted data onto a specially designed form. Main results We identified 31 studies, and 13 fulfilled the criteria for inclusion. We described trials that were not eligible for the review in the Discussion. The included studies involved a total of 85 participants, but the number in each individual trial was small; the largest treatment trial included 19 participants and the smallest study included only one participant. There was no benefit with: D‐ribose, glucagon, verapamil, vitamin B 6 , branched chain amino acids, dantrolene sodium, and high‐dose creatine. Minimal subjective benefit was found with low dose creatine and ramipril only for patients with a polymorphism known as the D/D angiotensin converting enzyme (ACE) phenotype. A carbohydrate‐rich diet resulted in better exercise performance compared with a protein‐rich diet. Two studies of oral sucrose given at different times and in different amounts before exercise showed an improvement in exercise performance. Four studies reported adverse effects. Oral ribose caused diarrhoea and symptoms suggestive of hypoglycaemia including light‐headedness and hunger. In one study, branched chain amino acids caused a deterioration of functional outcomes. Dantrolene was reported to cause a number of adverse effects including tiredness, somnolence, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of myalgia. Authors' conclusions Although there was low quality evidence of improvement in some parameters with creatine, oral sucrose, ramipril and a carbohydrate‐rich diet, none was sufficiently strong to indicate significant clinical benefit. Plain language summary Drug and nutritional treatment for McArdle disease Review question We reviewed the evidence about the effects of drug and nutritional treatment for McArdle disease. Background McArdle disease (also known as glycogen storage disease type V) is a disorder affecting muscle metabolism. The condition is caused by the lack of an enzyme called muscle phosphorylase. This results in an inability to break down glycogen 'fuel' stores. McArdle disease leads to pain and fatigue with strenuous exercise. Sometimes severe muscle damage develops and occasionally this results in acute reversible kidney failure. Study characteristics After a wide search, we identified 13 randomised studies that included 85 participants with McArdle disease. This is an update of a review first published in 2004. We found no new trials at this update. Key results and quality of the evidence The review found no benefit compared with placebo with the following treatments: D‐ribose, glucagon, verapamil, vitamin B 6 , oral branched chain amino acids, dantrolene sodium, high‐dose creatine and ramipril. Low dose creatine and ramipril produced minimal benefit for patients who also have the D/D angiotensin converting enzyme (ACE) phenotype. Taking low dose creatine supplements had a minor benefit in improving exercise tolerance in a small number of people with the condition. Taking a sugary drink before planned strenuous exercise can improve performance but this treatment is not practical for day‐to‐day living. A diet rich in carbohydrate may be superior to a diet rich in protein. Adverse effects were reported in four studies. Oral ribose caused symptoms suggestive of a low blood sugar including light‐headedness, hunger and diarrhoea. One study of branched chain amino acids resulted in a deterioration in participants. Dantrolene was reported to cause a number of side‐effects including tiredness, sleepiness, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause any side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of muscle pain. The quality of these studies was low due to the small number of participants; the largest number in one trial was 19 and one trial had only one participant. The evidence is current to August 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Quinlivan, R, Martinuzzi, A, Schoser, B", "articleTypes": [], "doi": "10.1002/14651858.CD003458.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.766Z" }, { "id": "458c5176-8b72-4ee0-bd56-241b970c4a7d", "pmid": "", "title": "Evaluation of Balance Tablets in Reducing Vitamin and Mineral Deficiencies in Patients Using GLP-1 Receptor Agonists for Weight Loss", "imported": false, "abstract": "Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), including Ozempic (semaglutide) and Saxenda (liraglutide), are gaining traction in treating obesity and its associated diseases due to their capacity to facilitate substantial weight loss through mechanisms such as appetite suppression and delayed gastric emptying. Clinical trials have consistently shown that patients prescribed GLP-1 RAs can achieve significant body weight reductions when combined with appropriate dosing and lifestyle modifications.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "4596a598-d3ee-4892-b47e-6827fa5c6016", "pmid": "", "title": "Prostaglandins for management of retained placenta", "imported": false, "abstract": "Abstract - Background Retained placenta affects 0.5% to 3% of women following delivery and it is a major cause of maternal death due to postpartum haemorrhage. Usually, retained placenta has been managed by manual removal or curettage under anaesthesia, which may be associated with haemorrhage, infection and uterine perforation. Medical management to facilitate the delivery of the retained placenta could be a safe alternative avoiding surgical intervention. Objectives To assess the effectiveness and safety of prostaglandins for the management of retained placenta. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013), LILACS (1982 to 1 December 2013), SciELO (1998 to 1 December 2013), Web of Science (2001 to 1 December 2013), openSIGLE (1997 to 1 December 2013 ) , World Health Organization International Clinical Trials Registry Platform ( ICTRP ) (1 December 2013) and the metaRegister of Controlled Trials ( mRCT ) (1 December 2013) . We also contacted authors of included studies and reviewed the reference lists of retrieved studies. Selection criteria Randomised controlled clinical trials comparing the use of prostaglandins (or prostaglandin analogues) with placebo, expectant management, tocolytic drugs, any other prostaglandins or surgical interventions for the management of retained placenta after vaginal delivery of singleton live infants of 20 or more weeks of gestation. Data collection and analysis Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. Any disagreements were resolved through consensus or consultation with a third review author when required. Authors of the included studies were contacted for additional information. Main results We included three trials, involving 244 women. The studies were considered to be at high risk of bias. The prostaglandins used were PG E2 analogue (sulprostone) in 50 participants and PG E1 analogue (misoprostol) in 194 participants at a dose of 250 mcg and 800 mcg respectively. The prostaglandins compared with placebo, were not superior in reducing the rate of manual removal of placenta (average risk ratio (RR) 0.82; 95% confidence interval (CI) 0.54 to 1.27), severe postpartum haemorrhage (RR 0.80; 95% CI 0.55 to 1.15), need for blood transfusion (RR 0.72; 95% CI 0.43 to 1.22), mean blood loss (mean difference (MD) ‐205.26 mL; 95% CI ‐536.31 to 125.79, random‐effects) and the mean time from injection to placental removal (MD ‐7.00 minutes; 95% CI ‐21.20 to 7.20). Side‐effects were no different between groups (vomiting, headache, pain and nausea between injection and discharge from the labour ward), with the exception of shivering, which was more frequent in women receiving prostaglandins (RR 10.00; 95% CI 1.40 to 71.49). We did not obtain any data for the primary outcomes of maternal mortality and the need to add another therapeutic uterotonic. Authors' conclusions Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes) or side‐effects (vomiting, headache, pain and nausea between injection and discharge from the labour ward) except for 'shivering' which was more frequent in women who received prostaglandin. The included studies were of poor quality and there is little confidence in the effect estimates; the true effect is likely to be substantially different. We can not make any recommendations about changes to clinical practice. More high‐quality research in this area is needed. Plain language summary Prostaglandins for management of retained placenta Medical research evidence is sparse and insufficient to support the routine use of the prostaglandins for the management of retained placenta. Retained placenta affects 0.5% to 3% of women following delivery and is a major cause of maternal death caused by postpartum haemorrhage. A retained placenta is usually managed by manual removal or curettage under anaesthesia (which is not always immediately available). Surgical procedures themselves can be associated with haemorrhage and also infection and uterine perforation. Prostaglandins or their analogues, administered by any route, could be an alternative treatment especially in developing countries. Such medical management may facilitate the delivery of the retained placenta and be a safer alternative to surgery. The review identified three randomised controlled studies (involving 244 women) that compared the use of prostaglandins with placebo. Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and need for blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes). The prostaglandin was administered by intravenous infusion (E2 analogue sulprostone) in one study including 50 women and was orally or sublingually administered (E1 analogue misoprostol) in the other two studies including 194 women. Shivering was more frequent in women receiving the prostaglandin but there were no clear differences in vomiting, headache, maternal pain or nausea compared with placebo. The trials were small and of poor methodological quality. The quality of evidence is very low due to study limitations, inconsistency and imprecise results (few women and outcome events with wide confidence intervals). Two studies were stopped early due to an apparent benefit.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Grillo‐Ardila, CF, Ruiz‐Parra, AI, Gaitán, HG, Rodriguez‐Malagon, N", "articleTypes": [], "doi": "10.1002/14651858.CD010312.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.800Z" }, { "id": "4598d4ec-6c6f-4425-8069-bee6f02e6899", "pmid": "", "title": "Intranasal steroids for acute sinusitis", "imported": false, "abstract": "Abstract - Background Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school. Objectives We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis in adults and children. Search methods We searched CENTRAL 2013, Issue 4, MEDLINE (January 1966 to May week 2, 2013), EMBASE (1990 to May 2013) and bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) comparing INCS treatment to placebo or no intervention in adults and children with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop‐outs before the end of the study, rates of relapse, complications and return to school or work. Data collection and analysis Two review authors independently extracted data, assessed trial quality and resolved discrepancies by consensus. Main results No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well‐designed and double‐blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow‐up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta‐analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% confidence interval (CI) 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop‐out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS. Authors' conclusions Current evidence is limited for acute sinusitis confirmed by radiology or nasal endoscopy but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy. Plain language summary Steroids for acute sinusitis in adults and children Acute sinusitis is a common reason for primary care visits; it is one of the 10 most common diagnoses in outpatient clinics, presenting with various symptoms and signs that include purulent nasal discharge and congestion and cough lasting beyond the typical seven to 10 days of a viral upper respiratory infection. There have been suggestions, based on studies of allergic rhinitis and chronic sinusitis, that intranasal corticosteroids (INCS) may relieve symptoms and hasten recovery in acute sinusitis due to their anti‐inflammatory properties. A critical systematic review of the literature found four well‐conducted, randomised, placebo‐controlled intervention studies, involving 1943 participants treated for 15 or 21 days. The results suggest that there may be a modest effect with INCS in the resolution or improvement of symptoms. Only minor adverse events such as epistaxis, headache and nasal itching were reported. Given the small number of studies included in this review, it is recommended that further randomised controlled trials be conducted. The evidence is up to date as of May 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zalmanovici Trestioreanu, A, Yaphe, J", "articleTypes": [], "doi": "10.1002/14651858.CD005149.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.079Z" }, { "id": "45c95135-0da4-424e-8e50-6be9e3e8e64a", "pmid": "", "title": "Interventions to prevent obesity in children aged 2 to 4 years old", "imported": false, "abstract": "Abstract - Rationale Early childhood presents an important opportunity for obesity prevention, an international public health priority. Interventions aiming to prevent obesity typically promote healthy diets or activity levels (physical activity, sedentary behaviour), or both. There is uncertainty over which approaches are more effective. This is one of a suite of three reviews addressing interventions for preventing obesity in children, each focusing on different age groups up to 18 years. These reviews replace and update a 2019 Cochrane review on interventions for preventing obesity in children from birth to 18 years. Objectives To assess the effects of interventions that aimed to prevent obesity in children aged two to four years by changing dietary intake or activity levels, or both, on body mass index (BMI), BMI z‐score (zBMI), BMI percentile, and serious adverse events. Search methods We searched CENTRAL, MEDLINE, Embase, six other databases, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify eligible studies. The latest search date was 7 February 2023. Eligibility criteria We included randomised controlled trials (RCTs) in children aged two to four years, comparing dietary or activity interventions (or both combined) to prevent overweight or obesity versus no intervention, usual care, or another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post‐baseline. There were no language restrictions. Outcomes Our outcomes were BMI, zBMI, BMI percentile, and serious adverse events. Risk of bias We used version 2 of the Cochrane risk of bias tool (RoB 2) to assess included RCTs. Synthesis methods Working independently, two authors screened studies, extracted data, and conducted risk of bias and GRADE assessments. We conducted random‐effects meta‐analyses stratified by type of intervention and follow‐up duration. Included studies We included 67 studies (36,601 participants), with 56 studies (21,404 participants) pooled in the meta‐analyses. Sixty‐three studies were conducted in high‐income countries. Study settings were split between childcare (26 studies; 39%), home (23 studies; 34%), and home plus childcare settings (10 studies; 15%). Few studies were conducted in the community (three studies; 5%) or healthcare settings (five studies; 7%). Most studies compared a combined dietary/activity intervention with a control group. Synthesis of results Dietary interventions versus control Dietary interventions may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0.00, 95% confidence interval (CI) ‐0.28 to 0.28; 1 study, 94 participants; low‐certainty evidence). At medium‐ and long‐term follow‐up, dietary interventions may result in little to no difference in BMI. One study (103 participants; low‐certainty evidence) reported no difference in BMI at medium‐term follow‐up, and one study (2238 participants; low‐certainty evidence) found lower rates of overweight and obesity in the intervention group at long‐term follow‐up. Dietary interventions likely result in little to no difference in zBMI at short‐term (MD 0.03, 95% CI ‐0.13 to 0.19; 2 studies, 145 participants) and medium‐term follow‐up (MD ‐0.17, 95% CI ‐0.44 to 0.10; 1 study, 389 participants), both with moderate‐certainty evidence. None of the included studies reported zBMI at long‐term follow‐up. None of the studies reported serious adverse events. Activity interventions versus control Activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.10, 95% CI ‐0.28 to 0.08; 6 studies, 826 participants; very low‐certainty evidence). They likely reduce BMI at medium‐term follow‐up (MD ‐0.70, 95% CI ‐1.09 to ‐0.31; 1 study, 567 participants; moderate‐certainty evidence). None of the studies reported BMI at long‐term follow‐up. Activity interventions likely result in little to no difference in zBMI at short‐term follow‐up (MD ‐0.06, 95% CI ‐0.19 to 0.07; 3 studies, 635 participants; moderate‐certainty evidence). They may result in little to no difference in zBMI at medium‐term follow‐up, but the evidence is very uncertain (MD ‐0.00, 95% CI ‐0.12 to 0.11; 4 studies, 1083 participants; very low‐certainty evidence). None of the included studies reported zBMI at long‐term follow‐up. Activity interventions may have little to no effect on serious adverse events, but the evidence is very uncertain (2 studies, 773 participants; very low‐certainty evidence). One study found no harms related to the intervention, and one study reported no difference in accident and infection rates between groups. Combined dietary/activity interventions versus control Combined dietary/activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.08, 95% CI ‐0.20 to 0.04; 13 studies, 3867 participants; very low‐certainty evidence). They may result in little to no difference in BMI at medium‐term follow‐up (MD ‐0.05, 95% CI ‐0.18 to 0.08; 9 studies, 7016 participants; low‐certainty evidence), and may result in a slight reduction in BMI at long‐term follow‐up (MD ‐0.20, 95% CI ‐0.39 to ‐0.01; 5 studies, 2074 participants; low‐certainty evidence). Combined interventions may have little to no effect on zBMI at short‐term follow‐up (MD ‐0.03, 95% CI ‐0.07 to 0.01; 14 studies, 5518 participants), and may result in a slight reduction in zBMI at medium‐term follow‐up, but the evidence for both time frames is very uncertain (MD ‐0.07, 95% CI ‐0.11 to ‐0.04; 15 studies; 11,043 participants). Combined interventions may result in a slight reduction in zBMI at long‐term follow‐up (MD ‐0.07, 95% CI ‐0.13 to ‐0.01; 10 studies, 4693 participants; low‐certainty evidence). Combined interventions may result in little to no difference in serious adverse events, but the evidence is very uncertain (4 studies, 1689 participants; very low‐certainty evidence). One study reported that a parent fractured an ankle while roller‐skating at a community centre; the remaining studies reported no adverse events. Authors' conclusions In early childhood, combined dietary/activity interventions may have very modest benefits on BMI and zBMI at long‐term follow‐up. When implemented alone, dietary or activity interventions may have little to no effect on BMI measures. Only six studies reported serious adverse events, with no serious harms resulting directly from the intervention, but the evidence is very uncertain. Funding This review was partly funded by the National Institute for Health Research, School for Public Health Research. Registration Protocol available: DOI: 10.1002/14651858.CD015326 Plain language summary Do dietary and activity strategies help prevent obesity in children aged 2 to 4 years? Key messages Combining strategies for changing diet and physical activity levels in children aged 2 to 4 years to help prevent overweight and obesity may reduce body mass index (BMI) slightly in the long term (after 15 months). There was very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but none of the strategies appeared to result in any serious harm to the children. Future research should carry out obesity prevention strategies in community settings, and target the wider determinants of obesity and obesity prevention. Why is preventing obesity in children important? There is an increasing number of young children living with overweight and obesity worldwide, with evidence of the rates increasing in line with social inequality. Living with overweight during childhood can cause physical and psychological health problems. Children living with overweight are more likely to live with overweight as adults, and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help people change diet or activity (or both) are effective at preventing obesity in children aged 2 to 4 years, and whether they are associated with any serious adverse events. To examine obesity, we used the measure of body mass index (BMI). BMI is calculated by dividing a person's weight (in kg) by their height (in m 2 ). What did we do? We searched for studies that looked at ways to prevent obesity in children aged 2 to 4 years. We did not include studies that only targeted children who were already living with overweight or obesity, but we did include studies involving children at a range of weights. We only included studies if they used methods aimed at changing children's diet, activity level (increasing physical activity or reducing sedentary behaviour), or both. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 67 studies involving 36,601 children aged 2 to 4 years. Most studies (63 of 67) were based in high‐income countries, and four in upper‐middle‐income countries. In 26 studies, the strategies were conducted in childcare settings, 23 studies were primarily home‐based, and 10 were performed in both childcare and home‐based settings. Only 3 studies were conducted in the community, and 5 in healthcare settings. The duration of the programmes varied: 47 ran for fewer than 9 months, with the shortest being 1 visit and the longest lasting 3 years. We analysed results from 56 studies involving 21,404 children. Main findings Children who were helped with a strategy to change their diet and activity levels may have had a reduced BMI, compared with children not given any strategy. This means that these children may have been able to minimise excess weight gain by a small amount, which, for public health, is important. Children who were helped with a strategy to change their diet or activity alone did not have a reduced BMI. Only six of the 67 included studies reported on serious adverse events, and no serious harms were identified. What are the limitations of the evidence? Overall, our confidence in the evidence is very low. However, we do not believe that results from more studies similar in design to those included in this review would produce a higher level of confidence in the results. Four main factors reduced our confidence in the evidence. Results were very inconsistent across different studies. There were not enough studies reporting specific types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons. Results from some studies were not reported in a way that we could include in our analyses and this may have had an impact on the combined results. Studies generally had limitations in how they were conducted, due to the complexity of studies in this age group. This review does not provide enough information to assess how well these strategies work for children with disabilities or those from low‐ and middle‐income countries. How current is this evidence? This review updates a previous review. The evidence is current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Phillips, SM, Spiga, F, Moore, THM, Dawson, S, Stockton, H, Rizk, R, Cheng, HY, Hodder, RK, Gao, Y, Hillier-Brown, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015326.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.794Z" }, { "id": "45ca7b7f-8dfa-45f5-9067-026f8417b350", "pmid": "", "title": "Momordica charantia for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Momordica charantia (bitter gourd) is not only a nutritious vegetable but it is also used in traditional medical practices to treat type 2 diabetes mellitus. Experimental studies with animals and humans suggested that the vegetable has a possible role in glycaemic control. Objectives To assess the effects of mormodica charantia for type 2 diabetes mellitus. Search methods Several electronic databases were searched, among these were The Cochrane Library (Issue 1, 2012), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2012), combined with handsearches. No language restriction was used. Selection criteria We included randomised controlled trials (RCTs) that compared momordica charantia with placebo or a control intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently extracted data. Risk of bias of the trials was evaluated using the parameters of randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. A meta‐analysis was not performed given the quality of data and the variability of preparations of momordica charantia used in the interventions (no similar preparation was tested twice). Main results Four randomised controlled trials with up to three months duration and investigating 479 participants met the inclusion criteria. Risk of bias of these trials (only two studies were published as a full peer‐reviewed publication) was generally high. Two RCTs compared the effects of preparations from different parts of the momordica charantia plant with placebo on glycaemic control in type 2 diabetes mellitus. There was no statistically significant difference in the glycaemic control with momordica charantia preparations compared to placebo. When momordica charantia was compared to metformin or glibenclamide, there was also no significant change in reliable parameters of glycaemic control. No serious adverse effects were reported in any trial. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions There is insufficient evidence on the effects of momordica charantia for type 2 diabetes mellitus. Further studies are therefore required to address the issues of standardization and the quality control of preparations. For medical nutritional therapy, further observational trials evaluating the effects of momordica charantia are needed before RCTs are established to guide any recommendations in clinical practice. Plain language summary Momordica charantia for type 2 diabetes mellitus Mormordica charantia (bitter gourd or bitter melon) is a climbing perennial that is characterized by elongated, warty fruit‐like gourds or cucumbers and is native to the tropical belt. Although momordica charantia is commonly used in traditional medical practices, along with research suggesting its benefits for people with type 2 diabetes, the current evidence does not warrant using the plant in treating this disease. This review of trials found only four studies which had an overall low quality. Three trials showed no significant differences between momordica charantia and placebo or antidiabetic drugs (glibenclamide and metformin) in the blood sugar response. The duration of treatment ranged from four weeks to three months, and altogether 479 patients with type 2 diabetes mellitus participated. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Adverse effects were mostly moderate, including diarrhoea and abdominal pain. However, reporting of adverse effects was incomplete in the included studies. There are many varieties of preparations of momordica charantia, as well as variations in its use as a vegetable. Further studies are needed to assess the quality of the various momordica charantia preparations as well as to further evaluate its use in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Ooi, CP, Yassin, Z, Hamid, TA", "articleTypes": [], "doi": "10.1002/14651858.CD007845.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.070Z" }, { "id": "45d9a2c1-d084-4406-8bb5-99b6285df305", "pmid": "", "title": "Pharmacological interventions for self‐harm in adults", "imported": false, "abstract": "Abstract - Background Self‐harm (SH; intentional self‐poisoning or self‐injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm. Objectives To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta‐analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients. Search methods For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co‐ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013. Selection criteria We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services. Data collection and analysis We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta‐analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow‐up. For this analysis, we pooled data using a random‐effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach. Main results We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low‐dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported. Authors' conclusions Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment. Plain language summary Drugs and natural products for self‐harm in adults We have reviewed the international literature regarding pharmacological (drug) and natural product (dietary supplementation) treatment trials in this field. A total of seven trials meeting our inclusion criteria were identified. There is little evidence of beneficial effects of either pharmacological or natural product treatments. However, few trials have been conducted and those that have are small, meaning that possible beneficial effects of some therapies cannot be ruled out. Why is this review important? Self‐harm (SH), which includes intentional self‐poisoning/overdose and self‐injury, is a major problem in many countries and is strongly linked to suicide. It is therefore important that effective treatments for SH patients are developed. Whilst there has been an increase in the use of psychosocial interventions for SH in adults (which is the focus of a separate review), drug treatments are frequently used in clinical practice. It is therefore important to assess the evidence for their effectiveness. Who will be interested in this review? Clinicians working with patients who engage in SH, patients themselves, and their relatives. What questions does this review aim to answer? This review is an update of a previous Cochrane review from 1999 which found little evidence of beneficial effects of drug treatments on repetition of SH apart from for flupenthixol. This update aims to further evaluate the evidence for effectiveness of drugs and natural products for patients with SH with a broader range of outcomes. Which studies were included in the review? To be included in the review, studies had to be randomised controlled trials of drug treatments for adults who had recently engaged in SH. What does the evidence from the review tell us? There is currently no clear evidence for the effectiveness of antidepressants, antipsychotics, mood stabilisers, or natural products in preventing repetition of SH. What should happen next? We recommend further trials of drugs for SH patients, possibly in combination with psychological treatment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hawton, K, Witt, KG, Taylor Salisbury, TL, Arensman, E, Gunnell, D, Hazell, P, Townsend, E, van Heeringen, K", "articleTypes": [], "doi": "10.1002/14651858.CD011777", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.776Z" }, { "id": "45e3dedd-ad7b-4e91-9360-c0bbd87df880", "pmid": "", "title": "Topical antibiotics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection (involving more than one micro‐organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms are ear discharge and hearing loss. Topical antibiotics, the most common treatment for CSOM, aim to kill or inhibit the growth of micro‐organisms that may be responsible for the infection. Antibiotics can be used alone or with other treatments for CSOM, such as antiseptics or ear cleaning (aural toileting). This is an update of a Cochrane review first published in 2020 and one of a suite of seven reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To evaluate the benefits and harms of topical antibiotics (without steroids) for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials with at least a one week of follow‐up involving adults and children with chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antibiotic(s) of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic compared to placebo or no intervention, and compared to another topical antibiotic (e.g. topical antibiotic A versus topical antibiotic B). Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks and up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This update found one new study (100 participants). Overall, we included 18 studies with 1783 participants (in 16 studies), plus 108 ears that could not be accounted for in participant numbers (in two studies). 1. Topical antibiotics versus placebo or no treatment (with aural toilet in both arms and no other background treatment) One study (50 participants, data unavailable for 15 participants) compared a topical antibiotic (ciprofloxacin) with placebo (saline). All participants received aural toilet. Topical ciprofloxacin may increase resolution of discharge at one to up to two weeks compared with placebo (84% with antibiotic versus 12% with placebo; risk ratio (RR) 6.74, 95% confidence interval (CI) 1.82 to 24.99; 35 participants; very low‐certainty evidence). The study authors reported \"no medical side‐effects and worsening of audiological measurements related to this topical medication were detected.\" 2. Topical antibiotics versus placebo or no treatment (with use of oral antibiotics in both arms) Four studies (438 participants) compared topical antibiotics versus no treatment, with oral antibiotics in both arms. These compared topical ciprofloxacin to no treatment (3 studies, 190 participants) or topical ceftizoxime to no treatment (1 study, 248 participants). In each study, all participants received the same antibiotic systemically (oral ciprofloxacin or injected ceftizoxime). In at least one study, all participants received aural toilet. There were no useable data comparing topical ceftizoxime to no treatment. Topical antibiotics in addition to systemic antibiotics may increase resolution of ear discharge at one to up to two weeks compared with systemic antibiotics alone (resolution of discharge occurring in 88% with topical antibiotics versus 60% without topical antibiotics; RR 1.47, 95% CI 1.14 to 1.88; 1 study, 100 participants; low‐certainty evidence). One study (40 participants) stated \"no side effect was recorded in any patient\" (low‐certainty evidence). 3. Comparisons of different topical antibiotics Eight studies (794 participants, plus 40 ears) compared aminoglycosides (gentamicin, neomycin, or tobramycin) with quinolones (ciprofloxacin or ofloxacin). Resolution of discharge at one to up to two weeks may be higher in the quinolones group, but the evidence is very uncertain (RR 1.92, 95% CI 1.00 to 3.67; 7 studies, 794 participants; very low‐certainty evidence). There was considerable heterogeneity (I 2 = 97%). One study (308 participants) stated there were no differences between the different groups for resolution of ear discharge after four weeks (low‐certainty evidence). The evidence is very uncertain about the effects of topical antibiotics on ear pain (1 study reported no differences between groups). The evidence is very uncertain about the effects of topical antibiotics on hearing loss (2 studies reported no differences between groups). 4. Other comparisons We assessed five studies (501 participants, plus 68 ears) over the following three additional comparisons: quinolones versus aminoglycosides/polymyxin B with/without gramicidin, aminoglycosides versus trimethoprim‐sulphacetamide‐polymixin B, and rifampicin versus chloramphenicol. However, these results have not been included in the abstract. Authors' conclusions We are very uncertain about the effectiveness of topical antibiotics in improving resolution of ear discharge in people with CSOM because of the limited amount of low‐ or very low‐certainty evidence available. This was mostly due to risk of bias and imprecision. However, amongst this uncertainty, there is some evidence to suggest that the use of topical antibiotics may be effective when compared to placebo, or when used in addition to a systemic antibiotic. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine whether quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, harmful effects were poorly reported. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and harms of using topical antibiotics to treat chronic suppurative otitis media? Key messages – We are uncertain whether topical antibiotics reduce ear discharge of people with swelling and infection of the middle ear (called chronic suppurative otitis media). – Topical antibiotics may reduce ear discharge compared to placebo (a salt solution), but we are very uncertain. Topical antibiotics used in addition to an antibiotic given by mouth may reduce ear discharge. – Overall, we are very uncertain which type of topical antibiotic is the most effective. What is chronic suppurative otitis media? Chronic suppurative otitis media, also known as chronic otitis media, is a swelling and infection of the middle ear that lasts for two weeks or more. People with chronic suppurative otitis media usually have ear discharge that is difficult to get rid of or keeps coming back (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Topical antibiotics (administered into the ear canal as ear drops, ointments, sprays, or creams) are the most commonly used treatment for chronic suppurative otitis media. Topical antibiotics kill or stop the growth of the bacteria (germs) that may be responsible for the infection. Topical antibiotics can be used on their own or be added to other treatments for chronic suppurative otitis media, such as antiseptics (which also kill germs) or ear cleaning (aural toileting) or systemic antibiotics (antibiotics taken either by mouth or by an injection into a muscle or vein). What was the aim of this review? We wanted to find out how effective topical antibiotics are for people with chronic suppurative otitis media, and whether they cause unwanted effects. We also wanted to know whether one type of topical antibiotic was more beneficial or harmful than any other. In particular, we wanted to know whether topical antibiotics stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found one new study (100 participants). Overall, we found 18 studies examining at least 1783 people, but it was difficult to determine precisely how many people were included as some studies did not clearly report the number. Two studies included \"mainly children,\" three included only adults, whilst the remainder appeared to include both children and adults. None of the studies reported the inclusion of people considered at high risk of having chronic suppurative otitis media (for example, people with cleft palate (where the roof of the mouth of a baby does not join together during pregnancy) or Down's syndrome; or people whose immune system does not work well enough to fight germs). The studies used different types of antibiotics and combinations of antibiotics. Comparison of topical antibiotics to placebo or no treatment One study (50 people) compared topical antibiotics to a saline (salt water) ear wash. Topical antibiotics may reduce ear discharge more than the saline ear wash when assessed one to up to two weeks after treatment, but we are very uncertain. The evidence is very uncertain about unwanted effects and worsening of hearing measurements. The study did not measure quality of life and reported that there were no serious complications. Comparison of topical antibiotics in addition to systemic (oral or injected) antibiotics Four studies (438 people) compared treatment with topical antibiotic (ciprofloxacin) drops in addition to a systemic (oral or injected) antibiotic, but one study did not contribute data. Topical plus oral antibiotics may reduce ear discharge more than oral antibiotics alone at one to up to two weeks and two to up to four weeks. One study stated there were no unwanted effects. The studies did not measure quality of life and did not report any serious complications. Comparisons of different topical antibiotics Eight studies (794 participants plus 40 ears) compared an aminoglycoside antibiotic (gentamicin, neomycin, or tobramycin) with a quinolone antibiotic (ciprofloxacin or ofloxacin). Quinolones may reduce ear discharge better than aminoglycosides, but the evidence is very uncertain. One study (100 people) measured ear pain and reported no difference between the groups, but the evidence is very uncertain. Two studies measured hearing loss, but the evidence is very uncertain. What are the limitations of the evidence? There were several limitations with the studies. For example, the results varied widely between studies, there were small numbers of people included, there was a lack of recent data, and limited information on groups of people who are more likely to have chronic suppurative otitis media. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Brennan-Jones, CG, Head, K, Chong, LY, Daw, J, Veselinović, T, Schilder, AGM, Bhutta, MF", "articleTypes": [], "doi": "10.1002/14651858.CD013051.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.107Z" }, { "id": "45ef017e-f8bb-470d-8076-255d3f805636", "pmid": "", "title": "Interventions for drooling in children with cerebral palsy", "imported": false, "abstract": "Abstract - Background Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation ( Blasco 1992 ; Van der Burg 2006 ). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP. Objectives (1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning. Search methods We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts. We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled‐trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts. Selection criteria Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included. Data collection and analysis Data were extracted independently by MW, MS and LP and differences resolved through discussion. Main results Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin‐A (BoNT‐A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro‐motor and oro‐sensory therapies, behavioural interventions, intra‐oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta‐analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies. Authors' conclusions It was not possible to reach a conclusion on the effectiveness and safety of either BoNT‐A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided. Plain language summary Interventions for drooling in children with cerebral palsy Many children with CP have difficulty controlling saliva. Drooling varies in severity and can be distressing for the children, families and caregivers. Excessive drooling can cause constant damp soiled clothing, unpleasant odour, irritated, chapped or sore skin around the mouth and chin, skin and mouth infections, dehydration, difficulties chewing, interference with speech, damage to books, communication aids, computer and audio equipment. There is also risk of social rejection and social isolation for these children. Many interventions are used to reduce or eliminate drooling. These include surgery, medications, botulinum toxin (BoNT‐A and BoNT‐B)), physical therapies, therapies to improve sensory function, behavioural therapies to assist the child in managing his/her own drooling, appliances placed in the mouth, and acupuncture. There is no clear consensus on which interventions are safe and effective in managing drooling in children with CP. This makes it hard to decide which intervention will be safest and most effective. Only RCTs and CCTs were included in this review. Trials were identified by electronic searches of databases, searches of clinical trials registers, peer reviewed journals, published conference proceedings and reference lists of relevant articles. Six trials were found. Four examined the safety and efficacy of BoNT‐A and two examined benztropine and glycopyrrolate. No trials were found on other interventions. The quality of trials was variable. The trials all differed in the children recruited, the product used, how the product was delivered and how its effectiveness was measured. All trials reported a positive reduction in drooling and all showed some statistically significant change for treatment groups up to 1 month post intervention. Few studies examined client and/or carer satisfaction with the intervention. Some looked at side effects of the intervention but no study examined the effect of interventions on the child's quality of life or psychological well being. There is insufficient evidence to support the use of one intervention over another. As trials on just two kinds of interventions were retrieved, and given the variation and quality of these studies, it is not possible to conclude that one intervention is more effective than another. The lack of trials on other interventions does not suggest that these interventions are ineffective. Adequately powered well designed trials are required across all interventions. In addition to using sensitive measures looking at change in salivary flow, measures are needed that examine client and carer satisfaction, changes in quality of life, psychological well being and in unwanted symptoms associated with drooling.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Walshe, M, Smith, M, Pennington, L", "articleTypes": [], "doi": "10.1002/14651858.CD008624.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.078Z" }, { "id": "4610c848-bb1d-40b7-939c-ac1cb27f0017", "pmid": "", "title": "Chloral hydrate as a sedating agent for neurodiagnostic procedures in children", "imported": false, "abstract": "Abstract - Background This is an updated version of a Cochrane Review published in 2017. Paediatric neurodiagnostic investigations, including brain neuroimaging and electroencephalography (EEG), play an important role in the assessment of neurodevelopmental disorders. The use of an appropriate sedative agent is important to ensure the successful completion of the neurodiagnostic procedures, particularly in children, who are usually unable to remain still throughout the procedure. Objectives To assess the effectiveness and adverse effects of chloral hydrate as a sedative agent for non‐invasive neurodiagnostic procedures in children. Search methods We searched the following databases on 14 May 2020, with no language restrictions: the Cochrane Register of Studies (CRS Web) and MEDLINE (Ovid, 1946 to 12 May 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including Cochrane Epilepsy. Selection criteria Randomised controlled trials that assessed chloral hydrate agent against other sedative agent(s), non‐drug agent(s), or placebo. Data collection and analysis Two review authors independently evaluated studies identified by the search for their eligibility, extracted data, and assessed risk of bias. Results were expressed in terms of risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CIs). Main results We included 16 studies with a total of 2922 children. The methodological quality of the included studies was mixed. Blinding of the participants and personnel was not achieved in most of the included studies, and three of the 16 studies were at high risk of bias for selective reporting. Evaluation of the efficacy of the sedative agents was also underpowered, with all the comparisons performed in small studies. Fewer children who received oral chloral hydrate had sedation failure compared with oral promethazine (RR 0.11, 95% CI 0.01 to 0.82; 1 study; moderate‐certainty evidence). More children who received oral chloral hydrate had sedation failure after one dose compared to intravenous pentobarbital (RR 4.33, 95% CI 1.35 to 13.89; 1 study; low‐certainty evidence), but there was no clear difference after two doses (RR 3.00, 95% CI 0.33 to 27.46; 1 study; very low‐certainty evidence). Children with oral chloral hydrate had more sedation failure compared with rectal sodium thiopental (RR 1.33, 95% CI 0.60 to 2.96; 1 study; moderate‐certainty evidence) and music therapy (RR 17.00, 95% CI 2.37 to 122.14; 1 study; very low‐certainty evidence). Sedation failure rates were similar between groups for comparisons with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam and oral clonidine. Children who received oral chloral hydrate had a shorter time to adequate sedation compared with those who received oral dexmedetomidine (MD −3.86, 95% CI −5.12 to −2.6; 1 study), oral hydroxyzine hydrochloride (MD −7.5, 95% CI −7.85 to −7.15; 1 study), oral promethazine (MD −12.11, 95% CI −18.48 to −5.74; 1 study) (moderate‐certainty evidence for three aforementioned outcomes), rectal midazolam (MD −95.70, 95% CI −114.51 to −76.89; 1 study), and oral clonidine (MD −37.48, 95% CI −55.97 to −18.99; 1 study) (low‐certainty evidence for two aforementioned outcomes). However, children with oral chloral hydrate took longer to achieve adequate sedation when compared with intravenous pentobarbital (MD 19, 95% CI 16.61 to 21.39; 1 study; low‐certainty evidence), intranasal midazolam (MD 12.83, 95% CI 7.22 to 18.44; 1 study; moderate‐certainty evidence), and intranasal dexmedetomidine (MD 2.80, 95% CI 0.77 to 4.83; 1 study, moderate‐certainty evidence). Children who received oral chloral hydrate appeared significantly less likely to complete neurodiagnostic procedure with child awakening when compared with rectal sodium thiopental (RR 0.95, 95% CI 0.83 to 1.09; 1 study; moderate‐certainty evidence). Chloral hydrate was associated with a higher risk of the following adverse events: desaturation versus rectal sodium thiopental (RR 5.00, 95% 0.24 to 102.30; 1 study), unsteadiness versus intranasal dexmedetomidine (MD 10.21, 95% CI 0.58 to 178.52; 1 study), vomiting versus intranasal dexmedetomidine (MD 10.59, 95% CI 0.61 to 185.45; 1 study) (low‐certainty evidence for aforementioned three outcomes), and crying during administration of sedation versus intranasal dexmedetomidine (MD 1.39, 95% CI 1.08 to 1.80; 1 study, moderate‐certainty evidence). Chloral hydrate was associated with a lower risk of the following: diarrhoea compared with rectal sodium thiopental (RR 0.04, 95% CI 0.00 to 0.72; 1 study), lower mean diastolic blood pressure compared with sodium thiopental (MD 7.40, 95% CI 5.11 to 9.69; 1 study), drowsiness compared with oral clonidine (RR 0.44, 95% CI 0.30 to 0.64; 1 study), vertigo compared with oral clonidine (RR 0.15, 95% CI 0.01 to 2.79; 1 study) (moderate‐certainty evidence for aforementioned four outcomes), and bradycardia compared with intranasal dexmedetomidine (MD 0.17, 95% CI 0.05 to 0.59; 1 study; high‐certainty evidence). No other adverse events were significantly associated with chloral hydrate, although there was an increased risk of combined adverse events overall (RR 7.66, 95% CI 1.78 to 32.91; 1 study; low‐certainty evidence). Authors' conclusions The certainty of evidence for the comparisons of oral chloral hydrate against several other methods of sedation was variable. Oral chloral hydrate appears to have a lower sedation failure rate when compared with oral promethazine. Sedation failure was similar between groups for other comparisons such as oral dexmedetomidine, oral hydroxyzine hydrochloride, and oral midazolam. Oral chloral hydrate had a higher sedation failure rate when compared with intravenous pentobarbital, rectal sodium thiopental, and music therapy. Chloral hydrate appeared to be associated with higher rates of adverse events than intranasal dexmedetomidine. However, the evidence for the outcomes for oral chloral hydrate versus intravenous pentobarbital, rectal sodium thiopental, intranasal dexmedetomidine, and music therapy was mostly of low certainty, therefore the findings should be interpreted with caution. Further research should determine the effects of oral chloral hydrate on major clinical outcomes such as successful completion of procedures, requirements for an additional sedative agent, and degree of sedation measured using validated scales, which were rarely assessed in the studies included in this review. The safety profile of chloral hydrate should be studied further, especially for major adverse effects such as oxygen desaturation. Plain language summary The effectiveness of chloral hydrate as a sedative agent for children undergoing neurodiagnostic procedures Review question In children undergoing non‐invasive neurodiagnostic procedures, is chloral hydrate more effective at producing adequate sedation (slowing of brain activity) and safer than other ways of achieving sedation? Background Neurodiagnostic procedures are non‐invasive neurological investigations important for children with suspected neurological disorders. These investigations include brain imaging and brain electrical activity testing. For these tests to be successfully performed, the child needs to remain still for at least 30 to 45 minutes during the investigation period. Sedative agents are required for children, who are usually unable to remain still for this period of time. Search date The evidence is current to May 2020. Study characteristics We included 16 studies involving a total of 2922 children (age up to 18 years old) in the review. All of the included studies were performed in hospitals that provided neurodiagnostic services. Most studies assessed the following three main outcomes: proportion of children who were unsuccessfully sedated for the neurodiagnostic procedure; length of time taken for adequate sedation; and side effects associated with the sedative agent. The quality of the evidence was mixed, ranging from very low to high. The main reason for lowering the quality of the evidence was that those closely involved in the trials, such as the doctors giving the sedation or the parents of the child, were not masked to the sedative agent used in the child, which could have affected their recording or interpretation of the results. Key results We summarised the evidence of effectiveness and harms of oral chloral hydrate sedation when compared with other sedative agents. Our review suggests that oral chloral hydrate is just as effective a sedative agent with similar sedation failure rate when compared with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam, and oral clonidine; and probably a more effective sedative agent with a lower sedation failure rate when compared with oral promethazine. Whilst most of the included studies showed that chloral hydrate was safe with no increase in side effects when compared to other sedative agents, one study reported an increased risk of side effects with oral chloral hydrate when compared with intranasal dexmedetomidine. Quality of the evidence The quality of most of the evidence was poor due to flaws in study methods and the small sample size of each study, therefore our confidence in the results of the studies is reduced. Conclusions Apart from intravenous pentobarbital, rectal sodium thiopental, and music therapy, oral chloral hydrate is either just as effective or more effective as a sedating agent when compared to other sedating agents for children undergoing non‐invasive neurodiagnostic procedures. Given the poor quality of the evidence, we could draw no clear conclusions on the effectiveness or safety of any of the paediatric sedative agents studied in the review. Further study is needed to look at the side effects of oral chloral hydrate when compared to other sedatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Fong, CY; Lim, WK; Li, L; Lai, NM", "articleTypes": [], "doi": "10.1002/14651858.CD011786.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "46385cfd-0386-4a3a-bc0e-f50d506ce502", "pmid": "", "title": "Statins for children with familial hypercholesterolemia", "imported": false, "abstract": "Abstract - Background Familial hypercholesterolemia is one of the most common inherited metabolic diseases and is an autosomal dominant disorder meaning heterozygotes, or carriers, are affected. Those who are homozygous have severe disease. The average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500, although recent genetic epidemiological data from Denmark and next generation sequencing data suggest the frequency may be closer to 1 in 250. Diagnosis of familial hypercholesterolemia in children is based on elevated total cholesterol and low‐density lipoprotein cholesterol levels or DNA‐based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong treatment, started in childhood, is needed to reduce the risk of cardiovascular disease. In children with the disease, diet was the cornerstone of treatment but the addition of lipid‐lowering medications has resulted in a significant improvement in treatment. Anion exchange resins, such as cholestyramine and colestipol, were found to be effective, but they are poorly tolerated. Since the 1990s studies carried out on children aged 6 to 17 years with heterozygous familial hypercholesterolemia have demonstrated significant reductions in their serum total and low‐density lipoprotein cholesterol levels. While statins seem to be safe and well‐tolerated in children, their long‐term safety in this age group is not firmly established. This is an update of a previously published version of this Cochane Review. Objectives To assess the effectiveness and safety of statins in children with heterozygous familial hypercholesterolemia. Search methods Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline. Date of most recent search: 04 November 2019. Selection criteria Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. Data collection and analysis Two authors independently assessed studies for inclusion and extracted data. Main results We found 26 potentially eligible studies, of which we included nine randomized placebo‐controlled studies (1177 participants). In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). There may be little or no difference in liver function (serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations) between treated and placebo groups at any time point (low‐quality evidence). There may be little or no difference in myopathy (as measured in change in creatinine levels) (low‐quality evidence) or clinical adverse events (moderate‐quality evidence) with statins compared to placebo. One study on simvastatin showed that this may slightly improve flow‐mediated dilatation of the brachial artery (low‐quality evidence), and on pravastatin for two years may have induced a regression in carotid intima media thickness (low‐quality evidence). No studies reported rhabdomyolysis (degeneration of skeletal muscle tissue) or death due to rhabdomyolysis, quality of life or compliance to study medication. Authors' conclusions Statin treatment is an effective lipid‐lowering therapy in children with familial hypercholesterolemia. Few or no safety issues were identified. Statin treatment seems to be safe in the short term, but long‐term safety remains unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians and their care transferred to an adult lipidologist once they reach 18 years of age. Large long‐term randomized controlled trials are needed to establish the long‐term safety issues of statins. Plain language summary Statins for children with inherited high blood cholesterol Review question We reviewed the evidence for the effectiveness and safety of statins in children with inherited high blood cholesterol. Background Familial hypercholesterolemia is an inherited disease in which the blood cholesterol level is high. Vascular disease, i.e. furring up of the blood vessels, often occurs at an earlier age than usual, especially amongst men. Thus lifelong therapies, started in childhood, to reduce blood cholesterol are needed. In children with familial hypercholesterolemia, diet has been the main treatment option. Medications, such as cholestyramine and colestipol, have been used effectively, but due to their unpleasant taste they are poorly tolerated and treatment plans are not followed. The advent of statin therapy for children has improved treatment and this review updates the previous published version. Search date The evidence is current to: 04 November 2019. Study characteristics The review included 9 studies with 1177 people with heterozygous familial hypercholesterolemia aged between 4 and 18 years of age. Studies compared different statin treatments with a substance which contains no medication (termed placebo) and people were selected for one treatment or the other randomly. The studies lasted from 12 weeks to 104 weeks. Key results In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins probably reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). The levels of the liver enzymes, serum aspartate and alanine aminotransferase, and the muscle enzyme, creatinine kinase, did not differ between treated and placebo groups at any time point (low‐quality evidence). The risks of myopathy (disease of muscle tissue) and side‐effects were very low and similar in both groups (low‐quality evidence). Two of the statins, simvastatin and pravastatin may have a positive effect on two of the major blood vessels typically affected by raised cholesterol levels (low‐quality evidence). Quality of the evidence Information regarding blinding (performance bias and detection bias), was available for all nine studies; each was described as double blind, indicating that participants and those participating in treatment procedures were blinded to treatment. In two studies information on how the participants were allocated to treatment groups (selection bias) was clearly presented, but this information was not clearly stated in the remaining seven studies. There is a lack of information whether investigators knew which treatment group participants would be put into (selection bias) and or whether selective reporting (reporting bias) occurred, but it is very unlikely. In conclusion, it can be stated all the studies appeared to be well run and we do not think any of the above‐mentioned factors influenced the results in a negative way. Quality of evidence varied from high (change in serum low‐density lipoprotein (LDL) cholesterol) through moderate (adverse events) to low (change in blood vessel wall (carotid intima‐media) thickness, change in measures if growth and maturation, liver dysfunction, myopathy and change in blood wall (endothelial) function).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Vuorio, A; Kuoppala, J; Kovanen, PT; Humphries, SE; Tonstad, S; Wiegman, A; Drogari, E; Ramaswami, U", "articleTypes": [], "doi": "10.1002/14651858.CD006401.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "465827f2-6efe-49e6-9a78-ffc7f29f4ab8", "pmid": "", "title": "Nedocromil sodium for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Exercise‐induced bronchoconstriction (EIB) following strenuous physical exertion afflicts many people. It can be the cause of sub‐optimal performance, symptoms such as cough, dyspnea, wheeze and chest tightness, and can lead people to avoid physical activity. Management of EIB focuses on prevention through pharmacotherapy and alternate strategies. Single use, pre‐exercise, beta‐agonists and non‐steroidal antiinflammatory agents are recommended. Objectives Bronchodilator medications have been commonly used to prevent narrowing of airways after exercise, but anti‐inflammatory drugs such as nedocromil sodium have also been used. The objective of this review was to assess the effects of a single dose of nedocromil sodium to prevent exercise‐induced bronchoconstriction. Search methods We searched the Cochrane Airways Group Specialised Regsiter, the Cochrane Central Register of Controlled Trials, Current Contents, review articles, textbooks and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. Searches have been updated to August 2008. Selection criteria Randomised trials comparing a single dose of nedocromil sodium with placebo to prevent exercise‐induced bronchoconstriction in patients with EIB over six years of age. Data collection and analysis Trial quality assessment and data extraction were conducted independently by two reviewers. Study authors were contacted for confirmation of data. No new studies were identified in an update search conducted in August 2008. Main results The combined results from 20 randomised controlled trials involving 280 participants, show that 4 mg, of nedocromil sodium inhaled 15 to 60 minutes prior to exercise significantly reduce the severity and duration of EIB in both adults and children, when compared to placebo. The maximum percentage fall in FEV1 was improved significantly compared to placebo (weighted mean difference 15.5 %; 95% confidence interval:13.2 to 18.1). For the maximum percentage fall in peak expiratory flow rate (PEFR) the improvement was similar: WMD 15.0%, (95% CI 8.3 to 21.6). Nedocromil shortened the time to recover lung normal function from more than 30 minutes with placebo to less than 10 minutes with the drug. It had a greater effect on those patients with more severe exercise‐induced bronchoconstriction (defined as an exercise‐induced fall in lung function > 30% from baseline). There were no significant adverse effects reported with the short term use of nedocromil. A further search conducted in August 2005 did not yield any further studies. Authors' conclusions Nedocromil sodium used before exercise reduces the severity and duration of exercise‐induced bronchoconstriction. This effect appears to be more pronounced in people with severe exercise‐induced bronchoconstriction. Plain language summary Nedocromil sodium for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. The review of trials found that nedocromil sodium (Tilade) inhaled 15 to 60 minutes before exercise may reduce the severity and length of this kind of asthma for both adults and children, particularly those who have severe episodes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Spooner, C, Saunders, LD, Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD001183", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.082Z" }, { "id": "46605f9e-1cfd-4643-821c-ee9871a78a2b", "pmid": "", "title": "Over the counter (OTC) artificial tear drops for dry eye syndrome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pucker, AD, Ng, SM, Nichols, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD009729.pub2 AB - Abstract - Background Over the counter (OTC) artificial tears historically have been the first line of treatment for dry eye syndrome and dry eye‐related conditions like contact lens discomfort, yet currently we know little regarding the overall efficacy of individual, commercially available artificial tears. This review provides a much needed meta‐analytical look at all randomized and quasi‐randomized clinical trials that have analyzed head‐to‐head comparisons of OTC artificial tears. Objectives To evaluate the effectiveness and toxicity of OTC artificial tear applications in the treatment of dry eye syndrome compared with another class of OTC artificial tears, no treatment, or placebo. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 12), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2015), EMBASE (January 1980 to December 2015), Latin American and Caribbean Health Sciences (LILACS) (January 1982 to December 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) and the US Food and Drugs Administration (FDA) website ( www.fda.gov ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 December 2015. We searched reference lists of included trials for any additional trials not identified by the electronic searches. Selection criteria This review includes randomized controlled trials with adult participants who were diagnosed with dry eye, regardless of race and gender. We included trials in which the age of participants was not reported, and clinical trials comparing OTC artificial tears with another class of OTC artificial tears, placebo, or no treatment. This review did not consider head‐to‐head comparisons of artificial tears with another type of dry‐eye therapy. Data collection and analysis We followed the standard methodological procedures expected by Cochrane. Two authors independently screened the search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. We performed meta‐analysis for trials that compared similar interventions and reported comparable outcomes with sufficient data. We summarized all other included trial results in the text. Main results We included 43 randomized controlled trials (3497 participants with dry eye). Due to the heterogeneity of study characteristics among the included trials with respect to types of diagnostic criteria, interventions, comparisons, and measurements taken, our ability to perform meta‐analyses was limited. The review found that, in general, there was uncertainty whether different OTC artificial tears provide similar relief of signs and symptoms when compared with each other or placebo. Nevertheless, we found that 0.2% polyacrylic acid‐based artificial tears were consistently more effective at treating dry eye symptoms than 1.4% polyvinyl alcohol‐based artificial tears in two trials assessing this comparison (175 participants). All other included artificial tears produced contradictory between‐group results or found no between‐group differences. Our review also found that OTC artificial tears may be generally safe, but not without adverse events. Overall, we assessed the quality of evidence as low due to high risks of bias among included trials and poor reporting of outcome measures which were insufficient for quantitative analysis. Furthermore, we identified an additional 18 potentially eligible trials that were reported only in clinical trial registers with no associated results or publications. These trials reportedly enrolled 2079 total participants for whom no data are available. Such lack of reporting of trial results represents a high risk of publication bias. Authors' conclusions OTC artificial tears may be safe and effective means for treating dry eye syndrome; the literature indicates that the majority of OTC artificial tears may have similar efficacies. This conclusion could be greatly skewed by the inconsistencies in study designs and inconsistencies in reporting trial results. Additional research is therefore needed before we can draw robust conclusions about the effectiveness of individual OTC artificial tear formulations. Plain language summary Efficacy of over the counter (OTC) artificial tears for dry eye syndrome Research question What is the effect of over the counter (OTC) artificial tears on dry eye syndrome? Background 
 Dry eye syndrome is a long‐term condition that is known to cause eye discomfort and visual disturbances like blurred vision. This condition affects millions of people around the world, and the first‐line treatment for dry eye is typically over the counter (OTC) artificial tears. OTC artificial tears are meant to replace or supplement the tears (fluid) that naturally cover the eye’s front surface (cornea and conjunctiva). There are a great number of commercially available artificial tears, yet there is currently no agreement about whether one formulation works better than another at treating dry eye. Our review attempts to bridge this knowledge gap. Study characteristics 
 This review included 43 randomized controlled trials (3497 people with dry eye) that compared OTC artificial tears with other OTC artificial tears, with no treatment, or with placebo. We considered participant symptoms to be the primary outcome for this review. We recorded other commonly performed dry eye tests as secondary outcomes (e.g. vision, tear stability). We measured primary and secondary outcomes at two and four weeks, although we also considered other time points in this review. We searched for trials up to December 2015. Key results 
 This review analyzed many OTC artificial tear formulations, and most of the literature indicates uncertainty as to which OTC artificial tear works best. The literature also shows that OTC artificial tears may be effective at treating dry eye symptoms and that OTC artificial tears are generally safe, although not without side effects. We also identified an additional 18 potentially eligible trials that were registered, but did not provide any results or publications. These trials may have enrolled 2079 total participants for whom no data are available. Without the results of these trials, the effects of the OTC artificial tears that they evaluated are unknown. Quality of the evidence The overall quality of the evidence was low for the various OTC artificial tear formulations compared in this review. This finding indicates that future published research may have an important impact on the conclusions currently provided in this review.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.770Z" }, { "id": "46637948-43fb-4b0b-9ab4-aba11b94fd6d", "pmid": "", "title": "Interventions for the management of dry mouth: non‐pharmacological interventions", "imported": false, "abstract": "Abstract - Background Xerostomia is the subjective sensation of dry mouth. Common causes of xerostomia include adverse effects of many commonly prescribed medications, disease (e.g. Sjogren's Syndrome) and radiotherapy treatment for head and neck cancers. Non‐pharmacological techniques such as acupuncture or mild electrostimulation may be used to improve symptoms. Objectives To assess the effects of non‐pharmacological interventions administered to stimulate saliva production for the relief of dry mouth. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 16th April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 3), MEDLINE via OVID (1948 to 16th April 2013), EMBASE via OVID (1980 to 16th April 2013), AMED via OVID (1985 to 16th April 2013), CINAHL via EBSCO (1981 to 16th April 2013), and CANCERLIT via PubMed (1950 to 16th April 2013). The meta Register of Controlled Clinical Trials ( www.controlled‐trials.com ) and ClinicalTrials.gov ( www.clinicaltrials.gov ) were also searched to identify ongoing and completed trials. References lists of included studies and relevant reviews were also searched. There were no restrictions on the language of publication or publication status. Selection criteria We included parallel group randomised controlled trials of non‐pharmacological interventions to treat dry mouth, where participants had dry mouth symptoms at baseline. Data collection and analysis At least two review authors assessed each of the included studies to confirm eligibility, assess risk of bias and extract data using a piloted data extraction form. We calculated mean difference (MD) and 95% confidence intervals (CI) for continuous outcomes or where different scales were used to assess an outcome, we calculated standardised mean differences (SMD) together with 95% CIs. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information. Main results There were nine studies (total 366 participants randomised) included in this review of non‐pharmacological interventions for dry mouth which were divided into three comparisons. Eight studies were assessed at high risk of bias in at least one domain and the remaining study was at unclear risk of bias. Five small studies (total 153 participants, with dry mouth following radiotherapy treatment) compared acupuncture with placebo. Four were assessed at high risk and one at unclear risk of bias. Two trials reported outcome data for dry mouth in a form suitable for meta‐analysis. The pooled estimate of these two trials (70 participants, low quality evidence) showed no difference between acupuncture and control in dry mouth symptoms (SMD ‐0.34, 95% CI ‐0.81 to 0.14, P value 0.17, I 2 = 39%) with the confidence intervals including both a possible reduction or a possible increase in dry mouth symptoms. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). There was a very small increase in unstimulated whole saliva (UWS) at the end of 4 to 6 weeks of treatment (three trials, 71 participants, low quality evidence) (MD 0.02 ml/minute, 95% CI 0 to 0.04, P value 0.04, I 2 = 57%), and this benefit persisted at the 12‐month follow‐up evaluation (two trials, 54 participants, low quality evidence) (UWS, MD 0.06 ml/minute, 95% CI 0.01 to 0.11, P value 0.03, I 2 = 10%). For the outcome of stimulated whole saliva (SWS, three trials, 71 participants, low quality evidence) there was a benefit favouring acupuncture (MD 0.19 ml/minute, 95% CI 0.07 to 0.31, P value 0.002, I 2 = 1%) an effect which also persisted at the 12‐month follow‐up evaluation (SWS MD 0.28 ml/minute, 95% CI 0.09 to 0.47, P value 0.004, I 2 = 0%) (two trials, 54 participants, low quality evidence). Two small studies, both at high risk of bias, compared the use of an electrostimulation device with a placebo device in participants with Sjögren's Syndrome (total 101 participants). A further study, also at high risk of bias, compared acupuncture‐like electrostimulation of different sets of points in participants who had previously been treated with radiotherapy. None of these studies reported the outcome of dry mouth. There was no difference between electrostimulation and placebo in the outcomes of UWS or SWS at the end of the 4‐week treatment period in the one study (very low that provided data for these outcomes. No adverse effects were reported. A single study at high risk of bias, compared the stimulatory effect of powered versus manual toothbrushing and found no difference for the outcomes of UWS or SWS. Authors' conclusions There is low quality evidence that acupuncture is no different from placebo acupuncture with regard to dry mouth symptoms, which is the most important outcome. This may be because there were insufficient participants included in the two trials to show a possible effect or it may be that there was some benefit due to 'placebo' acupuncture which could have biased the effect to the null. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms. It is well known that dry mouth symptoms may be problematic even when saliva production is increased, yet only two of the trials that evaluated acupuncture reported dry mouth symptoms, a worrying reporting bias. There is some low quality evidence that acupuncture results in a small increase in saliva production in patients with dry mouth following radiotherapy. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms or saliva production in patients with Sjögren's Syndrome. Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation. Plain language summary Non‐drug treatments for dry mouth symptoms Review question This review, carried out by authors of the Cochrane Oral Health Group, has been produced to assess the effects of non‐drug treatments used to stimulate saliva production for the relief of dry mouth (xerostomia) symptoms. Background Dry mouth is a common problem with an estimated incidence of between 10% and 26% in men and between 10% and 33% in women, which may or may not be due to reduced saliva secretion. Common causes of dry mouth include the side effects of many commonly prescribed medications, diseases (such as Sjögren's syndrome where the immune system destroys tissues in the glands which produce saliva) and radiotherapy treatments for head and neck cancers. Saliva moistens the skin in the mouth and helps to maintain oral health. The presence of saliva facilitates speech, acts to wash away food residue from around the teeth, neutralises potentially damaging food and bacterial acids, enhances a person's ability to taste the food, and generally lubricates the mouth. Saliva also acts to soften food, making it easier to chew and swallow. Enzymes in saliva start the digestion of starch and fats, and other substances in saliva, such as epidermal growth factors, promote tissue growth, differentiation and wound healing. The antibacterial, antifungal and antiviral agents in saliva balance the oral flora and help to prevent oral infections, while the minerals in saliva help to maintain tooth enamel. Non‐drug treatments such as acupuncture, mild electrical stimulation, lasers, tooth brushing and other stimulation techniques are used to improve dry mouth symptoms. Study characteristics The evidence on which this review is based was up‐to‐date as of 16 April 2013. Nine studies were included in this review. A total of 366 adult participants took part in these trials, with an average of 40 participants per trial, and an age range from 12 to 77 years. The causes of dry mouth were radiotherapy for oral cancers in four trials, Sjögren's syndrome in three trials, medication‐related in one trial, and in the remaining trial participants had a range of causes of dry mouth. The included studies were divided into three groups, according the interventions evaluated. 1. Five small studies with a total 153 participants evaluated acupuncture. 2. Three studies evaluated electrostimulation devices. 3. One study evaluated a power toothbrush. Key results The five studies evaluating the effects of acupuncture in people who had dry mouth were generally of poor quality. There was no evidence of a difference in dry mouth symptoms, but there was some evidence of a small increase in saliva production which persisted for a year after the end of the acupuncture treatment. There may not have been enough people included in the trials to show a difference in dry mouth, or it may have been that both the real acupuncture and the 'placebo' acupuncture had some beneficial effect. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). The studies evaluating the effects of electrostimulation devices were poorly conducted and reported, and provided insufficient evidence to determine the effects of these devices on either dry mouth or saliva production. The single small study of a powered versus a manual toothbrush also found no difference for either dry mouth or saliva production. None of the included studies reported the outcomes of duration of effectiveness, quality of life, patient satisfaction, or oral health assessment. Quality of the evidence These studies were generally of poor quality (low and very low).", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Furness, S, Bryan, G, McMillan, R, Birchenough, S, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD009603.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.739Z" }, { "id": "466672cc-48d8-4fd9-ae11-44431b2c1b5a", "pmid": "", "title": "Nutritional interventions for survivors of childhood cancer", "imported": false, "abstract": "Abstract - Background Childhood cancer survivors are at a higher risk of developing health conditions such as osteoporosis, and cardiovascular disease than their peers. Health‐promoting behaviour, such as consuming a healthy diet, could lessen the impact of these chronic issues, yet the prevalence rate of health‐protecting behaviour amongst survivors of childhood cancer is similar to that of the general population. Targeted nutritional interventions may prevent or reduce the incidence of these chronic diseases. Objectives The primary aim of this review was to assess the efficacy of a range of nutritional interventions designed to improve the nutritional intake of childhood cancer survivors, as compared to a control group of childhood cancer survivors who did not receive the intervention. Secondary objectives were to assess metabolic and cardiovascular risk factors, measures of weight and body fat distribution, behavioural change, changes in knowledge regarding disease risk and nutritional intake, participants' views of the intervention, measures of health status and quality of life, measures of harm associated with the process or outcomes of the intervention, and cost‐effectiveness of the intervention Search methods We searched the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 3), MEDLINE/PubMed (from 1945 to April 2013), and Embase/Ovid (from 1980 to April 2013). We ran the search again in August 2015; we have not yet fully assessed these results, but we have identified one ongoing trial. We conducted additional searching of ongoing trial registers ‐ the International Standard Randomised Controlled Trial Number register and the National Institutes of Health register (both screened in the first half of 2013) ‐ reference lists of relevant articles and reviews, and conference proceedings of the International Society for Paediatric Oncology and the International Conference on Long‐Term Complications of Treatment of Children and Adolescents for Cancer (both 2008 to 2012). Selection criteria We included all randomised controlled trials (RCTs) that compared the effects of a nutritional intervention with a control group which did not receive the intervention in this review. Participants were childhood cancer survivors of any age, diagnosed with any type of cancer when less than 18 years of age. Participating childhood cancer survivors had completed their treatment with curative intent prior to the intervention. Data collection and analysis Two review authors independently selected and extracted data from each identified study, using a standardised form. We assessed the validity of each identified study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Intervention s. We used the GRADE criteria to assess the quality of each trial. Main results Three RCTs were eligible for review. A total of 616 participants were included in the analysis. One study included participants who had been treated for acute lymphoblastic leukaemia (ALL) (275 participants). Two studies included participants who had all forms of paediatric malignancies (266 and 75 participants). All participants were less than 21 years of age at study entry. The follow‐up ranged from one month to 36 months from the initial assessment. All intended outcomes were not evaluated by each included study. All studies looked at different interventions, and so we were unable to pool results. We could not rule out the presence of bias in any of the studies. There was no clear evidence of a difference in calcium intake at one month between those who received the single, half‐day, group‐based education that focused on bone health, and those who received standard care (mean difference (MD) 111.60, 95% confidence interval (CI) ‐258.97 to 482.17; P = 0.56, low quality evidence). A regression analysis, adjusting for baseline calcium intake and changes in knowledge and self‐efficacy, showed a significantly greater calcium intake for the intervention as compared with the control group at the one‐month follow‐up (beta coefficient 4.92, 95% CI 0.33 to 9.52; P = 0.04). There was statistically significant higher, self‐reported milk consumption (MD 0.43, 95% CI 0.07 to 0.79; P = 0.02, low quality evidence), number of days on calcium supplementation (MD 11.42, 95% CI 7.11 to 15.73; P < 0.00001, low quality evidence), and use of any calcium supplementation (risk ratio (RR) 3.35, 95% CI 1.86 to 6.04; P < 0.0001, low quality evidence), with those who received this single, face‐to‐face, group‐based, health behaviour session. There was no clear evidence of a difference in bone density Z‐scores measured with a dual‐energy X‐ray absorptiometry (DEXA) scan at 36 months follow‐up (MD ‐0.05, 95% CI ‐0.26 to 0.16; P = 0.64, moderate quality evidence) between those who received calcium and vitamin D supplementation combined with nutrition education and those who received nutrition education alone. There was also no clear evidence of a difference in bone mineral density between the intervention and the control group at the 12‐month (median difference ‐0.17, P = 0.99) and 24‐month follow‐up (median difference ‐0.04, P = 0.54). A single multi‐component health behaviour change intervention, focusing on general healthy eating principles, with two telephone follow‐ups brought about a 0.17 lower score on the four‐point Likert scale of self‐reported junk food intake compared with the control group (MD ‐0.17, 95% CI ‐0.33 to ‐0.01; P = 0.04, low quality evidence); this result was statistically significant. There was no clear evidence of a difference between the groups in the self‐reported use of nutrition as a health protective behaviour (MD ‐0.05, 95% CI ‐0.24 to 0.14; P = 0.60, low quality evidence). Authors' conclusions Due to a paucity of studies, and the heterogeneity of the studies included in this review, we are unable to draw conclusions regarding the effectiveness of nutritional interventions for use with childhood cancer survivors. Although there is low quality evidence for the improvement in health behaviours using health behaviour change interventions, there remains no evidence as to whether this translates into an improvement in dietary intake. There was also no evidence that the studies reduced the risk of cardiovascular and metabolic disorders in childhood cancer survivors, although no evidence of effect is not the same as evidence of no effect. This review highlights the need for further well designed trials to be implemented in this population. Plain language summary Nutritional interventions for survivors of childhood cancer Background Survivors of childhood cancer are at a higher risk of chronic health conditions such as, osteoporosis, metabolic syndrome (including obesity and type II diabetes), and cardiovascular disease. These diseases have the potential to be reduced or prevented with targeted nutritional interventions. Objective This review looks at three randomised controlled trials that studied the effects of interventions designed to improve the dietary intake of children who have completed treatment for cancer. Study Characteristics The three studies included 616 participants who had completed their therapy for childhood cancer. All of the participants were less than 21 years of age at study entry. The interventions ranged from the promotion of health behaviours to vitamin and mineral supplementation. The follow‐up ranged from one month to 36 months from the initial assessment. Key results There was low quality evidence that those who received a health behaviour intervention decreased their self‐reported intake of “junk food”. They also increased their intake of dairy foods, as well as increasing their calcium supplementation. The interventions did not appear to translate to an improvement in their dietary intake, body composition, or bone mineral density. Quality of the evidence The results from this review do not provide enough evidence regarding the effectiveness of nutritional interventions for childhood cancer survivors. There was low quality evidence overall. Further well designed research is needed in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cohen, JE; Wakefield, CE; Cohn, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD009678.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "466da517-550c-4310-9643-b3a68a54b40e", "pmid": "", "title": "Intranasal steroids for acute sinusitis", "imported": false, "abstract": "Abstract - Background Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school. Objectives We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis in adults and children. Search methods We searched CENTRAL 2013, Issue 4, MEDLINE (January 1966 to May week 2, 2013), EMBASE (1990 to May 2013) and bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) comparing INCS treatment to placebo or no intervention in adults and children with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop‐outs before the end of the study, rates of relapse, complications and return to school or work. Data collection and analysis Two review authors independently extracted data, assessed trial quality and resolved discrepancies by consensus. Main results No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well‐designed and double‐blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow‐up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta‐analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% confidence interval (CI) 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop‐out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS. Authors' conclusions Current evidence is limited for acute sinusitis confirmed by radiology or nasal endoscopy but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy. Plain language summary Steroids for acute sinusitis in adults and children Acute sinusitis is a common reason for primary care visits; it is one of the 10 most common diagnoses in outpatient clinics, presenting with various symptoms and signs that include purulent nasal discharge and congestion and cough lasting beyond the typical seven to 10 days of a viral upper respiratory infection. There have been suggestions, based on studies of allergic rhinitis and chronic sinusitis, that intranasal corticosteroids (INCS) may relieve symptoms and hasten recovery in acute sinusitis due to their anti‐inflammatory properties. A critical systematic review of the literature found four well‐conducted, randomised, placebo‐controlled intervention studies, involving 1943 participants treated for 15 or 21 days. The results suggest that there may be a modest effect with INCS in the resolution or improvement of symptoms. Only minor adverse events such as epistaxis, headache and nasal itching were reported. Given the small number of studies included in this review, it is recommended that further randomised controlled trials be conducted. The evidence is up to date as of May 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zalmanovici Trestioreanu, A, Yaphe, J", "articleTypes": [], "doi": "10.1002/14651858.CD005149.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.763Z" }, { "id": "467ac83a-5404-4f38-a882-04dd2e0de0f5", "pmid": "", "title": "Mindfulness‐enhanced parenting programmes for improving the psychosocial outcomes of children (0 to 18 years) and their parents", "imported": false, "abstract": "Abstract - Background Emotional and behavioural difficulties (EBD) in children are common, characterised by externalising or internalising behaviours that can be highly stable over time. EBD are an important cause of functional disability in childhood, and predictive of poorer psychosocial, academic, and occupational functioning into adolescence and adulthood. The prevalence, stability, and long‐term consequences of EBD highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Multiple factors contribute to the aetiology of EBD in children, and parenting plays an important role. The relationship between parenting and EBD has been described as bidirectional, with parents and children shaping one another’s behaviour. One consequence of bidirectionality is that parents with insufficient parenting skills may become involved in increasingly negative behaviours when dealing with non‐compliance in children. This can have a cyclical effect, exacerbating child behavioural difficulties and further increasing parental distress. Behavioural or skills‐based parenting training can be highly effective in addressing EBD in children. However, emotional dysregulation may intercept some parents' ability to implement parenting skills, and there is recognition that skills‐based interventions may benefit from adjunct components that better target parental emotional responses. Mindful parenting interventions have demonstrated some efficacy in improving child outcomes via improvements in parental emotion regulation, and there is potential for mindfulness training to enhance the effectiveness of standard parent training programmes. Objectives To assess the effectiveness of mindfulness‐enhanced parent training programmes on the psychosocial functioning of children (aged 0 to 18 years) and their parents. Search methods We searched the following databases up to April 2023: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, PsycINFO, Sociological Abstracts, Social Sciences Citation Index, Conference Proceedings Citation Index – Social Science & Humanities, AMED, ERIC, ProQuest Dissertations & Theses, Cochrane Database of Systematic Reviews, Campbell Collaboration Library of Systematic Reviews, as well as the following trials registers: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also contacted organisations/experts in the field. Selection criteria We included randomised and quasi‐randomised trials. Participants were parents or caregivers of children under the age of 18. The intervention was mindfulness‐enhanced parent training programmes compared with a no‐intervention, waitlist, or attentional control, or a parent training programme with no mindfulness component. The intervention must have combined mindfulness parent training with behavioural or skills‐based parent training. We defined parent training programmes in terms of the delivery of a standardised and manualised intervention over a specified and limited period, on a one‐to‐one or group‐basis, with a well‐defined mindfulness component. The mindfulness component must have included mindfulness training (breath, visualisation, listening, or other sensory focus) and an explicit focus on present‐focused attention and non‐judgemental acceptance. Data collection and analysis We followed standard Cochrane procedures. Main results Eleven studies met our inclusion criteria, including one ongoing study. The studies compared a mindfulness‐enhanced parent training programme with a no‐treatment, waitlist, or attentional control (2 studies); a parent training programme with no mindfulness component (5 studies); both a no‐treatment, waitlist, or attentional control and a parent training programme with no mindfulness component (4 studies). We assessed all studies as being at an unclear or high risk of bias across multiple domains. We pooled child and parent outcome data from 2118 participants to produce effect estimates. No study explicitly reported on self‐compassion, and no adverse effects were reported in any of the studies. Mindfulness‐enhanced parent training programmes compared to a no‐treatment, waitlist, or attentional control Very low certainty evidence suggests there may be a small to moderate postintervention improvement in child emotional and behavioural adjustment (standardised mean difference (SMD) −0.46, 95% confidence interval (CI) −0.96 to 0.03; P = 0.06, I 2 = 62%; 3 studies, 270 participants); a small improvement in parenting skills (SMD 0.22, 95% CI 0.06 to 0.39; P = 0.008, I 2 = 0%; 3 studies, 587 participants); and a moderate decrease in parental depression or anxiety (SMD −0.50, 95% CI −0.96 to −0.04; P = 0.03; 1 study, 75 participants). There may also be a moderate to large decrease in parenting stress (SMD −0.79, 95% CI −1.80 to 0.23; P = 0.13, I 2 = 82%; 2 studies, 112 participants) and a small improvement in parent mindfulness (SMD 0.21, 95% CI −0.14 to 0.56; P = 0.24, I 2 = 69%; 3 studies, 515 participants), but we were not able to exclude little to no effect for these outcomes. Mindfulness‐enhanced parent training programmes compared to parent training with no mindfulness component Very low certainty evidence suggests there may be little to no difference postintervention in child emotional and behavioural adjustment (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.71, I 2 = 64%; 5 studies, 203 participants); parenting skills (SMD 0.13, 95% CI −0.16 to 0.42; P = 0.37, I 2 = 16%; 3 studies, 319 participants); and parent mindfulness (SMD 0.11, 95% CI −0.19 to 0.41; P = 0.48, I 2 = 44%; 4 studies, 412 participants). There may be a slight decrease in parental depression or anxiety (SMD −0.24, 95% CI −0.83 to 0.34; P = 0.41; 1 study, 45 participants; very low certainty evidence), though we cannot exclude little to no effect, and a moderate decrease in parenting stress (SMD −0.51, 95% CI −0.84 to −0.18; P = 0.002, I 2 = 2%; 3 studies, 150 participants; low certainty evidence). Authors' conclusions Mindfulness‐enhanced parenting training may improve some parent and child outcomes, with no studies reporting adverse effects. Evidence for the added value of mindfulness training to skills‐based parenting training programmes is suggestive at present, with moderate reductions in parenting stress. Given the very low to low certainty evidence reviewed here, these estimates will likely change as more high‐quality studies are produced. Plain language summary Mindfulness‐enhanced parenting programs for improving outcomes for children and their parents Key messages • Mindfulness‐enhanced parent training programmes may improve some child and parent outcomes, including child emotional and behavioural adjustment, parenting skills, parental depression or anxiety, parenting stress, and parent mindfulness. • When mindfulness parent training is combined with a skills‐based parent training programme, this may decrease parenting stress. • The current body of evidence is limited, with more research needed to be confident in our findings. Children's emotional and behavioural difficulties Emotional and behavioural difficulties in children are common, and are characterised by a range of externalising and/or internalising behaviours that can be highly stable over time. They are an important cause of functional disability in childhood, and predictive of poor psychosocial, academic, and occupational functioning into adolescence and beyond. The prevalence, stability, and long‐term consequences of emotional and behavioural difficulties highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Why mindfulness‐enhanced parent training? Parenting plays an important role in the development and/or maintenance of emotional and behavioural difficulties in children. Traditional behavioural or skills‐based parent training programmes have been shown to have a positive impact on a range of child and parent outcomes, but they do not work for all parents. One reason for this might be that parents' emotional reactions could prevent them from using parenting skills effectively. Including additional components into parenting training that aim to improve parental emotional responses may enhance the outcomes of these programmes. Recent research shows that mindful parenting interventions may promote positive outcomes for parents and children by improving parents' ability to regulate emotions and stress. Combining mindful parenting approaches with traditional parent training programmes may therefore be beneficial for both parents and their children. What did we want to find out? We explored whether behavioural or skills‐based parent training programmes with a mindfulness component – 'mindfulness‐enhanced' parent training programmes – can improve outcomes for children and their caregivers. What did we do? We searched a range of sources for literature that evaluated the effectiveness of mindfulness‐enhanced parent training programmes, including electronic databases, trial registries, and organisations and experts in the field. We included studies evaluating these interventions using randomised controlled trials (studies where participants are randomly assigned to one of two or more treatment groups) or quasi experimental designs (where participants are assigned to different treatment groups using a method that is not truly random). We included studies that assessed child emotional and behavioural adjustment, and/or a range of parent outcomes, including parenting skills, parenting stress, depression or anxiety, mindfulness or self‐compassion. What did we find out? We included 11 studies and data from 2118 participants in the review. The studies compared the outcomes of children or parents (or both) who participated in a mindfulness‐enhanced parent training programme to the outcomes of children or parents (or both) who did not participate in parent training, or who participated in an alternate behavioural or skills‐based parent training programme. When we combined the findings from these studies, we found that mindfulness‐enhanced parent training, when compared to no intervention, may improve child emotional and behavioural adjustment, parenting skills, parenting stress, parental depression and anxiety, and mindfulness, but we are very uncertain about these results. Evidence for the added value of mindfulness training when included in a skills‐based parent training programme suggests that mindfulness training may further promote reductions in parenting stress, and may also further reduce parental depression or anxiety, but we are uncertain about these results. It is unclear from the current body of evidence whether adding mindfulness training to a skills‐based parent training intervention has any further effect on child emotional and behavioural adjustment, parenting skills, or mindfulness. No studies reported adverse effects or measured self‐compassion. What are the limitations of the evidence? We are not confident in the overall body of evidence. This is primarily because there was a lot of variation across the interventions and the participant groups, as well as how the outcomes were measured. The studies were also usually quite small, and participants were likely to be aware of what intervention they were receiving, which can sometimes influence the results. It is likely that these findings will change as more studies are undertaken in this area of research. How up‐to‐date is this evidence? We searched for and included research up to April 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Featherston, R, Barlow, J, Song, Y, Haysom, Z, Loy, B, Tufford, L, Shlonsky, A", "articleTypes": [], "doi": "10.1002/14651858.CD012445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.817Z" }, { "id": "46818713-925d-41c5-a080-f9bbd7706418", "pmid": "", "title": "Vitamin C for preventing and treating pneumonia", "imported": false, "abstract": "Abstract - Background Pneumonia is one of the most common serious infections, causing two million deaths annually among young children in low‐income countries. In high‐income countries pneumonia is most significantly a problem of the elderly. Objectives To assess the prophylactic and therapeutic effects of vitamin C on pneumonia. Search methods We searched CENTRAL 2013, Issue 3, MEDLINE (1950 to March week 4, 2013), EMBASE (1974 to April 2013) and Web of Science (1955 to April 2013). Selection criteria To assess the therapeutic effects of vitamin C, we selected placebo‐controlled trials. To assess prophylactic effects, we selected controlled trials with or without a placebo. Data collection and analysis Two review authors independently read the trial reports and extracted data. Main results We identified three prophylactic trials which recorded 37 cases of community‐acquired pneumonia in 2335 people. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. Two trials examined military recruits and the third studied boys from \"lower wage‐earning classes\" attending a boarding school in the UK during World War II. Each of these three trials found a statistically significant (80% or greater) reduction in pneumonia incidence in the vitamin C group. We identified two therapeutic trials involving 197 community‐acquired pneumonia patients. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. That trial studied elderly patients in the UK and found lower mortality and reduced severity in the vitamin C group; however, the benefit was restricted to the most ill patients. The other therapeutic trial studied adults with a wide age range in the former Soviet Union and found a dose‐dependent reduction in the duration of pneumonia with two vitamin C doses. We identified one prophylactic trial recording 13 cases of hospital‐acquired pneumonia in 37 severely burned patients; one‐day administration of vitamin C had no effect on pneumonia incidence. The identified studies are clinically heterogeneous which limits their comparability. The included studies did not find adverse effects of vitamin C. Authors' conclusions The prophylactic use of vitamin C to prevent pneumonia should be further investigated in populations who have a high incidence of pneumonia, especially if dietary vitamin C intake is low. Similarly, the therapeutic effects of vitamin C should be studied, especially in patients with low plasma vitamin C levels. The current evidence is too weak to advocate prophylactic use of vitamin C to prevent pneumonia in the general population. Nevertheless, therapeutic vitamin C supplementation may be reasonable for pneumonia patients who have low vitamin C plasma levels because its cost and risks are low. Plain language summary Vitamin C for preventing and treating pneumonia Pneumonia is an infection of the lungs usually caused by bacteria and viruses. Its clinical diagnosis is sometimes difficult. Pneumonia is more common in young children and in the aged. In low‐income countries it causes two million deaths annually among young children. In the USA it is the most common cause of death from infection. Vitamin C was identified in the early 1900s and suggestions that one of its biological roles may be to resist infections are supported by numerous animal studies. We looked for studies in humans and found three trials with a total of 2335 participants that looked at whether vitamin C prevents pneumonia in the community. Two of these preventive trials studied soldiers while the third studied boys in a UK boarding school in the 1940s. Two therapeutic trials with a total of 197 pneumonia patients looked at whether vitamin C might be beneficial for pneumonia patients. One studied patients aged 66 to 94 years in the UK with pneumonia. The other therapeutic trial was conducted in the former Soviet Union but the social and nutritional backgrounds of the patients were not described. One study with 37 burns patients examined the effect of vitamin C on hospital‐acquired pneumonia. Our searches were up‐date‐as of April 2013. Five of the identified trials found preventive or therapeutic benefits of vitamin C against pneumonia but the study on hospital‐acquired pneumonia found no effect. The overall quality of the studies was good. However, the five trials with positive findings were carried out in such extraordinary conditions that the results should not be extrapolated to the general population. Therefore, more research is needed. In the meantime, supplementing pneumonia patients who have low plasma vitamin C levels may be reasonable because of its safety and low cost. None of the five trials reported noteworthy adverse effects of vitamin C.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H; Louhiala, P", "articleTypes": [], "doi": "10.1002/14651858.CD005532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "468b5263-b13b-44fe-b34f-00edbb804e29", "pmid": "", "title": "Topiramate for essential tremor", "imported": false, "abstract": "Abstract - Background Essential tremor (ET) is one of the most common movement disorders. The management is primarily based on pharmacological agents and in clinical practice propranolol and primidone are considered the first‐line therapy. However, these treatments can be ineffective in 25% to 55% of people and are frequently associated with serious adverse events (AEs). For these reasons, it is worthwhile evaluating other treatments for ET. Topiramate has been suggested as a potentially useful agent for the treatment of ET but there is uncertainty about its efficacy and safety. Objectives To assess the efficacy and safety of topiramate in the treatment of ET. Search methods We carried out a systematic search without language restrictions to identify all relevant trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to January 2017), Embase (January 1988 to January 2017), National Institute for Health and Care Excellence (1999 to January 2017), ClinicalTrials.gov (1997 to January 2017) and World Health Organization International Clinical Trials Registry Platform (ICTRP; 2004 to January 2017). We searched BIOSIS Citation Index (2000 to January 2017) for conference proceedings. We handsearched grey literature and the reference lists of identified studies and reviews. Selection criteria We included all randomised controlled trials (RCTs) of topiramate versus placebo/open control or any other treatments. We included studies in which the diagnosis of ET was made according to accepted and validated diagnostic criteria. We excluded studies conducted in people presenting with secondary forms of tremor or reporting only neurophysiological parameters to assess outcomes. Data collection and analysis Two review authors independently collected and extracted data using a data collection form. We assessed the risk of bias and the quality of evidence. We used a fixed‐effect meta‐analysis for data synthesis. Main results This review included three trials comparing topiramate to placebo (309 participants). They were all at high overall risk of bias. The quality of evidence ranged from very low to low. Compared to placebo, participants treated with topiramate showed a significant improvement in functional disability and an increased risk of withdrawal (risk ratio (RR) 1.78, 95% confidence interval (CI) 1.23 to 2.60). There were more AEs for topiramate‐treated participants, particularly paraesthesia, weight loss, appetite decrease and memory difficulty. Authors' conclusions This systematic review highlighted the presence of limited data and very low to low quality evidence to support the apparent efficacy and the occurrence of treatment‐limiting AEs in people with ET treated with topiramate. Further research to assess topiramate efficacy and safety on ET is needed. Plain language summary Use of topiramate for the treatment of essential tremor Review question The authors of this review tried to assess the effectiveness and safety of topiramate in people with essential tremor. Background Essential tremor is a type of uncontrollable shaking or trembling of parts of the body. Although it is not harmful in terms of its effect on life expectancy, it generally gets worse and may be disabling. Treatment is usually with medicines (called propranolol and primidone), which may not work in a quarter to a half of people with essential tremor. Some specialists have suggested that another medicine, topiramate, could be useful for treating the condition. Study characteristics We searched medical databases for studies of topiramate compared with placebo (a pretend tablet) or any other medicine in adults with essential tremor. We found three studies comparing topiramate versus placebo, involving 309 participants with moderate to severe essential tremor. Key results The effect of topiramate on daily activities, risk of stopping treatment and side effects was uncertain because the quality of evidence was very low to low. Quality of evidence We only found a few studies that had problems with their methods so we could not make firm conclusions about how well topiramate works and if it has side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Bruno, E; Nicoletti, A; Quattrocchi, G; Allegra, R; Filippini, G; Colosimo, C; Zappia, M", "articleTypes": [], "doi": "10.1002/14651858.CD009683.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "468f7f4f-6103-49cb-b535-10f7bfccc11a", "pmid": "", "title": "Fluvoxamine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Fluvoxamine, one of the oldest selective serotonin reuptake inhibitors (SSRIs), is prescribed to patients with major depression in many countries. Several studies have previously reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are now outdated. Objectives Our objective is to evaluate the effectiveness, tolerability and side effect profile of fluvoxamine for major depression in comparison with other anti‐depressive agents, including tricyclics (TCAs), heterocyclics, other SSRIs, SNRIs, other newer agents and other conventional psychotropic drugs. Search methods We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register. Trial databases and ongoing trial registers in North America, Europe, Japan and Australia, were handsearched for randomised controlled trials. We checked reference lists of the articles included in the review, previous systematic reviews and major textbooks of affective disorder for published reports and citations of unpublished research. The date of last search was 31 August 2008. Selection criteria We included all randomised controlled trials, published in any language, that compared fluvoxamine with any other active antidepressants in the acute phase treatment of major depression. Data collection and analysis Two independent review authors inspected citations and abstracts, obtained papers, extracted data and assessed the risk of bias of included studies. We analysed dichotomous data using odds ratios (ORs) and continuous data using the standardised mean difference (SMD). A random effects model was used to combine studies. Main results A total of 54 randomised controlled trials (n = 5122) were included. No strong evidence was found to indicate that fluvoxamine was either superior or inferior to other antidepressants regarding response, remission and tolerability. However, differing side effect profiles were evident, especially with regard to gastrointestinal side effects of fluvoxamine when compared to other antidepressants. For example, fluvoxamine was generally associated with a higher incidence of vomiting/nausea (versus imipramine, OR 2.23, CI 1.59 to 3.14; versus clomipramine, OR 2.13, CI 1.06 to 4.27; versus amitriptyline, OR 2.86, CI 1.31 to 2.63). Authors' conclusions We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, differing side effect profiles were evident. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations, including these differences in side effect profiles. Plain language summary Fluvoxamine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Although pharmacological and psychological interventions are both effective for major depression, antidepressant (AD) drugs remain the mainstay for treatment of moderate or severe depression. Fluvoxamine is one of the oldest selective serotonin reuptake inhibitors (SSRIs) and is prescribed to patients with major depression in many countries. This review reports trials comparing fluvoxamine with other antidepressants for treatment of major depression. We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, there is evidence of differing side‐effect profiles, especially when comparing gastrointestinal side effects between fluvoxamine and tricyclic antidepressants (TCAs). Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including these differences in side effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Omori, IM, Watanabe, N, Nakagawa, A, Cipriani, A, Barbui, C, McGuire, H, Churchill, R, Furukawa, TA", "articleTypes": [], "doi": "10.1002/14651858.CD006114.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.071Z" }, { "id": "4695d899-1a14-4ecf-8e97-73554d7f68dc", "pmid": "", "title": "Nutritional interventions for reducing morbidity and mortality in people with HIV", "imported": false, "abstract": "Abstract - Background Adequate nutrition is important for optimal immune and metabolic function. Dietary support may, therefore, improve clinical outcomes in HIV‐infected individuals by reducing the incidence of HIV‐associated complications and attenuating progression of HIV disease, improving quality of life and ultimately reducing disease‐related mortality. Objectives To evaluate the effectiveness of various macronutrient interventions, given orally, in reducing morbidity and mortality in adults and children living with HIV infection. Search methods We searched CENTRAL (up to August 2011), MEDLINE (1966 to August 2011), EMBASE (1988 to August 2011), LILACS (up to February 2012), and Gateway (March 2006‐February 2010). We also scanned reference lists of articles and contacted authors of relevant studies and other researchers. Selection criteria Randomised controlled trials evaluating the effectiveness of macronutrient interventions compared with no nutritional supplements or placebo in the management of adults and children infected with HIV. Data collection and analysis Three reviewers independently applied study selection criteria, assessed study quality, and extracted data. Effects were assessed using mean difference and 95% confidence intervals. Homogenous studies were combined wherever it was clinically meaningful to do so and a meta‐analysis using the random effects model was conducted. Main results Fourteen trials (including 1725 HIV positive adults and 271 HIV positive children), were included in this review. Neither supplementary food nor daily supplement of Spirulina significantly altered the risk of death compared with no supplement or placebo in malnourished, ART naive adult participants in the two studies which reported on this outcome. A nutritional supplement enhanced with protein did not significantly alter the risk of death compared to standard nutritional care in children with prolonged diarrhoea. Supplementation with macronutrient formulas given to provide protein and/or energy and fortified with micronutrients, in conjunction with nutrition counselling, significantly improved energy intake (3 trials; n=131; MD 393.57 kcal/day; 95% CI: 224.66 to 562.47;p<0.00001) and protein intake (2 trials; n=81; MD 23.5 g/day; 95% CI: 12.68, 34.01; p<0.00001) compared with no nutritional supplementation or nutrition counselling alone in adult participants with weight loss. In general supplementation with specific macronutrients such as amino acids, whey protein concentration or Spirulina did not significantly alter clinical, anthropometric or immunological outcomes compared with placebo in HIV‐infected adults and children. Authors' conclusions Given the current evidence base, which is limited to fourteen relatively small trials all evaluating different macronutrient supplements in different populations at different stages of HIV infection and with varying treatment status, no firm conclusions can be drawn about the effects of macronutrient supplementation on morbidity and mortality in people living with HIV. It is, however, promising to see more studies being conducted in low‐income countries, and particularly in children, where macronutrient supplementation both pre‐antiretroviral treatment and in conjunction with antiretroviral treatment might prove to be beneficial. Plain language summary Nutritional interventions for reducing morbidity and mortality in people with HIV Achieving and maintaining optimal nutrition is considered an important adjunct in the clinical care of patients infected with HIV, as good nutrition can improve an individual's immune function, limit disease‐specific complications, and improve quality of life and survival. We sought to determine whether macronutrient interventions, either given to provide protein and/or energy or test the effect of specific macronutrients (i.e. ch as amino acids, whey protein concentrate or Spirulina), given orally, influence morbidity and mortality in adults and children living with HIV infection. Our review, based on fourteen small trials, evaluating different macronutrient supplements, found limited evidence that balanced macronutrient formulas increase protein and energy intake. However, we found no evidence that such supplementation translates into reductions in disease progression or HIV‐related complications, such as opportunistic infections or death.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grobler, L, Siegfried, N, Visser, ME, Mahlungulu, SSN, Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD004536.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.743Z" }, { "id": "46bb82c7-7787-4fd1-a093-7229dd0f3514", "pmid": "", "title": "Interventions for preventing oral mucositis for patients with cancer receiving treatment", "imported": false, "abstract": "Abstract - Background Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers). Objectives To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment. Search methods Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL ( The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Selection criteria Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer. Data collection and analysis Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random‐effects models. Main results A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta‐analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte‐colony stimulating factor (G‐CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate. Authors' conclusions Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent. Plain language summary Interventions for preventing oral mucositis for patients with cancer receiving treatment Treatment for cancer (including bone marrow transplant) can cause oral mucositis (severe ulcers in the mouth). This painful condition can cause difficulties in eating, drinking and swallowing, and may also be associated with infections which may require the patient to stay longer in hospital. Different strategies are used to try and prevent this condition, and the review of trials found that some of these are effective. Two interventions, cryotherapy (ice chips) and keratinocyte growth factor (palifermin®) showed some benefit in preventing mucositis. Sucralfate is effective in reducing the severity of mucositis, and a further seven interventions, aloe vera, amifostine, intravenous glutamine, granulocyte‐colony stimulating factor (G‐CSF), honey, laser and antibiotic lozenges containing polymixin/tobramycin/amphotericin (PTA) showed weaker evidence of benefit. These were evaluated in patients with different types of cancer, undergoing different types of cancer treatment. Benefits may be restricted to the disease and treatment combinations evaluated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Worthington, HV, Clarkson, JE, Bryan, G, Furness, S, Glenny, A-M, Littlewood, A, McCabe, MG, Meyer, S, Khalid, T, Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD000978.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.810Z" }, { "id": "46be9de6-3fc8-40bd-8735-4224f180aeee", "pmid": "", "title": "Cough and Taste Preferences in Adolescents and Adults", "imported": false, "abstract": "This single-site, within-subject, experimental study is designed to test the hypothesis children who live in a household in which one or both of their parent smoke will exhibit a higher cough threshold and will prefer more intense sweet tastes than children who live in a household where neither parent smokes. Subjects will include at least 50 racially and ethnically diverse, healthy children aged 10 to 17 years (a critical time for experimenting with tobacco) and a parent. The sample will comprise two groups: Non-Environmental Tobacco Smoke (ETS) Exposed (neither the child nor parents has ever smoked or been exposed to environmental tobacco smoke (ETS) in the home), and ETS-Exposed (the parent has smoked at least 3 cigarettes per day for at least five years in the home, with the child living in the home continuously). Cough sensitivity will be measured using a standard single-inhalation challenge, a test of the minimum concentration of capsaicin (the spicy chemical in hot peppers) needed to elicit cough. Sweet taste preferences will be measured using a forced-choice paired comparison method of liquids which differ in sucrose content. Measures of breath carbon monoxide will validate the smoking status of parents and their adolescent children. The key comparison will be between Non-ETS Exposed and ETS-Exposed children, with the difference between smoking and non-smoking parents as a positive control. Because smoking and non-smoking families may differ in ways besides tobacco exposure, the investigators will obtain health histories (with a focus on respiratory illness), smoking histories, measures of body weight, diet, and responses to personality tests (including susceptibility to addiction). The investigators will also obtain genomic DNA from saliva samples. Genes for chemosensory receptors that are part of the cough reflex pathway and genotype may account for aspects of cough sensitivity.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "46c8629f-0d59-4764-8285-eee9d8b2b2f1", "pmid": "", "title": "Eradication therapy for peptic ulcer disease in Helicobacter pylori‐positive people", "imported": false, "abstract": "Abstract - Background Peptic ulcer disease is the cause of dyspepsia in about 10% of people. Ninety‐five percent of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori . Eradication of H. pylori reduces the relapse rate of ulcers but the magnitude of this effect is uncertain. This is an update of Ford AC, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori ‐positive patients. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003840. DOI: 10.1002/14651858.CD003840.pub4. Objectives To assess the proportion of peptic ulcers healed and the proportion of participants who remained free from relapse with eradication therapy against placebo or other pharmacological therapies in H. pylori ‐positive people. To assess the proportion of participants that achieved complete relief of symptoms and improvement in quality of life scores. To compare the incidence of adverse effects/drop‐outs (total number for each drug) associated with the different treatments. To assess the proportion of participants in whom successful eradication was achieved. Search methods In this update, we identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1950 to March 2016) and Ovid EMBASE (1980 to March 2016). To identify further relevant trials, we handsearched reference lists from trials selected by electronic searching, and published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ). The search was last updated in March 2016. We contacted members of Cochrane Upper GI and Pancreatic Diseases, and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials of short‐ and long‐term treatment of peptic ulcer disease in H. pylori ‐positive adults. Participants received at least one week of H. pylori eradication compared with ulcer healing drug, placebo or no treatment. Trials were included if they reported assessment from two weeks onwards. Data collection and analysis We collected data on ulcer healing, recurrence, relief of symptoms and adverse effects. We calculated the risk ratio (RR) with 95% confidence intervals (CI) using both fixed‐effect and random‐effects models with Review Manager software (RevMan 5.3) based on intention‐to‐treat analysis as far as possible. Main results A total of 55 trials were included for one or more outcomes for this review. In duodenal ulcer healing, eradication therapy was superior to ulcer healing drug (UHD) (34 trials, 3910 participants, RR of ulcer persisting = 0.66, 95% confidence interval (CI) 0.58 to 0.76; 381/2286 (adjusted proportion: 12.4%) in eradication therapy plus UHD versus 304/1624 (18.7%) in UHD; low quality evidence) and no treatment (two trials, 207 participants, RR 0.37, 95% CI 0.26 to 0.53; 30/125 (adjusted proportion: 21.7%) in eradication therapy versus 48/82 (58.5%) in no treatment; low quality evidence). In gastric ulcer healing, the differences were imprecise between eradication therapy and UHD (15 trials, 1974 participants, RR 1.23, 95% CI 0.90 to 1.68; 220/1192 (adjusted proportion: 16.0%) in eradication therapy plus UHD versus 102/782 (13.0%) in UHD; very low quality evidence). In preventing duodenal ulcer recurrence the differences were imprecise between maintenance therapy with H.pylori eradication therapy and maintenance therapy with UHD (four trials, 319 participants, RR of ulcer recurring 0.73; 95% CI 0.42 to 1.25; 19/159 (adjusted proportion: 11.9%) in eradication therapy versus 26/160 (16.3%) in UHD; very low quality evidence), but eradication therapy was superior to no treatment (27 trials 2509 participants, RR 0.20, 95% CI 0.15 to 0.26; 215/1501 (adjusted proportion: 12.9%) in eradication therapy versus 649/1008 (64.4%) in no treatment; very low quality evidence). In preventing gastric ulcer recurrence, eradication therapy was superior to no treatment (12 trials, 1476 participants, RR 0.31, 95% CI 0.22 to 0.45; 116/697 (adjusted proportion: 16.3%) in eradication therapy versus 356/679 (52.4%) in no treatment; very low quality evidence). None of the trials reported proportion of people with gastric ulcer not healed after initial therapy between H.pylori eradication therapy and no active treatment or the proportion of people with recurrent gastric ulcer or peptic ulcers during maintenance therapy between H.pylori eradication therapy and ulcer healing drug therapy. Authors' conclusions Adding a one to two‐week course of H. pylori eradication therapy is an effective treatment for people with H. pylori‐ positive duodenal ulcer when compared to ulcer healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer healing drug. However, confidence intervals were wide and significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment, and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Plain language summary Antibiotics for people with peptic ulcers caused by Helicobacter pylori infection Review question Are antibiotics useful for the treatment of peptic ulcer (ulcers in the stomach or upper small intestine) in people with Helicobacter pylori ( H. pylori ) infection? Background Peptic ulcers are caused by acidic stomach juices damaging the lining of the stomach (gastric ulcer) or upper small intestine (duodenal ulcer). This causes pain, indigestion and sometimes, bleeding. Ulcers can return after being healed, especially if the person is infected with Helicobacter pylori (a lifelong infection unless treated). H. pylori causes most peptic ulcers. It is not clear whether eradicating H.pylori by treating with antibiotics as part of a combination of drugs ( H.pylori eradication therapy) is helpful in the treatment of people with peptic ulcers compared to no treatment or other medical treatments. This is an update of a previous Cochrane review published in 2006. Study characteristics Fifty‐five studies provided information for the review. Thirty‐four studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of duodenal ulcer. Two studies compared H. pylori eradication therapy against no treatment in the healing of duodenal ulcer. Fifteen studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of gastric ulcer. Three studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of peptic ulcer (gastric or duodenal ulcer). One study compared H. pylori eradication therapy against no treatment in the healing of peptic ulcer (gastric or duodenal ulcer). Four studies compared H. pylori eradication therapy against ulcer‐healing drug in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twenty‐seven studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twelve studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of gastric ulcer after initial ulcer had been healed, while one study compared H. pylori eradication therapy against no treatment in preventing the recurrence of peptic ulcer (gastric or duodenal ulcer) after initial ulcer had been healed. Four studies compared H. pylori eradication therapy plus ulcer‐healing drug versus comparison regimen in the relief of symptoms from peptic ulcer (gastric or duodenal ulcer). There were no studies comparing H. pylori eradication therapy against no treatment in the healing of gastric ulcer, H. pylori eradication therapy against ulcer‐healing drug as maintenance therapy in preventing the recurrence of gastric ulcer after initial ulcer had been healed, or H. pylori eradication therapy plus ulcer‐healing drug against no treatment or ulcer‐healing drug in the relief of symptoms in people with peptic ulcer. Some trials provided information for more than one comparison. The evidence is current until March 2016. Key results Adding a one to two‐week course of H. pylori eradication therapy speeds up ulcer healing for people with H. pylori‐ positive duodenal ulcer when compared to ulcer‐healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer (ulcer returning after initial healing) compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer‐healing drugs. However, because of the small number of studies included for the last two comparisons, significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Quality of the evidence The quality of evidence was low or very low because most of the studies had errors in study design. As a result, there is a lot of uncertainty regarding the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Ford, AC; Gurusamy, KS; Delaney, B; Forman, D; Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD003840.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "46d0e649-14d2-4ab8-91a8-d1f3be9caeca", "pmid": "", "title": "Lifestyle interventions for chronic gout", "imported": false, "abstract": "Abstract - Background Although lifestyle interventions are commonly recommended in the management of patients with chronic gout, the evidence from trial data for their benefits and safety has not been previously examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with chronic gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies on 5 April 2013. We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials (RCTs or CCTs) which compared lifestyle interventions to another therapy (active or placebo) in patients with chronic gout. Outcomes of interest were changes in gout attack frequency, joint pain, serum urate levels, tophus size, function, quality of life and adverse effects. Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (120 participants), at moderate risk of bias, was included in the review. Patients were randomised to one of three interventions: either skim milk powder (SMP) enriched with glycomacropeptide (GMP) and G600, non‐enriched SMP or lactose powder, over a three‐month period. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the three‐month study period. Low quality evidence indicated that there was no difference between the SMP/GMP/G600 group and combined control groups (SMP and lactose powder) at three months (mean difference (MD) ‐0.21, 95% confidence interval (CI) ‐0.76 to 0.34). There were no significant between‐group differences in terms of withdrawals due to adverse effects (risk ratio (RR) 1.27, 95% CI 0.53 to 3.03), and serious adverse events resulting in hospitalisation (2/40 SMP/GMP/G600 group versus 3/80 controls; RR 1.33, 95% CI 0.23 to 7.66). Gastrointestinal adverse effects were the most commonly reported. Pain from self reported gout flares, measured on a 10‐point Likert scale, improved more in the SMP/GMP/G600 group compared to controls (MD ‐1.03, 95% CI ‐1.96 to ‐0.10), an absolute difference of 10% (absolute risk difference ‐0.10, 95% CI ‐0.20 to ‐0.01). This is unlikely to be of clinical significance. There was no significant difference in physical function between SMP/GMP/G600 and the control groups at three‐month followup (MD ‐0.03, 95% CI ‐0.14 to 0.08). Tophus regression and serum urate normalisation were not reported in this study. Authors' conclusions While there is good evidence from observational studies of an association between various lifestyle risk factors and gout development, there is a paucity of high‐quality evidence from randomised controlled trials to either support or refute the use of lifestyle modifications for improving outcomes in people with chronic gout. Plain language summary Lifestyle interventions for chronic gout This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with chronic gout. There was one study included in this review which looked at the benefits and safety of consuming skim milk powder (SMP) enriched with two components of dairy products (glycomacropeptide (GMP) and G600 milk fat extract) compared to standard skim milk or lactose powder in reducing the frequency of gout attacks over a three‐month period. The review shows that, in people with chronic gout : Compared with standard skim milk or lactose powder, SMP enriched with GMP and G600 may not reduce the frequency of gout attacks, may not improve physical function, but may reduce pain. We do not know if consuming these dairy preparations improves tophus size (tophi are gout crystal deposits commonly found in skin, on the surface of joints or in cartilage) or blood uric acid levels, as these were not reported. We do not have precise information about side effects and complications. Possible side effects may include nausea or diarrhoea. What is gout and what are lifestyle interventions? Gout is a very common form of painful joint inflammation (arthritis) caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness and swelling of affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic makeup, being overweight, ingesting certain medications (e.g. diuretics), having impaired kidney function and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Although medications are the mainstay of gout treatment, given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as losing weight, stopping smoking, exercising more, drinking more coffee and dairy products, and consuming less sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout. Best estimate of what happens to people with gout who consume enriched skim milk powder: Gout attacks People who consumed enriched skim milk powder had 0.21 fewer gout attacks per month at 3 months (or 2.5 fewer gout attacks per year) . ‐ People who consumed enriched skim milk powder had 0.49 gout attacks per month (or 6 gout attacks per year). ‐ People who consumed standard skim milk powder or lactose had 0.70 gout attacks per month (or 8 gout attacks per year). Withdrawals due to adverse events 4 more people out of 100 who consumed enriched skim milk powder discontinued the supplement at 3 months (4% more withdrawals absolute change, from 10% fewer to 18% more). ‐ 18 out of 100 stopped consuming enriched skim milk powder. ‐ 14 out of 100 stopped consuming standard skim milk powder or lactose. Pain (lower score means less pain) People who consumed enriched skim milk powder rated their pain 1 point lower on a 0 to 10 point pain scale (10% absolute improvement; 20% to 1% improvement) at 3 months. ‐ People who consumed enriched skim milk powder rated their pain to be 0.67 points on a scale of 0 to 10. ‐ People who consumed standard skim milk powder or lactose rated their pain to be 1.7 points on a scale of 0 to 10. Physical function (lower score means better function) People who consumed enriched skim milk powder rated their function 0.03 better (0.14 better to 0.08 worse) on a 0 to 3 point scale (1% absolute improvement; 5% improvement to 3% worse) at 3 months. ‐ People who consumed enriched skim milk powder rated their function to be 0.08 points on a scale of 0 to 3. ‐ People who consumed standard skim milk powder or lactose rated their function to be 0.11 points on a scale of 0 to 3. Serious adverse events 1 more person out of 100 who consumed enriched skim milk powder reported a serious adverse event. ‐ 5 out of 100 who consumed enriched skim milk powder had a serious adverse event. ‐ 4 out of 100 who consumed standard skim milk powder or lactose had a serious adverse event.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY, Sriranganathan, MK, Edwards, CJ, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.770Z" }, { "id": "46d0ffbc-c25a-40b8-bdc3-9ab1e7fa76e8", "pmid": "", "title": "Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia", "imported": false, "abstract": "Abstract - Background Fibromyalgia is a clinically defined chronic condition of unknown etiology characterized by chronic widespread pain that often co‐exists with sleep disturbances, cognitive dysfunction and fatigue. People with fibromyalgia often report high disability levels and poor quality of life. Drug therapy, for example, with serotonin and noradrenaline reuptake inhibitors (SNRIs), focuses on reducing key symptoms and improving quality of life. This review updates and extends the 2013 version of this systematic review. Objectives To assess the efficacy, tolerability and safety of serotonin and noradrenaline reuptake inhibitors (SNRIs) compared with placebo or other active drug(s) in the treatment of fibromyalgia in adults. Search methods For this update we searched CENTRAL, MEDLINE, Embase, the US National Institutes of Health and the World Health Organization (WHO) International Clinical Trials Registry Platform for published and ongoing trials and examined the reference lists of reviewed articles, to 8 August 2017. Selection criteria We selected randomized, controlled trials of any formulation of SNRIs against placebo or any other active treatment of fibromyalgia in adults. Data collection and analysis Three review authors independently extracted data, examined study quality, and assessed risk of bias. For efficacy, we calculated the number needed to treat for an additional beneficial outcome (NNTB) for pain relief of 50% or greater and of 30% or greater, patient's global impression to be much or very much improved, dropout rates due to lack of efficacy, and the standardized mean differences (SMD) for fatigue, sleep problems, health‐related quality of life, mean pain intensity, depression, anxiety, disability, sexual function, cognitive disturbances and tenderness. For tolerability we calculated number needed to treat for an additional harmful outcome (NNTH) for withdrawals due to adverse events and for nausea, insomnia and somnolence as specific adverse events. For safety we calculated NNTH for serious adverse events. We undertook meta‐analysis using a random‐effects model. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We added eight new studies with 1979 participants for a total of 18 included studies with 7903 participants. Seven studies investigated duloxetine and nine studies investigated milnacipran against placebo. One study compared desvenlafaxine with placebo and pregabalin. One study compared duloxetine with L‐carnitine. The majority of studies were at unclear or high risk of bias in three to five domains. The quality of evidence of all comparisons of desvenlafaxine, duloxetine and milnacipran versus placebo in studies with a parallel design was low due to concerns about publication bias and indirectness, and very low for serious adverse events due to concerns about publication bias, imprecision and indirectness. The quality of evidence of all comparisons of duloxetine and desvenlafaxine with other active drugs was very low due to concerns about publication bias, imprecision and indirectness. Duloxetine and milnacipran had no clinically relevant benefit over placebo for pain relief of 50% or greater: 1274 of 4104 (31%) on duloxetine and milnacipran reported pain relief of 50% or greater compared to 591 of 2814 (21%) participants on placebo (risk difference (RD) 0.09, 95% confidence interval (CI) 0.07 to 0.11; NNTB 11, 95% CI 9 to 14). Duloxetine and milnacipran had a clinically relevant benefit over placebo in patient's global impression to be much or very much improved: 888 of 1710 (52%) on duloxetine and milnacipran (RD 0.19, 95% CI 0.12 to 0.26; NNTB 5, 95% CI 4 to 8) reported to be much or very much improved compared to 354 of 1208 (29%) of participants on placebo. Duloxetine and milnacipran had a clinically relevant benefit compared to placebo for pain relief of 30% or greater. RD was 0.10; 95% CI 0.08 to 0.12; NNTB 10, 95% CI 8 to 12. Duloxetine and milnacipran had no clinically relevant benefit for fatigue (SMD ‐0.13, 95% CI ‐0.18 to ‐0.08; NNTB 18, 95% CI 12 to 29), compared to placebo. There were no differences between either duloxetine or milnacipran and placebo in reducing sleep problems (SMD ‐0.07; 95 % CI ‐0.15 to 0.01). Duloxetine and milnacipran had no clinically relevant benefit compared to placebo in improving health‐related quality of life (SMD ‐0.20, 95% CI ‐0.25 to ‐0.15; NNTB 11, 95% CI 8 to 14). There were 794 of 4166 (19%) participants on SNRIs who dropped out due to adverse events compared to 292 of 2863 (10%) of participants on placebo (RD 0.07, 95% CI 0.04 to 0.10; NNTH 14, 95% CI 10 to 25). There was no difference in serious adverse events between either duloxetine, milnacipran or desvenlafaxine and placebo (RD ‐0.00, 95% CI ‐0.01 to 0.00). There was no difference between desvenlafaxine and placebo in efficacy, tolerability and safety in one small trial. There was no difference between duloxetine and desvenlafaxine in efficacy, tolerability and safety in two trials with active comparators (L‐carnitine, pregabalin). Authors' conclusions The update did not change the major findings of the previous review. Based on low‐ to very low‐quality evidence, the SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in the frequency of pain relief of 50% or greater, but for patient's global impression to be much or very much improved and in the frequency of pain relief of 30% or greater there was a clinically relevant benefit. The SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in improving health‐related quality of life and in reducing fatigue. Duloxetine and milnacipran did not significantly differ from placebo in reducing sleep problems. The dropout rates due to adverse events were higher for duloxetine and milnacipran than for placebo. On average, the potential benefits of duloxetine and milnacipran in fibromyalgia were outweighed by their potential harms. However, a minority of people with fibromyalgia might experience substantial symptom relief without clinically relevant adverse events with duloxetine or milnacipran. We did not find placebo‐controlled studies with other SNRIs than desvenlafaxine, duloxetine and milnacipran. Plain language summary Serotonin and noradrenaline reuptake inhibitors for fibromyalgia Bottom line Duloxetine and milnacipran may reduce pain in people with fibromyalgia. However, some of these people may also experience side effects, such as nausea (feeling sick) and drowsiness. A minority of people with fibromyalgia experience symptom relief without side effects from duloxetine and milnacipran. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as problems with sleep, thinking and exhaustion. They often report poor health‐related quality of life. There is no cure for fibromyalgia at present, so the treatments aim to relieve the symptoms and to improve health‐related quality of life. Serotonin and noradrenaline are chemicals which are produced by the human body, involved in the regulation of pain, sleep and mood. Low concentrations of serotonin have been reported in people with fibromyalgia. Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a class of antidepressants that increase the concentration of serotonin and noradrenaline in the brain. Study characteristics In August 2017, we updated our searches for clinical trials in which SNRIs were used to treat symptoms of fibromyalgia in adults. We found eight new studies since the previous version of the review. In total, we found 18 studies with 7903 participants. The studies were four to 27 weeks long and compared the SNRIs desvenlafaxine, duloxetine and milnacipran against a fake medication (placebo). We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. Key results and quality of the evidence Duloxetine and milnacipran were better than placebo in reducing pain by 50% or more and in improving global well‐being (low‐quality evidence). Duloxetine and milnacipran were better than placebo in improving health‐related quality of life and in reducing fatigue (low‐quality evidence). Duloxetine and milnacipran were not better than placebo in reducing sleep problems (low‐quality evidence). More people dropped out of the trial due to side effects with duloxetine and milnacipran than with placebo (low‐quality evidence). More people reported nausea and drowsiness with duloxetine and milnacipran than with placebo (low‐quality evidence). Duloxetine, milnacipran and placebo did not differ in the frequency of serious side effects experienced (very low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Welsch, P; Üçeyler, N; Klose, P; Walitt, B; Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD010292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "46db31aa-946f-4941-b79c-f3a04ad64e2a", "pmid": "", "title": "Zinc supplementation for the treatment of measles in children", "imported": false, "abstract": "Abstract - Background Measles is an important cause of childhood morbidity and mortality globally, despite increasing vaccine coverage. Zinc plays a significant role in the maintenance of normal immunological functions, therefore supplements given to zinc‐deficient children will increase the availability of zinc and could reduce measles‐related morbidity and mortality. This is an update of a review first published in 2015. Objectives To assess the effects of zinc supplementation in reducing morbidity and mortality in children with measles. Search methods We searched CENTRAL (03 February 2017, Issue 2), MEDLINE (1946 to 03 February 2017), Embase (1974 to 03 February 2017), CINAHL (1981 to 03 February 2017), LILACS (1982 to 03 February 2017), Web of Science (1985 to 03 February 2017), and BIOSIS Previews (1985 to 27 June 2014). We also searched ClinicalTrials.gov, the Australian New Zealand Clinical Trials Registry and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 03 February 2017 to identify unpublished and ongoing studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of zinc in reducing morbidity and mortality in children with measles. Data collection and analysis Two review authors independently assessed the studies for inclusion and extracted data on outcomes, details of the interventions, and other study characteristics using a standardised data extraction form. We used risk ratio (RR) and hazard ratio (HR) as measures of effect with 95% confidence intervals (CI). We included only one study, and did not conduct meta‐analysis. Main results We did not identify any new studies for inclusion in this update. One RCT met our inclusion criteria. The study was conducted in India and included 85 children diagnosed with measles and pneumonia. The trial showed no significant difference in mortality between children with measles and pneumonia who received zinc supplements and those who received placebo (RR 0.34, 95% CI 0.01 to 8.14). There was no significant difference in time to absence of fever between children who received zinc supplements and those who did not (HR 1.08, 95% CI 0.67 to 1.74). No treatment‐related side effects were reported in either group. We assessed the overall quality of the evidence as very low. Authors' conclusions We could not draw any definitive conclusions from this review about the effects of zinc supplementation on clinical outcomes of children with measles due to the very low quality of the evidence available. There is insufficient evidence to confirm or refute the effect of zinc supplementation in children with measles. Plain language summary Zinc supplementation for the treatment of measles in children Review question What is the effect of zinc supplementation in the treatment of children with measles? Background Measles infection has reduced globally over the last decade, but large outbreaks still occur, especially in low‐income countries. Zinc is one of the essential micronutrients necessary for the optimal functioning of the immune system. Zinc deficiency is particularly common in children in low‐ and middle‐income countries. It was therefore important to examine the potential role of zinc supplementation in controlling the symptoms of measles infection in children. We aimed to critically assess the current evidence from published studies on the effect of zinc supplementation for the treatment of measles in children. Search date We searched for evidence up to 03 February 2017. This is an update of a review first published in 2015. We did not include any new studies for this update. Study characteristics We found one small randomised trial (involving 85 children) that compared zinc supplements versus placebo administered to children with measles and pneumonia. All 85 children received supportive care and vitamin A. The study was conducted in India and funded by the Child Health Foundation USA and the Nestlé Foundation. Key results The included study was small and did not provide enough data to determine whether zinc had an effect on mortality when compared with placebo. Although no adverse effects were reported, there was insufficient evidence to draw any conclusions about the use of zinc supplements to improve measles symptoms in children. More research is needed to clarify any benefits or harms. Quality of the evidence We assessed the quality of the evidence as very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Awotiwon, AA, Oduwole, O, Sinha, A, Okwundu, CI", "articleTypes": [], "doi": "10.1002/14651858.CD011177.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.077Z" }, { "id": "46ddb877-84b5-41d0-81f4-23933fbb66f0", "pmid": "", "title": "Management of gag reflex for patients undergoing dental treatment", "imported": false, "abstract": "Abstract - Background The gag reflex is an involuntary defence mechanism to protect the pharynx and throat from foreign objects. Gagging is a common problem encountered during dental treatment, making therapeutic procedures distressing and often difficult or even impossible to perform. Various interventions can be used to control the gag reflex: anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behavioural therapies, acupressure, acupuncture, laser, and prosthetic devices. This is an update of the Cochrane Review first published in 2015. Objectives To assess the effects of pharmacological and non‐pharmacological interventions for the management of gagging in people undergoing dental treatment. Search methods Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register (to 18 March 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2) in the Cochrane Library (searched 18 March 2019), MEDLINE Ovid (1946 to 18 March 2019), Embase Ovid (1980 to 18 March 2019), CINAHL EBSCO (1937 to 18 March 2019), AMED Ovid (1985 to 18 March 2019), and the proceedings of the International Association for Dental Research (IADR) online (2001 to 18 March 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We also conducted forwards citation searching on the included studies via Google Scholar. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs), involving people who were given a pharmacological or non‐pharmacological intervention to manage gagging that interfered with dental treatment. We excluded quasi‐RCTs. We excluded trials with participants who had central or peripheral nervous system disorders, who had oral lesions or were on systemic medications that might affect the gag sensation, or had undergone surgery which might alter anatomy permanently. Data collection and analysis We independently selected trials, extracted data, and assessed risk of bias. We followed Cochrane's statistical guidelines. We assessed the overall certainty of the evidence using GRADE. Main results We included four trials at unclear risk of bias with 328 participants (263 adults and 65 children who were four years or older), in which one trial compared acupuncture and acupressure (with thumb, device and sea band) at P6 (point located three‐finger breadths below the wrist on the inner forearm in between the two tendons) to sham acupuncture and acupressure with and without sedation. One trial compared acupuncture at P6 point to sham acupuncture. These trials reported both completion of dental procedure and reduction in gagging (assessor and patient reported) as their outcomes. One cross‐over and one split‐mouth trial studied the effect of laser at P6 point compared to control. One trial reported reduction in gagging and another reported presence or absence of gagging during dental procedure. Acupuncture at P6 showed uncertain evidence regarding the successful completion of dental procedure (RR 1.78, 95% CI 1.05 to 3.01; two trials, 59 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 2.57, 95% CI 1.12 to 5.89; one trial, 26 participants; very low‐certainty evidence) in comparison to sham acupuncture. Acupuncture at P6 with sedation did not show any difference when compared to sham acupuncture with sedation (RR 1.08, 95% CI 0.91 to 1.28; one trial, 34 participants; very low‐certainty evidence). Acupressure using thumb pressure with or without sedation showed no clear difference in completing dental procedure (RR 0.96, 95% CI 0.84 to 1.10; one trial, 39 participants; very low‐certainty evidence; and RR 0.85, 95% CI 0.50 to 1.46; one trial, 30 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 1.06, 95% CI 0.92 to 1.23; one trial, 39 participants; very low‐certainty evidence; and RR 0.92, 95% CI 0.60 to 1.41; one trial, 30 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Acupressure at P6 with device showed uncertain evidence regarding the successful completion of dental procedure (RR 2.63, 95% CI 1.33 to 5.18; one trial, 34 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 3.94, 95% CI 1.63 to 9.53; one trial, 34 participants; very low‐certainty evidence) when compared to sham acupressure. However, device combined with sedation showed no difference for either outcome (RR 1.16, 95% CI 0.90 to 1.48; one trial, 27 participants; very low‐certainty evidence; and RR 1.26, 95% CI 0.93 to 1.69; one trial, 27 participants; very low‐certainty evidence; respectively). Acupressure using a sea band with or without sedation showed no clear difference in completing dental procedure (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 1.80, 95% CI 0.63 to 5.16; one trial, 19 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 2.70, 95% CI 0.72 to 10.14; one trial, 19 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Laser at P6 showed a difference in absence of gagging (odds ratio (OR) 86.33, 95% CI 29.41 to 253.45; one trial, 40 participants; very low‐certainty evidence) and reduction in gagging (MD 1.80, 95% CI 1.53 to 2.07; one trial, 25 participants; very low‐certainty evidence) during dental procedure when compared to dummy laser application. No noteworthy adverse effects were reported. For acupuncture at P6, the trial authors were unsure whether the reported adverse effects were due to participant anxiety or due to the intervention. None of the trials on acupressure or laser reported on this outcome. We did not find trials evaluating any other interventions used to manage gagging in people undergoing dental treatment. Authors' conclusions We found very low‐certainty evidence from four trials that was insufficient to conclude if there is any benefit of acupuncture, acupressure or laser at P6 point in reducing gagging and allowing successful completion of dental procedures. We did not find any evidence on any other interventions for managing the gag reflex during dental treatment. More well‐designed and well‐reported trials evaluating different interventions are needed. Plain language summary Management of gagging in dental patients Review question With this Cochrane Review we tried to find out the best way to manage gagging in people having dental treatment. Background The gag reflex is a normal process to protect the throat and airway from foreign objects and prevent choking. Many people have an exaggerated gag reflex that causes distress during dental treatment. This can make it difficult or even impossible to perform the treatment. The interventions used to manage gagging include anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behaviour therapy and cognitive behaviour therapy, acupressure, acupuncture, laser, and prosthetic devices. We wanted to know how effective and safe these interventions are in helping people complete their dental treatment with less gagging. We compared them to no intervention or a placebo or to other interventions. Study characteristics This review is up‐to‐date as of 18 March 2019. We included four trials with 328 people (263 adults and 65 children who were 4 years or older). These people had nausea before when having dental treatment that caused the treatment to be stopped or not carried out properly. Key results Acupuncture at P6 point (a point located in the inside of the wrist) showed uncertain evidence regarding the successful completion of dental treatment and reduction in gagging when compared to sham (fake) acupuncture. The same intervention with sedation did not show a difference. Acupressure (with thumb or sea band (bands that fit around the wrist just like a sweat band with a pressure stud sewn inside)) at P6 point with or without sedation did not show any difference when compared to sham acupressure. Acupressure at P6 point with device showed a difference in completing dental treatment and reduction in gagging. It did not show a difference when combined with sedation. Laser at P6 point showed a difference in absence of gagging and reduction in gagging during dental treatment when compared to sham laser application. The included studies did not report any important harmful effects of the treatment. Certainty of the evidence The level of belief we have in these findings is very low. This was due to unclear risk of bias and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to manage gagging in people having dental treatment. We suggest that more well‐conducted studies should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Eachempati, P; Kumbargere Nagraj, S; Kiran Kumar Krishanappa, S; George, RP; Soe, HH; Karanth, L", "articleTypes": [], "doi": "10.1002/14651858.CD011116.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "46fe2ccf-08d8-4e25-aa63-31fade250076", "pmid": "", "title": "A PHASE 2, NON RANDOMIZED, OPEN LABEL, SINGLE ARM, MULTI CENTER STUDY OF TALAZOPARIB FOR NEOADJUVANT TREATMENT OF GERMLINE BRCA1/2 MUTATION PATIENTS WITH EARLY HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR 2 NEGATIVE BREAST CANCER", "imported": false, "abstract": "A PHASE 2, NON RANDOMIZED, OPEN LABEL, SINGLE ARM, MULTI CENTER STUDY OF TALAZOPARIB FOR NEOADJUVANT TREATMENT OF GERMLINE BRCA1/2 MUTATION PATIENTS WITH EARLY HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR 2 NEGATIVE BREAST CANCER", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.246Z" }, { "id": "4724a9dc-ff22-49e9-bd4b-76b2fb54a401", "pmid": "", "title": "Nasal decongestants in monotherapy for the common cold", "imported": false, "abstract": "Abstract - Background Many treatments for the common cold exist and are sold over‐the‐counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited. Objectives To assess the efficacy, and short‐ and long‐term safety, of nasal decongestants used in monotherapy to alleviate symptoms of the common cold in adults and children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6, June 2016), which contains the Cochrane Acute Respiratory Infections (ARI) Specialised Register, MEDLINE (1946 to July 2016), Embase (2010 to 15 July 2016), CINAHL (1981 to 15 July 2016), LILACS (1982 to July 2016), Web of Science (1955 to July 2016) and clinical trials registers. Selection criteria Randomised controlled trials (RCTs) and cluster‐RCTs investigating the effectiveness and adverse effects of nasal decongestants compared with placebo for treating the common cold in adults and children. We excluded quasi‐RCTs. Data collection and analysis Three review authors independently extracted and summarised data on subjective measures of nasal congestion, overall patient well‐being score, objective measures of nasal airway resistance, adverse effects and general recovery. One review author acted as arbiter in cases of disagreement. We categorised trials as single and multi‐dose and analysed data both separately and together. We also analysed studies using an oral or topical nasal decongestant separately and together. Main results We included 15 trials with 1838 participants. Fourteen studies included adult participants only (aged 18 years and over). In six studies the intervention was a single dose and in nine studies multiple doses were used. Nine studies used pseudoephedrine and three studies used oxymetazoline. Other decongestants included phenylpropanolamine, norephedrine and xylometazoline. Phenylpropanolamine (or norephedrine) is no longer available on the market therefore we did not include the results of these studies in the meta‐analyses. Eleven studies used oral decongestants; four studies used topical decongestants. Participants were included after contracting the common cold. The duration of symptoms differed among studies; in 10 studies participants had symptoms for less than three days, in three studies symptoms were present for less than five days, one study counted the number of colds over one year, and one study experimentally induced the common cold. In the single‐dose studies, the effectiveness of a nasal decongestant was measured on the same day, whereas the follow‐up in multi‐dose studies ranged between one and 10 days. Most studies were conducted in university settings (N = eight), six at a specific university common cold centre. Three studies were conducted at a university in collaboration with a hospital and two in a hospital only setting. In two studies the setting was unclear. There were large differences in the reporting of outcomes and the reporting of methods in most studies was limited. Therefore, we judged most studies to be at low or unclear risk of bias. Pooling was possible for a limited number of studies only; measures of effect are expressed as standardised mean differences (SMDs). A positive SMD represents an improvement in congestion. There is no defined minimal clinically important difference for measures of subjective improvement in nasal congestion, therefore we used the SMDs as a guide to assess whether an effect was small (0.2 to 0.49), moderate (0.5 to 0.79) or large (≥ 0.8). Single‐dose decongestant versus placebo: 10 studies compared a single dose of nasal decongestant with placebo and their effectiveness was tested between 15 minutes and 10 hours after dosing. Seven of 10 studies reported subjective symptom scores for nasal congestion; none reported overall patient well‐being. However, pooling was not possible due to the large diversity in the measurement and reporting of symptoms of congestion. Two studies recorded adverse events. Both studies used an oral decongestant and each of them showed that there was no statistical difference between the number of adverse events in the treatment group versus the placebo group. Multi‐dose decongestant versus placebo: nine studies compared multiple doses of nasal decongestants with placebo, but only five reported on the primary outcome, subjective symptom scores for nasal congestion. Only one study used a topical decongestant; none reported overall patient well‐being. Subjective measures of congestion were significantly better for the treatment group compared with placebo approximately three hours after the last dose (SMD 0.49, 95% confidence interval (CI) 0.07 to 0.92; P = 0.02; GRADE: low‐quality evidence). However, the SMD of 0.49 only indicates a small clinical effect. Pooling was based on two studies, one oral and one topical, therefore we were unable to assess the effects of oral and topical decongestants separately. Seven studies reported adverse events (six oral and one topical decongestant); meta‐analysis showed that there was no statistical difference between the number of adverse events in the treatment group (125 per 1000) compared to the placebo group (126 per 1000). The odds ratio (OR) for adverse events in the treatment group was 0.98 (95% CI 0.68 to 1.40; P = 0.90; GRADE: low‐quality evidence). The results remained the same when we only considered studies using an oral decongestant (OR 0.95, 95% CI 0.65 to 1.39; P = 0.80; GRADE: low‐quality evidence). Authors' conclusions We were unable to draw conclusions on the effectiveness of single‐dose nasal decongestants due to the limited evidence available. For multiple doses of nasal decongestants, the current evidence suggests that these may have a small positive effect on subjective measures of nasal congestion in adults with the common cold. However, the clinical relevance of this small effect is unknown and there is insufficient good‐quality evidence to draw any firm conclusions. Due to the small number of studies that used a topical nasal decongestant, we were also unable to draw conclusions on the effectiveness of oral versus topical decongestants. Nasal decongestants do not seem to increase the risk of adverse events in adults in the short term. The effectiveness and safety of nasal decongestants in children and the clinical relevance of their small effect in adults is yet to be determined. Plain language summary Do nasal decongestants used alone relieve cold symptoms? Review question We wanted to find out if nasal decongestants used alone can ease nasal congestion symptoms in people with colds. Background Colds, although not serious, are common illnesses responsible for many visits to family doctors and days lost from work and school. Cold symptoms include runny nose, sore throat and sneezing, and they can last up to two weeks. There is no cure for colds; treatments only ease the symptoms. Many people use over‐the‐counter medicines such as nasal decongestants to treat cold symptoms. However, there is little evidence that nasal decongestants actually work. We wanted to find out if nasal decongestants help ease congestion caused by colds. We considered studies that used a nasal decongestant as the only treatment for colds. We looked at subjective symptoms of congestion ‐ this means that symptoms and overall well‐being were self‐rated by patients. Search date We searched for studies in July 2016. Study characteristics We included 15 studies with 1838 participants; 14 included only adults aged 18 years or over. Six studies used a single‐dose nasal decongestant and measured the effects on the day it was administered. Nine studies used multiple doses and the effects were measured between one and 10 days after first administration. Eleven studies used tablets or syrup and four studies used nasal sprays. Eight studies were conducted at universities, three at universities in collaboration with hospitals and two in hospitals. The setting was unclear in two studies. Study funding sources Nine studies were funded by drug manufacturers or agencies with commercial interests in the study results. Funding sources were unclear in six studies. Key results We were unable to draw conclusions about single‐dose nasal decongestants. We found a small benefit in the relief of nasal congestion from multiple doses, but it was unclear if this was beneficial for patients. No studies reported overall patient well‐being. There was no difference in the numbers of adverse events between people who used a nasal decongestant and those who did not. We could not determine if there was a difference in effects between decongestant tablets and nasal sprays. The results relate to adults; there was no evidence on the effectiveness or safety of nasal decongestants for children. Quality of the evidence We assessed the quality of the evidence for subjective cold symptoms as low for the multi‐dose studies ‐ there were few data and reporting was unclear. We also assessed the quality of the evidence for adverse events as low because of unclear reporting and because the estimates were not precise (there were wide confidence intervals ‐ a measure of statistical uncertainty).", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Deckx, L; De Sutter, AIM; Guo, L; Mir, NA; van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009612.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "4746eff2-e7f4-4f65-8321-042de3847503", "pmid": "", "title": "School feeding programs for improving the physical and psychological health of school children experiencing socioeconomic disadvantage", "imported": false, "abstract": "Abstract - Rationale School feeding aims to alleviate hunger and enhance child outcomes. Since the first Cochrane systematic review of school meals, there has been a marked increase in studies and reviews of school feeding programs. However, most systematic reviews are geographically limited and use qualitative analysis. We reviewed worldwide papers and performed several meta‐analyses, providing a more comprehensive picture of the effectiveness of school feeding. Objectives 1. To assess effectiveness of school feeding programs for improving the physical and psychological health of children experiencing socioeconomic disadvantage worldwide.
2. To assess effectiveness of school feeding programs for improving the health of children experiencing socioeconomic disadvantage compared with children who are more advantaged. Search methods We searched 17 subject‐specific and multidisciplinary databases and registries up to November 2023. In November 2024, two Information Specialists ran a top‐up search for randomized controlled trials (RCTs). We handsearched references of included studies and relevant reviews. Eligibility criteria We included individually randomized, cluster‐randomized, and cross‐over trials, as well as longitudinal non‐randomized studies of interventions (NRSIs). Studies had to compare the provision of free or reduced‐price food in schools versus no school feeding, focusing on socioeconomically disadvantaged children. The food had to contain at least 3% of the daily energy requirement and at least 10% of the daily protein requirement for the specified age group(s). Eligible participants were primary or secondary school students aged five to 19 years. Outcomes Our critical outcomes were change in: math achievement, reading achievement, attendance, enrollment, height‐for‐age z‐score (HAZ), weight‐for‐age z‐score (WAZ), and overweight/obesity. Our important outcomes were change in: overall academic achievement, fluid intelligence, working memory, behavioral/emotional outcomes, height, weight, and anemia. We planned to study changes between baseline and final outcomes. In one study with extreme contamination, we used the first follow‐up. Risk of bias We assessed the risk of bias for RCTs by outcome using the appropriate version of the Cochrane risk of bias tool (RoB 2): RoB 2 for individually randomized trials, for cluster‐RCTs, and for cross‐over trials. We evaluated the quality of NRSIs using the School‐based Measurement & Assessment of Results Tool (SMART), which is adapted from the Newcastle Ottawa Scale. Synthesis methods We used standardized mean differences (SMDs) with 95% confidence intervals (CIs) for educational and cognitive outcomes. We used mean differences (MDs), odds ratios (ORs), or incidence rate ratios (IRRs) for others. All meta‐analyses used random‐effects generic inverse variance. We conducted equity subgroup analyses by sex and socioeconomic status. We used GRADE to assess our confidence in the evidence for critical outcomes reported in RCTs. Included studies We included 40 studies with 83 reports. There were 13 RCTs (12 cluster‐randomized trials and one individually randomized trial) and 27 NRSIs. Most studies (34) were from low‐ and middle‐income countries (LMICs). In total, there were more than 91,885 students (four studies didn't report sample size). One study involved 59,613 students, while the others had between 60 and 6038 students. The studies included 48 outcomes; we meta‐analyzed or reported 14. Synthesis of results Low‐ and middle‐income countries (LMICs) School feeding compared to no school feeding improves math achievement slightly (SMD 0.14, 95% CI 0.06 to 0.23; P = 0.001; I² = 68%; 6 cluster‐RCTs, 5587 participants; high‐certainty evidence), but may have little to no effect on reading achievement (SMD 0.02, 95% CI −0.06 to 0.11; P = 0.61; I 2 = 54%; 3 cluster‐RCTs, 3417 participants; low‐certainty evidence). School feeding programs lead to a slight increase in enrollment rates (MD 3.44% increase, 95% CI 0.83 to 6.04; P = 0.01; I² = 0%; 2 cluster‐RCTs, 5200 participants, high‐certainty evidence) but may have little to no effect on attendance (MD 0.17%, 95% CI −2.64% to 2.97%; P = 0.91; I 2 = 81%; 3 cluster‐RCTs, 3566 participants; low‐certainty evidence). School feeding programs likely lead to a slight increase in HAZ (MD 0.06, 95% CI 0.03 to 0.09; P < 0.001; I 2 = 0%; 2 cluster‐RCTs, 3678 participants; moderate‐certainty evidence) and WAZ (MD 0.08, 95% CI 0.05 to 0.12; P < 0.001; I 2 = 0%; 3 cluster‐RCTs, 2132 participants; moderate‐certainty evidence). Two cluster‐RCTs assessed change in obesity/overweight. One 10‐month study found that the odds of being overweight/obese were 53% lower among adolescents receiving school meals compared to control adolescents (OR 0.47, 95% CI 0.30 to 0.72). Another study found no cases of overweight/obesity before or after the intervention. These findings are of very low certainty. Some researchers encountered implementation problems beyond their control, including conflicts, delays, and bureaucratic decisions. Heterogeneity in contexts, outcomes, child populations, and statistics was a limitation of this review. High‐income countries (HICs) One NRSI found very uncertain evidence that children assigned to a breakfast club increased their attendance by more than 1.6% on average compared to children in the control group. Equity analyses The equity (subgroup) analyses by sex and by socio‐economic status were all non‐significant. There were only two studies in each subgroup analysis; they were likely underpowered. Authors' conclusions In LMICs, school feeding programs lead to a slight improvement in math achievement, but may have little to no effect on reading achievement. School feeding programs lead to a slight increase in enrollment, but may have little to no impact on attendance. They likely lead to slight gains in HAZ and WAZ. There may be little to no association between school feeding and overweight/obesity, but the evidence is very uncertain. We recommend that researchers and policymakers view research as an integral part of the implementation process. To reduce heterogeneity in outcomes, we recommend even greater co‐ordination of research, and that researchers and interest holders work together to identify a core set of outcomes. Funding The authors would like to thank the following donors for their generous support in making this review possible: Dubai Cares, the World Food Programme's School Meals and Social Protection Service, and the Research Consortium for School Health and Nutrition. Registration Protocol (2022): https://doi.org/10.1002/14651858.CD014794 
Original review (2007): https://doi.org/10.1002/14651858.CD004676.pub2 
Original Campbell protocol (2006): doi.org/10.1002/CL2.12 Plain language summary Can school meal programs improve health and educational goals in children experiencing socioeconomic disadvantage? Key messages School meal programs in low‐ and middle‐income countries lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. Research should be a key part of planning and running school meal programs. To make it easier to compare results from different studies, researchers, parents, and policymakers should work together to agree on a list of the most important goals for children's health, development, and success in school. Why did we want to review studies on school meals? Worldwide, many children do not get enough nutritious food to keep them healthy and ready to learn in school. This affects their ability to enroll, attend school regularly, and learn there. School meals aim to reduce hunger and improve children's learning, focus, and overall health. School meals are one of the world's largest social safety nets. We sought to understand their effectiveness for children in disadvantaged circumstances across the globe. Most previous reviews of the evidence are limited in geographical scope, and many use narrative analyses. What did we want to find out? We asked the following two health equity (fairness) questions. Do school meals improve the physical health of socioeconomically disadvantaged children worldwide? Do school meals benefit children who are disadvantaged by sex and low family income more than they benefit less disadvantaged children? What did we do? We searched for studies that evaluated the effects of school meals for school students aged five to 19 years. We included randomized studies, which allocate students or schools to different study groups at random. However, because randomized studies are not always possible, we included non‐randomized studies that compared school meal groups with groups that received no school meals. These non‐randomized studies needed to measure outcomes at least twice; once at the beginning of the study and once at the end. We rated our confidence in the findings separately for each outcome. What did we find? We found 13 randomized studies and 27 non‐randomized studies, which collectively involved more than 91,995 students aged five to 19 years. One study included 59,613 students, while others had student populations ranging from 40 to 6038 students. Across all studies, there was a similar number of boys and girls, although three studies included only girls. Most studies took place in low‐ and middle‐income countries (34 studies), while six were from high‐income countries. In low‐ and middle‐income countries, school meals lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. In high‐income countries, one study presented very uncertain evidence that school meals may increase attendance slightly. What are the limitations of the evidence? Because we found very few eligible studies conducted in high‐income countries, we do not recommend applying our findings to this setting. We are confident in the results for math test scores and enrollment. We are moderately confident in the results for height and weight for age, because we had some concerns about the study methods. We have little confidence in the results for reading test scores and attendance, because we had some concerns about the study methods, and the results differed substantially among the trials. We are not confident in the results for overweight/obesity, because we have some concerns about the study methods, the two studies measured the outcome in different ways, and one of the studies was very small. Several studies faced barriers due to their context, such as conflict, droughts, bureaucratic delays, and difficulties in distributing funds to caterers, as well as eagerness to initiate school meal programs in control schools. We need more evidence on school meals and their impact on disadvantaged school students—especially those in secondary school—in countries of all income levels. We also need more studies that assess the difference between disadvantaged groups and more advantaged children in high‐income countries. We suggest that researchers, school feeding experts, teachers, and parents collaborate to develop a core set of key outcomes, and that these outcomes be put in an open‐access repository. How up‐to‐date is this evidence? This review updates and expands our 2007 review of school meal programs. The evidence is current to November 2024. Funding Dubai Cares funded this review through the World Food Program School Feeding Program. The London School of Hygiene and Tropical Medicine also funded this review. The funders had no influence on the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kristjansson, E; Dignam, M; Rizvi, A; Osman, M; Magwood, O; Olarte, D; Cohen, JFW; Krasevec, J; Grover, T; Labelle, PR; Garner, JA; Janzen, L; Rossiter, S; Dewidar, O; Shea, B; Welch, V; Wells, GA", "articleTypes": [], "doi": "10.1002/14651858.CD014794.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "4758730d-1996-4fb5-a013-4cf7bbb4a699", "pmid": "", "title": "Complex Effects of Dietary Manipulation on Metabolic Function, Inflammation and Health", "imported": false, "abstract": "The purpose of this research study is to 1) understand how some, but not all people with obesity develop obesity related conditions such as type 2 diabetes and cardiovascular disease, and 2) compare the effects of 3 popular weight loss diets (Mediterranean, low-carbohydrate, or a very-low-fat plant-based diet) in people with obesity.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.247Z" }, { "id": "475f309a-27ac-4a0e-ae90-571574724ccf", "pmid": "", "title": "Diet-induced Modification of Sweet Taste Perception and Preference", "imported": false, "abstract": "Overconsumption of carbohydrates has been implicated as a cause of significant public health problems including obesity and diabetes. The most effective approach to alter dietary pattern and improve public health is unknown. Gradual and abrupt changes in dietary pattern have been tried in small, uncontrolled trials, but it is not clear which approach is most effective. The primary objective of this study is to evaluate different approaches to changing dietary pattern for altering flavor perception in foods and beverages and for altering preference for flavor.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "475fc360-1a30-4a5d-9b66-bd799bd9e22d", "pmid": "", "title": "Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)", "imported": false, "abstract": "Abstract - Background Idiopathic acute vestibular dysfunction (vestibular neuritis) is the second most common cause of peripheral vertigo after benign paroxysmal positional vertigo (BPPV) and accounts for 7% of the patients who present at outpatient clinics specialising in the treatment of dizziness. The exact aetiology of the condition is unknown and the effects of corticosteroids on the condition and its recovery are uncertain. Objectives To assess the effectiveness of corticosteroids in the management of patients with idiopathic acute vestibular dysfunction (vestibular neuritis). Search methods We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 28 December 2010. Selection criteria Randomised controlled trials comparing corticosteroids with placebo, no treatment or other active treatments, for adults diagnosed with idiopathic acute vestibular dysfunction. Data collection and analysis Two authors independently selected studies from the search results and extracted data. Three authors independently assessed risk of bias. Main results Four trials, involving a total of 149 participants, compared the effectiveness of oral corticosteroids against placebo. All the trials were small and of low methodological quality. Although there was an overall significant effect of corticosteroids compared with placebo medication on complete caloric recovery at one month (risk ratio (RR) of 2.81; 95% confidence interval (CI) 1.32 to 6.00, P = 0.007), no significant effect was seen on complete caloric recovery at 12 months (RR 1.58; 95% CI 0.45 to 5.62, P = 0.48), or on the extent of caloric recovery at either one month (mean difference (MD) 9.60%; 95% CI ‐20.66 to 39.86, P = 0.53) or at 12 months (MD 6.83%; 95% CI ‐27.69 to 41.36, P = 0.70). In addition, there was no significant difference between corticosteroids and placebo medication in the symptomatic recovery of vestibular function following idiopathic acute vestibular dysfunction with respect to vertigo at 24 hours (RR 0.39; 95% CI 0.04 to 3.57, P = 0.40) and use of the Dizziness Handicap Inventory score at one, three, six and 12 months. Authors' conclusions Overall, there is currently insufficient evidence from these trials to support the administration of corticosteroids to patients with idiopathic acute vestibular dysfunction. We found no trials with a low risk of methodological bias that used the highest level of diagnostic criteria and outcome measures. We recommend that future studies should include health‐related quality of life and symptom‐based outcome measures, in addition to objective measures of vestibular improvement, such as caloric testing and electronystagmography. Plain language summary Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis) Idiopathic acute vestibular dysfunction (vestibular neuritis) is a common condition of unknown cause. Patients with the condition often experience dizziness, nausea or vomiting, and trouble with vision, balance or mobility, but have normal hearing and no tinnitus. It has been proposed that a course of corticosteroids, if given early on, may improve recovery from the condition and long‐term patient outcome. However, corticosteroids can cause adverse effects (e.g. bleeding stomach ulcer, mood changes, etc.). This review identified four randomised controlled trials including 149 adult patients with idiopathic acute vestibular dysfunction (vestibular neuritis) treated with either corticosteroids or placebo. The studies were varied in that they used different drugs and different treatment regimens. On the basis of these studies, there is currently insufficient evidence in favour of corticosteroids over placebo medication in the symptomatic recovery and objective testing of vestibular function, both in the short‐term and long‐term. Further studies of higher quality are needed to test the effectiveness of corticosteroids in patients with the condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fishman, JM; Burgess, C; Waddell, A", "articleTypes": [], "doi": "10.1002/14651858.CD008607.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "47698478-6f18-4ede-afa3-75ab253866b9", "pmid": "", "title": "Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents", "imported": false, "abstract": "Abstract - Background Vomiting is a common manifestation of acute gastroenteritis in children and adolescents. When untreated it can be a hindrance to oral rehydration therapy, which is the cornerstone in the management of acute gastroenteritis. Evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in acute gastroenteritis in children. Objectives To assess the safety and effectiveness of antiemetics on gastroenteritis induced vomiting in children and adolescents. Search methods We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conferences.The search was re‐run and is up to date as on 20 July 2010. Selection criteria Randomized controlled trials comparing antiemetics with placebo or no treatment, in children and adolescents under the age of 18, for vomiting due to gastroenteritis. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We included seven trials involving 1,020 participants. Mean time to cessation of vomiting in one study was 0.34 days less with dimenhydrinate suppository compared to placebo (P value = 0.036). Pooled data from three studies comparing oral ondansetron with placebo showed: a reduction in the immediate hospital admission rate (RR 0.40, NNT 17, 95% CI 10 to 100) but no difference between the hospitalization rates at 72 hours after discharge from the Emergency Department (ED); a reduction in IV rehydration rates both during the ED stay (RR 0.41, NNT 5, 95% CI 4 to 8), and in follow‐up to 72 hours after discharge from the ED stay (worst‐best scenario for ondansetron RR 0.57, NNT 6, 95% CI 4 to 13) and an increase in the proportion of patients with cessation of vomiting (RR 1.34, NNT 5, 95% CI 3 to 7)). No significant difference was noted in the revisit rates or adverse events, although diarrhea was reported as a side effect in four of the five ondansetron studies. In one study the proportion of patients with cessation of vomiting in 24 hours was (58%) with IV ondansetron, (17%) placebo and (33%) in the metoclopramide group (P value = 0.039). Authors' conclusions Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting. Plain language summary Anti‐sickness medication for vomiting in acute stomach upsets in children Vomiting caused by acute gastroenteritis is very common in children and adolescents. Treatment of vomiting in children with acute gastroenteritis can be problematic and there is lack of agreement among clinicians on the indications for the use of antiemetics. There have also been concerns expressed about apparently unacceptable levels of side effects with some of the older generation of antiemetics. The small number of included trials provided evidence which appeared to favour the use of antiemetics over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. A single oral dose of ondansetron given to children with mild to moderate dehydration can control vomiting, avoid hospitalization and intravenous fluid administration which would otherwise be needed. There were no major side effects other than a few reports of increased frequency of diarrhea.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fedorowicz, Z, Jagannath, VA, Carter, B", "articleTypes": [], "doi": "10.1002/14651858.CD005506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.787Z" }, { "id": "47886ee3-2ce5-47ff-8b3c-5be3aa69e5d2", "pmid": "", "title": "Local interventions for the management of alveolar osteitis (dry socket)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Daly, BJM, Sharif, MO, Jones, K, Worthington, HV, Beattie, A", "articleTypes": [], "doi": "10.1002/14651858.CD006968.pub3 AB - Abstract - Background Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012. Objectives To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction. Search methods An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies. Selection criteria We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews. Data collection and analysis We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random‐effects models. For some of the split‐mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence. Main results We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate‐certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively. Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate‐certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low‐certainty evidence). The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low‐certainty evidence). A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) ‐1.40, 95% CI ‐1.75 to ‐1.04; P < 0.00001; 2 studies, 80 participants; very low‐certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects. Authors' conclusions Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate‐certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. Plain language summary What treatments can be used to prevent and treat alveolar osteitis (dry socket)? Key messages ‐ Rinsing with chlorhexidine mouthwash before a dental extraction or beginning 24 hours after may help to prevent a dry socket.
‐ Placing a chlorhexidine gel directly into the socket immediately after tooth extraction may help to prevent a dry socket.
‐ Chlorhexidine rinses cause some minor adverse (unwanted) effects; chlorhexidine intrasocket gels do not appear to cause adverse effects.
‐ Alvogyl reduces the pain of a dry socket when compared to zinc oxide eugenol, but the evidence for this is very uncertain.
‐ Alvogyl does not appear to cause unwanted effects.
‐ We need future studies to strengthen the evidence and investigate the best ways to prevent and treat dry socket in all teeth. What is dry socket? Dry socket is a painful condition that sometimes arises after a tooth has been extracted and is more likely to occur following extraction of wisdom teeth in the lower jaw. What causes dry socket? It is thought to be linked to the loss of some or all of the blood clot that forms at the bottom of a tooth socket after a tooth is taken out. How can we prevent dry socket? An option for prevention of dry socket is to reduce debris and the bacterial load in the mouth, though dry socket is not bacterial in origin. People with poor oral hygiene (food debris and plaque) are at greater risk of dry socket. Improved oral hygiene and rinsing before a dental extraction or beginning 24 hours after may reduce the likelihood of dry socket. How can we treat dry socket ? Options for treating dry socket largely focus on reducing pain locally around the tooth extraction site by placing an obtundent (a soothing medicated dressing). What did we want to find out ? We wanted to find out if antiseptic rinses, gels, or healing patches could help to prevent dry socket. We also wanted to find out if placing a medicated dressing could treat a dry socket and whether any unwanted side effects were produced. What did we do? We searched for studies that compared antiseptic rinses or intrasocket gels with a placebo (dummy) rinse or nothing and a placebo (dummy) intrasocket gel or nothing. To find the best way to treat dry socket we searched for studies that compared different soothing agents with a placebo (dummy) with other soothing agents or with nothing. We compared the results of the studies and summarised the findings. We made an assessment of our confidence in the evidence based on the design of the study and the number of patients recruited. What did we find? We identified 49 trials; 39 trials (6219 participants) investigated prevention of dry socket and 10 trials (552 participants) investigated the treatment of dry socket. We found that: ‐ rinsing both before and after tooth extraction (commencing 24 hours after extraction) with chlorhexidine gluconate rinse (at 0.12% and 0.2% strength) probably results in a reduction in dry socket;
‐ placing chlorhexidine gel (0.2% strength) in the socket of an extracted tooth probably results in a reduction in dry socket;
‐ chlorhexidine rinses and gels are equally effective at reducing dry socket, but the evidence for this comparison is very uncertain;
‐ chlorhexidine rinses produced some minor unwanted effects; chlorhexidine intrasocket gels appeared to produce no unwanted effects;
‐ there was a small amount of evidence of very low certainty from two studies that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. This evidence relates to the old formulation of Alvogyl which is no longer available. It should be noted that the formulation of Alvogyl has changed, it is now called Alveogyl. Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. What are the limitations of the evidence? The main limitation of the evidence are that studies: ‐ reported mostly on tooth extractions involving lower wisdom teeth;
‐ were undertaken in ways that introduced errors in the conduct of the study leading to errors in the results; and
‐ produced imprecise results when they were combined. Due to these errors we have some confidence in the results relating to chlorhexidine rinses and gels but further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. How up to date is this evidence? The search for existing studies was completed by 28 September 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.063Z" }, { "id": "47987b67-74ae-4296-a3db-fdc8c6b80202", "pmid": "", "title": "Intranasal steroids for acute sinusitis", "imported": false, "abstract": "Abstract - Background Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school. Objectives We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis in adults and children. Search methods We searched CENTRAL 2013, Issue 4, MEDLINE (January 1966 to May week 2, 2013), EMBASE (1990 to May 2013) and bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) comparing INCS treatment to placebo or no intervention in adults and children with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop‐outs before the end of the study, rates of relapse, complications and return to school or work. Data collection and analysis Two review authors independently extracted data, assessed trial quality and resolved discrepancies by consensus. Main results No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well‐designed and double‐blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow‐up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta‐analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% confidence interval (CI) 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop‐out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS. Authors' conclusions Current evidence is limited for acute sinusitis confirmed by radiology or nasal endoscopy but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy. Plain language summary Steroids for acute sinusitis in adults and children Acute sinusitis is a common reason for primary care visits; it is one of the 10 most common diagnoses in outpatient clinics, presenting with various symptoms and signs that include purulent nasal discharge and congestion and cough lasting beyond the typical seven to 10 days of a viral upper respiratory infection. There have been suggestions, based on studies of allergic rhinitis and chronic sinusitis, that intranasal corticosteroids (INCS) may relieve symptoms and hasten recovery in acute sinusitis due to their anti‐inflammatory properties. A critical systematic review of the literature found four well‐conducted, randomised, placebo‐controlled intervention studies, involving 1943 participants treated for 15 or 21 days. The results suggest that there may be a modest effect with INCS in the resolution or improvement of symptoms. Only minor adverse events such as epistaxis, headache and nasal itching were reported. Given the small number of studies included in this review, it is recommended that further randomised controlled trials be conducted. The evidence is up to date as of May 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zalmanovici Trestioreanu, A; Yaphe, J", "articleTypes": [], "doi": "10.1002/14651858.CD005149.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "4798923a-14c4-40f3-86e6-e921ac3adc76", "pmid": "", "title": "Helminth therapy (worms) for allergic rhinitis", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a disorder of the nasal membranes and surrounding tissues, and a worldwide cause of illness and disability. Helminths are complex tissue‐dwelling or lumen‐dwelling organisms that inhabit larger organisms and are frequently asymptomatic. Helminths modulate the natural immune responses of their human hosts, and may prevent or cure immune‐mediated or allergic diseases (e.g. allergic rhinitis) in the host. Non‐randomised studies support this hypothesis. Objectives To assess the safety and effectiveness of helminth therapy in people with allergic rhinitis. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2011. Selection criteria All randomised controlled trials where the intervention was any helminth species or combination of helminth species, administered to people with allergic rhinitis in any dose, by any route and for any duration of exposure. We accepted both intermittent and persistent allergic rhinitis patients. Data collection and analysis We independently extracted data and assessed eligibility and risk of bias using a standardised data collection form. We resolved any disagreement through discussion. We combined dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), presenting both with 95% confidence intervals (CI). Main results We found five reports of two single‐centre, placebo‐controlled, double‐blinded studies (130 participants). Participants in both studies were a mix of adults with either intermittent or persistent allergic rhinitis. Both studies had a low risk of bias. One study, with 12 weeks’ follow‐up, used a single percutaneous application of 10 Necator americanus (i.e. human hookworm) larvae. The other study, with 24 weeks’ follow‐up, used three‐weekly oral dosing with 2500 Trichuris suis (i.e. pig whipworm) eggs in aqueous suspension. Of 17 outcomes evaluated in this review, eight were positive (i.e. favoured helminths). Participants taking helminths had no reduction in allergic rhinitis symptoms, percentage of well days (i.e. days with minimal symptoms and no use of medication for allergic rhinitis), lung function measures and quality of life scores. Total use of medication for allergic rhinitis (eye drops, nasal sprays, tablets) did not change; however, in the helminth group there was a statistically significant reduction in the percentage of days during the grass pollen season when participants needed to take tablets as rescue medication for their allergic rhinitis symptoms (MD –14.0%, 95% CI –26.6 to –1.40); in a typical 60‐day pollen season this 14% reduction translates into 19 days when tablets would be needed in the helminth group versus 27 days when tablets would be needed in the placebo group. Participants taking helminths percutaneously (i.e. as hookworm larvae) had local skin itching and redness in the first few days after administration. Participants taking helminths were more likely to report any gastrointestinal adverse event (RR 1.79, 95% CI 1.31 to 2.45), moderate or severe abdominal pain (RR 7.67, 95% CI 1.87 to 31.57), moderate or severe flatulence (RR 2.01, 95% CI 1.06 to 3.81) and moderate or severe diarrhoea (RR 1.99, 95% CI 1.18 to 3.37). There was no difference between the helminth and placebo groups in the incidence of serious adverse events, and in study withdrawals. Authors' conclusions There is currently insufficient evidence on the efficacy, tolerability and likely costs of helminth therapy to support its use in the routine management of allergic rhinitis. Administered to humans in carefully measured doses, helminths appear to be safe. More preclinical studies should be performed, before larger and extended duration trials of helminths for allergic rhinitis are carried out. Future studies should collect and report comparative data on the costs of helminth therapy versus conventional pharmacotherapy. Plain language summary Helminth therapy (worms) for allergic rhinitis Allergic rhinitis is a common health problem affecting about 500 million people worldwide; its prevalence is increasing. The symptoms of allergic rhinitis include sneezing, and an itchy, runny and blocked nose. Several classes of drugs are used to treat allergic rhinitis, but these drugs may be ineffective, and some drug classes have side effects after long‐term use. Drugs may also be relatively expensive. Helminths are complex multicellular organisms that inhabit larger organisms, and in humans are often symptomless. Helminths modulate (that is, optimally adjust) the immune systems of their hosts and it is thought that this property of helminths could be used therapeutically, to prevent or treat allergic diseases, such as allergic rhinitis. We included two well‐designed studies with a total of 130 adult participants, each study using a different species of gastrointestinal helminth (human hookworm in one study and pig whipworm in the other) as the intervention. Both studies found no significant efficacy from helminths, although one helminth species ( Trichuris suis , the pig whipworm) reduced the need for participants to take tablets as ‘rescue medication’ during the grass pollen season. Adverse events such as abdominal pain and flatulence were commoner in the helminth group, but the two helminths species studied did not cause serious adverse reactions. Currently there is insufficient evidence to support the use of helminths for allergic rhinitis in routine clinical practice. More preclinical studies are needed, before larger and extended duration clinical trials of helminths for allergic rhinitis are performed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Croft, AM, Bager, P, Garg, SK", "articleTypes": [], "doi": "10.1002/14651858.CD009238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.763Z" }, { "id": "479d0d2f-b7ab-484d-a863-39924c67da1e", "pmid": "", "title": "Aversive smoking for smoking cessation", "imported": false, "abstract": "Abstract - Background Aversion therapy pairs the pleasurable stimulus of smoking a cigarette with some unpleasant stimulus. The objective is to extinguish the urge to smoke. Objectives This review has two aims: First, to determine the efficacy of rapid smoking and other aversive methods in helping smokers to stop smoking; Second, to determine whether there is a dose‐response effect on smoking cessation at different levels of aversive stimulation. Search methods We searched the Cochrane Tobacco Addiction Group specialised register (latest search date October 2009) for studies which evaluated any technique of aversive smoking. Selection criteria Randomized trials which compared aversion treatments with 'inactive' procedures or which compared aversion treatments of different intensity for smoking cessation. Trials must have reported follow up of least six months from beginning of treatment. Data collection and analysis We extracted data in duplicate on the study population, the type of aversion treatment, the outcome measure, method of randomization and completeness of follow up. The outcome measure was abstinence from smoking at maximum follow up, using the strictest measure reported by the authors. Subjects lost to follow up were regarded as smokers. Where appropriate, we performed meta‐analysis using a fixed effect model. Main results Twenty‐five trials met the inclusion criteria. Twelve included rapid smoking and nine used other aversion methods. Ten trials included two or more conditions allowing assessment of a dose‐response to aversive stimulation. The odds ratio (OR) for abstinence following rapid smoking compared to control was 2.01 (95% confidence intervals (CI): 1.36 to 2.95). Several factors suggest that this finding should be interpreted cautiously. A funnel plot of included studies was asymmetric, due to the relative absence of small studies with negative results. Most trials had a number of serious methodological problems likely to lead to spurious positive results. The only trial using biochemical validation of all self reported cessation gave a non‐significant result. Other aversion methods were not shown to be effective (OR 1.15, 95% CI 0.73 to 1.82). There was a borderline dose‐response to the level of aversive stimulation (OR 1.67, 95% CI 0.99 to 2.81). Authors' conclusions The existing studies provide insufficient evidence to determine the efficacy of rapid smoking, or whether there is a dose‐response to aversive stimulation. Milder versions of aversive smoking seem to lack specific efficacy. Rapid smoking is an unproven method with sufficient indications of promise to warrant evaluation using modern rigorous methodology. Plain language summary Does smoking in a way that is unpleasant help smokers to quit Aversion treatments pair undesirable behaviours with negative sensations. In smoking cessation, several approaches have been suggested such as rapid smoking, which requires smokers to take a puff every few seconds to make smoking unpleasant. The results of the existing trials suggest that this may be effective, but the evidence is not conclusive because most of the studies of this approach have methodological problems. A recent laboratory study also suggests that the method has an active ingredient. Further research may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Hajek, P, Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.735Z" }, { "id": "47aa70b0-29d8-49cc-95bc-7205befb05be", "pmid": "", "title": "Sumatriptan (intranasal route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Intranasal administration may be preferable to oral for individuals experiencing nausea and/or vomiting, although it is primarily absorbed in the gut, not the nasal mucosa. Objectives To determine the efficacy and tolerability of intranasal sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using intranasal sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Twelve studies (4755 participants) compared intranasal sumatriptan with placebo or an active comparator. Most of the data were for the 10 mg and 20 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 10 mg versus placebo the NNTs were 7.3, 7.4, and 5.5 for pain‐free at two hours, and headache relief at one and two hours, respectively. For sumatriptan 20 mg versus placebo the NNTs were 4.7, 4.9, and 3.5, respectively, for the same outcomes. The 20 mg dose was significantly better than the 10 mg dose for each of these three primary efficacy outcomes. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Direct comparison of sumatriptan with active treatments was limited to two studies, one comparing sumatriptan 20 mg and dihydroergotamine (DHE) 1 mg, and one comparing sumatriptan 20 mg with rizatriptan 10 mg. Authors' conclusions Intranasal sumatriptan is effective as an abortive treatment for acute migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events compared with placebo. Plain language summary Sumatriptan (intranasal route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a nasal spray, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, although absorption of the drug occurs primarily in the gut rather than the nasal mucosa. This review found that a single intranasal dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in approximately 2 in 10 people (24%) taking sumatriptan 10 mg, compared with about 1 in 10 (10%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 5 in 10 people (50%) taking sumatriptan 10 mg, compared with approximately 3 in 10 (32%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those who took placebo. The 20 mg dose had greater efficacy, but may be associated with more adverse events, most of which were of short duration and mild or moderate in severity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009663", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.064Z" }, { "id": "47b2c7d3-2b82-4596-8a14-56159eb94c36", "pmid": "", "title": "Oral nutritional interventions in hospitalised older people at nutritional risk: a network meta‐analysis of individual participant data", "imported": false, "abstract": "Abstract - Rationale Malnutrition affects 35% to 64% of hospitalised older people, and is associated with adverse health outcomes such as disease complications and hospital readmission. Identifying effective nutritional interventions is essential to improve clinical outcomes and reduce healthcare costs in this population. Objectives To evaluate the effects of various nutritional interventions, compared with either a control group (standard care or placebo) or each other, on patient‐relevant outcomes in hospitalised older people at risk of or with established malnutrition, and to rank the effects of these different interventions using network meta‐analysis (NMA) based on individual participant data (IPD). Search methods We searched CENTRAL, MEDLINE, five other databases, and two trial registries to 2 July 2024, and checked the reference lists of included studies and relevant systematic reviews. Eligibility criteria We included older people (≥ 65 years) hospitalised for different acute conditions at risk of or with malnutrition enrolled in randomised controlled trials (RCTs) comparing oral nutritional interventions with control or each other. For RCTs that met our inclusion criteria, either fully or partially, we requested IPD from the study authors. If we did not receive a response or IPD were unavailable, we used published aggregated data. We excluded RCTs that only partially met the eligibility criteria if neither IPD nor sufficient aggregated data were obtainable. Outcomes Critical outcomes were all‐cause mortality, serious adverse events (SAEs), and functional status (e.g. activities of daily living). Important outcomes were health‐related quality of life (HRQoL), length of hospital stay (LOS), body weight, and fat‐free mass. The main outcome assessment time point was at hospital discharge or 30 days after randomisation. Risk of bias We used the Cochrane risk of bias 2 (RoB 2) tool. Synthesis methods For each outcome, we first analysed IPD within each study. Second, we pooled results in an NMA which also included the aggregated data from RCTs without available IPD. We performed random‐effects NMAs based on the frequentist approach and ranked treatments by P‐scores. We rated the certainty of evidence using the GRADE approach. Included studies We included 21 RCTs (72 reports; 12 RCTs with IPD) with 3309 older participants (mean age ranged from 75 to 85 years; 1863 participants with IPD) with different acute conditions. Interventions included the provision of additional protein (three studies), energy supplements (two studies), oral nutritional supplements (ONS; eight studies), individualised feeding support (two studies), and comprehensive individualised nutritional care (eight studies). In all but two RCTs, interventions were compared to control (standard care with or without a placebo). We judged 16.1% of outcome assessments to be at low risk of bias and 16.8% at high risk. Synthesis of results ONS may reduce all‐cause mortality (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.25 to 0.84; absolute risk difference 57 fewer deaths per 1000 people, 95% CI 79 fewer to 17 fewer; low‐certainty evidence) compared to control, while comprehensive individualised nutritional care may show little to no effect (RR 0.98, 95% CI 0.55 to 1.73; 1 fewer per 1000 people, 95% CI 26 fewer to 46 more; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 13 RCTs, 2728 participants; Q between designs: not applicable (NA)). ONS may reduce SAEs compared to control (RR 0.56, 95% CI 0.32 to 0.95; 84 fewer SAEs per 1000 people, 95% CI 131 fewer to 10 fewer; Q between designs: Q 1.95, df 2, P = 0.3772; low‐certainty evidence ). For all other treatment comparisons, the evidence is very uncertain (NMA with 14 RCTs, 2184 participants). Comprehensive individualised nutritional care may make little to no difference in activities of daily living compared to control (standardised mean difference (SMD) 0.06, 95% CI −0.08 to 0.20; low‐certainty evidence) and ONS compared to energy supplements (SMD −0.15, 95% CI −0.53 to 0.23; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 5 RCTs, 1128 participants; Q between designs: NA). Energy supplements probably make little to no difference in HRQoL compared with ONS (mean difference (MD) 0.01, 95% CI −0.06 to 0.08; Q between designs: NA; moderate‐certainty evidence). All other comparisons of different nutritional interventions may make little to no difference to HRQoL (NMA with 3 RCTs, 1513 participants). The provision of additional protein, energy supplements, ONS, and comprehensive individualised nutritional care may make little to no difference in LOS compared to control (18 RCTs, 3013 participants; Q between designs: Q 2.86, df 3, P = 0.4145). Body weight (16 RCTs, 2114 participants; Q between designs: Q 2.03, df 3, P = 0.5655) may increase with ONS when compared to control (MD 0.9 kg, 95% CI 0.37 to 1.42) or comprehensive individualised nutritional care (MD 1.00 kg, 95% CI 0.12 to 1.87), but the evidence is very uncertain. Energy supplements and ONS probably have similar effects on body weight (MD 0.11 kg, 95% CI −0.85 to 0.63; moderate‐certainty evidence). For fat‐free mass, no meta‐analysis was possible. One RCT (102 participants) compared ONS with energy supplements and found little or no difference between groups (MD 0.13 kg, 95% CI −0.63 to 0.90; low‐certainty evidence), while evidence regarding the effects of additional protein compared with control was very uncertain (1 RCT, 19 participants). Rankings of treatments by P‐scores were not consistent across outcomes. Authors' conclusions In older hospitalised people at risk of or with malnutrition, oral nutritional supplements may reduce mortality and SAEs compared to control 30 days after randomisation . For other outcomes, there may be little or no differences in results. Overall, the evidence was of low to very low certainty, primarily due to a limited number of studies and participants per comparison. The comparison of treatment effects across outcomes was constrained by variations in network structure. When interpreting the results, the heterogeneity of the population in terms of acute and chronic conditions needs to be considered. To improve certainty, adequately powered studies with robust methodologies should compare interventions with controls as well as against each other. Funding The German Federal Ministry of Education and Research funded this work (grant number: 01KG2102). Registration Protocol (2022) doi.org/10.1002/14651858.CD015468 Plain language summary What are the benefits and risks of different types of nutritional support for older, hospitalised people who are malnourished or at risk of malnutrition? Key messages Compared to standard hospital care, specialised foods and drinks may reduce the chances of dying and of having a serious negative health event one month after hospital admission. In terms of people's ability to perform basic daily activities, their quality of life, length of hospital stay, and body weight, we are either very uncertain about the benefits and risks of the different types of nutritional support, or evidence shows they may make little or no difference compared to standard hospital care. Larger and well‐designed studies comparing different types of nutritional support may increase our confidence in these findings. What is malnutrition? People become malnourished when their intake of energy and protein is not enough to meet their body's needs. This condition can reduce someone's fat and muscle stores. Being malnourished threatens people's health and compromises the immune system's ability to fight infections. Older people who are malnourished are at higher risk of disease complications, losing their independence, and dying than non‐malnourished older people. They also experience a lower quality of life. Older people may become malnourished or be at risk of malnutrition for several reasons, including having a reduced appetite, chewing problems, physical limitations (e.g. unable to stand for long periods to prepare meals), and loneliness. Older people in hospital are particularly prone to malnutrition. They may not eat enough at a time when their illness increases their energy and protein needs. Malnutrition affects roughly one‐third to two‐thirds of hospitalised older people. How is malnutrition treated? There is a wide range of treatments for malnutrition, including: specialised foods and beverages that provide extra energy, protein, and other nutrients; practical help with eating and drinking; additional snacks, protein‐rich foods or supplements; nutritional counselling; or tailored combinations of these approaches. What did we want to find out? In older, hospitalised people who are malnourished or at risk of malnutrition, we wanted to know if different types of nutritional support are better than standard care at: reducing the risk of dying and serious negative health events (e.g. complications such as infections or wound healing); improving people's ability to perform basic daily activities and their quality of life; reducing time spent in hospital; and boosting people's body weight and muscle mass. We also wanted to know which type of nutritional support works best. What did we do? We searched for studies in people 65 years and older who were in hospital and malnourished or at risk of malnutrition. We included studies that compared one type of nutritional support to another type, or compared nutritional support to standard hospital care (i.e. usual hospital food service), sometimes in combination with a 'dummy treatment' that looked identical to the supplements tested. We summarised and compared all treatments, and rated our confidence in the results based on factors such as study methods and the numbers of people included. What did we find? We found 21 studies involving 3309 hospitalised older people with different acute conditions. We grouped the treatments they received into five categories: specialised foods and drinks; protein‐enriched foods or supplements; energy supplements; personalised feeding support from an assistant (who would, for example, accommodate food preferences, adjust someone's position, and help with eating); multi‐component personalised nutritional care from a dietitian or nutritionist (who would, for example, modify foods or offer counselling). Main findings Compared to standard hospital care, after a month in hospital, specialised foods and drinks may: reduce the chance of death: they may lead to 57 fewer deaths per 1000 people; reduce serious negative health events: they may lead to 84 fewer events per 1000 people. Compared to standard hospital care, we are either very uncertain about the effects of specialised foods and drinks, protein‐enriched foods or supplements, energy supplements, personalised feeding support, and multi‐component personalised nutritional care, or these treatments may make little or no difference to people's: ability to perform basic daily activities; quality of life; length of hospital stay; body weight and muscle mass. When we compared the different types of nutritional support to each other, we did not find that any one approach worked better than all others in improving the results we measured. What are the limitations of the evidence? Our confidence in the findings is low or very low for several reasons. Some studies used methods that may have led to errors in the results. Studies often involved too few people, or did not look at everything we were interested in, such as muscle mass as outcome or comparisons of different types of nutritional support. Moreover, older people in hospital have different illnesses and functional abilities, and we could not assess how the different types of nutritional support work for different people. How current is this evidence? The evidence is current to 2 July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E, Schwarzer, G, Stadelmaier, J, Lohner, S, Grummich, K, Dagnelie, PC, Beck, AM, Beelen, J, Botella-Carretero, JI, Faxén-Irving, G, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015468.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.798Z" }, { "id": "47b66557-b142-4a60-bc3a-ec4493597d2f", "pmid": "", "title": "Sumatriptan (intranasal route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Intranasal administration may be preferable to oral for individuals experiencing nausea and/or vomiting, although it is primarily absorbed in the gut, not the nasal mucosa. Objectives To determine the efficacy and tolerability of intranasal sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using intranasal sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Twelve studies (4755 participants) compared intranasal sumatriptan with placebo or an active comparator. Most of the data were for the 10 mg and 20 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 10 mg versus placebo the NNTs were 7.3, 7.4, and 5.5 for pain‐free at two hours, and headache relief at one and two hours, respectively. For sumatriptan 20 mg versus placebo the NNTs were 4.7, 4.9, and 3.5, respectively, for the same outcomes. The 20 mg dose was significantly better than the 10 mg dose for each of these three primary efficacy outcomes. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Direct comparison of sumatriptan with active treatments was limited to two studies, one comparing sumatriptan 20 mg and dihydroergotamine (DHE) 1 mg, and one comparing sumatriptan 20 mg with rizatriptan 10 mg. Authors' conclusions Intranasal sumatriptan is effective as an abortive treatment for acute migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events compared with placebo. Plain language summary Sumatriptan (intranasal route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a nasal spray, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, although absorption of the drug occurs primarily in the gut rather than the nasal mucosa. This review found that a single intranasal dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in approximately 2 in 10 people (24%) taking sumatriptan 10 mg, compared with about 1 in 10 (10%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 5 in 10 people (50%) taking sumatriptan 10 mg, compared with approximately 3 in 10 (32%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those who took placebo. The 20 mg dose had greater efficacy, but may be associated with more adverse events, most of which were of short duration and mild or moderate in severity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009663", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "47be526a-a94e-406e-8905-0936aa220180", "pmid": "", "title": "Long‐acting muscarinic antagonists (LAMA) added to combination long‐acting beta₂‐agonists and inhaled corticosteroids (LABA/ICS) versus LABA/ICS for adults with asthma", "imported": false, "abstract": "Abstract - Background Maintenance treatment with long‐acting beta 2 ‐agonists and inhaled corticosteroids (LABA/ICS) can relieve asthma symptoms and reduce the frequency of exacerbations, but there are limited treatment options for people who do not gain control on combination LABA/ICS. Long‐acting muscarinic antagonists (LAMA) are a class of inhaled drug which have been effective for people with chronic obstructive pulmonary disease and are now becoming available for people with asthma to take alongside their LABA/ICS inhaler. Objectives To assess the effects of adding a long‐acting muscarinic antagonist (LAMA) to combination long‐acting beta 2 ‐agonists (LABA) and inhaled corticosteroids (ICS) in adults whose asthma is not well controlled by LABA/ICS. Search methods We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to January 2016. We also searched ClinicalTrials.gov, the WHO trials portal, and reference lists of other reviews, and we contacted trial authors for additional information. Selection criteria We included parallel randomised controlled trials (RCTs) of at least 12 weeks' duration. Studies met the inclusion criteria if they compared LAMA as an add‐on to LABA/ICS versus LABA/ICS alone for adults with asthma. We included studies reported as full text, those published as abstract only, and unpublished data. Primary outcomes were exacerbations requiring oral corticosteroids (OCS), validated measures of asthma control, and serious adverse events (including mortality). Data collection and analysis Two review authors screened searches and independently extracted details on risk of bias and numerical data. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MD) using a random‐effects model. We rated all outcomes using GRADE. Main results We found four double‐blind, double‐dummy trials comparing LAMA to placebo, including 1197 people with asthma taking combination LABA/ICS. One of the trials was designed to study glycopyrronium bromide but was withdrawn prior to enrolment, and the other three all studied tiotropium bromide (mostly 5 µg once daily via Respimat) over 48 to 52 weeks. People in the trials had a mean forced expiratory volume in one second (FEV 1 ) of 55% of their predicted value, indicating severe asthma. People randomised to take tiotropium add‐on had fewer exacerbations requiring oral corticosteroids than those continuing to take LABA/ICS alone, but the confidence intervals did not rule out no difference (OR 0.76, 95% CI 0.57 to 1.02; moderate quality evidence). Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS would have to take oral corticosteroids for an exacerbation compared with 271 if they took tiotropium as well (95% CI 218 to 333 per 1000). Analyses comparing the number of exacerbations per patient in each group (rate ratio) and the time until first exacerbation (hazard ratio) were in keeping with the main result. Quality of life, as measured by the Asthma Quality of Life Questionnaire (AQLQ) was no better for those taking tiotropium add‐on than for those taking LABA/ICS alone when considered in light of the 0.5 minimal clinically important difference on the scale (MD 0.09, 95% CI − 0.03 to 0.20), and evidence for whether tiotropium increased or decreased serious adverse events in this population was inconsistent (OR 0.60, 95% CI 0.24 to 1.47; I 2 = 76%). Within the secondary outcomes, exacerbations requiring hospital admission were too rare to tell whether tiotropium was beneficial over LABA/ICS alone. There was high quality evidence showing benefits to lung function (trough FEV 1 and forced vital capacity (FVC)) and potentially small benefits to asthma control. People taking tiotropium add‐on were less likely to experience non‐serious adverse events. Authors' conclusions Tiotropium add‐on may have additional benefits over LABA/ICS alone in reducing the need for rescue oral steroids in people with severe asthma. The effect was imprecise, and there was no evidence for other LAMA preparations. Possible benefits on quality of life were negligible, and evidence for the effect on serious adverse events was inconsistent. There are likely to be small added benefits for tiotropium Respimat 5 µg daily on lung function and asthma control over LABA/ICS alone and fewer non‐serious adverse events. The benefit of tiotropium add‐on on the frequency of hospital admission is still unknown, despite year‐long trials. Ongoing and future trials should clearly describe participants' background medications to help clinicians judge how the findings relate to stepwise care. If studies test LAMAs other than tiotropium Respimat for asthma, they should be at least six months long and use accepted and validated outcomes to allow comparisons of the safety and effectiveness between different preparations. Plain language summary Does adding tiotropium, a long‐acting muscarinic antagonist (LAMA), to combination therapy (LABA/ICS) help to control asthma? Adding the LAMA tiotropium Respimat inhaler to combination LABA/ICS inhaler may reduce the need for rescue oral steroids. A noticeable benefit on quality of life is unlikely, and we couldn't tell if it reduced hospital admissions, but adding tiotropium has some benefit on lung function, asthma control, and non‐serious side effects. More detail about the studies and results: Taking a daily inhaler containing a long‐acting beta 2 ‐agonist and an inhaled corticosteroid (LABA/ICS) can improve symptoms and reduce the likelihood of asthma attacks. If this doesn't help, another type of inhaled drug called a long‐acting muscarinic antagonist (LAMA), which has been effective for people with other breathing conditions, is now available for people with asthma to take as well as their LABA/ICS inhaler. We wanted to find out whether adding a LAMA to LABA/ICS is better than continuing LABA/ICS alone for adults with asthma. We found four relevant studies, but one was withdrawn before anyone was signed up. The other three compared a LAMA called tiotropium Respimat to placebo for around a year, with participants in both groups continuing to take their usual LABA/ICS inhaler. People generally had quite poor lung function when they entered the studies, suggesting their asthma was not well controlled ‐ in respiratory medicine, this is known as 'severe asthma'. Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS had to take a course of oral steroids compared with 271 if they took tiotropium as well. However, uncertainty in the results meant that rather than there being 271 people taking oral steroids, there could be anywhere from 218 to 333 people per 1000 who would have to take oral steroids, so we couldn't be sure of the benefit. Quality of life scores were not that different between those who took tiotropium and those who didn't. The studies showed different results for whether people taking tiotropium were more likely to suffer a serious side effect, but fewer people had non‐serious side effects if they took tiotropium. We couldn't tell whether taking tiotropium on top of LABA/ICS reduced the number of people who had to go to hospital for an asthma attack because it didn't happen often enough for us to have confidence in the result. There was high quality evidence that showed benefits to lung function and probably small benefits on measures of asthma control.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Kew, KM, Dahri, K", "articleTypes": [], "doi": "10.1002/14651858.CD011721.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.109Z" }, { "id": "47d593ba-c5a3-43c4-9fc6-b8d6aedd9e65", "pmid": "", "title": "Chlorhexidine mouthrinse as an adjunctive treatment for gingival health", "imported": false, "abstract": "Abstract - Background Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build‐up of plaque thereby reducing gingivitis. Objectives To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day). To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs. Data collection and analysis Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random‐effects models for all meta‐analyses. Main results We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high‐quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high‐quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate‐quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies). Authors' conclusions There is high‐quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high‐quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies. Plain language summary Chlorhexidine mouthrinse to reduce gingivitis and plaque build‐up Review question Does the use of chlorhexidine mouthrinse (a broad spectrum antiseptic) in addition to other conventional tooth cleaning help to control and improve gingivitis (inflammation of the gums)? Does the frequency of rinsing or the concentration of the solution affect the result and are there any undesirable side effects? Background Gingivitis is a reversible condition when gums become red, swollen and can bleed easily. Gingivitis is also very common ‐ studies suggest that as many as 50% to 90% of adults in the UK and USA suffer from it. In susceptible people gingivitis may lead to periodontitis, which is not reversible. In periodontitis inflammation is accompanied by loss of ligaments and bone supporting the teeth. If untreated it may eventually lead to tooth loss. Severe periodontitis is the sixth most widespread disease globally. It is recognised that maintaining a high standard of oral hygiene is important for the prevention and treatment of gingivitis. Toothbrushing is the main method for maintaining good oral hygiene. Other cleaning methods commonly used include dental floss, interdental brushes and scaling and polishing carried out by a dental professional. Some people have difficulty controlling plaque build‐up and preventing gingivitis using only conventional tooth cleaning. Therefore people sometimes use mouthrinses containing chlorhexidine in addition to conventional tooth cleaning. These mouthrinses are readily available over the counter; prescriptions generally not being required outside the USA. Study characteristics We included 51 studies that analysed a total of 5345 participants. The evidence in this review is up to date as of 28 September 2016. Generally study participants were children and adults who had gingivitis or periodontitis, were able to use usual tooth cleaning methods and were healthy. We did not exclude studies where some or all participants had medical conditions or special care needs as we considered the use of mouthrinses with chlorhexidine to be particularly relevant to them. The included studies assessed the effects of chlorhexidine mouthrinse used for at least 4 weeks in addition to conventional tooth cleaning on gingivitis in children and adults. Key results There is high‐quality evidence that the use of mouthrinses containing chlorhexidine in addition to usual toothbrushing and cleaning for 4 to 6 weeks or 6 months leads to a large reduction in the build‐up of plaque. There is also high‐quality evidence of a moderate reduction in gingivitis in people with a mild level of it, although because the level of disease was already low this is not considered clinically important. The nature of the available evidence does not allow us to determine the level of reduction of gingivitis in people with moderate to severe levels of it. There was no evidence that one concentration or strength of chlorhexidine rinse was more effective than another. Rinsing for 4 weeks or longer causes tooth staining, which requires scaling and polishing carried out by a dental professional. Other side effects have been reported, including build‐up of calculus (tartar), temporary taste disturbance and temporary shedding of/damage to the lining of the mouth. Quality of the evidence One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "James, P, Worthington, HV, Parnell, C, Harding, M, Lamont, T, Cheung, A, Whelton, H, Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD008676.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.068Z" }, { "id": "47d699ef-43c6-436e-b816-c9ddc7a36b03", "pmid": "", "title": "Systemic interventions for recurrent aphthous stomatitis (mouth ulcers)", "imported": false, "abstract": "Abstract - Background Recurrent aphthous stomatitis (RAS) is the most frequent form of oral ulceration, characterised by recurrent oral mucosal ulceration in an otherwise healthy individual. At its worst RAS can cause significant difficulties in eating and drinking. Treatment is primarily aimed at pain relief and the promotion of healing to reduce the duration of the disease or reduce the rate of recurrence. A variety of topical and systemic therapies have been utilised. Objectives To determine the clinical effect of systemic interventions in the reduction of pain associated with RAS, a reduction in episode duration or frequency. Search methods We undertook electronic searches of: Cochrane Oral Health Group and PaPaS Trials Registers (to 6 June 2012); CENTRAL via The Cochrane Library (to Issue 4, 2012); MEDLINE via OVID (1950 to 6 June 2012); EMBASE via OVID (1980 to 6 June 2012); CINAHL via EBSCO (1980 to 6 June 2012); and AMED via PubMed (1950 to 6 June 2012). We searched reference lists from relevant articles and contacted the authors of eligible trials to identify further trials and obtain additional information. Selection criteria We included randomised controlled trials (RCTs) in which the primary outcome measures assess a reduction of pain associated with RAS, a reduction in episode duration or a reduction in episode frequency. Trials were not restricted by outcome alone. We also included RCTs of a cross‐over design. Data collection and analysis Two review authors independently extracted data in duplicate. We contacted trial authors for details of randomisation, blindness and withdrawals. We carried out risk of bias assessment on six domains. We followed The Cochrane Collaboration statistical guidelines and risk ratio (RR) values were to be calculated using fixed‐effect models (if two or three trials in each meta‐analysis) or random‐effects models (if four or more trials in each meta‐analysis). Main results A total of 25 trials were included, 22 of which were placebo controlled and eight made head‐to‐head comparisons (five trials had more than two treatment arms). Twenty‐one different interventions were assessed. The interventions were grouped into two categories: immunomodulatory/anti‐inflammatory and uncertain. Only one study was assessed as being at low risk of bias. There was insufficient evidence to support or refute the use of any intervention. Authors' conclusions No single treatment was found to be effective and therefore the results remain inconclusive in regard to the best systemic intervention for RAS. This is likely to reflect the poor methodological rigour of trials, and lack of studies for certain drugs, rather than the true effect of the intervention. It is also recognised that in clinical practice, individual drugs appear to work for individual patients and so the interventions are likely to be complex in nature. In addition, it is acknowledged that systemic interventions are often reserved for those patients who have been unresponsive to topical treatments, and therefore may represent a select group of patients. Plain language summary Systemic interventions for recurrent aphthous stomatitis (mouth ulcers) Mouth ulcers (sores) are one of the most common oral problems and many people suffer with them repeatedly. These can be painful and slow to heal. At its worst, this can cause significant difficulties in eating and drinking. This review found that many different treatments were used to manage this condition, although the evidence of their effectiveness remains inconclusive.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Brocklehurst, P; Tickle, M; Glenny, AM; Lewis, MA; Pemberton, MN; Taylor, J; Walsh, T; Riley, P; Yates, JM", "articleTypes": [], "doi": "10.1002/14651858.CD005411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "47da6ddc-a1e0-4c26-add4-7e5afc7a9abc", "pmid": "", "title": "Capsaicin for non‐allergic rhinitis", "imported": false, "abstract": "Abstract - Background There are many forms of rhinitis. Patients are diagnosed with non‐allergic rhinitis when anatomic, infectious and allergic aetiologies have been excluded. The symptoms, including nasal congestion, blockage or obstruction, clear rhinorrhoea, sneezing and, less frequently, nasal itching, can range from mild to debilitating. It affects between 25% and 50% of patients with rhinitis. Several medications are widely used in the treatment of non‐allergic rhinitis, including oral and topical nasal antihistamines, intranasal and (rarely) systemic corticosteroids, and anticholinergics. Capsaicin, the active component of chili peppers, delivered intranasally, is considered a treatment option for non‐allergic rhinitis. Objectives To assess the effectiveness of capsaicin in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications, or two or more of the above therapies in combination, or different capsaicin regimens. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 5); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2015. Selection criteria Randomised controlled trials in adult patients with non‐allergic rhinitis comparing intranasal capsaicin with no therapy, placebo or other topical or systemic medications, or their combinations. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We included four studies (five publications) involving 302 participants with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe, idiopathic non‐allergic rhinitis who were between the ages of 16 and 65. Studies had follow‐up periods ranging from four to 38 weeks. The overall risk of bias in the studies was either high or unclear (two studies had overall high risk of bias, while two others had low to unclear risk of bias). Using the GRADE system we assessed the evidence as being of low to moderate quality. A meta‐analysis was not possible, given lack of similarity of the reported outcomes. Two studies compared capsaicin with placebo. One study reported that capsaicin resulted in an improvement of overall nasal symptoms (a primary outcome) measured on a visual analogue scale (VAS) of 0 to 10. There was a mean difference (MD) of ‐3.34 (95% confidence interval (CI) ‐5.24 to ‐1.44), MD ‐3.73 (95% CI ‐5.45 to ‐2.01) and MD ‐3.52 (95% CI ‐5.55 to ‐1.48) at two, 12 and 36 weeks post‐treatment, respectively. Another study reported that, compared to placebo, capsaicin (at 4 µg/puff) was more likely to produce overall symptom resolution (reduction in nasal blockage, sneezing/itching/coughing and nasal secretion measured with a daily record chart) at four weeks post‐treatment (a primary outcome). The risk ratio (RR) was 3.17 (95% CI 1.38 to 7.29). One study compared capsaicin to budesonide (an intranasal corticosteroid). This study found that patients treated with capsaicin had a better overall symptom score compared to those treated with budesonide (MD 2.50, 95% CI 1.06 to 3.94, VAS of 0 to 10). However, there were no differences in the individual symptom scores for headache, postnasal drip, rhinorrhoea, nasal blockage, sneezing and sore throat assessed during the last three days of a four‐week treatment. One study compared two different regimens of capsaicin administration: five treatments in one day versus five treatments given every two to three days during two weeks. Using daily record charts, the study reported significant improvement of individual symptom scores for rhinorrhoea in patients treated five times per day, however numerical data were not presented. There were no improvements in the other outcomes: rhinorrhoea, nasal obstruction, sneezing and overall nasal symptoms, measured on a VAS. Finally, one of these studies also compared three doses of capsaicin (to placebo). Patients treated with a 1 µg versus 4 µg per puff dose of capsaicin had a worse daily record chart overall symptom score resolution (RR 0.63, 95% CI 0.34 to 1.16). Only one study attempted to measure adverse effects (a primary outcome), however due to methodological issues with the assessment we are unable to draw any conclusions. We sought to include other secondary outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Authors' conclusions Capsaicin may be an option in the treatment of idiopathic non‐allergic rhinitis. It is given in the form of brief treatments, usually during the same day. It appears to have beneficial effects on overall nasal symptoms up to 36 weeks after treatment, based on a few, small studies (low‐quality evidence). Well‐conducted randomised controlled trials are required to further advance our understanding of the effectiveness of capsaicin in non‐allergic rhinitis, especially in patients with non‐allergic rhinitis of different types and severity, and using different methods of capsaicin application. Plain language summary Capsaicin for non‐allergic rhinitis Review question Is capsaicin applied into the nose (intranasal) effective in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications? Background Rhinitis means inflammation of the nose. It affects 30% to 40% of the general population. There are many forms of rhinitis: rhinosinusitis (or simply sinusitis), allergic rhinitis and non‐allergic rhinitis. Non‐allergic rhinitis is diagnosed in patients who have negative tests for allergies and also do not have sinusitis. The symptoms include congestion of the nose, a blocked or obstructed sensation in the nose that causes difficulty breathing, clear nasal discharge (runny nose), sneezing and nasal itching. There are several subtypes of non‐allergic rhinitis: occupational (from exposure to chemicals), smoking, gustatory (related to eating food or drinking fluid), hormonal (from changes in hormone levels in the body), pregnancy, senile or elderly (mostly affecting the older population), medication‐induced (for example, from overuse of decongestant nasal sprays) and local allergic (local allergy in the nose, while skin or blood allergy tests are negative). The most common subtype of non‐allergic rhinitis is 'idiopathic' or 'vasomotor' rhinitis, which results from imbalance of the neural (nerve) system that manages the function of the nose. The mechanisms of many of these subtypes remain unknown. Non‐allergic rhinitis affects about 25% to 50% of patients with rhinitis and is therefore very common. Capsaicin is the active ingredient of chili peppers. It has medicinal properties and is used elsewhere in medicine, for example for neuralgias (nerve pain) and psoriasis (a skin disease). The side effects of using capsaicin in the nose include irritation, burning, sneezing and coughing, however there are no known long‐term side effects of capsaicin use. Capsaicin is given in the form of brief treatments, usually during the same day. It works by down‐regulating transient receptor potential vanilloid (TRPV) receptor expression on C‐sensory fibres. TRPV represents special ion channels involved in the sensations of pain, cold, hotness, tastes, pressure and vision. C fibres help to conduct some of these sensations. There is ongoing research into the effects of capsaicin on these mechanisms and its clinical uses. Study characteristics We included four studies involving 302 patients with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe idiopathic non‐allergic rhinitis, who were between the ages of 16 and 65. The studies had a follow‐up ranging from four to 38 weeks after treatment. Key results Individually, the studies reported that the overall function of the nose in patients with non‐allergic rhinitis improved when treated with capsaicin compared to placebo. Capsaicin also seems to work better than another common type of nasal medication, budesonide (a steroid). The best knowledge that we have on capsaicin treatment supports giving it five times in one day, and to use doses of at least 4 micrograms in each puff. We could not combine the results together. The included studies did not have sufficient information to allow us to draw a conclusion about side effects. We also wanted to include other outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Quality of the evidence Overall, we judged the quality of the evidence to be of low to moderate quality. The evidence is up to date to June 2015. Conclusions Given that many other options do not work well in non‐allergic rhinitis, capsaicin is a reasonable option to try under physician supervision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Gevorgyan, A, Segboer, C, Gorissen, R, van Drunen, CM, Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010591.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.817Z" }, { "id": "47e0b47d-cbc5-4847-bbf3-6564aeff105d", "pmid": "", "title": "Vasodilators for primary Raynaud's phenomenon", "imported": false, "abstract": "Abstract - Background Numerous agents have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered to be the drugs of choice, evidence of the effects of alternative pharmacological treatments is limited. This is an update of a review first published in 2008. Objectives To assess the effects of drugs with vasodilator effects on primary Raynaud's phenomenon as determined by frequency, severity, and duration of vasospastic attacks; quality of life; adverse events; and Raynauds Condition Score. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trial register to November 16, 2020. Selection criteria We included randomized controlled trials evaluating effects of oral, intravenous, and topical formulations of any drug with vasodilator effects on subjective symptoms, severity scores, and radiological outcomes in primary Raynaud's phenomenon. Treatment with calcium channel blockers was not assessed in this review, nor were these agents compared. Data collection and analysis Two review authors independently selected studies for inclusion, assessed studies using the Cochrane \"Risk of bias\" tool, and extracted study data. Outcomes of interest included frequency, severity, and duration of attacks; quality of life (QoL); adverse events (AEs); and the Raynaud Condition Score (RCS). We assessed the certainty of the evidence using GRADE. Main results We identified seven new studies for this update. In total, we included 15 studies involving 635 participants. These studies compared different vasodilators to placebo. Individual studies used different methods and measures to report different outcomes. Angiotensin‐converting enzyme (ACE) inhibitors Combining data from three studies revealed a possible small increase in the frequency of attacks per week after treatment (captopril or enalapril) compared to placebo (mean difference [MD] 0.79, 95% confidence interval [CI] 0.43 to 1.17; low‐certainty evidence). There was no evidence of a difference between groups in severity of attacks (MD ‐0.17, 95% CI ‐4.66 to 4.31; 34 participants, 2 studies; low‐certainty evidence); duration of attacks (MD 0.54, 95% CI ‐2.42 to 1.34; 14 participants, 1 study; low‐certainty evidence); or AEs (risk ratio [RR] 1.35, 95% CI 0.67 to 2.73; 46 participants, 3 studies; low‐certainty evidence). QoL and RCS were not reported. Alpha blockers Two studies used alpha blockers (buflomedil or moxisylyte). We were unable to combine data due to the way results were presented. Buflomedil probably reduced the frequency of attacks compared to placebo (MD ‐8.82, 95% CI ‐11.04 to ‐6.60; 31 participants, 1 study; moderate‐certainty evidence) and may improve severity scores (MD ‐0.41, 95% CI ‐0.62 to ‐0.30; moderate‐certainty evidence). With moxisylyte, investigators reported fewer attacks (P < 0.02), less severe symptoms (P < 0.01), and shorter duration of attacks, but the clinical relevance of these results is unclear. No evidence of a difference in AEs between buflomedil and placebo groups was noted (RR 1.41, 95% CI 0.27 to 7.28; 31 participants, 1 study; moderate‐certainty evidence). More AEs were observed in participants in the moxisylyte group than in the placebo group. Prostaglandin/prostacyclin analogues One study compared beraprost versus placebo. There was no evidence of benefit for frequency (MD 2.00, 95% CI ‐0.35 to 4.35; 118 participants, low‐certainty evidence) or severity (MD ‐0.06, 95% CI ‐0.34 to 0.22; 118 participants, low‐certainty evidence) of attacks. Overall, more AEs were noted in the beraprost group (RR 1.59, 95% CI 1.05 to 2.42; 125 participants; low‐certainty evidence). This study did not report on duration of attacks, QoL, or RCS. Thromboxane synthase inhibitors One study compared a thromboxane synthase inhibitor (dazoxiben) versus placebo. There was no evidence of benefit for frequency of attacks (MD 0.8, 95% CI ‐1.81 to 3.41; 6 participants; very low‐certainty evidence). Adverse events were not reported in subgroup analyses of participants with primary Raynaud's phenomenon, and the study did not report on duration of attacks, severity of symptoms, QoL, or RCS. Selective serotonin reuptake inhibitors One study compared ketanserin with placebo. There may be a slight reduction in the number of attacks per week with ketanserin compared to placebo (MD ‐14.0, 95% CI ‐27.72 to ‐0.28; 41 participants; very low‐certainty evidence) and reduced severity score (MD ‐133.00, 95% CI ‐162.40 to ‐103.60; 41 participants; very low‐certainty evidence). There was no evidence that ketanserin reduced the duration of attacks (MD ‐4.00, 95% CI ‐14.82 to 6.82; 41 participants; very low‐certainty evidence), or that AEs were increased in either group (RR 1.54, 95% CI 0.89 to 2.65; 41 participants; very low‐certainty evidence). This study did not report on QoL or RCS. Nitrate/nitrate derivatives Four studies compared topical treatments of nitroglycerin or glyceryl trinitrate versus placebo, each reporting on limited outcomes. Meta‐analysis demonstrated no evidence of effect on frequency of attacks per week (MD ‐1.57, 95% CI ‐4.31 to 1.17; 86 participants, 2 studies; very low‐certainty evidence). We were unable to pool any data for the remaining outcomes. Phosphodiesterase inhibitors Three studies compared phosphodiesterase inhibitors (vardenafil, cilostazol or PF‐00489791) to an equivalent placebo. Results showed no evidence of a difference in frequency of attacks (standardized MD [SMD] ‐0.05, 95% CI ‐6.71 to 6.61; 111 participants, 2 studies; low‐certainty evidence), severity of attacks (MD ‐0.03, 95% CI ‐1.04 to 0.97; 111 participants, 2 studies; very low‐certainty evidence), duration of attacks (MD ‐1.60, 95% CI ‐7.51 to 4.31; 73 participants, 1 study; low‐certainty evidence), or RCS (SMD ‐0.8, 95% CI ‐1.74 to 0.13; 79 participants, 2 studies; low‐certainty evidence). Study authors reported that 35% of participants on cilostazol complained of headaches, which were not reported in the placebo group. PF‐00489791 caused 34 of 54 participants to experience AEs versus 43 of 102 participants receiving placebo (RR 1.49). Headache was most common, affecting 14 participants (PF‐00489791) versus nine participants (placebo). Authors' conclusions The included studies investigated several different vasodilators (topical and oral) for treatment of primary Raynaud's phenomenon. Small sample sizes, limited data, and variability in outcome reporting yielded evidence of very low to moderate certainty. Evidence is insufficient to support the use of vasodilators and suggests that vasodilator use may even worsen disease. Plain language summary Vasodilator drugs to reduce the symptoms of primary Raynaud's phenomenon Background Raynaud's phenomenon (RP) is a condition affecting the small blood vessels in the extremities, usually in the fingers but also in the toes and other body parts. It is caused by temporary narrowing of the blood vessels, which leads to color changes with associated numbness, tingling, and pain. Various triggers for this condition are known, such as stress, cold, and use of vibrational hand tools. Conservative measures to control this condition include stopping smoking and maintaining both peripheral and ambient warmth. Medications that dilate the blood vessels such as calcium channel blockers (CCBs) may be used but can have side effects. This review aims to investigate the effectiveness and safety of drugs that dilate the blood vessels other than CCBs. Study characteristics and key results We found seven new studies for this update, bringing the total to 15 (search was good to November 16, 2020). This update now includes other routes of administration such as through the veins (intravenous) and the skin (topical), in contrast to previous reviews, which focused on oral forms of treatment. The studies were published between 1989 and 2013 and involved a total of 635 participants randomly assigned to receive treatment or placebo control. Many studies did not describe various aspects of study methods such as randomization, allocation concealment, and blinding. Treatment duration varied between two weeks and six months.
Angiotensin‐converting enzyme (ACE) inhibitors as a drug class, specifically enalapril and captopril in this review, in general increased the frequency of Raynaud's attacks per week but did not affect the severity of the attacks. Enalapril worsened subjective assessment of improvement, and captopril did not improve subjective outcomes or digital blood flow. Buflomedil showed a small reduction in the frequency and severity of attacks with increased side effects. Beraprost and dazoxiben did not demonstrate any change in frequency or severity of attacks nor in disability score and were associated with increased side effects. Ketanserin did not demonstrate improvement in frequency or duration of attacks nor in digital blood flow but did demonstrate improvement in severity scoring of RP. In a small study, moxisylyte was shown to reduce the frequency and severity of attacks to a small degree but with increased side effects. Topical glyceryl trinitrate did not show any effect on reducing the frequency of attacks per week. One study reported subjective improvement in Raynaud Condition Score (RCS). One small study reported improvements in frequency and severity of attacks as subjective changes. Headaches were the most significant and common side effect of treatment. Phosphodiesterase inhibitors did not cause a reduction in frequency, severity, or duration of attacks and did not improve RCS. One study reported in favor of vardenafil alone to reduce RCS but found that the effect is likely small. One study reported that cilostazol increased the frequency and severity of attacks; more research is needed to confirm this finding. Risk of headache as a side effect of treatment was increased with cilostazol use. PF‐00489791 at a dose of 20 mg was found to slightly improve all subjective outcome measures and RCS. Reliability of the evidence We have very low to moderate confidence in these results, so we cannot make any firm conclusions about the benefit of these drugs for improving symptoms of primary RP. We cannot be confident because of the small numbers of participants involved in studies, issues with how studies were designed, and differences in how they measured whether or not treatments were effective. Therefore, the clinical importance of these results is difficult to assess, especially when placebo response is high. It is also pertinent that the results for each drug class and for individual drugs within each drug class must be interpreted in the context that they may have varying pharmacologic effects in addition to vasodilation. This must be taken into consideration when any conclusions are made about the overall effects of each drug class and/or individual drug.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Su, KYC; Sharma, M; Kim, HJ; Kaganov, E; Hughes, I; Abdeen, MH; Ng, JH", "articleTypes": [], "doi": "10.1002/14651858.CD006687.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "480851ca-410b-40e3-9d34-dc77ed3f4cd0", "pmid": "", "title": "Lycopene for the prevention of prostate cancer", "imported": false, "abstract": "Abstract - Background Prostate cancer is a common cause of death in developed countries, yet the benefits of screening for prostate cancer still remain controversial. A prostate‐specific antigen (PSA) test result greater than 4 ng/mL (nanograms/millilitre) has commonly been used as the cut‐off level for seeking further tests to diagnose the presence (or absence) of prostate cancer. An increase in PSA levels may not necessarily be associated with an increased risk of prostate cancer, as PSA levels may also be increased in men with benign prostatic hyperplasia and prostatitis. Despite the uncertainty of the net benefit of early detection and treatment, safe and effective methods to prevent prostate cancer are of value. Consumers, seeking greater involvement in their healthcare, are increasingly turning to lifestyle modification and complementary and alternative medicines (CAMs) to maintain their health and prevent disease. Lycopene is a member of the carotenoid family, which is found abundantly in tomatoes, tomato‐based products, strawberries, and watermelon. It has been hypothesised that lycopene is a strong antioxidant, which may lower the risk of cancer (including prostate cancer) in people who have diets rich in lycopene. Objectives To determine whether lycopene reduces the incidence of prostate cancer and prostate cancer‐specific mortality. Secondary objectives include changes in PSA levels, prostate symptoms and the nature of adverse events associated with lycopene use. Search methods Electronic searches were conducted across MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases. No language or other limitations were imposed. Selection criteria Randomised controlled trials (RCTs) that investigated the use of lycopene for the prevention of prostate cancer were eligible for inclusion in this review. Data collection and analysis A search of electronic databases, performed in August 2011, identified 64 citations. All articles were selected for full‐text review. From these citations, three studies were identified as meeting the inclusion criteria. Handsearching did not provide any additional studies. Main results Three RCTs, with a total of 154 participants were included in this review. None of the studies reported data on prostate cancer mortality. All of the included studies differed with respect to design, participants included and allocation of lycopene. This clinical heterogeneity limits the value on the pooled estimated of the meta‐analyses. The methodological quality of two of the three included studies was assessed as posing a 'high' risk of bias. Meta‐analysis indicated no statistical difference in PSA levels between men randomised to receive lycopene and the comparison group (MD (mean difference) ‐0.34, 95% CI (confidence interval) ‐2.01 to 1.32). Only one study reported incidence of prostate cancer (10% in the lycopene group versus 30% in control group). The level of lycopene was also not statistically different in men randomised to receive lycopene and the comparison group (MD 0.39 µg/mL (micrograms/millilitre), 95% CI ‐0.19 to 0.98). No other meta‐analyses were possible since other outcomes assessed only had one study contributing data. Authors' conclusions Given that only three RCTs were included in this systematic review, and the high risk of bias in two of the three studies, there is insufficient evidence to either support, or refute, the use of lycopene for the prevention of prostate cancer. Similarly, there is no robust evidence from RCTs to identify the impact of lycopene consumption upon the incidence of prostate cancer, prostate symptoms, PSA levels or adverse events. Plain language summary Lycopene for the prevention of prostate cancer Prostate cancer is a common form of cancer affecting men worldwide. Pharmaceutical interventions, such as 5‐alpha reductase inhibitors, have been identified as potentially preventing prostate cancer incidence in men. Many men modify lifestyle and consume complementary and alternative medicines to maintain better health and prevent disease. Lycopene is a supplement that has been suggested may assist in the prevention of prostate cancer due to its antioxidant effects. The objective of this systematic review was to identify the effectiveness of lycopene in the prevention of prostate cancer. This review identified 3 relevant studies, comprising 154 participants in total. Two of the studies were assessed to be of 'high' risk of bias. Meta‐analysis of two studies indicated no statistical difference in prostate specific antigen (PSA) levels between men randomised to receive lycopene and the comparison group (MD ‐0.34, 95% CI ‐2.01 to 1.32). None of the studies assessed prostate cancer mortality. No other meta‐analyses were possible since other outcomes assessed only had one study contributing data.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Ilic, D; Forbes, KM; Hassed, C", "articleTypes": [], "doi": "10.1002/14651858.CD008007.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "4826e6c0-918a-4b3e-9576-508e1357349b", "pmid": "", "title": "Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non‐hospitalised term infants", "imported": false, "abstract": "Abstract - Background Many women express concern about their ability to produce enough milk, and insufficient milk is frequently cited as the reason for supplementation and early termination of breastfeeding. When addressing this concern, it is important first to consider the influence of maternal and neonatal health, infant suck, proper latch, and feeding frequency on milk production, and that steps be taken to correct or compensate for any contributing issues. Oral galactagogues are substances that stimulate milk production. They may be pharmacological or non‐pharmacological (natural). Natural galactagogues are usually botanical or other food agents. The choice between pharmacological or natural galactagogues is often influenced by familiarity and local customs. Evidence for the possible benefits and harms of galactagogues is important for making an informed decision on their use. Objectives To assess the effect of oral galactagogues for increasing milk production in non‐hospitalised breastfeeding mother‐term infant pairs. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov , the World Health Organization (WHO) International Clinical Trials Registry Platform ( ICTRP ), Health Research and Development Network ‐ Phillippines ( HERDIN ), Natural Products Alert ( Napralert ), the personal reference collection of author LM, and reference lists of retrieved studies (4 November 2019). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs (including published abstracts) comparing oral galactagogues with placebo, no treatment, or another oral galactagogue in mothers breastfeeding healthy term infants. We also included cluster‐randomised trials but excluded cross‐over trials. Data collection and analysis We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two to four review authors independently selected the studies, assessed the risk of bias, extracted data for analysis and checked accuracy. Where necessary, we contacted the study authors for clarification. Main results Forty‐one RCTs involving 3005 mothers and 3006 infants from at least 17 countries met the inclusion criteria. Studies were conducted either in hospitals immediately postpartum or in the community. There was considerable variation in mothers, particularly in parity and whether or not they had lactation insufficiency. Infants' ages at commencement of the studies ranged from newborn to 6 months. The overall certainty of evidence was low to very low because of high risk of biases (mainly due to lack of blinding), substantial clinical and statistical heterogeneity, and imprecision of measurements. Pharmacological galactagogues Nine studies compared a pharmacological galactagogue (domperidone, metoclopramide, sulpiride, thyrotropin‐releasing hormone) with placebo or no treatment. The primary outcome of proportion of mothers who continued breastfeeding at 3, 4 and 6 months was not reported. Only one study (metoclopramide) reported on the outcome of infant weight, finding little or no difference (mean difference (MD) 23.0 grams, 95% confidence interval (CI) ‐47.71 to 93.71; 1 study, 20 participants; low‐certainty evidence). Three studies (metoclopramide, domperidone, sulpiride) reported on milk volume, finding pharmacological galactagogues may increase milk volume (MD 63.82 mL, 95% CI 25.91 to 101.72; I² = 34%; 3 studies, 151 participants; low‐certainty evidence). Subgroup analysis indicates there may be increased milk volume with each drug, but with varying CIs. There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints, such as tiredness, nausea, headache and dry mouth (very low‐certainty evidence). No adverse effects were reported for infants. Natural galactagogues Twenty‐seven studies compared natural oral galactagogues (banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves or other natural mixtures) with placebo or no treatment. One study (Mother's Milk Tea) reported breastfeeding rates at six months with a concluding statement of \"no significant difference\" (no data and no measure of significance provided, 60 participants, very low‐certainty evidence). Three studies (fennel, fenugreek, moringa, mixed botanical tea) reported infant weight but could not be meta‐analysed due to substantial clinical and statistical heterogeneity (I 2 = 60%, 275 participants, very low‐certainty evidence). Subgroup analysis shows we are very uncertain whether fennel or fenugreek improves infant weight, whereas moringa and mixed botanical tea may increase infant weight compared to placebo. Thirteen studies (Bu Xue Sheng Ru, Chanbao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants) reported on milk volume, but meta‐analysis was not possible due to substantial heterogeneity (I 2 = 99%). The subgroup analysis for each intervention suggested either benefit or little or no difference (very low‐certainty evidence). There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints such as mothers with urine that smelled like maple syrup and urticaria in infants (very low‐certainty evidence). Galactagogue versus galactagogue Eight studies (Chanbao; Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one oral galactagogue with another. We were unable to perform meta‐analysis because there was only one small study for each match‐up, so we do not know if one galactagogue is better than another for any outcome. Authors' conclusions Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low‐certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High‐quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used. Plain language summary Milk boosters (galactagogues) for mothers breastfeeding their healthy infants born at term What is the issue? We set out to determine the ability of milk boosters taken by mouth (medicine, herb or food) to increase milk production in breastfeeding mothers of healthy infants born at term. Poor milk supply is often given as the reason for early supplementation and weaning sooner than desired. A range of factors, including mother's and baby's health, baby's sucking skills, proper latch and frequency of feeds, can affect milk production. Every attempt should first be made to identify and correct the causes for low milk production before trying a milk booster. Why is this important? Inadequate milk production can be distressing for mothers and threatening to babies' health. The choice of milk booster is often influenced by familiarity or local customs. Some mothers may prefer medications, while others prefer natural remedies. Evidence for the possible benefits and harms of milk boosters is important to assist mothers in making informed decisions. What evidence did we find? We searched for evidence from randomised controlled studies up to 4 November 2019 and identified 41 eligible studies involving 3005 mothers and 3006 infants from at least 17 countries. The studies varied widely in babies ages, type of milk boosters investigated, how long they were taken, and how outcomes were reported. Medications included sulpiride, metoclopramide, domperidone and thyrotropin‐releasing hormone. Natural interventions included banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves, and a variety of natural mixtures as teas or soups. Milk‐boosting medication Nine studies compared a milk‐boosting medication with placebo or no treatment. None reported exclusive breastfeeding rates at 3. 4 or 6 months and only one (metoclopramide, 20 participants) reported on weight gain in infants receiving only their mothers' own milk, with better results in the milk booster group. Three studies that tracked milk volume (domperidone, metoclopramide, sulpiride; 151 participants) reported more milk in the booster groups, though the certainty of the evidence was low. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as tiredness, nausea, decreased appetite, headache and dry mouth. Natural milk boosters Twenty‐seven studies compared natural milk boosters with placebo or no treatment. Only one (Mother’s Milk Tea; 60 participants) examined the impact on breastfeeding rates, reporting \"no significant difference at 6 months\" without providing any data (very low‐certainty evidence). Three studies (275 participants) reported infant weight, two of which (moringa, mixed botanical tea) reported higher gains in the milk booster group, while the other study (fennel and fenugreek) was inconclusive on whether infant weight gain improved with the milk boosters. In the 13 studies tracking changes in milk volume (Bu Xue Sheng Ru, Chan Bao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants), some showed benefits and others little or no difference, so we are very uncertain about the results for milk volume. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as mothers with urine that smells like maple syrup and rash in infants (very low‐certainty evidence). One milk booster compared with another Eight studies (Chanbao, Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one milk booster with another. There was only one small study for each particular match‐up, hence we cannot be certain if any one milk booster truly worked better than another. What does this mean? There is limited evidence that milk‐boosting medications may increase milk volume and that natural milk boosters may improve milk volume and infants' weight, but we are very uncertain about the supporting evidence. Due to limited information, we are also uncertain if there are any risks to the mother or baby in taking any particular milk booster. More high‐quality studies are needed to increase our certainty about the effects of milk boosters.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Foong, SC; Tan, ML; Foong, WC; Marasco, LA; Ho, JJ; Ong, JH", "articleTypes": [], "doi": "10.1002/14651858.CD011505.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "483516fe-b8f5-443d-a69c-b33b754fb9c7", "pmid": "", "title": "Randomised Controlled Trials to Assess Approved SARS-CoV-2 Vaccines in Immunocompromised Patients: A Master Protocol for the Set-up of a Swiss Cohorts Based Trial Platform", "imported": false, "abstract": "This study is to set up a flexible trial platform using two existing national cohorts of immunocompromised patients (i.e. Swiss HIV Cohort Study [SHCS] and Swiss Transplant Cohort Study [STCS]) to assess the comparative effectiveness and safety of approved SARS-CoV-2 vaccines in immunocompromised patients.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.265Z" }, { "id": "484431d3-8d53-4a01-865e-510946ca6276", "pmid": "", "title": "Interventions to prevent obesity in children aged 5 to 11 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well‐being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review. Objectives To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta‐analyses. One hundred forty‐six studies were based in high‐income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0, 95% confidence interval (CI) ‐0.10 to 0.10; 5 studies, 2107 participants; low‐certainty evidence) and at medium‐term follow‐up (MD ‐0.01, 95% CI ‐0.15 to 0.12; 9 studies, 6815 participants; low‐certainty evidence) or zBMI at long‐term follow‐up (MD ‐0.05, 95% CI ‐0.10 to 0.01; 7 studies, 5285 participants; low‐certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long‐term follow‐up (MD ‐0.17, 95% CI ‐0.48 to 0.13; 2 studies, 945 participants; moderate‐certainty evidence) and zBMI at short‐ or medium‐term follow‐up (MD ‐0.06, 95% CI ‐0.13 to 0.01; 8 studies, 3695 participants; MD ‐0.04, 95% CI ‐0.10 to 0.02; 9 studies, 7048 participants; moderate‐certainty evidence). Five studies (1913 participants; very low‐certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short‐term or long‐term follow‐up (BMI short‐term: MD ‐0.02, 95% CI ‐0.17 to 0.13; 14 studies, 4069 participants; zBMI short‐term: MD ‐0.02, 95% CI ‐0.07 to 0.02; 6 studies, 3580 participants; low‐certainty evidence; BMI long‐term: MD ‐0.07, 95% CI ‐0.24 to 0.10; 8 studies, 8302 participants; zBMI long‐term: MD ‐0.02, 95% CI ‐0.09 to 0.04; 6 studies, 6940 participants; low‐certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.18 to ‐0.05; 16 studies, 21,286 participants; zBMI: MD ‐0.05, 95% CI ‐0.09 to ‐0.02; 13 studies, 20,600 participants; moderate‐certainty evidence). Eleven studies (21,278 participants; low‐certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to ‐0.01; 27 studies, 16,066 participants; zBMI: MD ‐0.03, 95% CI ‐0.06 to 0.00; 26 studies, 12,784 participants; low‐certainty evidence) and likely result in a reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD ‐0.05, 95% CI ‐0.07 to ‐0.02; 24 studies, 20,998 participants; moderate‐certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long‐term follow‐up (BMI: MD 0.03, 95% CI ‐0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD ‐0.02, 95% CI ‐0.06 to 0.01; 22 studies, 23,594 participants; low‐certainty evidence). Nineteen studies (27,882 participants; low‐certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow‐up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high‐income versus non‐high‐income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability. Authors' conclusions The body of evidence in this review demonstrates that a range of school‐based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short‐ and medium‐term, but not at long‐term follow‐up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community‐based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities. Plain language summary Do dietary and activity strategies help prevent obesity in children aged 5 to 11 years? Key messages ‐ Strategies for changing activity levels, or both activity levels and diet, of children to help prevent them developing overweight or obesity might be effective in making small reductions in body mass index (BMI) in children aged 5 to 11 years. ‐ There is very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but from what we found there appears to be little or no effect. ‐ This change in BMI, when provided to many children across a whole population, is useful for parents concerned about their children becoming overweight as they move into adulthood and for governments in trying to tackle the problems of obesity through the life course. Why is preventing obesity in children important? More children are developing overweight and obesity worldwide. Being overweight as a child can cause health problems, and people may be affected psychologically and in their social life. Children that are overweight are likely to be overweight as adults and continue to experience poor physical and mental health. Indeed, childhood obesity is associated with type 2 diabetes and heart disease in adulthood and middle‐age mortality. What did we want to find out? We wanted to find out if strategies to help people modify their diet or activity (or both) are effective at preventing obesity in children aged 5 to 11 years. We also wanted to find out if these strategies were associated with any serious adverse events. What did we do? We searched many scientific databases to find studies that looked at ways of preventing obesity in children. We included studies aimed at children aged 5 to 11 years. We did not include studies only aimed at children who were already overweight or were already living with obesity. However, we included studies in which children who were overweight or living with obesity were included in the analysis. We only included studies if the methods they used were aimed at changing children's diet, or their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed people into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 172 studies that involved 189,707 children. One hundred forty‐six studies were based in high‐income countries (e.g. the USA and in Europe). In 111 studies, the strategies were tried in schools, though 15 were based in the community, eight in the home and seven in clinical settings; one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six strategies were implemented for less than nine months, with the shortest being conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry (e.g. food suppliers, pharmaceutical industry and private healthcare services). Our statistical analyses included results from 149 studies of 160,267 children. We found that children who were helped with a strategy to change their activity levels alone or in combination with a strategy to change their diet may have their BMI reduced, compared with children who were not given any strategy. This means that these children may have been able to minimise their excess weight gain by a small amount which, for public health, is important. In contrast, children who were helped with a strategy to change their diet only did not have their BMI reduced. Only a few studies reported any possible harms of the strategies, and no serious harms were identified in these. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low. However, it is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. A lot of the studies had limitations in how they were done. 3. There were not enough studies reporting particular types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons, and also certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way such that we could include them in our analyses (e.g. without any detail of the difference between the strategies examined) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for children with disabilities, or whether those implemented in community settings are effective. How up‐to‐date is this evidence? This review updates our previous review. The evidence is up‐to‐date to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F, Davies, AL, Tomlinson, E, Moore, THM, Dawson, S, Breheny, K, Savović, J, Gao, Y, Phillips, SM, Hillier-Brown, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015328.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.767Z" }, { "id": "484dbc65-beb7-4d90-b78d-719fc0cf5093", "pmid": "", "title": "Herbal medicines for fatty liver diseases", "imported": false, "abstract": "Abstract - Background Fatty liver disease is potentially a reversible condition that may lead to end‐stage liver disease. Since herbal medicines such as Crataegus pinnatifida and Salvia miltiorrhiza have increasingly been used in the management of fatty liver disease, a systematic review on herbal medicine for fatty liver disease is needed. Objectives To assess the beneficial and harmful effects of herbal medicines for people with alcoholic or non‐alcoholic fatty liver disease. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2012), MEDLINE, EMBASE, and Science Citation Index Expanded to 1 March 2012. We also searched the Chinese BioMedical Database, Traditional Chinese Medical Literature Analysis and Retrieval System, China National Knowledge Infrastructure, Chinese VIP Information, Chinese Academic Conference Papers Database and Chinese Dissertation Database, and the Allied and Complementary Medicine Database to 2 March 2012. Selection criteria We included randomised clinical trials comparing herbal medicines with placebo, no treatment, a pharmacological intervention, or a non‐pharmacological intervention such as diet or lifestyle, or Western interventions in participants with fatty liver disease. Data collection and analysis Two review authors extracted data independently. We used the 'risk of bias' tool to assess the risk of bias of the included trials. We assessed the following domains: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. We presented the effects estimates as risk ratios (RR) with 95% confidence intervals (CI) or as mean differences (MD) with 95% CI, depending on the variables of the outcome measures. Main results We included 77 randomised clinical trials, which included 6753 participants with fatty liver disease. The risks of bias (overestimation of benefits and underestimation of harms) was high in all trials. The mean sample size was 88 participants (ranging from 40 to 200 participants) per trial. Seventy‐five different herbal medicine products were tested. Herbal medicines tested in the randomised trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca) , proprietary herbal medicines commercially available, and combination formulas prescribed by practitioners. The most commonly used herbs were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia, Astragalus membranaceous, and Rheum palmatum . None of the trials reported death, hepatic‐related morbidity, quality of life, or costs. A large number of trials reported positive effects on putative surrogate outcomes such as serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases, ultrasound, and computed tomography scan. Twenty‐seven trials reported adverse effects and found no significant difference between herbal medicines versus control. However, the risk of bias of the included trials was high. The outcomes were ultrasound findings in 22 trials, liver computed tomography findings in eight trials, aspartate aminotransferase levels in 64 trials, alanine aminotransferase activity in 77 trials, and glutamyltransferase activities in 44 trials. Six herbal medicines showed statistically significant beneficial effects on ultrasound, four on liver computed tomography, 42 on aspartate aminotransferase activity, 49 on alanine aminotransferase activity, three on alkaline phosphatases activity, and 32 on glutamyltransferase activity compared with control interventions. Authors' conclusions Some herbal medicines seemed to have positive effects on aspartate aminotransferase, alanine aminotransferase, ultrasound, and computed tomography. We found no significant difference on adverse effects between herbal medicine and control groups. The findings are not conclusive due to the high risk of bias of the included trials and the limited number of trials testing individual herbal medicines. Accordingly, there is also high risk of random errors. Plain language summary Herbal medicines for fatty liver diseases Fatty liver disease is a potentially reversible illness where fat builds up within the cells of the liver. It may lead to the liver no longer being able to function properly; this is called end‐stage liver disease. This systematic review evaluated the effects and safety of herbal medicines (single herbs, branded herbal medicines, and prescribed formulas) for treating fatty liver disease. We included 77 randomised clinical trials in this review, which tested 75 herbal medicines. All trials had high risk of systematic errors (ie, bias or risk of overestimation of benefits and overestimation of harms) as well as high risks of random errors (ie, play of chance) due to the small number of people in the trials. Herbal medicines tested in the randomised clinical trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca ), commercially available branded herbal medicines, and combination formulas prescribed by practitioners. Herbs most commonly included as an ingredient in different products were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia , Astragalus membranaceous , and Rheum palmatum . We could not combine the results of the trials due to the range of different herbs used. We could not reach any conclusions about the use of herbal medicines for people with fatty liver disease as none of the trials reported results on death, liver‐related illnesses, quality of life, or costs. A number of trials showed positive effects of herbal medicines compared with control interventions on enzyme activity (enzymes are proteins that cause chemical reactions in the body; eg, serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases), ultrasound scan findings, and computed tomography scan findings. No serious adverse effects were reported for herbal medicines. However, the methodology of the trials had high risk of systematic errors (bias). Furthermore, the individual herbs were seldomly retested, and all trials had relatively low numbers of people, which increases the risk of random errors (play of chance). Therefore, the findings are inconclusive, and rigorously conducted randomised clinical trials are required to establish the benefits and harms of herbal medicines for fatty liver disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Liu, ZL, Xie, LZ, Zhu, J, Li, GQ, Grant, SJ, Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009059.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.795Z" }, { "id": "485378f8-8edb-49d6-b251-6b828e45142a", "pmid": "", "title": "Palliative drug treatments for breathlessness in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is a life‐limiting autosomal recessive genetic illness. A feeling of shortness of breath is common in cystic fibrosis, especially as the disease progresses. Reversing the underlying cause is the priority when treating breathlessness (dyspnoea), but when it is not feasible, palliation (easing) becomes the primary goal to improve an individual's quality of life. A range of drugs administered by various routes have been used, but no definite guidelines are available. A systematic review is needed to evaluate such treatments. Objectives To assess the efficacy and safety of drugs used to ease breathlessness in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 18 November 2019. We searched databases (clinicaltrials.gov, the ISRCTN registry, the Clinical Trials Registry India and WHO ICTRP) for ongoing trials. These searches were last run on 06 March 2020. Selection criteria We planned to include randomised and quasi‐randomised controlled trials in people with cystic fibrosis (diagnosed by a positive sweat chloride test or genetic testing) who have breathlessness. We considered studies comparing any drugs used for easing breathlessness to another drug administered by any route (inhaled (nebulised), intravenous, oral, subcutaneous, transmucosal (including buccal, sublingual and intra‐nasal) and transdermal). Data collection and analysis The authors assessed the search results according to the pre‐defined inclusion criteria. Main results The new searches in 2020 yielded two ongoing studies that were not relevant to the review question. Previous searches had found only one study (cross‐over in design), which did not fulfil the inclusion criteria as no data were available from the first treatment period alone. Authors' conclusions Due to the lack of available evidence, this review cannot provide any information for clinical practice. The authors call for specific research in this area after taking into account relevant ethical considerations. The research should focus on the efficacy and safety of the drugs with efficacy being measured in terms of improvement in quality of life, dyspnoea scores and hospital stay. Plain language summary Drug treatments to ease breathlessness in cystic fibrosis Review question What is the evidence that drug treatments for breathlessness (also known as dyspnoea) in people with cystic fibrosis are effective and safe? Background Cystic fibrosis is a life‐limiting genetic disease. As the disease progresses, thick sticky mucus is formed in the lungs, pancreas and other organs. This thick mucus increases risk of infection, blocks the airways and causes severe breathlessness. Easing of this breathlessness is an important goal for care of people with cystic fibrosis. Many methods have been suggested to address this problem and many drugs have been reported to ease breathlessness. The drugs can be administered through various routes ‐ they might be inhaled, swallowed, injected under the skin, into muscle or into a vein or be absorbed through the skin (either on the body or through membranes inside the mouth or nose). Despite so many drugs being available, there are no defined guidelines for drug treatments aimed at easing breathlessness in people with cystic fibrosis. Search date The evidence from the Cochrane Cystic Fibrosis Trials Register is current to 18 November 2019; the searches of ongoing trial registries are current to 06 March 2020. Study characteristics We had planned to include studies comparing different treatments to ease breathlessness in people with cystic fibrosis where the participants were put into the different treatment groups at random. Our search found only one study in which seven people first received either a drug called hydrocodone or a placebo (dummy treatment) and then swapped to the other treatment; but this study did not report results separately for each treatment arm, so we are not able to include it in the review. Key results No studies fulfilled the inclusion criteria, therefore it is not possible to comment on the outcomes we wished to report on in this review. Until evidence becomes available, the review authors feel that it is advisable for doctors to follow any local or national guidelines. The authors recommend research in this area should take ethical considerations into account and should focus on the safety of the drugs, improvement in quality of life, breathlessness scores and length of hospital stay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Jaiswal, N; Singh, M; Agarwal, A; Chauhan, A; Jaiswal, N", "articleTypes": [], "doi": "10.1002/14651858.CD011855.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "485ea140-94a0-45a5-8248-249decfacf1e", "pmid": "", "title": "Homeopathic Oscillococcinum® for preventing and treating influenza and influenza‐like illness", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mathie, RT, Frye, J, Fisher, P", "articleTypes": [], "doi": "10.1002/14651858.CD001957.pub6 AB - Abstract - Background Influenza is a highly infectious viral disease that is particularly common in the winter months. Oscillococcinum ® is a patented homeopathic medicine that is made from a 1% solution of wild duck heart and liver extract, which is then serially diluted 200 times with water and alcohol. Objectives To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Search methods We searched CENTRAL (2014, Issue 8), MEDLINE (1966 to August week 4, 2014), MEDLINE In‐Process & Other Non‐Indexed Citations (4 September 2014), AMED (2006 to September 2014), Web of Science (1985 to September 2014), LILACS (1985 to September 2014) and EMBASE (1980 to September 2014). We contacted the manufacturers of Oscillococcinum ® for information on further trials. Selection criteria Randomised, placebo‐controlled trials of Oscillococcinum ® in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Data collection and analysis Three review authors independently extracted data and assessed risk of bias in the eligible trials. Main results No new trials were included in this 2014 update. We included six studies: two prophylaxis trials (327 young to middle‐aged adults in Russia) and four treatment trials (1196 teenagers and adults in France and Germany). The overall standard of trial reporting was poor and hence many important methodological aspects of the trials had unclear risk of bias. There was no statistically significant difference between the effects of Oscillococcinum ® and placebo in the prevention of influenza‐like illness: risk ratio (RR) 0.48, 95% confidence interval (CI) 0.17 to 1.34, P value = 0.16. Two treatment trials (judged as 'low quality') reported sufficient information to allow full data extraction: 48 hours after commencing treatment, there was an absolute risk reduction of 7.7% in the frequency of symptom relief with Oscillococcinum ® compared with that of placebo (risk difference (RD) 0.077, 95% CI 0.03 to 0.12); the RR was 1.86 (95% CI 1.27 to 2.73; P value = 0.001). A significant but lesser effect was observed at three days (RR 1.27, 95% CI 1.03 to 1.56; P value = 0.03), and no significant difference between the groups was noted at four days (RR 1.11, 95% CI 0.98 to 1.27; P value = 0.10) or at five days (RR 1.06, 95% CI 0.96 to 1.16; P value = 0.25). One of the six studies reported one patient who suffered an adverse effect (headache) from taking Oscillococcinum ® . Authors' conclusions There is insufficient good evidence to enable robust conclusions to be made about Oscillococcinum ® in the prevention or treatment of influenza and influenza‐like illness. Our findings do not rule out the possibility that Oscillococcinum ® could have a clinically useful treatment effect but, given the low quality of the eligible studies, the evidence is not compelling. There was no evidence of clinically important harms due to Oscillococcinum ® . Plain language summary Homeopathic Oscillococcinum ® for preventing and treating influenza and influenza‐like illness Review question 
 To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Background 
 Influenza ('the flu') is a highly infectious viral respiratory disease. Other than treatments for complications (such as pneumonia), the conventional medical strategies for the prevention or treatment of flu are not entirely effective or satisfactory. Oscillococcinum ® is a highly diluted homeopathic preparation manufactured from wild duck heart and liver, which may be reservoirs of flu viruses. Some people take Oscillococcinum ® regularly over the winter months either to prevent flu or as a treatment for flu symptoms. Study characteristics 
 We included six studies, which comprised two prevention trials (a total of 327 young to middle‐aged adults in Russia) and four treatment trials (a total of 1196 teenagers and adults in France and Germany). Key results 
 The findings from the two prevention trials did not show that Oscillococcinum ® can prevent the onset of flu. Although the results from the four other clinical trials suggested that Oscillococcinum ® relieved flu symptoms at 48 hours, this might be due to bias in the trial methods. One patient reported headache after taking Oscillococcinum ® . The evidence is current to September 2014. Quality of the evidence 
 The overall standard of research reporting was poor, and thus many aspects of the trials' methods and results were at unclear risk of bias. We therefore judged the evidence overall as low quality, preventing clear conclusions from being made about Oscillococcinum ® in the prevention or treatment of flu and flu‐like illness.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.776Z" }, { "id": "487388b8-0e54-4280-945c-d5da96a54392", "pmid": "", "title": "Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long‐term central venous catheters in infants and children", "imported": false, "abstract": "Abstract - Background Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015. Objectives To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long‐term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC). Data collection and analysis Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random‐effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review. Main results We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin. Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC‐associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC‐associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low‐certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate‐certainty evidence), and not reported in the remaining studies. Authors' conclusions The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC‐associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains. Plain language summary Replacing heparin flushing with saline flushing to prevent complications in long‐term central venous catheters in children Background A central venous catheter (CVC) is a long, thin, flexible tube which is inserted into a large central vein. This enables access to the blood stream for people with serious medical conditions to receive medications and fluids, as well as the collection of blood specimens. Long‐term CVCs are used to access the blood system in children with complex medical conditions like cancer. To stop the catheter from becoming blocked it is usual to use heparin, a drug that prevents clots forming, to flush the catheter. However, some studies have shown that heparin is not necessary, and that normal saline (a sterile salt water solution) can be safely used instead. Heparin may be associated with complications, such as bleeding and infection, along with higher costs for healthcare providers. While the complications such as infections and occlusions are uncommon, practices vary around the world and there are many inconsistencies regarding the best flush solution to use to prevent complications in long‐term catheters. Study characteristics and key results This review included randomised controlled trials (clinical studies where people were randomly assigned into one of two or more treatment groups) that compared the use of saline and heparin to prevent blockage, and other complications related to long‐term catheters. The evidence is current to 9 April 2019. Two review authors independently reviewed the studies. We included four studies with a total of 255 participants in the review. The four trials were all undertaken in large teaching (tertiary) hospitals, and directly compared the use of saline and heparin. The studies were, however, very different in the way they compared saline and heparin, with different concentrations of heparin and different frequencies of flushes reported. We were able to combine the results of two studies: the analysis showed imprecise results for the blocking of catheters and blood stream infections for normal saline versus heparin. One study reported the duration of catheter placement to be similar between the two study arms. Certainty of the evidence The overall certainty of the evidence ranged from moderate to very low. There was high risk of bias for blinding, there were differences between the studies methods and interventions, inconsistent results between the studies, and not all studies reported all outcomes of interest. We found there was not enough evidence to determine which solution, saline or heparin, is more effective for reducing complications. Further research is required and is likely to have an important impact in this area. This review is an update of a review first published in 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bradford, NK, Edwards, RM, Chan, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD010996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.793Z" }, { "id": "487764c7-b7a4-4d2b-95fb-e93a6034fc29", "pmid": "", "title": "Exercise-induced Erythropoiesis: the Mechanistic of Angiotensin II", "imported": false, "abstract": "The major aims are to determine the effect of acute (single dose) blockade of ANGII receptor 1 (AT1) on the EPO response to a single session of endurance exercise, as well as determine the effect of chronic (8-week) blockade of AT1 on ET-induced adaptations in total circulating red blood volume and hemoglobin.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "487b002a-e066-4803-b6cd-dea7670ef212", "pmid": "", "title": "Antioxidants for male subfertility", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "de Ligny, W, Smits, RM, Mackenzie-Proctor, R, Jordan, V, Fleischer, K, de Bruin, JP, Showell, MG", "articleTypes": [], "doi": "10.1002/14651858.CD007411.pub5 AB - Abstract - Background The inability to have children affects 10% to 15% of couples worldwide. A male factor is estimated to account for up to half of the infertility cases with between 25% to 87% of male subfertility considered to be due to the effect of oxidative stress. Oral supplementation with antioxidants is thought to improve sperm quality by reducing oxidative damage. Antioxidants are widely available and inexpensive when compared to other fertility treatments, however most antioxidants are uncontrolled by regulation and the evidence for their effectiveness is uncertain. We compared the benefits and risks of different antioxidants used for male subfertility. Objectives To evaluate the effectiveness and safety of supplementary oral antioxidants in subfertile men. Search methods The Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, and two trial registers were searched on 15 February 2021, together with reference checking and contact with experts in the field to identify additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any type, dose or combination of oral antioxidant supplement with placebo, no treatment, or treatment with another antioxidant, among subfertile men of a couple attending a reproductive clinic. We excluded studies comparing antioxidants with fertility drugs alone and studies that included men with idiopathic infertility and normal semen parameters or fertile men attending a fertility clinic because of female partner infertility. Data collection and analysis We used standard methodological procedures recommended by Cochrane. The primary review outcome was live birth. Clinical pregnancy, adverse events and sperm parameters were secondary outcomes. Main results We included 90 studies with a total population of 10,303 subfertile men, aged between 18 and 65 years, part of a couple who had been referred to a fertility clinic and some of whom were undergoing medically assisted reproduction (MAR). Investigators compared and combined 20 different oral antioxidants. The evidence was of 'low' to 'very low' certainty: the main limitation was that out of the 67 included studies in the meta‐analysis only 20 studies reported clinical pregnancy, and of those 12 reported on live birth. The evidence is current up to February 2021. Live birth: antioxidants may lead to increased live birth rates (odds ratio (OR) 1.43, 95% confidence interval (CI) 1.07 to 1.91, P = 0.02, 12 RCTs, 1283 men, I 2 = 44%, very low‐certainty evidence). Results in the studies contributing to the analysis of live birth rate suggest that if the baseline chance of live birth following placebo or no treatment is assumed to be 16%, the chance following the use of antioxidants is estimated to be between 17% and 27%. However, this result was based on only 246 live births from 1283 couples in 12 small or medium‐sized studies. When studies at high risk of bias were removed from the analysis, there was no evidence of increased live birth (Peto OR 1.22, 95% CI 0.85 to 1.75, 827 men, 8 RCTs, P = 0.27, I 2 = 32%). Clinical pregnancy rate: antioxidants may lead to increased clinical pregnancy rates (OR 1.89, 95% CI 1.45 to 2.47, P < 0.00001, 20 RCTs, 1706 men, I 2 = 3%, low‐certainty evidence) compared with placebo or no treatment. This suggests that, in the studies contributing to the analysis of clinical pregnancy, if the baseline chance of clinical pregnancy following placebo or no treatment is assumed to be 15%, the chance following the use of antioxidants is estimated to be between 20% and 30%. This result was based on 327 clinical pregnancies from 1706 couples in 20 small studies. Adverse events
Miscarriage: only six studies reported on this outcome and the event rate was very low. No evidence of a difference in miscarriage rate was found between the antioxidant and placebo or no treatment group (OR 1.46, 95% CI 0.75 to 2.83, P = 0.27, 6 RCTs, 664 men, I 2 = 35%, very low‐certainty evidence). The findings suggest that in a population of subfertile couples, with male factor infertility, with an expected miscarriage rate of 5%, the risk of miscarriage following the use of an antioxidant would be between 4% and 13%. Gastrointestinal: antioxidants may lead to an increase in mild gastrointestinal discomfort when compared with placebo or no treatment (OR 2.70, 95% CI 1.46 to 4.99, P = 0.002, 16 RCTs, 1355 men, I 2 = 40%, low‐certainty evidence). This suggests that if the chance of gastrointestinal discomfort following placebo or no treatment is assumed to be 2%, the chance following the use of antioxidants is estimated to be between 2% and 7%. However, this result was based on a low event rate of 46 out of 1355 men in 16 small or medium‐sized studies, and the certainty of the evidence was rated low and heterogeneity was high. We were unable to draw conclusions from the antioxidant versus antioxidant comparison as insufficient studies compared the same interventions. Authors' conclusions In this review, there is very low‐certainty evidence from 12 small or medium‐sized randomised controlled trials suggesting that antioxidant supplementation in subfertile males may improve live birth rates for couples attending fertility clinics. Low‐certainty evidence suggests that clinical pregnancy rates may increase. There is no evidence of increased risk of miscarriage, however antioxidants may give more mild gastrointestinal discomfort, based on very low‐certainty evidence. Subfertile couples should be advised that overall, the current evidence is inconclusive based on serious risk of bias due to poor reporting of methods of randomisation, failure to report on the clinical outcomes live birth rate and clinical pregnancy, often unclear or even high attrition, and also imprecision due to often low event rates and small overall sample sizes. Further large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants. Plain language summary Antioxidants for male subfertility Review question 
Do supplementary oral antioxidants compared with placebo, no treatment or another antioxidant improve fertility outcomes for subfertile men? Background 
A couple may be considered to have fertility problems if they have been trying to conceive for over a year with no success. Many subfertile men undergoing fertility treatment also take dietary supplements in the hope of improving their fertility. Fertility treatment can be a very stressful time for men and their partners. It is important that these couples have access to high‐certainty evidence that will allow them to make informed decisions on whether to take a supplemental antioxidant. This is especially important as most antioxidant supplements are uncontrolled by regulation. This review aimed to assess whether supplements with oral antioxidants, taken by subfertile men, would increase the chances of a couple to achieve a (clinical) pregnancy confirmed by ultrasound and ultimately the birth of a baby (live birth). This review did not examine the use of antioxidants in men with normal sperm. Study characteristics Cochrane authors conducted a review including 90 randomised controlled trials comparing 18 different antioxidants with placebo, no treatment or another antioxidant in a total population of 10,303 subfertile men. The age range of the participants was 18 to 65 years; they were part of a couple who had been referred to a fertility clinic and some were undergoing fertility treatment. The evidence is current to February 2021. Main results 
Antioxidants may be associated with an increased live birth and clinical pregnancy rate. Based on the studied population for live birth, we would expect that out of 100 subfertile men not taking antioxidants, 16 couples would have a baby. In subfertile men taking antioxidants, between 17 and 27 per 100 couples would have a baby. If studies with high risk of bias were removed from the analysis, there was no evidence of increased live birth in the population taking antioxidants. In the people who were studied for clinical pregnancy, we would expect that out of 100 subfertile men not taking antioxidants, 15 couples would have a clinical pregnancy. In subfertile men taking antioxidants, between 20 and 30 per 100 couples would have a clinical pregnancy. Adverse events were poorly reported. Only six studies reported miscarriage. In these studies, miscarriage did not occur more often in the group using antioxidants when compared with the group with placebo or no treatment. However, there is insufficient evidence to draw conclusions about antioxidant use and the risk of miscarriage. The use of antioxidants may be associated with more mild stomach discomfort, with a frequency of 2% in subfertile men not taking antioxidants, and between 2% and 7% in men taking antioxidants. The oral supplements may cause discomforts such as nausea or stomach ache. Authors' conclusion and certainty of the evidence 
Antioxidant supplementation taken by subfertile males of a couple attending a fertility clinic may increase the chance of a live birth, however the overall certainty of evidence was very low from only 12 small to medium‐sized randomised controlled trials. Low‐certainty evidence suggests that clinical pregnancy rates may increase. Overall, there is no evidence of increased risk of miscarriage. Evidence of low certainty suggests that antioxidants may be associated with more gastrointestinal discomfort. Subfertile couples should be advised that overall the current evidence is inconclusive due to the poor reporting of methods, failure to report on live birth and clinical pregnancy rate, imprecision due to low event rates, high number of dropouts and small study group sizes. Large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.136Z" }, { "id": "487dcf36-3016-4055-b2a2-4aabbf1969bc", "pmid": "", "title": "Diet or exercise, or both, for weight reduction in women after childbirth", "imported": false, "abstract": "Abstract - Background Weight retention after pregnancy may contribute to obesity. It is known that diet and exercise are recommended components of any weight loss programme in the general population. However, strategies to achieve healthy body weight among postpartum women have not been adequately evaluated. Objectives The objectives of this review were to evaluate the effect of diet, exercise or both for weight reduction in women after childbirth, and to assess the impact of these interventions on maternal body composition, cardiorespiratory fitness, breastfeeding performance and other child and maternal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012) and LILACS (31 January 2012). We scanned secondary references and contacted experts in the field. We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 30 April 2013 and added the results to the awaiting classification section of the review. Selection criteria All published and unpublished randomised controlled trials (RCTs) and quasi‐randomised trials of diet or exercise or both, among women during the postpartum period. Data collection and analysis Both review authors independently assessed trial quality and extracted data. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data. Data were analysed with a fixed‐effect model. A random‐effects model was used in the presence of heterogeneity. Main results Fourteen trials were included, but only 12 trials involving 910 women contributed data to outcome analysis. Women who exercised did not lose significantly more weight than women in the usual care group (two trials; n = 53; MD ‐0.10 kg; 95% confidence interval (CI) ‐1.90 to 1.71). Women who took part in a diet (one trial; n = 45; MD ‐1.70 kg; 95% CI ‐2.08 to ‐1.32), or diet plus exercise programme (seven trials; n = 573; MD ‐1.93 kg; 95% CI ‐2.96 to ‐0.89; random‐effects, T² = 1.09, I² = 71%), lost significantly more weight than women in the usual care group. There was no difference in the magnitude of weight loss between diet alone and diet plus exercise group (one trial; n = 43; MD 0.30 kg; 95% CI ‐0.06 to 0.66). The interventions seemed not to affect breastfeeding performance adversely. Authors' conclusions Evidence from this review suggests that both diet and exercise together and diet alone help women to lose weight after childbirth. Nevertheless, it may be preferable to lose weight through a combination of diet and exercise as this improves maternal cardiorespiratory fitness and preserves fat‐free mass, while diet alone reduces fat‐free mass. This needs confirmation in large trials of high methodological quality. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby. Plain language summary Diet or exercise, or both, for weight reduction in women carrying excess weight after childbirth Women naturally gain weight during pregnancy and many gradually lose it afterwards. Some women, though, find it difficult to lose the gained weight in the year or two following the birth of the baby and there is concern that this may be a health risk for them. The retention of weight gained during pregnancy may contribute to obesity, which can increase the risk of diabetes, heart disease and high blood pressure. It is suggested that women who return to their pre‐pregnancy weight by about six months have a lower risk of being overweight 10 years later. The review looked for randomised studies to assess the impact of dieting or exercise, or both, on women's weight loss in the months after giving birth. It paid particular attention to breastfeeding women to be sure that breastfeeding was not compromised. The review of trials found 14 studies, with 12 studies involving 910 women carrying excess weight after childbirth that contributed data for analysis. The findings suggest that diet combined with exercise or diet alone compared with usual care seemed to help with weight loss after giving birth. There is potential for these interventions to play a role in preventing future maternal obesity. There was not sufficient evidence to be sure that exercise or diet did not interfere with breastfeeding though it appeared not to in the included studies. It seems preferable to lose weight through a combination of dieting and exercise, compared to dieting alone, because exercise is thought to improve circulation and heart fitness, and to preserve lean body mass. Further research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Amorim Adegboye, AR; Linne, YM", "articleTypes": [], "doi": "10.1002/14651858.CD005627.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "48834a18-8add-4f7a-8d9d-d2822cd3d1c9", "pmid": "", "title": "Opioids for restless legs syndrome", "imported": false, "abstract": "Abstract - Background Restless legs syndrome (RLS) is a distressing and common neurological disorder that may have a huge impact in the quality of life of those with frequent and intense symptoms. Patients complain of unpleasant sensations in the legs, at or before bedtime, and feel an urge to move the legs, which improves with movement, such as walking. Symptoms start with the patient at rest (e.g. sitting or lying down), and follow a circadian pattern, increasing during the evening or at night. Many pharmacological intervention are available for RLS, including drugs used to treat Parkinson's disease (L‐Dopa and dopaminergic agonists), epilepsy (anticonvulsants), anxiety (benzodiazepines), and pain (opioids). Dopaminergic drugs are those most frequently used for treatment of RLS, but some patients do not respond effectively and require other medication. Opioids, a class of medications used to treat severe pain, seem to be effective in treating RLS symptoms, and are recommended for patients with severe symptoms, because RLS and pain appear to share the same mechanism in the central nervous system. All available drugs are associated to some degree with side effects, which can impede treatment. Opioids are associated with adverse events such as constipation, tolerance, and dependence. This justifies the conduct of a systematic review to ascertain whether opioids are safe and effective for treatment of RLS. Objectives To asses the effects of opioids compared to placebo treatment for restless legs syndrome in adults. Search methods We searched the Cochrane Central Register of Controlled trials, CENTRAL 2016, issue 4 and MEDLINE, EMBASE, and LILACS up to April 2016, using a search strategy adapted by Cochraneto identify randomised clinical trials. We checked the references of each study and established personal communication with other authors to identify any additional studies. We considered publications in all languages. Selection criteria Randomised controlled clinical trials of opioid treatment in adults with idiopathic RLS. Data collection and analysis Two review authors independently screened articles, independently extracted data into a standard form, and assessed for risk of bias. If necessary, they discussed discrepancies with a third researcher to resolve any doubts. Main results We included one randomised clinical trial (N = 304 randomised; 204 completed; 276 analysed) that evaluated opioids (prolonged release oxycodone/naloxone) versus placebo. After 12 weeks, RSL symptoms had improved more in the drug group than in the placebo group (using the IRLSSS: MD ‐7.0; 95% CI ‐9.69 to ‐4.31 and the CGI: MD ‐1.11; 95% CI ‐1.49 to ‐0.73). More patients in the drug group than in the placebo group were drug responders (using the IRLSSS: RR 1.82; 95% CI 1.37 to 2.42 and the CGI: RR1.92; 95% ICI 1.49 to 2.48). The proportion of remitters was greater in the drug group than in the placebo group (using the IRLSSS: RR 2.14; 95% CI 1.45 to 3.16). Quality of life scores also improved more in the drug group than in the placebo group (MD ‐0.73; 95% CI ‐1.1 to ‐0.36). Quality of sleep was improved more in the drug group measured by sleep adequacy (MD ‐0.74; 95% CI ‐1.15 to ‐0.33), and sleep quantity (MD 0.89; 95% CI 0.52 to 1.26). There was no difference between groups for daytime somnolence, trouble staying awake during the day, or naps during the day. More adverse events were reported in the drug group (RR 1.22; 95% CI 1.07 to 1.39). The major adverse events were gastrointestinal problems, fatigue, and headache. Authors' conclusions Opioids seem to be effective for treating RLS symptoms, but there are no definitive data regarding the important problem of safety. This conclusion is based on only one study with a high dropout rate (low quality evidence). Plain language summary Opiods for restless legs syndrome Background Restless legs syndrome (RLS) is a very common neurological disorder in which patients complain of an intense need to move their legs, and unpleasant sensations felt deep in their legs, all occurring while at rest, mostly at bedtime. The number of patients complaining of RLS varies according to race, gender, age, country, and health status. About 5% to 10% of people are affected; , and, among these, 2% to 5% need continual pharmacological treatment (medication). When RLS does not respond to medications generally used for Parkinsons Disease and epilepsy, their doctors often prescribe opioids. Question Are opioids effective and safe for people with RLS? Methods We searched the literature for studies in any language, published or not, that considered opioids for the treatment of RLS Results We included one randomised controlled clinical trial with moderate risk of bias that tested a combination of oxycodone and naloxone against placebo capsules, taken twice daily in participants whodid not respond to more usual medications. Researchers used the International RLS severity scale to find out if patients were improved after 12 weeks of treatment. Particpants receiving the combined oxycodone and naloxone reported improvement in RLS symptoms, Quality of life, and sleep quality; 42% of the drug group were symptom‐free. Discussion The study was well designed overall, but was at a high risk of bias due to the high percentage of participants who withdrew from treatment (attrition bias). Eighty‐four percent of the drug group developed adverse events, which were mostly related to the gastrointestinal system, headache, fatigue, and sleepiness (somnolence); 9.8% left the study because of the adverse events. Conclusion The use of opioids for the treatment of RLS in patients resistant to conventional treatment is supported by low‐quality evidence. Prescription of these medications should be based on clinical experience, and caution used due to the potential for abuse, dependency, and adverse events. No patient on opioids complained that their symptoms worsened.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "de Oliveira, CO, Carvalho, LBC, Carlos, K, Conti, C, de Oliveira, MM, Prado, LBF, Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006941.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.094Z" }, { "id": "48948c17-0c4f-42d8-afe3-1327db61d458", "pmid": "", "title": "Oral anti‐diabetic pharmacological therapies for the treatment of women with gestational diabetes", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is a major public health issue with rates increasing globally. Gestational diabetes, glucose intolerance first recognised during pregnancy, usually resolves after birth and is associated with short‐ and long‐term complications for the mother and her infant. Treatment options can include oral anti‐diabetic pharmacological therapies. Objectives To evaluate the effects of oral anti‐diabetic pharmacological therapies for treating women with GDM. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (14 May 2016), ClinicalTrials.gov , WHO ICTRP (14 May 2016) and reference lists of retrieved studies. Selection criteria We included published and unpublished randomised controlled trials assessing the effects of oral anti‐diabetic pharmacological therapies for treating pregnant women with GDM. We included studies comparing oral anti‐diabetic pharmacological therapies with 1) placebo/standard care, 2) another oral anti‐diabetic pharmacological therapy, 3) combined oral anti‐diabetic pharmacological therapies. Trials using insulin as the comparator were excluded as they are the subject of a separate Cochrane systematic review. Women with pre‐existing type 1 or type 2 diabetes were excluded. Data collection and analysis Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and data were checked for accuracy. Main results We included 11 studies (19 publications) (1487 women and their babies). Eight studies had data that could be included in meta‐analyses. Studies were conducted in Brazil, India, Israel, UK, South Africa and USA. The studies varied in diagnostic criteria and treatment targets for glycaemic control for GDM. The overall risk of bias was 'unclear' due to inadequate reporting of methodology. Using GRADE the quality of the evidence ranged from moderate to very low quality . Evidence was downgraded for risk of bias (reporting bias, lack of blinding), inconsistency, indirectness, imprecision and for oral anti‐diabetic therapy versus placebo for generalisability. Oral anti‐diabetic pharmacological therapies versus placebo/standard care There was no evidence of a difference between glibenclamide and placebo groups for hypertensive disorders of pregnancy (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.81 to 1.90; one study, 375 women, very low‐quality evidence), birth by caesarean section (RR 1.03, 95% CI 0.79 to 1.34; one study, 375 women, very low‐quality evidence), perineal trauma (RR 0.98, 95% CI 0.06 to 15.62; one study, 375 women, very low‐quality evidence) or induction of labour (RR 1.18, 95% CI 0.79 to 1.76; one study, 375 women; very low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant, there was no evidence of a difference in the risk of being born large‐for‐gestational age (LGA) between infants whose mothers had been treated with glibenclamide and those in the placebo group (RR 0.89, 95% CI 0.51 to 1.58; one study, 375, low‐quality evidence). No data were reported for other infant primary or GRADE outcomes (perinatal mortality, death or serious morbidity composite, neurosensory disability in later childhood, neonatal hypoglycaemia, adiposity, diabetes). Metformin versus glibenclamide There was no evidence of a difference between metformin‐ and glibenclamide‐treated groups for the risk of hypertensive disorders of pregnancy (RR 0.70, 95% CI 0.38 to 1.30; three studies, 508 women, moderate‐quality evidence), birth by caesarean section (average RR 1.20, 95% CI 1.20; 95% CI 0.83 to 1.72, four studies, 554 women, I 2 = 61%, Tau 2 = 0.07 low‐quality evidence), induction of labour (0.81, 95% CI 0.61 to 1.07; one study, 159 women; low‐quality evidence) or perineal trauma (RR 1.67, 95% CI 0.22 to 12.52; two studies, 158 women; low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant there was no evidence of a difference between the metformin‐ and glibenclamide‐exposed groups for the risk of being born LGA (average RR 0.67, 95% CI 0.24 to 1.83; two studies, 246 infants, I 2 = 54%, Tau 2 = 0.30 low‐quality evidence). Metformin was associated with a decrease in a death or serious morbidity composite (RR 0.54, 95% CI 0.31 to 0.94; one study, 159 infants, low‐quality evidence). There was no clear difference between groups for neonatal hypoglycaemia (RR 0.86, 95% CI 0.42 to 1.77; four studies, 554 infants, low‐quality evidence) or perinatal mortality (RR 0.92, 95% CI 0.06 to 14.55, two studies, 359 infants). No data were reported for neurosensory disability in later childhood or for adiposity or diabetes. Glibenclamide versus acarbose There was no evidence of a difference between glibenclamide and acarbose from one study (43 women) for any of their maternal or infant primary outcomes (caesarean section, RR 0.95, 95% CI 0.53 to 1.70; low‐quality evidence; perinatal mortality ‐ no events; low‐quality evidence; LGA , RR 2.38, 95% CI 0.54 to 10.46; low‐quality evidence). There was no evidence of a difference between glibenclamide and acarbose for neonatal hypoglycaemia (RR 6.33, 95% CI 0.87 to 46.32; low‐quality evidence). There were no data reported for other pre‐specified GRADE or primary maternal outcomes (hypertensive disorders of pregnancy, development of type 2 diabetes, perineal trauma, return to pre‐pregnancy weight, postnatal depression, induction of labour) or neonatal outcomes (death or serious morbidity composite, adiposity or diabetes). Authors' conclusions There were insufficient data comparing oral anti‐diabetic pharmacological therapies with placebo/standard care (lifestyle advice) to inform clinical practice. There was insufficient high‐quality evidence to be able to draw any meaningful conclusions as to the benefits of one oral anti‐diabetic pharmacological therapy over another due to limited reporting of data for the primary and secondary outcomes in this review. Short‐ and long‐term clinical outcomes for this review were inadequately reported or not reported. Current choice of oral anti‐diabetic pharmacological therapy appears to be based on clinical preference, availability and national clinical practice guidelines. The benefits and potential harms of one oral anti‐diabetic pharmacological therapy compared with another, or compared with placebo/standard care remains unclear and requires further research. Future trials should attempt to report on the core outcomes suggested in this review, in particular long‐term outcomes for the woman and the infant that have been poorly reported to date, women's experiences and cost benefit. Plain language summary Oral medication for the treatment of women with gestational diabetes What is the issue? Globally the number of women being diagnosed with gestational diabetes mellitus (GDM) is increasing. GDM is an intolerance to glucose leading to high blood sugars, first recognised during pregnancy and usually resolving after birth. Standard care involves lifestyle advice on diet and exercise. Treatment for some women includes oral anti‐diabetic medications, such as metformin and glibenclamide, which are an alternative to, or can be used alongside, insulin to control the blood sugar. This review aimed to investigate benefits of taking oral medication to treat GDM in pregnant women. Another Cochrane Review compares the effects of insulin with oral anti‐diabetic pharmacological therapies ( Brown 2016 ). Why is this important? Women diagnosed with GDM are at a greater risk of experiencing complications such as high blood pressure during pregnancy and at birth. They have an increased risk of developing diabetes later in life. The babies of women who have been diagnosed with GDM can be larger than normal and this can cause injuries to the mother and the baby at birth. The birth is more likely to be induced or the baby born by caesarean section. These babies are at risk of developing diabetes as children or young adults. Finding the best medications to treat the women and prevent the complications that are linked to GDM is therefore important. What evidence did we find? We searched for studies on 14 May 2016. We included 11 randomised controlled trials involving 1487 mothers and their babies (but only eight trials contributed data to our analyses). The evidence was limited by the quality and number of studies and we advise caution when looking at the results. The criteria for diagnosis of GDM and treatment targets varied between studies, and each outcome is based on few studies with low numbers of women. Three studies compared oral medication with placebo/standard care but the following findings are from a single study (375 women). The quality of the evidence was very low or low. We found no differences between the oral medication and placebo group for the risk of high blood pressure, birth by caesarean section, induction of labour or perineal trauma. The number of babies born large‐for‐gestational age, with low blood sugars or dying at birth was not clearly different between the groups. Two studies (434 women) reported no difference in the need for insulin between the oral medication and placebo group. Six studies compared metformin with glibenclamide. The quality of the evidence was very low to moderate. We found no difference between metformin and glibenclamide for the risk of high blood pressure (three studies, 508 women, moderate‐quality evidence), birth by caesarean section (four studies, 554 women, low‐quality evidence), perineal trauma (two studies, 308 women, low‐quality evidence) or induction of labour (one study, 159 women, low‐quality evidence). We found no difference between metformin and glibenclamide for the baby having low blood sugars (four studies, 554 infants, low‐quality evidence), being born large‐for‐gestational age (two studies, 246 infants) or dying at birth (all low‐ or very low‐quality evidence). In one study, the babies of the mothers taking metformin were at reduced risk of having any serious outcome (low blood sugar, jaundice, being born large, breathing problems, injury at birth or death combined) (low‐quality evidence). One small study (43 women) comparing glibenclamide with acarbose reported no differences in outcomes for mothers or their babies. None of the included studies provided any data on many of the outcomes pre‐specified in this review, including long‐term outcomes for the mother or for the baby as a child or an adult. What does this mean? There is not enough high‐quality evidence available to guide us on if oral medication has better outcomes for women with gestational diabetes, and their babies, compared with a placebo or if one oral medication has better health outcomes than another oral medication. Because we are still unclear, further research is needed. Future studies should be encouraged to report on the outcomes suggested in this review and in particular the long‐term outcomes for the woman and the infant that have been poorly reported to date.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Brown, J, Martis, R, Hughes, B, Rowan, J, Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD011967.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.113Z" }, { "id": "4897469c-93de-4153-84b8-57561cf32341", "pmid": "", "title": "Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non‐hospitalised term infants", "imported": false, "abstract": "Abstract - Background Many women express concern about their ability to produce enough milk, and insufficient milk is frequently cited as the reason for supplementation and early termination of breastfeeding. When addressing this concern, it is important first to consider the influence of maternal and neonatal health, infant suck, proper latch, and feeding frequency on milk production, and that steps be taken to correct or compensate for any contributing issues. Oral galactagogues are substances that stimulate milk production. They may be pharmacological or non‐pharmacological (natural). Natural galactagogues are usually botanical or other food agents. The choice between pharmacological or natural galactagogues is often influenced by familiarity and local customs. Evidence for the possible benefits and harms of galactagogues is important for making an informed decision on their use. Objectives To assess the effect of oral galactagogues for increasing milk production in non‐hospitalised breastfeeding mother‐term infant pairs. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov , the World Health Organization (WHO) International Clinical Trials Registry Platform ( ICTRP ), Health Research and Development Network ‐ Phillippines ( HERDIN ), Natural Products Alert ( Napralert ), the personal reference collection of author LM, and reference lists of retrieved studies (4 November 2019). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs (including published abstracts) comparing oral galactagogues with placebo, no treatment, or another oral galactagogue in mothers breastfeeding healthy term infants. We also included cluster‐randomised trials but excluded cross‐over trials. Data collection and analysis We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two to four review authors independently selected the studies, assessed the risk of bias, extracted data for analysis and checked accuracy. Where necessary, we contacted the study authors for clarification. Main results Forty‐one RCTs involving 3005 mothers and 3006 infants from at least 17 countries met the inclusion criteria. Studies were conducted either in hospitals immediately postpartum or in the community. There was considerable variation in mothers, particularly in parity and whether or not they had lactation insufficiency. Infants' ages at commencement of the studies ranged from newborn to 6 months. The overall certainty of evidence was low to very low because of high risk of biases (mainly due to lack of blinding), substantial clinical and statistical heterogeneity, and imprecision of measurements. Pharmacological galactagogues Nine studies compared a pharmacological galactagogue (domperidone, metoclopramide, sulpiride, thyrotropin‐releasing hormone) with placebo or no treatment. The primary outcome of proportion of mothers who continued breastfeeding at 3, 4 and 6 months was not reported. Only one study (metoclopramide) reported on the outcome of infant weight, finding little or no difference (mean difference (MD) 23.0 grams, 95% confidence interval (CI) ‐47.71 to 93.71; 1 study, 20 participants; low‐certainty evidence). Three studies (metoclopramide, domperidone, sulpiride) reported on milk volume, finding pharmacological galactagogues may increase milk volume (MD 63.82 mL, 95% CI 25.91 to 101.72; I² = 34%; 3 studies, 151 participants; low‐certainty evidence). Subgroup analysis indicates there may be increased milk volume with each drug, but with varying CIs. There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints, such as tiredness, nausea, headache and dry mouth (very low‐certainty evidence). No adverse effects were reported for infants. Natural galactagogues Twenty‐seven studies compared natural oral galactagogues (banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves or other natural mixtures) with placebo or no treatment. One study (Mother's Milk Tea) reported breastfeeding rates at six months with a concluding statement of \"no significant difference\" (no data and no measure of significance provided, 60 participants, very low‐certainty evidence). Three studies (fennel, fenugreek, moringa, mixed botanical tea) reported infant weight but could not be meta‐analysed due to substantial clinical and statistical heterogeneity (I 2 = 60%, 275 participants, very low‐certainty evidence). Subgroup analysis shows we are very uncertain whether fennel or fenugreek improves infant weight, whereas moringa and mixed botanical tea may increase infant weight compared to placebo. Thirteen studies (Bu Xue Sheng Ru, Chanbao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants) reported on milk volume, but meta‐analysis was not possible due to substantial heterogeneity (I 2 = 99%). The subgroup analysis for each intervention suggested either benefit or little or no difference (very low‐certainty evidence). There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints such as mothers with urine that smelled like maple syrup and urticaria in infants (very low‐certainty evidence). Galactagogue versus galactagogue Eight studies (Chanbao; Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one oral galactagogue with another. We were unable to perform meta‐analysis because there was only one small study for each match‐up, so we do not know if one galactagogue is better than another for any outcome. Authors' conclusions Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low‐certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High‐quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used. Plain language summary Milk boosters (galactagogues) for mothers breastfeeding their healthy infants born at term What is the issue? We set out to determine the ability of milk boosters taken by mouth (medicine, herb or food) to increase milk production in breastfeeding mothers of healthy infants born at term. Poor milk supply is often given as the reason for early supplementation and weaning sooner than desired. A range of factors, including mother's and baby's health, baby's sucking skills, proper latch and frequency of feeds, can affect milk production. Every attempt should first be made to identify and correct the causes for low milk production before trying a milk booster. Why is this important? Inadequate milk production can be distressing for mothers and threatening to babies' health. The choice of milk booster is often influenced by familiarity or local customs. Some mothers may prefer medications, while others prefer natural remedies. Evidence for the possible benefits and harms of milk boosters is important to assist mothers in making informed decisions. What evidence did we find? We searched for evidence from randomised controlled studies up to 4 November 2019 and identified 41 eligible studies involving 3005 mothers and 3006 infants from at least 17 countries. The studies varied widely in babies ages, type of milk boosters investigated, how long they were taken, and how outcomes were reported. Medications included sulpiride, metoclopramide, domperidone and thyrotropin‐releasing hormone. Natural interventions included banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves, and a variety of natural mixtures as teas or soups. Milk‐boosting medication Nine studies compared a milk‐boosting medication with placebo or no treatment. None reported exclusive breastfeeding rates at 3. 4 or 6 months and only one (metoclopramide, 20 participants) reported on weight gain in infants receiving only their mothers' own milk, with better results in the milk booster group. Three studies that tracked milk volume (domperidone, metoclopramide, sulpiride; 151 participants) reported more milk in the booster groups, though the certainty of the evidence was low. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as tiredness, nausea, decreased appetite, headache and dry mouth. Natural milk boosters Twenty‐seven studies compared natural milk boosters with placebo or no treatment. Only one (Mother’s Milk Tea; 60 participants) examined the impact on breastfeeding rates, reporting \"no significant difference at 6 months\" without providing any data (very low‐certainty evidence). Three studies (275 participants) reported infant weight, two of which (moringa, mixed botanical tea) reported higher gains in the milk booster group, while the other study (fennel and fenugreek) was inconclusive on whether infant weight gain improved with the milk boosters. In the 13 studies tracking changes in milk volume (Bu Xue Sheng Ru, Chan Bao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants), some showed benefits and others little or no difference, so we are very uncertain about the results for milk volume. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as mothers with urine that smells like maple syrup and rash in infants (very low‐certainty evidence). One milk booster compared with another Eight studies (Chanbao, Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one milk booster with another. There was only one small study for each particular match‐up, hence we cannot be certain if any one milk booster truly worked better than another. What does this mean? There is limited evidence that milk‐boosting medications may increase milk volume and that natural milk boosters may improve milk volume and infants' weight, but we are very uncertain about the supporting evidence. Due to limited information, we are also uncertain if there are any risks to the mother or baby in taking any particular milk booster. More high‐quality studies are needed to increase our certainty about the effects of milk boosters.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Foong, SC, Tan, ML, Foong, WC, Marasco, LA, Ho, JJ, Ong, JH", "articleTypes": [], "doi": "10.1002/14651858.CD011505.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.778Z" }, { "id": "489feb3a-b725-4082-8926-f33ae1d533c9", "pmid": "", "title": "Interventions for hyperthyroidism pre‐pregnancy and during pregnancy", "imported": false, "abstract": "Abstract - Background Women with hyperthyroidism in pregnancy have increased risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction; and they can develop severe pre‐eclampsia or placental abruption. Objectives To identify interventions used in the management of hyperthyroidism pre‐pregnancy or during pregnancy and to ascertain the impact of these interventions on important maternal, fetal, neonatal and childhood outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 September 2013). Selection criteria We planned to include randomised controlled trials, quasi‐randomised controlled trials, and cluster‐randomised trials comparing antithyroid interventions for hyperthyroidism pre‐pregnancy or during pregnancy with another intervention or no intervention (placebo or no treatment). Data collection and analysis Two review authors assessed trial eligibility and planned to assess trial quality and extract the data independently. Main results No trials were included in the review. Authors' conclusions As we did not identify any eligible trials, we are unable to comment on implications for practice, although early identification of hyperthyroidism before pregnancy may allow a woman to choose radioactive iodine therapy or surgery before planning to have a child. Designing and conducting a trial of antithyroid interventions for pregnant women with hyperthyroidism presents formidable challenges. Not only is hyperthyroidism a relatively rare condition, both of the two main drugs used have potential for harm, one for the mother and the other for the child. More observational research is required about the potential harms of methimazole in early pregnancy and about the potential liver damage from propylthiouracil. Plain language summary No evidence found from randomised trials for drugs to treat pregnant women with hyperthyroidism Hyperthyroidism in pregnancy is a rare, serious condition which can increase the risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction. Pregnant women who are hyperthyroid may also develop severe pre‐eclampsia or placental abruption. Most of these women have Graves' disease, an autoimmune disease most common in women aged 20 to 40 years. Most pregnant women with hyperthyroidism are diagnosed with thyroid disease prior to conception and will have previously received treatment for the condition. Generally only drug therapy is considered for treating pregnant women with hyperthyroidism. Radioiodine treatment is not used in pregnancy because it destroys the fetal thyroid gland, resulting in permanent hypothyroidism in the newborn. The main antithyroid drugs used are the thionamides, propylthiouracil (PTU), methimazole and carbimazole. PTU is currently the favoured drug for use in pregnancy, as it is associated with fewer teratogenic effects (scalp lesions) than methimazole. However, since there have been reports of liver damage in people taking PTU, it may be reasonable for pregnant hyperthyroid women to be treated with PTU in the first trimester (to reduce any teratogenic effects of methimazole) and then to change to methimazole. We did not identify any randomised trials to help inform women and their doctors about which antithyroid drugs are most effective, with the lowest potential for harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Earl, R, Crowther, CA, Middleton, P", "articleTypes": [], "doi": "10.1002/14651858.CD008633.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.749Z" }, { "id": "48a2d57f-a8f3-4824-becc-d200a5dafb57", "pmid": "", "title": "Fluoride toothpastes of different concentrations for preventing dental caries", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Walsh, T, Worthington, HV, Glenny, AM, Marinho, VCC, Jeroncic, A", "articleTypes": [], "doi": "10.1002/14651858.CD007868.pub3 AB - Abstract - Background Caries (dental decay) is a disease of the hard tissues of the teeth caused by an imbalance, over time, in the interactions between cariogenic bacteria in dental plaque and fermentable carbohydrates (mainly sugars). Regular toothbrushing with fluoride toothpaste is the principal non‐professional intervention to prevent caries, but the caries‐preventive effect varies according to different concentrations of fluoride in toothpaste, with higher concentrations associated with increased caries control. Toothpastes with higher fluoride concentration increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Objectives To determine and compare the effects of toothpastes of different fluoride concentrations (parts per million (ppm)) in preventing dental caries in children, adolescents, and adults. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 August 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7) in the Cochrane Library (searched 15 August 2018); MEDLINE Ovid (1946 to 15 August 2018); and Embase Ovid (1980 to 15 August 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 August 2018). No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials that compared toothbrushing with fluoride toothpaste with toothbrushing with a non‐fluoride toothpaste or toothpaste of a different fluoride concentration, with a follow‐up period of at least 1 year. The primary outcome was caries increment measured by the change from baseline in the decayed, (missing), and filled surfaces or teeth index in all permanent or primary teeth (D(M)FS/T or d(m)fs/t). Data collection and analysis Two members of the review team, independently and in duplicate, undertook the selection of studies, data extraction, and risk of bias assessment. We graded the certainty of the evidence through discussion and consensus. The primary effect measure was the mean difference (MD) or standardised mean difference (SMD) caries increment. Where it was appropriate to pool data, we used random‐effects pairwise or network meta‐analysis. Main results We included 96 studies published between 1955 and 2014 in this updated review. Seven studies with 11,356 randomised participants (7047 evaluated) reported the effects of fluoride toothpaste up to 1500 ppm on the primary dentition; one study with 2500 randomised participants (2008 evaluated) reported the effects of 1450 ppm fluoride toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants (40,066 evaluated) reported the effects of toothpaste up to 2400 ppm on the immature permanent dentition; and three studies with 2675 randomised participants (2162 evaluated) reported the effects of up to 1100 ppm fluoride toothpaste on the mature permanent dentition. Follow‐up in most studies was 36 months. In the primary dentition of young children, 1500 ppm fluoride toothpaste reduces caries increment when compared with non‐fluoride toothpaste (MD ‐1.86 dfs, 95% confidence interval (CI) ‐2.51 to ‐1.21; 998 participants, one study, moderate‐certainty evidence); the caries‐preventive effects for the head‐to‐head comparison of 1055 ppm versus 550 ppm fluoride toothpaste are similar (MD ‐0.05, dmfs, 95% CI ‐0.38 to 0.28; 1958 participants, two studies, moderate‐certainty evidence), but toothbrushing with 1450 ppm fluoride toothpaste slightly reduces decayed, missing, filled teeth (dmft) increment when compared with 440 ppm fluoride toothpaste (MD ‐0.34, dmft, 95%CI ‐0.59 to ‐0.09; 2362 participants, one study, moderate‐certainty evidence). The certainty of the remaining evidence for this comparison was judged to be low. We included 81 studies in the network meta‐analysis of D(M)FS increment in the permanent dentition of children and adolescents. The network included 21 different comparisons of seven fluoride concentrations. The certainty of the evidence was judged to be low with the following exceptions: there was high‐ and moderate‐certainty evidence that 1000 to 1250 ppm or 1450 to 1500 ppm fluoride toothpaste reduces caries increments when compared with non‐fluoride toothpaste (SMD ‐0.28, 95% CI ‐0.32 to ‐0.25, 55 studies; and SMD ‐0.36, 95% CI ‐0.43 to ‐0.29, four studies); there was moderate‐certainty evidence that 1450 to 1500 ppm fluoride toothpaste slightly reduces caries increments when compared to 1000 to 1250 ppm (SMD ‐0.08, 95% CI ‐0.14 to ‐0.01, 10 studies); and moderate‐certainty evidence that the caries increments are similar for 1700 to 2200 ppm and 2400 to 2800 ppm fluoride toothpaste when compared to 1450 to 1500 ppm (SMD 0.04, 95% CI ‐0.07 to 0.15, indirect evidence only; SMD ‐0.05, 95% CI ‐0.14 to 0.05, two studies). In the adult permanent dentition, 1000 or 1100 ppm fluoride toothpaste reduces DMFS increment when compared with non‐fluoride toothpaste in adults of all ages (MD ‐0.53, 95% CI ‐1.02 to ‐0.04; 2162 participants, three studies, moderate‐certainty evidence). The evidence for DMFT was low certainty. Only a minority of studies assessed adverse effects of toothpaste. When reported, effects such as soft tissue damage and tooth staining were minimal. Authors' conclusions This Cochrane Review supports the benefits of using fluoride toothpaste in preventing caries when compared to non‐fluoride toothpaste. Evidence for the effects of different fluoride concentrations is more limited, but a dose‐response effect was observed for D(M)FS in children and adolescents. For many comparisons of different concentrations the caries‐preventive effects and our confidence in these effect estimates are uncertain and could be challenged by further research. The choice of fluoride toothpaste concentration for young children should be balanced against the risk of fluorosis. Plain language summary Fluoride toothpastes of different strengths for preventing tooth decay Review question 
 This review has been produced to assess the effects of toothpastes of different fluoride strengths on preventing tooth decay in children, adolescents and adults. Background 
 Tooth decay (caries) is a widespread disease, affecting billions of people worldwide. Fluoride has long been used to prevent decay, through a variety of different methods including toothpaste, water, milk, mouthrinses, tooth gels and varnish. Regular toothbrushing is recommended to prevent decay and other oral diseases, and toothbrushing for 2 minutes twice daily with a fluoride toothpaste is generally recommended. The typical strength of regular or family toothpaste is around 1000 to 1500 parts per million (ppm) fluoride, but many other strengths are available worldwide. There is no minimum fluoride concentration, but the maximum permissible fluoride concentration for a toothpaste varies according to age and country. Higher concentrations are rarely available over the counter, and are classed as a prescription‐only medicine. Stronger fluoride toothpaste may offer greater protection against decay but also increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Study characteristics 
 Authors from Cochrane Oral Health carried out this review and the evidence is current up to 15 August 2018. It includes 96 studies published between 1955 and 2014: seven studies with 11,356 randomised participants reported the effects of fluoride toothpaste up to 1500 ppm on the primary teeth; one study with 2500 randomised participants reported the effects of 1450 ppm toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants reported the effects of toothpaste up to 2400 ppm on the permanent teeth of children up to 18 years of age; and three studies with 2675 randomised participants reported the effects of up to 1100 ppm toothpaste on the permanent teeth of adults. Most studies assessed decay after participants had been using the toothpastes for 36 months. Main results 
 We present below findings for which there is moderate‐ or high‐certainty evidence. In primary teeth of young children, brushing teeth with a toothpaste containing 1500 ppm fluoride reduced the amount of new decay when compared with non‐fluoride toothpaste; the amount of new decay was similar with 1055 ppm compared with 550 ppm fluoride toothpaste; and there was a slight reduction in the amount of new decay with 1450 ppm toothpaste compared with 440 ppm fluoride toothpaste. Eighty‐one studies assessed the effects of different strengths of fluoride toothpaste compared against each other (seven different strengths in 21 combinations) in permanent teeth of children and adolescents. We found that there was less new decay when toothbrushing with toothpaste containing 1000 to 1250 ppm or 1450 to 1500 ppm fluoride compared with non‐fluoride toothpaste, and that toothbrushing with 1450 to 1500 ppm fluoride toothpaste reduced the amount of new decay more than 1000 to 1250 ppm toothpaste. We found that there was a similar amount of new decay when children and adolescents used a toothpaste of 1700 to 2200 ppm or 2400 to 2800 ppm fluoride compared to 1450 to 1500 ppm toothpaste. The evidence for the effects of other strengths of toothpaste was less certain. In permanent teeth of adults of all ages, 1000 or 1100 ppm toothpaste reduced decay compared with non‐fluoride toothpaste. Most studies did not measure harmful effects of toothpaste use, but when reported, effects such as soft tissue damage and tooth staining were minimal. Certainty of the evidence 
 There is high‐certainty evidence that toothpaste containing 1000 to 1250 ppm fluoride is more effective than non‐fluoride toothpaste. There is moderate‐certainty evidence for the other findings reported in 'Main results' above. For other toothpaste strengths compared against each other or against non‐fluoride toothpaste, there are too few studies with too few participants to have any clarity about the effects. Authors conclusions 
 There are benefits of using fluoride toothpaste at certain strengths to prevent tooth decay when compared with non‐fluoride toothpaste. The stronger the fluoride concentration, the more decay is prevented. For many of the comparisons of different strengths of toothpaste, the findings are uncertain and could be challenged by further research. The choice of fluoride toothpaste for young children should be balanced against the risk of fluorosis.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.737Z" }, { "id": "48be3104-fe41-4b35-a344-184006c503e3", "pmid": "", "title": "Short courses of antibiotics for children and adults with bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is an important cause of respiratory morbidity in both developing and developed countries. Antibiotics are considered standard therapy in the treatment of this condition but it is unknown whether short courses (four weeks or less) are efficacious. Objectives To determine whether short courses of antibiotics (i.e. less than or equal to four weeks) for treatment of acute and stable state bronchiectasis, in adults and children, are efficacious when compared to placebo or usual care. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library ), MEDLINE, EMBASE, OLDMEDLINE, CINAHL, AMED and PsycINFO and handsearching of respiratory journals and meeting abstracts were performed by the Cochrane Airways Group up to February 2011. Selection criteria Only randomised controlled trials were considered. Adults and children with bronchiectasis (defined clinically or radiologically) were included. Patients with cystic fibrosis were excluded. Data collection and analysis Two review authors independently reviewed the titles, abstracts and citations to assess eligibility for inclusion. Only one study fulfilled the inclusion criteria and thus meta‐analysis could not be performed. Main results The single eligible study showed a small benefit, when compared to placebo, of four weeks of inhaled antibiotic therapy in adults with bronchiectasis and pseudomonas in their sputum. There were no studies in children and no studies on oral or intravenous antibiotics. Authors' conclusions There is insufficient evidence in the current literature to make reasonable conclusions about the efficacy of short course antibiotics in the management of adults and children with bronchiectasis. Until further evidence is available, adherence to current treatment guidelines is recommended. Plain language summary Short courses of antibiotics for children and adults with bronchiectasis There is a paucity of evidence to conclude whether short courses of antibiotics (i.e. less than or equal to four weeks) are equivalent or superior to placebo in the treatment of stable or exacerbation state bronchiectasis. One single study showed some benefit of short‐course inhaled antibiotics over placebo, in terms of microbiological response and subjective improvement in medical condition, although this was balanced against an increase in adverse effects and antimicrobial resistance in the treatment group. Given the potential benefits of shorter duration antibiotic therapy in bronchiectasis, further RCTs are clearly needed to answer this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Wurzel, D; Marchant, JM; Yerkovich, ST; Upham, JW; Masters, IB; Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD008695.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "48c58216-090a-420d-8cc1-1d6a70b22b6a", "pmid": "", "title": "Finerenone and Empagliflozin Combination in Obesity With Hypertension: A 12-Week Prospective, Parallel-design, Double-blind, Randomized, Placebo-controlled Trial", "imported": false, "abstract": "The EFFORT Study (Empagliflozin and Finerenone Combination in Obesity with Hypertension) is a 12-week, randomized, double-blind, placebo-controlled trial that aims to test whether combining empagliflozin (10 mg/day) with finerenone (10 mg/day, up-titrated to 20 mg after 4 weeks) can significantly lower office systolic blood pressure in adults with obesity and stage 1 hypertension (systolic BP 140-160 mmHg) who are on up to two stable antihypertensives. The study will enroll 260 participants from community settings. Beyond blood pressure, the trial will also assess effects on diastolic pressure, cumulative BP exposure, urinary albumin-to-creatinine ratio, inflammation (hs-CRP), fasting glucose, body weight, and quality of life. Safety monitoring focuses on hyperkalemia, acute kidney injury, hypotension, and hypoglycemia. If positive, this research may offer a new, mechanism-based therapeutic strategy for the growing population with cardiometabolic risk, potentially providing better cardiovascular and kidney protection than conventional approaches.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.244Z" }, { "id": "48c7e142-9a0f-464b-b117-cc90ed292970", "pmid": "", "title": "Sumatriptan (intranasal route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Intranasal administration may be preferable to oral for individuals experiencing nausea and/or vomiting, although it is primarily absorbed in the gut, not the nasal mucosa. Objectives To determine the efficacy and tolerability of intranasal sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using intranasal sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Twelve studies (4755 participants) compared intranasal sumatriptan with placebo or an active comparator. Most of the data were for the 10 mg and 20 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 10 mg versus placebo the NNTs were 7.3, 7.4, and 5.5 for pain‐free at two hours, and headache relief at one and two hours, respectively. For sumatriptan 20 mg versus placebo the NNTs were 4.7, 4.9, and 3.5, respectively, for the same outcomes. The 20 mg dose was significantly better than the 10 mg dose for each of these three primary efficacy outcomes. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Direct comparison of sumatriptan with active treatments was limited to two studies, one comparing sumatriptan 20 mg and dihydroergotamine (DHE) 1 mg, and one comparing sumatriptan 20 mg with rizatriptan 10 mg. Authors' conclusions Intranasal sumatriptan is effective as an abortive treatment for acute migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events compared with placebo. Plain language summary Sumatriptan (intranasal route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a nasal spray, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, although absorption of the drug occurs primarily in the gut rather than the nasal mucosa. This review found that a single intranasal dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in approximately 2 in 10 people (24%) taking sumatriptan 10 mg, compared with about 1 in 10 (10%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 5 in 10 people (50%) taking sumatriptan 10 mg, compared with approximately 3 in 10 (32%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those who took placebo. The 20 mg dose had greater efficacy, but may be associated with more adverse events, most of which were of short duration and mild or moderate in severity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009663", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "48cafdb0-e439-4aa2-bf8b-faec36495731", "pmid": "", "title": "Snoezelen for dementia", "imported": false, "abstract": "Abstract - Background Snoezelen, multi‐sensory stimulation, provides sensory stimuli to stimulate the primary senses of sight, hearing, touch, taste and smell, through the use of lighting effects, tactile surfaces, meditative music and the odour of relaxing essential oils. The rationale for this lies in the proposition that the provision of a sensory environment for people with dementia places fewer demands on their intellectual abilities but capitalizes on their residual sensorimotor abilities. The clinical application of snoezelen often varies in form, nature, principles and procedures. Such variations not only make the examination of the therapeutic values of snoezelen difficult, but also impede the clinical development of snoezelen in dementia care. A systematic review of evidence for the efficacy of snoezelen in the care of people with dementia is therefore needed to inform future clinical applications and research directions. Objectives To examine the clinical efficacy of snoezelen (or multisensory stimulation) for older people with dementia and their caregivers. Search methods The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 23 March 2008 using the terms: snoezelen OR \"multi‐sensory*\". The CDCIG Specialized Register contains records from all major health care databases ( The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources. The reviewers hand‐searched PubMed and the ISI Web of Science. Selection criteria Randomized controlled trials and quasi‐randomized controlled trials in which snoezelen or multi‐sensory programmes was used as an intervention for older people suffering from any forms of dementia. Data collection and analysis The two reviewers independently reviewed and assessed the quality of the trials. Main results Two new trials were included in this update. Baker 2003 was an expanded study of Baker 2001 reported in the previous version. Both Baker 2003 and van Weert 2005 examined the short‐term and longer‐term effects of snoezelen on behaviour, mood, and communication of people with moderate to severe dementia. The format of implementation was different in the two trials: one was session‐based snoezelen programme (Baker 2003), whilst the other was a 24‐hour integrated snoezelen care (van Weert 2005). Owing to the differences in study methodology, the results of the two trials were not pooled for analysis. The session‐based snoezelen programme (Baker 2003) did not show any effects on behaviour, mood, cognition and communication / interaction in the short term (during or immediately after sessions) or longer term (at post‐intervention or 1‐month post‐intervention follow‐up). Likewise, the 24‐hour integrated snoezelen care (van Weert 2005) failed to demonstrate any significant short‐term and longer term effects on behaviour, mood and interaction. Authors' conclusions A more vigorous review methodology was adopted in this update. The study of Kragt 1997, reported in the previous version, was excluded because the snoezelen programme only consisted of three sessions, which was considered too brief for a therapeutic intervention. Two new trials were reviewed. Meta‐analyses could not be performed because of the limited number of trials and different study methods of the available trials. Overall, there is no evidence showing the efficacy of snoezelen for dementia. There is a need for more reliable and sound research‐based evidence to inform and justify the use of snoezelen in dementia care. Plain language summary No evidence of the efficacy of snoezelen or multi‐sensory stimulation programmes for people with dementia Snoezelen (or multi‐sensory stimulation) has become a commonly used intervention to manage maladaptive behaviours and to promote positive mood of older people with dementia. Originally, two randomised clinical trials were available for this review. Some short‐term benefits were documented in promoting adaptive behaviours in people with dementia during and immediately after their participation in the sessions. In this update, two new trials were included and revealed two different forms of applying snoezelen to dementia care. One is a session‐based snoezelen programme while the other is a 24‐hour integrated snoezelen care programme. Both trials did not show any significant effects on behaviour, interaction, and mood of people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Chung, JCC, Lai, CKY", "articleTypes": [], "doi": "10.1002/14651858.CD003152", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.103Z" }, { "id": "48ceaa9f-3ff7-4efe-955e-6e12ba807c28", "pmid": "", "title": "Convalescent plasma for people with COVID‐19", "imported": false, "abstract": "Abstract - Rationale Convalescent plasma (CP) may reduce mortality in people with viral respiratory diseases, and is being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). A thorough understanding of the current body of evidence regarding the benefits and risks of this intervention is required. Objectives To assess the effectiveness and safety of convalescent plasma transfusion in the treatment of people with COVID‐19. Search methods To identify completed and ongoing studies, we searched CENTRAL, MEDLINE, Embase, the Epistemonikos COVID‐19 L*OVE Platform, and clinical trial registries to October 2024. Eligibility criteria We included randomised controlled trials (RCTs) evaluating convalescent plasma for people with COVID‐19, irrespective of disease severity, age, gender, or ethnicity. We excluded studies investigating other coronavirus diseases or standard immunoglobulin. Outcomes We used the GRADE approach to rate the certainty of evidence for the following outcomes: all‐cause mortality (up to day 28), worsening and improvement of clinical status (for individuals with moderate to severe disease), hospital admission or death, COVID‐19 symptoms resolution (for individuals with mild disease), quality of life (QoL), grade 3/4 adverse events, and serious adverse events. Risk of bias We used RoB 2 to assess bias in included studies. Synthesis methods We followed standard Cochrane methodology. Included studies We included 48 RCTs (24,518 participants), 15 of which were added in this update. We also identified 36 new ongoing studies and 33 completed studies awaiting classification. Synthesis of results Individuals with a confirmed diagnosis of COVID‐19 and moderate to severe disease Forty‐two RCTs investigated the use of CP for 21,393 participants with moderate to severe disease. Of these, 36 RCTs (20,798 participants) compared CP to placebo or standard care, five (604 participants) to standard plasma, and one (190 participants) to human immunoglobulin. In the full review, we performed subgroup analyses by antibody detection, time since symptom onset, country income level, and key comorbidities. Convalescent plasma versus placebo or standard care alone CP does not reduce all‐cause mortality at up to day 28 (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.90 to 1.03; 31 RCTs, 20,798 participants; high‐certainty evidence). It has little to no impact on the need for invasive mechanical ventilation, or death (RR 1.03, 95% CI 0.98 to 1.08; 8 RCTs, 15,189 participants; high‐certainty evidence) and has no impact on whether participants are discharged from hospital (RR 1.00, 95% CI 0.97 to 1.02; 9 RCTs, 13,930 participants; high‐certainty evidence). CP may have little to no impact on QoL (MD 1.00, 95% CI −2.14 to 4.14; 1 RCT, 483 participants; low‐certainty evidence). CP may have little to no impact on the risk of grade 3/4 adverse events (RR 1.17, 95% CI 0.96 to 1.42; 6 RCTs, 2392 participants; low‐certainty evidence). It probably has little to no effect on the risk of serious adverse events (RR 1.19, 95% CI 1.02 to 1.38; 11 studies, 5298 participants; moderate‐certainty evidence). Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.77, 95% CI 0.53 to 1.10; 5 RCTs, 604 participants; very low‐certainty evidence) and whether it increases the need for invasive mechanical ventilation, or death (RR 5.59, 95% CI 0.29 to 108.38; 1 study, 34 participants; very low‐certainty evidence). The evidence is uncertain about whether convalescent plasma reduces or increases the risk of grade 3/4 adverse events (1 RCT, 248 participants). The evidence is also uncertain about whether CP reduces the risk of serious adverse events (RR 0.82, 95% CI 0.57 to 1.17; 4 RCTs, 447 participants; very low‐certainty evidence). No studies in this comparison reported clinical improvement or QoL. Individuals with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease Six RCTs investigated the use of CP for 2761 participants with mild disease. Four RCTs (1164 participants) compared CP to placebo or standard care alone, and two (1597 participants) to standard plasma. Convalescent plasma versus placebo or standard care alone The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (odds ratio (OR) 1.24, 95% CI 0.33 to 4.60; 3 RCTs, 1004 participants; very low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.45, 95% CI 0.04 to 4.81; 2 RCTs, 493 participants; very low‐certainty evidence). It may have little to no impact on time to COVID‐19 symptom resolution (hazard ratio (HR) 1.05, 95% CI 0.85 to 1.30; 1 RCT, 376 participants) and on the risk of grade 3/4 adverse events (RR 1.29, 95% CI 0.75 to 2.19; 1 RCT, 376 participants), both with low‐certainty evidence. The evidence is uncertain about whether CP has an impact on the risk of serious adverse events (RR 0.84, 95% CI 0.56 to 1.26; 2 RCTs, 494 participants; very low‐certainty evidence). No studies in this comparison reported other critical outcomes. Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.41, 95% CI 0.05 to 3.06; 2 RCTs, 1597 participants; very low‐certainty evidence). It probably reduces admission to hospital or death within 28 days (RR 0.50, 95% CI 0.32 to 0.78; 2 RCTs, 1597 participants; moderate‐certainty evidence). CP may have little to no effect on initial symptom resolution at up to day 28 (RR 1.12, 95% CI 0.82 to 1.54; 1 RCT, 416 participants; low‐certainty evidence). Neither study in this comparison reported other critical outcomes. Authors' conclusions Compared with placebo or standard care, high‐certainty evidence shows that CP does not reduce mortality in individuals with moderate to severe disease and has little to no effect on clinical improvement or worsening. CP probably has little to no effect on serious adverse events. Publication of ongoing studies might resolve some of the uncertainties around CP therapy for people with asymptomatic or mild disease. This review was previously a living systematic review, from the first version published in 2020 until our last search in October 2024. The research question is no longer a priority for decision‐making, new studies are less frequently published, and research that might impact the conclusions of the review is no longer emerging. Funding The European Commission, Belgium SUPorting high quality evaluation of COVID‐19 convalescent plasma thrOughouT Europe (SUPPORT‐E, grant number 101015756) supported this review. Registration Protocol registered with the Center for Open Science on 17 April 2020 (DOI: 10.17605/OSF.IO/DWF53). Access the 2023 version of this review here: DOI: 10.1002/14651858.CD013600.pub6. Plain language summary Does plasma (a blood product) from people who have recovered from COVID‐19 help treat COVID‐19? Key messages We are very confident that plasma from the blood of people who have recovered from COVID‐19 (convalescent plasma) does not help people with moderate to severe COVID‐19. Convalescent plasma may make little or no difference to people with mild COVID‐19. We still need more evidence about people with mild COVID‐19, those with no symptoms, and those with a weaker immune system. What is convalescent plasma? The body produces antibodies as one of its defences against infection. Antibodies are found in part of the blood called plasma. Plasma from people who have recovered from the COVID‐19 virus contains COVID‐19 antibodies. It can be used to make convalescent plasma, which is plasma that contains these antibodies. Convalescent plasma has been used successfully to treat some viruses. This treatment (given by a drip or injection) is generally well‐tolerated, but can cause unwanted effects. What did we want to find out? We wanted to find out whether convalescent plasma helps people with confirmed COVID‐19. We looked at: deaths from any cause; worsening of people's condition, measured by the number of people who needed a ventilator (a machine that helps people breathe) or died; improvement in people's condition, measured by the number of people discharged from hospital; quality of life; unwanted effects. What did we do? We searched for studies that investigated convalescent plasma to treat people with COVID‐19. Studies could take place anywhere in the world and include people with mild, moderate, or severe COVID‐19. Where possible, we combined the studies’ results to analyse them. We rated our confidence in the evidence, based on factors such as study methods and the number of people included. What did we find? We found 48 studies with 24,518 participants. Of these, 42 studies included people with moderate to severe COVID‐19, and six studies included people with mild COVID‐19. The following findings compare convalescent plasma with placebo (a 'dummy' treatment that does not contain any medicine but is given in the same way as the medicine being tested) or the standard care given to people with COVID‐19. People with moderate to severe COVID‐19 In people with moderate to severe COVID‐19, convalescent plasma: makes no difference to deaths from any cause up to 28 days after treatment. About 230 of 1000 people given placebo or standard care died, compared to 220 of 1000 people given convalescent plasma (31 studies, 20,798 people). makes little to no difference to needing support from a ventilator or dying . About 291 of 1000 people given placebo or standard care needed a ventilator or died, compared to 300 of 1000 people given convalescent plasma (8 studies, 15,189 people). makes no difference to people being discharged from hospital. About 670 of 1000 people in both groups were discharged from hospital (9 studies, 13,930 people). may result in no difference in people's quality of life (1 study, 483 people). probably makes no difference to serious unwanted effects. About 109 of 1000 people given placebo or standard care had serious unwanted effects, compared to 129 of 1000 people given convalescent plasma (11 studies, 5298 people). People with mild COVID‐19 We are uncertain whether convalescent plasma reduces deaths from any cause up to 28 days after treatment. About 8 of 1000 people given placebo or standard care died, compared to 10 of 1000 people given convalescent plasma (3 studies, 1004 people). We are uncertain whether convalescent plasma reduces admission to hospital or death within 28 days after treatment. About 106 of 1000 people given placebo or standard care were admitted to hospital or died, compared to 48 of 1000 people given convalescent plasma (2 studies, 493 people). Convalescent plasma may result in no difference in the time until COVID‐19 symptoms resolved (1 study, 376 people). None of the studies measured people's quality of life. We are uncertain whether convalescent plasma has an impact on serious unwanted effects. About 174 of 1000 people given placebo or standard care had serious unwanted effects, compared to 150 of 1000 people given convalescent plasma (2 studies, 494 people). What are the limitations of the evidence? For people with moderate to severe COVID‐19, we are very confident in the evidence about the number of deaths from any cause, and whether people's condition worsened or improved, because the results are drawn from many high‐quality studies with consistent results. We are only moderately confident about the evidence for serious unwanted effects because studies often reported these effects only for people treated with convalescent plasma, or did not report them. For people with mild COVID‐19, we have little to no confidence in the evidence because we could not identify enough consistent results from many of the studies. We still have little evidence about quality of life and about the effects of convalescent plasma for people with mild disease. How up to date is this evidence? This updates our previous review published in 2023. The evidence is current to October 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Iannizzi, C; Chai, KL; Piechotta, V; Monsef, I; Wood, EM; Lamikanra, AA; Roberts, DJ; McQuilten, Z; So-Osman, C; Jindal, A; Estcourt, LJ; Skoetz, N; Kreuzberger, N", "articleTypes": [], "doi": "10.1002/14651858.CD013600.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "48e971f2-8dbd-419f-b506-ebed04865f6d", "pmid": "", "title": "Selenium for preventing cancer", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Vinceti, M, Filippini, T, Del Giovane, C, Dennert, G, Zwahlen, M, Brinkman, M, Zeegers, MPA, Horneber, M, D'Amico, R, Crespi, CM", "articleTypes": [], "doi": "10.1002/14651858.CD005195.pub4 AB - Abstract - Background This review is the third update of the Cochrane review \"Selenium for preventing cancer\". Selenium is a naturally occurring element with both nutritional and toxicological properties. Higher selenium exposure and selenium supplements have been suggested to protect against several types of cancer. Objectives To gather and present evidence needed to address two research questions: 1. What is the aetiological relationship between selenium exposure and cancer risk in humans?
 2. Describe the efficacy of selenium supplementation for cancer prevention in humans. Search methods We updated electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), MEDLINE (Ovid, 2013 to January 2017, week 4), and Embase (2013 to 2017, week 6), as well as searches of clinical trial registries. Selection criteria We included randomised controlled trials (RCTs) and longitudinal observational studies that enrolled adult participants. Data collection and analysis We performed random‐effects (RE) meta‐analyses when two or more RCTs were available for a specific outcome. We conducted RE meta‐analyses when five or more observational studies were available for a specific outcome. We assessed risk of bias in RCTs and in observational studies using Cochrane's risk assessment tool and the Newcastle‐Ottawa Scale, respectively. We considered in the primary analysis data pooled from RCTs with low risk of bias. We assessed the certainty of evidence by using the GRADE approach. Main results We included 83 studies in this updated review: two additional RCTs (10 in total) and a few additional trial reports for previously included studies. RCTs involved 27,232 participants allocated to either selenium supplements or placebo. For analyses of RCTs with low risk of bias, the summary risk ratio (RR) for any cancer incidence was 1.01 (95% confidence interval (CI) 0.93 to 1.10; 3 studies, 19,475 participants; high‐certainty evidence). The RR for estimated cancer mortality was 1.02 (95% CI 0.80 to 1.30; 1 study, 17,448 participants). For the most frequently investigated site‐specific cancers, investigators provided little evidence of any effect of selenium supplementation. Two RCTs with 19,009 participants indicated that colorectal cancer was unaffected by selenium administration (RR 0.99, 95% CI 0.69 to 1.43), as were non‐melanoma skin cancer (RR 1.16, 95% CI 0.30 to 4.42; 2 studies, 2027 participants), lung cancer (RR 1.16, 95% CI 0.89 to 1.50; 2 studies, 19,009 participants), breast cancer (RR 2.04, 95% CI 0.44 to 9.55; 1 study, 802 participants), bladder cancer (RR 1.07, 95% CI 0.76 to 1.52; 2 studies, 19,009 participants), and prostate cancer (RR 1.01, 95% CI 0.90 to 1.14; 4 studies, 18,942 participants). Certainty of the evidence was high for all of these cancer sites, except for breast cancer, which was of moderate certainty owing to imprecision, and non‐melanoma skin cancer, which we judged as moderate certainty owing to high heterogeneity. RCTs with low risk of bias suggested increased melanoma risk. Results for most outcomes were similar when we included all RCTs in the meta‐analysis, regardless of risk of bias. Selenium supplementation did not reduce overall cancer incidence (RR 0.99, 95% CI 0.86 to 1.14; 5 studies, 21,860 participants) nor mortality (RR 0.81, 95% CI 0.49 to 1.32; 2 studies, 18,698 participants). Summary RRs for site‐specific cancers showed limited changes compared with estimates from high‐quality studies alone, except for liver cancer, for which results were reversed. In the largest trial, the Selenium and Vitamin E Cancer Trial, selenium supplementation increased risks of alopecia and dermatitis, and for participants with highest background selenium status, supplementation also increased risk of high‐grade prostate cancer. RCTs showed a slightly increased risk of type 2 diabetes associated with supplementation. A hypothesis generated by the Nutritional Prevention of Cancer Trial ‐ that individuals with low blood selenium levels could reduce their risk of cancer (particularly prostate cancer) by increasing selenium intake ‐ has not been confirmed. As RCT participants have been overwhelmingly male (88%), we could not assess the potential influence of sex or gender. We included 15 additional observational cohort studies (70 in total; over 2,360,000 participants). We found that lower cancer incidence (summary odds ratio (OR) 0.72, 95% CI 0.55 to 0.93; 7 studies, 76,239 participants) and lower cancer mortality (OR 0.76, 95% CI 0.59 to 0.97; 7 studies, 183,863 participants) were associated with the highest category of selenium exposure compared with the lowest. Cancer incidence was lower in men (OR 0.72, 95% CI 0.46 to 1.14, 4 studies, 29,365 men) than in women (OR 0.90, 95% CI 0.45 to 1.77, 2 studies, 18,244 women). Data show a decrease in risk of site‐specific cancers for stomach, colorectal, lung, breast, bladder, and prostate cancers. However, these studies have major weaknesses due to study design, exposure misclassification, and potential unmeasured confounding due to lifestyle or nutritional factors covarying with selenium exposure beyond those taken into account in multi‐variable analyses. In addition, no evidence of a dose‐response relation between selenium status and cancer risk emerged. Certainty of evidence was very low for each outcome. Some studies suggested that genetic factors might modify the relation between selenium and cancer risk ‐ an issue that merits further investigation. Authors' conclusions Well‐designed and well‐conducted RCTs have shown no beneficial effect of selenium supplements in reducing cancer risk (high certainty of evidence). Some RCTs have raised concerns by reporting a higher incidence of high‐grade prostate cancer and type 2 diabetes in participants with selenium supplementation. No clear evidence of an influence of baseline participant selenium status on outcomes has emerged in these studies. Observational longitudinal studies have shown an inverse association between selenium exposure and risk of some cancer types, but null and direct relations have also been reported, and no systematic pattern suggesting dose‐response relations has emerged. These studies suffer from limitations inherent to the observational design, including exposure misclassification and unmeasured confounding. Overall, there is no evidence to suggest that increasing selenium intake through diet or supplementation prevents cancer in humans. However, more research is needed to assess whether selenium may modify the risk of cancer in individuals with a specific genetic background or nutritional status, and to investigate possible differential effects of various forms of selenium. Plain language summary Selenium for preventing cancer Review question 
 We reviewed the evidence investigating the relation between selenium intake and cancer prevention. This review updates the most recent Cochrane review on this topic ( Vinceti 2014) , which was an update of Dennert 2011 . Background 
 Selenium is a naturally occurring element that individuals are exposed to mainly through food consumption, although exposure can also occur through air, drinking water, and dietary supplements. Small amounts of selenium are essential for certain biological functions in humans, but slightly higher amounts can pose a toxicity risk, making selenium an element with a narrow, but as yet not well‐defined, safe range of exposure. Selenium occurs in many different chemical forms with different biological activity. From the late 1960s, a few observational studies reported that people with high levels of selenium in their diet or in their body tissues had lower risk of cancer, and some laboratory studies showed that selenium could inhibit the growth of cancer cells. This led to widespread interest in selenium supplements and claims that taking such supplements could prevent cancer. Since that time, many more observational studies have been conducted to compare cancer rates among individuals with high and low selenium exposure. More recently, several randomised controlled trials designed to assess whether selenium supplementation can prevent cancer have been carried out. These trials played a major role in enhancing our understanding of the relation between selenium and cancer risk as a result of their stronger study design as compared with observational studies. The most recent trials in particular have shown high methodological quality and statistical power. Several trials focused on whether selenium could prevent prostate cancer. Study characteristics 
 This review includes 10 trials in which adults were randomly assigned to receive selenium supplements or placebo, and 70 observational studies in which adults were followed over time to determine whether their baseline selenium status was associated with their risk of cancer. The evidence is current to January 2017. Key results 
 All of the high‐quality randomised trials reported no effect of selenium on reducing overall risk of cancer or risk of particular cancers, including the most investigated outcome ‐ prostate cancer. Some trials unexpectedly suggested that selenium may increase risks of high‐grade prostate cancer, type 2 diabetes, and dermatological abnormalities. Observational studies have yielded inconsistent evidence of a possible effect of selenium exposure on cancer risk, with no evidence of a dose‐response relation. When we pooled results of these studies, overall they suggested an inverse relation between cancer exposure and subsequent incidence of any cancer or some specific cancers, such as colon and prostate cancer. However, observational studies have major weaknesses. The selenium exposure status of participants could have been misclassified owing to limitations of the indicators of selenium exposure used, as well as to uncertainty regarding the particular selenium species contributing to overall exposure. In addition, unmeasured confounding from lifestyle or nutritional factors ‐ a major and well‐known source of bias in nutritional epidemiology studies of observational design ‐ could have been present. Therefore, the internal validity of these studies is limited. Currently, the hypothesis that increasing selenium intake may reduce cancer risk is not supported by epidemiological evidence. Additional research is needed to assess whether selenium may affect the risk of cancer in individuals with specific genetic backgrounds or nutritional status, and to determine how the various chemical forms of selenium compounds may have different effects on cancer risk.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.061Z" }, { "id": "48f0d55d-e256-43a8-aa6e-d55fd6f402ad", "pmid": "", "title": "Combined aclidinium bromide and long‐acting beta2‐agonist for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Several dual bronchodilator combinations of long‐acting beta 2 ‐agonist (LABA) and long‐acting muscarinic antagonist (LAMA) have been approved for treatment of stable chronic obstructive pulmonary disease (COPD). The current GOLD (Global Initiative for Chronic Obstructive Lung Disease) recommendations suggest the use of LABA/LAMA combinations in people with group B COPD with persistent symptoms, group C COPD with further exacerbations on LAMA therapy alone and group D COPD with or without inhaled corticosteroids (ICS). Fixed‐dose combination (FDC) of aclidinium/formoterol is one of the approved LABA/LAMA therapies for people with stable COPD. Objectives To assess the efficacy and safety of combined aclidinium bromide and long‐acting beta 2 ‐agonists in stable COPD. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov, World Health Organization (WHO) trials portal, United States Food and Drug Administration (FDA) and manufacturers' websites as well as the reference list of published trials up to 12 October 2018. Selection criteria Parallel‐group randomised controlled trials (RCTs) assessing combined aclidinium bromide and LABAs in people with stable COPD. Data collection and analysis We used standard methodological procedures expected by Cochrane for data collection and analysis. The primary outcomes were exacerbations requiring a short course of an oral steroid or antibiotic, or both; quality of life measured by a validated scale and non‐fatal serious adverse events (SAEs). Where the outcome or study details were not reported, we contacted the study investigators or pharmaceutical company trial co‐ordinators (or both) for missing data. Main results We identified RCTs comparing aclidinium/formoterol FDC versus aclidinium, formoterol or placebo only. We included seven multicentre trials of four to 52 weeks' duration conducted in outpatient settings. There were 5921 participants, whose mean age ranged from 60.7 to 64.7 years, mostly men with a mean smoking pack‐years of 46.4 to 61.3 of which 43.9% to 63.4% were current smokers. They had a moderate‐to‐severe degree of COPD with a mean postbronchodilator forced expiratory volume in one second (FEV 1 ) between 50.5% and 61% of predicted normal and the baseline mean FEV 1 of 1.23 L to 1.43 L. We assessed performance and detection biases as low for all studies whereas selection, attrition and reporting biases were either low or unclear. FDC versus aclidinium There was no evidence of a difference between FDC and aclidinium for exacerbations requiring steroids or antibiotics, or both (OR 0.95, 95% CI 0.71 to 1.27; 2 trials, 2156 participants; moderate‐certainty evidence); quality of life measured by St George's Respiratory Questionnaire (SGRQ) total score (MD –0.92, 95% CI –2.15 to 0.30); participants with significant improvement in SGRQ score (OR 1.17, 95% CI 0.97 to 1.41; 2 trials, 2002 participants; moderate‐certainty evidence); non‐fatal SAE (OR 1.19, 95% CI 0.79 to 1.80; 3 trials, 2473 participants; moderate‐certainty evidence); hospital admissions due to severe exacerbations (OR 0.62, 95% CI 0.29 to 1.29; 2 trials, 2156 participants; moderate‐certainty evidence) or adverse events (OR 0.95, 95% CI 0.76 to 1.18; 3 trials, 2473 participants; moderate‐certainty evidence). Compared with aclidinium, FDC improved symptoms (Transitional Dyspnoea Index (TDI) focal score: MD 0.37, 95% CI 0.07 to 0.68; 2 trials, 2013 participants) with a higher chance of achieving a minimal clinically important difference (MCID) of at least one unit improvement (OR 1.34, 95% CI 1.11 to 1.62; high‐certainty evidence); the number needed to treat for an additional beneficial outcome (NNTB) being 14 (95% CI 9 to 39). FDC versus formoterol When compared to formoterol, combination therapy reduced exacerbations requiring steroids or antibiotics, or both (OR 0.78, 95% CI 0.62 to 0.99; 3 trials, 2694 participants; high‐certainty evidence); may decrease SGRQ total score (MD –1.88, 95% CI –3.10 to –0.65; 2 trials, 2002 participants; low‐certainty evidence; MCID for SGRQ is 4 units); increased TDI focal score (MD 0.42, 95% CI 0.11 to 0.72; 2 trials, 2010 participants) with more participants attaining an MCID (OR 1.30, 95% CI 1.07 to 1.56; high‐certainty evidence) and an NNTB of 16 (95% CI 10 to 60). FDC lowered the risk of adverse events compared to formoterol (OR 0.78, 95% CI 0.65 to 0.93; 5 trials, 3140 participants; high‐certainty evidence; NNTB 22). However, there was no difference between FDC and formoterol for hospital admissions, all‐cause mortality and non‐fatal SAEs. FDC versus placebo Compared with placebo, FDC demonstrated no evidence of a difference in exacerbations requiring steroids or antibiotics, or both (OR 0.82, 95% CI 0.60 to 1.12; 2 trials, 1960 participants; moderate‐certainty evidence) or hospital admissions due to severe exacerbations (OR 0.55, 95% CI 0.25 to 1.18; 2 trials, 1960 participants; moderate‐certainty evidence), although estimates were uncertain. Quality of life measure by SGRQ total score was significantly better with FDC compared to placebo (MD –2.91, 95% CI –4.33 to –1.50; 2 trials, 1823 participants) resulting in a corresponding increase in SGRQ responders who achieved at least four units decrease in SGRQ total score (OR 1.72, 95% CI 1.39 to 2.13; high‐certainty evidence) with an NNTB of 7 (95% CI 5 to 12). FDC also improved symptoms measured by TDI focal score (MD 1.32, 95% CI 0.96 to 1.69; 2 studies, 1832 participants) with more participants attaining at least one unit improvement in TDI focal score (OR 2.51, 95% CI 2.02 to 3.11; high‐certainty evidence; NNTB 4). There were no differences in non‐fatal SAEs, adverse events and all‐cause mortality between FDC and placebo. Combination therapy significantly improved trough FEV 1 compared to aclidinium, formoterol or placebo. Authors' conclusions FDC improved dyspnoea and lung function compared to aclidinium, formoterol or placebo, and this translated into an increase in the number of responders on combination treatment. Quality of life was better with combination compared to formoterol or placebo. There was no evidence of a difference between FDC and monotherapy or placebo for exacerbations, hospital admissions, mortality, non‐fatal SAEs or adverse events. Studies reported a lower risk of moderate exacerbations and adverse events with FDC compared to formoterol; however, larger studies would yield a more precise estimate for these outcomes. Plain language summary Are combined aclidinium and long‐acting beta 2 ‐agonist inhalers effective and safe for people with stable COPD? Background Chronic obstructive pulmonary disease (COPD) is a disease of the lungs that causes airways to narrow. As a result, people with COPD experience symptoms of breathlessness and cough with sputum production which worsen over time. It is mainly caused by smoking or inhaling dust. In people with COPD, inhalers that contain medicines to widen the airways are generally given to relieve symptoms. Long‐acting medicines whose action lasts for at least half a day or one day are preferred. Aclidinium and formoterol (a long‐acting beta 2 ‐agonist medicine) are such inhalers. We wanted to find out how a combination of aclidinium and long‐acting beta 2 ‐agonist fare against either inhaler alone and dummy (placebo) inhaler. Study characteristics We could only identify studies on aclidinium and formoterol combination and included seven studies involving 5921 people with COPD which ranged from four weeks to one year long. Most participants were men in their 60s, moderate‐to‐heavy smokers, around half of whom were current smokers. They had moderate‐to‐severe symptoms of COPD when they started treatment. People in the studies took either combined inhalers containing aclidinium and formoterol or aclidinium or formoterol or placebo through a similar inhaler. Both people doing the research and people in the study did not know which treatment participants were getting. The conclusions of this review are current to October 2018. Key results People taking combined inhaler and aclidinium inhaler were not different in terms of flare‐ups that need additional medicines, quality of life, hospitalisations, side effects or serious side effects. However, they were less breathless than those taking aclidinium inhaler. Fourteen people with COPD would need to be treated with combined inhalers to have one additional person with a clinically significant improvement in breathlessness. People on combined inhalers were likely to have fewer flare‐ups, side effects and symptoms and a better quality of life compared to those taking formoterol inhaler. But, there was little or no difference in hospital admissions due to severe flare‐ups, serious side effects or the risk of dying. When compared to dummy inhalers, people taking combined inhalers experienced less breathlessness and better quality of life. Seven people with COPD would need to be treated with combined inhaler to achieve a significant improvement in quality of life than dummy inhaler. For flare‐ups, hospital admissions, side effects, serious side effects and death, there was no difference between combined and dummy inhalers. The lungs worked better in people taking combined inhalers than those taking only one drug or dummy inhaler. Quality of the evidence We had to interpret the results carefully as all the included studies were sponsored by pharmaceutical companies, which could have led to bias. However, the included studies were generally conducted in a systematic and acceptable manner. We are confident that combined inhalers are more effective than single or dummy inhalers at improving breathlessness and lung function. However, we are less certain about its effects on flare‐ups, hospital admissions, quality of life and side effects. Conclusion Combined inhalers are more effective than individual or dummy inhalers for relieving breathlessness and improving lung performance. They also lead to better quality of life than formoterol or dummy inhalers. However, they are not different from individual or dummy inhalers in terms of flare‐ups or hospital admissions. These combined inhalers have similar safety profiles as individual or dummy inhalers in terms of death, side effects or serious side effects. Combined inhalers probably had lesser side effects and moderate flare‐ups than formoterol, but further studies are needed to confidently support this finding. In summary, the combined inhalers are an effective option for treatment of COPD and appear to have a similar safety profile to individual or dummy inhalers.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ni, H; Moe, S; Soe, Z; Myint, KT; Viswanathan, KN", "articleTypes": [], "doi": "10.1002/14651858.CD011594.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "48f461df-8c98-4f77-8ab9-39c4d1f5f451", "pmid": "", "title": "Omega‐3 fatty acids for the treatment of dementia", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) from fish and plant sources are commonly considered as a promising non‐medical alternative to improve brain functions and slow down the progression of dementia. This assumption is mostly based on findings of preclinical studies and epidemiological research. Resulting explanatory models aim at the role omega‐3 PUFAs play in the development and integrity of the brain's neurons, their protective antioxidative effect on cell membranes and potential neurochemical mechanisms directly related to Alzheimer‐specific pathology. Epidemiological research also found evidence of malnutrition in people with dementia. Considering this and the fact that omega‐3 PUFA cannot be synthesised by humans, omega‐3 PUFAs might be a promising treatment option for dementia. Objectives To assess the efficacy and safety of omega‐3 polyunsaturated fatty acid (PUFA) supplementation for the treatment of people with dementia. Search methods We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 10 December 2015. We contacted manufacturers of omega‐3 supplements and scanned reference lists of landmark papers and included articles. Selection criteria We included randomised controlled trials (RCTs) in which omega‐3 PUFA in the form of supplements or enriched diets were administered to people with Alzheimer's disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), Parkinson's disease dementia (PDD) or frontotemporal dementia (FTD). Data collection and analysis The primary outcome measures of interest were changes in global and specific cognitive functions, functional performance, dementia severity and adverse effects. Two review authors independently selected studies, extracted data and assessed the quality of trials according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We received unpublished data from the trial authors and collected adverse effects information from the published articles. We conducted meta‐analyses for available outcome measures at six months. Main results We included three comparable randomised, placebo‐controlled trials investigating omega‐3 PUFA supplements in 632 participants with mild to moderate AD over six, 12 and 18 months. We found no studies investigating other types of dementia. All trials were of high methodological quality. The overall quality of evidence for most of the outcomes was high. There was no evidence of a benefit from omega‐3 PUFAs on cognitive function when measured at six months with the Alzheimer's Disease Assessment Scale ‐ Cognitive subscale (standardised mean difference (SMD) ‐0.02, 95% confidence interval (CI) ‐0.19 to 0.15; 566 participants; 3 studies; high quality evidence) or Mini‐Mental State Examination (mean difference (MD) 0.18, 95% CI ‐1.05 to 1.41; 202 participants; 2 studies; high quality evidence) or on activities of daily living (SMD ‐0.02, 95% CI ‐0.19 to 0.16; 544 participants; 2 studies; high quality evidence). There was also no effect at six months of treatment on severity of dementia measured with the Clinical Dementia Rating ‐ Sum of Boxes (MD ‐0.00, 95% CI ‐0.58 to 0.57; 542 participants; 2 studies; high quality evidence) or on quality of life measured with the Quality of Life Alzheimer's Disease scale (MD ‐0.10, 95% CI ‐1.28 to 1.08; 322 participants; 1 study; high quality evidence). There was no difference at six months on mental health measured with the Montgomery‐Åsberg Depression Rating Scale (MD ‐0.10, 95% CI ‐0.74 to 0.54; 178 participants: 1 study; high quality of evidence) or the Neuropsychiatric Inventory (SMD 0.10, 95% CI ‐0.07 to 0.27; 543 participants; 2 studies; high quality of evidence). One very small study showed a benefit for omega‐3 PUFAs in instrumental activities of daily living after 12 months of treatment (MD ‐3.50, 95% CI ‐4.30 to ‐2.70; 22 participants; moderate quality evidence). The included studies did not measure specific cognitive function. The studies did not report adverse events well. Two studies stated that all adverse events were mild and that they did not differ in overall frequency between omega‐3 PUFA and placebo groups. Data from one study showed no difference between groups in frequency of any adverse event (risk ratio (RR) 1.02, 95% CI 0.95 to 1.10; 402 participants; 1 study; moderate quality evidence) or any serious adverse event (RR 1.05, 95% CI 0.78 to 1.41; 402 participants; 1 study; high quality evidence) at 18 months of treatment. Authors' conclusions We found no convincing evidence for the efficacy of omega‐3 PUFA supplements in the treatment of mild to moderate AD. This result was consistent for all outcomes relevant for people with dementia. Adverse effects of omega‐3 PUFAs seemed to be low, but based on the evidence synthesised in this review, we cannot make a final statement on tolerability. The effects on other populations remain unclear. Plain language summary Omega‐3 fatty acids for the treatment of dementia Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) are assumed to have a beneficial effect on the function of the brain. It has been suggested that they might improve or delay decline in memory and ability to carry out everyday tasks in people with dementia. In this review, we investigated randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) comparing omega‐3 PUFAs, given in the form of supplements or enriched diets, with placebo (a pretend treatment) in people with the most common types of dementia. Included trials We included three trials that investigated 632 people with Alzheimer's disease of mild to moderate severity. We found no trials on other types of dementia. In all trials participants took either placebo or omega‐3 PUFA supplements. The quality of the trials was good. The participants were allocated to the groups randomly. The participants and most of the investigators did not know which treatment was given. Results When we combined the results of the trials, we found that taking omega‐3 PUFA supplements for six months had no effect on cognition (learning and understanding), everyday functioning, quality of life or mental health. One very small study observed that omega‐3 PUFAs improved cognitively complex daily activities, such as shopping, when taken for a longer period of time. However, the quality of the evidence was only moderate, so this should be confirmed in further trials. Omega‐3 PUFAs also had no effect on ratings of the overall severity of the illness. The trials did not report side effects very well, but none of the studies reported significant harmful effects on health. Conclusion Altogether, the quality of the evidence was moderate or high for most of the effects that we measured, but we found no evidence for either benefit or harm from omega‐3 PUFA supplements in people with mild to moderate Alzheimer's disease. The effects on people with other types of dementia remain unclear.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Burckhardt, M, Herke, M, Wustmann, T, Watzke, S, Langer, G, Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD009002.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.098Z" }, { "id": "48fec5a0-074d-4a31-80a1-a73656fedfc7", "pmid": "", "title": "Green tea for weight loss and weight maintenance in overweight or obese adults", "imported": false, "abstract": "Abstract - Background Preparations of green tea are used as aids in weight loss and weight maintenance. Catechins and caffeine, both contained in green tea, are each believed to have a role in increasing energy metabolism, which may lead to weight loss. A number of randomised controlled trials (RCTs) evaluating the role of green tea in weight loss have been published; however, the efficacy of green tea preparations in weight loss remains unclear. Objectives To assess the efficacy and safety of green tea preparations for weight loss and weight maintenance in overweight or obese adults. Search methods We searched the following databases from inception to specified date as well as reference lists of relevant articles: The Cochrane Library (Issue 12, 2011), MEDLINE (December 2011), EMBASE (December 2011), CINAHL (January 2012), AMED (January 2012), Biological Abstracts (January 2012), IBIDS (August 2010), Obesity+ (January 2012), IPA (January 2012) and Web of Science (December 2011). Current Controlled Trials with links to other databases of ongoing trials was also searched. Selection criteria RCTs of at least 12 weeks' duration comparing green tea preparations to a control in overweight or obese adults. Data collection and analysis Three authors independently extracted data, assessed studies for risk of bias and quality, with differences resolved by consensus. Heterogeneity of included studies was assessed visually using forest plots and quantified using the I 2 statistic. We synthesised data using meta‐analysis and descriptive analysis as appropriate; subgroup and sensitivity analyses were conducted. Adverse effects reported in studies were recorded. Main results Due to the level of heterogeneity among studies, studies were divided into two groups; those conducted in Japan and those conducted outside Japan. Study length ranged between 12 and 13 weeks. Meta‐analysis of six studies conducted outside Japan showed a mean difference (MD) in weight loss of ‐0.04 kg (95% CI ‐0.5 to 0.4; P = 0.88; I 2 = 18%; 532 participants). The eight studies conducted in Japan were not similar enough to allow pooling of results and MD in weight loss ranged from ‐0.2 kg to ‐3.5 kg (1030 participants) in favour of green tea preparations. Meta‐analysis of studies measuring change in body mass index (BMI) conducted outside Japan showed a MD in BMI of ‐0.2 kg/m 2 (95% CI ‐0.5 to 0.1; P = 0.21; I 2 = 38%; 222 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed a reduction in BMI ranging from no effect to ‐1.3 kg/m 2 (1030 participants), in favour of green tea preparations over control. Meta‐analysis of five studies conducted outside Japan and measuring waist circumference reported a MD of ‐0.2 cm (95% CI ‐1.4 to 0.9; P = 0.70; I 2 = 58%; 404 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed effects on waist circumference ranging from a gain of 1 cm to a loss of 3.3 cm (1030 participants). Meta‐analysis for three weight loss studies, conducted outside Japan, with waist‐to‐hip ratio data (144 participants) yielded no significant change (MD 0; 95% CI ‐0.02 to 0.01). Analysis of two studies conducted to determine if green tea could help to maintain weight after a period of weight loss (184 participants) showed a change in weight loss of 0.6 to ‐1.6 kg, a change in BMI from 0.2 to ‐0.5 kg/m 2 and a change in waist circumference from 0.3 to ‐1.7 cm. In the eight studies that recorded adverse events, four reported adverse events that were mild to moderate, with the exception of two (green tea preparations group) that required hospitalisation (reported as not associated with the intervention). Nine studies reported on compliance/adherence, one study assessed attitude towards eating as part of the health‐related quality of life outcome. No studies reported on patient satisfaction, morbidity or cost. Authors' conclusions Green tea preparations appear to induce a small, statistically non‐significant weight loss in overweight or obese adults. Because the amount of weight loss is small, it is not likely to be clinically important. Green tea had no significant effect on the maintenance of weight loss. Of those studies recording information on adverse events, only two identified an adverse event requiring hospitalisation. The remaining adverse events were judged to be mild to moderate. Plain language summary Green tea for weight loss and weight maintenance in overweight or obese adults Green tea has a long history of many uses, one of which is helping overweight people to lose weight and to maintain weight loss. Believed to be able to increase a person's energy output, green tea weight loss preparations are extracts of green tea that contain a higher concentration of ingredients (catechins and caffeine) than the typical green tea beverage prepared from a tea bag and boiling water. This review looked at 15 weight loss studies and three studies measuring weight maintenance where some form of a green tea preparation was given to one group and results compared to a group receiving a control. Neither group knew whether they were receiving the green tea preparation or the control. A total of 1945 participants completed the studies, ranging in length from 12 to 13 weeks. In summary, the loss in weight in adults who had taken a green tea preparation was statistically not significant, was very small and is not likely to be clinically important. Similar results were found in studies that used other ways to measure loss in weight (body mass index, waist circumference). Studies examining the effect of green tea preparations on weight maintenance did not show any benefit compared to the use of a control preparation. Most adverse effects, such as nausea, constipation, abdominal discomfort and increased blood pressure, were judged to be mild to moderate and to be unrelated to the green tea or control intervention. No deaths were reported, although adverse events required hospitalisation. One study attempted to look at health‐related quality of life by asking participants about their attitudes towards eating. Nine studies tracked participants' compliance with green tea preparations. Studies did not include any information about the effects of green tea preparations on morbidity, costs or patient satisfaction.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Jurgens, TM; Whelan, AM; Killian, L; Doucette, S; Kirk, S; Foy, E", "articleTypes": [], "doi": "10.1002/14651858.CD008650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "4929c869-cde3-4872-ae6b-0972146abadb", "pmid": "", "title": "Interventions for the prevention of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "Abstract - Background Loss of olfactory function is well recognised as a symptom of COVID‐19 infection, and the pandemic has resulted in a large number of individuals with abnormalities in their sense of smell. For many, the condition is temporary and resolves within two to four weeks. However, in a significant minority the symptoms persist. At present, it is not known whether early intervention with any form of treatment (such as medication or olfactory training) can promote recovery and prevent persisting olfactory disturbance. This is an update of the 2021 review with four studies added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with acute olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance, which had been present for less than four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the presence of normal olfactory function, serious adverse effects and change in sense of smell. Secondary outcomes were the prevalence of parosmia, change in sense of taste, disease‐related quality of life and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included five studies with 691 participants. The studies evaluated the following interventions: intranasal corticosteroid sprays, intranasal corticosteroid drops, intranasal hypertonic saline and zinc sulphate. Intranasal corticosteroid spray compared to no intervention/placebo We included three studies with 288 participants who had olfactory dysfunction for less than four weeks following COVID‐19. Presence of normal olfactory function The evidence is very uncertain about the effect of intranasal corticosteroid spray on both self‐rated recovery of olfactory function and recovery of olfactory function using psychophysical tests at up to four weeks follow‐up ( self‐rated : risk ratio (RR) 1.19, 95% confidence interval (CI) 0.85 to 1.68; 1 study; 100 participants; psychophysical testing : RR 2.3, 95% CI 1.16 to 4.63; 1 study; 77 participants; very low‐certainty evidence). Change in sense of smell The evidence is also very uncertain about the effect of intranasal corticosteroid spray on self‐rated change in the sense of smell ( at less than 4 weeks : mean difference (MD) 0.5 points lower, 95% CI 1.38 lower to 0.38 higher; 1 study; 77 participants; at > 4 weeks to 3 months : MD 2.4 points higher, 95% CI 1.32 higher to 3.48 higher; 1 study; 100 participants; very low‐certainty evidence, rated on a scale of 1 to 10, higher scores mean better olfactory function). Intranasal corticosteroids may make little or no difference to the change in sense of smell when assessed with psychophysical testing (MD 0.2 points, 95% CI 2.06 points lower to 2.06 points higher; 1 study; 77 participants; low‐certainty evidence, 0‐ to 24‐point scale, higher scores mean better olfactory function). Serious adverse effects The authors of one study reported no adverse effects, but their intention to collect these data was not pre‐specified so we are uncertain if these were systematically sought and identified. The remaining two studies did not report on adverse effects. Intranasal corticosteroid drops compared to no intervention/placebo We included one study with 248 participants who had olfactory dysfunction for ≤ 15 days following COVID‐19. Presence of normal olfactory function Intranasal corticosteroid drops may make little or no difference to self‐rated recovery at > 4 weeks to 3 months (RR 1.00, 95% CI 0.89 to 1.11; 1 study; 248 participants; low‐certainty evidence). No other outcomes were assessed by this study. Data on the use of hypertonic saline nasal irrigation and the use of zinc sulphate to prevent persistent olfactory dysfunction are included in the full text of the review. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for preventing persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the prevention of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important COVID‐19 has been found to cause problems with the sense of smell. Sometimes this is a reduction in the ability to smell things, and sometimes it is a complete loss of the sense of smell. For many people this recovers in a short time, but for others it may last for weeks or months. This review considers whether there are treatments that people might take as soon as they have lost their sense of smell (within four weeks of the symptoms starting), to try and stop this becoming a long‐standing problem. How we identified and assessed the evidence We searched for all relevant studies in the medical literature to summarise the results. We also looked at how certain the evidence was, considering things like the size of the studies and how they were carried out. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found five studies that had been completed. Intranasal corticosteroids compared to no treatment Three studies looked at this treatment. Nasal corticosteroid spray might make little or no difference to the sense of smell when measured with specific tests (rather than when asking people about their sense of smell). The rest of the evidence was of very low certainty, so we do not know whether a nasal corticosteroid spray is better or worse than no treatment at: ‐ helping the sense of smell get back to normal (either people feeling that their sense of smell is back to normal, or having a normal sense of smell according to specific tests); ‐ making people feel that their sense of smell has improved; ‐ causing any unwanted side effects. Intranasal corticosteroid drops compared to placebo (dummy treatment) One study looked at this treatment. Intranasal corticosteroid drops might not make any difference to the number of people who think their sense of smell has recovered at 30 days. We did find a number of other studies that are being carried out, but no results from these studies were available yet to be included in this review. What this means We do not know whether using a nasal corticosteroid spray or nasal drops has any benefit in preventing longer‐term loss of the sense of smell that is related to COVID‐19, or whether they may cause any harm. This review is a 'living systematic review' ‐ meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Webster, KE; O'Byrne, L; MacKeith, S; Philpott, C; Hopkins, C; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013877.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "492a6dae-c532-4397-971a-e2abb66fe684", "pmid": "", "title": "Brexpiprazole versus placebo or other antidepressive agents for treating depression", "imported": false, "abstract": "Abstract - Background Brexpiprazole is the newest antipsychotic drug approved as an adjunctive for treatment‐resistant depression. This systematic review provides comprehensive, high‐quality evidence for the effects of brexpiprazole in major depressive disorder (MDD) based on existing and emerging randomised controlled trials (RCTs). Objectives To evaluate the benefits and harms of brexpiprazole as monotherapy or adjunct treatment in the acute and longer‐term treatment of MDD compared to placebo or other antidepressive agents. Search methods We used standard, extensive Cochrane search methods. The latest search date was November 2021. Selection criteria We included RCTs in people with a history of non‐response to one or more antidepressant monotherapies comparing brexpiprazole as monotherapy or adjunct treatment with placebo or other antidepressive agents. Data collection and analysis We used standard Cochrane methods. Primary outcomes were 1. response to treatment, measured as number of participants who achieved 50% or more reduction of the score on a validated scale for depression, 2. dropouts due to any reason, and 3. dropouts due to adverse effects, all measured at eight weeks (acute treatment). Our secondary outcomes were 4. number of participants who responded to treatment after two and 18 weeks, number of participants who achieved remission after eight weeks, 5. total number of participants with any adverse events, 6. social functioning or adjustment, and 7. health‐related quality of life. We used GRADE to assess certainty of evidence for each outcome. Main results We retrieved nine studies with 3424 participants with treatment‐resistant depression, defined as lack of response to at least two trials of antidepressant monotherapy. The age of participants was 18 to 65 years in seven studies, 18 to 75 years in one study, and older than 65 years in one study. Inclusion criteria for all studies required a diagnosis of MDD with a current major depressive episode per Diagnostic and Statistical Manual of Mental Disorders Text Revision Fourth Edition criteria and additional criteria on minimal scores on Montgomery–Åsberg Depression Rating Scale (MADRS) and Hamilton Depression Rating Scale which varied across studies. Eight studies compared brexpiprazole as adjunctive treatment to an antidepressant versus placebo as adjunctive treatment to an antidepressant. One study added brexpiprazole or placebo to a combination of antidepressant and ketamine. Four studies used fixed dosages and five studies used flexible dosages of brexpiprazole. The manufacturer sponsored eight studies and one study was independently funded. Brexpiprazole was superior in achieving response at eight weeks (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.23 to 1.75; 8 studies, 3409 participants; high‐certainty evidence). More participants randomised to brexpiprazole dropped out due to any cause at eight weeks (OR 1.37, 95% CI 1.02 to 1.83; 7 studies, 2523 participants; high‐certainty evidence) or due to adverse effects (OR 2.88, 95% CI 1.37 to 6.05; 6 studies, 2472 participants; high‐certainty evidence). Brexpiprazole was superior to placebo when added to an antidepressant for achieving remission at eight weeks (OR 1.46, 95% CI 1.19 to 1.79; 7 studies, 3358 participants; high‐certainty evidence). When response was defined based on a change in the score on MADRS, brexpiprazole also demonstrated better efficacy than placebo (mean difference (MD) –1.39, 95% CI –1.96 to –0.82; 8 studies, 3263 participants; high‐certainty evidence). Compared to placebo, add‐on brexpiprazole is probably more likely to result in akathisia (OR 2.95, 95% CI 2.06 to 4.21; 7 studies, 3358 participants; moderate‐certainty evidence) and weight gain (OR 3.14, 95% CI 2.19 to 4.49; 9 studies, 3424 participants; moderate‐certainty evidence). The risk of bias varied between low and unclear for most studies. Only one study was at high risk of selective reporting bias and other bias; however, this study had a small sample size and its impact on overall risk of bias was not considered significant. The certainty of the evidence on five of the main outcomes (response to treatment, measured as number of participants who achieved response and change in depressive symptoms, remission, dropouts due to any cause, dropouts due to adverse effects) was high. The certainty of evidence for akathisia and weight gain was downgraded one level to moderate due to indirectness. Authors' conclusions Our review supports the superior efficacy of add‐on brexpiprazole in comparison to placebo in adults with treatment‐resistant depression for the short‐term and acute treatment of depression. Our findings were limited by the small number of studies and the moderate‐certainty evidence for the most common adverse effects (akathisia and weight gain). There was insufficient evidence for the effects of brexpiprazole for depression in older people or children. In addition, we found no studies that compared brexpiprazole to other antidepressants or where brexpiprazole was added after lack of response to only one antidepressant. We also lacked sufficient data to establish the long‐term efficacy of brexpiprazole as adjunctive treatment. Active comparators, long‐term studies in different age groups and cost‐effect analyses are needed to more precisely establish the clinical role of brexpiprazole in the treatment of MDD. Plain language summary What are the benefits and harms of brexpiprazole, a new antipsychotic medication, for the treatment of depression when compared to dummy tablets or antidepressants? Key messages – Brexpiprazole added to an antidepressant is better at reducing the symptoms of depression than placebo (dummy tablet) added to an antidepressant. – Brexpiprazole might be more commonly associated with weight gain and akathisia (a feeling of restlessness that causes a compelling need to move all the time). What is depression? Depression is a common mental health condition which leads to low mood, inability to experience pleasure, sleep disruption, weight loss, fatigue or low energy, slower speech and movements, feeling worthless or excessively guilty, being unable to concentrate and having thoughts of committing suicide. To be diagnosed with depression, a person should experience five or more of these symptoms, including low mood or loss of sense of pleasure for at least two weeks. How is the condition treated? Unless the symptoms of depression are mild, the first option for treatment is an antidepressant medication, but antidepressants only help in half of cases when prescribed for the first time. When an antidepressant is not enough to treat depression, one available option is to add another medication to help the effects of the antidepressant. Other options include changing the antidepressant to another antidepressant, talking therapy or stimulation of the brain through electrical pulses. Brexpiprazole is a new medication which can be added to an antidepressant that has not worked by itself. Brexpiprazole can be prescribed in doses from 0.5 mg to 3 mg for the treatment of depression. It has also been approved for the treatment of schizophrenia. What did we want to find out? We wanted to examine the effects of brexpiprazole in the treatment of depression when prescribed by itself or when added to another antidepressant and how its effects compare to the effects of antidepressants or placebo. To do so we explored several effects. First, we looked into how well brexpiprazole decreased the symptoms of depression. Second, we explored how many participants gave up taking part in the studies for any reason. Third, we investigated how many stopped participating because of the unwanted effects they experienced. Fourth, we explored what unwanted effects emerged with the use of brexpiprazole. We also wanted to know how brexpiprazole affected the quality of life of the participants and how it affected the way they functioned in their everyday lives. What did we do? We searched scientific databases for studies that reported the effects of brexpiprazole versus placebo or antidepressants for depression. We included only studies in which the participants were assigned randomly to one or the other treatment. Neither them nor the team that was evaluating the effects of the treatment knew what was prescribed and this helped to objectively evaluate the results without the knowledge of what was prescribed impacting on the outcome. We compared and summarised the results and evaluated how confident we were that the results of the studies represented the real effects of the medication. We based our confidence on different factors such as the size of the effects, the methods used, and what and how the results were reported. What did we find and what were the limitations of our findings? We found nine studies, which included 3424 participants; two‐thirds of them were women and one‐third were men. We only found studies in which brexpiprazole was added after the participants had tried treatment with two or more antidepressants on their own. We have a high level of confidence that brexpiprazole added to an antidepressant reduced the symptoms of depression more after eight weeks of treatment than placebo added to an antidepressant. Brexpiprazole was also more likely to lead to no symptoms of depression than placebo when either of them was added to an antidepressant. We are moderately confident that brexpiprazole caused weight gain or subjective feelings of restlessness more often than placebo. We are less confident about the results around these unwanted effects as we could not find information about how they were measured and whether all studies used the same methods to measure them. What did we fail to find? We found no studies that explored how brexpiprazole would work for children or older people who have depression. We wanted to find how brexpiprazole would work when given for depression for longer periods of time, such as 18 to 24 weeks, but we found only one study and its results were not enough to draw a conclusion. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 1 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ralovska, S, Koychev, I, Marinov, P, Furukawa, TA, Mulsant, B, Cipriani, A", "articleTypes": [], "doi": "10.1002/14651858.CD013866.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.767Z" }, { "id": "4938d676-cb7f-405f-9866-91c9f63faa71", "pmid": "", "title": "Transitional discharge interventions for people with schizophrenia", "imported": false, "abstract": "Abstract - Background Schizophrenia is a chronic mental illness characterized by delusions, hallucinations, and important functional and social disability. Interventions labeled as 'transitional' add to care plans made during the hospital stay in preparation for discharge. They also include interventions developed after discharge to support people with serious mental illness as they make the transition from the hospital to the community. Transitional discharge interventions may anticipate the future needs of the patient after discharge by co‐ordinating the different levels of the health system that can effectively guarantee continuity of care in the community. This occurs through the provision of therapeutic relationships which give a safety net throughout the discharge and community reintegration processes to improve the general condition of users, level of functioning, use of health resources, and satisfaction with care. Objectives To assess the effects of transitional discharge interventions for people with schizophrenia. Search methods On 7 December 2022, we searched the Cochrane Schizophrenia Group's Study‐Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, PubMed, CINAHL, ClinicalTrials.gov, ISRCTN, PsycINFO, and WHO ICTRP. Selection criteria Randomized controlled trials (RCTs) evaluating the effects of transitional discharge interventions in people with schizophrenia and schizophrenia‐related disorders. Eligible interventions included three key elements: predischarge planning, co‐ordination of care and follow‐up, and postdischarge support. Data collection and analysis We used standard Cochrane methods. Outcomes of this review included global state (relapse), service use (hospitalization), general functioning, satisfaction with care, adverse effects/events, quality of life, and direct costs. For binary outcomes, we calculated risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardized mean difference (SMD) and their 95% CIs. We used GRADE to assess certainty of evidence. Main results We found 12 studies with 1748 participants comparing transitional discharge interventions to usual care. All were parallel‐group RCTs. No studies assessed global state (relapse) or reported data about adverse events/effects. All studies had a high risk of bias, mainly due to serious concerns about allocation concealment, deviations from intended interventions, measurement of the outcomes, and missing outcome data. Transitional discharge interventions may make little to no difference in service use (hospitalization) at short‐ and long‐term follow‐ups, but the evidence is very uncertain (RR 1.18, 95% CI 0.55 to 2.50; I 2 = 54%; 4 studies, 462 participants; very low‐certainty evidence). Transitional discharge intervention may increase the levels of functioning after discharge (clinically important change in general functioning) (SMD 0.95, 95% CI −0.06 to 1.97; I² = 95%; 4 studies, 437 participants; very low‐certainty evidence) and may increase the proportion of participants who are satisfied with the intervention (clinically important change in satisfaction) (RR 1.96, 95% CI 1.37 to 2.80; 1 study, 76 participants; very low‐certainty evidence), but for both outcomes the evidence is very uncertain. Transitional discharge intervention may make little to no difference in quality of life compared to treatment as usual (SMD 0.24, 95% CI −0.30 to 0.78; I² = 90%; 4 studies, 748 participants; very low‐certainty evidence), but we are very uncertain. For direct costs, one study with 124 participants did not report full details and thus the results were inconclusive. Authors' conclusions There is currently no clear evidence for or against implementing transitional discharge interventions for people with schizophrenia. Transitional discharge interventions may improve patient satisfaction and functionality, but this evidence is also very uncertain. For future research, it is important to improve the quality of the conduct and reporting of these trials, including using validated tools for measuring their outcomes. Plain language summary What are the benefits of transitional discharge care for people with schizophrenia? Key messages – Transitional discharge care (an intervention that supports a person move from a stay in hospital to the community) may make little to no difference in admissions to hospital and quality of life, and may improve how well a person functions in day‐to‐day life and how happy they are with their treatment when they return home, but we are very uncertain about the results. – The results on costs of running the transitional discharge care program are inconclusive, and the studies provided no information on relapse (a new mental health crisis) or unwanted effects. – We need more and better studies to investigate how to support people with schizophrenia or schizophrenia‐related disorders during the transition from hospital to community. What is schizophrenia? Schizophrenia is a persistent and severe mental health condition where people have hallucinations (where they hear, see, smell, taste, or feel things that appear to be real but only exist in their mind) and delusions (a strong belief in something that is untrue), among other debilitating symptoms, leading to poor quality of life. People with schizophrenia‐related disorders have symptoms that are similar to those of schizophrenia. The illness varies, with people having different symptoms at different times, often with them requiring admission to hospital for treatment. What happens when a person with schizophrenia or schizophrenia‐related disorders is discharged from hospital? People with schizophrenia or schizophrenia‐related disorders are sometimes admitted to hospital to improve their health, and afterward, they are discharged to their homes or other care facilities. This transition might be difficult and frightening for them and their carers, and they may need help to adapt. There are some interventions to support people with schizophrenia or schizophrenia‐related disorders after they leave the hospital, such as case management with an expert guide or continuous care with a nurse. What is transitional discharge care? Transitional discharge care is an intervention which provides support to people leaving hospital to cover their medical, practical, and emotional needs. This starts before hospital discharge and continues until people are confident in their homes or care facilities. This may include help with housing; communicating and co‐ordinating among healthcare staff, patients, and families; planning meetings; sessions with families; visits to the neighborhood; talking therapy sessions; telephone and face‐to‐face support; and support groups focusing on recreation, medication, shopping, cooking, and financial responsibilities. What did we want to find out? We wanted to know whether transitional discharge care helps people with schizophrenia or schizophrenia‐related disorders when leaving the hospital, especially if it reduces the rate of a new mental health crisis (relapse), repeat admissions to hospital, overall functioning in day‐to‐day life, satisfaction with the care they receive, quality of life, unwanted effects, and costs. What did we do? We searched for studies that investigated whether transitional discharge care, compared to no transitional discharge care or usual care, was effective in adults with schizophrenia or schizophrenia‐related disorders. What did we find? We found 12 studies with 1748 people that compared transitional discharge care to usual care. Transitional discharge care may make little to no difference to admissions to hospital (4 studies, 462 people). Transitional discharge care may improve functioning (4 studies, 437 people) and may increase people's satisfaction with care (1 study, 76 people), but we are very uncertain about the results. Transitional discharge care may make little to no difference to quality of life (4 studies, 748 people). The results on costs were inconclusive as the study did not fully report the methods (1 study, 124 people). ​​ None of the included studies provided data for relapse or unwanted effects of transitional discharge care. What are the limitations of the evidence? All 12 studies had problems with their methods and results were inconsistent. Some studies included people with other mental disorders, so the results might not apply directly to people with schizophrenia or schizophrenia‐related disorders. Therefore, we have very low confidence in our findings. How up to date is this evidence? The evidence is up to date to December 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Roson Rodriguez, P; Chen, X; Arancibia, M; Garegnani, L; Escobar Liquitay, CM; Mohammad, HA; Franco, JVA", "articleTypes": [], "doi": "10.1002/14651858.CD009788.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "494efb21-9df8-44a0-9182-49b34311a937", "pmid": "", "title": "Chlorhexidine mouthrinse as an adjunctive treatment for gingival health", "imported": false, "abstract": "Abstract - Background Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build‐up of plaque thereby reducing gingivitis. Objectives To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day). To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs. Data collection and analysis Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random‐effects models for all meta‐analyses. Main results We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high‐quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high‐quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate‐quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies). Authors' conclusions There is high‐quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high‐quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies. Plain language summary Chlorhexidine mouthrinse to reduce gingivitis and plaque build‐up Review question Does the use of chlorhexidine mouthrinse (a broad spectrum antiseptic) in addition to other conventional tooth cleaning help to control and improve gingivitis (inflammation of the gums)? Does the frequency of rinsing or the concentration of the solution affect the result and are there any undesirable side effects? Background Gingivitis is a reversible condition when gums become red, swollen and can bleed easily. Gingivitis is also very common ‐ studies suggest that as many as 50% to 90% of adults in the UK and USA suffer from it. In susceptible people gingivitis may lead to periodontitis, which is not reversible. In periodontitis inflammation is accompanied by loss of ligaments and bone supporting the teeth. If untreated it may eventually lead to tooth loss. Severe periodontitis is the sixth most widespread disease globally. It is recognised that maintaining a high standard of oral hygiene is important for the prevention and treatment of gingivitis. Toothbrushing is the main method for maintaining good oral hygiene. Other cleaning methods commonly used include dental floss, interdental brushes and scaling and polishing carried out by a dental professional. Some people have difficulty controlling plaque build‐up and preventing gingivitis using only conventional tooth cleaning. Therefore people sometimes use mouthrinses containing chlorhexidine in addition to conventional tooth cleaning. These mouthrinses are readily available over the counter; prescriptions generally not being required outside the USA. Study characteristics We included 51 studies that analysed a total of 5345 participants. The evidence in this review is up to date as of 28 September 2016. Generally study participants were children and adults who had gingivitis or periodontitis, were able to use usual tooth cleaning methods and were healthy. We did not exclude studies where some or all participants had medical conditions or special care needs as we considered the use of mouthrinses with chlorhexidine to be particularly relevant to them. The included studies assessed the effects of chlorhexidine mouthrinse used for at least 4 weeks in addition to conventional tooth cleaning on gingivitis in children and adults. Key results There is high‐quality evidence that the use of mouthrinses containing chlorhexidine in addition to usual toothbrushing and cleaning for 4 to 6 weeks or 6 months leads to a large reduction in the build‐up of plaque. There is also high‐quality evidence of a moderate reduction in gingivitis in people with a mild level of it, although because the level of disease was already low this is not considered clinically important. The nature of the available evidence does not allow us to determine the level of reduction of gingivitis in people with moderate to severe levels of it. There was no evidence that one concentration or strength of chlorhexidine rinse was more effective than another. Rinsing for 4 weeks or longer causes tooth staining, which requires scaling and polishing carried out by a dental professional. Other side effects have been reported, including build‐up of calculus (tartar), temporary taste disturbance and temporary shedding of/damage to the lining of the mouth. Quality of the evidence One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "James, P; Worthington, HV; Parnell, C; Harding, M; Lamont, T; Cheung, A; Whelton, H; Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD008676.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "495a37b2-714c-42a6-a891-2f5a1f1e7cf9", "pmid": "", "title": "Nutritional supplementation for hip fracture aftercare in older people", "imported": false, "abstract": "Abstract - Background Older people with hip fractures are often malnourished at the time of fracture, and subsequently have poor food intake. This is an update of a Cochrane review first published in 2000, and previously updated in 2010. Objectives To review the effects (benefits and harms) of nutritional interventions in older people recovering from hip fracture. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, MEDLINE In‐Process & Other Non‐Indexed Citations, Embase, CAB Abstracts, CINAHL, trial registers and reference lists. The search was last run in November 2015. Selection criteria Randomised and quasi‐randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture where the interventions were started within the first month after hip fracture. Data collection and analysis Two review authors independently selected trials, extracted data and assessed risk of bias. Where possible, we pooled data for primary outcomes which were: all cause mortality; morbidity; postoperative complications (e.g. wound infections, pressure sores, deep venous thromboses, respiratory and urinary infections, cardiovascular events); and 'unfavourable outcome' defined as the number of trial participants who died plus the number of survivors with complications. We also pooled data for adverse events such as diarrhoea. Main results We included 41 trials involving 3881 participants. Outcome data were limited and risk of bias assessment showed that trials were often methodologically flawed, with less than half of trials at low risk of bias for allocation concealment, incomplete outcome data, or selective reporting of outcomes. The available evidence was judged of either low or very low quality indicating that we were uncertain or very uncertain about the estimates. Eighteen trials evaluated oral multinutrient feeds that provided non‐protein energy, protein, vitamins and minerals. There was low‐quality evidence that oral feeds had little effect on mortality (24/486 versus 31/481; risk ratio (RR) 0.81 favouring supplementation, 95% confidence interval (CI) 0.49 to 1.32; 15 trials). Thirteen trials evaluated the effect of oral multinutrient feeds on complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was low‐quality evidence that the number of participants with complications may be reduced with oral multinutrient feeds (123/370 versus 157/367; RR 0.71, 95% CI 0.59 to 0.86; 11 trials). Based on very low‐quality evidence from six studies (334 participants), oral supplements may result in lower numbers with 'unfavourable outcome' (death or complications): RR 0.67, 95% CI 0.51 to 0.89. There was very low‐quality evidence for six studies (442 participants) that oral supplementation did not result in an increased incidence of vomiting and diarrhoea (RR 0.99, 95% CI 0.47 to 2.05). Only very low‐quality evidence was available from the four trials examining nasogastric multinutrient feeding. Pooled data from three heterogeneous trials showed no evidence of an effect of supplementation on mortality (14/142 versus 14/138; RR 0.99, 95% CI 0.50 to 1.97). One trial (18 participants) found no difference in complications. None reported on unfavourable outcome. Nasogastric feeding was poorly tolerated. One study reported no cases of aspiration pneumonia. There is very low‐quality evidence from one trial (57 participants, mainly men) of no evidence for an effect of tube feeding followed by oral supplementation on mortality or complications. Tube feeding, however, was poorly tolerated. There is very low‐quality evidence from one trial (80 participants) that a combination of intravenous feeding and oral supplements may not affect mortality but could reduce complications. However, this expensive intervention is usually reserved for people with non‐functioning gastrointestinal tracts, which is unlikely in this trial. Four trials tested increasing protein intake in an oral feed. These provided low‐quality evidence for no clear effect of increased protein intake on mortality (30/181 versus 21/180; RR 1.42, 95% CI 0.85 to 2.37; 4 trials) or number of participants with complications but very low‐quality and contradictory evidence of a reduction in unfavourable outcomes (66/113 versus 82/110; RR 0.78, 95% CI 0.65 to 0.95; 2 trials). There was no evidence of an effect on adverse events such as diarrhoea. Trials testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. Based on low‐quality evidence, one trial evaluating the use of dietetic assistants to help with feeding indicated that this intervention may reduce mortality (19/145 versus 36/157; RR 0.57, 95% CI 0.34 to 0.95) but not the number of participants with complications (79/130 versus 84/125). Authors' conclusions There is low‐quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low‐quality evidence that oral supplements may reduce 'unfavourable outcome' (death or complications) and that they do not result in an increased incidence of vomiting and diarrhoea. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding or nasogastric feeding in very malnourished people require further evaluation. Plain language summary Nutritional supplementation for older people after hip fracture Background and aim Older people with hip fractures are often malnourished at the time of their fracture and many have poor food intake while in hospital. Malnutrition may hinder recovery after hip fracture. We reviewed the effects of nutritional interventions in older people recovering from hip fracture. Search results We searched the scientific literature up to November 2015 and include 41 studies including 3881 participants. All nutritional interventions were started within one month of hip fracture. The studies had flaws in their methods that may affect the validity of their results. Some evidence was very low quality which means we are very unsure of the results. Key results Eighteen studies examined the use of additional oral feeds that provided energy from sources other than protein, protein, some vitamins and minerals. There was low‐quality evidence that these multinutrient oral feeds may not reduce mortality but that they may reduce the number of people with complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was very low‐quality evidence that oral multinutrient feeds may reduce unfavourable outcome (death or complications) and that they did not result in increased vomiting and diarrhoea. Four studies examined nasogastric tube feeding, where liquid food is delivered via a tube inserted into the nose and passed down into the stomach, with non‐protein energy, protein, some vitamins and minerals. These studies provided very low‐quality evidence that tube feeding, which was poorly tolerated, did not seem to make a difference to mortality or complications. Unfavourable outcome was not recorded and there was insufficient evidence on adverse events. One study provided very low‐quality evidence that nasogastric tube feeding followed by oral feeds may not affect mortality or complications. It reported that tube feeding was poorly tolerated. One study provided very low‐quality evidence that giving feed into a vein initially and then by mouth may not affect mortality but may reduce complications. However, we were surprised that this intervention was being used in people who seemed to be able to take nutrition orally. Increasing protein intake in an oral feed was tested in four studies. These provided low‐quality evidence of no clear effect on mortality or complications and very low‐quality evidence for a reduction in unfavourable outcome. Studies testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. One study, evaluating the use of dietetic assistants to help with feeding, provided low‐quality evidence that this may reduce mortality but not the numbers of people with complications. Conclusions Oral supplements with non‐protein energy, protein, vitamins and minerals started before or soon after surgery may prevent complications after hip fracture in older people but may not affect mortality. Adequately sized randomised studies with better design are required. We suggest that the role of dietetic assistants, and of peripheral venous feeding or nasogastric feeding in very malnourished patients, require further evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Avenell, A, Smith, TO, Curtain, JP, Mak, JCS, Myint, PK", "articleTypes": [], "doi": "10.1002/14651858.CD001880.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.110Z" }, { "id": "49876aac-71e4-48ef-9b7d-5a029425698d", "pmid": "", "title": "The Effects of Semaglutide on Modulation of Taste Sensitivity, Tongue Tissue Transcriptome, Gastric Emptying and Central Neural Responses in Women With PCOS and Obesity: a Randomized, Single-blind, Placebo-controlled Clinical Trial", "imported": false, "abstract": "The purpose of the study is to explore the effects of GLP-1 receptor agonist (GLP-1 RA) semaglutide on modulation of taste sensitivity, tongue tissue transcriptome, modulation of neural response in central reward processing regions and gastric emptying rate. In addition, we aim to investigate the associations between semaglutide induced modulation of taste sensitivity, neural responses and gastric emptying with changes in body mass, eating- behavioural pattern, food perception and food intake.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.235Z" }, { "id": "4987ddeb-d8cf-462f-9c1a-e483a01317c0", "pmid": "", "title": "Ghrelin for the management of cachexia associated with cancer", "imported": false, "abstract": "Abstract - Background Cancer sufferers are amongst the most malnourished of all the patient groups. Studies have shown that ghrelin, a gut hormone can be a potential therapeutic agent for cachexia (wasting syndrome) associated with cancer. A variety of mechanisms of action of ghrelin in people with cancer cachexia have been proposed. However, safety and efficacy of ghrelin for cancer‐associated cachexia have not been systematically reviewed. The aim of this review was to assess whether ghrelin is associated with better food intake, body composition and survival than other options for adults with cancer cachexia. Objectives To assess the efficacy and safety of ghrelin in improving food intake, body composition and survival in people with cachexia associated with cancer. Search methods We searched CENTRAL, MEDLINE and Embase without language restrictions up to July 2017. We also searched for ongoing studies in trials registers, performed handsearching, checked bibliographic references of relevant articles and contacted authors and experts in the field to seek potentially relevant research. We applied no restrictions on language, date, or publication status. Selection criteria We included randomised controlled (parallel‐group or cross‐over) trials comparing ghrelin (any formulation or route of administration) with placebo or an active comparator in adults (aged 18 years and over) who met any of the international criteria for cancer cachexia. Data collection and analysis Two review authors independently assessed studies for eligibility. Two review authors then extracted data and assessed the risk of bias for individual studies using standard Cochrane methodology. For dichotomous variables, we planned to calculate risk ratio with 95% confidence intervals (CI) and for continuous data, we planned to calculate mean differences (MD) with 95% CI. We assessed the evidence using GRADE and created 'Summary of findings' tables. Main results We screened 926 individual references and identified three studies that satisfied the inclusion criteria. Fifty‐nine participants (37 men and 22 women) aged between 54 and 78 years were randomised initially, 47 participants completed the treatment. One study had a parallel design and two had a cross‐over design. The studies included people with a variety of cancers and also differed in the dosage, route of administration, frequency and duration of treatment. One trial, which compared ghrelin with placebo, found that ghrelin improved food intake (very low‐quality evidence) and had no adverse events (very low‐quality evidence). Due to unavailability of data we were unable to report on comparisons for ghrelin versus no treatment or alternative experimental treatment modalities, or ghrelin in combination with other treatments or ghrelin analogues/ghrelin mimetics/ghrelin potentiators. Two studies compared a higher dose of ghrelin with a lower dose of ghrelin, however due to differences in study designs and great diversity in the treatment provided we did not pool the results. In both trials, food intake did not differ between participants on higher‐dose and lower‐dose ghrelin. None of the included studies assessed data on body weight. One study reported higher adverse events with a higher dose as compared to a lower dose of ghrelin. All studies were at high risk of attrition bias and bias for size of the study. Risk of bias in other domains was unclear or low. We rated the overall quality of the evidence for primary outcomes (food intake, body weight, adverse events) as very low. We downgraded the quality of the evidence due to lack of data, high or unclear risk of bias of the studies and small study size. Authors' conclusions There is insufficient evidence to be able to support or refute the use of ghrelin in people with cancer cachexia. Adequately powered randomised controlled trials focusing on evaluation of safety and efficacy of ghrelin in people with cancer cachexia is warranted. Plain language summary Ghrelin, a hunger hormone for management of cancer patients with loss of appetite and weight loss Bottom line There is no good evidence to support or reject the suggestion that ghrelin is useful in the management of cancer patients with loss of appetite and weight loss. There is insufficient evidence to recommend it for clinical practice. Background Sixty to eighty percent of cancer patients suffer from loss of appetite and weight loss, which in turn is associated with decreased life expectancy and quality of life. Ghrelin, a hunger hormone is secreted by the stomach and other organs of the body. Studies have shown that ghrelin can be used in treatment for loss of appetite and weight loss in cancer patients. However, the effectiveness and safety of ghrelin in such people have not been assessed. In this review we set out to examine all evidence on the effectiveness and safety of ghrelin in improving appetite and body weight in cancer patients with loss of appetite and weight loss. Search date The evidence is current to 20th July 2017. Study characteristics We found three studies that recruited a total of 59 cancer patients (37 men and 22 women) aged between 54 and 78 years. Forty‐seven cancer patients completed the treatment. Studies differed in study design and included people with a variety of cancers. Studies also differed in dosage, route of injection, frequency and duration of treatment. One study compared ghrelin with a placebo while two studies compared different doses of ghrelin (higher dose with lower dose). Outcomes of interest to cancer patients with loss of appetite and weight loss, such as improvement in food intake and improvement in body weight, were not adequately reported. All three included studies were funded by government agencies. One study received an additional grant from a pharmaceutical company. Key findings We found insufficient evidence that using ghrelin demonstrated differences in food intake. We found no evidence that using ghrelin alone or in combination made any difference to body weight. We could not reach any conclusions about its side effects. The limited amount of information means that we could not draw any conclusions. Quality of the evidence We rated the quality of evidence from studies using four levels: high, moderate, low, or very low. High‐quality evidence means that we are very confident in the results. Very low‐quality evidence means that we are very uncertain about the results. The evidence in this review was of very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Khatib, MN, Shankar, AH, Kirubakaran, R, Gaidhane, A, Gaidhane, S, Simkhada, P, Quazi Syed, Z", "articleTypes": [], "doi": "10.1002/14651858.CD012229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.776Z" }, { "id": "49c38af2-68c4-443d-a6dc-1ae5411358bf", "pmid": "", "title": "Eszopiclone for insomnia", "imported": false, "abstract": "Abstract - Background Insomnia is a major public health issue affecting between 6% to 10% of the adult population in Western countries. Eszopiclone is a hypnotic drug belonging to a newer group of hypnotic agents, known as new generation hypnotics, which was marketed as being just as effective as benzodiazepines for this condition, while being safer and having a lower risk for abuse and dependence. It is the aim of the review to integrate evidence from randomised controlled trials and to draw conclusions on eszopiclone's efficacy and safety profile, while taking methodological features and bias risks into consideration. Objectives To assess the efficacy and safety of eszopiclone for the treatment of insomnia compared to placebo or active control. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, Embase, PsycINFO, PSYNDEX and registry databases (WHO trials portal, ClinicalTrials.gov) with results incorporated from searches to 10 February 2016. To identify trials not registered in electronic databases, we contacted key informants and searched reference lists of identified studies. We ran an update search (21 February 2018) and have placed studies of interest in awaiting classification/ongoing studies. These will be incorporated into the next version of the review, as appropriate. Selection criteria Parallel group randomised controlled trials (RCTs) comparing eszopiclone with either placebo or active control were included in the review. Participants were adults with insomnia, as diagnosed with a standardised diagnostic system, including primary insomnia and comorbid insomnia. Data collection and analysis Two authors independently extracted outcome data; one reviewer assessed trial quality and the second author cross‐checked it. Main results A total of 14 RCTs, with 4732 participants, were included in this review covering short‐term (≤ 4 weeks; 6 studies), medium‐term (> 4 weeks ≤ 6 months; 6 studies) and long‐term treatment (> 6 months; 2 studies) with eszopiclone. Most RCTs included in the review included participants aged between 18 and 64 years, three RCTs only included elderly participants (64 to 85 years) and one RCT included participants with a broader age range (35 to 85 years). Seven studies considered primary insomnia; the remaining studies considered secondary insomnia comorbid with depression (2), generalised anxiety (1), back pain (1), Parkinson's disease (1), rheumatoid arthritis (1) and menopausal transition (1). Meta‐analytic integrations of participant‐reported data on sleep efficacy outcomes demonstrated better results for eszopiclone compared to placebo: a 12‐minute decrease of sleep onset latency (mean difference (MD) ‐11.94 min, 95% confidence interval (CI) ‐16.03 to ‐7.86; 9 studies, 2890 participants, moderate quality evidence), a 17‐minute decrease of wake time after sleep onset (MD ‐17.02 min, 95% CI ‐24.89 to ‐9.15; 8 studies, 2295 participants, moderate quality evidence) and a 28‐minute increase of total sleep time (MD 27.70 min, 95% CI 20.30 to 35.09; 10 studies, 2965 participants, moderate quality evidence). There were no significant changes from baseline to the first three nights after drug discontinuation for sleep onset latency (MD 17.00 min, 95% CI ‐4.29 to 38.29; 1 study, 291 participants, low quality evidence) and wake time after sleep onset (MD ‐6.71 min, 95% CI ‐21.25 to 7.83; 1 study, 291 participants, low quality evidence). Adverse events during treatment that were documented more frequently under eszopiclone compared to placebo included unpleasant taste (risk difference (RD) 0.18, 95% CI 0.14 to 0.21; 9 studies, 3787 participants), dry mouth (RD 0.04, 95% CI 0.02 to 0.06; 6 studies, 2802 participants), somnolence (RD 0.04, 95% CI 0.02 to 0.06; 8 studies, 3532 participants) and dizziness (RD 0.03, 95% CI 0.01 to 0.05; 7 studies, 2933 participants). According to the GRADE criteria, evidence was rated as being of moderate quality for sleep efficacy outcomes and adverse events and of low quality for rebound effects and next‐day functioning. Authors' conclusions Eszopiclone appears to be an efficient drug with moderate effects on sleep onset and maintenance. There was no or little evidence of harm if taken as recommended. However, as certain patient subgroups were underrepresented in RCTs included in the review, findings might not have displayed the entire spectrum of possible adverse events. Further, increased caution is required in elderly individuals with cognitive and motor impairments and individuals who are at increased risk of using eszopiclone in a non‐recommended way. Plain language summary Eszopiclone (Lunesta) for sleep difficulty Why is this review important? Insomnia is the medical term for sleep difficulty covering trouble falling asleep, difficulties staying asleep, waking up too early or experiencing sleep as non‐restorative. Insomnia can be treated with different methods including behaviour modification, relaxation techniques, or sleeping medication. Eszopiclone (Lunesta) is a sleeping medication that belongs to a class of sleeping tablets known as non‐benzodiazepine hypnotics. Who will be interested in this review? People who are affected by insomnia, general practitioners, professionals working in health services, and addiction treatment and health policy makers. What questions does this review aim to answer? The review aimed to find out more about the wanted effects and unwanted effects of eszopiclone. Wanted effects included the immediate effects eszopiclone has on sleep; unwanted effects included side effects, effects on next‐day functioning, but also addictive properties of the drug. Which studies were included in the review? The review summarised findings from 14 clinical studies with 4732 people, either receiving eszopiclone or an identically‐appearing, but inert substance (placebo). What does the evidence from the review tell us? On average, people taking eszopiclone fell asleep 12 minutes faster than those taking placebo, were 17 minutes less awake during the night and had, in total, about half an hour more sleep than people in the placebo group. As side effects, eszopiclone can cause unpleasant taste, dizziness, dry mouth, and tiredness during the day. Clinical studies did not find evidence that eszopiclone was causing serious harm or withdrawal symptoms or whether it was addictive if it was stopped and not taken after several weeks or months of treatment. Nevertheless, as clinical studies included in the review did not cover certain groups (e.g. elderly people with cognitive or motor problems or certain conditions of medication intake), it is important for patients to consult their doctor who knows their medical history and condition. What should happen next? Future research needs to compare eszopiclone with other sleep medications to help physicians and patients decide which of the available treatment options to prefer. In addition, sleep medications that are also well tolerated by elderly individuals and individuals with alcohol or drug problems need to be identified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rösner, S; Englbrecht, C; Wehrle, R; Hajak, G; Soyka, M", "articleTypes": [], "doi": "10.1002/14651858.CD010703.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "49c54671-3d11-4b33-800f-f04ed0659b82", "pmid": "", "title": "Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors", "imported": false, "abstract": "Abstract - Background Poor diet and insufficient physical activity are major risk factors for non‐communicable diseases. Developing healthy diet and physical activity behaviors early in life is important as these behaviors track between childhood and adulthood. Parents and other adult caregivers have important influences on children's health behaviors, but whether their involvement in children's nutrition and physical activity interventions contributes to intervention effectiveness is not known. Objectives • To assess effects of caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors, including those intended to prevent overweight and obesity • To describe intervention content and behavior change techniques employed, drawing from a behavior change technique taxonomy developed and advanced by Abraham, Michie, and colleagues (Abraham 2008; Michie 2011; Michie 2013; Michie 2015) • To identify content and techniques related to reported outcomes when such information was reported in included studies Search methods In January 2019, we searched CENTRAL, MEDLINE, Embase, 11 other databases, and three trials registers. We also searched the references lists of relevant reports and systematic reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of interventions to improve children's dietary intake or physical activity behavior, or both, with children aged 2 to 18 years as active participants and at least one component involving caregivers versus the same interventions but without the caregiver component(s). We excluded interventions meant as treatment or targeting children with pre‐existing conditions, as well as caregiver‐child units residing in orphanages and school hostel environments. Data collection and analysis We used standard methodological procedures outlined by Cochrane. Main results We included 23 trials with approximately 12,192 children in eligible intervention arms. With the exception of two studies, all were conducted in high‐income countries, with more than half performed in North America. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The specific intervention strategies used were not always reported completely. However, based on available reports, the behavior change techniques used most commonly in the child‐only arm were \"shaping knowledge,\" \"comparison of behavior,\" \"feedback and monitoring,\" and \"repetition and substitution.\" In the child + caregiver arm, the strategies used most commonly included additional \"shaping knowledge\" or \"feedback and monitoring\" techniques, as well as \"social support\" and \"natural consequences.\" We considered all trials to be at high risk of bias for at least one design factor. Seven trials did not contribute any data to analyses. The quality of reporting of intervention content varied between studies, and there was limited scope for meta‐analysis. Both validated and non‐validated instruments were used to measure outcomes of interest. Outcomes measured and reported differed between studies, with 16 studies contributing data to the meta‐analyses. About three‐quarters of studies reported their funding sources; no studies reported industry funding. We assessed the quality of evidence to be low or very low. Dietary behavior change interventions with a caregiver component versus interventions without a caregiver component Seven studies compared dietary behavior change interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (mean difference [MD] −0.42%, 95% confidence interval [CI] −1.25 to 0.41, 1 study, n = 207; low‐quality evidence) or from sodium intake (MD −0.12 g/d, 95% CI −0.36 to 0.12, 1 study, n = 207; low‐quality evidence). No trial in this comparison reported data for children's combined fruit and vegetable intake, sugar‐sweetened beverage (SSB) intake, or physical activity levels, nor for adverse effects of interventions. Physical activity interventions with a caregiver component versus interventions without a caregiver component Six studies compared physical activity interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's total physical activity (MD 0.20 min/h, 95% CI −1.19 to 1.59, 1 study, n = 54; low‐quality evidence) or moderate to vigorous physical activity (MVPA) (standard mean difference [SMD] 0.04, 95% CI −0.41 to 0.49, 2 studies, n = 80; moderate‐quality evidence). No trial in this comparison reported data for percentage of children's total energy intake from saturated fat, sodium intake, fruit and vegetable intake, or SSB intake, nor for adverse effects of interventions. Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component Ten studies compared dietary and physical activity interventions with and without a caregiver component. At the end of the intervention, we detected a small positive impact of a caregiver component on children's SSB intake (SMD −0.28, 95% CI −0.44 to −0.12, 3 studies, n = 651; moderate‐quality evidence). We did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (MD 0.06%, 95% CI −0.67 to 0.80, 2 studies, n = 216; very low‐quality evidence), sodium intake (MD 35.94 mg/d, 95% CI −322.60 to 394.47, 2 studies, n = 315; very low‐quality evidence), fruit and vegetable intake (MD 0.38 servings/d, 95% CI −0.51 to 1.27, 1 study, n = 134; very low‐quality evidence), total physical activity (MD 1.81 min/d, 95% CI −15.18 to 18.80, 2 studies, n = 573; low‐quality evidence), or MVPA (MD −0.05 min/d, 95% CI −18.57 to 18.47, 1 study, n = 622; very low‐quality evidence). One trial indicated that no adverse events were reported by study participants but did not provide data. Authors' conclusions Current evidence is insufficient to support the inclusion of caregiver involvement in interventions to improve children's dietary intake or physical activity behavior, or both. For most outcomes, the quality of the evidence is adversely impacted by the small number of studies with available data, limited effective sample sizes, risk of bias, and imprecision. To establish the value of caregiver involvement, additional studies measuring clinically important outcomes using valid and reliable measures, employing appropriate design and power, and following established reporting guidelines are needed, as is evidence on how such interventions might contribute to health equity. Plain language summary Effects of involving parents and other adult caregivers in children's diet and physical activity interventions Review question Does it make a difference if parents or other adult caregivers are involved in interventions to encourage children to eat healthier or be more physically active? Background Diet and physical activity behaviors are important determinants of health. Parents and other adult caregivers have an essential role in shaping children's health habits by controlling availability of and access to healthy foods and opportunities to be active; supporting, encouraging, and role‐modeling healthy behaviors; and adopting supportive feeding styles and practices. For these reasons, it often is argued that parent and caregiver involvement in children's diet and physical activity interventions is important; however, it remains unclear if involvement of parents and caregivers actually provides benefit. Objectives We assessed the effects of involving parents or other adult caregivers in children's healthy eating and physical activity interventions compared to the effects of the same child interventions without a parent or caregiver component. We were particularly interested in understanding effects on children's dietary intake, children's physical activity levels, and adverse effects of interventions. Study characteristics We found 23 studies, published between 1982 and 2019, that implemented diet interventions, physical activity interventions, or combined diet and physical activity interventions with children or adolescents, and evaluated the effects of adding an intervention component involving parents or other adult caregivers. Approximately 12,192 children aged 2 to 18 years were examined. More than half of studies took place in North America, and all but two were conducted in high‐income countries. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The breadth of information provided about intervention content varied between studies. The most commonly used intervention techniques were those aimed at shaping participants' knowledge, such as providing instruction about how to perform a behavior (e.g. dance, cooking lessons). About three‐quarters of studies reported their funding source; no studies reported industry funding. Key results The findings of this review suggest that adding a parent or caregiver component to dietary behavior change interventions or physical activity interventions may make little or no difference to children's dietary intake or physical activity levels. For interventions that target both diet and physical activity behaviors, involving a parent or caregiver probably slightly reduces children's sugar‐sweetened beverage intake by the end of the intervention. We do not know whether any of these types of interventions result in adverse effects because these data are not available. Quality of evidence Overall, the evidence from studies is of low or very low quality, which means that we are uncertain about study results. Currentness of evidence The evidence is current to January 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Morgan, EH, Schoonees, A, Sriram, U, Faure, M, Seguin‐Fowler, RA", "articleTypes": [], "doi": "10.1002/14651858.CD012547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.144Z" }, { "id": "49e8d5f3-8516-4f80-aba8-f8e429235931", "pmid": "", "title": "D‐penicillamine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is used for patients with primary biliary cirrhosis due to its hepatic copper decreasing and immunomodulatory potentials. The results from randomised clinical trials have been inconsistent. Objectives To systematically review the beneficial and harmful effects of D‐penicillamine for patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register (September 2003), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2003) , MEDLINE (January 1966 to September 2003) , EMBASE (January 1980 to September 2003) , The Chinese Biomedical CD Database (January 1979 to August 2003) , and LILACS (1982 to 2003); through manual searches of bibliographies; and by contacting authors of the trials and pharmaceutical companies. Selection criteria We included randomised clinical trials comparing D‐penicillamine with placebo/no intervention or other control intervention irrespective of language, year of publication, and publication status. Data collection and analysis Two reviewers independently assessed the methodological quality of the trials and extracted data, validated by a third reviewer. The primary outcomes were 1) mortality and 2) a combination of those who died or underwent liver transplantation. We analysed dichotomous outcomes as relative risk (RR) with 95% confidence interval (CI) by a fixed effect model and a random effects model. We investigated sources of heterogeneity by subgroup analyses and tested the robustness of our findings by sensitivity analyses. Main results We included seven trials randomising 706 patients with primary biliary cirrhosis. D‐penicillamine compared with placebo/no intervention tended to increase mortality (RR 1.34, 95% CI 1.09 to 1.64, fixed; RR 1.46, 95% CI 0.85 to 2.50, random). However, there was substantial heterogeneity. No significant differences were detected regarding the risks of mortality or liver transplantation, pruritus, liver complications, progression of liver histological stage, or the levels of liver biochemical variables (except alanine aminotransferase). D‐penicillamine versus placebo/no intervention significantly increased the risk of adverse events (RR 3.11, 95% CI 2.33 to 4.16, fixed; RR 4.18, 95% CI 1.38 to 12.69, random). Authors' conclusions D‐penicillamine did not appear to reduce the risk of mortality, but significantly increased the occurrences of adverse events in patients with primary biliary cirrhosis. We do not support the use of D‐penicillamine for patients with primary biliary cirrhosis. Plain language summary D‐penicillamine did not reduce the risk of mortality of patients with primary biliary cirrhosis but increased the occurrences of adverse events Primary biliary cirrhosis is an uncommon, chronic liver disease of unknown etiology. D‐penicillamine, a cupruretic drug, has been tested in randomised clinical trials and is used to treat patients with primary biliary cirrhosis. After combining results from seven trials, D‐penicillamine did not appear to improve survival of patients. D‐penicillamine was associated with a four‐time increase of adverse events. There were no significant differences between D‐penicillamine and placebo/no intervention with respect to clinical changes, liver histology, and liver biochemistry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y; Klingenberg, SL; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004789.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "4a02406a-8dd8-4b30-8c75-f9d2733e6605", "pmid": "", "title": "Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease", "imported": false, "abstract": "Abstract - Background Catheter malfunction, including thrombosis, is associated with reduced dialysis adequacy, as well as an increased risk of catheter‐related bacteraemia and mortality. The role of anticoagulants in the prevention of catheter malfunction remains uncertain. Objectives This review aimed to compare the prophylactic effect of different anticoagulant agents, preparations, doses and administration on the incidence of central venous haemodialysis catheter‐related malfunction and sepsis in patients with end‐stage kidney disease (ESKD). Search methods We searched the Cochrane Renal Group's Specialised Register to 7 January 2016 through contact with the Trials' Search Co‐ordinator using search terms relevant to this review. Selection criteria We included all randomised controlled trials (RCT) assessing anticoagulants compared with conventional care for the prevention of catheter malfunction in adult patients receiving haemodialysis for ESKD. Data collection and analysis The primary outcome was catheter malfunction defined as a catheter blood flow of 200 mL/min or less, or as defined by study authors. Secondary outcomes were catheter‐related bacteraemia, all‐cause mortality and bleeding events. Relative risks (RR) with 95% confidence intervals (CI) for individual studies were pooled using random effects models within treatment classes. Analyses were conducted by class, with subgroup analyses performed of individual agents within classes. Main results We included 27 studies (3003 participants) that were followed up for a median of six months. Study interventions included alternative anticoagulant locking solutions (19 studies, 2216 patients), systemic agents (6 studies, 664 patients) and low or no dose heparin (2 studies, 123 patients). The most common comparison treatment was a locking solution of heparin 5000 IU/mL, used in 17 studies. No significant effect on catheter malfunction was observed for alternative anticoagulant locking solutions (RR 0.96, 95% CI 0.74 to 1.26), systemic agents (RR 0.59, 95% CI 0.28 to 1.23), or low or no dose heparin (RR 0.90, 95% CI 0.10 to 8.31). A significant reduction on incidence of catheter‐related bacteraemia was observed for alternative anticoagulant locking solutions (RR 0.46, 95% CI 0.32 to 0.66) but not systemic agents (RR 2.41, 95% CI 0.89 to 6.55), and could not be assessed in reports of low or no dose heparin studies. No significant effect on all‐cause mortality was observed for alternative anticoagulant locking solutions (RR 0.88, 95% CI 0.54 to 1.43) or systemic agents (RR 0.78, 95% CI 0.37 to 1.65), and was not reported in studies of low or no dose heparin. Bleeding events were only reported in eight studies, including only 2/5 studies of systemic warfarin, with no clear effect demonstrated (RR 1.43, 95% CI 0.86 to 2.39). For individual agents, recombinant tissue plasminogen (rt‐PA) was the only locking solution shown to reduce catheter malfunction (RR 0.58, 95% CI 0.37 to 0.91) based on the results of a single study. No significant on catheter malfunction was observed for other individual classes of alternative anticoagulant locking solutions (citrate: RR 1.14, 95% CI 0.76 to 1.69; antibiotic: RR 1.48, 95% CI 0.79 to 2.77; ethanol: RR 0.88, 95% CI 0.21 to 3.67). On the other hand, all individual classes of alternative anticoagulant locking solutions, except ethanol, reduced catheter‐related bacteraemia (citrate: RR 0.49, 95% CI 0.36 to 0.68; antibiotic: RR 0.27, 95% CI 0.11 to 0.70; rt‐PA: RR 0.35, 95% CI 0.13 to 0.93; ethanol: RR 0.33, 95% CI 0.03 to 4.05). No significant effect on all‐cause mortality was observed for any individual agent within the class of alternative locking solutions. Studies were mainly of low quality and underpowered with an average participant number of 75 and study duration of six months. The interpretation of the study evidence was further limited by the variation in tested interventions and outcome reporting. Authors' conclusions The relative net benefit of anticoagulant therapies for prevention of catheter malfunction remains uncertain. Multiple agents appear to reduce catheter‐related bacteraemia although the lack of clear assessment of harms and the limitations of study quality mean these results should be interpreted with caution. Methodological approaches can be used to avoid methods of reporting unduly affecting on the results of meta‐analyses incorporating studies employed mixed reporting methods. Further high quality randomised studies, including safety outcomes, are needed. Plain language summary Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease Background Patients with end‐stage kidney disease require vascular access during haemodialysis. Central venous haemodialysis catheters are frequently used when permanent vascular access is not available. Catheter problems contribute to greater morbidity and mortality. Catheter malfunction leads to requirements for additional interventions, increased risk of catheter‐related infection and hospitalisation. Standard care for the prevention of catheter malfunction is the use of heparin solutions as a post dialysis ‘lock’ in the catheter ports. The potential impact of heparin treatment on bleeding risk is an acknowledged concern. Therefore newer approaches have been proposed to seek improvements in catheter patency or treatment‐associated harm rates. Study characteristics This review focused on randomised controlled trials (RCTs) of anticoagulants compared with conventional care for the prevention of catheter malfunction patients receiving haemodialysis. Key results We found 27 studies, involving 3003 patients followed for an average six months, which assessed alternative anticoagulant locking solutions, systemic agents and low or no dose heparin. Catheter malfunction were not affected by any of these classes of agents. Subgroup analysis showed that the only agent reducing catheter malfunction was recombinant tissue plasminogen locking solution based on the results of a single study. A significant reduction was observed on the incidence of catheter‐related bacteraemia for alternative anticoagulant locking solutions. There was no evidence to suggest that alternative anticoagulants to heparin locking solutions had an effect on death rates or bleeding events, although only a small proportion of studies reported bleeding events. Quality of the evidence Further high quality information is needed on both potential benefits and safety of alternative approaches to maintaining dialysis access catheter function.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Wang, Y, Ivany, JN, Perkovic, V, Gallagher, MP, Woodward, M, Jardine, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD009631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.768Z" }, { "id": "4a1f0758-f0d5-4b8a-843d-0e437724f7be", "pmid": "", "title": "Herbal interventions for chronic asthma in adults and children", "imported": false, "abstract": "Abstract - Background Herb and plant based preparations are a popular treatment for asthma, although there remain concerns as to their efficacy and safety. In Western societies, motivations for using such treatments may be both positive and negative, with their perceived safety and dissatisfaction with conventional medicine among them. In China such treatments are more commonly used and many compounds considered 'conventional' are derived from herbs or plants. Objectives To assess the efficacy and safety of herb and plant extracts in the management of chronic asthma. Search methods The Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, EMBASE and AMED were searched with pre‐defined terms. Searches are current as of February 2007. Selection criteria Randomised placebo controlled trials of any herb or plant extract were eligible. Study participants had to have a primary diagnosis of asthma. Studies in both adults and children were eligible for the review. Data collection and analysis Two reviewers assessed studies for suitability. Data were extracted and double‐checked. Main results Twenty‐seven studies (29 experimental groups) met the review entry criteria, randomising a total of 1925 participants. The studies identified assessed the effects of 21 different herbal preparations. Study quality varied considerably, and the sample sizes were often small. For primary outcomes (exacerbations, steroids use and lung function measurements): Two out of six studies reporting change in FEV1 were positive, with very few data available on the frequency of exacerbations. One study which did report these data was negative. Health‐related quality of life was only measured in one trial. Authors' conclusions The evidence base for the effects of herbal treatments is hampered by the variety of treatments assessed, poor reporting quality of the studies and lack of available data. The data that are available from the studies provide only a small insight into the long‐term efficacy and harm profiles of these treatments. The absence of common endpoint measurements limits the validity of our findings further. Positive findings in this review warrant additional well‐designed trials in this area. Plain language summary Herbal interventions for chronic asthma in adults and children Chronic asthma is a inflammatory disease of the airways characterised by wheeze and breathlessness. Drug therapy is usually used to control symptoms but complementary medicine is often used, including herbal treatments, and the efficacy and safety of such treatments is not clear. We reviewed evidence from 27 trials covering 21 different herbal treatments in both adults and children from both in‐patient and out‐patient settings. In general, the reporting of trials was poor. The outcomes measured by the trials varied considerably which made it difficult to compare the results of studies that did look at the same treatment. On the basis of the available evidence it is not possible to show whether any of these herbal treatments can improve asthma symptoms. Further trials of high quality are needed to assess the use of herbal treatments in asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Arnold, E, Clark, CE, Lasserson, TJ, Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD005989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.767Z" }, { "id": "4a465a88-daef-4ea1-b4fc-cac7b20a9c6f", "pmid": "", "title": "Preoperative fasting for preventing perioperative complications in children", "imported": false, "abstract": "Abstract - Background Children, like adults, are required to fast before general anaesthesia with the aim of reducing the volume and acidity of their stomach contents. It is thought that fasting reduces the risk of regurgitation and aspiration of gastric contents during surgery. Recent developments have encouraged a shift from the standard 'nil‐by‐mouth‐from‐midnight' fasting policy to more relaxed regimens. Practice has been slow to change due to questions relating to the duration of a total fast, the type and amount of intake permitted. Objectives To systematically assess the effects of different fasting regimens (duration, type and volume of permitted intake) and the impact on perioperative complications and patient well being (aspiration, regurgitation, related morbidity, thirst, hunger, pain, comfort, behaviour, nausea and vomiting) in children. Search methods We searched Cochrane Wounds Group Specialised Register (searched 25/6/09), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 2 2009), Ovid MEDLINE (1950 to June Week 2 2009), Ovid EMBASE (1980 to 2009 Week 25), EBSCO CINAHL (1982 to June Week 3 2009), the National Research Register, relevant conference proceedings and article reference lists and contacted experts. Selection criteria Randomised and quasi randomised controlled trials of preoperative fasting regimens for children were identified. Data collection and analysis Data extraction and trial quality assessment was conducted independently by three authors. Trial authors were contacted for additional information including adverse events. Main results This first update of the review identified two additional eligible studies, bringing the total number of included studies to 25 (forty seven randomised controlled comparisons involving 2543 children considered to be at normal risk of regurgitation or aspiration during anaesthesia). Only one incidence of aspiration and regurgitation was reported. Children permitted fluids up to 120 minutes preoperatively were not found to experience higher gastric volumes or lower gastric pH values than those who fasted. The children permitted fluids were less thirsty and hungry, better behaved and more comfortable than those who fasted. Clear fluids preoperatively did not result in a clinically important difference in children's gastric volume or pH. Evidence relating to the preoperative intake of milk was sparse. The volume of fluid permitted during the preoperative period did not appear to impact on children's intraoperative gastric volume or pH contents. Authors' conclusions There is no evidence that children who are denied oral fluids for more than six hours preoperatively benefit in terms of intraoperative gastric volume and pH compared with children permitted unlimited fluids up to two hours preoperatively. Children permitted fluids have a more comfortable preoperative experience in terms of thirst and hunger. This evidence applies only to children who are considered to be at normal risk of aspiration/regurgitation during anaesthesia. Plain language summary Preoperative fasting for children to prevent complications during surgery General anaesthetics inhibit the protective reflexes that stop the stomach contents reaching the lungs. In order to prevent the inadvertent inhalation of stomach contents, children are often advised to have nothing to eat or drink from the midnight before surgery. However, the review of trials found that drinking clear fluids up to a few hours before surgery did not increase the risk of regurgitation during or after surgery. Indeed there is an added benefit of a more comfortable preoperative experience in terms of thirst and hunger. Some children are considered more likely to regurgitate under anaesthetic, including those who are obese or have stomach disorders. More research is needed to determine whether these children can also safely drink up to a few hours before surgery.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brady, MC, Kinn, S, Ness, V, O'Rourke, K, Randhawa, N, Stuart, P", "articleTypes": [], "doi": "10.1002/14651858.CD005285.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.131Z" }, { "id": "4a4e8be5-963b-4b36-b200-8b7ffd52fc47", "pmid": "", "title": "Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications", "imported": false, "abstract": "Abstract - Background Radiotherapy as part of head and neck cancer treatment leaves patients requiring much dental rehabilitation in a compromised environment that is difficult for the patient and the dental team to manage. Objectives To assess the effects of maintaining the patient's natural dentition during radiotherapy in comparison to extracting teeth before radiotherapy in areas that are difficult to access by the patient and the dentist, should reduction in mouth opening occur after radiotherapy to the jaws. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 22 November 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 22 November 2012), EMBASE via OVID (1980 to 22 November 2012), CANCERLIT via PubMed (1950 to 22 November 2012), CINAHL via EBSCO (1980 to 22 November 2012) and reference lists of articles. We advertised for currently ongoing studies via the Cochrane Oral Health Group website and the Cochrane Oral Health Group Twitter feed. Selection criteria Randomised controlled trials comparing extraction of teeth prior to radiotherapy with leaving teeth in situ during radiotherapy to the jaws. Data collection and analysis Three review authors independently assessed the results of the searches for inclusion in the review. Main results No randomised controlled trials were found. Authors' conclusions There are no randomised controlled trials to assess the effect of extracting teeth prior to radiotherapy compared to leaving teeth in the mouth during radiotherapy to the jaws. Plain language summary Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications This review aimed to assess if removing the back teeth before radiotherapy would mean that patients had fewer tooth‐related problems after radiotherapy as part of head and neck cancer treatment, when compared to not removing the teeth. Electronic and handsearching found 357 titles of studies but none of them met the inclusion criteria for the review. There is currently no evidence available to answer this complex question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Eliyas, S, Al‐Khayatt, A, Porter, RWJ, Briggs, P", "articleTypes": [], "doi": "10.1002/14651858.CD008857.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.747Z" }, { "id": "4a4f5e39-70ad-47ae-b2ee-6ef9560e4478", "pmid": "", "title": "Anabolic‐androgenic steroids for alcoholic liver disease", "imported": false, "abstract": "Abstract - Background Alcohol is one of the most common causes of liver disease in the Western World. Randomised clinical trials have examined the effects of anabolic‐androgenic steroids for alcoholic liver disease. Objectives To assess the beneficial and harmful effects of anabolic‐androgenic steroids for patients with alcoholic liver disease based on the results of randomised clinical trials. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Controlled Trials Register in The Cochrane Library , MEDLINE , EMBASE, LILACS, and Science Citation Index Expanded until June 2006. Electronic searches were combined with full text searches. Manufacturers and researchers in the field were also contacted. Selection criteria Randomised clinical trials studying patients with alcoholic steatosis, alcoholic fibrosis, alcoholic hepatitis, and/or alcoholic cirrhosis were included. Interventions encompassed anabolic‐androgenic steroids at any dose or duration versus placebo or no intervention. The trials could be double blind, single blind, or unblinded. The trials could be unpublished or published, and no language limitations were applied. Data collection and analysis Outcomes are assessed at maximal follow‐up. All analyses were performed according to the intention‐to‐treat method. The statistical package RevMan Analyses was used. The methodological quality of the randomised clinical trials was assessed. Main results Combining the results of five randomised clinical trials randomising 499 patients with alcoholic hepatitis and/or cirrhosis demonstrated no significant effects of anabolic‐androgenic steroids on mortality (relative risk (RR) 1.01, 95% confidence interval (CI) 0.79 to 1.29), liver‐related mortality (RR 0.83, 95% CI 0.60 to 1.15), complications of liver disease (RR 1.25, 95% CI 0.74 to 2.10), and liver histology. Anabolic‐androgenic steroids did not significantly affect a number of other outcome measures, including sexual function and liver biochemistry. Anabolic‐androgenic steroids were not associated with a significantly increased risk of non‐serious adverse events (RR 1.14, 95% CI 0.50 to 2.59) or with serious adverse events (RR 4.54, 95% CI 0.57 to 36.30). Authors' conclusions This systematic review could not demonstrate any significant beneficial effects of anabolic‐androgenic steroids on any clinically important outcomes (mortality, liver‐related mortality, liver complications, and histology) of patients with alcoholic liver disease. Plain language summary No evidence to support anabolic‐androgenic steroids for alcoholic liver disease Alcohol causes a major part of the liver diseases in the Western World. Several trials have addressed the effects of anabolic‐androgenic steroids for alcoholic liver disease. This systematic review could not demonstrate any significant effects of anabolic‐androgenic steroids on mortality, liver‐related mortality, liver complications, and histology of patients with alcoholic liver disease. Anabolic‐androgenic steroid intervention is not associated with a significant increase in non‐serious adverse events, but with the seldom occurrence of serious adverse events. Accordingly, there is no evidence supporting the use of anabolic‐androgenic steroids for alcoholic liver disease, but further randomised clinical trials may be needed to settle the question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Rambaldi, A; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD003045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "4a55592f-6a52-41e0-a5c7-17a8e73bc75a", "pmid": "", "title": "Inhaled mannitol for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Several agents are used to clear secretions from the airways of people with cystic fibrosis. Mannitol increases mucociliary clearance, but its exact mechanism of action is unknown. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents which require delivery via a nebuliser. Phase III trials of inhaled dry powder mannitol for the treatment of cystic fibrosis have been completed and it is now available in Australia and some countries in Europe. This is an update of a previous review. Objectives To assess whether inhaled dry powder mannitol is well tolerated, whether it improves the quality of life and respiratory function in people with cystic fibrosis and which adverse events are associated with the treatment. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic databases, handsearching relevant journals and abstracts from conferences. Date of last search: 12 December 2019. Selection criteria All randomised controlled studies comparing mannitol with placebo, active inhaled comparators (for example, hypertonic saline or dornase alfa) or with no treatment. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction and assessed the risk of bias in included studies. The quality of the evidence was assessed using GRADE. Main results Six studies (reported in 36 unique publications) were included with a total of 784 participants. Duration of treatment in the included studies ranged from 12 days to six months, with open‐label treatment for an additional six months in two of the studies. Five studies compared mannitol with control (a very low dose of mannitol or non‐respirable mannitol) and the final study compared mannitol to dornase alfa alone and to mannitol plus dornase alfa. Two large studies had a similar parallel design and provided data for 600 participants, which could be pooled where data for a particular outcome and time point were available. The remaining studies had much smaller sample sizes (ranging from 22 to 95) and data could not be pooled due to differences in design, interventions and population. Pooled evidence from the two large parallel studies was judged to be of low to moderate quality and from the smaller studies was judged to be of low to very low quality. In all studies, there was an initial test to see if participants tolerated mannitol, with only those who could tolerate the drug being randomised; therefore, the study results are not applicable to the cystic fibrosis population as a whole. While the published papers did not provide all the data required for our analysis, additional unpublished data were provided by the drug's manufacturer and the author of one of the studies. Pooling the large parallel studies comparing mannitol to control, up to and including six months, lung function (forced expiratory volume at one second) measured in both mL and % predicted was significantly improved in the mannitol group compared to the control group (moderate‐quality evidence). Beneficial results were observed in these studies in adults and in both concomitant dornase alfa users and non‐users in these studies. In the smaller studies, statistically significant improvements in lung function were also observed in the mannitol groups compared to the non‐respirable mannitol groups; however, we judged this evidence to be of low to very low quality. For the comparisons of mannitol and control, we found no consistent differences in health‐related quality of life in any of the domains except for burden of treatment, which was less for mannitol up to four months in the two pooled studies of a similar design; this difference was not maintained at six months. It should be noted that the tool used to measure health‐related quality of life was not designed to assess mucolytics and pooling of the age‐appropriate tools (as done in some of the included studies) may not be valid so results were judged to be low to very low quality and should be interpreted with caution. Cough, haemoptysis, bronchospasm, pharyngolaryngeal pain and post‐tussive vomiting were the most commonly reported side effects in both treatment groups. Where rates of adverse events could be compared, statistically no significant differences were found between mannitol and control groups; although some of these events may have clinical relevance for people with CF. For the comparisons of mannitol to dornase alfa alone and to mannitol plus dornase alfa, very low‐quality evidence from a 12‐week cross‐over study of 28 participants showed no statistically significant differences in the recorded domains of health‐related quality of life or measures of lung function. Cough was the most common side effect in the mannitol alone arm but there was no occurrence of cough in the dornase alfa alone arm and the most commonly reported reason of withdrawal from the mannitol plus dornase alfa arm was pulmonary exacerbations. In terms of secondary outcomes of the review (pulmonary exacerbations, hospitalisations, symptoms, sputum microbiology), evidence provided by the included studies was more limited. For all comparisons, no consistent statistically significant and clinically meaningful differences were observed between mannitol and control treatments (including dornase alfa). Authors' conclusions There is moderate‐quality evidence to show that treatment with mannitol over a six‐month period is associated with an improvement in some measures of lung function in people with cystic fibrosis compared to control. There is low to very low‐quality evidence suggesting no difference in quality of life for participants taking mannitol compared to control. This review provides very low‐quality evidence suggesting no difference in lung function or quality of life comparing mannitol to dornase alfa alone and to mannitol plus dornase alfa. The clinical implications from this review suggest that mannitol could be considered as a treatment in cystic fibrosis; but further research is required in order to establish who may benefit most and whether this benefit is sustained in the longer term. Furthermore, studies comparing its efficacy against other (established) mucolytic therapies need to be undertaken before it can be considered for mainstream practice. Plain language summary Mannitol, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of inhaling mannitol to treat lung disease in people with cystic fibrosis. Background Cystic fibrosis is a genetic disorder that affects the exocrine glands (sweat glands and others). Lung infections produce thick mucus (phlegm) which can block air passages and cause more infection and repeated inflammation. In turn, this progressively damages the lungs and can eventually cause respiratory failure. There are several drugs that are used to clear mucus from the airways of people with cystic fibrosis and inhaled dry powder mannitol is a new one that may improve their lung function. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents delivered by a nebuliser (e.g. hypertonic saline). Mannitol is available in Australia and some European countries. This is an updated version of the review. Search date The evidence is current to: 12 December 2019. Study characteristics We included six studies (with a total of 784 adults and children) in this review. Five studies compared a standard dose of mannitol with control (a very low dose of mannitol or a version of mannitol which did not allow the active drug to reach the lungs) and the sixth study compared mannitol with nebulised recombinant human deoxyribonuclease (dornase alfa), both alone and taken together. Participants could continue using dornase alfa and other standard therapies, but were excluded from the five of the six studies if they were using hypertonic saline. Treatment in these studies lasted from 12 days to six months. Five studies provided the treatments to people as outpatients and in one study, the children treated were in hospital due to pulmonary exacerbations (flare ups of disease). Key results It was difficult to combine evidence from the studies in this review due to differences in the designs of the studies, treatments examined and the settings (hospital or outpatients). Some additional information was obtained from the drug manufacturer and one study author to aid the review. The review found low‐ to very low‐quality evidence that there is no difference between mannitol and control treatments or mannitol given either with or without additional dornase alfa in terms of quality of life. There was moderate‐quality evidence of improvements in some measures of lung function across the larger studies comparing mannitol to control. Beneficial effects were also seen in the subgroup of adults and in both those who were using dornase alfa and those who were not. Cough (including coughing up blood), contraction of the airways, pain in the pharynx or larynx and post‐treatment vomiting were the most commonly reported side effects on both treatments, but there was no evidence to suggest that these side effects occurred more on mannitol than on control treatments or on dornase alfa. None of the studies compared mannitol to nebulised hypertonic saline and so we can not comment on which agent is better for airway clearance. More research is needed to answer this question. Quality of the evidence We judged the quality of the evidence from this review to be of very low to moderate quality, depending on the outcome measured. We do not think that the way the studies were designed affected the results. We judged that everyone taking part had equal chances of being in either of the treatment groups and would not have known in advance or during the study which treatment they were receiving. However, the numbers of people who dropped out of the studies might affect how the results are interpreted, as well as how many people were recruited into the studies and how they were selected from all people with cystic fibrosis who could have been included. Although some of these issues were resolved when the drug's manufacturer (who also sponsored the studies) provided some additional information. It is important to realise that before people started the study, they took a test to see if they could tolerate mannitol and only those who did could carry on. This means that the results of the studies only apply to those people with cystic fibrosis who can tolerate mannitol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Nevitt, SJ; Thornton, J; Murray, CS; Dwyer, T", "articleTypes": [], "doi": "10.1002/14651858.CD008649.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "4a86d565-4bec-4d9b-9584-c5a954f88145", "pmid": "", "title": "Metabolic and bariatric surgery in adults with obesity and diabetes mellitus: a network meta‐analysis", "imported": false, "abstract": "Abstract - Rationale Obesity and its associated comorbidities, particularly type 2 diabetes (T2D), have reached epidemic dimensions globally. Both conditions are related to an increased risk of serious health outcomes and impose a substantial burden on those affected. Metabolic and bariatric surgery (MBS) may offer a therapeutic option for achieving sustained weight loss, improving comorbidities and thereby enhancing long‐term quality of life. Objectives To investigate the medium‐ and long‐term benefits and harms of different MBS procedures compared with each other and to non‐surgical treatment on outcomes relevant to adults with obesity and T2D, and to obtain a clinically meaningful ranking of these interventions by considering both randomised controlled trials (RCTs) and cohort studies. Search methods We searched MEDLINE, Cochrane CENTRAL, CINAHL, LILACS, BASE as well as the WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 25 June 2024. We did not apply any language restrictions. Eligibility criteria We included RCTs and both prospective and retrospective cohort studies with a minimum follow‐up of three years in adults (≥ 18 years) with obesity (body mass index ≥ 30 kg/m² or ethnic‐specific cut‐off values) and T2D. Eligible interventions include MBS procedures (i.e. laparoscopic adjustable gastric banding [LAGB], sleeve gastrectomy [SG], Roux‐en‐Y gastric bypass [RYGB], one‐anastomosis gastric bypass [OAGB], gastric plication [GCP], biliopancreatic diversion with duodenal switch, and their variations) or non‐surgical treatment (i.e. lifestyle intervention, medical treatment [LI/MT]). Outcomes Critical outcomes were medium‐ (≥ 3 to < 5 years) and long‐term (≥ 5 years) weight loss (%), waist circumference (cm), T2D remission (complete, partial), and serious adverse events (SAE). Important outcomes included all‐cause mortality, T2D complications, glycaemic control (glycated haemoglobin (HbA1c) in %) and health‐related quality of life (HRQoL). Risk of bias We used the Risk of Bias 2 (RoB 2) tool for RCTs and Risk Of Bias In Non‐randomized Studies – of Interventions (ROBINS‐I) for cohort studies. Synthesis methods We performed random‐effects network meta‐analyses based on the frequentist approach and ranked treatments by P scores. We rated the certainty of evidence according to the GRADE approach for long‐term outcomes (≥ 5 years). Included studies We included 18 studies (with 70 reports) with 15,282 participants in this review. Of these, 13 studies were RCTs (n = 911) and five were cohort studies (n = 14,371). Two RCTs compared MBS with LI/MT, ten compared two or three different MBS procedures and one with a 3‐arm design investigated two different MBS procedures as well as LI/MT. All cohort studies compared different MBS procedures. The networks were based on the following MBS procedures: RYGB, SG, OAGB, LAGB, GCP, and LI/MT. Synthesis of results NMA results (8 RCTs; n = 491) suggest greater long‐term weight loss after RYGB compared to LI/MT (MD ‐16.95%; 95% CI ‐24.19 to ‐9.71). OAGB (MD ‐12.10%; 95% CI ‐22.85 to ‐1.34) and SG (MD ‐9.40 %; 95% CI ‐17.45 to ‐1.34) may also result in greater weight loss compared to LI/MT, but the evidence is very uncertain. A reduction in waist circumference at long‐term follow‐up (6 RCTs; n = 348) is likely higher after RYGB compared to LI/MT (MD ‐12.34 cm; 95% CI ‐17.88 to ‐6.81). OAGB (MD: ‐13.28 cm; 95% CI ‐22.04 to ‐4.53) and SG (MD‐9.08 cm; 95% CI ‐15.74 to ‐2.43) may also lead to a higher reduction in waist circumference compared to LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effects of MBS procedures compared to LI/MT on long‐term complete T2D remission (9 RCTs; n = 536). All MBS procedures (8 RCTs; n = 588) may result more often in partial T2D remissions than LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effect of all MBS procedures compared to LI/MT on SAE (9 RCTs; n = 598) and all‐cause mortality in the long term (7 RCTs; n = 520). RYGB may reduce total long‐term T2D complications compared to LI/MT (Rate ratio (RaR) 0.17; 95% CI 0.03 to 0.89; 5 RCTs; n = 356), but the evidence is very uncertain. Based on NMA results (10 RCTs; n = 612), RYGB may reduce HbA1c compared to LI/MT (MD ‐1.44%; 95% CI ‐2.26 to ‐0.63). OAGB (MD ‐2.01%; 95%CI ‐3.42 to ‐0.60) and SG (MD ‐1.01%; 95%CI ‐1.94 to ‐0.08) may also reduce HbA1c compared to LI/MT, but the evidence is every uncertain. Both RYGB and SG may increase mental and physical components of HRQoL compared to LI/MT (both 2 RCTs; n = 118), but evidence is very uncertain. The inclusion of cohort studies in the analyses of percentage weight loss, partial type 2 diabetes remission, SAE, and all‐cause mortality confirmed the main findings. For most outcomes, the main reasons for downgrading certainty of evidence were related to risk of bias and imprecision. Authors' conclusions In people with obesity and T2D, RYGB, OAGB and, to a lesser extent, SG may lead to long‐term improvements in body weight, waist circumference, partial T2D remission, and HbA1c compared with LI/MT. However, due to imprecise results, the magnitude of the effects often remains uncertain or very uncertain. For other outcomes, especially complete T2D remission, SAE, all‐cause mortality and T2D complications, the evidence is mainly very uncertain, due to a low numbers of participants and events. When interpreting these findings, it should be noted that cohort studies were not, as originally planned, included in the certainty of evidence assessment, as these studies were judged to have a high or critical risk of bias. Larger and well‐designed studies may contribute to diminishing the existing uncertainties and enhancing our confidence in the findings. Funding This Cochrane review was funded by the German Federal Ministry of Education and Research (BMBF) (grant number: 01KG2201). Registration Protocol (2024) DOI: https://doi.org/10.1002/14651858.CD015622 PROSPERO ID: CRD42023457363 Plain language summary Review question What are the long‐term benefits and risks of different types of weight loss surgery (also called metabolic and bariatric surgery) to treat obesity and type 2 diabetes in adults? Key messages In people with obesity and type 2 diabetes, gastric (stomach) bypass (i.e. Roux‐en‐Y gastric bypass and one‐anastomosis gastric bypass) may be most beneficial for improving body weight, waist circumference, type 2 diabetes status and long‐term blood sugar levels at least five years after surgery, but for one‐anastomosis gastric bypass, we are very uncertain about the results. It is unclear whether the different surgical procedures have an effect on risks such as serious unwanted health effects and death from any cause at least five years after surgery. Larger and well‐designed studies may help reduce the existing uncertainties and increase our confidence in the findings. What are obesity and type 2 diabetes? 
Obesity is a condition with too many fat deposits that can damage health. In type 2 diabetes, the body has difficulty controlling blood sugar levels because the hormone insulin does not work properly. Type 2 diabetes often occurs in people with obesity, and both conditions increase the risk of premature death and other health problems, such as cardiovascular disease. How are obesity and type 2 diabetes treated? Lifestyle interventions such as nutrition, exercise, and behavioural programmes, along with medicines, are often used first for weight loss and improvement of diabetes status. When these do not work well, metabolic and bariatric surgery may be considered as an additional treatment option. There are a number of different types of bariatric surgery: gastric (stomach) banding; gastric sleeve (removal of a part of the stomach); Roux‐en‐Y gastric bypass (RYGB); one‐anastomosis gastric bypass, or mini‐gastric bypass; gastric plication (folding to make the stomach smaller); biliopancreatic diversion with duodenal switch. What did we want to find out? Which of the different types of surgery are the safest and most beneficial ones by comparing them with each other and with lifestyle and medication therapy regarding their long‐term (at least 5 years follow‐up) benefits and risks. Whether these surgical procedures improve body weight, waist circumference, type 2 diabetes status, long‐term blood sugar levels, and quality of life at least five years after surgery. Whether surgery affects serious unwanted health effects, death from any cause, and type 2 diabetes complications over this period. What did we do? 
We searched for studies involving people with obesity and type 2 diabetes. We included studies that compared at least two different surgical procedures, or surgery with lifestyle and medication treatment. We summarised and compared all treatments using a method called network meta‐analysis, and we rated our confidence in the results based on factors such as study methods and sample size. What did we find? 
We found 18 studies, including 15,282 people with obesity and type 2 diabetes. In 13 of these studies (including 911 people), participants were assigned randomly to two or more treatment groups. This is the best way to ensure that groups of people are similar. Five studies (with 14,371 people) used ‘real‐life’ observational data. The studies investigated surgical procedures such as gastric band, gastric sleeve, Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, and gastric plication. We found that: Roux‐en‐Y gastric bypass, may improve body weight and likely reduce waist circumference compared with lifestyle and medication treatment in the long term. One‐anastomosis gastric bypass and, to a lesser extent, gastric sleeve, may also improve body weight and waist circumference, but we are very uncertain about the results. Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, gastric sleeve, and gastric band may improve type 2 diabetes status, but we are very uncertain about the results. It is unclear whether the types of surgery have an effect on serious unwanted health effects or death from any cause. Roux‐en‐Y gastric bypass may reduce type 2 diabetes complications in the long term compared to non‐surgical treatments, but we are very uncertain about the results. Roux‐en‐Y gastric bypass may improve blood sugar levels compared to non‐surgical treatments. One‐anastomosis gastric bypass and gastric sleeve may also improve blood sugar levels, but we are very uncertain about the results. RYGB and SG may lead to a greater increase in health‐related quality of life than non‐surgical treatments, but again, we are very uncertain about the results. What are the limitations of the evidence? 
Our confidence in the evidence is often low to very low because the studies included only small numbers of people, and the results for some outcomes, especially serious unwanted health effects, death from any cause, and type 2 diabetes complications, were based on very few events. Moreover, for several surgical procedures, there were not enough studies to be certain about the outcomes. It is important to note that rating our confidence in findings was based only on studies in which participants were randomly assigned to groups and did not include observational studies. How up to date is this evidence? 
This evidence is up to date as of June 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E; Gorenflo, L; Schwarzer, G; Stadelmaier, J; Wallerer, S; Marjanovic, G; Fink, JM; Lehane, C; Metzendorf, MI; Meerpohl, J; Schwingshackl, L", "articleTypes": [], "doi": "10.1002/14651858.CD015622.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "4aadf4fe-3072-403d-bbbd-078fba24e66a", "pmid": "", "title": "Chelation therapy for atherosclerotic cardiovascular disease", "imported": false, "abstract": "Abstract - Background Chelation therapy is promoted and practiced around the world as a form of alternative medicine in the treatment of atherosclerotic cardiovascular disease. It has been suggested as a safe, relatively inexpensive, non‐surgical method of restoring blood flow in atherosclerotic vessels. However, there is currently limited high‐quality, adequately‐powered research informing evidence‐based medicine on the topic, specifically regarding clinical outcomes. Due to this limited evidence, the benefit of chelation therapy remains controversial at present. This is an update of a review first published in 2002. Objectives To assess the effects of ethylene diamine tetra‐acetic acid (EDTA) chelation therapy versus placebo or no treatment on clinical outcomes among people with atherosclerotic cardiovascular disease. Search methods For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 6 August 2019. We searched the bibliographies of the studies retrieved by the literature searches for further trials. Selection criteria We included studies if they were randomised controlled trials of EDTA chelation therapy versus placebo or no treatment in participants with atherosclerotic cardiovascular disease. The main outcome measures we considered include all‐cause or cause‐specific mortality, non‐fatal cardiovascular events, direct or indirect measurement of disease severity, and subjective measures of improvement or adverse events. Data collection and analysis Two review authors independently extracted data and assessed trial quality using standard Cochrane procedures. A third author considered any unresolved issues, and we discussed any discrepancies until a consensus was reached. We contacted study authors for additional information. Main results We included five studies with a total of 1993 randomised participants. Three studies enrolled participants with peripheral vascular disease and two studies included participants with coronary artery disease, one of which specifically recruited people who had had a myocardial infarction. The number of participants in each study varied widely (from 10 to 1708 participants), but all studies compared EDTA chelation to a placebo. Risk of bias for the included studies was generally moderate to low, but one study had high risk of bias because the study investigators broke their randomisation code halfway through the study and rolled the placebo participants over to active treatment. Certainty of the evidence, as assessed by GRADE, was generally low to very low, which was mostly due to a paucity of data in each outcome's meta‐analysis. This limited our ability to draw any strong conclusions. We also had concerns about one study's risk of bias regarding blinding and outcome assessment that may have biased the results. Two studies with coronary artery disease participants reported no evidence of a difference in all‐cause mortality between chelation therapy and placebo (risk ratio (RR) 0.97, 95% CI 0.73 to 1.28; 1792 participants; low‐certainty). One study with coronary artery disease participants reported no evidence of a difference in coronary heart disease deaths between chelation therapy and placebo (RR 1.02, 95% CI 0.70 to 1.48; 1708 participants; very low‐certainty). Two studies with coronary artery disease participants reported no evidence of a difference in myocardial infarction (RR 0.81, 95% CI 0.57 to 1.14; 1792 participants; moderate‐certainty), angina (RR 0.95, 95% CI 0.55 to 1.67; 1792 participants; very low‐certainty), and coronary revascularisation (RR 0.46, 95% CI 0.07 to 3.25; 1792 participants). Two studies (one with coronary artery disease participants and one with peripheral vascular disease participants) reported no evidence of a difference in stroke (RR 0.88, 95% CI 0.40 to 1.92; 1867 participants; low‐certainty). Ankle‐brachial pressure index (ABPI; also known as ankle brachial index) was measured in three studies, all including participants with peripheral vascular disease; two studies found no evidence of a difference in the treatment groups after three months after treatment (mean difference (MD) 0.02, 95% CI ‐0.03 to 0.06; 181 participants; low‐certainty). A third study reported an improvement in ABPI in the EDTA chelation group, but this study was at high risk of bias. Meta‐analysis of maximum and pain‐free walking distances three months after treatment included participants with peripheral vascular disease and showed no evidence of a difference between the treatment groups (MD ‐31.46, 95% CI ‐87.63 to 24.71; 165 participants; 2 studies; low‐certainty). Quality of life outcomes were reported by two studies that included participants with coronary artery disease, but we were unable to pool the data due to different methods of reporting and varied criteria. However, there did not appear to be any major differences between the treatment groups. None of the included studies reported on vascular deaths. Overall, there was no evidence of major or minor adverse events associated with EDTA chelation treatment. Authors' conclusions There is currently insufficient evidence to determine the effectiveness or ineffectiveness of chelation therapy in improving clinical outcomes of people with atherosclerotic cardiovascular disease. More high‐quality, randomised controlled trials are needed that assess the effects of chelation therapy on longevity and quality of life among people with atherosclerotic cardiovascular disease. Plain language summary Chelation therapy for atherosclerotic cardiovascular (heart and circulation) disease Background Atherosclerosis is caused by fatty deposits that cause a narrowing of people's arteries and restrict blood flow. People with blocked arteries are more likely to have strokes, heart attacks, and narrow blood vessels in their feet. Chelation therapy involves infusions into the bloodstream of substances believed to remove metals from the blood. This treatment is offered to people with atherosclerotic cardiovascular disease as a way of breaking down the blockages in their blood vessels. Chelation therapy is practiced in several places around the world as an alternative form of medicine, but there is currently a lack of knowledge surrounding this treatment. More information is needed to understand if this treatment should be more widely recommended. Key results This review included evidence from five studies with a total of 1993 participants (current until August 2019). Three studies enrolled participants with peripheral vascular disease, and two of the studies included participants with coronary artery disease, one of which specifically recruited people who had had a heart attack. All five studies compared chelation therapy with no treatment or placebo. Only two of the studies (both of which included participants with coronary artery disease) reported death from any cause, and these reported no difference in overall deaths between those that received chelation therapy and those who did not. Ony one study (in people with coronary artery disease) reported cardiovascular death, and this study found no difference between in risk between those who had chelation therapy and those who did not. Two studies of people with coronary artery disease reported rates of heart attack and angina, and found no difference in the risk of these between participants who had chelation treatment and those who did not. Similarly, two studies (one in people with coronary artery disease and one in people with peripheral vascular disease) reported the chance of having a stroke, and found no clear difference in the chance of this between people who did or did not received chelation treatment. Two studies in people with peripheral vascular disease used an indirect measure of blood flow known as the ankle‐brachial pressure index (ABPI), or ankle brachial index. These studies did not show any differences in this measure between people who received chelation therapy for three or six months and those who did not get the treatment. There was also no clear differences in the distance participants could walk. We could not combine specific measures of quality of life in a single analysis. Looking at the two studies in people with coronary artery disease that reported this outcome, there was no difference in the quality of life reported by people who received chelation therapy and those who did not get the treatment. Two studies reported information about adverse events, but we could not combine this in a single analysis because they reported them in different ways and the events were different. However, the people who had chelation therapy did not appear to have any increase in either minor or major adverse events, compared with people who did not have the therapy. Certainty of the evidence We considered most of the data we found to be of low certainty, mostly because there were very few studies that provided data. Even though we included five studies, not all of them reported on each outcome. There is currently not enough evidence about the effects of chelation therapy on blockages in the blood vessels of people with atherosclerotic cardiovascular (heart and circulation) disease. Conclusions Overall, this review did not find any clear differences between people treated with chelation and people given the control, for the outcomes we evaluated. None of the outcomes included more than two studies, therefore it is difficult at this time to determine if these are true findings or just because there is not enough data. Further high‐quality trials that focus on clinical outcomes are necessary.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Villarruz-Sulit, MVanessa, Forster, R, Dans, AL, Tan, FN, Sulit, DV", "articleTypes": [], "doi": "10.1002/14651858.CD002785.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.751Z" }, { "id": "4aba3295-309f-4b1a-a541-0206b1d113b3", "pmid": "", "title": "Multimodal interventions for cachexia management", "imported": false, "abstract": "Abstract - Background Cachexia (disease‐related wasting) is a complex metabolic syndrome which occurs in people with chronic illnesses, including cancer, HIV/AIDS, kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People with cachexia experience unintentional weight loss, muscle loss, fatigue, loss of appetite, and reduced quality of life. Multimodal interventions which work synergistically to treat the syndrome could lead to benefits. Objectives To assess the benefits and harms of multimodal interventions aimed at alleviating or stabilising cachexia in people with a chronic illness. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers in July 2024, together with reference checking, citation searching, and contact with study authors to identify studies. Selection criteria We included randomised controlled trials (RCTs) in adults with or at risk of cachexia, comparing multimodal interventions combining two or more modalities (of pharmacology, nutrition, exercise) to treatment as usual, variation of the intervention, or unimodal intervention. Data collection and analysis Two review authors independently screened potentially eligible studies, extracted data, and assessed risk of bias (RoB 1). Primary outcomes were physical function, strength, and adverse events. Secondary outcomes were body composition and weight, quality of life (QoL), appetite, fatigue, and biochemical markers. We assessed the certainty of evidence with GRADE. Main results We included nine studies with 926 adults (mean age: 63 years). Study sample sizes ranged from 20 to 332 participants. Six studies were conducted in Europe, and one each in Turkey, New Zealand, and the USA. There were six studies in people with cancer, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. We judged four studies to be at an overall high risk of bias, and five at an overall unclear risk. All outcomes in all comparisons had very low‐certainty evidence, downgraded once for risk of bias and/or indirectness and twice for imprecision. Multimodal intervention (pharmacological, nutritional, and/or exercise) compared to treatment as usual One cancer study randomised 46 participants, with 41 included in all analyses except adverse events. The study assessed outcomes immediately after treatment, lasting six weeks. Compared to treatment as usual, there is no clear evidence for an effect of a multimodal intervention on: physical function (mean difference (MD) −16.10 m, 95% confidence interval (CI) −79.06 to 46.86; 41 participants); strength (MD 3.80 kg, 95% CI −3.21 to 10.81; 41 participants); adverse events (risk ratio (RR) 1.36, 95% CI 0.70 to 2.65; 46 participants); body composition (MD 7.89 cm 2 , 95% CI −10.43 to 26.21; 41 participants); weight (MD 5.89 kg, 95% CI −1.45 to 13.23; 41 participants); appetite (MD 0.68 points, 95% CI −0.60 to 1.96; 41 participants); fatigue (MD 0.12, 95% CI −1.05 to 1.29; 41 participants); and biochemical markers (MD 2%, 95% CI 0.99 to 3.01; 41 participants), but the evidence was very uncertain; QoL was not reported. Multimodal intervention compared to variation of the intervention Three cancer studies and one HIV/AIDS study randomised 192 participants. We could not use the available data, nor obtain additional data, from two studies (one in cancer, one in HIV/AIDS). The studies assessed outcomes immediately after treatment, ranging from three to seven months. Compared to a variation of the intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (MD 10.0 m, 95% CI −36.27 to 56.27; 1 study, 56 participants); strength (MD 0.7 kg, 95% CI −3.75 to 5.15; 1 study, 56 participants); adverse events (RR 0.87, 95% CI 0.38 to 2.02; P = 0.75, I 2 = 0%; 2 studies, 95 participants); body composition (MD −2.67 kg, 95% CI −5.89 to 0.54; P = 0.10, I 2 = 0%; 2 studies, 95 participants); weight (MD −2.47 kg, 95% CI −7.11 to 2.16; P = 0.30, I 2 = 0%; 2 studies, 95 participants); QoL (standardised mean difference (SMD) −0.15, 95% CI −0.55 to 0.26; P = 0.47, I 2 = 0%; 2 studies, 95 participants); appetite (SMD −0.34, 95% CI −1.27 to 0.59; P = 0.48, I 2 = 79%; 2 studies, 95 participants); fatigue (MD 6.40 points, 95% CI −1.10 to 13.90; 1 study, 56 participants); or biochemical markers (MD 9.80 pg/mL, 95% CI −6.25 to 25.85; P = 0.23, I 2 = 73%; 2 studies, 95 participants), but the evidence is very uncertain. Multimodal intervention compared to unimodal intervention We included six studies (802 participants) in this comparison: three cancer studies, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. The studies assessed outcomes immediately after treatment, ranging from three to seven months. We could not use the available data, nor obtain additional data, from the HIV/AIDS study. Compared to a unimodal intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (SMD 0.02, 95% CI −0.22 to 0.26; P = 0.86, I 2 = 0%; 2 studies, 348 participants); strength (SMD 0.23, 95% CI −0.81 to 1.27; P = 0.66, I 2 = 0%; 2 studies, 348 participants); adverse events (RR 0.87, 95% CI −0.43 to 1.73; P = 0.68, I 2 = 45%; 2 studies, 395 participants); body composition (SMD 0.11, 95% CI −0.28 to 0.50; P = 0.58, I 2 = 74%; 5 studies, 742 participants); body weight (SMD −0.02, 95% CI −0.38 to 0.33; P = 0.90, I 2 = 49%; 4 studies, 431 participants); QoL (SMD 0.22, 95% CI −0.29 to 0.73; P = 0.39, I 2 = 61%; 3 studies, 411 participants); appetite (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.72, I 2 = 58%; 2 studies, 395 participants); fatigue (MD −6.80 points, 95% CI −12.44 to −1.17; 1 study, 244 participants); and biochemical markers (SMD 0.11, 95% CI −0.59 to 0.80; P = 0.76, I 2 = 79%; 3 studies, 411 participants), but the evidence is very uncertain. Authors' conclusions The review found insufficient evidence to support or refute the use of multimodal interventions in managing cachexia. The certainty of the evidence was very low. Methodologically rigorous, well‐powered RCTs with adequate interaction times are needed to assess the effectiveness of multimodal interventions in managing cachexia across chronic illnesses. Plain language summary What are the benefits and risks of using a combination of treatments to manage cachexia (disease‐related wasting)? Key messages: • We do not know if combinations of two or more treatments (of medication, diet, and exercise) benefit people who have or are at risk of developing cachexia (disease‐related wasting). This is because there are currently not enough robust studies in this area. • We need future research to increase our confidence in the evidence by conducting better designed and larger studies. What is cachexia? Cachexia is a complex metabolic syndrome that occurs in people with long‐term illnesses (known as chronic illnesses), such as cancer, HIV/AIDS, chronic kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People who have cachexia may: • lose weight unintentionally;
• lose muscle;
• feel tired, weak, or both; 
• lose their appetite. Cachexia affects well‐being and can be life‐threatening. How is cachexia treated? Studies are investigating how to best manage cachexia with different treatments. These treatments can include medications, diet, and exercise, provided in a single (unimodal) or combined (multimodal) treatment. It is thought that due to the complex biology of cachexia, a combination of treatments may work in a complementary way (synergistically) to help improve the symptoms associated with cachexia and people's well‐being, extend life, or both. What did we want to find out? We wanted to find out if combining at least two treatments (out of diet, exercise, and medication) helped to improve: physical function and strength; muscle loss; weight; well‐being; appetite; fatigue; and biological indicators within the blood (biochemical markers). We also wanted to find out if these interventions were associated with any unwanted or harmful (adverse) effects. What did we do? We searched for studies that compared treatment combinations of diet, exercise and/or medication (where at least two treatments were used together) to: different combinations of treatments; a single treatment; or treatment as usual (standard care) in adults with cachexia or at risk of developing cachexia. We compared and summarised the results of the included studies. We rated our confidence in the evidence based on factors such as study methods and the number of people included. What did we find? We found nine studies that included a total of 926 adults, with an average age of 63 years. Just over half of participants (57%) were men. Studies took place around the world, including Europe (six studies), Turkey (one study), New Zealand (one study), and the USA (one study). One study included people with HIV/AIDS (average age 43 years; 35 of 50 people in the study were men); one study included people with COPD (average age 72 years; 20 of 28 people in the study were men); and one study included people with chronic kidney disease (average age 70 years; 11 of 21 in the study were men). Six studies included people with cancer (average age 64 years; 461 of 893 people in the studies were men). The studies lasted six weeks to two years. The studies used combinations of treatments which could have included diet, exercise, and/or medication, where at least two treatments were used together, and compared these to: • treatment as usual (1 study, 46 people);
• different combinations of treatments (4 studies, 192 people);
• a single treatment (6 studies, 802 people). The studies did not provide enough robust evidence to determine if multimodal interventions are associated with benefits or harms in people with or at risk of cachexia. What are the limitations of the evidence? We are not confident in the evidence because not all the studies provided information about everything that we were interested in. Additionally, the studies used different ways of measuring results, and most of the studies included only small numbers of people. Importantly, future studies may change the conclusions of this review. How current is this review? The evidence is current to June 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Reid, J; Blair, C; Dempster, M; McKeaveney, C; Slee, A; Fitzsimons, D", "articleTypes": [], "doi": "10.1002/14651858.CD015749.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "4ac6ad8a-95e4-4b26-abaf-0ab27fef62ee", "pmid": "", "title": "Impact of active placebo controls on estimated drug effects in randomised trials: a systematic review of trials with both active placebo and standard placebo", "imported": false, "abstract": "Abstract - Background An estimated 60% of pharmacological randomised trials use placebo control interventions to blind (i.e. mask) participants. However, standard placebos do not control for perceptible non‐therapeutic effects (i.e. side effects) of the experimental drug, which may unblind participants. Trials rarely use active placebo controls, which contain pharmacological compounds designed to mimic the non‐therapeutic experimental drug effects in order to reduce the risk of unblinding. A relevant improvement in the estimated effects of active placebo compared with standard placebo would imply that trials with standard placebo may overestimate experimental drug effects. Objectives We aimed to estimate the difference in drug effects when an experimental drug is compared with an active placebo versus a standard placebo control intervention, and to explore causes for heterogeneity. In the context of a randomised trial, this difference in drug effects can be estimated by directly comparing the effect difference between the active placebo and standard placebo intervention. Search methods We searched PubMed, CENTRAL, Embase, two other databases, and two trial registries up to October 2020. We also searched reference lists and citations and contacted trial authors. Selection criteria We included randomised trials that compared an active placebo versus a standard placebo intervention. We considered trials both with and without a matching experimental drug arm. Data collection and analysis We extracted data, assessed risk of bias, scored active placebos for adequacy and risk of unintended therapeutic effect, and categorised active placebos as unpleasant, neutral, or pleasant. We requested individual participant data from the authors of four cross‐over trials published after 1990 and one unpublished trial registered after 1990. Our primary inverse‐variance, random‐effects meta‐analysis used standardised mean differences (SMDs) of active versus standard placebo for participant‐reported outcomes at earliest post‐treatment assessment. A negative SMD favoured the active placebo. We stratified analyses by trial type (clinical or preclinical) and supplemented with sensitivity and subgroup analyses and meta‐regression. In secondary analyses, we investigated observer‐reported outcomes, harms, attrition, and co‐intervention outcomes. Main results We included 21 trials (1462 participants). We obtained individual participant data from four trials. Our primary analysis of participant‐reported outcomes at earliest post‐treatment assessment resulted in a pooled SMD of −0.08 (95% confidence interval (CI) −0.20 to 0.04; I 2 = 31%; 14 trials), with no clear difference between clinical and preclinical trials. Individual participant data contributed 43% of the weight of this analysis. Two of seven sensitivity analyses found more pronounced and statistically significant differences; for example, in the five trials with low overall risk of bias, the pooled SMD was −0.24 (95% CI −0.34 to −0.13). The pooled SMD of observer‐reported outcomes was similar to the primary analysis. The pooled odds ratio (OR) for harms was 3.08 (95% CI 1.56 to 6.07), and for attrition, 1.22 (95% CI 0.74 to 2.03). Co‐intervention data were limited. Meta‐regression found no statistically significant association with adequacy of the active placebo or risk of unintended therapeutic effect. Authors' conclusions We did not find a statistically significant difference between active and standard placebo control interventions in our primary analysis, but the result was imprecise and the CI compatible with a difference ranging from important to irrelevant. Furthermore, the result was not robust, because two sensitivity analyses produced a more pronounced and statistically significant difference. We suggest that trialists and users of information from trials carefully consider the type of placebo control intervention in trials with high risk of unblinding, such as those with pronounced non‐therapeutic effects and participant‐reported outcomes. Plain language summary Do treatment effects in randomised trials differ when using active placebo compared to standard placebo? Key messages 1. We found no clear difference in effect between active and standard placebos, but we are very uncertain about the results. 2. We suggest that researchers carefully consider the type of placebo when investigating medicines with clear side effects. What are standard placebos and active placebos? Blinding (or masking) is an important part of randomised trials and ensures that participants and healthcare providers are not influenced by knowing whether the participant is receiving the experimental treatment. If they had this knowledge, they might unintentionally overestimate (or underestimate) the effect of the treatment. One method of blinding is to give the non‐treated group of participants a placebo, which looks like the medicine (e.g. a tablet of similar shape, colour, smell, taste, and texture) but does not contain its active ingredients. Blinding with a placebo may not always be successful. The treatment may have side effects that distinguish it from the placebo so that the treatment effect is still not measured accurately. For this reason, some trials use active placebos, which mimic some of the side effects of the experimental medicine. However, it is unclear whether the choice of placebo type actually makes a difference to the treatment effects. What did we want to find out? We wanted to find out whether treatment effects in randomised trials differ when using active placebos compared to standard placebos. What did we do? We collected and analysed trials that directly compared the two types of placebo, or that compared both placebos with an experimental medicine. If people receiving active placebo experience better results than those receiving standard placebo, this difference might be due to them believing that they are receiving the experimental medicine. It would also mean that in trials that compare a medicine with standard placebo, the beneficial effect of the medicine is exaggerated. This is important if the measured benefits of the treatment are small or moderate and thus especially sensitive to changes in the methods used for the trial. What did we find? We included 21 trials in this review, covering subjects such as pain and psychiatry. We found no clear difference between the two types of placebo in participant‐reported outcomes (such as pain intensity). However, because the result was uncertain, the possible range of this result included both no difference and a potentially important difference in favour of active placebo. When we limited our analysis to higher‐quality trials, active placebos were more beneficial than standard placebos, but these trials were not typical clinical trials and might not be applicable to clinical scenarios.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Laursen, DRT, Nejstgaard, CH, Bjørkedal, E, Frost, AD, Hansen, MR, Paludan-Müller, AS, Prosenz, J, Werner, CP, Hróbjartsson, A", "articleTypes": [], "doi": "10.1002/14651858.MR000055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.763Z" }, { "id": "4ad1cc4a-144a-44ac-bfec-dd6b5baf742d", "pmid": "", "title": "Pharmacological interventions for the treatment of depression in chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Studies report that up to 80% of individuals with chronic obstructive pulmonary disease (COPD) may struggle with symptoms of depression. However, this major comorbidity in COPD is rarely managed effectively. A number of recent studies indicate that left untreated, COPD‐related depression is associated with worse quality of life, worse compliance with COPD treatment plan, increased exacerbations, hospital admissions, and healthcare costs when compared to individuals with COPD without depression. Regrettably, COPD practice guidelines do not provide conclusive treatment recommendations for the use of antidepressants in patients with COPD, and base their guidelines on findings from trials in the general population. This may be problematic, as there is an elevated risk of respiratory issues associated with antidepressant treatment and COPD. Evaluating effectiveness and safety of pharmacological interventions specifically for patients with COPD and depression was therefore paramount. Objectives To assess the effectiveness and safety of pharmacological interventions for the treatment of depression in patients with COPD. Search methods The last search was performed on 26 November 2018. We initially searched the following databases via the Specialised Trials Registers of the Cochrane Airways and Common Mental Disorders Groups (to June 2016): MEDLINE, Embase, PsycINFO, CINAHL, AMED, and the Cochrane Library trials register (CENTRAL). Searches from June 2016 to November 2018 were performed directly on Ovid MEDLINE, Embase, PsycINFO and the Cochrane Library (Issue 11, 2018). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform to 26 November 2018. We searched the grey literature databases to identify studies not indexed in major databases and the reference lists of studies initially identified for full‐text screening. Selection criteria All published and unpublished randomised controlled trials (RCTs) comparing the efficacy of pharmacological interventions with no intervention, placebo or co‐intervention in adults with diagnosed COPD and depression were eligible for inclusion. Data collection and analysis Two review authors independently assessed articles identified by the search for eligibility. Our primary outcomes were change in depressive symptoms and adverse events. The secondary outcomes were: change in quality of life, change in dyspnoea, change in forced expiratory volume in one second (FEV 1 ), change in exercise tolerance, change in hospital utilisation (length of stay and readmission rates), and cost‐effectiveness. For continuous outcomes, we calculated the pooled mean difference (MD) or standardised mean difference (SMD) with 95% confidence interval (CI) as appropriate. For dichotomous outcomes, we calculated the pooled odds ratio (OR) and corresponding 95% CI using a random‐effects model. We assessed the quality of evidence using the GRADE framework. Main results Of the 1125 records screened for eligibility, four RCTs (N = 201 participants), and one on‐going study, met the inclusion criteria. Two classes of antidepressants were investigated in two separate comparisons with placebo: a tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitors (SSRIs). TCA versus placebo Only one RCT (N = 30 participants) provided results for this comparison. Primary outcomes The TCA (nortriptyline) reduced depressive symptoms post‐treatment compared to placebo (MD ‐10.20, 95% CI ‐16.75 to ‐3.65; P = 0.007; very low‐quality evidence), as measured by the Hamilton Depression Rating Scale (HAM‐D). Three participants withdrew from the trial due to adverse events related to the tested antidepressant (dry mouth, sedation, orthostatic hypotension). Secondary outcomes The overall results post‐treatment indicated that nortriptyline was not effective in improving the quality of life of individuals with COPD, as measured by the Sickness Impact Profile (MD ‐2.80, 95% CI ‐11.02 to 5.42; P = 0.50; very low‐quality evidence). The results for the change in dyspnoea for the domains examined (e.g. dyspnoea scores for 'most day‐to‐day activities') post‐treatment showed no improvement in the intervention group (MD 9.80, 95% CI ‐6.20 to 25.80; P = 0.23; very low‐quality evidence). No data were reported for change in FEV 1 , change in exercise tolerance, change in hospital utilisation, or cost‐effectiveness. The TCA study provided short‐term results, with the last follow‐up data collection at 12 weeks. The quality of the evidence for all the outcomes evaluated was very low due to a small sample size, imprecision, attrition, and selection and reporting bias. SSRIs versus placebo Three RCTs (N = 171 participants) provided results for this comparison. Primary outcomes The pooled results for two studies showed no difference for the change in depressive symptoms post‐intervention (SMD 0.75, 95% CI ‐1.14 to 2.64; 148 participants; 2 studies; P = 0.44; very low‐quality evidence). High heterogeneity was observed (I² = 95%), limiting the reliability of these findings. While it was not possible to meta‐analyse the total adverse events rates across the studies, it was possible to combine the results for two medication‐specific adverse effects: nausea and dizziness. There were no significant post‐treatment group differences for nausea (OR 2.32, 95% CI 0.66 to 8.12; 171 participants; 3 studies; P = 0.19; very low‐quality evidence) or dizziness (OR 0.61, 95% CI 0.09 to 4.06; 143 participants; 2 studies; P = 0.61; very low‐quality evidence). Secondary outcomes The pooled analysis of two trials reporting data for the change in quality of life did not show improvement post‐treatment in the intervention group compared to placebo (SMD 1.17, 95% CI ‐0.80 to 3.15; 148 participants; 2 studies; P = 0.25; very low‐quality evidence). There was no difference between groups in change in FEV 1 post‐treatment (MD 0.01, 95% CI ‐0.03 to 0.05; 148 participants; 2 studies; P = 0.60; low‐quality evidence). However, two trials reported improvement in exercise tolerance in the SSRI group versus the placebo group (MD 13.88, 95% CI 11.73 to 16.03; 148 participants; 2 studies; P < 0.001; very low‐quality evidence). The trials included in this comparison did not report data related to the change in dyspnoea, hospital utilisation rates, or cost‐effectiveness. Authors' conclusions There is insufficient evidence to make definitive statements about the efficacy or safety of antidepressants for treating COPD‐related depression. New RCTs are needed; with better methodological quality and more accurate reporting of the methods used. Moreover, longer‐term follow‐up data collection is needed, including outcomes such as adverse events, hospital utilisation and cost‐effectiveness. Plain language summary Medication for the treatment of depression in chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a term that mainly describes two lung conditions: chronic bronchitis and emphysema. The main symptoms of COPD include shortness of breath, persistent cough, wheezing, and/or frequent chest infections. There is no cure for COPD, but treatment can help slow the disease progress and relieve symptoms. Depression is very common in patients with COPD, but is often untreated. Studies show that untreated depression in patients with COPD can worsen quality of life, increase COPD exacerbations and hospital admissions, and make following a COPD treatment plan difficult. Treatment for depression can include antidepressant medication, psychological therapy, or both. However, evidence‐based recommendations regarding antidepressant medication use specifically for patients with COPD are not currently available. Why is this review important? There is currently no clear overview of existing evidence showing whether antidepressants can effectively and safely reduce depressive symptoms in patients with COPD, therefore it was important to assess the existing experimental studies. Who will be interested in this review? Healthcare professionals, people with COPD and depression, researchers, and policymakers will be interested in the findings of this review. What questions does this review aim to answer? Our main aim was to assess whether pharmacological treatment (e.g. antidepressants) could effectively and safely treat COPD‐related depression. Which studies were included in the review? This review included experimental studies called randomised controlled trials (studies in which participants are assigned to a treatment group based on a random method) that compared the effectiveness of pharmacological interventions (antidepressants) to placebo (inactive treatment in the same form as the active treatment, e.g. a pill). Study participants were adults diagnosed with COPD and depression. What does the evidence from the review tell us? We have identified only four studies worldwide that were eligible for inclusion in our review. This means limited evidence to support the use of antidepressants for the treatment of depression in patients with COPD. Only one study evaluated a tricyclic antidepressant, nortriptyline, finding that it reduced depressive symptoms when compared to a placebo. Three studies evaluated a newer generation class of antidepressants called selective serotonin reuptake inhibitors (SSRIs), finding no evidence for their effectiveness in improving depressive symptoms. Due to the limited evidence, we are unable to make definitive statements about the effectiveness but also safety of antidepressants when used for COPD‐related depression. However, SSRIs may increase exercise capacity in patients with COPD. Given that the current findings were based on only four small studies with evidence rated as of very low quality, it is important to interpret our results with caution. What should happen next? Insufficient evidence prevented us from making clear recommendations for doctors, other healthcare professionals, researchers, or policymakers. More studies with better methodological quality and a larger number of participants are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pollok, J; van Agteren, JEM; Carson‐Chahhoud, KV", "articleTypes": [], "doi": "10.1002/14651858.CD012346.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "4b37fbed-45f4-4f50-9429-2096f6d154db", "pmid": "", "title": "Adjunctive therapies in addition to land‐based exercise therapy for osteoarthritis of the hip or knee", "imported": false, "abstract": "Abstract - Background Land‐based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non‐pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land‐based exercise therapy is lacking. Objectives To evaluate the benefits and harms of adjunctive therapies used in addition to land‐based exercise therapy compared with placebo adjunctive therapy added to land‐based exercise therapy, or land‐based exercise therapy only for people with hip or knee osteoarthritis. Search methods We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land‐based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land‐based exercise therapy, or land‐based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant‐reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short‐term (6 months), medium‐term (6 to 12 months) and long‐term (12 months onwards) effects. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE. Main results We included 62 trials (60 RCTs and 2 quasi‐RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 60 included people with knee osteoarthritis only. Thirty‐six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty‐two trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in 11 (18%) trials. Comparing adjunctive therapies plus land‐based exercise therapy against placebo therapies plus exercise up to six months (short‐term), we found low‐certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate‐certainty evidence indicates that adjunctive therapies did not improve QOL (SF‐36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low‐certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant‐reported global assessment was not measured in any studies. Compared with land‐based exercise therapy, low‐certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short‐term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise‐only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (41 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (41 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low‐certainty evidence). Moderate‐certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant‐reported global assessment (short‐term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI ‐0.32 to ‐0.18 mm); 12% relative improvement (6% better to 18% better). Low‐certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27). Authors' conclusions Moderate‐ to low‐certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant‐reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis. Plain language summary Additional therapies used with exercise therapy for hip or knee osteoarthritis What was the aim of this review? Osteoarthritis, a chronic degenerative condition that commonly affects hip and knee joints, causes pain and difficulty with everyday activities such as walking. Land‐based exercise therapy refers to exercise conducted on land (as opposed to exercise in the water) and is a first‐line treatment. This review aimed to find out if adding additional therapies to land‐based exercise therapy improved pain, function, quality of life, participant‐reported overall change or X‐ray changes in people with hip or knee osteoarthritis. Additional therapies include manual (hands‐on) therapy, psychological or dietary therapies, electrophysical agents (such as heat, cold, nerve stimulation, ultrasound or laser therapy) or acupuncture. We included studies comparing additional therapies plus land‐based exercise therapy to either 1) sham (or dummy) therapy plus land‐based exercise therapy or 2) land‐based exercise therapy only. Search date This systematic review is up‐to‐date to 10 June 2021. What did we find? We found 62 randomised controlled trials with 6508 participants, mostly women, from 24 countries. The average age was between 52 and 83 years, with symptoms present from 9 months to 12 years. Sixty studies enrolled people with knee osteoarthritis, one enrolled people with hip osteoarthritis and one enrolled people with knee or hip osteoarthritis. Twenty‐two trials compared additional therapies plus exercise therapy to sham additional therapies plus exercise therapy, and 41 compared to exercise therapy. Thirty‐eight trials studied electrophysical agents, seven studied manual therapies, four studied acupuncture/dry needling or use of tape, three studied psychological or dietary interventions, whole body vibration (this involves standing on a vibration platform), or spa/mud therapy, and one studied foot orthotics (shoe insoles). Funding source Thirty‐eight studies were funded, four received no funding and funding support was not reported in 20. Main results Eleven trials (18%) measured adverse (unwanted harmful) events, which included both non‐serious and serious adverse events. The most common were increased pain, stiffness or swelling. There was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with sham additional therapies plus exercise therapy (22 studies) Compared with sham additional therapies used with land‐based exercise therapy, additional therapies such as electrophysical agents, acupuncture, dry needling or taping, used with exercise therapy, may not be more effective in improving pain, physical function or quality of life up to six months after treatment. Pain (lower scores mean less pain) Improved by 10% or 0.77 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 12% or 5.03 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 1% or 0.75 points worse on a zero to 100‐point scale. Adverse events Although not commonly reported in studies, there was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with exercise therapy (41 studies) Compared with land‐based exercise therapy, additional therapies (manual therapies, electrotherapy, dietary interventions, psychological therapies, whole body vibration, acupuncture, dry needling, taping, spa/mud therapy or foot orthotics) plus exercise therapy, may not be more effective in improving pain, physical function, quality of life or joint changes measured with X‐rays up to six months after treatment. Pain (lower scores mean less pain) Improved by 7% or 0.41 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 9% or 2.83 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 2%, or 1.04 points worse on a zero to 100‐point scale. Patient‐reported overall change 17% more people rated their treatment a success. X‐ray changes Improved by 12% (based on one study) Adverse effects Although not commonly reported in studies, risks appear no greater for additional therapies used with exercise compared to exercise only. Fewer studies assessed outcomes six or 12 months after treatment. Additional therapies plus land‐based exercise therapy may be no better in reducing pain or improving physical function or quality of life than exercise therapy at 6 or 12 months. In patient‐reported overall assessment, 31% reported improvement at 6 months, and 42% reported improvement at 12 months. Conclusions and certainty of evidence Additional therapies plus exercise therapy do not appear to offer meaningful improvements in pain, function, quality of life or overall change for people with hip or knee osteoarthritis compared with sham additional therapies plus land‐based exercise therapy; or in pain, function, quality of life or changes on X‐rays when compared with exercise therapy only. Compared with exercise therapy there is probably a clinical benefit in patient‐reported overall change for additional therapies plus exercise therapy, based on a small number of studies. Our confidence in the evidence varies between moderate to little or no confidence for different outcomes. Although results indicate no increased adverse events from additional therapies used with exercise therapy, this was poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "French, HP; Abbott, JH; Galvin, R", "articleTypes": [], "doi": "10.1002/14651858.CD011915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "4b3bdcef-6735-4c1f-854f-f285e857322f", "pmid": "", "title": "Corrector therapies (with or without potentiators) for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR variant F508del is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF)). The F508del variant lacks meaningful CFTR function ‐ faulty protein is degraded before reaching the cell membrane, where it needs to be to effect transepithelial salt transport. Corrective therapy could benefit many pwCF. This review evaluates single correctors (monotherapy) and any combination of correctors (most commonly lumacaftor, tezacaftor, elexacaftor, VX‐659, VX‐440 or VX‐152) and a potentiator (e.g. ivacaftor) (dual and triple therapies). Objectives To evaluate the effects of CFTR correctors (with or without potentiators) on clinically important benefits and harms in pwCF of any age with class II CFTR mutations (most commonly F508del). Search methods We searched the Cochrane CF Trials Register (28 November 2022), reference lists of relevant articles and online trials registries (3 December 2022). Selection criteria Randomised controlled trials (RCTs) (parallel design) comparing CFTR correctors to control in pwCF with class II mutations. Data collection and analysis Two authors independently extracted data, assessed risk of bias and judged evidence certainty (GRADE); we contacted investigators for additional data. Main results We included 34 RCTs (4781 participants), lasting between 1 day and 48 weeks; an extension of two lumacaftor‐ivacaftor studies provided additional 96‐week safety data (1029 participants). We assessed eight monotherapy RCTs (344 participants) (4PBA, CPX, lumacaftor, cavosonstat and FDL169), 16 dual‐therapy RCTs (2627 participants) (lumacaftor‐ivacaftor or tezacaftor‐ivacaftor) and 11 triple‐therapy RCTs (1804 participants) (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor). Participants in 21 RCTs had the genotype F508del/F508del, in seven RCTs they had F508del/minimal function (MF), in one RCT F508del/gating genotypes, in one RCT either F508del/F508del genotypes or F508del/residual function genotypes, in one RCT either F508del/gating or F508del/residual function genotypes, and in three RCTs either F508del/F508del genotypes or F508del/MF genotypes. Risk of bias judgements varied across different comparisons. Results from 16 RCTs may not be applicable to all pwCF due to age limits (e.g. adults only) or non‐standard designs (converting from monotherapy to combination therapy). Monotherapy Investigators reported no deaths or clinically relevant improvements in quality of life (QoL). There was insufficient evidence to determine effects on lung function. No placebo‐controlled monotherapy RCT demonstrated differences in mild, moderate or severe adverse effects (AEs); the clinical relevance of these events is difficult to assess due to their variety and few participants (all F508del/F508del). Dual therapy In a tezacaftor‐ivacaftor group there was one death (deemed unrelated to the study drug). QoL scores (respiratory domain) favoured both lumacaftor‐ivacaftor and tezacaftor‐ivacaftor therapy compared to placebo at all time points (moderate‐certainty evidence). At six months, relative change in forced expiratory volume in one second (FEV 1 ) % predicted improved with all dual combination therapies compared to placebo (high‐ to moderate‐certainty evidence). More pwCF reported early transient breathlessness with lumacaftor‐ivacaftor (odds ratio (OR) 2.05, 99% confidence interval (CI) 1.10 to 3.83; I 2 = 0%; 2 studies, 739 participants; high‐certainty evidence). Over 120 weeks (initial study period and follow‐up), systolic blood pressure rose by 5.1 mmHg and diastolic blood pressure by 4.1 mmHg with twice‐daily 400 mg lumacaftor‐ivacaftor (80 participants). The tezacaftor‐ivacaftor RCTs did not report these adverse effects. Pulmonary exacerbation rates decreased in pwCF receiving additional therapies to ivacaftor compared to placebo (all moderate‐certainty evidence): lumacaftor 600 mg (hazard ratio (HR) 0.70, 95% CI 0.57 to 0.87; I 2 = 0%; 2 studies, 739 participants); lumacaftor 400 mg (HR 0.61, 95% CI 0.49 to 0.76; I 2 = 0%; 2 studies, 740 participants); and tezacaftor (HR 0.64, 95% CI 0.46 to 0.89; 1 study, 506 participants). Triple therapy No study reported any deaths (high‐certainty evidence). All other evidence was low‐ to moderate‐certainty. QoL respiratory domain scores probably improved with triple therapy compared to control at six months (six studies). There was probably a greater relative and absolute change in FEV 1 % predicted with triple therapy (four studies each across all combinations). The absolute change in FEV 1 % predicted was probably greater for F508del/MF participants taking elexacaftor‐tezacaftor‐ivacaftor compared to placebo (mean difference 14.30, 95% CI 12.76 to 15.84; 1 study, 403 participants; moderate‐certainty evidence), with similar results for other drug combinations and genotypes. There was little or no difference in adverse events between triple therapy and control (10 studies). No study reported time to next pulmonary exacerbation, but fewer F508del/F508del participants experienced a pulmonary exacerbation with elexacaftor‐tezacaftor‐ivacaftor at four weeks (OR 0.17, 99% CI 0.06 to 0.45; 1 study, 175 participants) and 24 weeks (OR 0.29, 95% CI 0.14 to 0.60; 1 study, 405 participants); similar results were seen across other triple therapy and genotype combinations. Authors' conclusions There is insufficient evidence of clinically important effects from corrector monotherapy in pwCF with F508del/F508del. Additional data in this review reduced the evidence for efficacy of dual therapy; these agents can no longer be considered as standard therapy. Their use may be appropriate in exceptional circumstances (e.g. if triple therapy is not tolerated or due to age). Both dual therapies (lumacaftor‐ivacaftor, tezacaftor‐ivacaftor) result in similar small improvements in QoL and respiratory function with lower pulmonary exacerbation rates. While the effect sizes for QoL and FEV 1 still favour treatment, they have reduced compared to our previous findings. Lumacaftor‐ivacaftor was associated with an increase in early transient shortness of breath and longer‐term increases in blood pressure (not observed for tezacaftor‐ivacaftor). Tezacaftor‐ivacaftor has a better safety profile, although data are lacking in children under 12 years. In this population, lumacaftor‐ivacaftor had an important impact on respiratory function with no apparent immediate safety concerns, but this should be balanced against the blood pressure increase and shortness of breath seen in longer‐term adult data when considering lumacaftor‐ivacaftor. Data from triple therapy trials demonstrate improvements in several key outcomes, including FEV 1 and QoL. There is probably little or no difference in adverse events for triple therapy (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor) in pwCF with one or two F508del variants aged 12 years or older (moderate‐certainty evidence). Further RCTs are required in children under 12 years and those with more severe lung disease. Plain language summary CFTR correctors, a therapy for cystic fibrosis targeted at specific variants (most commonly F508del) Review question How do drugs (or drug combinations) for correcting the basic defect in the most common cystic fibrosis (CF)‐causing gene variant (F508del) impact on outcomes important to people with CF (pwCF), e.g. survival, quality of life (QoL), lung function and safety? Key messages There is a lack of evidence to support monotherapy and limited evidence to support dual therapy for pwCF who have the gene variant F508del. We found important differences across key outcomes, with fewer unwanted side effects in the triple therapy studies when compared to one dual therapy drug combination (lumacaftor plus ivacaftor). More research is needed to assess triple therapy combinations in children and to monitor their safety profiles over the longer term. How would drugs (or drug combinations) correct the basic defect in the most common CF‐causing gene variant (F508del)? The CF gene makes a protein that helps salts move across cells in many parts of the body. Over 80% of pwCF have at least one copy of the genetic variant F508del, meaning they make a full length of this protein, but it cannot move through the cell correctly. Laboratory experiments suggest that if this protein reaches the cell wall, it may be able to function, restore salt movement and correct the chronic problems that pwCF experience. What did we want to find out? How do drugs (or drug combinations) used to treat people of any age who have the genetic variant F508del impact their lives? Are these drugs associated with any unwanted side effects? What did we do? We searched for and included studies that looked at drugs (and drug combinations) used to treat pwCF who had at least one copy of the most common CF‐causing gene variant (F508del) compared to control medications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 34 studies that involved 4781 pwCF and which lasted between 1 day and 48 weeks; all studies compared an active drug treatment to a placebo (drug containing no active treatment). We do not have enough information to decide if 14 studies should be included or not and eight studies have not yet been completed. Eight studies looked at treatment with a single drug (monotherapy). These studies did not report any deaths or clinically relevant improvements in quality of life (QoL) scores. There was not enough evidence to show an effect on lung function. All studies reported side effects; there were a wide range of side effects each reported by a small number of participants in the studies. There were 16 studies assessing a combination of two drugs (dual therapy), either tezacaftor plus ivacaftor or lumacaftor plus ivacaftor. One participant taking tezacaftor plus ivacaftor died, but this was not thought to be related to the treatment. Both dual therapies resulted in improvements in QoL and lung function; rates of pulmonary exacerbations (a flare‐up of symptoms) were also lower. Neither dual therapy was linked to severe side effects, although people starting treatment with lumacaftor plus ivacaftor experienced shortness of breath for one to two weeks; this usually stopped without further treatment . More concerningly, in longer studies some people taking lumacaftor plus ivacaftor experienced a rise in blood pressure. Two people (out of over 500) even stopped lumacaftor plus ivacaftor treatment because of high blood pressure. These side effects were not reported for tezacaftor plus ivacaftor. There were 11 studies assessing different combinations of three drugs (triple therapy). The combinations were based on tezacaftor with ivacaftor (or deutivacaftor, which is a similar but chemically altered version of ivacaftor) and investigators then added either elexacaftor, VX‐659, VX‐440 or VX‐152 and compared these to either triple placebo, or tezacaftor with ivacaftor and one placebo. Some studies split groups by treatment and also by different genetic variants. No study reported any deaths. Triple therapies improved QoL scores and lung function in all comparisons, with no difference in the number or severity of side effects. Fewer people with two copies of F508del taking elexacaftor plus tezacaftor plus ivacaftor experienced a pulmonary exacerbation than those taking the control treatment. What are the limitations of the evidence? Our certainty in the evidence ranged from uncertain to very certain, but we were quite certain of the evidence for most results. While studies generally provided few details about their design, so we could not make clear judgements on potential biases, we had fewer concerns with the larger, more recent studies. Some of our findings are based on studies that were too small to show important effects and for 16 studies the results may not be applicable to all pwCF due to them only including people of certain ages (i.e. only adults or only children). Also, one study had an unusual design where people were given monotherapy and then later a dual therapy. How up‐to‐date is this evidence? This review updates our earlier review. We last looked for evidence on 28 November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Heneghan, M, Southern, KW, Murphy, J, Sinha, IP, Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD010966.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.141Z" }, { "id": "4b46bda6-3109-464e-869b-27cd7e6a6440", "pmid": "", "title": "Calcitonin for metastatic bone pain", "imported": false, "abstract": "Abstract - Background Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastases. The hormone calcitonin has the potential to relieve pain and also retain bone density, thus reducing the risk of fractures. This review is an update of a previously published review in the Cochrane Library (2003, Issue 3) which was also updated in 2006 (Issue 3) and in 2011 (Issue 9). Objectives The main objective of the review is to determine the effectiveness of calcitonin to reduce metastatic bone pain in patients with painful bone metastases. Secondary objectives are to assess the benefits of calcitonin in reducing the incidence of bone complications (hypercalcemia, fractures and nervous compression) and improving patient survival, and to report any adverse effects of the treatment. Search methods We updated the electronic searches in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2015. We also searched registers of clinical trials in progress up to February 2015. Selection criteria We included studies if they were randomised, double‐blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. Data collection and analysis Two independent review authors performed study selection and data extraction. Only two studies (90 participants) were eligible for inclusion in the review and therefore meta‐analysis of the data was not possible. We performed intention‐to‐treat (ITT) analysis by imputing all missing values as adverse effects. Main results The overall quality of the evidence was very low. In this update no new studies were identified for inclusion; one additional study was excluded. Of the two small included studies, one study showed a non‐significant effect of calcitonin on the number of patients with complete pain relief (risk ratio (RR) 2.50; 95% confidence interval (CI) 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; 95% CI 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases, for improving quality of life or for patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.50; 95% CI 0.77 to 15.88). Authors' conclusions Current available research evidence is of very low quality and there is a lack of evidence to support the use of calcitonin for managing bone pain from bone metastases. Since the last version of this review, we did not identify any additional studies. Plain language summary Calcitonin used to treat metastatic bone pain People who have cancer which has spread to their bones and the nerves adjacent to the bones often suffer severe pain. There are several treatments to help relieve this pain: radiotherapy, analgesic drugs (pain killers) such as opioids, and bone‐modulating drugs such as bisphosphonates and calcitonin. Calcitonin has the potential to relieve pain and maintain bone strength, thus reducing the risk of broken bones. This review looked at the effectiveness of calcitonin for controlling pain from bone metastases. However, only two studies were found with very low quality evidence to support the use of calcitonin for patients suffering from bone pain. We updated the review in 2015 and did not find any more studies. There were slightly more side effects for the patients given calcitonin. Unless new studies provide additional relevant information about this treatment, other therapeutic approaches should be considered.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Martinez-Zapata, MJ, Roqué i Figuls, M, Català, E, Roman, Y, Alonso Coello, P", "articleTypes": [], "doi": "10.1002/14651858.CD003223.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.756Z" }, { "id": "4b49d6a2-8a09-4cd9-8180-95fb787aa768", "pmid": "", "title": "ATATURK UNİVERSITY", "imported": false, "abstract": "'Pandemic' is a medical term that has become a ubiquitous part of the global vocabulary over the last year. Although pandemics have occurred throughout human history, their sociocultural, economic, and psychological impact can leave lasting damage. In the current COVID-19 pandemic, more than 200 million confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported to date. While most people present with mild symptoms such as loss of taste and smell, sore throat, joint pain, and headache, it can cause serious morbidity and mortality, especially in individuals over 65 years of age and those with comorbidities .", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.250Z" }, { "id": "4b589e10-5227-4aec-bf42-9684f2fcaf11", "pmid": "", "title": "Lycopene for the prevention of prostate cancer", "imported": false, "abstract": "Abstract - Background Prostate cancer is a common cause of death in developed countries, yet the benefits of screening for prostate cancer still remain controversial. A prostate‐specific antigen (PSA) test result greater than 4 ng/mL (nanograms/millilitre) has commonly been used as the cut‐off level for seeking further tests to diagnose the presence (or absence) of prostate cancer. An increase in PSA levels may not necessarily be associated with an increased risk of prostate cancer, as PSA levels may also be increased in men with benign prostatic hyperplasia and prostatitis. Despite the uncertainty of the net benefit of early detection and treatment, safe and effective methods to prevent prostate cancer are of value. Consumers, seeking greater involvement in their healthcare, are increasingly turning to lifestyle modification and complementary and alternative medicines (CAMs) to maintain their health and prevent disease. Lycopene is a member of the carotenoid family, which is found abundantly in tomatoes, tomato‐based products, strawberries, and watermelon. It has been hypothesised that lycopene is a strong antioxidant, which may lower the risk of cancer (including prostate cancer) in people who have diets rich in lycopene. Objectives To determine whether lycopene reduces the incidence of prostate cancer and prostate cancer‐specific mortality. Secondary objectives include changes in PSA levels, prostate symptoms and the nature of adverse events associated with lycopene use. Search methods Electronic searches were conducted across MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases. No language or other limitations were imposed. Selection criteria Randomised controlled trials (RCTs) that investigated the use of lycopene for the prevention of prostate cancer were eligible for inclusion in this review. Data collection and analysis A search of electronic databases, performed in August 2011, identified 64 citations. All articles were selected for full‐text review. From these citations, three studies were identified as meeting the inclusion criteria. Handsearching did not provide any additional studies. Main results Three RCTs, with a total of 154 participants were included in this review. None of the studies reported data on prostate cancer mortality. All of the included studies differed with respect to design, participants included and allocation of lycopene. This clinical heterogeneity limits the value on the pooled estimated of the meta‐analyses. The methodological quality of two of the three included studies was assessed as posing a 'high' risk of bias. Meta‐analysis indicated no statistical difference in PSA levels between men randomised to receive lycopene and the comparison group (MD (mean difference) ‐0.34, 95% CI (confidence interval) ‐2.01 to 1.32). Only one study reported incidence of prostate cancer (10% in the lycopene group versus 30% in control group). The level of lycopene was also not statistically different in men randomised to receive lycopene and the comparison group (MD 0.39 µg/mL (micrograms/millilitre), 95% CI ‐0.19 to 0.98). No other meta‐analyses were possible since other outcomes assessed only had one study contributing data. Authors' conclusions Given that only three RCTs were included in this systematic review, and the high risk of bias in two of the three studies, there is insufficient evidence to either support, or refute, the use of lycopene for the prevention of prostate cancer. Similarly, there is no robust evidence from RCTs to identify the impact of lycopene consumption upon the incidence of prostate cancer, prostate symptoms, PSA levels or adverse events. Plain language summary Lycopene for the prevention of prostate cancer Prostate cancer is a common form of cancer affecting men worldwide. Pharmaceutical interventions, such as 5‐alpha reductase inhibitors, have been identified as potentially preventing prostate cancer incidence in men. Many men modify lifestyle and consume complementary and alternative medicines to maintain better health and prevent disease. Lycopene is a supplement that has been suggested may assist in the prevention of prostate cancer due to its antioxidant effects. The objective of this systematic review was to identify the effectiveness of lycopene in the prevention of prostate cancer. This review identified 3 relevant studies, comprising 154 participants in total. Two of the studies were assessed to be of 'high' risk of bias. Meta‐analysis of two studies indicated no statistical difference in prostate specific antigen (PSA) levels between men randomised to receive lycopene and the comparison group (MD ‐0.34, 95% CI ‐2.01 to 1.32). None of the studies assessed prostate cancer mortality. No other meta‐analyses were possible since other outcomes assessed only had one study contributing data.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Ilic, D, Forbes, KM, Hassed, C", "articleTypes": [], "doi": "10.1002/14651858.CD008007.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.742Z" }, { "id": "4b7ab998-03b5-44b2-87b2-c9c5b4ef4350", "pmid": "", "title": "Short courses of antibiotics for children and adults with bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is an important cause of respiratory morbidity in both developing and developed countries. Antibiotics are considered standard therapy in the treatment of this condition but it is unknown whether short courses (four weeks or less) are efficacious. Objectives To determine whether short courses of antibiotics (i.e. less than or equal to four weeks) for treatment of acute and stable state bronchiectasis, in adults and children, are efficacious when compared to placebo or usual care. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library ), MEDLINE, EMBASE, OLDMEDLINE, CINAHL, AMED and PsycINFO and handsearching of respiratory journals and meeting abstracts were performed by the Cochrane Airways Group up to February 2011. Selection criteria Only randomised controlled trials were considered. Adults and children with bronchiectasis (defined clinically or radiologically) were included. Patients with cystic fibrosis were excluded. Data collection and analysis Two review authors independently reviewed the titles, abstracts and citations to assess eligibility for inclusion. Only one study fulfilled the inclusion criteria and thus meta‐analysis could not be performed. Main results The single eligible study showed a small benefit, when compared to placebo, of four weeks of inhaled antibiotic therapy in adults with bronchiectasis and pseudomonas in their sputum. There were no studies in children and no studies on oral or intravenous antibiotics. Authors' conclusions There is insufficient evidence in the current literature to make reasonable conclusions about the efficacy of short course antibiotics in the management of adults and children with bronchiectasis. Until further evidence is available, adherence to current treatment guidelines is recommended. Plain language summary Short courses of antibiotics for children and adults with bronchiectasis There is a paucity of evidence to conclude whether short courses of antibiotics (i.e. less than or equal to four weeks) are equivalent or superior to placebo in the treatment of stable or exacerbation state bronchiectasis. One single study showed some benefit of short‐course inhaled antibiotics over placebo, in terms of microbiological response and subjective improvement in medical condition, although this was balanced against an increase in adverse effects and antimicrobial resistance in the treatment group. Given the potential benefits of shorter duration antibiotic therapy in bronchiectasis, further RCTs are clearly needed to answer this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Wurzel, D, Marchant, JM, Yerkovich, ST, Upham, JW, Masters, IB, Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD008695.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.093Z" }, { "id": "4bce5be4-dc05-4d7c-9d20-90262dda5233", "pmid": "", "title": "Post COVID-19 Syndrome: A Pilot Study to Explore the Gut-lung Axis", "imported": false, "abstract": "The outbreak of the novel coronavirus (SARS-CoV-2)-infected disease (COVID-19) began in December 2019, spread throughout China in early 2020 and developed as a pandemic thereafter.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "4bd11408-f55d-4cf8-9d9b-947ea3c3e986", "pmid": "", "title": "Interventions to prevent obesity in children aged 2 to 4 years old", "imported": false, "abstract": "Abstract - Rationale Early childhood presents an important opportunity for obesity prevention, an international public health priority. Interventions aiming to prevent obesity typically promote healthy diets or activity levels (physical activity, sedentary behaviour), or both. There is uncertainty over which approaches are more effective. This is one of a suite of three reviews addressing interventions for preventing obesity in children, each focusing on different age groups up to 18 years. These reviews replace and update a 2019 Cochrane review on interventions for preventing obesity in children from birth to 18 years. Objectives To assess the effects of interventions that aimed to prevent obesity in children aged two to four years by changing dietary intake or activity levels, or both, on body mass index (BMI), BMI z‐score (zBMI), BMI percentile, and serious adverse events. Search methods We searched CENTRAL, MEDLINE, Embase, six other databases, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify eligible studies. The latest search date was 7 February 2023. Eligibility criteria We included randomised controlled trials (RCTs) in children aged two to four years, comparing dietary or activity interventions (or both combined) to prevent overweight or obesity versus no intervention, usual care, or another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post‐baseline. There were no language restrictions. Outcomes Our outcomes were BMI, zBMI, BMI percentile, and serious adverse events. Risk of bias We used version 2 of the Cochrane risk of bias tool (RoB 2) to assess included RCTs. Synthesis methods Working independently, two authors screened studies, extracted data, and conducted risk of bias and GRADE assessments. We conducted random‐effects meta‐analyses stratified by type of intervention and follow‐up duration. Included studies We included 67 studies (36,601 participants), with 56 studies (21,404 participants) pooled in the meta‐analyses. Sixty‐three studies were conducted in high‐income countries. Study settings were split between childcare (26 studies; 39%), home (23 studies; 34%), and home plus childcare settings (10 studies; 15%). Few studies were conducted in the community (three studies; 5%) or healthcare settings (five studies; 7%). Most studies compared a combined dietary/activity intervention with a control group. Synthesis of results Dietary interventions versus control Dietary interventions may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0.00, 95% confidence interval (CI) ‐0.28 to 0.28; 1 study, 94 participants; low‐certainty evidence). At medium‐ and long‐term follow‐up, dietary interventions may result in little to no difference in BMI. One study (103 participants; low‐certainty evidence) reported no difference in BMI at medium‐term follow‐up, and one study (2238 participants; low‐certainty evidence) found lower rates of overweight and obesity in the intervention group at long‐term follow‐up. Dietary interventions likely result in little to no difference in zBMI at short‐term (MD 0.03, 95% CI ‐0.13 to 0.19; 2 studies, 145 participants) and medium‐term follow‐up (MD ‐0.17, 95% CI ‐0.44 to 0.10; 1 study, 389 participants), both with moderate‐certainty evidence. None of the included studies reported zBMI at long‐term follow‐up. None of the studies reported serious adverse events. Activity interventions versus control Activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.10, 95% CI ‐0.28 to 0.08; 6 studies, 826 participants; very low‐certainty evidence). They likely reduce BMI at medium‐term follow‐up (MD ‐0.70, 95% CI ‐1.09 to ‐0.31; 1 study, 567 participants; moderate‐certainty evidence). None of the studies reported BMI at long‐term follow‐up. Activity interventions likely result in little to no difference in zBMI at short‐term follow‐up (MD ‐0.06, 95% CI ‐0.19 to 0.07; 3 studies, 635 participants; moderate‐certainty evidence). They may result in little to no difference in zBMI at medium‐term follow‐up, but the evidence is very uncertain (MD ‐0.00, 95% CI ‐0.12 to 0.11; 4 studies, 1083 participants; very low‐certainty evidence). None of the included studies reported zBMI at long‐term follow‐up. Activity interventions may have little to no effect on serious adverse events, but the evidence is very uncertain (2 studies, 773 participants; very low‐certainty evidence). One study found no harms related to the intervention, and one study reported no difference in accident and infection rates between groups. Combined dietary/activity interventions versus control Combined dietary/activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.08, 95% CI ‐0.20 to 0.04; 13 studies, 3867 participants; very low‐certainty evidence). They may result in little to no difference in BMI at medium‐term follow‐up (MD ‐0.05, 95% CI ‐0.18 to 0.08; 9 studies, 7016 participants; low‐certainty evidence), and may result in a slight reduction in BMI at long‐term follow‐up (MD ‐0.20, 95% CI ‐0.39 to ‐0.01; 5 studies, 2074 participants; low‐certainty evidence). Combined interventions may have little to no effect on zBMI at short‐term follow‐up (MD ‐0.03, 95% CI ‐0.07 to 0.01; 14 studies, 5518 participants), and may result in a slight reduction in zBMI at medium‐term follow‐up, but the evidence for both time frames is very uncertain (MD ‐0.07, 95% CI ‐0.11 to ‐0.04; 15 studies; 11,043 participants). Combined interventions may result in a slight reduction in zBMI at long‐term follow‐up (MD ‐0.07, 95% CI ‐0.13 to ‐0.01; 10 studies, 4693 participants; low‐certainty evidence). Combined interventions may result in little to no difference in serious adverse events, but the evidence is very uncertain (4 studies, 1689 participants; very low‐certainty evidence). One study reported that a parent fractured an ankle while roller‐skating at a community centre; the remaining studies reported no adverse events. Authors' conclusions In early childhood, combined dietary/activity interventions may have very modest benefits on BMI and zBMI at long‐term follow‐up. When implemented alone, dietary or activity interventions may have little to no effect on BMI measures. Only six studies reported serious adverse events, with no serious harms resulting directly from the intervention, but the evidence is very uncertain. Funding This review was partly funded by the National Institute for Health Research, School for Public Health Research. Registration Protocol available: DOI: 10.1002/14651858.CD015326 Plain language summary Do dietary and activity strategies help prevent obesity in children aged 2 to 4 years? Key messages Combining strategies for changing diet and physical activity levels in children aged 2 to 4 years to help prevent overweight and obesity may reduce body mass index (BMI) slightly in the long term (after 15 months). There was very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but none of the strategies appeared to result in any serious harm to the children. Future research should carry out obesity prevention strategies in community settings, and target the wider determinants of obesity and obesity prevention. Why is preventing obesity in children important? There is an increasing number of young children living with overweight and obesity worldwide, with evidence of the rates increasing in line with social inequality. Living with overweight during childhood can cause physical and psychological health problems. Children living with overweight are more likely to live with overweight as adults, and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help people change diet or activity (or both) are effective at preventing obesity in children aged 2 to 4 years, and whether they are associated with any serious adverse events. To examine obesity, we used the measure of body mass index (BMI). BMI is calculated by dividing a person's weight (in kg) by their height (in m 2 ). What did we do? We searched for studies that looked at ways to prevent obesity in children aged 2 to 4 years. We did not include studies that only targeted children who were already living with overweight or obesity, but we did include studies involving children at a range of weights. We only included studies if they used methods aimed at changing children's diet, activity level (increasing physical activity or reducing sedentary behaviour), or both. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 67 studies involving 36,601 children aged 2 to 4 years. Most studies (63 of 67) were based in high‐income countries, and four in upper‐middle‐income countries. In 26 studies, the strategies were conducted in childcare settings, 23 studies were primarily home‐based, and 10 were performed in both childcare and home‐based settings. Only 3 studies were conducted in the community, and 5 in healthcare settings. The duration of the programmes varied: 47 ran for fewer than 9 months, with the shortest being 1 visit and the longest lasting 3 years. We analysed results from 56 studies involving 21,404 children. Main findings Children who were helped with a strategy to change their diet and activity levels may have had a reduced BMI, compared with children not given any strategy. This means that these children may have been able to minimise excess weight gain by a small amount, which, for public health, is important. Children who were helped with a strategy to change their diet or activity alone did not have a reduced BMI. Only six of the 67 included studies reported on serious adverse events, and no serious harms were identified. What are the limitations of the evidence? Overall, our confidence in the evidence is very low. However, we do not believe that results from more studies similar in design to those included in this review would produce a higher level of confidence in the results. Four main factors reduced our confidence in the evidence. Results were very inconsistent across different studies. There were not enough studies reporting specific types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons. Results from some studies were not reported in a way that we could include in our analyses and this may have had an impact on the combined results. Studies generally had limitations in how they were conducted, due to the complexity of studies in this age group. This review does not provide enough information to assess how well these strategies work for children with disabilities or those from low‐ and middle‐income countries. How current is this evidence? This review updates a previous review. The evidence is current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Phillips, SM; Spiga, F; Moore, THM; Dawson, S; Stockton, H; Rizk, R; Cheng, HY; Hodder, RK; Gao, Y; Hillier-Brown, F; Rai, K; Yu, CB; O'Brien, KM; Summerbell, CD", "articleTypes": [], "doi": "10.1002/14651858.CD015326.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "4be7ac0e-b99d-4b6e-8b82-2814c1fd0dbc", "pmid": "", "title": "A Phase III Randomized, Double-blind, Placebo-controlled Multicenter Study in Adults, to Determine the Safety, Efficacy, and Immunogenicity of AZD1222, a Non-replicating ChAdOx1 Vector Vaccine, for the Prevention of COVID-19", "imported": false, "abstract": "The aim of the study is to assess the safety, efficacy, and immunogenicity of AZD1222 for the prevention of COVID-19.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.251Z" }, { "id": "4bf02dd8-0510-4f72-a007-f106df5d52e0", "pmid": "", "title": "Lasers for caries removal in deciduous and permanent teeth", "imported": false, "abstract": "Abstract - Background Despite considerable improvements in oral health, dental caries continue to be a public health issue. The most frequently used, and universally accepted technique, to remove caries is through mechanical ablation of decayed tissues by means of rotating drills (diamond or tungsten carbide, or both). In the past few decades, the introduction of adhesive filling materials (resin composites) has affected cavity filling procedures by reducing its retention needs, with advantages for dental tissue conservation. Consequently, new minimally invasive strategies were introduced into dental practice, such as the use of lasers to perform highly controlled tissue ablation. Laser use has also raised expectations of limiting pain and discomfort compared to using drills, as well as overcoming drill phobia. Objectives The main objective of the review was to compare the effects of laser‐based methods to conventional mechanical methods for removing dental caries in deciduous and permanent teeth. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (searched 22 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 22 June 2016), MEDLINE Ovid (1946 to 22 June 2016), Embase Ovid (1980 to 22 June 2016), ProQuest Dissertations and Theses (1980 to 22 June 2016), Zetoc (limited to conference proceedings) (1993 to 22 June 2016), and ISI Web of Knowledge (limited to conference proceedings) (1990 to 22 June 2016). We checked the reference lists of relevant articles to identify additional studies. We searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. Selection criteria We included randomised controlled trials, split‐mouth trials and cluster‐randomised trials (irrespective of their language) comparing laser therapy to drill ablation of caries. We included participants of any age (children, adolescents and adults). Data collection and analysis Two review authors independently screened titles and abstracts of citations identified by the review search strategy. Two review authors independently evaluated the full text of relevant primary studies, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. Main results We included nine randomised trials, published between 1998 and 2014, involving 662 participants. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Four studies examined only permanent teeth, and five studies evaluated both deciduous and permanent teeth. Six trials used Er:YAG (erbium‐doped yttrium aluminium garnet) lasers, two trials employed Er,Cr:YSGG (erbium, chromium: yttrium‐scandium‐gallium‐garnet) lasers, and one trial used Nd:YAG (neodymium‐doped yttrium aluminium garnet) laser. Overall, the trials had small sample sizes, and the majority were at unclear or high risk of bias. The primary outcomes were evaluated in a limited number of trials (removal of caries (four trials (but only two reported quantitative data)); episodes of pain (five studies)). There was insufficient evidence to suggest that either lasers or drill were better at caries removal (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.99 to 1.01; 2 studies; 256 treated caries; P = 0.75; I 2 = 0%; low‐quality evidence). The incidence of moderate or high pain was greater in the drill group compared to the laser group (RR 0.40, 95% CI 0.28 to 0.57; 2 studies; 143 participants; P < 0.001; I 2 = 50%). Similarly, the need for anaesthesia was significantly higher in the drill group than in the laser group (RR 0.25, 95% CI 0.10 to 0.65; 3 studies; 217 children/adolescents; P = 0.004; I 2 = 0%). In terms of marginal integrity of restoration, there was no evidence of a difference between laser and drill comparisons evaluated at 6 months (RR 1.00, 95% CI 0.21 to 4.78; 3 studies), 1 year (RR 1.59, 95% CI 0.34 to 7.38; 2 studies), or 2 years (RR 1.00, 95% CI 0.21 to 4.74; 1 study). There was no evidence of a difference for durability of restoration between laser therapy or drill at 6 months' follow‐up (RR 2.40, 95% CI 0.65 to 8.77; 4 studies), at 1 year (RR 1.40, 95% CI 0.29 to 6.78; 2 studies) or at 2 years' follow‐up (RR 0.50, 95% CI 0.02 to 14.60; 1 study). Only two trials investigated the recurrence of caries, but no events occurred during 6 months' follow‐up. There was insufficient evidence of a difference between laser or drill in terms of pulpal inflammation or necrosis at 1 week (RR 1.51, 95% CI 0.26 to 8.75; 3 studies) and at 6 months (RR 0.99, 95% CI 0.10 to 9.41; 2 studies). Authors' conclusions Given the low quality of the body of evidence, we concluded that evidence was insufficient to support the use of laser as an alternative to traditional drill therapy for caries removal. We found some evidence in favour of laser therapy for pain control, need of anaesthesia and patient discomfort, but, again, the body of evidence was of low quality. Additional well‐designed, randomised trials investigating the most relevant outcomes are needed. Plain language summary Lasers for the removal of decay in first and permanent teeth Review question This review addressed the issue of whether there is an advantage to laser therapy for the removal of decay in teeth and patient pain, compared to a traditional drill, in children, adolescents and adults. Background Dental decay is a cavity formation in teeth resulting from the destruction of dental tissue caused by bacteria under certain conditions, including poor oral hygiene and excessive sugar intake. Symptoms may include pain and difficulty with eating, and complications may include tooth loss, infection or inflammation of the gum. Rotating drills are traditionally used to remove decay. However, this mechanical tool may have unexpected side effects, such as the removal of too much or too little decay, in addition to discomfort due to pain, noise and vibration. Laser therapy is a potential alternative to a mechanical drill. Study characteristics Cochrane Oral Health provided the search strategies and carried out the search in several electronic databases. We selected nine randomised trials for inclusion in this review that were conducted between 1998 and 2014. The evidence in the review is up to date as of 22 June 2016. The trials involved a total of 662 participants, with 1498 teeth treated. Three studies were conducted in the USA, one in Taiwan, one in China, one in Bulgaria, one in Germany, one in Turkey and one in the UK. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Key results Despite the number of included studies, only a few trials adequately and completely reported information on the primary outcomes. Two trials reported on removal of decay, and there was not enough evidence to conclude that either lasers or drills were better at decay removal. Only five trials reported on episodes of pain, which was significantly reduced in people treated with lasers. There was no difference in terms of side effects, such as inflammation or death of dental pulp, between the two interventions. Quality of the evidence The overall quality of the evidence for the nine studies was low. Only one study adequately randomised participants, and none of the included studies was at low risk of bias. This review highlights the need for high‐quality studies comparing laser therapy and mechanical drills in the treatment of dental decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Montedori, A, Abraha, I, Orso, M, D'Errico, PG, Pagano, S, Lombardo, G", "articleTypes": [], "doi": "10.1002/14651858.CD010229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.758Z" }, { "id": "4bf839f1-42cf-4ffa-a5d4-7712ee8929a6", "pmid": "", "title": "Lactoferrin for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "Abstract - Background Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be due in part to disruption of the integrity of the gut and its altered intestinal microflora. Lactoferrin is a whey protein found in milk and is an important innate mammalian defence mechanism. Lactoferrin has been reported to have antimicrobial and anti‐inflammatory properties. It has also been reported to help establish a healthy gut microflora and aid in the intestinal immune system. Lactoferrin supplementation has been reported to decrease sepsis in preterm infants. There may be a role for lactoferrin to reduce the incidence of sepsis, thus reducing morbidity and mortality and improving enteral feeding in postoperative term neonates. Objectives The primary objective of this review was to evaluate the efficacy of administering lactoferrin on the incidence of sepsis and mortality in term neonates after gastrointestinal surgery. The secondary objective was to assess the impact of administering lactoferrin on time to full enteral feeds, the intestinal microflora, duration of hospital stay, and mortality before discharge in the same population. Search methods The Cochrane Neonatal Information Specialist searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase Ovid, CINAHL, the WHO ICTRP and ClinicalTrials.gov trials registries. The date of the last search was February 2023. There were no restrictions to language, publication year or publication type. We checked references of potentially relevant studies and systematic reviews. Selection criteria We planned to include randomised controlled trials that studied infants born at 37 or more weeks of gestation who had one or more episodes of gastrointestinal surgery within 28 days of birth, and compared administration of lactoferrin with a placebo. Data collection and analysis We used standard Cochrane methodological procedures. We planned to use the GRADE approach to assess the certainty of evidence for each outcome. Main results We identified no published randomised controlled studies that assessed the efficacy of lactoferrin for the postoperative management of term neonates following gastrointestinal surgery. Authors' conclusions There is currently no evidence available from randomised controlled trials to show whether lactoferrin is effective or ineffective for the postoperative management of term neonates after gastrointestinal surgery. There is a need for randomised controlled trials to be performed to assess the role of lactoferrin in this setting. Plain language summary What are the benefits and risks of giving lactoferrin to full‐term babies who had digestive tract surgery? Key message We found no medical studies that investigated the effects of giving lactoferrin (a protein found in milk) to babies born at full‐term (at or after 37 weeks of pregnancy) who had surgery of their digestive tract. What is lactoferrin? Lactoferrin is a protein found in milk that can protect against infection. Lactoferrin supplements are available and have been researched in premature babies. There is some evidence that lactoferrin can prevent infection in premature babies. What are some of the risks of digestive tract surgery in babies? Surgery of the digestive tract increases the risk of infection. Infections can increase the length of stay in hospital. Treatment with antibiotics (medicines that fight bacterial infections) and stress from surgery can disrupt good bacteria in the digestive tract. What did we want to find out? We wanted to find out if giving lactoferrin to full‐term babies, after digestive tract surgery, decreased rates of infection and death, and improved the presence of good bacteria in the digestive tract. What did we do? We searched for studies in which babies who had digestive tract surgery were assigned randomly to lactoferrin or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested). What did we find? We did not find any studies that compared giving lactoferrin to a placebo in full‐term babies who had digestive tract surgery. Well‐designed and large studies are needed to answer this question. How up to date is this evidence? The search is up‐to‐date as of February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Trivedi, A; Maheshwari, R; Tarnow-Mordi, WO; Saxena, N", "articleTypes": [], "doi": "10.1002/14651858.CD012218.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "4c200ab0-8864-4305-bd5c-2b04bb02d4e8", "pmid": "", "title": "Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Tan, ML, Ho, JJ, Teh, KH", "articleTypes": [], "doi": "10.1002/14651858.CD009398.pub3 AB - Abstract - Background About 5% of school children have a specific learning disorder, defined as unexpected failure to acquire adequate abilities in reading, writing or mathematics that is not a result of reduced intellectual ability, inadequate teaching or social deprivation. Of these events, 80% are reading disorders. Polyunsaturated fatty acids (PUFAs), in particular, omega‐3 and omega‐6 fatty acids, which normally are abundant in the brain and in the retina, are important for learning. Some children with specific learning disorders have been found to be deficient in these PUFAs, and it is argued that supplementation of PUFAs may help these children improve their learning abilities. Objectives 1. To assess effects on learning outcomes of supplementation of polyunsaturated fatty acids (PUFAs) for children with specific learning disorders.
 2. To determine whether adverse effects of supplementation of PUFAs are reported in these children. Search methods In November 2015, we searched CENTRAL, Ovid MEDLINE, Embase, PsycINFO, 10 other databases and two trials registers. We also searched the reference lists of relevant articles. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing PUFAs with placebo or no treatment in children younger than 18 years with specific learning disabilities, as diagnosed in accordance with the fifth (or earlier) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5), or the 10th (or earlier) revision of the International Classification of Diseases (ICD‐10) or equivalent criteria. We included children with coexisting developmental disorders such as attention deficit hyperactivity disorder (ADHD) or autism. Data collection and analysis Two review authors (MLT and KHT) independently screened the titles and abstracts of articles identified by the search and eliminated all studies that did not meet the inclusion criteria. We contacted study authors to ask for missing information and clarification, when needed. We used the GRADE approach to assess the quality of evidence. Main results Two small studies involving 116 children, mainly boys between 10 and 18 years of age, met the inclusion criteria. One study was conducted in a school setting, the other at a specialised clinic. Both studies used three months of a combination of omega‐3 and omega‐6 supplements as the intervention compared with placebo. Although both studies had generally low risk of bias, we judged the risk of reporting bias as unclear in one study, and as high in the other study. In addition, one of the studies was funded by industry and reported active company involvement in the study. None of the studies reported data on the primary outcomes of reading, writing, spelling and mathematics scores, as assessed by standardised tests. Evidence of low quality indicates that supplementation of PUFAs did not increase the risk of gastrointestinal disturbances (risk ratio 1.43, 95% confidence interval 0.25 to 8.15; two studies, 116 children). Investigators reported no other adverse effects. Both studies reported attention deficit hyperactivity disorder (ADHD)‐related behaviour outcomes. We were unable to combine the results in a meta‐analysis because one study reported findings as a continuous outcome, and the other as a dichotomous outcome. No other secondary outcomes were reported. We excluded one study because it used a cointervention (carnosine), and five other studies because they did not provide a robust diagnosis of a specific learning disorder. We identified one ongoing study and found three studies awaiting classification. Authors' conclusions Evidence is insufficient to permit any conclusions about the effect of PUFAs on the learning abilities of children with specific learning disorders. Well‐designed RCTs with clearly defined populations of children with specific learning disorders who have been diagnosed by standardised diagnostic criteria are needed. Plain language summary Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders Review question We reviewed the evidence on the effects of polyunsaturated fatty acids (PUFAs), compared with placebo or no treatment, on reading, writing or mathematical abilities of children up to 18 years of age who have specific learning disorders. Background Children with specific learning disorders are those whose abilities in reading, spelling, writing and mathematics are considerably below what is expected for their age, and whose problems are not a result of lower intelligence, inadequate teaching or social deprivation. A child may have a single disorder, such as a reading disorder, or a combined disorder, such as a reading and mathematics disorder. Children may have other problems too, such as attention deficit hyperactivity disorder (ADHD), along with a specific learning disorder. Polyunsaturated fatty acids are known to be necessary for normal brain development and function. The best known PUFAs are the omega‐3 fatty acids, which include docosahexaenoic acid (commonly known as DHA), but the omega‐6 fatty acids are also well known. Polyunsaturated fatty acids must be obtained from foods or supplements, as the human body cannot make them from other types of fat. Because they are needed for normal brain growth and development, PUFAs might help children with specific learning disorders. Study characteristics The evidence is current to November 2015. We found two small studies involving 116 children that met our inclusion criteria. Both studies gave children a combination of omega‐3 and omega‐6 capsules as the intervention for three months. Most of these studies involved boys between 10 and 18 years of age ‐ one was conducted in a school setting, and the other at a specialised clinic. One of the studies was funded by the company that supplied the omega‐3 and omega‐6 supplements. Another study could not be included in this review because investigators added carnosine (an amino acid that is highly concentrated in the brain) to the PUFAs. Carnosine and PUFAs might have similar effects, so it would not be possible to separate the effects of the two ingredients. Review authors excluded five studies because it was not confirmed that a specific learning disorder was diagnosed in these children. Key results None of the included studies reported effects of PUFAs on reading, writing, spelling or mathematical abilities of children. Evidence of low quality (because studies included few participants and showed evidence of bias) suggests that using PUFAs did not increase the risk of minor disturbances to the digestive system. Included studies reported no other types of adverse effects. Both studies reported on ADHD‐related behaviour. However, the format of available data did not allow us to readily combine them or to reach any conclusions. Included studies reported no other secondary outcomes. Conclusion Evidence is not sufficient to support or refute the use of PUFAs in children with specific learning disorders.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.733Z" }, { "id": "4c24cbd7-8bbc-4a84-90cf-ad5aa4d4611a", "pmid": "", "title": "Antiplatelet agents for the treatment of adults with COVID‐19", "imported": false, "abstract": "Abstract - Background Severe coronavirus disease 2019 (COVID‐19) can cause thrombotic events that lead to severe complications or death. Antiplatelet agents, such as acetylsalicylic acid, have been shown to effectively reduce thrombotic events in other diseases: they could influence the course of COVID‐19 in general. Objectives To assess the efficacy and safety of antiplatelets given with standard care compared to no treatment or standard care (with/without placebo) for adults with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (which comprises MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO ICTRP, medRxiv, CENTRAL), Web of Science, WHO COVID‐19 Global literature on coronavirus disease and the Epistemonikos COVID‐19 L*OVE Platform to identify completed and ongoing studies without language restrictions to December 2022. Selection criteria We followed standard Cochrane methodology. We included randomised controlled trials (RCTs) evaluating antiplatelet agents for the treatment of COVID‐19 in adults with COVID‐19, irrespective of disease severity, gender or ethnicity. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane risk of bias tool (RoB 2) for RCTs. We rated the certainty of evidence using the GRADE approach for the outcomes. Main results Antiplatelets plus standard care versus standard care (with/without placebo) Adults with a confirmed diagnosis of moderate to severe COVID‐19 We included four studies (17,541 participants) that recruited hospitalised people with a confirmed diagnosis of moderate to severe COVID‐19. A total of 8964 participants were analysed in the antiplatelet arm (either with cyclooxygenase inhibitors or P2Y12 inhibitors) and 8577 participants in the control arm. Most people were older than 50 years and had comorbidities such as hypertension, lung disease or diabetes. The studies were conducted in high‐ to lower middle‐income countries prior to wide‐scale vaccination programmes. Antiplatelets compared to standard care: – probably result in little to no difference in 28‐day mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.85 to 1.05; 3 studies, 17,249 participants; moderate‐certainty evidence). In absolute terms, this means that for every 177 deaths per 1000 people not receiving antiplatelets, there were 168 deaths per 1000 people who did receive the intervention (95% CI 151 to 186 per 1000 people); – probably result in little to no difference in worsening (new need for invasive mechanical ventilation or death up to day 28) (RR 0.95, 95% CI 0.90 to 1.01; 2 studies, 15,266 participants; moderate‐certainty evidence); – probably result in little to no difference in improvement (participants discharged alive up to day 28) (RR 1.00, 95% CI 0.96 to 1.04; 2 studies, 15,454 participants; moderate‐certainty evidence); – probably result in a slight reduction of thrombotic events at longest follow‐up (RR 0.90, 95% CI 0.80 to 1.02; 4 studies, 17,518 participants; moderate‐certainty evidence); – may result in a slight increase in serious adverse events at longest follow‐up (Peto odds ratio (OR) 1.57, 95% CI 0.48 to 5.14; 1 study, 1815 participants; low‐certainty evidence), but non‐serious adverse events during study treatment were not reported; – probably increase the occurrence of major bleeding events at longest follow‐up (Peto OR 1.68, 95% CI 1.29 to 2.19; 4 studies, 17,527 participants; moderate‐certainty evidence). Adults with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included two RCTs allocating participants, of whom 4209 had confirmed mild COVID‐19 and were not hospitalised. A total of 2109 participants were analysed in the antiplatelet arm (treated with acetylsalicylic acid) and 2100 participants in the control arm. No study included people with asymptomatic SARS‐CoV‐2 infection. Antiplatelets compared to standard care: – may result in little to no difference in all‐cause mortality at day 45 (Peto OR 1.00, 95% CI 0.45 to 2.22; 2 studies, 4209 participants; low‐certainty evidence); – may slightly decrease the incidence of new thrombotic events up to day 45 (Peto OR 0.37, 95% CI 0.09 to 1.46; 2 studies, 4209 participants; low‐certainty evidence); – may make little or no difference to the incidence of serious adverse events up to day 45 (Peto OR 1.00, 95% CI 0.60 to 1.64; 1 study, 3881 participants; low‐certainty evidence), but non‐serious adverse events were not reported. The evidence is very uncertain about the effect of antiplatelets on the following outcomes (compared to standard care plus placebo): – admission to hospital or death up to day 45 (Peto OR 0.79, 95% CI 0.57 to 1.10; 2 studies, 4209 participants; very low‐certainty evidence); – major bleeding events up to longest follow‐up (no event occurred in 328 participants; very low‐certainty evidence). Quality of life and adverse events during study treatment were not reported. Authors' conclusions In people with confirmed or suspected COVID‐19 and moderate to severe disease, we found moderate‐certainty evidence that antiplatelets probably result in little to no difference in 28‐day mortality, clinical worsening or improvement, but probably result in a slight reduction in thrombotic events. They probably increase the occurrence of major bleeding events. Low‐certainty evidence suggests that antiplatelets may result in a slight increase in serious adverse events. In people with confirmed COVID‐19 and mild symptoms, we found low‐certainty evidence that antiplatelets may result in little to no difference in 45‐day mortality and serious adverse events, and may slightly reduce thrombotic events. The effects on the combined outcome admission to hospital or death up to day 45 and major bleeding events are very uncertain. Quality of life was not reported. Included studies were conducted in high‐ to lower middle‐income settings using antiplatelets prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, adverse events and people with asymptomatic infection. The 14 ongoing and three completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. Plain language summary Are antiplatelets an effective treatment for people with COVID‐19? Key messages Antiplatelets are a group of different medicines that can prevent potentially fatal clot formation in the blood vessels ('thrombotic events'). For hospitalised patients with COVID‐19, they probably slightly reduce thrombotic events but probably do not affect deaths, clinical worsening or improvement in COVID‐19 compared with placebo or standard care. However, antiplatelets may result in a slight increase in serious unwanted effects ('adverse events') and probably increase major bleeding. Similarly, in non‐hospitalised people, antiplatelets slightly decrease thrombotic events. They may result in little to no difference in deaths or serious unwanted effects, however the evidence on admission to hospital or death and major bleeding events is very uncertain. There are 14 further studies that have not completed yet, and the results of three other completed studies are not yet available. What are antiplatelets? Antiplatelets are a group of drugs which, in different ways, stop blood from changing to a gel‐like substance called a clot, which we mean by the term 'thrombotic events'. They are taken mainly by mouth, usually by people who are at high risk of developing a clot (people who have already experienced or who tend to build up a clot). A clot could lead to a stroke, coronary heart disease, poor blood circulation in the legs, thromboses in the legs or clot obstruction ('embolism') in the lung circulation that could lead to shortness of breath, heart failure and death. How might antiplatelets treat COVID‐19? People with COVID‐19 might be at risk from blood clots. Antiplatelets prevent clots from forming in the body, and this could in turn prevent complications that lead to death and clinical deterioration. What did we want to find out? We wanted to know whether antiplatelets in addition to usual care are effective for adults with COVID‐19, when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in: – number of deaths from any cause up to 28 days after treatment, or longer if reported;
– whether people got better or worse after treatment (including unwanted effects of the disease itself, like thrombotic events);
– unwanted effects of the treatment (especially major bleeding). What did we do? We searched for studies that reported on people with COVID‐19 who received antiplatelets together with usual care, or usual care alone (with/without placebo). We summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We identified four studies, including 17,541 people with moderate to severe COVID‐19 (hospitalised). Of these, one compared acetylsalicylic acid (aspirin) with usual care, two studies compared 'P2Y12 inhibitors' (e.g. clopidogrel, prasugrel, ticagrelor) with usual care, and a fourth one compared either acetylsalicylic acid or P2Y12 inhibitors with usual care. The studies included people with a confirmed or suspected diagnosis of SARS‐CoV‐2 infection. Two studies compared acetylsalicylic acid to placebo in 4209 non‐hospitalised people with confirmed mild COVID‐19. We also found 14 ongoing studies, two studies without published results and another that had been withdrawn after a preprint version. We found no studies that included people with COVID‐19 infection but no symptoms. Main results Antiplatelets: – probably make little or no difference to deaths by 28 or 180 days, worsening up to day 28 (new invasive mechanical ventilation or death) or improvement (discharged alive) up to day 28, and they probably slightly decrease thrombotic events; – may result in a slight increase in serious unwanted effects and probably increase major bleeding events. In people not in hospital, with mild disease, antiplatelets may result in little to no difference in death within 45 days, or in the incidence of serious adverse events, and they may slightly decrease the incidence of thrombotic events. The evidence for these participants is very uncertain about the effects on worsening (hospitalisation or death within 45 days) and on major bleeding events. Studies did not report on quality of life and general unwanted effects. What are the limitations of the evidence? The studies were conducted in populations from high‐ to middle‐income countries, many of them prior to the roll‐out of COVID‐19 vaccination programmes and before Omicron became the most prevalent variant. We have moderate confidence in the evidence for mortality, worsening/improvement up to day 28, and major bleeding events or thrombotic events in hospitalised people. We have low confidence in the evidence for the effects on serious unwanted effects, because they occurred rarely. For non‐hospitalised people, our confidence in the evidence is low for the effects on death, thrombotic events and serious adverse events, and very low for the effects on worsening and major bleeding events (those events were rare and the time period between symptom onset and treatment was long). Information about other unwanted effects and quality of life was not available. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 22 December 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Fischer, A-L; Messer, S; Riera, R; Martimbianco, ALC; Stegemann, M; Estcourt, LJ; Weibel, S; Monsef, I; Andreas, M; Pacheco, RL; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015078", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "4c3579ad-453d-4d22-ac82-4ac314ae07c1", "pmid": "", "title": "Calcitonin for metastatic bone pain", "imported": false, "abstract": "Abstract - Background Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastases. The hormone calcitonin has the potential to relieve pain and also retain bone density, thus reducing the risk of fractures. This review is an update of a previously published review in the Cochrane Library (2003, Issue 3) which was also updated in 2006 (Issue 3) and in 2011 (Issue 9). Objectives The main objective of the review is to determine the effectiveness of calcitonin to reduce metastatic bone pain in patients with painful bone metastases. Secondary objectives are to assess the benefits of calcitonin in reducing the incidence of bone complications (hypercalcemia, fractures and nervous compression) and improving patient survival, and to report any adverse effects of the treatment. Search methods We updated the electronic searches in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2015. We also searched registers of clinical trials in progress up to February 2015. Selection criteria We included studies if they were randomised, double‐blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. Data collection and analysis Two independent review authors performed study selection and data extraction. Only two studies (90 participants) were eligible for inclusion in the review and therefore meta‐analysis of the data was not possible. We performed intention‐to‐treat (ITT) analysis by imputing all missing values as adverse effects. Main results The overall quality of the evidence was very low. In this update no new studies were identified for inclusion; one additional study was excluded. Of the two small included studies, one study showed a non‐significant effect of calcitonin on the number of patients with complete pain relief (risk ratio (RR) 2.50; 95% confidence interval (CI) 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; 95% CI 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases, for improving quality of life or for patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.50; 95% CI 0.77 to 15.88). Authors' conclusions Current available research evidence is of very low quality and there is a lack of evidence to support the use of calcitonin for managing bone pain from bone metastases. Since the last version of this review, we did not identify any additional studies. Plain language summary Calcitonin used to treat metastatic bone pain People who have cancer which has spread to their bones and the nerves adjacent to the bones often suffer severe pain. There are several treatments to help relieve this pain: radiotherapy, analgesic drugs (pain killers) such as opioids, and bone‐modulating drugs such as bisphosphonates and calcitonin. Calcitonin has the potential to relieve pain and maintain bone strength, thus reducing the risk of broken bones. This review looked at the effectiveness of calcitonin for controlling pain from bone metastases. However, only two studies were found with very low quality evidence to support the use of calcitonin for patients suffering from bone pain. We updated the review in 2015 and did not find any more studies. There were slightly more side effects for the patients given calcitonin. Unless new studies provide additional relevant information about this treatment, other therapeutic approaches should be considered.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Martinez-Zapata, MJ, Roqué i Figuls, M, Català, E, Roman, Y, Alonso Coello, P", "articleTypes": [], "doi": "10.1002/14651858.CD003223.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.095Z" }, { "id": "4c405046-e1af-4c82-80cd-ef7d7065331a", "pmid": "", "title": "Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder", "imported": false, "abstract": "Abstract - Background Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. Objectives To assess the effects ‐ and review the acceptability and tolerability ‐ of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. Selection criteria Double‐ or single‐blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. Data collection and analysis Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. Main results Thirty‐one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D‐cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP‐101,606 (1), decoglurant (1), MK‐0657 (1), N‐acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty‐eight studies were placebo‐controlled, and 48 were two‐arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild‐to‐moderate depression. Nineteen studies recruited only patients with treatment‐resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low‐certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) ‐0.87, 95% CI ‐1.26 to ‐0.48; n = 231, studies = 8, very low‐certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low‐certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low‐certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low‐certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and midazolam (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low‐certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate‐certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD ‐0.31, 95% CI ‐0.45 to ‐0.17; n = 824, studies = 4, moderate‐certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low‐certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate‐certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. Authors' conclusions Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta‐analyses for each comparison and the majority of comparisons included only one study. Long term non‐inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real‐world monitoring are needed to establish comprehensive data on safety and efficacy. Plain language summary Ketamine and other glutamate receptor modulators for depression in adults Why is this review important? Depression is one of the most common mental disorders, estimated to affect 350 million people worldwide. Antidepressant medication tends to be given as a first treatment for people with major depression. These drugs are however only effective in about one in four people at one year. Effective alternative medications to treat depression are needed, especially for rapid treatment. A new group of medications is called ‘glutamate receptor modulators’, which act on the glutamergic system. This group includes the medicine ketamine. In this review we examined the evidence for glutamate receptor modulators, including ketamine, as a treatment for depression. Who will be interested in this review? ‐ People with depression, their friends and families. ‐ General practitioners, psychiatrists, psychologists and pharmacists. ‐ Professionals working in adult mental health services. What questions does this review aim to answer? 1. Is treatment with ketamine and other glutamate receptor modulators more effective than treatment with placebo (dummy pill) or other drugs? 2. Is treatment with ketamine and other glutamate receptor modulators more acceptable than placebo or other drugs? Which studies were included in the review? We searched medical databases to find all relevant studies (specifically randomised controlled trials) completed up to 30 July 2020. To be included in the review, studies had to compare ketamine or other glutamate receptor modulators with placebo, other medicines or electroconvulsive therapy (ECT) for depression in adults (aged 18 and over). The studies also had to be single‐blind (the participant does not know which treatment they are receiving) or double‐blind (neither the participant or researcher know which treatment the participant is receiving), to attempt to reduce bias. We included 64 studies in the review, involving a total of 5299 people. The studies investigated16 different glutamate receptor modulator medications. The majority of participants had treatment‐resistant depression (depression which had not responded to two or more medications) at the start of the studies. Most studies were two‐armed, where the glutamate receptor modulator was compared with one other intervention. What does the evidence from the review tell us? Among the 16 drugs included in this review, only ketamine and esketamine were more effective than placebo at reducing symptoms of depression. The effects of ketamine lasted no more than one week after treatment and clearly disappeared after two weeks. Ketamine did, however, cause more side effects than placebo. The effects of esketamine were seen at 24 hours and could last up to four weeks with repeated doses. Esketamine caused a lot more side effects than placebo. The certainty of evidence varied considerably. There was no evidence of a difference between the other glutamate receptor modulators included in this review and placebo or other medications. What should happen next? Ketamine and esketamine appear to reduce the symptoms of depression. However, the trials were all short term so we do not know about the long‐term effects. It is important to note that in some trials attempts to prevent participants and investigators from knowing what medicine was being given were not successful and this may have inflated the positive effects of the active drugs. Future studies should examine what happens when people are repeatedly given the drug, with the aim to mimic the real‐world practice and assess longer‐term effects. More non‐inferiority trials should be conducted, where glutamate receptor modulators are compared with other active medications rather than placebo to find out whether they are better than alternative treatments. In most of the ketamine trials in this review, participants were given the drug by injection into a vein. This restricts the wide‐scale application of ketamine in clinical settings, so trials of ketamine by other routes are needed. Esketamine trials usually used nasal sprays, which are easier to use and could potentially be taken at home if further monitoring and trials found that it was safe to do so. Further studies assessing administration are needed in order to draw more reliable and firm conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Dean, RL; Hurducas, C; Hawton, K; Spyridi, S; Cowen, PJ; Hollingsworth, S; Marquardt, T; Barnes, A; Smith, R; McShane, R; Turner, EH; Cipriani, A", "articleTypes": [], "doi": "10.1002/14651858.CD011612.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "4c46e0b2-70a5-454d-a65e-10bac6a72f95", "pmid": "", "title": "Community‐based supplementary feeding for food insecure, vulnerable and malnourished populations – an overview of systematic reviews", "imported": false, "abstract": "Abstract - Background Supplementary feeding may help food insecure and vulnerable people by optimising the nutritional value and adequacy of the diet, improving quality of life and improving various health parameters of disadvantaged families. In low‐ and middle‐income countries (LMIC), the problems supplementary feeding aims to address are entangled with poverty and deprivation, the programmes are expensive and delivery is complicated. Objectives 1. To summarise the evidence from systematic reviews of supplementary feeding for food insecure, vulnerable and malnourished populations, including children under five years of age, school‐aged children, pregnant and lactating women, people with HIV or tuberculosis (or both), and older populations. 2. To describe and explore the effects of supplementary feeding given to people in these groups, and to describe the range of outcomes between reviews and range of effects in the different groups. Methods In January 2017, we searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase and nine other databases. We included systematic reviews evaluating community‐based supplementary feeding, and concerning food insecure, vulnerable and malnourished populations. Two review authors independently undertook selection of systematic reviews, data extraction and 'Risk of bias' assessment. We assessed review quality using the AMSTAR tool, and used GRADEpro 'Summary of findings' tables from each review to indicate the certainty of the evidence for the main comparisons. We summarised review findings in the text and reported the data for each outcome in additional tables. We also used forest plots to display results graphically. Main results This overview included eight systematic reviews (with last search dates between May 2006 and February 2016). Seven were Cochrane Reviews evaluating interventions in pregnant women; children (aged from birth to five years) from LMIC; disadvantaged infants and young children (aged three months to five years); children with moderate acute malnutrition (MAM); disadvantaged school children; adults and children who were HIV positive or with active tuberculosis (with or without HIV). One was a non‐Cochrane systematic review in older people with Alzheimer's disease. These reviews included 95 trials relevant to this overview, with the majority (74%) of participants from LMIC. The number of included participants varied between 91 and 7940 adults, and 271 and more than 12,595 children. Trials included a wide array of nutritional interventions that varied in duration, frequency and format, with micronutrients often reported as cointerventions. Follow‐up ranged from six weeks to two years; three trials investigated outcomes at four to 17 years of age. All reviews were rated as high quality (AMSTAR score between eight and 11). The GRADE certainty ratings ranged from very low to moderate for individual comparisons, with the evidence often comprising only one or two small trials, thereby resulting in many underpowered analyses (too small to detect small but important differences). The main outcome categories reported across reviews were death, anthropometry (adults and children) and other markers of nutritional status, disease‐related outcomes, neurocognitive development and psychosocial outcomes, and adverse events. Mortality data were limited and underpowered in meta‐analysis in all populations (children with MAM, in children with HIV, and in adults with tuberculosis) with the exception of balanced energy and protein supplementation in pregnancy, which may have reduced the risk of stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94; 5 trials, 3408 women). Supplementation in pregnancy also improved infant birth weight (mean difference (MD) 40.96 g, 95% CI 4.66 to 77.26; 11 trials, 5385 participants) and reduced risk of infants born small‐for‐gestational age (RR 0.79, 95% CI 0.69 to 0.90; 7 trials, 4408 participants). These effects did not translate into demonstrable long‐term benefits for children in terms of growth and neurocognitive development in the one to two trials reporting on longer‐term outcomes. In one study (505 participants), high‐protein supplementation was associated with increased risk of small‐for‐gestational age babies. Effects on growth in children were mixed. In children under five years of age from LMIC, one review found that supplementary feeding had a little or no effect on child growth; however, a more recent review in a similar population found that those who received food supplementation gained an average of 0.12 kg more in weight (MD 0.12 kg, 95% CI 0.05 to 0.18; 9 trials, 1057 participants) and 0.27 cm more in height (MD 0.27 cm, 95% CI 0.07 to 0.48; 9 trials, 1463 participants) than those who were not supplemented. Supplementary food was generally more effective for younger children (younger than two years of age) and for those who were poorer or less well‐nourished. In children with MAM, the provision of specially formulated food improved their weight, weight‐for‐height z scores and other key outcomes such as recovery rate (by 29%), as well as reducing the number of participants dropping out (by 70%). In LMIC, school meals seemed to lead to small benefits for children, including improvements in weight z scores, especially in children from lower‐income countries, height z scores, cognition or intelligence quotient tests, and maths and spelling performance. Supplementary feeding in adults who were HIV positive increased the daily energy and protein intake compared to nutritional counselling alone. Supplementation led to an initial improvement in weight gain or body mass index but did not seem to confer long‐term benefit. In adults with tuberculosis, one small trial found a significant benefit on treatment completion and sputum conversion rate. There were also significant but modest benefits in terms of weight gain (up to 2.60 kg) during active tuberculosis. The one study included in the Alzheimer's disease review found that three months of daily oral nutritional supplements improved nutritional outcomes in the intervention group. There was little or no evidence regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes. Authors' conclusions Considering the current evidence base included, supplementary food effects are modest at best, with inconsistent and limited mortality evidence. The trials reflected in the reviews mostly reported on short‐term outcomes and across the whole of the supplementation trial literature it appears important outcomes, such as quality of life and cost of programmes, are not systematically reported or summarised. Plain language summary Supplementary feeding for groups of people that are food insecure, vulnerable and malnourished What was the aim of this review? To summarise the effect of supplementary feeding on populations that were food insecure, vulnerable and malnourished. The overview authors found eight systematic reviews examining supplementary feeding in a variety of populations. Key messages Across a range of vulnerable populations, supplementary feeding programmes sometimes show modest benefit in nutritional outcomes. In a few studies examining mortality (death), effects were either small or absent, and research mostly looked at short‐term effects. What was studied in the review? Supplementary feeding means providing extra food to people or families over and above their home diet and has been used in populations that are food insecure (limited access to adequate and nutritious food) and vulnerable (including women and young children; school‐aged children; people living with diseases such as tuberculosis, HIV, and Alzheimer's disease; and older people) to improve their health and quality of life. What are the main results of the review? The evidence presented here was current to January 2017. We found eight systematic reviews to include in this summary. These reviews included 95 studies (including up to 7940 adults, and more than 12,595 children in a few studies). Most of the included studies lasted from six weeks to two years, with only three studies following people for longer periods of time (up to 17 years). In these reviews, there were a wide range of different types of supplementary feeding given to vulnerable groups over different periods of time, and often in combination with vitamins or minerals. In pregnancy, we found that energy and protein supplements that were balanced (i.e. providing adequate amounts of energy and nutrients, in this case protein) may have decreased the rate of stillbirth (death or loss of a baby before or during delivery), improved infant birth weight and reduced the risk of infants born small‐for‐gestational age (infants that are smaller than expected). We observed no long‐term benefits for children in terms of growth and cognitive (intellectual) development (although very few studies reported long‐term effects). High‐protein supplements (containing protein in higher amounts) were associated with risk and harm (increased risk of small‐for‐gestational age babies). We found that the effects of supplementary feeding on growth in children were varied. In children under five years of age from low‐ and middle‐income countries, supplementary feeding had a small impact on child growth. We observed some benefits in terms of weight and height gains, especially in younger children (those younger than two years of age) and in those who were poorer or less well‐nourished (or both). Some benefit could be seen in children with moderate acute malnutrition in terms of weight gain, other growth factors and recovery rate. School meals seemed to lead to a number of small benefits in school children (including improvements in weight, height, intelligence tests, and maths and spelling performance). Supplementary feeding in adults who were HIV positive increased the daily intake of energy and protein and led to an early improvement in weight gain or body mass index (measure of whether someone is overweight or underweight), or both, but did not seem to lead to long‐term benefits (although few studies reported long‐term effects). In adults with tuberculosis (serious infectious lung disease), we observed small benefits in terms of weight gain during active tuberculosis. In Alzheimer's disease (a type of dementia), providing a daily oral nutrition supplement for three months improved nutritional outcomes (such as weight and energy intake). There was little or no evidence available regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Visser, J, McLachlan, MH, Maayan, N, Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD010578.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.117Z" }, { "id": "4c4f9318-65ab-4429-8355-b0f66c8ae67d", "pmid": "", "title": "CFTR modulator monotherapy for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a common, life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR gene variant, F508del, is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF) in some populations). The F508del variant lacks meaningful CFTR function: the faulty protein is degraded before reaching the cell membrane, where it would normally transport salt across the epithelial membrane. Corrective therapy with CFTR modulators could benefit many pwCF. This review evaluates treatment with single modulators (monotherapy). Objectives To evaluate the clinically important benefits and harms of CFTR modulator monotherapy in people of any age with cystic fibrosis with class II CFTR gene variants (most commonly F508del). Search methods We last searched the Cochrane CF Trials Register and online trials registries on 27 June 2025. We also checked the reference lists of relevant articles for additional studies. Eligibility criteria We included parallel‐group randomised controlled trials (RCTs) comparing any single CFTR modulator to placebo or any other single CFTR modulator in pwCF of any age or disease severity with class II variants. Outcomes Our critical outcomes were survival, quality of life (total score and respiratory domain), and forced expiratory volume in one second (FEV 1 % predicted; relative and absolute change from baseline). Our important outcomes included adverse effects and time to first pulmonary exacerbation. We planned to assess outcomes in the immediate term, short term, and longer term. Risk of bias We assessed risk of bias using the original Cochrane tool (RoB 1). Synthesis methods We analysed available data with RevMan using a fixed‐effect model. We reported odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. For adverse events, we reported 99% confidence intervals (CIs); for all other outcomes, we reported 95% CIs. Where we were unable to analyse data, we reported the results narratively. We used GRADE to assess the certainty of the evidence. Included studies We included 10 early‐phase placebo‐controlled RCTs (424 participants) assessing eight different drugs (4PBA, CPX, N6022, cavosonstat, lumacaftor, FDL169, GLPG2222, and riociguat) in adults; one 4PBA study additionally included adolescents (age ≥ 14 years). All participants were homozygous for F508del. The longest study lasted just 29 days, so we could only assess immediate‐term outcomes. Only two studies received no funding from pharmaceutical companies. Our main results are for lumacaftor and cavosonstat, which were the only drugs selected for further investigation in subsequent studies. Synthesis of results Investigators reported no deaths, but also no clinically relevant improvements in quality of life. There was insufficient evidence to determine effects on any measure of lung function. No studies demonstrated differences in the risk of mild, moderate, or severe adverse effects, including pulmonary exacerbations, between CFTR modulator monotherapy and placebo. The clinical relevance of adverse effects is difficult to assess, because each occurred in only a few participants per trial. We assessed the certainty of the evidence for two comparisons (lumacaftor versus placebo and cavosonstat versus placebo), rating the certainty of the evidence to be very low. Authors' conclusions There is a lack of evidence to support monotherapy with a CFTR modulator for pwCF who have two F508del variants (F508del/F508del). Funding This review was completed under a programme of work that is part of the CF Foundation grant funding for Cochrane CF. Registration The protocol was registered on PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/view/CRD420251090914 ). Plain language summary Can single‐medicine treatment with CFTR modulators (medicines that correct the faulty protein in cystic fibrosis) help people who have specific genetic variants of cystic fibrosis (most commonly F508del)? Key messages All the studies only included people with two copies of the most common cystic fibrosis‐causing gene variant (F508del). Most studies were entirely or partly funded by medicine companies. No studies reported any deaths. None of the single medicines we looked at were clearly better than placebo (dummy treatment) for improving quality of life or lung function, and there was no evidence of the medicines causing more harm than placebo. However, we are unsure about these results. The evidence for using a single CFTR modulator is weak, and future research is likely to focus on combination therapies. What is cystic fibrosis and how can it be treated? Cystic fibrosis is a serious inherited illness that shortens life. It damages many organs in the body, particularly the lungs, pancreas, and liver. In the lungs, it causes a build‐up of thick, sticky mucus that leads to repeated infections and progressive damage. Most people with cystic fibrosis experience breathing difficulties, poor nutrition, and a reduced quality of life. Cystic fibrosis is caused by a fault in a gene that makes a protein called CFTR. CFTR regulates the movement of salt and water across cell surfaces, keeping the mucus thin and slippery. The most common CFTR gene variant (found in over 80% of people with cystic fibrosis) is F508del, which is a class II variant. People with two copies of F508del usually have more severe disease than people with one copy. In people with class II variants, the CFTR protein is degraded and cannot move properly through the cell. Laboratory experiments suggest that if the protein reaches the cell wall, it may be able to function, restore salt movement, and correct the chronic problems people with cystic fibrosis experience. CFTR modulators are medicines that help the faulty CFTR protein reach the cell wall. What did we want to find out? We wanted to know if CFTR modulator monotherapy (single‐medicine treatment) can help people of any age with cystic fibrosis who have a class II variant. Specifically, we wanted to know if these medicines can improve survival, quality of life, lung function, and time to the first worsening of lung symptoms. We also wanted to know if this treatment is associated with any unwanted effects. What did we do? We searched for studies that investigated the effects of any single CFTR modulator compared with placebo (dummy treatment) or any other single CFTR modulator in people with cystic fibrosis who had at least one copy of a class II variant. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 10 studies (with 424 participants, all of whom had two copies of F508del) assessing eight different medicines given as monotherapy. Nine studies included only adults, and one study included people from age 14 years. All the studies were small (including between 18 and 89 participants) and lasted between one day and 29 days. They took place in North America (mainly the USA), Europe, and Australia. Our main findings are for two of the eight medicines, lumacaftor and cavosonstat, which have gone on to be evaluated in larger populations. Main findings No studies reported any deaths or meaningful improvements in quality of life. We did not find enough evidence to show any effect of CFTR modulators on lung function. The studies reported a wide range of unwanted effects, but each occurred in only a few participants per study. We did not find enough evidence to support using CFTR modulator monotherapy in people with cystic fibrosis who have two copies of F508del. What are the limitations of the evidence? We are not confident in the evidence, for the following reasons. The studies were small. Most results are based on evidence from a single study. The evidence is not applicable to children. Not all studies provided enough data for us to analyse the results. The evidence related to unwanted effects of treatment was based on very few events. How up‐to‐date is this evidence? This review updates our earlier review of single‐ and multiple‐medicine therapy. The evidence is current to 27 June 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Heneghan, M; Smith, S; Jahnke, N; Nevitt, S; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD016290", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "4c6dcbc1-a3bb-4a1c-89a3-ca2d8eaca494", "pmid": "", "title": "A Randomized Placebo-Controlled Study to Assess the Efficacy and Safety of AF-219, a P2X3 Receptor Antagonist, in Subjects With Idiopathic Pulmonary Fibrosis (IPF) With Persistent Cough", "imported": false, "abstract": "A randomized, double-blind, placebo-controlled, crossover, dose escalation study of gefapixant (AF-219) in participants with Idiopathic Pulmonary Fibrosis (IPF) with persistent cough.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.242Z" }, { "id": "4c87ed94-67ee-48c9-a345-910a54f538cc", "pmid": "", "title": "Antibiotics versus placebo for acute bacterial conjunctivitis", "imported": false, "abstract": "Abstract - Background Acute bacterial conjunctivitis is an infection of the conjunctiva and is one of the most common ocular disorders in primary care. Antibiotics are generally prescribed on the basis that they may speed recovery, reduce persistence, and prevent keratitis. However, many cases of acute bacterial conjunctivitis are self‐limited, resolving without antibiotic therapy. This Cochrane Review was first published in The Cochrane Library in 1999, then updated in 2006, 2012, and 2022. Objectives To assess the benefits and side effects of antibiotic therapy in the management of acute bacterial conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2022, Issue 5), MEDLINE (January 1950 to May 2022), Embase (January 1980 to May 2022), the meta Register of Controlled Trials ( m RCT) ( www.controlled-trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ), and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases in May 2022. Selection criteria We included randomized controlled trials (RCTs) in which any form of antibiotic treatment, with or without steroid, had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical and systemic antibiotic treatments. Data collection and analysis Two authors independently reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies and determined the included RCTs, which were further assessed for risk of bias using Cochrane methodology. We performed data extraction in a standardized manner and conducted random‐effects meta‐analyses using RevMan Web. Main results We included 21 eligible RCTs, 10 of which were newly identified in this update. A total of 8805 participants were randomized. All treatments were topical in the form of drops or ointment. The trials were heterogeneous in terms of their eligibility criteria, the nature of the intervention (antibiotic drug class, which included fluoroquinolones [FQs] and non‐FQs; dosage frequency; duration of treatment), the outcomes assessed and the time points of assessment. We judged one trial to be of high risk of bias, four as low risk of bias, and the others as raising some concerns. Based on intention‐to‐treat (ITT) population, antibiotics likely improved clinical cure (resolution of clinical symptoms or signs) by 26% (RR 1.26, 95% CI 1.09 to 1.46; 5 trials, 1474 participants; moderate certainty) as compared with placebo. Subgroup analysis showed no differences by antibiotic class (P = 0.67) or treatment duration (P = 0.60). In the placebo group, 55.5% (408/735) of participants had spontaneous clinical resolution by days 4 to 9 versus 68.2% (504/739) of participants treated with an antibiotic. Based on modified ITT population, in which participants were analyzed after randomization on the basis of positive microbiological culture, antibiotics likely increased microbiological cure (RR 1.53, 95% CI 1.34 to 1.74; 10 trials, 2827 participants) compared with placebo at the end of therapy; there were no subgroup differences by drug class (P = 0.60). No study evaluated the cost‐effectiveness of antibiotic treatment. Patients receiving antibiotics had a lower risk of treatment incompletion than those in the placebo group (RR 0.64, 95% CI 0.52 to 0.78; 13 trials, 5573 participants; moderate certainty) and were 27% less likely to have persistent clinical infection (RR 0.73, 95% CI 0.65 to 0.81; 19 trials, 5280 participants; moderate certainty). There was no evidence of serious systemic side effects reported in either the antibiotic or placebo group (very low certainty). When compared with placebo, FQs (RR 0.70, 95% CI 0.54 to 0.90) but not non‐FQs (RR 4.05, 95% CI 1.36 to 12.00) may result in fewer participants with ocular side effects. However, the estimated effects were of very low certainty. Authors' conclusions The findings of this update suggest that the use of topical antibiotics is associated with a modestly improved chance of resolution in comparison to the use of placebo. Since no evidence of serious side effects was reported, use of antibiotics may therefore be considered to achieve better clinical and microbiologic efficacy than placebo. Increasing the proportion of participants with clinical cure or increasing the speed of recovery or both are important for individual return to work or school, allowing people to regain quality of life. Future studies may examine antiseptic treatments with topical antibiotics for reasons of cost and growing antibiotic resistance. Plain language summary What are the benefits and harms of antibiotics for acute bacterial conjunctivitis? Key messages Topical antibiotics may improve signs and symptoms as well as bacterial clearance in participants with acute bacterial conjunctivitis. However, some antibiotics can cause unwanted effects on the eyes or eyelids; no evidence suggests that antibiotics cause unwanted effects in other parts of the body. What is acute bacterial conjunctivitis? Acute bacterial conjunctivitis is a condition in which the thin layer over the white areas and the inside lining of the eyelids of one or both eyes becomes red and inflamed from a bacterial infection. Acute bacterial conjunctivitis is usually contagious and hence children and working adults are advised to avoid going to school or work when affected. Fortunately, it resolves spontaneously in most cases. How is acute bacterial conjunctivitis treated? People with acute bacterial conjunctivitis are often given treatment at the site of the infection, usually as antibiotic eye drops or ointment, to speed recovery. However, the benefits of antibiotics have been questioned when considering they can cause irritation or allergic reaction in and around the eyes or surrounding skin. What did we want to find out? We examined whether antibiotics alone or in combination with steroid, can improve signs and symptoms of conjunctivitis or help clear the associated bacteria. We also evaluated whether antibiotics would result in undesirable effects on the eyes. What did we do? We performed a systematic review by searching for studies that compared antibiotics in eyedrop, ointment, or tablet form with inactive controls. We summarized these study findings and reported the results together with our level of confidence in them based on how studies were conducted. What did we find? We found that antibiotics likely increase clinical cure and microbiological cure after a course of treatment in comparison with placebo. Antibiotic use also is associated with fewer participants stopping their treatment earlier than they are supposed to. However, for some individuals, non‐fluroquinolone but not fluoroquinolone antibiotics, may result in more unwanted effects on the eyes or eyelids than placebo though we were very uncertain about the relevant evidence. There was no evidence that antibiotics were associated with systemic side effects such as headache or altered sense of smell. What are the limitations of the evidence? The current update focused on adults and children aged one month or older. Therefore, the evidence does not pertain to antibiotic treatment for neonatal conjunctivitis in neonates younger than one month old. We did not find studies that compared effects of the same antibiotics used in short versus long duration. Therefore, the current review was unable to suggest for or against the prescription duration for acute bacterial conjunctivitis. How up‐to‐date is this evidence? The evidence is up‐to‐date as of April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Chen, Y-Y, Liu, A-HS, Nurmatov, U, van Schayck, OCP, Kuo, IC", "articleTypes": [], "doi": "10.1002/14651858.CD001211.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.099Z" }, { "id": "4c8ea4ab-281f-4a7c-a093-b21dec2d326d", "pmid": "", "title": "Fluoride toothpastes of different concentrations for preventing dental caries", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Walsh, T, Worthington, HV, Glenny, AM, Marinho, VCC, Jeroncic, A", "articleTypes": [], "doi": "10.1002/14651858.CD007868.pub3 AB - Abstract - Background Caries (dental decay) is a disease of the hard tissues of the teeth caused by an imbalance, over time, in the interactions between cariogenic bacteria in dental plaque and fermentable carbohydrates (mainly sugars). Regular toothbrushing with fluoride toothpaste is the principal non‐professional intervention to prevent caries, but the caries‐preventive effect varies according to different concentrations of fluoride in toothpaste, with higher concentrations associated with increased caries control. Toothpastes with higher fluoride concentration increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Objectives To determine and compare the effects of toothpastes of different fluoride concentrations (parts per million (ppm)) in preventing dental caries in children, adolescents, and adults. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 August 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7) in the Cochrane Library (searched 15 August 2018); MEDLINE Ovid (1946 to 15 August 2018); and Embase Ovid (1980 to 15 August 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 August 2018). No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials that compared toothbrushing with fluoride toothpaste with toothbrushing with a non‐fluoride toothpaste or toothpaste of a different fluoride concentration, with a follow‐up period of at least 1 year. The primary outcome was caries increment measured by the change from baseline in the decayed, (missing), and filled surfaces or teeth index in all permanent or primary teeth (D(M)FS/T or d(m)fs/t). Data collection and analysis Two members of the review team, independently and in duplicate, undertook the selection of studies, data extraction, and risk of bias assessment. We graded the certainty of the evidence through discussion and consensus. The primary effect measure was the mean difference (MD) or standardised mean difference (SMD) caries increment. Where it was appropriate to pool data, we used random‐effects pairwise or network meta‐analysis. Main results We included 96 studies published between 1955 and 2014 in this updated review. Seven studies with 11,356 randomised participants (7047 evaluated) reported the effects of fluoride toothpaste up to 1500 ppm on the primary dentition; one study with 2500 randomised participants (2008 evaluated) reported the effects of 1450 ppm fluoride toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants (40,066 evaluated) reported the effects of toothpaste up to 2400 ppm on the immature permanent dentition; and three studies with 2675 randomised participants (2162 evaluated) reported the effects of up to 1100 ppm fluoride toothpaste on the mature permanent dentition. Follow‐up in most studies was 36 months. In the primary dentition of young children, 1500 ppm fluoride toothpaste reduces caries increment when compared with non‐fluoride toothpaste (MD ‐1.86 dfs, 95% confidence interval (CI) ‐2.51 to ‐1.21; 998 participants, one study, moderate‐certainty evidence); the caries‐preventive effects for the head‐to‐head comparison of 1055 ppm versus 550 ppm fluoride toothpaste are similar (MD ‐0.05, dmfs, 95% CI ‐0.38 to 0.28; 1958 participants, two studies, moderate‐certainty evidence), but toothbrushing with 1450 ppm fluoride toothpaste slightly reduces decayed, missing, filled teeth (dmft) increment when compared with 440 ppm fluoride toothpaste (MD ‐0.34, dmft, 95%CI ‐0.59 to ‐0.09; 2362 participants, one study, moderate‐certainty evidence). The certainty of the remaining evidence for this comparison was judged to be low. We included 81 studies in the network meta‐analysis of D(M)FS increment in the permanent dentition of children and adolescents. The network included 21 different comparisons of seven fluoride concentrations. The certainty of the evidence was judged to be low with the following exceptions: there was high‐ and moderate‐certainty evidence that 1000 to 1250 ppm or 1450 to 1500 ppm fluoride toothpaste reduces caries increments when compared with non‐fluoride toothpaste (SMD ‐0.28, 95% CI ‐0.32 to ‐0.25, 55 studies; and SMD ‐0.36, 95% CI ‐0.43 to ‐0.29, four studies); there was moderate‐certainty evidence that 1450 to 1500 ppm fluoride toothpaste slightly reduces caries increments when compared to 1000 to 1250 ppm (SMD ‐0.08, 95% CI ‐0.14 to ‐0.01, 10 studies); and moderate‐certainty evidence that the caries increments are similar for 1700 to 2200 ppm and 2400 to 2800 ppm fluoride toothpaste when compared to 1450 to 1500 ppm (SMD 0.04, 95% CI ‐0.07 to 0.15, indirect evidence only; SMD ‐0.05, 95% CI ‐0.14 to 0.05, two studies). In the adult permanent dentition, 1000 or 1100 ppm fluoride toothpaste reduces DMFS increment when compared with non‐fluoride toothpaste in adults of all ages (MD ‐0.53, 95% CI ‐1.02 to ‐0.04; 2162 participants, three studies, moderate‐certainty evidence). The evidence for DMFT was low certainty. Only a minority of studies assessed adverse effects of toothpaste. When reported, effects such as soft tissue damage and tooth staining were minimal. Authors' conclusions This Cochrane Review supports the benefits of using fluoride toothpaste in preventing caries when compared to non‐fluoride toothpaste. Evidence for the effects of different fluoride concentrations is more limited, but a dose‐response effect was observed for D(M)FS in children and adolescents. For many comparisons of different concentrations the caries‐preventive effects and our confidence in these effect estimates are uncertain and could be challenged by further research. The choice of fluoride toothpaste concentration for young children should be balanced against the risk of fluorosis. Plain language summary Fluoride toothpastes of different strengths for preventing tooth decay Review question 
 This review has been produced to assess the effects of toothpastes of different fluoride strengths on preventing tooth decay in children, adolescents and adults. Background 
 Tooth decay (caries) is a widespread disease, affecting billions of people worldwide. Fluoride has long been used to prevent decay, through a variety of different methods including toothpaste, water, milk, mouthrinses, tooth gels and varnish. Regular toothbrushing is recommended to prevent decay and other oral diseases, and toothbrushing for 2 minutes twice daily with a fluoride toothpaste is generally recommended. The typical strength of regular or family toothpaste is around 1000 to 1500 parts per million (ppm) fluoride, but many other strengths are available worldwide. There is no minimum fluoride concentration, but the maximum permissible fluoride concentration for a toothpaste varies according to age and country. Higher concentrations are rarely available over the counter, and are classed as a prescription‐only medicine. Stronger fluoride toothpaste may offer greater protection against decay but also increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Study characteristics 
 Authors from Cochrane Oral Health carried out this review and the evidence is current up to 15 August 2018. It includes 96 studies published between 1955 and 2014: seven studies with 11,356 randomised participants reported the effects of fluoride toothpaste up to 1500 ppm on the primary teeth; one study with 2500 randomised participants reported the effects of 1450 ppm toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants reported the effects of toothpaste up to 2400 ppm on the permanent teeth of children up to 18 years of age; and three studies with 2675 randomised participants reported the effects of up to 1100 ppm toothpaste on the permanent teeth of adults. Most studies assessed decay after participants had been using the toothpastes for 36 months. Main results 
 We present below findings for which there is moderate‐ or high‐certainty evidence. In primary teeth of young children, brushing teeth with a toothpaste containing 1500 ppm fluoride reduced the amount of new decay when compared with non‐fluoride toothpaste; the amount of new decay was similar with 1055 ppm compared with 550 ppm fluoride toothpaste; and there was a slight reduction in the amount of new decay with 1450 ppm toothpaste compared with 440 ppm fluoride toothpaste. Eighty‐one studies assessed the effects of different strengths of fluoride toothpaste compared against each other (seven different strengths in 21 combinations) in permanent teeth of children and adolescents. We found that there was less new decay when toothbrushing with toothpaste containing 1000 to 1250 ppm or 1450 to 1500 ppm fluoride compared with non‐fluoride toothpaste, and that toothbrushing with 1450 to 1500 ppm fluoride toothpaste reduced the amount of new decay more than 1000 to 1250 ppm toothpaste. We found that there was a similar amount of new decay when children and adolescents used a toothpaste of 1700 to 2200 ppm or 2400 to 2800 ppm fluoride compared to 1450 to 1500 ppm toothpaste. The evidence for the effects of other strengths of toothpaste was less certain. In permanent teeth of adults of all ages, 1000 or 1100 ppm toothpaste reduced decay compared with non‐fluoride toothpaste. Most studies did not measure harmful effects of toothpaste use, but when reported, effects such as soft tissue damage and tooth staining were minimal. Certainty of the evidence 
 There is high‐certainty evidence that toothpaste containing 1000 to 1250 ppm fluoride is more effective than non‐fluoride toothpaste. There is moderate‐certainty evidence for the other findings reported in 'Main results' above. For other toothpaste strengths compared against each other or against non‐fluoride toothpaste, there are too few studies with too few participants to have any clarity about the effects. Authors conclusions 
 There are benefits of using fluoride toothpaste at certain strengths to prevent tooth decay when compared with non‐fluoride toothpaste. The stronger the fluoride concentration, the more decay is prevented. For many of the comparisons of different strengths of toothpaste, the findings are uncertain and could be challenged by further research. The choice of fluoride toothpaste for young children should be balanced against the risk of fluorosis.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.758Z" }, { "id": "4c934492-6075-4a24-842f-74b7ed3f1a59", "pmid": "", "title": "Models for delivery and co‐ordination of primary or secondary health care (or both) to older adults living in aged care facilities", "imported": false, "abstract": "Abstract - Background The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co‐ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost‐effectiveness of alternative models of providing health care to ACF residents. Objectives Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost‐effectiveness of the alternative models. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included individual and cluster‐randomised trials, and cost/cost‐effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co‐ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co‐ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline‐recommended care, health‐related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work‐related satisfaction and work‐related stress of ACF staff. Data collection and analysis Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. Main results We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co‐ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low‐certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I 2 = 53%; 8 trials, 1263 participants; low‐certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low‐certainty evidence) and adherence to guideline‐recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health‐related quality of life of ACF residents (MD ‐0.016, 95% CI ‐0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low‐certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate‐certainty evidence). We did not pool the cost‐effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co‐ordination of care), we are uncertain of the cost‐effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. Authors' conclusions Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health‐related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost‐effectiveness of alternative models of care due to the limited, disparate data available. Plain language summary Alternative ways to organise delivery of health care to older adults living in aged care facilities What is the aim of this review? This Cochrane review set out to determine if providing residents of aged care facilities (ACF) with the same care as usual care, just delivered in a different way (alternative models of care), is better in terms of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs. For example, are multidisciplinary teams (alternative model) a better way of delivering care to residents of ACFs compared to providing care through individual practitioners (usual care)? Key messages Compared to usual care, alternative models of care may reduce unplanned hospital admissions, but may make little or no difference to the number of emergency department visits and the health‐related quality of life of ACF residents, and probably make little or no difference to mortality. We are uncertain of the effect of alternative models of care on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guideline‐recommended care. Importantly, we are uncertain whether alternative models of care are cost‐effective due to the limited, conflicting data available. Studies differed widely in terms of intervention characteristics, health care settings and descriptions of usual care and this hindered many analyses in this review. Future studies should provide a detailed description of what intervention and usual care constitutes in their setting. What was studied in this review? The world's population is ageing and the number of persons living in residential ACFs is growing worldwide. ACF residents are often frail, elderly people with multiple health conditions that require intensive medical care. When an ACF is not able to deliver appropriate health care, residents are often transferred to a hospital for treatment. Such transfers are often burdensome and traumatic for ACF residents and their families and may lead to increased costs. Alternative models of care, designed to provide care that is better co‐ordinated and more timely, aim to reduce unnecessary hospital transfers and improve residents' well‐being. Alternative models of care may be more expensive to implement (e.g. employ more healthcare personnel) but may lead to cost savings down the line (e.g. more residents receive care in ACF, avoiding costly hospital transfers). The synthesised evidence in this review compares the effect of alternative models of care with usual care on the number of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs (i.e. does the model deliver better value for money compared to usual care). What are the main results of this review? We identified 40 studies (with in total 21,787 participants; three studies did not provide number of participants) conducted in 15 countries. The study participants differed with respect to their health needs. In 11 studies, the alternative model of care was aimed at all ACF residents (with mixed health needs/conditions). Other studies included residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers; 13 studies) or residents requiring a specific type of care (e.g. residents after discharge from a hospital; four studies). In most (31) of the studies, the alternative model of care focused on 'co‐ordination of care'. In three studies, the alternative models of care focused on 'who provides care' (e.g. nurse practitioner‐led care using best practice guide instead of GP‐led care) and in two studies, alternative models of care focused on 'where care is provided' (i.e. investigating alternative locations for the provision of care, for example within ACF versus outside of ACF). In four studies, the alternative models of care focused on the use of information and communications technology for the provision of care to ACF residents. In all studies, the alternative model of care was compared with usual care. We found that, compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits; however, the number of unplanned hospital admissions may be reduced. We are uncertain of the effect of alternative models of care on adverse events and adherence to clinical guideline‐recommended care compared with usual care. Alternative models of care may have little or no effect on ACF residents' health‐related quality of life and probably make little or no difference to mortality. Based on the findings of five studies that provided full economic evaluations (all alternative models of care focused on 'co‐ordination of care'), we are uncertain whether alternative models of care are more cost‐effective than usual care. What are the limitations of the evidence? Our confidence in the evidence is limited because participants in the studies were aware of which treatment they were getting. Usual care was poorly described by most of the studies. Usual care differs across countries and regions, so this lack of information limits our interpretation, contextualisation and generalisation of the comparisons. Not all of the studies provided data about outcomes we were looking to assess. How up‐to‐date is this review? The review authors searched for studies published up to October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Putrik, P; Grobler, L; Lalor, A; Ramsay, H; Gorelik, A; Karnon, J; Parker, D; Morgan, M; Buchbinder, R; O'Connor, D", "articleTypes": [], "doi": "10.1002/14651858.CD013880.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "4c942ba1-0726-4c47-892f-1fade7f15b81", "pmid": "", "title": "Iodised salt for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency is the main cause for potentially preventable mental retardation in childhood, as well as causing goitre and hypothyroidism in people of all ages. It is still prevalent in large parts of the world. Objectives To assess the effects of iodised salt in comparison with other forms of iodine supplementation or placebo in the prevention of iodine deficiency disorders. Search methods We searched The Cochrane Library , MEDLINE, the Register of Chinese trials developed by the Chinese Cochrane Centre, and the Chinese Med Database, China National knowledge Infrastructure, and searched reference lists, databases of ongoing trials and the Internet. Selection criteria We included prospective controlled studies of iodised salt versus other forms of iodine supplementation or placebo in people living in areas of iodine deficiency. Studies reported mainly goitre rates and urinary iodine excretion as outcome measures. Data collection and analysis The initial data selection and quality assessment of trials was done independently by two reviewers. Subsequently, after the scope of the review was slightly widened from including only randomised controlled trials to including non‐randomised prospective comparative studies, a third reviewer repeated the trials selection and quality assessment. As the studies identified were not sufficiently similar and not of sufficient quality, we did not do a meta‐analysis but summarised the data in a narrative format. Main results We found six prospective controlled trials relating to our question. Four of these were described as randomised controlled trials, one was a prospective controlled trial that did not specify allocation to comparison groups, and one was a repeated cross‐sectional study comparing different interventions. Comparison interventions included non‐iodised salt, iodised water, iodised oil, and salt iodisation with potassium iodide versus potassium iodate. Numbers of participants in the trials ranged from 35 to 334; over 20,000 people were included in the cross‐sectional study. Three studies were in children only, two investigated both groups of children and adults and one investigated pregnant women. There was a tendency towards goitre reduction with iodised salt, although this was not significant in all studies. There was also an improved iodine status in most studies (except in small children in one of the studies), although urinary iodine excretion did not always reach the levels recommended by the WHO. None of the studies observed any adverse effects of iodised salt. Authors' conclusions The results suggest that iodised salt is an effective means of improving iodine status. No conclusions can be made about improvements in other, more patient‐oriented outcomes, such as physical and mental development in children and mortality. None of the studies specifically investigated development of iodine‐induced hyperthyroidism, which can be easily overlooked if just assessed on the basis of symptoms. High quality controlled studies investigating relevant long term outcome measures are needed to address questions of dosage and best means of iodine supplementation in different population groups and settings. Plain language summary Iodised salt for preventing iodine deficiency disorders Iodine deficiency causes mental retardation in children as well as enlarged thyroid glands (goitre) and deficiencies in thyroid hormones in people of all ages. It still exists in large parts of the world. This review looked at studies of iodised salt in the diet that included a comparison group. Six studies, most of them in children but some also in adults, were included. Iodine in the urine increased in all but one studies, but there was some concern that small children did not eat enough salt to achieve adequate iodine status. Some studies, but not all, also showed a reduction in the enlargement of the thyroid gland (goitre) that can accompany lack of iodine in the diet. Adverse effects were not reported, but these may not have been studied adequately. More high quality long term studies measuring outcomes related to child development, to deaths associated with iodine‐deficiency and to adverse effects are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Wu, T, Liu, GJ, Li, P, Clar, C", "articleTypes": [], "doi": "10.1002/14651858.CD003204", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.761Z" }, { "id": "4ca8cc0b-6c77-47b9-a467-7c166794a872", "pmid": "", "title": "Treatment for primary postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries. Objectives To assess the effectiveness and safety of any intervention used for the treatment of primary PPH. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013). Selection criteria Randomised controlled trials comparing any interventions for the treatment of primary PPH. Data collection and analysis We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information. Main results Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review. Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41). Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering. Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre‐specified outcomes. One study compared lower segment compression but was too small to assess impact on primary outcomes. We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics. Authors' conclusions Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first‐line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit. The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy. Plain language summary Treatment for excessive bleeding after childbirth After a woman gives birth, womb muscles contract, clamping down on the blood vessels and helping to limit bleeding when the placenta has detached. If the muscles do not contract strongly enough, very heavy bleeding (postpartum haemorrhage) can occur, which can be life threatening. These situations are common in resource‐poor countries, and maternal mortality is about 100 times higher than in resource‐rich countries. It is a very serious problem that requires effective treatments that might avoid the use of surgery to remove the womb (hysterectomy). This is often the last treatment option and leaves the woman unable to have more children. In most settings, women are given a drug at the time of birth (before excessive bleeding occurs) to reduce the likelihood of excessive blood loss. However, despite this intervention, some women bleed excessively, and this review looked to see what interventions might be used to reduce the amount of blood lost by these women. Treatment options include drugs to increase muscles contractions (such as oxytocin, ergometrine and prostaglandins like misoprostol), drugs to help with blood clotting (haemostatic drugs such as tranexamic acid and recombinant activated factor VII), surgical techniques (such as tying off or blocking of the uterine artery) and radiological interventions (to assist in blocking the main artery to the womb by using gel foams). The review identified 10 randomised controlled trials involving 4052 women. Seven of these trials looked at a drug called misoprostol, which is a prostaglandin and so works by increasing muscle contractions. Overall, the trials suggest that misoprostol does not work as well as oxytocin infusion, and it has more side effects. However, oxytocin needs to be kept in a refrigerator, and so in settings where refrigeration and infusions are not readily available, misoprostol can be used. Other clinical trials looked into using other types of drugs or squeezing the main artery that supplies blood to the woman. The number of women included in these studies was too small for any useful conclusions regarding their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Mousa, HA, Blum, J, Abou El Senoun, G, Shakur, H, Alfirevic, Z", "articleTypes": [], "doi": "10.1002/14651858.CD003249.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.746Z" }, { "id": "4cb9117a-dc25-4009-8085-aeb272de4ab5", "pmid": "", "title": "Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2010 and previously updated in 2011. Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period. Objectives To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 4 July 2013. Selection criteria We included randomised controlled trials in which oral rinses, mouthwashes and sprays, used pre‐ and postoperatively, have been compared with placebo in adults or children undergoing tonsillectomy, with or without adenoidectomy. Data collection and analysis Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently. Main results We included seven trials (593 participants; 397 children and 196 adults). The period of follow‐up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre‐specified primary outcomes and none for the secondary outcomes. The risk of bias was high in most of the included trials. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage. Authors' conclusions Poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well‐constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data. Plain language summary Oral rinses, mouthwashes and sprays for improving outcomes following tonsillectomy Tonsillectomy is one of the most common operations performed in adults and children. Pain and bleeding following the operation are common. Postoperative tonsillectomy medication should aim to minimise some of these symptoms. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the period just after surgery. This review included seven studies involving 593 participants (397 children and 196 adults) and is up to date as of July 2013. The risk of bias was high in most of the included trials. We found that lidocaine spray appeared to be more effective than a placebo saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation when they used another spray containing benzydamine but this was not sufficient to discontinue its usage. Further research should aim to provide reliable evidence for people to make informed decisions as to whether these treatments can be effective in reducing the most common symptoms and complications following tonsillectomy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fedorowicz, Z; van Zuuren, EJ; Nasser, M; Carter, B; Al Langawi, JH", "articleTypes": [], "doi": "10.1002/14651858.CD007806.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "4cc557e4-0bad-4a7d-a271-ec4d7162989b", "pmid": "", "title": "Crave Crush: Sugar Cravings and ad Lib Candy Uptake", "imported": false, "abstract": "The purpose of the research is to determine if participants who take \"Crave Crush\" will report lower cravings and palatability ratings of candy as compared to subjects who receive the placebo. Participants are self-selected university students who pass our table and verbally agree to participate in a research study about taste preferences. Data will be recorded anonymously.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.236Z" }, { "id": "4cd00701-dd2c-4c28-8213-c5cd65f5bf2d", "pmid": "", "title": "Chinese medicinal herbs for measles", "imported": false, "abstract": "Abstract - Background Measles is an infectious disease caused by the Morbillivirus . Chinese physicians believe that medicinal herbs are effective in alleviating symptoms and preventing complications. Chinese herbal medicines are dispensed according to the particular symptoms. This is the second update of a Cochrane Review first published in 2006. Objectives To assess the effectiveness and possible adverse effects of Chinese medicinal herbs for measles. Search methods We searched the Cochrane Central Register of Controlled Clinical Trials (CENTRAL Issue 1, 2011) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to March week 5, 2011), EMBASE (1980 to April 2011), Web of Science (2005 to 30 April 2011), AMED (1985 to 30 April 2011), Chinese Biomedical Database (1976 to 30 June 2011), VIP Information (1989 to 30 June 2011), China National Knowledge Infrastructure (CNKI) (1976 to 30 June 2011), Chinese Journals full‐article database (1994 to 30 June 2011) and the meta Register of Controlled Trials for ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs in patients with measles (without complications). Data collection and analysis Two review authors (SC, TW) independently assessed trial quality and extracted data. We telephone interviewed the trial authors for missing information regarding participant allocation. Some trials allocated participants according to the sequence they were admitted to the trials, that is to say, by using a pseudo‐random allocation method. None of the trials concealed the allocation or used blinding methods. Main results We did not identify any suitable trials for inclusion. In this updated review we identified 80 trials which claimed to use random allocation. We contacted 32 trial authors by telephone and learned that the allocation methods used were not randomised. We excluded 34 studies because the participants experienced complications such as pneumonia. We excluded 10 trials because of non‐random allocation and complications experienced by the participants. We were unable to contact the remaining four trials' authors, so they require further assessment and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions There is no RCT evidence for or against Chinese medicinal herbs as a treatment for measles. We hope high‐quality, robust RCTs in this field will be conducted in the future. Plain language summary Chinese medicinal herbs for measles Measles (rubeola) is an infectious disease caused by multiplication of a single‐strand ribonucleic acid (RNA) virus of the genus Morbillivirus in the upper respiratory tract and conjunctiva. It can lead to serious complications and death. Chinese herbal medicines are believed to be effective in alleviating symptoms and shortening the duration of measles, and are widely used as the main or adjunctive therapy to treat measles in China and other countries. The review authors found a large number of clinical studies providing evidence of Chinese herbal medicines in the treatment of measles. Some of these reports claimed to be randomised controlled trials. However, after telephone interviewing 32 trial authors, we found that none of them used acceptable randomisation procedures to allocate participants and 34 studies included participants with measles complicated with other diseases, for example, pneumonia. Ten trials were non‐randomised controlled studies and four trials require further classification. In this update, we were unable to include any randomised controlled trial for assessment. Although no trials were included, the authors reviewed the articles and found no reports of adverse events in the use of Chinese herbal medicines for treating measles. High‐quality and large trials are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Chen, S, Wu, T, Kong, X, Yuan, H", "articleTypes": [], "doi": "10.1002/14651858.CD005531.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.074Z" }, { "id": "4cea0a9d-565f-464a-81e3-3442fc66e265", "pmid": "", "title": "Population‐level interventions in government jurisdictions for dietary sodium reduction", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McLaren, L, Sumar, N, Barberio, AM, Trieu, K, Lorenzetti, DL, Tarasuk, V, Webster, J, Campbell, NRC", "articleTypes": [], "doi": "10.1002/14651858.CD010166.pub2 AB - Abstract - Background Excess dietary sodium consumption is a risk factor for high blood pressure, stroke and cardiovascular disease. Currently, dietary sodium consumption in almost every country is too high. Excess sodium intake is associated with high blood pressure, which is common and costly and accounts for significant burden of disease. A large number of jurisdictions worldwide have implemented population‐level dietary sodium reduction initiatives. No systematic review has examined the impact of these initiatives. Objectives • To assess the impact of population‐level interventions for dietary sodium reduction in government jurisdictions worldwide. • To assess the differential impact of those initiatives by social and economic indicators. Search methods We searched the following electronic databases from their start date to 5 January 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); Cochrane Public Health Group Specialised Register; MEDLINE; MEDLINE In Process & Other Non‐Indexed Citations; EMBASE; Effective Public Health Practice Project Database; Web of Science; Trials Register of Promoting Health Interventions (TRoPHI) databases; and Latin American Caribbean Health Sciences Literature (LILACS). We also searched grey literature, other national sources and references of included studies. This review was conducted in parallel with a comprehensive review of national sodium reduction efforts under way worldwide ( Trieu 2015 ), through which we gained additional information directly from country contacts. We imposed no restrictions on language or publication status. Selection criteria We included population‐level initiatives (i.e. interventions that target whole populations, in this case, government jurisdictions, worldwide) for dietary sodium reduction, with at least one pre‐intervention data point and at least one post‐intervention data point of comparable jurisdiction. We included populations of all ages and the following types of study designs: cluster‐randomised, controlled pre‐post, interrupted time series and uncontrolled pre‐post. We contacted study authors at different points in the review to ask for missing information. Data collection and analysis Two review authors extracted data, and two review authors assessed risk of bias for each included initiative. We analysed the impact of initiatives by using estimates of sodium consumption from dietary surveys or urine samples. All estimates were converted to a common metric: salt intake in grams per day. We analysed impact by computing the mean change in salt intake (grams per day) from pre‐intervention to post‐intervention. Main results We reviewed a total of 881 full‐text documents. From these, we identified 15 national initiatives, including more than 260,000 people, that met the inclusion criteria. None of the initiatives were provided in lower‐middle‐income or low‐income countries. All initiatives except one used an uncontrolled pre‐post study design. Because of high levels of study heterogeneity (I 2 > 90%), we focused on individual initiatives rather than on pooled results. Ten initiatives provided sufficient data for quantitative analysis of impact (64,798 participants). As required by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) method, we graded the evidence as very low due to the risk of bias of the included studies, as well as variation in the direction and size of effect across the studies. Five of these showed mean decreases in average daily salt intake per person from pre‐intervention to post‐intervention, ranging from 1.15 grams/day less (Finland) to 0.35 grams/day less (Ireland). Two initiatives showed mean increase in salt intake from pre‐intervention to post‐intervention: Canada (1.66) and Switzerland (0.80 grams/day more per person); however in both countries the pre‐intervention data point was from several years prior to the initiation of the intervention. The remaining initiatives did not show a statistically significant mean change. Seven of the 10 initiatives were multi‐component and incorporated intervention activities of a structural nature (e.g. food product reformulation, food procurement policy in specific settings). Of those seven initiatives, four showed a statistically significant mean decrease in salt intake from pre‐intervention to post‐intervention, ranging from Finland to Ireland (see above), and one showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention (Switzerland; see above). Nine initiatives permitted quantitative analysis of differential impact by sex (men and women separately). For women, three initiatives (China, Finland, France) showed a statistically significant mean decrease, four (Austria, Netherlands, Switzerland, United Kingdom) showed no significant change and two (Canada, United States) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. For men, five initiatives (Austria, China, Finland, France, United Kingdom) showed a statistically significant mean decrease, three (Netherlands, Switzerland, United States) showed no significant change and one (Canada) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. Information was insufficient to indicate whether a differential change in mean salt intake occurred from pre‐intervention to post‐intervention by other axes of equity included in the PROGRESS framework (e.g. education, place of residence). We identified no adverse effects of these initiatives. The number of initiatives was insufficient to permit other subgroup analyses, including stratification by intervention type, economic status of country and duration (or start year) of the initiative. Many studies had methodological strengths, including large, nationally representative samples of the population and rigorous measurement of dietary sodium intake. However, all studies were scored as having high risk of bias, reflecting the observational nature of the research and the use of an uncontrolled study design. The quality of evidence for the main outcome was low. We could perform a sensitivity analysis only for impact. Authors' conclusions Population‐level interventions in government jurisdictions for dietary sodium reduction have the potential to result in population‐wide reductions in salt intake from pre‐intervention to post‐intervention, particularly if they are multi‐component (more than one intervention activity) and incorporate intervention activities of a structural nature (e.g. food product reformulation), and particularly amongst men. Heterogeneity across studies was significant, reflecting different contexts (population and setting) and initiative characteristics. Implementation of future initiatives should embed more effective means of evaluation to help us better understand the variation in the effects. Plain language summary National government initiatives to reduce salt intake in populations The problem 
 In almost all countries worldwide, most people eat too much salt. This is a problem because eating too much salt can cause high blood pressure, which can lead to health problems such as heart disease and stroke. To reduce the amount of salt eaten, governments in many countries have developed national salt reduction initiatives. The review question 
 Our aim was to examine whether national salt reduction initiatives have been effective in reducing the amount of salt consumed in those populations. Study characteristics 
 We searched research papers and government reports and had direct communication with individuals working in salt reduction in their respective countries. The evidence is current as of 5 January 2015, when we last searched electronic databases. Initiatives in 15 countries met the inclusion criteria. Ten of these countries provided sufficient data for quantitative analysis, gathered from studies that included 64,798 participants. Initiatives ranged from one activity (e.g. in Japan, which at the time of writing had a public information campaign) to many activities (e.g. in the United Kingdom, which provided five activities including on‐package nutrition information, restrictions on marketing to children and food product reformulation). Of the 15 countries that met inclusion criteria, seven provided information about funding source, of which six reported non‐industry funding. The other eight countries did not report a funding source for one or more data point(s). Key results and quality of the evidence 
 Five of the 10 countries included in the quantitative analysis (China, Finland, France, Ireland and England) showed a decrease in salt intake after the intervention. Two of the 10 countries (Canada, Switzerland) showed an increase in salt intake after the intervention, however, in both countries the only data available were from several years prior to the intervention starting. Because the initiatives were very different, we cannot present an overall finding of whether these types of initiatives work. When we focused on the subset of seven countries whose salt reduction initiatives included multiple components and were not focused solely on educating the public, we found that more than half (four of seven) showed a decrease in salt intake from pre‐intervention to post‐intervention. When we examined the nine initiatives that analysed men and women separately, we found that amongst men, more than half (five of nine) showed a decrease in salt intake after the intervention. Amongst women, the pattern of findings was less clear, with three of nine interventions showing a decrease, two showing an increase and four showing no change in salt intake. Low‐bias study designs, such as randomised controlled trials, typically are not suitable for evaluating complex initiatives such as these; therefore, we rated all of the studies included in this review as having low methodological quality. Large nationally representative samples of the population and careful measurement of dietary sodium intake were strengths of several studies. However, because of study design limitations, the trustworthiness of study results is not clear. Overall, our results show that national government initiatives have the potential to achieve population‐wide reductions in salt intake, especially amongst men, and particularly if they employ more than one strategy and include structural activities such as food product reformulation (i.e. food companies putting less salt in food products). The wide variation of results across the studies we found presents a challenge in interpreting the current evidence and this warrants more research to help us understand this.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.127Z" }, { "id": "4ceeb939-058e-4c1f-8f11-8143f65224ad", "pmid": "", "title": "Clonidine for pain in non‐ventilated infants", "imported": false, "abstract": "Abstract - Background Critically ill newborn infants undergo a variety of painful procedures or experience a variety of painful conditions during their early life in the neonatal unit. In the critically ill paediatric and neonatal population, clonidine is prescribed as an adjunct to opioids or benzodiazepines aiming to reduce the doses of these drugs that are required for analgesia or sedation, or to facilitate weaning from mechanical ventilation. It has been shown that clonidine premedication might have a positive effect on postoperative pain in children. Objectives To assess the benefit and harms of clonidine for the prevention or treatment of procedural pain; postoperative pain; or pain associated with clinical conditions in non‐ventilated neonates. Search methods We used the standard search strategy of Cochrane Neonatal to search the CENTRAL, MEDLINE via PubMed, Embase, and CINAHL to December 2018. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials. We ran an updated search from 1 January 2018 to 11 March 2020 in CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials, and cluster trials comparing clonidine to placebo or no treatment, opioids, paracetamol, dexmedetomidine, or non‐pharmacological pain‐reducing interventions for the management of procedural pain, postoperative pain, and pain associated with clinical conditions in preterm and term newborns. Data collection and analysis Two review authors independently planned to extract data (e.g. number of participants, birth weight, gestational age, modality of administration, and dose of clonidine) and assess the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow‐up). The primary outcome considered was pain: for procedural pain, the mean values of each analgesia scale assessed during the procedure and at one to two hours after the procedure; for postoperative pain and for pain associated with clinical conditions, the mean values of each analgesia scale assessed at 30 minutes, three hours, and 12 hours after the administration of the intervention. We planned to use the GRADE approach to assess the quality of evidence. Main results Our search strategy yielded 3383 references. Two review authors independently assessed all references for inclusion. We did not find any completed studies for inclusion. We excluded three trials where clonidine was administered for spinal anaesthesia. Authors' conclusions We did not find any studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of clonidine for the prevention or treatment of procedural or postoperative pain, or pain associated with clinical conditions in neonates. Plain language summary Clonidine for painful procedures and conditions in infants Review question: does clonidine administration reduce pain in newborns exposed to painful procedures or conditions? Background: newborns admitted to the hospital are exposed to a number of painful procedures which might include blood sampling, lumbar puncture (a medical procedure where a needle is inserted into the spinal canal, usually to collect cerebrospinal fluid for testing), tubes in the stomach, different types of catheters, and minor surgical procedures such as neonatal circumcision. In addition, newborns might have pain because of clinical conditions, such as, fractured bone, pain following traumatic vaginal birth, disease of the skin (open skin lesions from an inherited skin disorder), or intestines (necrotising enterocolitis (inflammation)). All babies, and especially those born too early (preterm), are very sensitive to pain. Moreover, the experience of repeated episodes of pain might cause problems, such as an altered development of the nervous system, in early life and an increased pain sensitivity when they grow up. Most of the medicines to manage pain and stress in babies have side effects, and might also harm the immature developing brain by inducing death of cells (apoptosis) in the brain. Study characteristics: we searched for studies up to 11 March 2020. The aim of this review was to assess if clonidine could reduce pain in newborns. This medicine can be given through injections, using a tube in the stomach (nasogastric tube), through the skin, and as spinal anaesthesia. However, the latter is not in the focus of this review as it is used for babies undergoing specific surgical procedures. Clonidine works on the brain modifying responses and reducing stress and agitation. Furthermore, clonidine may reduce pain, especially if used in combination with other medicines. Key results: we found no studies for our review. Three studies were excluded because clonidine was given for spinal anaesthesia, whereas our review focuses on other indications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Romantsik, O, Calevo, MG, Norman, E, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD013104.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.788Z" }, { "id": "4d067efd-e19a-4275-8658-eca7aa5a00c8", "pmid": "", "title": "A Randomized Double-blinded Placebo-controlled Outpatient Clinical Trial in High Risk Population Confirmed COVID-19 Patients Using Ivermectin and Doxycycline to Prevent COVID-19 Illness-related Hospitalization (COVIVER-OUT PLUS)", "imported": false, "abstract": "The purpose of this Clinical trial is to explore the therapeutic benefits of Ivermectin and Doxycycline in different combinations in high risk patients diagnosed with COVID-19.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.162Z" }, { "id": "4d08c461-78c4-45c0-9a06-c802ca8997bd", "pmid": "", "title": "Multiple micronutrient powders for home (point‐of‐use) fortification of foods in pregnant women", "imported": false, "abstract": "Abstract - Background It is estimated that 32 million pregnant women suffer from anaemia worldwide. Due to increased metabolic demands, pregnant women are particularly vulnerable to anaemia and vitamin and mineral deficiencies, leading to adverse health effects in both the mother and her baby. Despite the demonstrated benefits of prenatal supplementation with iron and folic acid or multiple micronutrients, poor adherence to routine supplementation has limited the effectiveness of this intervention in many settings. Micronutrient powders for point‐of‐use fortification are packed, single‐dose sachets containing vitamins and minerals that can be added onto prepared food to improve its nutrient profile. The use of multiple micronutrient powders for point‐of‐use fortification of foods in pregnant women could be an alternative intervention to prenatal micronutrient supplementation. Objectives To assess the effects of prenatal home (point‐of‐use) fortification of foods with multiple micronutrient powders on maternal and newborn health. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and the International Clinical Trials Registry Platform ( ICTRP ) (31 January 2015). We also contacted relevant agencies to identify ongoing and unpublished studies. Selection criteria Randomised controlled trials (both individual and cluster randomisation) and quasi‐randomised trials, irrespective of language or publication status. The intervention was micronutrient powders for point‐of‐use fortification of foods, containing at least three micronutrients with one of them being iron, provided to pregnant women of any gestational age and parity. Five comparison groups were considered: no intervention/placebo, iron and folic acid supplements, iron‐only supplements, folic‐acid only supplements, and multiple micronutrients in supplements. Data collection and analysis Two review authors independently assessed the eligibility of studies, extracted and checked data accuracy, and assessed the risk of bias of included studies. Main results Our search identified 12 reports (relating to six studies). We included two cluster‐randomised controlled trials (involving 1172 women) ‐ these trials were considered to be at a moderate to high risk of bias due to methodological limitations. One trial is ongoing, and three studies were excluded. Micronutrient powders for point‐of‐use fortification of foods versus iron and folic acid supplements One trial (involving 478 pregnant women attending 42 antenatal care centres) compared micronutrient powders containing iron, folic acid, vitamin C and zinc with iron and folic acid tablets provided daily from 14 to 22 weeks to 32 weeks' gestation. The trial did not report on any of this review's primary outcomes: maternal anaemia at or near term, maternal iron deficiency, maternal mortality, adverse effects, low birthweight, preterm births. Nor did the trial report on the majority of this review's secondary outcomes, with the exception of maternal adherence. Adherence to micronutrient powders was lower than adherence to iron and folic acid supplements (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.66 to 0.87, one study, n = 405). Micronutrient powders for point‐of‐use fortification of foods versus same multiple micronutrients in supplements One study (involving 694 pregnant women from 18 communities), compared micronutrient powders containing iron, folic acid, vitamin C, zinc, iodine, vitamin E and vitamin B 12 with tablets containing the same seven micronutrients. There was no difference in maternal anaemia at 37 weeks of gestation (RR 0.92, 95% CI 0.53 to 1.59, one study, n = 470, very low quality evidence ). The trial did not report on any of this review's other primary outcomes in relation to maternal iron deficiency, maternal mortality, adverse effects, low birthweight, or preterm birth. In terms of this review's secondary outcomes, the included trial did not report on the majority of this review's prespecified secondary outcomes with one exception ‐ there was no clear difference in maternal haemoglobin Hb or near term (mean difference (MD) 1.0 g/L, 95% CI ‐1.77 to 3.77, one study, n = 470). Authors' conclusions Limited evidence suggests that micronutrient powders for point‐of‐use fortification of foods have no clear difference as multiple micronutrient supplements on maternal anaemia ( very low quality evidence ) and Hb at or near term. There is limited evidence to suggest that women were more likely to adhere to taking tablets than using micronutrient powders. The overall quality of evidence was judged very low (due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes. Therefore, more evidence is needed to assess the potential benefits or harms of the use of micronutrient powders in pregnant women on maternal and infant health outcomes. Future trials should also assess adherence to micronutrient powders and be adequately powered to evaluate the effects on birth outcomes and morbidity. Plain language summary Powders of iron plus other micronutrients for home (point‐of‐use) fortification of foods consumed by pregnant women Pregnant women are particularly vulnerable to nutrient deficiencies due to the requirements of the growing baby during the pregnancy. In low‐income countries, many women have diets with low content of vitamins and minerals, and they participate in long hours of physical labour. They are also exposed to recurrent infections, which make nutritional deficiencies worse. Thus, lack of adequate nutrition can contribute to the poor health of these women their babies. Iron and folic acid supplements in pregnancy are widely recommended. However, getting the supplements to the women and encouraging them to take them is particularly challenging. Micronutrient powders containing iron, vitamin A, zinc and other vitamins and minerals are usually packaged in single‐use sachets and can be sprinkled onto any semi‐solid food at home or in any other place where meals are to be consumed. The use of micronutrient powders to fortify foods may overcome this problem with micronutrient supplements. Micronutrient powders have already been shown to be effective in reducing anaemia and iron deficiency in young children and so may be useful for pregnant women. This review looked at the use of micronutrient powders in pregnancy, compared with micronutrient supplements or with no additional micronutrients. We found only two studies involving a total of 1172 women, undertaken in Bangladesh and Mexico. The overall quality of evidence was judged very low (with a high risk of bias due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes of this review. One trial compared micronutrient powders with iron and folate supplements, and the other trial compared micronutrient powders with the same nutrients but given as supplements. Overall, micronutrient powders fortification of foods had a similar effect as multiple micronutrient supplements on anaemia in mothers at or near term ( very low quality evidence ) or the mother's haemoglobin (Hb) at or near term. The study that compared micronutrient powders with iron and folic acid supplements reported that women were more likely to take iron and folic acid tablets than micronutrient powders. Nearly all of the review's important outcomes were not reported in the included studies. Therefore, more evidence is needed for both mother and infant health outcomes in order to adequately evaluate the use of micronutrient powders in pregnant women.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Suchdev, PS; Peña‐Rosas, JP; De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD011158.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "4d09cad0-b0c4-454c-8dfc-b0a1c377e44c", "pmid": "", "title": "Ribavirin plus interferon versus interferon for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. Standard therapy is ribavirin plus pegylated interferon to achieve undetectable level of virus in the blood, but the effect on clinical outcomes is controversial. Objectives To assess the beneficial and harmful effects of ribavirin and interferon combination therapy versus interferon monotherapy for chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, approaching authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included randomised trials, irrespective of blinding, language, or publication status, comparing ribavirin plus interferon versus interferon for treatment of chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained loss of hepatitis C virus, liver‐related morbidity plus all‐cause mortality, and adverse events. We performed subgroup analyses of patients who were naive, relapsers, or non‐responders to previous antiviral treatment. All outcomes were analysed with the random‐effects model. We used Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of morbidity plus mortality. The remaining outcomes were presented as relative risks (RR). We used trial sequential analyses to examine the robustness of our findings. Main results We included 83 randomised trials with 12,707 patients. Most trials had unclear or high risk of bias. We did not find any significant influence of bias on our results but cannot exclude outcome measure reporting bias as many trials did not report on the primary outcomes of this review. Compared with interferon, ribavirin plus interferon had a significant beneficial effect on sustained virological response in subgroups of naive patients (RR 0.72, 95% confidence interval (CI) 0.68 to 0.75), relapsers (RR 0.62, 95% CI 0.54 to 0.70), non‐responders (RR 0.89, 95% CI 0.84 to 0.93), and in all patients (RR 0.75, 95% CI 0.71 to 0.79). Combination therapy significantly reduced morbidity plus mortality in all patients (Peto OR, 0.43, 95% CI 0.23 to 0.79), but not in naive, relapsers, or non‐responders individually. Combination therapy significantly increased the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous (cough, dyspnoea, fatigue) adverse reactions. Accordingly, combination therapy significantly increased the risk of treatment discontinuation and dose reductions. Trial sequential analyses confirmed our findings regarding virological effects, but not regarding liver‐related morbidity and all‐cause mortality. Authors' conclusions Compared with interferon alone, ribavirin plus interferon is more effective in clearing hepatitis C virus from the blood. Combination therapy may reduce liver‐related morbidity and all‐cause mortality, but we need more evidence. The number needed to treat to obtain a beneficial effect is considerable considering the increased risk of several severe adverse reactions and costs. Plain language summary Adding ribavirin to interferon increases the number of patients who clear hepatitis C virus but also leads to several adverse reactions Globally about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behavior, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die. It is known that treatment with the drug interferon clears hepatitis C virus from the blood in about 15% of patients. This review identified studies comparing ribavirin plus interferon with interferon alone in patients with chronic hepatitis C. This review shows, by combining the results from all trials, that adding ribavirin to interferon increases the number of patients who clear the hepatitis C virus to about 40% as well as the number of patients who demonstrate improved liver histology. Ribavirin and interferon may also reduce the risk of liver‐related morbidity or all‐cause mortality. However, the number needed to treat to prevent one patient developing morbidity or dying seems very large. Furthermore, combination therapy was associated with increased risk of anaemia and several other adverse reactions. The results gives rise to a dilemma ‐ should we, by adding ribavirin to interferon, increase the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous adverse reactions in a situation where it has not yet been clearly demonstrated that the antiviral effect of the intervention is directly linked to the reduction of all‐cause mortality? We, therefore, suggest that the combination intervention is applied only with stringent emphasis on the individual patients' well‐being. Furthermore, we suggest that all future trials within the area should focus more on adverse reactions and long‐term clinical outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Brok, J, Gluud, LL, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.116Z" }, { "id": "4d0be13b-24d6-4376-a7ce-98cfbd873f9d", "pmid": "", "title": "Statins for asthma", "imported": false, "abstract": "Abstract - Background Asthma is a common chronic respiratory disease. People with asthma have inflammation of their airways that causes recurrent episodes of wheezing, breathlessness and chest tightness, with or without a cough. Statins possess multiple therapeutic effects, including lowering lipid levels in the blood. Statins are reported to have a potential role as an adjunct treatment in asthma. However, comprehensive evidence of the benefits and harms of using statins is required to facilitate decision making. Objectives To assess the benefits and harms of statins as an adjunct therapy for asthma in adults and children. Search methods We searched for studies in the Cochrane Airways Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid SP and Embase Ovid SP, from their inception dates We handsearched the proceedings of major respiratory conferences. We also searched clinical trials registries for completed, ongoing and unpublished studies, and scanned the reference lists of included studies and relevant reviews to identify additional studies. The search is current to 7 February 2020. Selection criteria We included randomised controlled trials (RCTs) with a parallel‐group design that assessed statins for at least 12 weeks' duration. We considered all participants with a clinical diagnosis of asthma to be eligible, regardless of age, sex, disease severity and previous or current treatment. We planned to include studies reported as full text, those published as abstract only, and unpublished data. Data collection and analysis Two review authors independently screened and selected the studies, extracted outcome data and intervention characteristics from included studies, and assessed risk of bias according to standard Cochrane methodological procedures. We resolved any disagreement through discussion. Main results We found only one trial involving a total of 60 people living with asthma. The trial compared the effect of atorvastatin with a placebo (dummy treatment containing lactose) in treating people with chronic asthma. The trial did not report data for the primary outcomes or adverse events. There was uncertainty about the relative effect on forced expiratory volume in one second (FEV 1 ) and peak expiratory flow (PEF) in the atorvastatin group compared with the placebo group. The study did not report serious adverse effects for the interventions. The included study had internal discrepancies in its reported data. Authors' conclusions The evidence was of very low certainty, so we are unable to draw conclusions about the effectiveness and safety of statins to treat asthma. High‐quality RCTs are needed to assess the effect of statins on people with asthma. Well‐designed multicentre trials with larger samples and longer duration of treatment are required, which assess outcomes such as adverse events, hospital utilisation and costs, to provide better quality evidence. Future studies that include subgroups of obese people with asthma are also required. Plain language summary Statins for asthma Review question We reviewed the evidence about the effect of statins in people with asthma. Background Asthma is a common chronic (persistent) airway disease. Asthma is caused by inflammation in the lungs and bronchoconstriction (tightening of the small tubes in the lungs in response to a trigger such as pollen or cold air). Inflammation and bronchoconstriction cause airflow obstruction (narrowing and blockage). People with asthma experience recurrent attacks of wheezing, difficultly in breathing, and chest tightness, with or without a cough. Statins are anti‐inflammatory medicines. We wanted to review the evidence for statins because the theory is that their anti‐inflammatory properties will help people with asthma. We wanted to discover whether using statin therapy was better or worse than other alternatives, such as usual care alone or different types of statins (atorvastatin, simvastatin). Study characteristics We found only one trial that assessed atorvastatin (a type of statin drug) and placebo (dummy treatment) in 60 adults with asthma over a period of 12 weeks. These people had chronic asthma (persistent airway disease) when they started treatment. Key results We found that the statin (atorvastatin) did not result in any clear improvement in lung function in people with asthma, but may be better in asthma control than the dummy drug. However, because there is only one trial, we cannot draw firm conclusions. The trial did not report on adverse effects or severe adverse effects (harms). We are uncertain whether statins may have beneficial effects on relieving asthma or whether they may increase the risk of adverse events or non‐serious adverse events. Quality of the evidence The evidence was of very low certainty, so we cannot draw firm conclusions about whether statins are helpful and safe to be used by people with asthma. The evidence is current to 7 February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Naing, C; Ni, H", "articleTypes": [], "doi": "10.1002/14651858.CD013268.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "4d1bd8e1-42c9-4f68-ba75-8c2e46c2ab69", "pmid": "", "title": "A Phase 1, Randomized, Double-blinded, Placebo-controlled, Dose-escalation and Dose-expansion Study to Evaluate the Safety and Immunogenicity of DelNS1-nCoV-RBD LAIV for COVID-19 in Healthy Adults", "imported": false, "abstract": "To investigate the safety and immunogenicity profile of of a novel nasal spray investigational vaccine, which is a potential prophylactic vaccine for current pandemic disease COVID-19.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.240Z" }, { "id": "4d27d486-9d0e-4f3e-bfec-dab48a00e938", "pmid": "", "title": "Oral antifungal medication for toenail onychomycosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kreijkamp‐Kaspers, S, Hawke, K, Guo, L, Kerin, G, Bell‐Syer, SEM, Magin, P, Bell‐Syer, SV, van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD010031.pub2 AB - Abstract - Background Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence‐based choice for treatment. Objectives To assess the effects of oral antifungal treatments for toenail onychomycosis. Search methods We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies. Selection criteria RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years. We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high‐risk domain was 'blinding of personnel and participants'. We found high‐quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine‐treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate‐quality evidence). There was high‐quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu‐like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate‐quality evidence). Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low‐quality evidence). There is moderate‐quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate‐quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low‐quality evidence). Common adverse events in both groups included headache, viral infection, and nausea. Moderate‐quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate‐quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin‐treated participants) along with nausea and vomiting (in azole‐treated participants). Very low‐quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants). There is low‐quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low‐quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin‐treated participants) as well as taste loss and nausea (in terbinafine‐treated participants). No studies addressed recurrence rate for this comparison. No study addressed quality of life. Authors' conclusions We found high‐quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate‐quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate‐quality evidence). Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate‐quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low‐quality evidence). Only four comparisons assessed recurrence rate: low‐quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them. Only a limited number of studies reported adverse events, and the severity of the events was not taken into account. Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding. Plain language summary What is the best medication for a fungal infection of the toenail? Review question We aimed to find out which medications, taken by mouth for at least six weeks, are the most effective at curing fungal infection of the toenail, a condition that is known as onychomycosis, in people of any age. We compared these medications to each other or placebo (an inactive drug or treatment). Background Fungal infection of the toenails is a common condition, which has a low risk of complications and associated health risks. However, for those severely affected, it might affect normal daily activities. Medication taken by mouth appears to cure the condition more quickly and effectively than topical treatment. There are three main antifungal medications: griseofulvin, different medications in the azole group (itraconazole, fluconazole, albaconazole, posaconazole, ravuconazole), and terbinafine. We wanted to assess the following two main outcomes. 1. Does the nail look normal after treatment (clinical cure)?
 2. Is the nail free from fungus at a microscopic level (mycological cure)? Study characteristics We identified 48 studies with 10,200 participants of both sexes. The average age of the participants across studies ranged from 36 to 68; most studies included participants aged 18 and over. Our included studies compared the three main groups of medication against each other or to placebo. Most studies took place in outpatient dermatology settings in the USA and Europe. The participants mainly had fungal infection under the toenails. A small number of studies included a specific group of participants, such as those with diabetes. All but one study looked at fungal infections caused by dermatophyte, which are fungi that digest keratin. Study duration ranged from 4 months to 2 years, with most lasting 12 to 15 months. Key results The evidence is current to October 2016. We found high‐quality evidence that compared with placebo, both terbinafine and azoles are more effective for achieving a normal‐looking nail and curing the toenail infection (i.e. looking at the microscopic level to see if the fungus is gone). Terbinafine or azoles may also prevent the infection reoccurring more than placebo (low‐quality evidence). There was probably no significant difference in the risk of adverse events reported when comparing either azoles or terbinafine with placebo (moderate‐quality evidence). The most common adverse events amongst terbinafine‐treated and azole‐treated participants included stomach problems and headache. We found that compared to azoles, terbinafine was probably more effective in curing the nails in terms of appearance and infection (moderate‐quality evidence). The risk of side effects was probably the same for both treatments (moderate‐quality evidence), and the most common adverse events in both groups were headache, viral infection, and rash. There may be no difference in recurrence rate (low‐quality evidence). A third type of treatment, griseofulvin, was probably as effective as the azole medications in curing the nails in terms of appearance and infection (moderate‐quality evidence), but it may be less effective than terbinafine when assessing the same outcomes (low‐quality evidence). Griseofulvin caused more side effects than the other two treatments, although the quality of the evidence was moderate (compared to azole) to low (compared to terbinafine). The most common adverse events in both groups included stomach problems and feeling sick. We are uncertain about the effect of griseofulvin compared to azoles on the rate of recurrence, and studies comparing terbinafine and griseofulvin did not assess this outcome. Quality of the evidence The evidence for the primary outcomes of cure (in terms of appearance and infection) was high to moderate quality except for the comparisons of griseofulvin versus terbinafine (low quality) and combination terbinafine plus azole versus terbinafine alone (very low quality). The evidence quality for side effects was mainly moderate, but two comparisons had low evidence for this outcome. Not all comparisons measured recurrence rate, and the available evidence was based on low‐ to very low‐quality evidence. No studies reported on participants' quality of life. Many studies had problems in the study design: it was often unclear how they decided which participants would receive which treatment or ensured that participants weren't aware of the treatment allocation. Many studies also did not use a placebo.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.734Z" }, { "id": "4d29ffca-fe1a-4a34-99f4-267a302ccf93", "pmid": "", "title": "Interventions for latent autoimmune diabetes (LADA) in adults", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Brophy, S, Davies, H, Mannan, S, Brunt, H, Williams, R", "articleTypes": [], "doi": "10.1002/14651858.CD006165.pub3 AB - Abstract - Background Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes. Objectives To compare interventions used for LADA. Search methods Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta‐analysis or descriptive methods. Main results Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow‐up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: ‐1.3% (95% confidence interval (CI) ‐2.4 to ‐0.1; P = 0.03, 160 participants, four studies, follow‐up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C‐peptide, but insulin maintained stimulated C‐peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow‐up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C‐peptide levels (20 μg group) were maintained after five years. Short term (three months) follow‐up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C‐peptide levels compared to insulin alone (0.07 µg/L (95% CI ‐0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C‐peptide levels in the vitamin D group but declining fasting C‐peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow‐up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health‐related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes). Authors' conclusions Two studies show SU leading to earlier insulin dependence and a meta‐analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 μg) have been suggested to maintain fasting and stimulated C‐peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA. Plain language summary Interventions for latent autoimmune diabetes (LADA) in adults LADA is a condition that at diagnosis looks like type 2 diabetes (non‐insulin requiring diabetes mellitus) but actually is a type 1 diabetes, where the patient will become insulin requiring. In the UK approximately 3.6% of people who look like they have type 2 diabetes actually have type 1 diabetes, while other studies suggest the prevalence is higher and treatment for these patients may need to be different from that used in type 2 diabetes. 
 We identified 15 publications (10 studies) looking at 1019 patients who were followed between three months to 10 years. We found many of the publications had poor quality of reporting and had small numbers of participants. However, there does seem to be evidence from this review that the drug sulphonylurea (like glibenclamide or glyburide, gliclazide) could make patients insulin dependent sooner and it does not control blood sugar as well as insulin. Therefore, this suggests that this drug should not be a first line treatment for patients with LADA. In addition, insulin combined with vitamin D, or Chinese herbs may maintain natural insulin production better than insulin alone. Similarly, glutamic acid decarboxylase (GAD65) may maintain natural insulin production. However, there was no conclusive evidence that any of the other remaining treatment methods were better than each other. Studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic attacks. This review represents very early days of our understanding of the best way to treat LADA. It is limited by the poor reporting quality of the studies, small sample sizes, no clear single definition of LADA and many of the studies being carried out in different ethnic groups (China, Japan, Cuba, UK, Sweden) with different clinical care systems. 
 None of the publications reported on complications of diabetes, health‐related quality of life, costs or health service utilisation. All but one of the publications reported there were no deaths. 
 In summary, this review demonstrates that insulin treatment may be preferable compared to sulphonylurea treatment but there is little evidence regarding other forms of treatment. Future studies are needed, should have a clear definition of LADA, investigate patient‐important outcomes and use a common method of measuring stimulated C‐peptide (a marker of natural insulin production reflecting improved beta‐cell function of the pancreas).", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.808Z" }, { "id": "4d2c5a01-6e80-4322-8dff-b9bcc0178233", "pmid": "", "title": "Interventions for treating people with symptoms of bladder pain syndrome: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide‐ranging treatment options, used alone or in combination, with limited evidence. A network meta‐analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS. Objectives To conduct a network meta‐analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS). Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible. Data collection and analysis We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random‐effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta‐analysis of head‐to‐head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories. Main results We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low‐certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD ‐1.27, 95% CrI ‐3.25 to 0.71; low‐certainty evidence), daytime frequency (MD ‐2.41, 95% CrI ‐6.85 to 2.05; very low‐certainty evidence) or nocturia (MD 0.01, 95% CrI ‐2.53 to 2.50; very low‐certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low‐certainty evidence) or reduced pain (MD 0.42, 95% CrI ‐1.04 to 1.91; low‐certainty evidence), frequency (MD ‐0.37, 95% CrI ‐5.00 to 3.44; very low‐certainty evidence) or nocturia (MD ‐1.20, 95% CrI ‐3.62 to 1.28; very low‐certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD ‐0.33, 95% CrI ‐1.71 to 1.03), frequency (MD ‐0.91, 95% CrI ‐3.24, 1.29) or nocturia (MD ‐0.04, 95% CrI ‐1.35 to 1.27). The certainty of this evidence was always very low. Authors' conclusions We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base. Plain language summary Treatments for people with bladder pain syndrome What is bladder pain syndrome? Bladder pain syndrome (BPS; also called painful bladder syndrome or interstitial cystitis) is a long‐term painful condition that affects the bladder. ‘Syndrome’ refers to a collection of symptoms. In BPS, these symptoms include: intense pain in the pelvis (felt below the bellybutton); sudden strong urges to urinate; needing to urinate more often than usual; and waking up several times during the night to urinate. BPS is more common in women. We do not know what causes it or how to cure it. Symptoms sometimes come and go in phases. BPS can significantly affect lifestyle, work, emotional health and relationships. Treatments for BPS Lifestyle changes are usually tried first, then medicines and supportive therapies. Surgery may be needed as a last resort. Medicines used include pentosan polysulfate sodium – which may help to restore the inner surface of the bladder – anti‐inflammatories, antidepressants and antihistamines. Medicines that block the connection between nerves and muscles can be injected into the bladder muscle to try to relax it (‘neuromuscular blockade’). Supportive therapies and treatments include behavioural therapy, physiotherapy, bladder re‐training, psychological therapy and transcutaneous electrical nerve stimulation (TENS). Review question In this Cochrane Review, we wanted to find out which treatments work best to treat BPS. What did we do? We searched for studies that looked at any type of treatment for BPS. We looked for randomised controlled studies, in which the treatment people receive is randomly decided, because these studies usually give the most reliable evidence about treatments. Search date We included evidence published up to 11 May 2018. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. What we found We found 81 studies involving 4674 people with BPS. The biggest study included 369 people, and the smallest study included 10 people. Most studies lasted around three months; only six studies lasted 12 months or longer. Twenty‐four studies were funded by pharmaceutical companies. We found 65 treatments for BPS, which we grouped into 31 categories based on how the treatments worked. In most studies, a treatment for BPS was compared with a placebo (or dummy) treatment. We compared all treatments with each other using a mathematical method called network meta‐analysis. What are the results of our review? After 12 months, antidepressants or neuromuscular blockade (and some other treatments) may improve symptoms of BPS more than placebo, but we are not certain about this result. We did not find enough evidence to know if pentosan polysulfate sodium improves symptoms. We are uncertain whether 12 months of treatment with antidepressants, neuromuscular blockade or pentosan polysulfate sodium reduced pain (as measured on a scale); the number of times people had to urinate during the day; or the number of times people had to get up to urinate during the night. Our confidence in the results We are uncertain about our results because we did not find enough reliable evidence. Although we obtained results from 81 studies, most of these studies were small and did not include enough people for us to be certain of their results. Some of the studies (30%) were conducted by pharmaceutical companies, and this may have affected how the studies were designed, conducted and reported. Our results may change when results from more, and larger, studies become available. Conclusions We did not find enough reliable evidence about how well medicines, behavioural therapy, physiotherapy and neuromuscular blockade worked to treat all, or any, of the symptoms of BPS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Imamura, M, Scott, NW, Wallace, SA, Ogah, JA, Ford, AA, Dubos, YA, Brazzelli, M", "articleTypes": [], "doi": "10.1002/14651858.CD013325.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.781Z" }, { "id": "4d3811be-4422-4032-83fa-7a45c748888e", "pmid": "", "title": "Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under", "imported": false, "abstract": "Abstract - Background Although complementary feeding is a universal practice, the methods and manner in which it is practiced vary between cultures, individuals and socioeconomic classes. The period of complementary feeding is a critical time of transition in the life of an infant, and inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. Educational interventions are widely acknowledged as effective in promoting public health strategy, and those aimed at improving complementary feeding practices provide information about proper complementary feeding practices to caregivers of infants/children. It is therefore important to summarise evidence on the effectiveness of educational interventions to improve the complementary feeding practices of caregivers of infants. Objectives To assess the effectiveness of educational interventions for improving the complementary feeding (weaning) practices of primary caregivers of children of complementary feeding age, and related health and growth outcomes in infants. Search methods In November 2017, we searched CENTRAL, MEDLINE, Embase, 10 other databases and two trials registers. We also searched the reference lists of relevant studies and reviews to identify any additional studies. We did not limit the searches by date, language or publication status. Selection criteria Randomised controlled trials (RCTs), comparing educational interventions to no intervention, usual practice, or educational interventions provided in conjunction with another intervention, so long as the educational intervention was only available in the experimental group and the adjunctive intervention was available to the control group. Study participants included caregivers of infants aged 4 to 24 months undergoing complementary feeding. Pregnant women who were expected to give birth and commence complementary feeding during the period of the study were also included. Data collection and analysis Two review authors independently extracted data on participants, settings, interventions, methodology and outcomes using a specifically‐developed and piloted data extraction form. We calculated risk ratios (RR) and 95% confidence intervals (CIs) for dichotomous data, and mean differences (MD) and 95% CIs for continuous data. Where data permitted, we conducted a meta‐analysis using a random‐effects model. We assessed the included studies for risk of bias and also assessed the quality of evidence using the GRADE approach. Main results We included 23 studies (from 35 reports) with a total of 11,170 caregiver‐infant pairs who were randomly assigned to receive an educational intervention delivered to the caregiver or usual care. Nineteen of the included studies were community‐based studies while four were facility‐based studies. In addition, 13 of the included studies were cluster‐randomised while the others were individually randomised. Generally, the interventions were focused on the introduction of complementary feeding at the appropriate time, the types and amount of complementary foods to be fed to infants, and hygiene. Using the GRADE criteria, we assessed the quality of the evidence as moderate, mostly due to inadequate allocation concealment and insufficient blinding. Educational interventions led to improvements in complementary feeding practices for age at introduction of complementary foods (average RR 0.88, 95% CI 0.83 to 0.94; 4 studies, 1738 children; moderate‐quality evidence) and hygiene practices (average RR 1.38, 95% CI 1.23 to 1.55; 4 studies, 2029 participants; moderate‐quality evidence). For duration of exclusive breastfeeding, pooled results were compatible with both a reduction and an increase in the outcome (average RR 1.58, 95% CI 0.77 to 3.22; 3 studies, 1544 children; very low‐quality evidence). There was limited (low to very low‐quality) evidence of an effect for all growth outcomes. Quality of evidence There is moderate to very low‐quality evidence that educational interventions can improve complementary feeding practices but insufficient evidence to conclude that it impacts growth outcomes. Authors' conclusions Overall, we found evidence that education improves complementary feeding practices. Plain language summary Educational interventions for improving complementary feeding practices Background Complementary feeding is the period when an infant moves from taking only breast milk or breast‐milk substitutes (such as infant formula) to family food. It is a critical period in the life of an infant. Inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. This is because inappropriate complementary feeding practices, such as introduction of semi‐solid foods too early (before six months of age), poor hygiene or giving foods that do not contain adequate nutrients, are all major causes of illness. Such illnesses include malnutrition, diarrhoea, poor growth, infections and poor mental development of children. Education has been proposed as an effective means of improving complementary feeding practices. Review question Does education improve complementary feeding practices of caregivers of infants as well as the health and growth of the infants? Study characteristics We searched for randomised controlled trials (a type of experiment in which people are randomly allocated to one or more treatment groups) up until November 2017. The search identified 23 studies involving a total of 11,170 caregivers and their children. The ages of the children ranged from birth to 24 months. The caregivers received educational interventions alone while the control group received no intervention, usual care or any other non‐educational intervention. The educational methods included printed materials such as leaflets, counselling, teaching sessions, peer support, videos and practical demonstrations. Generally, the education messages were focused on the introduction of semi‐solid foods at the appropriate age, the types and amount of complementary foods to be fed to infants, and hygiene. Key results Education reduced the number of caregivers that introduced semi‐solid foods to their infants before six months of age by up to 12% (moderate‐quality evidence). Hygiene practices of caregivers who received education also showed some improvement compared to those that did not (moderate‐quality evidence). In studies conducted in the community, education increased the duration of exclusive breastfeeding, but not in studies conducted in health facilities. There was no convincing evidence of an effect of education on the growth of children (low to very low‐quality evidence). We could not combine the results from different studies for diarrhoea, knowledge of caregivers and adequacy of complementary food. However, from the individual reports of the study authors, education led to a reduction in diarrhoea and an improvement in the knowledge of caregivers. It also led to improvement in the quality and quantity of complementary foods fed to infants. Overall, we found evidence that education improves complementary feeding practices.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Arikpo, D; Edet, ES; Chibuzor, MT; Odey, F; Caldwell, DM", "articleTypes": [], "doi": "10.1002/14651858.CD011768.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "4d8e6501-d8c7-41d1-8ae3-527c4f8ba071", "pmid": "", "title": "Selenium for preventing cancer", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Vinceti, M, Filippini, T, Del Giovane, C, Dennert, G, Zwahlen, M, Brinkman, M, Zeegers, MPA, Horneber, M, D'Amico, R, Crespi, CM", "articleTypes": [], "doi": "10.1002/14651858.CD005195.pub4 AB - Abstract - Background This review is the third update of the Cochrane review \"Selenium for preventing cancer\". Selenium is a naturally occurring element with both nutritional and toxicological properties. Higher selenium exposure and selenium supplements have been suggested to protect against several types of cancer. Objectives To gather and present evidence needed to address two research questions: 1. What is the aetiological relationship between selenium exposure and cancer risk in humans?
 2. Describe the efficacy of selenium supplementation for cancer prevention in humans. Search methods We updated electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), MEDLINE (Ovid, 2013 to January 2017, week 4), and Embase (2013 to 2017, week 6), as well as searches of clinical trial registries. Selection criteria We included randomised controlled trials (RCTs) and longitudinal observational studies that enrolled adult participants. Data collection and analysis We performed random‐effects (RE) meta‐analyses when two or more RCTs were available for a specific outcome. We conducted RE meta‐analyses when five or more observational studies were available for a specific outcome. We assessed risk of bias in RCTs and in observational studies using Cochrane's risk assessment tool and the Newcastle‐Ottawa Scale, respectively. We considered in the primary analysis data pooled from RCTs with low risk of bias. We assessed the certainty of evidence by using the GRADE approach. Main results We included 83 studies in this updated review: two additional RCTs (10 in total) and a few additional trial reports for previously included studies. RCTs involved 27,232 participants allocated to either selenium supplements or placebo. For analyses of RCTs with low risk of bias, the summary risk ratio (RR) for any cancer incidence was 1.01 (95% confidence interval (CI) 0.93 to 1.10; 3 studies, 19,475 participants; high‐certainty evidence). The RR for estimated cancer mortality was 1.02 (95% CI 0.80 to 1.30; 1 study, 17,448 participants). For the most frequently investigated site‐specific cancers, investigators provided little evidence of any effect of selenium supplementation. Two RCTs with 19,009 participants indicated that colorectal cancer was unaffected by selenium administration (RR 0.99, 95% CI 0.69 to 1.43), as were non‐melanoma skin cancer (RR 1.16, 95% CI 0.30 to 4.42; 2 studies, 2027 participants), lung cancer (RR 1.16, 95% CI 0.89 to 1.50; 2 studies, 19,009 participants), breast cancer (RR 2.04, 95% CI 0.44 to 9.55; 1 study, 802 participants), bladder cancer (RR 1.07, 95% CI 0.76 to 1.52; 2 studies, 19,009 participants), and prostate cancer (RR 1.01, 95% CI 0.90 to 1.14; 4 studies, 18,942 participants). Certainty of the evidence was high for all of these cancer sites, except for breast cancer, which was of moderate certainty owing to imprecision, and non‐melanoma skin cancer, which we judged as moderate certainty owing to high heterogeneity. RCTs with low risk of bias suggested increased melanoma risk. Results for most outcomes were similar when we included all RCTs in the meta‐analysis, regardless of risk of bias. Selenium supplementation did not reduce overall cancer incidence (RR 0.99, 95% CI 0.86 to 1.14; 5 studies, 21,860 participants) nor mortality (RR 0.81, 95% CI 0.49 to 1.32; 2 studies, 18,698 participants). Summary RRs for site‐specific cancers showed limited changes compared with estimates from high‐quality studies alone, except for liver cancer, for which results were reversed. In the largest trial, the Selenium and Vitamin E Cancer Trial, selenium supplementation increased risks of alopecia and dermatitis, and for participants with highest background selenium status, supplementation also increased risk of high‐grade prostate cancer. RCTs showed a slightly increased risk of type 2 diabetes associated with supplementation. A hypothesis generated by the Nutritional Prevention of Cancer Trial ‐ that individuals with low blood selenium levels could reduce their risk of cancer (particularly prostate cancer) by increasing selenium intake ‐ has not been confirmed. As RCT participants have been overwhelmingly male (88%), we could not assess the potential influence of sex or gender. We included 15 additional observational cohort studies (70 in total; over 2,360,000 participants). We found that lower cancer incidence (summary odds ratio (OR) 0.72, 95% CI 0.55 to 0.93; 7 studies, 76,239 participants) and lower cancer mortality (OR 0.76, 95% CI 0.59 to 0.97; 7 studies, 183,863 participants) were associated with the highest category of selenium exposure compared with the lowest. Cancer incidence was lower in men (OR 0.72, 95% CI 0.46 to 1.14, 4 studies, 29,365 men) than in women (OR 0.90, 95% CI 0.45 to 1.77, 2 studies, 18,244 women). Data show a decrease in risk of site‐specific cancers for stomach, colorectal, lung, breast, bladder, and prostate cancers. However, these studies have major weaknesses due to study design, exposure misclassification, and potential unmeasured confounding due to lifestyle or nutritional factors covarying with selenium exposure beyond those taken into account in multi‐variable analyses. In addition, no evidence of a dose‐response relation between selenium status and cancer risk emerged. Certainty of evidence was very low for each outcome. Some studies suggested that genetic factors might modify the relation between selenium and cancer risk ‐ an issue that merits further investigation. Authors' conclusions Well‐designed and well‐conducted RCTs have shown no beneficial effect of selenium supplements in reducing cancer risk (high certainty of evidence). Some RCTs have raised concerns by reporting a higher incidence of high‐grade prostate cancer and type 2 diabetes in participants with selenium supplementation. No clear evidence of an influence of baseline participant selenium status on outcomes has emerged in these studies. Observational longitudinal studies have shown an inverse association between selenium exposure and risk of some cancer types, but null and direct relations have also been reported, and no systematic pattern suggesting dose‐response relations has emerged. These studies suffer from limitations inherent to the observational design, including exposure misclassification and unmeasured confounding. Overall, there is no evidence to suggest that increasing selenium intake through diet or supplementation prevents cancer in humans. However, more research is needed to assess whether selenium may modify the risk of cancer in individuals with a specific genetic background or nutritional status, and to investigate possible differential effects of various forms of selenium. Plain language summary Selenium for preventing cancer Review question 
 We reviewed the evidence investigating the relation between selenium intake and cancer prevention. This review updates the most recent Cochrane review on this topic ( Vinceti 2014) , which was an update of Dennert 2011 . Background 
 Selenium is a naturally occurring element that individuals are exposed to mainly through food consumption, although exposure can also occur through air, drinking water, and dietary supplements. Small amounts of selenium are essential for certain biological functions in humans, but slightly higher amounts can pose a toxicity risk, making selenium an element with a narrow, but as yet not well‐defined, safe range of exposure. Selenium occurs in many different chemical forms with different biological activity. From the late 1960s, a few observational studies reported that people with high levels of selenium in their diet or in their body tissues had lower risk of cancer, and some laboratory studies showed that selenium could inhibit the growth of cancer cells. This led to widespread interest in selenium supplements and claims that taking such supplements could prevent cancer. Since that time, many more observational studies have been conducted to compare cancer rates among individuals with high and low selenium exposure. More recently, several randomised controlled trials designed to assess whether selenium supplementation can prevent cancer have been carried out. These trials played a major role in enhancing our understanding of the relation between selenium and cancer risk as a result of their stronger study design as compared with observational studies. The most recent trials in particular have shown high methodological quality and statistical power. Several trials focused on whether selenium could prevent prostate cancer. Study characteristics 
 This review includes 10 trials in which adults were randomly assigned to receive selenium supplements or placebo, and 70 observational studies in which adults were followed over time to determine whether their baseline selenium status was associated with their risk of cancer. The evidence is current to January 2017. Key results 
 All of the high‐quality randomised trials reported no effect of selenium on reducing overall risk of cancer or risk of particular cancers, including the most investigated outcome ‐ prostate cancer. Some trials unexpectedly suggested that selenium may increase risks of high‐grade prostate cancer, type 2 diabetes, and dermatological abnormalities. Observational studies have yielded inconsistent evidence of a possible effect of selenium exposure on cancer risk, with no evidence of a dose‐response relation. When we pooled results of these studies, overall they suggested an inverse relation between cancer exposure and subsequent incidence of any cancer or some specific cancers, such as colon and prostate cancer. However, observational studies have major weaknesses. The selenium exposure status of participants could have been misclassified owing to limitations of the indicators of selenium exposure used, as well as to uncertainty regarding the particular selenium species contributing to overall exposure. In addition, unmeasured confounding from lifestyle or nutritional factors ‐ a major and well‐known source of bias in nutritional epidemiology studies of observational design ‐ could have been present. Therefore, the internal validity of these studies is limited. Currently, the hypothesis that increasing selenium intake may reduce cancer risk is not supported by epidemiological evidence. Additional research is needed to assess whether selenium may affect the risk of cancer in individuals with specific genetic backgrounds or nutritional status, and to determine how the various chemical forms of selenium compounds may have different effects on cancer risk.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.725Z" }, { "id": "4d95e422-5d60-41ba-bbef-30d21cc93620", "pmid": "", "title": "Omega‐3 fatty acids for bipolar disorder", "imported": false, "abstract": "Abstract - Background Bipolar disorder is a complex psychiatric disorder and is amongst the top thirty causes of worldwide disability. Mood stabilisers are the primary pharmacological intervention, both in the treatment of acute episodes and in prophylaxis. There is, however, mounting evidence that dietary supplementation with omega‐3 fatty acids may be beneficial in psychiatric conditions, particularly those involving disturbances of mood. Objectives To review the efficacy of omega‐3 fatty acids as either a monotherapy or an adjunctive treatment for bipolar disorder. Search methods Electronic searches of the following databases were performed: CCDANCTR‐Studies and CCDANCTR‐References were searched on 12/2/2008, Supplementary searches were carried out on Biological Abstracts, CINAHL, The Cochrane Library, CCDAN Register, EMBASE, MEDLINE, and PsycINFO. The search strategy also included cited reference searching, personal contact with all authors of studies initially included and contact with the omega‐3 producing pharmaceutical companies. Selection criteria All relevant randomised controlled trials were included in the review. Studies involving males and females of all ages with a diagnosis of bipolar disorder qualified for inclusion. Studies using any type or dose of omega‐3 fatty acid treatment as monotherapy or in addition to standard pharmacotherapy were eligible. The primary outcome was symptom severity; and secondary outcomes were adverse effects, dropout and satisfaction with treatment. Data collection and analysis Two review authors independently inspected the citations identified from the search. Potentially relevant abstracts were identified and full papers ordered and reassessed for inclusion and methodological quality. All relevant data were extracted. The weighted mean difference (WMD) was used for continuous outcome data, with 95% confidence intervals (CI). Main results Five studies met inclusion criteria for the review, however, methodological quality was highly variable. Only one study, involving 75 participants, provided data for analysis, and showed a benefit of active treatment over control for depression symptom levels (WMD ‐3.93, 95% CI ‐7.00 to ‐0.86)and Clinical Global Impression scores (WMD ‐0.75, 95% CI ‐1.33 to ‐0.17) but not for mania (WMD ‐2.81, 95% CI ‐7.68 to 1.90). No serious adverse effects were reported in the five studies. The pattern of dropout was highly variable between studies. Authors' conclusions Results from one study showed positive effects of omega‐3 as an adjunctive treatment for depressive but not manic symptoms in bipolar disorder. These findings must be regarded with caution owing to the limited data available. There is an acute need for well‐designed and executed randomised controlled trials in this field. Plain language summary Omega‐3 fatty acids for bipolar disorder This systematic review investigated the efficacy of omega‐3 fatty acids for bipolar disorder. Five randomised controlled trials met inclusion criteria for the review. Only one trial provided data that could be analysed, investigating ethyl‐EPA as an adjunctive treatment in a mixed outpatient population. Some positive benefits were found for depressive symptoms but not for mania, and no adverse events were reported. There is currently insufficient evidence on which to base any clear recommendations concerning omega‐3 fatty acids for bipolar disorder. However, given the general health benefits and safety of omega‐3, the preliminary evidence from this review provides a strong case for well‐powered, high‐quality trials in specific index populations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Montgomery, P; Richardson, AJ", "articleTypes": [], "doi": "10.1002/14651858.CD005169.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "4dad53b0-dd73-434d-9af7-002a99232d9f", "pmid": "", "title": "Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low‐ and middle‐income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid‐based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition. Objectives To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low‐ and middle‐income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective. Search methods In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. Selection criteria We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before‐and‐after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low‐ and middle‐income countries. Data collection and analysis Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses using the random‐effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods. Main results Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care ‐ the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight‐for‐height (MD 0.20 z‐score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid‐based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses ‐ there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid‐based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non‐recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight‐for‐height, and mid‐upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid‐based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses ‐ no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid‐based nutrient supplements versus specific types of blended foods ‐ a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods ‐ in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet ‐ no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. Authors' conclusions In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short‐term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent. Plain language summary Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries Moderate acute malnutrition (MAM) affects around 10% of children under five years of age in low‐ and middle‐income countries. Different food strategies have been used for the nutritional recovery of children with MAM, such as lipid‐based nutrient supplements or blended foods, which can be provided in full dose or in a low dose as a complement to the usual diet. However, there is no definitive consensus on the most effective way to treat children with MAM. We searched eight electronic databases and three trials registers (in October 2012 for all except Embase, which was searched in August 2012). We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. We found eight relevant randomised controlled trials, enrolling 10,037 children under five years of age. All but one study was conducted in Africa. The risk of bias in the studies was generally low, though two studies had a high dropout rate. The participants were aware which intervention group they were in and this may have influenced their behaviour but we thought it unlikely it would have influenced the results since the outcomes measured were objective ones. For four of the studies, we were unable to assess if the study authors reported all the outcomes they intended to measure. When any type of specially formulated food was compared to standard care (medical care and counselling without foods), the children treated with foods had a higher chance of recovering from moderate malnutrition (two studies), greater improvement in nutritional status (two studies), and a lower number of dropouts (one study). A reduction in mortality was not shown. When lipid‐based nutrient supplements (which are food with high energy density and high lipid content) at full dose were compared to blended foods at full dose (which are dry food mixtures without high lipid content), there was no difference between these two types of foods in terms of number of deaths (five studies), children progressing to severe acute malnutrition (three studies), and children dropping out (four studies). However, lipid‐based nutrient supplements increased the number recovered by 10% (five studies), decreased the number of children non‐recovering (three studies), and slightly improved the nutritional status among the recovered. One study observed more children vomiting when given lipid‐based nutrient supplements compared to blended foods, but this was not reported by the other studies. No other side effects were reported. Few studies evaluated foods at complementary dosage (i.e. foods given in low quantity, just to complement the diet and not to fully substitute it), and no conclusion could be drawn from these studies. When specific foods were compared to each other, a type of corn‐soy blended food called CSB++ compared to lipid‐based nutrient supplements resulted in similar outcomes, while results of another blended food (CSB pre‐mix) versus lipid‐based nutrient supplements were unclear. In one study, CSB++ did not show any significant benefit over locally‐made blended foods, for example, Misola. No study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with moderate acute malnutrition. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. There are no studies evaluating special recipes to improve the adequacy of the usual home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lazzerini, M, Rubert, L, Pani, P", "articleTypes": [], "doi": "10.1002/14651858.CD009584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.115Z" }, { "id": "4db7d9d0-8501-4772-a1eb-25889a71c761", "pmid": "", "title": "Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents", "imported": false, "abstract": "Abstract - Background Vomiting is a common manifestation of acute gastroenteritis in children and adolescents. When untreated it can be a hindrance to oral rehydration therapy, which is the cornerstone in the management of acute gastroenteritis. Evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in acute gastroenteritis in children. Objectives To assess the safety and effectiveness of antiemetics on gastroenteritis induced vomiting in children and adolescents. Search methods We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conferences.The search was re‐run and is up to date as on 20 July 2010. Selection criteria Randomized controlled trials comparing antiemetics with placebo or no treatment, in children and adolescents under the age of 18, for vomiting due to gastroenteritis. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We included seven trials involving 1,020 participants. Mean time to cessation of vomiting in one study was 0.34 days less with dimenhydrinate suppository compared to placebo (P value = 0.036). Pooled data from three studies comparing oral ondansetron with placebo showed: a reduction in the immediate hospital admission rate (RR 0.40, NNT 17, 95% CI 10 to 100) but no difference between the hospitalization rates at 72 hours after discharge from the Emergency Department (ED); a reduction in IV rehydration rates both during the ED stay (RR 0.41, NNT 5, 95% CI 4 to 8), and in follow‐up to 72 hours after discharge from the ED stay (worst‐best scenario for ondansetron RR 0.57, NNT 6, 95% CI 4 to 13) and an increase in the proportion of patients with cessation of vomiting (RR 1.34, NNT 5, 95% CI 3 to 7)). No significant difference was noted in the revisit rates or adverse events, although diarrhea was reported as a side effect in four of the five ondansetron studies. In one study the proportion of patients with cessation of vomiting in 24 hours was (58%) with IV ondansetron, (17%) placebo and (33%) in the metoclopramide group (P value = 0.039). Authors' conclusions Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting. Plain language summary Anti‐sickness medication for vomiting in acute stomach upsets in children Vomiting caused by acute gastroenteritis is very common in children and adolescents. Treatment of vomiting in children with acute gastroenteritis can be problematic and there is lack of agreement among clinicians on the indications for the use of antiemetics. There have also been concerns expressed about apparently unacceptable levels of side effects with some of the older generation of antiemetics. The small number of included trials provided evidence which appeared to favour the use of antiemetics over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. A single oral dose of ondansetron given to children with mild to moderate dehydration can control vomiting, avoid hospitalization and intravenous fluid administration which would otherwise be needed. There were no major side effects other than a few reports of increased frequency of diarrhea.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fedorowicz, Z, Jagannath, VA, Carter, B", "articleTypes": [], "doi": "10.1002/14651858.CD005506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.810Z" }, { "id": "4dca4e14-c487-44d6-a535-53799fdcc2e9", "pmid": "", "title": "Vitamin B12 supplementation during pregnancy for maternal and child health outcomes", "imported": false, "abstract": "Abstract - Background Vitamin B 12 deficiency is a major public health problem worldwide, with the highest burden in elderly people, pregnant women, and young children. Due to its role in DNA synthesis and methylation, folate metabolism, and erythropoiesis, vitamin B 12 supplementation during pregnancy may confer longer‐term benefits to maternal and child health outcomes. Objectives To evaluate the benefits and harms of oral vitamin B 12 supplementation during pregnancy on maternal and child health outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov , the World Health Organization International Clinical Trials Registry Platform ( ICTRP ) on 2 June 2023, and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs), quasi‐RCTs, or cluster‐RCTs evaluating the effects of oral vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation during pregnancy. Data collection and analysis We used standard Cochrane methods. Four review authors independently assessed trial eligibility. Two review authors independently extracted data from included studies and conducted checks for accuracy. Three review authors independently assessed the risk of bias of the included studies using the Cochrane RoB 1 tool. We used GRADE to evaluate the certainty of evidence for primary outcomes. Main results The review included five trials with 984 pregnant women. All trials were conducted in low‐ and middle‐income countries, including India, Bangladesh, South Africa, and Croatia. At enrolment, 26% to 51% of pregnant women had vitamin B 12 deficiency (less than 150 pmol/L), and the prevalence of anaemia (haemoglobin less than 11.0 g/dL) ranged from 30% to 46%. The dosage of vitamin B 12 supplementation varied from 5 μg/day to 250 μg/day, with administration beginning at 8 to 28 weeks' gestation through to delivery or three months' postpartum, and the duration of supplementation ranged from 8 to 16 weeks to 32 to 38 weeks. Three trials, involving 609 pregnant women, contributed data for meta‐analyses of the effects of vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation. Maternal anaemia: there may be little to no difference for maternal anaemia by intervention group, but the evidence is very uncertain (70.9% versus 65.0%; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.93 to 1.26; 2 trials, 284 women; very low‐certainty evidence). Maternal vitamin B 12 status: vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain (25.9% versus 67.9%; RR 0.38, 95% CI 0.28 to 0.51; 2 trials, 272 women; very low‐certainty evidence). Women who received vitamin B 12 supplements during pregnancy may have higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (mean difference (MD) 60.89 pmol/L, 95% CI 40.86 to 80.92; 3 trials, 412 women). However, there was substantial heterogeneity (I 2 = 85%). Adverse pregnancy outcomes: the evidence is uncertain about the effect on adverse pregnancy outcomes, including preterm birth (RR 0.97, 95% CI 0.55 to 1.74; 2 trials, 340 women; low‐certainty evidence), and low birthweight (RR 1.50, 95% CI 0.93 to 2.43; 2 trials, 344 women; low‐certainty evidence). Two trials reported data on spontaneous abortion (or miscarriage); however, the trials did not report quantitative data for meta‐analysis and there was no clear definition of spontaneous abortion in the study reports. No trials evaluated the effects of vitamin B 12 supplementation during pregnancy on neural tube defects. Infant vitamin B 12 status: children born to women who received vitamin B 12 supplementation had higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (MD 71.89 pmol/L, 95% CI 20.23 to 123.54; 2 trials, 144 children). Child cognitive outcomes : three ancillary analyses of one trial reported child cognitive outcomes; however, data were not reported in a format that could be included in quantitative meta‐analyses. In one study, maternal vitamin B 12 supplementation did not improve neurodevelopment status (e.g. cognitive, language (receptive and expressive), motor (fine and gross), social‐emotional, or adaptive (conceptual, social, practical) domains) in children compared to placebo (9 months, Bayley Scales of Infant and Toddler Development Third Edition (BSID‐III); 1 trial; low‐certainty evidence) or neurophysiological outcomes (72 months, event‐related potential measures; 1 trial; low‐certainty evidence), though children born to women who received vitamin B 12 supplementation had improved expressive language domain compared to placebo (30 months, BSID‐III; 1 trial; low‐certainty evidence). Authors' conclusions Oral vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency and may improve maternal vitamin B 12 concentrations during pregnancy or postpartum compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain. The effects of vitamin B 12 supplementation on other primary outcomes assessed in this review were not reported, or were not reported in a format for inclusion in quantitative analyses. Vitamin B 12 supplementation during pregnancy may improve maternal and infant vitamin B 12 status, but the potential impact on longer‐term clinical and functional maternal and child health outcomes has not yet been established. Plain language summary Vitamin B 12 supplementation for women during pregnancy Key messages – Women who took vitamin B 12 supplements during pregnancy may have improved vitamin B 12 status during pregnancy or postpartum, including less vitamin B 12 deficiency and higher vitamin B 12 levels, compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. – The effects of taking vitamin B 12 supplements during pregnancy on other health outcomes in pregnant women or their children are not known. Public health implications Vitamin B 12 is an important nutrient that helps keep your body's blood and nerve cells healthy. Vitamin B 12 deficiency is an important public health problem, particularly in low‐ and middle‐income countries, with a high burden amongst pregnant women and children. Lower vitamin B 12 levels in pregnancy have been linked to greater risk of some adverse pregnancy outcomes such as miscarriage, poor growth of the baby in the womb, problems with the baby's brain or spinal cord (called neural tube defects), and lower vitamin B 12 status in infants. Vitamin B 12 supplementation during pregnancy may help improve the health and nutrition of women and their babies. However, this has not been examined in well‐conducted reviews, and vitamin B 12 is not part of supplements recommended by the World Health Organization (WHO; a specialised agency of the United Nations responsible for international public health) for women during pregnancy. What did we want to find out? We wanted to find out if taking vitamin B 12 supplements during pregnancy would improve the health and nutrition of women and their babies. What did we do? We searched for clinical trials that looked at vitamin B 12 supplementation during pregnancy. We compared and summarised the results of the trials and rated our confidence in the information, based on factors such as trial methods and sizes. What did we find? We included five trials with 984 pregnant women. Three trials, including 609 pregnant women, had data included in analyses. Women who took vitamin B 12 supplements during pregnancy had less vitamin B 12 deficiency and higher vitamin B 12 levels compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. There were no differences between groups for maternal anaemia. We could not assess the effects of vitamin B 12 supplementation on other outcomes such as miscarriage, neural tube defects, and child cognition (a child's ability to gain knowledge through thought, understanding, and the senses) due to limited or no availability of results for analysis. What are the limitations of the evidence? The small number of trials and small size of trials were limitations in this review. Not all the trials provided data about the outcomes we were interested in. We are very unsure about the results. How up to date is this evidence? The evidence is up to date as of June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Finkelstein, JL, Fothergill, A, Venkatramanan, S, Layden, AJ, Williams, JL, Crider, KS, Qi, YP", "articleTypes": [], "doi": "10.1002/14651858.CD013823.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.088Z" }, { "id": "4dcb24e3-7d46-4ed2-9316-3d02d8ea34c3", "pmid": "", "title": "Treatment for recurrent vulvovaginal candidiasis (thrush)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Cooke, G, Watson, C, Deckx, L, Pirotta, M, Smith, J, van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009151.pub2 AB - Abstract - Background Recurrent vulvovaginal candidiasis (RVVC) affects up to 5% of women. No comprehensive systematic review of treatments for RVVC has been published. Objectives The primary objective was to assess the effectiveness and safety of pharmacological and non‐pharmacological treatments for RVVC. The secondary objective was to assess patient preference of treatment options. Search methods We conducted electronic searches of bibliographic databases, including CENTRAL, MEDLINE, Embase, and CINAHL (search date 6 October 2021). We also handsearched reference lists of identified trials and contacted authors of identified trials, experts in RVVC, and manufacturers of products for vulvovaginal candidiasis. Selection criteria We considered all published and unpublished randomised controlled trials evaluating RVVC treatments for at least six months, in women with four or more symptomatic episodes of vulvovaginal candidiasis in the past year. We excluded women with immunosuppressive disorders or taking immunosuppressant medication. We included women with diabetes mellitus and pregnant women. Diagnosis of RVVC must have been confirmed by presence of symptoms and a positive culture and/or microscopy. We included all drug and non‐drug therapies and partner treatment, assessing the following primary outcomes: • number of clinical recurrences per participant per year (recurrence defined as clinical signs and positive culture/microscopy);
• proportion of participants with at least one clinical recurrence during the treatment and follow‐up period; and
• adverse events. Data collection and analysis Two authors independently reviewed titles and abstracts to identify eligible trials. Duplicate data extraction was completed independently by two authors. We assessed risk of bias as described in the Cochrane Handbook for Systematic Reviews of Interventions . We used the fixed‐effects model for pooling and expressed the results as risk ratio (RR) with 95% confidence intervals (CI). Where important statistical heterogeneity was present we either did not pool data (I 2 > 70%) or used a random‐effects model (I 2 40‐70%). We used the GRADE tool to assess overall certainty of the evidence for the pooled primary outcomes. Main results Studies: Twenty‐three studies involving 2212 women aged 17 to 67 years met the inclusion criteria. Most studies excluded pregnant women and women with diabetes or immunosuppression. The predominant species found on culture at study entry was Candida albicans . Overall, the included studies were small (<100 participants). Six studies compared antifungal treatment with placebo (607 participants); four studies compared oral versus topical antifungals (543 participants); one study compared different oral antifungals (45 participants); two studies compared different dosing regimens for antifungals (100 participants); one study compared two different dosing regimens of the same topical agent (23 participants); one study compared short versus longer treatment duration (26 participants); two studies assessed the effect of partner treatment (98 participants); one study compared a complementary treatment (Lactobacillus vaginal tablets and probiotic oral tablets) with placebo (34 participants); three studies compared complementary medicine with antifungals (354 participants); two studies compared 'dermasilk' briefs with cotton briefs (130 participants); one study examined Lactobacillus vaccination versus heliotherapy versus ciclopyroxolamine (90 participants); one study compared CAM treatments to an antifungal treatment combined with CAM treatments (68 participants). We did not find any studies comparing different topical antifungals. Nine studies reported industry funding, three were funded by an independent source and eleven did not report their funding source. Risk of bias: Overall, the risk of bias was high or unclear due to insufficient blinding of allocation and participants and poor reporting. Primary outcomes: Meta‐analyses comparing drug treatments (oral and topical) with placebo or no treatment showed there may be a clinically relevant reduction in clinical recurrence at 6 months (RR 0.36, 95% CI 0.21 to 0.63; number needed to treat for an additional beneficial outcome (NNTB) = 2; participants = 607; studies = 6; I² = 82%; low‐certainty evidence) and 12 months (RR 0.80, 95% CI 0.72 to 0.89; NNTB = 6; participants = 585; studies = 6; I² = 21%; low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. We are very uncertain whether oral drug treatment compared to topical treatment increases the risk of clinical recurrence at 6 months (RR 1.66, 95% CI 0.83 to 3.31; participants = 206; studies = 3; I² = 0%; very low‐certainty evidence) and reduces the risk of clinical recurrence at 12 months (RR 0.95, 95% CI 0.71 to 1.27; participants = 206; studies = 3; I² = 10%; very low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. Adverse events were scarce across both treatment and control groups in both comparisons. The reporting of adverse events varied amongst studies, was generally of very low quality and could not be pooled. Overall the adverse event rate was low for both placebo and treatment arms and ranged from less than 5% to no side effects or complications. Authors' conclusions In women with RVVC, treatment with oral or topical antifungals may reduce symptomatic clinical recurrences when compared to placebo or no treatment. We were unable to find clear differences between different treatment options (e.g. oral versus topical treatment, different doses and durations). These findings are not applicable to pregnant or immunocompromised women and women with diabetes as the studies did not include or report on them. More research is needed to determine the optimal medication, dose and frequency. Plain language summary The effectiveness and safety of treatments for recurrent vulvovaginal candidiasis (thrush) Review question Cochrane authors set out to investigate the effectiveness and safety of drug treatments or non‐drug treatments (such as complementary and alternative medicines) for women with recurrent vulvovaginal candidiasis (thrush). Background Thrush of the vaginal/vulvar area is caused by Candida , a form of yeast that is commonly found in the vagina as part of normal flora without causing symptoms. For unknown reasons, Candida can start growing and cause symptoms of vulvovaginal candidiasis (commonly named thrush). Symptoms of vulvovaginal thrush include itching, swelling, and irritation of the vaginal and vulval areas. It is estimated that uncomplicated vulvovaginal thrush affects up to 75% of women at some time during their reproductive years. Recurrent vulvovaginal candidiasis (RVVC) occurs when a woman has four or more fungal infections during a 12‐month period. Up to 5% of women suffer from RVVC. Some doctors advise taking antifungals as a prevention, but there are no clear evidence‐based guidelines. Study characteristics We identified 23 studies involving 2212 participants between 17 and 67 years old with a diagnosis of RVVC confirmed by a positive test. The studies compared a range of antifungal medicines (taken by mouth or inserted into the vagina), and some complementary or alternative treatments (such as Lactobacillus vaccines or probiotics and special underwear). The studies reported the effects on recurrence of thrush after 6 and 12 months. Only one study reported the number of clinical recurrences at 12 months. Nine studies reported industry funding, three were funded by an independent source and nine studies did not report their funding source. The evidence is current to October 2021. Key results Six studies (607 participants) compared antifungal medication with placebo or no treatment. Based on low certainty evidence antifungal treatments may give a clinically relevant reduction in clinical recurrence at 6 and 12 months. We are uncertain if oral treatments are better than topical treatments (very low certainty evidence for no difference). Adverse effects of taking antifungal medication to prevent recurrence of thrush were not common. Studies reported on adverse effects differently, making comparisons difficult. More research is needed to determine the optimal medication, dose and frequency. We were unable to determine the effects in women who are pregnant or have diabetes. Certainty of the evidence Our confidence in the evidence was low to very low due to serious concerns about risk of bias, unclear reporting and the limited number of studies that could be combined. This means that new studies might change our confidence in the effects of treatments and our conclusions.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.120Z" }, { "id": "4df6c4ab-97cf-4837-aa10-1a2b5c3ac40a", "pmid": "", "title": "Interventions for erosive lichen planus affecting mucosal sites", "imported": false, "abstract": "Abstract - Background Erosive lichen planus (ELP) affecting mucosal surfaces is a chronic autoimmune disease of unknown aetiology. It is often more painful and debilitating than the non‐erosive types of lichen planus. Treatment of erosive lichen planus is difficult and aimed at palliation rather than cure. Several topical and systemic agents have been used with varying results. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth. Objectives To assess the effects of interventions in the treatment of erosive lichen planus affecting the oral, anogenital, and oesophageal regions. Search methods We searched the following databases up to September 2009: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched reference lists of articles and online trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) that evaluated the effectiveness of any topical or systemic interventions for ELP affecting either the mouth, genital region, or both areas, in participants of any age, gender, or race. Data collection and analysis The primary outcome measures were as follows: (a) Pain reduction using a visual analogue scale rated by participants; 
 (b) Physician Global Assessment; and
 (c) Participant global self‐assessment. Changes in scores at the end of therapy compared with baseline were analysed. Main results Fifteen RCTs were included, giving a total of 473 participants with ELP (study sizes ranged between 8‐94). All studies involved oral sites only. Six studies included participants with non‐erosive lichen planus but only the erosive subgroup was included for intended subgroup analysis. We were unable to pool data from any of the nine studies with only ELP participants or any of the six studies with the ELP subgroup, due to small numbers and the heterogeneity of the interventions, design methods, and outcome variables between studies. One study involving 50 participants found that 0.025% clobetasol propionate administered as liquid microspheres significantly reduced pain compared to ointment (Mean difference (MD) ‐18.30, 95% confidence interval (CI) ‐28.57 to ‐8.03), but outcome data was only available in 45 participants (high risk of performance bias for blinding of participants, low/unclear risk of bias overall). However, in another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (high risk of performance and detection bias due to likely lack of blinding, low/unclear risk of bias overall). Aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo in a study involving 45 ELP participants (Risk ratio (RR) 6.16, 95% CI 2.35 to 16.13) (low risk of bias overall). No significant difference was seen in Physician Global Assessment in these three studies. In a small single study involving 20 ELP participants, 1% pimecrolimus cream was 7 times more likely to result in a strong improvement as rated by the Physician Global Assessment when compared to vehicle cream (RR 7.00, 95% CI 1.04 to 46.95) (low risk of bias overall). In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease as rated by the Physician Global Assessment, in favour of the ciclosporin group when compared to the vehicle (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (unclear risk of selection bias for allocation concealment, overall risk of bias low). No statistically significant benefits were shown for topical tacrolimus or fluticasone spray in two separate studies of 29 and 44 participants respectively. There is no overwhelming evidence for the efficacy of a single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candidiasis and dyspepsia. Authors' conclusions This review suggests that there is only weak evidence for the effectiveness of any of the treatments for oral ELP, whilst no evidence was found for genital ELP. More RCTs on a larger scale are needed in the oral and genital ELP populations. We suggest that future studies should have standardised outcome variables that are clinically important to affected individuals. We recommend the measurement of a clinical severity score and a participant‐rated symptom score using agreed and validated severity scoring tools. We also recommend the development of a validated combined severity scoring tool for both oral and genital populations. Plain language summary Treatments for erosive lichen planus affecting mucosal sites Erosive lichen planus (ELP) is a condition that affects the mouth, oesophagus (food pipe or gullet), and anogenital region. It is caused by an over‐active immune system. It is often more painful and debilitating than the non‐erosive types of lichen planus. Depending on the site involved, affected individuals may experience pain, and difficulty eating; passing urine; or having sexual intercourse. Treatment is difficult and aimed at controlling symptoms, rather than cure. Several creams and tablets have been used with varying results. This review looked at the effectiveness of treatments for ELP and included 15 studies, with 473 participants with ELP. All involved oral, but not genital, disease. Many studies were excluded either because they were not randomised controlled trials (where participants are divided into two groups at random) or because they recruited participants with all types of lichen planus, rather than just the erosive subtypes. All of these studies recruited small numbers of participants (12 to 94) and used a variety of different assessment methods and timings; hence, it was not possible to combine or compare results between studies directly. We found only weak evidence for the effectiveness of any of the treatments for oral ELP. None of the studies involved genital or oesophageal disease; hence, no evidence was found for the treatment of these conditions. One small study found that 0.025% clobetasol propionate (a very potent topical steroid) administered as a spray significantly reduced pain when compared to ointment. In another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (a potent topical steroid). In a study involving 45 ELP participants, aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo. In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease in favour of the ciclosporin group when compared to the vehicle. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candida (yeast) infection and pain or discomfort in the upper abdomen. Temporary burning was a common side‐effect reported with tacrolimus 0.1% ointment and pimecrolimus 0.1% cream. Overall, there was no overwhelming evidence for the effectiveness of any single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. This was mainly due to the lack of good‐quality, well‐conducted trials and small participant numbers. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cheng, S; Kirtschig, G; Cooper, S; Thornhill, M; Leonardi‐Bee, J; Murphy, R", "articleTypes": [], "doi": "10.1002/14651858.CD008092.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "4e110f44-84e8-40f3-be1c-47139ba90519", "pmid": "", "title": "Effect of adrenergic agonist oral decongestants on blood pressure", "imported": false, "abstract": "Abstract - Background Adrenergic agonist oral decongestants are commonly taken daily over long periods of time to relieve sinus and nasal congestion. The mechanism of action of decongestants potentially increases blood pressure, and these effects may be acute or chronic. However, no systematic reviews to date have comprehensively assessed the chronic blood pressure effects of adrenergic agonist oral decongestants as a drug class, despite their widespread non‐prescription availability. Objectives Primary objective To assess the effects of adrenergic agonist oral decongestants on systolic and diastolic blood pressure compared to placebo. Secondary objective To assess the effects of adrenergic agonist oral decongestants on heart rate and withdrawals due to adverse effects. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCT) up to July 2024: Cochrane Hypertension Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Register of Studies, Ovid MEDLINE, Ovid Embase, and ClinicalTrials.gov. There were no language, publication year, or publication status restrictions. Selection criteria We included RCTs of at least seven days' duration with parallel groups (intervention and placebo) comparing adrenergic agonist oral decongestants versus placebo on blood pressure in people aged over six years. Data collection and analysis Two review authors (JJC and MC) independently assessed the trials for inclusion, extracted the data, and assessed the risk of bias from the included trials. In cases where there were disagreements, the third review author (JMW) adjudicated. For any missing or unclear information in the studies, we contacted the study author to request the missing information or seek clarification. The primary outcomes were systolic blood pressure and diastolic blood pressure. Secondary outcomes were heart rate and withdrawal due to adverse effects. We used a fixed‐effect model to combine the effect sizes from all studies. We assessed the certainty of the evidence using GRADE. Main results Five RCTs randomizing 882 participants met the inclusion criteria. The shortest study duration was one week, and the longest study duration was 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The largest study included 568 people, and the smallest study included 18 people. The mean age of participants was 20.0 years, with 326 males and 591 females. The studies were conducted in the USA and Europe; most were set in the USA. Pharmaceutical companies funded three of the five included studies. The findings are relevant to all people using adrenergic agonist oral decongestants for seven days or longer regardless of comorbidities or pre‐existing conditions. The adrenergic agonist oral decongestants included were ephedrine (one RCT), pseudoephedrine (one RCT), and phenylpropanolamine (three RCTs). Compared to placebo, adrenergic agonist oral decongestants may have little to no effect on systolic blood pressure , but the evidence is very uncertain (mean difference [MD] 0.91 mmHg, 95% confidence interval [CI] −0.57 to 2.38; 4 RCTs, 784 participants; I 2 = 54%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on diastolic blood pressure (MD 0.44 mmHg, 95% CI −0.59 to 1.48; 5 RCTs, 882 participants; I 2 = 30%; low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on heart rate, but the evidence is very uncertain (MD 1.92 beats per minute, 95% CI −0.62 to 4.47; 2 RCTs, 190 participants; I 2 = 79%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on the number of withdrawals due to adverse effects (risk ratio [RR] 1.20, 95% CI 0.37 to 3.88; 4 RCTs, 806 participants; low‐certainty evidence; note 1 study reported withdrawals due to adverse effects but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 3 studies rather than 4). Four studies were at overall high risk of bias, and one study was at overall low risk of bias. Authors' conclusions In this systematic review, chronic daily intake of adrenergic agonist oral decongestants had little to no effect on blood pressure, heart rate, and withdrawals due to adverse effects. People making decisions about using these medicines should consider the very low certainty of evidence and the theoretical risk of increased blood pressure. Independent trials free from biases that are designed to answer this question are required. The evidence was limited due to the small number of studies, and the blood pressure and heart rate not being measured at the optimal time after drug ingestion. Plain language summary What are the effects of oral decongestants on blood pressure? Key messages – We found no evidence that taking oral decongestants (medicine taken by mouth to relieve a stuffy nose) daily for a week or more changes blood pressure or heart rate or causes people to stop taking them due to unwanted effects. – There were only a few studies, and they were not well designed. More well‐conducted studies are needed. – Given that oral decongestants are sometimes taken daily for weeks or months, and have the potential to increase blood pressure, people should consider this potential risk alongside the limited evidence from this review when deciding whether to use these medicines. What are oral decongestants? Oral decongestants are medications taken by mouth to relieve nasal congestion (stuffy or blocked nose), often caused by colds, allergies, or sinus infections (small, empty spaces behind the cheekbones and forehead that are connected to the nose). They typically include medicines called pseudoephedrine or phenylephrine. How do oral decongestants work? These medicines shrink swollen blood vessels in the nasal passages. This reduces swelling and allows air to flow more freely, helping you breathe easier. What is hypertension? Hypertension (high blood pressure) is when resting blood pressure is consistently above 140/90 mmHg. It can lead to unwanted effects such as stroke (where the blood supply to parts of the brain is reduced or stopped) and heart attack (where the blood supply to the heart is reduced or stopped). Lowering blood pressure is the easiest way to reduce these diseases. How is hypertension treated? Treating hypertension involves lifestyle measures and taking blood pressure‐lowering medicines. Here, we focused on the effects of daily intake of oral decongestants. While these medicines help with nasal congestion, they may also increase blood pressure. What do we want to find out? We wanted to find out whether long‐term use of oral decongestants (for seven days or longer) increases blood pressure and has any unwanted effects. We also evaluated their effectiveness in relieving nasal congestion. This provides essential insights into their benefits and risks to guide informed use. What did we do? We searched for studies that compared the blood pressure effects of oral decongestants with placebo. A placebo is a substance or treatment with no active ingredients that is used in medical research to compare against the effects of real medications. We then compared and summarized the results, and rated our confidence in the evidence depending on the study design and methods. What did we find? We found five studies involving 882 children and adults (326 males and 591 females). The shortest study lasted one week, with the longest study lasting 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The size of the studies ranged from 18 to 568 people, and most were done in the USA. Pharmaceutical companies funded three studies. We found no clear evidence that taking oral decongestants daily changes blood pressure or heart rate, or causes people to stop taking them due to unwanted effects. What are the limitations of the evidence? There was a limited number of studies, and they were not well designed. None of the studies were primarily designed to assess the long‐term effects of oral decongestants on blood pressure. Trials designed to answer this question are needed. How up to date is the evidence? The evidence is up to date to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Chan, JJ; Chan, M; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007895.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "4e528f5f-26c5-4ae8-87f5-08705d3e877d", "pmid": "", "title": "Snoezelen for dementia", "imported": false, "abstract": "Abstract - Background Snoezelen, multi‐sensory stimulation, provides sensory stimuli to stimulate the primary senses of sight, hearing, touch, taste and smell, through the use of lighting effects, tactile surfaces, meditative music and the odour of relaxing essential oils. The rationale for this lies in the proposition that the provision of a sensory environment for people with dementia places fewer demands on their intellectual abilities but capitalizes on their residual sensorimotor abilities. The clinical application of snoezelen often varies in form, nature, principles and procedures. Such variations not only make the examination of the therapeutic values of snoezelen difficult, but also impede the clinical development of snoezelen in dementia care. A systematic review of evidence for the efficacy of snoezelen in the care of people with dementia is therefore needed to inform future clinical applications and research directions. Objectives To examine the clinical efficacy of snoezelen (or multisensory stimulation) for older people with dementia and their caregivers. Search methods The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 23 March 2008 using the terms: snoezelen OR \"multi‐sensory*\". The CDCIG Specialized Register contains records from all major health care databases ( The Cochrane Library , MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources. The reviewers hand‐searched PubMed and the ISI Web of Science. Selection criteria Randomized controlled trials and quasi‐randomized controlled trials in which snoezelen or multi‐sensory programmes was used as an intervention for older people suffering from any forms of dementia. Data collection and analysis The two reviewers independently reviewed and assessed the quality of the trials. Main results Two new trials were included in this update. Baker 2003 was an expanded study of Baker 2001 reported in the previous version. Both Baker 2003 and van Weert 2005 examined the short‐term and longer‐term effects of snoezelen on behaviour, mood, and communication of people with moderate to severe dementia. The format of implementation was different in the two trials: one was session‐based snoezelen programme (Baker 2003), whilst the other was a 24‐hour integrated snoezelen care (van Weert 2005). Owing to the differences in study methodology, the results of the two trials were not pooled for analysis. The session‐based snoezelen programme (Baker 2003) did not show any effects on behaviour, mood, cognition and communication / interaction in the short term (during or immediately after sessions) or longer term (at post‐intervention or 1‐month post‐intervention follow‐up). Likewise, the 24‐hour integrated snoezelen care (van Weert 2005) failed to demonstrate any significant short‐term and longer term effects on behaviour, mood and interaction. Authors' conclusions A more vigorous review methodology was adopted in this update. The study of Kragt 1997, reported in the previous version, was excluded because the snoezelen programme only consisted of three sessions, which was considered too brief for a therapeutic intervention. Two new trials were reviewed. Meta‐analyses could not be performed because of the limited number of trials and different study methods of the available trials. Overall, there is no evidence showing the efficacy of snoezelen for dementia. There is a need for more reliable and sound research‐based evidence to inform and justify the use of snoezelen in dementia care. Plain language summary No evidence of the efficacy of snoezelen or multi‐sensory stimulation programmes for people with dementia Snoezelen (or multi‐sensory stimulation) has become a commonly used intervention to manage maladaptive behaviours and to promote positive mood of older people with dementia. Originally, two randomised clinical trials were available for this review. Some short‐term benefits were documented in promoting adaptive behaviours in people with dementia during and immediately after their participation in the sessions. In this update, two new trials were included and revealed two different forms of applying snoezelen to dementia care. One is a session‐based snoezelen programme while the other is a 24‐hour integrated snoezelen care programme. Both trials did not show any significant effects on behaviour, interaction, and mood of people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Chung, JCC, Lai, CKY", "articleTypes": [], "doi": "10.1002/14651858.CD003152", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.785Z" }, { "id": "4e557c14-6cb9-4198-9f62-af0692158b7c", "pmid": "", "title": "Ibuprofen for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non‐steroidal anti‐inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period. Objectives 1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled). Search methods We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023. Selection criteria We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules. Data collection and analysis We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence. Main results We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child‐reported pain intensity less than two hours postintervention compared to placebo (SMD −1.12, 95% CI −1.39 to −0.86; 3 studies, 259 children; moderate‐certainty evidence). Ibuprofen may reduce child‐reported pain intensity, two hours to less than 24 hours postintervention (SMD −1.01, 95% CI −1.24 to −0.78; 5 studies, 345 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low‐certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child‐reported pain intensity less than two hours postintervention compared to paracetamol (SMD −0.42, 95% CI −0.82 to −0.02; 2 studies, 100 children; moderate‐certainty evidence). Ibuprofen may slightly reduce child‐reported pain intensity two hours to 24 hours postintervention (SMD −0.21, 95% CI −0.40 to −0.02; 6 studies, 422 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low‐certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) −0.25, 95% CI −0.40 to −0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate‐certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD −0.29, 95% CI −0.53 to −0.04; NNTB 4; 1 study, 59 children; low‐certainty evidence). Authors' conclusions Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs. Plain language summary What are the benefits and harms of ibuprofen for managing pain after an operation in children? Key messages • Ibuprofen probably reduces pain intensity just after an operation up to two hours compared to a placebo (dummy) and compared to paracetamol. The evidence compared to other medicines and in the longer term is unclear or lacking. • Overall, we are uncertain about unwanted effects of ibuprofen, especially serious unwanted effects, since the studies in the review rarely measured them. • Future studies should examine ibuprofen compared to commonly used medications and measure benefits and unwanted effects for both short‐ and long‐term use. Why is pain management important? It is common for children to experience pain after an operation (postoperative pain). Pain causes suffering and agitation, and it can delay recovery. One way to manage pain in children is by using different medicines, for example, ibuprofen. Ibuprofen is a type of medicine called a 'non‐steroidal anti‐inflammatory drug' (NSAID) that can reduce inflammation and pain. What did we want to find out? We wanted to find out if ibuprofen is an effective pain treatment and whether it causes unwanted effects compared to other pain treatments. Also, the most effective way to deliver ibuprofen to children. What did we do? We searched for studies that compared ibuprofen to other treatment options for postoperative pain as well as for studies that looked at different ways to deliver ibuprofen to children. We summarised the results and rated our confidence in the evidence. What did we find? We found 43 studies with 4265 children with postoperative pain. We used data from 3935 children in this review. The largest study included 741 children and the smallest, 23 children. The studies were conducted in many countries around the world; most commonly the USA (12 studies). Children's ages ranged from 2.2 months up to 17 years. Studies used ibuprofen to manage postoperative pain in 10 different types of surgery: mostly dental procedures (21 studies); and ear, nose and throat procedures (11 studies). Main results Compared to placebo (a dummy medicine), ibuprofen probably reduces pain intensity less than two hours after the operation and may reduce pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol , ibuprofen probably reduces pain intensity less than two hours after the operation and probably reduces pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol, ibuprofen probably makes little difference to the chances of bleeding. Compared to morphine , ibuprofen probably leads to a reduction in any reported unwanted effects. Compared to ketorolac , ibuprofen may lead to a reduction in overall harms. No studies reported pain intensity or serious unwanted effects, such as lasting disability or hospitalisation for either morphine or ketorolac. We did not find any studies that compared different routes of administration of ibuprofen. What are the limitations of the evidence? We are uncertain about the overall evidence of ibuprofen use in postoperative pain in children, primarily because there were not enough large studies to be certain about any differences in ibuprofen when compared to other alternatives. In addition, only a few of the studies provided data about important benefits and unwanted effects for children experiencing pain following surgery, especially in the longer term. How up to date is this evidence? The evidence is up‐to‐date to August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Pessano, S, Gloeck, NR, Tancredi, L, Ringsten, M, Hohlfeld, A, Ebrahim, S, Albertella, M, Kredo, T, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.789Z" }, { "id": "4e7717e7-8614-4542-aa7b-b68631b636e7", "pmid": "", "title": "Antiemetics for adults for prevention of nausea and vomiting caused by moderately or highly emetogenic chemotherapy: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background About 70% to 80% of adults with cancer experience chemotherapy‐induced nausea and vomiting (CINV). CINV remains one of the most distressing symptoms associated with cancer therapy and is associated with decreased adherence to chemotherapy. Combining 5‐hydroxytryptamine‐3 (5‐HT₃) receptor antagonists with corticosteroids or additionally with neurokinin‐1 (NK₁) receptor antagonists is effective in preventing CINV among adults receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Various treatment options are available, but direct head‐to‐head comparisons do not allow comparison of all treatments versus another. Objectives • In adults with solid cancer or haematological malignancy receiving HEC ‐ To compare the effects of antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids on prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting in network meta‐analysis (NMA) ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy • In adults with solid cancer or haematological malignancy receiving MEC ‐ To compare whether antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids are superior for prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting to treatment combinations including 5‐HT₃ receptor antagonists and corticosteroids solely, in network meta‐analysis ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy Search methods We searched CENTRAL, MEDLINE, Embase, conference proceedings, and study registries from 1988 to February 2021 for randomised controlled trials (RCTs). Selection criteria We included RCTs including adults with any cancer receiving HEC or MEC (according to the latest definition) and comparing combination therapies of NK₁ and 5‐HT₃ inhibitors and corticosteroids for prevention of CINV. Data collection and analysis We used standard methodological procedures expected by Cochrane. We expressed treatment effects as risk ratios (RRs). Prioritised outcomes were complete control of vomiting during delayed and overall phases, complete control of nausea during the overall phase, quality of life, serious adverse events (SAEs), and on‐study mortality. We assessed GRADE and developed 12 'Summary of findings' tables. We report results of most crucial outcomes in the abstract, that is, complete control of vomiting during the overall phase and SAEs. For a comprehensive illustration of results, we randomly chose aprepitant plus granisetron as exemplary reference treatment for HEC, and granisetron as exemplary reference treatment for MEC. Main results Highly emetogenic chemotherapy ( HEC) We included 73 studies reporting on 25,275 participants and comparing 14 treatment combinations with NK₁ and 5‐HT₃ inhibitors. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 704 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with aprepitant + granisetron. Evidence from NMA (39 RCTs, 21,642 participants; 12 treatment combinations with NK₁ and 5‐HT₃ inhibitors) suggests that the following drug combinations are more efficacious than aprepitant + granisetron for completely controlling vomiting during the overall treatment phase (one to five days): fosnetupitant + palonosetron (810 of 1000; RR 1.15, 95% confidence interval (CI) 0.97 to 1.37; moderate certainty), aprepitant + palonosetron (753 of 1000; RR 1.07, 95% CI 1.98 to 1.18; low‐certainty), aprepitant + ramosetron (753 of 1000; RR 1.07, 95% CI 0.95 to 1.21; low certainty), and fosaprepitant + palonosetron (746 of 1000; RR 1.06, 95% CI 0.96 to 1.19; low certainty). Netupitant + palonosetron (704 of 1000; RR 1.00, 95% CI 0.93 to 1.08; high‐certainty) and fosaprepitant + granisetron (697 of 1000; RR 0.99, 95% CI 0.93 to 1.06; high‐certainty) have little to no impact on complete control of vomiting during the overall treatment phase (one to five days) when compared to aprepitant + granisetron, respectively. Evidence further suggests that the following drug combinations are less efficacious than aprepitant + granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): aprepitant + ondansetron (676 of 1000; RR 0.96, 95% CI 0.88 to 1.05; low certainty), fosaprepitant + ondansetron (662 of 1000; RR 0.94, 95% CI 0.85 to 1.04; low certainty), casopitant + ondansetron (634 of 1000; RR 0.90, 95% CI 0.79 to 1.03; low certainty), rolapitant + granisetron (627 of 1000; RR 0.89, 95% CI 0.78 to 1.01; moderate certainty), and rolapitant + ondansetron (598 of 1000; RR 0.85, 95% CI 0.65 to 1.12; low certainty). We could not include two treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 35 of 1000 participants experience any SAEs when treated with aprepitant + granisetron. Evidence from NMA (23 RCTs, 16,065 participants; 11 treatment combinations) suggests that fewer participants may experience SAEs when treated with the following drug combinations than with aprepitant + granisetron: fosaprepitant + ondansetron (8 of 1000; RR 0.23, 95% CI 0.05 to 1.07; low certainty), casopitant + ondansetron (8 of 1000; RR 0.24, 95% CI 0.04 to 1.39; low certainty), netupitant + palonosetron (9 of 1000; RR 0.27, 95% CI 0.05 to 1.58; low certainty), fosaprepitant + granisetron (13 of 1000; RR 0.37, 95% CI 0.09 to 1.50; low certainty), and rolapitant + granisetron (20 of 1000; RR 0.57, 95% CI 0.19 to 1.70; low certainty). Evidence is very uncertain about the effects of aprepitant + ondansetron (8 of 1000; RR 0.22, 95% CI 0.04 to 1.14; very low certainty), aprepitant + ramosetron (11 of 1000; RR 0.31, 95% CI 0.05 to 1.90; very low certainty), fosaprepitant + palonosetron (12 of 1000; RR 0.35, 95% CI 0.04 to 2.95; very low certainty), fosnetupitant + palonosetron (13 of 1000; RR 0.36, 95% CI 0.06 to 2.16; very low certainty), and aprepitant + palonosetron (17 of 1000; RR 0.48, 95% CI 0.05 to 4.78; very low certainty) on the risk of SAEs when compared to aprepitant + granisetron, respectively. We could not include three treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron, rolapitant + ondansetron) in NMA for this outcome because of missing direct comparisons. Moderately emetogenic chemotherapy (MEC) We included 38 studies reporting on 12,038 participants and comparing 15 treatment combinations with NK₁ and 5‐HT₃ inhibitors, or 5‐HT₃ inhibitors solely. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 555 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with granisetron. Evidence from NMA (22 RCTs, 7800 participants; 11 treatment combinations) suggests that the following drug combinations are more efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days): aprepitant + palonosetron (716 of 1000; RR 1.29, 95% CI 1.00 to 1.66; low certainty), netupitant + palonosetron (694 of 1000; RR 1.25, 95% CI 0.92 to 1.70; low certainty), and rolapitant + granisetron (660 of 1000; RR 1.19, 95% CI 1.06 to 1.33; high certainty). Palonosetron (588 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) and aprepitant + granisetron (577 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) may or may not increase complete response in the overall treatment phase (one to five days) when compared to granisetron, respectively. Azasetron (560 of 1000; RR 1.01, 95% CI 0.76 to 1.34; low certainty) may result in little to no difference in complete response in the overall treatment phase (one to five days) when compared to granisetron. Evidence further suggests that the following drug combinations are less efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): fosaprepitant + ondansetron (500 of 1000; RR 0.90, 95% CI 0.66 to 1.22; low certainty), aprepitant + ondansetron (477 of 1000; RR 0.86, 95% CI 0.64 to 1.17; low certainty), casopitant + ondansetron (461 of 1000; RR 0.83, 95% CI 0.62 to 1.12; low certainty), and ondansetron (433 of 1000; RR 0.78, 95% CI 0.59 to 1.04; low certainty). We could not include five treatment combinations (fosaprepitant + granisetron, azasetron, dolasetron, ramosetron, tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 153 of 1000 participants experience any SAEs when treated with granisetron. Evidence from pair‐wise comparison (1 RCT, 1344 participants) suggests that more participants may experience SAEs when treated with rolapitant + granisetron (176 of 1000; RR 1.15, 95% CI 0.88 to 1.50; low certainty). NMA was not feasible for this outcome because of missing direct comparisons. Certainty of evidence Our main reason for downgrading was serious or very serious imprecision (e.g. due to wide 95% CIs crossing or including unity, few events leading to wide 95% CIs, or small information size). Additional reasons for downgrading some comparisons or whole networks were serious study limitations due to high risk of bias or moderate inconsistency within networks. Authors' conclusions This field of supportive cancer care is very well researched. However, new drugs or drug combinations are continuously emerging and need to be systematically researched and assessed. For people receiving HEC, synthesised evidence does not suggest one superior treatment for prevention and control of chemotherapy‐induced nausea and vomiting. For people receiving MEC, synthesised evidence does not suggest superiority for treatments including both NK₁ and 5‐HT₃ inhibitors when compared to treatments including 5‐HT₃ inhibitors only. Rather, the results of our NMA suggest that the choice of 5‐HT₃ inhibitor may have an impact on treatment efficacy in preventing CINV. When interpreting the results of this systematic review, it is important for the reader to understand that NMAs are no substitute for direct head‐to‐head comparisons, and that results of our NMA do not necessarily rule out differences that could be clinically relevant for some individuals. Plain language summary Which drug combinations are best for prevention of nausea and vomiting caused by chemotherapy in adults with cancer? The burden of nausea and vomiting caused by chemotherapy and what helps to prevent it? In about 70% to 80% of adults with cancer, chemotherapy induces nausea and vomiting (CINV). Depending on the type of chemotherapy, treatment can cause strong or moderate sickness (hereafter referred to as HEC (highly emetogenic chemotherapy) and MEC (moderately emetogenic chemotherapy)). Multiple drug combinations have showed high benefit for CINV among adults receiving HEC or MEC. What was the aim of our review? Using a network meta‐analysis, we aimed to compare the benefits and harms of different drug combinations for prevention of CINV among people receiving HEC or MEC, and to identify treatment ranking. A network meta‐analysis is a technique used to compare different treatments described in already published trials, even when the original individual trial does not describe such comparisons. What studies did we look at? We searched selected medical databases and trial registries until February 2021. We included studies comparing multiple drug combinations for prevention of CINV among adults with any type of cancer receiving HEC or MEC that is commonly used in clinical practice. In particular, we looked at drugs inhibiting two specific biochemical receptors (neurokinin receptor and serotonin receptor) that trigger nausea and vomiting after chemotherapy. We looked at the preventative effects of these treatments over five days. This is the period during which the maximum intensity of CINV and further peaks of intensity are expected, after the start of chemotherapy. Our key results... ...for people receiving HEC We found 73 studies that reported on the experience of 25,275 participants and compared 14 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped to prevent any vomiting in 60% to 81% of people on average. Those individuals also had no need for rescue medicines, which are used in case nausea and vomiting occur even though prophylactic treatment has been given. The results of our analysis suggest some differences in effectiveness of different treatments, but overall we had little confidence that those differences would be reflected in real‐world observations. Harms. We estimated that 1% to 4% of people experience serious side effects. The differences between treatments were small. ...for people receiving MEC We found 38 studies that reported on the experience of 12,038 participants and compared 15 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped prevent any vomiting in 43% to 72% of people on average. Those individuals also had no need for rescue medicines. The results of our analysis suggest some differences in the effectiveness of different treatments, but overall, we had little confidence that those differences would be reflected in real‐world observations. Harms. Few studies reported serious side effects. The ones that did suggest that on average 15% to 18% of people experience such events. Differences between treatments were small. However, we think that future research is needed to rule out potential differences between treatments. Our confidence in the findings We assessed how confident we were that there are differences between compared treatments. We had low or very low confidence that one treatment is better or worse than another in preventing CINV. Our confidence in differences between statistical results was mainly limited because measures of variation were wide apart and included both potential advantages and disadvantages, although measures of precision showed no or little effect. We also identified limitations in some of the included studies, which further limited our confidence in the effects. This was mainly the case when study personnel and participants knew which treatments were given and therefore may not adhere to the planned intervention, or may perceive or report effects differently. Our conclusions The results of our analysis suggest that there is no superior drug combination for prevention of CINV for people receiving HEC or MEC. However, results suggest that the choice of drugs targeting the serotonin receptor may impact effectiveness, irrespective of whether given with or without a drug targeting the neurokinin receptor. However, when interpreting these results, it is important for the reader to understand that these kinds of multiple‐comparison analyses are no substitute for head‐to‐head comparisons, and that the results do not necessarily rule out differences that could be clinically relevant for some individuals. How up‐to‐date is this evidence? Evidence is up‐to‐date to 2 February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Piechotta, V; Adams, A; Haque, M; Scheckel, B; Kreuzberger, N; Monsef, I; Jordan, K; Kuhr, K; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "4e860740-7c08-420b-b4d4-56c219d25d81", "pmid": "", "title": "Antihypertensive drug therapy for mild to moderate hypertension during pregnancy", "imported": false, "abstract": "Abstract - Background Antihypertensive drugs are often used in the belief that lowering blood pressure will prevent progression to more severe disease, and thereby improve pregnancy outcome. This Cochrane Review is an updated review, first published in 2001 and subsequently updated in 2007 and 2014. Objectives To assess the effects of antihypertensive drug treatments for women with mild to moderate hypertension during pregnancy. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (13 September 2017), and reference lists of retrieved studies. Selection criteria All randomised trials evaluating any antihypertensive drug treatment for mild to moderate hypertension during pregnancy, defined as systolic blood pressure 140 to 169 mmHg and/or diastolic blood pressure 90 to 109 mmHg. Comparisons were of one or more antihypertensive drug(s) with placebo, with no antihypertensive drug, or with another antihypertensive drug, and where treatment was planned to continue for at least seven days. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results For this update, we included 63 trials (data from 58 trials, 5909 women), with moderate to high risk of bias overall. We carried out GRADE assessments for the main 'antihypertensive drug versus placebo/no antihypertensive drug' comparison only. Evidence was graded from very low to moderate certainty, with downgrading mainly due to design limitations and imprecision.For many outcomes, trials contributing data evaluated different hypertensive drugs; while we did not downgrade for this indirectness, results should be interpreted with caution. Antihypertensive drug versus placebo/no antihypertensive drug (31 trials, 3485 women) Primary outcomes: moderate‐certainty evidence suggests that use of antihypertensive drug(s) probably halves the risk of developing severe hypertension (risk ratio (RR) 0.49; 95% confidence interval (CI) 0.40 to 0.60; 20 trials, 2558 women), but may have little or no effect on the risk of proteinuria/pre‐eclampsia (average risk ratio (aRR) 0.92; 95% CI 0.75 to 1.14; 23 trials, 2851 women; low‐certainty evidence). Moderate‐certainty evidence also shows that antihypertensive drug(s) probably have little or no effect in the risk of total reported fetal or neonatal death (including miscarriage) (aRR 0.72; 95% CI 0.50 to 1.04; 29 trials, 3365 women), small‐for‐gestational‐age babies (aRR 0.96; 95% CI 0.78 to 1.18; 21 trials, 2686 babies) or preterm birth less than 37 weeks (aRR 0.96; 95% CI 0.83 to 1.12; 15 trials, 2141 women). Secondary outcomes: we are uncertain of the effect of antihypertensive drug(s) on the risk of maternal death , severe pre‐eclampsia , or eclampsia, or impaired long‐term growth and development of the baby in infancy and childhood , because the certainty of this evidence is very low. There may be little or no effect on the risk of changed/stopped drugs due to maternal side‐effects, or admission to neonatal or intensive care nursery (low‐certainty evidence). There is probably little or no difference in the risk of elective delivery (moderate‐certainty evidence). Antihypertensive drug versus another antihypertensive drug (29 trials, 2774 women) Primary outcomes: beta blockers and calcium channel blockers together in the meta‐analysis appear to be more effective than methyldopa in avoiding an episode of severe hypertension (RR 0.70; 95% CI 0.56 to 0.88; 11 trials, 638 women). There was also an increase in this risk when other antihypertensive drugs were compared with calcium channel blockers (RR 1.86; 95% CI 1.09 to 3.15; 5 trials, 223 women), but no evidence of a difference when methyldopa and calcium channel blockers together were compared with beta blockers (RR1.18, 95% CI 0.95 to 1.48; 10 trials, 692 women). No evidence of a difference in the risk of proteinuria/pre‐eclampsia was found when alternative drugs were compared with methyldopa (aRR 0.78; 95% CI 0.58 to 1.06; 11 trials, 997 women), with calcium channel blockers (aRR: 1.24, 95% CI 0.70 to 2.19; 5 trials, 375 women), or with beta blockers (aRR 1.21, 95% CI 0.88 to 1.67; 12 trials, 1107 women). For the babies, we found no evidence of a difference in the risk of total reported fetal or neonatal death (including miscarriage) when comparing other antihypertensive drugs with methyldopa (aRR 0.77, 95% CI 0.52 to 1.14; 22 trials, 1791 babies), with calcium channel blockers (aRR 0.90, 95% CI 0.52 to 1.57; nine trials, 700 babies), or with beta blockers (aRR: 1.23, 95% CI 0.81 to 1.88; 19 trials, 1652 babies); nor in the risk for small‐for‐gestational age in the comparison with methyldopa (aRR 0.79, 95% CI 0.52 to 1.20; seven trials, 597 babies), with calcium channel blockers (aRR 1.05, 95% CI 0.64 to 1.73; four trials, 200 babies), or with beta blockers (average RR 1.13, 95% CI 0.80 to 1.60; 7 trials, 680 babies). No evidence of an overall difference among groups in the risk of preterm birth (less than 37 weeks) was found in the comparison with methyldopa (aRR: 0.91; 95% CI 0.68 to 1.22; 11 trials, 835 women), with calcium channel blockers (aRR 0.85, 95% CI 0.59 to 1.23; six trials, 330 women), or with beta blockers (aRR 1.22, 95% CI 0.90 to 1.66; 9 trials, 806 women). Secondary outcomes: There were no cases of maternal death and eclampsia. There is no evidence of a difference in the risk of severe pre‐eclampsia , changed/stopped drug due to maternal side‐effects , elective delivery, admission to neonatal or intensive care nursery when other antihypertensive drugs are compared with methyldopa, calcium channel blockers or beta blockers. Impaired long‐term growth and development in infancy and childhood was not reported for these comparisons. Authors' conclusions Antihypertensive drug therapy for mild to moderate hypertension during pregnancy reduces the risk of severe hypertension. The effect on other clinically important outcomes remains unclear. If antihypertensive drugs are used, beta blockers and calcium channel blockers appear to be more effective than the alternatives for preventing severe hypertension. High‐quality large sample‐sized randomised controlled trials are required in order to provide reliable estimates of the benefits and adverse effects of antihypertensive treatment for mild to moderate hypertension for both mother and baby, as well as costs to the health services, women and their families. Plain language summary Antihypertensive drug therapy for mild to moderate hypertension during pregnancy What is the issue? The aim of this review was to determine the benefits and adverse effects of blood pressure‐lowering drugs (antihypertensive drugs) for pregnant women with mild to moderate hypertension (high blood pressure). The other aim was to assess the benefits and adverse effects of these drugs for their babies. Why is this important? During pregnancy, up to one in 10 women have blood pressure readings that are above normal. For some women, their blood pressure remains slightly high (termed ‘mild to moderate high blood pressure’), with no apparent complications. Some of these women go on to develop very high blood pressure. Very high blood pressure can result in a medical emergency if it affects the woman’s organs (such as her liver, or brain in the form of a stroke). Also, it can seriously affect the growth and health of her baby. Drugs that lower blood pressure are used to treat mild to moderate high blood pressure, in the belief that this treatment will prevent the blood pressure from continuing to rise. Over the years, information from good quality research studies has been contradictory, so we cannot be sure if this drug treatment is worthwhile. What evidence did we find? This Cochrane Review is an update of a review that was first published in 2001 and updated in 2007 and 2014. We searched for randomised controlled trials in September 2017, and this review now includes data from 58 trials involving more than 5900 women. A total of 31 trials with 3485 women compared a number of different blood pressure‐lowering drugs to a placebo or no treatment. There were a further 29 trials involving 2774 women which compared one blood pressure‐lowering drug with another one. The evidence showed that treating pregnant women who had moderately raised blood pressure with blood pressure‐lowering drugs probably halved the number of the women developing severe high blood pressure (20 trials, 2558 women). However, blood pressure‐lowering drugs probably had little or no effect on the risk of the baby dying (29 trials, 3365 women), and there is insufficient data on maternal deaths to make a judgement on whether this risk is lowered (five trials, 525 women). The use of blood pressure‐lowering drugs may have little or no effect on the number of the women developing pre‐eclampsia (23 trials, 2851 women), or the number of women who had to change drugs because of side‐effects (16 trials, 1503 women). We found no difference in the number of babies born preterm, that is before 37 weeks (15 trials, 2141 women). There was also no difference in the number of babies born small for their gestational age (21 trials, 2686 babies). The quality of the evidence was mostly moderate (but for pre‐eclampsia it was low). This was due to a number of small studies, and problems with the way the studies were undertaken. The available evidence is still insufficient to demonstrate if there is any antihypertensive drug that is better than another. However, beta blockers and calcium channel blockers seem to be better than the alternative drugs for blood pressure control. What does this mean? More research is needed in order to confirm the true effect of antihypertensive drugs in mothers and in their babies, and to identify the drug which would be best.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abalos, E, Duley, L, Steyn, DW, Gialdini, C", "articleTypes": [], "doi": "10.1002/14651858.CD002252.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.110Z" }, { "id": "4e866305-1a01-42b3-a741-110a1f55daac", "pmid": "", "title": "Drug interventions for the treatment of obesity in children and adolescents", "imported": false, "abstract": "Abstract - Background Child and adolescent obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. Objectives To assess the efficacy of drug interventions for the treatment of obesity in children and adolescents. Search methods We searched CENTRAL , MEDLINE, Embase, PubMed (subsets not available on Ovid), LILACS as well as the trial registers ICTRP (WHO) and ClinicalTrials.gov. Searches were undertaken from inception to March 2016. We checked references and applied no language restrictions. Selection criteria We selected randomised controlled trials (RCTs) of pharmacological interventions for treating obesity (licensed and unlicensed for this indication) in children and adolescents (mean age under 18 years) with or without support of family members, with a minimum of three months' pharmacological intervention and six months' follow‐up from baseline. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. In addition, we excluded trials which included growth hormone therapies and pregnant participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data following standard Cochrane methodology. Where necessary we contacted authors for additional information. Main results We included 21 trials and identified eight ongoing trials. The included trials evaluated metformin (11 trials), sibutramine (six trials), orlistat (four trials), and one trial arm investigated the combination of metformin and fluoxetine. The ongoing trials evaluated metformin (four trials), topiramate (two trials) and exenatide (two trials). A total of 2484 people participated in the included trials, 1478 participants were randomised to drug intervention and 904 to comparator groups (91 participants took part in two cross‐over trials; 11 participants not specified). Eighteen trials used a placebo in the comparator group. Two trials had a cross‐over design while the remaining 19 trials were parallel RCTs. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up from baseline ranged from six months to 100 weeks. Trials generally had a low risk of bias for random sequence generation, allocation concealment and blinding (participants, personnel and assessors) for subjective and objective outcomes. We judged approximately half of the trials as having a high risk of bias in one or more domain such as selective reporting. The primary outcomes of this review were change in body mass index (BMI), change in weight and adverse events. All 21 trials measured these outcomes. The secondary outcomes were health‐related quality of life (only one trial reported results showing no marked differences; very low certainty evidence), body fat distribution (measured in 18 trials), behaviour change (measured in six trials), participants' views of the intervention (not reported), morbidity associated with the intervention (measured in one orlistat trial only reporting more new gallstones following the intervention; very low certainty evidence), all‐cause mortality (one suicide in the orlistat intervention group; low certainty evidence) and socioeconomic effects (not reported). Intervention versus comparator for mean difference (MD) in BMI change was ‐1.3 kg/m 2 (95% confidence interval (CI) ‐1.9 to ‐0.8; P < 0.00001; 16 trials; 1884 participants; low certainty evidence). When split by drug type, sibutramine, metformin and orlistat all showed reductions in BMI in favour of the intervention. Intervention versus comparator for change in weight showed a MD of ‐3.9 kg (95% CI ‐5.9 to ‐1.9; P < 0.00001; 11 trials; 1180 participants; low certainty evidence). As with BMI, when the trials were split by drug type, sibutramine, metformin and orlistat all showed reductions in weight in favour of the intervention. Five trials reported serious adverse events: 24/878 (2.7%) participants in the intervention groups versus 8/469 (1.7%) participants in the comparator groups (risk ratio (RR) 1.43, 95% CI 0.63 to 3.25; 1347 participants; low certainty evidence). A total 52/1043 (5.0%) participants in the intervention groups versus 17/621 (2.7%) in the comparator groups discontinued the trial because of adverse events (RR 1.45, 95% CI 0.83 to 2.52; 10 trials; 1664 participants; low certainty evidence). The most common adverse events in orlistat and metformin trials were gastrointestinal (such as diarrhoea, mild abdominal pain or discomfort, fatty stools). The most frequent adverse events in sibutramine trials included tachycardia, constipation and hypertension. The single fluoxetine trial reported dry mouth and loose stools. No trial investigated drug treatment for overweight children. Authors' conclusions This systematic review is part of a series of associated Cochrane reviews on interventions for obese children and adolescents and has shown that pharmacological interventions (metformin, sibutramine, orlistat and fluoxetine) may have small effects in reduction in BMI and bodyweight in obese children and adolescents. However, many of these drugs are not licensed for the treatment of obesity in children and adolescents, or have been withdrawn. Trials were generally of low quality with many having a short or no post‐intervention follow‐up period and high dropout rates (overall dropout of 25%). Future research should focus on conducting trials with sufficient power and long‐term follow‐up, to ensure the long‐term effects of any pharmacological intervention are comprehensively assessed. Adverse events should be reported in a more standardised manner specifying amongst other things the number of participants experiencing at least one adverse event. The requirement of regulatory authorities (US Food and Drug Administration and European Medicines Agency) for trials of all new medications to be used in children and adolescents should drive an increase in the number of high quality trials. Plain language summary Drug interventions for the treatment of obesity in children and adolescents Review question Do drug (medicine) interventions reduce weight in obese children and adolescents and are they safe? Background Across the world more children and adolescents are becoming overweight and obese. These children and adolescents are more likely to have health problems, both while as children or adolescents and in later life. More information is needed about what works best for treating this problem recognising that so‐called lifestyle changes (diet, exercise and counselling) have limited efficacy. Study characteristics We found 21 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) comparing various drugs plus a behaviour changing intervention such as diet, exercise or both (= intervention groups) usually with placebo (a pretend drug) plus a behaviour changing intervention (= control groups). We also identified eight ongoing studies (studies which are currently running but not completed yet). A total of 2484 children and adolescents took part in the included studies. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up ranged from six months to 100 weeks. Key results The included studies investigated metformin (10 studies), sibutramine (six studies), orlistat (four studies) and one study group evaluated the combination of metformin and fluoxetine. The ongoing studies are investigating metformin (four studies), topiramate (two studies) and exenatide (two studies). Most studies reported on body mass index (BMI) and bodyweight: BMI is a measure of body fat and is calculated from weight and height measurements (kg/m 2 ). In children, BMI is often measured in a way that takes into account sex, weight and height as children grow older (BMI z score). The average change in BMI across control groups was between a 1.8 kg/m 2 reduction to a 0.9 kg/m 2 increase, while across all intervention groups the average reduction was more pronounced (1.3 kg/m 2 reduction). The same effect was observed for weight change: on average, children and adolescents in the intervention groups lost 3.9 kg more weight than the children and adolescents in the control groups. Study authors reported an average of serious side effects in 24 per 1000 participants in the intervention groups compared with an average of 17 per 1000 participants in the control groups. The numbers of participants dropping out of the study because of side effects were 40 per 1000 in the intervention groups and 27 per 1000 in the control groups. The most common side effects in the orlistat and metformin studies were gut (such as diarrhoea and mild tummy pain). Common side effects in the sibutramine trials included increased heart rate (tachycardia), constipation and high blood pressure. The fluoxetine study reported dry mouth and loose stools. One study reported health‐related quality of life (a measure of physical, mental, emotional and social functioning) and found no marked differences between intervention and control. No study reported the participants' views of the intervention or socioeconomic effects. Only one study reported on morbidity (how often a disease occurs in a specific area) associated with the intervention, where there were more gallstones after the orlistat treatment. Study authors reported one suicide in the orlistat intervention group. However, studies were not long enough to reliably investigate death from any cause. No study investigated drug treatment for children who were only overweight (obese children have a much higher weight, BMI or BMI z score than children being overweight). This evidence is up to date to March 2016. Quality of the evidence The overall certainty of the evidence was low or very low, mainly because there were only a few studies per outcome measurement, the number of included children or adolescents was small, and due to variation in the results of the studies. In addition, many children or adolescents left the studies before the study had finished.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Axon, E, Atkinson, G, Richter, B, Metzendorf, MI, Baur, L, Finer, N, Corpeleijn, E, O'Malley, C, Ells, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012436", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.097Z" }, { "id": "4e924a0e-388c-48ee-a50f-632f5143d4f0", "pmid": "", "title": "Pharmacologic Augmentation of TMS for Depression With D-serine", "imported": false, "abstract": "The goal of this study is to test whether combining D-serine with 30 treatments of a) iTBS and b) 18-Hz protocols will enhance clinical outcomes compared to rTMS with placebo (i.e., sugar pill). The investigators hypothesize that NMDA receptor activation via D-serine combined with repeated sessions of rTMS will produce greater clinical outcomes than iTBS with placebo and 18-Hz with placebo.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.154Z" }, { "id": "4e964bca-38bb-44f9-bc98-d9cddcbbf1b7", "pmid": "", "title": "Interventions for dysphagia in oesophageal cancer", "imported": false, "abstract": "Abstract - Background Most patients with oesophageal and gastro‐oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009. Objectives The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro‐oesophageal carcinoma. Search methods To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Selection criteria Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, self‐expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head‐to‐head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30‐day mortality, adverse effects and quality of life. Data collection and analysis Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group. Main results We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re‐interventions and for adverse effects. Anti‐reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti‐reflux stents might have reduced gastro‐oesophageal reflux and complications. Newly‐designed double‐layered nitinol (Niti‐S) stents were preferable due to longer survival time and fewer complications compared to simple Niti‐S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy. Authors' conclusions Self‐expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high‐dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti‐reflux stents and newly‐designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self‐expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re‐interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia. Plain language summary Interventions for reducing difficulty in swallowing in people with oesophageal cancer Review question For most patients with unresectable or inoperable oesophageal cancer, providing clinical benefit with palliative treatment is highly desirable. However, the optimal palliative technique for dysphagia improvement and better quality of life is not established. Background Dysphagia (difficulty or discomfort in swallowing) is common among patients with unresectable or inoperable oesophageal cancer. There are five levels of dysphagia, ranging from the ability to eat a normal diet to some solids, semisolids, liquids and to complete dysphagia. Study characteristics The review included randomised controlled studies comparing the use of different interventions to improve dysphagia among patients with inoperable or unresectable primary oesophageal cancer. To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Key results The review updates the previous version but still fails to present any obvious superiority of one technique over another among the different kinds of interventions. Self‐expanding metal stents provided safer and more effective relief of dysphagia compared to rigid plastic stents. Other techniques like radiotherapy or brachytherapy were also suitable alternatives and might be favourable in improving quality of life and prolonging survival. Individual differences should be emphasised when the intervention type was determined. Quality of the evidence Half of the studies included in this review were of high quality. Most studies did not state the methods used to seek and report quality of life outcomes and adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Yang, C, Li, J, Fu, W, Xu, W, Yang, S", "articleTypes": [], "doi": "10.1002/14651858.CD005048.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.134Z" }, { "id": "4e9a3f41-4425-4322-af3d-ec938afc8298", "pmid": "", "title": "Oral water soluble contrast for malignant bowel obstruction", "imported": false, "abstract": "Abstract - Background Malignant bowel obstruction (MBO) is a common problem in patients with intra‐abdominal cancer. Oral water soluble contrast (OWSC) has been shown to be useful in the management of adhesive small bowel obstruction in identifying patients who will recover with conservative management alone and also in reducing the length of hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in patients with MBO. Objectives To determine the reliability of OWSC media and follow‐up abdominal radiographs in predicting the success of conservative treatment in resolving inoperable MBO with conservative management. To determine the efficacy and safety of OWSC media in reducing the duration of obstruction and reducing hospital stay in people with MBO. Search methods We identified studies from searching Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in Process, Embase, CINAHL, Science Citation Index (Web of Science) and Conference Proceedings Citation Index ‐ Science (Web of Science). We also searched registries of clinical trials and the CareSearch Grey Literature database. The date of the search was the 6 June 2017. Selection criteria Randomised controlled trials (RCTs), or prospective controlled studies, that evaluated the diagnostic potential of OWSC in predicting which malignant bowel obstructions will resolve with conservative treatment. RCTs, or prospective controlled studies, that assessed the therapeutic potential of OWSC in managing MBO at any level compared with placebo, no intervention or usual treatment or supportive care. Data collection and analysis We used standard methodological procedures expected by Cochrane. We assessed risk of bias and assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We found only one RCT meeting the selection criteria for the second objective (therapeutic potential) of this review. This study recruited nine participants. It compared the use of gastrografin versus placebo in adult patients with MBO with no indication for further intervention (surgery, endoscopy) apart from standardised conservative management. The overall risk of bias for the study was high due to issues with low numbers of participants, selective reporting of outcomes and a high attrition rate for the intervention arm. Primary outcomes The included trial was a pilot study whose primary outcome was to test the feasibility for a large study. The authors reported specifically on the number of patients screened, the number recruited and reasons for exclusion; this was not the focus of our review. Due to the low number of participants, the authors of the study decided not to report on our primary outcome of assessing the ability of OWSC to predict the likelihood of malignant small bowel obstruction resolving with conservative treatment alone (diagnostic effect). It also did not report on our primary outcome of rate of resolution of MBO in patients receiving OWSC compared with those not receiving it (therapeutic effect). The study reported that no issues regarding safety or tolerability of either gastrografin or placebo were identified. The overall quality of the evidence for the incidence of adverse events with OWSC was very low, downgraded twice for serious limitations to study quality (high risk of selective reporting and attrition bias) and downgraded once for imprecision (sparse data). Secondary outcomes The study planned to report on this review’s secondary outcome measures of length of hospital stay and time from administration of OWSC to resolution of MBO. However the authors of the study decided not to do so due to the low numbers of patients recruited. The study did not report on our secondary outcome measure of survival times from onset of inoperable MBO until death. Authors' conclusions There is insufficient evidence from RCTs to determine the place of OWSC in predicting which patients with inoperable MBO will respond with conservative treatment alone. There is also insufficient evidence from RCTs to determine the therapeutic effects and safety of OWSC in patients with malignant small bowel obstruction. Plain language summary Oral water soluble contrast for cancer‐related bowel obstruction Background Intra‐abdominal cancer is where the cancer has either started elsewhere in the body and spread into the stomach area or started in the bowel itself. It can commonly grow and block the movement of food or faeces through the bowel. A blockage of the bowel caused by cancer is known as malignant bowel obstruction (MBO). Some patients with MBO benefit from surgery to reverse the blockage. In others it is not possible to reverse the MBO and it either resolves or becomes permanent (limiting prognosis to days or weeks). Scar tissue around the bowel (called adhesions) can also cause a blockage, this is known as adhesive small bowel obstruction. Adhesive obstructions often resolve with conservative management in hospital (allowing the bowel to \"rest\" and recover). However in some, the obstruction requires surgery to remove the scar tissue and fix the blockage. Oral water soluble contrast (OWSC) is often prepared in liquid form and when swallowed before an x‐ray or computed tomography (CT) scan will show up clearly in the bowel. It can predict which people with adhesive small bowel obstruction will require surgery. In some patients it may also speed recovery leading to reduced hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in MBO. Study characteristics We searched for evidence that OWSC could be used to identify which patients with inoperable MBO would recover with conservative management. We also wanted to know if OWSC increased the likelihood of recovery from MBO, reduced hospital stay or improved prognosis. Finally, we wished to know what side effects OWSC might cause for patients with MBO. We conducted the search in June 2017 and found one study. It only recruited nine participants and did not fully report on the outcomes of using OWSC in MBO. Key Findings We found insufficient evidence that OWSC can identify which patients with MBO will recover with conservative management. We found insufficient evidence that patients with MBO benefit from OWSC in terms of length of hospital stay, recovery time or survival. No conclusions could be made about side effects from OWSC. Quality of Evidence We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. We rated the quality of the evidence as very low due to the lack of studies reporting on the benefits of using OWSC in MBO and the only study we found reporting on side effects recruited very few participants (nine). The low quality of the evidence means that we are very uncertain about the use of OWSC in the management of MBO and cannot confirm its benefits or harms in patients with this condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Syrmis, W; Richard, R; Jenkins-Marsh, S; Chia, SC; Good, P", "articleTypes": [], "doi": "10.1002/14651858.CD012014.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "4ee6ce6f-d21f-4c02-af61-7c9951ad8971", "pmid": "", "title": "Palliative drug treatments for breathlessness in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is a life‐limiting autosomal recessive genetic illness. A feeling of shortness of breath is common in cystic fibrosis, especially as the disease progresses. Reversing the underlying cause is the priority when treating breathlessness (dyspnoea), but when it is not feasible, palliation (easing) becomes the primary goal to improve an individual's quality of life. A range of drugs administered by various routes have been used, but no definite guidelines are available. A systematic review is needed to evaluate such treatments. Objectives To assess the efficacy and safety of drugs used to ease breathlessness in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 18 November 2019. We searched databases (clinicaltrials.gov, the ISRCTN registry, the Clinical Trials Registry India and WHO ICTRP) for ongoing trials. These searches were last run on 06 March 2020. Selection criteria We planned to include randomised and quasi‐randomised controlled trials in people with cystic fibrosis (diagnosed by a positive sweat chloride test or genetic testing) who have breathlessness. We considered studies comparing any drugs used for easing breathlessness to another drug administered by any route (inhaled (nebulised), intravenous, oral, subcutaneous, transmucosal (including buccal, sublingual and intra‐nasal) and transdermal). Data collection and analysis The authors assessed the search results according to the pre‐defined inclusion criteria. Main results The new searches in 2020 yielded two ongoing studies that were not relevant to the review question. Previous searches had found only one study (cross‐over in design), which did not fulfil the inclusion criteria as no data were available from the first treatment period alone. Authors' conclusions Due to the lack of available evidence, this review cannot provide any information for clinical practice. The authors call for specific research in this area after taking into account relevant ethical considerations. The research should focus on the efficacy and safety of the drugs with efficacy being measured in terms of improvement in quality of life, dyspnoea scores and hospital stay. Plain language summary Drug treatments to ease breathlessness in cystic fibrosis Review question What is the evidence that drug treatments for breathlessness (also known as dyspnoea) in people with cystic fibrosis are effective and safe? Background Cystic fibrosis is a life‐limiting genetic disease. As the disease progresses, thick sticky mucus is formed in the lungs, pancreas and other organs. This thick mucus increases risk of infection, blocks the airways and causes severe breathlessness. Easing of this breathlessness is an important goal for care of people with cystic fibrosis. Many methods have been suggested to address this problem and many drugs have been reported to ease breathlessness. The drugs can be administered through various routes ‐ they might be inhaled, swallowed, injected under the skin, into muscle or into a vein or be absorbed through the skin (either on the body or through membranes inside the mouth or nose). Despite so many drugs being available, there are no defined guidelines for drug treatments aimed at easing breathlessness in people with cystic fibrosis. Search date The evidence from the Cochrane Cystic Fibrosis Trials Register is current to 18 November 2019; the searches of ongoing trial registries are current to 06 March 2020. Study characteristics We had planned to include studies comparing different treatments to ease breathlessness in people with cystic fibrosis where the participants were put into the different treatment groups at random. Our search found only one study in which seven people first received either a drug called hydrocodone or a placebo (dummy treatment) and then swapped to the other treatment; but this study did not report results separately for each treatment arm, so we are not able to include it in the review. Key results No studies fulfilled the inclusion criteria, therefore it is not possible to comment on the outcomes we wished to report on in this review. Until evidence becomes available, the review authors feel that it is advisable for doctors to follow any local or national guidelines. The authors recommend research in this area should take ethical considerations into account and should focus on the safety of the drugs, improvement in quality of life, breathlessness scores and length of hospital stay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Jaiswal, N, Singh, M, Agarwal, A, Chauhan, A, Jaiswal, N", "articleTypes": [], "doi": "10.1002/14651858.CD011855.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.747Z" }, { "id": "4f1b1ed2-f8da-4694-95ca-f58f85cc5677", "pmid": "", "title": "Ivermectin for preventing and treating COVID‐19", "imported": false, "abstract": "Abstract - Background Ivermectin, an antiparasitic agent, inhibits the replication of viruses in vitro. The molecular hypothesis of ivermectin's antiviral mode of action suggests an inhibitory effect on severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) replication in early stages of infection. Currently, evidence on ivermectin for prevention of SARS‐CoV‐2 infection and COVID‐19 treatment is conflicting. Objectives To assess the efficacy and safety of ivermectin plus standard of care compared to standard of care plus/minus placebo, or any other proven intervention for people with COVID‐19 receiving treatment as inpatients or outpatients, and for prevention of an infection with SARS‐CoV‐2 (postexposure prophylaxis). Search methods We searched the Cochrane COVID‐19 Study Register, Web of Science (Emerging Citation Index and Science Citation Index), WHO COVID‐19 Global literature on coronavirus disease, and HTA database weekly to identify completed and ongoing trials without language restrictions to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022. Selection criteria We included randomized controlled trials (RCTs) comparing ivermectin to standard of care, placebo, or another proven intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. Co‐interventions had to be the same in both study arms. For this review update, we reappraised eligible trials for research integrity: only RCTs prospectively registered in a trial registry according to WHO guidelines for clinical trial registration were eligible for inclusion. Data collection and analysis We assessed RCTs for bias, using the Cochrane RoB 2 tool. We used GRADE to rate the certainty of evidence for outcomes in the following settings and populations: 1) to treat inpatients with moderate‐to‐severe COVID‐19, 2) to treat outpatients with mild COVID‐19 (outcomes: mortality, clinical worsening or improvement, (serious) adverse events, quality of life, and viral clearance), and 3) to prevent SARS‐CoV‐2 infection (outcomes: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, admission to hospital, mortality, adverse events and quality of life). Main results We excluded seven of the 14 trials included in the previous review version; six were not prospectively registered and one was non‐randomized. This updated review includes 11 trials with 3409 participants investigating ivermectin plus standard of care compared to standard of care plus/minus placebo. No trial investigated ivermectin for prevention of infection or compared ivermectin to an intervention with proven efficacy. Five trials treated participants with moderate COVID‐19 (inpatient settings); six treated mild COVID‐19 (outpatient settings). Eight trials were double‐blind and placebo‐controlled, and three were open‐label. We assessed around 50% of the trial results as low risk of bias. We identified 31 ongoing trials. In addition, there are 28 potentially eligible trials without publication of results, or with disparities in the reporting of the methods and results, held in ‘awaiting classification’ until the trial authors clarify questions upon request. Ivermectin for treating COVID‐19 in inpatient settings with moderate‐to‐severe disease We are uncertain whether ivermectin plus standard of care compared to standard of care plus/minus placebo reduces or increases all‐cause mortality at 28 days (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.14 to 2.51; 3 trials, 230 participants; very low‐certainty evidence); or clinical worsening, assessed by participants with new need for invasive mechanical ventilation or death at day 28 (RR 0.82, 95% CI 0.33 to 2.04; 2 trials, 118 participants; very low‐certainty evidence); or serious adverse events during the trial period (RR 1.55, 95% CI 0.07 to 35.89; 2 trials, 197 participants; very low‐certainty evidence). Ivermectin plus standard of care compared to standard of care plus placebo may have little or no effect on clinical improvement, assessed by the number of participants discharged alive at day 28 (RR 1.03, 95% CI 0.78 to 1.35; 1 trial, 73 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.04, 95% CI 0.61 to 1.79; 3 trials, 228 participants; low‐certainty evidence); and on viral clearance at 7 days (RR 1.12, 95% CI 0.80 to 1.58; 3 trials, 231 participants; low‐certainty evidence). No trial investigated quality of life at any time point. Ivermectin for treating COVID‐19 in outpatient settings with asymptomatic or mild disease Ivermectin plus standard of care compared to standard of care plus/minus placebo probably has little or no effect on all‐cause mortality at day 28 (RR 0.77, 95% CI 0.47 to 1.25; 6 trials, 2860 participants; moderate‐certainty evidence) and little or no effect on quality of life, measured with the PROMIS Global‐10 scale (physical component mean difference (MD) 0.00, 95% CI ‐0.98 to 0.98; and mental component MD 0.00, 95% CI ‐1.08 to 1.08; 1358 participants; high‐certainty evidence). Ivermectin may have little or no effect on clinical worsening, assessed by admission to hospital or death within 28 days (RR 1.09, 95% CI 0.20 to 6.02; 2 trials, 590 participants; low‐certainty evidence); on clinical improvement, assessed by the number of participants with all initial symptoms resolved up to 14 days (RR 0.90, 95% CI 0.60 to 1.36; 2 trials, 478 participants; low‐certainty evidence); on serious adverse events (RR 2.27, 95% CI 0.62 to 8.31; 5 trials, 1502 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.24, 95% CI 0.87 to 1.76; 5 trials, 1502 participants; low‐certainty evidence); and on viral clearance at day 7 compared to placebo(RR 1.01, 95% CI 0.69 to 1.48; 2 trials, 331 participants; low‐certainty evidence). None of the trials reporting duration of symptoms were eligible for meta‐analysis. Authors' conclusions For outpatients, there is currently low‐ to high‐certainty evidence that ivermectin has no beneficial effect for people with COVID‐19. Based on the very low‐certainty evidence for inpatients, we are still uncertain whether ivermectin prevents death or clinical worsening or increases serious adverse events, while there is low‐certainty evidence that it has no beneficial effect regarding clinical improvement, viral clearance and adverse events. No evidence is available on ivermectin to prevent SARS‐CoV‐2 infection. In this update, certainty of evidence increased through higher quality trials including more participants. According to this review's living approach, we will continually update our search. Plain language summary Ivermectin for preventing and treating COVID‐19 Is ivermectin effective for COVID‐19? Key messages We found no evidence to support the use of ivermectin for treating COVID‐19 or preventing SARS‐CoV‐2 infection. The evidence base improved slightly in this update, but is still limited. Evaluation of ivermectin is continuing in 31 ongoing trials, and we will update this review again when their results become available. What is ivermectin? Ivermectin is a medicine used to treat parasites, such as intestinal parasites in animals, and scabies in humans. It is inexpensive and is widely used in regions of the world where parasitic infestations are common. It has few unwanted effects. Medical regulators have not approved ivermectin for COVID‐19. What did we want to find out? We wanted to update our knowledge of whether ivermectin reduces death, illness, and length of infection in people with COVID‐19, or is useful in prevention of the infection. We included trials comparing the medicine to placebo (dummy treatment), usual care, or treatments for COVID‐19 that are known to work to some extent, such as dexamethasone. We excluded trials comparing ivermectin to other medicines that do not work, like hydroxychloroquine, or whose effectiveness against COVID‐19 is uncertain. We evaluated the effects of ivermectin in infected people on: – people dying;
– whether people's COVID‐19 got better or worse;
– quality of life;
– serious and non‐serious unwanted effects;
– viral clearance. For prevention, we sought the effect on preventing SARS‐CoV‐2 infection and COVID‐19 disease. What did we do? We searched for randomized controlled trials that investigated ivermectin to prevent or treat COVID‐19. People treated in hospital or as outpatients had to have laboratory‐confirmed COVID‐19. In this update, we also investigated the trustworthiness of the trials and only included them if they fulfilled clear ethical and scientific criteria. We compared and summarized the results of the trials and rated our confidence in the evidence, based on common criteria such as trial methods and sizes. What did we find? We excluded seven of the 14 trials included in the previous review as these trials did not fulfil the expected ethical and scientific criteria. Together with four new trials, we included 11 trials with 3409 participants that investigated ivermectin combined with any usual care compared to the same usual care or placebo. For treatment, there were five trials of people in hospital with moderate COVID‐19 and six trials of outpatients with mild COVID‐19. The trials used different doses of ivermectin and different durations of treatment. No trial investigated ivermectin to prevent SARS‐CoV‐2 infection. We also found 31 ongoing trials, and an additional 28 trials still requiring clarification from the authors or not yet published. Main results Treating people in hospital with COVID‐19 We do not know whether ivermectin compared with placebo or usual care 28 days after treatment: – leads to more or fewer deaths (3 trials, 230 people); 
– worsens or improves patients' condition, assessed by need for ventilation or death (2 trials, 118 people);
– increases or reduces serious unwanted events (2 trials, 197 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – improving patients' condition, assessed by discharge from hospital (1 trial, 73 people);
– non‐serious unwanted events (3 trials, 228 participants). Seven days after treatment, ivermectin may make little or no difference to reduction of negative COVID‐19 tests (3 trials, 231 participants) compared with placebo or usual care. Treating outpatients with COVID‐19 Ivermectin compared with placebo or usual care 28 days after treatment, probably makes little or no difference to people dying (6 trials, 2860 people). Ivermectin compared with placebo or usual care 28 days after treatment, makes little or no difference to quality of life (1 trial, 1358 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – worsening patients' condition, assessed by admission to hospital or death (2 trials, 590 people);
– serious unwanted events (5 trials, 1502 people); 
– non‐serious unwanted events (5 trials, 1502 participants); 
– improving people's COVID‐19 symptoms in the 14 days after treatment (2 trials, 478 people);
– number of people with negative COVID‐19 tests 7 days after treatment (2 trials, 331 people). What are the limitations of the evidence? Our confidence in the evidence, especially for outpatients, improved since the last review version, because we could look at more participants included in high‐quality trials. Although we are quite certain regarding our results on risk of people dying and quality of life, the confidence in the evidence is still low for many other outpatient and inpatient outcomes because there were only few events measured. The methods differed between trials, and they did not report everything we were interested in, such as relevant outcomes. How up to date is this evidence? The systematic literature search is up to date to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Popp, M; Reis, S; Schießer, S; Hausinger, RIlona; Stegemann, M; Metzendorf, M-I; Kranke, P; Meybohm, P; Skoetz, N; Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015017.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "4f2d1937-1e9d-4932-b7d0-4e56f96eca8b", "pmid": "", "title": "Impacts of Sugar-Sweetened Beverage Consumption on Body Weight Regulation", "imported": false, "abstract": "The obesity epidemic is a major public health problem. Weight gain is strongly associated with an increase in the incidence of complex health conditions such as type 2 diabetes (T2D), cardiovascular disease, stroke, and cancers. Behaviours linked to food and beverage consumption can greatly affect body weight. Frequent consumption of sugar-sweetened beverages such as carbonated soft-drinks, energy and sport drinks, fruit juices from concentrate, soda and flavoured milk and water is considered to be an unhealthy dietary behaviour.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.235Z" }, { "id": "4f48ecfb-43c2-4bc7-aeac-bbe7978930c1", "pmid": "", "title": "Interventions for treating iron deficiency anaemia in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease affects approximately seven million people globally. Iron deficiency anaemia can occur as a common systemic manifestation, with a prevalence of up to 90%, which can significantly affect quality of life, both during periods of active disease or in remission. It is important that iron deficiency anaemia is treated effectively and not be assumed to be a normal finding of inflammatory bowel disease. The various routes of iron administration, doses and preparations present varying advantages and disadvantages, and a significant proportion of people experience adverse effects with current therapies. Currently, no consensus has been reached amongst physicians as to which treatment path is most beneficial. Objectives The primary objective was to evaluate the efficacy and safety of the interventions for the treatment of iron deficiency anaemia in people with inflammatory bowel disease. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 21st November 2019. We also contacted experts in the field and searched references of trials for any additional trials. Selection criteria Randomised controlled trials investigating the effectiveness and safety of iron administration interventions compared to other iron administration interventions or placebo in the treatment of iron deficiency anaemia in inflammatory bowel disease. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors. Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We expressed dichotomous and continuous outcomes as risk ratios and mean differences with 95% confidence intervals. We assessed the certainty of the evidence using the GRADE methodology. Main results We included 11 studies (1670 randomised participants) that met the inclusion criteria. The studies compared intravenous iron sucrose vs oral iron sulphate (2 studies); oral iron sulphate vs oral iron hydroxide polymaltose complex (1 study); oral iron fumarate vs intravenous iron sucrose (1 study); intravenous ferric carboxymaltose vs intravenous iron sucrose (1 study); erythropoietin injection + intravenous iron sucrose vs intravenous iron sucrose + injection placebo (1 study); oral ferric maltol vs oral placebo (1 study); oral ferric maltol vs intravenous ferric carboxymaltose (1 study); intravenous ferric carboxymaltose vs oral iron sulphate (1 study); intravenous iron isomaltoside vs oral iron sulphate (1 study); erythropoietin injection vs oral placebo (1 study). All studies compared participants with CD and UC together, as well as considering a range of disease activity states. The primary outcome of number of responders, when defined, was stated to be an increase in haemoglobin of 20 g/L in all but two studies in which an increase in 10g/L was used. In one study comparing intravenous ferric carboxymaltose and intravenous iron sucrose, moderate‐certainty evidence was found that intravenous ferric carboxymaltose was probably superior to intravenous iron sucrose, although there were responders in both groups (150/244 versus 118/239, RR 1.25, 95% CI 1.06 to 1.46, number needed to treat for an additional beneficial outcome (NNTB) = 9). In one study comparing oral ferric maltol to placebo, there was low‐certainty evidence of superiority of the iron (36/64 versus 0/64, RR 73.00, 95% CI 4.58 to 1164.36). There were no other direct comparisons that found any difference in the primary outcomes, although certainty was low and very low for all outcomes, due to imprecision from sparse data and risk of bias varying between moderate and high risk. The reporting of secondary outcomes was inconsistent. The most common was the occurrence of serious adverse events or those requiring withdrawal of therapy. In no comparisons was there a difference seen between any of the intervention agents being studied, although the certainty was very low for all comparisons made, due to risk of bias and significant imprecision due to the low numbers of events. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes were reported in any of the studies. An analysis of all intravenous iron preparations to all oral iron preparations showed that intravenous administration may lead to more responders (368/554 versus 205/373, RR 1.17, 95% CI 1.05 to 1.31, NNTB = 11, low‐certainty due to risk of bias and inconsistency). Withdrawals due to adverse events may be greater in oral iron preparations vs intravenous (15/554 versus 31/373, RR 0.39, 95% CI 0.20 to 0.74, low‐certainty due to risk of bias, inconsistency and imprecision). Authors' conclusions Intravenous ferric carboxymaltose probably leads to more people having resolution of IDA (iron deficiency anaemia) than intravenous iron sucrose. Oral ferric maltol may lead to more people having resolution of IDA than placebo. We are unable to draw conclusions on which of the other treatments is most effective in IDA with IBD (inflammatory bowel disease) due to low numbers of studies in each comparison area and clinical heterogeneity within the studies. Therefore, there are no other conclusions regarding the treatments that can be made and certainty of all findings are low or very low. Overall, intravenous iron delivery probably leads to greater response in patients compared with oral iron, with a NNTB (number needed to treat) of 11. Whilst no serious adverse events were specifically elicited with any of the treatments studied, the numbers of reported events were low and the certainty of these findings very low for all comparisons, so no conclusions can be drawn. There may be more withdrawals due to such events when oral is compared with intravenous iron delivery. Other outcomes were poorly reported and once again no conclusions can be made as to the impact of IDA on any of these outcomes. Given the widespread use of many of these treatments in practice and the only guideline that exists recommending the use of intravenous iron in favour of oral iron, research to investigate this key issue is clearly needed. Considering the current ongoing trials identified in this review, these are more focussed on the impact in specific patient groups (young people) or on other symptoms (such as fatigue). Therefore, there is a need for studies to be performed to fill this evidence gap. Plain language summary Therapies for treating iron deficiency anaemia in Crohn's disease and ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether treatments in people with Crohn's disease and ulcerative colitis can improve iron deficiency anaemia. We analysed data from 11 studies to answer this question. Key messages Iron in the form of ferric carboxymaltose given intravenously is probably better than iron sucrose given intravenously in improving iron deficiency anaemia, although people improved taking both treatments. Oral iron in the form of ferric maltol may be better than placebo (dummy treatment). It is unclear whether any of the other treatments considered are better than each other, however, there is limited evidence due to low numbers of studies and issues due to low quality of the reporting of the research studies. What was studied in the review? People with both ulcerative colitis and Crohn's disease both commonly suffer with low iron levels that in turn lowers their haemoglobin (blood) levels (this is called anaemia). This can lead to a number of symptoms, including tiredness and pain. Several treatments exist to treat iron deficiency anaemia, consisting of delivering extra iron either orally or intravenously (through a vein). An additional treatment, erythropoietin, was also studied which stimulates the body to produce more blood itself. Currently, no consensus has been reached amongst physicians as to which treatment is better. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing any treatment with another or dummy treatment. We found 11 RCTs looking at 1670 participants. The trials looked at adult participants, with none considering children. 1) Intravenous iron in the form of ferric carboxymaltose probably leads to more people having an improvement in iron deficiency anaemia than intravenous iron sucrose (one extra person would improve for every 9 treated and five out of 10 people would improve with either therapy). 2) Oral iron as ferric maltol may lead to more people having resolution of iron deficiency than dummy treatment. 3) It is unclear whether there is any difference between any of the other treatments studied for treating iron deficiency anaemia. 4) It is unclear whether any therapy leads to a difference in adverse events (minor or serious) when compared to any other therapy. Conclusion Iron delivered via a vein as ferric carboxymaltose probably improves anaemia in more people that iron sucrose via a vein, although both groups of people improved. Oral iron as ferric maltol may improve more patients than dummy treatment. No conclusions can be drawn on other treatments due to lack of evidence and quality issues with the studies that were found. Further research is needed, particularly to investigate whether iron delivered through a vein is better than iron delivered orally and also how much treating anaemia in people with IBD makes a difference in terms of the symptoms they may experience. How up‐to‐date is this review? This review is up‐to‐date as of November 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gordon, M; Sinopoulou, V; Iheozor-Ejiofor, Z; Iqbal, T; Allen, P; Hoque, S; Engineer, J; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013529.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "4f4b56c9-3f74-49e5-bfb2-5aefe9147f12", "pmid": "", "title": "Horticultural therapy for schizophrenia", "imported": false, "abstract": "Abstract - Background Horticultural therapy is defined as the process of utilising fruits, vegetables, flowers and plants facilitated by a trained therapist or healthcare provider, to achieve specific treatment goals or to simply improve a person's well‐being. It can be used for therapy or rehabilitation programs for cognitive, physical, social, emotional, and recreational benefits, thus improving the person's body, mind and spirit. Between 5% to 15% of people with schizophrenia continue to experience symptoms in spite of medication, and may also develop undesirable adverse effects, horticultural therapy may be of value for these people. Objectives To evaluate the effects of horticultural therapy for people with schizophrenia or schizophrenia‐like illnesses compared with standard care or other additional psychosocial interventions. Search methods We searched the Cochrane Schizophrenia Group Trials Register (Janurary 2013) and supplemented this by contacting relevant study authors, and manually searching reference lists. Selection criteria We included one randomised controlled trial (RCT) comparing horticultural therapy plus standard care with standard care alone for people with schizophrenia. Data collection and analysis We reliably selected, quality assessed and extracted data. For continuous outcomes, we calculated a mean difference (MD) and for binary outcomes we calculated risk ratio (RR), both with 95% confidence intervals (CI). We assessed risk of bias and created a 'Summary of findings' table using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. Main results We included one single blind study (total n = 24). The overall risk of bias in the study was considered to be unclear although the randomisation was adequate. It compared a package of horticultural therapy which consisted of one hour per day of horticultural activity plus standard care with standard care alone over two weeks (10 consecutive days) with no long‐term follow‐up. Only two people were lost to follow‐up in the study, both in the horticultural therapy group (1 RCT n = 24,RR 5.00 95% CI 0.27 to 94.34, very low quality evidence ). There was no clear evidence of a difference in Personal Wellbeing Index (PWI‐C) change scores between groups, however confidence intervals were wide (1 RCT n = 22, MD ‐0.90 95% CI ‐10.35 to 8.55, very low quality evidence ). At the end of treatment, the Depression Anxiety Stress Scale (DASS21) change scores in horticultural therapy group were greater than that in the control group (1 RCT n = 22, MD ‐23.70 CI ‐35.37 to ‐ 12.03, very low quality evidence). The only included study did not report on adverse effects of interventions. Authors' conclusions Based on the current very low quality data, there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. This therapy remains unproven and more and larger randomised trials are needed to increase high quality evidence in this area. Plain language summary Gardening activity as a therapy for schizophrenia Horticultural therapy is based on the therapeutic value of participating in garden activities such as growing fruit or vegetables and/or flowers. Gardening is thought to improve people's well‐being through being a recreational and sociable activity which may lead to improvements in people's thinking, new friendships and more positive emotions. The benefits of gardening can also apply to people with serious mental illness such as schizophrenia. Gardening reduces stress, which is important because stress can often lead to mental illness. Gardening is also hard work and a physical activity, and so motivates people with mental illness who often feel tired and apathetic. Weight gain is common for people with mental illness and gardening is good physical exercise. Since 5% to 15% of people with schizophrenia experience symptoms in spite of taking antipsychotic drugs and also because these drugs have debilitating side effects, horticultural therapy may be of value to these people. This review focuses on the effects of horticultural therapy for people with schizophrenia. An electronic search for relevant randomised trials was run in January 2013. Only one trial was included, it randomised a total of 24 people with schizophrenia to received either their standard care plus horticultural therapy or standard care only. The trial only lasted 2 weeks (10 consecutive days) with no long‐term follow‐up. There are few results and the quality of evidence was rated by the review authors to be very low quality. Some of the information from this one study favoured horticultural therapy but there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. More large, better conducted and reported trials are required to determine the effectiveness and benefits of horticultural therapy. This plain language summary has been written by a consumer Ben Gray, Service User and Service User Expert, Rethink Mental Illness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Liu, Y, Li, B, Sampson, SJ, Roberts, S, Zhang, G, Wu, W", "articleTypes": [], "doi": "10.1002/14651858.CD009413.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.745Z" }, { "id": "4f7ef4eb-7853-4ebe-bff1-5a80e30639b7", "pmid": "", "title": "Nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy", "imported": false, "abstract": "Abstract - Background Across the developed world, an estimated 150,000 to 300,000 people are treated annually with pelvic radiotherapy and 80% will develop gastrointestinal (GI) symptoms during treatment. Acute GI symptoms are associated with a greater risk of chronic, often debilitating, GI symptoms. Up to one‐third of patients are malnourished before pelvic radiotherapy and up to four‐fifths of patients lose weight during treatment. Malnutrition is linked to a higher risk of GI toxicity, which can lead to breaks in radiotherapy and early cessation of chemotherapy, thus compromising the efficacy of the primary cancer treatment. Objectives To assess the effects of nutritional interventions for reducing GI toxicity in adults undergoing radical pelvic radiotherapy. Search methods We searched the Cochrane Gynaecological Cancer Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 4, 2012, MEDLINE and EMBASE to May 2012. We handsearched the citation lists of included studies and previous systematic reviews identified to identify further relevant trials. Selection criteria We included studies if they were randomised controlled trials (RCTs) or non‐randomised studies with concurrent comparison groups including quasi‐randomised trials, cluster RCTs, non‐randomised trials, prospective and retrospective cohort studies, and case series of 30 or more patients. We only included studies if they assessed the effect of a nutritional intervention in adults aged 18 years or over undergoing radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic malignancy. We excluded patients with stomas and a previous history of inflammatory bowel disease. Nutritional support interventions could be provided at any stage before or during pelvic radiotherapy and included dietary counselling; dietary modification of fibre, lactose or fat; supplementary foods or drinks or fortified foods; standard oral nutrition supplements including polymeric‐, peptide‐ or amino acid‐based supplements and those where novel substrates have been added; enteral tube feeds; or parenteral nutrition (partial or total). We excluded probiotics, prebiotics and synbiotics. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors to obtain missing data. We assessed bias for each of the included studies using the bias assessment tables in the Cochrane software Review Manager5. We performed meta‐analysis, when indicated, using the Mantel‐Haenszel fixed‐effect method or inverse variance fixed‐effect method displayed with heterogeneity. We undertook meta‐analyses on trials evaluating dietary modification against standard treatment for diarrhoea at the end of radiotherapy and for change in weight from baseline to end of radiotherapy. Main results The searches identified 7558 titles, and we excluded 7513 during title and abstract searches. We reviewed 45 papers in full, and excluded 39. We identified four studies on handsearching of the references, which, along with the six eligible papers from the database search, led to 10 studies being included. Four studies, three of which were RCTs and one prospective study, investigated the effect of elemental diet on GI symptoms; one RCT investigated the effect of dietary modification and elemental diet; and five RCTs investigated dietary modification. Studies were varied in terms of risk of bias. Data were dichotomised for presence and absence of diarrhoea at the end of radiotherapy for four trials evaluating dietary modification comprising modified fat, lactose, fibre or combinations of these dietary changes. A reduction in diarrhoea was demonstrated with nutritional intervention (risk ratio (RR) 0.66; 95% confidence interval (CI) 0.51 to 0.87, four studies, 413 participants, moderate quality of evidence) with low heterogeneity (Chi 2 = 3.50, I 2 = 14%). Two trials evaluating dietary modification on weight change (comparing baseline and end of radiotherapy) showed no difference between intervention or control (mean difference (MD) ‐0.57 kg; 95% CI ‐1.22 to 0.09) with low heterogeneity (Chi 2 = 1.41, I 2 = 29%). Generally adverse effects were poorly reported in included studies. Elemental diet in particular was poorly tolerated. GI symptoms or toxicity > 6 months after radiotherapy was not reported in included studies Authors' conclusions There have been benefits demonstrated with dietary modification during pelvic radiotherapy to reduce diarrhoea. Those diets included single interventions or combinations of modified fat, lactose‐restriction, fat‐restriction and fibre supplementation. We were unable to meta‐analyse elemental diet, as data were not available. We considered some of the studies to be at high risk of bias. There have been recent advances in novel, more targeted radiotherapy techniques, such that the findings of older studies need to be interpreted with caution. In addition, there were problems with compliance and palatability with some of the interventions, particularly elemental diet, which limits its usefulness in clinical practice. Plain language summary Do nutritional interventions reduce gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy? Background Research has shown that nutrition and radiotherapy have effects on each other. People with malnutrition tend to get more bowel side effects during radiotherapy. It has also been shown that many people lose weight during radiotherapy due to the treatment side effects. These side effects can lead to some people needing gaps in their radiotherapy and sometimes they even need to stop it entirely. This can reduce the chance of cancer cure. This review looked at the literature for providing extra nourishment or changes in diet to patients before or during radiotherapy, to determine whether this is of benefit in terms of reducing bowel symptoms, improving nutritional status and quality of life. Study characteristics Searches of all relevant sources of medical information identified 7558 articles, and, after initial screening of all these articles, we selected 45 as being suitable for this review. On reading the summaries of these 45 trials, 10 were suitable to be included in this review. We included trials that looked at the effects of a nutritional intervention in adults aged 18 years or over having radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic cancer. We excluded patients with stomas and a previous history of inflammatory bowel disease. Key results Results showed that studies evaluating dietary changes, including changes in dietary fat, fibre and lactose, during radiotherapy reduced diarrhoea at the end of treatment. However, these dietary changes did not seem to improve patients' weights. Quality of the evidence While some changes to diet during radiotherapy may benefit patients by reducing diarrhoea, it is important to recognise that some of the studies reviewed were dated and there have been changes in radiotherapy technique since then that may give patients less diarrhoea anyway. In addition, many studies were of poor quality and, therefore, only a small number were able to be included in this review. Some interventions described, for example, having to take a liquid diet, were not acceptable as many patients found them difficult to tolerate and were unable to take them completely.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Henson, CC; Burden, S; Davidson, SE; Lal, S", "articleTypes": [], "doi": "10.1002/14651858.CD009896.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "4f918444-191c-4534-ab7b-ef3ff76e986d", "pmid": "", "title": "Oral antifungal medication for toenail onychomycosis", "imported": false, "abstract": "Abstract - Background Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence‐based choice for treatment. Objectives To assess the effects of oral antifungal treatments for toenail onychomycosis. Search methods We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies. Selection criteria RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years. We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high‐risk domain was 'blinding of personnel and participants'. We found high‐quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine‐treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate‐quality evidence). There was high‐quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu‐like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate‐quality evidence). Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low‐quality evidence). There is moderate‐quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate‐quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low‐quality evidence). Common adverse events in both groups included headache, viral infection, and nausea. Moderate‐quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate‐quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin‐treated participants) along with nausea and vomiting (in azole‐treated participants). Very low‐quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants). There is low‐quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low‐quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin‐treated participants) as well as taste loss and nausea (in terbinafine‐treated participants). No studies addressed recurrence rate for this comparison. No study addressed quality of life. Authors' conclusions We found high‐quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate‐quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate‐quality evidence). Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate‐quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low‐quality evidence). Only four comparisons assessed recurrence rate: low‐quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them. Only a limited number of studies reported adverse events, and the severity of the events was not taken into account. Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding. Plain language summary What is the best medication for a fungal infection of the toenail? Review question We aimed to find out which medications, taken by mouth for at least six weeks, are the most effective at curing fungal infection of the toenail, a condition that is known as onychomycosis, in people of any age. We compared these medications to each other or placebo (an inactive drug or treatment). Background Fungal infection of the toenails is a common condition, which has a low risk of complications and associated health risks. However, for those severely affected, it might affect normal daily activities. Medication taken by mouth appears to cure the condition more quickly and effectively than topical treatment. There are three main antifungal medications: griseofulvin, different medications in the azole group (itraconazole, fluconazole, albaconazole, posaconazole, ravuconazole), and terbinafine. We wanted to assess the following two main outcomes. 1. Does the nail look normal after treatment (clinical cure)?
 2. Is the nail free from fungus at a microscopic level (mycological cure)? Study characteristics We identified 48 studies with 10,200 participants of both sexes. The average age of the participants across studies ranged from 36 to 68; most studies included participants aged 18 and over. Our included studies compared the three main groups of medication against each other or to placebo. Most studies took place in outpatient dermatology settings in the USA and Europe. The participants mainly had fungal infection under the toenails. A small number of studies included a specific group of participants, such as those with diabetes. All but one study looked at fungal infections caused by dermatophyte, which are fungi that digest keratin. Study duration ranged from 4 months to 2 years, with most lasting 12 to 15 months. Key results The evidence is current to October 2016. We found high‐quality evidence that compared with placebo, both terbinafine and azoles are more effective for achieving a normal‐looking nail and curing the toenail infection (i.e. looking at the microscopic level to see if the fungus is gone). Terbinafine or azoles may also prevent the infection reoccurring more than placebo (low‐quality evidence). There was probably no significant difference in the risk of adverse events reported when comparing either azoles or terbinafine with placebo (moderate‐quality evidence). The most common adverse events amongst terbinafine‐treated and azole‐treated participants included stomach problems and headache. We found that compared to azoles, terbinafine was probably more effective in curing the nails in terms of appearance and infection (moderate‐quality evidence). The risk of side effects was probably the same for both treatments (moderate‐quality evidence), and the most common adverse events in both groups were headache, viral infection, and rash. There may be no difference in recurrence rate (low‐quality evidence). A third type of treatment, griseofulvin, was probably as effective as the azole medications in curing the nails in terms of appearance and infection (moderate‐quality evidence), but it may be less effective than terbinafine when assessing the same outcomes (low‐quality evidence). Griseofulvin caused more side effects than the other two treatments, although the quality of the evidence was moderate (compared to azole) to low (compared to terbinafine). The most common adverse events in both groups included stomach problems and feeling sick. We are uncertain about the effect of griseofulvin compared to azoles on the rate of recurrence, and studies comparing terbinafine and griseofulvin did not assess this outcome. Quality of the evidence The evidence for the primary outcomes of cure (in terms of appearance and infection) was high to moderate quality except for the comparisons of griseofulvin versus terbinafine (low quality) and combination terbinafine plus azole versus terbinafine alone (very low quality). The evidence quality for side effects was mainly moderate, but two comparisons had low evidence for this outcome. Not all comparisons measured recurrence rate, and the available evidence was based on low‐ to very low‐quality evidence. No studies reported on participants' quality of life. Many studies had problems in the study design: it was often unclear how they decided which participants would receive which treatment or ensured that participants weren't aware of the treatment allocation. Many studies also did not use a placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kreijkamp‐Kaspers, S; Hawke, K; Guo, L; Kerin, G; Bell‐Syer, SEM; Magin, P; Bell‐Syer, SV; van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD010031.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "4fa2dac0-06fb-43d5-8e28-1ee81d05242d", "pmid": "", "title": "Tobacco packaging design for reducing tobacco use", "imported": false, "abstract": "Abstract - Background Tobacco use is the largest single preventable cause of death and disease worldwide. Standardised tobacco packaging is an intervention intended to reduce the promotional appeal of packs and can be defined as packaging with a uniform colour (and in some cases shape and size) with no logos or branding, apart from health warnings and other government‐mandated information, and the brand name in a prescribed uniform font, colour and size. Australia was the first country to implement standardised tobacco packaging between October and December 2012, France implemented standardised tobacco packaging on 1 January 2017 and several other countries are implementing, or intending to implement, standardised tobacco packaging. Objectives To assess the effect of standardised tobacco packaging on tobacco use uptake, cessation and reduction. Search methods We searched MEDLINE, Embase, PsycINFO and six other databases from 1980 to January 2016. We checked bibliographies and contacted study authors to identify additional peer‐reviewed studies. Selection criteria Primary outcomes included changes in tobacco use prevalence incorporating tobacco use uptake, cessation, consumption and relapse prevention. Secondary outcomes covered intermediate outcomes that can be measured and are relevant to tobacco use uptake, cessation or reduction. We considered multiple study designs: randomised controlled trials, quasi‐experimental and experimental studies, observational cross‐sectional and cohort studies. The review focused on all populations and people of any age; to be included, studies had to be published in peer‐reviewed journals. We examined studies that assessed the impact of changes in tobacco packaging such as colour, design, size and type of health warnings on the packs in relation to branded packaging. In experiments, the control condition was branded tobacco packaging but could include variations of standardised packaging. Data collection and analysis Screening and data extraction followed standard Cochrane methods. We used different 'Risk of bias' domains for different study types. We have summarised findings narratively. Main results Fifty‐one studies met our inclusion criteria, involving approximately 800,000 participants. The studies included were diverse, including observational studies, between‐ and within‐participant experimental studies, cohort and cross‐sectional studies, and time‐series analyses. Few studies assessed behavioural outcomes in youth and non‐smokers. Five studies assessed the primary outcomes: one observational study assessed smoking prevalence among 700,000 participants until one year after standardised packaging in Australia; four studies assessed consumption in 9394 participants, including a series of Australian national cross‐sectional surveys of 8811 current smokers, in addition to three smaller studies. No studies assessed uptake, cessation, or relapse prevention. Two studies assessed quit attempts. Twenty studies examined other behavioural outcomes and 45 studies examined non‐behavioural outcomes (e.g. appeal, perceptions of harm). In line with the challenges inherent in evaluating standardised tobacco packaging, a number of methodological imitations were apparent in the included studies and overall we judged most studies to be at high or unclear risk of bias in at least one domain. The one included study assessing the impact of standardised tobacco packaging on smoking prevalence in Australia found a 3.7% reduction in odds when comparing before to after the packaging change, or a 0.5 percentage point drop in smoking prevalence, when adjusting for confounders. Confidence in this finding is limited, due to the nature of the evidence available, and is therefore rated low by GRADE standards. Findings were mixed amongst the four studies assessing consumption, with some studies finding no difference and some studies finding evidence of a decrease; certainty in this outcome was rated very low by GRADE standards due to the limitations in study design. One national study of Australian adult smoker cohorts (5441 participants) found that quit attempts increased from 20.2% prior to the introduction of standardised packaging to 26.6% one year post‐implementation. A second study of calls to quitlines provides indirect support for this finding, with a 78% increase observed in the number of calls after the implementation of standardised packaging. Here again, certainty is low. Studies of other behavioural outcomes found evidence of increased avoidance behaviours when using standardised packs, reduced demand for standardised packs and reduced craving. Evidence from studies measuring eye‐tracking showed increased visual attention to health warnings on standardised compared to branded packs. Corroborative evidence for the latter finding came from studies assessing non‐behavioural outcomes, which in general found greater warning salience when viewing standardised, than branded packs. There was mixed evidence for quitting cognitions, whereas findings with youth generally pointed towards standardised packs being less likely to motivate smoking initiation than branded packs. We found the most consistent evidence for appeal, with standardised packs rating lower than branded packs. Tobacco in standardised packs was also generally perceived as worse‐tasting and lower quality than tobacco in branded packs. Standardised packaging also appeared to reduce misperceptions that some cigarettes are less harmful than others, but only when dark colours were used for the uniform colour of the pack. Authors' conclusions The available evidence suggests that standardised packaging may reduce smoking prevalence. Only one country had implemented standardised packaging at the time of this review, so evidence comes from one large observational study that provides evidence for this effect. A reduction in smoking behaviour is supported by routinely collected data by the Australian government. Data on the effects of standardised packaging on non‐behavioural outcomes (e.g. appeal) are clearer and provide plausible mechanisms of effect consistent with the observed decline in prevalence. As standardised packaging is implemented in different countries, research programmes should be initiated to capture long term effects on tobacco use prevalence, behaviour, and uptake. We did not find any evidence suggesting standardised packaging may increase tobacco use. Plain language summary Can the use of standardised packaging for tobacco products reduce the use of tobacco? Background Tobacco use kills more people worldwide than any other preventable cause of death. The best way to reduce tobacco use is by stopping people from starting to use tobacco and encouraging and helping existing users to stop. This can be done by introducing policies that can reach a wide number of people in a country, together with offering individual treatment and support to individuals who are already using tobacco to help them to stop. Many countries have introduced bans on tobacco advertising but have not controlled the look of the tobacco pack itself. Tobacco packs can be colourful and attractive, with exciting new shapes and sizes. Standardised tobacco packaging is a government policy which removes these bright designs by, for example, only allowing tobacco packs to be in one colour, shape or size. Standardised packaging generally involves the use of the same uniform colour on all tobacco packs, with no brand imagery, and the brand name written in a specified font, colour and size. Health warnings and other information that governments wish to put on the packs can remain. Australia was the first country to introduce standardised tobacco packaging by December 2012. France was the second by January 2017. Several other countries are introducing standardised packaging or planning to do so. We examined whether standardised packaging reduces tobacco use. Study characteristics We searched nine databases for articles evaluating standardised packaging that had been already reviewed by academics and published before January 2016. We also checked references in those papers to other studies and contacted the authors where necessary. Key results We found 51 studies involving approximately 800,000 participants. These studies varied considerably. Some studies focused on the effect of standardised packaging in Australia, and included looking at overall smoking levels, whether smokers altered their behaviour such as by cutting down the number of cigarettes they smoked, and whether smokers were making more quit attempts. We also included experiments in which people used or viewed standardised tobacco packs and examined their responses, compared to when they were viewing branded packs. We also included studies that assessed people’s eye movements when they looked at different packs and how willing people were to buy, and how much they were willing to pay for, standardised compared to branded packs. Only five studies looked at our key outcomes. One study in Australia looked at data from 700,000 people before and after standardised packaging was introduced. This study found that there was a half a percentage point drop in the proportion of people who used tobacco after the introduction of standardised packaging, compared to before, when adjusting for other factors which could affect this. Four other studies looked at whether current smokers changed the number of cigarettes they smoked. Two studies from Australia looked at this, one using surveys which included 8811 current smokers, and found no change in the number of cigarettes smoked. The three smaller studies found mixed results. Two further studies looked at quit attempts and observed increases in these in Australia after standardised packaging was introduced. The remainder of the studies looked at other outcomes, and the most consistent finding was that standardised packaging reduced how appealing people found the packs compared with branded packs. No studies reported the number of people who quit using tobacco, the number of people who started using tobacco, or the number of people who returned to using tobacco after quitting. Quality of the evidence Certainty in these findings is limited for several reasons, including the difficulties involved in studying national policies like standardised packaging. However, findings suggesting standardised packaging may decrease tobacco use are supported by routine data from the Australian government and studies looking at other outcomes. For example, in our included studies people consistently found standardised packs less appealing than branded packs. We did not find any evidence suggesting standardised packaging may increase tobacco use.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "McNeill, A, Gravely, S, Hitchman, SC, Bauld, L, Hammond, D, Hartmann‐Boyce, J", "articleTypes": [], "doi": "10.1002/14651858.CD011244.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.061Z" }, { "id": "4faa18a9-7b06-44e3-aa14-5ab4f048e408", "pmid": "", "title": "Janus kinase inhibitors for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background With potential antiviral and anti‐inflammatory properties, Janus kinase (JAK) inhibitors represent a potential treatment for symptomatic severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. They may modulate the exuberant immune response to SARS‐CoV‐2 infection. Furthermore, a direct antiviral effect has been described. An understanding of the current evidence regarding the efficacy and safety of JAK inhibitors as a treatment for coronavirus disease 2019 (COVID‐19) is required. Objectives To assess the effects of systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo) on clinical outcomes in individuals (outpatient or in‐hospital) with any severity of COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising MEDLINE, Embase, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform, medRxiv, and Cochrane Central Register of Controlled Trials), Web of Science, WHO COVID‐19 Global literature on coronavirus disease, and the US Department of Veterans Affairs Evidence Synthesis Program (VA ESP) Covid‐19 Evidence Reviews to identify studies up to February 2022. We monitor newly published randomised controlled trials (RCTs) weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials from this source until the first week of April 2022. Selection criteria We included RCTs that compared systemic JAK inhibitors plus standard of care to standard of care alone (plus/minus placebo) for the treatment of individuals with COVID‐19. We used the WHO definitions of illness severity for COVID‐19. Data collection and analysis We assessed risk of bias of primary outcomes using Cochrane's Risk of Bias 2 (RoB 2) tool. We used GRADE to rate the certainty of evidence for the following primary outcomes: all‐cause mortality (up to day 28), all‐cause mortality (up to day 60), improvement in clinical status: alive and without need for in‐hospital medical care (up to day 28), worsening of clinical status: new need for invasive mechanical ventilation or death (up to day 28), adverse events (any grade), serious adverse events, secondary infections. Main results We included six RCTs with 11,145 participants investigating systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo). Standard of care followed local protocols and included the application of glucocorticoids (five studies reported their use in a range of 70% to 95% of their participants; one study restricted glucocorticoid use to non‐COVID‐19 specific indications), antibiotic agents, anticoagulants, and antiviral agents, as well as non‐pharmaceutical procedures. At study entry, about 65% of participants required low‐flow oxygen, about 23% required high‐flow oxygen or non‐invasive ventilation, about 8% did not need any respiratory support, and only about 4% were intubated. We also identified 13 ongoing studies, and 9 studies that are completed or terminated and where classification is pending. Individuals with moderate to severe disease Four studies investigated the single agent baricitinib (10,815 participants), one tofacitinib (289 participants), and one ruxolitinib (41 participants). Systemic JAK inhibitors probably decrease all‐cause mortality at up to day 28 (95 of 1000 participants in the intervention group versus 131 of 1000 participants in the control group; risk ratio (RR) 0.72, 95% confidence interval (CI) 0.57 to 0.91; 6 studies, 11,145 participants; moderate‐certainty evidence), and decrease all‐cause mortality at up to day 60 (125 of 1000 participants in the intervention group versus 181 of 1000 participants in the control group; RR 0.69, 95% CI 0.56 to 0.86; 2 studies, 1626 participants; high‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in improvement in clinical status (discharged alive or hospitalised, but no longer requiring ongoing medical care) (801 of 1000 participants in the intervention group versus 778 of 1000 participants in the control group; RR 1.03, 95% CI 1.00 to 1.06; 4 studies, 10,802 participants; moderate‐certainty evidence). They probably decrease the risk of worsening of clinical status (new need for invasive mechanical ventilation or death at day 28) (154 of 1000 participants in the intervention group versus 172 of 1000 participants in the control group; RR 0.90, 95% CI 0.82 to 0.98; 2 studies, 9417 participants; moderate‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in the rate of adverse events (any grade) (427 of 1000 participants in the intervention group versus 441 of 1000 participants in the control group; RR 0.97, 95% CI 0.88 to 1.08; 3 studies, 1885 participants; moderate‐certainty evidence), and probably decrease the occurrence of serious adverse events (160 of 1000 participants in the intervention group versus 202 of 1000 participants in the control group; RR 0.79, 95% CI 0.68 to 0.92; 4 studies, 2901 participants; moderate‐certainty evidence). JAK inhibitors may make little or no difference to the rate of secondary infection (111 of 1000 participants in the intervention group versus 113 of 1000 participants in the control group; RR 0.98, 95% CI 0.89 to 1.09; 4 studies, 10,041 participants; low‐certainty evidence). Subgroup analysis by severity of COVID‐19 disease or type of JAK inhibitor did not identify specific subgroups which benefit more or less from systemic JAK inhibitors. Individuals with asymptomatic or mild disease We did not identify any trial for this population. Authors' conclusions In hospitalised individuals with moderate to severe COVID‐19, moderate‐certainty evidence shows that systemic JAK inhibitors probably decrease all‐cause mortality. Baricitinib was the most often evaluated JAK inhibitor. Moderate‐certainty evidence suggests that they probably make little or no difference in improvement in clinical status. Moderate‐certainty evidence indicates that systemic JAK inhibitors probably decrease the risk of worsening of clinical status and make little or no difference in the rate of adverse events of any grade, whilst they probably decrease the occurrence of serious adverse events. Based on low‐certainty evidence, JAK inhibitors may make little or no difference in the rate of secondary infection. Subgroup analysis by severity of COVID‐19 or type of agent failed to identify specific subgroups which benefit more or less from systemic JAK inhibitors. Currently, there is no evidence on the efficacy and safety of systemic JAK inhibitors for individuals with asymptomatic or mild disease (non‐hospitalised individuals). Plain language summary Are systemic Janus kinase inhibitors an effective treatment for people with COVID‐19? Key messages We found moderate‐ to high‐certainty evidence from 6 studies to conclude that systemic Janus kinase (JAK) inhibitors are an effective treatment for coronavirus disease 2019 (COVID‐19) in hospitalised people, because they resulted in fewer deaths and a lower rate of clinical deterioration. Evaluation of systemic JAK inhibitors is ongoing in 13 studies whilst the results of 9 further studies are awaiting publication. We will update this review and may adapt our conclusions when their results become available. What are JAK inhibitors? JAK inhibitors are medicines that block the activity of certain parts of the immune system that are sometimes problematic. They are taken orally (systemic) and usually are taken by people who suffer from autoimmune diseases, where the immune system attacks the body itself. JAK inhibitors might also be administered by inhalation but since this was not our focus, we refer to 'systemic JAK inhibitors' throughout the review. How might JAK inhibitors treat COVID‐19? In COVID‐19, the immune system sometimes overreacts, which can lead to a severe course of disease. JAK inhibitors can block parts of the immune system and counteract any clinical deteriorations. What did we want to find out? We wanted to know whether systemic JAK inhibitors, in addition to usual care, are effective for people with COVID‐19 when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in:
• number of deaths from any cause up to 60 days after treatment, or longer if reported;
• whether people got better or worse after treatment, based on their need for breathing support;
• unwanted effects of the treatment and infections acquired in hospital. What did we do? We searched for studies that reported on people with COVID‐19 who received systemic JAK inhibitors together with usual care, or usual care alone (plus/minus placebo). We compared and summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We found 6 suitable studies involving 11,145 people with COVID‐19. All studies compared systemic JAK inhibitors (baricitinib in 4 studies, tofacitinib in 1 study and ruxolitinib in 1 study) to usual care (in addition to placebo), and were performed in hospitalised people. We did not find studies performed in outpatients. Most participants needed oxygen supplementation through low‐flow devices (7220 participants) and few (463 participants) were mechanically ventilated at the study entry. We also identified 13 ongoing studies and 9 studies that are completed/terminated but unpublished yet. Main results Systemic JAK inhibitors plus usual care compared to usual care alone probably lead to fewer deaths from all causes at up to day 28 and lead to fewer deaths from all causes up to day 60 in the studies. It was not possible to identify subgroups of participants (according to severity of illness) who might benefit most from treatment with JAK inhibitors. Systemic JAK inhibitors probably make little or no difference in improvement in clinical status. They probably decrease the risk of worsening of clinical status. Systemic JAK inhibitors probably make little or no difference in the rate of unwanted effects, and probably decrease slightly the occurrence of serious unwanted effects. Systemic JAK inhibitors may result in little or no difference in the rate of infections acquired in hospital. What are the limitations of the evidence? As current studies on systemic JAK inhibitors in outpatients are lacking, evidence is limited in this group of people with COVID‐19. Studies used different ways to assess and report unwanted effects, especially in regard to infections acquired in hospital. In accordance with the living approach of this review, we will continually update our search and include eligible trials to fill this evidence gap. How up to date is this evidence? The evidence is up to date to February 2022. We monitor newly published studies weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials identified from this source until the first week of April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kramer, A; Prinz, C; Fichtner, F; Fischer, A-L; Thieme, V; Grundeis, F; Spagl, M; Seeber, C; Piechotta, V; Metzendorf, M-I; Golinski, M; Moerer, O; Stephani, C; Mikolajewska, A; Kluge, S; Stegemann, M; Laudi, S; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015209", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "4fe6e01e-a35f-45ff-93ef-02dabadbdf63", "pmid": "", "title": "Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015. Objectives To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate. Selection criteria We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non‐serious, general behaviour, and quality of life. Data collection and analysis Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel‐group trials and first‐period data from cross‐over trials formed the basis of our primary analyses. We undertook separate analyses using end‐of‐last period data from cross‐over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach. Main results We included 212 trials (16,302 participants randomised); 55 parallel‐group trials (8104 participants randomised), and 156 cross‐over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross‐over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male‐female ratio was 3:1. Most trials were carried out in high‐income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias. Primary outcomes: methylphenidate versus placebo or no intervention may improve teacher‐rated ADHD symptoms (standardised mean difference (SMD) −0.74, 95% confidence interval (CI) −0.88 to −0.61; I² = 38%; 21 trials; 1728 participants; very low‐certainty evidence). This corresponds to a mean difference (MD) of −10.58 (95% CI −12.58 to −8.72) on the ADHD Rating Scale (ADHD‐RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD‐RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68). Secondary outcomes: methylphenidate may cause more adverse events considered non‐serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher‐rated general behaviour versus placebo (SMD −0.62, 95% CI −0.91 to −0.33; I² = 68%; 7 trials 792 participants; very low‐certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI −0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low‐certainty evidence). Authors' conclusions The majority of our conclusions from the 2015 version of this review still apply. Our updated meta‐analyses suggest that methylphenidate versus placebo or no‐intervention may improve teacher‐rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non‐serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non‐serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes. Plain language summary Is methylphenidate an effective treatment for children and adolescents with attention deficit hyperactivity disorder (ADHD) and does it cause unwanted effects? Key messages ‐ Methylphenidate might reduce hyperactivity and impulsivity and might help children to concentrate. Methylphenidate might also help to improve general behaviour, but does not seem to affect quality of life. ‐ Methylphenidate does not seem to increase the risk of serious (life‐threatening) unwanted effects when used for periods of up to six months. However, it is associated with an increased risk of non‐serious unwanted effects like sleeping problems and decreased appetite. ‐ Future studies should focus more on reporting unwanted effects and should take place over longer periods of time. What is attention deficit hyperactivity disorder (ADHD)? ADHD is one of the most commonly diagnosed and treated childhood psychiatric disorders. Children with ADHD find it hard to concentrate. They are often hyperactive (fidgety, unable to sit still for long periods) and impulsive (doing things without stopping to think). ADHD can make it difficult for children to do well at school, because they find it hard to follow instructions and to concentrate. Their behavioural problems can interfere with their ability to get on well with family and friends, and they often get into more trouble than other children. How is ADHD treated? Methylphenidate (for example, Ritalin) is the medication most often prescribed to children and adolescents with ADHD. Methylphenidate is a stimulant that helps to increase activity in parts of the brain, such as those involved with concentration. Methylphenidate can be taken as a tablet or given as a skin patch. It can be formulated to have an immediate effect, or be delivered slowly, over a period of hours. Methylphenidate may cause unwanted effects, such as headaches, stomachaches and problems sleeping. It sometimes causes serious unwanted effects like heart problems, hallucinations, or facial 'tics' (twitches). What did we want to find out? We wanted to find out if methylphenidate improves children's ADHD symptoms (attention, hyperactivity) based mainly on teachers' ratings using various scales, and whether it causes serious unwanted effects, like death, hospitalisation, or disability. We were also interested in less serious unwanted effects like sleep problems and loss of appetite, and its effects on children's general behaviour and quality of life. What did we do? We searched for studies that investigated the use of methylphenidate in children and adolescents with ADHD. Participants in the studies had to be aged 18 years or younger and have a diagnosis of ADHD. They could have other disorders or illnesses and be taking other medication or undergoing behavioural treatments. They had to have a normal IQ (intelligence quotient). Studies could compare methylphenidate with placebo (something designed to look and taste the same as methylphenidate but with no active ingredient) or no treatment. Participants had to be randomly chosen to receive methylphenidate or not. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 212 studies with 16,302 children or adolescents with ADHD. Most of the trials compared methylphenidate with placebo. Most studies were small with around 70 children, with an average age of 10 years (ages ranged from 3 to 18 years). Most studies were short, lasting an average of around a month; the shortest study lasted just one day and the longest 425 days. Most studies were in the USA. Based on teachers' ratings, compared with placebo or no treatment, methylphenidate: ‐ may improve ADHD symptoms (21 studies, 1728 children) ‐ may make no difference to serious unwanted effects (26 studies, 3673 participants) ‐ may cause more non‐serious unwanted effects (35 studies, 5342 participants) ‐ may improve general behaviour (7 trials 792 participants) ‐ may not affect quality of life (4 trials, 608 participants) Limitations of the evidence Our confidence in the results of the review is limited for several reasons. It was often possible for people in the studies to know which treatment the children were taking, which could influence the results. The reporting of the results was not complete in many studies and for some outcomes the results varied across studies. Studies were small and they used different scales for measuring symptoms. And most of the studies only lasted for a short period of time, making it impossible to assess the long‐term effects of methylphenidate. Around 41% of studies were funded or partly funded by the pharmaceutical industry. How up to date is this evidence? This is an update of a review conducted in 2015. The evidence is current to March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Storebø, OJ; Storm, MR; Pereira Ribeiro, J; Skoog, M; Groth, C; Callesen, HE; Schaug, JP; Darling, P; Huus, C-ML; Zwi, M; Kirubakaran, R; Simonsen, E; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD009885.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "500735df-f2b1-4842-a7c0-ded59e1e3e72", "pmid": "", "title": "Xylitol‐containing products for preventing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is a highly prevalent chronic disease which affects the majority of people. It has been postulated that the consumption of xylitol could help to prevent caries. The evidence on the effects of xylitol products is not clear and therefore it is important to summarise the available evidence to determine its effectiveness and safety. Objectives To assess the effects of different xylitol‐containing products for the prevention of dental caries in children and adults. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 14 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , 2014, Issue 7), MEDLINE via OVID (1946 to 14 August 2014), EMBASE via OVID (1980 to 14 August 2014), CINAHL via EBSCO (1980 to 14 August 2014), Web of Science Conference Proceedings (1990 to 14 August 2014), Proquest Dissertations and Theses (1861 to 14 August 2014). We searched the US National Institutes of Health Trials Register ( http://clinicaltrials.gov ) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference and 95% confidence interval (CI). We used the continuous data to calculate prevented fractions (PF) and 95% CIs to summarise the percentage reduction in caries. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. As there were less than four studies included in the meta‐analysis, we used a fixed‐effect model. We planned to use a random‐effects model in the event that there were four or more studies in a meta‐analysis. Main results We included 10 studies that analysed a total of 5903 participants. One study was assessed as being at low risk of bias, two were assessed as being at unclear risk of bias, with the remaining seven being at high risk of bias. The main finding of the review was that, over 2.5 to 3 years of use, a fluoride toothpaste containing 10% xylitol may reduce caries by 13% when compared to a fluoride‐only toothpaste (PF ‐0.13, 95% CI ‐0.18 to ‐0.08, 4216 children analysed, low‐quality evidence). The remaining evidence on children, from small single studies with risk of bias issues and great uncertainty associated with the effect estimates, was insufficient to determine a benefit from xylitol products. One study reported that xylitol syrup (8 g per day) reduced caries by 58% (95% CI 33% to 83%, 94 infants analysed, low quality evidence) when compared to a low‐dose xylitol syrup (2.67 g per day) consumed for 1 year. The following results had 95% CIs that were compatible with both a reduction and an increase in caries associated with xylitol: xylitol lozenges versus no treatment in children (very low quality body of evidence); xylitol sucking tablets versus no treatment in infants (very low quality body of evidence); xylitol tablets versus control (sorbitol) tablets in infants (very low quality body of evidence); xylitol wipes versus control wipes in infants (low quality body of evidence). There was only one study investigating the effects of xylitol lozenges, when compared to control lozenges, in adults (low quality body of evidence). The effect estimate had a 95% CI that was compatible with both a reduction and an increase in caries associated with xylitol. Four studies reported that there were no adverse effects from any of the interventions. Two studies reported similar rates of adverse effects between study arms. The remaining studies either mentioned adverse effects but did not report any usable data, or did not mention them at all. Adverse effects include sores in the mouth, cramps, bloating, constipation, flatulence, and loose stool or diarrhoea. Authors' conclusions We found some low quality evidence to suggest that fluoride toothpaste containing xylitol may be more effective than fluoride‐only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse‐effects from such toothpastes. The effect estimate should be interpreted with caution due to high risk of bias and the fact that it results from two studies that were carried out by the same authors in the same population. The remaining evidence we found is of low to very low quality and is insufficient to determine whether any other xylitol‐containing products can prevent caries in infants, older children, or adults. Plain language summary Can xylitol used in products like sweets, candy, chewing gum and toothpaste help prevent tooth decay in children and adults? Review question This review has been produced to assess whether or not xylitol, a natural sweetener used in products such as sweets, candy, chewing gum and toothpaste, can help prevent tooth decay in children and adults. Background Tooth decay is a common disease affecting up to 90% of children and most adults worldwide. It impacts on quality of life and can be the reason for thousands of children needing dental treatment under general anaesthetic in hospital. However, it can easily be prevented and treated by good oral health habits such as brushing teeth regularly with toothpaste that contains fluoride and cutting down on sugary food and drinks. If left undisturbed, the unhelpful bacteria in the mouth ‐ which cause decay ‐ multiply and stick to the surfaces of teeth producing a sticky film. Then, when sugar is eaten or drank, the bad bacteria in the film are able to make acid resulting in tooth decay. Xylitol is a natural sweetener, which is equally as sweet as normal sugar (sucrose). As well as providing an alternative to sugar, it has other properties that are thought to help prevent tooth decay, such as increasing the production of saliva and reducing the growth of bad bacteria in the mouth so that less acid is produced. In humans, xylitol is known to cause possible side effects such as bloating, wind and diarrhoea. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 14 August 2014. It includes 10 studies published from 1991 to 2014 in which 7969 participants were randomised (5903 of whom were included in the analyses) to receive xylitol products or a placebo (a substitute without xylitol) or no treatment, and the amount of tooth decay was compared. One study included adults, the others included children aged from 1 month to 13 years. The products tested were the kind that are held in the mouth and sucked (lozenges, sucking tablets and sweets) or slowly released through a dummy/pacifier, as well as toothpastes, syrups, and wipes. Key results There is some evidence to suggest that using a fluoride toothpaste containing xylitol may reduce tooth decay in the permanent teeth of children by 13% over a 3 year period when compared to a fluoride‐only toothpaste. Over this period, there were no side effects reported by the children. The remaining evidence we found did not allow us to conclude whether or not any other xylitol‐containing products can prevent tooth decay in infants, older children, or adults. Quality of the evidence The evidence presented is of low to very low quality due to the small amount of available studies, uncertain results, and issues with the way in which they were conducted.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P, Moore, D, Ahmed, F, Sharif, MO, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD010743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.798Z" }, { "id": "500aed4b-164b-47d8-99a9-b01973dcd919", "pmid": "", "title": "Manipulating Tobacco Constituents in Male Menthol Smokers", "imported": false, "abstract": "This study examines the potential effect of reducing nicotine content or menthol or both in men. It will also examine whether there are gender differences in manipulating tobacco flavors and nicotine concentrations in cigarettes on smoking behavior.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.264Z" }, { "id": "504d7421-2108-405e-8ae2-2c7518f6cab0", "pmid": "", "title": "Cannabinoids for fibromyalgia", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue affecting approximately 2% of the general population. People often report high disability levels and poor health‐related quality of life (HRQoL). Drug therapy focuses on reducing key symptoms and disability, and improving HRQoL. Cannabis has been used for millennia to reduce pain and other somatic and psychological symptoms. Objectives To assess the efficacy, tolerability and safety of cannabinoids for fibromyalgia symptoms in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE to April 2016, together with reference lists of retrieved papers and reviews, three clinical trial registries, and contact with trial authors. Selection criteria We selected randomised controlled trials of at least four weeks' duration of any formulation of cannabis products used for the treatment of adults with fibromyalgia. Data collection and analysis Two review authors independently extracted the data of all included studies and assessed risk of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs; at least 200 participants in the comparison, eight to 12 weeks' duration, parallel design), second tier evidence from data that did not meet one or more of these criteria and were considered at some risk of bias but with adequate numbers (i.e. data from at least 200 participants) in the comparison, and third tier evidence from data involving small numbers of participants that were considered very likely to be biased or used outcomes of limited clinical utility, or both. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Main results We included two studies with 72 participants. Overall, the two studies were at moderate risk of bias. The evidence was derived from group mean data and completer analysis (very low quality evidence overall). We rated the quality of all outcomes according to GRADE as very low due to indirectness, imprecision and potential reporting bias. The primary outcomes in our review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Nabilone was compared to placebo and to amitriptyline in one study each. Study sizes were 32 and 40 participants. One study used a cross‐over design and one used a parallel group design; study duration was four or six weeks. Both studies used nabilone, a synthetic cannabinoid, with a bedtime dosage of 1 mg/day. No study reported the proportion of participants experiencing at least 30% or 50% pain relief or who were very much improved. No study provided first or second tier (high to moderate quality) evidence for an outcome of efficacy, tolerability and safety. Third tier (very low quality) evidence indicated greater reduction of pain and limitations of HRQoL compared to placebo in one study. There were no significant differences to placebo noted for fatigue and depression (very low quality evidence). Third tier evidence indicated better effects of nabilone on sleep than amitriptyline (very low quality evidence). There were no significant differences between the two drugs noted for pain, mood and HRQoL (very low quality evidence). More participants dropped out due to adverse events in the nabilone groups (4/52 participants) than in the control groups (1/20 in placebo and 0/32 in amitriptyline group). The most frequent adverse events were dizziness, nausea, dry mouth and drowsiness (six participants with nabilone). Neither study reported serious adverse events during the period of both studies. We planned to create a GRADE 'Summary of findings' table, but due to the scarcity of data we were unable to do this. We found no relevant study with herbal cannabis, plant‐based cannabinoids or synthetic cannabinoids other than nabilone in fibromyalgia. Authors' conclusions We found no convincing, unbiased, high quality evidence suggesting that nabilone is of value in treating people with fibromyalgia. The tolerability of nabilone was low in people with fibromyalgia. Plain language summary Cannabis products for people with fibromyalgia Background Fibromyalgia is characterised by chronic (longer than three months) widespread pain that often co‐exists with sleep problems, problems with thinking and fatigue (exhaustion). People often report severe limitations of daily functioning and poor health‐related quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. Cannabis has been used for 3000 years to reduce pain and other symptoms, such as loss of appetite and anxiety. Key results and quality of the evidence In April 2016 we searched for reports of clinical trials that used cannabis products to treat symptoms in adults with fibromyalgia. We found two small, moderate quality studies, of four and six weeks long, including 72 participants. Both studies tested nabilone, a synthetic (man‐made) cannabis product, comparing it with placebo (a dummy pill) or amitriptyline (an antidepressant frequently used in the treatment of fibromyalgia). Nabilone did not convincingly relieve fibromyalgia symptoms (pain, sleep, fatigue) better than placebo or amitriptyline (very low quality evidence). Compared with placebo and amitriptyline, more people experienced side effects and left the study due to side effects (very low quality evidence). There were no serious side effects reported. We found no relevant study with herbal cannabis, plant‐based cannabinoids or other synthetic cannabinoids than nabilone in fibromyalgia. There was not enough high quality evidence available to draw any robust conclusions. We found no studies on medical cannabis in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B; Klose, P; Fitzcharles, M-A; Phillips, T; Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "50560878-0c6a-44d3-8167-ef95066f5a57", "pmid": "", "title": "Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega‐3 PUFA and plant oils in omega‐6 PUFA. Evidence suggests that increasing PUFA‐rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear. Objectives To assess effects of increasing total PUFA intake on cardiovascular disease and all‐cause mortality, lipids and adiposity in adults. Search methods We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all‐cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions. Data collection and analysis Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta‐analyses used random‐effects analysis, sensitivity analyses included fixed‐effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence. Main results We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA. Increasing PUFA intake probably has little or no effect on all‐cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate‐quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) and stroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low‐quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality. Increasing PUFA intake probably slightly decreases triglycerides (by 15%, MD ‐0.12 mmol/L, 95% CI ‐0.20 to ‐0.04, 20 trials, 3905 participants), but has little or no effect on total cholesterol (mean difference (MD) ‐0.12 mmol/L, 95% CI ‐0.23 to ‐0.02, 26 trials, 8072 participants), high‐density lipoprotein (HDL) (MD ‐0.01 mmol/L, 95% CI ‐0.02 to 0.01, 18 trials, 4674 participants) or low‐density lipoprotein (LDL) (MD ‐0.01 mmol/L, 95% CI ‐0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably has little or no effect on adiposity (body weight MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants). Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality. Authors' conclusions This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all‐cause or cardiovascular disease mortality. The mechanism may be via TG reduction. Plain language summary Polyunsaturated fatty acids for prevention and treatment of diseases of the heart and circulation Review question We reviewed randomised trials (participants have an equal chance to be assigned to either treatment) examining effects of increasing intake of polyunsaturated fatty acids (PUFA) on deaths and diseases of the heart and circulation (cardiovascular diseases), including heart attacks and stroke. Background We eat PUFA in our usual food, but quantities of PUFA eaten vary. There is some evidence that increasing the amount of PUFA we eat can reduce our blood cholesterol and make us less likely to develop cardiovascular disease, particularly if PUFAs are eaten instead of saturated fats (fats from animal sources such as meat and cheese). But eating more PUFA may increase our body weight, and omega‐6 fats (one component of PUFA) may worsen cardiovascular risk by increasing inflammation. Evidence on the benefits or harms of increasing PUFA intake on diseases of the heart and circulation, or on other health outcomes, is inconclusive. Trial characteristics Evidence in this Cochrane Review is current to 27 April 2017. We included 49 trials randomising 24,272 participants, for one to eight years. These trials assessed effects of eating more, compared to less PUFA, on diseases of the heart and circulation, and deaths. Twelve trials were very trustworthy (had low risk of bias overall). Participants were men and women, some with existing illnesses and some not. Trials took place in North America, Asia, Europe and Australia, and sixteen were funded only by national or charitable agencies. Key results Increasing PUFA probably makes little or no difference (neither benefit nor harm) to our risk of death (moderate‐quality evidence), and may make little or no difference to our risk of dying from cardiovascular disease (low‐quality evidence). However, increasing PUFA probably slightly reduces our risk of heart disease events and of combined heart and stroke events (moderate‐quality evidence). Fifty three people would need to eat more PUFA to prevent one person experiencing a heart disease event, and 63 people to prevent one person experiencing a heart or stroke event. Increasing PUFA may very slightly reduce risk of death due to heart disease, as well as stroke, but harm is possible (low‐quality evidence). PUFA probably slightly reduces fats circulating in the blood (triglycerides, moderate‐quality evidence but without effects on other lipids or adiposity). The evidence mainly comes from dietary‐advice trials of men living in high‐income countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abdelhamid, AS; Martin, N; Bridges, C; Brainard, JS; Wang, X; Brown, TJ; Hanson, S; Jimoh, OF; Ajabnoor, SM; Deane, KHO; Song, F; Hooper, L", "articleTypes": [], "doi": "10.1002/14651858.CD012345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "505976c7-b1b0-436b-bb9d-a3f0ec7ded94", "pmid": "", "title": "Short‐course oral steroids alone for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of oral corticosteroids compared with placebo/no intervention or other pharmacological interventions (intranasal corticosteroids, antibiotics, antifungals) for chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids with placebo or no treatment or compared with other pharmacological interventions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included eight RCTs (474 randomised participants), which compared oral corticosteroids with placebo or no intervention. All trials only recruited adults with chronic rhinosinusitis with nasal polyps. All trials reported outcomes at two to three weeks, at the end of the short‐course oral steroid treatment period. Three trials additionally reported outcomes at three to six months. Two of these studies prescribed intranasal steroids to patients in both arms of the trial at the end of the oral steroid treatment period. Oral steroids versus placebo or no intervention Disease‐specific health‐related quality of life was reported by one study. This study reported improved quality of life after treatment (two to three weeks) in the group receiving oral steroids compared with the group who received placebo (standardised mean difference (SMD) ‐1.24, 95% confidence interval (CI) ‐1.92 to ‐0.56, 40 participants, modified RSOM‐31), which corresponds to a large effect size. We assessed the evidence to be low quality (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). Disease severity as measured by patient‐reported symptom scores was reported by two studies, which allowed the four key symptoms used to define chronic rhinosinusitis (nasal blockage, nasal discharge, facial pressure, hyposmia) to be combined into one score. The results at the end of treatment (two to three weeks) showed an improvement in patients receiving oral steroids compared to placebo, both when presented as a mean final value (SMD ‐2.84, 95% CI ‐4.09 to ‐1.59, 22 participants) and as a change from baseline (SMD ‐2.28, 95% CI ‐2.76 to ‐1.80, 114 participants). These correspond to large effect sizes but we assessed the evidence to be low quality. One study (114 participants) followed patients for 10 weeks after the two‐week treatment period. All patients in both arms received intranasal steroids at the end of the oral steroid treatment period. The results showed that the initial results after treatment were not sustained (SMD ‐0.22, 95% CI ‐0.59 to 0.15, 114 participants, percentage improvement from baseline). This corresponds to a small effect size and we assessed the evidence to be low quality. There was an increase in adverse events in people receiving orals steroids compared with placebo for gastrointestinal disturbances (risk ratio (RR) 3.45, 95% CI 1.11 to 10.78; 187 participants; three studies) and insomnia (RR 3.63, 95% CI 1.10 to 11.95; 187 participants; three studies). There was no significant impact of oral steroids on mood disturbances at the dosage used in the included study (risk ratio (RR) 2.50, 95% CI 0.55 to 11.41; 40 participants; one study). We assessed the evidence to be low quality due to the lack of definitions of the adverse events and the small number of events or sample size, or both). Other comparisons No studies that compared short‐course oral steroids with other treatment for chronic rhinosinusitis met the inclusion criteria. Authors' conclusions At the end of the treatment course (two to three weeks) there is an improvement in health‐related quality of life and symptom severity in patients with chronic rhinosinusitis with nasal polyps taking oral corticosteroids compared with placebo or no treatment. The quality of the evidence supporting this finding is low. At three to six months after the end of the oral steroid treatment period, there is little or no improvement in health‐related quality of life or symptom severity for patients taking an initial course of oral steroids compared with placebo or no treatment. The data on the adverse effects associated with short courses of oral corticosteroids indicate that there may be an increase in insomnia and gastrointestinal disturbances but it is not clear whether there is an increase in mood disturbances. All of the adverse events results are based on low quality evidence. More research in this area, particularly research evaluating patients with chronic rhinosinusitis without nasal polyps, longer‐term outcomes and adverse effects, is required. There is no evidence for oral steroids compared with other treatments. Plain language summary Short‐term oral corticosteroids compared with no treatment or other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of a short course (typically up to 21 days) of corticosteroid given by mouth to people with chronic rhinosinusitis compared with giving a placebo or no treatment, or another type of treatment. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling the inflammatory response and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included eight randomised controlled trials with a total of 474 participants. All of the patients were adults who had chronic rhinosinusitis with nasal polyps. All of the studies followed patients until the end of treatment (two to three weeks) and three studies (210 participants) followed up people for three to six months after the initial treatment had ended. Five of the eight reports mentioned how the trial was funded. None of the funding sources were pharmaceutical companies. Key results At the end of a two‐ or three‐week treatment course, people who took oral steroids may have had a better quality of life, less severe symptoms and smaller nasal polyps than people who had placebo or did not receive any treatment. After three to six months, there was little or no difference in quality of life, symptom severity or nasal polyps between the people who had oral steroids and the people who had placebo or no intervention. The people who took oral steroids may have had more gastrointestinal disturbances and insomnia than the people who had placebo or no intervention. It is not clear if the people who took oral steroids had more mood disturbances than the people who had placebo or no intervention. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate), as the some of the results are only from one or two studies, which do not have a lot of participants. Most of the trials do not have a high risk of bias, but only people with nasal polyps were included in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K; Chong, LY; Hopkins, C; Philpott, C; Burton, MJ; Schilder, AGM", "articleTypes": [], "doi": "10.1002/14651858.CD011991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "50661c33-e8f0-4b4c-931b-850cf0eda719", "pmid": "", "title": "Omega‐3 fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids from oily fish (long‐chain omega‐3 (LCn3)), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha‐linolenic acid (ALA)) may benefit cardiovascular health. Guidelines recommend increasing omega‐3‐rich foods, and sometimes supplementation, but recent trials have not confirmed this. Objectives To assess the effects of increased intake of fish‐ and plant‐based omega‐3 fats for all‐cause mortality, cardiovascular events, adiposity and lipids. Search methods We searched CENTRAL, MEDLINE and Embase to February 2019, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to August 2019, with no language restrictions. We handsearched systematic review references and bibliographies and contacted trial authors. Selection criteria We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation or advice to increase LCn3 or ALA intake, or both, versus usual or lower intake. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed validity. We performed separate random‐effects meta‐analysis for ALA and LCn3 interventions, and assessed dose‐response relationships through meta‐regression. Main results We included 86 RCTs (162,796 participants) in this review update and found that 28 were at low summary risk of bias. Trials were of 12 to 88 months' duration and included adults at varying cardiovascular risk, mainly in high‐income countries. Most trials assessed LCn3 supplementation with capsules, but some used LCn3‐ or ALA‐rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5 g a day to more than 5 g a day (19 RCTs gave at least 3 g LCn3 daily). Meta‐analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all‐cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.93 to 1.01; 143,693 participants; 11,297 deaths in 45 RCTs; high‐certainty evidence), cardiovascular mortality (RR 0.92, 95% CI 0.86 to 0.99; 117,837 participants; 5658 deaths in 29 RCTs; moderate‐certainty evidence), cardiovascular events (RR 0.96, 95% CI 0.92 to 1.01; 140,482 participants; 17,619 people experienced events in 43 RCTs; high‐certainty evidence), stroke (RR 1.02, 95% CI 0.94 to 1.12; 138,888 participants; 2850 strokes in 31 RCTs; moderate‐certainty evidence) or arrhythmia (RR 0.99, 95% CI 0.92 to 1.06; 77,990 participants; 4586 people experienced arrhythmia in 30 RCTs; low‐certainty evidence). Increasing LCn3 may slightly reduce coronary heart disease mortality (number needed to treat for an additional beneficial outcome (NNTB) 334 , RR 0.90, 95% CI 0.81 to 1.00; 127,378 participants; 3598 coronary heart disease deaths in 24 RCTs, low‐certainty evidence) and coronary heart disease events ( NNTB 167 , RR 0.91, 95% CI 0.85 to 0.97; 134,116 participants; 8791 people experienced coronary heart disease events in 32 RCTs, low‐certainty evidence). Overall, effects did not differ by trial duration or LCn3 dose in pre‐planned subgrouping or meta‐regression. There is little evidence of effects of eating fish. Increasing ALA intake probably makes little or no difference to all‐cause mortality (RR 1.01, 95% CI 0.84 to 1.20; 19,327 participants; 459 deaths in 5 RCTs, moderate‐certainty evidence), cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25; 18,619 participants; 219 cardiovascular deaths in 4 RCTs; moderate‐certainty evidence), coronary heart disease mortality (RR 0.95, 95% CI 0.72 to 1.26; 18,353 participants; 193 coronary heart disease deaths in 3 RCTs; moderate‐certainty evidence) and coronary heart disease events (RR 1.00, 95% CI 0.82 to 1.22; 19,061 participants; 397 coronary heart disease events in 4 RCTs; low‐certainty evidence). However, increased ALA may slightly reduce risk of cardiovascular disease events ( NNTB 500 , RR 0.95, 95% CI 0.83 to 1.07; but RR 0.91, 95% CI 0.79 to 1.04 in RCTs at low summary risk of bias; 19,327 participants; 884 cardiovascular disease events in 5 RCTs; low‐certainty evidence), and probably slightly reduces risk of arrhythmia ( NNTB 91 , RR 0.73, 95% CI 0.55 to 0.97; 4912 participants; 173 events in 2 RCTs; moderate‐certainty evidence). Effects on stroke are unclear . Increasing LCn3 and ALA had little or no effect on serious adverse events, adiposity, lipids and blood pressure, except increasing LCn3 reduced triglycerides by ˜15% in a dose‐dependent way (high‐certainty evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐3 fats on cardiovascular health to date. Moderate‐ and low‐certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials). Increasing ALA slightly reduces risk of cardiovascular events and arrhythmia. Plain language summary Omega‐3 intake for cardiovascular disease Review question We reviewed randomised trials (where participants have an equal chance of being assigned to either treatment) examining effects of increasing fish‐ and plant‐based omega‐3 fats on heart and circulatory disease (called cardiovascular diseases, which include heart attacks and stroke), fatness and blood fats (lipids, including cholesterol, triglycerides, high‐density lipoprotein (HDL – 'good' cholesterol) and low‐density lipoprotein (LDL – 'bad' cholesterol)). Background The main types of omega‐3 fats are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), both found in fish, and alpha‐linolenic acid (ALA) found in plant foods. Many people believe that taking omega‐3 supplements reduces risk of heart disease, stroke and death. Trial characteristics The evidence is current to February 2019. The review included 86 trials involving 162,796 people. These trials assessed effects of greater omega‐3 intake versus lower omega‐3 intake for at least a year on heart and circulatory disease. Twenty‐eight trials were very trustworthy (well‐designed so as not to give biased results). Participants were adults, some with existing illness and some healthy, living in North America, Europe, Australia and Asia. Most EPA and DHA trials provided capsules, few gave oily fish. Key results Increasing EPA and DHA has little or no effect on deaths and cardiovascular events (high‐certainty evidence) and probably makes little or no difference to cardiovascular death, stroke, or heart irregularities (moderate‐certainty evidence). However, increasing EPA and DHA may slightly reduce risk of coronary death and coronary events (low‐certainty evidence, coronary events are illnesses of arteries supplying the heart). To prevent one person having a coronary event, 167 people would need to increase their EPA and DHA, and 334 people would need to increase their EPA and DHA to prevent one person dying from coronary disease. EPA and DHA reduce triglycerides by about 15% but do not affect fatness or other lipids (high‐certainty evidence). Eating more ALA (for example, by increasing walnuts or enriched margarine) probably makes little or no difference to all‐cause, cardiovascular or coronary deaths or coronary events but probably slightly reduces cardiovascular events and heart irregularities (moderate‐ or low‐certainty evidence). To prevent one person having a coronary event, 500 people would need to increase their ALA, 91 people to prevent one person having arrhythmia. There is little evidence of effects of eating fish. EPA and DHA reduce triglycerides. EPA, DHA and ALA may be slightly protective of some heart and circulatory diseases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Abdelhamid, AS; Brown, TJ; Brainard, JS; Biswas, P; Thorpe, GC; Moore, HJ; Deane, KHO; Summerbell, CD; Worthington, HV; Song, F; Hooper, L", "articleTypes": [], "doi": "10.1002/14651858.CD003177.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "50715ffa-c797-49c4-892b-3e4a373b1c65", "pmid": "", "title": "Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight", "imported": false, "abstract": "Abstract - Background The global prevalence of childhood and adolescent obesity is high. Lifestyle changes towards a healthy diet, increased physical activity and reduced sedentary activities are recommended to prevent and treat obesity. Evidence suggests that changing these health behaviours can benefit cognitive function and school achievement in children and adolescents in general. There are various theoretical mechanisms that suggest that children and adolescents with excessive body fat may benefit particularly from these interventions. Objectives To assess whether lifestyle interventions (in the areas of diet, physical activity, sedentary behaviour and behavioural therapy) improve school achievement, cognitive function (e.g. executive functions) and/or future success in children and adolescents with obesity or overweight, compared with standard care, waiting‐list control, no treatment, or an attention placebo control group. Search methods In February 2017, we searched CENTRAL, MEDLINE and 15 other databases. We also searched two trials registries, reference lists, and handsearched one journal from inception. We also contacted researchers in the field to obtain unpublished data. Selection criteria We included randomised and quasi‐randomised controlled trials (RCTs) of behavioural interventions for weight management in children and adolescents with obesity or overweight. We excluded studies in children and adolescents with medical conditions known to affect weight status, school achievement and cognitive function. We also excluded self‐ and parent‐reported outcomes. Data collection and analysis Four review authors independently selected studies for inclusion. Two review authors extracted data, assessed quality and risks of bias, and evaluated the quality of the evidence using the GRADE approach. We contacted study authors to obtain additional information. We used standard methodological procedures expected by Cochrane. Where the same outcome was assessed across different intervention types, we reported standardised effect sizes for findings from single‐study and multiple‐study analyses to allow comparison of intervention effects across intervention types. To ease interpretation of the effect size, we also reported the mean difference of effect sizes for single‐study outcomes. Main results We included 18 studies (59 records) of 2384 children and adolescents with obesity or overweight. Eight studies delivered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies delivered dietary interventions. We included five RCTs and 13 cluster‐RCTs. The studies took place in 10 different countries. Two were carried out in children attending preschool, 11 were conducted in primary/elementary school‐aged children, four studies were aimed at adolescents attending secondary/high school and one study included primary/elementary and secondary/high school‐aged children. The number of studies included for each outcome was low, with up to only three studies per outcome. The quality of evidence ranged from high to very low and 17 studies had a high risk of bias for at least one item. None of the studies reported data on additional educational support needs and adverse events. Compared to standard practice, analyses of physical activity‐only interventions suggested high‐quality evidence for improved mean cognitive executive function scores. The mean difference (MD) was 5.00 scale points higher in an after‐school exercise group compared to standard practice (95% confidence interval (CI) 0.68 to 9.32; scale mean 100, standard deviation 15; 116 children, 1 study). There was no statistically significant beneficial effect in favour of the intervention for mathematics, reading, or inhibition control. The standardised mean difference (SMD) for mathematics was 0.49 (95% CI ‐0.04 to 1.01; 2 studies, 255 children, moderate‐quality evidence) and for reading was 0.10 (95% CI ‐0.30 to 0.49; 2 studies, 308 children, moderate‐quality evidence). The MD for inhibition control was ‐1.55 scale points (95% CI ‐5.85 to 2.75; scale range 0 to 100; SMD ‐0.15, 95% CI ‐0.58 to 0.28; 1 study, 84 children, very low‐quality evidence). No data were available for average achievement across subjects taught at school. There was no evidence of a beneficial effect of physical activity interventions combined with healthy lifestyle education on average achievement across subjects taught at school, mathematics achievement, reading achievement or inhibition control. The MD for average achievement across subjects taught at school was 6.37 points lower in the intervention group compared to standard practice (95% CI ‐36.83 to 24.09; scale mean 500, scale SD 70; SMD ‐0.18, 95% CI ‐0.93 to 0.58; 1 study, 31 children, low‐quality evidence). The effect estimate for mathematics achievement was SMD 0.02 (95% CI ‐0.19 to 0.22; 3 studies, 384 children, very low‐quality evidence), for reading achievement SMD 0.00 (95% CI ‐0.24 to 0.24; 2 studies, 284 children, low‐quality evidence), and for inhibition control SMD ‐0.67 (95% CI ‐1.50 to 0.16; 2 studies, 110 children, very low‐quality evidence). No data were available for the effect of combined physical activity and healthy lifestyle education on cognitive executive functions. There was a moderate difference in the average achievement across subjects taught at school favouring interventions targeting the improvement of the school food environment compared to standard practice in adolescents with obesity (SMD 0.46, 95% CI 0.25 to 0.66; 2 studies, 382 adolescents, low‐quality evidence), but not with overweight. Replacing packed school lunch with a nutrient‐rich diet in addition to nutrition education did not improve mathematics (MD ‐2.18, 95% CI ‐5.83 to 1.47; scale range 0 to 69; SMD ‐0.26, 95% CI ‐0.72 to 0.20; 1 study, 76 children, low‐quality evidence) and reading achievement (MD 1.17, 95% CI ‐4.40 to 6.73; scale range 0 to 108; SMD 0.13, 95% CI ‐0.35 to 0.61; 1 study, 67 children, low‐quality evidence). Authors' conclusions Despite the large number of childhood and adolescent obesity treatment trials, we were only able to partially assess the impact of obesity treatment interventions on school achievement and cognitive abilities. School and community‐based physical activity interventions as part of an obesity prevention or treatment programme can benefit executive functions of children with obesity or overweight specifically. Similarly, school‐based dietary interventions may benefit general school achievement in children with obesity. These findings might assist health and education practitioners to make decisions related to promoting physical activity and healthy eating in schools. Future obesity treatment and prevention studies in clinical, school and community settings should consider assessing academic and cognitive as well as physical outcomes. Plain language summary Healthy weight interventions for improving thinking skills and school performance in children and teenagers with obesity What is the aim of this review? The aim of this Cochrane Review was to find out if healthy weight interventions can improve thinking skills and school performance in children and teenagers with obesity. Cochrane researchers collected and analysed all relevant studies to answer this question. What are the key messages? This updated review provides some evidence that school programmes that encourage healthier child weight may also provide ‘co‐benefits’ of thinking skills and school performance. However, we need more high‐quality healthy‐weight interventions that test thinking skills and school performance, as well as health outcomes. What was studied in this review? The number of children and teenagers with obesity is high worldwide. Some children and teenagers with obesity have health issues or are bullied because of their body weight. These experiences have been linked to problems in performing well in school, where they tend to perform less well in thinking tasks such as problem‐solving. Physical activity and healthy eating benefit a healthy body weight and improve thinking skills and school performance in children with a healthy weight. Studies found that healthy‐weight interventions can reduce obesity in children and teenagers, but it is unknown if and how well healthy‐weight interventions can improve thinking skills and school performance in children and teenagers with obesity. What are the main results of this review? The review authors found 18 studies which included a total of 2384 children and teenagers with obesity. Five studies assigned individual children to intervention or control groups. Thirteen studies allocated entire classes, school or school districts to the intervention and control group. Of the 18 studies, 11 involved children at primary/elementary‐school age. Eight studies offered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies offered dietary changes. The studies took place in 10 different countries. Seventeen studies had at least one flaw in how the study was done. This reduces the level of confidence we can have in the findings. Few studies shared the same type of school performance or thinking skills. Only three studies reported the same outcome. None of the studies reported on additional educational support needs and harmful events. We found that, compared with usual routine, physical activity interventions can lead to small improvements in problem‐solving skills. This finding was based on high‐quality evidence. Moderate‐quality findings showed that physical activity interventions do not improve mathematics and reading achievement in children with obesity. Very low‐quality evidence also suggested no benefits of physical activity interventions for improving uncontrolled behavioural responses. General school achievement was not reported in studies comparing physical activity interventions with standard practice. Studies that compared physical activity interventions plus healthy lifestyle education with standard practice were of low to very low quality. They showed no improvement in school achievement or uncontrolled behavioural responses in the intervention group compared to the control group. Problem‐solving skills were not reported in studies comparing physical activity plus healthy lifestyle education with standard practice. Our findings indicate that changing knowledge about nutrition, and changing the food offered in schools can lead to moderate improvements in general school achievement of teenagers with obesity, when compared to standard school practice. Replacing packed school lunch with a nutrient‐rich diet plus nutrition education did not improve mathematics and reading achievement of children with obesity. However, the quality of evidence for general school achievement, mathematics and reading was low. This means that future research is very likely to change the results, because included studies showed some methodological weaknesses (for example, small numbers of children and a high dropout of children from studies). Problem‐solving skills and uncontrolled behavioural responses were not reported for dietary intervention studies. How up‐to‐date is this review? The review authors searched the scientific literature for relevant studies in February 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Martin, A; Booth, JN; Laird, Y; Sproule, J; Reilly, JJ; Saunders, DH", "articleTypes": [], "doi": "10.1002/14651858.CD009728.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "5076d779-d0ce-47e2-8f06-52dddf9d682a", "pmid": "", "title": "Antiviral treatment for preventing postherpetic neuralgia", "imported": false, "abstract": "Abstract - Background Postherpetic neuralgia (PHN) is a painful and refractory complication of herpes zoster. Treatments are either partially or totally ineffective for many people with PHN. Antiviral agents, used at the time of the rash, have been proposed as an intervention to prevent the development of PHN. This is the first update since the first publication of the review in 2009. Objectives To assess the effectiveness of antiviral agents in preventing PHN. Search methods On 26 April 2013, we updated the searches in the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and the Chinese Biomedical Retrieval System. We checked the references of published studies to identify additional trials, and contacted authors to obtain additional data. We searched other databases in The Cochrane Library for information for the Discussion and two clinical trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) of antiviral treatment given within 72 hours after the onset of herpes zoster for preventing PHN. There were no language restrictions. Data collection and analysis Two authors independently selected trials, evaluated the risk of bias in included trials, and extracted and analysed data. Main results Six RCTs with a total of 1211 participants were eligible; five trials evaluated oral aciclovir, and one, with 419 participants, evaluated oral famciclovir. We were able to conduct meta‐analyses as there were sufficient similarities in the included studies, such as the reporting of the presence of PHN, duration of rash before treatment initiation and treatment regimen. For our primary outcome, based on three trials (609 participants) we found no significant difference between the aciclovir and control groups in the incidence of PHN four months after the onset of the acute herpetic rash (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.51 to 1.11), nor was there a significant difference at six months (RR 1.05, 95% CI 0.87 to 1.27, two trials, 476 participants). In four of the trials (692 participants), there was some evidence for a reduction in the incidence of pain four weeks after the onset of rash. In the trial of famciclovir versus placebo, neither 500 mg nor 750 mg doses of famciclovir reduced the incidence of herpetic neuralgia significantly. The most commonly reported adverse events were nausea, vomiting, diarrhoea and headache for aciclovir, and headache and nausea for famciclovir. For neither treatment was the incidence of adverse events significantly different from placebo. None of the studies were at high risk of bias, although the risk of bias was unclear in at least one domain for all but one study. We found no new RCTs when we updated the searches in April 2013. Authors' conclusions There is high quality evidence that oral aciclovir does not reduce the incidence of PHN significantly. In addition, there is insufficient evidence to determine the effect of other antiviral treatments; therefore, further well‐designed RCTs are needed to investigate famciclovir or other new antiviral agents in preventing PHN. Future trials should pay more attention to the severity of pain and quality of life of participants, and should be conducted among different subgroups of people, such as people who are immunocompromised. Plain language summary Antiviral treatment for preventing nerve pain after shingles (postherpetic neuralgia) Review question We reviewed the evidence about the effect of antiviral medicines for preventing postherpetic neuralgia (PHN). Background PHN is a painful condition that can occur after shingles (herpes zoster) in the area where the rash occurred. Many people with PHN find that treatments work only a little or not at all. Attention has therefore turned to stopping the development of PHN. Some people suggested that medicines that target the virus that causes shingles (antiviral medicines), given at the time of the rash, might prevent PHN. The aim of this review was to assess the whether antiviral medicines are able to prevent PHN. Study characteristics We identified six clinical trials that met our standards for inclusion in the review. They included a total of 1319 participants. We decided that our main measure of whether antiviral medicines work in preventing PHN would be whether or not PHN had developed six months after a first attack of shingles (some of the studies we included of aciclovir measured PHN at four months). Key results and quality of the evidence Aciclovir, which is an antiviral medicine, was used in five trials (900 participants) and was not better than a placebo (dummy pill) in preventing PHN. In the other trial (419 participants), famciclovir, which is another antiviral drug, was no better than placebo in preventing pain following healing of the shingles rash. The number of side effects with aciclovir and famciclovir was not very different from the number with placebo. The trials did not have any major problems of design or conduct that put the results in doubt, although most of the reports did not provide enough information to fully assess every aspect. We conclude that according to high quality evidence, oral aciclovir was ineffective in reducing the incidence of PHN and there is not enough evidence on other antiviral treatments. There need to be further well‐designed trials of famciclovir or other new antiviral agents with a greater number of participants. Future trials should pay more attention to the severity of pain and quality of life of participants, and should include different groups of people, such as those who have lowered immunity. The evidence is current to April 2013, when the searches were last updated. Because new evidence on this topic is slow to emerge, we have scheduled the next update of this review for 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Chen, N, Li, Q, Yang, J, Zhou, M, Zhou, D, He, L", "articleTypes": [], "doi": "10.1002/14651858.CD006866.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.771Z" }, { "id": "50a01d82-bc54-4e7a-97fa-358142fa1ac0", "pmid": "", "title": "Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants)", "imported": false, "abstract": "Abstract - Background 'Immediate' implants are placed in dental sockets just after tooth extraction. 'Immediate‐delayed' implants are those implants inserted after weeks up to about a couple of months to allow for soft tissue healing. 'Delayed' implants are those placed thereafter in partially or completely healed bone. The potential advantages of immediate implants are that treatment time can be shortened and that bone volumes might be partially maintained thus possibly providing good aesthetic results. The potential disadvantages are an increased risk of infection and failures. After implant placement in postextractive sites, gaps can be present between the implant and the bony walls. It is possible to fill these gaps and to augment bone simultaneously to implant placement. There are many techniques to achieve this but it is unclear when augmentation is needed and which could be the best augmentation technique. Objectives To evaluate success, complications, aesthetics and patient satisfaction between 'immediate', 'immediate‐delayed' and 'delayed' implants. To evaluate whether and when augmentation procedures are necessary and which is the most effective technique. Search methods The Cochrane Oral Health Group's Trials Register (to 2 June 2010), CENTRAL ( The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 ‐ 2 June 2010) and EMBASE via OVID (1980 ‐ 2 June 2010) were searched. Several dental journals were handsearched. Selection criteria Randomised controlled trials (RCTs) comparing immediate, immediate‐delayed, and delayed implants, or comparing various bone augmentation procedures around the inserted implants, reporting the outcome of the interventions to at least 1 year after functional loading. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Trial authors were contacted for any missing information. Results were expressed as random‐effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). The statistical unit of the analysis was the patient. Main results Fourteen eligible RCTs were identified but only seven trials could be included. Four RCTs evaluated implant placement timing. Two RCTs compared immediate versus delayed implants in 126 patients and found no statistically significant differences. One RCT compared immediate‐delayed versus delayed implants in 46 patients. After 2 years patients in the immediate‐delayed group perceived the time to functional loading significantly shorter, were more satisfied and independent blinded assessor judged the level of the perimplant marginal mucosa in relation to that of the adjacent teeth as more appropriate (RR = 1.68; 95% CI 1.04 to 2.72). These differences disappeared 5 years after loading but significantly more complications occurred in the immediate‐delayed group (RR = 4.20; 95% CI 1.01 to 17.43). One RCT compared immediate with immediately delayed implants in 16 patients for 2 years and found no differences. Three RCTs evaluated different techniques of bone grafting for implants immediately placed in extraction sockets. No statistically significant difference was observed when evaluating whether autogenous bone is needed in postextractive sites (1 trial with 26 patients) or which was the most effective augmentation technique (2 trials with 56 patients). Authors' conclusions There is insufficient evidence to determine possible advantages or disadvantages of immediate, immediate‐delayed or delayed implants, therefore these preliminary conclusions are based on few underpowered trials often judged to be at high risk of bias. There is a suggestion that immediate and immediate‐delayed implants may be at higher risks of implant failures and complications than delayed implants on the other hand the aesthetic outcome might be better when placing implants just after teeth extraction. There is not enough reliable evidence supporting or refuting the need for augmentation procedures at immediate implants placed in fresh extraction sockets or whether any of the augmentation techniques is superior to the others. Plain language summary Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants) Dental implants can be placed in sockets just after tooth extraction (immediate implants) or after a couple of weeks up to a couple of months (immediate‐delayed implants) or thereafter (delayed implants). This review looked at which was the best time to place dental implants and whether it would be advantageous to augment sites with gaps present at implant placement. It also tried to determine the most effective bone augmentation procedure. The seven identified studies included too few patients to answer the questions. Four studies evaluated which is the best time to place implants. One study evaluated whether bone grafting is advantageous at implant placement and two studies evaluated which are the best grafting techniques. There is currently too little evidence to draw any reliable conclusions, however, the aesthetic outcome could be slightly better when placing implants early after tooth extraction, though early placed implants might be at a higher risk of failure. There is not enough evidence supporting or refusing the need of bone augmentation when extracted teeth are immediately replaced with dental implants, nor it is known whether any augmentation procedure is better than the others. Bone substitutes (anorganic bovine bone) can be used instead of self generated (autogenous) bone graft.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Esposito, M; Grusovin, MG; Polyzos, IP; Felice, P; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD005968.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "50a68394-4ab5-4bb3-a6ea-3f9bacb84a97", "pmid": "", "title": "Adjunctive therapies in addition to land‐based exercise therapy for osteoarthritis of the hip or knee", "imported": false, "abstract": "Abstract - Background Land‐based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non‐pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land‐based exercise therapy is lacking. Objectives To evaluate the benefits and harms of adjunctive therapies used in addition to land‐based exercise therapy compared with placebo adjunctive therapy added to land‐based exercise therapy, or land‐based exercise therapy only for people with hip or knee osteoarthritis. Search methods We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land‐based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land‐based exercise therapy, or land‐based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant‐reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short‐term (6 months), medium‐term (6 to 12 months) and long‐term (12 months onwards) effects. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE. Main results We included 62 trials (60 RCTs and 2 quasi‐RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 60 included people with knee osteoarthritis only. Thirty‐six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty‐two trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in 11 (18%) trials. Comparing adjunctive therapies plus land‐based exercise therapy against placebo therapies plus exercise up to six months (short‐term), we found low‐certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate‐certainty evidence indicates that adjunctive therapies did not improve QOL (SF‐36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low‐certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant‐reported global assessment was not measured in any studies. Compared with land‐based exercise therapy, low‐certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short‐term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise‐only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (41 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (41 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low‐certainty evidence). Moderate‐certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant‐reported global assessment (short‐term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI ‐0.32 to ‐0.18 mm); 12% relative improvement (6% better to 18% better). Low‐certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27). Authors' conclusions Moderate‐ to low‐certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant‐reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis. Plain language summary Additional therapies used with exercise therapy for hip or knee osteoarthritis What was the aim of this review? Osteoarthritis, a chronic degenerative condition that commonly affects hip and knee joints, causes pain and difficulty with everyday activities such as walking. Land‐based exercise therapy refers to exercise conducted on land (as opposed to exercise in the water) and is a first‐line treatment. This review aimed to find out if adding additional therapies to land‐based exercise therapy improved pain, function, quality of life, participant‐reported overall change or X‐ray changes in people with hip or knee osteoarthritis. Additional therapies include manual (hands‐on) therapy, psychological or dietary therapies, electrophysical agents (such as heat, cold, nerve stimulation, ultrasound or laser therapy) or acupuncture. We included studies comparing additional therapies plus land‐based exercise therapy to either 1) sham (or dummy) therapy plus land‐based exercise therapy or 2) land‐based exercise therapy only. Search date This systematic review is up‐to‐date to 10 June 2021. What did we find? We found 62 randomised controlled trials with 6508 participants, mostly women, from 24 countries. The average age was between 52 and 83 years, with symptoms present from 9 months to 12 years. Sixty studies enrolled people with knee osteoarthritis, one enrolled people with hip osteoarthritis and one enrolled people with knee or hip osteoarthritis. Twenty‐two trials compared additional therapies plus exercise therapy to sham additional therapies plus exercise therapy, and 41 compared to exercise therapy. Thirty‐eight trials studied electrophysical agents, seven studied manual therapies, four studied acupuncture/dry needling or use of tape, three studied psychological or dietary interventions, whole body vibration (this involves standing on a vibration platform), or spa/mud therapy, and one studied foot orthotics (shoe insoles). Funding source Thirty‐eight studies were funded, four received no funding and funding support was not reported in 20. Main results Eleven trials (18%) measured adverse (unwanted harmful) events, which included both non‐serious and serious adverse events. The most common were increased pain, stiffness or swelling. There was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with sham additional therapies plus exercise therapy (22 studies) Compared with sham additional therapies used with land‐based exercise therapy, additional therapies such as electrophysical agents, acupuncture, dry needling or taping, used with exercise therapy, may not be more effective in improving pain, physical function or quality of life up to six months after treatment. Pain (lower scores mean less pain) Improved by 10% or 0.77 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 12% or 5.03 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 1% or 0.75 points worse on a zero to 100‐point scale. Adverse events Although not commonly reported in studies, there was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with exercise therapy (41 studies) Compared with land‐based exercise therapy, additional therapies (manual therapies, electrotherapy, dietary interventions, psychological therapies, whole body vibration, acupuncture, dry needling, taping, spa/mud therapy or foot orthotics) plus exercise therapy, may not be more effective in improving pain, physical function, quality of life or joint changes measured with X‐rays up to six months after treatment. Pain (lower scores mean less pain) Improved by 7% or 0.41 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 9% or 2.83 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 2%, or 1.04 points worse on a zero to 100‐point scale. Patient‐reported overall change 17% more people rated their treatment a success. X‐ray changes Improved by 12% (based on one study) Adverse effects Although not commonly reported in studies, risks appear no greater for additional therapies used with exercise compared to exercise only. Fewer studies assessed outcomes six or 12 months after treatment. Additional therapies plus land‐based exercise therapy may be no better in reducing pain or improving physical function or quality of life than exercise therapy at 6 or 12 months. In patient‐reported overall assessment, 31% reported improvement at 6 months, and 42% reported improvement at 12 months. Conclusions and certainty of evidence Additional therapies plus exercise therapy do not appear to offer meaningful improvements in pain, function, quality of life or overall change for people with hip or knee osteoarthritis compared with sham additional therapies plus land‐based exercise therapy; or in pain, function, quality of life or changes on X‐rays when compared with exercise therapy only. Compared with exercise therapy there is probably a clinical benefit in patient‐reported overall change for additional therapies plus exercise therapy, based on a small number of studies. Our confidence in the evidence varies between moderate to little or no confidence for different outcomes. Although results indicate no increased adverse events from additional therapies used with exercise therapy, this was poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "French, HP, Abbott, JH, Galvin, R", "articleTypes": [], "doi": "10.1002/14651858.CD011915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.826Z" }, { "id": "50b23a86-7e9c-4949-a512-c91fefd31549", "pmid": "", "title": "Pharmacological interventions for the treatment of depression in chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Studies report that up to 80% of individuals with chronic obstructive pulmonary disease (COPD) may struggle with symptoms of depression. However, this major comorbidity in COPD is rarely managed effectively. A number of recent studies indicate that left untreated, COPD‐related depression is associated with worse quality of life, worse compliance with COPD treatment plan, increased exacerbations, hospital admissions, and healthcare costs when compared to individuals with COPD without depression. Regrettably, COPD practice guidelines do not provide conclusive treatment recommendations for the use of antidepressants in patients with COPD, and base their guidelines on findings from trials in the general population. This may be problematic, as there is an elevated risk of respiratory issues associated with antidepressant treatment and COPD. Evaluating effectiveness and safety of pharmacological interventions specifically for patients with COPD and depression was therefore paramount. Objectives To assess the effectiveness and safety of pharmacological interventions for the treatment of depression in patients with COPD. Search methods The last search was performed on 26 November 2018. We initially searched the following databases via the Specialised Trials Registers of the Cochrane Airways and Common Mental Disorders Groups (to June 2016): MEDLINE, Embase, PsycINFO, CINAHL, AMED, and the Cochrane Library trials register (CENTRAL). Searches from June 2016 to November 2018 were performed directly on Ovid MEDLINE, Embase, PsycINFO and the Cochrane Library (Issue 11, 2018). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform to 26 November 2018. We searched the grey literature databases to identify studies not indexed in major databases and the reference lists of studies initially identified for full‐text screening. Selection criteria All published and unpublished randomised controlled trials (RCTs) comparing the efficacy of pharmacological interventions with no intervention, placebo or co‐intervention in adults with diagnosed COPD and depression were eligible for inclusion. Data collection and analysis Two review authors independently assessed articles identified by the search for eligibility. Our primary outcomes were change in depressive symptoms and adverse events. The secondary outcomes were: change in quality of life, change in dyspnoea, change in forced expiratory volume in one second (FEV 1 ), change in exercise tolerance, change in hospital utilisation (length of stay and readmission rates), and cost‐effectiveness. For continuous outcomes, we calculated the pooled mean difference (MD) or standardised mean difference (SMD) with 95% confidence interval (CI) as appropriate. For dichotomous outcomes, we calculated the pooled odds ratio (OR) and corresponding 95% CI using a random‐effects model. We assessed the quality of evidence using the GRADE framework. Main results Of the 1125 records screened for eligibility, four RCTs (N = 201 participants), and one on‐going study, met the inclusion criteria. Two classes of antidepressants were investigated in two separate comparisons with placebo: a tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitors (SSRIs). TCA versus placebo Only one RCT (N = 30 participants) provided results for this comparison. Primary outcomes The TCA (nortriptyline) reduced depressive symptoms post‐treatment compared to placebo (MD ‐10.20, 95% CI ‐16.75 to ‐3.65; P = 0.007; very low‐quality evidence), as measured by the Hamilton Depression Rating Scale (HAM‐D). Three participants withdrew from the trial due to adverse events related to the tested antidepressant (dry mouth, sedation, orthostatic hypotension). Secondary outcomes The overall results post‐treatment indicated that nortriptyline was not effective in improving the quality of life of individuals with COPD, as measured by the Sickness Impact Profile (MD ‐2.80, 95% CI ‐11.02 to 5.42; P = 0.50; very low‐quality evidence). The results for the change in dyspnoea for the domains examined (e.g. dyspnoea scores for 'most day‐to‐day activities') post‐treatment showed no improvement in the intervention group (MD 9.80, 95% CI ‐6.20 to 25.80; P = 0.23; very low‐quality evidence). No data were reported for change in FEV 1 , change in exercise tolerance, change in hospital utilisation, or cost‐effectiveness. The TCA study provided short‐term results, with the last follow‐up data collection at 12 weeks. The quality of the evidence for all the outcomes evaluated was very low due to a small sample size, imprecision, attrition, and selection and reporting bias. SSRIs versus placebo Three RCTs (N = 171 participants) provided results for this comparison. Primary outcomes The pooled results for two studies showed no difference for the change in depressive symptoms post‐intervention (SMD 0.75, 95% CI ‐1.14 to 2.64; 148 participants; 2 studies; P = 0.44; very low‐quality evidence). High heterogeneity was observed (I² = 95%), limiting the reliability of these findings. While it was not possible to meta‐analyse the total adverse events rates across the studies, it was possible to combine the results for two medication‐specific adverse effects: nausea and dizziness. There were no significant post‐treatment group differences for nausea (OR 2.32, 95% CI 0.66 to 8.12; 171 participants; 3 studies; P = 0.19; very low‐quality evidence) or dizziness (OR 0.61, 95% CI 0.09 to 4.06; 143 participants; 2 studies; P = 0.61; very low‐quality evidence). Secondary outcomes The pooled analysis of two trials reporting data for the change in quality of life did not show improvement post‐treatment in the intervention group compared to placebo (SMD 1.17, 95% CI ‐0.80 to 3.15; 148 participants; 2 studies; P = 0.25; very low‐quality evidence). There was no difference between groups in change in FEV 1 post‐treatment (MD 0.01, 95% CI ‐0.03 to 0.05; 148 participants; 2 studies; P = 0.60; low‐quality evidence). However, two trials reported improvement in exercise tolerance in the SSRI group versus the placebo group (MD 13.88, 95% CI 11.73 to 16.03; 148 participants; 2 studies; P < 0.001; very low‐quality evidence). The trials included in this comparison did not report data related to the change in dyspnoea, hospital utilisation rates, or cost‐effectiveness. Authors' conclusions There is insufficient evidence to make definitive statements about the efficacy or safety of antidepressants for treating COPD‐related depression. New RCTs are needed; with better methodological quality and more accurate reporting of the methods used. Moreover, longer‐term follow‐up data collection is needed, including outcomes such as adverse events, hospital utilisation and cost‐effectiveness. Plain language summary Medication for the treatment of depression in chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a term that mainly describes two lung conditions: chronic bronchitis and emphysema. The main symptoms of COPD include shortness of breath, persistent cough, wheezing, and/or frequent chest infections. There is no cure for COPD, but treatment can help slow the disease progress and relieve symptoms. Depression is very common in patients with COPD, but is often untreated. Studies show that untreated depression in patients with COPD can worsen quality of life, increase COPD exacerbations and hospital admissions, and make following a COPD treatment plan difficult. Treatment for depression can include antidepressant medication, psychological therapy, or both. However, evidence‐based recommendations regarding antidepressant medication use specifically for patients with COPD are not currently available. Why is this review important? There is currently no clear overview of existing evidence showing whether antidepressants can effectively and safely reduce depressive symptoms in patients with COPD, therefore it was important to assess the existing experimental studies. Who will be interested in this review? Healthcare professionals, people with COPD and depression, researchers, and policymakers will be interested in the findings of this review. What questions does this review aim to answer? Our main aim was to assess whether pharmacological treatment (e.g. antidepressants) could effectively and safely treat COPD‐related depression. Which studies were included in the review? This review included experimental studies called randomised controlled trials (studies in which participants are assigned to a treatment group based on a random method) that compared the effectiveness of pharmacological interventions (antidepressants) to placebo (inactive treatment in the same form as the active treatment, e.g. a pill). Study participants were adults diagnosed with COPD and depression. What does the evidence from the review tell us? We have identified only four studies worldwide that were eligible for inclusion in our review. This means limited evidence to support the use of antidepressants for the treatment of depression in patients with COPD. Only one study evaluated a tricyclic antidepressant, nortriptyline, finding that it reduced depressive symptoms when compared to a placebo. Three studies evaluated a newer generation class of antidepressants called selective serotonin reuptake inhibitors (SSRIs), finding no evidence for their effectiveness in improving depressive symptoms. Due to the limited evidence, we are unable to make definitive statements about the effectiveness but also safety of antidepressants when used for COPD‐related depression. However, SSRIs may increase exercise capacity in patients with COPD. Given that the current findings were based on only four small studies with evidence rated as of very low quality, it is important to interpret our results with caution. What should happen next? Insufficient evidence prevented us from making clear recommendations for doctors, other healthcare professionals, researchers, or policymakers. More studies with better methodological quality and a larger number of participants are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pollok, J, van Agteren, JEM, Carson‐Chahhoud, KV", "articleTypes": [], "doi": "10.1002/14651858.CD012346.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.113Z" }, { "id": "50bb803d-4b77-4ffc-bdff-e7b6dc53b336", "pmid": "", "title": "Potentiators (specific therapies for class III and IV mutations) for cystic fibrosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Skilton, M, Krishan, A, Patel, S, Sinha, IP, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD009841.pub3 AB - Abstract - Background Cystic fibrosis (CF) is the commonest inherited life‐shortening illness in white populations, caused by a mutation in the gene that codes for the cystic fibrosis transmembrane regulator protein (CFTR), which functions as a salt transporter. This mutation mainly affects the airways where excess salt absorption dehydrates the airway lining leading to impaired mucociliary clearance. Consequently, thick, sticky mucus accumulates making the airway prone to chronic infection and progressive inflammation; respiratory failure often ensues. Other complications include malnutrition, diabetes and subfertility. Increased understanding of the condition has allowed pharmaceutical companies to design mutation‐specific therapies targeting the underlying molecular defect. CFTR potentiators target mutation classes III and IV and aim to normalise airway surface liquid and mucociliary clearance, which in turn impacts on the chronic infection and inflammation. This is an update of a previously published review. Objectives To evaluate the effects of CFTR potentiators on clinically important outcomes in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles, reviews and online clinical trial registries. Last search: 21 November 2018. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing CFTR potentiators to placebo in people with CF. A separate review examines trials combining CFTR potentiators with other mutation‐specific therapies. Data collection and analysis The authors independently extracted data, assessed the risk of bias in included trials and used GRADE to assess evidence quality. Trial authors were contacted for additional data. Main results We included five RCTs (447 participants with different mutations) lasting from 28 days to 48 weeks, all assessing the CFTR potentiator ivacaftor. The quality of the evidence was moderate to low, mainly due to risk of bias (incomplete outcome data and selective reporting) and imprecision of results, particularly where few individuals experienced adverse events. Trial design was generally well‐documented. All trials were industry‐sponsored and supported by other non‐pharmaceutical funding bodies. F508del (class II) (140 participants) One 16‐week trial reported no deaths, or changes in quality of life (QoL) or lung function (either relative or absolute change in forced expiratory volume in one second (FEV1) (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in ivacaftor and placebo groups, but there was no difference between groups (low‐quality evidence); there was also no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. There was also no difference in weight. Sweat chloride concentration decreased, mean difference (MD) ‐2.90 mmol/L (95% confidence interval (CI) ‐5.60 to ‐0.20). G551D (class III) (238 participants) The 28‐day phase 2 trial (19 participants) and two 48‐week phase 3 trials (adult trial (167 adults), paediatric trial (52 children)) reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor in the adult trial at 24 weeks, MD 8.10 (95% CI 4.77 to 11.43) and 48 weeks, MD 8.60 (95% CI 5.27 to 11.93 (moderate‐quality evidence). The adult trial reported a higher relative change in FEV1 with ivacaftor at 24 weeks, MD 16.90% (95% CI 13.60 to 20.20) and 48 weeks, MD 16.80% (95% CI 13.50 to 20.10); the paediatric trial reported this at 24 weeks, MD 17.4% (P < 0.0001)) (moderate‐quality evidence). These trials demonstrated absolute improvements in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32). The phase 3 trials reported increased cough, odds ratio (OR) 0.57 (95% CI 0.33 to 1.00) and episodes of decreased pulmonary function, OR 0.29 (95% CI 0.10 to 0.82) in the placebo group; ivacaftor led to increased dizziness in adults, OR 10.55 (95% CI 1.32 to 84.47). There was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Fewer participants taking ivacaftor developed serious pulmonary exacerbations; adults taking ivacaftor developed fewer exacerbations (serious or not), OR 0.54 (95% CI 0.29 to 1.01). A higher proportion of participants were exacerbation‐free at 24 weeks with ivacaftor (moderate‐quality evidence). Ivacaftor led to a greater absolute change from baseline in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32); weight also increased at 24 weeks, MD 2.37 kg (95% CI 1.68 to 3.06) and 48 weeks, MD 2.75 kg (95% CI 1.74 to 3.75). Sweat chloride concentration decreased at 24 weeks, MD ‐48.98 mmol/L (95% CI ‐52.07 to ‐45.89) and 48 weeks, MD ‐49.03 mmol/L (95% CI ‐52.11 to ‐45.94). R117H (class IV) (69 participants) One 24‐week trial reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor at 24 weeks, MD 8.40 (95% CI 2.17 to 14.63), but no relative changes in lung function were reported (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in both groups, but there was no difference between groups; there was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. No changes in absolute change in FEV1 or weight were reported. Sweat chloride concentration decreased, MD ‐24.00 mmol/L (CI 95% ‐24.69 to ‐23.31). Authors' conclusions There is no evidence supporting the use of ivacaftor in people with the F508del mutation. Both G551D phase 3 trials demonstrated a clinically relevant impact of ivacaftor on outcomes at 24 and 48 weeks in adults and children (over six years of age) with CF. The R117H trial demonstrated an improvement in the respiratory QoL score, but no improvement in respiratory function. As new mutation‐specific therapies emerge, it is important that trials examine outcomes relevant to people with CF and their families and that adverse events are reported robustly and consistently. Post‐market surveillance is essential and ongoing health economic evaluations are required. Plain language summary Ivacaftor (marketed as Kalydeco®), a new specific therapy for cystic fibrosis Review question How does ivacaftor affect clinical outcomes (survival, quality of life and lung function) in people with cystic fibrosis (CF)? Background In people with CF, airway surfaces do not have enough water because of an abnormal protein; this makes it difficult to clear thick and sticky mucus, which leads to lung infections. Ivacaftor works on the abnormal protein in people with some mutations to allow the airways retain more water and better clear mucus, so fewer lung infections develop. Ivacaftor was aimed at people with class III and IV mutations, and has been studied in people with G551D (class III), R117H (class IV) and F508del (class II) mutations. Trial characteristics We included five trials (447 participants) comparing ivacaftor to placebo (dummy treatment with no active medication) lasting between four and 48 weeks. Three trials enrolled a total of 238 people with at least one copy of the G551D mutation, one trial enrolled 140 people with two copies of the F508del mutation and one enrolled 69 people with at least one copy of the R117H mutation. The evidence is up to date as of 21 November 2018. Key results F508del mutation The trial did not report any deaths or show improvements in lung function, quality of life scores or weight. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. Sweat chloride concentrations were reduced with ivacaftor. G551D mutation No deaths were reported. Both children and adults taking ivacaftor showed improvements in lung function, but only adults reported higher quality of life scores. People given placebo reported more coughing and experienced more episodes of decreased lung function; more adults taking ivacaftor reported episodes of dizziness. Similar numbers of people taking ivacaftor and placebo delayed the course of medication, or withdrew from the trial altogether, due to side effects (e.g. psychological issues, liver disease, severe breathing problems). There were more serious pulmonary exacerbations whilst taking placebo compared to ivacaftor. Adults taking ivacaftor were admitted to hospital less often and had fewer courses of intravenous antibiotics for exacerbations. Both children and adults and children increased their weight with ivacaftor. There was a drop in sweat chloride concentrations with ivacaftor. R117H mutation No deaths occurred in this trial. While quality of life scores improved with ivacaftor, lung function did not. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. There was no difference in weight; but as for other mutations there was a reduction in sweat chloride concentration with ivacaftor.
 
 Evidence suggests that ivacaftor is an effective treatment for people (over six years of age) with cystic fibrosis and the G551D mutation, but not for those with the F508del or R117H mutations. Quality of the evidence In most trials, individuals were put into different treatment groups at random with equal chances of being given either placebo or ivacaftor; no one could work out which treatment the next person would receive, so that healthier people did not receive ivacaftor and make the results seem better. We were not sure whether anyone involved in the trial knew who was receiving which treatment and how this might affect results. No trials reported all results clearly; sometimes they did not report them in a way that we could use in the review and sometimes they did not report the data at all. This affected our certainty regarding the overall results. Information about some side effects was limited as not many people experienced them, therefore, it is difficult to judge whether there was a difference between treatment groups We judged the evidence in this review to be moderate to low quality. Trial funding sources All trials were sponsored by Vertex Pharmaceuticals Incorporated. The National Institute of Health (NIH), the Cystic Fibrosis Foundation (CFF) and other non‐pharmaceutical funding bodies also supported the trials.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.105Z" }, { "id": "50be1011-0dc0-49c0-95fd-1d51719b0cf0", "pmid": "", "title": "Eliciting adverse effects data from participants in clinical trials", "imported": false, "abstract": "Abstract - Background Analysis of drug safety in clinical trials involves assessing adverse events (AEs) individually or by aggregate statistical synthesis to provide evidence of likely adverse drug reactions (ADR). While some AEs may be ascertained from physical examinations or tests, there is great reliance on reports from participants to detect subjective symptoms, where he/she is often the only source of information. There is no consensus on how these reports should be elicited, although it is known that questioning methods influence the extent and nature of data detected. This leaves room for measurement error and undermines comparisons between studies and pooled analyses. This review investigated comparisons of methods used in trials to elicit participant‐reported AEs. This should contribute to knowledge about the methodological challenges and possible solutions for achieving better, or more consistent, AE ascertainment in trials. Objectives To systematically review the research that has compared methods used within clinical drug trials (or methods that would be specific for such trials) to elicit information about AEs defined in the protocol or in the planning for the trial. Search methods Databases (searched to March 2015 unless indicated otherwise) included: Embase; MEDLINE; MEDLINE in Process and Other Non‐Indexed Citations; Cochrane Methodology Register (July 2012); Cochrane Central Register of Controlled Trials (February 2015); Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects (January 2015); Health Technology Assessment database (January 2015); CINAHL; CAB Abstracts; BIOSIS (July 2013); Science Citation Index; Social Science Citation Index; Conference Proceedings Citation Index – Science. The search used thesaurus headings and synonyms for the following concepts: (A): Adverse events AND measurement; (B): Participants AND elicitation (also other synonyms for extraction of information about adverse effects from people); (C): Participants AND checklists (also other synonyms as for B). Pragmatic ways were used to limit the results whilst trying to maintain sensitivity. There were no date or sample size restrictions but only reports published in English were included fully, because of resource constraints as regards translation. Selection criteria Two types of studies were included: drug trials comparing two or more methods within‐ or between‐participants to elicit participant‐reported AEs, and research studies performed outside the context of a trial to compare methods which could be used in trials (evidenced by reference to such applicability). Primary outcome data included AEs elicited from participants taking part in any such clinical trial. We included any participant‐reported data relevant for an assessment of drug‐related harm, using the original authors' terminology (and definition, where available), with comment on whether the data were likely to be treatment‐emergent AEs or not. Data collection and analysis Titles and abstracts were independently reviewed for eligibility. Full texts of potentially eligible citations were independently reviewed for final eligibility. Relevant data were extracted and subjected to a 100% check. Disagreements were resolved by discussion, involving a third author. The risk of bias was independently assessed by two authors. The Cochrane 'Risk of bias' tool was used for reports comparing outcomes between participants, while for within‐participant comparisons, each study was critically evaluated in terms of potential impact of the design and conduct on findings using the framework of selection, performance, detection, attrition, reporting, and other biases. An attempt was made to contact authors to retrieve protocols or specific relevant missing information. Reports were not excluded on the basis of quality unless data for outcomes were impossible to compare (e.g. where denominators differed). A narrative synthesis was conducted because differences in study design and presentation meant that a quantitative meta‐analysis was not possible. Main results The 33 eligible studies largely compared open questions with checklist‐type questions or rating scales. Two included participant interviews. Despite different designs, populations and details of questioning methods, the narrative review showed that more specific questioning of participants led to more AEs detected compared to a more general enquiry. A subset of six studies suggested that more severe, bothersome, or otherwise clinically relevant AEs were reported when an initial open enquiry was used, while some less severe, bothersome, or clinically relevant AEs were only reported with a subsequent specific enquiry. However, two studies showed that quite severe or debilitating AEs were only detected by an interview, while other studies did not find a difference in the nature of AEs between elicitation methods. No conclusions could be made regarding the impact of question method on the ability to detect a statistically significant difference between study groups. There was no common statistical rubric, but we were able to represent some effect measures as a risk ratio of the proportion of participants with at least one AE. This showed a lower level of reporting for open questions (O) compared to checklists (CL), with a range for the risk ratios of 0.12 to 0.64. Authors' conclusions This review supports concerns that methods to elicit participant‐reported AEs influence the detection of these data. There was a risk for under‐detection of AEs in studies using a more general elicitation method compared to those using a comprehensive method. These AEs may be important from a clinical perspective or for patients. This under‐detection could compromise ability to pool AE data. However, the impact on the nature of the AE detected by different methods is unclear. The wide variety and low quality of methods to compare elicitation strategies limited this review. Future studies would be improved by using and reporting clear definitions and terminology for AEs (and other important variables), frequency and time period over which they were ascertained, how they were graded, assessed for a relationship to the study drug, coded, and tabulated/reported. While the many potential AE endpoints in a trial may preclude the development of general AE patient‐reported outcome measurement instruments, much could also be learnt from how these employ both quantitative and qualitative methods to better understand data elicited. Any chosen questioning method needs to be feasible for use by both staff and participants. Plain language summary Questioning clinical trial participants about their health in order to collect information on adverse effects of drugs Clinical drug trials or studies are usually conducted to assess how well the drug works but also whether it causes any harm (side effects or adverse effects). Adverse effects can be detected by the trial doctor examining participants or taking some blood samples or doing other kinds of tests. The trial staff can also ask participants about how they are feeling after taking the trial drug. However, the way participants are asked about their health can vary from trial to trial, or even within a trial. In some trials, participants may be asked a simple open question such as 'how have you been feeling?', while in other trials, participants may be asked about whether they have had any of a long list of possible symptoms (such as 'have you had a headache, stomach ache, or sore muscles?'). There has been concern that these different kinds of questions and how they are phrased will impact on what participants report about their health during a trial. This might then affect the trial's results and what we know about the side effects of drugs. We did this review to look at studies that compared different types of participant questioning methods in order to investigate these issues. We found 33 studies comparing mainly open questions with checklist‐type questions, but also some ratings scales and participant interviews. While the studies were all very different in terms of the types of disease, drugs, and patients studied, we found in general that, as would be expected, when a more specific type of question was asked (like a checklist), participants reported more symptoms. What is interesting is that, in those studies that looked more closely at the types of symptoms reported, it seems that an open question picks up the more severe or bothersome symptoms compared to a checklist‐type question. However, some studies found that even quite severe or bothersome symptoms were not reported when a participant is asked an open question and these severe symptoms will only be reported with the more specific question. This makes it difficult to say whether one method is better than any other and the different questioning methods may, in fact, be complementary and therefore should be used together. It is also difficult to say what a specific question should include, as it might take too long for a participant to have to answer a very long list. While more research is needed to resolve the remaining uncertainties, it is very important for trials to be clear about which kind of questioning was used when they publish their results. This will help readers understand the trial's findings about the side effects and make it easier to make accurate comparisons between trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Allen, EN; Chandler, CIR; Mandimika, N; Leisegang, C; Barnes, K", "articleTypes": [], "doi": "10.1002/14651858.MR000039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "50c8261d-f978-4cf5-8616-4296ab9d1d6a", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies to prevent COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as potential prophylaxis to prevent coronavirus disease 2019 (COVID‐19). Objectives To assess the effects of SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, to prevent infection with SARS‐CoV‐2 causing COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register, MEDLINE, Embase, and three other databases on 27 April 2022. We checked references, searched citations, and contacted study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that evaluated SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, alone or combined, versus an active comparator, placebo, or no intervention, for pre‐exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) of COVID‐19. We excluded studies of SARS‐CoV‐2‐neutralising mAbs to treat COVID‐19, as these are part of another review. Data collection and analysis Two review authors independently assessed search results, extracted data, and assessed risk of bias using Cochrane RoB 2. Prioritised outcomes were infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, all‐cause mortality, admission to hospital, quality of life, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We included four RCTs of 9749 participants who were previously uninfected and unvaccinated at baseline. Median age was 42 to 76 years. Around 20% to 77.5% of participants in the PrEP studies and 35% to 100% in the PEP studies had at least one risk factor for severe COVID‐19. At baseline, 72.8% to 82.2% were SARS‐CoV‐2 antibody seronegative. We identified four ongoing studies, and two studies awaiting classification. Pre‐exposure prophylaxis Tixagevimab/cilgavimab versus placebo One study evaluated tixagevimab/cilgavimab versus placebo in participants exposed to SARS‐CoV‐2 wild‐type, Alpha, Beta, and Delta variant. About 39.3% of participants were censored for efficacy due to unblinding and 13.8% due to vaccination. Within six months, tixagevimab/cilgavimab probably decreases infection with SARS‐CoV‐2 (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.29 to 0.70; 4685 participants; moderate‐certainty evidence), decreases development of clinical COVID‐19 symptoms (RR 0.18, 95% CI 0.09 to 0.35; 5172 participants; high‐certainty evidence), and may decrease admission to hospital (RR 0.03, 95% CI 0 to 0.59; 5197 participants; low‐certainty evidence). Tixagevimab/cilgavimab may result in little to no difference on mortality within six months, all‐grade AEs, and SAEs (low‐certainty evidence). Quality of life was not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and Delta variant. About 36.5% of participants opted for SARS‐CoV‐2 vaccination and had a mean of 66.1 days between last dose of intervention and vaccination. Within six months, casirivimab/imdevimab may decrease infection with SARS‐CoV‐2 (RR 0.01, 95% CI 0 to 0.14; 825 seronegative participants; low‐certainty evidence) and may decrease development of clinical COVID‐19 symptoms (RR 0.02, 95% CI 0 to 0.27; 969 participants; low‐certainty evidence). We are uncertain whether casirivimab/imdevimab affects mortality regardless of the SARS‐CoV‐2 antibody serostatus. Casirivimab/imdevimab may increase all‐grade AEs slightly (RR 1.14, 95% CI 0.98 to 1.31; 969 participants; low‐certainty evidence). The evidence is very uncertain about the effects on grade 3 to 4 AEs and SAEs within six months. Admission to hospital and quality of life were not reported. Postexposure prophylaxis Bamlanivimab versus placebo One study evaluated bamlanivimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type. Bamlanivimab probably decreases infection with SARS‐CoV‐2 versus placebo by day 29 (RR 0.76, 95% CI 0.59 to 0.98; 966 participants; moderate‐certainty evidence), may result in little to no difference on all‐cause mortality by day 60 (R 0.83, 95% CI 0.25 to 2.70; 966 participants; low‐certainty evidence), may increase all‐grade AEs by week eight (RR 1.12, 95% CI 0.86 to 1.46; 966 participants; low‐certainty evidence), and may increase slightly SAEs (RR 1.46, 95% CI 0.73 to 2.91; 966 participants; low‐certainty evidence). Development of clinical COVID‐19 symptoms, admission to hospital within 30 days, and quality of life were not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and potentially, but less likely to Delta variant. Within 30 days, casirivimab/imdevimab decreases infection with SARS‐CoV‐2 (RR 0.34, 95% CI 0.23 to 0.48; 1505 participants; high‐certainty evidence), development of clinical COVID‐19 symptoms (broad‐term definition) (RR 0.19, 95% CI 0.10 to 0.35; 1505 participants; high‐certainty evidence), may result in little to no difference on mortality (RR 3.00, 95% CI 0.12 to 73.43; 1505 participants; low‐certainty evidence), and may result in little to no difference in admission to hospital. Casirivimab/imdevimab may slightly decrease grade 3 to 4 AEs (RR 0.50, 95% CI 0.24 to 1.02; 2617 participants; low‐certainty evidence), decreases all‐grade AEs (RR 0.70, 95% CI 0.61 to 0.80; 2617 participants; high‐certainty evidence), and may result in little to no difference on SAEs in participants regardless of SARS‐CoV‐2 antibody serostatus. Quality of life was not reported. Authors' conclusions For PrEP, there is a decrease in development of clinical COVID‐19 symptoms (high certainty), infection with SARS‐CoV‐2 (moderate certainty), and admission to hospital (low certainty) with tixagevimab/cilgavimab. There is low certainty of a decrease in infection with SARS‐CoV‐2, and development of clinical COVID‐19 symptoms; and a higher rate for all‐grade AEs with casirivimab/imdevimab. For PEP, there is moderate certainty of a decrease in infection with SARS‐CoV‐2 and low certainty for a higher rate for all‐grade AEs with bamlanivimab. There is high certainty of a decrease in infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, and a higher rate for all‐grade AEs with casirivimab/imdevimab. Although there is high‐to‐moderate certainty evidence for some outcomes, it is insufficient to draw meaningful conclusions. These findings only apply to people unvaccinated against COVID‐19. They are only applicable to the variants prevailing during the study and not other variants (e.g. Omicron). In vitro, tixagevimab/cilgavimab is effective against Omicron, but there are no clinical data. Bamlanivimab and casirivimab/imdevimab are ineffective against Omicron in vitro. Further studies are needed and publication of four ongoing studies may resolve the uncertainties. Plain language summary Are laboratory‐made COVID‐19‐specific monoclonal antibodies effective to prevent COVID‐19 in adults? Key messages Pre‐exposure prophylaxis of COVID‐19: – tixagevimab/cilgavimab probably reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may reduce number of people admitted to hospital; – casirivimab/imdevimab may reduce number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may increase number of unwanted effects (any severity) slightly. Postexposure prophylaxis of COVID‐19: – bamlanivimab probably reduces number of people infected with COVID‐19; – casirivimab/imdevimab reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and reduces number of unwanted effects (any severity). What are 'monoclonal' antibodies? The body makes antibodies to defend against disease. However, they may be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that target only one specific protein – in this case, a protein on the SARS‐CoV‐2 virus (that causes COVID‐19) – are 'monoclonal'. They attach to the virus and stop it from entering and replicating in human cells to prevent and fight infection. They are relevant for people who do not respond or respond poorly to vaccinations. What did we want to find out? We wanted to know if COVID‐19‐specific monoclonal antibodies are effective at preventing COVID‐19 in people exposed to the virus or are at high risk of being exposed to the virus. We looked at: – confirmed COVID‐19 infections; – development of COVID‐19 symptoms; – death from any cause; – hospital admission; – quality of life; – unwanted effects, such as infections and cardiac disorders; – serious unwanted effects, such as life‐threatening, hospitalisation, disability, or death. What did we do? We searched for studies comparing monoclonal antibodies (e.g. bamlanivimab, tixagevimab/cilgavimab, and casirivimab/imdevimab) with placebo (sham treatment), another treatment, or no treatment to prevent COVID‐19 in people of any age, gender, or ethnicity. We summarised data and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? Four studies including 9749 people; two investigated people before being exposed to SARS‐CoV‐2 (pre‐exposure prophylaxis) and two investigated people who were in contact with an infected person (postexposure prophylaxis). Studies were conducted before the emergence of the Omicron variant and before or during widespread vaccine roll‐out. Participants were unvaccinated at baseline. Pre‐exposure prophylaxis One study (5197 people) compared tixagevimab/cilgavimab to placebo. Participants had been exposed to wild‐type, Alpha, Beta, and Delta variants. Tixagevimab/cilgavimab: – reduces development of symptoms; – probably reduces number of people infected; – may reduce number of hospital admissions; – may have little or no effect on deaths from any cause, unwanted effects (any severity), and serious unwanted effect. We found no data for quality of life, or mild and severe unwanted effects. One study (969 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and Delta variants. Casirivimab/imdevimab: – may reduce number of people infected and development of symptoms; – resulted in no deaths; – may increase unwanted effects (any severity) slightly; – we are uncertain whether casirivimab/imdevimab may have an effect on severe and serious unwanted effects. We found no data for number of people with COVID‐19 within 30 days, development of symptoms within 30 days, hospital admissions within 30 days, quality of life, and mild unwanted effects. Postexposure prophylaxis (two studies) One study (966 people) compared bamlanivimab to placebo. Participants may have been exposed to wild‐type variants. Bamlanivimab: – probably reduces number of people infected; – may have little or no effect on deaths from any cause; – may increase unwanted effects (any severity) and serious unwanted effects slightly. We found no data for number of people who developed symptoms, hospital admissions, quality of life, mild, and severe unwanted effects. One study (2617 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and potentially, but unlikely Delta variants. Casirivimab/ imdevimab: – reduces number of people infected, development of symptoms, and unwanted effects (any severity); – may slightly reduce severe unwanted effects; – may have little or no effect on deaths, hospital admissions, and serious unwanted effects. We found no data for quality of life and mild unwanted effects. What are the limitations of the evidence? One study reported each comparison. All participants were unvaccinated at the beginning of the studies, which were conducted prior to the occurrence of Omicron. Our confidence in the evidence is high to very low. Although we have high confidence in the evidence found for relevant outcomes, the findings are not transferable to vaccinated people and variants that occurred outside the study periods, such as Omicron. Although laboratory studies have shown that tixagevimab/cilgavimab is effective against Omicron, there are no data from clinical studies. The other monoclonal antibodies included in this review were ineffective against Omicron in laboratory studies. Four ongoing studies are likely to change our conclusions and may help us understand how new variants and COVID‐19 vaccines affect the effectiveness of monoclonal antibodies in preventing COVID‐19. How up to date is this evidence? The evidence is up‐to‐date to 27 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hirsch, C, Park, YS, Piechotta, V, Chai, KL, Estcourt, LJ, Monsef, I, Salomon, S, Wood, EM, So-Osman, C, McQuilten, Z, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014945.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.129Z" }, { "id": "50c9adf6-9c48-4816-b4f2-a930d9e212f6", "pmid": "", "title": "The effects of antimicrobial therapy on bacterial vaginosis in non‐pregnant women", "imported": false, "abstract": "Abstract - Background Bacterial vaginosis (BV) is a very common cause of vaginitis that has been associated with a high incidence of obstetric and gynaecologic complications and increased risk of HIV‐1 transmission. This has led to renewed research interest in its treatment. Objectives To assess the effects of antimicrobial agents on BV in non‐pregnant women. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE, LILACS, and African Healthline (December 2007); and proceedings of relevant international conferences (from 1981 to date). Selection criteria Randomised controlled trials comparing any two or more antimicrobial agents, or antimicrobial agents with placebo or no treatment, in women with clinical or Gram‐stain criteria of BV. Data collection and analysis Two authors independently assessed trial quality and extracted data from the original publications while the third author cross checked the data. Main results Twenty‐four trials involving 4422 participants were reviewed. Most examined symptomatic women only. Only seven trials analysed results by intention to treat; we re‐analysed the remainder. Compared with placebo, clindamycin showed a lower rate of treatment failure (relative risk (RR) 0.25, 95% confidence interval (CI) 0.16 to 0.37). Clindamycin and metronidazole showed identical rates of treatment failure, irrespective of regimen type, at two and four‐week follow up (RR 1.01, 95% CI 0.69 to 1.46; RR 0.91, 95% CI 0.70 to 1.18, respectively). Clindamycin tended to cause a lower rate of adverse events (RR 0.75, 95% CI 0.56 to 1.02); metallic taste, and nausea and vomiting were more common in the metronidazole group (RR 0.08, 95% CI 0.1 to 0.59; RR 0.23, 95% CI 0.10 to 0.51, respectively). Given intravaginally as gelatin tablets, lactobacillus was more effective than oral metronidazole (RR 0.20, 95% CI 0.05 to 0.08). Similarly, oral lactobacillus combined with metronidazole was more effective than metronidazole alone (RR 0.33, 95% CI 0.14 to 0.77). Clindamycin showed a lower rate of clinical failure than triple sulfonamide cream (RR 0.46, 95% CI 0.29 to 0.72). Hydrogen peroxide douche showed a higher rate of clinical failure (RR 1.75, 95% CI 1.02 to 3.00) and adverse events (RR 2.33, 95% CI 1.21 to 4.52) than a single 2 g dose of metronidazole. Authors' conclusions Clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus were effective for bacterial vaginosis. Hydrogen peroxide douche and triple sulphonamide cream were ineffective. Metronidazole caused metallic taste, nausea and vomiting. We need better‐designed trials with larger sample sizes to test the effectiveness of promising drugs. Plain language summary The effects of antimicrobial treatment on bacterial vaginosis in non‐pregnant women Bacterial vaginosis (BV) is a very common cause of symptomatic and asymptomatic vaginal infection. It has been associated with a high incidence of obstetric and gynaecologic complications and an increased risk of transmission of HIV (human immunodeficiency virus). This review evaluated the effectiveness and adverse effects of antimicrobial agents used to treat BV in non‐pregnant women. Twenty‐four trials involving 4422 women were reviewed. With regard to less treatment failure, clindamycin was superior to placebo but comparable to metronidazole, irrespective of the dose regimen. Metronidazole tended to cause a higher rate of adverse events, such as metallic taste and nausea and vomiting, than did clindamycin. Oral lactobacillus combined with metronidazole was more effective than metronidazole alone. Administered in an intravaginal gelatin tablet, lactobacillus was also more effective than oral metronidazole. Triple sulfonamide cream was less effective compared with clindamycin. Hydrogen peroxide douche was not as effective as a single 2 g dose of metronidazole yet caused more harms. Only one trial involved asymptomatic women and the result was not conclusive. There was insufficient evidence to reach a conclusion on the effectiveness of other promising drugs. Drugs effective for bacterial vaginosis include clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus. Adverse effects of metronidazole include metallic taste, and nausea and vomiting. Information on possible side effects of lactobacillus preparations is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Oduyebo, OO; Anorlu, RI; Ogunsola, FT", "articleTypes": [], "doi": "10.1002/14651858.CD006055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "50cc1839-9957-4cf5-bf2a-324095ebf022", "pmid": "", "title": "Interventions for acute otitis externa", "imported": false, "abstract": "Abstract - Background Acute otitis externa is an inflammatory condition of the ear canal, with or without infection. Symptoms include ear discomfort, itchiness, discharge and impaired hearing. It is also known as 'swimmer's ear' and can usually be treated successfully with a course of ear drops. Objectives To assess the effectiveness of interventions for acute otitis externa. Search methods Our search for published and unpublished trials included the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources. The date of the most recent search was 6 January 2009. Selection criteria Randomised controlled trials evaluating ear cleaning, topical medication or systemic therapy in the treatment of acute otitis externa were eligible. We excluded complicated acute otitis externa; otitis externa secondary to otitis media or chronic suppurative otitis media; chronic otitis externa; fungal otitis externa (otomycosis); eczematous otitis externa; viral otitis externa and furunculosis. Data collection and analysis Two authors assessed eligibility and quality. Main results Nineteen randomised controlled trials with a total of 3382 participants were included. Three meta‐analyses were possible. The overall quality of studies was low. Topical antimicrobials containing steroids were significantly more effective than placebo drops: OR 11 (95% CI 2.00 to 60.57; one trial). In general, no clinically meaningful differences were noted in clinical cure rates between the various topical interventions reviewed. One notable exception involved a trial of high quality which showed that acetic acid was significantly less effective when compared with antibiotic/steroid drops in terms of cure rate at two and three weeks (OR 0.29 (95% CI 0.13 to 0.62) and OR 0.25 (95% CI 0.11 to 0.58) respectively). One trial of low quality comparing quinolone with non‐quinolone antibiotics did not find any difference in clinical cure rate. No trials evaluated the effectiveness of ear cleaning. Only two trials evaluated steroid‐only drops. One trial of low quality suggested no significant difference between steroid and antibiotic/steroid but did not report the magnitude or precision of the result. Another trial of moderate quality comparing an oral antihistamine with topical steroid against topical steroid alone found that cure rates in both groups were high and comparable (100% (15/15) and 94% (14/15) respectively at three weeks). Authors' conclusions There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available: Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow‐up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid. The evidence for steroid‐only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed. Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision. Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated. Plain language summary Interventions to treat acute otitis externa, a specific form of ear canal inflammation also known as swimmer's ear Acute otitis externa causes inflammation of the ear canal. It is a common clinical problem encountered in general practice. This review assesses the various forms of medication used to treat the condition. Nineteen randomised controlled trials were included (3382 participants). Most were of low quality. The findings of the review may not be wholly relevant to primary care as most of the trials were conducted in a hospital setting and over half involved ear cleaning as part of the treatment (this is generally not available in primary care). However, the review does demonstrate that topical treatments alone are effective at treating acute otitis externa. There was little to choose between them in terms of effectiveness. However, when treatment needs to be extended beyond one week acetic acid drops appear to be less effective than antibiotic/steroid drops. In addition, symptoms persist for two days longer in those treated with acetic acid. More research is needed to determine the effectiveness of steroid‐only drops. Patients treated with antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Kaushik, V, Malik, T, Saeed, SR", "articleTypes": [], "doi": "10.1002/14651858.CD004740.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.791Z" }, { "id": "50d33d9a-1c5a-4177-976f-9e3a0e0babc4", "pmid": "", "title": "Interventions for preventing osteoradionecrosis of the jaws in adults receiving head and neck radiotherapy", "imported": false, "abstract": "Abstract - Background Osteoradionecrosis (ORN) of the jaws is among the most serious oral complications of head and neck cancer radiotherapy, arising from radiation‐induced fibro‐atrophic tissue injury, manifested by necrosis of osseous tissues and failure to heal, often secondary to operative interventions in the oral cavity. It is associated with considerable morbidity and has important quality of life ramifications. Since ORN is very difficult to treat effectively, preventive measures to limit the onset of this disease are needed; however, the effects of various preventive interventions has not been adequately quantified. Objectives To assess the effects of interventions for preventing ORN of the jaws in adult patients with head and neck cancer undergoing curative or adjuvant (i.e. non‐palliative) radiotherapy. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 5 November 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 10) in the Cochrane Library (searched 5 November 2019), MEDLINE Ovid (1946 to 5 November 2019), Embase Ovid (1980 to 5 November 2019), Allied and Complementary Medicine (AMED) Ovid (1985 to 5 November 2019), Scopus (1966 to 5 November 2019), Proquest Dissertations and Theses International (1861 to 5 November 2019) and Web of Science Conference Proceedings (1990 to 5 November 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We selected randomised controlled trials (RCTs) or quasi‐RCTs of adult patients 18 years or older with head and neck cancer who had undergone curative or adjuvant radiotherapy to the head and neck, who had received an intervention to prevent the onset of ORN. Eligible patients were those subjected to pre‐ or post‐irradiation dental evaluation. Management of these patients was to be with interventions independent of their cancer therapy, including but not limited to local, systemic, or behavioural interventions. Data collection and analysis Two review authors independently selected trials from search results, assessed risk of bias, and extracted relevant data for inclusion in the review. Authors of included studies were contacted to request missing data. We used standard methodological procedures expected by Cochrane. Main results Four studies were identified that met pre‐determined eligibility criteria, evaluating a total of 342 adults. From the four studies, all assessed as at high risk of bias, three broad interventions were identified that may potentially reduce the risk of ORN development: one study showed no reduction in ORN when using platelet‐rich plasma placed in the extraction sockets of prophylactically removed healthy mandibular molar teeth prior to radiotherapy (odds ratio (OR) 3.32, 95% confidence interval (CI) 0.58 to 19.09; one trial, 44 participants; very low‐certainty evidence). Another study involved comparing fluoride gel and high‐content fluoride toothpaste (1350 parts per million (ppm)) in prevention of post‐radiation caries, and found no difference between their use as no cases of ORN were reported (one trial, 220 participants; very low‐certainty evidence). The other two studies involved the use of perioperative hyperbaric oxygen (HBO) therapy and antibiotics. One study showed that treatment with HBO caused a reduction in the development of ORN in comparison to patients treated with antibiotics following dental extractions (risk ratio (RR) 0.18, 95% CI 0.43 to 0.76; one trial, 74 participants; very low‐certainty evidence). Another study found no difference between combined HBO and antibiotics compared to antibiotics alone prior to dental implant placement (RR 3.00, 95% CI 0.14 to 65.16; one trial, 26 participants; very low‐certainty evidence). Adverse effects of the different interventions were not reported clearly or were not important. Authors' conclusions Given the suboptimal reporting and inadequate sample sizes of the included studies, evidence regarding the interventions evaluated by the trials included in this review is uncertain. More well‐designed RCTs with larger samples are required to make conclusive statements regarding the efficacy of these interventions. Plain language summary Dental treatments for preventing damage to the jawbones in people with cancer receiving radiotherapy to the head and neck Review question With this Cochrane Review we tried to find out the best way to prevent the death and exposure of bone in the jaws of people who have had radiotherapy for head and neck cancer. This is a condition called osteoradionecrosis (ORN). Background ORN of the jaws is a serious problem which can happen after people have radiotherapy as part of their treatment for head and neck cancer. ORN refers to the death and exposure of bone that result from damage to the tissues due to being exposed to radiation. ORN is very difficult to treat and it is important that steps are taken to prevent it. In this review, we looked at any treatments that have been used to prevent ORN. Study characteristics This review is up‐to‐date as of 5 November 2019. The review includes four studies involving 342 adults who had received radiotherapy for the treatment of head and neck cancer. The review looks at three different ways to prevent ORN: ‐ the use of platelet‐rich plasma (PRP) in bone after removal of healthy teeth prior to radiotherapy. Plasma is a part of blood that contains special proteins that help the blood to clot, and PRP is concentrated plasma which supports cell growth. Injecting PRP into damaged tissue may stimulate the body to grow new, healthy cells to make it heal more quickly; ‐ taking out teeth because of tooth decay makes the risk of developing ORN greater. Preventing tooth decay in people having radiotherapy is very important. We looked at a study comparing using fluoride gel with a toothpaste with a higher level of fluoride than normal to prevent tooth decay after radiotherapy; ‐ hyperbaric oxygen therapy is breathing oxygen in a pressurized chamber to improve blood supply, which may help heal damaged tissue. Two studies compared the use of hyperbaric oxygen therapy for taking out teeth or placing dental implants with antibiotics. Antibiotics are drugs which stop or slow the growth of bacteria. Key results One study showed no reduction in ORN when using platelet‐rich plasma in bone after the removal of healthy teeth. Another study found no difference between fluoride gel and toothpaste with a higher level of fluoride than normal as no cases of ORN were reported. A third study showed that treatment with hyperbaric oxygen therapy caused a reduction in the development of ORN in comparison to patients treated with antibiotics following the removal of teeth. The fourth study found no difference between combined hyperbaric oxygen therapy and antibiotics compared to antibiotics alone. Harmful effects of the different interventions were not reported clearly or were not important. Certainty of the evidence The level of certainty we have in these findings is very low. This was due to high risk of bias, not all studies mentioning important details, and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to stop ORN of the jaws from happening or making it less severe in adults receiving head and neck radiotherapy. We suggest that more, well‐conducted, and bigger studies including more people, should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "El‐Rabbany, M; Duchnay, M; Raziee, HR; Zych, M; Tenenbaum, H; Shah, PS; Azarpazhooh, A", "articleTypes": [], "doi": "10.1002/14651858.CD011559.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "50d90471-2349-4eee-888f-dee9ee33bd6e", "pmid": "", "title": "Needle size for vaccination procedures in children and adolescents", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane Review first published in 2015. The conclusions have not changed. Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller the diameter of the needle (e.g. a 23 G needle is 0.6 mm in diameter, whereas a 25 G needle is 0.5 mm in diameter). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. Guidelines conflict regarding the sizes of needles that should be used for vaccinating children and adolescents. Objectives To assess the effects of using needles of different sizes for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration). Search methods We updated our searches of CENTRAL, MEDLINE, Embase, and CINAHL to October 2017. We also searched proceedings of vaccine conferences and two trials registers. Selection criteria Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years. Data collection and analysis Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system. Main results We included five trials involving 1350 participants in the original review. The updated review identified no new trials. The evidence from two small trials (one trial including infants and one including adolescents) was insufficient to allow any definitive statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity. The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials included infants predominantly aged from two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole‐cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP‐Hib) and hepatitis B (DTwP‐Hib‐Hep B) antigen components. Primary outcomes Incidence of vaccine‐preventable diseases: No trials reported this outcome. Procedural pain and crying: Using a wider gauge 23 G 25 mm needle may slightly reduce procedural pain (low‐quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate‐quality evidence) compared with a narrower gauge 25 G 25 mm needle (one trial, 320 participants). The effects are probably not large enough to be clinically relevant. Secondary outcomes Immune response: There is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between use of 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP‐Hib vaccine at ages two, three, and four months (moderate‐quality evidence, one trial, numbers of participants in analyses range from 309 to 402. The immune response to the pertussis antigen was not measured). Severe and non‐severe local reactions: 25 mm needles (either 25 G or 23 G) probably lead to fewer severe and non‐severe local reactions after DTwP‐Hib vaccination compared with 25 G 16 mm needles (moderate‐quality evidence, one trial, 447 to 458 participants in analyses). We estimate that one fewer infant will experience a severe local reaction (extensive redness and swelling) after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat for an additional beneficial outcome (NNTB) with a 25 G 25 mm needle: 25 (95% confidence interval (CI) 15 to 100); NNTB with a 23 G 25 mm needle: 25 (95% CI 17 to 100)). We estimate that one fewer infant will experience a non‐severe local reaction (any redness, swelling, tenderness, or hardness (composite outcome)) at 24 hours after the first vaccine dose for every 5 or 6 infants vaccinated with a 25 mm rather than a 16 mm needle (NNTB with a 25 G 25 mm needle: 5 (95% CI 4 to 10); NNTB with a 23 G 25 mm needle: 6 (95% CI 4 to 13)). The results are similar after the second and third vaccine doses. Using a narrow gauge 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with a wider gauge 23 G 25 mm needle, but the effect estimates are imprecise (low‐quality evidence, two trials, 100 to 459 participants in analyses). Systemic reactions: The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of postvaccination fever and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence. Authors' conclusions Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole‐cell pertussis antigen component. These vaccines are predominantly used in low‐ and middle‐income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain. Plain language summary Needle size for vaccination procedures in children and adolescents Background Vaccines contain antigens that make the body's immune system produce antibodies that can protect against disease, which is known as an immune response. Antigens are modified or partial forms of the virus, bacteria, or toxin that cause the disease that the vaccine protects against. Because the antigen is altered from its original form, it cannot cause disease, but it can produce an immune response. Vaccines can be injected using needles of different lengths and gauges. The needle gauge (G) refers to the width (diameter) of the needle. The higher the gauge number, the narrower the needle. For example, a 25 G needle is approximately 0.5 mm in diameter and is narrower than a 23 G needle, which has a diameter of 0.6 mm. Guidelines conflict regarding the lengths and gauges of needles that should be used for vaccinating children and adolescents. Review question We wanted to find out if the length and gauge of needles used to vaccinate children and adolescents has an influence on the: 1) immune response to the injected vaccine; 2) pain experienced during the vaccination procedure; 3) occurrence of reactions such as swelling, tenderness, and redness at the site where the vaccine is given; fever (high temperature); and other side effects that can occur after vaccination. Quality of the evidence We included five studies involving 1350 people. We rated the quality of the evidence from studies as very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. There were problems with the design of some studies, and data were insufficient to answer some parts of our review question. The quality of the evidence from two studies was too low to allow us to draw any conclusions about the effects of the needles compared in the studies. However, there was sufficient evidence from the remaining three studies to allow us to reach conclusions. Study characteristics The three studies that allowed us to reach conclusions involved 1135 healthy infants aged mostly between two and six months. The infants were vaccinated in the thigh with either 25 G 25 mm (narrow, long needles), 23 G 25 mm (wide, long needles), or 25 G 16 mm needles (narrow, short needles). The needles were inserted at right angles (90° angle) into the skin and pushed down into the muscle of the thigh. The vaccines injected were combination vaccines designed to protect against several diseases including diphtheria (D), tetanus (T), whooping cough (pertussis), and Haemophilus influenzae type b disease (Hib). The vaccines all contained whole‐cell pertussis (wP) vaccine antigens. These vaccines are commonly used in low‐ and middle‐income countries but not in high‐income countries. Our review findings are therefore most relevant to low‐ and middle‐income countries. Key findings We found moderate‐quality evidence that infants vaccinated in the thigh with 25 mm needles probably have fewer severe reactions (extensive redness and swelling in the thigh) after DTwP‐Hib vaccination than infants vaccinated with 16 mm needles. We also found that the longer needles probably lead to fewer non‐severe reactions such as mild swelling, tenderness, and redness after vaccination. The immune response to the vaccine is probably similar with the long and the short needles. We found low‐quality evidence that the wide, long needle may slightly reduce the pain of the vaccination procedure compared with the narrow, long needle. We found moderate‐quality evidence that the wide, long needle probably slightly reduces the duration of crying immediately following vaccination compared with the narrow, long needle. The differences in pain and crying between use of the wide and narrow needles are probably too small to be of any practical importance. We found low‐quality evidence that infants vaccinated with the narrow, long needle may have slightly fewer non‐severe reactions than infants vaccinated with the wide, long needle. We do not know if needle size has an effect on fever or other reactions that sometimes occur after vaccination including drowsiness, loss of appetite, and vomiting due to the very low quality of the evidence. The evidence in our review is current to October 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Beirne, PV, Hennessy, S, Cadogan, SL, Shiely, F, Fitzgerald, T, MacLeod, F", "articleTypes": [], "doi": "10.1002/14651858.CD010720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.144Z" }, { "id": "50e8c761-481d-47dd-9a0f-3a2eeb77e532", "pmid": "", "title": "Physical therapy for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Bell's palsy (idiopathic facial paralysis) is commonly treated by various physical therapy strategies and devices, but there are many questions about their efficacy. Objectives To evaluate physical therapies for Bell's palsy (idiopathic facial palsy). Search methods We searched the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2011), MEDLINE (January 1966 to February 2011), EMBASE (January 1946 to February 2011), LILACS (January 1982 to February 2011), PEDro (from 1929 to February 2011), and CINAHL (January 1982 to February 2011). We included searches in clinical trials register databases until February 2011. Selection criteria We selected randomised or quasi‐randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention. Data collection and analysis Two authors independently scrutinised titles and abstracts identified from the search results. Two authors independently carried out risk of bias assessments, which took into account secure methods of randomisation, allocation concealment, observer blinding, patient blinding, incomplete outcome data, selective outcome reporting and other bias. Two authors independently extracted data using a specially constructed data extraction form. We undertook separate subgroup analyses of participants with more and less severe disability. Main results For this update to the original review, the search identified 65 potentially relevant articles. Twelve studies met the inclusion criteria (872 participants). Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies compared or combined some form of physical therapy with acupuncture (360 participants). For most outcomes we were unable to perform meta‐analysis because the interventions and outcomes were not comparable. For the primary outcome of incomplete recovery after six months, electrostimulation produced no benefit over placebo (moderate quality evidence from one study with 86 participants). Low quality comparisons of electrostimulation with prednisolone (an active treatment) (149 participants), or the addition of electrostimulation to hot packs, massage and facial exercises (22 participants), reported no significant differences. Similarly a meta‐analysis from two studies, one of three months and the other of six months duration (142 participants) found no statistically significant difference in synkinesis, a complication of Bell's palsy, between participants receiving electrostimulation and controls. A single low quality study (56 participants), which reported at three months, found worse functional recovery with electrostimulation (mean difference (MD) 12.00 points (scale of 0 to 100) 95% confidence interval (CI) 1.26 to 22.74). Two trials of facial exercises, both at high risk of bias, found no difference in incomplete recovery at six months when exercises were compared to waiting list controls or conventional therapy. There is evidence from a single small study (34 participants) of moderate quality that exercises are beneficial on measures of facial disability to people with chronic facial palsy when compared with controls (MD 20.40 points (scale of 0 to 100), 95% CI 8.76 to 32.04) and from another single low quality study with 145 people with acute cases treated for three months, in which significantly fewer participants developed facial motor synkinesis after exercise (risk ratio 0.24, 95% CI 0.08 to 0.69). The same study showed statistically significant reduction in time for complete recovery, mainly in more severe cases (47 participants, MD ‐2.10 weeks, 95% CI ‐3.15 to ‐1.05) but this was not a prespecified outcome in this meta analysis. Acupuncture studies did not provide useful data as all were short and at high risk of bias. None of the studies included adverse events as an outcome. Authors' conclusions There is no high quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. There is low quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases. There is low quality evidence that facial exercise reduces sequelae in acute cases. The suggested effects of tailored facial exercises need to be confirmed with good quality randomised controlled trials. Plain language summary Physical treatments for idiopathic facial paralysis Bell's palsy is an acute disorder of the facial nerve, which produces full or partial loss of movement on one side of the face. The facial palsy gets completely better without treatment in most, but not all, people. Physical therapies, such as exercise, biofeedback, laser treatment, electrotherapy, massage and thermotherapy, are used to hasten recovery, improve facial function and minimise sequelae. For this updated review we found a total of 12 studies with 872 participants, most with high risk of bias. Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies combined some form of physical therapy and compared with acupuncture (360 participants). There is evidence from a single study of moderate quality that exercises are beneficial to people with chronic facial palsy when compared with controls and from another low quality study that it is possible that facial exercises could help to reduce synkinesis (a complication of Bell's palsy), and the time to recover. There is insufficient evidence to decide whether electrical stimulation works, to identify risks of these treatments or to assess whether the addition of acupuncture to facial exercises or other physical therapy could produce improvement. In conclusion, tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases, and early facial exercise may reduce recovery time and long term paralysis in acute cases, but the evidence for this is of poor quality. More trials are needed to assess the effects of facial exercises and any risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Teixeira, LJ; Valbuza, JS; Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006283.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "50eafeda-1154-4fcf-b23c-f82f0b1da2bc", "pmid": "", "title": "Antiviral treatment for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. This review was first published in 2001 and most recently updated in 2015. Since a significant benefit of corticosteroids for the early management of Bell's palsy has been demonstrated, the main focus of this update, as in the previous version, was to determine the effect of adding antivirals to corticosteroid treatment. We undertook this update to integrate additional evidence and to better assess the robustness of findings, taking risk of bias fully into account. Objectives To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy. Search methods We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS in July 2019. We reviewed the bibliographies of the identified trials and contacted trial authors to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies. Selection criteria We considered randomised controlled trials (RCTs) or quasi‐RCTs of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that followed‐up participants for less than three months. Data collection and analysis We independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures. We performed sensitivity analyses excluding trials at high or unclear risk of bias in at least five domains, and reported these data as the primary analyses. Main results Fourteen trials, including 2488 participants, met the inclusion criteria. Most were small, and most were at high or unclear risk of bias in multiple domains. We included four new studies at this update. Incomplete recovery A combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in people with Bell's palsy compared to corticosteroids alone (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.38 to 1.74; 3 trials, N = 766; random‐effects; low‐certainty evidence). We excluded 10 trials that were at high or unclear risk of bias in several domains from this analysis and limited all analyses to studies at lower risk of bias. Recovery rates were better in participants receiving corticosteroids alone than antivirals alone (RR 2.69, 95% CI 0.73 to 10.01; 2 trials, N = 667; random‐effects), but the result was imprecise and allowed for the possibility of no effect. The rate of incomplete recovery was lower with antivirals plus corticosteroids than with placebo or no treatment (RR 0.56, 95% CI 0.42 to 0.76; 2 trials, N = 658; random‐effects). Antivirals alone had no clear effect on incomplete recovery rates compared with placebo, but the result was imprecise (RR 1.10, 95% CI 0.87 to 1.40; 2 trials, N = 658; fixed‐effect). For people with severe Bell's palsy (House‐Brackmann score of 5 and 6, or equivalent on other scales), we found that the combination of antivirals and corticosteroids had no clear effect on incomplete recovery at month six compared to corticosteroids alone, although the result was again imprecise (RR 0.82, 95% CI 0.57 to 1.17; 2 trials, N = 98; random‐effects). Motor synkinesis or crocodile tears Antivirals plus corticosteroids reduced the proportion of participants who experienced these long‐term sequelae from Bell's palsy compared to placebo plus corticosteroids (RR 0.56, 95% CI 0.36 to 0.87; 2 trials, N = 469; fixed‐effect; moderate‐certainty evidence). Antivirals plus corticosteroids reduced long‐term sequelae compared to placebo but there was no clear difference in this outcome with antivirals alone compared to placebo. Adverse events Adverse event data were available in four studies providing data on 1592 participants. None of the four comparisons showed clear differences in adverse events between treatment and comparison arms (very low‐certainty evidence); for the comparison of antivirals plus corticosteroids and corticosteroids alone in studies at lower risk of bias, the RR was 1.17 (95% CI 0.81 to 1.69; 2 trials, N = 656; fixed‐effect; very low‐certainty evidence). Authors' conclusions The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, or in people with severe Bell's palsy, but the results were very imprecise. Corticosteroids alone were probably more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no clear benefit from antivirals alone over placebo. The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone. Studies also showed fewer episodes of long‐term sequelae in corticosteroid‐treated participants than antiviral‐treated participants. We found no clear difference in adverse events from the use of antivirals compared with either placebo or corticosteroids, but the evidence is too uncertain for us to draw conclusions. An adequately powered RCT in people with Bell’s palsy that compares different antiviral agents may be indicated. Plain language summary Antiviral treatment for Bell's palsy Review question We reviewed the evidence about the effect of antiviral therapy (drugs used specifically to treat viral infections), alone or in combination with any other therapy, on Bell's palsy. Our focus in this updated review was combined therapy with antiviral drugs and corticosteroids (which are drugs used to reduce inflammation) as there is already good evidence that corticosteroids can reduce rates of incomplete recovery from Bell's palsy. Background Bell's palsy is a disease of the facial nerve that causes one side of the face to be paralysed. Some studies have suggested that it is caused by the same viral infections that cause cold sores or shingles and investigated the effect of antiviral therapy. Earlier versions of this review have found that antivirals alone are not helpful compared to a dummy pill, and are less effective than corticosteroids alone. However, studies of antiviral treatment in combination with corticosteroids have conflicting results. Study characteristics We identified 14 trials, which included 2488 participants with mild, moderate, or severe one‐sided Bell's palsy of unknown cause. Participants were aged from 14 to 84 years. The trials compared:
 ‐ antivirals plus corticosteroids to corticosteroids alone or in combination with placebo;
 ‐ antivirals alone or in combination with placebo to placebo or no treatment;
 ‐ antivirals alone or in combination with placebo to corticosteroid treatment alone or in combination with placebo; or
 ‐ antivirals plus corticosteroids to placebo or no treatment. For the majority of the studies, no information on funding was given. The remaining were mostly partly public funded, and one trial was funded by a pharmaceutical company. Eleven studies had high or uncertain risk of bias from various factors that can systematically affect trial results. We chose to base our conclusions only on data from three studies at a lower risk of bias. Key results and certainty of the evidence The review showed that there may be no clear difference in rates of incomplete recovery from Bell's palsy after treatment with the combination of antivirals and corticosteroids, compared to corticosteroids alone. This finding was of low certainty and was based on data from three trials involving 766 people with Bell's palsy of various degrees of severity. We excluded data from 10 trials with multiple potential sources of bias. However, we can be moderately confident that the combined therapy reduced the number of people left with long‐term effects of Bell's palsy (excessive tearing of the eyes or an abnormal facial movement) compared to corticosteroid treatment alone. Data from two studies (98 participants) showed that in people with severe Bell's palsy (complete or almost complete facial paralysis), combined antivirals and corticosteroids had no clear effect on recovery compared with corticosteroid treatment alone. Corticosteroids alone were more effective than antivirals alone on rates of incomplete recovery (667 participants, 2 trials); antivirals and corticosteroids combined were more effective than placebo or no treatment (658 participants, 2 trials); and there was no clear benefit from antivirals alone over placebo (658 participants, 2 trials). Although, based on data from two trials (656 participants), we found no clear difference in the occurrence of side effects between people receiving both antivirals and corticosteroids, compared to those receiving corticosteroids alone, this evidence is too uncertain for us to draw conclusions. Large studies in people with Bell's palsy comparing additional antiviral agents may be indicated in the future.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gagyor, I; Madhok, VB; Daly, F; Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001869.pub9", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "512a6daf-10e5-481a-9bdb-d1dc42c67ce7", "pmid": "", "title": "Rinse‐free hand wash for reducing absenteeism among preschool and school children", "imported": false, "abstract": "Abstract - Background Illness‐related absenteeism is an important problem among preschool and school children for low‐, middle‐ and high‐ income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse‐free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness‐related absenteeism in preschool and school children. Objectives 1. To assess the effectiveness of rinse‐free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse‐free hand washing products are the most effective (if head‐to‐head comparisons exist), and what effect additional strategies in combination with rinse‐free hand washing have on the outcomes of interest. Search methods In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied. Selection criteria Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse‐free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions. Data collection and analysis Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings. Main results This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most‐notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse‐free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low‐certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse‐free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse‐free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low‐certainty evidence), which indicates rinse‐free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse‐free' group (eight days absent per 1000). There may be little to no difference between rinse‐free hand washing and 'no rinse‐free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low‐certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very‐low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse‐free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very‐low certainty evidence). Authors' conclusions The findings of this review may have identified a small yet potentially beneficial effect of rinse‐free hand washing regimes on illness‐related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse‐free hand washing regimens in order to provide more conclusive, higher‐certainty evidence regarding its impact. When considering the use of a rinse‐free hand washing program in a local setting, there needs to be consideration of the current rates of illness‐related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings. Plain language summary Rinse‐free hand wash for reducing absenteeism among preschool and school children Background Absenteeism from schooling is costly to parents, schools and governments and sustained absence is detrimental to student learning. Illness‐related absenteeism is a significant contributor to absenteeism from school, but can also result in parents missing work due to catching the illness themselves or having to stay home to care for their children. There are several strategies currently used to reduce illness‐related absenteeism, a common method is the implementation of appropriate hand hygiene practices. However, hand hygiene using soap and water is not always practical, and alternatives may prove to be more effective in reducing the overall rate of illness‐related absenteeism. One such alternative is the use of rinse‐free hand wash. Review question This review was designed to investigate if the use of rinse‐free hand wash can reduce the number of days spent absent from school in preschool and school children compared to no rinse‐free hand wash usage. Study characteristics The searches returned 19 relevant studies with a total of 30,747 participants. Eight studies were conducted in the USA, two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to14 years). These studies were quite varied in the composition and application of the rinse‐free hand washing program. Only two studies included information on the primary outcome (absenteeism due to any reason), whilst for absenteeism for any illness there were six studies that provided information. The evidence presented is up to date to February 2020. Key results The application of, and adherence to a rinse‐free hand wash, hand hygiene program may be associated with small, but potentially beneficial effects in reducing the number of days students were absent from school due to illness compared to no rinse‐free hand wash, hygiene program. However rinse‐free hand washing may be no different to controls at reducing absenteeism for any reason. There may also be no difference in the number of skin irritations between students who received the rinse‐free hand wash compared to those who used soap and water. Most students and teachers responded favorably to using rinse‐free hand wash and complied relatively well with its use. Certainty of the evidence The certainty of the evidence included in this review was low or very low, mainly due to the included studies using poor methods, providing imprecise data, and being very inconsistent from one another. This means that we have low and very‐low certainty, or confidence, in these results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Munn, Z; Tufanaru, C; Lockwood, C; Stern, C; McAneney, H; Barker, TH", "articleTypes": [], "doi": "10.1002/14651858.CD012566.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "51458da1-9349-43f6-adea-abfb653efe7b", "pmid": "", "title": "Open versus closed surgical exposure of canine teeth that are displaced in the roof of the mouth", "imported": false, "abstract": "Abstract - Background Palatally displaced canines or PDCs are upper permanent canines, commonly known as 'eye' teeth, that are displaced in the roof of the mouth. This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. PDCs are a frequent dental anomaly, present in 2% to 3% of young people. Management of this problem is both time consuming and expensive. It involves surgical exposure (uncovering) followed by fixed braces for two to three years to bring the canine into alignment within the dental arch. Two techniques for exposing palatal canines are routinely used in the UK: the closed technique and the open technique. The closed technique involves uncovering the canine, attaching an eyelet and gold chain and then suturing the palatal mucosa back over the tooth. The tooth is then moved into position covered by the palatal mucosa. The open technique involves uncovering the canine tooth and removing the overlying palatal tissue to leave it uncovered. The orthodontist can then see the crown of the canine to align it. Objectives To assess the effects of using either an open or closed surgical method to expose canines that have become displaced in the roof of the mouth, in terms of success and other clinical and patient‐reported outcomes. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 24 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (in the Cochrane Library, 2017, Issue 1), MEDLINE Ovid (1946 to 24 February 2017), and Embase Ovid (1980 to 24 February 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised and quasi‐randomised controlled trials assessing young people receiving surgical treatment to correct upper PDCs. There was no restriction on age, presenting malocclusion or type of active orthodontic treatment undertaken. We included unilaterally and bilaterally displaced canines. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias in the included studies. We attempted to contact study authors for missing data or clarification where feasible. We followed statistical guidelines from the Cochrane Handbook for Systematic Reviews of Interventions for data synthesis. Main results We included three studies, involving 146 participants. Two studies were assessed as being at high risk of bias. The main finding of the review was that the two techniques may be equally successful at exposing PDCs (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.93 to 1.06; three studies, 141 participants analysed, low‐quality evidence). One surgical failure was due to detachment of the gold chain (closed group). One study reported on complications following surgery and found two in the closed group: a post‐operative infection requiring antibiotics and pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to pool data for dental aesthetics, patient‐reported pain and discomfort, periodontal health and treatment time; however, individual studies did not find any differences between the surgical techniques (low‐ to very low‐quality evidence). Authors' conclusions Currently, the evidence suggests that neither the open or closed surgical technique for exposing palatally displaced maxillary canine teeth is superior for any of the outcomes included in this review; however, we considered the evidence to be low quality, with two of the three included studies being at high risk of bias. This suggests the need for more high‐quality studies. Three ongoing clinical trials have been identified and it is hoped that these will produce data that can be pooled to increase the degree of certainty in these findings. Plain language summary Open versus closed surgical exposure of eye teeth that are displaced in the roof of the mouth Review question Is it better to use an open or closed surgical method to expose eye teeth ('canines') that have become displaced in the roof of the mouth? Background Permanent canine teeth in the upper jaw usually erupt into the mouth between the ages of 11 to 12 years. In 2% to 3% of young people, the canine teeth fail to erupt (grow down) and become displaced in the roof of the mouth (palate).This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. Management of this problem is both time consuming and expensive. It usually involves surgical exposure (uncovering), followed by fixed orthodontic braces for two to three years, to move the canine into the correct position. Two surgical techniques are routinely used in the UK: the closed technique involves uncovering the buried tooth, gluing an attachment onto the exposed tooth and repositioning the palatal flap. Shortly after surgery, an orthodontic brace is used to apply gentle forces to bring the canine into its correct position within the dental arch. The canine moves into position beneath the gum. An alternative method is the open technique, which involves surgically uncovering the canine tooth as before, but instead of placing an attachment onto the exposed tooth, a window of gum from around the tooth is removed and a dressing (pack) placed to cover the exposed area. Approximately 10 days later, this pack is removed and the canine is allowed to erupt naturally. Once the tooth has erupted sufficiently for an orthodontic attachment to be glued onto its surface, orthodontic braces are used to bring the tooth in line with the other teeth. Study characteristics The evidence in this review is up‐to‐date as of February 2017. Authors with Cochrane Oral Health found three relevant studies, involving 146 participants who had eye teeth displaced in the roof of the mouth, either on one or both sides. The majority of participants were female and the average age in the studies ranged from 14 to 17 years. Two studies were designed in a way that made them likely to be biased. Key results We combined results from three studies and found that one technique did not seem to have an advantage over the other for ensuring the movement of the tooth into the correct position without the need for repeat surgery. Five out of 141 participants analysed were surgical failures, one of which was due to the complication of detachment of the gold chain during surgery. One study reported complications after surgery and found one participant in the closed group had a post‐operative infection requiring antibiotics and another participant in the closed group experienced pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to combine results from studies for any other outcomes, but individual studies did not show evidence of a difference between the two techniques for pain, discomfort, appearance, gum health, length of treatment time or cost (low to very low quality evidence). Quality of the evidence Overall, we assessed the quality of the evidence as low, which means we cannot be certain of the findings. Author conclusions It does not seem that one surgical technique is better than the other for moving displaced eye teeth into the correct position, or for other outcomes, but this finding is uncertain because the quality of the evidence is low. This suggests the need for more high‐quality studies. Three studies are currently in process. When they are completed, we will include them in an update of this review and may be able to reach firmer conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Parkin, N, Benson, PE, Thind, B, Shah, A, Khalil, I, Ghafoor, S", "articleTypes": [], "doi": "10.1002/14651858.CD006966.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.078Z" }, { "id": "514843f8-1ad6-4f6f-b8d1-190a821f19c7", "pmid": "", "title": "Interventions for acute otitis externa", "imported": false, "abstract": "Abstract - Background Acute otitis externa is an inflammatory condition of the ear canal, with or without infection. Symptoms include ear discomfort, itchiness, discharge and impaired hearing. It is also known as 'swimmer's ear' and can usually be treated successfully with a course of ear drops. Objectives To assess the effectiveness of interventions for acute otitis externa. Search methods Our search for published and unpublished trials included the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources. The date of the most recent search was 6 January 2009. Selection criteria Randomised controlled trials evaluating ear cleaning, topical medication or systemic therapy in the treatment of acute otitis externa were eligible. We excluded complicated acute otitis externa; otitis externa secondary to otitis media or chronic suppurative otitis media; chronic otitis externa; fungal otitis externa (otomycosis); eczematous otitis externa; viral otitis externa and furunculosis. Data collection and analysis Two authors assessed eligibility and quality. Main results Nineteen randomised controlled trials with a total of 3382 participants were included. Three meta‐analyses were possible. The overall quality of studies was low. Topical antimicrobials containing steroids were significantly more effective than placebo drops: OR 11 (95% CI 2.00 to 60.57; one trial). In general, no clinically meaningful differences were noted in clinical cure rates between the various topical interventions reviewed. One notable exception involved a trial of high quality which showed that acetic acid was significantly less effective when compared with antibiotic/steroid drops in terms of cure rate at two and three weeks (OR 0.29 (95% CI 0.13 to 0.62) and OR 0.25 (95% CI 0.11 to 0.58) respectively). One trial of low quality comparing quinolone with non‐quinolone antibiotics did not find any difference in clinical cure rate. No trials evaluated the effectiveness of ear cleaning. Only two trials evaluated steroid‐only drops. One trial of low quality suggested no significant difference between steroid and antibiotic/steroid but did not report the magnitude or precision of the result. Another trial of moderate quality comparing an oral antihistamine with topical steroid against topical steroid alone found that cure rates in both groups were high and comparable (100% (15/15) and 94% (14/15) respectively at three weeks). Authors' conclusions There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available: Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow‐up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid. The evidence for steroid‐only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed. Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision. Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated. Plain language summary Interventions to treat acute otitis externa, a specific form of ear canal inflammation also known as swimmer's ear Acute otitis externa causes inflammation of the ear canal. It is a common clinical problem encountered in general practice. This review assesses the various forms of medication used to treat the condition. Nineteen randomised controlled trials were included (3382 participants). Most were of low quality. The findings of the review may not be wholly relevant to primary care as most of the trials were conducted in a hospital setting and over half involved ear cleaning as part of the treatment (this is generally not available in primary care). However, the review does demonstrate that topical treatments alone are effective at treating acute otitis externa. There was little to choose between them in terms of effectiveness. However, when treatment needs to be extended beyond one week acetic acid drops appear to be less effective than antibiotic/steroid drops. In addition, symptoms persist for two days longer in those treated with acetic acid. More research is needed to determine the effectiveness of steroid‐only drops. Patients treated with antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Kaushik, V; Malik, T; Saeed, SR", "articleTypes": [], "doi": "10.1002/14651858.CD004740.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "514f99a7-e3f8-41a3-91d0-4738a7700a73", "pmid": "", "title": "Treatment of periodontitis for glycaemic control in people with diabetes mellitus", "imported": false, "abstract": "Abstract - Background Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontitis. Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus, and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement, or non‐surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe. This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care. Objectives To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis. Search methods An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. Selection criteria We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment or adjunctive antimicrobial therapy or both) to no active intervention or 'usual care' (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least 3 months and have measured HbA1c (glycated haemoglobin). Data collection and analysis At least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials, and assessed included trials for risk of bias. Where necessary and possible, we attempted to contact study authors. Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol). Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index, and probing pocket depth), quality of life, cost implications, and diabetic complications. Main results We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel‐RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 diabetes, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair, or poor. Most studies were carried out in secondary care. We assessed two studies as being at low risk of bias, 14 studies at high risk of bias, and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings. Moderate‐certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) ‐0.59% to ‐0.28%; ‐6.4 mmol/mol to ‐3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI ‐0.52% to ‐0.08%; ‐5.7 mmol/mol to ‐0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI ‐0.55% to ‐0.45%; ‐6.0 mmol/mol to ‐4.9 mmol/mol; 1 study, 264 participants). Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, adverse effects of periodontal treatments were not evaluated in most studies. Authors' conclusions Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate‐certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in this review. Plain language summary Does treatment for gum disease help people with diabetes control blood sugar levels? Review question The main question addressed by this review is: how effective is gum disease (periodontitis) treatment for controlling blood sugar levels (known as glycaemic control) in people with diabetes, compared to no active treatment or usual care? Background The aim of treating periodontitis is to reduce swelling and infection and stabilise the condition of the gums and supporting bone. The level of sugar in the blood is too high in people with diabetes, so keeping blood sugar levels under control is a key issue. Some clinical research suggests a relationship exists between gum disease treatment and glycaemic control. Glycaemic control can be measured in different ways. For this review, we focused on HbA1c, which shows average blood glucose levels over the preceding 3 months. It can be reported as a percentage (of total haemoglobin) or as mmol/mol (millimoles per mole). Excellent glycaemic control in a diabetic person might be around 6.5% or 48 mmol/mol. This review was carried out by authors working with the Cochrane Oral Health and is part one of an update of a review previously published in 2010 and 2015. This review evaluates gum disease treatment versus no active treatment or usual care. Part two of the review will compare different types of periodontal treatment. We carried out this review as it is important to discover if gum disease treatment does improve glycaemic control in order to ensure best use of clinical resources. Study characteristics We searched six research databases and found 35 relevant trials where people with diabetes and periodontitis were randomly allocated to an experimental group or a control group. The experimental groups received gum disease treatment called 'subgingival instrumentation', also known as scaling and root planing or deep cleaning. In some experimental groups, the deep cleaning was supplemented with instructions for cleaning teeth properly ('oral hygiene instruction'), or other gum treatments, for example, antimicrobials, which are used to treat infections. Control groups received no active treatment or 'usual care', which was oral hygiene instruction, support with oral hygiene, and/or removal of plaque above the gumline. The trials randomised 3249 participants in total. Almost all participants had type 2 diabetes, with a mix of good, fair, and poor diabetic control. Most of the studies were carried out in hospitals. The studies followed up participants for between 3 and 12 months. Key results Evidence from 30 trials (results from 2443 participants) showed that periodontitis treatment reduces blood sugar levels (measured by HbA1c) in diabetic patients on average by 0.43 percentage points (e.g. from 7.43% to 7%; 4.7 mmol/mol) 3 to 4 months after receiving the treatment compared with no active treatment or usual care. A difference of 0.30% (3.3 mmol/mol) was seen after 6 months (12 studies), and 0.50% (5.4 mmol/mol) at 12 months (one study). There were not enough studies measuring side effects to be able to evaluate the risk of harm from gum disease treatments. Certainty of the evidence Most of the studies were conducted in a way that meant they were at a high risk of bias or did not provide enough information for us to make a judgement on this. However, the consistency of our findings suggests they are reliable and future research is not likely to change them. In summary, currently there is moderate‐certainty evidence to support gum disease treatment (known as subgingival instrumentation) for controlling blood sugar levels in people with periodontitis (gum disease) and diabetes up to 12 months after the start of the periodontal treatment. Date of the search The evidence is current up to 7 September 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Simpson, TC, Clarkson, JE, Worthington, HV, MacDonald, L, Weldon, JC, Needleman, I, Iheozor-Ejiofor, Z, Wild, SH, Qureshi, A, Walker, A, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD004714.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.805Z" }, { "id": "515d989e-f84a-4755-a113-a18e35db5708", "pmid": "", "title": "Oral water soluble contrast for malignant bowel obstruction", "imported": false, "abstract": "Abstract - Background Malignant bowel obstruction (MBO) is a common problem in patients with intra‐abdominal cancer. Oral water soluble contrast (OWSC) has been shown to be useful in the management of adhesive small bowel obstruction in identifying patients who will recover with conservative management alone and also in reducing the length of hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in patients with MBO. Objectives To determine the reliability of OWSC media and follow‐up abdominal radiographs in predicting the success of conservative treatment in resolving inoperable MBO with conservative management. To determine the efficacy and safety of OWSC media in reducing the duration of obstruction and reducing hospital stay in people with MBO. Search methods We identified studies from searching Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in Process, Embase, CINAHL, Science Citation Index (Web of Science) and Conference Proceedings Citation Index ‐ Science (Web of Science). We also searched registries of clinical trials and the CareSearch Grey Literature database. The date of the search was the 6 June 2017. Selection criteria Randomised controlled trials (RCTs), or prospective controlled studies, that evaluated the diagnostic potential of OWSC in predicting which malignant bowel obstructions will resolve with conservative treatment. RCTs, or prospective controlled studies, that assessed the therapeutic potential of OWSC in managing MBO at any level compared with placebo, no intervention or usual treatment or supportive care. Data collection and analysis We used standard methodological procedures expected by Cochrane. We assessed risk of bias and assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We found only one RCT meeting the selection criteria for the second objective (therapeutic potential) of this review. This study recruited nine participants. It compared the use of gastrografin versus placebo in adult patients with MBO with no indication for further intervention (surgery, endoscopy) apart from standardised conservative management. The overall risk of bias for the study was high due to issues with low numbers of participants, selective reporting of outcomes and a high attrition rate for the intervention arm. Primary outcomes The included trial was a pilot study whose primary outcome was to test the feasibility for a large study. The authors reported specifically on the number of patients screened, the number recruited and reasons for exclusion; this was not the focus of our review. Due to the low number of participants, the authors of the study decided not to report on our primary outcome of assessing the ability of OWSC to predict the likelihood of malignant small bowel obstruction resolving with conservative treatment alone (diagnostic effect). It also did not report on our primary outcome of rate of resolution of MBO in patients receiving OWSC compared with those not receiving it (therapeutic effect). The study reported that no issues regarding safety or tolerability of either gastrografin or placebo were identified. The overall quality of the evidence for the incidence of adverse events with OWSC was very low, downgraded twice for serious limitations to study quality (high risk of selective reporting and attrition bias) and downgraded once for imprecision (sparse data). Secondary outcomes The study planned to report on this review’s secondary outcome measures of length of hospital stay and time from administration of OWSC to resolution of MBO. However the authors of the study decided not to do so due to the low numbers of patients recruited. The study did not report on our secondary outcome measure of survival times from onset of inoperable MBO until death. Authors' conclusions There is insufficient evidence from RCTs to determine the place of OWSC in predicting which patients with inoperable MBO will respond with conservative treatment alone. There is also insufficient evidence from RCTs to determine the therapeutic effects and safety of OWSC in patients with malignant small bowel obstruction. Plain language summary Oral water soluble contrast for cancer‐related bowel obstruction Background Intra‐abdominal cancer is where the cancer has either started elsewhere in the body and spread into the stomach area or started in the bowel itself. It can commonly grow and block the movement of food or faeces through the bowel. A blockage of the bowel caused by cancer is known as malignant bowel obstruction (MBO). Some patients with MBO benefit from surgery to reverse the blockage. In others it is not possible to reverse the MBO and it either resolves or becomes permanent (limiting prognosis to days or weeks). Scar tissue around the bowel (called adhesions) can also cause a blockage, this is known as adhesive small bowel obstruction. Adhesive obstructions often resolve with conservative management in hospital (allowing the bowel to \"rest\" and recover). However in some, the obstruction requires surgery to remove the scar tissue and fix the blockage. Oral water soluble contrast (OWSC) is often prepared in liquid form and when swallowed before an x‐ray or computed tomography (CT) scan will show up clearly in the bowel. It can predict which people with adhesive small bowel obstruction will require surgery. In some patients it may also speed recovery leading to reduced hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in MBO. Study characteristics We searched for evidence that OWSC could be used to identify which patients with inoperable MBO would recover with conservative management. We also wanted to know if OWSC increased the likelihood of recovery from MBO, reduced hospital stay or improved prognosis. Finally, we wished to know what side effects OWSC might cause for patients with MBO. We conducted the search in June 2017 and found one study. It only recruited nine participants and did not fully report on the outcomes of using OWSC in MBO. Key Findings We found insufficient evidence that OWSC can identify which patients with MBO will recover with conservative management. We found insufficient evidence that patients with MBO benefit from OWSC in terms of length of hospital stay, recovery time or survival. No conclusions could be made about side effects from OWSC. Quality of Evidence We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. We rated the quality of the evidence as very low due to the lack of studies reporting on the benefits of using OWSC in MBO and the only study we found reporting on side effects recruited very few participants (nine). The low quality of the evidence means that we are very uncertain about the use of OWSC in the management of MBO and cannot confirm its benefits or harms in patients with this condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Syrmis, W, Richard, R, Jenkins-Marsh, S, Chia, SC, Good, P", "articleTypes": [], "doi": "10.1002/14651858.CD012014.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.090Z" }, { "id": "51621d86-86b6-4a6e-baa7-4c3fa013b418", "pmid": "", "title": "Prophylactic TCM for Mitigation of EGFR-TKI Related Dermatological Adverse Effect", "imported": false, "abstract": "Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have become standard practice for advanced non-small cell lung cancer (NSCLC) with EGFR gene mutation. EGFR-TKIs involving Afatinib, Erlotinib, and Gefitinib were Food and Drug Administration (FDA) approved since 2006 and given payment continuously for lung adenocarcinoma with EGFR mutation in Taiwan.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.268Z" }, { "id": "51766e26-8d82-4efe-bf62-331c000ce2be", "pmid": "", "title": "Antiamoebic drugs for treating amoebic colitis", "imported": false, "abstract": "Abstract - Background Infection with the protozoan Entamoeba histolytica is common in low‐ and middle‐income countries, and up to 100,000 people with severe disease die every year. Adequate therapy for amoebic colitis is necessary to reduce illness, prevent development of complicated disease and extraintestinal spread, and decrease transmission. Objectives To evaluate antiamoebic drugs for treating amoebic colitis. Search methods We searched the available literature up to 22 March 2018. We searched the Cochrane Infectious Diseases Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, m RCT, and conference proceedings. We contacted individual researchers, organizations, and pharmaceutical companies, and we checked reference lists. Selection criteria Randomized controlled trials of antiamoebic drugs given alone or in combination, compared with placebo or another antiamoebic drug, for treating adults and children with a diagnosis of amoebic colitis. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of trials and extracted and analysed the data. We calculated clinical and parasitological failure rates and rates of relapse and adverse events as risk ratios (RRs) with 95% confidence intervals (CIs), using a random‐effects model. We determined statistical heterogeneity and explored possible sources of heterogeneity using subgroup analyses. We carried out sensitivity analysis by using trial quality to assess the robustness of reported results. Main results In total, 41 trials (4999 participants) met the inclusion criteria of this review. In this update, we added four trials to the 37 trials included in the first published review version. Thirty trials were published over 20 years ago. Only one trial used adequate methods of randomization and allocation concealment, was blinded, and analysed all randomized participants. Only one trial used an E histolytica stool antigen test, and two trials used amoebic culture. Tinidazole may be more effective than metronidazole for reducing clinical failure (RR 0.28, 95% CI 0.15 to 0.51; 477 participants, eight trials; low‐certainty evidence) and is probably associated with fewer adverse events (RR 0.65, 95% CI 0.46 to 0.92; 477 participants, 8 trials; moderate‐certainty evidence). Compared with metronidazole, combination therapy may result in fewer parasitological failures (RR 0.36, 95% CI 0.15 to 0.86; 720 participants, 3 trials; low‐certainty evidence), but we are uncertain which combination is more effective than another. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Authors' conclusions Compared with metronidazole, tinidazole may be more effective in reducing clinical failure and may be associated with fewer adverse events. Combination drug therapy may be more effective for reducing parasitological failure compared with metronidazole alone. However, these results are based mostly on small trials conducted over 20 years ago with a variety of poorly defined outcomes. Tests that detect E histolytica more accurately are needed, particularly in countries where concomitant infection with other bacteria and parasites is common. 11 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (22 Mar, 2018) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Antiamoebic drugs for treating amoebic colitis What is the aim of this review? This Cochrane Review aims to determine the effectiveness and safety of drugs used to treat people with amoebic colitis, which is an infection of the large intestines caused by the parasite, Entamoeba histolytica . Cochrane researchers searched for all relevant studies to answer this question and included 41 relevant studies in this review. Key messages Tinidazole may be more effective than metronidazole for reducing clinical symptoms and may be associated with fewer adverse events. Combination therapy resulted in fewer parasitological failures than occurred with metronidazole alone. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Better quality randomized trials using accurate diagnostic methods and standardized outcomes are needed to evaluate the efficacy of drugs for treating individuals with amoebic colitis. What was studied in the review? Entamoeba histolytica is distributed throughout the world and is commonly acquired by ingestion of contaminated food or water. An estimated 40 to 50 million people infected with E histolytica develop amoebic colitis or extraintestinal abscesses, resulting in up to 100,000 deaths per year. Metronidazole is currently the standard therapy for treating adults and children with invasive amoebiasis, but it may not be sufficient to eliminate amoebic cysts from the intestine. Some unpleasant adverse effects have been associated with metronidazole, and the possibility of parasite resistance to metronidazole has led to the development of alternative drugs. Combinations of metronidazole with other drugs that eradicate surviving cysts in the intestines have been recommended, so evidence to support this approach needs to be assessed. This review compares different drugs used against amoebic colitis, alone or in combination, and also assesses single‐dose regimens versus longer regimens. What are the main results of the review? This review included 41 studies, most of which were conducted in countries considered to be highly endemic for amoebiasis. Most trials were old: 30 were conducted before 1998. Trials varied in the inclusion criteria used to enrol participants and in the definition and timing of measured outcomes. Stool microscopy with direct wet saline smear was the method used most often to detect the presence of E histolytica in stools. Study participants ranged in age from seven months to 80 years. Included trials reported a variety of comparisons and involved 25 individual drugs, two herbal products, and 15 different combinations. The review shows that in individuals with amoebic colitis, tinidazole may be better for reducing clinical symptoms (low‐certainty evidence) and probably results in fewer adverse events when compared with metronidazole (moderate‐certainty evidence). However, we do not know whether it is more effective for eradicating amoebae from the stools. Combination drug therapy may be more effective than metronidazole alone for eradicating amoebae (low‐certainty evidence), but we are uncertain which drug combination is most effective, and if combination treatment will lead to more rapid resolution of clinical symptoms or in more adverse events (very low‐certainty evidence). Evidence is insufficient to allow conclusions regarding efficacy of the other antiamoebic drugs. How up‐to‐date is this review? 
 The review authors searched for studies that had been published up to 22 March 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gonzales, MLM; Dans, LF; Sio‐Aguilar, J", "articleTypes": [], "doi": "10.1002/14651858.CD006085.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "5177a4c9-065b-4679-9bc2-daa25282d257", "pmid": "", "title": "Triptans for acute cluster headache", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 ( Law 2010 ). Cluster headache is an uncommon, severely painful, and disabling condition, with rapid onset. Validated treatment options are limited; first‐line therapy includes inhaled oxygen. Other therapies such as intranasal lignocaine and ergotamine are not as commonly used and are less well studied. Triptans are successfully used to treat migraine attacks and they may also be useful for cluster headache. Objectives To assess the efficacy and tolerability of the triptan class of drugs compared to placebo and other active interventions in the acute treatment of episodic and chronic cluster headache in adult patients. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ClinicalTrials.gov, and reference lists for studies from inception to 22 January 2010 for the original review, and from 2009 to 4 April 2013 for this update. Selection criteria Randomised, double‐blind, placebo‐controlled studies of triptans for acute treatment of cluster headache episodes. Data collection and analysis Two review authors independently assessed study quality and extracted data. Numbers of participants with different levels of pain relief, requiring rescue medication, and experiencing adverse events and headache‐associated symptoms in treatment and control groups were used to calculate relative risk and numbers needed to treat for benefit (NNT) and harm (NNH). Main results New searches in 2013 did not identify any relevant new studies. All six included studies used a single dose of triptan to treat an attack of moderate to severe pain intensity. Subcutaneous sumatriptan was given to 131 participants at a 6 mg dose, and 88 at a 12 mg dose. Oral or intranasal zolmitriptan was given to 231 participants at a 5 mg dose, and 223 at a 10 mg dose. Placebo was given to 326 participants. Triptans were more effective than placebo for headache relief and pain‐free responses. By 15 minutes after treatment with subcutaneous sumatriptan 6 mg, 48% of participants were pain‐free and 75% had no pain or mild pain (17% and 32% respectively with placebo). NNTs for subcutaneous sumatriptan 6 mg were 3.3 (95% CI 2.4 to 5.0) and 2.4 (1.9 to 3.2) respectively. Intranasal zolmitriptan 10 mg was of less benefit, with 12% of participants pain‐free and 28% with no or mild pain (3% and 7% respectively with placebo). NNTs for intranasal zolmitriptan 10 mg were 11 (6.4 to 49) and 4.9 (3.3 to 9.2) respectively. Authors' conclusions Based on limited data, subcutaneous sumatriptan 6 mg was superior to intranasal zolmitriptan 5 mg or 10 mg for rapid (15 minute) responses, which are important in this condition. Oral routes of administration are not appropriate. Plain language summary Triptans for acute cluster headache Cluster headaches are excruciating headaches of extreme intensity. They can last for several hours, are usually on one side of the head only, and affect men more than women. Multiple headaches can occur over several days. Fast pain relief is important because of the intense nature of the pain with cluster headache. Triptans are a type of drug used to treat migraine. Although migraine is different from cluster headache, there are reasons to believe that some forms of these drugs could be useful in cluster headache. Triptans can be given by injection under the skin (subcutaneously) or by a spray into the nose (intranasally) to produce fast pain relief. The review found six studies examining two different triptans. The number of people in the studies was limited. Within 15 minutes of using subcutaneous sumatriptan 6 mg, almost 8 in 10 participants had no worse than mild pain, and 5 in 10 were pain‐free. Within 15 minutes of using intranasal zolmitriptan 5 mg, about 3 in 10 had no worse than mild pain, and 1 in 10 was pain‐free. Adverse events were more common with a triptan than with placebo but they were generally of mild to moderate severity. Cluster headache is an awful thing to have. More research on how to get better pain relief faster, and to more patients, would be welcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Law, S, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008042.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.083Z" }, { "id": "51840351-a03b-449d-8312-9568643e88a4", "pmid": "", "title": "Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five‐year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis. Objectives To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions. Search methods We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi‐randomised trials. The reference lists of relevant articles were also searched. Selection criteria All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded. Data collection and analysis Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author. Main results A total of 40 randomised or quasi‐randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials. For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights. Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects. Authors' conclusions There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials. Plain language summary Drug treatment for children with bedwetting (nocturnal enuresis) but not including the drug types desmopressin or tricyclics Bedwetting (nocturnal enuresis) is the involuntary loss of urine at night without an underlying organic disease as the cause. It can result in social problems, sibling teasing and lowered self esteem. It affects around 15% to 20% of five‐year olds, and up to 2% of adults. Many different types of drugs have been used to treat children with bed wetting. There is not enough reliable evidence to show that drugs other than desmopressin or tricyclics reduce bedwetting in children during treatment when used in isolation, despite their risk of unwanted side effects. In other Cochrane reviews, alarms triggered by wetting, desmopressin and tricyclic drugs have been shown to work during treatment. However, alarms have a more sustained effect than desmopressin and tricyclics after treatment has finished. The adverse effects of alarm therapy (tiredness and waking other members of the family) are relatively benign and self limiting compared with the adverse effects of drugs. One class of drugs (anticholinergic drugs) appears to improve the efficacy of other established treatments such as tricyclics, bedwetting alarms and desmopressin. The cost of treating children with bedwetting with alarm therapy or drugs may vary in different countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Deshpande, AV, Caldwell, PHY, Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.112Z" }, { "id": "51966888-bedf-4fa3-811b-83c9e2dde2e1", "pmid": "", "title": "Intranasal fentanyl for the management of acute pain in children", "imported": false, "abstract": "Abstract - Background Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula. Objectives We identified and evaluated all randomized controlled trials (RCTs) and quasi‐randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of \"rescue analgesia,\" patient/parental satisfaction and patient mortality. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014). Selection criteria We included RCTs comparing INF versus any other pharmacological/non‐pharmacological intervention for the treatment of children in acute pain (aged < 18 years). Data collection and analysis Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions. Main results Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a “bad taste” and vomiting with INF. Overall the risk of bias in all studies was considered low. Authors' conclusions INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non‐inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause. Plain language summary Intranasal fentanyl for the treatment of children in acute pain Background Pain is the most common reason why patients are seen in emergency departments (EDs). The challenging nature of treating children in acute severe pain is reflected in the medical literature by poor pain management in this population. We reviewed evidence on the effect of intranasal fentanyl (INF) (a strong pain relief drug, similar to morphine) compared with any other pain‐relieving technique for treatment of children in acute severe pain. Study characteristics We included studies with children (younger than 18 years of age) suffering from acute severe pain as a result of injury or medical illness. The target intervention was INF administered for pain relief compared with any other drug intervention for pain relief (e.g. intravenous morphine) or non‐drug intervention (e.g. limb splinting, wound dressing) provided in the emergency setting. The evidence is current to January 2014. Key results We identified three studies that included 313 children with acute severe pain resulting from broken bones of the upper and lower limbs. These trials compared INF versus morphine administered by a needle into a muscle (intramuscular morphine) or via a drip into a vein (intravenous morphine), as well as standard concentration INF versus high concentration INF. The collective study population in these trials consisted of children three to 15 years of age. Males accounted for approximately two‐thirds of the overall study population. The review concluded that INF may be an effective analgesic for the treatment of children in acute moderate to severe pain, and its administration appears to cause minimal distress to children; however, the evidence is insufficient to permit judgement of the effects of INF compared with intramuscular or intravenous morphine. No serious adverse events (e.g. opiate toxicity, death) were reported. Limitations Limitations of this review include the following: Few studies (three) were eligible for inclusion; no study examined the use of INF in children younger than three years of age; no study included children with pain resulting from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Murphy, A; O'Sullivan, R; Wakai, A; Grant, TS; Barrett, MJ; Cronin, J; McCoy, SC; Hom, J; Kandamany, N", "articleTypes": [], "doi": "10.1002/14651858.CD009942.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "5196ce68-6326-46ac-942b-2ac17553b478", "pmid": "", "title": "Interventions for the management of dry mouth: non‐pharmacological interventions", "imported": false, "abstract": "Abstract - Background Xerostomia is the subjective sensation of dry mouth. Common causes of xerostomia include adverse effects of many commonly prescribed medications, disease (e.g. Sjogren's Syndrome) and radiotherapy treatment for head and neck cancers. Non‐pharmacological techniques such as acupuncture or mild electrostimulation may be used to improve symptoms. Objectives To assess the effects of non‐pharmacological interventions administered to stimulate saliva production for the relief of dry mouth. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 16th April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 3), MEDLINE via OVID (1948 to 16th April 2013), EMBASE via OVID (1980 to 16th April 2013), AMED via OVID (1985 to 16th April 2013), CINAHL via EBSCO (1981 to 16th April 2013), and CANCERLIT via PubMed (1950 to 16th April 2013). The meta Register of Controlled Clinical Trials ( www.controlled‐trials.com ) and ClinicalTrials.gov ( www.clinicaltrials.gov ) were also searched to identify ongoing and completed trials. References lists of included studies and relevant reviews were also searched. There were no restrictions on the language of publication or publication status. Selection criteria We included parallel group randomised controlled trials of non‐pharmacological interventions to treat dry mouth, where participants had dry mouth symptoms at baseline. Data collection and analysis At least two review authors assessed each of the included studies to confirm eligibility, assess risk of bias and extract data using a piloted data extraction form. We calculated mean difference (MD) and 95% confidence intervals (CI) for continuous outcomes or where different scales were used to assess an outcome, we calculated standardised mean differences (SMD) together with 95% CIs. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information. Main results There were nine studies (total 366 participants randomised) included in this review of non‐pharmacological interventions for dry mouth which were divided into three comparisons. Eight studies were assessed at high risk of bias in at least one domain and the remaining study was at unclear risk of bias. Five small studies (total 153 participants, with dry mouth following radiotherapy treatment) compared acupuncture with placebo. Four were assessed at high risk and one at unclear risk of bias. Two trials reported outcome data for dry mouth in a form suitable for meta‐analysis. The pooled estimate of these two trials (70 participants, low quality evidence) showed no difference between acupuncture and control in dry mouth symptoms (SMD ‐0.34, 95% CI ‐0.81 to 0.14, P value 0.17, I 2 = 39%) with the confidence intervals including both a possible reduction or a possible increase in dry mouth symptoms. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). There was a very small increase in unstimulated whole saliva (UWS) at the end of 4 to 6 weeks of treatment (three trials, 71 participants, low quality evidence) (MD 0.02 ml/minute, 95% CI 0 to 0.04, P value 0.04, I 2 = 57%), and this benefit persisted at the 12‐month follow‐up evaluation (two trials, 54 participants, low quality evidence) (UWS, MD 0.06 ml/minute, 95% CI 0.01 to 0.11, P value 0.03, I 2 = 10%). For the outcome of stimulated whole saliva (SWS, three trials, 71 participants, low quality evidence) there was a benefit favouring acupuncture (MD 0.19 ml/minute, 95% CI 0.07 to 0.31, P value 0.002, I 2 = 1%) an effect which also persisted at the 12‐month follow‐up evaluation (SWS MD 0.28 ml/minute, 95% CI 0.09 to 0.47, P value 0.004, I 2 = 0%) (two trials, 54 participants, low quality evidence). Two small studies, both at high risk of bias, compared the use of an electrostimulation device with a placebo device in participants with Sjögren's Syndrome (total 101 participants). A further study, also at high risk of bias, compared acupuncture‐like electrostimulation of different sets of points in participants who had previously been treated with radiotherapy. None of these studies reported the outcome of dry mouth. There was no difference between electrostimulation and placebo in the outcomes of UWS or SWS at the end of the 4‐week treatment period in the one study (very low that provided data for these outcomes. No adverse effects were reported. A single study at high risk of bias, compared the stimulatory effect of powered versus manual toothbrushing and found no difference for the outcomes of UWS or SWS. Authors' conclusions There is low quality evidence that acupuncture is no different from placebo acupuncture with regard to dry mouth symptoms, which is the most important outcome. This may be because there were insufficient participants included in the two trials to show a possible effect or it may be that there was some benefit due to 'placebo' acupuncture which could have biased the effect to the null. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms. It is well known that dry mouth symptoms may be problematic even when saliva production is increased, yet only two of the trials that evaluated acupuncture reported dry mouth symptoms, a worrying reporting bias. There is some low quality evidence that acupuncture results in a small increase in saliva production in patients with dry mouth following radiotherapy. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms or saliva production in patients with Sjögren's Syndrome. Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation. Plain language summary Non‐drug treatments for dry mouth symptoms Review question This review, carried out by authors of the Cochrane Oral Health Group, has been produced to assess the effects of non‐drug treatments used to stimulate saliva production for the relief of dry mouth (xerostomia) symptoms. Background Dry mouth is a common problem with an estimated incidence of between 10% and 26% in men and between 10% and 33% in women, which may or may not be due to reduced saliva secretion. Common causes of dry mouth include the side effects of many commonly prescribed medications, diseases (such as Sjögren's syndrome where the immune system destroys tissues in the glands which produce saliva) and radiotherapy treatments for head and neck cancers. Saliva moistens the skin in the mouth and helps to maintain oral health. The presence of saliva facilitates speech, acts to wash away food residue from around the teeth, neutralises potentially damaging food and bacterial acids, enhances a person's ability to taste the food, and generally lubricates the mouth. Saliva also acts to soften food, making it easier to chew and swallow. Enzymes in saliva start the digestion of starch and fats, and other substances in saliva, such as epidermal growth factors, promote tissue growth, differentiation and wound healing. The antibacterial, antifungal and antiviral agents in saliva balance the oral flora and help to prevent oral infections, while the minerals in saliva help to maintain tooth enamel. Non‐drug treatments such as acupuncture, mild electrical stimulation, lasers, tooth brushing and other stimulation techniques are used to improve dry mouth symptoms. Study characteristics The evidence on which this review is based was up‐to‐date as of 16 April 2013. Nine studies were included in this review. A total of 366 adult participants took part in these trials, with an average of 40 participants per trial, and an age range from 12 to 77 years. The causes of dry mouth were radiotherapy for oral cancers in four trials, Sjögren's syndrome in three trials, medication‐related in one trial, and in the remaining trial participants had a range of causes of dry mouth. The included studies were divided into three groups, according the interventions evaluated. 1. Five small studies with a total 153 participants evaluated acupuncture. 2. Three studies evaluated electrostimulation devices. 3. One study evaluated a power toothbrush. Key results The five studies evaluating the effects of acupuncture in people who had dry mouth were generally of poor quality. There was no evidence of a difference in dry mouth symptoms, but there was some evidence of a small increase in saliva production which persisted for a year after the end of the acupuncture treatment. There may not have been enough people included in the trials to show a difference in dry mouth, or it may have been that both the real acupuncture and the 'placebo' acupuncture had some beneficial effect. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). The studies evaluating the effects of electrostimulation devices were poorly conducted and reported, and provided insufficient evidence to determine the effects of these devices on either dry mouth or saliva production. The single small study of a powered versus a manual toothbrush also found no difference for either dry mouth or saliva production. None of the included studies reported the outcomes of duration of effectiveness, quality of life, patient satisfaction, or oral health assessment. Quality of the evidence These studies were generally of poor quality (low and very low).", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Furness, S, Bryan, G, McMillan, R, Birchenough, S, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD009603.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.076Z" }, { "id": "51a8fe13-7966-49f3-ae1a-42357bc6caec", "pmid": "", "title": "Chinese medicinal herbs for cholelithiasis", "imported": false, "abstract": "Abstract - Background Cholelithiasis is a common disease of the biliary tract. Chinese medicinal herbs are being used widely as an alternative treatment in people with cholelithiasis, but their beneficial or harmful effects have not been assessed systematically. Objectives To assess the beneficial and harmful effects of Chinese medicinal herbs in people with cholelithiasis. Search methods We conducted searches in the Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, Science Citation Index Expanded, Chinese Medicine Conference Disc, and Chinese Bio‐Medicine Disc to January 2013. We handsearched four Chinese journals. No language or year of publication restrictions were applied. Selection criteria Randomised clinical trials studying Chinese medicinal herbs for treatment of cholelithiasis. Data collection and analysis Two review authors (SJ, TG) independently extracted data. For dichotomous data, we estimated the risk ratio (RR), and for continuous data, we calculated the mean difference. We also calculated 95% confidence intervals (CI). Main results Eleven randomised trials with 1205 participants with asymptomatic or mild‐to‐moderate cholelithiasis were included. None of the randomised clinical trials compared a single Chinese medicinal herb with a Western medicine or with surgery. No placebo‐controlled trials were identified. In the trials comparing one Chinese herbal medicine (Gandanxiaoshi tablet) versus another (Aihuodantong tablet), there was no significant difference in the improvement of upper abdominal pain after the end of treatment (RR 1.21; 95% CI 0.71 to 2.05), and the heterogeneity among trials was not substantial. No other outcomes could be assessed. The remaining trials of Chinese medicinal herbs (Qingdan capsule, Danshu capsule, Paishi capsule, Rongdanpaishi capsule), did not offer specific data on symptoms, signs, or change in gallstones that would permit assessment of significant differences in curative effects between the treatment and control groups. No serious adverse events were reported. Authors' conclusions This review reveals no strong evidence that the analysed Chinese medicinal herbs have any beneficial effects on asymptomatic or mild‐to‐moderate cholelithiasis. Definitive conclusions will require much better designed randomised trials to reduce risk of bias and allow detailed assessment of clinical outcomes. Plain language summary Chinese medicinal herbs for cholelithiasis Cholelithiasis (gallstone disease) causes significant morbidity, severe complications, and economic burden worldwide. Though current surgical therapies are effective for gallstones, some types of gallstones (e.g., calcium bilirubinate calculi) cannot easily be eradicated by surgery and they often recur in the bile duct system, putting people at high risk of severe complications. The objective of this review was to evaluate the benefits and harms of Chinese medicinal herbs for people with cholelithiasis. Though some Chinese medicinal herbs appear to be safe for people with asymptomatic, mild, or moderate disease, they have not been conclusively shown to have curative effects on gallstones due to the low methodological quality (high risk of bias) of the included trials. Thus, randomised clinical trials with low risk of bias should be conducted to assess the effects of Chinese medicinal herbs before they can be used widely in the clinic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Gan, T; Chen, J; Jin, SJ; Wang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD004547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "51c36ba6-3a0e-4139-801e-2aaf6dfe9446", "pmid": "", "title": "Inhaled anti‐pseudomonal antibiotics for long‐term therapy in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review. Objectives To evaluate the effects of long‐term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug‐sensitivity reactions and survival). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022. Selection criteria We selected trials where people with cystic fibrosis received inhaled anti‐pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi‐randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). Data collection and analysis Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system. Main results The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta‐analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low‐certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) ‐5.30 days, 95% CI ‐8.59 to ‐2.01; 1 trial, 245 participants; low‐certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta‐analyses. We are uncertain of the effect of the intervention on adverse events (very low‐certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEV 1 ) % predicted compared to tobramycin (MD ‐3.40%, 95% CI ‐6.63 to ‐0.17; 1 trial, 273 participants; moderate‐certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate‐certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high‐certainty evidence). Important treatment‐related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high. Authors' conclusions Long‐term treatment with inhaled anti‐pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer‐term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes. Plain language summary Inhaling antibiotics to treat lung infection in people with cystic fibrosis Review question Are inhaled antibiotics helpful against persistent infection with Pseudomonas aeruginosa in people with cystic fibrosis (CF)? Key messages As people with CF get older, they are more likely to become infected on a long‐term basis with Pseudomonas aeruginosa. This is the most common cause of chronic lung infection in people with CF . We wanted to find out whether antibiotics targeting Pseudomonas aeruginosa would reduce the effects of infection when they are breathed into the lungs. We wanted to learn whether this treatment would improve lung function, quality of life and survival. We also looked for any harmful effects. What is CF? Cystic fibrosis is an inherited disease which results in abnormal mucus in several parts of the body and mainly affects the lungs, which are susceptible to infection by certain bacteria. Infection causes inflammation which results in progressive damage to the lungs. What did we find? The review includes 18 trials with 3042 people with CF aged between five and 45 years of age . The trials lasted from three to 33 months. In 11 trials investigators compared inhaled antibiotics with a placebo (an inhaled substance without the medication in it) and people were selected for one treatment or the other randomly. Eight trials compared one inhaled antibiotic with either a different inhaled antibiotic or a different schedule of the same inhaled antibiotic. One of the trials compared an antibiotic both to placebo and to a different antibiotic and so fell into both groups. Main results Results from four trials showed that when compared to placebo, inhaled antibiotics may improve lung function and reduce the number of times the people with CF had a worsening of symptoms (exacerbation). Inhaled antibiotics may also mean fewer days off school or work (a measure of quality of life). They did not seem to have an effect on survival. We are not sure of the side effects of inhaled antibiotics, but tinnitus and changes in voice were reported more often in people inhaling antibiotics rather than the placebo. We did not find enough evidence to be able to comment on how inhaled antibiotics affect height and weight. Where the trials compared different inhaled antibiotics or schedules, there was only one trial in each of the eight different comparisons. The only differences we found in all these comparisons were for two outcomes. In one trial we found that aztreonam lysine probably improved lung function more than tobramycin, but no important differences were found in the other trials with regard to lung function. Aztreonam lysine also probably led to fewer people needing additional courses of antibiotics than tobramycin and there were fewer hospitalisations after levofloxacin compared to placebo. We noted that important side effects that were related to the treatment were not very common in the trials, but they were less common with tobramycin than with other antibiotics. What are the limitations of the evidence? The trials that we included in this review measured lung function in different ways and also how often people experienced a sudden worsening of symptoms. That made it difficult for us to combine the results of different trials to strengthen our evidence. We thought the overall certainty of evidence was low for most outcomes, mainly due to risks of bias within the trials and low event rates meaning results were not precise. How up to date is this evidence? The evidence is current to: 28 June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Smith, S; Rowbotham, NJ", "articleTypes": [], "doi": "10.1002/14651858.CD001021.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "51d7b2ed-48e5-4db1-9018-609699c16c5f", "pmid": "", "title": "Potentiators (specific therapies for class III and IV mutations) for cystic fibrosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Skilton, M, Krishan, A, Patel, S, Sinha, IP, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD009841.pub3 AB - Abstract - Background Cystic fibrosis (CF) is the commonest inherited life‐shortening illness in white populations, caused by a mutation in the gene that codes for the cystic fibrosis transmembrane regulator protein (CFTR), which functions as a salt transporter. This mutation mainly affects the airways where excess salt absorption dehydrates the airway lining leading to impaired mucociliary clearance. Consequently, thick, sticky mucus accumulates making the airway prone to chronic infection and progressive inflammation; respiratory failure often ensues. Other complications include malnutrition, diabetes and subfertility. Increased understanding of the condition has allowed pharmaceutical companies to design mutation‐specific therapies targeting the underlying molecular defect. CFTR potentiators target mutation classes III and IV and aim to normalise airway surface liquid and mucociliary clearance, which in turn impacts on the chronic infection and inflammation. This is an update of a previously published review. Objectives To evaluate the effects of CFTR potentiators on clinically important outcomes in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles, reviews and online clinical trial registries. Last search: 21 November 2018. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing CFTR potentiators to placebo in people with CF. A separate review examines trials combining CFTR potentiators with other mutation‐specific therapies. Data collection and analysis The authors independently extracted data, assessed the risk of bias in included trials and used GRADE to assess evidence quality. Trial authors were contacted for additional data. Main results We included five RCTs (447 participants with different mutations) lasting from 28 days to 48 weeks, all assessing the CFTR potentiator ivacaftor. The quality of the evidence was moderate to low, mainly due to risk of bias (incomplete outcome data and selective reporting) and imprecision of results, particularly where few individuals experienced adverse events. Trial design was generally well‐documented. All trials were industry‐sponsored and supported by other non‐pharmaceutical funding bodies. F508del (class II) (140 participants) One 16‐week trial reported no deaths, or changes in quality of life (QoL) or lung function (either relative or absolute change in forced expiratory volume in one second (FEV1) (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in ivacaftor and placebo groups, but there was no difference between groups (low‐quality evidence); there was also no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. There was also no difference in weight. Sweat chloride concentration decreased, mean difference (MD) ‐2.90 mmol/L (95% confidence interval (CI) ‐5.60 to ‐0.20). G551D (class III) (238 participants) The 28‐day phase 2 trial (19 participants) and two 48‐week phase 3 trials (adult trial (167 adults), paediatric trial (52 children)) reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor in the adult trial at 24 weeks, MD 8.10 (95% CI 4.77 to 11.43) and 48 weeks, MD 8.60 (95% CI 5.27 to 11.93 (moderate‐quality evidence). The adult trial reported a higher relative change in FEV1 with ivacaftor at 24 weeks, MD 16.90% (95% CI 13.60 to 20.20) and 48 weeks, MD 16.80% (95% CI 13.50 to 20.10); the paediatric trial reported this at 24 weeks, MD 17.4% (P < 0.0001)) (moderate‐quality evidence). These trials demonstrated absolute improvements in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32). The phase 3 trials reported increased cough, odds ratio (OR) 0.57 (95% CI 0.33 to 1.00) and episodes of decreased pulmonary function, OR 0.29 (95% CI 0.10 to 0.82) in the placebo group; ivacaftor led to increased dizziness in adults, OR 10.55 (95% CI 1.32 to 84.47). There was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Fewer participants taking ivacaftor developed serious pulmonary exacerbations; adults taking ivacaftor developed fewer exacerbations (serious or not), OR 0.54 (95% CI 0.29 to 1.01). A higher proportion of participants were exacerbation‐free at 24 weeks with ivacaftor (moderate‐quality evidence). Ivacaftor led to a greater absolute change from baseline in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32); weight also increased at 24 weeks, MD 2.37 kg (95% CI 1.68 to 3.06) and 48 weeks, MD 2.75 kg (95% CI 1.74 to 3.75). Sweat chloride concentration decreased at 24 weeks, MD ‐48.98 mmol/L (95% CI ‐52.07 to ‐45.89) and 48 weeks, MD ‐49.03 mmol/L (95% CI ‐52.11 to ‐45.94). R117H (class IV) (69 participants) One 24‐week trial reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor at 24 weeks, MD 8.40 (95% CI 2.17 to 14.63), but no relative changes in lung function were reported (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in both groups, but there was no difference between groups; there was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. No changes in absolute change in FEV1 or weight were reported. Sweat chloride concentration decreased, MD ‐24.00 mmol/L (CI 95% ‐24.69 to ‐23.31). Authors' conclusions There is no evidence supporting the use of ivacaftor in people with the F508del mutation. Both G551D phase 3 trials demonstrated a clinically relevant impact of ivacaftor on outcomes at 24 and 48 weeks in adults and children (over six years of age) with CF. The R117H trial demonstrated an improvement in the respiratory QoL score, but no improvement in respiratory function. As new mutation‐specific therapies emerge, it is important that trials examine outcomes relevant to people with CF and their families and that adverse events are reported robustly and consistently. Post‐market surveillance is essential and ongoing health economic evaluations are required. Plain language summary Ivacaftor (marketed as Kalydeco®), a new specific therapy for cystic fibrosis Review question How does ivacaftor affect clinical outcomes (survival, quality of life and lung function) in people with cystic fibrosis (CF)? Background In people with CF, airway surfaces do not have enough water because of an abnormal protein; this makes it difficult to clear thick and sticky mucus, which leads to lung infections. Ivacaftor works on the abnormal protein in people with some mutations to allow the airways retain more water and better clear mucus, so fewer lung infections develop. Ivacaftor was aimed at people with class III and IV mutations, and has been studied in people with G551D (class III), R117H (class IV) and F508del (class II) mutations. Trial characteristics We included five trials (447 participants) comparing ivacaftor to placebo (dummy treatment with no active medication) lasting between four and 48 weeks. Three trials enrolled a total of 238 people with at least one copy of the G551D mutation, one trial enrolled 140 people with two copies of the F508del mutation and one enrolled 69 people with at least one copy of the R117H mutation. The evidence is up to date as of 21 November 2018. Key results F508del mutation The trial did not report any deaths or show improvements in lung function, quality of life scores or weight. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. Sweat chloride concentrations were reduced with ivacaftor. G551D mutation No deaths were reported. Both children and adults taking ivacaftor showed improvements in lung function, but only adults reported higher quality of life scores. People given placebo reported more coughing and experienced more episodes of decreased lung function; more adults taking ivacaftor reported episodes of dizziness. Similar numbers of people taking ivacaftor and placebo delayed the course of medication, or withdrew from the trial altogether, due to side effects (e.g. psychological issues, liver disease, severe breathing problems). There were more serious pulmonary exacerbations whilst taking placebo compared to ivacaftor. Adults taking ivacaftor were admitted to hospital less often and had fewer courses of intravenous antibiotics for exacerbations. Both children and adults and children increased their weight with ivacaftor. There was a drop in sweat chloride concentrations with ivacaftor. R117H mutation No deaths occurred in this trial. While quality of life scores improved with ivacaftor, lung function did not. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. There was no difference in weight; but as for other mutations there was a reduction in sweat chloride concentration with ivacaftor.
 
 Evidence suggests that ivacaftor is an effective treatment for people (over six years of age) with cystic fibrosis and the G551D mutation, but not for those with the F508del or R117H mutations. Quality of the evidence In most trials, individuals were put into different treatment groups at random with equal chances of being given either placebo or ivacaftor; no one could work out which treatment the next person would receive, so that healthier people did not receive ivacaftor and make the results seem better. We were not sure whether anyone involved in the trial knew who was receiving which treatment and how this might affect results. No trials reported all results clearly; sometimes they did not report them in a way that we could use in the review and sometimes they did not report the data at all. This affected our certainty regarding the overall results. Information about some side effects was limited as not many people experienced them, therefore, it is difficult to judge whether there was a difference between treatment groups We judged the evidence in this review to be moderate to low quality. Trial funding sources All trials were sponsored by Vertex Pharmaceuticals Incorporated. The National Institute of Health (NIH), the Cystic Fibrosis Foundation (CFF) and other non‐pharmaceutical funding bodies also supported the trials.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.765Z" }, { "id": "51e0284d-3442-4dd2-9f70-5fdb832e53a8", "pmid": "", "title": "Probiotics for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "Abstract - Background The intestinal microflora has an essential role in providing a barrier against colonisation of pathogens, facilitating important metabolic functions, stimulating the development of the immune system, and maintaining intestinal motility. Probiotics are live microorganisms that can be administered to supplement the gut flora. Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be partly due to a disruption of the integrity of the gut and its intestinal microflora. There may be a role for probiotics in reducing the incidence of sepsis and improving intestinal motility, thus reducing morbidity and mortality and improving enteral feeding in neonates in the postoperative period. Objectives To evaluate the efficacy and safety of administering probiotics after gastrointestinal surgery for the postoperative management of neonates born from 35 weeks of gestation. Search methods We searched CENTRAL, MEDLINE, Embase, and trial registries in August 2023. We checked reference lists of included studies and relevant systematic reviews for additional studies. Selection criteria We included randomised controlled trials (RCTs) that investigated the postoperative administration of oral probiotics versus placebo or no treatment in neonates born from 35 weeks of gestation who had one or more gastrointestinal surgical procedures. We applied no restrictions regarding the type or dosage of probiotics or the duration of treatment. Data collection and analysis We used standard Cochrane methods, and we used GRADE to assess the certainty of evidence. Main results We identified one RCT that recruited 61 neonates with a gestational age of 35 weeks or more. All infants were admitted to a neonatal intensive care unit and had surgery for gastrointestinal pathologies. There may be little or no difference in proven sepsis (positive bacterial culture, local or systemic) between infants who receive probiotics compared with those who receive placebo (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.16 to 2.55; 61 infants; low‐certainty evidence). Probiotics compared to placebo may have little or no effect on time to full enteral feeds (mean difference (MD) 0.63 days, 95% CI −4.02 to 5.28; 61 infants; low‐certainty evidence). There were no reported deaths prior to discharge from hospital in either study arm. Two weeks after supplementation, the infants who received probiotics had a substantially higher relative abundance of non‐pathogenic intestinal microflora (Bifidobacteriaceae) than those who received placebo (MD 38.22, 95% CI 28.40 to 48.04; 39 infants; low‐certainty evidence). Authors' conclusions This review provides low‐certainty evidence from one small RCT that probiotics compared to placebo have little or no effect on the risk of proven sepsis (positive bacterial culture, local or systemic) or time to full‐enteral feeds in neonates who have undergone gastrointestinal surgery. Probiotics may substantially increase the abundance of beneficial bacterial in the intestine of these neonates, but the clinical implications of this finding are unknown. There is a need for adequately powered RCTs to assess the role of probiotics in this population. We identified two ongoing studies. As neither reported the gestational age of prospective study participants, we are unsure if they will be eligible for inclusion in this review. Plain language summary Benefits and harms of giving probiotics to newborns after digestive tract surgery Key message • Probiotics may have little or no effect on the risk of blood infection in infants born from 35 weeks of pregnancy who have undergone surgery of the digestive tract (food pipe, stomach, or bowel).
• Probiotics may increase the proportion of 'good' bacteria in the bowel, but we do not know if this has any real benefit for the infant. What are probiotics? Probiotics are live bacteria that may offer health benefits when consumed. There is evidence that probiotics can prevent an inflammatory disease of the bowel (necrotising enterocolitis) and infection in premature babies. What are some of the risks of bowel surgery in babies? Surgery of the digestive tract increases the risk of infection, and infection can increase the length of hospital stay. Treatment with antibiotics (medicines that treat bacterial infection) and the stress of surgery can diminish the 'good' bacteria in the bowel. What did we want to find out? We wanted to find out if giving probiotics to babies born from 35 weeks of pregnancy who underwent stomach or bowel surgery could improve rates of infection, length of hospital stay, rates of death, feeding, and the proportion of 'good' bacteria in the stomach and bowel. What did we do? We searched for studies that randomly assigned babies to experimental treatment (probiotics) or a control, which could be placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested) or no treatment. What did we find? We found one small study of 61 babies born from 35 weeks of pregnancy who had digestive tract surgery. Thirty babies received probiotics after the surgery, and 30 received a placebo. In the probiotics group, 13% of babies had a blood infection, compared with 19% in the placebo group. This difference is too small to be significant. On average, the babies in the probiotic group were receiving food into their stomach about 15 hours sooner than those in the placebo group. Again, this difference is not important. Among 39 infants who were tested, those in the probiotics group had considerably more 'good' bacteria in their bowel compared to the placebo group. What are the limitations of the evidence? We have little confidence in the evidence because it is based on a single study with few participants. The evidence is not strong enough to support giving probiotics routinely. Well‐designed and large studies are needed to determine the benefits and harms of giving probiotics to newborns after digestive tract surgery. How up to date is this evidence? The evidence is up to date to August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Trivedi, A; Teo, E; Walker, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012265.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "5218eb9b-3972-4c08-b116-1106c382ecd0", "pmid": "", "title": "Treatments for iron‐deficiency anaemia in pregnancy", "imported": false, "abstract": "Abstract - Background Iron deficiency, the most common cause of anaemia in pregnancy worldwide, can be mild, moderate or severe. Severe anaemia can have very serious consequences for mothers and babies, but there is controversy about whether treating mild or moderate anaemia provides more benefit than harm. Objectives To assess the effects of different treatments for anaemia in pregnancy attributed to iron deficiency (defined as haemoglobin less than 11 g/dL or other equivalent parameters) on maternal and neonatal morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2011), CENTRAL (2011, Issue 5), PubMed (1966 to June 2011), the International Clinical Trials Registry Platform (ICTRP) (2 May 2011), Health Technology Assessment Program (HTA) (2 May 2011) and LATINREC (Colombia) (2 May 2011). Selection criteria Randomised controlled trials comparing treatments for anaemia in pregnancy attributed to iron deficiency. Data collection and analysis We identified 23 trials, involving 3.198 women. We assessed their risk of bias. Three further studies identified are awaiting classification. Main results Many of the trials were from low‐income countries; they were generally small and frequently methodologically poor. They covered a very wide range of differing drugs, doses and routes of administration, making it difficult to pool data. Oral iron in pregnancy showed a reduction in the incidence of anaemia (risk ratio 0.38, 95% confidence interval 0.26 to 0.55, one trial, 125 women) and better haematological indices than placebo (two trials). It was not possible to assess the effects of treatment by severity of anaemia. A trend was found between dose and reported adverse effects. Most trials reported no clinically relevant outcomes nor adverse effects. Although the intramuscular and intravenous routes produced better haematological indices in women than the oral route, no clinical outcomes were assessed and there were insufficient data on adverse effects, for example, on venous thrombosis and severe allergic reactions. Daily low‐dose iron supplements may be effective at treating anaemia in pregnancy with less gastrointestinal side effects compared with higher doses. Authors' conclusions Despite the high incidence and burden of disease associated with this condition, there is a paucity of good quality trials assessing clinical maternal and neonatal effects of iron administration in women with anaemia. Daily oral iron treatment improves haematological indices but causes frequent gastrointestinal adverse effects. Parenteral (intramuscular and intravenous) iron enhances haematological response, compared with oral iron, but there are concerns about possible important adverse effects (for intravenous treatment venous thrombosis and allergic reactions and for intramuscular treatment important pain, discolouration and allergic reactions). Large, good quality trials, assessing clinical outcomes (including adverse effects) as well as the effects of treatment by severity of anaemia are required. Plain language summary Treatments for anaemia in pregnancy thought to be due to iron deficiency When the blood has insufficient red cells, or the red cells carry insufficient haemoglobin to deliver adequate oxygen to the tissues, this is called anaemia. There is normally a reduction in the haemoglobin concentrations in the mother's blood during pregnancy, and this allows a better blood flow around the womb (uterus) and to the baby. This is sometime called physiological anaemia and needs no treatment. True anaemia, however, can be mild, moderate or severe and can cause weakness, tiredness and dizziness. Severe anaemia makes women at risk of cardiac failure and is very common in low‐income countries Anaemia has many causes including a shortage or iron, folic acid or vitamin B 12 . These are all required for making red cells and are available in a good diet. Iron shortage, however, is the most common cause of anaemia during pregnancy. Iron treatment can be given by mouth (oral), by injection into the muscle (intramuscular) or injection into the vein (intravenous). Blood transfusion or giving something which stimulates the body to produce more red cells (erythropoietin) are also possible treatments. In this review, we identified 23 trials involving 3198 pregnant women. Many of the trials were in low‐income countries and many treatment variations were studied. Oral iron reduced the incidence of anaemia but is known to sometimes cause constipation and nausea. Although the intramuscular and intravenous routes produced better levels of red cells and iron stores than the oral route, no clinical outcomes (such as pre‐eclampsia, preterm births, postpartum haemorrhage) were assessed and there were insufficient data on adverse effects. Intravenous treatment can cause venous thrombosis (blockages in the veins) and intramuscular treatment causes important pain and discolouration at the injection site. It was unclear if women and babies were healthier when women were given iron for mild or moderate anaemia during pregnancy. There were no studies on using blood transfusions. Overall, there was insufficient evidence to say when or how anaemia in pregnancy needs to or should be treated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Reveiz, L, Gyte, GML, Cuervo, LG, Casasbuenas, A", "articleTypes": [], "doi": "10.1002/14651858.CD003094.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.733Z" }, { "id": "5219a56a-bc38-4cbc-adc5-ea021856bdf5", "pmid": "", "title": "Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery", "imported": false, "abstract": "Abstract - Background In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete. Objectives To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Date of the last search: 20 November 2014. Selection criteria Randomised and quasi‐randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention. Data collection and analysis Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta‐analyses were performed on available and relevant data. Main results Of the 16 identified trials, four (112 participants) were eligible for inclusion. Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon‐aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post‐operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re‐intervention was not reported by either trial. Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re‐intervention). In one trial a high‐dose rFVIIa regimen (90 μg/kg) was compared with a low‐dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety. Authors' conclusions There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well‐designed randomised controlled trials would be needed, in particular to address the cost‐effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies. Plain language summary Preventing bleeding in people with congenital bleeding disorders during and after surgery In haemophilia and other congenital bleeding disorders blood does not clot properly, which can cause excessive bleeding. This is particularly relevant during surgery, when the risk of bleeding depends on the type and severity of the clotting disorder and on the type of surgery. Therefore, during and after surgery, these individuals should receive treatment to improve the ability of their blood to clot and so prevent bleeding. Clotting factor concentrates (when available and appropriate in those individuals missing specific clotting proteins) or other non‐specific drugs for clotting, or a combination of both, are administered. It is not known what is the optimal dose or duration or method of administration of these treatments in these circumstances. We searched for randomised controlled trials comparing the efficacy (mortality, blood loss, need for re‐intervention, subjective assessment of efficacy, duration and dose of therapy) and the safety of any type of treatment given to people with congenital bleeding disorders during any type of surgery. We found four trials to be included in this review. Two trials evaluated 59 people with haemophilia A or B receiving antifibrinolytic drugs (agents that reduce the breakdown of clots) or placebo in addition to the initial standard treatment before dental extractions. The remaining two trials evaluated 53 people with haemophilia A or B and inhibitors (antibodies that act against the factor concentrate therapy) receiving an different clotting concentrate, recombinant activated factor VII, both during and after surgery. These two trials evaluated different treatment options: high‐dose compared with low‐dose and a single large (bolus) infusion compared with continuous infusion. The trials included in this review provide some information in two specific situations in people with congenital bleeding disorders undergoing surgery. However, on the whole, there is not enough evidence from trials to define the best treatments for the various types of disease and types of surgery. Further trials would be useful to improve our knowledge but are difficult to carry out and currently do not appear to be a clinical priority. Indeed, both major and minor surgery are safely performed in clinical practice in these individuals based on local experience and data from uncontrolled studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Coppola, A, Windyga, J, Tufano, A, Yeung, C, Di Minno, MND", "articleTypes": [], "doi": "10.1002/14651858.CD009961.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.772Z" }, { "id": "5220f206-6400-4a1c-a899-2fea6555d9e8", "pmid": "", "title": "Paroxetine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Paroxetine is the most potent inhibitor of the reuptake of serotonin of all selective serotonin reuptake inhibitors (SSRIs) and has been studied in many randomised controlled trials (RCTs). However, these comparative studies provided contrasting findings and systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to paroxetine alone. The present systematic review assessed the efficacy and tolerability profile of paroxetine in comparison with tricyclics (TCAs), SSRIs and newer or non‐conventional agents. Objectives 1. To determine the efficacy of paroxetine in comparison with other anti‐depressive agents in alleviating the acute symptoms of Major Depressive Disorder. 2. To review acceptability of treatment with paroxetine in comparison with other anti‐depressive agents. 3. To investigate the adverse effects of paroxetine in comparison with other anti‐depressive agents. Search methods We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR, to 30 September 2012), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Reference lists of relevant papers and previous systematic reviews were handsearched. Pharmaceutical companies marketing paroxetine and experts in this field were contacted for supplemental data. Selection criteria All randomised controlled trials allocating participants with major depression to paroxetine versus any other antidepressants (ADs), both conventional (such as TCAs, SSRIs) and newer or non‐conventional (such as hypericum). For trials which had a cross‐over design, only results from the first randomisation period were considered. Data collection and analysis Two review authors independently checked eligibility and extracted data using a standard form. Data were then entered in RevMan 5.2 with a double‐entry procedure. Information extracted included study and participant characteristics, intervention details, settings and efficacy, acceptability and tolerability measures. Main results A total of 115 randomised controlled trials (26,134 participants) were included. In 54 studies paroxetine was compared with older ADs, in 21 studies with another SSRI, and in 40 studies with a newer or non‐conventional antidepressant other than SSRIs. For the primary outcome (patients who responded to treatment), paroxetine was more effective than reboxetine at increasing patients who responded early to treatment (Odds Ratio (OR): 0.66, 95% Confidence Interval (CI) 0.50 to 0.87, number needed to treat to provide benefit (NNTb) = 16, 95% CI 10 to 50, at one to four weeks, 3 RCTs, 1375 participants, moderate quality of evidence), and less effective than mirtazapine (OR: 2.39, 95% CI 1.42 to 4.02, NNTb = 8, 95% CI 5 to 14, at one to four weeks, 3 RCTs, 726 participants, moderate quality of evidence). Paroxetine was less effective than citalopram in improving response to treatment (OR: 1.54, 95% CI 1.04 to 2.28, NNTb = 9, 95% CI 5 to 102, at six to 12 weeks, 1 RCT, 406 participants, moderate quality of evidence). We found no clear evidence that paroxetine was more or less effective compared with other antidepressants at increasing response to treatment at acute (six to 12 weeks), early (one to four weeks), or longer term follow‐up (four to six months). Paroxetine was associated with a lower rate of adverse events than amitriptyline, imipramine and older ADs as a class, but was less well tolerated than agomelatine and hypericum. Included studies were generally at unclear or high risk of bias due to poor reporting of allocation concealment and blinding of outcome assessment, and incomplete reporting of outcomes. Authors' conclusions Some possibly clinically meaningful differences between paroxetine and other ADs exist, but no definitive conclusions can be drawn from these findings. In terms of response, there was a moderate quality of evidence that citalopram was better than paroxetine in the acute phase (six to 12 weeks), although only one study contributed data. In terms of early response to treatment (one to four weeks) there was moderate quality of evidence that mirtazapine was better than paroxetine and that paroxetine was better than reboxetine. However there was no clear evidence that paroxetine was better or worse compared with other antidepressants at increasing response to treatment at any time point. Even if some differences were identified, the findings from this review are better thought as hypothesis forming rather than hypothesis testing and it would be reassuring to see the conclusions replicated in future trials. Finally, most of included studies were at unclear or high risk of bias, and were sponsored by the drug industry. The potential for overestimation of treatment effect due to sponsorship bias should be borne in mind. Plain language summary Paroxetine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms such as appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, inappropriate guilt and morbid thoughts of death. Although medication and psychological treatments are both effective for major depression, antidepressant drugs remain the mainstay of treatment in moderate to severe major depression. However, head‐to‐head comparisons of such drugs provide contrasting findings as to whether they are effective. This review of the research on the effect of an antidepressant drug called paroxetine was conducted to shed light on the field of drug treatment for depression. In September 2012 we searched, in a wide ranging way, for all the useful studies (randomised controlled trials) which had been completed which compared paroxetine with any other antidepressant in treating people with depression. One hundred and fifteen studies were included in this review, with a total of 26,134 people. We grouped the studies according to the types of drug they compared paroxetine against; we then analysed the combined findings of these groups of studies. For the primary outcome (number of people who responded to treatment) paroxetine was more effective than reboxetine, but less effective than mirtazapine (in the early phase: one to four weeks follow‐up) and probably citalopram (at endpoint: six weeks follow‐up). There was some evidence that paroxetine is less well tolerated than agomelatine and St John's Wort, as more patients allocated to paroxetine experienced at least some side effects (though this finding for St John's Wort was only based on one study). In conclusion, some possibly meaningful differences between paroxetine and other antidepressants exist, but no definitive concluions can be drawn due to the limited number of studies per comparison. In addition, most of included studies were sponsored by the drug industry, which means they might potentially have overestimated the effect of paroxetine. Therefore, the results of this review should be interpreted with caution.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Purgato, M, Papola, D, Gastaldon, C, Trespidi, C, Magni, LR, Rizzo, C, Furukawa, TA, Watanabe, N, Cipriani, A, Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006531.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.770Z" }, { "id": "52266e50-b27a-4e7a-8167-bb0615d1c633", "pmid": "", "title": "Dietary supplements for dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Dysmenorrhoea refers to painful menstrual cramps and is a common gynaecological complaint. Conventional treatments include non‐steroidal anti‐inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs), which both reduce myometrial activity (contractions of the uterus). A suggested alternative approach is dietary supplements. We used the term 'dietary supplement' to include herbs or other botanical, vitamins, minerals, enzymes, and amino acids. We excluded traditional Chinese medicines. Objectives To determine the efficacy and safety of dietary supplements for treating dysmenorrhoea. Search methods We searched sources including the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, PsycINFO (all from inception to 23 March 2015), trial registries, and the reference lists of relevant articles. Selection criteria We included randomised controlled trials (RCTs) of dietary supplements for moderate or severe primary or secondary dysmenorrhoea. We excluded studies of women with an intrauterine device. Eligible comparators were other dietary supplements, placebo, no treatment, or conventional analgesia. Data collection and analysis Two review authors independently performed study selection, performed data extraction and assessed the risk of bias in the included trials. The primary outcomes were pain intensity and adverse effects. We used a fixed‐effect model to calculate odds ratios (ORs) for dichotomous data, and mean differences (MDs) or standardised mean differences (SMDs) for continuous data, with 95% confidence intervals (CIs). We presented data that were unsuitable for analysis either descriptively or in additional tables. We assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods. Main results We included 27 RCTs (3101 women). Most included studies were conducted amongst cohorts of students with primary dysmenorrhoea in their late teens or early twenties. Twenty‐two studies were conducted in Iran and the rest were performed in other middle‐income countries. Only one study addressed secondary dysmenorrhoea. Interventions included 12 different herbal medicines (German chamomile ( Matricaria chamomilla, M recutita, Chamomilla recutita) , cinnamon ( Cinnamomum zeylanicum, C. verum) , Damask rose ( Rosa damascena), dill ( Anethum graveolens ), fennel ( Foeniculum vulgare ), fenugreek ( Trigonella foenum‐graecum ), ginger ( Zingiber officinale ), guava ( Psidium guajava ), rhubarb ( Rheum emodi ), uzara ( Xysmalobium undulatum ), valerian ( Valeriana officinalis ), and zataria ( Zataria multiflora )) and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Comparators included other supplements, placebo, no treatment, and NSAIDs. We judged all the evidence to be of low or very low quality. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few studies reported adverse effects. Effectiveness of supplements for primary dysmenorrhoea We have presented pain scores (all on a visual analogue scale (VAS) 0 to 10 point scale) or rates of pain relief, or both, at the first post‐treatment follow‐up. Supplements versus placebo or no treatment There was no evidence of effectiveness for vitamin E (MD 0.00 points, 95% CI −0.34 to 0.34; two RCTs, 135 women). There was no consistent evidence of effectiveness for dill (MD ‐1.15 points, 95% CI −2.22 to −0.08, one RCT, 46 women), guava (MD 0.59, 95% CI −0.13 to 1.31; one RCT, 151 women); one RCT, 73 women), or fennel (MD −0.34 points, 95% CI −0.74 to 0.06; one RCT, 43 women). There was very limited evidence of effectiveness for fenugreek (MD −1.71 points, 95% CI −2.35 to −1.07; one RCT, 101 women), fish oil (MD 1.11 points, 95% CI 0.45 to 1.77; one RCT, 120 women), fish oil plus vitamin B1 (MD −1.21 points, 95% CI −1.79 to −0.63; one RCT, 120 women), ginger (MD −1.55 points, 95% CI −2.43 to −0.68; three RCTs, 266 women; OR 5.44, 95% CI 1.80 to 16.46; one RCT, 69 women), valerian (MD −0.76 points, 95% CI −1.44 to −0.08; one RCT, 100 women), vitamin B1 alone (MD −2.70 points, 95% CI −3.32 to −2.08; one RCT, 120 women), zataria (OR 6.66, 95% CI 2.66 to 16.72; one RCT, 99 women), and zinc sulphate (MD −0.95 points, 95% CI −1.54 to −0.36; one RCT, 99 women). Data on chamomile and cinnamon versus placebo were unsuitable for analysis. Supplements versus NSAIDS There was no evidence of any difference between NSAIDs and dill (MD 0.13 points, 95% CI −1.01 to 1.27; one RCT, 47 women), fennel (MD −0.70 points, 95% CI −1.81 to 0.41; one RCT, 59 women), guava (MD 1.19, 95% CI 0.42 to 1.96; one RCT, 155 women), rhubarb (MD −0.20 points, 95% CI −0.44 to 0.04; one RCT, 45 women), or valerian (MD points 0.62 , 95% CI 0.03 to 1.21; one RCT, 99 women), There was no consistent evidence of a difference between Damask rose and NSAIDs (MD −0.15 points, 95% CI −0.55 to 0.25; one RCT, 92 women). There was very limited evidence that chamomile was more effective than NSAIDs (MD −1.42 points, 95% CI −1.69 to −1.15; one RCT, 160 women). Supplements versus other supplements There was no evidence of a difference in effectiveness between ginger and zinc sulphate (MD 0.02 points, 95% CI −0.58 to 0.62; one RCT, 101 women). Vitamin B1 may be more effective than fish oil (MD −1.59 points, 95% CI −2.25 to −0.93; one RCT, 120 women). Effectiveness of supplements for secondary dysmenorrhoea There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis (data were unsuitable for analysis). Safety of supplements Only four of the 27 included studies reported adverse effects in both treatment groups. There was no evidence of a difference between the groups but data were too scanty to reach any conclusions about safety. Authors' conclusions There is no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety is lacking. However for several supplements there was some low quality evidence of effectiveness and more research is justified. Plain language summary Dietary supplements for pain during menstruation Review question Cochrane authors reviewed the evidence of the effect of dietary supplements (e.g. vitamins, minerals, herbs) on period pain (dysmenorrhoea). Background Dietary supplements have been used in the treatment of period pain. It is important to explore their benefits and harms. We investigated the effectiveness of dietary supplements compared to other supplements, placebo, no treatment or conventional analgesics (pain relief) in women with either primary dysmenorrhoea (not related to any other diagnosis) or secondary dysmenorrhoea (related to other causes, such as endometriosis). The evidence is current to 23 March 2015. Study characteristics We included 27 randomised controlled trials (3101 women). Most participants were students in their late teens or early twenties with primary dysmenorrhoea. Most studies were conducted in Iran. Interventions included 12 different herbal medicines (chamomile, cinnamon, Damask rose, dill, fennel, fenugreek, ginger, guava, rhubarb, uzara, valerian, and zataria), and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Supplements were compared with other supplements, placebo, no treatment, and non‐steroidal anti‐inflammatory drugs (NSAIDs). Key results There was no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety was lacking. However, for several supplements there was some low quality evidence of effectiveness. Supplements for which there was some very limited evidence to suggest a potential benefit were fenugreek, ginger, valerian, zataria, zinc sulphate, fish oil, and vitamin B1. There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis. Quality of the evidence The evidence was of low or very low quality for all comparisons. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few included studies reported adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pattanittum, P; Kunyanone, N; Brown, J; Sangkomkamhang, US; Barnes, J; Seyfoddin, V; Marjoribanks, J", "articleTypes": [], "doi": "10.1002/14651858.CD002124.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "5228bb28-2f2c-47fd-bf6c-cda7f4465164", "pmid": "", "title": "CD36 Involvement on Fat Taste Perception and Fat Hedonic Value in Humans", "imported": false, "abstract": "The purpose of this study is to determine the effect of common human variants in in taste related genes, such as CD36 gene, a putative fat taste receptor, affect fat taste perception.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.231Z" }, { "id": "522e85fa-1c9d-4d42-8d71-690f36dfff6a", "pmid": "", "title": "Replacing salt with low‐sodium salt substitutes (LSSS) for cardiovascular health in adults, children and pregnant women", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Brand, A, Visser, ME, Schoonees, A, Naude, CE", "articleTypes": [], "doi": "10.1002/14651858.CD015207 AB - Abstract - Background Elevated blood pressure, or hypertension, is the leading cause of preventable deaths globally. Diets high in sodium (predominantly sodium chloride) and low in potassium contribute to elevated blood pressure. The WHO recommends decreasing mean population sodium intake through effective and safe strategies to reduce hypertension and its associated disease burden. Incorporating low‐sodium salt substitutes (LSSS) into population strategies has increasingly been recognised as a possible sodium reduction strategy, particularly in populations where a substantial proportion of overall sodium intake comes from discretionary salt. The LSSS contain lower concentrations of sodium through its displacement with potassium predominantly, or other minerals. Potassium‐containing LSSS can potentially simultaneously decrease sodium intake and increase potassium intake. Benefits of LSSS include their potential blood pressure‐lowering effect and relatively low cost. However, there are concerns about potential adverse effects of LSSS, such as hyperkalaemia, particularly in people at risk, for example, those with chronic kidney disease (CKD) or taking medications that impair potassium excretion. Objectives To assess the effects and safety of replacing salt with LSSS to reduce sodium intake on cardiovascular health in adults, pregnant women and children. Search methods We searched MEDLINE (PubMed), Embase (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection (Clarivate Analytics), Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCOhost), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) up to 18 August 2021, and screened reference lists of included trials and relevant systematic reviews. No language or publication restrictions were applied. Selection criteria We included randomised controlled trials (RCTs) and prospective analytical cohort studies in participants of any age in the general population, from any setting in any country. This included participants with non‐communicable diseases and those taking medications that impair potassium excretion. Studies had to compare any type and method of implementation of LSSS with the use of regular salt, or no active intervention, at an individual, household or community level, for any duration. Data collection and analysis Two review authors independently screened titles, abstracts and full‐text articles to determine eligibility; and extracted data, assessed risk of bias (RoB) using the Cochrane RoB tool, and assessed the certainty of the evidence using GRADE. We stratified analyses by adults, children (≤ 18 years) and pregnant women. Primary effectiveness outcomes were change in diastolic and systolic blood pressure (DBP and SBP), hypertension and blood pressure control; cardiovascular events and cardiovascular mortality were additionally assessed as primary effectiveness outcomes in adults. Primary safety outcomes were change in blood potassium, hyperkalaemia and hypokalaemia. Main results We included 26 RCTs, 16 randomising individual participants and 10 randomising clusters (families, households or villages). A total of 34,961 adult participants and 92 children were randomised to either LSSS or regular salt, with the smallest trial including 10 and the largest including 20,995 participants. No studies in pregnant women were identified. Studies included only participants with hypertension (11/26), normal blood pressure (1/26), pre‐hypertension (1/26), or participants with and without hypertension (11/26). This was unknown in the remaining studies. The largest study included only participants with an elevated risk of stroke at baseline. Seven studies included adult participants possibly at risk of hyperkalaemia. All 26 trials specifically excluded participants in whom an increased potassium intake is known to be potentially harmful. The majority of trials were conducted in rural or suburban settings, with more than half (14/26) conducted in low‐ and middle‐income countries. The proportion of sodium chloride replacement in the LSSS interventions varied from approximately 3% to 77%. The majority of trials (23/26) investigated LSSS where potassium‐containing salts were used to substitute sodium. In most trials, LSSS implementation was discretionary (22/26). Trial duration ranged from two months to nearly five years. We assessed the overall risk of bias as high in six trials and unclear in 12 trials. LSSS compared to regular salt in adults: LSSS compared to regular salt probably reduce DBP on average (mean difference (MD) ‐2.43 mmHg, 95% confidence interval (CI) ‐3.50 to ‐1.36; 20,830 participants, 19 RCTs, moderate‐certainty evidence) and SBP (MD ‐4.76 mmHg, 95% CI ‐6.01 to ‐3.50; 21,414 participants, 20 RCTs, moderate‐certainty evidence) slightly. On average, LSSS probably reduce non‐fatal stroke (absolute effect (AE) 20 fewer/100,000 person‐years, 95% CI ‐40 to 2; 21,250 participants, 3 RCTs, moderate‐certainty evidence), non‐fatal acute coronary syndrome (AE 150 fewer/100,000 person‐years, 95% CI ‐250 to ‐30; 20,995 participants, 1 RCT, moderate‐certainty evidence) and cardiovascular mortality (AE 180 fewer/100,000 person‐years, 95% CI ‐310 to 0; 23,200 participants, 3 RCTs, moderate‐certainty evidence) slightly, and probably increase blood potassium slightly (MD 0.12 mmol/L, 95% CI 0.07 to 0.18; 784 participants, 6 RCTs, moderate‐certainty evidence), compared to regular salt. LSSS may result in little to no difference, on average, in hypertension (AE 17 fewer/1000, 95% CI ‐58 to 17; 2566 participants, 1 RCT, low‐certainty evidence) and hyperkalaemia (AE 4 more/100,000, 95% CI ‐47 to 121; 22,849 participants, 5 RCTs, moderate‐certainty evidence) compared to regular salt. The evidence is very uncertain about the effects of LSSS on blood pressure control, various cardiovascular events, stroke mortality, hypokalaemia, and other adverse events (very‐low certainty evidence). LSSS compared to regular salt in children: The evidence is very uncertain about the effects of LSSS on DBP and SBP in children. We found no evidence about the effects of LSSS on hypertension, blood pressure control, blood potassium, hyperkalaemia and hypokalaemia in children. Authors' conclusions When compared to regular salt, LSSS probably reduce blood pressure, non‐fatal cardiovascular events and cardiovascular mortality slightly in adults. However, LSSS also probably increase blood potassium slightly in adults. These small effects may be important when LSSS interventions are implemented at the population level. Evidence is limited for adults without elevated blood pressure, and there is a lack of evidence in pregnant women and people in whom an increased potassium intake is known to be potentially harmful, limiting conclusions on the safety of LSSS in the general population. We also cannot draw firm conclusions about effects of non‐discretionary LSSS implementations. The evidence is very uncertain about the effects of LSSS on blood pressure in children. Plain language summary Does using low‐sodium salt substitutes (LSSS) instead of regular salt reduce blood pressure and heart disease risks, and is it safe? Key messages • In adults, using LSSS instead of regular salt in food probably lowers blood pressure slightly. Adults using LSSS instead of regular salt probably have a slightly lower risk of non‐fatal heart conditions, such as stroke or a sudden reduced blood flow to the heart, and death from heart disease. • Using LSSS instead of regular salt probably also slightly increases the level of blood potassium (a mineral that keeps your heart beating at the right pace) in adults. This could be harmful for people who cannot effectively regulate the potassium in their bodies. Other evidence on safety is very limited. • We are not certain about effects of using LSSS instead of regular salt on blood pressure in children, or whether using LSSS is safe in children. • This evidence may not directly apply to people known to be at risk of high blood potassium, such as people with kidney problems or on certain medications. What are low‐sodium salt substitutes (LSSS)? LSSS are products with less sodium than regular salt. Amounts of sodium in LSSS are lowered by replacing some of the sodium with potassium or other minerals. LSSS may help lower risks of using regular salt, since eating lots of sodium and not enough potassium contributes to high blood pressure. Globally, high blood pressure is the largest cause of preventable deaths, mainly because it causes stroke, acute coronary syndrome (ACS; where less blood flows to the heart), and kidney problems. However, LSSS also has potential health risks. Using LSSS may lead to higher than normal blood potassium (hyperkalaemia), which causes problems with the heartbeat speed and rhythm, or can cause the heart to stop. These risks are greater in certain people, for example, those whose kidneys do not work properly to remove potassium. What did we want to find out? We wanted to find out what the effects of using LSSS instead of regular salt are on blood pressure as well as on events (stroke and ACS) and heart disease death. We also wanted to know if using LSSS instead of regular salt is safe, both in the general population and in people who are known to be at risk of high blood potassium levels. We wanted to find this out for adults, children and pregnant women. What did we do? 
We searched five electronic databases and trial registries for studies that compared using LSSS with using regular salt. We compared and summarised the results of the studies and rated our confidence in the combined evidence, based on factors such as study methods and sizes. What did we find? We found 26 trials* involving 34,961 adults and 92 children. No studies in pregnant women were found. Most trials were undertaken in rural or suburban areas, with more than half done in low‐ and middle‐income countries. Most trials included some people with high blood pressure (22); the largest included only people with a high risk of stroke. Seven trials were done in people at possible risk of high blood potassium. All trials excluded people where high potassium intake is known to be harmful, such as people with kidney problems or on certain medications. Nearly all trials (23) examined LSSS types where some sodium was replaced with potassium. The amount of sodium replaced in the various LSSS used in the trials ranged from very small (3%) to large (77%). *Trials are types of studies in which participants are assigned randomly to two or more treatment groups. This is the best way to ensure similar groups of participants. Main results In adults, LSSS probably lowers blood pressure (diastolic and systolic) slightly when compared to regular salt. Using LSSS also probably lowers risk of non‐fatal stroke, non‐fatal ACS and heart disease death slightly when compared to regular salt. However, using LSSS instead of regular salt probably also slightly increases the level of potassium in the blood. Compared to regular salt, LSSS may result in little to no difference in high blood pressure and hyperkalaemia. We could not draw any conclusions about effects of LSSS on blood pressure control, various heart disease events, death caused by stroke, lower than normal blood potassium (hypokalaemia), and other adverse events. We could not draw any conclusions about the effects or safety of using LSSS instead of regular salt in children. What are the limitations of the evidence? We are moderately confident in the evidence. Our confidence was lowered mainly because of concerns about how some trials were conducted, and whether the results apply to the general population. We are not sure about the effects and safety of LSSS in children, pregnant women, people known to have a risk of high blood potassium, or those who do not have high blood pressure. We are also unsure about the effects of LSSS when used in foods not prepared at home. Further research may change these results. How up to date is this evidence? The evidence is up‐to‐date to August 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.774Z" }, { "id": "523ee8f6-1f83-461f-a4e6-c7d1dc7239af", "pmid": "", "title": "Souvenaid for Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Souvenaid is a dietary supplement with a patented composition (Fortasyn Connect™)which is intended to be used by people with Alzheimer's disease (AD). It has been designed to support the formation and function of synapses in the brain, which are thought to be strongly correlated with cognitive function. If effective, it might improve symptoms of Alzheimer's disease and also prevent the progression from prodromal Alzheimer's disease to dementia. We sought in this review to examine the evidence for this proposition. Objectives To assess the effects of Souvenaid on incidence of dementia, cognition, functional performance, and safety in people with Alzheimer's disease. Search methods We searched ALOIS, i.e. the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science (ISI Web of Science), Cinahl (EBSCOhost), Lilacs (BIREME), and clinical trials registries up to 24 June 2020. We also reviewed citations of reference lists of landmark papers, reviews, and included studies for additional studies and assessed their suitability for inclusion in the review. Selection criteria We included randomised, placebo‐controlled trials which evaluated Souvenaid in people diagnosed with mild cognitive impairment (MCI) due to AD (also termed prodromal AD) or with dementia due to AD, and with a treatment duration of at least 16 weeks. Data collection and analysis Our primary outcome measures were incidence of dementia, global and specific cognitive function, functional performance, combined cognitive‐functional outcomes and adverse events. We selected studies, extracted data, assessed the quality of trials and intended to conduct meta‐analyses according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We present all outcomes grouped by stage of AD. Main results We included three randomised, placebo‐controlled trials investigating Souvenaid in 1097 community‐dwelling participants with Alzheimer's disease. One study each included participants with prodromal AD, mild AD dementia and mild‐to‐moderate AD dementia. We rated the risks of bias of all trials as low. One study (in prodromal AD) was funded by European grants. The other two studies were funded by the manufacturer of Souvenaid. One trial investigated the incidence of dementia in people with prodromal AD at baseline, and found little to no difference between the Souvenaid group and the placebo group after 24 months (RR 1.09, 95% CI 0.82 to 1.43; 1 trial, 311 participants; moderate quality of evidence). In prodromal AD, and in mild and mild‐to‐moderate Alzheimer's disease dementia, Souvenaid probably results in little or no difference in global or specific cognitive functions (moderate quality of evidence). Everyday function, or the ability to perform activities of daily living, were measured in mild and mild‐to‐moderate AD dementia. Neither study found evidence of a difference between the groups after 24 weeks of treatment (moderate quality of evidence). Two studies investigated combined cognitive‐functional outcomes with the Clinical Dementia Rating Sum of Boxes and observed conflicting results. Souvenaid probably results in slight improvement, which is below estimates of meaningful change, in participants with prodromal Alzheimer's disease after 24 months (moderate quality of evidence), but probably has little to no effect in mild‐to‐moderate Alzheimer's disease dementia after 24 weeks (moderate quality of evidence). Adverse effects observed were low in all trials, and the available data were insufficient to determine any connection with Souvenaid. Authors' conclusions Two years of treatment with Souvenaid probably does not reduce the risk of progression to dementia in people with prodromal AD. There is no convincing evidence that Souvenaid affects other outcomes important to people with AD in the prodromal stage or mild‐to‐moderate stages of dementia. Conflicting evidence on combined cognitive‐functional outcomes in prodromal AD and mild AD dementia warrants further investigation. Adverse effects of Souvenaid seem to be uncommon, but the evidence synthesised in this review does not permit us to make a definitive statement on the long‐term tolerability of Souvenaid. The effects of Souvenaid in more severe AD dementia or in people with AD at risk of nutritional deficiencies remain unclear. Plain language summary The dietary supplement Souvenaid for preventing dementia or delaying cognitive decline in people with Alzheimer's disease Review question We investigated whether people with mild cognitive impairment (MCI) due to Alzheimer's disease (AD) can reduce their risk of developing dementia with a patented dietary supplement called Souvenaid. We also investigated the effect of Souvenaid on memory or other thinking skills, ability to carry out daily activities, and side effects in people with MCI or any stage of dementia due to AD. Background Alzheimer's disease is a brain disease. It is the commonest cause of dementia among older people. A person is said to have dementia when there has been a decline in their memory and thinking skills which is severe enough to stop them being fully independent in all their daily activities. Because AD develops slowly, it is also possible to pick up symptoms before dementia is fully developed. This pre‐dementia stage, when people with AD have a detectable decline in memory and thinking skills but are still able to manage their usual activities independently, is known as mild cognitive impairment due to AD, or 'prodromal' AD. Souvenaid is a patented mix of vitamins and minerals (Fortasyn Connect™) which was designed to improve brain function in AD. It is a drink which is to be taken once a day. It is intended to be consumed under medical supervision, in addition to the usual diet. Search for evidence We systematically searched for randomised controlled trials (RCTs) which were published up to June 2020 and which compared treatment with Souvenaid for at least 16 weeks with treatment with a dummy supplement (a placebo). For the comparison to be fair, it had to be decided randomly whether each participant was given Souvenaid or the placebo. Key results We found three RCTs with a total of 1097 participants to include in the review. Two of the trials investigated Souvenaid in people with dementia over a treatment period of 24 weeks. One of these included 527 participants with mild‐to‐moderate dementia due to AD and the other included 259 participants with mild dementia due to AD. The third trial investigated the use of Souvenaid for two years in 311 people with prodromal AD. We considered all of the trials to be well‐designed, but because of differences between them in the severity of the participants' symptoms and in the way the researchers measured their results, we were not able to combine the data numerically from the single trials. All the results we report are therefore based on single trials, which leads us to have only moderate confidence in the findings of this review. This means that results could be changed by further research. We found that people with prodromal AD who took Souvenaid daily for two years were probably no more or less likely than those taking placebo to develop dementia. Souvenaid probably had little or no effect on measures of memory or other thinking skills in people with prodromal AD (after two years of treatment) or with mild or mild‐to‐moderate dementia due to AD (after 24 weeks of treatment). It also probably had little or no effect on the ability of people with mild or mild‐to‐moderate dementia due to AD to manage everyday activities (again after 24 weeks). Two studies used an outcome scale which combined memory and thinking skills with practical skills (described as a combined cognitive‐functional outcome). There was probably a small benefit of Souvenaid on this outcome among people with prodromal AD who took Souvenaid for two years. However, there was probably little or no effect of Souvenaid on this outcome among people with mild‐to‐moderate AD dementia who took it for 24 weeks. There were only a few adverse events reported in the trials, and it was not possible to know whether any of them were side effects of Souvenaid. Study funding sources Two studies were funded by the manufacturer of Souvenaid. The third study (in prodromal AD) was funded by European grants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Burckhardt, M; Watzke, S; Wienke, A; Langer, G; Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD011679.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "52634fc7-d11c-47c6-ac3b-2bfc1bccedb1", "pmid": "", "title": "Interventions to prevent obesity in children aged 2 to 4 years old", "imported": false, "abstract": "Abstract - Rationale Early childhood presents an important opportunity for obesity prevention, an international public health priority. Interventions aiming to prevent obesity typically promote healthy diets or activity levels (physical activity, sedentary behaviour), or both. There is uncertainty over which approaches are more effective. This is one of a suite of three reviews addressing interventions for preventing obesity in children, each focusing on different age groups up to 18 years. These reviews replace and update a 2019 Cochrane review on interventions for preventing obesity in children from birth to 18 years. Objectives To assess the effects of interventions that aimed to prevent obesity in children aged two to four years by changing dietary intake or activity levels, or both, on body mass index (BMI), BMI z‐score (zBMI), BMI percentile, and serious adverse events. Search methods We searched CENTRAL, MEDLINE, Embase, six other databases, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify eligible studies. The latest search date was 7 February 2023. Eligibility criteria We included randomised controlled trials (RCTs) in children aged two to four years, comparing dietary or activity interventions (or both combined) to prevent overweight or obesity versus no intervention, usual care, or another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post‐baseline. There were no language restrictions. Outcomes Our outcomes were BMI, zBMI, BMI percentile, and serious adverse events. Risk of bias We used version 2 of the Cochrane risk of bias tool (RoB 2) to assess included RCTs. Synthesis methods Working independently, two authors screened studies, extracted data, and conducted risk of bias and GRADE assessments. We conducted random‐effects meta‐analyses stratified by type of intervention and follow‐up duration. Included studies We included 67 studies (36,601 participants), with 56 studies (21,404 participants) pooled in the meta‐analyses. Sixty‐three studies were conducted in high‐income countries. Study settings were split between childcare (26 studies; 39%), home (23 studies; 34%), and home plus childcare settings (10 studies; 15%). Few studies were conducted in the community (three studies; 5%) or healthcare settings (five studies; 7%). Most studies compared a combined dietary/activity intervention with a control group. Synthesis of results Dietary interventions versus control Dietary interventions may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0.00, 95% confidence interval (CI) ‐0.28 to 0.28; 1 study, 94 participants; low‐certainty evidence). At medium‐ and long‐term follow‐up, dietary interventions may result in little to no difference in BMI. One study (103 participants; low‐certainty evidence) reported no difference in BMI at medium‐term follow‐up, and one study (2238 participants; low‐certainty evidence) found lower rates of overweight and obesity in the intervention group at long‐term follow‐up. Dietary interventions likely result in little to no difference in zBMI at short‐term (MD 0.03, 95% CI ‐0.13 to 0.19; 2 studies, 145 participants) and medium‐term follow‐up (MD ‐0.17, 95% CI ‐0.44 to 0.10; 1 study, 389 participants), both with moderate‐certainty evidence. None of the included studies reported zBMI at long‐term follow‐up. None of the studies reported serious adverse events. Activity interventions versus control Activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.10, 95% CI ‐0.28 to 0.08; 6 studies, 826 participants; very low‐certainty evidence). They likely reduce BMI at medium‐term follow‐up (MD ‐0.70, 95% CI ‐1.09 to ‐0.31; 1 study, 567 participants; moderate‐certainty evidence). None of the studies reported BMI at long‐term follow‐up. Activity interventions likely result in little to no difference in zBMI at short‐term follow‐up (MD ‐0.06, 95% CI ‐0.19 to 0.07; 3 studies, 635 participants; moderate‐certainty evidence). They may result in little to no difference in zBMI at medium‐term follow‐up, but the evidence is very uncertain (MD ‐0.00, 95% CI ‐0.12 to 0.11; 4 studies, 1083 participants; very low‐certainty evidence). None of the included studies reported zBMI at long‐term follow‐up. Activity interventions may have little to no effect on serious adverse events, but the evidence is very uncertain (2 studies, 773 participants; very low‐certainty evidence). One study found no harms related to the intervention, and one study reported no difference in accident and infection rates between groups. Combined dietary/activity interventions versus control Combined dietary/activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.08, 95% CI ‐0.20 to 0.04; 13 studies, 3867 participants; very low‐certainty evidence). They may result in little to no difference in BMI at medium‐term follow‐up (MD ‐0.05, 95% CI ‐0.18 to 0.08; 9 studies, 7016 participants; low‐certainty evidence), and may result in a slight reduction in BMI at long‐term follow‐up (MD ‐0.20, 95% CI ‐0.39 to ‐0.01; 5 studies, 2074 participants; low‐certainty evidence). Combined interventions may have little to no effect on zBMI at short‐term follow‐up (MD ‐0.03, 95% CI ‐0.07 to 0.01; 14 studies, 5518 participants), and may result in a slight reduction in zBMI at medium‐term follow‐up, but the evidence for both time frames is very uncertain (MD ‐0.07, 95% CI ‐0.11 to ‐0.04; 15 studies; 11,043 participants). Combined interventions may result in a slight reduction in zBMI at long‐term follow‐up (MD ‐0.07, 95% CI ‐0.13 to ‐0.01; 10 studies, 4693 participants; low‐certainty evidence). Combined interventions may result in little to no difference in serious adverse events, but the evidence is very uncertain (4 studies, 1689 participants; very low‐certainty evidence). One study reported that a parent fractured an ankle while roller‐skating at a community centre; the remaining studies reported no adverse events. Authors' conclusions In early childhood, combined dietary/activity interventions may have very modest benefits on BMI and zBMI at long‐term follow‐up. When implemented alone, dietary or activity interventions may have little to no effect on BMI measures. Only six studies reported serious adverse events, with no serious harms resulting directly from the intervention, but the evidence is very uncertain. Funding This review was partly funded by the National Institute for Health Research, School for Public Health Research. Registration Protocol available: DOI: 10.1002/14651858.CD015326 Plain language summary Do dietary and activity strategies help prevent obesity in children aged 2 to 4 years? Key messages Combining strategies for changing diet and physical activity levels in children aged 2 to 4 years to help prevent overweight and obesity may reduce body mass index (BMI) slightly in the long term (after 15 months). There was very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but none of the strategies appeared to result in any serious harm to the children. Future research should carry out obesity prevention strategies in community settings, and target the wider determinants of obesity and obesity prevention. Why is preventing obesity in children important? There is an increasing number of young children living with overweight and obesity worldwide, with evidence of the rates increasing in line with social inequality. Living with overweight during childhood can cause physical and psychological health problems. Children living with overweight are more likely to live with overweight as adults, and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help people change diet or activity (or both) are effective at preventing obesity in children aged 2 to 4 years, and whether they are associated with any serious adverse events. To examine obesity, we used the measure of body mass index (BMI). BMI is calculated by dividing a person's weight (in kg) by their height (in m 2 ). What did we do? We searched for studies that looked at ways to prevent obesity in children aged 2 to 4 years. We did not include studies that only targeted children who were already living with overweight or obesity, but we did include studies involving children at a range of weights. We only included studies if they used methods aimed at changing children's diet, activity level (increasing physical activity or reducing sedentary behaviour), or both. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 67 studies involving 36,601 children aged 2 to 4 years. Most studies (63 of 67) were based in high‐income countries, and four in upper‐middle‐income countries. In 26 studies, the strategies were conducted in childcare settings, 23 studies were primarily home‐based, and 10 were performed in both childcare and home‐based settings. Only 3 studies were conducted in the community, and 5 in healthcare settings. The duration of the programmes varied: 47 ran for fewer than 9 months, with the shortest being 1 visit and the longest lasting 3 years. We analysed results from 56 studies involving 21,404 children. Main findings Children who were helped with a strategy to change their diet and activity levels may have had a reduced BMI, compared with children not given any strategy. This means that these children may have been able to minimise excess weight gain by a small amount, which, for public health, is important. Children who were helped with a strategy to change their diet or activity alone did not have a reduced BMI. Only six of the 67 included studies reported on serious adverse events, and no serious harms were identified. What are the limitations of the evidence? Overall, our confidence in the evidence is very low. However, we do not believe that results from more studies similar in design to those included in this review would produce a higher level of confidence in the results. Four main factors reduced our confidence in the evidence. Results were very inconsistent across different studies. There were not enough studies reporting specific types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons. Results from some studies were not reported in a way that we could include in our analyses and this may have had an impact on the combined results. Studies generally had limitations in how they were conducted, due to the complexity of studies in this age group. This review does not provide enough information to assess how well these strategies work for children with disabilities or those from low‐ and middle‐income countries. How current is this evidence? This review updates a previous review. The evidence is current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Phillips, SM, Spiga, F, Moore, THM, Dawson, S, Stockton, H, Rizk, R, Cheng, HY, Hodder, RK, Gao, Y, Hillier-Brown, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015326.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.135Z" }, { "id": "526e0f1d-b057-4729-abd3-1a663e659762", "pmid": "", "title": "Interventions for hyperthyroidism pre‐pregnancy and during pregnancy", "imported": false, "abstract": "Abstract - Background Women with hyperthyroidism in pregnancy have increased risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction; and they can develop severe pre‐eclampsia or placental abruption. Objectives To identify interventions used in the management of hyperthyroidism pre‐pregnancy or during pregnancy and to ascertain the impact of these interventions on important maternal, fetal, neonatal and childhood outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 September 2013). Selection criteria We planned to include randomised controlled trials, quasi‐randomised controlled trials, and cluster‐randomised trials comparing antithyroid interventions for hyperthyroidism pre‐pregnancy or during pregnancy with another intervention or no intervention (placebo or no treatment). Data collection and analysis Two review authors assessed trial eligibility and planned to assess trial quality and extract the data independently. Main results No trials were included in the review. Authors' conclusions As we did not identify any eligible trials, we are unable to comment on implications for practice, although early identification of hyperthyroidism before pregnancy may allow a woman to choose radioactive iodine therapy or surgery before planning to have a child. Designing and conducting a trial of antithyroid interventions for pregnant women with hyperthyroidism presents formidable challenges. Not only is hyperthyroidism a relatively rare condition, both of the two main drugs used have potential for harm, one for the mother and the other for the child. More observational research is required about the potential harms of methimazole in early pregnancy and about the potential liver damage from propylthiouracil. Plain language summary No evidence found from randomised trials for drugs to treat pregnant women with hyperthyroidism Hyperthyroidism in pregnancy is a rare, serious condition which can increase the risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction. Pregnant women who are hyperthyroid may also develop severe pre‐eclampsia or placental abruption. Most of these women have Graves' disease, an autoimmune disease most common in women aged 20 to 40 years. Most pregnant women with hyperthyroidism are diagnosed with thyroid disease prior to conception and will have previously received treatment for the condition. Generally only drug therapy is considered for treating pregnant women with hyperthyroidism. Radioiodine treatment is not used in pregnancy because it destroys the fetal thyroid gland, resulting in permanent hypothyroidism in the newborn. The main antithyroid drugs used are the thionamides, propylthiouracil (PTU), methimazole and carbimazole. PTU is currently the favoured drug for use in pregnancy, as it is associated with fewer teratogenic effects (scalp lesions) than methimazole. However, since there have been reports of liver damage in people taking PTU, it may be reasonable for pregnant hyperthyroid women to be treated with PTU in the first trimester (to reduce any teratogenic effects of methimazole) and then to change to methimazole. We did not identify any randomised trials to help inform women and their doctors about which antithyroid drugs are most effective, with the lowest potential for harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Earl, R; Crowther, CA; Middleton, P", "articleTypes": [], "doi": "10.1002/14651858.CD008633.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "526f8227-d863-426b-bf45-a29af0050e99", "pmid": "", "title": "Triptans for acute cluster headache", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 ( Law 2010 ). Cluster headache is an uncommon, severely painful, and disabling condition, with rapid onset. Validated treatment options are limited; first‐line therapy includes inhaled oxygen. Other therapies such as intranasal lignocaine and ergotamine are not as commonly used and are less well studied. Triptans are successfully used to treat migraine attacks and they may also be useful for cluster headache. Objectives To assess the efficacy and tolerability of the triptan class of drugs compared to placebo and other active interventions in the acute treatment of episodic and chronic cluster headache in adult patients. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ClinicalTrials.gov, and reference lists for studies from inception to 22 January 2010 for the original review, and from 2009 to 4 April 2013 for this update. Selection criteria Randomised, double‐blind, placebo‐controlled studies of triptans for acute treatment of cluster headache episodes. Data collection and analysis Two review authors independently assessed study quality and extracted data. Numbers of participants with different levels of pain relief, requiring rescue medication, and experiencing adverse events and headache‐associated symptoms in treatment and control groups were used to calculate relative risk and numbers needed to treat for benefit (NNT) and harm (NNH). Main results New searches in 2013 did not identify any relevant new studies. All six included studies used a single dose of triptan to treat an attack of moderate to severe pain intensity. Subcutaneous sumatriptan was given to 131 participants at a 6 mg dose, and 88 at a 12 mg dose. Oral or intranasal zolmitriptan was given to 231 participants at a 5 mg dose, and 223 at a 10 mg dose. Placebo was given to 326 participants. Triptans were more effective than placebo for headache relief and pain‐free responses. By 15 minutes after treatment with subcutaneous sumatriptan 6 mg, 48% of participants were pain‐free and 75% had no pain or mild pain (17% and 32% respectively with placebo). NNTs for subcutaneous sumatriptan 6 mg were 3.3 (95% CI 2.4 to 5.0) and 2.4 (1.9 to 3.2) respectively. Intranasal zolmitriptan 10 mg was of less benefit, with 12% of participants pain‐free and 28% with no or mild pain (3% and 7% respectively with placebo). NNTs for intranasal zolmitriptan 10 mg were 11 (6.4 to 49) and 4.9 (3.3 to 9.2) respectively. Authors' conclusions Based on limited data, subcutaneous sumatriptan 6 mg was superior to intranasal zolmitriptan 5 mg or 10 mg for rapid (15 minute) responses, which are important in this condition. Oral routes of administration are not appropriate. Plain language summary Triptans for acute cluster headache Cluster headaches are excruciating headaches of extreme intensity. They can last for several hours, are usually on one side of the head only, and affect men more than women. Multiple headaches can occur over several days. Fast pain relief is important because of the intense nature of the pain with cluster headache. Triptans are a type of drug used to treat migraine. Although migraine is different from cluster headache, there are reasons to believe that some forms of these drugs could be useful in cluster headache. Triptans can be given by injection under the skin (subcutaneously) or by a spray into the nose (intranasally) to produce fast pain relief. The review found six studies examining two different triptans. The number of people in the studies was limited. Within 15 minutes of using subcutaneous sumatriptan 6 mg, almost 8 in 10 participants had no worse than mild pain, and 5 in 10 were pain‐free. Within 15 minutes of using intranasal zolmitriptan 5 mg, about 3 in 10 had no worse than mild pain, and 1 in 10 was pain‐free. Adverse events were more common with a triptan than with placebo but they were generally of mild to moderate severity. Cluster headache is an awful thing to have. More research on how to get better pain relief faster, and to more patients, would be welcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Law, S; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008042.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "5295ab5b-4823-4045-b535-4157f6012bb9", "pmid": "", "title": "Graft interposition for preventing Frey's syndrome in patients undergoing parotidectomy", "imported": false, "abstract": "Abstract - Background Frey's syndrome is characterised by transient flushing and sometimes facial sweating in the area of the auriculotemporal nerve. It most commonly occurs after parotidectomy, but other causes may include submandibular gland surgery, mandibular condylar fracture, obstetric (forceps) trauma, sympathectomy and metabolic disease. Although the pathophysiology of Frey's syndrome remains controversial, the generally accepted hypothesis is that it occurs as the result of injury to the auriculotemporal nerve. There is currently no clear evidence to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome, therefore the prevention of this symptom during surgery is important. The main method used for prevention is the interposition of a graft between the skin flap and the parotid bed during surgery. Biomaterials, allograft or autograft can be used for this purpose. Objectives To evaluate the effects and safety of biomaterial, allograft or autograft interposition for the prevention of Frey's syndrome in patients undergoing parotidectomy, and to identify its effect on prevention and delayed occurrence. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Cochrane Register of Controlled Trials (CENTRAL; 2019, Issue 2); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 5 February 2019. Selection criteria We included randomised controlled trials (RCTs) in patients with parotid disease (including tumours, inflammation, trauma etc.) undergoing parotidectomy with a minimal follow‐up period of six months. We planned to include trials with interventions including biomaterial, allograft or autograft interposition alone or in combination with other surgical techniques. We included trials that compared any graft interposition and no graft interposition, or different graft interpositions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were incidence rate of Frey's syndrome assessed clinically (Minor's starch‐iodine test) and other complications (postoperative infection, subjective painful or restricted cervical movement, scar spread, rejection of the graft, complications related to the donor site such as accessory nerve injury and haematoma). Our secondary outcome measures were incidence rate of Frey's syndrome assessed by participants (by questionnaire) and sweating area assessed by Minor's starch‐iodine test. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included three RCTs (124 participants), two of which we assessed as at high risk of bias and one at unclear risk of bias. All studies were hospital‐based and recruited participants undergoing superficial parotidectomy. Most participants were diagnosed with benign lesions of the parotid gland. Participants were followed up for more than six months. The studies evaluated the two comparisons shown below: Sternocleidomastoid muscle flap versus no flap Two studies assessed this comparison. Both assessed the effects of the sternocleidomastoid muscle flap procedure on the incidence rate of Frey's syndrome assessed clinically but neither showed a significant difference between groups (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.23; 24 participants and RR 1.23, 95% CI 0.88 to 1.73; 36 participants; very low‐certainty evidence). We did not pool the data due to the high heterogeneity (I² = 87%). One study found that the sternocleidomastoid muscle flap may result in little or no difference in other complications including haematoma (RR 2.18, 95% CI 0.09 to 50.16; 36 participants; low‐certainty evidence), subjective painful or restricted cervical movement (RR 0.54, 95% CI 0.14 to 2.05; 36 participants; low‐certainty evidence) and scar spread in the cervical region (RR 0.71, 95% CI 0.05 to 10.54; 36 participants; low‐certainty evidence). Both studies reported the incidence rate of Frey's syndrome assessed by participants, with one reporting no events in either group and the other finding no evidence of a difference (RR 0.63, 95% CI 0.32 to 1.26; 36 participants; low‐certainty evidence). Acellular dermal matrix versus no graft Only one study assessed this comparison. Use of an acellular dermal matrix graft may result in little or no difference to the incidence rate of Frey's syndrome (assessed clinically) in comparison with the no graft group, but the evidence is very uncertain (RR 0.08, 95% CI 0.00 to 1.25; 30 participants; very low‐certainty evidence). Acellular dermal matrix may slightly increase the wound infection rate compared with control (RR 17.00, 95% CI 1.02 to 282.67; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence of seromas or sialoceles (RR 2.33, 95% CI 0.66 to 8.23; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence rate of Frey's syndrome (assessed by participants) in comparison with the no graft group (RR 0.33, 95% CI 0.04 to 3.04; 64 participants; low‐certainty evidence). Authors' conclusions The evidence for the effectiveness of graft interposition in preventing Frey's syndrome is of low or very low certainty. The use of acellular dermal matrix may be associated with an increase in the wound infection rate, and little or no difference in the incidence of seromas or sialoceles. Further studies are needed to draw reliable conclusions. Plain language summary Grafts for preventing Frey's syndrome after surgery to the parotid (salivary) glands Review question Does the use of a graft during surgery to the parotid glands prevent Frey's syndrome? Background The clinical symptoms of Frey's syndrome include sweating and flushing of the cheek when eating and chewing. It results from abnormal regrowth of damaged autonomic nerve fibres of the parotid glands, for example during surgery for parotid gland tumours. It is unclear whether placing a graft between the skin flap and the parotid bed during surgery can prevent this syndrome. Various types of grafts can be used, including biomaterial or skin, muscle or other tissue from the patient. These grafts may possibly hinder the abnormal connections of the nerves controlling the sweat glands and parotid glands when the cut nerves are re‐linking after surgery. Study characteristics We included three studies with 124 participants in this review, but the quality of these studies was not ideal. All of the participants in the studies had tumours of the parotid glands and were undergoing surgery to part of the glands. The studies assessed two types of grafts, tissue obtained from the sternocleidomastoid muscle and a biomaterial (a collagen framework without cells). Key results Two studies compared a tissue graft obtained from the sternocleidomastoid muscle to no graft. It is not known whether this type of tissue graft can prevent Frey's syndrome because the available evidence is very uncertain. One study compared a biomaterial graft to no graft. This type of graft may result in little or no difference to the incidence rate of Frey's syndrome, but the evidence is very uncertain. It may make the patient's wound slightly more likely to become infected. Certainty of the evidence The evidence in this review is mostly of low or very low certainty, because of the small number of studies on this question and the risk of bias in these studies. The findings must therefore be treated with caution and further studies are needed to draw reliable conclusions. The evidence in this review is up to date to 5 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ye, L; Cao, Y; Yang, W; Wu, F; Lin, J; Li, L; Li, C", "articleTypes": [], "doi": "10.1002/14651858.CD012323.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "5296d8c1-d215-4f83-989b-6beb9568cfe7", "pmid": "", "title": "Fortification of staple foods with vitamin A for vitamin A deficiency", "imported": false, "abstract": "Abstract - Background Vitamin A deficiency is a significant public health problem in many low‐ and middle‐income countries, especially affecting young children, women of reproductive age, and pregnant women. Fortification of staple foods with vitamin A has been used to increase vitamin A consumption among these groups. Objectives To assess the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving health‐related outcomes in the general population older than two years of age. Search methods We searched the following international databases with no language or date restrictions: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library; MEDLINE and MEDLINE In Process OVID; Embase OVID; CINAHL Ebsco; Web of Science (ISI) SCI, SSCI, CPCI‐exp and CPCI‐SSH; BIOSIS (ISI); POPLINE; Bibliomap; TRoPHI; ASSIA (Proquest); IBECS; SCIELO; Global Index Medicus ‐ AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched clinicaltrials.gov and the International Clinical Trials Registry Platform to identify ongoing and unpublished studies. The date of the last search was 19 July 2018. Selection criteria We included individually or cluster‐randomised controlled trials (RCTs) in this review. The intervention included fortification of staple foods (sugar, edible oils, edible fats, maize flour or corn meal, wheat flour, milk and dairy products, and condiments and seasonings) with vitamin A alone or in combination with other vitamins and minerals. We included the general population older than two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two authors independently screened and assessed eligibility of studies for inclusion, extracted data from included studies and assessed their risk of bias. We used standard Cochrane methodology to carry out the review. Main results We included 10 randomised controlled trials involving 4455 participants. All the studies were conducted in low‐ and upper‐middle income countries where vitamin A deficiency was a public health issue. One of the included trials did not contribute data to the outcomes of interest. Three trials compared provision of staple foods fortified with vitamin A versus unfortified staple food, five trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus unfortified staple foods, and two trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus no intervention. No studies compared staple foods fortified with vitamin A alone versus no intervention. The duration of interventions ranged from three to nine months. We assessed six studies at high risk of bias overall. Government organisations, non‐governmental organisations, the private sector, and academic institutions funded the included studies; funding source does not appear to have distorted the results. Staple food fortified with vitamin A versus unfortified staple food We are uncertain whether fortifying staple foods with vitamin A alone makes little or no difference for serum retinol concentration (mean difference (MD) 0.03 μmol/L, 95% CI −0.06 to 0.12; 3 studies, 1829 participants; I² = 90%, very low‐certainty evidence ). It is uncertain whether vitamin A alone reduces the risk of subclinical vitamin A deficiency (risk ratio (RR) 0.45, 95% CI 0.19 to 1.05; 2 studies; 993 participants; I² = 33%, very low‐certainty evidence ). The certainty of the evidence was mainly affected by risk of bias, imprecision and inconsistency. It is uncertain whether vitamin A fortification reduces clinical vitamin A deficiency, defined as night blindness (RR 0.11, 95% CI 0.01 to 1.98; 1 study, 581 participants, very low‐certainty evidence ). The certainty of the evidence was mainly affected by imprecision, inconsistency, and risk of bias. Staple foods fortified with vitamin A versus no intervention No studies provided data for this comparison. Staple foods fortified with vitamin A plus other micronutrients versus same unfortified staple foods Fortifying staple foods with vitamin A plus other micronutrients may not increase the serum retinol concentration (MD 0.08 μmol/L, 95% CI ‐0.06 to 0.22; 4 studies; 1009 participants; I² = 95%, low‐certainty evidence ). The certainty of the evidence was mainly affected by serious inconsistency and risk of bias. In comparison to unfortified staple foods, fortification with vitamin A plus other micronutrients probably reduces the risk of subclinical vitamin A deficiency (RR 0.27, 95% CI 0.16 to 0.49; 3 studies; 923 participants; I² = 0%; moderate‐certainty evidence ). The certainty of the evidence was mainly affected by serious risk of bias. Staple foods fortified with vitamin A plus other micronutrients versus no intervention Fortification of staple foods with vitamin A plus other micronutrients may increase serum retinol concentration (MD 0.22 μmol/L, 95% CI 0.15 to 0.30; 2 studies; 318 participants; I² = 0%; low‐certainty evidence ). When compared to no intervention, it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency (RR 0.71, 95% CI 0.52 to 0.98; 2 studies; 318 participants; I² = 0%; very low‐certainty evidence ) . The certainty of the evidence was affected mainly by serious imprecision and risk of bias. No trials reported on the outcomes of all‐cause morbidity, all‐cause mortality, adverse effects, food intake, congenital anomalies (for pregnant women), or breast milk concentration (for lactating women). Authors' conclusions Fortifying staple foods with vitamin A alone may make little or no difference to serum retinol concentrations or the risk of subclinical vitamin A deficiency. In comparison with provision of unfortified foods, provision of staple foods fortified with vitamin A plus other micronutrients may not increase serum retinol concentration but probably reduces the risk of subclinical vitamin A deficiency. Compared to no intervention, staple foods fortified with vitamin A plus other micronutrients may increase serum retinol concentration, although it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency as the certainty of the evidence has been assessed as very low. It was not possible to estimate the effect of staple food fortification on outcomes such as mortality, morbidity, adverse effects, congenital anomalies, or breast milk vitamin A, as no trials included these outcomes. The type of funding source for the studies did not appear to distort the results from the analysis. Plain language summary Fortification of staple foods with vitamin A for vitamin A deficiency What is the aim of the review? We wanted to investigate the effects of fortifying common staple foods with vitamin A, with or without other micronutrients, in populations two years of age and older. Staple foods used in public health fortification programmes have included refined sugar, edible vegetable oils and fats, rice, wheat flour, maize flours and corn meals, condiments and seasonings, and powdered or liquid milk. We searched for all the possible information on this question and found 10 eligible studies. Key messages Fortifiying staple foods with vitamin A plus other micronutrients may increase the serum retinol concentrations (an indicator of vitamin A stores in the body) and reduce the risk of subclinical vitamin A deficiency (those without clinical eye signs for risk of blinding undernutrition, detected through a serum/plasma retinol 70 μmol/L or less). However, adding vitamin A alone to the staple foods may have little or no effect on vitamin A status or deficiency. What was studied in this review? Vitamin A is an essential nutrient vital for good vision, cell growth, and immunity. Many people in low‐ and middle‐income countries have vitamin A deficiency, especially young children, pregnant women, and women of reproductive age, who may not get enough to eat to cover their increased nutritional demands. Long‐term deprivation of vitamin A could lead to visual impairment, blindness, common infections of the upper respiratory tract, diarrhoea, and measles. There are several strategies to combat the vitamin A deficiency, such as supplementing the diet with vitamin A capsules, adding vitamins and minerals in powder form to energy‐containing foods, eating more vitamin A‐rich foods, and fortifying staple foods with vitamin A during processing. This review focused on the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving the health of the general population older than two years of age. What are the main results of the review? We found 10 relevant studies (involving 4455 participants) from China, India, the Philippines, Bangladesh, Thailand, and Mexico. Three studies provided one study group with staple foods fortified with vitamin A alone, and another group with the same unfortified staple foods. Five studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus the same unfortified staple food, and two studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus no intervention. No studies compared staple foods fortified with vitamin A versus no intervention. Government agencies, private agencies, non‐governmental organisations, the private sector, and academic institutions funded the studies. The source of funding does not appear to have distorted the results. The effect of fortification of staple foods with vitamin A alone on vitamin A stores and on subclinical vitamin A deficiency is uncertain. It is uncertain whether this intervention might reduce clinical vitamin A deficiency (night blindness). We are moderately confident that fortifying staple foods with vitamin A and other micronutrients may not improve vitamin A status. However, children and adolescents in low‐ and middle‐income populations who eat foods fortified with vitamin A and other micronutrients may have a lower risk of subclinical vitamin A deficiency compared to those receiving unfortified staple foods. We do not know how vitamin A fortification affects other health indicators, such as the rate of disease in the population, mortality, adverse effects, food intake, birth defects (for pregnant women), or breast milk concentration for lactating women. We considered six of the included studies to be of poor methodological quality. The review authors searched for published studies up to July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hombali, AS, Solon, JA, Venkatesh, BT, Nair, NS, Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010068.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.786Z" }, { "id": "52da066e-09d7-45dc-b766-bb4004f8e08b", "pmid": "", "title": "Nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy", "imported": false, "abstract": "Abstract - Background Across the developed world, an estimated 150,000 to 300,000 people are treated annually with pelvic radiotherapy and 80% will develop gastrointestinal (GI) symptoms during treatment. Acute GI symptoms are associated with a greater risk of chronic, often debilitating, GI symptoms. Up to one‐third of patients are malnourished before pelvic radiotherapy and up to four‐fifths of patients lose weight during treatment. Malnutrition is linked to a higher risk of GI toxicity, which can lead to breaks in radiotherapy and early cessation of chemotherapy, thus compromising the efficacy of the primary cancer treatment. Objectives To assess the effects of nutritional interventions for reducing GI toxicity in adults undergoing radical pelvic radiotherapy. Search methods We searched the Cochrane Gynaecological Cancer Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 4, 2012, MEDLINE and EMBASE to May 2012. We handsearched the citation lists of included studies and previous systematic reviews identified to identify further relevant trials. Selection criteria We included studies if they were randomised controlled trials (RCTs) or non‐randomised studies with concurrent comparison groups including quasi‐randomised trials, cluster RCTs, non‐randomised trials, prospective and retrospective cohort studies, and case series of 30 or more patients. We only included studies if they assessed the effect of a nutritional intervention in adults aged 18 years or over undergoing radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic malignancy. We excluded patients with stomas and a previous history of inflammatory bowel disease. Nutritional support interventions could be provided at any stage before or during pelvic radiotherapy and included dietary counselling; dietary modification of fibre, lactose or fat; supplementary foods or drinks or fortified foods; standard oral nutrition supplements including polymeric‐, peptide‐ or amino acid‐based supplements and those where novel substrates have been added; enteral tube feeds; or parenteral nutrition (partial or total). We excluded probiotics, prebiotics and synbiotics. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors to obtain missing data. We assessed bias for each of the included studies using the bias assessment tables in the Cochrane software Review Manager5. We performed meta‐analysis, when indicated, using the Mantel‐Haenszel fixed‐effect method or inverse variance fixed‐effect method displayed with heterogeneity. We undertook meta‐analyses on trials evaluating dietary modification against standard treatment for diarrhoea at the end of radiotherapy and for change in weight from baseline to end of radiotherapy. Main results The searches identified 7558 titles, and we excluded 7513 during title and abstract searches. We reviewed 45 papers in full, and excluded 39. We identified four studies on handsearching of the references, which, along with the six eligible papers from the database search, led to 10 studies being included. Four studies, three of which were RCTs and one prospective study, investigated the effect of elemental diet on GI symptoms; one RCT investigated the effect of dietary modification and elemental diet; and five RCTs investigated dietary modification. Studies were varied in terms of risk of bias. Data were dichotomised for presence and absence of diarrhoea at the end of radiotherapy for four trials evaluating dietary modification comprising modified fat, lactose, fibre or combinations of these dietary changes. A reduction in diarrhoea was demonstrated with nutritional intervention (risk ratio (RR) 0.66; 95% confidence interval (CI) 0.51 to 0.87, four studies, 413 participants, moderate quality of evidence) with low heterogeneity (Chi 2 = 3.50, I 2 = 14%). Two trials evaluating dietary modification on weight change (comparing baseline and end of radiotherapy) showed no difference between intervention or control (mean difference (MD) ‐0.57 kg; 95% CI ‐1.22 to 0.09) with low heterogeneity (Chi 2 = 1.41, I 2 = 29%). Generally adverse effects were poorly reported in included studies. Elemental diet in particular was poorly tolerated. GI symptoms or toxicity > 6 months after radiotherapy was not reported in included studies Authors' conclusions There have been benefits demonstrated with dietary modification during pelvic radiotherapy to reduce diarrhoea. Those diets included single interventions or combinations of modified fat, lactose‐restriction, fat‐restriction and fibre supplementation. We were unable to meta‐analyse elemental diet, as data were not available. We considered some of the studies to be at high risk of bias. There have been recent advances in novel, more targeted radiotherapy techniques, such that the findings of older studies need to be interpreted with caution. In addition, there were problems with compliance and palatability with some of the interventions, particularly elemental diet, which limits its usefulness in clinical practice. Plain language summary Do nutritional interventions reduce gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy? Background Research has shown that nutrition and radiotherapy have effects on each other. People with malnutrition tend to get more bowel side effects during radiotherapy. It has also been shown that many people lose weight during radiotherapy due to the treatment side effects. These side effects can lead to some people needing gaps in their radiotherapy and sometimes they even need to stop it entirely. This can reduce the chance of cancer cure. This review looked at the literature for providing extra nourishment or changes in diet to patients before or during radiotherapy, to determine whether this is of benefit in terms of reducing bowel symptoms, improving nutritional status and quality of life. Study characteristics Searches of all relevant sources of medical information identified 7558 articles, and, after initial screening of all these articles, we selected 45 as being suitable for this review. On reading the summaries of these 45 trials, 10 were suitable to be included in this review. We included trials that looked at the effects of a nutritional intervention in adults aged 18 years or over having radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic cancer. We excluded patients with stomas and a previous history of inflammatory bowel disease. Key results Results showed that studies evaluating dietary changes, including changes in dietary fat, fibre and lactose, during radiotherapy reduced diarrhoea at the end of treatment. However, these dietary changes did not seem to improve patients' weights. Quality of the evidence While some changes to diet during radiotherapy may benefit patients by reducing diarrhoea, it is important to recognise that some of the studies reviewed were dated and there have been changes in radiotherapy technique since then that may give patients less diarrhoea anyway. In addition, many studies were of poor quality and, therefore, only a small number were able to be included in this review. Some interventions described, for example, having to take a liquid diet, were not acceptable as many patients found them difficult to tolerate and were unable to take them completely.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Henson, CC, Burden, S, Davidson, SE, Lal, S", "articleTypes": [], "doi": "10.1002/14651858.CD009896.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.089Z" }, { "id": "52dc607e-e83b-45d6-9e22-dcd84c940c2c", "pmid": "", "title": "Hyperimmune immunoglobulin for people with COVID‐19", "imported": false, "abstract": "Abstract - Background Hyperimmune immunoglobulin (hIVIG) contains polyclonal antibodies, which can be prepared from large amounts of pooled convalescent plasma or prepared from animal sources through immunisation. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). This review was previously part of a parent review addressing convalescent plasma and hIVIG for people with COVID‐19 and was split to address hIVIG and convalescent plasma separately. Objectives To assess the benefits and harms of hIVIG therapy for the treatment of people with COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods To identify completed and ongoing studies, we searched the World Health Organization (WHO) COVID‐19 Research Database, the Cochrane COVID‐19 Study Register, the Epistemonikos COVID‐19 L*OVE Platform and Medline and Embase from 1 January 2019 onwards. We carried out searches on 31 March 2022. Selection criteria We included randomised controlled trials (RCTs) that evaluated hIVIG for COVID‐19, irrespective of disease severity, age, gender or ethnicity. We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)), as well as studies that evaluated standard immunoglobulin. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used RoB 2. We rated the certainty of evidence, using the GRADE approach, for the following outcomes: all‐cause mortality, improvement and worsening of clinical status (for individuals with moderate to severe disease), quality of life, adverse events, and serious adverse events. Main results We included five RCTs with 947 participants, of whom 688 received hIVIG prepared from humans, 18 received heterologous swine glyco‐humanised polyclonal antibody, and 241 received equine‐derived processed and purified F(ab’) 2 fragments. All participants were hospitalised with moderate‐to‐severe disease, most participants were not vaccinated (only 12 participants were vaccinated). The studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with mild COVID‐19. We identified a further 10 ongoing studies evaluating hIVIG. Benefits of hIVIG prepared from humans We included data on one RCT (579 participants) that assessed the benefits and harms of hIVIG 0.4 g/kg compared to saline placebo. hIVIG may have little to no impact on all‐cause mortality at 28 days (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.43 to 1.44; absolute effect 77 per 1000 with placebo versus 61 per 1000 (33 to 111) with hIVIG; low‐certainty evidence). The evidence is very uncertain about the effect on worsening of clinical status at day 7 (RR 0.85, 95% CI 0.58 to 1.23; very low‐certainty evidence). It probably has little to no impact on improvement of clinical status on day 28 (RR 1.02, 95% CI 0.97 to 1.08; moderate‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if hIVIG has any impact on quality of life. Harms of hIVIG prepared from humans hIVIG may have little to no impact on adverse events at any grade on day 1 (RR 0.98, 95% CI 0.81 to 1.18; 431 per 1000; 1 study 579 participants; low‐certainty evidence). Patients receiving hIVIG probably experience more adverse events at grade 3‐4 severity than patients who receive placebo (RR 4.09, 95% CI 1.39 to 12.01; moderate‐certainty evidence). hIVIG may have little to no impact on the composite outcome of serious adverse events or death up to day 28 (RR 0.72, 95% CI 0.45 to 1.14; moderate‐certainty evidence). We also identified additional results on the benefits and harms of other dose ranges of hIVIG, not included in the summary of findings table, but summarised in additional tables. Benefits of animal‐derived polyclonal antibodies We included data on one RCT (241 participants) to assess the benefits and harms of receptor‐binding domain‐specific polyclonal F(ab´) 2 fragments of equine antibodies (EpAbs) compared to saline placebo. EpAbs may reduce all‐cause mortality at 28 days (RR 0.60, 95% CI 0.26 to 1.37; absolute effect 114 per 1000 with placebo versus 68 per 1000 (30 to 156) ; low‐certainty evidence). EpAbs may reduce worsening of clinical status up to day 28 (RR 0.67, 95% CI 0.38 to 1.18; absolute effect 203 per 1000 with placebo versus 136 per 1000 (77 to 240); low‐certainty evidence). It may have some effect on improvement of clinical status on day 28 (RR 1.06, 95% CI 0.96 to 1.17; low‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if EpAbs have any impact on quality of life. Harms of animal‐derived polyclonal antibodies EpAbs may have little to no impact on the number of adverse events at any grade up to 28 days (RR 0.99, 95% CI 0.74 to 1.31; low‐certainty evidence). Adverse events at grade 3‐4 severity were not reported. Individuals receiving EpAbs may experience fewer serious adverse events than patients receiving placebo (RR 0.67, 95% CI 0.38 to 1.19; low‐certainty evidence). We also identified additional results on the benefits and harms of other animal‐derived polyclonal antibody doses, not included in the summary of findings table, but summarised in additional tables. Authors' conclusions We included data from five RCTs that evaluated hIVIG compared to standard therapy, with participants with moderate‐to‐severe disease. As the studies evaluated different preparations (from humans or from various animals) and doses, we could not pool them. hIVIG prepared from humans may have little to no impact on mortality, and clinical improvement and worsening. hIVIG may increase grade 3‐4 adverse events. Studies did not evaluate quality of life. RBD‐specific polyclonal F(ab´) 2 fragments of equine antibodies may reduce mortality and serious adverse events, and may reduce clinical worsening. However, the studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern and prior to widespread vaccine rollout. As no studies evaluated hIVIG for participants with asymptomatic infection or mild disease, benefits for these individuals remains uncertain. This is a living systematic review. We search monthly for new evidence and update the review when we identify relevant new evidence. Plain language summary Are concentrated antibodies from people who have recovered from COVID‐19 or animals an effective treatment for people with COVID‐19? Key messages • We do not know whether hyperimmune immunoglobulin (a preparation made with antibodies from people who have recovered from COVID‐19) reduces deaths or serious unwanted effects in people with moderate to severe COVID‐19. But a similar preparation made by injecting animals with certain antibodies may reduce deaths, and serious unwanted effects and may stop people’s condition getting worse. • We found no studies that investigated people with COVID‐19 but without symptoms or people with mild COVID‐19, so we do not know how effective human or animal hyperimmune immunoglobulin is for them. • We found 10 ongoing studies. We will update this review when their results become available. What is hyperimmune immunoglobulin? The body produces antibodies as one of its defences against infection. Antibodies, or 'immunoglobulins', are found in blood plasma. They act as a critical part of the immune response. Plasma from people who have recovered from COVID‐19 contains COVID‐19 antibodies, and can be used to make two preparations. Firstly, it can be used to make convalescent plasma, which is plasma that contains these antibodies. Secondly, it can be used to make hyperimmune immunoglobulin, which is more concentrated, and therefore contains more antibodies. The manufacturing process of hyperimmune immunoglobulin is complex and requires large pools of human plasma. Similar antibodies can be made from animal sources and used in humans. Why is hyperimmune immunoglobulin a possible treatment for COVID‐19? Hyperimmune immunoglobulin products contain high levels of antibodies that target SARS‐CoV‐2, the virus that causes COVID‐19. The products are thought to inactivate the virus particles. What did we want to find out? We wanted to know if hyperimmune immunoglobulin is an effective and helpful treatment for people with suspected or confirmed COVID‐19 in any setting (for example, home or hospital). We were interested in: • death from any cause up 30 days after treatment, 60 days, or longer if reported; • improvement or worsening of symptoms; • quality of life; • unwanted effects. What did we do? We searched for studies that investigated hyperimmune immunoglobulin and usual care compared to usual care only, or in addition to a dummy medicine that did not contain any active ingredients (placebo). To make a fair comparison, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the hyperimmune immunoglobulin or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies. We used a standardised method to rate our confidence in the evidence. The confidence is based on study features such as how it was designed and the number of people in them. What did we find? We found five studies with 957 people. Studies took place in Pakistan, India, France, and Argentina, and one study was conducted in multiple countries, including Denmark, Greece, Japan, Nigeria, Spain, the UK and the USA. The studies took place before or during the emergence of several new COVID‐19 variants and prior to widespread vaccine rollout. All the participants in four studies were unvaccinated. In one study, 12 from 579 participants were vaccinated. We also found 10 ongoing studies. Main results All studies compared hyperimmune immunoglobulin from human or animal sources with usual care or placebo. The studies included only hospitalised people with moderate to severe disease. No studies looked at people without COVID‐19 symptoms or mild COVID‐19. No studies reported on quality of life. We are uncertain whether or not hyperimmune immunoglobulin prepared from humans affects risk of death from any cause up to 28 days after treatment. It may have little to no impact on improvement or worsening of symptoms up to 28 days after treatment. We are uncertain about a possible difference in unwanted or serious unwanted effects. The individual studies decided which events to classify as serious unwanted effects, but this usually means something that may cause hospitalisation or permanent harm. Hyperimmune immunoglobulin from animals may reduce deaths up to 28 days after treatment, may reduce worsening of symptoms, may improve patients' condition and may reduce serious unwanted events. What are the limitations of the evidence? We are uncertain whether hyperimmune immunoglobulin is an effective treatment for people hospitalised with COVID‐19, and whether it affects the number of unwanted or serious unwanted effects because the studies were small and did not all provide evidence on all our points of interest. The studies were conducted predominantly in people from wealthy countries, before the widespread rollout of COVID‐19 vaccines and the emergence of the omicron variant, so the results may not apply to people with omicron variant infection, or people who were vaccinated before falling ill. There was no evidence for people without symptoms or with mild COVID‐19. How up to date is this evidence? Our evidence is up‐to‐date to 31st March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kimber, C, Valk, SJ, Chai, KL, Piechotta, V, Iannizzi, C, Monsef, I, Wood, EM, Lamikanra, AA, Roberts, DJ, McQuilten, Z, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015167.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.129Z" }, { "id": "52e934d6-5c98-479d-a63c-9c2ae096cde3", "pmid": "", "title": "Tranexamic acid for patients with nasal haemorrhage (epistaxis)", "imported": false, "abstract": "Abstract - Background Epistaxis (nosebleed) most commonly affects children and the elderly. The majority of episodes are managed at home with simple measures. In more severe cases medical intervention is required to either cauterise the bleeding vessel, or to pack the nose with various materials. Tranexamic acid is used in a number of clinical settings to stop bleeding by preventing clot breakdown (fibrinolysis). It may have a role in the management of epistaxis as an adjunct to standard treatments, reducing the need for further intervention. Objectives To determine the effects of tranexamic acid (oral, intravenous or topical) compared with placebo, no additional intervention or any other haemostatic agent in the management of patients with epistaxis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register (via CRS Web); Central Register of Controlled Trials (CENTRAL) (via CRS Web); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 October 2018. Selection criteria Randomised controlled trials (RCTs) of tranexamic acid (in addition to usual care) compared with usual care plus placebo, usual care alone or usual care plus any other haemostatic agent, to control epistaxis in adults or children. Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were control of epistaxis: re‐bleeding (as measured by the proportion of patients re‐bleeding within a period of up to 10 days) and significant adverse effects (seizures, thromboembolic events). Secondary outcomes were control of epistaxis as measured by the time to stop initial bleeding (the proportion of patients whose bleeding is controlled within a period of up to 30 minutes); severity of re‐bleeding (as measured by (a) the proportion of patients requiring any further intervention and (b) the proportion of patients requiring blood transfusion); length of hospital stay and other adverse effects. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included six RCTs (692 participants). The overall risk of bias in the studies was low. Two studies assessed oral administration of tranexamic acid, given regularly over several days, and compared it to placebo. In the other four studies, a single application of topical tranexamic acid was compared with placebo (one study) and a combination of epinephrine and lidocaine or phenylephrine (three studies). All participants were adults. Tranexamic acid versus placebo For our primary outcome, control of epistaxis: re‐bleeding (proportion re‐bleeding within 10 days), we were able to pool data from three studies. The pooled result demonstrated a benefit of tranexamic acid compared to placebo, the risk of re‐bleeding reducing from 67% to 47% (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; three studies; 225 participants; moderate‐quality evidence ). When we compared the effects of oral and topical tranexamic acid separately the risk of re‐bleeding with oral tranexamic acid reduced from 69% to 49%, RR 0.73 (95% CI 0.55 to 0.96; two studies, 157 participants; moderate‐quality evidence ) and with topical tranexamic acid it reduced from 66% to 43%, RR 0.66 (95% CI 0.41 to 1.05; single study, 68 participants). We rated the quality of evidence provided by the single study as low , therefore it is uncertain whether topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. No study specifically sought to identify and report our primary outcome: significant adverse effects (i.e. seizures, thromboembolic events). The secondary outcome time to stop initial bleeding (proportion with bleeding controlled within 30 minutes) was measured in one study using topical tranexamic acid and there was no evidence of a difference at 30 minutes (RR 0.79, 95% CI 0.56 to 1.11; 68 participants; low‐quality evidence ). No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery, embolisation). One study of oral tranexamic acid reported the proportion of patients requiring blood transfusion and found no difference between groups: 5/45 (11%) versus 6/44 (14%) (RR 0.81, 95% CI 0.27 to 2.48; 89 participants; low‐quality evidence ). Two studies reported hospital length of stay. One study reported a significantly shorter stay in the oral tranexamic acid group (mean difference (MD) ‐1.60 days, 95% CI ‐2.49 to ‐0.71; 68 participants). The other study found no evidence of a difference between the groups. Tranexamic acid versus other haemostatic agents When we pooled the data from three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the topical tranexamic acid group compared to the group receiving another haemostatic agent (70% versus 30%: RR 2.35, 95% CI 1.90 to 2.92; 460 participants) ( moderate‐quality evidence ). Adverse effects across all studies Five studies recorded 'adverse effects' in a general way. None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient developed a superficial thrombophlebitis of both legs following discharge, however it is not reported in which group this occurred. No \"other serious adverse effect\" was reported in any study. Authors' conclusions We found moderate‐quality evidence that there is probably a reduction in the risk of re‐bleeding with the use of either oral or topical tranexamic acid in addition to usual care in adult patients with epistaxis, compared to placebo with usual care. However, the quality of evidence relating solely to topical tranexamic acid was low (one study only), so we are uncertain whether or not topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. We found moderate‐quality evidence that topical tranexamic acid is probably better than other topical agents in stopping bleeding in the first 10 minutes. There have been only three RCTs on this subject since 1995. Since then there have been significant changes in nasal cauterisation and packing techniques (for example, techniques including nasal endoscopy and more invasive approaches such as endoscopic sphenopalatine artery ligation). New trials would inform us about the effectiveness of tranexamic acid in light of these developments. Plain language summary Tranexamic acid to help treat nosebleeds (epistaxis) Background Nosebleeds are a very common condition, with the majority of those affected either children or those over the age of 60. They usually stop on their own or by simply compressing the nose with fingers, although a small number require medical attention. This will involve either cauterising (sealing) the bleeding vessel, if it can be seen, or packing the inside of the nose with a material to cause pressure to build up and stop the bleeding ('usual care'). Occasionally bleeding continues despite these measures, or it restarts having initially been controlled. This can lead to a prolonged hospital stay and the possibility of further procedures such as repacking with a different type of nasal pack or an operation. Tranexamic acid is a drug that is known to help promote blood clotting by preventing a natural process called fibrinolysis (dissolution of a clot). It is already used in a number of situations where bleeding is a significant worry, such as after heart surgery or major trauma. It can be given by mouth (orally), directly to the bleeding site (topically) or by injection into a vein (intravenously). Study characteristics We searched for randomised controlled trials in patients of any age with nosebleed requiring intervention. Patients were treated with tranexamic acid (in addition to usual care) compared to placebo, no treatment or any other agent used to stop bleeding. We found six studies that met our inclusion criteria, with a total of 692 participants. Two studies used oral administration of tranexamic acid and four used topical administration. All participants in the studies were adults. Three of the six studies were conducted over 20 years ago. Key results Three studies measured re‐bleeding within 10 days. When we combined the results we found that fewer patients who were given either oral or topical tranexamic acid had further episodes of re‐bleeding following an initial nosebleed compared to those treated with usual care. The time to stop initial bleeding (control of bleeding within 30 minutes) was measured in four studies. In three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the group receiving topical tranexamic acid compared to the group receiving a different drug (topical epinephrine and lidocaine or phenylephrine). In the other study there was no significant difference at 30 minutes when topical tranexamic acid was compared with placebo. No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery). Only one study of oral tranexamic acid reported the proportion of patients requiring a blood transfusion and there was no evidence of a difference between the groups. Length of hospital stay was reported in two studies. One study reported a significantly shorter stay in the oral tranexamic acid group, while the other found no evidence of a difference. Five studies mention recording \"adverse effects\". None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient did develop a superficial thrombophlebitis (inflammation and a blood clot in a vein near the surface of the skin) of both legs following discharge, but the study did not report in which treatment group this happened. No serious adverse event was seen in any of the studies. Quality of the evidence and conclusions Overall, the risk of bias in the six studies was low. We graded the quality of the evidence for the main outcome (control of epistaxis: re‐bleeding within 10 days) as moderate, which means that further research is likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate. In light of this and the fact that 'usual care' has changed, with the development of more modern nasal cauterisation and packing techniques, since three of the included studies were carried out, there remains uncertainty about the role of tranexamic acid in the treatment of patients with epistaxis. Newer research into the effect of tranexamic acid as a treatment for nosebleeds would inform future management decisions for this condition. The evidence in this review is up to date to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Joseph, J, Martinez‐Devesa, P, Bellorini, J, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.066Z" }, { "id": "52f5dbde-e019-409c-af0e-5978f6bd7183", "pmid": "", "title": "Antioxidant vitamin and mineral supplements for slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Evans, JR, Lawrenson, JG", "articleTypes": [], "doi": "10.1002/14651858.CD000254.pub5 AB - Abstract - Background Age‐related macular degeneration (AMD) is a degenerative condition of the back of the eye that occurs in people over the age of 50 years. Antioxidants may prevent cellular damage in the retina by reacting with free radicals that are produced in the process of light absorption. Higher dietary levels of antioxidant vitamins and minerals may reduce the risk of progression of AMD. This is the third update of the review. Objectives To assess the effects of antioxidant vitamin and mineral supplements on the progression of AMD in people with AMD. Search methods We searched CENTRAL, MEDLINE, Embase, one other database, and three trials registers, most recently on 29 November 2022. Selection criteria We included randomised controlled trials (RCTs) that compared antioxidant vitamin or mineral supplementation to placebo or no intervention, in people with AMD. Data collection and analysis We used standard methods expected by Cochrane. Main results We included 26 studies conducted in the USA, Europe, China, and Australia. These studies enroled 11,952 people aged 65 to 75 years and included slightly more women (on average 56% women). We judged the studies that contributed data to the review to be at low or unclear risk of bias. Thirteen studies compared multivitamins with control in people with early and intermediate AMD. Most evidence came from the Age‐Related Eye Disease Study (AREDS) in the USA. People taking antioxidant vitamins were less likely to progress to late AMD (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.58 to 0.90; 3 studies, 2445 participants; moderate‐certainty evidence). In people with early AMD, who are at low risk of progression, this means there would be approximately four fewer cases of progression to late AMD for every 1000 people taking vitamins (one fewer to six fewer cases). In people with intermediate AMD at higher risk of progression, this corresponds to approximately 78 fewer cases of progression for every 1000 people taking vitamins (26 fewer to 126 fewer). AREDS also provided evidence of a lower risk of progression for both neovascular AMD (OR 0.62, 95% CI 0.47 to 0.82; moderate‐certainty evidence) and geographic atrophy (OR 0.75, 95% CI 0.51 to 1.10; moderate‐certainty evidence), and a lower risk of losing 3 or more lines of visual acuity (OR 0.77, 95% CI 0.62 to 0.96; moderate‐certainty evidence). Low‐certainty evidence from one study of 110 people suggested higher quality of life scores (measured with the Visual Function Questionnaire) in treated compared with non‐treated people after 24 months (mean difference (MD) 12.30, 95% CI 4.24 to 20.36). In exploratory subgroup analyses in the follow‐on study to AREDS (AREDS2), replacing beta‐carotene with lutein/zeaxanthin gave hazard ratios (HR) of 0.82 (95% CI 0.69 to 0.96), 0.78 (95% CI 0.64 to 0.94), 0.94 (95% CI 0.70 to 1.26), and 0.88 (95% CI 0.75 to 1.03) for progression to late AMD, neovascular AMD, geographic atrophy, and vision loss, respectively. Six studies compared lutein (with or without zeaxanthin) with placebo and one study compared a multivitamin including lutein/zeaxanthin with multivitamin alone. The duration of supplementation and follow‐up ranged from six months to five years. Most evidence came from the AREDS2 study in the USA; almost all participants in AREDS2 also took the original AREDS supplementation formula. People taking lutein/zeaxanthin may have similar or slightly reduced risk of progression to late AMD (RR 0.94, 95% CI 0.87 to 1.01), neovascular AMD (RR 0.92, 95% CI 0.84 to 1.02), and geographic atrophy (RR 0.92, 95% CI 0.80 to 1.05) compared with control (1 study, 4176 participants, 6891 eyes; low‐certainty evidence). A similar risk of progression to visual loss of 15 or more letters was seen in the lutein/zeaxanthin and control groups (RR 0.98, 95% CI 0.91 to 1.05; 6656 eyes; low‐certainty evidence). Quality of life (Visual Function Questionnaire) was similar between groups (MD 1.21, 95% CI ‐2.59 to 5.01; 2 studies, 308 participants; moderate‐certainty evidence).
One study in Australia randomised 1204 people to vitamin E or placebo with four years of follow‐up; 19% of participants had AMD. The number of late AMD events was low (N = 7) and the estimate of effect was uncertain (RR 1.36, 95% CI 0.31 to 6.05; very low‐certainty evidence). There was no evidence of any effect of treatment on visual loss (RR 1.04, 95% CI 0.74 to 1.47; low‐certainty evidence). There were no data on neovascular AMD, geographic atrophy, or quality of life.
Five studies compared zinc with placebo. Evidence largely drawn from the largest study (AREDS) found a lower progression to late AMD over six years (OR 0.83, 95% CI 0.70 to 0.98; 3 studies, 3790 participants; moderate‐certainty evidence), neovascular AMD (OR 0.76, 95% CI 0.62 to 0.93; moderate‐certainty evidence), geographic atrophy (OR 0.84, 95% CI 0.64 to 1.10; moderate‐certainty evidence), or visual loss (OR 0.87, 95% CI 0.75 to 1.00; 2 studies, 3791 participants; moderate‐certainty evidence). There were no data on quality of life. Gastrointestinal symptoms were the main reported adverse effect. In AREDS, zinc was associated with a higher risk of genitourinary problems in men, but no difference was seen between high‐ and low‐dose zinc groups in AREDS2. Most studies were too small to detect rare adverse effects. Data from larger studies (AREDS/AREDS2) suggested there may be little or no effect on mortality with multivitamin (HR 0.87, 95% CI 0.60 to 1.25; low‐certainty evidence) or lutein/zeaxanthin supplementation (HR 1.06, 95% CI 0.87 to 1.31; very low‐certainty evidence), but confirmed the increased risk of lung cancer with beta‐carotene, mostly in former smokers. Authors' conclusions Moderate‐certainty evidence suggests that antioxidant vitamin and mineral supplementation (AREDS: vitamin C, E, beta‐carotene, and zinc) probably slows down progression to late AMD. People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than people with early AMD. Although low‐certainty evidence suggested little effect with lutein/zeaxanthin alone compared with placebo, exploratory subgroup analyses from one large American study support the view that lutein/zeaxanthin may be a suitable replacement for the beta‐carotene used in the original AREDS formula. Plain language summary Do antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD)? Key messages 
‐ Taking an antioxidant multivitamin supplement may slow down the progression of age‐related macular degeneration (AMD), an eye disease that blurs your central vision. ‐ People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than for people with early AMD. ‐ Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence as to safety as they were generally too small. What is age‐related macular degeneration? Age‐related macular degeneration (AMD) is an eye disease that blurs your central vision. It is usually only diagnosed in people aged 50 years and above. AMD affects the central area (macula) of the back of the eye (retina), as the macula degenerates with age. In early AMD, yellow spots (called drusen) can be seen under the retina by an eye health professional. The affected person will probably be unaware that they have a problem. As the disease progresses, the drusen become larger (intermediate AMD). In the later stages of the disease, there may be loss of the cells – needed for vision – in the back of the eye. This is known as geographic atrophy. Sometimes, new (harmful) blood vessels grow in the macula. These new blood vessels may bleed and cause scarring. This is known as neovascular AMD. Neovascular AMD and geographic atrophy are known as late AMD. Why might antioxidant vitamins and minerals be helpful? Antioxidant vitamins and minerals may help to protect the macula against this deterioration and loss of vision. Antioxidants are natural molecules that may prevent or delay some types of cell damage. Vitamins C and E, beta‐carotene, lutein, zeaxanthin, and zinc are examples of antioxidants commonly found in dietary supplements. What did we want to find out? 
We wanted to find out whether antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD) and prevent visual loss. What did we do? We searched for studies that compared antioxidant vitamin and mineral supplements with placebo (a ‘dummy’ treatment not containing any supplements) or no treatment. We only looked at the effects of these supplements in people with AMD. There is another Cochrane Review on the effects of these supplements in people who do not already have AMD. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 26 studies from the USA, Europe, China, and Australia that enroled 11,952 people with AMD. These studies compared multivitamin supplements, zinc, vitamin E, lutein (with or without zeaxanthin) with placebo. Participants were aged 65 to 75 years and there were slightly more women than men in the studies. Main findings • Taking an antioxidant multivitamin supplement (AREDS formula containing vitamins E and C, beta‐carotene plus zinc) probably slows down the progression of AMD to late AMD and vision loss. This may result in a small improvement in quality of life. • People with intermediate AMD have a higher risk of progression to late AMD and so may be more likely to benefit from supplements (78 fewer cases of progression for every 1000 people taking supplements). People with early AMD have a low risk of progression and so may be less likely to benefit (4 fewer cases of progression to late AMD for every 1000 people taking supplements). • Lutein with or without zeaxanthin may have little or no effect on progression to late AMD but may be a suitable replacement for beta‐carotene in the AREDS formula. Beta‐carotene may increase the chance of lung cancer in people who have smoked. • The effects of vitamin E alone on the progression to late AMD and vision loss are uncertain. Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence about safety because most of the studies were small and reported on harmful effects inconsistently. What are the limitations of the evidence? Our confidence in the evidence ranged from moderate to very low. This is because most of the included studies were small, and they did not cover all the comparisons and outcomes we were interested in. How up to date is this review? 
This review updates our previous version. The evidence is up to date to 29 November 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.122Z" }, { "id": "52f9fff7-3c0c-44ed-98ae-e82255baea80", "pmid": "", "title": "Antioxidant vitamin supplementation for preventing and slowing the progression of age‐related cataract", "imported": false, "abstract": "Abstract - Background Age‐related cataract is a major cause of visual impairment in the elderly. Oxidative stress has been implicated in its formation and progression. Antioxidant vitamin supplementation has been investigated in this context. Objectives To assess the effectiveness of antioxidant vitamin supplementation in preventing and slowing the progression of age‐related cataract. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 2), MEDLINE (January 1950 to March 2012), EMBASE (January 1980 to March 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to March 2012), Open Grey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 2 March 2012. We also checked the reference lists of included studies and ongoing trials and contacted investigators to identify eligible randomized trials. Selection criteria We included only randomized controlled trials in which supplementation with one or more antioxidant vitamins (beta‐carotene, vitamin C and vitamin E) in any form, dosage or combination for at least one year was compared to another antioxidant vitamin or to placebo. Data collection and analysis Two authors extracted data and assessed trial quality independently. We pooled results for the primary outcomes, i.e., incidence of cataract and incidence of cataract extraction. We did not pool results of the secondary outcomes ‐ progression of cataract and loss of visual acuity, because of differences in definitions of outcomes and data presentation. We pooled results by type of cataract when data were available. We did not perform a sensitivity analysis. Main results Nine trials involving 117,272 individuals of age 35 years or older are included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States, with duration of follow‐up ranging from 2.1 to 12 years. The doses of antioxidant vitamins were higher than the recommended daily allowance. There was no evidence of effect of antioxidant vitamin supplementation in reducing the risk of cataract, cataract extraction, progression of cataract or in slowing the loss of visual acuity. In the pooled analyses, there was no evidence of effect of beta‐carotene supplementation in reducing the risk of cataract (two trials) (relative risk (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.08; n = 57,703) or in reducing the risk of cataract extraction (three trials) (RR 1.00, 95% CI 0.91 to 1.10; n = 86,836) or of vitamin E supplementation in reducing the risk of cataract (three trials) (RR 0.97, 95% CI 0.91 to 1.04; n = 50,059) or of cataract extraction (five trials) (RR 0.98, 95% CI 0.91 to 1.05; n = 83,956). The proportion of participants developing hypercarotenodermia (yellowing of skin) while on beta‐carotene ranged from 7.4% to 15.8%. Authors' conclusions There is no evidence from RCTs that supplementation with antioxidant vitamins (beta‐carotene, vitamin C or vitamin E) prevents or slows the progression of age‐related cataract. We do not recommend any further studies to examine the role of antioxidant vitamins beta‐carotene, vitamin C and vitamin E in preventing or slowing the progression of age‐related cataract. Costs and adverse effects should be weighed carefully with unproven benefits before recommending their intake above recommended daily allowances. Plain language summary Antioxidant vitamins for preventing and slowing the progression of age‐related cataract A cataract occurs when the normally clear lens in the eye becomes cloudy. Cataracts are the leading cause of correctable reduced vision worldwide. Most cataracts develop slowly with normal aging. However, cataracts also may be related to genetic diseases and medical conditions such as diabetes. Other factors such as poor nutrition, sun damage, radiation, corticosteroids, smoking, alcohol, eye trauma or other eye surgery may influence cataract formation. Mild or early cataracts may not impair vision. In some cataracts, new eye‐glass prescriptions, brighter lighting or magnifying lenses may overcome the vision losses. When these interventions fail to improve poor vision due to cataracts, surgical removal (extraction) is the generally accepted effective treatment. However, cataract surgery is associated with some risks. The estimated annual costs for outpatient, inpatient and prescription drug services related to the treatment of cataract is USD 6.8 billion. Antioxidant vitamin supplementation has been studied as a means to prevent the formation or to slow the progression of cataract. Results from observational studies have been inconsistent. The review authors searched for randomized controlled trials in which supplementation with the antioxidant vitamins beta‐carotene (provitamin A), vitamin C and vitamin E was compared to inactive placebo or no supplement. Nine trials involving 117,272 adults of age 35 years or older were included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States and were of high methodological quality. The doses of antioxidants given in each trial were higher than the recommended daily allowances. The trials provided no evidence of effect of the antioxidant vitamins beta‐carotene, vitamin E and vitamin C given alone or in combination on the incidence of cataract, its extraction or progression and on the loss of visual acuity. Some participants (7% to 16%) on beta‐carotene developed yellowing of the skin (hypercarotenodermia).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mathew, MC; Ervin, AM; Tao, J; Davis, RM", "articleTypes": [], "doi": "10.1002/14651858.CD004567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "5300c5ef-4110-4dc9-b751-b596afa9b57f", "pmid": "", "title": "Colchicine for pericarditis", "imported": false, "abstract": "Abstract - Background Pericarditis is the inflammation of the pericardium, the membranous sac surrounding the heart. Recurrent pericarditis is the most common complication of acute pericarditis, causing severe and disabling chest pains. Recurrent pericarditis affects one in three patients with acute pericarditis within the first 18 months. Colchicine has been suggested to be beneficial in preventing recurrent pericarditis. Objectives To review all randomised controlled trials (RCTs) that assess the effects of colchicine alone or combined, compared to any other intervention to prevent further recurrences of pericarditis, in people with acute or recurrent pericarditis. Search methods We searched the following bibliographic databases on 4 August 2014: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2014 on The Cochrane Library ), MEDLINE (OVID, 1946 to July week 4, 2014), EMBASE (OVID, 1947 to 2014 week 31), and the Conference Proceedings Citation Index ‐ Science on Web of Science (Thomson Reuters) 1990 to 1 Aug 2014. We did not apply any language or time restrictions. Selection criteria RCTs of people with acute or recurrent pericarditis who are receiving colchicine compared to any other treatment, in order to prevent recurrences. Data collection and analysis Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The first primary outcome was the time to recurrence, measured by calculating the hazard ratios (HRs). The second primary outcome was the adverse effects of colchicine. Secondary outcomes were the rate of recurrences at 6, 12 and 18 months, and symptom relief. Main results We included four RCTs, involving 564 participants in this review. We compared the effects of colchicine in addition to a non‐steroidal anti‐inflammatory drug (NSAID) such as ibuprofen, aspirin or indomethacin to the effects of the NSAID alone. Two comparable trials studied the effects of colchicine in 204 participants with recurrent pericarditis and two trials studied 360 people with acute pericarditis. All trials had a moderate quality for the primary outcomes. We identified two on‐going trials; one of these trials examines acute pericarditis and the other assesses recurrent pericarditis. There was moderate quality evidence that colchicine reduces episodes of pericarditis in people with recurrent pericarditis over 18 months follow‐up (HR 0.37; 95% confidence interval (CI) 0.24 to 0.58). It is expected that at 18 months, the number needed to treat (NNT) is 4. In people with acute pericarditis, there was moderate quality evidence that colchicine reduces recurrence (HR 0.40; 95% CI 0.27 to 0.61) at 18 months follow‐up. Colchicine led to a greater chance of symptom relief at 72 hours (risk ratio (RR) 1.4; 95% CI 1.26 to 1.56; low quality evidence). Adverse effects were mainly gastrointestinal and included abdominal pain and diarrhoea. The pooled RR for adverse events was 1.26 (95% CI 0.75 to 2.12). While the number of people experiencing adverse effects was higher in the colchicine than the control groups (9% versus 7%), the quality of evidence was low owing to imprecision, and there was no statistically significant difference between the treatment groups (P = 0.42). There was moderate quality evidence that treatment with colchicine led to more people stopping treatment due to adverse events (RR 1.87; 95% CI 1.02 to 3.41). Authors' conclusions Colchicine, as adjunctive therapy to NSAIDs, is effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis. However, evidence is based on a limited number of small trials. Patients with multiple resistant recurrences were not represented in any published or on‐going trials, and it is these patients that are in the most need for treatment. Plain language summary Systematic review of randomised controlled trials about the efficacy and safety of colchicine in people with pericarditis Pericarditis is the inflammation and swelling of the tissue covering the outer layer of the heart. Pericarditis causes severe and disabling chest pain and fever, however the main issue is the repeated recurrence of pericarditis attacks. Colchicine is an ancient medication that has been used in the treatment of other inflammatory diseases such as gout. We wanted to discover whether colchicine alone or added to other medications is better or worse than alternative therapies in preventing pericarditis. We have reviewed all randomised controlled trials about the effect of colchicine in preventing recurrence of pericarditis in people with pericarditis. We found four trials involving 564 participants, who were followed up for at least 18 months. Two studies examined the use of colchicine in people with recurrent pericarditis and two examined the use of colchicine in people with a first episode of pericarditis. The evidence is current to August 2014. The trials showed that people taking colchicine have a lower risk of developing pericarditis recurrence and a higher proportion experience symptom relief. It is expected that at 18 months, one pericarditis recurrence can be avoided for every four people receiving colchicine with NSAIDs rather than NSAIDs alone. Adverse effects were reported in all trials and affected 15 people (9%) of the 162 taking colchicine. Adverse effects included abdominal pain, nausea and vomiting. Two studies were designed so that participants knew the type of intervention they were taking and people in the comparison group had no dummy pill. The results of these studies could exaggerate the effects of the drug. The evidence suggests beneficial effects of colchicine in preventing recurrence of pericarditis, however this is based on a limited number of small trials. More trials are currently being done and we await their results to see if the benefits of colchicine can be further confirmed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Alabed, S, Cabello, JB, Irving, GJ, Qintar, M, Burls, A", "articleTypes": [], "doi": "10.1002/14651858.CD010652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.750Z" }, { "id": "53086469-9f28-41e5-bb5d-356896fcdfc0", "pmid": "", "title": "Acetylcholinesterase inhibitors for autistic spectrum disorders", "imported": false, "abstract": "Abstract - Background Autism spectrum disorder (autism) is a neurodevelopmental condition characterised by impairments in social communication and interaction, plus restricted, repetitive patterns of behaviour and interests. Whilst some people embrace autism as part of their identity, others struggle with their difficulties, and some seek treatment. There are no current interventions that result in complete reduction of autism features. Acetylcholine is a neurotransmitter for the cholinergic system and has a role in attention, novelty seeking, and memory. Low levels of acetylcholine have been investigated as a potential contributor to autism symptomatology. Donepezil, galantamine, and rivastigmine (commonly referred to as acetylcholinesterase inhibitors) all inhibit acetylcholinesterase, and have slightly different modes of action and biological availability, so their effectiveness and side‐effect profiles may vary. The effect of various acetylcholinesterase inhibitor on core autism features across the lifespan, and possible adverse effects, have not been thoroughly investigated. Objectives To evaluate the efficacy and harms of acetylcholinesterase inhibitors for people with the core features (social interaction, communication, and restrictive and repetitive behaviours) of autism. To assess the effects of acetylcholinesterase inhibitors on non‐core features of autism. Search methods In November 2022, we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the reference lists of included studies and relevant reviews, and contacted authors of relevant studies. Selection criteria Randomised controlled trials (RCTs), comparing acetylcholinesterase inhibitors (e.g. galantamine, donepezil, or rivastigmine) of varying doses, delivered orally or via transdermal patch, either as monotherapy or adjunct therapy, with placebo. People of any age, with a clinical diagnosis of autism were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were core features of autism and adverse effects. Secondary outcomes were language, irritability, hyperactivity, and general health and function. We used GRADE to assess certainty of evidence. Main results We included two RCTs (74 participants). One study was conducted in Iran, the second in the USA, although exact location in the USA is unclear. Galantamine plus risperidone versus placebo plus risperidone One study compared the effects of galantamine plus risperidone to placebo plus risperidone (40 participants, aged 4 years to 12 years). Primary and secondary outcomes of interest were measured postintervention, using subscales of the Aberrant Behavior Checklist (score 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed there was little to no difference between the two groups postintervention for social communication (mean difference (MD) ‐2.75, 95% confidence interval (CI) ‐5.88 to 0.38), and restricted and repetitive behaviour (MD ‐0.55, 95% CI ‐3.47 to 2.37). Overall autism features were not assessed. Adverse events may be higher in the galantamine plus risperidone group (75%) compared with the placebo plus risperidone group (35%): odds ratio 5.57, 95% CI 1.42 to 21.86, low‐certainty evidence. No serious adverse events were reported. Low‐certainty evidence showed a small difference in irritability (MD ‐3.50, 95% CI ‐6.39 to ‐0.61), with the galantamine plus risperidone group showing a greater decline on the irritability subscale than the placebo group postintervention. There was no evidence of a difference between the groups in hyperactivity postintervention (MD ‐5.20, 95% CI ‐10.51 to 0.11). General health and function were not assessed. Donepezil versus placebo One study compared donepezil to placebo (34 participants aged 8 years to 17 years). Primary outcomes of interest were measured postintervention, using subscales of the Modified Version of The Real Life Rating Scale (scored 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed no evidence of group differences immediately postintervention in overall autism features (MD 0.07, 95% CI ‐0.19 to 0.33), or in the autism symptom domains of social communication (MD ‐0.02, 95% CI ‐0.34 to 0.30), and restricted and repetitive behaviours (MD 0.04, 95% CI ‐0.27 to 0.35). Significant adverse events leading to study withdrawal in at least one participant was implied in the data analysis section, but not explicitly reported. The evidence is very uncertain about the effect of donepezil, compared to placebo, on the secondary outcomes of interest, including irritability (MD 1.08, 95% CI ‐0.41 to 2.57), hyperactivity (MD 2.60, 95% CI 0.50 to 4.70), and general health and function (MD 0.03, 95% CI ‐0.48 to 0.54) postintervention. Across all analyses within this comparison, we judged the evidence to be very low‐certainty due to high risk of bias, and very serious imprecision (results based on one small study with wide confidence intervals). The study narratively reported adverse events for the study as a whole, rather than by treatment group. Authors' conclusions Evidence about the effectiveness of acetylcholinesterase inhibitors as a medication to improve outcomes for autistic adults is lacking, and for autistic children is very uncertain. There is a need for more evidence of improvement in outcomes of relevance to clinical care, autistic people, and their families. There are a number of ongoing studies involving acetylcholinesterase inhibitors, and future updates of this review may add to the current evidence. Plain language summary Do acetylcholinesterase inhibitors reduce the core impairments associated with autism spectrum disorder Key messages At present, it is unclear whether acetylcholinesterase inhibitors are effective in treating the core features of autism. This is because very few studies have been carried out. The two we found were small, and did not report the outcomes very well. However, there are a number of ongoing studies in this area. What is autism spectrum disorder? Autism spectrum disorder (autism) is a condition that affects the way a person thinks, feels, interacts with others, and experiences their environment. The core behaviours of autism include reduced sharing of interests, difficulties with nonverbal communication (for example, little eye contact), difficulties forming and maintaining relationships and restricted, or repetitive behaviours or interests. These behaviours can vary in severity, but they still interfere with the person's daily functioning and participation in activities. Medicines, called acetylcholinesterase inhibitors (chemicals that block the normal breakdown of nerve transmitters), have been used to treat Alzheimer's disease (for example, donepezil and galantamine). Recently, it has been suggested that they may also decrease some of the difficulties seen in people with autism. What did we want to find out? Do acetylcholinesterase inhibitors, alone or with other medicines, reduce the core features of autism (social communication and interaction, restrictive and repetitive behaviours) compared with a placebo (a dummy pill). We also wanted to find out if acetylcholinesterase inhibitors were associated with any unwanted side effects. What did we do? We searched for studies that explored whether there were any differences in autistic people's behaviours after they had taken acetylcholinesterase inhibitors compared to people who had taken placebo pills. We compared and summarised the results of the studies, and rated our confidence in the evidence, based on things, such how big and well carried out the studies were. What did we find? We found two relevant studies. One study looked at whether an acetylcholinesterase inhibitor called galantamine, combined with a drug called risperidone (traditionally used to treat psychosis), was better than a placebo combined with risperidone. The study included 40 children, aged between 4 and 12 years, with a diagnosis of autism. it took place over 10 weeks in Iran. A second study compared an acetylcholinesterase inhibitor called donepezil with placebo. It included 34 children, aged between 8 and 17 years, with a diagnosis of autism. It was carried out in the USA. All studies involved children attending outpatient clinics. What are the main results of the review? It is unclear if acetylcholinesterase inhibitors make any difference to the core features of autism in children or adults. Galantamine may cause little to no difference in social interaction and communication skills and irritability levels in children with autism after 10 weeks of treatment. There is no evidence that galantamine reduces difficulties associated with restricted or repetitive behaviours or hyperactivity. Galantamine may also cause some side effects, including nervousness, drowsiness, increased appetite, and tremor. There is no evidence that donepezil reduces difficulties associated with the core features of autism or associated secondary problems. We were unable to find out whether it causes unwanted side effects in children with autism, because the study did not report the results completely. What are the limitations of the evidence? We have little confidence in the evidence for using this medicine to treat problems associated with autism, because the evidence comes from only two small studies that were not very well carried out or reported. Each study looked at a different type of acetylcholinesterase inhibitor and delivered the medicine differently. They did not provide information about all the issues we were interested in, and they measured the side effects differently. If more studies are included in future reviews, these results may change. How up‐to‐date is this review? The evidence in this review is current to November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ure, A, Cox, GR, Haslam, R, Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD013851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.768Z" }, { "id": "530e6d3b-1b9e-4664-8567-4d72658684f9", "pmid": "", "title": "Inhaled hyperosmolar agents for bronchiectasis", "imported": false, "abstract": "Abstract - Background Mucus retention in the lungs is a prominent feature of bronchiectasis. The stagnant mucus becomes chronically colonised with bacteria, which elicit a host neutrophilic response. This fails to eliminate the bacteria, and the large concentration of host‐derived protease may contribute to the airway damage. The sensation of retained mucus is itself a cause of suffering, and the failure to maintain airway sterility probably contributes to the frequent respiratory infections experienced by many patients. Hypertonic saline inhalation is known to accelerate tracheobronchial clearance in many conditions, probably by inducing a liquid flux into the airway surface, which alters mucus rheology in a way favourable to mucociliary clearance. Inhaled dry powder mannitol has a similar effect. Such agents are an attractive approach to the problem of mucostasis, and deserve further clinical evaluation. Objectives To determine whether inhaled hyperosmolar substances are effective in the treatment of bronchiectasis. Search methods We searched the Cochrane Airways Group Specialised Register, trials registries, and the reference lists of included studies and review articles. Searches are current up to April 2014. Selection criteria Any randomised controlled trial (RCT) using hyperosmolar inhalation in patients with bronchiectasis not caused by cystic fibrosis. Data collection and analysis Two review authors assessed studies for suitability. We used standard methods recommended by The Cochrane Collaboration. Main results Eleven studies met the inclusion criteria of the review (1021 participants). Five studies on 833 participants compared inhaled mannitol with placebo but poor outcome reporting meant we could pool very little data and most outcomes were reported by only one study. One 12‐month trial on 461 participants provided results for exacerbations and demonstrated an advantage for mannitol in terms of time to first exacerbation (median time to exacerbation 165 versus 124 days for mannitol and placebo respectively (hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.63 to 0.96, P = 0.022) and number of days on antibiotics for bronchiectasis exacerbations was significantly better with mannitol (risk ratio (RR) 0.76, 95%CI 0.58 to 1.00, P = 0.0496). However, exacerbation rate per year was not significantly different between mannitol and placebo (RR 0.92 95% CI 0.78 to 1.08). The quality of this evidence was rated as moderate. There was also an indication, from only three trials, again based on moderate quality evidence, that mannitol improves health‐related quality of life (mean difference (MD) ‐2.05; 95% CI ‐3.69 to ‐0.40). An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo (OR 0.96; 95% CI 0.61 to 1.51). Two additional small trials on 25 participants compared mannitol versus no treatment and the data from these studies were inconclusive. Four studies (combined N = 113) compared hypertonic saline versus isotonic saline. On most outcomes there were conflicting results and the opportunities for the statistical aggregation of data from studies was very limited. It is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Authors' conclusions There is an indication from a single, large, unpublished study that inhaled mannitol increases time to first exacerbation in patients with bronchiectasis. In patients with near normal lung function, spirometry does not change dramatically with mannitol and adverse events are not more frequent than placebo. Further investigation is required in a patient population with impaired lung function. It is not possible to draw firm conclusions regarding the effect of nebulised hypertonic saline due to significant differences in the methodology, patient groups, and findings amongst the limited data available. The data suggest that it is unlikely to have benefit over isotonic saline in patients with milder disease, and hence future studies should test its use in those with more severe disease Plain language summary Inhaled hyperosmolar agents for bronchiectasis Review question We wanted to know if inhaled hyperosmolar agents ‐ treatments which help people cough up sputum ‐ may be helpful for people with bronchiectasis. We only included trials on people who had bronchiectasis and who did not have cystic fibrosis. Therefore we are unable to draw any conclusions for people with cystic fibrosis. Background Bronchiectasis is a lung condition that usually develops after a series of lung problems (such as childhood infections, problems in the lung structure, tuberculosis, and cystic fibrosis). A lot of mucus (phlegm) collects in the lungs, causing discomfort and the need to cough it up. The phlegm also collects bacteria, which can add to breathing difficulties and make people very ill by causing recurring lung infections that are difficult to clear with antibiotics. Breathing in (inhaling) hypertonic saline (salt solutions with a greater salt content than blood) liquids may help clear this mucus, as may the drug mannitol (inhaled in dry powder form). This is because the concentrated salt or sugar (mannitol) draws water into the mucus in the lung and makes it thinner and easier to cough out. Study characteristics We found 11 randomised controlled trials on 1021 participants that compared inhaled hyperosmolar agents versus no mucolytic treatment. Five studies compared inhaled mannitol versus placebo (with a total of 883 participants) and two very small studies (with a total of just 25 participants) compared inhaled mannitol with no treatment. We also found four studies (with a total of 113 participants) that compared hypertonic saline with isotonic (normal) saline. Key results For the comparison between mannitol and placebo only one study (a 12‐month trial with 461 participants) provided information on the number of people who had an exacerbation (or flare up) over the course of a year. This study showed that people who were treated with mannitol had 8% fewer exacerbations on average compared with placebo. Overall, we felt the quality of this evidence was moderate and new trials would be likely to change either how effective we think the treatment is or how confident we are about it. Three trials assessed the effect of mannitol on health‐related quality of life, and again the quality of the evidence was rated as moderate. An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo The trials comparing hypertonic saline with isotonic saline had conflicting results for most of the outcomes of interest. Because we were unable to combine the data, it is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Our analysis of adverse events between hypertonic saline versus isotonic saline showed no significant difference however this was based on a single study and the quality of the evidence was moderate. Quality of the evidence Details of how the patients in the trials were allocated to receive mannitol or not was clearly described in only one of the studies, and similarly only one of the hypertonic saline versus isotonic saline studies provided this information. The general lack of information on this point was considered carefully in the review in relation to our level of uncertainty in interpreting the results. Taking this into account, the quality of evidence was generally regarded as moderate both for the mannitol and hypertonic saline studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hart, A; Sugumar, K; Milan, SJ; Fowler, SJ; Crossingham, I", "articleTypes": [], "doi": "10.1002/14651858.CD002996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "5321c06e-7395-43ae-aef9-81e29a292a92", "pmid": "", "title": "Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, rhinorrhoea, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. The use of topical (intranasal) corticosteroids has been widely advocated for the treatment of chronic rhinosinusitis given the belief that inflammation is a major component of this condition. Objectives To assess the effects of intranasal corticosteroids in people with chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) with a follow‐up period of at least three months comparing intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) against placebo or no treatment in patients with chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity and the commonest adverse event ‐ epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation or other systemic adverse events. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 18 RCTs with a total of 2738 participants. Fourteen studies had participants with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. Intranasal corticosteroids versus placebo or no intervention Only one study (20 adult participants without polyps) measured our primary outcome disease‐specific HRQL using the Rhinosinusitis Outcome Measures‐31 (RSOM‐31). They reported no significant difference (numerical data not available) ( very low quality evidence). Our second primary outcome, disease severity , was measured using the Chronic Sinusitis Survey in a second study (134 participants without polyps), which found no important difference (mean difference (MD) 2.84, 95% confidence interval (CI) ‐5.02 to 10.70; scale 0 to 100). Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group (RR 2.78, 95% CI 1.76 to 4.40; 109 participants). The quality of the evidence was low . Six studies provided data on at least two of the individual symptoms used in the EPOS 2012 criteria to define chronic rhinosinusitis (nasal blockage, rhinorrhoea, loss of sense of smell and facial pain/pressure). When all four symptoms in the EPOS criteria were available on a scale of 0 to 3 (higher = more severe symptoms), the average MD in change from baseline was ‐0.26 (95% CI ‐0.37 to ‐0.15; 243 participants; two studies; low quality evidence). Although there were more studies and participants when only nasal blockage and rhinorrhoea were considered (MD ‐0.31, 95% CI ‐0.38 to ‐0.24; 1702 participants; six studies), the MD was almost identical to when loss of sense of smell was also considered (1345 participants, four studies; moderate quality evidence). When considering the results for the individual symptoms, benefit was shown in the intranasal corticosteroids group. The effect size was larger for nasal blockage (MD ‐0.40, 95% CI ‐0.52 to ‐0.29; 1702 participants; six studies) than for rhinorrhoea (MD ‐0.25, 95% CI ‐0.33 to ‐0.17; 1702 participants; six studies) or loss of sense of smell (MD ‐0.19, 95% CI ‐0.28 to ‐0.11; 1345 participants; four studies). There was heterogeneity in the analysis for facial pain/pressure (MD ‐0.27, 95% CI ‐0.56 to 0.02; 243 participants; two studies). The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure. There was an increased risk of epistaxis with intranasal corticosteroids (risk ratio (RR) 2.74, 95% CI 1.88 to 4.00; 2508 participants; 13 studies; high quality evidence). Considering our secondary outcome, general HRQL, one study (134 participants without polyps) measured this using the SF‐36 and reported a statistically significant benefit only on the general health subscale. The quality of the evidence was very low . It is unclear whether there is a difference in the risk of local irritation (RR 0.94, 95% CI 0.53 to 1.64; 2124 participants; 11 studies) ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis or stunted growth (children). Other comparisons We identified no other studies that compared intranasal corticosteroids plus co‐intervention A versus placebo plus co‐intervention A. Authors' conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life ( very low quality evidence). For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of epistaxis is increased ( high quality evidence), but these data included all levels of severity; small streaks of blood may not be a major concern for patients. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) . Plain language summary Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of intranasal (in the nose) steroids given to people with chronic rhinosinusitis. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose (rhinorrhoea), pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation in order to improve patient symptoms. Study characteristics We included 18 randomised controlled trials (RCTs) with a total of 2738 participants in this review. Most studies were relatively small, with as few as 9 or 10 patients per intervention arm. The largest study had 748 patients in total. Most were conducted in tertiary referral centres in northern Europe, the US and Canada. Fourteen studies only included participants with chronic rhinosinusitis with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Key results and quality of the evidence One study (20 participants) reported no statistically significant difference in disease‐specific health‐related quality of life. Another measured general health‐related quality of life and reported a statistically significant benefit only on a subscale for general health. Both studies recruited participants with chronic rhinosinusitis without nasal polyps. The quality of the evidence was very low (we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect). Disease severity was measured in one study (chronic rhinosinusitis without nasal polyps, 134 participants), which found no important difference. Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group. The quality of the evidence was low (our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect). When each type of symptom was measured separately (nasal blockage, rhinorrhoea, loss of sense of smell, facial pain/pressure), benefit was shown in the intranasal corticosteroids group. The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure (moderate quality evidence means we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different). There was an increased risk of nosebleeds (epistaxis) with intranasal corticosteroids ( high quality evidence). However, it was unclear whether there was a difference in the risk of local (nose or throat) irritation ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis (fragile bones) or stunted growth (in children). Conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life and the quality of this evidence is very low . For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of nosebleeds is increased ( high quality evidence), but this included all levels of severity; for some patients small streaks of blood may not be a major concern. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) .", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chong, LY; Head, K; Hopkins, C; Philpott, C; Schilder, AGM; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "532abbc1-5c20-43ec-88fd-b0808f24b2d2", "pmid": "", "title": "A Phase 1/2 Study of REGN7075 (EGFRxCD28 Costimulatory Bispecific Antibody) in Combination With Cemiplimab in Patients With Advanced Solid Tumors", "imported": false, "abstract": "This study is researching an investigational drug called marlotamig (REGN7075) by itself and in combination with cemiplimab with or without chemotherapy. The study is focused on patients with certain solid tumors that are in an advanced stage.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.268Z" }, { "id": "532d71a5-00b5-4aaa-86e7-ea0d029ab3c4", "pmid": "", "title": "Changes in Insulin Sensitivity in Liver and Esqueletal Muscle Due to Sucralose Consumption", "imported": false, "abstract": "Recently, it has been proposed that the consumption of non-nutritive sweeteners, including sucralose, it's not harmless and is related with metabolic effects. Some studies have reported that sucralose produces alterations in glucose homeostasis. In vitro studies indicate that sucralose is capable of interacting with sweet taste receptors (T1R2 and T1R3) in the intestine, thus increasing the expression of glucose transporters including the sodium-glucose cotransporter type 1 (SGLT1) and the glucose transporter 2 (GLUT2), increasing glucose absorption. This interaction with intestinal sweet taste receptors also generates an increase in the secretion of the incretins glucagon-like peptide type 1 (GLP-1) and the glucose-dependent insulinotropic polypeptide (GIP), which might enhance the postprandial insulin release. However, these results are preliminary and it's desirable to confirm if sucralose consumption is associated with glucose metabolism modifications using an appropriate methodological design and with gold standard methods. The aim of this triple-blind, placebo-controlled, parallel, randomized clinical trial is to confirm the changes in insulin sensitivity associated with sucralose consumption in humans, to identify whether these changes are in the liver or skeletal muscle and to investigate the pathophysiological mechanisms generating these changes. Specifically, we will investigate if sucralose generates a dysbiosis in the gut microbiota that could be related to insulin resistance by increasing concentrations of lipopolysaccharide, a toxin present in Gram-negative bacteria that triggers a low grade inflammation known as metabolic endotoxemia. In addition, the changes in postprandial concentrations of GLP-1, glucose, insulin and C-peptide due to the combination of sucralose with a mixed meal will be investigated. The results of this study will determine if sucralose consumption, frequently used as a non-nutritive sweetener, is associated to significant changes in glucose homeostasis in humans.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "5336f591-ddd6-4bdf-9080-3e376a4fc100", "pmid": "", "title": "Interventions for chronic kidney disease in people with sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD), one of the commonest severe monogenic disorders, is caused by the inheritance of two abnormal haemoglobin (beta‐globin) genes. SCD can cause severe pain, significant end‐organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD. Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD. Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, with increased prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end‐stage renal disease. This is an update of a review first published in 2017. Objectives To assess the effectiveness of any intervention for preventing or reducing kidney complications or chronic kidney disease in people with sickle cell disease. Possible interventions include red blood cell transfusions, hydroxyurea, and angiotensin‐converting enzyme inhibitors (ACEIs), either alone or in combination. Search methods We searched for relevant trials in the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, CENTRAL, MEDLINE, Embase, seven other databases, and two other trials registers. Selection criteria Randomised controlled trials (RCTs) comparing interventions to prevent or reduce kidney complications or CKD in people with SCD. We applied no restrictions related to outcomes examined, language, or publication status. Data collection and analysis Two review authors independently assessed trial eligibility, extracted data, assessed the risk of bias, and assessed the certainty of the evidence (GRADE). Main results We included three RCTs with 385 participants. We rated the certainty of the evidence as low to very low across different outcomes according to GRADE methodology, downgrading for risk of bias concerns, indirectness, and imprecision. Hydroxyurea versus placebo One RCT published in 2011 compared hydroxyurea to placebo in 193 children aged nine to 18 months. We are unsure if hydroxyurea compared to placebo reduces or prevents progression of kidney disease assessed by change in glomerular filtration rate (mean difference (MD) 0.58 mL/min /1.73 m 2 , 95% confidence interval (CI) −14.60 to 15.76; 142 participants; very low certainty). Hydroxyurea compared to placebo may improve the ability to concentrate urine (MD 42.23 mOsm/kg, 95% CI 12.14 to 72.32; 178 participants; low certainty), and may make little or no difference to SCD‐related serious adverse events, including acute chest syndrome (risk ratio (RR) 0.39, 99% CI 0.13 to 1.16; 193 participants; low certainty), painful crisis (RR 0.68, 99% CI 0.45 to 1.02; 193 participants; low certainty); and hospitalisations (RR 0.83, 99% CI 0.68 to 1.01; 193 participants; low certainty). No deaths occurred in either trial arm and the RCT did not report quality of life. Angiotensin‐converting enzyme inhibitors versus placebo One RCT published in 1998 compared an ACEI (captopril) to placebo in 22 adults with normal blood pressure and microalbuminuria. We are unsure if captopril compared to placebo reduces proteinuria (MD −49.00 mg/day, 95% CI −124.10 to 26.10; 22 participants; very low certainty). We are unsure if captopril reduces or prevents kidney disease as measured by creatinine clearance; the trial authors stated that creatinine clearance remained constant over six months in both groups, but provided no comparative data (very low certainty). The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Angiotensin‐converting enzyme inhibitors versus vitamin C One RCT published in 2020 compared an ACEI (lisinopril) with vitamin C in 170 children aged one to 18 years with normal blood pressure and microalbuminuria. It reported no data we could analyse. We are unsure if lisinopril compared to vitamin C reduces proteinuria in this population: the large drop in microalbuminuria in both arms of the trial after only one month on treatment may have been due to an overestimation of microalbuminuria at baseline rather than a true effect. The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Authors' conclusions We are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. We are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. We are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria. No RCTs assessed red blood cell transfusions or any combined interventions to prevent or reduce kidney complications. Due to lack of evidence, we cannot comment on the management of children aged over 18 months or adults with any known genotype of SCD. We have identified a lack of adequately designed and powered studies, although we found four ongoing trials since the last version of this review. Only one ongoing trial addresses renal function as a primary outcome in the short term, but such interventions have long‐term effects. Trials of hydroxyurea, ACEIs or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction of kidney complications in people with SCD. Plain language summary Interventions to prevent or reduce kidney complications in people with sickle cell disease Review question Are there any safe and effective interventions that prevent or reduce kidney complications in people with sickle cell disease (SCD)? Background SCD is a serious inherited blood disorder where the red blood cells, which carry oxygen around the body, develop abnormally. Normal red blood cells are flexible and disc‐shaped, but sickled cells are rigid and crescent‐shaped, and stickier than normal red blood cells. This can lead to blockage of blood vessels, resulting in tissue and organ damage and episodes of severe pain. The abnormal cells are fragile and break apart easily, which leads to a decreased number of red blood cells, known as anaemia. Kidney complications can start at an early age in children with SCD and are common in adults with the condition. Kidney complications leading to kidney protein leak and chronic kidney disease can be severe, with serious effects on health. Severe complications include the need for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) or a kidney transplant. Identifying therapies that can prevent or slow down the decline in kidney function in people with SCD is critical for improving health outcomes. Search date The evidence is current to 22 September 2022. Study characteristics We found three randomised controlled trials, which enroled a total of 385 people. One trial, published in 2011, compared the drug hydroxyurea (which helps to maintain the shape and flexibility of red blood cells), to placebo (dummy treatment) in 193 children aged nine to 18 months. The second trial, published in 1998, compared captopril (a drug used to treat high blood pressure) to placebo in 22 adults with normal blood pressure and microalbuminuria (high levels of protein in the urine). The third trial, published in 2020, compared lisinopril (a drug used to treat high blood pressure) to vitamin C in 170 children aged one to 18 years. Two trials received government funding; it was unclear how the third trial was funded. Key results In children aged nine to 18 months, hydroxyurea may increase the ability to produce normal urine, but we are unsure if it has any effect on the glomerular filtration rate (network of filters in the kidney that filter waste from the blood). Hydroxyurea may make little or no difference to the occurrence of serious complications including acute chest syndrome (pain, cough, fever, low oxygen levels, and abnormal substances in the lungs), painful crises, and hospitalisations. We are unsure if giving captopril to adults with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. We are unsure if giving lisinopril to children aged one to 18 years with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. No trials reported quality of life. Limitations of the evidence We have little or very little confidence in the evidence because we only found three trials, and they had specific populations (only children or only adults), few participants, and wide variations in results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Roy, NBA, Carpenter, A, Dale-Harris, I, Dorée, C, Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012380.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.775Z" }, { "id": "5337f538-b7aa-4c6d-a1e2-7a348337a9b9", "pmid": "", "title": "Antibiotics to prevent complications following tooth extractions", "imported": false, "abstract": "Abstract - Background The most frequent indications for tooth extractions, generally performed by general dental practitioners, are dental caries and periodontal infections. Systemic antibiotics may be prescribed to patients undergoing extractions to prevent complications due to infection. This is an update of a review first published in 2012. Objectives To determine the effect of systemic antibiotic prophylaxis on the prevention of infectious complications following tooth extractions. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 16 April 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 3), MEDLINE Ovid (1946 to 16 April 2020), Embase Ovid (1980 to 16 April 2020), and LILACS (1982 to 16 April 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised, double‐blind, placebo‐controlled trials of systemic antibiotic prophylaxis in patients undergoing tooth extraction(s) for any indication. Data collection and analysis At least two review authors independently performed data extraction and 'Risk of bias' assessment for the included studies. We contacted trial authors for further details where these were unclear. For dichotomous outcomes, we calculated risk ratios (RR) and 95% confidence intervals (CI) using random‐effects models. For continuous outcomes, we used mean differences (MD) with 95% CI using random‐effects models. We examined potential sources of heterogeneity. We assessed the certainty of the body of evidence for key outcomes as high, moderate, low, or very low, using the GRADE approach. Main results We included 23 trials that randomised approximately 3206 participants (2583 analysed) to prophylactic antibiotics or placebo. Although general dentists perform dental extractions because of severe dental caries or periodontal infection, only one of the trials evaluated the role of antibiotic prophylaxis in groups of patients affected by those clinical conditions. We assessed 16 trials as being at high risk of bias, three at low risk, and four as unclear. Compared to placebo, antibiotics may reduce the risk of postsurgical infectious complications in patients undergoing third molar extractions by approximately 66% (RR 0.34, 95% CI 0.19 to 0.64; 1728 participants; 12 studies; low‐certainty evidence), which means that 19 people (95% CI 15 to 34) need to be treated with antibiotics to prevent one infection following extraction of impacted wisdom teeth. Antibiotics may also reduce the risk of dry socket by 34% (RR 0.66, 95% CI 0.45 to 0.97; 1882 participants; 13 studies; low‐certainty evidence), which means that 46 people (95% CI 29 to 62) need to take antibiotics to prevent one case of dry socket following extraction of impacted wisdom teeth. The evidence for our other outcomes is uncertain: pain, whether measured dichotomously as presence or absence (RR 0.59, 95% CI 0.31 to 1.12; 675 participants; 3 studies) or continuously using a visual analogue scale (0‐to‐10‐centimetre scale, where 0 is no pain) (MD −0.26, 95% CI −0.59 to 0.07; 422 participants; 4 studies); fever (RR 0.66, 95% CI 0.24 to 1.79; 475 participants; 4 studies); and adverse effects, which were mild and transient (RR 1.46, 95% CI 0.81 to 2.64; 1277 participants; 8 studies) (very low‐certainty evidence). We found no clear evidence that the timing of antibiotic administration (preoperative, postoperative, or both) was important. The included studies enrolled a subset of patients undergoing dental extractions, that is healthy people who had surgical extraction of third molars. Consequently, the results of this review may not be generalisable to all people undergoing tooth extractions. Authors' conclusions The vast majority (21 out of 23) of the trials included in this review included only healthy patients undergoing extraction of impacted third molars, often performed by oral surgeons. None of the studies evaluated tooth extraction in immunocompromised patients. We found low‐certainty evidence that prophylactic antibiotics may reduce the risk of infection and dry socket following third molar extraction when compared to placebo, and very low‐certainty evidence of no increase in the risk of adverse effects. On average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection. It is unclear whether the evidence in this review is generalisable to patients with concomitant illnesses or patients at a higher risk of infection. Due to the increasing prevalence of bacteria that are resistant to antibiotic treatment, clinicians should evaluate if and when to prescribe prophylactic antibiotic therapy before a dental extraction for each patient on the basis of the patient's clinical conditions (healthy or affected by systemic pathology) and level of risk from infective complications. Immunocompromised patients, in particular, need an individualised approach in consultation with their treating medical specialist. Plain language summary Are antibiotics an effective way to prevent infection following tooth removal? What is the problem? Teeth that are affected by decay or gum disease or painful wisdom teeth are often removed (extracted) by dentists. Tooth extraction is a surgical procedure that leaves a wound in the mouth that can become infected. Infection can lead to swelling, pain, development of pus, fever, as well as ‘dry socket’ (where the tooth socket is not filled by a blood clot, and there is severe pain and bad odour). These complications are unpleasant for patients and may cause difficulty with chewing, speaking, and teeth cleaning, and may even result in days off work or study. Treatment of infection is generally simple and involves drainage of the infection from the wound and patients receiving antibiotics. Why is this question important? Antibiotics work by killing the bacteria that cause infections, or by slowing their growth. However, some infections clear up by themselves. Taking antibiotics unnecessarily may stop them working effectively in future. This ‘antimicrobial resistance’ is a growing problem throughout the world. Antibiotics may also cause unwanted effects such as diarrhoea and nausea. Some patients may be allergic to antibiotics, and antibiotics may not mix well with other medicines. Dentists frequently give patients antibiotics at the time of the extraction as a precaution in order to prevent infection occurring in the first place. This may be unnecessary and may lead to unwanted effects. What did we want to find out? We wanted to know whether giving antibiotics as a preventive measure reduces infection and other complications after tooth extraction. We also wanted to understand whether antibiotics work differently in healthy people compared with people with health conditions such as diabetes or HIV. What did we do? We searched for studies that assessed the effectiveness of antibiotics compared to placebo (sham medicine), given when no infection was present in order to prevent infection following tooth extraction. Studies could include people of any age undergoing tooth extraction. Where possible, we pooled the studies’ results and analysed them together. We also assessed the quality of each study to judge the reliability (certainty) of evidence of individual studies and the body of evidence. What we found We found 23 included studies with a total of more than 3200 participants, who received either antibiotics (of different kinds and dosages) or placebo immediately before or just after tooth extraction, or both. Four studies were conducted in Spain, three each in Brazil, Sweden, and the UK, two in India, and one each in Colombia, Denmark, Finland, France, Poland, New Zealand, Nigeria, and the USA. All but one study included healthy patients in their 20s. Twenty‐one studies assessed the removal of wisdom teeth in hospital dental departments, one assessed the removal of other teeth and one assessed complex oral surgery. None of the included studies assessed tooth extraction in general dental practice for the removal of decayed teeth. Main results Antibiotics given just before or just after surgery (or both) may reduce the risk of infection and dry socket after the removal of wisdom teeth by oral surgeons. However, antibiotics may cause more (generally brief and minor) unwanted effects for these patients. We found no evidence that antibiotics prevent pain, fever, swelling, or problems with restricted mouth opening in patients who have had wisdom teeth removed. There was no evidence to judge the effects of preventive antibiotics for extractions of severely decayed teeth, teeth in diseased gums, or extractions in patients who are sick or have low immunity to infection. How reliable are the results? Our confidence in the results is limited because we had concerns about aspects of the design and reporting of all of the included studies. What does this mean? We did not find studies in patients with depressed immune systems, other illnesses, or in young children or older patients, therefore the results of our review probably do not apply to people who may be at high risk of infection. Also, extractions were mainly carried out by oral surgeons, so the review may not apply to dentists working in general practice. Another concern, which cannot be assessed by clinical studies (i.e. studies testing new medical approaches in people), is that widespread use of antibiotics by people who do not have an infection is likely to contribute to the development of antimicrobial resistance. We concluded that antibiotics given to healthy people when they are having teeth extracted may help prevent infection, but the decision to use an antibiotic should be judged on an individual patient basis based on their state of health and possible complications of getting an infection. How up‐to‐date is this review? This is an updated review. The evidence is current to April 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lodi, G, Azzi, L, Varoni, EM, Pentenero, M, Del Fabbro, M, Carrassi, A, Sardella, A, Manfredi, M", "articleTypes": [], "doi": "10.1002/14651858.CD003811.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.108Z" }, { "id": "53520664-92cd-4a18-b2bc-d2e62113cb1e", "pmid": "", "title": "Interventions for iatrogenic inferior alveolar and lingual nerve injury", "imported": false, "abstract": "Abstract - Background Iatrogenic injury of the inferior alveolar or lingual nerve or both is a known complication of oral and maxillofacial surgery procedures. Injury to these two branches of the mandibular division of the trigeminal nerve may result in altered sensation associated with the ipsilateral lower lip or tongue or both and may include anaesthesia, paraesthesia, dysaesthesia, hyperalgesia, allodynia, hypoaesthesia and hyperaesthesia. Injury to the lingual nerve may also affect taste perception on the affected side of the tongue. The vast majority (approximately 90%) of these injuries are temporary in nature and resolve within eight weeks. However, if the injury persists beyond six months it is deemed to be permanent. Surgical, medical and psychological techniques have been used as a treatment for such injuries, though at present there is no consensus on the preferred intervention, or the timing of the intervention. Objectives To evaluate the effects of different interventions and timings of interventions to treat iatrogenic injury of the inferior alveolar or lingual nerves. Search methods We searched the following electronic databases: the Cochrane Oral Health Group's Trial Register (to 9 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 9 October 2013) and EMBASE via OVID (1980 to 9 October 2013). No language restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials (RCTs) involving interventions to treat patients with neurosensory defect of the inferior alveolar or lingual nerve or both as a sequela of iatrogenic injury. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. We performed data extraction and assessment of the risk of bias independently and in duplicate. We contacted authors to clarify the inclusion criteria of the studies. Main results Two studies assessed as at high risk of bias, reporting data from 26 analysed participants were included in this review. The age range of participants was from 17 to 55 years. Both trials investigated the effectiveness of low‐level laser treatment compared to placebo laser therapy on inferior alveolar sensory deficit as a result of iatrogenic injury. Patient‐reported altered sensation was partially reported in one study and fully reported in another. Following treatment with laser therapy, there was some evidence of an improvement in the subjective assessment of neurosensory deficit in the lip and chin areas compared to placebo, though the estimates were imprecise: a difference in mean change in neurosensory deficit of the chin of 8.40 cm (95% confidence interval (CI) 3.67 to 13.13) and a difference in mean change in neurosensory deficit of the lip of 21.79 cm (95% CI 5.29 to 38.29). The overall quality of the evidence for this outcome was very low; the outcome data were fully reported in one small study of 13 patients, with differential drop‐out in the control group, and patients suffered only partial loss of sensation. No studies reported on the effects of the intervention on the remaining primary outcomes of pain, difficulty eating or speaking or taste. No studies reported on quality of life or adverse events. The overall quality of the evidence was very low as a result of limitations in the conduct and reporting of the studies, indirectness of the evidence and the imprecision of the results. Authors' conclusions There is clearly a need for randomised controlled clinical trials to investigate the effectiveness of surgical, medical and psychological interventions for iatrogenic inferior alveolar and lingual nerve injuries. Primary outcomes of this research should include: patient‐focused morbidity measures including altered sensation and pain, pain, quantitative sensory testing and the effects of delayed treatment. Plain language summary Treatments for accidental damage during surgery to the nerves supplying sensation to the tongue, lower lip and chin Review question The main question addressed by this review is how effective are different treatments and what are the best timings for these treatments following accidental damage during surgery to the nerves that supply sensation to the tongue, lower lip and chin. Background The nerves (alveolar and lingual) supplying sensation to the tongue, lower lip and chin, may be injured as a result of surgical treatments to the mouth and face, including surgery to remove lower wisdom teeth. The vast majority (90%) of these injuries are temporary and get better within eight weeks. However if they last for longer than six months they are considered to be permanent. Damage to these nerves can lead to altered sensation in the region of the lower lip and chin, or tongue or both. Furthermore, damage to the nerve supplying the tongue may lead to altered taste perception. These injuries can affect people's quality of life leading to emotional problems, problems with socialising and disabilities. Accidental injury after surgery can also give rise to legal action. There are many interventions or treatments available, surgical and non‐surgical, that may enhance recovery, including improving sensation. They can be grouped as. 1. Surgical – a variety of procedures.
 2. Laser treatment – low‐level laser treatment has been used to treat partial loss of sensation.
 3. Medical – treatment with drugs including antiepileptics, antidepressants and painkillers.
 4. Counselling – including cognitive behavioural and relaxation therapy, changing behaviour and hypnosis. Study characteristics The Cochrane Oral Health Group carried out this review, and the evidence is current as of 9 October 2013. There are two studies included, both published in 1996, which compared low‐level laser treatment to placebo or fake treatment for partial loss of sensation following surgery to the lower jaw. There were 15 participants in one study and 16 in the other, their ages ranging from 17 to 55 years. All had suffered accidental damage to nerves of the lower jaw and tongue causing some loss of sensation following surgery. Key results Low‐level laser therapy was the only treatment to be evaluated in the included studies and this was compared to fake or placebo laser therapy. No studies were found that evaluated other surgical, medical or counselling treatments. There was some evidence of an improvement when participants reported whether or not sensation was better in the lip and chin areas with low‐level laser therapy. This is based on the results of a single, small study, so the results should be interpreted with caution. No studies reported on the effects of the treatment on other outcomes such as pain, difficulty eating or speaking or taste. No studies reported on quality of life or harm. Quality of the evidence The overall quality of the evidence is very low as a result of limitations in the conduct and reporting of the two included studies and the low number of participants, and evidence from participants with only partial sensory loss.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Coulthard, P; Kushnerev, E; Yates, JM; Walsh, T; Patel, N; Bailey, E; Renton, TF", "articleTypes": [], "doi": "10.1002/14651858.CD005293.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "535c7a77-c2fd-46ac-8898-09cd5336370b", "pmid": "", "title": "Interventions for leg cramps in pregnancy", "imported": false, "abstract": "Abstract - Background Many women experience leg cramps in pregnancy. They become more common as pregnancy progresses and are especially troublesome at night. Objectives The objective of this review was to assess methods of preventing and treating leg cramps in pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2001). We updated this search on 4 July 2011 and added the results to the awaiting classification section. Selection criteria Randomised trials of treatments for leg cramps in pregnancy. Data collection and analysis Trial quality was assessed and data were extracted independently by two reviewers. Main results Five trials involving 352 women were included. The trials were of moderate quality. The only placebo‐controlled trial of calcium treatment showed no evidence of benefit. Trials comparing sodium chloride with placebo (odds ratio 0.54, 95% confidence interval 0.23 to 1.29) and calcium with sodium chloride (odds ratio 1.23, 95% confidence intervals 0.47 to 3.27 ) showed no evidence of benefit. Placebo controlled trials of multivitamin with mineral supplements (odds ratio 0.23, 95% confidence intervals 0.05 to 1.01) and magnesium (odds ratio 0.18, 95% confidence intervals 0.05 to 0.60) provided some suggestion of benefit. Authors' conclusions The evidence that calcium reduces cramp is weak and seems to depend on placebo effect. The evidence for sodium chloride is stronger but the results of the sodium chloride trial may no longer be relevant because of dietary changes which include an increased sodium intake in the general population. It is not possible to recommend multivitamins with mineral supplementation, as it is not clear which ingredient, if any, is helping. If a woman finds cramp troublesome in pregnancy, the best evidence is for magnesium lactate or citrate taken as 5mmol in the morning and 10mmol in the evening. [Note: The five citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Interventions for leg cramps in pregnancy Sodium supplements may decrease the number of cramp attacks experienced by women in pregnancy but the effect is slight. Calcium is of no benefit. The evidence of benefit for magnesium is stronger. Multivitamin and mineral supplements also seem to help but the relevance of this is unclear as the preparation used contained twelve separate constituents and it is not possible to discover which of these was effective, or indeed if there was synergy between constituents. There is a theoretical risk that sodium supplementation could raise blood pressure. It is unlikely that magnesium supplementation would be harmful at the suggested doses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Young, G, Jewell, D", "articleTypes": [], "doi": "10.1002/14651858.CD000121", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.747Z" }, { "id": "53739598-cd45-4bf9-a594-3a21ea89b3a3", "pmid": "", "title": "Multiple micronutrient powders for home (point‐of‐use) fortification of foods in pregnant women", "imported": false, "abstract": "Abstract - Background It is estimated that 32 million pregnant women suffer from anaemia worldwide. Due to increased metabolic demands, pregnant women are particularly vulnerable to anaemia and vitamin and mineral deficiencies, leading to adverse health effects in both the mother and her baby. Despite the demonstrated benefits of prenatal supplementation with iron and folic acid or multiple micronutrients, poor adherence to routine supplementation has limited the effectiveness of this intervention in many settings. Micronutrient powders for point‐of‐use fortification are packed, single‐dose sachets containing vitamins and minerals that can be added onto prepared food to improve its nutrient profile. The use of multiple micronutrient powders for point‐of‐use fortification of foods in pregnant women could be an alternative intervention to prenatal micronutrient supplementation. Objectives To assess the effects of prenatal home (point‐of‐use) fortification of foods with multiple micronutrient powders on maternal and newborn health. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and the International Clinical Trials Registry Platform ( ICTRP ) (31 January 2015). We also contacted relevant agencies to identify ongoing and unpublished studies. Selection criteria Randomised controlled trials (both individual and cluster randomisation) and quasi‐randomised trials, irrespective of language or publication status. The intervention was micronutrient powders for point‐of‐use fortification of foods, containing at least three micronutrients with one of them being iron, provided to pregnant women of any gestational age and parity. Five comparison groups were considered: no intervention/placebo, iron and folic acid supplements, iron‐only supplements, folic‐acid only supplements, and multiple micronutrients in supplements. Data collection and analysis Two review authors independently assessed the eligibility of studies, extracted and checked data accuracy, and assessed the risk of bias of included studies. Main results Our search identified 12 reports (relating to six studies). We included two cluster‐randomised controlled trials (involving 1172 women) ‐ these trials were considered to be at a moderate to high risk of bias due to methodological limitations. One trial is ongoing, and three studies were excluded. Micronutrient powders for point‐of‐use fortification of foods versus iron and folic acid supplements One trial (involving 478 pregnant women attending 42 antenatal care centres) compared micronutrient powders containing iron, folic acid, vitamin C and zinc with iron and folic acid tablets provided daily from 14 to 22 weeks to 32 weeks' gestation. The trial did not report on any of this review's primary outcomes: maternal anaemia at or near term, maternal iron deficiency, maternal mortality, adverse effects, low birthweight, preterm births. Nor did the trial report on the majority of this review's secondary outcomes, with the exception of maternal adherence. Adherence to micronutrient powders was lower than adherence to iron and folic acid supplements (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.66 to 0.87, one study, n = 405). Micronutrient powders for point‐of‐use fortification of foods versus same multiple micronutrients in supplements One study (involving 694 pregnant women from 18 communities), compared micronutrient powders containing iron, folic acid, vitamin C, zinc, iodine, vitamin E and vitamin B 12 with tablets containing the same seven micronutrients. There was no difference in maternal anaemia at 37 weeks of gestation (RR 0.92, 95% CI 0.53 to 1.59, one study, n = 470, very low quality evidence ). The trial did not report on any of this review's other primary outcomes in relation to maternal iron deficiency, maternal mortality, adverse effects, low birthweight, or preterm birth. In terms of this review's secondary outcomes, the included trial did not report on the majority of this review's prespecified secondary outcomes with one exception ‐ there was no clear difference in maternal haemoglobin Hb or near term (mean difference (MD) 1.0 g/L, 95% CI ‐1.77 to 3.77, one study, n = 470). Authors' conclusions Limited evidence suggests that micronutrient powders for point‐of‐use fortification of foods have no clear difference as multiple micronutrient supplements on maternal anaemia ( very low quality evidence ) and Hb at or near term. There is limited evidence to suggest that women were more likely to adhere to taking tablets than using micronutrient powders. The overall quality of evidence was judged very low (due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes. Therefore, more evidence is needed to assess the potential benefits or harms of the use of micronutrient powders in pregnant women on maternal and infant health outcomes. Future trials should also assess adherence to micronutrient powders and be adequately powered to evaluate the effects on birth outcomes and morbidity. Plain language summary Powders of iron plus other micronutrients for home (point‐of‐use) fortification of foods consumed by pregnant women Pregnant women are particularly vulnerable to nutrient deficiencies due to the requirements of the growing baby during the pregnancy. In low‐income countries, many women have diets with low content of vitamins and minerals, and they participate in long hours of physical labour. They are also exposed to recurrent infections, which make nutritional deficiencies worse. Thus, lack of adequate nutrition can contribute to the poor health of these women their babies. Iron and folic acid supplements in pregnancy are widely recommended. However, getting the supplements to the women and encouraging them to take them is particularly challenging. Micronutrient powders containing iron, vitamin A, zinc and other vitamins and minerals are usually packaged in single‐use sachets and can be sprinkled onto any semi‐solid food at home or in any other place where meals are to be consumed. The use of micronutrient powders to fortify foods may overcome this problem with micronutrient supplements. Micronutrient powders have already been shown to be effective in reducing anaemia and iron deficiency in young children and so may be useful for pregnant women. This review looked at the use of micronutrient powders in pregnancy, compared with micronutrient supplements or with no additional micronutrients. We found only two studies involving a total of 1172 women, undertaken in Bangladesh and Mexico. The overall quality of evidence was judged very low (with a high risk of bias due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes of this review. One trial compared micronutrient powders with iron and folate supplements, and the other trial compared micronutrient powders with the same nutrients but given as supplements. Overall, micronutrient powders fortification of foods had a similar effect as multiple micronutrient supplements on anaemia in mothers at or near term ( very low quality evidence ) or the mother's haemoglobin (Hb) at or near term. The study that compared micronutrient powders with iron and folic acid supplements reported that women were more likely to take iron and folic acid tablets than micronutrient powders. Nearly all of the review's important outcomes were not reported in the included studies. Therefore, more evidence is needed for both mother and infant health outcomes in order to adequately evaluate the use of micronutrient powders in pregnant women.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Suchdev, PS, Peña‐Rosas, JP, De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD011158.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.105Z" }, { "id": "53807ff6-7686-4301-8e68-b110e5c09e6d", "pmid": "", "title": "Zinc for prevention and treatment of the common cold", "imported": false, "abstract": "Abstract - Background The common cold is an acute, self‐limiting viral respiratory illness. Symptoms include nasal congestion and mucus discharge, sneezing, sore throat, cough, and general malaise. Given the frequency of colds, they are a public health burden and a significant cause of lost work productivity and school absenteeism. There are no established interventions to prevent colds or shorten their duration. However, zinc supplements are commonly recommended and taken for this purpose. Objectives To assess the effectiveness and safety of zinc for the prevention and treatment of the common cold. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and LILACS to 22 May 2023, and searched Web of Science Core Collection and two trials registries to 14 June 2023. We also used reference checking, citation searching, and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) in children or adults that tested any form of zinc against placebo to prevent or treat the common cold or upper respiratory infection (URTI). We excluded zinc interventions in which zinc was combined with other minerals, vitamins, or herbs (e.g. a multivitamin, or mineral supplement containing zinc). Data collection and analysis We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We independently extracted data. When necessary, we contacted study authors for additional information. We assessed zinc (type and route) with placebo in the prevention and treatment of the common cold. Primary outcomes included the proportion of participants developing colds (for analyses of prevention trials only), duration of cold (measured in days from start to resolution of the cold), adverse events potentially due to zinc supplements (e.g. unpleasant taste, loss of smell, vomiting, stomach cramps, and diarrhoea), and adverse events considered to be potential complications of the common cold (e.g. respiratory bacterial infections). Main results We included 34 studies (15 prevention, 19 treatment) involving 8526 participants. Twenty‐two studies were conducted on adults and 12 studies were conducted on children. Most trials were conducted in the USA (n = 18), followed by India, Indonesia, Iran, and Turkey (two studies each), and Australia, Burkina Faso, Colombia, Denmark, Finland, Tanzania, Thailand, and the UK (one study each). The 15 prevention studies identified the condition as either common cold (n = 8) or URTI (n = 7). However, almost all therapeutic studies (17/19) focused on the common cold. Most studies (17/34) evaluated the effectiveness of zinc administered as lozenges (3 prevention; 14 treatment) in acetate, gluconate, and orotate forms; gluconate lozenges were the most common (9/17). Zinc gluconate was given at doses between 45 and 276 mg/day for between 4.5 and 21 days. Five (5/17) lozenge studies gave acetate lozenges and two (2/17) gave both acetate and gluconate lozenges. One (1/17) lozenge study administered intranasal ( gluconate ) and lozenge ( orotate ) zinc in tandem for cold treatment. Of the 17/34 studies that did not use lozenges, 1/17 gave capsules, 3/17 administered dissolved powders, 5/17 gave tablets, 4/17 used syrups, and 4/17 used intranasal administration. Most studies were at unclear or high risk of bias in at least one domain. There may be little or no reduction in the risk of developing a cold with zinc compared to placebo (risk ratio (RR) 0.93, 95% CI 0.85 to 1.01; I 2 = 20%; 9 studies, 1449 participants; low‐certainty evidence). There may be little or no reduction in the mean number of colds that occur over five to 18 months of follow‐up (mean difference (MD) ‐0.90, 95% CI ‐1.93 to 0.12; I 2 = 96%; 2 studies, 1284 participants; low‐certainty evidence). When colds occur, there is probably little or no difference in the duration of colds in days (MD ‐0.63, 95% CI ‐1.29 to 0.04; I² = 77%; 3 studies, 740 participants; moderate‐certainty evidence), and there may be little or no difference in global symptom severity (standardised mean difference (SMD) 0.04, 95% CI ‐0.35 to 0.43; I² = 0%; 2 studies, 101 participants; low‐certainty evidence). When zinc is used for cold treatment, there may be a reduction in the mean duration of the cold in days (MD ‐2.37, 95% CI ‐4.21 to ‐0.53; I² = 97%; 8 studies, 972 participants; low‐certainty evidence), although it is uncertain whether there is a reduction in the risk of having an ongoing cold at the end of follow‐up (RR 0.52, 95% CI 0.21 to 1.27; I² = 65%; 5 studies, 357 participants; very low‐certainty evidence), or global symptom severity (SMD ‐0.03, 95% CI ‐0.56 to 0.50; I² = 78%; 2 studies, 261 participants; very low‐certainty evidence), and there may be little or no difference in the risk of a change in global symptom severity (RR 1.02, 95% CI 0.85 to 1.23; 1 study, 114 participants; low‐certainty evidence). Thirty‐one studies reported non‐serious adverse events (2422 participants). It is uncertain whether there is a difference in the risk of adverse events with zinc used for cold prevention (RR 1.11, 95% CI 0.84 to 1.47; I 2 = 0%; 7 studies, 1517 participants; very low‐certainty evidence) or an increase in the risk of serious adverse events (RR 1.67, 95% CI 0.78 to 3.57; I 2 = 0%; 3 studies, 1563 participants; low‐certainty evidence). There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment (RR 1.34, 95% CI 1.15 to 1.55; I 2 = 44%; 2084 participants, 16 studies; moderate‐certainty evidence); no treatment study provided information on serious adverse events. No study provided clear information about adverse events considered to be potential complications of the common cold. Authors' conclusions The findings suggest that zinc supplementation may have little or no effect on the prevention of colds but may reduce the duration of ongoing colds, with an increase in non‐serious adverse events. Overall, there was wide variation in interventions (including concomitant therapy) and outcomes across the studies, as well as incomplete reporting of several domains, which should be considered when making conclusions about the efficacy of zinc for the common cold. Plain language summary Zinc for the prevention and treatment of the common cold Key messages 
‐ There may be little or no reduction in the risk of developing a cold with zinc supplements compared to placebo. ‐ For people who already have a cold, there may be a reduction in how long the cold lasts with zinc supplements compared to placebo. ‐ There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment. What is the common cold? 
The common cold is primarily a viral infection of the upper respiratory tract. There is no specific combination of symptoms that defines a cold, but symptoms can include nasal congestion, sneezing, sore throat, cough, fatigue, and runny nose, with or without fever. Most people usually recover from this illness without medical treatment; however, there are no definitive treatments to prevent colds or shorten their duration. Given the frequency of colds in adults and children, they are a public health burden and a significant cause of lost work productivity and school absenteeism. Prevention and treatment for the common cold with zinc is an ongoing interest. What did we want to find out? 
We wanted to find out if zinc was better than placebo at reducing the risk of developing a cold and shortening the duration of existing colds. A placebo is a substance similar in appearance to a treatment, but that has no known therapeutic effect. Placebos help assess the effects of the belief that a treatment has been received versus treatment actually being received. We also wanted to find out if zinc was associated with any adverse effects (e.g. harms), especially harms considered to be potential complications of the common cold. Additionally, we looked at self‐reported overall cold severity, individual symptom severity, individual symptom duration, and days missed from work or school. What did we do? 
We searched six databases and two clinical trials registers for studies comparing zinc with placebo for the treatment or prevention of the common cold in adults and children. We compared and summarised the results of the studies, and we found and rated our confidence in the evidence based on specific factors such as risk of bias and study methods. What did we find? 
We found 34 studies of cold prevention or treatment. The studies were conducted in 13 countries, a majority taking place in the USA. Twelve studies were conducted on children (aged under 18 years) and 22 studies were conducted on adults. Most treatments ended with self‐reported resolution of symptoms, and the minimum treatment period was five days with a maximum period of 540 days. Most of the studies were funded by an organisation with ties to related commerce/industry or did not report their funding. The remainder were funded by private clinics, non‐government foundations, universities, or governmental entities. We assessed the effects of: ‐ zinc as a preventative measure; and ‐ zinc as a treatment measure. We obtained the following results: Zinc for prevention Compared with placebo, taking zinc may make little to no difference in preventing people from catching a cold (9 studies, 1449 people). Preventative zinc also probably makes little to no difference to the length of the cold if one has been caught (3 studies, 740 participants) and may make little to no difference to the severity of the symptoms experienced (2 studies, 101 people). Negative side effects were reported by people taking either zinc or placebo; irregularities in taste and stomach upset were the most common. Zinc for treatment Zinc taken for treatment of a cold may reduce the length of time that symptoms are present, by approximately two days, when compared with placebo (8 studies, 972 people). However, we have little confidence in the evidence supporting this conclusion. It is unclear whether zinc makes a difference to the severity of the cold symptoms experienced (2 studies, 261 people). Negative side effects were reported more frequently for those taking zinc as a cold treatment when compared to those taking placebo; irregularities in taste and stomach upset were the most common. Studies administering intranasal zinc did not report any cases of anosmia (loss of sense of smell) but information about specific side effects is uncertain. What are the limitations of the evidence? 
Our confidence in the evidence is mostly low to very low, and the results of further research could differ from the results of this review. Several factors reduced our confidence in the evidence. Firstly, some studies did not report adequately on how people in the studies were randomly placed into treatment groups, meaning that differences between the study groups could be due to differences between the participants and not the treatments. Secondly, some studies used widely different ways of delivering treatments. Finally, due to the large differences between studies in the approaches used to test the effectiveness of zinc, it is likely that additional studies are required before any firm conclusions can be drawn. How up‐to‐date is this evidence? 
The evidence is current to 22 May 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Nault, D; Machingo, TA; Shipper, AG; Antiporta, DA; Hamel, C; Nourouzpour, S; Konstantinidis, M; Phillips, E; Lipski, EA; Wieland, LS", "articleTypes": [], "doi": "10.1002/14651858.CD014914.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "5383b5bf-24a6-4a76-a710-ee9f150680bc", "pmid": "", "title": "Chinese medicinal herbs for asymptomatic carriers of hepatitis B virus infection", "imported": false, "abstract": "Abstract - Background About 350 million people are chronically infected carriers of hepatitis B virus and are at a higher risk of serious illness and death from cirrhosis of the liver and liver cancer. Chinese medicinal herbs have been used widely for more than 2000 years to treat chronic liver disease. Objectives To assess whether Chinese medicinal herbs are effective and safe for treating asymptomatic carriers of hepatitis B virus. Search methods The trials registers of The Cochrane Hepato‐Biliary Group , The Cochrane Library , and The Cochrane Complementary Medicine Field were searched in combination with MEDLINE , EMBASE , and handsearches of Chinese journals and conference proceedings (October 2000). Selection criteria Randomised or quasi‐randomised trials (minimum follow‐up three months) in asymptomatic carriers of hepatitis B virus. Chinese medicinal herbs (single herb or compound of herbs) compared with placebo, no intervention, general non‐specific treatment, or interferon treatment. Trials of Chinese medicinal herbs plus interferon versus interferon alone were also included. Data collection and analysis Data were extracted independently by two authors. Analysis was performed by intention‐to‐treat where possible. Pre‐specified subgroup analyses were: ethnic origin, age at time of infection, and single herb or compound of herbs. Main results Three randomised clinical trials (307 patients) that followed patients for three months or more after the end of treatment were included. The methodological quality was poor. The herbal compound 'Jianpi Wenshen recipe' had significant effects on viral markers compared to interferon: relative risk 2.40 (95% CI 1.01 to 5.72) for clearance of serum HBsAg, 2.03 (95% CI 0.98 to 4.20) for clearance of HBeAg, and 2.54 (95% CI 1.13 to 5.70) for seroconversion of HBeAg to anti‐HBe. Phyllanthus amarus and Astragalus membranaceus showed no significant antiviral effect compared with placebo. Analysis of pooling eight randomised clinical trials with less than three months follow‐up did not show a significant benefit of Chinese medicinal herbs on viral markers. Data on long‐term clinical outcomes and quality of life were lacking. Authors' conclusions Based on one low quality trial, the medicinal herb 'Jianpi Wenshen recipe' may have an antiviral activity in asymptomatic carriers of hepatitis B virus. However, rigorous randomised, double‐blind, placebo‐controlled trials are needed before herbs should be used for this condition. Plain language summary Firm evidence for effect of Chinese medicinal herbs for asymptomatic hepatitis B virus carriers is still awaited Chinese medicinal herbs have a long history in the treatment of liver diseases. Three randomised clinical trials were included. Due to their poor methodologic quality and the existing small number of trials, there is currently insufficient evidence for treating asymptomatic hepatitis B virus carriers with Chinese medicinal herbs like the herbal compound 'Jianpi Wenshen recipe', Phyllanthus amarus and Astragalus membranaceus. Methodologically better and larger randomised trials are needed comparing medicinal herbs versus placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Liu, JP; McIntosh, H; Lin, H", "articleTypes": [], "doi": "10.1002/14651858.CD002231", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "53863865-65f9-472c-9818-c01113a93003", "pmid": "", "title": "Nutritional interventions for survivors of childhood cancer", "imported": false, "abstract": "Abstract - Background Childhood cancer survivors are at a higher risk of developing health conditions such as osteoporosis, and cardiovascular disease than their peers. Health‐promoting behaviour, such as consuming a healthy diet, could lessen the impact of these chronic issues, yet the prevalence rate of health‐protecting behaviour amongst survivors of childhood cancer is similar to that of the general population. Targeted nutritional interventions may prevent or reduce the incidence of these chronic diseases. Objectives The primary aim of this review was to assess the efficacy of a range of nutritional interventions designed to improve the nutritional intake of childhood cancer survivors, as compared to a control group of childhood cancer survivors who did not receive the intervention. Secondary objectives were to assess metabolic and cardiovascular risk factors, measures of weight and body fat distribution, behavioural change, changes in knowledge regarding disease risk and nutritional intake, participants' views of the intervention, measures of health status and quality of life, measures of harm associated with the process or outcomes of the intervention, and cost‐effectiveness of the intervention Search methods We searched the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 3), MEDLINE/PubMed (from 1945 to April 2013), and Embase/Ovid (from 1980 to April 2013). We ran the search again in August 2015; we have not yet fully assessed these results, but we have identified one ongoing trial. We conducted additional searching of ongoing trial registers ‐ the International Standard Randomised Controlled Trial Number register and the National Institutes of Health register (both screened in the first half of 2013) ‐ reference lists of relevant articles and reviews, and conference proceedings of the International Society for Paediatric Oncology and the International Conference on Long‐Term Complications of Treatment of Children and Adolescents for Cancer (both 2008 to 2012). Selection criteria We included all randomised controlled trials (RCTs) that compared the effects of a nutritional intervention with a control group which did not receive the intervention in this review. Participants were childhood cancer survivors of any age, diagnosed with any type of cancer when less than 18 years of age. Participating childhood cancer survivors had completed their treatment with curative intent prior to the intervention. Data collection and analysis Two review authors independently selected and extracted data from each identified study, using a standardised form. We assessed the validity of each identified study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Intervention s. We used the GRADE criteria to assess the quality of each trial. Main results Three RCTs were eligible for review. A total of 616 participants were included in the analysis. One study included participants who had been treated for acute lymphoblastic leukaemia (ALL) (275 participants). Two studies included participants who had all forms of paediatric malignancies (266 and 75 participants). All participants were less than 21 years of age at study entry. The follow‐up ranged from one month to 36 months from the initial assessment. All intended outcomes were not evaluated by each included study. All studies looked at different interventions, and so we were unable to pool results. We could not rule out the presence of bias in any of the studies. There was no clear evidence of a difference in calcium intake at one month between those who received the single, half‐day, group‐based education that focused on bone health, and those who received standard care (mean difference (MD) 111.60, 95% confidence interval (CI) ‐258.97 to 482.17; P = 0.56, low quality evidence). A regression analysis, adjusting for baseline calcium intake and changes in knowledge and self‐efficacy, showed a significantly greater calcium intake for the intervention as compared with the control group at the one‐month follow‐up (beta coefficient 4.92, 95% CI 0.33 to 9.52; P = 0.04). There was statistically significant higher, self‐reported milk consumption (MD 0.43, 95% CI 0.07 to 0.79; P = 0.02, low quality evidence), number of days on calcium supplementation (MD 11.42, 95% CI 7.11 to 15.73; P < 0.00001, low quality evidence), and use of any calcium supplementation (risk ratio (RR) 3.35, 95% CI 1.86 to 6.04; P < 0.0001, low quality evidence), with those who received this single, face‐to‐face, group‐based, health behaviour session. There was no clear evidence of a difference in bone density Z‐scores measured with a dual‐energy X‐ray absorptiometry (DEXA) scan at 36 months follow‐up (MD ‐0.05, 95% CI ‐0.26 to 0.16; P = 0.64, moderate quality evidence) between those who received calcium and vitamin D supplementation combined with nutrition education and those who received nutrition education alone. There was also no clear evidence of a difference in bone mineral density between the intervention and the control group at the 12‐month (median difference ‐0.17, P = 0.99) and 24‐month follow‐up (median difference ‐0.04, P = 0.54). A single multi‐component health behaviour change intervention, focusing on general healthy eating principles, with two telephone follow‐ups brought about a 0.17 lower score on the four‐point Likert scale of self‐reported junk food intake compared with the control group (MD ‐0.17, 95% CI ‐0.33 to ‐0.01; P = 0.04, low quality evidence); this result was statistically significant. There was no clear evidence of a difference between the groups in the self‐reported use of nutrition as a health protective behaviour (MD ‐0.05, 95% CI ‐0.24 to 0.14; P = 0.60, low quality evidence). Authors' conclusions Due to a paucity of studies, and the heterogeneity of the studies included in this review, we are unable to draw conclusions regarding the effectiveness of nutritional interventions for use with childhood cancer survivors. Although there is low quality evidence for the improvement in health behaviours using health behaviour change interventions, there remains no evidence as to whether this translates into an improvement in dietary intake. There was also no evidence that the studies reduced the risk of cardiovascular and metabolic disorders in childhood cancer survivors, although no evidence of effect is not the same as evidence of no effect. This review highlights the need for further well designed trials to be implemented in this population. Plain language summary Nutritional interventions for survivors of childhood cancer Background Survivors of childhood cancer are at a higher risk of chronic health conditions such as, osteoporosis, metabolic syndrome (including obesity and type II diabetes), and cardiovascular disease. These diseases have the potential to be reduced or prevented with targeted nutritional interventions. Objective This review looks at three randomised controlled trials that studied the effects of interventions designed to improve the dietary intake of children who have completed treatment for cancer. Study Characteristics The three studies included 616 participants who had completed their therapy for childhood cancer. All of the participants were less than 21 years of age at study entry. The interventions ranged from the promotion of health behaviours to vitamin and mineral supplementation. The follow‐up ranged from one month to 36 months from the initial assessment. Key results There was low quality evidence that those who received a health behaviour intervention decreased their self‐reported intake of “junk food”. They also increased their intake of dairy foods, as well as increasing their calcium supplementation. The interventions did not appear to translate to an improvement in their dietary intake, body composition, or bone mineral density. Quality of the evidence The results from this review do not provide enough evidence regarding the effectiveness of nutritional interventions for childhood cancer survivors. There was low quality evidence overall. Further well designed research is needed in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cohen, JE, Wakefield, CE, Cohn, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD009678.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.791Z" }, { "id": "538e3d43-3f97-4614-b629-70a8d830a813", "pmid": "", "title": "Antithyroid drug regimen for treating Graves' hyperthyroidism", "imported": false, "abstract": "Abstract - Background Antithyroid drugs are widely used in the therapy of hyperthyroidism. There are wide variations in the dose, regimen or duration of treatment used by health professionals. Objectives To assess the effects of dose, regimen and duration of antithyroid drug therapy for Graves' hyperthyroidism. Search methods We searched seven databases and reference lists. Selection criteria Randomised and quasi‐randomised trials of antithyroid medication for Graves' hyperthyroidism. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Pooling of data for primary outcomes, and select exploratory analyses were undertaken. Main results Twenty‐six randomised trials involving 3388 participants were included. Overall the quality of trials, as reported, was poor. None of the studies investigated incidence of hypothyroidism, changes in weight, health‐related quality of life, ophthalmopathy progression or economic outcomes. Four trials examined the effect of duration of therapy on relapse rates, and when using the titration regimen 12 months was superior to six months, but there was no benefit in extending treatment beyond 18 months. Twelve trials examined the effect of block‐replace versus titration block‐regimens. The relapse rates were similar in both groups at 51% in the block‐replace group and 54% in the titration block‐group (OR 0.86, 95% confidence interval (CI) 0.68 to1.08) though adverse effects (rashes (10% versus 6%) and withdrawing due to side effects (16% versus 9%)) were significantly higher in the block‐replace group. Three studies considered the addition of thyroxine with continued low dose antithyroid therapy after initial therapy with antithyroid drugs. There was significant heterogeneity between the studies and the difference between the two groups was not significant (OR 0.58, 95% CI 0.05 to 6.21). Four studies considered the addition of thyroxine alone after initial therapy with antithyroid drugs. There was no significant difference in the relapse rates between the groups after 12 months follow‐up (OR 1.15, 95% CI 0.79 to 1.67). Two studies considered the addition of immunosuppressive agents. The results which were in favour of the interventions would need to be validated in other populations. Authors' conclusions The evidence suggests that the optimal duration of antithyroid drug therapy for the titration regimen is 12 to 18 months. The titration (low dose) regimen had fewer adverse effects than the block‐replace (high dose) regimen and was no less effective. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Immunosuppressive therapies need further evaluation. Plain language summary Antithyroid drug regimen for treating Graves' hyperthyroidism People who have Graves' hyperthyroidism have thyroid glands which are releasing too much thyroid hormone. This can cause goitres (swelling in the neck around the thyroid gland), sweating, bowel or menstrual problems, and other, especially eye symptoms (ophthalmopathy). Treatments include anti‐thyroid drugs, surgery or radiation to reduce thyroid tissue. There are several choices to be made when considering the drug treatment of Graves' hyperthyroidism including the choice of drug, dose, duration of therapy, addition of thyroid hormone (thyroxine) and when to discontinue therapy. The antithyroid drugs which were used in the included randomised controlled trials (RCTs) comprised carbimazole, propylthiouracil and methimazole. Twenty‐six RCTs involving 3388 participants were identified. The majority of participants in all the studies were female (83% in the studies reporting sex distribution). The mean age was 40 years. The duration of follow up was between two to five years in eleven trials. In high dose ('block‐replace') versus low dose ('titration') studies the duration of therapy was six months in two studies, 18 months in four studies and 12 months in the remaining trials. The main outcome was the relapse rate of hyperthyroidism over one year after completion of drug treatment and this was the primary outcome in all the studies assessed. There were no deaths reported in any of the studies. None of the studies detailed incidence of hypothyroidism, changes in weight during the course of therapy, health‐related quality of life, ophthalmopathy progression or economic outcomes. The evidence (based on four studies) suggests that the optimal duration of antithyroid drug therapy for the low dose regimen is 12 to 18 months. The low dose regimen had fewer adverse effects than the high dose regimen and was no less effective in trials (based on 12 trials) of equal duration. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Studies using immunosuppressive agents need further validation of safety and efficacy in controlled trials among different populations. Data regarding side effects and number of participants withdrawn from therapy due to side effects were available in seven studies. The number of participants reporting rashes was significantly higher in the high versus low dose group (10% versus 6%). The number of participants withdrawing due to side effects were also significantly higher in the high versus low dose group (16% versus 9%).", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Abraham, P, Avenell, A, McGeoch, SC, Clark, LF, Bevan, JS", "articleTypes": [], "doi": "10.1002/14651858.CD003420.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.117Z" }, { "id": "53a7c2c9-213d-4004-b2c0-1caa624536e1", "pmid": "", "title": "Sucrose analgesia for heel‐lance procedures in neonates", "imported": false, "abstract": "Abstract - Background Sucrose has been examined for calming and pain‐relieving effects in neonates for invasive procedures such as heel lance. Objectives To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long‐term outcomes Search methods We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries. Selection criteria We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non‐nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin‐to‐skin care. Data collection and analysis We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. We assessed heterogeneity by the I 2 test. We used GRADE to assess certainty of evidence. Main results We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing. Sucrose vs control The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD ‐1.74 (95% CI ‐2.11 to ‐1.37); I 2 = 62%; moderate‐certainty evidence) and 60 seconds after lancing (MD ‐2.14, 95% CI ‐3.34 to ‐0.94; I 2 = 0%; moderate‐certainty evidence). The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD ‐1.90, 95% CI ‐8.58 to 4.78; heterogeneity not applicable (N/A); very low‐certainty evidence). The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD ‐2.00, 95% CI ‐2.42 to ‐1.58; heterogeneity N/A; moderate‐certainty evidence). Sucrose vs NNS The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI ‐0.30 to 1.50; heterogeneity not applicable; very low‐certainty evidence) and on DAN scores at 30 seconds after lancing (MD ‐1.20, 95% CI ‐7.87 to 5.47; heterogeneity N/A; very low‐certainty evidence). Sucrose + NNS vs NNS The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD ‐4.90, 95% CI ‐5.73 to ‐4.07; heterogeneity not applicable; very low‐certainty evidence) and during recovery after lancing (MD ‐3.80, 95% CI ‐4.47 to ‐3.13; heterogeneity N/A; very low‐certainty evidence). The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD ‐0.60, 95% CI ‐1.47 to 0.27; heterogeneity N/A; very low‐certainty evidence). Sucrose vs glucose The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI ‐0.70 to 1.22; heterogeneity not applicable; low‐certainty evidence) and 60 seconds after lancing (MD ‐0.02, 95% CI ‐0.79 to 0.75; heterogeneity N/A; low‐certainty evidence). Sucrose vs breastfeeding The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD ‐0.70, 95% CI ‐0.49 to 1.88; I 2 = 94%; very low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD ‐2.60, 95% CI ‐3.06 to ‐2.14; heterogeneity N/A; very low‐certainty evidence). Sucrose vs expressed breast milk The evidence suggests that sucrose may result in little to no difference in PIPP‐R scores compared to expressed breast milk during (MD 0.3, 95% CI ‐0.24 to 0.84; heterogeneity not applicable; low‐certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI ‐0.11 to 0.71; heterogeneity N/A; low‐certainty evidence). The evidence suggests that sucrose probably may result in slightly increased PIPP‐R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD ‐1.80, 95% CI ‐8.47 to 4.87; heterogeneity N/A; very low‐certainty evidence). Sucrose vs laser acupuncture There was no difference in PIPP‐R scores between sucrose and music groups; however, data were reported as medians and IQRs. The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD ‐0.86, 95% CI ‐1.43 to ‐0.29; heterogeneity N/A; very low‐certainty evidence). Sucrose vs facilitated tucking The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD ‐2.27, 95% CI ‐4.66 to 0.12; heterogeneity N/A; very low‐certainty evidence) and during recovery after lancing (MD ‐0.31, 95% CI ‐1.72 to 1.10; heterogeneity N/A; very low‐certainty evidence). Sucrose vs skin‐to‐skin + water (repeated lancing) The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 30 seconds after 1st (MD 0.13, 95% CI ‐0.70 to 0.96); 2nd (MD ‐0.56, 95% CI ‐1.57 to 0.45); or 3rd lancing (MD‐0.15, 95% CI ‐1.26 to 0.96); heterogeneity N/A, low‐certainty evidence for all comparisons. The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 60 seconds after 1st (MD –0.61, 95% CI ‐1.55 to 0.33); 2nd (MD ‐0.12, 95% CI ‐0.99 to 0.75); or 3rd lancing (MD‐0.40, 95% CI ‐1.48 to 0.68); heterogeneity N/A, low‐certainty evidence for all comparisons. Minor adverse events required no intervention. Authors' conclusions Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate‐certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin‐to‐skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing heel lance Key messages ‐ Sucrose, compared to control interventions, probably reduces pain for a single painful event (heel lance). ‐ There were a few minor immediate adverse events, such as gagging, that resolved without intervention. ‐ We need studies that assess the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. ‐ We need to assess how sucrose affects neonates who are extremely preterm, unstable, or ventilated (or a combination of these factors). What is sucrose analgesia? Sucrose (table sugar) is mixed with water in various concentrations (usually 24%) and is given to babies in very small amounts (e.g. a few drops) about two minutes before a painful procedure. Sucrose is also given with other nondrug pain‐relieving interventions such as a pacifier (non‐nutritive sucking ‐ NNS) or when the baby is receiving skin‐to‐skin care. Why is this important for newborn babies who are undergoing heel lance procedures? Babies who are sick or immature, and require a stay in hospital, have several painful procedures per day and multiple painful procedures throughout the hospital stay; for most babies, the majority of painful procedures are heel lances. If untreated, pain has immediate and long‐term consequences that can impact their brain and behavioural development. It is important to minimise the number of painful procedures and the associated pain and suffering. What did we want to find out? We wanted to know how well sucrose worked to relieve pain in newborn babies who are having heel lance procedures while they were in hospital. We also wanted to know whether there were any safety concerns about using sucrose to relieve pain from single painful events such as heel lance. What did we do? We searched for studies that investigated: ‐ Sucrose compared to no treatment or standard care; ‐ Sucrose compared to water, other sweet solutions (e.g. glucose); ‐ Sucrose compared to another nondrug intervention (e.g. NNS); ‐ Whether sucrose was effective in decreasing the amount and severity of pain that babies experienced as assessed by baby’s pain responses (e.g. crying, grimacing, heart rate) and by using standardised infant pain scales. We also wanted to know if sucrose was associated with any unwanted effects in preterm or term babies. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods. What did we find out? We reviewed 55 studies that included a total of 6273 babies. Twenty‐nine studies had full‐term babies only, 22 had preterm babies only, and four had both full‐term and preterm babies. Heel lance was the painful procedure in 50 studies. Five studies investigated a variety of other minor painful procedures in addition to heel lancing. Main results ‐ Sucrose compared to the control treatment probably reduces pain from single heel lances in babies. ‐ Results are uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, and facilitated tucking, in reducing pain scores. ‐ Results are uncertain about the effect of sucrose + NNS compared to NNS, in reducing pain. ‐ Sucrose does not seem to reduce pain from single heel lances compared to glucose, expressed breast milk, and skin‐to‐skin care. ‐ Reported adverse events were minor and resolved without any intervention. What are the limitations of the evidence? We have moderate‐certainty evidence that sucrose likely reduces pain from heel lance. How up‐to‐date is this evidence? This evidence is up‐to‐date as of February 2022. Study funding sources We did not identify any studies that received funding from industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yamada, J; Bueno, M; Santos, L; Haliburton, S; Campbell-Yeo, M; Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD014806", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "53d5c50f-a51f-4a27-9d06-c1df3accf918", "pmid": "", "title": "Transitional discharge interventions for people with schizophrenia", "imported": false, "abstract": "Abstract - Background Schizophrenia is a chronic mental illness characterized by delusions, hallucinations, and important functional and social disability. Interventions labeled as 'transitional' add to care plans made during the hospital stay in preparation for discharge. They also include interventions developed after discharge to support people with serious mental illness as they make the transition from the hospital to the community. Transitional discharge interventions may anticipate the future needs of the patient after discharge by co‐ordinating the different levels of the health system that can effectively guarantee continuity of care in the community. This occurs through the provision of therapeutic relationships which give a safety net throughout the discharge and community reintegration processes to improve the general condition of users, level of functioning, use of health resources, and satisfaction with care. Objectives To assess the effects of transitional discharge interventions for people with schizophrenia. Search methods On 7 December 2022, we searched the Cochrane Schizophrenia Group's Study‐Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, PubMed, CINAHL, ClinicalTrials.gov, ISRCTN, PsycINFO, and WHO ICTRP. Selection criteria Randomized controlled trials (RCTs) evaluating the effects of transitional discharge interventions in people with schizophrenia and schizophrenia‐related disorders. Eligible interventions included three key elements: predischarge planning, co‐ordination of care and follow‐up, and postdischarge support. Data collection and analysis We used standard Cochrane methods. Outcomes of this review included global state (relapse), service use (hospitalization), general functioning, satisfaction with care, adverse effects/events, quality of life, and direct costs. For binary outcomes, we calculated risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardized mean difference (SMD) and their 95% CIs. We used GRADE to assess certainty of evidence. Main results We found 12 studies with 1748 participants comparing transitional discharge interventions to usual care. All were parallel‐group RCTs. No studies assessed global state (relapse) or reported data about adverse events/effects. All studies had a high risk of bias, mainly due to serious concerns about allocation concealment, deviations from intended interventions, measurement of the outcomes, and missing outcome data. Transitional discharge interventions may make little to no difference in service use (hospitalization) at short‐ and long‐term follow‐ups, but the evidence is very uncertain (RR 1.18, 95% CI 0.55 to 2.50; I 2 = 54%; 4 studies, 462 participants; very low‐certainty evidence). Transitional discharge intervention may increase the levels of functioning after discharge (clinically important change in general functioning) (SMD 0.95, 95% CI −0.06 to 1.97; I² = 95%; 4 studies, 437 participants; very low‐certainty evidence) and may increase the proportion of participants who are satisfied with the intervention (clinically important change in satisfaction) (RR 1.96, 95% CI 1.37 to 2.80; 1 study, 76 participants; very low‐certainty evidence), but for both outcomes the evidence is very uncertain. Transitional discharge intervention may make little to no difference in quality of life compared to treatment as usual (SMD 0.24, 95% CI −0.30 to 0.78; I² = 90%; 4 studies, 748 participants; very low‐certainty evidence), but we are very uncertain. For direct costs, one study with 124 participants did not report full details and thus the results were inconclusive. Authors' conclusions There is currently no clear evidence for or against implementing transitional discharge interventions for people with schizophrenia. Transitional discharge interventions may improve patient satisfaction and functionality, but this evidence is also very uncertain. For future research, it is important to improve the quality of the conduct and reporting of these trials, including using validated tools for measuring their outcomes. Plain language summary What are the benefits of transitional discharge care for people with schizophrenia? Key messages – Transitional discharge care (an intervention that supports a person move from a stay in hospital to the community) may make little to no difference in admissions to hospital and quality of life, and may improve how well a person functions in day‐to‐day life and how happy they are with their treatment when they return home, but we are very uncertain about the results. – The results on costs of running the transitional discharge care program are inconclusive, and the studies provided no information on relapse (a new mental health crisis) or unwanted effects. – We need more and better studies to investigate how to support people with schizophrenia or schizophrenia‐related disorders during the transition from hospital to community. What is schizophrenia? Schizophrenia is a persistent and severe mental health condition where people have hallucinations (where they hear, see, smell, taste, or feel things that appear to be real but only exist in their mind) and delusions (a strong belief in something that is untrue), among other debilitating symptoms, leading to poor quality of life. People with schizophrenia‐related disorders have symptoms that are similar to those of schizophrenia. The illness varies, with people having different symptoms at different times, often with them requiring admission to hospital for treatment. What happens when a person with schizophrenia or schizophrenia‐related disorders is discharged from hospital? People with schizophrenia or schizophrenia‐related disorders are sometimes admitted to hospital to improve their health, and afterward, they are discharged to their homes or other care facilities. This transition might be difficult and frightening for them and their carers, and they may need help to adapt. There are some interventions to support people with schizophrenia or schizophrenia‐related disorders after they leave the hospital, such as case management with an expert guide or continuous care with a nurse. What is transitional discharge care? Transitional discharge care is an intervention which provides support to people leaving hospital to cover their medical, practical, and emotional needs. This starts before hospital discharge and continues until people are confident in their homes or care facilities. This may include help with housing; communicating and co‐ordinating among healthcare staff, patients, and families; planning meetings; sessions with families; visits to the neighborhood; talking therapy sessions; telephone and face‐to‐face support; and support groups focusing on recreation, medication, shopping, cooking, and financial responsibilities. What did we want to find out? We wanted to know whether transitional discharge care helps people with schizophrenia or schizophrenia‐related disorders when leaving the hospital, especially if it reduces the rate of a new mental health crisis (relapse), repeat admissions to hospital, overall functioning in day‐to‐day life, satisfaction with the care they receive, quality of life, unwanted effects, and costs. What did we do? We searched for studies that investigated whether transitional discharge care, compared to no transitional discharge care or usual care, was effective in adults with schizophrenia or schizophrenia‐related disorders. What did we find? We found 12 studies with 1748 people that compared transitional discharge care to usual care. Transitional discharge care may make little to no difference to admissions to hospital (4 studies, 462 people). Transitional discharge care may improve functioning (4 studies, 437 people) and may increase people's satisfaction with care (1 study, 76 people), but we are very uncertain about the results. Transitional discharge care may make little to no difference to quality of life (4 studies, 748 people). The results on costs were inconclusive as the study did not fully report the methods (1 study, 124 people). ​​ None of the included studies provided data for relapse or unwanted effects of transitional discharge care. What are the limitations of the evidence? All 12 studies had problems with their methods and results were inconsistent. Some studies included people with other mental disorders, so the results might not apply directly to people with schizophrenia or schizophrenia‐related disorders. Therefore, we have very low confidence in our findings. How up to date is this evidence? The evidence is up to date to December 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Roson Rodriguez, P, Chen, X, Arancibia, M, Garegnani, L, Escobar Liquitay, CM, Mohammad, HA, Franco, JVA", "articleTypes": [], "doi": "10.1002/14651858.CD009788.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.792Z" }, { "id": "53e873ab-e488-4847-8676-ab9cffc29187", "pmid": "", "title": "Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta‐analyses", "imported": false, "abstract": "Abstract - Background Tobacco smoking is the leading preventable cause of death and disease worldwide. Stopping smoking can reduce this harm and many people would like to stop. There are a number of medicines licenced to help people quit globally, and e‐cigarettes are used for this purpose in many countries. Typically treatments work by reducing cravings to smoke, thus aiding initial abstinence and preventing relapse. More information on comparative effects of these treatments is needed to inform treatment decisions and policies. Objectives To investigate the comparative benefits, harms and tolerability of different smoking cessation pharmacotherapies and e‐cigarettes, when used to help people stop smoking tobacco. Search methods We identified studies from recent updates of Cochrane Reviews investigating our interventions of interest. We updated the searches for each review using the Cochrane Tobacco Addiction Group (TAG) specialised register to 29 April 2022. Selection criteria We included randomised controlled trials (RCTs), cluster‐RCTs and factorial RCTs, which measured smoking cessation at six months or longer, recruited adults who smoked combustible cigarettes at enrolment (excluding pregnant people) and randomised them to approved pharmacotherapies and technologies used for smoking cessation worldwide (varenicline, cytisine, nortriptyline, bupropion, nicotine replacement therapy (NRT) and e‐cigarettes) versus no pharmacological intervention, placebo (control) or another approved pharmacotherapy. Studies providing co‐interventions (e.g. behavioural support) were eligible if the co‐intervention was provided equally to study arms. Data collection and analysis We followed standard Cochrane methods for screening, data extraction and risk of bias (RoB) assessment (using the RoB 1 tool). Primary outcome measures were smoking cessation at six months or longer, and the number of people reporting serious adverse events (SAEs). We also measured withdrawals due to treatment. We used Bayesian component network meta‐analyses (cNMA) to examine intervention type, delivery mode, dose, duration, timing in relation to quit day and tapering of nicotine dose, using odds ratios (OR) and 95% credibility intervals (CrIs). We calculated an effect estimate for combination NRT using an additive model. We evaluated the influence of population and study characteristics, provision of behavioural support and control arm rates using meta‐regression. We evaluated certainty using GRADE. Main results Of our 332 eligible RCTs, 319 (835 study arms, 157,179 participants) provided sufficient data to be included in our cNMA. Of these, we judged 51 to be at low risk of bias overall, 104 at high risk and 164 at unclear risk, and 118 reported pharmaceutical or e‐cigarette/tobacco industry funding. Removing studies at high risk of bias did not change our interpretation of the results. Benefits We found high‐certainty evidence that nicotine e‐cigarettes (OR 2.37, 95% CrI 1.73 to 3.24; 16 RCTs, 3828 participants), varenicline (OR 2.33, 95% CrI 2.02 to 2.68; 67 RCTs, 16,430 participants) and cytisine (OR 2.21, 95% CrI 1.66 to 2.97; 7 RCTs, 3848 participants) were associated with higher quit rates than control. In absolute terms, this might lead to an additional eight (95% CrI 4 to 13), eight (95% CrI 6 to 10) and seven additional quitters per 100 (95% CrI 4 to 12), respectively. These interventions appeared to be more effective than the other interventions apart from combination NRT (patch and a fast‐acting form of NRT), which had a lower point estimate (calculated additive effect) but overlapping 95% CrIs (OR 1.93, 95% CrI 1.61 to 2.34). There was also high‐certainty evidence that nicotine patch alone (OR 1.37, 95% CrI 1.20 to 1.56; 105 RCTs, 37,319 participants), fast‐acting NRT alone (OR 1.41, 95% CrI 1.29 to 1.55; 120 RCTs, 31,756 participants) and bupropion (OR 1.43, 95% CrI 1.26 to 1.62; 71 RCTs, 14,759 participants) were more effective than control, resulting in two (95% CrI 1 to 3), three (95% CrI 2 to 3) and three (95% CrI 2 to 4) additional quitters per 100 respectively. Nortriptyline is probably associated with higher quit rates than control (OR 1.35, 95% CrI 1.02 to 1.81; 10 RCTs, 1290 participants; moderate‐certainty evidence), resulting in two (CrI 0 to 5) additional quitters per 100. Non‐nicotine/placebo e‐cigarettes (OR 1.16, 95% CrI 0.74 to 1.80; 8 RCTs, 1094 participants; low‐certainty evidence), equating to one additional quitter (95% CrI ‐2 to 5), had point estimates favouring the intervention over control, but CrIs encompassed the potential for no difference and harm. There was low‐certainty evidence that tapering the dose of NRT prior to stopping treatment may improve effectiveness; however, 95% CrIs also incorporated the null (OR 1.14, 95% CrI 1.00 to 1.29; 111 RCTs, 33,156 participants). This might lead to an additional one quitter per 100 (95% CrI 0 to 2). Harms There were insufficient data to include nortriptyline and non‐nicotine EC in the final SAE model. Overall rates of SAEs for the remaining treatments were low (average 3%). Low‐certainty evidence did not show a clear difference in the number of people reporting SAEs for nicotine e‐cigarettes, varenicline, cytisine or NRT when compared to no pharmacotherapy/e‐cigarettes or placebo. Bupropion may slightly increase rates of SAEs, although the CrI also incorporated no difference (moderate certainty). In absolute terms bupropion may cause one more person in 100 to experience an SAE (95% CrI 0 to 2). Authors' conclusions The most effective interventions were nicotine e‐cigarettes, varenicline and cytisine (all high certainty), as well as combination NRT (additive effect, certainty not rated). There was also high‐certainty evidence for the effectiveness of nicotine patch, fast‐acting NRT and bupropion. Less certain evidence of benefit was present for nortriptyline (moderate certainty), non‐nicotine e‐cigarettes and tapering of nicotine dose (both low certainty). There was moderate‐certainty evidence that bupropion may slightly increase the frequency of SAEs, although there was also the possibility of no increased risk. There was no clear evidence that any other tested interventions increased SAEs. Overall, SAE data were sparse with very low numbers of SAEs, and so further evidence may change our interpretation and certainty. Future studies should report SAEs to strengthen certainty in this outcome. More head‐to‐head comparisons of the most effective interventions are needed, as are tests of combinations of these. Future work should unify data from behavioural and pharmacological interventions to inform approaches to combined support for smoking cessation. Plain language summary How effective are medications and e‐cigarettes for quitting smoking, and what works best? Key messages Some medicines and e‐cigarettes (handheld devices that work by heating liquid that usually contains nicotine and flavourings) can help people to quit smoking for six months or longer. E‐cigarettes, and the medicines cytisine (otherwise known as Tabex) and varenicline (otherwise known as Chantix and Champix), appear to help the most people to quit smoking, followed by using two types of nicotine replacement therapy at once (nicotine patch and another type, such as gum or lozenge). We need more evidence on possible long‐term harms of e‐cigarettes and medicines to help people quit smoking, but there were very low numbers of serious harms found. Stopping smoking Tobacco smoking is bad for people's health and stopping can lead to significant improvements. Most people would like to quit smoking and there are medicines and e‐cigarettes available to help people to do that. These medicines are called nicotine replacement therapy, cytisine, varenicline, bupropion (sometimes known as Zyban or Wellbutrin) and nortriptyline (sometimes known as Norpress). Nortriptyline is only available for quitting smoking in New Zealand, and cytisine is not available in many countries. At time of writing, there are shortages of varenicline due to a manufacturing issue. These medicines and e‐cigarettes can be provided alongside behavioural support, such as counselling. Stop smoking medications and e‐cigarettes are designed to reduce people's craving to smoke. By finding out more information on how these treatments compare to each other, we hope this review will be used to decide the best treatments to help people stop smoking. Why we did this Cochrane Review We wanted to find out: ‐ which treatments (medicines and e‐cigarettes) help people to stop smoking; ‐ how these treatments compare to each other; ‐ whether there are ways of providing these treatments that mean they are more likely to help people stop smoking (e.g. different doses or treatment lengths); ‐ whether these treatments are likely to cause serious harms; and ‐ whether certain treatments are better tolerated, as indicated by fewer people leaving a study due to treatment. What did we do? We searched for studies that looked at these treatments to help adults quit smoking. We looked for randomised controlled trials, where the treatments people received were decided at random. This type of study usually gives the most reliable evidence about the effects of treatments. We compared all treatments with each other using a method called network meta‐analysis. Search date: 29 April 2022 What we found We found 332 studies that met our criteria and 319 of these provided information that we could use in our analyses. These included 157,179 adults who smoked tobacco cigarettes. Most of the studies took place in the USA or Europe. The studies compared the effects of the stop smoking treatments listed above with: ‐ no medicine/e‐cigarettes for stopping smoking; ‐ e‐cigarettes that did not contain nicotine; ‐ placebo (a dummy medication); and ‐ other types of stop smoking medicine or e‐cigarettes. What are the main results of our review? E‐cigarettes, varenicline and cytisine were most likely to help people quit smoking. For every 100 people, 10 to 19 are likely to quit using an e‐cigarette; 12 to 16 using varenicline; and 10 to 18 using cytisine. This is compared to the 6 in 100 people likely to quit when using no medicine/e‐cigarette or placebo. People using two forms of nicotine replacement therapy at the same time, for example, a combination of nicotine patch and nicotine gum, seemed to have similar rates of quitting to people using e‐cigarettes, varenicline and cytisine. Nicotine patches alone, another form of nicotine replacement therapy alone (such as gum, lozenge) and bupropion appeared to help fewer people quit but still work better than no medicine/e‐cigarette or placebo (8, 9 and 9 people per 100, respectively). Nortriptyline appeared to result in the lowest number of people quitting smoking; for every 100 people using nortriptyline 6 to 11 are likely to quit. We are moderately confident that bupropion could rarely cause some serious health effects. The information we have for other treatments does not provide clear evidence of serious harms. For all treatments, findings suggest very few people experience serious harms when using them. How confident are we in our results? We are confident that e‐cigarettes, cytisine, varenicline, nicotine replacement therapy and bupropion help people stop smoking. We do not expect more evidence will change these results. However, more evidence on how these treatments compare to one another, particularly in relation to harms, would be useful. Due to the nature of our analyses we were not able to judge our confidence in the evidence for combination nicotine replacement therapy (two types used together). We are moderately confident that nortriptyline also helps people to stop smoking, but are less confident in our results for non‐nicotine e‐cigarettes and for potential harms of most of the treatments. We still need more evidence on potential harms and hope more studies will report on these in future; however, nicotine replacement therapy has been used since the 1980s with no evidence of serious harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lindson, N, Theodoulou, A, Ordóñez-Mena, JM, Fanshawe, TR, Sutton, AJ, Livingstone-Banks, J, Hajizadeh, A, Zhu, S, Aveyard, P, Freeman, SC, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015226.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.746Z" }, { "id": "53e9f6c6-a84a-49df-811a-a2642fe20933", "pmid": "", "title": "Smoking Cessation on the Human Airway: Mucus Secretion, Inflammatory and Proteomic Profile in Nasal Lavage and miRNAs in Blood", "imported": false, "abstract": "Smoking cessation improves health conditions with reduction of the risk factors for cardiovascular and respiratory disease, as functional capacity and quality of life. Smoking cessation has positive effects on the miRNAs regulation, however, genomics has been little explored. Smoking and aging induces changes miRNAs. Among the changes in airway epithelial cells, miR-125 called attention because it is enrolled in the suppression of ERBB7 (tirosin kinase receptors), a codified sequence of the growth factor receptor (EGFR) frequently expressed in cancer. The reduction of miR-125 expression may reduce cancer suppression resulting in cancer development. Other miRNA changes can be observed, such as miR-218 that were found in smokers airway epithelial cells as in MiR-15b that were found in lung tissue of COPD smokers. These miRNAs participated in the signalling pathway of TGF-β enrolled in leukocyte migration and cell proliferation. The investigators hypothesize that smoking cessation has a role in the regulation or reduction in the genetic changes smoking-induced. The investigators will assess the subject genomic profile at the baseline, 6 months and 12 months after smoking cessation.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.247Z" }, { "id": "540d73c0-3e3c-40f5-a653-2b382583ef22", "pmid": "", "title": "Statins for asthma", "imported": false, "abstract": "Abstract - Background Asthma is a common chronic respiratory disease. People with asthma have inflammation of their airways that causes recurrent episodes of wheezing, breathlessness and chest tightness, with or without a cough. Statins possess multiple therapeutic effects, including lowering lipid levels in the blood. Statins are reported to have a potential role as an adjunct treatment in asthma. However, comprehensive evidence of the benefits and harms of using statins is required to facilitate decision making. Objectives To assess the benefits and harms of statins as an adjunct therapy for asthma in adults and children. Search methods We searched for studies in the Cochrane Airways Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid SP and Embase Ovid SP, from their inception dates We handsearched the proceedings of major respiratory conferences. We also searched clinical trials registries for completed, ongoing and unpublished studies, and scanned the reference lists of included studies and relevant reviews to identify additional studies. The search is current to 7 February 2020. Selection criteria We included randomised controlled trials (RCTs) with a parallel‐group design that assessed statins for at least 12 weeks' duration. We considered all participants with a clinical diagnosis of asthma to be eligible, regardless of age, sex, disease severity and previous or current treatment. We planned to include studies reported as full text, those published as abstract only, and unpublished data. Data collection and analysis Two review authors independently screened and selected the studies, extracted outcome data and intervention characteristics from included studies, and assessed risk of bias according to standard Cochrane methodological procedures. We resolved any disagreement through discussion. Main results We found only one trial involving a total of 60 people living with asthma. The trial compared the effect of atorvastatin with a placebo (dummy treatment containing lactose) in treating people with chronic asthma. The trial did not report data for the primary outcomes or adverse events. There was uncertainty about the relative effect on forced expiratory volume in one second (FEV 1 ) and peak expiratory flow (PEF) in the atorvastatin group compared with the placebo group. The study did not report serious adverse effects for the interventions. The included study had internal discrepancies in its reported data. Authors' conclusions The evidence was of very low certainty, so we are unable to draw conclusions about the effectiveness and safety of statins to treat asthma. High‐quality RCTs are needed to assess the effect of statins on people with asthma. Well‐designed multicentre trials with larger samples and longer duration of treatment are required, which assess outcomes such as adverse events, hospital utilisation and costs, to provide better quality evidence. Future studies that include subgroups of obese people with asthma are also required. Plain language summary Statins for asthma Review question We reviewed the evidence about the effect of statins in people with asthma. Background Asthma is a common chronic (persistent) airway disease. Asthma is caused by inflammation in the lungs and bronchoconstriction (tightening of the small tubes in the lungs in response to a trigger such as pollen or cold air). Inflammation and bronchoconstriction cause airflow obstruction (narrowing and blockage). People with asthma experience recurrent attacks of wheezing, difficultly in breathing, and chest tightness, with or without a cough. Statins are anti‐inflammatory medicines. We wanted to review the evidence for statins because the theory is that their anti‐inflammatory properties will help people with asthma. We wanted to discover whether using statin therapy was better or worse than other alternatives, such as usual care alone or different types of statins (atorvastatin, simvastatin). Study characteristics We found only one trial that assessed atorvastatin (a type of statin drug) and placebo (dummy treatment) in 60 adults with asthma over a period of 12 weeks. These people had chronic asthma (persistent airway disease) when they started treatment. Key results We found that the statin (atorvastatin) did not result in any clear improvement in lung function in people with asthma, but may be better in asthma control than the dummy drug. However, because there is only one trial, we cannot draw firm conclusions. The trial did not report on adverse effects or severe adverse effects (harms). We are uncertain whether statins may have beneficial effects on relieving asthma or whether they may increase the risk of adverse events or non‐serious adverse events. Quality of the evidence The evidence was of very low certainty, so we cannot draw firm conclusions about whether statins are helpful and safe to be used by people with asthma. The evidence is current to 7 February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Naing, C, Ni, H", "articleTypes": [], "doi": "10.1002/14651858.CD013268.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.755Z" }, { "id": "5411c4c4-2861-469c-abf9-5557e1e03e9b", "pmid": "", "title": "Topical benzoyl peroxide for acne", "imported": false, "abstract": "Abstract - Background Acne is a common, economically burdensome condition that can cause psychological harm and, potentially, scarring. Topical benzoyl peroxide (BPO) is a widely used acne treatment; however, its efficacy and safety have not been clearly evaluated. Objectives To assess the effects of BPO for acne. Search methods We searched the following databases up to February 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of relevant randomised controlled trials (RCTs) and systematic reviews. Selection criteria We included RCTs that compared topical BPO used alone (including different formulations and concentrations of BPO) or as part of combination treatment against placebo, no treatment, or other active topical medications for clinically diagnosed acne (used alone or in combination with other topical drugs not containing BPO) on the face or trunk. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Primary outcome measures were 'participant global self‐assessment of acne improvement' and 'withdrawal due to adverse events in the whole course of a trial'. 'Percentage of participants experiencing any adverse event in the whole course of a trial' was a key secondary outcome. Main results We included 120 trials (29,592 participants randomised in 116 trials; in four trials the number of randomised participants was unclear). Ninety‐one studies included males and females. When reported, 72 trials included participants with mild to moderate acne, 26 included participants with severe acne, and the mean age of participants ranged from 18 to 30 years. Our included trials assessed BPO as monotherapy, as add‐on treatment, or combined with other active treatments, as well as BPO of different concentrations and BPO delivered through different vehicles. Comparators included different concentrations or formulations of BPO, placebo, no treatment, or other active treatments given alone or combined. Treatment duration in 80 trials was longer than eight weeks and was only up to 12 weeks in 108 trials. Industry funded 50 trials; 63 trials did not report funding. We commonly found high or unclear risk of performance, detection, or attrition bias. Trial setting was under‐reported but included hospitals, medical centres/departments, clinics, general practices, and student health centres. We reported on outcomes assessed at the end of treatment, and we classified treatment periods as short‐term (two to four weeks), medium‐term (five to eight weeks), or long‐term (longer than eight weeks). For 'participant‐reported acne improvement', BPO may be more effective than placebo or no treatment (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.12 to 1.45; 3 RCTs; 2234 participants; treatment for 10 to 12 weeks; low‐certainty evidence). Based on low‐certainty evidence, there may be little to no difference between BPO and adapalene (RR 0.99, 95% CI 0.90 to 1.10; 5 RCTs; 1472 participants; treatment for 11 to 12 weeks) or between BPO and clindamycin (RR 0.95, 95% CI 0.68 to 1.34; 1 RCT; 240 participants; treatment for 10 weeks) (outcome not reported for BPO versus erythromycin or salicylic acid). For 'withdrawal due to adverse effects', risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment (RR 2.13, 95% CI 1.55 to 2.93; 24 RCTs; 13,744 participants; treatment for 10 to 12 weeks; low‐certainty evidence); the most common causes of withdrawal were erythema, pruritus, and skin burning. Only very low‐certainty evidence was available for the following comparisons: BPO versus adapalene (RR 1.85, 95% CI 0.94 to 3.64; 11 RCTs; 3295 participants; treatment for 11 to 24 weeks; causes of withdrawal not clear), BPO versus clindamycin (RR 1.93, 95% CI 0.90 to 4.11; 8 RCTs; 3330 participants; treatment for 10 to 12 weeks; causes of withdrawal included local hypersensitivity, pruritus, erythema, face oedema, rash, and skin burning), erythromycin (RR 1.00, 95% CI 0.07 to 15.26; 1 RCT; 60 participants; treatment for 8 weeks; withdrawal due to dermatitis), and salicylic acid (no participants had adverse event‐related withdrawal; 1 RCT; 59 participants; treatment for 12 weeks). There may be little to no difference between these groups in terms of withdrawal; however, we are unsure of the results because the evidence is of very low certainty. For 'proportion of participants experiencing any adverse event', very low‐certainty evidence leaves us uncertain about whether BPO increased adverse events when compared with placebo or no treatment (RR 1.40, 95% CI 1.15 to 1.70; 21 RCTs; 11,028 participants; treatment for 10 to 12 weeks), with adapalene (RR 0.71, 95% CI 0.50 to 1.00; 7 RCTs; 2120 participants; treatment for 11 to 24 weeks), with erythromycin (no participants reported any adverse events; 1 RCT; 89 participants; treatment for 10 weeks), or with salicylic acid (RR 4.77, 95% CI 0.24 to 93.67; 1 RCT; 41 participants; treatment for 6 weeks). Moderate‐certainty evidence shows that the risk of adverse events may be increased for BPO versus clindamycin (RR 1.24, 95% CI 0.97 to 1.58; 6 RCTs; 3018 participants; treatment for 10 to 12 weeks); however, the 95% CI indicates that BPO might make little to no difference. Most reported adverse events were mild to moderate, and local dryness, irritation, dermatitis, erythema, application site pain, and pruritus were the most common. Authors' conclusions Current evidence suggests that BPO as monotherapy or add‐on treatment may be more effective than placebo or no treatment for improving acne, and there may be little to no difference between BPO and either adapalene or clindamycin. Our key efficacy evidence is based on participant self‐assessment; trials of BPO versus erythromycin or salicylic acid did not report this outcome. For adverse effects, the evidence is very uncertain regarding BPO compared with adapalene, erythromycin, or salicylic acid. However, risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment. Withdrawal may be linked to tolerability rather than to safety. Risk of mild to moderate adverse events may be higher with BPO compared with clindamycin. Further trials should assess the comparative effects of different preparations or concentrations of BPO and combination BPO versus monotherapy. These trials should fully assess and report adverse effects and patient‐reported outcomes measured on a standardised scale. Plain language summary Topical benzoyl peroxide for acne Review question We reviewed the evidence showing effects and safety of topical benzoyl peroxide (BPO), used alone or in combination. Eligible comparisons included placebo (an identical but inactive treatment), no treatment, or other active (medical) topical medications for treating acne (used alone or in combination with other topical drugs not containing BPO) (evidence is current to February 2019). The main outcomes of interest in this review were participant‐reported acne improvement and withdrawal from the study due to any side effects. More generally, we also considered the percentage of participants experiencing any side effects over the whole course of a trial. Background As a common skin disease, acne vulgaris affects the physical, mental, and social well‐being of millions of adolescents and young adults. A wide range of treatments for acne vulgaris are available, and topical BPO has been recommended as a priority therapy to be used alone or combined with other topical or oral treatments, depending on acne severity. However, the benefits and harms of BPO have yet to be evaluated. Study characteristics We included 120 studies (which comprised 29,592 people randomised in 116 trials; in four trials the number of randomised participants was unclear). Through our search, we found studies assessing different concentrations of BPO, BPO delivered through various means, or BPO used alone or given with other treatments that may or may not be considered as the primary treatment. These studies compared treatments against different concentrations or formulations of BPO, placebo, no treatment, or other medical treatments given alone or in combination. Most of the studies included male and female participants with mild to moderate acne; only 67% of studies reported participant age, which ranged between 18 and 30 years. Participants were treated for over eight weeks in nearly two‐thirds of the trials. Industry financially supported approximately two‐fifths of the trials, and more than half of the trials did not report their funding sources. Few studies reported where they were set, but locations included hospitals, medical centres, national medical institutes, clinics, medical departments, and general practices. Key results We found low‐certainty evidence to suggest that long‐term (i.e. given for longer than eight weeks) BPO treatment may increase self‐reported treatment success compared to placebo or no BPO treatment (three studies), but there may be little to no difference when BPO treatment is compared to adapalene (five studies) or clindamycin (one study). This outcome was not reported by studies comparing BPO treatment to erythromycin or salicylic acid. Long‐term BPO may lead to an increased chance of treatment discontinuation compared to placebo or no treatment (24 studies), with the most common causes being redness, itch, and skin burning (low‐certainty evidence). When medium‐ to long‐term BPO was compared to adapalene (11 studies), clindamycin (eight studies), erythromycin (one study), or salicylic acid (one study), we found only very low‐certainty evidence, meaning that although there may be little to no difference in withdrawal between these groups, we are not sure of the results. It should be noted that participant withdrawal may be linked to issues around treatment acceptability (dermatitis, rash, facial swelling, sensitivity) rather than to safety. Very low‐certainty evidence means that we are uncertain if BPO leads to more side effects among participants receiving medium‐ to long‐term BPO than among those given no treatment/placebo (21 studies), adapalene (seven studies), erythromycin (one study), or salicylic acid (one study). Medium‐term treatment with BPO may lead to increased risk of side effects when compared against clindamycin, but the effects of this treatment vary, so the treatment chosen may make little to no difference (six studies; moderate‐certainty evidence). Side effects reported in these studies were usually mild to moderate, and the most common were local dryness, irritation, eczema, redness, pain at the site of application, and pruritus. Certainty of the evidence For our key comparisons, we rated the certainty of evidence for 'participant‐reported acne improvement' as low. For the outcomes 'withdrawal due to adverse effects' and ‘percentage of participants having any adverse events', the evidence was mainly of very low certainty. Included trials were at high or unclear risk of bias, participant numbers were small, results were not consistent across trials, and we suspected publication bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Yang, Z, Zhang, Y, Lazic Mosler, E, Hu, J, Li, H, Zhang, Y, Liu, J, Zhang, Q", "articleTypes": [], "doi": "10.1002/14651858.CD011154.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.136Z" }, { "id": "54194470-1469-4d41-8683-7d88136619a7", "pmid": "", "title": "Chloroquine or hydroxychloroquine for prevention and treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The coronavirus disease 2019 (COVID‐19) pandemic has resulted in substantial mortality. Some specialists proposed chloroquine (CQ) and hydroxychloroquine (HCQ) for treating or preventing the disease. The efficacy and safety of these drugs have been assessed in randomized controlled trials. Objectives To evaluate the effects of chloroquine (CQ) or hydroxychloroquine (HCQ) for 1) treating people with COVID‐19 on death and time to clearance of the virus; 2) preventing infection in people at risk of SARS‐CoV‐2 exposure; 3) preventing infection in people exposed to SARS‐CoV‐2. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Current Controlled Trials (www.controlled‐trials.com), and the COVID‐19‐specific resources www.covid‐nma.com and covid‐19.cochrane.org, for studies of any publication status and in any language. We performed all searches up to 15 September 2020. We contacted researchers to identify unpublished and ongoing studies. Selection criteria We included randomized controlled trials (RCTs) testing chloroquine or hydroxychloroquine in people with COVID‐19, people at risk of COVID‐19 exposure, and people exposed to COVID‐19. Adverse events (any, serious, and QT‐interval prolongation on electrocardiogram) were also extracted. Data collection and analysis Two review authors independently assessed eligibility of search results, extracted data from the included studies, and assessed risk of bias using the Cochrane ‘Risk of bias’ tool. We contacted study authors for clarification and additional data for some studies. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). We performed meta‐analysis using a random‐effects model for outcomes where pooling of effect estimates was appropriate. Main results 1. Treatment of COVID‐19 disease We included 12 trials involving 8569 participants, all of whom were adults. Studies were from China (4); Brazil, Egypt, Iran, Spain, Taiwan, the UK, and North America (each 1 study); and a global study in 30 countries (1 study). Nine were in hospitalized patients, and three from ambulatory care. Disease severity, prevalence of comorbidities, and use of co‐interventions varied substantially between trials. We found potential risks of bias across all domains for several trials. Nine trials compared HCQ with standard care (7779 participants), and one compared HCQ with placebo (491 participants); dosing schedules varied. HCQ makes little or no difference to death due to any cause (RR 1.09, 95% CI 0.99 to 1.19; 8208 participants; 9 trials; high‐certainty evidence). A sensitivity analysis using modified intention‐to‐treat results from three trials did not influence the pooled effect estimate. HCQ may make little or no difference to the proportion of people having negative PCR for SARS‐CoV‐2 on respiratory samples at day 14 from enrolment (RR 1.00, 95% CI 0.91 to 1.10; 213 participants; 3 trials; low‐certainty evidence). HCQ probably results in little to no difference in progression to mechanical ventilation (RR 1.11, 95% CI 0.91 to 1.37; 4521 participants; 3 trials; moderate‐certainty evidence). HCQ probably results in an almost three‐fold increased risk of adverse events (RR 2.90, 95% CI 1.49 to 5.64; 1394 participants; 6 trials; moderate‐certainty evidence), but may make little or no difference to the risk of serious adverse events (RR 0.82, 95% CI 0.37 to 1.79; 1004 participants; 6 trials; low‐certainty evidence). We are very uncertain about the effect of HCQ on time to clinical improvement or risk of prolongation of QT‐interval on electrocardiogram (very low‐certainty evidence). One trial (22 participants) randomized patients to CQ versus lopinavir/ritonavir, a drug with unknown efficacy against SARS‐CoV‐2, and did not report any difference for clinical recovery or adverse events. One trial compared HCQ combined with azithromycin against standard care (444 participants). This trial did not detect a difference in death, requirement for mechanical ventilation, length of hospital admission, or serious adverse events. A higher risk of adverse events was reported in the HCQ‐and‐azithromycin arm; this included QT‐interval prolongation, when measured. One trial compared HCQ with febuxostat, another drug with unknown efficacy against SARS‐CoV‐2 (60 participants). There was no difference detected in risk of hospitalization or change in computed tomography (CT) scan appearance of the lungs; no deaths were reported. 2. Preventing COVID‐19 disease in people at risk of exposure to SARS‐CoV‐2 Ongoing trials are yet to report results for this objective. 3. Preventing COVID‐19 disease in people who have been exposed to SARS‐CoV‐2 One trial (821 participants) compared HCQ with placebo as a prophylactic agent in the USA (around 90% of participants) and Canada. Asymptomatic adults (66% healthcare workers; mean age 40 years; 73% without comorbidity) with a history of exposure to people with confirmed COVID‐19 were recruited. We are very uncertain about the effect of HCQ on the primary outcomes, for which few events were reported: 20/821 (2.4%) developed confirmed COVID‐19 at 14 days from enrolment, and 2/821 (0.2%) were hospitalized due to COVID‐19 (very low‐certainty evidence). HCQ probably increases the risk of adverse events compared with placebo (RR 2.39, 95% CI 1.83 to 3.11; 700 participants; 1 trial; moderate‐certainty evidence). HCQ may result in little or no difference in serious adverse events (no RR: no participants experienced serious adverse events; low‐certainty evidence). One cluster‐randomized trial (2525 participants) compared HCQ with standard care for the prevention of COVID‐19 in people with a history of exposure to SARS‐CoV‐2 in Spain. Most participants were working or residing in nursing homes; mean age was 49 years. There was no difference in the risk of symptomatic confirmed COVID‐19 or production of antibodies to SARS‐CoV‐2 between the two study arms. Authors' conclusions HCQ for people infected with COVID‐19 has little or no effect on the risk of death and probably no effect on progression to mechanical ventilation. Adverse events are tripled compared to placebo, but very few serious adverse events were found. No further trials of hydroxychloroquine or chloroquine for treatment should be carried out. These results make it less likely that the drug is effective in protecting people from infection, although this is not excluded entirely. It is probably sensible to complete trials examining prevention of infection, and ensure these are carried out to a high standard to provide unambiguous results. Plain language summary Is chloroquine or hydroxychloroquine useful in treating people with COVID‐19, or in preventing infection in people who have been exposed to the virus? What is the aim of this review? COVID‐19 is an infectious respiratory disease caused by a coronavirus called SARS‐CoV‐2. If the infection becomes severe, people may need intensive care and support in hospital, including mechanical ventilation. Drugs used for other diseases were tried out in COVID‐19, and this included chloroquine, used for malaria; and hydroxychloroquine used for rheumatic diseases, such as rheumatoid arthritis or systemic lupus erythematosus. We sought evidence of the effects of these drugs in treating people ill with the disease; in preventing the disease in people at risk of getting the disease, such as health workers; and people exposed to the virus developing the disease. Key messages Hydroxychloroquine does not reduce deaths from COVID‐19, and probably does not reduce the number of people needing mechanical ventilation. Hydroxychloroquine caused more unwanted effects than a placebo treatment, though it did not appear to increase the number of serious unwanted effects. We do not think new studies of hydroxychloroquine should be started for treatment of COVID‐19. What was studied in the review? We searched for studies that looked at giving chloroquine and hydroxychloroquine to people with COVID‐19; people at risk of being exposed to the virus; and people who have been exposed to the virus. We found 14 relevant studies: 12 studies of chloroquine or hydroxychloroquine used to treat COVID‐19 in 8569 adults; two studies of hydroxychloroquine to stop COVID‐19 in 3346 adults who had been exposed to the virus but had no symptoms of infection. We did not find any completed studies of these medicines to stop COVID‐19 in people who were at risk of exposure to the virus; studies are still under way. The studies took place in China, Brazil, Egypt, Iran, Taiwan, North America, and Europe; one study was worldwide. Some studies were partly funded by pharmaceutical companies that manufacture hydroxychloroquine. What are the main results of our review? Treating COVID‐19 Compared with usual care or placebo, hydroxychloroquine: · clearly did not affect how many people died (of any cause; 9 studies in 8208 people); · probably did not affect how many people needed mechanical ventilation (3 studies; 4521 people); · may not affect how many people still tested positive for the virus after 14 days (3 studies; 213 people). We are uncertain whether hydroxychloroquine affected the number of people whose symptoms improved after 28 days. Compared with other antiviral treatment (lopinavir plus ritonavir), chloroquine made little or no difference to the time taken for symptoms to improve (1 study; 22 people). Compared with usual care in one study in 444 people, hydroxychloroquine given with azithromycin (an antibiotic) made no difference to: · how many people died; · how many needed mechanical ventilation; or · time spent in hospital. Compared with febuxostat (a medicine to treat gout), hydroxychloroquine made no difference to how many people were admitted to hospital or to changes seen on scans of people's lungs; no deaths were reported (1 study; 60 people). Preventing COVID‐19 in people exposed to it We are uncertain whether hydroxychloroquine affected how many people developed COVID‐19, or how many people were admitted to hospital with COVID‐19, compared with those receiving a placebo treatment (1 study; 821 people). Compared with usual care, hydroxychloroquine made no difference to the risk of developing COVID‐19, or antibodies to the virus, in people exposed to it (1 study; 2525 people). Unwanted effects When used for treating COVID‐19, compared with usual care or placebo, hydroxychloroquine: · probably increases the risk of mild unwanted effects (6 studies; 1394 people); · may not increase the risk of serious harmful effects (6 studies; 1004 people). When given along with azithromycin, hydroxychloroquine increased the risk of any unwanted effects, but made no difference to the risk of serious unwanted effects (1 study; 444 people). Compared with lopinavir plus ritonavir, chloroquine made little or no difference to the risk of unwanted effects (1 study; 22 people). When used for preventing COVID‐19, hydroxychloroquine probably causes more unwanted effects than placebo, but may not increase the risk of serious, harmful unwanted effects (1 study; 700 people). How confident are we in our results? We are confident about our results for how many people died and moderately confident about how many needed mechanical ventilation. We are moderately confident about the unwanted effects of hydroxychloroquine treatment, but less confident about our results for serious unwanted effects; these results might change with further evidence. How up‐to‐date is this review? We included evidence published up to 15 September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Singh, B; Ryan, H; Kredo, T; Chaplin, M; Fletcher, T", "articleTypes": [], "doi": "10.1002/14651858.CD013587.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "545cab0c-f5be-494d-8bf5-e138eb50a64f", "pmid": "", "title": "Evaluating the Effect of a Food for Special Medical Purposes Containing Essential Amino Acids (EAA), Carnitine, Arginine, and Sucrosomial Minerals on the Preservation of Appendicular Skeletal Muscle Mass (ASMM) During a Weight Loss Program With GLP-1 Receptor Agonists", "imported": false, "abstract": "This study evaluates whether a Food for Special Medical Purposes (FSMP) can help to preserve appendicular skeletal muscle mass (ASMM) in adults undergoing weight loss treatment with GLP-1 receptor agonists or dual GIP/GLP-1 receptor agonists. Participants will receive the FSMP or a matching placebo for 24 weeks while continuing standard GLP-1-based therapy. ASMM will be measured using Bioelectrical Impedance Vector Analysis (BIVA).", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.239Z" }, { "id": "546346b6-8c6d-40a6-8d9b-511b813af3c5", "pmid": "", "title": "Interventions for treating oro‐antral communications and fistulae due to dental procedures", "imported": false, "abstract": "Abstract - Background An oro‐antral communication is an unnatural opening between the oral cavity and maxillary sinus. When it fails to close spontaneously, it remains patent and is epithelialized to develop into an oro‐antral fistula. Various surgical and non‐surgical techniques have been used for treating the condition. Surgical procedures include flaps, grafts and other techniques like re‐implantation of third molars. Non‐surgical techniques include allogenic materials and xenografts. This is an update of a review first published in May 2016. Objectives To assess the effectiveness and safety of various interventions for the treatment of oro‐antral communications and fistulae due to dental procedures. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 23 May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 4), MEDLINE Ovid (1946 to 23 May 2018), and Embase Ovid (1980 to 23 May 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the reference lists of included and excluded trials for any randomised controlled trials (RCTs). Selection criteria We included RCTs evaluating any intervention for treating oro‐antral communications or oro‐antral fistulae due to dental procedures. We excluded quasi‐RCTs and cross‐over trials. We excluded studies on participants who had oro‐antral communications, fistulae or both related to Caldwell‐Luc procedure or surgical excision of tumours. Data collection and analysis Two review authors independently selected trials. Two review authors assessed trial risk of bias and extracted data independently. We estimated risk ratios (RR) for dichotomous data, with 95% confidence intervals (CI). We assessed the overall quality of the evidence using the GRADE approach. Main results We included only one study in this review, which compared two surgical interventions: pedicled buccal fat pad flap and buccal flap for the treatment of oro‐antral communications. The study involved 20 participants. The risk of bias was unclear. The relevant outcome reported in this trial was successful (complete) closure of oro‐antral communication. The quality of the evidence for the primary outcome was very low. The study did not find evidence of a difference between interventions for the successful (complete) closure of an oro‐antral communication (RR 1.00, 95% Cl 0.83 to 1.20) one month after the surgery. All oro‐antral communications in both groups were successfully closed so there were no adverse effects due to treatment failure. We did not find trials evaluating any other intervention for treating oro‐antral communications or fistulae due to dental procedures. Authors' conclusions We found very low quality evidence from a single small study that compared pedicled buccal fat pad and buccal flap. The evidence was insufficient to judge whether there is a difference in the effectiveness of these interventions as all oro‐antral communications in the study were successfully closed by one month after surgery. Large, well‐conducted RCTs investigating different interventions for the treatment of oro‐antral communications and fistulae caused by dental procedures are needed to inform clinical practice. Plain language summary Treatment of communications between the oral cavity and the maxillary sinus due to dental procedures Review question What evidence is available for the safe and effective treatment of openings between the mouth and main sinus caused by dental procedures? Background The floor of the main sinus near the nose is thin and lies directly above the roots of the teeth at the back of the mouth. Sometimes following infection or dental treatment, this structure becomes damaged and openings or channels between the mouth and the sinus are formed. These are known as oro‐antral communications (OAC). If the OAC is left open (then described as an oro‐antral fistula (OAF), it may become permanent, leading to long‐lasting sinus infections. This condition can be treated surgically by using flaps, grafts and other techniques; or non‐surgically using a variety of methods and materials. There is little evidence for the most effective and safe treatments for closing OACs and OAFs and clinicians who treat these conditions have identified an urgent need for this. This is an update of a review first published in May 2016. Study characteristics We searched various databases until 23 May 2018. Only one study, which was conducted in Iran, is included in our review. The study ran for two years and involved 20 people with OAC aged between 25 and 56 years. Participants were divided into two groups and two surgical treatments were compared for treating oro‐antral communications; one group was treated with pedicled buccal fat pad flap (PBFPF) and the other with buccal flap (BF). Key results and quality of evidence The study did not find evidence of a difference between PBFPF and BF in terms of successful (complete) closure of OAC. Both interventions resulted in successful closure by one month after surgery. The study did not therefore report any adverse effects of treatment failure. It may not be possible to generalise these findings because the quality of the evidence was very low, due to unclear risk of bias and the small numbers studied in the single included trial. Conclusion The evidence currently available is insufficient to draw reliable conclusions regarding the effects of interventions used to treat OAC or fistulae due to dental procedures. More well‐designed and well‐reported trials evaluating different interventions are needed to provide reliable evidence to inform clinical decisions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Kiran Kumar Krishanappa, S; Eachempati, P; Kumbargere Nagraj, S; Shetty, NY; Moe, S; Aggarwal, H; Mathew, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD011784.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "54678579-0e6b-472f-afab-6570457bbafa", "pmid": "", "title": "Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery", "imported": false, "abstract": "Abstract - Background Postoperative pain may lead to adverse effects on the body, which might result in an increase in morbidity. Its management therefore poses a unique challenge for the clinician. Major shoulder surgery is associated with severe postoperative pain, and different modalities are available to manage such pain, including opioid and non‐opioid analgesics, local anaesthetics infiltrated into and around the shoulder joint and regional anaesthesia. All of these techniques, alone or in combination, have been used to treat the postoperative pain of major shoulder surgery but with varying success. Objectives The objective of this review was to compare the analgesic efficacy of continuous interscalene brachial plexus block (ISBPB) with parenteral opioid analgesia for pain relief after major shoulder surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12), MEDLINE (1950 to December 2012), EMBASE (1980 to December 2012), Web of Science (1954 to December 2012), CINAHL (1982 to December 2012) and bibliographies of published studies. Selection criteria We included randomized controlled trials assessing the effectiveness of continuous ISBPB compared with different forms of parenteral opioid analgesia in relieving pain in adult participants undergoing elective major shoulder surgery. Data collection and analysis Two review authors independently assessed trial quality and extracted outcome data. Main results We included two randomized controlled trials (147 participants). A total of 17 participants were excluded from one trial because of complications related to continuous ISBPB (16) or parenteral opioid analgesia (one). Thus we have information on 130 participants (66 in the continuous ISBPB group and 64 in the parenteral opioid group). The studies were clinically heterogeneous. No meta‐analysis was undertaken. However, results of the two included studies showed better pain relief with continuous ISBPB following major shoulder surgery and a lower incidence of complications when interscalene block is performed under ultrasound guidance rather than without it. Authors' conclusions Because of the small number of studies (two) relevant to the subject and the high risk of bias of the selected studies, no reasonable conclusion can be drawn. Plain language summary Comparison of an upper limb nerve block using local anaesthetic with opioid analgesia for pain relief following major shoulder surgery Pain following surgical procedures can sometimes increase the incidence of complications in the body. It is important to manage this pain effectively. Major shoulder surgery can cause severe pain. Effectively treating this pain will help reduce complications and will promote early mobilization. A wide range of methods are used to treat pain after major shoulder surgery, including administration of opioid (derived from opium) and non‐opioid pain killers and administration of drugs that produce numbness and hence pain relief in and around the shoulder joint or around the nerves supplying the upper limb. We compared the usefulness of a continuous upper limb nerve block performed by injecting local anaesthetic into the neck close to where the nerves originate (interscalene brachial plexus block—ISBPB group) with the administration of opioid pain killers into a vein, into a muscle or under the skin (any route other than by mouth)—the parenteral opioid group. Evidence obtained is current to December 2012. We included two studies involving 147 participants. Seventeen participants were excluded (16 from the ISBPB group and one from the other), leaving 130 participants: 66 in the ISBPB group and 64 in the parenteral opioid group. The studies were of medium to low quality because of issues with study design, and one of the trials was sponsored by a drug company. The severity of pain was assessed by the patient using a numerical scale on which zero was considered as no pain and 10 or 100 as the worst imaginable pain for 72 hours in one study and 48 hours in the other. The severity of postoperative pain was significantly less for the ISBPB group at all time points in one study and at all but one time point in the other study. No concrete conclusions can be drawn because of the small number of studies, which were not of high quality. However, from the available evidence, it can be seen that in one of the trials, the requirement for additional painkiller (piritramide) was significantly higher in the parenteral opioid group, whereas the other trial did not mention this. The incidence of nausea and vomiting was significantly less in the ISBPB group when compared with the parenteral opioid group. Complications related to ISBPB were virtually eliminated when ultrasound was used to perform ISBPB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ullah, H; Samad, K; Khan, FA", "articleTypes": [], "doi": "10.1002/14651858.CD007080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "547cce75-32b6-433d-b3c1-f58afccb082a", "pmid": "", "title": "Pharmacological interventions for people with borderline personality disorder", "imported": false, "abstract": "Abstract - Background Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off‐label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods. Objectives To assess the effects of pharmacological treatment for people with BPD. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. Selection criteria Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events. Data collection and analysis At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. Main results We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty‐nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD ‐0.18, 95% confidence interval (CI) ‐0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD −0.27, 95% CI −0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD −0.07, 95% CI −0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self‐harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale‐Modified‐Self‐Injury item (0‐5 points), 95% CI −10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide‐related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI −0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD −0.26, 95% CI −1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD −0.36, 95% CI −1.96 to 1.25; 2 trials, 44 participants). Very low‐certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD −0.16, 95% CI −0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD −0.25, 95% CI ‐0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD −0.01, 95% CI ‐0.28 to 0.26; 2 trials, 214 participants). Low‐certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD −0.21, 95% CI −0.34 to ‐0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD −0.58, 95% CI ‐1.14 to ‐0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD −0.07, 95% CI ‐0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low‐certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non‐standardised. The available evidence on non‐serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified. Authors' conclusions This review included 18 more trials than the 2010 version, so larger meta‐analyses with more statistical power were feasible. We found mostly very low‐certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma‐related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples. Plain language summary What are the benefits and risks of medication for people with borderline personality disorder? Key messages This review is an update of a previous review on the same topic published in 2010. Although this review includes an additional 18 studies, the conclusions remain the same: there are probably no benefits and risks of medications for borderline personality disorder (BDP), but the evidence is unclear. Better and larger studies comparing the effects of medication with placebo are needed. Such studies should focus on men, adolescents and those with additional psychiatric diagnoses. What is BPD? BPD affects how a person interacts with others and understands one's self. Although its exact causes are unclear, it is thought to result from a combination of genetic and environmental factors (e.g. stressful or traumatic life events when growing up). Approximately 2% of adults and 3% of adolescents are affected. The symptoms of BPD can be grouped into four categories. Instability in mood: People with BPD may experience intense feelings that change rapidly and are difficult to control. They may also feel empty and abandoned much of the time. Cognitive distortions (disturbed patterns of thinking): People with BPD often have upsetting thoughts (e.g. they may think that they are a terrible person). They can have brief episodes of strange experiences (e.g. paranoid ideations or stress‐induced dissociative experiences (i.e. feeling detached from the world around them). Impulsive behaviour: People with BPD may act impulsively and do things that could harm themselves (e.g. when sad and depressed, they may self‐harm or have suicidal feelings). They might also engage in reckless behaviour (e.g. drug misuse). Intense but unstable relationships: People with BPD may find it difficult to keep stable relationships (e.g. they may feel very worried about being abandoned and might constantly text or call, or make threats to harm or kill themselves if the person leaves them). A person only needs to experience five out of nine criteria across these categories to be given a diagnosis of BPD. How is BPD treated? No medication has been approved for the treatment of BPD. Nonetheless, a large proportion of people with BPD are given medications for sustained periods of time to alleviate their symptoms. The type of medication given is chosen based on its known effects on other disorders with similar symptoms. Review question We wanted to find out whether medications to treat BPD work better or worse than placebo; whether one medication works better than another; or whether one combination of medications work better than another combination of medications. We wanted to look at how well medications worked on BPD severity, self‐harm, suicide‐related outcomes, and functioning (how well a person performs in everyday life). We also wanted to find out if medications are associated with any unwanted side effects. What did we do? We searched for studies that compared the effects of different medications with placebo, another medication, or a combination of medications, in people diagnosed with BPD. We compared and summarised the results and rated our confidence in the evidence based on factors such as sample size and methods used. Below, we present the findings from our key comparison: medication versus placebo. What did we find? We found 46 studies that involved 2769 people with BPD. The smallest study had 13 participants and the largest 451 participants. There were four studies with more than 100 participants. Except for one study that included men only, all studies included women. The average age of the participants ranged from 16 years to 39 years. Most studies were conducted in outpatient settings (31 studies) in Europe (20 studies) and lasted between four and 52 weeks. Pharmaceutical companies fully or partially funded 16 studies. The studies looked at the effects of 27 different medications, mostly classified as: 1) antipsychotics (drugs to treat psychosis where a person’s thoughts and mood are so impaired that the person has lost contact with reality); 2) antidepressants (drugs to treat depression); or 3) mood stabilisers (drugs to control and even out mood swings, reducing both high moods (mania) and low moods (depression)). Compared with placebo, medications seem to make little to no difference to BPD severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. They may make little to no difference as to whether a person continues in a study or drops out. Compared to placebo, antipsychotics and mood stabilisers may make little to no difference to the occurrence of unwanted or harmful effects. No study reported on the side effects of antidepressants. What are the limitations of the evidence? Our confidence in the evidence varied between very low and low. The results of future research could differ from the results of this review. Four main factors reduced our confidence in the evidence. First, not all of the studies provided data about everything that we were interested in. Second, the results were very inconsistent across the different studies. Third, there were not enough studies to be certain about the results of our outcomes. Fourth, many studies did not clearly report how they were conducted. How up‐to‐date is this evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Stoffers-Winterling, JM, Storebø, OJ, Pereira Ribeiro, J, Kongerslev, MT, Völlm, BA, Mattivi, JT, Faltinsen, E, Todorovac, A, Jørgensen, MS, Callesen, HE, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.823Z" }, { "id": "548d8df4-df8a-471c-8526-061d6bdd1c2e", "pmid": "", "title": "Chinese medicinal herbs for influenza", "imported": false, "abstract": "Abstract - Background Influenza is a communicable acute respiratory infection which, during epidemics, can cause high morbidity and mortality rates. Traditional Chinese medicinal herbs, often administered following a particular Chinese medical theory, may be a potential treatment of choice. Objectives To assess the effect of Chinese medicinal herbs used to prevent and treat influenza and to estimate the frequency of adverse effects. Search methods We searched CENTRAL (2012, Issue 11), MEDLINE (January 1966 to November week 2, 2012), EMBASE (January 1988 to November 2012) and CNKI (January 1988 to 29 March 2012). We also searched reference lists of articles and the WHO ICTRP search portal (November 2012). Selection criteria Randomised controlled trials (RCTs) comparing traditional Chinese medicinal herbs with placebo, no treatment or conventional medicine normally used in preventing and treating uncomplicated influenza. Data collection and analysis Two review authors independently extracted data and assessed trial quality. Main results We included 18 studies involving 2521 participants. The methodological quality of 17 included studies was poor. Included RCTs separately compared medicinal herbs with different antiviral drugs, precluding any pooling of results. Only three indicated that compared with antiviral drugs, Chinese medicinal herbs may be effective in preventing influenza and alleviating influenza symptoms. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and speeding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. Ten studies reported mild adverse reactions. Authors' conclusions Most Chinese medical herbs in the included studies showed similar effects to antiviral drugs in preventing or treating influenza. Few were shown to be superior to antiviral drugs. No obvious adverse events were reported in the included studies. However, current evidence remains weak due to methodological limitations of the trials. More high‐quality RCTs with larger numbers of participants and clear reporting are needed. Plain language summary Chinese medicinal herbs for influenza Influenza is a viral respiratory infection that causes an acute febrile illness with myalgia, headache and cough, and can result in high morbidity and mortality rates during an epidemic. Annual epidemics are thought to result in between three and five million cases of severe influenza and between 250,000 and 500,000 deaths worldwide. Currently, annual vaccination is the primary strategy for preventing influenza, and four influenza antiviral agents (amantadine, rimantadine, zanamivir and oseltamivir) have been approved for treatment of influenza. However, high levels of drug resistance have been recorded. Many Chinese medicinal herbs are used to treat and prevent this condition. This updated review assessed the therapeutic effects and safety of Chinese medicinal herbs as an alternative and adjunctive therapy to other commonly used drugs for influenza. Eighteen studies involving 2521 participants were included in the review. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and aiding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. The remaining 17 Chinese herbal trials showed a similar effect to antiviral drugs in preventing or treating influenza. However, since these included studies were of poor quality, the evidence does not support or reject the use of any Chinese herbal preparations for influenza. High‐quality trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Jiang, L, Deng, L, Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD004559.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.758Z" }, { "id": "54a28a87-6bfe-4961-8155-34738afd547b", "pmid": "", "title": "Diclofenac for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically cyclo‐oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain. Objectives To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled'). Search methods We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022. Selection criteria We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI). Main results We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low‐certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child‐reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD ‐0.45, 95% CI ‐0.74 to ‐0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD ‐0.64, 95% CI ‐0.89 to ‐0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low‐certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low‐certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results. Authors' conclusions We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non‐pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered. Plain language summary What are the benefits and harms of diclofenac for managing children's pain after they have had an operation? Key messages • Due to a lack of robust evidence, the benefits and harms of diclofenac for managing children's pain after they've had an operation are unclear. • Diclofenac probably reduces nausea and vomiting, but probably increases the risk of bleeding, compared to opioids (such as morphine). • Well‐designed and comprehensively‐reported studies are needed to shed light on the benefits and harms of diclofenac compared to opioids or other medicines, or for different ways of giving diclofenac to children. Postoperative pain management Pain after surgery or a procedure is common and can influence recovery and return to normal activities. There are many ways to reduce pain after an operation, including medicines such as diclofenac. Diclofenac is part of a class of medicines called non‐steroidal anti‐inflammatory drugs (NSAIDs) that can reduce inflammation and pain. They can be given by different routes, such as by mouth or through the anus into the rectum (back passage), and before, during, and after an operation. What did we want to find out? We wanted to find out the benefits and harms of diclofenac compared to other treatments, as well as the most effective way to deliver diclofenac to children. What did we do? We searched for studies that compared (a) diclofenac to other treatments for postoperative pain; or (b) different ways of delivering diclofenac to children. We summarised the results and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 32 studies that included 2250 children with postoperative pain. The largest study included 183 children and the smallest, 31 children. The studies were conducted in many countries around the world; the most common location was the United Kingdom (10 studies). The average age of the children was between 2 and 14 years. Diclofenac was used to manage postoperative pain in 12 different types of surgery; most commonly, ear, nose, and throat surgery (9 studies) or eye surgery (6 studies). Main results It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor and serious harms compared to a placebo (a 'dummy' or sham treatment that does not contain any medicine but looks or tastes identical to the medicine being tested). It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief or pain intensity compared to other medicines, such as opioids, paracetamol, or bupivacaine. Diclofenac probably results in less nausea and vomiting compared to opioids (7 studies involving 463 children), but probably increases the risk of any bleeding (2 studies involving 222 children), but we are very unsure about serious harms (death, long‐term disability, or hospitalisation). It is thus unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor or serious harms compared to placebo or other medicines other than opioids. It is also unclear which route (by mouth or rectal delivery) is the most effective way to manage pain after surgery in children. What are the limitations of the evidence? We are not confident in the evidence because of study design limitations, and none of the studies measured some of our main outcomes of interest. There were also not enough large studies to be certain about the results. How up to date is this evidence? The evidence is current to April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ringsten, M; Kredo, T; Ebrahim, S; Hohlfeld, A; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015087.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "54bb8b53-fa94-4314-a19a-510bd39d7654", "pmid": "", "title": "Inhaled mannitol for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Several agents are used to clear secretions from the airways of people with cystic fibrosis. Mannitol increases mucociliary clearance, but its exact mechanism of action is unknown. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents which require delivery via a nebuliser. Phase III trials of inhaled dry powder mannitol for the treatment of cystic fibrosis have been completed and it is now available in Australia and some countries in Europe. This is an update of a previous review. Objectives To assess whether inhaled dry powder mannitol is well tolerated, whether it improves the quality of life and respiratory function in people with cystic fibrosis and which adverse events are associated with the treatment. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic databases, handsearching relevant journals and abstracts from conferences. Date of last search: 12 December 2019. Selection criteria All randomised controlled studies comparing mannitol with placebo, active inhaled comparators (for example, hypertonic saline or dornase alfa) or with no treatment. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction and assessed the risk of bias in included studies. The quality of the evidence was assessed using GRADE. Main results Six studies (reported in 36 unique publications) were included with a total of 784 participants. Duration of treatment in the included studies ranged from 12 days to six months, with open‐label treatment for an additional six months in two of the studies. Five studies compared mannitol with control (a very low dose of mannitol or non‐respirable mannitol) and the final study compared mannitol to dornase alfa alone and to mannitol plus dornase alfa. Two large studies had a similar parallel design and provided data for 600 participants, which could be pooled where data for a particular outcome and time point were available. The remaining studies had much smaller sample sizes (ranging from 22 to 95) and data could not be pooled due to differences in design, interventions and population. Pooled evidence from the two large parallel studies was judged to be of low to moderate quality and from the smaller studies was judged to be of low to very low quality. In all studies, there was an initial test to see if participants tolerated mannitol, with only those who could tolerate the drug being randomised; therefore, the study results are not applicable to the cystic fibrosis population as a whole. While the published papers did not provide all the data required for our analysis, additional unpublished data were provided by the drug's manufacturer and the author of one of the studies. Pooling the large parallel studies comparing mannitol to control, up to and including six months, lung function (forced expiratory volume at one second) measured in both mL and % predicted was significantly improved in the mannitol group compared to the control group (moderate‐quality evidence). Beneficial results were observed in these studies in adults and in both concomitant dornase alfa users and non‐users in these studies. In the smaller studies, statistically significant improvements in lung function were also observed in the mannitol groups compared to the non‐respirable mannitol groups; however, we judged this evidence to be of low to very low quality. For the comparisons of mannitol and control, we found no consistent differences in health‐related quality of life in any of the domains except for burden of treatment, which was less for mannitol up to four months in the two pooled studies of a similar design; this difference was not maintained at six months. It should be noted that the tool used to measure health‐related quality of life was not designed to assess mucolytics and pooling of the age‐appropriate tools (as done in some of the included studies) may not be valid so results were judged to be low to very low quality and should be interpreted with caution. Cough, haemoptysis, bronchospasm, pharyngolaryngeal pain and post‐tussive vomiting were the most commonly reported side effects in both treatment groups. Where rates of adverse events could be compared, statistically no significant differences were found between mannitol and control groups; although some of these events may have clinical relevance for people with CF. For the comparisons of mannitol to dornase alfa alone and to mannitol plus dornase alfa, very low‐quality evidence from a 12‐week cross‐over study of 28 participants showed no statistically significant differences in the recorded domains of health‐related quality of life or measures of lung function. Cough was the most common side effect in the mannitol alone arm but there was no occurrence of cough in the dornase alfa alone arm and the most commonly reported reason of withdrawal from the mannitol plus dornase alfa arm was pulmonary exacerbations. In terms of secondary outcomes of the review (pulmonary exacerbations, hospitalisations, symptoms, sputum microbiology), evidence provided by the included studies was more limited. For all comparisons, no consistent statistically significant and clinically meaningful differences were observed between mannitol and control treatments (including dornase alfa). Authors' conclusions There is moderate‐quality evidence to show that treatment with mannitol over a six‐month period is associated with an improvement in some measures of lung function in people with cystic fibrosis compared to control. There is low to very low‐quality evidence suggesting no difference in quality of life for participants taking mannitol compared to control. This review provides very low‐quality evidence suggesting no difference in lung function or quality of life comparing mannitol to dornase alfa alone and to mannitol plus dornase alfa. The clinical implications from this review suggest that mannitol could be considered as a treatment in cystic fibrosis; but further research is required in order to establish who may benefit most and whether this benefit is sustained in the longer term. Furthermore, studies comparing its efficacy against other (established) mucolytic therapies need to be undertaken before it can be considered for mainstream practice. Plain language summary Mannitol, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of inhaling mannitol to treat lung disease in people with cystic fibrosis. Background Cystic fibrosis is a genetic disorder that affects the exocrine glands (sweat glands and others). Lung infections produce thick mucus (phlegm) which can block air passages and cause more infection and repeated inflammation. In turn, this progressively damages the lungs and can eventually cause respiratory failure. There are several drugs that are used to clear mucus from the airways of people with cystic fibrosis and inhaled dry powder mannitol is a new one that may improve their lung function. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents delivered by a nebuliser (e.g. hypertonic saline). Mannitol is available in Australia and some European countries. This is an updated version of the review. Search date The evidence is current to: 12 December 2019. Study characteristics We included six studies (with a total of 784 adults and children) in this review. Five studies compared a standard dose of mannitol with control (a very low dose of mannitol or a version of mannitol which did not allow the active drug to reach the lungs) and the sixth study compared mannitol with nebulised recombinant human deoxyribonuclease (dornase alfa), both alone and taken together. Participants could continue using dornase alfa and other standard therapies, but were excluded from the five of the six studies if they were using hypertonic saline. Treatment in these studies lasted from 12 days to six months. Five studies provided the treatments to people as outpatients and in one study, the children treated were in hospital due to pulmonary exacerbations (flare ups of disease). Key results It was difficult to combine evidence from the studies in this review due to differences in the designs of the studies, treatments examined and the settings (hospital or outpatients). Some additional information was obtained from the drug manufacturer and one study author to aid the review. The review found low‐ to very low‐quality evidence that there is no difference between mannitol and control treatments or mannitol given either with or without additional dornase alfa in terms of quality of life. There was moderate‐quality evidence of improvements in some measures of lung function across the larger studies comparing mannitol to control. Beneficial effects were also seen in the subgroup of adults and in both those who were using dornase alfa and those who were not. Cough (including coughing up blood), contraction of the airways, pain in the pharynx or larynx and post‐treatment vomiting were the most commonly reported side effects on both treatments, but there was no evidence to suggest that these side effects occurred more on mannitol than on control treatments or on dornase alfa. None of the studies compared mannitol to nebulised hypertonic saline and so we can not comment on which agent is better for airway clearance. More research is needed to answer this question. Quality of the evidence We judged the quality of the evidence from this review to be of very low to moderate quality, depending on the outcome measured. We do not think that the way the studies were designed affected the results. We judged that everyone taking part had equal chances of being in either of the treatment groups and would not have known in advance or during the study which treatment they were receiving. However, the numbers of people who dropped out of the studies might affect how the results are interpreted, as well as how many people were recruited into the studies and how they were selected from all people with cystic fibrosis who could have been included. Although some of these issues were resolved when the drug's manufacturer (who also sponsored the studies) provided some additional information. It is important to realise that before people started the study, they took a test to see if they could tolerate mannitol and only those who did could carry on. This means that the results of the studies only apply to those people with cystic fibrosis who can tolerate mannitol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Nevitt, SJ, Thornton, J, Murray, CS, Dwyer, T", "articleTypes": [], "doi": "10.1002/14651858.CD008649.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.097Z" }, { "id": "54cb95ce-f8a3-4f25-b280-6f8a4a404a7c", "pmid": "", "title": "Prophylactic drug management for febrile seizures in children", "imported": false, "abstract": "Abstract - Background Febrile seizures occurring in a child older than one month during an episode of fever affect 2‐4% of children in Great Britain and the United States and recur in 30%. Rapid‐acting antiepileptics and antipyretics given during subsequent fever episodes have been used to avoid the adverse effects of continuous antiepileptic drugs. This is an updated version of a Cochrane Review previously published in 2017. Objectives To evaluate primarily the effectiveness and safety of antiepileptic and antipyretic drugs used prophylactically to treat children with febrile seizures; and also to evaluate any other drug intervention where there is a sound biological rationale for its use. Search methods For the latest update we searched the following databases on 3 February 2020: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to 31 January 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including the Cochrane Epilepsy Group. We imposed no language restrictions and contacted researchers to identify continuing or unpublished studies. Selection criteria Trials using randomised or quasi‐randomised participant allocation that compared the use of antiepileptics, antipyretics or recognised Central Nervous System active agents with each other, placebo, or no treatment. Data collection and analysis For the original review, two review authors independently applied predefined criteria to select trials for inclusion and extracted the predefined relevant data, recording methods for randomisation, blinding, and exclusions. For the 2016 update, a third review author checked all original inclusions, data analyses, and updated the search. For the 2020 update, one review author updated the search and performed the data analysis following a peer‐review process with the original review authors. We assessed seizure recurrence at 6, 12, 18, 24, 36, 48 months, and where data were available at age 5 to 6 years along with recorded adverse effects. We evaluated the presence of publication bias using funnel plots. Main results We included 42 articles describing 32 randomised trials, with 4431 randomised participants used in the analysis of this review. We analysed 15 interventions of continuous or intermittent prophylaxis and their control treatments. Methodological quality was moderate to poor in most studies. We found no significant benefit for intermittent phenobarbital, phenytoin, valproate, pyridoxine, ibuprofen, or zinc sulfate versus placebo or no treatment; nor for diclofenac versus placebo followed by ibuprofen, paracetamol, or placebo; nor for continuous phenobarbital versus diazepam, intermittent rectal diazepam versus intermittent valproate, or oral diazepam versus clobazam. There was a significant reduction of recurrent febrile seizures with intermittent diazepam versus placebo or no treatment at six months (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.48 to 0.85; 6 studies, 1151 participants; moderate‐certainty evidence), 12 months (RR 0.69, 95% CI 0.56 to 0.84; 8 studies, 1416 participants; moderate‐certainty evidence), 18 months (RR 0.37, 95% CI 0.23 to 0.60; 1 study, 289 participants; low‐certainty evidence), 24 months (RR 0.73, 95% CI 0.56 to 0.95; 4 studies, 739 participants; high‐certainty evidence), 36 months (RR 0.58, 95% CI 0.40 to 0.85; 1 study, 139 participants; low‐certainty evidence), 48 months (RR 0.36, 95% CI 0.15 to 0.89; 1 study, 110 participants; moderate‐certainty evidence), with no benefit at 60 to 72 months (RR 0.08, 95% CI 0.00 to 1.31; 1 study, 60 participants; very low‐certainty evidence). Phenobarbital versus placebo or no treatment reduced seizures at six months (RR 0.59, 95% CI 0.42 to 0.83; 6 studies, 833 participants; moderate‐certainty evidence), 12 months (RR 0.54, 95% CI 0.42 to 0.70; 7 studies, 807 participants; low‐certainty evidence), and 24 months (RR 0.69, 95% CI 0.53 to 0.89; 3 studies, 533 participants; moderate‐certainty evidence), but not at 18 months (RR 0.77, 95% CI 0.56 to 1.05; 2 studies, 264 participants) or 60 to 72 months follow‐up (RR 1.50, 95% CI 0.61 to 3.69; 1 study, 60 participants; very low‐certainty evidence). Intermittent clobazam compared to placebo at six months resulted in a RR of 0.36 (95% CI 0.20 to 0.64; 1 study, 60 participants; low‐certainty evidence), an effect found against an extremely high (83.3%) recurrence rate in the controls, a result that needs replication. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months (RR 0.45, 95% CI 0.18 to 1.15; 1 study, 60 participants; very‐low certainty evidence). When compared to placebo, intermittent oral levetiracetam significantly reduced recurrent seizures at 12 months (RR 0.27, 95% CI 0.15 to 0.52; 1 study, 115 participants; very low‐certainty evidence). The recording of adverse effects was variable. Two studies reported lower comprehension scores in phenobarbital‐treated children. Adverse effects were recorded in up to 30% of children in the phenobarbital‐treated groups and 36% in benzodiazepine‐treated groups. We found evidence of publication bias in the meta‐analyses of comparisons for phenobarbital versus placebo (seven studies) at 12 months but not at six months (six studies); and valproate versus placebo (four studies) at 12 months. There were too few studies to identify publication bias for the other comparisons. The methodological quality of most of the included studies was low or very low. Methods of randomisation and allocation concealment often did not meet current standards, and 'treatment versus no treatment' was more commonly seen than 'treatment versus placebo', leading to obvious risks of bias. Authors' conclusions We found reduced recurrence rates for intermittent diazepam and continuous phenobarbital, with adverse effects in up to 30% of children. The apparent benefit for clobazam treatment in one trial needs to be replicated. Levetiracetam also shows benefit with a good safety profile; however, further study is required. Given the benign nature of recurrent febrile seizures, and the high prevalence of adverse effects of these drugs, parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. Plain language summary Prophylactic drug management for febrile seizures in children Background Seizures occurring with a fever (febrile seizures) in children are common and affect about one in 30 children under the age of six years. On average, one out of three children who have had a febrile seizure will have at least one more. We reviewed the evidence about the effect of drugs to prevent seizures (antiepileptics), drugs to lower temperature (antipyretics), and zinc in children with febrile seizures. Objective We wanted to know in how many children these drugs would prevent a recurrence of febrile seizures or cause unwanted effects. Methods We included 32 studies with a total of 4431 children in the review. Children who had had at least one febrile seizure were assigned to one of two or more treatment groups. The studies recorded any further seizures at various time intervals between six months and up to six years of age in each group. Unwanted medication effects were also noted. Results The study design and evidence quality in the studies of antiepileptic drugs was often low or very low. Poor methods known to lead to obvious risks of bias were used. One issue was with the methods used to assign children to study groups and how random this allocation was. Other issues included whether the parents or doctors, or both, knew which group each child was in or if a treatment was compared to no treatment with no placebo (dummy pill) used. The quality of the trials of antipyretics or zinc was better, with the evidence assessed as moderate to high. Zinc therapy was found to provide no benefit. We also found no benefit in treating children just at the time of the fever with either antipyretic drugs or most antiepileptic drugs. A significant result was noted in some instances. For example, at times between 6 and 48 months follow‐up, intermittent diazepam (an antiepileptic drug) led to a reduction in the number of recurrent seizures by about a third. Continuous phenobarbital resulted in significantly fewer recurrences at 6, 12, and 24 months, but not at 18 and 60 to 72 months. One study showed that intermittent oral levetiracetam compared to placebo significantly reduced recurrent seizures at 12 months. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months. However, as recurrent seizures are only seen in about a third of children, this means that up to 16 children would have to be treated over a year or two to save just one child a further seizure. As febrile seizures are not harmful, we viewed these significant findings to be unimportant, in particular because adverse effects of the medications were common. Lower comprehension scores in phenobarbital‐treated children were found in two studies. In general, adverse effects were recorded in up to about a third of children in both the phenobarbital‐ and benzodiazepine‐treated groups. The benefit found for treatment with clobazam in one study published in 2011 needs to be repeated to test its reliability. Levetiracetam may be useful in treating children where family anxiety over possible seizure recurrence is high, but further study is required. Authors' conclusions There is currently insufficient evidence to support the use of continuous or intermittent treatment with zinc, antiepileptic or antipyretic drugs for children with febrile seizures. Febrile seizures can be frightening to witness. Parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. The evidence is current to February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Offringa, M; Newton, R; Nevitt, SJ; Vraka, K", "articleTypes": [], "doi": "10.1002/14651858.CD003031.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "54e2bf93-e043-4a14-883a-efca4dbf053c", "pmid": "", "title": "Colchicine for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The development of severe coronavirus disease 2019 (COVID‐19) and poor clinical outcomes are associated with hyperinflammation and a complex dysregulation of the immune response. Colchicine is an anti‐inflammatory medicine and is thought to improve disease outcomes in COVID‐19 through a wide range of anti‐inflammatory mechanisms. Patients and healthcare systems need more and better treatment options for COVID‐19 and a thorough understanding of the current body of evidence. Objectives To assess the effectiveness and safety of Colchicine as a treatment option for COVID‐19 in comparison to an active comparator, placebo, or standard care alone in any setting, and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising CENTRAL, MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv), Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index), and WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions to 21 May 2021. Selection criteria We included randomised controlled trials evaluating colchicine for the treatment of people with COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We excluded studies investigating the prophylactic effects of colchicine for people without severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection but at high risk of SARS‐CoV‐2 exposure. Data collection and analysis We followed standard Cochrane methodology. We used the Cochrane risk of bias tool (ROB 2) to assess bias in included studies and GRADE to rate the certainty of evidence for the following prioritised outcome categories considering people with moderate or severe COVID‐19: all‐cause mortality, worsening and improvement of clinical status, quality of life, adverse events, and serious adverse events and for people with asymptomatic infection or mild disease: all‐cause mortality, admission to hospital or death, symptom resolution, duration to symptom resolution, quality of life, adverse events, serious adverse events. Main results We included three RCTs with 11,525 hospitalised participants (8002 male) and one RCT with 4488 (2067 male) non‐hospitalised participants. Mean age of people treated in hospital was about 64 years, and was 55 years in the study with non‐hospitalised participants. Further, we identified 17 ongoing studies and 11 studies completed or terminated, but without published results. Colchicine plus standard care versus standard care (plus/minus placebo) Treatment of hospitalised people with moderate to severe COVID‐19 All‐cause mortality : colchicine plus standard care probably results in little to no difference in all‐cause mortality up to 28 days compared to standard care alone (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.93 to 1.08; 2 RCTs, 11,445 participants; moderate‐certainty evidence). Worsening of clinical status : colchicine plus standard care probably results in little to no difference in worsening of clinical status assessed as new need for invasive mechanical ventilation or death compared to standard care alone (RR 1.02, 95% CI 0.96 to 1.09; 2 RCTs, 10,916 participants; moderate‐certainty evidence). Improvement of clinical status : colchicine plus standard care probably results in little to no difference in improvement of clinical status, assessed as number of participants discharged alive up to day 28 without clinical deterioration or death compared to standard care alone (RR 0.99, 95% CI 0.96 to 1.01; 1 RCT, 11,340 participants; moderate‐certainty evidence). Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is very uncertain about the effect of colchicine on adverse events compared to placebo (RR 1.00, 95% CI 0.56 to 1.78; 1 RCT, 72 participants; very low‐certainty evidence). Serious adverse events : the evidence is very uncertain about the effect of colchicine plus standard care on serious adverse events compared to standard care alone (0 events observed in 1 RCT of 105 participants; very low‐certainty evidence). Treatment of non‐hospitalised people with asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 All‐cause mortality : the evidence is uncertain about the effect of colchicine on all‐cause mortality at 28 days (Peto odds ratio (OR) 0.57, 95% CI 0.20 to 1.62; 1 RCT, 4488 participants; low‐certainty evidence). Admission to hospital or death within 28 days : colchicine probably slightly reduces the need for hospitalisation or death within 28 days compared to placebo (RR 0.80, 95% CI 0.62 to 1.03; 1 RCT, 4488 participants; moderate‐certainty evidence). Symptom resolution : we identified no studies reporting this outcome. Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is uncertain about the effect of colchicine on adverse events compared to placebo . Results are from one RCT reporting treatment‐related events only in 4412 participants (low‐certainty evidence). Serious adverse events : colchicine probably slightly reduces serious adverse events (RR 0.78, 95% CI 0.61 to 1.00; 1 RCT, 4412 participants; moderate‐certainty evidence). Colchicine versus another active treatment (e.g. corticosteroids, anti‐viral drugs, monoclonal antibodies) No studies evaluated this comparison. Different formulations, doses, or schedules of colchicine No studies assessed this. Authors' conclusions Based on the current evidence, in people hospitalised with moderate to severe COVID‐19 the use of colchicine probably has little to no influence on mortality or clinical progression in comparison to placebo or standard care alone. We do not know whether colchicine increases the risk of (serious) adverse events. We are uncertain about the evidence of the effect of colchicine on all‐cause mortality for people with asymptomatic infection or mild disease. However, colchicine probably results in a slight reduction of hospital admissions or deaths within 28 days, and the rate of serious adverse events compared with placebo. None of the studies reported data on quality of life or compared the benefits and harms of colchicine versus other drugs, or different dosages of colchicine. We identified 17 ongoing and 11 completed but not published RCTs, which we expect to incorporate in future versions of this review as their results become available. Editorial note: due to the living approach of this work, we monitor newly published results of RCTs on colchicine on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Is colchicine an effective treatment for people with COVID‐19? Key messages ○ In hospitalised people with moderate to severe COVID‐19, colchicine probably has little to no benefit; we are uncertain about its side effects. ○In non‐hospitalised people with no symptoms or mild COVID‐19, we are uncertain whether colchicine prevents deaths or side effects, however it probably reduces the need for hospitalisation or death and serious side effects slightly. ○ Future studies should assess quality of life in people with no symptoms or mild COVID‐19 and non‐serious side effects and compare colchicine to other medicines for COVID‐19, such as corticosteroids. What is colchicine? Colchicine is a medicine used to reduce swelling and inflammation and may consequently relieve pain. It is often used to treat gout, a condition where people’s joints become swollen and painful. On the other hand, colchicine can be harmful to people with some health conditions, such as kidney or liver problems, or if you take too much of it. How might colchicine treat COVID‐19? Since colchicine is an anti‐inflammatory drug; researchers are interested in whether it might help with reducing inflammation caused by COVID‐19. What did we want to find out? We wanted to know whether colchicine is an effective treatment for people with COVID‐19 compared to placebo (a treatment that looks and tastes the same as colchicine but with no active ingredient) or usual care alone. We looked at people with moderate or severe disease being treated in hospital or with mild disease being treated in the community. We were particularly interested in the effects of colchicine on: ○ number of deaths; ○ whether people’s condition worsened or improved; ○ quality of life; ○ serious and non‐serious side effects What did we do? We searched for studies that compared colchicine together with usual care to usual care (plus/minus placebo). Studies could take place anywhere in the world and include people with mild or no symptoms, moderate or severe COVID‐19, of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our certainty in the evidence, based on factors such as study methods and sizes. What did we find? We identified four eligible randomised trials. Three included 11,525 hospitalised people and one included 4488 non‐hospitalised people. For hospitalised people, the average age was 64 years, and for non‐hospitalised people, the average age was 55 years. Two studies compared colchicine and usual care with usual care alone and 2 studies compared colchicine with usual care and placebo. None of the studies reported quality of life. We also found 17 ongoing studies and 11 completed but unpublished studies. Main results Hospitalised people with moderate to severe COVID‐19 (3 studies, 11,525 people) ○Colchicine probably does not reduce deaths in the 28 days after treatment (2 studies, 11,445 people). ○Colchicine probably does not prevent the worsening of patients’ condition (2 studies, 10,916 people) and probably does not improve it (1 study, 11,340 people). ○We are very uncertain about the effect of colchicine on side effects and serious side effects (2 studies, 177 people). Non‐hospitalised people with no symptoms or mild COVID‐19 (1 study, 4488 people) ○We are uncertain whether colchicine prevents deaths up to 28 days after treatment. ○Colchicine probably slightly reduces the risk of hospitalisation or death. ○We are uncertain about the effect of colchicine on side effects, but it probably slightly reduces serious side effects. What are the limitations of the evidence? Our certainty in the evidence is limited. Two studies did not use a placebo, so everybody knew who was treated with colchicine, which could influence the results. There were too few events for non‐hospitalised people, such as admissions to hospital and deaths, to be certain about the evidence. Studies used different ways to assess and report unwanted effects, so we could not combine studies into a single result to make a judgement. How up to date is this evidence? The evidence is up to date to 21 May 2021. Editorial note: this is a living systematic review. We search for new evidence every week and update the review when we identify relevant new evidence. Refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Mikolajewska, A, Fischer, A-L, Piechotta, V, Mueller, A, Metzendorf, M-I, Becker, M, Dorando, E, Pacheco, RL, Martimbianco, ALC, Riera, R, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015045", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.796Z" }, { "id": "54e3ef53-ce65-4cff-b4ff-620c213dff99", "pmid": "", "title": "Antibiotics for the induction and maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Antibiotics have been considered to treat ulcerative colitis (UC) due to their antimicrobial properties against intestinal bacteria linked to inflammation. However, there are concerns about their efficacy and safety. Objectives To determine whether antibiotic therapy is safe and effective for the induction and maintenance of remission in people with UC. Search methods We searched five electronic databases on 10 December 2021 for randomised controlled trials (RCTs) comparing antibiotic therapy to placebo or an active comparator. Selection criteria We considered people with UC of all ages, treated with antibiotics of any type, dose, and route of administration for inclusion. Induction studies required a minimum duration of two weeks for inclusion. Maintenance studies required a minimum duration of three months to be considered for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcome for induction studies was failure to achieve remission and for maintenance studies was relapse, as defined by the primary studies. Main results We included 12 RCTs (847 participants). One maintenance of remission study used sole antibiotic therapy compared with 5‐aminosalicylic acid (5‐ASA). All other trials used concurrent medications or standard care regimens and antibiotics as an adjunct therapy or compared antibiotics with other adjunct therapies to examine the effect on induction of remission. There is high certainty evidence that antibiotics (154/304 participants) compared to placebo (175/304 participants) result in no difference in failure to achieve clinical remission (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.06). A subgroup analysis found no differences when steroids, steroids plus 5‐ASA, or steroids plus 5‐ASA plus probiotics were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (102/168 participants) compared to placebo (121/175 participants) may result in no difference in failure to achieve clinical response (RR 0.75, 95% CI 0.47 to 1.22). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (6/342 participants) compared to placebo (5/349 participants) may result in no difference in serious adverse events (RR 1.19, 95% CI 0.38 to 3.71). A subgroup analysis found no differences when steroids were additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (3/342 participants) compared to placebo (1/349 participants) may result in no difference in withdrawals due to adverse events (RR 2.06, 95% CI 0.27 to 15.72). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were additional therapies to antibiotics and placebo. It is unclear if there is any difference between antibiotics in combination with probiotics compared to no treatment or placebo for failure to achieve clinical remission (RR 0.68, 95% CI 0.39 to 1.19), serious adverse events (RR 1.00, 95% CI 0.07 to 15.08), or withdrawals due to adverse events (RR 1.00, 95% CI 0.07 to 15.08). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to achieve clinical remission (RR 2.20, 95% CI 1.17 to 4.14). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to probiotics for failure to achieve clinical remission (RR 0.47, 95% CI 0.23 to 0.94). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to maintain clinical remission (RR 0.71, 95% CI 0.47 to 1.06). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to no treatment for failure to achieve clinical remission in a mixed population of people with active and inactive disease (RR 0.56, 95% CI 0.29 to 1.07). The certainty of the evidence is very low. For all other outcomes, no effects could be estimated due to a lack of data. Authors' conclusions There is high certainty evidence that there is no difference between antibiotics and placebo in the proportion of people who achieve clinical remission at the end of the intervention period. However, there is evidence that there may be a greater proportion of people who achieve clinical remission and probably a greater proportion who achieve clinical response with antibiotics when compared with placebo at 12 months. There may be no difference in serious adverse events or withdrawals due to adverse events between antibiotics and placebo. No clear conclusions can be drawn for any other comparisons. A clear direction for future research appears to be comparisons of antibiotics and placebo (in addition to standard therapies) with longer‐term measurement of outcomes. Additionally. As there were single studies of other head‐to‐head comparisons, there may be scope for future studies in this area. Plain language summary The use of antibiotics in the treatment of ulcerative colitis What was the aim of this review? This Cochrane Review aimed to determine whether antibiotics are useful and safe for people with ulcerative colitis (UC) in achieving or maintaining remission. Key messages We found that antibiotics, when added to standard therapies, are similar to placebo in how often they fail to achieve remission or disease improvement for people with UC, measured up to three months from taking them. We found that antibiotics when compared to placebo may be useful in achieving remission or some improvement of UC symptoms, measured at 12 months from taking them. In terms of safety, the evidence is of low certainty, but antibiotics may be as safe as placebo. We have confidence in the findings up to three months, but have less confidence in the evidence at 12 months due to low numbers of study participants. What is ulcerative colitis? UC is a chronic (long term) inflammatory disease that affects the large bowel. The most common symptoms include bloody diarrhoea, abdominal pain, and a sudden almost uncontrollable urge to pass stool. Some people have other symptoms including sore joints, mouth sores, and inflammation in their eyes. When someone is experiencing symptoms of UC, they are said to have 'active' disease. When symptoms improve with treatment, the disease is said to be responding to therapy. When symptoms stop, the disease is said to be in 'remission'. People with UC in remission are often given therapy with medicines to try and prolong (maintain) their remission or response to therapy. What did the review study? This review studied the use of antibiotics in the treatment of UC. Eleven studies considered antibiotics as a therapy for achieving remission and one study as therapy for maintaining remission. Antibiotics could theoretically be helpful as they might be able to fight harmful bacteria in the gut that are thought to be a partial cause for the presence of UC symptoms. Currently, most doctors do not recommend the use of antibiotics unless the patient has an infection. What were the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing antibiotics with another treatment or dummy treatment. We found 12 RCTs including 847 participants. The trials looked at people of all ages; using different types and doses of antibiotics; and at antibiotics taken as tablets, injections, or any other way. The main results from our review are as follows. 1. Antibiotics, when added to standard therapies, are no different from placebo in failing to achieve remission or improve disease symptoms for people with UC when measured up to three months from taking them. 2. Antibiotics probably fail less than placebo in achieving remission or some improvement of UC symptoms measured at 12 months from taking them. 3. In terms of safety, antibiotics may be similar to placebo, but the evidence is of low certainty. 4. We are uncertain about how antibiotics compare to other treatments because there is not enough good evidence to make a judgement. Conclusion There is no difference between antibiotics and placebo when added to standard therapies to achieve remission or improvement of symptoms in the short term. However, they may help to lessen the number of people who do not achieve remission, and they probably lead to fewer numbers of people who have not achieved improvement of symptoms at 12 months. No conclusions can be drawn on other treatments or safety due to lack of evidence, even though there may be a possibility that antibiotics are as safe as placebo. Further research would be needed to clarify the usefulness of antibiotics in the treatment of UC; however, such studies should focus on longer‐term outcomes given the findings of this review. How up‐to‐date is this review? This review is up‐to‐date as of December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Gordon, M; Sinopoulou, V; Grafton-Clarke, C; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "54e642ee-103f-45bc-af99-e78544176aea", "pmid": "", "title": "Oral zinc for the prevention of hyperbilirubinaemia in neonates", "imported": false, "abstract": "Abstract - Background Between 6% and 15% of neonates develop hyperbilirubinaemia requiring treatment. Successful management of neonatal hyperbilirubinaemia relies on prevention and early treatment, with phototherapy being the mainstay of treatment. Oral zinc has been reported to decrease the serum total bilirubin (STB), presumably by decreasing the enterohepatic circulation. Objectives To determine the effect of oral zinc supplementation compared to placebo or no treatment on the incidence of hyperbilirubinaemia in neonates during the first week of life and to assess the safety of oral zinc in enrolled neonates. Search methods We searched CENTRAL (The Cochrane Library 2014, Issue 1), MEDLINE (1966 to November 30, 2014), and EMBASE (1990 to November 30, 2014). Selection criteria Randomised controlled trials were eligible for inclusion if they enrolled neonates (term and preterm) to whom oral zinc, in a dose of 10 to 20 mg/day, was initiated within the first 96 hours of life, for any duration until day seven, compared with no treatment or placebo. Data collection and analysis We used the standard methods of The Cochrane Collaboration and its Neonatal Review Group for data collection and analysis. Main results Only one study met the criteria of inclusion in the review. This study compared oral zinc with placebo. Oral zinc was administered in a dose of 5 mL twice daily from day 2 to day 7 postpartum. The drug was administered into the mouth of the infant by the plastic measure provided with the bottle or with a spoon. Incidence of hyperbilirubinaemia, defined as serum total bilirubin (STB) ≥ 15 mg/dL, was similar between groups (N = 286; risk ratio (RR) 0.94, 95% confidence interval (CI) 0.58 to 1.52). Mean STB levels, mg/dL, at 72 ± 12 hours were comparable in both the groups (N = 286; mean difference (MD) ‐0.20; 95% CI ‐1.03 to 0.63). Although the duration of phototherapy in the zinc group was significantly shorter compared to the placebo group (N = 286; MD ‐12.80, 95% CI ‐16.93 to ‐8.67), the incidence of need for phototherapy was comparable across both the groups (N = 286; RR 1.20; 95% CI 0.66 to 2.18). Incidences of side effects like vomiting (N = 286; RR 0.65, 95% CI 0.19 to 2.25), diarrhoea (N = 286; RR 2.92, 95% CI 0.31 to 27.71), and rash (N = 286; RR 2.92, 95% CI 0.12 to 71.03) were found to be rare and statistically comparable between groups. Authors' conclusions The limited evidence available has not shown that oral zinc supplementation given to infants up to one week old reduces the incidence of hyperbilirubinaemia or need for phototherapy. Plain language summary Oral zinc for the prevention of hyperbilirubinaemia in neonates Review question In newborn infants less than one week old, does oral zinc salt supplementation compared to placebo or no treatment decrease the incidence of hyperbilirubinaemia (jaundice)? Background Jaundice, or yellowish discolouration of the skin, can occur due to an increased amount of bilirubin pigment in the blood. It is a commonly observed and usually harmless condition in newborn infants during the first week after birth. However, in some babies, the amount of bilirubin pigment can increase to dangerous levels and necessitate treatment. Bilirubin is metabolised in the liver and is excreted via the intestine in faeces. Increased reabsorption of bilirubin from the intestine is one of the major factors inducing hyperbilirubinaemia in newborn infants. Oral zinc salt, a relatively harmless medicine, can reduce the bilirubin level in newborn infants by decreasing its reabsorption from the intestine. Study characteristics Researchers from Cochrane searched for all available literature up to 30 November 2014. One randomised controlled trial met our inclusion criteria. Results In this review, the efficacy of oral zinc salt was compared with placebo. One study enrolling 294 infants was identified. This study evaluated oral zinc salt, given in a dose of 5 mg twice daily to infants between 25 and 168 hours old. The administration of oral zinc salt did not affect the incidence of jaundice (hyperbilirubinaemia) in these infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mishra, S; Cheema, A; Agarwal, R; Deorari, A; Paul, V", "articleTypes": [], "doi": "10.1002/14651858.CD008432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "54ee2ee8-aa87-40b8-b2c9-1c8f08c746ce", "pmid": "", "title": "Oral anti‐diabetic pharmacological therapies for the treatment of women with gestational diabetes", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is a major public health issue with rates increasing globally. Gestational diabetes, glucose intolerance first recognised during pregnancy, usually resolves after birth and is associated with short‐ and long‐term complications for the mother and her infant. Treatment options can include oral anti‐diabetic pharmacological therapies. Objectives To evaluate the effects of oral anti‐diabetic pharmacological therapies for treating women with GDM. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (14 May 2016), ClinicalTrials.gov , WHO ICTRP (14 May 2016) and reference lists of retrieved studies. Selection criteria We included published and unpublished randomised controlled trials assessing the effects of oral anti‐diabetic pharmacological therapies for treating pregnant women with GDM. We included studies comparing oral anti‐diabetic pharmacological therapies with 1) placebo/standard care, 2) another oral anti‐diabetic pharmacological therapy, 3) combined oral anti‐diabetic pharmacological therapies. Trials using insulin as the comparator were excluded as they are the subject of a separate Cochrane systematic review. Women with pre‐existing type 1 or type 2 diabetes were excluded. Data collection and analysis Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and data were checked for accuracy. Main results We included 11 studies (19 publications) (1487 women and their babies). Eight studies had data that could be included in meta‐analyses. Studies were conducted in Brazil, India, Israel, UK, South Africa and USA. The studies varied in diagnostic criteria and treatment targets for glycaemic control for GDM. The overall risk of bias was 'unclear' due to inadequate reporting of methodology. Using GRADE the quality of the evidence ranged from moderate to very low quality . Evidence was downgraded for risk of bias (reporting bias, lack of blinding), inconsistency, indirectness, imprecision and for oral anti‐diabetic therapy versus placebo for generalisability. Oral anti‐diabetic pharmacological therapies versus placebo/standard care There was no evidence of a difference between glibenclamide and placebo groups for hypertensive disorders of pregnancy (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.81 to 1.90; one study, 375 women, very low‐quality evidence), birth by caesarean section (RR 1.03, 95% CI 0.79 to 1.34; one study, 375 women, very low‐quality evidence), perineal trauma (RR 0.98, 95% CI 0.06 to 15.62; one study, 375 women, very low‐quality evidence) or induction of labour (RR 1.18, 95% CI 0.79 to 1.76; one study, 375 women; very low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant, there was no evidence of a difference in the risk of being born large‐for‐gestational age (LGA) between infants whose mothers had been treated with glibenclamide and those in the placebo group (RR 0.89, 95% CI 0.51 to 1.58; one study, 375, low‐quality evidence). No data were reported for other infant primary or GRADE outcomes (perinatal mortality, death or serious morbidity composite, neurosensory disability in later childhood, neonatal hypoglycaemia, adiposity, diabetes). Metformin versus glibenclamide There was no evidence of a difference between metformin‐ and glibenclamide‐treated groups for the risk of hypertensive disorders of pregnancy (RR 0.70, 95% CI 0.38 to 1.30; three studies, 508 women, moderate‐quality evidence), birth by caesarean section (average RR 1.20, 95% CI 1.20; 95% CI 0.83 to 1.72, four studies, 554 women, I 2 = 61%, Tau 2 = 0.07 low‐quality evidence), induction of labour (0.81, 95% CI 0.61 to 1.07; one study, 159 women; low‐quality evidence) or perineal trauma (RR 1.67, 95% CI 0.22 to 12.52; two studies, 158 women; low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant there was no evidence of a difference between the metformin‐ and glibenclamide‐exposed groups for the risk of being born LGA (average RR 0.67, 95% CI 0.24 to 1.83; two studies, 246 infants, I 2 = 54%, Tau 2 = 0.30 low‐quality evidence). Metformin was associated with a decrease in a death or serious morbidity composite (RR 0.54, 95% CI 0.31 to 0.94; one study, 159 infants, low‐quality evidence). There was no clear difference between groups for neonatal hypoglycaemia (RR 0.86, 95% CI 0.42 to 1.77; four studies, 554 infants, low‐quality evidence) or perinatal mortality (RR 0.92, 95% CI 0.06 to 14.55, two studies, 359 infants). No data were reported for neurosensory disability in later childhood or for adiposity or diabetes. Glibenclamide versus acarbose There was no evidence of a difference between glibenclamide and acarbose from one study (43 women) for any of their maternal or infant primary outcomes (caesarean section, RR 0.95, 95% CI 0.53 to 1.70; low‐quality evidence; perinatal mortality ‐ no events; low‐quality evidence; LGA , RR 2.38, 95% CI 0.54 to 10.46; low‐quality evidence). There was no evidence of a difference between glibenclamide and acarbose for neonatal hypoglycaemia (RR 6.33, 95% CI 0.87 to 46.32; low‐quality evidence). There were no data reported for other pre‐specified GRADE or primary maternal outcomes (hypertensive disorders of pregnancy, development of type 2 diabetes, perineal trauma, return to pre‐pregnancy weight, postnatal depression, induction of labour) or neonatal outcomes (death or serious morbidity composite, adiposity or diabetes). Authors' conclusions There were insufficient data comparing oral anti‐diabetic pharmacological therapies with placebo/standard care (lifestyle advice) to inform clinical practice. There was insufficient high‐quality evidence to be able to draw any meaningful conclusions as to the benefits of one oral anti‐diabetic pharmacological therapy over another due to limited reporting of data for the primary and secondary outcomes in this review. Short‐ and long‐term clinical outcomes for this review were inadequately reported or not reported. Current choice of oral anti‐diabetic pharmacological therapy appears to be based on clinical preference, availability and national clinical practice guidelines. The benefits and potential harms of one oral anti‐diabetic pharmacological therapy compared with another, or compared with placebo/standard care remains unclear and requires further research. Future trials should attempt to report on the core outcomes suggested in this review, in particular long‐term outcomes for the woman and the infant that have been poorly reported to date, women's experiences and cost benefit. Plain language summary Oral medication for the treatment of women with gestational diabetes What is the issue? Globally the number of women being diagnosed with gestational diabetes mellitus (GDM) is increasing. GDM is an intolerance to glucose leading to high blood sugars, first recognised during pregnancy and usually resolving after birth. Standard care involves lifestyle advice on diet and exercise. Treatment for some women includes oral anti‐diabetic medications, such as metformin and glibenclamide, which are an alternative to, or can be used alongside, insulin to control the blood sugar. This review aimed to investigate benefits of taking oral medication to treat GDM in pregnant women. Another Cochrane Review compares the effects of insulin with oral anti‐diabetic pharmacological therapies ( Brown 2016 ). Why is this important? Women diagnosed with GDM are at a greater risk of experiencing complications such as high blood pressure during pregnancy and at birth. They have an increased risk of developing diabetes later in life. The babies of women who have been diagnosed with GDM can be larger than normal and this can cause injuries to the mother and the baby at birth. The birth is more likely to be induced or the baby born by caesarean section. These babies are at risk of developing diabetes as children or young adults. Finding the best medications to treat the women and prevent the complications that are linked to GDM is therefore important. What evidence did we find? We searched for studies on 14 May 2016. We included 11 randomised controlled trials involving 1487 mothers and their babies (but only eight trials contributed data to our analyses). The evidence was limited by the quality and number of studies and we advise caution when looking at the results. The criteria for diagnosis of GDM and treatment targets varied between studies, and each outcome is based on few studies with low numbers of women. Three studies compared oral medication with placebo/standard care but the following findings are from a single study (375 women). The quality of the evidence was very low or low. We found no differences between the oral medication and placebo group for the risk of high blood pressure, birth by caesarean section, induction of labour or perineal trauma. The number of babies born large‐for‐gestational age, with low blood sugars or dying at birth was not clearly different between the groups. Two studies (434 women) reported no difference in the need for insulin between the oral medication and placebo group. Six studies compared metformin with glibenclamide. The quality of the evidence was very low to moderate. We found no difference between metformin and glibenclamide for the risk of high blood pressure (three studies, 508 women, moderate‐quality evidence), birth by caesarean section (four studies, 554 women, low‐quality evidence), perineal trauma (two studies, 308 women, low‐quality evidence) or induction of labour (one study, 159 women, low‐quality evidence). We found no difference between metformin and glibenclamide for the baby having low blood sugars (four studies, 554 infants, low‐quality evidence), being born large‐for‐gestational age (two studies, 246 infants) or dying at birth (all low‐ or very low‐quality evidence). In one study, the babies of the mothers taking metformin were at reduced risk of having any serious outcome (low blood sugar, jaundice, being born large, breathing problems, injury at birth or death combined) (low‐quality evidence). One small study (43 women) comparing glibenclamide with acarbose reported no differences in outcomes for mothers or their babies. None of the included studies provided any data on many of the outcomes pre‐specified in this review, including long‐term outcomes for the mother or for the baby as a child or an adult. What does this mean? There is not enough high‐quality evidence available to guide us on if oral medication has better outcomes for women with gestational diabetes, and their babies, compared with a placebo or if one oral medication has better health outcomes than another oral medication. Because we are still unclear, further research is needed. Future studies should be encouraged to report on the outcomes suggested in this review and in particular the long‐term outcomes for the woman and the infant that have been poorly reported to date.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Brown, J; Martis, R; Hughes, B; Rowan, J; Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD011967.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "54f8c9d4-2ca1-47cc-85a7-fcf1afe92f2a", "pmid": "", "title": "Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years", "imported": false, "abstract": "Abstract - Background Zinc deficiency is prevalent in low‐ and middle‐income countries, and is considered a significant risk factor for morbidity, mortality, and linear growth failure. The effectiveness of preventive zinc supplementation in reducing prevalence of zinc deficiency needs to be assessed. Objectives To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged 6 months to 12 years. Search methods A previous version of this review was published in 2014. In this update, we searched CENTRAL, MEDLINE, Embase, five other databases, and one trials register up to February 2022, together with reference checking and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) of preventive zinc supplementation in children aged 6 months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalized children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions. Data collection and analysis Two review authors screened studies, extracted data, and assessed the risk of bias. We contacted study authors for missing information and used GRADE to assess the certainty of evidence. The primary outcomes of this review were all‐cause mortality; and cause‐specific mortality, due to all‐cause diarrhea, lower respiratory tract infection (LRTI, including pneumonia), and malaria. We also collected information on a number of secondary outcomes, such as those related to diarrhea and LRTI morbidity, growth outcomes and serum levels of micronutrients, and adverse events. Main results We included 16 new studies in this review, resulting in a total of 96 RCTs with 219,584 eligible participants. The included studies were conducted in 34 countries; 87 of them in low‐ or middle‐income countries. Most of the children included in this review were under five years of age. The intervention was delivered most commonly in the form of syrup as zinc sulfate, and the most common dose was between 10 mg and 15 mg daily. The median duration of follow‐up was 26 weeks. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes was affected by risk of bias. High‐certainty evidence showed little to no difference in all‐cause mortality with preventive zinc supplementation compared to no zinc (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.84 to 1.03; 16 studies, 17 comparisons, 143,474 participants). Moderate‐certainty evidence showed that preventive zinc supplementation compared to no zinc likely results in little to no difference in mortality due to all‐cause diarrhea (RR 0.95, 95% CI 0.69 to 1.31; 4 studies, 132,321 participants); but probably reduces mortality due to LRTI (RR 0.86, 95% CI 0.64 to 1.15; 3 studies, 132,063 participants) and mortality due to malaria (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 42,818 participants); however, the confidence intervals around the summary estimates for these outcomes were wide, and we could not rule out a possibility of increased risk of mortality. Preventive zinc supplementation likely reduces the incidence of all‐cause diarrhea (RR 0.91, 95% CI 0.90 to 0.93; 39 studies, 19,468 participants; moderate‐certainty evidence) but results in little to no difference in morbidity due to LRTI (RR 1.01, 95% CI 0.95 to 1.08; 19 studies, 10,555 participants; high‐certainty evidence) compared to no zinc. There was moderate‐certainty evidence that preventive zinc supplementation likely leads to a slight increase in height (standardized mean difference (SMD) 0.12, 95% CI 0.09 to 0.14; 74 studies, 20,720 participants). Zinc supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46; 5 studies, 35,192 participants; high‐certainty evidence). We report a number of other outcomes, including the effect of zinc supplementation on weight and serum markers such as zinc, hemoglobin, iron, copper, etc. We also performed a number of subgroup analyses and there was a consistent finding for a number of outcomes that co‐supplementation of zinc with iron decreased the beneficial effect of zinc. Authors' conclusions Even though we included 16 new studies in this update, the overall conclusions of the review remain unchanged. Zinc supplementation might help prevent episodes of diarrhea and improve growth slightly, particularly in children aged 6 months to 12 years of age. The benefits of preventive zinc supplementation may outweigh the harms in regions where the risk of zinc deficiency is relatively high. Plain language summary Is zinc supplementation effective for preventing death and disease, and for promoting growth, in children aged 6 months to 12 years and does it cause unwanted effects? Key messages ‐ Zinc supplementation in children aged 6 months to 12 years makes little to no difference to all‐cause mortality and probably makes no difference to deaths from diarrea. Zinc supplementation probably reduces mortality due to lower respiratory tract infections and malaria but a small possibility of increased risk of mortality cannot be ruled out. ‐ Zinc supplementation in children aged 6 months to 12 years might prevent illness due to diarrhea, but might lead to vomiting after supplementation. It might lead to a small increase in height gain. Why is it important to study zinc supplementation? Zinc is an essential micronutrient. It is important to help children grow normally and to promote a healthy immune system. Lack of zinc may lead to diarrhea, pneumonia, malaria and even death. Low dietary zinc intake is often linked to poverty. As many as half of all children in low‐ and middle‐income countries may have zinc deficiency. Meat, fish, eggs and dairy products are good natural sources of zinc, but are expensive. Lack of clean water and poor sanitation increases exposure to diseases, which zinc might help to fight. The human body cannot produce or store zinc, so giving dietary supplements is important. What did we want to find out? We wanted to find out if giving children zinc supplements helps prevent child death and disease, and promotes growth. What did we do? We searched for studies that randomly assigned children aged 6 months to 12 years to receive zinc supplementation or no zinc. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 96 studies in the review, with 219,584 children. Studies took place in 34, mainly low‐ to middle‐income countries. Most of the children in the studies were under five years old. Zinc was most commonly given as a syrup (zinc sulfate), and the most common dose was between 10 mg and 15 mg daily. We found that giving children zinc supplementation might lead to a small to no reduction in the risk of death for any reason and the risk of death due to diarrhea. The risk of death due to lower respiratory tract infections or malaria may be reduced. Children given zinc experienced less disease due to diarrhea than children not given zinc; however, zinc does not seem to reduce children's risk of respiratory infection. Zinc supplementation may have a small positive effect on growth. Children who take zinc supplementation may experience vomiting as an unwanted effect. What are the limitations of the evidence? We are confident about our results on the effects of zinc supplements on reducing the risk of death due to any cause, illness due to respiratory infection, and occurrence of vomiting after supplementation. Our confidence in the results for our other outcomes was moderate because relatively few studies reported these outcomes and because studies sometimes reported different results from other studies for the same outcomes. How up to date is this evidence? This review updates a previous version published in 2014. The evidence is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Imdad, A, Rogner, J, Sherwani, RN, Sidhu, J, Regan, A, Haykal, MR, Tsistinas, O, Smith, A, Chan, XHS, Mayo-Wilson, E, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD009384.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.788Z" }, { "id": "5527bd7c-5c33-48dc-b9e7-9e822750a2ea", "pmid": "", "title": "Pine bark (Pinus spp.) extract for treating chronic disorders", "imported": false, "abstract": "Abstract - Background Pine bark ( Pinus spp.) extract is rich in bioflavonoids, predominantly proanthocyanidins, which are antioxidants. Commercially‐available extract supplements are marketed for preventing or treating various chronic conditions associated with oxidative stress. This is an update of a previously published review. Objectives To assess the efficacy and safety of pine bark extract supplements for treating chronic disorders. Search methods We searched three databases and three trial registries; latest search: 30 September 2019. We contacted the manufacturers of pine bark extracts to identify additional studies and hand‐searched bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) evaluating pine bark extract supplements in adults or children with any chronic disorder. Data collection and analysis Two authors independently assessed trial eligibility, extracted data and assessed risk of bias. Where possible, we pooled data in meta‐analyses. We used GRADE to evaluate the certainty of evidence. Primary outcomes were participant‐ and investigator‐reported clinical outcomes directly related to each disorder and all‐cause mortality. We also assessed adverse events and biomarkers of oxidative stress. Main results This review included 27 RCTs (22 parallel and five cross‐over designs; 1641 participants) evaluating pine bark extract supplements across 10 chronic disorders: asthma (two studies; 86 participants); attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), cardiovascular disease (CVD) and risk factors (seven studies; 338 participants), chronic venous insufficiency (CVI) (two studies; 60 participants), diabetes mellitus (DM) (six studies; 339 participants), erectile dysfunction (three studies; 277 participants), female sexual dysfunction (one study; 83 participants), osteoarthritis (three studies; 293 participants), osteopenia (one study; 44 participants) and traumatic brain injury (one study; 60 participants). Two studies exclusively recruited children; the remainder recruited adults. Trials lasted between four weeks and six months. Placebo was the control in 24 studies. Overall risk of bias was low for four, high for one and unclear for 22 studies. In adults with asthma, we do not know whether pine bark extract increases change in forced expiratory volume in one second (FEV 1 ) % predicted/forced vital capacity (FVC) (mean difference (MD) 7.70, 95% confidence interval (CI) 3.19 to 12.21; one study; 44 participants; very low‐certainty evidence), increases change in FEV 1 % predicted (MD 7.00, 95% CI 0.10 to 13.90; one study; 44 participants; very low‐certainty evidence), improves asthma symptoms (risk ratio (RR) 1.85, 95% CI 1.32 to 2.58; one study; 60 participants; very low‐certainty evidence) or increases the number of people able to stop using albuterol inhalers (RR 6.00, 95% CI 1.97 to 18.25; one study; 60 participants; very low‐certainty evidence). In children with ADHD, we do not know whether pine bark extract decreases inattention and hyperactivity assessed by parent‐ and teacher‐rating scales (narrative synthesis; one study; 57 participants; very low‐certainty evidence) or increases the change in visual‐motoric coordination and concentration (MD 3.37, 95% CI 2.41 to 4.33; one study; 57 participants; very low‐certainty evidence). In participants with CVD, we do not know whether pine bark extract decreases diastolic blood pressure (MD ‐3.00 mm Hg, 95% CI ‐4.51 to ‐1.49; one study; 61 participants; very low‐certainty evidence); increases HDL cholesterol (MD 0.05 mmol/L, 95% CI ‐0.01 to 0.11; one study; 61 participants; very low‐certainty evidence) or decreases LDL cholesterol (MD ‐0.03 mmol/L, 95% CI ‐0.05 to 0.00; one study; 61 participants; very low‐certainty evidence). In participants with CVI, we do not know whether pine bark extract decreases pain scores (MD ‐0.59, 95% CI ‐1.02 to ‐0.16; one study; 40 participants; very low‐certainty evidence), increases the disappearance of pain (RR 25.0, 95% CI 1.58 to 395.48; one study; 40 participants; very low‐certainty evidence) or increases physician‐judged treatment efficacy (RR 4.75, 95% CI 1.97 to 11.48; 1 study; 40 participants; very low‐certainty evidence). In type 2 DM, we do not know whether pine bark extract leads to a greater reduction in fasting blood glucose (MD 1.0 mmol/L, 95% CI 0.91 to 1.09; one study; 48 participants;very low‐certainty evidence) or decreases HbA1c (MD ‐0.90 %, 95% CI ‐1.78 to ‐0.02; 1 study; 48 participants; very low‐certainty evidence). In a mixed group of participants with type 1 and type 2 DM we do not know whether pine bark extract decreases HbA1c (MD ‐0.20 %, 95% CI ‐1.83 to 1.43; one study; 67 participants; very low‐certainty evidence). In men with erectile dysfunction, we do not know whether pine bark extract supplements increase International Index of Erectile Function‐5 scores (not pooled; two studies; 147 participants; very low‐certainty evidence). In women with sexual dysfunction, we do not know whether pine bark extract increases satisfaction as measured by the Female Sexual Function Index (MD 5.10, 95% CI 3.49 to 6.71; one study; 75 participants; very low‐certainty evidence) or leads to a greater reduction of pain scores (MD 4.30, 95% CI 2.69 to 5.91; one study; 75 participants; very low‐certainty evidence). In adults with osteoarthritis of the knee, we do not know whether pine bark extract decreases composite Western Ontario and McMaster Universities Osteoarthritis Index scores (MD ‐730.00, 95% CI ‐1011.95 to ‐448.05; one study; 37 participants; very low‐certainty evidence) or the use of non‐steroidal anti‐inflammatory medication (MD ‐18.30, 95% CI ‐25.14 to ‐11.46; one study; 35 participants; very low‐certainty evidence). We do not know whether pine bark extract increases bone alkaline phosphatase in post‐menopausal women with osteopenia (MD 1.16 ug/L, 95% CI ‐2.37 to 4.69; one study; 40 participants; very low‐certainty evidence). In individuals with traumatic brain injury, we do not know whether pine bark extract decreases cognitive failure scores (MD ‐2.24, 95% CI ‐11.17 to 6.69; one study; 56 participants; very low‐certainty evidence) or post‐concussion symptoms (MD ‐0.76, 95% CI ‐5.39 to 3.87; one study; 56 participants; very low‐certainty evidence). For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. Authors' conclusions Small sample sizes, limited numbers of RCTs per condition, variation in outcome measures, and poor reporting of the included RCTs mean no definitive conclusions regarding the efficacy or safety of pine bark extract supplements are possible. Plain language summary Using pine bark supplements to help treat a variety of chronic diseases Review question Can pine bark antioxidant supplements help to treat chronic diseases? Background The main ingredients in pine bark extract supplements are proanthocyanidins, which are antioxidants. These supplements are marketed to prevent or treat a wide range of chronic diseases. This is an update of a previously published review, where we assessed how well these supplements work for treating chronic diseases, as well as their safety. Search date The evidence is current to 30 September 2019. Study characteristics We included 27 studies (1641 participants) across 10 chronic diseases. These included: asthma (two studies; 86 participants), attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), heart disease and risk factors (seven studies; 332 participants), chronic venous insufficiency (leg veins not working effectively; two studies; 60 participants), diabetes (six studies; 336 participants), erectile dysfunction (three studies; 227 participants), female sexual dysfunction (one study; 75 participants), osteoarthritis (cartilage damage in joints; three studies; 293 participants), osteopenia (beginning of bone mass loss; one study; 44 participants) and traumatic brain injury (one study; 56 participants). Two of the studies were conducted exclusively in children; the others were in adults. Studies compared pine bark supplements with placebo (i.e. a dummy supplement) or non‐antioxidant interventions and participants were randomly selected for one treatment or the other. The duration of treatment ranged from four weeks to six months. Key results For most outcomes across the different chronic diseases we only included one study with a small number of participants. In adults with asthma, we do not know whether pine bark extract increases lung function, improves asthma symptoms or increases the number of people able to stop using albuterol inhalers (a specific type of asthma pump).
In children with ADHD, we do not know whether pine bark supplements decrease inattention and hyperactivity (assessed by parents and teachers) or whether it increases co‐ordination and concentration.
In people with heart disease we do not know if pine bark supplements decrease blood pressure and LDL cholesterol (the bad type) or whether it increases HDL cholesterol (the good type).
In adults with chronic venous insufficiency we do not know whether pine bark supplements decrease pain, increase the number of people free of pain, or how well doctors think the treatment works. In people with type 2 diabetes, we do not know whether pine bark supplements improve blood sugar levels or HbA1c levels (the long‐term marker for measuring blood sugar control); we also do not know if pine bark supplements decrease HbA1c in people with type 1 or type 2 diabetes.
In men with erectile dysfunction, we do not know if pine bark supplements increase erectile function. Similarly, in women with sexual dysfunction, we do not know if pine bark supplements increase sexual satisfaction or reduce pain.
In adults with osteoarthritis, it is not clear if pine bark supplements improve pain, swelling or stiffness in the knee, or whether it decreases the use of anti‐inflammatory drugs. We also do not know if pine bark supplements increase bone formation in postmenopausal women with weakened bones. Lastly, in people with a traumatic brain injury, it is not clear if pine bark supplements improve memory and post‐concussion symptoms . For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. With the available studies, we cannot clearly say how well (or not) pine bark supplements work and whether they are safe. Quality of the evidence The overall risk of bias was low for four studies, high for one and unclear for 22 studies. By this we mean the extent to which the methods used in a study enable it to determine the truth. The certainty of evidence was very low for all outcomes across all chronic diseases in the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Robertson, NU; Schoonees, A; Brand, A; Visser, J", "articleTypes": [], "doi": "10.1002/14651858.CD008294.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "5532ce3f-cf86-47d6-afc8-77756ae25d4f", "pmid": "", "title": "Chinese herbal medicine for schizophrenia", "imported": false, "abstract": "Abstract - Background Traditional Chinese medicine (TCM) was the main form of treatment in China for psychiatric illnesses until the development of antipsychotic drugs in the 1950's. Antipsychotic drugs have become the primary intervention for schizophrenia, although herbal medicines can still form part of the treatment. Objectives To review Chinese herbal medicine, used alone or as part of a TCM approach, for people with schizophrenia and related psychoses. Search methods We undertook electronic searches of the Cochrane Schizophrenia Group's register (December 2003), the Traditional Chinese Medical Literature Analysis and Retrieval Database (TCMLARS) (October 2003), Chinese Biomedical Database (CBM) (December 2003), China National Knowledge Infrastructure Database (May 2004), Complementary Medicine Database (AMED) (December 2003). We contacted the Chinese Cochrane Centre, the Cochrane Complementary Medicine Field and first authors of included studies and inspected reference lists for additional studies. Selection criteria We included all relevant randomised controlled trials involving people with schizophrenia‐like illnesses, allocated to Chinese herbal medicine, including any Chinese herbs (single or mixture), compared with placebo/no treatment or antipsychotic drugs. We updated this search July 2012 and added 45 new trials to the awaiting classification section. Data collection and analysis We independently extracted data and calculated fixed effects relative risk (RR), the 95% confidence intervals (CI) for homogeneous dichotomous data, and, where appropriate, the number needed to treat (NNT) on an intention‐to‐treat basis. For continuous data, we calculated weighted mean differences (WMD). Main results Only one small trial of the seven included studies truly evaluated TCM for schizophrenia. The other trials evaluated Chinese herbs for schizophrenia. We found one study comparing Chinese herbal medicine with antipsychotic drugs. Data for the global state outcome 'no change/worse' favoured people allocated to antipsychotic medication (n=90, RR 1.88 CI 1.2 to 2.9, NNH 4 CI 2 to 12). Six trials compared Chinese herbal medicine in combination with antipsychotic with antipsychotic drugs alone. One trial found global state 'not improved/worse' favoured the herbal medicine/antipsychotic combination (n=123, RR 0.19 CI 0.1 to 0.6, NNT 6 CI 5 to 11). Two studies (n=103) also found short‐term data from the Clinical Global Impression scale favoured the herbal medicine plus antipsychotic group (WMD ‐0.46 CI ‐0.9 to ‐0.1) compared with those given only antipsychotics. Significantly fewer people in the experimental group left the study early compared with those given antipsychotics alone (n=1004, 6 RCTs, RR 0.30 CI 0.16 to 0.58, NNT 21 CI 18 to 35). Reports of constipation were significantly lower in the treatment group compared to those receiving antipsychotics (n=67, 1 RCT, RR 0.03 CI 0.0 to 0.5, NNH 2 CI 2 to 4). Authors' conclusions Chinese herbal medicines, given in a Western biomedical context, may be beneficial for people with schizophrenia when combined with antipsychotics. Traditional Chinese medicine is also under‐evaluated, but results from one pioneering study that attempted to evaluate TCM should encourage further trials. Note: the 45 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed. Plain language summary Chinese herbal medicine for schizophrenia Antipsychotic medication is the mainstay of treatment for people with schizophrenia, and although effective, still leaves some people with distressing symptoms and/or disabling adverse effects. Safer and more effective health care interventions are needed. Traditional Chinese medicine (TCM) has been used to treat mental health disorders, including schizophrenia, for more than 2000 years. Chinese herbs may also have antipsychotic properties when used in a Western biomedical context. In this review we sought and found trials relevant to the effects of both approaches for schizophrenia. Traditional Chinese medicine methodology has been evaluated for schizophrenia, but the one included study was too limited in terms of sample size and study length to guide good practice. However, this pioneering study does show that TCM can be evaluated for its efficacy for people with schizophrenia , and should encourage trialists to undertake further, more comprehensive trials in this area. The use of Chinese herbs in a Western medicine context, without incorporating TCM methodology, has been evaluated in six trials, although again these are limited by their sample size and study length. The results of these six trials suggest that using Chinese herbs alone for psychotic symptoms may not be indicated, but if used in conjunction with Western antipsychotic drugs, they may be beneficial in terms of mental state, global functioning and decrease of adverse effects. However, further trials are needed before the effects of TCM for people with schizophrenia can be evaluated with any real confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Rathbone, J, Zhang, L, Zhang, M, Xia, J, Liu, X, Yang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD003444.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.815Z" }, { "id": "553d4180-26d6-4eae-96fd-430132c69757", "pmid": "", "title": "Antiamoebic drugs for treating amoebic colitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gonzales, MLM, Dans, LF, Sio‐Aguilar, J", "articleTypes": [], "doi": "10.1002/14651858.CD006085.pub3 AB - Abstract - Background Infection with the protozoan Entamoeba histolytica is common in low‐ and middle‐income countries, and up to 100,000 people with severe disease die every year. Adequate therapy for amoebic colitis is necessary to reduce illness, prevent development of complicated disease and extraintestinal spread, and decrease transmission. Objectives To evaluate antiamoebic drugs for treating amoebic colitis. Search methods We searched the available literature up to 22 March 2018. We searched the Cochrane Infectious Diseases Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, m RCT, and conference proceedings. We contacted individual researchers, organizations, and pharmaceutical companies, and we checked reference lists. Selection criteria Randomized controlled trials of antiamoebic drugs given alone or in combination, compared with placebo or another antiamoebic drug, for treating adults and children with a diagnosis of amoebic colitis. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of trials and extracted and analysed the data. We calculated clinical and parasitological failure rates and rates of relapse and adverse events as risk ratios (RRs) with 95% confidence intervals (CIs), using a random‐effects model. We determined statistical heterogeneity and explored possible sources of heterogeneity using subgroup analyses. We carried out sensitivity analysis by using trial quality to assess the robustness of reported results. Main results In total, 41 trials (4999 participants) met the inclusion criteria of this review. In this update, we added four trials to the 37 trials included in the first published review version. Thirty trials were published over 20 years ago. Only one trial used adequate methods of randomization and allocation concealment, was blinded, and analysed all randomized participants. Only one trial used an E histolytica stool antigen test, and two trials used amoebic culture. Tinidazole may be more effective than metronidazole for reducing clinical failure (RR 0.28, 95% CI 0.15 to 0.51; 477 participants, eight trials; low‐certainty evidence) and is probably associated with fewer adverse events (RR 0.65, 95% CI 0.46 to 0.92; 477 participants, 8 trials; moderate‐certainty evidence). Compared with metronidazole, combination therapy may result in fewer parasitological failures (RR 0.36, 95% CI 0.15 to 0.86; 720 participants, 3 trials; low‐certainty evidence), but we are uncertain which combination is more effective than another. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Authors' conclusions Compared with metronidazole, tinidazole may be more effective in reducing clinical failure and may be associated with fewer adverse events. Combination drug therapy may be more effective for reducing parasitological failure compared with metronidazole alone. However, these results are based mostly on small trials conducted over 20 years ago with a variety of poorly defined outcomes. Tests that detect E histolytica more accurately are needed, particularly in countries where concomitant infection with other bacteria and parasites is common. 11 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (22 Mar, 2018) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Antiamoebic drugs for treating amoebic colitis What is the aim of this review? This Cochrane Review aims to determine the effectiveness and safety of drugs used to treat people with amoebic colitis, which is an infection of the large intestines caused by the parasite, Entamoeba histolytica . Cochrane researchers searched for all relevant studies to answer this question and included 41 relevant studies in this review. Key messages Tinidazole may be more effective than metronidazole for reducing clinical symptoms and may be associated with fewer adverse events. Combination therapy resulted in fewer parasitological failures than occurred with metronidazole alone. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Better quality randomized trials using accurate diagnostic methods and standardized outcomes are needed to evaluate the efficacy of drugs for treating individuals with amoebic colitis. What was studied in the review? Entamoeba histolytica is distributed throughout the world and is commonly acquired by ingestion of contaminated food or water. An estimated 40 to 50 million people infected with E histolytica develop amoebic colitis or extraintestinal abscesses, resulting in up to 100,000 deaths per year. Metronidazole is currently the standard therapy for treating adults and children with invasive amoebiasis, but it may not be sufficient to eliminate amoebic cysts from the intestine. Some unpleasant adverse effects have been associated with metronidazole, and the possibility of parasite resistance to metronidazole has led to the development of alternative drugs. Combinations of metronidazole with other drugs that eradicate surviving cysts in the intestines have been recommended, so evidence to support this approach needs to be assessed. This review compares different drugs used against amoebic colitis, alone or in combination, and also assesses single‐dose regimens versus longer regimens. What are the main results of the review? This review included 41 studies, most of which were conducted in countries considered to be highly endemic for amoebiasis. Most trials were old: 30 were conducted before 1998. Trials varied in the inclusion criteria used to enrol participants and in the definition and timing of measured outcomes. Stool microscopy with direct wet saline smear was the method used most often to detect the presence of E histolytica in stools. Study participants ranged in age from seven months to 80 years. Included trials reported a variety of comparisons and involved 25 individual drugs, two herbal products, and 15 different combinations. The review shows that in individuals with amoebic colitis, tinidazole may be better for reducing clinical symptoms (low‐certainty evidence) and probably results in fewer adverse events when compared with metronidazole (moderate‐certainty evidence). However, we do not know whether it is more effective for eradicating amoebae from the stools. Combination drug therapy may be more effective than metronidazole alone for eradicating amoebae (low‐certainty evidence), but we are uncertain which drug combination is most effective, and if combination treatment will lead to more rapid resolution of clinical symptoms or in more adverse events (very low‐certainty evidence). Evidence is insufficient to allow conclusions regarding efficacy of the other antiamoebic drugs. How up‐to‐date is this review? 
 The review authors searched for studies that had been published up to 22 March 2018.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.748Z" }, { "id": "554670f2-0cfe-4a37-9ee9-114788c466ac", "pmid": "", "title": "Interventions for reducing inflammation in familial Mediterranean fever", "imported": false, "abstract": "Abstract - Background Familial Mediterranean fever (FMF), a hereditary auto‐inflammatory disease, mainly affects ethnic groups living in the Mediterranean region. Early studies reported colchicine may potentially prevent FMF attacks. For people who are colchicine‐resistant or intolerant, drugs such as anakinra, rilonacept, canakinumab, etanercept, infliximab or adalimumab might be beneficial. This is an update of the review last published in 2018. Objectives To evaluate the efficacy and safety of interventions for reducing inflammation in people with FMF. Search methods We searched CENTRAL, MEDLINE, Embase and four Chinese databases on in August 2021. We searched clinical trials registries and references listed in relevant reports. The last search was 17 August 2021. Selection criteria We included randomized controlled trials (RCTs) of people with FMF, comparing active interventions (including colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (herbal dietary supplement)) with placebo or no treatment, or comparing active drugs to each other. Data collection and analysis We used standard Cochrane methodology. We assessed certainty of the evidence using GRADE. Main results We included 10 RCTs with 312 participants (aged three to 53 years), including five parallel and five cross‐over designed studies. Six studies used oral colchicine, one used oral ImmunoGuard, and the remaining three used rilonacept, anakinra or canakinumab as a subcutaneous injection. The duration of each study arm ranged from one to eight months. There were inadequacies in the design of the four older colchicine studies and the two studies comparing a single to a divided dose of colchicine. However, the four studies of ImmunoGuard, rilonacept, anakinra and canakinumab were generally well‐designed. We aimed to report on the number of participants experiencing an attack, the timing of attacks, the prevention of amyloid A amyloidosis, adverse drug reactions and the response of a number of biochemical markers from the acute phase of an attack; but no study reported on the prevention of amyloid A amyloidosis. Colchicine (oral) versus placebo After three months, colchicine 0.6 mg three times daily may reduce the number of people experiencing attacks (risk ratio (RR) 0.21, 95% confidence interval (CI) 0.05 to 0.95; 1 study, 10 participants; low‐certainty evidence). One study (20 participants) of colchicine 0.5 mg twice daily showed there may be no difference in the number of participants experiencing attacks at two months (RR 0.78, 95% CI 0.49 to 1.23; low‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; very low‐certainty evidence), or in the number of days between attacks: (narrative summary; very low‐certainty evidence). Regarding adverse drug reactions, one study reported loose stools and frequent bowel movements and a second reported diarrhea (narrative summary; both very low‐certainty evidence). There were no data on acute‐phase response. Rilonacept versus placebo There is probably no difference in the number of people experiencing attacks at three months (RR 0.87, 95% CI 0.59 to 1.26; moderate‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; low‐certainty evidence) or in the number of days between attacks (narrative summary; low‐certainty evidence). Regarding adverse drug reactions, the rilonacept study reported there may be no differences in gastrointestinal symptoms, hypertension, headache, respiratory tract infections, injection site reactions and herpes, compared to placebo (narrative summary; low‐certainty evidence). The study narratively reported there may be no differences in acute‐phase response indicators after three months (low‐certainty evidence). ImmunoGuard versus placebo The ImmunoGuard study observed there are probably no differences in adverse effects (moderate‐certainty evidence) or in acute‐phase response indicators after one month of treatment (moderate‐certainty evidence). No data were reported for the number of people experiencing an attack, duration of attacks or days between attacks. Anakinra versus placebo A study of anakinra given to 25 colchicine‐resistant participants found there is probably no difference in the number of participants experiencing an attack at four months (RR 0.76, 95% CI 0.54 to 1.07; moderate‐certainty evidence). There were no data for duration of attacks or days between attacks. There are probably no differences between anakinra and placebo with regards to injection site reaction, headache, presyncope, dyspnea and itching (narrative summary; moderate‐certainty evidence). For acute‐phase response, anakinra probably reduced C‐reactive protein (CRP) after four months (narrative summary; moderate‐certainty evidence). Canakinumab versus placebo Canakinumab probably reduces the number of participants experiencing an attack at 16 weeks (RR 0.41, 95% CI 0.26 to 0.65; 1 study, 63 colchicine‐resistant participants; moderate‐certainty evidence). There were no data for the duration of attacks or days between attacks. The included study reported the number of serious adverse events per 100 patient‐years was probably 42.7 with canakinumab versus 97.4 with placebo among people with colchicine‐resistant FMF (moderate‐certainty evidence). For acute‐phase response, canakinumab probably caused a higher proportion of participants to have a CRP level of 10 mg/L or less compared to placebo (68% with canakinumab versus 6% with placebo; 1 study, 63 participants; moderate‐certainty evidence). Colchicine single dose versus divided dose There is probably no difference in the duration of attacks at three months (MD −0.04 hours, 95% CI −10.91 to 10.83) or six months (MD 2.80 hours, 95% CI −5.39 to 10.99; moderate‐certainty evidence). There were no data for the number of participants experiencing an attack or days between attacks. There is probably no difference in adverse events (including anorexia, nausea, diarrhea, abdominal pain, vomiting and elevated liver enzymes) between groups (narrative summary; moderate‐certainty evidence). For acute‐phase response, there may be no evidence of a difference between groups (narrative summary; low‐ to moderate‐certainty evidence). Authors' conclusions There were limited RCTs assessing interventions for people with FMF. Based on the evidence, three times daily colchicine may reduce the number of people experiencing attacks, colchicine single dose and divided dose may not be different for children with FMF, canakinumab probably reduces the number of people experiencing attacks, and anakinra or canakinumab probably reduce CRP in colchicine‐resistant participants; however, only a few RCTs contributed data for analysis. Further RCTs examining active interventions, not only colchicine, are necessary before a comprehensive conclusion regarding the efficacy and safety of interventions for reducing inflammation in FMF can be drawn. Plain language summary Medicines for reducing inflammation in people with familial Mediterranean fever Review question Can treatments such as colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (a herbal supplement)) reduce inflammation in people with familial Mediterranean fever (FMF)? Background FMF is a hereditary inflammatory disease, with symptoms of an attack often including fever over 38 °C, pain and inflammation of the membrane surrounding the chest cavity, the joints or the lungs. We wanted to discover whether these medicines were better for reducing inflammation for people with FMF than placebo (a dummy treatment containing no active medicine) or no treatment, and also to compare these medicines with each other. Search date The evidence is current to 17 August 2021. Study characteristics The review included 10 studies with 312 people with FMF aged between three and 53 years. Eight studies compared five medicines, colchicine, rilonacept, ImmunoGuard, anakinra and canakinumab, with placebo. Participants received one medicine or placebo at random over one to four months. The remaining two studies compared colchicine 1 mg per day once daily with colchicine two or three times daily in children for six to eight months. Key results We aimed to report on the number of participants experiencing an attack, the timing of attacks, prevention of amyloid A amyloidosis (which is a reaction to a chronic inflammatory disease or infection leading to a build‐up of an abnormal protein called amyloid in organs and tissues throughout the body stopping them working properly), and any side effects of treatment and the levels of a number of markers of inflammation during an attack. Not all studies reported these outcomes. Given the differences in treatments and study design, it was not possible to combine any of the results that we did obtain from these studies. One study (15 participants) with oral colchicine 0.6 mg three times a day and another study (63 participants) with subcutaneous (under the skin) canakinumab 150 mg every four weeks for 16 weeks may help to reduce the numbers of people with attacks of FMF. However, oral colchicine 0.5 mg twice a day (20 participants), rilonacept (14 participants) or anakinra (25 participants) did not reduce the numbers of people with attacks. ImmunoGuard (24 participants) did not reduce levels of the markers of inflammation in the blood which are raised during the attack phase of FMF; these include the rate of fall of red blood cells when placed in a test tube, the white blood cell count and the presence of C‐reactive protein (a protein that is produced in the liver). Anakinra and canakinumab reduced C‐reactive protein levels. Colchicine taken once daily and two or three times daily might not result in different outcomes including the timing of attacks, sider effects of the medicine and acute‐phase response indicators. Quality of the evidence Four studies were well‐designed, while the others had some design problems that might have affected the results. Four studies did not report clearly how the people were assigned to each treatment group. Four studies did not report whether researchers, who assessed the study outcomes, knew which individuals were assigned to which treatment. Four studies did not clearly explain the reasons for people withdrawing from a study and one study had a high percentage of participants who did not complete study. We could not confirm whether each planned outcome was reported in five studies. Five studies did not report the severity of FMF in groups at the beginning of treatment. We judged the evidence for the reported outcomes to be of moderate to very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Yin, X, Tian, F, Wu, B, Xu, T", "articleTypes": [], "doi": "10.1002/14651858.CD010893.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.124Z" }, { "id": "556273eb-30e0-4b83-8493-bbe9447316b0", "pmid": "", "title": "Homeopathic Oscillococcinum® for preventing and treating influenza and influenza‐like illness", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mathie, RT, Frye, J, Fisher, P", "articleTypes": [], "doi": "10.1002/14651858.CD001957.pub6 AB - Abstract - Background Influenza is a highly infectious viral disease that is particularly common in the winter months. Oscillococcinum ® is a patented homeopathic medicine that is made from a 1% solution of wild duck heart and liver extract, which is then serially diluted 200 times with water and alcohol. Objectives To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Search methods We searched CENTRAL (2014, Issue 8), MEDLINE (1966 to August week 4, 2014), MEDLINE In‐Process & Other Non‐Indexed Citations (4 September 2014), AMED (2006 to September 2014), Web of Science (1985 to September 2014), LILACS (1985 to September 2014) and EMBASE (1980 to September 2014). We contacted the manufacturers of Oscillococcinum ® for information on further trials. Selection criteria Randomised, placebo‐controlled trials of Oscillococcinum ® in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Data collection and analysis Three review authors independently extracted data and assessed risk of bias in the eligible trials. Main results No new trials were included in this 2014 update. We included six studies: two prophylaxis trials (327 young to middle‐aged adults in Russia) and four treatment trials (1196 teenagers and adults in France and Germany). The overall standard of trial reporting was poor and hence many important methodological aspects of the trials had unclear risk of bias. There was no statistically significant difference between the effects of Oscillococcinum ® and placebo in the prevention of influenza‐like illness: risk ratio (RR) 0.48, 95% confidence interval (CI) 0.17 to 1.34, P value = 0.16. Two treatment trials (judged as 'low quality') reported sufficient information to allow full data extraction: 48 hours after commencing treatment, there was an absolute risk reduction of 7.7% in the frequency of symptom relief with Oscillococcinum ® compared with that of placebo (risk difference (RD) 0.077, 95% CI 0.03 to 0.12); the RR was 1.86 (95% CI 1.27 to 2.73; P value = 0.001). A significant but lesser effect was observed at three days (RR 1.27, 95% CI 1.03 to 1.56; P value = 0.03), and no significant difference between the groups was noted at four days (RR 1.11, 95% CI 0.98 to 1.27; P value = 0.10) or at five days (RR 1.06, 95% CI 0.96 to 1.16; P value = 0.25). One of the six studies reported one patient who suffered an adverse effect (headache) from taking Oscillococcinum ® . Authors' conclusions There is insufficient good evidence to enable robust conclusions to be made about Oscillococcinum ® in the prevention or treatment of influenza and influenza‐like illness. Our findings do not rule out the possibility that Oscillococcinum ® could have a clinically useful treatment effect but, given the low quality of the eligible studies, the evidence is not compelling. There was no evidence of clinically important harms due to Oscillococcinum ® . Plain language summary Homeopathic Oscillococcinum ® for preventing and treating influenza and influenza‐like illness Review question 
 To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Background 
 Influenza ('the flu') is a highly infectious viral respiratory disease. Other than treatments for complications (such as pneumonia), the conventional medical strategies for the prevention or treatment of flu are not entirely effective or satisfactory. Oscillococcinum ® is a highly diluted homeopathic preparation manufactured from wild duck heart and liver, which may be reservoirs of flu viruses. Some people take Oscillococcinum ® regularly over the winter months either to prevent flu or as a treatment for flu symptoms. Study characteristics 
 We included six studies, which comprised two prevention trials (a total of 327 young to middle‐aged adults in Russia) and four treatment trials (a total of 1196 teenagers and adults in France and Germany). Key results 
 The findings from the two prevention trials did not show that Oscillococcinum ® can prevent the onset of flu. Although the results from the four other clinical trials suggested that Oscillococcinum ® relieved flu symptoms at 48 hours, this might be due to bias in the trial methods. One patient reported headache after taking Oscillococcinum ® . The evidence is current to September 2014. Quality of the evidence 
 The overall standard of research reporting was poor, and thus many aspects of the trials' methods and results were at unclear risk of bias. We therefore judged the evidence overall as low quality, preventing clear conclusions from being made about Oscillococcinum ® in the prevention or treatment of flu and flu‐like illness.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.093Z" }, { "id": "55650069-08c1-4082-bffc-abdfac7bc3ed", "pmid": "", "title": "Graft interposition for preventing Frey's syndrome in patients undergoing parotidectomy", "imported": false, "abstract": "Abstract - Background Frey's syndrome is characterised by transient flushing and sometimes facial sweating in the area of the auriculotemporal nerve. It most commonly occurs after parotidectomy, but other causes may include submandibular gland surgery, mandibular condylar fracture, obstetric (forceps) trauma, sympathectomy and metabolic disease. Although the pathophysiology of Frey's syndrome remains controversial, the generally accepted hypothesis is that it occurs as the result of injury to the auriculotemporal nerve. There is currently no clear evidence to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome, therefore the prevention of this symptom during surgery is important. The main method used for prevention is the interposition of a graft between the skin flap and the parotid bed during surgery. Biomaterials, allograft or autograft can be used for this purpose. Objectives To evaluate the effects and safety of biomaterial, allograft or autograft interposition for the prevention of Frey's syndrome in patients undergoing parotidectomy, and to identify its effect on prevention and delayed occurrence. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Cochrane Register of Controlled Trials (CENTRAL; 2019, Issue 2); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 5 February 2019. Selection criteria We included randomised controlled trials (RCTs) in patients with parotid disease (including tumours, inflammation, trauma etc.) undergoing parotidectomy with a minimal follow‐up period of six months. We planned to include trials with interventions including biomaterial, allograft or autograft interposition alone or in combination with other surgical techniques. We included trials that compared any graft interposition and no graft interposition, or different graft interpositions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were incidence rate of Frey's syndrome assessed clinically (Minor's starch‐iodine test) and other complications (postoperative infection, subjective painful or restricted cervical movement, scar spread, rejection of the graft, complications related to the donor site such as accessory nerve injury and haematoma). Our secondary outcome measures were incidence rate of Frey's syndrome assessed by participants (by questionnaire) and sweating area assessed by Minor's starch‐iodine test. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included three RCTs (124 participants), two of which we assessed as at high risk of bias and one at unclear risk of bias. All studies were hospital‐based and recruited participants undergoing superficial parotidectomy. Most participants were diagnosed with benign lesions of the parotid gland. Participants were followed up for more than six months. The studies evaluated the two comparisons shown below: Sternocleidomastoid muscle flap versus no flap Two studies assessed this comparison. Both assessed the effects of the sternocleidomastoid muscle flap procedure on the incidence rate of Frey's syndrome assessed clinically but neither showed a significant difference between groups (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.23; 24 participants and RR 1.23, 95% CI 0.88 to 1.73; 36 participants; very low‐certainty evidence). We did not pool the data due to the high heterogeneity (I² = 87%). One study found that the sternocleidomastoid muscle flap may result in little or no difference in other complications including haematoma (RR 2.18, 95% CI 0.09 to 50.16; 36 participants; low‐certainty evidence), subjective painful or restricted cervical movement (RR 0.54, 95% CI 0.14 to 2.05; 36 participants; low‐certainty evidence) and scar spread in the cervical region (RR 0.71, 95% CI 0.05 to 10.54; 36 participants; low‐certainty evidence). Both studies reported the incidence rate of Frey's syndrome assessed by participants, with one reporting no events in either group and the other finding no evidence of a difference (RR 0.63, 95% CI 0.32 to 1.26; 36 participants; low‐certainty evidence). Acellular dermal matrix versus no graft Only one study assessed this comparison. Use of an acellular dermal matrix graft may result in little or no difference to the incidence rate of Frey's syndrome (assessed clinically) in comparison with the no graft group, but the evidence is very uncertain (RR 0.08, 95% CI 0.00 to 1.25; 30 participants; very low‐certainty evidence). Acellular dermal matrix may slightly increase the wound infection rate compared with control (RR 17.00, 95% CI 1.02 to 282.67; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence of seromas or sialoceles (RR 2.33, 95% CI 0.66 to 8.23; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence rate of Frey's syndrome (assessed by participants) in comparison with the no graft group (RR 0.33, 95% CI 0.04 to 3.04; 64 participants; low‐certainty evidence). Authors' conclusions The evidence for the effectiveness of graft interposition in preventing Frey's syndrome is of low or very low certainty. The use of acellular dermal matrix may be associated with an increase in the wound infection rate, and little or no difference in the incidence of seromas or sialoceles. Further studies are needed to draw reliable conclusions. Plain language summary Grafts for preventing Frey's syndrome after surgery to the parotid (salivary) glands Review question Does the use of a graft during surgery to the parotid glands prevent Frey's syndrome? Background The clinical symptoms of Frey's syndrome include sweating and flushing of the cheek when eating and chewing. It results from abnormal regrowth of damaged autonomic nerve fibres of the parotid glands, for example during surgery for parotid gland tumours. It is unclear whether placing a graft between the skin flap and the parotid bed during surgery can prevent this syndrome. Various types of grafts can be used, including biomaterial or skin, muscle or other tissue from the patient. These grafts may possibly hinder the abnormal connections of the nerves controlling the sweat glands and parotid glands when the cut nerves are re‐linking after surgery. Study characteristics We included three studies with 124 participants in this review, but the quality of these studies was not ideal. All of the participants in the studies had tumours of the parotid glands and were undergoing surgery to part of the glands. The studies assessed two types of grafts, tissue obtained from the sternocleidomastoid muscle and a biomaterial (a collagen framework without cells). Key results Two studies compared a tissue graft obtained from the sternocleidomastoid muscle to no graft. It is not known whether this type of tissue graft can prevent Frey's syndrome because the available evidence is very uncertain. One study compared a biomaterial graft to no graft. This type of graft may result in little or no difference to the incidence rate of Frey's syndrome, but the evidence is very uncertain. It may make the patient's wound slightly more likely to become infected. Certainty of the evidence The evidence in this review is mostly of low or very low certainty, because of the small number of studies on this question and the risk of bias in these studies. The findings must therefore be treated with caution and further studies are needed to draw reliable conclusions. The evidence in this review is up to date to 5 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ye, L; Cao, Y; Yang, W; Wu, F; Lin, J; Li, L; Li, C", "articleTypes": [], "doi": "10.1002/14651858.CD012323.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "55651bbd-d044-46c7-aeca-0dcf5086229e", "pmid": "", "title": "Dissecting the Heterogeneity of Oral Cancer Pain", "imported": false, "abstract": "Oral squamous cell carcinoma (SCC) produces a higher prevalence and more severe pain than all other cancers. Orofacial pain is one of the most common initial symptoms of oral cancer and often leads to the diagnosis of oral cancer. However, the character, severity, and unique features of oral cancer widely differ between patients. There is currently no effective and lasting treatment available to alleviate suffering from oral cancer pain.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.262Z" }, { "id": "55934d44-c304-45f2-8f0a-0f620c9f94ad", "pmid": "", "title": "Non‐invasive diagnostic tests for Helicobacter pylori infection", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) infection has been implicated in a number of malignancies and non‐malignant conditions including peptic ulcers, non‐ulcer dyspepsia, recurrent peptic ulcer bleeding, unexplained iron deficiency anaemia, idiopathic thrombocytopaenia purpura, and colorectal adenomas. The confirmatory diagnosis of H pylori is by endoscopic biopsy, followed by histopathological examination using haemotoxylin and eosin (H & E) stain or special stains such as Giemsa stain and Warthin‐Starry stain. Special stains are more accurate than H & E stain. There is significant uncertainty about the diagnostic accuracy of non‐invasive tests for diagnosis of H pylori . Objectives To compare the diagnostic accuracy of urea breath test, serology, and stool antigen test, used alone or in combination, for diagnosis of H pylori infection in symptomatic and asymptomatic people, so that eradication therapy for H pylori can be started. Search methods We searched MEDLINE, Embase, the Science Citation Index and the National Institute for Health Research Health Technology Assessment Database on 4 March 2016. We screened references in the included studies to identify additional studies. We also conducted citation searches of relevant studies, most recently on 4 December 2016. We did not restrict studies by language or publication status, or whether data were collected prospectively or retrospectively. Selection criteria We included diagnostic accuracy studies that evaluated at least one of the index tests (urea breath test using isotopes such as 13 C or 14 C, serology and stool antigen test) against the reference standard (histopathological examination using H & E stain, special stains or immunohistochemical stain) in people suspected of having H pylori infection. Data collection and analysis Two review authors independently screened the references to identify relevant studies and independently extracted data. We assessed the methodological quality of studies using the QUADAS‐2 tool. We performed meta‐analysis by using the hierarchical summary receiver operating characteristic (HSROC) model to estimate and compare SROC curves. Where appropriate, we used bivariate or univariate logistic regression models to estimate summary sensitivities and specificities. Main results We included 101 studies involving 11,003 participants, of which 5839 participants (53.1%) had H pylori infection. The prevalence of H pylori infection in the studies ranged from 15.2% to 94.7%, with a median prevalence of 53.7% (interquartile range 42.0% to 66.5%). Most of the studies (57%) included participants with dyspepsia and 53 studies excluded participants who recently had proton pump inhibitors or antibiotics.There was at least an unclear risk of bias or unclear applicability concern for each study. Of the 101 studies, 15 compared the accuracy of two index tests and two studies compared the accuracy of three index tests. Thirty‐four studies (4242 participants) evaluated serology; 29 studies (2988 participants) evaluated stool antigen test; 34 studies (3139 participants) evaluated urea breath test‐ 13 C; 21 studies (1810 participants) evaluated urea breath test‐ 14 C; and two studies (127 participants) evaluated urea breath test but did not report the isotope used. The thresholds used to define test positivity and the staining techniques used for histopathological examination (reference standard) varied between studies. Due to sparse data for each threshold reported, it was not possible to identify the best threshold for each test. Using data from 99 studies in an indirect test comparison, there was statistical evidence of a difference in diagnostic accuracy between urea breath test‐ 13 C, urea breath test‐ 14 C, serology and stool antigen test (P = 0.024). The diagnostic odds ratios for urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test were 153 (95% confidence interval (CI) 73.7 to 316), 105 (95% CI 74.0 to 150), 47.4 (95% CI 25.5 to 88.1) and 45.1 (95% CI 24.2 to 84.1). The sensitivity (95% CI) estimated at a fixed specificity of 0.90 (median from studies across the four tests), was 0.94 (95% CI 0.89 to 0.97) for urea breath test‐ 13 C, 0.92 (95% CI 0.89 to 0.94) for urea breath test‐ 14 C, 0.84 (95% CI 0.74 to 0.91) for serology, and 0.83 (95% CI 0.73 to 0.90) for stool antigen test. This implies that on average, given a specificity of 0.90 and prevalence of 53.7% (median specificity and prevalence in the studies), out of 1000 people tested for H pylori infection, there will be 46 false positives (people without H pylori infection who will be diagnosed as having H pylori i nfection). In this hypothetical cohort, urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test will give 30 (95% CI 15 to 58), 42 (95% CI 30 to 58), 86 (95% CI 50 to 140), and 89 (95% CI 52 to 146) false negatives respectively (people with H pylori infection for whom the diagnosis of H pylori will be missed). Direct comparisons were based on few head‐to‐head studies. The ratios of diagnostic odds ratios (DORs) were 0.68 (95% CI 0.12 to 3.70; P = 0.56) for urea breath test‐ 13 C versus serology (seven studies), and 0.88 (95% CI 0.14 to 5.56; P = 0.84) for urea breath test‐ 13 C versus stool antigen test (seven studies). The 95% CIs of these estimates overlap with those of the ratios of DORs from the indirect comparison. Data were limited or unavailable for meta‐analysis of other direct comparisons. Authors' conclusions In people without a history of gastrectomy and those who have not recently had antibiotics or proton ,pump inhibitors, urea breath tests had high diagnostic accuracy while serology and stool antigen tests were less accurate for diagnosis of Helicobacter pylori infection.This is based on an indirect test comparison (with potential for bias due to confounding), as evidence from direct comparisons was limited or unavailable. The thresholds used for these tests were highly variable and we were unable to identify specific thresholds that might be useful in clinical practice. We need further comparative studies of high methodological quality to obtain more reliable evidence of relative accuracy between the tests. Such studies should be conducted prospectively in a representative spectrum of participants and clearly reported to ensure low risk of bias. Most importantly, studies should prespecify and clearly report thresholds used, and should avoid inappropriate exclusions. Plain language summary Accuracy of different non‐invasive methods for identifying Helicobacter pylori Why is it important to know whether someone has Helicobacter pylori ? Helicobacter pylori (H pylori) is a type of bacteria which may be present in the stomach of some people. H pylori is believed to cause a number of cancers, including stomach cancer, pancreatic cancer, and throat cancer. H pylori is also linked with other diseases including stomach ulcers, heart burn, and a bloated feeling. If H pylori is found in an individual, appropriate treatment can be started. What is the aim of this review? To compare the accuracy of three different types of test for H pylori. These are: urea breath tests, blood tests (the specific blood test is called serology), and stool tests (in faeces). What was studied in this review? There are two types of urea breath test which use two different forms of carbon known as 13 C and 14 C, as well as multiple versions of serology and stool tests. What are the main results of the review? We found 101 studies which included 11,003 people who were tested for H pylori . Of these 11,003 participants, 5839 (53.1%) had H pylori infection. All the studies used one of the three tests listed above and compared these test results with the diagnosis given by endoscopic biopsy. Endoscopic biopsy involves obtaining tissue from the stomach using a thin flexible tube introduced through the mouth and testing for the presence of H pylori under the microscope. It is currently the most accurate available test, however it causes physical discomfort to the patient, with associated risks for harm. This is in contrast to the alternative non‐invasive tests in this review which are significantly less uncomfortable and have minimal or no risk of harm, making them desirable alternatives if they can be shown to be as accurate at diagnosing H pylori as endoscopic biopsy. Most of the studies included participants with heart burn or similar problems in the stomach and excluded participants who had previously undergone partial removal of the stomach and those having treatment for H pylori . Thirty‐four studies (4242 participants) used serology; 29 studies (2988 participants) used stool antigen test; 34 studies (3139 participants) used urea breath test‐ 13 C; 21 studies (1810 participants) used urea breath test‐ 14 C; and two studies (127 participants) used urea breath test but did not report the type of carbon used. Studies varied in the limit they used before saying a test was positive for H pylori infection and the type of stains used to examine the biopsy material. When we looked at all the data we found that urea breath tests were more accurate than blood and stool tests. The results mean that, on average, if 1000 people are tested, there will be 46 people without H pylori who will be misdiagnosed as having H pylori . Also, there will be 30, 42, 86, and 89 people with H pylori infection for whom the diagnosis of H pylori infection will be missed by urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test, respectively. When we looked at the seven studies which compared urea breath test‐ 13 C and serology, or urea breath test‐ 13 C and stool antigen tests in the same participants, the results were uncertain and we cannot tell which test is more accurate. How reliable are the results of the studies? Except for one study, all the studies were of poor methodological quality, which makes their results unreliable. Who do the results of this review apply to? These results apply to children and adults with suspected H pylori infection, but only in those who have not previously undergone stomach operations and those who have not recently had antibiotics or treatment for H pylori infection. What are the implications of this review? Urea breath tests, blood tests, and stool tests may be suitable for identifying whether someone has H pylori infection. However, the level of the result of urea breath test, blood test, or stool test which should be used to make a diagnosis of H pylori infection remains unclear. How up‐to‐date is the review? We performed a thorough literature search for studies reporting the accuracy of these different tests until 4 March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Best, LMJ, Takwoingi, Y, Siddique, S, Selladurai, A, Gandhi, A, Low, B, Yaghoobi, M, Gurusamy, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.765Z" }, { "id": "5595ddd9-7fc7-4f4c-8707-bea4379583d6", "pmid": "", "title": "Interventions to prevent obesity in children aged 5 to 11 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well‐being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review. Objectives To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta‐analyses. One hundred forty‐six studies were based in high‐income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0, 95% confidence interval (CI) ‐0.10 to 0.10; 5 studies, 2107 participants; low‐certainty evidence) and at medium‐term follow‐up (MD ‐0.01, 95% CI ‐0.15 to 0.12; 9 studies, 6815 participants; low‐certainty evidence) or zBMI at long‐term follow‐up (MD ‐0.05, 95% CI ‐0.10 to 0.01; 7 studies, 5285 participants; low‐certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long‐term follow‐up (MD ‐0.17, 95% CI ‐0.48 to 0.13; 2 studies, 945 participants; moderate‐certainty evidence) and zBMI at short‐ or medium‐term follow‐up (MD ‐0.06, 95% CI ‐0.13 to 0.01; 8 studies, 3695 participants; MD ‐0.04, 95% CI ‐0.10 to 0.02; 9 studies, 7048 participants; moderate‐certainty evidence). Five studies (1913 participants; very low‐certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short‐term or long‐term follow‐up (BMI short‐term: MD ‐0.02, 95% CI ‐0.17 to 0.13; 14 studies, 4069 participants; zBMI short‐term: MD ‐0.02, 95% CI ‐0.07 to 0.02; 6 studies, 3580 participants; low‐certainty evidence; BMI long‐term: MD ‐0.07, 95% CI ‐0.24 to 0.10; 8 studies, 8302 participants; zBMI long‐term: MD ‐0.02, 95% CI ‐0.09 to 0.04; 6 studies, 6940 participants; low‐certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.18 to ‐0.05; 16 studies, 21,286 participants; zBMI: MD ‐0.05, 95% CI ‐0.09 to ‐0.02; 13 studies, 20,600 participants; moderate‐certainty evidence). Eleven studies (21,278 participants; low‐certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to ‐0.01; 27 studies, 16,066 participants; zBMI: MD ‐0.03, 95% CI ‐0.06 to 0.00; 26 studies, 12,784 participants; low‐certainty evidence) and likely result in a reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD ‐0.05, 95% CI ‐0.07 to ‐0.02; 24 studies, 20,998 participants; moderate‐certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long‐term follow‐up (BMI: MD 0.03, 95% CI ‐0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD ‐0.02, 95% CI ‐0.06 to 0.01; 22 studies, 23,594 participants; low‐certainty evidence). Nineteen studies (27,882 participants; low‐certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow‐up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high‐income versus non‐high‐income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability. Authors' conclusions The body of evidence in this review demonstrates that a range of school‐based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short‐ and medium‐term, but not at long‐term follow‐up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community‐based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities. Plain language summary Do dietary and activity strategies help prevent obesity in children aged 5 to 11 years? Key messages ‐ Strategies for changing activity levels, or both activity levels and diet, of children to help prevent them developing overweight or obesity might be effective in making small reductions in body mass index (BMI) in children aged 5 to 11 years. ‐ There is very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but from what we found there appears to be little or no effect. ‐ This change in BMI, when provided to many children across a whole population, is useful for parents concerned about their children becoming overweight as they move into adulthood and for governments in trying to tackle the problems of obesity through the life course. Why is preventing obesity in children important? More children are developing overweight and obesity worldwide. Being overweight as a child can cause health problems, and people may be affected psychologically and in their social life. Children that are overweight are likely to be overweight as adults and continue to experience poor physical and mental health. Indeed, childhood obesity is associated with type 2 diabetes and heart disease in adulthood and middle‐age mortality. What did we want to find out? We wanted to find out if strategies to help people modify their diet or activity (or both) are effective at preventing obesity in children aged 5 to 11 years. We also wanted to find out if these strategies were associated with any serious adverse events. What did we do? We searched many scientific databases to find studies that looked at ways of preventing obesity in children. We included studies aimed at children aged 5 to 11 years. We did not include studies only aimed at children who were already overweight or were already living with obesity. However, we included studies in which children who were overweight or living with obesity were included in the analysis. We only included studies if the methods they used were aimed at changing children's diet, or their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed people into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 172 studies that involved 189,707 children. One hundred forty‐six studies were based in high‐income countries (e.g. the USA and in Europe). In 111 studies, the strategies were tried in schools, though 15 were based in the community, eight in the home and seven in clinical settings; one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six strategies were implemented for less than nine months, with the shortest being conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry (e.g. food suppliers, pharmaceutical industry and private healthcare services). Our statistical analyses included results from 149 studies of 160,267 children. We found that children who were helped with a strategy to change their activity levels alone or in combination with a strategy to change their diet may have their BMI reduced, compared with children who were not given any strategy. This means that these children may have been able to minimise their excess weight gain by a small amount which, for public health, is important. In contrast, children who were helped with a strategy to change their diet only did not have their BMI reduced. Only a few studies reported any possible harms of the strategies, and no serious harms were identified in these. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low. However, it is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. A lot of the studies had limitations in how they were done. 3. There were not enough studies reporting particular types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons, and also certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way such that we could include them in our analyses (e.g. without any detail of the difference between the strategies examined) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for children with disabilities, or whether those implemented in community settings are effective. How up‐to‐date is this evidence? This review updates our previous review. The evidence is up‐to‐date to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F; Davies, AL; Tomlinson, E; Moore, THM; Dawson, S; Breheny, K; Savović, J; Gao, Y; Phillips, SM; Hillier-Brown, F; Hodder, RK; Wolfenden, L; Higgins, JPT; Summerbell, CD", "articleTypes": [], "doi": "10.1002/14651858.CD015328.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "55b3cbdc-a0f7-404b-8b8e-65e87e814dc9", "pmid": "", "title": "Interventions to improve adherence to antiretroviral therapy in children with HIV infection", "imported": false, "abstract": "Abstract - Background Achieving and maintaining high levels of medication adherence are required to achieve the full benefits of antiretroviral therapy (ART), yet suboptimal adherence among children is common in both developed and developing countries. Objectives To conduct a systematic review of the literature of evaluations of interventions for improving paediatric ART adherence. Search methods We created a comprehensive search strategy in order to identify all studies relevant to this topic. In July 2010, we searched the following electronic databases: EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, LILACS, Web of Science, Web of Social Science, NLM Gateway (supplemented by a manual search of the most recent abstracts not included in the Gateway database). We searched abstracts from the International AIDS Conference from 2002 to 2010, the International AIDS Society Conference on Pathogenesis, Treatment and Prevention from 2003 to 2009, and from the Conference on Retroviruses and Opportunistic Infections from 1997 to 2010. We used search strategies determined by the Cochrane Review Group on HIV/AIDS. We also contacted researchers who work in this field and checked reference lists of related systematic reviews and of all included studies. Selection criteria Randomised and non‐randomised controlled trials of interventions to improve adherence to ART among children and adolescents (age ≤18 years) were included. Studies had to report adherence to ART as an outcome. Data collection and analysis After one author performed an initial screening to exclude citations that did not meet the inclusion criteria, two authors did a second screening of those citations that likely met the criteria. For all articles that passed the second screening, full articles were pulled in order to make a final determination. Two authors then extracted data and graded methodological quality independently. Differences were resolved through discussion. Main results Four studies met the inclusion criteria. No single intervention was evaluated by more than one trial. Two studies were conducted in low‐income countries. Two studies were randomised controlled trials (RCT), and two were non‐randomised trials. An RCT of a home‐based nursing programme showed a positive effect of the intervention on knowledge and medication refills (p=.002), but no effect on CD4 count and viral load. A second RCT of caregiver medication diaries showed that the intervention group had fewer participants reporting no missed doses compared to the control group (85% vs. 92%, respectively), although this difference was not statistically significant (p=.08). The intervention had no effect on CD4 percentage or viral load. A non‐randomised trial of peer support group therapy for adolescents demonstrated no change in self‐reported adherence, yet the percentage of participants with suppressed viral load increased from 30% to 80% (p=.06). The second non‐randomised trial found that the percentage of children achieving >80% adherence was no different between children on a lopinavir‐ritonavir (LPV/r) regimen compared to children on a non‐nucleoside reverse transcriptase regimen (p=.781). However, the proportion of children achieving virological suppression was significantly greater for children on the LPV/r regimen than for children on the NNRTI‐containing regimen (p=.002). Authors' conclusions A home‐based nursing intervention has the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence or disease outcomes. Two interventions, an LPV/r‐containing regimen and peer support therapy for adolescents, did not demonstrate improvements in adherence, yet demonstrated greater viral load suppression compared to control groups, suggesting a different mechanism for improved health outcomes. Well‐designed evaluations of interventions to improve paediatric adherence to ART are needed. Plain language summary Interventions to improve adherence to ART in children and adolescents Achieving and maintaining high levels of medication adherence are required to realise the full benefits of antiretroviral therapy (ART). We identified four studies that evaluated interventions designed to improve adherence to ART among children and adolescents age 18 years and younger. These studies showed that home‐based nursing, peer support for adolescents and LPV/r‐containing regimens have the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence. There is a need for well‐designed evaluations of interventions to improve paediatric adherence to ART.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Bain‐Brickley, D; Butler, LM; Kennedy, GE; Rutherford, GW", "articleTypes": [], "doi": "10.1002/14651858.CD009513", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "55c9fe07-60b9-4c5c-a06e-a7147f466faf", "pmid": "", "title": "Potentiators (specific therapies for class III and IV mutations) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is the commonest inherited life‐shortening illness in white populations, caused by a mutation in the gene that codes for the cystic fibrosis transmembrane regulator protein (CFTR), which functions as a salt transporter. This mutation mainly affects the airways where excess salt absorption dehydrates the airway lining leading to impaired mucociliary clearance. Consequently, thick, sticky mucus accumulates making the airway prone to chronic infection and progressive inflammation; respiratory failure often ensues. Other complications include malnutrition, diabetes and subfertility. Increased understanding of the condition has allowed pharmaceutical companies to design mutation‐specific therapies targeting the underlying molecular defect. CFTR potentiators target mutation classes III and IV and aim to normalise airway surface liquid and mucociliary clearance, which in turn impacts on the chronic infection and inflammation. This is an update of a previously published review. Objectives To evaluate the effects of CFTR potentiators on clinically important outcomes in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles, reviews and online clinical trial registries. Last search: 21 November 2018. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing CFTR potentiators to placebo in people with CF. A separate review examines trials combining CFTR potentiators with other mutation‐specific therapies. Data collection and analysis The authors independently extracted data, assessed the risk of bias in included trials and used GRADE to assess evidence quality. Trial authors were contacted for additional data. Main results We included five RCTs (447 participants with different mutations) lasting from 28 days to 48 weeks, all assessing the CFTR potentiator ivacaftor. The quality of the evidence was moderate to low, mainly due to risk of bias (incomplete outcome data and selective reporting) and imprecision of results, particularly where few individuals experienced adverse events. Trial design was generally well‐documented. All trials were industry‐sponsored and supported by other non‐pharmaceutical funding bodies. F508del (class II) (140 participants) One 16‐week trial reported no deaths, or changes in quality of life (QoL) or lung function (either relative or absolute change in forced expiratory volume in one second (FEV1) (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in ivacaftor and placebo groups, but there was no difference between groups (low‐quality evidence); there was also no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. There was also no difference in weight. Sweat chloride concentration decreased, mean difference (MD) ‐2.90 mmol/L (95% confidence interval (CI) ‐5.60 to ‐0.20). G551D (class III) (238 participants) The 28‐day phase 2 trial (19 participants) and two 48‐week phase 3 trials (adult trial (167 adults), paediatric trial (52 children)) reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor in the adult trial at 24 weeks, MD 8.10 (95% CI 4.77 to 11.43) and 48 weeks, MD 8.60 (95% CI 5.27 to 11.93 (moderate‐quality evidence). The adult trial reported a higher relative change in FEV1 with ivacaftor at 24 weeks, MD 16.90% (95% CI 13.60 to 20.20) and 48 weeks, MD 16.80% (95% CI 13.50 to 20.10); the paediatric trial reported this at 24 weeks, MD 17.4% (P < 0.0001)) (moderate‐quality evidence). These trials demonstrated absolute improvements in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32). The phase 3 trials reported increased cough, odds ratio (OR) 0.57 (95% CI 0.33 to 1.00) and episodes of decreased pulmonary function, OR 0.29 (95% CI 0.10 to 0.82) in the placebo group; ivacaftor led to increased dizziness in adults, OR 10.55 (95% CI 1.32 to 84.47). There was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Fewer participants taking ivacaftor developed serious pulmonary exacerbations; adults taking ivacaftor developed fewer exacerbations (serious or not), OR 0.54 (95% CI 0.29 to 1.01). A higher proportion of participants were exacerbation‐free at 24 weeks with ivacaftor (moderate‐quality evidence). Ivacaftor led to a greater absolute change from baseline in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32); weight also increased at 24 weeks, MD 2.37 kg (95% CI 1.68 to 3.06) and 48 weeks, MD 2.75 kg (95% CI 1.74 to 3.75). Sweat chloride concentration decreased at 24 weeks, MD ‐48.98 mmol/L (95% CI ‐52.07 to ‐45.89) and 48 weeks, MD ‐49.03 mmol/L (95% CI ‐52.11 to ‐45.94). R117H (class IV) (69 participants) One 24‐week trial reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor at 24 weeks, MD 8.40 (95% CI 2.17 to 14.63), but no relative changes in lung function were reported (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in both groups, but there was no difference between groups; there was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. No changes in absolute change in FEV1 or weight were reported. Sweat chloride concentration decreased, MD ‐24.00 mmol/L (CI 95% ‐24.69 to ‐23.31). Authors' conclusions There is no evidence supporting the use of ivacaftor in people with the F508del mutation. Both G551D phase 3 trials demonstrated a clinically relevant impact of ivacaftor on outcomes at 24 and 48 weeks in adults and children (over six years of age) with CF. The R117H trial demonstrated an improvement in the respiratory QoL score, but no improvement in respiratory function. As new mutation‐specific therapies emerge, it is important that trials examine outcomes relevant to people with CF and their families and that adverse events are reported robustly and consistently. Post‐market surveillance is essential and ongoing health economic evaluations are required. Plain language summary Ivacaftor (marketed as Kalydeco®), a new specific therapy for cystic fibrosis Review question How does ivacaftor affect clinical outcomes (survival, quality of life and lung function) in people with cystic fibrosis (CF)? Background In people with CF, airway surfaces do not have enough water because of an abnormal protein; this makes it difficult to clear thick and sticky mucus, which leads to lung infections. Ivacaftor works on the abnormal protein in people with some mutations to allow the airways retain more water and better clear mucus, so fewer lung infections develop. Ivacaftor was aimed at people with class III and IV mutations, and has been studied in people with G551D (class III), R117H (class IV) and F508del (class II) mutations. Trial characteristics We included five trials (447 participants) comparing ivacaftor to placebo (dummy treatment with no active medication) lasting between four and 48 weeks. Three trials enrolled a total of 238 people with at least one copy of the G551D mutation, one trial enrolled 140 people with two copies of the F508del mutation and one enrolled 69 people with at least one copy of the R117H mutation. The evidence is up to date as of 21 November 2018. Key results F508del mutation The trial did not report any deaths or show improvements in lung function, quality of life scores or weight. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. Sweat chloride concentrations were reduced with ivacaftor. G551D mutation No deaths were reported. Both children and adults taking ivacaftor showed improvements in lung function, but only adults reported higher quality of life scores. People given placebo reported more coughing and experienced more episodes of decreased lung function; more adults taking ivacaftor reported episodes of dizziness. Similar numbers of people taking ivacaftor and placebo delayed the course of medication, or withdrew from the trial altogether, due to side effects (e.g. psychological issues, liver disease, severe breathing problems). There were more serious pulmonary exacerbations whilst taking placebo compared to ivacaftor. Adults taking ivacaftor were admitted to hospital less often and had fewer courses of intravenous antibiotics for exacerbations. Both children and adults and children increased their weight with ivacaftor. There was a drop in sweat chloride concentrations with ivacaftor. R117H mutation No deaths occurred in this trial. While quality of life scores improved with ivacaftor, lung function did not. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. There was no difference in weight; but as for other mutations there was a reduction in sweat chloride concentration with ivacaftor.
 
 Evidence suggests that ivacaftor is an effective treatment for people (over six years of age) with cystic fibrosis and the G551D mutation, but not for those with the F508del or R117H mutations. Quality of the evidence In most trials, individuals were put into different treatment groups at random with equal chances of being given either placebo or ivacaftor; no one could work out which treatment the next person would receive, so that healthier people did not receive ivacaftor and make the results seem better. We were not sure whether anyone involved in the trial knew who was receiving which treatment and how this might affect results. No trials reported all results clearly; sometimes they did not report them in a way that we could use in the review and sometimes they did not report the data at all. This affected our certainty regarding the overall results. Information about some side effects was limited as not many people experienced them, therefore, it is difficult to judge whether there was a difference between treatment groups We judged the evidence in this review to be moderate to low quality. Trial funding sources All trials were sponsored by Vertex Pharmaceuticals Incorporated. The National Institute of Health (NIH), the Cystic Fibrosis Foundation (CFF) and other non‐pharmaceutical funding bodies also supported the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Skilton, M; Krishan, A; Patel, S; Sinha, IP; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD009841.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "55d00011-d761-4c63-ac35-e135f4c58b87", "pmid": "", "title": "Antibiotics prior to amniotomy for reducing infectious morbidity in mother and infant", "imported": false, "abstract": "Abstract - Background Amniotomy (the deliberate rupture of membranes) was described almost two centuries ago and since then has been used both for induction and augmentation of labour ‐ which are common obstetric practices. Trends have shown a rise in the induction rates over the last decade and data suggest that the rate of labour inductions is increasing faster than the rate of pregnancy complications. Recent years have seen the emergence of a variety of other methods of induction of labour but amniotomy combined with oxytocin infusion remains the most commonly used method of augmentation of labour. The newer agents for induction are expensive and in resource‐poor settings amniotomy is still the chosen method for both induction and augmentation. As with any invasive procedure amniotomy can lead to infection, ascending from the vagina into the uterine cavity and can contribute significantly to both maternal and neonatal infectious morbidity. Objectives The objective of this review was to evaluate the prophylactic use of antibiotics versus placebo or no treatment prior to amniotomy on maternal and neonatal infectious morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014), the International Clinical Trials Registry Platform ( ICTRP ) and ClinicalTrials.gov (12 September 2014). Selection criteria Randomised controlled trials or cluster‐randomised trials comparing antibiotics prior to amniotomy versus placebo (or no treatment) were eligible for inclusion in this review but none were identified. Quasi‐randomised trials or cross‐over trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed one trial report for inclusion. In future updates of this review, two review authors will independently assess risk of bias and carry out data extraction. Data will be checked for accuracy. Main results We identified one trial report but this was excluded. No studies met the inclusion criteria for this review. Authors' conclusions High‐quality trials are needed to justify or refute the routine use of antibiotics at amniotomy for prevention of infection in the mother and infant. Future studies should be conducted, especially in resource‐constrained settings where amniotomy is still used as a means of induction of labour, in order to evaluate the routine use of antibiotics at amniotomy in these settings. Future research in this area should include important maternal and infant outcomes listed in this review and also consider cost effectiveness and side effects of antibiotic use, including the emergence of antibiotic‐resistant strains. Plain language summary Antibiotic use before amniotomy (artificially rupturing the membranes) for reducing infections in mother and infant The artificial rupture of the membranes (amniotomy) is a common obstetrical procedure. It may be done to either initiate or to augment labour, with or without oxytocin. This invasive procedure allows vaginal micro‐organisms access into the uterine cavity, which can in turn lead to infections in both the mother and the infant. A greater time interval between rupture of membranes and delivery, as with induction of labour, increases the chances of an infection. The purpose of this review was to evaluate the routine use of antibiotics immediately prior to amniotomy for both initiation and augmentation of labour using randomised controlled trials. However, our search only identified one trial which did not meet the inclusion criteria for this review. Consequently, there is no evidence to support or refute the routine use of antibiotics prior to amniotomy. Randomised controlled trials on this topic are needed, especially in resource‐constrained settings where amniotomy is still used as a means of inducing labour, to evaluate the routine use of antibiotics at amniotomy in such settings. Future research in this area should also consider cost effectiveness and side effects of antibiotic use including the emergence of antibiotic‐resistant strains.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ray, A, Ray, S", "articleTypes": [], "doi": "10.1002/14651858.CD010626.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.093Z" }, { "id": "55ec72a6-04c3-4824-9917-d53f629545ff", "pmid": "", "title": "Chlorhexidine mouthrinse as an adjunctive treatment for gingival health", "imported": false, "abstract": "Abstract - Background Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build‐up of plaque thereby reducing gingivitis. Objectives To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day). To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs. Data collection and analysis Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random‐effects models for all meta‐analyses. Main results We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high‐quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high‐quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate‐quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies). Authors' conclusions There is high‐quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high‐quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies. Plain language summary Chlorhexidine mouthrinse to reduce gingivitis and plaque build‐up Review question Does the use of chlorhexidine mouthrinse (a broad spectrum antiseptic) in addition to other conventional tooth cleaning help to control and improve gingivitis (inflammation of the gums)? Does the frequency of rinsing or the concentration of the solution affect the result and are there any undesirable side effects? Background Gingivitis is a reversible condition when gums become red, swollen and can bleed easily. Gingivitis is also very common ‐ studies suggest that as many as 50% to 90% of adults in the UK and USA suffer from it. In susceptible people gingivitis may lead to periodontitis, which is not reversible. In periodontitis inflammation is accompanied by loss of ligaments and bone supporting the teeth. If untreated it may eventually lead to tooth loss. Severe periodontitis is the sixth most widespread disease globally. It is recognised that maintaining a high standard of oral hygiene is important for the prevention and treatment of gingivitis. Toothbrushing is the main method for maintaining good oral hygiene. Other cleaning methods commonly used include dental floss, interdental brushes and scaling and polishing carried out by a dental professional. Some people have difficulty controlling plaque build‐up and preventing gingivitis using only conventional tooth cleaning. Therefore people sometimes use mouthrinses containing chlorhexidine in addition to conventional tooth cleaning. These mouthrinses are readily available over the counter; prescriptions generally not being required outside the USA. Study characteristics We included 51 studies that analysed a total of 5345 participants. The evidence in this review is up to date as of 28 September 2016. Generally study participants were children and adults who had gingivitis or periodontitis, were able to use usual tooth cleaning methods and were healthy. We did not exclude studies where some or all participants had medical conditions or special care needs as we considered the use of mouthrinses with chlorhexidine to be particularly relevant to them. The included studies assessed the effects of chlorhexidine mouthrinse used for at least 4 weeks in addition to conventional tooth cleaning on gingivitis in children and adults. Key results There is high‐quality evidence that the use of mouthrinses containing chlorhexidine in addition to usual toothbrushing and cleaning for 4 to 6 weeks or 6 months leads to a large reduction in the build‐up of plaque. There is also high‐quality evidence of a moderate reduction in gingivitis in people with a mild level of it, although because the level of disease was already low this is not considered clinically important. The nature of the available evidence does not allow us to determine the level of reduction of gingivitis in people with moderate to severe levels of it. There was no evidence that one concentration or strength of chlorhexidine rinse was more effective than another. Rinsing for 4 weeks or longer causes tooth staining, which requires scaling and polishing carried out by a dental professional. Other side effects have been reported, including build‐up of calculus (tartar), temporary taste disturbance and temporary shedding of/damage to the lining of the mouth. Quality of the evidence One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "James, P, Worthington, HV, Parnell, C, Harding, M, Lamont, T, Cheung, A, Whelton, H, Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD008676.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.752Z" }, { "id": "55eedc73-59e8-414a-9082-e80afdea4e63", "pmid": "", "title": "Interventions for treating iron deficiency anaemia in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease affects approximately seven million people globally. Iron deficiency anaemia can occur as a common systemic manifestation, with a prevalence of up to 90%, which can significantly affect quality of life, both during periods of active disease or in remission. It is important that iron deficiency anaemia is treated effectively and not be assumed to be a normal finding of inflammatory bowel disease. The various routes of iron administration, doses and preparations present varying advantages and disadvantages, and a significant proportion of people experience adverse effects with current therapies. Currently, no consensus has been reached amongst physicians as to which treatment path is most beneficial. Objectives The primary objective was to evaluate the efficacy and safety of the interventions for the treatment of iron deficiency anaemia in people with inflammatory bowel disease. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 21st November 2019. We also contacted experts in the field and searched references of trials for any additional trials. Selection criteria Randomised controlled trials investigating the effectiveness and safety of iron administration interventions compared to other iron administration interventions or placebo in the treatment of iron deficiency anaemia in inflammatory bowel disease. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors. Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We expressed dichotomous and continuous outcomes as risk ratios and mean differences with 95% confidence intervals. We assessed the certainty of the evidence using the GRADE methodology. Main results We included 11 studies (1670 randomised participants) that met the inclusion criteria. The studies compared intravenous iron sucrose vs oral iron sulphate (2 studies); oral iron sulphate vs oral iron hydroxide polymaltose complex (1 study); oral iron fumarate vs intravenous iron sucrose (1 study); intravenous ferric carboxymaltose vs intravenous iron sucrose (1 study); erythropoietin injection + intravenous iron sucrose vs intravenous iron sucrose + injection placebo (1 study); oral ferric maltol vs oral placebo (1 study); oral ferric maltol vs intravenous ferric carboxymaltose (1 study); intravenous ferric carboxymaltose vs oral iron sulphate (1 study); intravenous iron isomaltoside vs oral iron sulphate (1 study); erythropoietin injection vs oral placebo (1 study). All studies compared participants with CD and UC together, as well as considering a range of disease activity states. The primary outcome of number of responders, when defined, was stated to be an increase in haemoglobin of 20 g/L in all but two studies in which an increase in 10g/L was used. In one study comparing intravenous ferric carboxymaltose and intravenous iron sucrose, moderate‐certainty evidence was found that intravenous ferric carboxymaltose was probably superior to intravenous iron sucrose, although there were responders in both groups (150/244 versus 118/239, RR 1.25, 95% CI 1.06 to 1.46, number needed to treat for an additional beneficial outcome (NNTB) = 9). In one study comparing oral ferric maltol to placebo, there was low‐certainty evidence of superiority of the iron (36/64 versus 0/64, RR 73.00, 95% CI 4.58 to 1164.36). There were no other direct comparisons that found any difference in the primary outcomes, although certainty was low and very low for all outcomes, due to imprecision from sparse data and risk of bias varying between moderate and high risk. The reporting of secondary outcomes was inconsistent. The most common was the occurrence of serious adverse events or those requiring withdrawal of therapy. In no comparisons was there a difference seen between any of the intervention agents being studied, although the certainty was very low for all comparisons made, due to risk of bias and significant imprecision due to the low numbers of events. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes were reported in any of the studies. An analysis of all intravenous iron preparations to all oral iron preparations showed that intravenous administration may lead to more responders (368/554 versus 205/373, RR 1.17, 95% CI 1.05 to 1.31, NNTB = 11, low‐certainty due to risk of bias and inconsistency). Withdrawals due to adverse events may be greater in oral iron preparations vs intravenous (15/554 versus 31/373, RR 0.39, 95% CI 0.20 to 0.74, low‐certainty due to risk of bias, inconsistency and imprecision). Authors' conclusions Intravenous ferric carboxymaltose probably leads to more people having resolution of IDA (iron deficiency anaemia) than intravenous iron sucrose. Oral ferric maltol may lead to more people having resolution of IDA than placebo. We are unable to draw conclusions on which of the other treatments is most effective in IDA with IBD (inflammatory bowel disease) due to low numbers of studies in each comparison area and clinical heterogeneity within the studies. Therefore, there are no other conclusions regarding the treatments that can be made and certainty of all findings are low or very low. Overall, intravenous iron delivery probably leads to greater response in patients compared with oral iron, with a NNTB (number needed to treat) of 11. Whilst no serious adverse events were specifically elicited with any of the treatments studied, the numbers of reported events were low and the certainty of these findings very low for all comparisons, so no conclusions can be drawn. There may be more withdrawals due to such events when oral is compared with intravenous iron delivery. Other outcomes were poorly reported and once again no conclusions can be made as to the impact of IDA on any of these outcomes. Given the widespread use of many of these treatments in practice and the only guideline that exists recommending the use of intravenous iron in favour of oral iron, research to investigate this key issue is clearly needed. Considering the current ongoing trials identified in this review, these are more focussed on the impact in specific patient groups (young people) or on other symptoms (such as fatigue). Therefore, there is a need for studies to be performed to fill this evidence gap. Plain language summary Therapies for treating iron deficiency anaemia in Crohn's disease and ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether treatments in people with Crohn's disease and ulcerative colitis can improve iron deficiency anaemia. We analysed data from 11 studies to answer this question. Key messages Iron in the form of ferric carboxymaltose given intravenously is probably better than iron sucrose given intravenously in improving iron deficiency anaemia, although people improved taking both treatments. Oral iron in the form of ferric maltol may be better than placebo (dummy treatment). It is unclear whether any of the other treatments considered are better than each other, however, there is limited evidence due to low numbers of studies and issues due to low quality of the reporting of the research studies. What was studied in the review? People with both ulcerative colitis and Crohn's disease both commonly suffer with low iron levels that in turn lowers their haemoglobin (blood) levels (this is called anaemia). This can lead to a number of symptoms, including tiredness and pain. Several treatments exist to treat iron deficiency anaemia, consisting of delivering extra iron either orally or intravenously (through a vein). An additional treatment, erythropoietin, was also studied which stimulates the body to produce more blood itself. Currently, no consensus has been reached amongst physicians as to which treatment is better. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing any treatment with another or dummy treatment. We found 11 RCTs looking at 1670 participants. The trials looked at adult participants, with none considering children. 1) Intravenous iron in the form of ferric carboxymaltose probably leads to more people having an improvement in iron deficiency anaemia than intravenous iron sucrose (one extra person would improve for every 9 treated and five out of 10 people would improve with either therapy). 2) Oral iron as ferric maltol may lead to more people having resolution of iron deficiency than dummy treatment. 3) It is unclear whether there is any difference between any of the other treatments studied for treating iron deficiency anaemia. 4) It is unclear whether any therapy leads to a difference in adverse events (minor or serious) when compared to any other therapy. Conclusion Iron delivered via a vein as ferric carboxymaltose probably improves anaemia in more people that iron sucrose via a vein, although both groups of people improved. Oral iron as ferric maltol may improve more patients than dummy treatment. No conclusions can be drawn on other treatments due to lack of evidence and quality issues with the studies that were found. Further research is needed, particularly to investigate whether iron delivered through a vein is better than iron delivered orally and also how much treating anaemia in people with IBD makes a difference in terms of the symptoms they may experience. How up‐to‐date is this review? This review is up‐to‐date as of November 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gordon, M, Sinopoulou, V, Iheozor-Ejiofor, Z, Iqbal, T, Allen, P, Hoque, S, Engineer, J, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013529.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.128Z" }, { "id": "55f05404-24c2-47ca-998b-52c8b0d84289", "pmid": "", "title": "Eplerenone for hypertension", "imported": false, "abstract": "Abstract - Background Eplerenone is an aldosterone receptor blocker that is chemically derived from spironolactone. In Canada, it is indicated for use as adjunctive therapy to reduce mortality for heart failure patients with New York Heart Association (NYHA) class II systolic chronic heart failure and left ventricular systolic dysfunction. It is also used as adjunctive therapy for patients with heart failure following myocardial infarction. Additionally, it is indicated for the treatment of mild and moderate essential hypertension for patients who cannot be treated adequately with other agents. It is important to determine the clinical impact of all antihypertensive medications, including aldosterone antagonists, to support their continued use in essential hypertension. No previous systematic reviews have evaluated the effect of eplerenone on cardiovascular morbidity, mortality, and magnitude of blood pressure lowering in patients with hypertension. Objectives To assess the effects of eplerenone monotherapy versus placebo for primary hypertension in adults. Outcomes of interest were all‐cause mortality, cardiovascular events (fatal or non‐fatal myocardial infarction), cerebrovascular events (fatal or non fatal strokes), adverse events or withdrawals due to adverse events, and systolic and diastolic blood pressure. Search methods We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers up to 3 March 2016. We handsearched references from retrieved studies to identify any studies missed in the initial search. We also searched for unpublished data by contacting the corresponding authors of the included studies and pharmaceutical companies involved in conducting studies on eplerenone monotherapy in primary hypertension. The search had no language restrictions. Selection criteria We selected randomized placebo‐controlled trials studying adult patients with primary hypertension. We excluded studies in people with secondary or gestational hypertension and studies where participants were receiving multiple antihypertensives. Data collection and analysis Three review authors independently reviewed the search results for studies meeting our criteria. Three review authors independently extracted data and assessed trial quality using a standardized data extraction form. A fourth independent review author resolved discrepancies or disagreements. We performed data extraction and synthesis using a standardized format on Covidence. We conducted data analysis using Review Manager 5. Main results A total of 1437 adult patients participated in the five randomized parallel group studies, with treatment durations ranging from 8 to 16 weeks. The daily doses of eplerenone ranged from 25 mg to 400 mg daily. Meta‐analysis of these studies showed a reduction in systolic blood pressure of 9.21 mmHg (95% CI −11.08 to −7.34; I 2 = 58%) and a reduction of diastolic pressure of 4.18 mmHg (95% CI −5.03 to −3.33; I 2 = 0%) (moderate quality evidence). There may be a dose response effect for eplerenone in the reduction in systolic blood pressure at doses of 400 mg/day. However, this finding is uncertain, as it is based on a single included study with low quality evidence. Overall there does not appear to be a clinically important dose response in lowering systolic or diastolic blood pressure at eplerenone doses of 50 mg to 400 mg daily. There did not appear to be any differences in the number of patients who withdrew due to adverse events or the number of patients with at least one adverse event in the eplerenone group compared to placebo. However, only three of the five included studies reported adverse events. Most of the included studies were of moderate quality, as we judged multiple domains as being at unclear risk in the 'Risk of bias' assessment. Authors' conclusions Eplerenone 50 to 200 mg/day lowers blood pressure in people with primary hypertension by 9.21 mmHg systolic and 4.18 mmHg diastolic compared to placebo, with no difference of effect between doses of 50 mg/day to 200 mg/day. A dose of 25 mg/day did not produce a statistically significant reduction in systolic or diastolic blood pressure and there is insufficient evidence for doses above 200 mg/day. There is currently no available evidence to determine the effect of eplerenone on clinically meaningful outcomes such as mortality or morbidity in hypertensive patients. The evidence available on side effects is insufficient and of low quality, which makes it impossible to draw conclusions about potential harm associated with eplerenone treatment in hypertensive patients. Plain language summary Eplerenone for high blood pressure Review question The aim of this review was to determine the effectiveness of eplerenone for reducing blood pressure, its side effect profile, and its impact on clinically meaningful outcomes such as mortality and morbidity. Background Clinicians have used eplerenone to treat high blood pressure since 2002. It is important to determine the clinical impact of all antihypertensive medications used in patients to support their continued use in essential hypertension. We searched multiple databases and found five eligible studies in 1437 people who received either eplerenone or no medication in a random fashion. Study characteristics The doses of eplerenone used in these studies ranged from 25 mg to 400 mg daily. These studies followed patients for 8 to 16 weeks while on therapy. None of the studies reported on the clinically meaningful outcomes of eplerenone, such as whether eplerenone can reduce heart attacks, stroke, or death compared to placebo. Only three of the five studies reported on side effects. Key results There is currently no evidence that eplerenone has a beneficial effect on life expectancy or complications rleated to hypertension (e.g. heart attack, stroke). Evidence for risk of side effects with eplerenone is limited and of poor quality; it is difficult to tell the extent of possible harm with eplerenone versus placebo. This meta‐analysis shows that eplerenone 50 to 200 mg/day reduces systolic blood pressure by approximately 9 mmHg and diastolic blood pressure by 4 mmHg compared to taking no medication. Quality of the evidence We judged the five included trials to be of moderate quality, as authors did not extensively describe portions of their methodology.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tam, TSC, Wu, MHY, Masson, SC, Tsang, MP, Stabler, SN, Kinkade, A, Tung, A, Tejani, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.087Z" }, { "id": "561b0ec0-797c-4891-9db3-3bb95bdbf634", "pmid": "", "title": "Colchicine for acute gout", "imported": false, "abstract": "Abstract - Background This is an updated Cochrane Review, first published in 2006 and updated in 2014. Gout is one of the most common rheumatic diseases worldwide. Despite the use of colchicine as one of the first‐line therapies for the treatment of acute gout, evidence for its benefits and harms is relatively limited. Objectives To update the available evidence of the benefits and harms of colchicine for the treatment of acute gout. Search methods We updated the search of CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICTRP registries to 28 August 2020. We did not impose any date or language restrictions in the search. Selection criteria We considered published randomised controlled trials (RCTs) and quasi‐randomised controlled trials (quasi‐RCTs) evaluating colchicine therapy compared with another therapy (placebo or active) in acute gout; low‐dose colchicine at clinically relevant doses compared with placebo was the primary comparison. The major outcomes were pain, participant global assessment of treatment success (proportion with 50% or greater decrease in pain from baseline up to 32 to 36 hours), reduction of inflammation, function of target joint, serious adverse events, total adverse events and withdrawals due to adverse events. Data collection and analysis We used standard methodological procedures as expected by Cochrane in this review update. Main results We included four trials (803 randomised participants), including two new trials, in this updated review. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We did not identify any trials comparing colchicine to glucocorticoids (by any route). The mean age of participants ranged from 51.2 to 70 years, and trial duration from 48 hours to 12 weeks. Two trials were at low risk of bias, one was possibly susceptible to selection bias (random sequence generation), reporting bias and other bias, and one open‐label trial was at high risk of performance and detection bias. For the primary comparison, low‐quality evidence from one trial (103 participants, downgraded for imprecision and bias) suggests low‐dose colchicine may improve treatment outcome compared to placebo with little or no increased risk of adverse events. The number of people who reported treatment success (50% or greater pain reduction) at 32 to 36 hours was slightly larger with low‐dose colchicine (418 per 1000) compared with placebo (172 per 1000; risk ratio (RR) 2.43, 95% confidence interval (CI) 1.05 to 5.64; absolute improvement 25% more reported success (7% more to 42% more, the 95% CIs include both a clinically important and unimportant benefit); relative change of 143% more people reported treatment success (5% more to 464% more). The incidence of total adverse events was 364 per 1000 with low‐dose colchicine compared with 276 per 1000 with placebo: RR 1.32, 95% CI 0.68 to 2.56; absolute difference 9% more events with low‐dose colchicine (9% fewer to 43% more, the 95% CIs include both a clinically important effect and no effect); relative change of 32% more events (32% fewer to 156% more). No participants withdrew due to adverse events or reported any serious adverse events. Pain, inflammation and function were not reported. Low‐quality evidence (downgraded for imprecision and bias) from two trials (124 participants) suggests that high‐dose colchicine compared to placebo may improve symptoms, but with increased risk of harms. More participants reported treatment success at 32 to 36 hours with high‐dose colchicine (518 per 1000) compared with placebo (240 per 1000): RR 2.16, 95% CI 1.28 to 3.65, absolute improvement 28% (8% more to 46% more); more also had reduced inflammation at this time point with high‐dose colchicine (504 per 1000) compared with placebo (48 per 1000): RR 10.50, 95% CI 1.48 to 74.38; absolute improvement 45% greater (22% greater to 68% greater); but more adverse events were reported with high‐dose colchicine (829 per 1000 compared with 260 per 1000): RR 3.21, 95% CI 2.01 to 5.11, absolute difference 57% (26% more to 74% more). Pain and function were not reported. Low‐quality evidence from a single trial comparing high‐dose to low‐dose colchicine indicates there may be little or no difference in benefit in terms of treatment success at 32 to 36 hours but more adverse events associated with the higher dose. Similarly, low‐quality evidence from a single trial indicates there may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction at seven days, with a similar number of adverse events reported at four weeks follow‐up. Reduction of inflammation, function of target joint and withdrawals due to adverse events were not reported in either of these trials, and pain was not reported in the high‐dose versus low‐dose colchicine trial. We were unable to estimate the risk of serious adverse events for most comparisons as there were few events reported in the trials. One trial (399 participants) reported three serious adverse (one in a participant receiving low‐dose colchicine and two in participants receiving NSAIDs), due to reasons unrelated to the trial (low‐quality evidence downgraded for bias and imprecision). Authors' conclusions We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve pain when compared to placebo, low‐quality evidence suggests that high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo, while low‐quality evidence indicates that the number of adverse events may be similar with low‐dose colchicine and NSAIDs. Further trials comparing colchicine to placebo or other treatment will likely have an important impact on our confidence in the effect estimates and may change the conclusions of this review. There are no trials reporting the effect of colchicine in populations with comorbidities or in comparison with other commonly used treatments, such as glucocorticoids. Plain language summary Colchicine for treating acute gout flares Background Gout is a very common cause of inflammatory arthritis (pain, redness, warmth and swelling of affected joints) and is caused by urate crystals forming either within or around joints. Uric acid is a normal waste product that is usually excreted with urine. However, in the case of gout, there is either excessive production of uric acid, or the body is not able to excrete it quickly enough, or a combination of both. An attack of gout usually occurs rapidly and usually resolves within 7 to 10 days. Colchicine is a drug that is used mainly in gout to treat an acute attack or to prevent an attack while starting uric acid‐lowering therapy. Study characteristics This Cochrane Review is current to August 2020. We included four trials (803 randomised participants) in this updated review, including two new trials. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (fake medicine) (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We selected low‐dose colchicine compared with placebo as the primary comparison; the low dose is consistent with doses used in practice. Trials were performed in hospital and multicentre settings in four countries, the majority of participants were male, and mean age ranged between 51.2 and 70 years. One trial received funding from a pharmaceutical company that was involved in the study design, data collection, data analysis, and manuscript writing. Key results Compared with placebo medication, low‐dose colchicine for people with acute gout may slightly improve treatment outcomes with little or no increased risk of adverse events at 32 to 36 hours. Proportion of participants reporting treatment success (defined as 50% or more reduction in pain) 25% more people (7% more to 42% more) reported success, or 25 more out of 100 ‐ 42 people out of 100 reported treatment success with colchicine ‐ 17 people out of 100 reported treatment success with placebo Total adverse events (diarrhoea, vomiting or nausea) 6% more people reported adverse events (13% more to 23% more), or 6 more out of 100 ‐ 26 people out of 100 reported side effects with colchicine ‐ 20 people out of 100 reported side effects with placebo Pain, reduction of inflammation, function of target joint, serious adverse events or withdrawals due to adverse events were not reported for this comparison. Other comparisons are briefly summarised here: High‐dose colchicine may improve symptoms compared with placebo, but with more adverse events. High‐dose may have little or no benefit over low‐dose colchicine but more adverse events. There may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction, with a similar number of adverse events. There were no trials that compared colchicine to glucocorticoids. Quality of the evidence We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve treatment success when compared to placebo, high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo while the number of adverse events may be similar with low‐dose colchicine compared with NSAIDs. Further research is very likely to have an important impact on our confidence in the estimate of effect and may change the estimate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "McKenzie, BJ; Wechalekar, MD; Johnston, RV; Schlesinger, N; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD006190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "562f4558-9e18-4d8c-bf55-9eec81abef5a", "pmid": "", "title": "Echinacea for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Echinacea plant preparations (family Asteraceae ) are widely used in Europe and North America for common colds. Most consumers and physicians are not aware that products available under the term Echinacea differ appreciably in their composition, mainly due to the use of variable plant material, extraction methods and the addition of other components. Objectives To assess whether there is evidence that Echinacea preparations are effective and safe compared to placebo in the prevention and treatment of the common cold. Search methods We searched CENTRAL 2013, Issue 5, MEDLINE (1946 to May week 5, 2013), EMBASE (1991 to June 2013), CINAHL (1981 to June 2013), AMED (1985 to February 2012), LILACS (1981 to June 2013), Web of Science (1955 to June 2013), CAMBASE (no time limits), the Centre for Complementary Medicine Research (1988 to September 2007), WHO ICTRP and clinicaltrials.gov (last searched 5 June 2013), screened references and asked experts in the field about published and unpublished studies. Selection criteria Randomized controlled trials (RCTs) comparing mono‐preparations of Echinacea with placebo. Data collection and analysis At least two review authors independently assessed eligibility and trial quality and extracted data. The primary efficacy outcome was the number of individuals with at least one cold in prevention trials and the duration of colds in treatment trials. For all included trials the primary safety and acceptability outcome was the number of participants dropping out due to adverse events. We assessed trial quality using the Cochrane 'Risk of bias' tool. Main results Twenty‐four double‐blind trials with 4631 participants including a total of 33 comparisons of Echinacea preparations and placebo met the inclusion criteria. A variety of different Echinacea preparations based on different species and parts of plant were used. Evidence from seven trials was available for preparations based on the aerial parts of Echinacea purpurea. Ten trials were considered to have a low risk of bias, six to have an unclear risk of bias and eight to have a high risk of bias. Ten trials with 13 comparisons investigated prevention and 15 trials with 20 comparisons investigated treatment of colds (one trial addressed both prevention and treatment). Due to the strong clinical heterogeneity of the studies we refrained from pooling for the main analysis. None of the 12 prevention comparisons reporting the number of patients with at least one cold episode found a statistically significant difference. However a post hoc pooling of their results, suggests a relative risk reduction of 10% to 20%. Of the six treatment trials reporting data on the duration of colds, only two showed a significant effect of Echinacea over placebo. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. Authors' conclusions Echinacea products have not here been shown to provide benefits for treating colds, although, it is possible there is a weak benefit from some Echinacea products : the results of individual prophylaxis trials consistently show positive (if non‐significant) trends, although potential effects are of questionable clinical relevance. Plain language summary Echinacea for preventing and treating the common cold Preparations of the plant Echinacea are widely used in some European countries and in North America for common colds. Echinacea preparations available on the market differ greatly as different types (species) and parts (herb, root or both) of the plant are used, different manufacturing methods (drying, alcoholic extraction or pressing out the juice from fresh plants) are used and sometimes also other herbs are added. We reviewed 24 controlled clinical trials with 4631 participants investigating the effectiveness of several different Echinacea preparations for preventing and treating common colds or induced rhinovirus infections. Our review shows that a variety of products prepared from different Echinacea species, different plant parts and in a different form have been compared to placebo in randomized trials. Due to the significant differences in the preparations tested, it was difficult to draw strong conclusions. Five trials were rated as having a low risk of bias in all five categories of the Cochrane 'Risk of bias' tool. Five more trials were rated as low risk of bias, having an unclear risk of bias in only one category. Eight trials were rated as having a high risk of bias in at least one category and the remaining six as having an unclear risk of bias. The majority of trials investigated whether taking Echinacea preparations after the onset of cold symptoms shortens the duration, compared with placebo. Although it seems possible that some Echinacea products are more effective than a placebo for treating colds, the overall evidence for clinically relevant treatment effects is weak. In general, trials investigating Echinacea for preventing colds did not show statistically significant reductions in illness occurrence. However, nearly all prevention trials pointed in the direction of small preventive effects. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. The evidence is current to July 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Karsch‐Völk, M, Barrett, B, Kiefer, D, Bauer, R, Ardjomand‐Woelkart, K, Linde, K", "articleTypes": [], "doi": "10.1002/14651858.CD000530.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.076Z" }, { "id": "56484f6b-1602-4ba7-b8a2-4e4574e267f3", "pmid": "", "title": "Capsaicin for non‐allergic rhinitis", "imported": false, "abstract": "Abstract - Background There are many forms of rhinitis. Patients are diagnosed with non‐allergic rhinitis when anatomic, infectious and allergic aetiologies have been excluded. The symptoms, including nasal congestion, blockage or obstruction, clear rhinorrhoea, sneezing and, less frequently, nasal itching, can range from mild to debilitating. It affects between 25% and 50% of patients with rhinitis. Several medications are widely used in the treatment of non‐allergic rhinitis, including oral and topical nasal antihistamines, intranasal and (rarely) systemic corticosteroids, and anticholinergics. Capsaicin, the active component of chili peppers, delivered intranasally, is considered a treatment option for non‐allergic rhinitis. Objectives To assess the effectiveness of capsaicin in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications, or two or more of the above therapies in combination, or different capsaicin regimens. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 5); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2015. Selection criteria Randomised controlled trials in adult patients with non‐allergic rhinitis comparing intranasal capsaicin with no therapy, placebo or other topical or systemic medications, or their combinations. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We included four studies (five publications) involving 302 participants with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe, idiopathic non‐allergic rhinitis who were between the ages of 16 and 65. Studies had follow‐up periods ranging from four to 38 weeks. The overall risk of bias in the studies was either high or unclear (two studies had overall high risk of bias, while two others had low to unclear risk of bias). Using the GRADE system we assessed the evidence as being of low to moderate quality. A meta‐analysis was not possible, given lack of similarity of the reported outcomes. Two studies compared capsaicin with placebo. One study reported that capsaicin resulted in an improvement of overall nasal symptoms (a primary outcome) measured on a visual analogue scale (VAS) of 0 to 10. There was a mean difference (MD) of ‐3.34 (95% confidence interval (CI) ‐5.24 to ‐1.44), MD ‐3.73 (95% CI ‐5.45 to ‐2.01) and MD ‐3.52 (95% CI ‐5.55 to ‐1.48) at two, 12 and 36 weeks post‐treatment, respectively. Another study reported that, compared to placebo, capsaicin (at 4 µg/puff) was more likely to produce overall symptom resolution (reduction in nasal blockage, sneezing/itching/coughing and nasal secretion measured with a daily record chart) at four weeks post‐treatment (a primary outcome). The risk ratio (RR) was 3.17 (95% CI 1.38 to 7.29). One study compared capsaicin to budesonide (an intranasal corticosteroid). This study found that patients treated with capsaicin had a better overall symptom score compared to those treated with budesonide (MD 2.50, 95% CI 1.06 to 3.94, VAS of 0 to 10). However, there were no differences in the individual symptom scores for headache, postnasal drip, rhinorrhoea, nasal blockage, sneezing and sore throat assessed during the last three days of a four‐week treatment. One study compared two different regimens of capsaicin administration: five treatments in one day versus five treatments given every two to three days during two weeks. Using daily record charts, the study reported significant improvement of individual symptom scores for rhinorrhoea in patients treated five times per day, however numerical data were not presented. There were no improvements in the other outcomes: rhinorrhoea, nasal obstruction, sneezing and overall nasal symptoms, measured on a VAS. Finally, one of these studies also compared three doses of capsaicin (to placebo). Patients treated with a 1 µg versus 4 µg per puff dose of capsaicin had a worse daily record chart overall symptom score resolution (RR 0.63, 95% CI 0.34 to 1.16). Only one study attempted to measure adverse effects (a primary outcome), however due to methodological issues with the assessment we are unable to draw any conclusions. We sought to include other secondary outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Authors' conclusions Capsaicin may be an option in the treatment of idiopathic non‐allergic rhinitis. It is given in the form of brief treatments, usually during the same day. It appears to have beneficial effects on overall nasal symptoms up to 36 weeks after treatment, based on a few, small studies (low‐quality evidence). Well‐conducted randomised controlled trials are required to further advance our understanding of the effectiveness of capsaicin in non‐allergic rhinitis, especially in patients with non‐allergic rhinitis of different types and severity, and using different methods of capsaicin application. Plain language summary Capsaicin for non‐allergic rhinitis Review question Is capsaicin applied into the nose (intranasal) effective in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications? Background Rhinitis means inflammation of the nose. It affects 30% to 40% of the general population. There are many forms of rhinitis: rhinosinusitis (or simply sinusitis), allergic rhinitis and non‐allergic rhinitis. Non‐allergic rhinitis is diagnosed in patients who have negative tests for allergies and also do not have sinusitis. The symptoms include congestion of the nose, a blocked or obstructed sensation in the nose that causes difficulty breathing, clear nasal discharge (runny nose), sneezing and nasal itching. There are several subtypes of non‐allergic rhinitis: occupational (from exposure to chemicals), smoking, gustatory (related to eating food or drinking fluid), hormonal (from changes in hormone levels in the body), pregnancy, senile or elderly (mostly affecting the older population), medication‐induced (for example, from overuse of decongestant nasal sprays) and local allergic (local allergy in the nose, while skin or blood allergy tests are negative). The most common subtype of non‐allergic rhinitis is 'idiopathic' or 'vasomotor' rhinitis, which results from imbalance of the neural (nerve) system that manages the function of the nose. The mechanisms of many of these subtypes remain unknown. Non‐allergic rhinitis affects about 25% to 50% of patients with rhinitis and is therefore very common. Capsaicin is the active ingredient of chili peppers. It has medicinal properties and is used elsewhere in medicine, for example for neuralgias (nerve pain) and psoriasis (a skin disease). The side effects of using capsaicin in the nose include irritation, burning, sneezing and coughing, however there are no known long‐term side effects of capsaicin use. Capsaicin is given in the form of brief treatments, usually during the same day. It works by down‐regulating transient receptor potential vanilloid (TRPV) receptor expression on C‐sensory fibres. TRPV represents special ion channels involved in the sensations of pain, cold, hotness, tastes, pressure and vision. C fibres help to conduct some of these sensations. There is ongoing research into the effects of capsaicin on these mechanisms and its clinical uses. Study characteristics We included four studies involving 302 patients with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe idiopathic non‐allergic rhinitis, who were between the ages of 16 and 65. The studies had a follow‐up ranging from four to 38 weeks after treatment. Key results Individually, the studies reported that the overall function of the nose in patients with non‐allergic rhinitis improved when treated with capsaicin compared to placebo. Capsaicin also seems to work better than another common type of nasal medication, budesonide (a steroid). The best knowledge that we have on capsaicin treatment supports giving it five times in one day, and to use doses of at least 4 micrograms in each puff. We could not combine the results together. The included studies did not have sufficient information to allow us to draw a conclusion about side effects. We also wanted to include other outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Quality of the evidence Overall, we judged the quality of the evidence to be of low to moderate quality. The evidence is up to date to June 2015. Conclusions Given that many other options do not work well in non‐allergic rhinitis, capsaicin is a reasonable option to try under physician supervision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Gevorgyan, A; Segboer, C; Gorissen, R; van Drunen, CM; Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010591.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "5657ab2c-93c0-4a92-98df-b24057f65a6b", "pmid": "", "title": "Study of the Effect of Lactisole on the Responses to Intragastric Glucose Solution", "imported": false, "abstract": "The purpose of the study is to determine whether the sweet taste receptors in the gut are involved in sensing sweet substances and controlling appetite and the amount we eat. Lactisole is a substance commonly used in food products to reduce the perceived sweetness of certain sugars and sweeteners. The aim of this study is to investigate whether the responses to a glucose solution, intragastrically administered to healthy male and female volunteers, is affected by the presence of lactisole in the gut. Understanding the mechanisms by which nutrients are initially detected in the gut and how they influence food intake is critical to the development of novel food products that could reduce food consumption.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "565d548c-a4fc-42c9-af80-44e75552f558", "pmid": "", "title": "Adjunctive systemic antimicrobials for the non‐surgical treatment of periodontitis", "imported": false, "abstract": "Abstract - Background Systemic antimicrobials can be used as an adjunct to mechanical debridement (scaling and root planing (SRP)) as a non‐surgical treatment approach to manage periodontitis. A range of antibiotics with different dosage and combinations are documented in the literature. The review follows the previous classification of periodontitis as all included studies used this classification. Objectives To assess the effects of systemic antimicrobials as an adjunct to SRP for the non‐surgical treatment of patients with periodontitis. Search methods Cochrane Oral Health's Information Specialist searched the following databases to 9 March 2020: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, and Embase. The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included randomized controlled trials (RCTs) which involved individuals with clinically diagnosed untreated periodontitis. Trials compared SRP with systemic antibiotics versus SRP alone/placebo, or with other systemic antibiotics. Data collection and analysis We selected trials, extracted data, and assessed risk of bias in duplicate. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE. Main results We included 45 trials conducted worldwide involving 2664 adult participants. 14 studies were at low, 8 at high, and the remaining 23 at unclear overall risk of bias. Seven trials did not contribute data to the analysis. We assessed the certainty of the evidence for the 10 comparisons which reported long‐term follow‐up (≥ 1 year). None of the studies reported data on antimicrobial resistance and patient‐reported quality of life changes. Amoxicillin + metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐16.20%, 95% CI ‐25.87 to ‐6.53; 1 study, 44 participants); clinical attachment level (CAL) (MD ‐0.47 mm, 95% CI ‐0.90 to ‐0.05; 2 studies, 389 participants); probing pocket depth (PD) (MD ‐0.30 mm, 95% CI ‐0.42 to ‐0.18; 2 studies, 389 participants); and percentage of bleeding on probing (BOP) (MD ‐8.06%, 95% CI ‐14.26 to ‐1.85; 2 studies, 389 participants) was of very low certainty. Only the results for closed pockets and BOP showed a minimally important clinical difference (MICD) favouring amoxicillin + metronidazole + SRP. Metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐12.20%, 95% CI ‐29.23 to 4.83; 1 study, 22 participants); CAL (MD ‐1.12 mm, 95% CI ‐2.24 to 0; 3 studies, 71 participants); PD (MD ‐1.11 mm, 95% CI ‐2.84 to 0.61; 2 studies, 47 participants); and percentage of BOP (MD ‐6.90%, 95% CI ‐22.10 to 8.30; 1 study, 22 participants) was of very low certainty. Only the results for CAL and PD showed an MICD favouring the MTZ + SRP group. Azithromycin + SRP versus SRP for chronic/aggressive periodontitis: we found no evidence of a difference in percentage of closed pockets (MD 2.50%, 95% CI ‐10.19 to 15.19; 1 study, 40 participants); CAL (MD ‐0.59 mm, 95% CI ‐1.27 to 0.08; 2 studies, 110 participants); PD (MD ‐0.77 mm, 95% CI ‐2.33 to 0.79; 2 studies, 110 participants); and percentage of BOP (MD ‐1.28%, 95% CI ‐4.32 to 1.76; 2 studies, 110 participants) (very low‐certainty evidence for all outcomes). Amoxicillin + clavulanate + SRP versus SRP for chronic periodontitis: the evidence from 1 study, 21 participants for CAL (MD 0.10 mm, 95% CI ‐0.51 to 0.71); PD (MD 0.10 mm, 95% CI ‐0.17 to 0.37); and BOP (MD 0%, 95% CI ‐0.09 to 0.09) was of very low certainty and did not show a difference between the groups. Doxycycline + SRP versus SRP in aggressive periodontitis: the evidence from 1 study, 22 participants for CAL (MD ‐0.80 mm, 95% CI ‐1.49 to ‐0.11); and PD (MD ‐1.00 mm, 95% CI ‐1.78 to ‐0.22) was of very low certainty, with the doxycycline + SRP group showing an MICD in PD only. Tetracycline + SRP versus SRP for aggressive periodontitis: we found very low‐certainty evidence of a difference in long‐term improvement in CAL for the tetracycline group (MD ‐2.30 mm, 95% CI ‐2.50 to ‐2.10; 1 study, 26 participants). Clindamycin + SRP versus SRP in aggressive periodontitis: we found very low‐certainty evidence from 1 study, 21 participants of a difference in long‐term improvement in CAL (MD ‐1.70 mm, 95% CI ‐2.40 to ‐1.00); and PD (MD ‐1.80 mm, 95% CI ‐2.47 to ‐1.13) favouring clindamycin + SRP. Doxycycline + SRP versus metronidazole + SRP for aggressive periodontitis: there was very low‐certainty evidence from 1 study, 27 participants of a difference in long‐term CAL (MD 1.10 mm, 95% CI 0.36 to 1.84); and PD (MD 1.00 mm, 95% CI 0.30 to 1.70) favouring metronidazole + SRP. Clindamycin + SRP versus metronidazole + SRP for aggressive periodontitis: the evidence from 1 study, 26 participants for CAL (MD 0.20 mm, 95% CI ‐0.55 to 0.95); and PD (MD 0.20 mm, 95% CI ‐0.38 to 0.78) was of very low certainty and did not show a difference between the groups. Clindamycin + SRP versus doxycycline + SRP for aggressive periodontitis: the evidence from 1 study, 23 participants for CAL (MD ‐0.90 mm, 95% CI ‐1.62 to ‐0.18); and PD (MD ‐0.80 mm, 95% CI ‐1.58 to ‐0.02) was of very low certainty and did not show a difference between the groups. Most trials testing amoxicillin, metronidazole, and azithromycin reported adverse events such as nausea, vomiting, diarrhoea, mild gastrointestinal disturbances, and metallic taste. No serious adverse events were reported. Authors' conclusions There is very low‐certainty evidence (for long‐term follow‐up) to inform clinicians and patients if adjunctive systemic antimicrobials are of any help for the non‐surgical treatment of periodontitis. There is insufficient evidence to decide whether some antibiotics are better than others when used alongside SRP. None of the trials reported serious adverse events but patients should be made aware of the common adverse events related to these drugs. Well‐planned RCTs need to be conducted clearly defining the minimally important clinical difference for the outcomes closed pockets, CAL, PD, and BOP. Plain language summary What are the benefits and risks of using antibiotics as well as cleaning by a dental care professional to treat gum disease? Why is this question important? Gum disease is a common condition in which the gums become swollen, sore or infected. It is caused by bacteria that accumulate on gums and teeth. Diseased gums may bleed when people brush their teeth, and may cause bad breath. If gum disease is not treated, teeth can become loose and eventually fall out. This can affect a person’s ability to chew and speak. It can also make people feel self‐conscious about their appearance. Dental‐care professionals can clean teeth and gums to remove excess bacteria from the mouth. They use special instruments – typically, an ultrasound scraper followed by specialised hand‐held instruments – to scrape bacteria from the teeth, and stop these from affecting the gums. Antibiotics (medicines that kill bacteria) taken by mouth (orally) can be used alongside professional cleaning, to remove bacteria from the area between the teeth and gums. However, there are potential risks associated with antibiotics, such as allergic reactions and antibiotic resistance (changes in bacteria after exposure to antibiotics, that allow the bacteria to survive future antibiotic treatment). We conducted a review of the evidence from research studies to find out about the benefits and risks of using antibiotics alongside professional dental cleaning to treat gum disease. We also wanted to know if some antibiotics work better than others in this situation. How did we identify and evaluate the evidence? First, we searched for randomized controlled studies (clinical studies where people are randomly put into one of two or more treatment groups), because these studies provide the most robust evidence about the effects of a treatment. We then compared the results, and summarized the evidence from all the studies. Finally, we rated our confidence in the evidence, based on factors such as study methods and sizes, and the consistency of findings across studies. What did we find? We found 45 studies that involved a total of 2664 people over the age of 18 who had gum disease. The studies compared professional cleaning plus antibiotics against professional cleaning alone, or compared different antibiotics used alongside professional cleaning against one another. We cannot tell whether antibiotics reduce gum disease in the long term (one year or more after treatment), or whether some antibiotics are better than others. This is because we have very little confidence in the evidence we found. We cannot tell whether antibiotics are associated with unwanted effects, because we have too little confidence in the evidence. The most commonly reported unwanted effects were temporary, mild gastrointestinal disturbances, such as nausea, vomiting, diarrhoea, or a metallic taste in the mouth. No serious unwanted effects were reported. No studies reported on antimicrobial resistance or changes in people’s quality of life. What does this mean? We do not know whether: ‐ using antibiotics alongside professional cleaning is beneficial for treating gum disease in the long term (more than one year after treatment);
‐ using antibiotics alongside professional cleaning is associated with unwanted effects; or
‐ some antibiotics are better than others for treating gum disease alongside professional cleaning. Our confidence in the available evidence is very low. The results of our review are likely to change if more evidence becomes available. Future studies should clearly define what qualifies as a minimally important improvement in gum disease. How‐up‐to date is this review? The evidence in this Cochrane Review is current to March 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Khattri, S; Kumbargere Nagraj, S; Arora, A; Eachempati, P; Kusum, CK; Bhat, KG; Johnson, TM; Lodi, G", "articleTypes": [], "doi": "10.1002/14651858.CD012568.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "565e24a9-e249-4b3e-8caa-c97ff4707dc1", "pmid": "", "title": "Ribavirin plus interferon versus interferon for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. Standard therapy is ribavirin plus pegylated interferon to achieve undetectable level of virus in the blood, but the effect on clinical outcomes is controversial. Objectives To assess the beneficial and harmful effects of ribavirin and interferon combination therapy versus interferon monotherapy for chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, approaching authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included randomised trials, irrespective of blinding, language, or publication status, comparing ribavirin plus interferon versus interferon for treatment of chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained loss of hepatitis C virus, liver‐related morbidity plus all‐cause mortality, and adverse events. We performed subgroup analyses of patients who were naive, relapsers, or non‐responders to previous antiviral treatment. All outcomes were analysed with the random‐effects model. We used Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of morbidity plus mortality. The remaining outcomes were presented as relative risks (RR). We used trial sequential analyses to examine the robustness of our findings. Main results We included 83 randomised trials with 12,707 patients. Most trials had unclear or high risk of bias. We did not find any significant influence of bias on our results but cannot exclude outcome measure reporting bias as many trials did not report on the primary outcomes of this review. Compared with interferon, ribavirin plus interferon had a significant beneficial effect on sustained virological response in subgroups of naive patients (RR 0.72, 95% confidence interval (CI) 0.68 to 0.75), relapsers (RR 0.62, 95% CI 0.54 to 0.70), non‐responders (RR 0.89, 95% CI 0.84 to 0.93), and in all patients (RR 0.75, 95% CI 0.71 to 0.79). Combination therapy significantly reduced morbidity plus mortality in all patients (Peto OR, 0.43, 95% CI 0.23 to 0.79), but not in naive, relapsers, or non‐responders individually. Combination therapy significantly increased the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous (cough, dyspnoea, fatigue) adverse reactions. Accordingly, combination therapy significantly increased the risk of treatment discontinuation and dose reductions. Trial sequential analyses confirmed our findings regarding virological effects, but not regarding liver‐related morbidity and all‐cause mortality. Authors' conclusions Compared with interferon alone, ribavirin plus interferon is more effective in clearing hepatitis C virus from the blood. Combination therapy may reduce liver‐related morbidity and all‐cause mortality, but we need more evidence. The number needed to treat to obtain a beneficial effect is considerable considering the increased risk of several severe adverse reactions and costs. Plain language summary Adding ribavirin to interferon increases the number of patients who clear hepatitis C virus but also leads to several adverse reactions Globally about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behavior, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die. It is known that treatment with the drug interferon clears hepatitis C virus from the blood in about 15% of patients. This review identified studies comparing ribavirin plus interferon with interferon alone in patients with chronic hepatitis C. This review shows, by combining the results from all trials, that adding ribavirin to interferon increases the number of patients who clear the hepatitis C virus to about 40% as well as the number of patients who demonstrate improved liver histology. Ribavirin and interferon may also reduce the risk of liver‐related morbidity or all‐cause mortality. However, the number needed to treat to prevent one patient developing morbidity or dying seems very large. Furthermore, combination therapy was associated with increased risk of anaemia and several other adverse reactions. The results gives rise to a dilemma ‐ should we, by adding ribavirin to interferon, increase the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous adverse reactions in a situation where it has not yet been clearly demonstrated that the antiviral effect of the intervention is directly linked to the reduction of all‐cause mortality? We, therefore, suggest that the combination intervention is applied only with stringent emphasis on the individual patients' well‐being. Furthermore, we suggest that all future trials within the area should focus more on adverse reactions and long‐term clinical outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Brok, J; Gluud, LL; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "566cca5b-3073-4507-a166-5d4bb3f073b7", "pmid": "", "title": "Chloral hydrate as a sedating agent for neurodiagnostic procedures in children", "imported": false, "abstract": "Abstract - Background This is an updated version of a Cochrane Review published in 2017. Paediatric neurodiagnostic investigations, including brain neuroimaging and electroencephalography (EEG), play an important role in the assessment of neurodevelopmental disorders. The use of an appropriate sedative agent is important to ensure the successful completion of the neurodiagnostic procedures, particularly in children, who are usually unable to remain still throughout the procedure. Objectives To assess the effectiveness and adverse effects of chloral hydrate as a sedative agent for non‐invasive neurodiagnostic procedures in children. Search methods We searched the following databases on 14 May 2020, with no language restrictions: the Cochrane Register of Studies (CRS Web) and MEDLINE (Ovid, 1946 to 12 May 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including Cochrane Epilepsy. Selection criteria Randomised controlled trials that assessed chloral hydrate agent against other sedative agent(s), non‐drug agent(s), or placebo. Data collection and analysis Two review authors independently evaluated studies identified by the search for their eligibility, extracted data, and assessed risk of bias. Results were expressed in terms of risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CIs). Main results We included 16 studies with a total of 2922 children. The methodological quality of the included studies was mixed. Blinding of the participants and personnel was not achieved in most of the included studies, and three of the 16 studies were at high risk of bias for selective reporting. Evaluation of the efficacy of the sedative agents was also underpowered, with all the comparisons performed in small studies. Fewer children who received oral chloral hydrate had sedation failure compared with oral promethazine (RR 0.11, 95% CI 0.01 to 0.82; 1 study; moderate‐certainty evidence). More children who received oral chloral hydrate had sedation failure after one dose compared to intravenous pentobarbital (RR 4.33, 95% CI 1.35 to 13.89; 1 study; low‐certainty evidence), but there was no clear difference after two doses (RR 3.00, 95% CI 0.33 to 27.46; 1 study; very low‐certainty evidence). Children with oral chloral hydrate had more sedation failure compared with rectal sodium thiopental (RR 1.33, 95% CI 0.60 to 2.96; 1 study; moderate‐certainty evidence) and music therapy (RR 17.00, 95% CI 2.37 to 122.14; 1 study; very low‐certainty evidence). Sedation failure rates were similar between groups for comparisons with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam and oral clonidine. Children who received oral chloral hydrate had a shorter time to adequate sedation compared with those who received oral dexmedetomidine (MD −3.86, 95% CI −5.12 to −2.6; 1 study), oral hydroxyzine hydrochloride (MD −7.5, 95% CI −7.85 to −7.15; 1 study), oral promethazine (MD −12.11, 95% CI −18.48 to −5.74; 1 study) (moderate‐certainty evidence for three aforementioned outcomes), rectal midazolam (MD −95.70, 95% CI −114.51 to −76.89; 1 study), and oral clonidine (MD −37.48, 95% CI −55.97 to −18.99; 1 study) (low‐certainty evidence for two aforementioned outcomes). However, children with oral chloral hydrate took longer to achieve adequate sedation when compared with intravenous pentobarbital (MD 19, 95% CI 16.61 to 21.39; 1 study; low‐certainty evidence), intranasal midazolam (MD 12.83, 95% CI 7.22 to 18.44; 1 study; moderate‐certainty evidence), and intranasal dexmedetomidine (MD 2.80, 95% CI 0.77 to 4.83; 1 study, moderate‐certainty evidence). Children who received oral chloral hydrate appeared significantly less likely to complete neurodiagnostic procedure with child awakening when compared with rectal sodium thiopental (RR 0.95, 95% CI 0.83 to 1.09; 1 study; moderate‐certainty evidence). Chloral hydrate was associated with a higher risk of the following adverse events: desaturation versus rectal sodium thiopental (RR 5.00, 95% 0.24 to 102.30; 1 study), unsteadiness versus intranasal dexmedetomidine (MD 10.21, 95% CI 0.58 to 178.52; 1 study), vomiting versus intranasal dexmedetomidine (MD 10.59, 95% CI 0.61 to 185.45; 1 study) (low‐certainty evidence for aforementioned three outcomes), and crying during administration of sedation versus intranasal dexmedetomidine (MD 1.39, 95% CI 1.08 to 1.80; 1 study, moderate‐certainty evidence). Chloral hydrate was associated with a lower risk of the following: diarrhoea compared with rectal sodium thiopental (RR 0.04, 95% CI 0.00 to 0.72; 1 study), lower mean diastolic blood pressure compared with sodium thiopental (MD 7.40, 95% CI 5.11 to 9.69; 1 study), drowsiness compared with oral clonidine (RR 0.44, 95% CI 0.30 to 0.64; 1 study), vertigo compared with oral clonidine (RR 0.15, 95% CI 0.01 to 2.79; 1 study) (moderate‐certainty evidence for aforementioned four outcomes), and bradycardia compared with intranasal dexmedetomidine (MD 0.17, 95% CI 0.05 to 0.59; 1 study; high‐certainty evidence). No other adverse events were significantly associated with chloral hydrate, although there was an increased risk of combined adverse events overall (RR 7.66, 95% CI 1.78 to 32.91; 1 study; low‐certainty evidence). Authors' conclusions The certainty of evidence for the comparisons of oral chloral hydrate against several other methods of sedation was variable. Oral chloral hydrate appears to have a lower sedation failure rate when compared with oral promethazine. Sedation failure was similar between groups for other comparisons such as oral dexmedetomidine, oral hydroxyzine hydrochloride, and oral midazolam. Oral chloral hydrate had a higher sedation failure rate when compared with intravenous pentobarbital, rectal sodium thiopental, and music therapy. Chloral hydrate appeared to be associated with higher rates of adverse events than intranasal dexmedetomidine. However, the evidence for the outcomes for oral chloral hydrate versus intravenous pentobarbital, rectal sodium thiopental, intranasal dexmedetomidine, and music therapy was mostly of low certainty, therefore the findings should be interpreted with caution. Further research should determine the effects of oral chloral hydrate on major clinical outcomes such as successful completion of procedures, requirements for an additional sedative agent, and degree of sedation measured using validated scales, which were rarely assessed in the studies included in this review. The safety profile of chloral hydrate should be studied further, especially for major adverse effects such as oxygen desaturation. Plain language summary The effectiveness of chloral hydrate as a sedative agent for children undergoing neurodiagnostic procedures Review question In children undergoing non‐invasive neurodiagnostic procedures, is chloral hydrate more effective at producing adequate sedation (slowing of brain activity) and safer than other ways of achieving sedation? Background Neurodiagnostic procedures are non‐invasive neurological investigations important for children with suspected neurological disorders. These investigations include brain imaging and brain electrical activity testing. For these tests to be successfully performed, the child needs to remain still for at least 30 to 45 minutes during the investigation period. Sedative agents are required for children, who are usually unable to remain still for this period of time. Search date The evidence is current to May 2020. Study characteristics We included 16 studies involving a total of 2922 children (age up to 18 years old) in the review. All of the included studies were performed in hospitals that provided neurodiagnostic services. Most studies assessed the following three main outcomes: proportion of children who were unsuccessfully sedated for the neurodiagnostic procedure; length of time taken for adequate sedation; and side effects associated with the sedative agent. The quality of the evidence was mixed, ranging from very low to high. The main reason for lowering the quality of the evidence was that those closely involved in the trials, such as the doctors giving the sedation or the parents of the child, were not masked to the sedative agent used in the child, which could have affected their recording or interpretation of the results. Key results We summarised the evidence of effectiveness and harms of oral chloral hydrate sedation when compared with other sedative agents. Our review suggests that oral chloral hydrate is just as effective a sedative agent with similar sedation failure rate when compared with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam, and oral clonidine; and probably a more effective sedative agent with a lower sedation failure rate when compared with oral promethazine. Whilst most of the included studies showed that chloral hydrate was safe with no increase in side effects when compared to other sedative agents, one study reported an increased risk of side effects with oral chloral hydrate when compared with intranasal dexmedetomidine. Quality of the evidence The quality of most of the evidence was poor due to flaws in study methods and the small sample size of each study, therefore our confidence in the results of the studies is reduced. Conclusions Apart from intravenous pentobarbital, rectal sodium thiopental, and music therapy, oral chloral hydrate is either just as effective or more effective as a sedating agent when compared to other sedating agents for children undergoing non‐invasive neurodiagnostic procedures. Given the poor quality of the evidence, we could draw no clear conclusions on the effectiveness or safety of any of the paediatric sedative agents studied in the review. Further study is needed to look at the side effects of oral chloral hydrate when compared to other sedatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Fong, CY; Lim, WK; Li, L; Lai, NM", "articleTypes": [], "doi": "10.1002/14651858.CD011786.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "568fed3c-a031-425b-8db8-8bfad19948bb", "pmid": "", "title": "Hydroxyurea (hydroxycarbamide) for sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and a reduced life expectancy. Hydroxyurea (hydroxycarbamide), an oral chemotherapeutic drug, ameliorates some of the clinical problems of SCD, in particular that of pain, by raising foetal haemoglobin (HbF). This is an update of a previously published Cochrane Review. Objectives The aims of this review are to determine through a review of randomised or quasi‐randomised studies whether the use of hydroxyurea in people with SCD alters the pattern of acute events, including pain; prevents, delays or reverses organ dysfunction; alters mortality and quality of life; or is associated with adverse effects. In addition, we hoped to assess whether the response to hydroxyurea in SCD varies with the type of SCD, age of the individual, duration and dose of treatment, and healthcare setting. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Haemoglobinopathies Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. The date of the most recent search was 17 February 2022. Selection criteria Randomised and quasi‐randomised controlled trials (RCTs and quasi‐RCTs), of one month or longer, comparing hydroxyurea with placebo or standard therapy in people with SCD. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction, assessed the risk of bias and assessed the quality of the evidence using GRADE. Main results We included nine RCTs recruiting 1104 adults and children with SCD (haemoglobin SS (HbSS), haemoglobin SC (HbSC) or haemoglobin Sβºthalassaemia (HbSβºthal) genotypes). Studies lasted from six to 30 months. We judged the quality of the evidence for the first two comparisons below as moderate to low as the studies contributing to these comparisons were mostly large and well‐designed (and at low risk of bias); however, the evidence was limited and imprecise for some outcomes such as quality of life, deaths during the studies and adverse events, and the results are applicable only to individuals with HbSS and HbSβºthal genotypes. We judged the quality of the evidence for the third and fourth comparisons to be very low due to the limited number of participants, the lack of statistical power (both studies were terminated early with approximately only 20% of their target sample size recruited) and the lack of applicability to all age groups and genotypes. Hydroxyurea versus placebo Five studies (784 adults and children with HbSS or HbSβºthal) compared hydroxyurea to placebo; four recruited individuals with only severe disease and one recruited individuals with all disease severities. Hydroxyurea probably improves pain alteration (using measures such as pain crisis frequency, duration, intensity, hospital admissions and opoid use) and life‐threatening illness, but we found no difference in death rates (10 deaths occurred during the studies, but the rates did not differ by treatment group) (all moderate‐quality evidence). Hydroxyurea may improve measures of HbF (low‐quality evidence) and probably decreases neutrophil counts (moderate‐quality evidence). There were no consistent differences in terms of quality of life and adverse events (including serious or life‐threatening events) (low‐quality evidence). There were fewer occurrences of acute chest syndrome and blood transfusions in the hydroxyurea groups. Hydroxyurea and phlebotomy versus transfusion and chelation Two studies (254 children with HbSS or HbSβºthal also with risk of primary or secondary stroke) contributed to this comparison. There were no consistent differences in terms of pain alteration, death or adverse events (low‐quality evidence) or life‐threatening illness (moderate‐quality evidence). Hydroxyurea with phlebotomy probably increased HbF and decreased neutrophil counts (moderate‐quality evidence), but there were more occurrences of acute chest syndrome and infections. Quality of life was not reported. In the primary prevention study, no strokes occurred in either treatment group but in the secondary prevention study, seven strokes occurred in the hydroxyurea and phlebotomy group (none in the transfusion and chelation group) and the study was terminated early. Hydroxyurea versus observation One study (22 children with HbSS or HbSβºthal also at risk of stoke) compared hydroxyurea to observation. Pain alteration and quality of life were not reported. There were no differences in life‐threatening illness, death (no deaths reported in either group) or adverse events (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF or decreases neutrophil counts (very low‐quality evidence). Treatment regimens with and without hydroxyurea One study (44 adults and children with HbSC) compared treatment regimens with and without hydroxyurea. Pain alteration, life‐threatening illness and quality of life were not reported. There were no differences in death rates (no deaths reported in either group), adverse events or neutrophil levels (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF (very low‐quality evidence). Authors' conclusions There is evidence to suggest that hydroxyurea may be effective in decreasing the frequency of pain episodes and other acute complications in adults and children with sickle cell anaemia of HbSS or HbSβºthal genotypes and in preventing life‐threatening neurological events in those with sickle cell anaemia at risk of primary stroke by maintaining transcranial Doppler velocities. However, there is still insufficient evidence on the long‐term benefits of hydroxyurea, particularly with regard to preventing chronic complications of SCD, or recommending a standard dose or dose escalation to maximum tolerated dose. There is also insufficient evidence about the long‐term risks of hydroxyurea, including its effects on fertility and reproduction. Evidence is also limited on the effects of hydroxyurea on individuals with the HbSC genotype. Future studies should be designed to address such uncertainties. Plain language summary Hydroxyurea (also known as hydroxycarbamide) for people with sickle cell disease Review question What is the effect of hydroxyurea on clinical outcomes (changes in pain crises, life‐threatening illnesses, survival, haemoglobin levels, quality of life and side effects) in people with sickle cell disease (SCD) of any genotype? Background Sickle cell disease (SCD) is an inherited genetic disorder that creates problems with haemoglobin (the substance in red blood cells that carries oxygen around the body). The disease can be inherited in different ways; people can inherit two sickle genes (HbSS genotype) or they can inherit the sickle gene from one parent and a different haemoglobin gene such as haemoglobin C, resulting in the HbSC genotype, or a beta thalassaemia gene from the second parent, which gives rise to HbSβ+ or HbSβºthal. In people with SCD the abnormal sickle haemoglobin forms long polymers (chains) within the red blood cells when they become de‐oxygenated. This damages the red blood cells and makes them stickier, leading to blockages and reduced blood flow, causing pain and organ damage. Foetal haemoglobin (HbF) stops these polymers forming in the sickle haemoglobin within the red blood cell. The drug hydroxyurea is used to increase HbF and can reduce the effects of the disease. This is an update of a previously published Cochrane Review. Search date The evidence is current to 17 February 2022. Study characteristics We included nine randomised studies (1104 adults and children with SCD (HbSS, HbSC or HbSβºthal genotypes)). Studies lasted from six to 30 months. Key results and quality of the evidence In five studies, 784 adults and children with SCD were randomly selected to receive hydroxyurea or placebo. In two studies, 254 children with SCD, who were also at an increased risk of having a first or second stroke, were randomly selected to receive hydroxyurea and phlebotomy (collection of blood) or blood transfusion and chelation (administration of agents to remove excess iron from the body). These seven studies only recruited people with HbSS or HbSβºthal genotypes so the results do not apply to people with the HbSC genotype. There was moderate‐quality evidence from these seven studies that hydroxyurea may reduce the frequency of pain crises, may increase HbF and may decrease neutrophil (white blood cell) counts compared to the comparator treatment. We found no difference between people receiving hydroxyurea or other treatments in terms of quality of life, deaths during the studies and adverse effects (including serious and life‐threatening effects). However, there is less information about these outcomes in the studies, so the quality of this evidence is low. Two further studies were included in the review. In one study, 22 children with SCD, who were also at increased risk of having a stroke, were randomly selected to receive hydroxyurea or no treatment (observation only) and in one study 44 adults and children were randomly selected to receive treatments with or without adding hydroxyurea. In both studies we are unsure if hydroxyurea led to an increase in HbF compared to the comparator treatment. There were no deaths during the studies. There was no difference between people receiving hydroxyurea or other treatments in terms of pain crises and adverse effects (including serious or life‐threatening effects) and neither study measured quality of life. The quality of the evidence from these studies is very low, given the studies were very small and only recruited around 20% of the intended number of people, and the results do not apply to all people with SCD (different genotypes). Conclusions The evidence shows that hydroxyurea is likely to be effective in the short term at decreasing the frequency of painful episodes and raising HbF levels in the blood in people with SCD. Hydroxyurea is also likely to be effective in preventing first strokes for those at an increased risk of stroke and does not seem to be associated with an increase in any adverse effects (including serious and life‐threatening effects). There is currently little evidence from the studies that we examined on whether hydroxyurea is beneficial over a long period of time, what the best dose to take is, or whether treatment causes any long‐term or serious side effects. More studies are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Rankine-Mullings, AE, Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD002202.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.806Z" }, { "id": "56b2a211-6127-4181-b5dc-daf3518ca7da", "pmid": "", "title": "Pharmaceutical interventions for emotionalism after stroke", "imported": false, "abstract": "Abstract - Background Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2019. Objectives To evaluate the benefits and harms of pharmaceutical treatment in people with emotionalism after stroke. Search methods We searched the Cochrane Stroke Group Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registers (May 2022). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). Data collection and analysis Two review authors independently selected trials, assessed risk of bias, extracted data from all included trials, and used GRADE to assess the certainty of the body of evidence. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I 2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on the Center for Neurologic Study ‐ Lability Scale (CNS‐LS) or Clinician Interview‐Based Impression of Change (CIBIC), or diminished tearfulness. Main results We did not identify any new trials for this update. We included seven trials with a total of 239 participants. Two trials had a cross‐over design, but outcome data were not available from the first phase (precross‐over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with a total of 213 participants. It is uncertain whether fluoxetine increases the number of people who have a 50% reduction in emotionalism when compared to placebo (risk ratio (RR) 0.26, 95% CI 0.09 to 0.77; P = 0.02; 1 trial, 19 participants) because the certainty of evidence is very low. Sertraline may lead to little to no difference in Center for Neurologic Study ‐ Lability Scale (CNS‐LS) scores and Clinician Interview‐Based Impression of Change (CIBIC) scores when compared to placebo (RR 0.20, 95% CI 0.03 to 1.50; P = 0.12; 1 trial, 28 participants; low‐certainty evidence). Antidepressants probably increase the number of people who experience a reduction in tearfulness (RR 0.32, 95% CI 0.12 to 0.86; P = 0.02; 3 trials, 164 participants; moderate‐certainty evidence). No trials were found that evaluated the impact of other pharmaceutical interventions. Only two trial authors systematically recorded and reported adverse events, resulting in limited data on the potential harms of treatment. Six trials reported death as an adverse event and found no difference between the groups (antidepressants versus placebo) in the number of deaths reported (RR 0.59, 95% CI 0.08 to 4.50; P = 0.61; 172 participants; moderate‐certainty evidence). This review provides very low‐ to moderate‐certainty evidence that antidepressants may reduce the frequency and severity of emotionalism. The included trials were small and had some degree of bias. Authors' conclusions Antidepressants may reduce the frequency and severity of crying or laughing episodes when compared to placebo, based on very low‐certainty evidence. Our conclusions must be qualified by several methodological deficiencies in the trials and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post‐stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity, and assess change over time; provide treatment for a sufficient duration and follow‐up to better assess rates of relapse or maintenance; and include careful assessment and complete reporting of adverse events. Plain language summary Medicines for emotionalism after stroke Review question To evaluate the benefits and harms of medicine in people with emotionalism after stroke. Background Emotionalism often occurs after stroke. Emotionalism means that the person has difficulty controlling their emotional behaviour. After stroke, people may suddenly start crying or, less commonly, laughing for no apparent reason. This is distressing for that particular person and their carers. Antidepressants, known to be helpful in people with depression, may be an effective treatment for emotionalism after stroke, but there have been very few randomised controlled trials (RCTs) in this area. (RCTs are studies in which participants are assigned randomly to 2 or more treatment groups. This is the best way to ensure that groups of participants are similar, and that investigators and participants do not know who is in which group.) Search date We identified studies through searches conducted on 26 May 2022. Study characteristics We included 7 randomised controlled trials, involving 239 people with emotionalism, in the review, which reported on the use of antidepressants for treating emotionalism. The numbers of people included in the studies ranged from 10 to 92. The mean/median ages ranged from 57.8 years to 73 years. Studies were from Europe (UK: 1; Denmark: 1; Scotland: 1; and Sweden: 1); Asia (South Korea: 1 and Japan: 1); and the USA (1). Key results We did not identify any new studies in our search update. We included 7 studies involving 239 people. However, 2 studies were not available in the appropriate format to include in the analysis. Therefore, we included only 5 studies, with 213 people, in our analyses. It is uncertain whether antidepressants affect the number of people with at least a 50% reduction in emotional displays, tearfulness, and scores on the questionnaires that measure uncontrollable laughing or crying, but they had no effect on lability (frequency of mood changes) scores and whether a clinician thought there had been an improvement when compared to placebo. No studies of other types of medicine were found. Six studies reported death and found no differences between those who were on antidepressants and those who were not. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low, and the results of further research could differ from the results of this review. Our confidence is limited because the included studies were small, and there was no consistency in how emotionalism was measured across the studies. Conclusion It is uncertain whether antidepressant medicines reduce outbursts of crying or laughing. More studies with systematic assessment and reporting of unwanted or harmful effects of a treatment are needed to ensure that any benefits outweigh the risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Allida, S; House, A; Hackett, ML", "articleTypes": [], "doi": "10.1002/14651858.CD003690.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "56dfa0a0-b945-40f9-a2f3-21cc8fe9b0f9", "pmid": "", "title": "Olfactory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Preterm infants, often gavage‐fed due to immaturity, may benefit from interventions that hasten the move to breastfeeding. Olfactory stimulation may increase appetite and speed up the transition to full oral feeding, potentially shortening hospital stay and improving outcomes for both infants and families. Objectives To evaluate the benefits and harms of olfactory stimulation for reducing morbidity and promoting development in hospitalized preterm infants. Search methods We searched MEDLINE, Embase, CENTRAL, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 2 April 2025. We checked the reference lists of included studies and systematic reviews on olfactory or sensory stimulation. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs evaluating olfactory stimulation with different odorants (maternal breast milk, food‐associated odors, or non‐food‐associated odors) in preterm infants (born before 37 weeks' gestation). Eligible controls were no intervention, placebo, or standard care (considered together) or another odorant. We excluded studies combining olfactory stimulation with taste, as another review will focus on combined sensory stimulation. Outcomes Our critical outcomes were apnea, intermittent hypoxemia, duration of hospital stay, time to full oral feeding, and exclusive breastfeeding. Our important outcomes included blindness and sensorineural deafness requiring amplification. Risk of bias We used the Cochrane risk of bias tool (RoB 2) to assess risk of bias in the included studies. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, each with its 95% confidence interval (CI). We assessed the certainty of evidence using GRADE. Included studies We included 14 trials enrolling 1087 neonates. The types of olfactory stimulation under investigation were maternal breast milk (9 studies); food‐associated odors such as cinnamon, vanilla, or anise (5 studies); and non‐food‐associated odors such as rose or parents' scent (3 studies). Three studies evaluated two different odorants. Gestational age and bodyweight varied widely. The comparators were placebo, no intervention, and standard care. Eleven studies aimed to assess the effect of olfactory stimulation on infant feeding outcomes such as time to full oral feeding, weight gain, length of hospital stay, or a combination of these outcomes. Three studies aimed to assess the effect of olfactory stimulation on apnea prevention, oxygen saturation, or both. We identified five ongoing trials. Synthesis of results No studies reported apnea as a dichotomous outcome, intermittent hypoxemia, exclusive breastfeeding, or major neurodevelopmental disability for any of the comparisons. We downgraded the certainty of evidence for limitations in study design, imprecision, and indirectness. Olfactory stimulation with maternal breast milk versus no intervention, placebo, or standard care The evidence is very uncertain about the effect of olfactory stimulation with maternal breast milk on the mean number of daily apnea episodes (MD −0.50, 95% CI −1.27 to 0.27; 1 study, 26 participants; very low‐certainty evidence) and duration of hospital stay in days (MD −0.18, 95% CI −0.64 to 0.27; I² = 0%; 4 studies, 270 participants; very low‐certainty evidence). Olfactory stimulation with maternal breast milk may result in a slight reduction in time to full oral feeding in days (MD −1.68, 95% CI −3.25 to −0.11; I² = 30%; 3 studies, 204 participants; low‐certainty evidence). Olfactory stimulation with food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with food‐associated odors may result in a slight reduction in the mean number of daily apnea episodes (MD −1.99, 95% CI −2.69 to −1.29; I² = 58%; 2 studies, 62 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with food‐associated odors on duration of hospital stay in days (MD −2.65, 95% CI −6.18 to 0.89; I² = 20%; 3 studies, 185 participants; very low‐certainty evidence) and time to full oral feeding in days (MD −2.06, 95% CI −5.16 to 1.04; I² = 36%; 3 studies, 185 participants; very low‐certainty evidence). Olfactory stimulation with non‐food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with non‐food‐associated odors may result in a slight reduction in duration of hospital stay in days (MD −3.23, 95% CI −5.50 to −0.97; I² = 0%; 2 studies, 94 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with non‐food‐associated odor on the mean number of daily apnea episodes (MD −2.13, 95% CI −2.28 to −1.98; 1 study, 60 participants; very low‐certainty evidence) and time to full oral feeding (mean 21 (standard deviation 3.1) days in the intervention group and mean 21 (standard deviation 15.6) days in the control group; 1 study, 27 participants; very low‐certainty evidence). Authors' conclusions Olfactory stimulation with maternal breast milk compared to no intervention, placebo, or standard care may result in a slight reduction in time to full oral feeding, but the evidence is very uncertain about its effect on frequency of apnea episodes and duration of hospital stay. Olfactory stimulation with food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in frequency of apnea episodes, but the evidence is very uncertain about its effect on duration of hospital stay and time to full oral feeding. Olfactory stimulation with non‐food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in duration of hospital stay, but the evidence is very uncertain about its effect on frequency of apnea episodes and time to full oral feeding. Future studies should be more rigorous in their design, report using TIDieR (Template for Intervention Description and Replication) checklists, have larger sample sizes, and measure outcomes such as apnea (number of infants with ≥ 1 episode), intermittent hypoxemia (number of infants with ≥ 1 episode), exclusive breastfeeding, and major neurodevelopmental disabilities. Funding Dedicated funding for this review can be found in the 'Sources of support' section. Registration Protocol: https://doi.org/10.1002/14651858.CD016074 . Plain language summary Does introducing smells to preterm infants improve their physical and mental development? Key messages Introducing preterm infants to the smell of maternal breast milk may slightly reduce the time it takes for them to feed fully by mouth. Introducing them to food smells such as vanilla and cinnamon may slightly reduce how often they stop breathing. Finally, introducing preterm babies to the smell of rose or a parent's scent may reduce slightly the time they have to stay in hospital. All other results are very uncertain. Future studies should include more infants, use more rigorous designs, and measure outcomes such as breathing problems, low blood oxygen levels, exclusive breastfeeding, and long‐term neurodevelopmental outcomes. What is preterm birth? A normal pregnancy usually lasts from 37 weeks to 42 weeks. Preterm birth is when a baby is born before 37 weeks of pregnancy. Babies born preterm have not had enough time to fully develop before birth. Their organs may not yet be ready to work on their own, which means they often need intensive medical care and are at greater risk of breathing and feeding difficulties, infection, and problems that can affect their long‐term development. What is olfactory stimulation, and how does it work? Preterm infants often take time to build up the skills or physical capacity to feed by mouth, and in the meantime are fed through a tube passed into the stomach. Olfactory stimulation involves introducing smells to preterm infants while they are in hospital to see if it helps them start breastfeeding more quickly. These smells include breast milk, food smells such as vanilla or cinnamon, and other smells such as a floral scent or a parent's scent. What did we want to find out? We wanted to find out whether introducing a smell to preterm infants in hospital could be helpful and safe for their short‐term and long‐term well‐being. More specifically, we wanted to find out whether introducing a smell to preterm infants is better than placebo (dummy treatment), no treatment, or usual care for: reducing the number of infants who have apnea (brief pauses in breathing); reducing the number of infants with low oxygen levels in the blood; reducing the time spent in hospital; reducing the time needed for the infants to learn to feed fully by mouth; increasing the number of infants that are fed only with breast milk; reducing the number of infants with blindness or deafness between 18 and 24 months of age. What did we do? We searched for studies that compared olfactory stimulation with placebo, no treatment, or usual care in preterm infants. We summarized the results of the studies and rated our confidence in the evidence based on factors such as study size (number of infants) and methods. What did we find? We included 14 studies with 1087 infants. Nine studies used the smell of maternal breast milk, five used food‐associated smells (vanilla, cinnamon, or anise), and three studies used other smells (rose or parents' scent). All studies compared these smells with no treatment, placebo, or usual care. Main results Introducing the smell of maternal breast milk may reduce slightly the time it takes infants to feed fully by mouth. It is unclear whether stimulation with this smell has any effect on how often infants have apnea episodes and how long they stay in hospital. Introducing the smell of cinnamon, vanilla, or anise may slightly reduce how often infants have apnea episodes. It is unclear whether stimulation with these smells has any effect on how long infants stay in hospital or how long it takes them to feed fully by mouth. Introducing the scent of rose or a parent's scent may slightly reduce how long infants spend in hospital. It is unclear whether stimulation with these smells has any effect on how often infants have apnea episodes or how long it takes them to feed fully by mouth. What are the limitations of the evidence? We have little confidence in these results, as the studies included could have been better designed and included more babies. Several studies did not report outcomes we were interested in. How up to date is this evidence? The evidence is current to 2 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lenells, M, Prescott, MG, Wróblewska-Seniuk, K, Fiander, M, Soll, RF, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD016074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.752Z" }, { "id": "56e7b5fd-1212-4a05-8364-486683f45f83", "pmid": "", "title": "Pharmacological intervention for irritability, aggression, and self‐injury in autism spectrum disorder (ASD)", "imported": false, "abstract": "Abstract - Background Pharmacological interventions are frequently used for people with autism spectrum disorder (ASD) to manage behaviours of concern, including irritability, aggression, and self‐injury. Some pharmacological interventions might help treat some behaviours of concern, but can also have adverse effects (AEs). Objectives To assess the effectiveness and AEs of pharmacological interventions for managing the behaviours of irritability, aggression, and self‐injury in ASD. Search methods We searched CENTRAL, MEDLINE, Embase, 11 other databases and two trials registers up to June 2022. We also searched reference lists of relevant studies, and contacted study authors, experts and pharmaceutical companies. Selection criteria We included randomised controlled trials of participants of any age with a clinical diagnosis of ASD, that compared any pharmacological intervention to an alternative drug, standard care, placebo, or wait‐list control. Data collection and analysis We used standard Cochrane methods. Primary outcomes were behaviours of concern in ASD, (irritability, aggression and self‐injury); and AEs. Secondary outcomes were quality of life, and tolerability and acceptability. Two review authors independently assessed each study for risk of bias, and used GRADE to judge the certainty of the evidence for each outcome. Main results We included 131 studies involving 7014 participants in this review. We identified 26 studies as awaiting classification and 25 as ongoing. Most studies involved children (53 studies involved only children under 13 years), children and adolescents (37 studies), adolescents only (2 studies) children and adults (16 studies), or adults only (23 studies). All included studies compared a pharmacological intervention to a placebo or to another pharmacological intervention. Atypical antipsychotics versus placebo At short‐term follow−up (up to 6 months), atypical antipsychotics probably reduce irritability compared to placebo (standardised mean difference (SMD) −0.90, 95% confidence interval (CI) −1.25 to −0.55, 12 studies, 973 participants; moderate‐certainty evidence), which may indicate a large effect. However, there was no clear evidence of a difference in aggression between groups (SMD −0.44, 95% CI −0.89 to 0.01; 1 study, 77 participants; very low‐certainty evidence). Atypical antipsychotics may also reduce self‐injury (SMD −1.43, 95% CI −2.24 to −0.61; 1 study, 30 participants; low‐certainty evidence), possibly indicating a large effect. There may be higher rates of neurological AEs (dizziness, fatigue, sedation, somnolence, and tremor) in the intervention group (low‐certainty evidence), but there was no clear evidence of an effect on other neurological AEs. Increased appetite may be higher in the intervention group (low‐certainty evidence), but we found no clear evidence of an effect on other metabolic AEs. There was no clear evidence of differences between groups in musculoskeletal or psychological AEs. Neurohormones versus placebo At short‐term follow‐up, neurohormones may have minimal to no clear effect on irritability when compared to placebo (SMD −0.18, 95% CI −0.37 to −0.00; 8 studies; 466 participants; very low‐certainty evidence), although the evidence is very uncertain. No data were reported for aggression or self ‐injury. Neurohormones may reduce the risk of headaches slightly in the intervention group, although the evidence is very uncertain. There was no clear evidence of an effect of neurohormones on any other neurological AEs, nor on any psychological, metabolic, or musculoskeletal AEs (low‐ and very low‐certainty evidence). Attention‐deficit hyperactivity disorder (ADHD)‐related medications versus placebo At short‐term follow‐up, ADHD‐related medications may reduce irritability slightly (SMD −0.20, 95% CI −0.40 to −0.01; 10 studies, 400 participants; low‐certainty evidence), which may indicate a small effect. However, there was no clear evidence that ADHD‐related medications have an effect on self‐injury (SMD −0.62, 95% CI −1.63 to 0.39; 1 study, 16 participants; very low‐certainty evidence). No data were reported for aggression. Rates of neurological AEs (drowsiness, emotional AEs, fatigue, headache, insomnia, and irritability), metabolic AEs (decreased appetite) and psychological AEs (depression) may be higher in the intervention group, although the evidence is very uncertain (very low‐certainty evidence). There was no evidence of a difference between groups for any other metabolic, neurological, or psychological AEs (very low‐certainty evidence). No data were reported for musculoskeletal AEs. Antidepressants versus placebo At short‐term follow‐up, there was no clear evidence that antidepressants have an effect on irritability (SMD −0.06, 95% CI −0.30 to 0.18; 3 studies, 267 participants; low‐certainty evidence). No data for aggression or self‐injury were reported or could be included in the analysis. Rates of metabolic AEs (decreased energy) may be higher in participants receiving antidepressants (very low‐certainty evidence), although no other metabolic AEs showed clear evidence of a difference. Rates of neurological AEs (decreased attention) and psychological AEs (impulsive behaviour and stereotypy) may also be higher in the intervention group (very low‐certainty evidence) although the evidence is very uncertain. There was no clear evidence of any difference in the other metabolic, neurological, or psychological AEs (very low‐certainty evidence), nor between groups in musculoskeletal AEs (very low‐certainty evidence). Risk of bias We rated most of the studies across the four comparisons at unclear overall risk of bias due to having multiple domains rated as unclear, very few rated as low across all domains, and most having at least one domain rated as high risk of bias. Authors' conclusions Evidence suggests that atypical antipsychotics probably reduce irritability, ADHD‐related medications may reduce irritability slightly, and neurohormones may have little to no effect on irritability in the short term in people with ASD. There was some evidence that atypical antipsychotics may reduce self‐injury in the short term, although the evidence is uncertain. There was no clear evidence that antidepressants had an effect on irritability. There was also little to no difference in aggression between atypical antipsychotics and placebo, or self‐injury between ADHD‐related medications and placebo. However, there was some evidence that atypical antipsychotics may result in a large reduction in self‐injury, although the evidence is uncertain. No data were reported (or could be used) for self‐injury or aggression for neurohormones versus placebo. Studies reported a wide range of potential AEs. Atypical antipsychotics and ADHD‐related medications in particular were associated with an increased risk of metabolic and neurological AEs, although the evidence is uncertain for atypical antipsychotics and very uncertain for ADHD‐related medications. The other drug classes had minimal or no associated AEs. Plain language summary Which medications reduce irritability, aggression or self‐harm in people with autism spectrum disorder (ASD)? Key messages • Only 3 classes of medications showed any reduction in irritability, aggression or self‐harm when compared to placebo (a dummy medication). Atypical (second‐generation) antipsychotic medications probably reduce irritability and aggression, but appear to have little to no effect on self‐injury. Attention deficit hyperactivity disorder (ADHD)‐related medications may reduce irritability, although the evidence is uncertain. Neurohormones (oxytocin and secretin) may also reduce irritability, but we are very uncertain about the evidence. • Antidepressants appear to have no effect on irritability. Studies did not report on the effects of antidepressants, ADHD‐related medications and neurohormones on aggression or self‐injury. • Studies reported a wide range of unwanted effects, but only atypical antipsychotics, ADHD‐related medications, and neurohormones showed evidence of a higher risk of any unwanted effects compared to placebo. What is autism spectrum disorder (ASD)? Autism is a disorder that affects a child's physical, mental and behavioural development. It is a lifelong disability that starts in childhood but continues throughout adulthood. People with autism may find it difficult to communicate and interact with the world. However, autism affects each person differently and may be more or less severe in different people, so it is described as a 'spectrum' disorder. Some people with autism spectrum disorder (ASD) may be irritable, angry or aggressive, or hurt themselves physically (self‐injury), which are 'behaviours of concern' that can be difficult to manage and distressing for the person. How are behaviours of concern managed? Behaviours of concern are frequently managed with various types of medications that have been developed to treat other conditions. This means that their effectiveness for behaviours of concern is largely unknown, and they may cause serious and varied unwanted effects that affect all parts of the body. For example: • the heart and lungs; • the stomach and digestive system; • the immune system; • movement, joints and bones; and • mood and emotion. What did we want to find out? We wanted to know which types of medication were effective in reducing behaviours of concern in people with ASD and whether they caused unwanted effects. What did we do? We searched for studies that investigated any medication used to manage behaviours of concern. Studies compared the medication with placebo (a dummy medication) or another medication. People in the studies could be adults or children, but all had ASD with behaviours of concern. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 131 studies with 7014 people. Most studies involved children, although some studies involved both children and adults, or adults only. Studies looked at a wide range of medications, including those usually used to treat schizophrenia or bipolar disorder, depression, attention deficit hyperactivity disorder (ADHD), convulsions, emotional problems, heart and lungs, dementia, Parkinson's, and anxiety. Atypical (second‐generation) antipsychotics are usually used to treat schizophrenia or bipolar disorder. They probably reduce irritability, but they may have little to no effect on aggression and self‐injury. People receiving antipsychotics might be more likely to experience unwanted effects such as increased appetite, dizziness, sedation (slowed thought and movement), sleepiness, tiredness and tremor compared to those receiving no treatment or other medications. People receiving antipsychotics may be no more or less likely than those receiving placebo to experience other unwanted effects. Neurohormones (such as oxytocin and secretin) may have a minimal to small effect on irritability but no studies reported data for the effects of neurohormones on self‐harm or aggression. People receiving neurohormones may be no more or less likely than those receiving placebo to experience unwanted effects. ADHD‐related medications may reduce irritability but may have no effect on self‐injury. No studies reported data for aggression. People receiving ADHD‐related medications might be more likely to experience unwanted effects such as drowsiness, tiredness, headache, difficulties sleeping, and decreased appetite. But they may be no more or less likely than those receiving placebo to experience other unwanted effects. Antidepressants may have little to no effect on irritability. No studies reported useful data for aggression and self‐injury. People receiving antidepressants might be more likely to experience unwanted effects such as impulsive behaviour and making repetitive movements or sounds (stereotypy) compared to placebo. But they may be no more or less likely than those receiving placebo to experience other types of unwanted effects. What are the limitations of the evidence? Most of the studies lasted less than 3 months, and very few studies involved adults. Therefore, we are uncertain if the same effects would be seen over a longer period of time or in adults. How up‐to‐date is the evidence? The review authors searched for studies that had been published up to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Iffland, M, Livingstone, N, Jorgensen, M, Hazell, P, Gillies, D", "articleTypes": [], "doi": "10.1002/14651858.CD011769.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.796Z" }, { "id": "56f01d32-c323-4ade-9927-1ac31e894bd0", "pmid": "", "title": "Antiplatelet agents for the treatment of adults with COVID‐19", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Fischer, A-L, Messer, S, Riera, R, Martimbianco, ALC, Stegemann, M, Estcourt, LJ, Weibel, S, Monsef, I, Andreas, M, Pacheco, RL, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015078 AB - Abstract - Background Severe coronavirus disease 2019 (COVID‐19) can cause thrombotic events that lead to severe complications or death. Antiplatelet agents, such as acetylsalicylic acid, have been shown to effectively reduce thrombotic events in other diseases: they could influence the course of COVID‐19 in general. Objectives To assess the efficacy and safety of antiplatelets given with standard care compared to no treatment or standard care (with/without placebo) for adults with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (which comprises MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO ICTRP, medRxiv, CENTRAL), Web of Science, WHO COVID‐19 Global literature on coronavirus disease and the Epistemonikos COVID‐19 L*OVE Platform to identify completed and ongoing studies without language restrictions to December 2022. Selection criteria We followed standard Cochrane methodology. We included randomised controlled trials (RCTs) evaluating antiplatelet agents for the treatment of COVID‐19 in adults with COVID‐19, irrespective of disease severity, gender or ethnicity. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane risk of bias tool (RoB 2) for RCTs. We rated the certainty of evidence using the GRADE approach for the outcomes. Main results Antiplatelets plus standard care versus standard care (with/without placebo) Adults with a confirmed diagnosis of moderate to severe COVID‐19 We included four studies (17,541 participants) that recruited hospitalised people with a confirmed diagnosis of moderate to severe COVID‐19. A total of 8964 participants were analysed in the antiplatelet arm (either with cyclooxygenase inhibitors or P2Y12 inhibitors) and 8577 participants in the control arm. Most people were older than 50 years and had comorbidities such as hypertension, lung disease or diabetes. The studies were conducted in high‐ to lower middle‐income countries prior to wide‐scale vaccination programmes. Antiplatelets compared to standard care: – probably result in little to no difference in 28‐day mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.85 to 1.05; 3 studies, 17,249 participants; moderate‐certainty evidence). In absolute terms, this means that for every 177 deaths per 1000 people not receiving antiplatelets, there were 168 deaths per 1000 people who did receive the intervention (95% CI 151 to 186 per 1000 people); – probably result in little to no difference in worsening (new need for invasive mechanical ventilation or death up to day 28) (RR 0.95, 95% CI 0.90 to 1.01; 2 studies, 15,266 participants; moderate‐certainty evidence); – probably result in little to no difference in improvement (participants discharged alive up to day 28) (RR 1.00, 95% CI 0.96 to 1.04; 2 studies, 15,454 participants; moderate‐certainty evidence); – probably result in a slight reduction of thrombotic events at longest follow‐up (RR 0.90, 95% CI 0.80 to 1.02; 4 studies, 17,518 participants; moderate‐certainty evidence); – may result in a slight increase in serious adverse events at longest follow‐up (Peto odds ratio (OR) 1.57, 95% CI 0.48 to 5.14; 1 study, 1815 participants; low‐certainty evidence), but non‐serious adverse events during study treatment were not reported; – probably increase the occurrence of major bleeding events at longest follow‐up (Peto OR 1.68, 95% CI 1.29 to 2.19; 4 studies, 17,527 participants; moderate‐certainty evidence). Adults with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included two RCTs allocating participants, of whom 4209 had confirmed mild COVID‐19 and were not hospitalised. A total of 2109 participants were analysed in the antiplatelet arm (treated with acetylsalicylic acid) and 2100 participants in the control arm. No study included people with asymptomatic SARS‐CoV‐2 infection. Antiplatelets compared to standard care: – may result in little to no difference in all‐cause mortality at day 45 (Peto OR 1.00, 95% CI 0.45 to 2.22; 2 studies, 4209 participants; low‐certainty evidence); – may slightly decrease the incidence of new thrombotic events up to day 45 (Peto OR 0.37, 95% CI 0.09 to 1.46; 2 studies, 4209 participants; low‐certainty evidence); – may make little or no difference to the incidence of serious adverse events up to day 45 (Peto OR 1.00, 95% CI 0.60 to 1.64; 1 study, 3881 participants; low‐certainty evidence), but non‐serious adverse events were not reported. The evidence is very uncertain about the effect of antiplatelets on the following outcomes (compared to standard care plus placebo): – admission to hospital or death up to day 45 (Peto OR 0.79, 95% CI 0.57 to 1.10; 2 studies, 4209 participants; very low‐certainty evidence); – major bleeding events up to longest follow‐up (no event occurred in 328 participants; very low‐certainty evidence). Quality of life and adverse events during study treatment were not reported. Authors' conclusions In people with confirmed or suspected COVID‐19 and moderate to severe disease, we found moderate‐certainty evidence that antiplatelets probably result in little to no difference in 28‐day mortality, clinical worsening or improvement, but probably result in a slight reduction in thrombotic events. They probably increase the occurrence of major bleeding events. Low‐certainty evidence suggests that antiplatelets may result in a slight increase in serious adverse events. In people with confirmed COVID‐19 and mild symptoms, we found low‐certainty evidence that antiplatelets may result in little to no difference in 45‐day mortality and serious adverse events, and may slightly reduce thrombotic events. The effects on the combined outcome admission to hospital or death up to day 45 and major bleeding events are very uncertain. Quality of life was not reported. Included studies were conducted in high‐ to lower middle‐income settings using antiplatelets prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, adverse events and people with asymptomatic infection. The 14 ongoing and three completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. Plain language summary Are antiplatelets an effective treatment for people with COVID‐19? Key messages Antiplatelets are a group of different medicines that can prevent potentially fatal clot formation in the blood vessels ('thrombotic events'). For hospitalised patients with COVID‐19, they probably slightly reduce thrombotic events but probably do not affect deaths, clinical worsening or improvement in COVID‐19 compared with placebo or standard care. However, antiplatelets may result in a slight increase in serious unwanted effects ('adverse events') and probably increase major bleeding. Similarly, in non‐hospitalised people, antiplatelets slightly decrease thrombotic events. They may result in little to no difference in deaths or serious unwanted effects, however the evidence on admission to hospital or death and major bleeding events is very uncertain. There are 14 further studies that have not completed yet, and the results of three other completed studies are not yet available. What are antiplatelets? Antiplatelets are a group of drugs which, in different ways, stop blood from changing to a gel‐like substance called a clot, which we mean by the term 'thrombotic events'. They are taken mainly by mouth, usually by people who are at high risk of developing a clot (people who have already experienced or who tend to build up a clot). A clot could lead to a stroke, coronary heart disease, poor blood circulation in the legs, thromboses in the legs or clot obstruction ('embolism') in the lung circulation that could lead to shortness of breath, heart failure and death. How might antiplatelets treat COVID‐19? People with COVID‐19 might be at risk from blood clots. Antiplatelets prevent clots from forming in the body, and this could in turn prevent complications that lead to death and clinical deterioration. What did we want to find out? We wanted to know whether antiplatelets in addition to usual care are effective for adults with COVID‐19, when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in: – number of deaths from any cause up to 28 days after treatment, or longer if reported;
– whether people got better or worse after treatment (including unwanted effects of the disease itself, like thrombotic events);
– unwanted effects of the treatment (especially major bleeding). What did we do? We searched for studies that reported on people with COVID‐19 who received antiplatelets together with usual care, or usual care alone (with/without placebo). We summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We identified four studies, including 17,541 people with moderate to severe COVID‐19 (hospitalised). Of these, one compared acetylsalicylic acid (aspirin) with usual care, two studies compared 'P2Y12 inhibitors' (e.g. clopidogrel, prasugrel, ticagrelor) with usual care, and a fourth one compared either acetylsalicylic acid or P2Y12 inhibitors with usual care. The studies included people with a confirmed or suspected diagnosis of SARS‐CoV‐2 infection. Two studies compared acetylsalicylic acid to placebo in 4209 non‐hospitalised people with confirmed mild COVID‐19. We also found 14 ongoing studies, two studies without published results and another that had been withdrawn after a preprint version. We found no studies that included people with COVID‐19 infection but no symptoms. Main results Antiplatelets: – probably make little or no difference to deaths by 28 or 180 days, worsening up to day 28 (new invasive mechanical ventilation or death) or improvement (discharged alive) up to day 28, and they probably slightly decrease thrombotic events; – may result in a slight increase in serious unwanted effects and probably increase major bleeding events. In people not in hospital, with mild disease, antiplatelets may result in little to no difference in death within 45 days, or in the incidence of serious adverse events, and they may slightly decrease the incidence of thrombotic events. The evidence for these participants is very uncertain about the effects on worsening (hospitalisation or death within 45 days) and on major bleeding events. Studies did not report on quality of life and general unwanted effects. What are the limitations of the evidence? The studies were conducted in populations from high‐ to middle‐income countries, many of them prior to the roll‐out of COVID‐19 vaccination programmes and before Omicron became the most prevalent variant. We have moderate confidence in the evidence for mortality, worsening/improvement up to day 28, and major bleeding events or thrombotic events in hospitalised people. We have low confidence in the evidence for the effects on serious unwanted effects, because they occurred rarely. For non‐hospitalised people, our confidence in the evidence is low for the effects on death, thrombotic events and serious adverse events, and very low for the effects on worsening and major bleeding events (those events were rare and the time period between symptom onset and treatment was long). Information about other unwanted effects and quality of life was not available. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 22 December 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.781Z" }, { "id": "5706fe65-46f7-48f0-b997-5e4a94287672", "pmid": "", "title": "Changes in Insulin Sensitivity in Liver and Esqueletal Muscle Due to Sucralose Consumption", "imported": false, "abstract": "Recently, it has been proposed that the consumption of non-nutritive sweeteners, including sucralose, it's not harmless and is related with metabolic effects. Some studies have reported that sucralose produces alterations in glucose homeostasis. In vitro studies indicate that sucralose is capable of interacting with sweet taste receptors (T1R2 and T1R3) in the intestine, thus increasing the expression of glucose transporters including the sodium-glucose cotransporter type 1 (SGLT1) and the glucose transporter 2 (GLUT2), increasing glucose absorption. This interaction with intestinal sweet taste receptors also generates an increase in the secretion of the incretins glucagon-like peptide type 1 (GLP-1) and the glucose-dependent insulinotropic polypeptide (GIP), which might enhance the postprandial insulin release. However, these results are preliminary and it's desirable to confirm if sucralose consumption is associated with glucose metabolism modifications using an appropriate methodological design and with gold standard methods. The aim of this triple-blind, placebo-controlled, parallel, randomized clinical trial is to confirm the changes in insulin sensitivity associated with sucralose consumption in humans, to identify whether these changes are in the liver or skeletal muscle and to investigate the pathophysiological mechanisms generating these changes. Specifically, we will investigate if sucralose generates a dysbiosis in the gut microbiota that could be related to insulin resistance by increasing concentrations of lipopolysaccharide, a toxin present in Gram-negative bacteria that triggers a low grade inflammation known as metabolic endotoxemia. In addition, the changes in postprandial concentrations of GLP-1, glucose, insulin and C-peptide due to the combination of sucralose with a mixed meal will be investigated. The results of this study will determine if sucralose consumption, frequently used as a non-nutritive sweetener, is associated to significant changes in glucose homeostasis in humans.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.240Z" }, { "id": "570b2fde-8116-40e8-97c5-cb5f1ce80c8b", "pmid": "", "title": "Topical antibiotics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection (involving more than one micro‐organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms are ear discharge and hearing loss. Topical antibiotics, the most common treatment for CSOM, aim to kill or inhibit the growth of micro‐organisms that may be responsible for the infection. Antibiotics can be used alone or with other treatments for CSOM, such as antiseptics or ear cleaning (aural toileting). This is an update of a Cochrane review first published in 2020 and one of a suite of seven reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To evaluate the benefits and harms of topical antibiotics (without steroids) for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials with at least a one week of follow‐up involving adults and children with chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antibiotic(s) of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic compared to placebo or no intervention, and compared to another topical antibiotic (e.g. topical antibiotic A versus topical antibiotic B). Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks and up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This update found one new study (100 participants). Overall, we included 18 studies with 1783 participants (in 16 studies), plus 108 ears that could not be accounted for in participant numbers (in two studies). 1. Topical antibiotics versus placebo or no treatment (with aural toilet in both arms and no other background treatment) One study (50 participants, data unavailable for 15 participants) compared a topical antibiotic (ciprofloxacin) with placebo (saline). All participants received aural toilet. Topical ciprofloxacin may increase resolution of discharge at one to up to two weeks compared with placebo (84% with antibiotic versus 12% with placebo; risk ratio (RR) 6.74, 95% confidence interval (CI) 1.82 to 24.99; 35 participants; very low‐certainty evidence). The study authors reported \"no medical side‐effects and worsening of audiological measurements related to this topical medication were detected.\" 2. Topical antibiotics versus placebo or no treatment (with use of oral antibiotics in both arms) Four studies (438 participants) compared topical antibiotics versus no treatment, with oral antibiotics in both arms. These compared topical ciprofloxacin to no treatment (3 studies, 190 participants) or topical ceftizoxime to no treatment (1 study, 248 participants). In each study, all participants received the same antibiotic systemically (oral ciprofloxacin or injected ceftizoxime). In at least one study, all participants received aural toilet. There were no useable data comparing topical ceftizoxime to no treatment. Topical antibiotics in addition to systemic antibiotics may increase resolution of ear discharge at one to up to two weeks compared with systemic antibiotics alone (resolution of discharge occurring in 88% with topical antibiotics versus 60% without topical antibiotics; RR 1.47, 95% CI 1.14 to 1.88; 1 study, 100 participants; low‐certainty evidence). One study (40 participants) stated \"no side effect was recorded in any patient\" (low‐certainty evidence). 3. Comparisons of different topical antibiotics Eight studies (794 participants, plus 40 ears) compared aminoglycosides (gentamicin, neomycin, or tobramycin) with quinolones (ciprofloxacin or ofloxacin). Resolution of discharge at one to up to two weeks may be higher in the quinolones group, but the evidence is very uncertain (RR 1.92, 95% CI 1.00 to 3.67; 7 studies, 794 participants; very low‐certainty evidence). There was considerable heterogeneity (I 2 = 97%). One study (308 participants) stated there were no differences between the different groups for resolution of ear discharge after four weeks (low‐certainty evidence). The evidence is very uncertain about the effects of topical antibiotics on ear pain (1 study reported no differences between groups). The evidence is very uncertain about the effects of topical antibiotics on hearing loss (2 studies reported no differences between groups). 4. Other comparisons We assessed five studies (501 participants, plus 68 ears) over the following three additional comparisons: quinolones versus aminoglycosides/polymyxin B with/without gramicidin, aminoglycosides versus trimethoprim‐sulphacetamide‐polymixin B, and rifampicin versus chloramphenicol. However, these results have not been included in the abstract. Authors' conclusions We are very uncertain about the effectiveness of topical antibiotics in improving resolution of ear discharge in people with CSOM because of the limited amount of low‐ or very low‐certainty evidence available. This was mostly due to risk of bias and imprecision. However, amongst this uncertainty, there is some evidence to suggest that the use of topical antibiotics may be effective when compared to placebo, or when used in addition to a systemic antibiotic. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine whether quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, harmful effects were poorly reported. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and harms of using topical antibiotics to treat chronic suppurative otitis media? Key messages – We are uncertain whether topical antibiotics reduce ear discharge of people with swelling and infection of the middle ear (called chronic suppurative otitis media). – Topical antibiotics may reduce ear discharge compared to placebo (a salt solution), but we are very uncertain. Topical antibiotics used in addition to an antibiotic given by mouth may reduce ear discharge. – Overall, we are very uncertain which type of topical antibiotic is the most effective. What is chronic suppurative otitis media? Chronic suppurative otitis media, also known as chronic otitis media, is a swelling and infection of the middle ear that lasts for two weeks or more. People with chronic suppurative otitis media usually have ear discharge that is difficult to get rid of or keeps coming back (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Topical antibiotics (administered into the ear canal as ear drops, ointments, sprays, or creams) are the most commonly used treatment for chronic suppurative otitis media. Topical antibiotics kill or stop the growth of the bacteria (germs) that may be responsible for the infection. Topical antibiotics can be used on their own or be added to other treatments for chronic suppurative otitis media, such as antiseptics (which also kill germs) or ear cleaning (aural toileting) or systemic antibiotics (antibiotics taken either by mouth or by an injection into a muscle or vein). What was the aim of this review? We wanted to find out how effective topical antibiotics are for people with chronic suppurative otitis media, and whether they cause unwanted effects. We also wanted to know whether one type of topical antibiotic was more beneficial or harmful than any other. In particular, we wanted to know whether topical antibiotics stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found one new study (100 participants). Overall, we found 18 studies examining at least 1783 people, but it was difficult to determine precisely how many people were included as some studies did not clearly report the number. Two studies included \"mainly children,\" three included only adults, whilst the remainder appeared to include both children and adults. None of the studies reported the inclusion of people considered at high risk of having chronic suppurative otitis media (for example, people with cleft palate (where the roof of the mouth of a baby does not join together during pregnancy) or Down's syndrome; or people whose immune system does not work well enough to fight germs). The studies used different types of antibiotics and combinations of antibiotics. Comparison of topical antibiotics to placebo or no treatment One study (50 people) compared topical antibiotics to a saline (salt water) ear wash. Topical antibiotics may reduce ear discharge more than the saline ear wash when assessed one to up to two weeks after treatment, but we are very uncertain. The evidence is very uncertain about unwanted effects and worsening of hearing measurements. The study did not measure quality of life and reported that there were no serious complications. Comparison of topical antibiotics in addition to systemic (oral or injected) antibiotics Four studies (438 people) compared treatment with topical antibiotic (ciprofloxacin) drops in addition to a systemic (oral or injected) antibiotic, but one study did not contribute data. Topical plus oral antibiotics may reduce ear discharge more than oral antibiotics alone at one to up to two weeks and two to up to four weeks. One study stated there were no unwanted effects. The studies did not measure quality of life and did not report any serious complications. Comparisons of different topical antibiotics Eight studies (794 participants plus 40 ears) compared an aminoglycoside antibiotic (gentamicin, neomycin, or tobramycin) with a quinolone antibiotic (ciprofloxacin or ofloxacin). Quinolones may reduce ear discharge better than aminoglycosides, but the evidence is very uncertain. One study (100 people) measured ear pain and reported no difference between the groups, but the evidence is very uncertain. Two studies measured hearing loss, but the evidence is very uncertain. What are the limitations of the evidence? There were several limitations with the studies. For example, the results varied widely between studies, there were small numbers of people included, there was a lack of recent data, and limited information on groups of people who are more likely to have chronic suppurative otitis media. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Brennan-Jones, CG; Head, K; Chong, LY; Daw, J; Veselinović, T; Schilder, AGM; Bhutta, MF", "articleTypes": [], "doi": "10.1002/14651858.CD013051.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "57261b8a-17ef-4f28-9823-0f6b2d8401b7", "pmid": "", "title": "Sumatriptan (oral route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Objectives To determine the efficacy and tolerability of oral sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using oral sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Sixty‐one studies (37,250 participants) compared oral sumatriptan with placebo or an active comparator. Most of the data were for the 50 mg and 100 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 50 mg versus placebo the NNTs were 6.1, 7.5, and 4.0 for pain‐free at two hours and headache relief at one and two hours, respectively. NNTs for sustained pain‐free and sustained headache relief during the 24 hours postdose were 9.5 and 6.0, respectively. For sumatriptan 100 mg versus placebo the NNTs were 4.7, 6.8, 3.5, 6.5, and 5.2, respectively, for the same outcomes. Results for the 25 mg dose were similar to the 50 mg dose, while sumatriptan 100 mg was significantly better than 50 mg for pain‐free and headache relief at two hours, and for sustained pain‐free during 24 hours. Treating early, during the mild pain phase, gave significantly better NNTs for pain‐free at two hours and sustained pain‐free during 24 hours than did treating established attacks with moderate or severe pain intensity. Relief of associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than with placebo. For the most part, adverse events were transient and mild and were more common with the sumatriptan than with placebo, with a clear dose response relationship (25 mg to 100 mg). Sumatriptan was compared directly with a number of active treatments, including other triptans, paracetamol (acetaminophen), acetylsalicylic acid, non‐steroidal anti‐inflammatory drugs (NSAIDs), and ergotamine combinations. Authors' conclusions Oral sumatriptan is effective as an abortive treatment for migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (oral route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is widely available as an oral tablet. This review found that a single dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in about 3 in 10 people (32%) taking sumatriptan 100 mg, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 6 in 10 people (61%) taking sumatriptan 100 mg, compared with about 3 in 10 (32%) taking placebo. Almost a quarter (24%) of people taking sumatriptan 100 mg had freedom from pain at two hours which was sustained during 24 hours without the use of rescue medication, compared with fewer than 1 in 10 (8%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events were mostly of short duration and mild or moderate in severity, and were experienced by about 4 in 10 (43%) of people taking sumatriptan 100 mg, and by 2 in 10 (23%) taking placebo. The 50 mg dose had slightly lower efficacy, but was associated with fewer adverse events. Treating attacks while pain was still mild was more effective than treating established attacks with moderate or severe pain intensity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008615.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.739Z" }, { "id": "5738e628-83c1-428e-9ea6-f745f5606189", "pmid": "", "title": "Probiotics for treatment of chronic constipation in children", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wallace, C, Sinopoulou, V, Gordon, M, Akobeng, AK, Llanos-Chea, A, Hungria, G, Febo-Rodriguez, L, Fifi, A, Fernandez Valdes, L, Langshaw, A, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014257.pub2 AB - Abstract - Background Functional constipation is defined as chronic constipation with no identifiable underlying cause. It is a significant cause of morbidity in children, accounting for up to 25% of visits to paediatric gastroenterologists. Probiotic preparations may sufficiently alter the gut microbiome and promote normal gut physiology in a way that helps relieve functional constipation. Several studies have sought to address this hypothesis, as well as the role of probiotics in other functional gut disorders. Therefore, it is important to have a focused review to assess the evidence to date. Objectives To evaluate the efficacy and safety of probiotics for the management of chronic constipation without a physical explanation in children. Search methods On 28 June 2021, we searched CENTRAL, MEDLINE, Embase, CINAHL, AMED, WHO ICTR, and ClinicalTrials.gov, with no language, date, publication status, or document type limitations. Selection criteria We included randomised controlled trials (RCTs) that assessed probiotic preparations (including synbiotics) compared to placebo, no treatment or any other interventional preparation in people aged between 0 and 18 years old with a diagnosis of functional constipation according to consensus criteria (such as Rome IV). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 14 studies (1127 randomised participants): 12 studies assessed probiotics in the treatment of functional constipation, whilst two studies investigated synbiotic preparations. Three studies compared probiotics to placebo in relation to the frequency of defecation at study end, but we did not pool them as there was very significant unexplained heterogeneity. Four studies compared probiotics to placebo in relation to treatment success. There may be no difference in global improvement/treatment success (RR 1.29, 95% CI 0.73 to 2.26; 313 participants; low‐certainty evidence). Five studies compared probiotics to placebo in relation to withdrawals due to adverse events, with the pooled effect suggesting there may be no difference (RR 0.64, 95% CI 0.21 to 1.95; 357 participants; low‐certainty evidence). The pooled estimate from three studies that compared probiotics plus an osmotic laxative to osmotic laxative alone found there may be no difference in frequency of defecation (MD ‐0.01, 95% CI ‐0.57 to 0.56; 268 participants; low‐certainty evidence). Two studies compared probiotics plus an osmotic laxative to osmotic laxative alone in relation to global improvement/treatment success, and found there may be no difference between the treatments (RR 0.95, 95% CI 0.79 to 1.15; 139 participants; low‐certainty evidence). Three studies compared probiotics plus osmotic laxative to osmotic laxative alone in relation to withdrawals due to adverse events, but it is unclear if there is a difference between them (RR 2.86, 95% CI 0.12 to 68.35; 268 participants; very low‐certainty evidence). Two studies compared probiotics versus magnesium oxide. It is unclear if there is a difference in frequency of defecation (MD 0.28, 95% CI ‐0.58 to 1.14; 36 participants), treatment success (RR 1.08, 95% CI 0.74 to 1.57; 36 participants) or withdrawals due to adverse events (RR 0.50, 95% CI 0.05 to 5.04; 77 participants). The certainty of the evidence is very low for these outcomes. One study assessed the role of a synbiotic preparation in comparison to placebo. There may be higher treatment success in favour of synbiotics compared to placebo (RR 2.32, 95% CI 1.54 to 3.47; 155 participants; low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study assessed a synbiotic plus paraffin compared to paraffin alone. It is uncertain if there is a difference in frequency of defecation (MD 0.74, 95% CI ‐0.96, 2.44; 66 participants; very low‐certainty evidence), or treatment success (RR 0.91, 95% CI 0.71 to 1.17; 66 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study compared a synbiotic preparation to paraffin. It is uncertain if there is a difference in frequency of defecation (MD ‐1.53, 95% CI ‐3.00, ‐0.06; 60 participants; very low‐certainty evidence) or in treatment success (RR 0.86, 95% CI 0.65, 1.13; 60 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. All secondary outcomes were either not reported or reported in a way that did not allow for analysis. Authors' conclusions There is insufficient evidence to conclude whether probiotics are efficacious in successfully treating chronic constipation without a physical explanation in children or changing the frequency of defecation, or whether there is a difference in withdrawals due to adverse events when compared with placebo. There is limited evidence from one study to suggest a synbiotic preparation may be more likely than placebo to lead to treatment success, with no difference in withdrawals due to adverse events. There is insufficient evidence to draw efficacy or safety conclusions about the use of probiotics in combination with or in comparison to any of the other interventions reported. The majority of the studies that presented data on serious adverse events reported that no events occurred. Two studies did not report this outcome. Future studies are needed to confirm efficacy, but the research community requires guidance on the best context for probiotics in such studies, considering where they should be best considered in a potential treatment hierarchy and should align with core outcome sets to support future interpretation of findings. Plain language summary Probiotics for treatment of chronic constipation in children What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can be used to treat chronic constipation without a physical explanation in children (aged 0 to 18 years). We analysed data from 14 studies to answer this question. Key messages We were unable to draw conclusions when comparing probiotics to placebo for frequency of defecation in children treated for chronic constipation without a physical explanation. There may be no difference in treatment success between the two groups. There may not be a difference in frequency of defecation or treatment success when comparing probiotics and laxatives to using laxatives alone. We were unable to draw conclusions when comparing probiotics to magnesium oxide for frequency of defecation or treatment success. There may be a higher frequency of defecation in children treated with synbiotic preparations compared to placebo. There may not be a difference in participants withdrawing from the studies due to adverse events when comparing probiotic preparations to placebo. We were unable to draw conclusions on the safety of any of the other comparisons due to the low number of people who withdrew from the studies. What was studied in the review? Children often suffer from constipation for long periods of time, and when there is no underlying physical cause that can be found we call it 'functional constipation'. It has been suggested that probiotic and synbiotic preparations might help improve symptoms in these children. Probiotics are preparations that contain living bacteria that have been proposed to be beneficial to the digestive system. Synbiotics also include food substances that support the growth of these bacteria. There is currently no consensus about whether this is the case, or how these preparations are best used. What are the main results of the review? We searched for randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) comparing any probiotic or synbiotic treatment with any other treatment (such as dummy/placebo treatments) in children with chronic constipation without a physical explanation. We found 14 trials including a total of 1127 participants who were aged under 18. We made the following conclusions.
• There may be no difference in treatment success when comparing probiotics to placebo.
• We were unable to draw conclusions on whether there is a difference in the frequency of defecation.
• There may be no difference in treatment success when comparing probiotics and laxatives to laxatives alone.
• We were unable to draw conclusions on frequency of defecation or treatment success when comparing probiotics to magnesium oxide.
• Synbiotics may be better than placebo in improving the frequency of defection.
• There may be no difference in how many people withdrew from the trials because of side effects when comparing probiotics to placebo, or probiotics and laxative to laxative alone.
• We have limited confidence in the evidence because the studies only included a small number of children, and due to lack of detail on some of the methods used. All analyses were limited due to differences in the specific probiotics or the treatments they were compared with, low numbers of children included in the studies and, most importantly, the use of a range of different measures of success. This meant that combining studies was difficult, so the overall ability of this review to answer its core questions was limited. What next? Future studies are needed to find out how helpful probiotics are for childhood constipation. Researchers need to agree whether probiotics should be a first option therapy, an add‐on to other therapies, a second option after other therapies have failed, or a combination of all the above. Future research should measure the same items (known as a core outcome set) to ensure these results can support future reviews. How up‐to‐date is this review? This review is current to June 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.771Z" }, { "id": "573ffb4c-3fa7-4136-aa25-d2c4e95239df", "pmid": "", "title": "Interventions for dysphagia in oesophageal cancer", "imported": false, "abstract": "Abstract - Background Most patients with oesophageal and gastro‐oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009. Objectives The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro‐oesophageal carcinoma. Search methods To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Selection criteria Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, self‐expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head‐to‐head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30‐day mortality, adverse effects and quality of life. Data collection and analysis Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group. Main results We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re‐interventions and for adverse effects. Anti‐reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti‐reflux stents might have reduced gastro‐oesophageal reflux and complications. Newly‐designed double‐layered nitinol (Niti‐S) stents were preferable due to longer survival time and fewer complications compared to simple Niti‐S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy. Authors' conclusions Self‐expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high‐dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti‐reflux stents and newly‐designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self‐expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re‐interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia. Plain language summary Interventions for reducing difficulty in swallowing in people with oesophageal cancer Review question For most patients with unresectable or inoperable oesophageal cancer, providing clinical benefit with palliative treatment is highly desirable. However, the optimal palliative technique for dysphagia improvement and better quality of life is not established. Background Dysphagia (difficulty or discomfort in swallowing) is common among patients with unresectable or inoperable oesophageal cancer. There are five levels of dysphagia, ranging from the ability to eat a normal diet to some solids, semisolids, liquids and to complete dysphagia. Study characteristics The review included randomised controlled studies comparing the use of different interventions to improve dysphagia among patients with inoperable or unresectable primary oesophageal cancer. To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Key results The review updates the previous version but still fails to present any obvious superiority of one technique over another among the different kinds of interventions. Self‐expanding metal stents provided safer and more effective relief of dysphagia compared to rigid plastic stents. Other techniques like radiotherapy or brachytherapy were also suitable alternatives and might be favourable in improving quality of life and prolonging survival. Individual differences should be emphasised when the intervention type was determined. Quality of the evidence Half of the studies included in this review were of high quality. Most studies did not state the methods used to seek and report quality of life outcomes and adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Yang, C; Li, J; Fu, W; Xu, W; Yang, S", "articleTypes": [], "doi": "10.1002/14651858.CD005048.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "57539bd0-3e71-4336-b810-dcd30708496c", "pmid": "", "title": "Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years", "imported": false, "abstract": "Abstract - Background Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health. Objectives To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non‐dietary intervention. Secondary objectives were to assess the impact of ECEC‐based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality‐of‐life outcomes. We also report on cost and adverse consequences of ECEC‐based healthy eating interventions. Search methods We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers. Selection criteria We included randomised controlled trials (RCTs), including cluster‐RCTs, stepped‐wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross‐over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both. Data collection and analysis Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta‐analyses using a random‐effects model; otherwise, we described findings using vote‐counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes. Main results We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster‐RCTs. Twenty‐nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty‐eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC‐based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I 2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I 2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC‐based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI −0.01 to 0.25; P =0.08, I 2 = 70%; 13 studies, 3335 children). There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely result in little to no difference in children's consumption of non‐core (i.e. less healthy/discretionary) foods (SMD −0.05, 95% CI −0.17 to 0.08; P = 0.48, I 2 = 16%; 7 studies, 1369 children) or consumption of sugar‐sweetened beverages (SMD −0.10, 95% CI −0.34 to 0.14; P = 0.41, I 2 = 45%; 3 studies, 522 children). Thirty‐six studies measured BMI, BMI z‐score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC‐based healthy eating interventions may result in little to no difference in child BMI (MD −0.08, 95% CI −0.23 to 0.07; P = 0.30, I 2 = 65%; 15 studies, 3932 children) or in child BMI z‐score (MD −0.03, 95% CI −0.09 to 0.03; P = 0.36, I 2 = 0%; 17 studies; 4766 children). ECEC‐based healthy eating interventions may decrease child weight (MD −0.23, 95% CI −0.49 to 0.03; P = 0.09, I 2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I 2 = 0%; 5 studies, 1070 children). ECEC‐based healthy eating interventions may be cost‐effective but the evidence is very uncertain (6 studies). ECEC‐based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3). Authors' conclusions ECEC‐based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC‐based healthy eating interventions on vegetable consumption. ECEC‐based healthy eating interventions may result in little to no difference in child consumption of non‐core foods and sugar‐sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z‐scores. Future studies exploring the impact of specific intervention components, and describing cost‐effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC‐based healthy eating interventions. Plain language summary How successful are healthy eating programmes in preschools, kindergartens and childcare settings? Key messages • Healthy eating programmes delivered in early childhood education and care (ECEC) settings (e.g. preschools, kindergarten, family day care) may improve child diet quality, likely increase fruit consumption, may have favourable effects on vegetable consumption, and likely have no impact on consumption of less healthy foods and sugar‐sweetened drinks. They may have favourable effects on child weight and may reduce the risk of being overweight or obese. • We don't know if healthy eating interventions save money or cause unwanted effects because very few studies provided information about these points. • We found little evidence from low‐ and middle‐income countries, but healthy eating programmes in high‐income countries may benefit child health. We don't know how to support educators and staff to implement these programmes in practice. We need more research about delivering programmes and about their effect in low‐income countries. Why is it important to improve young children's diet? Having a poor diet puts people at risk of many long‐term diseases including heart disease, type 2 diabetes and certain types of cancers. Research estimates that over 11 million deaths worldwide are caused by having an unhealthy diet. Dietary behaviours and preferences are established early in life and persist into adulthood. What are healthy eating programmes? Healthy eating programmes aim to encourage children to eat a healthier diet. They may involve changes to lessons and the culture in preschools, kindergartens and day care centres (early childhood education and care (ECEC) settings), and working with children's families, teachers and healthcare staff. For example, introducing new fruits and vegetables to children, changing the menu to include healthier options or providing families with information about child healthy eating. Healthy eating programmes may establish lifelong healthy eating patterns, reduce excessive weight gain and improve overall health. What did we want to find out? We wanted to find out what impact healthy eating interventions have on child diet and health. We were interested in changes to diet, weight, language and cognitive performance, social, emotional and quality of life outcomes in children aged six months to six years attending preschool, long day care, nurseries, kindergartens and family day care services. We also wanted to know the cost of interventions and whether they had any potential unwanted effects. What did we do? We searched for studies that compared healthy eating programmes against no action, delayed delivery of the programme, or a programme that did not aim to change child diet. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 52 studies that looked at the effects of 58 healthy eating programmes in ECEC settings for children aged six months to six years. All studies were published in high and high‐middle‐income countries. The programmes were very different from each other. They: • lasted from 4 weeks to 3 years; • were delivered by a range of people including healthcare providers, ECEC staff, and researchers; • used different delivery methods (telephone, face‐to‐face, online, printed materials); and • measured results in a variety of ways (e.g. parent or staff surveys, observations of children's eating, and weighing foods before and after meals). Overall, the programmes aimed to: • change the ECEC environment (e.g. staff demonstrated healthy eating to children, and provided healthier foods); • change the curriculum (e.g. they provided lessons about foods and healthy eating); and • establish partnerships (e.g. they provided educational resources to families); and • increase children's physical activity (e.g. by structured physical activity lessons and encouraging less screen time). Healthy eating programmes may lead to small improvements in child diet quality, increase fruit consumption by 0.11 servings, potentially improve vegetable consumption by 0.12 servings and may have no effect on consumption of less healthy foods and sugar‐sweetened drinks. Further, we found child weight is potentially reduced by 230 g and for every 100 children, 19 would have better weight status. However, we found no evidence of impact on body mass index. The programmes may be cost‐effective and likely to have no unwanted effects, although few studies reported these points. Few studies reported on other learning, social and developmental outcomes. What are the limitations of the evidence? Our confidence in the evidence is low because the healthy eating programmes were conducted, delivered and assessed in different ways. Also, many of the people who received the healthy eating programmes were aware that they were being assessed and this can sometimes influence how they report their effects. For example, parents who reported their child's diet may have been more inclined to give positive answers because they felt they were doing what society expected or because they were grateful for the support and wanted to please the researchers. Also, not all studies provided information about everything we were interested in and there was often missing data when children were followed up after the study. How up‐to‐date is the evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yoong, SL, Lum, M, Wolfenden, L, Jackson, J, Barnes, C, Hall, AE, McCrabb, S, Pearson, N, Lane, C, Jones, JZ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013862.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.141Z" }, { "id": "57552bba-069c-4c92-b3af-b61e239033f2", "pmid": "", "title": "Adjunctive therapies in addition to land‐based exercise therapy for osteoarthritis of the hip or knee", "imported": false, "abstract": "Abstract - Background Land‐based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non‐pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land‐based exercise therapy is lacking. Objectives To evaluate the benefits and harms of adjunctive therapies used in addition to land‐based exercise therapy compared with placebo adjunctive therapy added to land‐based exercise therapy, or land‐based exercise therapy only for people with hip or knee osteoarthritis. Search methods We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land‐based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land‐based exercise therapy, or land‐based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant‐reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short‐term (6 months), medium‐term (6 to 12 months) and long‐term (12 months onwards) effects. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE. Main results We included 62 trials (60 RCTs and 2 quasi‐RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 60 included people with knee osteoarthritis only. Thirty‐six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty‐two trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in 11 (18%) trials. Comparing adjunctive therapies plus land‐based exercise therapy against placebo therapies plus exercise up to six months (short‐term), we found low‐certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate‐certainty evidence indicates that adjunctive therapies did not improve QOL (SF‐36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low‐certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant‐reported global assessment was not measured in any studies. Compared with land‐based exercise therapy, low‐certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short‐term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise‐only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (41 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (41 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low‐certainty evidence). Moderate‐certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant‐reported global assessment (short‐term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI ‐0.32 to ‐0.18 mm); 12% relative improvement (6% better to 18% better). Low‐certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27). Authors' conclusions Moderate‐ to low‐certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant‐reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis. Plain language summary Additional therapies used with exercise therapy for hip or knee osteoarthritis What was the aim of this review? Osteoarthritis, a chronic degenerative condition that commonly affects hip and knee joints, causes pain and difficulty with everyday activities such as walking. Land‐based exercise therapy refers to exercise conducted on land (as opposed to exercise in the water) and is a first‐line treatment. This review aimed to find out if adding additional therapies to land‐based exercise therapy improved pain, function, quality of life, participant‐reported overall change or X‐ray changes in people with hip or knee osteoarthritis. Additional therapies include manual (hands‐on) therapy, psychological or dietary therapies, electrophysical agents (such as heat, cold, nerve stimulation, ultrasound or laser therapy) or acupuncture. We included studies comparing additional therapies plus land‐based exercise therapy to either 1) sham (or dummy) therapy plus land‐based exercise therapy or 2) land‐based exercise therapy only. Search date This systematic review is up‐to‐date to 10 June 2021. What did we find? We found 62 randomised controlled trials with 6508 participants, mostly women, from 24 countries. The average age was between 52 and 83 years, with symptoms present from 9 months to 12 years. Sixty studies enrolled people with knee osteoarthritis, one enrolled people with hip osteoarthritis and one enrolled people with knee or hip osteoarthritis. Twenty‐two trials compared additional therapies plus exercise therapy to sham additional therapies plus exercise therapy, and 41 compared to exercise therapy. Thirty‐eight trials studied electrophysical agents, seven studied manual therapies, four studied acupuncture/dry needling or use of tape, three studied psychological or dietary interventions, whole body vibration (this involves standing on a vibration platform), or spa/mud therapy, and one studied foot orthotics (shoe insoles). Funding source Thirty‐eight studies were funded, four received no funding and funding support was not reported in 20. Main results Eleven trials (18%) measured adverse (unwanted harmful) events, which included both non‐serious and serious adverse events. The most common were increased pain, stiffness or swelling. There was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with sham additional therapies plus exercise therapy (22 studies) Compared with sham additional therapies used with land‐based exercise therapy, additional therapies such as electrophysical agents, acupuncture, dry needling or taping, used with exercise therapy, may not be more effective in improving pain, physical function or quality of life up to six months after treatment. Pain (lower scores mean less pain) Improved by 10% or 0.77 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 12% or 5.03 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 1% or 0.75 points worse on a zero to 100‐point scale. Adverse events Although not commonly reported in studies, there was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with exercise therapy (41 studies) Compared with land‐based exercise therapy, additional therapies (manual therapies, electrotherapy, dietary interventions, psychological therapies, whole body vibration, acupuncture, dry needling, taping, spa/mud therapy or foot orthotics) plus exercise therapy, may not be more effective in improving pain, physical function, quality of life or joint changes measured with X‐rays up to six months after treatment. Pain (lower scores mean less pain) Improved by 7% or 0.41 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 9% or 2.83 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 2%, or 1.04 points worse on a zero to 100‐point scale. Patient‐reported overall change 17% more people rated their treatment a success. X‐ray changes Improved by 12% (based on one study) Adverse effects Although not commonly reported in studies, risks appear no greater for additional therapies used with exercise compared to exercise only. Fewer studies assessed outcomes six or 12 months after treatment. Additional therapies plus land‐based exercise therapy may be no better in reducing pain or improving physical function or quality of life than exercise therapy at 6 or 12 months. In patient‐reported overall assessment, 31% reported improvement at 6 months, and 42% reported improvement at 12 months. Conclusions and certainty of evidence Additional therapies plus exercise therapy do not appear to offer meaningful improvements in pain, function, quality of life or overall change for people with hip or knee osteoarthritis compared with sham additional therapies plus land‐based exercise therapy; or in pain, function, quality of life or changes on X‐rays when compared with exercise therapy only. Compared with exercise therapy there is probably a clinical benefit in patient‐reported overall change for additional therapies plus exercise therapy, based on a small number of studies. Our confidence in the evidence varies between moderate to little or no confidence for different outcomes. Although results indicate no increased adverse events from additional therapies used with exercise therapy, this was poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "French, HP; Abbott, JH; Galvin, R", "articleTypes": [], "doi": "10.1002/14651858.CD011915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "578199d1-b3f5-44d9-9379-d9204262e340", "pmid": "", "title": "Statins for Smith‐Lemli‐Opitz syndrome", "imported": false, "abstract": "Abstract - Background Smith‐Lemli‐Opitz syndrome (SLOS) is a multiple congenital malformations syndrome caused by defective cholesterol biosynthesis. Affected individuals show cholesterol deficiency and accumulation of various precursor molecules, mainly 7‐dehydrocholesterol and 8‐dehydrocholesterol. There is currently no cure for SLOS, with cholesterol supplementation being primarily a biochemical therapy of limited evidence. However, several anecdotal reports and preclinical studies have highlighted statins as a potential therapy for SLOS. Objectives To evaluate the effects of statins, either alone or in combination with other non‐statin therapies (e.g. cholesterol, bile acid, or vitamin co‐supplementation), compared to cholesterol supplementation alone or in combination with other non‐statin therapies (e.g. bile acid or vitamin supplementation) on several important outcomes including overall survival, neurobehavioral features, and adverse effects in individuals with SLOS. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and three trials registers on 15 February 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs with parallel or cross‐over designs, and non‐randomized studies of interventions (NRSIs) including non‐randomized trials, cohort studies, and controlled before‐and‐after studies, were eligible for inclusion in this review if they met our prespecified inclusion criteria, i.e. involved human participants with biochemically or genetically diagnosed SLOS receiving statin therapy or cholesterol supplementation, or both. Data collection and analysis Two authors screened titles and abstracts and subsequently full‐texts for all potentially‐relevant references. Both authors independently extracted relevant data from included studies and assessed the risks of bias. We analyzed the data extracted from the included NRSIs and cohort studies separately from the data extracted from the single included RCT. We used a random‐effects model to account for the inherent heterogeneity and methodological variation between these different study designs. We used GRADE to assess the certainty of evidence. Main results We included six studies (61 participants with SLOS); one RCT (N = 18), three prospective NRSIs (N = 20), and two retrospective NRSIs (N = 22). Five studies included only children, and two limited their participant inclusion by disease severity. Overall, there were nearly twice as many males as females. All six studies compared add‐on statin therapy to cholesterol supplementation alone. However, the dosages, formulations, and durations of treatment were highly variable across studies. We judged the RCT as having a high risk of bias due to missing data and selective reporting. All included NRSIs had a serious or critical overall risk of bias assessed by the Risk Of Bias In Non‐randomized Studies of Interventions tool (ROBINS‐I). None of the included studies evaluated survival or reported quality of life (QoL). Only the included RCT formally assessed changes in the neurobehavioral manifestations of SLOS, and we are uncertain whether statin therapy improves this outcome (very low‐certainty evidence). We are also uncertain whether the adverse events reported in the RCT were statin‐related (very low‐certainty evidence). In contrast, the adverse events reported in the NRSIs seem to be possibly due to statin therapy (risk ratio 13.00, 95% confidence interval 1.85 to 91.49; P = 0.01; low‐certainty evidence), with only one of the NRSIs retrospectively mentioning changes in the irritability of two of their participants. We are uncertain whether statins affect growth based on the RCT or NRSI results (very low‐certainty evidence). The RCT showed that statins may make little or no difference to plasma biomarker levels (low‐certainty evidence), while we are uncertain of their effects on such parameters in the NRSIs (very low‐certainty evidence). Authors' conclusions Currently, there is no evidence on the potential effects of statin therapy in people with SLOS regarding survival or QoL, and very limited evidence on the effects on neurobehavioral manifestations. Likewise, current evidence is insufficient and of very low certainty regarding the effects of statins on growth parameters in children with SLOS and plasma or cerebrospinal fluid (CSF) levels of various disease biomarkers. Despite these limitations, current evidence seemingly suggests that statins may increase the risk of adverse reactions in individuals with SLOS receiving statins compared to those who are not. Given the insufficient evidence on potential benefits of statins in individuals with SLOS, and their potential for causing adverse reactions, anyone considering this therapy should take these findings into consideration. Future studies should address the highlighted gaps in evidence on the use of statins in individuals with SLOS by collecting prospective data on survival and performing serial standardized assessments of neurobehavioral features, QoL, anthropometric measures, and plasma and CSF biomarker levels after statin introduction. Future studies should also attempt to use consistent dosages, formulations and durations of cholesterol and statin therapy. Plain language summary Statins for Smith‐Lemli‐Opitz syndrome Review question Is statin therapy, either alone or combined with cholesterol therapy, linked to better outcomes (e.g. survival, quality of life, severity or frequency of neurobehavioral abnormalities, changes in growth parameters or biomarker levels) compared to cholesterol therapy alone for people with Smith‐Lemli‐Opitz syndrome (SLOS), and what are the risks of harmful effects for either option? Background Smith‐Lemli‐Opitz syndrome is a genetic malformation syndrome, which occurs when cholesterol is not able to be produced by the body and there is a build up of several toxic molecules that would, under normal circumstances, go on to become cholesterol, such as 7DHC and 8DHC. This means that people with SLOS may fail to achieve normal physical growth, show various degrees of intellectual disability or developmental delay (or both), and show a range of possible behavioral abnormalities (e.g. irritability, aggressiveness, anxiety, attention‐deficit hyperactivity disorder (ADHD), impulsivity and sleep disturbances, among others). It is also notable that SLOS may cause various possible physical abnormalities and disability. There is currently no cure for SLOS, but cholesterol supplementation remains common practice among clinicians caring for people with SLOS. This is based solely on our current understanding of the underlying biochemistry of the disease itself. However, there has been evidence from studies in the laboratory and in single individuals suggesting that statins may be helpful for treating people with SLOS. Search date We conducted our latest search on 15 February 2022. Study characteristics In this review, we included six studies of different designs that included a total of 61 people with SLOS, mostly males. Five of the studies only included children (18 years old or younger). All studies compared a combination of statin and cholesterol therapy to cholesterol supplementation alone. However, the studies used different doses and formulations of statin or cholesterol therapy (or both), as well as different durations of treatment. Key results We found no evidence for the effects of combined statin and cholesterol supplementation, compared to cholesterol supplementation alone, on survival or quality of life in people with SLOS. We are also not sure if combined statin and cholesterol therapy has positive effects on neurobehavioral manifestations or growth in individuals with SLOS compared with cholesterol therapy alone, as we have low confidence in the evidence. We think people with SLOS receiving statin therapy in addition to cholesterol supplementation are more likely to experience adverse events that are usually associated with using statins, compared to those who are only receiving cholesterol supplementation. Finally, we are uncertain about the effects of statin therapy on the levels of various biomarkers usually measured in the blood of people with SLOS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ballout, RA; Livinski, A; Fu, Y-P; Steiner, RD; Remaley, AT", "articleTypes": [], "doi": "10.1002/14651858.CD013521.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "57940b1d-ead4-4abf-92c4-d0653e7a9785", "pmid": "", "title": "Pharmacological interventions for promoting smoking cessation during pregnancy", "imported": false, "abstract": "Abstract - Background Tobacco smoking in pregnancy causes serious health problems for the developing fetus and mother. When used by non‐pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion, and varenicline) are effective for increasing smoking cessation, however their efficacy and safety in pregnancy remains unknown. Electronic cigarettes (ECs) are becoming widely used, but their efficacy and safety when used for smoking cessation in pregnancy are also unknown. Objectives To determine the efficacy and safety of smoking cessation pharmacotherapies and ECs used during pregnancy for smoking cessation in later pregnancy and after childbirth, and to determine adherence to smoking cessation pharmacotherapies and ECs for smoking cessation during pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2019), trial registers, and grey literature, and checked references of retrieved studies. Selection criteria Randomised controlled trials (RCTs) conducted in pregnant women, comparing smoking cessation pharmacotherapy or EC use with either placebo or no pharmacotherapy/EC control. We excluded quasi‐randomised, cross‐over, and within‐participant designs, and RCTs with additional intervention components not matched between trial arms. Data collection and analysis We followed standard Cochrane methods. The primary efficacy outcome was smoking cessation in later pregnancy; safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well‐being. We also collated data on adherence to trial treatments. We calculated the risk ratio (RR) or mean difference (MD) and the 95% confidence intervals (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta‐analyses where appropriate. Main results We included 11 trials that enrolled a total of 2412 pregnant women who smoked at enrolment, nine trials of NRT and two trials of bupropion as adjuncts to behavioural support, with comparable behavioural support provided in the control arms. No trials investigated varenicline or ECs. We assessed four trials as at low risk of bias overall. The overall certainty of the evidence was low across outcomes and comparisons as assessed using GRADE, with reductions in confidence due to risk of bias, imprecision, and inconsistency. Compared to placebo and non‐placebo (behavioural support only) controls, there was low‐certainty evidence that NRT increased the likelihood of smoking abstinence in later pregnancy (RR 1.37, 95% CI 1.08 to 1.74; I² = 34%, 9 studies, 2336 women). However, in subgroup analysis by comparator type, there was a subgroup difference between placebo‐controlled and non‐placebo controlled RCTs (test for subgroup differences P = 0.008). There was unclear evidence of an effect in placebo‐controlled RCTs (RR 1.21, 95% CI 0.95 to 1.55; I² = 0%, 6 studies, 2063 women), whereas non‐placebo‐controlled trials showed clearer evidence of a benefit (RR 8.55, 95% CI 2.05 to 35.71; I² = 0%, 3 studies, 273 women). An additional subgroup analysis in which studies were grouped by the type of NRT used found no difference in the effectiveness of NRT in those using patches or fast‐acting NRT (test for subgroup differences P = 0.08). There was no evidence of a difference between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities, or neonatal death. In one study infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' at two years of age compared to the placebo group. Non‐serious adverse effects observed with NRT included headache, nausea, and local reactions (e.g. skin irritation from patches or foul taste from gum), but data could not be pooled. Adherence to NRT treatment regimens was generally low. We identified low‐certainty evidence that there was no difference in smoking abstinence rates observed in later pregnancy in women using bupropion when compared to placebo control (RR 0.74, 95% CI 0.21 to 2.64; I² = 0%, 2 studies, 76 women). Evidence investigating the safety outcomes of bupropion use was sparse, but the existing evidence showed no difference between the bupropion and control group. Authors' conclusions NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy. However, this evidence is of low certainty, as the effect was not evident when potentially biased, non‐placebo‐controlled RCTs were excluded from the analysis. Future studies may therefore change this conclusion. We found no evidence that NRT has either positive or negative impacts on birth outcomes; however, the evidence for some of these outcomes was also judged to be of low certainty due to imprecision and inconsistency. We found no evidence that bupropion may be an effective aid for smoking cessation during pregnancy, and there was little evidence evaluating its safety in this population. Further research evidence on the efficacy and safety of pharmacotherapy and EC use for smoking cessation in pregnancy is needed, ideally from placebo‐controlled RCTs that achieve higher adherence rates and that monitor infants' outcomes into childhood. Future RCTs of NRT should investigate higher doses than those tested in the studies included in this review. Plain language summary Drug treatments and electronic cigarettes for stopping smoking in pregnancy What is the issue? Smoking during pregnancy harms women and infants. However, many women who smoke struggle to stop whilst pregnant. Medication for smoking cessation reduces the intensity of cravings, meaning that people trying to stop smoking are more likely to succeed in the long term. Providing pregnant women who smoke with these treatments could help them to stop smoking and have a positive impact on both their own health and the health of their infants. Why is this important? Medications commonly used to help people to stop smoking include nicotine replacement therapy (NRT), bupropion, and varenicline. Electronic cigarettes containing nicotine are also used by some who smoke to help avoid smoking. However, the safety and effectiveness of smoking cessation drugs and electronic cigarettes in pregnant women is unknown. We searched for studies looking at how good these aids were at helping pregnant women stop smoking and how safe they were when used during pregnancy. What evidence did we find? We searched for evidence on 20 May 2019 and identified 11 randomised studies (studies in which participants are assigned to one of two or more treatment groups using a random method) that enrolled a total of 2412 women. Nine studies tested NRT used alongside counselling to stop smoking, whilst the other two studies tested bupropion. Low‐quality evidence suggests that NRT combined with behavioural support might help women to stop smoking in later pregnancy more than behavioural support alone. Medication trials often use placebos, that is tablets or patches that look like the drug but do not actually include it, so that each comparison group has equal expectation of success and there is a fairer test of the benefits of the medicine itself. When just the higher‐quality, placebo‐controlled trials were analysed, the evidence suggested that NRT was more effective than placebo NRT. There was no evidence that either nicotine patches or fast‐acting NRT (such as gum or lozenge) was more effective than the other. Low‐quality evidence suggests that bupropion may be no more effective than placebo in helping women quit smoking later in pregnancy. We found no trials investigating other smoking cessation pharmacotherapies or electronic cigarettes. There was insufficient evidence to conclude whether NRT had either positive or negative impacts on rates of miscarriage, stillbirth, preterm birth (less than 37 weeks), mean birthweight, low birthweight (less than 2500 g), admissions of babies to neonatal intensive care, or newborn deaths. However, in one trial where infants were followed until two years of age, those infants born to women who had been randomised to NRT were more likely to have healthy development. Similarly, it is unclear whether bupropion had a positive or negative impact on birth outcomes. Studies that looked at whether women used their stop smoking medications as instructed found that use was generally low, and the majority of women used little of the NRT they were given. What does this mean? More research evidence is needed, in particular placebo‐controlled trials that test higher doses of NRT, encourage women to use sufficient medication, and follow infants into childhood. Furthermore, more studies are required investigating the effect and safety of bupropion, electronic cigarettes, and varenicline for giving up smoking during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Claire, R; Chamberlain, C; Davey, MA; Cooper, SE; Berlin, I; Leonardi‐Bee, J; Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD010078.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "57a60cfa-d4f9-42cd-b50b-eec75f377f64", "pmid": "", "title": "A Randomized, Active-Controlled, Partially Blinded, Biomarker Select, Phase III Clinical Trial of Pembrolizumab as Monotherapy and in Combination With Cisplatin+5-Fluorouracil Versus Placebo+Cisplatin+5-Fluorouracil as First-Line Treatment in Subjects With Advanced Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma", "imported": false, "abstract": "This is a study of pembrolizumab (MK-3475) as first-line treatment for participants with advanced gastric or gastroesophageal junction (GEJ) adenocarcinoma. Participants whose tumors express programmed death-ligand 1 (PD-L1) will be randomly assigned to one of the three treatment arms of the study: pembrolizumab as monotherapy [pembro mono], pembrolizumab plus standard of care (SOC) chemotherapy with cisplatin plus 5-fluorouracil (5-FU) or capecitabine [pembro combo], or placebo plus SOC chemotherapy with cisplatin plus 5-fluorouracil (5-FU) or capecitabine [SOC].", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.161Z" }, { "id": "57e967bb-ce6f-4d16-a9eb-1a80be68eb79", "pmid": "", "title": "Taste Preferences for Nutritive and Non Nutritive Sweeteners Among Children and Adults", "imported": false, "abstract": "The goal of the study is to determine whether there are age-, diet- and genetically-related differences in the perception of sweeteners, both nutritive and non-nutritive.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.234Z" }, { "id": "580cc5a3-0cd9-4416-a229-ec8a88e23df6", "pmid": "", "title": "Oral water soluble contrast for malignant bowel obstruction", "imported": false, "abstract": "Abstract - Background Malignant bowel obstruction (MBO) is a common problem in patients with intra‐abdominal cancer. Oral water soluble contrast (OWSC) has been shown to be useful in the management of adhesive small bowel obstruction in identifying patients who will recover with conservative management alone and also in reducing the length of hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in patients with MBO. Objectives To determine the reliability of OWSC media and follow‐up abdominal radiographs in predicting the success of conservative treatment in resolving inoperable MBO with conservative management. To determine the efficacy and safety of OWSC media in reducing the duration of obstruction and reducing hospital stay in people with MBO. Search methods We identified studies from searching Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in Process, Embase, CINAHL, Science Citation Index (Web of Science) and Conference Proceedings Citation Index ‐ Science (Web of Science). We also searched registries of clinical trials and the CareSearch Grey Literature database. The date of the search was the 6 June 2017. Selection criteria Randomised controlled trials (RCTs), or prospective controlled studies, that evaluated the diagnostic potential of OWSC in predicting which malignant bowel obstructions will resolve with conservative treatment. RCTs, or prospective controlled studies, that assessed the therapeutic potential of OWSC in managing MBO at any level compared with placebo, no intervention or usual treatment or supportive care. Data collection and analysis We used standard methodological procedures expected by Cochrane. We assessed risk of bias and assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We found only one RCT meeting the selection criteria for the second objective (therapeutic potential) of this review. This study recruited nine participants. It compared the use of gastrografin versus placebo in adult patients with MBO with no indication for further intervention (surgery, endoscopy) apart from standardised conservative management. The overall risk of bias for the study was high due to issues with low numbers of participants, selective reporting of outcomes and a high attrition rate for the intervention arm. Primary outcomes The included trial was a pilot study whose primary outcome was to test the feasibility for a large study. The authors reported specifically on the number of patients screened, the number recruited and reasons for exclusion; this was not the focus of our review. Due to the low number of participants, the authors of the study decided not to report on our primary outcome of assessing the ability of OWSC to predict the likelihood of malignant small bowel obstruction resolving with conservative treatment alone (diagnostic effect). It also did not report on our primary outcome of rate of resolution of MBO in patients receiving OWSC compared with those not receiving it (therapeutic effect). The study reported that no issues regarding safety or tolerability of either gastrografin or placebo were identified. The overall quality of the evidence for the incidence of adverse events with OWSC was very low, downgraded twice for serious limitations to study quality (high risk of selective reporting and attrition bias) and downgraded once for imprecision (sparse data). Secondary outcomes The study planned to report on this review’s secondary outcome measures of length of hospital stay and time from administration of OWSC to resolution of MBO. However the authors of the study decided not to do so due to the low numbers of patients recruited. The study did not report on our secondary outcome measure of survival times from onset of inoperable MBO until death. Authors' conclusions There is insufficient evidence from RCTs to determine the place of OWSC in predicting which patients with inoperable MBO will respond with conservative treatment alone. There is also insufficient evidence from RCTs to determine the therapeutic effects and safety of OWSC in patients with malignant small bowel obstruction. Plain language summary Oral water soluble contrast for cancer‐related bowel obstruction Background Intra‐abdominal cancer is where the cancer has either started elsewhere in the body and spread into the stomach area or started in the bowel itself. It can commonly grow and block the movement of food or faeces through the bowel. A blockage of the bowel caused by cancer is known as malignant bowel obstruction (MBO). Some patients with MBO benefit from surgery to reverse the blockage. In others it is not possible to reverse the MBO and it either resolves or becomes permanent (limiting prognosis to days or weeks). Scar tissue around the bowel (called adhesions) can also cause a blockage, this is known as adhesive small bowel obstruction. Adhesive obstructions often resolve with conservative management in hospital (allowing the bowel to \"rest\" and recover). However in some, the obstruction requires surgery to remove the scar tissue and fix the blockage. Oral water soluble contrast (OWSC) is often prepared in liquid form and when swallowed before an x‐ray or computed tomography (CT) scan will show up clearly in the bowel. It can predict which people with adhesive small bowel obstruction will require surgery. In some patients it may also speed recovery leading to reduced hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in MBO. Study characteristics We searched for evidence that OWSC could be used to identify which patients with inoperable MBO would recover with conservative management. We also wanted to know if OWSC increased the likelihood of recovery from MBO, reduced hospital stay or improved prognosis. Finally, we wished to know what side effects OWSC might cause for patients with MBO. We conducted the search in June 2017 and found one study. It only recruited nine participants and did not fully report on the outcomes of using OWSC in MBO. Key Findings We found insufficient evidence that OWSC can identify which patients with MBO will recover with conservative management. We found insufficient evidence that patients with MBO benefit from OWSC in terms of length of hospital stay, recovery time or survival. No conclusions could be made about side effects from OWSC. Quality of Evidence We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. We rated the quality of the evidence as very low due to the lack of studies reporting on the benefits of using OWSC in MBO and the only study we found reporting on side effects recruited very few participants (nine). The low quality of the evidence means that we are very uncertain about the use of OWSC in the management of MBO and cannot confirm its benefits or harms in patients with this condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Syrmis, W; Richard, R; Jenkins-Marsh, S; Chia, SC; Good, P", "articleTypes": [], "doi": "10.1002/14651858.CD012014.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "582096e5-eece-400a-bf10-662ab7f8b0a7", "pmid": "", "title": "Systemic interventions for recurrent aphthous stomatitis (mouth ulcers)", "imported": false, "abstract": "Abstract - Background Recurrent aphthous stomatitis (RAS) is the most frequent form of oral ulceration, characterised by recurrent oral mucosal ulceration in an otherwise healthy individual. At its worst RAS can cause significant difficulties in eating and drinking. Treatment is primarily aimed at pain relief and the promotion of healing to reduce the duration of the disease or reduce the rate of recurrence. A variety of topical and systemic therapies have been utilised. Objectives To determine the clinical effect of systemic interventions in the reduction of pain associated with RAS, a reduction in episode duration or frequency. Search methods We undertook electronic searches of: Cochrane Oral Health Group and PaPaS Trials Registers (to 6 June 2012); CENTRAL via The Cochrane Library (to Issue 4, 2012); MEDLINE via OVID (1950 to 6 June 2012); EMBASE via OVID (1980 to 6 June 2012); CINAHL via EBSCO (1980 to 6 June 2012); and AMED via PubMed (1950 to 6 June 2012). We searched reference lists from relevant articles and contacted the authors of eligible trials to identify further trials and obtain additional information. Selection criteria We included randomised controlled trials (RCTs) in which the primary outcome measures assess a reduction of pain associated with RAS, a reduction in episode duration or a reduction in episode frequency. Trials were not restricted by outcome alone. We also included RCTs of a cross‐over design. Data collection and analysis Two review authors independently extracted data in duplicate. We contacted trial authors for details of randomisation, blindness and withdrawals. We carried out risk of bias assessment on six domains. We followed The Cochrane Collaboration statistical guidelines and risk ratio (RR) values were to be calculated using fixed‐effect models (if two or three trials in each meta‐analysis) or random‐effects models (if four or more trials in each meta‐analysis). Main results A total of 25 trials were included, 22 of which were placebo controlled and eight made head‐to‐head comparisons (five trials had more than two treatment arms). Twenty‐one different interventions were assessed. The interventions were grouped into two categories: immunomodulatory/anti‐inflammatory and uncertain. Only one study was assessed as being at low risk of bias. There was insufficient evidence to support or refute the use of any intervention. Authors' conclusions No single treatment was found to be effective and therefore the results remain inconclusive in regard to the best systemic intervention for RAS. This is likely to reflect the poor methodological rigour of trials, and lack of studies for certain drugs, rather than the true effect of the intervention. It is also recognised that in clinical practice, individual drugs appear to work for individual patients and so the interventions are likely to be complex in nature. In addition, it is acknowledged that systemic interventions are often reserved for those patients who have been unresponsive to topical treatments, and therefore may represent a select group of patients. Plain language summary Systemic interventions for recurrent aphthous stomatitis (mouth ulcers) Mouth ulcers (sores) are one of the most common oral problems and many people suffer with them repeatedly. These can be painful and slow to heal. At its worst, this can cause significant difficulties in eating and drinking. This review found that many different treatments were used to manage this condition, although the evidence of their effectiveness remains inconclusive.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Brocklehurst, P, Tickle, M, Glenny, AM, Lewis, MA, Pemberton, MN, Taylor, J, Walsh, T, Riley, P, Yates, JM", "articleTypes": [], "doi": "10.1002/14651858.CD005411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.794Z" }, { "id": "5856364a-64ac-4115-9fc3-0c8a1fa8e27d", "pmid": "", "title": "Pain in Endometriosis And the Relation to Lifestyle: Effectiveness of a Dietary Intervention and Cognitive Behavioral Therapy in Endometriosis-associated Pain", "imported": false, "abstract": "The goal of this clinical trial is to investigate the effect of an anti-inflammatory diet and cognitive behavioral therapy (CBT) on pain symptoms, health related quality of life and the effect on inflammatory characteristics in serum and menstruum samples as well as the effect on the gut and vaginal microbiome in women with endometriosis. In addition, we want to investigate the differences in stress (measured by hair cortisol levels), inflammatory markers in peripheral blood, menstrual effluent, and the vaginal and intestinal microbiome between persons without and with endometriosis. Participants will be randomized between standard care (control group), standard care and an anti-inflammatory diet intervention, or standard care, an anti-inflammatory diet intervention and CBT or CBT alone. Participants will follow an anti-inflammatory diet based on the Dutch Dietary Guidelines or CBT or a combination of both interventions for 12 weeks. They will receive personalized dietary advice from a dietician and recipes will be available. cognitive behavioral therapy will be administered in a total of seven individual sessions led by a psychotherapist. The content of these sessions will be psycho-education regarding pain mechanisms (and diet).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.249Z" }, { "id": "585d37d5-6ae6-4596-8e33-9ad48f4cc118", "pmid": "", "title": "Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Ethnic minority groups in upper‐middle‐income and high‐income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population. Objectives To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Search methods A systematic literature search was performed of the following databases: The Cochrane Library , MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well. Selection criteria We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper‐middle‐income or high‐income countries. Data collection and analysis Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification. Main results A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta‐analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education. Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) ‐0.4% (95% confidence interval (CI) ‐0.5 to ‐0.2); 14 trials; 1442 participants; high‐quality evidence) and at six months (MD ‐0.5% (95% CI ‐0.7 to ‐0.4); 14 trials; 1972 participants; high‐quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD ‐0.2% (95% CI ‐0.3 to ‐0.04); 9 trials; 1936 participants) and at 24 months (MD ‐0.3% (95% CI ‐0.6 to ‐0.1); 4 trials; 2268 participants; moderate‐quality evidence) post intervention. Neutral effects on health‐related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies — the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI ‐40 to ‐8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low‐density lipoprotein (LDL) cholesterol or high‐density lipoprotein (HDL) cholesterol were reported at any follow‐up point. Other outcome measures (blood pressure, body mass index, self‐efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient. Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self‐reported via questionnaires, leading to high bias in subjective outcome assessment. Authors' conclusions Culturally appropriate health education has short‐ to medium‐term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long‐term trials, and so clinically important long‐term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long‐term, standardised, multi‐centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium‐term effects could lead to clinically important health outcomes, if sustained. Plain language summary Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus Review question Does culturally appropriate diabetes health education lead to better outcomes than 'usual care' for people in ethnic minority groups with type 2 diabetes? Background In upper‐middle‐income and high‐income countries, minority ethnic groups often have a higher prevalence of type 2 diabetes mellitus than is seen in the local population. They also tend to come from lower socioeconomic backgrounds, with attendant difficulties in accessing good‐quality health care. In some cases, cultural and communication barriers increase the problems that minority ethnic communities experience when attempting to access good‐quality diabetes health education, which is vital for those who wish to understand diabetes and use available services to gain empowerment and bring about behaviour change toward a healthier lifestyle. In this review, 'culturally appropriate' health education is taken to mean any type of health education that has been specifically tailored to the cultural needs of a target minority group with type 2 diabetes mellitus. Study characteristics This updated review found in the world literature 33 randomised controlled trials (RCTs) of culturally appropriate health education on diabetes that met the selection criteria (participants from a defined ethnic minority group living in a upper‐middle‐income or high‐income country, over 16 years of age, diagnosed with type 2 diabetes mellitus and receiving a culturally tailored health education intervention). The median duration of the intervention was six months, and a total of 7453 participants were involved in the studies. Key results Culturally appropriate health education improved blood sugar control among participants, compared with those receiving 'usual' care, at three, six, 12 and 24 months after the intervention was provided. Knowledge about diabetes improved, and participants attained healthier lifestyles. No information was available regarding complications of diabetes and death from any cause, and there was a general lack of reporting of adverse effects in most studies. Neutral effects were observed for health‐related quality of life, blood lipids like cholesterol, blood pressure and weight. The costs of educational programmes were rarely analysed. Compared with the first review, performed in 2008 (11 studies), many more published studies were identified in this review (altogether 33 studies), strengthening the original findings that blood sugar control and knowledge of diabetes are improved when culturally appropriate health education is provided to people in ethnic minority groups diagnosed with diabetes. The effects of this improvement are shown in this update as lasting longer — up to 24 months after health education was provided in some trials. However, additional high‐quality standardised RCTs of longer duration are needed, along with full evaluation of costs. Quality of the evidence Heterogeneity of the studies, in terms of populations studied, type and duration of health education provided, variety of outcomes measured and differences in timing of assessment, limits interpretation of our findings. Also, risk of bias was judged to be high for many outcomes. Currentness of evidence This evidence is up‐to‐date as of September 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Attridge, M; Creamer, J; Ramsden, M; Cannings‐John, R; Hawthorne, K", "articleTypes": [], "doi": "10.1002/14651858.CD006424.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "5860a362-3e53-4585-acdf-44b622e69af5", "pmid": "", "title": "Zolmitriptan for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a common, disabling condition and a burden for the individual, health services, and society. Zolmitriptan is an abortive medication for migraine attacks, belonging to the triptan family. These medicines work in a different way to analgesics such as paracetamol and ibuprofen. Objectives To determine the efficacy and tolerability of zolmitriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, and the Oxford Pain Relief Database, together with three online databases ( www.astrazenecaclinicaltrials.com , www.clinicaltrials.gov , and apps.who.int/trialsearch ) for studies to 12 March 2014. We also searched the reference lists of included studies and relevant reviews. Selection criteria We included randomised, double‐blind, placebo‐ or active‐controlled studies, with at least 10 participants per treatment arm, using zolmitriptan to treat a migraine headache episode. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate risk ratios and numbers needed to treat for an additional beneficial effect (NNT) or harmful effect (NNH) compared with placebo or a different active treatment. Main results Twenty‐five studies (20,162 participants) compared zolmitriptan with placebo or an active comparator. The evidence from placebo‐controlled studies was of high quality for all outcomes except 24 hour outcomes and serious adverse events where only limited data were available. The majority of included studies were at a low risk of performance, detection and attrition biases, but did not adequately describe methods of randomisation and concealment. Most of the data were for the 2.5 mg and 5 mg doses compared with placebo, for treatment of moderate to severe pain. For all efficacy outcomes, zolmitriptan surpassed placebo. For oral zolmitriptan 2.5 mg versus placebo, the NNTs were 5.0, 3.2, 7.7, and 4.1 for pain‐free at two hours, headache relief at two hours, sustained pain‐free during the 24 hours postdose, and sustained headache relief during the 24 hours postdose, respectively. Results for the oral 5 mg dose were similar to the 2.5 mg dose, while zolmitriptan 10 mg was significantly more effective than 5 mg for pain‐free and headache relief at two hours. For headache relief at one and two hours and sustained headache relief during the 24 hours postdose, but not pain‐free at two hours, zolmitriptan 5 mg nasal spray was significantly more effective than the 5 mg oral tablet. For the most part, adverse events were transient and mild and were more common with zolmitriptan than placebo, with a clear dose response relationship (1 mg to 10 mg). High quality evidence from two studies showed that oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people as oral sumatriptan 50 mg (66%, 67%, and 68% respectively), although not necessarily the same individuals. There was no significant difference in numbers experiencing adverse events. Single studies reported on other active treatment comparisons but are not described further because of the small amount of data. Authors' conclusions Zolmitriptan is effective as an abortive treatment for migraine attacks for some people, but is associated with increased adverse events compared to placebo. Zolmitriptan 2.5 mg and 5 mg benefited the same proportion of people as sumatriptan 50 mg, although not necessarily the same individuals, for headache relief at two hours. Plain language summary Zolmitriptan for acute migraine attacks in adults Migraine is a complex condition with a wide variety of symptoms. It affects about 1 person in 8, mainly women aged 30 to 50 years. For many people, the main feature is a painful, and often disabling, headache. Other symptoms include feeling sick, vomiting, disturbed vision, and sensitivity to light, sound, and smells. Zolmitriptan is one of the triptan family of drugs. It is used to treat migraine attacks when they occur, not to prevent attacks occurring. It is available as an oral tablet to swallow whole, an oral tablet to dissolve in the mouth, and a nasal spray. This review looked at 25 studies that involved over 20,000 participants reporting the effects of zolmitriptan on migraine attacks. Most information was for tablets taken by mouth. Overall methodological quality of the included studies was good, and treatment group sizes were large enough to avoid major bias. There were inconsistencies in the way use of rescue medication and adverse events were reported. A single oral dose of zolmitriptan relieved migraine headache pain in some people. Several different pain outcomes were reported. One outcome was pain reduced from moderate or severe to no pain at all two hours after taking treatment. An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 3 in 10 people (30%), compared with about 1 in 10 (10%) taking placebo. Another outcome was pain reduced from moderate or severe to no worse than mild pain two hours after taking treatment (called headache relief). An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 6 in 10 people (61%), compared with 3 in 10 (29%) taking placebo. Slightly better results were obtained with higher doses of 5 mg or 10 mg oral tablets, but the 10 mg dose was associated with more adverse events, most of which were of short duration and mild or moderate in severity. Results for the 5 mg nasal spray were generally similar to those for the oral tablet, but it was significantly better than the tablet at 1 hour. People with migraine want treatment that eliminates the headache and any associated symptoms quickly (maximum two hours) and prevents it returning (within 24 hours). Results indicate that with the 5 mg dose only 14% of those treated were pain‐free at 2 hours with no headache recurrence within 24 hours. Oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people (2 in 3) as oral sumatriptan 50 mg, with no difference in numbers experiencing adverse events. The individuals who respond to each drug may not be the same.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bird, S, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.743Z" }, { "id": "5865728f-c4d0-4006-80e0-5c9c5a269117", "pmid": "", "title": "Aclidinium bromide for stable chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Bronchodilators are the mainstay for symptom relief in the management of stable chronic obstructive pulmonary disease (COPD). Aclidinium bromide is a new long‐acting muscarinic antagonist (LAMA) that differs from tiotropium by its higher selectivity for M3 muscarinic receptors with a faster onset of action. However, the duration of action of aclidinium is shorter than for tiotropium. It has been approved as maintenance therapy for stable, moderate to severe COPD, but its efficacy and safety in the management of COPD is uncertain compared to other bronchodilators. Objectives To assess the efficacy and safety of aclidinium bromide in stable COPD. Search methods We identified randomised controlled trials (RCT) from the Cochrane Airways Group Specialised Register of trials (CAGR), as well as www.clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), US Food and Drug Administration (FDA) website and Almirall Clinical Trials Registry and Results. We contacted Forest Laboratories for any unpublished trials and checked the reference lists of identified articles for additional information. The last search was performed on 7 April 2014 for CAGR and 11 April 2014 for other sources. Selection criteria Parallel‐group RCTs of aclidinium bromide compared with placebo, long‐acting beta 2 ‐agonists (LABA) or LAMA in adults with stable COPD. Data collection and analysis Two review authors independently selected studies, assessed the risk of bias, and extracted data. We sought missing data from the trial authors as well as manufacturers of aclidinium. We used odds ratios (OR) for dichotomous data and mean difference (MD) for continuous data, and reported both with their 95% confidence intervals (CI). We used standard methodological procedures expected by The Cochrane Collaboration. We applied the GRADE approach to summarise results and to assess the overall quality of evidence. Main results This review included 12 multicentre RCTs randomly assigning 9547 participants with stable COPD. All the studies were industry‐sponsored and had similar inclusion criteria with relatively good methodological quality. All but one study included in the meta‐analysis were double‐blind and scored low risk of bias. The study duration ranged from four weeks to 52 weeks. Participants were more often males, mainly Caucasians, mean age ranging from 61.7 to 65.6 years, and with a smoking history of 10 or more pack years. They had moderate to severe symptoms at randomisation; the mean post‐bronchodilator forced expiratory volume in one second (FEV1) was between 46% and 57.6% of the predicted normal value, and the mean St George's Respiratory Questionnaire score (SGRQ) ranged from 45.1 to 50.4 when reported. There was no difference between aclidinium and placebo in all‐cause mortality (low quality) and number of patients with exacerbations requiring a short course of oral steroids or antibiotics, or both (moderate quality). Aclidinium improved quality of life by lowering the SGRQ total score with a mean difference of ‐2.34 (95% CI ‐3.18 to ‐1.51; I 2 = 48%, 7 trials, 4442 participants) when compared to placebo. More patients on aclidinium achieved a clinically meaningful improvement of at least four units decrease in SGRQ total score (OR 1.49; 95% CI 1.31 to 1.70; I 2 = 34%; number needed to treat (NNT) = 10, 95% CI 8 to 15, high quality evidence) over 12 to 52 weeks than on placebo. Aclidinium also resulted in a significantly greater improvement in pre‐dose FEV1 than placebo with a mean difference of 0.09 L (95% CI 0.08 to 0.10; I 2 = 39%, 9 trials, 4963 participants). No trials assessed functional capacity. Aclidinium reduced the number of patients with exacerbations requiring hospitalisation by 4 to 20 fewer per 1000 over 4 to 52 weeks (OR 0.64; 95% CI 0.46 to 0.88; I 2 = 0%, 10 trials, 5624 people; NNT = 77, 95% CI 51 to 233, high quality evidence) compared to placebo. There was no difference in non‐fatal serious adverse events (moderate quality evidence) between aclidinium and placebo. Compared to tiotropium, aclidinium did not demonstrate significant differences for exacerbations requiring oral steroids or antibiotics, or both, exacerbation‐related hospitalisations and non‐fatal serious adverse events (very low quality evidence). Inadequate data prevented the comparison of aclidinium to formoterol or other LABAs. Authors' conclusions Aclidinium is associated with improved quality of life and reduced hospitalisations due to severe exacerbations in patients with moderate to severe stable COPD compared to placebo. Overall, aclidinium did not significantly reduce mortality, serious adverse events or exacerbations requiring oral steroids or antibiotics, or both. Currently, the available data are insufficient and of very low quality in comparisons of the efficacy of aclidinium versus tiotropium. The efficacy of aclidinium versus LABAs cannot be assessed due to inaccurate data. Thus additional trials are recommended to assess the efficacy and safety of aclidinium compared to other LAMAs or LABAs. Plain language summary Effectiveness and safety of inhalers containing the drug aclidinium bromide for managing patients with stable COPD Review question We reviewed the evidence on the effectiveness and safety of aclidinium inhalers used by people with chronic obstructive pulmonary disease (COPD). Background COPD, also known as 'smoker's lung disease', includes conditions called emphysema and chronic bronchitis where there is airway narrowing that cannot be fully corrected. It is a progressive disease. COPD patients usually have breathing problems and a cough that produces a lot of phlegm. It is diagnosed by international guidelines set by the Global Initiative for Obstructive Lung Disease (GOLD). Symptoms may worsen during flare‐ups. The main aims of treating COPD patients are to relieve symptoms, reduce flare‐ups and improve quality of life. Aclidinium is a new inhaled drug that widens the airways (a bronchodilator). It is delivered by an inhaler called Genuair or Pressair. We wanted to discover whether aclidinium was better or worse than using other inhalers or a dummy inhaler. Study characteristics The evidence was current to 7 April 2014. We included 12 studies involving 9547 COPD patients over a period of four to 52 weeks. These studies were sponsored by drug companies and were well designed. Both patients and the people doing the research did not know which treatment the patients were getting; although in one study one treatment was known to both parties. More men than women took part, and they were mostly Caucasians. They were in their 60s and had smoked a lot in their lives. These people had moderate to severe symptoms when they started treatment. Key results Aclidinium did not reduce the number of people with flare‐ups that need additional drugs. There was little or no difference in deaths or serious side effects between aclidinium and a dummy inhaler. Aclidinium inhalers improved quality of life more than the dummy inhalers. People who took aclidinium had fewer hospital admissions due to serious flare‐ups. Based on our results, among 1000 COPD patients using a dummy inhaler over four weeks to one year 37 would have severe flare‐ups needing hospital admission. Only 17 to 33 patients out of 1000 would require hospital admission if they were using aclidinium inhalers. We also set out to compare this new medication with tiotropium, which is already used to treat COPD. There were only two studies for this comparison thus we could not be sure how aclidinium compared to tiotropium. We also could not compare aclidinium with another well known inhaler that contains the drug formoterol because of unreliable data. Quality of the evidence For the comparison of aclidinium inhalers and dummy inhalers, we are confident that there are benefits in terms of the number of hospitalisations and patients' quality of life; we are less certain about the numbers of flare‐ups needing additional drugs and serious side effects. We do not have enough information to assess any effect on the number of deaths. We did not have enough information to reliably compare aclidinium with tiotropium or formoterol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ni, H; Soe, Z; Moe, S", "articleTypes": [], "doi": "10.1002/14651858.CD010509.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "5871fafc-59bb-458e-966e-8e92078ce631", "pmid": "", "title": "The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement", "imported": false, "abstract": "Abstract - Background The World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework is an holistic, settings‐based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed. Objectives To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well‐being of students and their academic achievement. Search methods We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov , Current controlled trials , and WHO International Clinical Trials Registry Platform . We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles. Selection criteria We included cluster‐randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school’s ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements. Data collection and analysis At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random‐effects meta‐analyses to provide a summary of results across studies. Main results We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand‐washing (2), multiple risk behaviours (7), cycle‐helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self‐reported data and high attrition rates for some studies. In addition, there was a lack of long‐term follow‐up data for most studies. We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta‐analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school‐related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement. Authors' conclusions The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well‐designed research is required to establish the effectiveness of this approach for other health topics and academic achievement. Plain language summary The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement Background Health and education are strongly connected: healthy children achieve better results at school, which in turn are associated with improved health later in life. This relationship between health and education forms the basis of the World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework, an approach to promoting health in schools that addresses the whole school environment. Although the HPS framework is used in many schools, we currently do not know if it is effective. This review aimed to assess whether the HPS framework can improve students’ health and well‐being and their performance at school. Study characteristics We searched 20 health, education, and social science databases, as well as trials registries and relevant websites, for cluster‐randomised controlled trials of school‐based interventions aiming to improve the health of young people aged four to 18 years. We only included trials of programmes that addressed all three points in the HPS framework: including health education in the curriculum; changing the school’s social or physical environment, or both; and involving students’ families or the local community, or both. Key results We found 67 trials, comprising 1345 schools and 98 districts, that fulfilled our criteria. These focused on a wide range of health topics, including physical activity, nutrition, substance use (tobacco, alcohol, and drugs), bullying, violence, mental health, sexual health, hand‐washing, cycle‐helmet use, sun protection, eating disorders, and oral health. For each study, two review authors independently extracted relevant data and assessed the risk of the study being biased. We grouped together studies according to the health topic(s) they focused on. We found that interventions using the HPS approach were able to reduce students’ body mass index (BMI), increase physical activity and fitness levels, improve fruit and vegetable consumption, decrease cigarette use, and reduce reports of being bullied. However, we found little evidence of an effect on BMI when age and gender were taken into account (zBMI), and no evidence of effectiveness on fat intake, alcohol and drug use, mental health, violence, and bullying others. We did not have enough data to draw conclusions about the effectiveness of the HPS approach for sexual health, hand‐washing, cycle‐helmet use, eating disorders, sun protection, oral health or academic outcomes. Few studies discussed whether the health promotion activities, or the collection of data relating to these, could have caused any harm to the students involved. Quality of the evidence Overall, the quality of evidence was low to moderate. We identified some problems with the way studies were conducted, which may have introduced bias, including many studies relying on students’ accounts of their own behaviours (rather than these being measured objectively) and high numbers of students dropping out of studies. These problems, and the small number of studies included in our analysis, limit our ability to draw clear conclusions about the effectiveness of the HPS framework in general. Conclusions Overall, we found some evidence to suggest the HPS approach can produce improvements in certain areas of health, but there are not enough data to draw conclusions about its effectiveness for others. We need more studies to find out if this approach can improve other aspects of health and how students perform at school.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Langford, R; Bonell, CP; Jones, HE; Pouliou, T; Murphy, SM; Waters, E; Komro, KA; Gibbs, LF; Magnus, D; Campbell, R", "articleTypes": [], "doi": "10.1002/14651858.CD008958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "58834ab0-efd2-4e47-a3c2-f1f3b563bd97", "pmid": "", "title": "Iodine fortification of foods and condiments, other than salt, for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency disorders (IDD) affect close to 1.9 billion people worldwide, and are a major public health concern in many countries. Among children, iodine deficiency is the main cause of potentially preventable deficits of central nervous system development and impairment of cognitive function, as well as goitre and hypothyroidism in people of all ages. Salt iodisation is the preferred strategy for IDD prevention and control, however, in some instances where salt is not the major condiment, alternate vehicles for iodine fortification have been considered. Objectives To assess the effects of fortifying foods, beverages, condiments, or seasonings other than salt with iodine alone or in conjunction with other micronutrients, on iodine status and health‐related outcomes in all populations. Search methods Studies were identified through systematic searches of the following databases from their start date to January 2018: Cochrane Public Health Group Specialised Register; CENTRAL; MEDLINE; MEDLINE in Process; Embase; Web of Science; CINAHL; POPLINE; AGRICOLA; BIOSIS; Food Science and Technology Abstracts; OpenGrey; Bibliomap and TRoPHI; AGRIS; IBECS; Scielo; Global Index Medicus‐AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched reference list of relevant articles, conference proceedings, and databases of ongoing trials, and contacted experts and relevant organisations to identify any unpublished work. We applied no language or date restrictions. Selection criteria Studies were eligible if they were randomised or quasi‐randomised controlled trials (RCT) with randomisation at either the individual or cluster level (including cross‐over trials), non‐randomised RCTs, or prospective observational studies with a control group, such as cohort studies, controlled before‐and‐after studies, and interrupted time series. We included studies that examined the effects of fortification of food, beverage, condiment, or seasoning with iodine alone, or in combination with other micronutrients versus the same unfortified food, or no intervention. We considered the following measures: death (all‐cause), goitre, physical development, mental development, cognitive function and motor skill development, cretinism, hypothyroidism, adverse effects (any reported by trialists), urinary iodine concentration, thyroid‐stimulating hormone (TSH) concentration, and serum thyroglobulin concentration. We included all populations, including pregnant women, from any country. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias of included studies. We used random‐effects meta‐analyses to combine data and generate an overall estimate of treatment effect, when more than one study examined the same outcome measure. The overall effect estimate was calculated as the mean difference (MD) or standardised mean difference (SMD) between the intervention group and the comparison group for continuous outcomes, and as odds ratio (OR) for dichotomous outcomes. We assessed the level of heterogeneity through the I² statistic. We conducted post‐hoc subgroup analyses to explore possible sources of heterogeneity, and sensitivity analyses to check the robustness of the findings from the primary analyses. We assessed the quality of the evidence for each outcome using the GRADE framework. Where it was not possible to pool the results in a meta‐analysis, we provided a narrative summary of the outcomes. Main results Eleven studies met the criteria, providing 14 comparisons, and capturing data on 4317 participants. Seven studies were RCTs, three were cluster non‐RCTs, and one was a randomised cross‐over design. Seven studies were carried out among school children (N = 3636), three among women of reproductive age (N = 648), and one among infants (N = 33). The studies used diverse types of food as vehicle for iodine delivery: biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. Daily amounts of iodine provided ranged from 35 µg/day to 220 µg/day; trial duration ranged from 11 days to 48 weeks. Five studies examined the effect of iodine fortification alone, two against the same unfortified food, and three against no intervention. Six studies evaluated the effect of cofortification of iodine with other micronutrients versus the same food without iodine but with different levels of other micronutrients. We assessed one study to be at low risk of bias for all bias domains, three at low risk of bias for all domains apart from selective reporting, and seven at an overall rating of high risk of bias. No study assessed the primary outcomes of death, mental development, cognitive function, cretinism, or hypothyroidism, or secondary outcomes of TSH or serum thyroglobulin concentration. Two studies reported the effects on goitre, one on physical development measures, and one on adverse effects. All studies assessed urinary iodine concentration. The effects of iodine fortification compared to control on goitre prevalence (OR 1.60, 95% CI 0.60 to 4.31; 1 non‐RCT, 83 participants; very low‐quality evidence), and five physical development measures were uncertain (1 non‐RCT, 83 participants; very low‐quality evidence): weight (MD 0.23 kg, 95% CI ‐6.30 to 6.77); height (MD ‐0.66 cm, 95% CI ‐4.64 to 3.33); weight‐for‐age (MD 0.05, 95% CI ‐0.59 to 0.69); height‐for‐age (MD ‐0.30, 95% CI ‐0.75 to 0.15); and weight‐for‐height (MD ‐0.21, 95% CI ‐0.51 to 0.10). One study reported that there were no adverse events observed during the cross‐over trial (low‐quality evidence). Pooled results from RCTs showed that urinary iodine concentration significantly increased following iodine fortification (SMD 0.59, 95% CI 0.37 to 0.81; 6 RCTs, 2032 participants; moderate‐quality evidence). This is equivalent to an increase of 38.32 µg/L (95% CI 24.03 to 52.61 µg/L). This effect was not observed in the meta‐analysis of non‐RCTs (SMD 0.25, 95% CI ‐0.16 to 0.66; 3 non‐RCTs, 262 participants; very low‐quality evidence). Sensitivity analyses did not change the effect observed in the primary analyses. Authors' conclusions The evidence on the effect of iodine fortification of foods, beverages, condiments, or seasonings other than salt on reducing goitre, improving physical development measures, and any adverse effects is uncertain. However, our findings suggest that the intervention likely increases urinary iodine concentration. Additional, adequately powered, high‐quality studies on the effects of iodine fortification of foods on these, and other important outcomes, as well as its efficacy and safety, are required. Plain language summary Adding iodine to foods, other than salt, to prevent diseases caused by inadequate iodine intake Background and review question Many people around the world do not consume enough iodine. This is a problem because iodine is important for normal childhood growth and brain development, and for ensuring a healthy adult population. Inadequate intake of iodine can lead to health problems, such as intellectual disability and goitre (enlargement of the thyroid gland). Currently, the main strategy to increase the amount of iodine consumed in populations recommended by the World Health Organization is adding iodine to salt. However, in some areas where salt is not the major condiment, adding iodine to other foods has also been explored. The aim of our study was to examine the effect of adding iodine to foods, beverages, condiments, or seasonings, other than salt, on iodine nutrition status and health‐related outcomes in all populations. Study characteristics We searched for articles from different sources including published research papers, unpublished reports, and through direct communication with experts and organisations working to address iodine and micronutrient deficiency. We last searched the databases in January 2018. Eleven studies, which captured data on 4317 participants (3636 children, 648 women of reproductive age, and 33 infants), met our inclusion criteria. The type of foods used as vehicle to deliver iodine differed between the studies, and included biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. The amount of iodine provided to participants ranged from 35 µg/day to 220 µg/day, and study duration ranged from 11 days to 48 weeks. Of the 11 studies included, five examined the effect of adding iodine alone to foods compared to either no intervention or the same foods without iodine; while six evaluated the effect of adding iodine plus other micronutrients to foods compared to the same foods without iodine, but with different levels of other micronutrients. Key results No study evaluated the effect of adding iodine to foods on death, mental development, cognitive function, cretinism (a condition characterized by impaired control of physical movement and intellectual disability), hypothyroidism (underactive thyroid), thyroid‐stimulating hormone concentration, or serum thyroglobulin concentration (these are biological markers that indicate the presence of iodine deficiency when concentration in the blood is high). Two studies reported on the effect of the intervention on goitre, one study assessed five physical development measures (weight, height, weight‐for‐age, height‐for‐age, and weight‐for‐height scores), and one examined adverse effects. All studies assessed urinary iodine concentration (the concentration of iodine secreted in the urine, which indicates the presence of iodine deficiency when concentration is low in a population group, rather than in an individual). We combined the data that met our requirements in these studies in a meta‐analysis. We are uncertain of the effects of iodine fortification on the proportion of participants with goitre, or on any of the five physical development measures. One study reported narratively that no adverse effects were observed during the trial. We found a significant increase of 38.32 µg/L in urinary iodine concentration after adding iodine to foods, compared to the groups that did not have iodine added, from studies of higher quality. Quality of the evidence Using GRADE, we rated the quality of the evidence as very low for goitre and physical development measures, due to study limitations (risk of bias) and imprecise results, and low for adverse events due to indirectness and imprecise results. We rated the quality of the evidence for urinary iodine concentration, from studies in which participants were allocated to treatment groups at random (gold standard design for clinical research), as moderate. On the other hand, quality of the evidence for urinary iodine concentration from studies without this random element was rated as very low, due to study limitations and imprecise results. Conclusion Overall, there is no clear evidence on the effect of the intervention on reducing the proportion of people with goitre, improving physical growth, or adverse events. However, our results show that adding iodine to foods likely increases urinary iodine concentration. Additional studies to better quantify the effect of the intervention on these outcomes, as well as other outcomes, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Santos, JAR; Christoforou, A; Trieu, K; McKenzie, BL; Downs, S; Billot, L; Webster, J; Li, M", "articleTypes": [], "doi": "10.1002/14651858.CD010734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "5885c016-7c38-4dfe-80d4-ceaa5a2827e9", "pmid": "", "title": "Preventive lipid‐based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes", "imported": false, "abstract": "Abstract - Background One nutritional intervention advocated to prevent malnutrition among children is lipid‐based nutrient supplements (LNS). LNS provide a range of vitamins and minerals, but unlike most other micronutrient supplements, LNS also provide energy, protein and essential fatty acids. Alternative recipes and formulations to LNS include fortified blended foods (FBF), which are foods fortified with vitamins and minerals, and micronutrient powders (MNP), which are a combination of vitamins and minerals, Objectives To assess the effects and safety of preventive LNS given with complementary foods on health, nutrition and developmental outcomes of non‐hospitalised infants and children six to 23 months of age, and whether or not they are more effective than other foods (including FBF or MNP). This review did not assess the effects of LNS as supplementary foods or therapeutic foods in the management of moderate and severe acute malnutrition. Search methods In October 2018, we searched CENTRAL, MEDLINE, Embase, 21 other databases and two trials registers for relevant studies. We also checked the reference lists of included studies and relevant reviews and contacted the authors of studies and other experts in the area for any ongoing and unpublished studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs that evaluated the impact of LNS plus complementary foods given at point‐of‐use (for any dose, frequency, duration) to non‐hospitalised infants and young children aged six to 23 months in stable or emergency settings and compared to no intervention, other supplementary foods (i.e. FBF), nutrition counselling or multiple micronutrient supplements or powders for point‐of‐use fortification of complementary foods. Data collection and analysis Two review authors independently screened studies for relevance and, for those studies included in the review, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software. We used a random‐effects meta‐analysis for combining data as the interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables,. Main results Our search identified a total of 8124 records, from which we included 17 studies (54 papers) with 23,200 children in the review. The included studies reported on one or more of the pre‐specified primary outcomes, and five studies included multiple comparison groups. Overall, the majority of trials were at low risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias, but at high risk of bias for blinding of participants and personnel due to the nature of the intervention. Using the GRADE approach, we judged the quality of the evidence for most outcomes as low or moderate. LNS+complementary feeding compared with no intervention Thirteen studies compared LNS plus complementary feeding with no intervention. LNS plus complementary feeding reduced the prevalence of moderate stunting by 7% (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.88 to 0.98; nine studies, 13,372 participants; moderate‐quality evidence), severe stunting by 15% (RR 0.85, 95% CI 0.74 to 0.98; five studies, 6151 participants; moderate‐quality evidence), moderate wasting by 18% (RR 0.82, 95% CI 0.74 to 0.91; eight studies; 13,172 participants; moderate‐quality evidence), moderate underweight by 15% (RR 0.85, 95% CI 0.80 to 0.91; eight studies, 13,073 participants; moderate‐quality evidence), and anaemia by 21% (RR 0.79, 95% CI 0.69 to 0.90; five studies, 2332 participants; low‐quality evidence). There was no impact of LNS plus complementary feeding on severe wasting (RR 1.27, 95% CI 0.66 to 2.46; three studies, 2329 participants) and severe underweight (RR 0.78, 95%CI 0.54 to 1.13; two studies, 1729 participants). Adverse effects did not differ between the groups (RR 0.86, 95% CI 0.74 to 1.01; three studies, 3382 participants). LNS+complementary feeding compared with FBF Five studies compared LNS plus complementary feeding with other FBF, including corn soy blend and UNIMIX. We pooled four of the five studies in meta‐analyses and found that, when compared to other FBF, LNS plus complementary feeding significantly reduced the prevalence of moderate stunting (RR 0.89, 95% CI 0.82 to 0.97; three studies, 2828 participants; moderate‐quality evidence), moderate wasting (RR 0.79, 95% CI 0.65 to 0.97; two studies, 2290 participants; moderate‐quality evidence), and moderate underweight (RR 0.81, 95% CI 0.73 to 0.91; two studies, 2280 participants; moderate‐quality evidence). We found no difference between LNS plus complementary feeding and FBF for severe stunting (RR 0.41, 95% CI 0.12 to 1.42; two studies, 729 participants; low‐quality evidence), severe wasting (RR 0.64, 95% CI 0.19 to 2.81; two studies, 735 participants; moderate‐quality evidence), and severe underweight (RR 1.23, 95% CI 0.67 to 2.25; one study, 173 participants; low‐quality evidence). LNS+complementary feeding compared with MNP Four studies compared LNS plus complementary feeding with MNP. We pooled data from three of the four studies in meta‐analyses and found that compared to MNP, LNS plus complementary feeding significantly reduced the prevalence of moderate underweight (RR 0.88, 95% CI 0.78 to 0.99; two studies, 2004 participants; moderate‐quality evidence) and anaemia (RR 0.38, 95% CI 0.21 to 0.68; two studies, 557 participants; low‐quality evidence). There was no difference between LNS plus complementary feeding and MNP for moderate stunting (RR 0.92, 95% CI 0.82 to 1.02; three studies, 2365 participants) and moderate wasting (RR 0.97, 95% CI 0.77 to 1.23; two studies, 2004 participants). Authors' conclusions The findings of this review suggest that LNS plus complementary feeding compared to no intervention is effective at improving growth outcomes and anaemia without adverse effects among children aged six to 23 months in low‐ and middle‐income countries (LMIC) in Asia and Africa, and more effective if provided over a longer duration of time (over 12 months). Limited evidence also suggests that LNS plus complementary feeding is more effective than FBF and MNP at improving growth outcomes. Plain language summary Effect of lipid‐based nutrient supplementation on infants and young children Review question What is the impact of lipid‐based nutrient supplements (LNS) plus complementary foods on health, nutrition and developmental outcomes among infants and young children? Background LNS are food products which contain energy, minerals and vitamins that can improve growth in children. LNS provide vitamins, minerals and energy in the form of protein and essential fatty acids. We sought to assess the effect of LNS given jointly with complementary feeding, compared to no intervention, micronutrient powders (MNP; a mixture of vitamins and minerals that is sprinkled onto food) and other fortified blended food (FBF) products in healthy children. Study characteristics This review includes 17 studies (from 54 reports) with 23,200 children. Four of the included studies were conducted in Malawi, three in Bangladesh, two in Ghana and one each in Burkina Faso, Haiti, Honduras, Chad, Congo, Kenya, Niger, Peru, Guatemala, and Indonesia. Four included studies enrolled pregnant women and provided LNS plus complementary feeding during pregnancy and post‐partum, followed by infant supplementation starting at six months of age. The other studies provided LNS plus complementary feeding to children after six months of age. None of the included studies were conducted in emergency settings. Key results Findings of this review suggest that LNS plus complementary feeding is probably an effective intervention for improving growth outcomes and reducing the occurrence of children who are of short stature for their age (stunting), have low weight for their age (moderate underweight), have low weight for their height (moderate wasting) and anaemia. Additionally, LNS plus complementary feeding probably improves height and weight for age as well as mid‐upper arm circumference without adverse effects among children aged six to 23 months. The intervention seems to be more effective if provided for a duration longer than 12 months. Evidence also suggests that LNS plus complementary probably reduces moderate stunting, moderate wasting and moderate underweight, compared to other FBF. Furthermore, LNS plus complementary feeding is probably more effective than MNP at reducing moderate underweight and improving height and weight. Quality of evidence Overall, we considered most studies to be at high risk of bias for blinding of participants and personnel due to the nature of intervention. We rated the quality of the evidence for most outcomes as either low or moderate. Currentness of evidence The evidence is current to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Das, JK; Salam, RA; Hadi, YB; Sadiq Sheikh, S; Bhutta, AZ; Weise Prinzo, Z; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD012611.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "588f3ed7-2b6e-41a3-b5d1-136eea9b358b", "pmid": "", "title": "Interventions for the cessation of non‐nutritive sucking habits in children", "imported": false, "abstract": "Abstract - Background Comforting behaviours, such as the use of pacifiers (dummies, soothers), blankets and finger or thumb sucking, are common in babies and young children. These comforting habits, which can be referred to collectively as 'non‐nutritive sucking habits' (NNSHs), tend to stop as children get older, under their own impetus or with support from parents and carers. However, if the habit continues whilst the permanent dentition is becoming established, it can contribute to, or cause, development of a malocclusion (abnormal bite). A diverse variety of approaches has been used to help children with stopping a NNSH. These include advice, removal of the comforting object, fitting an orthodontic appliance to interfere with the habit, application of an aversive taste to the digit or behaviour modification techniques. Some of these interventions are easier to apply than others and less disturbing for the child and their parent; some are more applicable to a particular type of habit. Objectives The primary objective of the review was to evaluate the effects of different interventions for cessation of NNSHs in children. The secondary objectives were to determine which interventions work most quickly and are the most effective in terms of child and parent‐ or carer‐centred outcomes of least discomfort and psychological distress from the intervention, as well as the dental measures of malocclusion (reduction in anterior open bite, overjet and correction of posterior crossbite) and cost‐effectiveness. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 8 October 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 9), MEDLINE via OVID (1946 to 8 October 2014), EMBASE via OVID (1980 to 8 October 2014), PsycINFO via OVID (1980 to 8 October 2014) and CINAHL via EBSCO (1937 to 8 October 2014), the US National Institutes of Health Trials Register (Clinical Trials.gov) (to 8 October 2014) and the WHO International Clinical Trials Registry Platform (to 8 October 2014). There were no restrictions regarding language or date of publication in the searches of the electronic databases. We screened reference lists from relevant articles and contacted authors of eligible studies for further information where necessary. Selection criteria Randomised or quasi‐randomised controlled trials in children with a non‐nutritive sucking habit that compared one intervention with another intervention or a no‐intervention control group. The primary outcome of interest was cessation of the habit. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Three review authors were involved in screening the records identified; two undertook data extraction, two assessed risk of bias and two assessed overall quality of the evidence base. Most of the data could not be combined and only one meta‐analysis could be carried out. Main results We included six trials, which recruited 252 children (aged 2 and a half to 18 years), but presented follow‐up data on only 246 children. Digit sucking was the only NNSH assessed in the studies. Five studies compared single or multiple interventions with a no‐intervention or waiting list control group and one study made a head‐to‐head comparison. All the studies were at high risk of bias due to major limitations in methodology and reporting. There were small numbers of participants in the studies (20 to 38 participants per study) and follow‐up times ranged from 1 to 36 months. Short‐term outcomes were observed under one year post‐intervention and long‐term outcomes were observed at one year or more post‐intervention. Orthodontics appliance (with or without psychological intervention) versus no treatment Two trials that assessed this comparison evaluated our primary outcome of cessation of habit. One of the trials evaluated palatal crib and one used a mix of palatal cribs and arches. Both trials were at high risk of bias. The orthodontic appliance was more likely to stop digit sucking than no treatment, whether it was used over the short term (risk ratio (RR) 6.53, 95% confidence interval (CI) 1.67 to 25.53; 2 trials, 70 participants) or long term (RR 5.81, 95% CI 1.49 to 22.66; 1 trial, 37 participants) or used in combination with a psychological intervention (RR 6.36, 95% CI 0.97 to 41.96; 1 trial, 32 participants). Psychological intervention versus no treatment Two trials (78 participants) at high risk of bias evaluated positive reinforcement (alone or in combination with gaining the child's co‐operation) or negative reinforcement compared with no treatment. Pooling of data showed a statistically significant difference in favour of the psychological interventions in the short term (RR 6.16, 95% CI 1.18 to 32.10; I 2 = 0%). One study, with data from 57 participants, reported on the long‐term effect of positive and negative reinforcement on sucking cessation and found a statistically significant difference in favour of the psychological interventions (RR 6.25, 95% CI 1.65 to 23.65). Head‐to‐head comparisons Only one trial demonstrated a clear difference in effectiveness between different active interventions. This trial, which had only 22 participants, found a higher likelihood of cessation of habit with palatal crib than palatal arch (RR 0.13, 95% CI 0.03 to 0.59). Authors' conclusions This review found low‐quality evidence that orthodontic appliances (palatal arch and palatal crib) and psychological interventions (including positive and negative reinforcement) are effective at improving sucking cessation in children. There is very low‐quality evidence that palatal crib is more effective than palatal arch. This review has highlighted the need for high‐quality trials evaluating interventions to stop non‐nutritive sucking habits to be conducted and the need for a consolidated, standardised approach to reporting outcomes in these trials. Plain language summary Interventions for stopping dummy or finger or thumb sucking habits in children Review question This review has been produced to assess the effects of interventions to stop sucking habits in children, which are not linked to food. Important considerations are: which treatment or combination of treatments work most effectively, when should treatment be started, what is the optimum length of time for the intervention and what causes least upset to children and their parents? Background Often babies and children develop a habit of sucking objects to comfort and calm them. They frequently suck dummies (known as pacifiers in the USA), fingers, thumbs or other items like blankets. Eventually, most children grow out of the habit, or stop due to encouragement from their parents. Some children, however, continue sucking as a habit. If they continue to do so as their adult teeth start to grow through (around the age of six), there is a risk that these adult teeth will grow into the wrong position causing them to stick out too far or not meet properly when biting. As a result these children often need dental treatment to fix the problems caused by their sucking habit. Possible treatments to help children break their sucking habits examined in studies in this review include the use of two different braces in the mouth; giving advice and incentives for changing behaviour (known as psychological advice/treatment); applying a bitter, nasty tasting substance to the children’s thumbs/fingers or combinations of these treatments. None of the studies included looked at barrier methods, for example the use of gloves or plasters or withdrawal of dummies. Study characteristics Review authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 8 October 2014. The review includes six studies published from 1967 to 1997, which involved 252 children as participants (although data were supplied on only 246 of the children). Three of the studies were carried out in the USA, one in Canada, one in Sweden and one in Australia. Not all of the studies gave the ages of children involved; in four of the studies children were aged from two and a half to 18 years old, in one study they were aged four years and over and in another nine years and over. Results Use of an orthodontic brace (such as a palatal crib or arch) or a psychological intervention (such as use of positive or negative reinforcement), or both, was more likely to lead to cessation of the habit than no treatment. Most of the trials that compared two different interventions were inconclusive but one study suggested that, of two different types of braces,a palatal crib is more effective than a palatal arch design. Quality of the evidence The evidence presented is of low quality due to the small number of participants in the few available studies and problems with the way in which the studies were conducted. There was a high risk of bias across the studies. Conclusion Orthodontic braces or psychological intervention seems to be effective to help children stop sucking that does not have a feeding purpose but the evidence is low quality. Further high quality clinical trials are required to guide decision making for what is a common problem that can require lengthy and expensive dental treatment to correct.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Borrie, FRP, Bearn, DR, Innes, NPT, Iheozor-Ejiofor, Z", "articleTypes": [], "doi": "10.1002/14651858.CD008694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.750Z" }, { "id": "589111de-2d1e-4600-8b3e-064a569898cf", "pmid": "", "title": "Antioxidant vitamin supplementation for preventing and slowing the progression of age‐related cataract", "imported": false, "abstract": "Abstract - Background Age‐related cataract is a major cause of visual impairment in the elderly. Oxidative stress has been implicated in its formation and progression. Antioxidant vitamin supplementation has been investigated in this context. Objectives To assess the effectiveness of antioxidant vitamin supplementation in preventing and slowing the progression of age‐related cataract. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 2), MEDLINE (January 1950 to March 2012), EMBASE (January 1980 to March 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to March 2012), Open Grey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 2 March 2012. We also checked the reference lists of included studies and ongoing trials and contacted investigators to identify eligible randomized trials. Selection criteria We included only randomized controlled trials in which supplementation with one or more antioxidant vitamins (beta‐carotene, vitamin C and vitamin E) in any form, dosage or combination for at least one year was compared to another antioxidant vitamin or to placebo. Data collection and analysis Two authors extracted data and assessed trial quality independently. We pooled results for the primary outcomes, i.e., incidence of cataract and incidence of cataract extraction. We did not pool results of the secondary outcomes ‐ progression of cataract and loss of visual acuity, because of differences in definitions of outcomes and data presentation. We pooled results by type of cataract when data were available. We did not perform a sensitivity analysis. Main results Nine trials involving 117,272 individuals of age 35 years or older are included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States, with duration of follow‐up ranging from 2.1 to 12 years. The doses of antioxidant vitamins were higher than the recommended daily allowance. There was no evidence of effect of antioxidant vitamin supplementation in reducing the risk of cataract, cataract extraction, progression of cataract or in slowing the loss of visual acuity. In the pooled analyses, there was no evidence of effect of beta‐carotene supplementation in reducing the risk of cataract (two trials) (relative risk (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.08; n = 57,703) or in reducing the risk of cataract extraction (three trials) (RR 1.00, 95% CI 0.91 to 1.10; n = 86,836) or of vitamin E supplementation in reducing the risk of cataract (three trials) (RR 0.97, 95% CI 0.91 to 1.04; n = 50,059) or of cataract extraction (five trials) (RR 0.98, 95% CI 0.91 to 1.05; n = 83,956). The proportion of participants developing hypercarotenodermia (yellowing of skin) while on beta‐carotene ranged from 7.4% to 15.8%. Authors' conclusions There is no evidence from RCTs that supplementation with antioxidant vitamins (beta‐carotene, vitamin C or vitamin E) prevents or slows the progression of age‐related cataract. We do not recommend any further studies to examine the role of antioxidant vitamins beta‐carotene, vitamin C and vitamin E in preventing or slowing the progression of age‐related cataract. Costs and adverse effects should be weighed carefully with unproven benefits before recommending their intake above recommended daily allowances. Plain language summary Antioxidant vitamins for preventing and slowing the progression of age‐related cataract A cataract occurs when the normally clear lens in the eye becomes cloudy. Cataracts are the leading cause of correctable reduced vision worldwide. Most cataracts develop slowly with normal aging. However, cataracts also may be related to genetic diseases and medical conditions such as diabetes. Other factors such as poor nutrition, sun damage, radiation, corticosteroids, smoking, alcohol, eye trauma or other eye surgery may influence cataract formation. Mild or early cataracts may not impair vision. In some cataracts, new eye‐glass prescriptions, brighter lighting or magnifying lenses may overcome the vision losses. When these interventions fail to improve poor vision due to cataracts, surgical removal (extraction) is the generally accepted effective treatment. However, cataract surgery is associated with some risks. The estimated annual costs for outpatient, inpatient and prescription drug services related to the treatment of cataract is USD 6.8 billion. Antioxidant vitamin supplementation has been studied as a means to prevent the formation or to slow the progression of cataract. Results from observational studies have been inconsistent. The review authors searched for randomized controlled trials in which supplementation with the antioxidant vitamins beta‐carotene (provitamin A), vitamin C and vitamin E was compared to inactive placebo or no supplement. Nine trials involving 117,272 adults of age 35 years or older were included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States and were of high methodological quality. The doses of antioxidants given in each trial were higher than the recommended daily allowances. The trials provided no evidence of effect of the antioxidant vitamins beta‐carotene, vitamin E and vitamin C given alone or in combination on the incidence of cataract, its extraction or progression and on the loss of visual acuity. Some participants (7% to 16%) on beta‐carotene developed yellowing of the skin (hypercarotenodermia).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mathew, MC, Ervin, AM, Tao, J, Davis, RM", "articleTypes": [], "doi": "10.1002/14651858.CD004567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.739Z" }, { "id": "58a3e018-6186-4c43-82e0-68609dfe38d8", "pmid": "", "title": "Oral immunotherapy for milk allergy", "imported": false, "abstract": "Abstract - Background The mainstay of treatment of IgE‐mediated cow milk allergy (IMCMA) is an avoidance diet, which is especially difficult with a ubiquitous food like milk. Milk oral immunotherapy (MOIT) may be an alternative treatment, through desensitization or induction of tolerance. Objectives We aim to assess the clinical efficacy and safety of MOIT in children and adults with IMCMA as compared to a placebo treatment or avoidance strategy. Search methods We searched 13 databases for journal articles, conference proceedings, theses and unpublished trials, without language or date restrictions, using a combination of subject headings and text words. The search is up‐to‐date as of October 1, 2012. Selection criteria Only randomised controlled trials (RCT) were considered for inclusion. Blinded and open trial designs were included. Children and adults with IMCMA were included. MOIT administered by any protocol were included. Data collection and analysis A total of 2111 unique records were identified and screened for potential inclusion. Studies were selected, data extracted and methodological quality assessed independently by two reviewers. We attempted to contact the study investigators to inquire about data not published that was required for the analysis. Statistical heterogeneity was assessed using the I² test. We estimated a pooled risk ratio (RR) for each outcome using a Mantel‐Haenzel fixed‐effect model if statistical heterogeneity was low as evaluated by an I² value less than 50%. Main results Of 157 records reviewed, 16 were included, representing five trials. In general, the studies were small and had inconsistent methodological rigor. Overall, the quality of evidence was rated as low. Each study used a different MOIT protocol. A total of 196 patients were studied (106 MOIT, 90 control) and all were children. Three studies were blinded and two used an avoidance diet control. Sixty‐six patients (62%) in the MOIT group were able to tolerate a full serving of milk (about 200 mL) compared to seven (8%) of the control group (RR 6.61, 95% CI 3.51 to 12.44). In addition, 27 (25%) in the MOIT group could ingest a partial serving of milk (10 to 184 mL) while none could in the control group (RR 9.34, 95% CI 2.72 to 32.09). None of the studies assessed the patients following a period off immunotherapy. Adverse reactions were common (97 of 106 MOIT patients had at least one symptom), although most were local and mild. Because of variability in reporting methods, adverse effects could not be combined quantitatively. For every 11 patients receiving MOIT, one required intramuscular epinephrine. One patient required it on two occasions. Authors' conclusions Studies to date have involved small numbers of patients and the quality of evidence is generally low. The current evidence shows that MOIT can lead to desensitization in the majority of individuals with IMCMA although the development of long‐term tolerance has not been established. A major drawback of MOIT is the frequency of adverse effects, although most are mild and self‐limited. The use of parenteral epinephrine is not infrequent. Because there are no standardized protocols, guidelines would be required prior to incorporating desensitization into clinical practice. Plain language summary Repetitive, increasing doses of daily milk for treatment of milk allergy To date, the only option to treat food allergy is strict avoidance of the food and carrying an epinephrine injector (Epipen/Twinject) in case of an allergic reaction. For a food like cow's milk, avoidance is very difficult because it is found in many foods. The constant fear of accidentally eating or drinking cow's milk and anxiety related to carrying an injector has negative effects on quality of life. Accidentally having milk can cause life‐threatening reactions. Oral immunotherapy involves initially taking a very small amount of the allergen, in the case of milk allergy, cow's milk, and slowly increasing the amount each day until a full serving is reached. This may change the way the body's immune system sees the allergen, thereby increasing the amount of milk that can be eaten or drunk with no reaction. We identified randomized controlled trials that compared oral immunotherapy to placebo or continued avoidance diet in children and adults with cow's milk allergy. Five studies satisfied our inclusion criteria. In total there were 196 participants (106 in the treatment group and 90 in the control), all of whom were children. In general, the quality of the studies was low. Because the trials involved small numbers and there were problems with the way they were done, further research is needed. The current evidence shows that oral immunotherapy can help a majority of allergic children tolerate a full serving of milk, as long as they continue drinking this amount each day. However, it is not known if this protection is continued if the immunotherapy is stopped for some time. Side effects during oral immunotherapy are frequent and most patients will have at least some mild symptoms. In the studies we included, for every 11 patients who received oral immunotherapy, one needed to be treated with epinephrine injection at some point for a serious allergic reaction to the therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Yeung, JP, Kloda, LA, McDevitt, J, Ben‐Shoshan, M, Alizadehfar, R", "articleTypes": [], "doi": "10.1002/14651858.CD009542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.774Z" }, { "id": "58b0a3c0-0655-42dc-ac61-d714dce37b4b", "pmid": "", "title": "Pharmacological interventions for preventing dry mouth and salivary gland dysfunction following radiotherapy", "imported": false, "abstract": "Abstract - Background Salivary gland dysfunction is an 'umbrella' term for the presence of either xerostomia (subjective sensation of dryness), or salivary gland hypofunction (reduction in saliva production). It is a predictable side effect of radiotherapy to the head and neck region, and is associated with a significant impairment of quality of life. A wide range of pharmacological interventions, with varying mechanisms of action, have been used for the prevention of radiation‐induced salivary gland dysfunction. Objectives To assess the effects of pharmacological interventions for the prevention of radiation‐induced salivary gland dysfunction. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 14 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 14 September 2016); MEDLINE Ovid (1946 to 14 September 2016); Embase Ovid (1980 to 14 September 2016); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 14 September 2016); LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 14 September 2016); Zetoc Conference Proceedings (1993 to 14 September 2016); and OpenGrey (1997 to 14 September 2016). We searched the US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials, irrespective of their language of publication or publication status. Trials included participants of all ages, ethnic origin and gender, scheduled to receive radiotherapy on its own or in addition to chemotherapy to the head and neck region. Participants could be outpatients or inpatients. We included trials comparing any pharmacological agent regimen, prescribed prophylactically for salivary gland dysfunction prior to or during radiotherapy, with placebo, no intervention or an alternative pharmacological intervention. Comparisons of radiation techniques were excluded. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 39 studies that randomised 3520 participants; the number of participants analysed varied by outcome and time point. The studies were ordered into 14 separate comparisons with meta‐analysis only being possible in three of those. We found low‐quality evidence to show that amifostine, when compared to a placebo or no treatment control, might reduce the risk of moderate to severe xerostomia (grade 2 or higher on a 0 to 4 scale) at the end of radiotherapy (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.19 to 0.67; P = 0.001, 3 studies, 119 participants), and up to three months after radiotherapy (RR 0.66, 95% CI 0.48 to 0.92; P = 0.01, 5 studies, 687 participants), but there is insufficient evidence that the effect is sustained up to 12 months after radiotherapy (RR 0.70, 95% CI 0.40 to 1.23; P = 0.21, 7 studies, 682 participants). We found very low‐quality evidence that amifostine increased unstimulated salivary flow rate up to 12 months after radiotherapy, both in terms of mg of saliva per 5 minutes (mean difference (MD) 0.32, 95% CI 0.09 to 0.55; P = 0.006, 1 study, 27 participants), and incidence of producing greater than 0.1 g of saliva over 5 minutes (RR 1.45, 95% CI 1.13 to 1.86; P = 0.004, 1 study, 175 participants). However, there was insufficient evidence to show a difference when looking at stimulated salivary flow rates. There was insufficient (very low‐quality) evidence to show that amifostine compromised the effects of cancer treatment when looking at survival measures. There was some very low‐quality evidence of a small benefit for amifostine in terms of quality of life (10‐point scale) at 12 months after radiotherapy (MD 0.70, 95% CI 0.20 to 1.20; P = 0.006, 1 study, 180 participants), but insufficient evidence at the end of and up to three months postradiotherapy. A further study showed no evidence of a difference at 6, 12, 18 and 24 months postradiotherapy. There was low‐quality evidence that amifostine is associated with increases in: vomiting (RR 4.90, 95% CI 2.87 to 8.38; P < 0.00001, 5 studies, 601 participants); hypotension (RR 9.20, 95% CI 2.84 to 29.83; P = 0.0002, 3 studies, 376 participants); nausea (RR 2.60, 95% CI 1.81 to 3.74; P < 0.00001, 4 studies, 556 participants); and allergic response (RR 7.51, 95% CI 1.40 to 40.39; P = 0.02, 3 studies, 524 participants). We found insufficient evidence (that was of very low quality) to determine whether or not pilocarpine performed better or worse than a placebo or no treatment control for the outcomes: xerostomia, salivary flow rate, survival, and quality of life. There was some low‐quality evidence that pilocarpine was associated with an increase in sweating (RR 2.98, 95% CI 1.43 to 6.22; P = 0.004, 5 studies, 389 participants). We found insufficient evidence to determine whether or not palifermin performed better or worse than placebo for: xerostomia (low quality); survival (moderate quality); and any adverse effects. There was also insufficient evidence to determine the effects of the following interventions: biperiden plus pilocarpine, Chinese medicines, bethanechol, artificial saliva, selenium, antiseptic mouthrinse, antimicrobial lozenge, polaprezinc, azulene rinse, and Venalot Depot (coumarin plus troxerutin). Authors' conclusions There is some low‐quality evidence to suggest that amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months postradiotherapy). However, it is less clear whether or not this effect is sustained to 12 months postradiotherapy. The benefits of amifostine should be weighed against its high cost and side effects. There was insufficient evidence to show that any other intervention is beneficial. Plain language summary Drugs for preventing dry mouth and problems with saliva after radiotherapy Review question To assess the effects of treatment with drugs in order to prevent damage to salivary glands following radiotherapy to the head and neck Background Problems with saliva production and salivary glands are a significant and mostly permanent side effect for people after radiotherapy treatment to the head and neck. When this occurs the condition is known as dry mouth or xerostomia. Dry mouth is not measurable and is a subjective or personal expression of how the mouth feels. It can have other causes and is a consequence of the production of less saliva or by the consistency of saliva. The rate of flow of saliva in an individual's mouth however can be measured. People who have dry mouth have a reduced quality of life. They can experience issues with taste and general discomfort, difficulties chewing, swallowing and speaking as well as tooth decay, thrush and other infections of the mouth. A wide range of drugs that work in different ways have been used to try and prevent problems with salivary glands caused by radiotherapy. Unfortunately there is currently not enough evidence to show which drugs or which type of drugs are most effective. Study characteristics The evidence in this review is current up to 14 September 2016. 39 studies were included with a total of 3520 participants. Participants were male and female, all ages and ethnic origins, out patients or in patients, who were scheduled to have radiation therapy with or without chemotherapy to the head and neck. Drugs included were any prescribed to prevent salivary gland problems and given before or during radiotherapy. Information was collected from the end of radiotherapy except for that about adverse effects. Different techniques for giving radiation treatment that might reduce damage were not included. The main outcomes measured were participant's own assessment of dry mouth and the measurement of salivary flow. Secondary outcomes measured included adverse or unwanted effects such as sweating, crying, watery discharge from the nose, diarrhoea and nausea. Key results There is some low‐quality evidence to suggest that the drug amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months after radiotherapy). However it is less clear whether or not this effect is sustained to 12 months after radiotherapy. The benefits of amifostine should be weighed against its high costs and side effects. Adverse effects of vomiting, low blood pressure, feeling of sickness and allergic response were all more frequent in those receiving amifostine. There was insufficient evidence to show that any other treatment is beneficial. Quality of the evidence The quality of evidence for amifostine was found to be low because of risk of bias, inconsistency and imprecision caused by the small number of studies in the comparison or sample size. A standardized scale for measuring participant's experience of dry mouth would in future allow comparison and pooling together of results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P; Glenny, AM; Hua, F; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD012744", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "58b6d760-0c48-4de6-ae66-7c38ed7ca613", "pmid": "", "title": "The Role of the Endocannabinoid System in Sweet Taste Intensity and Liking", "imported": false, "abstract": "The endocannabinoid (eCB) system, a neurochemical signalling system consisting of CB-receptors and their endogenous ligands, has been found to be involved in food intake of sweet and palatable foods. Activation of the eCB system increases food intake and vice versa. The mechanism behind this effect is still unknown and the current study aims at clarifying why sweet food intake increases. It is hypothesized that sweet taste intensity increases and that sweet taste is experienced as more pleasant.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "58c78fbd-e0d3-4154-9724-fb3ba5912c17", "pmid": "", "title": "Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment", "imported": false, "abstract": "Abstract - Background Early dental decay or demineralised lesions (DLs, also known as white spot lesions) can appear on teeth during fixed orthodontic (brace) treatment. Fluoride reduces decay in susceptible individuals, including orthodontic patients. This review compared various forms of topical fluoride to prevent the development of DLs during orthodontic treatment. This is the second update of the Cochrane Review first published in 2004 and previously updated in 2013. Objectives The primary objective was to evaluate whether topical fluoride reduces the proportion of orthodontic patients with new DLs after fixed appliances. The secondary objectives were to examine the effectiveness of different modes of topical fluoride delivery in reducing the proportions of orthodontic patients with new DLs, as well as the severity of lesions, in terms of number, size and colour. Participant‐assessed outcomes, such as perception of DLs, and oral health‐related quality of life data were to be included, as would reports of adverse effects. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 1 February 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library (searched 1 February 2019), MEDLINE Ovid (1946 to 1 February 2019), and Embase Ovid (1980 to 1 February 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Parallel‐group, randomised controlled trials comparing the use of a fluoride‐containing product versus a placebo, no treatment or a different type of fluoride treatment, in which the outcome of enamel demineralisation was assessed at the start and at the end of orthodontic treatment. Data collection and analysis At least two review authors independently, in duplicate, conducted risk of bias assessments and extracted data. Authors of trials were contacted to obtain missing data or to ask for clarification of aspects of trial methodology. Cochrane's statistical guidelines were followed. Main results This update includes 10 studies and contains data from nine studies, comparing eight interventions, involving 1798 randomised participants (1580 analysed). One report contained insufficient information and the authors have been contacted. We assessed two studies as at low risk of bias, six at unclear risk of bias, and two at high risk of bias. Two placebo (non‐fluoride) controlled studies, at low risk of bias, investigated the professional application of varnish (7700 or 10,000 parts per million (ppm) fluoride (F)), every six weeks and found insufficient evidence of a difference regarding its effectiveness in preventing new DLs (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.14 to 1.93; 405 participants; low‐certainty evidence). One placebo (non‐fluoride) controlled study, at unclear risk of bias, provides a low level of certainty that fluoride foam (12,300 ppm F), professionally applied every two months, may reduce the incidence of new DLs (12% versus 49%) after fixed orthodontic treatment (RR 0.26, 95% CI 0.11 to 0.57; 95 participants). One study, at unclear risk of bias, also provides a low level of certainty that use of a high‐concentration fluoride toothpaste (5000 ppm F) by patients may reduce the incidence of new DLs (18% versus 27%) compared with a conventional fluoride toothpaste (1450 ppm F) (RR 0.68, 95% CI 0.46 to 1.00; 380 participants). There was no evidence for a difference in the proportions of orthodontic patients with new DLs on the teeth after treatment with fixed orthodontic appliances for the following comparisons:
 ‐ an amine fluoride and stannous fluoride toothpaste/mouthrinse combination versus a sodium fluoride toothpaste/mouthrinse,
 ‐ an amine fluoride gel versus a non‐fluoride placebo applied by participants at home once a week and by professional application every three months,
 ‐ resin‐modified glass ionomer cement versus light‐cured composite resin for bonding orthodontic brackets,
 ‐ a 250 ppm F mouthrinse versus 0 ppm F placebo mouthrinse,
 ‐ the use of an intraoral fluoride‐releasing glass bead device attached to the brace versus a daily fluoride mouthrinse. The last two comparisons involved studies that were assessed at high risk of bias, because a substantial number of participants were lost to follow‐up. Unfortunately, although the internal validity and hence the quality of the studies has improved since the first version of the review, they have compared different interventions; therefore, the findings are only considered to provide low level of certainty, because none has been replicated by follow‐up studies, in different settings, to confirm external validity. A patient‐reported outcome, such as concern about the aesthetics of any DLs, was still not included as an outcome in any study. Reports of adverse effects from topical fluoride applications were rare and unlikely to be significant. One study involving fluoride‐containing glass beads reported numerous breakages. Authors' conclusions This review found a low level of certainty that 12,300 ppm F foam applied by a professional every 6 to 8 weeks throughout fixed orthodontic treatment, might be effective in reducing the proportion of orthodontic patients with new DLs. In addition, there is a low level of certainty that the patient use of a high fluoride toothpaste (5000 ppm F) throughout orthodontic treatment, might be more effective than a conventional fluoride toothpaste. These two comparisons were based on single studies. There was insufficient evidence of a difference regarding the professional application of fluoride varnish (7700 or 10,000 ppm F). Further adequately powered, randomised controlled trials are required to increase the certainty of these findings and to determine the best means of preventing DLs in patients undergoing fixed orthodontic treatment. The most accurate means of assessing adherence with the use of fluoride products by patients and any possible adverse effects also need to be considered. Future studies should follow up participants beyond the end of orthodontic treatment to determine the effect of DLs on patient satisfaction with treatment. Plain language summary Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment Review question 
 Ugly white or brown marks sometimes appear on the teeth during treatment with braces to straighten teeth. These are due to early tooth decay and usually occur with fixed, glued‐on 'train track', braces, which make it more difficult to clean the teeth. We know that fluoride in toothpaste helps to prevent tooth decay and think that if extra fluoride is given to people wearing fixed braces, it will protect them from getting these marks. The aim of this Cochrane Oral Health's review was to look at how well fluorides help to prevent early tooth decay during fixed brace treatment and to find out the best way to get fluoride to the teeth. Background 
 Wearing a fixed brace makes it harder for people to keep their teeth clean and may also cause pain. Pain can make it more difficult for people to brush their teeth. This can lead to a build‐up of dental plaque around the brackets that attach the fixed brace to the teeth, and if the plaque stays on the tooth for long enough, it will cause early tooth decay, which looks like white or brown marks (demineralised lesions, also known as white spot lesions). People often wear braces for 18 months or longer and if the decay is left to progress, it can cause holes, which are sometimes bad enough to need fillings to be done in the teeth. Fluoride helps the tooth to heal, reducing tooth decay in people who are at risk of developing it. People receiving fixed brace treatment may be given different forms of fluoride treatment. It is important to think about how the fluoride gets to the teeth. Does the fluoride need to be placed by a dentist or dental nurse, or can people having treatment with braces apply the fluoride to their own teeth? Study characteristics 
 This review is up‐to‐date as of 1 February 2019. The review includes 10 studies but we could only use the information from nine studies involving 1798 randomised people. We have asked for more information about one study. The review looks at eight different ways of applying fluoride to the teeth. People taking part in the studies were all having treatment with fixed braces. The number of people with new decay on the teeth at end of fixed brace treatment, as well as the amount of decay in each person, were measured and counted. We compared the following treatments:
 ‐ dentist or nurse‐applied fluoride e.g. varnish, gel or foam,
 ‐ patient‐applied/used fluoride e.g. toothpaste, mouthwash, gel or foam, and
 ‐ materials that release fluoride over time e.g. glues, elastic bands. Key results 
 One study showed that when the dentist applies a foam with a high level of fluoride in it onto the teeth every time the patient is seen, this might reduce the risk of new decay. Another study found that if patients use a toothpaste with a higher level of fluoride than normal, then this might also reduce the risk of new marks on their teeth. No studies have shown that other ways of giving the teeth extra fluoride reduced the number and/or size of new decay on teeth in people wearing fixed braces. Harmful effects of the different ways of giving the teeth more fluoride were not reported in any of the included studies. Certainty of the evidence 
 The level of belief we have in these findings is low, due to the lack of studies testing the same fluorides and showing the same results. We suggest that more, well‐conducted studies should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Benson, PE; Parkin, N; Dyer, F; Millett, DT; Germain, P", "articleTypes": [], "doi": "10.1002/14651858.CD003809.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "58d473b3-6f55-4a72-9313-a64c4d8d116e", "pmid": "", "title": "Needle size for vaccination procedures in children and adolescents", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane Review first published in 2015. The conclusions have not changed. Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller the diameter of the needle (e.g. a 23 G needle is 0.6 mm in diameter, whereas a 25 G needle is 0.5 mm in diameter). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. Guidelines conflict regarding the sizes of needles that should be used for vaccinating children and adolescents. Objectives To assess the effects of using needles of different sizes for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration). Search methods We updated our searches of CENTRAL, MEDLINE, Embase, and CINAHL to October 2017. We also searched proceedings of vaccine conferences and two trials registers. Selection criteria Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years. Data collection and analysis Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system. Main results We included five trials involving 1350 participants in the original review. The updated review identified no new trials. The evidence from two small trials (one trial including infants and one including adolescents) was insufficient to allow any definitive statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity. The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials included infants predominantly aged from two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole‐cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP‐Hib) and hepatitis B (DTwP‐Hib‐Hep B) antigen components. Primary outcomes Incidence of vaccine‐preventable diseases: No trials reported this outcome. Procedural pain and crying: Using a wider gauge 23 G 25 mm needle may slightly reduce procedural pain (low‐quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate‐quality evidence) compared with a narrower gauge 25 G 25 mm needle (one trial, 320 participants). The effects are probably not large enough to be clinically relevant. Secondary outcomes Immune response: There is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between use of 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP‐Hib vaccine at ages two, three, and four months (moderate‐quality evidence, one trial, numbers of participants in analyses range from 309 to 402. The immune response to the pertussis antigen was not measured). Severe and non‐severe local reactions: 25 mm needles (either 25 G or 23 G) probably lead to fewer severe and non‐severe local reactions after DTwP‐Hib vaccination compared with 25 G 16 mm needles (moderate‐quality evidence, one trial, 447 to 458 participants in analyses). We estimate that one fewer infant will experience a severe local reaction (extensive redness and swelling) after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat for an additional beneficial outcome (NNTB) with a 25 G 25 mm needle: 25 (95% confidence interval (CI) 15 to 100); NNTB with a 23 G 25 mm needle: 25 (95% CI 17 to 100)). We estimate that one fewer infant will experience a non‐severe local reaction (any redness, swelling, tenderness, or hardness (composite outcome)) at 24 hours after the first vaccine dose for every 5 or 6 infants vaccinated with a 25 mm rather than a 16 mm needle (NNTB with a 25 G 25 mm needle: 5 (95% CI 4 to 10); NNTB with a 23 G 25 mm needle: 6 (95% CI 4 to 13)). The results are similar after the second and third vaccine doses. Using a narrow gauge 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with a wider gauge 23 G 25 mm needle, but the effect estimates are imprecise (low‐quality evidence, two trials, 100 to 459 participants in analyses). Systemic reactions: The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of postvaccination fever and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence. Authors' conclusions Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole‐cell pertussis antigen component. These vaccines are predominantly used in low‐ and middle‐income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain. Plain language summary Needle size for vaccination procedures in children and adolescents Background Vaccines contain antigens that make the body's immune system produce antibodies that can protect against disease, which is known as an immune response. Antigens are modified or partial forms of the virus, bacteria, or toxin that cause the disease that the vaccine protects against. Because the antigen is altered from its original form, it cannot cause disease, but it can produce an immune response. Vaccines can be injected using needles of different lengths and gauges. The needle gauge (G) refers to the width (diameter) of the needle. The higher the gauge number, the narrower the needle. For example, a 25 G needle is approximately 0.5 mm in diameter and is narrower than a 23 G needle, which has a diameter of 0.6 mm. Guidelines conflict regarding the lengths and gauges of needles that should be used for vaccinating children and adolescents. Review question We wanted to find out if the length and gauge of needles used to vaccinate children and adolescents has an influence on the: 1) immune response to the injected vaccine; 2) pain experienced during the vaccination procedure; 3) occurrence of reactions such as swelling, tenderness, and redness at the site where the vaccine is given; fever (high temperature); and other side effects that can occur after vaccination. Quality of the evidence We included five studies involving 1350 people. We rated the quality of the evidence from studies as very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. There were problems with the design of some studies, and data were insufficient to answer some parts of our review question. The quality of the evidence from two studies was too low to allow us to draw any conclusions about the effects of the needles compared in the studies. However, there was sufficient evidence from the remaining three studies to allow us to reach conclusions. Study characteristics The three studies that allowed us to reach conclusions involved 1135 healthy infants aged mostly between two and six months. The infants were vaccinated in the thigh with either 25 G 25 mm (narrow, long needles), 23 G 25 mm (wide, long needles), or 25 G 16 mm needles (narrow, short needles). The needles were inserted at right angles (90° angle) into the skin and pushed down into the muscle of the thigh. The vaccines injected were combination vaccines designed to protect against several diseases including diphtheria (D), tetanus (T), whooping cough (pertussis), and Haemophilus influenzae type b disease (Hib). The vaccines all contained whole‐cell pertussis (wP) vaccine antigens. These vaccines are commonly used in low‐ and middle‐income countries but not in high‐income countries. Our review findings are therefore most relevant to low‐ and middle‐income countries. Key findings We found moderate‐quality evidence that infants vaccinated in the thigh with 25 mm needles probably have fewer severe reactions (extensive redness and swelling in the thigh) after DTwP‐Hib vaccination than infants vaccinated with 16 mm needles. We also found that the longer needles probably lead to fewer non‐severe reactions such as mild swelling, tenderness, and redness after vaccination. The immune response to the vaccine is probably similar with the long and the short needles. We found low‐quality evidence that the wide, long needle may slightly reduce the pain of the vaccination procedure compared with the narrow, long needle. We found moderate‐quality evidence that the wide, long needle probably slightly reduces the duration of crying immediately following vaccination compared with the narrow, long needle. The differences in pain and crying between use of the wide and narrow needles are probably too small to be of any practical importance. We found low‐quality evidence that infants vaccinated with the narrow, long needle may have slightly fewer non‐severe reactions than infants vaccinated with the wide, long needle. We do not know if needle size has an effect on fever or other reactions that sometimes occur after vaccination including drowsiness, loss of appetite, and vomiting due to the very low quality of the evidence. The evidence in our review is current to October 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Beirne, PV; Hennessy, S; Cadogan, SL; Shiely, F; Fitzgerald, T; MacLeod, F", "articleTypes": [], "doi": "10.1002/14651858.CD010720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "58f2c9db-6d9f-4075-acff-16bb76b7f4f2", "pmid": "", "title": "Hyperimmune immunoglobulin for people with COVID‐19", "imported": false, "abstract": "Abstract - Background Hyperimmune immunoglobulin (hIVIG) contains polyclonal antibodies, which can be prepared from large amounts of pooled convalescent plasma or prepared from animal sources through immunisation. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). This review was previously part of a parent review addressing convalescent plasma and hIVIG for people with COVID‐19 and was split to address hIVIG and convalescent plasma separately. Objectives To assess the benefits and harms of hIVIG therapy for the treatment of people with COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods To identify completed and ongoing studies, we searched the World Health Organization (WHO) COVID‐19 Research Database, the Cochrane COVID‐19 Study Register, the Epistemonikos COVID‐19 L*OVE Platform and Medline and Embase from 1 January 2019 onwards. We carried out searches on 31 March 2022. Selection criteria We included randomised controlled trials (RCTs) that evaluated hIVIG for COVID‐19, irrespective of disease severity, age, gender or ethnicity. We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)), as well as studies that evaluated standard immunoglobulin. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used RoB 2. We rated the certainty of evidence, using the GRADE approach, for the following outcomes: all‐cause mortality, improvement and worsening of clinical status (for individuals with moderate to severe disease), quality of life, adverse events, and serious adverse events. Main results We included five RCTs with 947 participants, of whom 688 received hIVIG prepared from humans, 18 received heterologous swine glyco‐humanised polyclonal antibody, and 241 received equine‐derived processed and purified F(ab’) 2 fragments. All participants were hospitalised with moderate‐to‐severe disease, most participants were not vaccinated (only 12 participants were vaccinated). The studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with mild COVID‐19. We identified a further 10 ongoing studies evaluating hIVIG. Benefits of hIVIG prepared from humans We included data on one RCT (579 participants) that assessed the benefits and harms of hIVIG 0.4 g/kg compared to saline placebo. hIVIG may have little to no impact on all‐cause mortality at 28 days (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.43 to 1.44; absolute effect 77 per 1000 with placebo versus 61 per 1000 (33 to 111) with hIVIG; low‐certainty evidence). The evidence is very uncertain about the effect on worsening of clinical status at day 7 (RR 0.85, 95% CI 0.58 to 1.23; very low‐certainty evidence). It probably has little to no impact on improvement of clinical status on day 28 (RR 1.02, 95% CI 0.97 to 1.08; moderate‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if hIVIG has any impact on quality of life. Harms of hIVIG prepared from humans hIVIG may have little to no impact on adverse events at any grade on day 1 (RR 0.98, 95% CI 0.81 to 1.18; 431 per 1000; 1 study 579 participants; low‐certainty evidence). Patients receiving hIVIG probably experience more adverse events at grade 3‐4 severity than patients who receive placebo (RR 4.09, 95% CI 1.39 to 12.01; moderate‐certainty evidence). hIVIG may have little to no impact on the composite outcome of serious adverse events or death up to day 28 (RR 0.72, 95% CI 0.45 to 1.14; moderate‐certainty evidence). We also identified additional results on the benefits and harms of other dose ranges of hIVIG, not included in the summary of findings table, but summarised in additional tables. Benefits of animal‐derived polyclonal antibodies We included data on one RCT (241 participants) to assess the benefits and harms of receptor‐binding domain‐specific polyclonal F(ab´) 2 fragments of equine antibodies (EpAbs) compared to saline placebo. EpAbs may reduce all‐cause mortality at 28 days (RR 0.60, 95% CI 0.26 to 1.37; absolute effect 114 per 1000 with placebo versus 68 per 1000 (30 to 156) ; low‐certainty evidence). EpAbs may reduce worsening of clinical status up to day 28 (RR 0.67, 95% CI 0.38 to 1.18; absolute effect 203 per 1000 with placebo versus 136 per 1000 (77 to 240); low‐certainty evidence). It may have some effect on improvement of clinical status on day 28 (RR 1.06, 95% CI 0.96 to 1.17; low‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if EpAbs have any impact on quality of life. Harms of animal‐derived polyclonal antibodies EpAbs may have little to no impact on the number of adverse events at any grade up to 28 days (RR 0.99, 95% CI 0.74 to 1.31; low‐certainty evidence). Adverse events at grade 3‐4 severity were not reported. Individuals receiving EpAbs may experience fewer serious adverse events than patients receiving placebo (RR 0.67, 95% CI 0.38 to 1.19; low‐certainty evidence). We also identified additional results on the benefits and harms of other animal‐derived polyclonal antibody doses, not included in the summary of findings table, but summarised in additional tables. Authors' conclusions We included data from five RCTs that evaluated hIVIG compared to standard therapy, with participants with moderate‐to‐severe disease. As the studies evaluated different preparations (from humans or from various animals) and doses, we could not pool them. hIVIG prepared from humans may have little to no impact on mortality, and clinical improvement and worsening. hIVIG may increase grade 3‐4 adverse events. Studies did not evaluate quality of life. RBD‐specific polyclonal F(ab´) 2 fragments of equine antibodies may reduce mortality and serious adverse events, and may reduce clinical worsening. However, the studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern and prior to widespread vaccine rollout. As no studies evaluated hIVIG for participants with asymptomatic infection or mild disease, benefits for these individuals remains uncertain. This is a living systematic review. We search monthly for new evidence and update the review when we identify relevant new evidence. Plain language summary Are concentrated antibodies from people who have recovered from COVID‐19 or animals an effective treatment for people with COVID‐19? Key messages • We do not know whether hyperimmune immunoglobulin (a preparation made with antibodies from people who have recovered from COVID‐19) reduces deaths or serious unwanted effects in people with moderate to severe COVID‐19. But a similar preparation made by injecting animals with certain antibodies may reduce deaths, and serious unwanted effects and may stop people’s condition getting worse. • We found no studies that investigated people with COVID‐19 but without symptoms or people with mild COVID‐19, so we do not know how effective human or animal hyperimmune immunoglobulin is for them. • We found 10 ongoing studies. We will update this review when their results become available. What is hyperimmune immunoglobulin? The body produces antibodies as one of its defences against infection. Antibodies, or 'immunoglobulins', are found in blood plasma. They act as a critical part of the immune response. Plasma from people who have recovered from COVID‐19 contains COVID‐19 antibodies, and can be used to make two preparations. Firstly, it can be used to make convalescent plasma, which is plasma that contains these antibodies. Secondly, it can be used to make hyperimmune immunoglobulin, which is more concentrated, and therefore contains more antibodies. The manufacturing process of hyperimmune immunoglobulin is complex and requires large pools of human plasma. Similar antibodies can be made from animal sources and used in humans. Why is hyperimmune immunoglobulin a possible treatment for COVID‐19? Hyperimmune immunoglobulin products contain high levels of antibodies that target SARS‐CoV‐2, the virus that causes COVID‐19. The products are thought to inactivate the virus particles. What did we want to find out? We wanted to know if hyperimmune immunoglobulin is an effective and helpful treatment for people with suspected or confirmed COVID‐19 in any setting (for example, home or hospital). We were interested in: • death from any cause up 30 days after treatment, 60 days, or longer if reported; • improvement or worsening of symptoms; • quality of life; • unwanted effects. What did we do? We searched for studies that investigated hyperimmune immunoglobulin and usual care compared to usual care only, or in addition to a dummy medicine that did not contain any active ingredients (placebo). To make a fair comparison, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the hyperimmune immunoglobulin or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies. We used a standardised method to rate our confidence in the evidence. The confidence is based on study features such as how it was designed and the number of people in them. What did we find? We found five studies with 957 people. Studies took place in Pakistan, India, France, and Argentina, and one study was conducted in multiple countries, including Denmark, Greece, Japan, Nigeria, Spain, the UK and the USA. The studies took place before or during the emergence of several new COVID‐19 variants and prior to widespread vaccine rollout. All the participants in four studies were unvaccinated. In one study, 12 from 579 participants were vaccinated. We also found 10 ongoing studies. Main results All studies compared hyperimmune immunoglobulin from human or animal sources with usual care or placebo. The studies included only hospitalised people with moderate to severe disease. No studies looked at people without COVID‐19 symptoms or mild COVID‐19. No studies reported on quality of life. We are uncertain whether or not hyperimmune immunoglobulin prepared from humans affects risk of death from any cause up to 28 days after treatment. It may have little to no impact on improvement or worsening of symptoms up to 28 days after treatment. We are uncertain about a possible difference in unwanted or serious unwanted effects. The individual studies decided which events to classify as serious unwanted effects, but this usually means something that may cause hospitalisation or permanent harm. Hyperimmune immunoglobulin from animals may reduce deaths up to 28 days after treatment, may reduce worsening of symptoms, may improve patients' condition and may reduce serious unwanted events. What are the limitations of the evidence? We are uncertain whether hyperimmune immunoglobulin is an effective treatment for people hospitalised with COVID‐19, and whether it affects the number of unwanted or serious unwanted effects because the studies were small and did not all provide evidence on all our points of interest. The studies were conducted predominantly in people from wealthy countries, before the widespread rollout of COVID‐19 vaccines and the emergence of the omicron variant, so the results may not apply to people with omicron variant infection, or people who were vaccinated before falling ill. There was no evidence for people without symptoms or with mild COVID‐19. How up to date is this evidence? Our evidence is up‐to‐date to 31st March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kimber, C; Valk, SJ; Chai, KL; Piechotta, V; Iannizzi, C; Monsef, I; Wood, EM; Lamikanra, AA; Roberts, DJ; McQuilten, Z; So-Osman, C; Estcourt, LJ; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015167.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "58fe3908-1546-48be-a83a-2566700a91e2", "pmid": "", "title": "Chelation therapy for atherosclerotic cardiovascular disease", "imported": false, "abstract": "Abstract - Background Chelation therapy is promoted and practiced around the world as a form of alternative medicine in the treatment of atherosclerotic cardiovascular disease. It has been suggested as a safe, relatively inexpensive, non‐surgical method of restoring blood flow in atherosclerotic vessels. However, there is currently limited high‐quality, adequately‐powered research informing evidence‐based medicine on the topic, specifically regarding clinical outcomes. Due to this limited evidence, the benefit of chelation therapy remains controversial at present. This is an update of a review first published in 2002. Objectives To assess the effects of ethylene diamine tetra‐acetic acid (EDTA) chelation therapy versus placebo or no treatment on clinical outcomes among people with atherosclerotic cardiovascular disease. Search methods For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 6 August 2019. We searched the bibliographies of the studies retrieved by the literature searches for further trials. Selection criteria We included studies if they were randomised controlled trials of EDTA chelation therapy versus placebo or no treatment in participants with atherosclerotic cardiovascular disease. The main outcome measures we considered include all‐cause or cause‐specific mortality, non‐fatal cardiovascular events, direct or indirect measurement of disease severity, and subjective measures of improvement or adverse events. Data collection and analysis Two review authors independently extracted data and assessed trial quality using standard Cochrane procedures. A third author considered any unresolved issues, and we discussed any discrepancies until a consensus was reached. We contacted study authors for additional information. Main results We included five studies with a total of 1993 randomised participants. Three studies enrolled participants with peripheral vascular disease and two studies included participants with coronary artery disease, one of which specifically recruited people who had had a myocardial infarction. The number of participants in each study varied widely (from 10 to 1708 participants), but all studies compared EDTA chelation to a placebo. Risk of bias for the included studies was generally moderate to low, but one study had high risk of bias because the study investigators broke their randomisation code halfway through the study and rolled the placebo participants over to active treatment. Certainty of the evidence, as assessed by GRADE, was generally low to very low, which was mostly due to a paucity of data in each outcome's meta‐analysis. This limited our ability to draw any strong conclusions. We also had concerns about one study's risk of bias regarding blinding and outcome assessment that may have biased the results. Two studies with coronary artery disease participants reported no evidence of a difference in all‐cause mortality between chelation therapy and placebo (risk ratio (RR) 0.97, 95% CI 0.73 to 1.28; 1792 participants; low‐certainty). One study with coronary artery disease participants reported no evidence of a difference in coronary heart disease deaths between chelation therapy and placebo (RR 1.02, 95% CI 0.70 to 1.48; 1708 participants; very low‐certainty). Two studies with coronary artery disease participants reported no evidence of a difference in myocardial infarction (RR 0.81, 95% CI 0.57 to 1.14; 1792 participants; moderate‐certainty), angina (RR 0.95, 95% CI 0.55 to 1.67; 1792 participants; very low‐certainty), and coronary revascularisation (RR 0.46, 95% CI 0.07 to 3.25; 1792 participants). Two studies (one with coronary artery disease participants and one with peripheral vascular disease participants) reported no evidence of a difference in stroke (RR 0.88, 95% CI 0.40 to 1.92; 1867 participants; low‐certainty). Ankle‐brachial pressure index (ABPI; also known as ankle brachial index) was measured in three studies, all including participants with peripheral vascular disease; two studies found no evidence of a difference in the treatment groups after three months after treatment (mean difference (MD) 0.02, 95% CI ‐0.03 to 0.06; 181 participants; low‐certainty). A third study reported an improvement in ABPI in the EDTA chelation group, but this study was at high risk of bias. Meta‐analysis of maximum and pain‐free walking distances three months after treatment included participants with peripheral vascular disease and showed no evidence of a difference between the treatment groups (MD ‐31.46, 95% CI ‐87.63 to 24.71; 165 participants; 2 studies; low‐certainty). Quality of life outcomes were reported by two studies that included participants with coronary artery disease, but we were unable to pool the data due to different methods of reporting and varied criteria. However, there did not appear to be any major differences between the treatment groups. None of the included studies reported on vascular deaths. Overall, there was no evidence of major or minor adverse events associated with EDTA chelation treatment. Authors' conclusions There is currently insufficient evidence to determine the effectiveness or ineffectiveness of chelation therapy in improving clinical outcomes of people with atherosclerotic cardiovascular disease. More high‐quality, randomised controlled trials are needed that assess the effects of chelation therapy on longevity and quality of life among people with atherosclerotic cardiovascular disease. Plain language summary Chelation therapy for atherosclerotic cardiovascular (heart and circulation) disease Background Atherosclerosis is caused by fatty deposits that cause a narrowing of people's arteries and restrict blood flow. People with blocked arteries are more likely to have strokes, heart attacks, and narrow blood vessels in their feet. Chelation therapy involves infusions into the bloodstream of substances believed to remove metals from the blood. This treatment is offered to people with atherosclerotic cardiovascular disease as a way of breaking down the blockages in their blood vessels. Chelation therapy is practiced in several places around the world as an alternative form of medicine, but there is currently a lack of knowledge surrounding this treatment. More information is needed to understand if this treatment should be more widely recommended. Key results This review included evidence from five studies with a total of 1993 participants (current until August 2019). Three studies enrolled participants with peripheral vascular disease, and two of the studies included participants with coronary artery disease, one of which specifically recruited people who had had a heart attack. All five studies compared chelation therapy with no treatment or placebo. Only two of the studies (both of which included participants with coronary artery disease) reported death from any cause, and these reported no difference in overall deaths between those that received chelation therapy and those who did not. Ony one study (in people with coronary artery disease) reported cardiovascular death, and this study found no difference between in risk between those who had chelation therapy and those who did not. Two studies of people with coronary artery disease reported rates of heart attack and angina, and found no difference in the risk of these between participants who had chelation treatment and those who did not. Similarly, two studies (one in people with coronary artery disease and one in people with peripheral vascular disease) reported the chance of having a stroke, and found no clear difference in the chance of this between people who did or did not received chelation treatment. Two studies in people with peripheral vascular disease used an indirect measure of blood flow known as the ankle‐brachial pressure index (ABPI), or ankle brachial index. These studies did not show any differences in this measure between people who received chelation therapy for three or six months and those who did not get the treatment. There was also no clear differences in the distance participants could walk. We could not combine specific measures of quality of life in a single analysis. Looking at the two studies in people with coronary artery disease that reported this outcome, there was no difference in the quality of life reported by people who received chelation therapy and those who did not get the treatment. Two studies reported information about adverse events, but we could not combine this in a single analysis because they reported them in different ways and the events were different. However, the people who had chelation therapy did not appear to have any increase in either minor or major adverse events, compared with people who did not have the therapy. Certainty of the evidence We considered most of the data we found to be of low certainty, mostly because there were very few studies that provided data. Even though we included five studies, not all of them reported on each outcome. There is currently not enough evidence about the effects of chelation therapy on blockages in the blood vessels of people with atherosclerotic cardiovascular (heart and circulation) disease. Conclusions Overall, this review did not find any clear differences between people treated with chelation and people given the control, for the outcomes we evaluated. None of the outcomes included more than two studies, therefore it is difficult at this time to determine if these are true findings or just because there is not enough data. Further high‐quality trials that focus on clinical outcomes are necessary.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Villarruz-Sulit, MVanessa, Forster, R, Dans, AL, Tan, FN, Sulit, DV", "articleTypes": [], "doi": "10.1002/14651858.CD002785.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.089Z" }, { "id": "590a98d3-dae3-45e3-8e0c-562c8cac5d7e", "pmid": "", "title": "Interventions for the prevention of recurrent erysipelas and cellulitis", "imported": false, "abstract": "Abstract - Background Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. Objectives To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. Search methods We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. Selection criteria Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. Data collection and analysis Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. Main results We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study. Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow‐up period of up to one and a half to two years. Four studies were single‐centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria. Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate. Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate‐certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate‐certainty evidence). The protective effects of antibiotic did not last after prophylaxis had been stopped ('post‐prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty. Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years. We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay. The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin). None of the included studies assessed the development of antimicrobial resistance or quality‐of‐life measures. With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. Authors' conclusions In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate‐certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low‐certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low‐certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high‐quality studies are warranted, including long‐term follow‐up and other prophylactic measures. Plain language summary Preventive treatments for repeated episodes of cellulitis and erysipelas Background Cellulitis and erysipelas are both bacterial infections of the skin that most commonly affect the leg. Erysipelas affects the upper layers of the skin, and cellulitis affects its deeper parts, but in practice it is often hard to tell the difference between them, so we consider them together for this review (and refer to them as 'cellulitis'). Up to 50% of people with cellulitis experience repeated episodes. Despite the burden of this condition, there is a lack of high‐certainty, evidence‐based information about the desirable treatment for the prevention of recurrent cellulitis. Review question What are the best available treatments to prevent repeated episodes of cellulitis in adults aged over 16 years compared to no treatment, placebo, another intervention, or the same intervention with a different plan of treatment, and what are their side effects? Study characteristics We searched relevant databases and registers up to June 2016. We identified six trials, with 573 participants, who had an average age between 50 and 70. Both genders were included, but there were nearly twice as many women. Five trials used antibiotic treatment (four penicillin and one erythromycin), which was compared to either no treatment or placebo, and one trial used selenium compared to physiological salt solution. Treatments lasted from six to 18 months. The most common setting was the hospital, and two studies were multicentre. The studies were conducted in the UK, Sweden, Tunisia, Israel, and Austria. There was a small number of previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes in each study. The antibiotic trials assessed prevention with antibiotics in people with cellulitis of the legs, and the selenium trial assessed people with cellulitis of the arms. Key results Our main outcome was prevention of repeated episodes of cellulitis. Our other outcomes included the number of repeated attacks of cellulitis, time to next attack, hospitalisation, quality of life, development of antibiotic resistance, adverse reactions and death. Combining the results of all five trials that used antibiotics, we found moderate‐certainty evidence that for those people under preventative treatment, antibiotic treatment in general, and penicillin in particular, is probably both effective and safe for the prevention of repeated episodes of leg cellulitis when compared with no treatment or placebo. The analyses showed that, compared with no treatment or placebo, taking antibiotics decreased the risk of future episodes by 69%, reduced their number by more than 50%, and significantly reduced the rate until the next attack (moderate‐certainty evidence). However, we found low‐certainty evidence that the protective effect of antibiotics for these three outcomes tailed off over time after treatment had been stopped. In addition, the beneficial effect of antibiotics was relevant for people with at least two past episodes of cellulitis within a time frame of up to three years. We found low‐certainty evidence that there is no difference between antibiotics and no treatment/placebo for side effects and hospitalisation. The evidence did not allow for full exploration of the treatment's effect on length of hospital stay. No serious adverse effects were reported, and common side effects included diarrhoea, nausea, rash (severe skin adverse reactions were not reported) and thrush. In three studies, adverse effects caused those taking part to stop taking the antibiotic. Three people taking erythromycin had abdominal pain and nausea, causing them to stop taking the treatment and to take penicillin instead. In one study, two people withdrew from treatment with penicillin because of diarrhoea or nausea. In another study, because of pain at the site of injection, around 10% of those taking part stopped taking intramuscular injections of benzathine penicillin. None of the included studies measured quality of life or the development of antibiotic resistance. Certainty of evidence Evidence for the effects of antibiotics compared with no treatment or placebo on the recurrence, incidence rate and time to next episode of cellulitis under preventive treatment was of moderate certainty, and was limited by the small number of participants and events. Evidence for the remaining reported outcomes was of low certainty for the same reasons, as well as imprecise results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Dalal, A, Eskin‐Schwartz, M, Mimouni, D, Ray, S, Days, W, Hodak, E, Leibovici, L, Paul, M", "articleTypes": [], "doi": "10.1002/14651858.CD009758.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.764Z" }, { "id": "594537d5-bf6c-414d-a484-6c8dc8bb4d82", "pmid": "", "title": "Antioxidants for male subfertility", "imported": false, "abstract": "Abstract - Background The inability to have children affects 10% to 15% of couples worldwide. A male factor is estimated to account for up to half of the infertility cases with between 25% to 87% of male subfertility considered to be due to the effect of oxidative stress. Oral supplementation with antioxidants is thought to improve sperm quality by reducing oxidative damage. Antioxidants are widely available and inexpensive when compared to other fertility treatments, however most antioxidants are uncontrolled by regulation and the evidence for their effectiveness is uncertain. We compared the benefits and risks of different antioxidants used for male subfertility. Objectives To evaluate the effectiveness and safety of supplementary oral antioxidants in subfertile men. Search methods The Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, and two trial registers were searched on 15 February 2021, together with reference checking and contact with experts in the field to identify additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any type, dose or combination of oral antioxidant supplement with placebo, no treatment, or treatment with another antioxidant, among subfertile men of a couple attending a reproductive clinic. We excluded studies comparing antioxidants with fertility drugs alone and studies that included men with idiopathic infertility and normal semen parameters or fertile men attending a fertility clinic because of female partner infertility. Data collection and analysis We used standard methodological procedures recommended by Cochrane. The primary review outcome was live birth. Clinical pregnancy, adverse events and sperm parameters were secondary outcomes. Main results We included 90 studies with a total population of 10,303 subfertile men, aged between 18 and 65 years, part of a couple who had been referred to a fertility clinic and some of whom were undergoing medically assisted reproduction (MAR). Investigators compared and combined 20 different oral antioxidants. The evidence was of 'low' to 'very low' certainty: the main limitation was that out of the 67 included studies in the meta‐analysis only 20 studies reported clinical pregnancy, and of those 12 reported on live birth. The evidence is current up to February 2021. Live birth: antioxidants may lead to increased live birth rates (odds ratio (OR) 1.43, 95% confidence interval (CI) 1.07 to 1.91, P = 0.02, 12 RCTs, 1283 men, I 2 = 44%, very low‐certainty evidence). Results in the studies contributing to the analysis of live birth rate suggest that if the baseline chance of live birth following placebo or no treatment is assumed to be 16%, the chance following the use of antioxidants is estimated to be between 17% and 27%. However, this result was based on only 246 live births from 1283 couples in 12 small or medium‐sized studies. When studies at high risk of bias were removed from the analysis, there was no evidence of increased live birth (Peto OR 1.22, 95% CI 0.85 to 1.75, 827 men, 8 RCTs, P = 0.27, I 2 = 32%). Clinical pregnancy rate: antioxidants may lead to increased clinical pregnancy rates (OR 1.89, 95% CI 1.45 to 2.47, P < 0.00001, 20 RCTs, 1706 men, I 2 = 3%, low‐certainty evidence) compared with placebo or no treatment. This suggests that, in the studies contributing to the analysis of clinical pregnancy, if the baseline chance of clinical pregnancy following placebo or no treatment is assumed to be 15%, the chance following the use of antioxidants is estimated to be between 20% and 30%. This result was based on 327 clinical pregnancies from 1706 couples in 20 small studies. Adverse events
Miscarriage: only six studies reported on this outcome and the event rate was very low. No evidence of a difference in miscarriage rate was found between the antioxidant and placebo or no treatment group (OR 1.46, 95% CI 0.75 to 2.83, P = 0.27, 6 RCTs, 664 men, I 2 = 35%, very low‐certainty evidence). The findings suggest that in a population of subfertile couples, with male factor infertility, with an expected miscarriage rate of 5%, the risk of miscarriage following the use of an antioxidant would be between 4% and 13%. Gastrointestinal: antioxidants may lead to an increase in mild gastrointestinal discomfort when compared with placebo or no treatment (OR 2.70, 95% CI 1.46 to 4.99, P = 0.002, 16 RCTs, 1355 men, I 2 = 40%, low‐certainty evidence). This suggests that if the chance of gastrointestinal discomfort following placebo or no treatment is assumed to be 2%, the chance following the use of antioxidants is estimated to be between 2% and 7%. However, this result was based on a low event rate of 46 out of 1355 men in 16 small or medium‐sized studies, and the certainty of the evidence was rated low and heterogeneity was high. We were unable to draw conclusions from the antioxidant versus antioxidant comparison as insufficient studies compared the same interventions. Authors' conclusions In this review, there is very low‐certainty evidence from 12 small or medium‐sized randomised controlled trials suggesting that antioxidant supplementation in subfertile males may improve live birth rates for couples attending fertility clinics. Low‐certainty evidence suggests that clinical pregnancy rates may increase. There is no evidence of increased risk of miscarriage, however antioxidants may give more mild gastrointestinal discomfort, based on very low‐certainty evidence. Subfertile couples should be advised that overall, the current evidence is inconclusive based on serious risk of bias due to poor reporting of methods of randomisation, failure to report on the clinical outcomes live birth rate and clinical pregnancy, often unclear or even high attrition, and also imprecision due to often low event rates and small overall sample sizes. Further large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants. Plain language summary Antioxidants for male subfertility Review question 
Do supplementary oral antioxidants compared with placebo, no treatment or another antioxidant improve fertility outcomes for subfertile men? Background 
A couple may be considered to have fertility problems if they have been trying to conceive for over a year with no success. Many subfertile men undergoing fertility treatment also take dietary supplements in the hope of improving their fertility. Fertility treatment can be a very stressful time for men and their partners. It is important that these couples have access to high‐certainty evidence that will allow them to make informed decisions on whether to take a supplemental antioxidant. This is especially important as most antioxidant supplements are uncontrolled by regulation. This review aimed to assess whether supplements with oral antioxidants, taken by subfertile men, would increase the chances of a couple to achieve a (clinical) pregnancy confirmed by ultrasound and ultimately the birth of a baby (live birth). This review did not examine the use of antioxidants in men with normal sperm. Study characteristics Cochrane authors conducted a review including 90 randomised controlled trials comparing 18 different antioxidants with placebo, no treatment or another antioxidant in a total population of 10,303 subfertile men. The age range of the participants was 18 to 65 years; they were part of a couple who had been referred to a fertility clinic and some were undergoing fertility treatment. The evidence is current to February 2021. Main results 
Antioxidants may be associated with an increased live birth and clinical pregnancy rate. Based on the studied population for live birth, we would expect that out of 100 subfertile men not taking antioxidants, 16 couples would have a baby. In subfertile men taking antioxidants, between 17 and 27 per 100 couples would have a baby. If studies with high risk of bias were removed from the analysis, there was no evidence of increased live birth in the population taking antioxidants. In the people who were studied for clinical pregnancy, we would expect that out of 100 subfertile men not taking antioxidants, 15 couples would have a clinical pregnancy. In subfertile men taking antioxidants, between 20 and 30 per 100 couples would have a clinical pregnancy. Adverse events were poorly reported. Only six studies reported miscarriage. In these studies, miscarriage did not occur more often in the group using antioxidants when compared with the group with placebo or no treatment. However, there is insufficient evidence to draw conclusions about antioxidant use and the risk of miscarriage. The use of antioxidants may be associated with more mild stomach discomfort, with a frequency of 2% in subfertile men not taking antioxidants, and between 2% and 7% in men taking antioxidants. The oral supplements may cause discomforts such as nausea or stomach ache. Authors' conclusion and certainty of the evidence 
Antioxidant supplementation taken by subfertile males of a couple attending a fertility clinic may increase the chance of a live birth, however the overall certainty of evidence was very low from only 12 small to medium‐sized randomised controlled trials. Low‐certainty evidence suggests that clinical pregnancy rates may increase. Overall, there is no evidence of increased risk of miscarriage. Evidence of low certainty suggests that antioxidants may be associated with more gastrointestinal discomfort. Subfertile couples should be advised that overall the current evidence is inconclusive due to the poor reporting of methods, failure to report on live birth and clinical pregnancy rate, imprecision due to low event rates, high number of dropouts and small study group sizes. Large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "de Ligny, W; Smits, RM; Mackenzie-Proctor, R; Jordan, V; Fleischer, K; de Bruin, JP; Showell, MG", "articleTypes": [], "doi": "10.1002/14651858.CD007411.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "597988fa-714f-48b6-984a-4ac17f378f0a", "pmid": "", "title": "Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults", "imported": false, "abstract": "Abstract - Background Chancroid is a genital ulcerative disease caused by Haemophilus ducreyi . This microorganism is endemic in Africa, where it can cause up to 10% of genital ulcers. Macrolides may be an effective alternative to treat chancroid and, based on their oral administration and duration of therapy, could be considered as first line therapy. Objectives To assess the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults. Search methods We searched the Cochrane STI Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, WHO ICTRP, ClinicalTrials.gov and Web of Science to 30 October 2017. We also handsearched conference proceedings and reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) comparing macrolides in different regimens or with other therapeutic alternatives for chancroid. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We resolved disagreements through consensus. We used the GRADE approach to assess the quality of the evidence. Main results Seven RCTs (875 participants) met our inclusion criteria, of which four were funded by industry. Five studies (664 participants) compared macrolides with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Low quality evidence suggested there was no difference between the groups after treatment in terms of clinical cure (risk ratio (RR) 1.09, 95% confidence interval (CI) 0.97 to 1.21; 2 studies, 340 participants with syndromic approach and RR 1.06, 95% CI 0.98 to 1.15; 5 studies, 348 participants with aetiological diagnosis) or improvement (RR 0.89, 95% CI 0.52 to 1.52; 2 studies, 340 participants with syndromic approach and RR 0.80, 95% CI 0.42 to 1.51; 3 studies, 187 participants with aetiological diagnosis). Based on low and very low quality evidence, there was no difference between macrolides and any other antibiotic treatments for microbiological cure (RR 0.93, 95% CI 0.74 to 1.16; 1 study, 45 participants) and minor adverse effects (RR 1.34, 95% CI 0.24 to 7.51; 3 studies, 412 participants). Two trials (269 participants) compared erythromycin with any other macrolide type. Low quality evidence suggested that, compared with azithromycin or rosaramicin, long courses of erythromycin did not increase clinical cure (RR 1.00, 95% CI 0.91 to 1.10; 2 studies, 269 participants with syndromic approach and RR 1.04, 95% CI 0.93 to 1.16; 2 studies, 211 participants with aetiological diagnosis), with a similar frequency of minor adverse effects between the groups (RR 1.14, 95% CI 0.63 to 2.06; 1 trial, 101 participants). For this comparison, subgroup analysis found no difference between HIV‐positive participants (RR 1.02, 95% CI 0.73 to 1.43; 1 study, 38 participants) and HIV‐negative participants (RR 1.04, 95% CI 0.94 to 1.14; 1 study, 89 participants). We downgraded the quality of evidence to low, because of imprecision, some limitations on risk of bias and heterogeneity. None of the trials reported serious adverse events, cost effectiveness and participant satisfaction. Authors' conclusions At present, the quality of the evidence on the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults is low, implying that we are uncertain about the estimated treatment effect. There is no statistically significant difference between the available therapeutic alternatives for the treatment of sexually active adults with genital ulcers compatible with chancroid. Low quality evidence suggests that azithromycin could be considered as the first therapeutic alternative, based on their mono‐dose oral administration, with a similar safety and effectiveness profile, when it is compared with long‐term erythromycin use. Due to sparse available evidence about the safety and effectiveness of macrolides to treat H ducreyi infection in people with HIV, these results should be taken with caution. Plain language summary Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults Review question 
 In this Cochrane Review, we assess the effectiveness and safety of macrolides in different regimens or with other treatments for H ducreyi infection in adults. Background Chancroid is a sexually transmitted infection (STI) caused by infection with a bacteria called Haemophilus ducreyi . It causes ulcers in the genital area and is endemic in some low‐income countries. Control and eradication of chancroid could reduce transmission of the STI from one sexual partner to another. Macrolides are antibiotics that could be effective and safe for treating H ducreyi infection. Trial characteristics We searched the available literature up to 30 October 2017 and we included seven trials with 875 participants. The trials recruited men and non‐pregnant women over the age of 16 years who presented with genital ulcers compatible with chancroid. Three studies included people with high‐risk sexual behaviour as migrant mine workers, sex workers and men with prostitute contact. All the trials tested for other STIs, and discarded people who were also infected with syphilis and herpes simple virus. One study included people with HIV. The most frequent antibiotic treatment was erythromycin with azithromycin as an alternative. They were compared with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Five studies compared two types of antibiotic and two studies compared different ways of treating with macrolides. Four trials were funded by pharmaceutical companies. Key results There was no difference between the types of antibiotics in sexually active adults with genital ulcers compatible with chancroid. Erythromycin is usually the first choice for treatment but low quality evidence suggested that azithromycin (as a single dose, oral (by mouth) administration) had similar safety and effectiveness. Because of sparse evidence about the safety and effectiveness of macrolides to treat Haemophilus ducreyi infection in people with HIV, these results should be taken with caution. Quality of evidence The quality of evidence was low as there was a risk of bias due to poor methods, people dropping out of the study and pharmaceutical companies sponsored four studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Romero, L; Huerfano, C; Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD012492.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "5994f572-cd7e-4f70-a4a7-1689edbfae24", "pmid": "", "title": "Xiao Chai Hu Tang, a herbal medicine, for chronic hepatitis B", "imported": false, "abstract": "Abstract - Background Chronic hepatitis B is associated with high morbidity and mortality. Chronic hepatitis B requires long‐term management aiming at reduction of the risks of hepatocellular inflammatory necrosis, liver fibrosis, decompensated liver cirrhosis, liver failure, and liver cancer, and improving health‐related quality of life. The Chinese herbal medicine formula Xiao Chai Hu Tang has been used to decrease discomfort and replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established with rigorous review methodology. Objectives To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and seven other databases to 1 March 2019. We also searched the World Health Organization International Clinical Trials Registry Platform ( www.who.int/ictrp ), ClinicalTrials.gov ( www.clinicaltrials.gov/ ), and the Chinese Clinical Trial Registry for ongoing or unpublished trials to 1 March 2019. Selection criteria We included randomised clinical trials, irrespective of publication status, language, and blinding, comparing Xiao Chai Hu Tang formula versus no intervention or placebo in people with chronic hepatitis B. We included participants of any sex and age, diagnosed with chronic hepatitis B according to guidelines or as defined by the trialists. We allowed co‐interventions when the co‐interventions were administered equally to all the intervention groups. Data collection and analysis Review authors independently retrieved data from reports and after correspondence with investigators. Our primary outcomes were all‐cause mortality, serious adverse events, and health‐related quality of life. Our secondary outcomes were hepatitis B‐related mortality, hepatitis B‐related morbidity, and adverse events considered 'not to be serious'. We presented the meta‐analysed results as risk ratios (RR) with 95% confidence intervals (CI). We assessed the risks of bias using risk of bias domains with predefined definitions. We used GRADE methodology to evaluate our certainty in the evidence. Main results We included 10 randomised clinical trials with 934 participants, but only five trials with 490 participants provided data for analysis. All the trials compared Xiao Chai Hu Tang formula with no intervention. All trials appeared to have been conducted and published only in China. The included trials assessed heterogeneous forms of Xiao Chai Hu Tang formula, administered for three to eight months. One trial included participants with hepatitis B and comorbid tuberculosis, and one trial included participants with hepatitis B and liver cirrhosis. The remaining trials included participants with hepatitis B only. All the trials were at high risk of bias, and the certainty of evidence for all outcomes that provided data for analyses was very low. We downgraded the evidence by one or two levels because of outcome risk of bias, inconsistency or heterogeneity of results (opposite direction of effect), indirectness of evidence (use of surrogate outcomes instead of clinically relevant outcomes), imprecision of results (the CIs were wide), and publication bias (small sample size of the trials). Additionally, 47 trials lacked the necessary methodological information needed to ensure the inclusion of these trials in our review. None of the included trials aimed to assess clinically relevant outcomes such as all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, or hepatitis B‐related morbidity. The effects of Xiao Chai Hu Tang formula on the proportion of participants with adverse events considered 'not to be serious' is uncertain (RR 0.43, 95% CI 0.02 to 11.98; I 2 = 69%; very low‐certainty evidence). Only three trials with 222 participants reported the proportion of people with detectable hepatitis B virus DNA (HBV‐DNA), but the evidence that Xiao Chai Hu Tang formula reduces the presence of HBV‐DNA in the blood (a surrogate outcome) is uncertain (RR 0.62, 95% CI 0.45 to 0.85; I 2 = 0%; very low‐certainty evidence). Only two trials with 160 participants reported the proportion of people with detectable hepatitis B virus e‐antigen (HBeAg; a surrogate outcome) (RR 0.72, 95% CI 0.50 to 1.02; I 2 = 38%; very low‐certainty evidence) and the evidence is uncertain. The evidence is also uncertain for separately reported adverse events considered 'not to be serious'. Funding: two of the 10 included trials received academic funding from government or hospital. None of the remaining eight trials reported information on funding. Authors' conclusions The clinical effects of Xiao Chai Hu Tang formula for chronic hepatitis B remain unclear. The included trials were small and of low methodological quality. Despite the wide use of Xiao Chai Hu Tang formula, we lack data on all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, and hepatitis B‐related morbidity. The evidence in this systematic review comes from data obtained from a maximum three trials. We graded the certainty of evidence as very low for adverse events considered not to be serious and the surrogate outcomes HBeAg and HBV‐DNA. We found a large number of trials which lacked clear description of their design and conduct, and hence, these trials are not included in the present review. As all identified trials were conducted in China, there might be a concern about the applicability of this review outside China. Large‐sized, high‐quality randomised sham‐controlled trials with homogeneous groups of participants and transparent funding are lacking. Plain language summary Xiao Chai Hu Tang, a Chinese herbal medicine formula, for chronic hepatitis B Review question To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B virus infection. Background Chronic hepatitis B virus infection is a common liver disease, associated with high morbidity (illness) and death. It causes psychological stress and is a burden to people with chronic hepatitis B and their families. Xiao Chai Hu Tang formula has been used for treating people with chronic hepatitis B as it is believed that it decreases discomfort and prevents the replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established in reviews with rigorous review methodology. Search date The review includes trials published up to 1 March 2019. Study characteristics We included 10 randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) with 934 participants. All trials compared Xiao Chai Hu Tang formula with no treatment. The trials assessed different formulas and doses for three to eight months. One trial included participants with tuberculosis (a disease of the lungs that can make you cough mucous), and one trial included participants with liver cirrhosis (scarring). Only five trials with 490 participants provided data for analysis Study funding sources Two of the 10 included trials reported receiving academic funding. None of the remaining eight trials reported information of support or funding. Key results None of the 10 included trials reported data on all‐cause mortality (death from any cause), serious side effects (untoward medical occurrences that result in serious outcomes such as death or disability), health‐related quality of life (a measure of physical, mental, emotional, and social functioning a measure of a person's satisfaction with their life and health), hepatitis B‐related death, and hepatitis B‐related morbidity. We are uncertain whether Xiao Chai Hu Tang formula versus no intervention has a positive or negative effect regarding side effects considered 'not to be serious', the proportion of people with detectable HBeAg (a hepatitis B viral protein that indicates active viral replication), and separately reported side effects considered 'not to be serious'. Xiao Chai Hu Tang formula compared with no intervention seems to reduce the proportion of people with detectable HBV‐DNA (which is used to indicate how much hepatitis B virus is in the blood) but the reliability of this finding is low. Surrogate outcomes are markers that are used in research as a substitute for a clinically meaningful measure that directly measures patient outcomes. We cannot always be certain that such surrogate outcomes are reliable substitutes for important outcomes as they need to be officially examined. Caution is needed with this beneficial finding as the trials are at high risk of bias, and this outcome has not yet been proven relevant to patients. We identified an additional 47 studies as potential randomised clinical trials, but the data they reported were of no use. Accordingly, properly designed randomised clinical trials are needed before the benefits and harms of Xiao Chai Hu Tang formula for chronic hepatitis B can be determined. Reliability of the evidence The reliability of the evidence on the use of Xiao Chai Hu Tang formula in people with chronic hepatitis B virus in terms of its beneficial or harmful effects on death, health‐related quality of life, risk of dying due to hepatitis B virus infection, and serious side effects cannot be determined as no trials aimed to explore these. The reliability of the evidence that Xiao Chai Hu Tang formula, when compared with no intervention, in terms of side effects considered 'not to be serious', the proportion of people with detectable HBV‐DNA, and the proportion of people with detectable HBeAg is very low. These assessments of the reliability of the evidence are due to the poor design and reporting of the included trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kong, DZ, Liang, N, Yang, GL, Zhang, Z, Liu, Y, Li, J, Liu, X, Liang, S, Nikolova, D, Jakobsen, JC, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.081Z" }, { "id": "5995a0e0-7786-4003-90fa-b2d919be18e9", "pmid": "", "title": "Interventions to prevent obesity in children aged 2 to 4 years old", "imported": false, "abstract": "Abstract - Rationale Early childhood presents an important opportunity for obesity prevention, an international public health priority. Interventions aiming to prevent obesity typically promote healthy diets or activity levels (physical activity, sedentary behaviour), or both. There is uncertainty over which approaches are more effective. This is one of a suite of three reviews addressing interventions for preventing obesity in children, each focusing on different age groups up to 18 years. These reviews replace and update a 2019 Cochrane review on interventions for preventing obesity in children from birth to 18 years. Objectives To assess the effects of interventions that aimed to prevent obesity in children aged two to four years by changing dietary intake or activity levels, or both, on body mass index (BMI), BMI z‐score (zBMI), BMI percentile, and serious adverse events. Search methods We searched CENTRAL, MEDLINE, Embase, six other databases, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify eligible studies. The latest search date was 7 February 2023. Eligibility criteria We included randomised controlled trials (RCTs) in children aged two to four years, comparing dietary or activity interventions (or both combined) to prevent overweight or obesity versus no intervention, usual care, or another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post‐baseline. There were no language restrictions. Outcomes Our outcomes were BMI, zBMI, BMI percentile, and serious adverse events. Risk of bias We used version 2 of the Cochrane risk of bias tool (RoB 2) to assess included RCTs. Synthesis methods Working independently, two authors screened studies, extracted data, and conducted risk of bias and GRADE assessments. We conducted random‐effects meta‐analyses stratified by type of intervention and follow‐up duration. Included studies We included 67 studies (36,601 participants), with 56 studies (21,404 participants) pooled in the meta‐analyses. Sixty‐three studies were conducted in high‐income countries. Study settings were split between childcare (26 studies; 39%), home (23 studies; 34%), and home plus childcare settings (10 studies; 15%). Few studies were conducted in the community (three studies; 5%) or healthcare settings (five studies; 7%). Most studies compared a combined dietary/activity intervention with a control group. Synthesis of results Dietary interventions versus control Dietary interventions may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0.00, 95% confidence interval (CI) ‐0.28 to 0.28; 1 study, 94 participants; low‐certainty evidence). At medium‐ and long‐term follow‐up, dietary interventions may result in little to no difference in BMI. One study (103 participants; low‐certainty evidence) reported no difference in BMI at medium‐term follow‐up, and one study (2238 participants; low‐certainty evidence) found lower rates of overweight and obesity in the intervention group at long‐term follow‐up. Dietary interventions likely result in little to no difference in zBMI at short‐term (MD 0.03, 95% CI ‐0.13 to 0.19; 2 studies, 145 participants) and medium‐term follow‐up (MD ‐0.17, 95% CI ‐0.44 to 0.10; 1 study, 389 participants), both with moderate‐certainty evidence. None of the included studies reported zBMI at long‐term follow‐up. None of the studies reported serious adverse events. Activity interventions versus control Activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.10, 95% CI ‐0.28 to 0.08; 6 studies, 826 participants; very low‐certainty evidence). They likely reduce BMI at medium‐term follow‐up (MD ‐0.70, 95% CI ‐1.09 to ‐0.31; 1 study, 567 participants; moderate‐certainty evidence). None of the studies reported BMI at long‐term follow‐up. Activity interventions likely result in little to no difference in zBMI at short‐term follow‐up (MD ‐0.06, 95% CI ‐0.19 to 0.07; 3 studies, 635 participants; moderate‐certainty evidence). They may result in little to no difference in zBMI at medium‐term follow‐up, but the evidence is very uncertain (MD ‐0.00, 95% CI ‐0.12 to 0.11; 4 studies, 1083 participants; very low‐certainty evidence). None of the included studies reported zBMI at long‐term follow‐up. Activity interventions may have little to no effect on serious adverse events, but the evidence is very uncertain (2 studies, 773 participants; very low‐certainty evidence). One study found no harms related to the intervention, and one study reported no difference in accident and infection rates between groups. Combined dietary/activity interventions versus control Combined dietary/activity interventions may have little to no effect on BMI at short‐term follow‐up, but the evidence is very uncertain (MD ‐0.08, 95% CI ‐0.20 to 0.04; 13 studies, 3867 participants; very low‐certainty evidence). They may result in little to no difference in BMI at medium‐term follow‐up (MD ‐0.05, 95% CI ‐0.18 to 0.08; 9 studies, 7016 participants; low‐certainty evidence), and may result in a slight reduction in BMI at long‐term follow‐up (MD ‐0.20, 95% CI ‐0.39 to ‐0.01; 5 studies, 2074 participants; low‐certainty evidence). Combined interventions may have little to no effect on zBMI at short‐term follow‐up (MD ‐0.03, 95% CI ‐0.07 to 0.01; 14 studies, 5518 participants), and may result in a slight reduction in zBMI at medium‐term follow‐up, but the evidence for both time frames is very uncertain (MD ‐0.07, 95% CI ‐0.11 to ‐0.04; 15 studies; 11,043 participants). Combined interventions may result in a slight reduction in zBMI at long‐term follow‐up (MD ‐0.07, 95% CI ‐0.13 to ‐0.01; 10 studies, 4693 participants; low‐certainty evidence). Combined interventions may result in little to no difference in serious adverse events, but the evidence is very uncertain (4 studies, 1689 participants; very low‐certainty evidence). One study reported that a parent fractured an ankle while roller‐skating at a community centre; the remaining studies reported no adverse events. Authors' conclusions In early childhood, combined dietary/activity interventions may have very modest benefits on BMI and zBMI at long‐term follow‐up. When implemented alone, dietary or activity interventions may have little to no effect on BMI measures. Only six studies reported serious adverse events, with no serious harms resulting directly from the intervention, but the evidence is very uncertain. Funding This review was partly funded by the National Institute for Health Research, School for Public Health Research. Registration Protocol available: DOI: 10.1002/14651858.CD015326 Plain language summary Do dietary and activity strategies help prevent obesity in children aged 2 to 4 years? Key messages Combining strategies for changing diet and physical activity levels in children aged 2 to 4 years to help prevent overweight and obesity may reduce body mass index (BMI) slightly in the long term (after 15 months). There was very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but none of the strategies appeared to result in any serious harm to the children. Future research should carry out obesity prevention strategies in community settings, and target the wider determinants of obesity and obesity prevention. Why is preventing obesity in children important? There is an increasing number of young children living with overweight and obesity worldwide, with evidence of the rates increasing in line with social inequality. Living with overweight during childhood can cause physical and psychological health problems. Children living with overweight are more likely to live with overweight as adults, and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help people change diet or activity (or both) are effective at preventing obesity in children aged 2 to 4 years, and whether they are associated with any serious adverse events. To examine obesity, we used the measure of body mass index (BMI). BMI is calculated by dividing a person's weight (in kg) by their height (in m 2 ). What did we do? We searched for studies that looked at ways to prevent obesity in children aged 2 to 4 years. We did not include studies that only targeted children who were already living with overweight or obesity, but we did include studies involving children at a range of weights. We only included studies if they used methods aimed at changing children's diet, activity level (increasing physical activity or reducing sedentary behaviour), or both. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 67 studies involving 36,601 children aged 2 to 4 years. Most studies (63 of 67) were based in high‐income countries, and four in upper‐middle‐income countries. In 26 studies, the strategies were conducted in childcare settings, 23 studies were primarily home‐based, and 10 were performed in both childcare and home‐based settings. Only 3 studies were conducted in the community, and 5 in healthcare settings. The duration of the programmes varied: 47 ran for fewer than 9 months, with the shortest being 1 visit and the longest lasting 3 years. We analysed results from 56 studies involving 21,404 children. Main findings Children who were helped with a strategy to change their diet and activity levels may have had a reduced BMI, compared with children not given any strategy. This means that these children may have been able to minimise excess weight gain by a small amount, which, for public health, is important. Children who were helped with a strategy to change their diet or activity alone did not have a reduced BMI. Only six of the 67 included studies reported on serious adverse events, and no serious harms were identified. What are the limitations of the evidence? Overall, our confidence in the evidence is very low. However, we do not believe that results from more studies similar in design to those included in this review would produce a higher level of confidence in the results. Four main factors reduced our confidence in the evidence. Results were very inconsistent across different studies. There were not enough studies reporting specific types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons. Results from some studies were not reported in a way that we could include in our analyses and this may have had an impact on the combined results. Studies generally had limitations in how they were conducted, due to the complexity of studies in this age group. This review does not provide enough information to assess how well these strategies work for children with disabilities or those from low‐ and middle‐income countries. How current is this evidence? This review updates a previous review. The evidence is current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Phillips, SM; Spiga, F; Moore, THM; Dawson, S; Stockton, H; Rizk, R; Cheng, HY; Hodder, RK; Gao, Y; Hillier-Brown, F; Rai, K; Yu, CB; O'Brien, KM; Summerbell, CD", "articleTypes": [], "doi": "10.1002/14651858.CD015326.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "59cae657-f7a4-4d8d-b1e3-7eb203c444f3", "pmid": "", "title": "Phytoestrogens for menopausal vasomotor symptoms", "imported": false, "abstract": "Abstract - Background Vasomotor symptoms, such as hot flushes and night sweats, are very common during the menopausal transition. Hormone therapy has traditionally been used as a highly effective treatment, but concerns about increased risk of some chronic diseases have markedly increased the interest of women in alternative treatments. Some of the most popular of these treatments are foods or supplements enriched with phytoestrogens—plant‐derived chemicals that have estrogenic action. Objectives To assess the efficacy, safety and acceptability of food products, extracts and dietary supplements containing high levels of phytoestrogens when compared with no treatment, placebo or hormone therapy for the amelioration of vasomotor menopausal symptoms (such as hot flushes and night sweats) in perimenopausal and postmenopausal women. Search methods Searches targeted the following electronic databases: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of randomised trials (29 July 2013), the Cochrane Register of Controlled Trials (CENTRAL; 29 July 2013), MEDLINE (inception to 29 July 2013), EMBASE (inception to 29 July 2013), AMED (1985 to 29 July 2013), PsycINFO (inception to 29 July 2013) and CINAHL (inception to 29 July 2013). Attempts were made to access grey literature by sending letters to pharmaceutical companies and performing searches of ongoing trial registers. Reference lists of included trials were also searched. Selection criteria Studies were included if they were randomised, included perimenopausal or postmenopausal participants with vasomotor symptoms (hot flushes or night sweats), lasted at least 12 weeks and provided interventions such as foods or supplements with high levels of phytoestrogens (not combined with other herbal treatments). Trials that included women who had breast cancer or a history of breast cancer were excluded. Data collection and analysis Selection of trials, extraction of data and assessment of quality were undertaken by at least two review authors. Most trials were too dissimilar for their results to be combined in a meta‐analysis, so these findings are provided in narrative 'Summary of results' tables. Studies were grouped into broad categories: dietary soy, soy extracts, red clover extracts, genistein extracts and other types of phytoestrogens. Five trials used Promensil, a red clover extract; results of these trials were combined in a meta‐analysis, and summary effect measures were calculated. Main results A total of 43 randomised controlled trials (4,364 participants) were included in this review. Very few trials provided data suitable for inclusion in a meta‐analysis. Among the five trials that yielded data assessing the daily frequency of hot flushes suitable for pooling, no significant difference overall was noted in the incidence of hot flushes between participants taking Promensil (a red clover extract) and those given placebo (mean difference (MD) ‐0.93, 95% confidence interval (CI) ‐1.95 to 0.10, I 2 = 31%). No evidence indicated a difference in percentage reduction in hot flushes in two trials between Promensil and placebo (MD 20.15, 95% CI ‐12.08 to 52.38, I 2 = 82%). Four trials that were not combined in meta‐analyses suggested that extracts with high (> 30 mg/d) levels of genistein consistently reduced the frequency of hot flushes. Individual results from the remaining trials were compared in broad subgroups such as dietary soy, soy extracts and other types of phytoestrogens that could not be combined. Some of these trials found that phytoestrogen treatments alleviated the frequency and severity of hot flushes and night sweats when compared with placebo, but many trials were small and were determined to be at high risk of bias. A strong placebo effect was noted in most trials, with a reduction in frequency ranging from 1% to 59% with placebo. No indication suggested that discrepant results were due to the amount of isoflavone in the active treatment arm, the severity of vasomotor symptoms or trial quality factors. Also, no evidence indicated that these treatments caused oestrogenic stimulation of the endometrium or the vagina or other adverse effects when used for up to two years. Authors' conclusions No conclusive evidence shows that phytoestrogen supplements effectively reduce the frequency or severity of hot flushes and night sweats in perimenopausal or postmenopausal women, although benefits derived from concentrates of genistein should be further investigated. Plain language summary Phytoestrogens for vasomotor menopausal symptoms Review question: This Cochrane review has evaluated whether phytoestrogen treatments reduce the number and severity of hot flushes and whether they are safe and acceptable. Background: Hormone therapy is an effective treatment for controlling the most common menopausal symptoms—hot flushes and night sweats. However, it is now recommended only in low doses given for the shortest possible time because of concerns about increased risk of some chronic diseases. Many women have started to use therapies that they perceive as 'natural' and safe, but they often do not have good information about the potential benefits and risks. Some of these therapies contain phytoestrogens—a group of plant‐derived chemicals that are thought to prevent or treat disease. Phytoestrogens are found in a wide variety of plants, some of which are foods, particularly soy, alfalfa and red clover. Study characteristics: This review found 43 RCTs conducted up to July 2013 that included 4,084 participants with hot flushes who were close to the menopause or were menopausal. Evidence obtained is current to July 2013. Key results: Some trials reported a slight reduction in hot flushes and night sweats with phytoestrogen‐based treatment. Extracts containing high levels of genistein (a substance derived from soy) appeared to reduce the number of daily hot flushes and need to be investigated further. Overall no indication suggested that other types of phytoestrogens work any better than no treatment. No evidence was found of harmful effects on the lining of the womb, stimulation of the vagina or other adverse effects with short‐term use. Quality of the evidence: Many of the trials in this review were small, of short duration and of poor quality, and the types of phytoestrogens used varied substantially.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lethaby, A; Marjoribanks, J; Kronenberg, F; Roberts, H; Eden, J; Brown, J", "articleTypes": [], "doi": "10.1002/14651858.CD001395.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "59cc366d-9e0a-4e93-88c7-21699ece88d6", "pmid": "", "title": "A Phase 1/2 Study of REGN7075 (EGFRxCD28 Costimulatory Bispecific Antibody) in Combination With Cemiplimab in Patients With Advanced Solid Tumors", "imported": false, "abstract": "This study is researching an investigational drug called marlotamig (REGN7075) by itself and in combination with cemiplimab with or without chemotherapy. The study is focused on patients with certain solid tumors that are in an advanced stage.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.248Z" }, { "id": "59cf617e-79f1-42fd-acf6-c9eb6a15ffbf", "pmid": "", "title": "Universal screening for SARS‐CoV‐2 infection: a rapid review", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Viswanathan, M, Kahwati, L, Jahn, B, Giger, K, Dobrescu, AI, Hill, C, Klerings, I, Meixner, J, Persad, E, Teufer, B, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013718 AB - Abstract - Background Coronavirus disease 2019 (COVID‐19) is caused by the novel betacoronavirus, severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2). Most people infected with SARS‐CoV‐2 have mild disease with unspecific symptoms, but about 5% become critically ill with respiratory failure, septic shock and multiple organ failure. An unknown proportion of infected individuals never experience COVID‐19 symptoms although they are infectious, that is, they remain asymptomatic. Those who develop the disease, go through a presymptomatic period during which they are infectious. Universal screening for SARS‐CoV‐2 infections to detect individuals who are infected before they present clinically, could therefore be an important measure to contain the spread of the disease. Objectives We conducted a rapid review to assess (1) the effectiveness of universal screening for SARS‐CoV‐2 infection compared with no screening and (2) the accuracy of universal screening in people who have not presented to clinical care for symptoms of COVID‐19. Search methods An information specialist searched Ovid MEDLINE and the Centers for Disease Control (CDC) COVID‐19 Research Articles Downloadable Database up to 26 May 2020. We searched Embase.com, the CENTRAL, and the Cochrane Covid‐19 Study Register on 14 April 2020. We searched LitCovid to 4 April 2020. The World Health Organization (WHO) provided records from daily searches in Chinese databases and in PubMed up to 15 April 2020. We also searched three model repositories (Covid‐Analytics, Models of Infectious Disease Agent Study [MIDAS], and Society for Medical Decision Making) on 8 April 2020. Selection criteria Trials, observational studies, or mathematical modelling studies assessing screening effectiveness or screening accuracy among general populations in which the prevalence of SARS‐CoV2 is unknown. Data collection and analysis After pilot testing review forms, one review author screened titles and abstracts. Two review authors independently screened the full text of studies and resolved any disagreements by discussion with a third review author. Abstracts excluded by a first review author were dually reviewed by a second review author prior to exclusion. One review author independently extracted data, which was checked by a second review author for completeness and accuracy. Two review authors independently rated the quality of included studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool for diagnostic accuracy studies and a modified form designed originally for economic evaluations for modelling studies. We resolved differences by consensus. We synthesized the evidence in narrative and tabular formats. We rated the certainty of evidence for days to outbreak, transmission, cases missed and detected, diagnostic accuracy (i.e. true positives, false positives, true negatives, false negatives) using the GRADE approach. Main results We included 22 publications. Two modelling studies reported on effectiveness of universal screening. Twenty studies (17 cohort studies and 3 modelling studies) reported on screening test accuracy. Effectiveness of screening We included two modelling studies. One study suggests that symptom screening at travel hubs, such as airports, may slightly slow but not stop the importation of infected cases (assuming 10 or 100 infected travellers per week reduced the delay in a local outbreak to 8 days or 1 day, respectively). We assessed risk of bias as minor or no concerns, and certainty of evidence was low, downgraded for very serious indirectness. The second modelling study provides very low‐certainty evidence that screening of healthcare workers in emergency departments using laboratory tests may reduce transmission to patients and other healthcare workers (assuming a transmission constant of 1.2 new infections per 10,000 people, weekly screening reduced infections by 5.1% within 30 days). The certainty of evidence was very low, downgraded for high risk of bias (major concerns) and indirectness. No modelling studies reported on harms of screening. Screening test accuracy All 17 cohort studies compared an index screening strategy to a reference reverse transcriptase polymerase chain reaction (RT‐PCR) test. All but one study reported on the accuracy of single point‐in‐time screening and varied widely in prevalence of SARS‐CoV‐2, settings, and methods of measurement. We assessed the overall risk of bias as unclear in 16 out of 17 studies, mainly due to limited information on the index test and reference standard. We rated one study as being at high risk of bias due to the inclusion of two separate populations with likely different prevalences. For several screening strategies, the estimates of sensitivity came from small samples. For single point‐in‐time strategies, for symptom assessment, the sensitivity from 12 cohorts (524 people) ranged from 0.00 to 0.60 (very low‐certainty evidence) and the specificity from 12 cohorts (16,165 people) ranged from 0.66 to 1.00 (low‐certainty evidence). For screening using direct temperature measurement (3 cohorts, 822 people), international travel history (2 cohorts, 13,080 people), or exposure to known infected people (3 cohorts, 13,205 people) or suspected infected people (2 cohorts, 954 people), sensitivity ranged from 0.00 to 0.23 (very low‐ to low‐certainty evidence) and specificity ranged from 0.90 to 1.00 (low‐ to moderate‐certainty evidence). For symptom assessment plus direct temperature measurement (2 cohorts, 779 people), sensitivity ranged from 0.12 to 0.69 (very low‐certainty evidence) and specificity from 0.90 to 1.00 (low‐certainty evidence). For rapid PCR test (1 cohort, 21 people), sensitivity was 0.80 (95% confidence interval (CI) 0.44 to 0.96; very low‐certainty evidence) and specificity was 0.73 (95% CI 0.39 to 0.94; very low‐certainty evidence). One cohort (76 people) reported on repeated screening with symptom assessment and demonstrates a sensitivity of 0.44 (95% CI 0.29 to 0.59; very low‐certainty evidence) and specificity of 0.62 (95% CI 0.42 to 0.79; low‐certainty evidence). Three modelling studies evaluated the accuracy of screening at airports. The main outcomes measured were cases missed or detected by entry or exit screening, or both, at airports. One study suggests very low sensitivity at 0.30 (95% CI 0.1 to 0.53), missing 70% of infected travellers. Another study described an unrealistic scenario to achieve a 90% detection rate, requiring 0% asymptomatic infections. The final study provides very uncertain evidence due to low methodological quality. Authors' conclusions The evidence base for the effectiveness of screening comes from two mathematical modelling studies and is limited by their assumptions. Low‐certainty evidence suggests that screening at travel hubs may slightly slow the importation of infected cases. This review highlights the uncertainty and variation in accuracy of screening strategies. A high proportion of infected individuals may be missed and go on to infect others, and some healthy individuals may be falsely identified as positive, requiring confirmatory testing and potentially leading to the unnecessary isolation of these individuals. Further studies need to evaluate the utility of rapid laboratory tests, combined screening, and repeated screening. More research is also needed on reference standards with greater accuracy than RT‐PCR. Given the poor sensitivity of existing approaches, our findings point to the need for greater emphasis on other ways that may prevent transmission such as face coverings, physical distancing, quarantine, and adequate personal protective equipment for frontline workers. Plain language summary How effective is screening for COVID‐19? Why does screening matter? Screening aims to identify a condition in people who may not be showing any symptoms. Some people may have the COVID‐19 virus but appear healthy or have only mild symptoms. It is important to identify infected people so they can stay away from others and seek appropriate care. Incorrectly identifying COVID‐19 in healthy people could lead to unnecessary self‐isolation and further tests. Incorrectly identifying no infection in infected people could spread the virus. Screening for COVID‐19 can include temperature checks, or asking about international travel or contact with COVID‐19 cases, or rapid tests. Screening can occur over the telephone, online, or in person, in homes, clinics, workplaces, airports or schools. What did the review study? We wanted to identify: · the benefits and negative effects of screening apparently healthy people for COVID‐19 infection; · whether screening can identify those with and without the virus correctly. To answer these questions rapidly, we shortened some steps of the normal Cochrane Review process. We are confident these changes do not affect our overall conclusions. What did we do? We looked for studies that screened people who had not sought care for potential COVID‐19 symptoms. This review includes evidence up to May 2020. Key results We found 22 studies; 17 assessed people (cohort studies) and five were computer‐generated models (modelling studies). Studies took place in USA, Europe, and Asia. Benefits and negative effects 
Two modelling studies reported on the benefits and negative effects of screening. One suggested that asking about symptoms at airports may slightly slow, but not stop, the importation of infected people. Another model reported that weekly or biweekly screening of healthcare workers may reduce transmission to patients and other healthcare workers in emergency departments. No studies reported on negative effects of screening. Identification of infected people 
Seventeen cohort studies and three modelling studies reported on whether screening can correctly identify those with and without the virus. Studies varied widely in the baseline level of COVID‐19, settings, and methods. All cohort studies compared screening strategies to a ‘gold standard’ test called RT‐PCR. Cohort studies
All screening strategies (17 studies, 17,574 people), incorrectly identified: · between 20 and 100 out of 100 infected people as healthy; · between 0 and 38 people out of 100 healthy people as infected Asking about symptoms (13 studies, 16,762 people ), incorrectly identified: · between 40 to 100 out of 100 infected people as healthy · between 0 to 34 out of 100 healthy people as infected Temperature measurements , asking about international travel , exposure to known infected people and exposure to known or suspected infected people (6 studies, 14,741 people), incorrectly identified : · between 77 and 100 out of 100 infected people as healthy · between 0 and 10 out of 100 healthy people as infected Asking about symptoms plus temperature measurement (2 studies, 779 people), incorrectly identified: · between 31 and 88 out of 100 infected people as healthy · between 0 to 10 people out of 100 healthy people as infected There was insufficient evidence from two small studies on rapid laboratory tests and repeated symptom assessment to tell how accurate they were in identifying healthy and infected people. Modelling studies 
Three studies modelled entry and exit screening in airports. One study missed 70% of infected travellers. Another detected 90% of infections, but used an unrealistic scenario. The third used very unreliable methods so we cannot use evidence from this study. How confident are we in the results of the studies? Our confidence in these findings is limited because most studies did not describe their screening methods clearly, some found very few cases of infections and the types of participants and settings varied greatly, making it difficult to judge whether the results apply broadly. Authors’ conclusions One‐time screening in apparently healthy people is likely to miss people who are infected. We are unsure whether combined screenings, repeated symptom assessment, or rapid laboratory tests are useful. As more people become infected, screening will identify more cases. However, because screening can miss people who are infected, public health measures such as face coverings, physical distancing, and quarantine for those who are apparently healthy, continue to be very important.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.071Z" }, { "id": "59d3df24-217b-4abf-a178-d33d81422fe4", "pmid": "", "title": "Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration leading to increased fracture risk. Risedronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts. This is an update of a Cochrane Review that was originally published in 2003. Objectives We assessed the benefits and harms of risedronate in the primary and secondary prevention of osteoporotic fractures for postmenopausal women at lower and higher risk for fractures, respectively. Search methods With broader and updated strategies, we searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE and Embase. A grey literature search, including the online databases ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), and drug approval agencies, as well as bibliography checks of relevant systematic reviews was also performed. Eligible trials published between 1966 to 24 March 2021 were identified. Selection criteria We included randomised controlled trials that assessed the benefits and harms of risedronate in the prevention of fractures for postmenopausal women. Participants must have received at least one year of risedronate, placebo or other anti‐osteoporotic drugs, with or without concurrent calcium/vitamin D. Major outcomes were clinical vertebral, non‐vertebral, hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. In the interest of clinical relevance and applicability, we classified a study as secondary prevention if its population fulfilled more than one of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, low bone mineral density (BMD)T score ≤ ‐2.5, and age ≥ 75 years old. If none of these criteria was met, the study was considered to be primary prevention. Data collection and analysis We used standard methodology expected by Cochrane. We pooled the relative risk (RR) of fractures using a fixed‐effect model based on the expectation that the clinical and methodological characteristics of the respective primary and secondary prevention studies would be homogeneous, and the experience from the previous review suggesting that there would be a small number of studies. The base case included the data available for the longest treatment period in each placebo‐controlled trial and a >15% relative change was considered clinically important. The main findings of the review were presented in summary of findings tables, using the GRADE approach. In addition, we looked at benefit and harm comparisons between different dosage regimens for risedronate and between risedronate and other anti‐osteoporotic drugs. Main results Forty‐three trials fulfilled the eligibility criteria, among which 33 studies (27,348 participants) reported data that could be extracted and quantitatively synthesized. We had concerns about particular domains of risk of bias in each trial. Selection bias was the most frequent concern, with only 24% of the studies describing appropriate methods for both sequence generation and allocation concealment. Fifty per cent and 39% of the studies reporting benefit and harm outcomes, respectively, were subject to high risk. None of the studies included in the quantitative syntheses were judged to be at low risk of bias in all seven domains. The results described below pertain to the comparisons for daily risedronate 5 mg versus placebo which reported major outcomes. Other comparisons are described in the full text. For primary prevention, low‐ to very low‐certainty evidence was collected from four studies (one to two years in length) including 989 postmenopausal women at lower risk of fractures. Risedronate 5 mg/day may make little or no difference to wrist fractures [RR 0.48 ( 95% CI 0.03 to 7.50; two studies, 243 participants); absolute risk reduction (ARR) 0.6% fewer (95% CI 1% fewer to 7% more)] and withdrawals due to adverse events [RR 0.67 (95% CI 0.38 to 1.18; three studies, 748 participants); ARR 2% fewer (95% CI 5% fewer to 1% more)], based on low‐certainty evidence. However, its preventive effects on non‐vertebral fractures and serious adverse events are not known due to the very low‐certainty evidence. There were zero clinical vertebral and hip fractures reported therefore the effects of risedronate for these outcomes are not estimable. For secondary prevention, nine studies (one to three years in length) including 14,354 postmenopausal women at higher risk of fractures provided evidence. Risedronate 5 mg/day probably prevents non‐vertebral fractures [RR 0.80 (95% CI 0.72 to 0.90; six studies, 12,173 participants); RRR 20% (95% CI 10% to 28%) and ARR 2% fewer (95% CI 1% fewer to 3% fewer), moderate certainty], and may reduce hip fractures [RR 0.73 (95% CI 0.56 to 0.94); RRR 27% (95% CI 6% to 44%) and ARR 1% fewer (95% CI 0.2% fewer to 1% fewer), low certainty]. Both of these effects are probably clinically important. However, risedronate's effects are not known for wrist fractures [RR 0.64 (95% CI 0.33 to 1.24); three studies,1746 participants); ARR 1% fewer (95% CI 2% fewer to 1% more), very‐low certainty] and not estimable for clinical vertebral fractures due to zero events reported (low certainty). Risedronate results in little to no difference in withdrawals due to adverse events [RR 0.98 (95% CI 0.90 to 1.07; eight studies, 9529 participants); ARR 0.3% fewer (95% CI 2% fewer to 1% more); 16.9% in risedronate versus 17.2% in control, high certainty] and probably results in little to no difference in serious adverse events [RR 1.00 (95% CI 0.94 to 1.07; six studies, 9435 participants); ARR 0% fewer (95% CI 2% fewer to 2% more; 29.2% in both groups, moderate certainty). Authors' conclusions This update recaps the key findings from our previous review that, for secondary prevention, risedronate 5 mg/day probably prevents non‐vertebral fracture, and may reduce the risk of hip fractures. We are uncertain on whether risedronate 5mg/day reduces clinical vertebral and wrist fractures. Compared to placebo, risedronate probably does not increase the risk of serious adverse events. For primary prevention, the benefit and harms of risedronate were supported by limited evidence with high uncertainty. Plain language summary Risedronate for preventing fractures caused by osteoporosis in postmenopausal women This summary of a Cochrane Review presents what we know from the evidence up to 24 March 2021 about the effect of risedronate for preventing fractures (broken bones) caused by osteoporosis. What is osteoporosis and what is risedronate? 
Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow and old bone cells break down to make room for the new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break even after a minor injury, like a little bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. Risedronate belongs to the class of drugs called bisphosphonates. It is a type of medication that slows down the cells that break down the old bone. In postmenopausal women whose bone density is closer to normal or who may not yet have had a fracture in the bones of their spine therefore putting them at lower risk for fractures: ‐ there is insufficient evidence to tell us if risedronate leads to any reduction in the number of women sustaining bone fractures; ‐ based on limited data there is no evidence of an increase in adverse events for postmenopausal women at lower risk for fractures. In postmenopausal women who have already been diagnosed with osteoporosis (who have low bone density, or who have already had a fracture in the bones of their spine) putting them at higher risk for fractures, risedronate: ‐ probably prevents fractures in the bones of the hip and in bones other than in the spine; ‐ may not lead to any difference in preventing wrist fractures; ‐ does not have enough evidence to show if it may prevent fractures in the bones of the spine suggested by clinical signs and symptoms; ‐ might make little or no difference in adverse events for postmenopausal women at higher risk for fractures. Best estimate of what happens to postmenopausal women at lower risk for fractures who take risedronate or placebo: ‐ for spine fractures suggested by clinical signs and symptoms and hip fractures, it was not possible to calculate the effect because none of these fractures were reported in any of the studies; ‐ compared to placebo, there is not enough information to tell if risedronate prevents fractures in wrist and bones other than in the spine. Best estimate of what happens to postmenopausal women at higher risk for fractures who take risedronate or placebo: Fractures of the spine suggested by clinical signs and symptoms were not reported in any of the studies. Fractures in bones other than the spine: ‐ 10 out of 100 women had a fracture when taking a placebo; ‐ 8 out of 100 women had a fracture when taking risedronate; Fractures of the hip ‐ 3 out of 100 women had a fracture when taking a placebo; ‐ 2 out of 100 women had a fracture when taking risedronate. Fractures of the wrist: ‐ there is not enough information to tell if risedronate prevents wrist fractures.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wells, GA; Hsieh, S-C; Zheng, C; Peterson, J; Liu, W; Kelly, SE; Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD004523.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "59d6a813-4ef7-4a71-ad0d-feb60de60f5d", "pmid": "", "title": "The Role of Sweet Taste Receptor Blockade on Intraduodenal Glucose- and Liquid Meal-stimulated Secretion of Satiation Peptides in Healthy Humans", "imported": false, "abstract": "The purpose of this study is to determine the functional significance of sweet taste receptors in the secretion of GI satiation peptides by using a specific sweet taste receptor antagonist to block sweet taste perception in the gastrointestinal tract.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.143Z" }, { "id": "59dfeee0-2388-48f9-9d9f-6e2d6517c78c", "pmid": "", "title": "Antiemetics for adults for prevention of nausea and vomiting caused by moderately or highly emetogenic chemotherapy: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background About 70% to 80% of adults with cancer experience chemotherapy‐induced nausea and vomiting (CINV). CINV remains one of the most distressing symptoms associated with cancer therapy and is associated with decreased adherence to chemotherapy. Combining 5‐hydroxytryptamine‐3 (5‐HT₃) receptor antagonists with corticosteroids or additionally with neurokinin‐1 (NK₁) receptor antagonists is effective in preventing CINV among adults receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Various treatment options are available, but direct head‐to‐head comparisons do not allow comparison of all treatments versus another. Objectives • In adults with solid cancer or haematological malignancy receiving HEC ‐ To compare the effects of antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids on prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting in network meta‐analysis (NMA) ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy • In adults with solid cancer or haematological malignancy receiving MEC ‐ To compare whether antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids are superior for prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting to treatment combinations including 5‐HT₃ receptor antagonists and corticosteroids solely, in network meta‐analysis ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy Search methods We searched CENTRAL, MEDLINE, Embase, conference proceedings, and study registries from 1988 to February 2021 for randomised controlled trials (RCTs). Selection criteria We included RCTs including adults with any cancer receiving HEC or MEC (according to the latest definition) and comparing combination therapies of NK₁ and 5‐HT₃ inhibitors and corticosteroids for prevention of CINV. Data collection and analysis We used standard methodological procedures expected by Cochrane. We expressed treatment effects as risk ratios (RRs). Prioritised outcomes were complete control of vomiting during delayed and overall phases, complete control of nausea during the overall phase, quality of life, serious adverse events (SAEs), and on‐study mortality. We assessed GRADE and developed 12 'Summary of findings' tables. We report results of most crucial outcomes in the abstract, that is, complete control of vomiting during the overall phase and SAEs. For a comprehensive illustration of results, we randomly chose aprepitant plus granisetron as exemplary reference treatment for HEC, and granisetron as exemplary reference treatment for MEC. Main results Highly emetogenic chemotherapy ( HEC) We included 73 studies reporting on 25,275 participants and comparing 14 treatment combinations with NK₁ and 5‐HT₃ inhibitors. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 704 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with aprepitant + granisetron. Evidence from NMA (39 RCTs, 21,642 participants; 12 treatment combinations with NK₁ and 5‐HT₃ inhibitors) suggests that the following drug combinations are more efficacious than aprepitant + granisetron for completely controlling vomiting during the overall treatment phase (one to five days): fosnetupitant + palonosetron (810 of 1000; RR 1.15, 95% confidence interval (CI) 0.97 to 1.37; moderate certainty), aprepitant + palonosetron (753 of 1000; RR 1.07, 95% CI 1.98 to 1.18; low‐certainty), aprepitant + ramosetron (753 of 1000; RR 1.07, 95% CI 0.95 to 1.21; low certainty), and fosaprepitant + palonosetron (746 of 1000; RR 1.06, 95% CI 0.96 to 1.19; low certainty). Netupitant + palonosetron (704 of 1000; RR 1.00, 95% CI 0.93 to 1.08; high‐certainty) and fosaprepitant + granisetron (697 of 1000; RR 0.99, 95% CI 0.93 to 1.06; high‐certainty) have little to no impact on complete control of vomiting during the overall treatment phase (one to five days) when compared to aprepitant + granisetron, respectively. Evidence further suggests that the following drug combinations are less efficacious than aprepitant + granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): aprepitant + ondansetron (676 of 1000; RR 0.96, 95% CI 0.88 to 1.05; low certainty), fosaprepitant + ondansetron (662 of 1000; RR 0.94, 95% CI 0.85 to 1.04; low certainty), casopitant + ondansetron (634 of 1000; RR 0.90, 95% CI 0.79 to 1.03; low certainty), rolapitant + granisetron (627 of 1000; RR 0.89, 95% CI 0.78 to 1.01; moderate certainty), and rolapitant + ondansetron (598 of 1000; RR 0.85, 95% CI 0.65 to 1.12; low certainty). We could not include two treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 35 of 1000 participants experience any SAEs when treated with aprepitant + granisetron. Evidence from NMA (23 RCTs, 16,065 participants; 11 treatment combinations) suggests that fewer participants may experience SAEs when treated with the following drug combinations than with aprepitant + granisetron: fosaprepitant + ondansetron (8 of 1000; RR 0.23, 95% CI 0.05 to 1.07; low certainty), casopitant + ondansetron (8 of 1000; RR 0.24, 95% CI 0.04 to 1.39; low certainty), netupitant + palonosetron (9 of 1000; RR 0.27, 95% CI 0.05 to 1.58; low certainty), fosaprepitant + granisetron (13 of 1000; RR 0.37, 95% CI 0.09 to 1.50; low certainty), and rolapitant + granisetron (20 of 1000; RR 0.57, 95% CI 0.19 to 1.70; low certainty). Evidence is very uncertain about the effects of aprepitant + ondansetron (8 of 1000; RR 0.22, 95% CI 0.04 to 1.14; very low certainty), aprepitant + ramosetron (11 of 1000; RR 0.31, 95% CI 0.05 to 1.90; very low certainty), fosaprepitant + palonosetron (12 of 1000; RR 0.35, 95% CI 0.04 to 2.95; very low certainty), fosnetupitant + palonosetron (13 of 1000; RR 0.36, 95% CI 0.06 to 2.16; very low certainty), and aprepitant + palonosetron (17 of 1000; RR 0.48, 95% CI 0.05 to 4.78; very low certainty) on the risk of SAEs when compared to aprepitant + granisetron, respectively. We could not include three treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron, rolapitant + ondansetron) in NMA for this outcome because of missing direct comparisons. Moderately emetogenic chemotherapy (MEC) We included 38 studies reporting on 12,038 participants and comparing 15 treatment combinations with NK₁ and 5‐HT₃ inhibitors, or 5‐HT₃ inhibitors solely. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 555 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with granisetron. Evidence from NMA (22 RCTs, 7800 participants; 11 treatment combinations) suggests that the following drug combinations are more efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days): aprepitant + palonosetron (716 of 1000; RR 1.29, 95% CI 1.00 to 1.66; low certainty), netupitant + palonosetron (694 of 1000; RR 1.25, 95% CI 0.92 to 1.70; low certainty), and rolapitant + granisetron (660 of 1000; RR 1.19, 95% CI 1.06 to 1.33; high certainty). Palonosetron (588 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) and aprepitant + granisetron (577 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) may or may not increase complete response in the overall treatment phase (one to five days) when compared to granisetron, respectively. Azasetron (560 of 1000; RR 1.01, 95% CI 0.76 to 1.34; low certainty) may result in little to no difference in complete response in the overall treatment phase (one to five days) when compared to granisetron. Evidence further suggests that the following drug combinations are less efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): fosaprepitant + ondansetron (500 of 1000; RR 0.90, 95% CI 0.66 to 1.22; low certainty), aprepitant + ondansetron (477 of 1000; RR 0.86, 95% CI 0.64 to 1.17; low certainty), casopitant + ondansetron (461 of 1000; RR 0.83, 95% CI 0.62 to 1.12; low certainty), and ondansetron (433 of 1000; RR 0.78, 95% CI 0.59 to 1.04; low certainty). We could not include five treatment combinations (fosaprepitant + granisetron, azasetron, dolasetron, ramosetron, tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 153 of 1000 participants experience any SAEs when treated with granisetron. Evidence from pair‐wise comparison (1 RCT, 1344 participants) suggests that more participants may experience SAEs when treated with rolapitant + granisetron (176 of 1000; RR 1.15, 95% CI 0.88 to 1.50; low certainty). NMA was not feasible for this outcome because of missing direct comparisons. Certainty of evidence Our main reason for downgrading was serious or very serious imprecision (e.g. due to wide 95% CIs crossing or including unity, few events leading to wide 95% CIs, or small information size). Additional reasons for downgrading some comparisons or whole networks were serious study limitations due to high risk of bias or moderate inconsistency within networks. Authors' conclusions This field of supportive cancer care is very well researched. However, new drugs or drug combinations are continuously emerging and need to be systematically researched and assessed. For people receiving HEC, synthesised evidence does not suggest one superior treatment for prevention and control of chemotherapy‐induced nausea and vomiting. For people receiving MEC, synthesised evidence does not suggest superiority for treatments including both NK₁ and 5‐HT₃ inhibitors when compared to treatments including 5‐HT₃ inhibitors only. Rather, the results of our NMA suggest that the choice of 5‐HT₃ inhibitor may have an impact on treatment efficacy in preventing CINV. When interpreting the results of this systematic review, it is important for the reader to understand that NMAs are no substitute for direct head‐to‐head comparisons, and that results of our NMA do not necessarily rule out differences that could be clinically relevant for some individuals. Plain language summary Which drug combinations are best for prevention of nausea and vomiting caused by chemotherapy in adults with cancer? The burden of nausea and vomiting caused by chemotherapy and what helps to prevent it? In about 70% to 80% of adults with cancer, chemotherapy induces nausea and vomiting (CINV). Depending on the type of chemotherapy, treatment can cause strong or moderate sickness (hereafter referred to as HEC (highly emetogenic chemotherapy) and MEC (moderately emetogenic chemotherapy)). Multiple drug combinations have showed high benefit for CINV among adults receiving HEC or MEC. What was the aim of our review? Using a network meta‐analysis, we aimed to compare the benefits and harms of different drug combinations for prevention of CINV among people receiving HEC or MEC, and to identify treatment ranking. A network meta‐analysis is a technique used to compare different treatments described in already published trials, even when the original individual trial does not describe such comparisons. What studies did we look at? We searched selected medical databases and trial registries until February 2021. We included studies comparing multiple drug combinations for prevention of CINV among adults with any type of cancer receiving HEC or MEC that is commonly used in clinical practice. In particular, we looked at drugs inhibiting two specific biochemical receptors (neurokinin receptor and serotonin receptor) that trigger nausea and vomiting after chemotherapy. We looked at the preventative effects of these treatments over five days. This is the period during which the maximum intensity of CINV and further peaks of intensity are expected, after the start of chemotherapy. Our key results... ...for people receiving HEC We found 73 studies that reported on the experience of 25,275 participants and compared 14 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped to prevent any vomiting in 60% to 81% of people on average. Those individuals also had no need for rescue medicines, which are used in case nausea and vomiting occur even though prophylactic treatment has been given. The results of our analysis suggest some differences in effectiveness of different treatments, but overall we had little confidence that those differences would be reflected in real‐world observations. Harms. We estimated that 1% to 4% of people experience serious side effects. The differences between treatments were small. ...for people receiving MEC We found 38 studies that reported on the experience of 12,038 participants and compared 15 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped prevent any vomiting in 43% to 72% of people on average. Those individuals also had no need for rescue medicines. The results of our analysis suggest some differences in the effectiveness of different treatments, but overall, we had little confidence that those differences would be reflected in real‐world observations. Harms. Few studies reported serious side effects. The ones that did suggest that on average 15% to 18% of people experience such events. Differences between treatments were small. However, we think that future research is needed to rule out potential differences between treatments. Our confidence in the findings We assessed how confident we were that there are differences between compared treatments. We had low or very low confidence that one treatment is better or worse than another in preventing CINV. Our confidence in differences between statistical results was mainly limited because measures of variation were wide apart and included both potential advantages and disadvantages, although measures of precision showed no or little effect. We also identified limitations in some of the included studies, which further limited our confidence in the effects. This was mainly the case when study personnel and participants knew which treatments were given and therefore may not adhere to the planned intervention, or may perceive or report effects differently. Our conclusions The results of our analysis suggest that there is no superior drug combination for prevention of CINV for people receiving HEC or MEC. However, results suggest that the choice of drugs targeting the serotonin receptor may impact effectiveness, irrespective of whether given with or without a drug targeting the neurokinin receptor. However, when interpreting these results, it is important for the reader to understand that these kinds of multiple‐comparison analyses are no substitute for head‐to‐head comparisons, and that the results do not necessarily rule out differences that could be clinically relevant for some individuals. How up‐to‐date is this evidence? Evidence is up‐to‐date to 2 February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Piechotta, V; Adams, A; Haque, M; Scheckel, B; Kreuzberger, N; Monsef, I; Jordan, K; Kuhr, K; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "59ec319f-4150-4700-b7de-fb554af58e65", "pmid": "", "title": "Sucrose analgesia for heel‐lance procedures in neonates", "imported": false, "abstract": "Abstract - Background Sucrose has been examined for calming and pain‐relieving effects in neonates for invasive procedures such as heel lance. Objectives To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long‐term outcomes Search methods We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries. Selection criteria We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non‐nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin‐to‐skin care. Data collection and analysis We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. We assessed heterogeneity by the I 2 test. We used GRADE to assess certainty of evidence. Main results We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing. Sucrose vs control The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD ‐1.74 (95% CI ‐2.11 to ‐1.37); I 2 = 62%; moderate‐certainty evidence) and 60 seconds after lancing (MD ‐2.14, 95% CI ‐3.34 to ‐0.94; I 2 = 0%; moderate‐certainty evidence). The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD ‐1.90, 95% CI ‐8.58 to 4.78; heterogeneity not applicable (N/A); very low‐certainty evidence). The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD ‐2.00, 95% CI ‐2.42 to ‐1.58; heterogeneity N/A; moderate‐certainty evidence). Sucrose vs NNS The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI ‐0.30 to 1.50; heterogeneity not applicable; very low‐certainty evidence) and on DAN scores at 30 seconds after lancing (MD ‐1.20, 95% CI ‐7.87 to 5.47; heterogeneity N/A; very low‐certainty evidence). Sucrose + NNS vs NNS The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD ‐4.90, 95% CI ‐5.73 to ‐4.07; heterogeneity not applicable; very low‐certainty evidence) and during recovery after lancing (MD ‐3.80, 95% CI ‐4.47 to ‐3.13; heterogeneity N/A; very low‐certainty evidence). The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD ‐0.60, 95% CI ‐1.47 to 0.27; heterogeneity N/A; very low‐certainty evidence). Sucrose vs glucose The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI ‐0.70 to 1.22; heterogeneity not applicable; low‐certainty evidence) and 60 seconds after lancing (MD ‐0.02, 95% CI ‐0.79 to 0.75; heterogeneity N/A; low‐certainty evidence). Sucrose vs breastfeeding The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD ‐0.70, 95% CI ‐0.49 to 1.88; I 2 = 94%; very low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD ‐2.60, 95% CI ‐3.06 to ‐2.14; heterogeneity N/A; very low‐certainty evidence). Sucrose vs expressed breast milk The evidence suggests that sucrose may result in little to no difference in PIPP‐R scores compared to expressed breast milk during (MD 0.3, 95% CI ‐0.24 to 0.84; heterogeneity not applicable; low‐certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI ‐0.11 to 0.71; heterogeneity N/A; low‐certainty evidence). The evidence suggests that sucrose probably may result in slightly increased PIPP‐R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD ‐1.80, 95% CI ‐8.47 to 4.87; heterogeneity N/A; very low‐certainty evidence). Sucrose vs laser acupuncture There was no difference in PIPP‐R scores between sucrose and music groups; however, data were reported as medians and IQRs. The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD ‐0.86, 95% CI ‐1.43 to ‐0.29; heterogeneity N/A; very low‐certainty evidence). Sucrose vs facilitated tucking The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD ‐2.27, 95% CI ‐4.66 to 0.12; heterogeneity N/A; very low‐certainty evidence) and during recovery after lancing (MD ‐0.31, 95% CI ‐1.72 to 1.10; heterogeneity N/A; very low‐certainty evidence). Sucrose vs skin‐to‐skin + water (repeated lancing) The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 30 seconds after 1st (MD 0.13, 95% CI ‐0.70 to 0.96); 2nd (MD ‐0.56, 95% CI ‐1.57 to 0.45); or 3rd lancing (MD‐0.15, 95% CI ‐1.26 to 0.96); heterogeneity N/A, low‐certainty evidence for all comparisons. The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 60 seconds after 1st (MD –0.61, 95% CI ‐1.55 to 0.33); 2nd (MD ‐0.12, 95% CI ‐0.99 to 0.75); or 3rd lancing (MD‐0.40, 95% CI ‐1.48 to 0.68); heterogeneity N/A, low‐certainty evidence for all comparisons. Minor adverse events required no intervention. Authors' conclusions Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate‐certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin‐to‐skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing heel lance Key messages ‐ Sucrose, compared to control interventions, probably reduces pain for a single painful event (heel lance). ‐ There were a few minor immediate adverse events, such as gagging, that resolved without intervention. ‐ We need studies that assess the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. ‐ We need to assess how sucrose affects neonates who are extremely preterm, unstable, or ventilated (or a combination of these factors). What is sucrose analgesia? Sucrose (table sugar) is mixed with water in various concentrations (usually 24%) and is given to babies in very small amounts (e.g. a few drops) about two minutes before a painful procedure. Sucrose is also given with other nondrug pain‐relieving interventions such as a pacifier (non‐nutritive sucking ‐ NNS) or when the baby is receiving skin‐to‐skin care. Why is this important for newborn babies who are undergoing heel lance procedures? Babies who are sick or immature, and require a stay in hospital, have several painful procedures per day and multiple painful procedures throughout the hospital stay; for most babies, the majority of painful procedures are heel lances. If untreated, pain has immediate and long‐term consequences that can impact their brain and behavioural development. It is important to minimise the number of painful procedures and the associated pain and suffering. What did we want to find out? We wanted to know how well sucrose worked to relieve pain in newborn babies who are having heel lance procedures while they were in hospital. We also wanted to know whether there were any safety concerns about using sucrose to relieve pain from single painful events such as heel lance. What did we do? We searched for studies that investigated: ‐ Sucrose compared to no treatment or standard care; ‐ Sucrose compared to water, other sweet solutions (e.g. glucose); ‐ Sucrose compared to another nondrug intervention (e.g. NNS); ‐ Whether sucrose was effective in decreasing the amount and severity of pain that babies experienced as assessed by baby’s pain responses (e.g. crying, grimacing, heart rate) and by using standardised infant pain scales. We also wanted to know if sucrose was associated with any unwanted effects in preterm or term babies. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods. What did we find out? We reviewed 55 studies that included a total of 6273 babies. Twenty‐nine studies had full‐term babies only, 22 had preterm babies only, and four had both full‐term and preterm babies. Heel lance was the painful procedure in 50 studies. Five studies investigated a variety of other minor painful procedures in addition to heel lancing. Main results ‐ Sucrose compared to the control treatment probably reduces pain from single heel lances in babies. ‐ Results are uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, and facilitated tucking, in reducing pain scores. ‐ Results are uncertain about the effect of sucrose + NNS compared to NNS, in reducing pain. ‐ Sucrose does not seem to reduce pain from single heel lances compared to glucose, expressed breast milk, and skin‐to‐skin care. ‐ Reported adverse events were minor and resolved without any intervention. What are the limitations of the evidence? We have moderate‐certainty evidence that sucrose likely reduces pain from heel lance. How up‐to‐date is this evidence? This evidence is up‐to‐date as of February 2022. Study funding sources We did not identify any studies that received funding from industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yamada, J; Bueno, M; Santos, L; Haliburton, S; Campbell-Yeo, M; Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD014806", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "59f2da08-0840-45a6-8838-2e4b1f5d0bd3", "pmid": "", "title": "Environmental and behavioural modifications for improving food and fluid intake in people with dementia", "imported": false, "abstract": "Abstract - Background Weight loss, malnutrition and dehydration are common problems for people with dementia. Environmental modifications such as, change of routine, context or ambience at mealtimes, or behavioural modifications, such as education or training of people with dementia or caregivers, may be considered to try to improve food and fluid intake and nutritional status of people with dementia. Objectives Primary: To assess the effects of environmental or behavioural modifications on food and fluid intake and nutritional status in people with dementia. Secondary: To assess the effects of environmental or behavioural modifications in connection with nutrition on mealtime behaviour, cognitive and functional outcomes and quality of life, in specific settings (i.e. home care, residential care and nursing home care) for different stages of dementia. To assess the adverse consequences or effects of the included interventions. Search methods We searched the Specialized Register of Cochrane Dementia and Cognitive Improvement (ALOIS), MEDLINE, Eembase, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 17 January 2018. We scanned reference lists of other reviews and of included articles. Selection criteria We included randomised controlled trials (RCTs) investigating interventions designed to modify the mealtime environment of people with dementia, to modify the mealtime behaviour of people with dementia or their caregivers, or both, with the intention of improving food and fluid intake. We included people with any common dementia subtype. Data collection and analysis Two review authors independently selected studies, extracted data and assessed the risk of bias of included trials. We assessed the quality of evidence for each outcome using the GRADE approach. Main results We included nine studies, investigating 1502 people. Three studies explicitly investigated participants with Alzheimer's disease; six did not specify the type of dementia. Five studies provided clear measures to identify the severity of dementia at baseline, and overall very mild to severe stages were covered. The interventions and outcome measures were diverse. The overall quality of evidence was mainly low to very low. One study implemented environmental as well as behavioural modifications by providing additional food items between meals and personal encouragement to consume them. The control group received no intervention. Differences between groups were very small and the quality of the evidence from this study was very low, so we are very uncertain of any effect of this intervention. The remaining eight studies implemented behavioural modifications. Three studies provided nutritional education and nutrition promotion programmes. Control groups did not receive these programmes. After 12 months, the intervention group showed slightly higher protein intake per day (mean difference (MD) 0.11 g/kg, 95% confidence interval (CI) ‐0.01 to 0.23; n = 78, 1 study; low‐quality evidence), but there was no clear evidence of a difference in nutritional status assessed with body mass index (BMI) (MD ‐0.26 kg/m² favouring control, 95% CI ‐0.70 to 0.19; n = 734, 2 studies; moderate‐quality evidence), body weight (MD ‐1.60 kg favouring control, 95% CI ‐3.47 to 0.27; n = 656, 1 study; moderate‐quality evidence), or score on Mini Nutritional Assessment (MNA) (MD ‐0.10 favouring control, 95% CI ‐0.67 to 0.47; n = 656, 1 study; low‐quality evidence). After six months, the intervention group in one study had slightly lower BMI (MD ‐1.79 kg/m² favouring control, 95% CI ‐1.28 to ‐2.30; n = 52, 1 study; moderate‐quality evidence) and body weight (MD ‐8.11 kg favouring control, 95% CI ‐2.06 to ‐12.56; n = 52, 1 study; moderate‐quality evidence). This type of intervention may have a small positive effect on food intake, but little or no effect, or a negative effect, on nutritional status. Two studies compared self‐feeding skills training programmes. In one study, the control group received no training and in the other study the control group received a different self‐feeding skills training programme. For both comparisons the quality of the evidence was very low and we are very uncertain whether these interventions have any effect. One study investigated general training of nurses to impart knowledge on how to feed people with dementia and improve attitudes towards people with dementia. Again, the quality of the evidence was very low so that we cannot be certain of any effect. Two studies investigated vocal or tactile positive feedback provided by caregivers while feeding participants. After three weeks, the intervention group showed an increase in calories consumed per meal (MD 200 kcal, 95% CI 119.81 to 280.19; n = 42, 1 study; low‐quality evidence) and protein consumed per meal (MD 15g, 95% CI 7.74 to 22.26; n = 42, 1 study; low‐quality evidence). This intervention may increase the intake of food and liquids slightly; nutritional status was not assessed. Authors' conclusions Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia. Plain language summary Environmental and behavioural modifications for improving food and fluid intake in people with dementia What we wanted to know Weight loss, malnutrition and dehydration are common problems for people with dementia and can occur at any stage of the illness. People with dementia often develop psychological symptoms or behaviours which cause them to eat or drink less. In the later stages of the illness, they become dependent on others to help them eat or drink. We wanted to investigate how to keep people with dementia eating and drinking as well as possible. We looked for studies which changed the way food and drink are presented to people with dementia, and for studies which attempted to change the behaviour of people with dementia or of those helping them to eat. We called these environmental and behavioural modifications respectively, though some interventions include aspects of both. We were mainly interested in the effect on how much people with dementia ate and drank and on measures of how well‐nourished they were (e.g. body weight or body mass index (BMI)), but we also looked for effects on eating behaviour, symptoms of dementia and quality of life. How we tried to answer the question We searched for all the randomised controlled trials (RCTs) which were relevant to our question. In these trials, some people with dementia got an environmental or behavioural modification intended to improve their eating and drinking and were then compared with other people who had not had the intervention (the control group). Whether someone got the intervention or not was decided at random. We found nine RCTs to include in our review. In total, there were 1502 people in these trials. They had varying degrees of dementia, probably mostly due to Alzheimer's disease. Seven of the trials took place in care homes. In one trial, people were given extra snacks between meals and encouraged to eat them. In three trials, people with dementia were given education about diet and eating. In two trials, people with dementia were taught skills to help them to eat independently. In three trials, training was given to the carers responsible for helping people with dementia to eat. What we found out All the trials we found tested different interventions and measured their effects in different ways. Generally, the trials were small and there were problems with the way they were done, which reduced our confidence in the results. For some interventions, the quality of the evidence was so low that we could not draw any conclusions. For others, there was a mixture of positive and negative effects. What we concluded Because of the amount and quality of the evidence we found, we cannot at the moment, identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Herke, M, Fink, A, Langer, G, Wustmann, T, Watzke, S, Hanff, AM, Burckhardt, M", "articleTypes": [], "doi": "10.1002/14651858.CD011542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.773Z" }, { "id": "59f39550-3e46-46dd-9838-a0984536a5c2", "pmid": "", "title": "Vitamin D for the treatment of inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Vitamin D possesses immunomodulatory properties and has been implicated in the pathogenesis and severity of inflammatory bowel disease (IBD). Animal studies and emerging epidemiological evidence have demonstrated an association between vitamin D deficiency and worse disease activity. However, the role of vitamin D for the treatment of IBD is unclear. Objectives To evaluate the benefits and harms of vitamin D supplementation as a treatment for IBD. Search methods We used standard, extensive Cochrane search methods. The latest search date was Jun 2023. Selection criteria We included randomised controlled trials (RCTs) in people of all ages with active or inactive IBD comparing any dose of vitamin D with another dose of vitamin D, another intervention, placebo, or no intervention. We defined doses as: vitamin D (all doses), any‐treatment‐dose vitamin D (greater than 400 IU/day), high‐treatment‐dose vitamin D (greater than 1000 IU/day), low‐treatment‐dose vitamin D (400 IU/day to 1000 IU/day), and supplemental‐dose vitamin D (less than 400 IU/day). Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. clinical response for people with active disease, 2. clinical relapse for people in remission, 3. quality of life, and 4. withdrawals due to adverse events. Our secondary outcomes were 5. disease activity at end of study, 6. normalisation of vitamin D levels at end of study, and 7. total serious adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We included 22 RCTs with 1874 participants. Study duration ranged from four to 52 weeks. Ten studies enroled people with Crohn's disease (CD), five enroled people with ulcerative colitis (UC), and seven enroled people with CD and people with UC. Seventeen studies included adults, three included children, and two included both. Four studies enroled people with active disease, six enroled people in remission, and 12 enroled both. We assessed each study for risk of bias across seven individual domains. Five studies were at low risk of bias across all seven domains. Ten studies were at unclear risk of bias in at least one domain but with no areas of high risk of bias. Seven studies were at high risk of bias for blinding of participants and assessors. Vitamin D (all doses) versus placebo or no treatment Thirteen studies compared vitamin D against placebo or no treatment. We could not draw any conclusions on clinical response for UC as the certainty of the evidence was very low (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.51 to 10.57; 1 study, 60 participants). There were no data on CD. There may be fewer clinical relapses for IBD when using vitamin D compared to placebo or no treatment (RR 0.57, 95% CI 0.34 to 0.96; 3 studies, 310 participants). The certainty of the evidence was low. We could not draw any conclusions on quality of life for IBD (standardised mean difference (SMD) −0.13, 95% CI −3.10 to 2.83 (the SMD value indicates a negligent decrease in quality of life, and the corresponding CIs indicate that the effect can range from a large decrease to a large increase in quality of life); 2 studies, 243 participants) or withdrawals due to adverse events for IBD (RR 1.97, 95% CI 0.18 to 21.27; 12 studies, 1251 participants; note 11 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 12). The certainty of the evidence was very low. High‐treatment‐dose vitamin D versus low‐treatment‐dose vitamin D Five studies compared high treatment vitamin D doses against low treatment vitamin D doses. There were no data on clinical response. There may be no difference in clinical relapse for CD (RR 0.48, 95% CI 0.23 to 1.01; 1 study, 34 participants). The certainty of the evidence was low. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 0.89, 95% CI 0.06 to 13.08; 3 studies, 104 participants; note 2 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 3). The data on quality of life and disease activity could not be meta‐analysed, were of very low certainty, and no conclusions could be drawn. Any‐treatment‐dose vitamin D versus supplemental‐dose vitamin D Four studies compared treatment doses of vitamin D against supplemental doses. There were no data on clinical response and relapse. There were no data on quality of life that could be meta‐analysed. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 3.09, 95% CI 0.13 to 73.17; 4 studies, 233 participants; note 3 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 4). Authors' conclusions There may be fewer clinical relapses when comparing vitamin D with placebo, but we cannot draw any conclusions on differences in clinical response, quality of life, or withdrawals, due to very low‐certainty evidence. When comparing high and low doses of vitamin D, there were no data for clinical response, but there may be no difference in relapse for CD. We cannot draw conclusions on the other outcomes due to very low certainty evidence. Finally, comparing vitamin D (all doses) to supplemental‐dose vitamin D, there were no data on clinical relapse or response, and we could not draw conclusions on other outcomes due to very low certainty evidence or missing data. It is difficult to make any clear recommendations for future research on the basis of the findings of this review. Future studies must be clear on the baseline populations, the purpose of vitamin D treatment, and, therefore, study an appropriate dosing strategy. Stakeholders in the field may wish to reach consensus on such issues prior to new studies. Plain language summary Vitamin D for the treatment of inflammatory bowel disease Key messages The data we presently have for the use of vitamin D for the treatment of inflammatory bowel disease are of very low quality, and we do not know whether it works or if it is safe. What is inflammatory bowel disease? Inflammatory bowel disease is a life‐long disease that affects the gut. Its two main types are ulcerative colitis and Crohn's disease. Ulcerative colitis only affects the large intestine. Crohn's disease can affect any part of the gut, from mouth to bottom. Common symptoms include bloody poo, diarrhoea, stomach ache, fever, weight loss, and fatigue. We do not know exactly what causes it, but it is probably a mix of genes, problems with the immune system, bacteria in the gut, and something in the environment. There is no known cure, but the symptoms are usually managed with medicines, such as steroids and immune system medications, and sometimes surgery. Most people with inflammatory bowel disease have times when they have symptoms (called active disease) and other times when their symptoms are under control (called remission). When symptoms reappear after being in remission, it is called relapse. What did we want to find out? We wanted to find out if vitamin D works for the treatment of inflammatory bowel disease, and whether it is safe to use. Specifically, we looked at improvement of symptoms for people with active disease; relapse for people in remission; quality of life; and withdrawals from the trial because of side effects. What did we do? We searched for randomised controlled trials (studies where people are assigned to one of two or more treatment groups using a random method) comparing vitamin D with any other treatment, standard treatment, or different doses of vitamin D. What did we find? We found 22 trials with 1874 participants with inflammatory bowel disease. The studies lasted from four to 52 weeks. Ten studies were on Crohn's disease, five on ulcerative colitis, and seven on participants who had either of these. Seventeen studies were on adults, three on children, and two on both. Four included people with active disease, six in remission, and 12 on a mix of both. The studies included doses of vitamin D used to treat deficiency and doses given as supplements. Thirteen studies compared vitamin D (all doses) against placebo (dummy treatment) or no other treatment. There was low‐quality evidence that there may be fewer clinical relapses when using vitamin D compared to placebo or no treatment. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Five studies compared high‐treatment‐doses to low‐treatment‐doses of vitamin D. There were no data on improvement of symptoms. There was low‐quality evidence that there may be no difference on relapse in Crohn's disease, but there were no data on ulcerative colitis. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Four studies compared treatment doses to supplement doses of vitamin D. There were no data on improvement of symptoms, relapses, or quality of life changes. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. What are the limitations of the evidence? The evidence is mostly of very low and low quality. This is because of problems with the way the studies were carried out, and problems with how the results were reported. Additionally, the individual studies did not make the same measurements, meaning that we did not have enough numbers of people to strengthen the results of the measures we looked for. How up‐to‐date is this review? This review is up‐to‐date to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wallace, C, Gordon, M, Sinopoulou, V, Limketkai, BN", "articleTypes": [], "doi": "10.1002/14651858.CD011806.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.801Z" }, { "id": "5a048ebd-f1af-4cc7-a25d-d9dbc59d56a4", "pmid": "", "title": "Preoperative statin therapy for adults undergoing cardiac surgery", "imported": false, "abstract": "Abstract - Background Despite significant advances in surgical techniques and perioperative care, people undertaking cardiac surgery due to cardiovascular disease are more prone to the development of postoperative adverse events. Statins (5‐hydroxy‐3‐methylglutaryl‐co‐enzyme A (HMG‐CoA) reductase inhibitors) are well‐known for their anti‐inflammatory and antioxidant effects and are established for primary and secondary prevention of coronary artery disease. In addition, statins are thought to have clinical benefits in perioperative outcomes in people undergoing cardiac surgery. This review is an update of a review that was first published in 2012 and updated in 2015. Objectives To evaluate the benefits and harms of preoperative statin therapy in adults undergoing cardiac surgery compared to standard of care or placebo. Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2023), Ovid MEDLINE (1980 to 14 September 2023), and Ovid Embase (1980 to 2023 (week 36)). We applied no language restrictions. Selection criteria We included all randomised controlled trials (RCTs) comparing any statin treatment before cardiac surgery, for any given duration and dose, versus no preoperative statin therapy (standard of care) or placebo. We excluded trials without a registered trial protocol and trials without approval by an institutional ethics committee. Data collection and analysis We used standard Cochrane methodology. Primary outcomes were short‐term mortality and major adverse cardiovascular events. Secondary outcomes were myocardial infarction, atrial fibrillation, stroke, renal failure, length of intensive care unit (ICU) stay, length of hospital stay and adverse effects related to statin therapy. We reported effect measures as risk ratios (RRs) or mean differences (MDs) with corresponding 95% confidence intervals (CIs). We used the RoB 1 tool to assess the risk of bias in included trials, and GRADE to assess the certainty of the evidence. Main results We identified eight RCTs (five new to this review) including 5592 participants. Pooled analysis showed that statin treatment before surgery may result in little to no difference in the risk of postoperative short‐term mortality (RR 1.36, 95% CI 0.72 to 2.59; I 2 = 0%; 6 RCTs, 5260 participants; low‐certainty evidence; note 2 RCTs reported 0 events in both groups so RR calculated from 4 RCTs with 5143 participants). We are very uncertain about the effect of statins on major adverse cardiovascular events (RR 0.93, 95% CI 0.77 to 1.13; 1 RCT, 2406 participants; very low‐certainty evidence). Statins probably result in little to no difference in myocardial infarction (RR 0.88, 95% CI 0.73 to 1.06; I 2 = 0%; 5 RCTs, 4645 participants; moderate‐certainty evidence), may result in little to no difference in atrial fibrillation (RR 0.87, 95% CI 0.72 to 1.05; I 2 = 60%; 8 RCTs, 5592 participants; low‐certainty evidence), and may result in little to no difference in stroke (RR 1.47, 95% CI 0.90 to 2.40; I 2 = 0%; 4 RCTs, 5143 participants; low‐certainty evidence). We are very uncertain about the effect of statins on renal failure (RR 1.04, 95% CI 0.80 to 1.34; I 2 = 57%; 4 RCTs, 4728 participants; very low‐certainty evidence). Additionally, statins probably result in little to no difference in length of ICU stay (MD 1.40 hours, 95% CI −1.62 to 4.41; I 2 = 43%; 3 RCTs, 4528 participants; moderate‐certainty evidence) and overall hospital stay (MD −0.31 days, 95% CI −0.64 to 0.03; I 2 = 84%; 5 RCTs, 4788 participants; moderate‐certainty evidence). No study had any individual risk of bias domain classified as high. However, two studies were at high risk of bias overall given the classification of unclear risk of bias in three domains. Authors' conclusions In this updated Cochrane review, we found no evidence that statin use in the perioperative period of elective cardiac surgery was associated with any clinical benefit or worsening, when compared with placebo or standard of care. Compared with placebo or standard of care, statin use probably results in little to no difference in MIs, length of ICU stay and overall hospital stay; and may make little to no difference to mortality, atrial fibrillation and stroke. We are very uncertain about the effects of statins on major harmful cardiac events and renal failure. The certainty of the evidence validating this finding varied from moderate to very low, depending on the outcome. Future trials should focus on assessing the impact of statin therapy on mortality and major adverse cardiovascular events. Plain language summary Is it better to take statins before undergoing heart‐related surgery? Key messages – Taking statins may make little to no difference to death within 30 days of surgery, irregular heart rhythms and stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off); and probably results in little to no difference in heart attacks, length of intensive care unit stay and overall hospital stay. We are very uncertain about the effects of statins on kidney failure and harmful effects from statin treatment. – Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. What are the dangers of cardiac surgery and how may statins help? Cardiac surgeries can effectively treat people with heart and circulation problems. However, undergoing cardiac surgery also increases the risk of death, heart attack, stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off), irregular heart rhythms and kidney failure. This is partly because more than half of people undergoing cardiac surgery are over 70 years of age. To reduce these risks, we should try to improve recovery rates by preventing these problems from occurring before, during and after surgery. Statins are medications used throughout the world to lower blood cholesterol (a fatty substance found in the blood that may block blood vessels) levels and reduce the chances of cardiovascular issues becoming worse. Studies have shown that fewer people who had built up dangerous amounts of cholesterol in their blood vessels (arteries) died while taking statins. However, the potential benefits of taking statins in people undergoing cardiac surgery are unclear. What did we want to find out? We wanted to find out whether taking statins before undergoing cardiac surgery could help reduce the risk of: – death occurring shortly after surgery; or
– developing other heart or kidney problems. We also wanted to find out if there were any changes in the quality of care associated with cardiac surgeries for people who had been taking statins, such as reducing the length of hospital stay or intensive care unit stay, or if there were any harmful effects from statin treatment. What did we do? We searched for studies published up to September 2023 that compared treatment with statins to treatment with a placebo (a pretend medicine that looks or tastes identical to the medicine being tested) or usual care in people undergoing cardiac surgeries. Contrary to previous versions of this review, we only included trials that we were sure were approved by an ethical review board. What did we find? We found eight studies involving 5592 people with an average age of 63 years and 79% were men. Of these, 2798 people were treated with statins and 2794 people were not treated with statins before cardiac surgery. The smallest study included 57 people and the largest involved 2406 people. All studies were conducted in hospitals affiliated with universities in Asia, Europe and North America. Each study used different statin types (atorvastatin, fluvastatin, simvastatin, pravastatin or rosuvastatin) and doses (between 20 mg and 80 mg). Main results In people undergoing cardiac surgery, compared to no statin treatment, statin treatment: – probably results in little to no difference in heart attacks (5 studies, 4645 people), length of intensive care unit stay (3 studies, 4528 people) and overall hospital stay (5 studies, 4788 people); – may make little to no difference to death within 30 days of surgery (6 studies, 5260 people), irregular heart rhythm (8 studies, 5592 people) and stroke (4 studies, 5143 people). We are very uncertain about the effects of statins on major harmful cardiac events (1 study, 2406 people) and kidney failure (4 studies, 4728 people). What are the limitations of the evidence? We are moderately confident in our findings that there were probably little to no differences in the risk of heart attack, length of hospital and intensive care unit stay. However, we have little to very little confidence about our other findings, namely the most important finding we were looking for, which was a reduction in death. This is because most of the studies had many differences between them, there were fewer comparative cases than expected, and the studies did not always provide information about the statin intervention or treatment outcomes we were interested in. In addition, all studies used a different approach to statin treatment, which made them difficult to compare. Overall, this lowered our confidence in the evidence. Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. How up to date is this evidence? This is an update of a Cochrane review. The evidence is up to date to September 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Marques Antunes, M; Nunes-Ferreira, A; Duarte, GS; Gouveia e Melo, R; Sucena Rodrigues, B; Guerra, NC; Nobre, A; Pinto, FJ; Costa, J; Caldeira, D", "articleTypes": [], "doi": "10.1002/14651858.CD008493.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "5a1e96c3-aa02-4bc4-8b94-047c401cf263", "pmid": "", "title": "A Randomized, Multicenter, Adaptive Phase II/III Study To Evaluate The Efficacy And Safety Of Trastuzumab Emtansine (T-DM1) Versus Taxane (Docetaxel Or Paclitaxel) In Patients With Previously Treated Locally Advanced Or Metastatic HER2-Positive Gastric Cancer, Including Adenocarcinoma Of The Gastroesophageal Junction", "imported": false, "abstract": "This multicenter, randomized, adaptive Phase II/III study will evaluate the efficacy and safety of trastuzumab emtansine (T-DM1) compared to standard taxane (docetaxel or paclitaxel) treatment in participants with human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer. At the start of the trial (stage 1), participants will be randomized with a ratio 2:2:1 to one of three treatment arms: Arm A: trastuzumab emtansine 3.6 milligram per kilogram (mg/kg) per intravenous injection (IV) every 3 weeks; Arm B: trastuzumab emtansine 2.4 mg/kg IV every week; Arm C: standard taxane therapy (docetaxel 75 milligram per meter square [mg/m^2] IV every 3 weeks or paclitaxel 80 mg/m^2 kg IV every week per investigator choice). At the end of the first stage of the study, the dose and schedule of trastuzumab emtansine that will be used in the second stage of the study will be selected by an Independent Data Monitoring Committee (IDMC). The regimen selection analysis will be made after approximately 100 participants across all three study arms have been treated for at least 12 weeks.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.264Z" }, { "id": "5a30a071-56d9-4a8a-8064-ba43c5f600a4", "pmid": "", "title": "Combined aclidinium bromide and long‐acting beta2‐agonist for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Several dual bronchodilator combinations of long‐acting beta 2 ‐agonist (LABA) and long‐acting muscarinic antagonist (LAMA) have been approved for treatment of stable chronic obstructive pulmonary disease (COPD). The current GOLD (Global Initiative for Chronic Obstructive Lung Disease) recommendations suggest the use of LABA/LAMA combinations in people with group B COPD with persistent symptoms, group C COPD with further exacerbations on LAMA therapy alone and group D COPD with or without inhaled corticosteroids (ICS). Fixed‐dose combination (FDC) of aclidinium/formoterol is one of the approved LABA/LAMA therapies for people with stable COPD. Objectives To assess the efficacy and safety of combined aclidinium bromide and long‐acting beta 2 ‐agonists in stable COPD. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov, World Health Organization (WHO) trials portal, United States Food and Drug Administration (FDA) and manufacturers' websites as well as the reference list of published trials up to 12 October 2018. Selection criteria Parallel‐group randomised controlled trials (RCTs) assessing combined aclidinium bromide and LABAs in people with stable COPD. Data collection and analysis We used standard methodological procedures expected by Cochrane for data collection and analysis. The primary outcomes were exacerbations requiring a short course of an oral steroid or antibiotic, or both; quality of life measured by a validated scale and non‐fatal serious adverse events (SAEs). Where the outcome or study details were not reported, we contacted the study investigators or pharmaceutical company trial co‐ordinators (or both) for missing data. Main results We identified RCTs comparing aclidinium/formoterol FDC versus aclidinium, formoterol or placebo only. We included seven multicentre trials of four to 52 weeks' duration conducted in outpatient settings. There were 5921 participants, whose mean age ranged from 60.7 to 64.7 years, mostly men with a mean smoking pack‐years of 46.4 to 61.3 of which 43.9% to 63.4% were current smokers. They had a moderate‐to‐severe degree of COPD with a mean postbronchodilator forced expiratory volume in one second (FEV 1 ) between 50.5% and 61% of predicted normal and the baseline mean FEV 1 of 1.23 L to 1.43 L. We assessed performance and detection biases as low for all studies whereas selection, attrition and reporting biases were either low or unclear. FDC versus aclidinium There was no evidence of a difference between FDC and aclidinium for exacerbations requiring steroids or antibiotics, or both (OR 0.95, 95% CI 0.71 to 1.27; 2 trials, 2156 participants; moderate‐certainty evidence); quality of life measured by St George's Respiratory Questionnaire (SGRQ) total score (MD –0.92, 95% CI –2.15 to 0.30); participants with significant improvement in SGRQ score (OR 1.17, 95% CI 0.97 to 1.41; 2 trials, 2002 participants; moderate‐certainty evidence); non‐fatal SAE (OR 1.19, 95% CI 0.79 to 1.80; 3 trials, 2473 participants; moderate‐certainty evidence); hospital admissions due to severe exacerbations (OR 0.62, 95% CI 0.29 to 1.29; 2 trials, 2156 participants; moderate‐certainty evidence) or adverse events (OR 0.95, 95% CI 0.76 to 1.18; 3 trials, 2473 participants; moderate‐certainty evidence). Compared with aclidinium, FDC improved symptoms (Transitional Dyspnoea Index (TDI) focal score: MD 0.37, 95% CI 0.07 to 0.68; 2 trials, 2013 participants) with a higher chance of achieving a minimal clinically important difference (MCID) of at least one unit improvement (OR 1.34, 95% CI 1.11 to 1.62; high‐certainty evidence); the number needed to treat for an additional beneficial outcome (NNTB) being 14 (95% CI 9 to 39). FDC versus formoterol When compared to formoterol, combination therapy reduced exacerbations requiring steroids or antibiotics, or both (OR 0.78, 95% CI 0.62 to 0.99; 3 trials, 2694 participants; high‐certainty evidence); may decrease SGRQ total score (MD –1.88, 95% CI –3.10 to –0.65; 2 trials, 2002 participants; low‐certainty evidence; MCID for SGRQ is 4 units); increased TDI focal score (MD 0.42, 95% CI 0.11 to 0.72; 2 trials, 2010 participants) with more participants attaining an MCID (OR 1.30, 95% CI 1.07 to 1.56; high‐certainty evidence) and an NNTB of 16 (95% CI 10 to 60). FDC lowered the risk of adverse events compared to formoterol (OR 0.78, 95% CI 0.65 to 0.93; 5 trials, 3140 participants; high‐certainty evidence; NNTB 22). However, there was no difference between FDC and formoterol for hospital admissions, all‐cause mortality and non‐fatal SAEs. FDC versus placebo Compared with placebo, FDC demonstrated no evidence of a difference in exacerbations requiring steroids or antibiotics, or both (OR 0.82, 95% CI 0.60 to 1.12; 2 trials, 1960 participants; moderate‐certainty evidence) or hospital admissions due to severe exacerbations (OR 0.55, 95% CI 0.25 to 1.18; 2 trials, 1960 participants; moderate‐certainty evidence), although estimates were uncertain. Quality of life measure by SGRQ total score was significantly better with FDC compared to placebo (MD –2.91, 95% CI –4.33 to –1.50; 2 trials, 1823 participants) resulting in a corresponding increase in SGRQ responders who achieved at least four units decrease in SGRQ total score (OR 1.72, 95% CI 1.39 to 2.13; high‐certainty evidence) with an NNTB of 7 (95% CI 5 to 12). FDC also improved symptoms measured by TDI focal score (MD 1.32, 95% CI 0.96 to 1.69; 2 studies, 1832 participants) with more participants attaining at least one unit improvement in TDI focal score (OR 2.51, 95% CI 2.02 to 3.11; high‐certainty evidence; NNTB 4). There were no differences in non‐fatal SAEs, adverse events and all‐cause mortality between FDC and placebo. Combination therapy significantly improved trough FEV 1 compared to aclidinium, formoterol or placebo. Authors' conclusions FDC improved dyspnoea and lung function compared to aclidinium, formoterol or placebo, and this translated into an increase in the number of responders on combination treatment. Quality of life was better with combination compared to formoterol or placebo. There was no evidence of a difference between FDC and monotherapy or placebo for exacerbations, hospital admissions, mortality, non‐fatal SAEs or adverse events. Studies reported a lower risk of moderate exacerbations and adverse events with FDC compared to formoterol; however, larger studies would yield a more precise estimate for these outcomes. Plain language summary Are combined aclidinium and long‐acting beta 2 ‐agonist inhalers effective and safe for people with stable COPD? Background Chronic obstructive pulmonary disease (COPD) is a disease of the lungs that causes airways to narrow. As a result, people with COPD experience symptoms of breathlessness and cough with sputum production which worsen over time. It is mainly caused by smoking or inhaling dust. In people with COPD, inhalers that contain medicines to widen the airways are generally given to relieve symptoms. Long‐acting medicines whose action lasts for at least half a day or one day are preferred. Aclidinium and formoterol (a long‐acting beta 2 ‐agonist medicine) are such inhalers. We wanted to find out how a combination of aclidinium and long‐acting beta 2 ‐agonist fare against either inhaler alone and dummy (placebo) inhaler. Study characteristics We could only identify studies on aclidinium and formoterol combination and included seven studies involving 5921 people with COPD which ranged from four weeks to one year long. Most participants were men in their 60s, moderate‐to‐heavy smokers, around half of whom were current smokers. They had moderate‐to‐severe symptoms of COPD when they started treatment. People in the studies took either combined inhalers containing aclidinium and formoterol or aclidinium or formoterol or placebo through a similar inhaler. Both people doing the research and people in the study did not know which treatment participants were getting. The conclusions of this review are current to October 2018. Key results People taking combined inhaler and aclidinium inhaler were not different in terms of flare‐ups that need additional medicines, quality of life, hospitalisations, side effects or serious side effects. However, they were less breathless than those taking aclidinium inhaler. Fourteen people with COPD would need to be treated with combined inhalers to have one additional person with a clinically significant improvement in breathlessness. People on combined inhalers were likely to have fewer flare‐ups, side effects and symptoms and a better quality of life compared to those taking formoterol inhaler. But, there was little or no difference in hospital admissions due to severe flare‐ups, serious side effects or the risk of dying. When compared to dummy inhalers, people taking combined inhalers experienced less breathlessness and better quality of life. Seven people with COPD would need to be treated with combined inhaler to achieve a significant improvement in quality of life than dummy inhaler. For flare‐ups, hospital admissions, side effects, serious side effects and death, there was no difference between combined and dummy inhalers. The lungs worked better in people taking combined inhalers than those taking only one drug or dummy inhaler. Quality of the evidence We had to interpret the results carefully as all the included studies were sponsored by pharmaceutical companies, which could have led to bias. However, the included studies were generally conducted in a systematic and acceptable manner. We are confident that combined inhalers are more effective than single or dummy inhalers at improving breathlessness and lung function. However, we are less certain about its effects on flare‐ups, hospital admissions, quality of life and side effects. Conclusion Combined inhalers are more effective than individual or dummy inhalers for relieving breathlessness and improving lung performance. They also lead to better quality of life than formoterol or dummy inhalers. However, they are not different from individual or dummy inhalers in terms of flare‐ups or hospital admissions. These combined inhalers have similar safety profiles as individual or dummy inhalers in terms of death, side effects or serious side effects. Combined inhalers probably had lesser side effects and moderate flare‐ups than formoterol, but further studies are needed to confidently support this finding. In summary, the combined inhalers are an effective option for treatment of COPD and appear to have a similar safety profile to individual or dummy inhalers.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ni, H, Moe, S, Soe, Z, Myint, KT, Viswanathan, KN", "articleTypes": [], "doi": "10.1002/14651858.CD011594.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.795Z" }, { "id": "5a44c9f3-abab-4efc-bfd2-8111d3efe2d9", "pmid": "", "title": "Ready‐to‐use therapeutic food (RUTF) for home‐based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age", "imported": false, "abstract": "Abstract - Background Management of severe acute malnutrition (SAM) in children comprises two potential phases: stabilisation and rehabilitation. During the initial stabilisation phase, children receive treatment for dehydration, electrolyte imbalances, intercurrent infections and other complications. In the rehabilitation phase (applicable to children presenting with uncomplicated SAM or those with complicated SAM after complications have been resolved), catch‐up growth is the main focus and the recommended energy and protein requirements are much higher. In‐hospital rehabilitation of children with SAM is not always desirable or practical ‐ especially in rural settings ‐ and home‐based care can offer a better solution. Ready‐to‐use therapeutic food (RUTF) is a widely used option for home‐based rehabilitation, but the findings of our previous review were inconclusive. Objectives To assess the effects of home‐based RUTF used during the rehabilitation phase of SAM in children aged between six months and five years on recovery, relapse, mortality and rate of weight gain. Search methods We searched the following databases in October 2018: CENTRAL, MEDLINE, Embase, six other databases and three trials registers. We ran separate searches for cost‐effectiveness studies, contacted researchers and healthcare professionals in the field, and checked bibliographies of included studies and relevant reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs, where children aged between six months and five years with SAM were, during the rehabilitation phase, treated at home with RUTF compared to an alternative dietary approach, or with different regimens and formulations of RUTF compared to each other. We assessed recovery, deterioration or relapse and mortality as primary outcomes; and rate of weight gain, time to recovery, anthropometrical changes, cognitive development and function, adverse outcomes and acceptability as secondary outcomes. Data collection and analysis We screened for eligible studies, extracted data and assessed risk of bias of those included, independently and in duplicate. Where data allowed, we performed a random‐effects meta‐analysis using Review Manager 5, and investigated substantial heterogeneity through subgroup and sensitivity analyses. For the main outcomes, we evaluated the quality of the evidence using GRADE, and presented results in a 'Summary of findings' table per comparison. Main results We included 15 eligible studies (n = 7976; effective sample size = 6630), four of which were cluster trials. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. Six studies received funding or donations from industry whereas eight did not, and one study did not report the funding source. The overall risk of bias was high for six studies, unclear for three studies, and low for six studies. Among the 14 studies that contributed to meta‐analyses, none (n = 5), some (n = 5) or all (n = 4) children were stabilised in hospital prior to commencement of the study. One small study included only children known to be HIV‐infected, another study stratified the analysis for 'recovery' according to HIV status, while the remaining studies included HIV‐uninfected or untested children. Across all studies, the intervention lasted between 8 and 16 weeks. Only five studies followed up children postintervention (maximum of six months), and generally reported on a limited number of outcomes. We found seven studies with 2261 children comparing home‐based RUTF meeting the World Health Organization (WHO) recommendations for nutritional composition (referred to in this review as standard RUTF) with an alternative dietary approach (effective sample size = 1964). RUTF probably improves recovery (risk ratio (RR) 1.33; 95% confidence interval (CI) 1.16 to 1.54; 6 studies, 1852 children; moderate‐quality evidence), and may increase the rate of weight gain slightly (mean difference (MD) 1.12 g/kg/day, 95% CI 0.27 to 1.96; 4 studies, 1450 children; low‐quality evidence), but we do not know the effects on relapse (RR 0.55, 95% CI 0.30 to 1.01; 4 studies, 1505 children; very low‐quality evidence) and mortality (RR 1.05, 95% CI 0.51 to 2.16; 4 studies, 1505 children; very low‐quality evidence). Two quasi‐randomised cluster trials compared standard, home‐based RUTF meeting total daily nutritional requirements with a similar RUTF but given as a supplement to the usual diet (213 children; effective sample size = 210). Meta‐analysis showed that standard RUTF meeting total daily nutritional requirements may improve recovery (RR 1.41, 95% CI 1.19 to 1.68; low‐quality evidence) and reduce relapse (RR 0.11, 95% CI 0.01 to 0.85; low‐quality evidence), but the effects are unknown for mortality (RR 1.36, 95% CI 0.46 to 4.04; very low‐quality evidence) and rate of weight gain (MD 1.21 g/kg/day, 95% CI ‐ 0.74 to 3.16; very low‐quality evidence). Eight studies randomised 5502 children (effective sample size = 4456) and compared standard home‐based RUTF with RUTFs of alternative formulations (e.g. using locally available ingredients, containing less or no milk powder, containing specific fatty acids, or with added pre‐ and probiotics). For recovery, it made little or no difference whether standard or alternative formulation RUTF was used (RR 1.03, 95% CI 0.99 to 1.08; 6 studies, 4188 children; high‐quality evidence). Standard RUTF decreases relapse (RR 0.84, 95% CI 0.72 to 0.98; 6 studies, 4188 children; high‐quality evidence). However, it probably makes little or no difference to mortality (RR 1.00, 95% CI 0.80 to 1.24; 7 studies, 4309 children; moderate‐quality evidence) and may make little or no difference to the rate of weight gain (MD 0.11 g/kg/day, 95% CI −0.32 to 0.54; 6 studies, 3807 children; low‐quality evidence) whether standard or alternative formulation RUTF is used. Authors' conclusions Compared to alternative dietary approaches, standard RUTF probably improves recovery and may increase rate of weight gain slightly, but the effects on relapse and mortality are unknown. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given as a supplement to the usual diet, but the effects on mortality and rate of weight gain are not clear. When comparing RUTFs with different formulations, the current evidence does not favour a particular formulation, except for relapse, which is reduced with standard RUTF. Well‐designed, adequately powered, pragmatic RCTs with standardised outcome measures, stratified by HIV status, and that include diarrhoea as an outcome, are needed. Plain language summary Ready‐to‐use therapeutic food (RUTF) as home‐based treatment for severely malnourished children between six months and five years Background Malnourished children usually look very thin or wasted and they have a high risk of death and illness. Treating severely malnourished children in hospitals is not always desirable or practical in rural settings, and home‐based treatment may be better. Home‐based treatment can be food prepared by a caregiver (such as flour porridge or energy‐ and nutrient‐dense locally available foods), or ready‐to‐use therapeutic food (RUTF) provided by a clinic. RUTF is usually made according to a standard, energy‐rich composition defined by the World Health Organization (WHO). Typically, the ingredients for standard RUTF include milk powder, sugar, peanut butter, vegetable oil, vitamins and minerals; but ingredients vary depending on local availability, cost and acceptability. Benefits of RUTF include a long shelf life without refrigeration and they require no preparation. This is an update of our previous review, where definite conclusions about the effects of RUTF could not be drawn from the four studies that were available at that time. Review question We assessed standard RUTF compared to an alternative dietary approach (e.g. flour porridge or locally available foods) and examined whether smaller amounts and different formulations of RUTF can achieve similar health outcomes in severely malnourished children aged between six months and five years. The main health outcomes that we investigated were recovery from severe malnutrition, deterioration or relapse, death and the rate of weight gain. Included study characteristics We searched databases for studies up to the October 2018, and found 15 studies with 7976 children. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. One small study included only children infected with HIV, another study analysed children with and without HIV separately for the main outcome (recovery), while the other studies included children who were not infected with HIV or who were untested. Overall, we judged six studies to be at high risk of bias, three studies to be at unclear risk of bias, and six studies to be at low risk of bias. (With 'risk of bias', we mean the extent to which the methods used in a study enable it to determine the truth.) All the studies lasted between 8 and 16 weeks. Only five studies followed up children after the study (for a maximum of six months), and generally reported on a limited number of outcomes. Of our 15 included studies, six were linked to funding or donations from industry, one did not report the source of funding, and eight studies reported funding where sponsors did not include industry. Key findings Compared to alternative dietary approaches, standard RUTF probably improves recovery (moderate‐quality evidence) and may increase the rate of weight gain slightly (low‐quality evidence), but the effects on relapse and death are unknown (very low‐quality evidence). With 'quality of evidence' we mean how confident we are that the particular finding represents the true effect. For example, 'very low‐quality' means we are very uncertain about the finding, 'low‐quality evidence' means the future research is very likely to change the finding, 'moderate‐quality evidence' means that future studies may change this finding, and 'high‐quality evidence' means that it is unlikely that future studies will change the finding. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given supplementary to the usual diet (low‐quality evidence), but for death and the rate of weight gain, the effects are not known (very low‐quality evidence). When comparing RUTFs of different formulations, it makes little or no difference for recovery whether a standard or alternative formulation RUTF is used (high‐quality evidence). For relapse, using standard RUTF decreases relapse (high‐quality evidence). It probably makes little or no difference to death (moderate‐quality evidence) and to the rate of weight gain (low‐quality evidence) whether standard or alternative formulation RUTF is used. Well‐designed, randomised controlled trials (experimental studies where participants meeting the inclusion criteria have an equal chance of being allocated to any of the intervention or control groups) in which analyses have been performed separately for children with and without HIV, and that also measure and report on diarrhoea occurrence, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Schoonees, A; Lombard, MJ; Musekiwa, A; Nel, E; Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD009000.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "5a47e901-341d-4c78-b954-c8662496f160", "pmid": "", "title": "Environmental and behavioural modifications for improving food and fluid intake in people with dementia", "imported": false, "abstract": "Abstract - Background Weight loss, malnutrition and dehydration are common problems for people with dementia. Environmental modifications such as, change of routine, context or ambience at mealtimes, or behavioural modifications, such as education or training of people with dementia or caregivers, may be considered to try to improve food and fluid intake and nutritional status of people with dementia. Objectives Primary: To assess the effects of environmental or behavioural modifications on food and fluid intake and nutritional status in people with dementia. Secondary: To assess the effects of environmental or behavioural modifications in connection with nutrition on mealtime behaviour, cognitive and functional outcomes and quality of life, in specific settings (i.e. home care, residential care and nursing home care) for different stages of dementia. To assess the adverse consequences or effects of the included interventions. Search methods We searched the Specialized Register of Cochrane Dementia and Cognitive Improvement (ALOIS), MEDLINE, Eembase, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 17 January 2018. We scanned reference lists of other reviews and of included articles. Selection criteria We included randomised controlled trials (RCTs) investigating interventions designed to modify the mealtime environment of people with dementia, to modify the mealtime behaviour of people with dementia or their caregivers, or both, with the intention of improving food and fluid intake. We included people with any common dementia subtype. Data collection and analysis Two review authors independently selected studies, extracted data and assessed the risk of bias of included trials. We assessed the quality of evidence for each outcome using the GRADE approach. Main results We included nine studies, investigating 1502 people. Three studies explicitly investigated participants with Alzheimer's disease; six did not specify the type of dementia. Five studies provided clear measures to identify the severity of dementia at baseline, and overall very mild to severe stages were covered. The interventions and outcome measures were diverse. The overall quality of evidence was mainly low to very low. One study implemented environmental as well as behavioural modifications by providing additional food items between meals and personal encouragement to consume them. The control group received no intervention. Differences between groups were very small and the quality of the evidence from this study was very low, so we are very uncertain of any effect of this intervention. The remaining eight studies implemented behavioural modifications. Three studies provided nutritional education and nutrition promotion programmes. Control groups did not receive these programmes. After 12 months, the intervention group showed slightly higher protein intake per day (mean difference (MD) 0.11 g/kg, 95% confidence interval (CI) ‐0.01 to 0.23; n = 78, 1 study; low‐quality evidence), but there was no clear evidence of a difference in nutritional status assessed with body mass index (BMI) (MD ‐0.26 kg/m² favouring control, 95% CI ‐0.70 to 0.19; n = 734, 2 studies; moderate‐quality evidence), body weight (MD ‐1.60 kg favouring control, 95% CI ‐3.47 to 0.27; n = 656, 1 study; moderate‐quality evidence), or score on Mini Nutritional Assessment (MNA) (MD ‐0.10 favouring control, 95% CI ‐0.67 to 0.47; n = 656, 1 study; low‐quality evidence). After six months, the intervention group in one study had slightly lower BMI (MD ‐1.79 kg/m² favouring control, 95% CI ‐1.28 to ‐2.30; n = 52, 1 study; moderate‐quality evidence) and body weight (MD ‐8.11 kg favouring control, 95% CI ‐2.06 to ‐12.56; n = 52, 1 study; moderate‐quality evidence). This type of intervention may have a small positive effect on food intake, but little or no effect, or a negative effect, on nutritional status. Two studies compared self‐feeding skills training programmes. In one study, the control group received no training and in the other study the control group received a different self‐feeding skills training programme. For both comparisons the quality of the evidence was very low and we are very uncertain whether these interventions have any effect. One study investigated general training of nurses to impart knowledge on how to feed people with dementia and improve attitudes towards people with dementia. Again, the quality of the evidence was very low so that we cannot be certain of any effect. Two studies investigated vocal or tactile positive feedback provided by caregivers while feeding participants. After three weeks, the intervention group showed an increase in calories consumed per meal (MD 200 kcal, 95% CI 119.81 to 280.19; n = 42, 1 study; low‐quality evidence) and protein consumed per meal (MD 15g, 95% CI 7.74 to 22.26; n = 42, 1 study; low‐quality evidence). This intervention may increase the intake of food and liquids slightly; nutritional status was not assessed. Authors' conclusions Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia. Plain language summary Environmental and behavioural modifications for improving food and fluid intake in people with dementia What we wanted to know Weight loss, malnutrition and dehydration are common problems for people with dementia and can occur at any stage of the illness. People with dementia often develop psychological symptoms or behaviours which cause them to eat or drink less. In the later stages of the illness, they become dependent on others to help them eat or drink. We wanted to investigate how to keep people with dementia eating and drinking as well as possible. We looked for studies which changed the way food and drink are presented to people with dementia, and for studies which attempted to change the behaviour of people with dementia or of those helping them to eat. We called these environmental and behavioural modifications respectively, though some interventions include aspects of both. We were mainly interested in the effect on how much people with dementia ate and drank and on measures of how well‐nourished they were (e.g. body weight or body mass index (BMI)), but we also looked for effects on eating behaviour, symptoms of dementia and quality of life. How we tried to answer the question We searched for all the randomised controlled trials (RCTs) which were relevant to our question. In these trials, some people with dementia got an environmental or behavioural modification intended to improve their eating and drinking and were then compared with other people who had not had the intervention (the control group). Whether someone got the intervention or not was decided at random. We found nine RCTs to include in our review. In total, there were 1502 people in these trials. They had varying degrees of dementia, probably mostly due to Alzheimer's disease. Seven of the trials took place in care homes. In one trial, people were given extra snacks between meals and encouraged to eat them. In three trials, people with dementia were given education about diet and eating. In two trials, people with dementia were taught skills to help them to eat independently. In three trials, training was given to the carers responsible for helping people with dementia to eat. What we found out All the trials we found tested different interventions and measured their effects in different ways. Generally, the trials were small and there were problems with the way they were done, which reduced our confidence in the results. For some interventions, the quality of the evidence was so low that we could not draw any conclusions. For others, there was a mixture of positive and negative effects. What we concluded Because of the amount and quality of the evidence we found, we cannot at the moment, identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Herke, M; Fink, A; Langer, G; Wustmann, T; Watzke, S; Hanff, AM; Burckhardt, M", "articleTypes": [], "doi": "10.1002/14651858.CD011542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "5a824615-a432-434b-aa42-d4113668d1b9", "pmid": "", "title": "Interventions for iatrogenic inferior alveolar and lingual nerve injury", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Coulthard, P, Kushnerev, E, Yates, JM, Walsh, T, Patel, N, Bailey, E, Renton, TF", "articleTypes": [], "doi": "10.1002/14651858.CD005293.pub2 AB - Abstract - Background Iatrogenic injury of the inferior alveolar or lingual nerve or both is a known complication of oral and maxillofacial surgery procedures. Injury to these two branches of the mandibular division of the trigeminal nerve may result in altered sensation associated with the ipsilateral lower lip or tongue or both and may include anaesthesia, paraesthesia, dysaesthesia, hyperalgesia, allodynia, hypoaesthesia and hyperaesthesia. Injury to the lingual nerve may also affect taste perception on the affected side of the tongue. The vast majority (approximately 90%) of these injuries are temporary in nature and resolve within eight weeks. However, if the injury persists beyond six months it is deemed to be permanent. Surgical, medical and psychological techniques have been used as a treatment for such injuries, though at present there is no consensus on the preferred intervention, or the timing of the intervention. Objectives To evaluate the effects of different interventions and timings of interventions to treat iatrogenic injury of the inferior alveolar or lingual nerves. Search methods We searched the following electronic databases: the Cochrane Oral Health Group's Trial Register (to 9 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 9 October 2013) and EMBASE via OVID (1980 to 9 October 2013). No language restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials (RCTs) involving interventions to treat patients with neurosensory defect of the inferior alveolar or lingual nerve or both as a sequela of iatrogenic injury. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. We performed data extraction and assessment of the risk of bias independently and in duplicate. We contacted authors to clarify the inclusion criteria of the studies. Main results Two studies assessed as at high risk of bias, reporting data from 26 analysed participants were included in this review. The age range of participants was from 17 to 55 years. Both trials investigated the effectiveness of low‐level laser treatment compared to placebo laser therapy on inferior alveolar sensory deficit as a result of iatrogenic injury. Patient‐reported altered sensation was partially reported in one study and fully reported in another. Following treatment with laser therapy, there was some evidence of an improvement in the subjective assessment of neurosensory deficit in the lip and chin areas compared to placebo, though the estimates were imprecise: a difference in mean change in neurosensory deficit of the chin of 8.40 cm (95% confidence interval (CI) 3.67 to 13.13) and a difference in mean change in neurosensory deficit of the lip of 21.79 cm (95% CI 5.29 to 38.29). The overall quality of the evidence for this outcome was very low; the outcome data were fully reported in one small study of 13 patients, with differential drop‐out in the control group, and patients suffered only partial loss of sensation. No studies reported on the effects of the intervention on the remaining primary outcomes of pain, difficulty eating or speaking or taste. No studies reported on quality of life or adverse events. The overall quality of the evidence was very low as a result of limitations in the conduct and reporting of the studies, indirectness of the evidence and the imprecision of the results. Authors' conclusions There is clearly a need for randomised controlled clinical trials to investigate the effectiveness of surgical, medical and psychological interventions for iatrogenic inferior alveolar and lingual nerve injuries. Primary outcomes of this research should include: patient‐focused morbidity measures including altered sensation and pain, pain, quantitative sensory testing and the effects of delayed treatment. Plain language summary Treatments for accidental damage during surgery to the nerves supplying sensation to the tongue, lower lip and chin Review question The main question addressed by this review is how effective are different treatments and what are the best timings for these treatments following accidental damage during surgery to the nerves that supply sensation to the tongue, lower lip and chin. Background The nerves (alveolar and lingual) supplying sensation to the tongue, lower lip and chin, may be injured as a result of surgical treatments to the mouth and face, including surgery to remove lower wisdom teeth. The vast majority (90%) of these injuries are temporary and get better within eight weeks. However if they last for longer than six months they are considered to be permanent. Damage to these nerves can lead to altered sensation in the region of the lower lip and chin, or tongue or both. Furthermore, damage to the nerve supplying the tongue may lead to altered taste perception. These injuries can affect people's quality of life leading to emotional problems, problems with socialising and disabilities. Accidental injury after surgery can also give rise to legal action. There are many interventions or treatments available, surgical and non‐surgical, that may enhance recovery, including improving sensation. They can be grouped as. 1. Surgical – a variety of procedures.
 2. Laser treatment – low‐level laser treatment has been used to treat partial loss of sensation.
 3. Medical – treatment with drugs including antiepileptics, antidepressants and painkillers.
 4. Counselling – including cognitive behavioural and relaxation therapy, changing behaviour and hypnosis. Study characteristics The Cochrane Oral Health Group carried out this review, and the evidence is current as of 9 October 2013. There are two studies included, both published in 1996, which compared low‐level laser treatment to placebo or fake treatment for partial loss of sensation following surgery to the lower jaw. There were 15 participants in one study and 16 in the other, their ages ranging from 17 to 55 years. All had suffered accidental damage to nerves of the lower jaw and tongue causing some loss of sensation following surgery. Key results Low‐level laser therapy was the only treatment to be evaluated in the included studies and this was compared to fake or placebo laser therapy. No studies were found that evaluated other surgical, medical or counselling treatments. There was some evidence of an improvement when participants reported whether or not sensation was better in the lip and chin areas with low‐level laser therapy. This is based on the results of a single, small study, so the results should be interpreted with caution. No studies reported on the effects of the treatment on other outcomes such as pain, difficulty eating or speaking or taste. No studies reported on quality of life or harm. Quality of the evidence The overall quality of the evidence is very low as a result of limitations in the conduct and reporting of the two included studies and the low number of participants, and evidence from participants with only partial sensory loss.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.726Z" }, { "id": "5ab0e2bd-cd60-489c-9ec4-aada328189b4", "pmid": "", "title": "Iodised salt for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency is the main cause for potentially preventable mental retardation in childhood, as well as causing goitre and hypothyroidism in people of all ages. It is still prevalent in large parts of the world. Objectives To assess the effects of iodised salt in comparison with other forms of iodine supplementation or placebo in the prevention of iodine deficiency disorders. Search methods We searched The Cochrane Library , MEDLINE, the Register of Chinese trials developed by the Chinese Cochrane Centre, and the Chinese Med Database, China National knowledge Infrastructure, and searched reference lists, databases of ongoing trials and the Internet. Selection criteria We included prospective controlled studies of iodised salt versus other forms of iodine supplementation or placebo in people living in areas of iodine deficiency. Studies reported mainly goitre rates and urinary iodine excretion as outcome measures. Data collection and analysis The initial data selection and quality assessment of trials was done independently by two reviewers. Subsequently, after the scope of the review was slightly widened from including only randomised controlled trials to including non‐randomised prospective comparative studies, a third reviewer repeated the trials selection and quality assessment. As the studies identified were not sufficiently similar and not of sufficient quality, we did not do a meta‐analysis but summarised the data in a narrative format. Main results We found six prospective controlled trials relating to our question. Four of these were described as randomised controlled trials, one was a prospective controlled trial that did not specify allocation to comparison groups, and one was a repeated cross‐sectional study comparing different interventions. Comparison interventions included non‐iodised salt, iodised water, iodised oil, and salt iodisation with potassium iodide versus potassium iodate. Numbers of participants in the trials ranged from 35 to 334; over 20,000 people were included in the cross‐sectional study. Three studies were in children only, two investigated both groups of children and adults and one investigated pregnant women. There was a tendency towards goitre reduction with iodised salt, although this was not significant in all studies. There was also an improved iodine status in most studies (except in small children in one of the studies), although urinary iodine excretion did not always reach the levels recommended by the WHO. None of the studies observed any adverse effects of iodised salt. Authors' conclusions The results suggest that iodised salt is an effective means of improving iodine status. No conclusions can be made about improvements in other, more patient‐oriented outcomes, such as physical and mental development in children and mortality. None of the studies specifically investigated development of iodine‐induced hyperthyroidism, which can be easily overlooked if just assessed on the basis of symptoms. High quality controlled studies investigating relevant long term outcome measures are needed to address questions of dosage and best means of iodine supplementation in different population groups and settings. Plain language summary Iodised salt for preventing iodine deficiency disorders Iodine deficiency causes mental retardation in children as well as enlarged thyroid glands (goitre) and deficiencies in thyroid hormones in people of all ages. It still exists in large parts of the world. This review looked at studies of iodised salt in the diet that included a comparison group. Six studies, most of them in children but some also in adults, were included. Iodine in the urine increased in all but one studies, but there was some concern that small children did not eat enough salt to achieve adequate iodine status. Some studies, but not all, also showed a reduction in the enlargement of the thyroid gland (goitre) that can accompany lack of iodine in the diet. Adverse effects were not reported, but these may not have been studied adequately. More high quality long term studies measuring outcomes related to child development, to deaths associated with iodine‐deficiency and to adverse effects are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Wu, T; Liu, GJ; Li, P; Clar, C", "articleTypes": [], "doi": "10.1002/14651858.CD003204", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "5aba730e-4894-456f-a98a-c4a871c876fa", "pmid": "", "title": "Interventions for the management of dry mouth: topical therapies", "imported": false, "abstract": "Abstract - Background Xerostomia (the feeling of dry mouth) is a common symptom especially in older adults. Causes of dry mouth include medications, autoimmune disease (Sjögren's Syndrome), radiotherapy or chemotherapy for cancer, hormone disorders and infections. Objectives To determine which topical treatments for dry mouth are effective in reducing this symptom. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (28 October 2011), The Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 4 2011), MEDLINE via OVID (1950 to 28 October 2011), EMBASE via OVID (1980 to 28 October 2011), CINAHL via EBSCO (1980 to 28 October 2011), AMED via OVID (1985 to 28 October 2011), CANCERLIT via PubMed (1950 to 28 October 2011). Selection criteria We included randomised controlled trials of topical interventions such as lozenges, sprays, mouthrinses, gels, oils, chewing gum or toothpastes for the treatment of dry mouth symptom. We classified interventions into two broad categories, saliva stimulants and saliva substitutes, and these were compared with either placebo or another intervention. We included both parallel group and crossover trials. Data collection and analysis Two or more review authors independently carried out data extraction and assessed risk of bias. Trial authors were contacted for additional information as required. Main results Thirty‐six randomised controlled trials involving 1597 participants met the inclusion criteria. Two trials compared saliva stimulants to placebo, nine trials compared saliva substitutes to placebo, five trials compared saliva stimulants directly with saliva substitutes, 18 trials directly compared two or more saliva substitutes, and two trials directly compared two or more saliva stimulants. Only one trial was at low risk of bias and 17 were at high risk of bias. Due to the range of interventions, comparisons and outcome measures in the trials, meta‐analysis was possible for only a few comparisons. Oxygenated glycerol triester (OGT) saliva substitute spray shows evidence of effectiveness compared to an electrolyte spray (standardised mean difference (SMD) 0.77, 95% confidence interval (CI) 0.38 to 1.15) which corresponds to approximately a mean difference of 2 points on a 10‐point visual analogue scale (VAS) for mouth dryness. Both integrated mouthcare systems (toothpaste + gel + mouthwash) and oral reservoir devices show promising results but there is insufficient evidence at present to recommend their use. Although chewing gum is associated with increased saliva production in the majority of those with residual capacity, there is no evidence that gum is more or less effective than saliva substitutes. Authors' conclusions There is no strong evidence from this review that any topical therapy is effective for relieving the symptom of dry mouth. OGT spray is more effective than an aqueous electrolyte spray (SMD 0.77, 95% CI 0.38 to 1.15) which is approximately equivalent to a mean difference of 2 points on a 10‐point VAS scale for mouth dryness. Chewing gums appear to increase saliva production in those with residual secretory capacity and may be preferred by patients, but there is no evidence that gum is better or worse than saliva substitutes. Integrated mouthcare systems and oral reservoir devices may be helpful but further research is required to confirm this. Well designed, adequately powered randomised controlled trials of topical interventions for dry mouth, which are designed and reported according to CONSORT guidelines, are required to provide evidence to guide clinical care. For many people the symptom of dry mouth is a chronic problem and trials should evaluate whether treatments are palatable, effective in reducing xerostomia, as well as the long‐term effects of treatments on quality of life of those with chronic dry mouth symptoms. Plain language summary Interventions for the management of dry mouth: topical therapies Dry mouth is a common problem with a range of causes. The symptom may be due to a reduction in the quantity of saliva produced, or a change in the composition of saliva, but a feeling of dry mouth may also be present in people with normal saliva production. Radiotherapy or chemotherapy for head and neck cancers, and diseases such as Sjögren's Syndrome, may result in reduced saliva production. Many commonly prescribed medications are associated with a feeling of dry mouth, despite normal saliva production. As well as difficulty in speaking, chewing and swallowing, prolonged dry mouth may result in increased risk of tooth decay and reduced quality of life. In many sufferers dry mouth cannot be cured, but effective ways for people to manage dry mouth symptoms are available. Many topical treatments (applied directly to the inside of the mouth) such as sprays, lozenges, mouthrinses, gels, oils, chewing gum or toothpastes have been evaluated in this review, but there is no strong evidence that any topical treatment is effective for relieving the sensation of dry mouth. Oxygenated glycerol triester (OGT) saliva substitute spray is more effective than a water based electrolyte spray. A gel‐releasing device worn in the mouth, or a mouthcare system might be effective but more research is needed. Chewing gum increases saliva production but there is no evidence that gum is better or worse than saliva substitutes. Acidic products and those containing sugar should be avoided.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Furness, S, Worthington, HV, Bryan, G, Birchenough, S, McMillan, R", "articleTypes": [], "doi": "10.1002/14651858.CD008934.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.065Z" }, { "id": "5ac33a23-1636-4b80-a40a-ced3ea99cbb2", "pmid": "", "title": "Janus kinase inhibitors for the treatment of COVID‐19", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kramer, A, Prinz, C, Fichtner, F, Fischer, A-L, Thieme, V, Grundeis, F, Spagl, M, Seeber, C, Piechotta, V, Metzendorf, M-I, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015209 AB - Abstract - Background With potential antiviral and anti‐inflammatory properties, Janus kinase (JAK) inhibitors represent a potential treatment for symptomatic severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. They may modulate the exuberant immune response to SARS‐CoV‐2 infection. Furthermore, a direct antiviral effect has been described. An understanding of the current evidence regarding the efficacy and safety of JAK inhibitors as a treatment for coronavirus disease 2019 (COVID‐19) is required. Objectives To assess the effects of systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo) on clinical outcomes in individuals (outpatient or in‐hospital) with any severity of COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising MEDLINE, Embase, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform, medRxiv, and Cochrane Central Register of Controlled Trials), Web of Science, WHO COVID‐19 Global literature on coronavirus disease, and the US Department of Veterans Affairs Evidence Synthesis Program (VA ESP) Covid‐19 Evidence Reviews to identify studies up to February 2022. We monitor newly published randomised controlled trials (RCTs) weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials from this source until the first week of April 2022. Selection criteria We included RCTs that compared systemic JAK inhibitors plus standard of care to standard of care alone (plus/minus placebo) for the treatment of individuals with COVID‐19. We used the WHO definitions of illness severity for COVID‐19. Data collection and analysis We assessed risk of bias of primary outcomes using Cochrane's Risk of Bias 2 (RoB 2) tool. We used GRADE to rate the certainty of evidence for the following primary outcomes: all‐cause mortality (up to day 28), all‐cause mortality (up to day 60), improvement in clinical status: alive and without need for in‐hospital medical care (up to day 28), worsening of clinical status: new need for invasive mechanical ventilation or death (up to day 28), adverse events (any grade), serious adverse events, secondary infections. Main results We included six RCTs with 11,145 participants investigating systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo). Standard of care followed local protocols and included the application of glucocorticoids (five studies reported their use in a range of 70% to 95% of their participants; one study restricted glucocorticoid use to non‐COVID‐19 specific indications), antibiotic agents, anticoagulants, and antiviral agents, as well as non‐pharmaceutical procedures. At study entry, about 65% of participants required low‐flow oxygen, about 23% required high‐flow oxygen or non‐invasive ventilation, about 8% did not need any respiratory support, and only about 4% were intubated. We also identified 13 ongoing studies, and 9 studies that are completed or terminated and where classification is pending. Individuals with moderate to severe disease Four studies investigated the single agent baricitinib (10,815 participants), one tofacitinib (289 participants), and one ruxolitinib (41 participants). Systemic JAK inhibitors probably decrease all‐cause mortality at up to day 28 (95 of 1000 participants in the intervention group versus 131 of 1000 participants in the control group; risk ratio (RR) 0.72, 95% confidence interval (CI) 0.57 to 0.91; 6 studies, 11,145 participants; moderate‐certainty evidence), and decrease all‐cause mortality at up to day 60 (125 of 1000 participants in the intervention group versus 181 of 1000 participants in the control group; RR 0.69, 95% CI 0.56 to 0.86; 2 studies, 1626 participants; high‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in improvement in clinical status (discharged alive or hospitalised, but no longer requiring ongoing medical care) (801 of 1000 participants in the intervention group versus 778 of 1000 participants in the control group; RR 1.03, 95% CI 1.00 to 1.06; 4 studies, 10,802 participants; moderate‐certainty evidence). They probably decrease the risk of worsening of clinical status (new need for invasive mechanical ventilation or death at day 28) (154 of 1000 participants in the intervention group versus 172 of 1000 participants in the control group; RR 0.90, 95% CI 0.82 to 0.98; 2 studies, 9417 participants; moderate‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in the rate of adverse events (any grade) (427 of 1000 participants in the intervention group versus 441 of 1000 participants in the control group; RR 0.97, 95% CI 0.88 to 1.08; 3 studies, 1885 participants; moderate‐certainty evidence), and probably decrease the occurrence of serious adverse events (160 of 1000 participants in the intervention group versus 202 of 1000 participants in the control group; RR 0.79, 95% CI 0.68 to 0.92; 4 studies, 2901 participants; moderate‐certainty evidence). JAK inhibitors may make little or no difference to the rate of secondary infection (111 of 1000 participants in the intervention group versus 113 of 1000 participants in the control group; RR 0.98, 95% CI 0.89 to 1.09; 4 studies, 10,041 participants; low‐certainty evidence). Subgroup analysis by severity of COVID‐19 disease or type of JAK inhibitor did not identify specific subgroups which benefit more or less from systemic JAK inhibitors. Individuals with asymptomatic or mild disease We did not identify any trial for this population. Authors' conclusions In hospitalised individuals with moderate to severe COVID‐19, moderate‐certainty evidence shows that systemic JAK inhibitors probably decrease all‐cause mortality. Baricitinib was the most often evaluated JAK inhibitor. Moderate‐certainty evidence suggests that they probably make little or no difference in improvement in clinical status. Moderate‐certainty evidence indicates that systemic JAK inhibitors probably decrease the risk of worsening of clinical status and make little or no difference in the rate of adverse events of any grade, whilst they probably decrease the occurrence of serious adverse events. Based on low‐certainty evidence, JAK inhibitors may make little or no difference in the rate of secondary infection. Subgroup analysis by severity of COVID‐19 or type of agent failed to identify specific subgroups which benefit more or less from systemic JAK inhibitors. Currently, there is no evidence on the efficacy and safety of systemic JAK inhibitors for individuals with asymptomatic or mild disease (non‐hospitalised individuals). Plain language summary Are systemic Janus kinase inhibitors an effective treatment for people with COVID‐19? Key messages We found moderate‐ to high‐certainty evidence from 6 studies to conclude that systemic Janus kinase (JAK) inhibitors are an effective treatment for coronavirus disease 2019 (COVID‐19) in hospitalised people, because they resulted in fewer deaths and a lower rate of clinical deterioration. Evaluation of systemic JAK inhibitors is ongoing in 13 studies whilst the results of 9 further studies are awaiting publication. We will update this review and may adapt our conclusions when their results become available. What are JAK inhibitors? JAK inhibitors are medicines that block the activity of certain parts of the immune system that are sometimes problematic. They are taken orally (systemic) and usually are taken by people who suffer from autoimmune diseases, where the immune system attacks the body itself. JAK inhibitors might also be administered by inhalation but since this was not our focus, we refer to 'systemic JAK inhibitors' throughout the review. How might JAK inhibitors treat COVID‐19? In COVID‐19, the immune system sometimes overreacts, which can lead to a severe course of disease. JAK inhibitors can block parts of the immune system and counteract any clinical deteriorations. What did we want to find out? We wanted to know whether systemic JAK inhibitors, in addition to usual care, are effective for people with COVID‐19 when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in:
• number of deaths from any cause up to 60 days after treatment, or longer if reported;
• whether people got better or worse after treatment, based on their need for breathing support;
• unwanted effects of the treatment and infections acquired in hospital. What did we do? We searched for studies that reported on people with COVID‐19 who received systemic JAK inhibitors together with usual care, or usual care alone (plus/minus placebo). We compared and summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We found 6 suitable studies involving 11,145 people with COVID‐19. All studies compared systemic JAK inhibitors (baricitinib in 4 studies, tofacitinib in 1 study and ruxolitinib in 1 study) to usual care (in addition to placebo), and were performed in hospitalised people. We did not find studies performed in outpatients. Most participants needed oxygen supplementation through low‐flow devices (7220 participants) and few (463 participants) were mechanically ventilated at the study entry. We also identified 13 ongoing studies and 9 studies that are completed/terminated but unpublished yet. Main results Systemic JAK inhibitors plus usual care compared to usual care alone probably lead to fewer deaths from all causes at up to day 28 and lead to fewer deaths from all causes up to day 60 in the studies. It was not possible to identify subgroups of participants (according to severity of illness) who might benefit most from treatment with JAK inhibitors. Systemic JAK inhibitors probably make little or no difference in improvement in clinical status. They probably decrease the risk of worsening of clinical status. Systemic JAK inhibitors probably make little or no difference in the rate of unwanted effects, and probably decrease slightly the occurrence of serious unwanted effects. Systemic JAK inhibitors may result in little or no difference in the rate of infections acquired in hospital. What are the limitations of the evidence? As current studies on systemic JAK inhibitors in outpatients are lacking, evidence is limited in this group of people with COVID‐19. Studies used different ways to assess and report unwanted effects, especially in regard to infections acquired in hospital. In accordance with the living approach of this review, we will continually update our search and include eligible trials to fill this evidence gap. How up to date is this evidence? The evidence is up to date to February 2022. We monitor newly published studies weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials identified from this source until the first week of April 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.138Z" }, { "id": "5ad22098-2c8b-412d-b2f7-cda67e3bb50a", "pmid": "", "title": "Changes in Gut Microbiota and Postprandial GLP-1 Concentration Due to Sucralose Consumption", "imported": false, "abstract": "Recently, it has been proposed that the consumption of non-nutritive sweeteners, including sucralose, it's not harmless and is related with metabolic effects. Some studies have reported that sucralose produces alterations in glucose homeostasis. In vitro studies indicate that sucralose can interact with sweet taste receptors (T1R2 and T1R3) in the intestine, thus increasing the expression of glucose transporters including the sodium-glucose cotransporter type 1 (SGLT1) and the glucose transporter 2 (GLUT2), increasing glucose absorption. This interaction with intestinal sweet taste receptors also generates an increase in the secretion of the incretins glucagon-like peptide type 1 (GLP-1) and the glucose-dependent insulinotropic polypeptide (GIP), which might enhance the postprandial insulin release. However, these results are preliminary and it's desirable to confirm if sucralose consumption is associated with glucose metabolism modifications using an appropriate methodological design and with gold standard methods. The aim of this triple-blind, placebo-controlled, parallel, randomized clinical trial is to confirm the changes in insulin sensitivity associated with sucralose consumption in humans, to identify whether these changes are in the liver or skeletal muscle and to investigate the pathophysiological mechanisms generating these changes. Specifically, we will investigate if sucralose generates a dysbiosis in the gut microbiota that could be related to insulin resistance by increasing concentrations of lipopolysaccharide, a toxin found in Gram-negative bacteria that triggers a low-grade inflammation known as metabolic endotoxemia. In addition, the changes in postprandial concentrations of GLP-1, glucose, insulin, and C-peptide due to the combination of sucralose with a mixed meal will be investigated. The results of this study will determine if sucralose consumption, frequently used as a non-nutritive sweetener, is associated to significant changes in glucose homeostasis in humans.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "5adba8f4-480f-489b-aa18-ac0a6338c599", "pmid": "", "title": "Osmotic therapies added to antibiotics for acute bacterial meningitis", "imported": false, "abstract": "Abstract - Background Every day children and adults die from acute community‐acquired bacterial meningitis, particularly in low‐income countries, and survivors risk deafness, epilepsy and neurological disabilities. Osmotic therapies may attract extra‐vascular fluid and reduce cerebral oedema, and thus reduce death and improve neurological outcomes. This is an update of a Cochrane Review first published in 2013. Objectives To evaluate the effects of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults on mortality, deafness and neurological disability. Search methods We searched CENTRAL (2017, Issue 1), MEDLINE (1950 to 17 February 2017), Embase (1974 to 17 February 2017), CINAHL (1981 to 17 February 2017), LILACS (1982 to 17 February 2017) and registers of ongoing clinical trials (ClinicalTrials.com, WHO ICTRP) (21 February 2017). We also searched conference abstracts and contacted researchers in the field (up to 12 December 2015). Selection criteria Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis. Data collection and analysis Two review authors independently screened the search results and selected trials for inclusion. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not. We used the GRADE approach to assess the certainty of the evidence. Main results We included five trials with 1451 participants. Four trials evaluated glycerol against placebo, and one evaluated glycerol against 50% dextrose; in addition three trials evaluated dexamethasone and one trial evaluated acetaminophen (paracetamol) in a factorial design. Stratified analysis shows no effect modification with steroids; we present aggregate effect estimates. Compared to placebo, glycerol probably has little or no effect on death in people with bacterial meningitis (RR 1.08, 95% CI 0.90 to 1.30; 5 studies, 1272 participants; moderate‐certainty evidence ), but may reduce neurological disability (RR 0.73, 95% CI 0.53 to 1.00; 5 studies, 1270 participants; low‐certainty evidence ). Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30; 4 studies, 1090 participants; low‐certainty evidence ). Glycerol may reduce the risk of subsequent deafness (RR 0.64, 95% CI 0.44 to 0.93; 5 studies, 922 participants; low to moderate‐certainty evidence ). Glycerol probably has little or no effect on gastrointestinal bleeding (RR 0.93, 95% CI 0.39 to 2.19; 3 studies, 607 participants; moderate‐certainty evidence ). The evidence on nausea, vomiting and diarrhoea is uncertain (RR 1.09, 95% CI 0.81 to 1.47; 2 studies, 851 participants; very low‐certainty evidence ). Authors' conclusions Glycerol was the only osmotic therapy evaluated, and data from trials to date have not demonstrated an effect on death. Glycerol may reduce neurological deficiency and deafness. Plain language summary Osmotic therapies added to antibiotics for acute bacterial meningitis What is the aim of this review? The aim of this Cochrane Review is to collect and analyse trials evaluating osmotic therapies given orally or intravenously to people with acute bacterial meningitis. Cochrane authors collected and analysed all relevant studies to answer this question; they found five relevant studies. Key messages Giving glycerol, an osmotic diuretic, probably has little or no effect on death ( moderate‐certainty evidence ), but may reduce subsequent deafness ( moderate‐certainty evidence) or neurological disability ( low‐certainty evidence ). The evidence is current to 17 February 2017. What was studied in the review? In meningitis, the cerebrospinal fluid that surrounds the brain and spinal cord is infected, usually as a result of spread from the blood. Any form of meningitis can result in death or severe disability, but acute bacterial meningitis is rapidly fatal without treatment. Even with antibiotics, 10% to 15% of children with bacterial meningitis die in high‐income countries with much higher rates in low‐income settings. The infection causes the brain to swell, and this is thought to contribute to death and to long‐term brain damage in survivors. Osmotic therapies increase the concentration of the blood by exerting an osmotic pressure across a semi‐permeable membrane (such as a cell wall or blood vessel lining in the brain). This draws water from the brain into the blood, thereby reducing pressure in the brain. Potentially osmotic therapies could increase the rate of survival, or they could do harm. What are the main results of the review? We included five trials that compared glycerol with placebo in a total of 1451 patients with bacterial meningitis. In the studies steroids were often given as well, but this did not appear to modify any of the effects seen with glycerol. This review detected no benefit from glycerol relating to death. There appeared to be marginal protection against deafness and against neurological disability. No effect on epileptic seizures at follow‐up was noted. Glycerol was not associated with any severe adverse effects. The number of trials included was small and only two tested a large number of participants. All trials were from different healthcare settings and examined either adults or children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wall, ECB, Ajdukiewicz, KMB, Bergman, H, Heyderman, RS, Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD008806.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.091Z" }, { "id": "5af5493a-863f-4892-955b-e730c4719f9d", "pmid": "", "title": "Multimodal interventions for cachexia management", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Reid, J, Blair, C, Dempster, M, McKeaveney, C, Slee, A, Fitzsimons, D", "articleTypes": [], "doi": "10.1002/14651858.CD015749.pub2 AB - Abstract - Background Cachexia (disease‐related wasting) is a complex metabolic syndrome which occurs in people with chronic illnesses, including cancer, HIV/AIDS, kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People with cachexia experience unintentional weight loss, muscle loss, fatigue, loss of appetite, and reduced quality of life. Multimodal interventions which work synergistically to treat the syndrome could lead to benefits. Objectives To assess the benefits and harms of multimodal interventions aimed at alleviating or stabilising cachexia in people with a chronic illness. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers in July 2024, together with reference checking, citation searching, and contact with study authors to identify studies. Selection criteria We included randomised controlled trials (RCTs) in adults with or at risk of cachexia, comparing multimodal interventions combining two or more modalities (of pharmacology, nutrition, exercise) to treatment as usual, variation of the intervention, or unimodal intervention. Data collection and analysis Two review authors independently screened potentially eligible studies, extracted data, and assessed risk of bias (RoB 1). Primary outcomes were physical function, strength, and adverse events. Secondary outcomes were body composition and weight, quality of life (QoL), appetite, fatigue, and biochemical markers. We assessed the certainty of evidence with GRADE. Main results We included nine studies with 926 adults (mean age: 63 years). Study sample sizes ranged from 20 to 332 participants. Six studies were conducted in Europe, and one each in Turkey, New Zealand, and the USA. There were six studies in people with cancer, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. We judged four studies to be at an overall high risk of bias, and five at an overall unclear risk. All outcomes in all comparisons had very low‐certainty evidence, downgraded once for risk of bias and/or indirectness and twice for imprecision. Multimodal intervention (pharmacological, nutritional, and/or exercise) compared to treatment as usual One cancer study randomised 46 participants, with 41 included in all analyses except adverse events. The study assessed outcomes immediately after treatment, lasting six weeks. Compared to treatment as usual, there is no clear evidence for an effect of a multimodal intervention on: physical function (mean difference (MD) −16.10 m, 95% confidence interval (CI) −79.06 to 46.86; 41 participants); strength (MD 3.80 kg, 95% CI −3.21 to 10.81; 41 participants); adverse events (risk ratio (RR) 1.36, 95% CI 0.70 to 2.65; 46 participants); body composition (MD 7.89 cm 2 , 95% CI −10.43 to 26.21; 41 participants); weight (MD 5.89 kg, 95% CI −1.45 to 13.23; 41 participants); appetite (MD 0.68 points, 95% CI −0.60 to 1.96; 41 participants); fatigue (MD 0.12, 95% CI −1.05 to 1.29; 41 participants); and biochemical markers (MD 2%, 95% CI 0.99 to 3.01; 41 participants), but the evidence was very uncertain; QoL was not reported. Multimodal intervention compared to variation of the intervention Three cancer studies and one HIV/AIDS study randomised 192 participants. We could not use the available data, nor obtain additional data, from two studies (one in cancer, one in HIV/AIDS). The studies assessed outcomes immediately after treatment, ranging from three to seven months. Compared to a variation of the intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (MD 10.0 m, 95% CI −36.27 to 56.27; 1 study, 56 participants); strength (MD 0.7 kg, 95% CI −3.75 to 5.15; 1 study, 56 participants); adverse events (RR 0.87, 95% CI 0.38 to 2.02; P = 0.75, I 2 = 0%; 2 studies, 95 participants); body composition (MD −2.67 kg, 95% CI −5.89 to 0.54; P = 0.10, I 2 = 0%; 2 studies, 95 participants); weight (MD −2.47 kg, 95% CI −7.11 to 2.16; P = 0.30, I 2 = 0%; 2 studies, 95 participants); QoL (standardised mean difference (SMD) −0.15, 95% CI ���0.55 to 0.26; P = 0.47, I 2 = 0%; 2 studies, 95 participants); appetite (SMD −0.34, 95% CI −1.27 to 0.59; P = 0.48, I 2 = 79%; 2 studies, 95 participants); fatigue (MD 6.40 points, 95% CI −1.10 to 13.90; 1 study, 56 participants); or biochemical markers (MD 9.80 pg/mL, 95% CI −6.25 to 25.85; P = 0.23, I 2 = 73%; 2 studies, 95 participants), but the evidence is very uncertain. Multimodal intervention compared to unimodal intervention We included six studies (802 participants) in this comparison: three cancer studies, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. The studies assessed outcomes immediately after treatment, ranging from three to seven months. We could not use the available data, nor obtain additional data, from the HIV/AIDS study. Compared to a unimodal intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (SMD 0.02, 95% CI −0.22 to 0.26; P = 0.86, I 2 = 0%; 2 studies, 348 participants); strength (SMD 0.23, 95% CI −0.81 to 1.27; P = 0.66, I 2 = 0%; 2 studies, 348 participants); adverse events (RR 0.87, 95% CI −0.43 to 1.73; P = 0.68, I 2 = 45%; 2 studies, 395 participants); body composition (SMD 0.11, 95% CI −0.28 to 0.50; P = 0.58, I 2 = 74%; 5 studies, 742 participants); body weight (SMD −0.02, 95% CI −0.38 to 0.33; P = 0.90, I 2 = 49%; 4 studies, 431 participants); QoL (SMD 0.22, 95% CI −0.29 to 0.73; P = 0.39, I 2 = 61%; 3 studies, 411 participants); appetite (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.72, I 2 = 58%; 2 studies, 395 participants); fatigue (MD −6.80 points, 95% CI −12.44 to −1.17; 1 study, 244 participants); and biochemical markers (SMD 0.11, 95% CI −0.59 to 0.80; P = 0.76, I 2 = 79%; 3 studies, 411 participants), but the evidence is very uncertain. Authors' conclusions The review found insufficient evidence to support or refute the use of multimodal interventions in managing cachexia. The certainty of the evidence was very low. Methodologically rigorous, well‐powered RCTs with adequate interaction times are needed to assess the effectiveness of multimodal interventions in managing cachexia across chronic illnesses. Plain language summary What are the benefits and risks of using a combination of treatments to manage cachexia (disease‐related wasting)? Key messages: • We do not know if combinations of two or more treatments (of medication, diet, and exercise) benefit people who have or are at risk of developing cachexia (disease‐related wasting). This is because there are currently not enough robust studies in this area. • We need future research to increase our confidence in the evidence by conducting better designed and larger studies. What is cachexia? Cachexia is a complex metabolic syndrome that occurs in people with long‐term illnesses (known as chronic illnesses), such as cancer, HIV/AIDS, chronic kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People who have cachexia may: • lose weight unintentionally;
• lose muscle;
• feel tired, weak, or both; 
• lose their appetite. Cachexia affects well‐being and can be life‐threatening. How is cachexia treated? Studies are investigating how to best manage cachexia with different treatments. These treatments can include medications, diet, and exercise, provided in a single (unimodal) or combined (multimodal) treatment. It is thought that due to the complex biology of cachexia, a combination of treatments may work in a complementary way (synergistically) to help improve the symptoms associated with cachexia and people's well‐being, extend life, or both. What did we want to find out? We wanted to find out if combining at least two treatments (out of diet, exercise, and medication) helped to improve: physical function and strength; muscle loss; weight; well‐being; appetite; fatigue; and biological indicators within the blood (biochemical markers). We also wanted to find out if these interventions were associated with any unwanted or harmful (adverse) effects. What did we do? We searched for studies that compared treatment combinations of diet, exercise and/or medication (where at least two treatments were used together) to: different combinations of treatments; a single treatment; or treatment as usual (standard care) in adults with cachexia or at risk of developing cachexia. We compared and summarised the results of the included studies. We rated our confidence in the evidence based on factors such as study methods and the number of people included. What did we find? We found nine studies that included a total of 926 adults, with an average age of 63 years. Just over half of participants (57%) were men. Studies took place around the world, including Europe (six studies), Turkey (one study), New Zealand (one study), and the USA (one study). One study included people with HIV/AIDS (average age 43 years; 35 of 50 people in the study were men); one study included people with COPD (average age 72 years; 20 of 28 people in the study were men); and one study included people with chronic kidney disease (average age 70 years; 11 of 21 in the study were men). Six studies included people with cancer (average age 64 years; 461 of 893 people in the studies were men). The studies lasted six weeks to two years. The studies used combinations of treatments which could have included diet, exercise, and/or medication, where at least two treatments were used together, and compared these to: • treatment as usual (1 study, 46 people);
• different combinations of treatments (4 studies, 192 people);
• a single treatment (6 studies, 802 people). The studies did not provide enough robust evidence to determine if multimodal interventions are associated with benefits or harms in people with or at risk of cachexia. What are the limitations of the evidence? We are not confident in the evidence because not all the studies provided information about everything that we were interested in. Additionally, the studies used different ways of measuring results, and most of the studies included only small numbers of people. Importantly, future studies may change the conclusions of this review. How current is this review? The evidence is current to June 2024.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.131Z" }, { "id": "5b076134-ac79-4a5a-85a2-ecc967a13ed8", "pmid": "", "title": "Physical therapy for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Bell's palsy (idiopathic facial paralysis) is commonly treated by various physical therapy strategies and devices, but there are many questions about their efficacy. Objectives To evaluate physical therapies for Bell's palsy (idiopathic facial palsy). Search methods We searched the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2011), MEDLINE (January 1966 to February 2011), EMBASE (January 1946 to February 2011), LILACS (January 1982 to February 2011), PEDro (from 1929 to February 2011), and CINAHL (January 1982 to February 2011). We included searches in clinical trials register databases until February 2011. Selection criteria We selected randomised or quasi‐randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention. Data collection and analysis Two authors independently scrutinised titles and abstracts identified from the search results. Two authors independently carried out risk of bias assessments, which took into account secure methods of randomisation, allocation concealment, observer blinding, patient blinding, incomplete outcome data, selective outcome reporting and other bias. Two authors independently extracted data using a specially constructed data extraction form. We undertook separate subgroup analyses of participants with more and less severe disability. Main results For this update to the original review, the search identified 65 potentially relevant articles. Twelve studies met the inclusion criteria (872 participants). Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies compared or combined some form of physical therapy with acupuncture (360 participants). For most outcomes we were unable to perform meta‐analysis because the interventions and outcomes were not comparable. For the primary outcome of incomplete recovery after six months, electrostimulation produced no benefit over placebo (moderate quality evidence from one study with 86 participants). Low quality comparisons of electrostimulation with prednisolone (an active treatment) (149 participants), or the addition of electrostimulation to hot packs, massage and facial exercises (22 participants), reported no significant differences. Similarly a meta‐analysis from two studies, one of three months and the other of six months duration (142 participants) found no statistically significant difference in synkinesis, a complication of Bell's palsy, between participants receiving electrostimulation and controls. A single low quality study (56 participants), which reported at three months, found worse functional recovery with electrostimulation (mean difference (MD) 12.00 points (scale of 0 to 100) 95% confidence interval (CI) 1.26 to 22.74). Two trials of facial exercises, both at high risk of bias, found no difference in incomplete recovery at six months when exercises were compared to waiting list controls or conventional therapy. There is evidence from a single small study (34 participants) of moderate quality that exercises are beneficial on measures of facial disability to people with chronic facial palsy when compared with controls (MD 20.40 points (scale of 0 to 100), 95% CI 8.76 to 32.04) and from another single low quality study with 145 people with acute cases treated for three months, in which significantly fewer participants developed facial motor synkinesis after exercise (risk ratio 0.24, 95% CI 0.08 to 0.69). The same study showed statistically significant reduction in time for complete recovery, mainly in more severe cases (47 participants, MD ‐2.10 weeks, 95% CI ‐3.15 to ‐1.05) but this was not a prespecified outcome in this meta analysis. Acupuncture studies did not provide useful data as all were short and at high risk of bias. None of the studies included adverse events as an outcome. Authors' conclusions There is no high quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. There is low quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases. There is low quality evidence that facial exercise reduces sequelae in acute cases. The suggested effects of tailored facial exercises need to be confirmed with good quality randomised controlled trials. Plain language summary Physical treatments for idiopathic facial paralysis Bell's palsy is an acute disorder of the facial nerve, which produces full or partial loss of movement on one side of the face. The facial palsy gets completely better without treatment in most, but not all, people. Physical therapies, such as exercise, biofeedback, laser treatment, electrotherapy, massage and thermotherapy, are used to hasten recovery, improve facial function and minimise sequelae. For this updated review we found a total of 12 studies with 872 participants, most with high risk of bias. Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies combined some form of physical therapy and compared with acupuncture (360 participants). There is evidence from a single study of moderate quality that exercises are beneficial to people with chronic facial palsy when compared with controls and from another low quality study that it is possible that facial exercises could help to reduce synkinesis (a complication of Bell's palsy), and the time to recover. There is insufficient evidence to decide whether electrical stimulation works, to identify risks of these treatments or to assess whether the addition of acupuncture to facial exercises or other physical therapy could produce improvement. In conclusion, tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases, and early facial exercise may reduce recovery time and long term paralysis in acute cases, but the evidence for this is of poor quality. More trials are needed to assess the effects of facial exercises and any risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Teixeira, LJ, Valbuza, JS, Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006283.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.096Z" }, { "id": "5b319233-bbe5-4e39-8dfa-07c5105517fe", "pmid": "", "title": "Antibiotic treatment for the sexual partners of women with bacterial vaginosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Amaya‐Guio, J, Viveros‐Carreño, DA, Sierra‐Barrios, EM, Martinez‐Velasquez, MY, Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD011701.pub2 AB - Abstract - Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of BV after antibiotic treatment. Therefore, the treatment of sexual partners could decrease the recurrence of infection and possibly the burden of the disease. Objectives To assess the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for BV. Search methods We searched the Cochrane Sexually Transmitted Infections Group Specialized Register (23 July 2016), CENTRAL (1991 to 23 July 2016), MEDLINE (1946 to 23 July 2016), Embase (1974 to 23 July 2016), LILACS (1982 to 23 July 2016), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (23 July 2016), ClinicalTrials.gov (23 July 2016) and the Web of Science™ (2001 to 23 July 2016). We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) that compared the concurrent use of any antibiotic treatment with placebo, no intervention or any other intervention by the sexual partners of women treated for BV. Data collection and analysis Three review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach. Main results Seven RCTs (1026 participants) met our inclusion criteria, and pharmaceutical industry funded four of these trials. Five trials (854 patients) compared any antibiotic treatment of sexual partners with placebo. Based on high quality evidence, antibiotic treatment does not increase the rate of clinical or symptomatic improvement in women during the first week (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.96 to 1.03; 712 participants, four studies; RR 1.06, 95% CI 1.00 to 1.12; 577 patients, three studies, respectively), between the first and fourth week (RR 1.02, 95% CI 0.94 to 1.11; 590 participants, three studies; RR 0.93, 95% CI 0.84 to 1.03; 444 participants, two studies; respectively) or after the fourth week (RR 0.98, 95% CI 0.90 to 1.07; 572 participants, four studies; RR 1.03, 95% CI 0.90 to 1.17; 296 participants, two studies; respectively). Antibiotic treatment does not led to a lower recurrence during the first and fourth week (RR 1.28, 95% CI 0.68 to 2.43; 218 participants, one study; low quality evidence) or after the fourth week of treatment (RR 1.00, 95% CI 0.67 to 1.52; 372 participants, three studies; low quality evidence) in women, but increases the frequency of adverse events (most frequently gastrointestinal symptoms) reported by sexual partners (RR 2.55, 95% CI 1.55 to 4.18; 477 participants, three studies; low quality evidence).
 
 Two trials (172 participants) compared any antibiotic treatment for sexual partners with no intervention. When we compared it with no intervention, the effects of antibiotic treatment on recurrence rate after the fourth week (RR 1.71, 95% CI 0.65 to 4.55; 51 participants, one study), clinical improvement between the first and fourth week (RR 0.93, 95% CI 0.70 to 1.25; 152 participants, two studies) and symptomatic improvement after the fourth week (RR 0.66, 95% CI 0.39 to 1.11; 70 participants, one study) were imprecise and there were no differences between groups. We downgraded the quality of the evidence to low or very low. Authors' conclusions High quality evidence shows that antibiotic treatment for sexual partners of women with BV, compared with placebo, does not increase the rate of clinical or symptomatic improvement during the first, between the first and fourth or after the fourth week into the women. Low quality evidence suggests that antibiotic treatment does not led to a lower recurrence rate during the first and fourth or after the fourth week of treatment into the women, but increases the frequency of adverse events reported by sexual partners. Finally, compared with no intervention, antibiotic treatment does not decrease the recurrence rate after the fourth week and does not increase the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week into the women, respectively. Plain language summary Antibiotic treatment for the sexual partners of women with bacterial vaginosis Review question We assessed the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for bacterial vaginosis (BV). Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of infection after antibiotic treatment. Therefore, the treatment of sexual partners could offer the advantages of decreasing the recurrence of infection and possibly reducing the burden of the disease. Trial characteristics Cochrane researchers searched the available literature up to the 23 July 2016 and included seven trials with 1026 participants. The trials included sexually‐active non‐pregnant women between 17 and 56 years of age, either single or married, with symptomatic BV. Four studies only included women involved into a monogamous heterosexual relationship and there was no information about this for the remaining trials. Six trials used 5‐nitroimidazoles to treat the sexual partner, four trials used metronidazole and two trials used tinidazole; only one study used a lincosamide for treatment. Five trials compared antibiotic versus placebo (854 participants) and two trials compared antibiotic treatment with no intervention (172 participants). Pharmaceutical companies funded four of the included trials. Key results Compared with placebo, antibiotic treatment for the sexual partners of women treated for BV had no effects on clinical or symptomatic improvement in women, regardless of the time period over which the trials assessed these outcomes (during the first, between the first and fourth, or after the fourth week). Furthermore, antibiotic treatment of the sexual partner may have no effect on the recurrence of BV up to 12 weeks after treatment, but may increase the frequency of minor adverse events reported by sexual partners. Compared with no intervention, treatment of sexual partners of women with BV may have no effect on decreasing the recurrence rate or over the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week, respectively. Quality of evidence The quality of evidence was high for the outcomes of clinical and symptomatic improvement. The quality of evidence was very low for recurrence due to some limitations regarding risk of bias and imprecision.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.741Z" }, { "id": "5b31b8f5-b851-4f0d-8ac7-5f3366b66ab1", "pmid": "", "title": "Ginkgo biloba extract for age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Ginkgo is used in the treatment of peripheral vascular disease and 'cerebral insufficiency'. It is thought to have several potential mechanisms of action including increased blood flow, platelet activating factor antagonism, and prevention of membrane damage caused by free radicals. Vascular factors and oxidative damage are thought to be two potential mechanisms in the pathology of age‐related macular degeneration (AMD). Objectives The objective of this review was to determine the effect of Ginkgo biloba extract on the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2012), EMBASE (January 1980 to October 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to October 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 5 October 2012. We searched the reference lists of identified reports and the Science Citation Index. We also contacted investigators of included studies for additional information. Selection criteria All randomised trials in people with AMD where Ginkgo biloba extract had been compared to control were included. Data collection and analysis The review author extracted data using a standardised form. The data were verified with the trial investigators. Trial quality was assessed. Main results Two published trials were identified that randomised a total of 119 people. In one study conducted in France, 20 people were randomly allocated to Gingko biloba extract EGb 761 80 mg twice daily or placebo. In the other study conducted in Germany, 99 people were randomly allocated to two different doses of Ginkgo biloba extract EGb 761 (240 mg per day and 60 mg per day). Treatment duration in both studies was six months. Both trials reported some positive effects of Ginkgo biloba on vision however their results could not be pooled. Adverse effects and quality of life for people with AMD were not reported. Authors' conclusions The question as to whether people with AMD should take Ginkgo biloba extract to prevent progression of the disease has not been answered by research to date. Two small trials have suggested possible benefit of Gingko biloba on vision and further trials are warranted. Ginkgo biloba is widely used in China, Germany, and France. Future trials should be larger, and last longer, in order to provide a more robust measure of the effect of Gingko biloba extract on AMD. Plain language summary Use of Gingko biloba, an extract from the leaves of the maidenhair tree, for slowing the progression of age‐related macular degeneration Age‐related macular degeneration (AMD) is a condition affecting the central area of the retina (the back of the eye). The retina can deteriorate with age and some people get lesions that lead to loss of central vision. Gingko biloba, extracted from the leaves of the maidenhair tree, is used in Chinese herbal medicine to treat a variety of medical conditions, in particular circulatory problems. Ginkgo biloba extract contains two constituents (flavonoids and terpenoids) which have antioxidant properties. It is believed these may help to slow down the progression of AMD. The author identified two small randomised controlled studies (with a total of 119 participants); one in France and one in Germany. One trial compared Gingko biloba to placebo and the other compared two different doses of the extract. Although both trials reported some positive effects of Ginkgo biloba on vision, the trials were small and of short duration. Adverse effects and quality of life were not assessed. The overall conclusion of this review is that current research has not answered the question as to whether Ginkgo biloba is of benefit to people with AMD. Future trials need to include a larger number of participants and be conducted over a longer time.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD001775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "5b346cfa-1af9-4303-8609-1c0eb0554a7f", "pmid": "", "title": "Olfactory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Preterm infants, often gavage‐fed due to immaturity, may benefit from interventions that hasten the move to breastfeeding. Olfactory stimulation may increase appetite and speed up the transition to full oral feeding, potentially shortening hospital stay and improving outcomes for both infants and families. Objectives To evaluate the benefits and harms of olfactory stimulation for reducing morbidity and promoting development in hospitalized preterm infants. Search methods We searched MEDLINE, Embase, CENTRAL, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 2 April 2025. We checked the reference lists of included studies and systematic reviews on olfactory or sensory stimulation. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs evaluating olfactory stimulation with different odorants (maternal breast milk, food‐associated odors, or non‐food‐associated odors) in preterm infants (born before 37 weeks' gestation). Eligible controls were no intervention, placebo, or standard care (considered together) or another odorant. We excluded studies combining olfactory stimulation with taste, as another review will focus on combined sensory stimulation. Outcomes Our critical outcomes were apnea, intermittent hypoxemia, duration of hospital stay, time to full oral feeding, and exclusive breastfeeding. Our important outcomes included blindness and sensorineural deafness requiring amplification. Risk of bias We used the Cochrane risk of bias tool (RoB 2) to assess risk of bias in the included studies. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, each with its 95% confidence interval (CI). We assessed the certainty of evidence using GRADE. Included studies We included 14 trials enrolling 1087 neonates. The types of olfactory stimulation under investigation were maternal breast milk (9 studies); food‐associated odors such as cinnamon, vanilla, or anise (5 studies); and non‐food‐associated odors such as rose or parents' scent (3 studies). Three studies evaluated two different odorants. Gestational age and bodyweight varied widely. The comparators were placebo, no intervention, and standard care. Eleven studies aimed to assess the effect of olfactory stimulation on infant feeding outcomes such as time to full oral feeding, weight gain, length of hospital stay, or a combination of these outcomes. Three studies aimed to assess the effect of olfactory stimulation on apnea prevention, oxygen saturation, or both. We identified five ongoing trials. Synthesis of results No studies reported apnea as a dichotomous outcome, intermittent hypoxemia, exclusive breastfeeding, or major neurodevelopmental disability for any of the comparisons. We downgraded the certainty of evidence for limitations in study design, imprecision, and indirectness. Olfactory stimulation with maternal breast milk versus no intervention, placebo, or standard care The evidence is very uncertain about the effect of olfactory stimulation with maternal breast milk on the mean number of daily apnea episodes (MD −0.50, 95% CI −1.27 to 0.27; 1 study, 26 participants; very low‐certainty evidence) and duration of hospital stay in days (MD −0.18, 95% CI −0.64 to 0.27; I² = 0%; 4 studies, 270 participants; very low‐certainty evidence). Olfactory stimulation with maternal breast milk may result in a slight reduction in time to full oral feeding in days (MD −1.68, 95% CI −3.25 to −0.11; I² = 30%; 3 studies, 204 participants; low‐certainty evidence). Olfactory stimulation with food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with food‐associated odors may result in a slight reduction in the mean number of daily apnea episodes (MD −1.99, 95% CI −2.69 to −1.29; I² = 58%; 2 studies, 62 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with food‐associated odors on duration of hospital stay in days (MD −2.65, 95% CI −6.18 to 0.89; I² = 20%; 3 studies, 185 participants; very low‐certainty evidence) and time to full oral feeding in days (MD −2.06, 95% CI −5.16 to 1.04; I² = 36%; 3 studies, 185 participants; very low‐certainty evidence). Olfactory stimulation with non‐food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with non‐food‐associated odors may result in a slight reduction in duration of hospital stay in days (MD −3.23, 95% CI −5.50 to −0.97; I² = 0%; 2 studies, 94 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with non‐food‐associated odor on the mean number of daily apnea episodes (MD −2.13, 95% CI −2.28 to −1.98; 1 study, 60 participants; very low‐certainty evidence) and time to full oral feeding (mean 21 (standard deviation 3.1) days in the intervention group and mean 21 (standard deviation 15.6) days in the control group; 1 study, 27 participants; very low‐certainty evidence). Authors' conclusions Olfactory stimulation with maternal breast milk compared to no intervention, placebo, or standard care may result in a slight reduction in time to full oral feeding, but the evidence is very uncertain about its effect on frequency of apnea episodes and duration of hospital stay. Olfactory stimulation with food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in frequency of apnea episodes, but the evidence is very uncertain about its effect on duration of hospital stay and time to full oral feeding. Olfactory stimulation with non‐food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in duration of hospital stay, but the evidence is very uncertain about its effect on frequency of apnea episodes and time to full oral feeding. Future studies should be more rigorous in their design, report using TIDieR (Template for Intervention Description and Replication) checklists, have larger sample sizes, and measure outcomes such as apnea (number of infants with ≥ 1 episode), intermittent hypoxemia (number of infants with ≥ 1 episode), exclusive breastfeeding, and major neurodevelopmental disabilities. Funding Dedicated funding for this review can be found in the 'Sources of support' section. Registration Protocol: https://doi.org/10.1002/14651858.CD016074 . Plain language summary Does introducing smells to preterm infants improve their physical and mental development? Key messages Introducing preterm infants to the smell of maternal breast milk may slightly reduce the time it takes for them to feed fully by mouth. Introducing them to food smells such as vanilla and cinnamon may slightly reduce how often they stop breathing. Finally, introducing preterm babies to the smell of rose or a parent's scent may reduce slightly the time they have to stay in hospital. All other results are very uncertain. Future studies should include more infants, use more rigorous designs, and measure outcomes such as breathing problems, low blood oxygen levels, exclusive breastfeeding, and long‐term neurodevelopmental outcomes. What is preterm birth? A normal pregnancy usually lasts from 37 weeks to 42 weeks. Preterm birth is when a baby is born before 37 weeks of pregnancy. Babies born preterm have not had enough time to fully develop before birth. Their organs may not yet be ready to work on their own, which means they often need intensive medical care and are at greater risk of breathing and feeding difficulties, infection, and problems that can affect their long‐term development. What is olfactory stimulation, and how does it work? Preterm infants often take time to build up the skills or physical capacity to feed by mouth, and in the meantime are fed through a tube passed into the stomach. Olfactory stimulation involves introducing smells to preterm infants while they are in hospital to see if it helps them start breastfeeding more quickly. These smells include breast milk, food smells such as vanilla or cinnamon, and other smells such as a floral scent or a parent's scent. What did we want to find out? We wanted to find out whether introducing a smell to preterm infants in hospital could be helpful and safe for their short‐term and long‐term well‐being. More specifically, we wanted to find out whether introducing a smell to preterm infants is better than placebo (dummy treatment), no treatment, or usual care for: reducing the number of infants who have apnea (brief pauses in breathing); reducing the number of infants with low oxygen levels in the blood; reducing the time spent in hospital; reducing the time needed for the infants to learn to feed fully by mouth; increasing the number of infants that are fed only with breast milk; reducing the number of infants with blindness or deafness between 18 and 24 months of age. What did we do? We searched for studies that compared olfactory stimulation with placebo, no treatment, or usual care in preterm infants. We summarized the results of the studies and rated our confidence in the evidence based on factors such as study size (number of infants) and methods. What did we find? We included 14 studies with 1087 infants. Nine studies used the smell of maternal breast milk, five used food‐associated smells (vanilla, cinnamon, or anise), and three studies used other smells (rose or parents' scent). All studies compared these smells with no treatment, placebo, or usual care. Main results Introducing the smell of maternal breast milk may reduce slightly the time it takes infants to feed fully by mouth. It is unclear whether stimulation with this smell has any effect on how often infants have apnea episodes and how long they stay in hospital. Introducing the smell of cinnamon, vanilla, or anise may slightly reduce how often infants have apnea episodes. It is unclear whether stimulation with these smells has any effect on how long infants stay in hospital or how long it takes them to feed fully by mouth. Introducing the scent of rose or a parent's scent may slightly reduce how long infants spend in hospital. It is unclear whether stimulation with these smells has any effect on how often infants have apnea episodes or how long it takes them to feed fully by mouth. What are the limitations of the evidence? We have little confidence in these results, as the studies included could have been better designed and included more babies. Several studies did not report outcomes we were interested in. How up to date is this evidence? The evidence is current to 2 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lenells, M, Prescott, MG, Wróblewska-Seniuk, K, Fiander, M, Soll, RF, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD016074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.067Z" }, { "id": "5b3cfd39-4373-44bd-98d1-0247bf889fcf", "pmid": "", "title": "Non‐immunosuppressive treatment for IgA nephropathy", "imported": false, "abstract": "Abstract - Background IgA nephropathy (IgAN) is the most common primary glomerular disease, with approximately 20% to 40% of patients progressing to kidney failure within 25 years. Non‐immunosuppressive treatment has become a mainstay in the management of IgAN by improving blood pressure (BP) management, decreasing proteinuria, and avoiding the risks of long‐term immunosuppressive management. Due to the slowly progressive nature of the disease, clinical trials are often underpowered, and conflicting information about management with non‐immunosuppressive treatment is common. This is an update of a Cochrane review, first published in 2011. Objectives To assess the benefits and harms of non‐immunosuppressive treatment for treating IgAN in adults and children. We aimed to examine all non‐immunosuppressive therapies (e.g. anticoagulants, antihypertensives, dietary restriction and supplementation, tonsillectomy, and herbal medicines) in the management of IgAN. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to December 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs of non‐immunosuppressive agents in adults and children with biopsy‐proven IgAN were included. Data collection and analysis Two authors independently reviewed search results, extracted data and assessed study quality. Results were expressed as mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI) using random‐effects meta‐analysis. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results This review includes 80 studies (4856 participants), of which 24 new studies (2018 participants) were included in this review update. The risk of bias within the included studies was mostly high or unclear for many of the assessed methodological domains, with poor reporting of important key clinical trial methods in most studies. Antihypertensive therapies were the most examined non‐immunosuppressive therapy (37 studies, 1799 participants). Compared to placebo or no treatment, renin‐angiotensin system (RAS) inhibition probably decreases proteinuria (3 studies, 199 participants: MD ‐ 0.71 g/24 h, 95% CI ‐1.04 to ‐0.39; moderate certainty evidence) but may result in little or no difference to kidney failure or doubling of serum creatinine (SCr), or complete remission of proteinuria (low certainty evidence). Death, remission of haematuria, relapse of proteinuria or > 50% increase in SCr were not reported. Compared to symptomatic treatment, RAS inhibition (3 studies, 168 participants) probably decreases proteinuria (MD ‐1.16 g/24 h, 95% CI ‐1.52 to ‐0.81) and SCr (MD ‐9.37 µmol/L, 95% CI ‐71.95 to ‐6.80) and probably increases creatinine clearance (2 studies, 127 participants: MD 23.26 mL/min, 95% CI 10.40 to 36.12) (all moderate certainty evidence); however, the risk of kidney failure is uncertain (1 study, 34 participants: RR 0.20, 95% CI 0.01 to 3.88; very low certainty evidence). Death, remission of proteinuria or haematuria, or relapse of proteinuria were not reported. The risk of adverse events may be no different with RAS inhibition compared to either placebo or symptomatic treatment (low certainty evidence). In low certainty evidence, tonsillectomy in people with IgAN in addition to standard care may increase remission of proteinuria compared to standard care alone (2 studies, 143 participants: RR 1.90, 95% CI 1.45 to 2.47) and remission of microscopic haematuria (2 studies, 143 participants: RR 1.93, 95% CI 1.47 to 2.53) and may decrease relapse of proteinuria (1 study, 73 participants: RR 0.70, 95% CI 0.57 to 0.85) and relapse of haematuria (1 study, 72 participants: RR 0.70, 95% CI 0.51 to 0.98). Death, kidney failure and a > 50% increase in SCr were not reported. These trials have only been conducted in Japanese people with IgAN, and the findings' generalisability is unclear. Anticoagulant therapy, fish oil, and traditional Chinese medicines exhibited small benefits to kidney function in patients with IgAN when compared to placebo or no treatment. However, compared to standard care, the kidney function benefits are no longer evident. Antimalarial therapy compared to placebo in one study reported an increase in a > 50% reduction of proteinuria (53 participants: RR 3.13 g/24 h, 95% CI 1.17 to 8.36; low certainty evidence). Although, there was uncertainty regarding adverse events from this study due to very few events. Authors' conclusions Available RCTs focused on a diverse range of interventions. They were few, small, and of insufficient duration to determine potential long‐term benefits on important kidney and cardiovascular outcomes and harms of treatment. Antihypertensive agents appear to be the most beneficial non‐immunosuppressive intervention for IgAN. The antihypertensives examined were predominantly angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers. The benefits of RAS inhibition appear to outweigh the harms in patients with IgAN. The certainty of the evidence of RCTs demonstrating a benefit of tonsillectomy to patients with Japanese patients with IgAN was low. In addition, these findings are inconsistent across observational studies in people with IgAN of other ethnicities; hence, tonsillectomy is not widely recommended, given the potential harm of therapy. The RCT evidence is insufficiently robust to demonstrate efficacy for the other non‐immunosuppressive treatments evaluated here. Plain language summary Non‐immunosuppressive treatment for IgA nephropathy Key messages Treatment with renin‐angiotensin system (RAS) inhibition, namely angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, is the most common first‐line, non‐immunosuppressive therapy used for managing patients with IgA nephropathy (IgAN). The role of other non‐immunosuppressive treatments in managing IgAN is unclear and warrants further clinical studies. Why treat IgA nephropathy with non‐immunosuppressive therapies? IgAN is one of the most common kidney diseases, leading to reduced kidney function and kidney failure for about 20% to 40% of patients within 20 to 25 years. The cause of IgAN is not widely understood, but most people have an abnormality in their immune system that leads to damage to the kidney. However, other non‐immune functions play a role in the disease's impact on the kidney. What did we want to find out? We wanted to find out if non‐immunosuppressive treatments (e.g. antihypertensive agents, anticoagulants, fish oil, tonsillectomy, herbal medicine) improved kidney function in adults and children with IgAN. What did we do? We searched for all trials that assessed the benefits and harms of randomly allocated non‐immunosuppressive treatment in people with IgAN. We compared and summarised the results of the trials and rated our confidence in the information based on factors such as trial methods and sizes. What did we find? We included 80 studies involving 4856 people with IgAN treated with a diverse collection of non‐immunosuppressive treatments. Patients in studies were given various therapies, including blood pressure lowering agents (antihypertensives), removal of participant's tonsils (tonsillectomy), antimalarials, traditional Chinese medicine, dietary supplements (e.g. fish oil), and vitamin D receptor agonists. Antihypertensive medication aimed at inhibiting the RAS appears to slow damage to the kidney with minimal side effects. However, its impact in preventing people from progressing to kidney failure is unclear. Other interventions, such as tonsillectomy, antimalarial medication, and low‐calorie restricted diets role in treating patients are still unclear. What are the limitations of the evidence? The small number of studies per comparison and the small size of the studies were limitations in this review. Not all the studies provided data about the outcomes we were interested in. We are unsure about the results. How up to date is the evidence? The evidence is up to date as of December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Tunnicliffe, DJ, Reid, S, Craig, JC, Samuels, JA, Molony, DA, Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD003962.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.124Z" }, { "id": "5b55d81a-aaf2-45c6-a06e-e8ad25f0ca76", "pmid": "", "title": "Melatonin for the prevention and treatment of jet lag", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Herxheimer, A, Petrie, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD001520 AB - Abstract - Background Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Objectives To assess the effectiveness of oral melatonin taken in different dosage regimens for alleviating jet lag after air travel across several time zones. Search methods We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsychLit and Science Citation Index electronically, and the journals 'Aviation, Space and Environmental Medicine' and 'Sleep' by hand. We searched citation lists of relevant studies for other relevant trials. We asked principal authors of relevant studies to tell us about unpublished trials. Reports of adverse events linked to melatonin use outside randomised trials were searched for systematically in 'Side Effects of Drugs' (SED) and SED Annuals, 'Reactions Weekly', MEDLINE, and the adverse drug reactions databases of the WHO Uppsala Monitoring Centre (UMC) and the US Food & Drug Administration. An updating search was carried out on 12/2/2008 but no new studies were identified. Selection criteria Randomised trials in airline passengers, airline staff or military personnel given oral melatonin, compared with placebo or other medication. Outcome measures should consist of subjective rating of jet lag or related components, such as subjective well being, daytime tiredness, onset and quality of sleep, psychological functioning, duration of return to normal, or indicators of circadian rhythms. Data collection and analysis Ten trials met the inclusion criteria. All compared melatonin with placebo; one in addition compared it with a hypnotic, zolpidem. Nine of the trials were of adequate quality to contribute to the assessment, one had a design fault and could not be used in the assessment. 
 Reports of adverse events outside trials were found through MEDLINE, 'Reactions Weekly', and in the WHO UMC database. Main results Eight of the ten trials found that melatonin, taken close to the target bedtime at the destination (10pm to midnight), decreased jet‐lag from flights crossing five or more time zones. Daily doses of melatonin between 0.5 and 5mg are similarly effective, except that people fall asleep faster and sleep better after 5mg than 0.5mg. Doses above 5mg appear to be no more effective. The relative ineffectiveness of 2mg slow‐release melatonin suggests that a short‐lived higher peak concentration of melatonin works better. The estimated number needed to treat (NNT) is 2, based on the only two trials that gave the necessary data. The benefit is likely to be greater the more time zones are crossed, and less for westward flights. The timing of the melatonin dose is important: if it is taken at the wrong time, early in the day, it is liable to cause sleepiness and delay adaptation to local time. The incidence of other side effects is low. Case reports suggest that people with epilepsy, and patients taking warfarin may come to harm from melatonin. Authors' conclusions Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be. The pharmacology and toxicology of melatonin needs systematic study, and routine pharmaceutical quality control of melatonin products must be established. The effects of melatonin in people with epilepsy, and a possible interaction with warfarin, need investigation. Plain language summary Melatonin for the prevention and treatment of jet lag Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.097Z" }, { "id": "5b8c6102-9936-40ba-a0d5-f1ad3ddc49d3", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 1. Commonly‐used classes of drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres ( ˜ 8200 feet ). Acute hypoxia, acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude. In this review, the first in a series of three about preventive strategies for HAI, we assess the effectiveness of six of the most recommended classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of commonly‐used pharmacological interventions for preventing acute HAI. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), LILACS and trial registries in January 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text terms to search. Selection criteria We included randomized‐controlled and cross‐over trials conducted in any setting where commonly‐used classes of drugs were used to prevent acute HAI. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Main results We included 64 studies (78 references) and 4547 participants in this review, and classified 12 additional studies as ongoing. A further 12 studies await classification, as we were unable to obtain the full texts. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. Risks of bias were unclear for several domains, and a considerable number of studies did not report adverse events of the evaluated interventions. We found 26 comparisons, 15 of them comparing commonly‐used drugs versus placebo. We report results for the three most important comparisons: Acetazolamide versus placebo (28 parallel studies; 2345 participants) The risk of AMS was reduced with acetazolamide (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.56; I 2 = 0%; 16 studies; 2301 participants; moderate quality of evidence). No events of HAPE were reported and only one event of HACE (RR 0.32, 95% CI 0.01 to 7.48; 6 parallel studies; 1126 participants; moderate quality of evidence). Few studies reported side effects for this comparison, and they showed an increase in the risk of paraesthesia with the intake of acetazolamide (RR 5.53, 95% CI 2.81 to 10.88, I 2 = 60%; 5 studies, 789 participants; low quality of evidence). Budenoside versus placebo (2 parallel studies; 132 participants) Data on budenoside showed a reduction in the incidence of AMS compared with placebo (RR 0.37, 95% CI 0.23 to 0.61; I 2 = 0%; 2 studies, 132 participants; low quality of evidence). Studies included did not report events of HAPE or HACE, and they did not find side effects (low quality of evidence). Dexamethasone versus placebo (7 parallel studies; 205 participants) For dexamethasone, the data did not show benefits at any dosage (RR 0.60, 95% CI 0.36 to 1.00; I2 = 39%; 4 trials, 176 participants; low quality of evidence). Included studies did not report events of HAPE or HACE, and we rated the evidence about adverse events as of very low quality. Authors' conclusions Our assessment of the most commonly‐used pharmacological interventions suggests that acetazolamide is an effective pharmacological agent to prevent acute HAI in dosages of 250 to 750 mg/day. This information is based on evidence of moderate quality. Acetazolamide is associated with an increased risk of paraesthesia, although there are few reports about other adverse events from the available evidence. The clinical benefits and harms of other pharmacological interventions such as ibuprofen, budenoside and dexamethasone are unclear. Large multicentre studies are needed for most of the pharmacological agents evaluated in this review, to evaluate their effectiveness and safety. Plain language summary Drugs commonly‐used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and breathing conditions that can occur while travelling to altitudes above 2500 metres ( ˜ 8200 feet ). HAI is generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but may affect the brain or the lungs in different individuals. In this review, we assessed the most commonly‐used drugs to prevent the onset of this illness. Study characteristics The evidence is current to January 2017. We included 64 studies related to six different types of drugs recommended for HAI prevention. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. The participants' ages ranged between 16 and 65 years. Eleven studies included people at a high risk of this condition due to their history of HAI or other illnesses such as asthma. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. In 23 of the included studies, the source of funding was unclear. Only 18 studies declared their possible conflicts of interests. We classed 24 more studies as still ongoing or waiting for assessment. Key results Our findings suggest that acetazolamide is an effective treatment for the prevention of acute HAI in dosages of 250 to 750 mg/day, when this drug is compared to a placebo (i.e. a pill with no active agent). Most of the available information relates to the prevention of uncomplicated HAI (headache, nausea, vomiting and tiredness) rather than to more serious brain or lung problems. We also found that acetazolamide is associated with an increased risk of paraesthesia in the fingers (i.e. a sensation of tingling, tickling, pricking, or burning of the skin), although this outcome is not well reported in the available evidence. The benefits and harms of other drugs such as ibuprofen, budenoside and dexamethasone are unclear, due to the small number of studies. Quality of the evidence We rated the quality of the evidence as moderate to very low. Several studies had quality shortcomings, including their use of small numbers of participants and a lack of reporting of important outcomes such as side effects. For most of the drugs covered by the studies, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Nieto Estrada, VH, Molano Franco, D, Medina, RD, Gonzalez Garay, AG, Martí‐Carvajal, AJ, Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD009761.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.751Z" }, { "id": "5b9dd478-2c68-4789-97fa-a4fecc3d85cd", "pmid": "", "title": "Pharmacological treatments for Friedreich ataxia", "imported": false, "abstract": "Abstract - Rationale Friedreich ataxia (FRDA) is a rare inherited autosomal recessive neurological disorder, characterised initially by unsteadiness in standing and walking, and slowly progressing to wheelchair dependency, usually in the late teens or early twenties. Scoliosis, pes cavus and cardiomyopathy are often present at diagnosis. As the disease progresses, individuals usually develop slurred speech, auditory impairment (especially in a noisy environment), urinary tract morbidity, diabetes, anxiety, depression, muscle spasticity and visual disturbances. Cardiac abnormalities cause premature death in 60% of people with FRDA. There is no easily defined clinical or biochemical marker to assess progression and no known curative treatment. This is the third update of a review published in 2009 and updated in 2012 and 2016. Objectives To assess the effects of pharmacological treatments for people with Friedreich ataxia (FRDA) after 12 months of treatment. Search methods To identify studies for inclusion in this review, we searched CENTRAL, MEDLINE, Embase, CINAHL Plus, TRIP, Orphanet, WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. We also checked reference lists of relevant studies and contacted study authors. The most recent search was on 4 February 2025. Eligibility criteria We were interested in randomised controlled trials (RCTs) and quasi‐RCTs of pharmacological treatments (including vitamins) in people with genetically‐confirmed FRDA. To be included in the review, studies had to last at least 12 months. Outcomes We assessed the following outcomes after 12 months of treatment: change in score on a validated ataxia rating scale; change in interventricular septal thickness in diastole (IVSTd) by cardiac magnetic resonance imaging or echocardiogram; change in activities of daily living (ADL) using a validated questionnaire; change in upper limb dexterity; and change in cardiopulmonary exercise testing (CPET). We also assessed treatment‐related adverse events with medication continued for the study period, and treatment‐emergent adverse events leading to cessation of medication or death during the study period. Risk of bias Using the Cochrane risk of bias tool RoB 2, we assessed the risk of bias in the seven outcomes reported in our summary of findings tables. Synthesis methods We synthesised the results of the studies for each outcome using meta‐analysis, where possible. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and the risk ratio (RR) for dichotomous outcomes, all with 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for our prespecified outcomes as high, moderate, low or very low. Included studies We included eight RCTs in this updated review. We included seven of them in meta‐analysis, and these studies enroled a total of 574 participants, with sample sizes ranging from 29 to 232 participants per study. One study was international, with centres in North America, Europe and Australia. There were four other multicentre studies (three in Europe and one in North America). Single‐centre studies were conducted in the UK, Italy and France. Participants in the studies ranged from eight to 70 years of age at enrolment, with the mean age in each study being between 18 years and 35 years (with an unweighted pooled mean age across studies of 25.9 years). All of the studies enroled both males and females, with the proportion of female participants ranging from 21% to 58%. Sixty‐eight per cent of participants had severe ataxia, while the other 32% had moderate ataxia. The studies tested epoetin alpha, CoQ10 and vitamin E, idebenone, leriglitazone, omaveloxolone, and RT001. One study tested pioglitazone but has not published any results. Four of the studies were pharmaceutical‐industry‐controlled. Synthesis of results Meta‐analysis of seven studies demonstrated that pharmacological treatment probably makes little or no difference to scores on the ataxia rating scale after 12 months of treatment (SMD 0.02, 95% CI −0.23 to 0.26; I² = 42%; 7 studies, 513 participants; moderate‐certainty evidence). The evidence was very uncertain about the effects of treatment on IVSTd (MD −0.51, 95% CI −1.10 to 0.09; I² = 80%; 2 studies, 72 participants; very low‐certainty evidence) and on ADL (MD −0.59, 95% CI −1.39 to 0.21; I² = 24%; 3 studies, 167 participants; very low‐certainty evidence). Meta‐analysis of three studies showed that treatment probably improves upper limb dexterity (SMD −0.42, 95% CI −0.73 to −0.11; I² = 0%; 3 studies, 166 participants; moderate‐certainty evidence). We are very uncertain about the effect of pharmacological treatment on CPET (SMD −0.16, 95% CI −0.46 to 0.13; I² = 0%; 3 studies, 181 participants; very low‐certainty evidence). We are very uncertain whether pharmacological treatment has any effect on treatment‐related adverse events (RR 0.88, 95% CI 0.63 to 1.22; I² = 0%; 2 studies, 104 participants; very low‐certainty evidence). There were only 104 participants in this analysis out of a total of 545 participants, so the result may have little relevance. Meta‐analysis of six studies found that there may be little to no difference between pharmacological treatment and placebo in treatment‐emergent adverse events leading to cessation of medication or death (RR 1.24, 95% CI 0.44 to 3.48; I² = 0%; 6 studies, 313 participants; low‐certainty evidence). Our certainty in the evidence ranged from very low to moderate. We downgraded all outcomes by one or two levels for imprecision, with further downgrades for inconsistency (for the outcomes of IVSTd, ADL, CPET) and suspected publication bias (for the outcomes of IVSTd, ADL, CPET and adverse events). Authors' conclusions In this updated Cochrane systematic review, meta‐analysis of results on the ataxia rating scale showed that pharmacological treatments probably make little or no difference compared with placebo after 12 months of treatment. Given this result, the probable improvement that we found in upper limb dexterity was unexpected. Treatment‐emergent adverse events leading to cessation of medication or death may be no more common in treatment groups than placebo groups as there were few adverse events detected in the treated groups. However, the studies may not have detected all rare and serious adverse events. Funding The authors in this review received no funding. Registration Protocol (2009) DOI: 10.1002/14651858.CD007791 Original review (2009) DOI: 10.1002/14651858.CD99791.pub2 Update (2012) DOI: 10.1002/14651858.CD007791.pub3 Update (2016) DOI: 10.1002/14651858.CD007791.pub4 Plain language summary Does taking medicine help people with Friedreich ataxia? Key messages For people with a progressive genetic condition called Friedreich ataxia, which affects nerves and muscles, taking medicine for a year probably has little to no effect on measures of ataxia (problems with co‐ordination and balance) or speech, although it probably improves upper limb dexterity (the ability to co‐ordinate the action of the arms, hands and fingers). We are uncertain whether taking medicine has any effect on heart health, the ability to perform daily tasks, or the body's response to exercise in people with Friedreich ataxia. From the available evidence, it is very uncertain whether the medicines cause any unwanted effects. What is Friedreich ataxia? Friedreich ataxia is a rare inherited condition affecting the nerves and muscles, which usually appears in childhood, at between 5 and 15 years of age. It causes clumsiness of movement, which progresses to unsteadiness in standing and walking, and to being dependent on a wheelchair by the late teens or early twenties. It can be associated with a curved spine (scoliosis), foot deformity (a high arch) and heart problems. As the disease progresses, slurred speech, hearing difficulties, problems going to the toilet, muscle spasticity, depression, anxiety and visual disturbances are common. Heart problems are a cause of early death in nearly two‐thirds of people with Friedreich ataxia. Clinical examination and laboratory tests are not very useful for judging the progression of the disease, which makes it difficult to understand the results of studies with Friedreich ataxia patients. What are the possible options for treating Friedreich ataxia? There is currently no cure for Friedreich ataxia. Various medicines have been tried. A new medicine, omaveloxolone, was recently approved in the USA and Europe for people over 16 years of age with Friedreich ataxia. What did we want to find out? We wanted to know if any of the medicines tested in randomised clinical trials help improve the lives of people with Friedreich ataxia. Randomised clinical trials are studies where some people take medicine and others take placebo, which is a substance that has no medical benefit but looks the same as the active medicine. No‐one involved with the study knows who is taking medicine and who is taking placebo. This is the third update of a Cochrane review that was first published in 2009. What did we do? We searched for randomised clinical trials that compared medicine to placebo in people with Friedreich ataxia and lasted at least 12 months. We combined the results of the studies and rated our confidence in this evidence, based on factors such as study methods and the number of people involved. What did we find? We found eight studies, seven of which reported results after taking medicine or placebo for 12 months. The studies included a total of 574 people, whose average ages were between 18 and 35 years. Most of the participants (68%) had severe ataxia, while 32% had moderate ataxia. The studies took place in Europe, North America and Australia. Four of them were carried out by the pharmaceutical industry (i.e. by companies who make the medicines). Two studies used a medicine called idebenone, and each of the others used a different medicine: co‐Q10 with vitamin E, epoetin alpha, omaveloxolone, leriglitazone, pioglitazone, and RT001. We found that, after one year, there was probably little to no difference in the level of ataxia that people experienced, regardless of whether they took medicine or placebo (7 studies, 513 people). We are very uncertain whether medicine has any effect on heart health (based on measuring the thickness of the heart muscle) or the ability to do daily tasks or how people score on special tests designed to measure the body's response to exercise. We found that medicine probably improves upper limb dexterity after one year (3 studies (testing leriglitazone, epoetin alpha and omaveloxolone), 166 people). With regard to safety, we are very uncertain whether the medicines cause any more unwanted effects than placebo. We found that there may be little to no difference between people taking medicine and people taking placebo in terms of the number of who either stopped taking the medicine or placebo, or the number of who died during the study years (6 studies, 313 people). What are the limitations of the evidence? Our confidence in the effect of medicine on ataxia is only moderate. This is because the results were not very precise. We are only moderately confident about the effect of medicine on upper limb dexterity because this was only reported in small studies. We had very little confidence in the other outcomes because of the small numbers of people in the studies. The studies reported varied results, and some studies did not publish the results for all the assessments that were carried out. It is difficult to measure an individual's perceptions of the positive effects of any new medicine, which may vary depending on their expectations prior to starting the medicine and whether their illness is early or advanced. How up to date is this evidence? The evidence is current to 4 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lyons, S, Kearney, M, Fahey, MC, Janjal, P, Pandolfo, M, Patton, P", "articleTypes": [], "doi": "10.1002/14651858.CD007791.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.824Z" }, { "id": "5bac07d0-2ddb-4d09-b6cb-f20ddd27aa36", "pmid": "", "title": "Glutamine for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Crohn's disease is a chronic relapsing condition of the alimentary tract with a high morbidity secondary to bowel inflammation. Glutamine plays a key role in maintaining the integrity of the intestinal mucosa and has been shown to reduce inflammation and disease activity in experimental models of Crohn's disease. Objectives To evaluate the efficacy and safety of glutamine supplementation for induction of remission in Crohn's disease. Search methods We searched the following databases from inception to November 15, 2015: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane IBD Group Specialised Register. Study references were also searched for additional trials. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) that compared glutamine supplementation administered by any route to a placebo, active comparator or no intervention in people with active Crohn's disease were considered for inclusion. Data collection and analysis Two authors independently extracted data and assessed the methodological quality of the included studies. The Cochrane risk of bias tool was used to assess methodological quality. The primary outcome measure was clinical or endoscopic remission. Secondary outcomes included intestinal permeability, clinical response, quality of life, growth in children and adverse events. Risk ratios and 95% confidence intervals were calculated for dichotomous outcomes. The overall quality of the evidence supporting the primary outcome was evaluated using the GRADE criteria. Main results Two small RCTs (total 42 patients) met the inclusion criteria and were included in the review. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. The other study (24 patients) compared glutamine‐supplemented total parenteral nutrition to non‐supplemented total parenteral nutrition in adult patients (> 18 years of age) with acute exacerbation of inflammatory bowel disease. The paediatric study was rated as low risk of bias. The study in adult patients was rated as unclear risk of bias for blinding and low risk of bias for all other items. It was not possible to pool data for meta‐analysis because of significant differences in study populations, nature of interventions, and the way outcomes were assessed. Data from one study showed no statistically significant difference in clinical remission rates at four weeks. Forty‐four per cent (4/9) of patients who received a glutamine‐enriched polymeric diet achieved remission compared to 56% (5/9) of patients who received a standard low‐glutamine polymeric diet (RR 0.80, 95% CI 0.31 to 2.04). A GRADE analysis indicated that the overall quality of evidence for this outcome was low due to serious imprecision (9 events). In both included studies, no statistically significant changes in intestinal permeability were found between patients who received glutamine supplementation and those who did not. Neither study reported on clinical response, quality of life or growth in children. Adverse event data were not well documented. There were no serious adverse events in the paediatric study. The study in adult patients reported three central catheter infections with positive blood cultures in the glutamine group compared to none in the control group (RR 7.00, 95% CI 0.40 to 122.44). Authors' conclusions Currently there is insufficient evidence to allow firm conclusions regarding the efficacy and safety of glutamine for induction of remission in Crohn's disease. Data from two small studies suggest that glutamine supplementation may not be beneficial in active Crohn's disease but these results need to be interpreted with caution as they are based on small numbers of patients. This review highlights the need for adequately powered randomised controlled trials to investigate the efficacy and safety of glutamine for induction of remission in Crohn's disease. Plain language summary Glutamine for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disorder of the intestines which has periods of inactivity and periods when it flares up. Crohn's disease can affect any part of the digestive tract, from the mouth to the anus. The most common symptoms of the disease include abdominal pain, non‐bloody diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms of the disease it is said to be ‘active’; periods when the symptoms stop are called ‘remission’. What is glutamine? Glutamine is an amino acid that plays a key role in maintaining the integrity of the intestinal mucosa (lining of the intestines) and has been shown to reduce inflammation and disease activity in animal models of Crohn's disease. It has therefore been suggested that glutamine may reduce intestinal inflammation in people with Crohn's disease. What did the researchers investigate? The researchers investigated whether glutamine is effective for inducing remission in people with active Crohn's disease and whether this treatment causes any harms (side effects). The researchers searched the medical literature up to November 15, 2015. What did the researchers find? The researchers identified two randomised controlled trials (total 42 participants) that investigated the role of glutamine for the treatment of active Crohn's disease. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. Participants were encouraged to consume the diet orally. If this was not possible the diet was administered via a fine‐bore nasogastric tube. The other study (24 participants) compared glutamine‐supplemented total parenteral nutrition (TPN) to non‐supplemented TPN in adult patients (> 18 years of age) with sudden worsening of inflammatory bowel disease. The TPN diet was administered intravenously via a central catheter (a thin tube) for at least one week. Both studies were generally high quality. Neither study demonstrated any beneficial effects for glutamine. Side effects were not well documented in the two studies. There were no serious side effects noted in the paediatric study. The study in adult patients reported three central catheter‐related blood infections in the glutamine group compared to none in the non‐glutamine control group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and harms of glutamine for the treatment of active Crohn's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Akobeng, AK, Elawad, M, Gordon, M", "articleTypes": [], "doi": "10.1002/14651858.CD007348.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.748Z" }, { "id": "5bacc354-fcd6-41e6-9f39-05a75c39fa16", "pmid": "", "title": "Zinc for the common cold", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Singh, M, Das, RR", "articleTypes": [], "doi": "10.1002/14651858.CD001364.pub5 AB - Reason for withdrawal from publication September 2016 updated withdrawal notice 
 This Cochrane Review was withdrawn in April 2015, and this withdrawal notice was updated in September 2016. The review was withdrawn as result of comments submitted via the Cochrane Library by Harri Hemilä in February 2015. Hemilä identified multiple errors in this Cochrane Review and made allegations of plagiarism of text and data from a previously published systematic review (Hemilä H. Zinc Lozenges may shorten the duration of colds: a systematic review. Open Respiratory Medicine Journal 2011;5:51‐58. dx.doi.org/10.2174/1874306401105010051). The comments referred to the version of this review first published in June 2013 (Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2013;(6):CD001364. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001364.pub4/full) . The Cochrane Acute Respiratory Infections Group, which maintains the review, withdrew the review in April 2015, pending an assessment of the errors reported, and the group referred the allegations of plagiarism to the Editor in Chief. The Editor in Chief notified the authors of the concerns, and followed the Committee for Publication Ethics (COPE) guidelines. Replication of text was identified in the Cochrane Review. This was limited to copying of short phrases and was acknowledged by the authors. The level of text plagiarism was minor and at a level that would be addressed by a correction. The Editor in Chief carried out further investigation into the alleged plagiarism of data, with the co‐operation of the review authors, who provided supplementary information in support of their work. The allegations related to the derivation of means and standard deviations of data from some of the included studies. Although the authors acknowledge and cite the Hemilä 2011 review, the Editor in Chief considered that the authors’ explanation regarding some similarities in presented data between the two reviews was not conclusive. This version of the review will therefore remain withdrawn. April 2015 withdrawal notice 
 This review was withdrawn due to concerns raised via the feedback mechanism regarding the calculation and analysis of data in the review in April 2015. Whilst it is not unusual for reviews to be withdrawn, the editorial group took the view that it would be better to take a cautious approach and explore the source and calculation of data used in the analysis in more detail, rather than keep the review on the Cochrane Database of Systematic Reviews for the time being. The editorial group responsible for this previously published document have withdrawn it from publication.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.745Z" }, { "id": "5bdfffea-547b-4ce2-992c-02b4a2353dae", "pmid": "", "title": "Adjunctive therapies in addition to land‐based exercise therapy for osteoarthritis of the hip or knee", "imported": false, "abstract": "Abstract - Background Land‐based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non‐pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land‐based exercise therapy is lacking. Objectives To evaluate the benefits and harms of adjunctive therapies used in addition to land‐based exercise therapy compared with placebo adjunctive therapy added to land‐based exercise therapy, or land‐based exercise therapy only for people with hip or knee osteoarthritis. Search methods We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land‐based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land‐based exercise therapy, or land‐based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant‐reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short‐term (6 months), medium‐term (6 to 12 months) and long‐term (12 months onwards) effects. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE. Main results We included 62 trials (60 RCTs and 2 quasi‐RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 60 included people with knee osteoarthritis only. Thirty‐six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty‐two trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in 11 (18%) trials. Comparing adjunctive therapies plus land‐based exercise therapy against placebo therapies plus exercise up to six months (short‐term), we found low‐certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate‐certainty evidence indicates that adjunctive therapies did not improve QOL (SF‐36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low‐certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant‐reported global assessment was not measured in any studies. Compared with land‐based exercise therapy, low‐certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short‐term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise‐only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (41 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (41 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low‐certainty evidence). Moderate‐certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant‐reported global assessment (short‐term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI ‐0.32 to ‐0.18 mm); 12% relative improvement (6% better to 18% better). Low‐certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27). Authors' conclusions Moderate‐ to low‐certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant‐reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis. Plain language summary Additional therapies used with exercise therapy for hip or knee osteoarthritis What was the aim of this review? Osteoarthritis, a chronic degenerative condition that commonly affects hip and knee joints, causes pain and difficulty with everyday activities such as walking. Land‐based exercise therapy refers to exercise conducted on land (as opposed to exercise in the water) and is a first‐line treatment. This review aimed to find out if adding additional therapies to land‐based exercise therapy improved pain, function, quality of life, participant‐reported overall change or X‐ray changes in people with hip or knee osteoarthritis. Additional therapies include manual (hands‐on) therapy, psychological or dietary therapies, electrophysical agents (such as heat, cold, nerve stimulation, ultrasound or laser therapy) or acupuncture. We included studies comparing additional therapies plus land‐based exercise therapy to either 1) sham (or dummy) therapy plus land‐based exercise therapy or 2) land‐based exercise therapy only. Search date This systematic review is up‐to‐date to 10 June 2021. What did we find? We found 62 randomised controlled trials with 6508 participants, mostly women, from 24 countries. The average age was between 52 and 83 years, with symptoms present from 9 months to 12 years. Sixty studies enrolled people with knee osteoarthritis, one enrolled people with hip osteoarthritis and one enrolled people with knee or hip osteoarthritis. Twenty‐two trials compared additional therapies plus exercise therapy to sham additional therapies plus exercise therapy, and 41 compared to exercise therapy. Thirty‐eight trials studied electrophysical agents, seven studied manual therapies, four studied acupuncture/dry needling or use of tape, three studied psychological or dietary interventions, whole body vibration (this involves standing on a vibration platform), or spa/mud therapy, and one studied foot orthotics (shoe insoles). Funding source Thirty‐eight studies were funded, four received no funding and funding support was not reported in 20. Main results Eleven trials (18%) measured adverse (unwanted harmful) events, which included both non‐serious and serious adverse events. The most common were increased pain, stiffness or swelling. There was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with sham additional therapies plus exercise therapy (22 studies) Compared with sham additional therapies used with land‐based exercise therapy, additional therapies such as electrophysical agents, acupuncture, dry needling or taping, used with exercise therapy, may not be more effective in improving pain, physical function or quality of life up to six months after treatment. Pain (lower scores mean less pain) Improved by 10% or 0.77 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 12% or 5.03 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 1% or 0.75 points worse on a zero to 100‐point scale. Adverse events Although not commonly reported in studies, there was no difference in adverse events between additional therapies used with exercise and sham therapies with exercise. Additional therapies plus exercise therapy compared with exercise therapy (41 studies) Compared with land‐based exercise therapy, additional therapies (manual therapies, electrotherapy, dietary interventions, psychological therapies, whole body vibration, acupuncture, dry needling, taping, spa/mud therapy or foot orthotics) plus exercise therapy, may not be more effective in improving pain, physical function, quality of life or joint changes measured with X‐rays up to six months after treatment. Pain (lower scores mean less pain) Improved by 7% or 0.41 points on a zero to 10‐point scale. Physical function scores (lower scores mean better physical function) Improved by 9% or 2.83 points on a zero to 68‐point scale. Quality of life (higher scores mean better quality of life) Worse by 2%, or 1.04 points worse on a zero to 100‐point scale. Patient‐reported overall change 17% more people rated their treatment a success. X‐ray changes Improved by 12% (based on one study) Adverse effects Although not commonly reported in studies, risks appear no greater for additional therapies used with exercise compared to exercise only. Fewer studies assessed outcomes six or 12 months after treatment. Additional therapies plus land‐based exercise therapy may be no better in reducing pain or improving physical function or quality of life than exercise therapy at 6 or 12 months. In patient‐reported overall assessment, 31% reported improvement at 6 months, and 42% reported improvement at 12 months. Conclusions and certainty of evidence Additional therapies plus exercise therapy do not appear to offer meaningful improvements in pain, function, quality of life or overall change for people with hip or knee osteoarthritis compared with sham additional therapies plus land‐based exercise therapy; or in pain, function, quality of life or changes on X‐rays when compared with exercise therapy only. Compared with exercise therapy there is probably a clinical benefit in patient‐reported overall change for additional therapies plus exercise therapy, based on a small number of studies. Our confidence in the evidence varies between moderate to little or no confidence for different outcomes. Although results indicate no increased adverse events from additional therapies used with exercise therapy, this was poorly reported. Most studies evaluated short‐term effects, with limited medium‐ or long‐term evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "French, HP, Abbott, JH, Galvin, R", "articleTypes": [], "doi": "10.1002/14651858.CD011915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.143Z" }, { "id": "5be4832a-32ec-4a58-bd3f-442dc41e5189", "pmid": "", "title": "Inhaled mannitol for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Several agents are used to clear secretions from the airways of people with cystic fibrosis. Mannitol increases mucociliary clearance, but its exact mechanism of action is unknown. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents which require delivery via a nebuliser. Phase III trials of inhaled dry powder mannitol for the treatment of cystic fibrosis have been completed and it is now available in Australia and some countries in Europe. This is an update of a previous review. Objectives To assess whether inhaled dry powder mannitol is well tolerated, whether it improves the quality of life and respiratory function in people with cystic fibrosis and which adverse events are associated with the treatment. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic databases, handsearching relevant journals and abstracts from conferences. Date of last search: 12 December 2019. Selection criteria All randomised controlled studies comparing mannitol with placebo, active inhaled comparators (for example, hypertonic saline or dornase alfa) or with no treatment. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction and assessed the risk of bias in included studies. The quality of the evidence was assessed using GRADE. Main results Six studies (reported in 36 unique publications) were included with a total of 784 participants. Duration of treatment in the included studies ranged from 12 days to six months, with open‐label treatment for an additional six months in two of the studies. Five studies compared mannitol with control (a very low dose of mannitol or non‐respirable mannitol) and the final study compared mannitol to dornase alfa alone and to mannitol plus dornase alfa. Two large studies had a similar parallel design and provided data for 600 participants, which could be pooled where data for a particular outcome and time point were available. The remaining studies had much smaller sample sizes (ranging from 22 to 95) and data could not be pooled due to differences in design, interventions and population. Pooled evidence from the two large parallel studies was judged to be of low to moderate quality and from the smaller studies was judged to be of low to very low quality. In all studies, there was an initial test to see if participants tolerated mannitol, with only those who could tolerate the drug being randomised; therefore, the study results are not applicable to the cystic fibrosis population as a whole. While the published papers did not provide all the data required for our analysis, additional unpublished data were provided by the drug's manufacturer and the author of one of the studies. Pooling the large parallel studies comparing mannitol to control, up to and including six months, lung function (forced expiratory volume at one second) measured in both mL and % predicted was significantly improved in the mannitol group compared to the control group (moderate‐quality evidence). Beneficial results were observed in these studies in adults and in both concomitant dornase alfa users and non‐users in these studies. In the smaller studies, statistically significant improvements in lung function were also observed in the mannitol groups compared to the non‐respirable mannitol groups; however, we judged this evidence to be of low to very low quality. For the comparisons of mannitol and control, we found no consistent differences in health‐related quality of life in any of the domains except for burden of treatment, which was less for mannitol up to four months in the two pooled studies of a similar design; this difference was not maintained at six months. It should be noted that the tool used to measure health‐related quality of life was not designed to assess mucolytics and pooling of the age‐appropriate tools (as done in some of the included studies) may not be valid so results were judged to be low to very low quality and should be interpreted with caution. Cough, haemoptysis, bronchospasm, pharyngolaryngeal pain and post‐tussive vomiting were the most commonly reported side effects in both treatment groups. Where rates of adverse events could be compared, statistically no significant differences were found between mannitol and control groups; although some of these events may have clinical relevance for people with CF. For the comparisons of mannitol to dornase alfa alone and to mannitol plus dornase alfa, very low‐quality evidence from a 12‐week cross‐over study of 28 participants showed no statistically significant differences in the recorded domains of health‐related quality of life or measures of lung function. Cough was the most common side effect in the mannitol alone arm but there was no occurrence of cough in the dornase alfa alone arm and the most commonly reported reason of withdrawal from the mannitol plus dornase alfa arm was pulmonary exacerbations. In terms of secondary outcomes of the review (pulmonary exacerbations, hospitalisations, symptoms, sputum microbiology), evidence provided by the included studies was more limited. For all comparisons, no consistent statistically significant and clinically meaningful differences were observed between mannitol and control treatments (including dornase alfa). Authors' conclusions There is moderate‐quality evidence to show that treatment with mannitol over a six‐month period is associated with an improvement in some measures of lung function in people with cystic fibrosis compared to control. There is low to very low‐quality evidence suggesting no difference in quality of life for participants taking mannitol compared to control. This review provides very low‐quality evidence suggesting no difference in lung function or quality of life comparing mannitol to dornase alfa alone and to mannitol plus dornase alfa. The clinical implications from this review suggest that mannitol could be considered as a treatment in cystic fibrosis; but further research is required in order to establish who may benefit most and whether this benefit is sustained in the longer term. Furthermore, studies comparing its efficacy against other (established) mucolytic therapies need to be undertaken before it can be considered for mainstream practice. Plain language summary Mannitol, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of inhaling mannitol to treat lung disease in people with cystic fibrosis. Background Cystic fibrosis is a genetic disorder that affects the exocrine glands (sweat glands and others). Lung infections produce thick mucus (phlegm) which can block air passages and cause more infection and repeated inflammation. In turn, this progressively damages the lungs and can eventually cause respiratory failure. There are several drugs that are used to clear mucus from the airways of people with cystic fibrosis and inhaled dry powder mannitol is a new one that may improve their lung function. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents delivered by a nebuliser (e.g. hypertonic saline). Mannitol is available in Australia and some European countries. This is an updated version of the review. Search date The evidence is current to: 12 December 2019. Study characteristics We included six studies (with a total of 784 adults and children) in this review. Five studies compared a standard dose of mannitol with control (a very low dose of mannitol or a version of mannitol which did not allow the active drug to reach the lungs) and the sixth study compared mannitol with nebulised recombinant human deoxyribonuclease (dornase alfa), both alone and taken together. Participants could continue using dornase alfa and other standard therapies, but were excluded from the five of the six studies if they were using hypertonic saline. Treatment in these studies lasted from 12 days to six months. Five studies provided the treatments to people as outpatients and in one study, the children treated were in hospital due to pulmonary exacerbations (flare ups of disease). Key results It was difficult to combine evidence from the studies in this review due to differences in the designs of the studies, treatments examined and the settings (hospital or outpatients). Some additional information was obtained from the drug manufacturer and one study author to aid the review. The review found low‐ to very low‐quality evidence that there is no difference between mannitol and control treatments or mannitol given either with or without additional dornase alfa in terms of quality of life. There was moderate‐quality evidence of improvements in some measures of lung function across the larger studies comparing mannitol to control. Beneficial effects were also seen in the subgroup of adults and in both those who were using dornase alfa and those who were not. Cough (including coughing up blood), contraction of the airways, pain in the pharynx or larynx and post‐treatment vomiting were the most commonly reported side effects on both treatments, but there was no evidence to suggest that these side effects occurred more on mannitol than on control treatments or on dornase alfa. None of the studies compared mannitol to nebulised hypertonic saline and so we can not comment on which agent is better for airway clearance. More research is needed to answer this question. Quality of the evidence We judged the quality of the evidence from this review to be of very low to moderate quality, depending on the outcome measured. We do not think that the way the studies were designed affected the results. We judged that everyone taking part had equal chances of being in either of the treatment groups and would not have known in advance or during the study which treatment they were receiving. However, the numbers of people who dropped out of the studies might affect how the results are interpreted, as well as how many people were recruited into the studies and how they were selected from all people with cystic fibrosis who could have been included. Although some of these issues were resolved when the drug's manufacturer (who also sponsored the studies) provided some additional information. It is important to realise that before people started the study, they took a test to see if they could tolerate mannitol and only those who did could carry on. This means that the results of the studies only apply to those people with cystic fibrosis who can tolerate mannitol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Nevitt, SJ; Thornton, J; Murray, CS; Dwyer, T", "articleTypes": [], "doi": "10.1002/14651858.CD008649.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "5bf6b771-f8b0-49b8-8b55-277a2bbff763", "pmid": "", "title": "Prolonged Overnight Fasting and/or Exercise on Fatigue and Other Patient Reported Outcomes in Women With Hormone Receptor Positive Advanced Breast Cancer (FastER)", "imported": false, "abstract": "The purpose of this study is to test whether four different supportive care programs can reduce fatigue in women with advanced or metastatic breast cancer who are receiving a medication called a CDK4/6 inhibitor (palbociclib, ribociclib, or abemaciclib) alongwith endocrine therapy with or without a PI3K or AKT inhibitor.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.262Z" }, { "id": "5c23c146-d8d1-4c57-999f-3cf5d6891072", "pmid": "", "title": "Coblation versus other surgical techniques for tonsillectomy", "imported": false, "abstract": "Abstract - Background Tonsillectomy is a very common operation and is performed using various surgical methods. Coblation is a popular method because it purportedly causes less pain than other surgical methods. However, the superiority of coblation is unproven. Objectives To compare the effects of coblation tonsillectomy for chronic tonsillitis or tonsillar hypertrophy with other surgical techniques, both hot and cold, on intraoperative morbidity, postoperative morbidity and procedural cost. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2017, Issue 3); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 April 2017. Selection criteria Randomised controlled trials (RCTs) of children and adults undergoing tonsillectomy with coblation compared with any other surgical technique. This review is limited to trials of extracapsular (traditional) tonsillectomy and excludes trials of intracapsular tonsil removal (tonsillotomy). Data collection and analysis We used the standard Cochrane methods. Our primary outcomes were: patient‐reported pain using a validated pain scale at postoperative days 1, 3 and 7; intraoperative blood loss; primary postoperative bleeding (within 24 hours) and secondary postoperative bleeding (more than 24 hours after surgery). Secondary outcomes were: time until resumption of normal diet, time until resumption of normal activity, duration of surgery and adverse effects including blood transfusion and the need for reoperation. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 29 studies, with a total of 2561 participants. All studies had moderate or high risk of bias. Sixteen studies used an adequate randomisation technique, however the inability to mask the surgical teams and/or provide adequate methods to mitigate the risk of bias put nearly all studies at moderate or high risk of detection and measurement bias for intraoperative blood loss, and primary and secondary bleeding. In contrast most studies (20) were at low risk of bias for pain assessment. Most studies did not report data in a manner permitting meta‐analysis. Most studies did not clearly report the participant characteristics, surgical indications or whether patients underwent tonsillectomy or adenotonsillectomy. Most studies reported that tonsillitis (infection) and/or tonsillar hypertrophy (obstruction) were the indication for surgery. Seven studies included only adults, 16 studies included only children and six studies included both. Pain At postoperative day 1 there is very low quality evidence that patients in the coblation group had less pain, with a standardised mean difference (SMD) of ‐0.79 (95% confidence interval (CI) ‐1.38 to ‐0.19; 538 participants; six studies). This effect is reduced a SMD of ‐0.44 (95% CI ‐0.97 to 0.09; 401 participants; five studies; very low‐quality evidence ) at day 3, and at day 7 there is low quality evidence of little or no difference in pain (SMD ‐0.01, 95% CI ‐0.22 to 0.19; 420 participants; five studies). Although this suggests that pain may be slightly less in the coblation group between days 1 and 3, the clinical significance is unclear. Intraoperative blood loss Methodological differences between studies in the measurement of intraoperative blood loss precluded meta‐analysis. Primary and secondary bleeding The risk of primary bleeding was similar (risk ratio (RR) 0.99, 95% CI 0.48 to 2.05; 2055 participants; 25 studies; low‐quality evidence ). The risk of secondary bleeding was greater in the coblation group with a risk ratio of 1.36 (95% CI 0.95 to 1.95; 2118 participants; 25 studies; low‐quality evidence ). Using the median of the control group as the baseline risk, the absolute risk in the coblation group was 5% versus 3.6% in the control group. The difference of 1.3% has a 95% CI of 0.2% lower in the coblation group to 3.5% higher. Secondary outcomes Differences in study design and data reporting precluded the identification of differences in the time to resumption of normal diet or activity, or whether there was a difference in the duration of surgery. Although we could not feasibly compare the costs of equipment or operative facility, anaesthetic and surgical fees across different healthcare systems we used duration of surgery as a proxy for cost. Although this outcome was commonly reported in studies, it was not possible to pool the data to determine whether there was a difference. Adverse events other than bleeding were not well reported. It is unclear whether there is a difference in postoperative infections or the need for reoperation. Authors' conclusions The coblation technique may cause less pain on postoperative day 1, but the difference is small and may be clinically meaningless. By postoperative day 3, the difference decreases further and by postoperative day 7 there appears to be little or no difference. We found similar rates of primary bleeding but we cannot rule out a small increased risk of secondary bleeding with coblation. The evidence supporting these findings is of low or very low quality , i.e. there is a very high degree of uncertainty about the results. Moreover, for most outcomes data were only available from a few of the 29 included studies. The current evidence is of very low quality, therefore it is uncertain whether or not the coblation technique has any advantages over traditional tonsillectomy techniques. Despite the large number of studies, failure to use standardised or validated outcome measures precludes the ability to pool data across studies. Therefore, well‐conducted RCTs using consistent, validated outcome measures are needed to establish whether the coblation technique has a benefit over other methods. In the included studies we identified no clear difference in adverse events. However, given the rarity of these events, randomised trials lack the power to detect a difference. Data from large‐scale registries will provide a better estimate of any difference in these rare outcomes. Plain language summary Surgical removal of the tonsils (tonsillectomy) with coblation or another surgical method Review question This review compared the coblation method with other methods of tonsil removal to assess recovery following tonsillectomy or adenotonsillectomy. Background Surgical removal of the tonsils (tonsillectomy) is a very common operation. Patients may have pain for up to two weeks after surgery. Bleeding may occur either immediately after surgery ('primary bleeding' within 24 hours of surgery) or later ('secondary bleeding' more than 24 hours after surgery). There are many methods of tonsillectomy; the traditional method is with metal surgical instruments. Coblation is a new method where the surgeon uses an electrically powered handpiece that 'burns' tissues using low temperatures. Study characteristics This review included evidence available up to April 2017. We included 29 studies, with a total of 2561 participants. All studies had a moderate or high risk of bias. Seven studies included adults, 16 studies included children and six included both adults and children. Most studies measured pain using a patient‐reported scale (for example, asking people to rate their pain on a scale of 1 to 10). Key results The coblation technique may cause slightly less pain one day after surgery and three days after surgery, but it is unlikely that there is a difference in pain seven days after surgery. We are very uncertain whether the amount of pain reduction observed in days 1 to 3 after surgery would be important to patients. There is little or no difference in the risk of bleeding in the first day after surgery, but there may be a small increased risk of bleeding with coblation after the first day. For every 1000 patients having a tonsillectomy, 50 patients would have a bleed with coblation, compared to 36 with traditional surgical techniques. Quality of the evidence The evidence for the difference in pain is of low or very low quality and for the difference in bleeding after surgery it is of low quality . This means that we have little confidence in the results; the true effect may be very different ‐ we simply do not know at this stage.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Pynnonen, M; Brinkmeier, JV; Thorne, MC; Chong, LY; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "5c28835f-54f8-49c6-a713-54a0bc8b5e26", "pmid": "", "title": "Preventive lipid‐based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes", "imported": false, "abstract": "Abstract - Background One nutritional intervention advocated to prevent malnutrition among children is lipid‐based nutrient supplements (LNS). LNS provide a range of vitamins and minerals, but unlike most other micronutrient supplements, LNS also provide energy, protein and essential fatty acids. Alternative recipes and formulations to LNS include fortified blended foods (FBF), which are foods fortified with vitamins and minerals, and micronutrient powders (MNP), which are a combination of vitamins and minerals, Objectives To assess the effects and safety of preventive LNS given with complementary foods on health, nutrition and developmental outcomes of non‐hospitalised infants and children six to 23 months of age, and whether or not they are more effective than other foods (including FBF or MNP). This review did not assess the effects of LNS as supplementary foods or therapeutic foods in the management of moderate and severe acute malnutrition. Search methods In October 2018, we searched CENTRAL, MEDLINE, Embase, 21 other databases and two trials registers for relevant studies. We also checked the reference lists of included studies and relevant reviews and contacted the authors of studies and other experts in the area for any ongoing and unpublished studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs that evaluated the impact of LNS plus complementary foods given at point‐of‐use (for any dose, frequency, duration) to non‐hospitalised infants and young children aged six to 23 months in stable or emergency settings and compared to no intervention, other supplementary foods (i.e. FBF), nutrition counselling or multiple micronutrient supplements or powders for point‐of‐use fortification of complementary foods. Data collection and analysis Two review authors independently screened studies for relevance and, for those studies included in the review, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software. We used a random‐effects meta‐analysis for combining data as the interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables,. Main results Our search identified a total of 8124 records, from which we included 17 studies (54 papers) with 23,200 children in the review. The included studies reported on one or more of the pre‐specified primary outcomes, and five studies included multiple comparison groups. Overall, the majority of trials were at low risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias, but at high risk of bias for blinding of participants and personnel due to the nature of the intervention. Using the GRADE approach, we judged the quality of the evidence for most outcomes as low or moderate. LNS+complementary feeding compared with no intervention Thirteen studies compared LNS plus complementary feeding with no intervention. LNS plus complementary feeding reduced the prevalence of moderate stunting by 7% (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.88 to 0.98; nine studies, 13,372 participants; moderate‐quality evidence), severe stunting by 15% (RR 0.85, 95% CI 0.74 to 0.98; five studies, 6151 participants; moderate‐quality evidence), moderate wasting by 18% (RR 0.82, 95% CI 0.74 to 0.91; eight studies; 13,172 participants; moderate‐quality evidence), moderate underweight by 15% (RR 0.85, 95% CI 0.80 to 0.91; eight studies, 13,073 participants; moderate‐quality evidence), and anaemia by 21% (RR 0.79, 95% CI 0.69 to 0.90; five studies, 2332 participants; low‐quality evidence). There was no impact of LNS plus complementary feeding on severe wasting (RR 1.27, 95% CI 0.66 to 2.46; three studies, 2329 participants) and severe underweight (RR 0.78, 95%CI 0.54 to 1.13; two studies, 1729 participants). Adverse effects did not differ between the groups (RR 0.86, 95% CI 0.74 to 1.01; three studies, 3382 participants). LNS+complementary feeding compared with FBF Five studies compared LNS plus complementary feeding with other FBF, including corn soy blend and UNIMIX. We pooled four of the five studies in meta‐analyses and found that, when compared to other FBF, LNS plus complementary feeding significantly reduced the prevalence of moderate stunting (RR 0.89, 95% CI 0.82 to 0.97; three studies, 2828 participants; moderate‐quality evidence), moderate wasting (RR 0.79, 95% CI 0.65 to 0.97; two studies, 2290 participants; moderate‐quality evidence), and moderate underweight (RR 0.81, 95% CI 0.73 to 0.91; two studies, 2280 participants; moderate‐quality evidence). We found no difference between LNS plus complementary feeding and FBF for severe stunting (RR 0.41, 95% CI 0.12 to 1.42; two studies, 729 participants; low‐quality evidence), severe wasting (RR 0.64, 95% CI 0.19 to 2.81; two studies, 735 participants; moderate‐quality evidence), and severe underweight (RR 1.23, 95% CI 0.67 to 2.25; one study, 173 participants; low‐quality evidence). LNS+complementary feeding compared with MNP Four studies compared LNS plus complementary feeding with MNP. We pooled data from three of the four studies in meta‐analyses and found that compared to MNP, LNS plus complementary feeding significantly reduced the prevalence of moderate underweight (RR 0.88, 95% CI 0.78 to 0.99; two studies, 2004 participants; moderate‐quality evidence) and anaemia (RR 0.38, 95% CI 0.21 to 0.68; two studies, 557 participants; low‐quality evidence). There was no difference between LNS plus complementary feeding and MNP for moderate stunting (RR 0.92, 95% CI 0.82 to 1.02; three studies, 2365 participants) and moderate wasting (RR 0.97, 95% CI 0.77 to 1.23; two studies, 2004 participants). Authors' conclusions The findings of this review suggest that LNS plus complementary feeding compared to no intervention is effective at improving growth outcomes and anaemia without adverse effects among children aged six to 23 months in low‐ and middle‐income countries (LMIC) in Asia and Africa, and more effective if provided over a longer duration of time (over 12 months). Limited evidence also suggests that LNS plus complementary feeding is more effective than FBF and MNP at improving growth outcomes. Plain language summary Effect of lipid‐based nutrient supplementation on infants and young children Review question What is the impact of lipid‐based nutrient supplements (LNS) plus complementary foods on health, nutrition and developmental outcomes among infants and young children? Background LNS are food products which contain energy, minerals and vitamins that can improve growth in children. LNS provide vitamins, minerals and energy in the form of protein and essential fatty acids. We sought to assess the effect of LNS given jointly with complementary feeding, compared to no intervention, micronutrient powders (MNP; a mixture of vitamins and minerals that is sprinkled onto food) and other fortified blended food (FBF) products in healthy children. Study characteristics This review includes 17 studies (from 54 reports) with 23,200 children. Four of the included studies were conducted in Malawi, three in Bangladesh, two in Ghana and one each in Burkina Faso, Haiti, Honduras, Chad, Congo, Kenya, Niger, Peru, Guatemala, and Indonesia. Four included studies enrolled pregnant women and provided LNS plus complementary feeding during pregnancy and post‐partum, followed by infant supplementation starting at six months of age. The other studies provided LNS plus complementary feeding to children after six months of age. None of the included studies were conducted in emergency settings. Key results Findings of this review suggest that LNS plus complementary feeding is probably an effective intervention for improving growth outcomes and reducing the occurrence of children who are of short stature for their age (stunting), have low weight for their age (moderate underweight), have low weight for their height (moderate wasting) and anaemia. Additionally, LNS plus complementary feeding probably improves height and weight for age as well as mid‐upper arm circumference without adverse effects among children aged six to 23 months. The intervention seems to be more effective if provided for a duration longer than 12 months. Evidence also suggests that LNS plus complementary probably reduces moderate stunting, moderate wasting and moderate underweight, compared to other FBF. Furthermore, LNS plus complementary feeding is probably more effective than MNP at reducing moderate underweight and improving height and weight. Quality of evidence Overall, we considered most studies to be at high risk of bias for blinding of participants and personnel due to the nature of intervention. We rated the quality of the evidence for most outcomes as either low or moderate. Currentness of evidence The evidence is current to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Das, JK, Salam, RA, Hadi, YB, Sadiq Sheikh, S, Bhutta, AZ, Weise Prinzo, Z, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD012611.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.809Z" }, { "id": "5c2b8737-e41c-4ca5-85f8-d5f41a8e462c", "pmid": "", "title": "Individual Nutritional Support With High Protein Formula With Modified Sensory Component for H&N Cancer Patients on Chemo and Radiotherapy", "imported": false, "abstract": "Nutritional deficiency and subsequent weight loss in patients with head and neck cancer is a common problem and a negative predictor of treatment outcomes and mortality, as well as quality of life. Nutritional support for patients is a prerequisite for the successful management of cancer patients. Sensory changes can be side effects of chemotherapy or ionizing radiation, which damages sensory receptors in the area of radiation, disrupts the function of the salivary glands, leading to hyposalivation and a decrease in taste. Individual choice of nutrition based on sensory sensations can significantly improve the quality of life of patients and ensure timely correction of their eating behavior.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "5c31f175-78fb-4aa6-8691-49a65d8c645d", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Omega‐3 fatty acids (n‐3, fish oil) have been shown to have anti‐inflammatory properties. Therefore, n‐3 therapy may be beneficial in chronic inflammatory disorders such as ulcerative colitis. Objectives To systematically review the efficacy and safety of n‐3 for maintaining remission in ulcerative colitis (UC). Search methods The following databases were searched from their inception without language restriction: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Healthstar, PubMed, and ACP journal club. Experts were contacted for unpublished data. Selection criteria Randomized placebo‐controlled trials (RCT) of fish oil for maintenance of remission in UC were included. Studies must have enrolled patients (of any age group) who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. The primary outcome was relapse rate and the secondary outcome was frequency of adverse events. Other outcomes to assess efficacy were change in disease activity scores and time to first relapse. Data collection and analysis Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality. Meta‐analysis weighted by the Mantel‐Haenszel method was performed using RevMan 4.2.8 software. Random or fixed effect models were used according to degree of heterogeneity and subgroup analyses were performed to explore heterogeneity. A sensitivity analysis was performed excluding a study of questionable quality . Main results The three studies that were included used different formulation and dosing of n‐3 but none used enteric coated capsules. The pooled analysis showed a similar relapse rate in the n‐3 treated patients and controls (RR 1.02; 95% CI 0.51 to 2.03; P = 0.96). Combining the studies resulted in virtually no statistical heterogeneity (P = 0.93, I 2 = 0%). Various subgroup and sensitivity analyses showed similar results. However, the total number of patients enrolled in these studies was small (n = 138). No significant adverse events were recorded in any of the studies and not enough data were available to pool the other secondary outcomes for meta‐analysis. Authors' conclusions No evidence was found that supports the use of omega 3 fatty acids for maintenance of remission in UC. Further studies using enteric coated capsules may be justified. Plain language summary Omega 3 fatty acids for maintenance of remission in ulcerative colitis Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of ulcerative colitis patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of omega‐3 fatty acids to maintain remission in ulcerative colitis were reviewed. Three studies were included of which none reported a reduction in the rate of disease relapse in comparison with placebo. When the studies were pooled for meta‐analysis there was no benefit for omega 3 fatty acids. There were no serious side effects in any of the studies. None of the studies used enteric coated capsules which allow release of the fish oil in the small bowel. Non‐enteric coated omega‐3 fatty acids (fish oil) seem safe but ineffective for maintaining remission in ulcerative colitis. Further studies of enteric coated capsules may be justified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Turner, D; Steinhart, AH; Griffiths, AM", "articleTypes": [], "doi": "10.1002/14651858.CD006443.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "5c51d0a9-9384-40c5-8a98-0fbe8bbb83e8", "pmid": "", "title": "Vitamin C for preventing and treating pneumonia", "imported": false, "abstract": "Abstract - Background Pneumonia is one of the most common serious infections, causing two million deaths annually among young children in low‐income countries. In high‐income countries pneumonia is most significantly a problem of the elderly. Objectives To assess the prophylactic and therapeutic effects of vitamin C on pneumonia. Search methods We searched CENTRAL 2013, Issue 3, MEDLINE (1950 to March week 4, 2013), EMBASE (1974 to April 2013) and Web of Science (1955 to April 2013). Selection criteria To assess the therapeutic effects of vitamin C, we selected placebo‐controlled trials. To assess prophylactic effects, we selected controlled trials with or without a placebo. Data collection and analysis Two review authors independently read the trial reports and extracted data. Main results We identified three prophylactic trials which recorded 37 cases of community‐acquired pneumonia in 2335 people. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. Two trials examined military recruits and the third studied boys from \"lower wage‐earning classes\" attending a boarding school in the UK during World War II. Each of these three trials found a statistically significant (80% or greater) reduction in pneumonia incidence in the vitamin C group. We identified two therapeutic trials involving 197 community‐acquired pneumonia patients. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. That trial studied elderly patients in the UK and found lower mortality and reduced severity in the vitamin C group; however, the benefit was restricted to the most ill patients. The other therapeutic trial studied adults with a wide age range in the former Soviet Union and found a dose‐dependent reduction in the duration of pneumonia with two vitamin C doses. We identified one prophylactic trial recording 13 cases of hospital‐acquired pneumonia in 37 severely burned patients; one‐day administration of vitamin C had no effect on pneumonia incidence. The identified studies are clinically heterogeneous which limits their comparability. The included studies did not find adverse effects of vitamin C. Authors' conclusions The prophylactic use of vitamin C to prevent pneumonia should be further investigated in populations who have a high incidence of pneumonia, especially if dietary vitamin C intake is low. Similarly, the therapeutic effects of vitamin C should be studied, especially in patients with low plasma vitamin C levels. The current evidence is too weak to advocate prophylactic use of vitamin C to prevent pneumonia in the general population. Nevertheless, therapeutic vitamin C supplementation may be reasonable for pneumonia patients who have low vitamin C plasma levels because its cost and risks are low. Plain language summary Vitamin C for preventing and treating pneumonia Pneumonia is an infection of the lungs usually caused by bacteria and viruses. Its clinical diagnosis is sometimes difficult. Pneumonia is more common in young children and in the aged. In low‐income countries it causes two million deaths annually among young children. In the USA it is the most common cause of death from infection. Vitamin C was identified in the early 1900s and suggestions that one of its biological roles may be to resist infections are supported by numerous animal studies. We looked for studies in humans and found three trials with a total of 2335 participants that looked at whether vitamin C prevents pneumonia in the community. Two of these preventive trials studied soldiers while the third studied boys in a UK boarding school in the 1940s. Two therapeutic trials with a total of 197 pneumonia patients looked at whether vitamin C might be beneficial for pneumonia patients. One studied patients aged 66 to 94 years in the UK with pneumonia. The other therapeutic trial was conducted in the former Soviet Union but the social and nutritional backgrounds of the patients were not described. One study with 37 burns patients examined the effect of vitamin C on hospital‐acquired pneumonia. Our searches were up‐date‐as of April 2013. Five of the identified trials found preventive or therapeutic benefits of vitamin C against pneumonia but the study on hospital‐acquired pneumonia found no effect. The overall quality of the studies was good. However, the five trials with positive findings were carried out in such extraordinary conditions that the results should not be extrapolated to the general population. Therefore, more research is needed. In the meantime, supplementing pneumonia patients who have low plasma vitamin C levels may be reasonable because of its safety and low cost. None of the five trials reported noteworthy adverse effects of vitamin C.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H, Louhiala, P", "articleTypes": [], "doi": "10.1002/14651858.CD005532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.753Z" }, { "id": "5c5e6af9-6b69-4af8-a38b-897438bebcfe", "pmid": "", "title": "Pharmacological and nutritional treatment for McArdle disease (Glycogen Storage Disease type V)", "imported": false, "abstract": "Abstract - Background McArdle disease (Glycogen Storage Disease type V) is caused by an absence of muscle phosphorylase leading to exercise intolerance, myoglobinuria rhabdomyolysis and acute renal failure. This is an update of a review first published in 2004. Objectives To review systematically the evidence from randomised controlled trials (RCTs) of pharmacological or nutritional treatments for improving exercise performance and quality of life in McArdle disease. Search methods We searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE on 11 August 2014. Selection criteria We included RCTs (including cross‐over studies) and quasi‐RCTs. We included unblinded open trials and individual patient studies in the discussion. Interventions included any pharmacological agent or nutritional supplement. Primary outcome measures included any objective assessment of exercise endurance (for example aerobic capacity (VO 2 ) max, walking speed, muscle force or power and fatigability). Secondary outcome measures included metabolic changes (such as reduced plasma creatine kinase and a reduction in the frequency of myoglobinuria), subjective measures (including quality of life scores and indices of disability) and serious adverse events. Data collection and analysis Three review authors checked the titles and abstracts identified by the search and reviewed the manuscripts. Two review authors independently assessed the risk of bias of relevant studies, with comments from a third author. Two authors extracted data onto a specially designed form. Main results We identified 31 studies, and 13 fulfilled the criteria for inclusion. We described trials that were not eligible for the review in the Discussion. The included studies involved a total of 85 participants, but the number in each individual trial was small; the largest treatment trial included 19 participants and the smallest study included only one participant. There was no benefit with: D‐ribose, glucagon, verapamil, vitamin B 6 , branched chain amino acids, dantrolene sodium, and high‐dose creatine. Minimal subjective benefit was found with low dose creatine and ramipril only for patients with a polymorphism known as the D/D angiotensin converting enzyme (ACE) phenotype. A carbohydrate‐rich diet resulted in better exercise performance compared with a protein‐rich diet. Two studies of oral sucrose given at different times and in different amounts before exercise showed an improvement in exercise performance. Four studies reported adverse effects. Oral ribose caused diarrhoea and symptoms suggestive of hypoglycaemia including light‐headedness and hunger. In one study, branched chain amino acids caused a deterioration of functional outcomes. Dantrolene was reported to cause a number of adverse effects including tiredness, somnolence, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of myalgia. Authors' conclusions Although there was low quality evidence of improvement in some parameters with creatine, oral sucrose, ramipril and a carbohydrate‐rich diet, none was sufficiently strong to indicate significant clinical benefit. Plain language summary Drug and nutritional treatment for McArdle disease Review question We reviewed the evidence about the effects of drug and nutritional treatment for McArdle disease. Background McArdle disease (also known as glycogen storage disease type V) is a disorder affecting muscle metabolism. The condition is caused by the lack of an enzyme called muscle phosphorylase. This results in an inability to break down glycogen 'fuel' stores. McArdle disease leads to pain and fatigue with strenuous exercise. Sometimes severe muscle damage develops and occasionally this results in acute reversible kidney failure. Study characteristics After a wide search, we identified 13 randomised studies that included 85 participants with McArdle disease. This is an update of a review first published in 2004. We found no new trials at this update. Key results and quality of the evidence The review found no benefit compared with placebo with the following treatments: D‐ribose, glucagon, verapamil, vitamin B 6 , oral branched chain amino acids, dantrolene sodium, high‐dose creatine and ramipril. Low dose creatine and ramipril produced minimal benefit for patients who also have the D/D angiotensin converting enzyme (ACE) phenotype. Taking low dose creatine supplements had a minor benefit in improving exercise tolerance in a small number of people with the condition. Taking a sugary drink before planned strenuous exercise can improve performance but this treatment is not practical for day‐to‐day living. A diet rich in carbohydrate may be superior to a diet rich in protein. Adverse effects were reported in four studies. Oral ribose caused symptoms suggestive of a low blood sugar including light‐headedness, hunger and diarrhoea. One study of branched chain amino acids resulted in a deterioration in participants. Dantrolene was reported to cause a number of side‐effects including tiredness, sleepiness, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause any side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of muscle pain. The quality of these studies was low due to the small number of participants; the largest number in one trial was 19 and one trial had only one participant. The evidence is current to August 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Quinlivan, R; Martinuzzi, A; Schoser, B", "articleTypes": [], "doi": "10.1002/14651858.CD003458.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "5c6f8cf7-f3bb-4021-986e-0f303beb5381", "pmid": "", "title": "Effects of Synbiotic Supplement on Anthropometric Parameters, Cardiovascular Disease Risk Factors, and Bone Metabolism Markers in Transplanted Kidney Patients on Chronic Post-kidney Transplant Phase Diet", "imported": false, "abstract": "The aim of this double-blind randomized clinical trial is to determine the effects of synbiotic supplement on cardiovascular disease risk factors and bone metabolism markers and depression, in transplanted kidney patients on chronic post-kidney transplant phase diet.This study is a double-blind, randomized controlled clinical trial with two parallel groups. 44 patients will be randomly assigned into synbiotic and control group. Transplanted kidney patients referring to the hospital clinics will be invited to participate. After assessing the entrance criteria, 7 cc blood samples are taken. The food recall is completed. Supplements are given to patients for 10-12 weeks. Serum concentrations of malondialdehyde; high sensitivity c-reactive protein; Soluble intercellular adhesion molecule-1; glucose; pentosidine; carboxy-methyl lysine; osteoprotegerin; Receptor activator of nuclear factor kappa-Β ligand; N-telopeptide; Intact parathyroid hormone; triglyceride; total cholesterol; High-density lipoprotein cholesterol; low-density lipoprotein cholesterol; lipoprotein-a; albumin; calcium; phosphorous; blood nitrogen urea; creatinine; and also systolic blood pressure; diastolic blood pressure; Weight; Body mass index; Waist circumference; Hip circumference; and questionnaires including quality of depression.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.264Z" }, { "id": "5c7480b2-0a82-4432-9749-4ebcbe785853", "pmid": "", "title": "Dietary marine fatty acids (fish oil) for asthma in adults and children", "imported": false, "abstract": "Abstract - Background Epidemiological studies suggest that a diet high in marine fatty acids (fish oil) may have beneficial effects on inflammatory conditions such as rheumatoid arthritis and possibly asthma. Objectives (1) To determine the effect of marine n‐3 fatty acid (fish oil) supplementation in asthma.
 (2) To determine the effect of a diet high in fish oil in asthma. Search methods We searched the Cochrane Airways Group Specialised Register. We also searched bibliographies of retrieved trials and contacted fish oil manufacturers. Searches were current as of May 2010. Selection criteria We included randomised controlled trials in patients with asthma more than two years of age. The study duration had to be in excess of four weeks. Double blind trials were preferred, but we also reviewed single‐blind and open trials for possible inclusion. All four reviewers read each paper, blind to its identity. Decisions concerning inclusion were made by simple majority. We all performed quality assessment independently. Data collection and analysis The only comparison possible was between marine n‐3 fatty acid supplementation and placebo. There were insufficient trials to examine dietary manipulation alone. Main results Nine randomised controlled trials conducted between 1986 and 2001 satisfied the inclusion criteria. Seven were of parallel design and two were cross‐over studies. Eight compared fish oil with placebo whilst one compared high dose versus low dose marine n‐3 fatty acid supplementation. Two studies were conducted in children, whilst the remaining seven studies were conducted in adults. None of the included studies reported asthma exacerbations, health status or hospital admissions. There was no consistent effect on any of the analysable outcomes: FEV1, peak flow rate, asthma symptoms, asthma medication use or bronchial hyper reactivity. One of the studies performed in children which combined dietary manipulation with fish oil supplementation showed improved peak flow and reduced asthma medication use. There were no adverse events associated with fish oil supplements. Authors' conclusions There is little evidence to recommend that people with asthma supplement or modify their dietary intake of marine n‐3 fatty acids (fish oil) in order to improve their asthma control. Equally, there is no evidence that they are at risk if they do so. Plain language summary Dietary marine fatty acids (fish oil) for asthma in adults and children Eating more fish has been recommended as one way of possibly reducing asthma. Populations (such as Eskimo communities) with diets high in fish also have low rates of asthma. As diets in other communities have become higher in saturated fats, asthma has also increased. The theory has been that an ingredient in fish oil may reduce inflammation. Inflammation causes the swelling in the airways of the lungs that leads to asthma attacks. However, this review of trials found that people with asthma changing their diets to include more fish oil did not improve their asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Thien, FCK; De Luca, S; Woods, RK; Abramson, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD001283", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "5c8213f7-66af-4338-9c57-1509cc6f60e6", "pmid": "", "title": "Effect of Non-nutritive Sweeteners on Vascular Function in Humans", "imported": false, "abstract": "In recent decades, low-to-null caloric, non-nutritive sweeteners (NNS) have been increasingly used, replacing and offering an alternative to food and beverages sweetened by high-energy, added sugars. Indeed, by providing consumers with products that have a sweet taste with low energy content, NNS appear to be the magic bullet to enhance weight loss and reduce cardio-metabolic diseases. However, a recent meta-analysis of randomized trials does not show any benefit of NNS consumption on body weight loss. Moreover, epidemiological, descriptive and experimental studies have recently reported that NNS consumption is paradoxically associated with weight gain, glucose intolerance and increased risk of type 2 diabetes and/or cardiovascular events. Among the approved NNS, sucralose and AceK, both high intensity (respectively ~500-600 and 200 times sweeter than sugar) are the most widely used in foods and drinks, accounting more than 62 % of the global artificial sweetener market. Recent experimental data show an effect of sucralose and AceK (and other NNS) consumption on vascular reactivity in response to a physiological stress (hyperglycemic load) in rats. Since sweet taste receptors (T1R) have been recently found in the endothelium, investigators hypothesize that NNS, and especially sucralose and AceK, a potent T1R agonist, impairs micro- and macrovascular reactivity in humans, which, to the best of our knowledge, has never been explored.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.240Z" }, { "id": "5c8fb30c-2bad-4d99-9056-1f81a6e9336b", "pmid": "", "title": "Interventions for managing taste disturbances", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kumbargere Nagraj, S, George, RP, Shetty, N, Levenson, D, Ferraiolo, DM, Shrestha, A", "articleTypes": [], "doi": "10.1002/14651858.CD010470.pub3 AB - Abstract - Background The sense of taste is very much essential to the overall health of an individual. It is a necessary component to enjoy one's food, which in turn provides nutrition to an individual. Any disturbance in taste perception can hamper quality of life in such patients by influencing their appetite, body weight and psychological well‐being. Taste disorders have been treated using different modalities of treatment and there is no consensus for the best intervention. Hence this Cochrane Review was undertaken. This is an update of the Cochrane Review first published in November 2014. Objectives To assess the effects of interventions for the management of patients with taste disturbances. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 4 July 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017 Issue 6) in the Cochrane Library (searched 4 July 2017); MEDLINE Ovid (1946 to 4 July 2017); Embase Ovid (1980 to 4 July 2017); CINAHL EBSCO (1937 to 4 July 2017); and AMED Ovid (1985 to 4 July 2017). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for trials. Abstracts from scientific meetings and conferences were searched on 25 September 2017. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included all randomised controlled trials (RCTs) comparing any pharmacological agent with a control intervention or any non‐pharmacological agent with a control intervention. We also included cross‐over trials in the review. Data collection and analysis Two pairs of review authors independently, and in duplicate, assessed the quality of trials and extracted data. Wherever possible, we contacted trial authors for additional information. We collected adverse events information from the trials. Main results We included 10 trials (581 participants), nine of which we were able to include in the quantitative analyses (566 participants). We assessed three trials (30%) as having a low risk of bias, four trials (40%) at high risk of bias and three trials (30%) as having an unclear risk of bias. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Of these, nine trials with 544 people compared zinc supplements to placebo for patients with taste disorders. The participants in two trials were children and adolescents with respective mean ages of 10 and 11.2 years and the other seven trials had adult participants. Out of these nine, two trials assessed the patient‐reported outcome for improvement in taste acuity using zinc supplements (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.94 to 2.09; 119 participants, very low‐quality evidence). We meta‐analysed for taste acuity improvement using objective outcome (continuous data) in idiopathic and zinc‐deficient taste disorder patients (standardised mean difference (SMD) 0.44, 95% CI 0.23 to 0.65; 366 participants, three trials, very low‐quality evidence). We also analysed one cross‐over trial separately using the first half of the results for taste detection (mean difference (MD) 2.50, 95% CI 0.93 to 4.07; 14 participants, very low‐quality evidence), and taste recognition (MD 3.00, 95% CI 0.66 to 5.34; 14 participants, very low‐quality evidence). We meta‐analysed taste acuity improvement using objective outcome (dichotomous data) in idiopathic and zinc‐deficient taste disorder patients (RR 1.42, 95% 1.09 to 1.84; 292 participants, two trials, very low‐quality evidence). Out of the nine trials using zinc supplementation, four reported adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase, and minor increase in blood triglycerides. One trial tested taste discrimination using acupuncture (MD 2.80, 95% CI ‐1.18 to 6.78; 37 participants, very low‐quality evidence). No adverse events were reported in the acupuncture trial. None of the included trials could be included in the meta‐analysis for health‐related quality of life in taste disorder patients. Authors' conclusions We found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders. We did not find any evidence to conclude the role of zinc supplements for improving taste discrimination, or any evidence addressing health‐related quality of life due to taste disorders. We found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste). We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. Plain language summary Interventions for managing taste disturbances What is the aim of this review? The aim of this Cochrane Review was to find out what is the best method for the management of zinc‐deficient/idiopathic (of unknown cause) taste disorders and taste disorders secondary to chronic renal failure in children and adults. Key messages Giving zinc supplements or acupuncture may have some benefit in treating taste disorders. However, we still need more high‐quality studies to ascertain the role of zinc supplements and acupuncture in treating taste disorders. What was studied in the review? The sense of taste is essential to the health and psychological well‐being of an individual. Taste disorders can range from lack of taste, to distortion of taste, to reduced ability to taste. Any disorder in taste perception can lead to conditions like malnutrition and consumption of poisonous food substances. The cause may be due to disease, drugs, radiation treatment, or ageing; or it may result from unknown causes. Various treatment methods have been used to improve taste sensation. These include the use of zinc compounds, pilocarpine, alpha lipoic acid, transcranial magnetic stimulation, ginkgo biloba and acupuncture. What are the main results of the review? We collected and analysed all relevant studies to answer this question and found 10 trials in which a total of 581 subjects received different treatments. Nine trials assessed the benefits of zinc compounds and one trial assessed the effects of acupuncture. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Two trials were from Germany, three from Japan, two from the UK, and three from the US. These studies compared zinc with placebo or acupuncture with sham procedure for patients with taste disorders. Two were government funded, three were privately funded, two were funded by a pharmaceutical company and three trials did not mention funding details. When patients with taste disorders are given zinc, compared to placebo: ‐ we found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders;
 ‐ zinc supplementation showed adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase and minor increase in blood triglycerides;
 ‐ no studies were found that looked at improvement in taste discrimination or quality of life. When patients with taste disorders are given acupuncture, compared to sham procedure: ‐ we found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste);
 ‐ acupuncture trial did not show adverse events;
 ‐ no studies were found that looked at improvement in taste acuity or quality of life. We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. How up‐to‐date is this review? We searched for studies that had been published up to 4 July 2017.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.746Z" }, { "id": "5c903bcd-a053-4fc6-b0f4-f69c5688b5a5", "pmid": "", "title": "Phytoestrogens for menopausal vasomotor symptoms", "imported": false, "abstract": "Abstract - Background Vasomotor symptoms, such as hot flushes and night sweats, are very common during the menopausal transition. Hormone therapy has traditionally been used as a highly effective treatment, but concerns about increased risk of some chronic diseases have markedly increased the interest of women in alternative treatments. Some of the most popular of these treatments are foods or supplements enriched with phytoestrogens—plant‐derived chemicals that have estrogenic action. Objectives To assess the efficacy, safety and acceptability of food products, extracts and dietary supplements containing high levels of phytoestrogens when compared with no treatment, placebo or hormone therapy for the amelioration of vasomotor menopausal symptoms (such as hot flushes and night sweats) in perimenopausal and postmenopausal women. Search methods Searches targeted the following electronic databases: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of randomised trials (29 July 2013), the Cochrane Register of Controlled Trials (CENTRAL; 29 July 2013), MEDLINE (inception to 29 July 2013), EMBASE (inception to 29 July 2013), AMED (1985 to 29 July 2013), PsycINFO (inception to 29 July 2013) and CINAHL (inception to 29 July 2013). Attempts were made to access grey literature by sending letters to pharmaceutical companies and performing searches of ongoing trial registers. Reference lists of included trials were also searched. Selection criteria Studies were included if they were randomised, included perimenopausal or postmenopausal participants with vasomotor symptoms (hot flushes or night sweats), lasted at least 12 weeks and provided interventions such as foods or supplements with high levels of phytoestrogens (not combined with other herbal treatments). Trials that included women who had breast cancer or a history of breast cancer were excluded. Data collection and analysis Selection of trials, extraction of data and assessment of quality were undertaken by at least two review authors. Most trials were too dissimilar for their results to be combined in a meta‐analysis, so these findings are provided in narrative 'Summary of results' tables. Studies were grouped into broad categories: dietary soy, soy extracts, red clover extracts, genistein extracts and other types of phytoestrogens. Five trials used Promensil, a red clover extract; results of these trials were combined in a meta‐analysis, and summary effect measures were calculated. Main results A total of 43 randomised controlled trials (4,364 participants) were included in this review. Very few trials provided data suitable for inclusion in a meta‐analysis. Among the five trials that yielded data assessing the daily frequency of hot flushes suitable for pooling, no significant difference overall was noted in the incidence of hot flushes between participants taking Promensil (a red clover extract) and those given placebo (mean difference (MD) ‐0.93, 95% confidence interval (CI) ‐1.95 to 0.10, I 2 = 31%). No evidence indicated a difference in percentage reduction in hot flushes in two trials between Promensil and placebo (MD 20.15, 95% CI ‐12.08 to 52.38, I 2 = 82%). Four trials that were not combined in meta‐analyses suggested that extracts with high (> 30 mg/d) levels of genistein consistently reduced the frequency of hot flushes. Individual results from the remaining trials were compared in broad subgroups such as dietary soy, soy extracts and other types of phytoestrogens that could not be combined. Some of these trials found that phytoestrogen treatments alleviated the frequency and severity of hot flushes and night sweats when compared with placebo, but many trials were small and were determined to be at high risk of bias. A strong placebo effect was noted in most trials, with a reduction in frequency ranging from 1% to 59% with placebo. No indication suggested that discrepant results were due to the amount of isoflavone in the active treatment arm, the severity of vasomotor symptoms or trial quality factors. Also, no evidence indicated that these treatments caused oestrogenic stimulation of the endometrium or the vagina or other adverse effects when used for up to two years. Authors' conclusions No conclusive evidence shows that phytoestrogen supplements effectively reduce the frequency or severity of hot flushes and night sweats in perimenopausal or postmenopausal women, although benefits derived from concentrates of genistein should be further investigated. Plain language summary Phytoestrogens for vasomotor menopausal symptoms Review question: This Cochrane review has evaluated whether phytoestrogen treatments reduce the number and severity of hot flushes and whether they are safe and acceptable. Background: Hormone therapy is an effective treatment for controlling the most common menopausal symptoms—hot flushes and night sweats. However, it is now recommended only in low doses given for the shortest possible time because of concerns about increased risk of some chronic diseases. Many women have started to use therapies that they perceive as 'natural' and safe, but they often do not have good information about the potential benefits and risks. Some of these therapies contain phytoestrogens—a group of plant‐derived chemicals that are thought to prevent or treat disease. Phytoestrogens are found in a wide variety of plants, some of which are foods, particularly soy, alfalfa and red clover. Study characteristics: This review found 43 RCTs conducted up to July 2013 that included 4,084 participants with hot flushes who were close to the menopause or were menopausal. Evidence obtained is current to July 2013. Key results: Some trials reported a slight reduction in hot flushes and night sweats with phytoestrogen‐based treatment. Extracts containing high levels of genistein (a substance derived from soy) appeared to reduce the number of daily hot flushes and need to be investigated further. Overall no indication suggested that other types of phytoestrogens work any better than no treatment. No evidence was found of harmful effects on the lining of the womb, stimulation of the vagina or other adverse effects with short‐term use. Quality of the evidence: Many of the trials in this review were small, of short duration and of poor quality, and the types of phytoestrogens used varied substantially.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lethaby, A, Marjoribanks, J, Kronenberg, F, Roberts, H, Eden, J, Brown, J", "articleTypes": [], "doi": "10.1002/14651858.CD001395.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.740Z" }, { "id": "5c9092a9-8dfc-4136-bfd4-b87a0a9f6283", "pmid": "", "title": "Nebulised hypertonic saline for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Hypertonic saline enhances mucociliary clearance and may lessen the destructive inflammatory process in the airways. This is an update of a previously published review. Objectives To investigate efficacy and tolerability of nebulised hypertonic saline treatment in people with cystic fibrosis (CF) compared to placebo or other treatments that enhance mucociliary clearance. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also searched ongoing trials databases. Most recent search: 25 April 2022. Selection criteria We included randomised and quasi‐randomised controlled trials assessing hypertonic saline compared to placebo or other mucolytic therapy, for any duration or dose regimen in people with CF (any age or disease severity). Data collection and analysis Two authors independently reviewed all identified trials and data, and assessed trial quality. We assessed the certainty of the evidence using GRADE. For cross‐over trials we stipulated a one‐week washout period. We planned to use results from a paired analysis in the review, but this was only possible in one trial. For other cross‐over trials, we chose to treat the trials as if they were parallel. Main results We included 24 trials (1318 participants, aged one month to 56 years); we excluded 29 trials, two trials are ongoing and six are awaiting classification. We judged 15 of the 24 included trials to have a high risk of bias due to participants' ability to discern the taste of the solutions. Hypertonic saline 3% to 7% versus placebo (stable disease) We are uncertain whether the regular use of nebulised hypertonic saline in stable lung disease leads to an improvement in forced expiratory volume in one second (FEV 1 ) % predicted at four weeks, (mean difference (MD) 3.30%, 95% confidence interval (CI) 0.71 to 5.89; 4 trials, 246 participants; very low‐certainty evidence). In preschool children we found no difference in lung clearance index (LCI) at four weeks, but a small improvement after 48 weeks of treatment with hypertonic saline compared to isotonic saline (MD ‐0.60, 95% CI ‐1.00 to ‐0.19; 2 trials, 192 participants). We are also uncertain whether hypertonic saline made a difference to mucociliary clearance, pulmonary exacerbations or adverse events compared to placebo. Hypertonic saline versus control (acute exacerbation) Two trials compared hypertonic saline to control, but only one provided data. There may be little or no difference in lung function measured by FEV 1 % predicted after hypertonic saline compared to isotonic saline (MD 5.10%, 95% CI ‐14.67 to 24.87; 1 trial, 130 participants). Neither trial reported any deaths or measures of sputum clearance. There were no serious adverse events. Hypertonic saline versus rhDNase Three trials compared a similar dose of hypertonic saline to recombinant deoxyribonuclease (rhDNase); two trials (61 participants) provided data for inclusion in the review. We are uncertain whether there was an effect of hypertonic saline on FEV 1 % predicted after three weeks (MD 1.60%, 95% CI ‐7.96 to 11.16; 1 trial, 14 participants; very low‐certainty evidence). At three months, rhDNase may lead to a greater increase in FEV 1 % predicted than hypertonic saline (5 mL twice daily) at 12 weeks in participants with moderate to severe lung disease (MD 8.00%, 95% CI 2.00 to 14.00; low‐certainty evidence). We are uncertain whether adverse events differed between the two treatments. No deaths were reported. Hypertonic saline versus amiloride One trial (12 participants) compared hypertonic saline to amiloride but did not report on most of our outcomes. The trial found that there was no difference between treatments in measures of sputum clearance (very low‐certainty evidence). Hypertonic saline compared with sodium‐2‐mercaptoethane sulphonate (Mistabron®) One trial (29 participants) compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate. The trial did not measure our primary outcomes. There was no difference between treatments in any measures of sputum clearance, courses of antibiotics or adverse events (very low‐certainty evidence). Hypertonic saline versus mannitol One trial (12 participants) compared hypertonic saline to mannitol, but did not report lung function at relevant time points for this review; there were no differences in sputum clearance, but mannitol was reported to be more 'irritating' (very low‐certainty evidence). Hypertonic saline versus xylitol Two trials compared hypertonic saline to xylitol, but we are uncertain whether there is any difference in FEV 1 % predicted or median time to exacerbation between groups (very low‐certainty evidence). No other outcomes were reported in the review. Hypertonic saline 7% versus hypertonic saline 3% We are uncertain whether there was an improvement in FEV 1 % predicted after treatment with 7% hypertonic saline compared with 3% (very low‐certainty evidence). Authors' conclusions We are very uncertain if regular use of nebulised hypertonic saline by adults and children over the age of 12 years with CF results in an improvement in lung function after four weeks (three trials; very low‐certainty evidence); there was no difference seen at 48 weeks (one trial; low‐certainty evidence). Hypertonic saline improved LCI modestly in children under the age of six years. Evidence from one small cross‐over trial in children indicates that rhDNase may lead to better lung function than hypertonic saline at three months; qualifying this, we highlight that while the study did demonstrate that the improvement in FEV 1 was greater with daily rhDNase, there were no differences seen in any of the secondary outcomes. Hypertonic saline does appear to be an effective adjunct to physiotherapy during acute exacerbations of lung disease in adults. However, for the outcomes assessed, the certainty of the evidence ranged from very low to low at best, according to the GRADE criteria. The role of hypertonic saline in conjunction with cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy now needs to be considered, and future research needs to focus on this aspect. Plain language summary Hypertonic saline (salt water with at least 3% salt) nebulised as a fine mist through a mask or mouthpiece for cystic fibrosis Review question Is inhaling hypertonic saline (salt water with at least 3% salt) as a mist through a mask or mouthpiece better for improving mucus clearance in the lungs of people with cystic fibrosis (CF) than a placebo (a mist with no or very little salt) or other agents? Background People with CF produce large amounts of thick mucus which is difficult to clear and blocks up their airways. Chest physiotherapy or medication, e.g. hypertonic saline, or both combined, are used to try and clear this mucus from the airways. Hypertonic saline is water with a concentration of 3% to 7% salt and is inhaled as a fine mist. This is an update of an earlier review. Key messages • We are uncertain whether inhaling nebulised hypertonic saline regularly improves lung function compared to placebo. • Nebulised hypertonic saline does seem to work well as an add‐on to physiotherapy. What did we do? We searched for studies that looked at the use of nebulised hypertonic saline compared to either a placebo or a different type of treatment for clearing mucus from the lungs. We compared the size and methods of the studies and stated how confident we were in the results. What did we find? We included 24 trials with 1318 people with CF aged between one month and 56 years. Two thirds of the trials compared hypertonic saline to a placebo (a dummy treatment); the remaining trials compared hypertonic saline to another type of mucus clearing treatment (including mannitol; rhDNase (Pulmozyme®); amiloride; Mistabron®; xylitol); and one trial compared 7% hypertonic saline with 3% hypertonic saline. Trials assessed different concentrations of hypertonic saline with different nebulisers and different treatment schedules; the most common treatment was twice‐daily 7% hypertonic saline and the most common nebuliser was ultrasonic. Most trials treated people with a bronchodilator to widen the airways before giving the hypertonic saline. Main results Hypertonic saline 3% to 7% versus placebo We are not sure whether hypertonic saline leads to an improvement in lung function in stable disease after four weeks. Two trials showed that there may be a small improvement in lung function (measured using the lung clearance index) with hypertonic saline compared to placebo in preschool children. We are also unsure whether hypertonic saline makes a difference to clearing mucus from the lungs, exacerbations or side effects compared to placebo. During exacerbations, we found that there may be little or no difference in lung function after hypertonic saline compared to placebo. The trials did not report any serious side effects and there were no deaths. One study compared 7% hypertonic saline with a lower concentration of hypertonic saline (3%); we are uncertain whether the higher concentration improved lung function. Hypertonic saline versus mucus mobilising treatments Three trials compared hypertonic saline with rhDNase and found that rhDNase may lead to an improvement in lung function compared to hypertonic saline after three months. We are unsure whether there is any difference in side effects. One trial compared hypertonic saline to amiloride and a further trial compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate (Mistabron®), but neither of the trials gave information about the effect of the treatments on lung function. Similarly, a trial comparing hypertonic saline with mannitol did not give information about the effects on lung function, but they did report that there was no difference between treatments in clearing mucus from the lungs. People taking mannitol said it was more irritating than hypertonic saline. Two trials compared hypertonic saline with xylitol, but we are unsure if there is any difference in lung function and none of our other outcomes were measured. What are the limitations of this evidence? We are not confident in the evidence from these trials. There is a high risk that people knew which treatment they were receiving in half the trials as they could taste the difference between the solutions. Other factors that made us unsure of the results were the small numbers of people taking part in the trials combined with a wide variation in results; also, some trials limited participants to those who could tolerate hypertonic saline or to certain age groups. How up to date is this evidence? The evidence is current to 25 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wark, P; McDonald, VM; Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD001506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "5c973cdf-192d-47ad-97af-7110501e4a81", "pmid": "", "title": "Antibiotics to prevent complications following tooth extractions", "imported": false, "abstract": "Abstract - Background The most frequent indications for tooth extractions, generally performed by general dental practitioners, are dental caries and periodontal infections. Systemic antibiotics may be prescribed to patients undergoing extractions to prevent complications due to infection. This is an update of a review first published in 2012. Objectives To determine the effect of systemic antibiotic prophylaxis on the prevention of infectious complications following tooth extractions. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 16 April 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 3), MEDLINE Ovid (1946 to 16 April 2020), Embase Ovid (1980 to 16 April 2020), and LILACS (1982 to 16 April 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised, double‐blind, placebo‐controlled trials of systemic antibiotic prophylaxis in patients undergoing tooth extraction(s) for any indication. Data collection and analysis At least two review authors independently performed data extraction and 'Risk of bias' assessment for the included studies. We contacted trial authors for further details where these were unclear. For dichotomous outcomes, we calculated risk ratios (RR) and 95% confidence intervals (CI) using random‐effects models. For continuous outcomes, we used mean differences (MD) with 95% CI using random‐effects models. We examined potential sources of heterogeneity. We assessed the certainty of the body of evidence for key outcomes as high, moderate, low, or very low, using the GRADE approach. Main results We included 23 trials that randomised approximately 3206 participants (2583 analysed) to prophylactic antibiotics or placebo. Although general dentists perform dental extractions because of severe dental caries or periodontal infection, only one of the trials evaluated the role of antibiotic prophylaxis in groups of patients affected by those clinical conditions. We assessed 16 trials as being at high risk of bias, three at low risk, and four as unclear. Compared to placebo, antibiotics may reduce the risk of postsurgical infectious complications in patients undergoing third molar extractions by approximately 66% (RR 0.34, 95% CI 0.19 to 0.64; 1728 participants; 12 studies; low‐certainty evidence), which means that 19 people (95% CI 15 to 34) need to be treated with antibiotics to prevent one infection following extraction of impacted wisdom teeth. Antibiotics may also reduce the risk of dry socket by 34% (RR 0.66, 95% CI 0.45 to 0.97; 1882 participants; 13 studies; low‐certainty evidence), which means that 46 people (95% CI 29 to 62) need to take antibiotics to prevent one case of dry socket following extraction of impacted wisdom teeth. The evidence for our other outcomes is uncertain: pain, whether measured dichotomously as presence or absence (RR 0.59, 95% CI 0.31 to 1.12; 675 participants; 3 studies) or continuously using a visual analogue scale (0‐to‐10‐centimetre scale, where 0 is no pain) (MD −0.26, 95% CI −0.59 to 0.07; 422 participants; 4 studies); fever (RR 0.66, 95% CI 0.24 to 1.79; 475 participants; 4 studies); and adverse effects, which were mild and transient (RR 1.46, 95% CI 0.81 to 2.64; 1277 participants; 8 studies) (very low‐certainty evidence). We found no clear evidence that the timing of antibiotic administration (preoperative, postoperative, or both) was important. The included studies enrolled a subset of patients undergoing dental extractions, that is healthy people who had surgical extraction of third molars. Consequently, the results of this review may not be generalisable to all people undergoing tooth extractions. Authors' conclusions The vast majority (21 out of 23) of the trials included in this review included only healthy patients undergoing extraction of impacted third molars, often performed by oral surgeons. None of the studies evaluated tooth extraction in immunocompromised patients. We found low‐certainty evidence that prophylactic antibiotics may reduce the risk of infection and dry socket following third molar extraction when compared to placebo, and very low‐certainty evidence of no increase in the risk of adverse effects. On average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection. It is unclear whether the evidence in this review is generalisable to patients with concomitant illnesses or patients at a higher risk of infection. Due to the increasing prevalence of bacteria that are resistant to antibiotic treatment, clinicians should evaluate if and when to prescribe prophylactic antibiotic therapy before a dental extraction for each patient on the basis of the patient's clinical conditions (healthy or affected by systemic pathology) and level of risk from infective complications. Immunocompromised patients, in particular, need an individualised approach in consultation with their treating medical specialist. Plain language summary Are antibiotics an effective way to prevent infection following tooth removal? What is the problem? Teeth that are affected by decay or gum disease or painful wisdom teeth are often removed (extracted) by dentists. Tooth extraction is a surgical procedure that leaves a wound in the mouth that can become infected. Infection can lead to swelling, pain, development of pus, fever, as well as ‘dry socket’ (where the tooth socket is not filled by a blood clot, and there is severe pain and bad odour). These complications are unpleasant for patients and may cause difficulty with chewing, speaking, and teeth cleaning, and may even result in days off work or study. Treatment of infection is generally simple and involves drainage of the infection from the wound and patients receiving antibiotics. Why is this question important? Antibiotics work by killing the bacteria that cause infections, or by slowing their growth. However, some infections clear up by themselves. Taking antibiotics unnecessarily may stop them working effectively in future. This ‘antimicrobial resistance’ is a growing problem throughout the world. Antibiotics may also cause unwanted effects such as diarrhoea and nausea. Some patients may be allergic to antibiotics, and antibiotics may not mix well with other medicines. Dentists frequently give patients antibiotics at the time of the extraction as a precaution in order to prevent infection occurring in the first place. This may be unnecessary and may lead to unwanted effects. What did we want to find out? We wanted to know whether giving antibiotics as a preventive measure reduces infection and other complications after tooth extraction. We also wanted to understand whether antibiotics work differently in healthy people compared with people with health conditions such as diabetes or HIV. What did we do? We searched for studies that assessed the effectiveness of antibiotics compared to placebo (sham medicine), given when no infection was present in order to prevent infection following tooth extraction. Studies could include people of any age undergoing tooth extraction. Where possible, we pooled the studies’ results and analysed them together. We also assessed the quality of each study to judge the reliability (certainty) of evidence of individual studies and the body of evidence. What we found We found 23 included studies with a total of more than 3200 participants, who received either antibiotics (of different kinds and dosages) or placebo immediately before or just after tooth extraction, or both. Four studies were conducted in Spain, three each in Brazil, Sweden, and the UK, two in India, and one each in Colombia, Denmark, Finland, France, Poland, New Zealand, Nigeria, and the USA. All but one study included healthy patients in their 20s. Twenty‐one studies assessed the removal of wisdom teeth in hospital dental departments, one assessed the removal of other teeth and one assessed complex oral surgery. None of the included studies assessed tooth extraction in general dental practice for the removal of decayed teeth. Main results Antibiotics given just before or just after surgery (or both) may reduce the risk of infection and dry socket after the removal of wisdom teeth by oral surgeons. However, antibiotics may cause more (generally brief and minor) unwanted effects for these patients. We found no evidence that antibiotics prevent pain, fever, swelling, or problems with restricted mouth opening in patients who have had wisdom teeth removed. There was no evidence to judge the effects of preventive antibiotics for extractions of severely decayed teeth, teeth in diseased gums, or extractions in patients who are sick or have low immunity to infection. How reliable are the results? Our confidence in the results is limited because we had concerns about aspects of the design and reporting of all of the included studies. What does this mean? We did not find studies in patients with depressed immune systems, other illnesses, or in young children or older patients, therefore the results of our review probably do not apply to people who may be at high risk of infection. Also, extractions were mainly carried out by oral surgeons, so the review may not apply to dentists working in general practice. Another concern, which cannot be assessed by clinical studies (i.e. studies testing new medical approaches in people), is that widespread use of antibiotics by people who do not have an infection is likely to contribute to the development of antimicrobial resistance. We concluded that antibiotics given to healthy people when they are having teeth extracted may help prevent infection, but the decision to use an antibiotic should be judged on an individual patient basis based on their state of health and possible complications of getting an infection. How up‐to‐date is this review? This is an updated review. The evidence is current to April 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lodi, G; Azzi, L; Varoni, EM; Pentenero, M; Del Fabbro, M; Carrassi, A; Sardella, A; Manfredi, M", "articleTypes": [], "doi": "10.1002/14651858.CD003811.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "5cbadaee-064b-4b1d-9c25-80ee5492d946", "pmid": "", "title": "Sensory environment on health‐related outcomes of hospital patients", "imported": false, "abstract": "Abstract - Background Hospital environments have recently received renewed interest, with considerable investments into building and renovating healthcare estates. Understanding the effectiveness of environmental interventions is important for resource utilisation and providing quality care. Objectives To assess the effect of hospital environments on adult patient health‐related outcomes. Search methods We searched: the Cochrane Central Register of Controlled Trials (last searched January 2006); MEDLINE (1902 to December 2006); EMBASE (January 1980 to February 2006); 14 other databases covering health, psychology, and the built environment; reference lists; and organisation websites. This review is currently being updated (MEDLINE last search October 2010), see Studies awaiting classification. Selection criteria Randomised and non‐randomised controlled trials, controlled before‐and‐after studies, and interrupted times series of environmental interventions in adult hospital patients reporting health‐related outcomes. Data collection and analysis Two review authors independently undertook data extraction and 'Risk of bias' assessment. We contacted authors to obtain missing information. For continuous variables, we calculated a mean difference (MD) or standardized mean difference (SMD), and 95% confidence intervals (CI) for each study. For dichotomous variables, we calculated a risk ratio (RR) with 95% confidence intervals (95% CI). When appropriate, we used a random‐effects model of meta‐analysis. Heterogeneity was explored qualitatively and quantitatively based on risk of bias, case mix, hospital visit characteristics, and country of study. Main results Overall, 102 studies have been included in this review. Interventions explored were: 'positive distracters', to include aromas (two studies), audiovisual distractions (five studies), decoration (one study), and music (85 studies); interventions to reduce environmental stressors through physical changes, to include air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), and temperature (one study); and multifaceted interventions (two studies). We did not find any studies meeting the inclusion criteria to evaluate: art, access to nature for example, through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music may improve patient‐reported outcomes such as anxiety; however, the benefit for physiological outcomes, and medication consumption has less support. There are few studies to support or refute the implementation of physical changes, and except for air quality, the included studies demonstrated that physical changes to the hospital environment at least did no harm. Authors' conclusions Music may improve patient‐reported outcomes in certain circumstances, so support for this relatively inexpensive intervention may be justified. For some environmental interventions, well designed research studies have yet to take place. Plain language summary Sensory environment on health‐related outcomes of hospital patients The hospital environment (such as sounds, pictures, aromas, design, air quality, furnishings, architecture, and layout), may have an impact on the health of patients within it. This review aims to summarise the best available evidence on hospital environments, in order to help people involved in the design of hospital environments make decisions that will benefit patients' health. The review identified 102 relevant studies, 85 of which were on the use of music in hospital. Other environmental aspects considered were: aromas (two studies), audiovisual distractions (five studies), decoration (one study), air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), temperature (one study), and multiple design changes (two studies). No studies meeting the inclusion criteria were found to evaluate: art, access to nature for example through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music in hospital may help improve patient‐reported outcomes such as anxiety; however, there is less evidence to support the use of music for physiological outcomes (such as reducing heart rate and blood pressure) and for reducing the use of medications. For other aspects of hospital environments, there are not very many well designed studies to help with making evidence‐based design decisions. The studies that have been included in this review show that physical changes made to 'improve' the hospital environment on the whole do no harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Drahota, A, Ward, D, Mackenzie, H, Stores, R, Higgins, B, Gal, D, Dean, TP", "articleTypes": [], "doi": "10.1002/14651858.CD005315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.802Z" }, { "id": "5ccf3a40-6426-4f7a-b45d-a147d0f3a778", "pmid": "", "title": "Interventions for increasing fruit and vegetable consumption in children aged five years and under", "imported": false, "abstract": "Abstract - Background Insufficient consumption of fruits and vegetables in childhood increases the risk of future non‐communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child‐feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden. Objectives To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. Search methods We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials. Selection criteria We included randomised controlled trials (RCTs), including cluster‐randomised controlled trials (C‐RCTs) and cross‐over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no‐intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random‐effects models in meta‐analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures. Main results We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child‐feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child‐focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate‐certainty evidence that child‐feeding practice interventions versus no‐intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as‐desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post‐intervention follow‐up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low‐certainty evidence). Multicomponent interventions versus no‐intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate‐certainty evidence; mean post‐intervention follow‐up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden‐based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low‐certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short‐term impact on child consumption of fruit and vegetables versus no‐intervention control (SMD 0.10, 95% CI ‐0.02 to 0.22; 14 trials, 4122 participants; low‐certainty evidence; mean post‐intervention follow‐up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low‐certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low‐certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding. Authors' conclusions There was moderate‐certainty evidence that child‐feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low‐ and middle‐income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. Plain language summary What are the benefits and harms of interventions to increase eating of fruit and vegetables among children aged five years and under? Key messages • Child‐feeding interventions probably lead to a small increase in eating of vegetables in children aged five years and under. • Multicomponent interventions probably lead to a small increase in eating of fruit and vegetables in children aged five years and under. • Parent nutrition education interventions may lead to little or no increase in eating of fruit and vegetables in children aged five years and under. Why is eating enough fruit and vegetables important? Not eating enough fruit and vegetables leads to a considerable health burden in developed countries. Eating adequate amounts of fruit and vegetables is associated with a reduced risk of future non‐communicable diseases (such as heart and circulatory disease) amongst other immediate health benefits. Early childhood is a critical period for the establishment of dietary habits that track into adulthood. Interventions to increase consumption of fruit and vegetables in early childhood may therefore be an effective strategy to reduce this disease burden. What did we want to find out? We wanted to know the benefits and harms of interventions designed to increase eating of fruit or vegetables or both amongst children aged five years and under. What did we do? We searched various electronic databases to find studies. We contacted the authors of the included studies for additional potentially relevant studies. Any randomised study (where participants have the same chance of being assigned to treatment or a no‐treatment control) of interventions aiming to increase the intake of fruit or vegetables or both by children aged five years and under, which measured intake, was eligible. Two review authors independently searched for and extracted information from studies. We searched up to March 2023. What did we find? We included 53 studies with 12,350 people taking part. Sixteen studies examined child‐feeding practice interventions (e.g. repeated exposure to vegetables); 20 examined multicomponent interventions (e.g. combining two or more interventions, such as preschool policy changes with parent nutrition education); 17 examined parent nutrition education interventions; two examined child nutrition education interventions; and one each examined child‐focused mindfulness or providing families with fruit and vegetable interventions. Child‐feeding practice interventions and multicomponent interventions probably lead to small increases in children's intake of fruit and vegetables in the short term (less than 12 months). Parent nutrition education interventions may lead to little to no increase in children's eating of fruit and vegetables. Limited information was available on cost and unintended harms. Of the studies that did report these, intervention costs ranged from 325 to 1500 US dollars (USD). No unintended harms were found in the two studies that reported assessing them. Studies reporting funding support received governmental or charitable funds, except for one study that received industry funding. What are the limitations of the evidence? No studies were conducted in low‐income countries and only one study was conducted in a middle‐income country. Our confidence in the current evidence is moderate for child feeding and multicomponent interventions, and low for parent nutrition education interventions. How up‐to‐date is this evidence? This evidence is up‐to‐date to March 2023. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Hodder, RK, O'Brien, KM, Wyse, RJ, Tzelepis, F, Yoong, S, Stacey, FG, Wolfenden, L", "articleTypes": [], "doi": "10.1002/14651858.CD008552.pub8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.789Z" }, { "id": "5ce180b5-5acb-40f6-8ec5-1dfe68a70ac9", "pmid": "", "title": "Randomised Controlled Trials to Assess Approved SARS-CoV-2 Vaccines in Immunocompromised Patients: A Master Protocol for the Set-up of a Swiss Cohorts Based Trial Platform", "imported": false, "abstract": "This study is to set up a flexible trial platform using two existing national cohorts of immunocompromised patients (i.e. Swiss HIV Cohort Study [SHCS] and Swiss Transplant Cohort Study [STCS]) to assess the comparative effectiveness and safety of approved SARS-CoV-2 vaccines in immunocompromised patients.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.156Z" }, { "id": "5ce77bf6-b111-42e8-b983-58a158f4aa76", "pmid": "", "title": "Echinacea for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Echinacea plant preparations (family Asteraceae ) are widely used in Europe and North America for common colds. Most consumers and physicians are not aware that products available under the term Echinacea differ appreciably in their composition, mainly due to the use of variable plant material, extraction methods and the addition of other components. Objectives To assess whether there is evidence that Echinacea preparations are effective and safe compared to placebo in the prevention and treatment of the common cold. Search methods We searched CENTRAL 2013, Issue 5, MEDLINE (1946 to May week 5, 2013), EMBASE (1991 to June 2013), CINAHL (1981 to June 2013), AMED (1985 to February 2012), LILACS (1981 to June 2013), Web of Science (1955 to June 2013), CAMBASE (no time limits), the Centre for Complementary Medicine Research (1988 to September 2007), WHO ICTRP and clinicaltrials.gov (last searched 5 June 2013), screened references and asked experts in the field about published and unpublished studies. Selection criteria Randomized controlled trials (RCTs) comparing mono‐preparations of Echinacea with placebo. Data collection and analysis At least two review authors independently assessed eligibility and trial quality and extracted data. The primary efficacy outcome was the number of individuals with at least one cold in prevention trials and the duration of colds in treatment trials. For all included trials the primary safety and acceptability outcome was the number of participants dropping out due to adverse events. We assessed trial quality using the Cochrane 'Risk of bias' tool. Main results Twenty‐four double‐blind trials with 4631 participants including a total of 33 comparisons of Echinacea preparations and placebo met the inclusion criteria. A variety of different Echinacea preparations based on different species and parts of plant were used. Evidence from seven trials was available for preparations based on the aerial parts of Echinacea purpurea. Ten trials were considered to have a low risk of bias, six to have an unclear risk of bias and eight to have a high risk of bias. Ten trials with 13 comparisons investigated prevention and 15 trials with 20 comparisons investigated treatment of colds (one trial addressed both prevention and treatment). Due to the strong clinical heterogeneity of the studies we refrained from pooling for the main analysis. None of the 12 prevention comparisons reporting the number of patients with at least one cold episode found a statistically significant difference. However a post hoc pooling of their results, suggests a relative risk reduction of 10% to 20%. Of the six treatment trials reporting data on the duration of colds, only two showed a significant effect of Echinacea over placebo. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. Authors' conclusions Echinacea products have not here been shown to provide benefits for treating colds, although, it is possible there is a weak benefit from some Echinacea products : the results of individual prophylaxis trials consistently show positive (if non‐significant) trends, although potential effects are of questionable clinical relevance. Plain language summary Echinacea for preventing and treating the common cold Preparations of the plant Echinacea are widely used in some European countries and in North America for common colds. Echinacea preparations available on the market differ greatly as different types (species) and parts (herb, root or both) of the plant are used, different manufacturing methods (drying, alcoholic extraction or pressing out the juice from fresh plants) are used and sometimes also other herbs are added. We reviewed 24 controlled clinical trials with 4631 participants investigating the effectiveness of several different Echinacea preparations for preventing and treating common colds or induced rhinovirus infections. Our review shows that a variety of products prepared from different Echinacea species, different plant parts and in a different form have been compared to placebo in randomized trials. Due to the significant differences in the preparations tested, it was difficult to draw strong conclusions. Five trials were rated as having a low risk of bias in all five categories of the Cochrane 'Risk of bias' tool. Five more trials were rated as low risk of bias, having an unclear risk of bias in only one category. Eight trials were rated as having a high risk of bias in at least one category and the remaining six as having an unclear risk of bias. The majority of trials investigated whether taking Echinacea preparations after the onset of cold symptoms shortens the duration, compared with placebo. Although it seems possible that some Echinacea products are more effective than a placebo for treating colds, the overall evidence for clinically relevant treatment effects is weak. In general, trials investigating Echinacea for preventing colds did not show statistically significant reductions in illness occurrence. However, nearly all prevention trials pointed in the direction of small preventive effects. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. The evidence is current to July 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Karsch‐Völk, M, Barrett, B, Kiefer, D, Bauer, R, Ardjomand‐Woelkart, K, Linde, K", "articleTypes": [], "doi": "10.1002/14651858.CD000530.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.739Z" }, { "id": "5cfc56bd-ae36-46ee-810a-19288d7be90a", "pmid": "", "title": "Sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose or glucose with and without non‐nutritive sucking is frequently used as a non‐pharmacological intervention for needle‐related procedural pain relief in infants. Objectives To determine the effectiveness of sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet‐tasting solutions, or pharmacological or other non‐pharmacological pain‐relieving methods. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012); MEDLINE via Ovid (1966 to 2012); CINAHL via OVID (1982 to 2012). The World Health Organization International Clinical Trials Registry Platform was also searched for any ongoing trials. Clinical trial registries, conference proceedings and references for randomised controlled trials (RCTs) were also searched. An updated search was run to capture any new publications before finalising the review in April 2012 and no new included studies were identified. Two review authors (MK & JF) independently abstracted data and assessed quality using a standard form. Authors have been contacted for missing data. Selection criteria Randomised‐controlled trials using a sweet‐tasting solution to treat pain in healthy term infants (gestational age 37 weeks and over), between one month and 12 months of age who required needle‐related procedures. These procedures included but were not limited to: subcutaneous or intramuscular injections, venepuncture, and heel lance. Studies in which the painful procedure was circumcision, lumbar puncture or supra‐pubic bladder aspiration were not included as they are more severe and painful than needle‐related procedures. Control conditions included no treatment or placebo (water) or any other identical intervention (same appearance and consistency) without active ingredient, another sweet‐tasting solution, a pharmacological pain‐relieving method (e.g. paracetamol, topical anaesthetic cream), non‐pharmacological pain‐relieving method (e.g. distraction method, non‐nutritive sucking). Data collection and analysis Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Pain, Palliative and Supportive Care Group. We report mean differences (MD) with 95% confidence intervals (CI) using fixed‐effect models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. The Chi 2 test and I 2 statistic were used to assess between‐study heterogeneity. Main results Sixty‐five (65) studies were identified for possible inclusion in this review. Fourteen published RCTs with a total of 1551 participants met the inclusion criteria. Duration of cry was significantly reduced in infants who were administered a sweet‐tasting solution [MD ‐13.47 (95% CI ‐16.80 to ‐10.15)], P < 0.00001 compared with water. However, there was considerable heterogeneity between the studies (I 2 = 94%) that we were unable to explain. Meta‐analysis was not able to be undertaken for any of the other outcome measures, except for cry duration, because of differences in study design. However, most of the individual studies that measured pain found sucrose to significantly reduce pain compared with the control group. One study compared sucrose and Lidocaine‐prilocaine cream and no significant difference was found between the two treatments for the outcomes pain and cry duration. Due to the differences between the studies, we were unable to identify the optimal concentration, volume or method of administration of sweet‐tasting solutions in infants aged one to 12 months. Further large RCTs are needed. Authors' conclusions There is insufficient evidence to confidently judge the effectiveness of sweet‐tasting solutions in reducing needle‐related pain in infants (one month to 12 months of age). The treatments do, however, appear promising. Data from a series of individual trials are promising, as are the results from a subset meta‐analysis of studies measuring duration of crying. Further well controlled RCTs are warranted in this population to determine the optimal concentration, volume, method of administration, and possible adverse effects. Plain language summary Sweet‐tasting solutions for needle‐related pain in infants up to one year of age The use of needles that break the skin and cause pain is a common practice around the world with babies aged between one month and 12 months ( Appendix 4 ). In this review we were interested in whether giving babies sugar‐based solutions to taste when the needle breaks the skin will help reduce their pain. We found 14 separate studies that had asked this question. However, the differences between the studies were often too great to let us combine their findings. Overall, the studies show that different types of sugar‐based solutions were effective but we were not able to confidently assert that there is strong evidence for this treatment in reducing pain. We did find some evidence that babies may not cry for as long if given sugar‐based solutions. This review is broadly in agreement with two other reviews, one asking this question in younger children, and one in older children. There is a need for better studies in this field.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Kassab, M; Foster, JP; Foureur, M; Fowler, C", "articleTypes": [], "doi": "10.1002/14651858.CD008411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "5d0db186-c295-45b6-8682-cc7bc50b1aac", "pmid": "", "title": "Penicillamine for treating rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is a penicillin derived compound originally used to treat patients with rheumatoid arthritis (RA) in the 1950's. Although frequently used in the past, its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs) such as methotrexate. Objectives To estimate the short‐term effects of D‐penicillamine for the treatment of rheumatoid arthritis (RA). Search methods We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register (issue 3, 2000) and Medline up to and including August 2000 and Embase from 1988‐2000. We also carried out a handsearch of the reference lists of the trials retrieved from the electronic search. Selection criteria All randomized controlled trials and controlled clinical trials comparing D‐penicillamine against placebo in patients with rheumatoid arthritis. Data collection and analysis The methodological quality of the trials was assessed independently by two reviewers (CS, EB) and checked by a third (MS) using a validated quality assessment tool (Jadad 1996). Rheumatoid arthritis outcome measures were extracted from the publications for the six‐month endpoint and stratified according to D‐penicillamine dosages: low (<500mg/day), moderate (500 to <1000mg/day) and high (1000 mg/day or greater). Data was abstracted by one reviewer and checked by a second (CS, MS). The pooled analysis was performed using the standardized mean difference for joint counts, pain and global assessments. The weighted mean difference was used for erythrocyte sedimentation rate (ESR). Toxicity was evaluated with pooled odds ratios for withdrawals and adverse reactions. A chi‐square test was used to assess heterogeneity among trials. Fixed effects models were used throughout, since no statistical heterogeneity was found. Main results Six trials were identified, with 425 patients randomized to D‐penicillamine and 258 to placebo. A statistically significant benefit was observed for D‐penicillamine when compared to placebo for all three‐dose ranges and for most outcome measures including: tender joint counts, pain, physician's global assessments and ESR. The standardized weighted mean differences between treatment and placebo in moderate doses were ‐0.51 [95% CI ‐0.88, ‐0.14] for tender joint counts, ‐0.56 (95% CI ‐0.87, ‐0.26) for pain and ‐0.97 (95% CI ‐1.25, ‐0.70) for global assessment. The difference for ESR was ‐10.6 mm/hr. Similar results were observed for the higher dose group. Total withdrawals were significantly higher in the moderate and high dosage D‐penicillamine groups (OR=1.63 and 2.13 respectively), mostly due to increased adverse reactions (OR = 2.60 and 4.95 respectively), including renal and hematological abnormalities. Authors' conclusions D‐penicillamine appears to have a clinically and statistically significant benefit on the disease activity of patients with rheumatoid arthritis. Its efficacy appears to be similar to that of other disease modifying anti‐rheumatic drugs (DMARDs), but with a significantly higher toxicity. Its effects on long‐term functional status and radiological progression are not clear from this review. Plain language summary Penicillamine for treating rheumatoid arthritis Penicillamine is a penicillin derived compound. Studies showed that this could be used to treat rheumatoid arthritis originally in 1950. It was frequently used in the past, but its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs), such as methotrexate. The purpose of this summary was to find out if penicillamine is helpful in the treatment of rheumatoid arthritis. Penicillamine was seen to be beneficial for all ranges of dosages for disease activity on tender joint pain, physician global assessment and sed rate. No major differences were observed between placebo and low dose penicillamine (<500 mg/day). For higher dosages, patients on penicillamine were twice as likely to withdraw than those receiving placebo 500 to <1000 mg/day. D‐penicillamine appears be have a clinical and statistical benefit on the disease activity of patients with rheumatoid arthritis. Its benefit is similar to that of other such drugs, such as disease modifying anti‐rheumatic drugs (DMARDs). More adverse reactions are seen in patients being treated with D‐penicillamine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Suarez‐Almazor, ME, Belseck, E, Spooner, C", "articleTypes": [], "doi": "10.1002/14651858.CD001460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.749Z" }, { "id": "5d156fca-bef1-431c-a2cf-29c309ea4740", "pmid": "", "title": "Interventions for recurrent idiopathic epistaxis (nosebleeds) in children", "imported": false, "abstract": "Abstract - Background Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified. Although nosebleeds are very common in children, and most cases are self limiting or settle with simple measures (such as pinching the nose), more severe recurrent cases can require treatment from a healthcare professional. However, there is no consensus on the effectiveness of the different clinical interventions currently used in managing this condition. Objectives To assess the effects of different interventions for the management of recurrent idiopathic epistaxis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 5 March 2012. Selection criteria We identified all randomised controlled trials (RCTs) (with or without blinding) in which any surgical or medical intervention for the treatment of recurrent idiopathic epistaxis in children was evaluated in comparison with either no treatment, a placebo or another intervention, and in which the frequency and severity of episodes of nasal bleeding following treatment was stated or calculable. The two authors reviewed the full‐text articles of all retrieved trials of possible relevance and applied the inclusion criteria independently. Data collection and analysis We graded trials for risk of bias using the Cochrane approach. One author performed data extraction in a standardised manner and this was rechecked by the other author. Where necessary we contacted investigators to obtain missing information. We did not undertake a meta‐analysis because of the heterogeneity of the treatments, procedures and quality of the included trials. A narrative overview of the results is therefore presented. Main results Five studies (four RCTs and one quasi‐randomised controlled trial) involving 468 participants satisfied the inclusion criteria. The identified RCTs compared 0.5% neomycin + 0.1% chlorhexidine (Naseptin®) cream with no treatment, Vaseline® petroleum jelly with no treatment, 75% with 95% silver nitrate nasal cautery, and silver nitrate cautery combined with Naseptin® against Naseptin® alone; the quasi‐randomised controlled trial compared Naseptin® antiseptic cream with silver nitrate cautery. Overall results were inconclusive, with no statistically significant difference found between the compared treatments upon completion of the trials, however 75% silver nitrate was more effective than 95% silver nitrate at two weeks following application. The group treated with 75% silver nitrate had 88% complete resolution of epistaxis compared to 65% in the group treated with 95% silver nitrate (P = 0.01). No serious adverse effects were reported from any of the interventions, although children receiving silver nitrate cautery reported that it was a painful experience (despite the use of local anaesthetic). The pain scores were significantly less in those treated with 75% silver nitrate, the mean score being 1 compared to a mean score of 5 in those treated with 95% silver nitrate; this was statistically significant (P = 0.001). We carried out a 'Risk of bias' assessment of each study according to the Cochrane methodology and judged that two randomised controlled trials had a low risk of bias, two had an unclear risk of bias and the quasi‐randomised controlled trial had a high risk of bias. Authors' conclusions The optimal management of children with recurrent idiopathic epistaxis is unknown, however if silver nitrate nasal cautery is undertaken 75% is preferable to 95% as it is more effective in the short term and causes less pain. High‐quality randomised controlled trials comparing interventions either with placebo or no treatment, and with a follow‐up period of at least a year, are needed to assess the relative merits of the various treatments currently in use. Plain language summary Interventions for recurrent nosebleeds of unknown cause in children Nosebleeds in children usually just stop by themselves or after pinching the nose. However, some children get repeated nosebleeds with no specific cause (recurrent idiopathic epistaxis). The most common treatments are cautery or antiseptic cream, or both. Cautery (a method of sealing) can be painful even with local anaesthetic, and usually involves using a silver nitrate stick to seal off a visible blood vessel inside the nose that may be rupturing. Other options include ointments and nasal sprays. The review of trials found that there is not enough evidence to compare the effectiveness of different treatment options, however using a lower concentration of silver nitrate cautery is more effective in the short term and less painful. More research is needed to show the best options for reducing recurrent nosebleeds of unknown cause in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Qureishi, A; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004461.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "5d185611-ec7a-4267-8d9e-73745393f177", "pmid": "", "title": "Ivermectin for preventing and treating COVID‐19", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Popp, M, Reis, S, Schießer, S, Hausinger, RIlona, Stegemann, M, Metzendorf, M-I, Kranke, P, Meybohm, P, Skoetz, N, Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015017.pub3 AB - Abstract - Background Ivermectin, an antiparasitic agent, inhibits the replication of viruses in vitro. The molecular hypothesis of ivermectin's antiviral mode of action suggests an inhibitory effect on severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) replication in early stages of infection. Currently, evidence on ivermectin for prevention of SARS‐CoV‐2 infection and COVID‐19 treatment is conflicting. Objectives To assess the efficacy and safety of ivermectin plus standard of care compared to standard of care plus/minus placebo, or any other proven intervention for people with COVID‐19 receiving treatment as inpatients or outpatients, and for prevention of an infection with SARS‐CoV‐2 (postexposure prophylaxis). Search methods We searched the Cochrane COVID‐19 Study Register, Web of Science (Emerging Citation Index and Science Citation Index), WHO COVID‐19 Global literature on coronavirus disease, and HTA database weekly to identify completed and ongoing trials without language restrictions to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022. Selection criteria We included randomized controlled trials (RCTs) comparing ivermectin to standard of care, placebo, or another proven intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. Co‐interventions had to be the same in both study arms. For this review update, we reappraised eligible trials for research integrity: only RCTs prospectively registered in a trial registry according to WHO guidelines for clinical trial registration were eligible for inclusion. Data collection and analysis We assessed RCTs for bias, using the Cochrane RoB 2 tool. We used GRADE to rate the certainty of evidence for outcomes in the following settings and populations: 1) to treat inpatients with moderate‐to‐severe COVID‐19, 2) to treat outpatients with mild COVID‐19 (outcomes: mortality, clinical worsening or improvement, (serious) adverse events, quality of life, and viral clearance), and 3) to prevent SARS‐CoV‐2 infection (outcomes: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, admission to hospital, mortality, adverse events and quality of life). Main results We excluded seven of the 14 trials included in the previous review version; six were not prospectively registered and one was non‐randomized. This updated review includes 11 trials with 3409 participants investigating ivermectin plus standard of care compared to standard of care plus/minus placebo. No trial investigated ivermectin for prevention of infection or compared ivermectin to an intervention with proven efficacy. Five trials treated participants with moderate COVID‐19 (inpatient settings); six treated mild COVID‐19 (outpatient settings). Eight trials were double‐blind and placebo‐controlled, and three were open‐label. We assessed around 50% of the trial results as low risk of bias. We identified 31 ongoing trials. In addition, there are 28 potentially eligible trials without publication of results, or with disparities in the reporting of the methods and results, held in ‘awaiting classification’ until the trial authors clarify questions upon request. Ivermectin for treating COVID‐19 in inpatient settings with moderate‐to‐severe disease We are uncertain whether ivermectin plus standard of care compared to standard of care plus/minus placebo reduces or increases all‐cause mortality at 28 days (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.14 to 2.51; 3 trials, 230 participants; very low‐certainty evidence); or clinical worsening, assessed by participants with new need for invasive mechanical ventilation or death at day 28 (RR 0.82, 95% CI 0.33 to 2.04; 2 trials, 118 participants; very low‐certainty evidence); or serious adverse events during the trial period (RR 1.55, 95% CI 0.07 to 35.89; 2 trials, 197 participants; very low‐certainty evidence). Ivermectin plus standard of care compared to standard of care plus placebo may have little or no effect on clinical improvement, assessed by the number of participants discharged alive at day 28 (RR 1.03, 95% CI 0.78 to 1.35; 1 trial, 73 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.04, 95% CI 0.61 to 1.79; 3 trials, 228 participants; low‐certainty evidence); and on viral clearance at 7 days (RR 1.12, 95% CI 0.80 to 1.58; 3 trials, 231 participants; low‐certainty evidence). No trial investigated quality of life at any time point. Ivermectin for treating COVID‐19 in outpatient settings with asymptomatic or mild disease Ivermectin plus standard of care compared to standard of care plus/minus placebo probably has little or no effect on all‐cause mortality at day 28 (RR 0.77, 95% CI 0.47 to 1.25; 6 trials, 2860 participants; moderate‐certainty evidence) and little or no effect on quality of life, measured with the PROMIS Global‐10 scale (physical component mean difference (MD) 0.00, 95% CI ‐0.98 to 0.98; and mental component MD 0.00, 95% CI ‐1.08 to 1.08; 1358 participants; high‐certainty evidence). Ivermectin may have little or no effect on clinical worsening, assessed by admission to hospital or death within 28 days (RR 1.09, 95% CI 0.20 to 6.02; 2 trials, 590 participants; low‐certainty evidence); on clinical improvement, assessed by the number of participants with all initial symptoms resolved up to 14 days (RR 0.90, 95% CI 0.60 to 1.36; 2 trials, 478 participants; low‐certainty evidence); on serious adverse events (RR 2.27, 95% CI 0.62 to 8.31; 5 trials, 1502 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.24, 95% CI 0.87 to 1.76; 5 trials, 1502 participants; low‐certainty evidence); and on viral clearance at day 7 compared to placebo(RR 1.01, 95% CI 0.69 to 1.48; 2 trials, 331 participants; low‐certainty evidence). None of the trials reporting duration of symptoms were eligible for meta‐analysis. Authors' conclusions For outpatients, there is currently low‐ to high‐certainty evidence that ivermectin has no beneficial effect for people with COVID‐19. Based on the very low‐certainty evidence for inpatients, we are still uncertain whether ivermectin prevents death or clinical worsening or increases serious adverse events, while there is low‐certainty evidence that it has no beneficial effect regarding clinical improvement, viral clearance and adverse events. No evidence is available on ivermectin to prevent SARS‐CoV‐2 infection. In this update, certainty of evidence increased through higher quality trials including more participants. According to this review's living approach, we will continually update our search. Plain language summary Ivermectin for preventing and treating COVID‐19 Is ivermectin effective for COVID‐19? Key messages We found no evidence to support the use of ivermectin for treating COVID‐19 or preventing SARS‐CoV‐2 infection. The evidence base improved slightly in this update, but is still limited. Evaluation of ivermectin is continuing in 31 ongoing trials, and we will update this review again when their results become available. What is ivermectin? Ivermectin is a medicine used to treat parasites, such as intestinal parasites in animals, and scabies in humans. It is inexpensive and is widely used in regions of the world where parasitic infestations are common. It has few unwanted effects. Medical regulators have not approved ivermectin for COVID‐19. What did we want to find out? We wanted to update our knowledge of whether ivermectin reduces death, illness, and length of infection in people with COVID‐19, or is useful in prevention of the infection. We included trials comparing the medicine to placebo (dummy treatment), usual care, or treatments for COVID‐19 that are known to work to some extent, such as dexamethasone. We excluded trials comparing ivermectin to other medicines that do not work, like hydroxychloroquine, or whose effectiveness against COVID‐19 is uncertain. We evaluated the effects of ivermectin in infected people on: – people dying;
– whether people's COVID‐19 got better or worse;
– quality of life;
– serious and non‐serious unwanted effects;
– viral clearance. For prevention, we sought the effect on preventing SARS‐CoV‐2 infection and COVID‐19 disease. What did we do? We searched for randomized controlled trials that investigated ivermectin to prevent or treat COVID‐19. People treated in hospital or as outpatients had to have laboratory‐confirmed COVID‐19. In this update, we also investigated the trustworthiness of the trials and only included them if they fulfilled clear ethical and scientific criteria. We compared and summarized the results of the trials and rated our confidence in the evidence, based on common criteria such as trial methods and sizes. What did we find? We excluded seven of the 14 trials included in the previous review as these trials did not fulfil the expected ethical and scientific criteria. Together with four new trials, we included 11 trials with 3409 participants that investigated ivermectin combined with any usual care compared to the same usual care or placebo. For treatment, there were five trials of people in hospital with moderate COVID‐19 and six trials of outpatients with mild COVID‐19. The trials used different doses of ivermectin and different durations of treatment. No trial investigated ivermectin to prevent SARS‐CoV‐2 infection. We also found 31 ongoing trials, and an additional 28 trials still requiring clarification from the authors or not yet published. Main results Treating people in hospital with COVID‐19 We do not know whether ivermectin compared with placebo or usual care 28 days after treatment: – leads to more or fewer deaths (3 trials, 230 people); 
– worsens or improves patients' condition, assessed by need for ventilation or death (2 trials, 118 people);
– increases or reduces serious unwanted events (2 trials, 197 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – improving patients' condition, assessed by discharge from hospital (1 trial, 73 people);
– non‐serious unwanted events (3 trials, 228 participants). Seven days after treatment, ivermectin may make little or no difference to reduction of negative COVID‐19 tests (3 trials, 231 participants) compared with placebo or usual care. Treating outpatients with COVID‐19 Ivermectin compared with placebo or usual care 28 days after treatment, probably makes little or no difference to people dying (6 trials, 2860 people). Ivermectin compared with placebo or usual care 28 days after treatment, makes little or no difference to quality of life (1 trial, 1358 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – worsening patients' condition, assessed by admission to hospital or death (2 trials, 590 people);
– serious unwanted events (5 trials, 1502 people); 
– non‐serious unwanted events (5 trials, 1502 participants); 
– improving people's COVID‐19 symptoms in the 14 days after treatment (2 trials, 478 people);
– number of people with negative COVID‐19 tests 7 days after treatment (2 trials, 331 people). What are the limitations of the evidence? Our confidence in the evidence, especially for outpatients, improved since the last review version, because we could look at more participants included in high‐quality trials. Although we are quite certain regarding our results on risk of people dying and quality of life, the confidence in the evidence is still low for many other outpatient and inpatient outcomes because there were only few events measured. The methods differed between trials, and they did not report everything we were interested in, such as relevant outcomes. How up to date is this evidence? The systematic literature search is up to date to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.813Z" }, { "id": "5d1da2c2-001e-4cc6-acd2-f23918c76a9a", "pmid": "", "title": "Pharmacological interventions for people with borderline personality disorder", "imported": false, "abstract": "Abstract - Background Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off‐label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods. Objectives To assess the effects of pharmacological treatment for people with BPD. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. Selection criteria Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events. Data collection and analysis At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. Main results We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty‐nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD ‐0.18, 95% confidence interval (CI) ‐0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD −0.27, 95% CI −0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD −0.07, 95% CI −0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self‐harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale‐Modified‐Self‐Injury item (0‐5 points), 95% CI −10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide‐related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI −0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD −0.26, 95% CI −1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD −0.36, 95% CI −1.96 to 1.25; 2 trials, 44 participants). Very low‐certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD −0.16, 95% CI −0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD −0.25, 95% CI ‐0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD −0.01, 95% CI ‐0.28 to 0.26; 2 trials, 214 participants). Low‐certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD −0.21, 95% CI −0.34 to ‐0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD −0.58, 95% CI ‐1.14 to ‐0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD −0.07, 95% CI ‐0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low‐certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non‐standardised. The available evidence on non‐serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified. Authors' conclusions This review included 18 more trials than the 2010 version, so larger meta‐analyses with more statistical power were feasible. We found mostly very low‐certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma‐related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples. Plain language summary What are the benefits and risks of medication for people with borderline personality disorder? Key messages This review is an update of a previous review on the same topic published in 2010. Although this review includes an additional 18 studies, the conclusions remain the same: there are probably no benefits and risks of medications for borderline personality disorder (BDP), but the evidence is unclear. Better and larger studies comparing the effects of medication with placebo are needed. Such studies should focus on men, adolescents and those with additional psychiatric diagnoses. What is BPD? BPD affects how a person interacts with others and understands one's self. Although its exact causes are unclear, it is thought to result from a combination of genetic and environmental factors (e.g. stressful or traumatic life events when growing up). Approximately 2% of adults and 3% of adolescents are affected. The symptoms of BPD can be grouped into four categories. Instability in mood: People with BPD may experience intense feelings that change rapidly and are difficult to control. They may also feel empty and abandoned much of the time. Cognitive distortions (disturbed patterns of thinking): People with BPD often have upsetting thoughts (e.g. they may think that they are a terrible person). They can have brief episodes of strange experiences (e.g. paranoid ideations or stress‐induced dissociative experiences (i.e. feeling detached from the world around them). Impulsive behaviour: People with BPD may act impulsively and do things that could harm themselves (e.g. when sad and depressed, they may self‐harm or have suicidal feelings). They might also engage in reckless behaviour (e.g. drug misuse). Intense but unstable relationships: People with BPD may find it difficult to keep stable relationships (e.g. they may feel very worried about being abandoned and might constantly text or call, or make threats to harm or kill themselves if the person leaves them). A person only needs to experience five out of nine criteria across these categories to be given a diagnosis of BPD. How is BPD treated? No medication has been approved for the treatment of BPD. Nonetheless, a large proportion of people with BPD are given medications for sustained periods of time to alleviate their symptoms. The type of medication given is chosen based on its known effects on other disorders with similar symptoms. Review question We wanted to find out whether medications to treat BPD work better or worse than placebo; whether one medication works better than another; or whether one combination of medications work better than another combination of medications. We wanted to look at how well medications worked on BPD severity, self‐harm, suicide‐related outcomes, and functioning (how well a person performs in everyday life). We also wanted to find out if medications are associated with any unwanted side effects. What did we do? We searched for studies that compared the effects of different medications with placebo, another medication, or a combination of medications, in people diagnosed with BPD. We compared and summarised the results and rated our confidence in the evidence based on factors such as sample size and methods used. Below, we present the findings from our key comparison: medication versus placebo. What did we find? We found 46 studies that involved 2769 people with BPD. The smallest study had 13 participants and the largest 451 participants. There were four studies with more than 100 participants. Except for one study that included men only, all studies included women. The average age of the participants ranged from 16 years to 39 years. Most studies were conducted in outpatient settings (31 studies) in Europe (20 studies) and lasted between four and 52 weeks. Pharmaceutical companies fully or partially funded 16 studies. The studies looked at the effects of 27 different medications, mostly classified as: 1) antipsychotics (drugs to treat psychosis where a person’s thoughts and mood are so impaired that the person has lost contact with reality); 2) antidepressants (drugs to treat depression); or 3) mood stabilisers (drugs to control and even out mood swings, reducing both high moods (mania) and low moods (depression)). Compared with placebo, medications seem to make little to no difference to BPD severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. They may make little to no difference as to whether a person continues in a study or drops out. Compared to placebo, antipsychotics and mood stabilisers may make little to no difference to the occurrence of unwanted or harmful effects. No study reported on the side effects of antidepressants. What are the limitations of the evidence? Our confidence in the evidence varied between very low and low. The results of future research could differ from the results of this review. Four main factors reduced our confidence in the evidence. First, not all of the studies provided data about everything that we were interested in. Second, the results were very inconsistent across the different studies. Third, there were not enough studies to be certain about the results of our outcomes. Fourth, many studies did not clearly report how they were conducted. How up‐to‐date is this evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Stoffers-Winterling, JM; Storebø, OJ; Pereira Ribeiro, J; Kongerslev, MT; Völlm, BA; Mattivi, JT; Faltinsen, E; Todorovac, A; Jørgensen, MS; Callesen, HE; Sales, CP; Schaug, JP; Simonsen, E; Lieb, K", "articleTypes": [], "doi": "10.1002/14651858.CD012956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "5d210388-a4ff-4a10-bd57-0db641dd55fc", "pmid": "", "title": "Progestin‐only pills for contraception", "imported": false, "abstract": "Abstract - Background The introduction of a new progestin‐only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. Objectives This review examined randomized controlled trials of progestin‐only pills for differences in efficacy, acceptability, and continuation rates. Search methods Through October 2013, we searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, and LILACS for studies of progestin‐only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. Selection criteria We included all randomized controlled trials in any language that included progestin‐only pills for contraception. We incorporated any comparison with a progestin‐only pill; this could include different doses, other progestin‐only pills, combined oral contraceptives, or other contraceptives. Data collection and analysis The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry. We attempted to extract life‐table rates (actuarial or continuous) and used the rate difference as the effect measure. Where life‐table rates were not published, we used the incidence rate ratio (ratio of Pearl rates). Where only the crude number of events was published, we calculated the Peto odds ratio with 95% confidence interval (CI) using a fixed‐effect model. For continuous variables, the mean difference (MD) was computed with 95% CI. Because of disparate exposures, we were not able to combine studies in meta‐analysis. Main results Six trials met the inclusion criteria. We have not found any new studies since the initial review. In the trial comparing the desogestrel versus levonorgestrel progestin‐only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin‐only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low‐dose mifepristone versus a levonorgestrel progestin‐only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin‐only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin‐only and two combined oral contraceptives, the progestin‐only pill containing levonorgestrel 30 μg had higher efficacy than did the pill containing norethisterone 350 μg. An early trial found megestrol acetate inferior to other progestin‐only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. Authors' conclusions Evidence is insufficient to compare progestin‐only pills to each other or to combined oral contraceptives. Plain language summary Progestin‐only pills for contraception Progestin‐only pills, as their name implies, contain just one hormone. The more common birth control pills combine two hormones. How these one‐hormone pills compare to each other or to two‐hormone pills is not clear. Hence, we did this review to compare progestin‐only pills to other similar pills or to combined (two‐hormone) pills. Through October 2013, we did a computer search and literature search to find randomized trials of progestin‐only pills. We found six trials for the initial review. We have not found any more studies since then. Some studies are several decades old and not very relevant to pills available today. A newer pill containing the progestin desogestrel may work better to prevent pregnancy than an older pill with levonorgestrel. The newer pill caused more bleeding problems. Pills with levonorgestrel may be more effective than pills with other progestins that are no longer used. These studies are not adequate to tell how progestin‐only pills compare to each other or to combined (two‐hormone) pills. Larger studies with currently used pills are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grimes, DA; Lopez, LM; O'Brien, PA; Raymond, EG", "articleTypes": [], "doi": "10.1002/14651858.CD007541.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "5d229db4-1524-4ae2-a3e2-b581d53cb8af", "pmid": "", "title": "Roselle for hypertension in adults", "imported": false, "abstract": "Abstract - Background Hypertension is considered to be a serious health problem worldwide. Controlling and lowering blood pressure are of significant benefit to people with hypertension because hypertension is a risk factor for stroke, heart disease, and cardiovascular disease. Roselle, the tropical plant Hibiscus sabdariffa , also commonly called sour tea or red tea, has been used as both a thirst‐quenching drink and for medicinal purposes. Objectives To assess the effect of Roselle on blood pressure in people with primary hypertension. Search methods For this update, the Cochrane Hypertension Information Specialist searched the following databases and trials registers for randomised controlled trials (RCTs): the Cochrane Hypertension Specialised Register (to 6 August 2021), Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), MEDLINE Ovid (1946 to 5 August 2021), Embase Ovid (1974 to 5 August 2021), ProQuest Dissertations & Theses (to 6 August 2021), Web of Science Clarivate (to 7 August 2021), Food Science and Technology Abstracts Clarivate (to 7 August 2021), the WHO International Clinical Trials Registry Platform (to 6 August 2021), and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (to 6 August 2021). We searched Google Scholar and OpenSIGLE. We also handsearched local and regional Chinese databases: CBM, CMCC, TCMLARS, CNKI, CMAC, and the Index to Chinese Periodical Literature (to 14 September 2020), as well as Thai databases (ThaiJO, CUIR, TDC, CMU e‐Theses, TCTR) (to 3 October 2020). There were no language or publication date restrictions. Selection criteria We sought RCTs evaluating the use of any forms of Roselle with placebo or no treatment in adults with hypertension. Our primary outcome was change in trough and/or peak systolic and diastolic blood pressure (SBP, DBP). Secondary outcomes were withdrawals due to adverse effects, change in pulse pressure, and change in heart rate. Data collection and analysis All search results were managed using Covidence and re‐checked for the number of records, inclusion and exclusion of studies with Mendeley reference management software. We used standard methodological procedures expected by Cochrane. Two review authors worked independently in parallel for screening (titles and abstracts, and full reports), data extraction, risk of bias assessment, and assessment of the certainty of the evidence using the GRADE approach. Any disagreements were resolved by discussion or by consultation with the third review author if necessary. We presented mean difference (MD) of change in SBP and DBP with their corresponding 95% confidence interval (CI). Main results For this update, only one RCT with a parallel‐group design involving 60 participants with type 2 diabetes mellitus fulfilled the inclusion criteria. This study investigated the effect of Roselle extract capsules (total dose of 5600 mg) compared with placebo (lactose) at eight weeks. The study was at low risk of selection bias, performance bias, and detection bias. Conversely, it was at high risk of attrition bias, reporting bias, and other bias (baseline imbalance). We have very little confidence in the effect estimate of Roselle on change‐from‐baseline in both SBP and DBP between the two groups. The MD of change in SBP was 1.65, 95% CI −7.89 to 11.19 mmHg, 52 participants, very low‐certainty evidence. The MD of change in DBP was 4.60, 95% CI −1.38 to 10.58 mmHg, 52 participants, very low‐certainty evidence. Our secondary outcomes of withdrawals due to adverse effects, change in pulse pressure, and change in heart rate were not reported. Due to the limited available data, no secondary analyses were performed (subgroup and sensitivity analysis). Authors' conclusions The evidence is currently insufficient to determine the effectiveness of Roselle compared to placebo for controlling or lowering blood pressure in people with hypertension. The certainty of evidence was very low due to methodological limitations, imprecision, and indirectness. There is a need for rigorous RCTs that address the review question. Plain language summary Red tea (Roselle) for lowering blood pressure in adults Key messages: We don't know if taking Roselle lowers blood pressure in people with hypertension (high blood pressure). We don’t know if Roselle is safe for people with hypertension to consume or if it affects heart rate or pulse pressure. What did we want to find out? We wanted to know if red tea (Roselle) is a safe and effective treatment for lowering blood pressure in adults with high blood pressure when compared to placebo (dummy treatment) or no treatment. Roselle contains substances known as anthocyanins which have been shown to have lowered blood pressure in studies carried out in animals and humans. What did we do? We searched for studies that compared Roselle to placebo or no treatment in people with hypertension. What did we find? We included one study with 60 participants with type 2 diabetes and hypertension. Participants consumed either a capsule of pure Roselle extract or a placebo containing lactose for eight weeks. We are not sure if Roselle has an effect on blood pressure and the study did not report on the safety of Roselle or on changes to heart rate. What are the main limitations of the evidence? We found only one trial which included a small number of participants, all of whom had diabetes. More studies with various types of participants and different ways of taking Roselle (forms, amounts, and time of day, length of use) are needed. How up to date is the evidence? The review updates our previous review. We searched for randomised controlled trials (studies in which participants are randomly assigned to one of two or more treatment groups) in core databases up to August 2021, and searched local and regional Chinese and Thai databases by hand up to October 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Pattanittum, P; Ngamjarus, C; Buttramee, F; Somboonporn, C", "articleTypes": [], "doi": "10.1002/14651858.CD007894.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "5d332d27-fc68-480b-8594-3f259162970c", "pmid": "", "title": "Interventions for fatigue in people with kidney failure requiring dialysis", "imported": false, "abstract": "Abstract - Background Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD). Objectives We aimed to evaluate the effects of pharmacological and non‐pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Studies evaluating pharmacological and non‐pharmacological interventions affecting levels of fatigue or fatigue‐related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue‐related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered. Data collection and analysis Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta‐analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Ninety‐four studies involving 8191 randomised participants were eligible. Pharmacological and non‐pharmacological interventions were compared either to placebo or control, or to another pharmacological or non‐pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis‐Related Fatigue scale score): SMD ‐1.18, 95% CI ‐2.04 to ‐0.31; I 2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD ‐1.23, 95% CI ‐1.96 to ‐0.50; I 2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD ‐1.06, 95% CI ‐1.47, ‐0.65; I 2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I 2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD ‐0.64, 95% CI ‐1.03 to ‐0.25; I 2 = 75%) in HD. A wide range of heterogenous interventions and fatigue‐related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non‐pharmacological interventions on fatigue or fatigue‐related outcomes, including non‐physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive‐behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta‐blockers, anabolic steroids, glucose‐enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non‐pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported. Authors' conclusions Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non‐pharmacological interventions had uncertain effects on fatigue or fatigue‐related outcomes in people receiving dialysis. Future adequately powered, high‐quality studies are likely to change the estimated effects of interventions for fatigue and fatigue‐related outcomes in people receiving dialysis. Plain language summary Are interventions for fatigue effective among people with kidney failure requiring dialysis? What is the issue? Fatigue is a frequent and debilitating symptom that can limit life participation in people receiving dialysis. Fatigue is linked to impaired quality of life, cardiovascular disease, death and depression in people on dialysis. Several potential interventions, including drugs or other non‐pharmacological treatments (e.g. exercise, diet, massage, aromatherapy, acupressure), have been evaluated for their effect on fatigue in people on dialysis. What did we do? We evaluated whether drugs or other non‐pharmacological interventions are beneficial for adults and children receiving haemodialysis or peritoneal dialysis to manage fatigue. We evaluated all clinical studies available and summarised the results. We evaluated how certain we could be about the evidence related to interventions for fatigue using a system called \"GRADE\". What did we find? Ninety‐four studies involving 8191 randomised participants were available. Patients in the studies were given a drug, non‐pharmacological intervention, standard care or a sugar pill (placebo). The treatment they received was decided by random chance. The studies were generally short‐term (over a few months). There were no studies in children. Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. Drugs or other non‐pharmacological interventions have uncertain effects on fatigue in people on dialysis. Conclusions Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. It remains uncertain whether drugs or other non‐pharmacological interventions have any impact on fatigue in people on dialysis when compared to a sugar pill, standard care or other treatments for fatigue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Natale, P, Ju, A, Strippoli, GFM, Craig, JC, Saglimbene, VM, Unruh, ML, Stallone, G, Jaure, A", "articleTypes": [], "doi": "10.1002/14651858.CD013074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.118Z" }, { "id": "5d57188a-2035-4d6a-9e56-9851e4ca7eec", "pmid": "", "title": "Interventions for the cessation of non‐nutritive sucking habits in children", "imported": false, "abstract": "Abstract - Background Comforting behaviours, such as the use of pacifiers (dummies, soothers), blankets and finger or thumb sucking, are common in babies and young children. These comforting habits, which can be referred to collectively as 'non‐nutritive sucking habits' (NNSHs), tend to stop as children get older, under their own impetus or with support from parents and carers. However, if the habit continues whilst the permanent dentition is becoming established, it can contribute to, or cause, development of a malocclusion (abnormal bite). A diverse variety of approaches has been used to help children with stopping a NNSH. These include advice, removal of the comforting object, fitting an orthodontic appliance to interfere with the habit, application of an aversive taste to the digit or behaviour modification techniques. Some of these interventions are easier to apply than others and less disturbing for the child and their parent; some are more applicable to a particular type of habit. Objectives The primary objective of the review was to evaluate the effects of different interventions for cessation of NNSHs in children. The secondary objectives were to determine which interventions work most quickly and are the most effective in terms of child and parent‐ or carer‐centred outcomes of least discomfort and psychological distress from the intervention, as well as the dental measures of malocclusion (reduction in anterior open bite, overjet and correction of posterior crossbite) and cost‐effectiveness. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 8 October 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 9), MEDLINE via OVID (1946 to 8 October 2014), EMBASE via OVID (1980 to 8 October 2014), PsycINFO via OVID (1980 to 8 October 2014) and CINAHL via EBSCO (1937 to 8 October 2014), the US National Institutes of Health Trials Register (Clinical Trials.gov) (to 8 October 2014) and the WHO International Clinical Trials Registry Platform (to 8 October 2014). There were no restrictions regarding language or date of publication in the searches of the electronic databases. We screened reference lists from relevant articles and contacted authors of eligible studies for further information where necessary. Selection criteria Randomised or quasi‐randomised controlled trials in children with a non‐nutritive sucking habit that compared one intervention with another intervention or a no‐intervention control group. The primary outcome of interest was cessation of the habit. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Three review authors were involved in screening the records identified; two undertook data extraction, two assessed risk of bias and two assessed overall quality of the evidence base. Most of the data could not be combined and only one meta‐analysis could be carried out. Main results We included six trials, which recruited 252 children (aged 2 and a half to 18 years), but presented follow‐up data on only 246 children. Digit sucking was the only NNSH assessed in the studies. Five studies compared single or multiple interventions with a no‐intervention or waiting list control group and one study made a head‐to‐head comparison. All the studies were at high risk of bias due to major limitations in methodology and reporting. There were small numbers of participants in the studies (20 to 38 participants per study) and follow‐up times ranged from 1 to 36 months. Short‐term outcomes were observed under one year post‐intervention and long‐term outcomes were observed at one year or more post‐intervention. Orthodontics appliance (with or without psychological intervention) versus no treatment Two trials that assessed this comparison evaluated our primary outcome of cessation of habit. One of the trials evaluated palatal crib and one used a mix of palatal cribs and arches. Both trials were at high risk of bias. The orthodontic appliance was more likely to stop digit sucking than no treatment, whether it was used over the short term (risk ratio (RR) 6.53, 95% confidence interval (CI) 1.67 to 25.53; 2 trials, 70 participants) or long term (RR 5.81, 95% CI 1.49 to 22.66; 1 trial, 37 participants) or used in combination with a psychological intervention (RR 6.36, 95% CI 0.97 to 41.96; 1 trial, 32 participants). Psychological intervention versus no treatment Two trials (78 participants) at high risk of bias evaluated positive reinforcement (alone or in combination with gaining the child's co‐operation) or negative reinforcement compared with no treatment. Pooling of data showed a statistically significant difference in favour of the psychological interventions in the short term (RR 6.16, 95% CI 1.18 to 32.10; I 2 = 0%). One study, with data from 57 participants, reported on the long‐term effect of positive and negative reinforcement on sucking cessation and found a statistically significant difference in favour of the psychological interventions (RR 6.25, 95% CI 1.65 to 23.65). Head‐to‐head comparisons Only one trial demonstrated a clear difference in effectiveness between different active interventions. This trial, which had only 22 participants, found a higher likelihood of cessation of habit with palatal crib than palatal arch (RR 0.13, 95% CI 0.03 to 0.59). Authors' conclusions This review found low‐quality evidence that orthodontic appliances (palatal arch and palatal crib) and psychological interventions (including positive and negative reinforcement) are effective at improving sucking cessation in children. There is very low‐quality evidence that palatal crib is more effective than palatal arch. This review has highlighted the need for high‐quality trials evaluating interventions to stop non‐nutritive sucking habits to be conducted and the need for a consolidated, standardised approach to reporting outcomes in these trials. Plain language summary Interventions for stopping dummy or finger or thumb sucking habits in children Review question This review has been produced to assess the effects of interventions to stop sucking habits in children, which are not linked to food. Important considerations are: which treatment or combination of treatments work most effectively, when should treatment be started, what is the optimum length of time for the intervention and what causes least upset to children and their parents? Background Often babies and children develop a habit of sucking objects to comfort and calm them. They frequently suck dummies (known as pacifiers in the USA), fingers, thumbs or other items like blankets. Eventually, most children grow out of the habit, or stop due to encouragement from their parents. Some children, however, continue sucking as a habit. If they continue to do so as their adult teeth start to grow through (around the age of six), there is a risk that these adult teeth will grow into the wrong position causing them to stick out too far or not meet properly when biting. As a result these children often need dental treatment to fix the problems caused by their sucking habit. Possible treatments to help children break their sucking habits examined in studies in this review include the use of two different braces in the mouth; giving advice and incentives for changing behaviour (known as psychological advice/treatment); applying a bitter, nasty tasting substance to the children’s thumbs/fingers or combinations of these treatments. None of the studies included looked at barrier methods, for example the use of gloves or plasters or withdrawal of dummies. Study characteristics Review authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 8 October 2014. The review includes six studies published from 1967 to 1997, which involved 252 children as participants (although data were supplied on only 246 of the children). Three of the studies were carried out in the USA, one in Canada, one in Sweden and one in Australia. Not all of the studies gave the ages of children involved; in four of the studies children were aged from two and a half to 18 years old, in one study they were aged four years and over and in another nine years and over. Results Use of an orthodontic brace (such as a palatal crib or arch) or a psychological intervention (such as use of positive or negative reinforcement), or both, was more likely to lead to cessation of the habit than no treatment. Most of the trials that compared two different interventions were inconclusive but one study suggested that, of two different types of braces,a palatal crib is more effective than a palatal arch design. Quality of the evidence The evidence presented is of low quality due to the small number of participants in the few available studies and problems with the way in which the studies were conducted. There was a high risk of bias across the studies. Conclusion Orthodontic braces or psychological intervention seems to be effective to help children stop sucking that does not have a feeding purpose but the evidence is low quality. Further high quality clinical trials are required to guide decision making for what is a common problem that can require lengthy and expensive dental treatment to correct.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Borrie, FRP; Bearn, DR; Innes, NPT; Iheozor-Ejiofor, Z", "articleTypes": [], "doi": "10.1002/14651858.CD008694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "5d5dc85b-173d-48a0-b1b0-4d29b2d144e3", "pmid": "", "title": "Optimum duration of regimens for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background The optimal duration for Helicobacter pylori (H. pylori) eradication therapy is controversial, with recommendations ranging from 7 to 14 days. Several systematic reviews have attempted to address this issue but have given conflicting results and limited their analysis to proton pump inhibitor (PPI), two antibiotics (PPI triple) therapy. We performed a systematic review and meta‐analysis to investigate the optimal duration of multiple H. pylori eradication regimens. Objectives The primary objective was to assess the relative effectiveness of different durations (7, 10 or 14 days) of a variety of regimens for eradicating H. pylori . The primary outcome was H. pylori persistence. The secondary outcome was adverse events. Search methods The Cochrane Library , MEDLINE, EMBASE, and CINAHL were searched up to December 2011 to identify eligible randomised controlled trials (RCTs). We also searched the proceedings of six conferences from 1995 to 2011, dissertations and theses, and grey literature. There were no language restrictions applied to any search. Selection criteria Only parallel group RCTs assessing the efficacy of one to two weeks duration of first line H. pylori eradication regimens in adults were eligible. Within each regimen, the same combinations of drugs at the same dose were compared over different durations. Studies with at least two arms comparing 7, 10, or 14 days were eligible. Enrolled participants needed to be diagnosed with at least one positive test for H. pylori on the basis of a rapid urease test (RUT), histology, culture, urea breath test (UBT), or a stool antigen test (HpSA) before treatment. Eligible trials needed to confirm eradication of H. pylori as their primary outcome at least 28 days after completion of eradication treatment. Trials using only serology or a polymerase chain reaction (PCR) to determine H. pylori infection or eradication were excluded. Data collection and analysis Study eligibility and data extraction were performed by two independent review authors. Data analyses were performed within each type of intervention, for both primary and secondary outcomes. The relative risk (RR) and number needed to treat (NNT)/number needed to harm (NNTH) according to duration of therapy were calculated using the outcomes of H. pylori persistence and adverse events. A random‐effects model was used. Subgroup analyses and sensitivity analyses were planned a priori. Main results In total, 75 studies met the inclusion criteria. Eight types of regimens were reported with at least two comparative eligible durations. They included: PPI + two antibiotics triple therapy (n = 59), PPI bismuth‐based quadruple therapy (n = 6), PPI + three antibiotics quadruple therapy (n = 1), PPI dual therapy (n = 2), histamine H 2 ‐receptor antagonist (H 2 RA) bismuth quadruple therapy (n = 3), H 2 RA bismuth‐based triple therapy (n = 2), H 2 RA + two antibiotics triple therapy (n = 3), and bismuth + two antibiotics triple therapy (n = 2). Some studies provided data for more than one regimen or more than two durations. For the PPI triple therapy, 59 studies with five regimens were reported: PPI + clarithromycin + amoxicillin (PCA); PPI + clarithromycin + a nitroimidazole (PCN); PPI + amoxicillin + nitroimidazole (PAN); PPI + amoxicillin + a quinolone (PAQ); and PPI + amoxicillin + a nitrofuran (PANi). Regardless of type and dose of antibiotics, increased duration of PPI triple therapy from 7 to 14 days significantly increased the H. pylor i eradication rate (45 studies, 72.9% versus 81.9%), the RR for H. pylori persistence was 0.66 (95% CI 0.60 to 0.74), NNT was 11 (95% CI 9 to 14). Significant effects were seen in the subgroup of PCA (34 studies, RR 0.65, 95% CI 0.57 to 0.75; NNT 12, 95% CI 9 to 16); PAN (10 studies, RR 0.67, 95% CI 0.52 to 0.86; NNT = 11, 95% CI 8 to 25); and in PAQ (2 studies, RR 0.37, 95% CI 0.16 to 0.83; NNT 3, 95% CI 2 to 10); but not in PCN triple therapy (4 studies, RR 0.87, 95% CI 0.71 to 1.07). Significantly increased eradication rates were also seen for PPI triple therapy with 10 versus 7 days (24 studies, 79.9% versus 75.7%; RR 0.80, 95% CI 0.72 to 0.89; NNT 21, 95% CI 15 to 38) and 14 versus 10 days (12 studies, 84.4% versus 78.5%; RR 0.72, 95% CI 0.58 to 0.90; NNT 17, 95% CI 11 to 46); especially in the subgroup of PAC for 10 versus 7 days (17 studies, RR 0.80, 95% CI 0.70 to 0.91) and for 14 versus 10 days (10 studies, RR 0.69, 95% CI 0.52 to 0.91). A trend towards increased H. pylori eradication rates was seen with increased duration of PCN for 10 versus 7 days, and of PAN for 10 versus 7 days and 14 versus 10 days, though this was not statistical significant. The proportion of patients with adverse events, defined by authors, was marginally significantly increased only between 7 days and 14 days (15.5% versus 19.4%; RR 1.21, 95% CI 1.06 to 1.37; NNTH 31, 95% CI 18 to 104) but not for other duration comparisons. The proportion of patients discontinuing treatment due to adverse events was not significantly different between treatment durations. Only limited data were reported for different durations of regimens other than PPI triple therapy. No significant difference of the eradication rate was seen for all regimens according to different durations except for H 2 RA bismuth quadruple therapy, where a significantly higher eradication rate was seen for 14 days versus 7 days, however only one study reported outcome data. Authors' conclusions Increasing the duration of PPI‐based triple therapy increases H. pylori eradication rates. For PCA, prolonging treatment duration from 7 to 10 or from 10 to 14 days is associated with a significantly higher eradication rate. The optimal duration of therapy for PCA and PAN is at least 14 days. More data are needed to confirm if there is any benefit of increasing the duration of therapy for PCN therapy. Information is limited for regimens other than PPI triple therapy; more studies are needed to draw meaningful conclusions for optimal duration of other H. pylori eradication regimens. Plain language summary Ideal length of treatment for Helicobacter pylori ( H. pylori ) eradication The ideal duration of therapy for H. pylori eradication is controversial, with recommendations ranging from 7 to 14 days. A proton pump inhibitor (PPI) plus two antibiotics is the most commonly used first treatment to remove H. pylori infection. Current data suggest that increasing the length of treatment to 14 days of a PPI plus amoxicillin and clarithromycin or amoxicillin and a nitroimidazole significantly increases the eradication rate, while increasing the adverse events by a small amount. Based on the overall evidence, the ideal length of treatment with a PPI plus amoxicillin and clarithromycin is at least 14 days.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Yuan, Y; Ford, AC; Khan, KJ; Gisbert, JP; Forman, D; Leontiadis, GI; Tse, F; Calvet, X; Fallone, C; Fischbach, L; Oderda, G; Bazzoli, F; Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD008337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "5d616027-e0b6-4cce-b80c-d1440b27447b", "pmid": "", "title": "Momordica charantia for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Momordica charantia (bitter gourd) is not only a nutritious vegetable but it is also used in traditional medical practices to treat type 2 diabetes mellitus. Experimental studies with animals and humans suggested that the vegetable has a possible role in glycaemic control. Objectives To assess the effects of mormodica charantia for type 2 diabetes mellitus. Search methods Several electronic databases were searched, among these were The Cochrane Library (Issue 1, 2012), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2012), combined with handsearches. No language restriction was used. Selection criteria We included randomised controlled trials (RCTs) that compared momordica charantia with placebo or a control intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently extracted data. Risk of bias of the trials was evaluated using the parameters of randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. A meta‐analysis was not performed given the quality of data and the variability of preparations of momordica charantia used in the interventions (no similar preparation was tested twice). Main results Four randomised controlled trials with up to three months duration and investigating 479 participants met the inclusion criteria. Risk of bias of these trials (only two studies were published as a full peer‐reviewed publication) was generally high. Two RCTs compared the effects of preparations from different parts of the momordica charantia plant with placebo on glycaemic control in type 2 diabetes mellitus. There was no statistically significant difference in the glycaemic control with momordica charantia preparations compared to placebo. When momordica charantia was compared to metformin or glibenclamide, there was also no significant change in reliable parameters of glycaemic control. No serious adverse effects were reported in any trial. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions There is insufficient evidence on the effects of momordica charantia for type 2 diabetes mellitus. Further studies are therefore required to address the issues of standardization and the quality control of preparations. For medical nutritional therapy, further observational trials evaluating the effects of momordica charantia are needed before RCTs are established to guide any recommendations in clinical practice. Plain language summary Momordica charantia for type 2 diabetes mellitus Mormordica charantia (bitter gourd or bitter melon) is a climbing perennial that is characterized by elongated, warty fruit‐like gourds or cucumbers and is native to the tropical belt. Although momordica charantia is commonly used in traditional medical practices, along with research suggesting its benefits for people with type 2 diabetes, the current evidence does not warrant using the plant in treating this disease. This review of trials found only four studies which had an overall low quality. Three trials showed no significant differences between momordica charantia and placebo or antidiabetic drugs (glibenclamide and metformin) in the blood sugar response. The duration of treatment ranged from four weeks to three months, and altogether 479 patients with type 2 diabetes mellitus participated. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Adverse effects were mostly moderate, including diarrhoea and abdominal pain. However, reporting of adverse effects was incomplete in the included studies. There are many varieties of preparations of momordica charantia, as well as variations in its use as a vegetable. Further studies are needed to assess the quality of the various momordica charantia preparations as well as to further evaluate its use in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Ooi, CP; Yassin, Z; Hamid, TA", "articleTypes": [], "doi": "10.1002/14651858.CD007845.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "5d7eb42a-a39c-4f7f-8751-ce514ae91fb5", "pmid": "", "title": "COVID-19: Why Are Children Less Affected", "imported": false, "abstract": "Observational Study of Infants Fed on DHA (Breast Source or Milk Formula Source ) and Its Effect on COVID-19 Severity", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.159Z" }, { "id": "5d8031f3-5148-4780-89fb-8d469a36cb3e", "pmid": "", "title": "Corticosteroids for idiopathic pulmonary fibrosis", "imported": false, "abstract": "Abstract - Background Idiopathic pulmonary fibrosis (IPF) is a disease with significant morbidity and mortality. Patients short survival time, high mortality and generally rapid decline raise the importance of early treatment. Current guidelines suggest a combination of corticosteroids and immunosuppressants as \"gold standard\" for IPF treatment, although the evidence for this recommendation is weak. Based on animal models, it has been hypothesized a central role for aberrant wound healing following repeated epithelial lung injury, weakening the rationale for using corticosteroids in IPF, previously thought to be a chronic inflammatory disease. Objectives The aim of the review is to determine the efficacy of corticosteroids in the treatment of adults with familial and sporadic IPF. Search methods We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2008), MEDLINE (January 1966 to June 2008) and EMBASE (January 1985 to June 2008) and reference lists of articles. We searched reference lists of published articles to identify clinical trials. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) using corticosteroids alone for the treatment of adults with IPF. Data collection and analysis Abstracts of identified articles were retrieved and articles possibly fulfilling inclusion criteria were retrieved in full. Two reviewers would have independently assessed trial quality if there had been any included study. Main results Seventeen articles were selected as potentially eligible for meta‐analysis. After further analysis of full text papers, no RCTs or CCTs were identified as suitable and therefore no data was available for inclusion in any meta‐analysis. All studies were excluded due to inadequate methodologies. Authors' conclusions At present, there is no evidence for an effect of corticosteroid treatment in patients with IPF. On the other hand, other fibrotic lung diseases, such as non‐specific interstitial pneumonia (NSIP), are reported to show a better response to corticosteroids. Making a clear distinction between IPF and other entities grouped under the umbrella term interstitial lung disease is, therefore, essential as this may have therapeutic and prognostic implications. Plain language summary Currently there is no evidence to support the routine use of corticosteroids alone in the management of idiopathic pulmonary fibrosis. Idiopathic pulmonary fibrosis (IPF) is a chronic disorder of unknown cause that is progressive and leads to death. Existing evidence about the treatment of IPF is difficult to interpret because of evolving diagnostic criteria and classification schemes, grouping together diverse entities with markedly different natural histories and responses to therapy. Therefore, because the old studies did not include only IPF patients, their results cannot be extended to IPF as they are currently defined. In addition, methodologic problems mainly related to the lack of randomized placebo‐controlled treatment trials have made evidence‐based conclusions difficult. A systematic search for high quality placebo‐controlled randomised trials comparing corticosteroid treatment with placebo in subjects with a diagnosis of IPF was unable to identify any studies suitable for inclusion in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Richeldi, L, Davies, HRHR, Spagnolo, P, Luppi, F", "articleTypes": [], "doi": "10.1002/14651858.CD002880", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.093Z" }, { "id": "5d987aa3-2308-4862-9693-d155ebb6ea41", "pmid": "", "title": "Pimozide for schizophrenia or related psychoses", "imported": false, "abstract": "Abstract - Background Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been associated with cardiotoxicity and sudden unexplained death. Electrocardiogram monitoring is now required before and during use. Objectives To review the effects of pimozide for people with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medication. A secondary objective was to examine the effects of pimozide for people with delusional disorder. Search methods We searched the Cochrane Schizophrenia Group's Register (28 January 2013). Selection criteria We sought all relevant randomised clinical trials (RCTs) comparing pimozide with other treatments. Data collection and analysis Working independently, we inspected citations, ordered papers and then re‐inspected and assessed the quality of the studies and of extracted data. For homogeneous dichotomous data, we calculated the relative risk (RR), the 95% confidence interval (CI) and mean differences (MDs) for continuous data. We excluded data if loss to follow‐up was greater than 50%. We assessed risk of bias for included studies and used GRADE to rate the quality of the evidence. Main results We included 32 studies in total: Among the five studies that compared pimozide versus placebo, only one study provided data for global state relapse, for which no difference between groups was noted at medium term (1 RCT n = 20, RR 0.22 CI 0.03 to 1.78, very low quality of evidence ). None of the five studies provided data for no improvement or first‐rank symptoms in mental state. Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (1 RCT, n = 19, RR 5.50 CI 0.30 to 101.28, very low quality of evidence ) or at medium term (1 RCT n = 25, RR 1.33 CI 0.14 to 12.82, very low quality of evidence ), or for Parkinsonism (tremor) at medium term (1 RCT n = 25, RR 1 CI 0.2 to 4.95, very low quality of evidence ). No data were reported for quality of life at medium term. Of the 26 studies comparing pimozide versus any antipsychotic, seven studies provided data for global state relapse at medium term, for which no difference was noted (7 RCTs n = 227, RR 0.82 CI 0.57 to 1.17, moderate quality of evidence ). Data from one study demonstrated no difference in mental state (no improvement) at medium term (1 RCT n = 23, RR 1.09 CI 0.08 to 15.41, very low quality evidence ); another study demonstrated no difference in the presence of first‐rank symptoms at medium term (1 RCT n = 44, RR 0.53 CI 0.25 to 1.11, low quality of evidence ). Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (6 RCTs n = 186, RR 1.21 CI 0.71 to 2.05, low quality of evidence ) or medium term (5 RCTs n = 219, RR 1.12 CI 0.24 to 5.25, low quality of evidence ), or for Parkinsonism (tremor) at medium term (4 RCTs n = 174, RR 1.46 CI 0.68 to 3.11, very low quality of evidence ). No data were reported for quality of life at medium term. In the one study that compared pimozide plus any antipsychotic versus the same antipsychotic, significantly fewer relapses were noted in the augmented pimozide group at medium term (1 RCT n = 69, RR 0.28 CI 0.15 to 0.50, low quality evidence ). No data were reported for mental state outcomes or for extrapyramidal symptoms (EPS). Data were skewed for quality of life scores, which were not included in the meta‐analysis but were presented separately. Two studies compared pimozide plus any antipsychotics versus antipsychotic plus placebo; neither study reported data for outcomes of interest, apart from Parkinsonism at medium term and quality of life using the Specific Level of Functioning scale (SLOF); however, data were skewed. Only one study compared pimozide plus any antipsychotic versus antipsychotics plus antipsychotic; no data were reported for global state and mental state outcomes of interest. Data were provided for Parkinsonism (rigidity and tremor) using the Extrapyramidal Symptom Rating Scale (ESRS); however, these data were skewed. Authors' conclusions Although shortcomings in the data are evident, enough overall consistency over different outcomes and time scales is present to confirm that pimozide is a drug with efficacy similar to that of other, more commonly used antipsychotic drugs such as chlorpromazine for people with schizophrenia. No data support or refute its use for those with delusional disorder. Plain language summary Pimozide for schizophrenia or related psychoses People with schizophrenia have ‘positive symptoms’ such as hearing voices and seeing things (hallucinations) and fixed strange beliefs (delusions). People with schizophrenia also have ‘negative symptoms’ such as tiredness, apathy and loss of emotion. Antipsychotic drugs are the main treatment for the symptoms of schizophrenia and can be grouped into older drugs (first generation or ‘typical’) and newer drugs (second generation or ‘atypical’). Pimozide is a ‘typical’ antipsychotic drug that was first introduced in the late 1960s and was given to people with schizophrenia. Pimozide is thought to be effective in treating the positive and negative symptoms of schizophrenia or similar mental health problems such as delusional disorder, but it produces serious side effects such as muscle stiffness, tremors and slow body movements. Pimozide may also cause heart problems and has been linked to sudden unexplained death. Monitoring the heart via electrocardiogram is now required before and during treatment with pimozide. It is well known that people with mental health problems suffer from physical illnesses such as heart disease and diabetes and can die on average twenty years younger than those in the general population.
 An update search for this review was carried out 28 January 2013; the review now includes 32 studies that assess the effects of pimozide for people with schizophrenia or similar mental health problems. Pimozide was compared with other antipsychotic drugs, placebo (‘dummy’ treatment) or no treatment. Results suggest that pimozide is probably just as effective as other commonly used ‘typical’ antipsychotic drugs (for outcomes such as treating mental state, relapse, leaving the study early). No studies included delusional disorders, so no information is available on this group of people. No evidence was found to support the concern that pimozide causes heart problems (although this may be result of the fact that the studies were small and short term and the participants did not receive doses above recommended limits of 20 mg/d). Pimozide may cause less sleepiness than other typical antipsychotic drugs, but it may cause more tremors and uncontrollable shaking. The claim that pimozide is useful for treating people with negative symptoms also is not supported and proven. However, the quality of evidence in the main was low or very low quality, studies were small and of short duration and were poorly reported. Large‐scale, well‐conducted and well‐reported studies are required to assess the effectiveness of pimozide in the treatment of schizophrenia and other mental health problems such as delusional disorder. This plain language summary has been written by a consumer, Benjamin Gray (Service User and Service User Expert, Rethink Mental Illness).", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Mothi, M; Sampson, S", "articleTypes": [], "doi": "10.1002/14651858.CD001949.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "5d9a3e18-e81a-47ad-93ce-161866fdbdc5", "pmid": "", "title": "Oral nutritional interventions in hospitalised older people at nutritional risk: a network meta‐analysis of individual participant data", "imported": false, "abstract": "Abstract - Rationale Malnutrition affects 35% to 64% of hospitalised older people, and is associated with adverse health outcomes such as disease complications and hospital readmission. Identifying effective nutritional interventions is essential to improve clinical outcomes and reduce healthcare costs in this population. Objectives To evaluate the effects of various nutritional interventions, compared with either a control group (standard care or placebo) or each other, on patient‐relevant outcomes in hospitalised older people at risk of or with established malnutrition, and to rank the effects of these different interventions using network meta‐analysis (NMA) based on individual participant data (IPD). Search methods We searched CENTRAL, MEDLINE, five other databases, and two trial registries to 2 July 2024, and checked the reference lists of included studies and relevant systematic reviews. Eligibility criteria We included older people (≥ 65 years) hospitalised for different acute conditions at risk of or with malnutrition enrolled in randomised controlled trials (RCTs) comparing oral nutritional interventions with control or each other. For RCTs that met our inclusion criteria, either fully or partially, we requested IPD from the study authors. If we did not receive a response or IPD were unavailable, we used published aggregated data. We excluded RCTs that only partially met the eligibility criteria if neither IPD nor sufficient aggregated data were obtainable. Outcomes Critical outcomes were all‐cause mortality, serious adverse events (SAEs), and functional status (e.g. activities of daily living). Important outcomes were health‐related quality of life (HRQoL), length of hospital stay (LOS), body weight, and fat‐free mass. The main outcome assessment time point was at hospital discharge or 30 days after randomisation. Risk of bias We used the Cochrane risk of bias 2 (RoB 2) tool. Synthesis methods For each outcome, we first analysed IPD within each study. Second, we pooled results in an NMA which also included the aggregated data from RCTs without available IPD. We performed random‐effects NMAs based on the frequentist approach and ranked treatments by P‐scores. We rated the certainty of evidence using the GRADE approach. Included studies We included 21 RCTs (72 reports; 12 RCTs with IPD) with 3309 older participants (mean age ranged from 75 to 85 years; 1863 participants with IPD) with different acute conditions. Interventions included the provision of additional protein (three studies), energy supplements (two studies), oral nutritional supplements (ONS; eight studies), individualised feeding support (two studies), and comprehensive individualised nutritional care (eight studies). In all but two RCTs, interventions were compared to control (standard care with or without a placebo). We judged 16.1% of outcome assessments to be at low risk of bias and 16.8% at high risk. Synthesis of results ONS may reduce all‐cause mortality (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.25 to 0.84; absolute risk difference 57 fewer deaths per 1000 people, 95% CI 79 fewer to 17 fewer; low‐certainty evidence) compared to control, while comprehensive individualised nutritional care may show little to no effect (RR 0.98, 95% CI 0.55 to 1.73; 1 fewer per 1000 people, 95% CI 26 fewer to 46 more; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 13 RCTs, 2728 participants; Q between designs: not applicable (NA)). ONS may reduce SAEs compared to control (RR 0.56, 95% CI 0.32 to 0.95; 84 fewer SAEs per 1000 people, 95% CI 131 fewer to 10 fewer; Q between designs: Q 1.95, df 2, P = 0.3772; low‐certainty evidence ). For all other treatment comparisons, the evidence is very uncertain (NMA with 14 RCTs, 2184 participants). Comprehensive individualised nutritional care may make little to no difference in activities of daily living compared to control (standardised mean difference (SMD) 0.06, 95% CI −0.08 to 0.20; low‐certainty evidence) and ONS compared to energy supplements (SMD −0.15, 95% CI −0.53 to 0.23; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 5 RCTs, 1128 participants; Q between designs: NA). Energy supplements probably make little to no difference in HRQoL compared with ONS (mean difference (MD) 0.01, 95% CI −0.06 to 0.08; Q between designs: NA; moderate‐certainty evidence). All other comparisons of different nutritional interventions may make little to no difference to HRQoL (NMA with 3 RCTs, 1513 participants). The provision of additional protein, energy supplements, ONS, and comprehensive individualised nutritional care may make little to no difference in LOS compared to control (18 RCTs, 3013 participants; Q between designs: Q 2.86, df 3, P = 0.4145). Body weight (16 RCTs, 2114 participants; Q between designs: Q 2.03, df 3, P = 0.5655) may increase with ONS when compared to control (MD 0.9 kg, 95% CI 0.37 to 1.42) or comprehensive individualised nutritional care (MD 1.00 kg, 95% CI 0.12 to 1.87), but the evidence is very uncertain. Energy supplements and ONS probably have similar effects on body weight (MD 0.11 kg, 95% CI −0.85 to 0.63; moderate‐certainty evidence). For fat‐free mass, no meta‐analysis was possible. One RCT (102 participants) compared ONS with energy supplements and found little or no difference between groups (MD 0.13 kg, 95% CI −0.63 to 0.90; low‐certainty evidence), while evidence regarding the effects of additional protein compared with control was very uncertain (1 RCT, 19 participants). Rankings of treatments by P‐scores were not consistent across outcomes. Authors' conclusions In older hospitalised people at risk of or with malnutrition, oral nutritional supplements may reduce mortality and SAEs compared to control 30 days after randomisation . For other outcomes, there may be little or no differences in results. Overall, the evidence was of low to very low certainty, primarily due to a limited number of studies and participants per comparison. The comparison of treatment effects across outcomes was constrained by variations in network structure. When interpreting the results, the heterogeneity of the population in terms of acute and chronic conditions needs to be considered. To improve certainty, adequately powered studies with robust methodologies should compare interventions with controls as well as against each other. Funding The German Federal Ministry of Education and Research funded this work (grant number: 01KG2102). Registration Protocol (2022) doi.org/10.1002/14651858.CD015468 Plain language summary What are the benefits and risks of different types of nutritional support for older, hospitalised people who are malnourished or at risk of malnutrition? Key messages Compared to standard hospital care, specialised foods and drinks may reduce the chances of dying and of having a serious negative health event one month after hospital admission. In terms of people's ability to perform basic daily activities, their quality of life, length of hospital stay, and body weight, we are either very uncertain about the benefits and risks of the different types of nutritional support, or evidence shows they may make little or no difference compared to standard hospital care. Larger and well‐designed studies comparing different types of nutritional support may increase our confidence in these findings. What is malnutrition? People become malnourished when their intake of energy and protein is not enough to meet their body's needs. This condition can reduce someone's fat and muscle stores. Being malnourished threatens people's health and compromises the immune system's ability to fight infections. Older people who are malnourished are at higher risk of disease complications, losing their independence, and dying than non‐malnourished older people. They also experience a lower quality of life. Older people may become malnourished or be at risk of malnutrition for several reasons, including having a reduced appetite, chewing problems, physical limitations (e.g. unable to stand for long periods to prepare meals), and loneliness. Older people in hospital are particularly prone to malnutrition. They may not eat enough at a time when their illness increases their energy and protein needs. Malnutrition affects roughly one‐third to two‐thirds of hospitalised older people. How is malnutrition treated? There is a wide range of treatments for malnutrition, including: specialised foods and beverages that provide extra energy, protein, and other nutrients; practical help with eating and drinking; additional snacks, protein‐rich foods or supplements; nutritional counselling; or tailored combinations of these approaches. What did we want to find out? In older, hospitalised people who are malnourished or at risk of malnutrition, we wanted to know if different types of nutritional support are better than standard care at: reducing the risk of dying and serious negative health events (e.g. complications such as infections or wound healing); improving people's ability to perform basic daily activities and their quality of life; reducing time spent in hospital; and boosting people's body weight and muscle mass. We also wanted to know which type of nutritional support works best. What did we do? We searched for studies in people 65 years and older who were in hospital and malnourished or at risk of malnutrition. We included studies that compared one type of nutritional support to another type, or compared nutritional support to standard hospital care (i.e. usual hospital food service), sometimes in combination with a 'dummy treatment' that looked identical to the supplements tested. We summarised and compared all treatments, and rated our confidence in the results based on factors such as study methods and the numbers of people included. What did we find? We found 21 studies involving 3309 hospitalised older people with different acute conditions. We grouped the treatments they received into five categories: specialised foods and drinks; protein‐enriched foods or supplements; energy supplements; personalised feeding support from an assistant (who would, for example, accommodate food preferences, adjust someone's position, and help with eating); multi‐component personalised nutritional care from a dietitian or nutritionist (who would, for example, modify foods or offer counselling). Main findings Compared to standard hospital care, after a month in hospital, specialised foods and drinks may: reduce the chance of death: they may lead to 57 fewer deaths per 1000 people; reduce serious negative health events: they may lead to 84 fewer events per 1000 people. Compared to standard hospital care, we are either very uncertain about the effects of specialised foods and drinks, protein‐enriched foods or supplements, energy supplements, personalised feeding support, and multi‐component personalised nutritional care, or these treatments may make little or no difference to people's: ability to perform basic daily activities; quality of life; length of hospital stay; body weight and muscle mass. When we compared the different types of nutritional support to each other, we did not find that any one approach worked better than all others in improving the results we measured. What are the limitations of the evidence? Our confidence in the findings is low or very low for several reasons. Some studies used methods that may have led to errors in the results. Studies often involved too few people, or did not look at everything we were interested in, such as muscle mass as outcome or comparisons of different types of nutritional support. Moreover, older people in hospital have different illnesses and functional abilities, and we could not assess how the different types of nutritional support work for different people. How current is this evidence? The evidence is current to 2 July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E, Schwarzer, G, Stadelmaier, J, Lohner, S, Grummich, K, Dagnelie, PC, Beck, AM, Beelen, J, Botella-Carretero, JI, Faxén-Irving, G, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015468.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.138Z" }, { "id": "5dce8988-4f71-4fb3-8105-10f990b8e693", "pmid": "", "title": "Helicobacter pylori eradication for the prevention of gastric neoplasia", "imported": false, "abstract": "Abstract - Background Gastric cancer is the third most common cause of cancer death worldwide. Individuals infected with Helicobacter pylori have a higher likelihood of developing gastric cancer than individuals who are not infected. Eradication of H. pylori in healthy asymptomatic individuals in the general population may reduce the incidence of gastric cancer, but the magnitude of this effect is unclear. Objectives To assess the effectiveness of eradication of H. pylori in healthy asymptomatic individuals in the general population in reducing the incidence of gastric cancer. Search methods We identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 1), MEDLINE (1946 to February 2020), and EMBASE (1974 to February 2020). We handsearched reference lists from trials selected by electronic searching to identify further relevant trials. We handsearched published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ) between 2001 and 2019. We contacted members of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials comparing at least one week of H. pylori therapy with placebo or no treatment in preventing subsequent development of gastric cancer in otherwise healthy and asymptomatic H. pylori ‐positive adults. Trials had to follow up participants for at least two years and needed to have at least two participants with gastric cancer as an outcome. We defined gastric cancer as any gastric adenocarcinoma, including intestinal (differentiated) or diffuse (undifferentiated) type, with or without specified histology. Data collection and analysis We collected data on incidence of gastric cancer, incidence of oesophageal cancer, deaths from gastric cancer, deaths from any cause, and adverse effects arising due to therapy. Main results Six trials met all our eligibility criteria and provided extractable data in the previous version. Following our updated search, one new RCT was identified, meaning that seven trials were included in this updated review. In addition, one previously included trial provided fully published data out to 10 years, and another previously included trial provided fully published data out to 22 years of follow‐up. Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. Six trials were conducted in Asian populations. In preventing development of subsequent gastric cancer, H. pylori eradication therapy was superior to placebo or no treatment (RR 0.54, 95% confidence interval (CI) 0.40 to 0.72, 7 trials, 8323 participants, moderate certainty evidence). Only two trials reported the effect of eradication of H. pylori on the development of subsequent oesophageal cancer. Sixteen (0.8%) of 1947 participants assigned to eradication therapy subsequently developed oesophageal cancer compared with 13 (0.7%) of 1941 participants allocated to placebo (RR 1.22, 95% CI 0.59 to 2.54, moderate certainty evidence). H. pylori eradication reduced mortality from gastric cancer compared with placebo or no treatment (RR 0.61, 95% CI 0.40 to 0.92, 4 trials, 6301 participants, moderate certainty evidence). There was little or no evidence in all‐cause mortality (RR 0.97, 95% CI 0.85 to 1.12, 5 trials, 7079 participants, moderate certainty evidence). Adverse events data were poorly reported. Authors' conclusions We found moderate certainty evidence that searching for and eradicating H. pylori reduces the incidence of gastric cancer and death from gastric cancer in healthy asymptomatic infected Asian individuals, but we cannot necessarily extrapolate this data to other populations. Plain language summary Helicobacter pylori treatment for the prevention of stomach cancer Review question Whether testing healthy people for Helicobacter pylori and treating those infected with a course of antibiotics decreases the number of new cases of gastric cancer. Background Helicobacter pylori ( H. pylori ) is a bacteria that lives in the lining of the stomach with people usually not aware they are carrying the infection. People with H. pylori infection are more likely to develop gastric cancer than people who are not infected with the bacterium. For this reason, H. pylori is classed as carcinogenic (causing cancer) to humans. Many people worldwide die of gastric cancer every year, because by the time those affected seek the opinion of a doctor, the condition is often advanced. However, H. pylori infection is easily treatable with a one‐week course of antibiotics. Study characteristics A literature search up to 02 Feburary 2020 found seven trials (containing 8323 participants, four trials at low risk of bias). Six of the studies were based in Asia. Key results We found that antibiotics for H. pylori have a small benefit in preventing gastric cancer (68 (1.6%) of 4206 participants given treatment developed gastric cancer subsequently, compared with 125 (3.0%) of 4117 given no treatment or a placebo), and in decreasing the number of deaths from gastric cancer (36 (1.1%) of 3154, compared with 59 (1.9%) of 3147); but it is unclear whether or not they increase or decrease the number of deaths due to any cause, or increase or decrease the number of cases of oesophageal cancer. Data about side effects of treatment were poorly reported. Quality of the evidence Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. One study was at high risk of bias because no placebo was used for the active eradication therapy regimen, and so this part of the trial was unblinded, and the other study was at high risk of bias due to inconsistencies in data reporting at the two points of follow‐up. We were unable to resolve this discrepancy despite contacting the original authors. As a result, we downgraded the quality of evidence from high to moderate due to serious risk of bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ford, AC; Yuan, Y; Forman, D; Hunt, R; Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD005583.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "5de0ea96-37b1-4b86-b0e6-c1b4e683a2a5", "pmid": "", "title": "Omega‐6 fats for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐6 fats are polyunsaturated fats vital for many physiological functions, but their effect on cardiovascular disease (CVD) risk is debated. Objectives To assess effects of increasing omega‐6 fats (linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA)) on CVD and all‐cause mortality. Search methods We searched CENTRAL, MEDLINE and Embase to May 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher versus lower omega‐6 fat intake in adults with or without CVD, assessing effects over at least 12 months. We included full texts, abstracts, trials registry entries and unpublished studies. Outcomes were all‐cause mortality, CVD mortality, CVD events, risk factors (blood lipids, adiposity, blood pressure), and potential adverse events. We excluded trials where we could not separate omega‐6 fat effects from those of other dietary, lifestyle or medication interventions. Data collection and analysis Two authors independently screened titles/abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias of included trials. We wrote to authors of included studies. Meta‐analyses used random‐effects analysis, while sensitivity analyses used fixed‐effects and limited analyses to trials at low summary risk of bias. We assessed GRADE quality of evidence for 'Summary of findings' tables. Main results We included 19 RCTs in 6461 participants who were followed for one to eight years. Seven trials assessed the effects of supplemental GLA and 12 of LA, none DGLA or AA; the omega‐6 fats usually displaced dietary saturated or monounsaturated fats. We assessed three RCTs as being at low summary risk of bias. Primary outcomes : we found low‐quality evidence that increased intake of omega‐6 fats may make little or no difference to all‐cause mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.88 to 1.12, 740 deaths, 4506 randomised, 10 trials) or CVD events (RR 0.97, 95% CI 0.81 to 1.15, 1404 people experienced events of 4962 randomised, 7 trials). We are uncertain whether increasing omega‐6 fats affects CVD mortality (RR 1.09, 95% CI 0.76 to 1.55, 472 deaths, 4019 randomised, 7 trials), coronary heart disease events (RR 0.88, 95% CI 0.66 to 1.17, 1059 people with events of 3997 randomised, 7 trials), major adverse cardiac and cerebrovascular events (RR 0.84, 95% CI 0.59 to 1.20, 817 events, 2879 participants, 2 trials) or stroke (RR 1.36, 95% CI 0.45 to 4.11, 54 events, 3730 participants, 4 trials), as we assessed the evidence as being of very low quality. We found no evidence of dose‐response or duration effects for any primary outcome, but there was a suggestion of greater protection in participants with lower baseline omega‐6 intake across outcomes. Additional key outcomes : we found increased intake of omega‐6 fats may reduce myocardial infarction (MI) risk (RR 0.88, 95% CI 0.76 to 1.02, 609 events, 4606 participants, 7 trials, low‐quality evidence). High‐quality evidence suggests increasing omega‐6 fats reduces total serum cholesterol a little in the long term (mean difference (MD) −0.33 mmol/L, 95% CI −0.50 to −0.16, I 2 = 81%; heterogeneity partially explained by dose, 4280 participants, 10 trials). Increasing omega‐6 fats probably has little or no effect on adiposity (body mass index (BMI) MD −0.20 kg/m 2 , 95% CI −0.56 to 0.16, 371 participants, 1 trial, moderate‐quality evidence). It may make little or no difference to serum triglycerides (MD −0.01 mmol/L, 95% CI −0.23 to 0.21, 834 participants, 5 trials), HDL (MD −0.01 mmol/L, 95% CI −0.03 to 0.02, 1995 participants, 4 trials) or low‐density lipoprotein (MD −0.04 mmol/L, 95% CI −0.21 to 0.14, 244 participants, 2 trials, low‐quality evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐6 fats on cardiovascular health, mortality, lipids and adiposity to date, using previously unpublished data. We found no evidence that increasing omega‐6 fats reduces cardiovascular outcomes other than MI, where 53 people may need to increase omega‐6 fat intake to prevent 1 person from experiencing MI. Although benefits of omega‐6 fats remain to be proven, increasing omega‐6 fats may be of benefit in people at high risk of MI. Increased omega‐6 fats reduce serum total cholesterol but not other blood fat fractions or adiposity. Plain language summary Omega‐6 fats to prevent and treat heart and circulatory diseases Review question We reviewed randomised trials (participants had an equal chance to be assigned to either treatment) examining effects of higher omega‐6 fats compared to lower omega‐6 fats on deaths and heart and circulatory diseases (cardiovascular diseases (CVD), which include heart attacks and strokes). Background Omega‐6 fats are essential, we must obtain some from food. They are important for regulating energy production (part of metabolism), bone, skin and hair health. Many foods contain omega‐6 fats, particularly vegetable oils and nuts. Omega‐6 fats include linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA). Some evidence suggests that a higher intake of omega‐6 fats, along with a lower intake of saturated fat (from animal sources such as meat and cheese) can reduce coronary heart disease. In contrast, there is concern that high levels of omega‐6 fats may worsen cardiovascular risk by increasing inflammation. Overall, there is no conclusive evidence on the benefits or harms of omega‐6 fat intake on heart and circulatory diseases or on other health outcomes. Study characteristics Evidence in this review is current to May 2017. We found 19 studies recruiting 6461 adults. These studies assessed the effects of higher compared to lower omega‐6 fat intake on heart and circulatory diseases as well as deaths. We found that three trials were highly trustworthy (with good designs that produce reliable evidence). Studies took place in North America, Asia, Europe and Australia, and eight were funded only by national or charitable agencies. Participants increased their omega‐6 fats or maintained their usual fats for at least one year and up to eight years. Key results We found that increasing omega‐6 fats may make little or no difference to deaths or cardiovascular events but may reduce risk of heart attacks (low‐quality evidence). Evidence was weakened by study design problems, small numbers of events, low numbers of participants from developing countries, and few women. Evidence suggests that increasing omega‐6 fats reduces blood cholesterol (high‐quality evidence), probably has little or no effect on body weight adjusted for height (all moderate‐quality evidence), and may make little or no difference to triglycerides, high‐density lipoprotein (HDL, the 'good' cholesterol) or low‐density lipoprotein (LDL, the 'bad' cholesterol, low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hooper, L, Al‐Khudairy, L, Abdelhamid, AS, Rees, K, Brainard, JS, Brown, TJ, Ajabnoor, SM, O'Brien, AT, Winstanley, LE, Donaldson, DH, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011094.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.802Z" }, { "id": "5df630c6-8462-44a7-9276-dff4e3d41bdf", "pmid": "", "title": "Medically Utilized Tailored Traditional Meals to Optimize Nutrition in Heart Failure Pilot Trial", "imported": false, "abstract": "Study subjects with heart failure will receive either pre-prepared, home-delivered DASH/SRD-compliant meals incorporating local Navajo traditional foods or usual care for 30 days (14 meals weekly).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "5df6841f-d47f-4d6d-bb59-ddf571dae2ef", "pmid": "", "title": "Running Performance in Response to Different Forms of Carbohydrate", "imported": false, "abstract": "Carbohydrates serve as the body's primary energy source during intense exercise, and consuming carbohydrates during exercise has been shown to improve exercise performance. Previous research has shown that the presence of carbohydrates in the mouth activates sweet taste receptors on the tongue, which signal the brain to increase neural activation in areas associated with motor functioning, sensory perception, and reward centers during exercise through this CPR. The primary objective of this intervention is to establish how carbohydrates delivered in different forms (MR versus dissolvable strip (DS)) affect running performance during a 12.8km running TT.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.239Z" }, { "id": "5e237b8d-4ed2-42f9-af6b-2acacea0b619", "pmid": "", "title": "Different strategies for diagnosing gestational diabetes to improve maternal and infant health", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycaemia with onset or first recognition during pregnancy. If untreated, perinatal morbidity and mortality may be increased. Accurate diagnosis allows appropriate treatment. Use of different tests and different criteria will influence which women are diagnosed with GDM. This is an update of a review published in 2011 and 2015. Objectives To evaluate and compare different testing strategies for diagnosis of gestational diabetes mellitus to improve maternal and infant health while assessing their impact on healthcare service costs. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (9 January 2017) and reference lists of retrieved studies. Selection criteria We included randomised trials if they evaluated tests carried out to diagnose GDM. We excluded studies that used a quasi‐random model, cluster‐randomised or cross‐over trials. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. Main results We included a total of seven small trials, with 1420 women. One trial including 726 women was identified by this update and examined the two step versus one step approach. These trials were assessed as having varying risk of bias, with few outcomes reported. We prespecified six outcomes to be assessed for quality using the GRADE approach for one comparison: 75 g oral glucose tolerance test (OGTT) versus 100 g OGTT; data for only one outcome (diagnosis of gestational diabetes) were available for assessment. One trial compared three different methods of delivering glucose: a candy bar (39 women), a 50 g glucose polymer drink (40 women) and a 50 g glucose monomer drink (43 women). We have included the results reported by this trial as separate comparisons. No trial reported on measures of costs of health services. We examined six main comparisons. 75 g OGTT versus 100 g OGTT (1 trial, 248 women): women who received 75 g OGTT had a higher relative risk of being diagnosed with GDM (risk ratio (RR) 2.55, 95% confidence interval (CI) 0.96 to 6.75; very‐low quality evidence ). No data were reported for the following additional outcomes prespecified for GRADE assessment: caesarean section, macrosomia > 4.5 kg or however defined in the trial, long‐term type 2 diabetes maternal, long‐term type 2 diabetes infant and economic costs. Candy bar versus 50 g glucose monomer drink (1 trial, 60 women): more women receiving the candy bar, rather than glucose monomer, preferred the taste of the candy bar (RR 0.60, 95% CI 0.42 to 0.86) and 1‐hour glucose was less with the candy bar. There were no differences in the other outcomes reported (maternal side effects). No infant outcomes were reported or any review primary outcomes. 50 g glucose polymer drink versus 50 g glucose monomer drink (3 trials, 239 women): mean difference (MD) in gestation at birth was ‐0.80 weeks (1 trial, 100 women; 95% CI ‐1.69 to 0.09). Total side effects were less common with the glucose polymer drink (1 trial, 63 women; RR 0.21, 95% CI 0.07 to 0.59), and no clear difference in taste acceptability was reported (1 trial, 63 women; RR 0.99, 95% CI 0.76 to 1.29). Fewer women reported nausea following the 50 g glucose polymer drink compared with the 50 g glucose monomer drink (1 trial, 66 women; RR 0.29, 95% CI 0.11 to 0.78). No other measures of maternal morbidity or outcomes for the infant were reported. 50 g glucose food versus 50 g glucose drink (1 trial, 30 women): women receiving glucose in their food, rather than as a drink, reported fewer side effects (RR 0.08, 95% CI 0.01 to 0.56). No clear difference was noted in the number of women requiring further testing (RR 0.14, 95% CI 0.01 to 2.55). No other measures of maternal morbidity or outcome were reported for the infant or review primary outcomes. 75 g OGTT World Health Organization (WHO) criteria versus 75 g OGTT American Diabetes Association (ADA) criteria (1 trial, 116 women): no clear differences in included outcomes were observed between women who received the 75 g OGTT and were diagnosed using criteria based on WHO (1999) recommendations and women who received the 75 g OGTT and were diagnosed using criteria recommended by the ADA (1979). Outcomes measured included diagnosis of gestational diabetes (RR 1.47, 95% CI 0.66 to 3.25), caesarean section (RR 1.07, 95% CI 0.85 to 1.35), macrosomia defined as > 90th percentile by ultrasound or birthweight equal to or exceeding 4000 g (RR 0.73, 95% CI 0.19 to 2.79), stillbirth (RR 0.49, 95% CI 0.02 to 11.68) and instrumental birth (RR 0.21, 95% CI 0.01 to 3.94). No other secondary outcomes were reported. Two‐step approach (50 g oral glucose challenge test followed by selective 100 g OGTT Carpenter and Coustan criteria) versus one‐step approach (universal 75 g OGTT ADA criteria) (1 trial, 726 women): women allocated the two‐step approach had a lower risk of being diagnosed with GDM at 11 to 14 weeks' gestation compared to women allocated the one‐step approach (RR 0.51, 95% CI 0.28 to 0.95). No other primary or secondary outcomes were reported. Authors' conclusions There is insufficient evidence to suggest which strategy is best for diagnosing GDM. Large randomised trials are required to establish the best strategy for correctly identifying women with GDM. Plain language summary Different strategies for diagnosing gestational diabetes mellitus (GDM) to improve maternal and infant health What is the issue? We aimed to evaluate and compare different ways of diagnosing gestational diabetes mellitus (GDM). We searched for all relevant studies in January 2017. Why is this important? Between seven and 24 pregnant women in every 100 develop GDM. GDM is when there is an inability to process carbohydrates properly, which leads to high blood sugar (hyperglycaemia). GDM can result in increased risks of problems around the time of birth for the mother and her baby. Treatment can reduce these risks, and therefore diagnosing the condition accurately means that treatment can be given to improve the health of mothers and their babies. Different testing strategies aim to diagnose GDM. We wanted to compare the different strategies, to see how they affected the health of women and their infants, and to assess the cost of the strategies to the healthcare service. What evidence did we find? We found seven trials. A total of 1420 women were included, in settings in Turkey, Mexico, Nigeria, New Zealand, Canada and the USA. Across the trials, different testing approaches and criteria were evaluated as were different diagnostic tests including different oral glucose tolerance test loads; a glucose drink; a candy bar and food high in glucose. Women were given these items to eat/drink, and this was then followed by a blood test to measure blood sugar levels and questionnaires. In some tests, women were required to fast from the night before. The main outcomes we looked for were frequency of diagnosis, incidence of caesarean section, assisted birth and vaginal birth, and incidence of macrosomia in babies (larger than normal weight at birth). Other outcomes spanned a range, including any side effects of the tests, the mothers' preferences, and the health of the babies. There were a number of weaknesses among the studies: the methodology was not clear and there were important gaps in the data. The studies in this review do not provide enough evidence to guide clinical practice and health policy regarding identifying women with GDM. What does this mean? We are uncertain about which strategies to diagnose GDM are better, as we have assessed the quality of evidence as very low. Large randomised trials are needed to establish the best way for identifying women with GDM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Farrar, D, Duley, L, Dowswell, T, Lawlor, DA", "articleTypes": [], "doi": "10.1002/14651858.CD007122.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.732Z" }, { "id": "5e6eff32-9cc8-498e-a2c9-f663177baa6f", "pmid": "", "title": "Prognostic models for radiation‐induced complications after radiotherapy in head and neck cancer patients", "imported": false, "abstract": "Abstract - Background Radiotherapy is the mainstay of treatment for head and neck cancer (HNC) but may induce various side effects on surrounding normal tissues. To reach an optimal balance, normal tissue complication probability (NTCP) models have been reported to predict the risk of radiation‐induced side effects in patients with HNC. However, the quality of study design, conduct, and analysis (i.e. risk of bias (ROB)), as well as the predictive performance of these models, remains to be evaluated. Objectives To identify, describe and appraise NTCP models to predict the risk of radiation‐induced side effects in patients with HNC. Search methods We searched Ovid MEDLINE, Embase and the World Health Organization International Clinical Trials Registry Platform from conception to January 2024. In addition, we screened references cited in the retrieved articles. Selection criteria Two review authors independently included articles reporting on the development and external validation of NTCP models to predict any type of radiation‐induced side effects in patients with HNC. Data collection and analysis One reviewer extracted data from each article and assessed their applicability and ROB, while another reviewer carefully verified the results. For models externally validated at least twice for the same outcome as their original developmental study, we performed qualitative analyses of the model performance. The GRADE system was not applied, since it has not been established for reviews of prognostic model studies. Main results Amongst 617 models developed from 152 articles, including 162,527 HNC patients, only 58 (9%) models from seven articles were judged to have low ROB and low concerns for applicability. No external validation was performed for 481 models (78%). For the remaining 136 models and six additional models which were not eligible for the present review, 193 external validations were performed in 48,852 patients with HNC in 39 articles. Models for salivary‐related outcomes Amongst 285 models, two models were externally validated at least twice. The Beetz 2012b model for xerostomia six months after radiotherapy was validated in two studies. C‐statistics ranged from 0.70 to 0.74. Calibration performance was reported in one study. One validation study was rated as having low ROB in all domains, while the other was rated as having high ROB in the analysis domain. The Cavallo 2021 model for acute xerostomia during radiotherapy for patients with nasopharyngeal cancer was externally validated in the same study, using two different types of cohorts. C‐statistics ranged from 0.68 to 0.73 and calibration plots were reported in both cohorts. Both validations were rated as having unclear ROB in the participants' domain because no detailed information about recruiting was provided. Models for swallowing‐related outcomes Amongst 85 models, two models were externally validated at least twice. The Christianen 2012 model for dysphagia six months after radiotherapy was validated in five studies. C‐statistics ranged from 0.66 to 0.75. Calibration performance was assessed in all of them, while four of them were rated as having high ROB in the analysis domain due to the small sample size. The Wopken 2014b model for tube feeding dependence six months after radiotherapy was validated in three external validation studies. C‐statistics ranged from 0.79 to 0.95, while calibration was evaluated in all studies. Due to the small size of the validation datasets, they were judged as having high ROB in the analysis domain. Models for hypothyroidism Of 72 models for hypothyroidism, two models were externally validated at least twice. In addition, there was another model which was not originally developed for patients with HNC, but validated in this domain. The Boomsma 2012 for hypothyroidism within two years after radiotherapy was externally validated in two studies. C‐statistics ranged from 0.64 to 0.74, while only one study reported its calibration performance. Both validation studies were rated as having high ROB in the analysis domain. The Ronjom 2013 model for radiation‐induced hypothyroidism was validated in three studies. C‐statistics ranged from 0.65 to 0.69 and calibration plots were reported in only one study. Two validation studies were judged as having high and the other was rated as having unclear ROB in the analysis domain. The Cella 2012 model was originally developed to predict radiation‐induced hypothyroidism in patients with Hodgkin’s lymphoma. In two validation studies in patients with HNC, c‐statistics ranged from 0.65 to 0.68, but calibration performance was not reported. One validation study was rated as having a high ROB and the other was rated as being unclear in the analysis domain. Models for brain and nerve‐related outcomes Amongst 40 models, three were externally validated at least twice for temporal lobe injury. The OuYang 2023 model, using deep learning in patients with nasopharyngeal cancer, was validated in the same paper using two different cohorts. C‐statistics ranged from 0.80 to 0.82, while calibration performance was assessed in both cohorts. Both validations were judged as having low ROB in all domains. The Wen 2021 model was developed to predict temporal lobe injury in newly diagnosed nasopharyngeal cancer patients. The model was validated by OuYang 2023 using two cohorts and by Yang 2023a using four cohorts. C‐statistics ranged from 0.75 to 0.79, while calibration performance was not reported. The two validations by OuYang 2023 were judged as having unclear ROB in the analysis domain, and the four validations by Yang 2023a were judged as having high ROB in the analysis domain. The Yang 2023a model was validated in the same paper using two cohorts. C‐statistics ranged from 0.79 to 0.81, while calibration performance was assessed in both cohorts. Both validations were judged as having high ROB in the analysis domain. Models for outcomes related to hoarseness, fatigue, nausea‐vomiting, throat pain, aspiration No models were externally validated at least twice. Authors' conclusions Amongst 617 developed models, only one‐fifth were externally validated, of which, ten models at least twice. These ten models showed acceptable discriminative performance at external validation. However, their calibration was not always reported. Furthermore, most validation studies were judged as having high ROB. In conclusion, this review shows the need for more external validation studies and improvement of the quality of conducting and reporting of prediction model studies. Plain language summary Which normal tissue complication probability (NTCP) models are available to predict the risk of radiation‐induced side effects after radiotherapy in patients with head and neck cancer, what is their quality, and what is their predictive performance? Key messages ° Many NTCP models have been developed to predict unwanted effects following radiotherapy in head and neck cancer patients but most of them have not been sufficiently externally validated, that is, tested with patients who were not involved in the original model developmental study, to know how well they really predict the unwanted effects. ° For models tested in two or more studies in addition to their original model development studies, the quality of testing and reporting of their results was generally poor, so it is difficult to know how useful they might be. ° More and better designed studies are required to investigate this issue in the area of head and neck cancer. How can we decide on the likelihood of having unwanted effects as a result of treatment? The likelihood of having unwanted effects as a result of radiotherapy can be calculated by using so‐called NTCP models. NTCP models calculate the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. What did we want to find out? Radiotherapy is the mainstay of treatment of patients with head and neck cancer. However, radiotherapy exposes healthy, sometimes crucial, parts of the head and neck region to radiation. This may result in damage to these normal organs, e.g. disturbed saliva production, which may have important consequences for the quality of life of head and neck cancer patients treated with radiotherapy. To reach an optimal balance between tumour control and preventing radiation‐induced side effects, normal tissue complication probability (NTCP) models can be helpful. These models predict the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. There have been a substantial number of NTCP models for patients with head and neck cancer. We wanted to find out what the quality of study design, conduct, and analysis (i.e. risk of bias) is, and how well these models can predict the risk of radiation‐induced side effects. What did we do? We searched for studies that developed and/or validated NTCP models in patients with head and neck cancer. What did we find? In most of the 617 models developed from 162,527 patients in 152 identified articles, the quality of the models was not sufficient; and it has not been investigated how well they perform in new patients for 78% of these models. For the remaining 22% of the models, 193 external validations were found in 48,852 patients from 39 articles. There were only ten models with two or more external validations. The models were able to distinguish patients with and without the outcome well, but it was often unclear whether their predictions were in line with what was observed, because the latter was not always assessed and/or reported. Overall, the quality of most of these studies was low. How up to date is the review? The evidence is current to 8th January 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Takada, T; Tambas, M; Clementel, E; Leeuwenberg, A; Sharabiani, M; Damen, JAAG; Dunias, ZS; Nauta, JF; Idema, DL; Choi, J; Meijerink, LM; Langendijk, JA; Moons, KG; Schuit, E", "articleTypes": [], "doi": "10.1002/14651858.CD014745.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "5e719e50-964b-4bff-9d8b-b7c8c30b6f02", "pmid": "", "title": "Inhaled mannitol for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Several agents are used to clear secretions from the airways of people with cystic fibrosis. Mannitol increases mucociliary clearance, but its exact mechanism of action is unknown. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents which require delivery via a nebuliser. Phase III trials of inhaled dry powder mannitol for the treatment of cystic fibrosis have been completed and it is now available in Australia and some countries in Europe. This is an update of a previous review. Objectives To assess whether inhaled dry powder mannitol is well tolerated, whether it improves the quality of life and respiratory function in people with cystic fibrosis and which adverse events are associated with the treatment. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic databases, handsearching relevant journals and abstracts from conferences. Date of last search: 12 December 2019. Selection criteria All randomised controlled studies comparing mannitol with placebo, active inhaled comparators (for example, hypertonic saline or dornase alfa) or with no treatment. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction and assessed the risk of bias in included studies. The quality of the evidence was assessed using GRADE. Main results Six studies (reported in 36 unique publications) were included with a total of 784 participants. Duration of treatment in the included studies ranged from 12 days to six months, with open‐label treatment for an additional six months in two of the studies. Five studies compared mannitol with control (a very low dose of mannitol or non‐respirable mannitol) and the final study compared mannitol to dornase alfa alone and to mannitol plus dornase alfa. Two large studies had a similar parallel design and provided data for 600 participants, which could be pooled where data for a particular outcome and time point were available. The remaining studies had much smaller sample sizes (ranging from 22 to 95) and data could not be pooled due to differences in design, interventions and population. Pooled evidence from the two large parallel studies was judged to be of low to moderate quality and from the smaller studies was judged to be of low to very low quality. In all studies, there was an initial test to see if participants tolerated mannitol, with only those who could tolerate the drug being randomised; therefore, the study results are not applicable to the cystic fibrosis population as a whole. While the published papers did not provide all the data required for our analysis, additional unpublished data were provided by the drug's manufacturer and the author of one of the studies. Pooling the large parallel studies comparing mannitol to control, up to and including six months, lung function (forced expiratory volume at one second) measured in both mL and % predicted was significantly improved in the mannitol group compared to the control group (moderate‐quality evidence). Beneficial results were observed in these studies in adults and in both concomitant dornase alfa users and non‐users in these studies. In the smaller studies, statistically significant improvements in lung function were also observed in the mannitol groups compared to the non‐respirable mannitol groups; however, we judged this evidence to be of low to very low quality. For the comparisons of mannitol and control, we found no consistent differences in health‐related quality of life in any of the domains except for burden of treatment, which was less for mannitol up to four months in the two pooled studies of a similar design; this difference was not maintained at six months. It should be noted that the tool used to measure health‐related quality of life was not designed to assess mucolytics and pooling of the age‐appropriate tools (as done in some of the included studies) may not be valid so results were judged to be low to very low quality and should be interpreted with caution. Cough, haemoptysis, bronchospasm, pharyngolaryngeal pain and post‐tussive vomiting were the most commonly reported side effects in both treatment groups. Where rates of adverse events could be compared, statistically no significant differences were found between mannitol and control groups; although some of these events may have clinical relevance for people with CF. For the comparisons of mannitol to dornase alfa alone and to mannitol plus dornase alfa, very low‐quality evidence from a 12‐week cross‐over study of 28 participants showed no statistically significant differences in the recorded domains of health‐related quality of life or measures of lung function. Cough was the most common side effect in the mannitol alone arm but there was no occurrence of cough in the dornase alfa alone arm and the most commonly reported reason of withdrawal from the mannitol plus dornase alfa arm was pulmonary exacerbations. In terms of secondary outcomes of the review (pulmonary exacerbations, hospitalisations, symptoms, sputum microbiology), evidence provided by the included studies was more limited. For all comparisons, no consistent statistically significant and clinically meaningful differences were observed between mannitol and control treatments (including dornase alfa). Authors' conclusions There is moderate‐quality evidence to show that treatment with mannitol over a six‐month period is associated with an improvement in some measures of lung function in people with cystic fibrosis compared to control. There is low to very low‐quality evidence suggesting no difference in quality of life for participants taking mannitol compared to control. This review provides very low‐quality evidence suggesting no difference in lung function or quality of life comparing mannitol to dornase alfa alone and to mannitol plus dornase alfa. The clinical implications from this review suggest that mannitol could be considered as a treatment in cystic fibrosis; but further research is required in order to establish who may benefit most and whether this benefit is sustained in the longer term. Furthermore, studies comparing its efficacy against other (established) mucolytic therapies need to be undertaken before it can be considered for mainstream practice. Plain language summary Mannitol, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of inhaling mannitol to treat lung disease in people with cystic fibrosis. Background Cystic fibrosis is a genetic disorder that affects the exocrine glands (sweat glands and others). Lung infections produce thick mucus (phlegm) which can block air passages and cause more infection and repeated inflammation. In turn, this progressively damages the lungs and can eventually cause respiratory failure. There are several drugs that are used to clear mucus from the airways of people with cystic fibrosis and inhaled dry powder mannitol is a new one that may improve their lung function. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents delivered by a nebuliser (e.g. hypertonic saline). Mannitol is available in Australia and some European countries. This is an updated version of the review. Search date The evidence is current to: 12 December 2019. Study characteristics We included six studies (with a total of 784 adults and children) in this review. Five studies compared a standard dose of mannitol with control (a very low dose of mannitol or a version of mannitol which did not allow the active drug to reach the lungs) and the sixth study compared mannitol with nebulised recombinant human deoxyribonuclease (dornase alfa), both alone and taken together. Participants could continue using dornase alfa and other standard therapies, but were excluded from the five of the six studies if they were using hypertonic saline. Treatment in these studies lasted from 12 days to six months. Five studies provided the treatments to people as outpatients and in one study, the children treated were in hospital due to pulmonary exacerbations (flare ups of disease). Key results It was difficult to combine evidence from the studies in this review due to differences in the designs of the studies, treatments examined and the settings (hospital or outpatients). Some additional information was obtained from the drug manufacturer and one study author to aid the review. The review found low‐ to very low‐quality evidence that there is no difference between mannitol and control treatments or mannitol given either with or without additional dornase alfa in terms of quality of life. There was moderate‐quality evidence of improvements in some measures of lung function across the larger studies comparing mannitol to control. Beneficial effects were also seen in the subgroup of adults and in both those who were using dornase alfa and those who were not. Cough (including coughing up blood), contraction of the airways, pain in the pharynx or larynx and post‐treatment vomiting were the most commonly reported side effects on both treatments, but there was no evidence to suggest that these side effects occurred more on mannitol than on control treatments or on dornase alfa. None of the studies compared mannitol to nebulised hypertonic saline and so we can not comment on which agent is better for airway clearance. More research is needed to answer this question. Quality of the evidence We judged the quality of the evidence from this review to be of very low to moderate quality, depending on the outcome measured. We do not think that the way the studies were designed affected the results. We judged that everyone taking part had equal chances of being in either of the treatment groups and would not have known in advance or during the study which treatment they were receiving. However, the numbers of people who dropped out of the studies might affect how the results are interpreted, as well as how many people were recruited into the studies and how they were selected from all people with cystic fibrosis who could have been included. Although some of these issues were resolved when the drug's manufacturer (who also sponsored the studies) provided some additional information. It is important to realise that before people started the study, they took a test to see if they could tolerate mannitol and only those who did could carry on. This means that the results of the studies only apply to those people with cystic fibrosis who can tolerate mannitol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Nevitt, SJ; Thornton, J; Murray, CS; Dwyer, T", "articleTypes": [], "doi": "10.1002/14651858.CD008649.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "5e865300-ea06-45b1-b003-31ae5a29fa46", "pmid": "", "title": "Xiao Chai Hu Tang, a herbal medicine, for chronic hepatitis B", "imported": false, "abstract": "Abstract - Background Chronic hepatitis B is associated with high morbidity and mortality. Chronic hepatitis B requires long‐term management aiming at reduction of the risks of hepatocellular inflammatory necrosis, liver fibrosis, decompensated liver cirrhosis, liver failure, and liver cancer, and improving health‐related quality of life. The Chinese herbal medicine formula Xiao Chai Hu Tang has been used to decrease discomfort and replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established with rigorous review methodology. Objectives To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and seven other databases to 1 March 2019. We also searched the World Health Organization International Clinical Trials Registry Platform ( www.who.int/ictrp ), ClinicalTrials.gov ( www.clinicaltrials.gov/ ), and the Chinese Clinical Trial Registry for ongoing or unpublished trials to 1 March 2019. Selection criteria We included randomised clinical trials, irrespective of publication status, language, and blinding, comparing Xiao Chai Hu Tang formula versus no intervention or placebo in people with chronic hepatitis B. We included participants of any sex and age, diagnosed with chronic hepatitis B according to guidelines or as defined by the trialists. We allowed co‐interventions when the co‐interventions were administered equally to all the intervention groups. Data collection and analysis Review authors independently retrieved data from reports and after correspondence with investigators. Our primary outcomes were all‐cause mortality, serious adverse events, and health‐related quality of life. Our secondary outcomes were hepatitis B‐related mortality, hepatitis B‐related morbidity, and adverse events considered 'not to be serious'. We presented the meta‐analysed results as risk ratios (RR) with 95% confidence intervals (CI). We assessed the risks of bias using risk of bias domains with predefined definitions. We used GRADE methodology to evaluate our certainty in the evidence. Main results We included 10 randomised clinical trials with 934 participants, but only five trials with 490 participants provided data for analysis. All the trials compared Xiao Chai Hu Tang formula with no intervention. All trials appeared to have been conducted and published only in China. The included trials assessed heterogeneous forms of Xiao Chai Hu Tang formula, administered for three to eight months. One trial included participants with hepatitis B and comorbid tuberculosis, and one trial included participants with hepatitis B and liver cirrhosis. The remaining trials included participants with hepatitis B only. All the trials were at high risk of bias, and the certainty of evidence for all outcomes that provided data for analyses was very low. We downgraded the evidence by one or two levels because of outcome risk of bias, inconsistency or heterogeneity of results (opposite direction of effect), indirectness of evidence (use of surrogate outcomes instead of clinically relevant outcomes), imprecision of results (the CIs were wide), and publication bias (small sample size of the trials). Additionally, 47 trials lacked the necessary methodological information needed to ensure the inclusion of these trials in our review. None of the included trials aimed to assess clinically relevant outcomes such as all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, or hepatitis B‐related morbidity. The effects of Xiao Chai Hu Tang formula on the proportion of participants with adverse events considered 'not to be serious' is uncertain (RR 0.43, 95% CI 0.02 to 11.98; I 2 = 69%; very low‐certainty evidence). Only three trials with 222 participants reported the proportion of people with detectable hepatitis B virus DNA (HBV‐DNA), but the evidence that Xiao Chai Hu Tang formula reduces the presence of HBV‐DNA in the blood (a surrogate outcome) is uncertain (RR 0.62, 95% CI 0.45 to 0.85; I 2 = 0%; very low‐certainty evidence). Only two trials with 160 participants reported the proportion of people with detectable hepatitis B virus e‐antigen (HBeAg; a surrogate outcome) (RR 0.72, 95% CI 0.50 to 1.02; I 2 = 38%; very low‐certainty evidence) and the evidence is uncertain. The evidence is also uncertain for separately reported adverse events considered 'not to be serious'. Funding: two of the 10 included trials received academic funding from government or hospital. None of the remaining eight trials reported information on funding. Authors' conclusions The clinical effects of Xiao Chai Hu Tang formula for chronic hepatitis B remain unclear. The included trials were small and of low methodological quality. Despite the wide use of Xiao Chai Hu Tang formula, we lack data on all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, and hepatitis B‐related morbidity. The evidence in this systematic review comes from data obtained from a maximum three trials. We graded the certainty of evidence as very low for adverse events considered not to be serious and the surrogate outcomes HBeAg and HBV‐DNA. We found a large number of trials which lacked clear description of their design and conduct, and hence, these trials are not included in the present review. As all identified trials were conducted in China, there might be a concern about the applicability of this review outside China. Large‐sized, high‐quality randomised sham‐controlled trials with homogeneous groups of participants and transparent funding are lacking. Plain language summary Xiao Chai Hu Tang, a Chinese herbal medicine formula, for chronic hepatitis B Review question To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B virus infection. Background Chronic hepatitis B virus infection is a common liver disease, associated with high morbidity (illness) and death. It causes psychological stress and is a burden to people with chronic hepatitis B and their families. Xiao Chai Hu Tang formula has been used for treating people with chronic hepatitis B as it is believed that it decreases discomfort and prevents the replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established in reviews with rigorous review methodology. Search date The review includes trials published up to 1 March 2019. Study characteristics We included 10 randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) with 934 participants. All trials compared Xiao Chai Hu Tang formula with no treatment. The trials assessed different formulas and doses for three to eight months. One trial included participants with tuberculosis (a disease of the lungs that can make you cough mucous), and one trial included participants with liver cirrhosis (scarring). Only five trials with 490 participants provided data for analysis Study funding sources Two of the 10 included trials reported receiving academic funding. None of the remaining eight trials reported information of support or funding. Key results None of the 10 included trials reported data on all‐cause mortality (death from any cause), serious side effects (untoward medical occurrences that result in serious outcomes such as death or disability), health‐related quality of life (a measure of physical, mental, emotional, and social functioning a measure of a person's satisfaction with their life and health), hepatitis B‐related death, and hepatitis B‐related morbidity. We are uncertain whether Xiao Chai Hu Tang formula versus no intervention has a positive or negative effect regarding side effects considered 'not to be serious', the proportion of people with detectable HBeAg (a hepatitis B viral protein that indicates active viral replication), and separately reported side effects considered 'not to be serious'. Xiao Chai Hu Tang formula compared with no intervention seems to reduce the proportion of people with detectable HBV‐DNA (which is used to indicate how much hepatitis B virus is in the blood) but the reliability of this finding is low. Surrogate outcomes are markers that are used in research as a substitute for a clinically meaningful measure that directly measures patient outcomes. We cannot always be certain that such surrogate outcomes are reliable substitutes for important outcomes as they need to be officially examined. Caution is needed with this beneficial finding as the trials are at high risk of bias, and this outcome has not yet been proven relevant to patients. We identified an additional 47 studies as potential randomised clinical trials, but the data they reported were of no use. Accordingly, properly designed randomised clinical trials are needed before the benefits and harms of Xiao Chai Hu Tang formula for chronic hepatitis B can be determined. Reliability of the evidence The reliability of the evidence on the use of Xiao Chai Hu Tang formula in people with chronic hepatitis B virus in terms of its beneficial or harmful effects on death, health‐related quality of life, risk of dying due to hepatitis B virus infection, and serious side effects cannot be determined as no trials aimed to explore these. The reliability of the evidence that Xiao Chai Hu Tang formula, when compared with no intervention, in terms of side effects considered 'not to be serious', the proportion of people with detectable HBV‐DNA, and the proportion of people with detectable HBeAg is very low. These assessments of the reliability of the evidence are due to the poor design and reporting of the included trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kong, DZ, Liang, N, Yang, GL, Zhang, Z, Liu, Y, Li, J, Liu, X, Liang, S, Nikolova, D, Jakobsen, JC, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.765Z" }, { "id": "5e8c4bfd-c6ea-454e-9c14-e83210d59506", "pmid": "", "title": "Smectite for acute infectious diarrhoea in children", "imported": false, "abstract": "Abstract - Background As mortality secondary to acute infectious diarrhoea has decreased worldwide, the focus shifts to adjuvant therapies to lessen the burden of disease. Smectite, a medicinal clay, could offer a complementary intervention to reduce the duration of diarrhoea. Objectives To assess the effects of smectite for treating acute infectious diarrhoea in children. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Pubmed), Embase (Ovid), LILACS, reference lists from studies and previous reviews, and conference abstracts, up to 27 June 2017. Selection criteria Randomized and quasi‐randomized trials comparing smectite to a control group in children aged one month to 18 years old with acute infectious diarrhoea. Data collection and analysis Two review authors independently screened abstracts and the full texts for inclusion, extracted data, and assessed risk of bias. Our primary outcomes were duration of diarrhoea and clinical resolution at day 3. We summarized continuous outcomes using mean differences (MD) and dichotomous outcomes using risk ratios (RR), with 95% confidence intervals (CI). Where appropriate, we pooled data in meta‐analyses and assessed heterogeneity. We explored publication bias using a funnel plot. Main results Eighteen trials with 2616 children met our inclusion criteria. Studies were conducted in both ambulatory and in‐hospital settings, and in both high‐income and low‐ or middle‐income countries. Most studies included children with rotavirus infections, and half included breastfed children. Smectite may reduce the duration of diarrhoea by approximately a day (MD ‐24.38 hours, 95% CI ‐30.91 to ‐17.85; 14 studies; 2209 children; low‐certainty evidence); may increase clinical resolution at day 3 (risk ratio (RR) 2.10, 95% CI 1.30 to 3.39; 5 trials; 312 children; low‐certainty evidence); and may reduce stool output (MD ‐11.37, 95% CI ‐21.94 to ‐0.79; 3 studies; 634 children; low‐certainty evidence). We are uncertain whether smectite reduces stool frequency, measured as depositions per day (MD ‐1.33, 95% CI ‐2.28 to ‐0.38; 3 studies; 954 children; very low‐certainty evidence). There was no evidence of an effect on need for hospitalization (RR 0.93, 95% CI 0.75 to 1.15; 2 studies; 885 children; low‐certainty evidence) and need for intravenous rehydration (RR 0.77, 95% CI 0.54 to 1.11; 1 study; 81 children; moderate‐certainty evidence). The most frequently reported side effect was constipation, which did not differ between groups (RR 4.71, 95% CI 0.56 to 39.19; 2 studies; 128 children; low‐certainty evidence). No deaths or serious adverse effects were reported. Authors' conclusions Based on low‐certainty evidence, smectite used as an adjuvant to rehydration therapy may reduce the duration of diarrhoea in children with acute infectious diarrhoea by a day; may increase cure rate by day 3; and may reduce stool output, but has no effect on hospitalization rates or need for intravenous therapy. 2 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (27 Jun, 2017) were included Plain language summary Smectite for treating children with acute diarrhoea What is the aim of this review? The aim of this Cochrane Review was to find out if smectite (or diosmectite), a medicinal clay commonly prescribed to people who have diarrhoea in order to reduce their stool output, helps children with acute diarrhoea. We collected and analysed all relevant studies to answer this question and found 18 relevant studies. Key messages Giving smectite to children with acute diarrhoea may reduce its duration. However, more high‐quality studies are still needed, including studies that assess different causes of diarrhoea and the economic effects of this treatment. What was studied in the review? Acute diarrhoea is one of the most common diseases in children. It is usually caused by a viral infection. The main aim of treatment is to maintain a good level of hydration. This is achieved with oral rehydration solutions, and few children need to be hospitalized or require intravenous rehydration. Still, even with proper hydration, having loose stools is a burden for both parents and patients. Smectite may help by reducing inflammation in the gut; by acting as a barrier to reduce the penetration of toxins; or by increasing water absorption. What are the main results? We found 18 relevant studies with 2616 children that were conducted in both high‐income and low‐ or middle‐income countries. These studies compared children receiving smectite with children receiving routine care or a placebo (a pill or liquid that contains no medicine). Eight studies were funded by the manufacturer. Smectite may reduce the duration of diarrhoea by one day (low‐certainty evidence); may increase the number of children cured by day 3 (low‐certainty evidence); and may slightly reduce the quantity of loose stools (low‐certainty evidence). We are uncertain whether smectite has an effect on how many stools children have (very low‐certainty evidence). It may not have an effect on how many children need to be hospitalized (low‐certainty evidence), and probably does not have an effect on how many children need intravenous rehydration (moderate‐certainty evidence). We found no reports of serious adverse effects. Minor adverse effects included constipation, vomiting, and bad taste, but these did not differ between groups. How up‐to‐date is this review? We searched for studies published up to 27 June 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pérez‐Gaxiola, G; Cuello‐García, CA; Florez, ID; Pérez‐Pico, VM", "articleTypes": [], "doi": "10.1002/14651858.CD011526.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "5ec298c0-bf06-4e0b-884a-f954be58cba0", "pmid": "", "title": "Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low‐ and middle‐income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid‐based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition. Objectives To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low‐ and middle‐income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective. Search methods In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. Selection criteria We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before‐and‐after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low‐ and middle‐income countries. Data collection and analysis Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses using the random‐effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods. Main results Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care ‐ the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight‐for‐height (MD 0.20 z‐score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid‐based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses ‐ there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid‐based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non‐recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight‐for‐height, and mid‐upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid‐based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses ‐ no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid‐based nutrient supplements versus specific types of blended foods ‐ a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods ‐ in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet ‐ no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. Authors' conclusions In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short‐term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent. Plain language summary Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries Moderate acute malnutrition (MAM) affects around 10% of children under five years of age in low‐ and middle‐income countries. Different food strategies have been used for the nutritional recovery of children with MAM, such as lipid‐based nutrient supplements or blended foods, which can be provided in full dose or in a low dose as a complement to the usual diet. However, there is no definitive consensus on the most effective way to treat children with MAM. We searched eight electronic databases and three trials registers (in October 2012 for all except Embase, which was searched in August 2012). We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. We found eight relevant randomised controlled trials, enrolling 10,037 children under five years of age. All but one study was conducted in Africa. The risk of bias in the studies was generally low, though two studies had a high dropout rate. The participants were aware which intervention group they were in and this may have influenced their behaviour but we thought it unlikely it would have influenced the results since the outcomes measured were objective ones. For four of the studies, we were unable to assess if the study authors reported all the outcomes they intended to measure. When any type of specially formulated food was compared to standard care (medical care and counselling without foods), the children treated with foods had a higher chance of recovering from moderate malnutrition (two studies), greater improvement in nutritional status (two studies), and a lower number of dropouts (one study). A reduction in mortality was not shown. When lipid‐based nutrient supplements (which are food with high energy density and high lipid content) at full dose were compared to blended foods at full dose (which are dry food mixtures without high lipid content), there was no difference between these two types of foods in terms of number of deaths (five studies), children progressing to severe acute malnutrition (three studies), and children dropping out (four studies). However, lipid‐based nutrient supplements increased the number recovered by 10% (five studies), decreased the number of children non‐recovering (three studies), and slightly improved the nutritional status among the recovered. One study observed more children vomiting when given lipid‐based nutrient supplements compared to blended foods, but this was not reported by the other studies. No other side effects were reported. Few studies evaluated foods at complementary dosage (i.e. foods given in low quantity, just to complement the diet and not to fully substitute it), and no conclusion could be drawn from these studies. When specific foods were compared to each other, a type of corn‐soy blended food called CSB++ compared to lipid‐based nutrient supplements resulted in similar outcomes, while results of another blended food (CSB pre‐mix) versus lipid‐based nutrient supplements were unclear. In one study, CSB++ did not show any significant benefit over locally‐made blended foods, for example, Misola. No study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with moderate acute malnutrition. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. There are no studies evaluating special recipes to improve the adequacy of the usual home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lazzerini, M; Rubert, L; Pani, P", "articleTypes": [], "doi": "10.1002/14651858.CD009584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "5ec92052-a972-4c0b-b053-0b2e75b24150", "pmid": "", "title": "Oral zinc for treating diarrhoea in children", "imported": false, "abstract": "Abstract - Background In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). Objectives To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, m RCT, and reference lists up to 30 September 2016. We also contacted researchers. Selection criteria Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery. Data collection and analysis Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses (using either a fixed‐effect or random‐effects model) and assessed heterogeneity. We assessed the certainty of the evidence using the GRADE approach. Main results Thirty‐three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoea There is currently not enough evidence from well‐conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized ( very low certainty evidence ). In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD −11.46 hours, 95% CI −19.72 to −3.19; 2581 children, 9 trials, low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD −26.39 hours, 95% CI −36.54 to −16.23; 419 children, 5 trials, high certainty evidence ). Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI −4.00 to 14.45; 1334 children, 2 trials, low certainty evidence ), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, low certainty evidence ). None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence ; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence ). Persistent diarrhoea In children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD −15.84 hours, 95% CI −25.43 to −6.24; 529 children, 5 trials, moderate certainty evidence ). Authors' conclusions In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency. 12 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (30 Sep, 2016) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Oral zinc supplementation for treating diarrhoea in children In low‐ and middle‐income countries, millions of children suffer from severe diarrhoea every year and many die from dehydration. Giving fluids by mouth (using an oral rehydration solution (ORS)) has been shown to save children's lives, but it has no effect on the length of time the children suffer with diarrhoea. Zinc supplementation could help reduce the duration and the severity of diarrhoea, and therefore have an additional benefit over ORS in reducing children mortality. What is oral zinc and how may it shorten the duration and severity of diarrhoea Zinc is usually given as zinc sulphate, zinc acetate, or zinc gluconate, which are all water‐soluble compounds. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend 10 mg to 20 mg of zinc per day for children with diarrhoea. There are several mechanism of action of zinc on acute diarrhoea, some of which are specific to the gastrointestinal system: zinc restores mucosal barrier integrity and enterocyte brush‐border enzyme activity, it promotes the production of antibodies and circulating lymphocytes against intestinal pathogens, and has a direct effect on ion channels, acting as a potassium channel blocker of adenosine 3‐5‐cyclic monophosphate‐mediated chlorine secretion. Cochrane researchers examined the evidence available up to 30 September 2016. What the evidence in the review suggests Thirty‐three trials that included 10,841 children met the inclusion criteria of this review. Among children with acute diarrhoea, we don't know if treating children with zinc has an effect on death or number of children hospitalized ( very low certainty evidence ). In children older than six months, zinc supplementation may shorten the average duration of diarrhoea by around half a day ( low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven ( moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day ( high certainty evidence ). Conversely, in children younger than six months, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea ( low certainty evidence ), or the number of children who still have diarrhoea on day seven ( low certainty evidence ). Zinc supplementation increased the risk of vomiting in both age groups ( moderate certainty evidence ). No other adverse effects were reported. Among children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours ( moderate certainty ) but it probably increases the risk of vomiting ( moderate certainty evidence ). In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lazzerini, M; Wanzira, H", "articleTypes": [], "doi": "10.1002/14651858.CD005436.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "5ed6ea8d-ecdf-425d-b9ef-dba3d404e4d3", "pmid": "", "title": "Antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze", "imported": false, "abstract": "Abstract - Background Worldwide, pneumonia is the leading cause of death amongst children under five years of age, and accounts for approximately two million deaths annually. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, and the severity of the disease. Treatment is then tailored according to the classification. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. The WHO recommends treating non‐severe pneumonia with oral antibiotics. Pneumonia is more commonly caused by viruses that do not require antibiotic treatment, but pneumonia caused by bacteria needs management with antibiotics to avoid complications. There is no clear way to quickly distinguish between viral and bacterial pneumonia. It is considered safe to give antibiotics, however, this may lead to the development of antibiotic resistance, and thus, limit their use in future infections. Therefore, it is essential to explore the efficacy of antibiotics for children with WHO‐defined non‐severe pneumonia and wheeze. Objectives To evaluate the efficacy of antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze. Search methods We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers (December 2020). Selection criteria We included randomised controlled trials (RCTs) evaluating the efficacy of antibiotic therapy versus no antibiotic therapy for children, aged 2 to 59 months, with non‐severe pneumonia and wheeze. We defined non‐severe pneumonia as 'a cough or difficulty in breathing, with rapid breathing (a respiratory rate of 50 breaths per minute or more for children aged 2 to 12 months, or a respiratory rate of 40 breaths per minute or more for children aged 12 to 59 months), chest indrawing and wheeze'. We excluded trials involving children with severe or very severe pneumonia, and non‐RCTs. Data collection and analysis Our primary outcomes were clinical cure and treatment failure; secondary outcomes were relapse, mortality, and treatment harms. We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Two review authors independently assessed the search results, extracted data, assessed risk of bias and the certainty of the evidence. We contacted the authors of two included trials and the author of the trial awaiting classification to obtain missing numerical outcome data. Main results We included three trials involving 3256 children aged between 2 to 59 months, who exhibited features of non‐severe pneumonia with wheeze. The included trials were multi‐centre, double‐blind, randomised, placebo‐controlled trials carried out in Malawi, Pakistan, and India. The children were treated with a three‐day course of amoxicillin or placebo, and were followed up for a total of two weeks. We assessed the included trials at overall low risk of bias for random sequence generation, allocation concealment, blinding, attrition bias, and selective reporting. Only one trial was assessed to be at high risk for blinding of outcome assessors. One trial is awaiting classification Antibiotic therapy may result in a reduction of treatment failure by 20% (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.68 to 0.94; three trials; 3222 participants; low‐certainty evidence). Antibiotic therapy probably results in little or no difference to clinical cure (RR 1.02, 95% CI 0.96 to 1.08; one trial; 456 participants; moderate‐certainty evidence), and in little or no difference to relapse (RR 1.00, 95% CI 0.74 to 1.34; three trials; 2795 participants; low‐certainty evidence), and treatment harms (RR 0.81, 95% CI 0.60 to 1.09; three trials, 3253 participants; low‐certainty evidence). Two trials (2112 participants ) reported on mortality; no deaths occurred in either group. One trial reported cases of hospitalisation, diarrhoea (with and without dehydration), rash (without itch), tremors, mild nausea and vomiting. Authors' conclusions We do not currently have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. There is a clear need for RCTs to address this question in children aged 2 to 59 months with 2014 WHO‐defined non‐severe pneumonia and wheeze. Plain language summary Comparing treatment of non‐severe pneumonia, in children aged 2 to 59 months, with and without antibiotics Review question 
We tried to identify whether there was a difference in the outcomes for children aged 2 to 59 months with non‐severe pneumonia and wheeze, treated with or without antibiotics. Background 
Pneumonia is an infection of the lungs. In children, it is one of the leading causes of deaths globally. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, severity of the disease and its treatment according to the severity. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. More commonly, pneumonia is caused by viruses that require supportive care rather than antibiotic treatment; however, pneumonia caused by bacteria should be treated with antibiotics to avoid complications. Since there is no clear way to quickly distinguish which organism actually caused the pneumonia, it is considered safe to give antibiotics. However, this may lead to the development of antibiotic resistance, and limit their use in future infections. The question is whether the use of antibiotics is justified in non‐severe pneumonia. Search date Our evidence is current to 23 December 2020. Study characteristics We included three trials (3256 children). They were conducted in four hospitals in three cities in Pakistan (Islamabad, Lahore and Rawalpindi), and in hospital outpatient departments in India and Malawi. The children were treated with a three‐day course of amoxicillin (antibiotic) or placebo, and followed up for two weeks. One trial is awaiting classification. Study funding source The included trials were supported by the USAID through INCLEN and IndiaClen; ARI Research Cell, Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and by a grant from the Bill & Melinda Gates Foundation. Key results Limited data showed a 20% reduction in treatment failure, however, no impact was observed on clinical cure, relapse, and treatment harms. No deaths were reported in either group. Our review did not have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. Certainty of the evidence The certainty of evidence for clinical cure was moderate. The certainty of evidence for treatment failure, relapse, and treatments harms was low, due to downgrading for imprecision and risk of bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lassi, ZS; Padhani, ZA; Das, JK; Salam, RA; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD009576.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "5ee86827-03f3-45da-8949-929342c8da0e", "pmid": "", "title": "Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2010 and previously updated in 2011. Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period. Objectives To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 4 July 2013. Selection criteria We included randomised controlled trials in which oral rinses, mouthwashes and sprays, used pre‐ and postoperatively, have been compared with placebo in adults or children undergoing tonsillectomy, with or without adenoidectomy. Data collection and analysis Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently. Main results We included seven trials (593 participants; 397 children and 196 adults). The period of follow‐up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre‐specified primary outcomes and none for the secondary outcomes. The risk of bias was high in most of the included trials. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage. Authors' conclusions Poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well‐constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data. Plain language summary Oral rinses, mouthwashes and sprays for improving outcomes following tonsillectomy Tonsillectomy is one of the most common operations performed in adults and children. Pain and bleeding following the operation are common. Postoperative tonsillectomy medication should aim to minimise some of these symptoms. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the period just after surgery. This review included seven studies involving 593 participants (397 children and 196 adults) and is up to date as of July 2013. The risk of bias was high in most of the included trials. We found that lidocaine spray appeared to be more effective than a placebo saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation when they used another spray containing benzydamine but this was not sufficient to discontinue its usage. Further research should aim to provide reliable evidence for people to make informed decisions as to whether these treatments can be effective in reducing the most common symptoms and complications following tonsillectomy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fedorowicz, Z; van Zuuren, EJ; Nasser, M; Carter, B; Al Langawi, JH", "articleTypes": [], "doi": "10.1002/14651858.CD007806.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "5ee87b56-0aa4-4367-aafb-79a8106f3501", "pmid": "", "title": "Interventions for increasing fruit and vegetable consumption in children aged five years and under", "imported": false, "abstract": "Abstract - Background Insufficient consumption of fruits and vegetables in childhood increases the risk of future non‐communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child‐feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden. Objectives To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. Search methods We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials. Selection criteria We included randomised controlled trials (RCTs), including cluster‐randomised controlled trials (C‐RCTs) and cross‐over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no‐intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random‐effects models in meta‐analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures. Main results We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child‐feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child‐focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate‐certainty evidence that child‐feeding practice interventions versus no‐intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as‐desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post‐intervention follow‐up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low‐certainty evidence). Multicomponent interventions versus no‐intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate‐certainty evidence; mean post‐intervention follow‐up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden‐based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low‐certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short‐term impact on child consumption of fruit and vegetables versus no‐intervention control (SMD 0.10, 95% CI ‐0.02 to 0.22; 14 trials, 4122 participants; low‐certainty evidence; mean post‐intervention follow‐up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low‐certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low‐certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding. Authors' conclusions There was moderate‐certainty evidence that child‐feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low‐ and middle‐income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. Plain language summary What are the benefits and harms of interventions to increase eating of fruit and vegetables among children aged five years and under? Key messages • Child‐feeding interventions probably lead to a small increase in eating of vegetables in children aged five years and under. • Multicomponent interventions probably lead to a small increase in eating of fruit and vegetables in children aged five years and under. • Parent nutrition education interventions may lead to little or no increase in eating of fruit and vegetables in children aged five years and under. Why is eating enough fruit and vegetables important? Not eating enough fruit and vegetables leads to a considerable health burden in developed countries. Eating adequate amounts of fruit and vegetables is associated with a reduced risk of future non‐communicable diseases (such as heart and circulatory disease) amongst other immediate health benefits. Early childhood is a critical period for the establishment of dietary habits that track into adulthood. Interventions to increase consumption of fruit and vegetables in early childhood may therefore be an effective strategy to reduce this disease burden. What did we want to find out? We wanted to know the benefits and harms of interventions designed to increase eating of fruit or vegetables or both amongst children aged five years and under. What did we do? We searched various electronic databases to find studies. We contacted the authors of the included studies for additional potentially relevant studies. Any randomised study (where participants have the same chance of being assigned to treatment or a no‐treatment control) of interventions aiming to increase the intake of fruit or vegetables or both by children aged five years and under, which measured intake, was eligible. Two review authors independently searched for and extracted information from studies. We searched up to March 2023. What did we find? We included 53 studies with 12,350 people taking part. Sixteen studies examined child‐feeding practice interventions (e.g. repeated exposure to vegetables); 20 examined multicomponent interventions (e.g. combining two or more interventions, such as preschool policy changes with parent nutrition education); 17 examined parent nutrition education interventions; two examined child nutrition education interventions; and one each examined child‐focused mindfulness or providing families with fruit and vegetable interventions. Child‐feeding practice interventions and multicomponent interventions probably lead to small increases in children's intake of fruit and vegetables in the short term (less than 12 months). Parent nutrition education interventions may lead to little to no increase in children's eating of fruit and vegetables. Limited information was available on cost and unintended harms. Of the studies that did report these, intervention costs ranged from 325 to 1500 US dollars (USD). No unintended harms were found in the two studies that reported assessing them. Studies reporting funding support received governmental or charitable funds, except for one study that received industry funding. What are the limitations of the evidence? No studies were conducted in low‐income countries and only one study was conducted in a middle‐income country. Our confidence in the current evidence is moderate for child feeding and multicomponent interventions, and low for parent nutrition education interventions. How up‐to‐date is this evidence? This evidence is up‐to‐date to March 2023. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Hodder, RK, O'Brien, KM, Wyse, RJ, Tzelepis, F, Yoong, S, Stacey, FG, Wolfenden, L", "articleTypes": [], "doi": "10.1002/14651858.CD008552.pub8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.106Z" }, { "id": "5ef37881-9d19-4e15-948d-6c1f8edaeac0", "pmid": "", "title": "Chinese herbal medicine for menopausal symptoms", "imported": false, "abstract": "Abstract - Background Chinese herbal medicine (CHM) usage is expected to increase as women suffering from menopausal symptoms are seeking alternative therapy due to concerns from the adverse effects (AEs) associated with hormone therapy (HT). Scientific evidence for their effectiveness and safety is needed. Objectives To evaluate the effectiveness and safety of CHM in the treatment of menopausal symptoms. Search methods We searched the Gynaecology and Fertility Group's Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), MEDLINE, Embase, CINAHL, AMED, and PsycINFO (from inception to March 2015). Others included Current Control Trials, Citation Indexes, conference abstracts in the ISI Web of Knowledge, LILACS database, PubMed, OpenSIGLE database, and China National Knowledge Infrastructure database (CNKI, 1999 to 2015). Other resources included reference lists of articles as well as direct contact with authors. Selection criteria Randomised controlled trials (RCTs) comparing the effectiveness of CHM with placebo, HT, pharmaceutical drugs, acupuncture, or another CHM formula in women over 18 years of age, and suffering from menopausal symptoms. Data collection and analysis Two review authors independently assessed 864 studies for eligibility. Data extractions were performed by them with disagreements resolved through group discussion and clarification of data or direct contact with the study authors. Data analyses were performed in accordance with Cochrane Collaboration guidelines. Main results We included 22 RCTs (2902 women). Participants were from different ethnic backgrounds with the majority of Chinese origin. When CHM was compared with placebo (eight RCTs), there was little or no evidence of a difference between the groups for the following pooled outcomes: hot flushes per day (MD 0.00, 95% CI ‐0.88 to 0.89; 2 trials, 199 women; moderate quality evidence); hot flushes per day assessed by an overall hot flush score in which a difference of one point equates to one mild hot flush per day (MD ‐0.81 points, 95% CI ‐2.08 to 0.45; 3 RCTs, 263 women; low quality evidence); and overall vasomotor symptoms per month measured by the Menopause‐Specific Quality of Life questionnaire (MENQOL, scale 0 to 6) (MD ‐0.42 points; 95% CI ‐1.52 to 0.68; 3 RCTs, 256 women; low quality evidence). In addition, results from individual studies suggested there was no evidence of a difference between the groups for daily hot flushes assessed by severity (MD ‐0.70 points, 95% CI ‐1.00, ‐0.40; 1 RCT, 108 women; moderate quality evidence); or overall monthly hot flushes scores (MD ‐2.80 points, 95% CI ‐8.93 to 3.33; 1 RCT, 84 women; very low quality evidence); or overall daily night sweats scores (MD 0.07 points, 95% CI ‐0.19 to 0.33, 1 RCT, 64 women; low quality evidence); or overall monthly night sweats scores (MD 1.30 points, 95% CI ‐1.76 to 4.36, 1 RCT, 84 women; very low quality evidence). However one study using the Kupperman Index reported that overall monthly vasomotor symptom scores were lower in the CHM group (MD ‐4.79 points, 95% CI ‐5.52 to ‐4.06; 1 RCT, 69 women; low quality evidence). When CHM was compared with hormone therapy (HT) (10 RCTs), only two RCTs reported monthly vasomotor symptoms using MENQOL. It was uncertain whether CHM reduces vasomotor symptoms (MD 0.47 points, 95% CI ‐0.50 to 1.44; 2 RCTs, 127 women; very low quality evidence). Adverse effects were not fully reported in the included studies. Adverse events reported by women taking CHM included mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects were inconclusive because of imprecise estimates of effects: CHM versus placebo (RR 1.51; 95% CI 0.69 to 3.33; 7 trials, 705 women; I² = 40%); CHM versus HT (RR 0.96; 95% CI 0.66 to 1.39; 2 RCTs, 864 women; I² = 0%); and CHM versus specific conventional medications (such as Fluoxetine and Estazolam) (RR 0.20; 95% CI 0.03 to 1.17; 2 RCTs, 139 women; I² = 61%). Authors' conclusions We found insufficient evidence that Chinese herbal medicines were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Effects on safety were inconclusive. The quality of the evidence ranged from very low to moderate; there is a need for well‐designed randomised controlled studies. Plain language summary Title: Chinese herbal medicines for menopausal symptoms Review Question: Are Chinese herbal medicines effective and safe for relieving menopausal symptoms? Background: Menopause usually takes place when a woman is around 51 years of age. Women can experience symptoms such as hot flushes, sweats, poor sleep, joint pains, anxiousness, dry skin and vagina when the organs which produce female hormones slow down. Usually hormone therapy (HT) is prescribed to reduce the symptoms. Due to concerns on long term use of HT resulting in adverse effects, women have been looking for alternative treatments to relieve their symptoms. Chinese herbal medicines (CHM) is one of the popular choices. Although CHM has been used for a very long time clinically, its effectiveness and long‐term safety remained unanswered from a scientific perspective. Study characteristics: This review examined 22 randomised clinical trials where 2902 women took part in the studies; 1499 in the CHM group and 1403 in the control group which might include a placebo (non‐active compound made to look, taste and smell the same as the study compound) or a drug or HT or another CHM formula (different from the one being tested). Most of the studies had a trial period for 12 weeks. The data are current to March 2015. Key results: We found insufficient evidence that CHM were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Adverse effects were not well reported, some women taking CHM reported mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects on safety were inconclusive. Quality of the evidence: The quality of the evidence ranged from very low to moderate. The studies did not produce good quality evidence to allow the authors to draw a conclusive statement regarding the effectiveness or safety of CHM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Zhu, X; Liew, Y; Liu, ZL", "articleTypes": [], "doi": "10.1002/14651858.CD009023.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "5ef43ad2-58ac-437d-b049-5af6503044a4", "pmid": "", "title": "Zinc supplements for preventing otitis media", "imported": false, "abstract": "Abstract - Background Otitis media is inflammation of the middle ear and is usually caused by infection. It affects people of all ages but is particularly common in young children. Around 164 million people worldwide have long‐term hearing loss caused by this condition, 90% of them in low‐income countries. As zinc supplements prevent pneumonia in disadvantaged children, we wanted to investigate whether zinc supplements could also prevent otitis media. Objectives To evaluate whether zinc supplements prevent otitis media in adults and children of different ages. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (1950 to February week 4, 2014) and EMBASE (1974 to March 2014). Selection criteria Randomised, placebo‐controlled trials of zinc supplements given at least once a week for at least a month for preventing otitis media. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of the included trials and extracted and analysed data. We summarised results using risk ratios (RRs) or rate ratios for dichotomous data and mean differences (MDs) for continuous data. We combined trial results where appropriate. Main results No new trials were identified for inclusion in this update. We identified 12 trials for inclusion, 10 of which contributed outcomes data. There were a total of 6820 participants. In trials of healthy children living in low‐income communities, two trials did not demonstrate a significant difference between the zinc‐supplemented and placebo groups in the numbers of participants experiencing an episode of definite otitis media during follow‐up (3191 participants); another trial showed a significantly lower incidence rate of otitis media in the zinc group (rate ratio 0.69, 95% confidence interval (CI) 0.61 to 0.79, n = 1621). A small trial of 39 infants undergoing treatment for severe malnutrition suggested a benefit of zinc for the mean number of episodes of otitis media (mean difference (MD) ‐1.12 episodes, 95% CI ‐2.21 to ‐0.03). Zinc supplements did not seem to cause any serious adverse events but a small minority of children were reported to have vomited shortly after ingestion of the supplements. The trial evidence included is generally of good quality, with a low risk of bias. Authors' conclusions Evidence on whether zinc supplementation can reduce the incidence of otitis media in healthy children under the age of five years living in low‐ and middle‐income countries is mixed. There is some evidence of benefit in children being treated for marasmus (severe malnutrition), but this is based on one small trial and should therefore be treated with caution. Plain language summary Zinc supplements for preventing middle ear infections Background Middle ear infections are common, especially among young children, usually causing earache and some temporary (occasionally permanent) hearing loss. Zinc is an essential micronutrient, which has a role in the optimal functioning of the immune system and resistance to infection. It must be consumed regularly as it cannot be stored in the body. Some people, especially children in low‐ and middle‐income countries, may not have adequate zinc intake from food alone. Researchers have examined the potential role of zinc supplements in preventing infective illnesses. Therefore we wanted to discover whether zinc supplements have any role in preventing middle ear infections. Study characteristics The review authors searched the medical literature for studies up to March 2014. We searched for trials which compared middle ear infections in people randomly selected to receive zinc supplements or who did not receive supplements. We found 10 eligible studies, all conducted amongst young children. The total number of participants was 6820. Nine trials were conducted in low‐ and middle‐income countries. Seven trials were conducted on healthy children. Participants included both males and females. Results The results of the trials provided no convincing evidence that zinc supplements reduce the occurrence of middle ear infections in healthy children. However, in one small study of severely malnourished children, those receiving zinc supplements had fewer middle ear infections. The only adverse effect was vomiting. Quality of evidence The trial evidence included is generally of good quality, with a low risk of bias. All the included trials included otitis media only as a secondary outcome. Therefore, there was a potential to miss trials which were less publicised or less well indexed within the electronic databases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Gulani, A, Sachdev, HS", "articleTypes": [], "doi": "10.1002/14651858.CD006639.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.744Z" }, { "id": "5f15fd7f-3198-411e-824b-a326036de2a8", "pmid": "", "title": "Probiotics for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Trivedi, A, Teo, E, Walker, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012265.pub2 AB - Abstract - Background The intestinal microflora has an essential role in providing a barrier against colonisation of pathogens, facilitating important metabolic functions, stimulating the development of the immune system, and maintaining intestinal motility. Probiotics are live microorganisms that can be administered to supplement the gut flora. Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be partly due to a disruption of the integrity of the gut and its intestinal microflora. There may be a role for probiotics in reducing the incidence of sepsis and improving intestinal motility, thus reducing morbidity and mortality and improving enteral feeding in neonates in the postoperative period. Objectives To evaluate the efficacy and safety of administering probiotics after gastrointestinal surgery for the postoperative management of neonates born from 35 weeks of gestation. Search methods We searched CENTRAL, MEDLINE, Embase, and trial registries in August 2023. We checked reference lists of included studies and relevant systematic reviews for additional studies. Selection criteria We included randomised controlled trials (RCTs) that investigated the postoperative administration of oral probiotics versus placebo or no treatment in neonates born from 35 weeks of gestation who had one or more gastrointestinal surgical procedures. We applied no restrictions regarding the type or dosage of probiotics or the duration of treatment. Data collection and analysis We used standard Cochrane methods, and we used GRADE to assess the certainty of evidence. Main results We identified one RCT that recruited 61 neonates with a gestational age of 35 weeks or more. All infants were admitted to a neonatal intensive care unit and had surgery for gastrointestinal pathologies. There may be little or no difference in proven sepsis (positive bacterial culture, local or systemic) between infants who receive probiotics compared with those who receive placebo (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.16 to 2.55; 61 infants; low‐certainty evidence). Probiotics compared to placebo may have little or no effect on time to full enteral feeds (mean difference (MD) 0.63 days, 95% CI −4.02 to 5.28; 61 infants; low‐certainty evidence). There were no reported deaths prior to discharge from hospital in either study arm. Two weeks after supplementation, the infants who received probiotics had a substantially higher relative abundance of non‐pathogenic intestinal microflora (Bifidobacteriaceae) than those who received placebo (MD 38.22, 95% CI 28.40 to 48.04; 39 infants; low‐certainty evidence). Authors' conclusions This review provides low‐certainty evidence from one small RCT that probiotics compared to placebo have little or no effect on the risk of proven sepsis (positive bacterial culture, local or systemic) or time to full‐enteral feeds in neonates who have undergone gastrointestinal surgery. Probiotics may substantially increase the abundance of beneficial bacterial in the intestine of these neonates, but the clinical implications of this finding are unknown. There is a need for adequately powered RCTs to assess the role of probiotics in this population. We identified two ongoing studies. As neither reported the gestational age of prospective study participants, we are unsure if they will be eligible for inclusion in this review. Plain language summary Benefits and harms of giving probiotics to newborns after digestive tract surgery Key message • Probiotics may have little or no effect on the risk of blood infection in infants born from 35 weeks of pregnancy who have undergone surgery of the digestive tract (food pipe, stomach, or bowel).
• Probiotics may increase the proportion of 'good' bacteria in the bowel, but we do not know if this has any real benefit for the infant. What are probiotics? Probiotics are live bacteria that may offer health benefits when consumed. There is evidence that probiotics can prevent an inflammatory disease of the bowel (necrotising enterocolitis) and infection in premature babies. What are some of the risks of bowel surgery in babies? Surgery of the digestive tract increases the risk of infection, and infection can increase the length of hospital stay. Treatment with antibiotics (medicines that treat bacterial infection) and the stress of surgery can diminish the 'good' bacteria in the bowel. What did we want to find out? We wanted to find out if giving probiotics to babies born from 35 weeks of pregnancy who underwent stomach or bowel surgery could improve rates of infection, length of hospital stay, rates of death, feeding, and the proportion of 'good' bacteria in the stomach and bowel. What did we do? We searched for studies that randomly assigned babies to experimental treatment (probiotics) or a control, which could be placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested) or no treatment. What did we find? We found one small study of 61 babies born from 35 weeks of pregnancy who had digestive tract surgery. Thirty babies received probiotics after the surgery, and 30 received a placebo. In the probiotics group, 13% of babies had a blood infection, compared with 19% in the placebo group. This difference is too small to be significant. On average, the babies in the probiotic group were receiving food into their stomach about 15 hours sooner than those in the placebo group. Again, this difference is not important. Among 39 infants who were tested, those in the probiotics group had considerably more 'good' bacteria in their bowel compared to the placebo group. What are the limitations of the evidence? We have little confidence in the evidence because it is based on a single study with few participants. The evidence is not strong enough to support giving probiotics routinely. Well‐designed and large studies are needed to determine the benefits and harms of giving probiotics to newborns after digestive tract surgery. How up to date is this evidence? The evidence is up to date to August 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.128Z" }, { "id": "5f239b7c-6a71-4082-92e7-4183d972c4e2", "pmid": "", "title": "Non‐immunosuppressive treatment for IgA nephropathy", "imported": false, "abstract": "Abstract - Background IgA nephropathy (IgAN) is the most common primary glomerular disease, with approximately 20% to 40% of patients progressing to kidney failure within 25 years. Non‐immunosuppressive treatment has become a mainstay in the management of IgAN by improving blood pressure (BP) management, decreasing proteinuria, and avoiding the risks of long‐term immunosuppressive management. Due to the slowly progressive nature of the disease, clinical trials are often underpowered, and conflicting information about management with non‐immunosuppressive treatment is common. This is an update of a Cochrane review, first published in 2011. Objectives To assess the benefits and harms of non‐immunosuppressive treatment for treating IgAN in adults and children. We aimed to examine all non‐immunosuppressive therapies (e.g. anticoagulants, antihypertensives, dietary restriction and supplementation, tonsillectomy, and herbal medicines) in the management of IgAN. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to December 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs of non‐immunosuppressive agents in adults and children with biopsy‐proven IgAN were included. Data collection and analysis Two authors independently reviewed search results, extracted data and assessed study quality. Results were expressed as mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI) using random‐effects meta‐analysis. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results This review includes 80 studies (4856 participants), of which 24 new studies (2018 participants) were included in this review update. The risk of bias within the included studies was mostly high or unclear for many of the assessed methodological domains, with poor reporting of important key clinical trial methods in most studies. Antihypertensive therapies were the most examined non‐immunosuppressive therapy (37 studies, 1799 participants). Compared to placebo or no treatment, renin‐angiotensin system (RAS) inhibition probably decreases proteinuria (3 studies, 199 participants: MD ‐ 0.71 g/24 h, 95% CI ‐1.04 to ‐0.39; moderate certainty evidence) but may result in little or no difference to kidney failure or doubling of serum creatinine (SCr), or complete remission of proteinuria (low certainty evidence). Death, remission of haematuria, relapse of proteinuria or > 50% increase in SCr were not reported. Compared to symptomatic treatment, RAS inhibition (3 studies, 168 participants) probably decreases proteinuria (MD ‐1.16 g/24 h, 95% CI ‐1.52 to ‐0.81) and SCr (MD ‐9.37 µmol/L, 95% CI ‐71.95 to ‐6.80) and probably increases creatinine clearance (2 studies, 127 participants: MD 23.26 mL/min, 95% CI 10.40 to 36.12) (all moderate certainty evidence); however, the risk of kidney failure is uncertain (1 study, 34 participants: RR 0.20, 95% CI 0.01 to 3.88; very low certainty evidence). Death, remission of proteinuria or haematuria, or relapse of proteinuria were not reported. The risk of adverse events may be no different with RAS inhibition compared to either placebo or symptomatic treatment (low certainty evidence). In low certainty evidence, tonsillectomy in people with IgAN in addition to standard care may increase remission of proteinuria compared to standard care alone (2 studies, 143 participants: RR 1.90, 95% CI 1.45 to 2.47) and remission of microscopic haematuria (2 studies, 143 participants: RR 1.93, 95% CI 1.47 to 2.53) and may decrease relapse of proteinuria (1 study, 73 participants: RR 0.70, 95% CI 0.57 to 0.85) and relapse of haematuria (1 study, 72 participants: RR 0.70, 95% CI 0.51 to 0.98). Death, kidney failure and a > 50% increase in SCr were not reported. These trials have only been conducted in Japanese people with IgAN, and the findings' generalisability is unclear. Anticoagulant therapy, fish oil, and traditional Chinese medicines exhibited small benefits to kidney function in patients with IgAN when compared to placebo or no treatment. However, compared to standard care, the kidney function benefits are no longer evident. Antimalarial therapy compared to placebo in one study reported an increase in a > 50% reduction of proteinuria (53 participants: RR 3.13 g/24 h, 95% CI 1.17 to 8.36; low certainty evidence). Although, there was uncertainty regarding adverse events from this study due to very few events. Authors' conclusions Available RCTs focused on a diverse range of interventions. They were few, small, and of insufficient duration to determine potential long‐term benefits on important kidney and cardiovascular outcomes and harms of treatment. Antihypertensive agents appear to be the most beneficial non‐immunosuppressive intervention for IgAN. The antihypertensives examined were predominantly angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers. The benefits of RAS inhibition appear to outweigh the harms in patients with IgAN. The certainty of the evidence of RCTs demonstrating a benefit of tonsillectomy to patients with Japanese patients with IgAN was low. In addition, these findings are inconsistent across observational studies in people with IgAN of other ethnicities; hence, tonsillectomy is not widely recommended, given the potential harm of therapy. The RCT evidence is insufficiently robust to demonstrate efficacy for the other non‐immunosuppressive treatments evaluated here. Plain language summary Non‐immunosuppressive treatment for IgA nephropathy Key messages Treatment with renin‐angiotensin system (RAS) inhibition, namely angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, is the most common first‐line, non‐immunosuppressive therapy used for managing patients with IgA nephropathy (IgAN). The role of other non‐immunosuppressive treatments in managing IgAN is unclear and warrants further clinical studies. Why treat IgA nephropathy with non‐immunosuppressive therapies? IgAN is one of the most common kidney diseases, leading to reduced kidney function and kidney failure for about 20% to 40% of patients within 20 to 25 years. The cause of IgAN is not widely understood, but most people have an abnormality in their immune system that leads to damage to the kidney. However, other non‐immune functions play a role in the disease's impact on the kidney. What did we want to find out? We wanted to find out if non‐immunosuppressive treatments (e.g. antihypertensive agents, anticoagulants, fish oil, tonsillectomy, herbal medicine) improved kidney function in adults and children with IgAN. What did we do? We searched for all trials that assessed the benefits and harms of randomly allocated non‐immunosuppressive treatment in people with IgAN. We compared and summarised the results of the trials and rated our confidence in the information based on factors such as trial methods and sizes. What did we find? We included 80 studies involving 4856 people with IgAN treated with a diverse collection of non‐immunosuppressive treatments. Patients in studies were given various therapies, including blood pressure lowering agents (antihypertensives), removal of participant's tonsils (tonsillectomy), antimalarials, traditional Chinese medicine, dietary supplements (e.g. fish oil), and vitamin D receptor agonists. Antihypertensive medication aimed at inhibiting the RAS appears to slow damage to the kidney with minimal side effects. However, its impact in preventing people from progressing to kidney failure is unclear. Other interventions, such as tonsillectomy, antimalarial medication, and low‐calorie restricted diets role in treating patients are still unclear. What are the limitations of the evidence? The small number of studies per comparison and the small size of the studies were limitations in this review. Not all the studies provided data about the outcomes we were interested in. We are unsure about the results. How up to date is the evidence? The evidence is up to date as of December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Tunnicliffe, DJ, Reid, S, Craig, JC, Samuels, JA, Molony, DA, Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD003962.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.806Z" }, { "id": "5f347bcc-5b1a-4d21-a789-e8392c82ea4f", "pmid": "", "title": "Interventions for drooling in children with cerebral palsy", "imported": false, "abstract": "Abstract - Background Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation ( Blasco 1992 ; Van der Burg 2006 ). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP. Objectives (1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning. Search methods We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts. We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled‐trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts. Selection criteria Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included. Data collection and analysis Data were extracted independently by MW, MS and LP and differences resolved through discussion. Main results Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin‐A (BoNT‐A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro‐motor and oro‐sensory therapies, behavioural interventions, intra‐oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta‐analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies. Authors' conclusions It was not possible to reach a conclusion on the effectiveness and safety of either BoNT‐A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided. Plain language summary Interventions for drooling in children with cerebral palsy Many children with CP have difficulty controlling saliva. Drooling varies in severity and can be distressing for the children, families and caregivers. Excessive drooling can cause constant damp soiled clothing, unpleasant odour, irritated, chapped or sore skin around the mouth and chin, skin and mouth infections, dehydration, difficulties chewing, interference with speech, damage to books, communication aids, computer and audio equipment. There is also risk of social rejection and social isolation for these children. Many interventions are used to reduce or eliminate drooling. These include surgery, medications, botulinum toxin (BoNT‐A and BoNT‐B)), physical therapies, therapies to improve sensory function, behavioural therapies to assist the child in managing his/her own drooling, appliances placed in the mouth, and acupuncture. There is no clear consensus on which interventions are safe and effective in managing drooling in children with CP. This makes it hard to decide which intervention will be safest and most effective. Only RCTs and CCTs were included in this review. Trials were identified by electronic searches of databases, searches of clinical trials registers, peer reviewed journals, published conference proceedings and reference lists of relevant articles. Six trials were found. Four examined the safety and efficacy of BoNT‐A and two examined benztropine and glycopyrrolate. No trials were found on other interventions. The quality of trials was variable. The trials all differed in the children recruited, the product used, how the product was delivered and how its effectiveness was measured. All trials reported a positive reduction in drooling and all showed some statistically significant change for treatment groups up to 1 month post intervention. Few studies examined client and/or carer satisfaction with the intervention. Some looked at side effects of the intervention but no study examined the effect of interventions on the child's quality of life or psychological well being. There is insufficient evidence to support the use of one intervention over another. As trials on just two kinds of interventions were retrieved, and given the variation and quality of these studies, it is not possible to conclude that one intervention is more effective than another. The lack of trials on other interventions does not suggest that these interventions are ineffective. Adequately powered well designed trials are required across all interventions. In addition to using sensitive measures looking at change in salivary flow, measures are needed that examine client and carer satisfaction, changes in quality of life, psychological well being and in unwanted symptoms associated with drooling.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Walshe, M, Smith, M, Pennington, L", "articleTypes": [], "doi": "10.1002/14651858.CD008624.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.741Z" }, { "id": "5f44491b-3dd7-41f7-8663-3c964817940b", "pmid": "", "title": "Translational Health Research Into Vascular and Neurocognitive Effects of Weight Loss", "imported": false, "abstract": "The goal of this clinical trial is to learn about the nature of brain abnormalities associated with excess body fat in healthy adults aged 35-55. The main questions it aims to answer are:", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.265Z" }, { "id": "5f594cc3-869a-48f2-bee1-8438289134dc", "pmid": "", "title": "Sucrose and Non Nutritive Suck as Analgesia for Babies Undergoing Retinopathy of Prematurity Screening; a Randomised Placebo Controlled Trial", "imported": false, "abstract": "Retinopathy of Prematurity (ROP) screening is one of many potentially painful diagnostic and therapeutic procedures performed routinely on preterm infants in the Neonatal Intensive Care Unit. Therefore strategies for stress reduction and pain management are essential to promote growth and development and minimize long-term sequelae. Procedural analgesia should include concepts of developmental care, non nutritive suck (NNS), pharmacological and non-pharmacological agents. Sucrose is thought to stimulate the body's activation of lingual sweet taste receptors and release of endogenous opioids, when combined with NNS, non-opioid mechanisms are also activated. The administration of sucrose or the combination of sucrose and non-nutritive sucking is one of the most frequently studied non-pharmacological interventions for relief of pain in neonates and oral sucrose has been shown to be an effective and safe therapy for common neonatal procedures such as heal lance, blood-letting and venepuncture. There is conflicting evidence on the benefit of sucrose in ROP screening. Therefore the purpose of this study is to determine the efficacy of sucrose combined with NNS as a potential regime for reduction of pain associated with retinopathy of prematurity screening.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "5f7bbe73-8a3c-4713-b879-3d71dec9c3c7", "pmid": "", "title": "Topical lidocaine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Lidocaine is a local anaesthetic that is sometimes used on the skin to treat neuropathic pain. Objectives To assess the analgesic efficacy of topical lidocaine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 1 July 2014, together with the reference lists of retrieved papers and other reviews. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal to identify additional published or unpublished data. Selection criteria We included randomised, double‐blind studies of at least two weeks' duration comparing any formulation of topical lidocaine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts; at least 200 participants in the comparison, 8 to 12 weeks' duration, parallel design); second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison; and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. Main results We included 12 studies (508 participants) in comparisons with placebo or an active control. Six studies enrolled participants with moderate or severe postherpetic neuralgia, and the remaining studies enrolled different, or mixed, neuropathic pain conditions, including trigeminal neuralgia and postsurgical or post‐traumatic neuralgia. Four different formulations were used: 5% medicated patch, 5% cream, 5% gel, and 8% spray. Most studies used a cross‐over design, and two used a parallel‐group design. Two studies used enriched enrolment with randomised withdrawal. Seven studies used multiple doses, with one to four‐week treatment periods, and five used single applications. We judged all of the studies at high risk of bias because of small size or incomplete outcome assessment, or both. There was no first or second tier evidence, and no pooling of data was possible for efficacy outcomes. Only one multiple‐dose study reported our primary outcome of participants with ≥ 50% or ≥ 30% pain intensity reduction. Three single‐dose studies reported participants who were pain‐free at a particular time point, or had a 2‐point (of 10) reduction in pain intensity. The two enriched enrolment, randomised withdrawal studies reported time to loss of efficacy. In all but one study, third tier (very low quality) evidence indicated that lidocaine was better than placebo for some measure of pain relief. Pooling multiple‐dose studies across conditions demonstrated no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals, but there were few events and the withdrawal phase of enriched enrolment designs is not suitable to assess the true impact of adverse events (very low quality evidence). Authors' conclusions This review found no evidence from good quality randomised controlled studies to support the use of topical lidocaine to treat neuropathic pain, although individual studies indicated that it was effective for relief of pain. Clinical experience also supports efficacy in some patients. Several large ongoing studies, of adequate duration, with clinically useful outcomes should provide more robust conclusions about both efficacy and harm. Plain language summary Topical lidocaine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It differs from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are usually not effective in neuropathic pain, while medicines that are sometimes used to treat epilepsy or depression can be very effective in some people with neuropathic pain. Other possible treatments include the use of local anaesthetic applied to the skin. Lidocaine is a local anaesthetic. It is available in plasters (or patches), sprays, and creams, as topical lidocaine. These contain high concentrations of lidocaine because it crosses the skin poorly. Treatment with plasters usually involves applying one, two, or three plasters for up to 12 hours a day. In July 2014 we performed searches to look for clinical trials where topical lidocaine was used to treat neuropathic pain. We found 12 small studies of modest quality that tested topical lidocaine against topical placebo for a number of weeks. One study also tested a cream containing amitriptyline, which is an antidepressant. The 508 people in the studies had different types of neuropathic pain, with pain after herpes zoster infection the most common. There was some indication that topical lidocaine was beneficial in these studies (very low quality evidence). There was no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals (very low quality evidence). A number of studies of topical lidocaine in neuropathic pain are ongoing. Several are large and of long duration. They will be of great help in working out the benefits of topical lidocaine when they are completed and results can be incorporated in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Derry, S, Wiffen, PJ, Moore, RA, Quinlan, J", "articleTypes": [], "doi": "10.1002/14651858.CD010958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.090Z" }, { "id": "5f83e0df-5e87-4089-8806-8a9f590d4dac", "pmid": "", "title": "Anticholinergic agents for chronic asthma in adults", "imported": false, "abstract": "Abstract - Background Anticholinergic agents such as ipratropium bromide are sometimes used in the treatment of chronic asthma. They effect bronchodilation and have also been used in combination with ß2 ‐agonists in the management of chronic asthma. Objectives To examine the effectiveness of anticholinergic agents versus placebo and in comparison with ß2 ‐agonists or as adjunctive therapy to ß2 ‐agonists. Search methods The Cochrane Airways Group asthma and wheeze database was searched with a pre‐defined search strategy. Searches were current as of August 2008. Reference lists of articles were also examined. Selection criteria Randomised trials or quasi‐randomised trials were considered for inclusion. Studies assessing an anticholinergic agent versus placebo or in combination/comparison with ß2 ‐agonists were included. In practice, all ß2 ‐agonists were short acting. Short‐term (less than 24 hours duration) were not considered for this review. Data collection and analysis Two reviewers independently assessed abstracts for retrieval of full text articles. Papers were then assessed for suitability for inclusion in the review. Data from included studies were extracted by two reviewers and entered into the software package (RevMan 4.2). We contacted authors for missing data and some responded. Adverse effect data were analysed if reported in the included studies. Main results The studies analysed were in two groups: those comparing anticholinergics with placebo and those comparing the combination of anticholinergics with short acting ß2 ‐agonists versus short acting ß2 ‐agonists alone. The former group had 13 studies involving 205 participants included in this review, and the latter 9 studies involving 440 patients. Generally methodological quality was poorly reported, and there were some reservations with respect to the quality of the studies. Despite the limited number of studies that could be combined, anticholinergic agents in comparison with placebo resulted in more favourable symptom scores particularly in respect of daytime dyspnoea (WMD ‐0.09 (95%CI ‐0.14, ‐0.04, 3 studies, 59 patients). Daily peak flow measurements also showed a statistically significant improvement for the anticholinergic (e.g. morning PEF: WMD =14.38 litres/min (95%CI 7.69, 21.08; 3 studies, 59 patients). However the clinical significance is small and in terms of peak flow measurements equates to approximately a 7% increase over placebo. The more clinically relevant comparison of a combination of anticholinergic plus short acting ß2 ‐agonist versus short acting ß2 ‐agonist alone gave no evidence in respect of symptom scores or peak flow rates of any significant differences between the two regimes. Again there are reservations with respect to the quality of the information from which these conclusions are drawn. An update search in August 2004 did not identify any new studies. Authors' conclusions Overall this review provides no justification for routinely introducing anticholinergics as part of add‐on treatment for patients whose asthma is not well controlled on standard therapies. This does not exclude the possibility that there may be a sub‐group of patients who derive some benefit and a trial of treatment in individual patients may still be justified. The role of long term anticholinergics such as tiotropium bromide has yet to be established in patients with asthma and any future trials might draw on the messages derived from this review. Plain language summary Anticholinergic agents for chronic asthma in adults Anticholinergic agents such as Atrovent are sometimes used to treat people with asthma as a bronchodilator that opens up the airways in the lungs. This review found that although this treatment was better than placebo, the size of the effect was rather small. When the drug was used in combination with more widely used bronchodilators (beta‐agonists such as fenoterol), it did not appear to add much benefit. However, there are concerns about the quality of the studies that have been analysed. It could be that there are some adults with chronic asthma who respond to treatment with anticholinergic drugs, but the review has not been able to identify their common characteristics.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Westby, MJ, Benson, MK, Gibson, PG", "articleTypes": [], "doi": "10.1002/14651858.CD003269.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.758Z" }, { "id": "5f8a4956-55fe-4dbb-ac70-960e8d8aca64", "pmid": "", "title": "Muscle relaxants for pain management in rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background Pain management is a high priority for patients with rheumatoid arthritis (RA). Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan) and non‐benzodiazepines such as metaxalone (Skelaxin) or a combination of paracetamol and orphenadrine (Muscol)) and drugs that prevent increased muscle tone (baclofen and dantrolene). Despite a paucity of evidence supporting their use, antispasmodic and antispasticity muscle relaxants have gained widespread clinical acceptance as adjuvants in the management of patients with chronic musculoskeletal pain. Objectives The aim of this review was to determine the efficacy and safety of muscle relaxants in pain management in patients with RA. The muscle relaxants that were included in this review are the antispasmodic benzodiazepines (alprazolam, bromazepam, chlordiazepoxide,cinolazepam, clonazepam, cloxazolam, clorazepate, diazepam, estazolam, flunitrazepam, flurazepam, flutoprazepam, halazepam, ketazolam, loprazolam, lorazepam, lormetazepam, medazepam, midazolam, nimetazepam, nitrazepam, nordazepam, oxazepam, pinazepam, prazepam, quazepam, temazepam, tetrazepam, triazolam), antispasmodic non‐benzodiazepines (cyclobenzaprine, carisoprodol, chlorzoxazone, meprobamate, methocarbamol, metaxalone, orphenadrine, tizanidine and zopiclone), and antispasticity drugs (baclofen and dantrolene sodium). Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library, 4th quarter 2010), MEDLINE (1950 to week 1 November 2010), EMBASE (Week 44 2010), and PsycINFO (1806 to week 2 November 2010). We also searched the 2008 to 2009 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of reference lists of relevant articles. Selection criteria We included randomised controlled trials which compared a muscle relaxant to another therapy (active, including non‐pharmacological therapies, or placebo) in adult patients with RA and that reported at least one clinically relevant outcome. Data collection and analysis Two blinded review authors independently extracted data and assessed the risk of bias in the trials. Meta‐analyses were used to examine the efficacy of muscle relaxants on pain, depression, sleep and function, as well as their safety. Main results Six trials (126 participants) were included in this review. All trials were rated at high risk of bias. Five cross‐over trials evaluated a benzodiazepine, four assessed diazepam (n = 71) and one assessed triazolam (n = 15). The sixth trial assessed zopiclone (a non‐benzodiazepine) (n = 40) and was a parallel group study. No trial duration was longer than two weeks while three single dose trials assessed outcomes at 24 hours only. Overall the included trials failed to find evidence of a beneficial effect of muscle relaxants over placebo, alone (at 24 hrs, 1 or 2 weeks) or in addition to non‐steroidal anti‐inflammatory drugs (NSAIDs) (at 24 hrs), on pain intensity, function, or quality of life. Data from two trials of longer than 24 hours duration (n = 74) (diazepam and zopiclone) found that participants who received a muscle relaxant had significantly more adverse events compared with those who received placebo (number needed to harm (NNTH) 3, 95% CI 2 to 7). These were predominantly central nervous system side effects, including dizziness and drowsiness (NNTH 3, 95% CI 2 to 11). Authors' conclusions Based upon the currently available evidence in patients with RA, benzodiazepines (diazepam and triazolam) do not appear to be beneficial in improving pain over 24 hours or one week. The non‐benzodiazepine agent zopiclone also did not significantly reduce pain over two weeks. However, even short term muscle relaxant use (24 hours to 2 weeks) is associated with significant adverse events, predominantly drowsiness and dizziness. Plain language summary Muscle relaxants for pain management in rheumatoid arthritis This summary of a Cochrane review presents what we know from research about the effect of muscle relaxants on pain in patients with rheumatoid arthritis. The review shows that in people with rheumatoid arthritis: ‐ Muscle relaxants may not improve pain when taken as a single dose or for up to a two week period ‐ We are uncertain whether muscle relaxants affect functional status because of the very low quality of the evidence ‐ No trials were found that evaluated whether muscle relaxants affect quality of life ‐ No trials were found that evaluated whether antidepressants affect sleep ‐ We are uncertain whether muscle relaxants affect mood because of the very low quality of the evidence We also do not have precise information about side effects and complications. This is particularly true for rare but serious side effects. Possible side effects may include feeling tired or nauseous, headaches, blurred vision, a dry mouth, sexual dysfunction, or becoming dizzy or constipated. Rare complications may include increased suicidal thinking, liver inflammation, or a reduced white cell count. What is rheumatoid arthritis and what are muscle relaxants? When you have rheumatoid arthritis your immune system, which normally fights infection, attacks the lining of your joints. This makes your joints swollen, stiff, and painful. The small joints of your hands and feet are usually affected first. There is no cure for rheumatoid arthritis at present, so the treatments aim to relieve pain and stiffness and improve your ability to move. Muscle relaxants can be used to treat anxiety and promote sleep, and some people believe they may also reduce pain by acting on the nerves that cause pain, but this remains controversial. Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), Xanax, Ativan and non‐benzodiazepines such as Skelaxin, Muscol) and drugs that prevent increased muscle tone (baclofen and dantrolene). Best estimates of what happens to people with rheumatoid arthritis who take muscle relaxants: Pain at 24 hours: ‐ Non‐significant result. Pain at 1 to 2 weeks: ‐ Non‐significant result. Withdrawal due to adverse events, after 2 weeks: ‐ Non‐significant result. Total adverse events: ‐ 49 more people out of 100 experienced an adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 49%), ‐ 52 out of 100 people who took a muscle relaxant suffered an adverse event, ‐ 3 out of 100 people who took a placebo suffered an adverse event. Central nervous system (CNS) adverse events: ‐ 33 more people out of 100 experienced a CNS adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 33%), ‐ 39 out of 100 people who took a muscle relaxant suffered a CNS adverse event, ‐ 6 out of 100 people who took a placebo relaxant suffered a CNS adverse event. This record should be cited as: This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in the Cochrane Database of Systematic Reviews [Issue and date] © [year] The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464‐780X).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Richards, BL; Whittle, SL; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD008922.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "5f9d14e2-2e78-460c-8845-7ef955afd34c", "pmid": "", "title": "Neuraminidase inhibitors for preventing and treating influenza in adults and children", "imported": false, "abstract": "Abstract - Background Neuraminidase inhibitors (NIs) are stockpiled and recommended by public health agencies for treating and preventing seasonal and pandemic influenza. They are used clinically worldwide. Objectives To describe the potential benefits and harms of NIs for influenza in all age groups by reviewing all clinical study reports of published and unpublished randomised, placebo‐controlled trials and regulatory comments. Search methods We searched trial registries, electronic databases (to 22 July 2013) and regulatory archives, and corresponded with manufacturers to identify all trials. We also requested clinical study reports. We focused on the primary data sources of manufacturers but we checked that there were no published randomised controlled trials (RCTs) from non‐manufacturer sources by running electronic searches in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE (Ovid), EMBASE, Embase.com, PubMed (not MEDLINE), the Database of Reviews of Effects, the NHS Economic Evaluation Database and the Health Economic Evaluations Database. Selection criteria Randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Data collection and analysis We extracted clinical study reports and assessed risk of bias using purpose‐built instruments. We analysed the effects of zanamivir and oseltamivir on time to first alleviation of symptoms, influenza outcomes, complications, hospitalisations and adverse events in the intention‐to‐treat (ITT) population. All trials were sponsored by the manufacturers. Main results We obtained 107 clinical study reports from the European Medicines Agency (EMA), GlaxoSmithKline and Roche. We accessed comments by the US Food and Drug Administration (FDA), EMA and Japanese regulator. We included 53 trials in Stage 1 (a judgement of appropriate study design) and 46 in Stage 2 (formal analysis), including 20 oseltamivir (9623 participants) and 26 zanamivir trials (14,628 participants). Inadequate reporting put most of the zanamivir studies and half of the oseltamivir studies at a high risk of selection bias. There were inadequate measures in place to protect 11 studies of oseltamivir from performance bias due to non‐identical presentation of placebo. Attrition bias was high across the oseltamivir studies and there was also evidence of selective reporting for both the zanamivir and oseltamivir studies. The placebo interventions in both sets of trials may have contained active substances. Time to first symptom alleviation . For the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.8 hours (95% confidence interval (CI) 8.4 to 25.1 hours, P < 0.0001). This represents a reduction in the time to first alleviation of symptoms from 7 to 6.3 days. There was no effect in asthmatic children, but in otherwise healthy children there was (reduction by a mean difference of 29 hours, 95% CI 12 to 47 hours, P = 0.001). Zanamivir reduced the time to first alleviation of symptoms in adults by 0.60 days (95% CI 0.39 to 0.81 days, P < 0.00001), equating to a reduction in the mean duration of symptoms from 6.6 to 6.0 days. The effect in children was not significant. In subgroup analysis we found no evidence of a difference in treatment effect for zanamivir on time to first alleviation of symptoms in adults in the influenza‐infected and non‐influenza‐infected subgroups (P = 0.53). Hospitalisations . Treatment of adults with oseltamivir had no significant effect on hospitalisations: risk difference (RD) 0.15% (95% CI ‐0.78 to 0.91). There was also no significant effect in children or in prophylaxis. Zanamivir hospitalisation data were unreported. Serious influenza complications or those leading to study withdrawal . In adult treatment trials, oseltamivir did not significantly reduce those complications classified as serious or those which led to study withdrawal (RD 0.07%, 95% CI ‐0.78 to 0.44), nor in child treatment trials; neither did zanamivir in the treatment of adults or in prophylaxis. There were insufficient events to compare this outcome for oseltamivir in prophylaxis or zanamivir in the treatment of children. Pneumonia . Oseltamivir significantly reduced self reported, investigator‐mediated, unverified pneumonia (RD 1.00%, 95% CI 0.22 to 1.49); number needed to treat to benefit (NNTB) = 100 (95% CI 67 to 451) in the treated population. The effect was not significant in the five trials that used a more detailed diagnostic form for pneumonia. There were no definitions of pneumonia (or other complications) in any trial. No oseltamivir treatment studies reported effects on radiologically confirmed pneumonia. There was no significant effect on unverified pneumonia in children. There was no significant effect of zanamivir on either self reported or radiologically confirmed pneumonia. In prophylaxis, zanamivir significantly reduced the risk of self reported, investigator‐mediated, unverified pneumonia in adults (RD 0.32%, 95% CI 0.09 to 0.41); NNTB = 311 (95% CI 244 to 1086), but not oseltamivir. Bronchitis, sinusitis and otitis media . Zanamivir significantly reduced the risk of bronchitis in adult treatment trials (RD 1.80%, 95% CI 0.65 to 2.80); NNTB = 56 (36 to 155), but not oseltamivir. Neither NI significantly reduced the risk of otitis media and sinusitis in both adults and children. Harms of treatment . Oseltamivir in the treatment of adults increased the risk of nausea (RD 3.66%, 95% CI 0.90 to 7.39); number needed to treat to harm (NNTH) = 28 (95% CI 14 to 112) and vomiting (RD 4.56%, 95% CI 2.39 to 7.58); NNTH = 22 (14 to 42). The proportion of participants with four‐fold increases in antibody titre was significantly lower in the treated group compared to the control group (RR 0.92, 95% CI 0.86 to 0.97, I 2 statistic = 0%) (5% absolute difference between arms). Oseltamivir significantly decreased the risk of diarrhoea (RD 2.33%, 95% CI 0.14 to 3.81); NNTB = 43 (95% CI 27 to 709) and cardiac events (RD 0.68%, 95% CI 0.04 to 1.0); NNTB = 148 (101 to 2509) compared to placebo during the on‐treatment period. There was a dose‐response effect on psychiatric events in the two oseltamivir \"pivotal\" treatment trials, WV15670 and WV15671, at 150 mg (standard dose) and 300 mg daily (high dose) (P = 0.038). In the treatment of children, oseltamivir induced vomiting (RD 5.34%, 95% CI 1.75 to 10.29); NNTH = 19 (95% CI 10 to 57). There was a significantly lower proportion of children on oseltamivir with a four‐fold increase in antibodies (RR 0.90, 95% CI 0.80 to 1.00, I 2 = 0%). Prophylaxis . In prophylaxis trials, oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals (oseltamivir: RD 3.05% (95% CI 1.83 to 3.88); NNTB = 33 (26 to 55); zanamivir: RD 1.98% (95% CI 0.98 to 2.54); NNTB = 51 (40 to 103)) and in households (oseltamivir: RD 13.6% (95% CI 9.52 to 15.47); NNTB = 7 (6 to 11); zanamivir: RD 14.84% (95% CI 12.18 to 16.55); NNTB = 7 (7 to 9)). There was no significant effect on asymptomatic influenza (oseltamivir: RR 1.14 (95% CI 0.39 to 3.33); zanamivir: RR 0.97 (95% CI 0.76 to 1.24)). Non‐influenza, influenza‐like illness could not be assessed due to data not being fully reported. In oseltamivir prophylaxis studies, psychiatric adverse events were increased in the combined on‐ and off‐treatment periods (RD 1.06%, 95% CI 0.07 to 2.76); NNTH = 94 (95% CI 36 to 1538) in the study treatment population. Oseltamivir increased the risk of headaches whilst on treatment (RD 3.15%, 95% CI 0.88 to 5.78); NNTH = 32 (95% CI 18 to 115), renal events whilst on treatment (RD 0.67%, 95% CI ‐2.93 to 0.01); NNTH = 150 (NNTH 35 to NNTB > 1000) and nausea whilst on treatment (RD 4.15%, 95% CI 0.86 to 9.51); NNTH = 25 (95% CI 11 to 116). Authors' conclusions Oseltamivir and zanamivir have small, non‐specific effects on reducing the time to alleviation of influenza symptoms in adults, but not in asthmatic children. Using either drug as prophylaxis reduces the risk of developing symptomatic influenza. Treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced, because of a lack of diagnostic definitions. The use of oseltamivir increases the risk of adverse effects, such as nausea, vomiting, psychiatric effects and renal events in adults and vomiting in children. The lower bioavailability may explain the lower toxicity of zanamivir compared to oseltamivir. The balance between benefits and harms should be considered when making decisions about use of both NIs for either the prophylaxis or treatment of influenza. The influenza virus‐specific mechanism of action proposed by the producers does not fit the clinical evidence. Plain language summary Regulatory information on trials of oseltamivir (Tamiflu) and zanamivir (Relenza) for influenza in adults and children Oseltamivir and zanamivir have been stockpiled in many countries to treat and prevent seasonal and pandemic influenza, before an influenza vaccine matched to the circulating virus becomes available. Oseltamivir is classified by the World Health Organization as an essential medicine. How this review has been approached We have updated and combined our reviews on the antiviral drugs zanamivir and oseltamivir for influenza in adults and children on the basis of the manufacturers' reports to regulators (clinical study reports) and the regulators' comments. We have called these comments and reports 'regulatory information'. Clinical study reports are unpublished, extensive documents with great detail on the trials that formed the basis for market approval. They include the protocols, methods and results. Clinical study reports have until now been confidential, seen only by the manufacturers and regulators. Why we have taken this approach In previous versions of this review we identified unresolved discrepancies in the data presented in published trial reports and substantial publication bias. As a consequence, we elected not to use data from journal articles but included the documents generated during licensing processes. We have accessed such data from the UK, USA, European Medicines Agency (EMA), Japanese regulators and clinical study reports from the manufacturers (after a protracted media campaign). This has enabled us to verify information from the randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Based on our assessments of the regulatory documents (in excess of 160,000 pages), we came to the conclusion that there were substantial problems with the design, conduct, reporting and availability of information from many of the trials. What we have found We have used data from 46 trials (20 oseltamivir and 26 zanamivir studies) in this review. We identified problems in the design of many of the studies that we included, which affects our confidence in their results. We found that both drugs shorten the duration of symptoms of influenza‐like illness (unconfirmed influenza or 'the flu') by less than a day. Oseltamivir did not affect the number of hospitalisations, based on the data from all the people enrolled in treatment trials of oseltamivir. Zanamivir trials did not record this outcome. The effects on pneumonia and other complications of influenza, such as bronchitis, middle ear infection (otitis media) and sinusitis, were unreliably reported, as shown by the case report form in the trial documents. Some forms showed limitations in the diagnostic criteria for pneumonia. Regulatory comments noted problems with missing follow‐up diary cards from participants. In children with asthma there was no clear effect on the time to first alleviation of symptoms. Prophylaxis trials showed that oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals and households. There was no evidence of an effect on asymptomatic influenza or on non‐influenza, influenza‐like illness, but trial conduct problems prevent any definitive conclusion. Oseltamivir use was associated with nausea, vomiting, headaches, renal and psychiatric events; these last three were when it was used to prevent influenza (prophylaxis). Its effect on the heart is unclear: it may reduce cardiac symptoms, but may induce serious heart rhythm problems. In adult treatment trials of zanamivir there was no increased risk of reported adverse events. The evidence on the possible harms associated with the treatment of children with zanamivir was sparse. Agreement with other findings The lack of good evidence demonstrating an effect on complications agrees with the conservative conclusions on both drugs drawn by the US Food and Drug Administration (FDA). The FDA only allowed claims of effectiveness of both drugs for the prevention and treatment of symptoms of influenza and not for other effects (including the interruption of person‐to‐person spread of the influenza virus or prevention of pneumonia). The FDA described the overall performance of both drugs as 'modest'. Mechanism of action for beneficial effects These findings all suggest that the low immune response with low levels of pro‐inflammatory cytokines, which is induced by the action of oseltamivir carboxylate, may reduce the symptoms of influenza unrelated to an inhibition of influenza virus replication. The potential hypothermic or antipyretic effect of oseltamivir as a central nervous system depressant may also contribute to the apparent reduction of host symptoms. Statements made on the capacity of oseltamivir to interrupt viral transmission and reduce complications are not supported by any data we have been able to access. The mechanism of action proposed by the producers (influenza virus‐specific) does not fit the clinical evidence which suggests a multi‐system and central action.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Jefferson, T, Jones, MA, Doshi, P, Del Mar, CB, Hama, R, Thompson, MJ, Spencer, EA, Onakpoya, IJ, Mahtani, KR, Nunan, D, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD008965.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.799Z" }, { "id": "5fa23c5b-bd64-492d-954d-00d5fda2ee10", "pmid": "", "title": "Bile acids for liver‐transplanted patients", "imported": false, "abstract": "Abstract - Background Liver transplantation has become a widely accepted form of treatment for numerous end‐stage liver diseases. Bile acids may decrease allograft rejection after liver transplantation by changing the expression of major histocompatibility complex class molecules in bile duct epithelium and central vein endothelium. Objectives To assess the beneficial and harmful effects of bile acids for liver‐transplanted patients. Search methods We performed searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials in The Cochrane Library , MEDLINE , EMBASE , and Science Citation Expanded to September, 2009. Selection criteria Randomised clinical trials comparing any dose of bile acids or duration of treatment in liver‐transplanted patients versus placebo, no intervention, or another intervention. We included randomised clinical trials irrespective of blinding, language, and publication status. Data collection and analysis Two review authors extracted and checked data independently. We evaluated the risk of bias of the trials from the method of allocation sequence generation, allocation concealment, blinding, outcome data analysis, outcome data reporting, and other potential sources of bias. We used the intention‐to‐treat principle to perform meta‐analyses and presented the outcomes as relative risks (RR) or mean differences (MD), both with 95% confidence intervals (CI). Main results The updated search resulted in no new trials meeting the inclusion criteria of this review, thus leaving it to the seven already included randomised trials (six evaluating ursodeoxycholic acid versus placebo or no intervention, and one evaluating tauro‐ursodeoxycholic acid versus no intervention) enrolling a total of 335 participants. The administration of bile acids began one day or more after liver transplantation. All patients received the standard triple‐drug immunosuppressive regimen (steroids, azathioprine, and cyclosporine or tacrolimus) to suppress the allograft rejection response after liver transplantation. Bile acids compared with placebo or no intervention did not significantly change all‐cause mortality (RR 0.85, 95% CI 0.53 to 1.36), mortality related to allograft rejection (RR 0.30, 95% CI 0.01 to 7.12), retransplantation (RR 0.76, 95% CI 0.20 to 2.86), acute cellular rejection, or number of patients with steroid‐resistant rejection. Bile acids significantly reduced the number of patients who had chronic rejection in a fixed‐effect model but not in a random‐effects model meta‐analysis. Bile acids were safe and well tolerated by liver‐transplanted patients. However, this observation is based on data analysis from three trials with only 187 patients. Authors' conclusions We did not find evidence to support or refute bile acids for liver‐transplanted patients. Further randomised trials are necessary before bile acids can be recommended to liver‐transplanted patients. Plain language summary Bile acids for liver‐transplanted patients Liver transplantation is a major surgical procedure that has been practiced for more than forty years and has nowadays become a generally accepted treatment option in patients with end‐stage liver disease. The most common cause for liver transplantation in adults is cirrhosis caused by various types of liver injuries such as infections (hepatitis B and C), alcohol, autoimmune liver diseases, early‐stage liver cancer, metabolic and hereditary disorders, but also diseases of unknown aetiology. All transplant recipients need lifetime immunosuppressive therapy to prevent transplant rejection. Bile acids are being used for a variety of chronic liver diseases, mainly primary biliary cirrhosis and primary sclerosing cholangitis. However, their mechanisms of action and beneficial and harmful effects are poorly understood. This has led to the idea of the potential use of bile acids to prevent rejection in liver‐transplanted patients. Results of the seven randomised clinical trials included in the review in which patients received standard immunosuppressive treatment (steroids, azathioprine, and cyclosporine or tacrolimus) with or without bile acids after liver transplantation, did not show any significant effects of bile acids on all‐cause mortality, mortality related to rejection, acute cellular rejection, steroid resistant rejection, or need for retransplantation. One analysis suggested that bile acids might beneficially influence number of patients with chronic rejection, but was contradicted by the analyses. The evidence that the use of ursodeoxycholic acid might have beneficial effects on chronic rejection and length of hospitalisation is weak as it is produced from trials with high risk of bias and insufficient number of included patients. That bile acids seemed well tolerated, with no reports of serious adverse events, is good knowledge, but much more research is needed before their use is acquitted. None of the randomised clinical trials assessed the effects of bile acids on quality of life or cost‐effectiveness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Poropat, G; Giljaca, V; Stimac, D; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005442.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "5fa411d0-4f52-4878-9491-d439ba0a2834", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high risk patients. Ulceration can lead to severe pain and difficulty eating and drinking, which may necessitate opioid analgesics, hospitalisation and nasogastric or intravenous nutrition. These complications may lead to interruptions or alterations to cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Oral cryotherapy is a low‐cost, simple intervention which is unlikely to cause side‐effects. It has shown promise in clinical trials and warrants an up‐to‐date Cochrane review to assess and summarise the international evidence. Objectives To assess the effects of oral cryotherapy for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to 17 June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) ( Cochrane Library 2015, Issue 5), MEDLINE via Ovid (1946 to 17 June 2015), EMBASE via Ovid (1980 to 17 June 2015), CANCERLIT via PubMed (1950 to 17 June 2015) and CINAHL via EBSCO (1937 to 17 June 2015). We searched the US National Institutes of Health Trials Registry, and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching databases. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of oral cryotherapy in patients with cancer receiving treatment. We used outcomes from a published core outcome set registered on the COMET website. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. We contacted study authors for information where feasible. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 14 RCTs analysing 1280 participants. The vast majority of participants did not receive radiotherapy to the head and neck, so this review primarily assesses prevention of chemotherapy‐induced oral mucositis. All studies were at high risk of bias. The following results are for the main comparison: oral cryotherapy versus control (standard care or no treatment). Adults receiving fluorouracil‐based (5FU) chemotherapy for solid cancers Oral cryotherapy probably reduces oral mucositis of any severity (RR 0.61, 95% CI 0.52 to 0.72, 5 studies, 444 analysed, moderate quality evidence). In a population where 728 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 444 (95% CI 379 to 524). The number needed to treat to benefit one additional person (NNTB), i.e. to prevent them from developing oral mucositis, is 4 people (95% CI 3 to 5). The results were similar for moderate to severe oral mucositis (RR 0.52, 95% CI 0.41 to 0.65, 5 studies, 444 analysed, moderate quality evidence). NNTB 4 (95% CI 4 to 6). Severe oral mucositis is probably reduced (RR 0.40, 95% CI 0.27 to 0.61, 5 studies, 444 analysed, moderate quality evidence). Where 300 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 120 (95% CI 81 to 183), NNTB 6 (95% CI 5 to 9). Adults receiving high‐dose melphalan‐based chemotherapy before haematopoietic stem cell transplantation (HSCT) Oral cryotherapy may reduce oral mucositis of any severity (RR 0.59, 95% CI 0.35 to 1.01, 5 studies, 270 analysed, low quality evidence). Where 824 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 486 (95% CI reduced to 289 to increased to 833). The NNTB is 3, although the uncertainty surrounding the effect estimate means that the 95% CI ranges from 2 NNTB, to 111 NNTH (number needed to treat in order to harm one additional person, i.e. for one additional person to develop oral mucositis). The results were similar for moderate to severe oral mucositis (RR 0.43, 95% CI 0.17 to 1.09, 5 studies, 270 analysed, low quality evidence). NNTB 3 (95% CI 2 NNTB to 17 NNTH). Severe oral mucositis is probably reduced (RR 0.38, 95% CI 0.20 to 0.72, 5 studies, 270 analysed, moderate quality evidence). Where 427 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 162 (95% CI 85 to 308), NNTB 4 (95% CI 3 to 9). Oral cryotherapy was shown to be safe, with very low rates of minor adverse effects, such as headaches, chills, numbness/taste disturbance, and tooth pain. This appears to contribute to the high rates of compliance seen in the included studies. There was limited or no evidence on the secondary outcomes of this review, or on patients undergoing other chemotherapies, radiotherapy, targeted therapy, or on comparisons of oral cryotherapy with other interventions or different oral cryotherapy regimens. Therefore no further robust conclusions can be made. There was also no evidence on the effects of oral cryotherapy in children undergoing cancer treatment. Authors' conclusions We are confident that oral cryotherapy leads to large reductions in oral mucositis of all severities in adults receiving 5FU for solid cancers. We are less confident in the ability of oral cryotherapy to reduce oral mucositis in adults receiving high‐dose melphalan before HSCT. Evidence suggests that it does reduce oral mucositis in these adults, but we are less certain about the size of the reduction, which could be large or small. However, we are confident that there is an appreciable reduction in severe oral mucositis in these adults. This Cochrane review includes some very recent and currently unpublished data, and strengthens international guideline statements for adults receiving the above cancer treatments. Plain language summary Can keeping the mouth cold during cancer treatment help to prevent mouth soreness and ulcers in children and adults? Review question This review has been produced to assess whether or not keeping the mouth cold during cancer treatment, by using ice, ice‐cold water, ice cream or ice lollies/popsicles, can help prevent mouth soreness and ulcers in children and adults. Background People receiving treatment for cancer are at risk of developing a sore mouth and ulcers as a side effect. This side effect is called oral mucositis and affects over 75% of high‐risk patients (those receiving radiotherapy to the head and neck or high‐dose chemotherapy). The pain caused by this condition can be severe and can stop the person's ability to eat and drink, which may mean they need to take strong pain killers, stay in hospital and be fed through a tube into their stomach, or even into their veins. This in turn can lead to disruption to their cancer treatment, meaning they are not receiving the best possible treatment. The results may be a reduction in the patient's chances of survival, and increased costs to the healthcare system. Cancer patients have weakened immune systems due to their treatment, meaning that their bodies are less able to fight infections. This can be a problem if bacteria enter the body through the ulcer, which is an open wound. This can lead to sepsis (a dangerous inflammatory reaction of the body to infection), which requires antibiotics and hospitalisation, and can cause death. Oral cryotherapy is the cooling of the mouth using ice, ice‐cold water, ice cream or ice lollies/popsicles. It is thought to help prevent oral mucositis in people receiving certain types of chemotherapy because the coldness makes the blood vessels in the mouth more narrow, and this reduces the amount of blood containing chemotherapy drugs from reaching the mouth and causing oral mucositis. It is a low‐cost, natural treatment without serious side effects. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 17 June 2015. It includes 14 studies published from 1991 to 2015 in which 1316 participants were randomised (1280 of whom were included in the analyses) to receive oral cryotherapy versus standard care (usually saline mouthrinses) or no treatment or a different treatment or a different method of oral cryotherapy, and the number of people developing oral mucositis of different severities was compared. Nearly all the evidence was on adults receiving oral cryotherapy versus standard care or no treatment. This evidence fell into two main groups: 1) adults receiving fluorouracil‐based (5FU) treatment for solid cancers; or 2) adults receiving high‐dose melphalan‐based cancer treatment before haematopoietic stem cell transplantation (HSCT). HSCT is given to help the body to produce all types of blood cells, which are destroyed during cancer treatment. Key results There is evidence showing that oral cryotherapy can lead to large reductions in the numbers of adults who get oral mucositis of all severities after receiving 5FU‐based treatment for solid cancers. There is less certain evidence to suggest that oral cryotherapy may reduce the numbers of adults who get oral mucositis after receiving high‐dose melphalan‐based cancer treatment prior to HSCT. The evidence suggests that it does reduce oral mucositis in these adults, but the size of the reduction is much less certain. However, there is more certain evidence that there is a large reduction in severe oral mucositis in these adults. Oral cryotherapy did not cause any serious side effects in any of the participants of these studies, and most people seemed able to carry it out properly and complete it. Quality of the evidence The evidence presented, on the main outcome of whether or not people developed oral mucositis of all severities, is of moderate (because the nature of the oral cryotherapy treatment meant that the studies could not be 'blinded' which is a desirable characteristic of these studies) to low quality (because in addition to the above problem, the results of the individual studies were too different to give a precise result when they were combined).", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P; Glenny, AM; Worthington, HV; Littlewood, A; Clarkson, JE; McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011552.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "5faa820c-ce27-4c2c-85d8-4e1b378045e6", "pmid": "", "title": "Venepuncture versus heel lance for blood sampling in term neonates", "imported": false, "abstract": "Abstract - Rationale Reducing procedural pain is a key priority in neonatal care, as even routine procedures for blood sampling can cause significant discomfort and pain to the neonate. This systematic review aims to compare venepuncture and heel lance for blood sampling, focusing on pain response, to guide clinical practice. Objectives To evaluate the benefits (degree of pain) and harms (need for more than one skin puncture) of venepuncture compared to heel lance in term neonates. Search methods We searched CENTRAL, MEDLINE, Embase, two trial registries and conference abstracts, and checked references of included studies and related systematic reviews up to 04 July 2025. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs that compared pain response from venepuncture versus heel lance. Neonates could receive a sweet‐tasting solution (such as glucose or sucrose), which is a commonly used analgesic in neonates for pain relief. We excluded studies that reported on pain using physiological parameters in isolation, as they are reflective of overall clinical status and non‐specific arousal. Outcomes Our outcomes of interest were pain reported using validated pain scores (measured using one or more of the following scales: Neonatal Facial Coding System, Neonatal Infant Pain scores, or the Premature Infant Pain Profile) and the need for more than one skin puncture. Risk of bias We used the Risk of bias 1 (RoB) tool to assess bias in the included RCTs. Synthesis methods We conducted a meta‐analysis where possible by calculating standardized mean difference (SMD) and risk ratio (RR) with their 95% confidence intervals (CIs) for continuous and dichotomous outcomes, respectively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included eight studies with 826 neonates. The studies were performed in six high‐, upper‐middle, or low‐income countries. Synthesis of results We judged the overall risk of bias in the eight studies to be high. Most studies had concerns related to blinding and allocation concealment. Venepuncture compared to heel lance (with no sweet‐tasting solution) Pain scores 
Venepuncture probably reduces pain compared to heel lance during the procedure when no sweet‐tasting solution is administered (SMD −1.34, 95% CI −1.55 to −1.14; I² = 94%; 6 studies, 488 participants; moderate‐certainty evidence). Need for more than one skin puncture 
Venepuncture probably reduces the need for more than one skin puncture compared to heel lance when no sweet tasting solution is administered (RR 0.63, 95% CI 0.40 to 0.97; I² = 20%; 6 studies, 397 participants; moderate‐certainty evidence) Venepuncture compared to heel lance (with sweet‐tasting solution) Pain scores 
Venepuncture may reduce pain compared to heel lance during the procedure when a sweet‐tasting solution is administered (SMD −0.38, 95% CI −0.69 to −0.07; I² = 79%; 3 studies, 170 participants; low‐certainty evidence). Need for more than one skin puncture 
The evidence is very uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture when a sweet‐tasting solution is used (RR 7.00, 95% CI 0.38 to 129.93; I² not applicable; 2 studies, 110 participants; very low‐certainty evidence). This is due to the small number of participants in each group. Authors' conclusions Based on moderate‐certainty evidence, venepuncture probably reduces pain during the procedure and the need for more than one skin puncture compared to heel lance when no sweet‐tasting solution is used. When sweet‐tasting solutions are administered, venepuncture may reduce pain during the procedure compared to heel lance, based on low‐certainty evidence. The evidence is very uncertain about the effect of venepuncture compared to heel lance on the number of skin punctures required in the presence of sweet‐tasting solutions. This is due to the small sample size, and hence we could not draw any meaningful conclusions. Further high‐quality studies are needed, particularly in settings where sweet‐tasting solutions are used, to better understand the comparative effectiveness of venepuncture and heel lance for neonatal blood sampling. Funding Cochrane Neonatal editorial support for this review update, as part of a suite of reviews addressing “The infant and family experience in the neonatal intensive care unit”, has been provided by a grant from The Gerber Foundation. The Gerber Foundation is a separately endowed, private, 501(c)(3) foundation not related to Gerber Products Company in any way. Registration Original review (2001): DOI 10.1002/14651858.CD001452
Review update (2004): DOI 10.1002/14651858.CD001452.pub2
Review update (2007): DOI 10.1002/14651858.CD001452.pub3
Review update (2011): DOI 10.1002/14651858.CD001452.pub4 Plain language summary Is using a needle (venepuncture) better than using a device (heel lance) for taking a blood sample from full‐term newborn babies? Key messages Venepuncture (inserting a needle into a vein) may be less painful than heel lance (using a special device to puncture the skin) for newborn babies when having a blood sample taken, with or without sugar water for pain relief, and may reduce the need for more than one skin puncture when no sugar water is given for pain relief. We don’t know whether venepuncture reduces the need for more than one skin puncture compared with heel lance when sugar water is given for pain relief. We need better designed and larger studies that fully report their results to show which method is better for babies. Why do we take blood samples from newborn babies? In most countries, a blood sample from newborn babies is needed for routine screening tests. Blood samples may also be needed for other blood tests to diagnose and manage diseases, such as jaundice or low blood sugar (hypoglycemia). However, taking blood from babies is painful. Untreated pain in newborn babies may affect their physical growth and brain development. A sweet, sugar solution (such as sucrose) can be given to babies before the procedure, which helps to reduce the pain. It is difficult to measure pain in babies, but we rely on things like facial expressions, crying, and changes in heart rate to assess their pain. How are blood samples taken? Venepuncture Venepuncture is a method of taking a blood sample where a person uses a needle to directly puncture the vein. The person who performs this must be well‐trained to help ensure they successfully take a blood sample. This technique is often used when 1 mL or more of blood is required, and to prevent repeated punctures to the skin and associated complications (such as skin infections) from heel lance. Heel lance Heel lance is the standard way of taking a blood sample from newborn babies in hospitals worldwide. It is commonly used when the blood sample required is less than 1 mL. It does not require special training or expertise for successful use. The procedure involves making a small puncture (between 1 mm and 2 mm deep) on the heel of the foot using a lancet, which is usually an automatic device. Following the puncture, the infant's heel is squeezed to collect the required blood sample, which causes further pain. What did we want to find out? We wanted to find out: whether venepuncture is less painful than heel lance for newborn babies; and which procedure works best first time, so a second skin puncture is not needed. What did we do? We searched for studies that compared venepuncture and heel lance for taking blood samples in newborn babies. The studies needed to measure pain responses and the number of skin punctures needed for a successful sample. They also needed to record whether babies were given sugar solution as pain relief. Babies in the studies had to be healthy and born at full term. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included eight studies involving 826 full‐term newborn babies. Three studies took place in Sweden, and one each in Japan, Malaysia, Nepal, Spain, and the UK. When no sweet‐tasting solution was given: venepuncture probably causes less pain compared to heel lance (6 studies, 488 babies); and venepuncture probably reduces the need for more than one skin puncture compared to heel lance (6 studies, 397 babies). When a sweet‐tasting solution was given: venepuncture may cause less pain compared to heel lance (3 studies, 170 babies); and we are uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture (2 studies, 110 babies). What are the limitations of the evidence? Our confidence in the evidence was limited, and ranged from moderate to very low. This is because all the studies had limitations in how they were carried out. These included issues with how babies were assigned to each group, how the studies reported their results, and the number of babies included in the studies. In addition, the people doing the procedures knew which sampling method each baby received, which could have influenced how the studies assessed pain. How up to date is this evidence? This review updates our 2011 Cochrane review. The evidence is up to date to July 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Martins, G; Fiander, M; Taddio, A; Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD001452.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "5fbce85b-f319-42df-96c8-e9802ce89ef6", "pmid": "", "title": "Muscle relaxants for pain management in rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background Pain management is a high priority for patients with rheumatoid arthritis (RA). Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan) and non‐benzodiazepines such as metaxalone (Skelaxin) or a combination of paracetamol and orphenadrine (Muscol)) and drugs that prevent increased muscle tone (baclofen and dantrolene). Despite a paucity of evidence supporting their use, antispasmodic and antispasticity muscle relaxants have gained widespread clinical acceptance as adjuvants in the management of patients with chronic musculoskeletal pain. Objectives The aim of this review was to determine the efficacy and safety of muscle relaxants in pain management in patients with RA. The muscle relaxants that were included in this review are the antispasmodic benzodiazepines (alprazolam, bromazepam, chlordiazepoxide,cinolazepam, clonazepam, cloxazolam, clorazepate, diazepam, estazolam, flunitrazepam, flurazepam, flutoprazepam, halazepam, ketazolam, loprazolam, lorazepam, lormetazepam, medazepam, midazolam, nimetazepam, nitrazepam, nordazepam, oxazepam, pinazepam, prazepam, quazepam, temazepam, tetrazepam, triazolam), antispasmodic non‐benzodiazepines (cyclobenzaprine, carisoprodol, chlorzoxazone, meprobamate, methocarbamol, metaxalone, orphenadrine, tizanidine and zopiclone), and antispasticity drugs (baclofen and dantrolene sodium). Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library, 4th quarter 2010), MEDLINE (1950 to week 1 November 2010), EMBASE (Week 44 2010), and PsycINFO (1806 to week 2 November 2010). We also searched the 2008 to 2009 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of reference lists of relevant articles. Selection criteria We included randomised controlled trials which compared a muscle relaxant to another therapy (active, including non‐pharmacological therapies, or placebo) in adult patients with RA and that reported at least one clinically relevant outcome. Data collection and analysis Two blinded review authors independently extracted data and assessed the risk of bias in the trials. Meta‐analyses were used to examine the efficacy of muscle relaxants on pain, depression, sleep and function, as well as their safety. Main results Six trials (126 participants) were included in this review. All trials were rated at high risk of bias. Five cross‐over trials evaluated a benzodiazepine, four assessed diazepam (n = 71) and one assessed triazolam (n = 15). The sixth trial assessed zopiclone (a non‐benzodiazepine) (n = 40) and was a parallel group study. No trial duration was longer than two weeks while three single dose trials assessed outcomes at 24 hours only. Overall the included trials failed to find evidence of a beneficial effect of muscle relaxants over placebo, alone (at 24 hrs, 1 or 2 weeks) or in addition to non‐steroidal anti‐inflammatory drugs (NSAIDs) (at 24 hrs), on pain intensity, function, or quality of life. Data from two trials of longer than 24 hours duration (n = 74) (diazepam and zopiclone) found that participants who received a muscle relaxant had significantly more adverse events compared with those who received placebo (number needed to harm (NNTH) 3, 95% CI 2 to 7). These were predominantly central nervous system side effects, including dizziness and drowsiness (NNTH 3, 95% CI 2 to 11). Authors' conclusions Based upon the currently available evidence in patients with RA, benzodiazepines (diazepam and triazolam) do not appear to be beneficial in improving pain over 24 hours or one week. The non‐benzodiazepine agent zopiclone also did not significantly reduce pain over two weeks. However, even short term muscle relaxant use (24 hours to 2 weeks) is associated with significant adverse events, predominantly drowsiness and dizziness. Plain language summary Muscle relaxants for pain management in rheumatoid arthritis This summary of a Cochrane review presents what we know from research about the effect of muscle relaxants on pain in patients with rheumatoid arthritis. The review shows that in people with rheumatoid arthritis: ‐ Muscle relaxants may not improve pain when taken as a single dose or for up to a two week period ‐ We are uncertain whether muscle relaxants affect functional status because of the very low quality of the evidence ‐ No trials were found that evaluated whether muscle relaxants affect quality of life ‐ No trials were found that evaluated whether antidepressants affect sleep ‐ We are uncertain whether muscle relaxants affect mood because of the very low quality of the evidence We also do not have precise information about side effects and complications. This is particularly true for rare but serious side effects. Possible side effects may include feeling tired or nauseous, headaches, blurred vision, a dry mouth, sexual dysfunction, or becoming dizzy or constipated. Rare complications may include increased suicidal thinking, liver inflammation, or a reduced white cell count. What is rheumatoid arthritis and what are muscle relaxants? When you have rheumatoid arthritis your immune system, which normally fights infection, attacks the lining of your joints. This makes your joints swollen, stiff, and painful. The small joints of your hands and feet are usually affected first. There is no cure for rheumatoid arthritis at present, so the treatments aim to relieve pain and stiffness and improve your ability to move. Muscle relaxants can be used to treat anxiety and promote sleep, and some people believe they may also reduce pain by acting on the nerves that cause pain, but this remains controversial. Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), Xanax, Ativan and non‐benzodiazepines such as Skelaxin, Muscol) and drugs that prevent increased muscle tone (baclofen and dantrolene). Best estimates of what happens to people with rheumatoid arthritis who take muscle relaxants: Pain at 24 hours: ‐ Non‐significant result. Pain at 1 to 2 weeks: ‐ Non‐significant result. Withdrawal due to adverse events, after 2 weeks: ‐ Non‐significant result. Total adverse events: ‐ 49 more people out of 100 experienced an adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 49%), ‐ 52 out of 100 people who took a muscle relaxant suffered an adverse event, ‐ 3 out of 100 people who took a placebo suffered an adverse event. Central nervous system (CNS) adverse events: ‐ 33 more people out of 100 experienced a CNS adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 33%), ‐ 39 out of 100 people who took a muscle relaxant suffered a CNS adverse event, ‐ 6 out of 100 people who took a placebo relaxant suffered a CNS adverse event. This record should be cited as: This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in the Cochrane Database of Systematic Reviews [Issue and date] © [year] The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464‐780X).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Richards, BL; Whittle, SL; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD008922.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "5fc8a3c8-78ef-4796-9530-9488c7a386fe", "pmid": "", "title": "Exploring the Use of Genetic and Behavioural Data in Tailoring Dietary and Lifestyle Support: An n=1 Randomised Trial", "imported": false, "abstract": "Personalised nutrition approaches typically rely on static information such as health status, lifestyle and genetic data. However, adherence often remains low because daily behaviours are influenced by psychological states, motivation and real-time barriers. There is growing interest in whether integrating behavioural signals and timely prompts could strengthen engagement. The purpose of this study is to explore whether incorporating psychological adaptation and just-in-time behavioural prompts leads to better adherence to a personalised nutrition programme compared with commonly used personalised approach (combining health, lifestyle and genetics data without psycho-behavioural adaptation). Using a six-week n-of-1 randomised trial design implemented across multiple participants, the research will also assess the feasibility of delivering this adaptive support in a free-living environment, as well as participants' engagement, acceptability and perceived usefulness. Following completion of the 6-week intervention, an optional focus group will be conducted with a subset of participants (maximum 8) within four weeks of the final study day. The focus group will last approximately 60-90 minutes and will be conducted in person or via video call. Qualitative data from the focus group will be analysed using reflexive thematic analysis (Braun & Clarke, 2021). These findings will inform the development of an adaptive personalised nutrition AI agent.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.267Z" }, { "id": "5fd85c47-3337-4f2a-9fc5-d4f0fdeb1c96", "pmid": "", "title": "Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health services. Decay and gum disease can cause pain, eating and speaking difficulties, low self‐esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self‐administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area. Objectives To evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other. Search methods Cochrane Oral Health’s Information Specialist searched: Cochrane Oral Health’s Trials Register (to 16 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 12), MEDLINE Ovid (1946 to 16 January 2019), Embase Ovid (1980 to 16 January 2019) and CINAHL EBSCO (1937 to 16 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication. Selection criteria Randomised controlled trials (RCTs) that compared toothbrushing and a home‐use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks). Data collection and analysis At least two review authors independently screened searches, selected studies, extracted data, assessed studies' risk of bias, and assessed evidence certainty as high, moderate, low or very low, according to GRADE. We extracted indices measured on interproximal surfaces, where possible. We conducted random‐effects meta‐analyses, using mean differences (MDs) or standardised mean differences (SMDs). Main results We included 35 RCTs (3929 randomised adult participants). Studies were at high risk of performance bias as blinding of participants was not possible. Only two studies were otherwise at low risk of bias. Many participants had a low level of baseline gingival inflammation. Studies evaluated the following devices plus toothbrushing versus toothbrushing: floss (15 trials), interdental brushes (2 trials), wooden cleaning sticks (2 trials), rubber/elastomeric cleaning sticks (2 trials), oral irrigators (5 trials). Four devices were compared with floss: interdental brushes (9 trials), wooden cleaning sticks (3 trials), rubber/elastomeric cleaning sticks (9 trials) and oral irrigators (2 trials). Another comparison was rubber/elastomeric cleaning sticks versus interdental brushes (3 trials). No trials assessed interproximal caries, and most did not assess periodontitis. Gingivitis was measured by indices (most commonly, Löe‐Silness, 0 to 3 scale) and by proportion of bleeding sites. Plaque was measured by indices, most often Quigley‐Hein (0 to 5). Primary objective: comparisons against toothbrushing alone Low‐certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index (GI)) at one month (SMD ‐0.58, 95% confidence interval (CI) ‐1.12 to ‐0.04; 8 trials, 585 participants), three months or six months. The results for proportion of bleeding sites and plaque were inconsistent (very low‐certainty evidence). Very low‐certainty evidence suggested that using an interdental brush, plus toothbrushing, may reduce gingivitis (measured by GI) at one month (MD ‐0.53, 95% CI ‐0.83 to ‐0.23; 1 trial, 62 participants), though there was no clear difference in bleeding sites (MD ‐0.05, 95% CI ‐0.13 to 0.03; 1 trial, 31 participants). Low‐certainty evidence suggested interdental brushes may reduce plaque more than toothbrushing alone (SMD ‐1.07, 95% CI ‐1.51 to ‐0.63; 2 trials, 93 participants). Very low‐certainty evidence suggested that using wooden cleaning sticks, plus toothbrushing, may reduce bleeding sites at three months (MD ‐0.25, 95% CI ‐0.37 to ‐0.13; 1 trial, 24 participants), but not plaque (MD ‐0.03, 95% CI ‐0.13 to 0.07). Very low‐certainty evidence suggested that using rubber/elastomeric interdental cleaning sticks, plus toothbrushing, may reduce plaque at one month (MD ‐0.22, 95% CI ‐0.41 to ‐0.03), but this was not found for gingivitis (GI MD ‐0.01, 95% CI ‐0.19 to 0.21; 1 trial, 12 participants; bleeding MD 0.07, 95% CI ‐0.15 to 0.01; 1 trial, 30 participants). Very‐low certainty evidence suggested oral irrigators may reduce gingivitis measured by GI at one month (SMD ‐0.48, 95% CI ‐0.89 to ‐0.06; 4 trials, 380 participants), but not at three or six months. Low‐certainty evidence suggested that oral irrigators did not reduce bleeding sites at one month (MD ‐0.00, 95% CI ‐0.07 to 0.06; 2 trials, 126 participants) or three months, or plaque at one month (SMD ‐0.16, 95% CI ‐0.41 to 0.10; 3 trials, 235 participants), three months or six months, more than toothbrushing alone. Secondary objective: comparisons between devices Low‐certainty evidence suggested interdental brushes may reduce gingivitis more than floss at one and three months, but did not show a difference for periodontitis measured by probing pocket depth. Evidence for plaque was inconsistent. Low‐ to very low‐certainty evidence suggested oral irrigation may reduce gingivitis at one month compared to flossing, but very low‐certainty evidence did not suggest a difference between devices for plaque. Very low‐certainty evidence for interdental brushes or flossing versus interdental cleaning sticks did not demonstrate superiority of either intervention. Adverse events Studies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation. Authors' conclusions Using floss or interdental brushes in addition to toothbrushing may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low‐certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis. Plain language summary Home use of devices for cleaning between the teeth (in addition to toothbrushing) to prevent and control gum diseases and tooth decay Review question How effective are home‐use interdental cleaning devices, plus toothbrushing, compared with toothbrushing only or use of another device, for preventing and controlling periodontal (gum) diseases (gingivitis and periodontitis), tooth decay (dental caries) and plaque? Background Tooth decay and gum diseases affect most people. They can cause pain, difficulties with eating and speaking, low self‐esteem, and, in extreme cases, may lead to tooth loss and the need for surgery. The cost to health services of treating these diseases is very high. As dental plaque (a layer of bacteria in an organic matrix that forms on the teeth) is the root cause, it is important to remove plaque from teeth on a regular basis. While many people routinely brush their teeth to remove plaque up to the gum line, it is difficult for toothbrushes to reach into areas between teeth ('interdental'), so interdental cleaning is often recommended as an extra step in personal oral hygiene routines. Different tools can be used to clean interdentally, such as dental floss, interdental brushes, tooth cleaning sticks, and water pressure devices known as oral irrigators. Study characteristics Review authors working with Cochrane Oral Health searched for studies up to 16 January 2019. We identified 35 studies (3929 adult participants). Participants knew that they were in an experiment, which might have affected their teeth cleaning or eating behaviour. Some studies had other problems that might make their findings less reliable, such as people dropping out of the study or not using the assigned device. Studies evaluated the following devices plus toothbrushing compared to toothbrushing only: floss (15 studies), interdental brushes (2 studies), wooden cleaning sticks (2 studies), rubber/elastomeric cleaning sticks (2 studies) and oral irrigators (5 studies). Four devices were compared with floss: interdental brushes (9 studies), wooden cleaning sticks (3 studies), rubber/elastomeric cleaning sticks (9 studies), oral irrigators (2 studies). Three studies compared rubber/elastomeric cleaning sticks with interdental brushes. No studies evaluated decay, and few evaluated severe gum disease. Outcomes were measured at short (one month to six weeks) and medium term (three and six months). Key results We found that using floss, in addition to toothbrushing, may reduce gingivitis in the short and medium term. It is unclear if it reduces plaque. Using an interdental brush, in addition to a toothbrush, may reduce gingivitis and plaque in the short term. Using wooden tooth cleaning sticks may be better than toothbrushing only for reducing gingivitis (measured by bleeding sites) but not plaque in the medium term (only 24 participants). Using a tooth cleaning stick made of rubber or an elastomer may be better than toothbrushing only for reducing plaque but not gingivitis in the short term (only 30 participants). Toothbrushing plus oral irrigation (water pressure) may reduce gingivitis in the short term, but there was no evidence for this in the medium term. There was no evidence of a difference in plaque. Interdental brushes may be better than flossing for gingivitis at one and three months. The evidence for plaque is inconsistent. There was no evidence of a difference between the devices for periodontitis measured by probing pocket depth. There is some evidence that oral irrigation may be better than flossing for reducing gingivitis (but not plaque) in the short term. The available evidence for interdental cleaning sticks did not show them to be better or worse than floss or interdental brushes for controlling gingivitis or plaque. The studies that measured 'adverse events' found no serious effects and no evidence of differences between study groups in minor effects such as gum irritation. Certainty of the evidence The evidence is low to very low‐certainty. The effects observed may not be clinically important. Studies measured outcomes mostly in the short term and many participants had a low level of gum disease at the beginning of the studies. Future research Future studies should use the new periodontal diseases classification to describe the gum health of participants, and they should last long enough to measure periodontitis and tooth decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Worthington, HV; MacDonald, L; Poklepovic Pericic, T; Sambunjak, D; Johnson, TM; Imai, P; Clarkson, JE", "articleTypes": [], "doi": "10.1002/14651858.CD012018.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "5ff4db81-fdfa-4cdf-b928-a6b066e39bad", "pmid": "", "title": "Immediate‐release versus controlled‐release carbamazepine in the treatment of epilepsy", "imported": false, "abstract": "Abstract - Background Carbamazepine (CBZ) is a commonly used drug for epilepsy that is associated with troublesome adverse events including dizziness, double vision, drowsiness, poor co‐ordination and unsteadiness. These adverse events often occur during peaks in drug plasma concentration. These adverse events may limit the daily dose of CBZ that can be tolerated and reduce the chances of seizure control in patients who require high doses. A controlled‐release formulation of CBZ delivers the same dose over a longer period of time when compared to a standard immediate‐release formulation, thereby reducing post‐dose peaks in CBZ plasma concentration and potentially reducing adverse events. This is an updated version of the original Cochrane review published in Issue 12, 2014. Objectives To determine the efficacy of immediate‐release CBZ (IR CBZ) versus controlled‐release CBZ (CR CBZ) in patients diagnosed with epilepsy. The following review questions were investigated.
 (1) For newly diagnosed patients commencing CBZ, how do IR and CR formulations compare for efficacy and tolerability?
 (2) For patients on established treatment with IR CBZ but experiencing unacceptable adverse events, what is the effect on seizure control and the tolerability of a switch to a CR formulation versus remaining on the IR formulation? Search methods We searched the Cochrane Epilepsy Group Specialized Register, CENTRAL, and MEDLINE (Ovid) from inception to 30 August 2016. Selection criteria Randomised controlled trials comparing IR CBZ to CR CBZ in patients commencing monotherapy and patients presently treated with IR CBZ but experiencing unacceptable adverse events. Primary outcome measures included measures of seizure frequency, incidence of adverse events, proportion of patients with treatment failure and quality of life measures. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted the data and recorded relevant information on a standardised data extraction form. We used the Cochrane risk of bias tool to assess the methodological quality of included studies. The heterogeneity of the included trials with respect to the reporting of outcomes resulted in only a narrative, descriptive analysis being possible for both the categorical and time‐to‐event data. Main results Ten trials (296 participants) fulfilled the criteria for inclusion in this review. Only one study had a low risk of bias. Two studies had a high risk of bias and the rest of the studies were rated as unclear risk of bias. One trial included patients with newly diagnosed epilepsy and nine included patients on treatment with IR CBZ. Eight trials reported heterogeneous measures of seizure frequency with conflicting results. A statistically significant difference was observed in only one trial, with patients prescribed CR CBZ experiencing fewer seizures than patients prescribed IR CBZ. Nine trials reported measures of adverse events. There was a trend in favour of CR CBZ with four trials reporting a statistically significant reduction in adverse events compared to IR CBZ. A further two trials reported fewer adverse events with CR CBZ but the reduction was not statistically significant. One trial found no difference in adverse events, and another trial reported more adverse events in the CR CBZ group than the IR CBZ group, although the increase was not statistically significant. Authors' conclusions For this update no new eligible studies were identified and the conclusions drawn from the initial review remain unchanged. At present, data from trials do not confirm or refute an advantage for CR CBZ over IR CBZ for seizure frequency or adverse events in patients with newly diagnosed epilepsy. For trials involving epilepsy patients already prescribed IR CBZ, no conclusions can be drawn concerning the superiority of CR CBZ with respect to seizure frequency. There is a trend for CR CBZ to be associated with fewer adverse events when compared to IR CBZ. A change to CR CBZ may therefore be a worthwhile strategy in patients with acceptable seizure control on IR CBZ but experiencing unacceptable adverse events. The included trials were of small size and of poor methodological quality limiting the validity of this conclusion. Randomised controlled trials comparing CR CBZ to IR CBZ and using clinically relevant outcomes are required to inform the choice of CBZ preparation for patients with newly diagnosed epilepsy. Plain language summary Fast‐release versus slow‐release carbamazepine as medication for patients with epilepsy Background Epilepsy is a common brain disorder that is often treated with carbamazepine. With treatment, people often have fewer seizures but many people experience side effects. When carbamazepine is swallowed it is taken into the blood stream quickly and there is a sharp rise of drug levels in the blood. These 'peaks' may be associated with side effects such as dizziness, double vision, drowsiness, unsteadiness and poor co‐ordination. A type of carbamazepine that releases the medication into the body slowly may lessen these 'peaks' in the blood levels, possibly meaning fewer side effects. This review compared studies looking at the differences between a 'fast‐release' carbamazepine and a 'slow‐release' carbamazepine. Participants To be included in this review, all participants had to be diagnosed with epilepsy and be either just starting carbamazepine treatment or be already on it but with intolerable side effects. The participants could be of any age or gender. Studies Ten trials with a total of 296 people with epilepsy were included in the review. All 10 trials were randomised controlled trials (patients were compared in randomly assigned groups). All of the studies had at least two groups, one group taking fast‐release carbamazepine and one group taking slow‐release carbamazepine, and some also had a control group (a group of non‐epileptic people). The evidence is current to August 2016. Results Just one of 10 studies found a significant difference between the two carbamazepine types in the number of seizures experienced, with patients prescribed the slow‐release carbamazepine experiencing fewer seizures than patients prescribed the fast‐release drug. Patients taking slow‐release carbamazepine tended to experience fewer side effects. Quality of the evidence Out of the 10 trials in the review, only one study was judged to be of 'good' quality, and so the evidence in this review was rated as low quality. It must be stressed that there are not many studies assessing the differences between these two carbamazepine types and more studies are needed before we can make a definitive conclusion about one over the other.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, G; Saunders, M; Rigby, A; Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007124.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "6001e4a2-677c-4480-a217-0cdc62d6feef", "pmid": "", "title": "Ready‐to‐use therapeutic food (RUTF) for home‐based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age", "imported": false, "abstract": "Abstract - Background Management of severe acute malnutrition (SAM) in children comprises two potential phases: stabilisation and rehabilitation. During the initial stabilisation phase, children receive treatment for dehydration, electrolyte imbalances, intercurrent infections and other complications. In the rehabilitation phase (applicable to children presenting with uncomplicated SAM or those with complicated SAM after complications have been resolved), catch‐up growth is the main focus and the recommended energy and protein requirements are much higher. In‐hospital rehabilitation of children with SAM is not always desirable or practical ‐ especially in rural settings ‐ and home‐based care can offer a better solution. Ready‐to‐use therapeutic food (RUTF) is a widely used option for home‐based rehabilitation, but the findings of our previous review were inconclusive. Objectives To assess the effects of home‐based RUTF used during the rehabilitation phase of SAM in children aged between six months and five years on recovery, relapse, mortality and rate of weight gain. Search methods We searched the following databases in October 2018: CENTRAL, MEDLINE, Embase, six other databases and three trials registers. We ran separate searches for cost‐effectiveness studies, contacted researchers and healthcare professionals in the field, and checked bibliographies of included studies and relevant reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs, where children aged between six months and five years with SAM were, during the rehabilitation phase, treated at home with RUTF compared to an alternative dietary approach, or with different regimens and formulations of RUTF compared to each other. We assessed recovery, deterioration or relapse and mortality as primary outcomes; and rate of weight gain, time to recovery, anthropometrical changes, cognitive development and function, adverse outcomes and acceptability as secondary outcomes. Data collection and analysis We screened for eligible studies, extracted data and assessed risk of bias of those included, independently and in duplicate. Where data allowed, we performed a random‐effects meta‐analysis using Review Manager 5, and investigated substantial heterogeneity through subgroup and sensitivity analyses. For the main outcomes, we evaluated the quality of the evidence using GRADE, and presented results in a 'Summary of findings' table per comparison. Main results We included 15 eligible studies (n = 7976; effective sample size = 6630), four of which were cluster trials. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. Six studies received funding or donations from industry whereas eight did not, and one study did not report the funding source. The overall risk of bias was high for six studies, unclear for three studies, and low for six studies. Among the 14 studies that contributed to meta‐analyses, none (n = 5), some (n = 5) or all (n = 4) children were stabilised in hospital prior to commencement of the study. One small study included only children known to be HIV‐infected, another study stratified the analysis for 'recovery' according to HIV status, while the remaining studies included HIV‐uninfected or untested children. Across all studies, the intervention lasted between 8 and 16 weeks. Only five studies followed up children postintervention (maximum of six months), and generally reported on a limited number of outcomes. We found seven studies with 2261 children comparing home‐based RUTF meeting the World Health Organization (WHO) recommendations for nutritional composition (referred to in this review as standard RUTF) with an alternative dietary approach (effective sample size = 1964). RUTF probably improves recovery (risk ratio (RR) 1.33; 95% confidence interval (CI) 1.16 to 1.54; 6 studies, 1852 children; moderate‐quality evidence), and may increase the rate of weight gain slightly (mean difference (MD) 1.12 g/kg/day, 95% CI 0.27 to 1.96; 4 studies, 1450 children; low‐quality evidence), but we do not know the effects on relapse (RR 0.55, 95% CI 0.30 to 1.01; 4 studies, 1505 children; very low‐quality evidence) and mortality (RR 1.05, 95% CI 0.51 to 2.16; 4 studies, 1505 children; very low‐quality evidence). Two quasi‐randomised cluster trials compared standard, home‐based RUTF meeting total daily nutritional requirements with a similar RUTF but given as a supplement to the usual diet (213 children; effective sample size = 210). Meta‐analysis showed that standard RUTF meeting total daily nutritional requirements may improve recovery (RR 1.41, 95% CI 1.19 to 1.68; low‐quality evidence) and reduce relapse (RR 0.11, 95% CI 0.01 to 0.85; low‐quality evidence), but the effects are unknown for mortality (RR 1.36, 95% CI 0.46 to 4.04; very low‐quality evidence) and rate of weight gain (MD 1.21 g/kg/day, 95% CI ‐ 0.74 to 3.16; very low‐quality evidence). Eight studies randomised 5502 children (effective sample size = 4456) and compared standard home‐based RUTF with RUTFs of alternative formulations (e.g. using locally available ingredients, containing less or no milk powder, containing specific fatty acids, or with added pre‐ and probiotics). For recovery, it made little or no difference whether standard or alternative formulation RUTF was used (RR 1.03, 95% CI 0.99 to 1.08; 6 studies, 4188 children; high‐quality evidence). Standard RUTF decreases relapse (RR 0.84, 95% CI 0.72 to 0.98; 6 studies, 4188 children; high‐quality evidence). However, it probably makes little or no difference to mortality (RR 1.00, 95% CI 0.80 to 1.24; 7 studies, 4309 children; moderate‐quality evidence) and may make little or no difference to the rate of weight gain (MD 0.11 g/kg/day, 95% CI −0.32 to 0.54; 6 studies, 3807 children; low‐quality evidence) whether standard or alternative formulation RUTF is used. Authors' conclusions Compared to alternative dietary approaches, standard RUTF probably improves recovery and may increase rate of weight gain slightly, but the effects on relapse and mortality are unknown. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given as a supplement to the usual diet, but the effects on mortality and rate of weight gain are not clear. When comparing RUTFs with different formulations, the current evidence does not favour a particular formulation, except for relapse, which is reduced with standard RUTF. Well‐designed, adequately powered, pragmatic RCTs with standardised outcome measures, stratified by HIV status, and that include diarrhoea as an outcome, are needed. Plain language summary Ready‐to‐use therapeutic food (RUTF) as home‐based treatment for severely malnourished children between six months and five years Background Malnourished children usually look very thin or wasted and they have a high risk of death and illness. Treating severely malnourished children in hospitals is not always desirable or practical in rural settings, and home‐based treatment may be better. Home‐based treatment can be food prepared by a caregiver (such as flour porridge or energy‐ and nutrient‐dense locally available foods), or ready‐to‐use therapeutic food (RUTF) provided by a clinic. RUTF is usually made according to a standard, energy‐rich composition defined by the World Health Organization (WHO). Typically, the ingredients for standard RUTF include milk powder, sugar, peanut butter, vegetable oil, vitamins and minerals; but ingredients vary depending on local availability, cost and acceptability. Benefits of RUTF include a long shelf life without refrigeration and they require no preparation. This is an update of our previous review, where definite conclusions about the effects of RUTF could not be drawn from the four studies that were available at that time. Review question We assessed standard RUTF compared to an alternative dietary approach (e.g. flour porridge or locally available foods) and examined whether smaller amounts and different formulations of RUTF can achieve similar health outcomes in severely malnourished children aged between six months and five years. The main health outcomes that we investigated were recovery from severe malnutrition, deterioration or relapse, death and the rate of weight gain. Included study characteristics We searched databases for studies up to the October 2018, and found 15 studies with 7976 children. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. One small study included only children infected with HIV, another study analysed children with and without HIV separately for the main outcome (recovery), while the other studies included children who were not infected with HIV or who were untested. Overall, we judged six studies to be at high risk of bias, three studies to be at unclear risk of bias, and six studies to be at low risk of bias. (With 'risk of bias', we mean the extent to which the methods used in a study enable it to determine the truth.) All the studies lasted between 8 and 16 weeks. Only five studies followed up children after the study (for a maximum of six months), and generally reported on a limited number of outcomes. Of our 15 included studies, six were linked to funding or donations from industry, one did not report the source of funding, and eight studies reported funding where sponsors did not include industry. Key findings Compared to alternative dietary approaches, standard RUTF probably improves recovery (moderate‐quality evidence) and may increase the rate of weight gain slightly (low‐quality evidence), but the effects on relapse and death are unknown (very low‐quality evidence). With 'quality of evidence' we mean how confident we are that the particular finding represents the true effect. For example, 'very low‐quality' means we are very uncertain about the finding, 'low‐quality evidence' means the future research is very likely to change the finding, 'moderate‐quality evidence' means that future studies may change this finding, and 'high‐quality evidence' means that it is unlikely that future studies will change the finding. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given supplementary to the usual diet (low‐quality evidence), but for death and the rate of weight gain, the effects are not known (very low‐quality evidence). When comparing RUTFs of different formulations, it makes little or no difference for recovery whether a standard or alternative formulation RUTF is used (high‐quality evidence). For relapse, using standard RUTF decreases relapse (high‐quality evidence). It probably makes little or no difference to death (moderate‐quality evidence) and to the rate of weight gain (low‐quality evidence) whether standard or alternative formulation RUTF is used. Well‐designed, randomised controlled trials (experimental studies where participants meeting the inclusion criteria have an equal chance of being allocated to any of the intervention or control groups) in which analyses have been performed separately for children with and without HIV, and that also measure and report on diarrhoea occurrence, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Schoonees, A, Lombard, MJ, Musekiwa, A, Nel, E, Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD009000.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.797Z" }, { "id": "6006ba5c-85ee-4640-a0cf-dd7914427c3b", "pmid": "", "title": "A 6-month Multicenter, Randomized, Double-blind, Placebo-controlled Study to Evaluate the Efficacy, Safety and PK/PD of an age-and Body Weight-adjusted Oral Finerenone Regimen, in Addition to an ACEI or ARB, for the Treatment of Children, 6 Months to <18 Years of Age, With Chronic Kidney Disease and Proteinuria", "imported": false, "abstract": "Researchers are looking for a better way to treat children who have chronic kidney disease (CKD), which is long-term kidney disease, and proteinuria, a condition in which a person´s kidneys leak protein into the urine.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.245Z" }, { "id": "6047d279-7780-4d01-8b97-d5a8d17382c4", "pmid": "", "title": "Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults", "imported": false, "abstract": "Abstract - Background The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non‐opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. Objectives To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. Selection criteria We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. Data collection and analysis We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. Main results We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after). The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies. IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) −0.50, 95% confidence interval (CI) −0.72 to −0.28; 29 studies, 1656 participants; very low‐quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD −0.14, 95% CI −0.25 to −0.04; 33 studies, 1847 participants; moderate‐quality evidence), and at late time points (48 hours) (SMD −0.11, 95% CI −0.25 to 0.04; 24 studies, 1404 participants; moderate‐quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures. We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) −7.92 hours, 95% CI −12.71 to −3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD −4.52 mg morphine equivalents , 95% CI −6.25 to −2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes. The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low‐quality evidence). IV Lidocaine compared to TEA The effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI −0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI −1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD −1.66, 95% CI −10.88 to 7.56; 2 studies, 102 participants); all very low‐quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low‐quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low‐quality evidence). Authors' conclusions We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review. Plain language summary Intravenous infusion of lidocaine starting at the time of surgery for reduction of pain and improvement of recovery after surgery Background The most common problems immediately following surgery under general anaesthesia are pain, nausea and vomiting, delirium and slow or no movement of food through the digestive system. Opioid medications given to reduce postoperative pain may also be associated with nausea and constipation, also preventing a smooth recovery. It is of interest for patients and clinicians to reduce or prevent these complications leading to an early recovery so that patients can leave hospital earlier. One option for pain relief after surgery is epidural analgesia, where an opioid or local anaesthetic such as lidocaine is injected into the space surrounding the spinal cord. Not all patients may be suited to epidural analgesia, and so additional options such as intravenous non‐opioid analgesic medications that enable a rapid recovery are required. The aim of this review was to assess the benefits and risks of intravenous infusion of lidocaine in patients undergoing various surgical procedures. Lidocaine is a medication used to numb tissue in a specific area. Study characteristics This review was published in 2015, and updated in 2017. We found 68 randomized controlled studies (RCTs), (clinical studies where people are randomly put into one of two or more treatment groups), with results from a total of 4525 participants. RCTs are used because they provide the most reliable evidence. Intravenous lidocaine was compared with placebo or standard care in 66 of the studies, and with thoracic (chest area of spine) epidural analgesia in two studies. (A placebo is an inactive substance or procedure given to a participant in a medical trial to compare its effects with those of a real drug or other intervention). Lidocaine infusion was started during the surgery, before the first cut, and continued to at least the end of surgery. The included studies were moderately well conducted. Key results We are uncertain whether lidocaine infusion reduces pain, one to four hours after surgery when compared to placebo or usual care (29 studies, over 1600 participants). There was probably no difference in pain at 24 hours (33 studies, 1847 participants) and at 48 hours (24 studies, 1404 participants) between participants in the lidocaine and the placebo group. We are uncertain whether lidocaine infusion improves recovery of bowel function, with a reduction in the time to first defaecation or bowel movements (12 studies, 684 participants), and reduced risk of stopping the passage of food in the gut (4 studies, 273 participants). We are also uncertain whether lidocaine reduces postoperative nausea (35 studies, 1903 participants), and the requirement for opioids for pain relief (40 studies, 2201 participants). Only a limited number of studies systematically analysed adverse effects of intravenous lidocaine infusion. The side effects of intravenous lidocaine were unclear. In the two studies that investigated intravenous lidocaine compared to epidural analgesia (102 participants), the effect on pain at 24 and 48 hours, and on the time to first bowel movement, remains unclear. The effect of lidocaine on the risk of stopping the passage of food in the gut and for postoperative nausea is also unclear, as only one small trial assessed these outcomes. Neither study investigated the effect on pain immediately after surgery, or on opioid consumption. Both studies looked at adverse effects associated with lidocaine, but the effect is uncertain. Quality of the evidence We rated the quality of evidence for most outcomes as very low. This was because of inconsistent findings across studies and the fact that the evidence came from small studies that were of moderate design quality or a limited number of studies. The quality of the evidence for minimal or no effect on pain at 24 and 48 hours was moderate quality. The studies involved a variety of surgical procedures. The dose of lidocaine used, and how long it was delivered for after the end of surgery, also varied between studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Weibel, S, Jelting, Y, Pace, NL, Helf, A, Eberhart, LHJ, Hahnenkamp, K, Hollmann, MW, Poepping, DM, Schnabel, A, Kranke, P", "articleTypes": [], "doi": "10.1002/14651858.CD009642.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.772Z" }, { "id": "606a2b93-3546-497a-bd3f-b2b3e4716de5", "pmid": "", "title": "Postnatal phenobarbital for the prevention of intraventricular haemorrhage in preterm infants", "imported": false, "abstract": "Abstract - Background Intraventricular haemorrhage (IVH) is a major complication of preterm birth. Large haemorrhages are associated with a high risk of disability and hydrocephalus. Instability of blood pressure and cerebral blood in the newborn flow are postulated as causative factors. Another mechanism may involve reperfusion damage from oxygen free radicals. It has been suggested that phenobarbital stabilises blood pressure and may protect against free radicals. This is an update of a review first published in 2001 and updated in 2007 and 2013. Objectives To assess the benefits and harms of the postnatal administration of phenobarbital in preterm infants at risk of developing IVH compared to control (i.e. no intervention or placebo). Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL and clinical trial registries in January 2022. A new, more sensitive search strategy was developed, and searches were conducted without date limits. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs in which phenobarbital was given within the first 24 hours of life to preterm infants identified as being at risk of IVH because of gestational age below 34 weeks, birth weight below 1500 g or respiratory failure. Phenobarbital was compared to no intervention or placebo. We excluded infants with serious congenital malformations. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were all grades of IVH and severe IVH (i.e. grade III and IV); secondary outcomes were ventricular dilation or hydrocephalus, hypotension, pneumothorax, hypercapnia, acidosis, mechanical ventilation, neurodevelopmental impairment and death. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 10 RCTs (792 infants). The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH of any grade compared with control (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.84 to 1.19; risk difference (RD) 0.00, 95% CI ‐0.06 to 0.07; I² for RD = 65%; 10 RCTs, 792 participants; low certainty evidence) and in severe IVH (RR 0.88, 95% CI 0.64 to 1.21; 10 RCTs, 792 participants; low certainty evidence). The evidence is very uncertain about the effect of phenobarbital on posthaemorrhagic ventricular dilation or hydrocephalus (RR 0.62, 95% CI 0.31 to 1.26; 4 RCTs, 271 participants; very low certainty evidence), mild neurodevelopmental impairment (RR 0.57, 95% CI 0.15 to 2.17; 1RCT, 101 participants; very low certainty evidence), and severe neurodevelopmental impairment (RR 1.12, 95% CI 0.44 to 2.82; 2 RCTs, 153 participants; very low certainty evidence). Phenobarbital may result in little to no difference in death before discharge (RR 0.88, 95% CI 0.64 to 1.21; 9 RCTs, 740 participants; low certainty evidence) and mortality during study period (RR 0.98, 95% CI 0.72 to 1.33; 10 RCTs, 792 participants; low certainty evidence) compared with control. We identified no ongoing trials. Authors' conclusions The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH (any grade or severe) compared with control (i.e. no intervention or placebo). The evidence is very uncertain about the effects of phenobarbital on ventricular dilation or hydrocephalus and on neurodevelopmental impairment. The evidence suggests that phenobarbital results in little to no difference in death before discharge and all deaths during the study period compared with control. Since 1993, no randomised studies have been published on phenobarbital for the prevention of IVH in preterm infants, and no trials are ongoing. The effects of postnatal phenobarbital might be assessed in infants with both neonatal seizures and IVH, in both randomised and observational studies. The assessment of benefits and harms should include long‐term outcomes. Plain language summary What are the benefits and risks of phenobarbital for preventing bleeding to the brain in babies born too early? Key messages • Giving phenobarbital (a medicine used to control seizures) to babies born too early may have little to no effect in preventing intraventricular haemorrhage (bleeding to the brain) and death. • The evidence is very uncertain about the effect of phenobarbital on preventing ventricular dilation (enlarged spaces in the brain) and long‐term brain development. What is bleeding to the brain (intraventricular haemorrhage)? Large bleeds in the centre of the brain can cause disability or death in babies born too early. Unstable blood pressure and blood flow to the brain are believed to cause bleeding into the fluid‐filled cavities of the brain (ventricles). What did we want to find out? Phenobarbital is believed to stabilise blood pressure and therefore potentially help prevent bleeding to the brain. We wanted to find out whether phenobarbital was better than no medicine or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) to prevent bleeding to the brain. What did we do? We searched for studies that compared giving phenobarbital against no medicines. We compared and summarised the results of these studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We included 10 studies (792 babies). The evidence suggests that phenobarbital has little to no effect in preventing bleeding to the brain. The evidence is very uncertain about the effect of phenobarbital on dilation of the ventricles in the brain and long‐term development. The evidence suggests that phenobarbital has little to no effect in preventing deaths. We identified no ongoing trials. What are the limitations of the evidence? It is possible that people conducting the studies were aware of what treatment they were giving. Not all the studies provided data about everything that we were interested in. The studies were very small. How up to date is this evidence? This review updates our previous review. The evidence is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Romantsik, O; Smit, E; Odd, DE; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD001691.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "60a13a72-4bb7-47e1-b46e-dd59cd5824e0", "pmid": "", "title": "Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users", "imported": false, "abstract": "Abstract - Background Prolonged treatment with benzodiazepines is common practice despite clinical recommendations of short‐term use. Benzodiazepines are used by approximately 4% of the general population, with increased prevalence in psychiatric populations and the elderly. After long‐term use it is often difficult to discontinue benzodiazepines due to psychological and physiological dependence. This review investigated if pharmacological interventions can facilitate benzodiazepine tapering. Objectives To assess the benefits and harms of pharmacological interventions to facilitate discontinuation of chronic benzodiazepine use. Search methods We searched the following electronic databases up to October 2017: Cochrane Drugs and Alcohol Group's Specialised Register of Trials, CENTRAL, PubMed, Embase, CINAHL, and ISI Web of Science. We also searched ClinicalTrials.gov, the WHO ICTRP, and ISRCTN registry, and checked the reference lists of included studies for further references to relevant randomised controlled trials. Selection criteria We included randomised controlled trials comparing pharmacological treatment versus placebo or no intervention or versus another pharmacological intervention in adults who had been treated with benzodiazepines for at least two months and/or fulfilled criteria for benzodiazepine dependence (any criteria). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 38 trials (involving 2543 participants), but we could only extract data from 35 trials with 2295 participants. Many different interventions were studied, and no single intervention was assessed in more than four trials. We extracted data on 18 different comparisons. The risk of bias was high in all trials but one. Trial Sequential Analysis showed imprecision for all comparisons. For benzodiazepine discontinuation, we found a potential benefit of valproate at end of intervention (1 study, 27 participants; risk ratio (RR) 2.55, 95% confidence interval (CI) 1.08 to 6.03; very low‐quality evidence) and of tricyclic antidepressants at longest follow���up (1 study, 47 participants; RR 2.20, 95% CI 1.27 to 3.82; low‐quality evidence). We found potentially positive effects on benzodiazepine withdrawal symptoms of pregabalin (1 study, 106 participants; mean difference (MD) ‐3.10 points, 95% CI ‐3.51 to ‐2.69; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐1.00 points, 95% CI ‐1.13 to ‐0.87; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐3.57 points, 95% CI ‐5.34 to ‐1.80; very low‐quality evidence), tricyclic antidepressants (1 study, 38 participants; MD ‐19.78 points, 95% CI ‐20.25 to ‐19.31; very low‐quality evidence), and flumazenil (3 studies, 58 participants; standardised mean difference ‐0.95, 95% CI ‐1.71 to ‐0.19; very low‐quality evidence) at end of intervention. However, the positive effect of paroxetine on benzodiazepine withdrawal symptoms did not persist until longest follow‐up (1 study, 54 participants; MD ‐0.13 points, 95% CI ‐4.03 to 3.77; very low‐quality evidence). The following pharmacological interventions reduced symptoms of anxiety at end of intervention: carbamazepine (1 study, 36 participants; MD ‐6.00 points, 95% CI ‐9.58 to ‐2.42; very low‐quality evidence), pregabalin (1 study, 106 participants; MD ‐4.80 points, 95% CI ‐5.28 to ‐4.32; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐5.70 points, 95% CI ‐6.05 to ‐5.35; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐6.75 points, 95% CI ‐9.64 to ‐3.86; very low‐quality evidence), and flumazenil (1 study, 18 participants; MD ‐1.30 points, 95% CI ‐2.28 to ‐0.32; very low‐quality evidence). Two pharmacological treatments seemed to reduce the proportion of participants that relapsed to benzodiazepine use: valproate (1 study, 27 participants; RR 0.31, 95% CI 0.11 to 0.90; very low‐quality evidence) and cyamemazine (1 study, 124 participants; RR 0.33, 95% CI 0.14 to 0.78; very low‐quality evidence). Alpidem decreased the proportion of participants with benzodiazepine discontinuation (1 study, 25 participants; RR 0.41, 95% CI 0.17 to 0.99; number needed to treat for an additional harmful outcome (NNTH) 2.3 participants; low‐quality evidence) and increased the occurrence of withdrawal syndrome (1 study, 145 participants; RR 4.86, 95% CI 1.12 to 21.14; NNTH 5.9 participants; low‐quality evidence). Likewise, magnesium aspartate decreased the proportion of participants discontinuing benzodiazepines (1 study, 144 participants; RR 0.80, 95% CI 0.66 to 0.96; NNTH 5.8; very low‐quality evidence). Generally, adverse events were insufficiently reported. Specifically, one of the flumazenil trials was discontinued due to severe panic reactions. Authors' conclusions Given the low or very low quality of the evidence for the reported outcomes, and the small number of trials identified with a limited number of participants for each comparison, it is not possible to draw firm conclusions regarding pharmacological interventions to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Due to poor reporting, adverse events could not be reliably assessed across trials. More randomised controlled trials are required with less risk of systematic errors ('bias') and of random errors ('play of chance') and better and full reporting of patient‐centred and long‐term clinical outcomes. Such trials ought to be conducted independently of industry involvement. Plain language summary Medications for discontinuation of long‐term benzodiazepine use Background Benzodiazepines are widely prescribed for long‐term use despite recommendations of only short‐term use. It is often difficult to discontinue benzodiazepines after more than a few weeks of treatment due to the development of physical and psychological dependence. This review aimed to assess the effect and safety of medications to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Search date The evidence is current to October 2017. Study characteristics We identified 38 randomised controlled trials involving 2543 participants who had either been treated for more than two months with benzodiazepines, or who had been diagnosed with benzodiazepine dependence. We included studies irrespective of whether benzodiazepines were prescribed for anxiety, insomnia, or any other condition. The average age of participants was around 50 years, and the majority of participants were women in most studies. Twenty‐four trials were conducted in Europe; eight trials in the US or Canada; and six trials in Asia. The trials involved a wide range of medications to facilitate reduction or discontinuation of benzodiazepine use. Fourteen of the 38 included studies were partly funded by the drug manufacturer; nine studies were funded by government agencies; and 15 studies did not state the source of funding. The duration of the trials ranged between 1 and 24 weeks; the average trial duration was 9 weeks. Key results We extracted data on 18 different comparisons in a total of 2295 participants. We are uncertain whether valproate and tricyclic antidepressants increase the chance of discontinuing benzodiazepines, and whether benzodiazepine withdrawal symptoms are reduced by pregabalin, captodiame, paroxetine, tricyclic antidepressants, and flumazenil, as we assessed the quality of the evidence as very low. We are uncertain as to whether symptoms of anxiety after withdrawal of benzodiazepines are reduced by carbamazepine, pregabalin, captodiame, paroxetine, and flumazenil, as we assessed the quality of the evidence as very low. The effects of the evaluated medications were too uncertain to inform clinical practice due to risk of bias (systematic errors with overestimation of benefits and underestimation of harms) and risk of chance occurrence (random errors giving any result). Tolerability and safety were poorly reported across the included studies, making it impossible to assess the balance between possible benefits and adverse effects. Consequently, no conclusions can be drawn about the effectiveness of the interventions. Quality of the evidence The quality of the evidence was generally low or very low due to the small number of trials including a limited number of participants for each comparison; dissimilar results across studies; poor study design; and pronounced financial involvement of the pharmaceutical industry. Randomised controlled trials are therefore needed without risk of bias and random significant results involving long‐term assessments of participants conducted without involvement of industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Baandrup, L; Ebdrup, BH; Rasmussen, JØ; Lindschou, J; Gluud, C; Glenthøj, BY", "articleTypes": [], "doi": "10.1002/14651858.CD011481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "60b945f5-9a47-4c72-abf8-2eac7fab3527", "pmid": "", "title": "Topical anaesthetic or vasoconstrictor preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy", "imported": false, "abstract": "Abstract - Background Nasal pharyngolaryngoscopy (NPL) is performed as an outpatient and inpatient procedure on a daily basis, for a variety of indications. It frequently causes some degree of discomfort to the patient. Various different topical agents, which are intended to reduce this discomfort, are in common use. This review aimed to assess the effectiveness of the various agents. Objectives To assess the effectiveness of topical preparations used to reduce discomfort and facilitate NPL in adults. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 14 April 2010. Selection criteria Randomised controlled trials (RCTs) looking at the effect of topical anaesthetic or vasoconstrictor agents used reduce discomfort and facilitate NPL in adult patients. Data collection and analysis Two review authors independently selected studies, extracted data and assessed risk of bias. We contacted trial authors for further information where necessary. The primary outcome measured was pain/discomfort. Secondary outcomes that were looked at included side effects of the topical medications, ease of the procedure and the quality of the view from the operator's perspective. Main results We included eight RCTs (746 participants) in the review. The risk of bias in the studies was generally low. Five studies did not demonstrate any advantage in using a topical treatment prior to endoscopy. One study suggested that a vasoconstrictor alone should be used to reduce the general level of unpleasantness. Two studies did not compare treatment against placebo or no treatment, so it was not possible to draw meaningful conclusions from them. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. There was variation in the format of the outcome data and a lack of complete data; none of the included studies reported their results in a way that would allow pooling and we could not therefore perform meta‐analysis. Authors' conclusions The included studies do not demonstrate any evidence to support the use of topical treatments prior to the use of a fibre‐optic nasal endoscope. Some go as far as to suggest that these agents should not be used due to cost and unpleasant side effects. Five studies did not demonstrate any advantage in terms of reducing pain or discomfort when using a topical treatment prior to endoscopy. The absence of demonstrable effect may be due to relatively small patient groups. It is therefore possible that there is a small effect of using these sprays. Further research using standardised reporting methods is needed. Plain language summary Topical anaesthetic or vasoconstrictor (blood vessel narrowing) preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy Topical medications are often applied to the inside of a patient's nose prior to examining the nose, sinuses and throat with a flexible nasopharyngolaryngoscope. The aim of this is to reduce any discomfort the patient may feel and also to improve the adequacy of the examination. Types of preparation include lidocaine, phenylephrine and lidocaine, oxymetazoline, xylometazoline and cocaine and they are usually administered as a spray, although they may also be in the form of a solution which can be applied to cotton wool and placed in the nasal cavity, or as gels, pastes or creams. We looked for randomised controlled trials comparing any of these topical treatments with placebo, no treatment or another topical treatment in adult patients undergoing nasal pharyngolaryngoscopy (NPL). We included eight studies in the review (with a total of 746 patients). It was not possible to combine data from any of the studies, therefore we assessed the individual study results. Five of the studies did not demonstrate any advantage, in terms of reducing pain or discomfort, of using a topical treatment prior to endoscopy. One of these suggested that a vasoconstrictor (xylometazoline) alone reduced the level of \"general unpleasantness\". Two studies did not compare the treatment against placebo or no treatment. A final study actually suggested an increase in pain with the use of topical agents. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. Further standardised research is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Sunkaraneni, VS; Jones, SEM", "articleTypes": [], "doi": "10.1002/14651858.CD005606.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "60e84294-7b9b-4a63-a1b5-10a06f907bef", "pmid": "", "title": "Zinc supplementation for the treatment of measles in children", "imported": false, "abstract": "Abstract - Background Measles is an important cause of childhood morbidity and mortality globally, despite increasing vaccine coverage. Zinc plays a significant role in the maintenance of normal immunological functions, therefore supplements given to zinc‐deficient children will increase the availability of zinc and could reduce measles‐related morbidity and mortality. This is an update of a review first published in 2015. Objectives To assess the effects of zinc supplementation in reducing morbidity and mortality in children with measles. Search methods We searched CENTRAL (03 February 2017, Issue 2), MEDLINE (1946 to 03 February 2017), Embase (1974 to 03 February 2017), CINAHL (1981 to 03 February 2017), LILACS (1982 to 03 February 2017), Web of Science (1985 to 03 February 2017), and BIOSIS Previews (1985 to 27 June 2014). We also searched ClinicalTrials.gov, the Australian New Zealand Clinical Trials Registry and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 03 February 2017 to identify unpublished and ongoing studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of zinc in reducing morbidity and mortality in children with measles. Data collection and analysis Two review authors independently assessed the studies for inclusion and extracted data on outcomes, details of the interventions, and other study characteristics using a standardised data extraction form. We used risk ratio (RR) and hazard ratio (HR) as measures of effect with 95% confidence intervals (CI). We included only one study, and did not conduct meta‐analysis. Main results We did not identify any new studies for inclusion in this update. One RCT met our inclusion criteria. The study was conducted in India and included 85 children diagnosed with measles and pneumonia. The trial showed no significant difference in mortality between children with measles and pneumonia who received zinc supplements and those who received placebo (RR 0.34, 95% CI 0.01 to 8.14). There was no significant difference in time to absence of fever between children who received zinc supplements and those who did not (HR 1.08, 95% CI 0.67 to 1.74). No treatment‐related side effects were reported in either group. We assessed the overall quality of the evidence as very low. Authors' conclusions We could not draw any definitive conclusions from this review about the effects of zinc supplementation on clinical outcomes of children with measles due to the very low quality of the evidence available. There is insufficient evidence to confirm or refute the effect of zinc supplementation in children with measles. Plain language summary Zinc supplementation for the treatment of measles in children Review question What is the effect of zinc supplementation in the treatment of children with measles? Background Measles infection has reduced globally over the last decade, but large outbreaks still occur, especially in low‐income countries. Zinc is one of the essential micronutrients necessary for the optimal functioning of the immune system. Zinc deficiency is particularly common in children in low‐ and middle‐income countries. It was therefore important to examine the potential role of zinc supplementation in controlling the symptoms of measles infection in children. We aimed to critically assess the current evidence from published studies on the effect of zinc supplementation for the treatment of measles in children. Search date We searched for evidence up to 03 February 2017. This is an update of a review first published in 2015. We did not include any new studies for this update. Study characteristics We found one small randomised trial (involving 85 children) that compared zinc supplements versus placebo administered to children with measles and pneumonia. All 85 children received supportive care and vitamin A. The study was conducted in India and funded by the Child Health Foundation USA and the Nestlé Foundation. Key results The included study was small and did not provide enough data to determine whether zinc had an effect on mortality when compared with placebo. Although no adverse effects were reported, there was insufficient evidence to draw any conclusions about the use of zinc supplements to improve measles symptoms in children. More research is needed to clarify any benefits or harms. Quality of the evidence We assessed the quality of the evidence as very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Awotiwon, AA; Oduwole, O; Sinha, A; Okwundu, CI", "articleTypes": [], "doi": "10.1002/14651858.CD011177.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "60f22af8-4f15-42aa-b8bd-23634ba5113f", "pmid": "", "title": "School feeding programs for improving the physical and psychological health of school children experiencing socioeconomic disadvantage", "imported": false, "abstract": "Abstract - Rationale School feeding aims to alleviate hunger and enhance child outcomes. Since the first Cochrane systematic review of school meals, there has been a marked increase in studies and reviews of school feeding programs. However, most systematic reviews are geographically limited and use qualitative analysis. We reviewed worldwide papers and performed several meta‐analyses, providing a more comprehensive picture of the effectiveness of school feeding. Objectives 1. To assess effectiveness of school feeding programs for improving the physical and psychological health of children experiencing socioeconomic disadvantage worldwide.
2. To assess effectiveness of school feeding programs for improving the health of children experiencing socioeconomic disadvantage compared with children who are more advantaged. Search methods We searched 17 subject‐specific and multidisciplinary databases and registries up to November 2023. In November 2024, two Information Specialists ran a top‐up search for randomized controlled trials (RCTs). We handsearched references of included studies and relevant reviews. Eligibility criteria We included individually randomized, cluster‐randomized, and cross‐over trials, as well as longitudinal non‐randomized studies of interventions (NRSIs). Studies had to compare the provision of free or reduced‐price food in schools versus no school feeding, focusing on socioeconomically disadvantaged children. The food had to contain at least 3% of the daily energy requirement and at least 10% of the daily protein requirement for the specified age group(s). Eligible participants were primary or secondary school students aged five to 19 years. Outcomes Our critical outcomes were change in: math achievement, reading achievement, attendance, enrollment, height‐for‐age z‐score (HAZ), weight‐for‐age z‐score (WAZ), and overweight/obesity. Our important outcomes were change in: overall academic achievement, fluid intelligence, working memory, behavioral/emotional outcomes, height, weight, and anemia. We planned to study changes between baseline and final outcomes. In one study with extreme contamination, we used the first follow‐up. Risk of bias We assessed the risk of bias for RCTs by outcome using the appropriate version of the Cochrane risk of bias tool (RoB 2): RoB 2 for individually randomized trials, for cluster‐RCTs, and for cross‐over trials. We evaluated the quality of NRSIs using the School‐based Measurement & Assessment of Results Tool (SMART), which is adapted from the Newcastle Ottawa Scale. Synthesis methods We used standardized mean differences (SMDs) with 95% confidence intervals (CIs) for educational and cognitive outcomes. We used mean differences (MDs), odds ratios (ORs), or incidence rate ratios (IRRs) for others. All meta‐analyses used random‐effects generic inverse variance. We conducted equity subgroup analyses by sex and socioeconomic status. We used GRADE to assess our confidence in the evidence for critical outcomes reported in RCTs. Included studies We included 40 studies with 83 reports. There were 13 RCTs (12 cluster‐randomized trials and one individually randomized trial) and 27 NRSIs. Most studies (34) were from low‐ and middle‐income countries (LMICs). In total, there were more than 91,885 students (four studies didn't report sample size). One study involved 59,613 students, while the others had between 60 and 6038 students. The studies included 48 outcomes; we meta‐analyzed or reported 14. Synthesis of results Low‐ and middle‐income countries (LMICs) School feeding compared to no school feeding improves math achievement slightly (SMD 0.14, 95% CI 0.06 to 0.23; P = 0.001; I² = 68%; 6 cluster‐RCTs, 5587 participants; high‐certainty evidence), but may have little to no effect on reading achievement (SMD 0.02, 95% CI −0.06 to 0.11; P = 0.61; I 2 = 54%; 3 cluster‐RCTs, 3417 participants; low‐certainty evidence). School feeding programs lead to a slight increase in enrollment rates (MD 3.44% increase, 95% CI 0.83 to 6.04; P = 0.01; I² = 0%; 2 cluster‐RCTs, 5200 participants, high‐certainty evidence) but may have little to no effect on attendance (MD 0.17%, 95% CI −2.64% to 2.97%; P = 0.91; I 2 = 81%; 3 cluster‐RCTs, 3566 participants; low‐certainty evidence). School feeding programs likely lead to a slight increase in HAZ (MD 0.06, 95% CI 0.03 to 0.09; P < 0.001; I 2 = 0%; 2 cluster‐RCTs, 3678 participants; moderate‐certainty evidence) and WAZ (MD 0.08, 95% CI 0.05 to 0.12; P < 0.001; I 2 = 0%; 3 cluster‐RCTs, 2132 participants; moderate‐certainty evidence). Two cluster‐RCTs assessed change in obesity/overweight. One 10‐month study found that the odds of being overweight/obese were 53% lower among adolescents receiving school meals compared to control adolescents (OR 0.47, 95% CI 0.30 to 0.72). Another study found no cases of overweight/obesity before or after the intervention. These findings are of very low certainty. Some researchers encountered implementation problems beyond their control, including conflicts, delays, and bureaucratic decisions. Heterogeneity in contexts, outcomes, child populations, and statistics was a limitation of this review. High‐income countries (HICs) One NRSI found very uncertain evidence that children assigned to a breakfast club increased their attendance by more than 1.6% on average compared to children in the control group. Equity analyses The equity (subgroup) analyses by sex and by socio‐economic status were all non‐significant. There were only two studies in each subgroup analysis; they were likely underpowered. Authors' conclusions In LMICs, school feeding programs lead to a slight improvement in math achievement, but may have little to no effect on reading achievement. School feeding programs lead to a slight increase in enrollment, but may have little to no impact on attendance. They likely lead to slight gains in HAZ and WAZ. There may be little to no association between school feeding and overweight/obesity, but the evidence is very uncertain. We recommend that researchers and policymakers view research as an integral part of the implementation process. To reduce heterogeneity in outcomes, we recommend even greater co‐ordination of research, and that researchers and interest holders work together to identify a core set of outcomes. Funding The authors would like to thank the following donors for their generous support in making this review possible: Dubai Cares, the World Food Programme's School Meals and Social Protection Service, and the Research Consortium for School Health and Nutrition. Registration Protocol (2022): https://doi.org/10.1002/14651858.CD014794 
Original review (2007): https://doi.org/10.1002/14651858.CD004676.pub2 
Original Campbell protocol (2006): doi.org/10.1002/CL2.12 Plain language summary Can school meal programs improve health and educational goals in children experiencing socioeconomic disadvantage? Key messages School meal programs in low‐ and middle‐income countries lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. Research should be a key part of planning and running school meal programs. To make it easier to compare results from different studies, researchers, parents, and policymakers should work together to agree on a list of the most important goals for children's health, development, and success in school. Why did we want to review studies on school meals? Worldwide, many children do not get enough nutritious food to keep them healthy and ready to learn in school. This affects their ability to enroll, attend school regularly, and learn there. School meals aim to reduce hunger and improve children's learning, focus, and overall health. School meals are one of the world's largest social safety nets. We sought to understand their effectiveness for children in disadvantaged circumstances across the globe. Most previous reviews of the evidence are limited in geographical scope, and many use narrative analyses. What did we want to find out? We asked the following two health equity (fairness) questions. Do school meals improve the physical health of socioeconomically disadvantaged children worldwide? Do school meals benefit children who are disadvantaged by sex and low family income more than they benefit less disadvantaged children? What did we do? We searched for studies that evaluated the effects of school meals for school students aged five to 19 years. We included randomized studies, which allocate students or schools to different study groups at random. However, because randomized studies are not always possible, we included non‐randomized studies that compared school meal groups with groups that received no school meals. These non‐randomized studies needed to measure outcomes at least twice; once at the beginning of the study and once at the end. We rated our confidence in the findings separately for each outcome. What did we find? We found 13 randomized studies and 27 non‐randomized studies, which collectively involved more than 91,995 students aged five to 19 years. One study included 59,613 students, while others had student populations ranging from 40 to 6038 students. Across all studies, there was a similar number of boys and girls, although three studies included only girls. Most studies took place in low‐ and middle‐income countries (34 studies), while six were from high‐income countries. In low‐ and middle‐income countries, school meals lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. In high‐income countries, one study presented very uncertain evidence that school meals may increase attendance slightly. What are the limitations of the evidence? Because we found very few eligible studies conducted in high‐income countries, we do not recommend applying our findings to this setting. We are confident in the results for math test scores and enrollment. We are moderately confident in the results for height and weight for age, because we had some concerns about the study methods. We have little confidence in the results for reading test scores and attendance, because we had some concerns about the study methods, and the results differed substantially among the trials. We are not confident in the results for overweight/obesity, because we have some concerns about the study methods, the two studies measured the outcome in different ways, and one of the studies was very small. Several studies faced barriers due to their context, such as conflict, droughts, bureaucratic delays, and difficulties in distributing funds to caterers, as well as eagerness to initiate school meal programs in control schools. We need more evidence on school meals and their impact on disadvantaged school students—especially those in secondary school—in countries of all income levels. We also need more studies that assess the difference between disadvantaged groups and more advantaged children in high‐income countries. We suggest that researchers, school feeding experts, teachers, and parents collaborate to develop a core set of key outcomes, and that these outcomes be put in an open‐access repository. How up‐to‐date is this evidence? This review updates and expands our 2007 review of school meal programs. The evidence is current to November 2024. Funding Dubai Cares funded this review through the World Food Program School Feeding Program. The London School of Hygiene and Tropical Medicine also funded this review. The funders had no influence on the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kristjansson, E; Dignam, M; Rizvi, A; Osman, M; Magwood, O; Olarte, D; Cohen, JFW; Krasevec, J; Grover, T; Labelle, PR; Garner, JA; Janzen, L; Rossiter, S; Dewidar, O; Shea, B; Welch, V; Wells, GA", "articleTypes": [], "doi": "10.1002/14651858.CD014794.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "6115944f-65bb-46ca-b391-ec780ed8e20a", "pmid": "", "title": "Different strategies for diagnosing gestational diabetes to improve maternal and infant health", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycaemia with onset or first recognition during pregnancy. If untreated, perinatal morbidity and mortality may be increased. Accurate diagnosis allows appropriate treatment. Use of different tests and different criteria will influence which women are diagnosed with GDM. This is an update of a review published in 2011 and 2015. Objectives To evaluate and compare different testing strategies for diagnosis of gestational diabetes mellitus to improve maternal and infant health while assessing their impact on healthcare service costs. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (9 January 2017) and reference lists of retrieved studies. Selection criteria We included randomised trials if they evaluated tests carried out to diagnose GDM. We excluded studies that used a quasi‐random model, cluster‐randomised or cross‐over trials. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. Main results We included a total of seven small trials, with 1420 women. One trial including 726 women was identified by this update and examined the two step versus one step approach. These trials were assessed as having varying risk of bias, with few outcomes reported. We prespecified six outcomes to be assessed for quality using the GRADE approach for one comparison: 75 g oral glucose tolerance test (OGTT) versus 100 g OGTT; data for only one outcome (diagnosis of gestational diabetes) were available for assessment. One trial compared three different methods of delivering glucose: a candy bar (39 women), a 50 g glucose polymer drink (40 women) and a 50 g glucose monomer drink (43 women). We have included the results reported by this trial as separate comparisons. No trial reported on measures of costs of health services. We examined six main comparisons. 75 g OGTT versus 100 g OGTT (1 trial, 248 women): women who received 75 g OGTT had a higher relative risk of being diagnosed with GDM (risk ratio (RR) 2.55, 95% confidence interval (CI) 0.96 to 6.75; very‐low quality evidence ). No data were reported for the following additional outcomes prespecified for GRADE assessment: caesarean section, macrosomia > 4.5 kg or however defined in the trial, long‐term type 2 diabetes maternal, long‐term type 2 diabetes infant and economic costs. Candy bar versus 50 g glucose monomer drink (1 trial, 60 women): more women receiving the candy bar, rather than glucose monomer, preferred the taste of the candy bar (RR 0.60, 95% CI 0.42 to 0.86) and 1‐hour glucose was less with the candy bar. There were no differences in the other outcomes reported (maternal side effects). No infant outcomes were reported or any review primary outcomes. 50 g glucose polymer drink versus 50 g glucose monomer drink (3 trials, 239 women): mean difference (MD) in gestation at birth was ‐0.80 weeks (1 trial, 100 women; 95% CI ‐1.69 to 0.09). Total side effects were less common with the glucose polymer drink (1 trial, 63 women; RR 0.21, 95% CI 0.07 to 0.59), and no clear difference in taste acceptability was reported (1 trial, 63 women; RR 0.99, 95% CI 0.76 to 1.29). Fewer women reported nausea following the 50 g glucose polymer drink compared with the 50 g glucose monomer drink (1 trial, 66 women; RR 0.29, 95% CI 0.11 to 0.78). No other measures of maternal morbidity or outcomes for the infant were reported. 50 g glucose food versus 50 g glucose drink (1 trial, 30 women): women receiving glucose in their food, rather than as a drink, reported fewer side effects (RR 0.08, 95% CI 0.01 to 0.56). No clear difference was noted in the number of women requiring further testing (RR 0.14, 95% CI 0.01 to 2.55). No other measures of maternal morbidity or outcome were reported for the infant or review primary outcomes. 75 g OGTT World Health Organization (WHO) criteria versus 75 g OGTT American Diabetes Association (ADA) criteria (1 trial, 116 women): no clear differences in included outcomes were observed between women who received the 75 g OGTT and were diagnosed using criteria based on WHO (1999) recommendations and women who received the 75 g OGTT and were diagnosed using criteria recommended by the ADA (1979). Outcomes measured included diagnosis of gestational diabetes (RR 1.47, 95% CI 0.66 to 3.25), caesarean section (RR 1.07, 95% CI 0.85 to 1.35), macrosomia defined as > 90th percentile by ultrasound or birthweight equal to or exceeding 4000 g (RR 0.73, 95% CI 0.19 to 2.79), stillbirth (RR 0.49, 95% CI 0.02 to 11.68) and instrumental birth (RR 0.21, 95% CI 0.01 to 3.94). No other secondary outcomes were reported. Two‐step approach (50 g oral glucose challenge test followed by selective 100 g OGTT Carpenter and Coustan criteria) versus one‐step approach (universal 75 g OGTT ADA criteria) (1 trial, 726 women): women allocated the two‐step approach had a lower risk of being diagnosed with GDM at 11 to 14 weeks' gestation compared to women allocated the one‐step approach (RR 0.51, 95% CI 0.28 to 0.95). No other primary or secondary outcomes were reported. Authors' conclusions There is insufficient evidence to suggest which strategy is best for diagnosing GDM. Large randomised trials are required to establish the best strategy for correctly identifying women with GDM. Plain language summary Different strategies for diagnosing gestational diabetes mellitus (GDM) to improve maternal and infant health What is the issue? We aimed to evaluate and compare different ways of diagnosing gestational diabetes mellitus (GDM). We searched for all relevant studies in January 2017. Why is this important? Between seven and 24 pregnant women in every 100 develop GDM. GDM is when there is an inability to process carbohydrates properly, which leads to high blood sugar (hyperglycaemia). GDM can result in increased risks of problems around the time of birth for the mother and her baby. Treatment can reduce these risks, and therefore diagnosing the condition accurately means that treatment can be given to improve the health of mothers and their babies. Different testing strategies aim to diagnose GDM. We wanted to compare the different strategies, to see how they affected the health of women and their infants, and to assess the cost of the strategies to the healthcare service. What evidence did we find? We found seven trials. A total of 1420 women were included, in settings in Turkey, Mexico, Nigeria, New Zealand, Canada and the USA. Across the trials, different testing approaches and criteria were evaluated as were different diagnostic tests including different oral glucose tolerance test loads; a glucose drink; a candy bar and food high in glucose. Women were given these items to eat/drink, and this was then followed by a blood test to measure blood sugar levels and questionnaires. In some tests, women were required to fast from the night before. The main outcomes we looked for were frequency of diagnosis, incidence of caesarean section, assisted birth and vaginal birth, and incidence of macrosomia in babies (larger than normal weight at birth). Other outcomes spanned a range, including any side effects of the tests, the mothers' preferences, and the health of the babies. There were a number of weaknesses among the studies: the methodology was not clear and there were important gaps in the data. The studies in this review do not provide enough evidence to guide clinical practice and health policy regarding identifying women with GDM. What does this mean? We are uncertain about which strategies to diagnose GDM are better, as we have assessed the quality of evidence as very low. Large randomised trials are needed to establish the best way for identifying women with GDM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Farrar, D; Duley, L; Dowswell, T; Lawlor, DA", "articleTypes": [], "doi": "10.1002/14651858.CD007122.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "6124ed53-7fab-40f6-afe0-4d6472c42c0c", "pmid": "", "title": "Individual Nutritional Support With High Protein Formula With Modified Sensory Component for H&N Cancer Patients on Chemo and Radiotherapy", "imported": false, "abstract": "Nutritional deficiency and subsequent weight loss in patients with head and neck cancer is a common problem and a negative predictor of treatment outcomes and mortality, as well as quality of life. Nutritional support for patients is a prerequisite for the successful management of cancer patients. Sensory changes can be side effects of chemotherapy or ionizing radiation, which damages sensory receptors in the area of radiation, disrupts the function of the salivary glands, leading to hyposalivation and a decrease in taste. Individual choice of nutrition based on sensory sensations can significantly improve the quality of life of patients and ensure timely correction of their eating behavior.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.149Z" }, { "id": "615c3ff4-d9c2-430a-8e2b-af83da3430ba", "pmid": "", "title": "Interventions for improving adherence to ocular hypotensive therapy", "imported": false, "abstract": "Abstract - Background Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open‐angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence. Objectives To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma. Data collection and analysis At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity. Main results Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow‐up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross‐over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive. Authors' conclusions Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes. Plain language summary Interventions for helping people use eye drops as prescribed for raised eye pressure or glaucoma A large number of people do not use eye drops as prescribed. Glaucoma is a slowly progressive eye disease, which can result in severe vision loss. Drops prescribed for raised eye pressure or glaucoma are aimed at lowering the pressure to assist in reducing the rate of progression, or preventing the conversion of raised eye pressure to glaucoma. It is important that these eye drops are used continually, usually for life. Approximately one‐third of people who are prescribed eye drops for the first time fail to continue collecting prescriptions within the first year and even when patients collect prescriptions they do not always use the drops as frequently as they should. A number of reasons are thought to be the cause, for example, forgetfulness, being prescribed a large number of medications, difficulties instilling drops, lack of knowledge about glaucoma, a busy lifestyle and seeing no benefit. This review is based on 16 studies (1565 participants) that tried out different methods to help people to use drops as prescribed. All the studies took place in industrialised countries (Belgium, Denmark, France, Greece, Iceland, Japan, Sweden, Switzerland, UK and USA) and recruited participants in outpatient clinics. The following interventions were included: simplifying drop routines, reminder devices, automated telephone service, providing information about glaucoma and offering advice regarding day to day issues with eye care. Those studies which combined the provision of information about glaucoma and eye drops with other interventions, such as helping people to fit instillation of eye drops into their daily routine, appear to be more successful. Unfortunately, not all of these studies were of high quality and, therefore, until more evidence is available we cannot recommend any particular method. Good quality research is needed in this area in order to develop a better understanding of patients' individual needs and to help us provide more effective eye care services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Waterman, H, Evans, JR, Gray, TA, Henson, D, Harper, R", "articleTypes": [], "doi": "10.1002/14651858.CD006132.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.122Z" }, { "id": "617bb545-8165-4267-916f-5e3533eea789", "pmid": "", "title": "Effect of Fructose and Glucose and TAS1R2 in Glucose, Triglycerides, Uremia, Oxidative Stress, Feelings Related to Food Intake of Individuals With Type 1 Diabetes", "imported": false, "abstract": "- BACKGROUND: Individuals with diabetes report innate preference for sweet foods, possibly due to genetic variants. In addition, studies have shown that ingestion of fructose promotes lower postprandial blood glucose, compared to glucose. However, excessive intake may increase triglycerides, uric acid and oxidative stress, due to oxidative priority.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.241Z" }, { "id": "61845ac6-d7ad-48a1-8163-c7afea05f1d1", "pmid": "", "title": "Optimisation of antiretroviral therapy in HIV‐infected children under 3 years of age", "imported": false, "abstract": "Abstract - Background In the absence of antiretroviral therapy (ART), over 50% of HIV‐infected infants progress to AIDS and death by 2 years of age. However, there are challenges to initiation of ART in early life, including the possibility of drug resistance in the context of prevention of mother‐to‐child transmission (PMTCT) programs, a paucity of drug choices , uncertain dosing for some medications and long‐term toxicities. Key management decisions include when to start ART, what regimen to start, and whether and when to substitute drugs or interrupt therapy. This review, an update of a previous review, aims to summarize the currently available evidence on this topic and inform the ART management in HIV‐infected children less than 3 years of age. Objectives To evaluate 1) when to start ART in young children (less than 3 years); 2) what ART to start with, comparing first‐line non‐nucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI)‐based regimens; and 3) whether alternative strategies should be used to optimize antiretroviral treatment in this population: induction (initiation with 4 drugs rather than 3 drugs) followed by maintenance ART, interruption of ART and substitution of PI with NNRTI drugs once virological suppression is achieved on a PI‐based regimen. Search methods Search methods We searched for published studies in the Cochrane HIV/AIDS Review Group Trials Register, The Cochrane Library, Pubmed, EMBASE and CENTRAL. We screened abstracts from relevant conference proceedings and searched for unpublished and ongoing trials in clinical trial registries (ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform). Selection criteria We identified RCTs that recruited perinatally HIV‐infected children under 3 years of age without restriction of setting. We rejected trials that did not include children less than 3 years of age, did not provide stratified outcomes for those less than 3 years or did not evaluate either timing of ART initiation, choice of drug regimen or treatment switch/interruption strategy. Data collection and analysis Two reviewers independently applied study selection criteria, assessed study quality and extracted data. Effects were assessed using the hazard ratio (HR) for time‐to‐event outcomes, relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes. Main results A search of the databases identified a total of 735 unique, previously unreviewed studies, of which 731 were excluded to leave 4 new studies to incorporate into the review. Four additional studies were identified in conference proceedings, for a total of 8 studies addressing when to start treatment (n=2), what to start (n=3), whether to substitute lopinavir/ritonavir (LPV/r) with nevirapine (NVP) (n=1), whether to use an induction‐maintenance ART strategy (n=1) and whether to interrupt treatment (n=1). Treatment initiation in asymptomatic infants with good immunological status was associated with a 75% reduction (HR=0.25; 95%CI 0.12‐0.51; p=0.0002) in mortality or disease progression in the one trial with sufficient power to address this question. In a smaller pilot trial, median CD4 cell count was not significantly different between early and deferred treatment groups 12 months after ART. Regardless of previous exposure to nevirapine for PMTCT, the hazard for treatment failure at 24 weeks was 1.79 (95%CI 1.33, 2.41) times higher in children starting ART with a NVP‐based regimen compared to those starting with a LPV/r‐based regimen (p=0.0001) with no clear difference in the effect observed for children younger or older than 1 year. The hazard for virological failure at 24 weeks was overall 1.84 (95%CI 1.29, 2.63) times higher for children starting ART with a NVP‐based regimen compared to those starting with a LPV/r‐based regimen (p=0.0008) with a larger difference in time to virological failure (or death) between the NVP and LPV/r‐based regimens when ART was initiated in the first year of life. Infants starting a LPV/r regimen and achieving sustained virological suppression who then substituted LPV/r with NVP after median 9 months on LPV/r were less likely to develop virological failure (defined as at least one VL greater than 50 copies/mL) compared with infants who started and stayed on LPV/r (HR=0.62, 95%CI 0.41, 0.92, p=0.02). However the hazard for confirmed failure at a higher viral load (>1000 copies/mL) was greater among children who switched to NVP compared to those who remained on LPV/r (HR=10.19, 95% CI 2.36, 43.94, p=0.002). Children undergoing an induction‐maintenance ART approach with a 4‐drug NNRTI‐based regimen for 36 weeks, followed by 3‐drug ART, had significantly greater CD4 rise than children receiving a standard 3‐drug NNRTI‐based ART at 36 weeks (mean difference 1.70 [95%CI 0.61, 2.79] p=0.002) and significantly better viral load response at 24 weeks (OR 1.99 [95%CI 1.09, 3.62] p=0.02). However, the immunological and virological benefits were short‐term. The one trial of treatment interruption that compared children initiating continuous ART from infancy with children interrupting ART was terminated early because the duration of treatment interruption was less than 3 months in most infants. Children interrupting treatment had similar growth and occurrence of serious adverse events as those in the continuous arm. Authors' conclusions ART initiation in asymptomatic children under 1 year of age reduces morbidity and mortality, but it remains unclear whether there are clinical benefits to starting ART in asymptomatic children diagnosed with HIV infection between 1‐3 years. The available evidence shows that a LPV/r‐based first‐line regimen is more efficacious than a NVP‐based regimen, regardless of PMTCT exposure status. New formulations of LPV/r are urgently required to enable new WHO recommendations to be implemented. An alternative approach to long‐term LPV/r is substituting LPV/r with NVP once virological suppression is achieved. This strategy looked promising in the one trial undertaken, but may be difficult to implement in the absence of routine viral load testing. A 4‐drug induction‐maintenance approach showed short‐term virological and immunological benefits during the induction phase but, in the absence of sustained benefits, is not recommended as a routine treatment strategy. Treatment interruption following early ART initiation in infancy was challenging for children who were severely immunocompromised in the context of poor clinical immunological condition at ART initiation due to the short duration of interruption, and is therefore not practical in ART treatment programmes where close monitoring is not feasible. Plain language summary Using antiretroviral drugs to treat children under 3 years old who have HIV infection Children under 3 years of age who have HIV infection have a high risk of dying without antiretroviral therapy (ART). However, treatment in this age group is challenging because there are high levels of virus in the blood and few suitable drug choices. Results from this systematic review show that ART soon after birth is preferable to delaying treatment, because infants are less likely to die or become sick. Starting a first‐line treatment regimen that includes lopinavir/ritonavir rather than nevirapine is preferable, because infants and young children are less likely to have to stop treatment, whether or not they had previously been exposed to nevirapine. However, lopinavir/ritonavir is more expensive than nevirapine. It is also currently only available as an inconvenient liquid, which tastes bitter and has to be refrigerated, making it challenging to implement in all parts of the world. While waiting for better formulations to become available, it may be possible to switch from lopinavir/ritonavir to nevirapine once the HIV virus levels become undetectable. However, based on the evidence currently available, a viral load test would be required to identify those children who could safely substitute lopinavir/ritonavir with nevirapine. Viral loads are expensive and not widely available in most countries in sub‐Saharan Africa. An alternative treatment approach is to give a stronger drug combination (four different drugs together) when treatment is first started, then reduce down to three drugs after a short while. However, this strategy did not appear to have long‐term benefits. A 'treatment interruption' strategy, in which infants start ART soon after birth but then stop medication after 1‐2 years, is difficult to implement. Children stopping ART need to restart it very quickly to prevent them becoming sick, and monitoring a child off treatment is challenging in settings with few resources.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Penazzato, M, Prendergast, AJ, Muhe, LM, Tindyebwa, D, Abrams, E", "articleTypes": [], "doi": "10.1002/14651858.CD004772.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.793Z" }, { "id": "619a813c-c746-4fd3-9a3a-a94aff6ad4d5", "pmid": "", "title": "A Multimodel Examination of Bromocriptine on Homeostatic and Hedonic Mechanisms of Food Intake in Individuals at High Risk for Type 2 Diabetes", "imported": false, "abstract": "The current project applies an integrative three-prong approach to investigate the potential of the dopamine D2 receptor (DRD2) agonist bromocriptine to: 1) increase homeostatic satiation signaling, 2) alter neural circuitry to reduce hedonically motivated food intake, and 3) examines a genetic predisposition that may markedly impact the effectiveness of this medication in those at high risk for T2DM.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.152Z" }, { "id": "61c8addf-e59d-4abb-a872-8ca9538c7c2d", "pmid": "", "title": "Safety, Pharmacokinetics, and Preliminary Efficacy of Tafenoquine for the Treatment of Vivax Malaria in Papua New Guinean Children", "imported": false, "abstract": "Plasmodium vivax is the most geographically widespread malaria species and the second largest contributor to symptomatic malaria worldwide. It accounts for half of all malaria cases outside Africa, with an estimated 14.3 million clinical vivax malaria cases reported annually, contributing to an annual cost of US$359 million. Children are most vulnerable to infection, with P. vivax prevalence peaking between 2 to 6 years of age. In Papua New Guinea (PNG), there are >1.5 million suspected P. vivax cases annually, and while P. falciparum infections are the most prevalent, P. vivax transmission is the most intense in the world. P. vivax in PNG provides a unique epidemiological setting in which to assess innovative treatments in children.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.242Z" }, { "id": "61d08405-2b51-43ff-baef-6c1972a93e62", "pmid": "", "title": "The Molecular Basis for a Broad Range of Phenotypes Related to hTAS2R38", "imported": false, "abstract": "This single-site, within-subject, experimental study is designed to test the hypothesis that individuals express taste receptors differently and have different sensitivities to bitter taste samples, which results from uneven expression. Subjects will include 100 racially and ethnically diverse, healthy adults. All subjects will provide saliva samples for genetic analysis and undergo taste testing with common psychophysical stimuli. From the pool of 100 subjects, 36 subjects from the common heterozygous group (PAV/AVI) and two from each homozygous group (AVI/AVI, nontaster and PAV/PAV, taster) will be invited to return for two additional sessions. During both sessions the investigators will 1) measure bitterness thresholds for PROP, a common psychophysical stimulus; 2) measure bitterness perception of several vegetables; 3) obtain a saliva sample and 4) collect taste papillae. The investigators will then isolate DNA and RNA from the taste papillae and isolate DNA from saliva to evaluate molecular differences over time and between individuals and how it relates to taste psychophysics. All psychophysical and cellular measurements will be done during both sessions so that the investigators can determine how much variation is observed over a one-week time period in both cellular phenotype and psychophysical phenotype.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "61d6df95-c449-4d58-9212-aaed0d458420", "pmid": "", "title": "Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications", "imported": false, "abstract": "Abstract - Background Radiotherapy as part of head and neck cancer treatment leaves patients requiring much dental rehabilitation in a compromised environment that is difficult for the patient and the dental team to manage. Objectives To assess the effects of maintaining the patient's natural dentition during radiotherapy in comparison to extracting teeth before radiotherapy in areas that are difficult to access by the patient and the dentist, should reduction in mouth opening occur after radiotherapy to the jaws. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 22 November 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 22 November 2012), EMBASE via OVID (1980 to 22 November 2012), CANCERLIT via PubMed (1950 to 22 November 2012), CINAHL via EBSCO (1980 to 22 November 2012) and reference lists of articles. We advertised for currently ongoing studies via the Cochrane Oral Health Group website and the Cochrane Oral Health Group Twitter feed. Selection criteria Randomised controlled trials comparing extraction of teeth prior to radiotherapy with leaving teeth in situ during radiotherapy to the jaws. Data collection and analysis Three review authors independently assessed the results of the searches for inclusion in the review. Main results No randomised controlled trials were found. Authors' conclusions There are no randomised controlled trials to assess the effect of extracting teeth prior to radiotherapy compared to leaving teeth in the mouth during radiotherapy to the jaws. Plain language summary Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications This review aimed to assess if removing the back teeth before radiotherapy would mean that patients had fewer tooth‐related problems after radiotherapy as part of head and neck cancer treatment, when compared to not removing the teeth. Electronic and handsearching found 357 titles of studies but none of them met the inclusion criteria for the review. There is currently no evidence available to answer this complex question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Eliyas, S; Al‐Khayatt, A; Porter, RWJ; Briggs, P", "articleTypes": [], "doi": "10.1002/14651858.CD008857.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "61e33cc0-cef8-4cd9-8c46-722975915c98", "pmid": "", "title": "Ivermectin for preventing and treating COVID‐19", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Popp, M, Reis, S, Schießer, S, Hausinger, RIlona, Stegemann, M, Metzendorf, M-I, Kranke, P, Meybohm, P, Skoetz, N, Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015017.pub3 AB - Abstract - Background Ivermectin, an antiparasitic agent, inhibits the replication of viruses in vitro. The molecular hypothesis of ivermectin's antiviral mode of action suggests an inhibitory effect on severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) replication in early stages of infection. Currently, evidence on ivermectin for prevention of SARS‐CoV‐2 infection and COVID‐19 treatment is conflicting. Objectives To assess the efficacy and safety of ivermectin plus standard of care compared to standard of care plus/minus placebo, or any other proven intervention for people with COVID‐19 receiving treatment as inpatients or outpatients, and for prevention of an infection with SARS‐CoV‐2 (postexposure prophylaxis). Search methods We searched the Cochrane COVID‐19 Study Register, Web of Science (Emerging Citation Index and Science Citation Index), WHO COVID‐19 Global literature on coronavirus disease, and HTA database weekly to identify completed and ongoing trials without language restrictions to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022. Selection criteria We included randomized controlled trials (RCTs) comparing ivermectin to standard of care, placebo, or another proven intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. Co‐interventions had to be the same in both study arms. For this review update, we reappraised eligible trials for research integrity: only RCTs prospectively registered in a trial registry according to WHO guidelines for clinical trial registration were eligible for inclusion. Data collection and analysis We assessed RCTs for bias, using the Cochrane RoB 2 tool. We used GRADE to rate the certainty of evidence for outcomes in the following settings and populations: 1) to treat inpatients with moderate‐to‐severe COVID‐19, 2) to treat outpatients with mild COVID‐19 (outcomes: mortality, clinical worsening or improvement, (serious) adverse events, quality of life, and viral clearance), and 3) to prevent SARS‐CoV‐2 infection (outcomes: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, admission to hospital, mortality, adverse events and quality of life). Main results We excluded seven of the 14 trials included in the previous review version; six were not prospectively registered and one was non‐randomized. This updated review includes 11 trials with 3409 participants investigating ivermectin plus standard of care compared to standard of care plus/minus placebo. No trial investigated ivermectin for prevention of infection or compared ivermectin to an intervention with proven efficacy. Five trials treated participants with moderate COVID‐19 (inpatient settings); six treated mild COVID‐19 (outpatient settings). Eight trials were double‐blind and placebo‐controlled, and three were open‐label. We assessed around 50% of the trial results as low risk of bias. We identified 31 ongoing trials. In addition, there are 28 potentially eligible trials without publication of results, or with disparities in the reporting of the methods and results, held in ‘awaiting classification’ until the trial authors clarify questions upon request. Ivermectin for treating COVID‐19 in inpatient settings with moderate‐to‐severe disease We are uncertain whether ivermectin plus standard of care compared to standard of care plus/minus placebo reduces or increases all‐cause mortality at 28 days (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.14 to 2.51; 3 trials, 230 participants; very low‐certainty evidence); or clinical worsening, assessed by participants with new need for invasive mechanical ventilation or death at day 28 (RR 0.82, 95% CI 0.33 to 2.04; 2 trials, 118 participants; very low‐certainty evidence); or serious adverse events during the trial period (RR 1.55, 95% CI 0.07 to 35.89; 2 trials, 197 participants; very low‐certainty evidence). Ivermectin plus standard of care compared to standard of care plus placebo may have little or no effect on clinical improvement, assessed by the number of participants discharged alive at day 28 (RR 1.03, 95% CI 0.78 to 1.35; 1 trial, 73 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.04, 95% CI 0.61 to 1.79; 3 trials, 228 participants; low‐certainty evidence); and on viral clearance at 7 days (RR 1.12, 95% CI 0.80 to 1.58; 3 trials, 231 participants; low‐certainty evidence). No trial investigated quality of life at any time point. Ivermectin for treating COVID‐19 in outpatient settings with asymptomatic or mild disease Ivermectin plus standard of care compared to standard of care plus/minus placebo probably has little or no effect on all‐cause mortality at day 28 (RR 0.77, 95% CI 0.47 to 1.25; 6 trials, 2860 participants; moderate‐certainty evidence) and little or no effect on quality of life, measured with the PROMIS Global‐10 scale (physical component mean difference (MD) 0.00, 95% CI ‐0.98 to 0.98; and mental component MD 0.00, 95% CI ‐1.08 to 1.08; 1358 participants; high‐certainty evidence). Ivermectin may have little or no effect on clinical worsening, assessed by admission to hospital or death within 28 days (RR 1.09, 95% CI 0.20 to 6.02; 2 trials, 590 participants; low‐certainty evidence); on clinical improvement, assessed by the number of participants with all initial symptoms resolved up to 14 days (RR 0.90, 95% CI 0.60 to 1.36; 2 trials, 478 participants; low‐certainty evidence); on serious adverse events (RR 2.27, 95% CI 0.62 to 8.31; 5 trials, 1502 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.24, 95% CI 0.87 to 1.76; 5 trials, 1502 participants; low‐certainty evidence); and on viral clearance at day 7 compared to placebo(RR 1.01, 95% CI 0.69 to 1.48; 2 trials, 331 participants; low‐certainty evidence). None of the trials reporting duration of symptoms were eligible for meta‐analysis. Authors' conclusions For outpatients, there is currently low‐ to high‐certainty evidence that ivermectin has no beneficial effect for people with COVID‐19. Based on the very low‐certainty evidence for inpatients, we are still uncertain whether ivermectin prevents death or clinical worsening or increases serious adverse events, while there is low‐certainty evidence that it has no beneficial effect regarding clinical improvement, viral clearance and adverse events. No evidence is available on ivermectin to prevent SARS‐CoV‐2 infection. In this update, certainty of evidence increased through higher quality trials including more participants. According to this review's living approach, we will continually update our search. Plain language summary Ivermectin for preventing and treating COVID‐19 Is ivermectin effective for COVID‐19? Key messages We found no evidence to support the use of ivermectin for treating COVID‐19 or preventing SARS‐CoV‐2 infection. The evidence base improved slightly in this update, but is still limited. Evaluation of ivermectin is continuing in 31 ongoing trials, and we will update this review again when their results become available. What is ivermectin? Ivermectin is a medicine used to treat parasites, such as intestinal parasites in animals, and scabies in humans. It is inexpensive and is widely used in regions of the world where parasitic infestations are common. It has few unwanted effects. Medical regulators have not approved ivermectin for COVID‐19. What did we want to find out? We wanted to update our knowledge of whether ivermectin reduces death, illness, and length of infection in people with COVID‐19, or is useful in prevention of the infection. We included trials comparing the medicine to placebo (dummy treatment), usual care, or treatments for COVID‐19 that are known to work to some extent, such as dexamethasone. We excluded trials comparing ivermectin to other medicines that do not work, like hydroxychloroquine, or whose effectiveness against COVID‐19 is uncertain. We evaluated the effects of ivermectin in infected people on: – people dying;
– whether people's COVID‐19 got better or worse;
– quality of life;
– serious and non‐serious unwanted effects;
– viral clearance. For prevention, we sought the effect on preventing SARS‐CoV‐2 infection and COVID‐19 disease. What did we do? We searched for randomized controlled trials that investigated ivermectin to prevent or treat COVID‐19. People treated in hospital or as outpatients had to have laboratory‐confirmed COVID‐19. In this update, we also investigated the trustworthiness of the trials and only included them if they fulfilled clear ethical and scientific criteria. We compared and summarized the results of the trials and rated our confidence in the evidence, based on common criteria such as trial methods and sizes. What did we find? We excluded seven of the 14 trials included in the previous review as these trials did not fulfil the expected ethical and scientific criteria. Together with four new trials, we included 11 trials with 3409 participants that investigated ivermectin combined with any usual care compared to the same usual care or placebo. For treatment, there were five trials of people in hospital with moderate COVID‐19 and six trials of outpatients with mild COVID‐19. The trials used different doses of ivermectin and different durations of treatment. No trial investigated ivermectin to prevent SARS‐CoV‐2 infection. We also found 31 ongoing trials, and an additional 28 trials still requiring clarification from the authors or not yet published. Main results Treating people in hospital with COVID‐19 We do not know whether ivermectin compared with placebo or usual care 28 days after treatment: – leads to more or fewer deaths (3 trials, 230 people); 
– worsens or improves patients' condition, assessed by need for ventilation or death (2 trials, 118 people);
– increases or reduces serious unwanted events (2 trials, 197 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – improving patients' condition, assessed by discharge from hospital (1 trial, 73 people);
– non‐serious unwanted events (3 trials, 228 participants). Seven days after treatment, ivermectin may make little or no difference to reduction of negative COVID‐19 tests (3 trials, 231 participants) compared with placebo or usual care. Treating outpatients with COVID‐19 Ivermectin compared with placebo or usual care 28 days after treatment, probably makes little or no difference to people dying (6 trials, 2860 people). Ivermectin compared with placebo or usual care 28 days after treatment, makes little or no difference to quality of life (1 trial, 1358 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – worsening patients' condition, assessed by admission to hospital or death (2 trials, 590 people);
– serious unwanted events (5 trials, 1502 people); 
– non‐serious unwanted events (5 trials, 1502 participants); 
– improving people's COVID‐19 symptoms in the 14 days after treatment (2 trials, 478 people);
– number of people with negative COVID‐19 tests 7 days after treatment (2 trials, 331 people). What are the limitations of the evidence? Our confidence in the evidence, especially for outpatients, improved since the last review version, because we could look at more participants included in high‐quality trials. Although we are quite certain regarding our results on risk of people dying and quality of life, the confidence in the evidence is still low for many other outpatient and inpatient outcomes because there were only few events measured. The methods differed between trials, and they did not report everything we were interested in, such as relevant outcomes. How up to date is this evidence? The systematic literature search is up to date to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.130Z" }, { "id": "61ee8d82-1d40-44c6-b764-93fd75d76c55", "pmid": "", "title": "Helminth therapy (worms) for induction of remission in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease (IBD) is a chronic, globally‐occurring gastrointestinal disorder and a major cause of illness and disability. It is conventionally classified into Crohn’s disease (CD) and ulcerative colitis (UC). Helminths are parasitic worms with complex life cycles involving tissue‐ or lumen‐dwelling stages in their hosts, and causing long‐lasting or chronic infections that are frequently asymptomatic. Helminths modulate immune responses of their hosts, and many observational and experimental studies support the hypothesis that helminths suppress immune‐mediated chronic inflammation that occurs in asthma, allergy and IBD. Objectives The objective was to evaluate the efficacy and safety of helminth treatment for induction of remission in IBD. Search methods We searched the following databases from inception to 13 July 2013: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Inflammatory Bowel Disease Group Specialized Trials Register. We also searched four online trials registries, and abstracts from major meetings. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) where the intervention was any helminth species or combination of helminth species, administered in any dose and by any route and for any duration of exposure to people with active CD or UC, confirmed through any combination of clinical, endoscopic and histological criteria were eligible for inclusion. Data collection and analysis Two authors independently extracted data and assessed eligibility using a standardized data collection form. We used the RevMan software for analyses. The primary outcome was induction of remission as defined by the included studies. Secondary outcomes included clinical, histologic, or endoscopic improvement as defined by the authors, endoscopic mucosal healing, change in disease activity index score, change in quality of life score, hospital admissions, requirement for intravenous corticosteroids, surgery, study withdrawal and the incidence of adverse events. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. We calculated the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria. Main results Two RCTs (90 participants) were included. One trial assessed the efficacy and safety of Trichuris suis ( T. suis ) ova in patients with UC (n = 54). The other RCT was a phase one that assessed the safety and tolerability of T. suis ova in patients with CD (n = 36). The risk of bias in both studies was judged to be low. In the UC study, during the 12‐week study period, participants in the active arm received 2‐weekly aliquots of 2500 T. suis eggs, added to 0.8 mL of saline; those in the placebo arm received 0.8 mL saline only. There were sparse data available for the outcomes clinical remission and clinical improvement. Ten per cent (3/30) of patients in the T. suis arm entered remission compared to 4% (1/24) of patients in the placebo arm (RR 2.40, 95% CI 0.27 to 21.63). Forty‐three per cent (13/30) of patients in the T. suis group achieved clinical improvement compared to 17% (4/24) of placebo patients (RR 2.60, 95% CI 0.97 to 6.95). The mean ulcerative colitis disease activity index (UCDAI) score was lower in the T. suis group (6.1 +/‐ 0.61) compared to the placebo group (7.5 +/‐ 0.66) after 12 weeks of treatment (MD ‐1.40, 95% CI ‐1.75 to ‐1.05). There was only limited evidence relating to the proportion of patients who experienced an adverse event. Three per cent (1/30) of patients in the T. suis group experienced at least one adverse event compared to 12% (3/24) of placebo patients (RR 0.27, 95% CI 0.03 to 2.40). None of the adverse events reported in this study were judged to be related to the study treatment. GRADE analyses rated the overall quality of the evidence for the primary and secondary outcomes (i.e. clinical remission and improvement) as low due to serious imprecision. In the CD study, participants received a single treatment of T. suis ova at a dosage of 500 (n = 9), 2500 (n = 9), or 7500 (n = 9) embryonated eggs or matching placebo (n = 9). The CD study did not assess clinical remission or improvement as outcomes. There were sparse data on adverse events at two weeks. Thirty‐seven per cent (10/27) of patients in the T. suis group experienced at least one adverse event compared to 44% (4/9) of placebo patients (RR 0.83, 95% CI 0.35 to 2.01). Only one adverse event (dysgeusia) was judged to be possibly related to treatment in this study. Dysgeusia was reported in one patient in the T. suis group and in one patient in the placebo group. Authors' conclusions Currently, there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of helminths used to treat patients with IBD. The evidence for our primary efficacy outcomes in this review comes from one small study and is of low quality due to serious imprecision. We do not have enough evidence to determine whether helminths are safe when used in patients with UC and CD. Further RCTs are required to assess the efficacy and safety of helminth therapy in IBD. Plain language summary Helminth therapy (worms) for induction of remission in inflammatory bowel disease Inflammatory bowel disease (IBD) is comprised of two disorders: ulcerative colitis and Crohn’s disease. These disorders have both distinct and overlapping symptoms, but the underlying cause remains incompletely understood. Standard therapy for IBD includes sulfasalazine, 5‐ASA drugs, steroids, immunosuppressives such as azathioprine, 6‐mercaptopurine and methotrexate and biological agents such as infliximab. Helminths are worm‐like parasites, that inhabit larger organisms. Helminths cause changes in the immune systems of their hosts including an altered immunological response to antigens and this has implications for the treatment of inflammatory bowel disease which is thought to be caused by immune dysregulation. The purpose of this systematic review was to examine the effectiveness and safety of helminth therapy for inducing remission in people with IBD. This review identified two randomised controlled trials including a total of 90 participants. One study compared twice weekly treatment with helminths (an 0.8 mL solution containing 2500 live eggs of the helminth Trichuris suis ) for 12 weeks to a matching placebo (an 0.8 ml identical looking solution with no Trichuris suis eggs) in 54 patients with active ulcerative colitis. Few remissions occurred during the trial and helminth treatment had no detectable effect on these remissions. Ten per cent (3/30) of patients in the helminth group achieved remission compared to four per cent (1/24) of placebo patients. A higher proportion of patients in the helminth group (43% or 13/30) improved clinically compared to the placebo group (17% or 4/24). However, this difference could be a chance effect. We could not determine whether the proportion of patients who had a side effect was higher in either group. No observed side effects were thought to be related to treatment were reported in this study. The other study compared one treatment with various doses of helminths (a solution of 500, 2500 or 7500 Trichuris suis eggs) to a matching placebo in 36 patients with Crohn's disease. This study was designed to assess side effects and did not measure clinical remission or improvement. There amount of information available on side‐effects at two weeks was limited and the results were uncertain due to the small number of participants in the study. The only side effect that was judged to be possibly related to the study treatment was dysgeusia (a distortion of the sense of taste). This was reported in one patient in the helminth group and in one patient in the placebo group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and safety of helminths used to treat patients with IBD. The only information available relating to clinical improvement in patients with active ulcerative colitis comes from one small study. We do not know how safe helminths are when used in patients with ulcerative colitis and Crohn's disease. Further randomised controlled trials are required to assess the efficacy and safety of helminth therapy in IBD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Garg, SK; Croft, AM; Bager, P", "articleTypes": [], "doi": "10.1002/14651858.CD009400.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "620f3ba8-071a-4fa8-ae27-1e254b3275c7", "pmid": "", "title": "Lycopene for the prevention of prostate cancer", "imported": false, "abstract": "Abstract - Background Prostate cancer is a common cause of death in developed countries, yet the benefits of screening for prostate cancer still remain controversial. A prostate‐specific antigen (PSA) test result greater than 4 ng/mL (nanograms/millilitre) has commonly been used as the cut‐off level for seeking further tests to diagnose the presence (or absence) of prostate cancer. An increase in PSA levels may not necessarily be associated with an increased risk of prostate cancer, as PSA levels may also be increased in men with benign prostatic hyperplasia and prostatitis. Despite the uncertainty of the net benefit of early detection and treatment, safe and effective methods to prevent prostate cancer are of value. Consumers, seeking greater involvement in their healthcare, are increasingly turning to lifestyle modification and complementary and alternative medicines (CAMs) to maintain their health and prevent disease. Lycopene is a member of the carotenoid family, which is found abundantly in tomatoes, tomato‐based products, strawberries, and watermelon. It has been hypothesised that lycopene is a strong antioxidant, which may lower the risk of cancer (including prostate cancer) in people who have diets rich in lycopene. Objectives To determine whether lycopene reduces the incidence of prostate cancer and prostate cancer‐specific mortality. Secondary objectives include changes in PSA levels, prostate symptoms and the nature of adverse events associated with lycopene use. Search methods Electronic searches were conducted across MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases. No language or other limitations were imposed. Selection criteria Randomised controlled trials (RCTs) that investigated the use of lycopene for the prevention of prostate cancer were eligible for inclusion in this review. Data collection and analysis A search of electronic databases, performed in August 2011, identified 64 citations. All articles were selected for full‐text review. From these citations, three studies were identified as meeting the inclusion criteria. Handsearching did not provide any additional studies. Main results Three RCTs, with a total of 154 participants were included in this review. None of the studies reported data on prostate cancer mortality. All of the included studies differed with respect to design, participants included and allocation of lycopene. This clinical heterogeneity limits the value on the pooled estimated of the meta‐analyses. The methodological quality of two of the three included studies was assessed as posing a 'high' risk of bias. Meta‐analysis indicated no statistical difference in PSA levels between men randomised to receive lycopene and the comparison group (MD (mean difference) ‐0.34, 95% CI (confidence interval) ‐2.01 to 1.32). Only one study reported incidence of prostate cancer (10% in the lycopene group versus 30% in control group). The level of lycopene was also not statistically different in men randomised to receive lycopene and the comparison group (MD 0.39 µg/mL (micrograms/millilitre), 95% CI ‐0.19 to 0.98). No other meta‐analyses were possible since other outcomes assessed only had one study contributing data. Authors' conclusions Given that only three RCTs were included in this systematic review, and the high risk of bias in two of the three studies, there is insufficient evidence to either support, or refute, the use of lycopene for the prevention of prostate cancer. Similarly, there is no robust evidence from RCTs to identify the impact of lycopene consumption upon the incidence of prostate cancer, prostate symptoms, PSA levels or adverse events. Plain language summary Lycopene for the prevention of prostate cancer Prostate cancer is a common form of cancer affecting men worldwide. Pharmaceutical interventions, such as 5‐alpha reductase inhibitors, have been identified as potentially preventing prostate cancer incidence in men. Many men modify lifestyle and consume complementary and alternative medicines to maintain better health and prevent disease. Lycopene is a supplement that has been suggested may assist in the prevention of prostate cancer due to its antioxidant effects. The objective of this systematic review was to identify the effectiveness of lycopene in the prevention of prostate cancer. This review identified 3 relevant studies, comprising 154 participants in total. Two of the studies were assessed to be of 'high' risk of bias. Meta‐analysis of two studies indicated no statistical difference in prostate specific antigen (PSA) levels between men randomised to receive lycopene and the comparison group (MD ‐0.34, 95% CI ‐2.01 to 1.32). None of the studies assessed prostate cancer mortality. No other meta‐analyses were possible since other outcomes assessed only had one study contributing data.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Ilic, D, Forbes, KM, Hassed, C", "articleTypes": [], "doi": "10.1002/14651858.CD008007.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.764Z" }, { "id": "62477b02-ca63-46bd-87f7-096a93976c72", "pmid": "", "title": "Inhaled mannitol for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Several agents are used to clear secretions from the airways of people with cystic fibrosis. Mannitol increases mucociliary clearance, but its exact mechanism of action is unknown. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents which require delivery via a nebuliser. Phase III trials of inhaled dry powder mannitol for the treatment of cystic fibrosis have been completed and it is now available in Australia and some countries in Europe. This is an update of a previous review. Objectives To assess whether inhaled dry powder mannitol is well tolerated, whether it improves the quality of life and respiratory function in people with cystic fibrosis and which adverse events are associated with the treatment. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic databases, handsearching relevant journals and abstracts from conferences. Date of last search: 12 December 2019. Selection criteria All randomised controlled studies comparing mannitol with placebo, active inhaled comparators (for example, hypertonic saline or dornase alfa) or with no treatment. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction and assessed the risk of bias in included studies. The quality of the evidence was assessed using GRADE. Main results Six studies (reported in 36 unique publications) were included with a total of 784 participants. Duration of treatment in the included studies ranged from 12 days to six months, with open‐label treatment for an additional six months in two of the studies. Five studies compared mannitol with control (a very low dose of mannitol or non‐respirable mannitol) and the final study compared mannitol to dornase alfa alone and to mannitol plus dornase alfa. Two large studies had a similar parallel design and provided data for 600 participants, which could be pooled where data for a particular outcome and time point were available. The remaining studies had much smaller sample sizes (ranging from 22 to 95) and data could not be pooled due to differences in design, interventions and population. Pooled evidence from the two large parallel studies was judged to be of low to moderate quality and from the smaller studies was judged to be of low to very low quality. In all studies, there was an initial test to see if participants tolerated mannitol, with only those who could tolerate the drug being randomised; therefore, the study results are not applicable to the cystic fibrosis population as a whole. While the published papers did not provide all the data required for our analysis, additional unpublished data were provided by the drug's manufacturer and the author of one of the studies. Pooling the large parallel studies comparing mannitol to control, up to and including six months, lung function (forced expiratory volume at one second) measured in both mL and % predicted was significantly improved in the mannitol group compared to the control group (moderate‐quality evidence). Beneficial results were observed in these studies in adults and in both concomitant dornase alfa users and non‐users in these studies. In the smaller studies, statistically significant improvements in lung function were also observed in the mannitol groups compared to the non‐respirable mannitol groups; however, we judged this evidence to be of low to very low quality. For the comparisons of mannitol and control, we found no consistent differences in health‐related quality of life in any of the domains except for burden of treatment, which was less for mannitol up to four months in the two pooled studies of a similar design; this difference was not maintained at six months. It should be noted that the tool used to measure health‐related quality of life was not designed to assess mucolytics and pooling of the age‐appropriate tools (as done in some of the included studies) may not be valid so results were judged to be low to very low quality and should be interpreted with caution. Cough, haemoptysis, bronchospasm, pharyngolaryngeal pain and post‐tussive vomiting were the most commonly reported side effects in both treatment groups. Where rates of adverse events could be compared, statistically no significant differences were found between mannitol and control groups; although some of these events may have clinical relevance for people with CF. For the comparisons of mannitol to dornase alfa alone and to mannitol plus dornase alfa, very low‐quality evidence from a 12‐week cross‐over study of 28 participants showed no statistically significant differences in the recorded domains of health‐related quality of life or measures of lung function. Cough was the most common side effect in the mannitol alone arm but there was no occurrence of cough in the dornase alfa alone arm and the most commonly reported reason of withdrawal from the mannitol plus dornase alfa arm was pulmonary exacerbations. In terms of secondary outcomes of the review (pulmonary exacerbations, hospitalisations, symptoms, sputum microbiology), evidence provided by the included studies was more limited. For all comparisons, no consistent statistically significant and clinically meaningful differences were observed between mannitol and control treatments (including dornase alfa). Authors' conclusions There is moderate‐quality evidence to show that treatment with mannitol over a six‐month period is associated with an improvement in some measures of lung function in people with cystic fibrosis compared to control. There is low to very low‐quality evidence suggesting no difference in quality of life for participants taking mannitol compared to control. This review provides very low‐quality evidence suggesting no difference in lung function or quality of life comparing mannitol to dornase alfa alone and to mannitol plus dornase alfa. The clinical implications from this review suggest that mannitol could be considered as a treatment in cystic fibrosis; but further research is required in order to establish who may benefit most and whether this benefit is sustained in the longer term. Furthermore, studies comparing its efficacy against other (established) mucolytic therapies need to be undertaken before it can be considered for mainstream practice. Plain language summary Mannitol, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of inhaling mannitol to treat lung disease in people with cystic fibrosis. Background Cystic fibrosis is a genetic disorder that affects the exocrine glands (sweat glands and others). Lung infections produce thick mucus (phlegm) which can block air passages and cause more infection and repeated inflammation. In turn, this progressively damages the lungs and can eventually cause respiratory failure. There are several drugs that are used to clear mucus from the airways of people with cystic fibrosis and inhaled dry powder mannitol is a new one that may improve their lung function. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents delivered by a nebuliser (e.g. hypertonic saline). Mannitol is available in Australia and some European countries. This is an updated version of the review. Search date The evidence is current to: 12 December 2019. Study characteristics We included six studies (with a total of 784 adults and children) in this review. Five studies compared a standard dose of mannitol with control (a very low dose of mannitol or a version of mannitol which did not allow the active drug to reach the lungs) and the sixth study compared mannitol with nebulised recombinant human deoxyribonuclease (dornase alfa), both alone and taken together. Participants could continue using dornase alfa and other standard therapies, but were excluded from the five of the six studies if they were using hypertonic saline. Treatment in these studies lasted from 12 days to six months. Five studies provided the treatments to people as outpatients and in one study, the children treated were in hospital due to pulmonary exacerbations (flare ups of disease). Key results It was difficult to combine evidence from the studies in this review due to differences in the designs of the studies, treatments examined and the settings (hospital or outpatients). Some additional information was obtained from the drug manufacturer and one study author to aid the review. The review found low‐ to very low‐quality evidence that there is no difference between mannitol and control treatments or mannitol given either with or without additional dornase alfa in terms of quality of life. There was moderate‐quality evidence of improvements in some measures of lung function across the larger studies comparing mannitol to control. Beneficial effects were also seen in the subgroup of adults and in both those who were using dornase alfa and those who were not. Cough (including coughing up blood), contraction of the airways, pain in the pharynx or larynx and post‐treatment vomiting were the most commonly reported side effects on both treatments, but there was no evidence to suggest that these side effects occurred more on mannitol than on control treatments or on dornase alfa. None of the studies compared mannitol to nebulised hypertonic saline and so we can not comment on which agent is better for airway clearance. More research is needed to answer this question. Quality of the evidence We judged the quality of the evidence from this review to be of very low to moderate quality, depending on the outcome measured. We do not think that the way the studies were designed affected the results. We judged that everyone taking part had equal chances of being in either of the treatment groups and would not have known in advance or during the study which treatment they were receiving. However, the numbers of people who dropped out of the studies might affect how the results are interpreted, as well as how many people were recruited into the studies and how they were selected from all people with cystic fibrosis who could have been included. Although some of these issues were resolved when the drug's manufacturer (who also sponsored the studies) provided some additional information. It is important to realise that before people started the study, they took a test to see if they could tolerate mannitol and only those who did could carry on. This means that the results of the studies only apply to those people with cystic fibrosis who can tolerate mannitol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Nevitt, SJ, Thornton, J, Murray, CS, Dwyer, T", "articleTypes": [], "doi": "10.1002/14651858.CD008649.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.779Z" }, { "id": "624b858a-c7df-436a-87ec-e77effc2a20e", "pmid": "", "title": "Omega‐3 fatty acids supplementation for autism spectrum disorders (ASD)", "imported": false, "abstract": "Abstract - Background It has been suggested that impairments associated with autism spectrum disorders (ASD) may be partially explained by deficits of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. Objectives To review the efficacy of omega‐3 fatty acids for improving core features of ASD (for example, social interaction, communication, and stereotypies) and associated symptoms. Search methods We searched the following databases on 2 June 2010: CENTRAL (2010, Issue 2), MEDLINE (1950 to May Week 3 2010), EMBASE (1980 to 2010 Week 21), PsycINFO (1806 to current), BIOSIS (1985 to current), CINAHL (1982 to current), Science Citation Index (1970 to current), Social Science Citation Index (1970 to current), metaRegister of Controlled Trials (20 November 2008) and ClinicalTrials.gov (10 December 2010). Dissertation Abstracts International was searched on 10 December 2008, but was no longer available to the authors or editorial base in 2010. Selection criteria All randomised controlled trials of omega‐3 fatty acids supplementation compared to placebo in individuals with ASD. Data collection and analysis Three authors independently selected studies, assessed them for risk of bias and extracted relevant data. We conducted meta‐analysis of the included studies for three primary outcomes (social interaction, communication, and stereotypy) and one secondary outcome (hyperactivity). Main results We included two trials with a total of 37 children diagnosed with ASD who were randomised into groups that received either omega‐3 fatty acids supplementation or a placebo. We excluded six trials because they were either non‐randomised controlled trials, did not contain a control group, or the control group did not receive a placebo. Overall, there was no evidence that omega‐3 supplements had an effect on social interaction (mean difference (MD) 0.82, 95% confidence interval (CI) ‐2.84 to 4.48, I 2 = 0%), communication (MD 0.62, 95% CI ‐0.89 to 2.14, I 2 = 0%), stereotypy (MD 0.77, 95% CI ‐0.69 to 2.22, I 2 = 8%), or hyperactivity (MD 3.46, 95% CI ‐0.79 to 7.70, I 2 = 0%). Authors' conclusions To date there is no high quality evidence that omega‐3 fatty acids supplementation is effective for improving core and associated symptoms of ASD. Given the paucity of rigorous studies in this area, there is a need for large well‐conducted randomised controlled trials that examine both high and low functioning individuals with ASD, and that have longer follow‐up periods. Plain language summary Omega‐3 fatty acids for autism spectrum disorders (ASD) It has been suggested that difficulties associated with ASD may be explained in part by lack of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. The purpose of this review was to assess the evidence for the effectiveness of omega‐3 supplementation for core features of ASD and associated symptoms. We found only two small randomised controlled trials that evaluated omega‐3 fatty acids for ASD. There is insufficient evidence that omega‐3 fatty acids supplementation is an effective treatment for ASD. However, high quality large randomised controlled trials are needed before definite recommendations about this treatment can be made.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "James, S; Montgomery, P; Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD007992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "625d0b28-46ac-4859-9fe1-89268b05e782", "pmid": "", "title": "Aminoglycosides, vancomycin, and metronidazole for people with cirrhosis and hepatic encephalopathy", "imported": false, "abstract": "Abstract - Rationale Hepatic encephalopathy is a common complication of cirrhosis. Its development is associated with increased morbidity and mortality. Its exact pathogenesis is unknown, but ammonia, produced by bacterial action in the intestine, plays a key role. Antibiotics modulate the gut flora and may reduce intestinal ammonia production. Aminoglycosides such as neomycin, paromomycin, and ribostamycin have been used to treat hepatic encephalopathy, as have other antibiotics such as vancomycin and metronidazole. Objectives To assess the beneficial and harmful effects of aminoglycosides, vancomycin, and metronidazole versus placebo, no intervention, other antibiotics, or other active pharmacological interventions, for the prevention and treatment of hepatic encephalopathy in people with cirrhosis. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, and three other databases to 15 April 2025. We also searched online trials registries for ongoing and unpublished trials, undertook manual searches of meeting and conference proceedings, checked bibliographies of relevant articles, and corresponded with investigators and pharmaceutical companies. Eligibility criteria We included randomised clinical trials (RCTs) involving participants with cirrhosis and hepatic encephalopathy, or who were at risk of developing hepatic encephalopathy, comparing aminoglycosides, vancomycin, or metronidazole to (1) placebo or no intervention; or (2) other pharmacological agents, including non‐absorbable disaccharides, other antibiotics, or other potentially beneficial agents (e.g. branched‐chain amino acids, L‐ornithine L‐aspartate, nitazoxanide (a broad‐spectrum antiparasitic/antiviral agent), and nicotinohydroxamic acid (a potent urease inhibitor). We included trials irrespective of publication status, outcomes reported, language, or blinding. We excluded trials involving people with hepatic encephalopathy associated with acute liver failure or with non‐cirrhotic portal hypertension. Outcomes The critical outcomes were all‐cause mortality, hepatic encephalopathy, and serious adverse events. The important outcomes were non‐serious adverse events and health‐related quality of life (HRQoL). Our primary time point was the maximum length of follow‐up. Risk of bias We used Cochrane's original risk of bias tool (RoB 1) to assess the risk of bias. Synthesis methods We used standard Cochrane methods. We undertook random‐effects meta‐analyses to calculate risk ratios (RRs) or standardised mean differences (SMDs), with 95% confidence intervals (CIs). We assessed heterogeneity with the I 2 statistic, and the certainty of evidence with the GRADE framework. Included studies We included 24 RCTs, involving 1405 participants experiencing 1418 hepatic encephalopathy events. Twenty‐three trials evaluated the treatment of hepatic encephalopathy and one, the secondary prevention of hepatic encephalopathy; we analysed these trials jointly. The trials assessed three aminoglycosides: neomycin (15 trials), paromomycin (three trials), and ribostamycin (one trial), as well as vancomycin (two trials), and metronidazole (three trials). Overall, 670 participants received these pharmacotherapies while 735 participants received a placebo or other potentially beneficial agents. We classified 22 of the 24 trials to be at an overall high risk of bias based on domain‐level assessments. Synthesis of results The certainty of evidence for all comparisons was low to very low, mainly due to risk of bias, imprecision, and heterogeneity. Twenty‐three of the 24 trials, involving 1383 participants, reported all‐cause mortality data. Aminoglycosides may increase mortality slightly compared to other potentially active agents (RR 1.64, 95% CI 1.03 to 2.62; I² = 0%; 3 studies, 166 participants). The evidence was very uncertain about whether aminoglycosides versus a placebo (RR 1.02, 95% CI 0.62 to 1.69; I² = 0%; 3 studies, 137 participants), non‐absorbable disaccharides (RR 1.21, 95% CI 0.57 to 2.59; I² not applicable; 4 studies, 266 participants), or other antibiotics (RR 1.00, 95% CI 0.24 to 4.23; I² = 83%; 8 studies, 496 participants) result in a difference in mortality risk. The evidence was also very uncertain when comparing vancomycin to non‐absorbable disaccharides (RR 0.94, 95% CI 0.26 to 3.40; I² not applicable; 2 studies, 72 participants), and metronidazole to other active agents (RR 0.97, 95% CI 0.14 to 6.66; I² = 0%; 3 studies, 242 participants). Nineteen trials involving 1281 participants reported data on hepatic encephalopathy. There may be little to no difference in the effects of aminoglycosides versus non‐absorbable disaccharides (RR 0.84, 95% CI 0.67 to 1.05; I² = 0%; 3 studies, 251 participants), aminoglycosides versus other potentially active agents (RR 1.21, 95% CI 0.79 to 1.85; I² = 0%; 3 studies, 166 participants), and metronidazole versus other active agents (RR 1.50, 95% CI 0.89 to 2.54; I² = 48%; 2 studies, 208 participants). The evidence is very uncertain about the effect of aminoglycosides versus placebo, other antibiotics, and vancomycin versus non‐absorbable disaccharides. Twenty trials, involving 1186 participants, reported a total of 328 serious adverse events. Aminoglycosides may slightly increase the risk of serious adverse events compared with other potentially active agents (RR 1.60, 95% CI 1.03 to 2.47; I² = 0%; 3 studies, 166 participants). The evidence is very uncertain when comparing aminoglycosides to placebo and other antibiotics, or when comparing vancomycin to non‐absorbable disaccharides. Eighteen trials, involving 922 participants, reported a total of 96 non‐serious adverse events. There may be a slight increase in the risk of adverse events when comparing aminoglycosides to placebo (RR 2.80, 95% CI 1.11 to 7.04; I² not applicable; 2 studies, 98 participants), and to other antibiotics (RR 3.24, 95% CI 1.08 to 9.70; I² = 0%; 8 studies, 251 participants). The evidence is very uncertain about the effects of aminoglycosides versus non‐absorbable disaccharides or other active agents, and metronidazole versus other active agents. Only one trial assessed HRQoL, but reported the data in a form that precluded meta‐analysis. Eight trials received support from pharmaceutical companies while six did not. Ten trials did not provide this information. Authors' conclusions Due to low‐ or very low‐certainty evidence, we do not know if aminoglycosides benefit hepatic encephalopathy compared to placebo or other potentially active agents. There may be a slight increase in the risks of mortality and serious adverse events with aminoglycosides compared to other agents, and of non‐serious adverse events when compared to placebo and other antibiotics. We do not know if vancomycin or metronidazole improve clinically relevant outcomes. Only one trial assessed health‐related quality of life. Funding This Cochrane review received no specific funding. Registration https://doi.org/10.1002/14651858.CD012734 Plain language summary Do the antibiotics aminoglycosides, vancomycin, and metronidazole help people with cirrhosis and hepatic encephalopathy, a brain disorder associated with chronic liver disease? Key messages Antibiotics previously thought to help people with cirrhosis manage the risk of hepatic encephalopathy do not appear to benefit the condition. These antibiotics possibly cause more side effects than other treatments for this condition. Research is needed to establish whether combining these antibiotics with other treatments may be beneficial. What are cirrhosis and hepatic encephalopathy? Cirrhosis is a long‐term condition in which the liver becomes badly scarred. The liver normally helps clean the blood, process nutrients, and fight infections. When it is repeatedly damaged over time, the scar tissue which develops makes it harder for the liver to work properly. People with cirrhosis may develop hepatic encephalopathy, a condition that results in poor brain functioning. The reason why people develop hepatic encephalopathy is complex, but the build‐up in the blood of toxins from the gut, particularly of a compound called ammonia, plays a key role. Ammonia is produced in the gut mainly as a result of the activities of gut bacteria. How do antibiotics work in hepatic encephalopathy? Antibiotics are medicines used to treat infections caused by bacteria. They work by killing bacteria or stopping them from growing. Certain antibiotics may reduce the levels of ammonia in the blood by interfering with ammonia production in the gut. These antibiotics have been used to treat hepatic encephalopathy for many years, but the evidence that they help is unclear. The antibiotics considered in this review are: aminoglycosides (neomycin, paromomycin, and ribostamycin); vancomycin; metronidazole. What did we want to find out? We wanted to know if these antibiotics help to prevent or treat hepatic encephalopathy in people with cirrhosis. We analysed their effects on the number of people who died, whose symptoms of hepatic encephalopathy improved or failed to improve, and the number who experienced serious or non‐serious complications. What did we do? We searched for studies that compared aminoglycosides, vancomycin, or metronidazole to: placebo – an inactive or 'dummy' medicine; non‐absorbable disaccharides – sugars that mainly act in the gut, and are commonly used to treat some digestive and liver conditions; other antibiotics; other active agents that may help the condition. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 24 studies which involved 1405 participants. Of these, 23 studies evaluated the treatment of hepatic encephalopathy, and one study explored the prevention of hepatic encephalopathy in people at risk. We found evidence for the following comparisons: aminoglycosides versus placebo, non‐absorbable disaccharides, other antibiotics, and other active agents – 19 studies in total; vancomycin versus non‐absorbable disaccharides – 2 studies; metronidazole versus other active agents – 3 studies. Main results Death Aminoglycosides may slightly increase the risk of death compared to other active agents. We do not know if aminoglycosides make any difference to the risk of death compared to placebo, non‐absorbable disaccharides, and other antibiotics. We also do not know if there is any difference in the risk of death between: vancomycin and non‐absorbable disaccharides; metronidazole and other active agents. Hepatic encephalopathy: number of people in whom hepatic encephalopathy failed to improve Aminoglycosides may make little to no difference to the number of people whose condition improves compared to non‐absorbable disaccharides and other active agents. Metronidazole may make little to no difference to the number of people whose condition improves compared to other active agents. We do not know if there is any difference in the number of people whose condition improves when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Serious complications Aminoglycosides may slightly increase the risk of serious complications compared to other active agents. We do not know if there is any difference in serious complications when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Non‐serious complications Aminoglycosides may slightly increase the risk of non‐serious complications compared to placebo or other antibiotics. We do not know if there is any difference in the risk of non‐serious complications when comparing: aminoglycosides to non‐absorbable disaccharides or other active agents; metronidazole to other active agents; vancomycin to non‐absorbable disaccharides. Only one study, using metronidazole, reported on health‐related quality of life, so we were unable to draw any conclusions for this outcome. What are the limitations of the evidence? We had little to no confidence in the results of the review because the participants and researchers in some studies were aware of which treatment the participants received, which may have influenced the results, while some studies did not report on the outcomes we were interested in. The studies were generally small, and differed in how they were conducted. There were also too few studies to be certain about the outcomes. How current is this evidence? The evidence is current to 15 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Jeyaraj, R; Zacharias, HD; Vadera, S; Low, ZY; Gluud, LL; Morgan, MY", "articleTypes": [], "doi": "10.1002/14651858.CD012734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "62648e58-5ca9-4e33-b0bc-66945a98aa53", "pmid": "", "title": "Nutritional supplementation for hip fracture aftercare in older people", "imported": false, "abstract": "Abstract - Background Older people with hip fractures are often malnourished at the time of fracture, and subsequently have poor food intake. This is an update of a Cochrane review first published in 2000, and previously updated in 2010. Objectives To review the effects (benefits and harms) of nutritional interventions in older people recovering from hip fracture. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, MEDLINE In‐Process & Other Non‐Indexed Citations, Embase, CAB Abstracts, CINAHL, trial registers and reference lists. The search was last run in November 2015. Selection criteria Randomised and quasi‐randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture where the interventions were started within the first month after hip fracture. Data collection and analysis Two review authors independently selected trials, extracted data and assessed risk of bias. Where possible, we pooled data for primary outcomes which were: all cause mortality; morbidity; postoperative complications (e.g. wound infections, pressure sores, deep venous thromboses, respiratory and urinary infections, cardiovascular events); and 'unfavourable outcome' defined as the number of trial participants who died plus the number of survivors with complications. We also pooled data for adverse events such as diarrhoea. Main results We included 41 trials involving 3881 participants. Outcome data were limited and risk of bias assessment showed that trials were often methodologically flawed, with less than half of trials at low risk of bias for allocation concealment, incomplete outcome data, or selective reporting of outcomes. The available evidence was judged of either low or very low quality indicating that we were uncertain or very uncertain about the estimates. Eighteen trials evaluated oral multinutrient feeds that provided non‐protein energy, protein, vitamins and minerals. There was low‐quality evidence that oral feeds had little effect on mortality (24/486 versus 31/481; risk ratio (RR) 0.81 favouring supplementation, 95% confidence interval (CI) 0.49 to 1.32; 15 trials). Thirteen trials evaluated the effect of oral multinutrient feeds on complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was low‐quality evidence that the number of participants with complications may be reduced with oral multinutrient feeds (123/370 versus 157/367; RR 0.71, 95% CI 0.59 to 0.86; 11 trials). Based on very low‐quality evidence from six studies (334 participants), oral supplements may result in lower numbers with 'unfavourable outcome' (death or complications): RR 0.67, 95% CI 0.51 to 0.89. There was very low‐quality evidence for six studies (442 participants) that oral supplementation did not result in an increased incidence of vomiting and diarrhoea (RR 0.99, 95% CI 0.47 to 2.05). Only very low‐quality evidence was available from the four trials examining nasogastric multinutrient feeding. Pooled data from three heterogeneous trials showed no evidence of an effect of supplementation on mortality (14/142 versus 14/138; RR 0.99, 95% CI 0.50 to 1.97). One trial (18 participants) found no difference in complications. None reported on unfavourable outcome. Nasogastric feeding was poorly tolerated. One study reported no cases of aspiration pneumonia. There is very low‐quality evidence from one trial (57 participants, mainly men) of no evidence for an effect of tube feeding followed by oral supplementation on mortality or complications. Tube feeding, however, was poorly tolerated. There is very low‐quality evidence from one trial (80 participants) that a combination of intravenous feeding and oral supplements may not affect mortality but could reduce complications. However, this expensive intervention is usually reserved for people with non‐functioning gastrointestinal tracts, which is unlikely in this trial. Four trials tested increasing protein intake in an oral feed. These provided low‐quality evidence for no clear effect of increased protein intake on mortality (30/181 versus 21/180; RR 1.42, 95% CI 0.85 to 2.37; 4 trials) or number of participants with complications but very low‐quality and contradictory evidence of a reduction in unfavourable outcomes (66/113 versus 82/110; RR 0.78, 95% CI 0.65 to 0.95; 2 trials). There was no evidence of an effect on adverse events such as diarrhoea. Trials testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. Based on low‐quality evidence, one trial evaluating the use of dietetic assistants to help with feeding indicated that this intervention may reduce mortality (19/145 versus 36/157; RR 0.57, 95% CI 0.34 to 0.95) but not the number of participants with complications (79/130 versus 84/125). Authors' conclusions There is low‐quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low‐quality evidence that oral supplements may reduce 'unfavourable outcome' (death or complications) and that they do not result in an increased incidence of vomiting and diarrhoea. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding or nasogastric feeding in very malnourished people require further evaluation. Plain language summary Nutritional supplementation for older people after hip fracture Background and aim Older people with hip fractures are often malnourished at the time of their fracture and many have poor food intake while in hospital. Malnutrition may hinder recovery after hip fracture. We reviewed the effects of nutritional interventions in older people recovering from hip fracture. Search results We searched the scientific literature up to November 2015 and include 41 studies including 3881 participants. All nutritional interventions were started within one month of hip fracture. The studies had flaws in their methods that may affect the validity of their results. Some evidence was very low quality which means we are very unsure of the results. Key results Eighteen studies examined the use of additional oral feeds that provided energy from sources other than protein, protein, some vitamins and minerals. There was low‐quality evidence that these multinutrient oral feeds may not reduce mortality but that they may reduce the number of people with complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was very low‐quality evidence that oral multinutrient feeds may reduce unfavourable outcome (death or complications) and that they did not result in increased vomiting and diarrhoea. Four studies examined nasogastric tube feeding, where liquid food is delivered via a tube inserted into the nose and passed down into the stomach, with non‐protein energy, protein, some vitamins and minerals. These studies provided very low‐quality evidence that tube feeding, which was poorly tolerated, did not seem to make a difference to mortality or complications. Unfavourable outcome was not recorded and there was insufficient evidence on adverse events. One study provided very low‐quality evidence that nasogastric tube feeding followed by oral feeds may not affect mortality or complications. It reported that tube feeding was poorly tolerated. One study provided very low‐quality evidence that giving feed into a vein initially and then by mouth may not affect mortality but may reduce complications. However, we were surprised that this intervention was being used in people who seemed to be able to take nutrition orally. Increasing protein intake in an oral feed was tested in four studies. These provided low‐quality evidence of no clear effect on mortality or complications and very low‐quality evidence for a reduction in unfavourable outcome. Studies testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. One study, evaluating the use of dietetic assistants to help with feeding, provided low‐quality evidence that this may reduce mortality but not the numbers of people with complications. Conclusions Oral supplements with non‐protein energy, protein, vitamins and minerals started before or soon after surgery may prevent complications after hip fracture in older people but may not affect mortality. Adequately sized randomised studies with better design are required. We suggest that the role of dietetic assistants, and of peripheral venous feeding or nasogastric feeding in very malnourished patients, require further evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Avenell, A; Smith, TO; Curtain, JP; Mak, JCS; Myint, PK", "articleTypes": [], "doi": "10.1002/14651858.CD001880.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "627e0514-4e18-4c10-b053-03e151bb1863", "pmid": "", "title": "Models for delivery and co‐ordination of primary or secondary health care (or both) to older adults living in aged care facilities", "imported": false, "abstract": "Abstract - Background The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co‐ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost‐effectiveness of alternative models of providing health care to ACF residents. Objectives Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost‐effectiveness of the alternative models. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included individual and cluster‐randomised trials, and cost/cost‐effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co‐ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co‐ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline‐recommended care, health‐related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work‐related satisfaction and work‐related stress of ACF staff. Data collection and analysis Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. Main results We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co‐ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low‐certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I 2 = 53%; 8 trials, 1263 participants; low‐certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low‐certainty evidence) and adherence to guideline‐recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health‐related quality of life of ACF residents (MD ‐0.016, 95% CI ‐0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low‐certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate‐certainty evidence). We did not pool the cost‐effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co‐ordination of care), we are uncertain of the cost‐effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. Authors' conclusions Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health‐related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost‐effectiveness of alternative models of care due to the limited, disparate data available. Plain language summary Alternative ways to organise delivery of health care to older adults living in aged care facilities What is the aim of this review? This Cochrane review set out to determine if providing residents of aged care facilities (ACF) with the same care as usual care, just delivered in a different way (alternative models of care), is better in terms of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs. For example, are multidisciplinary teams (alternative model) a better way of delivering care to residents of ACFs compared to providing care through individual practitioners (usual care)? Key messages Compared to usual care, alternative models of care may reduce unplanned hospital admissions, but may make little or no difference to the number of emergency department visits and the health‐related quality of life of ACF residents, and probably make little or no difference to mortality. We are uncertain of the effect of alternative models of care on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guideline‐recommended care. Importantly, we are uncertain whether alternative models of care are cost‐effective due to the limited, conflicting data available. Studies differed widely in terms of intervention characteristics, health care settings and descriptions of usual care and this hindered many analyses in this review. Future studies should provide a detailed description of what intervention and usual care constitutes in their setting. What was studied in this review? The world's population is ageing and the number of persons living in residential ACFs is growing worldwide. ACF residents are often frail, elderly people with multiple health conditions that require intensive medical care. When an ACF is not able to deliver appropriate health care, residents are often transferred to a hospital for treatment. Such transfers are often burdensome and traumatic for ACF residents and their families and may lead to increased costs. Alternative models of care, designed to provide care that is better co‐ordinated and more timely, aim to reduce unnecessary hospital transfers and improve residents' well‐being. Alternative models of care may be more expensive to implement (e.g. employ more healthcare personnel) but may lead to cost savings down the line (e.g. more residents receive care in ACF, avoiding costly hospital transfers). The synthesised evidence in this review compares the effect of alternative models of care with usual care on the number of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs (i.e. does the model deliver better value for money compared to usual care). What are the main results of this review? We identified 40 studies (with in total 21,787 participants; three studies did not provide number of participants) conducted in 15 countries. The study participants differed with respect to their health needs. In 11 studies, the alternative model of care was aimed at all ACF residents (with mixed health needs/conditions). Other studies included residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers; 13 studies) or residents requiring a specific type of care (e.g. residents after discharge from a hospital; four studies). In most (31) of the studies, the alternative model of care focused on 'co‐ordination of care'. In three studies, the alternative models of care focused on 'who provides care' (e.g. nurse practitioner‐led care using best practice guide instead of GP‐led care) and in two studies, alternative models of care focused on 'where care is provided' (i.e. investigating alternative locations for the provision of care, for example within ACF versus outside of ACF). In four studies, the alternative models of care focused on the use of information and communications technology for the provision of care to ACF residents. In all studies, the alternative model of care was compared with usual care. We found that, compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits; however, the number of unplanned hospital admissions may be reduced. We are uncertain of the effect of alternative models of care on adverse events and adherence to clinical guideline‐recommended care compared with usual care. Alternative models of care may have little or no effect on ACF residents' health‐related quality of life and probably make little or no difference to mortality. Based on the findings of five studies that provided full economic evaluations (all alternative models of care focused on 'co‐ordination of care'), we are uncertain whether alternative models of care are more cost‐effective than usual care. What are the limitations of the evidence? Our confidence in the evidence is limited because participants in the studies were aware of which treatment they were getting. Usual care was poorly described by most of the studies. Usual care differs across countries and regions, so this lack of information limits our interpretation, contextualisation and generalisation of the comparisons. Not all of the studies provided data about outcomes we were looking to assess. How up‐to‐date is this review? The review authors searched for studies published up to October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Putrik, P; Grobler, L; Lalor, A; Ramsay, H; Gorelik, A; Karnon, J; Parker, D; Morgan, M; Buchbinder, R; O'Connor, D", "articleTypes": [], "doi": "10.1002/14651858.CD013880.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "6284f6d2-4b11-4760-8cfa-fbe6d72bb389", "pmid": "", "title": "Probiotic treatment for women with gestational diabetes to improve maternal and infant health and well‐being", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance first recognised during pregnancy and associated with complications for mothers and babies. Probiotics are naturally occurring micro‐organisms, which when ingested in adequate amounts, may confer health benefits. Evidence of the role of probiotics as treatment for GDM is limited. Objectives To evaluate the safety and effectiveness of probiotics in treating women with GDM on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth’s Trials Register ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (24 July 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing the use of probiotics versus placebo/standard care for the treatment of GDM. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, checked data accuracy, and assessed risk of bias of included trials. The certainty of evidence for selected maternal and infant/child outcomes was assessed using GRADE. Main results Nine RCTs (695 pregnant women with GDM) comparing probiotics versus placebo were identified. The overall risk of bias in the nine RCTs was low to unclear and the evidence was downgraded for imprecision due to the small numbers of women participating in the trials. The trials were carried out in hospitals and universities in Iran (seven trials), Thailand (one trial) and Ireland (one trial). All trials compared probiotics with placebo. Maternal outcomes We are uncertain if probiotics have any effect compared with placebo on hypertensive disorders of pregnancy, (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.64 to 3.53; participants = 256; studies = 3; low‐certainty evidence) and mode of birth as caesareans (average RR 0.64, 95% CI 0.30 to 1.35; participants = 267; studies = 3; low‐certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm . No trials reported primary outcomes of: mode of birth as vaginal/assisted and subsequent development of type 2 diabetes. We are uncertain if probiotics have any effect compared with placebo on induction of labour (RR 1.33, 95% CI 0.74 to 2.37; participants = 127; studies = 1; very low‐certainty evidence). For other secondary maternal outcomes, we are uncertain if there are differences between probiotics and placebo for: postpartum haemorrhage; weight gain during pregnancy intervention and total gestational weight gain; fasting plasma glucose and need for extra pharmacotherapy (insulin). Probiotics may be associated with a slight reduction in triglycerides and total cholesterol. In probiotics compared with placebo, there was evidence of reduction in markers for insulin resistance (HOMA‐IR) and HOMA‐B; and insulin secretion. There was also an increase in quantitative insulin sensitivity check index (QUICKI). Probiotics were associated with minor benefits in relevant bio‐markers with evidence of a reduction in inflammatory markers high‐sensitivity C‐reactive protein (hs‐CRP), interleukin 6 (IL‐6), and marker of oxidative stress malondialdehyde; and an increase in antioxidant total glutathione, but we are uncertain if there is any difference in total antioxidant capacity. No trials reported secondary outcomes: perineal trauma, postnatal weight retention or return to pre‐pregnancy weight and postnatal depression. Infant/child/adult outcomes We are uncertain if probiotics have any effect, compared with placebo, on the risk of large‐for‐gestational‐age babies (RR 0.73, 95% CI 0.35 to 1.52; participants = 174; studies = 2; low‐certainty evidence) or infant hypoglycaemia (RR 0.85, 95% CI 0.39 to 1.84; participants = 177; studies = 3; low ‐ certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm. No trials reported primary outcomes of: perinatal (fetal/neonatal) mortality; or neurosensory disability. For other secondary outcomes, we are uncertain if there is any difference between probiotics and placebo in gestational age at birth, preterm birth, macrosomia, birthweight, head circumference, length, infant hypoglycaemia, and neonatal intensive care unit (NICU) admissions. There was evidence of a reduction in infant hyperbilirubinaemia with probiotics compared with placebo. No trials reported secondary outcomes: infant adiposity, and later childhood adiposity. There were no adverse events reported by any of the trials. Authors' conclusions Low‐certainty evidence means we are not certain if there is any difference between probiotic and placebo groups in maternal hypertensive disorders of pregnancy, caesareans; and large‐for‐gestational‐age babies . There were no adverse events reported by the trials. Due to the variability of probiotics used and small sample sizes of trials, evidence from this review has limited ability to inform practice. Well‐designed adequately‐powered trials are needed to identify whether probiotics may improve maternal blood glucose levels and/or infant/child/adult outcomes; and whether they can be used to treat GDM. Plain language summary Probiotics as an added treatment for gestational diabetes to improve mother and baby outcomes What is the issue? Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in high blood glucose levels, first recognised during pregnancy. Pregnant women with GDM are at risk of high blood pressure, labour induction, and caesareans. Their babies are at risk of being born large, birth difficulties, respiratory distress, low blood glucose at birth and jaundice that can cause brain injury. There is increased risks of having long‐term diabetes in the mother, and the baby being overweight. Probiotics are micro‐organisms naturally in food and are in fermented milk, yogurt, or capsules. There are many different probiotics; the two most used are Lactobacillus and Bifidobacterium, and if consumed in adequate amounts may confer health benefits. Why is this important? Probiotics need to be safe and maternal blood glucose levels carefully managed during pregnancy. Women with GDM may receive dietary and physical activity education with monitoring blood glucose levels as initial management. When blood glucose levels are above a certain threshold, women with GDM are prescribed glucose‐lowering medications including metformin and/or insulin. This review aimed to determine the safety and effectiveness of probiotics in treating women with GDM. What evidence did we find? We searched for evidence for randomised controlled trials (latest July 2019). We identified nine studies, involving 695 women with GDM. All trials compared probiotics with placebo. The certainty of the evidence was assessed as very low or low. The overall risk of bias was low to unclear. Seven trials were conducted in Iran; one in Thailand, and one in Ireland. Trials took place in hospitals and universities. We are uncertain if there is any difference between probiotic and placebo in rates of: high blood‐pressure disorders (three studies, 256 participants, low‐certainty evidence); caesarean section (three studies, 267 women, low‐certainty evidence ); and large‐for‐gestational‐age babies (two studies, 174 participants, low‐certainty evidence). We are uncertain if there is any difference between probiotic and placebo for induction of labour (one study, 127 participants, very low‐certainty evidence) and low blood glucose levels in the newborn (three studies, 177 participants, low‐certainty evidence). We are also uncertain if there is any difference between probiotics and placebo for heavy bleeding immediately after birth, weight gain during pregnancy or total gestational weight gain. We are uncertain if there is any difference in fasting blood glucose between probiotics and placebo (seven studies, 554 participants). Probiotics may be assoicated with a slight reduction in triglycerides and total cholesterol (four studies, 320 participants). There was reduction in insulin secretion with probiotics (seven studies, 505 participants). One trial (60 participants) showed no difference between groups in need for insulin. Biomarkers, did show a reduction in insulin resistance (HOMA‐IR), (seven studies, 505 participants) and insulin resistance and β cell function (HOMA‐B) (two studies,130 participants) with probiotics. Quantitative insulin sensitivity check index (QUICKI) increased (four studies, 276 participants) with probiotics. Inflammatory markers, hs‐CRP (four studies, 248 participants) and interleukin 6 (two studies, 128 participants) were reduced with probiotics. Antioxidant total glutathione was increased (two studies, 120 participants) and the oxidative stress biomarker malondialdehyde was reduced with probiotics (three studies, 176 participants). We are uncertain if there is any difference in total antioxidant capacity (four studies 266 participants). For the newborn baby, we are uncertain if there is any difference between groups for: birthweight, gestational age at birth, preterm births, large babies, head circumference and length scores, or need for admission to the neonatal intensive care unit. The number of babies with high levels of bilirubin was reduced with probiotics. No adverse events were reported by the trials. What does this mean? Based on the clinical trials available, the evidence is limited to support the use of probiotics as treatment for women with GDM to improve pregnancy outcomes for mothers and their babies. Larger well‐designed randomised controlled trials are needed to assess the effects of probiotics on management of glucose levels and when available, they can be included in the update of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Okesene-Gafa, KAM, Moore, AE, Jordan, V, McCowan, L, Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD012970.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.790Z" }, { "id": "62881485-3958-4abd-a381-83aebca30ffd", "pmid": "", "title": "Interventions for fatigue in people with kidney failure requiring dialysis", "imported": false, "abstract": "Abstract - Background Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD). Objectives We aimed to evaluate the effects of pharmacological and non‐pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Studies evaluating pharmacological and non‐pharmacological interventions affecting levels of fatigue or fatigue‐related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue‐related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered. Data collection and analysis Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta‐analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Ninety‐four studies involving 8191 randomised participants were eligible. Pharmacological and non‐pharmacological interventions were compared either to placebo or control, or to another pharmacological or non‐pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis‐Related Fatigue scale score): SMD ‐1.18, 95% CI ‐2.04 to ‐0.31; I 2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD ‐1.23, 95% CI ‐1.96 to ‐0.50; I 2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD ‐1.06, 95% CI ‐1.47, ‐0.65; I 2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I 2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD ‐0.64, 95% CI ‐1.03 to ‐0.25; I 2 = 75%) in HD. A wide range of heterogenous interventions and fatigue‐related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non‐pharmacological interventions on fatigue or fatigue‐related outcomes, including non‐physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive‐behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta‐blockers, anabolic steroids, glucose‐enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non‐pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported. Authors' conclusions Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non‐pharmacological interventions had uncertain effects on fatigue or fatigue‐related outcomes in people receiving dialysis. Future adequately powered, high‐quality studies are likely to change the estimated effects of interventions for fatigue and fatigue‐related outcomes in people receiving dialysis. Plain language summary Are interventions for fatigue effective among people with kidney failure requiring dialysis? What is the issue? Fatigue is a frequent and debilitating symptom that can limit life participation in people receiving dialysis. Fatigue is linked to impaired quality of life, cardiovascular disease, death and depression in people on dialysis. Several potential interventions, including drugs or other non‐pharmacological treatments (e.g. exercise, diet, massage, aromatherapy, acupressure), have been evaluated for their effect on fatigue in people on dialysis. What did we do? We evaluated whether drugs or other non‐pharmacological interventions are beneficial for adults and children receiving haemodialysis or peritoneal dialysis to manage fatigue. We evaluated all clinical studies available and summarised the results. We evaluated how certain we could be about the evidence related to interventions for fatigue using a system called \"GRADE\". What did we find? Ninety‐four studies involving 8191 randomised participants were available. Patients in the studies were given a drug, non‐pharmacological intervention, standard care or a sugar pill (placebo). The treatment they received was decided by random chance. The studies were generally short‐term (over a few months). There were no studies in children. Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. Drugs or other non‐pharmacological interventions have uncertain effects on fatigue in people on dialysis. Conclusions Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. It remains uncertain whether drugs or other non‐pharmacological interventions have any impact on fatigue in people on dialysis when compared to a sugar pill, standard care or other treatments for fatigue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Natale, P; Ju, A; Strippoli, GFM; Craig, JC; Saglimbene, VM; Unruh, ML; Stallone, G; Jaure, A", "articleTypes": [], "doi": "10.1002/14651858.CD013074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "629f46cd-ece3-47e3-a58e-d1dd33ad1b12", "pmid": "", "title": "Dietary advice with or without oral nutritional supplements for disease‐related malnutrition in adults", "imported": false, "abstract": "Abstract - Background Disease‐related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social‐care costs. Dietary advice (DA) encouraging consumption of energy‐ and nutrient‐rich foods rather than oral nutritional supplements (ONS) may be an initial treatment. Objectives To examine evidence that DA with/without ONS in adults with disease‐related malnutrition improves survival, weight, anthropometry and quality of life (QoL). Search methods We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021. Selection criteria Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease‐related malnutrition in any healthcare setting compared with no advice, ONS or DA alone. Data collection and analysis Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence. Main results We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity. Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years. DA versus no advice ‐ 24 RCTs (3523 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three‐month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI ‐0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat‐free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS ‐ 12 RCTs (852 participants) All outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD ‐0.14 kg (95% CI ‐2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS ‐ 22 RCTs (1286 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD ‐1.07 (95% CI ‐4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS ‐ 31 RCTs (3308 participants) Evidence was moderate‐ to low‐certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD ‐0.12 (95% CI ‐2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS ‐ 13 RCTs (1315 participants) Evidence was low‐ to very low‐certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD ‐1.81 (95% CI ‐3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI ‐0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point. Authors' conclusions We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow‐up required for benefits to emerge were inconsistent for all other outcomes. There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient‐centred and healthcare outcomes are needed to address the questions in this review. Plain language summary Advice on diet for adults with malnutrition that is the result of disease Review question Can dietary advice with or without oral nutritional supplements (ONS) improve disease‐related malnutrition in adults? Background Ill people often have a poor appetite or feel sick because of medicines or other treatments and eat less than usual. Eating less over a longer time can cause weight loss, malnutrition, more health problems and death. Healthcare professionals may offer advice about dietary changes to help people to re‐establish good eating habits. They might recommend high‐protein and high‐energy foods so that these people can gain weight and improve their nutrition and general health. It is common for sick people to be offered ONS with or without advice about changing their food intake. To find the best answer to our review question, we looked for studies that compared five different treatment options: dietary advice compared with no advice; dietary advice compared with ONS; dietary advice plus ONS compared with dietary advice; dietary advice plus ONS if appropriate compared with no dietary advice; and dietary advice plus ONS compared with no dietary advice and no ONS. To make these comparisons fair, we looked for randomised controlled trials (RCTs), where the people taking part had an equal chance (like the flip of a coin) of being in either group that was being compared. Search date The evidence is current to: 01 March 2021. Study characteristics We found 94 studies (with a total of 10,284 people) that we could include in our review. Although older people have a higher risk of malnutrition, the people in these studies ranged from 17 to over 80 years of age and they were living either at home, in the community, or in hospital. They had a wide range of health conditions, including cancer, dementia and kidney disease. The studies reported on the participants for the length of their hospital stay or in some people in the community for up to six and a half years. Key results There is no evidence that any of the treatments affected how long many of the people in the studies lived. They did report some positive changes in energy intake (measured in calories), protein intake, weight, muscle bulk and quality of life. There were some reductions in complications and the length of time spent in hospital. However, there is no clear evidence about which treatment is the most helpful or the time it takes to achieve any benefit. Few studies reported results separately for men and women and so we cannot comment on whether there were any overall differences by sex. No studies recorded information about adverse events (harms) so we cannot offer a summary about possible harms. More research is needed to work out the best ways to help people who are losing weight because of illness in order to improve their clinical outcomes and quality of life. Certainty of the evidence Overall we rated the certainty of the evidence as low for most results, which means that we cannot be confident about the findings we report. There were several reasons for this. Some of the treatment comparisons that we looked at had only a few studies and some of those had small numbers of participants. There were problems with the design of some studies that may have affected the results. Some people knew which treatment they were receiving. We think this may influence the way that they reported some changes, e.g. their energy and protein intake, body weight and quality of life. We think that the way the decision about which group a person went into at the start of the study may have affected the results for some outcomes, e.g. change in weight, change in muscle bulk and mortality. We needed to see particular results to help us understand whether adults living with disease‐related malnutrition can improve their survival, weight and general quality of life if they receive advice about diet with or without ONS. None of the studies reported all of the results that we needed to do this. We were not able to estimate whether participants gain any benefits from the treatments, such as shortening the length of hospital stay, lowering the risk of readmission to hospital or developing complications. The low certainty of evidence, with no evidence in many areas, means we cannot make statements about any benefits and the possible disadvantages of these treatments despite the fact they are being used extensively in clinical practice. We recommend that future studies should be designed to measure these important patient‐centred and healthcare outcomes as well as any potential harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Baldwin, C, de van der Schueren, MAE, Kruizenga, HM, Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD002008.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.799Z" }, { "id": "629ffb15-f854-467e-a443-52ab0c636ebc", "pmid": "", "title": "Folic acid for fragile X syndrome", "imported": false, "abstract": "Abstract - Background It has been argued that individuals with fragile X syndrome could have low folate levels in their bodies and that supplementing their dietary intake might remediate the adverse developmental and behavioural effects of the condition. Objectives To review the efficacy and safety of folic acid in the treatment of people with fragile X syndrome. Search methods We searched four databases in November 2010: CENTRAL, PubMed, EMBASE and PsycINFO. Selection criteria Randomised controlled trials. Data collection and analysis Two review authors independently extracted data and assessed risk of bias using the Cochrane 'Risk of bias' tool. Main results We included five trials, which were published between 1986 and 1992. Overall, they included 67 patients, all male, with ages ranging from one to 54 years. Intellectual disability in participants varied from borderline to severe and some studies included patients with an additional diagnosis of autism or autistic behaviour. Four of the studies were placebo‐controlled cross‐over trials and one study was a parallel design. The duration of follow‐up ranged from two months to 12 months and the period on folic acid or placebo ranged from two to eight months. Doses of folic acid ranged from 10 mg to 250 mg per day, 10 mg per day being the most common. Most of the younger patients involved were also taking part in special education programmes (usually involving language and occupational therapy). We were not able to perform meta‐analysis to combine results but none of the individual studies found evidence of clinical benefit with the use of folic acid medication in fragile X syndrome patients on any of the areas of interest, either psychological and learning capabilities or behaviour and social performance, as measured with standardised tools. Separate analysis of evidence for patients of different age groups, i.e. prepubertal children and postpubertal young people, found some statistically significant results, but did not show clear evidence of benefit for either group. Adverse effects of folic acid treatment were rare, not serious and transient. Studies were generally poorly reported and we classified only one study as being at low risk of bias. Authors' conclusions The quality of available evidence is low and not suitable for drawing conclusions about the effect of folic acid on fragile X syndrome patients. It consists of few studies with small samples of patients, all of them male, with little statistical power to detect anything other than huge effects. Plain language summary Folic acid for fragile X syndrome People with fragile X syndrome (or FXS) have intellectual limitations that can range from mild to severe. Fragile X syndrome is considered the most common form of inherited intellectual disability and it has been estimated that it affects approximately 1 in 4000 males and 1 in 8000 females. Folate is particularly important during the early development of the brain and in later life is involved in methylation processes that are essential for the maintenance of normal brain function. It was observed that cells from patients with fragile X syndrome cultured in solutions deficient in folic acid revealed a fragile site at the X chromosome; consequently it was thought that individuals with fragile X syndrome had low folate levels in their bodies, which may be due to insufficient dietary intake, inefficient absorption or impaired metabolic utilisation. It was argued that supplementing their dietary intake might help improve the adverse developmental and behavioural effects of the condition. This review asks whether folic acid helps improve symptoms in people with fragile X syndrome and whether it has any side effects. We found five randomised controlled trials, all of which were published between 1986 and 1992. These studies included 69 people, all male. One of the studies compared a folic acid group with a control group; the other four used a cross‐over design (i.e. participants received first one treatment and then the other). The quality of reporting of the trials was generally poor, particularly the methods used, which made it difficult to assess the risk of bias in the studies. The results of the few published studies did not find significant differences in the effects of folic acid or placebo on psychological or learning capabilities, behaviour or social performance, as measured by standardised tools. There is therefore no evidence to support the recommendation of supplementing dietary intake with folic acid medication for people with fragile X syndrome. However, due to the number and quality of the studies, it is not possible to conclude with any certainty that folic acid does not help. Given that intellectual, behavioural, emotional and/or learning performance in people with fragile X syndrome are strongly influenced by different social factors, future studies should also pay attention to the evaluation of non‐pharmacological interventions, such as modifications in the home environment, tailored behavioural interventions and classroom environments, or language and occupational therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Rueda, JR, Ballesteros, J, Guillen, V, Tejada, MI, Solà, I", "articleTypes": [], "doi": "10.1002/14651858.CD008476.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.100Z" }, { "id": "62a0eb05-fc44-41be-95db-1839eeab8b5b", "pmid": "", "title": "Brexpiprazole versus placebo or other antidepressive agents for treating depression", "imported": false, "abstract": "Abstract - Background Brexpiprazole is the newest antipsychotic drug approved as an adjunctive for treatment‐resistant depression. This systematic review provides comprehensive, high‐quality evidence for the effects of brexpiprazole in major depressive disorder (MDD) based on existing and emerging randomised controlled trials (RCTs). Objectives To evaluate the benefits and harms of brexpiprazole as monotherapy or adjunct treatment in the acute and longer‐term treatment of MDD compared to placebo or other antidepressive agents. Search methods We used standard, extensive Cochrane search methods. The latest search date was November 2021. Selection criteria We included RCTs in people with a history of non‐response to one or more antidepressant monotherapies comparing brexpiprazole as monotherapy or adjunct treatment with placebo or other antidepressive agents. Data collection and analysis We used standard Cochrane methods. Primary outcomes were 1. response to treatment, measured as number of participants who achieved 50% or more reduction of the score on a validated scale for depression, 2. dropouts due to any reason, and 3. dropouts due to adverse effects, all measured at eight weeks (acute treatment). Our secondary outcomes were 4. number of participants who responded to treatment after two and 18 weeks, number of participants who achieved remission after eight weeks, 5. total number of participants with any adverse events, 6. social functioning or adjustment, and 7. health‐related quality of life. We used GRADE to assess certainty of evidence for each outcome. Main results We retrieved nine studies with 3424 participants with treatment‐resistant depression, defined as lack of response to at least two trials of antidepressant monotherapy. The age of participants was 18 to 65 years in seven studies, 18 to 75 years in one study, and older than 65 years in one study. Inclusion criteria for all studies required a diagnosis of MDD with a current major depressive episode per Diagnostic and Statistical Manual of Mental Disorders Text Revision Fourth Edition criteria and additional criteria on minimal scores on Montgomery–Åsberg Depression Rating Scale (MADRS) and Hamilton Depression Rating Scale which varied across studies. Eight studies compared brexpiprazole as adjunctive treatment to an antidepressant versus placebo as adjunctive treatment to an antidepressant. One study added brexpiprazole or placebo to a combination of antidepressant and ketamine. Four studies used fixed dosages and five studies used flexible dosages of brexpiprazole. The manufacturer sponsored eight studies and one study was independently funded. Brexpiprazole was superior in achieving response at eight weeks (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.23 to 1.75; 8 studies, 3409 participants; high‐certainty evidence). More participants randomised to brexpiprazole dropped out due to any cause at eight weeks (OR 1.37, 95% CI 1.02 to 1.83; 7 studies, 2523 participants; high‐certainty evidence) or due to adverse effects (OR 2.88, 95% CI 1.37 to 6.05; 6 studies, 2472 participants; high‐certainty evidence). Brexpiprazole was superior to placebo when added to an antidepressant for achieving remission at eight weeks (OR 1.46, 95% CI 1.19 to 1.79; 7 studies, 3358 participants; high‐certainty evidence). When response was defined based on a change in the score on MADRS, brexpiprazole also demonstrated better efficacy than placebo (mean difference (MD) –1.39, 95% CI –1.96 to –0.82; 8 studies, 3263 participants; high‐certainty evidence). Compared to placebo, add‐on brexpiprazole is probably more likely to result in akathisia (OR 2.95, 95% CI 2.06 to 4.21; 7 studies, 3358 participants; moderate‐certainty evidence) and weight gain (OR 3.14, 95% CI 2.19 to 4.49; 9 studies, 3424 participants; moderate‐certainty evidence). The risk of bias varied between low and unclear for most studies. Only one study was at high risk of selective reporting bias and other bias; however, this study had a small sample size and its impact on overall risk of bias was not considered significant. The certainty of the evidence on five of the main outcomes (response to treatment, measured as number of participants who achieved response and change in depressive symptoms, remission, dropouts due to any cause, dropouts due to adverse effects) was high. The certainty of evidence for akathisia and weight gain was downgraded one level to moderate due to indirectness. Authors' conclusions Our review supports the superior efficacy of add‐on brexpiprazole in comparison to placebo in adults with treatment‐resistant depression for the short‐term and acute treatment of depression. Our findings were limited by the small number of studies and the moderate‐certainty evidence for the most common adverse effects (akathisia and weight gain). There was insufficient evidence for the effects of brexpiprazole for depression in older people or children. In addition, we found no studies that compared brexpiprazole to other antidepressants or where brexpiprazole was added after lack of response to only one antidepressant. We also lacked sufficient data to establish the long‐term efficacy of brexpiprazole as adjunctive treatment. Active comparators, long‐term studies in different age groups and cost‐effect analyses are needed to more precisely establish the clinical role of brexpiprazole in the treatment of MDD. Plain language summary What are the benefits and harms of brexpiprazole, a new antipsychotic medication, for the treatment of depression when compared to dummy tablets or antidepressants? Key messages – Brexpiprazole added to an antidepressant is better at reducing the symptoms of depression than placebo (dummy tablet) added to an antidepressant. – Brexpiprazole might be more commonly associated with weight gain and akathisia (a feeling of restlessness that causes a compelling need to move all the time). What is depression? Depression is a common mental health condition which leads to low mood, inability to experience pleasure, sleep disruption, weight loss, fatigue or low energy, slower speech and movements, feeling worthless or excessively guilty, being unable to concentrate and having thoughts of committing suicide. To be diagnosed with depression, a person should experience five or more of these symptoms, including low mood or loss of sense of pleasure for at least two weeks. How is the condition treated? Unless the symptoms of depression are mild, the first option for treatment is an antidepressant medication, but antidepressants only help in half of cases when prescribed for the first time. When an antidepressant is not enough to treat depression, one available option is to add another medication to help the effects of the antidepressant. Other options include changing the antidepressant to another antidepressant, talking therapy or stimulation of the brain through electrical pulses. Brexpiprazole is a new medication which can be added to an antidepressant that has not worked by itself. Brexpiprazole can be prescribed in doses from 0.5 mg to 3 mg for the treatment of depression. It has also been approved for the treatment of schizophrenia. What did we want to find out? We wanted to examine the effects of brexpiprazole in the treatment of depression when prescribed by itself or when added to another antidepressant and how its effects compare to the effects of antidepressants or placebo. To do so we explored several effects. First, we looked into how well brexpiprazole decreased the symptoms of depression. Second, we explored how many participants gave up taking part in the studies for any reason. Third, we investigated how many stopped participating because of the unwanted effects they experienced. Fourth, we explored what unwanted effects emerged with the use of brexpiprazole. We also wanted to know how brexpiprazole affected the quality of life of the participants and how it affected the way they functioned in their everyday lives. What did we do? We searched scientific databases for studies that reported the effects of brexpiprazole versus placebo or antidepressants for depression. We included only studies in which the participants were assigned randomly to one or the other treatment. Neither them nor the team that was evaluating the effects of the treatment knew what was prescribed and this helped to objectively evaluate the results without the knowledge of what was prescribed impacting on the outcome. We compared and summarised the results and evaluated how confident we were that the results of the studies represented the real effects of the medication. We based our confidence on different factors such as the size of the effects, the methods used, and what and how the results were reported. What did we find and what were the limitations of our findings? We found nine studies, which included 3424 participants; two‐thirds of them were women and one‐third were men. We only found studies in which brexpiprazole was added after the participants had tried treatment with two or more antidepressants on their own. We have a high level of confidence that brexpiprazole added to an antidepressant reduced the symptoms of depression more after eight weeks of treatment than placebo added to an antidepressant. Brexpiprazole was also more likely to lead to no symptoms of depression than placebo when either of them was added to an antidepressant. We are moderately confident that brexpiprazole caused weight gain or subjective feelings of restlessness more often than placebo. We are less confident about the results around these unwanted effects as we could not find information about how they were measured and whether all studies used the same methods to measure them. What did we fail to find? We found no studies that explored how brexpiprazole would work for children or older people who have depression. We wanted to find how brexpiprazole would work when given for depression for longer periods of time, such as 18 to 24 weeks, but we found only one study and its results were not enough to draw a conclusion. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 1 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ralovska, S; Koychev, I; Marinov, P; Furukawa, TA; Mulsant, B; Cipriani, A", "articleTypes": [], "doi": "10.1002/14651858.CD013866.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "62b6c23e-d866-4210-aa2e-94b90b45cde5", "pmid": "", "title": "Antibiotics for induction and maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Several antibiotics have been evaluated in Crohn's disease (CD), however randomised controlled trials (RCTs) have produced conflicting results. Objectives To assess the efficacy and safety of antibiotics for induction and maintenance of remission in CD. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and Clinicaltrials.gov database from inception to 28 February 2018. We also searched reference lists and conference proceedings. Selection criteria RCTs comparing antibiotics to placebo or an active comparator in adult (> 15 years) CD patients were considered for inclusion. Data collection and analysis Two authors screened search results and extracted data. Bias was evaluated using the Cochrane risk of bias tool. The primary outcomes were failure to achieve clinical remission and relapse. Secondary outcomes included clinical response, endoscopic response, endoscopic remission, endoscopic relapse, histologic response, histologic remission, adverse events (AEs), serious AEs, withdrawal due to AEs and quality of life. Remission is commonly defined as a Crohn's disease activity index (CDAI) of < 150. Clinical response is commonly defined as a decrease in CDAI from baseline of 70 or 100 points. Relapse is defined as a CDAI > 150. For studies that enrolled participants with fistulizing CD, response was defined as a 50% reduction in draining fistulas. Remission was defined as complete closure of fistulas. We calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for dichotomous outcomes. We calculated the mean difference (MD) and corresponding 95% CI for continuous outcomes. GRADE was used to assess the certainty of the evidence. Main results Thirteen RCTs (N = 1303 participants) were eligible. Two trials were rated as high risk of bias (no blinding). Seven trials were rated as unclear risk of bias and four trials were rated as low risk of bias. Comparisons included ciprofloxacin (500 mg twice daily) versus placebo, rifaximin (800 to 2400 mg daily) versus placebo, metronidazole (400 mg to 500 mg twice daily) versus placebo, clarithromycin (1 g/day) versus placebo, cotrimoxazole (960 mg twice daily) versus placebo, ciprofloxacin (500 mg twice daily) and metronidazole (250 mg four time daily) versus methylprednisolone (0.7 to 1 mg/kg daily), ciprofloxacin (500 mg daily), metronidazole (500 mg daily) and budesonide (9 mg daily) versus placebo with budesonide (9 mg daily), ciprofloxacin (500 mg twice daily) versus mesalazine (2 g twice daily), ciprofloxacin (500 mg twice daily) with adalimumab versus placebo with adalimumab, ciprofloxacin (500 mg twice daily) with infliximab versus placebo with infliximab, clarithromycin (750 mg daily) and antimycobacterial versus placebo, and metronidazole (400 mg twice daily) and cotrimoxazole (960 mg twice daily) versus placebo. We pooled all antibiotics as a class versus placebo and antibiotics with anti‐tumour necrosis factor (anti‐TNF) versus placebo with anti‐TNF. The effect of individual antibiotics on CD was generally uncertain due to imprecision. When we pooled antibiotics as a class, 55% (289/524) of antibiotic participants failed to achieve remission at 6 to 10 weeks compared with 64% (149/231) of placebo participants (RR 0.86, 95% CI 0.76 to 0.98; 7 studies; high certainty evidence). At 10 to 14 weeks, 41% (174/428) of antibiotic participants failed to achieve a clinical response compared to 49% (93/189) of placebo participants (RR 0.77, 95% CI 0.64 to 0.93; 5 studies; moderate certainty evidence). The effect of antibiotics on relapse in uncertain. Forty‐five per cent (37/83) of antibiotic participants relapsed at 52 weeks compared to 57% (41/72) of placebo participants (RR 0.87, 95% CI 0.52 to 1.47; 2 studies; low certainty evidence). Relapse of endoscopic remission was not reported in the included studies. Antibiotics do not appear to increase the risk of AEs. Thirty‐eight per cent (214/568) of antibiotic participants had at least one adverse event compared to 45% (128/284) of placebo participants (RR 0.87, 95% CI 0.75 to 1.02; 9 studies; high certainty evidence). The effect of antibiotics on serious AEs and withdrawal due to AEs was uncertain. Two per cent (6/377) of antibiotic participants had at least one adverse event compared to 0.7% (1/143) of placebo participants (RR 1.70, 95% CI 0.29 to 10.01; 3 studies; low certainty evidence). Nine per cent (53/569) of antibiotic participants withdrew due to AEs compared to 12% (36/289) of placebo participants (RR 0.86, 95% CI 0.57 to 1.29; 9 studies; low certainty evidence) is uncertain. Common adverse events in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation and headache, change in taste and paraesthesia When we pooled antibiotics used with anti‐TNF, 21% (10/48) of patients on combination therapy failed to achieve a clinical response(50% closure of fistulas) or remission (closure of fistulas) at week 12 compared with 36% (19/52) of placebo and anti‐TNF participants (RR 0.57, 95% CI 0.29 to 1.10; 2 studies; low certainty evidence). These studies did not assess the effect of antibiotics and anti‐TNF on clinical or endoscopic relapse. Seventy‐seven per cent (37/48) of antibiotics and anti‐TNF participants had an AE compared to 83% (43/52) of anti‐TNF and placebo participants (RR 0.93, 95% CI 0.76 to 1.12; 2 studies, moderate certainty evidence). The effect of antibiotics and anti‐TNF on withdrawal due to AEs is uncertain. Six per cent (3/48) of antibiotics and anti‐TNF participants withdrew due to an AE compared to 8% (4/52) of anti‐TNF and placebo participants (RR 0.82, 95% CI 0.19 to 3.45; 2 studies, low certainty evidence). Common adverse events included nausea, vomiting, upper respiratory tract infections, change in taste, fatigue and headache Authors' conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be modest and may not be clinically meaningful. High quality evidence suggests that there is no increased risk of adverse events with antibiotics compared to placebo. The effect of antibiotics on the risk of serious adverse events is uncertain. The effect of antibiotics on maintenance of remission in CD is uncertain. Thus, no firm conclusions regarding the efficacy and safety of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the efficacy and safety of antibiotics as therapy in CD Plain language summary Antibiotics for the treatment of Crohn's disease What is Crohn's disease? Crohn's disease (CD) is an inflammatory disorder that can affect any segment of the gastrointestinal tract from the mouth to the anus. Common symptoms of CD include fever, diarrhea, abdominal pain and weight loss. CD is characterized by periods of relapse when people experience symptoms and periods of remission when the symptoms stop. What are antibiotics? Antibiotics are medications used to treat bacterial infections. Antibiotics are designed to target specific bacterial populations and have different mechanisms of action to stop a bacterial population from growing or eradicate the bacteria. What is the purpose this study? Antibiotics are commonly used for managing patients with CD because the inflammatory process in the bowel was believed to be triggered by a specific bacterial pathogen. Elimination of this bacterial target would allow the inflammatory process to resolve. However, current clinical guidelines do not recommend use of antibiotic agents to induce or maintain clinical remission in patients with CD because there is no definitive evidence to suggest a benefit to using antibiotics in this way. How was this study performed? A systematic review of current literature was performed to determine whether antibiotic therapy is effective to induce or maintain remission in CD. An electronic search of several databases was performed and studies that met our inclusion criteria were selected for further evaluation. Statistical analyses were performed to determine which specific antibiotics had an overall benefit. What were the results? Several antibiotics, including ciprofloxacin, metronidazole, clarithromycin, rifaximin and cotrimoxazole, have been studied in CD. Most of the included studies were small in size. When we pooled antibiotics as a class, these drugs provided a modest benefit over placebo (i.e. a fake drug such as a sugar pill) for induction of remission and improvement of CD symptoms. For example, remission rates were 45% (253/542) in participants who received antibiotics compared to 36% (82/231) in participants who received placebo. We rated the quality of evidence supporting this outcome as high. Few studies assessed the use of antibiotics for maintenance of remission in CD. The impact of antibiotics on preventing relapse in CD is uncertain. Antibiotics do not appear to increase the risk of side effects when compared to placebo. Common side effects reported in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation, headache, change in taste and paraesthesia (pins and needles in the extremities). Serious side effects were not well reported in the studies and the impact of antibiotics on the risk of serious side effects is uncertain. Conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be very modest. High quality evidence suggests that there is no increased risk of side effects with antibiotics compared to placebo. The effect of antibiotics on the risk of serious side effects is uncertain. The effect of antibiotics on preventing relapse in CD is uncertain. Thus, no firm conclusions regarding the benefits and harms of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the harms and benefits of antibiotic therapy in CD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Townsend, CM; Parker, CE; MacDonald, JK; Nguyen, TM; Jairath, V; Feagan, BG; Khanna, R", "articleTypes": [], "doi": "10.1002/14651858.CD012730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "62d11d6b-7e24-42bd-9cac-e59861a27262", "pmid": "", "title": "Zinc supplementation for improving pregnancy and infant outcome", "imported": false, "abstract": "Abstract - Background It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy, such as prolonged labour, atonic postpartum haemorrhage, pregnancy‐induced hypertension, preterm labour and post‐term pregnancies, although these associations have not yet been established. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Objectives 1. To compare the effects on maternal, fetal, neonatal and infant outcomes in healthy pregnant women receiving zinc supplementation versus no zinc supplementation, or placebo.
2. To assess the above outcomes in a subgroup analysis reviewing studies performed in women who are, or are likely to be, zinc‐deficient. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (3 July 2020), and reference lists of retrieved studies. Selection criteria Randomised trials of zinc supplementation versus no zinc supplementation or placebo administration during pregnancy, earlier than 27 weeks' gestation. We excluded quasi‐randomised controlled trials. We intended to include studies presented only as abstracts, if they provided enough information or, if necessary, by contacting authors to analyse them against our criteria; we did not find any such studies. Data collection and analysis Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information. We assessed the certainty of the evidence using GRADE. Main results For this update, we included 25 randomised controlled trials (RCTs) involving over 18,000 women and their babies. The overall risk of bias was low in half of the studies. The evidence suggests that zinc supplementation may result in little or no difference in reducing preterm births (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.74 to 1.03; 21 studies, 9851 participants; low‐certainty evidence). Further, zinc supplementation may make little or no difference in reducing the risk of stillbirth (RR 1.22, 95% CI 0.80 to 1.88; 7 studies, 3295 participants; low‐certainty evidence), or perinatal deaths (RR 1.10, 95% CI 0.81 to 1.51; 2 studies, 2489 participants; low‐certainty evidence). It is unclear whether zinc supplementation reduces neonatal death, because the certainty of the evidence is very low. Finally, for other birth outcomes, zinc supplementation may make little or no difference to mean birthweight (MD 13.83, 95% CI ‐15.81 to 43.46; 22 studies, 7977 participants; low‐certainty evidence), and probably makes little or no difference in reducing the risk of low birthweight (RR 0.94, 95% CI 0.79 to 1.13; 17 studies, 7399 participants; moderate‐certainty evidence) and small‐for‐gestational age babies when compared to placebo or no zinc supplementation (RR 1.02, 95% CI 0.92 to 1.12; 9 studies, 5330 participants; moderate‐certainty evidence). We did not conduct subgroup analyses, as very few studies used normal zinc populations. Authors' conclusions There is not enough evidence that zinc supplementation during pregnancy results in improvements in maternal or neonatal outcomes. Future research to address ways of improving the overall nutritional status of pregnant women, particularly in low‐income regions, and not looking at zinc in isolation, should be an urgent priority. Plain language summary Zinc supplementation for improving pregnancy and infant outcome What is the issue? In low‐ and middle‐income countries, many women have poor diets and are deficient in key micronutrients that are required for good health. This is especially concerning during pregnancy, when energy and nutrient needs are greater for both the mother and the growing baby. Zinc plays a critical role in normal growth and development. Deficiency in zinc could lead to adverse health outcomes, such as being born too soon or too small. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Why is this important? Although severe zinc deficiency is rare, it is estimated that mild‐to‐moderate deficiency is common in several regions of the world. Studies of human pregnancy and zinc supplementation, including those from low‐ and middle‐income countries, have failed to document a consistent beneficial effect on fetal growth, length of gestation, and early newborn survival. What evidence did we find? We searched for studies in July 2020. This updated review now includes 25 randomised controlled trials, involving over 18,000 women and their babies. We found that zinc supplementation in pregnancy may make little to no difference in reducing the risk of preterm births, stillbirths, or deaths around the time of birth, when compared to no zinc supplementation or placebo. Zinc supplementation may make little or no difference to the birthweight of babies, and probably makes little or no difference to the number of babies born either with a low birthweight or small for their gestational age, when compared with no zinc supplementation, or with giving a placebo. We cannot be sure whether zinc supplementation reduces death in newborns, because the certainty of the evidence is very low. What does this mean? There is not enough evidence that zinc supplementation during pregnancy results in better outcomes for women and their babies. Finding ways to improve women's overall nutritional status, particularly in low‐income areas, will do more to improve the health of mothers and babies than supplementing pregnant women with zinc alone. This should be an urgent research priority for the future.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carducci, B; Keats, EC; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD000230.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "62d5a27e-08b7-4e0b-9cfb-2dc2ca9fc72b", "pmid": "", "title": "Inhaled hyperosmolar agents for bronchiectasis", "imported": false, "abstract": "Abstract - Background Mucus retention in the lungs is a prominent feature of bronchiectasis. The stagnant mucus becomes chronically colonised with bacteria, which elicit a host neutrophilic response. This fails to eliminate the bacteria, and the large concentration of host‐derived protease may contribute to the airway damage. The sensation of retained mucus is itself a cause of suffering, and the failure to maintain airway sterility probably contributes to the frequent respiratory infections experienced by many patients. Hypertonic saline inhalation is known to accelerate tracheobronchial clearance in many conditions, probably by inducing a liquid flux into the airway surface, which alters mucus rheology in a way favourable to mucociliary clearance. Inhaled dry powder mannitol has a similar effect. Such agents are an attractive approach to the problem of mucostasis, and deserve further clinical evaluation. Objectives To determine whether inhaled hyperosmolar substances are effective in the treatment of bronchiectasis. Search methods We searched the Cochrane Airways Group Specialised Register, trials registries, and the reference lists of included studies and review articles. Searches are current up to April 2014. Selection criteria Any randomised controlled trial (RCT) using hyperosmolar inhalation in patients with bronchiectasis not caused by cystic fibrosis. Data collection and analysis Two review authors assessed studies for suitability. We used standard methods recommended by The Cochrane Collaboration. Main results Eleven studies met the inclusion criteria of the review (1021 participants). Five studies on 833 participants compared inhaled mannitol with placebo but poor outcome reporting meant we could pool very little data and most outcomes were reported by only one study. One 12‐month trial on 461 participants provided results for exacerbations and demonstrated an advantage for mannitol in terms of time to first exacerbation (median time to exacerbation 165 versus 124 days for mannitol and placebo respectively (hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.63 to 0.96, P = 0.022) and number of days on antibiotics for bronchiectasis exacerbations was significantly better with mannitol (risk ratio (RR) 0.76, 95%CI 0.58 to 1.00, P = 0.0496). However, exacerbation rate per year was not significantly different between mannitol and placebo (RR 0.92 95% CI 0.78 to 1.08). The quality of this evidence was rated as moderate. There was also an indication, from only three trials, again based on moderate quality evidence, that mannitol improves health‐related quality of life (mean difference (MD) ‐2.05; 95% CI ‐3.69 to ‐0.40). An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo (OR 0.96; 95% CI 0.61 to 1.51). Two additional small trials on 25 participants compared mannitol versus no treatment and the data from these studies were inconclusive. Four studies (combined N = 113) compared hypertonic saline versus isotonic saline. On most outcomes there were conflicting results and the opportunities for the statistical aggregation of data from studies was very limited. It is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Authors' conclusions There is an indication from a single, large, unpublished study that inhaled mannitol increases time to first exacerbation in patients with bronchiectasis. In patients with near normal lung function, spirometry does not change dramatically with mannitol and adverse events are not more frequent than placebo. Further investigation is required in a patient population with impaired lung function. It is not possible to draw firm conclusions regarding the effect of nebulised hypertonic saline due to significant differences in the methodology, patient groups, and findings amongst the limited data available. The data suggest that it is unlikely to have benefit over isotonic saline in patients with milder disease, and hence future studies should test its use in those with more severe disease Plain language summary Inhaled hyperosmolar agents for bronchiectasis Review question We wanted to know if inhaled hyperosmolar agents ‐ treatments which help people cough up sputum ‐ may be helpful for people with bronchiectasis. We only included trials on people who had bronchiectasis and who did not have cystic fibrosis. Therefore we are unable to draw any conclusions for people with cystic fibrosis. Background Bronchiectasis is a lung condition that usually develops after a series of lung problems (such as childhood infections, problems in the lung structure, tuberculosis, and cystic fibrosis). A lot of mucus (phlegm) collects in the lungs, causing discomfort and the need to cough it up. The phlegm also collects bacteria, which can add to breathing difficulties and make people very ill by causing recurring lung infections that are difficult to clear with antibiotics. Breathing in (inhaling) hypertonic saline (salt solutions with a greater salt content than blood) liquids may help clear this mucus, as may the drug mannitol (inhaled in dry powder form). This is because the concentrated salt or sugar (mannitol) draws water into the mucus in the lung and makes it thinner and easier to cough out. Study characteristics We found 11 randomised controlled trials on 1021 participants that compared inhaled hyperosmolar agents versus no mucolytic treatment. Five studies compared inhaled mannitol versus placebo (with a total of 883 participants) and two very small studies (with a total of just 25 participants) compared inhaled mannitol with no treatment. We also found four studies (with a total of 113 participants) that compared hypertonic saline with isotonic (normal) saline. Key results For the comparison between mannitol and placebo only one study (a 12‐month trial with 461 participants) provided information on the number of people who had an exacerbation (or flare up) over the course of a year. This study showed that people who were treated with mannitol had 8% fewer exacerbations on average compared with placebo. Overall, we felt the quality of this evidence was moderate and new trials would be likely to change either how effective we think the treatment is or how confident we are about it. Three trials assessed the effect of mannitol on health‐related quality of life, and again the quality of the evidence was rated as moderate. An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo The trials comparing hypertonic saline with isotonic saline had conflicting results for most of the outcomes of interest. Because we were unable to combine the data, it is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Our analysis of adverse events between hypertonic saline versus isotonic saline showed no significant difference however this was based on a single study and the quality of the evidence was moderate. Quality of the evidence Details of how the patients in the trials were allocated to receive mannitol or not was clearly described in only one of the studies, and similarly only one of the hypertonic saline versus isotonic saline studies provided this information. The general lack of information on this point was considered carefully in the review in relation to our level of uncertainty in interpreting the results. Taking this into account, the quality of evidence was generally regarded as moderate both for the mannitol and hypertonic saline studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hart, A, Sugumar, K, Milan, SJ, Fowler, SJ, Crossingham, I", "articleTypes": [], "doi": "10.1002/14651858.CD002996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.769Z" }, { "id": "62db94a6-cee3-4bd9-80c2-ffd5f843e61a", "pmid": "", "title": "Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery", "imported": false, "abstract": "Abstract - Background In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete. Objectives To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Date of the last search: 20 November 2014. Selection criteria Randomised and quasi‐randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention. Data collection and analysis Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta‐analyses were performed on available and relevant data. Main results Of the 16 identified trials, four (112 participants) were eligible for inclusion. Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon‐aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post‐operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re‐intervention was not reported by either trial. Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re‐intervention). In one trial a high‐dose rFVIIa regimen (90 μg/kg) was compared with a low‐dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety. Authors' conclusions There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well‐designed randomised controlled trials would be needed, in particular to address the cost‐effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies. Plain language summary Preventing bleeding in people with congenital bleeding disorders during and after surgery In haemophilia and other congenital bleeding disorders blood does not clot properly, which can cause excessive bleeding. This is particularly relevant during surgery, when the risk of bleeding depends on the type and severity of the clotting disorder and on the type of surgery. Therefore, during and after surgery, these individuals should receive treatment to improve the ability of their blood to clot and so prevent bleeding. Clotting factor concentrates (when available and appropriate in those individuals missing specific clotting proteins) or other non‐specific drugs for clotting, or a combination of both, are administered. It is not known what is the optimal dose or duration or method of administration of these treatments in these circumstances. We searched for randomised controlled trials comparing the efficacy (mortality, blood loss, need for re‐intervention, subjective assessment of efficacy, duration and dose of therapy) and the safety of any type of treatment given to people with congenital bleeding disorders during any type of surgery. We found four trials to be included in this review. Two trials evaluated 59 people with haemophilia A or B receiving antifibrinolytic drugs (agents that reduce the breakdown of clots) or placebo in addition to the initial standard treatment before dental extractions. The remaining two trials evaluated 53 people with haemophilia A or B and inhibitors (antibodies that act against the factor concentrate therapy) receiving an different clotting concentrate, recombinant activated factor VII, both during and after surgery. These two trials evaluated different treatment options: high‐dose compared with low‐dose and a single large (bolus) infusion compared with continuous infusion. The trials included in this review provide some information in two specific situations in people with congenital bleeding disorders undergoing surgery. However, on the whole, there is not enough evidence from trials to define the best treatments for the various types of disease and types of surgery. Further trials would be useful to improve our knowledge but are difficult to carry out and currently do not appear to be a clinical priority. Indeed, both major and minor surgery are safely performed in clinical practice in these individuals based on local experience and data from uncontrolled studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Coppola, A, Windyga, J, Tufano, A, Yeung, C, Di Minno, MND", "articleTypes": [], "doi": "10.1002/14651858.CD009961.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.112Z" }, { "id": "62f61315-3605-40cd-976d-a9a7b3c325b2", "pmid": "", "title": "Sodium channel blockers for cystic fibrosis", "imported": false, "abstract": "Abstract - Background People with cystic fibrosis (CF) have increased transport of the salt, sodium across their airway lining. Over‐absorption of sodium results in the dehydration of the liquid that lines the airway surface and (along with defective chloride secretion) is a primary defect in people with CF. Objectives To determine whether the topical administration of drugs that block sodium transport improves the respiratory condition of people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We contacted principal investigators known to work in the field, previous authors and pharmaceutical companies who manufacture ion transport agents for unpublished or follow‐up data. Most recent search of the Group's register: 19 December 2013. Selection criteria Published or unpublished randomised controlled trials (RCTs) or quasi‐randomised controlled trials of sodium channel blockers compared to placebo or another sodium channel blocker or the same sodium channel blocker at a different dosing regimen. Data collection and analysis Two authors independently extracted data. Meta‐analysis was limited due to differing study designs. Main results Five RCTs, with a total of 226 participants, examining the topical administration of the short‐acting sodium channel blocker, amiloride, compared to placebo were identified as eligible for inclusion in the review. In three studies over six months, there was a significant difference found in the difference in relative change in FVC in favour of placebo (weighted mean difference 1.51% (95% confidence interval ‐2.77 to ‐0.25), although heterogeneity was evident. A two‐week study demonstrated that hypertonic saline with amiloride pre‐treatment did not result in a significant improvement in respiratory function or mucus clearance, in contrast to pre‐treatment with placebo. There were no significant differences identified in other clinically relevant outcomes. Authors' conclusions We found no evidence that the topical administration of a short‐acting sodium channel blocker improves respiratory condition in people with cystic fibrosis and some limited evidence of deterioration in lung function. Plain language summary Drugs to control the movement of salt in the lungs of people with cystic fibrosis Usually salt is absorbed from liquid on the surface of the lungs to stop fluid building up there. In cystic fibrosis too much salt is absorbed and there is little liquid left on the airway surfaces. As a result people with cystic fibrosis have problems clearing their lungs of sticky secretions. Thus the lungs are left open to infection. Drugs applied directly to the lungs may prevent too much salt being absorbed. This may lead to better clearance of mucus and less lung infection and damage. The review includes five studies with a total of 226 participants. All studies looked at short‐acting drugs applied directly to the lungs compared to placebo. When the results from three studies over six months were combined, the placebo group showed a slower rate of decline in forced vital capacity than the treatment group. However, each of these differed in their results. A further study showed that people receiving a sodium channel blocker before receiving hypertonic saline did not achieve better lung function or mucus clearance than those receiving placebo before hypertonic saline. We found no evidence that short‐acting sodium channel blockers administered directly to the lungs improve respiratory status in people with cystic fibrosis. There was even some limited evidence of a decline in lung function. Trials of long‐acting sodium channel blockers are ongoing.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Burrows, EF; Southern, KW; Noone, PG", "articleTypes": [], "doi": "10.1002/14651858.CD005087.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "630d47c5-f47d-43cd-9b11-cadd755da6de", "pmid": "", "title": "Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Ethnic minority groups in upper‐middle‐income and high‐income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population. Objectives To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Search methods A systematic literature search was performed of the following databases: The Cochrane Library , MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well. Selection criteria We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper‐middle‐income or high‐income countries. Data collection and analysis Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification. Main results A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta‐analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education. Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) ‐0.4% (95% confidence interval (CI) ‐0.5 to ‐0.2); 14 trials; 1442 participants; high‐quality evidence) and at six months (MD ‐0.5% (95% CI ‐0.7 to ‐0.4); 14 trials; 1972 participants; high‐quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD ‐0.2% (95% CI ‐0.3 to ‐0.04); 9 trials; 1936 participants) and at 24 months (MD ‐0.3% (95% CI ‐0.6 to ‐0.1); 4 trials; 2268 participants; moderate‐quality evidence) post intervention. Neutral effects on health‐related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies — the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI ‐40 to ‐8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low‐density lipoprotein (LDL) cholesterol or high‐density lipoprotein (HDL) cholesterol were reported at any follow‐up point. Other outcome measures (blood pressure, body mass index, self‐efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient. Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self‐reported via questionnaires, leading to high bias in subjective outcome assessment. Authors' conclusions Culturally appropriate health education has short‐ to medium‐term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long‐term trials, and so clinically important long‐term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long‐term, standardised, multi‐centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium‐term effects could lead to clinically important health outcomes, if sustained. Plain language summary Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus Review question Does culturally appropriate diabetes health education lead to better outcomes than 'usual care' for people in ethnic minority groups with type 2 diabetes? Background In upper‐middle‐income and high‐income countries, minority ethnic groups often have a higher prevalence of type 2 diabetes mellitus than is seen in the local population. They also tend to come from lower socioeconomic backgrounds, with attendant difficulties in accessing good‐quality health care. In some cases, cultural and communication barriers increase the problems that minority ethnic communities experience when attempting to access good‐quality diabetes health education, which is vital for those who wish to understand diabetes and use available services to gain empowerment and bring about behaviour change toward a healthier lifestyle. In this review, 'culturally appropriate' health education is taken to mean any type of health education that has been specifically tailored to the cultural needs of a target minority group with type 2 diabetes mellitus. Study characteristics This updated review found in the world literature 33 randomised controlled trials (RCTs) of culturally appropriate health education on diabetes that met the selection criteria (participants from a defined ethnic minority group living in a upper‐middle‐income or high‐income country, over 16 years of age, diagnosed with type 2 diabetes mellitus and receiving a culturally tailored health education intervention). The median duration of the intervention was six months, and a total of 7453 participants were involved in the studies. Key results Culturally appropriate health education improved blood sugar control among participants, compared with those receiving 'usual' care, at three, six, 12 and 24 months after the intervention was provided. Knowledge about diabetes improved, and participants attained healthier lifestyles. No information was available regarding complications of diabetes and death from any cause, and there was a general lack of reporting of adverse effects in most studies. Neutral effects were observed for health‐related quality of life, blood lipids like cholesterol, blood pressure and weight. The costs of educational programmes were rarely analysed. Compared with the first review, performed in 2008 (11 studies), many more published studies were identified in this review (altogether 33 studies), strengthening the original findings that blood sugar control and knowledge of diabetes are improved when culturally appropriate health education is provided to people in ethnic minority groups diagnosed with diabetes. The effects of this improvement are shown in this update as lasting longer — up to 24 months after health education was provided in some trials. However, additional high‐quality standardised RCTs of longer duration are needed, along with full evaluation of costs. Quality of the evidence Heterogeneity of the studies, in terms of populations studied, type and duration of health education provided, variety of outcomes measured and differences in timing of assessment, limits interpretation of our findings. Also, risk of bias was judged to be high for many outcomes. Currentness of evidence This evidence is up‐to‐date as of September 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Attridge, M, Creamer, J, Ramsden, M, Cannings‐John, R, Hawthorne, K", "articleTypes": [], "doi": "10.1002/14651858.CD006424.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.799Z" }, { "id": "631bf318-106d-46dd-9a23-f3775841dba4", "pmid": "", "title": "Fortification of maize flour with iron for controlling anaemia and iron deficiency in populations", "imported": false, "abstract": "Abstract - Background Approximately 800 million women and children have anaemia, a condition thought to cause almost 9% of the global burden of years lived with disability. Around half this burden could be amenable to interventions that involve the provision of iron. Maize (corn) is one of the world's most important cereal grains and is cultivated across most of the globe. Several programmes around the world have fortified maize flour and other maize‐derived foodstuffs with iron and other vitamins and minerals to combat anaemia and iron deficiency. Objectives To assess the effects of iron fortification of maize flour, corn meal and fortified maize flour products for anaemia and iron status in the general population. Search methods We searched the following international and regional sources in December 2017 and January 2018: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE (R) In Process; Embase; Web of Science (both the Social Science Citation Index and the Science Citation Index); CINAHL Ebsco; POPLINE; AGRICOLA ( agricola.nal.usda.gov ); BIOSIS (ISI); Bibliomap and TRoPHI; IBECS; Scielo; Global Index Medicus ‐ AFRO (includes African Index Medicus); EMRO (includes Index Medicus for the Eastern Mediterranean Region); LILACS; PAHO (Pan American Health Library); WHOLIS (WHO Library); WPRO (includes Western Pacific Region Index Medicus); IMSEAR, Index Medicus for the South‐East Asian Region; IndMED, Indian medical journals; and the Native Health Research Database. We searched clinicaltrials.gov and the International Clinical Trials Registry Platform ( ICTRP ) for any ongoing or planned studies on 17 January 2018 and contacted authors of such studies to obtain further information or eligible data if available. For assistance in identifying ongoing or unpublished studies, we also contacted relevant international organisations and agencies working in food fortification on 9 August 2016. Selection criteria We included cluster‐ or individually randomised controlled trials and observational studies. Interventions included (central/industrial) fortification of maize flour or corn meal with iron alone or with other vitamins and minerals and provided to individuals over 2 years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies and assessed the risk of bias of the included studies. Trial designs with a comparison group were included to assess the effects of interventions. Trial designs without a control or comparison group (uncontrolled before‐and‐after studies) were included for completeness but were not considered in assessments of the overall effectiveness of interventions or used to draw conclusions regarding the effects of interventions in the review. Main results Our search yielded 4529 records. After initial screening of titles and abstracts, we reviewed the full text of 75 studies (80 records). We included 5 studies and excluded 70. All the included studies assessed the effects of providing maize products fortified with iron plus other vitamins and minerals versus unfortified maize flour. No studies compared this intervention to no intervention or looked at the relative effect of flour and products fortified with iron alone (without other vitamins and minerals). Three were randomised trials involving 2610 participants, and two were uncontrolled before‐and‐after studies involving 849 participants. Only three studies contributed data for the meta‐analysis and included children aged 2 to 11.9 years and women. Compared to unfortified maize flour, it is uncertain whether fortifying maize flour or corn meal with iron and other vitamins and minerals has any effect on anaemia (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.58 to 1.40; 2 studies; 1027 participants; very low‐certainty evidence), or on the risk of iron deficiency (RR 0.75, 95% CI 0.49 to 1.15; 2 studies; 1102 participants; very low‐certainty evidence), haemoglobin concentration (mean difference (MD) 1.25 g/L, 95% CI −2.36 to 4.86 g/L; 3 studies; 1144 participants; very low‐certainty evidence) or ferritin concentrations (MD 0.48 µg/L, 95% CI −0.37 to 1.33 µg/L; 1 study; 584 participants; very low‐certainty evidence). None of the studies reported on any adverse effects. We judged the certainty of the evidence to be very low based on GRADE, so we are uncertain whether the results reflect the true effect of the intervention. We downgraded evidence due to high risk of selection bias and unclear risk of performance bias in one of two included studies, high heterogeneity and wide CIs crossing the line of no effect for anaemia prevalence and haemoglobin concentration. Authors' conclusions It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of anaemia or iron deficiency in children aged over 2 years or in adults. Moreover, the evidence is too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population, as the certainty of the evidence is very low. No studies reported on any adverse effects. Public organisations funded three of the five included studies, while the private sector gave grants to universities to perform the other two. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. The reduced number of studies, including only two age groups (children and women of reproductive age), as well as the limited number of comparisons (only one out of the four planned) constitute the main limitations of this review. Plain language summary Fortification of maize flour with iron for preventing anaemia and iron deficiency What is the aim of this review? The aim of this Cochrane Review was to determine the effects of fortifying maize flour, corn meal and fortified‐maize flour products with iron for anaemia and iron status in the general population. We searched for relevant published studies to answer this question and analysed all relevant information. Key messages It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We do not know whether fortifying maize flour with iron reduces anaemia in the general population, as the evidence was very unreliable. No studies reported on any harmful effects. What was studied in the review? Approximately 496 million non‐pregnant women, 32 million pregnant women, and 273 million children were thought to be anaemic as of 2011. Iron deficiency is considered to be the single most prevalent nutrient deficiency worldwide, but at least half this burden is considered responsive to interventions that involve providing people with iron. Fortification means adding vitamins and minerals to foods to increase their nutritional value. In public health, fortifying staple foods is considered one way of reducing micronutrient deficiencies without changing usual and culturally acceptable diets. Maize (corn) is one of the world's most important cereal grains. In sub‐Saharan Africa, some parts of Southeast Asia and Latin America, where iron deficiency is endemic, maize is a dietary staple for more than 200 million people. Fortification of maize flour with iron (and in some cases, other nutrients) is mandatory in Brazil, Costa Rica, El Salvador, Kenya, Mexico, Nigeria, Rwanda, South Africa, Tanzania, Uganda, the USA and Venezuela. What are the main results of the review? We found five relevant studies, but none looked at the effects of maize flour or maize flour products fortified with iron alone. Five studies compared the effects of maize flour or maize‐flour products fortified with iron plus other vitamins and minerals versus unfortified maize flours or maize‐flour products (not containing iron or any other vitamin and minerals). Three of these five studies randomly divided a collective total of 2302 children aged 2 to 12 years and 130 indigenous women into groups receiving fortified versus unfortified maize flour or corn flour. One study was from Kenya and the other two took place in Mexico. The remaining two studies did not provide data to assess the effects of fortification relative to a comparison group. Three of five of the included studies were funded by public organisations and two by funds granted by private sector to universities. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency in the general population. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population. How up‐to‐date is this review? We searched for studies that had been published up to 17 January 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Garcia‐Casal, MN, Peña‐Rosas, JP, De‐Regil, LM, Gwirtz, JA, Pasricha, SR", "articleTypes": [], "doi": "10.1002/14651858.CD010187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.077Z" }, { "id": "632bbbde-9096-4120-b8e2-7a53767552ec", "pmid": "", "title": "Progestin‐only pills for contraception", "imported": false, "abstract": "Abstract - Background The introduction of a new progestin‐only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. Objectives This review examined randomized controlled trials of progestin‐only pills for differences in efficacy, acceptability, and continuation rates. Search methods Through October 2013, we searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, and LILACS for studies of progestin‐only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. Selection criteria We included all randomized controlled trials in any language that included progestin‐only pills for contraception. We incorporated any comparison with a progestin‐only pill; this could include different doses, other progestin‐only pills, combined oral contraceptives, or other contraceptives. Data collection and analysis The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry. We attempted to extract life‐table rates (actuarial or continuous) and used the rate difference as the effect measure. Where life‐table rates were not published, we used the incidence rate ratio (ratio of Pearl rates). Where only the crude number of events was published, we calculated the Peto odds ratio with 95% confidence interval (CI) using a fixed‐effect model. For continuous variables, the mean difference (MD) was computed with 95% CI. Because of disparate exposures, we were not able to combine studies in meta‐analysis. Main results Six trials met the inclusion criteria. We have not found any new studies since the initial review. In the trial comparing the desogestrel versus levonorgestrel progestin‐only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin‐only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low‐dose mifepristone versus a levonorgestrel progestin‐only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin‐only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin‐only and two combined oral contraceptives, the progestin‐only pill containing levonorgestrel 30 μg had higher efficacy than did the pill containing norethisterone 350 μg. An early trial found megestrol acetate inferior to other progestin‐only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. Authors' conclusions Evidence is insufficient to compare progestin‐only pills to each other or to combined oral contraceptives. Plain language summary Progestin‐only pills for contraception Progestin‐only pills, as their name implies, contain just one hormone. The more common birth control pills combine two hormones. How these one‐hormone pills compare to each other or to two‐hormone pills is not clear. Hence, we did this review to compare progestin‐only pills to other similar pills or to combined (two‐hormone) pills. Through October 2013, we did a computer search and literature search to find randomized trials of progestin‐only pills. We found six trials for the initial review. We have not found any more studies since then. Some studies are several decades old and not very relevant to pills available today. A newer pill containing the progestin desogestrel may work better to prevent pregnancy than an older pill with levonorgestrel. The newer pill caused more bleeding problems. Pills with levonorgestrel may be more effective than pills with other progestins that are no longer used. These studies are not adequate to tell how progestin‐only pills compare to each other or to combined (two‐hormone) pills. Larger studies with currently used pills are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grimes, DA, Lopez, LM, O'Brien, PA, Raymond, EG", "articleTypes": [], "doi": "10.1002/14651858.CD007541.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.784Z" }, { "id": "63385806-b5a7-48fe-a908-10c4796ce7e0", "pmid": "", "title": "The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents", "imported": false, "abstract": "Abstract - Background Erythropoiesis‐stimulating agents (ESAs) are commonly used to treat chemotherapy‐induced anemia (CIA). However, about half of patients do not benefit. Objectives To evaluate the benefits and harms related to the use of iron as a supplement to ESA and iron alone compared with ESA alone in the management of CIA. Search methods We searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1 January 2016), MEDLINE (1950 to February 2016), and www.clinicaltrials.gov without using any language limits. Selection criteria All randomized controlled trials (RCTs) comparing 'iron plus ESA' or 'iron alone' versus 'ESA alone' in people with CIA were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included eight RCTs (12 comparisons) comparing ESA plus iron versus ESA alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone in people with CIA. None of the included RCTs reported overall survival. There was a beneficial effect of iron supplementation to ESAs compared with ESAs alone on hematopoietic response (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.09 to 1.26; P < 0.0001; 1712 participants; 11 comparisons; high‐quality evidence). Assuming a baseline risk of 35% to 80% for hematopoietic response without iron supplementation, between seven and 16 patients should be treated to achieve hematopoietic response in one patient. In subgroup analyses, RCTs that used intravenous (IV) iron favored ESAs and iron (RR 1.20 (95% CI 1.10 to 1.31); P < 0.00001; 1321 participants; eight comparisons), whereas we found no evidence for a difference in hematopoietic response in RCTs using oral iron (RR 1.04 (95% CI 0.87 to 1.24); P = 0.68; 391 participants; three comparisons). There was no evidence for a difference between the subgroups of IV and oral iron (P = 0.16). There was no evidence for a difference between the subgroups of types of iron (P = 0.31) and types of ESAs (P = 0.16) for hematopoietic response. The iron supplementation to ESAs might be beneficial as fewer participants treated with iron supplementation required red blood cell (RBC) transfusions compared to the number of participants treated with ESAs alone (RR 0.74 (95% CI 0.60 to 0.92); P = 0.007; 1719 participants; 11 comparisons; moderate‐quality evidence). Assuming a baseline risk of 7% to 40% for RBC transfusion without iron supplementation, between 10 and 57 patients should be treated to avoid RBC transfusion in one patient. We found no evidence for a difference in the median time to hematopoietic response with addition of iron to ESAs (hazard ratio (HR) 0.93 (95% CI 0.67 to 1.28); P = 0.65; 1042 participants; seven comparisons; low‐quality evidence). In subgroup analyses, RCTs in which dextran (HR 0.95 (95% CI 0.36 to 2.52); P = 0.92; 340 participants; three comparisons), sucrose iron (HR 1.15 (95% CI 0.60 to 2.21); P = 0.67; 102 participants; one comparison) and sulfate iron (HR 1.24 (95% CI 0.99 to 1.56); P = 0.06; 55 participants; one comparison) were used showed no evidence for difference between iron supplementation versus ESAs alone compared with RCTs in which gluconate (HR 0.78 (95% CI 0.65 to 0.94); P = 0.01; 464 participants; two comparisons) was used for median time to hematopoietic response (P = 0.02). There was no evidence for a difference between the subgroups of route of iron administration (P = 0.13) and types of ESAs (P = 0.46) for median time to hematopoietic response. Our results indicated that there could be improvement in the hemoglobin (Hb) levels with addition of iron to ESAs (mean difference (MD) 0.48 (95% CI 0.10 to 0.86); P = 0.01; 827 participants; seven comparisons; low‐quality evidence). In RCTs in which IV iron was used there was evidence for a difference (MD 0.84 (95% CI 0.21 to 1.46); P = 0.009; 436 participants; four comparisons) compared with oral iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) for mean change in Hb level (P = 0.03). RCTs in which dextran (MD 1.55 (95% CI 0.62 to 2.47); P = 0.001; 102 participants; two comparisons) was used showed evidence for a difference with iron supplementation versus ESAs alone compared with RCTs in which gluconate (MD 0.54 (95% CI ‐0.15 to 1.22); P = 0.12; 334 participants; two comparisons) and sulfate iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) were used for mean change in Hb level (P = 0.007). RCTs in which epoetin was used showed evidence for a difference with iron supplementation versus ESAs alone (MD 0.77 (95% CI 0.25 to 1.29); P = 0.004; 337 participants; five comparisons) compared with darbepoetin use (MD 0.10 (95% CI ‐0.13 to 0.33); P = 0.38; 490 participants; two comparisons) for mean change in Hb level (P = 0.02). We found no evidence for a difference in quality of life with addition of iron to ESAs (standardized mean difference 0.01 (95% CI ‐0.10 to 0.12); P = 0.88; 1124 participants; three RCTs; high‐quality evidence). We found no evidence for a difference in risk of grade III‐IV thromboembolic events (RR 0.95 (95% CI 0.54 to 1.65); P = 0.85; 783 participants; three RCTs; moderate‐quality evidence). The incidence of treatment‐related mortality (TRM) was 0% (997 participants; four comparisons; high‐quality evidence). Other common adverse events included vomiting, asthenia, and leukopenia, and were similar in both arms. Overall the risk of bias across outcomes was high to low. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown. Our main reasons for downgrading the quality of evidence were inconsistency across the included studies and imprecision of results. Authors' conclusions Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation. Plain language summary The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents Review question: Is iron alone or iron as a supplement to erythropoiesis‐stimulating agents (ESAs) superior to ESAs alone in the management of people diagnosed with chemotherapy‐induced anemia (CIA)? Background: The current treatment of CIA is ESAs, which increase the production of red blood cells (erythropoiesis), and in some cases ESAs and iron. In some cases, strategies such as no therapy or wait and watch with clinical oversight and red blood cell transfusion may be safe and suitable options. We conducted a systematic review to evaluate the benefits and harms of iron in the management of CIA. Search date: The evidence is current to February 2016. Study characteristics: We included eight industry‐funded randomized controlled trials (RCTs) comparing ESAs plus iron versus ESAs alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone. Study funding source: All the included trials were industry funded. Key results: Adding iron to ESAs improves the hematopoietic response in people with CIA. Use of iron with ESAs might reduce the risk of blood transfusions and improve hemoglobin. We found no improvement in quality of life with addition of iron. We found no evidence for a difference in time to hematopoietic response and risk of development of blood clot in veins of people with CIA treated with iron and ESAs compared with ESAs alone. There were zero treatment‐related deaths among 997 participants in the four trials that reported this outcome. Other harms included constipation, vomiting, and diarrhea, and were similar with ESAs and iron compared with ESAs alone. None of the trials reported data on survival. Quality of evidence: The quality of evidence for hematopoietic response was high. The quality of evidence for red blood cell transfusion was moderate, as the pooled estimate had large variation. The quality of evidence for change in hemoglobin and time to hematopoietic response was low, as the pooled estimates had large variation and results were not similar across studies. The quality of evidence for quality of life was high. The quality of evidence for risk of blood clots in veins was moderate due to variation in pooled estimate. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Mhaskar, R, Wao, H, Miladinovic, B, Kumar, A, Djulbegovic, B", "articleTypes": [], "doi": "10.1002/14651858.CD009624.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.095Z" }, { "id": "633afdb4-2f50-40d0-a524-bcc4291e6cbe", "pmid": "", "title": "Interventions for treating people with symptoms of bladder pain syndrome: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide‐ranging treatment options, used alone or in combination, with limited evidence. A network meta‐analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS. Objectives To conduct a network meta‐analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS). Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible. Data collection and analysis We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random‐effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta‐analysis of head‐to‐head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories. Main results We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low‐certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD ‐1.27, 95% CrI ‐3.25 to 0.71; low‐certainty evidence), daytime frequency (MD ‐2.41, 95% CrI ‐6.85 to 2.05; very low‐certainty evidence) or nocturia (MD 0.01, 95% CrI ‐2.53 to 2.50; very low‐certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low‐certainty evidence) or reduced pain (MD 0.42, 95% CrI ‐1.04 to 1.91; low‐certainty evidence), frequency (MD ‐0.37, 95% CrI ‐5.00 to 3.44; very low‐certainty evidence) or nocturia (MD ‐1.20, 95% CrI ‐3.62 to 1.28; very low‐certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD ‐0.33, 95% CrI ‐1.71 to 1.03), frequency (MD ‐0.91, 95% CrI ‐3.24, 1.29) or nocturia (MD ‐0.04, 95% CrI ‐1.35 to 1.27). The certainty of this evidence was always very low. Authors' conclusions We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base. Plain language summary Treatments for people with bladder pain syndrome What is bladder pain syndrome? Bladder pain syndrome (BPS; also called painful bladder syndrome or interstitial cystitis) is a long‐term painful condition that affects the bladder. ‘Syndrome’ refers to a collection of symptoms. In BPS, these symptoms include: intense pain in the pelvis (felt below the bellybutton); sudden strong urges to urinate; needing to urinate more often than usual; and waking up several times during the night to urinate. BPS is more common in women. We do not know what causes it or how to cure it. Symptoms sometimes come and go in phases. BPS can significantly affect lifestyle, work, emotional health and relationships. Treatments for BPS Lifestyle changes are usually tried first, then medicines and supportive therapies. Surgery may be needed as a last resort. Medicines used include pentosan polysulfate sodium – which may help to restore the inner surface of the bladder – anti‐inflammatories, antidepressants and antihistamines. Medicines that block the connection between nerves and muscles can be injected into the bladder muscle to try to relax it (‘neuromuscular blockade’). Supportive therapies and treatments include behavioural therapy, physiotherapy, bladder re‐training, psychological therapy and transcutaneous electrical nerve stimulation (TENS). Review question In this Cochrane Review, we wanted to find out which treatments work best to treat BPS. What did we do? We searched for studies that looked at any type of treatment for BPS. We looked for randomised controlled studies, in which the treatment people receive is randomly decided, because these studies usually give the most reliable evidence about treatments. Search date We included evidence published up to 11 May 2018. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. What we found We found 81 studies involving 4674 people with BPS. The biggest study included 369 people, and the smallest study included 10 people. Most studies lasted around three months; only six studies lasted 12 months or longer. Twenty‐four studies were funded by pharmaceutical companies. We found 65 treatments for BPS, which we grouped into 31 categories based on how the treatments worked. In most studies, a treatment for BPS was compared with a placebo (or dummy) treatment. We compared all treatments with each other using a mathematical method called network meta‐analysis. What are the results of our review? After 12 months, antidepressants or neuromuscular blockade (and some other treatments) may improve symptoms of BPS more than placebo, but we are not certain about this result. We did not find enough evidence to know if pentosan polysulfate sodium improves symptoms. We are uncertain whether 12 months of treatment with antidepressants, neuromuscular blockade or pentosan polysulfate sodium reduced pain (as measured on a scale); the number of times people had to urinate during the day; or the number of times people had to get up to urinate during the night. Our confidence in the results We are uncertain about our results because we did not find enough reliable evidence. Although we obtained results from 81 studies, most of these studies were small and did not include enough people for us to be certain of their results. Some of the studies (30%) were conducted by pharmaceutical companies, and this may have affected how the studies were designed, conducted and reported. Our results may change when results from more, and larger, studies become available. Conclusions We did not find enough reliable evidence about how well medicines, behavioural therapy, physiotherapy and neuromuscular blockade worked to treat all, or any, of the symptoms of BPS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Imamura, M, Scott, NW, Wallace, SA, Ogah, JA, Ford, AA, Dubos, YA, Brazzelli, M", "articleTypes": [], "doi": "10.1002/14651858.CD013325.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.121Z" }, { "id": "63526323-8b52-44c5-ac83-b43240f732b1", "pmid": "", "title": "Vitamin B12 supplementation during pregnancy for maternal and child health outcomes", "imported": false, "abstract": "Abstract - Background Vitamin B 12 deficiency is a major public health problem worldwide, with the highest burden in elderly people, pregnant women, and young children. Due to its role in DNA synthesis and methylation, folate metabolism, and erythropoiesis, vitamin B 12 supplementation during pregnancy may confer longer‐term benefits to maternal and child health outcomes. Objectives To evaluate the benefits and harms of oral vitamin B 12 supplementation during pregnancy on maternal and child health outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov , the World Health Organization International Clinical Trials Registry Platform ( ICTRP ) on 2 June 2023, and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs), quasi‐RCTs, or cluster‐RCTs evaluating the effects of oral vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation during pregnancy. Data collection and analysis We used standard Cochrane methods. Four review authors independently assessed trial eligibility. Two review authors independently extracted data from included studies and conducted checks for accuracy. Three review authors independently assessed the risk of bias of the included studies using the Cochrane RoB 1 tool. We used GRADE to evaluate the certainty of evidence for primary outcomes. Main results The review included five trials with 984 pregnant women. All trials were conducted in low‐ and middle‐income countries, including India, Bangladesh, South Africa, and Croatia. At enrolment, 26% to 51% of pregnant women had vitamin B 12 deficiency (less than 150 pmol/L), and the prevalence of anaemia (haemoglobin less than 11.0 g/dL) ranged from 30% to 46%. The dosage of vitamin B 12 supplementation varied from 5 μg/day to 250 μg/day, with administration beginning at 8 to 28 weeks' gestation through to delivery or three months' postpartum, and the duration of supplementation ranged from 8 to 16 weeks to 32 to 38 weeks. Three trials, involving 609 pregnant women, contributed data for meta‐analyses of the effects of vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation. Maternal anaemia: there may be little to no difference for maternal anaemia by intervention group, but the evidence is very uncertain (70.9% versus 65.0%; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.93 to 1.26; 2 trials, 284 women; very low‐certainty evidence). Maternal vitamin B 12 status: vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain (25.9% versus 67.9%; RR 0.38, 95% CI 0.28 to 0.51; 2 trials, 272 women; very low‐certainty evidence). Women who received vitamin B 12 supplements during pregnancy may have higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (mean difference (MD) 60.89 pmol/L, 95% CI 40.86 to 80.92; 3 trials, 412 women). However, there was substantial heterogeneity (I 2 = 85%). Adverse pregnancy outcomes: the evidence is uncertain about the effect on adverse pregnancy outcomes, including preterm birth (RR 0.97, 95% CI 0.55 to 1.74; 2 trials, 340 women; low‐certainty evidence), and low birthweight (RR 1.50, 95% CI 0.93 to 2.43; 2 trials, 344 women; low‐certainty evidence). Two trials reported data on spontaneous abortion (or miscarriage); however, the trials did not report quantitative data for meta‐analysis and there was no clear definition of spontaneous abortion in the study reports. No trials evaluated the effects of vitamin B 12 supplementation during pregnancy on neural tube defects. Infant vitamin B 12 status: children born to women who received vitamin B 12 supplementation had higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (MD 71.89 pmol/L, 95% CI 20.23 to 123.54; 2 trials, 144 children). Child cognitive outcomes : three ancillary analyses of one trial reported child cognitive outcomes; however, data were not reported in a format that could be included in quantitative meta‐analyses. In one study, maternal vitamin B 12 supplementation did not improve neurodevelopment status (e.g. cognitive, language (receptive and expressive), motor (fine and gross), social‐emotional, or adaptive (conceptual, social, practical) domains) in children compared to placebo (9 months, Bayley Scales of Infant and Toddler Development Third Edition (BSID‐III); 1 trial; low‐certainty evidence) or neurophysiological outcomes (72 months, event‐related potential measures; 1 trial; low‐certainty evidence), though children born to women who received vitamin B 12 supplementation had improved expressive language domain compared to placebo (30 months, BSID‐III; 1 trial; low‐certainty evidence). Authors' conclusions Oral vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency and may improve maternal vitamin B 12 concentrations during pregnancy or postpartum compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain. The effects of vitamin B 12 supplementation on other primary outcomes assessed in this review were not reported, or were not reported in a format for inclusion in quantitative analyses. Vitamin B 12 supplementation during pregnancy may improve maternal and infant vitamin B 12 status, but the potential impact on longer‐term clinical and functional maternal and child health outcomes has not yet been established. Plain language summary Vitamin B 12 supplementation for women during pregnancy Key messages – Women who took vitamin B 12 supplements during pregnancy may have improved vitamin B 12 status during pregnancy or postpartum, including less vitamin B 12 deficiency and higher vitamin B 12 levels, compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. – The effects of taking vitamin B 12 supplements during pregnancy on other health outcomes in pregnant women or their children are not known. Public health implications Vitamin B 12 is an important nutrient that helps keep your body's blood and nerve cells healthy. Vitamin B 12 deficiency is an important public health problem, particularly in low‐ and middle‐income countries, with a high burden amongst pregnant women and children. Lower vitamin B 12 levels in pregnancy have been linked to greater risk of some adverse pregnancy outcomes such as miscarriage, poor growth of the baby in the womb, problems with the baby's brain or spinal cord (called neural tube defects), and lower vitamin B 12 status in infants. Vitamin B 12 supplementation during pregnancy may help improve the health and nutrition of women and their babies. However, this has not been examined in well‐conducted reviews, and vitamin B 12 is not part of supplements recommended by the World Health Organization (WHO; a specialised agency of the United Nations responsible for international public health) for women during pregnancy. What did we want to find out? We wanted to find out if taking vitamin B 12 supplements during pregnancy would improve the health and nutrition of women and their babies. What did we do? We searched for clinical trials that looked at vitamin B 12 supplementation during pregnancy. We compared and summarised the results of the trials and rated our confidence in the information, based on factors such as trial methods and sizes. What did we find? We included five trials with 984 pregnant women. Three trials, including 609 pregnant women, had data included in analyses. Women who took vitamin B 12 supplements during pregnancy had less vitamin B 12 deficiency and higher vitamin B 12 levels compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. There were no differences between groups for maternal anaemia. We could not assess the effects of vitamin B 12 supplementation on other outcomes such as miscarriage, neural tube defects, and child cognition (a child's ability to gain knowledge through thought, understanding, and the senses) due to limited or no availability of results for analysis. What are the limitations of the evidence? The small number of trials and small size of trials were limitations in this review. Not all the trials provided data about the outcomes we were interested in. We are very unsure about the results. How up to date is this evidence? The evidence is up to date as of June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Finkelstein, JL; Fothergill, A; Venkatramanan, S; Layden, AJ; Williams, JL; Crider, KS; Qi, YP", "articleTypes": [], "doi": "10.1002/14651858.CD013823.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "63666bea-d961-40a1-b626-549d202314ac", "pmid": "", "title": "Open versus closed surgical exposure of canine teeth that are displaced in the roof of the mouth", "imported": false, "abstract": "Abstract - Background Palatally displaced canines or PDCs are upper permanent canines, commonly known as 'eye' teeth, that are displaced in the roof of the mouth. This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. PDCs are a frequent dental anomaly, present in 2% to 3% of young people. Management of this problem is both time consuming and expensive. It involves surgical exposure (uncovering) followed by fixed braces for two to three years to bring the canine into alignment within the dental arch. Two techniques for exposing palatal canines are routinely used in the UK: the closed technique and the open technique. The closed technique involves uncovering the canine, attaching an eyelet and gold chain and then suturing the palatal mucosa back over the tooth. The tooth is then moved into position covered by the palatal mucosa. The open technique involves uncovering the canine tooth and removing the overlying palatal tissue to leave it uncovered. The orthodontist can then see the crown of the canine to align it. Objectives To assess the effects of using either an open or closed surgical method to expose canines that have become displaced in the roof of the mouth, in terms of success and other clinical and patient‐reported outcomes. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 24 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (in the Cochrane Library, 2017, Issue 1), MEDLINE Ovid (1946 to 24 February 2017), and Embase Ovid (1980 to 24 February 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised and quasi‐randomised controlled trials assessing young people receiving surgical treatment to correct upper PDCs. There was no restriction on age, presenting malocclusion or type of active orthodontic treatment undertaken. We included unilaterally and bilaterally displaced canines. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias in the included studies. We attempted to contact study authors for missing data or clarification where feasible. We followed statistical guidelines from the Cochrane Handbook for Systematic Reviews of Interventions for data synthesis. Main results We included three studies, involving 146 participants. Two studies were assessed as being at high risk of bias. The main finding of the review was that the two techniques may be equally successful at exposing PDCs (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.93 to 1.06; three studies, 141 participants analysed, low‐quality evidence). One surgical failure was due to detachment of the gold chain (closed group). One study reported on complications following surgery and found two in the closed group: a post‐operative infection requiring antibiotics and pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to pool data for dental aesthetics, patient‐reported pain and discomfort, periodontal health and treatment time; however, individual studies did not find any differences between the surgical techniques (low‐ to very low‐quality evidence). Authors' conclusions Currently, the evidence suggests that neither the open or closed surgical technique for exposing palatally displaced maxillary canine teeth is superior for any of the outcomes included in this review; however, we considered the evidence to be low quality, with two of the three included studies being at high risk of bias. This suggests the need for more high‐quality studies. Three ongoing clinical trials have been identified and it is hoped that these will produce data that can be pooled to increase the degree of certainty in these findings. Plain language summary Open versus closed surgical exposure of eye teeth that are displaced in the roof of the mouth Review question Is it better to use an open or closed surgical method to expose eye teeth ('canines') that have become displaced in the roof of the mouth? Background Permanent canine teeth in the upper jaw usually erupt into the mouth between the ages of 11 to 12 years. In 2% to 3% of young people, the canine teeth fail to erupt (grow down) and become displaced in the roof of the mouth (palate).This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. Management of this problem is both time consuming and expensive. It usually involves surgical exposure (uncovering), followed by fixed orthodontic braces for two to three years, to move the canine into the correct position. Two surgical techniques are routinely used in the UK: the closed technique involves uncovering the buried tooth, gluing an attachment onto the exposed tooth and repositioning the palatal flap. Shortly after surgery, an orthodontic brace is used to apply gentle forces to bring the canine into its correct position within the dental arch. The canine moves into position beneath the gum. An alternative method is the open technique, which involves surgically uncovering the canine tooth as before, but instead of placing an attachment onto the exposed tooth, a window of gum from around the tooth is removed and a dressing (pack) placed to cover the exposed area. Approximately 10 days later, this pack is removed and the canine is allowed to erupt naturally. Once the tooth has erupted sufficiently for an orthodontic attachment to be glued onto its surface, orthodontic braces are used to bring the tooth in line with the other teeth. Study characteristics The evidence in this review is up‐to‐date as of February 2017. Authors with Cochrane Oral Health found three relevant studies, involving 146 participants who had eye teeth displaced in the roof of the mouth, either on one or both sides. The majority of participants were female and the average age in the studies ranged from 14 to 17 years. Two studies were designed in a way that made them likely to be biased. Key results We combined results from three studies and found that one technique did not seem to have an advantage over the other for ensuring the movement of the tooth into the correct position without the need for repeat surgery. Five out of 141 participants analysed were surgical failures, one of which was due to the complication of detachment of the gold chain during surgery. One study reported complications after surgery and found one participant in the closed group had a post‐operative infection requiring antibiotics and another participant in the closed group experienced pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to combine results from studies for any other outcomes, but individual studies did not show evidence of a difference between the two techniques for pain, discomfort, appearance, gum health, length of treatment time or cost (low to very low quality evidence). Quality of the evidence Overall, we assessed the quality of the evidence as low, which means we cannot be certain of the findings. Author conclusions It does not seem that one surgical technique is better than the other for moving displaced eye teeth into the correct position, or for other outcomes, but this finding is uncertain because the quality of the evidence is low. This suggests the need for more high‐quality studies. Three studies are currently in process. When they are completed, we will include them in an update of this review and may be able to reach firmer conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Parkin, N, Benson, PE, Thind, B, Shah, A, Khalil, I, Ghafoor, S", "articleTypes": [], "doi": "10.1002/14651858.CD006966.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.762Z" }, { "id": "6367a07d-84be-4c17-8dbd-3d80bbba3da4", "pmid": "", "title": "Sustained‐release naltrexone for opioid dependence", "imported": false, "abstract": "Abstract - Background Opioid dependence is a severe and often lifelong disorder with a high risk of overdose and premature death, as well as severe psychosocial difficulties. Sustained‐release naltrexone is a treatment option that works by blocking the euphoric and overdose effects of opioids. When injected intramuscularly, naltrexone provides blockade for one month, while the blocking effects with implants can last for up to six months. Objectives To assess the benefits and harms of sustained‐release naltrexone for the treatment of opioid dependence. Search methods For this update, we searched the following databases from 2007 up to 20 December 2023: the Cochrane Drugs and Alcohol Specialised Register of Trials, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, ISI Web of Science, LILACS, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We manually searched the reference lists of identified studies, published reviews and relevant websites. Selection criteria Randomised controlled trials comparing the effects of injectable or implantable naltrexone with other treatment, no treatment or placebo in adults with opioid dependence. Data collection and analysis Primary outcomes were illicit opioid use, retention in treatment, treatment acceptability and adverse events. Secondary outcomes were opioid craving, recreational use of substances other than opioids, mental health, quality of life and criminal activity. We assessed the risk of bias using the Cochrane risk of bias tool (RoB 1). We combined the results of individual trials through meta‐analysis where possible using a random‐effects model. Two review authors independently assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We identified 22 studies (3416 participants) that met our inclusion criteria. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. Sustained‐release naltrexone compared with opioid agonist treatment We found moderate‐certainty evidence that sustained‐release naltrexone probably increases in‐treatment illicit opioid use slightly (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.01 to 1.31; 1 study, 570 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 1.17, 95% CI 0.78 to 1.76; 3 studies, 773 participants) and treatment acceptability (RR 0.92, 95% CI 0.73 to 1.16; 3 studies, 773 participants). There was low‐certainty evidence that sustained‐release naltrexone may increase serious adverse events slightly in comparison with opioid agonist treatment for serious adverse events (RR 1.40, 95% CI 0.92 to 2.11; 2 studies, 713 participants). Sustained‐release naltrexone compared with oral naltrexone treatment We found low‐certainty evidence that sustained‐release naltrexone may reduce in‐treatment illicit opioid use (RR 0.65, 95% CI 0.45 to 0.93; 1 study, 69 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 2.40, 95% CI 1.64 to 3.52; 3 studies, 464 participants) and on serious adverse events (RR 1.25, 95% CI 0.46 to 3.36; 2 studies, 260 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in treatment acceptability in comparison with oral naltrexone treatment (RR 1.00, 95% CI 0.99 to 1.01; 3 studies, 474 participants). Sustained‐release naltrexone compared with placebo We found low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in in‐treatment illicit opioid use (RR 0.83, 95% CI 0.66 to 1.03; 3 studies, 443 participants), treatment acceptability (RR 1.00, 95% CI 0.98 to 1.02; 1 study, 204 participants) and serious adverse events (RR 0.74, 95% CI 0.17 to 3.23; 3 studies, 443 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment in comparison with placebo (RR 2.10, 95% CI 1.23 to 3.60; 4 studies, 594 participants). Sustained‐release naltrexone compared with treatment as usual We found high‐certainty evidence that sustained‐release naltrexone reduces in‐treatment illicit opioid use (RR 0.72, 95% CI 0.57 to 0.90; 4 studies, 479 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little or no difference in retention in treatment (RR 1.20, 95% CI 0.79 to 1.82; 3 studies, 126 participants) and that it may result in a slight reduction in treatment acceptability (RR 0.79, 95% CI 0.69 to 0.90; 8 studies, 1094 participants). There was moderate‐certainty evidence that sustained‐release naltrexone probably reduces serious adverse events in comparison with treatment as usual (RR 0.59, 95% CI 0.36 to 0.95; 6 studies, 1009 participants). Our primary outcome measures were not reported for sustained‐release naltrexone compared with psychosocial treatments. Amongst the most common methodological weaknesses were the risk of performance bias and imprecision due to few studies and small sample size for many outcomes. Authors' conclusions Sustained‐release naltrexone may slightly increase illicit opioid use and serious adverse events compared to opioid agonists, with uncertain effects on retention and acceptability. It may reduce illicit opioid use compared to oral naltrexone but has uncertain effects on other outcomes. Compared to placebo, it may have little to no impact on key outcomes. Compared to treatment as usual, it reduces illicit opioid use and may reduce serious adverse events but has little effect on retention and slightly reduces acceptability. Significant gaps remain in the evidence on sustained‐release naltrexone for opioid dependence. Future research should include comparisons with psychosocial treatments, larger and higher‐quality studies, and analyses of differences between formulations and comparator treatments. Improved study designs are needed to reduce bias, and more inclusive research should address under‐represented populations and synthetic opioid users. The lack of long‐term outcome data limits understanding of sustained effects, highlighting the need for extended follow‐up and exploration of diverse treatment settings and populations. Plain language summary What are the benefits and risks of sustained‐release (long‐acting) naltrexone for the treatment of dependence on opioid drugs (addiction)? Key messages • It is unclear whether people treated with sustained‐release naltrexone use illicit opioids, such as heroin, less frequently than people treated with opioid agonists, such as buprenorphine or methadone. • People treated with sustained‐release naltrexone may use illicit opioids less frequently than people treated with oral naltrexone, placebo or treatment as usual. • Treatment with sustained‐release naltrexone may be less safe than opioid agonist treatment, but safer than treatment as usual. • Clinicians and patients should weigh the availability and characteristics of treatment options, noting that sustained‐release naltrexone aids abstinence without restricting freedom but requires detoxification; more evidence is needed on long‐term safety and retention. What is dependence on opioid drugs? Opioid drugs, including heroin and prescription painkillers like oxycodone, carry the risk of addiction and serious health consequences. Treatment often involves replacing these opioids with safer alternatives such as methadone or buprenorphine, although other options like therapy or naltrexone are available. However, overcoming opioid dependence remains a persistent challenge due to its complex nature and the associated risks of relapse and overdose. What did we want to find out? In this review we sought to compare sustained‐release naltrexone treatment with other treatments or no treatment for opioid dependence. Naltrexone should not be confused with naloxone, which is a short‐acting drug used for opioid overdose reversal. Other treatments include opioid agonist treatment (such as methadone or buprenorphine), oral naltrexone (taken by mouth, tablets), placebo (sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested), treatment as usual and psychosocial treatments (therapeutic approaches that address both psychological and social aspects of mental health conditions, e.g. psychotherapy, psychoeducation and support groups). What did we do? We searched scientific databases for studies up to December 2023. We identified 22 randomised controlled trials (studies where people were allocated at random to one of two or more treatment or control conditions) involving 3416 adults and adolescents with opioid dependence. Seventy‐four per cent of the people in the studies were male, and they had an average age of 40 years. Twelve of the 22 studies were conducted in the USA or Canada, five in Russia, three in Norway, and one in the UK and Australia, respectively. The main outcomes we examined were opioid use and treatment safety. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. What did we find? We found that when comparing sustained‐release naltrexone to opioid agonist treatment, illicit opioid use probably increases slightly. On the other hand, when comparing sustained‐release naltrexone to treatment as usual, sustained‐release naltrexone reduces illicit opioid use. Compared to oral naltrexone, illicit opioid use may decrease, and compared to placebo, there may be little or no difference. We found no studies comparing sustained‐release naltrexone with psychosocial treatments for any of our primary outcomes. It is generally unclear whether people remain longer in sustained‐release naltrexone treatment than in other treatments or placebo. We do not know whether more people will initiate sustained‐release naltrexone treatment than opioid agonist treatment. When compared to oral naltrexone or placebo, there may be little or no difference in the proportion of people who will initiate treatment. Compared to treatment as usual, it may be that fewer people will initiate sustained‐release naltrexone treatment. Compared to opioid agonist treatment, sustained‐release naltrexone may increase serious adverse (unwanted or harmful) events slightly. It is unclear whether sustained‐release naltrexone results in more or fewer serious adverse events than oral naltrexone. When compared to placebo, there may be little or no difference in the proportion of people who will experience serious adverse events. Sustained‐release naltrexone probably reduces serious adverse events in comparison to treatment as usual. What were the limitations of the evidence? Overall, we have limited confidence in the evidence. One of the reasons is that it is very likely that participants knew which treatments they were assigned to, even if the researchers in many cases tried to conceal the assigned treatment condition for participants and treatment providers. Opioid dependence comes with strong drug cravings and an increased risk of relapse during any treatment. Therefore, participants experiencing cravings and those who maybe even tried to use drugs like heroin would have understood what type of treatment they were assigned to. Another major reason for our limited confidence in the evidence was that the number of studies, and people participating in them, was often too small to obtain precise results. Other reasons for lowering our confidence were inconsistencies in study results and national treatment policies in some studies that make it difficult to apply the results in other countries. How up‐to‐date is this evidence? The evidence is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kornør, H; Lobmaier, PPK; Kunøe, N", "articleTypes": [], "doi": "10.1002/14651858.CD006140.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "636c6272-951b-4965-ac66-5c0580496edc", "pmid": "", "title": "Siponimod for multiple sclerosis", "imported": false, "abstract": "Abstract - Background Multiple sclerosis (MS) is a chronic immune‐mediated disease of the central nervous system, with an unpredictable course. Current MS therapies such as disease‐modifying therapies focus on treating exacerbations, preventing new exacerbations and avoiding the progression of disability. Siponimod (BAF312) is an oral treatment, a selective sphingosine‐1‐phosphate (S1P) receptor modulator, for the treatment of adults with relapsing forms of MS including active, secondary progressive MS with relapses. Objectives To assess the benefits and adverse effects of siponimod as monotherapy or combination therapy versus placebo or any active comparator for people diagnosed with MS. Search methods We searched the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Trials Register, which contains studies from CENTRAL, MEDLINE and Embase, and the trials registry databases ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 10 September 2021. We also handsearched relevant journals and screened the reference lists of published reviews and retrieved articles and searched reports (2004 to September 2021) from the MS societies in Europe and America. Selection criteria We included randomised parallel controlled clinical trials (RCTs) that evaluated siponimod, as monotherapy or combination therapy, versus placebo or any active comparator in people with MS. There were no restrictions on dose or administration frequency. Data collection and analysis We used standard methodological procedures expected by Cochrane. We discussed disagreements and resolved them by consensus among the review authors. Our primary outcomes wereworsening disability , relapse and adverse events, and secondary outcomes were annualised relapse rate, gadolinium‐enhancing lesions, new lesions or enlarged pre‐existing lesions and mean change of brain volume. We independently evaluated the certainty of evidence using the GRADE approach. We contacted principal investigators of included studies for additional data or confirmation of data. Main results Two studies (1948 participants) met our selection criteria, 608 controls and 1334 treated with siponimod. The included studies compared siponimod with placebo. Overall, all studies had a high risk of bias due to selective reporting and attrition bias. Comparing siponimod administered at a dose of 2 mg to placebo, we found that siponimod may reduce the number of participants with disability progression at six months (56 fewer people per 1000; risk ratio (RR) 0.78, 95% confidence interval (CI) 0.65 to 0.94; 1 study, 1641 participants; low‐certainty evidence) and annualised relapse rate (RR 0.43, 95% CI 0.34 to 0.56; 2 studies, 1739 participants; low‐certainty evidence). But it might lead to little reduction in the number of participants with new relapse (166 fewer people per 1000; RR 0.38, 95% CI 0.15 to 1.00; 1 study, 94 participants; very low‐certainty evidence). We observed no evidence of a difference due to adverse events for siponimod at 2 mg compared to placebo (14 more people per 1000; RR 1.52, 95% CI 0.85 to 2.71; 2 studies, 1739 participants, low‐certainty evidence). In addition, due to the high risk of inaccurate magnetic resonance imaging (MRI) data in the two included studies, we could not combine data for active lesions on MRI scans. Both studies had high attrition bias resulting from the unbalanced reasons for dropouts among groups and high risk of bias due to conflicts of interest. Siponimod may reduce the number of gadolinium‐enhancing T1‐weighted lesions at two years of follow‐up (RR 0.14, 95% CI 0.10 to 0.19; P < 0.0001; 1 study, 1641 participants; very low‐certainty evidence). There may be no evidence of a difference between groups in the number of participants with at least one serious adverse event excluding relapses (113 more people per 1000; RR 1.80, 95% CI 0.37 to 8.77; 2 studies, 1739 participants; low‐certainty evidence) at six months. No data were available regarding cardiac adverse events. In terms of safety profile, the most common adverse events associated with siponimod were headache, back pain, bradycardia, dizziness, fatigue, influenza, urinary tract infection, lymphopenia, nausea, alanine amino transferase increase and upper respiratory tract infection. These adverse events have dose‐related effects and rarely led to discontinuation of treatment. Authors' conclusions Based on the findings of the RCTs included in this review, we are uncertain whether siponimod interventions are beneficial for people with MS. There was low‐certainty evidence to support that siponimod at a dose of 2 mg orally once daily as monotherapy compared with placebo may reduce the annualised relapse rate and the number of participants who experienced disability worsening, at 6 months. However, the certainty of the evidence to support the benefit in reducing the number of people with a relapse is very low. The risk of withdrawals due to adverse events requires careful monitoring of participants over time. The duration of all studies was less than 24 months, so the efficacy and safety of siponimod over 24 months are still uncertain, and further exploration is needed in the future. There is no high‐certainty data available to evaluate the benefit on MRI outcomes. We assessed the certainty of the body of evidence for all outcomes was low to very low, downgraded due to serious study limitations, imprecision and indirectness. We are uncertain whether siponimod is beneficial for people with MS. More new studies with robust methodology and longer follow‐up are needed to evaluate the benefit of siponimod for the management of MS and to observe long‐term adverse effects. Also, in addition to comparing with placebo, more new studies are needed to evaluate siponimod versus other therapeutic options. Plain language summary Is siponimod an effective treatment for multiple sclerosis (MS) and does it cause unwanted effects? Key messages · We don’t know whether siponimod is an effective treatment for people with multiple sclerosis (MS). At a dose of 2 mg once a day, siponimod may reduce recurrence of symptoms (relapse, calculated as an annual rate) after six months of treatment and may reduce the number of participants whose disability worsens after three months of treatment. · We don’t know if siponimod causes unwanted effects because studies did not last long enough to fully assess them. · Future studies should last longer in order to monitor unwanted and beneficial effects of siponimod better, and should use more robust methods. They should compare siponimod with other medicines. What is multiple sclerosis? Multiple sclerosis (MS) is a condition caused when the body’s immune system – which defends the body against disease and infection – mistakenly attacks parts of the central nervous system (the brain and spinal cord). Symptoms include problems with balance and walking, and blurred vision. MS is a lifelong condition that can cause serious disability. Some people’s symptoms may develop gradually. However, most people experience ‘attacks’ when new symptoms develop or existing symptoms worsen (called ‘relapse’), followed by periods with no changes to their symptoms (called ‘remittance’). This type of MS is called ‘relapsing remitting’ MS. Eventually, the course of their MS may change. These periods when there are no symptoms, or no worsening of symptoms, may stop and then symptoms may worsen continually. This is called ‘secondary progressive MS’. How does siponimod work? Siponimod is a medicine that attaches to the white blood cells (lymphocytes) that attack the central nervous system. This causes the lymphocytes to stay in the lymph glands instead of circulating in the blood to the brain. Fewer lymphocytes reach the brain so the attack by the immune system is reduced. Siponimod is a tablet taken once a day. What did we want to find out? We wanted to know if siponimod is an effective treatment for MS and whether it causes any unwanted effects. We were interested in the number of people: · who experienced relapses; · whose disability worsened; · who left the studies because of unwanted effects of siponimod; · who developed new or larger brain lesions (damage to the brain); and · who experienced serious unwanted effects, and which unwanted effects they experienced. What did we do? 
We searched for studies that investigated siponimod compared with placebo (a sham medicine that looks and tastes the same as siponimod but with no active ingredients) or another medicine to treat MS. Studies could investigate siponimod alone or combined with another treatment, at any dose over any length of time. Participants had to be aged over 18 years, with confirmed MS. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found two studies with 1948 participants. Both studies compared siponimod with placebo. One study included 1651 people with secondary progressive MS, who were given 2 mg siponimod for up to 3 years. The other study included 297 participants with relapsing remitting MS, who were given siponimod at doses of 10 mg, 2 mg or 0.5 mg for 6 months, or 1.25 mg or 0.25 mg for 3 months. We report the results for 2 mg daily because both studies looked at this dose. At 2 mg a day, compared to placebo: · siponimod may lead to a small reduction (166 fewer people per 1000) in the number of people with a new relapse up to six months after starting treatment, and may also reduce relapses when calculated at an annual rate; · siponimod may reduce the number of people whose disability worsened during the six months after starting treatment (by 56 people per 1000); · there may be no difference to the number of people (14 more per 1000) who left the studies in the six months after starting treatment due to unwanted effects; · siponimod may reduce the number of brain lesions of different types after six months and after two years of follow‐up. · siponimod may make no difference to the number of people with at least one serious unwanted effect in the six months after starting treatment. The most common unwanted effects associated with siponimod were headache, back pain, dizziness, tiredness, influenza, urinary tract infection, reduced white blood cells (lymphopenia), feeling sick, possible liver damage, and infections in the mouth and nose. No information was available about heart‐related unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only 2 studies. They did not provide information about everything we were interested and they included people with different types of MS. Also, they did not last long enough to judge the impact of unwanted effects. Both studies were funded by the company that makes siponimod.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Cao, L; Li, M; Yao, L; Yan, P; Wang, X; Yang, Z; Lao, Y; Li, H; Yang, K; Li, K", "articleTypes": [], "doi": "10.1002/14651858.CD013647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "636df23d-9014-45b9-861c-a2e60ab646cd", "pmid": "", "title": "Antiviral treatment for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. This review was first published in 2001 and most recently updated in 2015. Since a significant benefit of corticosteroids for the early management of Bell's palsy has been demonstrated, the main focus of this update, as in the previous version, was to determine the effect of adding antivirals to corticosteroid treatment. We undertook this update to integrate additional evidence and to better assess the robustness of findings, taking risk of bias fully into account. Objectives To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy. Search methods We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS in July 2019. We reviewed the bibliographies of the identified trials and contacted trial authors to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies. Selection criteria We considered randomised controlled trials (RCTs) or quasi‐RCTs of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that followed‐up participants for less than three months. Data collection and analysis We independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures. We performed sensitivity analyses excluding trials at high or unclear risk of bias in at least five domains, and reported these data as the primary analyses. Main results Fourteen trials, including 2488 participants, met the inclusion criteria. Most were small, and most were at high or unclear risk of bias in multiple domains. We included four new studies at this update. Incomplete recovery A combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in people with Bell's palsy compared to corticosteroids alone (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.38 to 1.74; 3 trials, N = 766; random‐effects; low‐certainty evidence). We excluded 10 trials that were at high or unclear risk of bias in several domains from this analysis and limited all analyses to studies at lower risk of bias. Recovery rates were better in participants receiving corticosteroids alone than antivirals alone (RR 2.69, 95% CI 0.73 to 10.01; 2 trials, N = 667; random‐effects), but the result was imprecise and allowed for the possibility of no effect. The rate of incomplete recovery was lower with antivirals plus corticosteroids than with placebo or no treatment (RR 0.56, 95% CI 0.42 to 0.76; 2 trials, N = 658; random‐effects). Antivirals alone had no clear effect on incomplete recovery rates compared with placebo, but the result was imprecise (RR 1.10, 95% CI 0.87 to 1.40; 2 trials, N = 658; fixed‐effect). For people with severe Bell's palsy (House‐Brackmann score of 5 and 6, or equivalent on other scales), we found that the combination of antivirals and corticosteroids had no clear effect on incomplete recovery at month six compared to corticosteroids alone, although the result was again imprecise (RR 0.82, 95% CI 0.57 to 1.17; 2 trials, N = 98; random‐effects). Motor synkinesis or crocodile tears Antivirals plus corticosteroids reduced the proportion of participants who experienced these long‐term sequelae from Bell's palsy compared to placebo plus corticosteroids (RR 0.56, 95% CI 0.36 to 0.87; 2 trials, N = 469; fixed‐effect; moderate‐certainty evidence). Antivirals plus corticosteroids reduced long‐term sequelae compared to placebo but there was no clear difference in this outcome with antivirals alone compared to placebo. Adverse events Adverse event data were available in four studies providing data on 1592 participants. None of the four comparisons showed clear differences in adverse events between treatment and comparison arms (very low‐certainty evidence); for the comparison of antivirals plus corticosteroids and corticosteroids alone in studies at lower risk of bias, the RR was 1.17 (95% CI 0.81 to 1.69; 2 trials, N = 656; fixed‐effect; very low‐certainty evidence). Authors' conclusions The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, or in people with severe Bell's palsy, but the results were very imprecise. Corticosteroids alone were probably more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no clear benefit from antivirals alone over placebo. The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone. Studies also showed fewer episodes of long‐term sequelae in corticosteroid‐treated participants than antiviral‐treated participants. We found no clear difference in adverse events from the use of antivirals compared with either placebo or corticosteroids, but the evidence is too uncertain for us to draw conclusions. An adequately powered RCT in people with Bell’s palsy that compares different antiviral agents may be indicated. Plain language summary Antiviral treatment for Bell's palsy Review question We reviewed the evidence about the effect of antiviral therapy (drugs used specifically to treat viral infections), alone or in combination with any other therapy, on Bell's palsy. Our focus in this updated review was combined therapy with antiviral drugs and corticosteroids (which are drugs used to reduce inflammation) as there is already good evidence that corticosteroids can reduce rates of incomplete recovery from Bell's palsy. Background Bell's palsy is a disease of the facial nerve that causes one side of the face to be paralysed. Some studies have suggested that it is caused by the same viral infections that cause cold sores or shingles and investigated the effect of antiviral therapy. Earlier versions of this review have found that antivirals alone are not helpful compared to a dummy pill, and are less effective than corticosteroids alone. However, studies of antiviral treatment in combination with corticosteroids have conflicting results. Study characteristics We identified 14 trials, which included 2488 participants with mild, moderate, or severe one‐sided Bell's palsy of unknown cause. Participants were aged from 14 to 84 years. The trials compared:
 ‐ antivirals plus corticosteroids to corticosteroids alone or in combination with placebo;
 ‐ antivirals alone or in combination with placebo to placebo or no treatment;
 ‐ antivirals alone or in combination with placebo to corticosteroid treatment alone or in combination with placebo; or
 ‐ antivirals plus corticosteroids to placebo or no treatment. For the majority of the studies, no information on funding was given. The remaining were mostly partly public funded, and one trial was funded by a pharmaceutical company. Eleven studies had high or uncertain risk of bias from various factors that can systematically affect trial results. We chose to base our conclusions only on data from three studies at a lower risk of bias. Key results and certainty of the evidence The review showed that there may be no clear difference in rates of incomplete recovery from Bell's palsy after treatment with the combination of antivirals and corticosteroids, compared to corticosteroids alone. This finding was of low certainty and was based on data from three trials involving 766 people with Bell's palsy of various degrees of severity. We excluded data from 10 trials with multiple potential sources of bias. However, we can be moderately confident that the combined therapy reduced the number of people left with long‐term effects of Bell's palsy (excessive tearing of the eyes or an abnormal facial movement) compared to corticosteroid treatment alone. Data from two studies (98 participants) showed that in people with severe Bell's palsy (complete or almost complete facial paralysis), combined antivirals and corticosteroids had no clear effect on recovery compared with corticosteroid treatment alone. Corticosteroids alone were more effective than antivirals alone on rates of incomplete recovery (667 participants, 2 trials); antivirals and corticosteroids combined were more effective than placebo or no treatment (658 participants, 2 trials); and there was no clear benefit from antivirals alone over placebo (658 participants, 2 trials). Although, based on data from two trials (656 participants), we found no clear difference in the occurrence of side effects between people receiving both antivirals and corticosteroids, compared to those receiving corticosteroids alone, this evidence is too uncertain for us to draw conclusions. Large studies in people with Bell's palsy comparing additional antiviral agents may be indicated in the future.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gagyor, I; Madhok, VB; Daly, F; Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001869.pub9", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "6372c2ce-3977-4d37-88a8-066f5aa20598", "pmid": "", "title": "Nutritional labelling for healthier food or non‐alcoholic drink purchasing and consumption", "imported": false, "abstract": "Abstract - Background Nutritional labelling is advocated as a means to promote healthier food purchasing and consumption, including lower energy intake. Internationally, many different nutritional labelling schemes have been introduced. There is no consensus on whether such labelling is effective in promoting healthier behaviour. Objectives To assess the impact of nutritional labelling for food and non‐alcoholic drinks on purchasing and consumption of healthier items. Our secondary objective was to explore possible effect moderators of nutritional labelling on purchasing and consumption. Search methods We searched 13 electronic databases including CENTRAL, MEDLINE and Embase to 26 April 2017. We also handsearched references and citations and sought unpublished studies through websites and trials registries. Selection criteria Eligible studies: were randomised or quasi‐randomised controlled trials (RCTs/Q‐RCTs), controlled before‐and‐after studies, or interrupted time series (ITS) studies; compared a labelled product (with information on nutrients or energy) with the same product without a nutritional label; assessed objectively measured purchasing or consumption of foods or non‐alcoholic drinks in real‐world or laboratory settings. Data collection and analysis Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of bias' tool and GRADE to assess the quality of evidence. We pooled studies that evaluated similar interventions and outcomes using a random‐effects meta‐analysis, and we synthesised data from other studies in a narrative summary. Main results We included 28 studies, comprising 17 RCTs, 5 Q‐RCTs and 6 ITS studies. Most (21/28) took place in the USA, and 19 took place in university settings, 14 of which mainly involved university students or staff. Most (20/28) studies assessed the impact of labelling on menus or menu boards, or nutritional labelling placed on, or adjacent to, a range of foods or drinks from which participants could choose. Eight studies provided participants with only one labelled food or drink option (in which labelling was present on a container or packaging, adjacent to the food or on a display board) and measured the amount consumed. The most frequently assessed labelling type was energy (i.e. calorie) information (12/28). Eleven studies assessed the impact of nutritional labelling on purchasing food or drink options in real‐world settings, including purchases from vending machines (one cluster‐RCT), grocery stores (one ITS), or restaurants, cafeterias or coffee shops (three RCTs, one Q‐RCT and five ITS). Findings on vending machines and grocery stores were not interpretable, and were rated as very low quality. A meta‐analysis of the three RCTs, all of which assessed energy labelling on menus in restaurants, demonstrated a statistically significant reduction of 47 kcal in energy purchased (MD −46.72 kcal, 95% CI −78.35, −15.10, N = 1877). Assuming an average meal of 600 kcal, energy labelling on menus would reduce energy purchased per meal by 7.8% (95% CI 2.5% to 13.1%). The quality of the evidence for these three studies was rated as low, so our confidence in the effect estimate is limited and may change with further studies. Of the remaining six studies, only two (both ITS studies involving energy labels on menus or menus boards in a coffee shop or cafeteria) were at low risk of bias, and their results support the meta‐analysis. The results of the other four studies which were conducted in a restaurant, cafeterias (2 studies) or a coffee shop, were not clearly reported and were at high risk of bias. Seventeen studies assessed the impact of nutritional labels on consumption in artificial settings or scenarios (henceforth referred to as laboratory studies or settings). Of these, eight (all RCTs) assessed the effect of labels on menus or placed on a range of food options. A meta‐analysis of these studies did not conclusively demonstrate a reduction in energy consumed during a meal (MD −50 kcal, 95% CI −104.41, 3.88, N = 1705). We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. Six laboratory studies (four RCTs and two Q‐RCTs) assessed the impact of labelling a single food or drink option (such as chocolate, pasta or soft drinks) on energy consumed during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant difference in energy (kcal) consumed (SMD 0.05, 95% CI −0.17 to 0.27, N = 732). However, the confidence intervals were wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. There was no evidence that nutritional labelling had the unintended harm of increasing energy purchased or consumed. Indirect evidence came from five laboratory studies that involved mislabelling single nutrient content (i.e. placing low energy or low fat labels on high‐energy foods) during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant increase in energy (kcal) consumed (SMD 0.19, 95% CI −0.14to 0.51, N = 718). The effect was small and the confidence intervals wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence from these studies as very low, providing very little confidence in the effect estimate. Authors' conclusions Findings from a small body of low‐quality evidence suggest that nutritional labelling comprising energy information on menus may reduce energy purchased in restaurants. The evidence assessing the impact on consumption of energy information on menus or on a range of food options in laboratory settings suggests a similar effect to that observed for purchasing, although the evidence is less definite and also of low quality. Accordingly, and in the absence of observed harms, we tentatively suggest that nutritional labelling on menus in restaurants could be used as part of a wider set of measures to tackle obesity. Additional high‐quality research in real‐world settings is needed to enable more certain conclusions. Further high‐quality research is also needed to address the dearth of evidence from grocery stores and vending machines and to assess potential moderators of the intervention effect, including socioeconomic status. Plain language summary Nutritional labelling to promote healthier consumption and purchasing of food or drinks A poor diet including excessive energy intake is an important cause of ill health. Nutritional labelling may help people to make healthier food choices. What is the aim of this review? This review investigated whether nutritional labels (i.e. labels providing information about nutritional content) persuade people to buy or consume different (healthy) kinds of food. We searched for all available evidence to answer this question and found 28 studies. Key messages There is evidence to suggest that nutritional labelling, with energy information (e.g. calorie counts) on menus, may reduce energy purchased in restaurants, but more high‐quality studies are needed to make this finding more certain. What was studied in the review? Some studies assessed buying food or drinks from vending machines, grocery stores, restaurants, cafeterias, or coffee shops. Others assessed the amount of food or drink consumed during a snack or meal in an artificial setting or scenario (referred to as laboratory studies or settings). What are the main results of the review? Nutritional labelling on restaurant menus reduced the amount of energy (i.e. calories) purchased, but the quality of the three studies that contributed to this finding was low, so our confidence in the effect estimate is limited and may change with further studies. Eight studies assessed this same type of intervention in laboratory settings, but instead of evaluating how much energy participants purchased, these studies evaluated how much energy participants consumed. These studies did not conclusively demonstrate a reduction in energy consumed when menus or foods were labelled, and they were also of low quality. In addition, six laboratory studies assessed how much energy participants consumed when they were given one food or drink option with or without labels, and five laboratory studies assessed how much energy participants consumed when foods were experimentally labelled as low energy or low fat when they were actually high‐energy foods (i.e. mislabelling). Results from these two groups of studies were inconclusive and of low, or in the case of mislabelling studies, very low quality. We found some studies that assessed labelling on vending machines and grocery stores, but their results were not easy to interpret, so we could not use them to inform this review. How up‐to‐date is this review? The evidence is current to 26 April 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Crockett, RA, King, SE, Marteau, TM, Prevost, AT, Bignardi, G, Roberts, NW, Stubbs, B, Hollands, GJ, Jebb, SA", "articleTypes": [], "doi": "10.1002/14651858.CD009315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.765Z" }, { "id": "637838dc-25dc-404f-8714-583d117472d0", "pmid": "", "title": "Antihypertensive drug therapy for mild to moderate hypertension during pregnancy", "imported": false, "abstract": "Abstract - Background Antihypertensive drugs are often used in the belief that lowering blood pressure will prevent progression to more severe disease, and thereby improve pregnancy outcome. This Cochrane Review is an updated review, first published in 2001 and subsequently updated in 2007 and 2014. Objectives To assess the effects of antihypertensive drug treatments for women with mild to moderate hypertension during pregnancy. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (13 September 2017), and reference lists of retrieved studies. Selection criteria All randomised trials evaluating any antihypertensive drug treatment for mild to moderate hypertension during pregnancy, defined as systolic blood pressure 140 to 169 mmHg and/or diastolic blood pressure 90 to 109 mmHg. Comparisons were of one or more antihypertensive drug(s) with placebo, with no antihypertensive drug, or with another antihypertensive drug, and where treatment was planned to continue for at least seven days. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results For this update, we included 63 trials (data from 58 trials, 5909 women), with moderate to high risk of bias overall. We carried out GRADE assessments for the main 'antihypertensive drug versus placebo/no antihypertensive drug' comparison only. Evidence was graded from very low to moderate certainty, with downgrading mainly due to design limitations and imprecision.For many outcomes, trials contributing data evaluated different hypertensive drugs; while we did not downgrade for this indirectness, results should be interpreted with caution. Antihypertensive drug versus placebo/no antihypertensive drug (31 trials, 3485 women) Primary outcomes: moderate‐certainty evidence suggests that use of antihypertensive drug(s) probably halves the risk of developing severe hypertension (risk ratio (RR) 0.49; 95% confidence interval (CI) 0.40 to 0.60; 20 trials, 2558 women), but may have little or no effect on the risk of proteinuria/pre‐eclampsia (average risk ratio (aRR) 0.92; 95% CI 0.75 to 1.14; 23 trials, 2851 women; low‐certainty evidence). Moderate‐certainty evidence also shows that antihypertensive drug(s) probably have little or no effect in the risk of total reported fetal or neonatal death (including miscarriage) (aRR 0.72; 95% CI 0.50 to 1.04; 29 trials, 3365 women), small‐for‐gestational‐age babies (aRR 0.96; 95% CI 0.78 to 1.18; 21 trials, 2686 babies) or preterm birth less than 37 weeks (aRR 0.96; 95% CI 0.83 to 1.12; 15 trials, 2141 women). Secondary outcomes: we are uncertain of the effect of antihypertensive drug(s) on the risk of maternal death , severe pre‐eclampsia , or eclampsia, or impaired long‐term growth and development of the baby in infancy and childhood , because the certainty of this evidence is very low. There may be little or no effect on the risk of changed/stopped drugs due to maternal side‐effects, or admission to neonatal or intensive care nursery (low‐certainty evidence). There is probably little or no difference in the risk of elective delivery (moderate‐certainty evidence). Antihypertensive drug versus another antihypertensive drug (29 trials, 2774 women) Primary outcomes: beta blockers and calcium channel blockers together in the meta‐analysis appear to be more effective than methyldopa in avoiding an episode of severe hypertension (RR 0.70; 95% CI 0.56 to 0.88; 11 trials, 638 women). There was also an increase in this risk when other antihypertensive drugs were compared with calcium channel blockers (RR 1.86; 95% CI 1.09 to 3.15; 5 trials, 223 women), but no evidence of a difference when methyldopa and calcium channel blockers together were compared with beta blockers (RR1.18, 95% CI 0.95 to 1.48; 10 trials, 692 women). No evidence of a difference in the risk of proteinuria/pre‐eclampsia was found when alternative drugs were compared with methyldopa (aRR 0.78; 95% CI 0.58 to 1.06; 11 trials, 997 women), with calcium channel blockers (aRR: 1.24, 95% CI 0.70 to 2.19; 5 trials, 375 women), or with beta blockers (aRR 1.21, 95% CI 0.88 to 1.67; 12 trials, 1107 women). For the babies, we found no evidence of a difference in the risk of total reported fetal or neonatal death (including miscarriage) when comparing other antihypertensive drugs with methyldopa (aRR 0.77, 95% CI 0.52 to 1.14; 22 trials, 1791 babies), with calcium channel blockers (aRR 0.90, 95% CI 0.52 to 1.57; nine trials, 700 babies), or with beta blockers (aRR: 1.23, 95% CI 0.81 to 1.88; 19 trials, 1652 babies); nor in the risk for small‐for‐gestational age in the comparison with methyldopa (aRR 0.79, 95% CI 0.52 to 1.20; seven trials, 597 babies), with calcium channel blockers (aRR 1.05, 95% CI 0.64 to 1.73; four trials, 200 babies), or with beta blockers (average RR 1.13, 95% CI 0.80 to 1.60; 7 trials, 680 babies). No evidence of an overall difference among groups in the risk of preterm birth (less than 37 weeks) was found in the comparison with methyldopa (aRR: 0.91; 95% CI 0.68 to 1.22; 11 trials, 835 women), with calcium channel blockers (aRR 0.85, 95% CI 0.59 to 1.23; six trials, 330 women), or with beta blockers (aRR 1.22, 95% CI 0.90 to 1.66; 9 trials, 806 women). Secondary outcomes: There were no cases of maternal death and eclampsia. There is no evidence of a difference in the risk of severe pre‐eclampsia , changed/stopped drug due to maternal side‐effects , elective delivery, admission to neonatal or intensive care nursery when other antihypertensive drugs are compared with methyldopa, calcium channel blockers or beta blockers. Impaired long‐term growth and development in infancy and childhood was not reported for these comparisons. Authors' conclusions Antihypertensive drug therapy for mild to moderate hypertension during pregnancy reduces the risk of severe hypertension. The effect on other clinically important outcomes remains unclear. If antihypertensive drugs are used, beta blockers and calcium channel blockers appear to be more effective than the alternatives for preventing severe hypertension. High‐quality large sample‐sized randomised controlled trials are required in order to provide reliable estimates of the benefits and adverse effects of antihypertensive treatment for mild to moderate hypertension for both mother and baby, as well as costs to the health services, women and their families. Plain language summary Antihypertensive drug therapy for mild to moderate hypertension during pregnancy What is the issue? The aim of this review was to determine the benefits and adverse effects of blood pressure‐lowering drugs (antihypertensive drugs) for pregnant women with mild to moderate hypertension (high blood pressure). The other aim was to assess the benefits and adverse effects of these drugs for their babies. Why is this important? During pregnancy, up to one in 10 women have blood pressure readings that are above normal. For some women, their blood pressure remains slightly high (termed ‘mild to moderate high blood pressure’), with no apparent complications. Some of these women go on to develop very high blood pressure. Very high blood pressure can result in a medical emergency if it affects the woman’s organs (such as her liver, or brain in the form of a stroke). Also, it can seriously affect the growth and health of her baby. Drugs that lower blood pressure are used to treat mild to moderate high blood pressure, in the belief that this treatment will prevent the blood pressure from continuing to rise. Over the years, information from good quality research studies has been contradictory, so we cannot be sure if this drug treatment is worthwhile. What evidence did we find? This Cochrane Review is an update of a review that was first published in 2001 and updated in 2007 and 2014. We searched for randomised controlled trials in September 2017, and this review now includes data from 58 trials involving more than 5900 women. A total of 31 trials with 3485 women compared a number of different blood pressure‐lowering drugs to a placebo or no treatment. There were a further 29 trials involving 2774 women which compared one blood pressure‐lowering drug with another one. The evidence showed that treating pregnant women who had moderately raised blood pressure with blood pressure‐lowering drugs probably halved the number of the women developing severe high blood pressure (20 trials, 2558 women). However, blood pressure‐lowering drugs probably had little or no effect on the risk of the baby dying (29 trials, 3365 women), and there is insufficient data on maternal deaths to make a judgement on whether this risk is lowered (five trials, 525 women). The use of blood pressure‐lowering drugs may have little or no effect on the number of the women developing pre‐eclampsia (23 trials, 2851 women), or the number of women who had to change drugs because of side‐effects (16 trials, 1503 women). We found no difference in the number of babies born preterm, that is before 37 weeks (15 trials, 2141 women). There was also no difference in the number of babies born small for their gestational age (21 trials, 2686 babies). The quality of the evidence was mostly moderate (but for pre‐eclampsia it was low). This was due to a number of small studies, and problems with the way the studies were undertaken. The available evidence is still insufficient to demonstrate if there is any antihypertensive drug that is better than another. However, beta blockers and calcium channel blockers seem to be better than the alternative drugs for blood pressure control. What does this mean? More research is needed in order to confirm the true effect of antihypertensive drugs in mothers and in their babies, and to identify the drug which would be best.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abalos, E, Duley, L, Steyn, DW, Gialdini, C", "articleTypes": [], "doi": "10.1002/14651858.CD002252.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.792Z" }, { "id": "6379fa01-431f-4f91-9ddf-b2972a6474dd", "pmid": "", "title": "Interventions for the treatment of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "O'Byrne, L, Webster, KE, MacKeith, S, Philpott, C, Hopkins, C, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013876.pub3 AB - Abstract - Background Olfactory dysfunction is a common consequence of COVID‐19 infection and persistent symptoms can have a profound impact on quality of life. At present there is little guidance on how best to treat this condition. A variety of interventions have been suggested to promote recovery, including medication and olfactory training. However, it is uncertain whether any intervention is of benefit. This is an update of the 2021 review with one additional study added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with persisting olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance that had persisted for at least four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the recovery of sense of smell, disease‐related quality of life and serious adverse effects. Secondary outcomes were the change in sense of smell, general quality of life, prevalence of parosmia and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included two studies with 30 participants. The studies evaluated the following interventions: systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant and palmitoylethanolamide plus luteolin. Systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant compared to no intervention We included a single RCT with 18 participants who had anosmia for at least 30 days following COVID‐19 infection. Participants received a 15‐day course of oral corticosteroids combined with nasal irrigation (consisting of an intranasal corticosteroid/mucolytic/decongestant solution) or no intervention. Psychophysical testing was used to assess olfactory function at 40 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Palmitoylethanolamide plus luteolin compared to no intervention We included a single RCT with 12 participants who had anosmia or hyposmia for at least 90 days following COVID‐19 infection. Participants received a 30‐day course of palmitoylethanolamide and luteolin or no intervention. Psychophysical testing was used to assess olfactory function at 30 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the treatment of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important The sense of smell is critical to one's enjoyment of odours and tastes, and is important for safety. During the COVID‐19 pandemic there has been an increasing focus on change in sense of smell as one of the early symptoms associated with infection. This can be a reduction, change or complete loss of the sense of smell. For most people this is temporary, however for some this lasts weeks or even months. If a person has lost their sense of smell for a long time (over four weeks after having COVID‐19), we do not know if there are any treatments that might help it to recover. How we identified and assessed the evidence We searched the medical literature, identifying relevant studies and summarising the results. We assessed the quality of the studies as well as the certainty of the evidence. Factors influencing this included the size of the studies, the methods used to perform them and how results were reported by researchers. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found two small studies to include in the review, including a total of 30 people. All participants had problems with their sense of smell that had lasted for at least four weeks, and started after a COVID‐19 infection. Problems with the sense of smell were identified using special smell identification tests carried out by the research team. The patients were randomly divided into two groups: those who would receive treatment and those who would not. The treatment in one study was a course of corticosteroid tablets ('systemic') and nasal irrigation (with a wash consisting of a mix of corticosteroids, decongestant and an agent that breaks down mucus). The second study used a course of a supplement known as palmitoylethanolamide and luteolin. Systemic corticosteroids and nasal irrigation (intranasal corticosteroids/decongestant/mucolytic) compared to no treatment We do not know whether corticosteroid tablets with nasal irrigation is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 40 days;
 ‐ changing the sense of smell after 40 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. Palmitoylethanolamide and luteolin compared to no treatment We do not know whether palmitoylethanolamide and luteolin is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 30 days;
 ‐ changing the sense of smell after 30 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. We did find a number of other studies that are being carried out, but no results from these studies are yet available to be included in this review. What this means It is unclear whether using corticosteroids with nasal irrigation, or using a palmitoylethanolamide and luteolin supplement, might treat problems with the sense of smell after COVID‐19, or whether these treatments can potentially cause harm. Other treatments are under investigation. This review is a 'living systematic review', meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.080Z" }, { "id": "63a48049-5010-4d4b-b7e0-fc5da85c109b", "pmid": "", "title": "Oral nutritional interventions in hospitalised older people at nutritional risk: a network meta‐analysis of individual participant data", "imported": false, "abstract": "Abstract - Rationale Malnutrition affects 35% to 64% of hospitalised older people, and is associated with adverse health outcomes such as disease complications and hospital readmission. Identifying effective nutritional interventions is essential to improve clinical outcomes and reduce healthcare costs in this population. Objectives To evaluate the effects of various nutritional interventions, compared with either a control group (standard care or placebo) or each other, on patient‐relevant outcomes in hospitalised older people at risk of or with established malnutrition, and to rank the effects of these different interventions using network meta‐analysis (NMA) based on individual participant data (IPD). Search methods We searched CENTRAL, MEDLINE, five other databases, and two trial registries to 2 July 2024, and checked the reference lists of included studies and relevant systematic reviews. Eligibility criteria We included older people (≥ 65 years) hospitalised for different acute conditions at risk of or with malnutrition enrolled in randomised controlled trials (RCTs) comparing oral nutritional interventions with control or each other. For RCTs that met our inclusion criteria, either fully or partially, we requested IPD from the study authors. If we did not receive a response or IPD were unavailable, we used published aggregated data. We excluded RCTs that only partially met the eligibility criteria if neither IPD nor sufficient aggregated data were obtainable. Outcomes Critical outcomes were all‐cause mortality, serious adverse events (SAEs), and functional status (e.g. activities of daily living). Important outcomes were health‐related quality of life (HRQoL), length of hospital stay (LOS), body weight, and fat‐free mass. The main outcome assessment time point was at hospital discharge or 30 days after randomisation. Risk of bias We used the Cochrane risk of bias 2 (RoB 2) tool. Synthesis methods For each outcome, we first analysed IPD within each study. Second, we pooled results in an NMA which also included the aggregated data from RCTs without available IPD. We performed random‐effects NMAs based on the frequentist approach and ranked treatments by P‐scores. We rated the certainty of evidence using the GRADE approach. Included studies We included 21 RCTs (72 reports; 12 RCTs with IPD) with 3309 older participants (mean age ranged from 75 to 85 years; 1863 participants with IPD) with different acute conditions. Interventions included the provision of additional protein (three studies), energy supplements (two studies), oral nutritional supplements (ONS; eight studies), individualised feeding support (two studies), and comprehensive individualised nutritional care (eight studies). In all but two RCTs, interventions were compared to control (standard care with or without a placebo). We judged 16.1% of outcome assessments to be at low risk of bias and 16.8% at high risk. Synthesis of results ONS may reduce all‐cause mortality (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.25 to 0.84; absolute risk difference 57 fewer deaths per 1000 people, 95% CI 79 fewer to 17 fewer; low‐certainty evidence) compared to control, while comprehensive individualised nutritional care may show little to no effect (RR 0.98, 95% CI 0.55 to 1.73; 1 fewer per 1000 people, 95% CI 26 fewer to 46 more; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 13 RCTs, 2728 participants; Q between designs: not applicable (NA)). ONS may reduce SAEs compared to control (RR 0.56, 95% CI 0.32 to 0.95; 84 fewer SAEs per 1000 people, 95% CI 131 fewer to 10 fewer; Q between designs: Q 1.95, df 2, P = 0.3772; low‐certainty evidence ). For all other treatment comparisons, the evidence is very uncertain (NMA with 14 RCTs, 2184 participants). Comprehensive individualised nutritional care may make little to no difference in activities of daily living compared to control (standardised mean difference (SMD) 0.06, 95% CI −0.08 to 0.20; low‐certainty evidence) and ONS compared to energy supplements (SMD −0.15, 95% CI −0.53 to 0.23; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 5 RCTs, 1128 participants; Q between designs: NA). Energy supplements probably make little to no difference in HRQoL compared with ONS (mean difference (MD) 0.01, 95% CI −0.06 to 0.08; Q between designs: NA; moderate‐certainty evidence). All other comparisons of different nutritional interventions may make little to no difference to HRQoL (NMA with 3 RCTs, 1513 participants). The provision of additional protein, energy supplements, ONS, and comprehensive individualised nutritional care may make little to no difference in LOS compared to control (18 RCTs, 3013 participants; Q between designs: Q 2.86, df 3, P = 0.4145). Body weight (16 RCTs, 2114 participants; Q between designs: Q 2.03, df 3, P = 0.5655) may increase with ONS when compared to control (MD 0.9 kg, 95% CI 0.37 to 1.42) or comprehensive individualised nutritional care (MD 1.00 kg, 95% CI 0.12 to 1.87), but the evidence is very uncertain. Energy supplements and ONS probably have similar effects on body weight (MD 0.11 kg, 95% CI −0.85 to 0.63; moderate‐certainty evidence). For fat‐free mass, no meta‐analysis was possible. One RCT (102 participants) compared ONS with energy supplements and found little or no difference between groups (MD 0.13 kg, 95% CI −0.63 to 0.90; low‐certainty evidence), while evidence regarding the effects of additional protein compared with control was very uncertain (1 RCT, 19 participants). Rankings of treatments by P‐scores were not consistent across outcomes. Authors' conclusions In older hospitalised people at risk of or with malnutrition, oral nutritional supplements may reduce mortality and SAEs compared to control 30 days after randomisation . For other outcomes, there may be little or no differences in results. Overall, the evidence was of low to very low certainty, primarily due to a limited number of studies and participants per comparison. The comparison of treatment effects across outcomes was constrained by variations in network structure. When interpreting the results, the heterogeneity of the population in terms of acute and chronic conditions needs to be considered. To improve certainty, adequately powered studies with robust methodologies should compare interventions with controls as well as against each other. Funding The German Federal Ministry of Education and Research funded this work (grant number: 01KG2102). Registration Protocol (2022) doi.org/10.1002/14651858.CD015468 Plain language summary What are the benefits and risks of different types of nutritional support for older, hospitalised people who are malnourished or at risk of malnutrition? Key messages Compared to standard hospital care, specialised foods and drinks may reduce the chances of dying and of having a serious negative health event one month after hospital admission. In terms of people's ability to perform basic daily activities, their quality of life, length of hospital stay, and body weight, we are either very uncertain about the benefits and risks of the different types of nutritional support, or evidence shows they may make little or no difference compared to standard hospital care. Larger and well‐designed studies comparing different types of nutritional support may increase our confidence in these findings. What is malnutrition? People become malnourished when their intake of energy and protein is not enough to meet their body's needs. This condition can reduce someone's fat and muscle stores. Being malnourished threatens people's health and compromises the immune system's ability to fight infections. Older people who are malnourished are at higher risk of disease complications, losing their independence, and dying than non‐malnourished older people. They also experience a lower quality of life. Older people may become malnourished or be at risk of malnutrition for several reasons, including having a reduced appetite, chewing problems, physical limitations (e.g. unable to stand for long periods to prepare meals), and loneliness. Older people in hospital are particularly prone to malnutrition. They may not eat enough at a time when their illness increases their energy and protein needs. Malnutrition affects roughly one‐third to two‐thirds of hospitalised older people. How is malnutrition treated? There is a wide range of treatments for malnutrition, including: specialised foods and beverages that provide extra energy, protein, and other nutrients; practical help with eating and drinking; additional snacks, protein‐rich foods or supplements; nutritional counselling; or tailored combinations of these approaches. What did we want to find out? In older, hospitalised people who are malnourished or at risk of malnutrition, we wanted to know if different types of nutritional support are better than standard care at: reducing the risk of dying and serious negative health events (e.g. complications such as infections or wound healing); improving people's ability to perform basic daily activities and their quality of life; reducing time spent in hospital; and boosting people's body weight and muscle mass. We also wanted to know which type of nutritional support works best. What did we do? We searched for studies in people 65 years and older who were in hospital and malnourished or at risk of malnutrition. We included studies that compared one type of nutritional support to another type, or compared nutritional support to standard hospital care (i.e. usual hospital food service), sometimes in combination with a 'dummy treatment' that looked identical to the supplements tested. We summarised and compared all treatments, and rated our confidence in the results based on factors such as study methods and the numbers of people included. What did we find? We found 21 studies involving 3309 hospitalised older people with different acute conditions. We grouped the treatments they received into five categories: specialised foods and drinks; protein‐enriched foods or supplements; energy supplements; personalised feeding support from an assistant (who would, for example, accommodate food preferences, adjust someone's position, and help with eating); multi‐component personalised nutritional care from a dietitian or nutritionist (who would, for example, modify foods or offer counselling). Main findings Compared to standard hospital care, after a month in hospital, specialised foods and drinks may: reduce the chance of death: they may lead to 57 fewer deaths per 1000 people; reduce serious negative health events: they may lead to 84 fewer events per 1000 people. Compared to standard hospital care, we are either very uncertain about the effects of specialised foods and drinks, protein‐enriched foods or supplements, energy supplements, personalised feeding support, and multi‐component personalised nutritional care, or these treatments may make little or no difference to people's: ability to perform basic daily activities; quality of life; length of hospital stay; body weight and muscle mass. When we compared the different types of nutritional support to each other, we did not find that any one approach worked better than all others in improving the results we measured. What are the limitations of the evidence? Our confidence in the findings is low or very low for several reasons. Some studies used methods that may have led to errors in the results. Studies often involved too few people, or did not look at everything we were interested in, such as muscle mass as outcome or comparisons of different types of nutritional support. Moreover, older people in hospital have different illnesses and functional abilities, and we could not assess how the different types of nutritional support work for different people. How current is this evidence? The evidence is current to 2 July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E; Schwarzer, G; Stadelmaier, J; Lohner, S; Grummich, K; Dagnelie, PC; Beck, AM; Beelen, J; Botella-Carretero, JI; Faxén-Irving, G; Hickson, M; Iff, S; Johansen, A; Sharma, Y; Sorensen, JM; Kaegi-Braun, N; Wunderle, C; Bongaerts, B; Meerpohl, JJ; Norman, K; Schuetz, P; Torbahn, G; Visser, M; Volkert, D; Schwingshackl, L", "articleTypes": [], "doi": "10.1002/14651858.CD015468.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "63b4b05e-57ba-4f5a-b377-5edba8c58704", "pmid": "", "title": "Chlorambucil for patients with primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. But it is unknown whether it benefits or harms these patients. Objectives To evaluate the beneficial and any harmful effects of chlorambucil for primary biliary cirrhosis patients. Search methods Eligible trials were identified by searching the Cochrane Hepato‐Biliary Group Controlled Trials Register (March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2012, Issue 2), MEDLINE (1946 to March 2012), EMBASE (1974 to March 2012), Science Citation Index EXPANDED (1900 to March 2012), The Chinese Biomedical Database (1976 to March 2012), The Chinese Medical Current Contents (1994 to March 2012), The China Hospital Knowledge Database (1994 to March 2012), and a database of ongoing trials (http://www.controlled‐trials.com/mrct/) (accessed 6 March 2012). The reference lists of the retrieved publications and review articles were also read through, and pharmaceutical companies known to produce chlorambucil were contacted. Selection criteria Randomised clinical trials, irrespective of language, year of publication, and publication status, comparing chlorambucil at any dose versus placebo, no intervention, another active drug, or one dose of chlorambucil with another dose. Data collection and analysis We planned to assess continuous data with mean differences (MD), and dichotomous outcomes with relative risk (RR), both with 95% confidence intervals (CI). As we only identified one trial, Fisher's exact tests were employed. Main results Only one randomised trial was identified and included in the review. The bias risk in the trial was high. The trial compared chlorambucil versus no intervention in 24 patients with primary biliary cirrhosis. Fisher's exact test did not show a significant reduction of mortality when comparing chlorambucil with no treatment (0/13 (0%) versus (2/11 (18.2%); P = 0.20). There was no significant difference regarding adverse events for chlorambucil compared with no treatment, but all patients receiving chlorambucil experienced adverse events (13/13 (100%) versus (3/11 (27%); P = 0.1). According to the authors of the trial, chlorambucil led to a significant improvement in mean serum levels of bilirubin (P < 0.05), albumin (P < 0.05), immunoglobulin M (P < 0.01), serum aspartate aminotransferase activity (P < 0.01), and hepatic inflammatory infiltrates (P < 0.01). Authors' conclusions There is not sufficient evidence to support or reject the use of chlorambucil for patients with primary biliary cirrhosis. Chlorambucil may show benefit in some unvalidated surrogate outcome measures (for example, serum bilirubin and immunoglobulin M levels). Chlorambucil is, however, connected with a number of adverse events. Bone marrow suppression should be noted in particular. Further randomised clinical trials are necessary to assess the benefits and harms of chlorambucil in this indication. Plain language summary Chlorambucil for patients with primary biliary cirrhosis Primary biliary cirrhosis is an autoimmune disease of the liver. Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. This review aimed to assess the beneficial or harmful effects of chlorambucil for primary biliary cirrhosis. The authors identified only one randomised trial, with 24 participants included. This trial compared chlorambucil with no intervention. The trial is small and at a high risk of bias, which suggests that the results may not be reliable. Meta‐analyses were not possible because of the inclusion of one trial only. Fisher's exact test and t‐test were used instead. Chlorambucil was not associated with significantly lower mortality when compared with no intervention. All patients on chlorambucil experienced adverse events, especially bone marrow suppression. Chlorambucil led to a significant improvement in mean serum levels of bilirubin, albumin, immunoglobulin M, serum aspartate aminotransferase activity, and hepatic inflammatory infiltrates. However, these outcomes are unvalidated surrogate outcomes for patient‐relevant outcomes. This means that improvement of these biochemistry measures cannot be taken as proof of improvement of patient‐relevant outcomes. It remains unclear whether chlorambucil can be supported or rejected for use in patients with primary biliary cirrhosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Li, WX; Yan, X; Shi, CR; Zhang, AP", "articleTypes": [], "doi": "10.1002/14651858.CD008714.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "63b757fc-6ff1-420e-84ed-9ce374a83f87", "pmid": "", "title": "The effect of sample site and collection procedure on identification of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Sample collection is a key driver of accuracy in the diagnosis of SARS‐CoV‐2 infection. Viral load may vary at different anatomical sampling sites and accuracy may be compromised by difficulties obtaining specimens and the expertise of the person taking the sample. It is important to optimise sampling accuracy within cost, safety and accessibility constraints. Objectives To compare the sensitivity of different sampling collection sites and methods for the detection of current SARS‐CoV‐2 infection with any molecular or antigen‐based test. Search methods Electronic searches of the Cochrane COVID‐19 Study Register and the COVID‐19 Living Evidence Database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) were undertaken on 22 February 2022. We included independent evaluations from national reference laboratories, FIND and the Diagnostics Global Health website. We did not apply language restrictions. Selection criteria We included studies of symptomatic or asymptomatic people with suspected SARS‐CoV‐2 infection undergoing testing. We included studies of any design that compared results from different sample types (anatomical location, operator, collection device) collected from the same participant within a 24‐hour period. Data collection and analysis Within a sample pair, we defined a reference sample and an index sample collected from the same participant within the same clinical encounter (within 24 hours). Where the sample comparison was different anatomical sites, the reference standard was defined as a nasopharyngeal or combined naso/oropharyngeal sample collected into the same sample container and the index sample as the alternative anatomical site. Where the sample comparison was concerned with differences in the sample collection method from the same site, we defined the reference sample as that closest to standard practice for that sample type. Where the sample pair comparison was concerned with differences in personnel collecting the sample, the more skilled or experienced operator was considered the reference sample. Two review authors independently assessed the risk of bias and applicability concerns using the QUADAS‐2 and QUADAS‐C checklists, tailored to this review. We present estimates of the difference in the sensitivity (reference sample (%) minus index sample sensitivity (%)) in a pair and as an average across studies for each index sampling method using forest plots and tables. We examined heterogeneity between studies according to population (age, symptom status) and index sample (time post‐symptom onset, operator expertise, use of transport medium) characteristics. Main results This review includes 106 studies reporting 154 evaluations and 60,523 sample pair comparisons, of which 11,045 had SARS‐CoV‐2 infection. Ninety evaluations were of saliva samples, 37 nasal, seven oropharyngeal, six gargle, six oral and four combined nasal/oropharyngeal samples. Four evaluations were of the effect of operator expertise on the accuracy of three different sample types. The majority of included evaluations (146) used molecular tests, of which 140 used RT‐PCR (reverse transcription polymerase chain reaction). Eight evaluations were of nasal samples used with Ag‐RDTs (rapid antigen tests). The majority of studies were conducted in Europe (35/106, 33%) or the USA (27%) and conducted in dedicated COVID‐19 testing clinics or in ambulatory hospital settings (53%). Targeted screening or contact tracing accounted for only 4% of evaluations. Where reported, the majority of evaluations were of adults (91/154, 59%), 28 (18%) were in mixed populations with only seven (4%) in children. The median prevalence of confirmed SARS‐CoV‐2 was 23% (interquartile (IQR) 13%‐40%). Risk of bias and applicability assessment were hampered by poor reporting in 77% and 65% of included studies, respectively. Risk of bias was low across all domains in only 3% of evaluations due to inappropriate inclusion or exclusion criteria, unclear recruitment, lack of blinding, nonrandomised sampling order or differences in testing kit within a sample pair. Sixty‐eight percent of evaluation cohorts were judged as being at high or unclear applicability concern either due to inflation of the prevalence of SARS‐CoV‐2 infection in study populations by selectively including individuals with confirmed PCR‐positive samples or because there was insufficient detail to allow replication of sample collection. When used with RT‐PCR • There was no evidence of a difference in sensitivity between gargle and nasopharyngeal samples (on average ‐1 percentage points, 95% CI ‐5 to +2, based on 6 evaluations, 2138 sample pairs, of which 389 had SARS‐CoV‐2). • There was no evidence of a difference in sensitivity between saliva collection from the deep throat and nasopharyngeal samples (on average +10 percentage points, 95% CI ‐1 to +21, based on 2192 sample pairs, of which 730 had SARS‐CoV‐2). • There was evidence that saliva collection using spitting, drooling or salivating was on average ‐12 percentage points less sensitive (95% CI ‐16 to ‐8, based on 27,253 sample pairs, of which 4636 had SARS‐CoV‐2) compared to nasopharyngeal samples. We did not find any evidence of a difference in the sensitivity of saliva collected using spitting, drooling or salivating (sensitivity difference: range from ‐13 percentage points (spit) to –21 percentage points (salivate)). • Nasal samples (anterior and mid‐turbinate collection combined) were, on average, 12 percentage points less sensitive compared to nasopharyngeal samples (95% CI ‐17 to ‐7), based on 9291 sample pairs, of which 1485 had SARS‐CoV‐2. We did not find any evidence of a difference in sensitivity between nasal samples collected from the mid‐turbinates (3942 sample pairs) or from the anterior nares (8272 sample pairs). • There was evidence that oropharyngeal samples were, on average, 17 percentage points less sensitive than nasopharyngeal samples (95% CI ‐29 to ‐5), based on seven evaluations, 2522 sample pairs, of which 511 had SARS‐CoV‐2. A much smaller volume of evidence was available for combined nasal/oropharyngeal samples and oral samples. Age, symptom status and use of transport media do not appear to affect the sensitivity of saliva samples and nasal samples. When used with Ag‐RDTs • There was no evidence of a difference in sensitivity between nasal samples compared to nasopharyngeal samples (sensitivity, on average, 0 percentage points ‐0.2 to +0.2, based on 3688 sample pairs, of which 535 had SARS‐CoV‐2). Authors' conclusions When used with RT‐PCR, there is no evidence for a difference in sensitivity of self‐collected gargle or deep‐throat saliva samples compared to nasopharyngeal samples collected by healthcare workers when used with RT‐PCR. Use of these alternative, self‐collected sample types has the potential to reduce cost and discomfort and improve the safety of sampling by reducing risk of transmission from aerosol spread which occurs as a result of coughing and gagging during the nasopharyngeal or oropharyngeal sample collection procedure. This may, in turn, improve access to and uptake of testing. Other types of saliva, nasal, oral and oropharyngeal samples are, on average, less sensitive compared to healthcare worker‐collected nasopharyngeal samples, and it is unlikely that sensitivities of this magnitude would be acceptable for confirmation of SARS‐CoV‐2 infection with RT‐PCR. When used with Ag‐RDTs, there is no evidence of a difference in sensitivity between nasal samples and healthcare worker‐collected nasopharyngeal samples for detecting SARS‐CoV‐2. The implications of this for self‐testing are unclear as evaluations did not report whether nasal samples were self‐collected or collected by healthcare workers. Further research is needed in asymptomatic individuals, children and in Ag‐RDTs, and to investigate the effect of operator expertise on accuracy. Quality assessment of the evidence base underpinning these conclusions was restricted by poor reporting. There is a need for further high‐quality studies, adhering to reporting standards for test accuracy studies. Plain language summary How accurate are different types of sample collection for diagnosing COVID‐19 infection? Key messages • When used with RT‐PCR tests (a molecular test that detects genetic material in COVID‐19 using a technique called reverse transcription polymerase chain reaction), self‐collected gargle and deep throat saliva samples have a similar sensitivity compared to trained healthcare worker‐collected nasopharyngeal samples (taken from the back of the throat through the nose) in detecting COVID‐19. • When used with RT‐PCR, samples collected from the nose, oropharynx (throat via the mouth), oral cavity, and other saliva collection methods are less sensitive for detecting COVID‐19 compared to healthcare worker‐collected nasopharyngeal samples. • When used with rapid antigen tests (Ag‐RDTs; at‐home/self‐tests), samples collected from the nose have a similar sensitivity to healthcare worker‐collected nasopharyngeal samples in detecting COVID‐19. Why is improving the diagnosis of COVID‐19 important? Coronavirus disease (COVID‐19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). People with suspected COVID‐19 may decide to take a test to know whether they are infected, so that they can receive treatment, and follow recommended guidance to self‐isolate and inform close contacts. Not detecting COVID‐19 when it is present (a false negative result) risks spreading infection and results in missed opportunities for treatment. Types of sample collection methods for diagnosing COVID‐19? The type and quality of sample taken for confirmation of COVID‐19 affects the reliability of diagnosis. The most accurate type of sample to diagnose COVID‐19 is that taken by a trained healthcare worker from the back of the throat through the nose (a nasopharyngeal sample). This type of test detects genetic material in the virus using a technique called reverse transcription polymerase chain reaction (RT‐PCR). However, this sample is difficult to obtain correctly, causes discomfort and risks spreading infection if individuals cough or sneeze when the sample is taken. Alternative sample types, particularly those that can be self‐collected using rapid antigen tests (Ag‐RDTs; i.e. self‐tests), may reduce cost and discomfort and improve the safety of sampling. This may, in turn, improve access to and uptake of testing. What did we want to find out? We wanted to compare the sensitivity of different sample sites and collection methods in detecting COVID‐19 with molecular tests (RT‐PCR tests) or self‐based tests (Ag‐RDT tests). What did we do? We searched for studies that had compared the accuracy of nasopharyngeal samples to any alternative that could be used in patients outside of hospital, including nose (nasal) samples, throat samples taken through the mouth (oropharyngeal), gargle samples and saliva samples. We looked at the use of samples with either RT‐PCR or Ag‐RDTs. We also searched for studies that had compared different methods for taking samples, such as samples collected by a healthcare worker compared to those collected by individuals with no or minimal instructions. What did we find? The review included 106 studies with a total of 60,523 participants, of whom 11,045 had COVID‐19 infection. Fifty‐nine per cent of studies were conducted on adults and 79% on symptomatic or mixed symptomatic and asymptomatic participants. Sixty per cent of studies took place in Europe or the USA; just over half (55%) took place in dedicated COVID‐19 testing centres or in outpatient settings. Main results With RT‐PCR, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also test positive on self‐collected gargle samples or saliva samples (collected by coughing and then spitting (deep throat saliva)); ‐ 88% of positive nasopharyngeal samples collected by healthcare workers would also test positive with self‐ or healthcare worker‐collected nose samples; ‐ 87% of positive nasopharyngeal samples collected by healthcare workers would also be detected by saliva self‐collected using spitting, 84% by saliva self‐collected using drooling and 79% by saliva self‐collected by sucking on a swab; and ‐ 83% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐ or healthcare worker‐collected oropharyngeal samples. With Ag‐RDTs, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐collected or healthcare worker‐collected nose samples. Summary results The results of these studies indicate that in a group of 1000 people, of whom 230 (23%) have COVID‐19, then: when used with PCR, compared to healthcare worker‐collected nasopharyngeal samples: ‐ no cases of COVID‐19 would be missed using self‐collected gargle samples (12 less to 5 more) or deep throat saliva samples (2 less to 48 more); ‐ 28 (16 to 39) fewer cases of COVID‐19 infection would be detected using healthcare worker‐ or self‐collected nose sample; ‐ 30 (18 to 41) fewer cases of COVID‐19 infection would be detected by saliva self‐collected using spitting, 37 (12 to 62) fewer by saliva collected by drooling and 48 (12 to 85) fewer by saliva collected by sucking on a swab; ‐ 39 (12 to 67) fewer cases of COVID‐19 infection would be detected by healthcare worker‐ or self‐collected oropharyngeal samples; and when used with Ag‐RDTs, compared to healthcare worker‐collected nasopharyngeal samples: no cases of COVID‐19 infection would be missed using healthcare worker‐ or self‐collected nose samples. What are the limitations of the evidence? It was often not clear whether included studies deliberately excluded inadequate samples or whether the results of the more accurate nasopharyngeal sample were known when alternative samples were interpreted. This may have resulted in alternative sample types appearing more accurate than they are in practice, decreasing the number of missed cases of COVID‐19 infection. More than half of studies did not give information about how long participants had had symptoms at the time of sampling. This reduces our confidence in the comparison of different sample types. Most studies evaluated self‐collected samples by adults with symptoms for use with RT‐PCR; therefore, the findings of this review may not be applicable to asymptomatic individuals or children. For studies conducted with Ag‐RDTs, it is unclear whether sensitivity estimates of nose samples are applicable to home use (self‐collected and self‐interpreted). How up to date is this review? The evidence is current to 22 February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Davenport, C, Arevalo-Rodriguez, I, Mateos-Haro, M, Berhane, S, Dinnes, J, Spijker, R, Buitrago-Garcia, D, Ciapponi, A, Takwoingi, Y, Deeks, JJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014780", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.104Z" }, { "id": "63bd79f5-3229-4262-b79b-a0eecbc0877a", "pmid": "", "title": "Dietary marine fatty acids (fish oil) for asthma in adults and children", "imported": false, "abstract": "Abstract - Background Epidemiological studies suggest that a diet high in marine fatty acids (fish oil) may have beneficial effects on inflammatory conditions such as rheumatoid arthritis and possibly asthma. Objectives (1) To determine the effect of marine n‐3 fatty acid (fish oil) supplementation in asthma.
 (2) To determine the effect of a diet high in fish oil in asthma. Search methods We searched the Cochrane Airways Group Specialised Register. We also searched bibliographies of retrieved trials and contacted fish oil manufacturers. Searches were current as of May 2010. Selection criteria We included randomised controlled trials in patients with asthma more than two years of age. The study duration had to be in excess of four weeks. Double blind trials were preferred, but we also reviewed single‐blind and open trials for possible inclusion. All four reviewers read each paper, blind to its identity. Decisions concerning inclusion were made by simple majority. We all performed quality assessment independently. Data collection and analysis The only comparison possible was between marine n‐3 fatty acid supplementation and placebo. There were insufficient trials to examine dietary manipulation alone. Main results Nine randomised controlled trials conducted between 1986 and 2001 satisfied the inclusion criteria. Seven were of parallel design and two were cross‐over studies. Eight compared fish oil with placebo whilst one compared high dose versus low dose marine n‐3 fatty acid supplementation. Two studies were conducted in children, whilst the remaining seven studies were conducted in adults. None of the included studies reported asthma exacerbations, health status or hospital admissions. There was no consistent effect on any of the analysable outcomes: FEV1, peak flow rate, asthma symptoms, asthma medication use or bronchial hyper reactivity. One of the studies performed in children which combined dietary manipulation with fish oil supplementation showed improved peak flow and reduced asthma medication use. There were no adverse events associated with fish oil supplements. Authors' conclusions There is little evidence to recommend that people with asthma supplement or modify their dietary intake of marine n‐3 fatty acids (fish oil) in order to improve their asthma control. Equally, there is no evidence that they are at risk if they do so. Plain language summary Dietary marine fatty acids (fish oil) for asthma in adults and children Eating more fish has been recommended as one way of possibly reducing asthma. Populations (such as Eskimo communities) with diets high in fish also have low rates of asthma. As diets in other communities have become higher in saturated fats, asthma has also increased. The theory has been that an ingredient in fish oil may reduce inflammation. Inflammation causes the swelling in the airways of the lungs that leads to asthma attacks. However, this review of trials found that people with asthma changing their diets to include more fish oil did not improve their asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Thien, FCK; De Luca, S; Woods, RK; Abramson, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD001283", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "63c3a177-3809-4c7c-b619-9bbc897e67a9", "pmid": "", "title": "Topical silver diamine fluoride (SDF) for preventing and managing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is the world's most prevalent disease. Untreated caries can cause pain and negatively impact psychosocial health, functioning, and nutrition. It is important to identify cost‐effective, easy‐to‐use agents, which can prevent or arrest caries. This review evaluates silver diamine fluoride (SDF). Objectives To assess the effects of silver diamine fluoride for preventing and managing caries in primary and permanent teeth (coronal and root caries) compared to any other intervention including placebo or no treatment. Search methods We searched CENTRAL, MEDLINE, Embase, Cochrane Oral Health's Trial Register and two clinical trials registers in June 2023. Selection criteria We included randomised controlled trials (RCTs), with parallel‐group or split‐mouth design, in children and adults (with or without carious lesions) that compared SDF with placebo or no treatment; different frequencies, concentrations or duration of SDF; or any other intervention. Data collection and analysis We used standard methodological procedures expected by Cochrane, and GRADE to assess the certainty of the evidence. We collected data for primary caries prevention (change in caries increment), arrest of carious lesions, secondary prevention of caries (lesions do not progress from initial classification), adverse effects, dental pain or sensitivity, and aesthetics at the end of study follow‐up. Main results We included 29 RCTs (13,036 participants; 12,020 children, 1016 older adults). We summarise outcome data for the five most clinically relevant comparisons. All studies included high risks of bias, and some findings were imprecise (e.g. because of small sample sizes). SDF versus placebo or no treatment (14 studies; 2695 children, 905 older adults) Compared to placebo or no treatment, SDF may help prevent new caries in the primary dentition (1 study, 373 participants), or on the coronal surfaces of permanent dentition (1 study, 373 participants) but the evidence is very uncertain. SDF likely prevents new root caries (mean difference (MD) −0.79 surfaces, 95% confidence interval (CI) −1.40 to −0.17; 3 studies, 439 participants; moderate‐certainty evidence). SDF may help arrest caries in the primary dentition (MD 0.86 surfaces, 95% CI 0.39 to 1.33; 2 studies, 841 participants; low‐certainty evidence) and the permanent dentition (coronal: 1 study, 373 participants; root: 1 study, 158 participants) but the evidence is very uncertain. The evidence is very uncertain for secondary prevention of caries (primary dentition: 1 study, 128 participants; permanent dentition (coronal): 1 study, 663 participants), for adverse effects (5 studies, 1299 participants), and aesthetics (1 study, 43 participants). Different approaches to SDF application (5 studies, 1808 children) Studies compared different frequencies or intervals of application, different concentrations of SDF, and different durations of treatment. Some studies included multiple comparisons of different approaches. Because of the different approaches, we could not combine findings from these studies. Due to very low‐certainty evidence, we were unsure whether any approach to SDF application was better than another for caries arrest (4 studies, including 8 comparisons of different approaches, 1360 participants); secondary prevention of caries (1 study, 203 participants), or led to differences in adverse effects (3 studies, 1121 children) or aesthetics (1 study, 119 children). SDF versus fluoride varnish (8 studies, 2868 children, 223 older adults) Compared to flouride varnish, SDF may result in little or no difference to the prevention of new caries in the primary dentition (MD 0.00, 95% CI ‐0.26 to 0.26; 1 study, 434 participants; low‐certainty evidence). The evidence is very uncertain for this outcome measure in the permanent dentition (coronal: 1 study, 237 participants; root: 1 study, 100 participants; very low‐certainty evidence). Due to very low‐certainty evidence, we were unsure whether or not there were any differences between flouride varnish (applied weekly for three applications) and SDF for caries arrest and secondary prevention of caries in the primary dentition (1 study, 309 participants). Similarly, we were unsure of adverse effects (3 studies, 980 children), dental pain or sensitivity (1 study, 62 children), or aesthetics (1 study, 263 children). SDF versus sealants and resin infiltration (2 studies, 343 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other for primary prevention of caries in permanent dentition (coronal: 1 study, 242 participants), or adverse effects (2 studies, 336 participants). SDF versus atraumatic restorative treatment (ART) with glass ionomer cement (GIC) or GI material (4 studies, 610 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other at arresting caries in the primary dentition (1 study, 143 participants). We were also unsure whether there were any differences between treatments in adverse effects (3 studies, 482 participants), dental pain or sensitivity (1 study, 234 participants), or aesthetics (2 studies, 248 participants). Authors' conclusions In the primary dentition, evidence remains uncertain whether SDF prevents new caries or progression of existing caries compared to placebo or no treatment, but it may offer benefit over placebo or no treatment in caries arrest. Compared to placebo or no treatment, SDF probably also helps prevent new root caries. However, the evidence is uncertain for other caries outcome measures in this dentition and in all caries outcomes for coronal surfaces of permanent dentition. Compared to flouride varnish, SDF may offer little or no benefit in preventing new caries in the primary dentition, but the evidence is very uncertain for other caries outcome measures in the primary dentition and for preventing new caries in the permanent dentition. We were unable to establish whether one SDF treatment approach was better than another, or how SDF compared to other treatments, because of very low‐certainty evidence. The impact of SDF staining of teeth was poorly reported and the evidence for adverse effects is very uncertain. Additional well‐conducted studies are needed. These should measure the impact of staining and be analysed to take account of clustering issues within participants. Plain language summary Is silver diamine fluoride varnish an effective treatment for preventing and managing tooth decay in children and adults? Key messages ‐ We can't tell if silver diamine fluoride (SDF) is better than no treatment at preventing or treating tooth decay. ‐ We can't tell if SDF is better or worse than other treatments at preventing or treating tooth decay. ‐ New studies could help to find out about the unwanted effects of SDF, whether people are bothered by the staining on the teeth caused by SDF, and the best treatment approach. What is tooth decay? Tooth decay happens when bacteria in your mouth break down sugars from food, producing acids that damage tooth enamel (hard surfaces). This can lead to holes, or cavities, in the teeth. Tooth decay affects the crown of the tooth (the part above the gum) of baby teeth, and the crown and root of permanent teeth. If it is not prevented or treated it can cause toothache, infections and tooth loss. How is tooth decay treated? Treatments for tooth decay include liquids, gels (varnishes) and sealants. These treatments are painted onto the tooth to protect against bacteria. Treatment may also include fillings in larger cavities. Silver diamine fluoride (SDF) is a low‐cost liquid that can be painted on a tooth by a dentist or another trained person. It is suitable for people of all ages, including people with special health needs. However, SDF can permanently stain the treated tooth surface black or dark brown. What did we want to find out? We wanted to find out: ‐ if SDF was better than no treatment or other treatments at preventing new tooth decay, stopping existing tooth decay or preventing tooth decay from progressing; ‐ if there were benefits to applying SDF for different numbers of times, strengths of solution, or durations; ‐ if SDF caused unwanted effects, toothache, or if people were bothered by staining. What did we do? We searched for studies that compared SDF with no treatment or placebo (a dummy treatment), other treatments, or different application approaches. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 29 studies, with 12,020 children and 1016 older adults. Main results Compared with no treatment or placebo, we can't tell if SDF prevents new tooth decay in baby teeth or crown surfaces of permanent teeth. SDF is likely to prevent new tooth decay on root surfaces of permanent teeth. It may also completely stop existing tooth decay in baby teeth. However, we are unsure if it completely stops existing tooth decay on crown and root surfaces of permanent teeth, prevents existing tooth decay from progressing in any types of teeth, increases the risk of unwanted effects, or if people are bothered by the appearance of staining. Studies used different combinations of treatment approaches (number of times SDF is applied and how often, the strength of solution, and duration of treatment). We can't tell if one approach is better than another at stopping or preventing further decay, unwanted effects, or bother with appearance of staining. When SDF is compared with fluoride varnish, neither treatment may be better than the other at preventing new tooth decay in baby teeth. We are unsure about the effect on crown and root surfaces of permanent teeth. We also can't tell if either treatment is better than the other at stopping existing tooth decay or preventing further decay in baby teeth, or if there are any differences in unwanted effects, toothache, or bother with appearance of staining. When SDF is compared with sealants, we can't tell if there are any differences between treatments in preventing new tooth decay on the crown surfaces of permanent teeth, or whether there are any differences between these treatments in unwanted effects. When SDF is compared with fillings (with tooth decay first removed using only hand tools), we can't tell if there were any differences between treatments in stopping existing decay in baby teeth, unwanted effects, toothache, or bother with appearance of staining. What are the limitations of the evidence? Often we were very unsure of the evidence for the following reasons. ‐ SDF stains the teeth. Everyone in the studies would have known what treatment they were given. This might affect their usual teeth‐brushing routine. In most studies, the person checking teeth for new or existing decay would also have known this information. ‐ When we compared different approaches to SDF, the studies were too different from one another to allow us to compare them. ‐ Although we found 29 studies, most evidence was from individual (or few) studies, which were very small. How current is this evidence? The evidence is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Worthington, HV, Lewis, SR, Glenny, A-M, Huang, SS, Innes, NPT, O'Malley, L, Riley, P, Walsh, T, Wong, MC, Clarkson, JE, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012718.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.732Z" }, { "id": "63cf525a-4a28-4aee-b933-4cbf65fd915f", "pmid": "", "title": "Interventions for the management of dry mouth: non‐pharmacological interventions", "imported": false, "abstract": "Abstract - Background Xerostomia is the subjective sensation of dry mouth. Common causes of xerostomia include adverse effects of many commonly prescribed medications, disease (e.g. Sjogren's Syndrome) and radiotherapy treatment for head and neck cancers. Non‐pharmacological techniques such as acupuncture or mild electrostimulation may be used to improve symptoms. Objectives To assess the effects of non‐pharmacological interventions administered to stimulate saliva production for the relief of dry mouth. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 16th April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 3), MEDLINE via OVID (1948 to 16th April 2013), EMBASE via OVID (1980 to 16th April 2013), AMED via OVID (1985 to 16th April 2013), CINAHL via EBSCO (1981 to 16th April 2013), and CANCERLIT via PubMed (1950 to 16th April 2013). The meta Register of Controlled Clinical Trials ( www.controlled‐trials.com ) and ClinicalTrials.gov ( www.clinicaltrials.gov ) were also searched to identify ongoing and completed trials. References lists of included studies and relevant reviews were also searched. There were no restrictions on the language of publication or publication status. Selection criteria We included parallel group randomised controlled trials of non‐pharmacological interventions to treat dry mouth, where participants had dry mouth symptoms at baseline. Data collection and analysis At least two review authors assessed each of the included studies to confirm eligibility, assess risk of bias and extract data using a piloted data extraction form. We calculated mean difference (MD) and 95% confidence intervals (CI) for continuous outcomes or where different scales were used to assess an outcome, we calculated standardised mean differences (SMD) together with 95% CIs. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information. Main results There were nine studies (total 366 participants randomised) included in this review of non‐pharmacological interventions for dry mouth which were divided into three comparisons. Eight studies were assessed at high risk of bias in at least one domain and the remaining study was at unclear risk of bias. Five small studies (total 153 participants, with dry mouth following radiotherapy treatment) compared acupuncture with placebo. Four were assessed at high risk and one at unclear risk of bias. Two trials reported outcome data for dry mouth in a form suitable for meta‐analysis. The pooled estimate of these two trials (70 participants, low quality evidence) showed no difference between acupuncture and control in dry mouth symptoms (SMD ‐0.34, 95% CI ‐0.81 to 0.14, P value 0.17, I 2 = 39%) with the confidence intervals including both a possible reduction or a possible increase in dry mouth symptoms. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). There was a very small increase in unstimulated whole saliva (UWS) at the end of 4 to 6 weeks of treatment (three trials, 71 participants, low quality evidence) (MD 0.02 ml/minute, 95% CI 0 to 0.04, P value 0.04, I 2 = 57%), and this benefit persisted at the 12‐month follow‐up evaluation (two trials, 54 participants, low quality evidence) (UWS, MD 0.06 ml/minute, 95% CI 0.01 to 0.11, P value 0.03, I 2 = 10%). For the outcome of stimulated whole saliva (SWS, three trials, 71 participants, low quality evidence) there was a benefit favouring acupuncture (MD 0.19 ml/minute, 95% CI 0.07 to 0.31, P value 0.002, I 2 = 1%) an effect which also persisted at the 12‐month follow‐up evaluation (SWS MD 0.28 ml/minute, 95% CI 0.09 to 0.47, P value 0.004, I 2 = 0%) (two trials, 54 participants, low quality evidence). Two small studies, both at high risk of bias, compared the use of an electrostimulation device with a placebo device in participants with Sjögren's Syndrome (total 101 participants). A further study, also at high risk of bias, compared acupuncture‐like electrostimulation of different sets of points in participants who had previously been treated with radiotherapy. None of these studies reported the outcome of dry mouth. There was no difference between electrostimulation and placebo in the outcomes of UWS or SWS at the end of the 4‐week treatment period in the one study (very low that provided data for these outcomes. No adverse effects were reported. A single study at high risk of bias, compared the stimulatory effect of powered versus manual toothbrushing and found no difference for the outcomes of UWS or SWS. Authors' conclusions There is low quality evidence that acupuncture is no different from placebo acupuncture with regard to dry mouth symptoms, which is the most important outcome. This may be because there were insufficient participants included in the two trials to show a possible effect or it may be that there was some benefit due to 'placebo' acupuncture which could have biased the effect to the null. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms. It is well known that dry mouth symptoms may be problematic even when saliva production is increased, yet only two of the trials that evaluated acupuncture reported dry mouth symptoms, a worrying reporting bias. There is some low quality evidence that acupuncture results in a small increase in saliva production in patients with dry mouth following radiotherapy. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms or saliva production in patients with Sjögren's Syndrome. Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation. Plain language summary Non‐drug treatments for dry mouth symptoms Review question This review, carried out by authors of the Cochrane Oral Health Group, has been produced to assess the effects of non‐drug treatments used to stimulate saliva production for the relief of dry mouth (xerostomia) symptoms. Background Dry mouth is a common problem with an estimated incidence of between 10% and 26% in men and between 10% and 33% in women, which may or may not be due to reduced saliva secretion. Common causes of dry mouth include the side effects of many commonly prescribed medications, diseases (such as Sjögren's syndrome where the immune system destroys tissues in the glands which produce saliva) and radiotherapy treatments for head and neck cancers. Saliva moistens the skin in the mouth and helps to maintain oral health. The presence of saliva facilitates speech, acts to wash away food residue from around the teeth, neutralises potentially damaging food and bacterial acids, enhances a person's ability to taste the food, and generally lubricates the mouth. Saliva also acts to soften food, making it easier to chew and swallow. Enzymes in saliva start the digestion of starch and fats, and other substances in saliva, such as epidermal growth factors, promote tissue growth, differentiation and wound healing. The antibacterial, antifungal and antiviral agents in saliva balance the oral flora and help to prevent oral infections, while the minerals in saliva help to maintain tooth enamel. Non‐drug treatments such as acupuncture, mild electrical stimulation, lasers, tooth brushing and other stimulation techniques are used to improve dry mouth symptoms. Study characteristics The evidence on which this review is based was up‐to‐date as of 16 April 2013. Nine studies were included in this review. A total of 366 adult participants took part in these trials, with an average of 40 participants per trial, and an age range from 12 to 77 years. The causes of dry mouth were radiotherapy for oral cancers in four trials, Sjögren's syndrome in three trials, medication‐related in one trial, and in the remaining trial participants had a range of causes of dry mouth. The included studies were divided into three groups, according the interventions evaluated. 1. Five small studies with a total 153 participants evaluated acupuncture. 2. Three studies evaluated electrostimulation devices. 3. One study evaluated a power toothbrush. Key results The five studies evaluating the effects of acupuncture in people who had dry mouth were generally of poor quality. There was no evidence of a difference in dry mouth symptoms, but there was some evidence of a small increase in saliva production which persisted for a year after the end of the acupuncture treatment. There may not have been enough people included in the trials to show a difference in dry mouth, or it may have been that both the real acupuncture and the 'placebo' acupuncture had some beneficial effect. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). The studies evaluating the effects of electrostimulation devices were poorly conducted and reported, and provided insufficient evidence to determine the effects of these devices on either dry mouth or saliva production. The single small study of a powered versus a manual toothbrush also found no difference for either dry mouth or saliva production. None of the included studies reported the outcomes of duration of effectiveness, quality of life, patient satisfaction, or oral health assessment. Quality of the evidence These studies were generally of poor quality (low and very low).", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Furness, S; Bryan, G; McMillan, R; Birchenough, S; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD009603.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "63d0491e-7041-4911-b8ea-74b13c2d14a6", "pmid": "", "title": "Treatment for recurrent vulvovaginal candidiasis (thrush)", "imported": false, "abstract": "Abstract - Background Recurrent vulvovaginal candidiasis (RVVC) affects up to 5% of women. No comprehensive systematic review of treatments for RVVC has been published. Objectives The primary objective was to assess the effectiveness and safety of pharmacological and non‐pharmacological treatments for RVVC. The secondary objective was to assess patient preference of treatment options. Search methods We conducted electronic searches of bibliographic databases, including CENTRAL, MEDLINE, Embase, and CINAHL (search date 6 October 2021). We also handsearched reference lists of identified trials and contacted authors of identified trials, experts in RVVC, and manufacturers of products for vulvovaginal candidiasis. Selection criteria We considered all published and unpublished randomised controlled trials evaluating RVVC treatments for at least six months, in women with four or more symptomatic episodes of vulvovaginal candidiasis in the past year. We excluded women with immunosuppressive disorders or taking immunosuppressant medication. We included women with diabetes mellitus and pregnant women. Diagnosis of RVVC must have been confirmed by presence of symptoms and a positive culture and/or microscopy. We included all drug and non‐drug therapies and partner treatment, assessing the following primary outcomes: • number of clinical recurrences per participant per year (recurrence defined as clinical signs and positive culture/microscopy);
• proportion of participants with at least one clinical recurrence during the treatment and follow‐up period; and
• adverse events. Data collection and analysis Two authors independently reviewed titles and abstracts to identify eligible trials. Duplicate data extraction was completed independently by two authors. We assessed risk of bias as described in the Cochrane Handbook for Systematic Reviews of Interventions . We used the fixed‐effects model for pooling and expressed the results as risk ratio (RR) with 95% confidence intervals (CI). Where important statistical heterogeneity was present we either did not pool data (I 2 > 70%) or used a random‐effects model (I 2 40‐70%). We used the GRADE tool to assess overall certainty of the evidence for the pooled primary outcomes. Main results Studies: Twenty‐three studies involving 2212 women aged 17 to 67 years met the inclusion criteria. Most studies excluded pregnant women and women with diabetes or immunosuppression. The predominant species found on culture at study entry was Candida albicans . Overall, the included studies were small (<100 participants). Six studies compared antifungal treatment with placebo (607 participants); four studies compared oral versus topical antifungals (543 participants); one study compared different oral antifungals (45 participants); two studies compared different dosing regimens for antifungals (100 participants); one study compared two different dosing regimens of the same topical agent (23 participants); one study compared short versus longer treatment duration (26 participants); two studies assessed the effect of partner treatment (98 participants); one study compared a complementary treatment (Lactobacillus vaginal tablets and probiotic oral tablets) with placebo (34 participants); three studies compared complementary medicine with antifungals (354 participants); two studies compared 'dermasilk' briefs with cotton briefs (130 participants); one study examined Lactobacillus vaccination versus heliotherapy versus ciclopyroxolamine (90 participants); one study compared CAM treatments to an antifungal treatment combined with CAM treatments (68 participants). We did not find any studies comparing different topical antifungals. Nine studies reported industry funding, three were funded by an independent source and eleven did not report their funding source. Risk of bias: Overall, the risk of bias was high or unclear due to insufficient blinding of allocation and participants and poor reporting. Primary outcomes: Meta‐analyses comparing drug treatments (oral and topical) with placebo or no treatment showed there may be a clinically relevant reduction in clinical recurrence at 6 months (RR 0.36, 95% CI 0.21 to 0.63; number needed to treat for an additional beneficial outcome (NNTB) = 2; participants = 607; studies = 6; I² = 82%; low‐certainty evidence) and 12 months (RR 0.80, 95% CI 0.72 to 0.89; NNTB = 6; participants = 585; studies = 6; I² = 21%; low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. We are very uncertain whether oral drug treatment compared to topical treatment increases the risk of clinical recurrence at 6 months (RR 1.66, 95% CI 0.83 to 3.31; participants = 206; studies = 3; I² = 0%; very low‐certainty evidence) and reduces the risk of clinical recurrence at 12 months (RR 0.95, 95% CI 0.71 to 1.27; participants = 206; studies = 3; I² = 10%; very low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. Adverse events were scarce across both treatment and control groups in both comparisons. The reporting of adverse events varied amongst studies, was generally of very low quality and could not be pooled. Overall the adverse event rate was low for both placebo and treatment arms and ranged from less than 5% to no side effects or complications. Authors' conclusions In women with RVVC, treatment with oral or topical antifungals may reduce symptomatic clinical recurrences when compared to placebo or no treatment. We were unable to find clear differences between different treatment options (e.g. oral versus topical treatment, different doses and durations). These findings are not applicable to pregnant or immunocompromised women and women with diabetes as the studies did not include or report on them. More research is needed to determine the optimal medication, dose and frequency. Plain language summary The effectiveness and safety of treatments for recurrent vulvovaginal candidiasis (thrush) Review question Cochrane authors set out to investigate the effectiveness and safety of drug treatments or non‐drug treatments (such as complementary and alternative medicines) for women with recurrent vulvovaginal candidiasis (thrush). Background Thrush of the vaginal/vulvar area is caused by Candida , a form of yeast that is commonly found in the vagina as part of normal flora without causing symptoms. For unknown reasons, Candida can start growing and cause symptoms of vulvovaginal candidiasis (commonly named thrush). Symptoms of vulvovaginal thrush include itching, swelling, and irritation of the vaginal and vulval areas. It is estimated that uncomplicated vulvovaginal thrush affects up to 75% of women at some time during their reproductive years. Recurrent vulvovaginal candidiasis (RVVC) occurs when a woman has four or more fungal infections during a 12‐month period. Up to 5% of women suffer from RVVC. Some doctors advise taking antifungals as a prevention, but there are no clear evidence‐based guidelines. Study characteristics We identified 23 studies involving 2212 participants between 17 and 67 years old with a diagnosis of RVVC confirmed by a positive test. The studies compared a range of antifungal medicines (taken by mouth or inserted into the vagina), and some complementary or alternative treatments (such as Lactobacillus vaccines or probiotics and special underwear). The studies reported the effects on recurrence of thrush after 6 and 12 months. Only one study reported the number of clinical recurrences at 12 months. Nine studies reported industry funding, three were funded by an independent source and nine studies did not report their funding source. The evidence is current to October 2021. Key results Six studies (607 participants) compared antifungal medication with placebo or no treatment. Based on low certainty evidence antifungal treatments may give a clinically relevant reduction in clinical recurrence at 6 and 12 months. We are uncertain if oral treatments are better than topical treatments (very low certainty evidence for no difference). Adverse effects of taking antifungal medication to prevent recurrence of thrush were not common. Studies reported on adverse effects differently, making comparisons difficult. More research is needed to determine the optimal medication, dose and frequency. We were unable to determine the effects in women who are pregnant or have diabetes. Certainty of the evidence Our confidence in the evidence was low to very low due to serious concerns about risk of bias, unclear reporting and the limited number of studies that could be combined. This means that new studies might change our confidence in the effects of treatments and our conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Cooke, G; Watson, C; Deckx, L; Pirotta, M; Smith, J; van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009151.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "63d88c93-fce3-4f05-b907-3155ddfd3787", "pmid": "", "title": "Immunosuppressive agents for myasthenia gravis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Hart, IK, Sathasivam, S, Sharshar, T", "articleTypes": [], "doi": "10.1002/14651858.CD005224.pub2 AB - Abstract - Background The benefits of different immunosuppressants for myasthenia gravis (MG) are unclear. Objectives Assessment of immunosuppressant drug efficacy in MG. Search methods We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to July 2007), EMBASE (from January 1980 to July 2007), review and trial bibliographies and contacted trial authors. Selection criteria Types of studies: Randomised and quasi‐randomised controlled trials. Types of participants: Any age, any type or severity of MG regardless of concomitant treatment. Types of interventions: Any immunosuppressive agent. Types of outcome measures: Primary: 
 (1) Improvement or not at six months Secondary: 
 (1) Improvement or not at one year 
 (2) Need for other treatment, for example corticosteroid dose, at six months 
 (3) Number of exacerbations during the first year 
 (4) Acetylcholine receptor antibody titre after at least six months 
 (5) Occurrence of one or more adverse events at any time after the introduction of treatment. Data collection and analysis One author extracted and two checked the data. Main results Seven trials are included but few reported the outcomes selected for this review. A meta‐analysis of ciclosporin versus placebo from two trials (59 participants) ‐ one as monotherapy (20 participants) and the other with corticosteroids (39 participants) ‐ showed that it resulted in improvement of participants in the ciclosporin group compared with those in the placebo group, with a relative rate of improvement of 2.44 (95% confidence interval (CI) 1.13 to 5.27). In addition the weighted mean difference in QMG score between the ciclosporin and placebo groups was ‐0.34 (95% CI ‐0.52 to ‐0.17). Azathioprine (plus prednisolone for first month) had no significant benefit over prednisolone alone (41 participants). The effects of azathioprine plus prednisolone versus prednisolone plus placebo were similar (34 participants). Cyclophosphamide was reported to be statistically more efficacious than placebo at 12 months in corticosteroid‐dependent participants (23 participants), but no raw data were available. Trials of mycophenolate mofetil and tacrolimus did not provide relevant endpoint data for this review. All trials had low numbers of participants. Adverse event reporting was variable. Trial protocol heterogeneity prevented comparison of the different immunosuppressants. Authors' conclusions In generalised MG, limited evidence from small RCTs suggests that ciclosporin, as monotherapy or with corticosteroids, or cyclophosphamide with corticosteroids, significantly improve MG. 
 Limited evidence from RCTs shows no significant benefit from azathioprine (as monotherapy or with steroids), mycophenolate mofetil (as monotherapy or with either corticosteroids or ciclosporin) or tacrolimus (with corticosteroids or plasma exchange). Bigger, better‐designed, longer trials are needed. Plain language summary A review of the use of drugs that suppress the immune system (immunosuppressants) in myasthenia gravis. Myasthenia gravis (MG) is caused by antibodies produced by the immune system that impair the transmission of nerve impulses to muscles. This results in muscle weakness that characteristically fluctuates. About one person in every 10 000 ‐ 50 000 develops MG each year. The natural history of the disorder is typically a series of exacerbations and remissions. Severe attacks can be life‐threatening because of weakness of muscles involved in swallowing causing choking, and chest muscles causing difficulty with breathing. In MG, immunosuppressant drugs act mainly by reducing the production of antibodies. There were seven randomised controlled trials to include in this review. Each trial compared different interventions in generalised MG: (1) azathioprine plus initial prednisolone versus prednisolone ‐ 41 participants; (2) azathioprine plus prednisolone versus prednisolone plus placebo (dummy treatment) ‐ 34 participants; (3) ciclosporin monotherapy versus placebo ‐ 20 participants; (4) ciclosporin plus prednisolone versus prednisolone plus placebo ‐ 39 participants; (5) cyclophosphamide plus prednisolone versus prednisolone plus placebo ‐ 23 participants; (6) mycophenolate mofetil plus either ciclosporin or prednisolone or no immunosuppressants versus placebo plus either ciclosporin or prednisolone or no immunosuppressants trial ‐ 14 participants; (7) tacrolimus plus corticosteroids with or without plasma exchange versus no tacrolimus plus corticosteroids with or without plasma exchange trial ‐ 34 participants. It is difficult to draw useful clinical conclusions from this small number of often short‐term, randomised controlled trials. Each trial had relatively few participants and different trials used different study designs. The limited evidence available found that MG improved significantly with either ciclosporin (alone or in combination with corticosteroids) or cyclophosphamide (in combination with corticosteroids) compared with placebo. There is no clear evidence from randomised controlled trials of benefit for any of the immunosuppressant drugs used more commonly in MG ‐ azathioprine (alone or in combination with corticosteroids), mycophenolate mofetil (as monotherapy or in combination with either corticosteroids or ciclosporin) or tacrolimus (in combination with corticosteroids or plasma exchange or both). There is no randomised controlled trial of methotrexate in MG. Long‐term studies of the potentially formidable toxic effects of all of these drugs are lacking in MG.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.799Z" }, { "id": "63dec402-8f41-4f13-a8b3-9e1712dda70e", "pmid": "", "title": "Zinc for prevention and treatment of the common cold", "imported": false, "abstract": "Abstract - Background The common cold is an acute, self‐limiting viral respiratory illness. Symptoms include nasal congestion and mucus discharge, sneezing, sore throat, cough, and general malaise. Given the frequency of colds, they are a public health burden and a significant cause of lost work productivity and school absenteeism. There are no established interventions to prevent colds or shorten their duration. However, zinc supplements are commonly recommended and taken for this purpose. Objectives To assess the effectiveness and safety of zinc for the prevention and treatment of the common cold. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and LILACS to 22 May 2023, and searched Web of Science Core Collection and two trials registries to 14 June 2023. We also used reference checking, citation searching, and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) in children or adults that tested any form of zinc against placebo to prevent or treat the common cold or upper respiratory infection (URTI). We excluded zinc interventions in which zinc was combined with other minerals, vitamins, or herbs (e.g. a multivitamin, or mineral supplement containing zinc). Data collection and analysis We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We independently extracted data. When necessary, we contacted study authors for additional information. We assessed zinc (type and route) with placebo in the prevention and treatment of the common cold. Primary outcomes included the proportion of participants developing colds (for analyses of prevention trials only), duration of cold (measured in days from start to resolution of the cold), adverse events potentially due to zinc supplements (e.g. unpleasant taste, loss of smell, vomiting, stomach cramps, and diarrhoea), and adverse events considered to be potential complications of the common cold (e.g. respiratory bacterial infections). Main results We included 34 studies (15 prevention, 19 treatment) involving 8526 participants. Twenty‐two studies were conducted on adults and 12 studies were conducted on children. Most trials were conducted in the USA (n = 18), followed by India, Indonesia, Iran, and Turkey (two studies each), and Australia, Burkina Faso, Colombia, Denmark, Finland, Tanzania, Thailand, and the UK (one study each). The 15 prevention studies identified the condition as either common cold (n = 8) or URTI (n = 7). However, almost all therapeutic studies (17/19) focused on the common cold. Most studies (17/34) evaluated the effectiveness of zinc administered as lozenges (3 prevention; 14 treatment) in acetate, gluconate, and orotate forms; gluconate lozenges were the most common (9/17). Zinc gluconate was given at doses between 45 and 276 mg/day for between 4.5 and 21 days. Five (5/17) lozenge studies gave acetate lozenges and two (2/17) gave both acetate and gluconate lozenges. One (1/17) lozenge study administered intranasal ( gluconate ) and lozenge ( orotate ) zinc in tandem for cold treatment. Of the 17/34 studies that did not use lozenges, 1/17 gave capsules, 3/17 administered dissolved powders, 5/17 gave tablets, 4/17 used syrups, and 4/17 used intranasal administration. Most studies were at unclear or high risk of bias in at least one domain. There may be little or no reduction in the risk of developing a cold with zinc compared to placebo (risk ratio (RR) 0.93, 95% CI 0.85 to 1.01; I 2 = 20%; 9 studies, 1449 participants; low‐certainty evidence). There may be little or no reduction in the mean number of colds that occur over five to 18 months of follow‐up (mean difference (MD) ‐0.90, 95% CI ‐1.93 to 0.12; I 2 = 96%; 2 studies, 1284 participants; low‐certainty evidence). When colds occur, there is probably little or no difference in the duration of colds in days (MD ‐0.63, 95% CI ‐1.29 to 0.04; I² = 77%; 3 studies, 740 participants; moderate‐certainty evidence), and there may be little or no difference in global symptom severity (standardised mean difference (SMD) 0.04, 95% CI ‐0.35 to 0.43; I² = 0%; 2 studies, 101 participants; low‐certainty evidence). When zinc is used for cold treatment, there may be a reduction in the mean duration of the cold in days (MD ‐2.37, 95% CI ‐4.21 to ‐0.53; I² = 97%; 8 studies, 972 participants; low‐certainty evidence), although it is uncertain whether there is a reduction in the risk of having an ongoing cold at the end of follow‐up (RR 0.52, 95% CI 0.21 to 1.27; I² = 65%; 5 studies, 357 participants; very low‐certainty evidence), or global symptom severity (SMD ‐0.03, 95% CI ‐0.56 to 0.50; I² = 78%; 2 studies, 261 participants; very low‐certainty evidence), and there may be little or no difference in the risk of a change in global symptom severity (RR 1.02, 95% CI 0.85 to 1.23; 1 study, 114 participants; low‐certainty evidence). Thirty‐one studies reported non‐serious adverse events (2422 participants). It is uncertain whether there is a difference in the risk of adverse events with zinc used for cold prevention (RR 1.11, 95% CI 0.84 to 1.47; I 2 = 0%; 7 studies, 1517 participants; very low‐certainty evidence) or an increase in the risk of serious adverse events (RR 1.67, 95% CI 0.78 to 3.57; I 2 = 0%; 3 studies, 1563 participants; low‐certainty evidence). There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment (RR 1.34, 95% CI 1.15 to 1.55; I 2 = 44%; 2084 participants, 16 studies; moderate‐certainty evidence); no treatment study provided information on serious adverse events. No study provided clear information about adverse events considered to be potential complications of the common cold. Authors' conclusions The findings suggest that zinc supplementation may have little or no effect on the prevention of colds but may reduce the duration of ongoing colds, with an increase in non‐serious adverse events. Overall, there was wide variation in interventions (including concomitant therapy) and outcomes across the studies, as well as incomplete reporting of several domains, which should be considered when making conclusions about the efficacy of zinc for the common cold. Plain language summary Zinc for the prevention and treatment of the common cold Key messages 
‐ There may be little or no reduction in the risk of developing a cold with zinc supplements compared to placebo. ‐ For people who already have a cold, there may be a reduction in how long the cold lasts with zinc supplements compared to placebo. ‐ There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment. What is the common cold? 
The common cold is primarily a viral infection of the upper respiratory tract. There is no specific combination of symptoms that defines a cold, but symptoms can include nasal congestion, sneezing, sore throat, cough, fatigue, and runny nose, with or without fever. Most people usually recover from this illness without medical treatment; however, there are no definitive treatments to prevent colds or shorten their duration. Given the frequency of colds in adults and children, they are a public health burden and a significant cause of lost work productivity and school absenteeism. Prevention and treatment for the common cold with zinc is an ongoing interest. What did we want to find out? 
We wanted to find out if zinc was better than placebo at reducing the risk of developing a cold and shortening the duration of existing colds. A placebo is a substance similar in appearance to a treatment, but that has no known therapeutic effect. Placebos help assess the effects of the belief that a treatment has been received versus treatment actually being received. We also wanted to find out if zinc was associated with any adverse effects (e.g. harms), especially harms considered to be potential complications of the common cold. Additionally, we looked at self‐reported overall cold severity, individual symptom severity, individual symptom duration, and days missed from work or school. What did we do? 
We searched six databases and two clinical trials registers for studies comparing zinc with placebo for the treatment or prevention of the common cold in adults and children. We compared and summarised the results of the studies, and we found and rated our confidence in the evidence based on specific factors such as risk of bias and study methods. What did we find? 
We found 34 studies of cold prevention or treatment. The studies were conducted in 13 countries, a majority taking place in the USA. Twelve studies were conducted on children (aged under 18 years) and 22 studies were conducted on adults. Most treatments ended with self‐reported resolution of symptoms, and the minimum treatment period was five days with a maximum period of 540 days. Most of the studies were funded by an organisation with ties to related commerce/industry or did not report their funding. The remainder were funded by private clinics, non‐government foundations, universities, or governmental entities. We assessed the effects of: ‐ zinc as a preventative measure; and ‐ zinc as a treatment measure. We obtained the following results: Zinc for prevention Compared with placebo, taking zinc may make little to no difference in preventing people from catching a cold (9 studies, 1449 people). Preventative zinc also probably makes little to no difference to the length of the cold if one has been caught (3 studies, 740 participants) and may make little to no difference to the severity of the symptoms experienced (2 studies, 101 people). Negative side effects were reported by people taking either zinc or placebo; irregularities in taste and stomach upset were the most common. Zinc for treatment Zinc taken for treatment of a cold may reduce the length of time that symptoms are present, by approximately two days, when compared with placebo (8 studies, 972 people). However, we have little confidence in the evidence supporting this conclusion. It is unclear whether zinc makes a difference to the severity of the cold symptoms experienced (2 studies, 261 people). Negative side effects were reported more frequently for those taking zinc as a cold treatment when compared to those taking placebo; irregularities in taste and stomach upset were the most common. Studies administering intranasal zinc did not report any cases of anosmia (loss of sense of smell) but information about specific side effects is uncertain. What are the limitations of the evidence? 
Our confidence in the evidence is mostly low to very low, and the results of further research could differ from the results of this review. Several factors reduced our confidence in the evidence. Firstly, some studies did not report adequately on how people in the studies were randomly placed into treatment groups, meaning that differences between the study groups could be due to differences between the participants and not the treatments. Secondly, some studies used widely different ways of delivering treatments. Finally, due to the large differences between studies in the approaches used to test the effectiveness of zinc, it is likely that additional studies are required before any firm conclusions can be drawn. How up‐to‐date is this evidence? 
The evidence is current to 22 May 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Nault, D; Machingo, TA; Shipper, AG; Antiporta, DA; Hamel, C; Nourouzpour, S; Konstantinidis, M; Phillips, E; Lipski, EA; Wieland, LS", "articleTypes": [], "doi": "10.1002/14651858.CD014914.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "63f3b695-d972-4676-80f8-ea8a89da521c", "pmid": "", "title": "Spironolactone in Alcohol Use Disorder (SAUD): A Double-Blind, Placebo-Controlled, Ascending Dose, Phase 1b Study", "imported": false, "abstract": "Background:", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.155Z" }, { "id": "63fbf045-4a10-44c9-bd95-f215cce66562", "pmid": "", "title": "Interventions for the prevention of recurrent erysipelas and cellulitis", "imported": false, "abstract": "Abstract - Background Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. Objectives To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. Search methods We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. Selection criteria Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. Data collection and analysis Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. Main results We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study. Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow‐up period of up to one and a half to two years. Four studies were single‐centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria. Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate. Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate‐certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate‐certainty evidence). The protective effects of antibiotic did not last after prophylaxis had been stopped ('post‐prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty. Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years. We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay. The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin). None of the included studies assessed the development of antimicrobial resistance or quality‐of‐life measures. With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. Authors' conclusions In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate‐certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low‐certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low‐certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high‐quality studies are warranted, including long‐term follow‐up and other prophylactic measures. Plain language summary Preventive treatments for repeated episodes of cellulitis and erysipelas Background Cellulitis and erysipelas are both bacterial infections of the skin that most commonly affect the leg. Erysipelas affects the upper layers of the skin, and cellulitis affects its deeper parts, but in practice it is often hard to tell the difference between them, so we consider them together for this review (and refer to them as 'cellulitis'). Up to 50% of people with cellulitis experience repeated episodes. Despite the burden of this condition, there is a lack of high‐certainty, evidence‐based information about the desirable treatment for the prevention of recurrent cellulitis. Review question What are the best available treatments to prevent repeated episodes of cellulitis in adults aged over 16 years compared to no treatment, placebo, another intervention, or the same intervention with a different plan of treatment, and what are their side effects? Study characteristics We searched relevant databases and registers up to June 2016. We identified six trials, with 573 participants, who had an average age between 50 and 70. Both genders were included, but there were nearly twice as many women. Five trials used antibiotic treatment (four penicillin and one erythromycin), which was compared to either no treatment or placebo, and one trial used selenium compared to physiological salt solution. Treatments lasted from six to 18 months. The most common setting was the hospital, and two studies were multicentre. The studies were conducted in the UK, Sweden, Tunisia, Israel, and Austria. There was a small number of previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes in each study. The antibiotic trials assessed prevention with antibiotics in people with cellulitis of the legs, and the selenium trial assessed people with cellulitis of the arms. Key results Our main outcome was prevention of repeated episodes of cellulitis. Our other outcomes included the number of repeated attacks of cellulitis, time to next attack, hospitalisation, quality of life, development of antibiotic resistance, adverse reactions and death. Combining the results of all five trials that used antibiotics, we found moderate‐certainty evidence that for those people under preventative treatment, antibiotic treatment in general, and penicillin in particular, is probably both effective and safe for the prevention of repeated episodes of leg cellulitis when compared with no treatment or placebo. The analyses showed that, compared with no treatment or placebo, taking antibiotics decreased the risk of future episodes by 69%, reduced their number by more than 50%, and significantly reduced the rate until the next attack (moderate‐certainty evidence). However, we found low‐certainty evidence that the protective effect of antibiotics for these three outcomes tailed off over time after treatment had been stopped. In addition, the beneficial effect of antibiotics was relevant for people with at least two past episodes of cellulitis within a time frame of up to three years. We found low‐certainty evidence that there is no difference between antibiotics and no treatment/placebo for side effects and hospitalisation. The evidence did not allow for full exploration of the treatment's effect on length of hospital stay. No serious adverse effects were reported, and common side effects included diarrhoea, nausea, rash (severe skin adverse reactions were not reported) and thrush. In three studies, adverse effects caused those taking part to stop taking the antibiotic. Three people taking erythromycin had abdominal pain and nausea, causing them to stop taking the treatment and to take penicillin instead. In one study, two people withdrew from treatment with penicillin because of diarrhoea or nausea. In another study, because of pain at the site of injection, around 10% of those taking part stopped taking intramuscular injections of benzathine penicillin. None of the included studies measured quality of life or the development of antibiotic resistance. Certainty of evidence Evidence for the effects of antibiotics compared with no treatment or placebo on the recurrence, incidence rate and time to next episode of cellulitis under preventive treatment was of moderate certainty, and was limited by the small number of participants and events. Evidence for the remaining reported outcomes was of low certainty for the same reasons, as well as imprecise results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Dalal, A, Eskin‐Schwartz, M, Mimouni, D, Ray, S, Days, W, Hodak, E, Leibovici, L, Paul, M", "articleTypes": [], "doi": "10.1002/14651858.CD009758.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.104Z" }, { "id": "6407d9e3-704f-4622-918d-56fc88ae1bdd", "pmid": "", "title": "Factors influencing the uptake and use of nicotine replacement therapy and e‐cigarettes in pregnant women who smoke: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) delivers nicotine without the toxic chemicals present in tobacco smoke. It is an effective smoking cessation aid in non‐pregnant smokers, but there is less evidence of effectiveness in pregnancy. Systematic review evidence suggests that pregnant women do not adhere to NRT as prescribed, which might undermine effectiveness. Electronic cigarettes (e‐cigarettes) have grown in popularity, but effectiveness and safety in pregnancy are not yet established. The determinants of uptake and use of NRT and e‐cigarettes in pregnancy are unknown. Objectives To explore factors affecting uptake and use of NRT and e‐cigarettes in pregnancy. Search methods We searched MEDLINE(R), CINAHL and PsycINFO on 1 February 2019. We manually searched OpenGrey database and screened references of included studies and relevant reviews. We also conducted forward citation searches of included studies. Selection criteria We selected studies that used qualitative methods of data collection and analysis, included women who had smoked in pregnancy, and elicited participants' views about using NRT/e‐cigarettes for smoking cessation or harm reduction (i.e. to smoke fewer cigarettes) during pregnancy. Data collection and analysis We identified determinants of uptake and use of NRT/e‐cigarettes in pregnancy using a thematic synthesis approach. Two review authors assessed the quality of included studies with the Wallace tool. Two review authors used the CERQual approach to assess confidence in review findings. The contexts of studies from this review and the relevant Cochrane effectiveness review were not similar enough to fully integrate findings; however, we created a matrix to juxtapose findings from this review with the descriptions of behavioural support from trials in the effectiveness review. Main results We included 21 studies: 15 focused on NRT, 3 on e‐cigarettes, and 3 on both. Studies took place in five high‐income countries. Most studies contributed few relevant data; substantially fewer data were available on determinants of e‐cigarettes. Many studies focused predominantly on issues relating to smoking cessation, and determinants of NRT/e‐cigarette use was often presented as one of the themes. We identified six descriptive themes and 18 findings within those themes; from these we developed three overarching analytical themes representing key determinants of uptake and adherence to NRT and/or e‐cigarettes in pregnancy. The analytical themes show that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. Furthermore, women consider advice from health professionals when deciding whether to use NRT or e‐cigarettes; when health professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay for them to use these in pregnancy, women report feeling more confident about using them. Conversely, women who are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them during pregnancy feel less confident about using them. Women's past experiences with NRT can also affect their willingness to use NRT in pregnancy; women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. No trials on e‐cigarette use in pregnancy were included in the Cochrane effectiveness review, so we considered only NRT findings when integrating results from this review and the effectiveness review. No qualitative studies were conducted alongside trials, making full integration of the findings challenging. Women enrolled in trials would have agreed to being allocated to NRT or control group and would have received standardised information on NRT at the start of the trial. Overall, the findings of this synthesis are less relevant to women's decisions about starting NRT in trials and more likely to help explain trial participants' adherence to NRT after starting it. We considered most findings to be of moderate certainty; we assessed findings on NRT use as being of higher certainty than those on e‐cigarette use. This was mainly due to the limited data from fewer studies (only in the UK and USA) that contributed to e‐cigarette findings. Overall, we judged studies to be of acceptable quality with only minor methodological issues. Authors' conclusions Consistent messages from health professionals, based on high‐quality evidence and clearly explaining the safety of NRT and e‐cigarettes compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and subsequently encourage them to stay smoke‐free. Plain language summary Factors affecting use of nicotine replacement therapy and e‐cigarettes in pregnancy What was studied in this review? Nicotine replacement therapy (NRT) delivers nicotine without the harmful chemicals found in tobacco smoke. NRT helps some non‐pregnant adults to stop smoking, but it does not seem to work so well in pregnancy. This may be because pregnant women generally do not use NRT as prescribed. Studies show that some pregnant women use e‐cigarettes to help them cut down or quit, although their safety and effectiveness in pregnancy is not known. Little is known about the issues that influence pregnant women's use of NRT/e‐cigarettes. What is the aim of this review? To explore factors that affect whether women take up and use NRT or e‐cigarettes to reduce or quit smoking in pregnancy. What are the key messages of this review? Three main factors influence whether women take up and use NRT and e‐cigarettes in pregnancy: advice women receive from health professionals on using NRT or e‐cigarette in pregnancy, women's desire to protect their unborn baby from harm, and past personal experience with NRT. Each of these factors can either encourage or discourage women from using these products. What are the key findings? We included 21 studies; 15 of these focused on NRT, 3 on e‐cigarettes and 3 on both. Our findings suggest that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. They also consider the advice from their health professionals; when professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay to use them in pregnancy, their confidence about using them increases. When women are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them when they are pregnant, they feel less confident about using them. Women's past experiences with NRT will also affect how willing they are to use NRT in pregnancy. For example, women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. We conclude that consistent messages that are based on high‐quality research and clearly explain how safe NRT and e‐cigarettes are compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and encourage them to stay smoke‐free. How up‐to‐date is this review? We searched for studies that had been published before 1 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Campbell, K, Coleman-Haynes, T, Bowker, K, Cooper, SE, Connelly, S, Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD013629", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.786Z" }, { "id": "6410d68e-46a4-4bb0-a614-354bd2edd057", "pmid": "", "title": "Oral immunotherapy for milk allergy", "imported": false, "abstract": "Abstract - Background The mainstay of treatment of IgE‐mediated cow milk allergy (IMCMA) is an avoidance diet, which is especially difficult with a ubiquitous food like milk. Milk oral immunotherapy (MOIT) may be an alternative treatment, through desensitization or induction of tolerance. Objectives We aim to assess the clinical efficacy and safety of MOIT in children and adults with IMCMA as compared to a placebo treatment or avoidance strategy. Search methods We searched 13 databases for journal articles, conference proceedings, theses and unpublished trials, without language or date restrictions, using a combination of subject headings and text words. The search is up‐to‐date as of October 1, 2012. Selection criteria Only randomised controlled trials (RCT) were considered for inclusion. Blinded and open trial designs were included. Children and adults with IMCMA were included. MOIT administered by any protocol were included. Data collection and analysis A total of 2111 unique records were identified and screened for potential inclusion. Studies were selected, data extracted and methodological quality assessed independently by two reviewers. We attempted to contact the study investigators to inquire about data not published that was required for the analysis. Statistical heterogeneity was assessed using the I² test. We estimated a pooled risk ratio (RR) for each outcome using a Mantel‐Haenzel fixed‐effect model if statistical heterogeneity was low as evaluated by an I² value less than 50%. Main results Of 157 records reviewed, 16 were included, representing five trials. In general, the studies were small and had inconsistent methodological rigor. Overall, the quality of evidence was rated as low. Each study used a different MOIT protocol. A total of 196 patients were studied (106 MOIT, 90 control) and all were children. Three studies were blinded and two used an avoidance diet control. Sixty‐six patients (62%) in the MOIT group were able to tolerate a full serving of milk (about 200 mL) compared to seven (8%) of the control group (RR 6.61, 95% CI 3.51 to 12.44). In addition, 27 (25%) in the MOIT group could ingest a partial serving of milk (10 to 184 mL) while none could in the control group (RR 9.34, 95% CI 2.72 to 32.09). None of the studies assessed the patients following a period off immunotherapy. Adverse reactions were common (97 of 106 MOIT patients had at least one symptom), although most were local and mild. Because of variability in reporting methods, adverse effects could not be combined quantitatively. For every 11 patients receiving MOIT, one required intramuscular epinephrine. One patient required it on two occasions. Authors' conclusions Studies to date have involved small numbers of patients and the quality of evidence is generally low. The current evidence shows that MOIT can lead to desensitization in the majority of individuals with IMCMA although the development of long‐term tolerance has not been established. A major drawback of MOIT is the frequency of adverse effects, although most are mild and self‐limited. The use of parenteral epinephrine is not infrequent. Because there are no standardized protocols, guidelines would be required prior to incorporating desensitization into clinical practice. Plain language summary Repetitive, increasing doses of daily milk for treatment of milk allergy To date, the only option to treat food allergy is strict avoidance of the food and carrying an epinephrine injector (Epipen/Twinject) in case of an allergic reaction. For a food like cow's milk, avoidance is very difficult because it is found in many foods. The constant fear of accidentally eating or drinking cow's milk and anxiety related to carrying an injector has negative effects on quality of life. Accidentally having milk can cause life‐threatening reactions. Oral immunotherapy involves initially taking a very small amount of the allergen, in the case of milk allergy, cow's milk, and slowly increasing the amount each day until a full serving is reached. This may change the way the body's immune system sees the allergen, thereby increasing the amount of milk that can be eaten or drunk with no reaction. We identified randomized controlled trials that compared oral immunotherapy to placebo or continued avoidance diet in children and adults with cow's milk allergy. Five studies satisfied our inclusion criteria. In total there were 196 participants (106 in the treatment group and 90 in the control), all of whom were children. In general, the quality of the studies was low. Because the trials involved small numbers and there were problems with the way they were done, further research is needed. The current evidence shows that oral immunotherapy can help a majority of allergic children tolerate a full serving of milk, as long as they continue drinking this amount each day. However, it is not known if this protection is continued if the immunotherapy is stopped for some time. Side effects during oral immunotherapy are frequent and most patients will have at least some mild symptoms. In the studies we included, for every 11 patients who received oral immunotherapy, one needed to be treated with epinephrine injection at some point for a serious allergic reaction to the therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Yeung, JP; Kloda, LA; McDevitt, J; Ben‐Shoshan, M; Alizadehfar, R", "articleTypes": [], "doi": "10.1002/14651858.CD009542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "641532d3-f206-4b96-a6f4-51ec0cb164b3", "pmid": "", "title": "Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration leading to increased fracture risk. Risedronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts. This is an update of a Cochrane Review that was originally published in 2003. Objectives We assessed the benefits and harms of risedronate in the primary and secondary prevention of osteoporotic fractures for postmenopausal women at lower and higher risk for fractures, respectively. Search methods With broader and updated strategies, we searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE and Embase. A grey literature search, including the online databases ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), and drug approval agencies, as well as bibliography checks of relevant systematic reviews was also performed. Eligible trials published between 1966 to 24 March 2021 were identified. Selection criteria We included randomised controlled trials that assessed the benefits and harms of risedronate in the prevention of fractures for postmenopausal women. Participants must have received at least one year of risedronate, placebo or other anti‐osteoporotic drugs, with or without concurrent calcium/vitamin D. Major outcomes were clinical vertebral, non‐vertebral, hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. In the interest of clinical relevance and applicability, we classified a study as secondary prevention if its population fulfilled more than one of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, low bone mineral density (BMD)T score ≤ ‐2.5, and age ≥ 75 years old. If none of these criteria was met, the study was considered to be primary prevention. Data collection and analysis We used standard methodology expected by Cochrane. We pooled the relative risk (RR) of fractures using a fixed‐effect model based on the expectation that the clinical and methodological characteristics of the respective primary and secondary prevention studies would be homogeneous, and the experience from the previous review suggesting that there would be a small number of studies. The base case included the data available for the longest treatment period in each placebo‐controlled trial and a >15% relative change was considered clinically important. The main findings of the review were presented in summary of findings tables, using the GRADE approach. In addition, we looked at benefit and harm comparisons between different dosage regimens for risedronate and between risedronate and other anti‐osteoporotic drugs. Main results Forty‐three trials fulfilled the eligibility criteria, among which 33 studies (27,348 participants) reported data that could be extracted and quantitatively synthesized. We had concerns about particular domains of risk of bias in each trial. Selection bias was the most frequent concern, with only 24% of the studies describing appropriate methods for both sequence generation and allocation concealment. Fifty per cent and 39% of the studies reporting benefit and harm outcomes, respectively, were subject to high risk. None of the studies included in the quantitative syntheses were judged to be at low risk of bias in all seven domains. The results described below pertain to the comparisons for daily risedronate 5 mg versus placebo which reported major outcomes. Other comparisons are described in the full text. For primary prevention, low‐ to very low‐certainty evidence was collected from four studies (one to two years in length) including 989 postmenopausal women at lower risk of fractures. Risedronate 5 mg/day may make little or no difference to wrist fractures [RR 0.48 ( 95% CI 0.03 to 7.50; two studies, 243 participants); absolute risk reduction (ARR) 0.6% fewer (95% CI 1% fewer to 7% more)] and withdrawals due to adverse events [RR 0.67 (95% CI 0.38 to 1.18; three studies, 748 participants); ARR 2% fewer (95% CI 5% fewer to 1% more)], based on low‐certainty evidence. However, its preventive effects on non‐vertebral fractures and serious adverse events are not known due to the very low‐certainty evidence. There were zero clinical vertebral and hip fractures reported therefore the effects of risedronate for these outcomes are not estimable. For secondary prevention, nine studies (one to three years in length) including 14,354 postmenopausal women at higher risk of fractures provided evidence. Risedronate 5 mg/day probably prevents non‐vertebral fractures [RR 0.80 (95% CI 0.72 to 0.90; six studies, 12,173 participants); RRR 20% (95% CI 10% to 28%) and ARR 2% fewer (95% CI 1% fewer to 3% fewer), moderate certainty], and may reduce hip fractures [RR 0.73 (95% CI 0.56 to 0.94); RRR 27% (95% CI 6% to 44%) and ARR 1% fewer (95% CI 0.2% fewer to 1% fewer), low certainty]. Both of these effects are probably clinically important. However, risedronate's effects are not known for wrist fractures [RR 0.64 (95% CI 0.33 to 1.24); three studies,1746 participants); ARR 1% fewer (95% CI 2% fewer to 1% more), very‐low certainty] and not estimable for clinical vertebral fractures due to zero events reported (low certainty). Risedronate results in little to no difference in withdrawals due to adverse events [RR 0.98 (95% CI 0.90 to 1.07; eight studies, 9529 participants); ARR 0.3% fewer (95% CI 2% fewer to 1% more); 16.9% in risedronate versus 17.2% in control, high certainty] and probably results in little to no difference in serious adverse events [RR 1.00 (95% CI 0.94 to 1.07; six studies, 9435 participants); ARR 0% fewer (95% CI 2% fewer to 2% more; 29.2% in both groups, moderate certainty). Authors' conclusions This update recaps the key findings from our previous review that, for secondary prevention, risedronate 5 mg/day probably prevents non‐vertebral fracture, and may reduce the risk of hip fractures. We are uncertain on whether risedronate 5mg/day reduces clinical vertebral and wrist fractures. Compared to placebo, risedronate probably does not increase the risk of serious adverse events. For primary prevention, the benefit and harms of risedronate were supported by limited evidence with high uncertainty. Plain language summary Risedronate for preventing fractures caused by osteoporosis in postmenopausal women This summary of a Cochrane Review presents what we know from the evidence up to 24 March 2021 about the effect of risedronate for preventing fractures (broken bones) caused by osteoporosis. What is osteoporosis and what is risedronate? 
Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow and old bone cells break down to make room for the new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break even after a minor injury, like a little bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. Risedronate belongs to the class of drugs called bisphosphonates. It is a type of medication that slows down the cells that break down the old bone. In postmenopausal women whose bone density is closer to normal or who may not yet have had a fracture in the bones of their spine therefore putting them at lower risk for fractures: ‐ there is insufficient evidence to tell us if risedronate leads to any reduction in the number of women sustaining bone fractures; ‐ based on limited data there is no evidence of an increase in adverse events for postmenopausal women at lower risk for fractures. In postmenopausal women who have already been diagnosed with osteoporosis (who have low bone density, or who have already had a fracture in the bones of their spine) putting them at higher risk for fractures, risedronate: ‐ probably prevents fractures in the bones of the hip and in bones other than in the spine; ‐ may not lead to any difference in preventing wrist fractures; ‐ does not have enough evidence to show if it may prevent fractures in the bones of the spine suggested by clinical signs and symptoms; ‐ might make little or no difference in adverse events for postmenopausal women at higher risk for fractures. Best estimate of what happens to postmenopausal women at lower risk for fractures who take risedronate or placebo: ‐ for spine fractures suggested by clinical signs and symptoms and hip fractures, it was not possible to calculate the effect because none of these fractures were reported in any of the studies; ‐ compared to placebo, there is not enough information to tell if risedronate prevents fractures in wrist and bones other than in the spine. Best estimate of what happens to postmenopausal women at higher risk for fractures who take risedronate or placebo: Fractures of the spine suggested by clinical signs and symptoms were not reported in any of the studies. Fractures in bones other than the spine: ‐ 10 out of 100 women had a fracture when taking a placebo; ‐ 8 out of 100 women had a fracture when taking risedronate; Fractures of the hip ‐ 3 out of 100 women had a fracture when taking a placebo; ‐ 2 out of 100 women had a fracture when taking risedronate. Fractures of the wrist: ‐ there is not enough information to tell if risedronate prevents wrist fractures.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wells, GA; Hsieh, S-C; Zheng, C; Peterson, J; Liu, W; Kelly, SE; Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD004523.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "641b8fec-03b3-4662-8ee6-1f21cd94a684", "pmid": "", "title": "Siponimod for multiple sclerosis", "imported": false, "abstract": "Abstract - Background Multiple sclerosis (MS) is a chronic immune‐mediated disease of the central nervous system, with an unpredictable course. Current MS therapies such as disease‐modifying therapies focus on treating exacerbations, preventing new exacerbations and avoiding the progression of disability. Siponimod (BAF312) is an oral treatment, a selective sphingosine‐1‐phosphate (S1P) receptor modulator, for the treatment of adults with relapsing forms of MS including active, secondary progressive MS with relapses. Objectives To assess the benefits and adverse effects of siponimod as monotherapy or combination therapy versus placebo or any active comparator for people diagnosed with MS. Search methods We searched the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Trials Register, which contains studies from CENTRAL, MEDLINE and Embase, and the trials registry databases ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 10 September 2021. We also handsearched relevant journals and screened the reference lists of published reviews and retrieved articles and searched reports (2004 to September 2021) from the MS societies in Europe and America. Selection criteria We included randomised parallel controlled clinical trials (RCTs) that evaluated siponimod, as monotherapy or combination therapy, versus placebo or any active comparator in people with MS. There were no restrictions on dose or administration frequency. Data collection and analysis We used standard methodological procedures expected by Cochrane. We discussed disagreements and resolved them by consensus among the review authors. Our primary outcomes wereworsening disability , relapse and adverse events, and secondary outcomes were annualised relapse rate, gadolinium‐enhancing lesions, new lesions or enlarged pre‐existing lesions and mean change of brain volume. We independently evaluated the certainty of evidence using the GRADE approach. We contacted principal investigators of included studies for additional data or confirmation of data. Main results Two studies (1948 participants) met our selection criteria, 608 controls and 1334 treated with siponimod. The included studies compared siponimod with placebo. Overall, all studies had a high risk of bias due to selective reporting and attrition bias. Comparing siponimod administered at a dose of 2 mg to placebo, we found that siponimod may reduce the number of participants with disability progression at six months (56 fewer people per 1000; risk ratio (RR) 0.78, 95% confidence interval (CI) 0.65 to 0.94; 1 study, 1641 participants; low‐certainty evidence) and annualised relapse rate (RR 0.43, 95% CI 0.34 to 0.56; 2 studies, 1739 participants; low‐certainty evidence). But it might lead to little reduction in the number of participants with new relapse (166 fewer people per 1000; RR 0.38, 95% CI 0.15 to 1.00; 1 study, 94 participants; very low‐certainty evidence). We observed no evidence of a difference due to adverse events for siponimod at 2 mg compared to placebo (14 more people per 1000; RR 1.52, 95% CI 0.85 to 2.71; 2 studies, 1739 participants, low‐certainty evidence). In addition, due to the high risk of inaccurate magnetic resonance imaging (MRI) data in the two included studies, we could not combine data for active lesions on MRI scans. Both studies had high attrition bias resulting from the unbalanced reasons for dropouts among groups and high risk of bias due to conflicts of interest. Siponimod may reduce the number of gadolinium‐enhancing T1‐weighted lesions at two years of follow‐up (RR 0.14, 95% CI 0.10 to 0.19; P < 0.0001; 1 study, 1641 participants; very low‐certainty evidence). There may be no evidence of a difference between groups in the number of participants with at least one serious adverse event excluding relapses (113 more people per 1000; RR 1.80, 95% CI 0.37 to 8.77; 2 studies, 1739 participants; low‐certainty evidence) at six months. No data were available regarding cardiac adverse events. In terms of safety profile, the most common adverse events associated with siponimod were headache, back pain, bradycardia, dizziness, fatigue, influenza, urinary tract infection, lymphopenia, nausea, alanine amino transferase increase and upper respiratory tract infection. These adverse events have dose‐related effects and rarely led to discontinuation of treatment. Authors' conclusions Based on the findings of the RCTs included in this review, we are uncertain whether siponimod interventions are beneficial for people with MS. There was low‐certainty evidence to support that siponimod at a dose of 2 mg orally once daily as monotherapy compared with placebo may reduce the annualised relapse rate and the number of participants who experienced disability worsening, at 6 months. However, the certainty of the evidence to support the benefit in reducing the number of people with a relapse is very low. The risk of withdrawals due to adverse events requires careful monitoring of participants over time. The duration of all studies was less than 24 months, so the efficacy and safety of siponimod over 24 months are still uncertain, and further exploration is needed in the future. There is no high‐certainty data available to evaluate the benefit on MRI outcomes. We assessed the certainty of the body of evidence for all outcomes was low to very low, downgraded due to serious study limitations, imprecision and indirectness. We are uncertain whether siponimod is beneficial for people with MS. More new studies with robust methodology and longer follow‐up are needed to evaluate the benefit of siponimod for the management of MS and to observe long‐term adverse effects. Also, in addition to comparing with placebo, more new studies are needed to evaluate siponimod versus other therapeutic options. Plain language summary Is siponimod an effective treatment for multiple sclerosis (MS) and does it cause unwanted effects? Key messages · We don’t know whether siponimod is an effective treatment for people with multiple sclerosis (MS). At a dose of 2 mg once a day, siponimod may reduce recurrence of symptoms (relapse, calculated as an annual rate) after six months of treatment and may reduce the number of participants whose disability worsens after three months of treatment. · We don’t know if siponimod causes unwanted effects because studies did not last long enough to fully assess them. · Future studies should last longer in order to monitor unwanted and beneficial effects of siponimod better, and should use more robust methods. They should compare siponimod with other medicines. What is multiple sclerosis? Multiple sclerosis (MS) is a condition caused when the body’s immune system – which defends the body against disease and infection – mistakenly attacks parts of the central nervous system (the brain and spinal cord). Symptoms include problems with balance and walking, and blurred vision. MS is a lifelong condition that can cause serious disability. Some people’s symptoms may develop gradually. However, most people experience ‘attacks’ when new symptoms develop or existing symptoms worsen (called ‘relapse’), followed by periods with no changes to their symptoms (called ‘remittance’). This type of MS is called ‘relapsing remitting’ MS. Eventually, the course of their MS may change. These periods when there are no symptoms, or no worsening of symptoms, may stop and then symptoms may worsen continually. This is called ‘secondary progressive MS’. How does siponimod work? Siponimod is a medicine that attaches to the white blood cells (lymphocytes) that attack the central nervous system. This causes the lymphocytes to stay in the lymph glands instead of circulating in the blood to the brain. Fewer lymphocytes reach the brain so the attack by the immune system is reduced. Siponimod is a tablet taken once a day. What did we want to find out? We wanted to know if siponimod is an effective treatment for MS and whether it causes any unwanted effects. We were interested in the number of people: · who experienced relapses; · whose disability worsened; · who left the studies because of unwanted effects of siponimod; · who developed new or larger brain lesions (damage to the brain); and · who experienced serious unwanted effects, and which unwanted effects they experienced. What did we do? 
We searched for studies that investigated siponimod compared with placebo (a sham medicine that looks and tastes the same as siponimod but with no active ingredients) or another medicine to treat MS. Studies could investigate siponimod alone or combined with another treatment, at any dose over any length of time. Participants had to be aged over 18 years, with confirmed MS. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found two studies with 1948 participants. Both studies compared siponimod with placebo. One study included 1651 people with secondary progressive MS, who were given 2 mg siponimod for up to 3 years. The other study included 297 participants with relapsing remitting MS, who were given siponimod at doses of 10 mg, 2 mg or 0.5 mg for 6 months, or 1.25 mg or 0.25 mg for 3 months. We report the results for 2 mg daily because both studies looked at this dose. At 2 mg a day, compared to placebo: · siponimod may lead to a small reduction (166 fewer people per 1000) in the number of people with a new relapse up to six months after starting treatment, and may also reduce relapses when calculated at an annual rate; · siponimod may reduce the number of people whose disability worsened during the six months after starting treatment (by 56 people per 1000); · there may be no difference to the number of people (14 more per 1000) who left the studies in the six months after starting treatment due to unwanted effects; · siponimod may reduce the number of brain lesions of different types after six months and after two years of follow‐up. · siponimod may make no difference to the number of people with at least one serious unwanted effect in the six months after starting treatment. The most common unwanted effects associated with siponimod were headache, back pain, dizziness, tiredness, influenza, urinary tract infection, reduced white blood cells (lymphopenia), feeling sick, possible liver damage, and infections in the mouth and nose. No information was available about heart‐related unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only 2 studies. They did not provide information about everything we were interested and they included people with different types of MS. Also, they did not last long enough to judge the impact of unwanted effects. Both studies were funded by the company that makes siponimod.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Cao, L; Li, M; Yao, L; Yan, P; Wang, X; Yang, Z; Lao, Y; Li, H; Yang, K; Li, K", "articleTypes": [], "doi": "10.1002/14651858.CD013647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "641db541-7132-44fc-801d-45efc2941a8a", "pmid": "", "title": "Modafinil for people with schizophrenia or related disorders", "imported": false, "abstract": "Abstract - Background People with schizophrenia have a range of different symptoms, including positive symptoms (hallucinations and delusions), negative symptoms (such as social withdrawal and lack of affect), and cognitive impairment. The standard medication for people with schizophrenia is antipsychotics. However, these medications may not be effective for all symptoms of schizophrenia, as cognitive and negative symptoms are usually hard to treat. Additional therapies or medications are available for the management of these symptoms. Modafinil, a wakefulness‐promoting agent most frequently used in narcolepsy or shift work sleep disorder, is one intervention that is theorised to have an effect of these symptoms. Objectives The primary objective of this review was to assess the effects of modafinil for people with schizophrenia or related disorders. Search methods On 27 April 2015, 24 May 2017, and 31 October 2019, we searched the Cochrane Schizophrenia Group's register of trials, which is based on regular searches of CENTRAL, MEDLINE, Embase, AMED, BIOSIS, CINAHL, PsycINFO, PubMed, and registries of clinical trials. There are no language, time, document type, or publication status limitations for the inclusion of records in the register. Selection criteria We selected all randomised controlled trials comparing modafinil with placebo or other treatments for people with schizophrenia or schizophrenia‐spectrum disorders. Data collection and analysis We independently extracted data from the included studies. We analysed dichotomous data using risk ratios (RR) and 95% confidence intervals (CI). We analysed continuous data using mean difference (MD) with a 95% CI. We used a random‐effects model for the meta‐analysis. We used GRADE to complete a 'Summary of findings' table and assessed risk of bias for the included studies. Main results Eleven studies including a total of 422 participants contributed to data analyses. Most studies had a small population size (average 38 people per study) and were of short duration. We also detected a high risk of bias for selective outcome reporting in just under 50% of the trials. We therefore rated the overall methodological quality of the included studies as low. We considered seven main outcomes of interest: clinically important change in overall mental state, clinically important change in cognitive functioning, incidence of a clinically important adverse effect/event, clinically important change in global state, leaving the study early for any reason, clinically important change in quality of life, and hospital admission. All studies assessed the effects of adding modafinil to participants' usual antipsychotic treatment compared to adding placebo to usual antipsychotic treatment. Six studies found that adding modafinil to antipsychotic treatment may have little or no effect on overall mental state of people with schizophrenia, specifically the risk of worsening psychosis (RR 0.91, 95% CI 0.28 to 2.98; participants = 209; studies = 6, low‐quality evidence ). Regarding the effect of modafinil on cognitive function, the trials did not report clinically important change data, but one study reported endpoint scores on the MATRICS Consensus Cognitive Battery (MCCB): in this study we found no clear difference in scores between modafinil and placebo treatment groups (MD −3.10, 95% CI −10.9 to 4.7; participants = 48; studies = 1, very low‐quality evidence ). Only one study (N = 35) reported adverse effect/event data. In this study one serious adverse event occurred in each group (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). One study measured change in global state using the Clinical Global Impression ‐ Improvement Scale. This study found that adding modafinil to antipsychotic treatment may have little or no effect on global state (RR 6.36, 95% CI 0.94 to 43.07, participants = 21; studies = 1, very low‐quality evidence ). Nine studies found that modafinil has no effect on numbers of participants leaving the study early (RR 1.26, 95% CI 0.63 to 2.52 participants = 357; studies = 9, moderate‐quality evidence ). None of the trials reported clinically important change in quality of life, but one study did report quality of life using endpoint scores on the Quality of Life Inventory, finding no clear difference between treatment groups (MD −0.2, 95% CI −1.18 to 0.78; participants = 20; studies = 1, very low‐quality evidence ). Finally, one study reported data for number of participants needing hospitalisation: one participant in each group was hospitalised (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). Authors' conclusions Due to methodological issues, low sample size, and short duration of the clinical trials as well as high risk of bias for outcome reporting, most of the evidence available for this review is of very low or low quality. For results where quality is low or very low, we are uncertain or very uncertain if the effect estimates are true effects, limiting our conclusions. Specifically, we found that modafinil is no better or worse than placebo at preventing worsening of psychosis; however, we are uncertain about this result. We have more confidence that participants receiving modafinil are no more likely to leave a trial early than participants receiving placebo. However, we are very uncertain about the remaining equivocal results between modafinil and placebo for outcomes such as improvement in global state or cognitive function, incidence of adverse events, and changes in quality of life. More high‐quality data are needed before firm conclusions regarding the effects of modafinil for people with schizophrenia or related disorders can be made. Plain language summary Modafinil for schizophrenia Review question: Is adding modafinil to antipsychotic treatment effective and safe for people with schizophrenia? Background Schizophrenia is a complicated and chronic mental disorder that usually presents with a wide range of symptoms. The standard treatment (antipsychotics) is considered to be effective for the positive symptoms (such as delusions and hallucinations or bizarre thoughts). However, there are negative and cognitive symptoms (such as social withdrawal, lack of affect, problems with memory) that are not adequately treated with these medications. These symptoms tend to be chronic and can therefore have a long‐term impact on an individual's quality of life. Additional treatments are often added to antipsychotic treatment, of which one is modafinil, a wakefulness‐promoting medication usually used for sleep disorders. Searching for evidence We ran an electronic search of Cochrane Schizophrenia's register of trials in April 2015, May 2017, and October 2019 for trials that randomised (allocated participants to treatment groups using a random method) people with schizophrenia to receive add‐on modafinil (modafinil added to their standard care) or to receive add‐on placebo. We identified 67 records that referred to 25 studies. Evidence found Eleven studies met the review requirements and reported data that could be used in analyses. However, the trials included small numbers of participants and were of short duration; schizophrenia is a long‐term health problem that ideally requires studies of longer duration. Our analysis of the data showed there is no clear difference between add‐on modafinil and add‐on placebo for improving mental state or global state, changing cognitive functioning, causing participants to leave a study early, producing adverse effects, or affecting rates of hospitalisation. However, most of these results were based on very low‐ or low‐quality data, therefore it is uncertain if these statistical effect sizes found by our data analyses are true effects. Conclusions The results of this review indicate no clear difference in effectiveness and safety between add‐on modafinil and add‐on placebo, however these results are not conclusive as they are based low‐ or very low‐quality evidence. Based on the current evidence we were unable to provide an answer to our review question as to whether modafinil is better than placebo for improving the symptoms of schizophrenia, or if it is safe to use for people with schizophrenia. More high‐quality research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ortiz-Orendain, J; Covarrubias-Castillo, SA; Vazquez-Alvarez, AO; Castiello-de Obeso, S; Arias Quiñones, GE; Seegers, M; Colunga-Lozano, LE", "articleTypes": [], "doi": "10.1002/14651858.CD008661.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "642747fe-09dd-4608-b492-3365ca3bb167", "pmid": "", "title": "Non‐invasive diagnostic tests for Helicobacter pylori infection", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) infection has been implicated in a number of malignancies and non‐malignant conditions including peptic ulcers, non‐ulcer dyspepsia, recurrent peptic ulcer bleeding, unexplained iron deficiency anaemia, idiopathic thrombocytopaenia purpura, and colorectal adenomas. The confirmatory diagnosis of H pylori is by endoscopic biopsy, followed by histopathological examination using haemotoxylin and eosin (H & E) stain or special stains such as Giemsa stain and Warthin‐Starry stain. Special stains are more accurate than H & E stain. There is significant uncertainty about the diagnostic accuracy of non‐invasive tests for diagnosis of H pylori . Objectives To compare the diagnostic accuracy of urea breath test, serology, and stool antigen test, used alone or in combination, for diagnosis of H pylori infection in symptomatic and asymptomatic people, so that eradication therapy for H pylori can be started. Search methods We searched MEDLINE, Embase, the Science Citation Index and the National Institute for Health Research Health Technology Assessment Database on 4 March 2016. We screened references in the included studies to identify additional studies. We also conducted citation searches of relevant studies, most recently on 4 December 2016. We did not restrict studies by language or publication status, or whether data were collected prospectively or retrospectively. Selection criteria We included diagnostic accuracy studies that evaluated at least one of the index tests (urea breath test using isotopes such as 13 C or 14 C, serology and stool antigen test) against the reference standard (histopathological examination using H & E stain, special stains or immunohistochemical stain) in people suspected of having H pylori infection. Data collection and analysis Two review authors independently screened the references to identify relevant studies and independently extracted data. We assessed the methodological quality of studies using the QUADAS‐2 tool. We performed meta‐analysis by using the hierarchical summary receiver operating characteristic (HSROC) model to estimate and compare SROC curves. Where appropriate, we used bivariate or univariate logistic regression models to estimate summary sensitivities and specificities. Main results We included 101 studies involving 11,003 participants, of which 5839 participants (53.1%) had H pylori infection. The prevalence of H pylori infection in the studies ranged from 15.2% to 94.7%, with a median prevalence of 53.7% (interquartile range 42.0% to 66.5%). Most of the studies (57%) included participants with dyspepsia and 53 studies excluded participants who recently had proton pump inhibitors or antibiotics.There was at least an unclear risk of bias or unclear applicability concern for each study. Of the 101 studies, 15 compared the accuracy of two index tests and two studies compared the accuracy of three index tests. Thirty‐four studies (4242 participants) evaluated serology; 29 studies (2988 participants) evaluated stool antigen test; 34 studies (3139 participants) evaluated urea breath test‐ 13 C; 21 studies (1810 participants) evaluated urea breath test‐ 14 C; and two studies (127 participants) evaluated urea breath test but did not report the isotope used. The thresholds used to define test positivity and the staining techniques used for histopathological examination (reference standard) varied between studies. Due to sparse data for each threshold reported, it was not possible to identify the best threshold for each test. Using data from 99 studies in an indirect test comparison, there was statistical evidence of a difference in diagnostic accuracy between urea breath test‐ 13 C, urea breath test‐ 14 C, serology and stool antigen test (P = 0.024). The diagnostic odds ratios for urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test were 153 (95% confidence interval (CI) 73.7 to 316), 105 (95% CI 74.0 to 150), 47.4 (95% CI 25.5 to 88.1) and 45.1 (95% CI 24.2 to 84.1). The sensitivity (95% CI) estimated at a fixed specificity of 0.90 (median from studies across the four tests), was 0.94 (95% CI 0.89 to 0.97) for urea breath test‐ 13 C, 0.92 (95% CI 0.89 to 0.94) for urea breath test‐ 14 C, 0.84 (95% CI 0.74 to 0.91) for serology, and 0.83 (95% CI 0.73 to 0.90) for stool antigen test. This implies that on average, given a specificity of 0.90 and prevalence of 53.7% (median specificity and prevalence in the studies), out of 1000 people tested for H pylori infection, there will be 46 false positives (people without H pylori infection who will be diagnosed as having H pylori i nfection). In this hypothetical cohort, urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test will give 30 (95% CI 15 to 58), 42 (95% CI 30 to 58), 86 (95% CI 50 to 140), and 89 (95% CI 52 to 146) false negatives respectively (people with H pylori infection for whom the diagnosis of H pylori will be missed). Direct comparisons were based on few head‐to‐head studies. The ratios of diagnostic odds ratios (DORs) were 0.68 (95% CI 0.12 to 3.70; P = 0.56) for urea breath test‐ 13 C versus serology (seven studies), and 0.88 (95% CI 0.14 to 5.56; P = 0.84) for urea breath test‐ 13 C versus stool antigen test (seven studies). The 95% CIs of these estimates overlap with those of the ratios of DORs from the indirect comparison. Data were limited or unavailable for meta‐analysis of other direct comparisons. Authors' conclusions In people without a history of gastrectomy and those who have not recently had antibiotics or proton ,pump inhibitors, urea breath tests had high diagnostic accuracy while serology and stool antigen tests were less accurate for diagnosis of Helicobacter pylori infection.This is based on an indirect test comparison (with potential for bias due to confounding), as evidence from direct comparisons was limited or unavailable. The thresholds used for these tests were highly variable and we were unable to identify specific thresholds that might be useful in clinical practice. We need further comparative studies of high methodological quality to obtain more reliable evidence of relative accuracy between the tests. Such studies should be conducted prospectively in a representative spectrum of participants and clearly reported to ensure low risk of bias. Most importantly, studies should prespecify and clearly report thresholds used, and should avoid inappropriate exclusions. Plain language summary Accuracy of different non‐invasive methods for identifying Helicobacter pylori Why is it important to know whether someone has Helicobacter pylori ? Helicobacter pylori (H pylori) is a type of bacteria which may be present in the stomach of some people. H pylori is believed to cause a number of cancers, including stomach cancer, pancreatic cancer, and throat cancer. H pylori is also linked with other diseases including stomach ulcers, heart burn, and a bloated feeling. If H pylori is found in an individual, appropriate treatment can be started. What is the aim of this review? To compare the accuracy of three different types of test for H pylori. These are: urea breath tests, blood tests (the specific blood test is called serology), and stool tests (in faeces). What was studied in this review? There are two types of urea breath test which use two different forms of carbon known as 13 C and 14 C, as well as multiple versions of serology and stool tests. What are the main results of the review? We found 101 studies which included 11,003 people who were tested for H pylori . Of these 11,003 participants, 5839 (53.1%) had H pylori infection. All the studies used one of the three tests listed above and compared these test results with the diagnosis given by endoscopic biopsy. Endoscopic biopsy involves obtaining tissue from the stomach using a thin flexible tube introduced through the mouth and testing for the presence of H pylori under the microscope. It is currently the most accurate available test, however it causes physical discomfort to the patient, with associated risks for harm. This is in contrast to the alternative non‐invasive tests in this review which are significantly less uncomfortable and have minimal or no risk of harm, making them desirable alternatives if they can be shown to be as accurate at diagnosing H pylori as endoscopic biopsy. Most of the studies included participants with heart burn or similar problems in the stomach and excluded participants who had previously undergone partial removal of the stomach and those having treatment for H pylori . Thirty‐four studies (4242 participants) used serology; 29 studies (2988 participants) used stool antigen test; 34 studies (3139 participants) used urea breath test‐ 13 C; 21 studies (1810 participants) used urea breath test‐ 14 C; and two studies (127 participants) used urea breath test but did not report the type of carbon used. Studies varied in the limit they used before saying a test was positive for H pylori infection and the type of stains used to examine the biopsy material. When we looked at all the data we found that urea breath tests were more accurate than blood and stool tests. The results mean that, on average, if 1000 people are tested, there will be 46 people without H pylori who will be misdiagnosed as having H pylori . Also, there will be 30, 42, 86, and 89 people with H pylori infection for whom the diagnosis of H pylori infection will be missed by urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test, respectively. When we looked at the seven studies which compared urea breath test‐ 13 C and serology, or urea breath test‐ 13 C and stool antigen tests in the same participants, the results were uncertain and we cannot tell which test is more accurate. How reliable are the results of the studies? Except for one study, all the studies were of poor methodological quality, which makes their results unreliable. Who do the results of this review apply to? These results apply to children and adults with suspected H pylori infection, but only in those who have not previously undergone stomach operations and those who have not recently had antibiotics or treatment for H pylori infection. What are the implications of this review? Urea breath tests, blood tests, and stool tests may be suitable for identifying whether someone has H pylori infection. However, the level of the result of urea breath test, blood test, or stool test which should be used to make a diagnosis of H pylori infection remains unclear. How up‐to‐date is the review? We performed a thorough literature search for studies reporting the accuracy of these different tests until 4 March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Best, LMJ; Takwoingi, Y; Siddique, S; Selladurai, A; Gandhi, A; Low, B; Yaghoobi, M; Gurusamy, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "64331d17-ad15-4c97-9ad1-c1c0b21ac572", "pmid": "", "title": "Omega‐3 fatty acids for the treatment of dementia", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) from fish and plant sources are commonly considered as a promising non‐medical alternative to improve brain functions and slow down the progression of dementia. This assumption is mostly based on findings of preclinical studies and epidemiological research. Resulting explanatory models aim at the role omega‐3 PUFAs play in the development and integrity of the brain's neurons, their protective antioxidative effect on cell membranes and potential neurochemical mechanisms directly related to Alzheimer‐specific pathology. Epidemiological research also found evidence of malnutrition in people with dementia. Considering this and the fact that omega‐3 PUFA cannot be synthesised by humans, omega‐3 PUFAs might be a promising treatment option for dementia. Objectives To assess the efficacy and safety of omega‐3 polyunsaturated fatty acid (PUFA) supplementation for the treatment of people with dementia. Search methods We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 10 December 2015. We contacted manufacturers of omega‐3 supplements and scanned reference lists of landmark papers and included articles. Selection criteria We included randomised controlled trials (RCTs) in which omega‐3 PUFA in the form of supplements or enriched diets were administered to people with Alzheimer's disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), Parkinson's disease dementia (PDD) or frontotemporal dementia (FTD). Data collection and analysis The primary outcome measures of interest were changes in global and specific cognitive functions, functional performance, dementia severity and adverse effects. Two review authors independently selected studies, extracted data and assessed the quality of trials according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We received unpublished data from the trial authors and collected adverse effects information from the published articles. We conducted meta‐analyses for available outcome measures at six months. Main results We included three comparable randomised, placebo‐controlled trials investigating omega‐3 PUFA supplements in 632 participants with mild to moderate AD over six, 12 and 18 months. We found no studies investigating other types of dementia. All trials were of high methodological quality. The overall quality of evidence for most of the outcomes was high. There was no evidence of a benefit from omega‐3 PUFAs on cognitive function when measured at six months with the Alzheimer's Disease Assessment Scale ‐ Cognitive subscale (standardised mean difference (SMD) ‐0.02, 95% confidence interval (CI) ‐0.19 to 0.15; 566 participants; 3 studies; high quality evidence) or Mini‐Mental State Examination (mean difference (MD) 0.18, 95% CI ‐1.05 to 1.41; 202 participants; 2 studies; high quality evidence) or on activities of daily living (SMD ‐0.02, 95% CI ‐0.19 to 0.16; 544 participants; 2 studies; high quality evidence). There was also no effect at six months of treatment on severity of dementia measured with the Clinical Dementia Rating ‐ Sum of Boxes (MD ‐0.00, 95% CI ‐0.58 to 0.57; 542 participants; 2 studies; high quality evidence) or on quality of life measured with the Quality of Life Alzheimer's Disease scale (MD ‐0.10, 95% CI ‐1.28 to 1.08; 322 participants; 1 study; high quality evidence). There was no difference at six months on mental health measured with the Montgomery‐Åsberg Depression Rating Scale (MD ‐0.10, 95% CI ‐0.74 to 0.54; 178 participants: 1 study; high quality of evidence) or the Neuropsychiatric Inventory (SMD 0.10, 95% CI ‐0.07 to 0.27; 543 participants; 2 studies; high quality of evidence). One very small study showed a benefit for omega‐3 PUFAs in instrumental activities of daily living after 12 months of treatment (MD ‐3.50, 95% CI ‐4.30 to ‐2.70; 22 participants; moderate quality evidence). The included studies did not measure specific cognitive function. The studies did not report adverse events well. Two studies stated that all adverse events were mild and that they did not differ in overall frequency between omega‐3 PUFA and placebo groups. Data from one study showed no difference between groups in frequency of any adverse event (risk ratio (RR) 1.02, 95% CI 0.95 to 1.10; 402 participants; 1 study; moderate quality evidence) or any serious adverse event (RR 1.05, 95% CI 0.78 to 1.41; 402 participants; 1 study; high quality evidence) at 18 months of treatment. Authors' conclusions We found no convincing evidence for the efficacy of omega‐3 PUFA supplements in the treatment of mild to moderate AD. This result was consistent for all outcomes relevant for people with dementia. Adverse effects of omega‐3 PUFAs seemed to be low, but based on the evidence synthesised in this review, we cannot make a final statement on tolerability. The effects on other populations remain unclear. Plain language summary Omega‐3 fatty acids for the treatment of dementia Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) are assumed to have a beneficial effect on the function of the brain. It has been suggested that they might improve or delay decline in memory and ability to carry out everyday tasks in people with dementia. In this review, we investigated randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) comparing omega‐3 PUFAs, given in the form of supplements or enriched diets, with placebo (a pretend treatment) in people with the most common types of dementia. Included trials We included three trials that investigated 632 people with Alzheimer's disease of mild to moderate severity. We found no trials on other types of dementia. In all trials participants took either placebo or omega‐3 PUFA supplements. The quality of the trials was good. The participants were allocated to the groups randomly. The participants and most of the investigators did not know which treatment was given. Results When we combined the results of the trials, we found that taking omega‐3 PUFA supplements for six months had no effect on cognition (learning and understanding), everyday functioning, quality of life or mental health. One very small study observed that omega‐3 PUFAs improved cognitively complex daily activities, such as shopping, when taken for a longer period of time. However, the quality of the evidence was only moderate, so this should be confirmed in further trials. Omega‐3 PUFAs also had no effect on ratings of the overall severity of the illness. The trials did not report side effects very well, but none of the studies reported significant harmful effects on health. Conclusion Altogether, the quality of the evidence was moderate or high for most of the effects that we measured, but we found no evidence for either benefit or harm from omega‐3 PUFA supplements in people with mild to moderate Alzheimer's disease. The effects on people with other types of dementia remain unclear.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Burckhardt, M; Herke, M; Wustmann, T; Watzke, S; Langer, G; Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD009002.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "644446b2-6fd8-4d60-b799-180ea2514010", "pmid": "", "title": "Nebulised hypertonic saline for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Hypertonic saline enhances mucociliary clearance and may lessen the destructive inflammatory process in the airways. This is an update of a previously published review. Objectives To investigate efficacy and tolerability of nebulised hypertonic saline treatment in people with cystic fibrosis (CF) compared to placebo or other treatments that enhance mucociliary clearance. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also searched ongoing trials databases. Most recent search: 25 April 2022. Selection criteria We included randomised and quasi‐randomised controlled trials assessing hypertonic saline compared to placebo or other mucolytic therapy, for any duration or dose regimen in people with CF (any age or disease severity). Data collection and analysis Two authors independently reviewed all identified trials and data, and assessed trial quality. We assessed the certainty of the evidence using GRADE. For cross‐over trials we stipulated a one‐week washout period. We planned to use results from a paired analysis in the review, but this was only possible in one trial. For other cross‐over trials, we chose to treat the trials as if they were parallel. Main results We included 24 trials (1318 participants, aged one month to 56 years); we excluded 29 trials, two trials are ongoing and six are awaiting classification. We judged 15 of the 24 included trials to have a high risk of bias due to participants' ability to discern the taste of the solutions. Hypertonic saline 3% to 7% versus placebo (stable disease) We are uncertain whether the regular use of nebulised hypertonic saline in stable lung disease leads to an improvement in forced expiratory volume in one second (FEV 1 ) % predicted at four weeks, (mean difference (MD) 3.30%, 95% confidence interval (CI) 0.71 to 5.89; 4 trials, 246 participants; very low‐certainty evidence). In preschool children we found no difference in lung clearance index (LCI) at four weeks, but a small improvement after 48 weeks of treatment with hypertonic saline compared to isotonic saline (MD ‐0.60, 95% CI ‐1.00 to ‐0.19; 2 trials, 192 participants). We are also uncertain whether hypertonic saline made a difference to mucociliary clearance, pulmonary exacerbations or adverse events compared to placebo. Hypertonic saline versus control (acute exacerbation) Two trials compared hypertonic saline to control, but only one provided data. There may be little or no difference in lung function measured by FEV 1 % predicted after hypertonic saline compared to isotonic saline (MD 5.10%, 95% CI ‐14.67 to 24.87; 1 trial, 130 participants). Neither trial reported any deaths or measures of sputum clearance. There were no serious adverse events. Hypertonic saline versus rhDNase Three trials compared a similar dose of hypertonic saline to recombinant deoxyribonuclease (rhDNase); two trials (61 participants) provided data for inclusion in the review. We are uncertain whether there was an effect of hypertonic saline on FEV 1 % predicted after three weeks (MD 1.60%, 95% CI ‐7.96 to 11.16; 1 trial, 14 participants; very low‐certainty evidence). At three months, rhDNase may lead to a greater increase in FEV 1 % predicted than hypertonic saline (5 mL twice daily) at 12 weeks in participants with moderate to severe lung disease (MD 8.00%, 95% CI 2.00 to 14.00; low‐certainty evidence). We are uncertain whether adverse events differed between the two treatments. No deaths were reported. Hypertonic saline versus amiloride One trial (12 participants) compared hypertonic saline to amiloride but did not report on most of our outcomes. The trial found that there was no difference between treatments in measures of sputum clearance (very low‐certainty evidence). Hypertonic saline compared with sodium‐2‐mercaptoethane sulphonate (Mistabron®) One trial (29 participants) compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate. The trial did not measure our primary outcomes. There was no difference between treatments in any measures of sputum clearance, courses of antibiotics or adverse events (very low‐certainty evidence). Hypertonic saline versus mannitol One trial (12 participants) compared hypertonic saline to mannitol, but did not report lung function at relevant time points for this review; there were no differences in sputum clearance, but mannitol was reported to be more 'irritating' (very low‐certainty evidence). Hypertonic saline versus xylitol Two trials compared hypertonic saline to xylitol, but we are uncertain whether there is any difference in FEV 1 % predicted or median time to exacerbation between groups (very low‐certainty evidence). No other outcomes were reported in the review. Hypertonic saline 7% versus hypertonic saline 3% We are uncertain whether there was an improvement in FEV 1 % predicted after treatment with 7% hypertonic saline compared with 3% (very low‐certainty evidence). Authors' conclusions We are very uncertain if regular use of nebulised hypertonic saline by adults and children over the age of 12 years with CF results in an improvement in lung function after four weeks (three trials; very low‐certainty evidence); there was no difference seen at 48 weeks (one trial; low‐certainty evidence). Hypertonic saline improved LCI modestly in children under the age of six years. Evidence from one small cross‐over trial in children indicates that rhDNase may lead to better lung function than hypertonic saline at three months; qualifying this, we highlight that while the study did demonstrate that the improvement in FEV 1 was greater with daily rhDNase, there were no differences seen in any of the secondary outcomes. Hypertonic saline does appear to be an effective adjunct to physiotherapy during acute exacerbations of lung disease in adults. However, for the outcomes assessed, the certainty of the evidence ranged from very low to low at best, according to the GRADE criteria. The role of hypertonic saline in conjunction with cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy now needs to be considered, and future research needs to focus on this aspect. Plain language summary Hypertonic saline (salt water with at least 3% salt) nebulised as a fine mist through a mask or mouthpiece for cystic fibrosis Review question Is inhaling hypertonic saline (salt water with at least 3% salt) as a mist through a mask or mouthpiece better for improving mucus clearance in the lungs of people with cystic fibrosis (CF) than a placebo (a mist with no or very little salt) or other agents? Background People with CF produce large amounts of thick mucus which is difficult to clear and blocks up their airways. Chest physiotherapy or medication, e.g. hypertonic saline, or both combined, are used to try and clear this mucus from the airways. Hypertonic saline is water with a concentration of 3% to 7% salt and is inhaled as a fine mist. This is an update of an earlier review. Key messages • We are uncertain whether inhaling nebulised hypertonic saline regularly improves lung function compared to placebo. • Nebulised hypertonic saline does seem to work well as an add‐on to physiotherapy. What did we do? We searched for studies that looked at the use of nebulised hypertonic saline compared to either a placebo or a different type of treatment for clearing mucus from the lungs. We compared the size and methods of the studies and stated how confident we were in the results. What did we find? We included 24 trials with 1318 people with CF aged between one month and 56 years. Two thirds of the trials compared hypertonic saline to a placebo (a dummy treatment); the remaining trials compared hypertonic saline to another type of mucus clearing treatment (including mannitol; rhDNase (Pulmozyme®); amiloride; Mistabron®; xylitol); and one trial compared 7% hypertonic saline with 3% hypertonic saline. Trials assessed different concentrations of hypertonic saline with different nebulisers and different treatment schedules; the most common treatment was twice‐daily 7% hypertonic saline and the most common nebuliser was ultrasonic. Most trials treated people with a bronchodilator to widen the airways before giving the hypertonic saline. Main results Hypertonic saline 3% to 7% versus placebo We are not sure whether hypertonic saline leads to an improvement in lung function in stable disease after four weeks. Two trials showed that there may be a small improvement in lung function (measured using the lung clearance index) with hypertonic saline compared to placebo in preschool children. We are also unsure whether hypertonic saline makes a difference to clearing mucus from the lungs, exacerbations or side effects compared to placebo. During exacerbations, we found that there may be little or no difference in lung function after hypertonic saline compared to placebo. The trials did not report any serious side effects and there were no deaths. One study compared 7% hypertonic saline with a lower concentration of hypertonic saline (3%); we are uncertain whether the higher concentration improved lung function. Hypertonic saline versus mucus mobilising treatments Three trials compared hypertonic saline with rhDNase and found that rhDNase may lead to an improvement in lung function compared to hypertonic saline after three months. We are unsure whether there is any difference in side effects. One trial compared hypertonic saline to amiloride and a further trial compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate (Mistabron®), but neither of the trials gave information about the effect of the treatments on lung function. Similarly, a trial comparing hypertonic saline with mannitol did not give information about the effects on lung function, but they did report that there was no difference between treatments in clearing mucus from the lungs. People taking mannitol said it was more irritating than hypertonic saline. Two trials compared hypertonic saline with xylitol, but we are unsure if there is any difference in lung function and none of our other outcomes were measured. What are the limitations of this evidence? We are not confident in the evidence from these trials. There is a high risk that people knew which treatment they were receiving in half the trials as they could taste the difference between the solutions. Other factors that made us unsure of the results were the small numbers of people taking part in the trials combined with a wide variation in results; also, some trials limited participants to those who could tolerate hypertonic saline or to certain age groups. How up to date is this evidence? The evidence is current to 25 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wark, P, McDonald, VM, Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD001506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.730Z" }, { "id": "64466526-9a7d-4a56-8fda-dca9032219ba", "pmid": "", "title": "Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Tan, ML, Ho, JJ, Teh, KH", "articleTypes": [], "doi": "10.1002/14651858.CD009398.pub3 AB - Abstract - Background About 5% of school children have a specific learning disorder, defined as unexpected failure to acquire adequate abilities in reading, writing or mathematics that is not a result of reduced intellectual ability, inadequate teaching or social deprivation. Of these events, 80% are reading disorders. Polyunsaturated fatty acids (PUFAs), in particular, omega‐3 and omega‐6 fatty acids, which normally are abundant in the brain and in the retina, are important for learning. Some children with specific learning disorders have been found to be deficient in these PUFAs, and it is argued that supplementation of PUFAs may help these children improve their learning abilities. Objectives 1. To assess effects on learning outcomes of supplementation of polyunsaturated fatty acids (PUFAs) for children with specific learning disorders.
 2. To determine whether adverse effects of supplementation of PUFAs are reported in these children. Search methods In November 2015, we searched CENTRAL, Ovid MEDLINE, Embase, PsycINFO, 10 other databases and two trials registers. We also searched the reference lists of relevant articles. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing PUFAs with placebo or no treatment in children younger than 18 years with specific learning disabilities, as diagnosed in accordance with the fifth (or earlier) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5), or the 10th (or earlier) revision of the International Classification of Diseases (ICD‐10) or equivalent criteria. We included children with coexisting developmental disorders such as attention deficit hyperactivity disorder (ADHD) or autism. Data collection and analysis Two review authors (MLT and KHT) independently screened the titles and abstracts of articles identified by the search and eliminated all studies that did not meet the inclusion criteria. We contacted study authors to ask for missing information and clarification, when needed. We used the GRADE approach to assess the quality of evidence. Main results Two small studies involving 116 children, mainly boys between 10 and 18 years of age, met the inclusion criteria. One study was conducted in a school setting, the other at a specialised clinic. Both studies used three months of a combination of omega‐3 and omega‐6 supplements as the intervention compared with placebo. Although both studies had generally low risk of bias, we judged the risk of reporting bias as unclear in one study, and as high in the other study. In addition, one of the studies was funded by industry and reported active company involvement in the study. None of the studies reported data on the primary outcomes of reading, writing, spelling and mathematics scores, as assessed by standardised tests. Evidence of low quality indicates that supplementation of PUFAs did not increase the risk of gastrointestinal disturbances (risk ratio 1.43, 95% confidence interval 0.25 to 8.15; two studies, 116 children). Investigators reported no other adverse effects. Both studies reported attention deficit hyperactivity disorder (ADHD)‐related behaviour outcomes. We were unable to combine the results in a meta‐analysis because one study reported findings as a continuous outcome, and the other as a dichotomous outcome. No other secondary outcomes were reported. We excluded one study because it used a cointervention (carnosine), and five other studies because they did not provide a robust diagnosis of a specific learning disorder. We identified one ongoing study and found three studies awaiting classification. Authors' conclusions Evidence is insufficient to permit any conclusions about the effect of PUFAs on the learning abilities of children with specific learning disorders. Well‐designed RCTs with clearly defined populations of children with specific learning disorders who have been diagnosed by standardised diagnostic criteria are needed. Plain language summary Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders Review question We reviewed the evidence on the effects of polyunsaturated fatty acids (PUFAs), compared with placebo or no treatment, on reading, writing or mathematical abilities of children up to 18 years of age who have specific learning disorders. Background Children with specific learning disorders are those whose abilities in reading, spelling, writing and mathematics are considerably below what is expected for their age, and whose problems are not a result of lower intelligence, inadequate teaching or social deprivation. A child may have a single disorder, such as a reading disorder, or a combined disorder, such as a reading and mathematics disorder. Children may have other problems too, such as attention deficit hyperactivity disorder (ADHD), along with a specific learning disorder. Polyunsaturated fatty acids are known to be necessary for normal brain development and function. The best known PUFAs are the omega‐3 fatty acids, which include docosahexaenoic acid (commonly known as DHA), but the omega‐6 fatty acids are also well known. Polyunsaturated fatty acids must be obtained from foods or supplements, as the human body cannot make them from other types of fat. Because they are needed for normal brain growth and development, PUFAs might help children with specific learning disorders. Study characteristics The evidence is current to November 2015. We found two small studies involving 116 children that met our inclusion criteria. Both studies gave children a combination of omega‐3 and omega‐6 capsules as the intervention for three months. Most of these studies involved boys between 10 and 18 years of age ‐ one was conducted in a school setting, and the other at a specialised clinic. One of the studies was funded by the company that supplied the omega‐3 and omega‐6 supplements. Another study could not be included in this review because investigators added carnosine (an amino acid that is highly concentrated in the brain) to the PUFAs. Carnosine and PUFAs might have similar effects, so it would not be possible to separate the effects of the two ingredients. Review authors excluded five studies because it was not confirmed that a specific learning disorder was diagnosed in these children. Key results None of the included studies reported effects of PUFAs on reading, writing, spelling or mathematical abilities of children. Evidence of low quality (because studies included few participants and showed evidence of bias) suggests that using PUFAs did not increase the risk of minor disturbances to the digestive system. Included studies reported no other types of adverse effects. Both studies reported on ADHD‐related behaviour. However, the format of available data did not allow us to readily combine them or to reach any conclusions. Included studies reported no other secondary outcomes. Conclusion Evidence is not sufficient to support or refute the use of PUFAs in children with specific learning disorders.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.754Z" }, { "id": "6454b8b3-27b8-4f07-87fe-d67ccd498f0f", "pmid": "", "title": "Cranberries for preventing urinary tract infections", "imported": false, "abstract": "Abstract - Background Cranberries contain proanthocyanidins (PACs), which inhibit the adherence of p‐fimbriated Escherichia coli to the urothelial cells lining the bladder. Cranberry products have been used widely for several decades to prevent urinary tract infections (UTIs). This is the fifth update of a review first published in 1998 and updated in 2003, 2004, 2008, and 2012. Objectives To assess the effectiveness of cranberry products in preventing UTIs in susceptible populations. Search methods We searched the Cochrane Kidney and Transplant Specialised Register up to 13 March 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria All randomised controlled trials (RCTs) or quasi‐RCTs of cranberry products compared with placebo, no specific treatment or other intervention (antibiotics, probiotics) for the prevention of UTIs were included. Data collection and analysis At least two authors independently assessed and extracted data. Information was collected on methods, participants, interventions and outcomes (incidence of symptomatic UTIs, positive culture results, side effects, adherence to therapy). Risk ratios (RR) with 95% confidence intervals (CI) were calculated where appropriate. Study quality was assessed using the Cochrane risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results For this update, 26 new studies were added, bringing the total number of included studies to 50 (8857 randomised participants). The risk of bias for sequence generation and allocation concealment was low for 29 and 28 studies, respectively. Thirty‐six studies were at low risk of performance bias, and 23 studies were at low risk of detection bias. Twenty‐seven, 41, and 17 studies were at low risk of attrition bias, reporting bias and other bias, respectively. Forty‐five studies compared cranberry products with placebo, water or no specific treatment in six different groups of participants. Twenty‐six of these 45 studies could be meta‐analysed for the outcome of symptomatic, culture‐verified UTIs. In moderate certainty evidence, cranberry products reduced the risk of UTIs (6211 participants: RR 0.70, 95% CI 0.58 to 0.84; I² = 69%). When studies were divided into groups according to the treatment indication, cranberry products probably reduced the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs (8 studies, 1555 participants: RR 0.74, 95% CI 0.55 to 0.99; I² = 54%), in children (5 studies, 504 participants: RR 0.46, 95% CI 0.32 to 0.68; I² = 21%) and in people with a susceptibility to UTIs due to an intervention (6 studies, 1434 participants: RR 0.47, 95% CI 0.37 to 0.61; I² = 0%). However, there may be little or no benefit in elderly institutionalised men and women (3 studies, 1489 participants: RR 0.93, 95% CI 0.67 to 1.30; I² = 9%; moderate certainty evidence), pregnant women (3 studies, 765 participants: RR 1.06, 95% CI 0.75 to 1.50; I² = 3%; moderate certainty evidence), or adults with neuromuscular bladder dysfunction with incomplete bladder emptying (3 studies, 464 participants: RR 0.97, 95% CI 0.78 to 1.19; I² = 0%; low certainty evidence). Other comparisons were cranberry products with probiotics (three studies) or antibiotics (six studies), cranberry tablets with cranberry liquid (one study), and different doses of PACs (two studies). Compared to antibiotics, cranberry products may make little or no difference to the risk of symptomatic, culture‐verified UTIs (2 studies, 385 participants: RR 1.03, 95% CI 0.80 to 1.33; I² = 0%) or the risk of clinical symptoms without culture (2 studies, 336 participants: RR 1.30, 95% CI 0.79 to 2.14; I² = 68%). Compared to probiotics, cranberry products may reduce the risk of symptomatic, culture‐verified UTIs (3 studies, 215 participants: RR 0.39, 95% CI 0.27 to 0.56; I = 0%). It is unclear whether efficacy differs between cranberry juice and tablets or between different doses of PACs, as the certainty of the evidence was very low. The number of participants with gastrointestinal side effects probably does not differ between those taking cranberry products and those receiving a placebo or no specific treatment (10 studies, 2166 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%; moderate certainty evidence). There was no clear relationship between compliance with therapy and the risk for repeat UTIs. No difference in the risk for UTIs could be demonstrated between low, moderate and high doses of PACs. Authors' conclusions This update adds a further 26 studies, taking the total number of studies to 50 with 8857 participants. These data support the use of cranberry products to reduce the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs, in children, and in people susceptible to UTIs following interventions. The evidence currently available does not support its use in the elderly, patients with bladder emptying problems, or pregnant women. Plain language summary Cranberries for preventing urinary tract infections What is the issue? Cranberries (as cranberry juice, tablets or capsules) have been used for many years to prevent urinary tract infections (UTIs). Cranberries contain proanthocyanidins (PACs), substances that can prevent bacteria from sticking to the walls of the bladder. This may help prevent infections and reduce the need for working people to take time for medical appointments. However, there is currently no established regimen for what PACs dose to use and no formal regulation by health authorities of cranberry products. In particular, the dose suggested may not be included on the package. What did we do? We analysed the results of randomised controlled trials (RCTs), which compared the occurrence of UTIs in people taking a cranberry product with those taking a placebo or no treatment. We also analysed the results of RCTs comparing a cranberry product with other treatments such as antibiotics or probiotics. What did we find? We found 50 RCTs involving 8857 people. Forty‐five RCTs compared cranberry with a placebo or no treatment. Taking cranberries as a juice, tablets or capsules reduced the number of UTIs in women with recurrent UTIs, in children with UTIs and in people susceptible to UTIs following an intervention such as bladder radiotherapy. However, UTIs did not appear to be reduced in elderly institutionalised men and women, in adults with neuromuscular bladder dysfunction and incomplete bladder emptying, or in pregnant women. Few people reported any side effects with the most common being tummy pain. We did not find enough information to determine if cranberry products are more or less effective compared with antibiotics or probiotics in preventing further UTIs. Conclusions Cranberry products may help to prevent UTIs which cause symptoms in women with frequent UTIs, in children with UTIs and in people who have undergone an intervention involving the bladder. However, further assessment is required in well‐designed and prospectively registered RCTs to clarify further who with UTIs would benefit from cranberry products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Williams, G, Stothart, CI, Hahn, D, Stephens, JH, Craig, JC, Hodson, EM", "articleTypes": [], "doi": "10.1002/14651858.CD001321.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.115Z" }, { "id": "645beb68-9712-46c8-877b-36e34e26752e", "pmid": "", "title": "Selenium for preventing cancer", "imported": false, "abstract": "Abstract - Background This review is the third update of the Cochrane review \"Selenium for preventing cancer\". Selenium is a naturally occurring element with both nutritional and toxicological properties. Higher selenium exposure and selenium supplements have been suggested to protect against several types of cancer. Objectives To gather and present evidence needed to address two research questions: 1. What is the aetiological relationship between selenium exposure and cancer risk in humans?
 2. Describe the efficacy of selenium supplementation for cancer prevention in humans. Search methods We updated electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), MEDLINE (Ovid, 2013 to January 2017, week 4), and Embase (2013 to 2017, week 6), as well as searches of clinical trial registries. Selection criteria We included randomised controlled trials (RCTs) and longitudinal observational studies that enrolled adult participants. Data collection and analysis We performed random‐effects (RE) meta‐analyses when two or more RCTs were available for a specific outcome. We conducted RE meta‐analyses when five or more observational studies were available for a specific outcome. We assessed risk of bias in RCTs and in observational studies using Cochrane's risk assessment tool and the Newcastle‐Ottawa Scale, respectively. We considered in the primary analysis data pooled from RCTs with low risk of bias. We assessed the certainty of evidence by using the GRADE approach. Main results We included 83 studies in this updated review: two additional RCTs (10 in total) and a few additional trial reports for previously included studies. RCTs involved 27,232 participants allocated to either selenium supplements or placebo. For analyses of RCTs with low risk of bias, the summary risk ratio (RR) for any cancer incidence was 1.01 (95% confidence interval (CI) 0.93 to 1.10; 3 studies, 19,475 participants; high‐certainty evidence). The RR for estimated cancer mortality was 1.02 (95% CI 0.80 to 1.30; 1 study, 17,448 participants). For the most frequently investigated site‐specific cancers, investigators provided little evidence of any effect of selenium supplementation. Two RCTs with 19,009 participants indicated that colorectal cancer was unaffected by selenium administration (RR 0.99, 95% CI 0.69 to 1.43), as were non‐melanoma skin cancer (RR 1.16, 95% CI 0.30 to 4.42; 2 studies, 2027 participants), lung cancer (RR 1.16, 95% CI 0.89 to 1.50; 2 studies, 19,009 participants), breast cancer (RR 2.04, 95% CI 0.44 to 9.55; 1 study, 802 participants), bladder cancer (RR 1.07, 95% CI 0.76 to 1.52; 2 studies, 19,009 participants), and prostate cancer (RR 1.01, 95% CI 0.90 to 1.14; 4 studies, 18,942 participants). Certainty of the evidence was high for all of these cancer sites, except for breast cancer, which was of moderate certainty owing to imprecision, and non‐melanoma skin cancer, which we judged as moderate certainty owing to high heterogeneity. RCTs with low risk of bias suggested increased melanoma risk. Results for most outcomes were similar when we included all RCTs in the meta‐analysis, regardless of risk of bias. Selenium supplementation did not reduce overall cancer incidence (RR 0.99, 95% CI 0.86 to 1.14; 5 studies, 21,860 participants) nor mortality (RR 0.81, 95% CI 0.49 to 1.32; 2 studies, 18,698 participants). Summary RRs for site‐specific cancers showed limited changes compared with estimates from high‐quality studies alone, except for liver cancer, for which results were reversed. In the largest trial, the Selenium and Vitamin E Cancer Trial, selenium supplementation increased risks of alopecia and dermatitis, and for participants with highest background selenium status, supplementation also increased risk of high‐grade prostate cancer. RCTs showed a slightly increased risk of type 2 diabetes associated with supplementation. A hypothesis generated by the Nutritional Prevention of Cancer Trial ‐ that individuals with low blood selenium levels could reduce their risk of cancer (particularly prostate cancer) by increasing selenium intake ‐ has not been confirmed. As RCT participants have been overwhelmingly male (88%), we could not assess the potential influence of sex or gender. We included 15 additional observational cohort studies (70 in total; over 2,360,000 participants). We found that lower cancer incidence (summary odds ratio (OR) 0.72, 95% CI 0.55 to 0.93; 7 studies, 76,239 participants) and lower cancer mortality (OR 0.76, 95% CI 0.59 to 0.97; 7 studies, 183,863 participants) were associated with the highest category of selenium exposure compared with the lowest. Cancer incidence was lower in men (OR 0.72, 95% CI 0.46 to 1.14, 4 studies, 29,365 men) than in women (OR 0.90, 95% CI 0.45 to 1.77, 2 studies, 18,244 women). Data show a decrease in risk of site‐specific cancers for stomach, colorectal, lung, breast, bladder, and prostate cancers. However, these studies have major weaknesses due to study design, exposure misclassification, and potential unmeasured confounding due to lifestyle or nutritional factors covarying with selenium exposure beyond those taken into account in multi‐variable analyses. In addition, no evidence of a dose‐response relation between selenium status and cancer risk emerged. Certainty of evidence was very low for each outcome. Some studies suggested that genetic factors might modify the relation between selenium and cancer risk ‐ an issue that merits further investigation. Authors' conclusions Well‐designed and well‐conducted RCTs have shown no beneficial effect of selenium supplements in reducing cancer risk (high certainty of evidence). Some RCTs have raised concerns by reporting a higher incidence of high‐grade prostate cancer and type 2 diabetes in participants with selenium supplementation. No clear evidence of an influence of baseline participant selenium status on outcomes has emerged in these studies. Observational longitudinal studies have shown an inverse association between selenium exposure and risk of some cancer types, but null and direct relations have also been reported, and no systematic pattern suggesting dose‐response relations has emerged. These studies suffer from limitations inherent to the observational design, including exposure misclassification and unmeasured confounding. Overall, there is no evidence to suggest that increasing selenium intake through diet or supplementation prevents cancer in humans. However, more research is needed to assess whether selenium may modify the risk of cancer in individuals with a specific genetic background or nutritional status, and to investigate possible differential effects of various forms of selenium. Plain language summary Selenium for preventing cancer Review question 
 We reviewed the evidence investigating the relation between selenium intake and cancer prevention. This review updates the most recent Cochrane review on this topic ( Vinceti 2014) , which was an update of Dennert 2011 . Background 
 Selenium is a naturally occurring element that individuals are exposed to mainly through food consumption, although exposure can also occur through air, drinking water, and dietary supplements. Small amounts of selenium are essential for certain biological functions in humans, but slightly higher amounts can pose a toxicity risk, making selenium an element with a narrow, but as yet not well‐defined, safe range of exposure. Selenium occurs in many different chemical forms with different biological activity. From the late 1960s, a few observational studies reported that people with high levels of selenium in their diet or in their body tissues had lower risk of cancer, and some laboratory studies showed that selenium could inhibit the growth of cancer cells. This led to widespread interest in selenium supplements and claims that taking such supplements could prevent cancer. Since that time, many more observational studies have been conducted to compare cancer rates among individuals with high and low selenium exposure. More recently, several randomised controlled trials designed to assess whether selenium supplementation can prevent cancer have been carried out. These trials played a major role in enhancing our understanding of the relation between selenium and cancer risk as a result of their stronger study design as compared with observational studies. The most recent trials in particular have shown high methodological quality and statistical power. Several trials focused on whether selenium could prevent prostate cancer. Study characteristics 
 This review includes 10 trials in which adults were randomly assigned to receive selenium supplements or placebo, and 70 observational studies in which adults were followed over time to determine whether their baseline selenium status was associated with their risk of cancer. The evidence is current to January 2017. Key results 
 All of the high‐quality randomised trials reported no effect of selenium on reducing overall risk of cancer or risk of particular cancers, including the most investigated outcome ‐ prostate cancer. Some trials unexpectedly suggested that selenium may increase risks of high‐grade prostate cancer, type 2 diabetes, and dermatological abnormalities. Observational studies have yielded inconsistent evidence of a possible effect of selenium exposure on cancer risk, with no evidence of a dose‐response relation. When we pooled results of these studies, overall they suggested an inverse relation between cancer exposure and subsequent incidence of any cancer or some specific cancers, such as colon and prostate cancer. However, observational studies have major weaknesses. The selenium exposure status of participants could have been misclassified owing to limitations of the indicators of selenium exposure used, as well as to uncertainty regarding the particular selenium species contributing to overall exposure. In addition, unmeasured confounding from lifestyle or nutritional factors ‐ a major and well‐known source of bias in nutritional epidemiology studies of observational design ‐ could have been present. Therefore, the internal validity of these studies is limited. Currently, the hypothesis that increasing selenium intake may reduce cancer risk is not supported by epidemiological evidence. Additional research is needed to assess whether selenium may affect the risk of cancer in individuals with specific genetic backgrounds or nutritional status, and to determine how the various chemical forms of selenium compounds may have different effects on cancer risk.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Vinceti, M; Filippini, T; Del Giovane, C; Dennert, G; Zwahlen, M; Brinkman, M; Zeegers, MPA; Horneber, M; D'Amico, R; Crespi, CM", "articleTypes": [], "doi": "10.1002/14651858.CD005195.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "647b22c0-cdd4-4cc7-8db0-8497880098e5", "pmid": "", "title": "CD36 Involvement on Fat Taste Perception and Fat Hedonic Value in Humans", "imported": false, "abstract": "The purpose of this study is to determine the effect of common human variants in in taste related genes, such as CD36 gene, a putative fat taste receptor, affect fat taste perception.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.142Z" }, { "id": "64997db3-09fc-411f-a7f9-ec94ac03d74d", "pmid": "", "title": "Definitive Radiochemotherapy With 5-FU / Cisplatin Plus/Minus Cetuximab in Unresectable Locally Advanced Esophageal Cancer: a Phase II Study", "imported": false, "abstract": "Esophageal cancer is a highly aggressive tumor. Treatment options are various and range from chemotherapy to radiotherapy and several surgical techniques. Nevertheless, the overall survival rates for this disease remain poor.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.250Z" }, { "id": "64a0a45c-9f5a-483b-8525-685b4ff77d4e", "pmid": "", "title": "Vasodilators for primary Raynaud's phenomenon", "imported": false, "abstract": "Abstract - Background Numerous agents have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered to be the drugs of choice, evidence of the effects of alternative pharmacological treatments is limited. This is an update of a review first published in 2008. Objectives To assess the effects of drugs with vasodilator effects on primary Raynaud's phenomenon as determined by frequency, severity, and duration of vasospastic attacks; quality of life; adverse events; and Raynauds Condition Score. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trial register to November 16, 2020. Selection criteria We included randomized controlled trials evaluating effects of oral, intravenous, and topical formulations of any drug with vasodilator effects on subjective symptoms, severity scores, and radiological outcomes in primary Raynaud's phenomenon. Treatment with calcium channel blockers was not assessed in this review, nor were these agents compared. Data collection and analysis Two review authors independently selected studies for inclusion, assessed studies using the Cochrane \"Risk of bias\" tool, and extracted study data. Outcomes of interest included frequency, severity, and duration of attacks; quality of life (QoL); adverse events (AEs); and the Raynaud Condition Score (RCS). We assessed the certainty of the evidence using GRADE. Main results We identified seven new studies for this update. In total, we included 15 studies involving 635 participants. These studies compared different vasodilators to placebo. Individual studies used different methods and measures to report different outcomes. Angiotensin‐converting enzyme (ACE) inhibitors Combining data from three studies revealed a possible small increase in the frequency of attacks per week after treatment (captopril or enalapril) compared to placebo (mean difference [MD] 0.79, 95% confidence interval [CI] 0.43 to 1.17; low‐certainty evidence). There was no evidence of a difference between groups in severity of attacks (MD ‐0.17, 95% CI ‐4.66 to 4.31; 34 participants, 2 studies; low‐certainty evidence); duration of attacks (MD 0.54, 95% CI ‐2.42 to 1.34; 14 participants, 1 study; low‐certainty evidence); or AEs (risk ratio [RR] 1.35, 95% CI 0.67 to 2.73; 46 participants, 3 studies; low‐certainty evidence). QoL and RCS were not reported. Alpha blockers Two studies used alpha blockers (buflomedil or moxisylyte). We were unable to combine data due to the way results were presented. Buflomedil probably reduced the frequency of attacks compared to placebo (MD ‐8.82, 95% CI ‐11.04 to ‐6.60; 31 participants, 1 study; moderate‐certainty evidence) and may improve severity scores (MD ‐0.41, 95% CI ‐0.62 to ‐0.30; moderate‐certainty evidence). With moxisylyte, investigators reported fewer attacks (P < 0.02), less severe symptoms (P < 0.01), and shorter duration of attacks, but the clinical relevance of these results is unclear. No evidence of a difference in AEs between buflomedil and placebo groups was noted (RR 1.41, 95% CI 0.27 to 7.28; 31 participants, 1 study; moderate‐certainty evidence). More AEs were observed in participants in the moxisylyte group than in the placebo group. Prostaglandin/prostacyclin analogues One study compared beraprost versus placebo. There was no evidence of benefit for frequency (MD 2.00, 95% CI ‐0.35 to 4.35; 118 participants, low‐certainty evidence) or severity (MD ‐0.06, 95% CI ‐0.34 to 0.22; 118 participants, low‐certainty evidence) of attacks. Overall, more AEs were noted in the beraprost group (RR 1.59, 95% CI 1.05 to 2.42; 125 participants; low‐certainty evidence). This study did not report on duration of attacks, QoL, or RCS. Thromboxane synthase inhibitors One study compared a thromboxane synthase inhibitor (dazoxiben) versus placebo. There was no evidence of benefit for frequency of attacks (MD 0.8, 95% CI ‐1.81 to 3.41; 6 participants; very low‐certainty evidence). Adverse events were not reported in subgroup analyses of participants with primary Raynaud's phenomenon, and the study did not report on duration of attacks, severity of symptoms, QoL, or RCS. Selective serotonin reuptake inhibitors One study compared ketanserin with placebo. There may be a slight reduction in the number of attacks per week with ketanserin compared to placebo (MD ‐14.0, 95% CI ‐27.72 to ‐0.28; 41 participants; very low‐certainty evidence) and reduced severity score (MD ‐133.00, 95% CI ‐162.40 to ‐103.60; 41 participants; very low‐certainty evidence). There was no evidence that ketanserin reduced the duration of attacks (MD ‐4.00, 95% CI ‐14.82 to 6.82; 41 participants; very low‐certainty evidence), or that AEs were increased in either group (RR 1.54, 95% CI 0.89 to 2.65; 41 participants; very low‐certainty evidence). This study did not report on QoL or RCS. Nitrate/nitrate derivatives Four studies compared topical treatments of nitroglycerin or glyceryl trinitrate versus placebo, each reporting on limited outcomes. Meta‐analysis demonstrated no evidence of effect on frequency of attacks per week (MD ‐1.57, 95% CI ‐4.31 to 1.17; 86 participants, 2 studies; very low‐certainty evidence). We were unable to pool any data for the remaining outcomes. Phosphodiesterase inhibitors Three studies compared phosphodiesterase inhibitors (vardenafil, cilostazol or PF‐00489791) to an equivalent placebo. Results showed no evidence of a difference in frequency of attacks (standardized MD [SMD] ‐0.05, 95% CI ‐6.71 to 6.61; 111 participants, 2 studies; low‐certainty evidence), severity of attacks (MD ‐0.03, 95% CI ‐1.04 to 0.97; 111 participants, 2 studies; very low‐certainty evidence), duration of attacks (MD ‐1.60, 95% CI ‐7.51 to 4.31; 73 participants, 1 study; low‐certainty evidence), or RCS (SMD ‐0.8, 95% CI ‐1.74 to 0.13; 79 participants, 2 studies; low‐certainty evidence). Study authors reported that 35% of participants on cilostazol complained of headaches, which were not reported in the placebo group. PF‐00489791 caused 34 of 54 participants to experience AEs versus 43 of 102 participants receiving placebo (RR 1.49). Headache was most common, affecting 14 participants (PF‐00489791) versus nine participants (placebo). Authors' conclusions The included studies investigated several different vasodilators (topical and oral) for treatment of primary Raynaud's phenomenon. Small sample sizes, limited data, and variability in outcome reporting yielded evidence of very low to moderate certainty. Evidence is insufficient to support the use of vasodilators and suggests that vasodilator use may even worsen disease. Plain language summary Vasodilator drugs to reduce the symptoms of primary Raynaud's phenomenon Background Raynaud's phenomenon (RP) is a condition affecting the small blood vessels in the extremities, usually in the fingers but also in the toes and other body parts. It is caused by temporary narrowing of the blood vessels, which leads to color changes with associated numbness, tingling, and pain. Various triggers for this condition are known, such as stress, cold, and use of vibrational hand tools. Conservative measures to control this condition include stopping smoking and maintaining both peripheral and ambient warmth. Medications that dilate the blood vessels such as calcium channel blockers (CCBs) may be used but can have side effects. This review aims to investigate the effectiveness and safety of drugs that dilate the blood vessels other than CCBs. Study characteristics and key results We found seven new studies for this update, bringing the total to 15 (search was good to November 16, 2020). This update now includes other routes of administration such as through the veins (intravenous) and the skin (topical), in contrast to previous reviews, which focused on oral forms of treatment. The studies were published between 1989 and 2013 and involved a total of 635 participants randomly assigned to receive treatment or placebo control. Many studies did not describe various aspects of study methods such as randomization, allocation concealment, and blinding. Treatment duration varied between two weeks and six months.
Angiotensin‐converting enzyme (ACE) inhibitors as a drug class, specifically enalapril and captopril in this review, in general increased the frequency of Raynaud's attacks per week but did not affect the severity of the attacks. Enalapril worsened subjective assessment of improvement, and captopril did not improve subjective outcomes or digital blood flow. Buflomedil showed a small reduction in the frequency and severity of attacks with increased side effects. Beraprost and dazoxiben did not demonstrate any change in frequency or severity of attacks nor in disability score and were associated with increased side effects. Ketanserin did not demonstrate improvement in frequency or duration of attacks nor in digital blood flow but did demonstrate improvement in severity scoring of RP. In a small study, moxisylyte was shown to reduce the frequency and severity of attacks to a small degree but with increased side effects. Topical glyceryl trinitrate did not show any effect on reducing the frequency of attacks per week. One study reported subjective improvement in Raynaud Condition Score (RCS). One small study reported improvements in frequency and severity of attacks as subjective changes. Headaches were the most significant and common side effect of treatment. Phosphodiesterase inhibitors did not cause a reduction in frequency, severity, or duration of attacks and did not improve RCS. One study reported in favor of vardenafil alone to reduce RCS but found that the effect is likely small. One study reported that cilostazol increased the frequency and severity of attacks; more research is needed to confirm this finding. Risk of headache as a side effect of treatment was increased with cilostazol use. PF‐00489791 at a dose of 20 mg was found to slightly improve all subjective outcome measures and RCS. Reliability of the evidence We have very low to moderate confidence in these results, so we cannot make any firm conclusions about the benefit of these drugs for improving symptoms of primary RP. We cannot be confident because of the small numbers of participants involved in studies, issues with how studies were designed, and differences in how they measured whether or not treatments were effective. Therefore, the clinical importance of these results is difficult to assess, especially when placebo response is high. It is also pertinent that the results for each drug class and for individual drugs within each drug class must be interpreted in the context that they may have varying pharmacologic effects in addition to vasodilation. This must be taken into consideration when any conclusions are made about the overall effects of each drug class and/or individual drug.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Su, KYC; Sharma, M; Kim, HJ; Kaganov, E; Hughes, I; Abdeen, MH; Ng, JH", "articleTypes": [], "doi": "10.1002/14651858.CD006687.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "64a48cba-07cf-47fe-ac8d-5d043221059e", "pmid": "", "title": "The Impact of Multivitamin Supplementation on Micronutrient Levels in GLP-1 Users: A Randomized, Double-Blind, Placebo-Controlled Trial", "imported": false, "abstract": "Rationale: Glucagon-Like Peptide-1 (GLP-1) receptor agonists have emerged as effective treatments for obesity and associated medical conditions. However, patients may be at risk of micronutrient deficiencies during therapy due to reduced appetite, altered gastrointestinal physiology, and weight loss. Multivitamin supplementation is commonly prescribed to mitigate these risks, but the necessity and efficacy of multivitamin use in GLP-1 users remain debatable, as some clinicians advocate for routine supplementation while others do not.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.242Z" }, { "id": "64cdfa27-9872-4f55-8688-862780ff278a", "pmid": "", "title": "Immunostimulants for preventing respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are a major cause of childhood morbidity and mortality. Immunostimulants (IS) may reduce the incidence of ARTIs. Objectives To determine the efficacy and safety of IS in preventing ARTIs in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 1, which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to February week 4, 2011), EMBASE (1990 to February 2011), Google Scholar (2009 to February 2011), Scopus (2009 to February 2011), PASCAL (1990 to February 2010), SciSearch (1990 to February 2010) and IPA (1990 to February 2010). Selection criteria We included all comparative randomized controlled trials (RCTs) which enrolled participants less than 18 years of age. The intervention was IS medication, administered by any method, compared to placebo to prevent ARTIs. Data collection and analysis We analyzed the outcome on ARTIs both as the mean number of ARTIs by group and as a percent change in the rate of ARTIs. We undertook meta‐analyses using a random‐effects model and presented results as mean differences (MD) with 95% confidence intervals (CI). Two review authors independently assessed the search results and risk of bias, and extracted data. A funnel plot suggested there may be publication bias in the identified trials. Main results Thirty‐five placebo‐controlled trials (4060 participants) provided data in a form suitable for inclusion in the meta‐analyses. When compared with placebo, the use of IS was shown to reduce ARTIs measured as the total numbers of ARTIs (MD ‐1.24; 95% CI ‐1.54 to ‐0.94) and the difference in ARTI rates (MD ‐38.84%; 95% CI ‐46.37% to ‐31.31%). Trial quality was generally poor and a high level of statistical heterogeneity was evident. The subgroup analysis of bacterial IS, D53 and OM‐85 studies produced similar results, with lower heterogeneity. No difference in adverse events was evident between the placebo and IS groups. Authors' conclusions This review shows that IS reduce the incidence of ARTIs by 40% on average in susceptible children. Studies in healthy children are not available. Although the safety profile in the studies was good, some IS may be unsafe. ARTI‐susceptible children may benefit from IS treatment. Further high‐quality trials are needed and we encourage national health authorities to conduct large, multicentre, double‐blind, placebo‐controlled RCTs on the role of IS in preventing ARTIs in children. Plain language summary Immunostimulants to prevent acute respiratory tract infections in children Acute respiratory tract infections (ARTIs) are responsible for 19% of all deaths in children younger than five years of age, mainly in low‐income countries in Africa, Asia and Latin America. In high‐income countries ARTIs are among the most frequent illnesses, leading to 20% of medical consultations, 30% of days lost from work and 75% of antibiotic prescriptions. In the USA the total cost of non‐influenza‐related viral ARTIs is around $40 billion annually, while the corresponding cost for influenza is US $87.1 billion. The main signs and symptoms of ARTIs include sneezing, runny nose, sore throat, cough and malaise. Children living in rural communities, not attending daycare centres, suffer about seven ARTI episodes in the first year of life; eight ARTIs per year from the ages of one to four; six per year aged five to nine; and five per year aged 10 to 19. Children exposed to risks factors, such as attendance at daycare centres, overcrowding, contact with older siblings, smoking at home and lack of breast feeding, may suffer more ARTIs. Several treatments have been used to reduce the incidence of ARTIs (vitamin A, vitamin C, zinc, antibiotics). Among them are immunostimulants (herbal extracts, bacterial extracts, synthetic compounds), which aim to increase the immune defences of the respiratory tract. We searched for clinical trials of immunostimulants to prevent ARTIs in children compared to placebo. Our review includes 35 studies with 4060 participants. However, the quality of many of the studies was poor and the results were very diverse. By combining results, immunostimulants reduced 1.24 ARTIs in a six‐month period, equivalent to a 39% reduction in ARTIs compared to the placebo group. Only 20 studies provided adequate data on adverse events: the most frequent were rash, nausea, vomiting, abdominal pain and diarrhea. The main limitations of this review were the poor methodological quality and diverse trial results. We conclude that ARTI‐susceptible children may benefit from immunostimulants, but more high‐quality studies are needed. We suggest that national health authorities conduct high‐quality randomized controlled trials to assess the true effects of immunostimulant preparations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Del‐Rio‐Navarro, BE; Espinosa‐Rosales, FJ; Flenady, V; Sienra‐Monge, JJL", "articleTypes": [], "doi": "10.1002/14651858.CD004974.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "64d57f48-49f1-4313-8e83-1687633eb9cf", "pmid": "", "title": "Neurogenic Mechanisms in Burning Mouth Syndrome With Focus on Localization and Desensibilization of Vanilloid Receptor TRPV1", "imported": false, "abstract": "Burning mouth syndrome (BMS) is characterized by a bilateral burning sensation in the anterior tongue, hard palate and lips in the absence of any clinical or laboratory findings. The term syndrome implicates the simultaneous presence of oral dryness (xerostomia) and altered taste (dysgeusia) in addition to the burning sensation in the oral mucosa. BMS is most often seen in women and is more frequent during menopause. The etiology and pathogenesis are still unclear but recent studies suggest that BMS is a neuropathic pain condition.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "64d81d37-471e-405d-82ae-ba139862ce01", "pmid": "", "title": "Ribavirin monotherapy for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. A high proportion of patients never experience symptoms. Peginterferon plus ribavirin is the recommended treatment for chronic hepatitis C. However, ribavirin monotherapy may be considered for some patients. Objectives To assess the beneficial and harmful effects of ribavirin monotherapy for patients with chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included all randomised trials irrespective of blinding, language, or publication status comparing ribavirin versus no intervention, placebo, or interferon for chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained virological response (loss of hepatitis C virus RNA at least six months after treatment), liver‐related morbidity plus all‐cause mortality, and adverse events. Secondary outcome measures were end of treatment virological response, biochemical response (transaminase activity), and histological response. Randomisation methods, blinding, data handling, and funding were extracted as measures of bias control. Random‐effects and fixed‐effect meta‐analyses were performed for all outcomes. We only present the results of the fixed‐effect model if both models provide the same result regarding statistical significance. We present data as risk difference (RD) with 95% confidence intervals (CI). Main results We included 14 randomised trials with 657 patients. The majority of trials had unclear control of bias. Compared with placebo or no intervention, ribavirin had no significant effect on the sustained virological response (RD 0%, 95% CI ‐2% to 3%, five trials) or end of treatment virological response (RD 0% 95% CI ‐3% to 3%, ten trials). Ribavirin had no significant effect on liver‐related morbidity plus mortality (RD 0%, 95% CI ‐2% to 3%, 11 trials). Ribavirin significantly increased the risk of adverse reactions, including anaemia. Ribavirin significantly improved end of treatment biochemical and histological response but not the sustained biochemical response. Ribavirin was significantly inferior to interferon regarding virological and biochemical responses (five trials). Authors' conclusions Ribavirin seems without beneficial effects on serum virological response and liver‐related morbidity or mortality, and significantly increased the risk of adverse reactions. Ribavirin monotherapy seems significantly inferior to interferon monotherapy. The total number of included patients is small, and more trials are perhaps needed. The use of ribavirin monotherapy for chronic hepatitis C cannot be recommended outside randomised trials. Plain language summary Treatment of patients infected with hepatitis C virus Globally, about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behaviour, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die from it. Treatment with interferon clears hepatitis C virus from the blood in about 15% of the patients. Adding ribavirin to interferon (combination therapy) significantly improves the number that clears hepatitis C from the blood to about 40%. Not all patients are tolerant to interferon, and also interferon is costly. This is why ribavirin given as a single drug may be considered as an option for patients with chronic hepatitis C. This review identified 11 randomised trials comparing ribavirin with no antiviral treatment in patient with chronic hepatitis C. Combining the results from all identified trials ribavirin alone seemed without beneficial effects for patients with chronic hepatitis C. Moreover, ribavirin given alone was significantly inferior compared with interferon regarding clearing hepatitis C from the blood and regarding reducing liver enzymes activity in the blood. Furthermore, ribavirin given alone increased the risk of anaemia. Thus, ribavirin given alone cannot be recommended, but more trials may be needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brok, J, Gluud, LL, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005527.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.761Z" }, { "id": "64dee234-e464-4462-9e75-3137eb4e4cbd", "pmid": "", "title": "Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Herpes zoster oticus (HZO) is a viral infection of the ear and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first‐line treatment for herpes zoster infections at other body sites and are thought to reduce or minimise nerve damage, thereby improving outcomes. It has been suggested that these agents improve the chance of facial weakness improving or resolving completely in patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy). Search methods We searched the Cochrane ENT Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medline (1950 ‐ 2007), PubMed 2007 ‐ 2008, EMBASE (1974 onwards) and other relevant databases. The date of the most recent search was June 2008. Selection criteria Two authors scrutinized all possible citations to identify randomised controlled trials in which antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) were given as treatment for Ramsay Hunt syndrome. We contacted an author for further information. Data collection and analysis Two reviewers independently assessed eligibility and trial quality. Main results Only one randomised, controlled trial was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, intravenous acyclovir and corticosteroids were compared with corticosteroids alone. Our analysis found no statistically significant difference between the two groups. Authors' conclusions We found no evidence that anti‐viral agents have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. The use of these drugs in patients with herpes zoster infections in other parts of the body might suggest that they have a role in herpes zoster oticus. As usual, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically under‐powered study) does not necessarily indicate that antivirals are ineffective. However, these drugs are associated with a number of adverse effects and this must be taken into consideration when undertaking the requisite risk‐benefit analysis before instigating treatment. Plain language summary Uncertainty about usefulness of antiviral drugs in Ramsay Hunt syndrome It seems logical that antiviral drugs might help patients with a herpes virus infection of the ear producing facial weakness (a condition known as 'Ramsay Hunt syndrome'). These drugs often help similar viral infections elsewhere in the body. However, trials that might address this issue have not been done and there is therefore some uncertainty about their usefulness. Since patients can experience side‐effects when taking these drugs, the risks of these have to be balanced with the unknown prospect of benefit when considering whether to use them in Ramsay Hunt syndrome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T, Doree, C, Chamberlain, IJ, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.756Z" }, { "id": "64f3868a-df94-4959-8266-dd0621126ad3", "pmid": "", "title": "A Phase 1, Randomized, Double-blinded, Placebo-controlled, Dose-escalation and Dose-expansion Study to Evaluate the Safety and Immunogenicity of DelNS1-nCoV-RBD LAIV for COVID-19 in Healthy Adults", "imported": false, "abstract": "To investigate the safety and immunogenicity profile of of a novel nasal spray investigational vaccine, which is a potential prophylactic vaccine for current pandemic disease COVID-19.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "64f4bc0b-9a78-4727-acee-e63387a92014", "pmid": "", "title": "Chelation therapy for atherosclerotic cardiovascular disease", "imported": false, "abstract": "Abstract - Background Chelation therapy is promoted and practiced around the world as a form of alternative medicine in the treatment of atherosclerotic cardiovascular disease. It has been suggested as a safe, relatively inexpensive, non‐surgical method of restoring blood flow in atherosclerotic vessels. However, there is currently limited high‐quality, adequately‐powered research informing evidence‐based medicine on the topic, specifically regarding clinical outcomes. Due to this limited evidence, the benefit of chelation therapy remains controversial at present. This is an update of a review first published in 2002. Objectives To assess the effects of ethylene diamine tetra‐acetic acid (EDTA) chelation therapy versus placebo or no treatment on clinical outcomes among people with atherosclerotic cardiovascular disease. Search methods For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 6 August 2019. We searched the bibliographies of the studies retrieved by the literature searches for further trials. Selection criteria We included studies if they were randomised controlled trials of EDTA chelation therapy versus placebo or no treatment in participants with atherosclerotic cardiovascular disease. The main outcome measures we considered include all‐cause or cause‐specific mortality, non‐fatal cardiovascular events, direct or indirect measurement of disease severity, and subjective measures of improvement or adverse events. Data collection and analysis Two review authors independently extracted data and assessed trial quality using standard Cochrane procedures. A third author considered any unresolved issues, and we discussed any discrepancies until a consensus was reached. We contacted study authors for additional information. Main results We included five studies with a total of 1993 randomised participants. Three studies enrolled participants with peripheral vascular disease and two studies included participants with coronary artery disease, one of which specifically recruited people who had had a myocardial infarction. The number of participants in each study varied widely (from 10 to 1708 participants), but all studies compared EDTA chelation to a placebo. Risk of bias for the included studies was generally moderate to low, but one study had high risk of bias because the study investigators broke their randomisation code halfway through the study and rolled the placebo participants over to active treatment. Certainty of the evidence, as assessed by GRADE, was generally low to very low, which was mostly due to a paucity of data in each outcome's meta‐analysis. This limited our ability to draw any strong conclusions. We also had concerns about one study's risk of bias regarding blinding and outcome assessment that may have biased the results. Two studies with coronary artery disease participants reported no evidence of a difference in all‐cause mortality between chelation therapy and placebo (risk ratio (RR) 0.97, 95% CI 0.73 to 1.28; 1792 participants; low‐certainty). One study with coronary artery disease participants reported no evidence of a difference in coronary heart disease deaths between chelation therapy and placebo (RR 1.02, 95% CI 0.70 to 1.48; 1708 participants; very low‐certainty). Two studies with coronary artery disease participants reported no evidence of a difference in myocardial infarction (RR 0.81, 95% CI 0.57 to 1.14; 1792 participants; moderate‐certainty), angina (RR 0.95, 95% CI 0.55 to 1.67; 1792 participants; very low‐certainty), and coronary revascularisation (RR 0.46, 95% CI 0.07 to 3.25; 1792 participants). Two studies (one with coronary artery disease participants and one with peripheral vascular disease participants) reported no evidence of a difference in stroke (RR 0.88, 95% CI 0.40 to 1.92; 1867 participants; low‐certainty). Ankle‐brachial pressure index (ABPI; also known as ankle brachial index) was measured in three studies, all including participants with peripheral vascular disease; two studies found no evidence of a difference in the treatment groups after three months after treatment (mean difference (MD) 0.02, 95% CI ‐0.03 to 0.06; 181 participants; low‐certainty). A third study reported an improvement in ABPI in the EDTA chelation group, but this study was at high risk of bias. Meta‐analysis of maximum and pain‐free walking distances three months after treatment included participants with peripheral vascular disease and showed no evidence of a difference between the treatment groups (MD ‐31.46, 95% CI ‐87.63 to 24.71; 165 participants; 2 studies; low‐certainty). Quality of life outcomes were reported by two studies that included participants with coronary artery disease, but we were unable to pool the data due to different methods of reporting and varied criteria. However, there did not appear to be any major differences between the treatment groups. None of the included studies reported on vascular deaths. Overall, there was no evidence of major or minor adverse events associated with EDTA chelation treatment. Authors' conclusions There is currently insufficient evidence to determine the effectiveness or ineffectiveness of chelation therapy in improving clinical outcomes of people with atherosclerotic cardiovascular disease. More high‐quality, randomised controlled trials are needed that assess the effects of chelation therapy on longevity and quality of life among people with atherosclerotic cardiovascular disease. Plain language summary Chelation therapy for atherosclerotic cardiovascular (heart and circulation) disease Background Atherosclerosis is caused by fatty deposits that cause a narrowing of people's arteries and restrict blood flow. People with blocked arteries are more likely to have strokes, heart attacks, and narrow blood vessels in their feet. Chelation therapy involves infusions into the bloodstream of substances believed to remove metals from the blood. This treatment is offered to people with atherosclerotic cardiovascular disease as a way of breaking down the blockages in their blood vessels. Chelation therapy is practiced in several places around the world as an alternative form of medicine, but there is currently a lack of knowledge surrounding this treatment. More information is needed to understand if this treatment should be more widely recommended. Key results This review included evidence from five studies with a total of 1993 participants (current until August 2019). Three studies enrolled participants with peripheral vascular disease, and two of the studies included participants with coronary artery disease, one of which specifically recruited people who had had a heart attack. All five studies compared chelation therapy with no treatment or placebo. Only two of the studies (both of which included participants with coronary artery disease) reported death from any cause, and these reported no difference in overall deaths between those that received chelation therapy and those who did not. Ony one study (in people with coronary artery disease) reported cardiovascular death, and this study found no difference between in risk between those who had chelation therapy and those who did not. Two studies of people with coronary artery disease reported rates of heart attack and angina, and found no difference in the risk of these between participants who had chelation treatment and those who did not. Similarly, two studies (one in people with coronary artery disease and one in people with peripheral vascular disease) reported the chance of having a stroke, and found no clear difference in the chance of this between people who did or did not received chelation treatment. Two studies in people with peripheral vascular disease used an indirect measure of blood flow known as the ankle‐brachial pressure index (ABPI), or ankle brachial index. These studies did not show any differences in this measure between people who received chelation therapy for three or six months and those who did not get the treatment. There was also no clear differences in the distance participants could walk. We could not combine specific measures of quality of life in a single analysis. Looking at the two studies in people with coronary artery disease that reported this outcome, there was no difference in the quality of life reported by people who received chelation therapy and those who did not get the treatment. Two studies reported information about adverse events, but we could not combine this in a single analysis because they reported them in different ways and the events were different. However, the people who had chelation therapy did not appear to have any increase in either minor or major adverse events, compared with people who did not have the therapy. Certainty of the evidence We considered most of the data we found to be of low certainty, mostly because there were very few studies that provided data. Even though we included five studies, not all of them reported on each outcome. There is currently not enough evidence about the effects of chelation therapy on blockages in the blood vessels of people with atherosclerotic cardiovascular (heart and circulation) disease. Conclusions Overall, this review did not find any clear differences between people treated with chelation and people given the control, for the outcomes we evaluated. None of the outcomes included more than two studies, therefore it is difficult at this time to determine if these are true findings or just because there is not enough data. Further high‐quality trials that focus on clinical outcomes are necessary.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Villarruz-Sulit, MVanessa, Forster, R, Dans, AL, Tan, FN, Sulit, DV", "articleTypes": [], "doi": "10.1002/14651858.CD002785.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.772Z" }, { "id": "6517dd57-d59b-4a28-8752-4bed10b33362", "pmid": "", "title": "Probiotics for treatment of chronic constipation in children", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wallace, C, Sinopoulou, V, Gordon, M, Akobeng, AK, Llanos-Chea, A, Hungria, G, Febo-Rodriguez, L, Fifi, A, Fernandez Valdes, L, Langshaw, A, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014257.pub2 AB - Abstract - Background Functional constipation is defined as chronic constipation with no identifiable underlying cause. It is a significant cause of morbidity in children, accounting for up to 25% of visits to paediatric gastroenterologists. Probiotic preparations may sufficiently alter the gut microbiome and promote normal gut physiology in a way that helps relieve functional constipation. Several studies have sought to address this hypothesis, as well as the role of probiotics in other functional gut disorders. Therefore, it is important to have a focused review to assess the evidence to date. Objectives To evaluate the efficacy and safety of probiotics for the management of chronic constipation without a physical explanation in children. Search methods On 28 June 2021, we searched CENTRAL, MEDLINE, Embase, CINAHL, AMED, WHO ICTR, and ClinicalTrials.gov, with no language, date, publication status, or document type limitations. Selection criteria We included randomised controlled trials (RCTs) that assessed probiotic preparations (including synbiotics) compared to placebo, no treatment or any other interventional preparation in people aged between 0 and 18 years old with a diagnosis of functional constipation according to consensus criteria (such as Rome IV). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 14 studies (1127 randomised participants): 12 studies assessed probiotics in the treatment of functional constipation, whilst two studies investigated synbiotic preparations. Three studies compared probiotics to placebo in relation to the frequency of defecation at study end, but we did not pool them as there was very significant unexplained heterogeneity. Four studies compared probiotics to placebo in relation to treatment success. There may be no difference in global improvement/treatment success (RR 1.29, 95% CI 0.73 to 2.26; 313 participants; low‐certainty evidence). Five studies compared probiotics to placebo in relation to withdrawals due to adverse events, with the pooled effect suggesting there may be no difference (RR 0.64, 95% CI 0.21 to 1.95; 357 participants; low‐certainty evidence). The pooled estimate from three studies that compared probiotics plus an osmotic laxative to osmotic laxative alone found there may be no difference in frequency of defecation (MD ‐0.01, 95% CI ‐0.57 to 0.56; 268 participants; low‐certainty evidence). Two studies compared probiotics plus an osmotic laxative to osmotic laxative alone in relation to global improvement/treatment success, and found there may be no difference between the treatments (RR 0.95, 95% CI 0.79 to 1.15; 139 participants; low‐certainty evidence). Three studies compared probiotics plus osmotic laxative to osmotic laxative alone in relation to withdrawals due to adverse events, but it is unclear if there is a difference between them (RR 2.86, 95% CI 0.12 to 68.35; 268 participants; very low‐certainty evidence). Two studies compared probiotics versus magnesium oxide. It is unclear if there is a difference in frequency of defecation (MD 0.28, 95% CI ‐0.58 to 1.14; 36 participants), treatment success (RR 1.08, 95% CI 0.74 to 1.57; 36 participants) or withdrawals due to adverse events (RR 0.50, 95% CI 0.05 to 5.04; 77 participants). The certainty of the evidence is very low for these outcomes. One study assessed the role of a synbiotic preparation in comparison to placebo. There may be higher treatment success in favour of synbiotics compared to placebo (RR 2.32, 95% CI 1.54 to 3.47; 155 participants; low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study assessed a synbiotic plus paraffin compared to paraffin alone. It is uncertain if there is a difference in frequency of defecation (MD 0.74, 95% CI ‐0.96, 2.44; 66 participants; very low‐certainty evidence), or treatment success (RR 0.91, 95% CI 0.71 to 1.17; 66 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study compared a synbiotic preparation to paraffin. It is uncertain if there is a difference in frequency of defecation (MD ‐1.53, 95% CI ‐3.00, ‐0.06; 60 participants; very low‐certainty evidence) or in treatment success (RR 0.86, 95% CI 0.65, 1.13; 60 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. All secondary outcomes were either not reported or reported in a way that did not allow for analysis. Authors' conclusions There is insufficient evidence to conclude whether probiotics are efficacious in successfully treating chronic constipation without a physical explanation in children or changing the frequency of defecation, or whether there is a difference in withdrawals due to adverse events when compared with placebo. There is limited evidence from one study to suggest a synbiotic preparation may be more likely than placebo to lead to treatment success, with no difference in withdrawals due to adverse events. There is insufficient evidence to draw efficacy or safety conclusions about the use of probiotics in combination with or in comparison to any of the other interventions reported. The majority of the studies that presented data on serious adverse events reported that no events occurred. Two studies did not report this outcome. Future studies are needed to confirm efficacy, but the research community requires guidance on the best context for probiotics in such studies, considering where they should be best considered in a potential treatment hierarchy and should align with core outcome sets to support future interpretation of findings. Plain language summary Probiotics for treatment of chronic constipation in children What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can be used to treat chronic constipation without a physical explanation in children (aged 0 to 18 years). We analysed data from 14 studies to answer this question. Key messages We were unable to draw conclusions when comparing probiotics to placebo for frequency of defecation in children treated for chronic constipation without a physical explanation. There may be no difference in treatment success between the two groups. There may not be a difference in frequency of defecation or treatment success when comparing probiotics and laxatives to using laxatives alone. We were unable to draw conclusions when comparing probiotics to magnesium oxide for frequency of defecation or treatment success. There may be a higher frequency of defecation in children treated with synbiotic preparations compared to placebo. There may not be a difference in participants withdrawing from the studies due to adverse events when comparing probiotic preparations to placebo. We were unable to draw conclusions on the safety of any of the other comparisons due to the low number of people who withdrew from the studies. What was studied in the review? Children often suffer from constipation for long periods of time, and when there is no underlying physical cause that can be found we call it 'functional constipation'. It has been suggested that probiotic and synbiotic preparations might help improve symptoms in these children. Probiotics are preparations that contain living bacteria that have been proposed to be beneficial to the digestive system. Synbiotics also include food substances that support the growth of these bacteria. There is currently no consensus about whether this is the case, or how these preparations are best used. What are the main results of the review? We searched for randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) comparing any probiotic or synbiotic treatment with any other treatment (such as dummy/placebo treatments) in children with chronic constipation without a physical explanation. We found 14 trials including a total of 1127 participants who were aged under 18. We made the following conclusions.
• There may be no difference in treatment success when comparing probiotics to placebo.
• We were unable to draw conclusions on whether there is a difference in the frequency of defecation.
• There may be no difference in treatment success when comparing probiotics and laxatives to laxatives alone.
• We were unable to draw conclusions on frequency of defecation or treatment success when comparing probiotics to magnesium oxide.
• Synbiotics may be better than placebo in improving the frequency of defection.
• There may be no difference in how many people withdrew from the trials because of side effects when comparing probiotics to placebo, or probiotics and laxative to laxative alone.
• We have limited confidence in the evidence because the studies only included a small number of children, and due to lack of detail on some of the methods used. All analyses were limited due to differences in the specific probiotics or the treatments they were compared with, low numbers of children included in the studies and, most importantly, the use of a range of different measures of success. This meant that combining studies was difficult, so the overall ability of this review to answer its core questions was limited. What next? Future studies are needed to find out how helpful probiotics are for childhood constipation. Researchers need to agree whether probiotics should be a first option therapy, an add‐on to other therapies, a second option after other therapies have failed, or a combination of all the above. Future research should measure the same items (known as a core outcome set) to ensure these results can support future reviews. How up‐to‐date is this review? This review is current to June 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.750Z" }, { "id": "6521124b-2fc5-47e7-b795-e396b7a7cc70", "pmid": "", "title": "Effects of Morbid Obesity and Bariatric Surgery on Brain Inflammation, Insulin Resistance and Activation of Central Reward System Studied Using PET- and MRI-imaging", "imported": false, "abstract": "Background: Morbid obesity is associated with decreased brain µ-opioid receptor availability, possibly resulting in higher food intake needed to gain pleasure from eating. This decrease seems to normalize already 6 months after bariatric surgery, but the longer-term effects have not been studied. Obesity and insulin resistance result in significantly increased brain insulin-stimulated glucose uptake, whereas in every other tissue glucose uptake is lower. One possible explanation to this could be central inflammation and activation of brain glial cells, which has been shown to occur in animal models of obesity. Obesity has also been shown to associate with increased risk of Alzheimer's disease and cognitive decline in several studies.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.152Z" }, { "id": "652b4421-8b1a-4795-8bc9-db9fc43c2999", "pmid": "", "title": "Antiplatelet agents for the treatment of adults with COVID‐19", "imported": false, "abstract": "Abstract - Background Severe coronavirus disease 2019 (COVID‐19) can cause thrombotic events that lead to severe complications or death. Antiplatelet agents, such as acetylsalicylic acid, have been shown to effectively reduce thrombotic events in other diseases: they could influence the course of COVID‐19 in general. Objectives To assess the efficacy and safety of antiplatelets given with standard care compared to no treatment or standard care (with/without placebo) for adults with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (which comprises MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO ICTRP, medRxiv, CENTRAL), Web of Science, WHO COVID‐19 Global literature on coronavirus disease and the Epistemonikos COVID‐19 L*OVE Platform to identify completed and ongoing studies without language restrictions to December 2022. Selection criteria We followed standard Cochrane methodology. We included randomised controlled trials (RCTs) evaluating antiplatelet agents for the treatment of COVID‐19 in adults with COVID‐19, irrespective of disease severity, gender or ethnicity. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane risk of bias tool (RoB 2) for RCTs. We rated the certainty of evidence using the GRADE approach for the outcomes. Main results Antiplatelets plus standard care versus standard care (with/without placebo) Adults with a confirmed diagnosis of moderate to severe COVID‐19 We included four studies (17,541 participants) that recruited hospitalised people with a confirmed diagnosis of moderate to severe COVID‐19. A total of 8964 participants were analysed in the antiplatelet arm (either with cyclooxygenase inhibitors or P2Y12 inhibitors) and 8577 participants in the control arm. Most people were older than 50 years and had comorbidities such as hypertension, lung disease or diabetes. The studies were conducted in high‐ to lower middle‐income countries prior to wide‐scale vaccination programmes. Antiplatelets compared to standard care: – probably result in little to no difference in 28‐day mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.85 to 1.05; 3 studies, 17,249 participants; moderate‐certainty evidence). In absolute terms, this means that for every 177 deaths per 1000 people not receiving antiplatelets, there were 168 deaths per 1000 people who did receive the intervention (95% CI 151 to 186 per 1000 people); – probably result in little to no difference in worsening (new need for invasive mechanical ventilation or death up to day 28) (RR 0.95, 95% CI 0.90 to 1.01; 2 studies, 15,266 participants; moderate‐certainty evidence); – probably result in little to no difference in improvement (participants discharged alive up to day 28) (RR 1.00, 95% CI 0.96 to 1.04; 2 studies, 15,454 participants; moderate‐certainty evidence); – probably result in a slight reduction of thrombotic events at longest follow‐up (RR 0.90, 95% CI 0.80 to 1.02; 4 studies, 17,518 participants; moderate‐certainty evidence); – may result in a slight increase in serious adverse events at longest follow‐up (Peto odds ratio (OR) 1.57, 95% CI 0.48 to 5.14; 1 study, 1815 participants; low‐certainty evidence), but non‐serious adverse events during study treatment were not reported; – probably increase the occurrence of major bleeding events at longest follow‐up (Peto OR 1.68, 95% CI 1.29 to 2.19; 4 studies, 17,527 participants; moderate‐certainty evidence). Adults with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included two RCTs allocating participants, of whom 4209 had confirmed mild COVID‐19 and were not hospitalised. A total of 2109 participants were analysed in the antiplatelet arm (treated with acetylsalicylic acid) and 2100 participants in the control arm. No study included people with asymptomatic SARS‐CoV‐2 infection. Antiplatelets compared to standard care: – may result in little to no difference in all‐cause mortality at day 45 (Peto OR 1.00, 95% CI 0.45 to 2.22; 2 studies, 4209 participants; low‐certainty evidence); – may slightly decrease the incidence of new thrombotic events up to day 45 (Peto OR 0.37, 95% CI 0.09 to 1.46; 2 studies, 4209 participants; low‐certainty evidence); – may make little or no difference to the incidence of serious adverse events up to day 45 (Peto OR 1.00, 95% CI 0.60 to 1.64; 1 study, 3881 participants; low‐certainty evidence), but non‐serious adverse events were not reported. The evidence is very uncertain about the effect of antiplatelets on the following outcomes (compared to standard care plus placebo): – admission to hospital or death up to day 45 (Peto OR 0.79, 95% CI 0.57 to 1.10; 2 studies, 4209 participants; very low‐certainty evidence); – major bleeding events up to longest follow‐up (no event occurred in 328 participants; very low‐certainty evidence). Quality of life and adverse events during study treatment were not reported. Authors' conclusions In people with confirmed or suspected COVID‐19 and moderate to severe disease, we found moderate‐certainty evidence that antiplatelets probably result in little to no difference in 28‐day mortality, clinical worsening or improvement, but probably result in a slight reduction in thrombotic events. They probably increase the occurrence of major bleeding events. Low‐certainty evidence suggests that antiplatelets may result in a slight increase in serious adverse events. In people with confirmed COVID‐19 and mild symptoms, we found low‐certainty evidence that antiplatelets may result in little to no difference in 45‐day mortality and serious adverse events, and may slightly reduce thrombotic events. The effects on the combined outcome admission to hospital or death up to day 45 and major bleeding events are very uncertain. Quality of life was not reported. Included studies were conducted in high‐ to lower middle‐income settings using antiplatelets prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, adverse events and people with asymptomatic infection. The 14 ongoing and three completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. Plain language summary Are antiplatelets an effective treatment for people with COVID‐19? Key messages Antiplatelets are a group of different medicines that can prevent potentially fatal clot formation in the blood vessels ('thrombotic events'). For hospitalised patients with COVID‐19, they probably slightly reduce thrombotic events but probably do not affect deaths, clinical worsening or improvement in COVID‐19 compared with placebo or standard care. However, antiplatelets may result in a slight increase in serious unwanted effects ('adverse events') and probably increase major bleeding. Similarly, in non‐hospitalised people, antiplatelets slightly decrease thrombotic events. They may result in little to no difference in deaths or serious unwanted effects, however the evidence on admission to hospital or death and major bleeding events is very uncertain. There are 14 further studies that have not completed yet, and the results of three other completed studies are not yet available. What are antiplatelets? Antiplatelets are a group of drugs which, in different ways, stop blood from changing to a gel‐like substance called a clot, which we mean by the term 'thrombotic events'. They are taken mainly by mouth, usually by people who are at high risk of developing a clot (people who have already experienced or who tend to build up a clot). A clot could lead to a stroke, coronary heart disease, poor blood circulation in the legs, thromboses in the legs or clot obstruction ('embolism') in the lung circulation that could lead to shortness of breath, heart failure and death. How might antiplatelets treat COVID‐19? People with COVID‐19 might be at risk from blood clots. Antiplatelets prevent clots from forming in the body, and this could in turn prevent complications that lead to death and clinical deterioration. What did we want to find out? We wanted to know whether antiplatelets in addition to usual care are effective for adults with COVID‐19, when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in: – number of deaths from any cause up to 28 days after treatment, or longer if reported;
– whether people got better or worse after treatment (including unwanted effects of the disease itself, like thrombotic events);
– unwanted effects of the treatment (especially major bleeding). What did we do? We searched for studies that reported on people with COVID‐19 who received antiplatelets together with usual care, or usual care alone (with/without placebo). We summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We identified four studies, including 17,541 people with moderate to severe COVID‐19 (hospitalised). Of these, one compared acetylsalicylic acid (aspirin) with usual care, two studies compared 'P2Y12 inhibitors' (e.g. clopidogrel, prasugrel, ticagrelor) with usual care, and a fourth one compared either acetylsalicylic acid or P2Y12 inhibitors with usual care. The studies included people with a confirmed or suspected diagnosis of SARS‐CoV‐2 infection. Two studies compared acetylsalicylic acid to placebo in 4209 non‐hospitalised people with confirmed mild COVID‐19. We also found 14 ongoing studies, two studies without published results and another that had been withdrawn after a preprint version. We found no studies that included people with COVID‐19 infection but no symptoms. Main results Antiplatelets: – probably make little or no difference to deaths by 28 or 180 days, worsening up to day 28 (new invasive mechanical ventilation or death) or improvement (discharged alive) up to day 28, and they probably slightly decrease thrombotic events; – may result in a slight increase in serious unwanted effects and probably increase major bleeding events. In people not in hospital, with mild disease, antiplatelets may result in little to no difference in death within 45 days, or in the incidence of serious adverse events, and they may slightly decrease the incidence of thrombotic events. The evidence for these participants is very uncertain about the effects on worsening (hospitalisation or death within 45 days) and on major bleeding events. Studies did not report on quality of life and general unwanted effects. What are the limitations of the evidence? The studies were conducted in populations from high‐ to middle‐income countries, many of them prior to the roll‐out of COVID‐19 vaccination programmes and before Omicron became the most prevalent variant. We have moderate confidence in the evidence for mortality, worsening/improvement up to day 28, and major bleeding events or thrombotic events in hospitalised people. We have low confidence in the evidence for the effects on serious unwanted effects, because they occurred rarely. For non‐hospitalised people, our confidence in the evidence is low for the effects on death, thrombotic events and serious adverse events, and very low for the effects on worsening and major bleeding events (those events were rare and the time period between symptom onset and treatment was long). Information about other unwanted effects and quality of life was not available. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 22 December 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Fischer, A-L; Messer, S; Riera, R; Martimbianco, ALC; Stegemann, M; Estcourt, LJ; Weibel, S; Monsef, I; Andreas, M; Pacheco, RL; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015078", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "6545bd49-13ae-46e3-b3df-ef8c86e2ab12", "pmid": "", "title": "Antipsychotics for fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue. It affects approximately 2% of the general population. Up to 70% of patients with fibromyalgia meet the criteria for a depressive or anxiety disorder. People often report high disability levels and poor health‐related quality of life. Drug therapy focuses on reducing key symptoms and disability, and improving health‐related quality of life. Antipsychotics might reduce fibromyalgia and associated mental health symptoms. Objectives To assess the efficacy, tolerability and safety of antipsychotics in fibromyalgia in adults. Search methods We searched CENTRAL (2016, Issue 4), MEDLINE and EMBASE to 20 May 2016, together with reference lists of retrieved papers and reviews and two clinical trial registries. We also contacted trial authors. Selection criteria We selected controlled trials of at least four weeks duration of any formulation of antipsychotics used for the treatment of fibromyalgia in adults. Data collection and analysis We extracted the data from all included studies and two review authors independently assessed study risks of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. We derived first tier evidence from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs, at least 200 participants in the comparison, eight to 12 weeks duration, parallel design), second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison, and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. We rated the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main results We included a total of four studies with 296 participants. Three studies with 206 participants compared quetiapine, an atypical (second‐generation) antipsychotic, with placebo. One study used a cross‐over design and two studies a parallel‐group design. Study duration was eight or 12 weeks. Quetiapine was used in all studies with a bedtime dosage between 50 and 300 mg/day. All studies had one or more sources of potential major bias and we judged them to be at moderate risk of bias overall. The primary outcomes in this review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Second tier evidence indicated that quetiapine was not statistically superior to placebo in the number of participants with a 50% or more pain reduction (very low quality evidence). No study reported data on PGIC. A greater proportion of participants on quetiapine reported a 30% or more pain reduction (risk difference (RD) 0.12, 95% confidence interval (CI) 0.00 to 0.23; number needed to treat for an additional benefit (NNTB) 8, 95% CI 5 to 100) (very low quality evidence). A greater proportion of participants on quetiapine reported a clinically relevant improvement of health‐related quality of life compared to placebo ( RD 0.18, 95% CI 0.05 to 0.31; NNTB 5, 95% CI 3 to 20) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing sleep problems (standardised mean difference (SMD) ‐0.67, 95% CI ‐1.10 to ‐0.23), depression (SMD ‐0.39, 95% CI ‐0.74 to ‐0.04) and anxiety (SMD ‐0.40, 95% CI ‐0.69 to ‐0.11) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing the risk of withdrawing from the study due to a lack of efficacy (RD ‐0.14, 95% CI ‐0.23 to ‐0.05) (very low quality evidence). There was no statistically significant difference between quetiapine and placebo in the proportion of participants withdrawing due to adverse events (tolerability) (very low quality evidence), in the frequency of serious adverse events (safety) (very low quality evidence) and in the proportion of participants reporting dizziness and somnolence as an adverse event (very low quality evidence). In more participants in the quetiapine group a substantial weight gain was noted (RD 0.08, 95% CI 0.02 to 0.15; number needed to treat for an additional harm (NNTH) 12, 95% CI 6 to 50) (very low quality evidence). We downgraded the quality of evidence by three levels to a very low quality rating because of limitations of study design, indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). One parallel design study with 90 participants compared quetiapine (50 to 300 mg/day flexible at bedtime) to amitriptyline (10 to 75 mg/day flexible at bedtime). The study had three major risks of bias and we judged it to be at moderate risk of bias overall. We downgraded the quality of evidence by two levels to a low quality rating because of indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). Third tier evidence indicated no statistically significant differences between the two drugs. Both drugs did not statistically significantly differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life and in the proportion of participants reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared to amitriptyline, more participants left the study due to adverse events (low quality evidence). No serious adverse events were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia. Authors' conclusions Very low quality evidence suggests that quetiapine may be considered for a time‐limited trial (4 to 12 weeks) to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits in shared decision making with the patient. Plain language summary Antipsychotics for fibromyalgia symptoms in adults Bottom line Quetiapine may be considered for 4 to 12 weeks to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as sleep problems, problems with thinking and exhaustion. They often report severe limitations of daily functioning and poor quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. In addition, many patients with fibromyalgia suffer from depression. Medicines used to treat depression can reduce the main symptoms in some people with fibromyalgia. Quetiapine is a drug for the treatment of psychosis (an abnormal condition of the mind described as involving a loss of contact with reality), which is also licensed for the treatment of major depression in some countries. Study characteristics In May 2016, we searched for clinical trials in which antipsychotics were used to treat symptoms of fibromyalgia in adults. We found a total of four studies with 298 participants. We found three studies with 208 participants, which were eight and 12 weeks long and compared quetiapine, an antipsychotic, against a fake medication (placebo). One hundred and sixty‐six participants were diagnosed with major depression. We also found one study comprising 90 patients that compared quetiapine to an antidepressant named amitriptyline, which is frequently used in the treatment of fibromyalgia. Five people in this study were diagnosed with major depression. Key results and quality of the evidence Quetiapine was not better than a fake medication in achieving a pain reduction of 50% or more (very low quality evidence). Quetiapine was better than the fake medication in achieving a pain reduction of 30% or more, reducing sleep problems, and improving depressed mood and anxiety (very low quality evidence). Quetiapine was better than the fake medication in improving health‐related quality of life. Fewer participants dropped out of the trial due to lack of efficacy with quetiapine than with fake medication (very low quality evidence). There was no difference in tolerability and safety between quetiapine and a fake medication (very low quality evidence). For some people, quetiapine led to substantial weight gain and somnolence (sleepiness). Quetiapine and amitriptyline (an antidepressant which is frequently used to improve sleep and reduce pain in people with fibromyalgia) did not differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life. Both drugs did not differ in the proportion of patients reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared with amitriptyline, more people experienced side effects and left the study due to side effects with quetiapine (low quality evidence). No serious side effects with either drug were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B, Klose, P, Üçeyler, N, Phillips, T, Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011804.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.111Z" }, { "id": "65561abe-caa6-4a4c-8fd3-d7242cc0e7d0", "pmid": "", "title": "Music‐based therapeutic interventions for people with dementia", "imported": false, "abstract": "Abstract - Background Dementia is a clinical syndrome with a number of different causes. It is characterised by deterioration in cognitive, behavioural, social and emotional functioning. Pharmacological interventions are available but have limited effect on many of the syndrome's features. However, receptivity to music may remain until the late phases of dementia, and music‐based therapeutic interventions (which include, but are not limited to, music therapy) are suitable for people with advanced dementia. As there is uncertainty about the effectiveness of music‐based therapeutic interventions, trials are being conducted to evaluate this. This review updates one last published in 2018 and examines the current evidence for the effects of music‐based interventions for people with dementia. Objectives To assess the effects of music‐based therapeutic interventions for people with dementia on emotional well‐being (including quality of life), mood disturbance or negative affect (i.e. depressive symptoms and anxiety), behavioural problems (i.e. overall behavioural problems or neuropsychiatric symptoms, and more specifically agitation or aggression), social behaviour and cognition, at the end of therapy and four or more weeks after the end of treatment, and to assess any adverse effects. Search methods We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organisation's meta‐register‐the International Clinical Trials Registry Platform on 30 November 2023. Selection criteria We included randomised controlled trials of music‐based therapeutic interventions (of at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music. Data collection and analysis Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data from included studies and assess their risk of bias. If necessary, we contacted trial authors to ask for additional data, such as relevant subscales. We pooled data using the random‐effects model. We assessed the certainty of the evidence for our two comparisons and our main outcomes of interest using GRADE. Main results We included 30 studies with 1720 randomised participants that were conducted in 15 countries. Twenty‐eight studies with 1366 participants contributed data to meta‐analyses. Ten studies contributed data to long‐term outcomes. Participants had dementia of varying degrees of severity and resided in institutions in most of the studies. Seven studies delivered an individual intervention; the other studies delivered the intervention to groups. Most interventions involved both active and receptive elements of musical experience. The studies were at high risk of performance bias and some were at high risk of detection or other bias. For music‐based therapeutic interventions compared to usual care, we found moderate‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions probably improved depressive symptoms slightly (standardised mean difference (SMD) −0.23, 95% confidence interval (CI) −0.42 to −0.04; 9 studies, 441 participants), and we found low‐certainty evidence that it may have improved overall behavioural problems (SMD −0.31, 95% CI −0.60 to −0.02; 10 studies, 385 participants). We found moderate‐certainty evidence that music‐based therapeutic interventions likely did not improve agitation or aggression (SMD −0.05, 95% CI −0.27 to 0.17; 11 studies, 503 participants). Low to very low certainty evidence showed that they did not improve emotional well‐being (SMD 0.14, 95% CI ‐0.29 to 0.56; 4 studies, 154 participants), anxiety (SMD −0.15, 95% CI −0.39 to 0.09; 7 studies, 282 participants), social behaviour (SMD 0.22, 95% CI −0.14 to 0.57; 2 studies; 121 participants) or cognition (SMD 0.19, 95% CI −0.02 to 0.41; 7 studies, 353 participants). Low or very‐low ‐certainty evidence showed that music‐based therapeutic interventions may not have been more effective than usual care in the long term (four weeks or more after the end of treatment) for any of the outcomes. For music‐based therapeutic interventions compared to other interventions, we found low‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions may have been more effective than the other activities for social behaviour (SMD 0.52, 95% CI 0.08 to 0.96; 4 studies, 84 participants). We found very low‐certainty evidence of a positive effect on anxiety (SMD −0.75, 95% CI −1.27 to −0.24; 10 studies, 291 participants). For all other outcomes, low‐certainty evidence showed no evidence of an effect: emotional well‐being (SMD 0.20, 95% CI −0.09 to 0.49; 9 studies, 298 participants); depressive symptoms (SMD −0.14, 95% CI ‐0.36 to 0.08; 10 studies, 359 participants); agitation or aggression (SMD 0.01, 95% CI −0.31 to 0.32; 6 studies, 168 participants); overall behavioural problems (SMD −0.08, 95% CI −0.33 to 0.17; 8 studies, 292 participants) and cognition (SMD 0.12, 95% CI −0.21 to 0.45; 5 studies; 147 participants). We found low or very‐low certainty evidence that music‐based therapeutic interventions may not have been more effective than other interventions in the long term (four weeks or more after the end of treatment) for any of the outcomes. Adverse effects were inconsistently measured or recorded, but no serious adverse events were reported. Authors' conclusions When compared to usual care, providing people with dementia with at least five sessions of a music‐based therapeutic intervention probably improves depressive symptoms and may improve overall behavioural problems at the end of treatment. When compared to other activities, music‐based therapeutic interventions may improve social behaviour at the end of treatment. No conclusions can be reached about the outcome of anxiety as the certainty of the evidence is very low. There may be no effects on other outcomes at the end of treatment. There was no evidence of long‐term effects from music‐based therapeutic interventions. Adverse effects may be rare, but the studies were inconsistent in their reporting of adverse effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions. Plain language summary Does music‐based therapy help people with dementia? Key messages · Compared to usual care (i.e. without specific activities), providing people with dementia with music‐based therapy sessions probably improves depression, and may improve overall behavioural problems. · Compared to other activities, music‐based therapy may improve social behaviour, but we are unsure if it improves anxiety. · These effects may not last beyond the end of treatment. · There is no evidence that music‐based therapy makes a difference to the emotional well‐being, agitation or cognition (e.g. thinking and remembering) of people with dementia, although there is uncertainty about this. · There is uncertainty in the evidence for long‐term effects, but no long‐term effects were observed in the studies. · Adverse effects (unwanted side effects) may be rare, but the studies were inconsistent in their reporting, so we need more evidence before we can reach reliable conclusions. Why offer music‐based therapy to people with dementia? People with dementia gradually develop increasing difficulty with thinking and daily activities. Dementia is often associated with emotional and behavioural problems and may decrease a person's quality of life. In the later stages of dementia, it may be difficult for people to communicate with words, but even when they can no longer speak, they may still be able to hum or play along with music. Therapy involving music may therefore be especially suitable for people with dementia to improve their lives. Who provides music‐based therapy? Music therapists are certified to work with individuals or groups of people, using music to try to help meet their physical, psychological and social needs. Other professionals may also be trained to provide similar therapies. What did we want to find out? We wanted to find out if, for people with dementia, music‐based therapy works better than usual care or other activities, such as painting. We were interested in whether the therapy changed these outcomes at the end of treatment: · emotional well‐being including quality of life; · depression and anxiety; · agitation or aggression and overall behavioural problems; · social behaviour; and · cognition (e.g. thinking and remembering). We also wanted to find out if there were any long‐term effects after therapy ended or any unwanted effects. What did we do? We searched for studies in which people with dementia were randomly allocated to receive music‐based therapy (of at least five sessions) or to a comparison group with no activities or different activities. We combined the results of the studies to estimate the effects of music‐based therapy as accurately as possible. We also rated our level of confidence in the findings. What did we find? We found 30 studies performed in 15 countries. The studies involved 1720 people with dementia of varying severity. In most of the studies, the participants lived in nursing homes. Seven studies delivered the music‐based therapy to individuals; the other studies delivered the intervention to groups. We were able to use results from 28 studies involving 1366 people with dementia for one or more outcomes at the end of treatment. Ten studies contributed information about long‐term results. Main results At the end of treatment Music‐based therapy probably improves depression and may improve overall behavioural problems, compared with providing usual care. Music‐based therapy may improve social behaviour compared to other activities. We were less confident about the effects of music‐based therapy on anxiety compared to other activities. The available evidence does not suggest any benefit of music‐based therapy for emotional well‐being (including quality of life), agitation and aggression, or cognition, but the evidence is limited and there is uncertainty about this. In the longer term Some studies measured outcomes four weeks or more after treatment ended. We did not find any lasting effects, but there were fewer results measured in the longer term, and we are uncertain about this evidence. Further studies are likely to have a significant impact on what we know about the effects of music‐based therapy for people with dementia, so it is important that research continues. What are the limitations of the evidence? There was variation in the quality of the studies and how well they were reported. In all studies, participants and personnel might have known which treatment participants were getting, and in some, the assessors might have known this as well. This could have affected the results. Regarding effects at the end of music‐based therapy, we are moderately confident in the evidence for the beneficial effect on depression compared to usual care. We have little confidence in the effects or lack of effects on any of the other outcomes. Adverse effects were rarely reported. How up to date is this evidence? This review updates our previous review. We added eight new studies and reached new conclusions. The evidence is current to 30 November 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "van der Steen, JT, van der Wouden, JC, Methley, AM, Smaling, HJ A, Vink, AC, Bruinsma, MS", "articleTypes": [], "doi": "10.1002/14651858.CD003477.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.106Z" }, { "id": "6556d8a2-69ef-42d3-a47d-22ad7b9bd950", "pmid": "", "title": "Colchicine for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The development of severe coronavirus disease 2019 (COVID‐19) and poor clinical outcomes are associated with hyperinflammation and a complex dysregulation of the immune response. Colchicine is an anti‐inflammatory medicine and is thought to improve disease outcomes in COVID‐19 through a wide range of anti‐inflammatory mechanisms. Patients and healthcare systems need more and better treatment options for COVID‐19 and a thorough understanding of the current body of evidence. Objectives To assess the effectiveness and safety of Colchicine as a treatment option for COVID‐19 in comparison to an active comparator, placebo, or standard care alone in any setting, and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising CENTRAL, MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv), Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index), and WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions to 21 May 2021. Selection criteria We included randomised controlled trials evaluating colchicine for the treatment of people with COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We excluded studies investigating the prophylactic effects of colchicine for people without severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection but at high risk of SARS‐CoV‐2 exposure. Data collection and analysis We followed standard Cochrane methodology. We used the Cochrane risk of bias tool (ROB 2) to assess bias in included studies and GRADE to rate the certainty of evidence for the following prioritised outcome categories considering people with moderate or severe COVID‐19: all‐cause mortality, worsening and improvement of clinical status, quality of life, adverse events, and serious adverse events and for people with asymptomatic infection or mild disease: all‐cause mortality, admission to hospital or death, symptom resolution, duration to symptom resolution, quality of life, adverse events, serious adverse events. Main results We included three RCTs with 11,525 hospitalised participants (8002 male) and one RCT with 4488 (2067 male) non‐hospitalised participants. Mean age of people treated in hospital was about 64 years, and was 55 years in the study with non‐hospitalised participants. Further, we identified 17 ongoing studies and 11 studies completed or terminated, but without published results. Colchicine plus standard care versus standard care (plus/minus placebo) Treatment of hospitalised people with moderate to severe COVID‐19 All‐cause mortality : colchicine plus standard care probably results in little to no difference in all‐cause mortality up to 28 days compared to standard care alone (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.93 to 1.08; 2 RCTs, 11,445 participants; moderate‐certainty evidence). Worsening of clinical status : colchicine plus standard care probably results in little to no difference in worsening of clinical status assessed as new need for invasive mechanical ventilation or death compared to standard care alone (RR 1.02, 95% CI 0.96 to 1.09; 2 RCTs, 10,916 participants; moderate‐certainty evidence). Improvement of clinical status : colchicine plus standard care probably results in little to no difference in improvement of clinical status, assessed as number of participants discharged alive up to day 28 without clinical deterioration or death compared to standard care alone (RR 0.99, 95% CI 0.96 to 1.01; 1 RCT, 11,340 participants; moderate‐certainty evidence). Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is very uncertain about the effect of colchicine on adverse events compared to placebo (RR 1.00, 95% CI 0.56 to 1.78; 1 RCT, 72 participants; very low‐certainty evidence). Serious adverse events : the evidence is very uncertain about the effect of colchicine plus standard care on serious adverse events compared to standard care alone (0 events observed in 1 RCT of 105 participants; very low‐certainty evidence). Treatment of non‐hospitalised people with asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 All‐cause mortality : the evidence is uncertain about the effect of colchicine on all‐cause mortality at 28 days (Peto odds ratio (OR) 0.57, 95% CI 0.20 to 1.62; 1 RCT, 4488 participants; low‐certainty evidence). Admission to hospital or death within 28 days : colchicine probably slightly reduces the need for hospitalisation or death within 28 days compared to placebo (RR 0.80, 95% CI 0.62 to 1.03; 1 RCT, 4488 participants; moderate‐certainty evidence). Symptom resolution : we identified no studies reporting this outcome. Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is uncertain about the effect of colchicine on adverse events compared to placebo . Results are from one RCT reporting treatment‐related events only in 4412 participants (low‐certainty evidence). Serious adverse events : colchicine probably slightly reduces serious adverse events (RR 0.78, 95% CI 0.61 to 1.00; 1 RCT, 4412 participants; moderate‐certainty evidence). Colchicine versus another active treatment (e.g. corticosteroids, anti‐viral drugs, monoclonal antibodies) No studies evaluated this comparison. Different formulations, doses, or schedules of colchicine No studies assessed this. Authors' conclusions Based on the current evidence, in people hospitalised with moderate to severe COVID‐19 the use of colchicine probably has little to no influence on mortality or clinical progression in comparison to placebo or standard care alone. We do not know whether colchicine increases the risk of (serious) adverse events. We are uncertain about the evidence of the effect of colchicine on all‐cause mortality for people with asymptomatic infection or mild disease. However, colchicine probably results in a slight reduction of hospital admissions or deaths within 28 days, and the rate of serious adverse events compared with placebo. None of the studies reported data on quality of life or compared the benefits and harms of colchicine versus other drugs, or different dosages of colchicine. We identified 17 ongoing and 11 completed but not published RCTs, which we expect to incorporate in future versions of this review as their results become available. Editorial note: due to the living approach of this work, we monitor newly published results of RCTs on colchicine on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Is colchicine an effective treatment for people with COVID‐19? Key messages ○ In hospitalised people with moderate to severe COVID‐19, colchicine probably has little to no benefit; we are uncertain about its side effects. ○In non‐hospitalised people with no symptoms or mild COVID‐19, we are uncertain whether colchicine prevents deaths or side effects, however it probably reduces the need for hospitalisation or death and serious side effects slightly. ○ Future studies should assess quality of life in people with no symptoms or mild COVID‐19 and non‐serious side effects and compare colchicine to other medicines for COVID‐19, such as corticosteroids. What is colchicine? Colchicine is a medicine used to reduce swelling and inflammation and may consequently relieve pain. It is often used to treat gout, a condition where people’s joints become swollen and painful. On the other hand, colchicine can be harmful to people with some health conditions, such as kidney or liver problems, or if you take too much of it. How might colchicine treat COVID‐19? Since colchicine is an anti‐inflammatory drug; researchers are interested in whether it might help with reducing inflammation caused by COVID‐19. What did we want to find out? We wanted to know whether colchicine is an effective treatment for people with COVID‐19 compared to placebo (a treatment that looks and tastes the same as colchicine but with no active ingredient) or usual care alone. We looked at people with moderate or severe disease being treated in hospital or with mild disease being treated in the community. We were particularly interested in the effects of colchicine on: ○ number of deaths; ○ whether people’s condition worsened or improved; ○ quality of life; ○ serious and non‐serious side effects What did we do? We searched for studies that compared colchicine together with usual care to usual care (plus/minus placebo). Studies could take place anywhere in the world and include people with mild or no symptoms, moderate or severe COVID‐19, of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our certainty in the evidence, based on factors such as study methods and sizes. What did we find? We identified four eligible randomised trials. Three included 11,525 hospitalised people and one included 4488 non‐hospitalised people. For hospitalised people, the average age was 64 years, and for non‐hospitalised people, the average age was 55 years. Two studies compared colchicine and usual care with usual care alone and 2 studies compared colchicine with usual care and placebo. None of the studies reported quality of life. We also found 17 ongoing studies and 11 completed but unpublished studies. Main results Hospitalised people with moderate to severe COVID‐19 (3 studies, 11,525 people) ○Colchicine probably does not reduce deaths in the 28 days after treatment (2 studies, 11,445 people). ○Colchicine probably does not prevent the worsening of patients’ condition (2 studies, 10,916 people) and probably does not improve it (1 study, 11,340 people). ○We are very uncertain about the effect of colchicine on side effects and serious side effects (2 studies, 177 people). Non‐hospitalised people with no symptoms or mild COVID‐19 (1 study, 4488 people) ○We are uncertain whether colchicine prevents deaths up to 28 days after treatment. ○Colchicine probably slightly reduces the risk of hospitalisation or death. ○We are uncertain about the effect of colchicine on side effects, but it probably slightly reduces serious side effects. What are the limitations of the evidence? Our certainty in the evidence is limited. Two studies did not use a placebo, so everybody knew who was treated with colchicine, which could influence the results. There were too few events for non‐hospitalised people, such as admissions to hospital and deaths, to be certain about the evidence. Studies used different ways to assess and report unwanted effects, so we could not combine studies into a single result to make a judgement. How up to date is this evidence? The evidence is up to date to 21 May 2021. Editorial note: this is a living systematic review. We search for new evidence every week and update the review when we identify relevant new evidence. Refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Mikolajewska, A; Fischer, A-L; Piechotta, V; Mueller, A; Metzendorf, M-I; Becker, M; Dorando, E; Pacheco, RL; Martimbianco, ALC; Riera, R; Skoetz, N; Stegemann, M", "articleTypes": [], "doi": "10.1002/14651858.CD015045", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "6572737e-ed67-42ad-9e73-a8aac02db33c", "pmid": "", "title": "Management of gag reflex for patients undergoing dental treatment", "imported": false, "abstract": "Abstract - Background The gag reflex is an involuntary defence mechanism to protect the pharynx and throat from foreign objects. Gagging is a common problem encountered during dental treatment, making therapeutic procedures distressing and often difficult or even impossible to perform. Various interventions can be used to control the gag reflex: anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behavioural therapies, acupressure, acupuncture, laser, and prosthetic devices. This is an update of the Cochrane Review first published in 2015. Objectives To assess the effects of pharmacological and non‐pharmacological interventions for the management of gagging in people undergoing dental treatment. Search methods Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register (to 18 March 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2) in the Cochrane Library (searched 18 March 2019), MEDLINE Ovid (1946 to 18 March 2019), Embase Ovid (1980 to 18 March 2019), CINAHL EBSCO (1937 to 18 March 2019), AMED Ovid (1985 to 18 March 2019), and the proceedings of the International Association for Dental Research (IADR) online (2001 to 18 March 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We also conducted forwards citation searching on the included studies via Google Scholar. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs), involving people who were given a pharmacological or non‐pharmacological intervention to manage gagging that interfered with dental treatment. We excluded quasi‐RCTs. We excluded trials with participants who had central or peripheral nervous system disorders, who had oral lesions or were on systemic medications that might affect the gag sensation, or had undergone surgery which might alter anatomy permanently. Data collection and analysis We independently selected trials, extracted data, and assessed risk of bias. We followed Cochrane's statistical guidelines. We assessed the overall certainty of the evidence using GRADE. Main results We included four trials at unclear risk of bias with 328 participants (263 adults and 65 children who were four years or older), in which one trial compared acupuncture and acupressure (with thumb, device and sea band) at P6 (point located three‐finger breadths below the wrist on the inner forearm in between the two tendons) to sham acupuncture and acupressure with and without sedation. One trial compared acupuncture at P6 point to sham acupuncture. These trials reported both completion of dental procedure and reduction in gagging (assessor and patient reported) as their outcomes. One cross‐over and one split‐mouth trial studied the effect of laser at P6 point compared to control. One trial reported reduction in gagging and another reported presence or absence of gagging during dental procedure. Acupuncture at P6 showed uncertain evidence regarding the successful completion of dental procedure (RR 1.78, 95% CI 1.05 to 3.01; two trials, 59 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 2.57, 95% CI 1.12 to 5.89; one trial, 26 participants; very low‐certainty evidence) in comparison to sham acupuncture. Acupuncture at P6 with sedation did not show any difference when compared to sham acupuncture with sedation (RR 1.08, 95% CI 0.91 to 1.28; one trial, 34 participants; very low‐certainty evidence). Acupressure using thumb pressure with or without sedation showed no clear difference in completing dental procedure (RR 0.96, 95% CI 0.84 to 1.10; one trial, 39 participants; very low‐certainty evidence; and RR 0.85, 95% CI 0.50 to 1.46; one trial, 30 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 1.06, 95% CI 0.92 to 1.23; one trial, 39 participants; very low‐certainty evidence; and RR 0.92, 95% CI 0.60 to 1.41; one trial, 30 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Acupressure at P6 with device showed uncertain evidence regarding the successful completion of dental procedure (RR 2.63, 95% CI 1.33 to 5.18; one trial, 34 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 3.94, 95% CI 1.63 to 9.53; one trial, 34 participants; very low‐certainty evidence) when compared to sham acupressure. However, device combined with sedation showed no difference for either outcome (RR 1.16, 95% CI 0.90 to 1.48; one trial, 27 participants; very low‐certainty evidence; and RR 1.26, 95% CI 0.93 to 1.69; one trial, 27 participants; very low‐certainty evidence; respectively). Acupressure using a sea band with or without sedation showed no clear difference in completing dental procedure (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 1.80, 95% CI 0.63 to 5.16; one trial, 19 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 2.70, 95% CI 0.72 to 10.14; one trial, 19 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Laser at P6 showed a difference in absence of gagging (odds ratio (OR) 86.33, 95% CI 29.41 to 253.45; one trial, 40 participants; very low‐certainty evidence) and reduction in gagging (MD 1.80, 95% CI 1.53 to 2.07; one trial, 25 participants; very low‐certainty evidence) during dental procedure when compared to dummy laser application. No noteworthy adverse effects were reported. For acupuncture at P6, the trial authors were unsure whether the reported adverse effects were due to participant anxiety or due to the intervention. None of the trials on acupressure or laser reported on this outcome. We did not find trials evaluating any other interventions used to manage gagging in people undergoing dental treatment. Authors' conclusions We found very low‐certainty evidence from four trials that was insufficient to conclude if there is any benefit of acupuncture, acupressure or laser at P6 point in reducing gagging and allowing successful completion of dental procedures. We did not find any evidence on any other interventions for managing the gag reflex during dental treatment. More well‐designed and well‐reported trials evaluating different interventions are needed. Plain language summary Management of gagging in dental patients Review question With this Cochrane Review we tried to find out the best way to manage gagging in people having dental treatment. Background The gag reflex is a normal process to protect the throat and airway from foreign objects and prevent choking. Many people have an exaggerated gag reflex that causes distress during dental treatment. This can make it difficult or even impossible to perform the treatment. The interventions used to manage gagging include anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behaviour therapy and cognitive behaviour therapy, acupressure, acupuncture, laser, and prosthetic devices. We wanted to know how effective and safe these interventions are in helping people complete their dental treatment with less gagging. We compared them to no intervention or a placebo or to other interventions. Study characteristics This review is up‐to‐date as of 18 March 2019. We included four trials with 328 people (263 adults and 65 children who were 4 years or older). These people had nausea before when having dental treatment that caused the treatment to be stopped or not carried out properly. Key results Acupuncture at P6 point (a point located in the inside of the wrist) showed uncertain evidence regarding the successful completion of dental treatment and reduction in gagging when compared to sham (fake) acupuncture. The same intervention with sedation did not show a difference. Acupressure (with thumb or sea band (bands that fit around the wrist just like a sweat band with a pressure stud sewn inside)) at P6 point with or without sedation did not show any difference when compared to sham acupressure. Acupressure at P6 point with device showed a difference in completing dental treatment and reduction in gagging. It did not show a difference when combined with sedation. Laser at P6 point showed a difference in absence of gagging and reduction in gagging during dental treatment when compared to sham laser application. The included studies did not report any important harmful effects of the treatment. Certainty of the evidence The level of belief we have in these findings is very low. This was due to unclear risk of bias and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to manage gagging in people having dental treatment. We suggest that more well‐conducted studies should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Eachempati, P, Kumbargere Nagraj, S, Kiran Kumar Krishanappa, S, George, RP, Soe, HH, Karanth, L", "articleTypes": [], "doi": "10.1002/14651858.CD011116.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.738Z" }, { "id": "659f8664-3bc6-414f-8996-4311c4122265", "pmid": "", "title": "Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Herpes zoster oticus (HZO) is a viral infection of the ear and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first‐line treatment for herpes zoster infections at other body sites and are thought to reduce or minimise nerve damage, thereby improving outcomes. It has been suggested that these agents improve the chance of facial weakness improving or resolving completely in patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy). Search methods We searched the Cochrane ENT Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medline (1950 ‐ 2007), PubMed 2007 ‐ 2008, EMBASE (1974 onwards) and other relevant databases. The date of the most recent search was June 2008. Selection criteria Two authors scrutinized all possible citations to identify randomised controlled trials in which antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) were given as treatment for Ramsay Hunt syndrome. We contacted an author for further information. Data collection and analysis Two reviewers independently assessed eligibility and trial quality. Main results Only one randomised, controlled trial was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, intravenous acyclovir and corticosteroids were compared with corticosteroids alone. Our analysis found no statistically significant difference between the two groups. Authors' conclusions We found no evidence that anti‐viral agents have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. The use of these drugs in patients with herpes zoster infections in other parts of the body might suggest that they have a role in herpes zoster oticus. As usual, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically under‐powered study) does not necessarily indicate that antivirals are ineffective. However, these drugs are associated with a number of adverse effects and this must be taken into consideration when undertaking the requisite risk‐benefit analysis before instigating treatment. Plain language summary Uncertainty about usefulness of antiviral drugs in Ramsay Hunt syndrome It seems logical that antiviral drugs might help patients with a herpes virus infection of the ear producing facial weakness (a condition known as 'Ramsay Hunt syndrome'). These drugs often help similar viral infections elsewhere in the body. However, trials that might address this issue have not been done and there is therefore some uncertainty about their usefulness. Since patients can experience side‐effects when taking these drugs, the risks of these have to be balanced with the unknown prospect of benefit when considering whether to use them in Ramsay Hunt syndrome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T; Doree, C; Chamberlain, IJ; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "65a63aca-dd28-4d6e-89ff-da46f75fcdb3", "pmid": "", "title": "Cranberries for preventing urinary tract infections", "imported": false, "abstract": "Abstract - Background Cranberries contain proanthocyanidins (PACs), which inhibit the adherence of p‐fimbriated Escherichia coli to the urothelial cells lining the bladder. Cranberry products have been used widely for several decades to prevent urinary tract infections (UTIs). This is the fifth update of a review first published in 1998 and updated in 2003, 2004, 2008, and 2012. Objectives To assess the effectiveness of cranberry products in preventing UTIs in susceptible populations. Search methods We searched the Cochrane Kidney and Transplant Specialised Register up to 13 March 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria All randomised controlled trials (RCTs) or quasi‐RCTs of cranberry products compared with placebo, no specific treatment or other intervention (antibiotics, probiotics) for the prevention of UTIs were included. Data collection and analysis At least two authors independently assessed and extracted data. Information was collected on methods, participants, interventions and outcomes (incidence of symptomatic UTIs, positive culture results, side effects, adherence to therapy). Risk ratios (RR) with 95% confidence intervals (CI) were calculated where appropriate. Study quality was assessed using the Cochrane risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results For this update, 26 new studies were added, bringing the total number of included studies to 50 (8857 randomised participants). The risk of bias for sequence generation and allocation concealment was low for 29 and 28 studies, respectively. Thirty‐six studies were at low risk of performance bias, and 23 studies were at low risk of detection bias. Twenty‐seven, 41, and 17 studies were at low risk of attrition bias, reporting bias and other bias, respectively. Forty‐five studies compared cranberry products with placebo, water or no specific treatment in six different groups of participants. Twenty‐six of these 45 studies could be meta‐analysed for the outcome of symptomatic, culture‐verified UTIs. In moderate certainty evidence, cranberry products reduced the risk of UTIs (6211 participants: RR 0.70, 95% CI 0.58 to 0.84; I² = 69%). When studies were divided into groups according to the treatment indication, cranberry products probably reduced the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs (8 studies, 1555 participants: RR 0.74, 95% CI 0.55 to 0.99; I² = 54%), in children (5 studies, 504 participants: RR 0.46, 95% CI 0.32 to 0.68; I² = 21%) and in people with a susceptibility to UTIs due to an intervention (6 studies, 1434 participants: RR 0.47, 95% CI 0.37 to 0.61; I² = 0%). However, there may be little or no benefit in elderly institutionalised men and women (3 studies, 1489 participants: RR 0.93, 95% CI 0.67 to 1.30; I² = 9%; moderate certainty evidence), pregnant women (3 studies, 765 participants: RR 1.06, 95% CI 0.75 to 1.50; I² = 3%; moderate certainty evidence), or adults with neuromuscular bladder dysfunction with incomplete bladder emptying (3 studies, 464 participants: RR 0.97, 95% CI 0.78 to 1.19; I² = 0%; low certainty evidence). Other comparisons were cranberry products with probiotics (three studies) or antibiotics (six studies), cranberry tablets with cranberry liquid (one study), and different doses of PACs (two studies). Compared to antibiotics, cranberry products may make little or no difference to the risk of symptomatic, culture‐verified UTIs (2 studies, 385 participants: RR 1.03, 95% CI 0.80 to 1.33; I² = 0%) or the risk of clinical symptoms without culture (2 studies, 336 participants: RR 1.30, 95% CI 0.79 to 2.14; I² = 68%). Compared to probiotics, cranberry products may reduce the risk of symptomatic, culture‐verified UTIs (3 studies, 215 participants: RR 0.39, 95% CI 0.27 to 0.56; I = 0%). It is unclear whether efficacy differs between cranberry juice and tablets or between different doses of PACs, as the certainty of the evidence was very low. The number of participants with gastrointestinal side effects probably does not differ between those taking cranberry products and those receiving a placebo or no specific treatment (10 studies, 2166 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%; moderate certainty evidence). There was no clear relationship between compliance with therapy and the risk for repeat UTIs. No difference in the risk for UTIs could be demonstrated between low, moderate and high doses of PACs. Authors' conclusions This update adds a further 26 studies, taking the total number of studies to 50 with 8857 participants. These data support the use of cranberry products to reduce the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs, in children, and in people susceptible to UTIs following interventions. The evidence currently available does not support its use in the elderly, patients with bladder emptying problems, or pregnant women. Plain language summary Cranberries for preventing urinary tract infections What is the issue? Cranberries (as cranberry juice, tablets or capsules) have been used for many years to prevent urinary tract infections (UTIs). Cranberries contain proanthocyanidins (PACs), substances that can prevent bacteria from sticking to the walls of the bladder. This may help prevent infections and reduce the need for working people to take time for medical appointments. However, there is currently no established regimen for what PACs dose to use and no formal regulation by health authorities of cranberry products. In particular, the dose suggested may not be included on the package. What did we do? We analysed the results of randomised controlled trials (RCTs), which compared the occurrence of UTIs in people taking a cranberry product with those taking a placebo or no treatment. We also analysed the results of RCTs comparing a cranberry product with other treatments such as antibiotics or probiotics. What did we find? We found 50 RCTs involving 8857 people. Forty‐five RCTs compared cranberry with a placebo or no treatment. Taking cranberries as a juice, tablets or capsules reduced the number of UTIs in women with recurrent UTIs, in children with UTIs and in people susceptible to UTIs following an intervention such as bladder radiotherapy. However, UTIs did not appear to be reduced in elderly institutionalised men and women, in adults with neuromuscular bladder dysfunction and incomplete bladder emptying, or in pregnant women. Few people reported any side effects with the most common being tummy pain. We did not find enough information to determine if cranberry products are more or less effective compared with antibiotics or probiotics in preventing further UTIs. Conclusions Cranberry products may help to prevent UTIs which cause symptoms in women with frequent UTIs, in children with UTIs and in people who have undergone an intervention involving the bladder. However, further assessment is required in well‐designed and prospectively registered RCTs to clarify further who with UTIs would benefit from cranberry products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Williams, G, Stothart, CI, Hahn, D, Stephens, JH, Craig, JC, Hodson, EM", "articleTypes": [], "doi": "10.1002/14651858.CD001321.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.797Z" }, { "id": "65b0211d-a2b5-47d5-9516-2b8d7e15edbe", "pmid": "", "title": "Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common, life‐shortening, genetic disorder in populations of Northern European descent caused by the mutation of a single gene that codes for the production of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. This protein coordinates the transport of salt (and bicarbonate) across cell surfaces, and the mutation most notably affects the airways. In the lungs of people with CF, the defective protein compromises mucociliary clearance and makes the airway prone to chronic infection and inflammation, damaging the structure of the airways and eventually leading to respiratory failure. In addition, abnormalities in the truncated CFTR protein lead to other systemic complications, including malnutrition, diabetes and subfertility. Five classes of mutation have been described, depending on the impact of the mutation on the processing of the CFTR protein in the cell. In class I mutations, premature termination codons prevent the production of any functional protein, resulting in severe CF. Therapies targeting class I mutations aim to enable the normal cellular mechanism to read through the mutation, potentially restoring the production of the CFTR protein. This could, in turn, normalise salt transport in the cells and decrease the chronic infection and inflammation that characterises lung disease in people with CF. This is an update of a previously published review. Objectives To evaluate the benefits and harms of ataluren and similar compounds on clinically important outcomes in people with CF with class I mutations (premature termination codons). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles. The last search of the Cochrane Cystic Fibrosis Trials Register was conducted on 7 March 2022. We searched clinical trial registries maintained by the European Medicines Agency, the US National Institutes of Health and the World Health Organization. The last search of the clinical trials registries was conducted on 4 October 2022. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing ataluren and similar compounds (specific therapies for class I mutations) with placebo in people with CF who have at least one class I mutation. Data collection and analysis For the included trials, the review authors independently extracted data, assessed the risk of bias and evaluated the certainty of the evidence using GRADE; trial authors were contacted for additional data. Main results Our searches identified 56 references to 20 trials; of these, 18 trials were excluded. Both the included parallel RCTs compared ataluren to placebo for 48 weeks in 517 participants (males and females; age range six to 53 years) with CF who had at least one nonsense mutation (a type of class I mutation). The certainty of evidence and risk of bias assessments for the trials were moderate overall. Random sequence generation, allocation concealment and blinding of trial personnel were well documented; participant blinding was less clear. Some participant data were excluded from the analysis in one trial that also had a high risk of bias for selective outcome reporting. PTC Therapeutics Incorporated sponsored both trials with grant support from the Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the National Institutes of Health. The trials reported no difference between treatment groups in terms of quality of life, and no improvement in respiratory function measures. Ataluren was associated with a higher rate of episodes of renal impairment (risk ratio 12.81, 95% confidence interval 2.46 to 66.65; P = 0.002; I 2 = 0%; 2 trials, 517 participants). The trials reported no treatment effect for ataluren for the review's secondary outcomes of pulmonary exacerbation, computed tomography score, weight, body mass index and sweat chloride. No deaths were reported in the trials. The earlier trial performed a post hoc subgroup analysis of participants not receiving concomitant chronic inhaled tobramycin (n = 146). This analysis demonstrated favourable results for ataluren (n = 72) for the relative change in forced expiratory volume in one second (FEV 1 ) per cent (%) predicted and pulmonary exacerbation rate. The later trial aimed to prospectively assess the efficacy of ataluren in participants not concomitantly receiving inhaled aminoglycosides, and found no difference between ataluren and placebo in FEV 1 % predicted and pulmonary exacerbation rate. Authors' conclusions There is currently insufficient evidence to determine the effect of ataluren as a therapy for people with CF with class I mutations. One trial reported favourable results for ataluren in a post hoc subgroup analysis of participants not receiving chronic inhaled aminoglycosides, but these were not reproduced in the later trial, suggesting that the earlier results may have occurred by chance. Future trials should carefully assess for adverse events, notably renal impairment, and consider the possibility of drug interactions. Cross‐over trials should be avoided, given the potential for the treatment to change the natural history of CF. Plain language summary Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis Review question Can ataluren (and similar compounds specifically targeting class I mutations in cystic fibrosis (CF)) improve the quality of life and lung function of people with CF without having adverse effects? Key messages What is CF? In people with CF, the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. This especially affects the airways, causing the airway surface to dry out and making it difficult to clear thick mucus. This leads to progressive infection and damages the lungs, shortening life expectancy. How will ataluren treat CF? In people with certain CF genetic mutations where the genetic instructions for producing the CFTR protein are interrupted (known as premature termination codon or class I mutations), ataluren (and similar medicines) may be able to skip over the break in the faulty gene sequence and allow the body to produce a corrected version of the CFTR protein. By correcting the protein, the airway surface should remain hydrated, allowing people with CF to better clear their mucus and so develop fewer lung infections. What did we want to find out? We wanted to know whether ataluren can improve the quality of life and lung function of people with CF, and whether it can do so without any side effects. We also wanted to measure the effects on lung infections (need for hospital visits or additional antibiotics), survival, nutritional status (weight, body mass index and height) and whether treatment was cost‐effective. What did we do? We searched for trials that directly compared drugs such as ataluren to placebo (treatment not containing an active drug) or to a different treatment for these specific genetic mutations in any people with CF. What did we find? We found two trials including 517 people (males and females between 6 and 53 years of age) comparing ataluren to a placebo. The trials lasted 48 weeks and everyone taking part in the trials had at least one gene with a class I mutation. Key results In people taking ataluren, there was no improvement in clinical outcomes such as quality of life, lung function, exacerbations (flare up of disease), sweat chloride (salt) levels or weight compared with people taking placebo. The trials found that kidney damage was more common in people taking ataluren. The earlier trial analysed their results in a way not originally planned to see whether the effects of ataluren and placebo were different in people using inhaled tobramycin (an antibiotic) on a long‐term basis compared with people not taking the inhaled antibiotic. In people taking ataluren but not using inhaled tobramycin, lung function declined at a slower rate and there were fewer exacerbations than in people in the placebo group also not using inhaled tobramycin. The later trial specifically recruited people not taking tobramycin to see whether this really was an effect of the antibiotic, but the investigators did not find any difference between the ataluren and placebo groups for changes in lung function or exacerbations. This suggests that the earlier results occurred by chance. There were no deaths and we did not find any differences between ataluren and placebo in side effects or nutritional status. Neither trial reported on hospitalisations, extra courses of antibiotics or cost‐effectiveness. We have not found enough high‐quality evidence to determine the effect of ataluren for treating CF. We recommend that future trials are designed and reported clearly so that their results can be included in a systematic review. What are the limitations of the evidence? We are moderately confident in our findings, but there is some uncertainty due to how widely the results varied between participants. We are satisfied that everyone taking part had an equal chance of being in either group (ataluren or placebo) and that no one could work out which group the next person would be put into (so that healthier people did not receive the treatment and make the results seem better). We believe that the clinicians running the trials and those taking part in the trials did not know which treatment each person was receiving. We have some concerns about the emphasis the investigators of one trial placed on the results of a comparison they had not planned (the use of long‐term inhaled tobramycin). Unfortunately, that trial did not report all its results clearly. Sometimes, the results were reported in a way that meant they could not be used in this review, and sometimes the information was not reported at all. This affected our confidence in the overall results. Trial funding sources Both trials were sponsored by PTC Therapeutics Incorporated, who make ataluren. The Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the US National Institutes of Health also supported the trials. How up to date is this evidence? We last searched for evidence on 4 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aslam, AA, Sinha, IP, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD012040.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.766Z" }, { "id": "65b96759-295e-4a71-95e4-57069b298a48", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Omega‐3 fatty acids (n‐3, fish oil) have been shown to have anti‐inflammatory properties. Therefore, n‐3 therapy may be beneficial in chronic inflammatory disorders such as ulcerative colitis. Objectives To systematically review the efficacy and safety of n‐3 for maintaining remission in ulcerative colitis (UC). Search methods The following databases were searched from their inception without language restriction: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Healthstar, PubMed, and ACP journal club. Experts were contacted for unpublished data. Selection criteria Randomized placebo‐controlled trials (RCT) of fish oil for maintenance of remission in UC were included. Studies must have enrolled patients (of any age group) who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. The primary outcome was relapse rate and the secondary outcome was frequency of adverse events. Other outcomes to assess efficacy were change in disease activity scores and time to first relapse. Data collection and analysis Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality. Meta‐analysis weighted by the Mantel‐Haenszel method was performed using RevMan 4.2.8 software. Random or fixed effect models were used according to degree of heterogeneity and subgroup analyses were performed to explore heterogeneity. A sensitivity analysis was performed excluding a study of questionable quality . Main results The three studies that were included used different formulation and dosing of n‐3 but none used enteric coated capsules. The pooled analysis showed a similar relapse rate in the n‐3 treated patients and controls (RR 1.02; 95% CI 0.51 to 2.03; P = 0.96). Combining the studies resulted in virtually no statistical heterogeneity (P = 0.93, I 2 = 0%). Various subgroup and sensitivity analyses showed similar results. However, the total number of patients enrolled in these studies was small (n = 138). No significant adverse events were recorded in any of the studies and not enough data were available to pool the other secondary outcomes for meta‐analysis. Authors' conclusions No evidence was found that supports the use of omega 3 fatty acids for maintenance of remission in UC. Further studies using enteric coated capsules may be justified. Plain language summary Omega 3 fatty acids for maintenance of remission in ulcerative colitis Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of ulcerative colitis patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of omega‐3 fatty acids to maintain remission in ulcerative colitis were reviewed. Three studies were included of which none reported a reduction in the rate of disease relapse in comparison with placebo. When the studies were pooled for meta‐analysis there was no benefit for omega 3 fatty acids. There were no serious side effects in any of the studies. None of the studies used enteric coated capsules which allow release of the fish oil in the small bowel. Non‐enteric coated omega‐3 fatty acids (fish oil) seem safe but ineffective for maintaining remission in ulcerative colitis. Further studies of enteric coated capsules may be justified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Turner, D; Steinhart, AH; Griffiths, AM", "articleTypes": [], "doi": "10.1002/14651858.CD006443.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "65df00b3-5258-4c2c-b6a7-9cc0cbda9026", "pmid": "", "title": "Interventions for reducing inflammation in familial Mediterranean fever", "imported": false, "abstract": "Abstract - Background Familial Mediterranean fever (FMF), a hereditary auto‐inflammatory disease, mainly affects ethnic groups living in the Mediterranean region. Early studies reported colchicine may potentially prevent FMF attacks. For people who are colchicine‐resistant or intolerant, drugs such as anakinra, rilonacept, canakinumab, etanercept, infliximab or adalimumab might be beneficial. This is an update of the review last published in 2018. Objectives To evaluate the efficacy and safety of interventions for reducing inflammation in people with FMF. Search methods We searched CENTRAL, MEDLINE, Embase and four Chinese databases on in August 2021. We searched clinical trials registries and references listed in relevant reports. The last search was 17 August 2021. Selection criteria We included randomized controlled trials (RCTs) of people with FMF, comparing active interventions (including colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (herbal dietary supplement)) with placebo or no treatment, or comparing active drugs to each other. Data collection and analysis We used standard Cochrane methodology. We assessed certainty of the evidence using GRADE. Main results We included 10 RCTs with 312 participants (aged three to 53 years), including five parallel and five cross‐over designed studies. Six studies used oral colchicine, one used oral ImmunoGuard, and the remaining three used rilonacept, anakinra or canakinumab as a subcutaneous injection. The duration of each study arm ranged from one to eight months. There were inadequacies in the design of the four older colchicine studies and the two studies comparing a single to a divided dose of colchicine. However, the four studies of ImmunoGuard, rilonacept, anakinra and canakinumab were generally well‐designed. We aimed to report on the number of participants experiencing an attack, the timing of attacks, the prevention of amyloid A amyloidosis, adverse drug reactions and the response of a number of biochemical markers from the acute phase of an attack; but no study reported on the prevention of amyloid A amyloidosis. Colchicine (oral) versus placebo After three months, colchicine 0.6 mg three times daily may reduce the number of people experiencing attacks (risk ratio (RR) 0.21, 95% confidence interval (CI) 0.05 to 0.95; 1 study, 10 participants; low‐certainty evidence). One study (20 participants) of colchicine 0.5 mg twice daily showed there may be no difference in the number of participants experiencing attacks at two months (RR 0.78, 95% CI 0.49 to 1.23; low‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; very low‐certainty evidence), or in the number of days between attacks: (narrative summary; very low‐certainty evidence). Regarding adverse drug reactions, one study reported loose stools and frequent bowel movements and a second reported diarrhea (narrative summary; both very low‐certainty evidence). There were no data on acute‐phase response. Rilonacept versus placebo There is probably no difference in the number of people experiencing attacks at three months (RR 0.87, 95% CI 0.59 to 1.26; moderate‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; low‐certainty evidence) or in the number of days between attacks (narrative summary; low‐certainty evidence). Regarding adverse drug reactions, the rilonacept study reported there may be no differences in gastrointestinal symptoms, hypertension, headache, respiratory tract infections, injection site reactions and herpes, compared to placebo (narrative summary; low‐certainty evidence). The study narratively reported there may be no differences in acute‐phase response indicators after three months (low‐certainty evidence). ImmunoGuard versus placebo The ImmunoGuard study observed there are probably no differences in adverse effects (moderate‐certainty evidence) or in acute‐phase response indicators after one month of treatment (moderate‐certainty evidence). No data were reported for the number of people experiencing an attack, duration of attacks or days between attacks. Anakinra versus placebo A study of anakinra given to 25 colchicine‐resistant participants found there is probably no difference in the number of participants experiencing an attack at four months (RR 0.76, 95% CI 0.54 to 1.07; moderate‐certainty evidence). There were no data for duration of attacks or days between attacks. There are probably no differences between anakinra and placebo with regards to injection site reaction, headache, presyncope, dyspnea and itching (narrative summary; moderate‐certainty evidence). For acute‐phase response, anakinra probably reduced C‐reactive protein (CRP) after four months (narrative summary; moderate‐certainty evidence). Canakinumab versus placebo Canakinumab probably reduces the number of participants experiencing an attack at 16 weeks (RR 0.41, 95% CI 0.26 to 0.65; 1 study, 63 colchicine‐resistant participants; moderate‐certainty evidence). There were no data for the duration of attacks or days between attacks. The included study reported the number of serious adverse events per 100 patient‐years was probably 42.7 with canakinumab versus 97.4 with placebo among people with colchicine‐resistant FMF (moderate‐certainty evidence). For acute‐phase response, canakinumab probably caused a higher proportion of participants to have a CRP level of 10 mg/L or less compared to placebo (68% with canakinumab versus 6% with placebo; 1 study, 63 participants; moderate‐certainty evidence). Colchicine single dose versus divided dose There is probably no difference in the duration of attacks at three months (MD −0.04 hours, 95% CI −10.91 to 10.83) or six months (MD 2.80 hours, 95% CI −5.39 to 10.99; moderate‐certainty evidence). There were no data for the number of participants experiencing an attack or days between attacks. There is probably no difference in adverse events (including anorexia, nausea, diarrhea, abdominal pain, vomiting and elevated liver enzymes) between groups (narrative summary; moderate‐certainty evidence). For acute‐phase response, there may be no evidence of a difference between groups (narrative summary; low‐ to moderate‐certainty evidence). Authors' conclusions There were limited RCTs assessing interventions for people with FMF. Based on the evidence, three times daily colchicine may reduce the number of people experiencing attacks, colchicine single dose and divided dose may not be different for children with FMF, canakinumab probably reduces the number of people experiencing attacks, and anakinra or canakinumab probably reduce CRP in colchicine‐resistant participants; however, only a few RCTs contributed data for analysis. Further RCTs examining active interventions, not only colchicine, are necessary before a comprehensive conclusion regarding the efficacy and safety of interventions for reducing inflammation in FMF can be drawn. Plain language summary Medicines for reducing inflammation in people with familial Mediterranean fever Review question Can treatments such as colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (a herbal supplement)) reduce inflammation in people with familial Mediterranean fever (FMF)? Background FMF is a hereditary inflammatory disease, with symptoms of an attack often including fever over 38 °C, pain and inflammation of the membrane surrounding the chest cavity, the joints or the lungs. We wanted to discover whether these medicines were better for reducing inflammation for people with FMF than placebo (a dummy treatment containing no active medicine) or no treatment, and also to compare these medicines with each other. Search date The evidence is current to 17 August 2021. Study characteristics The review included 10 studies with 312 people with FMF aged between three and 53 years. Eight studies compared five medicines, colchicine, rilonacept, ImmunoGuard, anakinra and canakinumab, with placebo. Participants received one medicine or placebo at random over one to four months. The remaining two studies compared colchicine 1 mg per day once daily with colchicine two or three times daily in children for six to eight months. Key results We aimed to report on the number of participants experiencing an attack, the timing of attacks, prevention of amyloid A amyloidosis (which is a reaction to a chronic inflammatory disease or infection leading to a build‐up of an abnormal protein called amyloid in organs and tissues throughout the body stopping them working properly), and any side effects of treatment and the levels of a number of markers of inflammation during an attack. Not all studies reported these outcomes. Given the differences in treatments and study design, it was not possible to combine any of the results that we did obtain from these studies. One study (15 participants) with oral colchicine 0.6 mg three times a day and another study (63 participants) with subcutaneous (under the skin) canakinumab 150 mg every four weeks for 16 weeks may help to reduce the numbers of people with attacks of FMF. However, oral colchicine 0.5 mg twice a day (20 participants), rilonacept (14 participants) or anakinra (25 participants) did not reduce the numbers of people with attacks. ImmunoGuard (24 participants) did not reduce levels of the markers of inflammation in the blood which are raised during the attack phase of FMF; these include the rate of fall of red blood cells when placed in a test tube, the white blood cell count and the presence of C‐reactive protein (a protein that is produced in the liver). Anakinra and canakinumab reduced C‐reactive protein levels. Colchicine taken once daily and two or three times daily might not result in different outcomes including the timing of attacks, sider effects of the medicine and acute‐phase response indicators. Quality of the evidence Four studies were well‐designed, while the others had some design problems that might have affected the results. Four studies did not report clearly how the people were assigned to each treatment group. Four studies did not report whether researchers, who assessed the study outcomes, knew which individuals were assigned to which treatment. Four studies did not clearly explain the reasons for people withdrawing from a study and one study had a high percentage of participants who did not complete study. We could not confirm whether each planned outcome was reported in five studies. Five studies did not report the severity of FMF in groups at the beginning of treatment. We judged the evidence for the reported outcomes to be of moderate to very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Yin, X, Tian, F, Wu, B, Xu, T", "articleTypes": [], "doi": "10.1002/14651858.CD010893.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.806Z" }, { "id": "65f2136e-e189-4d8f-88ff-f0a86b7588cf", "pmid": "", "title": "Nutritional supplementation for hip fracture aftercare in older people", "imported": false, "abstract": "Abstract - Background Older people with hip fractures are often malnourished at the time of fracture, and subsequently have poor food intake. This is an update of a Cochrane review first published in 2000, and previously updated in 2010. Objectives To review the effects (benefits and harms) of nutritional interventions in older people recovering from hip fracture. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, MEDLINE In‐Process & Other Non‐Indexed Citations, Embase, CAB Abstracts, CINAHL, trial registers and reference lists. The search was last run in November 2015. Selection criteria Randomised and quasi‐randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture where the interventions were started within the first month after hip fracture. Data collection and analysis Two review authors independently selected trials, extracted data and assessed risk of bias. Where possible, we pooled data for primary outcomes which were: all cause mortality; morbidity; postoperative complications (e.g. wound infections, pressure sores, deep venous thromboses, respiratory and urinary infections, cardiovascular events); and 'unfavourable outcome' defined as the number of trial participants who died plus the number of survivors with complications. We also pooled data for adverse events such as diarrhoea. Main results We included 41 trials involving 3881 participants. Outcome data were limited and risk of bias assessment showed that trials were often methodologically flawed, with less than half of trials at low risk of bias for allocation concealment, incomplete outcome data, or selective reporting of outcomes. The available evidence was judged of either low or very low quality indicating that we were uncertain or very uncertain about the estimates. Eighteen trials evaluated oral multinutrient feeds that provided non‐protein energy, protein, vitamins and minerals. There was low‐quality evidence that oral feeds had little effect on mortality (24/486 versus 31/481; risk ratio (RR) 0.81 favouring supplementation, 95% confidence interval (CI) 0.49 to 1.32; 15 trials). Thirteen trials evaluated the effect of oral multinutrient feeds on complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was low‐quality evidence that the number of participants with complications may be reduced with oral multinutrient feeds (123/370 versus 157/367; RR 0.71, 95% CI 0.59 to 0.86; 11 trials). Based on very low‐quality evidence from six studies (334 participants), oral supplements may result in lower numbers with 'unfavourable outcome' (death or complications): RR 0.67, 95% CI 0.51 to 0.89. There was very low‐quality evidence for six studies (442 participants) that oral supplementation did not result in an increased incidence of vomiting and diarrhoea (RR 0.99, 95% CI 0.47 to 2.05). Only very low‐quality evidence was available from the four trials examining nasogastric multinutrient feeding. Pooled data from three heterogeneous trials showed no evidence of an effect of supplementation on mortality (14/142 versus 14/138; RR 0.99, 95% CI 0.50 to 1.97). One trial (18 participants) found no difference in complications. None reported on unfavourable outcome. Nasogastric feeding was poorly tolerated. One study reported no cases of aspiration pneumonia. There is very low‐quality evidence from one trial (57 participants, mainly men) of no evidence for an effect of tube feeding followed by oral supplementation on mortality or complications. Tube feeding, however, was poorly tolerated. There is very low‐quality evidence from one trial (80 participants) that a combination of intravenous feeding and oral supplements may not affect mortality but could reduce complications. However, this expensive intervention is usually reserved for people with non‐functioning gastrointestinal tracts, which is unlikely in this trial. Four trials tested increasing protein intake in an oral feed. These provided low‐quality evidence for no clear effect of increased protein intake on mortality (30/181 versus 21/180; RR 1.42, 95% CI 0.85 to 2.37; 4 trials) or number of participants with complications but very low‐quality and contradictory evidence of a reduction in unfavourable outcomes (66/113 versus 82/110; RR 0.78, 95% CI 0.65 to 0.95; 2 trials). There was no evidence of an effect on adverse events such as diarrhoea. Trials testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. Based on low‐quality evidence, one trial evaluating the use of dietetic assistants to help with feeding indicated that this intervention may reduce mortality (19/145 versus 36/157; RR 0.57, 95% CI 0.34 to 0.95) but not the number of participants with complications (79/130 versus 84/125). Authors' conclusions There is low‐quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low‐quality evidence that oral supplements may reduce 'unfavourable outcome' (death or complications) and that they do not result in an increased incidence of vomiting and diarrhoea. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding or nasogastric feeding in very malnourished people require further evaluation. Plain language summary Nutritional supplementation for older people after hip fracture Background and aim Older people with hip fractures are often malnourished at the time of their fracture and many have poor food intake while in hospital. Malnutrition may hinder recovery after hip fracture. We reviewed the effects of nutritional interventions in older people recovering from hip fracture. Search results We searched the scientific literature up to November 2015 and include 41 studies including 3881 participants. All nutritional interventions were started within one month of hip fracture. The studies had flaws in their methods that may affect the validity of their results. Some evidence was very low quality which means we are very unsure of the results. Key results Eighteen studies examined the use of additional oral feeds that provided energy from sources other than protein, protein, some vitamins and minerals. There was low‐quality evidence that these multinutrient oral feeds may not reduce mortality but that they may reduce the number of people with complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was very low‐quality evidence that oral multinutrient feeds may reduce unfavourable outcome (death or complications) and that they did not result in increased vomiting and diarrhoea. Four studies examined nasogastric tube feeding, where liquid food is delivered via a tube inserted into the nose and passed down into the stomach, with non‐protein energy, protein, some vitamins and minerals. These studies provided very low‐quality evidence that tube feeding, which was poorly tolerated, did not seem to make a difference to mortality or complications. Unfavourable outcome was not recorded and there was insufficient evidence on adverse events. One study provided very low‐quality evidence that nasogastric tube feeding followed by oral feeds may not affect mortality or complications. It reported that tube feeding was poorly tolerated. One study provided very low‐quality evidence that giving feed into a vein initially and then by mouth may not affect mortality but may reduce complications. However, we were surprised that this intervention was being used in people who seemed to be able to take nutrition orally. Increasing protein intake in an oral feed was tested in four studies. These provided low‐quality evidence of no clear effect on mortality or complications and very low‐quality evidence for a reduction in unfavourable outcome. Studies testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. One study, evaluating the use of dietetic assistants to help with feeding, provided low‐quality evidence that this may reduce mortality but not the numbers of people with complications. Conclusions Oral supplements with non‐protein energy, protein, vitamins and minerals started before or soon after surgery may prevent complications after hip fracture in older people but may not affect mortality. Adequately sized randomised studies with better design are required. We suggest that the role of dietetic assistants, and of peripheral venous feeding or nasogastric feeding in very malnourished patients, require further evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Avenell, A, Smith, TO, Curtain, JP, Mak, JCS, Myint, PK", "articleTypes": [], "doi": "10.1002/14651858.CD001880.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.792Z" }, { "id": "65f6c1ee-00f6-4667-806b-3050f0e41ca7", "pmid": "", "title": "Vitamin C for preventing and treating pneumonia", "imported": false, "abstract": "Abstract - Background Pneumonia is one of the most common serious infections, causing two million deaths annually among young children in low‐income countries. In high‐income countries pneumonia is most significantly a problem of the elderly. Objectives To assess the prophylactic and therapeutic effects of vitamin C on pneumonia. Search methods We searched CENTRAL 2013, Issue 3, MEDLINE (1950 to March week 4, 2013), EMBASE (1974 to April 2013) and Web of Science (1955 to April 2013). Selection criteria To assess the therapeutic effects of vitamin C, we selected placebo‐controlled trials. To assess prophylactic effects, we selected controlled trials with or without a placebo. Data collection and analysis Two review authors independently read the trial reports and extracted data. Main results We identified three prophylactic trials which recorded 37 cases of community‐acquired pneumonia in 2335 people. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. Two trials examined military recruits and the third studied boys from \"lower wage‐earning classes\" attending a boarding school in the UK during World War II. Each of these three trials found a statistically significant (80% or greater) reduction in pneumonia incidence in the vitamin C group. We identified two therapeutic trials involving 197 community‐acquired pneumonia patients. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. That trial studied elderly patients in the UK and found lower mortality and reduced severity in the vitamin C group; however, the benefit was restricted to the most ill patients. The other therapeutic trial studied adults with a wide age range in the former Soviet Union and found a dose‐dependent reduction in the duration of pneumonia with two vitamin C doses. We identified one prophylactic trial recording 13 cases of hospital‐acquired pneumonia in 37 severely burned patients; one‐day administration of vitamin C had no effect on pneumonia incidence. The identified studies are clinically heterogeneous which limits their comparability. The included studies did not find adverse effects of vitamin C. Authors' conclusions The prophylactic use of vitamin C to prevent pneumonia should be further investigated in populations who have a high incidence of pneumonia, especially if dietary vitamin C intake is low. Similarly, the therapeutic effects of vitamin C should be studied, especially in patients with low plasma vitamin C levels. The current evidence is too weak to advocate prophylactic use of vitamin C to prevent pneumonia in the general population. Nevertheless, therapeutic vitamin C supplementation may be reasonable for pneumonia patients who have low vitamin C plasma levels because its cost and risks are low. Plain language summary Vitamin C for preventing and treating pneumonia Pneumonia is an infection of the lungs usually caused by bacteria and viruses. Its clinical diagnosis is sometimes difficult. Pneumonia is more common in young children and in the aged. In low‐income countries it causes two million deaths annually among young children. In the USA it is the most common cause of death from infection. Vitamin C was identified in the early 1900s and suggestions that one of its biological roles may be to resist infections are supported by numerous animal studies. We looked for studies in humans and found three trials with a total of 2335 participants that looked at whether vitamin C prevents pneumonia in the community. Two of these preventive trials studied soldiers while the third studied boys in a UK boarding school in the 1940s. Two therapeutic trials with a total of 197 pneumonia patients looked at whether vitamin C might be beneficial for pneumonia patients. One studied patients aged 66 to 94 years in the UK with pneumonia. The other therapeutic trial was conducted in the former Soviet Union but the social and nutritional backgrounds of the patients were not described. One study with 37 burns patients examined the effect of vitamin C on hospital‐acquired pneumonia. Our searches were up‐date‐as of April 2013. Five of the identified trials found preventive or therapeutic benefits of vitamin C against pneumonia but the study on hospital‐acquired pneumonia found no effect. The overall quality of the studies was good. However, the five trials with positive findings were carried out in such extraordinary conditions that the results should not be extrapolated to the general population. Therefore, more research is needed. In the meantime, supplementing pneumonia patients who have low plasma vitamin C levels may be reasonable because of its safety and low cost. None of the five trials reported noteworthy adverse effects of vitamin C.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H, Louhiala, P", "articleTypes": [], "doi": "10.1002/14651858.CD005532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.732Z" }, { "id": "660d9359-09d7-4562-bcd3-b1b0e9818070", "pmid": "", "title": "Fortification of staple foods with vitamin A for vitamin A deficiency", "imported": false, "abstract": "Abstract - Background Vitamin A deficiency is a significant public health problem in many low‐ and middle‐income countries, especially affecting young children, women of reproductive age, and pregnant women. Fortification of staple foods with vitamin A has been used to increase vitamin A consumption among these groups. Objectives To assess the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving health‐related outcomes in the general population older than two years of age. Search methods We searched the following international databases with no language or date restrictions: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library; MEDLINE and MEDLINE In Process OVID; Embase OVID; CINAHL Ebsco; Web of Science (ISI) SCI, SSCI, CPCI‐exp and CPCI‐SSH; BIOSIS (ISI); POPLINE; Bibliomap; TRoPHI; ASSIA (Proquest); IBECS; SCIELO; Global Index Medicus ‐ AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched clinicaltrials.gov and the International Clinical Trials Registry Platform to identify ongoing and unpublished studies. The date of the last search was 19 July 2018. Selection criteria We included individually or cluster‐randomised controlled trials (RCTs) in this review. The intervention included fortification of staple foods (sugar, edible oils, edible fats, maize flour or corn meal, wheat flour, milk and dairy products, and condiments and seasonings) with vitamin A alone or in combination with other vitamins and minerals. We included the general population older than two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two authors independently screened and assessed eligibility of studies for inclusion, extracted data from included studies and assessed their risk of bias. We used standard Cochrane methodology to carry out the review. Main results We included 10 randomised controlled trials involving 4455 participants. All the studies were conducted in low‐ and upper‐middle income countries where vitamin A deficiency was a public health issue. One of the included trials did not contribute data to the outcomes of interest. Three trials compared provision of staple foods fortified with vitamin A versus unfortified staple food, five trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus unfortified staple foods, and two trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus no intervention. No studies compared staple foods fortified with vitamin A alone versus no intervention. The duration of interventions ranged from three to nine months. We assessed six studies at high risk of bias overall. Government organisations, non‐governmental organisations, the private sector, and academic institutions funded the included studies; funding source does not appear to have distorted the results. Staple food fortified with vitamin A versus unfortified staple food We are uncertain whether fortifying staple foods with vitamin A alone makes little or no difference for serum retinol concentration (mean difference (MD) 0.03 μmol/L, 95% CI −0.06 to 0.12; 3 studies, 1829 participants; I² = 90%, very low‐certainty evidence ). It is uncertain whether vitamin A alone reduces the risk of subclinical vitamin A deficiency (risk ratio (RR) 0.45, 95% CI 0.19 to 1.05; 2 studies; 993 participants; I² = 33%, very low‐certainty evidence ). The certainty of the evidence was mainly affected by risk of bias, imprecision and inconsistency. It is uncertain whether vitamin A fortification reduces clinical vitamin A deficiency, defined as night blindness (RR 0.11, 95% CI 0.01 to 1.98; 1 study, 581 participants, very low‐certainty evidence ). The certainty of the evidence was mainly affected by imprecision, inconsistency, and risk of bias. Staple foods fortified with vitamin A versus no intervention No studies provided data for this comparison. Staple foods fortified with vitamin A plus other micronutrients versus same unfortified staple foods Fortifying staple foods with vitamin A plus other micronutrients may not increase the serum retinol concentration (MD 0.08 μmol/L, 95% CI ‐0.06 to 0.22; 4 studies; 1009 participants; I² = 95%, low‐certainty evidence ). The certainty of the evidence was mainly affected by serious inconsistency and risk of bias. In comparison to unfortified staple foods, fortification with vitamin A plus other micronutrients probably reduces the risk of subclinical vitamin A deficiency (RR 0.27, 95% CI 0.16 to 0.49; 3 studies; 923 participants; I² = 0%; moderate‐certainty evidence ). The certainty of the evidence was mainly affected by serious risk of bias. Staple foods fortified with vitamin A plus other micronutrients versus no intervention Fortification of staple foods with vitamin A plus other micronutrients may increase serum retinol concentration (MD 0.22 μmol/L, 95% CI 0.15 to 0.30; 2 studies; 318 participants; I² = 0%; low‐certainty evidence ). When compared to no intervention, it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency (RR 0.71, 95% CI 0.52 to 0.98; 2 studies; 318 participants; I² = 0%; very low‐certainty evidence ) . The certainty of the evidence was affected mainly by serious imprecision and risk of bias. No trials reported on the outcomes of all‐cause morbidity, all‐cause mortality, adverse effects, food intake, congenital anomalies (for pregnant women), or breast milk concentration (for lactating women). Authors' conclusions Fortifying staple foods with vitamin A alone may make little or no difference to serum retinol concentrations or the risk of subclinical vitamin A deficiency. In comparison with provision of unfortified foods, provision of staple foods fortified with vitamin A plus other micronutrients may not increase serum retinol concentration but probably reduces the risk of subclinical vitamin A deficiency. Compared to no intervention, staple foods fortified with vitamin A plus other micronutrients may increase serum retinol concentration, although it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency as the certainty of the evidence has been assessed as very low. It was not possible to estimate the effect of staple food fortification on outcomes such as mortality, morbidity, adverse effects, congenital anomalies, or breast milk vitamin A, as no trials included these outcomes. The type of funding source for the studies did not appear to distort the results from the analysis. Plain language summary Fortification of staple foods with vitamin A for vitamin A deficiency What is the aim of the review? We wanted to investigate the effects of fortifying common staple foods with vitamin A, with or without other micronutrients, in populations two years of age and older. Staple foods used in public health fortification programmes have included refined sugar, edible vegetable oils and fats, rice, wheat flour, maize flours and corn meals, condiments and seasonings, and powdered or liquid milk. We searched for all the possible information on this question and found 10 eligible studies. Key messages Fortifiying staple foods with vitamin A plus other micronutrients may increase the serum retinol concentrations (an indicator of vitamin A stores in the body) and reduce the risk of subclinical vitamin A deficiency (those without clinical eye signs for risk of blinding undernutrition, detected through a serum/plasma retinol 70 μmol/L or less). However, adding vitamin A alone to the staple foods may have little or no effect on vitamin A status or deficiency. What was studied in this review? Vitamin A is an essential nutrient vital for good vision, cell growth, and immunity. Many people in low‐ and middle‐income countries have vitamin A deficiency, especially young children, pregnant women, and women of reproductive age, who may not get enough to eat to cover their increased nutritional demands. Long‐term deprivation of vitamin A could lead to visual impairment, blindness, common infections of the upper respiratory tract, diarrhoea, and measles. There are several strategies to combat the vitamin A deficiency, such as supplementing the diet with vitamin A capsules, adding vitamins and minerals in powder form to energy‐containing foods, eating more vitamin A‐rich foods, and fortifying staple foods with vitamin A during processing. This review focused on the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving the health of the general population older than two years of age. What are the main results of the review? We found 10 relevant studies (involving 4455 participants) from China, India, the Philippines, Bangladesh, Thailand, and Mexico. Three studies provided one study group with staple foods fortified with vitamin A alone, and another group with the same unfortified staple foods. Five studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus the same unfortified staple food, and two studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus no intervention. No studies compared staple foods fortified with vitamin A versus no intervention. Government agencies, private agencies, non‐governmental organisations, the private sector, and academic institutions funded the studies. The source of funding does not appear to have distorted the results. The effect of fortification of staple foods with vitamin A alone on vitamin A stores and on subclinical vitamin A deficiency is uncertain. It is uncertain whether this intervention might reduce clinical vitamin A deficiency (night blindness). We are moderately confident that fortifying staple foods with vitamin A and other micronutrients may not improve vitamin A status. However, children and adolescents in low‐ and middle‐income populations who eat foods fortified with vitamin A and other micronutrients may have a lower risk of subclinical vitamin A deficiency compared to those receiving unfortified staple foods. We do not know how vitamin A fortification affects other health indicators, such as the rate of disease in the population, mortality, adverse effects, food intake, birth defects (for pregnant women), or breast milk concentration for lactating women. We considered six of the included studies to be of poor methodological quality. The review authors searched for published studies up to July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hombali, AS; Solon, JA; Venkatesh, BT; Nair, NS; Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010068.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "6616a353-ef36-484e-a003-f1739d112e0a", "pmid": "", "title": "Omega‐3 fatty acid supplementation for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Studies suggest that a diet rich in omega‐3 essential fatty acids may have beneficial anti‐inflammatory effects for chronic conditions such as cystic fibrosis. This is an updated version of a previously published review. Objectives To determine whether there is evidence that omega‐3 polyunsaturated fatty acid supplementation reduces morbidity and mortality and to identify any adverse events associated with supplementation. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of last search: 01 April 2020. We also searched online study registries and contacted authors. Date of last search: 12 February 2020. Selection criteria Randomised controlled trials in people with cystic fibrosis comparing omega‐3 fatty acid supplements with placebo. Data collection and analysis Two authors independently selected studies for inclusion, extracted data and assessed the risk of bias of the studies. The quality of the evidence was assessed using GRADE. Main results The searches identified 23 studies; five studies with 106 participants (children and adults) were included; duration of studies and interventions differed. Two studies compared omega‐3 fatty acids to olive oil for six weeks; one study compared omega‐3 fatty acids and omega‐6 fatty acids to control capsules (customised fatty acid blends) for three months; one study compared a liquid dietary supplement containing omega‐3 fatty acids to one without for six months; and one study compared omega‐3 fatty acids to a placebo for 12 months. Three studies had a low risk of bias for randomisation, but the risk was unclear in the remaining two studies; all studies had an unclear risk of bias for allocation concealment. Three of the studies adequately blinded participants; the risk of bias for selective reporting was high in one study and unclear for four studies. Two studies reported the number of respiratory exacerbations. At three months, one study (43 participants) reported no change in antibiotic usage. At 12 months the second study (15 participants) reported a reduction in the number of pulmonary exacerbations and cumulative antibiotic days in the supplement group compared to the previous year (no data for the control group); very low‐quality evidence means we are unsure whether supplementation has any effect on this outcome. With regards to adverse events, one six‐week study (12 participants) reported no difference in diarrhoea between omega‐3 or placebo capsules; the very low‐quality evidence means we are unsure if supplementation has any effect on this outcome. Additionally, one study reported an increase in steatorrhoea requiring participants to increase their daily dose of pancreatic enzymes, but three studies had already increased pancreatic enzyme dose at study begin so as to reduce the incidence of steatorrhoea. One study (43 participants) reported stomach pains at three months (treatment or control group not specified). One six‐week study (19 participants) reported three asthma exacerbations leading to exclusion of participants since corticosteroid treatment could affect affect essential fatty acid metabolism. Four studies reported lung function. One six‐week study (19 participants) reported an increase in forced expiratory volume in one second (FEV 1 ) (L) and forced vital capacity (FVC) (L), but the very low‐quality evidence means we are unsure if supplementation has any effect on lung function. The remaining studies did not report any difference in lung function at three months (unit of measurement not specified) or at six months and one year (FEV 1 % predicted and FVC % predicted). No deaths were reported in any of the five studies. Four studies reported clinical variables. One study reported an increase in Schwachman score and weight alongside a reduction in sputum volume with supplementation compared to placebo at three months (data not analysable). However, three studies reported no differences in either weight at six weeks, in body mass index (BMI) standard deviation (SD) score at six months (very low‐quality evidence) or BMI Z score at 12 months. Three studies reported biochemical markers of fatty acid status. One study showed an increase from baseline in both EPA and DHA content of serum phospholipids in the omega‐3 group compared to placebo at three months and also a significant decrease in n‐6/n‐3 ratio in the supplement group compared to placebo; since the quality of the evidence is very low we are not certain that these changes are due to supplementation. One six‐month cross‐over study showed a higher EPA content of the neutrophil membrane in the supplement group compared to the placebo group, but, no difference in DHA membrane concentration. Furthermore, the leukotriene B 4 to leukotriene B 5 ratio was lower at six months in the omega‐3 group compared to placebo. A one‐year study reported a greater increase in the essential fatty acid profile and a decrease in AA levels in the treatment arm compared to placebo. Authors' conclusions This review found that regular omega‐3 supplements may provide some limited benefits for people with cystic fibrosis with relatively few adverse effects: however, the quality of the evidence across all outcomes was very low. The current evidence is insufficient to draw firm conclusions or recommend routine use of these supplements in people with cystic fibrosis. A large, long‐term, multicentre, randomised controlled study is needed to determine any significant therapeutic effect and to assess the influence of disease severity, dosage and duration of treatment. Future researchers should note the need for additional pancreatic enzymes when providing omega‐3 supplementation or olive oil placebo capsules. More research is required to determine the exact dose of pancreatic enzyme required. Plain language summary The use of omega‐3 supplements in people with cystic fibrosis Review question We reviewed the evidence about the effect of giving omega‐3 supplements to people with cystic fibrosis. Background In people with cystic fibrosis recurring cycles of infection and inflammation are thought to worsen lung function. Studies suggest that omega‐3 fatty acids, such as those derived from fish oils, may work to counter the inflammation and may be of benefit in chronic inflammatory diseases including cystic fibrosis. This is an updated version of the review. Search date The evidence is current to: 01 April 2020. Study characteristics This review includes five small studies which compare omega‐3 supplements to a different supplement without omega‐3. In total there were 106 participants, including both children and adults. The studies lasted between six weeks and 12 months. Key results Due to the very low‐quality evidence, we are uncertain whether the following effects are due to supplementation or not. One 12‐month study reported a reduction in pulmonary exacerbations and antibiotic use when taking omega‐3 supplementation compared to placebo and one three‐month study reported no change in antibiotic use during the study period. Few side effects were reported in any of the studies. One six‐week study reported that lung function and clinical status improved when taking omega‐3 supplements. Sputum levels were also noted to be reduced in this six‐week study. Three studies reported no difference in lung function when taking omega‐3 supplementation compared to placebo. Two longer studies found that people taking omega‐3 supplements showed definite increases in levels of essential fatty acids in their white blood cell membranes and also in levels of phospholipids (molecules that provide structure and protection to cells) measured in blood samples. We are uncertain whether regular omega‐3 supplements benefit people with cystic fibrosis and whether they cause side effects, or not. We are not able to draw firm conclusions or recommend the routine use of these supplements in people with cystic fibrosis. Larger and longer studies are needed to assess the clinical benefit of omega‐3 supplementation and to determine the appropriate dosage. Quality of the evidence We judged the quality of the evidence to be very low due to very low participant numbers, low event rates, limited reporting and poor study design. There was no consistency with regards to the time points when results were reported or the measurements used for the same outcome in different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Watson, H; Stackhouse, C", "articleTypes": [], "doi": "10.1002/14651858.CD002201.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "661b3f3d-c37a-457c-b472-9303a007c572", "pmid": "", "title": "Siponimod for multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Cao, L, Li, M, Yao, L, Yan, P, Wang, X, Yang, Z, Lao, Y, Li, H, Yang, K, Li, K", "articleTypes": [], "doi": "10.1002/14651858.CD013647.pub2 AB - Abstract - Background Multiple sclerosis (MS) is a chronic immune‐mediated disease of the central nervous system, with an unpredictable course. Current MS therapies such as disease‐modifying therapies focus on treating exacerbations, preventing new exacerbations and avoiding the progression of disability. Siponimod (BAF312) is an oral treatment, a selective sphingosine‐1‐phosphate (S1P) receptor modulator, for the treatment of adults with relapsing forms of MS including active, secondary progressive MS with relapses. Objectives To assess the benefits and adverse effects of siponimod as monotherapy or combination therapy versus placebo or any active comparator for people diagnosed with MS. Search methods We searched the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Trials Register, which contains studies from CENTRAL, MEDLINE and Embase, and the trials registry databases ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 10 September 2021. We also handsearched relevant journals and screened the reference lists of published reviews and retrieved articles and searched reports (2004 to September 2021) from the MS societies in Europe and America. Selection criteria We included randomised parallel controlled clinical trials (RCTs) that evaluated siponimod, as monotherapy or combination therapy, versus placebo or any active comparator in people with MS. There were no restrictions on dose or administration frequency. Data collection and analysis We used standard methodological procedures expected by Cochrane. We discussed disagreements and resolved them by consensus among the review authors. Our primary outcomes wereworsening disability , relapse and adverse events, and secondary outcomes were annualised relapse rate, gadolinium‐enhancing lesions, new lesions or enlarged pre‐existing lesions and mean change of brain volume. We independently evaluated the certainty of evidence using the GRADE approach. We contacted principal investigators of included studies for additional data or confirmation of data. Main results Two studies (1948 participants) met our selection criteria, 608 controls and 1334 treated with siponimod. The included studies compared siponimod with placebo. Overall, all studies had a high risk of bias due to selective reporting and attrition bias. Comparing siponimod administered at a dose of 2 mg to placebo, we found that siponimod may reduce the number of participants with disability progression at six months (56 fewer people per 1000; risk ratio (RR) 0.78, 95% confidence interval (CI) 0.65 to 0.94; 1 study, 1641 participants; low‐certainty evidence) and annualised relapse rate (RR 0.43, 95% CI 0.34 to 0.56; 2 studies, 1739 participants; low‐certainty evidence). But it might lead to little reduction in the number of participants with new relapse (166 fewer people per 1000; RR 0.38, 95% CI 0.15 to 1.00; 1 study, 94 participants; very low‐certainty evidence). We observed no evidence of a difference due to adverse events for siponimod at 2 mg compared to placebo (14 more people per 1000; RR 1.52, 95% CI 0.85 to 2.71; 2 studies, 1739 participants, low‐certainty evidence). In addition, due to the high risk of inaccurate magnetic resonance imaging (MRI) data in the two included studies, we could not combine data for active lesions on MRI scans. Both studies had high attrition bias resulting from the unbalanced reasons for dropouts among groups and high risk of bias due to conflicts of interest. Siponimod may reduce the number of gadolinium‐enhancing T1‐weighted lesions at two years of follow‐up (RR 0.14, 95% CI 0.10 to 0.19; P < 0.0001; 1 study, 1641 participants; very low‐certainty evidence). There may be no evidence of a difference between groups in the number of participants with at least one serious adverse event excluding relapses (113 more people per 1000; RR 1.80, 95% CI 0.37 to 8.77; 2 studies, 1739 participants; low‐certainty evidence) at six months. No data were available regarding cardiac adverse events. In terms of safety profile, the most common adverse events associated with siponimod were headache, back pain, bradycardia, dizziness, fatigue, influenza, urinary tract infection, lymphopenia, nausea, alanine amino transferase increase and upper respiratory tract infection. These adverse events have dose‐related effects and rarely led to discontinuation of treatment. Authors' conclusions Based on the findings of the RCTs included in this review, we are uncertain whether siponimod interventions are beneficial for people with MS. There was low‐certainty evidence to support that siponimod at a dose of 2 mg orally once daily as monotherapy compared with placebo may reduce the annualised relapse rate and the number of participants who experienced disability worsening, at 6 months. However, the certainty of the evidence to support the benefit in reducing the number of people with a relapse is very low. The risk of withdrawals due to adverse events requires careful monitoring of participants over time. The duration of all studies was less than 24 months, so the efficacy and safety of siponimod over 24 months are still uncertain, and further exploration is needed in the future. There is no high‐certainty data available to evaluate the benefit on MRI outcomes. We assessed the certainty of the body of evidence for all outcomes was low to very low, downgraded due to serious study limitations, imprecision and indirectness. We are uncertain whether siponimod is beneficial for people with MS. More new studies with robust methodology and longer follow‐up are needed to evaluate the benefit of siponimod for the management of MS and to observe long‐term adverse effects. Also, in addition to comparing with placebo, more new studies are needed to evaluate siponimod versus other therapeutic options. Plain language summary Is siponimod an effective treatment for multiple sclerosis (MS) and does it cause unwanted effects? Key messages · We don’t know whether siponimod is an effective treatment for people with multiple sclerosis (MS). At a dose of 2 mg once a day, siponimod may reduce recurrence of symptoms (relapse, calculated as an annual rate) after six months of treatment and may reduce the number of participants whose disability worsens after three months of treatment. · We don’t know if siponimod causes unwanted effects because studies did not last long enough to fully assess them. · Future studies should last longer in order to monitor unwanted and beneficial effects of siponimod better, and should use more robust methods. They should compare siponimod with other medicines. What is multiple sclerosis? Multiple sclerosis (MS) is a condition caused when the body’s immune system – which defends the body against disease and infection – mistakenly attacks parts of the central nervous system (the brain and spinal cord). Symptoms include problems with balance and walking, and blurred vision. MS is a lifelong condition that can cause serious disability. Some people’s symptoms may develop gradually. However, most people experience ‘attacks’ when new symptoms develop or existing symptoms worsen (called ‘relapse’), followed by periods with no changes to their symptoms (called ‘remittance’). This type of MS is called ‘relapsing remitting’ MS. Eventually, the course of their MS may change. These periods when there are no symptoms, or no worsening of symptoms, may stop and then symptoms may worsen continually. This is called ‘secondary progressive MS’. How does siponimod work? Siponimod is a medicine that attaches to the white blood cells (lymphocytes) that attack the central nervous system. This causes the lymphocytes to stay in the lymph glands instead of circulating in the blood to the brain. Fewer lymphocytes reach the brain so the attack by the immune system is reduced. Siponimod is a tablet taken once a day. What did we want to find out? We wanted to know if siponimod is an effective treatment for MS and whether it causes any unwanted effects. We were interested in the number of people: · who experienced relapses; · whose disability worsened; · who left the studies because of unwanted effects of siponimod; · who developed new or larger brain lesions (damage to the brain); and · who experienced serious unwanted effects, and which unwanted effects they experienced. What did we do? 
We searched for studies that investigated siponimod compared with placebo (a sham medicine that looks and tastes the same as siponimod but with no active ingredients) or another medicine to treat MS. Studies could investigate siponimod alone or combined with another treatment, at any dose over any length of time. Participants had to be aged over 18 years, with confirmed MS. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found two studies with 1948 participants. Both studies compared siponimod with placebo. One study included 1651 people with secondary progressive MS, who were given 2 mg siponimod for up to 3 years. The other study included 297 participants with relapsing remitting MS, who were given siponimod at doses of 10 mg, 2 mg or 0.5 mg for 6 months, or 1.25 mg or 0.25 mg for 3 months. We report the results for 2 mg daily because both studies looked at this dose. At 2 mg a day, compared to placebo: · siponimod may lead to a small reduction (166 fewer people per 1000) in the number of people with a new relapse up to six months after starting treatment, and may also reduce relapses when calculated at an annual rate; · siponimod may reduce the number of people whose disability worsened during the six months after starting treatment (by 56 people per 1000); · there may be no difference to the number of people (14 more per 1000) who left the studies in the six months after starting treatment due to unwanted effects; · siponimod may reduce the number of brain lesions of different types after six months and after two years of follow‐up. · siponimod may make no difference to the number of people with at least one serious unwanted effect in the six months after starting treatment. The most common unwanted effects associated with siponimod were headache, back pain, dizziness, tiredness, influenza, urinary tract infection, reduced white blood cells (lymphopenia), feeling sick, possible liver damage, and infections in the mouth and nose. No information was available about heart‐related unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only 2 studies. They did not provide information about everything we were interested and they included people with different types of MS. Also, they did not last long enough to judge the impact of unwanted effects. Both studies were funded by the company that makes siponimod.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.128Z" }, { "id": "661c4e94-a4a1-45dd-a4a6-134ee58f1c0f", "pmid": "", "title": "Opioids for restless legs syndrome", "imported": false, "abstract": "Abstract - Background Restless legs syndrome (RLS) is a distressing and common neurological disorder that may have a huge impact in the quality of life of those with frequent and intense symptoms. Patients complain of unpleasant sensations in the legs, at or before bedtime, and feel an urge to move the legs, which improves with movement, such as walking. Symptoms start with the patient at rest (e.g. sitting or lying down), and follow a circadian pattern, increasing during the evening or at night. Many pharmacological intervention are available for RLS, including drugs used to treat Parkinson's disease (L‐Dopa and dopaminergic agonists), epilepsy (anticonvulsants), anxiety (benzodiazepines), and pain (opioids). Dopaminergic drugs are those most frequently used for treatment of RLS, but some patients do not respond effectively and require other medication. Opioids, a class of medications used to treat severe pain, seem to be effective in treating RLS symptoms, and are recommended for patients with severe symptoms, because RLS and pain appear to share the same mechanism in the central nervous system. All available drugs are associated to some degree with side effects, which can impede treatment. Opioids are associated with adverse events such as constipation, tolerance, and dependence. This justifies the conduct of a systematic review to ascertain whether opioids are safe and effective for treatment of RLS. Objectives To asses the effects of opioids compared to placebo treatment for restless legs syndrome in adults. Search methods We searched the Cochrane Central Register of Controlled trials, CENTRAL 2016, issue 4 and MEDLINE, EMBASE, and LILACS up to April 2016, using a search strategy adapted by Cochraneto identify randomised clinical trials. We checked the references of each study and established personal communication with other authors to identify any additional studies. We considered publications in all languages. Selection criteria Randomised controlled clinical trials of opioid treatment in adults with idiopathic RLS. Data collection and analysis Two review authors independently screened articles, independently extracted data into a standard form, and assessed for risk of bias. If necessary, they discussed discrepancies with a third researcher to resolve any doubts. Main results We included one randomised clinical trial (N = 304 randomised; 204 completed; 276 analysed) that evaluated opioids (prolonged release oxycodone/naloxone) versus placebo. After 12 weeks, RSL symptoms had improved more in the drug group than in the placebo group (using the IRLSSS: MD ‐7.0; 95% CI ‐9.69 to ‐4.31 and the CGI: MD ‐1.11; 95% CI ‐1.49 to ‐0.73). More patients in the drug group than in the placebo group were drug responders (using the IRLSSS: RR 1.82; 95% CI 1.37 to 2.42 and the CGI: RR1.92; 95% ICI 1.49 to 2.48). The proportion of remitters was greater in the drug group than in the placebo group (using the IRLSSS: RR 2.14; 95% CI 1.45 to 3.16). Quality of life scores also improved more in the drug group than in the placebo group (MD ‐0.73; 95% CI ‐1.1 to ‐0.36). Quality of sleep was improved more in the drug group measured by sleep adequacy (MD ‐0.74; 95% CI ‐1.15 to ‐0.33), and sleep quantity (MD 0.89; 95% CI 0.52 to 1.26). There was no difference between groups for daytime somnolence, trouble staying awake during the day, or naps during the day. More adverse events were reported in the drug group (RR 1.22; 95% CI 1.07 to 1.39). The major adverse events were gastrointestinal problems, fatigue, and headache. Authors' conclusions Opioids seem to be effective for treating RLS symptoms, but there are no definitive data regarding the important problem of safety. This conclusion is based on only one study with a high dropout rate (low quality evidence). Plain language summary Opiods for restless legs syndrome Background Restless legs syndrome (RLS) is a very common neurological disorder in which patients complain of an intense need to move their legs, and unpleasant sensations felt deep in their legs, all occurring while at rest, mostly at bedtime. The number of patients complaining of RLS varies according to race, gender, age, country, and health status. About 5% to 10% of people are affected; , and, among these, 2% to 5% need continual pharmacological treatment (medication). When RLS does not respond to medications generally used for Parkinsons Disease and epilepsy, their doctors often prescribe opioids. Question Are opioids effective and safe for people with RLS? Methods We searched the literature for studies in any language, published or not, that considered opioids for the treatment of RLS Results We included one randomised controlled clinical trial with moderate risk of bias that tested a combination of oxycodone and naloxone against placebo capsules, taken twice daily in participants whodid not respond to more usual medications. Researchers used the International RLS severity scale to find out if patients were improved after 12 weeks of treatment. Particpants receiving the combined oxycodone and naloxone reported improvement in RLS symptoms, Quality of life, and sleep quality; 42% of the drug group were symptom‐free. Discussion The study was well designed overall, but was at a high risk of bias due to the high percentage of participants who withdrew from treatment (attrition bias). Eighty‐four percent of the drug group developed adverse events, which were mostly related to the gastrointestinal system, headache, fatigue, and sleepiness (somnolence); 9.8% left the study because of the adverse events. Conclusion The use of opioids for the treatment of RLS in patients resistant to conventional treatment is supported by low‐quality evidence. Prescription of these medications should be based on clinical experience, and caution used due to the potential for abuse, dependency, and adverse events. No patient on opioids complained that their symptoms worsened.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "de Oliveira, CO; Carvalho, LBC; Carlos, K; Conti, C; de Oliveira, MM; Prado, LBF; Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006941.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "664439f1-0408-4fe1-ab87-71e9a36f1a68", "pmid": "", "title": "Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Madsen, KS, Chi, Y, Metzendorf, MI, Richter, B, Hemmingsen, B", "articleTypes": [], "doi": "10.1002/14651858.CD008558.pub2 AB - Abstract - Background The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether metformin can prevent or delay T2DM and its complications in people with increased risk of developing T2DM is unknown. Objectives To assess the effects of metformin for the prevention or delay of T2DM and its associated complications in persons at increased risk for the T2DM. Search methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was March 2019. Selection criteria We included randomised controlled trials (RCTs) with a duration of one year or more comparing metformin with any pharmacological glucose‐lowering intervention, behaviour‐changing intervention, placebo or standard care in people with impaired glucose tolerance, impaired fasting glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or combinations of these. Data collection and analysis Two review authors read all abstracts and full‐text articles and records, assessed risk of bias and extracted outcome data independently. We used a random‐effects model to perform meta‐analysis and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using GRADE. Main results We included 20 RCTs randomising 6774 participants. One trial contributed 48% of all participants. The duration of intervention in the trials varied from one to five years. We judged none of the trials to be at low risk of bias in all 'Risk of bias' domains. Our main outcome measures were all‐cause mortality, incidence of T2DM, serious adverse events (SAEs), cardiovascular mortality, non‐fatal myocardial infarction or stroke, health‐related quality of life and socioeconomic effects.The following comparisons mostly reported only a fraction of our main outcome set.
 Fifteen RCTs compared metformin with diet and exercise with or without placebo: all‐cause mortality was 7/1353 versus 7/1480 (RR 1.11, 95% CI 0.41 to 3.01; P = 0.83; 2833 participants, 5 trials; very low‐quality evidence); incidence of T2DM was 324/1751 versus 529/1881 participants (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 3632 participants, 12 trials; moderate‐quality evidence); the reporting of SAEs was insufficient and diverse and meta‐analysis could not be performed (reported numbers were 4/118 versus 2/191; 309 participants; 4 trials; very low‐quality evidence); cardiovascular mortality was 1/1073 versus 4/1082 (2416 participants; 2 trials; very low‐quality evidence). One trial reported no clear difference in health‐related quality of life after 3.2 years of follow‐up (very low‐quality evidence). Two trials estimated the direct medical costs (DMC) per participant for metformin varying from $220 to $1177 versus $61 to $184 in the comparator group (2416 participants; 2 trials; low‐quality evidence). Eight RCTs compared metformin with intensive diet and exercise: all‐cause mortality was 7/1278 versus 4/1272 (RR 1.61, 95% CI 0.50 to 5.23; P = 0.43; 2550 participants, 4 trials; very low‐quality evidence); incidence of T2DM was 304/1455 versus 251/1505 (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 2960 participants, 7 trials; moderate‐quality evidence); the reporting of SAEs was sparse and meta‐analysis could not be performed (one trial reported 1/44 in the metformin group versus 0/36 in the intensive exercise and diet group with SAEs). One trial reported that 1/1073 participants in the metformin group compared with 2/1079 participants in the comparator group died from cardiovascular causes. One trial reported that no participant died due to cardiovascular causes (very low‐quality evidence). Two trials estimated the DMC per participant for metformin varying from $220 to $1177 versus $225 to $3628 in the comparator group (2400 participants; 2 trials; very low‐quality evidence). Three RCTs compared metformin with acarbose: all‐cause mortality was 1/44 versus 0/45 (89 participants; 1 trial; very low‐quality evidence); incidence of T2DM was 12/147 versus 7/148 (RR 1.72, 95% CI 0.72 to 4.14; P = 0.22; 295 participants; 3 trials; low‐quality evidence); SAEs were 1/51 versus 2/50 (101 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin with thiazolidinediones: incidence of T2DM was 9/161 versus 9/159 (RR 0.99, 95% CI 0.41 to 2.40; P = 0.98; 320 participants; 3 trials; low‐quality evidence). SAEs were 3/45 versus 0/41 (86 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin plus intensive diet and exercise with identical intensive diet and exercise: all‐cause mortality was 1/121 versus 1/120 participants (450 participants; 2 trials; very low‐quality evidence); incidence of T2DM was 48/166 versus 53/166 (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; 332 participants; 2 trials; very low‐quality evidence). One trial estimated the DMC of metformin plus intensive diet and exercise to be $270 per participant compared with $225 in the comparator group (94 participants; 1 trial; very‐low quality evidence). One trial in 45 participants compared metformin with a sulphonylurea. The trial reported no patient‐important outcomes. For all comparisons there were no data on non‐fatal myocardial infarction, non‐fatal stroke or microvascular complications. We identified 11 ongoing trials which potentially could provide data of interest for this review. These trials will add a total of 17,853 participants in future updates of this review. Authors' conclusions Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate‐quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate‐quality evidence). Likewise, the combination of metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of T2DM (very low‐quality evidence). Data on patient‐important outcomes such as mortality, macrovascular and microvascular diabetic complications and health‐related quality of life were sparse or missing. Plain language summary Metformin for prevention/delay of type 2 diabetes mellitus (T2DM) and associated complications in persons at increased risk for development of T2DM Review question Is the antidiabetic drug metformin able to prevent or delay the development of type 2 diabetes and its associated complications in people with moderately elevated blood sugar levels? Background People with moderately elevated blood sugar levels (often referred to as 'prediabetes') are said to have an increased risk for developing diabetes. Metformin is a blood sugar‐lowering medicine which has been used for a long time to treat people with type 2 diabetes. Type 2 diabetes, also known as adult‐onset diabetes, is the most common type of diabetes and prevents the body from using insulin properly (insulin resistance). Type 2 diabetes can have bad effects on health in the long term (diabetic complications), such as severe eye or kidney disease or 'diabetic feet', eventually resulting in foot ulcers. We investigated whether metformin can also be used to prevent or delay type 2 diabetes in people at increased risk. We examined the effects of metformin on patient‐important outcomes, such as complications of diabetes, death from any cause, health‐related quality of life and side effects of the drug. Study characteristics To be included, people had to have blood sugar levels higher than normal, but below the levels that are used to diagnose diabetes. We found 20 randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 6774 participants. The comparator group consisted of diet and exercise, intensive diet and exercise or another blood sugar‐lowering drug. One study dominated the evidence (48% of the total number of all participants). Twelve studies were performed in China. We only included studies with a treatment duration of one year or more. The treatment duration in the included studies varied from one to five years. This evidence is up to date as of March 2019. Key results Fifteen studies compared metformin against diet and exercise. Eight studies compared metformin against intensive diet and exercise and three studies compared metformin plus intensive diet and exercise against intensive diet and exercise only. When compared to standard diet and exercise metformin slightly reduces or delays development of diabetes. However, when compared to intensive diet and exercise, metformin does not provide an additional benefit in reducing or delaying development of diabetes. Seven studies compared metformin with another glucose‐lowering drug: three studies compared metformin with acarbose. Three studies compared metformin with a thiazolidinedione (such as pioglitazone). There was neither an advantage or disadvantage when comparing metformin with these drugs with respect to the development of diabetes. One study compared metformin with a sulphonylurea (glimepiride). The trial did not report patient‐important outcomes. In general, the reporting of serious side effects was sparse. Few participants died and we did not detect a clear difference between the intervention and comparator groups. We also did not detect an advantage or disadvantage of metformin in relation to health‐related quality of life. Our included studies did not report on non‐fatal heart attacks, strokes or complications of diabetes such as kidney or eye disease. Few studies estimated the direct medical costs. When compared to diet and exercise, metformin was more expensive. When compared to intensive diet and exercise, metformin was less expensive. We identified 11 ongoing studies which potentially could provide data for this review. These studies will add a total of 17,853 participants in future updates of our review. Future studies should investigate more patient‐important outcomes such as complications of diabetes and especially the side effects of the drugs. We do not know whether 'prediabetes' is just a condition defined by laboratory measurements, or whether it is in fact a real risk factor for diabetes. It is also unknown whether treatment of this condition translates into better patient‐important outcomes. Certainty of the evidence All included studies had problems in the way they were conduced or reported.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.081Z" }, { "id": "66509ec8-62f3-4905-b6f1-a80d42367a01", "pmid": "", "title": "Carbetocin for preventing postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Postpartum haemorrhage (PPH) is one of the major contributors to maternal mortality and morbidity worldwide. Active management of the third stage of labour has been proven to be effective in the prevention of PPH. Syntometrine is more effective than oxytocin but is associated with more side effects. Carbetocin, a long‐acting oxytocin agonist, appears to be a promising agent for the prevention of PPH. Objectives To determine if the use of oxytocin agonist is as effective as conventional uterotonic agents for the prevention of PPH, and assess the best routes of administration and optimal doses of oxytocin agonist. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2011, Issue 1 of 4), MEDLINE (1966 to 1 March 2011) and EMBASE (1974 to 1 March 2011). We checked references of articles and communicated with authors and pharmaceutical industry contacts. Selection criteria Randomised controlled trials which compared oxytocin agonist (carbetocin) with other uterotonic agents or with placebo or no treatment for the prevention of PPH. Data collection and analysis Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Main results We included 11 studies (2635 women) in the review. Six trials compared carbetocin with oxytocin; four of these were conducted for women undergoing caesarean deliveries, one was for women following vaginal deliveries and one did not state the mode of delivery clearly. The carbetocin was administered as 100 µg intravenous dosage across the trials, while oxytocin was administered intravenously but at varied dosages. Four trials compared intramuscular carbetocin and intramuscular syntometrine for women undergoing vaginal deliveries. Three of the trials were on women with no risk factor for PPH, while one trial was on women with risk factors for PPH. One trial compared the use of intravenous carbetocin with placebo. Use of carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics (risk ratio (RR) 0.62; 95% confidence interval (CI) 0.44 to 0.88; four trials, 1173 women) compared to oxytocin for those who underwent caesarean section, but not for vaginal delivery. Compared to oxytocin, carbetocin was associated with a reduced need for uterine massage following both caesarean delivery (RR 0.54; 95% CI 0.37 to 0.79; two trials, 739 women) and vaginal delivery (RR 0.70; 95% CI 0.51 to 0.94; one trial, 160 women). There were no statistically significant differences between carbetocin and oxytocin in terms of risk of any PPH (blood loss greater than 500 ml) or in risk of severe PPH (blood loss greater than 1000 ml). Comparison between carbetocin and syntometrine showed a lower mean blood loss in women who received carbetocin compared to syntometrine (mean difference (MD) ‐48.84 ml; 95% CI ‐94.82 to ‐2.85; four trials, 1030 women). There was no statistically significant difference in terms of the need for therapeutic uterotonic agents, but the risk of adverse effects such as nausea and vomiting were significantly lower in the carbetocin group: nausea (RR 0.24; 95% CI 0.15 to 0.40; four trials, 1030 women); vomiting (RR 0.21; 95% CI 0.11 to 0.39; four trials, 1030 women). The incidence of postpartum hypertension was also significantly lower in women who received carbetocin compared to those who received syntometrine. Cost‐effectiveness of carbetocin was investigated by one study published as an abstract, with limited data. Authors' conclusions For women who undergo caesarean section, carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics compared to oxytocin, but there is no difference in the incidence of postpartum haemorrhage. Carbetocin is associated with less blood loss compared to syntometrine in the prevention of PPH for women who have vaginal deliveries and is associated with significantly fewer adverse effects. Further research is needed to analyse the cost‐effectiveness of carbetocin as a uterotonic agent. Plain language summary Carbetocin for preventing postpartum haemorrhage In low‐ and middle‐income countries, postpartum haemorrhage is a major cause of maternal deaths and ill health. In high‐income countries, the problems are much less but there is still a small risk of major bleeding problems for women after giving birth. Active management of the third stage of labour, which is generally used to reduce blood loss at birth, consists of giving the mother a drug that helps the uterus to contract, early cord clamping and controlled cord traction to deliver the placenta. Different drugs have been tried and generally either intramuscular oxytocin or intramuscular syntometrine is given. Carbetocin is an oxytocin agonist. Oxytocin agonists are a group of drugs that mimic the oxytocin action, oxytocin being the natural hormone that helps to reduce blood loss at birth. This review includes 11 randomised controlled trials involving 2635 women. The trials compared carbetocin against either oxytocin or syntometrine given after delivery, vaginally or by caesarean section. The comparison between intramuscular carbetocin and oxytocin showed that there was no difference in the risk of heavy bleeding, but that women who received carbetocin were less likely to require other medications to produce uterine contractions following caesarean sections. Comparisons between carbetocin and syntometrine showed that women who received carbetocin had less blood loss compared to women who received syntometrine after vaginal delivery, and were much less likely to experience side effects such as nausea and vomiting. The incidence of hypertension at 30 and 60 minutes post delivery was also significantly lower in women who received carbetocin compared to those who received syntometrine. Five of the 11 studies were known to be supported by a pharmaceutical company.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Su, LL, Chong, YS, Samuel, M", "articleTypes": [], "doi": "10.1002/14651858.CD005457.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.798Z" }, { "id": "66572fc1-13ae-4ffc-a129-c0cdd8d79c6c", "pmid": "", "title": "Full‐mouth treatment modalities (within 24 hours) for periodontitis in adults", "imported": false, "abstract": "Abstract - Background Periodontitis is a highly prevalent, chronic inflammation that causes damage to the soft tissues and bones supporting the teeth. Conventional treatment is quadrant scaling and root planing (the second step of periodontal therapy), which comprises scaling and root planing of teeth in one quadrant of the mouth at a time, with the four different sessions separated by at least one week. Alternative protocols for anti‐infective periodontal therapy have been introduced to help enhance treatment outcomes: full‐mouth scaling (subgingival instrumentation of all quadrants within 24 hours), or full‐mouth disinfection (subgingival instrumentation of all quadrants in 24 hours plus adjunctive antiseptic). We use the older term 'scaling and root planing' (SRP) interchangeably with the newer term 'subgingival instrumentation' in this iteration of the review, which updates one originally published in 2008 and first updated in 2015. Objectives To evaluate the clinical effects of full‐mouth scaling or full‐mouth disinfection (within 24 hours) for the treatment of periodontitis compared to conventional quadrant subgingival instrumentation (over a series of visits at least one week apart) and to evaluate whether there was a difference in clinical effects between full‐mouth disinfection and full‐mouth scaling. Search methods An information specialist searched five databases up to 17 June 2021 and used additional search methods to identify published, unpublished and ongoing studies. Selection criteria We included randomised controlled trials (RCTs) lasting at least three months that evaluated full‐mouth scaling and root planing within 24 hours, with or without adjunctive use of an antiseptic, compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of (chronic) periodontitis according to the International Classification of Periodontal Diseases from 1999. A new periodontitis classification was launched in 2018; however, we used the 1999 classification for inclusion or exclusion of studies, as most studies used it. We excluded studies of people with systemic disorders, taking antibiotics or with the older diagnosis of 'aggressive periodontitis'. Data collection and analysis Several review authors independently conducted data extraction and risk of bias assessment (based on randomisation method, allocation concealment, examiner blinding and completeness of follow‐up). Our primary outcomes were tooth loss and change in probing pocket depth (PPD); secondary outcomes were change in probing attachment (i.e. clinical attachment level (CAL)), bleeding on probing (BOP), adverse events and pocket closure (the number/proportion of sites with PPD of 4 mm or less after treatment). We followed Cochrane's methodological guidelines for data extraction and analysis. Main results We included 20 RCTs, with 944 participants, in this updated review. No studies assessed the primary outcome tooth loss. Thirteen trials compared full‐mouth scaling and root planing within 24 hours without the use of antiseptic (FMS) versus control, 13 trials compared full‐mouth scaling and root planing within 24 hours with adjunctive use of an antiseptic (FMD) versus control, and six trials compared FMS with FMD. Of the 13 trials comparing FMS versus control, we assessed three at high risk of bias, six at low risk of bias and four at unclear risk of bias. We assessed our certainty about the evidence as low or very low for the outcomes in this comparison. There was no evidence for a benefit for FMS over control for change in PPD, gain in CAL or reduction in BOP at six to eight months (PPD: mean difference (MD) 0.03 mm, 95% confidence interval (CI) –0.14 to 0.20; 5 trials, 148 participants; CAL: MD 0.10 mm, 95% CI –0.05 to 0.26; 5 trials, 148 participants; BOP: MD 2.64%, 95% CI –8.81 to 14.09; 3 trials, 80 participants). There was evidence of heterogeneity for BOP (I² = 50%), but none for PPD and CAL. Of the 13 trials comparing FMD versus control, we judged four at high risk of bias, one at low risk of bias and eight at unclear risk of bias. At six to eight months, there was no evidence for a benefit for FMD over control for change in PPD or CAL (PPD: MD 0.11 mm, 95% CI –0.04 to 0.27; 6 trials, 224 participants; low‐certainty evidence; CAL: 0.07 mm, 95% CI –0.11 to 0.24; 6 trials, 224 participants; low‐certainty evidence). The analyses found no evidence of a benefit for FMD over control for BOP (very low‐certainty evidence). There was no evidence of heterogeneity for PPD or CAL, but considerable evidence of heterogeneity for BOP, attributed to one study. There were no consistent differences in these outcomes between intervention and control (low‐ to very low‐certainty evidence). Of the six trials comparing FMS and FMD, we judged two trials at high risk of bias, one at low risk of bias and three as unclear. At six to eight months, there was no evidence of a benefit of FMD over FMS for change in PPD or gain in CAL (PPD: MD –0.11 mm, 95% CI –0.30 to 0.07; P = 0.22; 4 trials, 112 participants; low‐certainty evidence; CAL: MD –0.05 mm, 95% CI –0.23 to –0.13; P = 0.58; 4 trials, 112 participants; low‐certainty evidence). There was no evidence of a difference between FMS and FMD for BOP at any time point (P = 0.98; 2 trials, 22 participants; low‐ to very low‐certainty evidence). There was evidence of heterogeneity for BOP (I² = 52%), but not for PPD or CAL. Thirteen studies predefined adverse events as an outcome; three reported an event after FMD or FMS. The most important harm identified was an increase in body temperature. We assessed the certainty of the evidence for most comparisons and outcomes as low because of design limitations leading to risk of bias, and the small number of trials and participants, leading to imprecision in the effect estimates. Authors' conclusions The inclusion of nine new RCTs in this updated review has not changed the conclusions of the previous version of the review. There is still no clear evidence that FMS or FMD approaches provide additional clinical benefit compared to conventional mechanical treatment for adult periodontitis. In practice, the decision to select one approach to non‐surgical periodontal therapy over another should include patient preference and the convenience of the treatment schedule. Plain language summary Treating all teeth (full mouth) within 24 hours for gum disease (periodontitis) in adults Background Long‐lasting gum disease (periodontitis) is a common chronic inflammatory disease that causes damage to soft tissues (gums) and bone around teeth, and can result in tooth loss. Non‐surgical treatments are used to stop and control the disease. These are based on 'subgingival instrumentation', that is, the mechanical removal of bacteria below the gums from the infected root surfaces of the teeth. Conventional treatment is carried out in two to four sessions over several weeks, scaling a different section (or 'quadrant') of the mouth each time. This has traditionally been known as 'scaling and root planing' (SRP). An alternative approach is to treat the whole mouth within 24 hours in one or two sessions (known as full‐mouth scaling (FMS)). When an antiseptic agent (like chlorhexidine) is added to FMS, the intervention is called full‐mouth disinfection (FMD). The rationale for using these full‐mouth approaches is to reduce the likelihood of re‐infection in already treated sites. Review question This review, produced within Cochrane Oral Health, is the second update of one we originally published in 2008. It evaluates the effectiveness of full‐mouth treatments within 24 hours (FMS and FMD) compared to conventional treatment over a number of weeks, and whether there is a difference between FMS and FMD. The evidence is current up to June 2021. Study characteristics The included studies were randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that evaluated a full‐mouth approach to subgingival instrumentation, with at least three months of monitoring (follow‐up). Both FMS and FMD were compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of chronic periodontitis and we excluded studies of people with aggressive periodontitis, systemic disorders (affecting other part of the body) or who were taking antibiotics. We included nine new studies in this update and we excluded one trial that had been included in the previous version of the review. In total, the review now includes 20 studies that involved 944 participants. Key results Treatment effects of FMS and FMD are modest and there are no clear implications for periodontal care. Neither treatment was superior to the usual treatment of scaling and root planing a quarter of the mouth at a time. The most important harm identified was an increased body temperature after FMS or FMD treatments, reported in three out of 13 studies. In practice, the decision to select one approach over another will be based on preference and convenience for patient and dentist. Certainty of the evidence Our confidence in the results is low for most comparisons and outcomes, due to the small number of studies and participants involved, and limitations in study designs. The addition of nine studies has not changed the findings of our previous version of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jervøe-Storm, P-M; Eberhard, J; Needleman, I; Worthington, HV; Jepsen, S", "articleTypes": [], "doi": "10.1002/14651858.CD004622.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "667a533d-504b-4fd2-bbb2-60c44463973e", "pmid": "", "title": "Pine bark (Pinus spp.) extract for treating chronic disorders", "imported": false, "abstract": "Abstract - Background Pine bark ( Pinus spp.) extract is rich in bioflavonoids, predominantly proanthocyanidins, which are antioxidants. Commercially‐available extract supplements are marketed for preventing or treating various chronic conditions associated with oxidative stress. This is an update of a previously published review. Objectives To assess the efficacy and safety of pine bark extract supplements for treating chronic disorders. Search methods We searched three databases and three trial registries; latest search: 30 September 2019. We contacted the manufacturers of pine bark extracts to identify additional studies and hand‐searched bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) evaluating pine bark extract supplements in adults or children with any chronic disorder. Data collection and analysis Two authors independently assessed trial eligibility, extracted data and assessed risk of bias. Where possible, we pooled data in meta‐analyses. We used GRADE to evaluate the certainty of evidence. Primary outcomes were participant‐ and investigator‐reported clinical outcomes directly related to each disorder and all‐cause mortality. We also assessed adverse events and biomarkers of oxidative stress. Main results This review included 27 RCTs (22 parallel and five cross‐over designs; 1641 participants) evaluating pine bark extract supplements across 10 chronic disorders: asthma (two studies; 86 participants); attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), cardiovascular disease (CVD) and risk factors (seven studies; 338 participants), chronic venous insufficiency (CVI) (two studies; 60 participants), diabetes mellitus (DM) (six studies; 339 participants), erectile dysfunction (three studies; 277 participants), female sexual dysfunction (one study; 83 participants), osteoarthritis (three studies; 293 participants), osteopenia (one study; 44 participants) and traumatic brain injury (one study; 60 participants). Two studies exclusively recruited children; the remainder recruited adults. Trials lasted between four weeks and six months. Placebo was the control in 24 studies. Overall risk of bias was low for four, high for one and unclear for 22 studies. In adults with asthma, we do not know whether pine bark extract increases change in forced expiratory volume in one second (FEV 1 ) % predicted/forced vital capacity (FVC) (mean difference (MD) 7.70, 95% confidence interval (CI) 3.19 to 12.21; one study; 44 participants; very low‐certainty evidence), increases change in FEV 1 % predicted (MD 7.00, 95% CI 0.10 to 13.90; one study; 44 participants; very low‐certainty evidence), improves asthma symptoms (risk ratio (RR) 1.85, 95% CI 1.32 to 2.58; one study; 60 participants; very low‐certainty evidence) or increases the number of people able to stop using albuterol inhalers (RR 6.00, 95% CI 1.97 to 18.25; one study; 60 participants; very low‐certainty evidence). In children with ADHD, we do not know whether pine bark extract decreases inattention and hyperactivity assessed by parent‐ and teacher‐rating scales (narrative synthesis; one study; 57 participants; very low‐certainty evidence) or increases the change in visual‐motoric coordination and concentration (MD 3.37, 95% CI 2.41 to 4.33; one study; 57 participants; very low‐certainty evidence). In participants with CVD, we do not know whether pine bark extract decreases diastolic blood pressure (MD ‐3.00 mm Hg, 95% CI ‐4.51 to ‐1.49; one study; 61 participants; very low‐certainty evidence); increases HDL cholesterol (MD 0.05 mmol/L, 95% CI ‐0.01 to 0.11; one study; 61 participants; very low‐certainty evidence) or decreases LDL cholesterol (MD ‐0.03 mmol/L, 95% CI ‐0.05 to 0.00; one study; 61 participants; very low‐certainty evidence). In participants with CVI, we do not know whether pine bark extract decreases pain scores (MD ‐0.59, 95% CI ‐1.02 to ‐0.16; one study; 40 participants; very low‐certainty evidence), increases the disappearance of pain (RR 25.0, 95% CI 1.58 to 395.48; one study; 40 participants; very low‐certainty evidence) or increases physician‐judged treatment efficacy (RR 4.75, 95% CI 1.97 to 11.48; 1 study; 40 participants; very low‐certainty evidence). In type 2 DM, we do not know whether pine bark extract leads to a greater reduction in fasting blood glucose (MD 1.0 mmol/L, 95% CI 0.91 to 1.09; one study; 48 participants;very low‐certainty evidence) or decreases HbA1c (MD ‐0.90 %, 95% CI ‐1.78 to ‐0.02; 1 study; 48 participants; very low‐certainty evidence). In a mixed group of participants with type 1 and type 2 DM we do not know whether pine bark extract decreases HbA1c (MD ‐0.20 %, 95% CI ‐1.83 to 1.43; one study; 67 participants; very low‐certainty evidence). In men with erectile dysfunction, we do not know whether pine bark extract supplements increase International Index of Erectile Function‐5 scores (not pooled; two studies; 147 participants; very low‐certainty evidence). In women with sexual dysfunction, we do not know whether pine bark extract increases satisfaction as measured by the Female Sexual Function Index (MD 5.10, 95% CI 3.49 to 6.71; one study; 75 participants; very low‐certainty evidence) or leads to a greater reduction of pain scores (MD 4.30, 95% CI 2.69 to 5.91; one study; 75 participants; very low‐certainty evidence). In adults with osteoarthritis of the knee, we do not know whether pine bark extract decreases composite Western Ontario and McMaster Universities Osteoarthritis Index scores (MD ‐730.00, 95% CI ‐1011.95 to ‐448.05; one study; 37 participants; very low‐certainty evidence) or the use of non‐steroidal anti‐inflammatory medication (MD ‐18.30, 95% CI ‐25.14 to ‐11.46; one study; 35 participants; very low‐certainty evidence). We do not know whether pine bark extract increases bone alkaline phosphatase in post‐menopausal women with osteopenia (MD 1.16 ug/L, 95% CI ‐2.37 to 4.69; one study; 40 participants; very low‐certainty evidence). In individuals with traumatic brain injury, we do not know whether pine bark extract decreases cognitive failure scores (MD ‐2.24, 95% CI ‐11.17 to 6.69; one study; 56 participants; very low‐certainty evidence) or post‐concussion symptoms (MD ‐0.76, 95% CI ‐5.39 to 3.87; one study; 56 participants; very low‐certainty evidence). For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. Authors' conclusions Small sample sizes, limited numbers of RCTs per condition, variation in outcome measures, and poor reporting of the included RCTs mean no definitive conclusions regarding the efficacy or safety of pine bark extract supplements are possible. Plain language summary Using pine bark supplements to help treat a variety of chronic diseases Review question Can pine bark antioxidant supplements help to treat chronic diseases? Background The main ingredients in pine bark extract supplements are proanthocyanidins, which are antioxidants. These supplements are marketed to prevent or treat a wide range of chronic diseases. This is an update of a previously published review, where we assessed how well these supplements work for treating chronic diseases, as well as their safety. Search date The evidence is current to 30 September 2019. Study characteristics We included 27 studies (1641 participants) across 10 chronic diseases. These included: asthma (two studies; 86 participants), attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), heart disease and risk factors (seven studies; 332 participants), chronic venous insufficiency (leg veins not working effectively; two studies; 60 participants), diabetes (six studies; 336 participants), erectile dysfunction (three studies; 227 participants), female sexual dysfunction (one study; 75 participants), osteoarthritis (cartilage damage in joints; three studies; 293 participants), osteopenia (beginning of bone mass loss; one study; 44 participants) and traumatic brain injury (one study; 56 participants). Two of the studies were conducted exclusively in children; the others were in adults. Studies compared pine bark supplements with placebo (i.e. a dummy supplement) or non‐antioxidant interventions and participants were randomly selected for one treatment or the other. The duration of treatment ranged from four weeks to six months. Key results For most outcomes across the different chronic diseases we only included one study with a small number of participants. In adults with asthma, we do not know whether pine bark extract increases lung function, improves asthma symptoms or increases the number of people able to stop using albuterol inhalers (a specific type of asthma pump).
In children with ADHD, we do not know whether pine bark supplements decrease inattention and hyperactivity (assessed by parents and teachers) or whether it increases co‐ordination and concentration.
In people with heart disease we do not know if pine bark supplements decrease blood pressure and LDL cholesterol (the bad type) or whether it increases HDL cholesterol (the good type).
In adults with chronic venous insufficiency we do not know whether pine bark supplements decrease pain, increase the number of people free of pain, or how well doctors think the treatment works. In people with type 2 diabetes, we do not know whether pine bark supplements improve blood sugar levels or HbA1c levels (the long‐term marker for measuring blood sugar control); we also do not know if pine bark supplements decrease HbA1c in people with type 1 or type 2 diabetes.
In men with erectile dysfunction, we do not know if pine bark supplements increase erectile function. Similarly, in women with sexual dysfunction, we do not know if pine bark supplements increase sexual satisfaction or reduce pain.
In adults with osteoarthritis, it is not clear if pine bark supplements improve pain, swelling or stiffness in the knee, or whether it decreases the use of anti‐inflammatory drugs. We also do not know if pine bark supplements increase bone formation in postmenopausal women with weakened bones. Lastly, in people with a traumatic brain injury, it is not clear if pine bark supplements improve memory and post‐concussion symptoms . For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. With the available studies, we cannot clearly say how well (or not) pine bark supplements work and whether they are safe. Quality of the evidence The overall risk of bias was low for four studies, high for one and unclear for 22 studies. By this we mean the extent to which the methods used in a study enable it to determine the truth. The certainty of evidence was very low for all outcomes across all chronic diseases in the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Robertson, NU; Schoonees, A; Brand, A; Visser, J", "articleTypes": [], "doi": "10.1002/14651858.CD008294.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "667fe731-09e8-46c0-a6b0-6d0e812b0e16", "pmid": "", "title": "Fatty Acid Taste Thresholds: Caproic, Lauric, Oleic, Linoleic, Linolenic", "imported": false, "abstract": "Differences in human oral sensitivity for caproic, lauric, oleic, linoleic, and linolenic acids will be explored. Prior work indicates that there may be a learning effect in measuring detection thresholds for free fatty acids. This study is designed to determine the number of visits necessary to attenuate this learning effect and also to test whether this effect continues across different types of fatty acids or is specific to each fatty acid. This will aid in understanding how many visits are required to obtain reliable data and if less expensive fatty acids can be used to attenuate learning before testing thresholds for more expensive fatty acids.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.143Z" }, { "id": "6689eda7-0ac5-4b3f-8b0c-964f0ece86f0", "pmid": "", "title": "Prognostic models for radiation‐induced complications after radiotherapy in head and neck cancer patients", "imported": false, "abstract": "Abstract - Background Radiotherapy is the mainstay of treatment for head and neck cancer (HNC) but may induce various side effects on surrounding normal tissues. To reach an optimal balance, normal tissue complication probability (NTCP) models have been reported to predict the risk of radiation‐induced side effects in patients with HNC. However, the quality of study design, conduct, and analysis (i.e. risk of bias (ROB)), as well as the predictive performance of these models, remains to be evaluated. Objectives To identify, describe and appraise NTCP models to predict the risk of radiation‐induced side effects in patients with HNC. Search methods We searched Ovid MEDLINE, Embase and the World Health Organization International Clinical Trials Registry Platform from conception to January 2024. In addition, we screened references cited in the retrieved articles. Selection criteria Two review authors independently included articles reporting on the development and external validation of NTCP models to predict any type of radiation‐induced side effects in patients with HNC. Data collection and analysis One reviewer extracted data from each article and assessed their applicability and ROB, while another reviewer carefully verified the results. For models externally validated at least twice for the same outcome as their original developmental study, we performed qualitative analyses of the model performance. The GRADE system was not applied, since it has not been established for reviews of prognostic model studies. Main results Amongst 617 models developed from 152 articles, including 162,527 HNC patients, only 58 (9%) models from seven articles were judged to have low ROB and low concerns for applicability. No external validation was performed for 481 models (78%). For the remaining 136 models and six additional models which were not eligible for the present review, 193 external validations were performed in 48,852 patients with HNC in 39 articles. Models for salivary‐related outcomes Amongst 285 models, two models were externally validated at least twice. The Beetz 2012b model for xerostomia six months after radiotherapy was validated in two studies. C‐statistics ranged from 0.70 to 0.74. Calibration performance was reported in one study. One validation study was rated as having low ROB in all domains, while the other was rated as having high ROB in the analysis domain. The Cavallo 2021 model for acute xerostomia during radiotherapy for patients with nasopharyngeal cancer was externally validated in the same study, using two different types of cohorts. C‐statistics ranged from 0.68 to 0.73 and calibration plots were reported in both cohorts. Both validations were rated as having unclear ROB in the participants' domain because no detailed information about recruiting was provided. Models for swallowing‐related outcomes Amongst 85 models, two models were externally validated at least twice. The Christianen 2012 model for dysphagia six months after radiotherapy was validated in five studies. C‐statistics ranged from 0.66 to 0.75. Calibration performance was assessed in all of them, while four of them were rated as having high ROB in the analysis domain due to the small sample size. The Wopken 2014b model for tube feeding dependence six months after radiotherapy was validated in three external validation studies. C‐statistics ranged from 0.79 to 0.95, while calibration was evaluated in all studies. Due to the small size of the validation datasets, they were judged as having high ROB in the analysis domain. Models for hypothyroidism Of 72 models for hypothyroidism, two models were externally validated at least twice. In addition, there was another model which was not originally developed for patients with HNC, but validated in this domain. The Boomsma 2012 for hypothyroidism within two years after radiotherapy was externally validated in two studies. C‐statistics ranged from 0.64 to 0.74, while only one study reported its calibration performance. Both validation studies were rated as having high ROB in the analysis domain. The Ronjom 2013 model for radiation‐induced hypothyroidism was validated in three studies. C‐statistics ranged from 0.65 to 0.69 and calibration plots were reported in only one study. Two validation studies were judged as having high and the other was rated as having unclear ROB in the analysis domain. The Cella 2012 model was originally developed to predict radiation‐induced hypothyroidism in patients with Hodgkin’s lymphoma. In two validation studies in patients with HNC, c‐statistics ranged from 0.65 to 0.68, but calibration performance was not reported. One validation study was rated as having a high ROB and the other was rated as being unclear in the analysis domain. Models for brain and nerve‐related outcomes Amongst 40 models, three were externally validated at least twice for temporal lobe injury. The OuYang 2023 model, using deep learning in patients with nasopharyngeal cancer, was validated in the same paper using two different cohorts. C‐statistics ranged from 0.80 to 0.82, while calibration performance was assessed in both cohorts. Both validations were judged as having low ROB in all domains. The Wen 2021 model was developed to predict temporal lobe injury in newly diagnosed nasopharyngeal cancer patients. The model was validated by OuYang 2023 using two cohorts and by Yang 2023a using four cohorts. C‐statistics ranged from 0.75 to 0.79, while calibration performance was not reported. The two validations by OuYang 2023 were judged as having unclear ROB in the analysis domain, and the four validations by Yang 2023a were judged as having high ROB in the analysis domain. The Yang 2023a model was validated in the same paper using two cohorts. C‐statistics ranged from 0.79 to 0.81, while calibration performance was assessed in both cohorts. Both validations were judged as having high ROB in the analysis domain. Models for outcomes related to hoarseness, fatigue, nausea‐vomiting, throat pain, aspiration No models were externally validated at least twice. Authors' conclusions Amongst 617 developed models, only one‐fifth were externally validated, of which, ten models at least twice. These ten models showed acceptable discriminative performance at external validation. However, their calibration was not always reported. Furthermore, most validation studies were judged as having high ROB. In conclusion, this review shows the need for more external validation studies and improvement of the quality of conducting and reporting of prediction model studies. Plain language summary Which normal tissue complication probability (NTCP) models are available to predict the risk of radiation‐induced side effects after radiotherapy in patients with head and neck cancer, what is their quality, and what is their predictive performance? Key messages ° Many NTCP models have been developed to predict unwanted effects following radiotherapy in head and neck cancer patients but most of them have not been sufficiently externally validated, that is, tested with patients who were not involved in the original model developmental study, to know how well they really predict the unwanted effects. ° For models tested in two or more studies in addition to their original model development studies, the quality of testing and reporting of their results was generally poor, so it is difficult to know how useful they might be. ° More and better designed studies are required to investigate this issue in the area of head and neck cancer. How can we decide on the likelihood of having unwanted effects as a result of treatment? The likelihood of having unwanted effects as a result of radiotherapy can be calculated by using so‐called NTCP models. NTCP models calculate the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. What did we want to find out? Radiotherapy is the mainstay of treatment of patients with head and neck cancer. However, radiotherapy exposes healthy, sometimes crucial, parts of the head and neck region to radiation. This may result in damage to these normal organs, e.g. disturbed saliva production, which may have important consequences for the quality of life of head and neck cancer patients treated with radiotherapy. To reach an optimal balance between tumour control and preventing radiation‐induced side effects, normal tissue complication probability (NTCP) models can be helpful. These models predict the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. There have been a substantial number of NTCP models for patients with head and neck cancer. We wanted to find out what the quality of study design, conduct, and analysis (i.e. risk of bias) is, and how well these models can predict the risk of radiation‐induced side effects. What did we do? We searched for studies that developed and/or validated NTCP models in patients with head and neck cancer. What did we find? In most of the 617 models developed from 162,527 patients in 152 identified articles, the quality of the models was not sufficient; and it has not been investigated how well they perform in new patients for 78% of these models. For the remaining 22% of the models, 193 external validations were found in 48,852 patients from 39 articles. There were only ten models with two or more external validations. The models were able to distinguish patients with and without the outcome well, but it was often unclear whether their predictions were in line with what was observed, because the latter was not always assessed and/or reported. Overall, the quality of most of these studies was low. How up to date is the review? The evidence is current to 8th January 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Takada, T, Tambas, M, Clementel, E, Leeuwenberg, A, Sharabiani, M, Damen, JAAG, Dunias, ZS, Nauta, JF, Idema, DL, Choi, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014745.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.749Z" }, { "id": "668a77ed-033b-40bd-8c00-52b40ed2595a", "pmid": "", "title": "Antibiotics for the induction and maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Antibiotics have been considered to treat ulcerative colitis (UC) due to their antimicrobial properties against intestinal bacteria linked to inflammation. However, there are concerns about their efficacy and safety. Objectives To determine whether antibiotic therapy is safe and effective for the induction and maintenance of remission in people with UC. Search methods We searched five electronic databases on 10 December 2021 for randomised controlled trials (RCTs) comparing antibiotic therapy to placebo or an active comparator. Selection criteria We considered people with UC of all ages, treated with antibiotics of any type, dose, and route of administration for inclusion. Induction studies required a minimum duration of two weeks for inclusion. Maintenance studies required a minimum duration of three months to be considered for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcome for induction studies was failure to achieve remission and for maintenance studies was relapse, as defined by the primary studies. Main results We included 12 RCTs (847 participants). One maintenance of remission study used sole antibiotic therapy compared with 5‐aminosalicylic acid (5‐ASA). All other trials used concurrent medications or standard care regimens and antibiotics as an adjunct therapy or compared antibiotics with other adjunct therapies to examine the effect on induction of remission. There is high certainty evidence that antibiotics (154/304 participants) compared to placebo (175/304 participants) result in no difference in failure to achieve clinical remission (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.06). A subgroup analysis found no differences when steroids, steroids plus 5‐ASA, or steroids plus 5‐ASA plus probiotics were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (102/168 participants) compared to placebo (121/175 participants) may result in no difference in failure to achieve clinical response (RR 0.75, 95% CI 0.47 to 1.22). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (6/342 participants) compared to placebo (5/349 participants) may result in no difference in serious adverse events (RR 1.19, 95% CI 0.38 to 3.71). A subgroup analysis found no differences when steroids were additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (3/342 participants) compared to placebo (1/349 participants) may result in no difference in withdrawals due to adverse events (RR 2.06, 95% CI 0.27 to 15.72). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were additional therapies to antibiotics and placebo. It is unclear if there is any difference between antibiotics in combination with probiotics compared to no treatment or placebo for failure to achieve clinical remission (RR 0.68, 95% CI 0.39 to 1.19), serious adverse events (RR 1.00, 95% CI 0.07 to 15.08), or withdrawals due to adverse events (RR 1.00, 95% CI 0.07 to 15.08). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to achieve clinical remission (RR 2.20, 95% CI 1.17 to 4.14). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to probiotics for failure to achieve clinical remission (RR 0.47, 95% CI 0.23 to 0.94). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to maintain clinical remission (RR 0.71, 95% CI 0.47 to 1.06). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to no treatment for failure to achieve clinical remission in a mixed population of people with active and inactive disease (RR 0.56, 95% CI 0.29 to 1.07). The certainty of the evidence is very low. For all other outcomes, no effects could be estimated due to a lack of data. Authors' conclusions There is high certainty evidence that there is no difference between antibiotics and placebo in the proportion of people who achieve clinical remission at the end of the intervention period. However, there is evidence that there may be a greater proportion of people who achieve clinical remission and probably a greater proportion who achieve clinical response with antibiotics when compared with placebo at 12 months. There may be no difference in serious adverse events or withdrawals due to adverse events between antibiotics and placebo. No clear conclusions can be drawn for any other comparisons. A clear direction for future research appears to be comparisons of antibiotics and placebo (in addition to standard therapies) with longer‐term measurement of outcomes. Additionally. As there were single studies of other head‐to‐head comparisons, there may be scope for future studies in this area. Plain language summary The use of antibiotics in the treatment of ulcerative colitis What was the aim of this review? This Cochrane Review aimed to determine whether antibiotics are useful and safe for people with ulcerative colitis (UC) in achieving or maintaining remission. Key messages We found that antibiotics, when added to standard therapies, are similar to placebo in how often they fail to achieve remission or disease improvement for people with UC, measured up to three months from taking them. We found that antibiotics when compared to placebo may be useful in achieving remission or some improvement of UC symptoms, measured at 12 months from taking them. In terms of safety, the evidence is of low certainty, but antibiotics may be as safe as placebo. We have confidence in the findings up to three months, but have less confidence in the evidence at 12 months due to low numbers of study participants. What is ulcerative colitis? UC is a chronic (long term) inflammatory disease that affects the large bowel. The most common symptoms include bloody diarrhoea, abdominal pain, and a sudden almost uncontrollable urge to pass stool. Some people have other symptoms including sore joints, mouth sores, and inflammation in their eyes. When someone is experiencing symptoms of UC, they are said to have 'active' disease. When symptoms improve with treatment, the disease is said to be responding to therapy. When symptoms stop, the disease is said to be in 'remission'. People with UC in remission are often given therapy with medicines to try and prolong (maintain) their remission or response to therapy. What did the review study? This review studied the use of antibiotics in the treatment of UC. Eleven studies considered antibiotics as a therapy for achieving remission and one study as therapy for maintaining remission. Antibiotics could theoretically be helpful as they might be able to fight harmful bacteria in the gut that are thought to be a partial cause for the presence of UC symptoms. Currently, most doctors do not recommend the use of antibiotics unless the patient has an infection. What were the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing antibiotics with another treatment or dummy treatment. We found 12 RCTs including 847 participants. The trials looked at people of all ages; using different types and doses of antibiotics; and at antibiotics taken as tablets, injections, or any other way. The main results from our review are as follows. 1. Antibiotics, when added to standard therapies, are no different from placebo in failing to achieve remission or improve disease symptoms for people with UC when measured up to three months from taking them. 2. Antibiotics probably fail less than placebo in achieving remission or some improvement of UC symptoms measured at 12 months from taking them. 3. In terms of safety, antibiotics may be similar to placebo, but the evidence is of low certainty. 4. We are uncertain about how antibiotics compare to other treatments because there is not enough good evidence to make a judgement. Conclusion There is no difference between antibiotics and placebo when added to standard therapies to achieve remission or improvement of symptoms in the short term. However, they may help to lessen the number of people who do not achieve remission, and they probably lead to fewer numbers of people who have not achieved improvement of symptoms at 12 months. No conclusions can be drawn on other treatments or safety due to lack of evidence, even though there may be a possibility that antibiotics are as safe as placebo. Further research would be needed to clarify the usefulness of antibiotics in the treatment of UC; however, such studies should focus on longer‐term outcomes given the findings of this review. How up‐to‐date is this review? This review is up‐to‐date as of December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Gordon, M, Sinopoulou, V, Grafton-Clarke, C, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.747Z" }, { "id": "66a38878-1574-4901-b0b3-6a173f26f93b", "pmid": "", "title": "Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption", "imported": false, "abstract": "Abstract - Background Overconsumption of food, alcohol, and tobacco products increases the risk of non‐communicable diseases. Interventions to change characteristics of physical micro‐environments where people may select or consume these products ‐ including shops, restaurants, workplaces, and schools – are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers. Objectives 1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non‐alcoholic beverages), (b) alcohol, and (c) tobacco products. 2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii. participants. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches. Selection criteria We included randomised controlled trials with between‐participants (parallel group) or within‐participants (cross‐over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product. Data collection and analysis We used a novel semi‐automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random‐effects meta‐analysis and meta‐regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE. Main results We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between‐participants designs (19/24). All studies were conducted in high‐income countries, predominantly in the USA (14/24). Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less‐healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta‐analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD −1.13 (95% confidence interval (CI) −1.90 to −0.37) (low certainty evidence). For consumption outcomes, meta‐analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD −0.55 (95% CI −1.27 to 0.18) (low certainty evidence). Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD −0.65 (95% CI −1.29 to −0.01) (very low certainty evidence). For consumption outcomes, meta‐analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD −0.60 (95% CI −0.84 to −0.36) (low certainty evidence). Meta‐regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias. Authors' conclusions The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real‐world settings, intervening across a wider range of foods ‐ as well as alcohol and tobacco products ‐ and over sustained time periods. Plain language summary Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption Unhealthy patterns of consumption of food, alcohol, and tobacco products are important causes of ill health. Changing the availability (the range or amount of options, or both) of these products or their proximity (the distance at which they are positioned) to potential consumers could help people make healthier choices. What is the aim of this review? This review investigated whether altering the availability or proximity of food (including non‐alcoholic beverages), alcohol, and tobacco products changed people's selection (such as purchasing) or consumption of those products. We searched for all available evidence from randomised controlled trials (a type of study in which participants are assigned to one of two or more treatment groups using a random method) to answer this question, and found 24 studies, all of which were conducted in high‐income countries. What are the main results of the review? Six studies involved availability interventions, of which four changed the relative proportion of less‐healthy to healthier options, and two changed the absolute number of different options available. In statistical analyses that combined results from multiple studies, it was found that reducing the number of available options for a particular range or category of food(s) reduced selection of those food products (from analysing 154 participants) and possibly reduced consumption of those products (from 150 participants). However, the certainty of the evidence for these effects was low. Eighteen studies involved proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. One study found that this reduced selection of food (from analysing 41 participants), whilst in a statistical analysis combining results from multiple studies, it was found that placing food farther away reduced consumption of those food products (from analysing 1098 participants). However, the certainty of the evidence for these effects was very low and low, respectively. Key messages Mindful of its limitations, the current evidence suggests that changing the number of available food options or changing where foods are positioned could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes to food environments. However, more high‐quality studies in real‐world settings are needed to make this finding more certain. How up‐to‐date is this review? The evidence is current to 23 July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hollands, GJ; Carter, P; Anwer, S; King, SE; Jebb, SA; Ogilvie, D; Shemilt, I; Higgins, JPT; Marteau, TM", "articleTypes": [], "doi": "10.1002/14651858.CD012573.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "66c0edbb-acc0-4cdb-9c62-f5abffc8360f", "pmid": "", "title": "Zinc supplementation for tinnitus", "imported": false, "abstract": "Abstract - Background Tinnitus is the perception of sound without external acoustic stimuli. Patients with severe tinnitus may have physical and psychological complaints and their tinnitus can cause deterioration in their quality of life. At present no specific therapy for tinnitus has been found to be satisfactory in all patients. In recent decades, a number of reports have suggested that oral zinc supplementation may be effective in the management of tinnitus. Since zinc has a role in cochlear physiology and in the synapses of the auditory system, there is a plausible mechanism of action for this treatment. Objectives To evaluate the effectiveness and safety of oral zinc supplementation in the management of patients with tinnitus. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 6); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 July 2016. Selection criteria Randomised controlled trials comparing zinc supplementation versus placebo in adults (18 years and over) with tinnitus. Data collection and analysis We used the standard methodological procedures recommended by Cochrane. Our primary outcome measures were improvement in tinnitus severity and disability, measured by a validated tinnitus‐specific questionnaire, and adverse effects. Secondary outcomes were quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters, change in tinnitus loudness, change in overall severity of tinnitus and change in thresholds on pure tone audiometry. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included three trials involving a total of 209 participants. The studies were at moderate to high risk of bias. All included studies had differences in participant selection criteria, length of follow‐up and outcome measurement, precluding a meta‐analysis. The participants were all adults over 18 years with subjective tinnitus, but one study conducted in 2013 (n = 109) included only elderly patients. Improvement in tinnitus severity and disability Only the study in elderly patients used a validated instrument (Tinnitus Handicap Questionnaire) for this primary outcome. The authors of this cross‐over study did not report the results of the two phases separately and found no significant differences in the proportion of patients reporting tinnitus improvement at four months of follow‐up: 5% (5/93) versus 2% (2/94) in the zinc and placebo groups, respectively (risk ratio (RR) 2.53, 95% confidence interval (CI) 0.50 to 12.70; very low‐quality evidence ). None of the included studies reported any significant adverse effects. Secondary outcomes For the secondary outcome change in tinnitus loudness, one study reported no significant difference between the zinc and placebo groups after eight weeks: mean difference in tinnitus loudness ‐9.71 dB (95% CI ‐25.53 to 6.11; very low‐quality evidence ). Another study also measured tinnitus loudness but used a 0‐ to 100‐point scale. The authors of this second study reported no significant difference between the zinc and placebo groups after four months: mean difference in tinnitus loudness rating scores 0.50 (95% CI ‐5.08 to 6.08; very low‐quality evidence ). Two studies used unvalidated instruments to assess tinnitus severity. One (with 50 participants) reported the severity of tinnitus using a non‐validated scale (0 to 7 points) and found no significant difference in subjective tinnitus scores between the zinc and placebo groups at the end of eight weeks of follow‐up (mean difference (MD) ‐1.41, 95% CI ‐2.97 to 0.15; very low‐quality evidence ). A third trial (n = 50) also evaluated the improvement of tinnitus using a non‐validated instrument (a 0 to 10 scale: 10 = severe and unbearable tinnitus). In this study, after eight weeks there was no difference in the proportion of patients with improvement in their tinnitus, 8.7% (2/23) treated with zinc versus 8% (2/25) of those who received a placebo (RR 1.09, 95% CI 0.17 to 7.10, very low‐quality evidence ). None of the included studies reported any of our other secondary outcomes (quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters or change in thresholds on pure tone audiometry). Authors' conclusions We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. Plain language summary Zinc supplements for tinnitus Background Tinnitus is the perceived sensation of sound in the ear or head. Severe tinnitus affects 1% to 2% of the population. People with severe tinnitus frequently have psychological changes and a decrease in their quality of life. Tinnitus is difficult to control and many doctors are testing new treatments to improve the quality of life of people who suffer from this problem. This review looked for high‐quality studies in the literature that involved zinc supplements as a possible treatment for tinnitus in adults. The aim was to evaluate whether oral zinc is effective in the treatment of tinnitus. Study characteristics We included a total of three trials involving 209 participants who were treated with oral zinc pills or placebo. All patients were adults over 18 years who had subjective tinnitus. All three studies investigated improvement in tinnitus as their primary outcome. One study assessed adverse effects and our secondary outcome 'change in overall severity of tinnitus'. Two studies assessed tinnitus loudness. Only one study, which enrolled only elderly patients, used a validated instrument (the Tinnitus Handicap Questionnaire (THQ)) to measure the primary outcome. The other two studies measured tinnitus using scales (from 0 to 7 and from 0 to 10), but these scales were not validated instruments for studying tinnitus. Key results All three included studies had differences in their participant selection, length of follow‐up and outcome measurement, which prevented a meta‐analysis (combining of results). Only one trial (conducted in 2013) used a validated instrument (the THQ) to measure improvement in tinnitus, our primary outcome. The authors reported no significant difference between the groups. Another study (2003) reported the severity of tinnitus using a non‐validated scale (0 to 7) and found a significant difference in the subjective tinnitus scores, which favoured the zinc group. However, this result may be biased because the losses were unbalanced and higher in the placebo group. A third study (1991) also evaluated improvement of tinnitus using a non‐validated instrument (a scale of 0 to 10) and found no significant difference between groups. There were no severe adverse effects associated with zinc. Three cases of mild adverse effects were reported in different participants (e.g. mild gastric symptoms). Two studies (2003 and 2013) assessed change in tinnitus loudness (one of our secondary outcomes), but did not find a difference between patients treated with zinc compared to those who took a placebo. Two studies assessed change in the overall severity of tinnitus. One study, published in 1991, did not find any difference for this outcome between the groups. The second study, published in 2003, reported a significant reduction in subjective tinnitus score in the zinc group and no difference in the placebo group. However, both studies used a non‐validated scale. Quality of the evidence The quality of the evidence is very low. We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. This evidence is up to date to 14 July 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Person, OC, Puga, MES, da Silva, EMK, Torloni, MR", "articleTypes": [], "doi": "10.1002/14651858.CD009832.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.756Z" }, { "id": "66ce788a-fe85-4eda-81bd-f957f9e387b8", "pmid": "", "title": "Zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance", "imported": false, "abstract": "Abstract - Background Diabetes is associated with long‐term damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity. Insulin resistance is a fundamental aspect of the aetiology of type 2 diabetes. Insulin resistance has been shown to be associated with atherosclerosis, dyslipidaemia, glucose intolerance, hyperuricaemia, hypertension and polycystic ovary syndrome. The mineral zinc plays a key role in the synthesis and action of insulin, both physiologically and in diabetes mellitus. Zinc seems to stimulate insulin action and insulin receptor tyrosine kinase activity. Objectives To assess the effects of zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance. Search methods This review is an update of a previous Cochrane systematic review published in 2007. We searched the Cochrane Library (2015, Issue 3), MEDLINE, EMBASE, LILACS and the ICTRP trial register (from inception to March 2015). There were no language restrictions. We conducted citation searches and screened reference lists of included studies. Selection criteria We included studies if they had a randomised or quasi‐randomised design and if they investigated zinc supplementation compared with placebo or no intervention in adults with insulin resistance living in the community. Data collection and analysis Two review authors selected relevant trials, assessed risk of bias and extracted data. Main results We included three trials with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Risk of bias was unclear for most studies regarding selection bias (random sequence generation, allocation concealment) and detection bias (blinding of outcome assessment). No study reported on our key outcome measures (incidence of type 2 diabetes mellitus, adverse events, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). Evaluation of insulin resistance as measured by the Homeostasis Model Assessment of Insulin Resistance (HOMA‐IR) showed neutral effects when comparing zinc supplementation with control (two trials; 114 participants). There were neutral effects for trials comparing zinc supplementation with placebo for total cholesterol, high‐density lipoprotein (HDL) cholesterol, low‐density lipoprotein (LDL) cholesterol and triglycerides (2 studies, 70 participants). The one trial comparing zinc supplementation with exercise also showed neutral effects for total cholesterol, HDL and LDL cholesterol, and a mean difference in triglycerides of ‐30 mg/dL (95% confidence interval (CI) ‐49 to ‐10) in favour of zinc supplementation (53 participants). Various surrogate laboratory parameters were also analysed in the included trials. Authors' conclusions There is currently no evidence on which to base the use of zinc supplementation for the prevention of type 2 diabetes mellitus. Future trials should investigate patient‐important outcome measures such as incidence of type 2 diabetes mellitus, health‐related quality of life, diabetic complications, all‐cause mortality and socioeconomic effects. Plain language summary Zinc supplementation for the prevention of type 2 diabetes mellitus Review question What are the effects of zinc supplementation compared with placebo or no treatment for the prevention of type 2 diabetes in adults with insulin resistance? Background Some studies have shown that zinc improves glucose levels (glycaemic control) in people with diabetes. As a consequence of diabetes long‐term complications may develop, such as kidney, nerve and eye disease. Also, the risk of cardiovascular complications like heart attacks and strokes is raised. Type 1 diabetes is a form of diabetes where the body cannot produce insulin any more. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity and is characterised by an increasing inability of the body to make good use of insulin (insulin resistance). The mineral zinc plays a key role in the action of insulin and theoretically zinc supplementation used by people with insulin resistance could prevent the onset of diabetes. Study characteristics We included three randomised controlled studies with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Key results No study reported on our patient‐important key outcomes (new onset of type 2 diabetes mellitus, side effects, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). The effects of zinc supplementation are uncertain regarding insulin resistance and lipid levels in the blood (mainly cholesterol and triglycerides). Quality of evidence The overall quality of the included studies was unclear because study authors did not provide important information for us to judge how the studies were performed (unclear risk of bias in most cases). In addition, the number of studies and participants is low and the study authors did not investigate important outcomes such as new onset of type 2 diabetes mellitus or side effects of zinc supplementation. Currentness of evidence This evidence is up to date as of March 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El Dib, R; Gameiro, OLF; Ogata, MSP; Módolo, NSP; Braz, LG; Jorge, EC; do Nascimento Junior, P; Beletate, V", "articleTypes": [], "doi": "10.1002/14651858.CD005525.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "66d0b966-dc49-48a8-a5f0-f6eed51c89d9", "pmid": "", "title": "Potentiators (specific therapies for class III and IV mutations) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is the commonest inherited life‐shortening illness in white populations, caused by a mutation in the gene that codes for the cystic fibrosis transmembrane regulator protein (CFTR), which functions as a salt transporter. This mutation mainly affects the airways where excess salt absorption dehydrates the airway lining leading to impaired mucociliary clearance. Consequently, thick, sticky mucus accumulates making the airway prone to chronic infection and progressive inflammation; respiratory failure often ensues. Other complications include malnutrition, diabetes and subfertility. Increased understanding of the condition has allowed pharmaceutical companies to design mutation‐specific therapies targeting the underlying molecular defect. CFTR potentiators target mutation classes III and IV and aim to normalise airway surface liquid and mucociliary clearance, which in turn impacts on the chronic infection and inflammation. This is an update of a previously published review. Objectives To evaluate the effects of CFTR potentiators on clinically important outcomes in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles, reviews and online clinical trial registries. Last search: 21 November 2018. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing CFTR potentiators to placebo in people with CF. A separate review examines trials combining CFTR potentiators with other mutation‐specific therapies. Data collection and analysis The authors independently extracted data, assessed the risk of bias in included trials and used GRADE to assess evidence quality. Trial authors were contacted for additional data. Main results We included five RCTs (447 participants with different mutations) lasting from 28 days to 48 weeks, all assessing the CFTR potentiator ivacaftor. The quality of the evidence was moderate to low, mainly due to risk of bias (incomplete outcome data and selective reporting) and imprecision of results, particularly where few individuals experienced adverse events. Trial design was generally well‐documented. All trials were industry‐sponsored and supported by other non‐pharmaceutical funding bodies. F508del (class II) (140 participants) One 16‐week trial reported no deaths, or changes in quality of life (QoL) or lung function (either relative or absolute change in forced expiratory volume in one second (FEV1) (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in ivacaftor and placebo groups, but there was no difference between groups (low‐quality evidence); there was also no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. There was also no difference in weight. Sweat chloride concentration decreased, mean difference (MD) ‐2.90 mmol/L (95% confidence interval (CI) ‐5.60 to ‐0.20). G551D (class III) (238 participants) The 28‐day phase 2 trial (19 participants) and two 48‐week phase 3 trials (adult trial (167 adults), paediatric trial (52 children)) reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor in the adult trial at 24 weeks, MD 8.10 (95% CI 4.77 to 11.43) and 48 weeks, MD 8.60 (95% CI 5.27 to 11.93 (moderate‐quality evidence). The adult trial reported a higher relative change in FEV1 with ivacaftor at 24 weeks, MD 16.90% (95% CI 13.60 to 20.20) and 48 weeks, MD 16.80% (95% CI 13.50 to 20.10); the paediatric trial reported this at 24 weeks, MD 17.4% (P < 0.0001)) (moderate‐quality evidence). These trials demonstrated absolute improvements in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32). The phase 3 trials reported increased cough, odds ratio (OR) 0.57 (95% CI 0.33 to 1.00) and episodes of decreased pulmonary function, OR 0.29 (95% CI 0.10 to 0.82) in the placebo group; ivacaftor led to increased dizziness in adults, OR 10.55 (95% CI 1.32 to 84.47). There was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Fewer participants taking ivacaftor developed serious pulmonary exacerbations; adults taking ivacaftor developed fewer exacerbations (serious or not), OR 0.54 (95% CI 0.29 to 1.01). A higher proportion of participants were exacerbation‐free at 24 weeks with ivacaftor (moderate‐quality evidence). Ivacaftor led to a greater absolute change from baseline in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32); weight also increased at 24 weeks, MD 2.37 kg (95% CI 1.68 to 3.06) and 48 weeks, MD 2.75 kg (95% CI 1.74 to 3.75). Sweat chloride concentration decreased at 24 weeks, MD ‐48.98 mmol/L (95% CI ‐52.07 to ‐45.89) and 48 weeks, MD ‐49.03 mmol/L (95% CI ‐52.11 to ‐45.94). R117H (class IV) (69 participants) One 24‐week trial reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor at 24 weeks, MD 8.40 (95% CI 2.17 to 14.63), but no relative changes in lung function were reported (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in both groups, but there was no difference between groups; there was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. No changes in absolute change in FEV1 or weight were reported. Sweat chloride concentration decreased, MD ‐24.00 mmol/L (CI 95% ‐24.69 to ‐23.31). Authors' conclusions There is no evidence supporting the use of ivacaftor in people with the F508del mutation. Both G551D phase 3 trials demonstrated a clinically relevant impact of ivacaftor on outcomes at 24 and 48 weeks in adults and children (over six years of age) with CF. The R117H trial demonstrated an improvement in the respiratory QoL score, but no improvement in respiratory function. As new mutation‐specific therapies emerge, it is important that trials examine outcomes relevant to people with CF and their families and that adverse events are reported robustly and consistently. Post‐market surveillance is essential and ongoing health economic evaluations are required. Plain language summary Ivacaftor (marketed as Kalydeco®), a new specific therapy for cystic fibrosis Review question How does ivacaftor affect clinical outcomes (survival, quality of life and lung function) in people with cystic fibrosis (CF)? Background In people with CF, airway surfaces do not have enough water because of an abnormal protein; this makes it difficult to clear thick and sticky mucus, which leads to lung infections. Ivacaftor works on the abnormal protein in people with some mutations to allow the airways retain more water and better clear mucus, so fewer lung infections develop. Ivacaftor was aimed at people with class III and IV mutations, and has been studied in people with G551D (class III), R117H (class IV) and F508del (class II) mutations. Trial characteristics We included five trials (447 participants) comparing ivacaftor to placebo (dummy treatment with no active medication) lasting between four and 48 weeks. Three trials enrolled a total of 238 people with at least one copy of the G551D mutation, one trial enrolled 140 people with two copies of the F508del mutation and one enrolled 69 people with at least one copy of the R117H mutation. The evidence is up to date as of 21 November 2018. Key results F508del mutation The trial did not report any deaths or show improvements in lung function, quality of life scores or weight. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. Sweat chloride concentrations were reduced with ivacaftor. G551D mutation No deaths were reported. Both children and adults taking ivacaftor showed improvements in lung function, but only adults reported higher quality of life scores. People given placebo reported more coughing and experienced more episodes of decreased lung function; more adults taking ivacaftor reported episodes of dizziness. Similar numbers of people taking ivacaftor and placebo delayed the course of medication, or withdrew from the trial altogether, due to side effects (e.g. psychological issues, liver disease, severe breathing problems). There were more serious pulmonary exacerbations whilst taking placebo compared to ivacaftor. Adults taking ivacaftor were admitted to hospital less often and had fewer courses of intravenous antibiotics for exacerbations. Both children and adults and children increased their weight with ivacaftor. There was a drop in sweat chloride concentrations with ivacaftor. R117H mutation No deaths occurred in this trial. While quality of life scores improved with ivacaftor, lung function did not. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. There was no difference in weight; but as for other mutations there was a reduction in sweat chloride concentration with ivacaftor.
 
 Evidence suggests that ivacaftor is an effective treatment for people (over six years of age) with cystic fibrosis and the G551D mutation, but not for those with the F508del or R117H mutations. Quality of the evidence In most trials, individuals were put into different treatment groups at random with equal chances of being given either placebo or ivacaftor; no one could work out which treatment the next person would receive, so that healthier people did not receive ivacaftor and make the results seem better. We were not sure whether anyone involved in the trial knew who was receiving which treatment and how this might affect results. No trials reported all results clearly; sometimes they did not report them in a way that we could use in the review and sometimes they did not report the data at all. This affected our certainty regarding the overall results. Information about some side effects was limited as not many people experienced them, therefore, it is difficult to judge whether there was a difference between treatment groups We judged the evidence in this review to be moderate to low quality. Trial funding sources All trials were sponsored by Vertex Pharmaceuticals Incorporated. The National Institute of Health (NIH), the Cystic Fibrosis Foundation (CFF) and other non‐pharmaceutical funding bodies also supported the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Skilton, M; Krishan, A; Patel, S; Sinha, IP; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD009841.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "66d4f56c-5957-4e97-b4c9-31c7b5008f5b", "pmid": "", "title": "Chinese medicinal herbs for measles", "imported": false, "abstract": "Abstract - Background Measles is an infectious disease caused by the Morbillivirus . Chinese physicians believe that medicinal herbs are effective in alleviating symptoms and preventing complications. Chinese herbal medicines are dispensed according to the particular symptoms. This is the second update of a Cochrane Review first published in 2006. Objectives To assess the effectiveness and possible adverse effects of Chinese medicinal herbs for measles. Search methods We searched the Cochrane Central Register of Controlled Clinical Trials (CENTRAL Issue 1, 2011) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to March week 5, 2011), EMBASE (1980 to April 2011), Web of Science (2005 to 30 April 2011), AMED (1985 to 30 April 2011), Chinese Biomedical Database (1976 to 30 June 2011), VIP Information (1989 to 30 June 2011), China National Knowledge Infrastructure (CNKI) (1976 to 30 June 2011), Chinese Journals full‐article database (1994 to 30 June 2011) and the meta Register of Controlled Trials for ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs in patients with measles (without complications). Data collection and analysis Two review authors (SC, TW) independently assessed trial quality and extracted data. We telephone interviewed the trial authors for missing information regarding participant allocation. Some trials allocated participants according to the sequence they were admitted to the trials, that is to say, by using a pseudo‐random allocation method. None of the trials concealed the allocation or used blinding methods. Main results We did not identify any suitable trials for inclusion. In this updated review we identified 80 trials which claimed to use random allocation. We contacted 32 trial authors by telephone and learned that the allocation methods used were not randomised. We excluded 34 studies because the participants experienced complications such as pneumonia. We excluded 10 trials because of non‐random allocation and complications experienced by the participants. We were unable to contact the remaining four trials' authors, so they require further assessment and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions There is no RCT evidence for or against Chinese medicinal herbs as a treatment for measles. We hope high‐quality, robust RCTs in this field will be conducted in the future. Plain language summary Chinese medicinal herbs for measles Measles (rubeola) is an infectious disease caused by multiplication of a single‐strand ribonucleic acid (RNA) virus of the genus Morbillivirus in the upper respiratory tract and conjunctiva. It can lead to serious complications and death. Chinese herbal medicines are believed to be effective in alleviating symptoms and shortening the duration of measles, and are widely used as the main or adjunctive therapy to treat measles in China and other countries. The review authors found a large number of clinical studies providing evidence of Chinese herbal medicines in the treatment of measles. Some of these reports claimed to be randomised controlled trials. However, after telephone interviewing 32 trial authors, we found that none of them used acceptable randomisation procedures to allocate participants and 34 studies included participants with measles complicated with other diseases, for example, pneumonia. Ten trials were non‐randomised controlled studies and four trials require further classification. In this update, we were unable to include any randomised controlled trial for assessment. Although no trials were included, the authors reviewed the articles and found no reports of adverse events in the use of Chinese herbal medicines for treating measles. High‐quality and large trials are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Chen, S; Wu, T; Kong, X; Yuan, H", "articleTypes": [], "doi": "10.1002/14651858.CD005531.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "66dd24e2-9a1c-4fa1-aa59-113cc551f423", "pmid": "", "title": "Nitrous oxide‐based techniques versus nitrous oxide‐free techniques for general anaesthesia", "imported": false, "abstract": "Abstract - Background Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise. Objectives To determine if nitrous oxide‐based anaesthesia results in similar outcomes to nitrous oxide‐free anaesthesia in adults undergoing surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites ( http://clinicaltrials.gov/ , http://controlled‐trials.com/ , and http://www.centerwatch.com ). Selection criteria We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol‐based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay. Data collection and analysis Two review authors independently assessed trial quality and extracted the outcome data. We used meta‐analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed‐effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random‐effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Main results We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta‐analyses showed that nitrous oxide‐based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta‐analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide‐based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low. Authors' conclusions Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review. Plain language summary Nitrous oxide (laughing gas)‐based techniques versus nitrous oxide‐free techniques for general anaesthesia Review question We reviewed the evidence about the harmful effects of nitrous oxide on people undergoing general anaesthesia. Background Nitrous oxide is an anaesthetic gas which has been used for more than 160 years for inducing anaesthesia and keeping patients anaesthetized throughout an operation. It is also known as 'laughing gas'. It is a colourless non‐flammable gas with a pleasant, faint sweet odour and taste. Its low cost and low toxicity have made nitrous oxide by far the most commonly used general anaesthetic. However, some studies have reported that adding nitrous oxide may lead to harmful effects. This has led many anaesthetists to question its continued routine use in a variety of operating room settings. We wanted to discover whether using nitrous oxide in general anaesthesia was better or worse than not using nitrous oxide. Study characteristics We examined the evidence available up to 17 October 2014. We included 35 trials involving 13,872 adult participants, all of whom were randomized to either receive nitrous oxide or no nitrous oxide. The trials covered a variety of situations during general anaesthesia. Key results We found that general anaesthesia with nitrous oxide increased the risk of pulmonary atelectasis (i.e. failure of the lungs to expand fully). When we restricted the results to the highest quality studies only, we found evidence that nitrous oxide may potentially increase the risk of pneumonia and severe nausea and vomiting. However, nitrous oxide had no effect on the patients' survival, the incidence of heart attack, stroke, wound infection, the occurrence of blood clots within veins, the length of hospital stay, or the length of intensive care unit stay. Quality of the evidence The evidence related to survival of participants was of moderate quality because we did not have enough data. The evidence related to some harmful effects, such as failure of the lungs to expand fully and heart attack, was of high quality, while for other harmful effects, such as stroke and the occurrence of blood clots within veins, the evidence was of moderate quality. For others, such as pneumonia, severe nausea and vomiting, and wound infection, the evidence was of low quality. The evidence related to the length of time spend in hospital was of moderate quality. Authors conclusions The avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Sun, R; Jia, WQ; Zhang, P; Yang, K; Tian, JH; Ma, B; Liu, Y; Jia, RH; Luo, XF; Kuriyama, A", "articleTypes": [], "doi": "10.1002/14651858.CD008984.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "66e7c10b-7068-4c83-b3c3-4e6ea87aaa66", "pmid": "", "title": "Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve due to viral infection by the herpes zoster virus are implicated in the aetiology and clinical manifestation of Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Corticosteroids, with their powerful anti‐inflammatory effect, have a potential role to play in the reduction or minimisation of nerve damage when administered together with antiviral therapy, and therefore may improve the outcome for patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of corticosteroids as an adjuvant to antiviral therapy in adult patients with Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Search methods We searched the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 4, 2007), MEDLINE (1950 to December 2007) and EMBASE (1974 to December 2007), CINAHL (1982 to December 2007), LILACS, KoreaMed, IndMed, PakMediNet, ZETOC, Cambridge Scientific Abstracts (Conference Proceedings Database), ISI Proceedings (Web of Science), the National Research Register (NRR), the UK Clinical Research Network Portfolio Database (UKCRN), the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Research Findings Register (ReFeR) and the metaRegister of Controlled Trials (mRCT). Selection criteria All randomised controlled trials in which corticosteroids (by any route of administration at any dosage) were given as an adjuvant to antiviral agents in the treatment of Ramsay Hunt syndrome. Data collection and analysis Two reviewers independently assessed eligibility and trial quality of the available studies, whether they were published or unpublished. No trials were found and therefore no data were analysed. Main results This is an empty review as no trials were found that fulfilled the inclusion criteria. Authors' conclusions Since no randomised controlled trials investigating the use of corticosteroids as an adjuvant to antiviral treatment in Ramsay Hunt syndrome were identified, such studies are needed to assess the effects of such therapy. Plain language summary Corticosteroids used in addition to antiviral drugs in patients with Ramsay Hunt syndrome Ramsay Hunt syndrome (also known as herpes zoster oticus) consists of weakness of the face due to infection with the varicella zoster virus. Five cases arise per 100,000 of the population per year in the US. It is more common among those over 60 and rare in children. Other symptoms may include severe ear pain and small blisters on the outer ear or in the mouth. Prompt diagnosis and treatment (ideally within 72 hours of the onset of symptoms) are crucial to secure the best outcomes. In cases where treatment has been started within this time period, facial weakness recovers in up to 75% of patients. Standard treatment is with antiviral therapy (most commonly acyclovir). Corticosteroids are known for their anti‐inflammatory properties and are commonly used together with antivirals to reduce the inflammation in the facial nerve. This is thought to be the cause of the facial weakness. The aim of the review was to see if corticosteroids, used at the same time as antiviral drugs, improved outcomes in patients with Ramsay Hunt syndrome. However the review found no trials matching the inclusion criteria, and no conclusions can be drawn about the effectiveness of using corticosteroids in this way. It is recommended that high‐quality randomised controlled trials be undertaken to address this issue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T; Doree, C; Chamberlain, IJ; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006852.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "66e917a9-193f-405b-880c-4dce88244a90", "pmid": "", "title": "Ribavirin plus interferon versus interferon for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. Standard therapy is ribavirin plus pegylated interferon to achieve undetectable level of virus in the blood, but the effect on clinical outcomes is controversial. Objectives To assess the beneficial and harmful effects of ribavirin and interferon combination therapy versus interferon monotherapy for chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, approaching authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included randomised trials, irrespective of blinding, language, or publication status, comparing ribavirin plus interferon versus interferon for treatment of chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained loss of hepatitis C virus, liver‐related morbidity plus all‐cause mortality, and adverse events. We performed subgroup analyses of patients who were naive, relapsers, or non‐responders to previous antiviral treatment. All outcomes were analysed with the random‐effects model. We used Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of morbidity plus mortality. The remaining outcomes were presented as relative risks (RR). We used trial sequential analyses to examine the robustness of our findings. Main results We included 83 randomised trials with 12,707 patients. Most trials had unclear or high risk of bias. We did not find any significant influence of bias on our results but cannot exclude outcome measure reporting bias as many trials did not report on the primary outcomes of this review. Compared with interferon, ribavirin plus interferon had a significant beneficial effect on sustained virological response in subgroups of naive patients (RR 0.72, 95% confidence interval (CI) 0.68 to 0.75), relapsers (RR 0.62, 95% CI 0.54 to 0.70), non‐responders (RR 0.89, 95% CI 0.84 to 0.93), and in all patients (RR 0.75, 95% CI 0.71 to 0.79). Combination therapy significantly reduced morbidity plus mortality in all patients (Peto OR, 0.43, 95% CI 0.23 to 0.79), but not in naive, relapsers, or non‐responders individually. Combination therapy significantly increased the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous (cough, dyspnoea, fatigue) adverse reactions. Accordingly, combination therapy significantly increased the risk of treatment discontinuation and dose reductions. Trial sequential analyses confirmed our findings regarding virological effects, but not regarding liver‐related morbidity and all‐cause mortality. Authors' conclusions Compared with interferon alone, ribavirin plus interferon is more effective in clearing hepatitis C virus from the blood. Combination therapy may reduce liver‐related morbidity and all‐cause mortality, but we need more evidence. The number needed to treat to obtain a beneficial effect is considerable considering the increased risk of several severe adverse reactions and costs. Plain language summary Adding ribavirin to interferon increases the number of patients who clear hepatitis C virus but also leads to several adverse reactions Globally about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behavior, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die. It is known that treatment with the drug interferon clears hepatitis C virus from the blood in about 15% of patients. This review identified studies comparing ribavirin plus interferon with interferon alone in patients with chronic hepatitis C. This review shows, by combining the results from all trials, that adding ribavirin to interferon increases the number of patients who clear the hepatitis C virus to about 40% as well as the number of patients who demonstrate improved liver histology. Ribavirin and interferon may also reduce the risk of liver‐related morbidity or all‐cause mortality. However, the number needed to treat to prevent one patient developing morbidity or dying seems very large. Furthermore, combination therapy was associated with increased risk of anaemia and several other adverse reactions. The results gives rise to a dilemma ‐ should we, by adding ribavirin to interferon, increase the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous adverse reactions in a situation where it has not yet been clearly demonstrated that the antiviral effect of the intervention is directly linked to the reduction of all‐cause mortality? We, therefore, suggest that the combination intervention is applied only with stringent emphasis on the individual patients' well‐being. Furthermore, we suggest that all future trials within the area should focus more on adverse reactions and long‐term clinical outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Brok, J; Gluud, LL; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "66eba573-aa22-45c0-b310-14c61e8febce", "pmid": "", "title": "Combined aclidinium bromide and long‐acting beta2‐agonist for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Several dual bronchodilator combinations of long‐acting beta 2 ‐agonist (LABA) and long‐acting muscarinic antagonist (LAMA) have been approved for treatment of stable chronic obstructive pulmonary disease (COPD). The current GOLD (Global Initiative for Chronic Obstructive Lung Disease) recommendations suggest the use of LABA/LAMA combinations in people with group B COPD with persistent symptoms, group C COPD with further exacerbations on LAMA therapy alone and group D COPD with or without inhaled corticosteroids (ICS). Fixed‐dose combination (FDC) of aclidinium/formoterol is one of the approved LABA/LAMA therapies for people with stable COPD. Objectives To assess the efficacy and safety of combined aclidinium bromide and long‐acting beta 2 ‐agonists in stable COPD. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov, World Health Organization (WHO) trials portal, United States Food and Drug Administration (FDA) and manufacturers' websites as well as the reference list of published trials up to 12 October 2018. Selection criteria Parallel‐group randomised controlled trials (RCTs) assessing combined aclidinium bromide and LABAs in people with stable COPD. Data collection and analysis We used standard methodological procedures expected by Cochrane for data collection and analysis. The primary outcomes were exacerbations requiring a short course of an oral steroid or antibiotic, or both; quality of life measured by a validated scale and non‐fatal serious adverse events (SAEs). Where the outcome or study details were not reported, we contacted the study investigators or pharmaceutical company trial co‐ordinators (or both) for missing data. Main results We identified RCTs comparing aclidinium/formoterol FDC versus aclidinium, formoterol or placebo only. We included seven multicentre trials of four to 52 weeks' duration conducted in outpatient settings. There were 5921 participants, whose mean age ranged from 60.7 to 64.7 years, mostly men with a mean smoking pack‐years of 46.4 to 61.3 of which 43.9% to 63.4% were current smokers. They had a moderate‐to‐severe degree of COPD with a mean postbronchodilator forced expiratory volume in one second (FEV 1 ) between 50.5% and 61% of predicted normal and the baseline mean FEV 1 of 1.23 L to 1.43 L. We assessed performance and detection biases as low for all studies whereas selection, attrition and reporting biases were either low or unclear. FDC versus aclidinium There was no evidence of a difference between FDC and aclidinium for exacerbations requiring steroids or antibiotics, or both (OR 0.95, 95% CI 0.71 to 1.27; 2 trials, 2156 participants; moderate‐certainty evidence); quality of life measured by St George's Respiratory Questionnaire (SGRQ) total score (MD –0.92, 95% CI –2.15 to 0.30); participants with significant improvement in SGRQ score (OR 1.17, 95% CI 0.97 to 1.41; 2 trials, 2002 participants; moderate‐certainty evidence); non‐fatal SAE (OR 1.19, 95% CI 0.79 to 1.80; 3 trials, 2473 participants; moderate‐certainty evidence); hospital admissions due to severe exacerbations (OR 0.62, 95% CI 0.29 to 1.29; 2 trials, 2156 participants; moderate‐certainty evidence) or adverse events (OR 0.95, 95% CI 0.76 to 1.18; 3 trials, 2473 participants; moderate‐certainty evidence). Compared with aclidinium, FDC improved symptoms (Transitional Dyspnoea Index (TDI) focal score: MD 0.37, 95% CI 0.07 to 0.68; 2 trials, 2013 participants) with a higher chance of achieving a minimal clinically important difference (MCID) of at least one unit improvement (OR 1.34, 95% CI 1.11 to 1.62; high‐certainty evidence); the number needed to treat for an additional beneficial outcome (NNTB) being 14 (95% CI 9 to 39). FDC versus formoterol When compared to formoterol, combination therapy reduced exacerbations requiring steroids or antibiotics, or both (OR 0.78, 95% CI 0.62 to 0.99; 3 trials, 2694 participants; high‐certainty evidence); may decrease SGRQ total score (MD –1.88, 95% CI –3.10 to –0.65; 2 trials, 2002 participants; low‐certainty evidence; MCID for SGRQ is 4 units); increased TDI focal score (MD 0.42, 95% CI 0.11 to 0.72; 2 trials, 2010 participants) with more participants attaining an MCID (OR 1.30, 95% CI 1.07 to 1.56; high‐certainty evidence) and an NNTB of 16 (95% CI 10 to 60). FDC lowered the risk of adverse events compared to formoterol (OR 0.78, 95% CI 0.65 to 0.93; 5 trials, 3140 participants; high‐certainty evidence; NNTB 22). However, there was no difference between FDC and formoterol for hospital admissions, all‐cause mortality and non‐fatal SAEs. FDC versus placebo Compared with placebo, FDC demonstrated no evidence of a difference in exacerbations requiring steroids or antibiotics, or both (OR 0.82, 95% CI 0.60 to 1.12; 2 trials, 1960 participants; moderate‐certainty evidence) or hospital admissions due to severe exacerbations (OR 0.55, 95% CI 0.25 to 1.18; 2 trials, 1960 participants; moderate‐certainty evidence), although estimates were uncertain. Quality of life measure by SGRQ total score was significantly better with FDC compared to placebo (MD –2.91, 95% CI –4.33 to –1.50; 2 trials, 1823 participants) resulting in a corresponding increase in SGRQ responders who achieved at least four units decrease in SGRQ total score (OR 1.72, 95% CI 1.39 to 2.13; high‐certainty evidence) with an NNTB of 7 (95% CI 5 to 12). FDC also improved symptoms measured by TDI focal score (MD 1.32, 95% CI 0.96 to 1.69; 2 studies, 1832 participants) with more participants attaining at least one unit improvement in TDI focal score (OR 2.51, 95% CI 2.02 to 3.11; high‐certainty evidence; NNTB 4). There were no differences in non‐fatal SAEs, adverse events and all‐cause mortality between FDC and placebo. Combination therapy significantly improved trough FEV 1 compared to aclidinium, formoterol or placebo. Authors' conclusions FDC improved dyspnoea and lung function compared to aclidinium, formoterol or placebo, and this translated into an increase in the number of responders on combination treatment. Quality of life was better with combination compared to formoterol or placebo. There was no evidence of a difference between FDC and monotherapy or placebo for exacerbations, hospital admissions, mortality, non‐fatal SAEs or adverse events. Studies reported a lower risk of moderate exacerbations and adverse events with FDC compared to formoterol; however, larger studies would yield a more precise estimate for these outcomes. Plain language summary Are combined aclidinium and long‐acting beta 2 ‐agonist inhalers effective and safe for people with stable COPD? Background Chronic obstructive pulmonary disease (COPD) is a disease of the lungs that causes airways to narrow. As a result, people with COPD experience symptoms of breathlessness and cough with sputum production which worsen over time. It is mainly caused by smoking or inhaling dust. In people with COPD, inhalers that contain medicines to widen the airways are generally given to relieve symptoms. Long‐acting medicines whose action lasts for at least half a day or one day are preferred. Aclidinium and formoterol (a long‐acting beta 2 ‐agonist medicine) are such inhalers. We wanted to find out how a combination of aclidinium and long‐acting beta 2 ‐agonist fare against either inhaler alone and dummy (placebo) inhaler. Study characteristics We could only identify studies on aclidinium and formoterol combination and included seven studies involving 5921 people with COPD which ranged from four weeks to one year long. Most participants were men in their 60s, moderate‐to‐heavy smokers, around half of whom were current smokers. They had moderate‐to‐severe symptoms of COPD when they started treatment. People in the studies took either combined inhalers containing aclidinium and formoterol or aclidinium or formoterol or placebo through a similar inhaler. Both people doing the research and people in the study did not know which treatment participants were getting. The conclusions of this review are current to October 2018. Key results People taking combined inhaler and aclidinium inhaler were not different in terms of flare‐ups that need additional medicines, quality of life, hospitalisations, side effects or serious side effects. However, they were less breathless than those taking aclidinium inhaler. Fourteen people with COPD would need to be treated with combined inhalers to have one additional person with a clinically significant improvement in breathlessness. People on combined inhalers were likely to have fewer flare‐ups, side effects and symptoms and a better quality of life compared to those taking formoterol inhaler. But, there was little or no difference in hospital admissions due to severe flare‐ups, serious side effects or the risk of dying. When compared to dummy inhalers, people taking combined inhalers experienced less breathlessness and better quality of life. Seven people with COPD would need to be treated with combined inhaler to achieve a significant improvement in quality of life than dummy inhaler. For flare‐ups, hospital admissions, side effects, serious side effects and death, there was no difference between combined and dummy inhalers. The lungs worked better in people taking combined inhalers than those taking only one drug or dummy inhaler. Quality of the evidence We had to interpret the results carefully as all the included studies were sponsored by pharmaceutical companies, which could have led to bias. However, the included studies were generally conducted in a systematic and acceptable manner. We are confident that combined inhalers are more effective than single or dummy inhalers at improving breathlessness and lung function. However, we are less certain about its effects on flare‐ups, hospital admissions, quality of life and side effects. Conclusion Combined inhalers are more effective than individual or dummy inhalers for relieving breathlessness and improving lung performance. They also lead to better quality of life than formoterol or dummy inhalers. However, they are not different from individual or dummy inhalers in terms of flare‐ups or hospital admissions. These combined inhalers have similar safety profiles as individual or dummy inhalers in terms of death, side effects or serious side effects. Combined inhalers probably had lesser side effects and moderate flare‐ups than formoterol, but further studies are needed to confidently support this finding. In summary, the combined inhalers are an effective option for treatment of COPD and appear to have a similar safety profile to individual or dummy inhalers.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ni, H, Moe, S, Soe, Z, Myint, KT, Viswanathan, KN", "articleTypes": [], "doi": "10.1002/14651858.CD011594.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.113Z" }, { "id": "66f10d3c-8655-4416-a7a7-af8cd4136ab5", "pmid": "", "title": "Pharmacotherapy for hypertension‐induced left ventricular hypertrophy", "imported": false, "abstract": "Abstract - Background Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension‐induced LVH. Objectives To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension‐induced LVH. Search methods Cochrane Hypertension’s Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) with at least 12 months’ follow‐up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension‐induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all‐cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. Data collection and analysis Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. Main results We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow‐up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention‐to‐treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add‐on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low‐certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low‐certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low‐certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low‐certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low‐certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. Authors' conclusions We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low‐certainty evidence requires that caution be used when interpreting the findings. High‐quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension‐induced LVH are warranted. Plain language summary What are the main benefits and risks of drugs for reducing blood pressure in the treatment of people with thickening of the heart muscle caused by high blood pressure? Key messages Given the lack of robust evidence, the benefits and risks of adding additional drugs for reducing blood pressure to treat people with thickening of the heart muscle and high blood pressure are unclear. It is unclear if adding drugs for reducing blood pressure causes more serious harms in patients than placebo (dummy treatment) or no treatment; however, it may increase treatment discontinuation due to unwanted effects. There is a need for future studies to better understand the benefits and harms of adding drugs for reducing blood pressure in people with thickening of the heart muscle caused by high blood pressure. What is thickening of the heart muscle? Thickening of the heart muscle is a condition where the muscle gets bigger and affects the function of the heart. This can happen when the heart has worked too hard over time and is mainly caused by high blood pressure. People with thickening of the heart muscle can experience shortness of breath, fatigue, chest pain, heart palpitations, and dizziness or fainting. How is thickening of the heart muscle treated? Thickening of the heart muscle can be treated with drugs for reducing blood pressure. What did we want to find out? We wanted to find out if adding drugs for reducing blood pressure was better than placebo or no drug treatment at preventing illness and death in people with thickening of the heart muscle and high blood pressure. We also wanted to learn if the addition of drugs for reducing blood pressure was associated with any unwanted or harmful effects. What did we do? We searched for studies that investigated the addition of drugs for reducing blood pressure compared with placebo or no drug treatment. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as methods and sizes of participant groups. What did we find? We found 3 studies that involved 930 people with thickening of the heart muscle and high blood pressure. The largest study was in 692 people, and the smallest study was in 15 people. Study participants were of both genders and on average between 66 and 75 years old. Participants were followed for between three and four years. The studies were conducted in several countries in Europe, Asia, and North and South America. One study received pharmaceutical industry funding. It is uncertain if adding drugs for reducing blood pressure has an effect on death, development of heart and blood vessel diseases, or on hospitalisation for heart failure. It is unclear if adding drugs for reducing blood pressure causes more serious harms than placebo or no drug treatment, but it may increase treatment discontinuations due to unwanted effects. It is unclear if adding drugs for reducing blood pressure has an effect on heart muscle mass. What are the limitations of the evidence? Our confidence in the evidence is lacking because of the small number of identified studies. The available evidence is based on a small percentage of people with thickening of the heart muscle and high blood pressure identified from larger populations in the included studies. Further evidence may change our results. How up‐to‐date is the evidence? The evidence is current to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Leache, L; Gutiérrez-Valencia, M; Finizola, RM; Infante, E; Finizola, B; Pardo Pardo, J; Flores, Y; Granero, R; Arai, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD012039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "6708be28-5f7b-4bc9-84b0-3e8a7053996b", "pmid": "", "title": "Acetylcholinesterase inhibitors for autistic spectrum disorders", "imported": false, "abstract": "Abstract - Background Autism spectrum disorder (autism) is a neurodevelopmental condition characterised by impairments in social communication and interaction, plus restricted, repetitive patterns of behaviour and interests. Whilst some people embrace autism as part of their identity, others struggle with their difficulties, and some seek treatment. There are no current interventions that result in complete reduction of autism features. Acetylcholine is a neurotransmitter for the cholinergic system and has a role in attention, novelty seeking, and memory. Low levels of acetylcholine have been investigated as a potential contributor to autism symptomatology. Donepezil, galantamine, and rivastigmine (commonly referred to as acetylcholinesterase inhibitors) all inhibit acetylcholinesterase, and have slightly different modes of action and biological availability, so their effectiveness and side‐effect profiles may vary. The effect of various acetylcholinesterase inhibitor on core autism features across the lifespan, and possible adverse effects, have not been thoroughly investigated. Objectives To evaluate the efficacy and harms of acetylcholinesterase inhibitors for people with the core features (social interaction, communication, and restrictive and repetitive behaviours) of autism. To assess the effects of acetylcholinesterase inhibitors on non‐core features of autism. Search methods In November 2022, we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the reference lists of included studies and relevant reviews, and contacted authors of relevant studies. Selection criteria Randomised controlled trials (RCTs), comparing acetylcholinesterase inhibitors (e.g. galantamine, donepezil, or rivastigmine) of varying doses, delivered orally or via transdermal patch, either as monotherapy or adjunct therapy, with placebo. People of any age, with a clinical diagnosis of autism were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were core features of autism and adverse effects. Secondary outcomes were language, irritability, hyperactivity, and general health and function. We used GRADE to assess certainty of evidence. Main results We included two RCTs (74 participants). One study was conducted in Iran, the second in the USA, although exact location in the USA is unclear. Galantamine plus risperidone versus placebo plus risperidone One study compared the effects of galantamine plus risperidone to placebo plus risperidone (40 participants, aged 4 years to 12 years). Primary and secondary outcomes of interest were measured postintervention, using subscales of the Aberrant Behavior Checklist (score 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed there was little to no difference between the two groups postintervention for social communication (mean difference (MD) ‐2.75, 95% confidence interval (CI) ‐5.88 to 0.38), and restricted and repetitive behaviour (MD ‐0.55, 95% CI ‐3.47 to 2.37). Overall autism features were not assessed. Adverse events may be higher in the galantamine plus risperidone group (75%) compared with the placebo plus risperidone group (35%): odds ratio 5.57, 95% CI 1.42 to 21.86, low‐certainty evidence. No serious adverse events were reported. Low‐certainty evidence showed a small difference in irritability (MD ‐3.50, 95% CI ‐6.39 to ‐0.61), with the galantamine plus risperidone group showing a greater decline on the irritability subscale than the placebo group postintervention. There was no evidence of a difference between the groups in hyperactivity postintervention (MD ‐5.20, 95% CI ‐10.51 to 0.11). General health and function were not assessed. Donepezil versus placebo One study compared donepezil to placebo (34 participants aged 8 years to 17 years). Primary outcomes of interest were measured postintervention, using subscales of the Modified Version of The Real Life Rating Scale (scored 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed no evidence of group differences immediately postintervention in overall autism features (MD 0.07, 95% CI ‐0.19 to 0.33), or in the autism symptom domains of social communication (MD ‐0.02, 95% CI ‐0.34 to 0.30), and restricted and repetitive behaviours (MD 0.04, 95% CI ‐0.27 to 0.35). Significant adverse events leading to study withdrawal in at least one participant was implied in the data analysis section, but not explicitly reported. The evidence is very uncertain about the effect of donepezil, compared to placebo, on the secondary outcomes of interest, including irritability (MD 1.08, 95% CI ‐0.41 to 2.57), hyperactivity (MD 2.60, 95% CI 0.50 to 4.70), and general health and function (MD 0.03, 95% CI ‐0.48 to 0.54) postintervention. Across all analyses within this comparison, we judged the evidence to be very low‐certainty due to high risk of bias, and very serious imprecision (results based on one small study with wide confidence intervals). The study narratively reported adverse events for the study as a whole, rather than by treatment group. Authors' conclusions Evidence about the effectiveness of acetylcholinesterase inhibitors as a medication to improve outcomes for autistic adults is lacking, and for autistic children is very uncertain. There is a need for more evidence of improvement in outcomes of relevance to clinical care, autistic people, and their families. There are a number of ongoing studies involving acetylcholinesterase inhibitors, and future updates of this review may add to the current evidence. Plain language summary Do acetylcholinesterase inhibitors reduce the core impairments associated with autism spectrum disorder Key messages At present, it is unclear whether acetylcholinesterase inhibitors are effective in treating the core features of autism. This is because very few studies have been carried out. The two we found were small, and did not report the outcomes very well. However, there are a number of ongoing studies in this area. What is autism spectrum disorder? Autism spectrum disorder (autism) is a condition that affects the way a person thinks, feels, interacts with others, and experiences their environment. The core behaviours of autism include reduced sharing of interests, difficulties with nonverbal communication (for example, little eye contact), difficulties forming and maintaining relationships and restricted, or repetitive behaviours or interests. These behaviours can vary in severity, but they still interfere with the person's daily functioning and participation in activities. Medicines, called acetylcholinesterase inhibitors (chemicals that block the normal breakdown of nerve transmitters), have been used to treat Alzheimer's disease (for example, donepezil and galantamine). Recently, it has been suggested that they may also decrease some of the difficulties seen in people with autism. What did we want to find out? Do acetylcholinesterase inhibitors, alone or with other medicines, reduce the core features of autism (social communication and interaction, restrictive and repetitive behaviours) compared with a placebo (a dummy pill). We also wanted to find out if acetylcholinesterase inhibitors were associated with any unwanted side effects. What did we do? We searched for studies that explored whether there were any differences in autistic people's behaviours after they had taken acetylcholinesterase inhibitors compared to people who had taken placebo pills. We compared and summarised the results of the studies, and rated our confidence in the evidence, based on things, such how big and well carried out the studies were. What did we find? We found two relevant studies. One study looked at whether an acetylcholinesterase inhibitor called galantamine, combined with a drug called risperidone (traditionally used to treat psychosis), was better than a placebo combined with risperidone. The study included 40 children, aged between 4 and 12 years, with a diagnosis of autism. it took place over 10 weeks in Iran. A second study compared an acetylcholinesterase inhibitor called donepezil with placebo. It included 34 children, aged between 8 and 17 years, with a diagnosis of autism. It was carried out in the USA. All studies involved children attending outpatient clinics. What are the main results of the review? It is unclear if acetylcholinesterase inhibitors make any difference to the core features of autism in children or adults. Galantamine may cause little to no difference in social interaction and communication skills and irritability levels in children with autism after 10 weeks of treatment. There is no evidence that galantamine reduces difficulties associated with restricted or repetitive behaviours or hyperactivity. Galantamine may also cause some side effects, including nervousness, drowsiness, increased appetite, and tremor. There is no evidence that donepezil reduces difficulties associated with the core features of autism or associated secondary problems. We were unable to find out whether it causes unwanted side effects in children with autism, because the study did not report the results completely. What are the limitations of the evidence? We have little confidence in the evidence for using this medicine to treat problems associated with autism, because the evidence comes from only two small studies that were not very well carried out or reported. Each study looked at a different type of acetylcholinesterase inhibitor and delivered the medicine differently. They did not provide information about all the issues we were interested in, and they measured the side effects differently. If more studies are included in future reviews, these results may change. How up‐to‐date is this review? The evidence in this review is current to November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ure, A, Cox, GR, Haslam, R, Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD013851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.108Z" }, { "id": "6714afd1-712a-4c5d-a9a1-0518f2fde829", "pmid": "", "title": "Benperidol for schizophrenia", "imported": false, "abstract": "Abstract - Background Benperidol is a relatively old antipsychotic drug that has been marketed since 1966. It has been used in Germany for 30 years but is also available in Belgium, Greece, Italy, the Netherlands and the UK. Benperidol is a butyrophenone antipsychotic, with the highest neuroleptic potency in terms of D2 receptor blockade. Those taking it are therefore reputed to be at high risk of extrapyramidal side‐effects, but benperidol's unusual profile may render it valuable to certain subgroups of people with schizophrenia. Objectives To examine the clinical effects and safety of benperidol for those with schizophrenia and schizophrenia‐like psychoses. Search methods We searched the Cochrane Schizophrenia Group's register (March 2009) for this update. Selection criteria We included all randomised controlled trials that compared benperidol with other treatments for people with schizophrenia, or schizophrenia‐like psychoses. Data collection and analysis We reliably selected studies, quality rated them and extracted data. We independently extracted data but excluded data if loss to follow up was greater than 50%. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results The update yielded no further studies for inclusion in the review. We identified only one unpublished poorly randomised controlled trial (N=40, duration 30 days, comparison perphenazine). Although benperidol was inferior to perphenazine (1 RCT, N=40, global state no better or worse RR 8.0 CI 2.1 to 30, NNH 1.4 CI 1 to 2) poor reporting suggests that an overestimate of effect is likely. It was not possible to report other outcomes. Authors' conclusions Currently, there are insufficient data from randomised trials to assess the clinical effects of benperidol. This compound merits further research interest. Plain language summary Benperidol for schizophrenia Benperidol is a relatively old drug that is used for the treatment of schizophrenia in several European countries. We identified only one small, poorly reported, unpublished, randomised trial comparing benperidol with another antipsychotic. Unfortunately the quality of reporting is so poor that the results cannot be considered reliable. Although benperidol was first marketed in 1966, more trials on this drug are justified as with the advent of new compounds there is a danger that inexpensive drugs such as benperidol remain under‐researched and overlooked.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Schwarz, C; Hartung, B; Leucht, S", "articleTypes": [], "doi": "10.1002/14651858.CD003083.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "671b872c-be2f-4f94-9f3a-985a03805ec4", "pmid": "", "title": "Padma 28 for intermittent claudication", "imported": false, "abstract": "Abstract - Background Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease that develops in a limb during exercise and is relieved with rest. Most drug treatments of IC have a limited effect in improving walking distance. Padma 28, a Tibetan herbal preparation, has been used to treat IC, but there is debate as to whether Padma 28 produces a clinical benefit beyond the placebo effect. This is an update of a review first published in 2013. Objectives To determine whether Padma 28 is effective, compared with placebo or other medications, in increasing pain‐free and maximum walking distance for patients with intermittent claudication. Search methods For this update the Cochrane Vascular Trials Search Co‐ordinator searched the Specialised Register (September 2015), the Cochrane Register of Studies ((CENTRAL) (2015, Issue 8)) and clinical trials databases. Selection criteria Randomised controlled trials of Padma 28 compared with placebo or other pharmacological treatments in people suffering from IC. Data collection and analysis All review authors independently assessed the selected studies and extracted the data. Risk of bias was evaluated independently by two review authors. Depending on the data provided in the individual trials, we extracted mean or median walking distance at the end of the trial, or change in walking distance over the course of the trial, or both. Where not provided, and whenever possible, the statistical significance of differences in these parameters between treatment and placebo groups in individual trials was calculated. Where possible, data were combined by meta‐analysis. Main results No new trials were identified in the search for this review update. In total five trials involving 365 participants were included in this review. All trials compared Padma 28 with placebo for at least 16 weeks of follow‐up. Pain‐free and maximum walking distances both increased significantly in the groups treated with Padma 28, with no significant change in the placebo group. In general, the studies presented results comparing the treatment arms before and after treatment but made no comparisons between the Padma 28 and placebo groups. Pooled data of maximum walking distance after treatment with Padma 28 and placebo from two studies (193 participants) indicated a higher maximum walking distance (mean difference (MD) 95.97 m, 95% confidence interval (CI) 79.07 m to 112.88 m, P < 0.00001, very low quality evidence) in the Padma 28 group compared with placebo. The clinical importance of these observed changes in walking distance is unclear as no quality of life data were reported. There was no effect on ankle brachial index (ABI): change in ABI values between baseline and six months follow up MD ‐0.01, 95% CI ‐0.07 to 0.05, 1 study, 56 participants, P = 0.72, very low quality evidence). Mild side effects, especially gastrointestinal discomfort, tiredness and skin eruption, were reported but this outcome was not different between the Padma 28 and placebo groups (odds ratio 1.09, 95% CI 0.42 to 2.83, four studies, 231 participants, P = 0.86, very low quality evidence). Authors' conclusions Some evidence exists from individual trials to suggest that Padma 28 may be effective in increasing walking distances, at least in the short term (four months), in people with IC. Side effects do not appear to be a problem. However, the longer term effects of treatment are unknown and the clinical significance of the improvements in walking distance are questionable. Moreover, the quality of the evidence is limited by the small sample size of the available trials, limited reporting of statistical analyses that compared treatment groups, and relatively high withdrawal rates that were linked to the outcome. That is, patients were withdrawn if they failed to improve walking distance. There was also evidence of publication bias. We therefore feel there is currently insufficient evidence to draw conclusions regards the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation. Plain language summary Padma 28 for intermittent claudication Background Intermittent claudication (IC) is pain in the leg that occurs on exercise and is relieved by rest. It is caused by an inadequate blood supply to the legs due to blockage of arteries. Conservative drug treatment is commonly used in an attempt to improve walking distance in these patients. Padma 28 is a Tibetan herbal preparation used for treating intermittent claudication. Study characteristics and key results This review on the effects of Padma 28 includes five trials with a total of 365 participants (current until September 2015). The review showed that Padma 28 has some beneficial effects in improving maximum and pain‐free walking distance. The groups treated with placebo did not show an improved maximum and pain‐free walking distance. Unfortunately the studies reported insufficient data to allow the comparison of the change in walking distances in the Padma 28 group with the change in walking distances in the placebo group. Combining the data of maximum walking distance after treatment in two studies showed that there was a longer maximum walking distance in the Padma 28 group compared with the placebo group after 16 weeks of treatment. No change in ankle brachial pressure was observed. Mild side effects such as gastrointestinal discomfort, tiredness and skin eruption were also noted but these were not different between the Padma 28 and placebo groups. Quality of the evidence Overall, the quality of the studies was low, with evidence of publication bias, small number of trials, limited reporting of the analyses that compared treatment groups and bias due to a high percentage of withdrawals in the placebo groups because of lack of improvement or deterioration of the overall condition. We therefore feel there is currently insufficient evidence to draw conclusions about the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stewart, M, Morling, JR, Maxwell, H", "articleTypes": [], "doi": "10.1002/14651858.CD007371.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.108Z" }, { "id": "6726b859-18a7-4552-b130-2b7843c8549e", "pmid": "", "title": "Interventions for the prevention of recurrent erysipelas and cellulitis", "imported": false, "abstract": "Abstract - Background Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. Objectives To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. Search methods We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. Selection criteria Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. Data collection and analysis Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. Main results We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study. Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow‐up period of up to one and a half to two years. Four studies were single‐centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria. Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate. Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate‐certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate‐certainty evidence). The protective effects of antibiotic did not last after prophylaxis had been stopped ('post‐prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty. Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years. We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay. The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin). None of the included studies assessed the development of antimicrobial resistance or quality‐of‐life measures. With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. Authors' conclusions In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate‐certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low‐certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low‐certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high‐quality studies are warranted, including long‐term follow‐up and other prophylactic measures. Plain language summary Preventive treatments for repeated episodes of cellulitis and erysipelas Background Cellulitis and erysipelas are both bacterial infections of the skin that most commonly affect the leg. Erysipelas affects the upper layers of the skin, and cellulitis affects its deeper parts, but in practice it is often hard to tell the difference between them, so we consider them together for this review (and refer to them as 'cellulitis'). Up to 50% of people with cellulitis experience repeated episodes. Despite the burden of this condition, there is a lack of high‐certainty, evidence‐based information about the desirable treatment for the prevention of recurrent cellulitis. Review question What are the best available treatments to prevent repeated episodes of cellulitis in adults aged over 16 years compared to no treatment, placebo, another intervention, or the same intervention with a different plan of treatment, and what are their side effects? Study characteristics We searched relevant databases and registers up to June 2016. We identified six trials, with 573 participants, who had an average age between 50 and 70. Both genders were included, but there were nearly twice as many women. Five trials used antibiotic treatment (four penicillin and one erythromycin), which was compared to either no treatment or placebo, and one trial used selenium compared to physiological salt solution. Treatments lasted from six to 18 months. The most common setting was the hospital, and two studies were multicentre. The studies were conducted in the UK, Sweden, Tunisia, Israel, and Austria. There was a small number of previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes in each study. The antibiotic trials assessed prevention with antibiotics in people with cellulitis of the legs, and the selenium trial assessed people with cellulitis of the arms. Key results Our main outcome was prevention of repeated episodes of cellulitis. Our other outcomes included the number of repeated attacks of cellulitis, time to next attack, hospitalisation, quality of life, development of antibiotic resistance, adverse reactions and death. Combining the results of all five trials that used antibiotics, we found moderate‐certainty evidence that for those people under preventative treatment, antibiotic treatment in general, and penicillin in particular, is probably both effective and safe for the prevention of repeated episodes of leg cellulitis when compared with no treatment or placebo. The analyses showed that, compared with no treatment or placebo, taking antibiotics decreased the risk of future episodes by 69%, reduced their number by more than 50%, and significantly reduced the rate until the next attack (moderate‐certainty evidence). However, we found low‐certainty evidence that the protective effect of antibiotics for these three outcomes tailed off over time after treatment had been stopped. In addition, the beneficial effect of antibiotics was relevant for people with at least two past episodes of cellulitis within a time frame of up to three years. We found low‐certainty evidence that there is no difference between antibiotics and no treatment/placebo for side effects and hospitalisation. The evidence did not allow for full exploration of the treatment's effect on length of hospital stay. No serious adverse effects were reported, and common side effects included diarrhoea, nausea, rash (severe skin adverse reactions were not reported) and thrush. In three studies, adverse effects caused those taking part to stop taking the antibiotic. Three people taking erythromycin had abdominal pain and nausea, causing them to stop taking the treatment and to take penicillin instead. In one study, two people withdrew from treatment with penicillin because of diarrhoea or nausea. In another study, because of pain at the site of injection, around 10% of those taking part stopped taking intramuscular injections of benzathine penicillin. None of the included studies measured quality of life or the development of antibiotic resistance. Certainty of evidence Evidence for the effects of antibiotics compared with no treatment or placebo on the recurrence, incidence rate and time to next episode of cellulitis under preventive treatment was of moderate certainty, and was limited by the small number of participants and events. Evidence for the remaining reported outcomes was of low certainty for the same reasons, as well as imprecise results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Dalal, A; Eskin‐Schwartz, M; Mimouni, D; Ray, S; Days, W; Hodak, E; Leibovici, L; Paul, M", "articleTypes": [], "doi": "10.1002/14651858.CD009758.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "672b9df8-36e4-4f13-a4c5-8695535a4eb7", "pmid": "", "title": "Clonidine for pain in non‐ventilated infants", "imported": false, "abstract": "Abstract - Background Critically ill newborn infants undergo a variety of painful procedures or experience a variety of painful conditions during their early life in the neonatal unit. In the critically ill paediatric and neonatal population, clonidine is prescribed as an adjunct to opioids or benzodiazepines aiming to reduce the doses of these drugs that are required for analgesia or sedation, or to facilitate weaning from mechanical ventilation. It has been shown that clonidine premedication might have a positive effect on postoperative pain in children. Objectives To assess the benefit and harms of clonidine for the prevention or treatment of procedural pain; postoperative pain; or pain associated with clinical conditions in non‐ventilated neonates. Search methods We used the standard search strategy of Cochrane Neonatal to search the CENTRAL, MEDLINE via PubMed, Embase, and CINAHL to December 2018. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials. We ran an updated search from 1 January 2018 to 11 March 2020 in CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials, and cluster trials comparing clonidine to placebo or no treatment, opioids, paracetamol, dexmedetomidine, or non‐pharmacological pain‐reducing interventions for the management of procedural pain, postoperative pain, and pain associated with clinical conditions in preterm and term newborns. Data collection and analysis Two review authors independently planned to extract data (e.g. number of participants, birth weight, gestational age, modality of administration, and dose of clonidine) and assess the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow‐up). The primary outcome considered was pain: for procedural pain, the mean values of each analgesia scale assessed during the procedure and at one to two hours after the procedure; for postoperative pain and for pain associated with clinical conditions, the mean values of each analgesia scale assessed at 30 minutes, three hours, and 12 hours after the administration of the intervention. We planned to use the GRADE approach to assess the quality of evidence. Main results Our search strategy yielded 3383 references. Two review authors independently assessed all references for inclusion. We did not find any completed studies for inclusion. We excluded three trials where clonidine was administered for spinal anaesthesia. Authors' conclusions We did not find any studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of clonidine for the prevention or treatment of procedural or postoperative pain, or pain associated with clinical conditions in neonates. Plain language summary Clonidine for painful procedures and conditions in infants Review question: does clonidine administration reduce pain in newborns exposed to painful procedures or conditions? Background: newborns admitted to the hospital are exposed to a number of painful procedures which might include blood sampling, lumbar puncture (a medical procedure where a needle is inserted into the spinal canal, usually to collect cerebrospinal fluid for testing), tubes in the stomach, different types of catheters, and minor surgical procedures such as neonatal circumcision. In addition, newborns might have pain because of clinical conditions, such as, fractured bone, pain following traumatic vaginal birth, disease of the skin (open skin lesions from an inherited skin disorder), or intestines (necrotising enterocolitis (inflammation)). All babies, and especially those born too early (preterm), are very sensitive to pain. Moreover, the experience of repeated episodes of pain might cause problems, such as an altered development of the nervous system, in early life and an increased pain sensitivity when they grow up. Most of the medicines to manage pain and stress in babies have side effects, and might also harm the immature developing brain by inducing death of cells (apoptosis) in the brain. Study characteristics: we searched for studies up to 11 March 2020. The aim of this review was to assess if clonidine could reduce pain in newborns. This medicine can be given through injections, using a tube in the stomach (nasogastric tube), through the skin, and as spinal anaesthesia. However, the latter is not in the focus of this review as it is used for babies undergoing specific surgical procedures. Clonidine works on the brain modifying responses and reducing stress and agitation. Furthermore, clonidine may reduce pain, especially if used in combination with other medicines. Key results: we found no studies for our review. Three studies were excluded because clonidine was given for spinal anaesthesia, whereas our review focuses on other indications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Romantsik, O; Calevo, MG; Norman, E; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD013104.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "67358c86-0669-4d33-83cc-3369ad2680e1", "pmid": "", "title": "Melatonin in cancer treatment", "imported": false, "abstract": "Abstract - Rationale Preserving health‐related quality of life is an aspect of care that requires constant attention from the time of cancer diagnosis. Melatonin has been used to diminish treatment‐related side effects and cancer symptoms, and as a medication to regulate circadian rhythm. An up‐to‐date systematic review is needed to investigate the current evidence concerning possible beneficial effects of melatonin on quality of life and sleep in cancer patients. Objectives To evaluate the benefits and harms of melatonin for preserving health‐related quality of life and sleep in cancer patients. Search methods To identify studies for inclusion in this review, we used CENTRAL, MEDLINE, 10 other databases, and four trial registers, together with reference checking, citation searching, and contact with study authors. The latest search date was 10 September 2024. Eligibility criteria We included randomised controlled trials (RCTs) of adults (18 years or over) with histologically proven cancer of any stage that evaluated melatonin (alone or in combination with standard anticancer treatment) versus no treatment or placebo (alone or in combination with standard anticancer treatment), or standard anticancer treatment. Standard anticancer treatment refers to treatments to stop or prevent cancer, including chemotherapy, radiation therapy, surgery, immunotherapy, and hormonal therapies (such as androgen deprivation therapy). Outcomes The primary outcomes of interest were quality of life and sleep quality within three months, and melatonin‐related adverse events. Other outcomes included survival, disease‐free survival, progression‐free survival, tumour response, and anticancer treatment‐related harms. Risk of bias We used Cochrane's risk of bias tool (RoB 1) to assess the risk of bias in the studies included in the review. Synthesis methods We synthesised results for each outcome using random‐effects meta‐analysis. The effect size was presented as risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CI). If this was not possible, due to the nature of the data, we synthesised results in a narrative format. We used GRADE to assess the certainty of evidence for each outcome. Included studies We identified 30 RCTs (reported in 49 publications) involving 5093 adult participants with cancer (2470 males, 2228 females, 395 not reported). Studies were conducted in a hospital setting and took place in at least 10 countries. We assessed two studies at low risk of bias and the other 28 at high risk of bias. Synthesis of results Melatonin plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life score (MD 2.60, 95% CI −14.53 to 19.73; 1 study, 126 participants; very low certainty evidence), and sleep score (MD 2.80, 95% CI 0.18 to 5.42; 1 study, 50 participants; very low certainty evidence) within three months. We are also very uncertain about potential adverse effects of melatonin: headache (RR 2.77, 95% CI 0.33 to 23.14; 1 study, 25 participants; very low certainty evidence); fatigue (RR 1.02, 95% CI 0.90 to 1.17; 2 studies, 170 participants; very low certainty evidence); and nausea (RR 1.01, 95% CI 0.66 to 1.56; 1 study, 146 participants; very low certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of high risk of bias, small sample size, the width of the 95% confidence interval, and indirectness due to inadequate reporting of cancer type. Melatonin plus standard treatment versus standard treatment No data are available relating to quality of life and sleep within three months. The evidence is very uncertain about headaches (experienced by 15 of 820 participants in melatonin groups, with no data available for control groups; 2 studies, 1640 participants; very low certainty evidence). Melatonin likely reduces the incidence of fatigue (RR 0.46, 95% CI 0.39 to 0.55; 10 studies, 1359 participants; moderate‐certainty evidence) and may reduce nausea (RR 0.85, 95% CI 0.72 to 1.00; 6 studies, 710 participants; low‐certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of the high risk of bias and the width of the 95% confidence interval. Melatonin (topical use) plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life (one study reported no difference between groups, both having the same median score of 66.7; 48 participants; very low certainty evidence). No data are available relating to sleep and adverse events (including headache, dizziness, fatigue, and nausea). We downgraded the certainty of the evidence because of the high risk of bias, small sample size, and insufficient data. Authors' conclusions The available evidence is of very low certainty, so we are unable to draw conclusions about the effects of melatonin on quality of life and sleep at three months in people receiving treatment for cancer. There may be no difference in adverse events between melatonin plus standard treatment and placebo plus standard treatment, but the evidence is very uncertain. Data were lacking for some outcomes, such as dizziness. Melatonin used alongside standard treatment probably reduces the risk of fatigue and may reduce nausea when compared to standard treatment alone. Since the evidence base for melatonin in people with cancer is limited due to insufficient data and risks of bias in study design, the decision for or against using melatonin as an adjunct to cancer treatment cannot easily be made at the current time. Funding This Cochrane Review was partially funded by AG Biologische Krebstherapie, Deutsche Krebshilfe (grant numbers 70‐301 and 109863). The funding agency had no role in the design or conduct of the study. Registration The protocol for this review is available via DOI 10.1002/14651858.CD010145. Plain language summary For cancer patients, what are the benefits and risks of taking the hormone melatonin? Key messages Due to a lack of robust evidence, the effects of melatonin on quality of life and sleep quality in people receiving treatment for cancer are unclear. Melatonin might not increase the risk of adverse events, but the available evidence is not strong enough for us to be certain. Well designed studies using melatonin over a period of up to three months are needed to give better estimates of the benefits and risks. What is melatonin? Melatonin is a hormone produced in the body to regulate the daily sleep and wakefulness cycle. It has been suggested that melatonin may improve sleep quality and quality of life, which are very important in cancer treatment. Moreover, there is research suggesting that melatonin is effective against solid tumours and may be effective for the treatment of cancer. What did we want to find out? We wanted to find out if melatonin can be used in cancer treatment, particularly for preserving the quality of life and sleep quality of cancer patients. We also wanted to find out if melatonin causes any unwanted side effects ('adverse events'). What did we do? We searched for studies that looked at melatonin used with other standard cancer treatments compared with standard cancer treatments used alone or with placebo (fake treatment). What did we find? We found 30 studies that involved 5093 cancer patients, both men and women, with cancer of any type. The studies were conducted in 10 countries around the world. We focused on the effects of melatonin over a period of three months. When compared to placebo plus standard cancer treatments, it is unclear if melatonin has an effect on quality of life and sleep. Melatonin may have little to no effect on potential adverse events like headache, fatigue, and nausea, but we are very uncertain about these results. No results are available for dizziness. We found no studies to help us answer our questions about quality of life and sleep quality when melatonin is used with standard cancer treatments compared to the standard treatment alone. However, the studies did evaluate potential adverse events that might be related to melatonin, and they found that melatonin probably reduces the risk of tiredness (fatigue), and may reduce the risk of feeling sick (nausea). It is unclear if melatonin has an effect on headaches. No results are available for dizziness. When melatonin is used topically, such as in a cream to put on the skin or in a mouth wash, it is unclear if it has an effect on quality of life. We found no studies to help us answer our questions about sleep quality. No data are available for adverse events like headache, fatigue, nausea, and dizziness, as these are not relevant if the melatonin is used topically. It is unclear if melatonin has any other unwanted effects when used topically. What are the limitations of the evidence? We are not confident in the evidence because it is possible that people in the studies were aware of which treatment they were getting. The evidence relating to some benefits and risks we are interested in does not cover all cancer types, or it is based on only a few cases. How up to date is this evidence? The evidence is up‐to‐date to September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Yu, ZY, Peng, RY, Cheng, N, Wang, RT, Nan, MD, Milazzo, S, Pilkington, K, Seely, D, Horneber, M, Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010145.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.774Z" }, { "id": "6738eafb-7e7c-496a-aaa7-b1733e57683b", "pmid": "", "title": "Foetal haemoglobin inducers for reducing blood transfusion in non‐transfusion‐dependent beta‐thalassaemias", "imported": false, "abstract": "Abstract - Background Non‐transfusion‐dependent β‐thalassaemia (NTDβT) is a subset of inherited haemoglobin disorders characterised by reduced production of the β‐globin chain of haemoglobin leading to anaemia of varying severity. Although blood transfusion is not a necessity for survival, it may be required to prevent complications of chronic anaemia, such as impaired growth and hypercoagulability. People with NTDβT also experience iron overload due to increased iron absorption from food sources which becomes more pronounced in those requiring blood transfusion. People with a higher foetal haemoglobin (HbF) level have been found to require fewer blood transfusions, thus leading to the emergence of treatments that could increase its level. HbF inducers stimulate HbF production without altering any gene structures. Evidence for the possible benefits and harms of these inducers is important for making an informed decision on their use. Objectives To compare the effectiveness and safety of the following for reducing blood transfusion for people with NTDβT: 1. HbF inducers versus usual care or placebo; 2. single HbF inducer with another HbF inducer, and single dose with another dose; and 3. combination of HbF inducers versus usual care or placebo, or single HbF inducer. Search methods We used standard, extensive Cochrane search methods. The latest search date was 21 August 2022. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs comparing single HbF inducer with placebo or usual care, with another single HbF inducer or with a combination of HbF inducers; or comparing different doses of the same HbF inducer. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were blood transfusion and haemoglobin levels. Our secondary outcomes were HbF levels, the long‐term sequelae of NTDβT, quality of life and adverse events. Main results We included seven RCTs involving 291 people with NTDβT, aged two to 49 years, from five countries. We reported 10 comparisons using eight different HbF inducers (four pharmacological and four natural): three RCTs compared a single HbF inducer to placebo and seven to another HbF inducer. The duration of the intervention lasted from 56 days to six months. Most studies did not adequately report the randomisation procedures or whether and how blinding was achieved. HbF inducer against placebo or usual care Three HbF inducers, HQK‐1001, Radix Astragali or a 3‐in‐1 combined natural preparation (CNP), were compared with a placebo. None of the comparisons reported the frequency of blood transfusion. We are uncertain whether Radix Astragali and CNP increase haemoglobin at three months (mean difference (MD) 1.33 g/dL, 95% confidence interval (CI) 0.54 to 2.11; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). We are uncertain whether Radix Astragali and CNP have any effect on HbF (MD 12%, 95% CI −0.74% to 24.75%; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). Only medians on haemoglobin and HbF levels were reported for HQK‐1001. Adverse effects reported for HQK‐1001 were nausea, vomiting, dizziness and suprapubic pain. There were no prespecified adverse effects for Radix Astragali and CNP. HbF inducer versus another HbF inducer Four studies compared a single inducer with another over three to six months. Comparisons included hydroxyurea versus resveratrol, hydroxyurea versus thalidomide, hydroxyurea versus decitabine and Radix Astragali versus CNP. No study reported our prespecified outcomes on blood transfusion. Haemoglobin and HbF were reported for the comparison Radix Astragali versus CNP, but we are uncertain whether there were any differences (1 study, 24 participants; low‐certainty evidence). Different doses of the same HbF inducer Two studies compared two different types of HbF inducers at different doses over two to six months. Comparisons included hydroxyurea 20 mg/kg/day versus 10 mg/kg/day and HQK‐1001 10 mg/kg/day, 20 mg/kg/day, 30 mg/kg/day and 40 mg/kg/day. Blood transfusion, as prespecified, was not reported. In one study (61 participants) we are uncertain whether the lower levels of both haemoglobin and HbF at 24 weeks were due to the higher dose of hydroxyurea (haemoglobin: MD −2.39 g/dL, 95% CI −2.80 to −1.98; very low‐certainty evidence; HbF: MD −10.20%, 95% CI −16.28% to −4.12%; very low‐certainty evidence). The study of the four different doses of HQK‐1001 did not report results for either haemoglobin or HbF. We are not certain if major adverse effects may be more common with higher hydroxyurea doses (neutropenia: risk ratio (RR) 9.93, 95% CI 1.34 to 73.97; thrombocytopenia: RR 3.68, 95% CI 1.12 to 12.07; very low‐certainty evidence). Taking HQK‐1001 20 mg/kg/day may result in the fewest adverse effects. A combination of HbF inducers versus a single HbF inducer Two studies compared three combinations of two inducers with a single inducer over six months: hydroxyurea plus resveratrol versus resveratrol or hydroxyurea alone, and hydroxyurea plus l‐carnitine versus hydroxyurea alone. Blood transfusion was not reported. Hydroxyurea plus resveratrol may reduce haemoglobin compared with either resveratrol or hydroxyurea alone (MD −0.74 g/dL, 95% CI −1.45 to −0.03; 1 study, 54 participants; low‐certainty evidence). We are not certain whether the gastrointestinal disturbances, headache and malaise more commonly reported with hydroxyurea plus resveratrol than resveratrol alone were due to the interventions. We are uncertain whether hydroxyurea plus l‐carnitine compared with hydroxyurea alone may increase mean haemoglobin, and reduce pulmonary hypertension (1 study, 60 participants; very low‐certainty evidence). Adverse events were reported but not in the intervention group. None of the comparisons reported the outcome of HbF. Authors' conclusions We are uncertain whether any of the eight HbF inducers in this review have a beneficial effect on people with NTDβT. For each of these HbF inducers, we found only one or at the most two small studies. There is no information on whether any of these HbF inducers have an effect on our primary outcome, blood transfusion. For the second primary outcome, haemoglobin, there may be small differences between intervention groups, but these may not be clinically meaningful and are of low‐ to very low‐certainty evidence. Data on adverse effects and optimal doses are limited. Five studies are awaiting classification, but none are ongoing. Plain language summary Medicines to increase foetal haemoglobin levels and reduce the need for blood transfusion in people with non‐transfusion‐dependent thalassaemia Review question Do medicines that increase foetal haemoglobin (HbF) levels in people with non‐transfusion‐dependent β‐thalassaemia (NTDβT) reduce their need for blood transfusion? What is thalassaemia? Thalassaemia is a genetic (inherited) blood disorder that causes defects in adult haemoglobin (the oxygen carrying component of red blood cells) leading to destruction of the red blood cells and anaemia with different degrees of severity. Persistent anaemia can affect general health and reduce quality of life. People with NTDβT may require periodic blood transfusion to replace the red blood cells and this could lead to excess iron being deposited in various organs in the body, affecting their function. People with NTDβT have higher levels of HbF (the main form of haemoglobin found during the development of a baby before birth) which persists after birth. The amount of HbF that persists varies and people with a higher HbF level require less frequent blood transfusions. What are HbF inducers? HbF inducers are substances which increase HbF levels without alteration to the gene. They may reduce the need for blood transfusion in people with NTDβT. However, it is not known which HbF inducers are effective and safe, and if so, what the optimal dose is and at what age treatment should be started. What did we do? We searched medical databases for studies comparing single HbF inducer with placebo (dummy treatment) or usual care, with another inducer or with a combination of inducers; or comparing different doses for a same inducer. What did we find? We found seven very small randomised controlled trials (where people taking part in the trial had equal chances of being in the treatment or the control group), involving 291 people with NTDβT, aged between two and 49 years, from five countries. These studies varied widely in the type of HbF inducers investigated and their comparison, the doses and how outcomes were reported. The duration of the trials ranged from two to six months. The inducers used include hydroxyurea, decitabine, HQK‐1001, thalidomide, Radix Astragali, resveratrol, l‐carnitine and combined natural preparation (CNP). Main results None of the studies reported our main outcome of changes to the frequency of blood transfusion. All inducers may have caused a small increase in haemoglobin and HbF when compared to placebo, but we are very uncertain about this. Four studies compared a single HbF inducer against another, for three to six months. There were changes to haemoglobin and HbF, but we cannot be certain if a single HbF inducer or a combination of HbF inducers would work better than another. Two studies, each compared a different dose of the same inducer. Lower doses of hydroxyurea appeared to increase haemoglobin and HbF levels more than the higher doses, but we are very uncertain. The other study used four different doses of HQK‐1001 but did not actually look for a difference in the effect of these four different doses on haemoglobin or HbF. Two studies compared a combination of two HbF inducers with a single HbF inducer for six months. We are very uncertain whether the combination or a single inducer improves haemoglobin. None of the studies reported whether HbF inducers have any effect on quality of life. Adverse (unwanted) drug effects were reported for each HbF inducer, but there was little information available to guide us on the safety of these substances. What are the limitations of the evidence? The main reason we are very uncertain about the effects of HbF inducers are because the studies were all very small and had weaknesses in their design. None of the studies lasted long enough to provide meaningful information for many of the outcomes we measured. How up to date is this evidence? The evidence is current to 21 August 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Foong, WC, Loh, CK, Ho, JJ, Lau, DSC", "articleTypes": [], "doi": "10.1002/14651858.CD013767.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.095Z" }, { "id": "67395a35-9da7-4a9f-bee3-0c9e9ab665ee", "pmid": "", "title": "Physical therapy for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Bell's palsy (idiopathic facial paralysis) is commonly treated by various physical therapy strategies and devices, but there are many questions about their efficacy. Objectives To evaluate physical therapies for Bell's palsy (idiopathic facial palsy). Search methods We searched the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2011), MEDLINE (January 1966 to February 2011), EMBASE (January 1946 to February 2011), LILACS (January 1982 to February 2011), PEDro (from 1929 to February 2011), and CINAHL (January 1982 to February 2011). We included searches in clinical trials register databases until February 2011. Selection criteria We selected randomised or quasi‐randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention. Data collection and analysis Two authors independently scrutinised titles and abstracts identified from the search results. Two authors independently carried out risk of bias assessments, which took into account secure methods of randomisation, allocation concealment, observer blinding, patient blinding, incomplete outcome data, selective outcome reporting and other bias. Two authors independently extracted data using a specially constructed data extraction form. We undertook separate subgroup analyses of participants with more and less severe disability. Main results For this update to the original review, the search identified 65 potentially relevant articles. Twelve studies met the inclusion criteria (872 participants). Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies compared or combined some form of physical therapy with acupuncture (360 participants). For most outcomes we were unable to perform meta‐analysis because the interventions and outcomes were not comparable. For the primary outcome of incomplete recovery after six months, electrostimulation produced no benefit over placebo (moderate quality evidence from one study with 86 participants). Low quality comparisons of electrostimulation with prednisolone (an active treatment) (149 participants), or the addition of electrostimulation to hot packs, massage and facial exercises (22 participants), reported no significant differences. Similarly a meta‐analysis from two studies, one of three months and the other of six months duration (142 participants) found no statistically significant difference in synkinesis, a complication of Bell's palsy, between participants receiving electrostimulation and controls. A single low quality study (56 participants), which reported at three months, found worse functional recovery with electrostimulation (mean difference (MD) 12.00 points (scale of 0 to 100) 95% confidence interval (CI) 1.26 to 22.74). Two trials of facial exercises, both at high risk of bias, found no difference in incomplete recovery at six months when exercises were compared to waiting list controls or conventional therapy. There is evidence from a single small study (34 participants) of moderate quality that exercises are beneficial on measures of facial disability to people with chronic facial palsy when compared with controls (MD 20.40 points (scale of 0 to 100), 95% CI 8.76 to 32.04) and from another single low quality study with 145 people with acute cases treated for three months, in which significantly fewer participants developed facial motor synkinesis after exercise (risk ratio 0.24, 95% CI 0.08 to 0.69). The same study showed statistically significant reduction in time for complete recovery, mainly in more severe cases (47 participants, MD ‐2.10 weeks, 95% CI ‐3.15 to ‐1.05) but this was not a prespecified outcome in this meta analysis. Acupuncture studies did not provide useful data as all were short and at high risk of bias. None of the studies included adverse events as an outcome. Authors' conclusions There is no high quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. There is low quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases. There is low quality evidence that facial exercise reduces sequelae in acute cases. The suggested effects of tailored facial exercises need to be confirmed with good quality randomised controlled trials. Plain language summary Physical treatments for idiopathic facial paralysis Bell's palsy is an acute disorder of the facial nerve, which produces full or partial loss of movement on one side of the face. The facial palsy gets completely better without treatment in most, but not all, people. Physical therapies, such as exercise, biofeedback, laser treatment, electrotherapy, massage and thermotherapy, are used to hasten recovery, improve facial function and minimise sequelae. For this updated review we found a total of 12 studies with 872 participants, most with high risk of bias. Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies combined some form of physical therapy and compared with acupuncture (360 participants). There is evidence from a single study of moderate quality that exercises are beneficial to people with chronic facial palsy when compared with controls and from another low quality study that it is possible that facial exercises could help to reduce synkinesis (a complication of Bell's palsy), and the time to recover. There is insufficient evidence to decide whether electrical stimulation works, to identify risks of these treatments or to assess whether the addition of acupuncture to facial exercises or other physical therapy could produce improvement. In conclusion, tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases, and early facial exercise may reduce recovery time and long term paralysis in acute cases, but the evidence for this is of poor quality. More trials are needed to assess the effects of facial exercises and any risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Teixeira, LJ; Valbuza, JS; Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006283.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "673c2e6b-338a-43e0-98e1-a1cf5efa26d5", "pmid": "", "title": "Multiple micronutrient powders for home (point‐of‐use) fortification of foods in pregnant women", "imported": false, "abstract": "Abstract - Background It is estimated that 32 million pregnant women suffer from anaemia worldwide. Due to increased metabolic demands, pregnant women are particularly vulnerable to anaemia and vitamin and mineral deficiencies, leading to adverse health effects in both the mother and her baby. Despite the demonstrated benefits of prenatal supplementation with iron and folic acid or multiple micronutrients, poor adherence to routine supplementation has limited the effectiveness of this intervention in many settings. Micronutrient powders for point‐of‐use fortification are packed, single‐dose sachets containing vitamins and minerals that can be added onto prepared food to improve its nutrient profile. The use of multiple micronutrient powders for point‐of‐use fortification of foods in pregnant women could be an alternative intervention to prenatal micronutrient supplementation. Objectives To assess the effects of prenatal home (point‐of‐use) fortification of foods with multiple micronutrient powders on maternal and newborn health. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and the International Clinical Trials Registry Platform ( ICTRP ) (31 January 2015). We also contacted relevant agencies to identify ongoing and unpublished studies. Selection criteria Randomised controlled trials (both individual and cluster randomisation) and quasi‐randomised trials, irrespective of language or publication status. The intervention was micronutrient powders for point‐of‐use fortification of foods, containing at least three micronutrients with one of them being iron, provided to pregnant women of any gestational age and parity. Five comparison groups were considered: no intervention/placebo, iron and folic acid supplements, iron‐only supplements, folic‐acid only supplements, and multiple micronutrients in supplements. Data collection and analysis Two review authors independently assessed the eligibility of studies, extracted and checked data accuracy, and assessed the risk of bias of included studies. Main results Our search identified 12 reports (relating to six studies). We included two cluster‐randomised controlled trials (involving 1172 women) ‐ these trials were considered to be at a moderate to high risk of bias due to methodological limitations. One trial is ongoing, and three studies were excluded. Micronutrient powders for point‐of‐use fortification of foods versus iron and folic acid supplements One trial (involving 478 pregnant women attending 42 antenatal care centres) compared micronutrient powders containing iron, folic acid, vitamin C and zinc with iron and folic acid tablets provided daily from 14 to 22 weeks to 32 weeks' gestation. The trial did not report on any of this review's primary outcomes: maternal anaemia at or near term, maternal iron deficiency, maternal mortality, adverse effects, low birthweight, preterm births. Nor did the trial report on the majority of this review's secondary outcomes, with the exception of maternal adherence. Adherence to micronutrient powders was lower than adherence to iron and folic acid supplements (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.66 to 0.87, one study, n = 405). Micronutrient powders for point‐of‐use fortification of foods versus same multiple micronutrients in supplements One study (involving 694 pregnant women from 18 communities), compared micronutrient powders containing iron, folic acid, vitamin C, zinc, iodine, vitamin E and vitamin B 12 with tablets containing the same seven micronutrients. There was no difference in maternal anaemia at 37 weeks of gestation (RR 0.92, 95% CI 0.53 to 1.59, one study, n = 470, very low quality evidence ). The trial did not report on any of this review's other primary outcomes in relation to maternal iron deficiency, maternal mortality, adverse effects, low birthweight, or preterm birth. In terms of this review's secondary outcomes, the included trial did not report on the majority of this review's prespecified secondary outcomes with one exception ‐ there was no clear difference in maternal haemoglobin Hb or near term (mean difference (MD) 1.0 g/L, 95% CI ‐1.77 to 3.77, one study, n = 470). Authors' conclusions Limited evidence suggests that micronutrient powders for point‐of‐use fortification of foods have no clear difference as multiple micronutrient supplements on maternal anaemia ( very low quality evidence ) and Hb at or near term. There is limited evidence to suggest that women were more likely to adhere to taking tablets than using micronutrient powders. The overall quality of evidence was judged very low (due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes. Therefore, more evidence is needed to assess the potential benefits or harms of the use of micronutrient powders in pregnant women on maternal and infant health outcomes. Future trials should also assess adherence to micronutrient powders and be adequately powered to evaluate the effects on birth outcomes and morbidity. Plain language summary Powders of iron plus other micronutrients for home (point‐of‐use) fortification of foods consumed by pregnant women Pregnant women are particularly vulnerable to nutrient deficiencies due to the requirements of the growing baby during the pregnancy. In low‐income countries, many women have diets with low content of vitamins and minerals, and they participate in long hours of physical labour. They are also exposed to recurrent infections, which make nutritional deficiencies worse. Thus, lack of adequate nutrition can contribute to the poor health of these women their babies. Iron and folic acid supplements in pregnancy are widely recommended. However, getting the supplements to the women and encouraging them to take them is particularly challenging. Micronutrient powders containing iron, vitamin A, zinc and other vitamins and minerals are usually packaged in single‐use sachets and can be sprinkled onto any semi‐solid food at home or in any other place where meals are to be consumed. The use of micronutrient powders to fortify foods may overcome this problem with micronutrient supplements. Micronutrient powders have already been shown to be effective in reducing anaemia and iron deficiency in young children and so may be useful for pregnant women. This review looked at the use of micronutrient powders in pregnancy, compared with micronutrient supplements or with no additional micronutrients. We found only two studies involving a total of 1172 women, undertaken in Bangladesh and Mexico. The overall quality of evidence was judged very low (with a high risk of bias due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes of this review. One trial compared micronutrient powders with iron and folate supplements, and the other trial compared micronutrient powders with the same nutrients but given as supplements. Overall, micronutrient powders fortification of foods had a similar effect as multiple micronutrient supplements on anaemia in mothers at or near term ( very low quality evidence ) or the mother's haemoglobin (Hb) at or near term. The study that compared micronutrient powders with iron and folic acid supplements reported that women were more likely to take iron and folic acid tablets than micronutrient powders. Nearly all of the review's important outcomes were not reported in the included studies. Therefore, more evidence is needed for both mother and infant health outcomes in order to adequately evaluate the use of micronutrient powders in pregnant women.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Suchdev, PS, Peña‐Rosas, JP, De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD011158.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.788Z" }, { "id": "67401d24-2a4d-4b7c-b133-a2015c399457", "pmid": "", "title": "Chinese medicinal herbs for measles", "imported": false, "abstract": "Abstract - Background Measles is an infectious disease caused by the Morbillivirus . Chinese physicians believe that medicinal herbs are effective in alleviating symptoms and preventing complications. Chinese herbal medicines are dispensed according to the particular symptoms. This is the second update of a Cochrane Review first published in 2006. Objectives To assess the effectiveness and possible adverse effects of Chinese medicinal herbs for measles. Search methods We searched the Cochrane Central Register of Controlled Clinical Trials (CENTRAL Issue 1, 2011) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to March week 5, 2011), EMBASE (1980 to April 2011), Web of Science (2005 to 30 April 2011), AMED (1985 to 30 April 2011), Chinese Biomedical Database (1976 to 30 June 2011), VIP Information (1989 to 30 June 2011), China National Knowledge Infrastructure (CNKI) (1976 to 30 June 2011), Chinese Journals full‐article database (1994 to 30 June 2011) and the meta Register of Controlled Trials for ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs in patients with measles (without complications). Data collection and analysis Two review authors (SC, TW) independently assessed trial quality and extracted data. We telephone interviewed the trial authors for missing information regarding participant allocation. Some trials allocated participants according to the sequence they were admitted to the trials, that is to say, by using a pseudo‐random allocation method. None of the trials concealed the allocation or used blinding methods. Main results We did not identify any suitable trials for inclusion. In this updated review we identified 80 trials which claimed to use random allocation. We contacted 32 trial authors by telephone and learned that the allocation methods used were not randomised. We excluded 34 studies because the participants experienced complications such as pneumonia. We excluded 10 trials because of non‐random allocation and complications experienced by the participants. We were unable to contact the remaining four trials' authors, so they require further assessment and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions There is no RCT evidence for or against Chinese medicinal herbs as a treatment for measles. We hope high‐quality, robust RCTs in this field will be conducted in the future. Plain language summary Chinese medicinal herbs for measles Measles (rubeola) is an infectious disease caused by multiplication of a single‐strand ribonucleic acid (RNA) virus of the genus Morbillivirus in the upper respiratory tract and conjunctiva. It can lead to serious complications and death. Chinese herbal medicines are believed to be effective in alleviating symptoms and shortening the duration of measles, and are widely used as the main or adjunctive therapy to treat measles in China and other countries. The review authors found a large number of clinical studies providing evidence of Chinese herbal medicines in the treatment of measles. Some of these reports claimed to be randomised controlled trials. However, after telephone interviewing 32 trial authors, we found that none of them used acceptable randomisation procedures to allocate participants and 34 studies included participants with measles complicated with other diseases, for example, pneumonia. Ten trials were non‐randomised controlled studies and four trials require further classification. In this update, we were unable to include any randomised controlled trial for assessment. Although no trials were included, the authors reviewed the articles and found no reports of adverse events in the use of Chinese herbal medicines for treating measles. High‐quality and large trials are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Chen, S, Wu, T, Kong, X, Yuan, H", "articleTypes": [], "doi": "10.1002/14651858.CD005531.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.759Z" }, { "id": "6748eb2f-1bc7-41cc-a76d-9c58961e6eea", "pmid": "", "title": "Neuraminidase inhibitors for preventing and treating influenza in adults and children", "imported": false, "abstract": "Abstract - Background Neuraminidase inhibitors (NIs) are stockpiled and recommended by public health agencies for treating and preventing seasonal and pandemic influenza. They are used clinically worldwide. Objectives To describe the potential benefits and harms of NIs for influenza in all age groups by reviewing all clinical study reports of published and unpublished randomised, placebo‐controlled trials and regulatory comments. Search methods We searched trial registries, electronic databases (to 22 July 2013) and regulatory archives, and corresponded with manufacturers to identify all trials. We also requested clinical study reports. We focused on the primary data sources of manufacturers but we checked that there were no published randomised controlled trials (RCTs) from non‐manufacturer sources by running electronic searches in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE (Ovid), EMBASE, Embase.com, PubMed (not MEDLINE), the Database of Reviews of Effects, the NHS Economic Evaluation Database and the Health Economic Evaluations Database. Selection criteria Randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Data collection and analysis We extracted clinical study reports and assessed risk of bias using purpose‐built instruments. We analysed the effects of zanamivir and oseltamivir on time to first alleviation of symptoms, influenza outcomes, complications, hospitalisations and adverse events in the intention‐to‐treat (ITT) population. All trials were sponsored by the manufacturers. Main results We obtained 107 clinical study reports from the European Medicines Agency (EMA), GlaxoSmithKline and Roche. We accessed comments by the US Food and Drug Administration (FDA), EMA and Japanese regulator. We included 53 trials in Stage 1 (a judgement of appropriate study design) and 46 in Stage 2 (formal analysis), including 20 oseltamivir (9623 participants) and 26 zanamivir trials (14,628 participants). Inadequate reporting put most of the zanamivir studies and half of the oseltamivir studies at a high risk of selection bias. There were inadequate measures in place to protect 11 studies of oseltamivir from performance bias due to non‐identical presentation of placebo. Attrition bias was high across the oseltamivir studies and there was also evidence of selective reporting for both the zanamivir and oseltamivir studies. The placebo interventions in both sets of trials may have contained active substances. Time to first symptom alleviation . For the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.8 hours (95% confidence interval (CI) 8.4 to 25.1 hours, P < 0.0001). This represents a reduction in the time to first alleviation of symptoms from 7 to 6.3 days. There was no effect in asthmatic children, but in otherwise healthy children there was (reduction by a mean difference of 29 hours, 95% CI 12 to 47 hours, P = 0.001). Zanamivir reduced the time to first alleviation of symptoms in adults by 0.60 days (95% CI 0.39 to 0.81 days, P < 0.00001), equating to a reduction in the mean duration of symptoms from 6.6 to 6.0 days. The effect in children was not significant. In subgroup analysis we found no evidence of a difference in treatment effect for zanamivir on time to first alleviation of symptoms in adults in the influenza‐infected and non‐influenza‐infected subgroups (P = 0.53). Hospitalisations . Treatment of adults with oseltamivir had no significant effect on hospitalisations: risk difference (RD) 0.15% (95% CI ‐0.78 to 0.91). There was also no significant effect in children or in prophylaxis. Zanamivir hospitalisation data were unreported. Serious influenza complications or those leading to study withdrawal . In adult treatment trials, oseltamivir did not significantly reduce those complications classified as serious or those which led to study withdrawal (RD 0.07%, 95% CI ‐0.78 to 0.44), nor in child treatment trials; neither did zanamivir in the treatment of adults or in prophylaxis. There were insufficient events to compare this outcome for oseltamivir in prophylaxis or zanamivir in the treatment of children. Pneumonia . Oseltamivir significantly reduced self reported, investigator‐mediated, unverified pneumonia (RD 1.00%, 95% CI 0.22 to 1.49); number needed to treat to benefit (NNTB) = 100 (95% CI 67 to 451) in the treated population. The effect was not significant in the five trials that used a more detailed diagnostic form for pneumonia. There were no definitions of pneumonia (or other complications) in any trial. No oseltamivir treatment studies reported effects on radiologically confirmed pneumonia. There was no significant effect on unverified pneumonia in children. There was no significant effect of zanamivir on either self reported or radiologically confirmed pneumonia. In prophylaxis, zanamivir significantly reduced the risk of self reported, investigator‐mediated, unverified pneumonia in adults (RD 0.32%, 95% CI 0.09 to 0.41); NNTB = 311 (95% CI 244 to 1086), but not oseltamivir. Bronchitis, sinusitis and otitis media . Zanamivir significantly reduced the risk of bronchitis in adult treatment trials (RD 1.80%, 95% CI 0.65 to 2.80); NNTB = 56 (36 to 155), but not oseltamivir. Neither NI significantly reduced the risk of otitis media and sinusitis in both adults and children. Harms of treatment . Oseltamivir in the treatment of adults increased the risk of nausea (RD 3.66%, 95% CI 0.90 to 7.39); number needed to treat to harm (NNTH) = 28 (95% CI 14 to 112) and vomiting (RD 4.56%, 95% CI 2.39 to 7.58); NNTH = 22 (14 to 42). The proportion of participants with four‐fold increases in antibody titre was significantly lower in the treated group compared to the control group (RR 0.92, 95% CI 0.86 to 0.97, I 2 statistic = 0%) (5% absolute difference between arms). Oseltamivir significantly decreased the risk of diarrhoea (RD 2.33%, 95% CI 0.14 to 3.81); NNTB = 43 (95% CI 27 to 709) and cardiac events (RD 0.68%, 95% CI 0.04 to 1.0); NNTB = 148 (101 to 2509) compared to placebo during the on‐treatment period. There was a dose‐response effect on psychiatric events in the two oseltamivir \"pivotal\" treatment trials, WV15670 and WV15671, at 150 mg (standard dose) and 300 mg daily (high dose) (P = 0.038). In the treatment of children, oseltamivir induced vomiting (RD 5.34%, 95% CI 1.75 to 10.29); NNTH = 19 (95% CI 10 to 57). There was a significantly lower proportion of children on oseltamivir with a four‐fold increase in antibodies (RR 0.90, 95% CI 0.80 to 1.00, I 2 = 0%). Prophylaxis . In prophylaxis trials, oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals (oseltamivir: RD 3.05% (95% CI 1.83 to 3.88); NNTB = 33 (26 to 55); zanamivir: RD 1.98% (95% CI 0.98 to 2.54); NNTB = 51 (40 to 103)) and in households (oseltamivir: RD 13.6% (95% CI 9.52 to 15.47); NNTB = 7 (6 to 11); zanamivir: RD 14.84% (95% CI 12.18 to 16.55); NNTB = 7 (7 to 9)). There was no significant effect on asymptomatic influenza (oseltamivir: RR 1.14 (95% CI 0.39 to 3.33); zanamivir: RR 0.97 (95% CI 0.76 to 1.24)). Non‐influenza, influenza‐like illness could not be assessed due to data not being fully reported. In oseltamivir prophylaxis studies, psychiatric adverse events were increased in the combined on‐ and off‐treatment periods (RD 1.06%, 95% CI 0.07 to 2.76); NNTH = 94 (95% CI 36 to 1538) in the study treatment population. Oseltamivir increased the risk of headaches whilst on treatment (RD 3.15%, 95% CI 0.88 to 5.78); NNTH = 32 (95% CI 18 to 115), renal events whilst on treatment (RD 0.67%, 95% CI ‐2.93 to 0.01); NNTH = 150 (NNTH 35 to NNTB > 1000) and nausea whilst on treatment (RD 4.15%, 95% CI 0.86 to 9.51); NNTH = 25 (95% CI 11 to 116). Authors' conclusions Oseltamivir and zanamivir have small, non‐specific effects on reducing the time to alleviation of influenza symptoms in adults, but not in asthmatic children. Using either drug as prophylaxis reduces the risk of developing symptomatic influenza. Treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced, because of a lack of diagnostic definitions. The use of oseltamivir increases the risk of adverse effects, such as nausea, vomiting, psychiatric effects and renal events in adults and vomiting in children. The lower bioavailability may explain the lower toxicity of zanamivir compared to oseltamivir. The balance between benefits and harms should be considered when making decisions about use of both NIs for either the prophylaxis or treatment of influenza. The influenza virus‐specific mechanism of action proposed by the producers does not fit the clinical evidence. Plain language summary Regulatory information on trials of oseltamivir (Tamiflu) and zanamivir (Relenza) for influenza in adults and children Oseltamivir and zanamivir have been stockpiled in many countries to treat and prevent seasonal and pandemic influenza, before an influenza vaccine matched to the circulating virus becomes available. Oseltamivir is classified by the World Health Organization as an essential medicine. How this review has been approached We have updated and combined our reviews on the antiviral drugs zanamivir and oseltamivir for influenza in adults and children on the basis of the manufacturers' reports to regulators (clinical study reports) and the regulators' comments. We have called these comments and reports 'regulatory information'. Clinical study reports are unpublished, extensive documents with great detail on the trials that formed the basis for market approval. They include the protocols, methods and results. Clinical study reports have until now been confidential, seen only by the manufacturers and regulators. Why we have taken this approach In previous versions of this review we identified unresolved discrepancies in the data presented in published trial reports and substantial publication bias. As a consequence, we elected not to use data from journal articles but included the documents generated during licensing processes. We have accessed such data from the UK, USA, European Medicines Agency (EMA), Japanese regulators and clinical study reports from the manufacturers (after a protracted media campaign). This has enabled us to verify information from the randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Based on our assessments of the regulatory documents (in excess of 160,000 pages), we came to the conclusion that there were substantial problems with the design, conduct, reporting and availability of information from many of the trials. What we have found We have used data from 46 trials (20 oseltamivir and 26 zanamivir studies) in this review. We identified problems in the design of many of the studies that we included, which affects our confidence in their results. We found that both drugs shorten the duration of symptoms of influenza‐like illness (unconfirmed influenza or 'the flu') by less than a day. Oseltamivir did not affect the number of hospitalisations, based on the data from all the people enrolled in treatment trials of oseltamivir. Zanamivir trials did not record this outcome. The effects on pneumonia and other complications of influenza, such as bronchitis, middle ear infection (otitis media) and sinusitis, were unreliably reported, as shown by the case report form in the trial documents. Some forms showed limitations in the diagnostic criteria for pneumonia. Regulatory comments noted problems with missing follow‐up diary cards from participants. In children with asthma there was no clear effect on the time to first alleviation of symptoms. Prophylaxis trials showed that oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals and households. There was no evidence of an effect on asymptomatic influenza or on non‐influenza, influenza‐like illness, but trial conduct problems prevent any definitive conclusion. Oseltamivir use was associated with nausea, vomiting, headaches, renal and psychiatric events; these last three were when it was used to prevent influenza (prophylaxis). Its effect on the heart is unclear: it may reduce cardiac symptoms, but may induce serious heart rhythm problems. In adult treatment trials of zanamivir there was no increased risk of reported adverse events. The evidence on the possible harms associated with the treatment of children with zanamivir was sparse. Agreement with other findings The lack of good evidence demonstrating an effect on complications agrees with the conservative conclusions on both drugs drawn by the US Food and Drug Administration (FDA). The FDA only allowed claims of effectiveness of both drugs for the prevention and treatment of symptoms of influenza and not for other effects (including the interruption of person‐to‐person spread of the influenza virus or prevention of pneumonia). The FDA described the overall performance of both drugs as 'modest'. Mechanism of action for beneficial effects These findings all suggest that the low immune response with low levels of pro‐inflammatory cytokines, which is induced by the action of oseltamivir carboxylate, may reduce the symptoms of influenza unrelated to an inhibition of influenza virus replication. The potential hypothermic or antipyretic effect of oseltamivir as a central nervous system depressant may also contribute to the apparent reduction of host symptoms. Statements made on the capacity of oseltamivir to interrupt viral transmission and reduce complications are not supported by any data we have been able to access. The mechanism of action proposed by the producers (influenza virus‐specific) does not fit the clinical evidence which suggests a multi‐system and central action.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Jefferson, T; Jones, MA; Doshi, P; Del Mar, CB; Hama, R; Thompson, MJ; Spencer, EA; Onakpoya, IJ; Mahtani, KR; Nunan, D; Howick, J; Heneghan, CJ", "articleTypes": [], "doi": "10.1002/14651858.CD008965.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "6761ba89-bed1-47a1-b2f6-73e8f45d8c06", "pmid": "", "title": "The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents", "imported": false, "abstract": "Abstract - Background Erythropoiesis‐stimulating agents (ESAs) are commonly used to treat chemotherapy‐induced anemia (CIA). However, about half of patients do not benefit. Objectives To evaluate the benefits and harms related to the use of iron as a supplement to ESA and iron alone compared with ESA alone in the management of CIA. Search methods We searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1 January 2016), MEDLINE (1950 to February 2016), and www.clinicaltrials.gov without using any language limits. Selection criteria All randomized controlled trials (RCTs) comparing 'iron plus ESA' or 'iron alone' versus 'ESA alone' in people with CIA were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included eight RCTs (12 comparisons) comparing ESA plus iron versus ESA alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone in people with CIA. None of the included RCTs reported overall survival. There was a beneficial effect of iron supplementation to ESAs compared with ESAs alone on hematopoietic response (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.09 to 1.26; P < 0.0001; 1712 participants; 11 comparisons; high‐quality evidence). Assuming a baseline risk of 35% to 80% for hematopoietic response without iron supplementation, between seven and 16 patients should be treated to achieve hematopoietic response in one patient. In subgroup analyses, RCTs that used intravenous (IV) iron favored ESAs and iron (RR 1.20 (95% CI 1.10 to 1.31); P < 0.00001; 1321 participants; eight comparisons), whereas we found no evidence for a difference in hematopoietic response in RCTs using oral iron (RR 1.04 (95% CI 0.87 to 1.24); P = 0.68; 391 participants; three comparisons). There was no evidence for a difference between the subgroups of IV and oral iron (P = 0.16). There was no evidence for a difference between the subgroups of types of iron (P = 0.31) and types of ESAs (P = 0.16) for hematopoietic response. The iron supplementation to ESAs might be beneficial as fewer participants treated with iron supplementation required red blood cell (RBC) transfusions compared to the number of participants treated with ESAs alone (RR 0.74 (95% CI 0.60 to 0.92); P = 0.007; 1719 participants; 11 comparisons; moderate‐quality evidence). Assuming a baseline risk of 7% to 40% for RBC transfusion without iron supplementation, between 10 and 57 patients should be treated to avoid RBC transfusion in one patient. We found no evidence for a difference in the median time to hematopoietic response with addition of iron to ESAs (hazard ratio (HR) 0.93 (95% CI 0.67 to 1.28); P = 0.65; 1042 participants; seven comparisons; low‐quality evidence). In subgroup analyses, RCTs in which dextran (HR 0.95 (95% CI 0.36 to 2.52); P = 0.92; 340 participants; three comparisons), sucrose iron (HR 1.15 (95% CI 0.60 to 2.21); P = 0.67; 102 participants; one comparison) and sulfate iron (HR 1.24 (95% CI 0.99 to 1.56); P = 0.06; 55 participants; one comparison) were used showed no evidence for difference between iron supplementation versus ESAs alone compared with RCTs in which gluconate (HR 0.78 (95% CI 0.65 to 0.94); P = 0.01; 464 participants; two comparisons) was used for median time to hematopoietic response (P = 0.02). There was no evidence for a difference between the subgroups of route of iron administration (P = 0.13) and types of ESAs (P = 0.46) for median time to hematopoietic response. Our results indicated that there could be improvement in the hemoglobin (Hb) levels with addition of iron to ESAs (mean difference (MD) 0.48 (95% CI 0.10 to 0.86); P = 0.01; 827 participants; seven comparisons; low‐quality evidence). In RCTs in which IV iron was used there was evidence for a difference (MD 0.84 (95% CI 0.21 to 1.46); P = 0.009; 436 participants; four comparisons) compared with oral iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) for mean change in Hb level (P = 0.03). RCTs in which dextran (MD 1.55 (95% CI 0.62 to 2.47); P = 0.001; 102 participants; two comparisons) was used showed evidence for a difference with iron supplementation versus ESAs alone compared with RCTs in which gluconate (MD 0.54 (95% CI ‐0.15 to 1.22); P = 0.12; 334 participants; two comparisons) and sulfate iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) were used for mean change in Hb level (P = 0.007). RCTs in which epoetin was used showed evidence for a difference with iron supplementation versus ESAs alone (MD 0.77 (95% CI 0.25 to 1.29); P = 0.004; 337 participants; five comparisons) compared with darbepoetin use (MD 0.10 (95% CI ‐0.13 to 0.33); P = 0.38; 490 participants; two comparisons) for mean change in Hb level (P = 0.02). We found no evidence for a difference in quality of life with addition of iron to ESAs (standardized mean difference 0.01 (95% CI ‐0.10 to 0.12); P = 0.88; 1124 participants; three RCTs; high‐quality evidence). We found no evidence for a difference in risk of grade III‐IV thromboembolic events (RR 0.95 (95% CI 0.54 to 1.65); P = 0.85; 783 participants; three RCTs; moderate‐quality evidence). The incidence of treatment‐related mortality (TRM) was 0% (997 participants; four comparisons; high‐quality evidence). Other common adverse events included vomiting, asthenia, and leukopenia, and were similar in both arms. Overall the risk of bias across outcomes was high to low. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown. Our main reasons for downgrading the quality of evidence were inconsistency across the included studies and imprecision of results. Authors' conclusions Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation. Plain language summary The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents Review question: Is iron alone or iron as a supplement to erythropoiesis‐stimulating agents (ESAs) superior to ESAs alone in the management of people diagnosed with chemotherapy‐induced anemia (CIA)? Background: The current treatment of CIA is ESAs, which increase the production of red blood cells (erythropoiesis), and in some cases ESAs and iron. In some cases, strategies such as no therapy or wait and watch with clinical oversight and red blood cell transfusion may be safe and suitable options. We conducted a systematic review to evaluate the benefits and harms of iron in the management of CIA. Search date: The evidence is current to February 2016. Study characteristics: We included eight industry‐funded randomized controlled trials (RCTs) comparing ESAs plus iron versus ESAs alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone. Study funding source: All the included trials were industry funded. Key results: Adding iron to ESAs improves the hematopoietic response in people with CIA. Use of iron with ESAs might reduce the risk of blood transfusions and improve hemoglobin. We found no improvement in quality of life with addition of iron. We found no evidence for a difference in time to hematopoietic response and risk of development of blood clot in veins of people with CIA treated with iron and ESAs compared with ESAs alone. There were zero treatment‐related deaths among 997 participants in the four trials that reported this outcome. Other harms included constipation, vomiting, and diarrhea, and were similar with ESAs and iron compared with ESAs alone. None of the trials reported data on survival. Quality of evidence: The quality of evidence for hematopoietic response was high. The quality of evidence for red blood cell transfusion was moderate, as the pooled estimate had large variation. The quality of evidence for change in hemoglobin and time to hematopoietic response was low, as the pooled estimates had large variation and results were not similar across studies. The quality of evidence for quality of life was high. The quality of evidence for risk of blood clots in veins was moderate due to variation in pooled estimate. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Mhaskar, R; Wao, H; Miladinovic, B; Kumar, A; Djulbegovic, B", "articleTypes": [], "doi": "10.1002/14651858.CD009624.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "6784d44a-b649-4074-881b-11d46a201d74", "pmid": "", "title": "Interventions for the treatment of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "Abstract - Background Olfactory dysfunction is a common consequence of COVID‐19 infection and persistent symptoms can have a profound impact on quality of life. At present there is little guidance on how best to treat this condition. A variety of interventions have been suggested to promote recovery, including medication and olfactory training. However, it is uncertain whether any intervention is of benefit. This is an update of the 2021 review with one additional study added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with persisting olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance that had persisted for at least four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the recovery of sense of smell, disease‐related quality of life and serious adverse effects. Secondary outcomes were the change in sense of smell, general quality of life, prevalence of parosmia and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included two studies with 30 participants. The studies evaluated the following interventions: systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant and palmitoylethanolamide plus luteolin. Systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant compared to no intervention We included a single RCT with 18 participants who had anosmia for at least 30 days following COVID‐19 infection. Participants received a 15‐day course of oral corticosteroids combined with nasal irrigation (consisting of an intranasal corticosteroid/mucolytic/decongestant solution) or no intervention. Psychophysical testing was used to assess olfactory function at 40 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Palmitoylethanolamide plus luteolin compared to no intervention We included a single RCT with 12 participants who had anosmia or hyposmia for at least 90 days following COVID‐19 infection. Participants received a 30‐day course of palmitoylethanolamide and luteolin or no intervention. Psychophysical testing was used to assess olfactory function at 30 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the treatment of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important The sense of smell is critical to one's enjoyment of odours and tastes, and is important for safety. During the COVID‐19 pandemic there has been an increasing focus on change in sense of smell as one of the early symptoms associated with infection. This can be a reduction, change or complete loss of the sense of smell. For most people this is temporary, however for some this lasts weeks or even months. If a person has lost their sense of smell for a long time (over four weeks after having COVID‐19), we do not know if there are any treatments that might help it to recover. How we identified and assessed the evidence We searched the medical literature, identifying relevant studies and summarising the results. We assessed the quality of the studies as well as the certainty of the evidence. Factors influencing this included the size of the studies, the methods used to perform them and how results were reported by researchers. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found two small studies to include in the review, including a total of 30 people. All participants had problems with their sense of smell that had lasted for at least four weeks, and started after a COVID‐19 infection. Problems with the sense of smell were identified using special smell identification tests carried out by the research team. The patients were randomly divided into two groups: those who would receive treatment and those who would not. The treatment in one study was a course of corticosteroid tablets ('systemic') and nasal irrigation (with a wash consisting of a mix of corticosteroids, decongestant and an agent that breaks down mucus). The second study used a course of a supplement known as palmitoylethanolamide and luteolin. Systemic corticosteroids and nasal irrigation (intranasal corticosteroids/decongestant/mucolytic) compared to no treatment We do not know whether corticosteroid tablets with nasal irrigation is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 40 days;
 ‐ changing the sense of smell after 40 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. Palmitoylethanolamide and luteolin compared to no treatment We do not know whether palmitoylethanolamide and luteolin is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 30 days;
 ‐ changing the sense of smell after 30 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. We did find a number of other studies that are being carried out, but no results from these studies are yet available to be included in this review. What this means It is unclear whether using corticosteroids with nasal irrigation, or using a palmitoylethanolamide and luteolin supplement, might treat problems with the sense of smell after COVID‐19, or whether these treatments can potentially cause harm. Other treatments are under investigation. This review is a 'living systematic review', meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "O'Byrne, L; Webster, KE; MacKeith, S; Philpott, C; Hopkins, C; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013876.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "6786d970-c1ce-4ced-97f8-b13e14e375b9", "pmid": "", "title": "Cough and Taste Preferences in Adolescents and Adults", "imported": false, "abstract": "This single-site, within-subject, experimental study is designed to test the hypothesis children who live in a household in which one or both of their parent smoke will exhibit a higher cough threshold and will prefer more intense sweet tastes than children who live in a household where neither parent smokes. Subjects will include at least 50 racially and ethnically diverse, healthy children aged 10 to 17 years (a critical time for experimenting with tobacco) and a parent. The sample will comprise two groups: Non-Environmental Tobacco Smoke (ETS) Exposed (neither the child nor parents has ever smoked or been exposed to environmental tobacco smoke (ETS) in the home), and ETS-Exposed (the parent has smoked at least 3 cigarettes per day for at least five years in the home, with the child living in the home continuously). Cough sensitivity will be measured using a standard single-inhalation challenge, a test of the minimum concentration of capsaicin (the spicy chemical in hot peppers) needed to elicit cough. Sweet taste preferences will be measured using a forced-choice paired comparison method of liquids which differ in sucrose content. Measures of breath carbon monoxide will validate the smoking status of parents and their adolescent children. The key comparison will be between Non-ETS Exposed and ETS-Exposed children, with the difference between smoking and non-smoking parents as a positive control. Because smoking and non-smoking families may differ in ways besides tobacco exposure, the investigators will obtain health histories (with a focus on respiratory illness), smoking histories, measures of body weight, diet, and responses to personality tests (including susceptibility to addiction). The investigators will also obtain genomic DNA from saliva samples. Genes for chemosensory receptors that are part of the cough reflex pathway and genotype may account for aspects of cough sensitivity.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.233Z" }, { "id": "6794bf47-38e7-409a-ac5b-9a643c3398b6", "pmid": "", "title": "Paediatric formulations of artemisinin‐based combination therapies for treating uncomplicated malaria in children", "imported": false, "abstract": "Abstract - Background In endemic malarial areas, young children have high levels of malaria morbidity and mortality. The World Health Organization recommends oral artemisinin‐based combination therapy (ACT) for treating uncomplicated malaria. Paediatric formulations of ACT have been developed to make it easier to treat children. Objectives To evaluate evidence from trials on the efficacy, safety, tolerability, and acceptability of paediatric ACT formulations compared to tablet ACT formulations for uncomplicated P falciparum malaria in children up to 14 years old. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; the Latin American and Caribbean Health Science Information database (LILACS); ISI Web of Science; Google Scholar; Scopus; and the metaRegister of Controlled Trials (mRCT) to 11 December 2019. Selection criteria We included randomised controlled clinical trials (RCTs) of paediatric versus non‐paediatric formulated ACT in children aged 14 years or younger with acute uncomplicated malaria. Data collection and analysis Two authors independently assessed eligibility and risk of bias, and carried out data extraction. We analyzed the primary outcomes of efficacy, safety and tolerability of paediatric versus non‐paediatric ACT using risk ratios (RR) and 95% confidence intervals (CI). Secondary outcomes were: treatment failure on the last day of observation (day 42), fever clearance time, parasite clearance time, pharmacokinetics, and acceptability. Main results Three trials met the inclusion criteria. Two compared a paediatric dispersible tablet formulation against crushed tablets of artemether‐lumefantrine (AL) and dihydroartemisinin‐piperaquine (DHA‐PQ), and one trial assessed artemether‐lumefantrine formulated as powder for suspension compared with crushed tablets. The trials were carried out between 2006 and 2015 in sub‐Saharan Africa (Benin, Mali, Mozambique, Tanzania, Kenya, Democratic Republic of the Congo, Burkina Faso, and The Gambia). In all three trials, the paediatric and control ACT achieved polymerase chain reaction (PCR)‐adjusted treatment failure rates of < 10% on day 28 in the per‐protocol (PP) population. For the comparison of dispersible versus crushed tablets, the two trials did not detect a difference for treatment failure by day 28 (PCR‐adjusted PP population: RR 1.35, 95% CI 0.49 to 3.72; 1061 participants, 2 studies, low‐certainty evidence). Similarly, for the comparison of suspension versus crushed tablet ACT, we did not detect any difference in treatment failure at day 28 (PCR‐adjusted PP population: RR 1.64, 95% CI 0.55 to 4.87; 245 participants, 1 study). We did not detect any difference in serious adverse events for the comparison of dispersible versus crushed tablets (RR 1.05, 95% CI 0.38 to 2.88; 1197 participants, 2 studies, low‐certainty evidence), or for the comparison of suspension versus crushed tablet ACT (RR 0.74, 95% CI 0.17 to 3.26; 267 participants, 1 study). In the dispersible ACT arms, drug‐related adverse events occurred in 9% of children in the AL study and 34% of children in the DHA‐PQ study. In the control arms, drug‐related adverse events occurred in 12% of children in the AL study and in 42% of children in the DHA‐PQ study. Drug‐related adverse events were lower in the dispersible ACT arms (RR 0.78, 95% CI 0.62 to 0.99; 1197 participants, 2 studies, moderate‐certainty evidence). There was no detected difference in the rate of drug‐related adverse events for suspension ACT versus crushed tablet ACT (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study). Drug‐related vomiting appeared to be less common in the dispersible ACT arms (RR 0.75, 95% CI 0.56 to 1.01; 1197 participants, 2 studies, low‐certainty evidence) and in the suspension ACT arm (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study), but both analyses were underpowered. No study assessed acceptability. Authors' conclusions Trials did not demonstrate a difference in efficacy between paediatric dispersible or suspension ACT when compared with the respective crushed tablet ACT for treating uncomplicated P falciparum malaria in children. However, the evidence is of low to moderate certainty due to limited power. There appeared to be fewer drug‐related adverse events with dispersible ACT compared to crushed tablet ACT. None of the included studies assessed acceptability of paediatric ACT formulation. Plain language summary Treating uncomplicated malaria in children: do child‐friendly formulations of medicines work better than usual tablet formulations? What is the aim of this review? We wanted to find out about the potential benefits and harms of child‐friendly formulations of artemisinin‐based combination therapy (ACT) to treat uncomplicated malaria in children. We searched for studies that investigated the use of child‐friendly formulations of ACTs, compared with the usual ACT tablet formulations, to treat uncomplicated malaria in children aged under 14 years. We looked for randomized controlled studies, in which the treatments the children received were decided at random. This type of study usually gives the most reliable evidence about the effects of a treatment. We found three relevant studies of two child‐friendly formulations. Key messages Child‐friendly formulations of ACT probably work as well as crushed tablets to treat uncomplicated malaria in children, and probably cause fewer unwanted effects. What was studied in this review? Malaria is a tropical disease spread by mosquitoes infected with Plasmodium parasites. The most common, and most serious, type of malaria is caused by Plasmodium falciparum . This parasite causes high levels of illness and death, particularly in young children in regions where malaria is widespread. Malaria can be a mild illness, but is sometimes severe and life‐threatening if not treated soon enough or with the right medicines. Medicines based on artemisinin, a compound derived from a plant ( Artemisia annua ), are commonly taken by mouth (orally) to treat malaria in combination with other drugs. The World Health Organization recommends treating uncomplicated malaria with oral artemisinin‐based combination therapy (called ACT). Oral ACT tablets are often crushed to help make them easier for children to swallow. New formulations of oral ACTs have been developed especially for children, such as syrups, and granules, powders or tablets that can be dissolved in water, and which may be flavoured. What are the main results of this review? We found three relevant studies in 1306 children (aged 6 months to 11 years) with uncomplicated malaria. The studies were conducted in sub‐Saharan Africa between 2006 and 2015. All studies were funded by pharmaceutical companies that made child‐friendly formulations of the ACTs. The studies compared crushed ACT tablets to child‐friendly formulations of ACTs: these were dissolvable tablets of artemether‐lumefantrine or dihydroartemisinin‐piperaquine, or artemether‐lumefantrine syrup. We were interested in: · whether children remained cured of malaria after 28 days (measured by absence of Plasmodium parasites in the blood); and · whether the medicines caused any unwanted effects. None of the studies looked at how any of the medicine formulations were accepted by children. There may be little or no difference between the child‐friendly formulations of ACTs (dissolvable tablets or syrup) and the usual crushed tablets for how many children: · were successfully treated after 28 days; or · experienced serious unwanted effects. The crushed ACT tablets and the child‐friendly formulations successfully treated most cases of uncomplicated malaria. After 28 days the rates of treatment failure were similar in both groups. On average, 59 of every 1000 children taking crushed ACT tablets and 62 of every 1000 children taking dissolvable tablets would still have Plasmodium infection (2 studies; 1139 children). Similar numbers of serious unwanted effects were reported for the usual crushed tablets and the dissolvable tablets (2 studies; 1197 children) or syrup (1 study; 267 children), therefore differences as a result of the formulation are unlikely. A dissolvable tablet probably reduces unwanted effects of the medicine, including vomiting (throwing up), compared with the usual crushed tablets. Children taking dissolvable tablets had fewer unwanted effects associated with the medicine (139 of every 1000 children) than those taking crushed tablets (178 of every 1000 children). There was no difference in the number of unwanted effects found in the study with the syrup formulation compared with the usual crushed tablets. Our confidence in our results is low to moderate. The results come from a small number of studies. All studies were supported by manufacturers of the child‐friendly formulations, which could have affected how the studies were designed, conducted, and reported. How up‐to‐date is this review? We searched for studies that had been published up to 11 December 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bélard, S, Ramharter, M, Kurth, F", "articleTypes": [], "doi": "10.1002/14651858.CD009568.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.760Z" }, { "id": "6795e516-d964-4c7e-a82b-f8e2c6bdfd98", "pmid": "", "title": "Melatonin and agomelatine for preventing seasonal affective disorder", "imported": false, "abstract": "Abstract - Background Seasonal affective disorder (SAD) is a seasonal pattern of recurrent major depressive episodes that most commonly starts in autumn or winter and remits in spring. The prevalence of SAD depends on latitude and ranges from 1.5% to 9%. The predictable seasonal aspect of SAD provides a promising opportunity for prevention in people who have a history of SAD. This is one of four reviews on the efficacy and safety of interventions to prevent SAD; we focus on agomelatine and melatonin as preventive interventions. Objectives To assess the efficacy and safety of agomelatine and melatonin (in comparison with each other, placebo, second‐generation antidepressants, light therapy, psychological therapy or lifestyle interventions) in preventing SAD and improving person‐centred outcomes among adults with a history of SAD. Search methods We searched Ovid MEDLINE (1950‐ ), Embase (1974‐ ), PsycINFO (1967‐ ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 19 June 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD‐CTR) (all years to 11 August 2015). Furthermore, we searched the Cumulative Index to Nursing and Allied Health Literature, Web of Science, the Cochrane Library , the Allied and Complementary Medicine Database and international trial registers (to 19 June 2018). We also conducted a grey literature search and handsearched the reference lists of included studies and pertinent review articles. Selection criteria To examine efficacy, we included randomised controlled trials (RCTs) on adults with a history of winter‐type SAD who were free of symptoms at the beginning of the study. For adverse events, we intended also to include non‐randomised studies. We planned to include studies that compared agomelatine versus melatonin, or agomelatine or melatonin versus placebo, any second‐generation antidepressant, light therapy, psychological therapies or lifestyle changes. We also intended to compare melatonin or agomelatine in combination with any of the comparator interventions mentioned above versus the same comparator intervention as monotherapy. Data collection and analysis Two review authors screened abstracts and full‐text publications, abstracted data and assessed risk of bias of included studies independently. We intended to pool data in a meta‐analysis using a random‐effects model, but included only one study. Main results We identified 3745 citations through electronic searches and reviews of reference lists after deduplication of search results. We excluded 3619 records during title and abstract review and assessed 126 full‐text papers for inclusion in the review. Only one study, providing data of 225 participants, met our eligibility criteria and compared agomelatine (25 mg/day) with placebo. We rated it as having high risk of attrition bias because nearly half of the participants left the study before completion. We rated the certainty of the evidence as very low for all outcomes, because of high risk of bias, indirectness, and imprecision. The main analysis based on data of 199 participants rendered an indeterminate result with wide confidence intervals (CIs) that may encompass both a relevant reduction as well as a relevant increase of SAD incidence by agomelatine (risk ratio (RR) 0.83, 95% CI 0.51 to 1.34; 199 participants; very low‐certainty evidence). Also the severity of SAD may be similar in both groups at the end of the study with a mean SIGH‐SAD (Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders) score of 8.3 (standard deviation (SD) 9.4) in the agomelatine group and 10.1 (SD 10.6) in the placebo group (mean difference (MD) ‐1.80, 95% CI ‐4.58 to 0.98; 199 participants; very low‐certainty evidence). The incidence of adverse events and serious adverse events may be similar in both groups. In the agomelatine group, 64 out of 112 participants experienced at least one adverse event, while 61 out of 113 did in the placebo group (RR 1.06, 95% CI 0.84 to 1.34; 225 participants; very low‐certainty evidence). Three out of 112 patients experienced serious adverse events in the agomelatine group, compared to 4 out of 113 in the placebo group (RR 0.76, 95% CI 0.17 to 3.30; 225 participants; very low‐certainty evidence). No data on quality of life or interpersonal functioning were reported. We did not identify any studies on melatonin. Authors' conclusions Given the uncertain evidence on agomelatine and the absence of studies on melatonin, no conclusion about efficacy and safety of agomelatine and melatonin for prevention of SAD can currently be drawn. The decision for or against initiating preventive treatment of SAD and the treatment selected should consider patient preferences and reflect on the evidence base of all available treatment options. Plain language summary Melatonin and agomelatine for prevention of winter depression Why is this review important? Many people in northern latitudes suffer from seasonal affective disorder (SAD), which occurs as a reaction to reduced sunlight. Three‐quarters of those affected are women. Lethargy, overeating, craving for carbohydrates and depressed mood are common symptoms. In some people, SAD becomes depression that seriously affects their daily lives. Up to two‐thirds experience depressive symptoms every winter. Who might be interested in this review? General practitioners, psychiatrists, pharmacists, other health professionals working in adult mental health services, and researchers could be interested in the results of this review. Anyone who has experienced winter depression, or who has friends or relatives who have experienced winter depression might also be interested. What questions does this review aim to answer? Because of the seasonal pattern and high recurrence of SAD, melatonin or agomelatine could be used to prevent the onset of depressed mood. The goal of this report is to examine whether benefits outweigh harms of melatonin or agomelatine when used to prevent onset of a new depressive episode in people with a history of SAD who were free of symptoms when the preventive intervention started. To date, this question has not been examined in a systematic way. This is one of four reviews on the efficacy and potential harms of interventions to prevent SAD. Which studies were included in the review? We searched databases up to June 2018 for studies on melatonin or agomelatine for prevention of winter depression. Among 3745 records, we found one randomised controlled study comparing agomelatine with placebo for one year. All 225 participants had a history of winter depression but were not depressed when the prevention study started. What does evidence from the review reveal? The included study showed neither a clear effect in favour nor against agomelatine as a preventive treatment. In addition, the certainty of evidence for all outcomes was very low, making it impossible to draw any conclusions about the efficacy and safety of agomelatine for the prevention of winter depression. No evidence on melatonin for prevention of SAD was identified. Doctors need to discuss with persons with a history of SAD that currently evidence on agomelatine or melatonin for preventive treatment options for SAD is inconclusive, therefore treatment selection should be strongly based on peoples' preferences and reflect on the evidence base of all available treatment options. What should happen next? Review authors recommend that future studies should evaluate the efficacy of agomelatine or melatonin in preventing SAD and should directly compare these interventions against other treatment options, such as light therapy, antidepressants, or psychological therapies to determine the best treatment option for prevention of SAD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nussbaumer‐Streit, B, Greenblatt, A, Kaminski‐Hartenthaler, A, Van Noord, MG, Forneris, CA, Morgan, LC, Gaynes, BN, Wipplinger, J, Lux, LJ, Winkler, D, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011271.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.076Z" }, { "id": "67989b22-f0da-4911-b47b-6e9474b63655", "pmid": "", "title": "Omega‐3 fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids from oily fish (long‐chain omega‐3 (LCn3)), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha‐linolenic acid (ALA)) may benefit cardiovascular health. Guidelines recommend increasing omega‐3‐rich foods, and sometimes supplementation, but recent trials have not confirmed this. Objectives To assess the effects of increased intake of fish‐ and plant‐based omega‐3 fats for all‐cause mortality, cardiovascular events, adiposity and lipids. Search methods We searched CENTRAL, MEDLINE and Embase to February 2019, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to August 2019, with no language restrictions. We handsearched systematic review references and bibliographies and contacted trial authors. Selection criteria We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation or advice to increase LCn3 or ALA intake, or both, versus usual or lower intake. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed validity. We performed separate random‐effects meta‐analysis for ALA and LCn3 interventions, and assessed dose‐response relationships through meta‐regression. Main results We included 86 RCTs (162,796 participants) in this review update and found that 28 were at low summary risk of bias. Trials were of 12 to 88 months' duration and included adults at varying cardiovascular risk, mainly in high‐income countries. Most trials assessed LCn3 supplementation with capsules, but some used LCn3‐ or ALA‐rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5 g a day to more than 5 g a day (19 RCTs gave at least 3 g LCn3 daily). Meta‐analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all‐cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.93 to 1.01; 143,693 participants; 11,297 deaths in 45 RCTs; high‐certainty evidence), cardiovascular mortality (RR 0.92, 95% CI 0.86 to 0.99; 117,837 participants; 5658 deaths in 29 RCTs; moderate‐certainty evidence), cardiovascular events (RR 0.96, 95% CI 0.92 to 1.01; 140,482 participants; 17,619 people experienced events in 43 RCTs; high‐certainty evidence), stroke (RR 1.02, 95% CI 0.94 to 1.12; 138,888 participants; 2850 strokes in 31 RCTs; moderate‐certainty evidence) or arrhythmia (RR 0.99, 95% CI 0.92 to 1.06; 77,990 participants; 4586 people experienced arrhythmia in 30 RCTs; low‐certainty evidence). Increasing LCn3 may slightly reduce coronary heart disease mortality (number needed to treat for an additional beneficial outcome (NNTB) 334 , RR 0.90, 95% CI 0.81 to 1.00; 127,378 participants; 3598 coronary heart disease deaths in 24 RCTs, low‐certainty evidence) and coronary heart disease events ( NNTB 167 , RR 0.91, 95% CI 0.85 to 0.97; 134,116 participants; 8791 people experienced coronary heart disease events in 32 RCTs, low‐certainty evidence). Overall, effects did not differ by trial duration or LCn3 dose in pre‐planned subgrouping or meta‐regression. There is little evidence of effects of eating fish. Increasing ALA intake probably makes little or no difference to all‐cause mortality (RR 1.01, 95% CI 0.84 to 1.20; 19,327 participants; 459 deaths in 5 RCTs, moderate‐certainty evidence), cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25; 18,619 participants; 219 cardiovascular deaths in 4 RCTs; moderate‐certainty evidence), coronary heart disease mortality (RR 0.95, 95% CI 0.72 to 1.26; 18,353 participants; 193 coronary heart disease deaths in 3 RCTs; moderate‐certainty evidence) and coronary heart disease events (RR 1.00, 95% CI 0.82 to 1.22; 19,061 participants; 397 coronary heart disease events in 4 RCTs; low‐certainty evidence). However, increased ALA may slightly reduce risk of cardiovascular disease events ( NNTB 500 , RR 0.95, 95% CI 0.83 to 1.07; but RR 0.91, 95% CI 0.79 to 1.04 in RCTs at low summary risk of bias; 19,327 participants; 884 cardiovascular disease events in 5 RCTs; low‐certainty evidence), and probably slightly reduces risk of arrhythmia ( NNTB 91 , RR 0.73, 95% CI 0.55 to 0.97; 4912 participants; 173 events in 2 RCTs; moderate‐certainty evidence). Effects on stroke are unclear . Increasing LCn3 and ALA had little or no effect on serious adverse events, adiposity, lipids and blood pressure, except increasing LCn3 reduced triglycerides by ˜15% in a dose‐dependent way (high‐certainty evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐3 fats on cardiovascular health to date. Moderate‐ and low‐certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials). Increasing ALA slightly reduces risk of cardiovascular events and arrhythmia. Plain language summary Omega‐3 intake for cardiovascular disease Review question We reviewed randomised trials (where participants have an equal chance of being assigned to either treatment) examining effects of increasing fish‐ and plant‐based omega‐3 fats on heart and circulatory disease (called cardiovascular diseases, which include heart attacks and stroke), fatness and blood fats (lipids, including cholesterol, triglycerides, high‐density lipoprotein (HDL – 'good' cholesterol) and low‐density lipoprotein (LDL – 'bad' cholesterol)). Background The main types of omega‐3 fats are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), both found in fish, and alpha‐linolenic acid (ALA) found in plant foods. Many people believe that taking omega‐3 supplements reduces risk of heart disease, stroke and death. Trial characteristics The evidence is current to February 2019. The review included 86 trials involving 162,796 people. These trials assessed effects of greater omega‐3 intake versus lower omega‐3 intake for at least a year on heart and circulatory disease. Twenty‐eight trials were very trustworthy (well‐designed so as not to give biased results). Participants were adults, some with existing illness and some healthy, living in North America, Europe, Australia and Asia. Most EPA and DHA trials provided capsules, few gave oily fish. Key results Increasing EPA and DHA has little or no effect on deaths and cardiovascular events (high‐certainty evidence) and probably makes little or no difference to cardiovascular death, stroke, or heart irregularities (moderate‐certainty evidence). However, increasing EPA and DHA may slightly reduce risk of coronary death and coronary events (low‐certainty evidence, coronary events are illnesses of arteries supplying the heart). To prevent one person having a coronary event, 167 people would need to increase their EPA and DHA, and 334 people would need to increase their EPA and DHA to prevent one person dying from coronary disease. EPA and DHA reduce triglycerides by about 15% but do not affect fatness or other lipids (high‐certainty evidence). Eating more ALA (for example, by increasing walnuts or enriched margarine) probably makes little or no difference to all‐cause, cardiovascular or coronary deaths or coronary events but probably slightly reduces cardiovascular events and heart irregularities (moderate‐ or low‐certainty evidence). To prevent one person having a coronary event, 500 people would need to increase their ALA, 91 people to prevent one person having arrhythmia. There is little evidence of effects of eating fish. EPA and DHA reduce triglycerides. EPA, DHA and ALA may be slightly protective of some heart and circulatory diseases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Abdelhamid, AS, Brown, TJ, Brainard, JS, Biswas, P, Thorpe, GC, Moore, HJ, Deane, KHO, Summerbell, CD, Worthington, HV, Song, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD003177.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.826Z" }, { "id": "67a6674a-827a-46d9-a2bb-e029d439d0e0", "pmid": "", "title": "Lactoferrin for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "Abstract - Background Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be due in part to disruption of the integrity of the gut and its altered intestinal microflora. Lactoferrin is a whey protein found in milk and is an important innate mammalian defence mechanism. Lactoferrin has been reported to have antimicrobial and anti‐inflammatory properties. It has also been reported to help establish a healthy gut microflora and aid in the intestinal immune system. Lactoferrin supplementation has been reported to decrease sepsis in preterm infants. There may be a role for lactoferrin to reduce the incidence of sepsis, thus reducing morbidity and mortality and improving enteral feeding in postoperative term neonates. Objectives The primary objective of this review was to evaluate the efficacy of administering lactoferrin on the incidence of sepsis and mortality in term neonates after gastrointestinal surgery. The secondary objective was to assess the impact of administering lactoferrin on time to full enteral feeds, the intestinal microflora, duration of hospital stay, and mortality before discharge in the same population. Search methods The Cochrane Neonatal Information Specialist searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase Ovid, CINAHL, the WHO ICTRP and ClinicalTrials.gov trials registries. The date of the last search was February 2023. There were no restrictions to language, publication year or publication type. We checked references of potentially relevant studies and systematic reviews. Selection criteria We planned to include randomised controlled trials that studied infants born at 37 or more weeks of gestation who had one or more episodes of gastrointestinal surgery within 28 days of birth, and compared administration of lactoferrin with a placebo. Data collection and analysis We used standard Cochrane methodological procedures. We planned to use the GRADE approach to assess the certainty of evidence for each outcome. Main results We identified no published randomised controlled studies that assessed the efficacy of lactoferrin for the postoperative management of term neonates following gastrointestinal surgery. Authors' conclusions There is currently no evidence available from randomised controlled trials to show whether lactoferrin is effective or ineffective for the postoperative management of term neonates after gastrointestinal surgery. There is a need for randomised controlled trials to be performed to assess the role of lactoferrin in this setting. Plain language summary What are the benefits and risks of giving lactoferrin to full‐term babies who had digestive tract surgery? Key message We found no medical studies that investigated the effects of giving lactoferrin (a protein found in milk) to babies born at full‐term (at or after 37 weeks of pregnancy) who had surgery of their digestive tract. What is lactoferrin? Lactoferrin is a protein found in milk that can protect against infection. Lactoferrin supplements are available and have been researched in premature babies. There is some evidence that lactoferrin can prevent infection in premature babies. What are some of the risks of digestive tract surgery in babies? Surgery of the digestive tract increases the risk of infection. Infections can increase the length of stay in hospital. Treatment with antibiotics (medicines that fight bacterial infections) and stress from surgery can disrupt good bacteria in the digestive tract. What did we want to find out? We wanted to find out if giving lactoferrin to full‐term babies, after digestive tract surgery, decreased rates of infection and death, and improved the presence of good bacteria in the digestive tract. What did we do? We searched for studies in which babies who had digestive tract surgery were assigned randomly to lactoferrin or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested). What did we find? We did not find any studies that compared giving lactoferrin to a placebo in full‐term babies who had digestive tract surgery. Well‐designed and large studies are needed to answer this question. How up to date is this evidence? The search is up‐to‐date as of February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Trivedi, A; Maheshwari, R; Tarnow-Mordi, WO; Saxena, N", "articleTypes": [], "doi": "10.1002/14651858.CD012218.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "67c272cb-dfb1-4082-bd4d-275b8bd65f7f", "pmid": "", "title": "Drugs for the acute treatment of migraine in children and adolescents", "imported": false, "abstract": "Abstract - Background Numerous medications are available for the acute treatment of migraine in adults, and some have now been approved for use in children and adolescents in the ambulatory setting. A systematic review of acute treatment of migraine medication trials in children and adolescents will help clinicians make evidence‐informed management choices. Objectives To assess the effects of pharmacological interventions by any route of administration versus placebo for migraine in children and adolescents 17 years of age or less. For the purposes of this review, children were defined as under 12 years of age and adolescents 12 to 17 years of age. Search methods We searched seven bibliographic databases and four clinical trial registers as well as gray literature for studies through February 2016. Selection criteria We included prospective randomized controlled clinical trials of children and adolescents with migraine, comparing acute symptom relieving migraine medications with placebo in the ambulatory setting. Data collection and analysis Two reviewers screened titles and abstracts and reviewed the full text of potentially eligible studies. Two independent reviewers extracted data for studies meeting inclusion criteria. We calculated the risk ratios (RRs) and number needed to treat for an additional beneficial outcome (NNTB) for dichotomous data. We calculated the risk difference (RD) and number needed to treat for an additional harmful outcome (NNTH) for proportions of adverse events. The percentage of pain‐free patients at two hours was the primary efficacy outcome measure. We used adverse events to evaluate safety and tolerability. Secondary outcome measures included headache relief, use of rescue medication, headache recurrence, presence of nausea, and presence of vomiting. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables. Main results We identified a total of 27 randomized controlled trials (RCTs) of migraine symptom‐relieving medications, in which 9158 children and adolescents were enrolled and 7630 (range of mean age between 8.2 and 14.7 years) received medication. Twenty‐four studies focused on drugs in the triptan class, including almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, sumatriptan + naproxen sodium, and zolmitriptan. Other medications studied included paracetamol (acetaminophen), ibuprofen, and dihydroergotamine (DHE). More than half of the studies evaluated sumatriptan. All but one study reported adverse event data. Most studies presented a low or unclear risk of bias, and the overall quality of evidence, according to GRADE criteria, was low to moderate, downgraded mostly due to imprecision and inconsistency. Ibuprofen was more effective than placebo for producing pain freedom at two hours in two small studies that included 162 children (RR 1.87, 95% confidence interval (CI) 1.15 to 3.04) with low quality evidence (due to imprecision). Paracetamol was not superior to placebo in one small study of 80 children. Triptans as a class of medication were superior to placebo in producing pain freedom in 3 studies involving 273 children (RR 1.67, 95% CI 1.06 to 2.62, NNTB 13) (moderate quality evidence) and 21 studies involving 7026 adolescents (RR 1.32, 95% CI 1.19 to 1.47, NNTB 6) (moderate quality evidence). There was no significant difference in the effect sizes between studies involving children versus adolescents. Triptans were associated with an increased risk of minor (non‐serious) adverse events in adolescents (RD 0.13, 95% CI 0.08 to 0.18, NNTH 8), but studies did not report any serious adverse events. The risk of minor adverse events was not significant in children (RD 0.06, 95% CI − 0.04 to 0.17, NNTH 17). Sumatriptan plus naproxen sodium was superior to placebo in one study involving 490 adolescents (RR 3.25, 95% CI 1.78 to 5.94, NNTB 6) (moderate quality evidence). Oral dihydroergotamine was not superior to placebo in one small study involving 13 children. Authors' conclusions Low quality evidence from two small trials shows that ibuprofen appears to improve pain freedom for the acute treatment of children with migraine. We have only limited information on adverse events associated with ibuprofen in the trials included in this review. Triptans as a class are also effective at providing pain freedom in children and adolescents but are associated with higher rates of minor adverse events. Sumatriptan plus naproxen sodium is also effective in treating adolescents with migraine. Plain language summary Drugs for the acute treatment of migraine in children and adolescents Background and review question Migraine is a painful and debilitating disorder that is common in children (under 12 years of age) and adolescents (12 to 17 years of age). Common symptoms reported during a migraine attack are headache, nausea, vomiting, and sensitivity to light and sound. Many treatments for migraine are available, of which the most common are paracetamol (also known as acetaminophen), ibuprofen and other anti‐inflammatories, and triptans. Not all triptan medications are approved for use in children or adolescents, and approvals vary from country to country. Study characteristics In our review, we looked at 27 randomized controlled trials of drugs compared to placebo to find out which treatments were effective at providing pain freedom two hours after treatment. We also wanted to know what side effects might be caused by the treatments. A total of 7630 children received medication in the studies. The evidence is current to February 2016. Each study had between 13 and 888 participants. Their average age was 12.9 years and ranged from 8.2 to 14.7 years. Nineteen of the studies were funded by the drug manufacturer. Key results Ibuprofen appears to be effective in treating children with migraine, but the evidence is limited to only two small trials. Ibuprofen is readily available and inexpensive, making it an excellent first choice for migraine treatment. Paracetamol was not shown to be effective in providing pain freedom in children, but we only found one small study. Triptans are a type of medication designed specifically to treat migraine and are often effective at providing greater pain freedom in children and adolescents. The triptans examined in children included rizatriptan and sumatriptan, while almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan were examined in adolescents. The combination of sumatriptan plus naproxen sodium is also effective at treating adolescents with migraine. Overall, there is a risk that the triptan medications may cause minor unwanted side effects like taste disturbance, nasal symptoms, dizziness, fatigue, low energy, nausea, or vomiting. The studies did not report any serious side effects. Quality of the evidence The overall quality of the evidence provided by the review was moderate for the triptans, but low for paracetamol and ibuprofen, as we only identified a few studies. More studies need to look at the effects of each of the migraine treatments in children and adolescents separately.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Richer, L; Billinghurst, L; Linsdell, MA; Russell, K; Vandermeer, B; Crumley, ET; Durec, T; Klassen, TP; Hartling, L", "articleTypes": [], "doi": "10.1002/14651858.CD005220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "67c2b25b-c355-4a8f-a6bd-cba40e57b327", "pmid": "", "title": "Adhesives for bonded molar tubes during fixed brace treatment", "imported": false, "abstract": "Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. The success of a fixed appliance depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a fixed appliance. It can also be costly in terms of clinical time, materials and time lost from education/work for the patient. This is an update of the Cochrane review first published in 2011. A new full search was conducted on 15 February 2017 but no new studies were identified. We have only updated the search methods section in this new version. The conclusions of this Cochrane review remain the same. Objectives To evaluate the effectiveness of the adhesives used to attach bonded molar tubes, and the relative effectiveness of the adhesives used to attach bonded molar tubes versus adhesives used to attach bands, during fixed appliance treatment, in terms of: (1) how often the tubes (or bands) come off during treatment; and (2) whether they protect the bonded (or banded) teeth against decay. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (to 15 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library (searched 15 February 2017), MEDLINE Ovid (1946 to 15 February 2017), and Embase Ovid (1980 to 15 February 2017). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials of participants with full arch fixed orthodontic appliance(s) with molar tubes, bonded to first or second permanent molars. Trials which compared any type of adhesive used to bond molar tubes (stainless steel or titanium) with any other adhesive, were included. Trials were also included where: (1) a tube was bonded to a molar tooth on one side of an arch and a band cemented to the same tooth type on the opposite side of the same arch;
 (2) molar tubes had been allocated to one tooth type in one patient group and molar bands to the same tooth type in another patient group. Data collection and analysis The selection of papers, decision about eligibility and data extraction were carried out independently and in duplicate without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Two trials (n = 190), at low risk of bias, were included in the review and both presented data on first time failure at the tooth level. Pooling of the data showed a statistically significant difference in favour of molar bands, with a hazard ratio of 2.92 (95% confidence intervals (CI) 1.80 to 4.72). No statistically significant heterogeneity was shown between the two studies. Data on first time failure at the patient level were also available and showed statistically different difference in favour of molar bands (risk ratio 2.30; 95% CI 1.56 to 3.41) (risk of event for molar tubes = 57%; risk of event for molar bands 25%). One trial presented data on decalcification again showing a statistically significant difference in favour of molar bands. No other adverse events identified. Authors' conclusions From the two well‐designed and low risk of bias trials included in this review it was shown that the failure of molar tubes bonded with either a chemically‐cured or light‐cured adhesive was considerably higher than that of molar bands cemented with glass ionomer cement. One trial indicated that there was less decalcification with molar bands cemented with glass ionomer cement than with bonded molar tubes cemented with a light‐cured adhesive. However, given there are limited data for this outcome, further evidence is required to draw more robust conclusions. Plain language summary Adhesives for bonded molar tubes during fixed brace treatment Background Orthodontic treatment involves using fixed or removable dental braces to correct the positions of teeth. The success of dental braces depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a dental brace. Study characteristics The evidence in this review, which was carried out together with Cochrane Oral Health, is up‐to‐date as of 15 February 2017. We included two studies that evaluated 190 participants. Both trials were conducted in the UK and both compared bonded molar tubes with molar bands. Key results From the limited data of two studies at low risk of bias, it would appear that bonded molar tubes are associated with a higher failure rate than with molar bands.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Millett, DT; Mandall, NA; Mattick, RCR; Hickman, J; Glenny, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008236.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "6828da25-c052-43d6-95cd-44895f9a8bdc", "pmid": "", "title": "Oral treatments for fungal infections of the skin of the foot", "imported": false, "abstract": "Abstract - Background About 15% of the world population have fungal infections of the feet (tinea pedis or athlete's foot). There are many clinical presentations of tinea pedis, and most commonly, tinea pedis is seen between the toes (interdigital) and on the soles, heels, and sides of the foot (plantar). Plantar tinea pedis is known as moccasin foot. Once acquired, the infection can spread to other sites including the nails, which can be a source of re‐infection. Oral therapy is usually used for chronic conditions or when topical treatment has failed. Objectives To assess the effects of oral treatments for fungal infections of the skin of the foot (tinea pedis). Search methods For this update we searched the following databases to July 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library , MEDLINE (from 1946), EMBASE (from 1974), and CINAHL (from 1981). We checked the bibliographies of retrieved trials for further references to relevant trials, and we searched online trials registers. Selection criteria Randomised controlled trials of oral treatments in participants who have a clinically diagnosed tinea pedis, confirmed by microscopy and growth of dermatophytes (fungi) in culture. Data collection and analysis Two review authors independently undertook study selection, 'Risk of bias' assessment, and data extraction. Main results We included 15 trials, involving 1438 participants. The 2 trials (71 participants) comparing terbinafine and griseofulvin produced a pooled risk ratio (RR) of 2.26 (95% confidence interval (CI) 1.49 to 3.44) in favour of terbinafine's ability to cure infection. No significant difference was detected between terbinafine and itraconazole, fluconazole and itraconazole, fluconazole and ketoconazole, or between griseofulvin and ketoconazole, although the trials were generally small. Two trials showed that terbinafine and itraconazole were effective compared with placebo: terbinafine (31 participants, RR 24.54, 95% CI 1.57 to 384.32) and itraconazole (72 participants, RR 6.67, 95% CI 2.17 to 20.48). All drugs reported adverse effects, with gastrointestinal effects most commonly reported. Ten of the trials were published over 15 years ago, and this is reflected by the poor reporting of information from which to make a clear 'Risk of bias' assessment. Only one trial was at low risk of bias overall. The majority of the remaining trials were judged as 'unclear' risk of bias because of the lack of clear statements with respect to methods of generating the randomisation sequence and allocation concealment. More trials achieved blinding of participants and personnel than blinding of the outcome assessors, which was again poorly reported. Authors' conclusions The evidence suggests that terbinafine is more effective than griseofulvin, and terbinafine and itraconazole are more effective than no treatment. In order to produce more reliable data, a rigorous evaluation of different drug therapies needs to be undertaken with larger sample sizes to ensure they are large enough to show any real difference when two treatments are being compared. It is also important to continue to follow up and collect data, preferably for six months after the end of the intervention period, to establish whether or not the infection recurred. Plain language summary Oral antifungal drugs for treating athlete's foot (tinea pedis) Athlete's foot (tinea pedis) is a fungal infection of the feet that is easily spread and difficult to get rid of. This review compared different oral antifungal drugs (i.e. drugs taken by mouth), and it included 15 trials, involving 1438 participants. There are several different kinds of oral treatments, and the trials we found considered all the oral drugs used to treat athlete's foot. We found terbinafine and itraconazole to be more effective than placebo. And we found terbinafine to be more effective than griseofulvin. Griseofulvin is a treatment that was developed much earlier than the new treatments, such as terbinafine and itraconazole; these newer treatments tend to be most evaluated. Trials of other drugs were not large enough to show differences between them. All drugs had side‐effects; gastrointestinal effects were the most common. In future clinical trials, larger numbers of participants are needed to test different treatments in order to produce more reliable data. Also, future research should consider the costs of the different treatment approaches.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Bell‐Syer, SEM; Khan, SM; Torgerson, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD003584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "68312a0d-8d9a-46c5-9977-0350c3d26d77", "pmid": "", "title": "Environmental interventions to reduce the consumption of sugar‐sweetened beverages and their effects on health", "imported": false, "abstract": "Abstract - Background Frequent consumption of excess amounts of sugar‐sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB. Objectives To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar‐sweetened beverages and sugar‐sweetened milk, diet‐related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes. Search methods We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors. Selection criteria We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet‐related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) and interrupted‐time‐series (ITS) studies, implemented in real‐world settings with a combined length of intervention and follow‐up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB‐specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review. Data collection and analysis Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta‐analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented ‘Summary of findings’ tables. Main results We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow‐up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non‐randomised designs. The studies examine a broad range of interventions, and we present results for these separately. Labelling interventions (8 studies): We found moderate‐certainty evidence that traffic‐light labelling is associated with decreasing sales of SSBs, and low‐certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu‐board calorie labelling reported effects on SSB sales varied. Nutrition standards in public institutions (16 studies): We found low‐certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low‐certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied. Economic tools (7 studies): We found moderate‐certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low‐calorie beverages reported effects on SSB sales varied. Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied. Retail and food service interventions (7 studies): We found low‐certainty evidence that healthier default beverages in children’s menus in chain restaurants are associated with decreasing SSB sales, and moderate‐certainty evidence that in‐store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low‐certainty evidence that urban planning restrictions on new fast‐food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied. Intersectoral approaches (8 studies): We found moderate‐certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate‐certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied. Home‐based interventions (7 studies): We found moderate‐certainty evidence that improved availability of low‐calorie beverages in the home environment is associated with decreased SSB intake, and high‐certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs. Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low‐calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes. We analysed interventions targeting sugar‐sweetened milk separately, and found low‐ to moderate‐certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar‐sweetened milk. We found low‐certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar‐sweetened milk consumption. Authors' conclusions The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high‐quality evaluations using appropriate study designs, with a particular focus on the long‐term effects of approaches suitable for large‐scale implementation. Plain language summary Cutting back on sugar‐sweetened beverages: What works? What are sugar‐sweetened beverages? Sugar‐sweetened beverages (SSBs) are cold and hot drinks with added sugar. Common SSBs are non‐diet soft drinks, regular soda, iced tea, sports drinks, energy drinks, fruit punches, sweetened waters, and sweetened tea and coffee. Why are SSBs an important health topic? Research shows that people who drink a lot of SSBs often gain weight. Drinking a lot of SSBs can also increase the risk of diabetes, heart disease, and dental decay. Doctors therefore recommend that children, teenagers and adults drink fewer SSBs. Governments, businesses, schools and workplaces have taken various measures to support healthier beverage choices. What is the aim of this review? We wanted to find out whether the measures taken so far have been successful in helping people to drink fewer SSBs to improve their health. We focused on measures that change the environment in which people make beverage choices. We did not look at studies on educational programmes or on SSB taxes, as these are examined in separate reviews. (We did, however, examine price increases on SSB which were not due to taxes.) We searched for all available studies meeting clearly‐defined criteria to answer this question. This review reflects the state of the evidence up until January 2018. What studies did we find? We found 58 studies, which included more than one million adults, teenagers and children. Most studies lasted about one year, and were done in schools, stores or restaurants. Some studies used methods that are not very reliable. For example, in some studies participants were simply asked how much SSB they drank, which is not very reliable, as people sometimes forget how much SSB they drank. Some of the findings of our review may therefore change when more and better studies become available. What do these studies tell us? We have found some evidence that some of the measures implemented to help people drink fewer SSBs have been successful, including the following: ▪ Labels which are easy to understand, such as traffic‐light labels, and labels which rate the healthfulness of beverages with stars or numbers. ▪ Limits to the availability of SSB in schools (e.g. replacing SSBs with water in school cafeterias). ▪ Price increases on SSBs in restaurants, stores and leisure centres. ▪ Children’s menus in chain restaurants which include healthier beverages as their standard beverage. ▪ Promotion of healthier beverages in supermarkets. ▪ Government food benefits (e.g. food stamps) which cannot be used to buy SSBs. ▪ Community campaigns focused on SSBs. ▪ Measures that improve the availability of low‐calorie beverages at home, e.g. through home deliveries of bottled water and diet beverages. We have also found some evidence that improved availability of drinking water and diet beverages at home can help people lose weight. There are also other measures which may influence how much SSB people drink, but for these the available evidence is less certain. Some, but not all studies found that such measures can have effects which were not intended and which may be negative. Some studies reported that profits of stores and restaurants decreased when the measures were implemented, but other studies showed that profits increased or stayed the same. Children who get free drinking water in schools may drink less milk. Some studies reported that people were unhappy with the measures. We also looked at studies on sugar‐sweetened milk. We found that small prizes for children who chose plain milk in their school cafeteria, as well as emoticon labels, may help children drink less sugar‐sweetened milk. However, this may also drive up the share of milk which is wasted because children choose but do not drink it. What does this mean in practice? Our review shows that measures which change the environment in which people make beverage choices can help people drink less SSB. Based on our findings we suggest that such measures may be used more widely. Government officials, business people and health professionals implementing such measures should work together with researchers to find out more about their effects in the short and long term.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "von Philipsborn, P; Stratil, JM; Burns, J; Busert, LK; Pfadenhauer, LM; Polus, S; Holzapfel, C; Hauner, H; Rehfuess, E", "articleTypes": [], "doi": "10.1002/14651858.CD012292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "6831e5d1-6c6d-4d83-9493-04ea43a6e183", "pmid": "", "title": "Environmental and behavioural modifications for improving food and fluid intake in people with dementia", "imported": false, "abstract": "Abstract - Background Weight loss, malnutrition and dehydration are common problems for people with dementia. Environmental modifications such as, change of routine, context or ambience at mealtimes, or behavioural modifications, such as education or training of people with dementia or caregivers, may be considered to try to improve food and fluid intake and nutritional status of people with dementia. Objectives Primary: To assess the effects of environmental or behavioural modifications on food and fluid intake and nutritional status in people with dementia. Secondary: To assess the effects of environmental or behavioural modifications in connection with nutrition on mealtime behaviour, cognitive and functional outcomes and quality of life, in specific settings (i.e. home care, residential care and nursing home care) for different stages of dementia. To assess the adverse consequences or effects of the included interventions. Search methods We searched the Specialized Register of Cochrane Dementia and Cognitive Improvement (ALOIS), MEDLINE, Eembase, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 17 January 2018. We scanned reference lists of other reviews and of included articles. Selection criteria We included randomised controlled trials (RCTs) investigating interventions designed to modify the mealtime environment of people with dementia, to modify the mealtime behaviour of people with dementia or their caregivers, or both, with the intention of improving food and fluid intake. We included people with any common dementia subtype. Data collection and analysis Two review authors independently selected studies, extracted data and assessed the risk of bias of included trials. We assessed the quality of evidence for each outcome using the GRADE approach. Main results We included nine studies, investigating 1502 people. Three studies explicitly investigated participants with Alzheimer's disease; six did not specify the type of dementia. Five studies provided clear measures to identify the severity of dementia at baseline, and overall very mild to severe stages were covered. The interventions and outcome measures were diverse. The overall quality of evidence was mainly low to very low. One study implemented environmental as well as behavioural modifications by providing additional food items between meals and personal encouragement to consume them. The control group received no intervention. Differences between groups were very small and the quality of the evidence from this study was very low, so we are very uncertain of any effect of this intervention. The remaining eight studies implemented behavioural modifications. Three studies provided nutritional education and nutrition promotion programmes. Control groups did not receive these programmes. After 12 months, the intervention group showed slightly higher protein intake per day (mean difference (MD) 0.11 g/kg, 95% confidence interval (CI) ‐0.01 to 0.23; n = 78, 1 study; low‐quality evidence), but there was no clear evidence of a difference in nutritional status assessed with body mass index (BMI) (MD ‐0.26 kg/m² favouring control, 95% CI ‐0.70 to 0.19; n = 734, 2 studies; moderate‐quality evidence), body weight (MD ‐1.60 kg favouring control, 95% CI ‐3.47 to 0.27; n = 656, 1 study; moderate‐quality evidence), or score on Mini Nutritional Assessment (MNA) (MD ‐0.10 favouring control, 95% CI ‐0.67 to 0.47; n = 656, 1 study; low‐quality evidence). After six months, the intervention group in one study had slightly lower BMI (MD ‐1.79 kg/m² favouring control, 95% CI ‐1.28 to ‐2.30; n = 52, 1 study; moderate‐quality evidence) and body weight (MD ‐8.11 kg favouring control, 95% CI ‐2.06 to ‐12.56; n = 52, 1 study; moderate‐quality evidence). This type of intervention may have a small positive effect on food intake, but little or no effect, or a negative effect, on nutritional status. Two studies compared self‐feeding skills training programmes. In one study, the control group received no training and in the other study the control group received a different self‐feeding skills training programme. For both comparisons the quality of the evidence was very low and we are very uncertain whether these interventions have any effect. One study investigated general training of nurses to impart knowledge on how to feed people with dementia and improve attitudes towards people with dementia. Again, the quality of the evidence was very low so that we cannot be certain of any effect. Two studies investigated vocal or tactile positive feedback provided by caregivers while feeding participants. After three weeks, the intervention group showed an increase in calories consumed per meal (MD 200 kcal, 95% CI 119.81 to 280.19; n = 42, 1 study; low‐quality evidence) and protein consumed per meal (MD 15g, 95% CI 7.74 to 22.26; n = 42, 1 study; low‐quality evidence). This intervention may increase the intake of food and liquids slightly; nutritional status was not assessed. Authors' conclusions Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia. Plain language summary Environmental and behavioural modifications for improving food and fluid intake in people with dementia What we wanted to know Weight loss, malnutrition and dehydration are common problems for people with dementia and can occur at any stage of the illness. People with dementia often develop psychological symptoms or behaviours which cause them to eat or drink less. In the later stages of the illness, they become dependent on others to help them eat or drink. We wanted to investigate how to keep people with dementia eating and drinking as well as possible. We looked for studies which changed the way food and drink are presented to people with dementia, and for studies which attempted to change the behaviour of people with dementia or of those helping them to eat. We called these environmental and behavioural modifications respectively, though some interventions include aspects of both. We were mainly interested in the effect on how much people with dementia ate and drank and on measures of how well‐nourished they were (e.g. body weight or body mass index (BMI)), but we also looked for effects on eating behaviour, symptoms of dementia and quality of life. How we tried to answer the question We searched for all the randomised controlled trials (RCTs) which were relevant to our question. In these trials, some people with dementia got an environmental or behavioural modification intended to improve their eating and drinking and were then compared with other people who had not had the intervention (the control group). Whether someone got the intervention or not was decided at random. We found nine RCTs to include in our review. In total, there were 1502 people in these trials. They had varying degrees of dementia, probably mostly due to Alzheimer's disease. Seven of the trials took place in care homes. In one trial, people were given extra snacks between meals and encouraged to eat them. In three trials, people with dementia were given education about diet and eating. In two trials, people with dementia were taught skills to help them to eat independently. In three trials, training was given to the carers responsible for helping people with dementia to eat. What we found out All the trials we found tested different interventions and measured their effects in different ways. Generally, the trials were small and there were problems with the way they were done, which reduced our confidence in the results. For some interventions, the quality of the evidence was so low that we could not draw any conclusions. For others, there was a mixture of positive and negative effects. What we concluded Because of the amount and quality of the evidence we found, we cannot at the moment, identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Herke, M, Fink, A, Langer, G, Wustmann, T, Watzke, S, Hanff, AM, Burckhardt, M", "articleTypes": [], "doi": "10.1002/14651858.CD011542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.796Z" }, { "id": "687d4c93-a239-45a2-9593-126ebd3cd4cd", "pmid": "", "title": "Evaluation of the Efficacy and Safety of a Drinkable Nutraceutical in Improving Hair Loss in Patients Treated With GLP-1/GIP Receptor Agonists: a Double-blind, 1:1 Randomized, Placebo-controlled Study.", "imported": false, "abstract": "The purpose of this clinical trial is to evaluate the efficacy of Olistic© Next Women, a nutraceutical supplement, compared with placebo in improving hair loss in patients undergoing treatment with GLP-1/GIP agonists. This 6-month, randomized, placebo-controlled clinical study investigates whether daily supplementation with Olistic© Next Women leads to significant improvements in hair loss in this patient population. In addition, the study assesses the safety and tolerability of the product throughout the treatment period.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "689626a0-6154-42ef-96d1-79ff57100272", "pmid": "", "title": "Safety, Pharmacokinetics, and Preliminary Efficacy of Tafenoquine for the Treatment of Vivax Malaria in Papua New Guinean Children", "imported": false, "abstract": "Plasmodium vivax is the most geographically widespread malaria species and the second largest contributor to symptomatic malaria worldwide. It accounts for half of all malaria cases outside Africa, with an estimated 14.3 million clinical vivax malaria cases reported annually, contributing to an annual cost of US$359 million. Children are most vulnerable to infection, with P. vivax prevalence peaking between 2 to 6 years of age. In Papua New Guinea (PNG), there are >1.5 million suspected P. vivax cases annually, and while P. falciparum infections are the most prevalent, P. vivax transmission is the most intense in the world. P. vivax in PNG provides a unique epidemiological setting in which to assess innovative treatments in children.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.152Z" }, { "id": "68ae2c40-0e97-4198-9aec-5da0266bee7a", "pmid": "", "title": "Antioxidant vitamin supplementation for preventing and slowing the progression of age‐related cataract", "imported": false, "abstract": "Abstract - Background Age‐related cataract is a major cause of visual impairment in the elderly. Oxidative stress has been implicated in its formation and progression. Antioxidant vitamin supplementation has been investigated in this context. Objectives To assess the effectiveness of antioxidant vitamin supplementation in preventing and slowing the progression of age‐related cataract. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 2), MEDLINE (January 1950 to March 2012), EMBASE (January 1980 to March 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to March 2012), Open Grey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 2 March 2012. We also checked the reference lists of included studies and ongoing trials and contacted investigators to identify eligible randomized trials. Selection criteria We included only randomized controlled trials in which supplementation with one or more antioxidant vitamins (beta‐carotene, vitamin C and vitamin E) in any form, dosage or combination for at least one year was compared to another antioxidant vitamin or to placebo. Data collection and analysis Two authors extracted data and assessed trial quality independently. We pooled results for the primary outcomes, i.e., incidence of cataract and incidence of cataract extraction. We did not pool results of the secondary outcomes ‐ progression of cataract and loss of visual acuity, because of differences in definitions of outcomes and data presentation. We pooled results by type of cataract when data were available. We did not perform a sensitivity analysis. Main results Nine trials involving 117,272 individuals of age 35 years or older are included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States, with duration of follow‐up ranging from 2.1 to 12 years. The doses of antioxidant vitamins were higher than the recommended daily allowance. There was no evidence of effect of antioxidant vitamin supplementation in reducing the risk of cataract, cataract extraction, progression of cataract or in slowing the loss of visual acuity. In the pooled analyses, there was no evidence of effect of beta‐carotene supplementation in reducing the risk of cataract (two trials) (relative risk (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.08; n = 57,703) or in reducing the risk of cataract extraction (three trials) (RR 1.00, 95% CI 0.91 to 1.10; n = 86,836) or of vitamin E supplementation in reducing the risk of cataract (three trials) (RR 0.97, 95% CI 0.91 to 1.04; n = 50,059) or of cataract extraction (five trials) (RR 0.98, 95% CI 0.91 to 1.05; n = 83,956). The proportion of participants developing hypercarotenodermia (yellowing of skin) while on beta‐carotene ranged from 7.4% to 15.8%. Authors' conclusions There is no evidence from RCTs that supplementation with antioxidant vitamins (beta‐carotene, vitamin C or vitamin E) prevents or slows the progression of age‐related cataract. We do not recommend any further studies to examine the role of antioxidant vitamins beta‐carotene, vitamin C and vitamin E in preventing or slowing the progression of age‐related cataract. Costs and adverse effects should be weighed carefully with unproven benefits before recommending their intake above recommended daily allowances. Plain language summary Antioxidant vitamins for preventing and slowing the progression of age‐related cataract A cataract occurs when the normally clear lens in the eye becomes cloudy. Cataracts are the leading cause of correctable reduced vision worldwide. Most cataracts develop slowly with normal aging. However, cataracts also may be related to genetic diseases and medical conditions such as diabetes. Other factors such as poor nutrition, sun damage, radiation, corticosteroids, smoking, alcohol, eye trauma or other eye surgery may influence cataract formation. Mild or early cataracts may not impair vision. In some cataracts, new eye‐glass prescriptions, brighter lighting or magnifying lenses may overcome the vision losses. When these interventions fail to improve poor vision due to cataracts, surgical removal (extraction) is the generally accepted effective treatment. However, cataract surgery is associated with some risks. The estimated annual costs for outpatient, inpatient and prescription drug services related to the treatment of cataract is USD 6.8 billion. Antioxidant vitamin supplementation has been studied as a means to prevent the formation or to slow the progression of cataract. Results from observational studies have been inconsistent. The review authors searched for randomized controlled trials in which supplementation with the antioxidant vitamins beta‐carotene (provitamin A), vitamin C and vitamin E was compared to inactive placebo or no supplement. Nine trials involving 117,272 adults of age 35 years or older were included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States and were of high methodological quality. The doses of antioxidants given in each trial were higher than the recommended daily allowances. The trials provided no evidence of effect of the antioxidant vitamins beta‐carotene, vitamin E and vitamin C given alone or in combination on the incidence of cataract, its extraction or progression and on the loss of visual acuity. Some participants (7% to 16%) on beta‐carotene developed yellowing of the skin (hypercarotenodermia).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mathew, MC; Ervin, AM; Tao, J; Davis, RM", "articleTypes": [], "doi": "10.1002/14651858.CD004567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "68b65345-f270-4d51-994f-d34340a26513", "pmid": "", "title": "Prognostic models for radiation‐induced complications after radiotherapy in head and neck cancer patients", "imported": false, "abstract": "Abstract - Background Radiotherapy is the mainstay of treatment for head and neck cancer (HNC) but may induce various side effects on surrounding normal tissues. To reach an optimal balance, normal tissue complication probability (NTCP) models have been reported to predict the risk of radiation‐induced side effects in patients with HNC. However, the quality of study design, conduct, and analysis (i.e. risk of bias (ROB)), as well as the predictive performance of these models, remains to be evaluated. Objectives To identify, describe and appraise NTCP models to predict the risk of radiation‐induced side effects in patients with HNC. Search methods We searched Ovid MEDLINE, Embase and the World Health Organization International Clinical Trials Registry Platform from conception to January 2024. In addition, we screened references cited in the retrieved articles. Selection criteria Two review authors independently included articles reporting on the development and external validation of NTCP models to predict any type of radiation‐induced side effects in patients with HNC. Data collection and analysis One reviewer extracted data from each article and assessed their applicability and ROB, while another reviewer carefully verified the results. For models externally validated at least twice for the same outcome as their original developmental study, we performed qualitative analyses of the model performance. The GRADE system was not applied, since it has not been established for reviews of prognostic model studies. Main results Amongst 617 models developed from 152 articles, including 162,527 HNC patients, only 58 (9%) models from seven articles were judged to have low ROB and low concerns for applicability. No external validation was performed for 481 models (78%). For the remaining 136 models and six additional models which were not eligible for the present review, 193 external validations were performed in 48,852 patients with HNC in 39 articles. Models for salivary‐related outcomes Amongst 285 models, two models were externally validated at least twice. The Beetz 2012b model for xerostomia six months after radiotherapy was validated in two studies. C‐statistics ranged from 0.70 to 0.74. Calibration performance was reported in one study. One validation study was rated as having low ROB in all domains, while the other was rated as having high ROB in the analysis domain. The Cavallo 2021 model for acute xerostomia during radiotherapy for patients with nasopharyngeal cancer was externally validated in the same study, using two different types of cohorts. C‐statistics ranged from 0.68 to 0.73 and calibration plots were reported in both cohorts. Both validations were rated as having unclear ROB in the participants' domain because no detailed information about recruiting was provided. Models for swallowing‐related outcomes Amongst 85 models, two models were externally validated at least twice. The Christianen 2012 model for dysphagia six months after radiotherapy was validated in five studies. C‐statistics ranged from 0.66 to 0.75. Calibration performance was assessed in all of them, while four of them were rated as having high ROB in the analysis domain due to the small sample size. The Wopken 2014b model for tube feeding dependence six months after radiotherapy was validated in three external validation studies. C‐statistics ranged from 0.79 to 0.95, while calibration was evaluated in all studies. Due to the small size of the validation datasets, they were judged as having high ROB in the analysis domain. Models for hypothyroidism Of 72 models for hypothyroidism, two models were externally validated at least twice. In addition, there was another model which was not originally developed for patients with HNC, but validated in this domain. The Boomsma 2012 for hypothyroidism within two years after radiotherapy was externally validated in two studies. C‐statistics ranged from 0.64 to 0.74, while only one study reported its calibration performance. Both validation studies were rated as having high ROB in the analysis domain. The Ronjom 2013 model for radiation‐induced hypothyroidism was validated in three studies. C‐statistics ranged from 0.65 to 0.69 and calibration plots were reported in only one study. Two validation studies were judged as having high and the other was rated as having unclear ROB in the analysis domain. The Cella 2012 model was originally developed to predict radiation‐induced hypothyroidism in patients with Hodgkin’s lymphoma. In two validation studies in patients with HNC, c‐statistics ranged from 0.65 to 0.68, but calibration performance was not reported. One validation study was rated as having a high ROB and the other was rated as being unclear in the analysis domain. Models for brain and nerve‐related outcomes Amongst 40 models, three were externally validated at least twice for temporal lobe injury. The OuYang 2023 model, using deep learning in patients with nasopharyngeal cancer, was validated in the same paper using two different cohorts. C‐statistics ranged from 0.80 to 0.82, while calibration performance was assessed in both cohorts. Both validations were judged as having low ROB in all domains. The Wen 2021 model was developed to predict temporal lobe injury in newly diagnosed nasopharyngeal cancer patients. The model was validated by OuYang 2023 using two cohorts and by Yang 2023a using four cohorts. C‐statistics ranged from 0.75 to 0.79, while calibration performance was not reported. The two validations by OuYang 2023 were judged as having unclear ROB in the analysis domain, and the four validations by Yang 2023a were judged as having high ROB in the analysis domain. The Yang 2023a model was validated in the same paper using two cohorts. C‐statistics ranged from 0.79 to 0.81, while calibration performance was assessed in both cohorts. Both validations were judged as having high ROB in the analysis domain. Models for outcomes related to hoarseness, fatigue, nausea‐vomiting, throat pain, aspiration No models were externally validated at least twice. Authors' conclusions Amongst 617 developed models, only one‐fifth were externally validated, of which, ten models at least twice. These ten models showed acceptable discriminative performance at external validation. However, their calibration was not always reported. Furthermore, most validation studies were judged as having high ROB. In conclusion, this review shows the need for more external validation studies and improvement of the quality of conducting and reporting of prediction model studies. Plain language summary Which normal tissue complication probability (NTCP) models are available to predict the risk of radiation‐induced side effects after radiotherapy in patients with head and neck cancer, what is their quality, and what is their predictive performance? Key messages ° Many NTCP models have been developed to predict unwanted effects following radiotherapy in head and neck cancer patients but most of them have not been sufficiently externally validated, that is, tested with patients who were not involved in the original model developmental study, to know how well they really predict the unwanted effects. ° For models tested in two or more studies in addition to their original model development studies, the quality of testing and reporting of their results was generally poor, so it is difficult to know how useful they might be. ° More and better designed studies are required to investigate this issue in the area of head and neck cancer. How can we decide on the likelihood of having unwanted effects as a result of treatment? The likelihood of having unwanted effects as a result of radiotherapy can be calculated by using so‐called NTCP models. NTCP models calculate the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. What did we want to find out? Radiotherapy is the mainstay of treatment of patients with head and neck cancer. However, radiotherapy exposes healthy, sometimes crucial, parts of the head and neck region to radiation. This may result in damage to these normal organs, e.g. disturbed saliva production, which may have important consequences for the quality of life of head and neck cancer patients treated with radiotherapy. To reach an optimal balance between tumour control and preventing radiation‐induced side effects, normal tissue complication probability (NTCP) models can be helpful. These models predict the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. There have been a substantial number of NTCP models for patients with head and neck cancer. We wanted to find out what the quality of study design, conduct, and analysis (i.e. risk of bias) is, and how well these models can predict the risk of radiation‐induced side effects. What did we do? We searched for studies that developed and/or validated NTCP models in patients with head and neck cancer. What did we find? In most of the 617 models developed from 162,527 patients in 152 identified articles, the quality of the models was not sufficient; and it has not been investigated how well they perform in new patients for 78% of these models. For the remaining 22% of the models, 193 external validations were found in 48,852 patients from 39 articles. There were only ten models with two or more external validations. The models were able to distinguish patients with and without the outcome well, but it was often unclear whether their predictions were in line with what was observed, because the latter was not always assessed and/or reported. Overall, the quality of most of these studies was low. How up to date is the review? The evidence is current to 8th January 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Takada, T; Tambas, M; Clementel, E; Leeuwenberg, A; Sharabiani, M; Damen, JAAG; Dunias, ZS; Nauta, JF; Idema, DL; Choi, J; Meijerink, LM; Langendijk, JA; Moons, KG; Schuit, E", "articleTypes": [], "doi": "10.1002/14651858.CD014745.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "68b996d4-2c5c-4863-ad44-1a3eec0c1860", "pmid": "", "title": "Oral protein‐based supplements versus placebo or no treatment for people with chronic kidney disease requiring dialysis", "imported": false, "abstract": "Abstract - Background Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein‐based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein‐based nutritional supplements in this population is limited. Objectives The aims of this review were to determine the benefits and harms of using oral protein‐based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein‐based nutritional supplements to no oral protein‐based nutritional supplements or placebo. Data collection and analysis Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes. Main results Twenty‐two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow‐up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self‐reported outcomes. Oral protein‐based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I 2 = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein‐based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I 2 = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein‐based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid‐arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein‐based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI ‐0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD ‐0.04 kg/m 2 , 95% CI ‐0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI ‐1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein‐based nutritional supplements affect triceps skinfold thickness, mid‐arm circumference, C‐reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein‐based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies. Authors' conclusions Overall, it is likely that oral protein‐based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid‐arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well‐designed RCTs in this population are required. Plain language summary Oral protein‐based nutritional supplement in people with chronic kidney disease requiring dialysis What is the issue? People with chronic kidney disease requiring dialysis are at risk of developing malnutrition for many reasons and often do not eat enough because their appetite is poor. Oral nutritional supplements are commonly provided to people who do not eat enough to meet their needs. Provision of nutritional supplements to dialysis patients requires careful consideration of potassium, phosphate and fluid limits. What did we do? We aimed to determine if giving oral protein‐based nutritional supplements improved serum albumin levels and other measures of nutrition. What did we find? A total of 1278 people took part in 22 studies that were included in this review to investigate the effects of oral protein‐based nutritional supplements. All participants were adults on maintenance dialysis (79% haemodialysis and 21% peritoneal dialysis). The studies lasted from one to 12 months. The findings suggest that giving oral protein‐based nutritional supplementation probably results in a slightly greater increase in albumin level and may improve prealbumin level and mid‐arm muscle circumference. The increase in albumin level was more evident in participants who were on haemodialysis and in those who were malnourished. It is uncertain whether oral protein‐based nutritional supplementation affects potassium and phosphate levels. Oral protein‐based nutritional supplements may result in little or no difference in the risk of developing abdominal symptoms.There were some differences between the quality of the studies and their designs. Conclusions The authors conclude that oral protein‐based nutritional supplements appear to be effective in improving some nutritional markers in people who need dialysis; however, it remains uncertain whether these results translate to meaningful outcomes for this population. More research is required to determine the cost‐effectiveness of this treatment, and if it can bring benefit to patients such as feeling better and living longer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Mah, JY, Choy, SW, Roberts, MA, Desai, AM, Corken, M, Gwini, SM, McMahon, LP", "articleTypes": [], "doi": "10.1002/14651858.CD012616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.782Z" }, { "id": "68ce6480-5816-4907-8a2b-1990a12b8af2", "pmid": "", "title": "Tranexamic acid for patients with nasal haemorrhage (epistaxis)", "imported": false, "abstract": "Abstract - Background Epistaxis (nosebleed) most commonly affects children and the elderly. The majority of episodes are managed at home with simple measures. In more severe cases medical intervention is required to either cauterise the bleeding vessel, or to pack the nose with various materials. Tranexamic acid is used in a number of clinical settings to stop bleeding by preventing clot breakdown (fibrinolysis). It may have a role in the management of epistaxis as an adjunct to standard treatments, reducing the need for further intervention. Objectives To determine the effects of tranexamic acid (oral, intravenous or topical) compared with placebo, no additional intervention or any other haemostatic agent in the management of patients with epistaxis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register (via CRS Web); Central Register of Controlled Trials (CENTRAL) (via CRS Web); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 October 2018. Selection criteria Randomised controlled trials (RCTs) of tranexamic acid (in addition to usual care) compared with usual care plus placebo, usual care alone or usual care plus any other haemostatic agent, to control epistaxis in adults or children. Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were control of epistaxis: re‐bleeding (as measured by the proportion of patients re‐bleeding within a period of up to 10 days) and significant adverse effects (seizures, thromboembolic events). Secondary outcomes were control of epistaxis as measured by the time to stop initial bleeding (the proportion of patients whose bleeding is controlled within a period of up to 30 minutes); severity of re‐bleeding (as measured by (a) the proportion of patients requiring any further intervention and (b) the proportion of patients requiring blood transfusion); length of hospital stay and other adverse effects. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included six RCTs (692 participants). The overall risk of bias in the studies was low. Two studies assessed oral administration of tranexamic acid, given regularly over several days, and compared it to placebo. In the other four studies, a single application of topical tranexamic acid was compared with placebo (one study) and a combination of epinephrine and lidocaine or phenylephrine (three studies). All participants were adults. Tranexamic acid versus placebo For our primary outcome, control of epistaxis: re‐bleeding (proportion re‐bleeding within 10 days), we were able to pool data from three studies. The pooled result demonstrated a benefit of tranexamic acid compared to placebo, the risk of re‐bleeding reducing from 67% to 47% (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; three studies; 225 participants; moderate‐quality evidence ). When we compared the effects of oral and topical tranexamic acid separately the risk of re‐bleeding with oral tranexamic acid reduced from 69% to 49%, RR 0.73 (95% CI 0.55 to 0.96; two studies, 157 participants; moderate‐quality evidence ) and with topical tranexamic acid it reduced from 66% to 43%, RR 0.66 (95% CI 0.41 to 1.05; single study, 68 participants). We rated the quality of evidence provided by the single study as low , therefore it is uncertain whether topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. No study specifically sought to identify and report our primary outcome: significant adverse effects (i.e. seizures, thromboembolic events). The secondary outcome time to stop initial bleeding (proportion with bleeding controlled within 30 minutes) was measured in one study using topical tranexamic acid and there was no evidence of a difference at 30 minutes (RR 0.79, 95% CI 0.56 to 1.11; 68 participants; low‐quality evidence ). No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery, embolisation). One study of oral tranexamic acid reported the proportion of patients requiring blood transfusion and found no difference between groups: 5/45 (11%) versus 6/44 (14%) (RR 0.81, 95% CI 0.27 to 2.48; 89 participants; low‐quality evidence ). Two studies reported hospital length of stay. One study reported a significantly shorter stay in the oral tranexamic acid group (mean difference (MD) ‐1.60 days, 95% CI ‐2.49 to ‐0.71; 68 participants). The other study found no evidence of a difference between the groups. Tranexamic acid versus other haemostatic agents When we pooled the data from three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the topical tranexamic acid group compared to the group receiving another haemostatic agent (70% versus 30%: RR 2.35, 95% CI 1.90 to 2.92; 460 participants) ( moderate‐quality evidence ). Adverse effects across all studies Five studies recorded 'adverse effects' in a general way. None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient developed a superficial thrombophlebitis of both legs following discharge, however it is not reported in which group this occurred. No \"other serious adverse effect\" was reported in any study. Authors' conclusions We found moderate‐quality evidence that there is probably a reduction in the risk of re‐bleeding with the use of either oral or topical tranexamic acid in addition to usual care in adult patients with epistaxis, compared to placebo with usual care. However, the quality of evidence relating solely to topical tranexamic acid was low (one study only), so we are uncertain whether or not topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. We found moderate‐quality evidence that topical tranexamic acid is probably better than other topical agents in stopping bleeding in the first 10 minutes. There have been only three RCTs on this subject since 1995. Since then there have been significant changes in nasal cauterisation and packing techniques (for example, techniques including nasal endoscopy and more invasive approaches such as endoscopic sphenopalatine artery ligation). New trials would inform us about the effectiveness of tranexamic acid in light of these developments. Plain language summary Tranexamic acid to help treat nosebleeds (epistaxis) Background Nosebleeds are a very common condition, with the majority of those affected either children or those over the age of 60. They usually stop on their own or by simply compressing the nose with fingers, although a small number require medical attention. This will involve either cauterising (sealing) the bleeding vessel, if it can be seen, or packing the inside of the nose with a material to cause pressure to build up and stop the bleeding ('usual care'). Occasionally bleeding continues despite these measures, or it restarts having initially been controlled. This can lead to a prolonged hospital stay and the possibility of further procedures such as repacking with a different type of nasal pack or an operation. Tranexamic acid is a drug that is known to help promote blood clotting by preventing a natural process called fibrinolysis (dissolution of a clot). It is already used in a number of situations where bleeding is a significant worry, such as after heart surgery or major trauma. It can be given by mouth (orally), directly to the bleeding site (topically) or by injection into a vein (intravenously). Study characteristics We searched for randomised controlled trials in patients of any age with nosebleed requiring intervention. Patients were treated with tranexamic acid (in addition to usual care) compared to placebo, no treatment or any other agent used to stop bleeding. We found six studies that met our inclusion criteria, with a total of 692 participants. Two studies used oral administration of tranexamic acid and four used topical administration. All participants in the studies were adults. Three of the six studies were conducted over 20 years ago. Key results Three studies measured re‐bleeding within 10 days. When we combined the results we found that fewer patients who were given either oral or topical tranexamic acid had further episodes of re‐bleeding following an initial nosebleed compared to those treated with usual care. The time to stop initial bleeding (control of bleeding within 30 minutes) was measured in four studies. In three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the group receiving topical tranexamic acid compared to the group receiving a different drug (topical epinephrine and lidocaine or phenylephrine). In the other study there was no significant difference at 30 minutes when topical tranexamic acid was compared with placebo. No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery). Only one study of oral tranexamic acid reported the proportion of patients requiring a blood transfusion and there was no evidence of a difference between the groups. Length of hospital stay was reported in two studies. One study reported a significantly shorter stay in the oral tranexamic acid group, while the other found no evidence of a difference. Five studies mention recording \"adverse effects\". None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient did develop a superficial thrombophlebitis (inflammation and a blood clot in a vein near the surface of the skin) of both legs following discharge, but the study did not report in which treatment group this happened. No serious adverse event was seen in any of the studies. Quality of the evidence and conclusions Overall, the risk of bias in the six studies was low. We graded the quality of the evidence for the main outcome (control of epistaxis: re‐bleeding within 10 days) as moderate, which means that further research is likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate. In light of this and the fact that 'usual care' has changed, with the development of more modern nasal cauterisation and packing techniques, since three of the included studies were carried out, there remains uncertainty about the role of tranexamic acid in the treatment of patients with epistaxis. Newer research into the effect of tranexamic acid as a treatment for nosebleeds would inform future management decisions for this condition. The evidence in this review is up to date to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Joseph, J, Martinez‐Devesa, P, Bellorini, J, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.730Z" }, { "id": "68d1b951-64b5-45bb-a299-db601e104386", "pmid": "", "title": "Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen‐ultraviolet A photochemotherapy for psoriasis", "imported": false, "abstract": "Abstract - Background The most commonly used types of phototherapy for treating psoriasis are narrow‐band ultraviolet B (NB‐UVB); broad‐band ultraviolet B (BB‐UVB), which includes selective (delivering radiation with a wavelength range of 305 to 325 nm) and conventional BB‐UVB (280 to 320 nm); and psoralen ultraviolet A photochemotherapy (oral or bath PUVA). There is substantial controversy regarding their efficacy when compared with each other. Objectives To assess the effects of narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for psoriasis. Search methods We searched the following databases up to August 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 7), MEDLINE (from 1946), and EMBASE (from 1974). We searched the following databases up to November 2012: CNKI (from 1974) and CBM (from 1978). We also searched trials registers and the OpenGrey database. Selection criteria We included all randomised controlled trials (RCTs) that compared NB‐UVB phototherapy with BB‐UVB or PUVA for treating psoriasis, which included chronic plaque psoriasis (CPP), guttate psoriasis (GP), and palmoplantar psoriasis (PPP). Data collection and analysis Two review authors independently conducted the study selection, 'Risk of bias' assessment, and data extraction. Main results We included 13 RCTs, with a total of 662 participants. We report the results of intention‐to‐treat analyses (ITT) here. Our primary outcomes of interest were as follows: Participant‐rated global improvement, Percentage of participants reaching Psoriasis Area and Severity Index (PASI) 75 (which meant equal to or more than 75% reduction in PASI score), Withdrawal due to side‐effects, and Clearance rate. In one RCT of NB‐UVB compared with oral PUVA in participants with CPP, the difference in PASI 75 was not statistically significant (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.63 to 1.32; N = 51; low quality). In three other RCTs of CPP, the clearance rates were inconsistent because in one, there was no difference between the groups (RR 1.01, 95% CI 0.91 to 1.12; N = 54), and in the other two, the clearance rates were statistically significantly in favour of oral PUVA: RR 0.66, 95% CI 0.47 to 0.93; N = 93 and RR 0.75, 95% CI 0.59 to 0.96; N = 100, respectively. Pooled data from these three studies indicated that withdrawals due to adverse events were not significantly different between either group (RR 0.71, 95% CI 0.20 to 2.54; N = 247; low quality). The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate for CPP was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the NB‐UVB and bath PUVA groups (RR 1.79, 95% CI 0.46 to 6.91; N = 92; low quality), while a parallel RCT favoured bath PUVA (RR 0.18, 95% CI 0.05 to 0.71; N = 36; low quality). In participants with PPP, one RCT found there were no significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate (RR 0.09, 95% CI 0.01 to 1.56; N = 50; low quality). Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or GP in terms of clearance rate (RR 0.93, 95% CI 0.79 to 1.10; N = 90; low quality). One RCT in people with CPP found no significant differences between NB‐UVB and selective BB‐UVB in terms of clearance rate (RR 1.40, 95% CI 0.92 to 2.13; N = 100; low quality) and withdrawals due to adverse events (RR 3.00, 95% CI 0.32 to 27.87; N = 100; low quality). No studies reported our primary outcomes for NB‐UVB compared with conventional BB‐UVB. Authors' conclusions Current evidence is very heterogeneous and needs to be interpreted with caution. The clearance rate between oral PUVA and NB‐UVB is inconsistent among the included studies. Evidence regarding NB‐UVB versus bath PUVA is also inconsistent. Re‐NB‐UVB and re‐PUVA are similarly effective for treating people with CPP or GP. In practice, NB‐UVB may be more convenient to use since exogenous photosensitiser is not required before phototherapy. NB‐UVB is considered ineffective for PPP in clinical practice, and a small RCT did not detect a statistically significant difference between NB‐UVB and topical PUVA for clearing PPP. NB‐UVB seemed to be similar to selective BB‐UVB for clearing CPP. Larger prospective studies are needed to confirm the long‐term safety of NB‐UVB. Plain language summary Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for treating psoriasis Psoriasis is a common, chronic inflammatory skin disease, with an estimated global prevalence ranging from 0.5% to 4.6%. Based on clinical features, psoriasis is generally divided into the following: chronic plaque psoriasis (CPP); psoriasis associated with psoriatic arthritis; and pustular, erythrodermic, or guttate psoriasis. We also considered psoriasis affecting the palms and soles (palmoplantar psoriasis, or PPP). Although psoriasis is rarely life‐threatening, it can affect a person's quality of life significantly. Phototherapy is an essential treatment option for people with psoriasis. The most commonly used types of phototherapy are narrow‐band ultraviolet B (NB‐UVB), broad‐band ultraviolet B (BB‐UVB), and psoralen ultraviolet A photochemotherapy (PUVA). PUVA can be further divided into oral, bath, and topical PUVA according to the administrative route of psoralen. NB‐UVB delivers almost exclusively 311 nm radiation, whereas BB‐UVB can be divided into two types: selective BB‐UVB (305 to 325 nm radiation) and conventional BB‐UVB (280 to 320 nm radiation). This review included 13 small randomised controlled trials (RCT), with a total of 662 participants. Most of these were of poor methodological quality. For treating CPP, the clearance rate between the NB‐UVB and oral PUVA groups were inconsistent in three RCTs. In one, there was no difference between the groups, and in the other two, the clearance rate was in favour of oral PUVA. The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the two groups, while another RCT favoured bath PUVA. Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or guttate psoriasis. One RCT found no significant differences between NB‐UVB and selective BB‐UVB for clearing CPP or in the number of withdrawals due to side‐effects. In participants with PPP, one RCT found there were no statistically significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate. In summary, NB‐UVB may be preferred to oral or bath PUVA because it is more convenient to use. NB‐UVB seemed to be equal to selective BB‐UVB for clearing CPP. Evidence regarding NB‐UVB and conventional BB‐UVB is limited. The long‐term safety of NB‐UVB needs to be confirmed. The efficacy of NB‐UVB for clearing PPP needs to be confirmed in future studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Chen, X, Yang, M, Cheng, Y, Liu, GJ, Zhang, M", "articleTypes": [], "doi": "10.1002/14651858.CD009481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.778Z" }, { "id": "68db4e7f-fea7-4b75-af01-8a15242b455d", "pmid": "", "title": "Glutamatergic drugs for schizophrenia", "imported": false, "abstract": "Abstract - Background It has been shown that central nervous system dopamine can play a major role in the pathophysiology of schizophrenia. Brain glutamate is thought to mediate symptoms in schizophrenia due to the influence of glutamate neurons on the dopaminergic transmission in the brain. It might be possible to decrease negative symptoms and the cognitive impairment of people with schizophrenia by treatment with glutamatergic drugs. Objectives To determine the efficacy of glutamatergic drugs in the treatment of schizophrenia. Search methods We searched the Cochrane Schizophrenia Group's Trials Register (May 2002 and October 2003), inspected references of all identified studies and contacted relevant authors. Selection criteria We included all randomised controlled trials in which glutamatergic medication was administered to people with schizophrenia. Data collection and analysis We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results We included eighteen short‐term trials with 358 randomised participants. The single studies were small with numbers of participants ranging between six and 51. All trials were short‐term trials with a maximum duration of 12 weeks. In all of these trials, glycine, D‐serine, D‐cycloserine, or ampakine CX516 was used to augment the effect of antipsychotic drugs. D‐cycloserine, a partial agonist of NMDA receptors' glycine site, seemed ineffective towards the symptoms of schizophrenia. NMDA receptor co‐agonists glycine and D‐serine showed some effects in reducing the negative symptoms of schizophrenia (n=132, SMD ‐0.66, CI ‐1.0 to ‐0.3, p=0.0004), but the magnitude of the effect was moderate. Furthermore, when responder rates rather than mean scores of negative symptoms were analysed the data were inconsistent: There was no difference in responder rates between glycine and the control in terms of more than 20% improvement of negative symptoms (n=62, RR 0.70, CI 0.3 to 1.71) and only a borderline significant superiority in terms of more than 50% improvement (n=62, RR 0.87, CI 0.8 to 1.00). There were also some effects in favour of glycine and/or D‐serine in terms of overall and general symptoms, but the results were again inconsistent and depended on the response definition applied. Available rating scale data on positive symptoms and cognitive functioning did not indicate a statistically significant effect of glycine or D‐serine. Authors' conclusions In general, all glutamatergic drugs appeared to be ineffective in further reducing positive symptoms of the disease when added to the existing antipsychotic treatment. Glycine and D‐serine may somewhat improve negative symptoms when added to regular antipsychotic medication, but the results were not fully consistent and data are too few to allow any firm conclusions. Many participants in the included trials were treatment‐resistant which may have reduced treatment response. Additional research on glutamatergic mechanisms of schizophrenia is needed. Plain language summary Glutamatergic drugs for schizophrenia Schizophrenia is a severe psychiatric disease characterised by positive symptoms such as hallucinations and delusions and negative symptoms such as blunted affect and emotional withdrawal. People with schizophrenia may also suffer from cognitive deficits. Current medication is effective in reducing positive symptoms, but negative and cognitive symptoms are fairly resistant to treatment. Antipsychotic drugs act mainly on the dopamine system in the brain, although other neurotransmitter systems may also play a role in schizophrenia. We sought to review all randomised trials that used glutamatergic drugs in the treatment of schizophrenia. This review shows that substances acting on the glutamate system may improve symptoms when added to regular antipsychotic medication, although the available evidence base is too limited to allow for any firm conclusions. Presently, glutamatergic drugs are not available for clinical use. Additional research is needed to determine their ultimate role in the treatment of schizophrenia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Tiihonen, J; Wahlbeck, K", "articleTypes": [], "doi": "10.1002/14651858.CD003730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "68ebf616-5867-4cef-8e22-3c8d78a26de8", "pmid": "", "title": "Opioids for restless legs syndrome", "imported": false, "abstract": "Abstract - Background Restless legs syndrome (RLS) is a distressing and common neurological disorder that may have a huge impact in the quality of life of those with frequent and intense symptoms. Patients complain of unpleasant sensations in the legs, at or before bedtime, and feel an urge to move the legs, which improves with movement, such as walking. Symptoms start with the patient at rest (e.g. sitting or lying down), and follow a circadian pattern, increasing during the evening or at night. Many pharmacological intervention are available for RLS, including drugs used to treat Parkinson's disease (L‐Dopa and dopaminergic agonists), epilepsy (anticonvulsants), anxiety (benzodiazepines), and pain (opioids). Dopaminergic drugs are those most frequently used for treatment of RLS, but some patients do not respond effectively and require other medication. Opioids, a class of medications used to treat severe pain, seem to be effective in treating RLS symptoms, and are recommended for patients with severe symptoms, because RLS and pain appear to share the same mechanism in the central nervous system. All available drugs are associated to some degree with side effects, which can impede treatment. Opioids are associated with adverse events such as constipation, tolerance, and dependence. This justifies the conduct of a systematic review to ascertain whether opioids are safe and effective for treatment of RLS. Objectives To asses the effects of opioids compared to placebo treatment for restless legs syndrome in adults. Search methods We searched the Cochrane Central Register of Controlled trials, CENTRAL 2016, issue 4 and MEDLINE, EMBASE, and LILACS up to April 2016, using a search strategy adapted by Cochraneto identify randomised clinical trials. We checked the references of each study and established personal communication with other authors to identify any additional studies. We considered publications in all languages. Selection criteria Randomised controlled clinical trials of opioid treatment in adults with idiopathic RLS. Data collection and analysis Two review authors independently screened articles, independently extracted data into a standard form, and assessed for risk of bias. If necessary, they discussed discrepancies with a third researcher to resolve any doubts. Main results We included one randomised clinical trial (N = 304 randomised; 204 completed; 276 analysed) that evaluated opioids (prolonged release oxycodone/naloxone) versus placebo. After 12 weeks, RSL symptoms had improved more in the drug group than in the placebo group (using the IRLSSS: MD ‐7.0; 95% CI ‐9.69 to ‐4.31 and the CGI: MD ‐1.11; 95% CI ‐1.49 to ‐0.73). More patients in the drug group than in the placebo group were drug responders (using the IRLSSS: RR 1.82; 95% CI 1.37 to 2.42 and the CGI: RR1.92; 95% ICI 1.49 to 2.48). The proportion of remitters was greater in the drug group than in the placebo group (using the IRLSSS: RR 2.14; 95% CI 1.45 to 3.16). Quality of life scores also improved more in the drug group than in the placebo group (MD ‐0.73; 95% CI ‐1.1 to ‐0.36). Quality of sleep was improved more in the drug group measured by sleep adequacy (MD ‐0.74; 95% CI ‐1.15 to ‐0.33), and sleep quantity (MD 0.89; 95% CI 0.52 to 1.26). There was no difference between groups for daytime somnolence, trouble staying awake during the day, or naps during the day. More adverse events were reported in the drug group (RR 1.22; 95% CI 1.07 to 1.39). The major adverse events were gastrointestinal problems, fatigue, and headache. Authors' conclusions Opioids seem to be effective for treating RLS symptoms, but there are no definitive data regarding the important problem of safety. This conclusion is based on only one study with a high dropout rate (low quality evidence). Plain language summary Opiods for restless legs syndrome Background Restless legs syndrome (RLS) is a very common neurological disorder in which patients complain of an intense need to move their legs, and unpleasant sensations felt deep in their legs, all occurring while at rest, mostly at bedtime. The number of patients complaining of RLS varies according to race, gender, age, country, and health status. About 5% to 10% of people are affected; , and, among these, 2% to 5% need continual pharmacological treatment (medication). When RLS does not respond to medications generally used for Parkinsons Disease and epilepsy, their doctors often prescribe opioids. Question Are opioids effective and safe for people with RLS? Methods We searched the literature for studies in any language, published or not, that considered opioids for the treatment of RLS Results We included one randomised controlled clinical trial with moderate risk of bias that tested a combination of oxycodone and naloxone against placebo capsules, taken twice daily in participants whodid not respond to more usual medications. Researchers used the International RLS severity scale to find out if patients were improved after 12 weeks of treatment. Particpants receiving the combined oxycodone and naloxone reported improvement in RLS symptoms, Quality of life, and sleep quality; 42% of the drug group were symptom‐free. Discussion The study was well designed overall, but was at a high risk of bias due to the high percentage of participants who withdrew from treatment (attrition bias). Eighty‐four percent of the drug group developed adverse events, which were mostly related to the gastrointestinal system, headache, fatigue, and sleepiness (somnolence); 9.8% left the study because of the adverse events. Conclusion The use of opioids for the treatment of RLS in patients resistant to conventional treatment is supported by low‐quality evidence. Prescription of these medications should be based on clinical experience, and caution used due to the potential for abuse, dependency, and adverse events. No patient on opioids complained that their symptoms worsened.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "de Oliveira, CO, Carvalho, LBC, Carlos, K, Conti, C, de Oliveira, MM, Prado, LBF, Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006941.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.755Z" }, { "id": "68f4c4d9-e067-4f8e-b575-fb96bfac36aa", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies to prevent COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as potential prophylaxis to prevent coronavirus disease 2019 (COVID‐19). Objectives To assess the effects of SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, to prevent infection with SARS‐CoV‐2 causing COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register, MEDLINE, Embase, and three other databases on 27 April 2022. We checked references, searched citations, and contacted study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that evaluated SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, alone or combined, versus an active comparator, placebo, or no intervention, for pre‐exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) of COVID‐19. We excluded studies of SARS‐CoV‐2‐neutralising mAbs to treat COVID‐19, as these are part of another review. Data collection and analysis Two review authors independently assessed search results, extracted data, and assessed risk of bias using Cochrane RoB 2. Prioritised outcomes were infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, all‐cause mortality, admission to hospital, quality of life, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We included four RCTs of 9749 participants who were previously uninfected and unvaccinated at baseline. Median age was 42 to 76 years. Around 20% to 77.5% of participants in the PrEP studies and 35% to 100% in the PEP studies had at least one risk factor for severe COVID‐19. At baseline, 72.8% to 82.2% were SARS‐CoV‐2 antibody seronegative. We identified four ongoing studies, and two studies awaiting classification. Pre‐exposure prophylaxis Tixagevimab/cilgavimab versus placebo One study evaluated tixagevimab/cilgavimab versus placebo in participants exposed to SARS‐CoV‐2 wild‐type, Alpha, Beta, and Delta variant. About 39.3% of participants were censored for efficacy due to unblinding and 13.8% due to vaccination. Within six months, tixagevimab/cilgavimab probably decreases infection with SARS‐CoV‐2 (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.29 to 0.70; 4685 participants; moderate‐certainty evidence), decreases development of clinical COVID‐19 symptoms (RR 0.18, 95% CI 0.09 to 0.35; 5172 participants; high‐certainty evidence), and may decrease admission to hospital (RR 0.03, 95% CI 0 to 0.59; 5197 participants; low‐certainty evidence). Tixagevimab/cilgavimab may result in little to no difference on mortality within six months, all‐grade AEs, and SAEs (low‐certainty evidence). Quality of life was not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and Delta variant. About 36.5% of participants opted for SARS‐CoV‐2 vaccination and had a mean of 66.1 days between last dose of intervention and vaccination. Within six months, casirivimab/imdevimab may decrease infection with SARS‐CoV‐2 (RR 0.01, 95% CI 0 to 0.14; 825 seronegative participants; low‐certainty evidence) and may decrease development of clinical COVID‐19 symptoms (RR 0.02, 95% CI 0 to 0.27; 969 participants; low‐certainty evidence). We are uncertain whether casirivimab/imdevimab affects mortality regardless of the SARS‐CoV‐2 antibody serostatus. Casirivimab/imdevimab may increase all‐grade AEs slightly (RR 1.14, 95% CI 0.98 to 1.31; 969 participants; low‐certainty evidence). The evidence is very uncertain about the effects on grade 3 to 4 AEs and SAEs within six months. Admission to hospital and quality of life were not reported. Postexposure prophylaxis Bamlanivimab versus placebo One study evaluated bamlanivimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type. Bamlanivimab probably decreases infection with SARS‐CoV‐2 versus placebo by day 29 (RR 0.76, 95% CI 0.59 to 0.98; 966 participants; moderate‐certainty evidence), may result in little to no difference on all‐cause mortality by day 60 (R 0.83, 95% CI 0.25 to 2.70; 966 participants; low‐certainty evidence), may increase all‐grade AEs by week eight (RR 1.12, 95% CI 0.86 to 1.46; 966 participants; low‐certainty evidence), and may increase slightly SAEs (RR 1.46, 95% CI 0.73 to 2.91; 966 participants; low‐certainty evidence). Development of clinical COVID‐19 symptoms, admission to hospital within 30 days, and quality of life were not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and potentially, but less likely to Delta variant. Within 30 days, casirivimab/imdevimab decreases infection with SARS‐CoV‐2 (RR 0.34, 95% CI 0.23 to 0.48; 1505 participants; high‐certainty evidence), development of clinical COVID‐19 symptoms (broad‐term definition) (RR 0.19, 95% CI 0.10 to 0.35; 1505 participants; high‐certainty evidence), may result in little to no difference on mortality (RR 3.00, 95% CI 0.12 to 73.43; 1505 participants; low‐certainty evidence), and may result in little to no difference in admission to hospital. Casirivimab/imdevimab may slightly decrease grade 3 to 4 AEs (RR 0.50, 95% CI 0.24 to 1.02; 2617 participants; low‐certainty evidence), decreases all‐grade AEs (RR 0.70, 95% CI 0.61 to 0.80; 2617 participants; high‐certainty evidence), and may result in little to no difference on SAEs in participants regardless of SARS‐CoV‐2 antibody serostatus. Quality of life was not reported. Authors' conclusions For PrEP, there is a decrease in development of clinical COVID‐19 symptoms (high certainty), infection with SARS‐CoV‐2 (moderate certainty), and admission to hospital (low certainty) with tixagevimab/cilgavimab. There is low certainty of a decrease in infection with SARS‐CoV‐2, and development of clinical COVID‐19 symptoms; and a higher rate for all‐grade AEs with casirivimab/imdevimab. For PEP, there is moderate certainty of a decrease in infection with SARS‐CoV‐2 and low certainty for a higher rate for all‐grade AEs with bamlanivimab. There is high certainty of a decrease in infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, and a higher rate for all‐grade AEs with casirivimab/imdevimab. Although there is high‐to‐moderate certainty evidence for some outcomes, it is insufficient to draw meaningful conclusions. These findings only apply to people unvaccinated against COVID‐19. They are only applicable to the variants prevailing during the study and not other variants (e.g. Omicron). In vitro, tixagevimab/cilgavimab is effective against Omicron, but there are no clinical data. Bamlanivimab and casirivimab/imdevimab are ineffective against Omicron in vitro. Further studies are needed and publication of four ongoing studies may resolve the uncertainties. Plain language summary Are laboratory‐made COVID‐19‐specific monoclonal antibodies effective to prevent COVID‐19 in adults? Key messages Pre‐exposure prophylaxis of COVID‐19: – tixagevimab/cilgavimab probably reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may reduce number of people admitted to hospital; – casirivimab/imdevimab may reduce number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may increase number of unwanted effects (any severity) slightly. Postexposure prophylaxis of COVID‐19: – bamlanivimab probably reduces number of people infected with COVID‐19; – casirivimab/imdevimab reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and reduces number of unwanted effects (any severity). What are 'monoclonal' antibodies? The body makes antibodies to defend against disease. However, they may be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that target only one specific protein – in this case, a protein on the SARS‐CoV‐2 virus (that causes COVID‐19) – are 'monoclonal'. They attach to the virus and stop it from entering and replicating in human cells to prevent and fight infection. They are relevant for people who do not respond or respond poorly to vaccinations. What did we want to find out? We wanted to know if COVID‐19‐specific monoclonal antibodies are effective at preventing COVID‐19 in people exposed to the virus or are at high risk of being exposed to the virus. We looked at: – confirmed COVID‐19 infections; – development of COVID‐19 symptoms; – death from any cause; – hospital admission; – quality of life; – unwanted effects, such as infections and cardiac disorders; – serious unwanted effects, such as life‐threatening, hospitalisation, disability, or death. What did we do? We searched for studies comparing monoclonal antibodies (e.g. bamlanivimab, tixagevimab/cilgavimab, and casirivimab/imdevimab) with placebo (sham treatment), another treatment, or no treatment to prevent COVID‐19 in people of any age, gender, or ethnicity. We summarised data and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? Four studies including 9749 people; two investigated people before being exposed to SARS‐CoV‐2 (pre‐exposure prophylaxis) and two investigated people who were in contact with an infected person (postexposure prophylaxis). Studies were conducted before the emergence of the Omicron variant and before or during widespread vaccine roll‐out. Participants were unvaccinated at baseline. Pre‐exposure prophylaxis One study (5197 people) compared tixagevimab/cilgavimab to placebo. Participants had been exposed to wild‐type, Alpha, Beta, and Delta variants. Tixagevimab/cilgavimab: – reduces development of symptoms; – probably reduces number of people infected; – may reduce number of hospital admissions; – may have little or no effect on deaths from any cause, unwanted effects (any severity), and serious unwanted effect. We found no data for quality of life, or mild and severe unwanted effects. One study (969 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and Delta variants. Casirivimab/imdevimab: – may reduce number of people infected and development of symptoms; – resulted in no deaths; – may increase unwanted effects (any severity) slightly; – we are uncertain whether casirivimab/imdevimab may have an effect on severe and serious unwanted effects. We found no data for number of people with COVID‐19 within 30 days, development of symptoms within 30 days, hospital admissions within 30 days, quality of life, and mild unwanted effects. Postexposure prophylaxis (two studies) One study (966 people) compared bamlanivimab to placebo. Participants may have been exposed to wild‐type variants. Bamlanivimab: – probably reduces number of people infected; – may have little or no effect on deaths from any cause; – may increase unwanted effects (any severity) and serious unwanted effects slightly. We found no data for number of people who developed symptoms, hospital admissions, quality of life, mild, and severe unwanted effects. One study (2617 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and potentially, but unlikely Delta variants. Casirivimab/ imdevimab: – reduces number of people infected, development of symptoms, and unwanted effects (any severity); – may slightly reduce severe unwanted effects; – may have little or no effect on deaths, hospital admissions, and serious unwanted effects. We found no data for quality of life and mild unwanted effects. What are the limitations of the evidence? One study reported each comparison. All participants were unvaccinated at the beginning of the studies, which were conducted prior to the occurrence of Omicron. Our confidence in the evidence is high to very low. Although we have high confidence in the evidence found for relevant outcomes, the findings are not transferable to vaccinated people and variants that occurred outside the study periods, such as Omicron. Although laboratory studies have shown that tixagevimab/cilgavimab is effective against Omicron, there are no data from clinical studies. The other monoclonal antibodies included in this review were ineffective against Omicron in laboratory studies. Four ongoing studies are likely to change our conclusions and may help us understand how new variants and COVID‐19 vaccines affect the effectiveness of monoclonal antibodies in preventing COVID‐19. How up to date is this evidence? The evidence is up‐to‐date to 27 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hirsch, C, Park, YS, Piechotta, V, Chai, KL, Estcourt, LJ, Monsef, I, Salomon, S, Wood, EM, So-Osman, C, McQuilten, Z, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014945.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.812Z" }, { "id": "690289e9-dfbc-4de2-b889-9f06f22733a8", "pmid": "", "title": "Inhaled corticosteroids for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Inhaled corticosteroids are well established for the long‐term treatment of inflammatory respiratory diseases such as asthma or chronic obstructive pulmonary disease. They have been investigated for the treatment of coronavirus disease 2019 (COVID‐19). The anti‐inflammatory action of inhaled corticosteroids might have the potential to reduce the risk of severe illness resulting from hyperinflammation in COVID‐19. Objectives To assess whether inhaled corticosteroids are effective and safe in the treatment of COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (which includes CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO ICTRP, and medRxiv), Web of Science (Science Citation Index, Emerging Citation Index), and the WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies to 7 October 2021. Selection criteria We included randomised controlled trials (RCTs) evaluating inhaled corticosteroids for COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We included the following interventions: any type or dose of inhaled corticosteroids. We included the following comparison: inhaled corticosteroids plus standard care versus standard care (with or without placebo). We excluded studies examining nasal or topical steroids. Data collection and analysis We followed standard Cochrane methodology. For risk of bias assessment, we used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the outcomes of mortality, admission to hospital or death, symptom resolution, time to symptom resolution, serious adverse events, adverse events, and infections. Main results Inhaled corticosteroids plus standard care versus standard care (with/without placebo) People with a confirmed diagnosis of moderate‐to‐severe COVID‐19 We found no studies that included people with a confirmed diagnosis of moderate‐to‐severe COVID‐19. People with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included three RCTs allocating 3607 participants, of whom 2490 had confirmed mild COVID���19. We analysed a subset of the total number of participants recruited to the studies (2171, 52% female) as some trials had a platform design where not all participants were allocated to treatment groups simultaneously. The included studies were community‐based, recruiting people who were able to use inhaler devices to deliver steroids and relied on remote assessment and self‐reporting of outcomes. Most people were older than 50 years and had co‐morbidities such as hypertension, lung disease, or diabetes. The studies were conducted in high‐income countries prior to wide‐scale vaccination programmes. A total of 1057 participants were analysed in the inhaled corticosteroid arm (budesonide: 860 participants; ciclesonide: 197 participants), and 1075 participants in the control arm. No studies included people with asymptomatic SARS‐CoV‐2 infection. With respect to the following outcomes, inhaled corticosteroids compared to standard care: – may result in little to no difference in all‐cause mortality (at up to day 30) (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.22 to 1.67; 2132 participants; low‐certainty evidence). In absolute terms, this means that for every nine deaths per 1000 people not receiving inhaled corticosteroids, there were six deaths per 1000 people who did receive the intervention (95% CI 2 to 16 per 1000 people); – probably reduces admission to hospital or death (at up to 30 days) (RR 0.72, 95% CI 0.51 to 0.99; 2025 participants; moderate‐certainty evidence); – probably increases resolution of all initial symptoms at day 14 (RR 1.19, 95% CI 1.09 to 1.30; 1986 participants; moderate‐certainty evidence); – may reduce the duration to symptom resolution (at up to day 30) (by −4.00 days, 95% CI −6.22 to −1.78 less than control group rate of 12 days; 139 participants; low‐certainty evidence); – the evidence is very uncertain about the effect on serious adverse events (during study period) (RR 0.51, 95% CI 0.09 to 2.76; 1586 participants; very low‐certainty evidence); – may result in little to no difference in adverse events (at up to day 30) (RR 0.78, 95% CI 0.47 to 1.31; 400 participants; low‐certainty evidence); – may result in little to no difference in infections (during study period) (RR 0.88, 95% CI 0.30 to 2.58; 400 participants; low‐certainty evidence). As studies did not report outcomes for subgroups (e.g. age, ethnicity, sex), we did not perform subgroup analyses. Authors' conclusions In people with confirmed COVID‐19 and mild symptoms who are able to use inhaler devices, we found moderate‐certainty evidence that inhaled corticosteroids probably reduce the combined endpoint of admission to hospital or death and increase the resolution of all initial symptoms at day 14. Low‐certainty evidence suggests that corticosteroids make little to no difference in all‐cause mortality up to day 30 and may decrease the duration to symptom resolution. We do not know whether inhaled corticosteroids increase or decrease serious adverse events due to heterogeneity in the way they were reported across the studies. There is low‐certainty evidence that inhaled corticosteroids may decrease infections. The evidence we identified came from studies in high‐income settings using budesonide and ciclesonide prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, serious adverse events, and people with asymptomatic infection or with moderate‐to‐severe COVID‐19. The 10 ongoing and four completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. We monitor newly published results of RCTs on inhaled corticosteroids on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Are inhaled corticosteroids an effective treatment for people with mild COVID‐19? Key messages Inhaled corticosteroids (anti‐inflammatory medicines) given via the oral inhaled route are evaluated for treatment of coronavirus disease 2019 (COVID‐19). We identified three published studies for people with mild disease. Inhaled corticosteroids probably reduce the risk of people going to hospital or death (admission to hospital or death before hospital admission). Inhaled corticosteroids may lower the number of days people have symptoms of mild COVID‐19 and probably increase resolution of COVID‐19 symptoms at day 14. They may make little to no difference in death from any cause, and we do not have enough evidence to know whether they cause serious harms. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with moderate‐to‐severe COVID‐19. We found 10 ongoing and four completed unpublished studies. We will update this review when their results become available. What are inhaled corticosteroids? Inhaled corticosteroids are medicines that are breathed into the lower airways through an inhaler where they reduce inflammation in the lungs. They are commonly used to treat respiratory diseases like asthma and chronic obstructive pulmonary disease. Long‐term use and incorrect inhaler technique may lead to side effects that include a mouth infection called thrush, a change in voice, and an increased risk of lung infections. Good inhaler technique means the medicine does not stay in the mouth and throat. Why are inhaled corticosteroids possible treatments for COVID‐19? COVID‐19 mainly affects the lungs and airways. When the immune system fights the virus, the lungs and airways become inflamed. This inflammation causes breathing difficulties, and the lungs cannot easily move oxygen into the blood and remove carbon dioxide from the blood. What did we want to find out? People need more and better treatment options for asymptomatic SARS‐CoV‐2 infection (the virus that causes COVID‐19) or mild, moderate, or severe COVID‐19. We wanted to know if inhaled corticosteroids are an effective and helpful treatment option for COVID‐19 in any setting (for example, home or hospital) and whether they cause unwanted effects. We were interested in: – death from any cause up to day 30, day 60, or longer if reported; – admission to hospital or death within 30 days; – whether symptoms resolved and how fast; – quality of life; – unwanted effects. What did we do? We looked for studies where the investigators compared inhaled corticosteroids and usual care to usual care only, sometimes in addition to a dummy medicine that did not contain any active ingredients (placebo) but was given in the same way. To make the comparison least skewed and more fair, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the inhaled corticosteroids or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Three studies compared inhaled corticosteroids plus usual care compared to usual care with or without placebo in people with a confirmed diagnosis of mild COVID‐19. These studies analysed 2171 participants mostly older than 50 years and with other medical problems, 52% of them were female, of whom 1057 received inhaled corticosteroids in our analyses. We found no studies that included people with asymptomatic infection or confirmed diagnosis of moderate‐to‐severe COVID‐19. We also found 10 ongoing studies, and four completed studies without published results. Main results All studies compared inhaled corticosteroids with usual care or placebo. The studies included only people with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease. No studies looked at hospitalised people or people with asymptomatic SARS‐CoV‐2 infection. Inhaled corticosteroids – may make little to no difference in death from any cause up to day 30; – probably reduce the risk of admission to hospital or occurrence of death up to day 30; – probably increase resolution of COVID‐19 symptoms at day 14 and may reduce time to symptom resolution. We are very uncertain about a possible difference in serious unwanted effects. Moreover, inhaled corticosteroids may result in little to no difference in the number of any unwanted effects or additional infections. What are the limitations of the evidence? The studies were conducted in populations from wealthy countries, prior to the roll‐out of COVID‐19 vaccination programmes. We have moderate confidence in the evidence for the outcomes of symptom resolution at day 14 and hospital admission. We have low confidence in the evidence for the effects on deaths from any cause for people with mild COVID‐19 and time to symptom resolution. The confidence in the unwanted or serious unwanted effects and infections is low or very low, because of the differences in the way investigators recorded and reported results. There was no evidence for people with asymptomatic infection or moderate‐to‐severe COVID‐19 who were hospitalised. How up to date is this evidence? Our evidence is up‐to‐date to 7 October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Griesel, M; Wagner, C; Mikolajewska, A; Stegemann, M; Fichtner, F; Metzendorf, M-I; Nair, AAnil; Daniel, J; Fischer, A-L; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015125", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "690957c1-4e1f-4ad3-b542-9d340fd94361", "pmid": "", "title": "Perioperative nutrition interventions for women with ovarian cancer", "imported": false, "abstract": "Abstract - Background Women with ovarian cancer have been shown to be at significant risk of malnutrition with incidence rates described as being between 28% to 67%. Nutrition interventions may improve clinical outcomes positively, nutritional status or quality of life measures in this patient group. Objectives This review was conducted to assess the effects of nutrition interventions during the perioperative period for women with ovarian cancer. Search methods Electronic searches were conducted of the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 7), Medline (1946 to July week 4 2012), Embase (1980 to 2012 week 31), DARE (to 7th August 2012) AMED (1985 to April 2012), BNI (1992 to April 2012), CINAHL (to April 2012). We also searched trials databases, conference proceedings and related citation lists. Reference listings were handsearched. No restrictions were applied on language or date. Selection criteria Randomised controlled trials (RCTs) in which women 18 years and over with any stage of ovarian cancer, including recurrent cancer, were in the perioperative phase of treatment and received any type of nutrition intervention. Data collection and analysis Titles and abstracts were screened by two review authors with study selection discussed by a team. Pairs of review authors worked independently on data collection and compared findings. Main results A total of 4092 titles were screened and 14 full text reports reviewed; a single small study met the inclusion criteria. In the included RCT, 40 women (35 with ovarian cancer) had extensive elective surgery including bowel resection for treatment of gynaecological malignancy. Randomisation was made to either early oral feeding (oral fluids in the first 24 hours, solid foods on the following day) or to a 'traditional' feeding regimen where oral fluids and foods were delayed until there was evidence of bowel function. Most women in the early feeding group (14/18) were able to resume eating solid food one day after surgery. This resulted in a significantly shorter hospital stay with no increase in postoperative complications or change in quality of life measures in comparison with the women on the 'traditional' feeding regimen. The incidence of nausea and vomiting during the postoperative stay was similar in both groups and was noted in slightly more than half of the women. Overall survival was evaluated until 30 days following discharge from hospital; in this period, there was one death of a woman who had been in the 'traditional oral feeding' group, cause of death was not noted. We assessed risk of bias and found no high risk of bias was identified in the methodology and reporting of the included study, although there was an increased risk of bias due to the small size of the study in which not all of the women had ovarian cancer. Authors' conclusions Although women with ovarian cancer have been shown to be at risk of malnutrition, there is a lack of evidence derived from RCTs evaluating the identification, assessment and treatment of malnutrition during the perioperative phase of treatment. There is evidence from one small study that some women with ovarian cancer undergoing surgery with associated bowel resection may safely commence oral fluids within 24 hours of surgery and solid foods on the following day. Further research is required, including a RCT, to generate guidance concerning the treatment of malnutrition in this patient group. Plain language summary Nutrition for women who are having surgery for ovarian cancer Women who have ovarian cancer, (a cancer which develops in the two organs (ovaries) that produce eggs in women) are more likely to have difficulties with food and with eating a nourishing diet in comparison to women with other types of gynaecological cancers. One reason may be because the symptoms of ovarian cancer can be difficult to recognise. Women may have a lack of interest in food, feel full, feel sick or have a painful or swollen abdomen. Some women become thinner in parts of their bodies while becoming bigger around their abdomen due to an abnormal build up of fluid or large tumours. There may be no change in body weight or weight may increase, this can make it difficult to know which women are developing problems due to a poor food intake. Women who are unable to eat and drink well are at risk of becoming malnourished and may then have more complications from the treatments for ovarian cancer than women who are not malnourished. It is recommended that people who are having difficulties with eating and drinking should be identified and helped when they receive hospital care. Currently, there is no agreed method for finding and treating nutritional problems for women with ovarian cancer. In this review, the authors looked for studies (randomised controlled trials (RCTs)) from around the world to find out how women with ovarian cancer were assessed to see if they were eating and drinking well and what help they may be given with nutrition before or after surgery. A lack of information was found on this topic. One RCT was found where a small group of women (40 including 35 with ovarian cancer) requiring extensive elective surgery for gynaecological cancer including surgery to the gut, were able to restart eating normal foods on the day after surgery. They were able to leave hospital earlier and did not have more complications in the month after surgery than women who were not allowed to resume eating normal foods until at least three days after the operation. More studies are needed to confirm whether restarting normal eating one day after surgery can be recommended for women having surgery for ovarian cancer. More research is needed to provide information about how to identify and treat problems of malnutrition in women with ovarian cancer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Billson, HA; Holland, C; Curwell, J; Davey, VL; Kinsey, L; Lawton, LJ; Whitworth, AJ; Burden, S", "articleTypes": [], "doi": "10.1002/14651858.CD009884.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "6909f4ec-e048-4172-95fd-6c32d77b8a24", "pmid": "", "title": "Activation and Inhibition of the Sweet Taste Receptor T1R2-T1R3 Differentially Affect Glucose Tolerance in Humans", "imported": false, "abstract": "In the present study, our objective was to determine whether T1R2-T1R3 influences glucose metabolism bidirectionally via hyperactivation with sucralose and inhibition with sodium lactisole in mixture with glucose loads during tolerance tests in humans. In 12 healthy participants we conducted oral glucose tolerance tests (OGTTs) of 75 g glucose with and without the addition of the T1R2-T1R3 agonist, sucralose (5 mM). We also conducted OGTTs in 10 healthy participants with and without the addition of a T1R2-T1R3 antagonist, sodium lactisole (2 mM). Plasma glucose, insulin, and glucagon were measured before, during, and after OGTTs up to 120 minutes post-prandially. We also assessed individual participants' sweet taste responses to sucralose, their sensitivities to sweetness inhibition by lactisole, and their BMIs.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.144Z" }, { "id": "690a994d-258e-4cea-9569-4159df474fb8", "pmid": "", "title": "Cannabinoids for fibromyalgia", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue affecting approximately 2% of the general population. People often report high disability levels and poor health‐related quality of life (HRQoL). Drug therapy focuses on reducing key symptoms and disability, and improving HRQoL. Cannabis has been used for millennia to reduce pain and other somatic and psychological symptoms. Objectives To assess the efficacy, tolerability and safety of cannabinoids for fibromyalgia symptoms in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE to April 2016, together with reference lists of retrieved papers and reviews, three clinical trial registries, and contact with trial authors. Selection criteria We selected randomised controlled trials of at least four weeks' duration of any formulation of cannabis products used for the treatment of adults with fibromyalgia. Data collection and analysis Two review authors independently extracted the data of all included studies and assessed risk of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs; at least 200 participants in the comparison, eight to 12 weeks' duration, parallel design), second tier evidence from data that did not meet one or more of these criteria and were considered at some risk of bias but with adequate numbers (i.e. data from at least 200 participants) in the comparison, and third tier evidence from data involving small numbers of participants that were considered very likely to be biased or used outcomes of limited clinical utility, or both. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Main results We included two studies with 72 participants. Overall, the two studies were at moderate risk of bias. The evidence was derived from group mean data and completer analysis (very low quality evidence overall). We rated the quality of all outcomes according to GRADE as very low due to indirectness, imprecision and potential reporting bias. The primary outcomes in our review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Nabilone was compared to placebo and to amitriptyline in one study each. Study sizes were 32 and 40 participants. One study used a cross‐over design and one used a parallel group design; study duration was four or six weeks. Both studies used nabilone, a synthetic cannabinoid, with a bedtime dosage of 1 mg/day. No study reported the proportion of participants experiencing at least 30% or 50% pain relief or who were very much improved. No study provided first or second tier (high to moderate quality) evidence for an outcome of efficacy, tolerability and safety. Third tier (very low quality) evidence indicated greater reduction of pain and limitations of HRQoL compared to placebo in one study. There were no significant differences to placebo noted for fatigue and depression (very low quality evidence). Third tier evidence indicated better effects of nabilone on sleep than amitriptyline (very low quality evidence). There were no significant differences between the two drugs noted for pain, mood and HRQoL (very low quality evidence). More participants dropped out due to adverse events in the nabilone groups (4/52 participants) than in the control groups (1/20 in placebo and 0/32 in amitriptyline group). The most frequent adverse events were dizziness, nausea, dry mouth and drowsiness (six participants with nabilone). Neither study reported serious adverse events during the period of both studies. We planned to create a GRADE 'Summary of findings' table, but due to the scarcity of data we were unable to do this. We found no relevant study with herbal cannabis, plant‐based cannabinoids or synthetic cannabinoids other than nabilone in fibromyalgia. Authors' conclusions We found no convincing, unbiased, high quality evidence suggesting that nabilone is of value in treating people with fibromyalgia. The tolerability of nabilone was low in people with fibromyalgia. Plain language summary Cannabis products for people with fibromyalgia Background Fibromyalgia is characterised by chronic (longer than three months) widespread pain that often co‐exists with sleep problems, problems with thinking and fatigue (exhaustion). People often report severe limitations of daily functioning and poor health‐related quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. Cannabis has been used for 3000 years to reduce pain and other symptoms, such as loss of appetite and anxiety. Key results and quality of the evidence In April 2016 we searched for reports of clinical trials that used cannabis products to treat symptoms in adults with fibromyalgia. We found two small, moderate quality studies, of four and six weeks long, including 72 participants. Both studies tested nabilone, a synthetic (man‐made) cannabis product, comparing it with placebo (a dummy pill) or amitriptyline (an antidepressant frequently used in the treatment of fibromyalgia). Nabilone did not convincingly relieve fibromyalgia symptoms (pain, sleep, fatigue) better than placebo or amitriptyline (very low quality evidence). Compared with placebo and amitriptyline, more people experienced side effects and left the study due to side effects (very low quality evidence). There were no serious side effects reported. We found no relevant study with herbal cannabis, plant‐based cannabinoids or other synthetic cannabinoids than nabilone in fibromyalgia. There was not enough high quality evidence available to draw any robust conclusions. We found no studies on medical cannabis in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B, Klose, P, Fitzcharles, M-A, Phillips, T, Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.788Z" }, { "id": "692ba440-c937-485d-b99b-03a2ca67707d", "pmid": "", "title": "Topiramate for essential tremor", "imported": false, "abstract": "Abstract - Background Essential tremor (ET) is one of the most common movement disorders. The management is primarily based on pharmacological agents and in clinical practice propranolol and primidone are considered the first‐line therapy. However, these treatments can be ineffective in 25% to 55% of people and are frequently associated with serious adverse events (AEs). For these reasons, it is worthwhile evaluating other treatments for ET. Topiramate has been suggested as a potentially useful agent for the treatment of ET but there is uncertainty about its efficacy and safety. Objectives To assess the efficacy and safety of topiramate in the treatment of ET. Search methods We carried out a systematic search without language restrictions to identify all relevant trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to January 2017), Embase (January 1988 to January 2017), National Institute for Health and Care Excellence (1999 to January 2017), ClinicalTrials.gov (1997 to January 2017) and World Health Organization International Clinical Trials Registry Platform (ICTRP; 2004 to January 2017). We searched BIOSIS Citation Index (2000 to January 2017) for conference proceedings. We handsearched grey literature and the reference lists of identified studies and reviews. Selection criteria We included all randomised controlled trials (RCTs) of topiramate versus placebo/open control or any other treatments. We included studies in which the diagnosis of ET was made according to accepted and validated diagnostic criteria. We excluded studies conducted in people presenting with secondary forms of tremor or reporting only neurophysiological parameters to assess outcomes. Data collection and analysis Two review authors independently collected and extracted data using a data collection form. We assessed the risk of bias and the quality of evidence. We used a fixed‐effect meta‐analysis for data synthesis. Main results This review included three trials comparing topiramate to placebo (309 participants). They were all at high overall risk of bias. The quality of evidence ranged from very low to low. Compared to placebo, participants treated with topiramate showed a significant improvement in functional disability and an increased risk of withdrawal (risk ratio (RR) 1.78, 95% confidence interval (CI) 1.23 to 2.60). There were more AEs for topiramate‐treated participants, particularly paraesthesia, weight loss, appetite decrease and memory difficulty. Authors' conclusions This systematic review highlighted the presence of limited data and very low to low quality evidence to support the apparent efficacy and the occurrence of treatment‐limiting AEs in people with ET treated with topiramate. Further research to assess topiramate efficacy and safety on ET is needed. Plain language summary Use of topiramate for the treatment of essential tremor Review question The authors of this review tried to assess the effectiveness and safety of topiramate in people with essential tremor. Background Essential tremor is a type of uncontrollable shaking or trembling of parts of the body. Although it is not harmful in terms of its effect on life expectancy, it generally gets worse and may be disabling. Treatment is usually with medicines (called propranolol and primidone), which may not work in a quarter to a half of people with essential tremor. Some specialists have suggested that another medicine, topiramate, could be useful for treating the condition. Study characteristics We searched medical databases for studies of topiramate compared with placebo (a pretend tablet) or any other medicine in adults with essential tremor. We found three studies comparing topiramate versus placebo, involving 309 participants with moderate to severe essential tremor. Key results The effect of topiramate on daily activities, risk of stopping treatment and side effects was uncertain because the quality of evidence was very low to low. Quality of evidence We only found a few studies that had problems with their methods so we could not make firm conclusions about how well topiramate works and if it has side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Bruno, E; Nicoletti, A; Quattrocchi, G; Allegra, R; Filippini, G; Colosimo, C; Zappia, M", "articleTypes": [], "doi": "10.1002/14651858.CD009683.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "692c96ff-59c5-4a99-8f71-c9f21531721f", "pmid": "", "title": "Oral anti‐diabetic pharmacological therapies for the treatment of women with gestational diabetes", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is a major public health issue with rates increasing globally. Gestational diabetes, glucose intolerance first recognised during pregnancy, usually resolves after birth and is associated with short‐ and long‐term complications for the mother and her infant. Treatment options can include oral anti‐diabetic pharmacological therapies. Objectives To evaluate the effects of oral anti‐diabetic pharmacological therapies for treating women with GDM. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (14 May 2016), ClinicalTrials.gov , WHO ICTRP (14 May 2016) and reference lists of retrieved studies. Selection criteria We included published and unpublished randomised controlled trials assessing the effects of oral anti‐diabetic pharmacological therapies for treating pregnant women with GDM. We included studies comparing oral anti‐diabetic pharmacological therapies with 1) placebo/standard care, 2) another oral anti‐diabetic pharmacological therapy, 3) combined oral anti‐diabetic pharmacological therapies. Trials using insulin as the comparator were excluded as they are the subject of a separate Cochrane systematic review. Women with pre‐existing type 1 or type 2 diabetes were excluded. Data collection and analysis Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and data were checked for accuracy. Main results We included 11 studies (19 publications) (1487 women and their babies). Eight studies had data that could be included in meta‐analyses. Studies were conducted in Brazil, India, Israel, UK, South Africa and USA. The studies varied in diagnostic criteria and treatment targets for glycaemic control for GDM. The overall risk of bias was 'unclear' due to inadequate reporting of methodology. Using GRADE the quality of the evidence ranged from moderate to very low quality . Evidence was downgraded for risk of bias (reporting bias, lack of blinding), inconsistency, indirectness, imprecision and for oral anti‐diabetic therapy versus placebo for generalisability. Oral anti‐diabetic pharmacological therapies versus placebo/standard care There was no evidence of a difference between glibenclamide and placebo groups for hypertensive disorders of pregnancy (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.81 to 1.90; one study, 375 women, very low‐quality evidence), birth by caesarean section (RR 1.03, 95% CI 0.79 to 1.34; one study, 375 women, very low‐quality evidence), perineal trauma (RR 0.98, 95% CI 0.06 to 15.62; one study, 375 women, very low‐quality evidence) or induction of labour (RR 1.18, 95% CI 0.79 to 1.76; one study, 375 women; very low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant, there was no evidence of a difference in the risk of being born large‐for‐gestational age (LGA) between infants whose mothers had been treated with glibenclamide and those in the placebo group (RR 0.89, 95% CI 0.51 to 1.58; one study, 375, low‐quality evidence). No data were reported for other infant primary or GRADE outcomes (perinatal mortality, death or serious morbidity composite, neurosensory disability in later childhood, neonatal hypoglycaemia, adiposity, diabetes). Metformin versus glibenclamide There was no evidence of a difference between metformin‐ and glibenclamide‐treated groups for the risk of hypertensive disorders of pregnancy (RR 0.70, 95% CI 0.38 to 1.30; three studies, 508 women, moderate‐quality evidence), birth by caesarean section (average RR 1.20, 95% CI 1.20; 95% CI 0.83 to 1.72, four studies, 554 women, I 2 = 61%, Tau 2 = 0.07 low‐quality evidence), induction of labour (0.81, 95% CI 0.61 to 1.07; one study, 159 women; low‐quality evidence) or perineal trauma (RR 1.67, 95% CI 0.22 to 12.52; two studies, 158 women; low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant there was no evidence of a difference between the metformin‐ and glibenclamide‐exposed groups for the risk of being born LGA (average RR 0.67, 95% CI 0.24 to 1.83; two studies, 246 infants, I 2 = 54%, Tau 2 = 0.30 low‐quality evidence). Metformin was associated with a decrease in a death or serious morbidity composite (RR 0.54, 95% CI 0.31 to 0.94; one study, 159 infants, low‐quality evidence). There was no clear difference between groups for neonatal hypoglycaemia (RR 0.86, 95% CI 0.42 to 1.77; four studies, 554 infants, low‐quality evidence) or perinatal mortality (RR 0.92, 95% CI 0.06 to 14.55, two studies, 359 infants). No data were reported for neurosensory disability in later childhood or for adiposity or diabetes. Glibenclamide versus acarbose There was no evidence of a difference between glibenclamide and acarbose from one study (43 women) for any of their maternal or infant primary outcomes (caesarean section, RR 0.95, 95% CI 0.53 to 1.70; low‐quality evidence; perinatal mortality ‐ no events; low‐quality evidence; LGA , RR 2.38, 95% CI 0.54 to 10.46; low‐quality evidence). There was no evidence of a difference between glibenclamide and acarbose for neonatal hypoglycaemia (RR 6.33, 95% CI 0.87 to 46.32; low‐quality evidence). There were no data reported for other pre‐specified GRADE or primary maternal outcomes (hypertensive disorders of pregnancy, development of type 2 diabetes, perineal trauma, return to pre‐pregnancy weight, postnatal depression, induction of labour) or neonatal outcomes (death or serious morbidity composite, adiposity or diabetes). Authors' conclusions There were insufficient data comparing oral anti‐diabetic pharmacological therapies with placebo/standard care (lifestyle advice) to inform clinical practice. There was insufficient high‐quality evidence to be able to draw any meaningful conclusions as to the benefits of one oral anti‐diabetic pharmacological therapy over another due to limited reporting of data for the primary and secondary outcomes in this review. Short‐ and long‐term clinical outcomes for this review were inadequately reported or not reported. Current choice of oral anti‐diabetic pharmacological therapy appears to be based on clinical preference, availability and national clinical practice guidelines. The benefits and potential harms of one oral anti‐diabetic pharmacological therapy compared with another, or compared with placebo/standard care remains unclear and requires further research. Future trials should attempt to report on the core outcomes suggested in this review, in particular long‐term outcomes for the woman and the infant that have been poorly reported to date, women's experiences and cost benefit. Plain language summary Oral medication for the treatment of women with gestational diabetes What is the issue? Globally the number of women being diagnosed with gestational diabetes mellitus (GDM) is increasing. GDM is an intolerance to glucose leading to high blood sugars, first recognised during pregnancy and usually resolving after birth. Standard care involves lifestyle advice on diet and exercise. Treatment for some women includes oral anti‐diabetic medications, such as metformin and glibenclamide, which are an alternative to, or can be used alongside, insulin to control the blood sugar. This review aimed to investigate benefits of taking oral medication to treat GDM in pregnant women. Another Cochrane Review compares the effects of insulin with oral anti‐diabetic pharmacological therapies ( Brown 2016 ). Why is this important? Women diagnosed with GDM are at a greater risk of experiencing complications such as high blood pressure during pregnancy and at birth. They have an increased risk of developing diabetes later in life. The babies of women who have been diagnosed with GDM can be larger than normal and this can cause injuries to the mother and the baby at birth. The birth is more likely to be induced or the baby born by caesarean section. These babies are at risk of developing diabetes as children or young adults. Finding the best medications to treat the women and prevent the complications that are linked to GDM is therefore important. What evidence did we find? We searched for studies on 14 May 2016. We included 11 randomised controlled trials involving 1487 mothers and their babies (but only eight trials contributed data to our analyses). The evidence was limited by the quality and number of studies and we advise caution when looking at the results. The criteria for diagnosis of GDM and treatment targets varied between studies, and each outcome is based on few studies with low numbers of women. Three studies compared oral medication with placebo/standard care but the following findings are from a single study (375 women). The quality of the evidence was very low or low. We found no differences between the oral medication and placebo group for the risk of high blood pressure, birth by caesarean section, induction of labour or perineal trauma. The number of babies born large‐for‐gestational age, with low blood sugars or dying at birth was not clearly different between the groups. Two studies (434 women) reported no difference in the need for insulin between the oral medication and placebo group. Six studies compared metformin with glibenclamide. The quality of the evidence was very low to moderate. We found no difference between metformin and glibenclamide for the risk of high blood pressure (three studies, 508 women, moderate‐quality evidence), birth by caesarean section (four studies, 554 women, low‐quality evidence), perineal trauma (two studies, 308 women, low‐quality evidence) or induction of labour (one study, 159 women, low‐quality evidence). We found no difference between metformin and glibenclamide for the baby having low blood sugars (four studies, 554 infants, low‐quality evidence), being born large‐for‐gestational age (two studies, 246 infants) or dying at birth (all low‐ or very low‐quality evidence). In one study, the babies of the mothers taking metformin were at reduced risk of having any serious outcome (low blood sugar, jaundice, being born large, breathing problems, injury at birth or death combined) (low‐quality evidence). One small study (43 women) comparing glibenclamide with acarbose reported no differences in outcomes for mothers or their babies. None of the included studies provided any data on many of the outcomes pre‐specified in this review, including long‐term outcomes for the mother or for the baby as a child or an adult. What does this mean? There is not enough high‐quality evidence available to guide us on if oral medication has better outcomes for women with gestational diabetes, and their babies, compared with a placebo or if one oral medication has better health outcomes than another oral medication. Because we are still unclear, further research is needed. Future studies should be encouraged to report on the outcomes suggested in this review and in particular the long‐term outcomes for the woman and the infant that have been poorly reported to date.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Brown, J; Martis, R; Hughes, B; Rowan, J; Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD011967.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "695944f2-b0fc-4a70-9854-a735bb5adffa", "pmid": "", "title": "Interactions of Human Gut Microbiota With Intestinal Sweet Taste Receptors", "imported": false, "abstract": "The purpose of this study is to collect data to examine whether short-term consumption of non-caloric artificial sweeteners (NCASs), such as saccharin, can lead to changes in blood sugar levels and in the composition of the bacteria in the large intestine.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.230Z" }, { "id": "695f6f48-57e9-4e01-92ce-82ab92dce1da", "pmid": "", "title": "Green tea for weight loss and weight maintenance in overweight or obese adults", "imported": false, "abstract": "Abstract - Background Preparations of green tea are used as aids in weight loss and weight maintenance. Catechins and caffeine, both contained in green tea, are each believed to have a role in increasing energy metabolism, which may lead to weight loss. A number of randomised controlled trials (RCTs) evaluating the role of green tea in weight loss have been published; however, the efficacy of green tea preparations in weight loss remains unclear. Objectives To assess the efficacy and safety of green tea preparations for weight loss and weight maintenance in overweight or obese adults. Search methods We searched the following databases from inception to specified date as well as reference lists of relevant articles: The Cochrane Library (Issue 12, 2011), MEDLINE (December 2011), EMBASE (December 2011), CINAHL (January 2012), AMED (January 2012), Biological Abstracts (January 2012), IBIDS (August 2010), Obesity+ (January 2012), IPA (January 2012) and Web of Science (December 2011). Current Controlled Trials with links to other databases of ongoing trials was also searched. Selection criteria RCTs of at least 12 weeks' duration comparing green tea preparations to a control in overweight or obese adults. Data collection and analysis Three authors independently extracted data, assessed studies for risk of bias and quality, with differences resolved by consensus. Heterogeneity of included studies was assessed visually using forest plots and quantified using the I 2 statistic. We synthesised data using meta‐analysis and descriptive analysis as appropriate; subgroup and sensitivity analyses were conducted. Adverse effects reported in studies were recorded. Main results Due to the level of heterogeneity among studies, studies were divided into two groups; those conducted in Japan and those conducted outside Japan. Study length ranged between 12 and 13 weeks. Meta‐analysis of six studies conducted outside Japan showed a mean difference (MD) in weight loss of ‐0.04 kg (95% CI ‐0.5 to 0.4; P = 0.88; I 2 = 18%; 532 participants). The eight studies conducted in Japan were not similar enough to allow pooling of results and MD in weight loss ranged from ‐0.2 kg to ‐3.5 kg (1030 participants) in favour of green tea preparations. Meta‐analysis of studies measuring change in body mass index (BMI) conducted outside Japan showed a MD in BMI of ‐0.2 kg/m 2 (95% CI ‐0.5 to 0.1; P = 0.21; I 2 = 38%; 222 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed a reduction in BMI ranging from no effect to ‐1.3 kg/m 2 (1030 participants), in favour of green tea preparations over control. Meta‐analysis of five studies conducted outside Japan and measuring waist circumference reported a MD of ‐0.2 cm (95% CI ‐1.4 to 0.9; P = 0.70; I 2 = 58%; 404 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed effects on waist circumference ranging from a gain of 1 cm to a loss of 3.3 cm (1030 participants). Meta‐analysis for three weight loss studies, conducted outside Japan, with waist‐to‐hip ratio data (144 participants) yielded no significant change (MD 0; 95% CI ‐0.02 to 0.01). Analysis of two studies conducted to determine if green tea could help to maintain weight after a period of weight loss (184 participants) showed a change in weight loss of 0.6 to ‐1.6 kg, a change in BMI from 0.2 to ‐0.5 kg/m 2 and a change in waist circumference from 0.3 to ‐1.7 cm. In the eight studies that recorded adverse events, four reported adverse events that were mild to moderate, with the exception of two (green tea preparations group) that required hospitalisation (reported as not associated with the intervention). Nine studies reported on compliance/adherence, one study assessed attitude towards eating as part of the health‐related quality of life outcome. No studies reported on patient satisfaction, morbidity or cost. Authors' conclusions Green tea preparations appear to induce a small, statistically non‐significant weight loss in overweight or obese adults. Because the amount of weight loss is small, it is not likely to be clinically important. Green tea had no significant effect on the maintenance of weight loss. Of those studies recording information on adverse events, only two identified an adverse event requiring hospitalisation. The remaining adverse events were judged to be mild to moderate. Plain language summary Green tea for weight loss and weight maintenance in overweight or obese adults Green tea has a long history of many uses, one of which is helping overweight people to lose weight and to maintain weight loss. Believed to be able to increase a person's energy output, green tea weight loss preparations are extracts of green tea that contain a higher concentration of ingredients (catechins and caffeine) than the typical green tea beverage prepared from a tea bag and boiling water. This review looked at 15 weight loss studies and three studies measuring weight maintenance where some form of a green tea preparation was given to one group and results compared to a group receiving a control. Neither group knew whether they were receiving the green tea preparation or the control. A total of 1945 participants completed the studies, ranging in length from 12 to 13 weeks. In summary, the loss in weight in adults who had taken a green tea preparation was statistically not significant, was very small and is not likely to be clinically important. Similar results were found in studies that used other ways to measure loss in weight (body mass index, waist circumference). Studies examining the effect of green tea preparations on weight maintenance did not show any benefit compared to the use of a control preparation. Most adverse effects, such as nausea, constipation, abdominal discomfort and increased blood pressure, were judged to be mild to moderate and to be unrelated to the green tea or control intervention. No deaths were reported, although adverse events required hospitalisation. One study attempted to look at health‐related quality of life by asking participants about their attitudes towards eating. Nine studies tracked participants' compliance with green tea preparations. Studies did not include any information about the effects of green tea preparations on morbidity, costs or patient satisfaction.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Jurgens, TM, Whelan, AM, Killian, L, Doucette, S, Kirk, S, Foy, E", "articleTypes": [], "doi": "10.1002/14651858.CD008650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.767Z" }, { "id": "696d89fb-ff64-4711-8a50-b59268a7bbd0", "pmid": "", "title": "Eradication therapy for peptic ulcer disease in Helicobacter pylori‐positive people", "imported": false, "abstract": "Abstract - Background Peptic ulcer disease is the cause of dyspepsia in about 10% of people. Ninety‐five percent of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori . Eradication of H. pylori reduces the relapse rate of ulcers but the magnitude of this effect is uncertain. This is an update of Ford AC, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori ‐positive patients. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003840. DOI: 10.1002/14651858.CD003840.pub4. Objectives To assess the proportion of peptic ulcers healed and the proportion of participants who remained free from relapse with eradication therapy against placebo or other pharmacological therapies in H. pylori ‐positive people. To assess the proportion of participants that achieved complete relief of symptoms and improvement in quality of life scores. To compare the incidence of adverse effects/drop‐outs (total number for each drug) associated with the different treatments. To assess the proportion of participants in whom successful eradication was achieved. Search methods In this update, we identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1950 to March 2016) and Ovid EMBASE (1980 to March 2016). To identify further relevant trials, we handsearched reference lists from trials selected by electronic searching, and published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ). The search was last updated in March 2016. We contacted members of Cochrane Upper GI and Pancreatic Diseases, and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials of short‐ and long‐term treatment of peptic ulcer disease in H. pylori ‐positive adults. Participants received at least one week of H. pylori eradication compared with ulcer healing drug, placebo or no treatment. Trials were included if they reported assessment from two weeks onwards. Data collection and analysis We collected data on ulcer healing, recurrence, relief of symptoms and adverse effects. We calculated the risk ratio (RR) with 95% confidence intervals (CI) using both fixed‐effect and random‐effects models with Review Manager software (RevMan 5.3) based on intention‐to‐treat analysis as far as possible. Main results A total of 55 trials were included for one or more outcomes for this review. In duodenal ulcer healing, eradication therapy was superior to ulcer healing drug (UHD) (34 trials, 3910 participants, RR of ulcer persisting = 0.66, 95% confidence interval (CI) 0.58 to 0.76; 381/2286 (adjusted proportion: 12.4%) in eradication therapy plus UHD versus 304/1624 (18.7%) in UHD; low quality evidence) and no treatment (two trials, 207 participants, RR 0.37, 95% CI 0.26 to 0.53; 30/125 (adjusted proportion: 21.7%) in eradication therapy versus 48/82 (58.5%) in no treatment; low quality evidence). In gastric ulcer healing, the differences were imprecise between eradication therapy and UHD (15 trials, 1974 participants, RR 1.23, 95% CI 0.90 to 1.68; 220/1192 (adjusted proportion: 16.0%) in eradication therapy plus UHD versus 102/782 (13.0%) in UHD; very low quality evidence). In preventing duodenal ulcer recurrence the differences were imprecise between maintenance therapy with H.pylori eradication therapy and maintenance therapy with UHD (four trials, 319 participants, RR of ulcer recurring 0.73; 95% CI 0.42 to 1.25; 19/159 (adjusted proportion: 11.9%) in eradication therapy versus 26/160 (16.3%) in UHD; very low quality evidence), but eradication therapy was superior to no treatment (27 trials 2509 participants, RR 0.20, 95% CI 0.15 to 0.26; 215/1501 (adjusted proportion: 12.9%) in eradication therapy versus 649/1008 (64.4%) in no treatment; very low quality evidence). In preventing gastric ulcer recurrence, eradication therapy was superior to no treatment (12 trials, 1476 participants, RR 0.31, 95% CI 0.22 to 0.45; 116/697 (adjusted proportion: 16.3%) in eradication therapy versus 356/679 (52.4%) in no treatment; very low quality evidence). None of the trials reported proportion of people with gastric ulcer not healed after initial therapy between H.pylori eradication therapy and no active treatment or the proportion of people with recurrent gastric ulcer or peptic ulcers during maintenance therapy between H.pylori eradication therapy and ulcer healing drug therapy. Authors' conclusions Adding a one to two‐week course of H. pylori eradication therapy is an effective treatment for people with H. pylori‐ positive duodenal ulcer when compared to ulcer healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer healing drug. However, confidence intervals were wide and significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment, and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Plain language summary Antibiotics for people with peptic ulcers caused by Helicobacter pylori infection Review question Are antibiotics useful for the treatment of peptic ulcer (ulcers in the stomach or upper small intestine) in people with Helicobacter pylori ( H. pylori ) infection? Background Peptic ulcers are caused by acidic stomach juices damaging the lining of the stomach (gastric ulcer) or upper small intestine (duodenal ulcer). This causes pain, indigestion and sometimes, bleeding. Ulcers can return after being healed, especially if the person is infected with Helicobacter pylori (a lifelong infection unless treated). H. pylori causes most peptic ulcers. It is not clear whether eradicating H.pylori by treating with antibiotics as part of a combination of drugs ( H.pylori eradication therapy) is helpful in the treatment of people with peptic ulcers compared to no treatment or other medical treatments. This is an update of a previous Cochrane review published in 2006. Study characteristics Fifty‐five studies provided information for the review. Thirty‐four studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of duodenal ulcer. Two studies compared H. pylori eradication therapy against no treatment in the healing of duodenal ulcer. Fifteen studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of gastric ulcer. Three studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of peptic ulcer (gastric or duodenal ulcer). One study compared H. pylori eradication therapy against no treatment in the healing of peptic ulcer (gastric or duodenal ulcer). Four studies compared H. pylori eradication therapy against ulcer‐healing drug in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twenty‐seven studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twelve studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of gastric ulcer after initial ulcer had been healed, while one study compared H. pylori eradication therapy against no treatment in preventing the recurrence of peptic ulcer (gastric or duodenal ulcer) after initial ulcer had been healed. Four studies compared H. pylori eradication therapy plus ulcer‐healing drug versus comparison regimen in the relief of symptoms from peptic ulcer (gastric or duodenal ulcer). There were no studies comparing H. pylori eradication therapy against no treatment in the healing of gastric ulcer, H. pylori eradication therapy against ulcer‐healing drug as maintenance therapy in preventing the recurrence of gastric ulcer after initial ulcer had been healed, or H. pylori eradication therapy plus ulcer‐healing drug against no treatment or ulcer‐healing drug in the relief of symptoms in people with peptic ulcer. Some trials provided information for more than one comparison. The evidence is current until March 2016. Key results Adding a one to two‐week course of H. pylori eradication therapy speeds up ulcer healing for people with H. pylori‐ positive duodenal ulcer when compared to ulcer‐healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer (ulcer returning after initial healing) compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer‐healing drugs. However, because of the small number of studies included for the last two comparisons, significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Quality of the evidence The quality of evidence was low or very low because most of the studies had errors in study design. As a result, there is a lot of uncertainty regarding the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Ford, AC, Gurusamy, KS, Delaney, B, Forman, D, Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD003840.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.067Z" }, { "id": "696e3916-c692-465c-bf5d-93db67d8098f", "pmid": "", "title": "Short‐course oral steroids alone for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of oral corticosteroids compared with placebo/no intervention or other pharmacological interventions (intranasal corticosteroids, antibiotics, antifungals) for chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids with placebo or no treatment or compared with other pharmacological interventions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included eight RCTs (474 randomised participants), which compared oral corticosteroids with placebo or no intervention. All trials only recruited adults with chronic rhinosinusitis with nasal polyps. All trials reported outcomes at two to three weeks, at the end of the short‐course oral steroid treatment period. Three trials additionally reported outcomes at three to six months. Two of these studies prescribed intranasal steroids to patients in both arms of the trial at the end of the oral steroid treatment period. Oral steroids versus placebo or no intervention Disease‐specific health‐related quality of life was reported by one study. This study reported improved quality of life after treatment (two to three weeks) in the group receiving oral steroids compared with the group who received placebo (standardised mean difference (SMD) ‐1.24, 95% confidence interval (CI) ‐1.92 to ‐0.56, 40 participants, modified RSOM‐31), which corresponds to a large effect size. We assessed the evidence to be low quality (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). Disease severity as measured by patient‐reported symptom scores was reported by two studies, which allowed the four key symptoms used to define chronic rhinosinusitis (nasal blockage, nasal discharge, facial pressure, hyposmia) to be combined into one score. The results at the end of treatment (two to three weeks) showed an improvement in patients receiving oral steroids compared to placebo, both when presented as a mean final value (SMD ‐2.84, 95% CI ‐4.09 to ‐1.59, 22 participants) and as a change from baseline (SMD ‐2.28, 95% CI ‐2.76 to ‐1.80, 114 participants). These correspond to large effect sizes but we assessed the evidence to be low quality. One study (114 participants) followed patients for 10 weeks after the two‐week treatment period. All patients in both arms received intranasal steroids at the end of the oral steroid treatment period. The results showed that the initial results after treatment were not sustained (SMD ‐0.22, 95% CI ‐0.59 to 0.15, 114 participants, percentage improvement from baseline). This corresponds to a small effect size and we assessed the evidence to be low quality. There was an increase in adverse events in people receiving orals steroids compared with placebo for gastrointestinal disturbances (risk ratio (RR) 3.45, 95% CI 1.11 to 10.78; 187 participants; three studies) and insomnia (RR 3.63, 95% CI 1.10 to 11.95; 187 participants; three studies). There was no significant impact of oral steroids on mood disturbances at the dosage used in the included study (risk ratio (RR) 2.50, 95% CI 0.55 to 11.41; 40 participants; one study). We assessed the evidence to be low quality due to the lack of definitions of the adverse events and the small number of events or sample size, or both). Other comparisons No studies that compared short‐course oral steroids with other treatment for chronic rhinosinusitis met the inclusion criteria. Authors' conclusions At the end of the treatment course (two to three weeks) there is an improvement in health‐related quality of life and symptom severity in patients with chronic rhinosinusitis with nasal polyps taking oral corticosteroids compared with placebo or no treatment. The quality of the evidence supporting this finding is low. At three to six months after the end of the oral steroid treatment period, there is little or no improvement in health‐related quality of life or symptom severity for patients taking an initial course of oral steroids compared with placebo or no treatment. The data on the adverse effects associated with short courses of oral corticosteroids indicate that there may be an increase in insomnia and gastrointestinal disturbances but it is not clear whether there is an increase in mood disturbances. All of the adverse events results are based on low quality evidence. More research in this area, particularly research evaluating patients with chronic rhinosinusitis without nasal polyps, longer‐term outcomes and adverse effects, is required. There is no evidence for oral steroids compared with other treatments. Plain language summary Short‐term oral corticosteroids compared with no treatment or other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of a short course (typically up to 21 days) of corticosteroid given by mouth to people with chronic rhinosinusitis compared with giving a placebo or no treatment, or another type of treatment. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling the inflammatory response and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included eight randomised controlled trials with a total of 474 participants. All of the patients were adults who had chronic rhinosinusitis with nasal polyps. All of the studies followed patients until the end of treatment (two to three weeks) and three studies (210 participants) followed up people for three to six months after the initial treatment had ended. Five of the eight reports mentioned how the trial was funded. None of the funding sources were pharmaceutical companies. Key results At the end of a two‐ or three‐week treatment course, people who took oral steroids may have had a better quality of life, less severe symptoms and smaller nasal polyps than people who had placebo or did not receive any treatment. After three to six months, there was little or no difference in quality of life, symptom severity or nasal polyps between the people who had oral steroids and the people who had placebo or no intervention. The people who took oral steroids may have had more gastrointestinal disturbances and insomnia than the people who had placebo or no intervention. It is not clear if the people who took oral steroids had more mood disturbances than the people who had placebo or no intervention. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate), as the some of the results are only from one or two studies, which do not have a lot of participants. Most of the trials do not have a high risk of bias, but only people with nasal polyps were included in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K, Chong, LY, Hopkins, C, Philpott, C, Burton, MJ, Schilder, AGM", "articleTypes": [], "doi": "10.1002/14651858.CD011991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.079Z" }, { "id": "6988d868-d542-4dd9-9fe7-e1c29d892dd5", "pmid": "", "title": "Paroxetine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Paroxetine is the most potent inhibitor of the reuptake of serotonin of all selective serotonin reuptake inhibitors (SSRIs) and has been studied in many randomised controlled trials (RCTs). However, these comparative studies provided contrasting findings and systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to paroxetine alone. The present systematic review assessed the efficacy and tolerability profile of paroxetine in comparison with tricyclics (TCAs), SSRIs and newer or non‐conventional agents. Objectives 1. To determine the efficacy of paroxetine in comparison with other anti‐depressive agents in alleviating the acute symptoms of Major Depressive Disorder. 2. To review acceptability of treatment with paroxetine in comparison with other anti‐depressive agents. 3. To investigate the adverse effects of paroxetine in comparison with other anti‐depressive agents. Search methods We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR, to 30 September 2012), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Reference lists of relevant papers and previous systematic reviews were handsearched. Pharmaceutical companies marketing paroxetine and experts in this field were contacted for supplemental data. Selection criteria All randomised controlled trials allocating participants with major depression to paroxetine versus any other antidepressants (ADs), both conventional (such as TCAs, SSRIs) and newer or non‐conventional (such as hypericum). For trials which had a cross‐over design, only results from the first randomisation period were considered. Data collection and analysis Two review authors independently checked eligibility and extracted data using a standard form. Data were then entered in RevMan 5.2 with a double‐entry procedure. Information extracted included study and participant characteristics, intervention details, settings and efficacy, acceptability and tolerability measures. Main results A total of 115 randomised controlled trials (26,134 participants) were included. In 54 studies paroxetine was compared with older ADs, in 21 studies with another SSRI, and in 40 studies with a newer or non‐conventional antidepressant other than SSRIs. For the primary outcome (patients who responded to treatment), paroxetine was more effective than reboxetine at increasing patients who responded early to treatment (Odds Ratio (OR): 0.66, 95% Confidence Interval (CI) 0.50 to 0.87, number needed to treat to provide benefit (NNTb) = 16, 95% CI 10 to 50, at one to four weeks, 3 RCTs, 1375 participants, moderate quality of evidence), and less effective than mirtazapine (OR: 2.39, 95% CI 1.42 to 4.02, NNTb = 8, 95% CI 5 to 14, at one to four weeks, 3 RCTs, 726 participants, moderate quality of evidence). Paroxetine was less effective than citalopram in improving response to treatment (OR: 1.54, 95% CI 1.04 to 2.28, NNTb = 9, 95% CI 5 to 102, at six to 12 weeks, 1 RCT, 406 participants, moderate quality of evidence). We found no clear evidence that paroxetine was more or less effective compared with other antidepressants at increasing response to treatment at acute (six to 12 weeks), early (one to four weeks), or longer term follow‐up (four to six months). Paroxetine was associated with a lower rate of adverse events than amitriptyline, imipramine and older ADs as a class, but was less well tolerated than agomelatine and hypericum. Included studies were generally at unclear or high risk of bias due to poor reporting of allocation concealment and blinding of outcome assessment, and incomplete reporting of outcomes. Authors' conclusions Some possibly clinically meaningful differences between paroxetine and other ADs exist, but no definitive conclusions can be drawn from these findings. In terms of response, there was a moderate quality of evidence that citalopram was better than paroxetine in the acute phase (six to 12 weeks), although only one study contributed data. In terms of early response to treatment (one to four weeks) there was moderate quality of evidence that mirtazapine was better than paroxetine and that paroxetine was better than reboxetine. However there was no clear evidence that paroxetine was better or worse compared with other antidepressants at increasing response to treatment at any time point. Even if some differences were identified, the findings from this review are better thought as hypothesis forming rather than hypothesis testing and it would be reassuring to see the conclusions replicated in future trials. Finally, most of included studies were at unclear or high risk of bias, and were sponsored by the drug industry. The potential for overestimation of treatment effect due to sponsorship bias should be borne in mind. Plain language summary Paroxetine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms such as appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, inappropriate guilt and morbid thoughts of death. Although medication and psychological treatments are both effective for major depression, antidepressant drugs remain the mainstay of treatment in moderate to severe major depression. However, head‐to‐head comparisons of such drugs provide contrasting findings as to whether they are effective. This review of the research on the effect of an antidepressant drug called paroxetine was conducted to shed light on the field of drug treatment for depression. In September 2012 we searched, in a wide ranging way, for all the useful studies (randomised controlled trials) which had been completed which compared paroxetine with any other antidepressant in treating people with depression. One hundred and fifteen studies were included in this review, with a total of 26,134 people. We grouped the studies according to the types of drug they compared paroxetine against; we then analysed the combined findings of these groups of studies. For the primary outcome (number of people who responded to treatment) paroxetine was more effective than reboxetine, but less effective than mirtazapine (in the early phase: one to four weeks follow‐up) and probably citalopram (at endpoint: six weeks follow‐up). There was some evidence that paroxetine is less well tolerated than agomelatine and St John's Wort, as more patients allocated to paroxetine experienced at least some side effects (though this finding for St John's Wort was only based on one study). In conclusion, some possibly meaningful differences between paroxetine and other antidepressants exist, but no definitive concluions can be drawn due to the limited number of studies per comparison. In addition, most of included studies were sponsored by the drug industry, which means they might potentially have overestimated the effect of paroxetine. Therefore, the results of this review should be interpreted with caution.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Purgato, M, Papola, D, Gastaldon, C, Trespidi, C, Magni, LR, Rizzo, C, Furukawa, TA, Watanabe, N, Cipriani, A, Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006531.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.792Z" }, { "id": "698ba930-6427-4cbd-a9f9-6e6861342cdc", "pmid": "", "title": "Beclomethasone versus placebo for chronic asthma", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Adams, NP, Bestall, JC, Malouf, R, Lasserson, TJ, Jones, P", "articleTypes": [], "doi": "10.1002/14651858.CD002738.pub2 AB - Abstract - Background Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti‐inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane‐134a (HFA) propellant which is free from chlorofluorocarbon (CFC). Objectives The objectives of this review were to: 
 (1) Compare the efficacy of BDP with placebo with both CFC and HFA propellants in the treatment of chronic asthma. 
 (2) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. 
 (3) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies. Search methods Electronic searches were current as of January 2003. Selection criteria Randomised parallel group design trials for a minimum period of four weeks, in children and adults comparing CFC‐BDP or HFA‐BDP with placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality. Data collection and analysis One reviewer extracted data; authors were contacted to clarify missing information. We analysed data with RevMan Analyses 1.0.2. Main results 60 studies recruiting 6542 participants met the inclusion criteria. CFC‐BDP (57 studies): In non‐oral steroid treated patients, at doses of 400mcg/day or less CFC‐BDP produced significant improvements from baseline in a number of efficacy measures compared with placebo, including forced expiratory volume in one second (FEV1) 360 ml (95% CI 260 to 460); FEV1 (% predicted) WMD 12.41% (95% CI 8.18 to 16.64) and morning peak expiratory flow rate (am PEF) WMD 35.95 L/min (95% CI 27.85 to 44.04). BDP also led to reductions in rescue beta‐2 agonist use compared with placebo of ‐2.32 puffs/d (95% CI ‐2.55 to ‐2.09) and reduced the relative risk (RR) of trial withdrawal due to an asthma exacerbation 0.25 (95% CI 0.12 to 0.51). Subgroup analyses based on treatment duration provide support to the proposal that a treatment period of greater than four weeks is required to realise a fuller treatment effect. In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD ‐4.91 mg/d (95% CI ‐5.88 to ‐3.94 mg/d) and greater likelihood of withdrawing oral steroid treatment RR 8.02 (95% CI 3.23 to 19.92). HFA‐BDP (3 studies): In non‐oral steroid‐treated patients, HFA‐BDP was significantly more effective than placebo in improving FEV1, morning and evening PEF, FEF25 to 75%, reduced asthma symptoms and beta2‐agonists daily consumption. Significant effects for such outcomes were apparent after six weeks of treatment. In oral steroid treated patients, HFA‐BDP improved significantly FEV1 and am PEF. The summary estimates for these outcomes suggested a high level of heterogeneity, and divergent aims of the studies may contribute to the variation we observed. Limited data on adverse events were reported. Authors' conclusions This review has quantified the efficacy of CFC‐BDP and HFA‐BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose‐response in people with severe asthma. Plain language summary Inhaled beclomethasone compared with placebo for chronic asthma During an asthma attack, the airways narrow, causing breathing problems, wheezing and coughing. Inhaled corticosteroids (ICS) are used to reduce swelling of the airways. Inhaled beclomethasone dipropionate (BDP) is commonly used. There is now a new formulation of the drug which uses a new propellant (HFA‐BDP). This review of trials found that BDP delivered with the old and new propellant is effective in helping people with chronic asthma. BDP at all doses improves airflow, reduces symptoms and the need for rescue bronchodilators. The review only included studies conducted for more than 4 weeks. The drug was well tolerated and the safety profile was comparable with placebo. The findings apply to both children and adults. The effects of the new propellant suggest that it could be more effective than the older version, although a different review will address that particular question.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.792Z" }, { "id": "69979bf9-2e20-44a6-bb97-3ba4b121b124", "pmid": "", "title": "Randomised Controlled Trials to Assess Approved SARS-CoV-2 Vaccines in Immunocompromised Patients: A Master Protocol for the Set-up of a Swiss Cohorts Based Trial Platform", "imported": false, "abstract": "This study is to set up a flexible trial platform using two existing national cohorts of immunocompromised patients (i.e. Swiss HIV Cohort Study [SHCS] and Swiss Transplant Cohort Study [STCS]) to assess the comparative effectiveness and safety of approved SARS-CoV-2 vaccines in immunocompromised patients.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.246Z" }, { "id": "699d860f-a43e-495b-b48b-7b4f0f030cf2", "pmid": "", "title": "Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users", "imported": false, "abstract": "Abstract - Background Prolonged treatment with benzodiazepines is common practice despite clinical recommendations of short‐term use. Benzodiazepines are used by approximately 4% of the general population, with increased prevalence in psychiatric populations and the elderly. After long‐term use it is often difficult to discontinue benzodiazepines due to psychological and physiological dependence. This review investigated if pharmacological interventions can facilitate benzodiazepine tapering. Objectives To assess the benefits and harms of pharmacological interventions to facilitate discontinuation of chronic benzodiazepine use. Search methods We searched the following electronic databases up to October 2017: Cochrane Drugs and Alcohol Group's Specialised Register of Trials, CENTRAL, PubMed, Embase, CINAHL, and ISI Web of Science. We also searched ClinicalTrials.gov, the WHO ICTRP, and ISRCTN registry, and checked the reference lists of included studies for further references to relevant randomised controlled trials. Selection criteria We included randomised controlled trials comparing pharmacological treatment versus placebo or no intervention or versus another pharmacological intervention in adults who had been treated with benzodiazepines for at least two months and/or fulfilled criteria for benzodiazepine dependence (any criteria). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 38 trials (involving 2543 participants), but we could only extract data from 35 trials with 2295 participants. Many different interventions were studied, and no single intervention was assessed in more than four trials. We extracted data on 18 different comparisons. The risk of bias was high in all trials but one. Trial Sequential Analysis showed imprecision for all comparisons. For benzodiazepine discontinuation, we found a potential benefit of valproate at end of intervention (1 study, 27 participants; risk ratio (RR) 2.55, 95% confidence interval (CI) 1.08 to 6.03; very low‐quality evidence) and of tricyclic antidepressants at longest follow‐up (1 study, 47 participants; RR 2.20, 95% CI 1.27 to 3.82; low‐quality evidence). We found potentially positive effects on benzodiazepine withdrawal symptoms of pregabalin (1 study, 106 participants; mean difference (MD) ‐3.10 points, 95% CI ‐3.51 to ‐2.69; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐1.00 points, 95% CI ‐1.13 to ‐0.87; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐3.57 points, 95% CI ‐5.34 to ‐1.80; very low‐quality evidence), tricyclic antidepressants (1 study, 38 participants; MD ‐19.78 points, 95% CI ‐20.25 to ‐19.31; very low‐quality evidence), and flumazenil (3 studies, 58 participants; standardised mean difference ‐0.95, 95% CI ‐1.71 to ‐0.19; very low‐quality evidence) at end of intervention. However, the positive effect of paroxetine on benzodiazepine withdrawal symptoms did not persist until longest follow‐up (1 study, 54 participants; MD ‐0.13 points, 95% CI ‐4.03 to 3.77; very low‐quality evidence). The following pharmacological interventions reduced symptoms of anxiety at end of intervention: carbamazepine (1 study, 36 participants; MD ‐6.00 points, 95% CI ‐9.58 to ‐2.42; very low‐quality evidence), pregabalin (1 study, 106 participants; MD ‐4.80 points, 95% CI ‐5.28 to ‐4.32; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐5.70 points, 95% CI ‐6.05 to ‐5.35; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐6.75 points, 95% CI ‐9.64 to ‐3.86; very low‐quality evidence), and flumazenil (1 study, 18 participants; MD ‐1.30 points, 95% CI ‐2.28 to ‐0.32; very low‐quality evidence). Two pharmacological treatments seemed to reduce the proportion of participants that relapsed to benzodiazepine use: valproate (1 study, 27 participants; RR 0.31, 95% CI 0.11 to 0.90; very low‐quality evidence) and cyamemazine (1 study, 124 participants; RR 0.33, 95% CI 0.14 to 0.78; very low‐quality evidence). Alpidem decreased the proportion of participants with benzodiazepine discontinuation (1 study, 25 participants; RR 0.41, 95% CI 0.17 to 0.99; number needed to treat for an additional harmful outcome (NNTH) 2.3 participants; low‐quality evidence) and increased the occurrence of withdrawal syndrome (1 study, 145 participants; RR 4.86, 95% CI 1.12 to 21.14; NNTH 5.9 participants; low‐quality evidence). Likewise, magnesium aspartate decreased the proportion of participants discontinuing benzodiazepines (1 study, 144 participants; RR 0.80, 95% CI 0.66 to 0.96; NNTH 5.8; very low‐quality evidence). Generally, adverse events were insufficiently reported. Specifically, one of the flumazenil trials was discontinued due to severe panic reactions. Authors' conclusions Given the low or very low quality of the evidence for the reported outcomes, and the small number of trials identified with a limited number of participants for each comparison, it is not possible to draw firm conclusions regarding pharmacological interventions to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Due to poor reporting, adverse events could not be reliably assessed across trials. More randomised controlled trials are required with less risk of systematic errors ('bias') and of random errors ('play of chance') and better and full reporting of patient‐centred and long‐term clinical outcomes. Such trials ought to be conducted independently of industry involvement. Plain language summary Medications for discontinuation of long‐term benzodiazepine use Background Benzodiazepines are widely prescribed for long‐term use despite recommendations of only short‐term use. It is often difficult to discontinue benzodiazepines after more than a few weeks of treatment due to the development of physical and psychological dependence. This review aimed to assess the effect and safety of medications to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Search date The evidence is current to October 2017. Study characteristics We identified 38 randomised controlled trials involving 2543 participants who had either been treated for more than two months with benzodiazepines, or who had been diagnosed with benzodiazepine dependence. We included studies irrespective of whether benzodiazepines were prescribed for anxiety, insomnia, or any other condition. The average age of participants was around 50 years, and the majority of participants were women in most studies. Twenty‐four trials were conducted in Europe; eight trials in the US or Canada; and six trials in Asia. The trials involved a wide range of medications to facilitate reduction or discontinuation of benzodiazepine use. Fourteen of the 38 included studies were partly funded by the drug manufacturer; nine studies were funded by government agencies; and 15 studies did not state the source of funding. The duration of the trials ranged between 1 and 24 weeks; the average trial duration was 9 weeks. Key results We extracted data on 18 different comparisons in a total of 2295 participants. We are uncertain whether valproate and tricyclic antidepressants increase the chance of discontinuing benzodiazepines, and whether benzodiazepine withdrawal symptoms are reduced by pregabalin, captodiame, paroxetine, tricyclic antidepressants, and flumazenil, as we assessed the quality of the evidence as very low. We are uncertain as to whether symptoms of anxiety after withdrawal of benzodiazepines are reduced by carbamazepine, pregabalin, captodiame, paroxetine, and flumazenil, as we assessed the quality of the evidence as very low. The effects of the evaluated medications were too uncertain to inform clinical practice due to risk of bias (systematic errors with overestimation of benefits and underestimation of harms) and risk of chance occurrence (random errors giving any result). Tolerability and safety were poorly reported across the included studies, making it impossible to assess the balance between possible benefits and adverse effects. Consequently, no conclusions can be drawn about the effectiveness of the interventions. Quality of the evidence The quality of the evidence was generally low or very low due to the small number of trials including a limited number of participants for each comparison; dissimilar results across studies; poor study design; and pronounced financial involvement of the pharmaceutical industry. Randomised controlled trials are therefore needed without risk of bias and random significant results involving long‐term assessments of participants conducted without involvement of industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Baandrup, L, Ebdrup, BH, Rasmussen, JØ, Lindschou, J, Gluud, C, Glenthøj, BY", "articleTypes": [], "doi": "10.1002/14651858.CD011481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.786Z" }, { "id": "69c9f66f-7f65-4215-9414-86e11ad7b482", "pmid": "", "title": "The Effects of Genetic Variation in the Bitter and Fat Taste Receptor Genes on Taste Perception, Dietary Behaviour and Obesity Status", "imported": false, "abstract": "Obesity is an increasing problem for adults in the UK. Diets high in fat and sugar are the major contributors to weight gain. Individual differences in taste perception are a crucial factor in determining the investigator's choice of foods and an individual's sensitivity to the either bitter or fat taste compounds has been linked to a preference for different foods including sweet and high fat foods. Previous research has not comprehensively explored the effect of both fat and bitter taste sensitivity on dietary intake and obesity status. Therefore, the aim of this study is to explore the associations between genetics, fat and bitter taste sensitivity, food preference, dietary intake and obesity measures in the adult UK population.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "69cab0f7-893d-4cbb-8610-ffaf015e6e5b", "pmid": "", "title": "Interventions for preventing oral mucositis for patients with cancer receiving treatment", "imported": false, "abstract": "Abstract - Background Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers). Objectives To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment. Search methods Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL ( The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Selection criteria Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer. Data collection and analysis Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random‐effects models. Main results A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta‐analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte‐colony stimulating factor (G‐CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate. Authors' conclusions Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent. Plain language summary Interventions for preventing oral mucositis for patients with cancer receiving treatment Treatment for cancer (including bone marrow transplant) can cause oral mucositis (severe ulcers in the mouth). This painful condition can cause difficulties in eating, drinking and swallowing, and may also be associated with infections which may require the patient to stay longer in hospital. Different strategies are used to try and prevent this condition, and the review of trials found that some of these are effective. Two interventions, cryotherapy (ice chips) and keratinocyte growth factor (palifermin®) showed some benefit in preventing mucositis. Sucralfate is effective in reducing the severity of mucositis, and a further seven interventions, aloe vera, amifostine, intravenous glutamine, granulocyte‐colony stimulating factor (G‐CSF), honey, laser and antibiotic lozenges containing polymixin/tobramycin/amphotericin (PTA) showed weaker evidence of benefit. These were evaluated in patients with different types of cancer, undergoing different types of cancer treatment. Benefits may be restricted to the disease and treatment combinations evaluated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Worthington, HV; Clarkson, JE; Bryan, G; Furness, S; Glenny, A-M; Littlewood, A; McCabe, MG; Meyer, S; Khalid, T; Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD000978.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "69cd62d0-b7af-4158-b9ca-449c918b36e3", "pmid": "", "title": "Effects of opioid, hypnotic and sedating medications on sleep‐disordered breathing in adults with obstructive sleep apnoea", "imported": false, "abstract": "Abstract - Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by partial or complete upper airway occlusion during sleep, leading to intermittent cessation (apnoea) or reduction (hypopnoea) of airflow and dips in arterial oxygen saturation during sleep. Many patients with recognised and unrecognised OSA receive hypnotics, sedatives and opiates/opioids to treat conditions including pain, anxiety and difficulty sleeping. Concerns have been expressed that administration of these drugs to people with co‐existing OSA may worsen OSA. Objectives To investigate whether administration of sedative and hypnotic drugs exacerbates the severity of OSA (as measured by the apnoea‐hypopnoea index (AHI) or the 4% oxygen desaturation index (ODI)) in people with known OSA. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR) of trials. The search was current as of March 2015. Selection criteria Randomised, placebo‐controlled trials including adult participants with confirmed OSA, where participants were randomly assigned to use opiates or opioids, sedatives, hypnotics or placebo. We included participants already using continuous positive airway pressure (CPAP) or a mandibular advancement device. Data collection and analysis We used standard methodological procedures as recommended by The Cochrane Collaboration. Main results Fourteen studies examining the effects of 10 drugs and including a total of 293 participants contributed to this review. Trials were small, with only two trials, which used sodium oxybate, recruiting more than 40 participants, and all but three trials were of only one to three nights in duration. Most participants had mild to moderate OSA with a mean AHI of 11 to 25 events/h, and only two trials recruited patients with severe OSA. Two trials investigating the effects of ramelteon, a treatment option for insomnia, recruited adults over 60 years of age with OSA and concomitant insomnia. The drugs studied in this review included remifentanil (infusion) 0.75 mcg/kg/h, eszopiclone 3 mg, zolpidem 10 and 20 mg, brotizolam 0.25 mg, flurazepam 30 mg, nitrazepam 10 mg to 15 mg, temazepam 10 mg, triazolam 0.25 mg, ramelteon 8 mg and 16 mg and sodium oxybate 4.5 g and 9 g. We were unable to pool most of the data, with the exception of data for eszopiclone and ramelteon. None of the drugs in this review produced a significant increase in AHI or ODI. Two trials have shown a beneficial effect on OSA. One study showed that a single administration of eszopiclone 3 mg significantly decreased AHI compared with placebo (24 ± 4 vs 31 ± 5; P value < 0.05), and a second study of sodium oxybate 4.5 g showed a significant decrease in AHI compared with placebo (mean difference (MD) ‐7.41, 95% confidence interval (CI) ‐14.17 to ‐0.65; N = 48). Only four trials reported outcome data on ODI. No significant increase, in comparison with placebo, was shown with eszopiclone (21 (22 to 37) vs 28.0 (15 to 36); P value = NS), zolpidem (0.81 ± 0.29 vs 1.46 ± 0.53; P value = NS), flurazepam (18.6 ± 19 vs 19.6 ± 15.9; P value = NS) and temazepam (6.53 ± 9.4 vs 6.56 ± 8.3; P value = 0.98). A significant decrease in minimum nocturnal peripheral capillary oxygen saturation (SpO 2 ) was observed with zolpidem 20 mg (76.8 vs 85.2; P value = 0.002), flurazepam 30 mg (81.7 vs 85.2; P value = 0.002), remifentanil infusion (MD ‐7.00, 95% CI ‐11.95 to ‐2.05) and triazolam 0.25 mg in both rapid eye movement (REM) and non‐REM (NREM) sleep (MD ‐14.00, 95% CI ‐21.84 to ‐6.16; MD ‐10.20, 95% CI ‐16.08 to ‐4.32, respectively. One study investigated the effect of an opiate (remifentanil) on patients with moderate OSA. Remifentanil infusion did not significantly change AHI (MD 10.00, 95% CI ‐9.83 to 29.83); however it did significantly decrease the number of obstructive apnoeas (MD ‐9.00, 95% CI ‐17.40 to ‐0.60) and significantly increased the number of central apnoeas (MD 16.00, 95% CI ‐2.21 to 34.21). Similarly, although without significant effect on obstructive apnoeas, central apnoeas were increased in the sodium oxybate 9 g treatment group (MD 7.3 (18); P value = 0.005) in a cross‐over trial. Drugs studied in this review were generally well tolerated, apart from adverse events reported in 19 study participants prescribed remifentanil (n = 1), eszopiclone (n = 6), sodium oxybate (n = 9) or ramelteon (n = 3). Authors' conclusions The findings of this review show that currently no evidence suggests that the pharmacological compounds assessed have a deleterious effect on the severity of OSA as measured by change in AHI or ODI. Significant clinical and statistical decreases in minimum overnight SpO 2 were observed with remifentanil, zolpidem 20 mg and triazolam 0.25 mg. Eszopiclone 3 mg and sodium oxybate 4.5 g showed a beneficial effect on the severity of OSA with a reduction in AHI and may merit further assessment as a potential therapeutic option for a subgroup of patients with OSA. Only one trial assessed the effect of an opioid (remifentanil); some studies included CPAP treatment, whilst in a significant number of participants, previous treatment with CPAP was not stated and thus a residual treatment effect of CPAP could not be excluded. Most studies were small and of short duration, with indiscernible methodological quality.Caution is therefore required when such agents are prescribed for patients with OSA, especially outside the severity of the OSA cohorts and the corresponding dose of compounds given in the particular studies. Larger, longer trials involving patients across a broader spectrum of OSA severity are needed to clarify these results. Plain language summary Effects of opioid, hypnotic and sedating medications on obstructive sleep apnoea (OSA) in adults with known OSA Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by intermittent apnoeas (pauses in breathing) leading to dips in oxygen levels in the blood during sleep. Many people with known or unknown (undiagnosed) OSA receive hypnotics, sedatives and opiate/opioid drugs to treat other conditions including pain, anxiety and difficulty sleeping. Opiates/opioids are commonly prescribed to treat pain after major surgery. These drugs might make sleep apnoea worse ‐ increasing the frequency and duration of apnoeas. Review question We set out to look at evidence derived from randomised placebo‐controlled trials to identify the risks of these drugs for patients with known OSA. What we did We searched and reviewed all randomised placebo‐controlled trials involving adult patients with known OSA who received these drugs. Most of the trials were short at just one or two nights' duration, involved only a small number of patients and used poorly described methodology. Therefore it was difficult to find out the exact effects of these drugs on patients with OSA. Results We found 14 studies examining the effects of 10 drugs in trials including 293 people. Opiates and opioids (treatment of acute and chronic pain) Remifentanil infusion Remifentanil infusion did not significantly change severity of OSA as measured by numbers and duration of pauses in breathing during sleep, but it significantly lowered minimum oxygen levels during the night when compared with placebo. Sedatives and hypnotics 'Z drugs' (a treatment for insomnia, inability to fall asleep or inability to maintain sleep) Eszopiclone and zolpidem Eszopiclone did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, it reduced the severity of OSA, and it might be beneficial in treating this condition, although further studies are needed to assess this effect. Zolpidem did not significantly worsen OSA as measured by the numbers and duration of pauses in breathing during sleep, but in one trial, it significantly lowered minimum oxygen levels during the night when compared with placebo. Benzodiazepines (short‐term relief of severe anxiety, behavioural disturbance or agitation and panic disorders) Brotizolam, flurazepam, nitrazepam, temazepam and triazolam None of the drugs examined had significantly worsened OSA as measured by the numbers and duration of pauses in breathing during sleep. In small, single‐night studies, zolpidem 20 mg, flurazepam 20 mg and triazolam 0.25 mg showed a tendency to increase numbers and duration of pauses during sleep, which was not statistically significant, but these drugs significantly lowered minimum oxygen levels during the night when compared with placebo. Sodium oxybate (a treatment for narcolepsy, a condition causing excessive sleepiness during the day) Sodium oxybate was compared with placebo in two trials. Results showed that sodium oxybate did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, sodium oxybate 4.5 g reduced the severity of OSA and might have proved beneficial in treating this condition, although further studies are needed to assess this effect. Melatonin and melatonin‐related drugs Ramelteon (a treatment drug for insomnia) Ramelteon was assessed in older adults, over 60 years of age, with OSA and insomnia and was found not to worsen OSA. Results of this review show that the drugs studied do not worsen the severity of OSA as measured by the numbers and duration of pauses in breathing during sleep, but significant clinical and statistical decreases in minimum oxygen levels during the night were observed with remifentanil, zolpidem and triazolam; therefore prescribing these drugs for patients with OSA still warrants caution. Sodium oxybate 4.5 g and eszopiclone reduced the severity of OSA and might be beneficial in treating this condition; nonetheless further studies are needed to support these results. Bottom line The long‐term effect and potential side effects of sedative drugs in people with OSA need to be assessed in larger, longer and methodologically robust studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mason, M; Cates, CJ; Smith, I", "articleTypes": [], "doi": "10.1002/14651858.CD011090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "69e5d74b-0d66-46fc-95f9-f5d95c4365ac", "pmid": "", "title": "Complex Effects of Dietary Manipulation on Metabolic Function, Inflammation and Health", "imported": false, "abstract": "The purpose of this research study is to 1) understand how some, but not all people with obesity develop obesity related conditions such as type 2 diabetes and cardiovascular disease, and 2) compare the effects of 3 popular weight loss diets (Mediterranean, low-carbohydrate, or a very-low-fat plant-based diet) in people with obesity.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.266Z" }, { "id": "69e9cd41-f3b7-4242-9f80-b2cdfcc0161f", "pmid": "", "title": "Interventions for leg cramps in pregnancy", "imported": false, "abstract": "Abstract - Background Many women experience leg cramps in pregnancy. They become more common as pregnancy progresses and are especially troublesome at night. Objectives The objective of this review was to assess methods of preventing and treating leg cramps in pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2001). We updated this search on 4 July 2011 and added the results to the awaiting classification section. Selection criteria Randomised trials of treatments for leg cramps in pregnancy. Data collection and analysis Trial quality was assessed and data were extracted independently by two reviewers. Main results Five trials involving 352 women were included. The trials were of moderate quality. The only placebo‐controlled trial of calcium treatment showed no evidence of benefit. Trials comparing sodium chloride with placebo (odds ratio 0.54, 95% confidence interval 0.23 to 1.29) and calcium with sodium chloride (odds ratio 1.23, 95% confidence intervals 0.47 to 3.27 ) showed no evidence of benefit. Placebo controlled trials of multivitamin with mineral supplements (odds ratio 0.23, 95% confidence intervals 0.05 to 1.01) and magnesium (odds ratio 0.18, 95% confidence intervals 0.05 to 0.60) provided some suggestion of benefit. Authors' conclusions The evidence that calcium reduces cramp is weak and seems to depend on placebo effect. The evidence for sodium chloride is stronger but the results of the sodium chloride trial may no longer be relevant because of dietary changes which include an increased sodium intake in the general population. It is not possible to recommend multivitamins with mineral supplementation, as it is not clear which ingredient, if any, is helping. If a woman finds cramp troublesome in pregnancy, the best evidence is for magnesium lactate or citrate taken as 5mmol in the morning and 10mmol in the evening. [Note: The five citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Interventions for leg cramps in pregnancy Sodium supplements may decrease the number of cramp attacks experienced by women in pregnancy but the effect is slight. Calcium is of no benefit. The evidence of benefit for magnesium is stronger. Multivitamin and mineral supplements also seem to help but the relevance of this is unclear as the preparation used contained twelve separate constituents and it is not possible to discover which of these was effective, or indeed if there was synergy between constituents. There is a theoretical risk that sodium supplementation could raise blood pressure. It is unlikely that magnesium supplementation would be harmful at the suggested doses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Young, G; Jewell, D", "articleTypes": [], "doi": "10.1002/14651858.CD000121", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "69f8fcdc-61cd-49ba-8129-54f6e80880ae", "pmid": "", "title": "Immediate‐release versus controlled‐release carbamazepine in the treatment of epilepsy", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, G, Saunders, M, Rigby, A, Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007124.pub5 AB - Abstract - Background Carbamazepine (CBZ) is a commonly used drug for epilepsy that is associated with troublesome adverse events including dizziness, double vision, drowsiness, poor co‐ordination and unsteadiness. These adverse events often occur during peaks in drug plasma concentration. These adverse events may limit the daily dose of CBZ that can be tolerated and reduce the chances of seizure control in patients who require high doses. A controlled‐release formulation of CBZ delivers the same dose over a longer period of time when compared to a standard immediate‐release formulation, thereby reducing post‐dose peaks in CBZ plasma concentration and potentially reducing adverse events. This is an updated version of the original Cochrane review published in Issue 12, 2014. Objectives To determine the efficacy of immediate‐release CBZ (IR CBZ) versus controlled‐release CBZ (CR CBZ) in patients diagnosed with epilepsy. The following review questions were investigated.
 (1) For newly diagnosed patients commencing CBZ, how do IR and CR formulations compare for efficacy and tolerability?
 (2) For patients on established treatment with IR CBZ but experiencing unacceptable adverse events, what is the effect on seizure control and the tolerability of a switch to a CR formulation versus remaining on the IR formulation? Search methods We searched the Cochrane Epilepsy Group Specialized Register, CENTRAL, and MEDLINE (Ovid) from inception to 30 August 2016. Selection criteria Randomised controlled trials comparing IR CBZ to CR CBZ in patients commencing monotherapy and patients presently treated with IR CBZ but experiencing unacceptable adverse events. Primary outcome measures included measures of seizure frequency, incidence of adverse events, proportion of patients with treatment failure and quality of life measures. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted the data and recorded relevant information on a standardised data extraction form. We used the Cochrane risk of bias tool to assess the methodological quality of included studies. The heterogeneity of the included trials with respect to the reporting of outcomes resulted in only a narrative, descriptive analysis being possible for both the categorical and time‐to‐event data. Main results Ten trials (296 participants) fulfilled the criteria for inclusion in this review. Only one study had a low risk of bias. Two studies had a high risk of bias and the rest of the studies were rated as unclear risk of bias. One trial included patients with newly diagnosed epilepsy and nine included patients on treatment with IR CBZ. Eight trials reported heterogeneous measures of seizure frequency with conflicting results. A statistically significant difference was observed in only one trial, with patients prescribed CR CBZ experiencing fewer seizures than patients prescribed IR CBZ. Nine trials reported measures of adverse events. There was a trend in favour of CR CBZ with four trials reporting a statistically significant reduction in adverse events compared to IR CBZ. A further two trials reported fewer adverse events with CR CBZ but the reduction was not statistically significant. One trial found no difference in adverse events, and another trial reported more adverse events in the CR CBZ group than the IR CBZ group, although the increase was not statistically significant. Authors' conclusions For this update no new eligible studies were identified and the conclusions drawn from the initial review remain unchanged. At present, data from trials do not confirm or refute an advantage for CR CBZ over IR CBZ for seizure frequency or adverse events in patients with newly diagnosed epilepsy. For trials involving epilepsy patients already prescribed IR CBZ, no conclusions can be drawn concerning the superiority of CR CBZ with respect to seizure frequency. There is a trend for CR CBZ to be associated with fewer adverse events when compared to IR CBZ. A change to CR CBZ may therefore be a worthwhile strategy in patients with acceptable seizure control on IR CBZ but experiencing unacceptable adverse events. The included trials were of small size and of poor methodological quality limiting the validity of this conclusion. Randomised controlled trials comparing CR CBZ to IR CBZ and using clinically relevant outcomes are required to inform the choice of CBZ preparation for patients with newly diagnosed epilepsy. Plain language summary Fast‐release versus slow‐release carbamazepine as medication for patients with epilepsy Background Epilepsy is a common brain disorder that is often treated with carbamazepine. With treatment, people often have fewer seizures but many people experience side effects. When carbamazepine is swallowed it is taken into the blood stream quickly and there is a sharp rise of drug levels in the blood. These 'peaks' may be associated with side effects such as dizziness, double vision, drowsiness, unsteadiness and poor co‐ordination. A type of carbamazepine that releases the medication into the body slowly may lessen these 'peaks' in the blood levels, possibly meaning fewer side effects. This review compared studies looking at the differences between a 'fast‐release' carbamazepine and a 'slow‐release' carbamazepine. Participants To be included in this review, all participants had to be diagnosed with epilepsy and be either just starting carbamazepine treatment or be already on it but with intolerable side effects. The participants could be of any age or gender. Studies Ten trials with a total of 296 people with epilepsy were included in the review. All 10 trials were randomised controlled trials (patients were compared in randomly assigned groups). All of the studies had at least two groups, one group taking fast‐release carbamazepine and one group taking slow‐release carbamazepine, and some also had a control group (a group of non‐epileptic people). The evidence is current to August 2016. Results Just one of 10 studies found a significant difference between the two carbamazepine types in the number of seizures experienced, with patients prescribed the slow‐release carbamazepine experiencing fewer seizures than patients prescribed the fast‐release drug. Patients taking slow‐release carbamazepine tended to experience fewer side effects. Quality of the evidence Out of the 10 trials in the review, only one study was judged to be of 'good' quality, and so the evidence in this review was rated as low quality. It must be stressed that there are not many studies assessing the differences between these two carbamazepine types and more studies are needed before we can make a definitive conclusion about one over the other.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.791Z" }, { "id": "69faee16-35b3-405c-9932-7800d4160df6", "pmid": "", "title": "Interventions for treating iron deficiency anaemia in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease affects approximately seven million people globally. Iron deficiency anaemia can occur as a common systemic manifestation, with a prevalence of up to 90%, which can significantly affect quality of life, both during periods of active disease or in remission. It is important that iron deficiency anaemia is treated effectively and not be assumed to be a normal finding of inflammatory bowel disease. The various routes of iron administration, doses and preparations present varying advantages and disadvantages, and a significant proportion of people experience adverse effects with current therapies. Currently, no consensus has been reached amongst physicians as to which treatment path is most beneficial. Objectives The primary objective was to evaluate the efficacy and safety of the interventions for the treatment of iron deficiency anaemia in people with inflammatory bowel disease. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 21st November 2019. We also contacted experts in the field and searched references of trials for any additional trials. Selection criteria Randomised controlled trials investigating the effectiveness and safety of iron administration interventions compared to other iron administration interventions or placebo in the treatment of iron deficiency anaemia in inflammatory bowel disease. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors. Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We expressed dichotomous and continuous outcomes as risk ratios and mean differences with 95% confidence intervals. We assessed the certainty of the evidence using the GRADE methodology. Main results We included 11 studies (1670 randomised participants) that met the inclusion criteria. The studies compared intravenous iron sucrose vs oral iron sulphate (2 studies); oral iron sulphate vs oral iron hydroxide polymaltose complex (1 study); oral iron fumarate vs intravenous iron sucrose (1 study); intravenous ferric carboxymaltose vs intravenous iron sucrose (1 study); erythropoietin injection + intravenous iron sucrose vs intravenous iron sucrose + injection placebo (1 study); oral ferric maltol vs oral placebo (1 study); oral ferric maltol vs intravenous ferric carboxymaltose (1 study); intravenous ferric carboxymaltose vs oral iron sulphate (1 study); intravenous iron isomaltoside vs oral iron sulphate (1 study); erythropoietin injection vs oral placebo (1 study). All studies compared participants with CD and UC together, as well as considering a range of disease activity states. The primary outcome of number of responders, when defined, was stated to be an increase in haemoglobin of 20 g/L in all but two studies in which an increase in 10g/L was used. In one study comparing intravenous ferric carboxymaltose and intravenous iron sucrose, moderate‐certainty evidence was found that intravenous ferric carboxymaltose was probably superior to intravenous iron sucrose, although there were responders in both groups (150/244 versus 118/239, RR 1.25, 95% CI 1.06 to 1.46, number needed to treat for an additional beneficial outcome (NNTB) = 9). In one study comparing oral ferric maltol to placebo, there was low‐certainty evidence of superiority of the iron (36/64 versus 0/64, RR 73.00, 95% CI 4.58 to 1164.36). There were no other direct comparisons that found any difference in the primary outcomes, although certainty was low and very low for all outcomes, due to imprecision from sparse data and risk of bias varying between moderate and high risk. The reporting of secondary outcomes was inconsistent. The most common was the occurrence of serious adverse events or those requiring withdrawal of therapy. In no comparisons was there a difference seen between any of the intervention agents being studied, although the certainty was very low for all comparisons made, due to risk of bias and significant imprecision due to the low numbers of events. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes were reported in any of the studies. An analysis of all intravenous iron preparations to all oral iron preparations showed that intravenous administration may lead to more responders (368/554 versus 205/373, RR 1.17, 95% CI 1.05 to 1.31, NNTB = 11, low‐certainty due to risk of bias and inconsistency). Withdrawals due to adverse events may be greater in oral iron preparations vs intravenous (15/554 versus 31/373, RR 0.39, 95% CI 0.20 to 0.74, low‐certainty due to risk of bias, inconsistency and imprecision). Authors' conclusions Intravenous ferric carboxymaltose probably leads to more people having resolution of IDA (iron deficiency anaemia) than intravenous iron sucrose. Oral ferric maltol may lead to more people having resolution of IDA than placebo. We are unable to draw conclusions on which of the other treatments is most effective in IDA with IBD (inflammatory bowel disease) due to low numbers of studies in each comparison area and clinical heterogeneity within the studies. Therefore, there are no other conclusions regarding the treatments that can be made and certainty of all findings are low or very low. Overall, intravenous iron delivery probably leads to greater response in patients compared with oral iron, with a NNTB (number needed to treat) of 11. Whilst no serious adverse events were specifically elicited with any of the treatments studied, the numbers of reported events were low and the certainty of these findings very low for all comparisons, so no conclusions can be drawn. There may be more withdrawals due to such events when oral is compared with intravenous iron delivery. Other outcomes were poorly reported and once again no conclusions can be made as to the impact of IDA on any of these outcomes. Given the widespread use of many of these treatments in practice and the only guideline that exists recommending the use of intravenous iron in favour of oral iron, research to investigate this key issue is clearly needed. Considering the current ongoing trials identified in this review, these are more focussed on the impact in specific patient groups (young people) or on other symptoms (such as fatigue). Therefore, there is a need for studies to be performed to fill this evidence gap. Plain language summary Therapies for treating iron deficiency anaemia in Crohn's disease and ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether treatments in people with Crohn's disease and ulcerative colitis can improve iron deficiency anaemia. We analysed data from 11 studies to answer this question. Key messages Iron in the form of ferric carboxymaltose given intravenously is probably better than iron sucrose given intravenously in improving iron deficiency anaemia, although people improved taking both treatments. Oral iron in the form of ferric maltol may be better than placebo (dummy treatment). It is unclear whether any of the other treatments considered are better than each other, however, there is limited evidence due to low numbers of studies and issues due to low quality of the reporting of the research studies. What was studied in the review? People with both ulcerative colitis and Crohn's disease both commonly suffer with low iron levels that in turn lowers their haemoglobin (blood) levels (this is called anaemia). This can lead to a number of symptoms, including tiredness and pain. Several treatments exist to treat iron deficiency anaemia, consisting of delivering extra iron either orally or intravenously (through a vein). An additional treatment, erythropoietin, was also studied which stimulates the body to produce more blood itself. Currently, no consensus has been reached amongst physicians as to which treatment is better. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing any treatment with another or dummy treatment. We found 11 RCTs looking at 1670 participants. The trials looked at adult participants, with none considering children. 1) Intravenous iron in the form of ferric carboxymaltose probably leads to more people having an improvement in iron deficiency anaemia than intravenous iron sucrose (one extra person would improve for every 9 treated and five out of 10 people would improve with either therapy). 2) Oral iron as ferric maltol may lead to more people having resolution of iron deficiency than dummy treatment. 3) It is unclear whether there is any difference between any of the other treatments studied for treating iron deficiency anaemia. 4) It is unclear whether any therapy leads to a difference in adverse events (minor or serious) when compared to any other therapy. Conclusion Iron delivered via a vein as ferric carboxymaltose probably improves anaemia in more people that iron sucrose via a vein, although both groups of people improved. Oral iron as ferric maltol may improve more patients than dummy treatment. No conclusions can be drawn on other treatments due to lack of evidence and quality issues with the studies that were found. Further research is needed, particularly to investigate whether iron delivered through a vein is better than iron delivered orally and also how much treating anaemia in people with IBD makes a difference in terms of the symptoms they may experience. How up‐to‐date is this review? This review is up‐to‐date as of November 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gordon, M; Sinopoulou, V; Iheozor-Ejiofor, Z; Iqbal, T; Allen, P; Hoque, S; Engineer, J; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013529.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "6a0a59e7-f04e-4da1-9e4b-760c289e6cc4", "pmid": "", "title": "Interventions for the eradication of meticillin‐resistant Staphylococcus aureus (MRSA) in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a genetic disorder characterised by recurrent and persistent pulmonary infections from resistant organisms, resulting in deterioration of lung function and early mortality. Meticillin‐resistant Staphylococcus aureus (MRSA) is an important infection in hospital patients and harmful to people with CF (pwCF). Chronic pulmonary MRSA infection may confer a worse clinical outcome on pwCF and result in a faster decline in lung function. Robust evidence clearly guiding MRSA eradication in CF is urgently needed. This is an updated review. Objectives To evaluate the effectiveness of antibiotic treatment designed to eradicate MRSA, to determine whether eradication confers better clinical and microbiological outcomes for pwCF, and to ascertain whether attempts at eradicating MRSA lead to increased acquisition of other resistant organisms (including Pseudomonas aeruginosa ), increased adverse effects from drugs, or both. Search methods We searched the Cochrane CF's Trials Register, PubMed, MEDLINE and three trials registries; handsearched article reference lists; and contacted experts in the field. We last searched Cochrane CF's Trials Register and the trials registries on 28 April 2026. Eligibility criteria Randomised controlled trials (RCTs) or quasi‐RCTs of any combination of topical, inhaled, oral or intravenous antibiotics for treating MRSA compared with placebo, standard treatment or no treatment in pwCF, regardless of age or disease severity. Outcomes We planned to assess these outcomes at up to 12 months following therapy: eradication of MRSA from respiratory cultures, time until next positive MRSA isolate, quality of life (QoL), change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted, change in weight (kg), frequency of pulmonary exacerbations and adverse effects of treatment. Risk of bias Using the original Cochrane risk of bias tool, we assessed individual domains and produced an overall risk of bias for each trial. Synthesis methods We followed Cochrane's standard methodology, conducting fixed‐effect meta‐analyses or reporting narratively. We assessed evidence certainty using GRADE. Included studies We included five RCTs (410 participants). Synthesis of results Oral antibiotics versus no treatment Two trials (106 participants) compared observation to oral trimethoprim plus sulfamethoxazole combined with rifampicin; in one trial for two weeks alongside topical decontamination and a three‐week environmental decontamination, and in a second for 21 days alongside intranasal mupirocin (five days); 29 participants withdrew from the second trial by the end of follow‐up. Oral antibiotics have little or no effect on any outcome reported below, in contrast to one study (45 participants) which was terminated early due to results clearly favouring treatment. In one trial defining eradication as negative MRSA respiratory cultures at day 28 and remaining so at day 168 (45 participants), treatment may result in more negative cultures than observation (odds ratio (OR) 12.6 (95% confidence interval (CI) 2.84 to 55.84; low‐certainty). There may be little to no difference between groups by day 168 of follow‐up (OR 1.17, 95% CI 0.31 to 4.42), and also in one trial defining successful eradication as no MRSA in at least three cultures over six months follow‐up (OR 2.74, 95% CI 0.64 to 11.75; low‐certainty). Treatment may result in an increase in FEV 1 % predicted from baseline (MD 5.67%, 95% CI 1.43 to 9.90; 2 trials, 58 participants; low‐certainty evidence). There may be little to no differences between groups in QoL, frequency of pulmonary exacerbations (although one study reported a lower hospitalisation rate through day 168 with treatment (P = 0.01)), adverse effects, or weight (all low‐certainty evidence). Nebulised antibiotics versus placebo Two trials (275 participants randomised, 251 analysed) compared a standard dose of vancomycin (one trial additionally compared a high dose) to placebo. The multi‐arm trial reported a decrease in MRSA colony forming units (CFUs) at each time point, up to one month. There were no differences in most lung function results in either trial, but treatment probably increased FEV 1 % predicted at 20 weeks (MD 3.55%, 95% CI 0.33 to 6.77; P = 0.03; 1 trial, 133 participants; moderate‐certainty evidence). This trial also reported no difference in pulmonary exacerbation frequency, while the multi‐arm trial reported a longer time to the next exacerbation with the lower vancomycin dose (no placebo data available). Evidence from both trials suggests that nebulised antibiotics may make little or no difference in QoL (high to low‐certainty), or frequency of adverse outcomes or of exacerbations (low‐to‐moderate‐certainty evidence). Oral antibiotics plus nebulised antibiotics (vancomycin) versus oral antibiotics plus placebo One trial (29 participants randomised, 25 participants analysed) compared combination antibiotic treatment (inhaled plus oral) to oral antibiotics plus inhaled placebo, defining eradication as a negative MRSA respiratory sample at one month following treatment. Combination antibiotic treatment may result in little or no difference in MRSA eradication at three months (OR 1.63, 95% CI 0.19 to 13.93; low‐certainty evidence), lung function (no data available for analysis) or adverse effects (low‐certainty evidence), in QoL (very low‐certainty evidence) or nasal colonisation with MRSA. Authors' conclusions Early eradication of MRSA is possible in pwCF; evidence from one trial suggested active MRSA treatment may result in a higher proportion of MRSA‐negative respiratory cultures after one month compared with observation. However, longer follow‐up showed treatment may make little or no difference in the proportion of participants remaining MRSA‐negative. One trial of nebulised antibiotics alone compared to placebo reported a decrease in MRSA CFUs with a higher antibiotic dose. The longer‐term clinical consequences of any treatment option – in terms of lung function, mortality and cost of care – remain unclear. We judged the evidence to range from high to very low‐certainty, due to potential biases from trial design, high attrition rates and small sample sizes. While early eradication of respiratory MRSA in pwCF may be possible, the currently available evidence does not demonstrate that routine treatment of respiratory MRSA in pwCF is effective. Research is needed to assess MRSA infection and treatment in the age of modulator therapies. Funding The 2025 update was undertaken as part of Cochrane CF funding from the UK CF Trust and the CF Foundation. Registration Protocol (2012) DOI: 10.1002/14651858.CD009650. Original review (2013) DOI: 10.1002/14651858.CD009650.pub2. Review updates: (2015) DOI: 10.1002/14651858.CD009650.pub3; (2018) DOI: 10.1002/14651858.CD123456.pub4; (2022) DOI: 10.1002/14651858.CD009650.pub5. Plain language summary Can treatment with antibiotics clear the 'superbug' MRSA from the lungs of people with cystic fibrosis? Key messages Early treatment of meticillin‐resistant Staphylococcus aureus (MRSA) (a type of bacteria which are resistant to some antibiotics) infection in people with cystic fibrosis (CF) seems possible, but we are unsure about the effectiveness of current routine treatment. Longer‐term implications of treatment are not clear. Research is needed to assess MRSA infection and treatment in the age of cystic fibrosis transmembrane conductance regulator (CFTR) modulators (drugs that fix the broken protein made by the CF gene so salt and water can move correctly across cells and help move mucus from the lungs). What is cystic fibrosis (CF)? CF is an inherited condition which causes thick mucus to build up in the lungs and other organs. It is very difficult for people with CF to cough up this thick mucus, making it an ideal breeding ground for germs (including MRSA), and making them more prone to chest infections. CF worsens over time. Although there is currently no cure, many people with CF can lead active and full lives. What is MRSA and how is it treated? MRSA (meticillin‐resistant Staphyloccocus aureus) are bacteria which cause infection that is treated with antibiotics. However, MRSA are resistant to some types of antibiotics, making the infection hard to treat. They are sometimes called 'superbugs' and infection with MRSA is particularly worrying for people with CF, as it is thought that MRSA can cause more damage than other bacteria which are not resistant to antibiotics. MRSA is usually treated with a combination of antibiotics, taken orally (by mouth) or inhaled, alongside decontamination treatment (antibiotic creams applied to the skin and nasal cavities). What did we want to find out? We wanted to know whether treatment with antibiotics: can get rid of MRSA infection in the lungs of children or adults with CF; does not cause infection with other resistant bacteria; does not cause unwanted effects. What did we do? We looked for studies that investigated antibiotics (oral or inhaled) to treat MRSA infections in people with CF. Studies had to compare antibiotic treatment with either no treatment, placebo (sham treatment) or other type of antibiotics. People had to have CF and current infection with MRSA. What did we find? We found five studies which recruited 410 people with CF and a diagnosed MRSA infection. Studies took place in Italy or North America and lasted from eight weeks to six months. People in the studies (equal numbers of males and females) were young (average age ranged from 11 to 25 years). Oral antibiotics compared to no treatment (2 studies, 106 people) One group of people with CF were treated with oral antibiotics (trimethoprim, sulfamethoxazole and rifampicin or co‐trimoxazole and rifampicin), plus decontamination treatment; the other group received no treatment. Oral antibiotics may clear MRSA. One trial stopped early due to clear benefits of antibiotics, but some people cleared the infection with no treatment. In six months, there was no difference between groups in the number of people who still had MRSA. Antibiotics may increase lung function. There may be little to no difference between groups in quality of life, frequency of flare‐ups of the disease (although one study reported fewer people taking antibiotics were admitted to hospital in the first six months), unwanted effects of treatment, or changes in weight. Inhaled antibiotics compared to placebo (2 studies, 251 people) Both studies compared a standard dose of vancomycin (an inhaled antibiotic) to placebo (a dummy drug) and one study also compared a standard dose of vancomycin to a high dose. Inhaled antibiotics probably make no difference to lung function compared to placebo (2 studies), but results from one study indicated that inhaled antibiotics probably lead to a small increase after 20 weeks. A standard dose of vancomycin probably makes no difference to the frequency of flare‐ups compared to placebo (2 studies); One study reported a longer time to the next flare‐up with the lower dose of vancomycin; One study reported a decrease in MRSA bacteria levels with a higher dose of vancomycin for up to one month; Neither study reported any differences in quality of life or unwanted effects. Oral plus inhaled antibiotics compared to oral antibiotics plus placebo (1 study, 25 people) One study compared a combination of oral plus inhaled antibiotics to inhaled antibiotics plus placebo. We are uncertain if either treatment made any difference to MRSA clearance; There may be few or no differences between groups in lung function, quality of life or unwanted effects; The study did not report changes in weight or frequency of flare‐ups. What are the limitations of the evidence? Our confidence in the results ranged from high to very low. This was due to potential issues with the trial designs (people knew which treatment they were receiving), or because there were small numbers of people in each trial and many of them dropped out. How up to date is this evidence? This review updates our previous review published in 2022. The evidence is current to 28 April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lo, DKH, Jahnke, N, Smith, S, Muhlebach, MS, Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD009650.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.118Z" }, { "id": "6a0c4ade-e244-4f68-aec7-2361321e01f8", "pmid": "", "title": "Surgical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Surgical treatment of chronic rhinosinusitis with nasal polyps is an established treatment for medically resistant nasal polyp disease. Whether a nasal polypectomy with additional sinus dissection offers any advantage over an isolated nasal polypectomy has not been systematically reviewed. Objectives To assess the effectiveness of simple polyp surgery versus more extensive surgical clearance in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 1); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised and quasi‐randomised controlled trials in patients over 16 with chronic rhinosinusitis with nasal polyps, who have failed a course of medical management and who have not previously undergone any previous surgical intervention for their nasal disease. Studies compared nasal polypectomy with more extensive sinus clearance in this patient cohort. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no trials which met our inclusion criteria. Six controlled trials (five randomised) met some but not all of the inclusion criteria and were therefore excluded from the review. Authors' conclusions We are unable to reach any conclusions as to whether isolated nasal polypectomy or more extensive sinus surgery is a superior surgical treatment modality for chronic rhinosinusitis with nasal polyps. There is a need for high‐quality randomised controlled trials to assess whether additional sinus surgery confers any benefit when compared to nasal polypectomy performed in isolation. Plain language summary Surgical interventions for chronic rhinosinusitis with nasal polyps Background Benign nasal polyps are abnormal tissue growths inside the nasal passages and sinuses, often on both sides of the nose. They can cause a wide array of symptoms including blocked nose, poor sense of smell that can lead to a loss of taste, runny nose and nasal congestion. Sinuses are air‐filled cavities in the bones of the face, which are in continuity with the nasal passages. The first‐line treatment for nasal polyps is usually medical therapy in the form of steroids ‐ as sprays (topically) or by mouth (orally). In patients where this treatment has failed to relieve the symptoms, the polyps can be removed surgically. These surgical procedures are often not curative and patients may need to continue medical therapy or undergo further surgeries. A number of well‐established surgical techniques can be used to remove polyps. What has not been established is whether removing the nasal polyps and clearing out the sinuses offers any advantage in the control of the disease when compared to simply removing the polyps and leaving the sinuses unchanged. We sought evidence in the literature to establish whether there was any difference in patients who underwent nasal polyp removal alone versus those who had nasal polyps removed as well as opening up of the sinuses. Study characteristics No trials met our inclusion criteria. We did identify six controlled trials (five of which were randomised) in which some but not all of our inclusion criteria were met, but we had to exclude these studies from the review. Key results No trials met our inclusion criteria. Quality of evidence At present, we cannot comment on whether taking nasal polyps out alone or also opening up the sinuses at the same time is a better treatment for patients with this disease. There is a need for high‐quality randomised controlled trials to answer this question. This evidence is current to February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Sharma, R, Lakhani, R, Rimmer, J, Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.115Z" }, { "id": "6a0e0d1f-d35a-4448-9391-903abee18726", "pmid": "", "title": "Phytoestrogens for menopausal vasomotor symptoms", "imported": false, "abstract": "Abstract - Background Vasomotor symptoms, such as hot flushes and night sweats, are very common during the menopausal transition. Hormone therapy has traditionally been used as a highly effective treatment, but concerns about increased risk of some chronic diseases have markedly increased the interest of women in alternative treatments. Some of the most popular of these treatments are foods or supplements enriched with phytoestrogens—plant‐derived chemicals that have estrogenic action. Objectives To assess the efficacy, safety and acceptability of food products, extracts and dietary supplements containing high levels of phytoestrogens when compared with no treatment, placebo or hormone therapy for the amelioration of vasomotor menopausal symptoms (such as hot flushes and night sweats) in perimenopausal and postmenopausal women. Search methods Searches targeted the following electronic databases: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of randomised trials (29 July 2013), the Cochrane Register of Controlled Trials (CENTRAL; 29 July 2013), MEDLINE (inception to 29 July 2013), EMBASE (inception to 29 July 2013), AMED (1985 to 29 July 2013), PsycINFO (inception to 29 July 2013) and CINAHL (inception to 29 July 2013). Attempts were made to access grey literature by sending letters to pharmaceutical companies and performing searches of ongoing trial registers. Reference lists of included trials were also searched. Selection criteria Studies were included if they were randomised, included perimenopausal or postmenopausal participants with vasomotor symptoms (hot flushes or night sweats), lasted at least 12 weeks and provided interventions such as foods or supplements with high levels of phytoestrogens (not combined with other herbal treatments). Trials that included women who had breast cancer or a history of breast cancer were excluded. Data collection and analysis Selection of trials, extraction of data and assessment of quality were undertaken by at least two review authors. Most trials were too dissimilar for their results to be combined in a meta‐analysis, so these findings are provided in narrative 'Summary of results' tables. Studies were grouped into broad categories: dietary soy, soy extracts, red clover extracts, genistein extracts and other types of phytoestrogens. Five trials used Promensil, a red clover extract; results of these trials were combined in a meta‐analysis, and summary effect measures were calculated. Main results A total of 43 randomised controlled trials (4,364 participants) were included in this review. Very few trials provided data suitable for inclusion in a meta‐analysis. Among the five trials that yielded data assessing the daily frequency of hot flushes suitable for pooling, no significant difference overall was noted in the incidence of hot flushes between participants taking Promensil (a red clover extract) and those given placebo (mean difference (MD) ‐0.93, 95% confidence interval (CI) ‐1.95 to 0.10, I 2 = 31%). No evidence indicated a difference in percentage reduction in hot flushes in two trials between Promensil and placebo (MD 20.15, 95% CI ‐12.08 to 52.38, I 2 = 82%). Four trials that were not combined in meta‐analyses suggested that extracts with high (> 30 mg/d) levels of genistein consistently reduced the frequency of hot flushes. Individual results from the remaining trials were compared in broad subgroups such as dietary soy, soy extracts and other types of phytoestrogens that could not be combined. Some of these trials found that phytoestrogen treatments alleviated the frequency and severity of hot flushes and night sweats when compared with placebo, but many trials were small and were determined to be at high risk of bias. A strong placebo effect was noted in most trials, with a reduction in frequency ranging from 1% to 59% with placebo. No indication suggested that discrepant results were due to the amount of isoflavone in the active treatment arm, the severity of vasomotor symptoms or trial quality factors. Also, no evidence indicated that these treatments caused oestrogenic stimulation of the endometrium or the vagina or other adverse effects when used for up to two years. Authors' conclusions No conclusive evidence shows that phytoestrogen supplements effectively reduce the frequency or severity of hot flushes and night sweats in perimenopausal or postmenopausal women, although benefits derived from concentrates of genistein should be further investigated. Plain language summary Phytoestrogens for vasomotor menopausal symptoms Review question: This Cochrane review has evaluated whether phytoestrogen treatments reduce the number and severity of hot flushes and whether they are safe and acceptable. Background: Hormone therapy is an effective treatment for controlling the most common menopausal symptoms—hot flushes and night sweats. However, it is now recommended only in low doses given for the shortest possible time because of concerns about increased risk of some chronic diseases. Many women have started to use therapies that they perceive as 'natural' and safe, but they often do not have good information about the potential benefits and risks. Some of these therapies contain phytoestrogens—a group of plant‐derived chemicals that are thought to prevent or treat disease. Phytoestrogens are found in a wide variety of plants, some of which are foods, particularly soy, alfalfa and red clover. Study characteristics: This review found 43 RCTs conducted up to July 2013 that included 4,084 participants with hot flushes who were close to the menopause or were menopausal. Evidence obtained is current to July 2013. Key results: Some trials reported a slight reduction in hot flushes and night sweats with phytoestrogen‐based treatment. Extracts containing high levels of genistein (a substance derived from soy) appeared to reduce the number of daily hot flushes and need to be investigated further. Overall no indication suggested that other types of phytoestrogens work any better than no treatment. No evidence was found of harmful effects on the lining of the womb, stimulation of the vagina or other adverse effects with short‐term use. Quality of the evidence: Many of the trials in this review were small, of short duration and of poor quality, and the types of phytoestrogens used varied substantially.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lethaby, A, Marjoribanks, J, Kronenberg, F, Roberts, H, Eden, J, Brown, J", "articleTypes": [], "doi": "10.1002/14651858.CD001395.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.761Z" }, { "id": "6a11f3c7-d2c7-46a4-8588-9384798cf356", "pmid": "", "title": "Finerenone and Empagliflozin Combination in Obesity With Hypertension: A 12-Week Prospective, Parallel-design, Double-blind, Randomized, Placebo-controlled Trial", "imported": false, "abstract": "The EFFORT Study (Empagliflozin and Finerenone Combination in Obesity with Hypertension) is a 12-week, randomized, double-blind, placebo-controlled trial that aims to test whether combining empagliflozin (10 mg/day) with finerenone (10 mg/day, up-titrated to 20 mg after 4 weeks) can significantly lower office systolic blood pressure in adults with obesity and stage 1 hypertension (systolic BP 140-160 mmHg) who are on up to two stable antihypertensives. The study will enroll 260 participants from community settings. Beyond blood pressure, the trial will also assess effects on diastolic pressure, cumulative BP exposure, urinary albumin-to-creatinine ratio, inflammation (hs-CRP), fasting glucose, body weight, and quality of life. Safety monitoring focuses on hyperkalemia, acute kidney injury, hypotension, and hypoglycemia. If positive, this research may offer a new, mechanism-based therapeutic strategy for the growing population with cardiometabolic risk, potentially providing better cardiovascular and kidney protection than conventional approaches.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "6a2df530-e35e-456a-b684-5160d52e2b8b", "pmid": "", "title": "Siponimod for multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Cao, L, Li, M, Yao, L, Yan, P, Wang, X, Yang, Z, Lao, Y, Li, H, Yang, K, Li, K", "articleTypes": [], "doi": "10.1002/14651858.CD013647.pub2 AB - Abstract - Background Multiple sclerosis (MS) is a chronic immune‐mediated disease of the central nervous system, with an unpredictable course. Current MS therapies such as disease‐modifying therapies focus on treating exacerbations, preventing new exacerbations and avoiding the progression of disability. Siponimod (BAF312) is an oral treatment, a selective sphingosine‐1‐phosphate (S1P) receptor modulator, for the treatment of adults with relapsing forms of MS including active, secondary progressive MS with relapses. Objectives To assess the benefits and adverse effects of siponimod as monotherapy or combination therapy versus placebo or any active comparator for people diagnosed with MS. Search methods We searched the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Trials Register, which contains studies from CENTRAL, MEDLINE and Embase, and the trials registry databases ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 10 September 2021. We also handsearched relevant journals and screened the reference lists of published reviews and retrieved articles and searched reports (2004 to September 2021) from the MS societies in Europe and America. Selection criteria We included randomised parallel controlled clinical trials (RCTs) that evaluated siponimod, as monotherapy or combination therapy, versus placebo or any active comparator in people with MS. There were no restrictions on dose or administration frequency. Data collection and analysis We used standard methodological procedures expected by Cochrane. We discussed disagreements and resolved them by consensus among the review authors. Our primary outcomes wereworsening disability , relapse and adverse events, and secondary outcomes were annualised relapse rate, gadolinium‐enhancing lesions, new lesions or enlarged pre‐existing lesions and mean change of brain volume. We independently evaluated the certainty of evidence using the GRADE approach. We contacted principal investigators of included studies for additional data or confirmation of data. Main results Two studies (1948 participants) met our selection criteria, 608 controls and 1334 treated with siponimod. The included studies compared siponimod with placebo. Overall, all studies had a high risk of bias due to selective reporting and attrition bias. Comparing siponimod administered at a dose of 2 mg to placebo, we found that siponimod may reduce the number of participants with disability progression at six months (56 fewer people per 1000; risk ratio (RR) 0.78, 95% confidence interval (CI) 0.65 to 0.94; 1 study, 1641 participants; low‐certainty evidence) and annualised relapse rate (RR 0.43, 95% CI 0.34 to 0.56; 2 studies, 1739 participants; low‐certainty evidence). But it might lead to little reduction in the number of participants with new relapse (166 fewer people per 1000; RR 0.38, 95% CI 0.15 to 1.00; 1 study, 94 participants; very low‐certainty evidence). We observed no evidence of a difference due to adverse events for siponimod at 2 mg compared to placebo (14 more people per 1000; RR 1.52, 95% CI 0.85 to 2.71; 2 studies, 1739 participants, low‐certainty evidence). In addition, due to the high risk of inaccurate magnetic resonance imaging (MRI) data in the two included studies, we could not combine data for active lesions on MRI scans. Both studies had high attrition bias resulting from the unbalanced reasons for dropouts among groups and high risk of bias due to conflicts of interest. Siponimod may reduce the number of gadolinium‐enhancing T1‐weighted lesions at two years of follow‐up (RR 0.14, 95% CI 0.10 to 0.19; P < 0.0001; 1 study, 1641 participants; very low‐certainty evidence). There may be no evidence of a difference between groups in the number of participants with at least one serious adverse event excluding relapses (113 more people per 1000; RR 1.80, 95% CI 0.37 to 8.77; 2 studies, 1739 participants; low‐certainty evidence) at six months. No data were available regarding cardiac adverse events. In terms of safety profile, the most common adverse events associated with siponimod were headache, back pain, bradycardia, dizziness, fatigue, influenza, urinary tract infection, lymphopenia, nausea, alanine amino transferase increase and upper respiratory tract infection. These adverse events have dose‐related effects and rarely led to discontinuation of treatment. Authors' conclusions Based on the findings of the RCTs included in this review, we are uncertain whether siponimod interventions are beneficial for people with MS. There was low‐certainty evidence to support that siponimod at a dose of 2 mg orally once daily as monotherapy compared with placebo may reduce the annualised relapse rate and the number of participants who experienced disability worsening, at 6 months. However, the certainty of the evidence to support the benefit in reducing the number of people with a relapse is very low. The risk of withdrawals due to adverse events requires careful monitoring of participants over time. The duration of all studies was less than 24 months, so the efficacy and safety of siponimod over 24 months are still uncertain, and further exploration is needed in the future. There is no high‐certainty data available to evaluate the benefit on MRI outcomes. We assessed the certainty of the body of evidence for all outcomes was low to very low, downgraded due to serious study limitations, imprecision and indirectness. We are uncertain whether siponimod is beneficial for people with MS. More new studies with robust methodology and longer follow‐up are needed to evaluate the benefit of siponimod for the management of MS and to observe long‐term adverse effects. Also, in addition to comparing with placebo, more new studies are needed to evaluate siponimod versus other therapeutic options. Plain language summary Is siponimod an effective treatment for multiple sclerosis (MS) and does it cause unwanted effects? Key messages · We don’t know whether siponimod is an effective treatment for people with multiple sclerosis (MS). At a dose of 2 mg once a day, siponimod may reduce recurrence of symptoms (relapse, calculated as an annual rate) after six months of treatment and may reduce the number of participants whose disability worsens after three months of treatment. · We don’t know if siponimod causes unwanted effects because studies did not last long enough to fully assess them. · Future studies should last longer in order to monitor unwanted and beneficial effects of siponimod better, and should use more robust methods. They should compare siponimod with other medicines. What is multiple sclerosis? Multiple sclerosis (MS) is a condition caused when the body’s immune system – which defends the body against disease and infection – mistakenly attacks parts of the central nervous system (the brain and spinal cord). Symptoms include problems with balance and walking, and blurred vision. MS is a lifelong condition that can cause serious disability. Some people’s symptoms may develop gradually. However, most people experience ‘attacks’ when new symptoms develop or existing symptoms worsen (called ‘relapse’), followed by periods with no changes to their symptoms (called ‘remittance’). This type of MS is called ‘relapsing remitting’ MS. Eventually, the course of their MS may change. These periods when there are no symptoms, or no worsening of symptoms, may stop and then symptoms may worsen continually. This is called ‘secondary progressive MS’. How does siponimod work? Siponimod is a medicine that attaches to the white blood cells (lymphocytes) that attack the central nervous system. This causes the lymphocytes to stay in the lymph glands instead of circulating in the blood to the brain. Fewer lymphocytes reach the brain so the attack by the immune system is reduced. Siponimod is a tablet taken once a day. What did we want to find out? We wanted to know if siponimod is an effective treatment for MS and whether it causes any unwanted effects. We were interested in the number of people: · who experienced relapses; · whose disability worsened; · who left the studies because of unwanted effects of siponimod; · who developed new or larger brain lesions (damage to the brain); and · who experienced serious unwanted effects, and which unwanted effects they experienced. What did we do? 
We searched for studies that investigated siponimod compared with placebo (a sham medicine that looks and tastes the same as siponimod but with no active ingredients) or another medicine to treat MS. Studies could investigate siponimod alone or combined with another treatment, at any dose over any length of time. Participants had to be aged over 18 years, with confirmed MS. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found two studies with 1948 participants. Both studies compared siponimod with placebo. One study included 1651 people with secondary progressive MS, who were given 2 mg siponimod for up to 3 years. The other study included 297 participants with relapsing remitting MS, who were given siponimod at doses of 10 mg, 2 mg or 0.5 mg for 6 months, or 1.25 mg or 0.25 mg for 3 months. We report the results for 2 mg daily because both studies looked at this dose. At 2 mg a day, compared to placebo: · siponimod may lead to a small reduction (166 fewer people per 1000) in the number of people with a new relapse up to six months after starting treatment, and may also reduce relapses when calculated at an annual rate; · siponimod may reduce the number of people whose disability worsened during the six months after starting treatment (by 56 people per 1000); · there may be no difference to the number of people (14 more per 1000) who left the studies in the six months after starting treatment due to unwanted effects; · siponimod may reduce the number of brain lesions of different types after six months and after two years of follow‐up. · siponimod may make no difference to the number of people with at least one serious unwanted effect in the six months after starting treatment. The most common unwanted effects associated with siponimod were headache, back pain, dizziness, tiredness, influenza, urinary tract infection, reduced white blood cells (lymphopenia), feeling sick, possible liver damage, and infections in the mouth and nose. No information was available about heart‐related unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only 2 studies. They did not provide information about everything we were interested and they included people with different types of MS. Also, they did not last long enough to judge the impact of unwanted effects. Both studies were funded by the company that makes siponimod.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.788Z" }, { "id": "6a3b2856-c48d-43ed-90bd-aec903fda20e", "pmid": "", "title": "Intestinal Sweet Taste Receptor Function and Adaptation to Dietary Sugars and Sweeteners", "imported": false, "abstract": "The purpose of this study is to collect data that will help researchers better understand the various causes of obesity and diabetes; particularly to understand how consumption of NCASs affects the way the body uses nutrients.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.143Z" }, { "id": "6a559ff6-3ff3-4395-a694-4f26634fb7cb", "pmid": "", "title": "Interventions for iatrogenic inferior alveolar and lingual nerve injury", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Coulthard, P, Kushnerev, E, Yates, JM, Walsh, T, Patel, N, Bailey, E, Renton, TF", "articleTypes": [], "doi": "10.1002/14651858.CD005293.pub2 AB - Abstract - Background Iatrogenic injury of the inferior alveolar or lingual nerve or both is a known complication of oral and maxillofacial surgery procedures. Injury to these two branches of the mandibular division of the trigeminal nerve may result in altered sensation associated with the ipsilateral lower lip or tongue or both and may include anaesthesia, paraesthesia, dysaesthesia, hyperalgesia, allodynia, hypoaesthesia and hyperaesthesia. Injury to the lingual nerve may also affect taste perception on the affected side of the tongue. The vast majority (approximately 90%) of these injuries are temporary in nature and resolve within eight weeks. However, if the injury persists beyond six months it is deemed to be permanent. Surgical, medical and psychological techniques have been used as a treatment for such injuries, though at present there is no consensus on the preferred intervention, or the timing of the intervention. Objectives To evaluate the effects of different interventions and timings of interventions to treat iatrogenic injury of the inferior alveolar or lingual nerves. Search methods We searched the following electronic databases: the Cochrane Oral Health Group's Trial Register (to 9 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 9 October 2013) and EMBASE via OVID (1980 to 9 October 2013). No language restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials (RCTs) involving interventions to treat patients with neurosensory defect of the inferior alveolar or lingual nerve or both as a sequela of iatrogenic injury. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. We performed data extraction and assessment of the risk of bias independently and in duplicate. We contacted authors to clarify the inclusion criteria of the studies. Main results Two studies assessed as at high risk of bias, reporting data from 26 analysed participants were included in this review. The age range of participants was from 17 to 55 years. Both trials investigated the effectiveness of low‐level laser treatment compared to placebo laser therapy on inferior alveolar sensory deficit as a result of iatrogenic injury. Patient‐reported altered sensation was partially reported in one study and fully reported in another. Following treatment with laser therapy, there was some evidence of an improvement in the subjective assessment of neurosensory deficit in the lip and chin areas compared to placebo, though the estimates were imprecise: a difference in mean change in neurosensory deficit of the chin of 8.40 cm (95% confidence interval (CI) 3.67 to 13.13) and a difference in mean change in neurosensory deficit of the lip of 21.79 cm (95% CI 5.29 to 38.29). The overall quality of the evidence for this outcome was very low; the outcome data were fully reported in one small study of 13 patients, with differential drop‐out in the control group, and patients suffered only partial loss of sensation. No studies reported on the effects of the intervention on the remaining primary outcomes of pain, difficulty eating or speaking or taste. No studies reported on quality of life or adverse events. The overall quality of the evidence was very low as a result of limitations in the conduct and reporting of the studies, indirectness of the evidence and the imprecision of the results. Authors' conclusions There is clearly a need for randomised controlled clinical trials to investigate the effectiveness of surgical, medical and psychological interventions for iatrogenic inferior alveolar and lingual nerve injuries. Primary outcomes of this research should include: patient‐focused morbidity measures including altered sensation and pain, pain, quantitative sensory testing and the effects of delayed treatment. Plain language summary Treatments for accidental damage during surgery to the nerves supplying sensation to the tongue, lower lip and chin Review question The main question addressed by this review is how effective are different treatments and what are the best timings for these treatments following accidental damage during surgery to the nerves that supply sensation to the tongue, lower lip and chin. Background The nerves (alveolar and lingual) supplying sensation to the tongue, lower lip and chin, may be injured as a result of surgical treatments to the mouth and face, including surgery to remove lower wisdom teeth. The vast majority (90%) of these injuries are temporary and get better within eight weeks. However if they last for longer than six months they are considered to be permanent. Damage to these nerves can lead to altered sensation in the region of the lower lip and chin, or tongue or both. Furthermore, damage to the nerve supplying the tongue may lead to altered taste perception. These injuries can affect people's quality of life leading to emotional problems, problems with socialising and disabilities. Accidental injury after surgery can also give rise to legal action. There are many interventions or treatments available, surgical and non‐surgical, that may enhance recovery, including improving sensation. They can be grouped as. 1. Surgical – a variety of procedures.
 2. Laser treatment – low‐level laser treatment has been used to treat partial loss of sensation.
 3. Medical – treatment with drugs including antiepileptics, antidepressants and painkillers.
 4. Counselling – including cognitive behavioural and relaxation therapy, changing behaviour and hypnosis. Study characteristics The Cochrane Oral Health Group carried out this review, and the evidence is current as of 9 October 2013. There are two studies included, both published in 1996, which compared low‐level laser treatment to placebo or fake treatment for partial loss of sensation following surgery to the lower jaw. There were 15 participants in one study and 16 in the other, their ages ranging from 17 to 55 years. All had suffered accidental damage to nerves of the lower jaw and tongue causing some loss of sensation following surgery. Key results Low‐level laser therapy was the only treatment to be evaluated in the included studies and this was compared to fake or placebo laser therapy. No studies were found that evaluated other surgical, medical or counselling treatments. There was some evidence of an improvement when participants reported whether or not sensation was better in the lip and chin areas with low‐level laser therapy. This is based on the results of a single, small study, so the results should be interpreted with caution. No studies reported on the effects of the treatment on other outcomes such as pain, difficulty eating or speaking or taste. No studies reported on quality of life or harm. Quality of the evidence The overall quality of the evidence is very low as a result of limitations in the conduct and reporting of the two included studies and the low number of participants, and evidence from participants with only partial sensory loss.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.746Z" }, { "id": "6a7990d5-a997-4c12-829b-6c81572c93e0", "pmid": "", "title": "Zinc for the common cold", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Singh, M, Das, RR", "articleTypes": [], "doi": "10.1002/14651858.CD001364.pub5 AB - Reason for withdrawal from publication September 2016 updated withdrawal notice 
 This Cochrane Review was withdrawn in April 2015, and this withdrawal notice was updated in September 2016. The review was withdrawn as result of comments submitted via the Cochrane Library by Harri Hemilä in February 2015. Hemilä identified multiple errors in this Cochrane Review and made allegations of plagiarism of text and data from a previously published systematic review (Hemilä H. Zinc Lozenges may shorten the duration of colds: a systematic review. Open Respiratory Medicine Journal 2011;5:51‐58. dx.doi.org/10.2174/1874306401105010051). The comments referred to the version of this review first published in June 2013 (Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2013;(6):CD001364. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001364.pub4/full) . The Cochrane Acute Respiratory Infections Group, which maintains the review, withdrew the review in April 2015, pending an assessment of the errors reported, and the group referred the allegations of plagiarism to the Editor in Chief. The Editor in Chief notified the authors of the concerns, and followed the Committee for Publication Ethics (COPE) guidelines. Replication of text was identified in the Cochrane Review. This was limited to copying of short phrases and was acknowledged by the authors. The level of text plagiarism was minor and at a level that would be addressed by a correction. The Editor in Chief carried out further investigation into the alleged plagiarism of data, with the co‐operation of the review authors, who provided supplementary information in support of their work. The allegations related to the derivation of means and standard deviations of data from some of the included studies. Although the authors acknowledge and cite the Hemilä 2011 review, the Editor in Chief considered that the authors’ explanation regarding some similarities in presented data between the two reviews was not conclusive. This version of the review will therefore remain withdrawn. April 2015 withdrawal notice 
 This review was withdrawn due to concerns raised via the feedback mechanism regarding the calculation and analysis of data in the review in April 2015. Whilst it is not unusual for reviews to be withdrawn, the editorial group took the view that it would be better to take a cautious approach and explore the source and calculation of data used in the analysis in more detail, rather than keep the review on the Cochrane Database of Systematic Reviews for the time being. The editorial group responsible for this previously published document have withdrawn it from publication.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.724Z" }, { "id": "6a8bd8d4-9dfe-44f6-b3fc-d9b7a65a0077", "pmid": "", "title": "Pharmacological interventions for self‐harm in adults", "imported": false, "abstract": "Abstract - Background Self‐harm (SH; intentional self‐poisoning or self‐injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm. Objectives To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta‐analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients. Search methods For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co‐ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013. Selection criteria We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services. Data collection and analysis We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta‐analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow‐up. For this analysis, we pooled data using a random‐effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach. Main results We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low‐dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported. Authors' conclusions Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment. Plain language summary Drugs and natural products for self‐harm in adults We have reviewed the international literature regarding pharmacological (drug) and natural product (dietary supplementation) treatment trials in this field. A total of seven trials meeting our inclusion criteria were identified. There is little evidence of beneficial effects of either pharmacological or natural product treatments. However, few trials have been conducted and those that have are small, meaning that possible beneficial effects of some therapies cannot be ruled out. Why is this review important? Self‐harm (SH), which includes intentional self‐poisoning/overdose and self‐injury, is a major problem in many countries and is strongly linked to suicide. It is therefore important that effective treatments for SH patients are developed. Whilst there has been an increase in the use of psychosocial interventions for SH in adults (which is the focus of a separate review), drug treatments are frequently used in clinical practice. It is therefore important to assess the evidence for their effectiveness. Who will be interested in this review? Clinicians working with patients who engage in SH, patients themselves, and their relatives. What questions does this review aim to answer? This review is an update of a previous Cochrane review from 1999 which found little evidence of beneficial effects of drug treatments on repetition of SH apart from for flupenthixol. This update aims to further evaluate the evidence for effectiveness of drugs and natural products for patients with SH with a broader range of outcomes. Which studies were included in the review? To be included in the review, studies had to be randomised controlled trials of drug treatments for adults who had recently engaged in SH. What does the evidence from the review tell us? There is currently no clear evidence for the effectiveness of antidepressants, antipsychotics, mood stabilisers, or natural products in preventing repetition of SH. What should happen next? We recommend further trials of drugs for SH patients, possibly in combination with psychological treatment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hawton, K; Witt, KG; Taylor Salisbury, TL; Arensman, E; Gunnell, D; Hazell, P; Townsend, E; van Heeringen, K", "articleTypes": [], "doi": "10.1002/14651858.CD011777", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "6a928114-4ed1-4bfd-b9a6-abf8c4d45108", "pmid": "", "title": "Reduced dietary salt for the prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review that was first published in 2011 of the effects of reducing dietary salt intake, through advice to reduce salt intake or low‐sodium salt substitution, on mortality and cardiovascular events. Objectives 1. To assess the long‐term effects of advice and salt substitution, aimed at reducing dietary salt, on mortality and cardiovascular morbidity. 2. To investigate whether a reduction in blood pressure is an explanatory factor in the effect of such dietary interventions on mortality and cardiovascular outcomes. Search methods We updated the searches of CENTRAL (2013, Issue 4), MEDLINE (OVID, 1946 to April week 3 2013), EMBASE (OVID, 1947 to 30 April 2013) and CINAHL (EBSCO, inception to 1 April 2013) and last ran these on 1 May 2013. We also checked the references of included studies and reviews. We applied no language restrictions. Selection criteria Trials fulfilled the following criteria: (1) randomised, with follow‐up of at least six months, (2) the intervention was reduced dietary salt (through advice to reduce salt intake or low‐sodium salt substitution), (3) participants were adults and (4) mortality or cardiovascular morbidity data were available. Two review authors independently assessed whether studies met these criteria. Data collection and analysis A single author extracted data and assessed study validity, and a second author checked this. We contacted trial authors where possible to obtain missing information. We extracted events and calculated risk ratios (RRs) and 95% confidence intervals (CIs). Main results Eight studies met the inclusion criteria: three in normotensives (n = 3518) and five in hypertensives or mixed populations of normo‐ and hypertensives (n = 3766). End of trial follow‐up ranged from six to 36 months and the longest observational follow‐up (after trial end) was 12.7 years. The risk ratios (RR) for all‐cause mortality in normotensives were imprecise and showed no evidence of reduction (end of trial RR 0.67, 95% confidence interval (CI) 0.40 to 1.12, 60 deaths; longest follow‐up RR 0.90, 95% CI 0.58 to 1.40, 79 deaths n=3518) or in hypertensives (end of trial RR 1.00, 95% CI 0.86 to 1.15, 565 deaths; longest follow‐up RR 0.99, 95% CI 0.87 to 1.14, 674 deaths n=3085). There was weak evidence of benefit for cardiovascular mortality (hypertensives: end of trial RR 0.67, 95% CI 0.45 to 1.01, 106 events n=2656) and for cardiovascular events (hypertensives: end of trial RR 0.76, 95% CI 0.57 to 1.01, 194 events, four studies, n = 3397; normotensives: at longest follow‐up RR 0.84, 95% CI 0.64 to 1.10, 200 events; hypertensives: RR 0.77, 95% CI 0.58 to 1.02, 192 events; pooled analysis of six trials (RR 0.81, 95% CI 0.66 to 0.98; n = 5762). These findings were driven by one trial among retirement home residents that reduced salt intake in the kitchens of the homes, thereby not requiring individual behaviour change. Advice to reduce salt showed small reductions in systolic blood pressure (mean difference (MD) ‐1.15 mmHg, 95% CI ‐2.32 to 0.02 n=2079) and diastolic blood pressure (MD ‐0.80 mmHg, 95% CI ‐1.37 to ‐0.23 n=2079) in normotensives and greater reductions in systolic blood pressure in hypertensives (MD ‐4.14 mmHg, 95% CI ‐5.84 to ‐2.43 n=675), but no difference in diastolic blood pressure (MD ‐3.74 mmHg, 95% CI ‐8.41 to 0.93 n=675). Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Health‐related quality of life was assessed in one trial in normotensives, which reported significant improvements in well‐being but no data were presented. Authors' conclusions Despite collating more event data than previous systematic reviews of randomised controlled trials, there is insufficient power to confirm clinically important effects of dietary advice and salt substitution on cardiovascular mortality in normotensive or hypertensive populations. Our estimates of the clinical benefits from advice to reduce dietary salt are imprecise, but are larger than would be predicted from the small blood pressure reductions achieved. Further well‐powered studies would be needed to obtain more precise estimates. Our findings do not support individual dietary advice as a means of restricting salt intake. It is possible that alternative strategies that do not require individual behaviour change may be effective and merit further trials. Plain language summary Reduced dietary salt for the prevention of cardiovascular disease Cardiovascular disease includes heart attacks and strokes and is a major cause of premature death and disability. This is an update of a review first published in 2011. This review sets out to assess whether intensive support and encouragement to cut down on salt in foods, and substituting low‐sodium salt, reduces the risk of death or cardiovascular disease. This update includes two new studies and eliminates one problematic study, giving a total of eight trials with 7284 participants. Dietary advice and salt substitution did reduce the amount of salt eaten, which led to a small reduction in blood pressure by six months. There was weak evidence of benefit for cardiovascular events, but these findings were inconclusive and were driven by a single trial among retirement home residents, which reduced salt intake in the kitchens of the homes. The findings of our review do not mean that advising people to reduce salt should be stopped. However, additional measures ‐ reducing the amount of hidden salt in processed foods, for example – will make it much easier for people to achieve a lower salt diet. Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Further evidence of the effects of different ways of reducing dietary salt on clinical events is needed from experimental and observational studies to underpin public health policies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Adler, AJ, Taylor, F, Martin, N, Gottlieb, S, Taylor, RS, Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD009217.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.817Z" }, { "id": "6aa28240-1693-4392-a4c6-b38b14c558d5", "pmid": "", "title": "Antibiotics versus placebo for acute bacterial conjunctivitis", "imported": false, "abstract": "Abstract - Background Acute bacterial conjunctivitis is an infection of the conjunctiva and is one of the most common ocular disorders in primary care. Antibiotics are generally prescribed on the basis that they may speed recovery, reduce persistence, and prevent keratitis. However, many cases of acute bacterial conjunctivitis are self‐limited, resolving without antibiotic therapy. This Cochrane Review was first published in The Cochrane Library in 1999, then updated in 2006, 2012, and 2022. Objectives To assess the benefits and side effects of antibiotic therapy in the management of acute bacterial conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2022, Issue 5), MEDLINE (January 1950 to May 2022), Embase (January 1980 to May 2022), the meta Register of Controlled Trials ( m RCT) ( www.controlled-trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ), and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases in May 2022. Selection criteria We included randomized controlled trials (RCTs) in which any form of antibiotic treatment, with or without steroid, had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical and systemic antibiotic treatments. Data collection and analysis Two authors independently reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies and determined the included RCTs, which were further assessed for risk of bias using Cochrane methodology. We performed data extraction in a standardized manner and conducted random‐effects meta‐analyses using RevMan Web. Main results We included 21 eligible RCTs, 10 of which were newly identified in this update. A total of 8805 participants were randomized. All treatments were topical in the form of drops or ointment. The trials were heterogeneous in terms of their eligibility criteria, the nature of the intervention (antibiotic drug class, which included fluoroquinolones [FQs] and non‐FQs; dosage frequency; duration of treatment), the outcomes assessed and the time points of assessment. We judged one trial to be of high risk of bias, four as low risk of bias, and the others as raising some concerns. Based on intention‐to‐treat (ITT) population, antibiotics likely improved clinical cure (resolution of clinical symptoms or signs) by 26% (RR 1.26, 95% CI 1.09 to 1.46; 5 trials, 1474 participants; moderate certainty) as compared with placebo. Subgroup analysis showed no differences by antibiotic class (P = 0.67) or treatment duration (P = 0.60). In the placebo group, 55.5% (408/735) of participants had spontaneous clinical resolution by days 4 to 9 versus 68.2% (504/739) of participants treated with an antibiotic. Based on modified ITT population, in which participants were analyzed after randomization on the basis of positive microbiological culture, antibiotics likely increased microbiological cure (RR 1.53, 95% CI 1.34 to 1.74; 10 trials, 2827 participants) compared with placebo at the end of therapy; there were no subgroup differences by drug class (P = 0.60). No study evaluated the cost‐effectiveness of antibiotic treatment. Patients receiving antibiotics had a lower risk of treatment incompletion than those in the placebo group (RR 0.64, 95% CI 0.52 to 0.78; 13 trials, 5573 participants; moderate certainty) and were 27% less likely to have persistent clinical infection (RR 0.73, 95% CI 0.65 to 0.81; 19 trials, 5280 participants; moderate certainty). There was no evidence of serious systemic side effects reported in either the antibiotic or placebo group (very low certainty). When compared with placebo, FQs (RR 0.70, 95% CI 0.54 to 0.90) but not non‐FQs (RR 4.05, 95% CI 1.36 to 12.00) may result in fewer participants with ocular side effects. However, the estimated effects were of very low certainty. Authors' conclusions The findings of this update suggest that the use of topical antibiotics is associated with a modestly improved chance of resolution in comparison to the use of placebo. Since no evidence of serious side effects was reported, use of antibiotics may therefore be considered to achieve better clinical and microbiologic efficacy than placebo. Increasing the proportion of participants with clinical cure or increasing the speed of recovery or both are important for individual return to work or school, allowing people to regain quality of life. Future studies may examine antiseptic treatments with topical antibiotics for reasons of cost and growing antibiotic resistance. Plain language summary What are the benefits and harms of antibiotics for acute bacterial conjunctivitis? Key messages Topical antibiotics may improve signs and symptoms as well as bacterial clearance in participants with acute bacterial conjunctivitis. However, some antibiotics can cause unwanted effects on the eyes or eyelids; no evidence suggests that antibiotics cause unwanted effects in other parts of the body. What is acute bacterial conjunctivitis? Acute bacterial conjunctivitis is a condition in which the thin layer over the white areas and the inside lining of the eyelids of one or both eyes becomes red and inflamed from a bacterial infection. Acute bacterial conjunctivitis is usually contagious and hence children and working adults are advised to avoid going to school or work when affected. Fortunately, it resolves spontaneously in most cases. How is acute bacterial conjunctivitis treated? People with acute bacterial conjunctivitis are often given treatment at the site of the infection, usually as antibiotic eye drops or ointment, to speed recovery. However, the benefits of antibiotics have been questioned when considering they can cause irritation or allergic reaction in and around the eyes or surrounding skin. What did we want to find out? We examined whether antibiotics alone or in combination with steroid, can improve signs and symptoms of conjunctivitis or help clear the associated bacteria. We also evaluated whether antibiotics would result in undesirable effects on the eyes. What did we do? We performed a systematic review by searching for studies that compared antibiotics in eyedrop, ointment, or tablet form with inactive controls. We summarized these study findings and reported the results together with our level of confidence in them based on how studies were conducted. What did we find? We found that antibiotics likely increase clinical cure and microbiological cure after a course of treatment in comparison with placebo. Antibiotic use also is associated with fewer participants stopping their treatment earlier than they are supposed to. However, for some individuals, non‐fluroquinolone but not fluoroquinolone antibiotics, may result in more unwanted effects on the eyes or eyelids than placebo though we were very uncertain about the relevant evidence. There was no evidence that antibiotics were associated with systemic side effects such as headache or altered sense of smell. What are the limitations of the evidence? The current update focused on adults and children aged one month or older. Therefore, the evidence does not pertain to antibiotic treatment for neonatal conjunctivitis in neonates younger than one month old. We did not find studies that compared effects of the same antibiotics used in short versus long duration. Therefore, the current review was unable to suggest for or against the prescription duration for acute bacterial conjunctivitis. How up‐to‐date is this evidence? The evidence is up‐to‐date as of April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Chen, Y-Y; Liu, A-HS; Nurmatov, U; van Schayck, OCP; Kuo, IC", "articleTypes": [], "doi": "10.1002/14651858.CD001211.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "6aac1fb9-c522-4f74-82b3-a5889bf05cd5", "pmid": "", "title": "Xiao Chai Hu Tang, a herbal medicine, for chronic hepatitis B", "imported": false, "abstract": "Abstract - Background Chronic hepatitis B is associated with high morbidity and mortality. Chronic hepatitis B requires long‐term management aiming at reduction of the risks of hepatocellular inflammatory necrosis, liver fibrosis, decompensated liver cirrhosis, liver failure, and liver cancer, and improving health‐related quality of life. The Chinese herbal medicine formula Xiao Chai Hu Tang has been used to decrease discomfort and replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established with rigorous review methodology. Objectives To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and seven other databases to 1 March 2019. We also searched the World Health Organization International Clinical Trials Registry Platform ( www.who.int/ictrp ), ClinicalTrials.gov ( www.clinicaltrials.gov/ ), and the Chinese Clinical Trial Registry for ongoing or unpublished trials to 1 March 2019. Selection criteria We included randomised clinical trials, irrespective of publication status, language, and blinding, comparing Xiao Chai Hu Tang formula versus no intervention or placebo in people with chronic hepatitis B. We included participants of any sex and age, diagnosed with chronic hepatitis B according to guidelines or as defined by the trialists. We allowed co‐interventions when the co‐interventions were administered equally to all the intervention groups. Data collection and analysis Review authors independently retrieved data from reports and after correspondence with investigators. Our primary outcomes were all‐cause mortality, serious adverse events, and health‐related quality of life. Our secondary outcomes were hepatitis B‐related mortality, hepatitis B‐related morbidity, and adverse events considered 'not to be serious'. We presented the meta‐analysed results as risk ratios (RR) with 95% confidence intervals (CI). We assessed the risks of bias using risk of bias domains with predefined definitions. We used GRADE methodology to evaluate our certainty in the evidence. Main results We included 10 randomised clinical trials with 934 participants, but only five trials with 490 participants provided data for analysis. All the trials compared Xiao Chai Hu Tang formula with no intervention. All trials appeared to have been conducted and published only in China. The included trials assessed heterogeneous forms of Xiao Chai Hu Tang formula, administered for three to eight months. One trial included participants with hepatitis B and comorbid tuberculosis, and one trial included participants with hepatitis B and liver cirrhosis. The remaining trials included participants with hepatitis B only. All the trials were at high risk of bias, and the certainty of evidence for all outcomes that provided data for analyses was very low. We downgraded the evidence by one or two levels because of outcome risk of bias, inconsistency or heterogeneity of results (opposite direction of effect), indirectness of evidence (use of surrogate outcomes instead of clinically relevant outcomes), imprecision of results (the CIs were wide), and publication bias (small sample size of the trials). Additionally, 47 trials lacked the necessary methodological information needed to ensure the inclusion of these trials in our review. None of the included trials aimed to assess clinically relevant outcomes such as all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, or hepatitis B‐related morbidity. The effects of Xiao Chai Hu Tang formula on the proportion of participants with adverse events considered 'not to be serious' is uncertain (RR 0.43, 95% CI 0.02 to 11.98; I 2 = 69%; very low‐certainty evidence). Only three trials with 222 participants reported the proportion of people with detectable hepatitis B virus DNA (HBV‐DNA), but the evidence that Xiao Chai Hu Tang formula reduces the presence of HBV‐DNA in the blood (a surrogate outcome) is uncertain (RR 0.62, 95% CI 0.45 to 0.85; I 2 = 0%; very low‐certainty evidence). Only two trials with 160 participants reported the proportion of people with detectable hepatitis B virus e‐antigen (HBeAg; a surrogate outcome) (RR 0.72, 95% CI 0.50 to 1.02; I 2 = 38%; very low‐certainty evidence) and the evidence is uncertain. The evidence is also uncertain for separately reported adverse events considered 'not to be serious'. Funding: two of the 10 included trials received academic funding from government or hospital. None of the remaining eight trials reported information on funding. Authors' conclusions The clinical effects of Xiao Chai Hu Tang formula for chronic hepatitis B remain unclear. The included trials were small and of low methodological quality. Despite the wide use of Xiao Chai Hu Tang formula, we lack data on all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, and hepatitis B‐related morbidity. The evidence in this systematic review comes from data obtained from a maximum three trials. We graded the certainty of evidence as very low for adverse events considered not to be serious and the surrogate outcomes HBeAg and HBV‐DNA. We found a large number of trials which lacked clear description of their design and conduct, and hence, these trials are not included in the present review. As all identified trials were conducted in China, there might be a concern about the applicability of this review outside China. Large‐sized, high‐quality randomised sham‐controlled trials with homogeneous groups of participants and transparent funding are lacking. Plain language summary Xiao Chai Hu Tang, a Chinese herbal medicine formula, for chronic hepatitis B Review question To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B virus infection. Background Chronic hepatitis B virus infection is a common liver disease, associated with high morbidity (illness) and death. It causes psychological stress and is a burden to people with chronic hepatitis B and their families. Xiao Chai Hu Tang formula has been used for treating people with chronic hepatitis B as it is believed that it decreases discomfort and prevents the replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established in reviews with rigorous review methodology. Search date The review includes trials published up to 1 March 2019. Study characteristics We included 10 randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) with 934 participants. All trials compared Xiao Chai Hu Tang formula with no treatment. The trials assessed different formulas and doses for three to eight months. One trial included participants with tuberculosis (a disease of the lungs that can make you cough mucous), and one trial included participants with liver cirrhosis (scarring). Only five trials with 490 participants provided data for analysis Study funding sources Two of the 10 included trials reported receiving academic funding. None of the remaining eight trials reported information of support or funding. Key results None of the 10 included trials reported data on all‐cause mortality (death from any cause), serious side effects (untoward medical occurrences that result in serious outcomes such as death or disability), health‐related quality of life (a measure of physical, mental, emotional, and social functioning a measure of a person's satisfaction with their life and health), hepatitis B‐related death, and hepatitis B‐related morbidity. We are uncertain whether Xiao Chai Hu Tang formula versus no intervention has a positive or negative effect regarding side effects considered 'not to be serious', the proportion of people with detectable HBeAg (a hepatitis B viral protein that indicates active viral replication), and separately reported side effects considered 'not to be serious'. Xiao Chai Hu Tang formula compared with no intervention seems to reduce the proportion of people with detectable HBV‐DNA (which is used to indicate how much hepatitis B virus is in the blood) but the reliability of this finding is low. Surrogate outcomes are markers that are used in research as a substitute for a clinically meaningful measure that directly measures patient outcomes. We cannot always be certain that such surrogate outcomes are reliable substitutes for important outcomes as they need to be officially examined. Caution is needed with this beneficial finding as the trials are at high risk of bias, and this outcome has not yet been proven relevant to patients. We identified an additional 47 studies as potential randomised clinical trials, but the data they reported were of no use. Accordingly, properly designed randomised clinical trials are needed before the benefits and harms of Xiao Chai Hu Tang formula for chronic hepatitis B can be determined. Reliability of the evidence The reliability of the evidence on the use of Xiao Chai Hu Tang formula in people with chronic hepatitis B virus in terms of its beneficial or harmful effects on death, health‐related quality of life, risk of dying due to hepatitis B virus infection, and serious side effects cannot be determined as no trials aimed to explore these. The reliability of the evidence that Xiao Chai Hu Tang formula, when compared with no intervention, in terms of side effects considered 'not to be serious', the proportion of people with detectable HBV‐DNA, and the proportion of people with detectable HBeAg is very low. These assessments of the reliability of the evidence are due to the poor design and reporting of the included trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kong, DZ; Liang, N; Yang, GL; Zhang, Z; Liu, Y; Li, J; Liu, X; Liang, S; Nikolova, D; Jakobsen, JC; Gluud, C; Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD013090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "6adf2b75-e4f4-499e-887c-289655ee3dc8", "pmid": "", "title": "Study of the Genetic Factors That Influence the Susceptibility to and Severity of COVID-19", "imported": false, "abstract": "COVID-19 is a viral disease induced by infection with the novel SARS-CoV-2 coronavirus. Infection arises from the inhalation of viral particles spread by an infected individual. The main virus entry pathways are the nose and mouth mucous membranes, particularly rich in ACE2 receptors, that are used by the virus to enter cells and begin its replication.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.266Z" }, { "id": "6ae48aaa-975d-4066-b1bc-4da80e69504d", "pmid": "", "title": "Fortification of staple foods with zinc for improving zinc status and other health outcomes in the general population", "imported": false, "abstract": "Abstract - Background Zinc deficiency is a global nutritional problem, particularly in children and women residing in settings where diets are cereal based and monotonous. It has several negative health consequences. Fortification of staple foods with zinc may be an effective strategy for preventing zinc deficiency and improving zinc‐related health outcomes. Objectives To evaluate the beneficial and adverse effects of fortification of staple foods with zinc on health‐related outcomes and biomarkers of zinc status in the general population. Search methods We searched the following databases in April 2015: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3 of 12, 2015, the Cochrane Library), MEDLINE & MEDLINE In Process (OVID) (1950 to 8 April 2015), EMBASE (OVID) (1974 to 8 April 2015), CINAHL (1982 to April 2015), Web of Science (1900 to 9 April 2015), BIOSIS (1969 to 9 April 2015), POPLINE (1970 to April 2015), AGRICOLA, OpenGrey, BiblioMap, and Trials Register of Promoting Health Interventions (TRoPHI), besides regional databases (April 2015) and theses. We also searched clinical trial registries (17 March 2015) and contacted relevant organisations (May 2014) in order to identify ongoing and unpublished studies. Selection criteria We included randomised controlled trials, randomised either at the level of the individual or cluster. We also included non‐randomised trials at the level of the individual if there was a concurrent comparison group. We included non‐randomised cluster trials and controlled before‐after studies only if there were at least two intervention sites and two control sites. Interventions included fortification (central/industrial) of staple foods (cereal flours, edible fats, sugar, condiments, seasonings, milk and beverages) with zinc for a minimum period of two weeks. Participants were members of the general population who were over two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies, and assessed the risk of bias of the included studies. Main results We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Four trials compared the effect of zinc‐fortified staple foods with unfortified foods (comparison 1), and four compared zinc‐fortified staple foods in combination with other nutrients/factors with the same foods containing other nutrients or factors without zinc (comparison 2). The interventions lasted between one and nine months. We categorised most trials as having unclear or high risk of bias for randomisation, but low risk of bias for blinding and attrition. None of the studies in comparison 1 reported data on zinc deficiency. Foods fortified with zinc increased the serum or plasma zinc levels in comparison to foods without added zinc (mean difference (MD) 2.12 µmol/L, 95% confidence interval (CI) 1.25 to 3.00 µmol/L; 3 studies; 158 participants; low‐quality evidence). Participants consuming foods fortified with zinc versus participants consuming the same food without zinc had similar risk of underweight (average risk ratio 3.10, 95% CI 0.52 to 18.38; 2 studies; 397 participants; low‐quality evidence) and stunting (risk ratio (RR) 0.88, 95% CI 0.36 to 2.13; 2 studies; 397 participants; low‐quality evidence). A single trial of addition of zinc to iron in wheat flour did not find a reduction in proportion of zinc deficiency (RR 0.17, 95% CI 0.01 to 3.94; very low‐quality evidence). We did not find a difference in serum or plasma zinc levels in participants consuming foods fortified with zinc plus other micronutrients when compared with participants consuming the same foods with micronutrients but no added zinc (MD 0.03 µmol/L, 95% CI ‐0.67 to 0.72 µmol/L; 4 studies; 250 participants; low‐quality evidence). No trial in comparison 2 provided information about underweight or stunting. There was no reported adverse effect of fortification of foods with zinc on indicators of iron or copper status. Authors' conclusions Fortification of foods with zinc may improve the serum zinc status of populations if zinc is the only micronutrient used for fortification. If zinc is added to food in combination with other micronutrients, it may make little or no difference to the serum zinc status. Effects of fortification of foods with zinc on other outcomes including zinc deficiency, children’s growth, cognition, work capacity of adults, or on haematological indicators are unknown. Given the small number of trials and participants in each trial, further investigation of these outcomes is required. Plain language summary The effects of fortification of common foods with zinc on health outcomes Background It is believed that zinc deficiency is widespread globally, particularly in children and women living in low‐ and middle‐income countries. Cereal‐based foods are rich in dietary fibre and phytates, which reduce absorption of zinc from the intestine. As people in low‐income households eat a lot of cereal‐based foods, they are more likely to develop zinc deficiency. Fortification of common staple foods with zinc alone or in combination with other vitamins and minerals has been proposed as an intervention to increase intake of zinc in populations who consume these foods. Review question We evaluated the effects of fortification of staple foods with zinc on blood zinc levels and health‐related outcomes in the general population above two years of age. Study characteristics We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Key results and quality of the evidence The effect of fortification of foods with zinc on incidence of zinc deficiency is uncertain. Fortification of foods with zinc may slightly improve the blood zinc levels of populations if zinc is the only micronutrient used for fortification. Zinc added to food in combination with other micronutrients may make little or no difference to blood zinc levels. The fortification of foods with zinc may make little or no difference on incidence of underweight or stunting. The effects of fortification of foods with zinc on other outcomes, including wasting and weight/height, are unknown. Fortification of foods with zinc does not seem to have any adverse effect on indicators of iron or copper status. Most studies included in this review involved a small number of participants and were judged to be at low or unclear risk of bias. There were also some inconsistencies in the results across different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Shah, D, Sachdev, HS, Gera, T, De‐Regil, LM, Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010697.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.792Z" }, { "id": "6ae7e536-376c-4297-b620-1ad437fde9dc", "pmid": "", "title": "Interventions for hand eczema", "imported": false, "abstract": "Abstract - Background Hand eczema is an inflammation of the skin of the hands that tends to run a chronic, relapsing course. This common condition is often associated with itch, social stigma, and impairment in employment. Many different interventions of unknown effectiveness are used to treat hand eczema. Objectives To assess the effects of topical and systemic interventions for hand eczema in adults and children. Search methods We searched the following up to April 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, AMED, LILACS, GREAT, and four trials registries. We checked the reference lists of included studies for further references to relevant trials. Selection criteria We included randomised controlled trials (RCTs) that compared interventions for hand eczema, regardless of hand eczema type and other affected sites, versus no treatment, placebo, vehicle, or active treatments. Data collection and analysis We used standard methodological procedures expected by Cochrane. Primary outcomes were participant‐ and investigator‐rated good/excellent control of symptoms, and adverse events. Main results We included 60 RCTs, conducted in secondary care (5469 participants with mild to severe chronic hand eczema). Most participants were over 18 years old. The duration of treatment was short, generally up to four months. Only 24 studies included a follow‐up period. Clinical heterogeneity in treatments and outcome measures was evident. Few studies performed head‐to‐head comparisons of different interventions. Risk of bias varied considerably, with only five studies at low risk in all domains. Twenty‐two studies were industry‐funded. Eighteen trials studied topical corticosteroids or calcineurin inhibitors; 10 studies, phototherapy; three studies, systemic immunosuppressives; and five studies, oral retinoids. Most studies compared an active intervention against no treatment, variants of the same medication, or placebo (or vehicle). Below, we present results from the main comparisons. Corticosteroid creams/ointments: when assessed 15 days after the start of treatment, clobetasol propionate 0.05% foam probably improves participant‐rated control of symptoms compared to vehicle (risk ratio (RR) 2.32, 95% confidence interval (CI) 1.38 to 3.91; number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 8; 1 study, 125 participants); the effect of clobetasol compared to vehicle for investigator‐rated improvement is less clear (RR 1.43, 95% CI 0.86 to 2.40). More participants had at least one adverse event with clobetasol (11/62 versus 5/63; RR 2.24, 95% CI 0.82 to 6.06), including application site burning/pruritus. This evidence was rated as moderate certainty. When assessed 36 weeks after the start of treatment, mometasone furoate cream used thrice weekly may slightly improve investigator‐rated symptom control compared to twice weekly (RR 1.23, 95% CI 0.94 to 1.61; 1 study, 72 participants) after remission is reached. Participant‐rated symptoms were not measured. Some mild atrophy was reported in both groups (RR 1.76, 95% CI 0.45 to 6.83; 5/35 versus 3/37). This evidence was rated as low certainty. Irradiation with ultraviolet (UV) light: local combination ultraviolet light therapy (PUVA) may lead to improvement in investigator‐rated symptom control when compared to local narrow‐band UVB after 12 weeks of treatment (RR 0.50, 95% CI 0.22 to 1.16; 1 study, 60 participants). However, the 95% CI indicates that PUVA might make little or no difference. Participant‐rated symptoms were not measured. Adverse events (mainly erythema) were reported by 9/30 participants in the narrow‐band UVB group versus none in the PUVA group. This evidence was rated as moderate certainty. Topical calcineurin inhibitors: tacrolimus 0.1% over two weeks probably improves investigator‐rated symptom control measured after three weeks compared to vehicle (14/14 tacrolimus versus 0/14 vehicle; 1 study). Participant‐rated symptoms were not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. A within‐participant study in 16 participants compared 0.1% tacrolimus to 0.1% mometasone furoate but did not measure investigator‐ or participant‐rated symptoms. Both treatments were well tolerated when assessed at two weeks during four weeks of treatment. Evidence from these studies was rated as moderate certainty. Oral interventions: oral cyclosporin 3 mg/kg/d probably slightly improves investigator‐rated (RR 1.88, 95% CI 0.88 to 3.99; 1 study, 34 participants) or participant‐rated (RR 1.25, 95% CI 0.69 to 2.27) control of symptoms compared to topical betamethasone dipropionate 0.05% after six weeks of treatment. The risk of adverse events such as dizziness was similar between groups (up to 36 weeks; RR 1.22, 95% CI 0.80 to 1.86, n = 55; 15/27 betamethasone versus 19/28 cyclosporin). The evidence was rated as moderate certainty. Alitretinoin 10 mg improves investigator‐rated symptom control compared with placebo (RR 1.58, 95% CI 1.20 to 2.07; NNTB 11, 95% CI 6.3 to 26.5; 2 studies, n = 781) and alitretinoin 30 mg also improves this outcome compared with placebo (RR 2.75, 95% CI 2.20 to 3.43; NNTB 4, 95% CI 3 to 5; 2 studies, n = 1210). Similar results were found for participant‐rated symptom control: alitretinoin 10 mg RR 1.73 (95% CI 1.25 to 2.40) and 30 mg RR 2.75 (95% CI 2.18 to 3.48). Evidence was rated as high certainty. The number of adverse events (including headache) probably did not differ between alitretinoin 10 mg and placebo (RR 1.01, 95% CI 0.66 to 1.55; 1 study, n = 158; moderate‐certainty evidence), but the risk of headache increased with alitretinoin 30 mg (RR 3.43, 95% CI 2.45 to 4.81; 2 studies, n = 1210; high‐certainty evidence). Outcomes were assessed between 48 and 72 weeks. Authors' conclusions Most findings were from single studies with low precision, so they should be interpreted with caution. Topical corticosteroids and UV phototherapy were two of the major standard treatments, but evidence is insufficient to support one specific treatment over another. The effect of topical calcineurin inhibitors is not certain. Alitretinoin is more effective than placebo in controlling symptoms, but advantages over other treatments need evaluating. Well‐designed and well‐reported, long‐term (more than three months), head‐to‐head studies comparing different treatments are needed. Consensus is required regarding the definition of hand eczema and its subtypes, and a standard severity scale should be established. The main limitation was heterogeneity between studies. Small sample size impacted our ability to detect differences between treatments. Plain language summary Treatments for hand eczema Review question We reviewed evidence on the effects of topical and systemic (oral or injected medicines that work throughout the entire body) treatments for hand eczema when compared against placebo (an identical but inactive treatment), no treatment, vehicle (inactive ingredients that help deliver an active treatment), or another treatment. We included 60 randomised trials (5469 participants) published up to April 2018. Background Hand eczema is an inflammation of the skin of the hands that can be caused by contact allergens (i.e. substances that cause an allergic reaction) such as rubber chemicals, but other external factors (e.g. irritants such as water or detergents) and atopic predisposition are often important triggers. Hand eczema can cause a reduction in quality of life leading to many work‐related problems. Various types of hand eczema exist, and different topical (creams, ointments, or lotions) and systemic treatments with unknown effectiveness can be used. Study characteristics Most participants were hospital outpatients over 18 years of age with mild to severe chronic hand eczema. Treatment was usually given for up to four months, and outcomes were mainly assessed after treatment. A large variety of treatments were studied and compared to no treatment, variants of the same medication, placebo, or vehicle. Twenty‐two studies were funded by pharmaceutical companies. Key results Limited data are available to support the best way of managing hand eczema due to varying study quality and inability to pool data from studies with similar interventions. Corticosteroid creams/ointments and phototherapy (irradiation with UV light) are the major treatment options, although comparisons between these options are lacking. Below, we present results for the main comparisons of interest. Corticosteroid creams/ointments: clobetasol propionate foam probably increases participant‐rated good/excellent control of hand eczema when compared to vehicle (516 versus 222 per 1000), but the difference between groups was less clear for investigator‐rated control, and more adverse events were reported with clobetasol propionate (178 versus 79 per 1000) (all based on moderate‐certainty evidence). Mometasone furoate cream used thrice weekly may slightly improve investigator‐rated good/excellent control compared to twice weekly treatment, and participant‐rated control was not measured. Mild skin thinning occurred in both groups, but cases were few (all based on low‐certainty evidence). Irradiation with UV light: various types of irradiation (i.e. exposure to radiation) were compared. Local PUVA may improve investigator‐rated good/excellent control compared to narrow‐band UVB (400 versus 200 per 1000); however, we are uncertain of this finding because results also show that local PUVA may make little or no difference. Participant‐rated symptoms were not measured. Nine out of 30 participants in the narrow‐band UVB group reported adverse events (mainly redness) compared to none in the PUVA group (all based on moderate‐certainty evidence). Topical calcineurin inhibitors: people receiving tacrolimus are probably more likely to achieve improved investigator‐rated good/excellent symptom control compared to those given vehicle (14/14 participants with tacrolimus compared to none with vehicle), but participant‐rated control of symptoms was not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. One small study compared tacrolimus to mometasone furoate, which were both well tolerated, but did not measure investigator‐ or participant‐rated control (all based on moderate‐certainty evidence). Oral interventions: oral immunosuppressant (a drug that hinders the immune response) cyclosporin probably slightly improves investigator‐ or participant‐rated control of good/excellent symptoms compared to topical betamethasone cream (a corticosteroid). The risk of adverse events such as dizziness was similar between groups (all based on moderate‐certainty evidence). The oral vitamin A derivative (retinoid) alitretinoin (10 mg) achieved investigator‐rated good/excellent symptom control in 307 compared to 194 participants per 1000 with placebo, and alitretinoin 30 mg achieved investigator‐rated control in 432 compared to 157 participants per 1000 with placebo. Similar results were shown for participant‐rated control (high‐certainty evidence). When the dosage of alitretinoin was increased to 30 mg, risk of headache was higher compared to placebo (74 versus 251 per 1000; high‐certainty evidence), but this probably does not differ between alitretinoin 10 mg and placebo (based on moderate‐certainty evidence). Quality of the evidence The quality of evidence was mainly moderate, with most analyses based on single studies that had small sample sizes; therefore, some results should be interpreted with care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Christoffers, WA; Coenraads, PJ; Svensson, Å; Diepgen, TL; Dickinson‐Blok, JL; Xia, J; Williams, HC", "articleTypes": [], "doi": "10.1002/14651858.CD004055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "6af78cde-f35a-47c1-a641-c63c4004561f", "pmid": "", "title": "Advice to reduce dietary salt for prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Restricting sodium intake in hypertensive patients over short periods of time reduces blood pressure. Long term effects (on mortality, morbidity or blood pressure) of advice to reduce salt in patients with elevated or normal blood pressure are unclear. Objectives To assess in adults the long term effects (mortality, cardiovascular events, blood pressure, quality of life, weight, urinary sodium excretion, other nutrients and use of anti‐hypertensive medications) of advice to restrict dietary sodium using all relevant randomised controlled trials. Search methods The Cochrane Library, MEDLINE, EMBASE, bibliographies of included studies and related systematic reviews were searched for unconfounded randomised trials in healthy adults aiming to reduce sodium intake over at least 6 months. Attempts were made to trace unpublished or missed studies and authors of all included trials were contacted. There were no language restrictions. Selection criteria Inclusion decisions were independently duplicated and based on the following criteria: 1) randomisation was adequate; 2) there was a usual or control diet group; 3) the intervention aimed to reduce sodium intake; 4) the intervention was not multifactorial; 5) the participants were not children, acutely ill, pregnant or institutionalised; 6) follow‐up was at least 26 weeks; 7) data on any of the outcomes of interest were available. Data collection and analysis Decisions on validity and data extraction were made independently by two reviewers, disagreements were resolved by discussion or if necessary by a third reviewer. Random effects meta‐analysis, sub‐grouping, sensitivity analysis and meta‐regression were performed. Main results Three trials in normotensives (n=2326), five in untreated hypertensives (n=387) and three in treated hypertensives (n=801) were included, with follow up from six months to seven years. The large, high quality (and therefore most informative) studies used intensive behavioural interventions. Deaths and cardiovascular events were inconsistently defined and reported; only 17 deaths equally distributed between intervention and control groups occurred. Systolic and diastolic blood pressures were reduced at 13 to 60 months in those given low sodium advice as compared with controls (systolic by 1.1 mm Hg, 95% CI 1.8 to 0.4, diastolic by 0.6 mm hg, 95% CI 1.5 to ‐0.3), as was urinary 24 hour sodium excretion (by 35.5 mmol/ 24 hours, 95% CI 47.2 to 23.9). Degree of reduction in sodium intake and change in blood pressure were not related. People on anti‐hypertensive medications were able to stop their medication more often on a reduced sodium diet as compared with controls, while maintaining similar blood pressure control. Authors' conclusions Intensive interventions, unsuited to primary care or population prevention programmes, provide only minimal reductions in blood pressure during long‐term trials. Further evaluations to assess effects on morbidity and mortality outcomes are needed for populations as a whole and for patients with elevated blood pressure. A low sodium diet may help in maintenance of lower blood pressure following withdrawal of antihypertensives. If this is confirmed, with no increase in cardiovascular events, then targeting of comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. Plain language summary The long term effects of advice to cut down on salt in food on deaths, cardiovascular disease and blood pressure in adults Intensive support and encouragement to reduce salt intake did lead to reduction in salt eaten. It also lowered blood pressure but only by a small amount (about 1 mmHg for systolic blood pressure, less for diastolic) after more than a year. This reduction was not enough to expect an important health benefit. It was also very hard to keep to a low salt diet. However, the reduction in blood pressure appeared larger for people with higher blood pressure. There was not enough information to assess the effect of these changes in salt intake on health or deaths. Evidence from a large and small trial showed that advice to reduce salt helps to maintain lower blood pressure following withdrawal of antihypertensive medication. If this is confirmed, with no increase in cardiovascular events, then comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. See also the Cochrane review of short‐term salt reduction trials: Jurgens 2003 .", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Hooper, L; Bartlett, C; Davey Smith, G; Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD003656.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "6b02918d-29c9-4951-8329-3b298b61eaef", "pmid": "", "title": "Silver acetate for smoking cessation", "imported": false, "abstract": "Abstract - Background Silver acetate produces an unpleasant taste when combined with cigarettes, thereby producing an aversive stimulus. It has been marketed in various forms with the aim of extinguishing the urge to smoke, by pairing the urge with an unpleasant stimulus. Objectives The aim of this review was to determine the effectiveness of silver acetate products (gum, lozenge, spray) in promoting smoking cessation. Search methods We searched the Cochrane Tobacco Addiction Group specialised trials register. Most recent search was in July 2012. Selection criteria We included randomised trials of silver acetate for smoking cessation with reports of smoking status at least six months after the beginning of treatment. Data collection and analysis We extracted data in duplicate on the type of subjects, the dose and form of silver acetate, the outcome measures, method of randomisation, and completeness of follow‐up. The main outcome measure was biochemically validated abstinence from smoking after at least six months follow‐up in patients smoking at baseline. Subjects lost to follow‐up were counted as continuing smokers. Where appropriate, we performed meta‐analysis using a fixed effects model. Main results Two studies provided long‐term follow‐up data on patients randomised to silver acetate or placebo. In one of these studies, there was a third arm, randomised to 2mg nicotine gum. The pooled risk ratio for quitting for silver acetate vs placebo was 1.04 (95% confidence interval 0.69 to 1.57). Authors' conclusions Existing trials show little evidence for a specific effect of silver acetate in promoting smoking cessation. The confidence intervals for the ratio are quite wide. However, the upper limit of the confidence intervals for a positive effect equates to an absolute increase in the smoking cessation rate of about 4%. Any effect of this agent is therefore likely to be smaller than nicotine replacement therapy. The lack of effect of silver acetate may reflect poor compliance with a treatment whose rationale is to create an unpleasant stimulus. Plain language summary Does silver acetate help people stop smoking Silver acetate products (gum, lozenge, and spray) produce an unpleasant metallic taste when combined with cigarettes, so they are used as a form of aversion therapy for smoking. However, the review of trials found little evidence to show that silver acetate helps smokers quit. Any beneficial effect of silver acetate is likely to be very small, and less than the effect already proven for nicotine replacement therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lancaster, T; Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000191.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "6b0fb2bd-fe5d-4eac-bf6d-2d2037efcc4b", "pmid": "", "title": "Hydroxyurea (hydroxycarbamide) for sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and a reduced life expectancy. Hydroxyurea (hydroxycarbamide), an oral chemotherapeutic drug, ameliorates some of the clinical problems of SCD, in particular that of pain, by raising foetal haemoglobin (HbF). This is an update of a previously published Cochrane Review. Objectives The aims of this review are to determine through a review of randomised or quasi‐randomised studies whether the use of hydroxyurea in people with SCD alters the pattern of acute events, including pain; prevents, delays or reverses organ dysfunction; alters mortality and quality of life; or is associated with adverse effects. In addition, we hoped to assess whether the response to hydroxyurea in SCD varies with the type of SCD, age of the individual, duration and dose of treatment, and healthcare setting. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Haemoglobinopathies Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. The date of the most recent search was 17 February 2022. Selection criteria Randomised and quasi‐randomised controlled trials (RCTs and quasi‐RCTs), of one month or longer, comparing hydroxyurea with placebo or standard therapy in people with SCD. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction, assessed the risk of bias and assessed the quality of the evidence using GRADE. Main results We included nine RCTs recruiting 1104 adults and children with SCD (haemoglobin SS (HbSS), haemoglobin SC (HbSC) or haemoglobin Sβºthalassaemia (HbSβºthal) genotypes). Studies lasted from six to 30 months. We judged the quality of the evidence for the first two comparisons below as moderate to low as the studies contributing to these comparisons were mostly large and well‐designed (and at low risk of bias); however, the evidence was limited and imprecise for some outcomes such as quality of life, deaths during the studies and adverse events, and the results are applicable only to individuals with HbSS and HbSβºthal genotypes. We judged the quality of the evidence for the third and fourth comparisons to be very low due to the limited number of participants, the lack of statistical power (both studies were terminated early with approximately only 20% of their target sample size recruited) and the lack of applicability to all age groups and genotypes. Hydroxyurea versus placebo Five studies (784 adults and children with HbSS or HbSβºthal) compared hydroxyurea to placebo; four recruited individuals with only severe disease and one recruited individuals with all disease severities. Hydroxyurea probably improves pain alteration (using measures such as pain crisis frequency, duration, intensity, hospital admissions and opoid use) and life‐threatening illness, but we found no difference in death rates (10 deaths occurred during the studies, but the rates did not differ by treatment group) (all moderate‐quality evidence). Hydroxyurea may improve measures of HbF (low‐quality evidence) and probably decreases neutrophil counts (moderate‐quality evidence). There were no consistent differences in terms of quality of life and adverse events (including serious or life‐threatening events) (low‐quality evidence). There were fewer occurrences of acute chest syndrome and blood transfusions in the hydroxyurea groups. Hydroxyurea and phlebotomy versus transfusion and chelation Two studies (254 children with HbSS or HbSβºthal also with risk of primary or secondary stroke) contributed to this comparison. There were no consistent differences in terms of pain alteration, death or adverse events (low‐quality evidence) or life‐threatening illness (moderate‐quality evidence). Hydroxyurea with phlebotomy probably increased HbF and decreased neutrophil counts (moderate‐quality evidence), but there were more occurrences of acute chest syndrome and infections. Quality of life was not reported. In the primary prevention study, no strokes occurred in either treatment group but in the secondary prevention study, seven strokes occurred in the hydroxyurea and phlebotomy group (none in the transfusion and chelation group) and the study was terminated early. Hydroxyurea versus observation One study (22 children with HbSS or HbSβºthal also at risk of stoke) compared hydroxyurea to observation. Pain alteration and quality of life were not reported. There were no differences in life‐threatening illness, death (no deaths reported in either group) or adverse events (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF or decreases neutrophil counts (very low‐quality evidence). Treatment regimens with and without hydroxyurea One study (44 adults and children with HbSC) compared treatment regimens with and without hydroxyurea. Pain alteration, life‐threatening illness and quality of life were not reported. There were no differences in death rates (no deaths reported in either group), adverse events or neutrophil levels (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF (very low‐quality evidence). Authors' conclusions There is evidence to suggest that hydroxyurea may be effective in decreasing the frequency of pain episodes and other acute complications in adults and children with sickle cell anaemia of HbSS or HbSβºthal genotypes and in preventing life‐threatening neurological events in those with sickle cell anaemia at risk of primary stroke by maintaining transcranial Doppler velocities. However, there is still insufficient evidence on the long‐term benefits of hydroxyurea, particularly with regard to preventing chronic complications of SCD, or recommending a standard dose or dose escalation to maximum tolerated dose. There is also insufficient evidence about the long‐term risks of hydroxyurea, including its effects on fertility and reproduction. Evidence is also limited on the effects of hydroxyurea on individuals with the HbSC genotype. Future studies should be designed to address such uncertainties. Plain language summary Hydroxyurea (also known as hydroxycarbamide) for people with sickle cell disease Review question What is the effect of hydroxyurea on clinical outcomes (changes in pain crises, life‐threatening illnesses, survival, haemoglobin levels, quality of life and side effects) in people with sickle cell disease (SCD) of any genotype? Background Sickle cell disease (SCD) is an inherited genetic disorder that creates problems with haemoglobin (the substance in red blood cells that carries oxygen around the body). The disease can be inherited in different ways; people can inherit two sickle genes (HbSS genotype) or they can inherit the sickle gene from one parent and a different haemoglobin gene such as haemoglobin C, resulting in the HbSC genotype, or a beta thalassaemia gene from the second parent, which gives rise to HbSβ+ or HbSβºthal. In people with SCD the abnormal sickle haemoglobin forms long polymers (chains) within the red blood cells when they become de‐oxygenated. This damages the red blood cells and makes them stickier, leading to blockages and reduced blood flow, causing pain and organ damage. Foetal haemoglobin (HbF) stops these polymers forming in the sickle haemoglobin within the red blood cell. The drug hydroxyurea is used to increase HbF and can reduce the effects of the disease. This is an update of a previously published Cochrane Review. Search date The evidence is current to 17 February 2022. Study characteristics We included nine randomised studies (1104 adults and children with SCD (HbSS, HbSC or HbSβºthal genotypes)). Studies lasted from six to 30 months. Key results and quality of the evidence In five studies, 784 adults and children with SCD were randomly selected to receive hydroxyurea or placebo. In two studies, 254 children with SCD, who were also at an increased risk of having a first or second stroke, were randomly selected to receive hydroxyurea and phlebotomy (collection of blood) or blood transfusion and chelation (administration of agents to remove excess iron from the body). These seven studies only recruited people with HbSS or HbSβºthal genotypes so the results do not apply to people with the HbSC genotype. There was moderate‐quality evidence from these seven studies that hydroxyurea may reduce the frequency of pain crises, may increase HbF and may decrease neutrophil (white blood cell) counts compared to the comparator treatment. We found no difference between people receiving hydroxyurea or other treatments in terms of quality of life, deaths during the studies and adverse effects (including serious and life‐threatening effects). However, there is less information about these outcomes in the studies, so the quality of this evidence is low. Two further studies were included in the review. In one study, 22 children with SCD, who were also at increased risk of having a stroke, were randomly selected to receive hydroxyurea or no treatment (observation only) and in one study 44 adults and children were randomly selected to receive treatments with or without adding hydroxyurea. In both studies we are unsure if hydroxyurea led to an increase in HbF compared to the comparator treatment. There were no deaths during the studies. There was no difference between people receiving hydroxyurea or other treatments in terms of pain crises and adverse effects (including serious or life‐threatening effects) and neither study measured quality of life. The quality of the evidence from these studies is very low, given the studies were very small and only recruited around 20% of the intended number of people, and the results do not apply to all people with SCD (different genotypes). Conclusions The evidence shows that hydroxyurea is likely to be effective in the short term at decreasing the frequency of painful episodes and raising HbF levels in the blood in people with SCD. Hydroxyurea is also likely to be effective in preventing first strokes for those at an increased risk of stroke and does not seem to be associated with an increase in any adverse effects (including serious and life‐threatening effects). There is currently little evidence from the studies that we examined on whether hydroxyurea is beneficial over a long period of time, what the best dose to take is, or whether treatment causes any long‐term or serious side effects. More studies are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Rankine-Mullings, AE; Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD002202.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "6b33ba5d-034b-44a1-8124-e4a12d374ee7", "pmid": "", "title": "The Effects of GLP-1 Receptor Agonists on Sensory Systems and Ingestive Behavior", "imported": false, "abstract": "The goal of this study is to explore whether of GLP-1 receptor agonist use is associated with differences in taste, smell, food preferences, appetite, food cravings, and responses to food cues in adults. The study includes adults who are not currently taking a GLP-1 receptor agonist but may be eligible to use one, and adults who are already taking a GLP-1 receptor agonist as part of their regular medical care for approximately 1 month or approximately 6 months.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.142Z" }, { "id": "6b3739a6-ca8d-48bc-8834-87f8d23c689a", "pmid": "", "title": "Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women", "imported": false, "abstract": "Abstract - Background Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions, particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia. However, its long‐term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teeth staining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation for preventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent. Objectives To assess the effects of intermittent oral iron supplementation, alone or in combination with other nutrients, on anaemia and its associated impairments among menstruating women, compared with no intervention, a placebo, or daily supplementation. Search methods In February 2018, we searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers. In March 2018, we also searched LILACS, IBECS and IMBIOMED. In addition, we examined reference lists, and contacted authors and known experts to identify additional studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs with either individual or cluster randomisation. Participants were menstruating women; that is, women beyond menarche and prior to menopause who were not pregnant or lactating and did not have a known condition that impeded the presence of menstrual periods. The intervention was the use of iron supplements intermittently (one, two or three times a week on non‐consecutive days) compared with placebo, no intervention, or the same supplements provided on a daily basis. Data collection and analysis Both review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy, assessed the risk of bias of the included studies, and rated the quality of the evidence using GRADE. Main results We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessing risk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one third of the included studies did not provide a funding source. Although quality across studies was variable, the results consistently showed that intermittent iron supplementation (alone or with any other vitamins and minerals) compared with no intervention or a placebo, reduced the risk of having anaemia (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.49 to 0.87; 11 studies, 3135 participants; low‐quality evidence), and improved the concentration of haemoglobin (mean difference (MD) 5.19 g/L, 95% CI 3.07 to 7.32; 15 studies, 2886 participants; moderate‐quality evidence), and ferritin (MD 7.46 μg/L, 95% CI 5.02 to 9.90; 7 studies, 1067 participants; low‐quality evidence). Intermittent regimens may also reduce the risk of having iron deficiency (RR 0.50, 95% CI 0.24 to 1.04; 3 studies, 624 participants; low‐quality evidence), but evidence was inconclusive regarding iron deficiency anaemia (RR 0.07, 95% CI 0.00 to 1.16; 1 study, 97 participants; very low‐quality evidence) and all‐cause morbidity (RR 1.12, 95% CI 0.82 to 1.52; 1 study, 119 participants; very low‐quality evidence). Women in the control group were less likely to have any adverse side effects than those receiving intermittent iron supplements (RR 1.98, 95% CI 0.31 to 12.72; 3 studies, 630 participants; moderate‐quality evidence). In comparison with daily supplementation, results showed that intermittent supplementation (alone or with any other vitamins and minerals) produced similar effects to daily supplementation (alone or with any other vitamins and minerals) on anaemia (RR 1.09, 95% CI 0.93 to 1.29; 8 studies, 1749 participants; moderate‐quality evidence). Intermittent supplementation may produce similar haemoglobin concentrations (MD 0.43 g/L, 95% CI −1.44 to 2.31; 10 studies, 2127 participants; low‐quality evidence) but lower ferritin concentrations on average (MD −6.07 μg/L, 95% CI −10.66 to −1.48; 4 studies, 988 participants; low‐quality evidence) compared to daily supplementation. Compared to daily regimens, intermittent regimens may also reduce the risk of having iron deficiency (RR 4.30, 95% CI 0.56 to 33.20; 1 study, 198 participants; very low‐quality evidence). Women receiving iron supplements intermittently were less likely to have any adverse side effects than those receiving iron supplements daily (RR 0.41, 95% CI 0.21 to 0.82; 6 studies, 1166 participants; moderate‐quality evidence). No studies reported on the effect of intermittent regimens versus daily regimens on iron deficiency anaemia and all‐cause morbidity. Information on disease outcomes, adherence, economic productivity, and work performance was scarce, and evidence about the effects of intermittent supplementation on these outcomes unclear. Overall, whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline did not seem to affect the findings. Furthermore, the response did not differ in areas where malaria was frequent, although very few trials were conducted in these settings. Authors' conclusions Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations with different anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittently is probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base ranged from very low to moderate quality, suggesting that we are uncertain about these effects. Plain language summary Iron supplements taken one, two or three times a week for preventing anaemia, and its consequences in menstruating women What is the issue? Across the globe, approximately one out of three non‐pregnant women of reproductive age are anaemic; i.e. have fewer red blood cells or less haemoglobin (a red substance that combines with oxygen and carries it around the body) in each red blood cell than normal. Although there are several causes of anaemia, it very often results from sustained iron deficiency. The standard practice to prevent or treat anaemia in women has been daily iron supplementation (sometimes combined with folic acid and other vitamins and minerals) for three months. However, it is frequently associated with side effects such as nausea or constipation. Intermittent supplementation (that is, the consumption of supplements one, two or three times a week on non‐consecutive days) has been proposed as an effective and safer alternative to daily supplementation. Why is this important? Women with anaemia may have less energy for physical work and become more prone to infections. Most women throughout the world enter pregnancy with anaemia, putting them at greater risk of having low birth‐weight babies and other complications during delivery. Some scientists believe that taking iron a few times a week – instead of every day – can help women with anaemia to feel better and improve their haemoglobin without giving them as many side effects. If women have fewer side effects, they may be more likely to take iron supplements more regularly and for longer periods. What evidence did we find? We reviewed the evidence in February 2018. We included 25 randomised controlled trials (a type of experiment in which participants are randomly assigned to one or more treatment groups) involving 10,996 women. We included studies examining the administration of intermittent iron supplements versus no intervention, a placebo (dummy pill) or the same supplements given on a daily basis. Most studies were implemented in school settings and were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one‐third of the included studies did not provide a funding source. The findings show that women receiving intermittent supplementation with iron alone, or in combination with folic acid or other nutrients, were less likely to be anaemic or iron deficient than those women who received no iron supplements or a placebo. They also had higher concentrations of haemoglobin and ferritin (a protein that carries iron) but reported more side effects. In addition, the findings indicate that intermittent supplementation was as effective as daily supplementation in reducing the prevalence of anaemia and increasing haemoglobin concentrations, with fewer side effects. It may have reduced the risk of having iron deficiency also, but it had no effect on raising ferritin concentrations more than the daily dose. We found scarce evidence on the effect of intermittent supplementation compared to placebo or daily supplementation on iron deficiency anaemia, all‐cause morbidity, disease outcomes, adherence, economic productivity, and work performance. What does this mean? Intermittent iron supplementation in menstruating women may be an effective intervention for reducing anaemia and improving haemoglobin concentrations compared to no treatment, placebo or daily supplementation. Intermittent supplementation may be associated with fewer side effects compared to daily supplementation. The findings were not affected by whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline (starting point for comparisons). The evidence base was of overall low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fernández-Gaxiola, AC; De-Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD009218.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "6b47b710-1478-4a4f-808b-c9638a92c20f", "pmid": "", "title": "Corticosteroids for the long‐term treatment in multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Ciccone, A, Beretta, S, Brusaferri, F, Galea, I, Protti, A, Spreafico, C", "articleTypes": [], "doi": "10.1002/14651858.CD006264.pub2 AB - Abstract - Background Short term high dose corticosteroid treatment improves symptoms and short term disability after an acute exacerbation of multiple sclerosis (MS) but it is unknown whether its long‐term use can reduce the accumulation of disability. Objectives To determine the efficacy and safety of long‐term corticosteroid use in MS. Search methods We searched The Cochrane MS Group Trials Register (February 2007),the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to February 2007) and EMBASE (1980 to February 2007). In an effort to identify further published, unpublished and ongoing trials we searched reference lists and contacted trial authors and one pharmaceutical company. Selection criteria We considered controlled, randomised trials (RCTs), with or without blinding, of long term treatment (i.e. longer than 6 months) of any type of corticosteroid in MS, irrespective of disease course. Data collection and analysis Reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Three trials, all classified at high risk of bias, contributed to this review (Miller 1961; BPSM 1995; Zivadinov 2001) resulting in a total of 183 participants (91 treated). Corticosteroid therapy did not reduce the risk of being worse at the end of follow‐up (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.26 to 1.02) but there was a substantial heterogeneity between studies (I 2 : 78.4%). I. v. periodic high dose methylprednisolone (MP) was associated with a significant reduction in the risk of disability progression at 5 years in relapsing‐remitting (RR) MS (OR 0.26, 95% CI 0.10 to 0.66), while oral continuous low dose prednisolone was not associated with any risk reduction in disability progression at 18 months (OR 1.23, 95% CI 0.43 to 3.56). Risk of experiencing at least one exacerbation at end of follow‐up was not significantly reduced with corticosteroid treatment (OR 0.36; 95% CI 0.10 to 1.25). 
 Only one study recorded adverse events: in one patient i. v. MP was discontinued after the fourth pulse when he developed acute glomerulonephritis; a second patient was removed from the study after the fifth i. v. MP pulse because of severe osteoporosis. Authors' conclusions There is no enough evidence that long‐term corticosteroid treatment delays progression of long term disability in patients with MS. Since one study at high risk of bias showed that the administration of pulsed high dose i. v. MP is associated with a significant reduction in the risk of long term disability progression in patients with RR MS, an adequately powered, high quality RCT is needed to investigate this finding. Plain language summary The long‐term use of anti‐inflammatory corticosteroids for treating multiple sclerosis Multiple sclerosis is an inflammatory disease affecting the brain and spinal cord. It results in episodes of neurological deficit which recover (relapses) as well as accumulation of sustained disability with the passage of time. Corticosteroids are potent anti‐inflammatory drugs. It is postulated that long‐term use of steroids may reduce the accumulation of disability. The reviewers found three studies addressing this issue. A meta‐analysis showed a trend towards a beneficial effect of long‐term corticosteroids on accumulation of disability; however only two small studies contributed to this result. It was not possible to reliably comment on the effect of long‐term corticosteroids on the frequency of relapses. Side effects were poorly documented. Therefore rigorous randomised controlled trials of this treatment are warranted.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.762Z" }, { "id": "6b69f654-92a5-475c-a0c5-dca2bd1ce724", "pmid": "", "title": "Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID‐19", "imported": false, "abstract": "Abstract - Background COVID‐19 illness is highly variable, ranging from infection with no symptoms through to pneumonia and life‐threatening consequences. Symptoms such as fever, cough, or loss of sense of smell (anosmia) or taste (ageusia), can help flag early on if the disease is present. Such information could be used either to rule out COVID‐19 disease, or to identify people who need to go for COVID‐19 diagnostic tests. This is the second update of this review, which was first published in 2020. Objectives To assess the diagnostic accuracy of signs and symptoms to determine if a person presenting in primary care or to hospital outpatient settings, such as the emergency department or dedicated COVID‐19 clinics, has COVID‐19. Search methods We undertook electronic searches up to 10 June 2021 in the University of Bern living search database. In addition, we checked repositories of COVID‐19 publications. We used artificial intelligence text analysis to conduct an initial classification of documents. We did not apply any language restrictions. Selection criteria Studies were eligible if they included people with clinically suspected COVID‐19, or recruited known cases with COVID‐19 and also controls without COVID‐19 from a single‐gate cohort. Studies were eligible when they recruited people presenting to primary care or hospital outpatient settings. Studies that included people who contracted SARS‐CoV‐2 infection while admitted to hospital were not eligible. The minimum eligible sample size of studies was 10 participants. All signs and symptoms were eligible for this review, including individual signs and symptoms or combinations. We accepted a range of reference standards. Data collection and analysis Pairs of review authors independently selected all studies, at both title and abstract, and full‐text stage. They resolved any disagreements by discussion with a third review author. Two review authors independently extracted data and assessed risk of bias using the QUADAS‐2 checklist, and resolved disagreements by discussion with a third review author. Analyses were restricted to prospective studies only. We presented sensitivity and specificity in paired forest plots, in receiver operating characteristic (ROC) space and in dumbbell plots. We estimated summary parameters using a bivariate random‐effects meta‐analysis whenever five or more primary prospective studies were available, and whenever heterogeneity across studies was deemed acceptable. Main results We identified 90 studies; for this update we focused on the results of 42 prospective studies with 52,608 participants. Prevalence of COVID‐19 disease varied from 3.7% to 60.6% with a median of 27.4%. Thirty‐five studies were set in emergency departments or outpatient test centres (46,878 participants), three in primary care settings (1230 participants), two in a mixed population of in‐ and outpatients in a paediatric hospital setting (493 participants), and two overlapping studies in nursing homes (4007 participants). The studies did not clearly distinguish mild COVID‐19 disease from COVID‐19 pneumonia, so we present the results for both conditions together. Twelve studies had a high risk of bias for selection of participants because they used a high level of preselection to decide whether reverse transcription polymerase chain reaction (RT‐PCR) testing was needed, or because they enrolled a non‐consecutive sample, or because they excluded individuals while they were part of the study base. We rated 36 of the 42 studies as high risk of bias for the index tests because there was little or no detail on how, by whom and when, the symptoms were measured. For most studies, eligibility for testing was dependent on the local case definition and testing criteria that were in effect at the time of the study, meaning most people who were included in studies had already been referred to health services based on the symptoms that we are evaluating in this review. The applicability of the results of this review iteration improved in comparison with the previous reviews. This version has more studies of people presenting to ambulatory settings, which is where the majority of assessments for COVID‐19 take place. Only three studies presented any data on children separately, and only one focused specifically on older adults. We found data on 96 symptoms or combinations of signs and symptoms. Evidence on individual signs as diagnostic tests was rarely reported, so this review reports mainly on the diagnostic value of symptoms. Results were highly variable across studies. Most had very low sensitivity and high specificity. RT‐PCR was the most often used reference standard (40/42 studies). Only cough (11 studies) had a summary sensitivity above 50% (62.4%, 95% CI 50.6% to 72.9%)); its specificity was low (45.4%, 95% CI 33.5% to 57.9%)). Presence of fever had a sensitivity of 37.6% (95% CI 23.4% to 54.3%) and a specificity of 75.2% (95% CI 56.3% to 87.8%). The summary positive likelihood ratio of cough was 1.14 (95% CI 1.04 to 1.25) and that of fever 1.52 (95% CI 1.10 to 2.10). Sore throat had a summary positive likelihood ratio of 0.814 (95% CI 0.714 to 0.929), which means that its presence increases the probability of having an infectious disease other than COVID‐19. Dyspnoea (12 studies) and fatigue (8 studies) had a sensitivity of 23.3% (95% CI 16.4% to 31.9%) and 40.2% (95% CI 19.4% to 65.1%) respectively. Their specificity was 75.7% (95% CI 65.2% to 83.9%) and 73.6% (95% CI 48.4% to 89.3%). The summary positive likelihood ratio of dyspnoea was 0.96 (95% CI 0.83 to 1.11) and that of fatigue 1.52 (95% CI 1.21 to 1.91), which means that the presence of fatigue slightly increases the probability of having COVID‐19. Anosmia alone (7 studies), ageusia alone (5 studies), and anosmia or ageusia (6 studies) had summary sensitivities below 50% but summary specificities over 90%. Anosmia had a summary sensitivity of 26.4% (95% CI 13.8% to 44.6%) and a specificity of 94.2% (95% CI 90.6% to 96.5%). Ageusia had a summary sensitivity of 23.2% (95% CI 10.6% to 43.3%) and a specificity of 92.6% (95% CI 83.1% to 97.0%). Anosmia or ageusia had a summary sensitivity of 39.2% (95% CI 26.5% to 53.6%) and a specificity of 92.1% (95% CI 84.5% to 96.2%). The summary positive likelihood ratios of anosmia alone and anosmia or ageusia were 4.55 (95% CI 3.46 to 5.97) and 4.99 (95% CI 3.22 to 7.75) respectively, which is just below our arbitrary definition of a 'red flag', that is, a positive likelihood ratio of at least 5. The summary positive likelihood ratio of ageusia alone was 3.14 (95% CI 1.79 to 5.51). Twenty‐four studies assessed combinations of different signs and symptoms, mostly combining olfactory symptoms. By combining symptoms with other information such as contact or travel history, age, gender, and a local recent case detection rate, some multivariable prediction scores reached a sensitivity as high as 90%. Authors' conclusions Most individual symptoms included in this review have poor diagnostic accuracy. Neither absence nor presence of symptoms are accurate enough to rule in or rule out the disease. The presence of anosmia or ageusia may be useful as a red flag for the presence of COVID‐19. The presence of cough also supports further testing. There is currently no evidence to support further testing with PCR in any individuals presenting only with upper respiratory symptoms such as sore throat, coryza or rhinorrhoea. Combinations of symptoms with other readily available information such as contact or travel history, or the local recent case detection rate may prove more useful and should be further investigated in an unselected population presenting to primary care or hospital outpatient settings. The diagnostic accuracy of symptoms for COVID‐19 is moderate to low and any testing strategy using symptoms as selection mechanism will result in both large numbers of missed cases and large numbers of people requiring testing. Which one of these is minimised, is determined by the goal of COVID‐19 testing strategies, that is, controlling the epidemic by isolating every possible case versus identifying those with clinically important disease so that they can be monitored or treated to optimise their prognosis. The former will require a testing strategy that uses very few symptoms as entry criterion for testing, the latter could focus on more specific symptoms such as fever and anosmia. Plain language summary How accurate are symptoms and medical examination to diagnose COVID‐19? Key messages ‐ The results suggest that a single symptom included in this review cannot accurately diagnose COVID‐19. ‐ Loss of sense of taste or smell could be a 'red flag' for the presence of COVID‐19. Cough or fever might be useful to identify people who might have COVID‐19. These symptoms might be useful to prompt further testing when they are present. ‐ We need more research to investigate combinations of symptoms and signs with other information such as recent contact or travel history, or vaccination status, and in children, and adults aged 65 years and over. What are symptoms or signs of COVID‐19? Symptoms are experienced by patients. COVID‐19 symptoms include cough, sore throat, high temperature, diarrhoea, headache, muscle or joint pain, fatigue, and loss of sense of smell and taste. Signs are measured by healthcare workers during clinical examination. They include lung sounds, blood pressure, blood oxygen level and heart rate. Symptoms and signs of COVID‐19 might be important to help people know whether they and the people they come into contact with should isolate at home, undergo testing with a rapid lateral flow test or PCR (laboratory‐based) test, or be hospitalised. What did we want to find out? Symptoms and signs of COVID‐19 are varied and may indicate other diseases, not just COVID‐19. We wanted to know how accurate diagnosis of COVID‐19 is, based on symptoms and signs from medical examination. We were interested in people with suspected COVID‐19, who go to their doctor, outpatient test centres or hospital. What did we do? We searched for studies that assessed the accuracy of symptoms and signs to diagnose COVID‐19. Studies had to be conducted in general practice, outpatient test centres or hospital outpatient settings only. We only included studies of people in hospital if signs and symptoms were recorded when they were admitted to the hospital, for example through the emergency department. What did we find? We focused on 42 studies with 52,608 participants in this review. The studies assessed 96 separate or combined symptoms and signs. Thirty‐five studies were conducted in emergency departments or outpatient COVID‐19 test centres (46,878 participants), 3 studies in general practice (1230 participants), 2 studies in children’s hospitals (493 in‐ and outpatients), and 2 studies in nursing homes (4007 participants). The studies were conducted in 18 different countries around the world. Twenty‐three studies were conducted in Europe, 8 in North‐America, 5 in Asia, and 3 in South‐America and 3 in Australia. We didn’t find any studies conducted in Africa. Three focused specifically on children, and only 1 focused on adults aged 65 years and over. Most studies did not clearly distinguish between mild and severe COVID‐19, so we present the results for mild, moderate and severe disease together. Few studies reported individual signs as diagnostic tests, so we focus mainly on the diagnostic value of symptoms. The most frequently reported symptoms were cough, fever, shortness of breath and sore throat. According to the studies in our review, in a group of 1000 people with suspected COVID‐19 of whom 270 (27%) would actually have COVID‐19, around 567 people would have a cough. Of these 567, 168 would actually have COVID‐19. Of the 433 who do not have a cough, 102 would have COVID‐19. In the same 1000 people, around 283 people would have a fever. Of these 283, 102 would actually have COVID‐19. Of the 717 people without fever, 168 would have COVID‐19. Someone who has lost their sense of smell or taste is five times more likely to have COVID‐19 than someone who hasn’t. Other symptoms, such as a sore throat or runny nose, are more likely to indicate the presence of an infectious disease other than COVID‐19. In the same 1000 people as described above, around 362 people would have a sore throat. Of these, only 84 would actually have COVID‐19. Of the 638 patients without sore throat, 186 would have COVID‐19. We found similar figures for having a runny nose. What are the limitations of the evidence? The results of this updated review are more reliable than those in previous versions as we included more high‐quality studies. However, the accuracy of individual symptoms varied across studies and the diagnostic value of symptoms such as fever, cough or other respiratory symptoms might still be overestimated, as most studies deliberately included participants because they had these symptoms. The results do not clearly differentiate between people with mild, moderate or severe COVID‐19. Only a few studies investigated the symptom‐based diagnosis of COVID‐19 in children or older adults. How up to date is this review? This review updates our previous review. The evidence is up to date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Struyf, T, Deeks, JJ, Dinnes, J, Takwoingi, Y, Davenport, C, Leeflang, MMG, Spijker, R, Hooft, L, Emperador, D, Domen, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013665.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.736Z" }, { "id": "6b9791d2-5f82-402d-bd05-1478bcfecd40", "pmid": "", "title": "Interventions for leg cramps in pregnancy", "imported": false, "abstract": "Abstract - Background Many women experience leg cramps in pregnancy. They become more common as pregnancy progresses and are especially troublesome at night. Objectives The objective of this review was to assess methods of preventing and treating leg cramps in pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2001). We updated this search on 4 July 2011 and added the results to the awaiting classification section. Selection criteria Randomised trials of treatments for leg cramps in pregnancy. Data collection and analysis Trial quality was assessed and data were extracted independently by two reviewers. Main results Five trials involving 352 women were included. The trials were of moderate quality. The only placebo‐controlled trial of calcium treatment showed no evidence of benefit. Trials comparing sodium chloride with placebo (odds ratio 0.54, 95% confidence interval 0.23 to 1.29) and calcium with sodium chloride (odds ratio 1.23, 95% confidence intervals 0.47 to 3.27 ) showed no evidence of benefit. Placebo controlled trials of multivitamin with mineral supplements (odds ratio 0.23, 95% confidence intervals 0.05 to 1.01) and magnesium (odds ratio 0.18, 95% confidence intervals 0.05 to 0.60) provided some suggestion of benefit. Authors' conclusions The evidence that calcium reduces cramp is weak and seems to depend on placebo effect. The evidence for sodium chloride is stronger but the results of the sodium chloride trial may no longer be relevant because of dietary changes which include an increased sodium intake in the general population. It is not possible to recommend multivitamins with mineral supplementation, as it is not clear which ingredient, if any, is helping. If a woman finds cramp troublesome in pregnancy, the best evidence is for magnesium lactate or citrate taken as 5mmol in the morning and 10mmol in the evening. [Note: The five citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Interventions for leg cramps in pregnancy Sodium supplements may decrease the number of cramp attacks experienced by women in pregnancy but the effect is slight. Calcium is of no benefit. The evidence of benefit for magnesium is stronger. Multivitamin and mineral supplements also seem to help but the relevance of this is unclear as the preparation used contained twelve separate constituents and it is not possible to discover which of these was effective, or indeed if there was synergy between constituents. There is a theoretical risk that sodium supplementation could raise blood pressure. It is unlikely that magnesium supplementation would be harmful at the suggested doses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Young, G, Jewell, D", "articleTypes": [], "doi": "10.1002/14651858.CD000121", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.726Z" }, { "id": "6bb7c833-e253-4692-bee6-7d1ff7f824ce", "pmid": "", "title": "Topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antiseptics, a possible treatment for CSOM, inhibit the micro‐organisms that may be responsible for the infection. Antiseptics can be used alone or in addition to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). However, the effects of topical antiseptics for CSOM remain unclear. This is an update of a review last published in 2020, with one new study added. It is one of a suite of seven Cochrane reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To assess the effects of topical antiseptics for people with CSOM. Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The date of the latest search was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antiseptic agent of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antiseptics (a) compared to placebo or no intervention, and (b) compared to another topical antiseptic (e.g. topical antiseptic A versus topical antiseptic B). Within each comparison, we separated studies into (a) those in which both groups of participants had received aural toileting in addition to the topical antiseptics, and those where neither group had received aural toileting, and (b) those in which both groups had received some other concomitant treatment (such as antibiotics) and those with no such concomitant treatment. Data collection and analysis We used standard Cochrane methodological procedures. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results We found one new study (32 participants) in this update, for a total of six included studies with 435 participants (over four studies), plus 222 ears that could not be accounted for in participant numbers (in two studies). Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics (boric acid versus acetic acid, and boric acid versus hydrogen peroxide). The two core comparisons of interest are reported below; other comparisons are described in the Results section of the review. No study measured health‐related quality of life or ear pain. 1. Topical antiseptic versus placebo or no treatment Three studies (297 participants plus 174 ears) compared topical antiseptics with no treatment. Evidence from one study (unclear number of participants, 174 ears) is very uncertain about the effect of a single application of povidone iodine in hydroxypropyl methyl‐cellulose (HPMC) on resolution of ear discharge at one week compared to HPMC alone; however, these results were only provided by ear (rather than by participant) and therefore could not be used quantitatively (very low‐certainty evidence). One study (254 children; cluster‐RCT) found that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge after four weeks compared with dry mopping alone, but the evidence is very uncertain (risk ratio (RR) 1.73, 95% confidence interval (CI) 1.21 to 2.47; 180 participants; very low‐certainty evidence). We made adjustments to the data to account for the intracluster correlation. This study narratively described no clear differences in suspected ototoxicity or hearing outcomes between study arms, but the evidence is very uncertain (very low‐certainty evidence). Evidence from one study (43 children; 58 ears) is very uncertain about the effect of antiseptics on serious complications. The study reported one case of mastoiditis and one of meningitis with focal encephalitis; however, it was unclear whether these were detected pre‐randomisation or during/after treatment. 2. Topical antiseptics versus no treatment/placebo, where both study arms received systemic antibiotics One study (32 participants) compared topical povidone iodine with placebo (saline) in conjunction with oral amoxicillin and dry mopping. Topical povidone iodine with oral amoxicillin and dry mopping may increase resolution of ear discharge at one to two weeks (RR 3.25, 95% CI 1.35 to 7.84; 32 participants; low‐certainty evidence). The study narratively reported no ototoxicity in the topical antiseptic arm; however, this was unclear for the placebo group, so we do not know if povidone iodine increases suspected ototoxicity (low‐certainty evidence). The study did not assess resolution of ear discharge after four weeks, hearing, or serious complications. Authors' conclusions We are very uncertain about the effect of topical antiseptics on improving resolution of ear discharge in people with CSOM given the low and very low certainty of the evidence, which was mostly due to risk of bias and imprecision. However, there is some evidence suggesting that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge compared with dry mopping alone, and that topical povidone iodine may be more effective than placebo (where both arms used systemic beta‐lactam antibiotics and dry mopping). There is insufficient evidence to draw any conclusions about harmful effects. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and risks of topical antiseptics for treating long‐term middle ear infection (chronic suppurative otitis media)? Key messages • Due to a lack of studies, we are very uncertain of the benefits and risks of topical antiseptics in the treatment of chronic suppurative otitis media (long‐term middle ear infection). • We need more information about possible harmful effects of topical antiseptics, as these were not well reported in the studies. What was studied in the review? Chronic suppurative otitis media (CSOM) is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (eardrum). The main symptoms are ear discharge and hearing loss. Topical antiseptics (antiseptics put directly into the ear as ear drops or as a powder) are sometimes used to treat CSOM. Topical antiseptics kill or stop the growth of the micro‐organisms that may be responsible for the infection. Topical antiseptics can be used on their own or added to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). Applying topical antiseptics can cause irritation of the skin within the outer ear, which may result in discomfort, pain, or itching. Some antiseptics (such as alcohol) can be toxic to the inner ear (ototoxicity), which means they may cause irreparable hearing loss (sensorineural), dizziness, or ringing in the ear (tinnitus). What is the aim of this review? The aim of this Cochrane review was to find out the benefits and risks of topical antiseptics compared to placebo (dummy medicine) or no treatment for CSOM. We also wanted to know whether one topical antiseptic was more effective than another. We collected and analysed all relevant studies to answer this question. This is an update of a review last published in 2020, with one new study added. What are the main results of the review? We included a total of six studies in the review. The total number of people in the studies was unclear, as two studies only reported how many ears were treated. However, there were 435 participants plus 222 ears (between 111 and 222 participants) that could not be accounted for in participant numbers. Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics. Different types of antiseptics were used, some in the form of ear drops and others as powders. No study measured health‐related quality of life or ear pain. Topical antiseptic versus placebo or no treatment (with a background treatment of ear cleaning) Three studies (297 participants plus 174 ears) compared topical antiseptics with placebo/no treatment. Based on evidence from one study (unclear number of participants, 174 ears), we do not know if a single application of antiseptic (povidone iodine plus hydroxypropyl methyl‐cellulose) resolves ear discharge at one to two weeks compared with no treatment. Another study (180 children) compared topical antiseptics (boric acid in alcohol ear drops) with no topical antiseptics. All children also had their ears cleaned daily using cotton wool sticks (dry mopping). It is unclear if antiseptics (boric acid) led to an increase in resolution of ear discharge at four weeks or at three to four months compared with no antiseptics. The same study (254 participants) also reported no clear difference between groups in hearing or suspected ototoxicity (hearing or balance problems that develop as a result of taking a medicine), but the evidence is very uncertain. A third study (43 children; 58 ears) found no clear evidence that antiseptics have any effect on serious complications, but it is not known if this was assessed before, during, or after treatment. Topical antiseptic (povidone iodine) versus no treatment/placebo, where both study groups received systemic antibiotics One study (32 participants) compared one antiseptic (povidone iodine) with placebo (saline). All participants also received oral antibiotics (amoxicillin) and ear cleaning. This study found that topical povidone iodine, when given in addition to antibiotics and ear cleaning, may increase the number of people with resolution of ear discharge at between one and two weeks, compared with placebo plus antibiotics and ear cleaning. We do not know if povidone iodine increases suspected ototoxicity. In their report, the study authors stated there was no ototoxicity in participants in the topical antiseptic group, but this was unclear for the placebo group. There was no information on resolution of ear discharge after four weeks, hearing, or serious complications. What are the limitations of the evidence? There is limited information on certain population groups or treatments. Also, the evidence in the review comes from studies that were not conducted recently. How up‐to‐date is the review? The evidence is current to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K; Chong, LY; Bhutta, MF; Daw, J; Veselinović, T; Morris, PS; Vijayasekaran, S; Schilder, AGM; Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013055.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "6bccb9df-7feb-4e39-a0b0-1ddc3a320299", "pmid": "", "title": "Breastfeeding for procedural pain in infants beyond the neonatal period", "imported": false, "abstract": "Abstract - Background Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin‐to‐skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk. Objectives To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin‐to‐skin contact, expressed breast milk, formula milk, bottle feeding, sweet‐tasting solutions (e.g. sucrose or glucose), distraction, or other interventions. Search methods We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In‐Process & Other Non‐Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials. Selection criteria We included RCTs and quasi‐RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet‐tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin‐to‐skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random‐effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information. Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38‐second reduction in cry time (MD ‐38, 95% CI ‐50 to ‐26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12‐month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7‐point reduction in standardised pain scores (SMD ‐1.7, 95% CI ‐2.2 to ‐1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD ‐3.6, ‐23 to 16). Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage. No included studies reported adverse events. Authors' conclusions We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin‐breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted. Plain language summary Does breastfeeding reduce vaccination pain in babies aged 1 to 12 months? Bottom line We found that breastfeeding before and during vaccination injections helped to reduce pain in most babies up to the age of one year. Background Needles are used for babies' early childhood vaccinations and medical care during childhood illnesses. These are essential, but painful. They cause distress for the babies and often their parents/caregivers, and can result in future anxiety and fear about needles. Breastfeeding during blood tests in newborn babies reduces pain. Breastfeeding when possible and feasible may also help to comfort babies and reduce their pain beyond the newborn period and throughout infancy. Study characteristics In February 2016 we searched the medical literature for studies examining the effectiveness of breastfeeding babies 1 to 12 months old during the use of needles. We compared effectiveness of breastfeeding in reducing pain (as scored by crying time and pain scores), to holding, babies lying flat, or the giving of water or sweet solutions. We found 10 studies with a total of 1066 infants. All studies examined if breastfeeding reduced pain during vaccinations. Key results Breastfeeding reduced crying in young babies having vaccinations. On average, breastfed babies cried for 38 seconds less than babies who were not breastfed (6 studies; 547 infants; moderate‐quality evidence), and pain scores were significantly lower (5 studies; 310 infants; moderate‐quality evidence). No studies reported on any harm (very low‐quality evidence). We could draw no conclusions on risk of harm while breastfeeding healthy babies during vaccination. Going forward: if mothers are breastfeeding, it could be considered when possible for babies during vaccinations. More evidence is needed to learn if breastfeeding helps older babies and babies in hospital during blood work or procedures such as insertion of drips. Quality of the evidence The quality of the evidence was moderate for crying time and pain scores. Most studies included younger infants aged 1 to 6 months. Further research including older infants up to 12 months of age may change our conclusions. In addition, the studies evaluated the effects of breastfeeding during vaccination. We do not know whether breastfeeding helps sick babies aged 1 to 12 months in hospital during blood sampling or drip insertion.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Harrison, D, Reszel, J, Bueno, M, Sampson, M, Shah, VS, Taddio, A, Larocque, C, Turner, L", "articleTypes": [], "doi": "10.1002/14651858.CD011248.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.073Z" }, { "id": "6bd5e6b9-4adc-42c4-9475-64bb0b379174", "pmid": "", "title": "Carbetocin for preventing postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Postpartum haemorrhage (PPH) is one of the major contributors to maternal mortality and morbidity worldwide. Active management of the third stage of labour has been proven to be effective in the prevention of PPH. Syntometrine is more effective than oxytocin but is associated with more side effects. Carbetocin, a long‐acting oxytocin agonist, appears to be a promising agent for the prevention of PPH. Objectives To determine if the use of oxytocin agonist is as effective as conventional uterotonic agents for the prevention of PPH, and assess the best routes of administration and optimal doses of oxytocin agonist. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2011, Issue 1 of 4), MEDLINE (1966 to 1 March 2011) and EMBASE (1974 to 1 March 2011). We checked references of articles and communicated with authors and pharmaceutical industry contacts. Selection criteria Randomised controlled trials which compared oxytocin agonist (carbetocin) with other uterotonic agents or with placebo or no treatment for the prevention of PPH. Data collection and analysis Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Main results We included 11 studies (2635 women) in the review. Six trials compared carbetocin with oxytocin; four of these were conducted for women undergoing caesarean deliveries, one was for women following vaginal deliveries and one did not state the mode of delivery clearly. The carbetocin was administered as 100 µg intravenous dosage across the trials, while oxytocin was administered intravenously but at varied dosages. Four trials compared intramuscular carbetocin and intramuscular syntometrine for women undergoing vaginal deliveries. Three of the trials were on women with no risk factor for PPH, while one trial was on women with risk factors for PPH. One trial compared the use of intravenous carbetocin with placebo. Use of carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics (risk ratio (RR) 0.62; 95% confidence interval (CI) 0.44 to 0.88; four trials, 1173 women) compared to oxytocin for those who underwent caesarean section, but not for vaginal delivery. Compared to oxytocin, carbetocin was associated with a reduced need for uterine massage following both caesarean delivery (RR 0.54; 95% CI 0.37 to 0.79; two trials, 739 women) and vaginal delivery (RR 0.70; 95% CI 0.51 to 0.94; one trial, 160 women). There were no statistically significant differences between carbetocin and oxytocin in terms of risk of any PPH (blood loss greater than 500 ml) or in risk of severe PPH (blood loss greater than 1000 ml). Comparison between carbetocin and syntometrine showed a lower mean blood loss in women who received carbetocin compared to syntometrine (mean difference (MD) ‐48.84 ml; 95% CI ‐94.82 to ‐2.85; four trials, 1030 women). There was no statistically significant difference in terms of the need for therapeutic uterotonic agents, but the risk of adverse effects such as nausea and vomiting were significantly lower in the carbetocin group: nausea (RR 0.24; 95% CI 0.15 to 0.40; four trials, 1030 women); vomiting (RR 0.21; 95% CI 0.11 to 0.39; four trials, 1030 women). The incidence of postpartum hypertension was also significantly lower in women who received carbetocin compared to those who received syntometrine. Cost‐effectiveness of carbetocin was investigated by one study published as an abstract, with limited data. Authors' conclusions For women who undergo caesarean section, carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics compared to oxytocin, but there is no difference in the incidence of postpartum haemorrhage. Carbetocin is associated with less blood loss compared to syntometrine in the prevention of PPH for women who have vaginal deliveries and is associated with significantly fewer adverse effects. Further research is needed to analyse the cost‐effectiveness of carbetocin as a uterotonic agent. Plain language summary Carbetocin for preventing postpartum haemorrhage In low‐ and middle‐income countries, postpartum haemorrhage is a major cause of maternal deaths and ill health. In high‐income countries, the problems are much less but there is still a small risk of major bleeding problems for women after giving birth. Active management of the third stage of labour, which is generally used to reduce blood loss at birth, consists of giving the mother a drug that helps the uterus to contract, early cord clamping and controlled cord traction to deliver the placenta. Different drugs have been tried and generally either intramuscular oxytocin or intramuscular syntometrine is given. Carbetocin is an oxytocin agonist. Oxytocin agonists are a group of drugs that mimic the oxytocin action, oxytocin being the natural hormone that helps to reduce blood loss at birth. This review includes 11 randomised controlled trials involving 2635 women. The trials compared carbetocin against either oxytocin or syntometrine given after delivery, vaginally or by caesarean section. The comparison between intramuscular carbetocin and oxytocin showed that there was no difference in the risk of heavy bleeding, but that women who received carbetocin were less likely to require other medications to produce uterine contractions following caesarean sections. Comparisons between carbetocin and syntometrine showed that women who received carbetocin had less blood loss compared to women who received syntometrine after vaginal delivery, and were much less likely to experience side effects such as nausea and vomiting. The incidence of hypertension at 30 and 60 minutes post delivery was also significantly lower in women who received carbetocin compared to those who received syntometrine. Five of the 11 studies were known to be supported by a pharmaceutical company.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Su, LL; Chong, YS; Samuel, M", "articleTypes": [], "doi": "10.1002/14651858.CD005457.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "6bdcb475-4478-49fc-a441-a017ec2fda92", "pmid": "", "title": "Oral anti‐diabetic pharmacological therapies for the treatment of women with gestational diabetes", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is a major public health issue with rates increasing globally. Gestational diabetes, glucose intolerance first recognised during pregnancy, usually resolves after birth and is associated with short‐ and long‐term complications for the mother and her infant. Treatment options can include oral anti‐diabetic pharmacological therapies. Objectives To evaluate the effects of oral anti‐diabetic pharmacological therapies for treating women with GDM. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (14 May 2016), ClinicalTrials.gov , WHO ICTRP (14 May 2016) and reference lists of retrieved studies. Selection criteria We included published and unpublished randomised controlled trials assessing the effects of oral anti‐diabetic pharmacological therapies for treating pregnant women with GDM. We included studies comparing oral anti‐diabetic pharmacological therapies with 1) placebo/standard care, 2) another oral anti‐diabetic pharmacological therapy, 3) combined oral anti‐diabetic pharmacological therapies. Trials using insulin as the comparator were excluded as they are the subject of a separate Cochrane systematic review. Women with pre‐existing type 1 or type 2 diabetes were excluded. Data collection and analysis Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and data were checked for accuracy. Main results We included 11 studies (19 publications) (1487 women and their babies). Eight studies had data that could be included in meta‐analyses. Studies were conducted in Brazil, India, Israel, UK, South Africa and USA. The studies varied in diagnostic criteria and treatment targets for glycaemic control for GDM. The overall risk of bias was 'unclear' due to inadequate reporting of methodology. Using GRADE the quality of the evidence ranged from moderate to very low quality . Evidence was downgraded for risk of bias (reporting bias, lack of blinding), inconsistency, indirectness, imprecision and for oral anti‐diabetic therapy versus placebo for generalisability. Oral anti‐diabetic pharmacological therapies versus placebo/standard care There was no evidence of a difference between glibenclamide and placebo groups for hypertensive disorders of pregnancy (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.81 to 1.90; one study, 375 women, very low‐quality evidence), birth by caesarean section (RR 1.03, 95% CI 0.79 to 1.34; one study, 375 women, very low‐quality evidence), perineal trauma (RR 0.98, 95% CI 0.06 to 15.62; one study, 375 women, very low‐quality evidence) or induction of labour (RR 1.18, 95% CI 0.79 to 1.76; one study, 375 women; very low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant, there was no evidence of a difference in the risk of being born large‐for‐gestational age (LGA) between infants whose mothers had been treated with glibenclamide and those in the placebo group (RR 0.89, 95% CI 0.51 to 1.58; one study, 375, low‐quality evidence). No data were reported for other infant primary or GRADE outcomes (perinatal mortality, death or serious morbidity composite, neurosensory disability in later childhood, neonatal hypoglycaemia, adiposity, diabetes). Metformin versus glibenclamide There was no evidence of a difference between metformin‐ and glibenclamide‐treated groups for the risk of hypertensive disorders of pregnancy (RR 0.70, 95% CI 0.38 to 1.30; three studies, 508 women, moderate‐quality evidence), birth by caesarean section (average RR 1.20, 95% CI 1.20; 95% CI 0.83 to 1.72, four studies, 554 women, I 2 = 61%, Tau 2 = 0.07 low‐quality evidence), induction of labour (0.81, 95% CI 0.61 to 1.07; one study, 159 women; low‐quality evidence) or perineal trauma (RR 1.67, 95% CI 0.22 to 12.52; two studies, 158 women; low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant there was no evidence of a difference between the metformin‐ and glibenclamide‐exposed groups for the risk of being born LGA (average RR 0.67, 95% CI 0.24 to 1.83; two studies, 246 infants, I 2 = 54%, Tau 2 = 0.30 low‐quality evidence). Metformin was associated with a decrease in a death or serious morbidity composite (RR 0.54, 95% CI 0.31 to 0.94; one study, 159 infants, low‐quality evidence). There was no clear difference between groups for neonatal hypoglycaemia (RR 0.86, 95% CI 0.42 to 1.77; four studies, 554 infants, low‐quality evidence) or perinatal mortality (RR 0.92, 95% CI 0.06 to 14.55, two studies, 359 infants). No data were reported for neurosensory disability in later childhood or for adiposity or diabetes. Glibenclamide versus acarbose There was no evidence of a difference between glibenclamide and acarbose from one study (43 women) for any of their maternal or infant primary outcomes (caesarean section, RR 0.95, 95% CI 0.53 to 1.70; low‐quality evidence; perinatal mortality ‐ no events; low‐quality evidence; LGA , RR 2.38, 95% CI 0.54 to 10.46; low‐quality evidence). There was no evidence of a difference between glibenclamide and acarbose for neonatal hypoglycaemia (RR 6.33, 95% CI 0.87 to 46.32; low‐quality evidence). There were no data reported for other pre‐specified GRADE or primary maternal outcomes (hypertensive disorders of pregnancy, development of type 2 diabetes, perineal trauma, return to pre‐pregnancy weight, postnatal depression, induction of labour) or neonatal outcomes (death or serious morbidity composite, adiposity or diabetes). Authors' conclusions There were insufficient data comparing oral anti‐diabetic pharmacological therapies with placebo/standard care (lifestyle advice) to inform clinical practice. There was insufficient high‐quality evidence to be able to draw any meaningful conclusions as to the benefits of one oral anti‐diabetic pharmacological therapy over another due to limited reporting of data for the primary and secondary outcomes in this review. Short‐ and long‐term clinical outcomes for this review were inadequately reported or not reported. Current choice of oral anti‐diabetic pharmacological therapy appears to be based on clinical preference, availability and national clinical practice guidelines. The benefits and potential harms of one oral anti‐diabetic pharmacological therapy compared with another, or compared with placebo/standard care remains unclear and requires further research. Future trials should attempt to report on the core outcomes suggested in this review, in particular long‐term outcomes for the woman and the infant that have been poorly reported to date, women's experiences and cost benefit. Plain language summary Oral medication for the treatment of women with gestational diabetes What is the issue? Globally the number of women being diagnosed with gestational diabetes mellitus (GDM) is increasing. GDM is an intolerance to glucose leading to high blood sugars, first recognised during pregnancy and usually resolving after birth. Standard care involves lifestyle advice on diet and exercise. Treatment for some women includes oral anti‐diabetic medications, such as metformin and glibenclamide, which are an alternative to, or can be used alongside, insulin to control the blood sugar. This review aimed to investigate benefits of taking oral medication to treat GDM in pregnant women. Another Cochrane Review compares the effects of insulin with oral anti‐diabetic pharmacological therapies ( Brown 2016 ). Why is this important? Women diagnosed with GDM are at a greater risk of experiencing complications such as high blood pressure during pregnancy and at birth. They have an increased risk of developing diabetes later in life. The babies of women who have been diagnosed with GDM can be larger than normal and this can cause injuries to the mother and the baby at birth. The birth is more likely to be induced or the baby born by caesarean section. These babies are at risk of developing diabetes as children or young adults. Finding the best medications to treat the women and prevent the complications that are linked to GDM is therefore important. What evidence did we find? We searched for studies on 14 May 2016. We included 11 randomised controlled trials involving 1487 mothers and their babies (but only eight trials contributed data to our analyses). The evidence was limited by the quality and number of studies and we advise caution when looking at the results. The criteria for diagnosis of GDM and treatment targets varied between studies, and each outcome is based on few studies with low numbers of women. Three studies compared oral medication with placebo/standard care but the following findings are from a single study (375 women). The quality of the evidence was very low or low. We found no differences between the oral medication and placebo group for the risk of high blood pressure, birth by caesarean section, induction of labour or perineal trauma. The number of babies born large‐for‐gestational age, with low blood sugars or dying at birth was not clearly different between the groups. Two studies (434 women) reported no difference in the need for insulin between the oral medication and placebo group. Six studies compared metformin with glibenclamide. The quality of the evidence was very low to moderate. We found no difference between metformin and glibenclamide for the risk of high blood pressure (three studies, 508 women, moderate‐quality evidence), birth by caesarean section (four studies, 554 women, low‐quality evidence), perineal trauma (two studies, 308 women, low‐quality evidence) or induction of labour (one study, 159 women, low‐quality evidence). We found no difference between metformin and glibenclamide for the baby having low blood sugars (four studies, 554 infants, low‐quality evidence), being born large‐for‐gestational age (two studies, 246 infants) or dying at birth (all low‐ or very low‐quality evidence). In one study, the babies of the mothers taking metformin were at reduced risk of having any serious outcome (low blood sugar, jaundice, being born large, breathing problems, injury at birth or death combined) (low‐quality evidence). One small study (43 women) comparing glibenclamide with acarbose reported no differences in outcomes for mothers or their babies. None of the included studies provided any data on many of the outcomes pre‐specified in this review, including long‐term outcomes for the mother or for the baby as a child or an adult. What does this mean? There is not enough high‐quality evidence available to guide us on if oral medication has better outcomes for women with gestational diabetes, and their babies, compared with a placebo or if one oral medication has better health outcomes than another oral medication. Because we are still unclear, further research is needed. Future studies should be encouraged to report on the outcomes suggested in this review and in particular the long‐term outcomes for the woman and the infant that have been poorly reported to date.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Brown, J, Martis, R, Hughes, B, Rowan, J, Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD011967.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.773Z" }, { "id": "6bfbd680-76fa-4608-a28b-60d902653fd0", "pmid": "", "title": "Zinc supplementation for the promotion of growth and prevention of infections in infants less than six months of age", "imported": false, "abstract": "Abstract - Background Zinc is a vital micronutrient for humans and is essential for protein synthesis, cell growth, and differentiation. Severe zinc deficiency can lead to slower physical, cognitive and sexual growth, cause skin disorders, decrease immunity, increase incidence of acute illnesses in infants and children and contribute to childhood stunting. By estimation, 17.3% of the world population is at risk of inadequate zinc intake. Such nutritional impairment increases the risk of diarrhoea and pneumonia by 20%, as well as leads to a global loss of more than 16 million disability‐adjusted life years in children less than five years of age. Not only does zinc deficiency affect lives, it adds to the considerable financial burden on depleted resources in countries that are most affected. By preventing or curing this deficiency, we can improve childhood mortality, morbidity and growth. Objectives To assess the effectiveness of zinc supplementation for the promotion of growth, reduction in mortality, and the prevention of infections in infants less than six months of age. Search methods We used the standard search strategy of the Cochrane Neonatal Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 4), MEDLINE via PubMed (1966 to 18 May 2018), Embase (1980 to 18 May 2018), and CINAHL (1982 to 18 May 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials . An updated search from 1 January 2018 to 29 January 2020 was run in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria All randomised controlled (individual and cluster randomised) and quasi‐randomised trials of zinc supplementation in healthy, term infants, less than six months of age comparing infant mortality, incidence of diarrhoea or respiratory illnesses, growth and/or serum zinc levels were eligible. Data collection and analysis Two review authors screened search results (title and abstracts) and relevant full texts. Studies fulfilling prespecified inclusion criteria were included with any disagreements resolved by consensus. Extraction and analysis were then conducted. We used the GRADE approach to assess the quality of evidence as indicated by certainty in effect estimates. Main results Eight studies (with 85,629 infants) were included and five studies were meta‐analysed, out of which four studies compared zinc with placebo, and one compared zinc plus riboflavin versus riboflavin. Certain growth outcomes after six months of intervention (Weight for Age Z‐scores (WAZ) (standardised mean difference) (SMD) 0.16, 95% CI 0.03 to 0.29; three studies, n = 955; fixed‐effect; heterogeneity Chi² P = 0.96); I² = 0%); change in WAZ (SMD 0.16, 95% CI 0.07 to 0.25; one study, n = 386; fixed‐effect); (Weight‐for‐Length Z‐score (WLZ) (SMD 0.15, 95% CI 0.02 to 0.28; three studies, n = 955; fixed‐effect; heterogeneity: Chi² P = 0.81); I² = 0%); (change in WLZ (SMD 0.17, 95% CI 0.06 to 0.28; one study, n = 386; fixed‐effect)) were positively affected by zinc supplementation compared to placebo. A single study reported no difference in the incidence of diarrhoea and lower respiratory tract infection with zinc supplementation. Zinc had no effect on mortality in children younger than 12 months. When zinc plus riboflavin was compared to riboflavin only, significant improvement was observed in the incidence of wasting at 24 months (risk ratio (RR) 0.59, 95% CI 0.37 to 0.96; one study, n = 296; fixed‐effect), but significant worsening of incidence of stunting was present at 21 months (RR 1.53, 95% CI 1.09 to 2.16; one study, n = 298; fixed‐effect). Authors' conclusions There was a significant positive impact of zinc supplementation on WAZ and WLZ after six months of intervention in infants compared to placebo. When a combined supplement of zinc and riboflavin was compared to riboflavin, there was a significant reduction in wasting at 24 months, but stunting at 21 months was negatively affected. Although included trials were of good‐to‐moderate quality, evidence that could be meta‐analysed was based on a few studies which affected the overall quality of results. Regardless, there is a need for strong trials conducted in infants younger than six months before a strong recommendation can be made supporting zinc supplementation in this age group. Plain language summary Zinc supplementation for improving the health and survival of infants less than six months old Review question: does zinc supplementation reduce mortality, morbidity and increase growth in infants aged less than six months old? Background: zinc deficiency is prevalent in the world. Adequate zinc levels are linked to decreased deaths, illnesses and improved growth in all populations particularly in developing countries. Zinc supplementation in older children has shown some positive effects. Study characteristics: we searched for studies through January 2020 that enrolled healthy infants aged less than six months old and provided at least six months of zinc supplementation. We included eight studies that covered zinc supplementation compared with placebo, zinc and riboflavin compared with riboflavin only, zinc, riboflavin and B complex vitamins compared with riboflavin and B complex vitamins. Key results and certainty of evidence: zinc had no effect on decreasing deaths or illnesses in children younger than 12 months. Moderate‐ to good‐certainty evidence from three studies suggested an increase in weight‐for‐age Z‐scores and weight‐for‐length Z‐scores after zinc supplementation for six months compared to placebo only. Only one study could be analysed for zinc and riboflavin supplementation compared to riboflavin only, and the results suggested a decrease in wasting after 24 months of supplementation and an increase in stunting after 21 months. Conclusion: with this evidence, we cannot strongly recommend clinicians to prescribe zinc supplements to children under six months of age. We also encourage the development of trials that will provide zinc as well as other micronutrients in this age group and for such trials to evaluate outcomes such as death, disease, side effects and growth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lassi, ZS; Kurji, J; Oliveira, CSD; Moin, A; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD010205.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "6c1baecf-ea55-4be5-b250-647658589513", "pmid": "", "title": "Synbiotics, prebiotics and probiotics for people with chronic kidney disease", "imported": false, "abstract": "Abstract - Background Chronic kidney disease (CKD) is a major public health problem affecting 13% of the global population. Prior research has indicated that CKD is associated with gut dysbiosis. Gut dysbiosis may lead to the development and/or progression of CKD, which in turn may in turn lead to gut dysbiosis as a result of uraemic toxins, intestinal wall oedema, metabolic acidosis, prolonged intestinal transit times, polypharmacy (frequent antibiotic exposures) and dietary restrictions used to treat CKD. Interventions such as synbiotics, prebiotics, and probiotics may improve the balance of the gut flora by altering intestinal pH, improving gut microbiota balance and enhancing gut barrier function (i.e. reducing gut permeability). Objectives This review aimed to evaluate the benefits and harms of synbiotics, prebiotics, and probiotics for people with CKD. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria We included randomised controlled trials (RCTs) measuring and reporting the effects of synbiotics, prebiotics, or probiotics in any combination and any formulation given to people with CKD (CKD stages 1 to 5, including dialysis and kidney transplant). Two authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. Data collection and analysis Data extraction was independently carried out by two authors using a standard data extraction form. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross‐checked by another. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Forty‐five studies (2266 randomised participants) were included in this review. Study participants were adults (two studies in children) with CKD ranging from stages 1 to 5, with patients receiving and not receiving dialysis, of whom half also had diabetes and hypertension. No studies investigated the same synbiotic, prebiotic or probiotic of similar strains, doses, or frequencies. Most studies were judged to be low risk for selection bias, performance bias and reporting bias, unclear risk for detection bias and for control of confounding factors, and high risk for attrition and other biases. Compared to prebiotics, it is uncertain whether synbiotics improve estimated glomerular filtration rate (eGFR) at four weeks (1 study, 34 participants: MD ‐3.80 mL/min/1.73 m², 95% CI ‐17.98 to 10.38), indoxyl sulfate at four weeks (1 study, 42 participants: MD 128.30 ng/mL, 95% CI ‐242.77 to 499.37), change in gastrointestinal (GI) upset (borborymgi) at four weeks (1 study, 34 participants: RR 15.26, 95% CI 0.99 to 236.23), or change in GI upset (Gastrointestinal Symptom Rating Scale) at 12 months (1 study, 56 participants: MD 0.00, 95% CI ‐0.27 to 0.27), because the certainty of the evidence was very low. Compared to certain strains of prebiotics, it is uncertain whether a different strain of prebiotics improves eGFR at 12 weeks (1 study, 50 participants: MD 0.00 mL/min, 95% CI ‐1.73 to 1.73), indoxyl sulfate at six weeks (2 studies, 64 participants: MD ‐0.20 μg/mL, 95% CI ‐1.01 to 0.61; I² = 0%) or change in any GI upset, intolerance or microbiota composition, because the certainty of the evidence was very low. Compared to certain strains of probiotics, it is uncertain whether a different strain of probiotic improves eGFR at eight weeks (1 study, 30 participants: MD ‐0.64 mL/min, 95% CI ‐9.51 to 8.23; very low certainty evidence). Compared to placebo or no treatment, it is uncertain whether synbiotics improve eGFR at six or 12 weeks (2 studies, 98 participants: MD 1.42 mL/min, 95% CI 0.65 to 2.2) or change in any GI upset or intolerance at 12 weeks because the certainty of the evidence was very low. Compared to placebo or no treatment, it is uncertain whether prebiotics improves indoxyl sulfate at eight weeks (2 studies, 75 participants: SMD ‐0.14 mg/L, 95% CI ‐0.60 to 0.31; very low certainty evidence) or microbiota composition because the certainty of the evidence is very low. Compared to placebo or no treatment, it is uncertain whether probiotics improve eGFR at eight, 12 or 15 weeks (3 studies, 128 participants: MD 2.73 mL/min, 95% CI ‐2.28 to 7.75; I² = 78%), proteinuria at 12 or 24 weeks (1 study, 60 participants: MD ‐15.60 mg/dL, 95% CI ‐34.30 to 3.10), indoxyl sulfate at 12 or 24 weeks (2 studies, 83 participants: MD ‐4.42 mg/dL, 95% CI ‐9.83 to 1.35; I² = 0%), or any change in GI upset or intolerance because the certainty of the evidence was very low. Probiotics may have little or no effect on albuminuria at 12 or 24 weeks compared to placebo or no treatment (4 studies, 193 participants: MD 0.02 g/dL, 95% CI ‐0.08 to 0.13; I² = 0%; low certainty evidence). For all comparisons, adverse events were poorly reported and were minimal (flatulence, nausea, diarrhoea, abdominal pain) and non‐serious, and withdrawals were not related to the study treatment. Authors' conclusions We found very few studies that adequately test biotic supplementation as alternative treatments for improving kidney function, GI symptoms, dialysis outcomes, allograft function, patient‐reported outcomes, CVD, cancer, reducing uraemic toxins, and adverse effects. We are not certain whether synbiotics, prebiotics, or probiotics are more or less effective compared to one another, antibiotics, or standard care for improving patient outcomes in people with CKD. Adverse events were uncommon and mild. Plain language summary Prebiotics (dietary fibre), probiotics (good bacteria) or synbiotics (prebiotics plus probiotics) for people with chronic kidney disease Key messages Chronic kidney disease (CKD) is a serious health problem that affects over 850 million people worldwide. People with kidney disease have an unhealthy balance of good and bad bacteria in their guts, called 'gut dysbiosis'. This imbalance arises because of the effects of reduced kidney function (retained toxic waste products, fluid retention causing the gut wall to swell), drugs frequently used in people with CKD (especially antibiotics), and dietary restrictions placed on people with CKD. Gut dysbiosis can, in turn, cause or worsen CKD because bacteria can produce toxins that cross the bowel wall and damage the kidneys. Gut dysbiosis can also cause stomach problems (like bloating, cramping, constipation and diarrhoea) and reduce quality of life. To improve the balance of the gut flora, good bacteria can be taken in tablets of high doses of prebiotics and probiotics. Prebiotics, or indigestible plant fibre, can encourage the growth of good bacteria. Synbiotics are a combination of prebiotics and probiotics. Some research suggests that taking high doses of the good bacteria can re‐balance the good bacteria in people's gut, thereby improving bowel symptoms and the conditions that lead to worsening of CKD. What did we do? We reviewed all of the evidence on synbiotics, prebiotics and probiotics to see whether they can improve outcomes in people who have CKD (all stages 1 to 5). What did we find? We found 45 studies randomising 2266 participants. Half of these looked at participants receiving dialysis (mostly haemodialysis), and the other half not receiving dialysis. Half also had diabetes and hypertension. We are uncertain whether synbiotics, prebiotics, or probiotics improve bowel outcomes, quality of life, kidney toxin levels or kidney function. The quality of the evidence that we found is low quality and very low certainty. All studies were conducted using moderate to poor‐quality methods with too few patients. Summary Currently, we do not have enough information from trials to know whether synbiotics, prebiotics or probiotics work to improve bowel symptoms, quality of life, kidney toxin levels, or kidney function in people with CKD. Ten studies are currently ongoing; therefore, it is possible that findings may change with the inclusion of these studies in future updates. The evidence is up to date to 9 October 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Cooper, TE; Khalid, R; Chan, S; Craig, JC; Hawley, CM; Howell, M; Johnson, DW; Jaure, A; Teixeira-Pinto, A; Wong, G", "articleTypes": [], "doi": "10.1002/14651858.CD013631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "6c2763e1-8929-4890-ba49-afea0d1b708a", "pmid": "", "title": "Palliative drug treatments for breathlessness in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is a life‐limiting autosomal recessive genetic illness. A feeling of shortness of breath is common in cystic fibrosis, especially as the disease progresses. Reversing the underlying cause is the priority when treating breathlessness (dyspnoea), but when it is not feasible, palliation (easing) becomes the primary goal to improve an individual's quality of life. A range of drugs administered by various routes have been used, but no definite guidelines are available. A systematic review is needed to evaluate such treatments. Objectives To assess the efficacy and safety of drugs used to ease breathlessness in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 18 November 2019. We searched databases (clinicaltrials.gov, the ISRCTN registry, the Clinical Trials Registry India and WHO ICTRP) for ongoing trials. These searches were last run on 06 March 2020. Selection criteria We planned to include randomised and quasi‐randomised controlled trials in people with cystic fibrosis (diagnosed by a positive sweat chloride test or genetic testing) who have breathlessness. We considered studies comparing any drugs used for easing breathlessness to another drug administered by any route (inhaled (nebulised), intravenous, oral, subcutaneous, transmucosal (including buccal, sublingual and intra‐nasal) and transdermal). Data collection and analysis The authors assessed the search results according to the pre‐defined inclusion criteria. Main results The new searches in 2020 yielded two ongoing studies that were not relevant to the review question. Previous searches had found only one study (cross‐over in design), which did not fulfil the inclusion criteria as no data were available from the first treatment period alone. Authors' conclusions Due to the lack of available evidence, this review cannot provide any information for clinical practice. The authors call for specific research in this area after taking into account relevant ethical considerations. The research should focus on the efficacy and safety of the drugs with efficacy being measured in terms of improvement in quality of life, dyspnoea scores and hospital stay. Plain language summary Drug treatments to ease breathlessness in cystic fibrosis Review question What is the evidence that drug treatments for breathlessness (also known as dyspnoea) in people with cystic fibrosis are effective and safe? Background Cystic fibrosis is a life‐limiting genetic disease. As the disease progresses, thick sticky mucus is formed in the lungs, pancreas and other organs. This thick mucus increases risk of infection, blocks the airways and causes severe breathlessness. Easing of this breathlessness is an important goal for care of people with cystic fibrosis. Many methods have been suggested to address this problem and many drugs have been reported to ease breathlessness. The drugs can be administered through various routes ‐ they might be inhaled, swallowed, injected under the skin, into muscle or into a vein or be absorbed through the skin (either on the body or through membranes inside the mouth or nose). Despite so many drugs being available, there are no defined guidelines for drug treatments aimed at easing breathlessness in people with cystic fibrosis. Search date The evidence from the Cochrane Cystic Fibrosis Trials Register is current to 18 November 2019; the searches of ongoing trial registries are current to 06 March 2020. Study characteristics We had planned to include studies comparing different treatments to ease breathlessness in people with cystic fibrosis where the participants were put into the different treatment groups at random. Our search found only one study in which seven people first received either a drug called hydrocodone or a placebo (dummy treatment) and then swapped to the other treatment; but this study did not report results separately for each treatment arm, so we are not able to include it in the review. Key results No studies fulfilled the inclusion criteria, therefore it is not possible to comment on the outcomes we wished to report on in this review. Until evidence becomes available, the review authors feel that it is advisable for doctors to follow any local or national guidelines. The authors recommend research in this area should take ethical considerations into account and should focus on the safety of the drugs, improvement in quality of life, breathlessness scores and length of hospital stay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Jaiswal, N; Singh, M; Agarwal, A; Chauhan, A; Jaiswal, N", "articleTypes": [], "doi": "10.1002/14651858.CD011855.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "6c285789-c96f-4bd9-a05d-b6d34d1de565", "pmid": "", "title": "Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Subcutaneous administration may be preferable to oral for individuals experiencing nausea and/or vomiting Objectives To determine the efficacy and tolerability of subcutaneous sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using subcutaneous sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Thirty‐five studies (9365 participants) compared subcutaneous sumatriptan with placebo or an active comparator. Most of the data were for the 6 mg dose. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 6 mg versus placebo the NNTs were 2.9, 2.3, 2.2, and 2.1 for pain‐free at one and two hours, and headache relief at one and two hours, respectively, and 6.1 for sustained pain‐free at 24 hours. Results for the 4 mg and 8 mg doses were similar to the 6 mg dose, with 6 mg significantly better than 4 mg only for pain‐free at one hour, and 8 mg significantly better than 6 mg only for headache relief at one hour. There was no evidence of increased migraine relief if a second dose of sumatriptan 6 mg was given after an inadequate response to the first. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Sumatriptan was compared directly with a number of active treatments, including other triptans, acetylsalicylic acid plus metoclopramide, and dihydroergotamine, but there were insufficient data for any pooled analyses. Authors' conclusions Subcutaneous sumatriptan is effective as an abortive treatment for acute migraine attacks, quickly relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a subcutaneous injection, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, or needing fast relief. This review found that a single subcutaneous dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in almost 6 in 10 people (59%) taking sumatriptan 6 mg, compared with about 1 in 7 (15%) taking placebo, and reduced from moderate or severe to no worse than mild pain by two hours in almost 8 in 10 people (79%) taking sumatriptan compared with about 3 in 10 (31%) taking placebo. Subcutaneous sumatriptan was fast‐acting, and the majority of people experiencing pain relief had done so by one hour. About 3 in 10 (31%) people had freedom from pain at two hours which was sustained during the 24 hours postdose without the use of rescue medication, compared with about 1 in 7 (15%) with placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events, most of which were of short duration and mild or moderate in severity, were more frequent with sumatriptan than with placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009665", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.074Z" }, { "id": "6c33d482-c9d6-4706-8b3b-42f30dc70522", "pmid": "", "title": "Potentiators (specific therapies for class III and IV mutations) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is the commonest inherited life‐shortening illness in white populations, caused by a mutation in the gene that codes for the cystic fibrosis transmembrane regulator protein (CFTR), which functions as a salt transporter. This mutation mainly affects the airways where excess salt absorption dehydrates the airway lining leading to impaired mucociliary clearance. Consequently, thick, sticky mucus accumulates making the airway prone to chronic infection and progressive inflammation; respiratory failure often ensues. Other complications include malnutrition, diabetes and subfertility. Increased understanding of the condition has allowed pharmaceutical companies to design mutation‐specific therapies targeting the underlying molecular defect. CFTR potentiators target mutation classes III and IV and aim to normalise airway surface liquid and mucociliary clearance, which in turn impacts on the chronic infection and inflammation. This is an update of a previously published review. Objectives To evaluate the effects of CFTR potentiators on clinically important outcomes in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles, reviews and online clinical trial registries. Last search: 21 November 2018. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing CFTR potentiators to placebo in people with CF. A separate review examines trials combining CFTR potentiators with other mutation‐specific therapies. Data collection and analysis The authors independently extracted data, assessed the risk of bias in included trials and used GRADE to assess evidence quality. Trial authors were contacted for additional data. Main results We included five RCTs (447 participants with different mutations) lasting from 28 days to 48 weeks, all assessing the CFTR potentiator ivacaftor. The quality of the evidence was moderate to low, mainly due to risk of bias (incomplete outcome data and selective reporting) and imprecision of results, particularly where few individuals experienced adverse events. Trial design was generally well‐documented. All trials were industry‐sponsored and supported by other non‐pharmaceutical funding bodies. F508del (class II) (140 participants) One 16‐week trial reported no deaths, or changes in quality of life (QoL) or lung function (either relative or absolute change in forced expiratory volume in one second (FEV1) (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in ivacaftor and placebo groups, but there was no difference between groups (low‐quality evidence); there was also no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. There was also no difference in weight. Sweat chloride concentration decreased, mean difference (MD) ‐2.90 mmol/L (95% confidence interval (CI) ‐5.60 to ‐0.20). G551D (class III) (238 participants) The 28‐day phase 2 trial (19 participants) and two 48‐week phase 3 trials (adult trial (167 adults), paediatric trial (52 children)) reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor in the adult trial at 24 weeks, MD 8.10 (95% CI 4.77 to 11.43) and 48 weeks, MD 8.60 (95% CI 5.27 to 11.93 (moderate‐quality evidence). The adult trial reported a higher relative change in FEV1 with ivacaftor at 24 weeks, MD 16.90% (95% CI 13.60 to 20.20) and 48 weeks, MD 16.80% (95% CI 13.50 to 20.10); the paediatric trial reported this at 24 weeks, MD 17.4% (P < 0.0001)) (moderate‐quality evidence). These trials demonstrated absolute improvements in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32). The phase 3 trials reported increased cough, odds ratio (OR) 0.57 (95% CI 0.33 to 1.00) and episodes of decreased pulmonary function, OR 0.29 (95% CI 0.10 to 0.82) in the placebo group; ivacaftor led to increased dizziness in adults, OR 10.55 (95% CI 1.32 to 84.47). There was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Fewer participants taking ivacaftor developed serious pulmonary exacerbations; adults taking ivacaftor developed fewer exacerbations (serious or not), OR 0.54 (95% CI 0.29 to 1.01). A higher proportion of participants were exacerbation‐free at 24 weeks with ivacaftor (moderate‐quality evidence). Ivacaftor led to a greater absolute change from baseline in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32); weight also increased at 24 weeks, MD 2.37 kg (95% CI 1.68 to 3.06) and 48 weeks, MD 2.75 kg (95% CI 1.74 to 3.75). Sweat chloride concentration decreased at 24 weeks, MD ‐48.98 mmol/L (95% CI ‐52.07 to ‐45.89) and 48 weeks, MD ‐49.03 mmol/L (95% CI ‐52.11 to ‐45.94). R117H (class IV) (69 participants) One 24‐week trial reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor at 24 weeks, MD 8.40 (95% CI 2.17 to 14.63), but no relative changes in lung function were reported (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in both groups, but there was no difference between groups; there was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. No changes in absolute change in FEV1 or weight were reported. Sweat chloride concentration decreased, MD ‐24.00 mmol/L (CI 95% ‐24.69 to ‐23.31). Authors' conclusions There is no evidence supporting the use of ivacaftor in people with the F508del mutation. Both G551D phase 3 trials demonstrated a clinically relevant impact of ivacaftor on outcomes at 24 and 48 weeks in adults and children (over six years of age) with CF. The R117H trial demonstrated an improvement in the respiratory QoL score, but no improvement in respiratory function. As new mutation‐specific therapies emerge, it is important that trials examine outcomes relevant to people with CF and their families and that adverse events are reported robustly and consistently. Post‐market surveillance is essential and ongoing health economic evaluations are required. Plain language summary Ivacaftor (marketed as Kalydeco®), a new specific therapy for cystic fibrosis Review question How does ivacaftor affect clinical outcomes (survival, quality of life and lung function) in people with cystic fibrosis (CF)? Background In people with CF, airway surfaces do not have enough water because of an abnormal protein; this makes it difficult to clear thick and sticky mucus, which leads to lung infections. Ivacaftor works on the abnormal protein in people with some mutations to allow the airways retain more water and better clear mucus, so fewer lung infections develop. Ivacaftor was aimed at people with class III and IV mutations, and has been studied in people with G551D (class III), R117H (class IV) and F508del (class II) mutations. Trial characteristics We included five trials (447 participants) comparing ivacaftor to placebo (dummy treatment with no active medication) lasting between four and 48 weeks. Three trials enrolled a total of 238 people with at least one copy of the G551D mutation, one trial enrolled 140 people with two copies of the F508del mutation and one enrolled 69 people with at least one copy of the R117H mutation. The evidence is up to date as of 21 November 2018. Key results F508del mutation The trial did not report any deaths or show improvements in lung function, quality of life scores or weight. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. Sweat chloride concentrations were reduced with ivacaftor. G551D mutation No deaths were reported. Both children and adults taking ivacaftor showed improvements in lung function, but only adults reported higher quality of life scores. People given placebo reported more coughing and experienced more episodes of decreased lung function; more adults taking ivacaftor reported episodes of dizziness. Similar numbers of people taking ivacaftor and placebo delayed the course of medication, or withdrew from the trial altogether, due to side effects (e.g. psychological issues, liver disease, severe breathing problems). There were more serious pulmonary exacerbations whilst taking placebo compared to ivacaftor. Adults taking ivacaftor were admitted to hospital less often and had fewer courses of intravenous antibiotics for exacerbations. Both children and adults and children increased their weight with ivacaftor. There was a drop in sweat chloride concentrations with ivacaftor. R117H mutation No deaths occurred in this trial. While quality of life scores improved with ivacaftor, lung function did not. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. There was no difference in weight; but as for other mutations there was a reduction in sweat chloride concentration with ivacaftor.
 
 Evidence suggests that ivacaftor is an effective treatment for people (over six years of age) with cystic fibrosis and the G551D mutation, but not for those with the F508del or R117H mutations. Quality of the evidence In most trials, individuals were put into different treatment groups at random with equal chances of being given either placebo or ivacaftor; no one could work out which treatment the next person would receive, so that healthier people did not receive ivacaftor and make the results seem better. We were not sure whether anyone involved in the trial knew who was receiving which treatment and how this might affect results. No trials reported all results clearly; sometimes they did not report them in a way that we could use in the review and sometimes they did not report the data at all. This affected our certainty regarding the overall results. Information about some side effects was limited as not many people experienced them, therefore, it is difficult to judge whether there was a difference between treatment groups We judged the evidence in this review to be moderate to low quality. Trial funding sources All trials were sponsored by Vertex Pharmaceuticals Incorporated. The National Institute of Health (NIH), the Cystic Fibrosis Foundation (CFF) and other non‐pharmaceutical funding bodies also supported the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Skilton, M; Krishan, A; Patel, S; Sinha, IP; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD009841.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "6c3b9094-6508-45d0-8a98-03d4f16c2bab", "pmid": "", "title": "Colchicine for acute gout", "imported": false, "abstract": "Abstract - Background This is an updated Cochrane Review, first published in 2006 and updated in 2014. Gout is one of the most common rheumatic diseases worldwide. Despite the use of colchicine as one of the first‐line therapies for the treatment of acute gout, evidence for its benefits and harms is relatively limited. Objectives To update the available evidence of the benefits and harms of colchicine for the treatment of acute gout. Search methods We updated the search of CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICTRP registries to 28 August 2020. We did not impose any date or language restrictions in the search. Selection criteria We considered published randomised controlled trials (RCTs) and quasi‐randomised controlled trials (quasi‐RCTs) evaluating colchicine therapy compared with another therapy (placebo or active) in acute gout; low‐dose colchicine at clinically relevant doses compared with placebo was the primary comparison. The major outcomes were pain, participant global assessment of treatment success (proportion with 50% or greater decrease in pain from baseline up to 32 to 36 hours), reduction of inflammation, function of target joint, serious adverse events, total adverse events and withdrawals due to adverse events. Data collection and analysis We used standard methodological procedures as expected by Cochrane in this review update. Main results We included four trials (803 randomised participants), including two new trials, in this updated review. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We did not identify any trials comparing colchicine to glucocorticoids (by any route). The mean age of participants ranged from 51.2 to 70 years, and trial duration from 48 hours to 12 weeks. Two trials were at low risk of bias, one was possibly susceptible to selection bias (random sequence generation), reporting bias and other bias, and one open‐label trial was at high risk of performance and detection bias. For the primary comparison, low‐quality evidence from one trial (103 participants, downgraded for imprecision and bias) suggests low‐dose colchicine may improve treatment outcome compared to placebo with little or no increased risk of adverse events. The number of people who reported treatment success (50% or greater pain reduction) at 32 to 36 hours was slightly larger with low‐dose colchicine (418 per 1000) compared with placebo (172 per 1000; risk ratio (RR) 2.43, 95% confidence interval (CI) 1.05 to 5.64; absolute improvement 25% more reported success (7% more to 42% more, the 95% CIs include both a clinically important and unimportant benefit); relative change of 143% more people reported treatment success (5% more to 464% more). The incidence of total adverse events was 364 per 1000 with low‐dose colchicine compared with 276 per 1000 with placebo: RR 1.32, 95% CI 0.68 to 2.56; absolute difference 9% more events with low‐dose colchicine (9% fewer to 43% more, the 95% CIs include both a clinically important effect and no effect); relative change of 32% more events (32% fewer to 156% more). No participants withdrew due to adverse events or reported any serious adverse events. Pain, inflammation and function were not reported. Low‐quality evidence (downgraded for imprecision and bias) from two trials (124 participants) suggests that high‐dose colchicine compared to placebo may improve symptoms, but with increased risk of harms. More participants reported treatment success at 32 to 36 hours with high‐dose colchicine (518 per 1000) compared with placebo (240 per 1000): RR 2.16, 95% CI 1.28 to 3.65, absolute improvement 28% (8% more to 46% more); more also had reduced inflammation at this time point with high‐dose colchicine (504 per 1000) compared with placebo (48 per 1000): RR 10.50, 95% CI 1.48 to 74.38; absolute improvement 45% greater (22% greater to 68% greater); but more adverse events were reported with high‐dose colchicine (829 per 1000 compared with 260 per 1000): RR 3.21, 95% CI 2.01 to 5.11, absolute difference 57% (26% more to 74% more). Pain and function were not reported. Low‐quality evidence from a single trial comparing high‐dose to low‐dose colchicine indicates there may be little or no difference in benefit in terms of treatment success at 32 to 36 hours but more adverse events associated with the higher dose. Similarly, low‐quality evidence from a single trial indicates there may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction at seven days, with a similar number of adverse events reported at four weeks follow‐up. Reduction of inflammation, function of target joint and withdrawals due to adverse events were not reported in either of these trials, and pain was not reported in the high‐dose versus low‐dose colchicine trial. We were unable to estimate the risk of serious adverse events for most comparisons as there were few events reported in the trials. One trial (399 participants) reported three serious adverse (one in a participant receiving low‐dose colchicine and two in participants receiving NSAIDs), due to reasons unrelated to the trial (low‐quality evidence downgraded for bias and imprecision). Authors' conclusions We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve pain when compared to placebo, low‐quality evidence suggests that high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo, while low‐quality evidence indicates that the number of adverse events may be similar with low‐dose colchicine and NSAIDs. Further trials comparing colchicine to placebo or other treatment will likely have an important impact on our confidence in the effect estimates and may change the conclusions of this review. There are no trials reporting the effect of colchicine in populations with comorbidities or in comparison with other commonly used treatments, such as glucocorticoids. Plain language summary Colchicine for treating acute gout flares Background Gout is a very common cause of inflammatory arthritis (pain, redness, warmth and swelling of affected joints) and is caused by urate crystals forming either within or around joints. Uric acid is a normal waste product that is usually excreted with urine. However, in the case of gout, there is either excessive production of uric acid, or the body is not able to excrete it quickly enough, or a combination of both. An attack of gout usually occurs rapidly and usually resolves within 7 to 10 days. Colchicine is a drug that is used mainly in gout to treat an acute attack or to prevent an attack while starting uric acid‐lowering therapy. Study characteristics This Cochrane Review is current to August 2020. We included four trials (803 randomised participants) in this updated review, including two new trials. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (fake medicine) (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We selected low‐dose colchicine compared with placebo as the primary comparison; the low dose is consistent with doses used in practice. Trials were performed in hospital and multicentre settings in four countries, the majority of participants were male, and mean age ranged between 51.2 and 70 years. One trial received funding from a pharmaceutical company that was involved in the study design, data collection, data analysis, and manuscript writing. Key results Compared with placebo medication, low‐dose colchicine for people with acute gout may slightly improve treatment outcomes with little or no increased risk of adverse events at 32 to 36 hours. Proportion of participants reporting treatment success (defined as 50% or more reduction in pain) 25% more people (7% more to 42% more) reported success, or 25 more out of 100 ‐ 42 people out of 100 reported treatment success with colchicine ‐ 17 people out of 100 reported treatment success with placebo Total adverse events (diarrhoea, vomiting or nausea) 6% more people reported adverse events (13% more to 23% more), or 6 more out of 100 ‐ 26 people out of 100 reported side effects with colchicine ‐ 20 people out of 100 reported side effects with placebo Pain, reduction of inflammation, function of target joint, serious adverse events or withdrawals due to adverse events were not reported for this comparison. Other comparisons are briefly summarised here: High‐dose colchicine may improve symptoms compared with placebo, but with more adverse events. High‐dose may have little or no benefit over low‐dose colchicine but more adverse events. There may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction, with a similar number of adverse events. There were no trials that compared colchicine to glucocorticoids. Quality of the evidence We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve treatment success when compared to placebo, high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo while the number of adverse events may be similar with low‐dose colchicine compared with NSAIDs. Further research is very likely to have an important impact on our confidence in the estimate of effect and may change the estimate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "McKenzie, BJ, Wechalekar, MD, Johnston, RV, Schlesinger, N, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD006190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.774Z" }, { "id": "6c40b197-0dbf-4452-adfc-9e9a9de79611", "pmid": "", "title": "Universal screening for SARS‐CoV‐2 infection: a rapid review", "imported": false, "abstract": "Abstract - Background Coronavirus disease 2019 (COVID‐19) is caused by the novel betacoronavirus, severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2). Most people infected with SARS‐CoV‐2 have mild disease with unspecific symptoms, but about 5% become critically ill with respiratory failure, septic shock and multiple organ failure. An unknown proportion of infected individuals never experience COVID‐19 symptoms although they are infectious, that is, they remain asymptomatic. Those who develop the disease, go through a presymptomatic period during which they are infectious. Universal screening for SARS‐CoV‐2 infections to detect individuals who are infected before they present clinically, could therefore be an important measure to contain the spread of the disease. Objectives We conducted a rapid review to assess (1) the effectiveness of universal screening for SARS‐CoV‐2 infection compared with no screening and (2) the accuracy of universal screening in people who have not presented to clinical care for symptoms of COVID‐19. Search methods An information specialist searched Ovid MEDLINE and the Centers for Disease Control (CDC) COVID‐19 Research Articles Downloadable Database up to 26 May 2020. We searched Embase.com, the CENTRAL, and the Cochrane Covid‐19 Study Register on 14 April 2020. We searched LitCovid to 4 April 2020. The World Health Organization (WHO) provided records from daily searches in Chinese databases and in PubMed up to 15 April 2020. We also searched three model repositories (Covid‐Analytics, Models of Infectious Disease Agent Study [MIDAS], and Society for Medical Decision Making) on 8 April 2020. Selection criteria Trials, observational studies, or mathematical modelling studies assessing screening effectiveness or screening accuracy among general populations in which the prevalence of SARS‐CoV2 is unknown. Data collection and analysis After pilot testing review forms, one review author screened titles and abstracts. Two review authors independently screened the full text of studies and resolved any disagreements by discussion with a third review author. Abstracts excluded by a first review author were dually reviewed by a second review author prior to exclusion. One review author independently extracted data, which was checked by a second review author for completeness and accuracy. Two review authors independently rated the quality of included studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool for diagnostic accuracy studies and a modified form designed originally for economic evaluations for modelling studies. We resolved differences by consensus. We synthesized the evidence in narrative and tabular formats. We rated the certainty of evidence for days to outbreak, transmission, cases missed and detected, diagnostic accuracy (i.e. true positives, false positives, true negatives, false negatives) using the GRADE approach. Main results We included 22 publications. Two modelling studies reported on effectiveness of universal screening. Twenty studies (17 cohort studies and 3 modelling studies) reported on screening test accuracy. Effectiveness of screening We included two modelling studies. One study suggests that symptom screening at travel hubs, such as airports, may slightly slow but not stop the importation of infected cases (assuming 10 or 100 infected travellers per week reduced the delay in a local outbreak to 8 days or 1 day, respectively). We assessed risk of bias as minor or no concerns, and certainty of evidence was low, downgraded for very serious indirectness. The second modelling study provides very low‐certainty evidence that screening of healthcare workers in emergency departments using laboratory tests may reduce transmission to patients and other healthcare workers (assuming a transmission constant of 1.2 new infections per 10,000 people, weekly screening reduced infections by 5.1% within 30 days). The certainty of evidence was very low, downgraded for high risk of bias (major concerns) and indirectness. No modelling studies reported on harms of screening. Screening test accuracy All 17 cohort studies compared an index screening strategy to a reference reverse transcriptase polymerase chain reaction (RT‐PCR) test. All but one study reported on the accuracy of single point‐in‐time screening and varied widely in prevalence of SARS‐CoV‐2, settings, and methods of measurement. We assessed the overall risk of bias as unclear in 16 out of 17 studies, mainly due to limited information on the index test and reference standard. We rated one study as being at high risk of bias due to the inclusion of two separate populations with likely different prevalences. For several screening strategies, the estimates of sensitivity came from small samples. For single point‐in‐time strategies, for symptom assessment, the sensitivity from 12 cohorts (524 people) ranged from 0.00 to 0.60 (very low‐certainty evidence) and the specificity from 12 cohorts (16,165 people) ranged from 0.66 to 1.00 (low‐certainty evidence). For screening using direct temperature measurement (3 cohorts, 822 people), international travel history (2 cohorts, 13,080 people), or exposure to known infected people (3 cohorts, 13,205 people) or suspected infected people (2 cohorts, 954 people), sensitivity ranged from 0.00 to 0.23 (very low‐ to low‐certainty evidence) and specificity ranged from 0.90 to 1.00 (low‐ to moderate‐certainty evidence). For symptom assessment plus direct temperature measurement (2 cohorts, 779 people), sensitivity ranged from 0.12 to 0.69 (very low‐certainty evidence) and specificity from 0.90 to 1.00 (low‐certainty evidence). For rapid PCR test (1 cohort, 21 people), sensitivity was 0.80 (95% confidence interval (CI) 0.44 to 0.96; very low‐certainty evidence) and specificity was 0.73 (95% CI 0.39 to 0.94; very low‐certainty evidence). One cohort (76 people) reported on repeated screening with symptom assessment and demonstrates a sensitivity of 0.44 (95% CI 0.29 to 0.59; very low‐certainty evidence) and specificity of 0.62 (95% CI 0.42 to 0.79; low‐certainty evidence). Three modelling studies evaluated the accuracy of screening at airports. The main outcomes measured were cases missed or detected by entry or exit screening, or both, at airports. One study suggests very low sensitivity at 0.30 (95% CI 0.1 to 0.53), missing 70% of infected travellers. Another study described an unrealistic scenario to achieve a 90% detection rate, requiring 0% asymptomatic infections. The final study provides very uncertain evidence due to low methodological quality. Authors' conclusions The evidence base for the effectiveness of screening comes from two mathematical modelling studies and is limited by their assumptions. Low‐certainty evidence suggests that screening at travel hubs may slightly slow the importation of infected cases. This review highlights the uncertainty and variation in accuracy of screening strategies. A high proportion of infected individuals may be missed and go on to infect others, and some healthy individuals may be falsely identified as positive, requiring confirmatory testing and potentially leading to the unnecessary isolation of these individuals. Further studies need to evaluate the utility of rapid laboratory tests, combined screening, and repeated screening. More research is also needed on reference standards with greater accuracy than RT‐PCR. Given the poor sensitivity of existing approaches, our findings point to the need for greater emphasis on other ways that may prevent transmission such as face coverings, physical distancing, quarantine, and adequate personal protective equipment for frontline workers. Plain language summary How effective is screening for COVID‐19? Why does screening matter? Screening aims to identify a condition in people who may not be showing any symptoms. Some people may have the COVID‐19 virus but appear healthy or have only mild symptoms. It is important to identify infected people so they can stay away from others and seek appropriate care. Incorrectly identifying COVID‐19 in healthy people could lead to unnecessary self‐isolation and further tests. Incorrectly identifying no infection in infected people could spread the virus. Screening for COVID‐19 can include temperature checks, or asking about international travel or contact with COVID‐19 cases, or rapid tests. Screening can occur over the telephone, online, or in person, in homes, clinics, workplaces, airports or schools. What did the review study? We wanted to identify: · the benefits and negative effects of screening apparently healthy people for COVID‐19 infection; · whether screening can identify those with and without the virus correctly. To answer these questions rapidly, we shortened some steps of the normal Cochrane Review process. We are confident these changes do not affect our overall conclusions. What did we do? We looked for studies that screened people who had not sought care for potential COVID‐19 symptoms. This review includes evidence up to May 2020. Key results We found 22 studies; 17 assessed people (cohort studies) and five were computer‐generated models (modelling studies). Studies took place in USA, Europe, and Asia. Benefits and negative effects 
Two modelling studies reported on the benefits and negative effects of screening. One suggested that asking about symptoms at airports may slightly slow, but not stop, the importation of infected people. Another model reported that weekly or biweekly screening of healthcare workers may reduce transmission to patients and other healthcare workers in emergency departments. No studies reported on negative effects of screening. Identification of infected people 
Seventeen cohort studies and three modelling studies reported on whether screening can correctly identify those with and without the virus. Studies varied widely in the baseline level of COVID‐19, settings, and methods. All cohort studies compared screening strategies to a ‘gold standard’ test called RT‐PCR. Cohort studies
All screening strategies (17 studies, 17,574 people), incorrectly identified: · between 20 and 100 out of 100 infected people as healthy; · between 0 and 38 people out of 100 healthy people as infected Asking about symptoms (13 studies, 16,762 people ), incorrectly identified: · between 40 to 100 out of 100 infected people as healthy · between 0 to 34 out of 100 healthy people as infected Temperature measurements , asking about international travel , exposure to known infected people and exposure to known or suspected infected people (6 studies, 14,741 people), incorrectly identified : · between 77 and 100 out of 100 infected people as healthy · between 0 and 10 out of 100 healthy people as infected Asking about symptoms plus temperature measurement (2 studies, 779 people), incorrectly identified: · between 31 and 88 out of 100 infected people as healthy · between 0 to 10 people out of 100 healthy people as infected There was insufficient evidence from two small studies on rapid laboratory tests and repeated symptom assessment to tell how accurate they were in identifying healthy and infected people. Modelling studies 
Three studies modelled entry and exit screening in airports. One study missed 70% of infected travellers. Another detected 90% of infections, but used an unrealistic scenario. The third used very unreliable methods so we cannot use evidence from this study. How confident are we in the results of the studies? Our confidence in these findings is limited because most studies did not describe their screening methods clearly, some found very few cases of infections and the types of participants and settings varied greatly, making it difficult to judge whether the results apply broadly. Authors’ conclusions One‐time screening in apparently healthy people is likely to miss people who are infected. We are unsure whether combined screenings, repeated symptom assessment, or rapid laboratory tests are useful. As more people become infected, screening will identify more cases. However, because screening can miss people who are infected, public health measures such as face coverings, physical distancing, and quarantine for those who are apparently healthy, continue to be very important.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Viswanathan, M; Kahwati, L; Jahn, B; Giger, K; Dobrescu, AI; Hill, C; Klerings, I; Meixner, J; Persad, E; Teufer, B; Gartlehner, G", "articleTypes": [], "doi": "10.1002/14651858.CD013718", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "6c5dbce9-e375-4316-afe2-badc7fddc378", "pmid": "", "title": "Antibiotics for induction and maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Several antibiotics have been evaluated in Crohn's disease (CD), however randomised controlled trials (RCTs) have produced conflicting results. Objectives To assess the efficacy and safety of antibiotics for induction and maintenance of remission in CD. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and Clinicaltrials.gov database from inception to 28 February 2018. We also searched reference lists and conference proceedings. Selection criteria RCTs comparing antibiotics to placebo or an active comparator in adult (> 15 years) CD patients were considered for inclusion. Data collection and analysis Two authors screened search results and extracted data. Bias was evaluated using the Cochrane risk of bias tool. The primary outcomes were failure to achieve clinical remission and relapse. Secondary outcomes included clinical response, endoscopic response, endoscopic remission, endoscopic relapse, histologic response, histologic remission, adverse events (AEs), serious AEs, withdrawal due to AEs and quality of life. Remission is commonly defined as a Crohn's disease activity index (CDAI) of < 150. Clinical response is commonly defined as a decrease in CDAI from baseline of 70 or 100 points. Relapse is defined as a CDAI > 150. For studies that enrolled participants with fistulizing CD, response was defined as a 50% reduction in draining fistulas. Remission was defined as complete closure of fistulas. We calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for dichotomous outcomes. We calculated the mean difference (MD) and corresponding 95% CI for continuous outcomes. GRADE was used to assess the certainty of the evidence. Main results Thirteen RCTs (N = 1303 participants) were eligible. Two trials were rated as high risk of bias (no blinding). Seven trials were rated as unclear risk of bias and four trials were rated as low risk of bias. Comparisons included ciprofloxacin (500 mg twice daily) versus placebo, rifaximin (800 to 2400 mg daily) versus placebo, metronidazole (400 mg to 500 mg twice daily) versus placebo, clarithromycin (1 g/day) versus placebo, cotrimoxazole (960 mg twice daily) versus placebo, ciprofloxacin (500 mg twice daily) and metronidazole (250 mg four time daily) versus methylprednisolone (0.7 to 1 mg/kg daily), ciprofloxacin (500 mg daily), metronidazole (500 mg daily) and budesonide (9 mg daily) versus placebo with budesonide (9 mg daily), ciprofloxacin (500 mg twice daily) versus mesalazine (2 g twice daily), ciprofloxacin (500 mg twice daily) with adalimumab versus placebo with adalimumab, ciprofloxacin (500 mg twice daily) with infliximab versus placebo with infliximab, clarithromycin (750 mg daily) and antimycobacterial versus placebo, and metronidazole (400 mg twice daily) and cotrimoxazole (960 mg twice daily) versus placebo. We pooled all antibiotics as a class versus placebo and antibiotics with anti‐tumour necrosis factor (anti‐TNF) versus placebo with anti‐TNF. The effect of individual antibiotics on CD was generally uncertain due to imprecision. When we pooled antibiotics as a class, 55% (289/524) of antibiotic participants failed to achieve remission at 6 to 10 weeks compared with 64% (149/231) of placebo participants (RR 0.86, 95% CI 0.76 to 0.98; 7 studies; high certainty evidence). At 10 to 14 weeks, 41% (174/428) of antibiotic participants failed to achieve a clinical response compared to 49% (93/189) of placebo participants (RR 0.77, 95% CI 0.64 to 0.93; 5 studies; moderate certainty evidence). The effect of antibiotics on relapse in uncertain. Forty‐five per cent (37/83) of antibiotic participants relapsed at 52 weeks compared to 57% (41/72) of placebo participants (RR 0.87, 95% CI 0.52 to 1.47; 2 studies; low certainty evidence). Relapse of endoscopic remission was not reported in the included studies. Antibiotics do not appear to increase the risk of AEs. Thirty‐eight per cent (214/568) of antibiotic participants had at least one adverse event compared to 45% (128/284) of placebo participants (RR 0.87, 95% CI 0.75 to 1.02; 9 studies; high certainty evidence). The effect of antibiotics on serious AEs and withdrawal due to AEs was uncertain. Two per cent (6/377) of antibiotic participants had at least one adverse event compared to 0.7% (1/143) of placebo participants (RR 1.70, 95% CI 0.29 to 10.01; 3 studies; low certainty evidence). Nine per cent (53/569) of antibiotic participants withdrew due to AEs compared to 12% (36/289) of placebo participants (RR 0.86, 95% CI 0.57 to 1.29; 9 studies; low certainty evidence) is uncertain. Common adverse events in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation and headache, change in taste and paraesthesia When we pooled antibiotics used with anti‐TNF, 21% (10/48) of patients on combination therapy failed to achieve a clinical response(50% closure of fistulas) or remission (closure of fistulas) at week 12 compared with 36% (19/52) of placebo and anti‐TNF participants (RR 0.57, 95% CI 0.29 to 1.10; 2 studies; low certainty evidence). These studies did not assess the effect of antibiotics and anti‐TNF on clinical or endoscopic relapse. Seventy‐seven per cent (37/48) of antibiotics and anti‐TNF participants had an AE compared to 83% (43/52) of anti‐TNF and placebo participants (RR 0.93, 95% CI 0.76 to 1.12; 2 studies, moderate certainty evidence). The effect of antibiotics and anti‐TNF on withdrawal due to AEs is uncertain. Six per cent (3/48) of antibiotics and anti‐TNF participants withdrew due to an AE compared to 8% (4/52) of anti‐TNF and placebo participants (RR 0.82, 95% CI 0.19 to 3.45; 2 studies, low certainty evidence). Common adverse events included nausea, vomiting, upper respiratory tract infections, change in taste, fatigue and headache Authors' conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be modest and may not be clinically meaningful. High quality evidence suggests that there is no increased risk of adverse events with antibiotics compared to placebo. The effect of antibiotics on the risk of serious adverse events is uncertain. The effect of antibiotics on maintenance of remission in CD is uncertain. Thus, no firm conclusions regarding the efficacy and safety of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the efficacy and safety of antibiotics as therapy in CD Plain language summary Antibiotics for the treatment of Crohn's disease What is Crohn's disease? Crohn's disease (CD) is an inflammatory disorder that can affect any segment of the gastrointestinal tract from the mouth to the anus. Common symptoms of CD include fever, diarrhea, abdominal pain and weight loss. CD is characterized by periods of relapse when people experience symptoms and periods of remission when the symptoms stop. What are antibiotics? Antibiotics are medications used to treat bacterial infections. Antibiotics are designed to target specific bacterial populations and have different mechanisms of action to stop a bacterial population from growing or eradicate the bacteria. What is the purpose this study? Antibiotics are commonly used for managing patients with CD because the inflammatory process in the bowel was believed to be triggered by a specific bacterial pathogen. Elimination of this bacterial target would allow the inflammatory process to resolve. However, current clinical guidelines do not recommend use of antibiotic agents to induce or maintain clinical remission in patients with CD because there is no definitive evidence to suggest a benefit to using antibiotics in this way. How was this study performed? A systematic review of current literature was performed to determine whether antibiotic therapy is effective to induce or maintain remission in CD. An electronic search of several databases was performed and studies that met our inclusion criteria were selected for further evaluation. Statistical analyses were performed to determine which specific antibiotics had an overall benefit. What were the results? Several antibiotics, including ciprofloxacin, metronidazole, clarithromycin, rifaximin and cotrimoxazole, have been studied in CD. Most of the included studies were small in size. When we pooled antibiotics as a class, these drugs provided a modest benefit over placebo (i.e. a fake drug such as a sugar pill) for induction of remission and improvement of CD symptoms. For example, remission rates were 45% (253/542) in participants who received antibiotics compared to 36% (82/231) in participants who received placebo. We rated the quality of evidence supporting this outcome as high. Few studies assessed the use of antibiotics for maintenance of remission in CD. The impact of antibiotics on preventing relapse in CD is uncertain. Antibiotics do not appear to increase the risk of side effects when compared to placebo. Common side effects reported in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation, headache, change in taste and paraesthesia (pins and needles in the extremities). Serious side effects were not well reported in the studies and the impact of antibiotics on the risk of serious side effects is uncertain. Conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be very modest. High quality evidence suggests that there is no increased risk of side effects with antibiotics compared to placebo. The effect of antibiotics on the risk of serious side effects is uncertain. The effect of antibiotics on preventing relapse in CD is uncertain. Thus, no firm conclusions regarding the benefits and harms of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the harms and benefits of antibiotic therapy in CD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Townsend, CM, Parker, CE, MacDonald, JK, Nguyen, TM, Jairath, V, Feagan, BG, Khanna, R", "articleTypes": [], "doi": "10.1002/14651858.CD012730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.751Z" }, { "id": "6c5ef3b7-7d55-4726-a91e-81bc3b612d0e", "pmid": "", "title": "Chelation therapy for atherosclerotic cardiovascular disease", "imported": false, "abstract": "Abstract - Background Chelation therapy is promoted and practiced around the world as a form of alternative medicine in the treatment of atherosclerotic cardiovascular disease. It has been suggested as a safe, relatively inexpensive, non‐surgical method of restoring blood flow in atherosclerotic vessels. However, there is currently limited high‐quality, adequately‐powered research informing evidence‐based medicine on the topic, specifically regarding clinical outcomes. Due to this limited evidence, the benefit of chelation therapy remains controversial at present. This is an update of a review first published in 2002. Objectives To assess the effects of ethylene diamine tetra‐acetic acid (EDTA) chelation therapy versus placebo or no treatment on clinical outcomes among people with atherosclerotic cardiovascular disease. Search methods For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 6 August 2019. We searched the bibliographies of the studies retrieved by the literature searches for further trials. Selection criteria We included studies if they were randomised controlled trials of EDTA chelation therapy versus placebo or no treatment in participants with atherosclerotic cardiovascular disease. The main outcome measures we considered include all‐cause or cause‐specific mortality, non‐fatal cardiovascular events, direct or indirect measurement of disease severity, and subjective measures of improvement or adverse events. Data collection and analysis Two review authors independently extracted data and assessed trial quality using standard Cochrane procedures. A third author considered any unresolved issues, and we discussed any discrepancies until a consensus was reached. We contacted study authors for additional information. Main results We included five studies with a total of 1993 randomised participants. Three studies enrolled participants with peripheral vascular disease and two studies included participants with coronary artery disease, one of which specifically recruited people who had had a myocardial infarction. The number of participants in each study varied widely (from 10 to 1708 participants), but all studies compared EDTA chelation to a placebo. Risk of bias for the included studies was generally moderate to low, but one study had high risk of bias because the study investigators broke their randomisation code halfway through the study and rolled the placebo participants over to active treatment. Certainty of the evidence, as assessed by GRADE, was generally low to very low, which was mostly due to a paucity of data in each outcome's meta‐analysis. This limited our ability to draw any strong conclusions. We also had concerns about one study's risk of bias regarding blinding and outcome assessment that may have biased the results. Two studies with coronary artery disease participants reported no evidence of a difference in all‐cause mortality between chelation therapy and placebo (risk ratio (RR) 0.97, 95% CI 0.73 to 1.28; 1792 participants; low‐certainty). One study with coronary artery disease participants reported no evidence of a difference in coronary heart disease deaths between chelation therapy and placebo (RR 1.02, 95% CI 0.70 to 1.48; 1708 participants; very low‐certainty). Two studies with coronary artery disease participants reported no evidence of a difference in myocardial infarction (RR 0.81, 95% CI 0.57 to 1.14; 1792 participants; moderate‐certainty), angina (RR 0.95, 95% CI 0.55 to 1.67; 1792 participants; very low‐certainty), and coronary revascularisation (RR 0.46, 95% CI 0.07 to 3.25; 1792 participants). Two studies (one with coronary artery disease participants and one with peripheral vascular disease participants) reported no evidence of a difference in stroke (RR 0.88, 95% CI 0.40 to 1.92; 1867 participants; low‐certainty). Ankle‐brachial pressure index (ABPI; also known as ankle brachial index) was measured in three studies, all including participants with peripheral vascular disease; two studies found no evidence of a difference in the treatment groups after three months after treatment (mean difference (MD) 0.02, 95% CI ‐0.03 to 0.06; 181 participants; low‐certainty). A third study reported an improvement in ABPI in the EDTA chelation group, but this study was at high risk of bias. Meta‐analysis of maximum and pain‐free walking distances three months after treatment included participants with peripheral vascular disease and showed no evidence of a difference between the treatment groups (MD ‐31.46, 95% CI ‐87.63 to 24.71; 165 participants; 2 studies; low‐certainty). Quality of life outcomes were reported by two studies that included participants with coronary artery disease, but we were unable to pool the data due to different methods of reporting and varied criteria. However, there did not appear to be any major differences between the treatment groups. None of the included studies reported on vascular deaths. Overall, there was no evidence of major or minor adverse events associated with EDTA chelation treatment. Authors' conclusions There is currently insufficient evidence to determine the effectiveness or ineffectiveness of chelation therapy in improving clinical outcomes of people with atherosclerotic cardiovascular disease. More high‐quality, randomised controlled trials are needed that assess the effects of chelation therapy on longevity and quality of life among people with atherosclerotic cardiovascular disease. Plain language summary Chelation therapy for atherosclerotic cardiovascular (heart and circulation) disease Background Atherosclerosis is caused by fatty deposits that cause a narrowing of people's arteries and restrict blood flow. People with blocked arteries are more likely to have strokes, heart attacks, and narrow blood vessels in their feet. Chelation therapy involves infusions into the bloodstream of substances believed to remove metals from the blood. This treatment is offered to people with atherosclerotic cardiovascular disease as a way of breaking down the blockages in their blood vessels. Chelation therapy is practiced in several places around the world as an alternative form of medicine, but there is currently a lack of knowledge surrounding this treatment. More information is needed to understand if this treatment should be more widely recommended. Key results This review included evidence from five studies with a total of 1993 participants (current until August 2019). Three studies enrolled participants with peripheral vascular disease, and two of the studies included participants with coronary artery disease, one of which specifically recruited people who had had a heart attack. All five studies compared chelation therapy with no treatment or placebo. Only two of the studies (both of which included participants with coronary artery disease) reported death from any cause, and these reported no difference in overall deaths between those that received chelation therapy and those who did not. Ony one study (in people with coronary artery disease) reported cardiovascular death, and this study found no difference between in risk between those who had chelation therapy and those who did not. Two studies of people with coronary artery disease reported rates of heart attack and angina, and found no difference in the risk of these between participants who had chelation treatment and those who did not. Similarly, two studies (one in people with coronary artery disease and one in people with peripheral vascular disease) reported the chance of having a stroke, and found no clear difference in the chance of this between people who did or did not received chelation treatment. Two studies in people with peripheral vascular disease used an indirect measure of blood flow known as the ankle‐brachial pressure index (ABPI), or ankle brachial index. These studies did not show any differences in this measure between people who received chelation therapy for three or six months and those who did not get the treatment. There was also no clear differences in the distance participants could walk. We could not combine specific measures of quality of life in a single analysis. Looking at the two studies in people with coronary artery disease that reported this outcome, there was no difference in the quality of life reported by people who received chelation therapy and those who did not get the treatment. Two studies reported information about adverse events, but we could not combine this in a single analysis because they reported them in different ways and the events were different. However, the people who had chelation therapy did not appear to have any increase in either minor or major adverse events, compared with people who did not have the therapy. Certainty of the evidence We considered most of the data we found to be of low certainty, mostly because there were very few studies that provided data. Even though we included five studies, not all of them reported on each outcome. There is currently not enough evidence about the effects of chelation therapy on blockages in the blood vessels of people with atherosclerotic cardiovascular (heart and circulation) disease. Conclusions Overall, this review did not find any clear differences between people treated with chelation and people given the control, for the outcomes we evaluated. None of the outcomes included more than two studies, therefore it is difficult at this time to determine if these are true findings or just because there is not enough data. Further high‐quality trials that focus on clinical outcomes are necessary.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Villarruz-Sulit, MVanessa; Forster, R; Dans, AL; Tan, FN; Sulit, DV", "articleTypes": [], "doi": "10.1002/14651858.CD002785.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "6c60f204-623f-43fc-a27c-f5f181b0a5bf", "pmid": "", "title": "Pharmacological interventions for cognitive decline in people with Down syndrome", "imported": false, "abstract": "Abstract - Background People with Down syndrome are vulnerable to developing dementia at an earlier age than the general population. Alzheimer's disease and cognitive decline in people with Down syndrome can place a significant burden on both the person with Down syndrome and their family and carers. Various pharmacological interventions, including donepezil, galantamine, memantine and rivastigmine, appear to have some effect in treating cognitive decline in people without Down syndrome, but their effectiveness for those with Down syndrome remains unclear. Objectives To assess the effectiveness of anti‐dementia pharmacological interventions and nutritional supplements for treating cognitive decline in people with Down syndrome. Search methods In January 2015, we searched CENTRAL, ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), Ovid MEDLINE, Embase, PsycINFO, seven other databases, and two trials registers. In addition, we checked the references of relevant reviews and studies and contacted study authors, other researchers and relevant drug manufacturers to identify additional studies. Selection criteria Randomised controlled trials (RCTs) of anti‐dementia pharmacological interventions or nutritional supplements for adults (aged 18 years and older) with Down syndrome, in which treatment was administered and compared with either placebo or no treatment. Data collection and analysis Two review authors independently assessed the risk of bias of included trials and extracted the relevant data. Review authors contacted study authors to obtain missing information where necessary. Main results Only nine studies (427 participants) met the inclusion criteria for this review. Four of these (192 participants) assessed the effectiveness of donepezil, two (139 participants) assessed memantine, one (21 participants) assessed simvastatin, one study (35 participants) assessed antioxidants, and one study (40 participants) assessed acetyl‐L‐carnitine. Five studies focused on adults aged 45 to 55 years, while the remaining four studies focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one between Norway and the UK, and one in Japan. Follow‐up periods in studies ranged from four weeks to two years. The reviewers judged all included studies to be at low or unclear risk of bias. Analyses indicate that for participants who received donepezil, scores in measures of cognitive functioning (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) ‐0.27 to 1.13) and measures of behaviour (SMD 0.42, 95% CI ‐0.06 to 0.89) were similar to those who received placebo. However, participants who received donepezil were significantly more likely to experience an adverse event (odds ratio (OR) 0.32, 95% CI 0.16 to 0.62). The quality of this body of evidence was low. None of the included donepezil studies reported data for carer stress, institutional/home care, or death. For participants who received memantine, scores in measures of cognitive functioning (SMD 0.05, 95% CI ‐0.43 to 0.52), behaviour (SMD ‐0.17, 95% CI ‐0.46 to 0.11), and occurrence of adverse events (OR 0.45, 95% CI 0.18 to 1.17) were similar to those who received placebo. The quality of this body of evidence was low. None of the included memantine studies reported data for carer stress, institutional/home care, or death. Due to insufficient data, it was possible to provide a narrative account only of the outcomes for simvastatin, antioxidants, and acetyl‐L‐carnitine. Results from one pilot study suggest that participants who received simvastatin may have shown a slight improvement in cognitive measures. Authors' conclusions Due to the low quality of the body of evidence in this review, it is difficult to draw conclusions about the effectiveness of any pharmacological intervention for cognitive decline in people with Down syndrome. Plain language summary Medications for cognitive decline in people with Down syndrome People with Down syndrome often experience cognitive decline (a deterioration in memory, language, thinking and judgment that are greater than normal age‐related changes) at a younger age and in greater numbers than the general population. Various medicines have been shown to improve, or at least slow down the progression of these symptoms in people without Down syndrome. Review question Do adults (18 years and older) with Down syndrome benefit from treatment with medicine to prevent cognitive decline, compared with other adults with Down syndrome who receive either fake medicine (placebos) or no medicine? Study characteristics In January 2015, we, a team of Cochrane researchers, searched for all medical studies that investigated the effect of any medicine or nutritional supplement on cognitive decline in adults with Down syndrome. We found nine relevant randomised controlled trials (this design produces the most reliable results) that we could include in this overview. These studies tested: ‐ donepezil, a medicine used to treat Alzheimer's disease (four studies); ‐ memantine, a medicine used to treat Alzheimer's disease (two studies); ‐ simvastatin, a (statin) medicine used to prevent heart disease (one study); ‐ a mixture of antioxidants, including forms of vitamins C and E, and alpha‐lipoic acid (one study); and ‐ acetyl‐L‐carnitine, a dietary supplement that has previously been used to treat dementia (one study). Five of the studies focused on adults aged 45 to 55 years and four focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one took place in Norway and the UK, and one study was conducted in Japan. Key results The nine studies we found examined the effects of five medicines that are, or have been, used to prevent cognitive decline. All the studies compared the medicine being tested with a placebo (a tablet or capsule that looked and tasted like the medicine, but which contained no medicine). Generally, those who received the medicine did no better than those who received the placebo in any of the areas assessed in the studies. The areas assessed included general functioning (including memory and thinking, speech, mood and behaviour); cognitive functioning (including memory, following what’s going on around you); adaptive behaviours (being able to do day‐to‐day tasks); or behaviour problems (such as being irritable or aggressive). The only medicine to show any positive effect was the statin, simvastatin. Preliminary findings from a very small study showed that simvastin had some benefit on improving memory compared to placebo. In the four donepezil studies, those participants given donepezil reported more headaches, dizziness, and nausea than participants given placebo. In the two memantine studies, there was no difference between participants given memantine or placebo for reports of headaches, dizziness, and nausea. Quality of the evidence Although the included studies were well conducted, most involved small numbers of participants and for many of the areas assessed we could not combine results from two or more studies. Overall, the quality of this evidence is low. We cannot be certain whether any of these medicines are effective. Running more trials with more people over a longer period of time would allow us answer this question with greater certainty. We could not find any trials that investigated many of the medicines used to prevent cognitive decline, and so research is needed to explore the effectiveness of these medications in the Down syndrome population.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Livingstone, N, Hanratty, J, McShane, R, Macdonald, G", "articleTypes": [], "doi": "10.1002/14651858.CD011546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.816Z" }, { "id": "6c6f5371-5363-41b5-bc4d-85489bf3cf44", "pmid": "", "title": "Systemic administration of local anesthetic agents to relieve neuropathic pain", "imported": false, "abstract": "Abstract - Background Lidocaine, mexiletine, tocainide, and flecainide are local anesthetics which give an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain. Interest reappeared decades later when patient series and clinical trials reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients. With the recent publication of clinical trials with high quality standards, we have reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to update our knowledge, to measure their benefit and harm, and to better define their role in therapy. Objectives To evaluate pain relief and adverse effect rates between systemic local anesthetic‐type drugs and other control interventions. Search methods We searched MEDLINE (1966 through 15 May 2004), EMBASE (January 1980 to December 2002), Cancer Lit (through 15 December 2002), Cochrane Central Register of Controlled Trials (2nd Quarter, 2004), System for Information on Grey Literature in Europe (SIGLE), and LILACS, from January 1966 through March 2001. We also hand searched conference proceedings, textbooks, original articles and reviews. Selection criteria We included trials with random allocation, that were double blinded, with a parallel or crossover design. The control intervention was a placebo or an analgesic drug for neuropathic pain from any cause. Data collection and analysis We collected efficacy and safety data from all published and unpublished trials. We calculated combined effect sizes using continuous and binary data for pain relief and adverse effects as primary and secondary outcome measurements, respectively. Main results Thirty‐two controlled clinical trials met the selection criteria; two were duplicate articles. The treatment drugs were intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (one trial), and tocainide (one trial). Twenty‐one trials were crossover studies, and nine were parallel. Lidocaine and mexiletine were superior to placebo [weighted mean difference (WMD) = ‐11; 95% CI: ‐15 to ‐7; P < 0.00001], and limited data showed no difference in efficacy (WMD = ‐0.6; 95% CI: ‐7 to 6), or adverse effects versus carbamazepine, amantadine, gabapentin or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life‐threatening toxicities. Sensitivity analysis identified data distribution in three trials as a probable source of heterogeneity. There was no publication bias. Authors' conclusions Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. Future trials should enroll specific diseases and test novel lidocaine analogs with better toxicity profiles. More emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful. Plain language summary Systemic administration of local anesthetic agents to relieve neuropathic pain Intravenous lidocaine and oral derivatives relieve pain from damage to the nervous system (neuropathic pain). In early reports, intravenous lidocaine and its oral analogs mexiletine and tocainide relieved neuropathic pain, a type of pain caused by disease in the nervous system. However, the evidence was conflicting. The authors reviewed all randomized studies comparing these drugs with placebo or with other analgesics and found that: local anesthetics were superior to placebo in decreasing intensity of neuropathic pain; limited data showed no difference in efficacy or adverse effects between local anesthetics and carbamazepine, amantadine, gabapentin or morphine; local anesthetics had more adverse effects than placebo; and local anesthetics were safe.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Challapalli, V; Tremont-Lukats, IW; McNicol, ED; Lau, J; Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD003345.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "6c734b13-c521-4b65-aaa6-06760c76b4c9", "pmid": "", "title": "Micronutrient supplementation in pregnant women with HIV infection", "imported": false, "abstract": "Abstract - Background Micronutrient deficiencies are widespread and compound the effects of HIV disease; micronutrient supplements may be effective and safe in reducing this burden. Objectives To assess whether micronutrient supplements are effective and safe in reducing mortality and morbidity in pregnant and lactating women with HIV infection and their infants. Search methods The review has been updated three times since publication in 2005. In reviews prior to this update (2011), we searched the CENTRAL, EMBASE, PubMed, and GATEWAY databases to identify randomised controlled trials of micronutrient supplements using the search methods of the Cochrane HIV/AIDS Group. In the 2011 review the PubMed, EMBASE, and CENTRAL databases were searched in July 2011. As the GATEWAY database does not include conference abstracts after 2006, we also searched the AIDS‐specific conference database, www.aegis.org , and contacted researchers and organisations active in the field of research to identify additional unpublished trials. Selection criteria Randomised controlled trials were selected that compared the effects of micronutrient supplements (vitamins, trace elements, and combinations of these) with other supplements, placebo or no treatment on mortality, morbidity, pregnancy outcomes, immunologic indicators, and anthropometric measures in HIV‐positive pregnant and lactating women. Any adverse effects of supplementation were recorded. Data collection and analysis Two reviewer authors independently selected trials, appraised trial quality for risk of bias using standardised criteria, and extracted data using standardised forms. Where disagreements arose, a third author, acted as arbiter. Main results One additional trial is included in this update in addition to the three trials included in the 2010 update of the initial Cochrane review. Four relatively large, well‐conducted randomised controlled trials of the benefits of micronutrient supplementation have been conducted in pregnant and lactating women infected with HIV. Each of the trials evaluated a different micronutrient supplement and no direct comparisons or analyses can be made across the four trials. The four trials were conducted between 1995 and 2006. The trials have all been conducted by the same research team in Dar es Salaam in Tanzania, in an urban setting in hospital‐based antenatal clinics. Pregnant women were recruited with gestational age ranging from 12 to 27 weeks in each of the trials. Sample sizes range from 400 to 1129 with a median of 1000 participants. Three of the trials were placebo‐controlled. Different interventions have been evaluated in each trial, viz.:Vitamin A versus Vitamin A and multivitamins versus Multivitamins versus placebo; Selenium versus placebo; Zinc versus placebo; and Multiple RDA multivitamins versus Single RDA multivitamins. None of the women were receiving antiretrovrial therapy (ART). Multiple micronutrient supplements conferred multiple clinical benefits to pregnant women and their offspring. No significant adverse effects were reported. No significant clinical benefits were found from zinc supplementation of pregnant Tanzanian women. Selenium supplements given during and after pregnancy did not delay maternal HIV disease progression or improve pregnancy outcomes, but may improve child survival and decrease maternal diarrhoeal morbidity. There were no differences in maternal and infant outcomes when women received single RDA multivitamins or multiple RDA multivitamin supplementation. The evidence is lacking for the effects of micronutrient supplementation given concomitantly to pregnant women already initiated on antiretroviral therapy for treatment purposes. GRADE assessments were conducted on outcomes for each trial and included reviewing the data and the potential biases in each trial before grading the level of evidence. None of the trials were graded as providing high quality evidence primarily because there was no replication of results in other trials in other settings. Authors' conclusions In keeping with previous World Health Organization (WHO) recommendations everything possible should be done to promote and support adequate dietary intake of micronutrients, while recognising that this may not be sufficient to correct specific micronutrient deficiencies in all HIV‐infected individuals. Specific recommendations for pregnant and lactating women infected with HIV would be to include the provision of multivitamin supplements in single RDA formulations during the antenatal period and at least for 6 weeks post‐partum, especially for women who are breast‐feeding. There is no conclusive evidence to provide stand‐alone zinc or selenium supplementation to HIV‐infected pregnant and lactating women. Micronutrient supplementation should not be used as a substitute for provision of recommended antiretroviral medication for preventing mother‐to‐child transmission of HIV and treating maternal HIV infection when this is recommended. Further trials of single supplements are required to build the evidence base. The long‐term clinical benefits, adverse effects, and optimal formulation of multiple micronutrient supplements require further investigation in pregnant women at different stages of HIV infection. Plain language summary Micronutrient supplementation interventions to reduce harm in pregnant and lactating women living with HIV Micronutrients are vital components of a person’s daily food intake. Though only a small portion is necessary, a lack of micronutrients has been linked to tiredness, anaemia (low iron in blood), reduced learning ability, weaker immune system, and night blindness. In pregnant women, inadequate micronutrients have been shown to affect the development of the foetus and also the well‐being of the mother. In regions with high HIV prevalence, food availability may be scarce, which could lead to a double burden of disease in vulnerable/at‐risk populations. Specifically, pregnant and lactating women living with HIV may encounter the challenge of adequate food (including micronutrients) consumption, a weakened immune system, and the nutritional demands of a growing foetus or child. In this review, four randomised controlled trials, conducted between 1995 and 2006, assessed the benefits of micronutrient supplementation. The trials took place in an urban setting in hospital‐based antenatal clinics, with participants being pregnant women who ranged between 12‐27 weeks of their pregnancy, and sample sizes ranging from 400 to 1129 participants. Multiple micronutrient supplements improved the health of pregnant women and their offspring. No significant adverse effects were reported. Zinc supplementation did not show any significant beneficcial effects. Although it did not have any effect on the mother's pregnancy or her HIV disease, supplementation with selenium may increase the likelihood of a child surviving, and may reduce the likelihood of the mothers having diarrhoea. However, there is not enough evidence to determine the effect of micronutrient supplementation to pregnant women living with HIV who are being treated with antiretroviral medications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Siegfried, N; Irlam, JH; Visser, ME; Rollins, NN", "articleTypes": [], "doi": "10.1002/14651858.CD009755", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "6c79377e-d0c2-4db5-99ac-2dbb26ce0b55", "pmid": "", "title": "Antibiotic treatment for the sexual partners of women with bacterial vaginosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Amaya‐Guio, J, Viveros‐Carreño, DA, Sierra‐Barrios, EM, Martinez‐Velasquez, MY, Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD011701.pub2 AB - Abstract - Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of BV after antibiotic treatment. Therefore, the treatment of sexual partners could decrease the recurrence of infection and possibly the burden of the disease. Objectives To assess the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for BV. Search methods We searched the Cochrane Sexually Transmitted Infections Group Specialized Register (23 July 2016), CENTRAL (1991 to 23 July 2016), MEDLINE (1946 to 23 July 2016), Embase (1974 to 23 July 2016), LILACS (1982 to 23 July 2016), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (23 July 2016), ClinicalTrials.gov (23 July 2016) and the Web of Science™ (2001 to 23 July 2016). We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) that compared the concurrent use of any antibiotic treatment with placebo, no intervention or any other intervention by the sexual partners of women treated for BV. Data collection and analysis Three review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach. Main results Seven RCTs (1026 participants) met our inclusion criteria, and pharmaceutical industry funded four of these trials. Five trials (854 patients) compared any antibiotic treatment of sexual partners with placebo. Based on high quality evidence, antibiotic treatment does not increase the rate of clinical or symptomatic improvement in women during the first week (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.96 to 1.03; 712 participants, four studies; RR 1.06, 95% CI 1.00 to 1.12; 577 patients, three studies, respectively), between the first and fourth week (RR 1.02, 95% CI 0.94 to 1.11; 590 participants, three studies; RR 0.93, 95% CI 0.84 to 1.03; 444 participants, two studies; respectively) or after the fourth week (RR 0.98, 95% CI 0.90 to 1.07; 572 participants, four studies; RR 1.03, 95% CI 0.90 to 1.17; 296 participants, two studies; respectively). Antibiotic treatment does not led to a lower recurrence during the first and fourth week (RR 1.28, 95% CI 0.68 to 2.43; 218 participants, one study; low quality evidence) or after the fourth week of treatment (RR 1.00, 95% CI 0.67 to 1.52; 372 participants, three studies; low quality evidence) in women, but increases the frequency of adverse events (most frequently gastrointestinal symptoms) reported by sexual partners (RR 2.55, 95% CI 1.55 to 4.18; 477 participants, three studies; low quality evidence).
 
 Two trials (172 participants) compared any antibiotic treatment for sexual partners with no intervention. When we compared it with no intervention, the effects of antibiotic treatment on recurrence rate after the fourth week (RR 1.71, 95% CI 0.65 to 4.55; 51 participants, one study), clinical improvement between the first and fourth week (RR 0.93, 95% CI 0.70 to 1.25; 152 participants, two studies) and symptomatic improvement after the fourth week (RR 0.66, 95% CI 0.39 to 1.11; 70 participants, one study) were imprecise and there were no differences between groups. We downgraded the quality of the evidence to low or very low. Authors' conclusions High quality evidence shows that antibiotic treatment for sexual partners of women with BV, compared with placebo, does not increase the rate of clinical or symptomatic improvement during the first, between the first and fourth or after the fourth week into the women. Low quality evidence suggests that antibiotic treatment does not led to a lower recurrence rate during the first and fourth or after the fourth week of treatment into the women, but increases the frequency of adverse events reported by sexual partners. Finally, compared with no intervention, antibiotic treatment does not decrease the recurrence rate after the fourth week and does not increase the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week into the women, respectively. Plain language summary Antibiotic treatment for the sexual partners of women with bacterial vaginosis Review question We assessed the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for bacterial vaginosis (BV). Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of infection after antibiotic treatment. Therefore, the treatment of sexual partners could offer the advantages of decreasing the recurrence of infection and possibly reducing the burden of the disease. Trial characteristics Cochrane researchers searched the available literature up to the 23 July 2016 and included seven trials with 1026 participants. The trials included sexually‐active non‐pregnant women between 17 and 56 years of age, either single or married, with symptomatic BV. Four studies only included women involved into a monogamous heterosexual relationship and there was no information about this for the remaining trials. Six trials used 5‐nitroimidazoles to treat the sexual partner, four trials used metronidazole and two trials used tinidazole; only one study used a lincosamide for treatment. Five trials compared antibiotic versus placebo (854 participants) and two trials compared antibiotic treatment with no intervention (172 participants). Pharmaceutical companies funded four of the included trials. Key results Compared with placebo, antibiotic treatment for the sexual partners of women treated for BV had no effects on clinical or symptomatic improvement in women, regardless of the time period over which the trials assessed these outcomes (during the first, between the first and fourth, or after the fourth week). Furthermore, antibiotic treatment of the sexual partner may have no effect on the recurrence of BV up to 12 weeks after treatment, but may increase the frequency of minor adverse events reported by sexual partners. Compared with no intervention, treatment of sexual partners of women with BV may have no effect on decreasing the recurrence rate or over the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week, respectively. Quality of evidence The quality of evidence was high for the outcomes of clinical and symptomatic improvement. The quality of evidence was very low for recurrence due to some limitations regarding risk of bias and imprecision.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.078Z" }, { "id": "6c926dfe-995c-4b17-94ae-16a49ad93e13", "pmid": "", "title": "The Effect of Artificial Sweeteners on Blood Glucose Response", "imported": false, "abstract": "The purpose of this study is to determine whether the presece of the artificial sweeteners aspartame, saccharin and asceulfame-k affect the blood glucose responses to an orally incested glucose solution.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.146Z" }, { "id": "6ca48a46-ccb0-4d86-80ef-2e0578c9b430", "pmid": "", "title": "Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age‐inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long‐term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega‐3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents. Objectives To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents. Search methods We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references. Selection criteria We included randomised and quasi‐randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD. Data collection and analysis We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow‐up; and cost. We used GRADE to assess the certainty of evidence for each outcome. Main results We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross‐over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega‐3 PUFA, six used a combined omega‐3/omega‐6 supplement, and two used an omega‐6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co‐intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega‐3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega‐3 PUFA plus atomoxetine to atomoxetine; omega‐3 PUFA plus physical training to physical training; and an omega‐3 or omega‐6 supplement plus methylphenidate to methylphenidate; and two trials compared omega‐3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months. Although we found low‐certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high‐certainty evidence that PUFA had no effect on parent‐rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) −0.08, 95% CI −0.24 to 0.07; 16 studies, 1166 participants). There was also high‐certainty evidence that parent‐rated inattention (medium‐term: SMD −0.01, 95% CI −0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium‐term: SMD 0.09, 95% CI −0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo. There was moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate‐certainty evidence that medium‐term loss to follow‐up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants). Authors' conclusions Although we found low‐certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high‐certainty evidence that PUFA had no effect on total parent‐rated ADHD symptoms. There was also high‐certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups. We found moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate‐certainty evidence that follow‐up was similar between groups. It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times. Plain language summary Polyunsaturated fatty acids (PUFA) supplements for attention deficit hyperactivity disorder (ADHD) in children and adolescents What is ADHD? Attention deficit hyperactivity disorder (ADHD) is a common problem in children and adolescents. Those affected may struggle to concentrate, feel restless, or act on impulse. As a result of these difficulties, ADHD can cause long‐term social, academic, and mental health problems. Medicines are the most frequently used treatments for ADHD, but they are not always effective and can cause unwanted side effects. What are polyunsaturated fatty acids (PUFA)? Polyunsaturated fatty acids (PUFA) are a type of fat. They are necessary for normal brain development and are found in foods such as fish (omega‐3 PUFA) and vegetable oils (omega‐6 PUFA). How could PUFA be useful in ADHD? There is some evidence that ADHD could be related to low levels of PUFA, in particular omega‐3 PUFA. PUFA supplements may therefore improve ADHD symptoms, behavioural problems, and related mental health symptoms such as anxiety and depression. What did we want to find out? We wanted to know whether PUFA supplements improve ADHD symptoms in children and adolescents with ADHD. Although there were some limited data in the original review that suggested PUFA improved symptoms of ADHD, there is currently little evidence that PUFA supplementation is beneficial. It was important to update the evidence to incorporate new studies that have been published since the original review. What did we do? We searched for all trials that compared PUFA to placebo (dummy pill), medicines, or psychological or medical therapies in children or adolescents with ADHD. We searched 13 databases and two trials registers up to October 2021. What did we find? We found 24 new studies in this update, bringing the total number of studies included in the review to 37, which involved more than 2374 children and adolescents with ADHD. Seven studies were conducted in Iran; four each in the USA and Israel; two each in Australia, Canada, New Zealand, Sweden, and the UK; and one each in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Thirty‐six studies compared PUFA to placebo. Treatment with PUFA lasted between two weeks and six months. Although there was some evidence that PUFA could improve ADHD symptoms in children and adolescents, most of the evidence indicated that PUFA did not improve ADHD symptoms such as inattention or hyperactivity‐impulsivity. PUFA probably makes little to no difference to overall side effects or whether a person drops out of a study (i.e. does not complete it). How confident are we about what we found? We are confident that PUFA has no effect on ADHD symptoms when compared to placebo. Although there was some evidence that ADHD symptoms may be more likely to improve in children and adolescents receiving PUFA compared to those receiving placebo, we have little confidence in this finding. We are fairly confident that there are no differences between PUFA and placebo groups in overall side effects or dropout. Limitations of the analyses included small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Gillies, D, Leach, MJ, Perez Algorta, G", "articleTypes": [], "doi": "10.1002/14651858.CD007986.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.119Z" }, { "id": "6cbab778-618b-4bf0-85ee-2731d5e57130", "pmid": "", "title": "Pharmacological interventions for preventing dry mouth and salivary gland dysfunction following radiotherapy", "imported": false, "abstract": "Abstract - Background Salivary gland dysfunction is an 'umbrella' term for the presence of either xerostomia (subjective sensation of dryness), or salivary gland hypofunction (reduction in saliva production). It is a predictable side effect of radiotherapy to the head and neck region, and is associated with a significant impairment of quality of life. A wide range of pharmacological interventions, with varying mechanisms of action, have been used for the prevention of radiation‐induced salivary gland dysfunction. Objectives To assess the effects of pharmacological interventions for the prevention of radiation‐induced salivary gland dysfunction. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 14 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 14 September 2016); MEDLINE Ovid (1946 to 14 September 2016); Embase Ovid (1980 to 14 September 2016); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 14 September 2016); LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 14 September 2016); Zetoc Conference Proceedings (1993 to 14 September 2016); and OpenGrey (1997 to 14 September 2016). We searched the US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials, irrespective of their language of publication or publication status. Trials included participants of all ages, ethnic origin and gender, scheduled to receive radiotherapy on its own or in addition to chemotherapy to the head and neck region. Participants could be outpatients or inpatients. We included trials comparing any pharmacological agent regimen, prescribed prophylactically for salivary gland dysfunction prior to or during radiotherapy, with placebo, no intervention or an alternative pharmacological intervention. Comparisons of radiation techniques were excluded. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 39 studies that randomised 3520 participants; the number of participants analysed varied by outcome and time point. The studies were ordered into 14 separate comparisons with meta‐analysis only being possible in three of those. We found low‐quality evidence to show that amifostine, when compared to a placebo or no treatment control, might reduce the risk of moderate to severe xerostomia (grade 2 or higher on a 0 to 4 scale) at the end of radiotherapy (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.19 to 0.67; P = 0.001, 3 studies, 119 participants), and up to three months after radiotherapy (RR 0.66, 95% CI 0.48 to 0.92; P = 0.01, 5 studies, 687 participants), but there is insufficient evidence that the effect is sustained up to 12 months after radiotherapy (RR 0.70, 95% CI 0.40 to 1.23; P = 0.21, 7 studies, 682 participants). We found very low‐quality evidence that amifostine increased unstimulated salivary flow rate up to 12 months after radiotherapy, both in terms of mg of saliva per 5 minutes (mean difference (MD) 0.32, 95% CI 0.09 to 0.55; P = 0.006, 1 study, 27 participants), and incidence of producing greater than 0.1 g of saliva over 5 minutes (RR 1.45, 95% CI 1.13 to 1.86; P = 0.004, 1 study, 175 participants). However, there was insufficient evidence to show a difference when looking at stimulated salivary flow rates. There was insufficient (very low‐quality) evidence to show that amifostine compromised the effects of cancer treatment when looking at survival measures. There was some very low‐quality evidence of a small benefit for amifostine in terms of quality of life (10‐point scale) at 12 months after radiotherapy (MD 0.70, 95% CI 0.20 to 1.20; P = 0.006, 1 study, 180 participants), but insufficient evidence at the end of and up to three months postradiotherapy. A further study showed no evidence of a difference at 6, 12, 18 and 24 months postradiotherapy. There was low‐quality evidence that amifostine is associated with increases in: vomiting (RR 4.90, 95% CI 2.87 to 8.38; P < 0.00001, 5 studies, 601 participants); hypotension (RR 9.20, 95% CI 2.84 to 29.83; P = 0.0002, 3 studies, 376 participants); nausea (RR 2.60, 95% CI 1.81 to 3.74; P < 0.00001, 4 studies, 556 participants); and allergic response (RR 7.51, 95% CI 1.40 to 40.39; P = 0.02, 3 studies, 524 participants). We found insufficient evidence (that was of very low quality) to determine whether or not pilocarpine performed better or worse than a placebo or no treatment control for the outcomes: xerostomia, salivary flow rate, survival, and quality of life. There was some low‐quality evidence that pilocarpine was associated with an increase in sweating (RR 2.98, 95% CI 1.43 to 6.22; P = 0.004, 5 studies, 389 participants). We found insufficient evidence to determine whether or not palifermin performed better or worse than placebo for: xerostomia (low quality); survival (moderate quality); and any adverse effects. There was also insufficient evidence to determine the effects of the following interventions: biperiden plus pilocarpine, Chinese medicines, bethanechol, artificial saliva, selenium, antiseptic mouthrinse, antimicrobial lozenge, polaprezinc, azulene rinse, and Venalot Depot (coumarin plus troxerutin). Authors' conclusions There is some low‐quality evidence to suggest that amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months postradiotherapy). However, it is less clear whether or not this effect is sustained to 12 months postradiotherapy. The benefits of amifostine should be weighed against its high cost and side effects. There was insufficient evidence to show that any other intervention is beneficial. Plain language summary Drugs for preventing dry mouth and problems with saliva after radiotherapy Review question To assess the effects of treatment with drugs in order to prevent damage to salivary glands following radiotherapy to the head and neck Background Problems with saliva production and salivary glands are a significant and mostly permanent side effect for people after radiotherapy treatment to the head and neck. When this occurs the condition is known as dry mouth or xerostomia. Dry mouth is not measurable and is a subjective or personal expression of how the mouth feels. It can have other causes and is a consequence of the production of less saliva or by the consistency of saliva. The rate of flow of saliva in an individual's mouth however can be measured. People who have dry mouth have a reduced quality of life. They can experience issues with taste and general discomfort, difficulties chewing, swallowing and speaking as well as tooth decay, thrush and other infections of the mouth. A wide range of drugs that work in different ways have been used to try and prevent problems with salivary glands caused by radiotherapy. Unfortunately there is currently not enough evidence to show which drugs or which type of drugs are most effective. Study characteristics The evidence in this review is current up to 14 September 2016. 39 studies were included with a total of 3520 participants. Participants were male and female, all ages and ethnic origins, out patients or in patients, who were scheduled to have radiation therapy with or without chemotherapy to the head and neck. Drugs included were any prescribed to prevent salivary gland problems and given before or during radiotherapy. Information was collected from the end of radiotherapy except for that about adverse effects. Different techniques for giving radiation treatment that might reduce damage were not included. The main outcomes measured were participant's own assessment of dry mouth and the measurement of salivary flow. Secondary outcomes measured included adverse or unwanted effects such as sweating, crying, watery discharge from the nose, diarrhoea and nausea. Key results There is some low‐quality evidence to suggest that the drug amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months after radiotherapy). However it is less clear whether or not this effect is sustained to 12 months after radiotherapy. The benefits of amifostine should be weighed against its high costs and side effects. Adverse effects of vomiting, low blood pressure, feeling of sickness and allergic response were all more frequent in those receiving amifostine. There was insufficient evidence to show that any other treatment is beneficial. Quality of the evidence The quality of evidence for amifostine was found to be low because of risk of bias, inconsistency and imprecision caused by the small number of studies in the comparison or sample size. A standardized scale for measuring participant's experience of dry mouth would in future allow comparison and pooling together of results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P; Glenny, AM; Hua, F; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD012744", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "6ce3c9f9-c003-484e-bca1-7815bd771e34", "pmid": "", "title": "Interventions for the prevention of recurrent erysipelas and cellulitis", "imported": false, "abstract": "Abstract - Background Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. Objectives To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. Search methods We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. Selection criteria Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. Data collection and analysis Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. Main results We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study. Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow‐up period of up to one and a half to two years. Four studies were single‐centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria. Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate. Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate‐certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate‐certainty evidence). The protective effects of antibiotic did not last after prophylaxis had been stopped ('post‐prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty. Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years. We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay. The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin). None of the included studies assessed the development of antimicrobial resistance or quality‐of‐life measures. With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. Authors' conclusions In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate‐certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low‐certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low‐certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high‐quality studies are warranted, including long‐term follow‐up and other prophylactic measures. Plain language summary Preventive treatments for repeated episodes of cellulitis and erysipelas Background Cellulitis and erysipelas are both bacterial infections of the skin that most commonly affect the leg. Erysipelas affects the upper layers of the skin, and cellulitis affects its deeper parts, but in practice it is often hard to tell the difference between them, so we consider them together for this review (and refer to them as 'cellulitis'). Up to 50% of people with cellulitis experience repeated episodes. Despite the burden of this condition, there is a lack of high‐certainty, evidence‐based information about the desirable treatment for the prevention of recurrent cellulitis. Review question What are the best available treatments to prevent repeated episodes of cellulitis in adults aged over 16 years compared to no treatment, placebo, another intervention, or the same intervention with a different plan of treatment, and what are their side effects? Study characteristics We searched relevant databases and registers up to June 2016. We identified six trials, with 573 participants, who had an average age between 50 and 70. Both genders were included, but there were nearly twice as many women. Five trials used antibiotic treatment (four penicillin and one erythromycin), which was compared to either no treatment or placebo, and one trial used selenium compared to physiological salt solution. Treatments lasted from six to 18 months. The most common setting was the hospital, and two studies were multicentre. The studies were conducted in the UK, Sweden, Tunisia, Israel, and Austria. There was a small number of previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes in each study. The antibiotic trials assessed prevention with antibiotics in people with cellulitis of the legs, and the selenium trial assessed people with cellulitis of the arms. Key results Our main outcome was prevention of repeated episodes of cellulitis. Our other outcomes included the number of repeated attacks of cellulitis, time to next attack, hospitalisation, quality of life, development of antibiotic resistance, adverse reactions and death. Combining the results of all five trials that used antibiotics, we found moderate‐certainty evidence that for those people under preventative treatment, antibiotic treatment in general, and penicillin in particular, is probably both effective and safe for the prevention of repeated episodes of leg cellulitis when compared with no treatment or placebo. The analyses showed that, compared with no treatment or placebo, taking antibiotics decreased the risk of future episodes by 69%, reduced their number by more than 50%, and significantly reduced the rate until the next attack (moderate‐certainty evidence). However, we found low‐certainty evidence that the protective effect of antibiotics for these three outcomes tailed off over time after treatment had been stopped. In addition, the beneficial effect of antibiotics was relevant for people with at least two past episodes of cellulitis within a time frame of up to three years. We found low‐certainty evidence that there is no difference between antibiotics and no treatment/placebo for side effects and hospitalisation. The evidence did not allow for full exploration of the treatment's effect on length of hospital stay. No serious adverse effects were reported, and common side effects included diarrhoea, nausea, rash (severe skin adverse reactions were not reported) and thrush. In three studies, adverse effects caused those taking part to stop taking the antibiotic. Three people taking erythromycin had abdominal pain and nausea, causing them to stop taking the treatment and to take penicillin instead. In one study, two people withdrew from treatment with penicillin because of diarrhoea or nausea. In another study, because of pain at the site of injection, around 10% of those taking part stopped taking intramuscular injections of benzathine penicillin. None of the included studies measured quality of life or the development of antibiotic resistance. Certainty of evidence Evidence for the effects of antibiotics compared with no treatment or placebo on the recurrence, incidence rate and time to next episode of cellulitis under preventive treatment was of moderate certainty, and was limited by the small number of participants and events. Evidence for the remaining reported outcomes was of low certainty for the same reasons, as well as imprecise results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Dalal, A, Eskin‐Schwartz, M, Mimouni, D, Ray, S, Days, W, Hodak, E, Leibovici, L, Paul, M", "articleTypes": [], "doi": "10.1002/14651858.CD009758.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.786Z" }, { "id": "6ce99156-de01-40bf-bda9-2f72acf146b5", "pmid": "", "title": "Cannabinoids for Tourette's Syndrome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Curtis, A, Clarke, CE, Rickards, HE", "articleTypes": [], "doi": "10.1002/14651858.CD006565.pub2 AB - Abstract - Background Gilles de la Tourette Syndrome (GTS) is a developmental neuropsychiatric disorder characterised by the presence of chronic motor and phonic tics. Drugs currently used in the treatment of GTS either lack efficacy or are associated with intolerable side effects. There is some anecdotal and experimental evidence that cannabinoids may be effective in treating tics and compulsive behaviour in patients with GTS. There are currently no systematic Cochrane reviews of treatments used in GTS. There is one other Cochrane review being undertaken at present, on the use of fluoxetine for tics in GTS. Objectives To evaluate the efficacy and safety of cannabinoids as compared to placebo or other drugs in treating tics, premonitory urges and obsessive compulsive symptoms (OCS), in patients with GTS. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (in The Cochrane Library Issue 4 2008) , MEDLINE (January 1996 to date), EMBASE (January 1974 to date), PsycINFO (January 1887 to date), CINAHL (January 1982 to date), AMED (January 1985 to date), British Nursing Index (January 1994 to date) and DH DATA (January 1994 to date). 
 
 We also searched the reference lists of located trials and review articles for further information. Selection criteria We included randomised controlled trials (RCTs) comparing any cannabinoid preparation with placebo or other drugs used in the treatment of tics and OCS in patients with GTS. Data collection and analysis Two authors abstracted data independently and settled any differences by discussion. Main results Only two trials were found that met the inclusion criteria. Both compared a cannabinoid, delta‐9‐Tetrahydrocannabinol (Δ 9 THC), either as monotherapy or as adjuvant therapy, with placebo. One was a double blind, single dose crossover trial and the other was a double blind, parallel group study. A total of 28 different patients were studied. Although both trials reported a positive effect from Δ 9 THC, the improvements in tic frequency and severity were small and were only detected by some of the outcome measures. Authors' conclusions Not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome. Plain language summary Cannabinoids for Tourette syndrome Cannabinoid medication might be useful in the treatment of the symptoms in patients with Tourette's syndrome. At the present time only two relevant studies have been conducted. Both studies used tetrahydrocannabinol (Δ 9 THC). In both studies Δ 9 THC was associated with tic reduction. However the sample size was small and a large number of multiple comparisons were made . There were only 28 participants in total, since eight participants took part in both studies. Possibly the patients who derived the greatest benefit and experienced the least adverse effects would be the most inclined to participate in further studies. There were a high number of drop outs/exclusions in the six week study and it is unclear whether intention to treat analysis (ITT) was performed. The results that are reported are analyses done on the patients who remained in the study on the study medication at the correct dose. In reality, patients do opt not to continue treatment if there is limited efficacy or unpalatable side effects. This introduces attrition bias. Whilst there were some significant results, the authors themselves accept that very few of these results are significant if a Bonferroni correction is performed. It is possible that cannabinoid medication has a beneficial effect which is too weak to be detected using ITT and such a small sample size. There is some weak evidence that cannabinoid medication may have an effect on obsessive compulsive behaviour but the measure used was an addition to the TSSL which has not been validated.There were no data on the effect of Δ 9 THC on quality of life.There is not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.756Z" }, { "id": "6cf2bee2-649e-43b1-8fec-048426fa5b87", "pmid": "", "title": "Interventions for American cutaneous and mucocutaneous leishmaniasis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Pinart, M, Rueda, J-R, Romero, GAS, Pinzón-Flórez, CE, Osorio-Arango, K, Silveira Maia-Elkhoury, AN, Reveiz, L, Elias, VM, Tweed, JA", "articleTypes": [], "doi": "10.1002/14651858.CD004834.pub3 AB - Abstract - Background On the American continent, cutaneous and mucocutaneous leishmaniasis (CL and MCL) are diseases associated with infection by several species of Leishmania parasites. Pentavalent antimonials remain the first‐choice treatment. There are alternative interventions, but reviewing their effectiveness and safety is important as availability is limited. This is an update of a Cochrane Review first published in 2009. Objectives To assess the effects of interventions for all immuno‐competent people who have American cutaneous and mucocutaneous leishmaniasis (ACML). Search methods We updated our database searches of the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and CINAHL to August 2019. We searched five trials registers. Selection criteria Randomised controlled trials (RCTs) assessing either single or combination treatments for ACML in immuno‐competent people, diagnosed by clinical presentation and Leishmania infection confirmed by smear, culture, histology, or polymerase chain reaction on a biopsy specimen. The comparators were either no treatment, placebo only, or another active compound. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our key outcomes were the percentage of participants 'cured' at least three months after the end of treatment, adverse effects, and recurrence. We used GRADE to assess evidence certainty for each outcome. Main results We included 75 studies (37 were new), totalling 6533 randomised participants with ATL. The studies were mainly conducted in Central and South America at regional hospitals, local healthcare clinics, and research centres. More male participants were included (mean age: roughly 28.9 years (SD: 7.0)). The most common confirmed species were L. braziliensis , L. panamensis , and L. mexicana . The most assessed interventions and comparators were non‐antimonial systemics (particularly oral miltefosine) and antimonials (particularly meglumine antimoniate (MA), which was also a common intervention), respectively. Three studies included moderate‐to‐severe cases of mucosal leishmaniasis but none included cases with diffuse cutaneous or disseminated CL, considered the severe cutaneous form. Lesions were mainly ulcerative and located in the extremities and limbs. The follow‐up (FU) period ranged from 28 days to 7 years. All studies had high or unclear risk of bias in at least one domain (especially performance bias). None of the studies reported the degree of functional or aesthetic impairment, scarring, or quality of life. Compared to placebo, at one‐year FU, intramuscular (IM) MA given for 20 days to treat L. braziliensis and L. panamensis infections in ACML may increase the likelihood of complete cure (risk ratio (RR) 4.23, 95% confidence interval (CI) 0.84 to 21.38; 2 RCTs, 157 participants; moderate‐certainty evidence), but may also make little to no difference, since the 95% CI includes the possibility of both increased and reduced healing (cure rates), and IMMA probably increases severe adverse effects such as myalgias and arthralgias (RR 1.51, 95% CI 1.17 to 1.96; 1 RCT, 134 participants; moderate‐certainty evidence). IMMA may make little to no difference to the recurrence risk, but the 95% CI includes the possibility of both increased and reduced risk (RR 1.79, 95% CI 0.17 to 19.26; 1 RCT, 127 participants; low‐certainty evidence). Compared to placebo, at six‐month FU, oral miltefosine given for 28 days to treat L. mexicana , L. panamensis and L. braziliensis infections in American cutaneous leishmaniasis (ACL) probably improves the likelihood of complete cure (RR 2.25, 95% CI 1.42 to 3.38), and probably increases nausea rates (RR 3.96, 95% CI 1.49 to 10.48) and vomiting (RR 6.92, 95% CI 2.68 to 17.86) (moderate‐certainty evidence). Oral miltefosine may make little to no difference to the recurrence risk (RR 2.97, 95% CI 0.37 to 23.89; low‐certainty evidence), but the 95% CI includes the possibility of both increased and reduced risk (all based on 1 RCT, 133 participants). Compared to IMMA, at 6 to 12 months FU, oral miltefosine given for 28 days to treat L. braziliensis , L. panamensis , L. guyanensis and L. amazonensis infections in ACML may make little to no difference to the likelihood of complete cure (RR 1.05, 95% CI 0.90 to 1.23; 7 RCTs, 676 participants; low‐certainty evidence). Based on moderate‐certainty evidence (3 RCTs, 464 participants), miltefosine probably increases nausea rates (RR 2.45, 95% CI 1.72 to 3.49) and vomiting (RR 4.76, 95% CI 1.82 to 12.46) compared to IMMA. Recurrence risk was not reported. For the rest of the key comparisons, recurrence risk was not reported, and risk of adverse events could not be estimated. Compared to IMMA, at 6 to 12 months FU, oral azithromycin given for 20 to 28 days to treat L. braziliensis infections in ACML probably reduces the likelihood of complete cure (RR 0.51, 95% CI 0.34 to 0.76; 2 RCTs, 93 participants; moderate‐certainty evidence). Compared to intravenous MA (IVMA) and placebo, at 12 month FU, adding topical imiquimod to IVMA, given for 20 days to treat L. braziliensis , L. guyanensis and L. peruviana infections in ACL probably makes little to no difference to the likelihood of complete cure (RR 1.30, 95% CI 0.95 to 1.80; 1 RCT, 80 participants; moderate‐certainty evidence). Compared to MA, at 6 months FU, one session of local thermotherapy to treat L. panamensis and L. braziliensis infections in ACL reduces the likelihood of complete cure (RR 0.80, 95% CI 0.68 to 0.95; 1 RCT, 292 participants; high‐certainty evidence). Compared to IMMA and placebo, at 26 weeks FU, adding oral pentoxifylline to IMMA to treat CL (species not stated) probably makes little to no difference to the likelihood of complete cure (RR 0.86, 95% CI 0.63 to 1.18; 1 RCT, 70 participants; moderate‐certainty evidence). Authors' conclusions Evidence certainty was mostly moderate or low, due to methodological shortcomings, which precluded conclusive results. Overall, both IMMA and oral miltefosine probably result in an increase in cure rates, and nausea and vomiting are probably more common with miltefosine than with IMMA. Future trials should investigate interventions for mucosal leishmaniasis and evaluate recurrence rates of cutaneous leishmaniasis and its progression to mucosal disease. Plain language summary What are the benefits and risks of different treatments for American (muco)cutaneous leishmaniasis (a parasitic disease of the skin and mucous membranes)? Why this question is important American (muco)cutaneous leishmaniasis (ACML) is a disfiguring disease that affects people in Central and South America. It is caused by parasites that are transmitted to humans by sandflies. Different forms of ACML have different symptoms. People with the cutaneous form develop skin sores that often heal within a few months without treatment, but can leave scars. In people with mucosal or mucocutaneous leishmaniasis, destructive sores develop in the protective lining (mucous membranes) of the nose, mouth and throat. To compare the effectiveness and risks of the many treatments for ACML, we reviewed evidence from research studies (randomised controlled trials). We looked for information on the proportion of people whose sores had healed three months or more after treatment, unwanted effects, quality of life, re‐appearance of sores, damage associated with the disease and prevention of scarring. How we identified and assessed the evidence First, we searched for all relevant studies. We then compared the results, summarised the evidence, and assessed the certainty of the evidence. What we found We found 75 studies on 6533 people (approximately 75% male; average age: 29 years). ‐ One study investigated children (2 to 12 years).
‐ Most studies (67) involved people with cutaneous leishmaniasis.
‐ Eight studies investigated people with mucosal or mucocutaneous leishmaniasis.
‐ The parasite Leishmania braziliensis caused the disease in 52 studies.
‐ Studies were conducted at regional hospitals, local clinics, and research centres.
‐ Studies lasted between 28 days and seven years.
‐ Most studies reported their funding source: the US army funded eight studies, industry funded 10, and institutional grants funded 33 (five of these also reported industry funding). Treatments were mainly compared to a placebo (fake treatment) or meglumine antimoniate (an antimonial). Here we report this review's main results. We were only able to report the risk of recurrence and side effects for the comparisons of meglumine antimoniate (MA) or miltefosine versus placebo and miltefosine versus MA. Main results Antimonials Compared to placebo, MA may increase chances of complete healing of ACML, but treatment effects vary, so it is possible that it may make little to no difference. MA probably increases the likelihood of pain in the muscles or joints. There may be little to no difference in the risk of developing the disease again, but there is also a possibility of increased or reduced risk due to the wide range of effects seen. Non‐antimonials Miltefosine probably improves chances of complete healing of American cutaneous leishmaniasis (ACL) compared to placebo, but there may be little to no difference compared to treatment with MA in ACML. Miltefosine may make little to no difference to the risk of developing ACL again when compared to placebo, but treatment effects on recurrence varied, so it may also increase or decrease the risk. Miltefosine probably increases the likelihood of vomiting or nausea when compared to either placebo or MA in ACML. We do not know the effect on recurrence of miltefosine compared to MA. Azithromycin probably reduces chances of complete healing of ACML compared to MA. Imiquimod in combination with MA probably makes little to no difference to the chance of complete healing of ACL compared to MA in combination with placebo. Physical therapies Thermotherapy lowers the chance of complete healing of ACL compared to MA. Immuno‐chemotherapy Pentoxifylline plus MA probably makes little to no difference to chances of complete healing of ACML compared with MA plus placebo. No study reported information about damage, prevention of scarring, or quality of life. What this means The main findings of this review suggest that: ‐ MA and miltefosine probably increase chances of complete healing; and
‐ vomiting or nausea are probably more common with miltefosine, and joint or muscle ache is probably more common with MA. The evidence was mostly of moderate certainty, so the true results are likely close to what we found. Evidence was limited by the inclusion of very few people in some studies, and participants or investigators knowing which treatments they were receiving. How‐up‐to date is this review? The evidence in this Cochrane Review is current to August 2019.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.125Z" }, { "id": "6d0043e3-b717-44bc-aded-4e97d58be551", "pmid": "", "title": "The Role of Bitter Taste Receptors Expressed in the Gastrointestinal Tract in Altering Food Intake and Gastrointestinal Motility", "imported": false, "abstract": "In this study, the investigators aimed at evaluating the role of bitter taste receptors in the gastrointestinal tract (GIT). Intragastric or intraduodenal administration of denatonium benzoate (DB) or quinine hydrochloride were compared with placebo administration for their effects on lingual sensitivity, gastrointestinal motility (both in the fasted and fed state), gut hormone release (motilin, ghrelin, glucagon-like peptide-1 (GLP-1) and cholecystokinin (CCK)) and food intake. Differences between lean and obese subjects will be evaluated.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.233Z" }, { "id": "6d1cae12-0f7e-45dd-bb06-936918320333", "pmid": "", "title": "Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010. For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established. Objectives To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications. Search methods Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012. Selection criteria Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Data collection and analysis Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information. Main results One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012. Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study. Weight loss was greater for the NG group at six weeks post‐treatment than for the PEG group (P = 0.001). At six months post‐treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post‐treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively. We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review. Authors' conclusions There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required. Plain language summary Artificial tube feeding methods for use with patients with head and neck cancer who are receiving treatment with radiotherapy, chemotherapy or both Patients with cancer of the head and neck are at risk of malnutrition during radiotherapy treatment due to the side effects of this treatment and they may need tube feeding to meet their nutritional needs. Tube feeding can either be delivered via a nasogastric feeding tube, which is a fine tube inserted through the nose into the stomach, or a gastrostomy tube which is inserted through the skin of the abdomen directly into the stomach. Both of these methods allow the delivery of nutrients directly into the stomach. Tube feeding is essential to meet the nutritional needs of head and neck cancer patients as malnutrition can lead to a poorer prognosis for this patient group. There is debate over which method of tube feeding provides the most benefit to the patient for outcomes such as nutritional benefit and quality of life, as well as avoiding delays in radiotherapy treatment. Following our analysis of the available literature, only one clinical trial was eligible to be included in this review. The authors of this review found no evidence to support the use of any one method of tube feeding over another.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Nugent, B, Lewis, S, O'Sullivan, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007904.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.742Z" }, { "id": "6d3211d0-860e-4207-9f00-911e51e8bc6f", "pmid": "", "title": "Chinese medicinal herbs for cholelithiasis", "imported": false, "abstract": "Abstract - Background Cholelithiasis is a common disease of the biliary tract. Chinese medicinal herbs are being used widely as an alternative treatment in people with cholelithiasis, but their beneficial or harmful effects have not been assessed systematically. Objectives To assess the beneficial and harmful effects of Chinese medicinal herbs in people with cholelithiasis. Search methods We conducted searches in the Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, Science Citation Index Expanded, Chinese Medicine Conference Disc, and Chinese Bio‐Medicine Disc to January 2013. We handsearched four Chinese journals. No language or year of publication restrictions were applied. Selection criteria Randomised clinical trials studying Chinese medicinal herbs for treatment of cholelithiasis. Data collection and analysis Two review authors (SJ, TG) independently extracted data. For dichotomous data, we estimated the risk ratio (RR), and for continuous data, we calculated the mean difference. We also calculated 95% confidence intervals (CI). Main results Eleven randomised trials with 1205 participants with asymptomatic or mild‐to‐moderate cholelithiasis were included. None of the randomised clinical trials compared a single Chinese medicinal herb with a Western medicine or with surgery. No placebo‐controlled trials were identified. In the trials comparing one Chinese herbal medicine (Gandanxiaoshi tablet) versus another (Aihuodantong tablet), there was no significant difference in the improvement of upper abdominal pain after the end of treatment (RR 1.21; 95% CI 0.71 to 2.05), and the heterogeneity among trials was not substantial. No other outcomes could be assessed. The remaining trials of Chinese medicinal herbs (Qingdan capsule, Danshu capsule, Paishi capsule, Rongdanpaishi capsule), did not offer specific data on symptoms, signs, or change in gallstones that would permit assessment of significant differences in curative effects between the treatment and control groups. No serious adverse events were reported. Authors' conclusions This review reveals no strong evidence that the analysed Chinese medicinal herbs have any beneficial effects on asymptomatic or mild‐to‐moderate cholelithiasis. Definitive conclusions will require much better designed randomised trials to reduce risk of bias and allow detailed assessment of clinical outcomes. Plain language summary Chinese medicinal herbs for cholelithiasis Cholelithiasis (gallstone disease) causes significant morbidity, severe complications, and economic burden worldwide. Though current surgical therapies are effective for gallstones, some types of gallstones (e.g., calcium bilirubinate calculi) cannot easily be eradicated by surgery and they often recur in the bile duct system, putting people at high risk of severe complications. The objective of this review was to evaluate the benefits and harms of Chinese medicinal herbs for people with cholelithiasis. Though some Chinese medicinal herbs appear to be safe for people with asymptomatic, mild, or moderate disease, they have not been conclusively shown to have curative effects on gallstones due to the low methodological quality (high risk of bias) of the included trials. Thus, randomised clinical trials with low risk of bias should be conducted to assess the effects of Chinese medicinal herbs before they can be used widely in the clinic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Gan, T; Chen, J; Jin, SJ; Wang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD004547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "6d5e4dbd-92e4-4d39-bbaf-e5eba1b14ca8", "pmid": "", "title": "Could Docosahexaenoic Acid (DHA), Contained in Breast Milk and Artificial Baby Milks, Protect Infants and Children From COVID-19 and Make Them Less Prone to COVID-19-related Severe Illness Than Adults?", "imported": false, "abstract": "Could Docosahexaenoic Acid (DHA) Protect Infants and Children From COVID-19 and Make Them Less Susceptible to COVID-19-related Severe Illness Than Adults?", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.250Z" }, { "id": "6d923c87-4fb9-42ad-b902-ccbad074fb7b", "pmid": "", "title": "Adverse events in people taking macrolide antibiotics versus placebo for any indication", "imported": false, "abstract": "Abstract - Background Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment‐specific, rather than disease‐specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases. Objectives To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides. Selection criteria We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups. Data collection and analysis Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide‐resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta‐analysis when three or more included studies reported a specific adverse event. Main results We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events or at least stated that no adverse events were observed. Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low‐quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low‐quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate‐quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate‐quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate‐quality evidence) were also reported more often in participants taking macrolides compared to placebo. The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000. The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting. There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration. Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low‐quality evidence). Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low‐quality evidence). We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low‐quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low‐quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low‐quality evidence) compared to placebo. We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo. Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate‐quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate‐quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate‐quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non‐significant. There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low‐quality evidence). Only 24 studies (13%) provided useful data on macrolide‐resistant bacteria. Macrolide‐resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent. Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials. Authors' conclusions The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as \"none were observed\". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance. Plain language summary Adverse events in people taking macrolide antibiotics Review question We wanted to find out if people treated with a macrolide antibiotic experienced more adverse events than those treated with placebo. Background Macrolide antibiotics are a group of antibiotics that are commonly used to treat both acute and chronic infections. The four most frequently used macrolides are: azithromycin, clarithromycin, erythromycin, and roxithromycin. People taking macrolide antibiotics are at risk of experiencing adverse events such as nausea, diarrhoea, or rash. Search date We searched the literature up to May 2018. Study characteristics We included 183 studies with a total of 252,886 participants. Most studies were conducted in the hospital setting. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events, or at least stated that no adverse events were observed. Study funding sources Drug companies supplied trial medications or funding, or both, in 91 studies. Funding sources were unclear in 59 studies. Key results People treated with a macrolide antibiotic experienced gastrointestinal adverse events such as nausea, vomiting, abdominal pain, and diarrhoea more often than those treated with placebo. Taste disturbances were reported more often by people taking macrolides than those taking a placebo. However, as very few studies reported on these adverse events, these results should be interpreted with caution. Hearing loss was reported more often by people taking macrolide antibiotics, however only four studies reported this outcome. Macrolides caused less cough and fewer respiratory tract infections than placebo. We did not find any evidence that macrolides caused more cardiac disorders, liver disorders, blood infections, skin and soft tissue infections, changes in liver enzymes, appetite loss, dizziness, headache, respiratory symptoms, itching, or rashes than placebo. We did not find more deaths in people treated with macrolides than in those treated with placebo. Very limited information was available to assess if people treated with a macrolide antibiotic were at greater risk of developing resistant bacteria than those treated with placebo. However, bacteria that did not respond to macrolide antibiotics were more commonly identified immediately after treatment in people taking a macrolide than in those taking a placebo, but differences in resistance thereafter were inconsistent. Quality of the evidence The quality of the evidence ranged from very low (cardiac disorders, change in liver enzymes, liver disorders) to low (abdominal pain, death, diarrhoea, dizziness, hearing loss, skin and soft tissue infections, taste disturbance, wheeze) to moderate (appetite loss, blood infection, cough, fever, headache, itching, nausea, rash, respiratory symptoms, respiratory tract infections, vomiting).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hansen, MP; Scott, AM; McCullough, A; Thorning, S; Aronson, JK; Beller, EM; Glasziou, PP; Hoffmann, TC; Clark, J; Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD011825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "6dbb2164-56ab-47a0-b33c-a9c0a335b482", "pmid": "", "title": "Nutritional labelling for healthier food or non‐alcoholic drink purchasing and consumption", "imported": false, "abstract": "Abstract - Background Nutritional labelling is advocated as a means to promote healthier food purchasing and consumption, including lower energy intake. Internationally, many different nutritional labelling schemes have been introduced. There is no consensus on whether such labelling is effective in promoting healthier behaviour. Objectives To assess the impact of nutritional labelling for food and non‐alcoholic drinks on purchasing and consumption of healthier items. Our secondary objective was to explore possible effect moderators of nutritional labelling on purchasing and consumption. Search methods We searched 13 electronic databases including CENTRAL, MEDLINE and Embase to 26 April 2017. We also handsearched references and citations and sought unpublished studies through websites and trials registries. Selection criteria Eligible studies: were randomised or quasi‐randomised controlled trials (RCTs/Q‐RCTs), controlled before‐and‐after studies, or interrupted time series (ITS) studies; compared a labelled product (with information on nutrients or energy) with the same product without a nutritional label; assessed objectively measured purchasing or consumption of foods or non‐alcoholic drinks in real‐world or laboratory settings. Data collection and analysis Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of bias' tool and GRADE to assess the quality of evidence. We pooled studies that evaluated similar interventions and outcomes using a random‐effects meta‐analysis, and we synthesised data from other studies in a narrative summary. Main results We included 28 studies, comprising 17 RCTs, 5 Q‐RCTs and 6 ITS studies. Most (21/28) took place in the USA, and 19 took place in university settings, 14 of which mainly involved university students or staff. Most (20/28) studies assessed the impact of labelling on menus or menu boards, or nutritional labelling placed on, or adjacent to, a range of foods or drinks from which participants could choose. Eight studies provided participants with only one labelled food or drink option (in which labelling was present on a container or packaging, adjacent to the food or on a display board) and measured the amount consumed. The most frequently assessed labelling type was energy (i.e. calorie) information (12/28). Eleven studies assessed the impact of nutritional labelling on purchasing food or drink options in real‐world settings, including purchases from vending machines (one cluster‐RCT), grocery stores (one ITS), or restaurants, cafeterias or coffee shops (three RCTs, one Q‐RCT and five ITS). Findings on vending machines and grocery stores were not interpretable, and were rated as very low quality. A meta‐analysis of the three RCTs, all of which assessed energy labelling on menus in restaurants, demonstrated a statistically significant reduction of 47 kcal in energy purchased (MD −46.72 kcal, 95% CI −78.35, −15.10, N = 1877). Assuming an average meal of 600 kcal, energy labelling on menus would reduce energy purchased per meal by 7.8% (95% CI 2.5% to 13.1%). The quality of the evidence for these three studies was rated as low, so our confidence in the effect estimate is limited and may change with further studies. Of the remaining six studies, only two (both ITS studies involving energy labels on menus or menus boards in a coffee shop or cafeteria) were at low risk of bias, and their results support the meta‐analysis. The results of the other four studies which were conducted in a restaurant, cafeterias (2 studies) or a coffee shop, were not clearly reported and were at high risk of bias. Seventeen studies assessed the impact of nutritional labels on consumption in artificial settings or scenarios (henceforth referred to as laboratory studies or settings). Of these, eight (all RCTs) assessed the effect of labels on menus or placed on a range of food options. A meta‐analysis of these studies did not conclusively demonstrate a reduction in energy consumed during a meal (MD −50 kcal, 95% CI −104.41, 3.88, N = 1705). We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. Six laboratory studies (four RCTs and two Q‐RCTs) assessed the impact of labelling a single food or drink option (such as chocolate, pasta or soft drinks) on energy consumed during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant difference in energy (kcal) consumed (SMD 0.05, 95% CI −0.17 to 0.27, N = 732). However, the confidence intervals were wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. There was no evidence that nutritional labelling had the unintended harm of increasing energy purchased or consumed. Indirect evidence came from five laboratory studies that involved mislabelling single nutrient content (i.e. placing low energy or low fat labels on high‐energy foods) during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant increase in energy (kcal) consumed (SMD 0.19, 95% CI −0.14to 0.51, N = 718). The effect was small and the confidence intervals wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence from these studies as very low, providing very little confidence in the effect estimate. Authors' conclusions Findings from a small body of low‐quality evidence suggest that nutritional labelling comprising energy information on menus may reduce energy purchased in restaurants. The evidence assessing the impact on consumption of energy information on menus or on a range of food options in laboratory settings suggests a similar effect to that observed for purchasing, although the evidence is less definite and also of low quality. Accordingly, and in the absence of observed harms, we tentatively suggest that nutritional labelling on menus in restaurants could be used as part of a wider set of measures to tackle obesity. Additional high‐quality research in real‐world settings is needed to enable more certain conclusions. Further high‐quality research is also needed to address the dearth of evidence from grocery stores and vending machines and to assess potential moderators of the intervention effect, including socioeconomic status. Plain language summary Nutritional labelling to promote healthier consumption and purchasing of food or drinks A poor diet including excessive energy intake is an important cause of ill health. Nutritional labelling may help people to make healthier food choices. What is the aim of this review? This review investigated whether nutritional labels (i.e. labels providing information about nutritional content) persuade people to buy or consume different (healthy) kinds of food. We searched for all available evidence to answer this question and found 28 studies. Key messages There is evidence to suggest that nutritional labelling, with energy information (e.g. calorie counts) on menus, may reduce energy purchased in restaurants, but more high‐quality studies are needed to make this finding more certain. What was studied in the review? Some studies assessed buying food or drinks from vending machines, grocery stores, restaurants, cafeterias, or coffee shops. Others assessed the amount of food or drink consumed during a snack or meal in an artificial setting or scenario (referred to as laboratory studies or settings). What are the main results of the review? Nutritional labelling on restaurant menus reduced the amount of energy (i.e. calories) purchased, but the quality of the three studies that contributed to this finding was low, so our confidence in the effect estimate is limited and may change with further studies. Eight studies assessed this same type of intervention in laboratory settings, but instead of evaluating how much energy participants purchased, these studies evaluated how much energy participants consumed. These studies did not conclusively demonstrate a reduction in energy consumed when menus or foods were labelled, and they were also of low quality. In addition, six laboratory studies assessed how much energy participants consumed when they were given one food or drink option with or without labels, and five laboratory studies assessed how much energy participants consumed when foods were experimentally labelled as low energy or low fat when they were actually high‐energy foods (i.e. mislabelling). Results from these two groups of studies were inconclusive and of low, or in the case of mislabelling studies, very low quality. We found some studies that assessed labelling on vending machines and grocery stores, but their results were not easy to interpret, so we could not use them to inform this review. How up‐to‐date is this review? The evidence is current to 26 April 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Crockett, RA, King, SE, Marteau, TM, Prevost, AT, Bignardi, G, Roberts, NW, Stubbs, B, Hollands, GJ, Jebb, SA", "articleTypes": [], "doi": "10.1002/14651858.CD009315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.787Z" }, { "id": "6dde81d5-c141-4c88-bf42-de8c755ae6c9", "pmid": "", "title": "Triclosan/copolymer containing toothpastes for oral health", "imported": false, "abstract": "Abstract - Background Periodontal disease and dental caries are highly prevalent oral diseases that can lead to pain and discomfort, oral hygiene and aesthetic problems, and eventually tooth loss, all of which can be costly to treat and are a burden to healthcare systems. Triclosan is an antibacterial agent with low toxicity, which, along with a copolymer for aiding retention, can be added to toothpastes to reduce plaque and gingivitis (inflammation of the gums). It is important that these additional ingredients do not interfere with the anticaries effect of the fluoride present in toothpastes, and that they are safe. Objectives To assess the effects of triclosan/copolymer containing fluoride toothpastes, compared with fluoride toothpastes, for the long‐term control of caries, plaque and gingivitis in children and adults. Search methods We searched the Cochrane Oral Health's Trials Register (to 19 August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 7), MEDLINE via OVID (1946 to 19 August 2013), Embase via OVID (1980 to 19 August 2013), and the US National Institutes of Health Trials Register ( clinicaltrials.gov ) (to 19 August 2013). We applied no restrictions regarding language or date of publication in the searches of the electronic databases. Selection criteria We included randomised controlled trials (RCTs) assessing the effects triclosan/copolymer containing toothpastes on oral health. Data collection and analysis Two review authors independently assessed the search results against the inclusion criteria for this review, extracted data and carried out risk of bias assessments. We attempted to contact study authors for missing information or clarification when feasible. We combined sufficiently similar studies in meta‐analyses using random‐effects models when there were at least four studies (fixed‐effect models when fewer than four studies), reporting mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data. Main results We included 30 studies, analysing 14,835 participants, in this review. We assessed 10 studies (33%) as at low risk of bias, nine (30%) as at high risk of bias and 11 (37%) as unclear. Plaque Compared with control, after six to seven months of use, triclosan/copolymer toothpaste reduced plaque by 0.47 on a 0 to 5 scale (MD ‐0.47, 95% confidence interval (CI) ‐0.60 to ‐0.34, 20 studies, 2675 participants, moderate‐quality evidence). The control group mean was 2.17, representing a 22% reduction in plaque. After six to seven months of use, it also reduced the proportion of sites scoring 3 to 5 on a 0 to 5 scale by 0.15 (MD ‐0.15, 95% CI ‐0.20 to ‐0.10, 13 studies, 1850 participants, moderate‐quality evidence). The control group mean was 0.37, representing a 41% reduction in plaque severity. Gingivitis After six to nine months of use, triclosan/copolymer toothpaste reduced inflammation by 0.27 on a 0 to 3 scale (MD ‐0.27, 95% CI ‐0.33 to ‐0.21, 20 studies, 2743 participants, moderate‐quality evidence). The control group mean was 1.22, representing a 22% reduction in inflammation. After six to seven months of use, it reduced the proportion of bleeding sites (i.e. scoring 2 or 3 on the 0 to 3 scale) by 0.13 (MD ‐0.13, 95% CI ‐0.17 to ‐0.08, 15 studies, 1998 participants, moderate‐quality evidence). The control group mean was 0.27, representing a 48% reduction in bleeding. Periodontitis After 36 months of use, there was no evidence of a difference between triclosan/copolymer toothpaste and control in the development of periodontitis (attachment loss) (RR 0.92, 95% CI 0.67 to 1.27, one study, 480 participants, low‐quality evidence). Caries After 24 to 36 months of use, triclosan/copolymer toothpaste slightly reduced coronal caries when using the decayed and filled surfaces (DFS) index (MD ‐0.16, 95% CI ‐0.31 to ‐0.02, four studies, 9692 participants, high‐quality evidence). The control group mean was 3.44, representing a 5% reduction in coronal caries. After 36 months of use, triclosan/copolymer toothpaste probably reduced root caries (MD ‐0.31, 95% CI ‐0.39 to ‐0.23, one study, 1357 participants, moderate‐quality evidence). Calculus After six months of use, triclosan/copolymer toothpaste may have reduced the mean total calculus per participant by 2.12 mm (MD ‐2.12 mm, 95% CI ‐3.39 to ‐0.84, two studies, 415 participants, low‐quality evidence). The control group mean was 14.61 mm, representing a 15% reduction in calculus. Adverse effects There were no data available for meta‐analysis regarding adverse effects, but 22 studies (73%) reported that there were no adverse effects caused by either the experimental or control toothpaste. There was considerable heterogeneity present in the meta‐analyses for plaque, gingivitis and calculus. Plaque and gingivitis showed such consistent results that it did not affect our conclusions, but the reader may wish to interpret the results with more caution. Authors' conclusions There was moderate‐quality evidence showing that toothpastes containing triclosan/copolymer, in addition to fluoride, reduced plaque, gingival inflammation and gingival bleeding when compared with fluoride toothpastes without triclosan/copolymer. These reductions may or may not be clinically important, and are evident regardless of initial plaque and gingivitis levels, or whether a baseline oral prophylaxis had taken place or not. High‐quality evidence showed that triclosan/copolymer toothpastes lead to a small reduction in coronal caries. There was weaker evidence to show that triclosan/copolymer toothpastes may have reduced root caries and calculus, but insufficient evidence to show whether or not they prevented periodontitis. There do not appear to be any serious safety concerns regarding the use of triclosan/copolymer toothpastes in studies up to three years in duration. Plain language summary Triclosan/copolymer containing toothpastes for oral health Review question This Cochrane Review has been conducted to assess the effects of using a toothpaste containing triclosan (an antibacterial ingredient) plus copolymer (an ingredient to reduce the amount of triclosan that is washed away by rinsing or saliva) plus fluoride (a mineral that prevents tooth decay) compared with using a fluoride toothpaste (without triclosan/copolymer) for oral health. Background Gum disease and dental decay are the main reasons for tooth loss. Unless brushed away, plaque (a sticky film containing bacteria) can build up on the teeth. This can lead to gingivitis (a swelling and redness of the gums that affects most adults), which, if not treated, can then lead to a more serious form of gum disease called periodontitis (which affects up to one out of every five adults aged 35 to 44 years worldwide). Periodontitis can cause pain, eating difficulties, an unpleasant facial appearance and eventually tooth loss. Plaque build‐up can also lead to tooth decay, a problem affecting up to 90% of schoolchildren in industrialised countries, and the majority of adults. Vast healthcare resources are used worldwide to treat gum disease and tooth decay, which are both preventable. Currently there is a lot of ongoing research into possible links between periodontitis and other medical conditions such as diabetes, rheumatoid arthritis, heart disease and also to the premature (too early) birth of underweight babies. Adding an effective and safe antibacterial ingredient to toothpastes could be an easy and low‐cost answer to these problems. It is thought that triclosan could fight the harmful bacteria in plaque while also reducing the swelling that leads to serious gum disease. It is important that adding triclosan to fluoride toothpastes does not reduce the beneficial effects that fluoride has on preventing tooth decay. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 19 August 2013. It includes 30 studies published from 1990 to 2012 in which 14,835 participants were randomised to receive a triclosan/copolymer containing fluoride toothpaste or a fluoride toothpaste that did not include triclosan/copolymer. The toothpaste that was used in most of the studies is sold by the manufacturer Colgate. Key results The evidence produced shows benefits in using a triclosan/copolymer fluoride toothpaste when compared with a fluoride toothpaste (without triclosan/copolymer). There was a 22% reduction in plaque, a 22% reduction in gingivitis, a 48% reduction in bleeding gums and a 5% reduction in tooth decay. There was insufficient evidence to show a difference between either toothpaste in preventing periodontitis. There was no evidence of any harmful effects associated with the use of triclosan/copolymer toothpastes in studies up to three years in length. Quality of the evidence The evidence relating to plaque and gingivitis was considered to be of moderate quality. The evidence on tooth decay was high quality, while the evidence on periodontitis was low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Riley, P; Lamont, T", "articleTypes": [], "doi": "10.1002/14651858.CD010514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "6de41146-5dac-4403-b873-fdac2e4bed78", "pmid": "", "title": "Interventions for increasing fruit and vegetable consumption in children aged five years and under", "imported": false, "abstract": "Abstract - Background Insufficient consumption of fruits and vegetables in childhood increases the risk of future non‐communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child‐feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden. Objectives To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. Search methods We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials. Selection criteria We included randomised controlled trials (RCTs), including cluster‐randomised controlled trials (C‐RCTs) and cross‐over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no‐intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random‐effects models in meta‐analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures. Main results We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child‐feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child‐focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate‐certainty evidence that child‐feeding practice interventions versus no‐intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as‐desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post‐intervention follow‐up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low‐certainty evidence). Multicomponent interventions versus no‐intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate‐certainty evidence; mean post‐intervention follow‐up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden‐based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low‐certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short‐term impact on child consumption of fruit and vegetables versus no‐intervention control (SMD 0.10, 95% CI ‐0.02 to 0.22; 14 trials, 4122 participants; low‐certainty evidence; mean post‐intervention follow‐up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low‐certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low‐certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding. Authors' conclusions There was moderate‐certainty evidence that child‐feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low‐ and middle‐income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. Plain language summary What are the benefits and harms of interventions to increase eating of fruit and vegetables among children aged five years and under? Key messages • Child‐feeding interventions probably lead to a small increase in eating of vegetables in children aged five years and under. • Multicomponent interventions probably lead to a small increase in eating of fruit and vegetables in children aged five years and under. • Parent nutrition education interventions may lead to little or no increase in eating of fruit and vegetables in children aged five years and under. Why is eating enough fruit and vegetables important? Not eating enough fruit and vegetables leads to a considerable health burden in developed countries. Eating adequate amounts of fruit and vegetables is associated with a reduced risk of future non‐communicable diseases (such as heart and circulatory disease) amongst other immediate health benefits. Early childhood is a critical period for the establishment of dietary habits that track into adulthood. Interventions to increase consumption of fruit and vegetables in early childhood may therefore be an effective strategy to reduce this disease burden. What did we want to find out? We wanted to know the benefits and harms of interventions designed to increase eating of fruit or vegetables or both amongst children aged five years and under. What did we do? We searched various electronic databases to find studies. We contacted the authors of the included studies for additional potentially relevant studies. Any randomised study (where participants have the same chance of being assigned to treatment or a no‐treatment control) of interventions aiming to increase the intake of fruit or vegetables or both by children aged five years and under, which measured intake, was eligible. Two review authors independently searched for and extracted information from studies. We searched up to March 2023. What did we find? We included 53 studies with 12,350 people taking part. Sixteen studies examined child‐feeding practice interventions (e.g. repeated exposure to vegetables); 20 examined multicomponent interventions (e.g. combining two or more interventions, such as preschool policy changes with parent nutrition education); 17 examined parent nutrition education interventions; two examined child nutrition education interventions; and one each examined child‐focused mindfulness or providing families with fruit and vegetable interventions. Child‐feeding practice interventions and multicomponent interventions probably lead to small increases in children's intake of fruit and vegetables in the short term (less than 12 months). Parent nutrition education interventions may lead to little to no increase in children's eating of fruit and vegetables. Limited information was available on cost and unintended harms. Of the studies that did report these, intervention costs ranged from 325 to 1500 US dollars (USD). No unintended harms were found in the two studies that reported assessing them. Studies reporting funding support received governmental or charitable funds, except for one study that received industry funding. What are the limitations of the evidence? No studies were conducted in low‐income countries and only one study was conducted in a middle‐income country. Our confidence in the current evidence is moderate for child feeding and multicomponent interventions, and low for parent nutrition education interventions. How up‐to‐date is this evidence? This evidence is up‐to‐date to March 2023. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Hodder, RK; O'Brien, KM; Wyse, RJ; Tzelepis, F; Yoong, S; Stacey, FG; Wolfenden, L", "articleTypes": [], "doi": "10.1002/14651858.CD008552.pub8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "6e0b2356-99c1-4486-9691-b700915619ae", "pmid": "", "title": "Physical therapy for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Bell's palsy (idiopathic facial paralysis) is commonly treated by various physical therapy strategies and devices, but there are many questions about their efficacy. Objectives To evaluate physical therapies for Bell's palsy (idiopathic facial palsy). Search methods We searched the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2011), MEDLINE (January 1966 to February 2011), EMBASE (January 1946 to February 2011), LILACS (January 1982 to February 2011), PEDro (from 1929 to February 2011), and CINAHL (January 1982 to February 2011). We included searches in clinical trials register databases until February 2011. Selection criteria We selected randomised or quasi‐randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention. Data collection and analysis Two authors independently scrutinised titles and abstracts identified from the search results. Two authors independently carried out risk of bias assessments, which took into account secure methods of randomisation, allocation concealment, observer blinding, patient blinding, incomplete outcome data, selective outcome reporting and other bias. Two authors independently extracted data using a specially constructed data extraction form. We undertook separate subgroup analyses of participants with more and less severe disability. Main results For this update to the original review, the search identified 65 potentially relevant articles. Twelve studies met the inclusion criteria (872 participants). Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies compared or combined some form of physical therapy with acupuncture (360 participants). For most outcomes we were unable to perform meta‐analysis because the interventions and outcomes were not comparable. For the primary outcome of incomplete recovery after six months, electrostimulation produced no benefit over placebo (moderate quality evidence from one study with 86 participants). Low quality comparisons of electrostimulation with prednisolone (an active treatment) (149 participants), or the addition of electrostimulation to hot packs, massage and facial exercises (22 participants), reported no significant differences. Similarly a meta‐analysis from two studies, one of three months and the other of six months duration (142 participants) found no statistically significant difference in synkinesis, a complication of Bell's palsy, between participants receiving electrostimulation and controls. A single low quality study (56 participants), which reported at three months, found worse functional recovery with electrostimulation (mean difference (MD) 12.00 points (scale of 0 to 100) 95% confidence interval (CI) 1.26 to 22.74). Two trials of facial exercises, both at high risk of bias, found no difference in incomplete recovery at six months when exercises were compared to waiting list controls or conventional therapy. There is evidence from a single small study (34 participants) of moderate quality that exercises are beneficial on measures of facial disability to people with chronic facial palsy when compared with controls (MD 20.40 points (scale of 0 to 100), 95% CI 8.76 to 32.04) and from another single low quality study with 145 people with acute cases treated for three months, in which significantly fewer participants developed facial motor synkinesis after exercise (risk ratio 0.24, 95% CI 0.08 to 0.69). The same study showed statistically significant reduction in time for complete recovery, mainly in more severe cases (47 participants, MD ‐2.10 weeks, 95% CI ‐3.15 to ‐1.05) but this was not a prespecified outcome in this meta analysis. Acupuncture studies did not provide useful data as all were short and at high risk of bias. None of the studies included adverse events as an outcome. Authors' conclusions There is no high quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. There is low quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases. There is low quality evidence that facial exercise reduces sequelae in acute cases. The suggested effects of tailored facial exercises need to be confirmed with good quality randomised controlled trials. Plain language summary Physical treatments for idiopathic facial paralysis Bell's palsy is an acute disorder of the facial nerve, which produces full or partial loss of movement on one side of the face. The facial palsy gets completely better without treatment in most, but not all, people. Physical therapies, such as exercise, biofeedback, laser treatment, electrotherapy, massage and thermotherapy, are used to hasten recovery, improve facial function and minimise sequelae. For this updated review we found a total of 12 studies with 872 participants, most with high risk of bias. Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies combined some form of physical therapy and compared with acupuncture (360 participants). There is evidence from a single study of moderate quality that exercises are beneficial to people with chronic facial palsy when compared with controls and from another low quality study that it is possible that facial exercises could help to reduce synkinesis (a complication of Bell's palsy), and the time to recover. There is insufficient evidence to decide whether electrical stimulation works, to identify risks of these treatments or to assess whether the addition of acupuncture to facial exercises or other physical therapy could produce improvement. In conclusion, tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases, and early facial exercise may reduce recovery time and long term paralysis in acute cases, but the evidence for this is of poor quality. More trials are needed to assess the effects of facial exercises and any risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Teixeira, LJ, Valbuza, JS, Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006283.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.779Z" }, { "id": "6e258ac3-d5c9-4f82-b68e-607c6023c565", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 1. Commonly‐used classes of drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres ( ˜ 8200 feet ). Acute hypoxia, acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude. In this review, the first in a series of three about preventive strategies for HAI, we assess the effectiveness of six of the most recommended classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of commonly‐used pharmacological interventions for preventing acute HAI. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), LILACS and trial registries in January 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text terms to search. Selection criteria We included randomized‐controlled and cross‐over trials conducted in any setting where commonly‐used classes of drugs were used to prevent acute HAI. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Main results We included 64 studies (78 references) and 4547 participants in this review, and classified 12 additional studies as ongoing. A further 12 studies await classification, as we were unable to obtain the full texts. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. Risks of bias were unclear for several domains, and a considerable number of studies did not report adverse events of the evaluated interventions. We found 26 comparisons, 15 of them comparing commonly‐used drugs versus placebo. We report results for the three most important comparisons: Acetazolamide versus placebo (28 parallel studies; 2345 participants) The risk of AMS was reduced with acetazolamide (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.56; I 2 = 0%; 16 studies; 2301 participants; moderate quality of evidence). No events of HAPE were reported and only one event of HACE (RR 0.32, 95% CI 0.01 to 7.48; 6 parallel studies; 1126 participants; moderate quality of evidence). Few studies reported side effects for this comparison, and they showed an increase in the risk of paraesthesia with the intake of acetazolamide (RR 5.53, 95% CI 2.81 to 10.88, I 2 = 60%; 5 studies, 789 participants; low quality of evidence). Budenoside versus placebo (2 parallel studies; 132 participants) Data on budenoside showed a reduction in the incidence of AMS compared with placebo (RR 0.37, 95% CI 0.23 to 0.61; I 2 = 0%; 2 studies, 132 participants; low quality of evidence). Studies included did not report events of HAPE or HACE, and they did not find side effects (low quality of evidence). Dexamethasone versus placebo (7 parallel studies; 205 participants) For dexamethasone, the data did not show benefits at any dosage (RR 0.60, 95% CI 0.36 to 1.00; I2 = 39%; 4 trials, 176 participants; low quality of evidence). Included studies did not report events of HAPE or HACE, and we rated the evidence about adverse events as of very low quality. Authors' conclusions Our assessment of the most commonly‐used pharmacological interventions suggests that acetazolamide is an effective pharmacological agent to prevent acute HAI in dosages of 250 to 750 mg/day. This information is based on evidence of moderate quality. Acetazolamide is associated with an increased risk of paraesthesia, although there are few reports about other adverse events from the available evidence. The clinical benefits and harms of other pharmacological interventions such as ibuprofen, budenoside and dexamethasone are unclear. Large multicentre studies are needed for most of the pharmacological agents evaluated in this review, to evaluate their effectiveness and safety. Plain language summary Drugs commonly‐used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and breathing conditions that can occur while travelling to altitudes above 2500 metres ( ˜ 8200 feet ). HAI is generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but may affect the brain or the lungs in different individuals. In this review, we assessed the most commonly‐used drugs to prevent the onset of this illness. Study characteristics The evidence is current to January 2017. We included 64 studies related to six different types of drugs recommended for HAI prevention. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. The participants' ages ranged between 16 and 65 years. Eleven studies included people at a high risk of this condition due to their history of HAI or other illnesses such as asthma. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. In 23 of the included studies, the source of funding was unclear. Only 18 studies declared their possible conflicts of interests. We classed 24 more studies as still ongoing or waiting for assessment. Key results Our findings suggest that acetazolamide is an effective treatment for the prevention of acute HAI in dosages of 250 to 750 mg/day, when this drug is compared to a placebo (i.e. a pill with no active agent). Most of the available information relates to the prevention of uncomplicated HAI (headache, nausea, vomiting and tiredness) rather than to more serious brain or lung problems. We also found that acetazolamide is associated with an increased risk of paraesthesia in the fingers (i.e. a sensation of tingling, tickling, pricking, or burning of the skin), although this outcome is not well reported in the available evidence. The benefits and harms of other drugs such as ibuprofen, budenoside and dexamethasone are unclear, due to the small number of studies. Quality of the evidence We rated the quality of the evidence as moderate to very low. Several studies had quality shortcomings, including their use of small numbers of participants and a lack of reporting of important outcomes such as side effects. For most of the drugs covered by the studies, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Nieto Estrada, VH; Molano Franco, D; Medina, RD; Gonzalez Garay, AG; Martí‐Carvajal, AJ; Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD009761.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "6e4724b9-e3af-4762-9584-81328290853c", "pmid": "", "title": "Interventions for fatigue in peripheral neuropathy", "imported": false, "abstract": "Abstract - Background Persistent feelings of fatigue (or subjective fatigue), which may be experienced in the absence of physiological factors, affect many people with peripheral neuropathy. A variety of interventions for subjective fatigue are available, but little is known about their efficacy or the likelihood of any adverse effects for people with peripheral neuropathy. Objectives To assess the effects of drugs and physical, psychological or behavioural interventions for fatigue in adults or children with peripheral neuropathy. Search methods On 5 November 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, CINAHL Plus, LILACS and AMED. We also searched reference lists of all studies identified for inclusion and relevant reviews, and contacted the authors of included studies and known experts in the field to identify additional published or unpublished data. We also searched trials registries for ongoing studies. Selection criteria We considered for inclusion randomised controlled trials (RCTs) and quasi‐RCTs comparing any form of intervention for fatigue management in adults with peripheral neuropathy with placebo, no intervention or an alternative form of intervention for fatigue. Interventions considered included drugs, pacing and grading of physical activity, general or specific exercise, compensatory strategies such as orthotics, relaxation, counselling, cognitive and educational strategies. Data collection and analysis Two review authors independently assessed risk of bias and extracted study data. We contacted study authors for additional information. We collected information on adverse events from the included trials. Main results The review includes three trials, which were all at low risk of bias, involving 530 people with peripheral neuropathy. The effects of amantadine from one randomised, double‐blind, placebo‐controlled, cross‐over trial comparing amantadine with placebo for the treatment of fatigue in 80 people with Guillain‐Barré syndrome (GBS) were uncertain for the proportion of people achieving a favourable outcome six weeks post‐intervention (odds ratio (OR) 0.56 (95% confidence interval (CI) 0.22 to 1.35, N = 74, P = 0.16). We assessed the quality of this evidence as low. Two parallel‐group randomised double‐blind, placebo‐controlled trials comparing the effects of two doses of ascorbic acid with placebo for reducing fatigue in adults with Charcot‐Marie‐Tooth disease type 1A (CMT1A) showed that the effects of ascorbic acid at either dose are probably small (standardised mean difference (SMD) ‐0.12 (95% CI ‐0.32 to 0.08, n = 404, P = 0.25)) for change in fatigue after 12 to 24 months (moderate quality evidence). Neither ascorbic acid study measured fatigue at four to 12 weeks, which was our primary outcome measure. No serious adverse events were reported with amantadine. Serious adverse events were reported in the trials of ascorbic acid. However,risk of serious adverse events was similar with ascorbic acid and placebo. Authors' conclusions One small imprecise study in people with GBS showed uncertain effects of amantadine on fatigue. In two studies in people with CMT1A there is moderate‐quality evidence that ascorbic acid has little meaningful benefit on fatigue. Information about adverse effects was limited, although both treatments appear to be well tolerated and safe in these conditions. There was no evidence available from RCTs to evaluate the effect of other drugs or other interventions for fatigue in either GBS, CMT1A or other causes of peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future randomised clinical trials. Plain language summary Treatments for fatigue in peripheral neuropathy Review question To assess the effects of treatments for fatigue in people with peripheral neuropathy. Background Peripheral neuropathy is damage to the nerves outside the brain and spinal cord. Many people with peripheral neuropathy have feelings of severe tiredness (fatigue) that are not necessarily related to physical problems such as muscle weakness. Evidence in other long‐term illnesses where fatigue is a problem suggests that medicines and other forms of treatment may help. The aim of this review was to assess the effect of drugs and other treatments, such as general or specific exercise, orthotics (devices such as braces), relaxation, counselling and cognitive, behavioural and educational strategies on feelings of fatigue in people with peripheral neuropathy. Study characteristics From a wide search, we identified three RCTs that met our selection criteria. The trials involved a total of 530 adults with peripheral neuropathy. Treatments were ascorbic acid (vitamin C) in people with Charcot‐Marie‐Tooth disease in two trials, and amantadine in Guillain‐Barré syndrome in the third. Charcot‐Marie‐Tooth disease is an inherited nerve disease and Guillain‐Barré syndrome is a condition where there is inflammation of the peripheral nerves. We chose measures of fatigue at four to 12 weeks as our preferred measure of the effects of treatment. The amantadine trial but not the ascorbic acid trials provided data at this time point; the ascorbic acid trials provided data more than 12 months after the start of the intervention. Key results and quality of the evidence There was insufficient evidence to determine the effects of amantadine when compared with an inactive treatment (placebo) for fatigue. and there were no major unwanted effects. We found evidence that ascorbic acid probably has little meaningful benefit for fatigue. No major unwanted effects were identified, but the trials were small. We assessed the quality of this evidence as moderate because the results were imprecise, which means they do not rule out the possibility that the drugs could have an effect. We found no evidence from RCTs on other medicines or treatments for fatigue in peripheral neuropathy. There is insufficient evidence to determine the effect of amantadine for fatigue in GBS and ascorbic acid for fatigue in CMT1A. More high‐quality studies are needed to provide evidence on which to base management of feelings of fatigue in peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future RCTs. The evidence in this review is current to November 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "White, CM; van Doorn, PA; Garssen, MPJ; Stockley, RC", "articleTypes": [], "doi": "10.1002/14651858.CD008146.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "6e4c54e5-edb4-4fa3-98a2-c39b33d305ff", "pmid": "", "title": "Zinc for prevention and treatment of the common cold", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Nault, D, Machingo, TA, Shipper, AG, Antiporta, DA, Hamel, C, Nourouzpour, S, Konstantinidis, M, Phillips, E, Lipski, EA, Wieland, LS", "articleTypes": [], "doi": "10.1002/14651858.CD014914.pub2 AB - Abstract - Background The common cold is an acute, self‐limiting viral respiratory illness. Symptoms include nasal congestion and mucus discharge, sneezing, sore throat, cough, and general malaise. Given the frequency of colds, they are a public health burden and a significant cause of lost work productivity and school absenteeism. There are no established interventions to prevent colds or shorten their duration. However, zinc supplements are commonly recommended and taken for this purpose. Objectives To assess the effectiveness and safety of zinc for the prevention and treatment of the common cold. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and LILACS to 22 May 2023, and searched Web of Science Core Collection and two trials registries to 14 June 2023. We also used reference checking, citation searching, and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) in children or adults that tested any form of zinc against placebo to prevent or treat the common cold or upper respiratory infection (URTI). We excluded zinc interventions in which zinc was combined with other minerals, vitamins, or herbs (e.g. a multivitamin, or mineral supplement containing zinc). Data collection and analysis We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We independently extracted data. When necessary, we contacted study authors for additional information. We assessed zinc (type and route) with placebo in the prevention and treatment of the common cold. Primary outcomes included the proportion of participants developing colds (for analyses of prevention trials only), duration of cold (measured in days from start to resolution of the cold), adverse events potentially due to zinc supplements (e.g. unpleasant taste, loss of smell, vomiting, stomach cramps, and diarrhoea), and adverse events considered to be potential complications of the common cold (e.g. respiratory bacterial infections). Main results We included 34 studies (15 prevention, 19 treatment) involving 8526 participants. Twenty‐two studies were conducted on adults and 12 studies were conducted on children. Most trials were conducted in the USA (n = 18), followed by India, Indonesia, Iran, and Turkey (two studies each), and Australia, Burkina Faso, Colombia, Denmark, Finland, Tanzania, Thailand, and the UK (one study each). The 15 prevention studies identified the condition as either common cold (n = 8) or URTI (n = 7). However, almost all therapeutic studies (17/19) focused on the common cold. Most studies (17/34) evaluated the effectiveness of zinc administered as lozenges (3 prevention; 14 treatment) in acetate, gluconate, and orotate forms; gluconate lozenges were the most common (9/17). Zinc gluconate was given at doses between 45 and 276 mg/day for between 4.5 and 21 days. Five (5/17) lozenge studies gave acetate lozenges and two (2/17) gave both acetate and gluconate lozenges. One (1/17) lozenge study administered intranasal ( gluconate ) and lozenge ( orotate ) zinc in tandem for cold treatment. Of the 17/34 studies that did not use lozenges, 1/17 gave capsules, 3/17 administered dissolved powders, 5/17 gave tablets, 4/17 used syrups, and 4/17 used intranasal administration. Most studies were at unclear or high risk of bias in at least one domain. There may be little or no reduction in the risk of developing a cold with zinc compared to placebo (risk ratio (RR) 0.93, 95% CI 0.85 to 1.01; I 2 = 20%; 9 studies, 1449 participants; low‐certainty evidence). There may be little or no reduction in the mean number of colds that occur over five to 18 months of follow‐up (mean difference (MD) ‐0.90, 95% CI ‐1.93 to 0.12; I 2 = 96%; 2 studies, 1284 participants; low‐certainty evidence). When colds occur, there is probably little or no difference in the duration of colds in days (MD ‐0.63, 95% CI ‐1.29 to 0.04; I² = 77%; 3 studies, 740 participants; moderate‐certainty evidence), and there may be little or no difference in global symptom severity (standardised mean difference (SMD) 0.04, 95% CI ‐0.35 to 0.43; I² = 0%; 2 studies, 101 participants; low‐certainty evidence). When zinc is used for cold treatment, there may be a reduction in the mean duration of the cold in days (MD ‐2.37, 95% CI ‐4.21 to ‐0.53; I² = 97%; 8 studies, 972 participants; low‐certainty evidence), although it is uncertain whether there is a reduction in the risk of having an ongoing cold at the end of follow‐up (RR 0.52, 95% CI 0.21 to 1.27; I² = 65%; 5 studies, 357 participants; very low‐certainty evidence), or global symptom severity (SMD ‐0.03, 95% CI ‐0.56 to 0.50; I² = 78%; 2 studies, 261 participants; very low‐certainty evidence), and there may be little or no difference in the risk of a change in global symptom severity (RR 1.02, 95% CI 0.85 to 1.23; 1 study, 114 participants; low‐certainty evidence). Thirty‐one studies reported non‐serious adverse events (2422 participants). It is uncertain whether there is a difference in the risk of adverse events with zinc used for cold prevention (RR 1.11, 95% CI 0.84 to 1.47; I 2 = 0%; 7 studies, 1517 participants; very low‐certainty evidence) or an increase in the risk of serious adverse events (RR 1.67, 95% CI 0.78 to 3.57; I 2 = 0%; 3 studies, 1563 participants; low‐certainty evidence). There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment (RR 1.34, 95% CI 1.15 to 1.55; I 2 = 44%; 2084 participants, 16 studies; moderate‐certainty evidence); no treatment study provided information on serious adverse events. No study provided clear information about adverse events considered to be potential complications of the common cold. Authors' conclusions The findings suggest that zinc supplementation may have little or no effect on the prevention of colds but may reduce the duration of ongoing colds, with an increase in non‐serious adverse events. Overall, there was wide variation in interventions (including concomitant therapy) and outcomes across the studies, as well as incomplete reporting of several domains, which should be considered when making conclusions about the efficacy of zinc for the common cold. Plain language summary Zinc for the prevention and treatment of the common cold Key messages 
‐ There may be little or no reduction in the risk of developing a cold with zinc supplements compared to placebo. ‐ For people who already have a cold, there may be a reduction in how long the cold lasts with zinc supplements compared to placebo. ‐ There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment. What is the common cold? 
The common cold is primarily a viral infection of the upper respiratory tract. There is no specific combination of symptoms that defines a cold, but symptoms can include nasal congestion, sneezing, sore throat, cough, fatigue, and runny nose, with or without fever. Most people usually recover from this illness without medical treatment; however, there are no definitive treatments to prevent colds or shorten their duration. Given the frequency of colds in adults and children, they are a public health burden and a significant cause of lost work productivity and school absenteeism. Prevention and treatment for the common cold with zinc is an ongoing interest. What did we want to find out? 
We wanted to find out if zinc was better than placebo at reducing the risk of developing a cold and shortening the duration of existing colds. A placebo is a substance similar in appearance to a treatment, but that has no known therapeutic effect. Placebos help assess the effects of the belief that a treatment has been received versus treatment actually being received. We also wanted to find out if zinc was associated with any adverse effects (e.g. harms), especially harms considered to be potential complications of the common cold. Additionally, we looked at self‐reported overall cold severity, individual symptom severity, individual symptom duration, and days missed from work or school. What did we do? 
We searched six databases and two clinical trials registers for studies comparing zinc with placebo for the treatment or prevention of the common cold in adults and children. We compared and summarised the results of the studies, and we found and rated our confidence in the evidence based on specific factors such as risk of bias and study methods. What did we find? 
We found 34 studies of cold prevention or treatment. The studies were conducted in 13 countries, a majority taking place in the USA. Twelve studies were conducted on children (aged under 18 years) and 22 studies were conducted on adults. Most treatments ended with self‐reported resolution of symptoms, and the minimum treatment period was five days with a maximum period of 540 days. Most of the studies were funded by an organisation with ties to related commerce/industry or did not report their funding. The remainder were funded by private clinics, non‐government foundations, universities, or governmental entities. We assessed the effects of: ‐ zinc as a preventative measure; and ‐ zinc as a treatment measure. We obtained the following results: Zinc for prevention Compared with placebo, taking zinc may make little to no difference in preventing people from catching a cold (9 studies, 1449 people). Preventative zinc also probably makes little to no difference to the length of the cold if one has been caught (3 studies, 740 participants) and may make little to no difference to the severity of the symptoms experienced (2 studies, 101 people). Negative side effects were reported by people taking either zinc or placebo; irregularities in taste and stomach upset were the most common. Zinc for treatment Zinc taken for treatment of a cold may reduce the length of time that symptoms are present, by approximately two days, when compared with placebo (8 studies, 972 people). However, we have little confidence in the evidence supporting this conclusion. It is unclear whether zinc makes a difference to the severity of the cold symptoms experienced (2 studies, 261 people). Negative side effects were reported more frequently for those taking zinc as a cold treatment when compared to those taking placebo; irregularities in taste and stomach upset were the most common. Studies administering intranasal zinc did not report any cases of anosmia (loss of sense of smell) but information about specific side effects is uncertain. What are the limitations of the evidence? 
Our confidence in the evidence is mostly low to very low, and the results of further research could differ from the results of this review. Several factors reduced our confidence in the evidence. Firstly, some studies did not report adequately on how people in the studies were randomly placed into treatment groups, meaning that differences between the study groups could be due to differences between the participants and not the treatments. Secondly, some studies used widely different ways of delivering treatments. Finally, due to the large differences between studies in the approaches used to test the effectiveness of zinc, it is likely that additional studies are required before any firm conclusions can be drawn. How up‐to‐date is this evidence? 
The evidence is current to 22 May 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.733Z" }, { "id": "6e4e7eae-9e2d-4cc2-abd3-df6b0311a25c", "pmid": "", "title": "Replacing salt with low‐sodium salt substitutes (LSSS) for cardiovascular health in adults, children and pregnant women", "imported": false, "abstract": "Abstract - Background Elevated blood pressure, or hypertension, is the leading cause of preventable deaths globally. Diets high in sodium (predominantly sodium chloride) and low in potassium contribute to elevated blood pressure. The WHO recommends decreasing mean population sodium intake through effective and safe strategies to reduce hypertension and its associated disease burden. Incorporating low‐sodium salt substitutes (LSSS) into population strategies has increasingly been recognised as a possible sodium reduction strategy, particularly in populations where a substantial proportion of overall sodium intake comes from discretionary salt. The LSSS contain lower concentrations of sodium through its displacement with potassium predominantly, or other minerals. Potassium‐containing LSSS can potentially simultaneously decrease sodium intake and increase potassium intake. Benefits of LSSS include their potential blood pressure‐lowering effect and relatively low cost. However, there are concerns about potential adverse effects of LSSS, such as hyperkalaemia, particularly in people at risk, for example, those with chronic kidney disease (CKD) or taking medications that impair potassium excretion. Objectives To assess the effects and safety of replacing salt with LSSS to reduce sodium intake on cardiovascular health in adults, pregnant women and children. Search methods We searched MEDLINE (PubMed), Embase (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection (Clarivate Analytics), Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCOhost), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) up to 18 August 2021, and screened reference lists of included trials and relevant systematic reviews. No language or publication restrictions were applied. Selection criteria We included randomised controlled trials (RCTs) and prospective analytical cohort studies in participants of any age in the general population, from any setting in any country. This included participants with non‐communicable diseases and those taking medications that impair potassium excretion. Studies had to compare any type and method of implementation of LSSS with the use of regular salt, or no active intervention, at an individual, household or community level, for any duration. Data collection and analysis Two review authors independently screened titles, abstracts and full‐text articles to determine eligibility; and extracted data, assessed risk of bias (RoB) using the Cochrane RoB tool, and assessed the certainty of the evidence using GRADE. We stratified analyses by adults, children (≤ 18 years) and pregnant women. Primary effectiveness outcomes were change in diastolic and systolic blood pressure (DBP and SBP), hypertension and blood pressure control; cardiovascular events and cardiovascular mortality were additionally assessed as primary effectiveness outcomes in adults. Primary safety outcomes were change in blood potassium, hyperkalaemia and hypokalaemia. Main results We included 26 RCTs, 16 randomising individual participants and 10 randomising clusters (families, households or villages). A total of 34,961 adult participants and 92 children were randomised to either LSSS or regular salt, with the smallest trial including 10 and the largest including 20,995 participants. No studies in pregnant women were identified. Studies included only participants with hypertension (11/26), normal blood pressure (1/26), pre‐hypertension (1/26), or participants with and without hypertension (11/26). This was unknown in the remaining studies. The largest study included only participants with an elevated risk of stroke at baseline. Seven studies included adult participants possibly at risk of hyperkalaemia. All 26 trials specifically excluded participants in whom an increased potassium intake is known to be potentially harmful. The majority of trials were conducted in rural or suburban settings, with more than half (14/26) conducted in low‐ and middle‐income countries. The proportion of sodium chloride replacement in the LSSS interventions varied from approximately 3% to 77%. The majority of trials (23/26) investigated LSSS where potassium‐containing salts were used to substitute sodium. In most trials, LSSS implementation was discretionary (22/26). Trial duration ranged from two months to nearly five years. We assessed the overall risk of bias as high in six trials and unclear in 12 trials. LSSS compared to regular salt in adults: LSSS compared to regular salt probably reduce DBP on average (mean difference (MD) ‐2.43 mmHg, 95% confidence interval (CI) ‐3.50 to ‐1.36; 20,830 participants, 19 RCTs, moderate‐certainty evidence) and SBP (MD ‐4.76 mmHg, 95% CI ‐6.01 to ‐3.50; 21,414 participants, 20 RCTs, moderate‐certainty evidence) slightly. On average, LSSS probably reduce non‐fatal stroke (absolute effect (AE) 20 fewer/100,000 person‐years, 95% CI ‐40 to 2; 21,250 participants, 3 RCTs, moderate‐certainty evidence), non‐fatal acute coronary syndrome (AE 150 fewer/100,000 person‐years, 95% CI ‐250 to ‐30; 20,995 participants, 1 RCT, moderate‐certainty evidence) and cardiovascular mortality (AE 180 fewer/100,000 person‐years, 95% CI ‐310 to 0; 23,200 participants, 3 RCTs, moderate‐certainty evidence) slightly, and probably increase blood potassium slightly (MD 0.12 mmol/L, 95% CI 0.07 to 0.18; 784 participants, 6 RCTs, moderate‐certainty evidence), compared to regular salt. LSSS may result in little to no difference, on average, in hypertension (AE 17 fewer/1000, 95% CI ‐58 to 17; 2566 participants, 1 RCT, low‐certainty evidence) and hyperkalaemia (AE 4 more/100,000, 95% CI ‐47 to 121; 22,849 participants, 5 RCTs, moderate‐certainty evidence) compared to regular salt. The evidence is very uncertain about the effects of LSSS on blood pressure control, various cardiovascular events, stroke mortality, hypokalaemia, and other adverse events (very‐low certainty evidence). LSSS compared to regular salt in children: The evidence is very uncertain about the effects of LSSS on DBP and SBP in children. We found no evidence about the effects of LSSS on hypertension, blood pressure control, blood potassium, hyperkalaemia and hypokalaemia in children. Authors' conclusions When compared to regular salt, LSSS probably reduce blood pressure, non‐fatal cardiovascular events and cardiovascular mortality slightly in adults. However, LSSS also probably increase blood potassium slightly in adults. These small effects may be important when LSSS interventions are implemented at the population level. Evidence is limited for adults without elevated blood pressure, and there is a lack of evidence in pregnant women and people in whom an increased potassium intake is known to be potentially harmful, limiting conclusions on the safety of LSSS in the general population. We also cannot draw firm conclusions about effects of non‐discretionary LSSS implementations. The evidence is very uncertain about the effects of LSSS on blood pressure in children. Plain language summary Does using low‐sodium salt substitutes (LSSS) instead of regular salt reduce blood pressure and heart disease risks, and is it safe? Key messages • In adults, using LSSS instead of regular salt in food probably lowers blood pressure slightly. Adults using LSSS instead of regular salt probably have a slightly lower risk of non‐fatal heart conditions, such as stroke or a sudden reduced blood flow to the heart, and death from heart disease. • Using LSSS instead of regular salt probably also slightly increases the level of blood potassium (a mineral that keeps your heart beating at the right pace) in adults. This could be harmful for people who cannot effectively regulate the potassium in their bodies. Other evidence on safety is very limited. • We are not certain about effects of using LSSS instead of regular salt on blood pressure in children, or whether using LSSS is safe in children. • This evidence may not directly apply to people known to be at risk of high blood potassium, such as people with kidney problems or on certain medications. What are low‐sodium salt substitutes (LSSS)? LSSS are products with less sodium than regular salt. Amounts of sodium in LSSS are lowered by replacing some of the sodium with potassium or other minerals. LSSS may help lower risks of using regular salt, since eating lots of sodium and not enough potassium contributes to high blood pressure. Globally, high blood pressure is the largest cause of preventable deaths, mainly because it causes stroke, acute coronary syndrome (ACS; where less blood flows to the heart), and kidney problems. However, LSSS also has potential health risks. Using LSSS may lead to higher than normal blood potassium (hyperkalaemia), which causes problems with the heartbeat speed and rhythm, or can cause the heart to stop. These risks are greater in certain people, for example, those whose kidneys do not work properly to remove potassium. What did we want to find out? We wanted to find out what the effects of using LSSS instead of regular salt are on blood pressure as well as on events (stroke and ACS) and heart disease death. We also wanted to know if using LSSS instead of regular salt is safe, both in the general population and in people who are known to be at risk of high blood potassium levels. We wanted to find this out for adults, children and pregnant women. What did we do? 
We searched five electronic databases and trial registries for studies that compared using LSSS with using regular salt. We compared and summarised the results of the studies and rated our confidence in the combined evidence, based on factors such as study methods and sizes. What did we find? We found 26 trials* involving 34,961 adults and 92 children. No studies in pregnant women were found. Most trials were undertaken in rural or suburban areas, with more than half done in low‐ and middle‐income countries. Most trials included some people with high blood pressure (22); the largest included only people with a high risk of stroke. Seven trials were done in people at possible risk of high blood potassium. All trials excluded people where high potassium intake is known to be harmful, such as people with kidney problems or on certain medications. Nearly all trials (23) examined LSSS types where some sodium was replaced with potassium. The amount of sodium replaced in the various LSSS used in the trials ranged from very small (3%) to large (77%). *Trials are types of studies in which participants are assigned randomly to two or more treatment groups. This is the best way to ensure similar groups of participants. Main results In adults, LSSS probably lowers blood pressure (diastolic and systolic) slightly when compared to regular salt. Using LSSS also probably lowers risk of non‐fatal stroke, non‐fatal ACS and heart disease death slightly when compared to regular salt. However, using LSSS instead of regular salt probably also slightly increases the level of potassium in the blood. Compared to regular salt, LSSS may result in little to no difference in high blood pressure and hyperkalaemia. We could not draw any conclusions about effects of LSSS on blood pressure control, various heart disease events, death caused by stroke, lower than normal blood potassium (hypokalaemia), and other adverse events. We could not draw any conclusions about the effects or safety of using LSSS instead of regular salt in children. What are the limitations of the evidence? We are moderately confident in the evidence. Our confidence was lowered mainly because of concerns about how some trials were conducted, and whether the results apply to the general population. We are not sure about the effects and safety of LSSS in children, pregnant women, people known to have a risk of high blood potassium, or those who do not have high blood pressure. We are also unsure about the effects of LSSS when used in foods not prepared at home. Further research may change these results. How up to date is this evidence? The evidence is up‐to‐date to August 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Brand, A; Visser, ME; Schoonees, A; Naude, CE", "articleTypes": [], "doi": "10.1002/14651858.CD015207", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "6e731815-f46b-4d1d-83e1-01ac288ecd7b", "pmid": "", "title": "Preoperative carbohydrate treatment for enhancing recovery after elective surgery", "imported": false, "abstract": "Abstract - Background Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast‐track surgery protocols. Although fast‐track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis. Objectives To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data. Selection criteria We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time. Data collection and analysis Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis. Main results We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I‐II or I‐III. A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding. In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low‐quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference ‐0.13 days; 95% CI ‐0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high‐quality evidence). As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low‐quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation. Authors' conclusions Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases. Plain language summary Does giving patients carbohydrate supplements before planned surgery lead to improved recovery? Review question We reviewed the evidence on effects of carbohydrate supplements on the recovery of people undergoing planned surgical procedures. We found 27 studies investigating this question. Background Carbohydrate (sugar‐containing) nutritional supplements have become a routine part of the package of care for people undergoing planned surgical procedures. We wanted to discover whether carbohydrate supplements are a useful part of care packages used by doctors to improve recovery after planned surgical procedures. Study characteristics The evidence is current up to March 2014. We identified 27 studies and included the outcomes of 1976 participants. Studies investigated the outcomes of patients undergoing planned surgical procedures on the abdomen (18), the bones or joints (4), the heart (4) or the thyroid gland (1). Eighteen studies compared carbohydrate supplements versus an identical appearing placebo drink that did not contain carbohydrates; in six of these studies, an additional group of patients had nothing to eat or drink for at least six hours before surgery. In nine studies, taking carbohydrate supplements was compared with having nothing to eat or drink for six hours before surgery. The primary outcomes of length of hospital stay and complication rate were reported by 19 and 14 studies, respectively. Key results Patients given carbohydrates before planned surgical procedures went home between 0.04 and 0.56 days sooner than those receiving a placebo drink or having nothing to eat or drink before surgery. Carbohydrate supplements had little or no effect on complication rate or on how people feel in‐hospital during recovery from surgery. Quality of the evidence The overall quality of the evidence varied from very low to high. The quality of evidence in support of carbohydrate supplements resulting in a shorter hospital stay was very low because the included studies had important flaws in their design, a very wide range of results was described and evidence revealed that studies showing no differences in length of hospital stay may not have been published. When we looked only at well‐conducted studies, we found that carbohydrate supplements had little or no effect on length of hospital stay. The quality of evidence to support the effects of carbohydrate supplements on complication rate was low because issues with study design were identified and results were not similar across studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Smith, MD; McCall, J; Plank, L; Herbison, GP; Soop, M; Nygren, J", "articleTypes": [], "doi": "10.1002/14651858.CD009161.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "6e7c6a16-268d-43e6-939c-50b02b1ed67f", "pmid": "", "title": "Sensory and Gastrointestinal Impact of Taste Receptor Variants on Human Metabolism and Nutrition", "imported": false, "abstract": "We investigate the impact of taste receptors (sweet, bitter and umami) on human metabolism. There ist growing evidence, that components of the taste signalling system, including the taste receptor proteins , have important functions in the regulation of metabolic parameters in non-gustatory tissues.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.230Z" }, { "id": "6e8225dc-79e0-4e23-b692-4e18d7fcf2d0", "pmid": "", "title": "Herbal interventions for chronic asthma in adults and children", "imported": false, "abstract": "Abstract - Background Herb and plant based preparations are a popular treatment for asthma, although there remain concerns as to their efficacy and safety. In Western societies, motivations for using such treatments may be both positive and negative, with their perceived safety and dissatisfaction with conventional medicine among them. In China such treatments are more commonly used and many compounds considered 'conventional' are derived from herbs or plants. Objectives To assess the efficacy and safety of herb and plant extracts in the management of chronic asthma. Search methods The Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, EMBASE and AMED were searched with pre‐defined terms. Searches are current as of February 2007. Selection criteria Randomised placebo controlled trials of any herb or plant extract were eligible. Study participants had to have a primary diagnosis of asthma. Studies in both adults and children were eligible for the review. Data collection and analysis Two reviewers assessed studies for suitability. Data were extracted and double‐checked. Main results Twenty‐seven studies (29 experimental groups) met the review entry criteria, randomising a total of 1925 participants. The studies identified assessed the effects of 21 different herbal preparations. Study quality varied considerably, and the sample sizes were often small. For primary outcomes (exacerbations, steroids use and lung function measurements): Two out of six studies reporting change in FEV1 were positive, with very few data available on the frequency of exacerbations. One study which did report these data was negative. Health‐related quality of life was only measured in one trial. Authors' conclusions The evidence base for the effects of herbal treatments is hampered by the variety of treatments assessed, poor reporting quality of the studies and lack of available data. The data that are available from the studies provide only a small insight into the long‐term efficacy and harm profiles of these treatments. The absence of common endpoint measurements limits the validity of our findings further. Positive findings in this review warrant additional well‐designed trials in this area. Plain language summary Herbal interventions for chronic asthma in adults and children Chronic asthma is a inflammatory disease of the airways characterised by wheeze and breathlessness. Drug therapy is usually used to control symptoms but complementary medicine is often used, including herbal treatments, and the efficacy and safety of such treatments is not clear. We reviewed evidence from 27 trials covering 21 different herbal treatments in both adults and children from both in‐patient and out‐patient settings. In general, the reporting of trials was poor. The outcomes measured by the trials varied considerably which made it difficult to compare the results of studies that did look at the same treatment. On the basis of the available evidence it is not possible to show whether any of these herbal treatments can improve asthma symptoms. Further trials of high quality are needed to assess the use of herbal treatments in asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Arnold, E, Clark, CE, Lasserson, TJ, Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD005989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.746Z" }, { "id": "6e8505f5-196b-4ce3-8b36-acad27cba8b2", "pmid": "", "title": "Desmopressin for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐old children and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Desmopressin has been used to treat bedwetting since the 1970s. This is an update of a Cochrane review first published in 2000 and last updated in 2006. Objectives To assess the effects of desmopressin on treating nocturnal enuresis in children. Search methods We searched Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched January 2023) and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of desmopressin or desmopressin combined with another intervention for treating nocturnal enuresis in children between five and 16 years old. Data collection and analysis Three review authors independently extracted data and assessed the risk of bias in the eligible trials. We used standard methodological procedures expected by Cochrane. Main results We identified 50 new studies for this review, which now includes 95 studies (8473) participants, of whom 5434 received desmopressin. In this review we continued the assessment of the effect of combination therapy involving desmopressin. The majority of the trials were in children between the ages of five to 16 years in an outpatient setting. The quality of the evidence was assessed as low or very low. The first comparison was desmopressin versus placebo. Desmopressin may reduce the mean number of wet nights per week compared with placebo (MD ‐1.81, 95% CI ‐2.24 to ‐1.39; participants = 1267; studies = 16; low‐certainty evidence). Desmopressin probably leads to more children achieving 14 consecutive dry nights by the end of treatment compared with placebo (RR 3.18, 95% CI 1.75 to 5.80; participants = 922: studies = 11; moderate‐certainty evidence). There may be little to no difference in children experiencing adverse effects with desmopressin compared to placebo (RR 1.11, 95% CI 0.81 to 1.52; participants = 269; studies = 3; low‐certainty evidence). Desmopressin was compared with alarm therapy. It is uncertain if there is any difference between desmopressin compared with alarm training in reducing the number of wet nights per week (MD 0.63, 95% CI ‐0.49 to 1.75; participants = 285; studies = 4; I 2 = 82%; very low‐certainty evidence). There may be little or no difference between desmopressin and alarm therapy in the number of children achieving 14 consecutive dry nights (RR 0.98, 95% CI 0.88 to 1.09; participants = 1530; studies = 15; low‐certainty evidence). There may be little to no difference in children experiencing side effects with desmopressin therapy compared with alarm therapy (RR 1.50, 95% CI 0.33 to 6.78; participants = 461, studies = 4; low‐certainty evidence). We compared desmopressin with other medications, including tricyclics and anticholinergics. It is uncertain if there is any difference between desmopressin compared to tricyclics in reducing the mean number of wet nights per week (MD 0.23, 95% CI ‐ 0.88 to 1.33; participants = 331; studies = 4; I 2 = 79%; very low‐certainty evidence) or in the number of children achieving 14 consecutive dry nights at the end of treatment (RR 0.94, 95% CI 0.63 to 1.38; participants = 371; studies = 7; I 2 = 71%; very low‐certainty evidence). It is uncertain whether children experience more side effects with desmopressin compared with tricyclics (RR 0.29, 95%CI 0.06 to 1.39; participants = 351; studies = 4, very low‐certainty evidence). This review included studies with combination therapies. It is uncertain if desmopressin combined with alarm therapy reduces the mean number of wet nights at the end of treatment compared with alarm monotherapy (MD ‐0.80, 95% CI ‐1.34 to ‐0.25; participants = 528; studies = 6; I 2 = 84%; very low‐certainty evidence); or if it increases the number of children achieving 14 consecutive dry nights (RR 1.25, 95% CI 0.96 to 1.63; participants = 822; studies = 10; very low‐certainty evidence). Desmopressin plus alarm therapy may make little to no difference in children experiencing side effects compared with alarm therapy alone (RR 1.05 95% CI 0.07 to 16.56; participants = 207; studies = 1; low‐certainty evidence). Combining desmopressin with alarm therapy probably reduces the number of wet nights at the end of treatment (MD ‐0.88; 95%CI ‐1.38 to ‐0.38; participants = 156; studies = 2; moderate‐certainty evidence), and may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin monotherapy (RR 1.26, 95% CI 1.06 to 1.51; participants = 370; studies = 5; low‐certainty evidence). It is uncertain if combined desmopressin and anticholinergic therapy versus desmopressin monotherapy reduces the mean number of wet nights at the end of therapy (MD ‐0.50; 95% CI ‐1.05 to 0.06; participants = 188; studies = 3; I 2 = 66%; very low‐certainty evidence); or if it may increase the number of children achieving 14 consecutive dry nights at the end of treatment (RR 1.53, 95% CI 1.10 to 2.11; participants = 611; studies = 8; low‐certainty evidence). There may be little to no difference in adverse events between desmopressin plus anticholinergics and desmopressin monotherapy (RR 1.51 95% CI 0.73 to 3.09, participants = 187; studies =2; low‐certainty evidence). Minor adverse effects were common for desmopressin, including dizziness, headache, mood changes, gastrointestinal discomfort, nasal discomfort, hyponatraemia and one report of a convulsion. Authors' conclusions Desmopressin compared with placebo may increase the number of dry nights per week at the end of treatment in children. Desmopressin therapy may be as effective as alarm therapy at the end of treatment. However, the quality of evidence was assessed as low or very low. Alarm therapy compared to desmopressin may improve the number of children who are dry at follow‐up (moderate‐certainty evidence). Plain language summary Desmopressin for bedwetting in children Review question Is desmopressin an effective treatment for bedwetting in children? Key messages: Desmopressin may improve bedwetting. Only one study assessed quality of life. Further studies with good patient numbers are required. What is enuresis? What does desmopressin do ? Enuresis or bedwetting is involuntary wetting during sleep at an age when a child should be dry, usually at age five. The generally quoted prevalence rates (that is the proportion of a population with bedwetting in a given time period) are 15% to 20% of five‐year‐olds, 7% of seven‐year‐olds, 5% of 10‐year‐old children, and 2% to 3% of teenagers. Various treatments have been used to treat bedwetting. Desmopressin is a man‐made form of vasopressin, a chemical released from the brain that helps control the amount of urine made by the kidneys. Desmopressin is used to control bedwetting at night and reduces the number of bedwetting episodes. Why was it important to do this review? Although bedwetting is not a harmful condition and, with time, stops spontaneously, it is stigmatising and can impact the child’s quality of life, emotional and psychological wellbeing. It is a condition that unsettles the whole family and the affected children may suffer parental discontentment, teasing and may be at risk of physical or emotional abuse. Successful therapies that reduce bedwetting improve the child's self‐esteem and, therefore, it is important to see if desmopressin is as effective as other known treatments. How is the condition treated ? • Desmopressin therapy • Alarm therapy • Anticholinergic medications • Combination therapy – such as desmopressin and alarm therapy compared to desmopressin therapy There are several other therapies, such as behavioural therapies and laser therapy, though we have concentrated on the main therapies utilised. What did we want to find out? We wanted to see if desmopressin: • was effective in reducing the episodes of wet nights children may have; • was as effective as other treatments such as alarm therapy in treating bedwetting; • worked in combination with other treatments; • was associated with any unwanted effects. What did we do? We searched for studies where people were randomly placed into different treatment groups. We searched for and included studies that compared: • desmopressin with no treatment or placebo; • desmopressin and alarm therapy; • combination treatments of desmopressin and alarm. We compared and analysed our results, then rated our confidence in the evidence based on factors such as study methods and size of the studies. What did we find? We found 98 studies with 8699 participants, of whom 5616 received desmopressin. Main results • We found the use of desmopressin compared with placebo may improve wetting by giving children one more dry night a week while receiving treatment. This suggests that more children may stop wetting while using desmopressin (28% versus 1% who are given placebo or no treatment). • More children who received desmopressin therapy compared with placebo probably achieved 14 consecutive dry nights at the end of treatment. • We found that, when desmopressin was compared with alarm therapy, there was little to no difference in the number of children achieving 14 dry nights in a row. The evidence is also uncertain if desmopressin versus alarm therapy reduces the number of dry nights per week. • We found that combining desmopressin with alarm therapy may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin alone. • We found that side effects were commonly reported for desmopressin. These included dizziness, headache, mood changes, abdominal discomfort, nasal discomfort, hyponatraemia (low sodium level) and one report of a seizure. Thirty‐two studies reported no adverse effects occurring, and 25 studies omitted to report or mention adverse effects. What are the limitations of the evidence? We, however, have little confidence in the evidence as, in several studies, participants were aware of the therapy they were receiving, and several studies were very small. How up‐to‐date is this review? The evidence is current up to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hahn, D, Stewart, F, Raman, G", "articleTypes": [], "doi": "10.1002/14651858.CD002112.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.806Z" }, { "id": "6e8798d9-a6cf-4b92-8e40-aa0f951190ed", "pmid": "", "title": "Pharmacological and non‐pharmacological strategies for obese women with subfertility", "imported": false, "abstract": "Abstract - Background Clinicians primarily recommend weight loss for obese women seeking pregnancy. The effectiveness of interventions aimed at weight loss in obese women with subfertility is unclear. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for achieving weight loss in obese women with subfertility. Search methods We searched the CGF Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and AMED from inception to 18 August 2020. We also checked reference lists and contacted experts in the field for additional relevant papers. Selection criteria We included published and unpublished randomised controlled trials in which weight loss was the main goal of the intervention. Our primary effectiveness outcomes were live birth or ongoing pregnancy and primary safety outcomes were miscarriage and adverse events. Secondary outcomes included clinical pregnancy, weight change, quality of life, and mental health outcome. Data collection and analysis Review authors followed standard Cochrane methodology. Main results This review includes 10 trials. Evidence was of very low to low quality: the main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision. Non‐pharmacological intervention versus no intervention or placebo Evidence is insufficient to determine whether a diet or lifestyle intervention compared to no intervention affects live birth (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.65 to 1.11; 918 women, 3 studies; I² = 78%; low‐quality evidence). This suggests that if the chance of live birth following no intervention is assumed to be 43%, the chance following diet or lifestyle changes would be 33% to 46%. We are uncertain if lifestyle change compared with no intervention affects miscarriage rate (OR 1.54, 95% CI 0.99 to 2.39; 917 women, 3 studies; I² = 0%; very low‐quality evidence). Evidence is insufficient to determine whether lifestyle change compared with no intervention affects clinical pregnancy (OR 1.06, 95% CI 0.81 to 1.40; 917 women, 3 studies; I² = 73%; low‐quality evidence). Lifestyle intervention resulted in a decrease in body mass index (BMI), but data were not pooled due to heterogeneity in effect (mean difference (MD) ‐3.70, 95% CI ‐4.10 to ‐3.30; 305 women, 1 study; low‐quality evidence; and MD ‐1.80, 95% CI ‐2.67 to ‐0.93; 43 women, 1 study; very low‐quality evidence). Non‐pharmacological versus non‐pharmacological intervention We are uncertain whether intensive weight loss interventions compared to standard care nutrition counselling affects live birth (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), BMI (MD ‐3.00, 95% CI ‐5.37 to ‐0.63; 11 women, 1 study; very low‐quality evidence), weight change (MD ‐9.00, 95% CI ‐15.50 to ‐2.50; 11 women, 1 study; very low‐quality evidence), quality of life (MD 0.06, 95% CI ‐0.03 to 0.15; 11 women, 1 study; very low‐quality evidence), or mental health (MD ‐7.00, 95% CI ‐13.92 to ‐0.08; 11 women, 1 study; very low‐quality evidence). No study reported on adverse events . Pharmacological versus pharmacological intervention For metformin plus liraglutide compared to metformin we are uncertain of an effect on the adverse events nausea (OR 7.22, 95% CI 0.72 to 72.7; 28 women, 1 study; very low‐quality evidence), diarrhoea (OR 0.31, 95% CI 0.01 to 8.3; 28 women, 1 study; very low‐quality evidence), and headache (OR 5.80, 95% CI 0.25 to 133; 28 women, 1 study; very low‐quality evidence). We are uncertain if a combination of metformin plus liraglutide vs metformin affects BMI (MD 2.1, 95% CI ‐0.42 to 2.62; 28 women, 1 study; very low‐quality evidence) and total body fat (MD ‐0.50, 95% CI ‐4.65 to 3.65; 28 women, 1 study; very low‐quality evidence). For metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo, we are uncertain of an effect on miscarriage (OR 3.58, 95% CI 0.73 to 17.55; 274 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 5.56, 95% CI 2.57 to 12.02; 274 women, 1 study; very low‐quality evidence) or BMI (MD ‐0.3, 95% CI 1.17 to 0.57, 274 women, 1 study, very low‐quality evidence). We are uncertain if dexfenfluramine versus placebo affects weight loss in kilograms (MD ‐0.10, 95% CI ‐2.77 to 2.57; 21 women, 1 study; very low‐quality evidence). No study reported on live birth, quality of life, or mental health outcomes. Pharmacological intervention versus no intervention or placebo We are uncertain if metformin compared with placebo affects live birth (OR 1.57, 95% CI 0.44 to 5.57; 65 women, 1 study; very low‐quality evidence). This suggests that if the chance of live birth following placebo is assumed to be 15%, the chance following metformin would be 7% to 50%. We are uncertain if metformin compared with placebo affects gastrointestinal adverse events (OR 0.91, 95% CI 0.32 to 2.57; 65 women, 1 study; very low‐quality evidence) or miscarriage (OR 0.50, 95% CI 0.04 to 5.80; 65 women, 1 study; very low‐quality evidence) or clinical pregnancy (OR 2.67, 95% CI 0.90 to 7.93; 96 women, 2 studies; I² = 48%; very low‐quality evidence). We are also uncertain if diet combined with metformin versus diet and placebo affects BMI (MD ‐0.30, 95% CI ‐2.16 to 1.56; 143 women, 1 study; very low‐quality evidence) or waist‐to‐hip ratio (WHR) (MD 2.00, 95% CI ‐2.21 to 6.21; 143 women, 1 study; very low‐quality evidence). Pharmacological versus non‐pharmacological intervention No study undertook this comparison. Authors' conclusions Evidence is insufficient to support the use of pharmacological and non‐pharmacological strategies for obese women with subfertility. No data are available for the comparison of pharmacological versus non‐pharmacological strategies. We are uncertain whether pharmacological or non‐pharmacological strategies effect live birth, ongoing pregnancy, adverse events, clinical pregnancy, quality of life, or mental health outcomes. However, for obese women with subfertility, a lifestyle intervention may reduce BMI. Future studies should compare a combination of pharmacological and lifestyle interventions for obese women with subfertility. Plain language summary Do pharmacological and non‐pharmacological strategies reduce weight in obese women with subfertility? To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for weight reduction in obese women with subfertility. Background To prevent the adverse effects of obesity, weight loss is recommended as the first line of treatment for obese women seeking pregnancy. The effectiveness of pharmacological and non‐pharmacological interventions for obese women with subfertility is unclear. Study characteristics We found 10 randomised trials comparing pharmacological and non‐pharmacological strategies in 1490 obese women with subfertility. Key results Lack of data is a major concern in interpretation of these data. Only 10 studies were included in the analysis. Three studies compared non‐pharmacological intervention versus no intervention or placebo. We are uncertain whether diet versus no intervention improves live birth, ongoing pregnancy, clinical pregnancy, or adverse events. A diet or lifestyle intervention may result in body mass index (BMI) weight change. Evidence was insufficient to show a difference in waist‐to‐hip ratio (WHR) with diet or lifestyle change compared to no intervention. No study reported on quality of life, or mental health outcomes for this comparison. One study compared non‐pharmacological interventions ‐ intensive weight loss intervention versus standard of care nutrition counselling; however due to the very low quality of evidence, we are uncertain whether intensive weight loss interventions improve live birth, clinical pregnancy, quality of life, or mental health outcomes. No study reported on adverse events, or weight changes, for this comparison. Three studies reported on pharmacological versus pharmacological interventions. Evidence was insufficient to show a difference in adverse events between metformin compared to metformin plus liraglutide. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for miscarriage. Evidence was insufficient to reveal a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo or metformin plus liraglutide versus metformin in clinical pregnancy. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for weight change using BMI. Moreover, evidence was insufficient to reveal a difference between dexfenfluramine versus placebo or metformin plus liraglutide versus metformin for weight loss in kilograms, or per cent of total body fat. No study reported on live birth and change in quality of life or mental health outcomes for this comparison. In the comparison of pharmacological intervention versus no intervention or placebo, three studies were included. Evidence was insufficient to show a difference between metformin and control groups related to live birth. Evidence was insufficient to reveal a difference between metformin compared to placebo in live birth, clinical pregnancy, or adverse events. Evidence was insufficient to demonstrate a difference between diet combined with metformin versus diet combined with placebo for weight change using BMI or WHR. No study reported on quality of life or mental health outcomes for this comparison. We found no study comparing non‐pharmacological with pharmacological interventions. Quality of the evidence The evidence was of very low to low quality. The main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading of evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Taghavi, SA, van Wely, M, Jahanfar, S, Bazarganipour, F", "articleTypes": [], "doi": "10.1002/14651858.CD012650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.790Z" }, { "id": "6eae23ce-8425-4ead-8c4e-ca4236750ae8", "pmid": "", "title": "Sucrose analgesia for heel‐lance procedures in neonates", "imported": false, "abstract": "Abstract - Background Sucrose has been examined for calming and pain‐relieving effects in neonates for invasive procedures such as heel lance. Objectives To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long‐term outcomes Search methods We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries. Selection criteria We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non‐nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin‐to‐skin care. Data collection and analysis We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. We assessed heterogeneity by the I 2 test. We used GRADE to assess certainty of evidence. Main results We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing. Sucrose vs control The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD ‐1.74 (95% CI ‐2.11 to ‐1.37); I 2 = 62%; moderate‐certainty evidence) and 60 seconds after lancing (MD ‐2.14, 95% CI ‐3.34 to ‐0.94; I 2 = 0%; moderate‐certainty evidence). The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD ‐1.90, 95% CI ‐8.58 to 4.78; heterogeneity not applicable (N/A); very low‐certainty evidence). The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD ‐2.00, 95% CI ‐2.42 to ‐1.58; heterogeneity N/A; moderate‐certainty evidence). Sucrose vs NNS The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI ‐0.30 to 1.50; heterogeneity not applicable; very low‐certainty evidence) and on DAN scores at 30 seconds after lancing (MD ‐1.20, 95% CI ‐7.87 to 5.47; heterogeneity N/A; very low‐certainty evidence). Sucrose + NNS vs NNS The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD ‐4.90, 95% CI ‐5.73 to ‐4.07; heterogeneity not applicable; very low‐certainty evidence) and during recovery after lancing (MD ‐3.80, 95% CI ‐4.47 to ‐3.13; heterogeneity N/A; very low‐certainty evidence). The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD ‐0.60, 95% CI ‐1.47 to 0.27; heterogeneity N/A; very low‐certainty evidence). Sucrose vs glucose The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI ‐0.70 to 1.22; heterogeneity not applicable; low‐certainty evidence) and 60 seconds after lancing (MD ‐0.02, 95% CI ‐0.79 to 0.75; heterogeneity N/A; low‐certainty evidence). Sucrose vs breastfeeding The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD ‐0.70, 95% CI ‐0.49 to 1.88; I 2 = 94%; very low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD ‐2.60, 95% CI ‐3.06 to ‐2.14; heterogeneity N/A; very low‐certainty evidence). Sucrose vs expressed breast milk The evidence suggests that sucrose may result in little to no difference in PIPP‐R scores compared to expressed breast milk during (MD 0.3, 95% CI ‐0.24 to 0.84; heterogeneity not applicable; low‐certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI ‐0.11 to 0.71; heterogeneity N/A; low‐certainty evidence). The evidence suggests that sucrose probably may result in slightly increased PIPP‐R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD ‐1.80, 95% CI ‐8.47 to 4.87; heterogeneity N/A; very low‐certainty evidence). Sucrose vs laser acupuncture There was no difference in PIPP‐R scores between sucrose and music groups; however, data were reported as medians and IQRs. The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD ‐0.86, 95% CI ‐1.43 to ‐0.29; heterogeneity N/A; very low‐certainty evidence). Sucrose vs facilitated tucking The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD ‐2.27, 95% CI ‐4.66 to 0.12; heterogeneity N/A; very low‐certainty evidence) and during recovery after lancing (MD ‐0.31, 95% CI ‐1.72 to 1.10; heterogeneity N/A; very low‐certainty evidence). Sucrose vs skin‐to‐skin + water (repeated lancing) The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 30 seconds after 1st (MD 0.13, 95% CI ‐0.70 to 0.96); 2nd (MD ‐0.56, 95% CI ‐1.57 to 0.45); or 3rd lancing (MD‐0.15, 95% CI ‐1.26 to 0.96); heterogeneity N/A, low‐certainty evidence for all comparisons. The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 60 seconds after 1st (MD –0.61, 95% CI ‐1.55 to 0.33); 2nd (MD ‐0.12, 95% CI ‐0.99 to 0.75); or 3rd lancing (MD‐0.40, 95% CI ‐1.48 to 0.68); heterogeneity N/A, low‐certainty evidence for all comparisons. Minor adverse events required no intervention. Authors' conclusions Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate‐certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin‐to‐skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing heel lance Key messages ‐ Sucrose, compared to control interventions, probably reduces pain for a single painful event (heel lance). ‐ There were a few minor immediate adverse events, such as gagging, that resolved without intervention. ‐ We need studies that assess the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. ‐ We need to assess how sucrose affects neonates who are extremely preterm, unstable, or ventilated (or a combination of these factors). What is sucrose analgesia? Sucrose (table sugar) is mixed with water in various concentrations (usually 24%) and is given to babies in very small amounts (e.g. a few drops) about two minutes before a painful procedure. Sucrose is also given with other nondrug pain‐relieving interventions such as a pacifier (non‐nutritive sucking ‐ NNS) or when the baby is receiving skin‐to‐skin care. Why is this important for newborn babies who are undergoing heel lance procedures? Babies who are sick or immature, and require a stay in hospital, have several painful procedures per day and multiple painful procedures throughout the hospital stay; for most babies, the majority of painful procedures are heel lances. If untreated, pain has immediate and long‐term consequences that can impact their brain and behavioural development. It is important to minimise the number of painful procedures and the associated pain and suffering. What did we want to find out? We wanted to know how well sucrose worked to relieve pain in newborn babies who are having heel lance procedures while they were in hospital. We also wanted to know whether there were any safety concerns about using sucrose to relieve pain from single painful events such as heel lance. What did we do? We searched for studies that investigated: ‐ Sucrose compared to no treatment or standard care; ‐ Sucrose compared to water, other sweet solutions (e.g. glucose); ‐ Sucrose compared to another nondrug intervention (e.g. NNS); ‐ Whether sucrose was effective in decreasing the amount and severity of pain that babies experienced as assessed by baby’s pain responses (e.g. crying, grimacing, heart rate) and by using standardised infant pain scales. We also wanted to know if sucrose was associated with any unwanted effects in preterm or term babies. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods. What did we find out? We reviewed 55 studies that included a total of 6273 babies. Twenty‐nine studies had full‐term babies only, 22 had preterm babies only, and four had both full‐term and preterm babies. Heel lance was the painful procedure in 50 studies. Five studies investigated a variety of other minor painful procedures in addition to heel lancing. Main results ‐ Sucrose compared to the control treatment probably reduces pain from single heel lances in babies. ‐ Results are uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, and facilitated tucking, in reducing pain scores. ‐ Results are uncertain about the effect of sucrose + NNS compared to NNS, in reducing pain. ‐ Sucrose does not seem to reduce pain from single heel lances compared to glucose, expressed breast milk, and skin‐to‐skin care. ‐ Reported adverse events were minor and resolved without any intervention. What are the limitations of the evidence? We have moderate‐certainty evidence that sucrose likely reduces pain from heel lance. How up‐to‐date is this evidence? This evidence is up‐to‐date as of February 2022. Study funding sources We did not identify any studies that received funding from industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yamada, J, Bueno, M, Santos, L, Haliburton, S, Campbell-Yeo, M, Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD014806", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.072Z" }, { "id": "6eb03e8c-d0b4-483b-8f60-650931398f00", "pmid": "", "title": "Penicillamine for treating rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is a penicillin derived compound originally used to treat patients with rheumatoid arthritis (RA) in the 1950's. Although frequently used in the past, its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs) such as methotrexate. Objectives To estimate the short‐term effects of D‐penicillamine for the treatment of rheumatoid arthritis (RA). Search methods We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register (issue 3, 2000) and Medline up to and including August 2000 and Embase from 1988‐2000. We also carried out a handsearch of the reference lists of the trials retrieved from the electronic search. Selection criteria All randomized controlled trials and controlled clinical trials comparing D‐penicillamine against placebo in patients with rheumatoid arthritis. Data collection and analysis The methodological quality of the trials was assessed independently by two reviewers (CS, EB) and checked by a third (MS) using a validated quality assessment tool (Jadad 1996). Rheumatoid arthritis outcome measures were extracted from the publications for the six‐month endpoint and stratified according to D‐penicillamine dosages: low (<500mg/day), moderate (500 to <1000mg/day) and high (1000 mg/day or greater). Data was abstracted by one reviewer and checked by a second (CS, MS). The pooled analysis was performed using the standardized mean difference for joint counts, pain and global assessments. The weighted mean difference was used for erythrocyte sedimentation rate (ESR). Toxicity was evaluated with pooled odds ratios for withdrawals and adverse reactions. A chi‐square test was used to assess heterogeneity among trials. Fixed effects models were used throughout, since no statistical heterogeneity was found. Main results Six trials were identified, with 425 patients randomized to D‐penicillamine and 258 to placebo. A statistically significant benefit was observed for D‐penicillamine when compared to placebo for all three‐dose ranges and for most outcome measures including: tender joint counts, pain, physician's global assessments and ESR. The standardized weighted mean differences between treatment and placebo in moderate doses were ‐0.51 [95% CI ‐0.88, ‐0.14] for tender joint counts, ‐0.56 (95% CI ‐0.87, ‐0.26) for pain and ‐0.97 (95% CI ‐1.25, ‐0.70) for global assessment. The difference for ESR was ‐10.6 mm/hr. Similar results were observed for the higher dose group. Total withdrawals were significantly higher in the moderate and high dosage D‐penicillamine groups (OR=1.63 and 2.13 respectively), mostly due to increased adverse reactions (OR = 2.60 and 4.95 respectively), including renal and hematological abnormalities. Authors' conclusions D‐penicillamine appears to have a clinically and statistically significant benefit on the disease activity of patients with rheumatoid arthritis. Its efficacy appears to be similar to that of other disease modifying anti‐rheumatic drugs (DMARDs), but with a significantly higher toxicity. Its effects on long‐term functional status and radiological progression are not clear from this review. Plain language summary Penicillamine for treating rheumatoid arthritis Penicillamine is a penicillin derived compound. Studies showed that this could be used to treat rheumatoid arthritis originally in 1950. It was frequently used in the past, but its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs), such as methotrexate. The purpose of this summary was to find out if penicillamine is helpful in the treatment of rheumatoid arthritis. Penicillamine was seen to be beneficial for all ranges of dosages for disease activity on tender joint pain, physician global assessment and sed rate. No major differences were observed between placebo and low dose penicillamine (<500 mg/day). For higher dosages, patients on penicillamine were twice as likely to withdraw than those receiving placebo 500 to <1000 mg/day. D‐penicillamine appears be have a clinical and statistical benefit on the disease activity of patients with rheumatoid arthritis. Its benefit is similar to that of other such drugs, such as disease modifying anti‐rheumatic drugs (DMARDs). More adverse reactions are seen in patients being treated with D‐penicillamine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Suarez‐Almazor, ME; Belseck, E; Spooner, C", "articleTypes": [], "doi": "10.1002/14651858.CD001460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "6eb7965f-c765-408f-b938-1c3ef3279753", "pmid": "", "title": "Nutritional labelling for healthier food or non‐alcoholic drink purchasing and consumption", "imported": false, "abstract": "Abstract - Background Nutritional labelling is advocated as a means to promote healthier food purchasing and consumption, including lower energy intake. Internationally, many different nutritional labelling schemes have been introduced. There is no consensus on whether such labelling is effective in promoting healthier behaviour. Objectives To assess the impact of nutritional labelling for food and non‐alcoholic drinks on purchasing and consumption of healthier items. Our secondary objective was to explore possible effect moderators of nutritional labelling on purchasing and consumption. Search methods We searched 13 electronic databases including CENTRAL, MEDLINE and Embase to 26 April 2017. We also handsearched references and citations and sought unpublished studies through websites and trials registries. Selection criteria Eligible studies: were randomised or quasi‐randomised controlled trials (RCTs/Q‐RCTs), controlled before‐and‐after studies, or interrupted time series (ITS) studies; compared a labelled product (with information on nutrients or energy) with the same product without a nutritional label; assessed objectively measured purchasing or consumption of foods or non‐alcoholic drinks in real‐world or laboratory settings. Data collection and analysis Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of bias' tool and GRADE to assess the quality of evidence. We pooled studies that evaluated similar interventions and outcomes using a random‐effects meta‐analysis, and we synthesised data from other studies in a narrative summary. Main results We included 28 studies, comprising 17 RCTs, 5 Q‐RCTs and 6 ITS studies. Most (21/28) took place in the USA, and 19 took place in university settings, 14 of which mainly involved university students or staff. Most (20/28) studies assessed the impact of labelling on menus or menu boards, or nutritional labelling placed on, or adjacent to, a range of foods or drinks from which participants could choose. Eight studies provided participants with only one labelled food or drink option (in which labelling was present on a container or packaging, adjacent to the food or on a display board) and measured the amount consumed. The most frequently assessed labelling type was energy (i.e. calorie) information (12/28). Eleven studies assessed the impact of nutritional labelling on purchasing food or drink options in real‐world settings, including purchases from vending machines (one cluster‐RCT), grocery stores (one ITS), or restaurants, cafeterias or coffee shops (three RCTs, one Q‐RCT and five ITS). Findings on vending machines and grocery stores were not interpretable, and were rated as very low quality. A meta‐analysis of the three RCTs, all of which assessed energy labelling on menus in restaurants, demonstrated a statistically significant reduction of 47 kcal in energy purchased (MD −46.72 kcal, 95% CI −78.35, −15.10, N = 1877). Assuming an average meal of 600 kcal, energy labelling on menus would reduce energy purchased per meal by 7.8% (95% CI 2.5% to 13.1%). The quality of the evidence for these three studies was rated as low, so our confidence in the effect estimate is limited and may change with further studies. Of the remaining six studies, only two (both ITS studies involving energy labels on menus or menus boards in a coffee shop or cafeteria) were at low risk of bias, and their results support the meta‐analysis. The results of the other four studies which were conducted in a restaurant, cafeterias (2 studies) or a coffee shop, were not clearly reported and were at high risk of bias. Seventeen studies assessed the impact of nutritional labels on consumption in artificial settings or scenarios (henceforth referred to as laboratory studies or settings). Of these, eight (all RCTs) assessed the effect of labels on menus or placed on a range of food options. A meta‐analysis of these studies did not conclusively demonstrate a reduction in energy consumed during a meal (MD −50 kcal, 95% CI −104.41, 3.88, N = 1705). We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. Six laboratory studies (four RCTs and two Q‐RCTs) assessed the impact of labelling a single food or drink option (such as chocolate, pasta or soft drinks) on energy consumed during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant difference in energy (kcal) consumed (SMD 0.05, 95% CI −0.17 to 0.27, N = 732). However, the confidence intervals were wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. There was no evidence that nutritional labelling had the unintended harm of increasing energy purchased or consumed. Indirect evidence came from five laboratory studies that involved mislabelling single nutrient content (i.e. placing low energy or low fat labels on high‐energy foods) during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant increase in energy (kcal) consumed (SMD 0.19, 95% CI −0.14to 0.51, N = 718). The effect was small and the confidence intervals wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence from these studies as very low, providing very little confidence in the effect estimate. Authors' conclusions Findings from a small body of low‐quality evidence suggest that nutritional labelling comprising energy information on menus may reduce energy purchased in restaurants. The evidence assessing the impact on consumption of energy information on menus or on a range of food options in laboratory settings suggests a similar effect to that observed for purchasing, although the evidence is less definite and also of low quality. Accordingly, and in the absence of observed harms, we tentatively suggest that nutritional labelling on menus in restaurants could be used as part of a wider set of measures to tackle obesity. Additional high‐quality research in real‐world settings is needed to enable more certain conclusions. Further high‐quality research is also needed to address the dearth of evidence from grocery stores and vending machines and to assess potential moderators of the intervention effect, including socioeconomic status. Plain language summary Nutritional labelling to promote healthier consumption and purchasing of food or drinks A poor diet including excessive energy intake is an important cause of ill health. Nutritional labelling may help people to make healthier food choices. What is the aim of this review? This review investigated whether nutritional labels (i.e. labels providing information about nutritional content) persuade people to buy or consume different (healthy) kinds of food. We searched for all available evidence to answer this question and found 28 studies. Key messages There is evidence to suggest that nutritional labelling, with energy information (e.g. calorie counts) on menus, may reduce energy purchased in restaurants, but more high‐quality studies are needed to make this finding more certain. What was studied in the review? Some studies assessed buying food or drinks from vending machines, grocery stores, restaurants, cafeterias, or coffee shops. Others assessed the amount of food or drink consumed during a snack or meal in an artificial setting or scenario (referred to as laboratory studies or settings). What are the main results of the review? Nutritional labelling on restaurant menus reduced the amount of energy (i.e. calories) purchased, but the quality of the three studies that contributed to this finding was low, so our confidence in the effect estimate is limited and may change with further studies. Eight studies assessed this same type of intervention in laboratory settings, but instead of evaluating how much energy participants purchased, these studies evaluated how much energy participants consumed. These studies did not conclusively demonstrate a reduction in energy consumed when menus or foods were labelled, and they were also of low quality. In addition, six laboratory studies assessed how much energy participants consumed when they were given one food or drink option with or without labels, and five laboratory studies assessed how much energy participants consumed when foods were experimentally labelled as low energy or low fat when they were actually high‐energy foods (i.e. mislabelling). Results from these two groups of studies were inconclusive and of low, or in the case of mislabelling studies, very low quality. We found some studies that assessed labelling on vending machines and grocery stores, but their results were not easy to interpret, so we could not use them to inform this review. How up‐to‐date is this review? The evidence is current to 26 April 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Crockett, RA; King, SE; Marteau, TM; Prevost, AT; Bignardi, G; Roberts, NW; Stubbs, B; Hollands, GJ; Jebb, SA", "articleTypes": [], "doi": "10.1002/14651858.CD009315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "6eb8d943-35d2-4650-a500-a47d2e408e3b", "pmid": "", "title": "Interventions for dysphagia in oesophageal cancer", "imported": false, "abstract": "Abstract - Background Most patients with oesophageal and gastro‐oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009. Objectives The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro‐oesophageal carcinoma. Search methods To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Selection criteria Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, self‐expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head‐to‐head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30‐day mortality, adverse effects and quality of life. Data collection and analysis Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group. Main results We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re‐interventions and for adverse effects. Anti‐reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti‐reflux stents might have reduced gastro‐oesophageal reflux and complications. Newly‐designed double‐layered nitinol (Niti‐S) stents were preferable due to longer survival time and fewer complications compared to simple Niti‐S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy. Authors' conclusions Self‐expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high‐dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti‐reflux stents and newly‐designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self‐expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re‐interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia. Plain language summary Interventions for reducing difficulty in swallowing in people with oesophageal cancer Review question For most patients with unresectable or inoperable oesophageal cancer, providing clinical benefit with palliative treatment is highly desirable. However, the optimal palliative technique for dysphagia improvement and better quality of life is not established. Background Dysphagia (difficulty or discomfort in swallowing) is common among patients with unresectable or inoperable oesophageal cancer. There are five levels of dysphagia, ranging from the ability to eat a normal diet to some solids, semisolids, liquids and to complete dysphagia. Study characteristics The review included randomised controlled studies comparing the use of different interventions to improve dysphagia among patients with inoperable or unresectable primary oesophageal cancer. To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Key results The review updates the previous version but still fails to present any obvious superiority of one technique over another among the different kinds of interventions. Self‐expanding metal stents provided safer and more effective relief of dysphagia compared to rigid plastic stents. Other techniques like radiotherapy or brachytherapy were also suitable alternatives and might be favourable in improving quality of life and prolonging survival. Individual differences should be emphasised when the intervention type was determined. Quality of the evidence Half of the studies included in this review were of high quality. Most studies did not state the methods used to seek and report quality of life outcomes and adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Yang, C; Li, J; Fu, W; Xu, W; Yang, S", "articleTypes": [], "doi": "10.1002/14651858.CD005048.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "6ec18fad-853e-4030-9c21-6245b6d7d62b", "pmid": "", "title": "Nedocromil sodium for chronic asthma in children", "imported": false, "abstract": "Abstract - Background Currently inhaled corticosteroids are the main stay in the maintenance treatment of chronic asthma in children. Although inhaled corticosteroids play a crucial role in the management of childhood asthma, the long‐term side effects of inhaled corticosteroids used in the management of chronic asthma in children are not clearly known. Objectives The objective of this review is to compare the safety and efficacy of inhaled nedocromil sodium with placebo in the treatment of chronic asthma in children. Search methods We searched the Cochrane Airway Group trials register, review articles, and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. We also searched abstracts of major respiratory society meetings. The last search was carried out in November 2009. Selection criteria Randomised placebo controlled trials comparing nedocromil sodium to placebo in the treatment of chronic asthma in children (0 to 18 years). Data collection and analysis Both authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Fifteen trials (twelve parallel group studies; three crossover trials recruiting 1422 children (837 males and 585 females)) were included. The studies were generally of good methodological quality. Two large long term studies used nedocromil for six months and four to six years and showed conflicting results in symptom free days. Short term studies (duration between 4 weeks to 12 weeks) showed that nedocromil sodium produced some improvement in a number of efficacy measures compared to placebo including FEV 1 , FVC, FEV 1 % predicted, PC20 FEV 1 , evening PEF and symptom scores. The parent's assessment of efficacy was in favour of nedocromil (odds ratio (OR) 0.5 (95% CI 0.3 to 0.8). Nedocromil sodium has a good safety profile. The only significant side effect observed was unpleasant taste. There was little evidence for a clinically dose response effect and only a few studies recruited participants with severe asthma. Authors' conclusions A limited number of small studies have shown that nedocromil is of benefit in improving lung function and some measures of symptoms, but the evidence with regard to the primary outcome of the review was conflicting. Two long‐term trials did not show consistent effects on lung function outcomes, whereas several small short‐term trials have shown benefit in these outcomes. Differing severities at baseline may explain this difference with milder participants experiencing less benefit, although the discrepancy between study findings may also reflect publication bias. Nedocromil sodium is associated with a very good safety profile with no significant short term or long‐ term adverse side effects. Although nedocromil may have advantages over inhaled corticosteroids in terms of side effects, there is a need for head to head trials of nedocromil and inhaled corticosteroids to establish whether asthma control is similar, especially in mild asthma. It is not yet clear where nedocromil should sit in relation to other therapies in the treatment of asthma in children. Plain language summary Nedocromil sodium for chronic asthma in children Nedocromil (or Tilade) is a 'preventer' therapy used to treat chronic asthma in children. It is thought to be safer than inhaled steroids and can be used for the management of mild to moderate asthma. The review of studies including 15 trials and 1422 children found that there were some encouraging results in short term studies when nedocromil was compared on its own with placebo, particularly with regard to lung function tests. However, these results were not confirmed in one large, longer term study of four to six years duration, which did not show significant difference in the primary outcome of symptom free days. This study was conducted in children who had mild asthma. There may be a role for nedocromil in the management of moderate asthma, but it should be assessed in relation to inhaled steroids, whose efficacy is well‐established. This particularly important in symptomatic asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Sridhar, AV; McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD004108.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "6edc2218-9d6f-4797-b233-e7ecb9b69f8d", "pmid": "", "title": "Preoperative carbohydrate treatment for enhancing recovery after elective surgery", "imported": false, "abstract": "Abstract - Background Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast‐track surgery protocols. Although fast‐track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis. Objectives To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data. Selection criteria We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time. Data collection and analysis Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis. Main results We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I‐II or I‐III. A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding. In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low‐quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference ‐0.13 days; 95% CI ‐0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high‐quality evidence). As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low‐quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation. Authors' conclusions Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases. Plain language summary Does giving patients carbohydrate supplements before planned surgery lead to improved recovery? Review question We reviewed the evidence on effects of carbohydrate supplements on the recovery of people undergoing planned surgical procedures. We found 27 studies investigating this question. Background Carbohydrate (sugar‐containing) nutritional supplements have become a routine part of the package of care for people undergoing planned surgical procedures. We wanted to discover whether carbohydrate supplements are a useful part of care packages used by doctors to improve recovery after planned surgical procedures. Study characteristics The evidence is current up to March 2014. We identified 27 studies and included the outcomes of 1976 participants. Studies investigated the outcomes of patients undergoing planned surgical procedures on the abdomen (18), the bones or joints (4), the heart (4) or the thyroid gland (1). Eighteen studies compared carbohydrate supplements versus an identical appearing placebo drink that did not contain carbohydrates; in six of these studies, an additional group of patients had nothing to eat or drink for at least six hours before surgery. In nine studies, taking carbohydrate supplements was compared with having nothing to eat or drink for six hours before surgery. The primary outcomes of length of hospital stay and complication rate were reported by 19 and 14 studies, respectively. Key results Patients given carbohydrates before planned surgical procedures went home between 0.04 and 0.56 days sooner than those receiving a placebo drink or having nothing to eat or drink before surgery. Carbohydrate supplements had little or no effect on complication rate or on how people feel in‐hospital during recovery from surgery. Quality of the evidence The overall quality of the evidence varied from very low to high. The quality of evidence in support of carbohydrate supplements resulting in a shorter hospital stay was very low because the included studies had important flaws in their design, a very wide range of results was described and evidence revealed that studies showing no differences in length of hospital stay may not have been published. When we looked only at well‐conducted studies, we found that carbohydrate supplements had little or no effect on length of hospital stay. The quality of evidence to support the effects of carbohydrate supplements on complication rate was low because issues with study design were identified and results were not similar across studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Smith, MD; McCall, J; Plank, L; Herbison, GP; Soop, M; Nygren, J", "articleTypes": [], "doi": "10.1002/14651858.CD009161.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "6eddd0ee-6040-4a9b-9f24-8a861187a370", "pmid": "", "title": "Iodine fortification of foods and condiments, other than salt, for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency disorders (IDD) affect close to 1.9 billion people worldwide, and are a major public health concern in many countries. Among children, iodine deficiency is the main cause of potentially preventable deficits of central nervous system development and impairment of cognitive function, as well as goitre and hypothyroidism in people of all ages. Salt iodisation is the preferred strategy for IDD prevention and control, however, in some instances where salt is not the major condiment, alternate vehicles for iodine fortification have been considered. Objectives To assess the effects of fortifying foods, beverages, condiments, or seasonings other than salt with iodine alone or in conjunction with other micronutrients, on iodine status and health‐related outcomes in all populations. Search methods Studies were identified through systematic searches of the following databases from their start date to January 2018: Cochrane Public Health Group Specialised Register; CENTRAL; MEDLINE; MEDLINE in Process; Embase; Web of Science; CINAHL; POPLINE; AGRICOLA; BIOSIS; Food Science and Technology Abstracts; OpenGrey; Bibliomap and TRoPHI; AGRIS; IBECS; Scielo; Global Index Medicus‐AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched reference list of relevant articles, conference proceedings, and databases of ongoing trials, and contacted experts and relevant organisations to identify any unpublished work. We applied no language or date restrictions. Selection criteria Studies were eligible if they were randomised or quasi‐randomised controlled trials (RCT) with randomisation at either the individual or cluster level (including cross‐over trials), non‐randomised RCTs, or prospective observational studies with a control group, such as cohort studies, controlled before‐and‐after studies, and interrupted time series. We included studies that examined the effects of fortification of food, beverage, condiment, or seasoning with iodine alone, or in combination with other micronutrients versus the same unfortified food, or no intervention. We considered the following measures: death (all‐cause), goitre, physical development, mental development, cognitive function and motor skill development, cretinism, hypothyroidism, adverse effects (any reported by trialists), urinary iodine concentration, thyroid‐stimulating hormone (TSH) concentration, and serum thyroglobulin concentration. We included all populations, including pregnant women, from any country. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias of included studies. We used random‐effects meta‐analyses to combine data and generate an overall estimate of treatment effect, when more than one study examined the same outcome measure. The overall effect estimate was calculated as the mean difference (MD) or standardised mean difference (SMD) between the intervention group and the comparison group for continuous outcomes, and as odds ratio (OR) for dichotomous outcomes. We assessed the level of heterogeneity through the I² statistic. We conducted post‐hoc subgroup analyses to explore possible sources of heterogeneity, and sensitivity analyses to check the robustness of the findings from the primary analyses. We assessed the quality of the evidence for each outcome using the GRADE framework. Where it was not possible to pool the results in a meta‐analysis, we provided a narrative summary of the outcomes. Main results Eleven studies met the criteria, providing 14 comparisons, and capturing data on 4317 participants. Seven studies were RCTs, three were cluster non‐RCTs, and one was a randomised cross‐over design. Seven studies were carried out among school children (N = 3636), three among women of reproductive age (N = 648), and one among infants (N = 33). The studies used diverse types of food as vehicle for iodine delivery: biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. Daily amounts of iodine provided ranged from 35 µg/day to 220 µg/day; trial duration ranged from 11 days to 48 weeks. Five studies examined the effect of iodine fortification alone, two against the same unfortified food, and three against no intervention. Six studies evaluated the effect of cofortification of iodine with other micronutrients versus the same food without iodine but with different levels of other micronutrients. We assessed one study to be at low risk of bias for all bias domains, three at low risk of bias for all domains apart from selective reporting, and seven at an overall rating of high risk of bias. No study assessed the primary outcomes of death, mental development, cognitive function, cretinism, or hypothyroidism, or secondary outcomes of TSH or serum thyroglobulin concentration. Two studies reported the effects on goitre, one on physical development measures, and one on adverse effects. All studies assessed urinary iodine concentration. The effects of iodine fortification compared to control on goitre prevalence (OR 1.60, 95% CI 0.60 to 4.31; 1 non‐RCT, 83 participants; very low‐quality evidence), and five physical development measures were uncertain (1 non‐RCT, 83 participants; very low‐quality evidence): weight (MD 0.23 kg, 95% CI ‐6.30 to 6.77); height (MD ‐0.66 cm, 95% CI ‐4.64 to 3.33); weight‐for‐age (MD 0.05, 95% CI ‐0.59 to 0.69); height‐for‐age (MD ‐0.30, 95% CI ‐0.75 to 0.15); and weight‐for‐height (MD ‐0.21, 95% CI ‐0.51 to 0.10). One study reported that there were no adverse events observed during the cross‐over trial (low‐quality evidence). Pooled results from RCTs showed that urinary iodine concentration significantly increased following iodine fortification (SMD 0.59, 95% CI 0.37 to 0.81; 6 RCTs, 2032 participants; moderate‐quality evidence). This is equivalent to an increase of 38.32 µg/L (95% CI 24.03 to 52.61 µg/L). This effect was not observed in the meta‐analysis of non‐RCTs (SMD 0.25, 95% CI ‐0.16 to 0.66; 3 non‐RCTs, 262 participants; very low‐quality evidence). Sensitivity analyses did not change the effect observed in the primary analyses. Authors' conclusions The evidence on the effect of iodine fortification of foods, beverages, condiments, or seasonings other than salt on reducing goitre, improving physical development measures, and any adverse effects is uncertain. However, our findings suggest that the intervention likely increases urinary iodine concentration. Additional, adequately powered, high‐quality studies on the effects of iodine fortification of foods on these, and other important outcomes, as well as its efficacy and safety, are required. Plain language summary Adding iodine to foods, other than salt, to prevent diseases caused by inadequate iodine intake Background and review question Many people around the world do not consume enough iodine. This is a problem because iodine is important for normal childhood growth and brain development, and for ensuring a healthy adult population. Inadequate intake of iodine can lead to health problems, such as intellectual disability and goitre (enlargement of the thyroid gland). Currently, the main strategy to increase the amount of iodine consumed in populations recommended by the World Health Organization is adding iodine to salt. However, in some areas where salt is not the major condiment, adding iodine to other foods has also been explored. The aim of our study was to examine the effect of adding iodine to foods, beverages, condiments, or seasonings, other than salt, on iodine nutrition status and health‐related outcomes in all populations. Study characteristics We searched for articles from different sources including published research papers, unpublished reports, and through direct communication with experts and organisations working to address iodine and micronutrient deficiency. We last searched the databases in January 2018. Eleven studies, which captured data on 4317 participants (3636 children, 648 women of reproductive age, and 33 infants), met our inclusion criteria. The type of foods used as vehicle to deliver iodine differed between the studies, and included biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. The amount of iodine provided to participants ranged from 35 µg/day to 220 µg/day, and study duration ranged from 11 days to 48 weeks. Of the 11 studies included, five examined the effect of adding iodine alone to foods compared to either no intervention or the same foods without iodine; while six evaluated the effect of adding iodine plus other micronutrients to foods compared to the same foods without iodine, but with different levels of other micronutrients. Key results No study evaluated the effect of adding iodine to foods on death, mental development, cognitive function, cretinism (a condition characterized by impaired control of physical movement and intellectual disability), hypothyroidism (underactive thyroid), thyroid‐stimulating hormone concentration, or serum thyroglobulin concentration (these are biological markers that indicate the presence of iodine deficiency when concentration in the blood is high). Two studies reported on the effect of the intervention on goitre, one study assessed five physical development measures (weight, height, weight‐for‐age, height‐for‐age, and weight‐for‐height scores), and one examined adverse effects. All studies assessed urinary iodine concentration (the concentration of iodine secreted in the urine, which indicates the presence of iodine deficiency when concentration is low in a population group, rather than in an individual). We combined the data that met our requirements in these studies in a meta‐analysis. We are uncertain of the effects of iodine fortification on the proportion of participants with goitre, or on any of the five physical development measures. One study reported narratively that no adverse effects were observed during the trial. We found a significant increase of 38.32 µg/L in urinary iodine concentration after adding iodine to foods, compared to the groups that did not have iodine added, from studies of higher quality. Quality of the evidence Using GRADE, we rated the quality of the evidence as very low for goitre and physical development measures, due to study limitations (risk of bias) and imprecise results, and low for adverse events due to indirectness and imprecise results. We rated the quality of the evidence for urinary iodine concentration, from studies in which participants were allocated to treatment groups at random (gold standard design for clinical research), as moderate. On the other hand, quality of the evidence for urinary iodine concentration from studies without this random element was rated as very low, due to study limitations and imprecise results. Conclusion Overall, there is no clear evidence on the effect of the intervention on reducing the proportion of people with goitre, improving physical growth, or adverse events. However, our results show that adding iodine to foods likely increases urinary iodine concentration. Additional studies to better quantify the effect of the intervention on these outcomes, as well as other outcomes, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Santos, JAR, Christoforou, A, Trieu, K, McKenzie, BL, Downs, S, Billot, L, Webster, J, Li, M", "articleTypes": [], "doi": "10.1002/14651858.CD010734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.119Z" }, { "id": "6ee4a476-2405-4e20-a615-0141dc8d0656", "pmid": "", "title": "Exposure to the smell and taste of milk to accelerate feeding in preterm infants", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Delgado Paramo, L, Bronnert, A, Lin, L, Bloomfield, FH, Muelbert, M, Harding, JE", "articleTypes": [], "doi": "10.1002/14651858.CD013038.pub3 AB - Abstract - Background Preterm infants (born before 37 weeks' gestation) are often unable to co‐ordinate sucking, swallowing, and breathing for oral feeding because of their immaturity. In such cases, initial nutrition is provided by orogastric or nasogastric tube feeding. Feeding intolerance is common and can delay attainment of full enteral and sucking feeds, prolonging the need for nutritional support and the hospital stay. Smell and taste play an important role in the activation of physiological pre‐absorptive processes that contribute to food digestion and absorption. However, during tube feeding, milk bypasses the nasal and oral cavities, limiting exposure to the smell and taste of milk. Provision of the smell and taste of milk with tube feeds offers a non‐invasive and low‐cost intervention that, if effective in accelerating the transition to enteral feeds and subsequently to sucking feeds, would bring considerable advantages to infants, their families, and healthcare systems. Objectives To assess whether exposure to the smell or taste (or both) of breastmilk or formula administered with tube feeds can accelerate the transition to full sucking feeds without adverse effects in preterm infants. Search methods We conducted searches in CENTRAL, MEDLINE, Embase, CINAHL, and Epistemonikos to 26 April 2023. We also searched clinical trial databases and conference proceedings. Selection criteria We included randomised and quasi‐randomised studies that evaluated exposure versus no exposure to the smell or taste of milk (or both) immediately before or at the time of tube feeds. Data collection and analysis Two review authors independently selected studies, assessed risk of bias, and extracted data according to Cochrane Neonatal methodology. We performed meta‐analyses using risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence. Main results We included eight studies (1277 preterm infants). Seven studies (1244 infants) contributed data for meta‐analysis. The evidence suggests that exposure to the smell and taste of milk with tube feeds has little to no effect on time taken to reach full sucking feeds (MD −1.07 days, 95% CI −2.63 to 0.50; 3 studies, 662 infants; very low‐certainty evidence). Two studies reported no adverse effects related to the intervention. The intervention may have little to no effect on duration of parenteral nutrition (MD 0.23 days, 95% CI −0.24 to 0.71; 3 studies, 977 infants; low‐certainty evidence), time to reach full enteral feeds (MD −0.16 days, 95% CI −0.45 to 0.12; 1 study, 736 infants; very low‐certainty evidence) or risk of necrotising enterocolitis (RR 0.93, 95% CI 0.47 to 1.84; 2 studies, 435 infants; low‐certainty evidence), although the evidence for time to reach full enteral feeds is very uncertain. Exposure to the smell and taste of milk with tube feeds probably has little to no effect on risk of late infection (RR 1.14, 95% CI 0.74 to 1.75; 2 studies, 436 infants; moderate‐certainty evidence). There were no data available to assess feeding intolerance. The included studies had small sample sizes and methodological limitations, including unclear or lack of randomisation (four studies), lack of blinding of participants and personnel (five studies), unclear or lack of blinding of the outcome assessor (all eight studies), and different inclusion criteria and methods of administering the interventions. Authors' conclusions The results of our meta‐analyses suggest that exposure to the smell and taste of milk with tube feeds may have little to no effect on time to reach full sucking feeds and time to reach full enteral feeds. We found no clear difference between exposure and no exposure to the smell or taste of milk on safety outcomes (adverse effects, necrotising enterocolitis, and late infection). Results from one ongoing study and two studies awaiting classification may alter the conclusions of this review. Future research should examine the effect of exposing preterm infants to the smell and taste of milk with tube feeds on health outcomes during hospitalisation, such as attainment of feeding skills, safety, feed tolerance, infection, and growth. Future studies should be powered to detect the effect of the intervention in infants of different gestational ages and on each sex separately. It is also important to determine the optimal method, frequency, and duration of exposure. Plain language summary Does exposure to the smell and taste of milk accelerate feeding in tube‐fed preterm infants? Key messages • Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time it takes preterm infants to reach full sucking feeds.
• We found no evidence of any unwanted effects of exposure to the smell and taste of milk with tube feeds in newborn infants. What is tube feeding? Infants born preterm (before 37 weeks of pregnancy) often need to be fed via a thin tube inserted through the mouth (orogastric tube) or nose (nasogastric tube) into the stomach until they are able to suck all of their feeds. Why is the smell and taste of milk important for tube‐fed babies? Initially, only small volumes of milk are given, and this is gradually increased depending on how well the babies tolerate the milk. Smell and taste have a significant role in helping with digestion and absorption of food, and since infants being fed by a tube may not experience the smell or taste of milk, they might be taking longer to tolerate larger volumes of milk. What did we want to find out? We wanted to find out if exposing infants to the smell and taste of milk before or while they were being fed through a tube could help them tolerate greater volumes of milk more quickly and improve their overall growth and development. We also wanted to know if this method had any unwanted effects. What did we do? We searched for studies that investigated exposing preterm infants to the smell or taste (or both) of milk with tube feeds, compared to no such exposure. We compared and summarised the results of the studies and rated the certainty of the evidence, based on factors such as study methods and number of infants included. What did we find? We identified eight completed studies involving 1277 preterm infants admitted to a neonatal intensive care unit. Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time to reach full sucking feeds, but the results are very uncertain. Two studies reported that no infants had any unwanted effects related to exposure to the smell and taste of milk with tube feeds. Exposure to the smell and taste of milk may have little to no effect on duration of intravenous nutrition (feeding through a vein), time to reach full enteral feeds (feeds though a tube into the stomach), or on the risk of necrotising enterocolitis (a serious intestinal disease), although the results for time to full enteral feeds are very uncertain. Exposure to the smell and taste of milk probably has little or no effect on the risk of developing an infection more than two days after birth. What are the limitations of the evidence? We have little confidence in the evidence because: • we identified few studies;
• most studies were small and provided different types of exposure to smell and taste;
• in many studies, clinicians and parents were aware of which treatment the infant was receiving; and
• the studies did not investigate all the outcomes we were interested in. How up‐to‐date is this evidence? This review is current to April 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.744Z" }, { "id": "6efcca1b-fee4-4b1b-a9ba-fd64f8246470", "pmid": "", "title": "Progesterone receptor modulators for endometriosis", "imported": false, "abstract": "Abstract - Rationale Endometriosis is defined as the presence of endometrium‐like tissue developing outside the uterine cavity. This condition is oestrogen‐dependent and thus is seen primarily during the reproductive years. Owing to their antiproliferative effects on the endometrium, progesterone receptor modulators (PRMs) have been advocated for the treatment of endometriosis. This is an update of a Cochrane review previously published in 2017. Objectives To assess the effectiveness and safety of progesterone receptor modulators (PRMs) in the management of endometriosis. Search methods To identify studies, we searched online sources, including the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, ClinicalTrials.gov and the WHO (World Health Organization) trial registry up to 16 April 2026. We also checked reference lists and contacted study authors and experts. Eligibility criteria We included randomised controlled trials (RCTs) comparing PRMs with placebo, no treatment or other medical treatment, in women with symptomatic endometriosis. Outcomes Our critical outcomes were overall pain; improvement in the most troublesome symptom, including dysmenorrhoea and dyspareunia; and adverse events resulting from the PRM intervention. Our important outcomes included quality of life (QoL) and patient satisfaction with treatment. Risk of bias We used the Cochrane tool RoB 2 to assess the risk of bias in the outcomes of this review. Synthesis methods Two review authors independently assessed studies against the inclusion criteria, extracted data and assessed risk of bias, consulting a third review author where required. We analysed dichotomous outcomes using Mantel‐Haenszel odds ratios (ORs), 95% confidence intervals (CIs) and the fixed‐effect model. We analysed continuous outcomes using the mean difference (MD) between groups, presented with 95% CIs. We employed the GRADE approach to assess the certainty of the evidence as high, moderate, low or very low. Included studies No new studies were eligible for inclusion in this update. Of the nine studies (922 women) already included in the review, two compared mifepristone versus placebo or compared different doses of mifepristone, and four either compared gestrinone versus danazol, gestrinone versus gonadotropin‐releasing hormone (GnRH) analogues or compared different doses of gestrinone. One study compared asoprisnil versus placebo. The asoprisnil study did not provide extractable numerical data and was included in the narrative synthesis only. Two of the studies did not report any of the review's prespecified outcomes. Synthesis of results Certainty of the evidence We judged the certainty of evidence as low to very low. The main limitations of the evidence were serious risk of bias (associated with poor reporting of methods and high or unclear rates of attrition), very serious imprecision (associated with low event rates and wide confidence intervals, with some large effect estimates) and serious indirectness (outcomes assessed in selected subgroups). PRM versus placebo Mifepristone versus placebo These results are based on one study (360 participants) that measured outcomes after three months. The study did not report overall pain. At three months, mifepristone may improve dysmenorrhoea (OR 0.07, 95% CI 0.03 to 0.15; 1 study, 342 participants; low‐certainty evidence), suggesting that if 40% of women taking placebo experience dysmenorrhoea, then between 3% and 10% of women taking mifepristone will do so. We are uncertain whether mifepristone improves dyspareunia (OR 0.23, 95% CI 0.10 to 0.51; 1 study, 223 participants; very low‐certainty evidence). However, mifepristone may increase hot flushes (OR 28.79, 95% CI 3.93 to 210.73; 1 study, 360 participants; low‐certainty evidence). Mifepristone may make little or no difference after three months of treatment to the prevalence of nausea (OR 1.72, 95% CI 0.20 to 15.03; 1 study, 360 participants; low‐certainty evidence). PRM versus other medical treatment Gestrinone versus danazol These results are based on two studies (302 participants) that measured outcomes after six months. We are uncertain of the effects of gestrinone relative to danazol on the improvement of overall pain (dichotomous outcome: participants reporting no or mild pelvic pain counted as 'improved') (OR 0.47, 95% CI 0.04 to 5.70; 1 study, 38 participants), dysmenorrhoea (Not estimable; 1 study, 38 participants), or dyspareunia (OR 1.00, 95% CI 0.13 to 7.94; 1 study, 38 participants (all very low‐certainty evidence). We are uncertain about the effects of gestrinone relative to danazol on hot flushes (OR 0.79, 95% CI 0.50 to 1.26; 2 studies, 302 participants; very low‐certainty evidence). There may be little or no difference between gestrinone and danazol in rates of nausea (OR 1.36, 95% CI 0.84 to 2.19; 2 studies, 302 participants; low‐certainty evidence). Gestrinone versus a GnRH analogue (leuprorelin) These results are based on one study (55 participants) that measured outcomes after six months. There may be little to no difference between gestrinone and leuprorelin in non‐menstrual pain (MD −0.41, 95% CI −1.76 to 0.94; 1 study, 55 participants; low‐certainty evidence). Women taking gestrinone may have higher dysmenorrhoea scores than those taking leuprorelin (MD 0.82, 95% CI 0.15 to 1.49; 1 study, 55 participants; low‐certainty evidence), but gestrinone may improve dyspareunia more than leuprorelin (MD −1.16, 95% CI −2.08 to −0.24; 1 study, 52 participants; low‐certainty evidence). There may be lower rates of hot flushes with gestrinone than leuprorelin (OR 0.20, 95% CI 0.06 to 0.63; 1 study, 55 participants; low‐certainty evidence). There may be little or no difference between gestrinone and leuprorelin in rates of nausea (OR 1.04, 95% CI 0.06 to 17.49; 1 study, 55 participants; low‐certainty evidence). Authors' conclusions Mifepristone may improve dysmenorrhoea in women with endometriosis, but it might increase the prevalence of adverse events, such as hot flushes. The evidence is very uncertain regarding its effect on dyspareunia. Gestrinone may be less effective than leuprorelin in treating dysmenorrhoea, but it may improve dyspareunia. It may be associated with lower rates of hot flushes and similar rates of nausea. We are uncertain about the effect of gestrinone compared to danazol. We found insufficient evidence to permit firm conclusions about the safety and effectiveness of other progesterone receptor modulators. Funding This Cochrane review had no dedicated funding. Registration Protocol (2012) DOI: 10.1002/14651858.CD009881 Review (2017) DOI: 10.1002/14651858.CD009881.pub2 Plain language summary What are the benefits and risks of medicines called progesterone receptor modulators (PRMs) for treating endometriosis (a condition where tissue grows outside the womb)? Key messages In the management of endometriosis (a condition where tissue grows outside the womb), studies that compared a progesterone receptor modulator (PRM; a medicine that changes how the hormone progesterone acts in the body) against placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested) found that a PRM called mifepristone may improve painful periods. However, it may cause hot flushes. A PRM called gestrinone may be less effective than medicines known as gonadotropin‐releasing hormone (GnRH) analogues (which reduce the amount of oestrogen made by the ovaries) for treating painful periods, but may improve pain during sex. Gestrinone may also cause fewer hot flushes. We do not know how gestrinone compares to a treatment called danazol in terms of pain not related to periods, painful periods or pain during sex. We do not know whether gestrinone or danazol causes more unwanted effects. Future studies should compare progesterone receptor modulators with medicines currently used to treat endometriosis symptoms and focus on assessing pain using recognised and reliable methods. Larger, well‐designed studies are also needed to assess the benefits and unwanted effects of progesterone receptor modulators other than mifepristone and gestrinone. What is endometriosis? Endometriosis is a condition where tissue similar to the lining of the womb (uterus) grows outside the womb. Endometriosis is oestrogen‐dependent and thus is seen mainly during the reproductive years. It can cause pain in the tummy area (abdomen), generally during periods (menstruation) or associated with sexual intercourse. Endometriosis is treated through different types of medical or surgical treatment. Progesterone receptor modulators (PRMs) are medicines that change how the hormone progesterone acts in the body. PRMs include mifepristone, gestrinone, ulipristal acetate, vilaprisan and asoprisnil. Because they can slow down or stop the growth of tissue in the lining of the uterus, they have been suggested as a treatment for endometriosis. What did we want to find out? We wanted to know whether, in patients with endometriosis, PRMs are better than placebo ('dummy' treatment), no treatment or other medical treatment for improving overall pain, pain during periods and pain during sexual intercourse. We also wanted to know if these medications were safe by assessing unwanted effects experienced by patients, such as hot flushes and feeling sick (nausea). What did we do? We searched for studies that investigated the effectiveness of PRMs for symptoms associated with endometriosis and whether they caused unwanted effects. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included nine studies involving 922 women aged 18 to 45 years. Most studies tested the PRMs mifepristone or gestrinone. One study tested asoprisnil, but the study was published only as a short summary without results that we could use. Two of the studies did not measure any of the effects we were interested in. Main results Progesterone receptor modulators versus placebo When compared to a placebo, mifepristone: may reduce painful periods after three months of treatment (based on 1 study of 342 women); may cause more unwanted effects, such as hot flushes (1 study, 360 women); may make little or no difference to nausea (1 study, 360 women); and we are uncertain whether mifepristone reduces pain during sex (1 study, 223 women). Progesterone receptor modulators versus other medical treatment When compared to danazol, one study of 38 women showed that: we do not know whether gestrinone improves pain symptoms after six months of treatment (1 study, 38 women); we do not know whether gestrinone causes more or fewer hot flushes or makes no difference (2 studies, 302 women); and gestrinone and danazol may cause similar rates of nausea, but the results are very uncertain (2 studies, 302 women). When compared to a GnRH analogue (leuprorelin), one study of 55 women found that: gestrinone may be less efficient in treating painful periods after six months of treatment (1 study, 55 women); but gestrinone may reduce pain during sex (1 study, 52 women); gestrinone may be similar to leuprorelin in terms of general pain experienced (1 study, 55 women); gestrinone may cause fewer hot flushes and similar levels of nausea (1 study, 55 women). What are the limitations of the evidence? Our confidence in the evidence is low to very low, mainly because some studies had one or more of these problems: they did not have many people taking part; they focused on specific settings or populations; they used methods likely to introduce errors in their results; they did not clearly report how they were conducted; they did not clearly report whether the people taking part knew which treatment they had received, which could have affected the study results. How up to date is this evidence? This review updates a previous review. The evidence is up to date to April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Grammatis, AL; Gibbons, T; Anucha, EN; Becker, CM", "articleTypes": [], "doi": "10.1002/14651858.CD009881.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "6f01236a-44e2-4274-8ed4-e510e473ff73", "pmid": "", "title": "Xylitol for preventing acute otitis media in children up to 12 years of age", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Azarpazhooh, A, Lawrence, HP, Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD007095.pub3 AB - Abstract - Background Acute otitis media (AOM) is the most common bacterial infection among young children in the United States. There are limitations and concerns over its treatment with antibiotics and surgery and so effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk of dental decay. Xylitol can reduce the adherence of Streptococcus pneumoniae ( S pneumoniae ) and Haemophilus influenzae ( H influenzae ) to nasopharyngeal cells in vitro. This is an update of a review first published in 2011. Objectives To assess the efficacy and safety of xylitol to prevent AOM in children aged up to 12 years. Search methods We searched CENTRAL (to Issue 12, 2015), MEDLINE (1950 to January 2016), Embase (1974 to January 2016), CINAHL (1981 to January 2016), LILACS (1982 to January 2016), Web of Science (2011 to January 2016) and International Pharmaceutical Abstracts (2000 to January 2016). Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs of children aged 12 years or younger where xylitol supplementation was compared with placebo or no treatment to prevent AOM. Data collection and analysis Two review authors independently selected trials from search results, assessed and rated study quality and extracted relevant data for inclusion in the review. We contacted trial authors to request missing data. We noted data on any adverse events of xylitol. We extracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR), risk difference (RD) and associated 95% confidence intervals (CI). Main results We identified five clinical trials that involved 3405 children for inclusion. For this 2016 update, we identified one new trial for inclusion. This trial was systematically reviewed but due to several sources of heterogeneity, was not included in the meta‐analysis. The remaining four trials were of adequate methodological quality. In three RCTs that involved a total of 1826 healthy Finnish children attending daycare, there is moderate quality evidence that xylitol (in any form) can reduce the risk of AOM from 30% to around 22% compared with the control group (RR 0.75, 95% CI 0.65 to 0.88). Among the reasons for dropouts, there were no significant differences in abdominal discomfort and rash between the xylitol and the control groups. Xylitol was not effective in reducing AOM among healthy children during a respiratory infection (RR 1.13, 95% CI 0.83 to 1.53; moderate quality evidence) or among otitis‐prone healthy children (RR 0.90, 95% CI 0.67 to 1.21; low‐quality evidence). Authors' conclusions There is moderate quality evidence showing that the prophylactic administration of xylitol among healthy children attending daycare centres can reduce the occurrence of AOM. There is inconclusive evidence with regard to the efficacy of xylitol in preventing AOM among children with respiratory infection, or among otitis‐prone children. The meta‐analysis was limited because data came from a small number of studies, and most were from the same research group. Plain language summary Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age Review question 
 We reviewed the evidence about the effectiveness and safety of xylitol to prevent acute middle ear infection (acute otitis media; AOM) in children up to 12 years old. Background 
 AOM is the most common bacterial infection among young children in the United States. Although serious complications are rare, this common childhood ailment imposes a huge impact on the healthcare system. In the United States, it accounted for almost 20 million office visits. Antibiotic treatment of AOM is costly and raises concerns about the development of antibiotic‐resistant strains of bacteria. Surgery is invasive and costly, and because of these factors, effective measures for preventing AOM are sought. An alternative treatment is xylitol or birch sugar. Xylitol has been used for decades as a natural non‐sugar sweetener principally in chewing gums, confectionery, toothpaste and medicines, and can reduce the risk of tooth decay. Search date We searched the literature up to January 2016. This is an update of a review that was last published in 2011. Study characteristics 
 We identified five clinical trials that involved 3405 children, mostly from the same research group. Four trials were conducted in Finland and enrolled healthy children (three trials) or children with an acute respiratory infection (one trial). The fifth trial was conducted in the USA and enrolled otitis‐prone children who were recruited from attendance at general medical practices. Study funding sources All five trials received governmental funding; and the Finnish study investigators have a US patent for the use of xylitol to treat respiratory infections. Key results Xylitol, administered in chewing gum, lozenges or syrup, can reduce the occurrence of AOM among healthy children with no acute upper respiratory infection from 30% to 22%. There is no difference in side effects (namely, abdominal discomfort and rash). Based on these results we would expect that out of 1000 children up to 12 years of age, 299 would experience an AOM compared with between 194 and 263 children who would experience an AOM if they are provided with xylitol chewing gum. The preventive effect among healthy children with respiratory infection or among otitis‐prone children is inconclusive. Quality of the evidence 
 The quality of evidence was moderate for healthy children and children with respiratory infections but low for otitis‐prone children.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.740Z" }, { "id": "6f212beb-f208-4c43-bb8a-17e0fd50b465", "pmid": "", "title": "A Randomized, Double-blind, Placebo-controlled, Crossover Study to Evaluate the Influence of the A118G Polymorphism in the mu Opioid Receptor Gene (OPRM1) on Effects of GSK1521498 and Naltrexone on Physiological and Behavioural Markers of Brain Function in Healthy Social Drinkers", "imported": false, "abstract": "A total of at least 48 healthy subjects with a history of social drinking will be recruited into this single-centre, randomized, double-blind, cross-over study. Subjects will be genetically stratified to result in equal numbers of A118G 'AA' homozygotes (n=24) and A118G 'G' carriers (n=24).", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "6f3594c6-05af-401e-a8f1-17d60d7740ea", "pmid": "", "title": "Using Fenfluramine to Test the Serotonin Deficiency Theory of Depression", "imported": false, "abstract": "Clinical depression is a common and disabling condition characterised by persistent low mood and loss of interest that interferes with daily functioning. Serotonin is a key brain neurotransmitter involved in mood regulation, and a leading theory proposes that depression is associated with impaired serotonin function (the serotonin deficiency hypothesis), which underpins the use of selective serotonin reuptake inhibitors (SSRIs) as first-line antidepressant treatments. However, the strength and specificity of the link between serotonin dysfunction and depressive symptoms in humans remains uncertain and requires direct evidence in living human brains.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.158Z" }, { "id": "6f3eb906-c595-480f-8d7c-ea9385405059", "pmid": "", "title": "Diet or exercise, or both, for weight reduction in women after childbirth", "imported": false, "abstract": "Abstract - Background Weight retention after pregnancy may contribute to obesity. It is known that diet and exercise are recommended components of any weight loss programme in the general population. However, strategies to achieve healthy body weight among postpartum women have not been adequately evaluated. Objectives The objectives of this review were to evaluate the effect of diet, exercise or both for weight reduction in women after childbirth, and to assess the impact of these interventions on maternal body composition, cardiorespiratory fitness, breastfeeding performance and other child and maternal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012) and LILACS (31 January 2012). We scanned secondary references and contacted experts in the field. We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 30 April 2013 and added the results to the awaiting classification section of the review. Selection criteria All published and unpublished randomised controlled trials (RCTs) and quasi‐randomised trials of diet or exercise or both, among women during the postpartum period. Data collection and analysis Both review authors independently assessed trial quality and extracted data. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data. Data were analysed with a fixed‐effect model. A random‐effects model was used in the presence of heterogeneity. Main results Fourteen trials were included, but only 12 trials involving 910 women contributed data to outcome analysis. Women who exercised did not lose significantly more weight than women in the usual care group (two trials; n = 53; MD ‐0.10 kg; 95% confidence interval (CI) ‐1.90 to 1.71). Women who took part in a diet (one trial; n = 45; MD ‐1.70 kg; 95% CI ‐2.08 to ‐1.32), or diet plus exercise programme (seven trials; n = 573; MD ‐1.93 kg; 95% CI ‐2.96 to ‐0.89; random‐effects, T² = 1.09, I² = 71%), lost significantly more weight than women in the usual care group. There was no difference in the magnitude of weight loss between diet alone and diet plus exercise group (one trial; n = 43; MD 0.30 kg; 95% CI ‐0.06 to 0.66). The interventions seemed not to affect breastfeeding performance adversely. Authors' conclusions Evidence from this review suggests that both diet and exercise together and diet alone help women to lose weight after childbirth. Nevertheless, it may be preferable to lose weight through a combination of diet and exercise as this improves maternal cardiorespiratory fitness and preserves fat‐free mass, while diet alone reduces fat‐free mass. This needs confirmation in large trials of high methodological quality. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby. Plain language summary Diet or exercise, or both, for weight reduction in women carrying excess weight after childbirth Women naturally gain weight during pregnancy and many gradually lose it afterwards. Some women, though, find it difficult to lose the gained weight in the year or two following the birth of the baby and there is concern that this may be a health risk for them. The retention of weight gained during pregnancy may contribute to obesity, which can increase the risk of diabetes, heart disease and high blood pressure. It is suggested that women who return to their pre‐pregnancy weight by about six months have a lower risk of being overweight 10 years later. The review looked for randomised studies to assess the impact of dieting or exercise, or both, on women's weight loss in the months after giving birth. It paid particular attention to breastfeeding women to be sure that breastfeeding was not compromised. The review of trials found 14 studies, with 12 studies involving 910 women carrying excess weight after childbirth that contributed data for analysis. The findings suggest that diet combined with exercise or diet alone compared with usual care seemed to help with weight loss after giving birth. There is potential for these interventions to play a role in preventing future maternal obesity. There was not sufficient evidence to be sure that exercise or diet did not interfere with breastfeeding though it appeared not to in the included studies. It seems preferable to lose weight through a combination of dieting and exercise, compared to dieting alone, because exercise is thought to improve circulation and heart fitness, and to preserve lean body mass. Further research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Amorim Adegboye, AR, Linne, YM", "articleTypes": [], "doi": "10.1002/14651858.CD005627.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.751Z" }, { "id": "6f47b1ba-b9ac-4f7e-bdc1-5809c4fb0a3e", "pmid": "", "title": "Chinese medicinal herbs for the common cold", "imported": false, "abstract": "Abstract - Background Chinese medicinal herbs are frequently used to treat the common cold in China. Until now, their efficacy has not been systematically reviewed. Objectives To assess the effectiveness and safety of Chinese medicinal herbs for the common cold. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2008, issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to May 2008); EMBASE (1980 to May 2008); AMED (1985 to May 2008); the Chinese Biomedical Database (CBMdisc) (1978 to May 2008); and China National Knowledge Infrastructure (CNKI) (1994 to May 2008). Selection criteria Randomised controlled trials (RCTs) studying the efficacy of Chinese medicinal herb(s) for the treatment of the common cold. Data collection and analysis Four review authors telephoned the original trial authors of the RCTs identified by our searches to verify the randomisation procedure. Two review authors extracted and analysed data from trials which met the inclusion criteria. Main results We found17 studies involving 3212 patients. The methods of 15 studies were at high risk of bias. In only two studies was the risk of bias low. Trials used \"positive drugs\", of which the efficacy was not known, as controls. Different Chinese herbal preparations were tested in nearly all trials. In only one trial was a Chinese herbal preparation tested twice. In seven trials, six herbal preparations were found to be more effective at enhancing recovery than the control preparations. In the other 10 studies, seven herbal preparations were not shown to be significantly different from the control. One study did not describe the difference between the intervention and control groups. Authors' conclusions Chinese herbal medicines may shorten the symptomatic phase in patients with the common cold. However, the lack of trials of low enough risk of bias, or using a placebo or a drug clearly identified as a control, means that we are uncertain enough to be unable to recommend any kind of Chinese medicinal herbs for the common cold. Plain language summary Chinese medicinal herbs to treat the common cold The common cold is the most widespread acute respiratory tract illness affecting all age groups. Many Chinese herbal medicines are used to treat this illness in China. Although we included 17 trials, involving 3212 patients, in this review, the risk of bias was so high that the evidence did not support using any Chinese herbal preparation(s) for the common cold. Well‐designed clinical trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Zhang, X, Wu, T, Zhang, J, Yan, Q, Xie, L, Liu, GJ", "articleTypes": [], "doi": "10.1002/14651858.CD004782.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.081Z" }, { "id": "6f526d9c-36de-499e-a4ab-97a274392f7d", "pmid": "", "title": "Statins for children with familial hypercholesterolemia", "imported": false, "abstract": "Abstract - Background Familial hypercholesterolemia is one of the most common inherited metabolic diseases and is an autosomal dominant disorder meaning heterozygotes, or carriers, are affected. Those who are homozygous have severe disease. The average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500, although recent genetic epidemiological data from Denmark and next generation sequencing data suggest the frequency may be closer to 1 in 250. Diagnosis of familial hypercholesterolemia in children is based on elevated total cholesterol and low‐density lipoprotein cholesterol levels or DNA‐based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong treatment, started in childhood, is needed to reduce the risk of cardiovascular disease. In children with the disease, diet was the cornerstone of treatment but the addition of lipid‐lowering medications has resulted in a significant improvement in treatment. Anion exchange resins, such as cholestyramine and colestipol, were found to be effective, but they are poorly tolerated. Since the 1990s studies carried out on children aged 6 to 17 years with heterozygous familial hypercholesterolemia have demonstrated significant reductions in their serum total and low‐density lipoprotein cholesterol levels. While statins seem to be safe and well‐tolerated in children, their long‐term safety in this age group is not firmly established. This is an update of a previously published version of this Cochane Review. Objectives To assess the effectiveness and safety of statins in children with heterozygous familial hypercholesterolemia. Search methods Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline. Date of most recent search: 04 November 2019. Selection criteria Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. Data collection and analysis Two authors independently assessed studies for inclusion and extracted data. Main results We found 26 potentially eligible studies, of which we included nine randomized placebo‐controlled studies (1177 participants). In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). There may be little or no difference in liver function (serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations) between treated and placebo groups at any time point (low‐quality evidence). There may be little or no difference in myopathy (as measured in change in creatinine levels) (low‐quality evidence) or clinical adverse events (moderate‐quality evidence) with statins compared to placebo. One study on simvastatin showed that this may slightly improve flow‐mediated dilatation of the brachial artery (low‐quality evidence), and on pravastatin for two years may have induced a regression in carotid intima media thickness (low‐quality evidence). No studies reported rhabdomyolysis (degeneration of skeletal muscle tissue) or death due to rhabdomyolysis, quality of life or compliance to study medication. Authors' conclusions Statin treatment is an effective lipid‐lowering therapy in children with familial hypercholesterolemia. Few or no safety issues were identified. Statin treatment seems to be safe in the short term, but long‐term safety remains unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians and their care transferred to an adult lipidologist once they reach 18 years of age. Large long‐term randomized controlled trials are needed to establish the long‐term safety issues of statins. Plain language summary Statins for children with inherited high blood cholesterol Review question We reviewed the evidence for the effectiveness and safety of statins in children with inherited high blood cholesterol. Background Familial hypercholesterolemia is an inherited disease in which the blood cholesterol level is high. Vascular disease, i.e. furring up of the blood vessels, often occurs at an earlier age than usual, especially amongst men. Thus lifelong therapies, started in childhood, to reduce blood cholesterol are needed. In children with familial hypercholesterolemia, diet has been the main treatment option. Medications, such as cholestyramine and colestipol, have been used effectively, but due to their unpleasant taste they are poorly tolerated and treatment plans are not followed. The advent of statin therapy for children has improved treatment and this review updates the previous published version. Search date The evidence is current to: 04 November 2019. Study characteristics The review included 9 studies with 1177 people with heterozygous familial hypercholesterolemia aged between 4 and 18 years of age. Studies compared different statin treatments with a substance which contains no medication (termed placebo) and people were selected for one treatment or the other randomly. The studies lasted from 12 weeks to 104 weeks. Key results In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins probably reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). The levels of the liver enzymes, serum aspartate and alanine aminotransferase, and the muscle enzyme, creatinine kinase, did not differ between treated and placebo groups at any time point (low‐quality evidence). The risks of myopathy (disease of muscle tissue) and side‐effects were very low and similar in both groups (low‐quality evidence). Two of the statins, simvastatin and pravastatin may have a positive effect on two of the major blood vessels typically affected by raised cholesterol levels (low‐quality evidence). Quality of the evidence Information regarding blinding (performance bias and detection bias), was available for all nine studies; each was described as double blind, indicating that participants and those participating in treatment procedures were blinded to treatment. In two studies information on how the participants were allocated to treatment groups (selection bias) was clearly presented, but this information was not clearly stated in the remaining seven studies. There is a lack of information whether investigators knew which treatment group participants would be put into (selection bias) and or whether selective reporting (reporting bias) occurred, but it is very unlikely. In conclusion, it can be stated all the studies appeared to be well run and we do not think any of the above‐mentioned factors influenced the results in a negative way. Quality of evidence varied from high (change in serum low‐density lipoprotein (LDL) cholesterol) through moderate (adverse events) to low (change in blood vessel wall (carotid intima‐media) thickness, change in measures if growth and maturation, liver dysfunction, myopathy and change in blood wall (endothelial) function).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Vuorio, A; Kuoppala, J; Kovanen, PT; Humphries, SE; Tonstad, S; Wiegman, A; Drogari, E; Ramaswami, U", "articleTypes": [], "doi": "10.1002/14651858.CD006401.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "6f5b9d26-5cbe-4535-b41d-254f89bbabcf", "pmid": "", "title": "Desferrioxamine mesylate for managing transfusional iron overload in people with transfusion‐dependent thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. Desferrioxamine mesylate (desferrioxamine) is one of the most widely used iron chelators. Substantial data have shown the beneficial effects of desferrioxamine, although adherence to desferrioxamine therapy is a challenge. Alternative oral iron chelators, deferiprone and deferasirox, are now commonly used. Important questions exist about whether desferrioxamine, as monotherapy or in combination with an oral iron chelator, is the best treatment for iron chelation therapy. Objectives To determine the effectiveness (dose and method of administration) of desferrioxamine in people with transfusion‐dependent thalassaemia. To summarise data from trials on the clinical efficacy and safety of desferrioxamine for thalassaemia and to compare these with deferiprone and deferasirox. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We also searched MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus ongoing trials registers and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). All searches were updated to 5 March 2013. Selection criteria Randomised controlled trials comparing desferrioxamine with placebo, with another iron chelator, or comparing two schedules or doses of desferrioxamine, in people with transfusion‐dependent thalassaemia. Data collection and analysis Six authors working independently were involved in trial quality assessment and data extraction. For one trial, investigators supplied additional data upon request. Main results A total of 22 trials involving 2187 participants (range 11 to 586 people) were included. These trials included eight comparisons between desferrioxamine alone and deferiprone alone; five comparisons between desferrioxamine combined with deferiprone and deferiprone alone; eight comparisons between desferrioxamine alone and desferrioxamine combined with deferiprone; two comparisons of desferrioxamine with deferasirox; and two comparisons of different routes of desferrioxamine administration (bolus versus continuous infusion). Overall, few trials measured the same or long‐term outcomes. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage; none of these included a comparison with deferasirox. Five trials reported a total of seven deaths; three in patients who received desferrioxamine alone, two in patients who received desferrioxamine and deferiprone. A further death occurred in a patient who received deferiprone in another who received deferasirox alone. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. One trial planned five years of follow up but was stopped early due to the beneficial effects of a reduction in serum ferritin levels in those receiving combined desferrioxamine and deferiprone treatment compared with deferiprone alone. The results of this and three other trials suggest an advantage of combined therapy with desferrioxamine and deferiprone over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no evidence for the improved efficacy of combined desferrioxamine and deferiprone therapy against monotherapy from direct or indirect measures of liver iron. Earlier trials measuring the cardiac iron load indirectly by measurement of the magnetic resonance imaging T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, meta‐analysis of two trials showed a significantly lower left ventricular ejection fraction in patients who received desferrioxamine alone compared with those who received combination therapy using desferrioxamine with deferiprone. Adverse events were recorded by 18 trials. These occurred with all treatments, but were significantly less likely with desferrioxamine than deferiprone in one trial, relative risk 0.45 (95% confidence interval 0.24 to 0.84) and significantly less likely with desferrioxamine alone than desferrioxamine combined with deferiprone in two other trials, relative risk 0.33 (95% confidence interval 0.13 to 0.84). In particular, four studies reported permanent treatment withdrawal due to adverse events from deferiprone; only one of these reported permanent withdrawals associated with desferrioxamine. Adverse events also occurred at a higher frequency in patients who received deferasirox than desferrioxamine in one trial. Eight trials reported local adverse reactions at the site of desferrioxamine infusion including pain and swelling. Adverse events associated with deferiprone included joint pain, gastrointestinal disturbance, increases in liver enzymes and neutropenia; adverse events associated with deferasirox comprised increases in liver enzymes and renal impairment. Regular monitoring of white cell counts has been recommended for deferiprone and monitoring of liver and renal function for deferasirox. In summary, desferrioxamine and the oral iron chelators deferiprone and deferasirox produce significant reductions in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised clinical trials to suggest that any one of these has a greater reduction of clinically significant end organ damage, although in two trials, combination therapy with desferrioxamine and deferiprone showed a greater improvement in left ventricular ejection fraction than desferrioxamine used alone. Authors' conclusions Desferrioxamine is the recommended first‐line therapy for iron overload in people with thalassaemia major and deferiprone or deferasirox are indicated for treating iron overload when desferrioxamine is contraindicated or inadequate. Oral deferasirox has been licensed for use in children aged over six years who receive frequent blood transfusions and in children aged two to five years who receive infrequent blood transfusions. In the absence of randomised controlled trials with long‐term follow up, there is no compelling evidence to change this conclusion. Worsening iron deposition in the myocardium in patients receiving desferrioxamine alone would suggest a change of therapy by intensification of desferrioxamine treatment or the use of desferrioxamine and deferiprone combination therapy. Adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. People treated with all chelators must be kept under close medical supervision and treatment with deferiprone or deferasirox requires regular monitoring of neutrophil counts or renal function respectively. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcomes of deferiprone, deferasirox and desferrioxamine. Plain language summary Desferrioxamine mesylate (desferrioxamine) for managing excess iron levels in the blood of people with thalassaemia who depend on blood transfusions Haemoglobin carries oxygen in the blood. In thalassaemia, a genetic disease, sometimes the body cannot produce enough haemoglobin. This can be managed by receiving regular blood transfusions, but may lead to excess iron in the body which must be removed to prevent organ damage. Iron is removed by iron chelation therapy using a substance called an iron chelator. This works by sticking to excess iron molecules in the body. When patients go to the toilet, this excess iron leaves the body. Three iron chelators are commonly used. One (desferrioxamine) is injected and two (deferiprone and deferasirox) are taken orally. Deferasirox is licensed for use in children. Desferrioxamine is inconvenient and expensive; motivating researchers to find safe, effective oral iron chelators. We found 22 randomised controlled trials comparing iron chelators. These do not provide enough information about death or organ damage. However, they showed all three chelators performed similarly well in removing excess iron. Several trials found combining desferrioxamine and deferiprone removed more excess iron than using just one iron chelator. Trials showing side effects must be considered carefully. Side effects with desferrioxamine included pain or skin reactions at the injection site and joint pain. Side effects with deferiprone included joint pain, nausea, stomach upsets and low white blood cell count. Side effects with deferasirox included skin rashes, increases in liver enzymes and reduced kidney function. Low white blood cell count and reduced kidney function are important side effects and in patients receiving deferiprone or deferasirox these should be monitored regularly. Patients were three times more likely to experience a side effect when deferiprone and desferrioxamine were combined, compared with desferrioxamine alone. Three studies showed that patients using deferiprone were two and a half times more likely to have joint pain compared with using desferrioxamine alone. We have found no evidence for changing current treatment recommendations, which state that deferiprone or deferasirox should be used to remove excess iron when desferrioxamine cannot be used or is inadequate. The Food and Drug Administration in the United States of America have approved deferiprone only as \"last resort treatment of iron overload in thalassemia\". Larger randomised control trials of iron chelation therapy are needed, using standardised agreed measures of iron levels and organ damage to allow comparison of such valuable treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA, Brunskill, SJ, Doree, C, Gooding, S, Chowdhury, O, Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004450.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.796Z" }, { "id": "6f5d75b1-b483-40f0-802c-c3b9394ec0ad", "pmid": "", "title": "Muscle relaxants for pain management in rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background Pain management is a high priority for patients with rheumatoid arthritis (RA). Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan) and non‐benzodiazepines such as metaxalone (Skelaxin) or a combination of paracetamol and orphenadrine (Muscol)) and drugs that prevent increased muscle tone (baclofen and dantrolene). Despite a paucity of evidence supporting their use, antispasmodic and antispasticity muscle relaxants have gained widespread clinical acceptance as adjuvants in the management of patients with chronic musculoskeletal pain. Objectives The aim of this review was to determine the efficacy and safety of muscle relaxants in pain management in patients with RA. The muscle relaxants that were included in this review are the antispasmodic benzodiazepines (alprazolam, bromazepam, chlordiazepoxide,cinolazepam, clonazepam, cloxazolam, clorazepate, diazepam, estazolam, flunitrazepam, flurazepam, flutoprazepam, halazepam, ketazolam, loprazolam, lorazepam, lormetazepam, medazepam, midazolam, nimetazepam, nitrazepam, nordazepam, oxazepam, pinazepam, prazepam, quazepam, temazepam, tetrazepam, triazolam), antispasmodic non‐benzodiazepines (cyclobenzaprine, carisoprodol, chlorzoxazone, meprobamate, methocarbamol, metaxalone, orphenadrine, tizanidine and zopiclone), and antispasticity drugs (baclofen and dantrolene sodium). Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library, 4th quarter 2010), MEDLINE (1950 to week 1 November 2010), EMBASE (Week 44 2010), and PsycINFO (1806 to week 2 November 2010). We also searched the 2008 to 2009 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of reference lists of relevant articles. Selection criteria We included randomised controlled trials which compared a muscle relaxant to another therapy (active, including non‐pharmacological therapies, or placebo) in adult patients with RA and that reported at least one clinically relevant outcome. Data collection and analysis Two blinded review authors independently extracted data and assessed the risk of bias in the trials. Meta‐analyses were used to examine the efficacy of muscle relaxants on pain, depression, sleep and function, as well as their safety. Main results Six trials (126 participants) were included in this review. All trials were rated at high risk of bias. Five cross‐over trials evaluated a benzodiazepine, four assessed diazepam (n = 71) and one assessed triazolam (n = 15). The sixth trial assessed zopiclone (a non‐benzodiazepine) (n = 40) and was a parallel group study. No trial duration was longer than two weeks while three single dose trials assessed outcomes at 24 hours only. Overall the included trials failed to find evidence of a beneficial effect of muscle relaxants over placebo, alone (at 24 hrs, 1 or 2 weeks) or in addition to non‐steroidal anti‐inflammatory drugs (NSAIDs) (at 24 hrs), on pain intensity, function, or quality of life. Data from two trials of longer than 24 hours duration (n = 74) (diazepam and zopiclone) found that participants who received a muscle relaxant had significantly more adverse events compared with those who received placebo (number needed to harm (NNTH) 3, 95% CI 2 to 7). These were predominantly central nervous system side effects, including dizziness and drowsiness (NNTH 3, 95% CI 2 to 11). Authors' conclusions Based upon the currently available evidence in patients with RA, benzodiazepines (diazepam and triazolam) do not appear to be beneficial in improving pain over 24 hours or one week. The non‐benzodiazepine agent zopiclone also did not significantly reduce pain over two weeks. However, even short term muscle relaxant use (24 hours to 2 weeks) is associated with significant adverse events, predominantly drowsiness and dizziness. Plain language summary Muscle relaxants for pain management in rheumatoid arthritis This summary of a Cochrane review presents what we know from research about the effect of muscle relaxants on pain in patients with rheumatoid arthritis. The review shows that in people with rheumatoid arthritis: ‐ Muscle relaxants may not improve pain when taken as a single dose or for up to a two week period ‐ We are uncertain whether muscle relaxants affect functional status because of the very low quality of the evidence ‐ No trials were found that evaluated whether muscle relaxants affect quality of life ‐ No trials were found that evaluated whether antidepressants affect sleep ‐ We are uncertain whether muscle relaxants affect mood because of the very low quality of the evidence We also do not have precise information about side effects and complications. This is particularly true for rare but serious side effects. Possible side effects may include feeling tired or nauseous, headaches, blurred vision, a dry mouth, sexual dysfunction, or becoming dizzy or constipated. Rare complications may include increased suicidal thinking, liver inflammation, or a reduced white cell count. What is rheumatoid arthritis and what are muscle relaxants? When you have rheumatoid arthritis your immune system, which normally fights infection, attacks the lining of your joints. This makes your joints swollen, stiff, and painful. The small joints of your hands and feet are usually affected first. There is no cure for rheumatoid arthritis at present, so the treatments aim to relieve pain and stiffness and improve your ability to move. Muscle relaxants can be used to treat anxiety and promote sleep, and some people believe they may also reduce pain by acting on the nerves that cause pain, but this remains controversial. Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), Xanax, Ativan and non‐benzodiazepines such as Skelaxin, Muscol) and drugs that prevent increased muscle tone (baclofen and dantrolene). Best estimates of what happens to people with rheumatoid arthritis who take muscle relaxants: Pain at 24 hours: ‐ Non‐significant result. Pain at 1 to 2 weeks: ‐ Non‐significant result. Withdrawal due to adverse events, after 2 weeks: ‐ Non‐significant result. Total adverse events: ‐ 49 more people out of 100 experienced an adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 49%), ‐ 52 out of 100 people who took a muscle relaxant suffered an adverse event, ‐ 3 out of 100 people who took a placebo suffered an adverse event. Central nervous system (CNS) adverse events: ‐ 33 more people out of 100 experienced a CNS adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 33%), ‐ 39 out of 100 people who took a muscle relaxant suffered a CNS adverse event, ‐ 6 out of 100 people who took a placebo relaxant suffered a CNS adverse event. This record should be cited as: This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in the Cochrane Database of Systematic Reviews [Issue and date] © [year] The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464‐780X).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Richards, BL, Whittle, SL, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD008922.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.753Z" }, { "id": "6f7f5259-2e16-4ca5-9cf8-40eaa5a1d799", "pmid": "", "title": "Breastfeeding or breast milk for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Pain in the neonate is associated with acute behavioural and physiological changes. Cumulative pain is associated with morbidities, including adverse neurodevelopmental outcomes. Studies have shown a reduction in changes in physiological parameters and pain score measurements following pre‐emptive analgesic administration in neonates experiencing pain or stress. Non‐pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for analgesia. This is an update of a review first published in 2006 and updated in 2012. Objectives The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries (ICTRP, ISRCTN and clinicaltrials.gov) in August 2022; searches were limited from 2011 forwards. We checked the reference lists of included studies and relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates. We included both term (≥ 37 completed weeks postmenstrual age) and preterm infants (< 37 completed weeks' postmenstrual age) up to a maximum of 44 weeks' postmenstrual age. The study must have reported on either physiological markers of pain or validated pain scores. Data collection and analysis We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a mean difference (MD). We used the GRADE approach to assess the certainty of evidence. Main results Of the 66 included studies, 36 evaluated breastfeeding, 29 evaluated supplemental breast milk and one study compared them against each other. The procedures conducted in the studies were: heel lance (39), venipuncture (11), intramuscular vaccination (nine), eye examination for retinopathy of prematurity (four), suctioning (four) and adhesive tape removal as procedure (one). We noted marked heterogeneity in the control interventions and pain assessment measures amongst the studies. Since many studies included multiple arms with breastfeeding/supplemental breast milk as the main comparator, we were not able to synthesise all interventions together. Individual interventions are compared to breastfeeding/supplemental breast milk and reported. The numbers of studies/participants presented with the findings are not taken from pooled analyses (as is usual in Cochrane Reviews), but are the overall totals in each comparison. Overall, the included studies were at low risk of bias except for masking of intervention and outcome assessment, where nearly one‐third of studies were at high risk of bias. Breastfeeding versus control Breastfeeding may reduce the increase in heart rate compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration of sucrose/glucose (20% to 33%) with skin‐to‐skin contact (low‐certainty evidence, 8 studies, 784 participants). Breastfeeding likely reduces the duration of crying compared to no intervention, lying on table, rocking, heel warming, holding by mother, skin‐to‐skin contact, bottle feeding mother's milk and moderate concentration of glucose (moderate‐certainty evidence, 16 studies, 1866 participants). Breastfeeding may reduce percentage time crying compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration sucrose and moderate concentration of sucrose with skin‐to‐skin contact (low‐certainty evidence, 4 studies, 359 participants). Breastfeeding likely reduces the Neonatal Infant Pain Scale (NIPS) score compared to no intervention, holding by mother, heel warming, music, EMLA cream, moderate glucose concentration, swaddling, swaddling and holding (moderate‐certainty evidence, 12 studies, 1432 participants). Breastfeeding may reduce the Neonatal Facial Coding System (NFCS) score compared to no intervention, holding, pacifier and moderate concentration of glucose (low‐certainty evidence, 2 studies, 235 participants). Breastfeeding may reduce the Douleur Aigue Nouveau‐né (DAN) score compared to positioning, holding or placebo (low‐certainty evidence, 4 studies, 709 participants). In the majority of the other comparisons there was little or no difference between the breastfeeding and control group in any of the outcome measures. Supplemental breast milk versus control Supplemental breast milk may reduce the increase in heart rate compared to water or no intervention (low‐certainty evidence, 5 studies, 336 participants). Supplemental breast milk likely reduces the duration of crying compared to positioning, massage or placebo (moderate‐certainty evidence, 11 studies, 1283 participants). Supplemental breast milk results in little or no difference in percentage time crying compared to placebo or glycine (low‐certainty evidence, 1 study, 70 participants). Supplemental breast milk results in little or no difference in NIPS score compared to no intervention, pacifier, moderate concentration of sucrose, eye drops, gentle touch and verbal comfort, and breast milk odour and verbal comfort (low‐certainty evidence, 3 studies, 291 participants). Supplemental breast milk may reduce NFCS score compared to glycine (overall low‐certainty evidence, 1 study, 40 participants). DAN scores were lower when compared to massage and water; no different when compared to no intervention, EMLA and moderate concentration of sucrose; and higher when compared to rocking or pacifier (low‐certainty evidence, 2 studies, 224 participants). Due to the high number of comparator interventions, other measures of pain were assessed in a very small number of studies in both comparisons, rendering the evidence of low certainty. The majority of studies did not report on adverse events, considering the benign nature of the intervention. Those that reported on adverse events identified none in any participants. Subgroup analyses were not conducted due to the small number of studies. Authors' conclusions Moderate‐/low‐certainty evidence suggests that breastfeeding or supplemental breast milk may reduce pain in neonates undergoing painful procedures compared to no intervention/positioning/holding or placebo or non‐pharmacological interventions. Low‐certainty evidence suggests that moderate concentration (20% to 33%) glucose/sucrose may lead to little or no difference in reducing pain compared to breastfeeding. The effectiveness of breast milk for painful procedures should be studied in the preterm population, as there are currently a limited number of studies that have assessed its effectiveness in this population. Plain language summary Breastfeeding or breast milk for procedural pain in newborn babies Review question We investigated how well breastfeeding or supplemental breast milk (expressed breast milk given via feeding tube or by placing breast milk in baby's mouth) works as a pain reliever in newborn babies while they undergo painful procedures (e.g. vaccination, heel prick, blood sampling for tests or eye examinations). The babies' pain responses (e.g. changes in heart rate, oxygen level, blood pressure, percentages of crying time, duration of crying etc.) were assessed by health care professionals to measure the pain that babies are experiencing. Background Breastfeeding may provide pain relief for newborn babies undergoing painful procedures. Medication for pain relief is commonly given for major painful procedures, but may not be given for minor painful procedures such as blood sampling (by heel prick or taking a sample from a vein). There are different forms of non‐drug strategies that can be used to reduce pain in babies, such as holding or swaddling them, sucking on a pacifier, or giving sweet solutions (such as sucrose or glucose). Different studies done in newborn babies have shown that breastfeeding may be a good way to reduce the pain they feel when subjected to minor painful procedures. These studies have been done in full‐term babies, and they have shown that breastfeeding may be effective by demonstrating that it reduces babies' crying time and various pain scores that have been validated for babies. Breast milk given by syringe has not shown the same efficacy as breastfeeding itself. Very few studies have been done in preterm babies, and so new studies are needed to determine if the use of supplemental breast milk in these small babies is effective in reducing their pain. Study characteristics We searched the medical literature thoroughly up to 1 August 2022 for studies that investigated the pain‐relieving effect of breastfeeding or supplemental breast milk for minor medical procedures in newborn full‐term and preterm neonates We included randomised trials only, as they provide the most reliable medical evidence. We identified 66 studies that reported on a total of more than 6200 infants in this Cochrane Review. Thirty‐six studies evaluated breastfeeding, 29 studies evaluated supplemental breast milk, while one study compared both against each other. In over half of the studies, pain relief was during a heel prick procedure. In others, it was during vaccination, drawing blood from a vein or other procedures. The studies used a variety of comparative groups, for example, placebo, no intervention, maternal holding, skin‐to‐skin contact, similar volume of water, a pacifier, routine care, various concentrations of sucrose or glucose, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), swaddling, heel warmth, anaesthetic cream for the skin, or a combination of these. The studies used a wide variety of pain scales as well as changes in heart rate and blood pressure and cry duration to assess pain. Study funding sources The studies included in the review were not externally funded according to information given in the reports. Key results Newborn babies in the breastfeeding group experienced a lower heart rate, shorter duration of cry, lower percentage of cry time and lower scores on the Neonatal Infant Pain Scale than babies who received no intervention. Moderate concentrations of glucose/sucrose may have similar effectiveness to breastfeeding. Studies of supplemental breast milk showed variable results. Supplemental breast milk was found to have a lower increase in heart rate when compared to water, and a lower duration of crying when compared to placebo. What are the limitations of the evidence We are moderately confident that breastfeeding reduces pain as assessed by heart rate, cry duration or validated pain scale compared to no intervention. Supplemental breast milk for painful procedures may reduce pain when compared to no intervention or placebo. Due to the high number of comparator groups, other measures of pain were assessed in a very small number of studies. The majority of the studies did not report on any unwanted or harmful effects of treatment. Those that did this identified no unwanted or harmful effects of treatment in any infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Shah, PS, Torgalkar, R, Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD004950.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.733Z" }, { "id": "6f806a79-1e4b-4515-9b92-ece6eee1bb15", "pmid": "", "title": "Probiotic Modulation of Gut Microflora in Cirrhosis: Influence on Immune Function and Infections", "imported": false, "abstract": "Liver cirrhosis is the 10th most common cause of death in the western world. Infection is the most common precipitant of deterioration of liver function in cirrhosis. Endotoxin, derived from gram-negative organisms in the gut, can enter the circulation due to increased gut permeability and contributes to neutrophil dysfunction, infection risk and mortality in alcoholic cirrhotics. As probiotics decrease gram-negative organisms in the gut and/or decrease gut permeability, the investigators hypothesize that probiotic treatment would restore neutrophil function and prevent infection in alcoholic cirrhosis.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.149Z" }, { "id": "6f8ea82c-0bf3-4e7f-998e-ecfe5d2d00b6", "pmid": "", "title": "Systemic antifungal therapy for tinea capitis in children", "imported": false, "abstract": "Abstract - Background Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread. This is an update of the original Cochrane review. Objectives To assess the effects of systemic antifungal drugs for tinea capitis in children. Search methods We updated our searches of the following databases to November 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and CINAHL (from 1981). We searched five trial registers and checked the reference lists of studies for references to relevant randomised controlled trials (RCTs). We obtained unpublished, ongoing trials and grey literature via correspondence with experts in the field and from pharmaceutical companies. Selection criteria RCTs of systemic antifungal therapy in children with normal immunity under the age of 18 with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 25 studies (N = 4449); 4 studies (N = 2637) were new to this update. Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy for the primary outcome of complete (i.e. clinical and mycological) cure in three studies involving 328 participants with Trichophyton species infections (84.2% versus 79.0%; risk ratio (RR) 1.06, 95% confidence interval (CI) 0.98 to 1.15; low quality evidence). Complete cure with itraconazole (two to six weeks) and griseofulvin (six weeks) was similar in two studies (83.6% versus 91.0%; RR 0.92, 95% CI 0.81 to 1.05; N = 134; very low quality evidence). In two studies, there was no difference between itraconazole and terbinafine for two to three weeks treatment (73.8% versus 78.8%; RR 0.93, 95% CI 0.72 to 1.19; N = 160; low quality evidence). In three studies, there was a similar proportion achieving complete cured with two to four weeks of fluconazole or six weeks of griseofulvin (41.4% versus 52.7%; RR 0.92, 95% CI 0.81 to 1.05; N = 615; moderate quality evidence). Current evidence for ketoconazole versus griseofulvin was limited. One study favoured griseofulvin (12 weeks) because ketoconazole (12 weeks) appeared less effective for complete cure (RR 0.76, 95% CI 0.62 to 0.94; low quality evidence). However, their effects appeared to be similar when the treatment lasted 26 weeks (RR 0.95, 95% CI 0.83 to 1.07; low quality evidence). Another study indicated that complete cure was similar for ketoconazole (12 weeks) and griseofulvin (12 weeks) (RR 0.89, 95% CI 0.57 to 1.39; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole (for two to three weeks) and terbinafine (for two to three weeks) (82.0% versus 94.0%; RR 0.87, 95% CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, we did not find a significant difference between fluconazole (for two to three weeks) and itraconazole (for two to three weeks) (82.0% versus 82.0%; RR 1.00, 95% CI 0.83 to 1.20; low quality evidence). This update provides new data: in children with Microsporum infections, a meta‐analysis of two studies found that the complete cure was lower for terbinafine (6 weeks) than for griseofulvin (6‐12 weeks) (34.7% versus 50.9%; RR 0.68, 95% CI 0.53 to 0.86; N = 334; moderate quality evidence). In the original review, there was no significant difference in complete cure between terbinafine (four weeks) and griseofulvin (eight weeks) in children with Microsporum infections in one small study (27.2% versus 60.0%; RR 0.45, 95% CI 0.15 to 1.35; N = 21; low quality evidence). One study provides new evidence that terbinafine and griseofulvin for six weeks show similar efficacy (49.5% versus 37.8%; RR 1.18, 95% CI 0.74 to 1.88; N = 1006; low quality evidence). However, in children infected with T. tonsurans , terbinafine was better than griseofulvin (52.1% versus 35.4%; RR 1.47, 95% CI 1.22 to 1.77; moderate quality evidence). For children infected with T. violaceum, these two regimens have similar effects (41.3% versus 45.1%; RR 0.91, 95% CI 0.68 to 1.24; low quality evidence). Additionally, three weeks of fluconazole was similar to six weeks of fluconazole in one study in 491 participants infected with T. tonsurans and M. canis (30.2% versus 34.1%; RR 0.88, 95% CI 0.68 to 1.14; low quality evidence). The frequency of adverse events attributed to the study drugs was similar for terbinafine and griseofulvin (9.2% versus 8.3%; RR 1.11, 95% CI 0.79 to 1.57; moderate quality evidence), and severe adverse events were rare (0.6% versus 0.6%; RR 0.97, 95% CI 0.24 to 3.88; moderate quality evidence). Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible. All of the included studies were at either high or unclear risk of bias in at least one domain. Using GRADE to rate the overall quality of the evidence, lower quality evidence resulted in lower confidence in the estimate of effect. Authors' conclusions Newer treatments including terbinafine, itraconazole and fluconazole are at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Limited evidence suggests that terbinafine, itraconazole and fluconazole have similar effects, whereas ketoconazole may be less effective than griseofulvin in children infected with Trichophyton . With some interventions the proportion achieving complete clinical cure was in excess of 90% (e.g. one study of terbinafine or griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. New evidence from this update suggests that terbinafine is more effective than griseofulvin in children with T. tonsurans infection. However, in children with Microsporum infections, new evidence suggests that the effect of griseofulvin is better than terbinafine. We did not find any evidence to support a difference in terms of adherence between four weeks of terbinafine versus eight weeks of griseofulvin. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles. Plain language summary Antifungal medicines for treating children with ringworm Background Tinea capitis, or ringworm, is a fungal infection of the scalp caused mainly by two species of fungi called Trichophyton and Microsporum . It is common in children. Most fungal infections can be treated with antifungal creams applied directly to the skin (topical treatments). However, because the fungal infection is found at the root of the hair follicles, where topical treatments cannot reach, tinea capitis always requires medication administered by mouth so that the treatment spreads throughout the entire body (systemic treatments). There are several different types of antifungal medicines available. Review question Which antifungal medicine is best for treating ringworm on the scalp in children? Study characteristics In November 2015, we searched for studies that used the gold standard design for clinical trials (randomised controlled trials) of antifungal treatments taken by mouth. We found 25 studies in which 4449 children under 18 years (4 studies with 2637 children were new to this update) had taken part. Key results With respect to complete cure (both cure of the infection and visible cure (i.e. fungal and clinical cure) low to moderate quality evidence suggests that newer treatments such as terbinafine, itraconazole and fluconazole are at least as good as griseofulvin, the usual treatment in children with tinea capitis caused by Trichophyton infections. However, new evidence in this update suggests that terbinafine may have better effects than griseofulvin for completely curing children with T. tonsurans infection. By contrast, in children with Microsporum infections, new evidence seems to indicate that griseofulvin is more effective than terbinafine. Terbinafine, itraconazole and fluconazole appear to have similar effects in terms of the proportion of participants achieving complete cure, whereas ketoconazole appears to be less effective than griseofulvin for children with tinea capitis caused by Trichophyton species. However, the quality of this evidence is low. With some interventions, the proportion with complete clinical cure was in excess of 90% (e.g. one study of terbinafine versus griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. The included studies reported on negative side effects, which were similarly mild and reversible for terbinafine, griseofulvin, itraconazole, ketoconazole and fluconazole. They included skin‐specific effects such as itching as well as abdominal discomfort, headache and nausea. Quality of the evidence The quality of the evidence in this review was generally low to moderate, so further research is likely to have an important effect on our confidence in these results. Some evidence was even of very low quality. We still need more and better evidence to help us understand the effectiveness and adverse events of systemic antifungal drugs for tinea capitis in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chen, X; Jiang, X; Yang, M; González, U; Lin, X; Hua, X; Xue, S; Zhang, M; Bennett, C", "articleTypes": [], "doi": "10.1002/14651858.CD004685.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "6f95d643-8fdf-4983-bb42-d6529f05aec3", "pmid": "", "title": "Fluvoxamine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Fluvoxamine, one of the oldest selective serotonin reuptake inhibitors (SSRIs), is prescribed to patients with major depression in many countries. Several studies have previously reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are now outdated. Objectives Our objective is to evaluate the effectiveness, tolerability and side effect profile of fluvoxamine for major depression in comparison with other anti‐depressive agents, including tricyclics (TCAs), heterocyclics, other SSRIs, SNRIs, other newer agents and other conventional psychotropic drugs. Search methods We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register. Trial databases and ongoing trial registers in North America, Europe, Japan and Australia, were handsearched for randomised controlled trials. We checked reference lists of the articles included in the review, previous systematic reviews and major textbooks of affective disorder for published reports and citations of unpublished research. The date of last search was 31 August 2008. Selection criteria We included all randomised controlled trials, published in any language, that compared fluvoxamine with any other active antidepressants in the acute phase treatment of major depression. Data collection and analysis Two independent review authors inspected citations and abstracts, obtained papers, extracted data and assessed the risk of bias of included studies. We analysed dichotomous data using odds ratios (ORs) and continuous data using the standardised mean difference (SMD). A random effects model was used to combine studies. Main results A total of 54 randomised controlled trials (n = 5122) were included. No strong evidence was found to indicate that fluvoxamine was either superior or inferior to other antidepressants regarding response, remission and tolerability. However, differing side effect profiles were evident, especially with regard to gastrointestinal side effects of fluvoxamine when compared to other antidepressants. For example, fluvoxamine was generally associated with a higher incidence of vomiting/nausea (versus imipramine, OR 2.23, CI 1.59 to 3.14; versus clomipramine, OR 2.13, CI 1.06 to 4.27; versus amitriptyline, OR 2.86, CI 1.31 to 2.63). Authors' conclusions We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, differing side effect profiles were evident. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations, including these differences in side effect profiles. Plain language summary Fluvoxamine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Although pharmacological and psychological interventions are both effective for major depression, antidepressant (AD) drugs remain the mainstay for treatment of moderate or severe depression. Fluvoxamine is one of the oldest selective serotonin reuptake inhibitors (SSRIs) and is prescribed to patients with major depression in many countries. This review reports trials comparing fluvoxamine with other antidepressants for treatment of major depression. We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, there is evidence of differing side‐effect profiles, especially when comparing gastrointestinal side effects between fluvoxamine and tricyclic antidepressants (TCAs). Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including these differences in side effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Omori, IM, Watanabe, N, Nakagawa, A, Cipriani, A, Barbui, C, McGuire, H, Churchill, R, Furukawa, TA", "articleTypes": [], "doi": "10.1002/14651858.CD006114.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.735Z" }, { "id": "6fc4a8c5-6ec9-408f-a8f1-ee85c61a962b", "pmid": "", "title": "Interventions for paracetamol (acetaminophen) overdose", "imported": false, "abstract": "Abstract - Background Paracetamol (acetaminophen) is the most widely used non‐prescription analgesic in the world. Paracetamol is commonly taken in overdose either deliberately or unintentionally. In high‐income countries, paracetamol toxicity is a common cause of acute liver injury. There are various interventions to treat paracetamol poisoning, depending on the clinical status of the person. These interventions include inhibiting the absorption of paracetamol from the gastrointestinal tract (decontamination), removal of paracetamol from the vascular system, and antidotes to prevent the formation of, or to detoxify, metabolites. Objectives To assess the benefits and harms of interventions for paracetamol overdosage irrespective of the cause of the overdose. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register (January 2017), CENTRAL (2016, Issue 11), MEDLINE (1946 to January 2017), Embase (1974 to January 2017), and Science Citation Index Expanded (1900 to January 2017). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov database (US National Institute of Health) for any ongoing or completed trials (January 2017). We examined the reference lists of relevant papers identified by the search and other published reviews. Selection criteria Randomised clinical trials assessing benefits and harms of interventions in people who have ingested a paracetamol overdose. The interventions could have been gastric lavage, ipecacuanha, or activated charcoal, or various extracorporeal treatments, or antidotes. The interventions could have been compared with placebo, no intervention, or to each other in differing regimens. Data collection and analysis Two review authors independently extracted data from the included trials. We used fixed‐effect and random‐effects Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of the review outcomes. We used the Cochrane 'Risk of bias' tool to assess the risks of bias (i.e. systematic errors leading to overestimation of benefits and underestimation of harms). We used Trial Sequential Analysis to control risks of random errors (i.e. play of chance) and GRADE to assess the quality of the evidence and constructed 'Summary of findings' tables using GRADE software. Main results We identified 11 randomised clinical trials (of which one acetylcysteine trial was abandoned due to low numbers recruited), assessing several different interventions in 700 participants. The variety of interventions studied included decontamination, extracorporeal measures, and antidotes to detoxify paracetamol's toxic metabolite; which included methionine, cysteamine, dimercaprol, or acetylcysteine. There were no randomised clinical trials of agents that inhibit cytochrome P‐450 to decrease the activation of the toxic metabolite N ‐acetyl‐ p ‐benzoquinone imine. Of the 11 trials, only two had two common outcomes, and hence, we could only meta‐analyse two comparisons. Each of the remaining comparisons included outcome data from one trial only and hence their results are presented as described in the trials. All trial analyses lack power to access efficacy. Furthermore, all the trials were at high risk of bias. Accordingly, the quality of evidence was low or very low for all comparisons. Interventions that prevent absorption, such as gastric lavage, ipecacuanha, or activated charcoal were compared with placebo or no intervention and with each other in one four‐armed randomised clinical trial involving 60 participants with an uncertain randomisation procedure and hence very low quality. The trial presented results on lowering plasma paracetamol levels. Activated charcoal seemed to reduce the absorption of paracetamol, but the clinical benefits were unclear. Activated charcoal seemed to have the best risk:benefit ratio among gastric lavage, ipecacuanha, or supportive treatment if given within four hours of ingestion. There seemed to be no difference between gastric lavage and ipecacuanha, but gastric lavage and ipecacuanha seemed more effective than no treatment (very low quality of evidence). Extracorporeal interventions included charcoal haemoperfusion compared with conventional treatment (supportive care including gastric lavage, intravenous fluids, and fresh frozen plasma) in one trial with 16 participants. The mean cumulative amount of paracetamol removed was 1.4 g. One participant from the haemoperfusion group who had ingested 135 g of paracetamol, died. There were no deaths in the conventional treatment group. Accordingly, we found no benefit of charcoal haemoperfusion (very low quality of evidence). Acetylcysteine appeared superior to placebo and had fewer adverse effects when compared with dimercaprol or cysteamine. Acetylcysteine superiority to methionine was unproven. One small trial (low quality evidence) found that acetylcysteine may reduce mortality in people with fulminant hepatic failure (Peto OR 0.29, 95% CI 0.09 to 0.94). The most recent randomised clinical trials studied different acetylcysteine regimens, with the primary outcome being adverse events. It was unclear which acetylcysteine treatment protocol offered the best efficacy, as most trials were underpowered to look at this outcome. One trial showed that a modified 12‐hour acetylcysteine regimen with a two‐hour acetylcysteine 100 mg/kg bodyweight loading dose was associated with significantly fewer adverse reactions compared with the traditional three‐bag 20.25‐hour regimen (low quality of evidence). All Trial Sequential Analyses showed lack of sufficient power. Children were not included in the majority of trials. Hence, the evidence pertains only to adults. Authors' conclusions These results highlight the paucity of randomised clinical trials comparing different interventions for paracetamol overdose and their routes of administration and the low or very low level quality of the evidence that is available. Evidence from a single trial found activated charcoal seemed the best choice to reduce absorption of paracetamol. Acetylcysteine should be given to people at risk of toxicity including people presenting with liver failure. Further randomised clinical trials with low risk of bias and adequate number of participants are required to determine which regimen results in the fewest adverse effects with the best efficacy. Current management of paracetamol poisoning worldwide involves the administration of intravenous or oral acetylcysteine which is based mainly on observational studies. Results from these observational studies indicate that treatment with acetylcysteine seems to result in a decrease in morbidity and mortality, However, further evidence from randomised clinical trials comparing different treatments are needed. Plain language summary Interventions for paracetamol (acetaminophen) overdose Review question: in this review, we looked at the evidence for the interventions (treatments) used to treat people with paracetamol (acetaminophen) poisoning. Mainly, we tried to assess what effects the interventions had on the number of deaths and the need for a liver transplant. Background: paracetamol is one of the most common drugs taken in overdose. Intentional or accidental poisoning with paracetamol is a common cause of liver injury. Search date: the evidence is current to January 2017. Study characteristics: randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) where participants had come to medical attention because they had taken a paracetamol overdose, intentionally or by accident, regardless of the amount of paracetamol taken or the age, sex, or other medical conditions of the person involved. There are many different interventions that can be used to try to treat people with paracetamol poisoning. These interventions include decreasing the absorption of the paracetamol ingested and hence decreasing the amount absorbed into the bloodstream. The agents include activated charcoal (that binds paracetamol together in the stomach), gastric lavage (stomach washout to remove as much paracetamol as possible), or ipecacuanha (a syrup that is swallowed and causes vomiting (being sick)). Paracetamol once absorbed into the bloodstream goes to the liver where the majority is broken down to harmless products. However, a small amount of the medicine is converted into a toxic product that the liver can normally handle but, when large amounts of paracetamol are taken, the liver is overwhelmed. As a consequence, the toxic product can damage the liver leading to liver failure, kidney failure, and in some cases death. Other interventions to treat paracetamol poisoning include medicines (antidotes) that may decrease the amount of the toxic products (such as a medicine called cimetidine) or breakdown the toxic products (including medicines called methionine, cysteamine, dimercaprol, or acetylcysteine). Finally, attempts can be made to remove paracetamol and its toxic products from the bloodstream using special blood cleansing equipment. All these treatments were examined. We found 11 randomised clinical trials with 700 participants. Most of these trials looked at different treatments. Key results: activated charcoal, gastric lavage, and ipecacuanha may reduce absorption of paracetamol if started within one to two hours of paracetamol ingestion, but the clinical benefit was unclear. Activated charcoal seems to be the best choice if the person is able to take it. People may not be able to take charcoal if they are drowsy and some may dislike its taste or texture (or both). Of the treatments that remove the toxic products of paracetamol, acetylcysteine seems to reduce the rate of liver injury from paracetamol poisoning. Furthermore, it has fewer side effects than some other antidotes such as dimercaprol and cysteamine; its superiority to methionine was unclear. Acetylcysteine should be given to people with paracetamol poisoning at risk of liver damage, risk is determined by the dose ingested, time of ingestion, and investigations. More recent clinical trials have looked at ways to decrease side effects of intravenous (into a vein) acetylcysteine treatment, by altering the way it is given. These trials have shown that by using a slower infusion and lower initial dose of acetylcysteine, the proportion of side effects such as nausea (feeling sick) and vomiting, and allergy (the body's bad reaction to the medicine such as a rash) may be lowered. Quality of the evidence: this review of interventions for paracetamol poisoning found surprisingly few published randomised clinical trials for this very common condition. Furthermore, the majority of trials had few participants and all were at high risk of bias. Accordingly, the quality of the evidence should be considered as low or very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Chiew, AL; Gluud, C; Brok, J; Buckley, NA", "articleTypes": [], "doi": "10.1002/14651858.CD003328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "6fcb71dd-91cb-4c41-a7b6-c3bb566f7618", "pmid": "", "title": "Antiviral treatment for preventing postherpetic neuralgia", "imported": false, "abstract": "Abstract - Background Postherpetic neuralgia (PHN) is a painful and refractory complication of herpes zoster. Treatments are either partially or totally ineffective for many people with PHN. Antiviral agents, used at the time of the rash, have been proposed as an intervention to prevent the development of PHN. This is the first update since the first publication of the review in 2009. Objectives To assess the effectiveness of antiviral agents in preventing PHN. Search methods On 26 April 2013, we updated the searches in the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and the Chinese Biomedical Retrieval System. We checked the references of published studies to identify additional trials, and contacted authors to obtain additional data. We searched other databases in The Cochrane Library for information for the Discussion and two clinical trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) of antiviral treatment given within 72 hours after the onset of herpes zoster for preventing PHN. There were no language restrictions. Data collection and analysis Two authors independently selected trials, evaluated the risk of bias in included trials, and extracted and analysed data. Main results Six RCTs with a total of 1211 participants were eligible; five trials evaluated oral aciclovir, and one, with 419 participants, evaluated oral famciclovir. We were able to conduct meta‐analyses as there were sufficient similarities in the included studies, such as the reporting of the presence of PHN, duration of rash before treatment initiation and treatment regimen. For our primary outcome, based on three trials (609 participants) we found no significant difference between the aciclovir and control groups in the incidence of PHN four months after the onset of the acute herpetic rash (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.51 to 1.11), nor was there a significant difference at six months (RR 1.05, 95% CI 0.87 to 1.27, two trials, 476 participants). In four of the trials (692 participants), there was some evidence for a reduction in the incidence of pain four weeks after the onset of rash. In the trial of famciclovir versus placebo, neither 500 mg nor 750 mg doses of famciclovir reduced the incidence of herpetic neuralgia significantly. The most commonly reported adverse events were nausea, vomiting, diarrhoea and headache for aciclovir, and headache and nausea for famciclovir. For neither treatment was the incidence of adverse events significantly different from placebo. None of the studies were at high risk of bias, although the risk of bias was unclear in at least one domain for all but one study. We found no new RCTs when we updated the searches in April 2013. Authors' conclusions There is high quality evidence that oral aciclovir does not reduce the incidence of PHN significantly. In addition, there is insufficient evidence to determine the effect of other antiviral treatments; therefore, further well‐designed RCTs are needed to investigate famciclovir or other new antiviral agents in preventing PHN. Future trials should pay more attention to the severity of pain and quality of life of participants, and should be conducted among different subgroups of people, such as people who are immunocompromised. Plain language summary Antiviral treatment for preventing nerve pain after shingles (postherpetic neuralgia) Review question We reviewed the evidence about the effect of antiviral medicines for preventing postherpetic neuralgia (PHN). Background PHN is a painful condition that can occur after shingles (herpes zoster) in the area where the rash occurred. Many people with PHN find that treatments work only a little or not at all. Attention has therefore turned to stopping the development of PHN. Some people suggested that medicines that target the virus that causes shingles (antiviral medicines), given at the time of the rash, might prevent PHN. The aim of this review was to assess the whether antiviral medicines are able to prevent PHN. Study characteristics We identified six clinical trials that met our standards for inclusion in the review. They included a total of 1319 participants. We decided that our main measure of whether antiviral medicines work in preventing PHN would be whether or not PHN had developed six months after a first attack of shingles (some of the studies we included of aciclovir measured PHN at four months). Key results and quality of the evidence Aciclovir, which is an antiviral medicine, was used in five trials (900 participants) and was not better than a placebo (dummy pill) in preventing PHN. In the other trial (419 participants), famciclovir, which is another antiviral drug, was no better than placebo in preventing pain following healing of the shingles rash. The number of side effects with aciclovir and famciclovir was not very different from the number with placebo. The trials did not have any major problems of design or conduct that put the results in doubt, although most of the reports did not provide enough information to fully assess every aspect. We conclude that according to high quality evidence, oral aciclovir was ineffective in reducing the incidence of PHN and there is not enough evidence on other antiviral treatments. There need to be further well‐designed trials of famciclovir or other new antiviral agents with a greater number of participants. Future trials should pay more attention to the severity of pain and quality of life of participants, and should include different groups of people, such as those who have lowered immunity. The evidence is current to April 2013, when the searches were last updated. Because new evidence on this topic is slow to emerge, we have scheduled the next update of this review for 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Chen, N; Li, Q; Yang, J; Zhou, M; Zhou, D; He, L", "articleTypes": [], "doi": "10.1002/14651858.CD006866.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "6fd51c21-4e8b-4479-92f3-b75366b7f43b", "pmid": "", "title": "Polyunsaturated fatty acid supplementation for schizophrenia", "imported": false, "abstract": "Abstract - Background Limited evidence supports a hypothesis suggesting that the symptoms of schizophrenia may be the result of altered neuronal membrane structure and metabolism. The structure and metabolism is dependent on blood plasma levels of certain essential fatty acids and their metabolites. Objectives To assess the effects of polyunsaturated fatty acids for people with schizophrenia. Search methods We have updated the initial searches of 1998, 2002 and 2005 with a search of the Cochrane Schizophrenia Group's Register, November 2008, which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. Where necessary, we contacted authors and relevant pharmaceutical companies for additional information. Selection criteria We included all randomised controlled trials of polyunsaturated fatty acid treatment for schizophrenia. Data collection and analysis Working independently, we selected studies for quality assessment and extracted relevant data. We analysed on an intention‐to‐treat basis. Where possible and appropriate we calculated the Relative Risk (RR) and their 95% confidence intervals (CI) and estimated the number needed to treat (NNT). For continuous data we calculated weighted mean differences (WMD) and their 95% confidence intervals. We also inspected the data for heterogeneity. Main results Eight studies are now included in this review. When any dose omega‐3 (E‐EPA or EPA) is compared with placebo, small short trials suggest that the need for neuroleptics appears to be reduced for people allocated omega‐3 supplementation (n=30, 1 RCT, RR 0.73 CI 0.54 to 1.00) and mental state may improve (n=30, 1 RCT, RR not gaining 25% change in PANSS scores 0.54 CI 0.30 to 0.96, NNT 3 CI 2 to 29). There are no differences in the number of people leaving the study early (n=595, 6 RCTs, RR 0.86 CI 0.50 to 1.48). There are few data on the comparison of any dose omega‐6 (GLA) with placebo. For movement disorder outcomes, the one small study we found does not show any difference for average short‐term endpoint AIMS score (n=16, 1 RCT, WMD 1.30 CI ‐1.96 to 4.56). When any dose omega‐3 (E‐EPA or EPA) is compared with any dose omega‐3 (DHA) there is no significant difference for mental state outcome of not gaining 25% change in PANSS scores (n=31, 1 RCT, RR 0.66 CI 0.39 to 1.11). When different doses of omega‐3 (E‐EPA) are compared with placebo there are no differences in measures of global and mental state between the studies. For the outcome of 'experiencing at least one adverse effect' no differences between groups are found for any dose (1 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.97 CI 0.60 to 1.56; 2 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.67 CI 0.37 to 1.20; 4 g/day E‐EPA vs placebo n=58, 1 RCT, RR 1.15 CI 0.72 to 1.82). Authors' conclusions Three updates of this review have resulted in more included studies and more people randomised but still relatively little useful additional data. The results remain inconclusive. The new trials all compare the omega‐3 polyunsaturated fatty acids, in particular eicosapentaenoic acid and its ester, ethyl‐eicosapentaenoic acid. The use of omega‐3 polyunsaturated fatty acids for schizophrenia still remains experimental and this review highlights the need for large, well designed, conducted and reported studies. Plain language summary Polyunsaturated fatty acid supplementation for schizophrenia Schizophrenia is a serious mental health problem that affects about one percent of any population. For some people it can become an illness that they have to live with for their entire life. Early research has suggested that supplementing the diet with omega 3 or omega 6 fatty acids may have a positive effect on the symptoms of schizophrenia. This review looks at randomised control trials where omega 3 or omega 6 were used in combination with antipsychotic medication, or as a treatment in their own right for schizophrenia. Eight studies were found which included a total of 517 people who had a diagnosis of schizophrenia or schizoaffective disorder (combined symptoms of schizophrenia and a mood disorder). They ranged from six to 16 weeks in length and were in both hospital and community settings. The majority of the trials compared two different types of omega 3 fatty acids, EPA (usually as E‐EPA) and DHA with placebo, in people with schizophrenia who are stable on antipsychotic medication. Some of these trials show some improvement in general functioning and in mental state but not to a statistically significant degree. In the longest trial there was no difference between the two groups at the end of the study. One trial compared E‐EPA with DHA and found a suggestion that E‐EPA works better than DHA, but again it was not statistically significant. Where EPA was compared to placebo as a first line treatment for schizophrenia (30 people), those taking EPA had a better overall outcome and improvement in mental state. However, this was a short trial with few people. Finally, one trial compared a type of omega 6 with placebo in men who had the movement disorder tardive dykinesia (16 people). There was no improvement in the symptoms of movement adverse effects in either group at the end of six weeks. These trials were both small and short. In addition most of the data they reported were not able to be used, and half of the trials were funded by the group supplying the trial medication. Therefore it is still not clear whether taking manufactured omega 3 or 6 improves overall functioning or mental state in people with schizophrenia. (Plain language summary prepared for this review by Janey Antoniou of RETHINK, UK www.rethink.org )", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Irving, CB, Mumby‐Croft, R, Joy, LA", "articleTypes": [], "doi": "10.1002/14651858.CD001257.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.792Z" }, { "id": "6fd5899b-e62d-47ed-a37b-5e0e7e83e428", "pmid": "", "title": "Chloral hydrate as a sedating agent for neurodiagnostic procedures in children", "imported": false, "abstract": "Abstract - Background This is an updated version of a Cochrane Review published in 2017. Paediatric neurodiagnostic investigations, including brain neuroimaging and electroencephalography (EEG), play an important role in the assessment of neurodevelopmental disorders. The use of an appropriate sedative agent is important to ensure the successful completion of the neurodiagnostic procedures, particularly in children, who are usually unable to remain still throughout the procedure. Objectives To assess the effectiveness and adverse effects of chloral hydrate as a sedative agent for non‐invasive neurodiagnostic procedures in children. Search methods We searched the following databases on 14 May 2020, with no language restrictions: the Cochrane Register of Studies (CRS Web) and MEDLINE (Ovid, 1946 to 12 May 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including Cochrane Epilepsy. Selection criteria Randomised controlled trials that assessed chloral hydrate agent against other sedative agent(s), non‐drug agent(s), or placebo. Data collection and analysis Two review authors independently evaluated studies identified by the search for their eligibility, extracted data, and assessed risk of bias. Results were expressed in terms of risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CIs). Main results We included 16 studies with a total of 2922 children. The methodological quality of the included studies was mixed. Blinding of the participants and personnel was not achieved in most of the included studies, and three of the 16 studies were at high risk of bias for selective reporting. Evaluation of the efficacy of the sedative agents was also underpowered, with all the comparisons performed in small studies. Fewer children who received oral chloral hydrate had sedation failure compared with oral promethazine (RR 0.11, 95% CI 0.01 to 0.82; 1 study; moderate‐certainty evidence). More children who received oral chloral hydrate had sedation failure after one dose compared to intravenous pentobarbital (RR 4.33, 95% CI 1.35 to 13.89; 1 study; low‐certainty evidence), but there was no clear difference after two doses (RR 3.00, 95% CI 0.33 to 27.46; 1 study; very low‐certainty evidence). Children with oral chloral hydrate had more sedation failure compared with rectal sodium thiopental (RR 1.33, 95% CI 0.60 to 2.96; 1 study; moderate‐certainty evidence) and music therapy (RR 17.00, 95% CI 2.37 to 122.14; 1 study; very low‐certainty evidence). Sedation failure rates were similar between groups for comparisons with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam and oral clonidine. Children who received oral chloral hydrate had a shorter time to adequate sedation compared with those who received oral dexmedetomidine (MD −3.86, 95% CI −5.12 to −2.6; 1 study), oral hydroxyzine hydrochloride (MD −7.5, 95% CI −7.85 to −7.15; 1 study), oral promethazine (MD −12.11, 95% CI −18.48 to −5.74; 1 study) (moderate‐certainty evidence for three aforementioned outcomes), rectal midazolam (MD −95.70, 95% CI −114.51 to −76.89; 1 study), and oral clonidine (MD −37.48, 95% CI −55.97 to −18.99; 1 study) (low‐certainty evidence for two aforementioned outcomes). However, children with oral chloral hydrate took longer to achieve adequate sedation when compared with intravenous pentobarbital (MD 19, 95% CI 16.61 to 21.39; 1 study; low‐certainty evidence), intranasal midazolam (MD 12.83, 95% CI 7.22 to 18.44; 1 study; moderate‐certainty evidence), and intranasal dexmedetomidine (MD 2.80, 95% CI 0.77 to 4.83; 1 study, moderate‐certainty evidence). Children who received oral chloral hydrate appeared significantly less likely to complete neurodiagnostic procedure with child awakening when compared with rectal sodium thiopental (RR 0.95, 95% CI 0.83 to 1.09; 1 study; moderate‐certainty evidence). Chloral hydrate was associated with a higher risk of the following adverse events: desaturation versus rectal sodium thiopental (RR 5.00, 95% 0.24 to 102.30; 1 study), unsteadiness versus intranasal dexmedetomidine (MD 10.21, 95% CI 0.58 to 178.52; 1 study), vomiting versus intranasal dexmedetomidine (MD 10.59, 95% CI 0.61 to 185.45; 1 study) (low‐certainty evidence for aforementioned three outcomes), and crying during administration of sedation versus intranasal dexmedetomidine (MD 1.39, 95% CI 1.08 to 1.80; 1 study, moderate‐certainty evidence). Chloral hydrate was associated with a lower risk of the following: diarrhoea compared with rectal sodium thiopental (RR 0.04, 95% CI 0.00 to 0.72; 1 study), lower mean diastolic blood pressure compared with sodium thiopental (MD 7.40, 95% CI 5.11 to 9.69; 1 study), drowsiness compared with oral clonidine (RR 0.44, 95% CI 0.30 to 0.64; 1 study), vertigo compared with oral clonidine (RR 0.15, 95% CI 0.01 to 2.79; 1 study) (moderate‐certainty evidence for aforementioned four outcomes), and bradycardia compared with intranasal dexmedetomidine (MD 0.17, 95% CI 0.05 to 0.59; 1 study; high‐certainty evidence). No other adverse events were significantly associated with chloral hydrate, although there was an increased risk of combined adverse events overall (RR 7.66, 95% CI 1.78 to 32.91; 1 study; low‐certainty evidence). Authors' conclusions The certainty of evidence for the comparisons of oral chloral hydrate against several other methods of sedation was variable. Oral chloral hydrate appears to have a lower sedation failure rate when compared with oral promethazine. Sedation failure was similar between groups for other comparisons such as oral dexmedetomidine, oral hydroxyzine hydrochloride, and oral midazolam. Oral chloral hydrate had a higher sedation failure rate when compared with intravenous pentobarbital, rectal sodium thiopental, and music therapy. Chloral hydrate appeared to be associated with higher rates of adverse events than intranasal dexmedetomidine. However, the evidence for the outcomes for oral chloral hydrate versus intravenous pentobarbital, rectal sodium thiopental, intranasal dexmedetomidine, and music therapy was mostly of low certainty, therefore the findings should be interpreted with caution. Further research should determine the effects of oral chloral hydrate on major clinical outcomes such as successful completion of procedures, requirements for an additional sedative agent, and degree of sedation measured using validated scales, which were rarely assessed in the studies included in this review. The safety profile of chloral hydrate should be studied further, especially for major adverse effects such as oxygen desaturation. Plain language summary The effectiveness of chloral hydrate as a sedative agent for children undergoing neurodiagnostic procedures Review question In children undergoing non‐invasive neurodiagnostic procedures, is chloral hydrate more effective at producing adequate sedation (slowing of brain activity) and safer than other ways of achieving sedation? Background Neurodiagnostic procedures are non‐invasive neurological investigations important for children with suspected neurological disorders. These investigations include brain imaging and brain electrical activity testing. For these tests to be successfully performed, the child needs to remain still for at least 30 to 45 minutes during the investigation period. Sedative agents are required for children, who are usually unable to remain still for this period of time. Search date The evidence is current to May 2020. Study characteristics We included 16 studies involving a total of 2922 children (age up to 18 years old) in the review. All of the included studies were performed in hospitals that provided neurodiagnostic services. Most studies assessed the following three main outcomes: proportion of children who were unsuccessfully sedated for the neurodiagnostic procedure; length of time taken for adequate sedation; and side effects associated with the sedative agent. The quality of the evidence was mixed, ranging from very low to high. The main reason for lowering the quality of the evidence was that those closely involved in the trials, such as the doctors giving the sedation or the parents of the child, were not masked to the sedative agent used in the child, which could have affected their recording or interpretation of the results. Key results We summarised the evidence of effectiveness and harms of oral chloral hydrate sedation when compared with other sedative agents. Our review suggests that oral chloral hydrate is just as effective a sedative agent with similar sedation failure rate when compared with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam, and oral clonidine; and probably a more effective sedative agent with a lower sedation failure rate when compared with oral promethazine. Whilst most of the included studies showed that chloral hydrate was safe with no increase in side effects when compared to other sedative agents, one study reported an increased risk of side effects with oral chloral hydrate when compared with intranasal dexmedetomidine. Quality of the evidence The quality of most of the evidence was poor due to flaws in study methods and the small sample size of each study, therefore our confidence in the results of the studies is reduced. Conclusions Apart from intravenous pentobarbital, rectal sodium thiopental, and music therapy, oral chloral hydrate is either just as effective or more effective as a sedating agent when compared to other sedating agents for children undergoing non‐invasive neurodiagnostic procedures. Given the poor quality of the evidence, we could draw no clear conclusions on the effectiveness or safety of any of the paediatric sedative agents studied in the review. Further study is needed to look at the side effects of oral chloral hydrate when compared to other sedatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Fong, CY, Lim, WK, Li, L, Lai, NM", "articleTypes": [], "doi": "10.1002/14651858.CD011786.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.804Z" }, { "id": "6fe049bd-7520-4018-8535-260e1d418b76", "pmid": "", "title": "A Study on the Correlation Between Oral Health and Delirium in Surgical Inpatients", "imported": false, "abstract": "Delirium is a clinical syndrome characterized by acute attention deficits, altered consciousness, and fluctuating cognitive dysfunction, typically triggered by multifactorial causes such as physical illness, medication use, or postoperative stress . As the most common complication in hospitalized patients, delirium is highly prevalent among elderly surgical populations, with postoperative delirium (POD) occurring in 7.5%-27.5% of cases, and rates rising to 50%-70% in intensive care unit (ICU) patients . Its onset is closely associated with poor prognoses, including long-term postoperative cognitive decline , increased mortality, prolonged hospitalization, and elevated healthcare costs (annual costs in the United States ranging from 38billionto152 billion) . Early prevention and screening of POD are therefore critical to improving patient outcomes and reducing healthcare burdens.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.160Z" }, { "id": "6fe99b4d-9f3e-447d-b324-161f18c12fdc", "pmid": "", "title": "Factors influencing the uptake and use of nicotine replacement therapy and e‐cigarettes in pregnant women who smoke: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) delivers nicotine without the toxic chemicals present in tobacco smoke. It is an effective smoking cessation aid in non‐pregnant smokers, but there is less evidence of effectiveness in pregnancy. Systematic review evidence suggests that pregnant women do not adhere to NRT as prescribed, which might undermine effectiveness. Electronic cigarettes (e‐cigarettes) have grown in popularity, but effectiveness and safety in pregnancy are not yet established. The determinants of uptake and use of NRT and e‐cigarettes in pregnancy are unknown. Objectives To explore factors affecting uptake and use of NRT and e‐cigarettes in pregnancy. Search methods We searched MEDLINE(R), CINAHL and PsycINFO on 1 February 2019. We manually searched OpenGrey database and screened references of included studies and relevant reviews. We also conducted forward citation searches of included studies. Selection criteria We selected studies that used qualitative methods of data collection and analysis, included women who had smoked in pregnancy, and elicited participants' views about using NRT/e‐cigarettes for smoking cessation or harm reduction (i.e. to smoke fewer cigarettes) during pregnancy. Data collection and analysis We identified determinants of uptake and use of NRT/e‐cigarettes in pregnancy using a thematic synthesis approach. Two review authors assessed the quality of included studies with the Wallace tool. Two review authors used the CERQual approach to assess confidence in review findings. The contexts of studies from this review and the relevant Cochrane effectiveness review were not similar enough to fully integrate findings; however, we created a matrix to juxtapose findings from this review with the descriptions of behavioural support from trials in the effectiveness review. Main results We included 21 studies: 15 focused on NRT, 3 on e‐cigarettes, and 3 on both. Studies took place in five high‐income countries. Most studies contributed few relevant data; substantially fewer data were available on determinants of e‐cigarettes. Many studies focused predominantly on issues relating to smoking cessation, and determinants of NRT/e‐cigarette use was often presented as one of the themes. We identified six descriptive themes and 18 findings within those themes; from these we developed three overarching analytical themes representing key determinants of uptake and adherence to NRT and/or e‐cigarettes in pregnancy. The analytical themes show that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. Furthermore, women consider advice from health professionals when deciding whether to use NRT or e‐cigarettes; when health professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay for them to use these in pregnancy, women report feeling more confident about using them. Conversely, women who are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them during pregnancy feel less confident about using them. Women's past experiences with NRT can also affect their willingness to use NRT in pregnancy; women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. No trials on e‐cigarette use in pregnancy were included in the Cochrane effectiveness review, so we considered only NRT findings when integrating results from this review and the effectiveness review. No qualitative studies were conducted alongside trials, making full integration of the findings challenging. Women enrolled in trials would have agreed to being allocated to NRT or control group and would have received standardised information on NRT at the start of the trial. Overall, the findings of this synthesis are less relevant to women's decisions about starting NRT in trials and more likely to help explain trial participants' adherence to NRT after starting it. We considered most findings to be of moderate certainty; we assessed findings on NRT use as being of higher certainty than those on e‐cigarette use. This was mainly due to the limited data from fewer studies (only in the UK and USA) that contributed to e‐cigarette findings. Overall, we judged studies to be of acceptable quality with only minor methodological issues. Authors' conclusions Consistent messages from health professionals, based on high‐quality evidence and clearly explaining the safety of NRT and e‐cigarettes compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and subsequently encourage them to stay smoke‐free. Plain language summary Factors affecting use of nicotine replacement therapy and e‐cigarettes in pregnancy What was studied in this review? Nicotine replacement therapy (NRT) delivers nicotine without the harmful chemicals found in tobacco smoke. NRT helps some non‐pregnant adults to stop smoking, but it does not seem to work so well in pregnancy. This may be because pregnant women generally do not use NRT as prescribed. Studies show that some pregnant women use e‐cigarettes to help them cut down or quit, although their safety and effectiveness in pregnancy is not known. Little is known about the issues that influence pregnant women's use of NRT/e‐cigarettes. What is the aim of this review? To explore factors that affect whether women take up and use NRT or e‐cigarettes to reduce or quit smoking in pregnancy. What are the key messages of this review? Three main factors influence whether women take up and use NRT and e‐cigarettes in pregnancy: advice women receive from health professionals on using NRT or e‐cigarette in pregnancy, women's desire to protect their unborn baby from harm, and past personal experience with NRT. Each of these factors can either encourage or discourage women from using these products. What are the key findings? We included 21 studies; 15 of these focused on NRT, 3 on e‐cigarettes and 3 on both. Our findings suggest that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. They also consider the advice from their health professionals; when professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay to use them in pregnancy, their confidence about using them increases. When women are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them when they are pregnant, they feel less confident about using them. Women's past experiences with NRT will also affect how willing they are to use NRT in pregnancy. For example, women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. We conclude that consistent messages that are based on high‐quality research and clearly explain how safe NRT and e‐cigarettes are compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and encourage them to stay smoke‐free. How up‐to‐date is this review? We searched for studies that had been published before 1 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Campbell, K; Coleman-Haynes, T; Bowker, K; Cooper, SE; Connelly, S; Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD013629", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "700ad3da-7f52-4114-9a86-b2a7774d717f", "pmid": "", "title": "Childhood adversity and 5-HTTLPR across mental health outcomes: A transdiagnostic meta-analysis", "imported": false, "abstract": "Background Childhood maltreatment is associated with increased risk for various psychiatric disorders, although individual responses to early adversity vary. The serotonin transporter-linked polymorphic region (5-HTTLPR) has been examined as a potential moderator of sensitivity to environmental stress, but findings across studies have been inconsistent. Objective This meta-analysis examined whether 5-HTTLPR polymorphisms moderate the association between childhood adversity and clinically diagnosed psychiatric disorders. Participants and settings Fourteen studies (N = 3479) were included, representing community, population-based, and clinical samples from multiple regions. Childhood adversity was assessed using validated interviews, questionnaires, or official electronic records. Methods Systematic searches of eight databases (last updated 3 December 2025) identified studies reporting 5-HTTLPR genotype, childhood adversity, and psychiatric diagnoses. Ratio-of-odds-ratios (ROR) quantifies differences in adversity effects between S-allele carriers and LL homozygotes. Multilevel random-effects models generated pooled estimates. Sensitivity, moderator, and publication-bias analyses were performed. Study quality was assessed using the Newcastle–Ottawa Scale, and certainty of evidence using GRADE. Results Pooled analyses indicated no statistically significant interaction between childhood adversity and 5-HTTLPR genotype (ROR = 1.11, 95% CI 0.89–1.37). Analyses restricted to SS-only or SL-only groups and sexual abuse-specific subgroups produced similar results. Heterogeneity was moderate, and small-study effects were borderline. Moderator analyses did not identify consistent influences of diagnosis or ancestry. Conclusion Across available studies, evidence for an interaction between childhood adversity and 5-HTTLPR genotype was limited. Unlike previous meta-analyses that focused primarily on symptom-level or trait-based measures, the present study evaluates clinically diagnosed outcomes, offering evidence that 5-HTTLPR is unlikely to represent a robust moderator of adversity effects. These findings may suggest that, within current research parameters, 5-HTTLPR does not show a consistent moderating role in clinically diagnosed psychiatric outcomes.", "journal": "Child Abuse & Neglect", "year": "2026", "authors": "Shivam, Vishnu", "articleTypes": [], "doi": "https://doi.org/10.1016/j.chiabu.2026.107901", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:07.574Z" }, { "id": "700ef5ef-0894-4a2d-b734-4da1ebdd2c57", "pmid": "", "title": "Statins for children with familial hypercholesterolemia", "imported": false, "abstract": "Abstract - Background Familial hypercholesterolemia is one of the most common inherited metabolic diseases and is an autosomal dominant disorder meaning heterozygotes, or carriers, are affected. Those who are homozygous have severe disease. The average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500, although recent genetic epidemiological data from Denmark and next generation sequencing data suggest the frequency may be closer to 1 in 250. Diagnosis of familial hypercholesterolemia in children is based on elevated total cholesterol and low‐density lipoprotein cholesterol levels or DNA‐based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong treatment, started in childhood, is needed to reduce the risk of cardiovascular disease. In children with the disease, diet was the cornerstone of treatment but the addition of lipid‐lowering medications has resulted in a significant improvement in treatment. Anion exchange resins, such as cholestyramine and colestipol, were found to be effective, but they are poorly tolerated. Since the 1990s studies carried out on children aged 6 to 17 years with heterozygous familial hypercholesterolemia have demonstrated significant reductions in their serum total and low‐density lipoprotein cholesterol levels. While statins seem to be safe and well‐tolerated in children, their long‐term safety in this age group is not firmly established. This is an update of a previously published version of this Cochane Review. Objectives To assess the effectiveness and safety of statins in children with heterozygous familial hypercholesterolemia. Search methods Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline. Date of most recent search: 04 November 2019. Selection criteria Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. Data collection and analysis Two authors independently assessed studies for inclusion and extracted data. Main results We found 26 potentially eligible studies, of which we included nine randomized placebo‐controlled studies (1177 participants). In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). There may be little or no difference in liver function (serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations) between treated and placebo groups at any time point (low‐quality evidence). There may be little or no difference in myopathy (as measured in change in creatinine levels) (low‐quality evidence) or clinical adverse events (moderate‐quality evidence) with statins compared to placebo. One study on simvastatin showed that this may slightly improve flow‐mediated dilatation of the brachial artery (low‐quality evidence), and on pravastatin for two years may have induced a regression in carotid intima media thickness (low‐quality evidence). No studies reported rhabdomyolysis (degeneration of skeletal muscle tissue) or death due to rhabdomyolysis, quality of life or compliance to study medication. Authors' conclusions Statin treatment is an effective lipid‐lowering therapy in children with familial hypercholesterolemia. Few or no safety issues were identified. Statin treatment seems to be safe in the short term, but long‐term safety remains unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians and their care transferred to an adult lipidologist once they reach 18 years of age. Large long‐term randomized controlled trials are needed to establish the long‐term safety issues of statins. Plain language summary Statins for children with inherited high blood cholesterol Review question We reviewed the evidence for the effectiveness and safety of statins in children with inherited high blood cholesterol. Background Familial hypercholesterolemia is an inherited disease in which the blood cholesterol level is high. Vascular disease, i.e. furring up of the blood vessels, often occurs at an earlier age than usual, especially amongst men. Thus lifelong therapies, started in childhood, to reduce blood cholesterol are needed. In children with familial hypercholesterolemia, diet has been the main treatment option. Medications, such as cholestyramine and colestipol, have been used effectively, but due to their unpleasant taste they are poorly tolerated and treatment plans are not followed. The advent of statin therapy for children has improved treatment and this review updates the previous published version. Search date The evidence is current to: 04 November 2019. Study characteristics The review included 9 studies with 1177 people with heterozygous familial hypercholesterolemia aged between 4 and 18 years of age. Studies compared different statin treatments with a substance which contains no medication (termed placebo) and people were selected for one treatment or the other randomly. The studies lasted from 12 weeks to 104 weeks. Key results In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins probably reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). The levels of the liver enzymes, serum aspartate and alanine aminotransferase, and the muscle enzyme, creatinine kinase, did not differ between treated and placebo groups at any time point (low‐quality evidence). The risks of myopathy (disease of muscle tissue) and side‐effects were very low and similar in both groups (low‐quality evidence). Two of the statins, simvastatin and pravastatin may have a positive effect on two of the major blood vessels typically affected by raised cholesterol levels (low‐quality evidence). Quality of the evidence Information regarding blinding (performance bias and detection bias), was available for all nine studies; each was described as double blind, indicating that participants and those participating in treatment procedures were blinded to treatment. In two studies information on how the participants were allocated to treatment groups (selection bias) was clearly presented, but this information was not clearly stated in the remaining seven studies. There is a lack of information whether investigators knew which treatment group participants would be put into (selection bias) and or whether selective reporting (reporting bias) occurred, but it is very unlikely. In conclusion, it can be stated all the studies appeared to be well run and we do not think any of the above‐mentioned factors influenced the results in a negative way. Quality of evidence varied from high (change in serum low‐density lipoprotein (LDL) cholesterol) through moderate (adverse events) to low (change in blood vessel wall (carotid intima‐media) thickness, change in measures if growth and maturation, liver dysfunction, myopathy and change in blood wall (endothelial) function).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Vuorio, A, Kuoppala, J, Kovanen, PT, Humphries, SE, Tonstad, S, Wiegman, A, Drogari, E, Ramaswami, U", "articleTypes": [], "doi": "10.1002/14651858.CD006401.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.076Z" }, { "id": "70541f45-446e-4b89-9eab-f30e77ad7f44", "pmid": "", "title": "Pharmacological interventions for cognitive decline in people with Down syndrome", "imported": false, "abstract": "Abstract - Background People with Down syndrome are vulnerable to developing dementia at an earlier age than the general population. Alzheimer's disease and cognitive decline in people with Down syndrome can place a significant burden on both the person with Down syndrome and their family and carers. Various pharmacological interventions, including donepezil, galantamine, memantine and rivastigmine, appear to have some effect in treating cognitive decline in people without Down syndrome, but their effectiveness for those with Down syndrome remains unclear. Objectives To assess the effectiveness of anti‐dementia pharmacological interventions and nutritional supplements for treating cognitive decline in people with Down syndrome. Search methods In January 2015, we searched CENTRAL, ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), Ovid MEDLINE, Embase, PsycINFO, seven other databases, and two trials registers. In addition, we checked the references of relevant reviews and studies and contacted study authors, other researchers and relevant drug manufacturers to identify additional studies. Selection criteria Randomised controlled trials (RCTs) of anti‐dementia pharmacological interventions or nutritional supplements for adults (aged 18 years and older) with Down syndrome, in which treatment was administered and compared with either placebo or no treatment. Data collection and analysis Two review authors independently assessed the risk of bias of included trials and extracted the relevant data. Review authors contacted study authors to obtain missing information where necessary. Main results Only nine studies (427 participants) met the inclusion criteria for this review. Four of these (192 participants) assessed the effectiveness of donepezil, two (139 participants) assessed memantine, one (21 participants) assessed simvastatin, one study (35 participants) assessed antioxidants, and one study (40 participants) assessed acetyl‐L‐carnitine. Five studies focused on adults aged 45 to 55 years, while the remaining four studies focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one between Norway and the UK, and one in Japan. Follow‐up periods in studies ranged from four weeks to two years. The reviewers judged all included studies to be at low or unclear risk of bias. Analyses indicate that for participants who received donepezil, scores in measures of cognitive functioning (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) ‐0.27 to 1.13) and measures of behaviour (SMD 0.42, 95% CI ‐0.06 to 0.89) were similar to those who received placebo. However, participants who received donepezil were significantly more likely to experience an adverse event (odds ratio (OR) 0.32, 95% CI 0.16 to 0.62). The quality of this body of evidence was low. None of the included donepezil studies reported data for carer stress, institutional/home care, or death. For participants who received memantine, scores in measures of cognitive functioning (SMD 0.05, 95% CI ‐0.43 to 0.52), behaviour (SMD ‐0.17, 95% CI ‐0.46 to 0.11), and occurrence of adverse events (OR 0.45, 95% CI 0.18 to 1.17) were similar to those who received placebo. The quality of this body of evidence was low. None of the included memantine studies reported data for carer stress, institutional/home care, or death. Due to insufficient data, it was possible to provide a narrative account only of the outcomes for simvastatin, antioxidants, and acetyl‐L‐carnitine. Results from one pilot study suggest that participants who received simvastatin may have shown a slight improvement in cognitive measures. Authors' conclusions Due to the low quality of the body of evidence in this review, it is difficult to draw conclusions about the effectiveness of any pharmacological intervention for cognitive decline in people with Down syndrome. Plain language summary Medications for cognitive decline in people with Down syndrome People with Down syndrome often experience cognitive decline (a deterioration in memory, language, thinking and judgment that are greater than normal age‐related changes) at a younger age and in greater numbers than the general population. Various medicines have been shown to improve, or at least slow down the progression of these symptoms in people without Down syndrome. Review question Do adults (18 years and older) with Down syndrome benefit from treatment with medicine to prevent cognitive decline, compared with other adults with Down syndrome who receive either fake medicine (placebos) or no medicine? Study characteristics In January 2015, we, a team of Cochrane researchers, searched for all medical studies that investigated the effect of any medicine or nutritional supplement on cognitive decline in adults with Down syndrome. We found nine relevant randomised controlled trials (this design produces the most reliable results) that we could include in this overview. These studies tested: ‐ donepezil, a medicine used to treat Alzheimer's disease (four studies); ‐ memantine, a medicine used to treat Alzheimer's disease (two studies); ‐ simvastatin, a (statin) medicine used to prevent heart disease (one study); ‐ a mixture of antioxidants, including forms of vitamins C and E, and alpha‐lipoic acid (one study); and ‐ acetyl‐L‐carnitine, a dietary supplement that has previously been used to treat dementia (one study). Five of the studies focused on adults aged 45 to 55 years and four focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one took place in Norway and the UK, and one study was conducted in Japan. Key results The nine studies we found examined the effects of five medicines that are, or have been, used to prevent cognitive decline. All the studies compared the medicine being tested with a placebo (a tablet or capsule that looked and tasted like the medicine, but which contained no medicine). Generally, those who received the medicine did no better than those who received the placebo in any of the areas assessed in the studies. The areas assessed included general functioning (including memory and thinking, speech, mood and behaviour); cognitive functioning (including memory, following what’s going on around you); adaptive behaviours (being able to do day‐to‐day tasks); or behaviour problems (such as being irritable or aggressive). The only medicine to show any positive effect was the statin, simvastatin. Preliminary findings from a very small study showed that simvastin had some benefit on improving memory compared to placebo. In the four donepezil studies, those participants given donepezil reported more headaches, dizziness, and nausea than participants given placebo. In the two memantine studies, there was no difference between participants given memantine or placebo for reports of headaches, dizziness, and nausea. Quality of the evidence Although the included studies were well conducted, most involved small numbers of participants and for many of the areas assessed we could not combine results from two or more studies. Overall, the quality of this evidence is low. We cannot be certain whether any of these medicines are effective. Running more trials with more people over a longer period of time would allow us answer this question with greater certainty. We could not find any trials that investigated many of the medicines used to prevent cognitive decline, and so research is needed to explore the effectiveness of these medications in the Down syndrome population.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Livingstone, N; Hanratty, J; McShane, R; Macdonald, G", "articleTypes": [], "doi": "10.1002/14651858.CD011546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "70645fc5-05a0-4a6e-9485-64cfb42b0214", "pmid": "", "title": "Vitamin and mineral supplementation for maintaining cognitive function in cognitively healthy people in mid and late life", "imported": false, "abstract": "Abstract - Background Vitamins and minerals play multiple functions within the central nervous system which may help to maintain brain health and optimal cognitive functioning. Supplementation of the diet with various vitamins and minerals has been suggested as a means of maintaining cognitive function, or even of preventing dementia, in later life. Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function in cognitively healthy people aged 40 years or more. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov and the WHO Portal/ICTRP from inception to 26th January 2018. Selection criteria We included randomised controlled trials that evaluated the cognitive effects on people aged 40 years or more of any vitamin or mineral supplements taken by mouth for at least three months. Data collection and analysis Study selection, data extraction, and quality assessments were done in duplicate. Vitamins were considered broadly in the categories of B vitamins, antioxidant vitamins, and combinations of both. Minerals were considered separately, where possible. If interventions and outcomes were considered sufficiently similar, then data were pooled. In order to separate short‐term cognitive effects from possible longer‐term effects on the trajectory of cognitive decline, data were pooled for various treatment durations from 3 months to 12 months and up to 10 years or more. Main results In total, we included 28 studies with more than 83,000 participants. There were some general limitations of the evidence. Most participants were enrolled in studies which were not designed primarily to assess cognition. These studies often had no baseline cognitive assessment and used only brief cognitive assessments at follow‐up. Very few studies assessed the incidence of dementia. Most study reports did not mention adverse events or made only very general statements about them. Only 10 studies had a mean follow‐up > 5 years. Only two studies had participants whose mean age was < 60 years at baseline. The risk of bias in the included studies was generally low, other than a risk of attrition bias for longer‐term outcomes. We considered the certainty of the evidence behind almost all results to be moderate or low. We included 14 studies with 27,882 participants which compared folic acid, vitamin B12, vitamin B6, or a combination of these to placebo. The majority of participants were aged over 60 years and had a history of cardio‐ or cerebrovascular disease. We found that giving B vitamin supplements to cognitively healthy adults, mainly in their 60s and 70s, probably has little or no effect on global cognitive function at any time point up to 5 years (SMD values from ‐0.03 to 0.06) and may also have no effect at 5‐10 years (SMD ‐0.01). There were very sparse data on adverse effects or on incidence of cognitive impairment or dementia. We included 8 studies with 47,840 participants in which the active intervention was one or more of the antioxidant vitamins: ß‐carotene, vitamin C or vitamin E. Results were mixed. For overall cognitive function, there was low‐certainty evidence of benefit associated with ß‐carotene after a mean of 18 years of treatment (MD 0.18 TICS points, 95% CI 0.01 to 0.35) and of vitamin C after 5 years to 10 years (MD 0.46 TICS points, 95% CI 0.14 to 0.78), but not at earlier time points. From two studies which reported on dementia incidence, there was low‐certainty evidence of no effect of an antioxidant vitamin combination or of vitamin E, either alone or combined with selenium. One of the included studies had been designed to look for effects on the incidence of prostate cancer; it found a statistically significant increase in prostate cancer diagnoses among men taking vitamin E. One trial with 4143 participants compared vitamin D3 (400 IU/day) and calcium supplements to placebo. We found low‐ to moderate‐certainty evidence of no effect of vitamin D3 and calcium supplements at any time‐point up to 10 years on overall cognitive function (MD after a mean of 7.8 years ‐0.1 MMSE points, 95% CI ‐0.81 to 0.61) or the incidence of dementia (HR 0.94, 95% CI 0.72 to 1.24). A pilot study with 60 participants used a higher dose of vitamin D3 (4000 IU on alternate days) and found preliminary evidence that this dose probably has no effect on cognitive function over six months. We included data from one trial of zinc and copper supplementation with 1072 participants. There was moderate‐certainty evidence of little or no effect on overall cognitive function (MD 0.6 MMSE points, 95% CI ‐0.19 to 1.39) or on the incidence of cognitive impairment after 5 years to 10 years. A second smaller trial provided no usable data, but reported no cognitive effects of six months of supplementation with zinc gluconate. From one study with 3711 participants, there was low‐certainty evidence of no effect of approximately five years of selenium supplementation on the incidence of dementia (HR 0.83, 95% CI 0.61 to 1.13). Finally, we included three trials of complex supplements (combinations of B vitamins, antioxidant vitamins, and minerals) with 6306 participants. From the one trial which assessed overall cognitive function, there was low‐certainty evidence of little or no effect on the TICS (MD after a mean of 8.5 years 0.12, 95% CI ‐0.14 to 0.38). Authors' conclusions We did not find evidence that any vitamin or mineral supplementation strategy for cognitively healthy adults in mid or late life has a meaningful effect on cognitive decline or dementia, although the evidence does not permit definitive conclusions. There were very few data on supplementation starting in midlife (< 60 years); studies designed to assess cognitive outcomes tended to be too short to assess maintenance of cognitive function; longer studies often had other primary outcomes and used cognitive measures which may have lacked sensitivity. The only positive signals of effect came from studies of long‐term supplementation with antioxidant vitamins. These may be the most promising for further research. Plain language summary Vitamin and mineral supplementation for preventing cognitive deterioration in cognitively healthy people in mid and late life Review question This review aimed to find out whether people aged 40 years or older could maintain their mental abilities or reduce their risk of dementia by taking vitamin or mineral supplements. Background There is great interest in anything people might do to keep themselves mentally healthy as they age and, especially, to reduce their risk of developing dementia. Various vitamin and mineral supplements have been suggested as ways to do this. Vitamins and minerals have many functions in the body and the ways they might affect brain health are not well understood. Therefore, we were interested in the effects of any vitamins or minerals, either alone or in combination. What we did We searched up to January 2018 for all trials which had studied the effect on cognition (thinking and remembering) of any vitamin or mineral supplements in people aged 40 years or more who had no cognitive problems at the beginning of the study. The studies had to include a comparison group which had not taken the supplement being studied and, to be sure the comparison was fair, it should have been decided at random whether people got the supplement or not. What we found We grouped the 28 included trials according to the kind of supplement they used and how it might work. Most of the trials were not originally designed to study cognition or dementia and used only simple measures of cognition. Very few studies investigated whether participants developed dementia. Long‐term studies are probably needed to find effects on the risk of dementia or cognitive decline but only 10 studies had an average length of follow‐up longer than five years. The studies were generally well‐conducted although the longer trials had difficulty following up all of the participants and this could have biased some of the longer‐term results. There were 14 trials of B vitamins (folic acid, vitamin B6, vitamin B12) with nearly 28,000 participants, mainly in their 60s and 70s. Most of these trials were quite short (less than two years). We found no evidence that B vitamins had any effect on cognition. There were 8 trials of antioxidant vitamins (beta‐carotene/vitamin A, vitamin C, vitamin E) with approximately 47,000 participants. These trials tended to be longer than the B vitamin trials so may have had more chance of detecting effects on dementia and cognitive decline. The results were mixed. We found low‐certainty evidence of better overall cognitive function after an average of 18 years taking beta‐carotene and after five years to 10 years taking vitamin C, but no effects after shorter periods of treatment. There were also small benefits of beta‐carotene, vitamin C, and antioxidant combinations on memory at some time points but not others. There was no evidence of any benefits from vitamin E alone. Two studies examined the risk of developing dementia. One found no effect of a combination of antioxidant vitamins and the other found no effect of vitamin E, either alone or combined with the mineral selenium. Most of the studies did not report any information about harmful effects. One included trial was designed to look for an effect on the risk of prostate cancer; it found a higher risk among the men taking vitamin E. There was a small trial of vitamin D supplements which found they probably had no effect on cognition over six months. There were longer trials of vitamin D with calcium (one trial), zinc and copper (one trial), and complex multivitamins (three trials). All lasted between five and 10 years, but none of them found any evidence of beneficial effects on cognition. One trial found no effect of selenium taken for approximately five years on the risk of developing dementia. Conclusions We found no good evidence to suggest that middle‐aged or older people can preserve cognitive function or prevent dementia by taking vitamin or mineral supplements. There were a few positive results associated with long‐term use of antioxidant vitamins, particularly beta‐carotene and vitamin C, although the effects were small. Further research into the effects of these vitamins may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rutjes, AWS, Denton, DA, Di Nisio, M, Chong, LY, Abraham, RP, Al‐Assaf, AS, Anderson, JL, Malik, MA, Vernooij, RWM, Martínez, G, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011906.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.796Z" }, { "id": "70702da0-0647-40cd-84e2-dd4026da2124", "pmid": "", "title": "Oral immunotherapy for milk allergy", "imported": false, "abstract": "Abstract - Background The mainstay of treatment of IgE‐mediated cow milk allergy (IMCMA) is an avoidance diet, which is especially difficult with a ubiquitous food like milk. Milk oral immunotherapy (MOIT) may be an alternative treatment, through desensitization or induction of tolerance. Objectives We aim to assess the clinical efficacy and safety of MOIT in children and adults with IMCMA as compared to a placebo treatment or avoidance strategy. Search methods We searched 13 databases for journal articles, conference proceedings, theses and unpublished trials, without language or date restrictions, using a combination of subject headings and text words. The search is up‐to‐date as of October 1, 2012. Selection criteria Only randomised controlled trials (RCT) were considered for inclusion. Blinded and open trial designs were included. Children and adults with IMCMA were included. MOIT administered by any protocol were included. Data collection and analysis A total of 2111 unique records were identified and screened for potential inclusion. Studies were selected, data extracted and methodological quality assessed independently by two reviewers. We attempted to contact the study investigators to inquire about data not published that was required for the analysis. Statistical heterogeneity was assessed using the I² test. We estimated a pooled risk ratio (RR) for each outcome using a Mantel‐Haenzel fixed‐effect model if statistical heterogeneity was low as evaluated by an I² value less than 50%. Main results Of 157 records reviewed, 16 were included, representing five trials. In general, the studies were small and had inconsistent methodological rigor. Overall, the quality of evidence was rated as low. Each study used a different MOIT protocol. A total of 196 patients were studied (106 MOIT, 90 control) and all were children. Three studies were blinded and two used an avoidance diet control. Sixty‐six patients (62%) in the MOIT group were able to tolerate a full serving of milk (about 200 mL) compared to seven (8%) of the control group (RR 6.61, 95% CI 3.51 to 12.44). In addition, 27 (25%) in the MOIT group could ingest a partial serving of milk (10 to 184 mL) while none could in the control group (RR 9.34, 95% CI 2.72 to 32.09). None of the studies assessed the patients following a period off immunotherapy. Adverse reactions were common (97 of 106 MOIT patients had at least one symptom), although most were local and mild. Because of variability in reporting methods, adverse effects could not be combined quantitatively. For every 11 patients receiving MOIT, one required intramuscular epinephrine. One patient required it on two occasions. Authors' conclusions Studies to date have involved small numbers of patients and the quality of evidence is generally low. The current evidence shows that MOIT can lead to desensitization in the majority of individuals with IMCMA although the development of long‐term tolerance has not been established. A major drawback of MOIT is the frequency of adverse effects, although most are mild and self‐limited. The use of parenteral epinephrine is not infrequent. Because there are no standardized protocols, guidelines would be required prior to incorporating desensitization into clinical practice. Plain language summary Repetitive, increasing doses of daily milk for treatment of milk allergy To date, the only option to treat food allergy is strict avoidance of the food and carrying an epinephrine injector (Epipen/Twinject) in case of an allergic reaction. For a food like cow's milk, avoidance is very difficult because it is found in many foods. The constant fear of accidentally eating or drinking cow's milk and anxiety related to carrying an injector has negative effects on quality of life. Accidentally having milk can cause life‐threatening reactions. Oral immunotherapy involves initially taking a very small amount of the allergen, in the case of milk allergy, cow's milk, and slowly increasing the amount each day until a full serving is reached. This may change the way the body's immune system sees the allergen, thereby increasing the amount of milk that can be eaten or drunk with no reaction. We identified randomized controlled trials that compared oral immunotherapy to placebo or continued avoidance diet in children and adults with cow's milk allergy. Five studies satisfied our inclusion criteria. In total there were 196 participants (106 in the treatment group and 90 in the control), all of whom were children. In general, the quality of the studies was low. Because the trials involved small numbers and there were problems with the way they were done, further research is needed. The current evidence shows that oral immunotherapy can help a majority of allergic children tolerate a full serving of milk, as long as they continue drinking this amount each day. However, it is not known if this protection is continued if the immunotherapy is stopped for some time. Side effects during oral immunotherapy are frequent and most patients will have at least some mild symptoms. In the studies we included, for every 11 patients who received oral immunotherapy, one needed to be treated with epinephrine injection at some point for a serious allergic reaction to the therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Yeung, JP, Kloda, LA, McDevitt, J, Ben‐Shoshan, M, Alizadehfar, R", "articleTypes": [], "doi": "10.1002/14651858.CD009542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.091Z" }, { "id": "70cdab22-1bb7-4bb7-b8c6-74485369de0a", "pmid": "", "title": "Parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review on parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy (published in Issue 3, 2007). Salivary gland dysfunction is a predictable side effect of radiotherapy to the head and neck region. Pilocarpine hydrochloride (a choline ester) is licensed in many countries for the treatment of radiation‐induced salivary gland dysfunction. Other parasympathomimetics have also been used 'off licence' in the treatment of this condition. Objectives To determine the efficacy and tolerability of parasympathomimetic drugs in the treatment of radiation‐induced salivary gland dysfunction (specifically radiation‐induced xerostomia). Search methods For this update, we ran searches of the Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 6), MEDLINE, EMBASE, and CINAHL in July 2015. We checked the reference lists of retrieved articles for additional studies, contacted experts in the field for unpublished and ongoing trials, and contacted relevant pharmaceutical companies for unpublished and ongoing trials. Selection criteria The selection criteria for the review were: 1) randomised controlled trials; 2) people suffering from radiation‐induced salivary gland dysfunction; 3) people treated with parasympathomimetic drugs; and 4) assessable data available on primary outcome measure. Data collection and analysis The two review authors independently collected data from the full‐text version of relevant papers including: 1) citation details; 2) participants; 3) interventions; 4) assessments; 5) outcomes (that is efficacy, tolerability); and 6) quality issues. Due to a lack of appropriate data, we were unable to perform a meta‐analysis. Main results In the original review, three studies, including a total of 298 participants, fulfilled the inclusion criteria. All three studies involved the use of pilocarpine hydrochloride. We have included no additional studies in the update of the review; we have excluded eight additional studies. The data suggest that pilocarpine hydrochloride is more effective than placebo and at least as effective as artificial saliva. The response rate was 42% to 51%. The time to response was up to 12 weeks. The overall side effect rate was high, and side effects were the main reason for withdrawal (6% to 15% of participants taking 5 mg three times a day had to withdraw). The side effects were usually the result of generalised parasympathomimetic stimulation (for example sweating, headaches, urinary frequency, vasodilatation). Response rates were not dose dependent, but side effect rates were dose dependent. Authors' conclusions There is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced xerostomia. Currently, there is little evidence to support the use of other parasympathomimetic drugs in the treatment of radiation‐induced xerostomia. Available studies suggest that approximately half of patients will respond, but side effects can be problematic. The conclusions of the update are the same as the conclusions of the original review, since no new relevant studies have been published in the interim. Plain language summary Parasympathomimetic drugs for the treatment of 'dry mouth' due to radiotherapy This updated review found there is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced salivary gland dysfunction ('dry mouth'). Salivary gland damage is a frequent and important complication of radiotherapy to the head and neck area; it causes dryness of the mouth with resultant problems with eating, talking, and local infection. The parasympathomimetic group of drugs have been used to treat radiotherapy‐induced salivary gland damage. We identified three studies that involved a total of 289 participants, and they all used the drug pilocarpine. The review found that 42% to 51% of participants (4 to 5 in 10) responded to pilocarpine, although in some participants the response did not occur for up to 12 weeks. Pilocarpine was more effective than a placebo treatment, and at least as effective as an artificial saliva. Side effects were common with pilocarpine (for example sweating, headache, passing urine frequently, flushing), but were usually reported to be mild; 6% to 15% (0.6 to 1.5 in 10) participants had to stop taking pilocarpine due to side effects. The findings of this review are limited by the small number of good‐quality trials that have been performed in this area. The update of this review did not find any new information on this topic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Davies, AN, Thompson, J", "articleTypes": [], "doi": "10.1002/14651858.CD003782.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.752Z" }, { "id": "70d2b467-5b45-409b-bd3d-9c158c26843c", "pmid": "", "title": "Hyperbaric oxygen therapy for late radiation tissue injury", "imported": false, "abstract": "Abstract - Background This is the third update of the original Cochrane Review published in July 2005 and updated previously in 2012 and 2016. Cancer is a significant global health issue. Radiotherapy is a treatment modality for many malignancies, and about 50% of people having radiotherapy will be long‐term survivors. Some will experience late radiation tissue injury (LRTI), developing months or years following radiotherapy. Hyperbaric oxygen therapy (HBOT) has been suggested as a treatment for LRTI based on the ability to improve the blood supply to these tissues. It is postulated that HBOT may result in both healing of tissues and the prevention of complications following surgery and radiotherapy. Objectives To evaluate the benefits and harms of hyperbaric oxygen therapy (HBOT) for treating or preventing late radiation tissue injury (LRTI) compared to regimens that excluded HBOT. Search methods We used standard, extensive Cochrane search methods. The latest search date was 24 January 2022. Selection criteria We included randomised controlled trials (RCTs) comparing the effect of HBOT versus no HBOT on LRTI prevention or healing. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. survival from time of randomisation to death from any cause; 2. complete or substantial resolution of clinical problem; 3. site‐specific outcomes; and 4. adverse events. Our secondary outcomes were 5. resolution of pain; 6. improvement in quality of life, function, or both; and 7. site‐specific outcomes. We used GRADE to assess certainty of evidence. Main results Eighteen studies contributed to this review (1071 participants) with publications ranging from 1985 to 2022. We added four new studies to this updated review and evidence for the treatment of radiation proctitis, radiation cystitis, and the prevention and treatment of osteoradionecrosis (ORN). HBOT may not prevent death at one year (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.47 to 1.83; I 2 = 0%; 3 RCTs, 166 participants; low‐certainty evidence). There is some evidence that HBOT may result in complete resolution or provide significant improvement of LRTI (RR 1.39, 95% CI 1.02 to 1.89; I 2 = 64%; 5 RCTs, 468 participants; low‐certainty evidence) and HBOT may result in a large reduction in wound dehiscence following head and neck soft tissue surgery (RR 0.24, 95% CI 0.06 to 0.94; I 2 = 70%; 2 RCTs, 264 participants; low‐certainty evidence). In addition, pain scores in ORN improve slightly after HBOT at 12 months (mean difference (MD) −10.72, 95% CI −18.97 to −2.47; I 2 = 40%; 2 RCTs, 157 participants; moderate‐certainty evidence). Regarding adverse events, HBOT results in a higher risk of a reduction in visual acuity (RR 4.03, 95% CI 1.65 to 9.84; 5 RCTs, 438 participants; high‐certainty evidence). There was a risk of ear barotrauma in people receiving HBOT when no sham pressurisation was used for the control group (RR 9.08, 95% CI 2.21 to 37.26; I 2 = 0%; 4 RCTs, 357 participants; high‐certainty evidence), but no such increase when a sham pressurisation was employed (RR 1.07, 95% CI 0.52 to 2.21; I 2 = 74%; 2 RCTs, 158 participants; high‐certainty evidence). Authors' conclusions These small studies suggest that for people with LRTI affecting tissues of the head, neck, bladder and rectum, HBOT may be associated with improved outcomes (low‐ to moderate‐certainty evidence). HBOT may also result in a reduced risk of wound dehiscence and a modest reduction in pain following head and neck irradiation. However, HBOT is unlikely to influence the risk of death in the short term. HBOT also carries a risk of adverse events, including an increased risk of a reduction in visual acuity (usually temporary) and of ear barotrauma on compression. Hence, the application of HBOT to selected participants may be justified. The small number of studies and participants, and the methodological and reporting inadequacies of some of the primary studies included in this review demand a cautious interpretation. More information is required on the subset of disease severity and tissue type affected that is most likely to benefit from this therapy, the time for which we can expect any benefits to persist and the most appropriate oxygen dose. Further research is required to establish the optimum participant selection and timing of any therapy. An economic evaluation should also be undertaken. Plain language summary Hyperbaric oxygen therapy for the treatment of the late effects of radiotherapy Key message – In selected people and areas of the body hyperbaric oxygen therapy (HBOT) may help resolve symptoms associated with late radiation tissue injury (LRTI) but further research is required to establish which people may respond and the best timing of such therapy. What are the problems after radiation treatment and how can it be treated? There is a risk of serious complications developing in the months and years after radiation treatment (radiotherapy) for cancer. These problems are collectively called LRTI and are due to progressive damage to normal tissue (cells within the body) that has been exposed to radiation. These problems can be very difficult to resolve, and there is some doubt as to the best approaches to treatment. HBOT involves breathing oxygen in a specially designed pressurised chamber. It is used to improve oxygen supply to damaged tissue and support healing. What did we want to find out? We wanted to find out if HBOT results in both healing of tissues and the prevention of complications following surgery in an irradiated field and radiotherapy for cancer. What did we do? We searched medical databases for clinical studies reporting the evidence for or against the ability of HBOT to improve these complications compared to either no treatment or alternative treatments. What were the main findings? There was some evidence that HBOT may improve outcomes in LRTI affecting both bone and soft tissues of the head and neck, the bladder and the lower bowel. There was also some evidence that HBOT may reduce wound breakdown and improve pain following LRTI. HBOT did not affect the risk of dying over the short time that these studies followed their patients. HBOT is generally safe and well‐tolerated, but there is a risk of becoming temporarily short‐sighted from the oxygen exposure and of injury to the ear drum on compression. What are the limitations of the evidence? The evidence was mainly limited by small numbers of people and studies, poor reporting of methods and results, and uncertainty as to the exact degree of improvement with HBOT. A study of costs would also be useful. How up to date is this evidence? The evidence is current to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lin, ZC; Bennett, MH; Hawkins, GC; Azzopardi, CP; Feldmeier, J; Smee, R; Milross, C", "articleTypes": [], "doi": "10.1002/14651858.CD005005.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "70dacc15-bbd8-4d52-937e-aa28e13cadaf", "pmid": "", "title": "Effect of Non-nutritive Sweeteners on Vascular Function in Humans", "imported": false, "abstract": "In recent decades, low-to-null caloric, non-nutritive sweeteners (NNS) have been increasingly used, replacing and offering an alternative to food and beverages sweetened by high-energy, added sugars. Indeed, by providing consumers with products that have a sweet taste with low energy content, NNS appear to be the magic bullet to enhance weight loss and reduce cardio-metabolic diseases. However, a recent meta-analysis of randomized trials does not show any benefit of NNS consumption on body weight loss. Moreover, epidemiological, descriptive and experimental studies have recently reported that NNS consumption is paradoxically associated with weight gain, glucose intolerance and increased risk of type 2 diabetes and/or cardiovascular events. Among the approved NNS, sucralose and AceK, both high intensity (respectively ~500-600 and 200 times sweeter than sugar) are the most widely used in foods and drinks, accounting more than 62 % of the global artificial sweetener market. Recent experimental data show an effect of sucralose and AceK (and other NNS) consumption on vascular reactivity in response to a physiological stress (hyperglycemic load) in rats. Since sweet taste receptors (T1R) have been recently found in the endothelium, investigators hypothesize that NNS, and especially sucralose and AceK, a potent T1R agonist, impairs micro- and macrovascular reactivity in humans, which, to the best of our knowledge, has never been explored.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "70de5ab4-3b79-42ea-bb9e-22af4c8e89de", "pmid": "", "title": "Surgical techniques for the removal of mandibular wisdom teeth", "imported": false, "abstract": "Abstract - Background Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short‐term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity. Objectives To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication. Selection criteria Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth. Data collection and analysis Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel‐group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross‐over or split‐mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split‐mouth studies in our analyses, and combined parallel‐group and split‐mouth studies using the generic inverse‐variance method. We used the fixed‐effect model for three studies or fewer, and random‐effects model for more than three studies. Main results We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low‐certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low‐certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low‐certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low‐certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand‐piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low‐certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low‐certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low‐certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low‐certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low‐certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported. Authors' conclusions In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future. Plain language summary Comparing different surgical techniques used to remove wisdom teeth from the lower jaw Background The removal of wisdom teeth is a common operation, but it can cause short‐ and long‐term side effects. People may have their wisdom teeth removed if they are causing pain or infection, or if they are damaging other teeth or not breaking through the gum properly. Surgery has a risk of complications. One of the most common is dry socket (also known as alveolar osteitis). This is when a blood clot fails to form in the socket that the tooth has come out of, or the clot is disturbed before the socket has properly healed. Because the bones and nerves underlying the socket are exposed, it can be a very painful condition. Review question We aimed to find out the benefits and harms of different surgical techniques used to remove wisdom teeth from the lower jaw, specifically how surgeons can reduce the risk of complications following surgery. We considered the most important outcomes to be: dry socket, wound infection, long‐term damage to the nerves supplying sensation to the tongue and skin of the lower lip and chin, and problems such as excessive bleeding or a broken jaw. Study characteristics We searched for relevant studies up to 8 July 2019. We included 62 studies with 4643 participants. Many studies excluded people who were not in excellent health so the participants in the trials may not be truly representative. Key results The available evidence is inconclusive. It is unclear if the position of the cut into the gum makes any difference to the outcomes. It is unclear whether it is possible to avoid damaging a nerve to the tongue by using a surgical instrument called a lingual retractor. It is unclear as to whether the type of surgical tool (a chisel or a rotating drill) used to remove bone from the jaw makes a difference to the likelihood of the wound becoming infected. It is unclear if the amount and method of delivering saltwater to clean the tooth socket after the extraction makes any difference to the outcomes. It is unclear whether different methods to stitch the gum after the tooth is removed makes any difference to the outcomes. Placing products that are derived from the patient’s own blood into the tooth socket may help to reduce the occurrence of dry socket (a condition that causes intense pain a few days after extraction). Another three surgical approaches were tested in the studies, but they did not measure the important outcomes. Certainty of the evidence None of the included studies were at low risk of bias. All of the studies were quite small. The quality of the studies varied, with most having flaws that could have biased their results. In addition, some of the results were very imprecise, with variation between them that could not be explained. For these reasons, we consider the available evidence to be uncertain. Future research may be able to provide dental surgeons and patients with clearer conclusions than those listed above.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bailey, E, Kashbour, W, Shah, N, Worthington, HV, Renton, TF, Coulthard, P", "articleTypes": [], "doi": "10.1002/14651858.CD004345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.791Z" }, { "id": "70f990db-ffff-45bb-a48d-1b76d9cc08df", "pmid": "", "title": "Macrolide antibiotics (including azithromycin) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a life‐limiting genetic condition, affecting over 90,000 people worldwide. CF affects several organs in the body, but airway damage has the most profound impact on quality of life (QoL) and survival. Causes of lower airway infection in people with CF are, most notably, Staphylococcus aureus in the early course of the disease and Pseudomonas aeruginosa at a later stage. Macrolide antibiotics, e.g. azithromycin and clarithromycin, are usually taken orally, have a broad spectrum of action against gram‐positive (e.g. S aureus ) and some gram‐negative bacteria (e.g. Haemophilus influenzae ), and may have a modifying role in diseases involving airway infection and inflammation such as CF. They are well‐tolerated and relatively inexpensive, but widespread use has resulted in the emergence of resistant bacteria. This is an updated review. Objectives To assess the potential effects of macrolide antibiotics on clinical status in terms of benefit and harm in people with CF. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals, and abstract books of conference proceedings. We last searched the Group's Cystic Fibrosis Trials Register on 2 November 2022. We last searched the trial registries WHO ICTRP and clinicaltrials.gov on 9 November 2022. We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow‐up data, where possible. Selection criteria We included randomised controlled trials of macrolide antibiotics in adults and children with CF. We compared them to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose or type of administration. Data collection and analysis Two authors independently extracted data and assessed risk of bias. We assessed the certainty of evidence using GRADE. Main results We included 14 studies (1467 participants) lasting 28 days to 36 months. All the studies assessed azithromycin: 11 compared oral azithromycin to placebo (1167 participants); one compared a high dose to a low dose (47 participants); one compared nebulised to oral azithromycin (45 participants); and one looked at weekly versus daily dose (208 participants). Oral azithromycin versus placebo There is a slight improvement in forced expiratory volume (FEV 1 % predicted) in one second in the azithromycin group at up to six months compared to placebo (mean difference (MD) 3.97, 95% confidence interval (CI) 1.74 to 6.19; high‐certainty evidence), although there is probably no difference at three months, (MD 2.70%, 95% CI ‐0.12 to 5.52), or 12 months (MD ‐0.13, 95% CI ‐4.96 to 4.70). Participants in the azithromycin group are probably at a decreased risk of pulmonary exacerbation with a longer time to exacerbation (hazard ratio (HR) 0.61, 95% CI 0.50 to 0.75; moderate‐certainty evidence). Mild side effects were common, but there was no difference between groups (moderate‐certainty evidence). There is no difference in hospital admissions at six months (odds ratio (OR) 0.61, 95% CI 0.36 to 1.04; high‐certainty evidence), or in new acquisition of P aeruginosa at 12 months (HR 1.00, 95% CI 0.64 to 1.55; moderate‐certainty evidence). High‐dose versus low‐dose azithromycin We are uncertain whether there is any difference in FEV 1 % predicted at six months between the two groups (no data available) or in the rate of exacerbations per child per month (MD ‐0.05 (95% CI ‐0.20 to 0.10)); very low‐certainty evidence for both outcomes. Only children were included in the study and the study did not report on any of our other clinically important outcomes. Nebulised azithromycin versus oral azithromycin We were unable to include any of the data into our analyses and have reported findings directly from the paper; we graded all evidence as being of very low certainty. The authors reported that there was a greater mean change in FEV 1 % predicted at one month in the nebulised azithromycin group (P < 0.001). We are uncertain whether there was a change in P aeruginosa count. Weekly azithromycin versus daily azithromycin There is probably a lower mean change in FEV 1 % predicted at six months in the weekly group compared to the daily group (MD ‐0.70, 95% CI ‐0.95 to ‐0.45) and probably also a longer period of time until first exacerbation in the weekly group (MD 17.30 days, 95% CI 4.32 days to 30.28 days). Gastrointestinal side effects are probably more common in the weekly group and there is likely no difference in admissions to hospital or QoL. We graded all evidence as moderate certainty. Authors' conclusions Azithromycin therapy is associated with a small but consistent improvement in respiratory function, a decreased risk of exacerbation and longer time to exacerbation at six months; but evidence for treatment efficacy beyond six months remains limited. Azithromycin appears to have a good safety profile (although a weekly dose was associated with more gastrointestinal side effects, which makes it less acceptable for long‐term therapy), with a relatively minimal treatment burden for people with CF, and it is inexpensive. A wider concern may be the emergence of macrolide resistance reported in the most recent study which, combined with the lack of long‐term data, means we do not feel that the current evidence is strong enough to support azithromycin therapy for all people with CF. Future research should report over longer time frames using validated tools and consistent reporting, to allow for easier synthesis of data. In particular, future trials should report important adverse events such as hearing impairment or liver disease. More data on the effects of azithromycin given in different ways and reporting on our primary outcomes would benefit decision‐making on whether and how to give macrolide antibiotics. Finally, it is important to assess azithromycin therapy for people with CF who are established on the relatively new cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies which correct the underlying molecular defect associated with CF (none of the trials included in the review are relevant to this population). Plain language summary Treatment with macrolide antibiotics (including azithromycin) for people with cystic fibrosis Review question What are the effects of macrolide antibiotics in people with cystic fibrosis (CF) and infection of their airways? Key messages ‐ People with CF are more prone to chest infections caused by bacteria that can be hard to treat. ‐ Macrolide antibiotics (such as azithromycin and clarithromycin) may lessen the effects of bacteria. ‐ One macrolide antibiotic, azithromycin, can improve lung function at six months compared to a placebo (treatment with no active ingredient) and may reduce the risk of getting a flare‐up of lung infection. We are not sure whether a higher dose of azithromycin is any better than a lower dose, or if azithromycin when inhaled is any better than azithromycin when swallowed (oral). Oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. ‐ Current evidence does not support longer‐term use of azithromycin for all people with CF. Introduction People with CF suffer from infections in their airways, often caused by the bug Pseudomonas aeruginosa , which is resistant to nearly all antibiotics that can be swallowed (oral). Macrolide antibiotics, e.g. azithromycin and clarithromycin, have no direct killing effect on Pseudomonas aeruginosa , but they may reduce the activity of these bacteria. What did we want to find out? We wanted to discover whether the use of macrolide antibiotics (usually taken orally) affected the health of people with CF and whether these drugs have any side effects. What did we do? We searched for studiesthat looked at the effects of macrolide antibiotics in children and adults with CF and summarised the evidence. What did we find? We found 14 studies, which put the total of 1467 children and adults into different treatment groups at random, which we included in this review. Eleven studies compared azithromycin to placebo, one compared two different doses of azithromycin (high versus low dose), one compared inhaled azithromycin to oral azithromycin, and one compared oral azithromycin once a week to once a day. Main results We found that there was a slight improvement in lung function in people that were given azithromycin compared to a placebo at six months and also that the risk of a flare‐up of infection was lower. The risk of side effects (such as vomiting, diarrhoea and headache) was similar in both groups, as was the chance of a new infection with Pseudomonas aeruginosa. In terms of lung function and flare‐up of infection, we were unsure whether a higher dose of azithromycin is better than a lower dose (but only one study in children examined dose), or whether inhaled azithromycin is better than oral azithromycin. Taking oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. What are the limitations of the evidence? We were unable to combine all the study results because they were measured in different ways and at different time points; future trials should address this issue. Also, now that many people with CF are being treated with the new modulator therapies (e.g. elexacaftor‐tezacaftor‐ivacaftor), it is important to assess how macrolide antibiotics affect the health of these people. In the studies we found for this review, none of the people taking part were being treated with modulator therapies. We are able to report the results of the studies that compared azithromycin to placebo with certainty as the studies were well conducted and included a larger number of participants. The evidence from the studies comparing high and low doses or nebulised and oral azithromycin was much less certain because the studies were small and there was risk of bias in the way they were carried out. We were moderately certain of the results of the study comparing weekly azithromycin to daily azithromycin. How up to date is this evidence? The studies we have reported are the most up to date we could find. We last searched for studies in November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Southern, KW; Solis-Moya, A; Kurz, D; Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD002203.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "7141770f-8f5e-4ff2-8720-cfdea5461d6b", "pmid": "", "title": "Eszopiclone for insomnia", "imported": false, "abstract": "Abstract - Background Insomnia is a major public health issue affecting between 6% to 10% of the adult population in Western countries. Eszopiclone is a hypnotic drug belonging to a newer group of hypnotic agents, known as new generation hypnotics, which was marketed as being just as effective as benzodiazepines for this condition, while being safer and having a lower risk for abuse and dependence. It is the aim of the review to integrate evidence from randomised controlled trials and to draw conclusions on eszopiclone's efficacy and safety profile, while taking methodological features and bias risks into consideration. Objectives To assess the efficacy and safety of eszopiclone for the treatment of insomnia compared to placebo or active control. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, Embase, PsycINFO, PSYNDEX and registry databases (WHO trials portal, ClinicalTrials.gov) with results incorporated from searches to 10 February 2016. To identify trials not registered in electronic databases, we contacted key informants and searched reference lists of identified studies. We ran an update search (21 February 2018) and have placed studies of interest in awaiting classification/ongoing studies. These will be incorporated into the next version of the review, as appropriate. Selection criteria Parallel group randomised controlled trials (RCTs) comparing eszopiclone with either placebo or active control were included in the review. Participants were adults with insomnia, as diagnosed with a standardised diagnostic system, including primary insomnia and comorbid insomnia. Data collection and analysis Two authors independently extracted outcome data; one reviewer assessed trial quality and the second author cross‐checked it. Main results A total of 14 RCTs, with 4732 participants, were included in this review covering short‐term (≤ 4 weeks; 6 studies), medium‐term (> 4 weeks ≤ 6 months; 6 studies) and long‐term treatment (> 6 months; 2 studies) with eszopiclone. Most RCTs included in the review included participants aged between 18 and 64 years, three RCTs only included elderly participants (64 to 85 years) and one RCT included participants with a broader age range (35 to 85 years). Seven studies considered primary insomnia; the remaining studies considered secondary insomnia comorbid with depression (2), generalised anxiety (1), back pain (1), Parkinson's disease (1), rheumatoid arthritis (1) and menopausal transition (1). Meta‐analytic integrations of participant‐reported data on sleep efficacy outcomes demonstrated better results for eszopiclone compared to placebo: a 12‐minute decrease of sleep onset latency (mean difference (MD) ‐11.94 min, 95% confidence interval (CI) ‐16.03 to ‐7.86; 9 studies, 2890 participants, moderate quality evidence), a 17‐minute decrease of wake time after sleep onset (MD ‐17.02 min, 95% CI ‐24.89 to ‐9.15; 8 studies, 2295 participants, moderate quality evidence) and a 28‐minute increase of total sleep time (MD 27.70 min, 95% CI 20.30 to 35.09; 10 studies, 2965 participants, moderate quality evidence). There were no significant changes from baseline to the first three nights after drug discontinuation for sleep onset latency (MD 17.00 min, 95% CI ‐4.29 to 38.29; 1 study, 291 participants, low quality evidence) and wake time after sleep onset (MD ‐6.71 min, 95% CI ‐21.25 to 7.83; 1 study, 291 participants, low quality evidence). Adverse events during treatment that were documented more frequently under eszopiclone compared to placebo included unpleasant taste (risk difference (RD) 0.18, 95% CI 0.14 to 0.21; 9 studies, 3787 participants), dry mouth (RD 0.04, 95% CI 0.02 to 0.06; 6 studies, 2802 participants), somnolence (RD 0.04, 95% CI 0.02 to 0.06; 8 studies, 3532 participants) and dizziness (RD 0.03, 95% CI 0.01 to 0.05; 7 studies, 2933 participants). According to the GRADE criteria, evidence was rated as being of moderate quality for sleep efficacy outcomes and adverse events and of low quality for rebound effects and next‐day functioning. Authors' conclusions Eszopiclone appears to be an efficient drug with moderate effects on sleep onset and maintenance. There was no or little evidence of harm if taken as recommended. However, as certain patient subgroups were underrepresented in RCTs included in the review, findings might not have displayed the entire spectrum of possible adverse events. Further, increased caution is required in elderly individuals with cognitive and motor impairments and individuals who are at increased risk of using eszopiclone in a non‐recommended way. Plain language summary Eszopiclone (Lunesta) for sleep difficulty Why is this review important? Insomnia is the medical term for sleep difficulty covering trouble falling asleep, difficulties staying asleep, waking up too early or experiencing sleep as non‐restorative. Insomnia can be treated with different methods including behaviour modification, relaxation techniques, or sleeping medication. Eszopiclone (Lunesta) is a sleeping medication that belongs to a class of sleeping tablets known as non‐benzodiazepine hypnotics. Who will be interested in this review? People who are affected by insomnia, general practitioners, professionals working in health services, and addiction treatment and health policy makers. What questions does this review aim to answer? The review aimed to find out more about the wanted effects and unwanted effects of eszopiclone. Wanted effects included the immediate effects eszopiclone has on sleep; unwanted effects included side effects, effects on next‐day functioning, but also addictive properties of the drug. Which studies were included in the review? The review summarised findings from 14 clinical studies with 4732 people, either receiving eszopiclone or an identically‐appearing, but inert substance (placebo). What does the evidence from the review tell us? On average, people taking eszopiclone fell asleep 12 minutes faster than those taking placebo, were 17 minutes less awake during the night and had, in total, about half an hour more sleep than people in the placebo group. As side effects, eszopiclone can cause unpleasant taste, dizziness, dry mouth, and tiredness during the day. Clinical studies did not find evidence that eszopiclone was causing serious harm or withdrawal symptoms or whether it was addictive if it was stopped and not taken after several weeks or months of treatment. Nevertheless, as clinical studies included in the review did not cover certain groups (e.g. elderly people with cognitive or motor problems or certain conditions of medication intake), it is important for patients to consult their doctor who knows their medical history and condition. What should happen next? Future research needs to compare eszopiclone with other sleep medications to help physicians and patients decide which of the available treatment options to prefer. In addition, sleep medications that are also well tolerated by elderly individuals and individuals with alcohol or drug problems need to be identified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rösner, S; Englbrecht, C; Wehrle, R; Hajak, G; Soyka, M", "articleTypes": [], "doi": "10.1002/14651858.CD010703.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "7141aff2-01a5-40cb-b7e9-f37460d3e79d", "pmid": "", "title": "Helminth therapy (worms) for induction of remission in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease (IBD) is a chronic, globally‐occurring gastrointestinal disorder and a major cause of illness and disability. It is conventionally classified into Crohn’s disease (CD) and ulcerative colitis (UC). Helminths are parasitic worms with complex life cycles involving tissue‐ or lumen‐dwelling stages in their hosts, and causing long‐lasting or chronic infections that are frequently asymptomatic. Helminths modulate immune responses of their hosts, and many observational and experimental studies support the hypothesis that helminths suppress immune‐mediated chronic inflammation that occurs in asthma, allergy and IBD. Objectives The objective was to evaluate the efficacy and safety of helminth treatment for induction of remission in IBD. Search methods We searched the following databases from inception to 13 July 2013: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Inflammatory Bowel Disease Group Specialized Trials Register. We also searched four online trials registries, and abstracts from major meetings. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) where the intervention was any helminth species or combination of helminth species, administered in any dose and by any route and for any duration of exposure to people with active CD or UC, confirmed through any combination of clinical, endoscopic and histological criteria were eligible for inclusion. Data collection and analysis Two authors independently extracted data and assessed eligibility using a standardized data collection form. We used the RevMan software for analyses. The primary outcome was induction of remission as defined by the included studies. Secondary outcomes included clinical, histologic, or endoscopic improvement as defined by the authors, endoscopic mucosal healing, change in disease activity index score, change in quality of life score, hospital admissions, requirement for intravenous corticosteroids, surgery, study withdrawal and the incidence of adverse events. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. We calculated the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria. Main results Two RCTs (90 participants) were included. One trial assessed the efficacy and safety of Trichuris suis ( T. suis ) ova in patients with UC (n = 54). The other RCT was a phase one that assessed the safety and tolerability of T. suis ova in patients with CD (n = 36). The risk of bias in both studies was judged to be low. In the UC study, during the 12‐week study period, participants in the active arm received 2‐weekly aliquots of 2500 T. suis eggs, added to 0.8 mL of saline; those in the placebo arm received 0.8 mL saline only. There were sparse data available for the outcomes clinical remission and clinical improvement. Ten per cent (3/30) of patients in the T. suis arm entered remission compared to 4% (1/24) of patients in the placebo arm (RR 2.40, 95% CI 0.27 to 21.63). Forty‐three per cent (13/30) of patients in the T. suis group achieved clinical improvement compared to 17% (4/24) of placebo patients (RR 2.60, 95% CI 0.97 to 6.95). The mean ulcerative colitis disease activity index (UCDAI) score was lower in the T. suis group (6.1 +/‐ 0.61) compared to the placebo group (7.5 +/‐ 0.66) after 12 weeks of treatment (MD ‐1.40, 95% CI ‐1.75 to ‐1.05). There was only limited evidence relating to the proportion of patients who experienced an adverse event. Three per cent (1/30) of patients in the T. suis group experienced at least one adverse event compared to 12% (3/24) of placebo patients (RR 0.27, 95% CI 0.03 to 2.40). None of the adverse events reported in this study were judged to be related to the study treatment. GRADE analyses rated the overall quality of the evidence for the primary and secondary outcomes (i.e. clinical remission and improvement) as low due to serious imprecision. In the CD study, participants received a single treatment of T. suis ova at a dosage of 500 (n = 9), 2500 (n = 9), or 7500 (n = 9) embryonated eggs or matching placebo (n = 9). The CD study did not assess clinical remission or improvement as outcomes. There were sparse data on adverse events at two weeks. Thirty‐seven per cent (10/27) of patients in the T. suis group experienced at least one adverse event compared to 44% (4/9) of placebo patients (RR 0.83, 95% CI 0.35 to 2.01). Only one adverse event (dysgeusia) was judged to be possibly related to treatment in this study. Dysgeusia was reported in one patient in the T. suis group and in one patient in the placebo group. Authors' conclusions Currently, there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of helminths used to treat patients with IBD. The evidence for our primary efficacy outcomes in this review comes from one small study and is of low quality due to serious imprecision. We do not have enough evidence to determine whether helminths are safe when used in patients with UC and CD. Further RCTs are required to assess the efficacy and safety of helminth therapy in IBD. Plain language summary Helminth therapy (worms) for induction of remission in inflammatory bowel disease Inflammatory bowel disease (IBD) is comprised of two disorders: ulcerative colitis and Crohn’s disease. These disorders have both distinct and overlapping symptoms, but the underlying cause remains incompletely understood. Standard therapy for IBD includes sulfasalazine, 5‐ASA drugs, steroids, immunosuppressives such as azathioprine, 6‐mercaptopurine and methotrexate and biological agents such as infliximab. Helminths are worm‐like parasites, that inhabit larger organisms. Helminths cause changes in the immune systems of their hosts including an altered immunological response to antigens and this has implications for the treatment of inflammatory bowel disease which is thought to be caused by immune dysregulation. The purpose of this systematic review was to examine the effectiveness and safety of helminth therapy for inducing remission in people with IBD. This review identified two randomised controlled trials including a total of 90 participants. One study compared twice weekly treatment with helminths (an 0.8 mL solution containing 2500 live eggs of the helminth Trichuris suis ) for 12 weeks to a matching placebo (an 0.8 ml identical looking solution with no Trichuris suis eggs) in 54 patients with active ulcerative colitis. Few remissions occurred during the trial and helminth treatment had no detectable effect on these remissions. Ten per cent (3/30) of patients in the helminth group achieved remission compared to four per cent (1/24) of placebo patients. A higher proportion of patients in the helminth group (43% or 13/30) improved clinically compared to the placebo group (17% or 4/24). However, this difference could be a chance effect. We could not determine whether the proportion of patients who had a side effect was higher in either group. No observed side effects were thought to be related to treatment were reported in this study. The other study compared one treatment with various doses of helminths (a solution of 500, 2500 or 7500 Trichuris suis eggs) to a matching placebo in 36 patients with Crohn's disease. This study was designed to assess side effects and did not measure clinical remission or improvement. There amount of information available on side‐effects at two weeks was limited and the results were uncertain due to the small number of participants in the study. The only side effect that was judged to be possibly related to the study treatment was dysgeusia (a distortion of the sense of taste). This was reported in one patient in the helminth group and in one patient in the placebo group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and safety of helminths used to treat patients with IBD. The only information available relating to clinical improvement in patients with active ulcerative colitis comes from one small study. We do not know how safe helminths are when used in patients with ulcerative colitis and Crohn's disease. Further randomised controlled trials are required to assess the efficacy and safety of helminth therapy in IBD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Garg, SK, Croft, AM, Bager, P", "articleTypes": [], "doi": "10.1002/14651858.CD009400.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.127Z" }, { "id": "71445d2f-140a-4f46-80dc-1f615dec2efa", "pmid": "", "title": "Exposure to the smell and taste of milk to accelerate feeding in preterm infants", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Delgado Paramo, L, Bronnert, A, Lin, L, Bloomfield, FH, Muelbert, M, Harding, JE", "articleTypes": [], "doi": "10.1002/14651858.CD013038.pub3 AB - Abstract - Background Preterm infants (born before 37 weeks' gestation) are often unable to co‐ordinate sucking, swallowing, and breathing for oral feeding because of their immaturity. In such cases, initial nutrition is provided by orogastric or nasogastric tube feeding. Feeding intolerance is common and can delay attainment of full enteral and sucking feeds, prolonging the need for nutritional support and the hospital stay. Smell and taste play an important role in the activation of physiological pre‐absorptive processes that contribute to food digestion and absorption. However, during tube feeding, milk bypasses the nasal and oral cavities, limiting exposure to the smell and taste of milk. Provision of the smell and taste of milk with tube feeds offers a non‐invasive and low‐cost intervention that, if effective in accelerating the transition to enteral feeds and subsequently to sucking feeds, would bring considerable advantages to infants, their families, and healthcare systems. Objectives To assess whether exposure to the smell or taste (or both) of breastmilk or formula administered with tube feeds can accelerate the transition to full sucking feeds without adverse effects in preterm infants. Search methods We conducted searches in CENTRAL, MEDLINE, Embase, CINAHL, and Epistemonikos to 26 April 2023. We also searched clinical trial databases and conference proceedings. Selection criteria We included randomised and quasi‐randomised studies that evaluated exposure versus no exposure to the smell or taste of milk (or both) immediately before or at the time of tube feeds. Data collection and analysis Two review authors independently selected studies, assessed risk of bias, and extracted data according to Cochrane Neonatal methodology. We performed meta‐analyses using risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence. Main results We included eight studies (1277 preterm infants). Seven studies (1244 infants) contributed data for meta‐analysis. The evidence suggests that exposure to the smell and taste of milk with tube feeds has little to no effect on time taken to reach full sucking feeds (MD −1.07 days, 95% CI −2.63 to 0.50; 3 studies, 662 infants; very low‐certainty evidence). Two studies reported no adverse effects related to the intervention. The intervention may have little to no effect on duration of parenteral nutrition (MD 0.23 days, 95% CI −0.24 to 0.71; 3 studies, 977 infants; low‐certainty evidence), time to reach full enteral feeds (MD −0.16 days, 95% CI −0.45 to 0.12; 1 study, 736 infants; very low‐certainty evidence) or risk of necrotising enterocolitis (RR 0.93, 95% CI 0.47 to 1.84; 2 studies, 435 infants; low‐certainty evidence), although the evidence for time to reach full enteral feeds is very uncertain. Exposure to the smell and taste of milk with tube feeds probably has little to no effect on risk of late infection (RR 1.14, 95% CI 0.74 to 1.75; 2 studies, 436 infants; moderate‐certainty evidence). There were no data available to assess feeding intolerance. The included studies had small sample sizes and methodological limitations, including unclear or lack of randomisation (four studies), lack of blinding of participants and personnel (five studies), unclear or lack of blinding of the outcome assessor (all eight studies), and different inclusion criteria and methods of administering the interventions. Authors' conclusions The results of our meta‐analyses suggest that exposure to the smell and taste of milk with tube feeds may have little to no effect on time to reach full sucking feeds and time to reach full enteral feeds. We found no clear difference between exposure and no exposure to the smell or taste of milk on safety outcomes (adverse effects, necrotising enterocolitis, and late infection). Results from one ongoing study and two studies awaiting classification may alter the conclusions of this review. Future research should examine the effect of exposing preterm infants to the smell and taste of milk with tube feeds on health outcomes during hospitalisation, such as attainment of feeding skills, safety, feed tolerance, infection, and growth. Future studies should be powered to detect the effect of the intervention in infants of different gestational ages and on each sex separately. It is also important to determine the optimal method, frequency, and duration of exposure. Plain language summary Does exposure to the smell and taste of milk accelerate feeding in tube‐fed preterm infants? Key messages • Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time it takes preterm infants to reach full sucking feeds.
• We found no evidence of any unwanted effects of exposure to the smell and taste of milk with tube feeds in newborn infants. What is tube feeding? Infants born preterm (before 37 weeks of pregnancy) often need to be fed via a thin tube inserted through the mouth (orogastric tube) or nose (nasogastric tube) into the stomach until they are able to suck all of their feeds. Why is the smell and taste of milk important for tube‐fed babies? Initially, only small volumes of milk are given, and this is gradually increased depending on how well the babies tolerate the milk. Smell and taste have a significant role in helping with digestion and absorption of food, and since infants being fed by a tube may not experience the smell or taste of milk, they might be taking longer to tolerate larger volumes of milk. What did we want to find out? We wanted to find out if exposing infants to the smell and taste of milk before or while they were being fed through a tube could help them tolerate greater volumes of milk more quickly and improve their overall growth and development. We also wanted to know if this method had any unwanted effects. What did we do? We searched for studies that investigated exposing preterm infants to the smell or taste (or both) of milk with tube feeds, compared to no such exposure. We compared and summarised the results of the studies and rated the certainty of the evidence, based on factors such as study methods and number of infants included. What did we find? We identified eight completed studies involving 1277 preterm infants admitted to a neonatal intensive care unit. Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time to reach full sucking feeds, but the results are very uncertain. Two studies reported that no infants had any unwanted effects related to exposure to the smell and taste of milk with tube feeds. Exposure to the smell and taste of milk may have little to no effect on duration of intravenous nutrition (feeding through a vein), time to reach full enteral feeds (feeds though a tube into the stomach), or on the risk of necrotising enterocolitis (a serious intestinal disease), although the results for time to full enteral feeds are very uncertain. Exposure to the smell and taste of milk probably has little or no effect on the risk of developing an infection more than two days after birth. What are the limitations of the evidence? We have little confidence in the evidence because: • we identified few studies;
• most studies were small and provided different types of exposure to smell and taste;
• in many studies, clinicians and parents were aware of which treatment the infant was receiving; and
• the studies did not investigate all the outcomes we were interested in. How up‐to‐date is this evidence? This review is current to April 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.724Z" }, { "id": "7144d58e-5749-496a-b0d4-823cdcbbb5d2", "pmid": "", "title": "Efficacy of Cannabidiol in Combination With Red Algae (CBDRA60) to Prevent or Reduce Symptoms of COVID-19 and Post-Acute Sequelae of SARS-CoV-2 Infection PASC", "imported": false, "abstract": "Coronavirus disease (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents a major threat to human health. SARS-CoV-2 is highly infectious and is associated with extensive morbidity and mortality. Our study shares important features with other clinical trials using supplements or other widely available medications (e.g., Ascorbic Acid, Zinc, Vitamin D, Vitamin C). Our study shares two important elements with these previous studies, including:", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.159Z" }, { "id": "714d2d56-c441-451e-8fa5-e7ac9b43d420", "pmid": "", "title": "Environmental enrichment for stroke and other non‐progressive brain injury", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Qin, H, Reid, I, Gorelik, A, Ng, L", "articleTypes": [], "doi": "10.1002/14651858.CD011879.pub2 AB - Abstract - Background Rehabilitation is effective for recovery after stroke and other non‐progressive brain injuries but it is unclear if the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. Environmental enrichment is a relatively new concept within rehabilitation for humans. In this review, this is defined as an intervention designed to facilitate physical (motor and sensory), cognitive and social activity by the provision of equipment and organisation of a structured, stimulating environment. The environment should be designed to encourage (but not force) activities without additional specialised rehabilitation input. Objectives To assess the effects of environmental enrichment on well‐being, functional recovery, activity levels and quality of life in people who have stroke or non‐progressive brain injury. Search methods We conducted the search on 26 October 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers. Selection criteria We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services. Data collection and analysis Two review authors independently assessed eligible studies, extracted data, and assessed study quality. Any disagreements were resolved through discussion with a third review author. We determined the risk of bias for the included study and performed a 'best evidence' synthesis using the GRADE approach. Main results We identified one RCT, involving 53 participants with stroke, comparing environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. We excluded five studies, found two studies awaiting classification and one ongoing study which described environmental enrichment in their interventions. Of the excluded studies, three were non‐RCTs and two described co‐interventions with a significant component of rehabilitation. Based on the single small included RCT at high risk of bias, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the provision of environmental enrichment. Authors' conclusions The gap in current research should not, however, be interpreted as proof that environmental enrichment is ineffective. Further research is needed with robust study designs, such as cluster RCTs, and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (inpatient versus outpatient), the relative effectiveness of various components of environmental enrichment, cost‐effectiveness, and safety of the intervention in people following stroke or other non‐progressive brain injuries. It should be noted, however, that it is challenging to randomise or double‐blind trials of environmental enrichment given the nature of the intervention. Plain language summary Treatment using environmental enrichment for supporting rehabilitation following stroke and other brain injuries which do not get worse over time (non‐progressive brain injury) Background Rehabilitation helps with recovery after stroke and other non‐progressive brain injuries through therapy. However, outside of therapy hours, people may have very little to keep them stimulated. Environmental enrichment is a relatively new concept in rehabilitation where the environment itself is designed to be engaging and to include physical, thinking, and social activities like exercises and games. For example, a nursery for babies may be interesting and stimulating but a hospital environment for adults is generally not. The design of the environment alone should encourage (but not force) activities without additional specialised rehabilitation. Review question 
We wanted to find out whether treatment with environmental enrichment is better or worse than alternatives. Search date 
The evidence is current to 26 October 2020. Study characteristics 
Population: we planned to include studies in which participants were adults who had had a stroke or a non‐progressive brain injury (such as traumatic brain injury but not dementia, Alzheimer's diease, or multiple sclerosis). Intervention: environmental enrichment interventions will usually include multiple activities, such as computers plus gaming technology plus music and reading. Comparison: we planned to compare environmental interventions with usual care (regular physiotherapy, speech therapy, occupational therapy) or alternative treatment. Outcomes: we divided outcomes into primary and secondary outcomes. Primary outcomes focused on psychological well‐being (anxiety, depression, stress) and coping. Secondary outcomes focused on quality of life, physical function, communication and cognitive function, and activity levels. We also planned to report adverse events. Key results 
We found one trial that compared environmental intervention alone with usual care or alternative treatment. The trial included 53 participants who had had a stroke and was based in a hospital rehabilitation ward. The trial compared environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services. The main outcomes related to psychological well‐being and coping. We were uncertain of the results because the trial was very small and highly prone to bias. Conclusion 
The gap in current research does not mean that environmental enrichment is ineffective. Further research is needed with strong study designs and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (in hospital versus out of hospital), which components of environmental enrichment are effective, whether environmental enrichment is cost‐effective, and if it is safe for people following stroke or other non‐progressive brain injuries.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.776Z" }, { "id": "71658eca-b7a3-4248-bbd8-3d3a1e23bd04", "pmid": "", "title": "Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults", "imported": false, "abstract": "Abstract - Background The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non‐opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. Objectives To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. Selection criteria We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. Data collection and analysis We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. Main results We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after). The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies. IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) −0.50, 95% confidence interval (CI) −0.72 to −0.28; 29 studies, 1656 participants; very low‐quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD −0.14, 95% CI −0.25 to −0.04; 33 studies, 1847 participants; moderate‐quality evidence), and at late time points (48 hours) (SMD −0.11, 95% CI −0.25 to 0.04; 24 studies, 1404 participants; moderate‐quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures. We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) −7.92 hours, 95% CI −12.71 to −3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD −4.52 mg morphine equivalents , 95% CI −6.25 to −2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes. The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low‐quality evidence). IV Lidocaine compared to TEA The effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI −0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI −1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD −1.66, 95% CI −10.88 to 7.56; 2 studies, 102 participants); all very low‐quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low‐quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low‐quality evidence). Authors' conclusions We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review. Plain language summary Intravenous infusion of lidocaine starting at the time of surgery for reduction of pain and improvement of recovery after surgery Background The most common problems immediately following surgery under general anaesthesia are pain, nausea and vomiting, delirium and slow or no movement of food through the digestive system. Opioid medications given to reduce postoperative pain may also be associated with nausea and constipation, also preventing a smooth recovery. It is of interest for patients and clinicians to reduce or prevent these complications leading to an early recovery so that patients can leave hospital earlier. One option for pain relief after surgery is epidural analgesia, where an opioid or local anaesthetic such as lidocaine is injected into the space surrounding the spinal cord. Not all patients may be suited to epidural analgesia, and so additional options such as intravenous non‐opioid analgesic medications that enable a rapid recovery are required. The aim of this review was to assess the benefits and risks of intravenous infusion of lidocaine in patients undergoing various surgical procedures. Lidocaine is a medication used to numb tissue in a specific area. Study characteristics This review was published in 2015, and updated in 2017. We found 68 randomized controlled studies (RCTs), (clinical studies where people are randomly put into one of two or more treatment groups), with results from a total of 4525 participants. RCTs are used because they provide the most reliable evidence. Intravenous lidocaine was compared with placebo or standard care in 66 of the studies, and with thoracic (chest area of spine) epidural analgesia in two studies. (A placebo is an inactive substance or procedure given to a participant in a medical trial to compare its effects with those of a real drug or other intervention). Lidocaine infusion was started during the surgery, before the first cut, and continued to at least the end of surgery. The included studies were moderately well conducted. Key results We are uncertain whether lidocaine infusion reduces pain, one to four hours after surgery when compared to placebo or usual care (29 studies, over 1600 participants). There was probably no difference in pain at 24 hours (33 studies, 1847 participants) and at 48 hours (24 studies, 1404 participants) between participants in the lidocaine and the placebo group. We are uncertain whether lidocaine infusion improves recovery of bowel function, with a reduction in the time to first defaecation or bowel movements (12 studies, 684 participants), and reduced risk of stopping the passage of food in the gut (4 studies, 273 participants). We are also uncertain whether lidocaine reduces postoperative nausea (35 studies, 1903 participants), and the requirement for opioids for pain relief (40 studies, 2201 participants). Only a limited number of studies systematically analysed adverse effects of intravenous lidocaine infusion. The side effects of intravenous lidocaine were unclear. In the two studies that investigated intravenous lidocaine compared to epidural analgesia (102 participants), the effect on pain at 24 and 48 hours, and on the time to first bowel movement, remains unclear. The effect of lidocaine on the risk of stopping the passage of food in the gut and for postoperative nausea is also unclear, as only one small trial assessed these outcomes. Neither study investigated the effect on pain immediately after surgery, or on opioid consumption. Both studies looked at adverse effects associated with lidocaine, but the effect is uncertain. Quality of the evidence We rated the quality of evidence for most outcomes as very low. This was because of inconsistent findings across studies and the fact that the evidence came from small studies that were of moderate design quality or a limited number of studies. The quality of the evidence for minimal or no effect on pain at 24 and 48 hours was moderate quality. The studies involved a variety of surgical procedures. The dose of lidocaine used, and how long it was delivered for after the end of surgery, also varied between studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Weibel, S, Jelting, Y, Pace, NL, Helf, A, Eberhart, LHJ, Hahnenkamp, K, Hollmann, MW, Poepping, DM, Schnabel, A, Kranke, P", "articleTypes": [], "doi": "10.1002/14651858.CD009642.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.089Z" }, { "id": "716dfc2f-a661-49c6-8ab3-63f8794cabad", "pmid": "", "title": "Pharmacotherapy for hypertension‐induced left ventricular hypertrophy", "imported": false, "abstract": "Abstract - Background Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension‐induced LVH. Objectives To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension‐induced LVH. Search methods Cochrane Hypertension’s Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) with at least 12 months’ follow‐up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension‐induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all‐cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. Data collection and analysis Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. Main results We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow‐up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention‐to‐treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add‐on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low‐certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low‐certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low‐certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low‐certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low‐certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. Authors' conclusions We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low‐certainty evidence requires that caution be used when interpreting the findings. High‐quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension‐induced LVH are warranted. Plain language summary What are the main benefits and risks of drugs for reducing blood pressure in the treatment of people with thickening of the heart muscle caused by high blood pressure? Key messages Given the lack of robust evidence, the benefits and risks of adding additional drugs for reducing blood pressure to treat people with thickening of the heart muscle and high blood pressure are unclear. It is unclear if adding drugs for reducing blood pressure causes more serious harms in patients than placebo (dummy treatment) or no treatment; however, it may increase treatment discontinuation due to unwanted effects. There is a need for future studies to better understand the benefits and harms of adding drugs for reducing blood pressure in people with thickening of the heart muscle caused by high blood pressure. What is thickening of the heart muscle? Thickening of the heart muscle is a condition where the muscle gets bigger and affects the function of the heart. This can happen when the heart has worked too hard over time and is mainly caused by high blood pressure. People with thickening of the heart muscle can experience shortness of breath, fatigue, chest pain, heart palpitations, and dizziness or fainting. How is thickening of the heart muscle treated? Thickening of the heart muscle can be treated with drugs for reducing blood pressure. What did we want to find out? We wanted to find out if adding drugs for reducing blood pressure was better than placebo or no drug treatment at preventing illness and death in people with thickening of the heart muscle and high blood pressure. We also wanted to learn if the addition of drugs for reducing blood pressure was associated with any unwanted or harmful effects. What did we do? We searched for studies that investigated the addition of drugs for reducing blood pressure compared with placebo or no drug treatment. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as methods and sizes of participant groups. What did we find? We found 3 studies that involved 930 people with thickening of the heart muscle and high blood pressure. The largest study was in 692 people, and the smallest study was in 15 people. Study participants were of both genders and on average between 66 and 75 years old. Participants were followed for between three and four years. The studies were conducted in several countries in Europe, Asia, and North and South America. One study received pharmaceutical industry funding. It is uncertain if adding drugs for reducing blood pressure has an effect on death, development of heart and blood vessel diseases, or on hospitalisation for heart failure. It is unclear if adding drugs for reducing blood pressure causes more serious harms than placebo or no drug treatment, but it may increase treatment discontinuations due to unwanted effects. It is unclear if adding drugs for reducing blood pressure has an effect on heart muscle mass. What are the limitations of the evidence? Our confidence in the evidence is lacking because of the small number of identified studies. The available evidence is based on a small percentage of people with thickening of the heart muscle and high blood pressure identified from larger populations in the included studies. Further evidence may change our results. How up‐to‐date is the evidence? The evidence is current to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Leache, L, Gutiérrez-Valencia, M, Finizola, RM, Infante, E, Finizola, B, Pardo Pardo, J, Flores, Y, Granero, R, Arai, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD012039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.806Z" }, { "id": "7173287c-9b89-4a57-a001-b106fcd3c76c", "pmid": "", "title": "Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Subcutaneous administration may be preferable to oral for individuals experiencing nausea and/or vomiting Objectives To determine the efficacy and tolerability of subcutaneous sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using subcutaneous sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Thirty‐five studies (9365 participants) compared subcutaneous sumatriptan with placebo or an active comparator. Most of the data were for the 6 mg dose. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 6 mg versus placebo the NNTs were 2.9, 2.3, 2.2, and 2.1 for pain‐free at one and two hours, and headache relief at one and two hours, respectively, and 6.1 for sustained pain‐free at 24 hours. Results for the 4 mg and 8 mg doses were similar to the 6 mg dose, with 6 mg significantly better than 4 mg only for pain‐free at one hour, and 8 mg significantly better than 6 mg only for headache relief at one hour. There was no evidence of increased migraine relief if a second dose of sumatriptan 6 mg was given after an inadequate response to the first. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Sumatriptan was compared directly with a number of active treatments, including other triptans, acetylsalicylic acid plus metoclopramide, and dihydroergotamine, but there were insufficient data for any pooled analyses. Authors' conclusions Subcutaneous sumatriptan is effective as an abortive treatment for acute migraine attacks, quickly relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a subcutaneous injection, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, or needing fast relief. This review found that a single subcutaneous dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in almost 6 in 10 people (59%) taking sumatriptan 6 mg, compared with about 1 in 7 (15%) taking placebo, and reduced from moderate or severe to no worse than mild pain by two hours in almost 8 in 10 people (79%) taking sumatriptan compared with about 3 in 10 (31%) taking placebo. Subcutaneous sumatriptan was fast‐acting, and the majority of people experiencing pain relief had done so by one hour. About 3 in 10 (31%) people had freedom from pain at two hours which was sustained during the 24 hours postdose without the use of rescue medication, compared with about 1 in 7 (15%) with placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events, most of which were of short duration and mild or moderate in severity, were more frequent with sumatriptan than with placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009665", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.759Z" }, { "id": "7184a516-5aaf-4113-a18e-ede464ec2ec1", "pmid": "", "title": "Interventions for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is the most common, life‐limiting, genetically inherited disease. It affects multiple organs, particularly the respiratory system. However, gastrointestinal problems such as constipation and distal intestinal obstruction syndrome (DIOS) are also important and well‐recognised complications in CF. They share similar symptoms e.g. bloating, abdominal pain, but are distinct conditions. Constipation occurs when there is gradual faecal impaction of the colon, but DIOS occurs when there is an accumulation of faeces and sticky mucus, forming a mass in the distal part of the small intestine. The mass may partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). Symptoms of DIOS can affect quality of life and other aspects of CF health, such as airway clearance, exercise, sleep and nutritional status. Treatment of constipation and prevention of complete bowel obstruction are required for gastrointestinal management in CF. However, many different strategies are used in clinical practice and there is a lack of consensus. The importance of this topic was highlighted in a recent research priority setting exercise by the James Lind Alliance. Objectives To evaluate the effectiveness and safety of laxative agents of differing types for preventing DIOS (complete and incomplete) in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised and quasi‐randomised controlled parallel trials comparing laxative therapy for preventing DIOS (including osmotic agents, stimulants, mucolytics and substances with more than one action) at any dose to placebo, no treatment or an alternative laxative therapy, in people of any age with pancreatic sufficient or insufficient CF and any stage of lung disease. Randomised cross‐over trials were judged on an individual basis. Data collection and analysis Two authors independently assessed trials for inclusion, extracted outcome data and performed a risk of bias assessment for the included data. We judged the certainty of the evidence using GRADE criteria. Main results We included one cross‐over trial (17 participants) with a duration of 12 months, in which participants were randomly allocated to either cisapride (a gastro‐prokinetic agent) or placebo for six months each. The trial had an unclear risk of bias for most domains but had a high risk of reporting bias. Radiograph scores revealed no difference in occurrence of DIOS between cisapride and placebo (narrative report, no data provided). There were no adverse effects. Symptom scores were the only secondary outcome within the review that were reported. Total gastrointestinal symptom scores favoured cisapride with a statistically significant mean difference (MD) of ‐7.60 (95% confidence interval (CI) ‐14.73 to ‐0.47). There was no significant difference at six months between cisapride and placebo for abdominal distension, MD ‐0.90 (95% CI ‐2.39 to 0.59) or abdominal pain, MD ‐0.4 (95% CI ‐2.05 to 1.25). The global symptom scores (whether individuals felt better or worse) were reported in the paper to favour cisapride and be statistically significant (P < 0.05). We assessed the available data to be very low certainty. There was a great deal of missing data from the included trial and the investigators failed to report numerical data for many outcomes. The overall risk of bias of the trial was unclear and it had a high risk for reporting bias. There was also indirectness; the trial drug (cisapride) has since been removed from the market in several countries due to adverse effects, thus it has no current applicability for preventing DIOS. The included trial also had very few participants, which downgraded the certainty a further level for precision. Authors' conclusions There is an absence of evidence for interventions for the prevention of DIOS. As there was only one included trial, we could not perform a meta‐analysis of the data. Furthermore, the included trial compared a prokinetic agent (cisapride) that is no longer licensed for use in a number of countries due to the risk of serious cardiac events, a finding that came to light after the trial was conducted. Therefore, the limited findings from the trial are not applicable in current clinical practice. Overall, a great deal more research needs to be undertaken on gastrointestinal complications in CF, as this is a very poorly studied area compared to respiratory complications in CF. Plain language summary Which interventions are effective and safe for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis? Background Cystic fibrosis (CF) is an inherited, life‐long condition that causes organ systems in the body to produce large amounts of thick and sticky mucus. The most commonly affected area is the lungs, in which thick mucus leads to recurrent chest infections and breathing difficulties. Another commonly affected area is the digestive system. Many people with CF suffer from bloating and abdominal pain which may be caused by constipation or distal intestinal obstruction syndrome (DIOS). In DIOS, overproduction of thick mucus combines with stool and sticks to the intestinal wall. This mass can partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). The latter causes severe pain, vomiting and is treated as a medical emergency. As part of effective care for people with CF, constipation should therefore be treated and complete bowel obstruction be prevented. It is also important to recognise that constipation and DIOS impact on other aspects of CF health. Bloating, abdominal pain and nausea may affect airway clearance, exercise and sleep. Nutritional status may also be affected due to decreased appetite and malabsorption. DIOS may affect the absorption of other medications taken by people with CF. Overall, DIOS can significantly impair quality of life. Different laxatives are currently used in clinics, but prescribing practices differ and there is no consensus on optimal treatment strategies. Hence, this review aimed to analyse the evidence for the preventing DIOS. Search date We last searched for evidence: 12 October 2021. Trial characteristics We included one trial in the review, which included 17 people aged between 13 to 35 years. These people were randomly put into groups to take either a placebo drug (with no active medication) or cisapride for six months each and then to cross over and take the alternative treatment for a further six months. Key results The trial used radiography to diagnose DIOS, but did not provide any data and only stated that there was no difference between cisapride and placebo. The trial also stated that there were no adverse effects from the cisapride. The trial assessed participant‐reported total and individual gastrointestinal symptom scores. People in the cisapride group reported an improvement in total gastrointestinal symptom scores compared to those in the placebo group. However, there were no differences reported between groups for the individual symptom scores of abdominal pain and abdominal distension (swelling). Participants also reported global symptom scores, which showed that most people felt better taking cisapride compared to placebo. Certainty of the evidence The overall certainty of the evidence was very low. With one trial in this review, we could not combine data from different trials. The trial did not provide enough information about the methods used for allocating participants or about missing data and did not fully report certain results. The small number of participants also lowered the precision of the results. Since this trial was conducted, cisapride has been removed from the market in a number of countries due to rare but serious heart complications, therefore it has no applicability to current clinical practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carroll, W, Green, J, Gilchrist, FJ", "articleTypes": [], "doi": "10.1002/14651858.CD012619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.766Z" }, { "id": "7190b5ec-f94a-492d-9ac7-1b7fb6099944", "pmid": "", "title": "Herbal medicines for fatty liver diseases", "imported": false, "abstract": "Abstract - Background Fatty liver disease is potentially a reversible condition that may lead to end‐stage liver disease. Since herbal medicines such as Crataegus pinnatifida and Salvia miltiorrhiza have increasingly been used in the management of fatty liver disease, a systematic review on herbal medicine for fatty liver disease is needed. Objectives To assess the beneficial and harmful effects of herbal medicines for people with alcoholic or non‐alcoholic fatty liver disease. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2012), MEDLINE, EMBASE, and Science Citation Index Expanded to 1 March 2012. We also searched the Chinese BioMedical Database, Traditional Chinese Medical Literature Analysis and Retrieval System, China National Knowledge Infrastructure, Chinese VIP Information, Chinese Academic Conference Papers Database and Chinese Dissertation Database, and the Allied and Complementary Medicine Database to 2 March 2012. Selection criteria We included randomised clinical trials comparing herbal medicines with placebo, no treatment, a pharmacological intervention, or a non‐pharmacological intervention such as diet or lifestyle, or Western interventions in participants with fatty liver disease. Data collection and analysis Two review authors extracted data independently. We used the 'risk of bias' tool to assess the risk of bias of the included trials. We assessed the following domains: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. We presented the effects estimates as risk ratios (RR) with 95% confidence intervals (CI) or as mean differences (MD) with 95% CI, depending on the variables of the outcome measures. Main results We included 77 randomised clinical trials, which included 6753 participants with fatty liver disease. The risks of bias (overestimation of benefits and underestimation of harms) was high in all trials. The mean sample size was 88 participants (ranging from 40 to 200 participants) per trial. Seventy‐five different herbal medicine products were tested. Herbal medicines tested in the randomised trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca) , proprietary herbal medicines commercially available, and combination formulas prescribed by practitioners. The most commonly used herbs were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia, Astragalus membranaceous, and Rheum palmatum . None of the trials reported death, hepatic‐related morbidity, quality of life, or costs. A large number of trials reported positive effects on putative surrogate outcomes such as serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases, ultrasound, and computed tomography scan. Twenty‐seven trials reported adverse effects and found no significant difference between herbal medicines versus control. However, the risk of bias of the included trials was high. The outcomes were ultrasound findings in 22 trials, liver computed tomography findings in eight trials, aspartate aminotransferase levels in 64 trials, alanine aminotransferase activity in 77 trials, and glutamyltransferase activities in 44 trials. Six herbal medicines showed statistically significant beneficial effects on ultrasound, four on liver computed tomography, 42 on aspartate aminotransferase activity, 49 on alanine aminotransferase activity, three on alkaline phosphatases activity, and 32 on glutamyltransferase activity compared with control interventions. Authors' conclusions Some herbal medicines seemed to have positive effects on aspartate aminotransferase, alanine aminotransferase, ultrasound, and computed tomography. We found no significant difference on adverse effects between herbal medicine and control groups. The findings are not conclusive due to the high risk of bias of the included trials and the limited number of trials testing individual herbal medicines. Accordingly, there is also high risk of random errors. Plain language summary Herbal medicines for fatty liver diseases Fatty liver disease is a potentially reversible illness where fat builds up within the cells of the liver. It may lead to the liver no longer being able to function properly; this is called end‐stage liver disease. This systematic review evaluated the effects and safety of herbal medicines (single herbs, branded herbal medicines, and prescribed formulas) for treating fatty liver disease. We included 77 randomised clinical trials in this review, which tested 75 herbal medicines. All trials had high risk of systematic errors (ie, bias or risk of overestimation of benefits and overestimation of harms) as well as high risks of random errors (ie, play of chance) due to the small number of people in the trials. Herbal medicines tested in the randomised clinical trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca ), commercially available branded herbal medicines, and combination formulas prescribed by practitioners. Herbs most commonly included as an ingredient in different products were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia , Astragalus membranaceous , and Rheum palmatum . We could not combine the results of the trials due to the range of different herbs used. We could not reach any conclusions about the use of herbal medicines for people with fatty liver disease as none of the trials reported results on death, liver‐related illnesses, quality of life, or costs. A number of trials showed positive effects of herbal medicines compared with control interventions on enzyme activity (enzymes are proteins that cause chemical reactions in the body; eg, serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases), ultrasound scan findings, and computed tomography scan findings. No serious adverse effects were reported for herbal medicines. However, the methodology of the trials had high risk of systematic errors (bias). Furthermore, the individual herbs were seldomly retested, and all trials had relatively low numbers of people, which increases the risk of random errors (play of chance). Therefore, the findings are inconclusive, and rigorously conducted randomised clinical trials are required to establish the benefits and harms of herbal medicines for fatty liver disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Liu, ZL; Xie, LZ; Zhu, J; Li, GQ; Grant, SJ; Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009059.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "7193339e-63a1-422a-8731-0def8ebc6b15", "pmid": "", "title": "Oral treatments for fungal infections of the skin of the foot", "imported": false, "abstract": "Abstract - Background About 15% of the world population have fungal infections of the feet (tinea pedis or athlete's foot). There are many clinical presentations of tinea pedis, and most commonly, tinea pedis is seen between the toes (interdigital) and on the soles, heels, and sides of the foot (plantar). Plantar tinea pedis is known as moccasin foot. Once acquired, the infection can spread to other sites including the nails, which can be a source of re‐infection. Oral therapy is usually used for chronic conditions or when topical treatment has failed. Objectives To assess the effects of oral treatments for fungal infections of the skin of the foot (tinea pedis). Search methods For this update we searched the following databases to July 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library , MEDLINE (from 1946), EMBASE (from 1974), and CINAHL (from 1981). We checked the bibliographies of retrieved trials for further references to relevant trials, and we searched online trials registers. Selection criteria Randomised controlled trials of oral treatments in participants who have a clinically diagnosed tinea pedis, confirmed by microscopy and growth of dermatophytes (fungi) in culture. Data collection and analysis Two review authors independently undertook study selection, 'Risk of bias' assessment, and data extraction. Main results We included 15 trials, involving 1438 participants. The 2 trials (71 participants) comparing terbinafine and griseofulvin produced a pooled risk ratio (RR) of 2.26 (95% confidence interval (CI) 1.49 to 3.44) in favour of terbinafine's ability to cure infection. No significant difference was detected between terbinafine and itraconazole, fluconazole and itraconazole, fluconazole and ketoconazole, or between griseofulvin and ketoconazole, although the trials were generally small. Two trials showed that terbinafine and itraconazole were effective compared with placebo: terbinafine (31 participants, RR 24.54, 95% CI 1.57 to 384.32) and itraconazole (72 participants, RR 6.67, 95% CI 2.17 to 20.48). All drugs reported adverse effects, with gastrointestinal effects most commonly reported. Ten of the trials were published over 15 years ago, and this is reflected by the poor reporting of information from which to make a clear 'Risk of bias' assessment. Only one trial was at low risk of bias overall. The majority of the remaining trials were judged as 'unclear' risk of bias because of the lack of clear statements with respect to methods of generating the randomisation sequence and allocation concealment. More trials achieved blinding of participants and personnel than blinding of the outcome assessors, which was again poorly reported. Authors' conclusions The evidence suggests that terbinafine is more effective than griseofulvin, and terbinafine and itraconazole are more effective than no treatment. In order to produce more reliable data, a rigorous evaluation of different drug therapies needs to be undertaken with larger sample sizes to ensure they are large enough to show any real difference when two treatments are being compared. It is also important to continue to follow up and collect data, preferably for six months after the end of the intervention period, to establish whether or not the infection recurred. Plain language summary Oral antifungal drugs for treating athlete's foot (tinea pedis) Athlete's foot (tinea pedis) is a fungal infection of the feet that is easily spread and difficult to get rid of. This review compared different oral antifungal drugs (i.e. drugs taken by mouth), and it included 15 trials, involving 1438 participants. There are several different kinds of oral treatments, and the trials we found considered all the oral drugs used to treat athlete's foot. We found terbinafine and itraconazole to be more effective than placebo. And we found terbinafine to be more effective than griseofulvin. Griseofulvin is a treatment that was developed much earlier than the new treatments, such as terbinafine and itraconazole; these newer treatments tend to be most evaluated. Trials of other drugs were not large enough to show differences between them. All drugs had side‐effects; gastrointestinal effects were the most common. In future clinical trials, larger numbers of participants are needed to test different treatments in order to produce more reliable data. Also, future research should consider the costs of the different treatment approaches.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Bell‐Syer, SEM, Khan, SM, Torgerson, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD003584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.762Z" }, { "id": "7195929c-550e-470b-aff3-217310f1bd48", "pmid": "", "title": "Effects of Infant Formula Composition on Infant Feeding Behaviors", "imported": false, "abstract": "There is a paucity of information on whether and how the composition of formulas fed to infants influences their short-term feeding behaviors during the first few months of life. The purpose of this study is to investigate whether the composition of infant formula affects infants' feeding behaviors, in particular, how much formula is consumed within a given feed (i.e., measure of satiation) and how much time elapses after the feed until the infant exhibits signs of hunger (i.e., measure of satiety). The investigators will also examine the relationship between the composition of infant formula consumed and infant temperature, activity, sleep, and mothers' perceptions of infants' intake and regulatory behaviors.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.155Z" }, { "id": "7196ca47-1813-4969-be69-ba1b5e2e7f9e", "pmid": "", "title": "Intranasal corticosteroids for non‐allergic rhinitis", "imported": false, "abstract": "Abstract - Background Non‐allergic rhinitis is defined as dysfunction and non‐infectious inflammation of the nasal mucosa that is caused by provoking agents other than allergens or microbes. It is common, with an estimated prevalence of around 10% to 20%. Patients experience symptoms of nasal obstruction, anterior rhinorrhoea/post‐nasal drip and sneezing. Several subgroups of non‐allergic rhinitis can be distinguished, depending on the trigger responsible for symptoms; these include occupation, cigarette smoke, hormones, medication, food and age. On a cellular molecular level different disease mechanisms can also be identified. People with non‐allergic rhinitis often lack an effective treatment as a result of poor understanding and lack of recognition of the underlying disease mechanism. Intranasal corticosteroids are one of the most common types of medication prescribed in patients with rhinitis or rhinosinusitis symptoms, including those with non‐allergic rhinitis. However, it is unclear whether intranasal corticosteroids are truly effective in these patients. Objectives To assess the effects of intranasal corticosteroids in the management of non‐allergic rhinitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 7); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 July 2019. Selection criteria Randomised controlled trials (RCTs) comparing intranasal corticosteroids, delivered by any means and in any volume, with (a) placebo/no intervention or (b) other active treatments in adults and children (aged ≥ 12 years). Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were patient‐reported disease severity and a
 significant adverse effect ‐ epistaxis. Secondary outcomes were (disease‐specific) health‐related quality of life, objective measurements of airflow and other adverse events. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 34 studies (4452 participants); however, only 13 studies provided data for our main comparison, intranasal corticosteroids versus placebo. The participants were mainly defined as patients with perennial rhinitis symptoms and negative allergy tests. No distinction between different pheno‐ and endotypes could be made, although a few studies only included a specific phenotype such as pregnancy rhinitis, vasomotor rhinitis, rhinitis medicamentosa or senile rhinitis. Most studies were conducted in a secondary or tertiary healthcare setting. No studies reported outcomes beyond three months follow‐up. Intranasal corticosteroid dosage in the review ranged from 50 µg to 2000 µg daily. Intranasal corticosteroids versus placebo Thirteen studies (2045 participants) provided data for this comparison. These studies used different scoring systems for patient‐reported disease severity, so we pooled the data in each analysis using the standardised mean difference (SMD). Intranasal corticosteroid treatment may improve patient‐reported disease severity as measured by total nasal symptom score compared with placebo at up to four weeks (SMD ‐0.74, 95% confidence interval (CI) ‐1.15 to ‐0.33; 4 studies; 131 participants; I 2 = 22%) (low‐certainty evidence). However, between four weeks and three months the evidence is very uncertain (SMD ‐0.24, 95% CI ‐0.67 to 0.20; 3 studies; 85 participants; I 2 = 0%) (very low‐certainty evidence). Intranasal corticosteroid treatment may slightly improve patient‐reported disease severity as measured by total nasal symptom score change from baseline when compared with placebo at up to four weeks (SMD ‐0.15, 95% CI ‐0.25 to ‐0.05; 4 studies; 1465 participants; I 2 = 35%) (low‐certainty evidence) . All four studies evaluating the risk of epistaxis showed that there is probably a higher risk in the intranasal corticosteroids group (65 per 1000) compared to placebo (31 per 1000) (risk ratio (RR) 2.10, 95% CI 1.24 to 3.57; 4 studies; 1174 participants; I 2 = 0%) (moderate‐certainty evidence). The absolute risk difference (RD) was 0.04 with a number needed to treat for an additional harmful outcome (NNTH) of 25 (95% CI 16.7 to 100). Only one study reported numerical data for quality of life. It did report a higher quality of life score in the intranasal corticosteroids group (152.3 versus 145.6; SF‐12v2 range 0 to 800); however, this disappeared at longer‐term follow‐up (148.4 versus 145.6) (low‐certainty evidence). Only two studies provided data for the outcome objective measurements of airflow. These data could not be pooled because they used different methods of outcome measurement. Neither found a significant difference between the intranasal corticosteroids and placebo group (rhinomanometry SMD ‐0.46, 95% CI ‐1.06 to 0.14; 44 participants; peak expiratory flow rate SMD 0.78, 95% CI ‐0.47 to 2.03; 11 participants) (very low‐certainty evidence). Intranasal corticosteroids probably resulted in little or no difference in the risk of other adverse events compared to placebo (RR 0.99, 95% CI 0.87 to 1.12; 3 studies; 1130 participants; I 2 = 0%) (moderate‐certainty evidence) . Intranasal corticosteroids versus other treatments Only one or a few studies assessed each of the other comparisons (intranasal corticosteroids versus saline irrigation, intranasal antihistamine, capsaicin, cromoglycate sodium, ipratropium bromide, intranasal corticosteroids combined with intranasal antihistamine, intranasal corticosteroids combined with intranasal antihistamine and intranasal corticosteroids with saline compared to saline alone). It is therefore uncertain whether there are differences between intranasal corticosteroids and other active treatments for any of the outcomes reported. Authors' conclusions Overall, the certainty of the evidence for most outcomes in this review was low or very low. It is unclear whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. However, intranasal corticosteroids probably have a higher risk of the adverse effect epistaxis. There are very few studies comparing intranasal corticosteroids to other treatment modalities making it difficult to draw conclusions. Plain language summary Intranasal corticosteroids for non‐allergic rhinitis Review question We wanted to find out whether intranasal corticosteroids (steroids applied into the nose) are effective for the treatment of rhinitis that is not caused by allergy. Background Non‐allergic rhinitis is a chronic disease of the nose, which is not caused by infection or allergies. People with non‐allergic rhinitis experience symptoms that affect their quality of life, such as nasal obstruction, runny nose and sneezing. Non‐allergic rhinitis patients can be divided into different subgroups who have different underlying causes for their disease. The underlying causes of non‐allergic rhinitis are not fully understood, therefore treatment is often unsuccessful in these patients. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation. They are the most commonly prescribed drug in other chronic diseases of the nose and sinuses, such as allergic rhinitis and chronic rhinosinusitis. Intranasal corticosteroid treatment can be delivered with sprays or drops and for different time periods. Study characteristics We included 34 randomised controlled trials (RCTs) with a total of 4452 participants in this review. Most of the studies were relatively small, although the largest study had 983 patients in total. All of the patients were either adults or adolescents (aged between 12 and 18 years old) with non‐allergic rhinitis. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Nine studies were sponsored by the pharmaceutical industry or had commercial sponsors. One study was funded by the government. In several studies, the pharmaceutical industry or commercial sponsor may have provided medications, but the funding role was unclear. Funding was not reported in eight studies. Key results Intranasal corticosteroids compared with placebo It is uncertain whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. They may improve patient‐reported disease severity compared with placebo at up to four weeks, however this evidence is of low certainty. Treatment with intranasal corticosteroids probably increases the risk of epistaxis (nosebleed) but there is no difference in the risk of other adverse effects. It is not possible to tell from this review whether there is a difference between the different concentrations, delivery methods or treatment plans of intranasal corticosteroids. There are no good‐quality studies assessing changes in quality of life with intranasal corticosteroids. Intranasal corticosteroids compared with other treatments There is not enough evidence to know whether intranasal corticosteroid treatment is better, worse or the same as using other treatment strategies such as saline irrigation, intranasal antihistamines, capsaicin or ipratropium bromide for non‐allergic rhinitis. Certainty of the evidence Overall, the evidence for intranasal corticosteroids compared with placebo for most outcomes was either low‐certainty (our confidence in the effect estimate is low) or very low‐certainty (our confidence in the effect estimate is very low). This was because most studies were very small and used different methods to measure the same outcome. This evidence is up to date to July 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Segboer, C; Gevorgyan, A; Avdeeva, K; Chusakul, S; Kanjanaumporn, J; Aeumjaturapat, S; Reeskamp, LF; Snidvongs, K; Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010592.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "7199b0f4-f265-4d48-b5de-a6e3bad6e266", "pmid": "", "title": "Interventions to reduce harm from continued tobacco use", "imported": false, "abstract": "Abstract - Background Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced‐exposure tobacco products (PREPs), as an alternative to cigarettes. Objectives To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long‐term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco? Search methods We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free‐text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. Selection criteria Randomized or quasi‐randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention. Data collection and analysis We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long‐term smoking abstinence), using fixed‐effect models. Where it was not possible to meta‐analyse data, we summarized findings narratively. Main results Twenty‐four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically‐heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as ‘low’ or ‘very low’, due to imprecision and indirectness. A ‘low’ grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A ‘very low’ grade means we are very uncertain about the estimate. Authors' conclusions People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high‐quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high‐quality RCTs are conducted, and that these also measure the long‐term health effects of treatments. Plain language summary Can smokers be helped to reduce the harm caused by cigarette smoking by smoking fewer cigarettes or using different tobacco products? Background The best thing to do to reduce the harms caused by smoking is to quit, but some people may not want to do this or may feel that they are unable to stop smoking completely. Cutting down the number of cigarettes smoked daily or using different tobacco products, such as chewing tobacco or low‐tar cigarettes, may reduce some of the harm caused by smoking. It may also help people to stop smoking completely in the long term. On the other hand, reducing smoking or using other tobacco products may not improve health and could reduce a person's motivation to quit smoking altogether. It is important that we review the evidence to find out whether these approaches could help smokers who do not want to or cannot quit to reduce the harm caused by their smoking. We were mainly interested in whether these approaches improved the health of smokers, but also looked at smoking reduction and quitting rates. Study characteristics We found 20 randomised controlled trials that tested ways to help people to cut down the number of cigarettes they smoked. Some of these just advised smokers to smoke less, but most also provided them with a product to help them cut down: nicotine replacement therapy (NRT), varenicline, bupropion, electronic cigarettes (ecigs), or snus (a form of smokeless, oral tobacco). We also found four randomized controlled trials that tested the effects of using cigarettes designed to reduce the damage caused by smoking: reduced tar, carbon or nicotine cigarettes. Most of the studies used NRT to help people to reduce their smoking. All of the studies included people who were not planning to quit smoking soon. The research is current to October 2015. Key results Eight studies (with 3081 smokers) found that using NRT roughly doubled the likelihood of halving the number of cigarettes smoked each day, compared to using a placebo. Using NRT in this way also nearly doubled the likelihood of quitting completely. One trial each tested bupropion, varenicline, ecigs and snus to help reduce the harms caused by smoking, and there was no evidence that any of these treatments helped smokers to reduce the number of cigarettes they were smoking each day. This may be because there has not yet been enough research into these methods. Only one of the trials testing cigarettes designed to reduce risk measured their effect on the number of people quitting smoking. It found that people were not more likely to quit smoking if they used reduced‐nicotine cigarettes than if they smoked their usual cigarettes. We did not find any trials which reported the long‐term health effects of the treatments, and so it remains uncertain how much health benefit there is from reducing the number of cigarettes smoked each day or smoking cigarettes designed to be less harmful. Quality of evidence The tobacco industry funded three of the included studies of cigarettes designed to reduce risk. None of the studies looked at whether there had been a long‐term change in the health of the users. We rate the quality of the evidence looking at how many people quit smoking as 'low' or 'very low', generally because the findings are based on a small number of studies. We need more studies to investigate methods of reducing the harm caused by continued smoking. These need to measure the health of the users over a long period.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lindson‐Hawley, N; Hartmann‐Boyce, J; Fanshawe, TR; Begh, R; Farley, A; Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD005231.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "71aa8218-c5c6-4478-b88b-52129f4ff9a9", "pmid": "", "title": "Treatments for iron‐deficiency anaemia in pregnancy", "imported": false, "abstract": "Abstract - Background Iron deficiency, the most common cause of anaemia in pregnancy worldwide, can be mild, moderate or severe. Severe anaemia can have very serious consequences for mothers and babies, but there is controversy about whether treating mild or moderate anaemia provides more benefit than harm. Objectives To assess the effects of different treatments for anaemia in pregnancy attributed to iron deficiency (defined as haemoglobin less than 11 g/dL or other equivalent parameters) on maternal and neonatal morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2011), CENTRAL (2011, Issue 5), PubMed (1966 to June 2011), the International Clinical Trials Registry Platform (ICTRP) (2 May 2011), Health Technology Assessment Program (HTA) (2 May 2011) and LATINREC (Colombia) (2 May 2011). Selection criteria Randomised controlled trials comparing treatments for anaemia in pregnancy attributed to iron deficiency. Data collection and analysis We identified 23 trials, involving 3.198 women. We assessed their risk of bias. Three further studies identified are awaiting classification. Main results Many of the trials were from low‐income countries; they were generally small and frequently methodologically poor. They covered a very wide range of differing drugs, doses and routes of administration, making it difficult to pool data. Oral iron in pregnancy showed a reduction in the incidence of anaemia (risk ratio 0.38, 95% confidence interval 0.26 to 0.55, one trial, 125 women) and better haematological indices than placebo (two trials). It was not possible to assess the effects of treatment by severity of anaemia. A trend was found between dose and reported adverse effects. Most trials reported no clinically relevant outcomes nor adverse effects. Although the intramuscular and intravenous routes produced better haematological indices in women than the oral route, no clinical outcomes were assessed and there were insufficient data on adverse effects, for example, on venous thrombosis and severe allergic reactions. Daily low‐dose iron supplements may be effective at treating anaemia in pregnancy with less gastrointestinal side effects compared with higher doses. Authors' conclusions Despite the high incidence and burden of disease associated with this condition, there is a paucity of good quality trials assessing clinical maternal and neonatal effects of iron administration in women with anaemia. Daily oral iron treatment improves haematological indices but causes frequent gastrointestinal adverse effects. Parenteral (intramuscular and intravenous) iron enhances haematological response, compared with oral iron, but there are concerns about possible important adverse effects (for intravenous treatment venous thrombosis and allergic reactions and for intramuscular treatment important pain, discolouration and allergic reactions). Large, good quality trials, assessing clinical outcomes (including adverse effects) as well as the effects of treatment by severity of anaemia are required. Plain language summary Treatments for anaemia in pregnancy thought to be due to iron deficiency When the blood has insufficient red cells, or the red cells carry insufficient haemoglobin to deliver adequate oxygen to the tissues, this is called anaemia. There is normally a reduction in the haemoglobin concentrations in the mother's blood during pregnancy, and this allows a better blood flow around the womb (uterus) and to the baby. This is sometime called physiological anaemia and needs no treatment. True anaemia, however, can be mild, moderate or severe and can cause weakness, tiredness and dizziness. Severe anaemia makes women at risk of cardiac failure and is very common in low‐income countries Anaemia has many causes including a shortage or iron, folic acid or vitamin B 12 . These are all required for making red cells and are available in a good diet. Iron shortage, however, is the most common cause of anaemia during pregnancy. Iron treatment can be given by mouth (oral), by injection into the muscle (intramuscular) or injection into the vein (intravenous). Blood transfusion or giving something which stimulates the body to produce more red cells (erythropoietin) are also possible treatments. In this review, we identified 23 trials involving 3198 pregnant women. Many of the trials were in low‐income countries and many treatment variations were studied. Oral iron reduced the incidence of anaemia but is known to sometimes cause constipation and nausea. Although the intramuscular and intravenous routes produced better levels of red cells and iron stores than the oral route, no clinical outcomes (such as pre‐eclampsia, preterm births, postpartum haemorrhage) were assessed and there were insufficient data on adverse effects. Intravenous treatment can cause venous thrombosis (blockages in the veins) and intramuscular treatment causes important pain and discolouration at the injection site. It was unclear if women and babies were healthier when women were given iron for mild or moderate anaemia during pregnancy. There were no studies on using blood transfusions. Overall, there was insufficient evidence to say when or how anaemia in pregnancy needs to or should be treated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Reveiz, L, Gyte, GML, Cuervo, LG, Casasbuenas, A", "articleTypes": [], "doi": "10.1002/14651858.CD003094.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.753Z" }, { "id": "71bee925-eadf-4564-a4cc-6d011867c530", "pmid": "", "title": "A Phase 3, Global, Multi-center, Double-blind, Randomized Study of ASP2138 Plus Chemotherapy (CAPOX or mFOLFOX6) With Pembrolizumab vs Placebo Plus Chemotherapy With or Without Pembrolizumab in First-line Treatment of Locally Advanced Unresectable or Metastatic Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma in Participants Whose Tumors Are HER2-negative and Claudin (CLDN) 18.2-positive", "imported": false, "abstract": "Claudin 18.2 or CLDN18.2 is a protein found on cells in the digestive system. It is also found in some tumors. Researchers are looking at ways to attack CLDN18.2 to help control tumors. ASP2138 is thought to bind to CLDN18.2 and a type of immune cell called a T cell. This \"tells\" the immune system to attack the tumor. ASP2138 is a potential treatment for people with gastric cancer (also known as stomach cancer) or gastroesophageal junction cancer (GEJ cancer). GEJ is where the tube that carries food (esophagus) joins the stomach.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "71c4e009-9b6c-4a00-8b0d-dbf95c3032bd", "pmid": "", "title": "Oral nicotine pouches for cessation or reduction of use of other tobacco or nicotine products", "imported": false, "abstract": "Abstract - Rationale Oral nicotine pouches (ONP) emerged in the late 2000s, but have gained popularity since their introduction to the global market in 2016, with claims about their harm reduction potential. Objectives Primary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from combustible tobacco use (smoking). • To evaluate the impact of ONP on the prevalence of combustible tobacco use. Secondary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from other non‐combustible tobacco/commercial nicotine product use. • To evaluate the impact of ONP on the prevalence of use of other non‐combustible tobacco/commercial nicotine products. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO from 2000 to 13 January 2025. We also covered ClinicalTrials.gov and the WHO ICTRP through our search of CENTRAL. Eligibility criteria We included randomised controlled trials (RCTs) of ONP in people using tobacco or other non‐combustible tobacco/non‐pharmaceutical nicotine products. RCTs must have reported tobacco/nicotine use at 4+ weeks or biomarkers or adverse events at 1+ weeks. We also sought interrupted/multiple time‐series studies of ONP's population‐level effects on the prevalence of use of other tobacco/nicotine products. Outcomes Our critical outcomes were: smoking abstinence at 4+ weeks; number of people reporting serious adverse events (SAEs) at 1+ weeks; and change in the prevalence of smoking. Important outcomes included tobacco‐specific nitrosamines (TSNAs), carboxyhaemoglobin (COHb), metals, and inflammatory markers detected in human biosamples. Risk of bias We used the Cochrane RoB 1 tool to assess risk of bias. Synthesis methods We synthesised results using random‐effects meta‐analysis where possible. We used I 2 to quantify statistical heterogeneity. Where meta‐analysis was not possible, we graphically plotted available data in forest plots. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CI). We assessed the certainty of evidence using GRADE. Included studies We included four small studies (n < 150 for each, total n = 284; 3 independent, 1 industry‐funded; 3 at high risk of bias and 1 at unclear risk of bias). All were RCTs in people who smoked combustible cigarettes at baseline. Three were conducted in the USA, and one in New Zealand. Two compared higher‐ versus lower‐nicotine dose ONP. Two compared ONP to instructions to continue smoking as usual. One each compared ONP to electronic cigarettes (e‐cigarettes), snus, and pharmaceutical nicotine replacement therapy (NRT). Synthesis of results Smoking abstinence Smoking abstinence may be slightly higher in people randomised to ONP compared to no intervention at eight‐week follow‐up (RR 1.58, 95% CI 0.07 to 35.32; 1 study, 27 participants; very low‐certainty evidence (risk of bias and imprecision; CI incorporated possibility of no difference)), but the evidence is very uncertain. Low‐certainty evidence (serious imprecision; CI incorporated possibility of no difference) suggests there may be lower abstinence rates in those randomised to ONP compared to e‐cigarettes (RR 0.25, 95% CI 0.03 to 2.02; 1 study, 36 participants). Evidence from one study (n = 30) comparing higher‐ versus lower‐dose ONP found a higher quit rate in the higher‐dose arm, but again with wide CI encompassing the possibility of no difference and of higher quit rates in the lower‐dose arm (RR 5.00, 95% CI 0.26 to 96.13; evidence certainty not assessed). Serious adverse events No SAEs occurred in the three studies reporting this outcome. Data were available for the comparisons ONP versus minimal control (2 studies, 124 participants; very low‐certainty evidence (risk of bias and serious imprecision)) and ONP versus e‐cigarettes (1 study, 26 participants; low‐certainty evidence (serious imprecision)). TSNA One study reported on a TSNA (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol (NNAL)) comparing ONP with instructions to continue smoking. There may be lower levels with ONP (MD −265.30 ng/g creatinine, 95% CI −350.64 to −179.96; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. Data from two studies suggested no difference in NNAL levels between higher‐ and lower‐dose ONP (SMD −0.16, 95% CI −1.87 to 1.56; I 2 = 0%; 77 participants; evidence certainty not assessed). COHb Based on one study, there may be lower levels of COHb with ONP compared to instructions to continue smoking (MD −6.7%, 95% CI −8.33 to −5.07; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. When comparing higher‐ versus lower‐dose ONP, the same study found very slightly lower levels in the higher‐dose group, with the 95% CI incorporating the possibility of no difference (MD −0.40%, 95% CI −1.19 to 0.39; evidence certainty not assessed). No studies reported on prevalence, inflammatory markers, metals, or use of tobacco/nicotine products other than cigarettes. Authors' conclusions There is limited evidence on the use of ONP for cessation or reduction of cigarette use. There is no evidence on the use of ONP for cessation or reduction of other tobacco or nicotine products or on the effects of ONP on prevalence of tobacco use/nicotine vaping. Low‐certainty evidence suggests that people randomised to ONP may be slightly less likely to quit smoking than those randomised to e‐cigarettes, but data were from one small study and therefore imprecise. Limited, short‐term data did not identify any serious health harms from ONP when used to help people transition away from tobacco smoking. More research on the effects of ONP for cessation or reduction of use of other tobacco or non‐pharmaceutical nicotine products is urgently needed. Future trials should prioritise comparing ONP to other active interventions (e.g. NRT and e‐cigarettes). Funding This Cochrane review was funded by the National Cancer Institute of the National Institutes of Health (NIH) and FDA Center for Tobacco Products (CTP) under Award Number 2U54CA229974. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food & Drug Administration. Registration Registration: Cochrane, via protocol available via DOI:10.1002/14651858.CD016220. Plain language summary What are the benefits and risks of oral nicotine pouches when used to help people stop smoking, vaping nicotine, or using other forms of tobacco? Key messages Limited evidence from three small studies found no short‐term serious health harms of oral nicotine pouches in people who smoke. We are uncertain if oral nicotine pouches help people quit smoking compared to instructions to continue smoking as usual or no support to quit. Future research is needed, in particular comparing oral nicotine pouches to other active treatments (e.g. nicotine replacement therapy and e‐cigarettes). What are oral nicotine pouches? Oral nicotine pouches are preportioned pouches containing nicotine, sold in various flavours and nicotine strengths. They are similar in appearance and use to snus. Snus is a form of smokeless tobacco placed between the gum and lip that is popular in Nordic countries, but whose sale is banned in the UK and European Union countries excluding Sweden. Unlike snus, nicotine pouches do not contain tobacco leaf. Like nicotine e‐cigarettes and pharmaceutical forms of nicotine replacement therapy (such as nicotine patches and gums), oral nicotine pouches may be able to help people transition away from harmful forms of tobacco/nicotine product use by replacing them with a product that does not contain tobacco leaf and which, unlike e‐cigarettes, does not involve inhaling vapour into the lungs. Common brand names of oral nicotine pouches include Zyn, Velo, and Nordic Spirit. What did we want to find out? We wanted to find out if oral nicotine pouches can help people transition away from smoking, nicotine vaping, or other forms of tobacco use. We also wanted to know if oral nicotine pouches caused any unwanted effects when used for this purpose. What did we do? We searched for studies where people who smoked, vaped, or used other tobacco products were given oral nicotine pouches as a way to quit. We included studies if they tracked tobacco use or vaping for at least four weeks or looked at unwanted effects or chemical changes in the blood, breath, or urine for at least one week. What did we find? We found four studies including a total of 284 people who were smokers at study start. The studies were conducted between 2006 and 2023, and in those that reported race or ethnicity, were conducted in majority white populations. The average age across studies ranged from 34 to 50 years. The average number of cigarettes smoked by participants at study start was between 14 and 23 per day. The longest study ran for eight weeks. Three studies were independently funded, and one was funded by a tobacco manufacturer. Based on two small studies, it was not clear whether using nicotine pouches helped more people to quit smoking compared to instructions to continue smoking as usual or no support to quit, and there may be lower quit rates in those using nicotine pouches compared to those using a nicotine e‐cigarette (vaping). No serious health harms occurred in any group in the three studies that reported this information, so it is unclear if using nicotine pouches affects the chances of experiencing a serious health harm. We also looked at certain chemicals measured in blood, breath, or urine that can signal exposures to harmful substances. Tobacco use exposes the body to cancer‐causing chemicals. NNAL (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol), a chemical formed when these cancer‐causing chemicals enter the body, measures exposure to harmful ingredients in tobacco smoke. One small study reported lower levels of NNAL in people using oral nicotine pouches compared to those given no specific treatment to stop smoking. Combined evidence from two studies suggested no difference in NNAL levels between people receiving higher‐ versus lower‐dose nicotine pouches. Carbon monoxide is a poisonous gas present in tobacco smoke. When carbon monoxide binds with blood haemoglobin, it forms a substance called carboxyhaemoglobin. Carboxyhaemoglobin measures how much carbon monoxide a person has been exposed to in their blood. One study found lower levels of carboxyhaemoglobin in people using oral nicotine pouches compared to those who continued smoking. When comparing higher‐ versus lower‐dose nicotine pouches, the same study found very slightly lower carboxyhaemoglobin levels in the higher‐dose group. What are the limitations of the evidence? We have little to very low confidence in the evidence because the studies were relatively small, and there are not enough studies to be certain about the results. Also, some studies had issues with the way they were designed that could have affected their results. Many studies are currently underway, and we plan to update this review when their findings become available. How up‐to‐date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hartmann-Boyce, J; Tattan-Birch, H; Brown, J; Shahab, L; Goniewicz, ML; Ma, CL; Wu, AD; Travis, N; Jarman, H; Livingstone-Banks, J; Lindson, N", "articleTypes": [], "doi": "10.1002/14651858.CD016220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "71cab890-d14f-4bb1-bbcd-d34817406ead", "pmid": "", "title": "The Effect of Seven Day Fenfluramine Administration on Cognition in Healthy Volunteers", "imported": false, "abstract": "In this study, the investigators will investigate the cognitive effects of fenfluramine, a drug that directly stimulates the release of serotonin in the brain and positively modulates σ1 function. The investigators will use fenfluramine to assess the cognitive effects of modulating serotonin and σ1 function in healthy volunteers using a battery of cognitive tasks that measure learning and memory, executive functioning, reward processing, and emotional processing. The study design is double-blind, and participants will be randomised to either seven days of fenfluramine or placebo administration. All participants will attend two screening visits to assess eligibility. There are two main study visits; during the first, participants will undertake cognitive tasks and questionnaires before taking the initial study dose. One the second study visit, participants will once again complete these tasks and questionnaires after a week of fenfluramine/placebo administration.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "71cd2e24-b591-4cee-abcd-505b57e531cc", "pmid": "", "title": "Citalopram versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Recent US and UK clinical practice guidelines recommend that second‐generation antidepressants should be considered amongst the best first‐line options when drug therapy is indicated for a depressive episode. Systematic reviews have already highlighted some differences in efficacy between second‐generation antidepressants. Citalopram, one of the first selective serotonin reuptake inhibitors (SSRI) introduced in the market, is one of these antidepressant drugs that clinicians use for routine depression care. Objectives To assess the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with tricyclics, heterocyclics, other SSRIs and other conventional and non‐conventional antidepressants in the acute‐phase treatment of major depression. Search methods We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to February 2012. No language restriction was applied. We contacted pharmaceutical companies and experts in this field for supplemental data. Selection criteria Randomised controlled trials allocating patients with major depression to citalopram versus any other antidepressants. Data collection and analysis Two reviewers independently extracted data. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (the number of patients who responded or remitted), patient acceptability (the number of patients who failed to complete the study) and tolerability (side‐effects). Main results Thirty‐seven trials compared citalopram with other antidepressants (such as tricyclics, heterocyclics, SSRIs and other antidepressants, either conventional ones, such as mirtazapine, venlafaxine and reboxetine, or non‐conventional, like hypericum ). Citalopram was shown to be significantly less effective than escitalopram in achieving acute response (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.08 to 2.02), but more effective than paroxetine (OR 0.65, 95% CI 0.44 to 0.96) and reboxetine (OR 0.63, 95% CI 0.43 to 0.91). Significantly fewer patients allocated to citalopram withdrew from trials due to adverse events compared with patients allocated to tricyclics (OR 0.54, 95% CI 0.38 to 0.78) and fewer patients allocated to citalopram reported at least one side effect than reboxetine or venlafaxine (OR 0.64, 95% CI 0.42 to 0.97 and OR 0.46, 95% CI 0.24 to 0.88, respectively). Authors' conclusions Some statistically significant differences between citalopram and other antidepressants for the acute phase treatment of major depression were found in terms of efficacy, tolerability and acceptability. Citalopram was more efficacious than paroxetine and reboxetine and more acceptable than tricyclics, reboxetine and venlafaxine, however, it seemed to be less efficacious than escitalopram. As with most systematic reviews in psychopharmacology, the potential for overestimation of treatment effect due to sponsorship bias and publication bias should be borne in mind when interpreting review findings. Economic analyses were not reported in the included studies, however, cost effectiveness information is needed in the field of antidepressant trials. Plain language summary Citalopram versus other antidepressants for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Antidepressant drugs remain the mainstay of treatment in moderate‐to‐severe major depression. During the last 20 years, selective serotonin reuptake inhibitors (SSRIs) have progressively become the most commonly prescribed antidepressants. Citalopram, one of the first SSRIs introduced in the market, is the racemic mixture of S‐ and R‐enantiomer. In the present review we assessed the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with all other antidepressants in the acute‐phase treatment of major depression. Thirty‐seven randomised controlled trials (more than 6000 participants) were included in the present review. In terms of efficacy, citalopram was more efficacious than other reference compounds like paroxetine or reboxetine, but worse than escitalopram. In terms of side effects, citalopram was more acceptable than older antidepressants, like tricyclics. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including differences in efficacy and side‐effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cipriani, A, Purgato, M, Furukawa, TA, Trespidi, C, Imperadore, G, Signoretti, A, Churchill, R, Watanabe, N, Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006534.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.745Z" }, { "id": "71d7edaa-d7ca-460a-90d8-c2c2cd5175fe", "pmid": "", "title": "Drug interventions for the treatment of obesity in children and adolescents", "imported": false, "abstract": "Abstract - Background Child and adolescent obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. Objectives To assess the efficacy of drug interventions for the treatment of obesity in children and adolescents. Search methods We searched CENTRAL , MEDLINE, Embase, PubMed (subsets not available on Ovid), LILACS as well as the trial registers ICTRP (WHO) and ClinicalTrials.gov. Searches were undertaken from inception to March 2016. We checked references and applied no language restrictions. Selection criteria We selected randomised controlled trials (RCTs) of pharmacological interventions for treating obesity (licensed and unlicensed for this indication) in children and adolescents (mean age under 18 years) with or without support of family members, with a minimum of three months' pharmacological intervention and six months' follow‐up from baseline. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. In addition, we excluded trials which included growth hormone therapies and pregnant participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data following standard Cochrane methodology. Where necessary we contacted authors for additional information. Main results We included 21 trials and identified eight ongoing trials. The included trials evaluated metformin (11 trials), sibutramine (six trials), orlistat (four trials), and one trial arm investigated the combination of metformin and fluoxetine. The ongoing trials evaluated metformin (four trials), topiramate (two trials) and exenatide (two trials). A total of 2484 people participated in the included trials, 1478 participants were randomised to drug intervention and 904 to comparator groups (91 participants took part in two cross‐over trials; 11 participants not specified). Eighteen trials used a placebo in the comparator group. Two trials had a cross‐over design while the remaining 19 trials were parallel RCTs. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up from baseline ranged from six months to 100 weeks. Trials generally had a low risk of bias for random sequence generation, allocation concealment and blinding (participants, personnel and assessors) for subjective and objective outcomes. We judged approximately half of the trials as having a high risk of bias in one or more domain such as selective reporting. The primary outcomes of this review were change in body mass index (BMI), change in weight and adverse events. All 21 trials measured these outcomes. The secondary outcomes were health‐related quality of life (only one trial reported results showing no marked differences; very low certainty evidence), body fat distribution (measured in 18 trials), behaviour change (measured in six trials), participants' views of the intervention (not reported), morbidity associated with the intervention (measured in one orlistat trial only reporting more new gallstones following the intervention; very low certainty evidence), all‐cause mortality (one suicide in the orlistat intervention group; low certainty evidence) and socioeconomic effects (not reported). Intervention versus comparator for mean difference (MD) in BMI change was ‐1.3 kg/m 2 (95% confidence interval (CI) ‐1.9 to ‐0.8; P < 0.00001; 16 trials; 1884 participants; low certainty evidence). When split by drug type, sibutramine, metformin and orlistat all showed reductions in BMI in favour of the intervention. Intervention versus comparator for change in weight showed a MD of ‐3.9 kg (95% CI ‐5.9 to ‐1.9; P < 0.00001; 11 trials; 1180 participants; low certainty evidence). As with BMI, when the trials were split by drug type, sibutramine, metformin and orlistat all showed reductions in weight in favour of the intervention. Five trials reported serious adverse events: 24/878 (2.7%) participants in the intervention groups versus 8/469 (1.7%) participants in the comparator groups (risk ratio (RR) 1.43, 95% CI 0.63 to 3.25; 1347 participants; low certainty evidence). A total 52/1043 (5.0%) participants in the intervention groups versus 17/621 (2.7%) in the comparator groups discontinued the trial because of adverse events (RR 1.45, 95% CI 0.83 to 2.52; 10 trials; 1664 participants; low certainty evidence). The most common adverse events in orlistat and metformin trials were gastrointestinal (such as diarrhoea, mild abdominal pain or discomfort, fatty stools). The most frequent adverse events in sibutramine trials included tachycardia, constipation and hypertension. The single fluoxetine trial reported dry mouth and loose stools. No trial investigated drug treatment for overweight children. Authors' conclusions This systematic review is part of a series of associated Cochrane reviews on interventions for obese children and adolescents and has shown that pharmacological interventions (metformin, sibutramine, orlistat and fluoxetine) may have small effects in reduction in BMI and bodyweight in obese children and adolescents. However, many of these drugs are not licensed for the treatment of obesity in children and adolescents, or have been withdrawn. Trials were generally of low quality with many having a short or no post‐intervention follow‐up period and high dropout rates (overall dropout of 25%). Future research should focus on conducting trials with sufficient power and long‐term follow‐up, to ensure the long‐term effects of any pharmacological intervention are comprehensively assessed. Adverse events should be reported in a more standardised manner specifying amongst other things the number of participants experiencing at least one adverse event. The requirement of regulatory authorities (US Food and Drug Administration and European Medicines Agency) for trials of all new medications to be used in children and adolescents should drive an increase in the number of high quality trials. Plain language summary Drug interventions for the treatment of obesity in children and adolescents Review question Do drug (medicine) interventions reduce weight in obese children and adolescents and are they safe? Background Across the world more children and adolescents are becoming overweight and obese. These children and adolescents are more likely to have health problems, both while as children or adolescents and in later life. More information is needed about what works best for treating this problem recognising that so‐called lifestyle changes (diet, exercise and counselling) have limited efficacy. Study characteristics We found 21 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) comparing various drugs plus a behaviour changing intervention such as diet, exercise or both (= intervention groups) usually with placebo (a pretend drug) plus a behaviour changing intervention (= control groups). We also identified eight ongoing studies (studies which are currently running but not completed yet). A total of 2484 children and adolescents took part in the included studies. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up ranged from six months to 100 weeks. Key results The included studies investigated metformin (10 studies), sibutramine (six studies), orlistat (four studies) and one study group evaluated the combination of metformin and fluoxetine. The ongoing studies are investigating metformin (four studies), topiramate (two studies) and exenatide (two studies). Most studies reported on body mass index (BMI) and bodyweight: BMI is a measure of body fat and is calculated from weight and height measurements (kg/m 2 ). In children, BMI is often measured in a way that takes into account sex, weight and height as children grow older (BMI z score). The average change in BMI across control groups was between a 1.8 kg/m 2 reduction to a 0.9 kg/m 2 increase, while across all intervention groups the average reduction was more pronounced (1.3 kg/m 2 reduction). The same effect was observed for weight change: on average, children and adolescents in the intervention groups lost 3.9 kg more weight than the children and adolescents in the control groups. Study authors reported an average of serious side effects in 24 per 1000 participants in the intervention groups compared with an average of 17 per 1000 participants in the control groups. The numbers of participants dropping out of the study because of side effects were 40 per 1000 in the intervention groups and 27 per 1000 in the control groups. The most common side effects in the orlistat and metformin studies were gut (such as diarrhoea and mild tummy pain). Common side effects in the sibutramine trials included increased heart rate (tachycardia), constipation and high blood pressure. The fluoxetine study reported dry mouth and loose stools. One study reported health‐related quality of life (a measure of physical, mental, emotional and social functioning) and found no marked differences between intervention and control. No study reported the participants' views of the intervention or socioeconomic effects. Only one study reported on morbidity (how often a disease occurs in a specific area) associated with the intervention, where there were more gallstones after the orlistat treatment. Study authors reported one suicide in the orlistat intervention group. However, studies were not long enough to reliably investigate death from any cause. No study investigated drug treatment for children who were only overweight (obese children have a much higher weight, BMI or BMI z score than children being overweight). This evidence is up to date to March 2016. Quality of the evidence The overall certainty of the evidence was low or very low, mainly because there were only a few studies per outcome measurement, the number of included children or adolescents was small, and due to variation in the results of the studies. In addition, many children or adolescents left the studies before the study had finished.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Axon, E, Atkinson, G, Richter, B, Metzendorf, MI, Baur, L, Finer, N, Corpeleijn, E, O'Malley, C, Ells, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012436", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.780Z" }, { "id": "71e72b01-1b78-40bd-b428-1c44f4944051", "pmid": "", "title": "High-dose Vitamin D Supplement for the Prevention of Acute Asthma-like Symptoms in Preschool Children - a Double-blind, Randomized, Controlled Trial", "imported": false, "abstract": "To investigate whether high-dose vitamin D supplementation may have a beneficial effect on secondary prevention in preschool children (1-5 years of age), with respiratory infections being the primary cause of acute exacerbations with asthma-like symptoms.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.245Z" }, { "id": "720d610d-cd58-495f-8a8c-0bb0a1ccebe2", "pmid": "", "title": "Multimodal interventions for cachexia management", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Reid, J, Blair, C, Dempster, M, McKeaveney, C, Slee, A, Fitzsimons, D", "articleTypes": [], "doi": "10.1002/14651858.CD015749.pub2 AB - Abstract - Background Cachexia (disease‐related wasting) is a complex metabolic syndrome which occurs in people with chronic illnesses, including cancer, HIV/AIDS, kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People with cachexia experience unintentional weight loss, muscle loss, fatigue, loss of appetite, and reduced quality of life. Multimodal interventions which work synergistically to treat the syndrome could lead to benefits. Objectives To assess the benefits and harms of multimodal interventions aimed at alleviating or stabilising cachexia in people with a chronic illness. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers in July 2024, together with reference checking, citation searching, and contact with study authors to identify studies. Selection criteria We included randomised controlled trials (RCTs) in adults with or at risk of cachexia, comparing multimodal interventions combining two or more modalities (of pharmacology, nutrition, exercise) to treatment as usual, variation of the intervention, or unimodal intervention. Data collection and analysis Two review authors independently screened potentially eligible studies, extracted data, and assessed risk of bias (RoB 1). Primary outcomes were physical function, strength, and adverse events. Secondary outcomes were body composition and weight, quality of life (QoL), appetite, fatigue, and biochemical markers. We assessed the certainty of evidence with GRADE. Main results We included nine studies with 926 adults (mean age: 63 years). Study sample sizes ranged from 20 to 332 participants. Six studies were conducted in Europe, and one each in Turkey, New Zealand, and the USA. There were six studies in people with cancer, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. We judged four studies to be at an overall high risk of bias, and five at an overall unclear risk. All outcomes in all comparisons had very low‐certainty evidence, downgraded once for risk of bias and/or indirectness and twice for imprecision. Multimodal intervention (pharmacological, nutritional, and/or exercise) compared to treatment as usual One cancer study randomised 46 participants, with 41 included in all analyses except adverse events. The study assessed outcomes immediately after treatment, lasting six weeks. Compared to treatment as usual, there is no clear evidence for an effect of a multimodal intervention on: physical function (mean difference (MD) −16.10 m, 95% confidence interval (CI) −79.06 to 46.86; 41 participants); strength (MD 3.80 kg, 95% CI −3.21 to 10.81; 41 participants); adverse events (risk ratio (RR) 1.36, 95% CI 0.70 to 2.65; 46 participants); body composition (MD 7.89 cm 2 , 95% CI −10.43 to 26.21; 41 participants); weight (MD 5.89 kg, 95% CI −1.45 to 13.23; 41 participants); appetite (MD 0.68 points, 95% CI −0.60 to 1.96; 41 participants); fatigue (MD 0.12, 95% CI −1.05 to 1.29; 41 participants); and biochemical markers (MD 2%, 95% CI 0.99 to 3.01; 41 participants), but the evidence was very uncertain; QoL was not reported. Multimodal intervention compared to variation of the intervention Three cancer studies and one HIV/AIDS study randomised 192 participants. We could not use the available data, nor obtain additional data, from two studies (one in cancer, one in HIV/AIDS). The studies assessed outcomes immediately after treatment, ranging from three to seven months. Compared to a variation of the intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (MD 10.0 m, 95% CI −36.27 to 56.27; 1 study, 56 participants); strength (MD 0.7 kg, 95% CI −3.75 to 5.15; 1 study, 56 participants); adverse events (RR 0.87, 95% CI 0.38 to 2.02; P = 0.75, I 2 = 0%; 2 studies, 95 participants); body composition (MD −2.67 kg, 95% CI −5.89 to 0.54; P = 0.10, I 2 = 0%; 2 studies, 95 participants); weight (MD −2.47 kg, 95% CI −7.11 to 2.16; P = 0.30, I 2 = 0%; 2 studies, 95 participants); QoL (standardised mean difference (SMD) −0.15, 95% CI ���0.55 to 0.26; P = 0.47, I 2 = 0%; 2 studies, 95 participants); appetite (SMD −0.34, 95% CI −1.27 to 0.59; P = 0.48, I 2 = 79%; 2 studies, 95 participants); fatigue (MD 6.40 points, 95% CI −1.10 to 13.90; 1 study, 56 participants); or biochemical markers (MD 9.80 pg/mL, 95% CI −6.25 to 25.85; P = 0.23, I 2 = 73%; 2 studies, 95 participants), but the evidence is very uncertain. Multimodal intervention compared to unimodal intervention We included six studies (802 participants) in this comparison: three cancer studies, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. The studies assessed outcomes immediately after treatment, ranging from three to seven months. We could not use the available data, nor obtain additional data, from the HIV/AIDS study. Compared to a unimodal intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (SMD 0.02, 95% CI −0.22 to 0.26; P = 0.86, I 2 = 0%; 2 studies, 348 participants); strength (SMD 0.23, 95% CI −0.81 to 1.27; P = 0.66, I 2 = 0%; 2 studies, 348 participants); adverse events (RR 0.87, 95% CI −0.43 to 1.73; P = 0.68, I 2 = 45%; 2 studies, 395 participants); body composition (SMD 0.11, 95% CI −0.28 to 0.50; P = 0.58, I 2 = 74%; 5 studies, 742 participants); body weight (SMD −0.02, 95% CI −0.38 to 0.33; P = 0.90, I 2 = 49%; 4 studies, 431 participants); QoL (SMD 0.22, 95% CI −0.29 to 0.73; P = 0.39, I 2 = 61%; 3 studies, 411 participants); appetite (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.72, I 2 = 58%; 2 studies, 395 participants); fatigue (MD −6.80 points, 95% CI −12.44 to −1.17; 1 study, 244 participants); and biochemical markers (SMD 0.11, 95% CI −0.59 to 0.80; P = 0.76, I 2 = 79%; 3 studies, 411 participants), but the evidence is very uncertain. Authors' conclusions The review found insufficient evidence to support or refute the use of multimodal interventions in managing cachexia. The certainty of the evidence was very low. Methodologically rigorous, well‐powered RCTs with adequate interaction times are needed to assess the effectiveness of multimodal interventions in managing cachexia across chronic illnesses. Plain language summary What are the benefits and risks of using a combination of treatments to manage cachexia (disease‐related wasting)? Key messages: • We do not know if combinations of two or more treatments (of medication, diet, and exercise) benefit people who have or are at risk of developing cachexia (disease‐related wasting). This is because there are currently not enough robust studies in this area. • We need future research to increase our confidence in the evidence by conducting better designed and larger studies. What is cachexia? Cachexia is a complex metabolic syndrome that occurs in people with long‐term illnesses (known as chronic illnesses), such as cancer, HIV/AIDS, chronic kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People who have cachexia may: • lose weight unintentionally;
• lose muscle;
• feel tired, weak, or both; 
• lose their appetite. Cachexia affects well‐being and can be life‐threatening. How is cachexia treated? Studies are investigating how to best manage cachexia with different treatments. These treatments can include medications, diet, and exercise, provided in a single (unimodal) or combined (multimodal) treatment. It is thought that due to the complex biology of cachexia, a combination of treatments may work in a complementary way (synergistically) to help improve the symptoms associated with cachexia and people's well‐being, extend life, or both. What did we want to find out? We wanted to find out if combining at least two treatments (out of diet, exercise, and medication) helped to improve: physical function and strength; muscle loss; weight; well‐being; appetite; fatigue; and biological indicators within the blood (biochemical markers). We also wanted to find out if these interventions were associated with any unwanted or harmful (adverse) effects. What did we do? We searched for studies that compared treatment combinations of diet, exercise and/or medication (where at least two treatments were used together) to: different combinations of treatments; a single treatment; or treatment as usual (standard care) in adults with cachexia or at risk of developing cachexia. We compared and summarised the results of the included studies. We rated our confidence in the evidence based on factors such as study methods and the number of people included. What did we find? We found nine studies that included a total of 926 adults, with an average age of 63 years. Just over half of participants (57%) were men. Studies took place around the world, including Europe (six studies), Turkey (one study), New Zealand (one study), and the USA (one study). One study included people with HIV/AIDS (average age 43 years; 35 of 50 people in the study were men); one study included people with COPD (average age 72 years; 20 of 28 people in the study were men); and one study included people with chronic kidney disease (average age 70 years; 11 of 21 in the study were men). Six studies included people with cancer (average age 64 years; 461 of 893 people in the studies were men). The studies lasted six weeks to two years. The studies used combinations of treatments which could have included diet, exercise, and/or medication, where at least two treatments were used together, and compared these to: • treatment as usual (1 study, 46 people);
• different combinations of treatments (4 studies, 192 people);
• a single treatment (6 studies, 802 people). The studies did not provide enough robust evidence to determine if multimodal interventions are associated with benefits or harms in people with or at risk of cachexia. What are the limitations of the evidence? We are not confident in the evidence because not all the studies provided information about everything that we were interested in. Additionally, the studies used different ways of measuring results, and most of the studies included only small numbers of people. Importantly, future studies may change the conclusions of this review. How current is this review? The evidence is current to June 2024.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.814Z" }, { "id": "7214e84c-201b-4e31-bf0a-3649af591ce3", "pmid": "", "title": "Folic acid supplementation and malaria susceptibility and severity among people taking antifolate antimalarial drugs in endemic areas", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Qi, YP, Crider, KS, Gutman, J, Centeno-Tablante, E, Fothergill, A, Daniels, K, Yeung, LF, Mai, CT, Mehta, S, Williams, JL, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014217.pub2 AB - Abstract - Background Malaria is an infectious disease transmitted by female Anopheles mosquitoes, with ongoing transmission in over 80 countries. The malaria parasite requires folate for survival and growth; antifolate antimalarial medications used for prevention and treatment target enzymes in folate metabolism as their mechanism of action. Periconceptional folic acid (synthetic form of folate) supplementation (400 μg/day) is the standard of care for neural tube defect prevention. Concerns have been raised about the potential effects of folic acid (including above the tolerable upper intake level (UL) > 1.0 mg/day) in the context of malaria prevention and treatment, including the efficacy of antimalarial medications. Examining the potential impact of folic acid on malaria risk and severity amongst people taking antifolate antimalarial medications may inform public health programmes in malaria‐endemic areas. Objectives To examine the effects of folic acid supplementation on the risk and severity of malaria infection amongst people taking antifolate antimalarials and living in areas with malaria endemicity. Prevention: Amongst uninfected people taking antifolate antimalarial medications for malaria prevention, does folic acid supplementation increase susceptibility or severity of malaria infection? Treatment: Amongst people with malaria infection who are being treated with antifolate antimalarial drugs, does folic acid supplementation reduce parasite clearance or increase the risk of treatment failure? Search methods We searched databases including CENTRAL, MEDLINE, Embase, CINAHL, Scopus, and trial registries (September 13, 2024), grey literature, and reference searches to identify additional studies. Selection criteria Randomised trials evaluating the effects of folic acid supplementation (alone or in combination with iron or other vitamins and minerals) amongst individuals taking antifolate antimalarial medications in malaria‐endemic areas. Data collection and analysis Primary outcomes included uncomplicated malaria or severe malaria, parasite clearance, and treatment failure. Cochrane RoB 2 was used to evaluate the risk of bias. Certainty of evidence was assessed using GRADE for primary outcomes. We performed meta‐analyses using random‐effects models for all outcomes. Main results Eight trials with 3486 participants were included: three malaria prevention trials and five malaria treatment trials. Most treatment trials included folic acid doses above the UL ( > 1.0 mg/d); one trial included 400 μg per day. Antifolate antimalarials included sulfadoxine‐pyrimethamine (SP; five trials), sulfisoxazole plus pyrimethamine (one trial), atovaquone‐proguanil (one trial), and proguanil (one trial). Some studies had unclear or high risk of bias due to missing outcome data. Malaria prevention Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medications. Data for primary outcomes, uncomplicated and severe malaria, were not reported. One trial reported laboratory parasitaemia; there was little to no difference in malaria parasitaemia amongst pregnant women receiving folic acid (with iron) and antifolate antimalarials compared to iron and antifolate antimalarials (Risk Ratio (RR) 1.21; 95% CI 0.56 to 2.62; P = 0.63; 1 trial, 643 individuals). Comparisons 2–4: No studies reported data for Comparisons 2–4. Malaria treatment 
 Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarial medications versus placebo/no folic acid with antifolate antimalarials. People receiving folic acid (alone or with iron) and antifolate antimalarials were less likely to clear malaria parasites (day 3) compared to individuals who did not receive folic acid (RR 0.89; 95% CI 0.84 to 0.95, 4 trials, 929 individuals, moderate‐certainty evidence); and had increased risk of treatment failure on day 7 (RR 2.12; 95% CI 1.41 to 3.19, 4 trials, 1062 individuals, moderate‐certainty evidence), day 14 (RR 1.97; 95% CI 1.44 to 2.70, 3 trials; 891 individuals; moderate‐certainty evidence), and day 28 (RR 1.35; 95% CI 1.21 to 1.51; 4 trials; 1012 individuals, moderate‐certainty evidence). Comparison 2: Folic acid alone + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medication. Folic acid supplementation with antifolate antimalarials likely had lower parasite clearance (day 3) (RR 0.87; 95% CI 0.79 to 0.96, 2 trials, 229 individuals, moderate certainty of the evidence), and increased treatment failure (day 7: RR 2.58; 95% CI 0.89 to 7.45; P = 0.08; 2 trials; 344 individuals, moderate‐certainty evidence; day 14: RR 4.15; 95% CI 0.92 to 18.65; P = 0.06; 1 trial; 173 individuals, moderate‐certainty evidence; and day 28: RR 1.47; 95% CI 0.86 to 2.49; P = 0.16; 2 trials; 294 individuals, moderate‐certainty evidence), compared to no folic acid and antifolate antimalarials. Comparison 3: Folic acid with iron + antifolate antimalarial medication versus placebo/no folic acid with iron + antifolate antimalarial medication. People receiving folic acid with iron and antifolate antimalarials were less likely to clear malaria parasites (day 3: RR 0.90; 95% CI 0.83 to 0.98; P = 0.02; 2 trials; 700 individuals, moderate‐certainty evidence), and had increased treatment failure (day 7: RR 1.96; 95% CI 1.05 to 3.65; P = 0.03; 2 trials; 718 individuals; day 14: RR 1.90; 95% CI 1.35 to 2.67; 2 trials; 718 individuals; day 28: RR 1.17; 95% CI 0.79 to 1.74; 2 trials; 578 individuals; all moderate‐certainty evidence), compared to iron and antifolate antimalarials. Comparison 4: No studies reported data. Authors' conclusions Malaria prevention: None of the included trials reported primary outcomes. Malaria treatment: People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to clear malaria parasitaemia (day 3), and had increased treatment failure (days 7, 14, 28). Most of the included trials provided folic acid with doses above the tolerable UL ( > 1.0 mg). One trial included folic acid at a dose of 400 μg/d (recommended dose for preventing neural tube defects) and showed little to no difference in parasite clearance or treatment failure. Plain language summary Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common? Review question 
Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common?

 Key messages 
° People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to eliminate malaria parasites and had increased treatment failure. 
° There were not enough studies to examine whether taking folic acid supplementation at a lower dose, like 400 μg, might affect the risk of malaria infection or health outcomes if infected. This low dose is currently recommended before and during early pregnancy for the prevention of neural tube defects. Malaria and the importance of folate 
Malaria is a disease spread by the bite of certain types of female mosquitoes and is found in over 80 countries. The malaria parasite needs folate to grow and survive, and some medicines used to prevent and treat malaria target folate. Folic acid (the synthetic form of folate) is recommended at a dose of 400 μg daily to prevent neural tube defects. There are some concerns that folic acid (particularly higher doses) may affect malaria and how well some medicines work to prevent and treat malaria. What did we want to find out? 
This review was done to see how folic acid affects malaria risk and severity amongst people taking antifolate antimalarial medications and living in areas where malaria is common. Specifically, we aimed to answer the following questions: Prevention: For people who do not have malaria and are taking antimalarial drugs to prevent malaria, do folic acid supplements increase their risk of getting malaria or having worse outcomes? Treatment: For people who have malaria and are being treated with antifolate antimalarial medications, does taking folic acid supplements affect how well the drugs work to treat malaria? What did we do? 
We searched for trials that looked at folic acid supplementation in people taking antifolate antimalarial medications to prevent or treat malaria. We compared and summarised the results of the trials and rated our confidence in the information based on how the study was done. What did we find? 
We included eight trials (3486 people); three were prevention trials and five were treatment trials. Most trials used higher folic acid doses ( > 1.0 mg) and included the medication sulfadoxine‐pyrimethamine (SP). The prevention studies did not include the main outcomes we were trying to assess. In the treatment studies, people who took folic acid and antifolate antimalarial drugs were less likely to clear malaria parasites from their bodies (day 3) and were more likely to have treatment failure (up to 28 days after treatment) compared to the same treatment but without folic acid. Most of the included trials provided the antimalarial SP and folic acid with doses above the tolerable upper intake level (upper limit; > 1.0 mg). Only one trial included folic acid at a dose of 400 μg per day (the recommended daily dose of folic acid for prevention of neural tube defects); there were no differences in parasite clearance or treatment failure between the arm with 400 μg per day of folic acid and the arm with no folic acid. What are the limitations of the evidence? 
The small number of trials and the size of the studies were limitations of this review, and no prevention studies reported main outcomes. How up to date is this evidence? 
The evidence is up‐to‐date as of September 13, 2024.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.787Z" }, { "id": "722e80f2-7f73-469e-9ef5-9c801add394c", "pmid": "", "title": "Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status", "imported": false, "abstract": "Abstract - Background Iron deficiency is an important micronutrient deficiency contributing to the global burden of disease, and particularly affects children, premenopausal women, and people in low‐resource settings. Anaemia is a possible consequence of iron deficiency, although clinical and functional manifestations of anemia can occur without iron deficiency (e.g. from other nutritional deficiencies, inflammation, and parasitic infections). Direct nutritional interventions, such as large‐scale food fortification, can improve micronutrient status, especially in vulnerable populations. Given the highly successful delivery of iodine through salt iodisation, fortifying salt with iodine and iron has been proposed as a method for preventing iron deficiency anaemia. Further investigation of the effect of double‐fortified salt (i.e. with iron and iodine) on iron deficiency and related outcomes is warranted. Objectives To assess the effect of double‐fortified salt (DFS) compared to iodised salt (IS) on measures of iron and iodine status in all age groups. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases, and two trial registries up to April 2021. We also searched relevant websites, reference lists, and contacted the authors of included studies. Selection criteria All prospective randomised controlled trials (RCTs), including cluster‐randomised controlled trials (cRCTs), and controlled before‐after (CBA) studies, comparing DFS with IS on measures of iron and iodine status were eligible, irrespective of language or publication status. Study reports published as abstracts were also eligible. Data collection and analysis Three review authors applied the study selection criteria, extracted data, and assessed risk of bias. Two review authors rated the certainty of the evidence using GRADE. When necessary, we contacted study authors for additional information. We assessed RCTs, cRCTs and CBA studies using the Cochrane RoB 1 tool and Cochrane Effective Practice and Organisation of Care (EPOC) tool across the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other potential sources of bias due to similar baseline characteristics, similar baseline outcome assessments, and declarations of conflicts of interest and funding sources. We also assessed cRCTs for recruitment bias, baseline imbalance, loss of clusters, incorrect analysis, and comparability with individually randomised studies. We assigned studies an overall risk of bias judgement (low risk, high risk, or unclear). Main results We included 18 studies (7 RCTs, 7 cRCTs, 4 CBA studies), involving over 8800 individuals from five countries. One study did not contribute to analyses. All studies used IS as the comparator and measured and reported outcomes at study endpoint. With regards to risk of bias, five RCTs had unclear risk of bias, with some concerns in random sequence generation and allocation concealment, while we assessed two RCTs to have a high risk of bias overall, whereby high risk was noted in at least one or more domain(s). Of the seven cRCTs, we assessed six at high risk of bias overall, with one or more domain(s) judged as high risk and one cRCT had an unclear risk of bias with concerns around allocation and blinding. The four CBA studies had high or unclear risk of bias for most domains. The RCT evidence suggested that, compared to IS, DFS may slightly improve haemoglobin concentration (mean difference (MD) 0.43 g/dL, 95% confidence interval (CI) 0.23 to 0.63; 13 studies, 4564 participants; low‐certainty evidence), but DFS may reduce urinary iodine concentration compared to IS (MD −96.86 μg/L, 95% CI −164.99 to −28.73; 7 studies, 1594 participants; low‐certainty evidence), although both salts increased mean urinary iodine concentration above the cut‐off deficiency. For CBA studies, we found DFS made no difference in haemoglobin concentration (MD 0.26 g/dL, 95% CI −0.10 to 0.63; 4 studies, 1397 participants) or urinary iodine concentration (MD −17.27 µg/L, 95% CI −49.27 to 14.73; 3 studies, 1127 participants). No studies measured blood pressure. For secondary outcomes reported in RCTs, DFS may result in little to no difference in ferritin concentration (MD −3.94 µg/L, 95% CI −20.65 to 12.77; 5 studies, 1419 participants; low‐certainty evidence) or transferrin receptor concentration (MD −4.68 mg/L, 95% CI −11.67 to 2.31; 5 studies, 1256 participants; low‐certainty evidence) compared to IS . However, DFS may reduce zinc protoporphyrin concentration (MD −27.26 µmol/mol, 95% CI −47.49 to −7.03; 3 studies, 921 participants; low‐certainty evidence) and result in a slight increase in body iron stores (MD 1.77 mg/kg, 95% CI 0.79 to 2.74; 4 studies, 847 participants; low‐certainty evidence). In terms of prevalence of anaemia, DFS may reduce the risk of anaemia by 21% (risk ratio (RR) 0.79, 95% CI 0.66 to 0.94; P = 0.007; 8 studies, 2593 participants; moderate‐certainty evidence). Likewise, DFS may reduce the risk of iron deficiency anaemia by 65% (RR 0.35, 95% CI 0.24 to 0.52; 5 studies, 1209 participants; low‐certainty evidence). Four studies measured salt intake at endline, although only one study reported this for both groups. Two studies reported prevalence of goitre, while one CBA study measured and reported serum iron concentration. One study reported adverse effects. No studies measured hepcidin concentration. Authors' conclusions Our findings suggest DFS may have a small positive impact on haemoglobin concentration and the prevalence of anaemia compared to IS, particularly when considering efficacy studies. Future research should prioritise studies that incorporate robust study designs and outcome measures (e.g. anaemia, iron status measures) to better understand the effect of DFS provision to a free‐living population (non‐research population), where there could be an added cost to purchase double‐fortified salt. Adequately measuring salt intake, both at baseline and endline, and adjusting for inflammation will be important to understanding the true effect on measures of iron status. Plain language summary Fortification of salt with iron and iodine compared to salt fortified with iodine only for improving iron and iodine status Key messages Compared to iodised salt, double‐fortified salt (salt fortified with iron and iodine) may improve some measures of iron and iodine nutrition, such as haemoglobin (i.e. the substance that gives red blood cells their colour) concentrations and body iron stores. However, it may reduce urinary iodine concentration and may make little or no difference to ferritin (i.e. iron‐storage protein) concentrations and transferrin receptor (i.e. protein that affects the uptake of iron) concentrations. It probably also reduces the prevalence of anaemia (lack of haemoglobin), and may reduce the prevalence of iron deficiency anaemia (lack of iron), compared to iodised salt. Well‐designed studies that assess the effects of double‐fortified salt within non‐research populations (i.e. real‐life settings), and that measure salt intake, including changes in salt consumption, are needed. What is iron deficiency? Almost two billion people experience a deficiency in a vitamin or mineral (or both), with women and children in resource‐limited settings most frequently affected. Iron‐related deficiencies are among the most common deficiencies in the world and have important short‐ and long‐term health consequences. Interventions to provide iron frequently include iron supplementation, including iron tablets, powders, or syrups. However, these have known barriers, and food fortification strategies may be attractive alternatives. Salt is one of few universally consumed food vehicles. Iodised salt is fortified to provide 100% of a person's iodine requirements and is highly effective. Double‐fortified salt was developed to provide 30% of a person's daily dietary iron requirement and 100% of their iodine requirement. In some resource‐limited settings, where iron‐related deficiencies are a common problem, there has been interest in making double‐fortified salt more available to the public. This calls for further understanding of the effect of double‐fortified salt on related outcomes. What did we want to find out? If double‐fortified salt is better than salt fortified with iodine alone for improving measures of iron and iodine‐related nutrition, in particular: ‐ haemoglobin concentration; ‐ urinary iodine concentration; ‐ blood pressure; ‐ ferritin concentration; ‐ transferrin receptor concentration; ‐ prevalence of anaemia; ‐ prevalence of iron deficiency anaemia. What did we do? We looked for studies that provided double‐fortified salt to one group of participants and iodised salt to another. We compared their results, and rated our confidence in the evidence, based on factors such as study methods and sample size. What did we find? We identified 18 studies, involving over 8800 individuals from five countries; 13 studies were conducted in India. In 13 studies the intervention lasted between 6 and 12 months; in two studies it lasted 3 months, and in single studies it lasted for 18 months, 24 months, or the duration was unclear. Nine studies were conducted in children and adolescents (5 to 17 years), four in adults (18 years and older), and five included multiple age groups. All studies compared double‐fortified salt to iodised salt. Most studies were funded by non‐profit organisations, university grants or academic institutes. In four studies, double‐fortified salt was provided by a commercial organisation, and in three studies the funding source unclear. Compared to iodised salt, double‐fortified salt may improve haemoglobin concentration and body iron stores slightly, and probably reduces the prevalence of anaemia by 21%. However, double‐fortified salt may also reduce urinary iodine concentration compared to iodised salt and may make little or no difference in ferritin and transferrin receptor concentration. Double‐fortified salt may reduce the prevalence of iron deficiency anaemia by 65%, compared to iodised salt, although this conclusion is uncertain because of some problems with the way the studies were conducted. Very few studies measured zinc protoporphyrin concentration, adverse effects, prevalence of goitre and salt intake. One study measured serum iron concentration. No studies measured blood pressure or hepcidin concentration. What are the limitations of the evidence? We have relatively low confidence in the evidence for the outcomes: haemoglobin, urinary iodine, ferritin, and transferrin receptor concentration, and prevalence of iron deficiency anaemia. Not all studies provided data about all outcomes of interest; studies delivered the intervention differently; and studies were small, both in number and size. For the prevalence of anaemia, we are moderately confident in the evidence because studies used different ways of delivering the intervention. Care should be taken in interpreting our findings in relation to public health policy and programmes. Most studies were conducted in monitored research settings and double‐fortified salt was provided without an added cost. We are unsure if the effect we observed would be the same in real‐life (i.e. non‐research population), where purchasing double‐fortified salt could increase the cost. More studies looking at the effect of double‐fortified salt within real‐life settings are needed to understand the true effects of double‐fortified salt with greater certainty. Given the changing guidelines for salt intake, future studies should measure salt intake to understand if double‐fortified salt should be considered to prevent anaemia at the population level and how to integrate double‐fortified salt into the supply chain. How up to date is this evidence? The evidence is up to date to April 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Baxter, J-AB; Carducci, B; Kamali, M; Zlotkin, SH; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD013463.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "7246f9a9-e878-4c62-8d3a-6d9cb08dc971", "pmid": "", "title": "Interventions for chronic blepharitis", "imported": false, "abstract": "Abstract - Background Blepharitis, an inflammatory condition associated with itchiness, redness, flaking, and crusting of the eyelids, is a common eye condition that affects both children and adults. It is common in all ethnic groups and across all ages. Although infrequent, blepharitis can lead to permanent alterations to the eyelid margin or vision loss from superficial keratopathy (abnormality of the cornea), corneal neovascularization, and ulceration. Most importantly, blepharitis frequently causes significant ocular symptoms such as burning sensation, irritation, tearing, and red eyes as well as visual problems such as photophobia and blurred vision. The exact etiopathogenesis is unknown, but suspected to be multifactorial, including chronic low‐grade infections of the ocular surface with bacteria, infestations with certain parasites such as demodex, and inflammatory skin conditions such as atopy and seborrhea. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. Objectives To examine the effectiveness of interventions in the treatment of chronic blepharitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 1), MEDLINE (January 1950 to February 2012), EMBASE (January 1980 to February 2012), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 9 February 2012. Selection criteria We included randomized controlled trials (RCTs) and quasi‐randomized controlled trials (CCTs) in which participants were adults aged 16 years or older and clinically diagnosed with chronic blepharitis. We also included trials where participants with chronic blepharitis were a subset of the participants included in the study and data were reported separately for these participants. Interventions within the scope of this review included medical treatment and lid hygiene measures. Data collection and analysis Two authors independently assessed search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. Data were meta‐analyzed for studies comparing similar interventions and reporting comparable outcomes with the same timing. Otherwise, results for included studies were summarized in the text. Main results There were 34 studies (2169 participants with blepharitis) included in this review: 20 studies (14 RCTs and 6 CCTs) included 1661 participants with anterior or mixed blepharitis and 14 studies (12 RCTs and 2 CCTs) included 508 participants with posterior blepharitis (MGD). Due to the heterogeneity of study characteristics among the included studies, with respect to follow‐up periods and types of interventions, comparisons, and condition of participants, our ability to perform meta‐analyses was limited. Topical antibiotics were shown to provide some symptomatic relief and were effective in eradicating bacteria from the eyelid margin for anterior blepharitis. Lid hygiene may provide symptomatic relief for anterior and posterior blepharitis. The effectiveness of other treatments for blepharitis, such as topical steroids and oral antibiotics, were inconclusive. Authors' conclusions Despite identifying 34 trials related to treatments for blepharitis, there is no strong evidence for any of the treatments in terms of curing chronic blepharitis. Commercial products are marketed to consumers and prescribed to patients without substantial evidence of effectiveness. Further research is needed to evaluate the effectiveness of such treatments. Any RCT designed for this purpose should separate participants by type of condition (e.g. staphylococcal blepharitis or MGD) in order to minimize imbalances between groups (type I errors) and to achieve statistical power for analyses (prevent type II errors). Medical interventions and commercial products should be compared with conventional lid hygiene measures, such as warm compresses and eyelid margin washing, to determine effectiveness, as well as head‐to‐head to show comparative effectiveness between treatments. Outcomes of interest should be patient‐centered and measured using validated questionnaires or scales. It is important that participants be followed long‐term, at least one year, to assess chronic outcomes properly. Plain language summary Interventions for blepharitis Blepharitis, defined as inflammation of the eyelids, is a common eye condition and affects both children and adults. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. There were 34 studies (2169 participants with blepharitis) included in the review, 20 of which included participants with anterior blepharitis and 14 of which included participants with posterior blepharitis. For anterior blepharitis, topical antibiotics provided some symptomatic relief and were effective in clearing bacteria from the eyelid margins. There was no difference between the types of topical antibiotics used. Topical steroids also provided some symptomatic relief; however, they were ineffective in eliminating bacteria. Lid hygiene, including warm compresses and lid scrubs, showed some symptomatic relief in both anterior and posterior blepharitis. Overall, there was no strong evidence for any of the treatments in terms of curing chronic blepharitis. Further research should be done to evaluate the effectiveness of treatments for blepharitis, with particular attention paid to adequate diagnosis and classification of the disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lindsley, K, Matsumura, S, Hatef, E, Akpek, EK", "articleTypes": [], "doi": "10.1002/14651858.CD005556.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.771Z" }, { "id": "724ff569-1d9d-4bfc-bd53-a608781b55f9", "pmid": "", "title": "SOMESThesia in Patients With Head and Neck Cancer: Variability and Influence on the ALIMentation Experience", "imported": false, "abstract": "Cancer patients are at high risk for undernutrition. A study with head and neck cancer patients showed that 50% suffered from undernutrition (Prevost et al., 2014). Sensory alterations may also involve sensory changes from the physiological structures of the mouth or neural pathways and hedonic changes, i.e., although food may taste the same as usual, that taste is no longer judged as pleasant. These changes lead to an aversion to food and a decrease in the pleasure of eating (Bernhardson et al., 2009).", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "7251847e-d6a1-43e2-994f-346069060ac8", "pmid": "", "title": "A Randomized, Multicenter, Adaptive Phase II/III Study To Evaluate The Efficacy And Safety Of Trastuzumab Emtansine (T-DM1) Versus Taxane (Docetaxel Or Paclitaxel) In Patients With Previously Treated Locally Advanced Or Metastatic HER2-Positive Gastric Cancer, Including Adenocarcinoma Of The Gastroesophageal Junction", "imported": false, "abstract": "This multicenter, randomized, adaptive Phase II/III study will evaluate the efficacy and safety of trastuzumab emtansine (T-DM1) compared to standard taxane (docetaxel or paclitaxel) treatment in participants with human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer. At the start of the trial (stage 1), participants will be randomized with a ratio 2:2:1 to one of three treatment arms: Arm A: trastuzumab emtansine 3.6 milligram per kilogram (mg/kg) per intravenous injection (IV) every 3 weeks; Arm B: trastuzumab emtansine 2.4 mg/kg IV every week; Arm C: standard taxane therapy (docetaxel 75 milligram per meter square [mg/m^2] IV every 3 weeks or paclitaxel 80 mg/m^2 kg IV every week per investigator choice). At the end of the first stage of the study, the dose and schedule of trastuzumab emtansine that will be used in the second stage of the study will be selected by an Independent Data Monitoring Committee (IDMC). The regimen selection analysis will be made after approximately 100 participants across all three study arms have been treated for at least 12 weeks.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.155Z" }, { "id": "7252a965-c7fa-496c-acd0-cbf6a9780445", "pmid": "", "title": "Guided imagery for treating hypertension in pregnancy", "imported": false, "abstract": "Abstract - Background Hypertension (high blood pressure) in pregnancy carries a high risk of maternal morbidity and mortality. Although antihypertensive drugs are commonly used, they have adverse effects on mothers and fetuses. Guided imagery is a non‐pharmacological technique that has the potential to lower blood pressure among pregnant women with hypertension. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. Objectives To determine the effect of guided imagery as a non‐pharmacological treatment of hypertension in pregnancy and its influence on perinatal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, and two trials registers (October 2018). We also searched relevant conference proceedings and journals, and scanned the reference lists of retrieved studies. Selection criteria We included randomised controlled trials (RCTs). We would have included RCTs using a cluster‐randomised design, but none were identified. We excluded quasi‐RCTs and cross‐over trials. We sought intervention studies of various guided imagery techniques performed during pregnancy in comparison with no intervention or other non‐pharmacological treatments for hypertension (e.g. quiet rest, music therapy, aromatherapy, relaxation therapy, acupuncture, acupressure, massage, device‐guided slow breathing, hypnosis, physical exercise, and yoga). Data collection and analysis Three review authors independently assessed the trials for inclusion, extracted data, and assessed risk of bias for the included studies. We checked extracted data for accuracy, and resolved differences in assessments by discussion. We assessed the certainty of the evidence using the GRADE approach. Main results We included two small trials (involving a total of 99 pregnant women) that compared guided imagery with quiet rest. The trials were conducted in Canada and the USA. We assessed both trials as at high risk of performance bias, and low risk of attrition bias; one trial was at low risk for selection, detection, and reporting bias, while the other was at unclear risk for the same domains. We could not perform a meta‐analysis because the two included studies reported different outcomes, and the frequency of the intervention was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks, or until the baby was born (whichever came first). In the other study, the intervention included guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for four total hours; the participants were instructed to practice the procedures twice daily and complete at least three relief relaxation breaks each day. The control groups were similar ‐ one was quiet rest, and the other was quiet rest as bed rest. None of our primary outcomes were reported in the included trials: severe hypertension (either systolic blood pressure of 160 mmHg or higher, or diastolic blood pressure of 110 mmHg or higher); severe pre‐eclampsia, or perinatal death (stillbirths plus deaths in the first week of life). Only one of the secondary outcomes was measured. Low‐certainty evidence from one trial (69 women) suggests that guided imagery may make little or no difference in the use of antihypertensive drugs (risk ratio 1.27, 95% confidence interval 0.72 to 2.22). Authors' conclusions There is insufficient evidence to inform practice about the use of guided imagery for hypertension in pregnancy. The available evidence for this review topic is sparse, and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. There was low‐certainty evidence that guided imagery made little or no difference to the use of antihypertensive drugs, downgraded because of imprecision. The two included trials did not report on any of the primary outcomes of this review. We did not identify any trials comparing guided imagery with no intervention, or with another non‐pharmacological method for hypertension. Large and well‐designed RCTs are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with short‐term and long‐term maternal and neonatal health. Trials could also consider utilisation and costs of health service. Plain language summary Guided imagery for treating hypertension in pregnancy What is the issue? Some women have long‐term high blood pressure, or hypertension, whereas approximately 10% of pregnant women develop high blood pressure as a complication of pregnancy. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. It can be performed by oneself, one‐to‐one, or in groups with an instructor using audio or scripts. Why is this important? High blood pressure during pregnancy is associated with an increased risk of the mother developing pre‐eclampsia with proteinuria, eclampsia with seizures and liver and blood disorders, and kidney failure. The baby of a pregnant woman with high blood pressure is more likely to be born too soon, be too small, and may need neonatal intensive care. High blood pressure drugs are recommended for women with severe high blood pressure and pre‐eclampsia because of the risk of life‐threatening complications, but such drugs can have adverse effects for the mother (including headache, decreased mental alertness, and exercise intolerance). Such drugs can also cross the placenta and may affect the unborn baby, and are not generally recommended for pregnant women with mild to moderate high blood pressure, which is when other ways of managing blood pressure are sought. Guided imagery is a non‐pharmacological technique that could potentially lower blood pressure among pregnant women with hypertension and improve pregnancy outcomes for the mother and her baby. What evidence did we find? We searched for evidence (October 2018) and found two trials (involving 99 women) conducted in Canada and the USA. Both trials compared guided imagery with quiet rest. There were no trials comparing guided imagery with no intervention, or other with another non‐pharmacological method for hypertension. The two included studies reported different outcomes and the Intervention frequency was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks or until the baby was born (whichever came first). The other study involved guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for a total of four hours; the women were instructed to practice the procedures twice daily and complete at least three relaxation breaks each day. The control groups between the two studies were similar ‐ one used quiet rest and the other used quiet rest as bed rest. Neither trial reported data for our main outcomes of interest: severe hypertension, severe pre‐eclampsia, or death of the baby during birth or within the first week of life. The trials provided data for only one of our secondary outcomes of interest. Low‐certainty evidence from the one trial (69 women) suggests that, compared with quiet rest, guided imagery may make little or no difference in the use of antihypertensive drugs. What does this mean? We included two small trials comparing guided imagery with quiet rest. We did not identify any trials comparing guided imagery with no intervention, or another non‐pharmacological treatment for hypertension. The available evidence for this review is sparse and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. The included trials did not report on any of the main outcomes in this review and only provided low‐certainty evidence on the uncertain effect on the use of antihypertensive drugs. There is insufficient evidence to inform practice about using guided imagery for hypertension in pregnancy. Large and well‐designed studies are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with the short‐term and long‐term health of mothers and their babies. The trials should also consider the use and costs of health services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Haruna, M; Matsuzaki, M; Ota, E; Shiraishi, M; Hanada, N; Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD011337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "72572d82-ff3f-431a-906e-fd6f6e1daedc", "pmid": "", "title": "Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions", "imported": false, "abstract": "Abstract - Background Individuals on continuous treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) are at increased risk of bleeding complications during and after oral or dental procedures. Anticoagulant treatment is preferably continued at the same dose, since dose reduction or discontinuation of treatment is associated with an increased risk of thromboembolism. The use of haemostatic measures during or after the procedure (or both) could enable continuation of the oral anticoagulant treatment. Objectives We aimed to assess the efficacy of antifibrinolytic agents for preventing bleeding complications in people on oral anticoagulants undergoing minor oral surgery or dental extractions. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and the Cochrane Library. Additional searches were performed using ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), the CINAHL database of nursing and allied health services, the open access ProQuest dissertation database, papers and reports from the American College of Clinical Pharmacy (ACCP) and abstract books from annual scientific conferences. Date of last search: 04 January 2018. Selection criteria Randomised and quasi‐randomised controlled trials in people on continuous treatment with VKAs or DOACs undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid (TXA) or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. Data collection and analysis Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained from potentially relevant abstracts and two authors independently assessed these for inclusion based of the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. The quality of the evidence was assessed using GRADE. Main results No eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures were identified. Three randomised trials and one quasi‐randomised trial (follow‐up in all was seven days) in people on continuous treatment with VKAs were included with a total of 253 participants (mean age 60 years). Two trials published in 1989 and 1993 compared the antifibrinolytic agent TXA with placebo in people using VKAs. Two other trials were published in 1999 and 2015 and compared TXA with gelatin sponge and sutures, and dry gauze compression, respectively. In all included trials, those who were treated with VKAs had international normalised ratio (INR) values within the therapeutic range and TXA was applied locally, not systemically. The two trials from 1989 and 1993 comparing TXA with placebo showed a statistically significant beneficial effect regarding the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) of ‐0.25 (95% confidence interval (CI) ‐0.36 to ‐0.14) (128 participants) (moderate‐quality evidence). For the two trials that compared TXA with either gelatin sponge and sutures or with dry gauze compression, there was no difference between the TXA and the standard care group, RD 0.02 (95% CI ‐0.07 to 0.11) (125 participants) (moderate‐quality evidence). The combined RD of all included trials was ‐0.13 (95% CI ‐0.30 to 0.05) (moderate‐quality evidence). There were no side effects of antifibrinolytic therapy that required treatment withdrawal (128 participants) (moderate‐quality evidence). Despite heterogeneity between trials with respect to the different haemostatic measures used in the control groups, the trials were comparable regarding design and baseline participant characteristics. Overall, we considered the risk of bias to be low in the trials comparing TXA with placebo and moderate in the trials comparing TXA with alternative haemostatic measures. Authors' conclusions Based on the results of this Cochrane Review, there seems to be a beneficial effect of locally applied TXA in preventing oral bleeding in people on continuous treatment with VKAs undergoing minor oral surgery or dental extractions. However, the small number of identified randomised controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population. We were unable to identify any eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures. Therefore, a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs. Plain language summary Drugs that prevent oral bleeding in people using oral anticoagulants undergoing minor oral surgery or dental extractions Review question We reviewed the evidence about whether antifibrinolytic medicine (drugs that prevent breakdown of a blood clot), such as tranexamic acid or epsilon aminocaproic acid, can prevent oral bleeding after minor oral surgery or dental extractions in people using oral anticoagulants (blood thinners that are taken by mouth) without interruption during the procedure. Background People on continuous oral anticoagulant treatment are at an increased risk of bleeding complications during and after oral surgery or dental extractions. There are two types of oral anticoagulant treatment: vitamin K antagonists (VKAs) (e.g. warfarin and coumarin) and direct oral anticoagulants (DOACs) (e.g. dabigatran, rivaroxaban, apixaban, edoxaban). DOACs are becoming an increasingly popular alternative for VKAs, traditionally used for preventing blood clotting in people at risk of thrombosis. The number of bleeds and the severity of each bleed depend on medication‐related factors (such as the degree of anticoagulation, measured by the international normalised ratio (INR)), surgery‐related factors (such as the size of the wound or the number of roots extracted), as well as patient‐related factors (such as inflammation of the gums or blood vessel diseases). The INR level is important to determine how well the anticoagulant treatment is preventing blood clots. Within the desired range of the INR level, a person has both the least risk of blood clotting complications and the least risk of excessive bleeding. In routine practice antifibrinolytic medicine is often used before, during and after minor oral surgery or dental extractions for people using oral anticoagulants. The question is whether there is reliable scientific evidence for this practice. Search date The evidence is current to: 04 January 2018. Study characteristics We did not find any trials of antifibrinolytic medicine for preventing bleeding after minor oral surgery or dental extractions in people using DOACs. This review includes four trials (253 participants) in people continuously treated with VKAs during minor oral surgery or dental extractions. The earliest included trial was published in 1989 and the most recent one in 2015. The mean age of all participants was 60 years. The follow‐up time in all trials was seven days. Key results Overall, the included trials showed a reduction in the number of bleeds after dental extraction when using tranexamic acid solution in the mouth. Combining the results of the separate trials it appeared that antifibrinolytic medication reduces the bleeding rate after dental extractions by 25% when compared to placebo ('dummy' treatment). However, there was no difference in bleeding rate between people treated with tranexamic acid and those treated with standard care (e.g. gauze compression or stitches). Side effects of the antifibrinolytic medication rarely occurred and did not lead to individuals discontinuing tranexamic acid treatment. No evidence was found for people being treated with DOACs. It could, however, be argued that, if antifibrinolytic medicine is effective in people on continuous treatment with VKAs, it might also work for people receiving other comparable anticoagulant drugs. Quality of evidence In relation to the review's two primary outcomes of number of postoperative bleeds and side effects of therapy, we judged there to be moderate‐quality evidence. In the two trials comparing tranexamic acid with placebo, the risk of bias, in relation to trial design, was considered to be low, in the two trials comparing tranexamic acid to standard care (gelatin sponge and sutures; or dry gauze compression) the risk of bias was considered to be moderate. This was mainly due to the lack of blinding (a way of making sure that the people involved in the trial do not know which trial arm they are assigned to) and inadequate allocation concealment (using the play of chance to assign participants to comparison groups to prevent selection bias) in two of these trials. There were differences between the trials with regards to different standard care treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Engelen, ET, Schutgens, REG, Mauser‐Bunschoten, EP, van Es, RJJ, van Galen, KPM", "articleTypes": [], "doi": "10.1002/14651858.CD012293.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.089Z" }, { "id": "728d5d52-4f17-459e-bd0c-078ff6238473", "pmid": "", "title": "Aspirin with or without an antiemetic for acute migraine headaches in adults", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010). Migraine is a common, disabling condition and a burden for the individual, health services and society. Many sufferers choose not to, or are unable to, seek professional help and rely on over‐the‐counter analgesics. Co‐therapy with an antiemetic should help to reduce nausea and vomiting commonly associated with migraine headaches. Objectives To determine the efficacy and tolerability of aspirin, alone or in combination with an antiemetic, compared to placebo and other active interventions in the treatment of acute migraine headaches in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, ClinicalTrials.gov, and reference lists for studies through 10 March 2010 for the original review and to 31 January 2013 for the update. Selection criteria We included randomised, double‐blind, placebo‐controlled or active‐controlled studies, or both, using aspirin to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and numbers needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment. Main results No new studies were found for this update. Thirteen studies (4222 participants) compared aspirin 900 mg or 1000 mg, alone or in combination with metoclopramide 10 mg, with placebo or other active comparators, mainly sumatriptan 50 mg or 100 mg. For all efficacy outcomes, all active treatments were superior to placebo, with NNTs of 8.1, 4.9 and 6.6 for 2‐hour pain‐free, 2‐hour headache relief, and 24‐hour headache relief with aspirin alone versus placebo, and 8.8, 3.3 and 6.2 with aspirin plus metoclopramide versus placebo. Sumatriptan 50 mg did not differ from aspirin alone for 2‐hour pain‐free and headache relief, while sumatriptan 100 mg was better than the combination of aspirin plus metoclopramide for 2‐hour pain‐free, but not headache relief; there were no data for 24‐hour headache relief. Adverse events were mostly mild and transient, occurring slightly more often with aspirin than placebo. Additional metoclopramide significantly reduced nausea (P < 0.00006) and vomiting (P = 0.002) compared with aspirin alone. Authors' conclusions We found no new studies since the last version of this review. Aspirin 1000 mg is an effective treatment for acute migraine headaches, similar to sumatriptan 50 mg or 100 mg. Addition of metoclopramide 10 mg improves relief of nausea and vomiting. Adverse events were mainly mild and transient, and were slightly more common with aspirin than placebo, but less common than with sumatriptan 100 mg. Plain language summary Aspirin with or without an antiemetic for acute migraine headaches in adults This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010); no new studies were found. A single oral dose of 1000 mg of aspirin reduced pain from moderate or severe to none by two hours in approximately 1 in 4 people (24%) taking aspirin, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (52%) taking aspirin compared with approximately 1 in 3 (32%) taking placebo. Of those who experienced effective headache relief at two hours, more had that relief sustained over 24 hours with aspirin than with placebo. Addition of 10 mg of the antiemetic metoclopramide substantially increased relief of nausea and vomiting compared with aspirin alone, but made little difference to pain. Oral sumatriptan 100 mg was better than aspirin plus metoclopramide for pain‐free response at two hours, but otherwise there were no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short‐term use were mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Kirthi, V; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008041.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "7291bf10-3e16-44b7-b260-8ac8d17f88ea", "pmid": "", "title": "Antitumour antibiotic containing regimens for metastatic breast cancer", "imported": false, "abstract": "Abstract - Background Antitumour antibiotics are used in the management of metastatic breast cancer. Some of these agents have demonstrated higher tumour response rates than non‐antitumour antibiotic regimens, however a survival benefit has not been established in this setting. Objectives To review the randomised evidence comparing antitumour antibiotic containing chemotherapy regimens with regimens not containing an antitumour antibiotic in the management of women with metastatic breast cancer. Search methods The Specialised Register maintained by the Cochrane Breast Cancer Group was searched on 3rd October, 2006 using the codes for 'advanced breast cancer' and 'chemotherapy'. Details of the search strategy and coding applied by the Group to create the register are described in the Group's module on The Cochrane Library. Selection criteria Randomised trials comparing antitumour antibiotic containing regimens with regimens not containing antitumour antibiotics in women with metastatic breast cancer. Data collection and analysis Data were collected from published trials. Studies were assessed for eligibility and quality, and data were extracted by two independent reviewers. Hazard Ratios (HRs) were derived from time‐to‐event outcomes where possible, and a fixed effect model was used for meta‐analysis. Response rates were analysed as dichotomous variables. Quality of life and toxicity data were extracted where present. A primary analysis was conducted for all trials and by class of antitumour antibiotic. Main results Thirty‐four trials reporting on 46 treatment comparisons were identified. All trials published results for tumour response and 27 trials published time‐to‐event data for overall survival. The observed 4244 deaths in 5605 randomised women did not demonstrate a statistically significant difference in survival between regimens that contained antitumour antibiotics and those that did not (HR 0.96, 95% CI 0.90 to 1.02, P = 0.22) and no significant heterogeneity. Antitumour antibiotic regimens were favourably associated with time‐to‐progression (HR 0.84, 95% CI 0.77 to 0.91) and tumour response rates (odds ratio (OR) 1.33, 95% CI 1.21 to 1.48) although statistically significant heterogeneity was observed for these outcomes. These associations were consistent when the analysis was restricted to the 30 trials that reported on anthracyclines. Patients receiving anthracycline containing regimens were also more likely to experience toxic events compared to patients receiving non‐antitumour antibiotic regimens. No statistically significant difference was observed in any outcome between mitoxantrone containing and non‐antitumour antibiotic‐containing regimens. Authors' conclusions Compared to regimens without antitumour antibiotics, regimens that contained these agents showed a statistically significant advantage for tumour response and time to progression in women with metastatic breast cancer but were not associated with an improvement in overall survival. The favourable effect on tumour response and time to progression observed in anthracycline containing regimens was also associated with greater toxicity. Plain language summary Antitumour antibiotic containing regimens for metastatic breast cancer Advanced (metastatic) breast cancer is cancer that has spread beyond the breast. Treatment for metastatic disease usually involves some type of chemotherapy (anti‐cancer drugs) to try to reduce the cancer. Chemotherapy drugs can either be given as a single agent or in combination with other chemotherapy drugs. This is done according to a plan or a course of the drug referred to as a regimen. There are many types of chemotherapy drugs which work in various ways. Antitumour antibiotics work by damaging the cancer cells thereby preventing those cells from multiplying. Chemotherapy in general produces a range of side effects or adverse events related to the treatment. The known side effects of antitumour antibiotics include nausea, vomiting, a reduction in the number of white blood cells (known as leukopenia), and in some cases a toxic reaction which alters the working of the heart (called cardiotoxicity). This review sought to identify and review the randomised evidence comparing courses of chemotherapy containing antitumour antibiotics against courses not containing antitumour antibiotics. This review identified 34 eligible trials involving 5605 women. This review found that for women with advanced breast cancer, taking antitumour antibiotics did not result in better survival than women who took other types of chemotherapy drugs. Despite the lack of evidence of survival benefit, this review demonstrated that women taking these drugs had an advantage in time to progression (the length of time it takes for the cancer to progress after taking the drug) and tumour response (shrinking of the tumour) compared to women who did not take the antitumour antibiotic drugs. In addition however, the risks of side effects including cardiotoxicity, leukopenia and nausea/vomiting were all significantly increased in the women taking the antitumour antibiotics. Given that this review failed to show a benefit in survival for women taking this group of drugs but a higher rate of side effects, the use of these drugs in the management of metastatic breast cancer must be carefully weighed against the risk of these side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Lord, SJ; Ghersi, D; Gattellari, M; Wortley, S; Wilcken, N; Thornton, C; Simes, J", "articleTypes": [], "doi": "10.1002/14651858.CD003367.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "72a8db64-74d7-475b-adff-75a3a05e2f9d", "pmid": "", "title": "Sapropterin dihydrochloride for phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria results from a deficiency of the enzyme phenylalanine hydroxylase. Dietary restriction of phenylalanine keeps blood phenylalanine concentration low. Most natural foods are excluded from diet and supplements are used to supply other nutrients. Recent publications report a decrease in blood phenylalanine concentration in some patients treated with sapropterin dihydrochloride. We examined the evidence for the use of sapropterin dihydrochloride to treat phenylketonuria. This is an update of a previously published Cochrane Review. Objectives To assess the safety and efficacy of sapropterin dihydrochloride in lowering blood phenylalanine concentration in people with phenylketonuria. Search methods We identified relevant trials from the Group's Inborn Errors of Metabolism Trials Register. Date of last search: 11 August 2014. We also searched ClinicalTrials.gov and Current controlled trials. Last search: 4 September 2014 We contacted the manufacturers of the drug (BioMarin Pharmaceutical Inc.) for information regarding any unpublished trials. Selection criteria Randomized controlled trials comparing sapropterin with no supplementation or placebo in people with phenylketonuria due to phenylalanine hydroxylase deficiency. Data collection and analysis Two authors independently assessed trials and extracted outcome data. Main results Two placebo‐controlled trials were included. One trial administered 10 mg/kg/day sapropterin in 89 children and adults with phenylketonuria whose diets were not restricted and who had previously responded to saproterin.This trial measured change in blood phenylalanine concentration. The second trial screened 90 children (4 to 12 years) with phenylketonuria whose diet was restricted, for responsiveness to sapropterin. Forty‐six responders entered the placebo‐controlled part of the trial and received 20 mg/kg/day sapropterin. This trial measured change in both phenylalanine concentration and protein tolerance. Both trials reported adverse events. The trials showed an overall low risk of bias; but both are Biomarin‐sponsored. One trial showed a significant lowering in blood phenylalanine concentration in the sapropterin group (10 mg/kg/day), mean difference ‐238.80 μmol/L (95% confidence interval ‐343.09 to ‐134.51); a second trial (20 mg/kg/day sapropterin) showed a non‐significant difference, mean difference ‐51.90 μmol/L (95% confidence interval ‐197.27 to 93.47). The second trial also reported a significant increase in phenylalanine tolerance, mean difference18.00 mg/kg/day (95% confidence interval 12.28 to 23.72) in the 20 mg/kg/day sapropterin group. Authors' conclusions There is evidence of short‐term benefit from using sapropterin in some people with sapropterin‐responsive forms of phenylketonuria; blood phenylalanine concentration is lowered and protein tolerance increased. There are no serious adverse events associated with using sapropterin in the short term. There is no evidence on the long‐term effects of sapropterin and no clear evidence of effectiveness in severe phenylketonuria. Plain language summary The use of sapropterin to lower phenylalanine concentration in blood in people with phenylketonuria. Phenylketonuria occurs due to an inherited deficiency of the enzyme phenylalanine hydroxylase. If untreated it causes an excessive accumulation of the amino acid phenylalanine in the body which prevents normal brain development. The established treatment for phenylketonuria consists of dietary restriction of natural protein but with prescribed phenylalanine‐free amino acid, mineral and vitamin supplements. With this treatment the long‐term outcome for people with phenylketonuria is excellent but the diet is onerous. Sapropterin dihydrochloride, the cofactor for phenylalanine hydroxylase, could lower phenylalanine concentration significantly in phenylketonuria and might allow a relaxation of dietary restrictions. The review identified two trials of sapropterin dihydrochloride; one in children and adults with no restricted diet and one in just children whose diet was restricted. The trials used different doses of sapropterin dihydrochloride (10 mg/kg/day and 20 mg/kg/day). We could not combine any data due to different formats of presentation. We found evidence to show that some people with mild or moderate phenylketonuria can benefit from the use of sapropterin dihydrochloride in the short term; the concentration of blood phenylalanine was lowered after treatment in both trials. The trial with the higher dose also measured the outcome change in protein tolerance. It reported an increase in protein tolerance in response to sapropterin. There were no adverse effects associated with the use of sapropterin dihydrochloride in the short term. We found no evidence on the effects of long‐term treatment. We could not draw any conclusions on its benefits in severe phenylketonuria.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Somaraju, UR, Merrin, M", "articleTypes": [], "doi": "10.1002/14651858.CD008005.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.741Z" }, { "id": "72cd8bb5-d9df-49e7-9d3a-2d0acb15d49f", "pmid": "", "title": "Changes in Taste Perception, Eating Habits, and Other Behavioral Aspects Associated With the Use of GLP-1 Receptor Agonists in Patients Undergoing Weight Loss Treatment: A Retrospective Observational Study.", "imported": false, "abstract": "This observational retrospective study aims to evaluate changes in taste perception, eating habits, and behavioral aspects in adults treated with GLP-1 receptor agonists for weight loss. Participants include adults aged 18-60 receiving treatment at specialized nutrition centers in Italy. Data are collected from clinical records, dietary questionnaires, and metabolic assessments before and after at least 12 weeks of GLP-1 agonist treatment. The study's primary goal is to understand how these treatments affect food preferences and taste perception. Secondary outcomes include changes in body weight, body composition, gastrointestinal side effects, and treatment adherence. All data are anonymized and collected according to ethical guidelines.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "72ce6c66-8873-499d-a0b9-4eface6d44d5", "pmid": "", "title": "Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women", "imported": false, "abstract": "Abstract - Background Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions, particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia. However, its long‐term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teeth staining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation for preventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent. Objectives To assess the effects of intermittent oral iron supplementation, alone or in combination with other nutrients, on anaemia and its associated impairments among menstruating women, compared with no intervention, a placebo, or daily supplementation. Search methods In February 2018, we searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers. In March 2018, we also searched LILACS, IBECS and IMBIOMED. In addition, we examined reference lists, and contacted authors and known experts to identify additional studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs with either individual or cluster randomisation. Participants were menstruating women; that is, women beyond menarche and prior to menopause who were not pregnant or lactating and did not have a known condition that impeded the presence of menstrual periods. The intervention was the use of iron supplements intermittently (one, two or three times a week on non‐consecutive days) compared with placebo, no intervention, or the same supplements provided on a daily basis. Data collection and analysis Both review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy, assessed the risk of bias of the included studies, and rated the quality of the evidence using GRADE. Main results We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessing risk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one third of the included studies did not provide a funding source. Although quality across studies was variable, the results consistently showed that intermittent iron supplementation (alone or with any other vitamins and minerals) compared with no intervention or a placebo, reduced the risk of having anaemia (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.49 to 0.87; 11 studies, 3135 participants; low‐quality evidence), and improved the concentration of haemoglobin (mean difference (MD) 5.19 g/L, 95% CI 3.07 to 7.32; 15 studies, 2886 participants; moderate‐quality evidence), and ferritin (MD 7.46 μg/L, 95% CI 5.02 to 9.90; 7 studies, 1067 participants; low‐quality evidence). Intermittent regimens may also reduce the risk of having iron deficiency (RR 0.50, 95% CI 0.24 to 1.04; 3 studies, 624 participants; low‐quality evidence), but evidence was inconclusive regarding iron deficiency anaemia (RR 0.07, 95% CI 0.00 to 1.16; 1 study, 97 participants; very low‐quality evidence) and all‐cause morbidity (RR 1.12, 95% CI 0.82 to 1.52; 1 study, 119 participants; very low‐quality evidence). Women in the control group were less likely to have any adverse side effects than those receiving intermittent iron supplements (RR 1.98, 95% CI 0.31 to 12.72; 3 studies, 630 participants; moderate‐quality evidence). In comparison with daily supplementation, results showed that intermittent supplementation (alone or with any other vitamins and minerals) produced similar effects to daily supplementation (alone or with any other vitamins and minerals) on anaemia (RR 1.09, 95% CI 0.93 to 1.29; 8 studies, 1749 participants; moderate‐quality evidence). Intermittent supplementation may produce similar haemoglobin concentrations (MD 0.43 g/L, 95% CI −1.44 to 2.31; 10 studies, 2127 participants; low‐quality evidence) but lower ferritin concentrations on average (MD −6.07 μg/L, 95% CI −10.66 to −1.48; 4 studies, 988 participants; low‐quality evidence) compared to daily supplementation. Compared to daily regimens, intermittent regimens may also reduce the risk of having iron deficiency (RR 4.30, 95% CI 0.56 to 33.20; 1 study, 198 participants; very low‐quality evidence). Women receiving iron supplements intermittently were less likely to have any adverse side effects than those receiving iron supplements daily (RR 0.41, 95% CI 0.21 to 0.82; 6 studies, 1166 participants; moderate‐quality evidence). No studies reported on the effect of intermittent regimens versus daily regimens on iron deficiency anaemia and all‐cause morbidity. Information on disease outcomes, adherence, economic productivity, and work performance was scarce, and evidence about the effects of intermittent supplementation on these outcomes unclear. Overall, whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline did not seem to affect the findings. Furthermore, the response did not differ in areas where malaria was frequent, although very few trials were conducted in these settings. Authors' conclusions Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations with different anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittently is probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base ranged from very low to moderate quality, suggesting that we are uncertain about these effects. Plain language summary Iron supplements taken one, two or three times a week for preventing anaemia, and its consequences in menstruating women What is the issue? Across the globe, approximately one out of three non‐pregnant women of reproductive age are anaemic; i.e. have fewer red blood cells or less haemoglobin (a red substance that combines with oxygen and carries it around the body) in each red blood cell than normal. Although there are several causes of anaemia, it very often results from sustained iron deficiency. The standard practice to prevent or treat anaemia in women has been daily iron supplementation (sometimes combined with folic acid and other vitamins and minerals) for three months. However, it is frequently associated with side effects such as nausea or constipation. Intermittent supplementation (that is, the consumption of supplements one, two or three times a week on non‐consecutive days) has been proposed as an effective and safer alternative to daily supplementation. Why is this important? Women with anaemia may have less energy for physical work and become more prone to infections. Most women throughout the world enter pregnancy with anaemia, putting them at greater risk of having low birth‐weight babies and other complications during delivery. Some scientists believe that taking iron a few times a week – instead of every day – can help women with anaemia to feel better and improve their haemoglobin without giving them as many side effects. If women have fewer side effects, they may be more likely to take iron supplements more regularly and for longer periods. What evidence did we find? We reviewed the evidence in February 2018. We included 25 randomised controlled trials (a type of experiment in which participants are randomly assigned to one or more treatment groups) involving 10,996 women. We included studies examining the administration of intermittent iron supplements versus no intervention, a placebo (dummy pill) or the same supplements given on a daily basis. Most studies were implemented in school settings and were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one‐third of the included studies did not provide a funding source. The findings show that women receiving intermittent supplementation with iron alone, or in combination with folic acid or other nutrients, were less likely to be anaemic or iron deficient than those women who received no iron supplements or a placebo. They also had higher concentrations of haemoglobin and ferritin (a protein that carries iron) but reported more side effects. In addition, the findings indicate that intermittent supplementation was as effective as daily supplementation in reducing the prevalence of anaemia and increasing haemoglobin concentrations, with fewer side effects. It may have reduced the risk of having iron deficiency also, but it had no effect on raising ferritin concentrations more than the daily dose. We found scarce evidence on the effect of intermittent supplementation compared to placebo or daily supplementation on iron deficiency anaemia, all‐cause morbidity, disease outcomes, adherence, economic productivity, and work performance. What does this mean? Intermittent iron supplementation in menstruating women may be an effective intervention for reducing anaemia and improving haemoglobin concentrations compared to no treatment, placebo or daily supplementation. Intermittent supplementation may be associated with fewer side effects compared to daily supplementation. The findings were not affected by whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline (starting point for comparisons). The evidence base was of overall low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fernández-Gaxiola, AC, De-Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD009218.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.809Z" }, { "id": "72e5a0f6-4fee-4f4b-859c-83b11684da28", "pmid": "", "title": "Chlorambucil for patients with primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. But it is unknown whether it benefits or harms these patients. Objectives To evaluate the beneficial and any harmful effects of chlorambucil for primary biliary cirrhosis patients. Search methods Eligible trials were identified by searching the Cochrane Hepato‐Biliary Group Controlled Trials Register (March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2012, Issue 2), MEDLINE (1946 to March 2012), EMBASE (1974 to March 2012), Science Citation Index EXPANDED (1900 to March 2012), The Chinese Biomedical Database (1976 to March 2012), The Chinese Medical Current Contents (1994 to March 2012), The China Hospital Knowledge Database (1994 to March 2012), and a database of ongoing trials (http://www.controlled‐trials.com/mrct/) (accessed 6 March 2012). The reference lists of the retrieved publications and review articles were also read through, and pharmaceutical companies known to produce chlorambucil were contacted. Selection criteria Randomised clinical trials, irrespective of language, year of publication, and publication status, comparing chlorambucil at any dose versus placebo, no intervention, another active drug, or one dose of chlorambucil with another dose. Data collection and analysis We planned to assess continuous data with mean differences (MD), and dichotomous outcomes with relative risk (RR), both with 95% confidence intervals (CI). As we only identified one trial, Fisher's exact tests were employed. Main results Only one randomised trial was identified and included in the review. The bias risk in the trial was high. The trial compared chlorambucil versus no intervention in 24 patients with primary biliary cirrhosis. Fisher's exact test did not show a significant reduction of mortality when comparing chlorambucil with no treatment (0/13 (0%) versus (2/11 (18.2%); P = 0.20). There was no significant difference regarding adverse events for chlorambucil compared with no treatment, but all patients receiving chlorambucil experienced adverse events (13/13 (100%) versus (3/11 (27%); P = 0.1). According to the authors of the trial, chlorambucil led to a significant improvement in mean serum levels of bilirubin (P < 0.05), albumin (P < 0.05), immunoglobulin M (P < 0.01), serum aspartate aminotransferase activity (P < 0.01), and hepatic inflammatory infiltrates (P < 0.01). Authors' conclusions There is not sufficient evidence to support or reject the use of chlorambucil for patients with primary biliary cirrhosis. Chlorambucil may show benefit in some unvalidated surrogate outcome measures (for example, serum bilirubin and immunoglobulin M levels). Chlorambucil is, however, connected with a number of adverse events. Bone marrow suppression should be noted in particular. Further randomised clinical trials are necessary to assess the benefits and harms of chlorambucil in this indication. Plain language summary Chlorambucil for patients with primary biliary cirrhosis Primary biliary cirrhosis is an autoimmune disease of the liver. Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. This review aimed to assess the beneficial or harmful effects of chlorambucil for primary biliary cirrhosis. The authors identified only one randomised trial, with 24 participants included. This trial compared chlorambucil with no intervention. The trial is small and at a high risk of bias, which suggests that the results may not be reliable. Meta‐analyses were not possible because of the inclusion of one trial only. Fisher's exact test and t‐test were used instead. Chlorambucil was not associated with significantly lower mortality when compared with no intervention. All patients on chlorambucil experienced adverse events, especially bone marrow suppression. Chlorambucil led to a significant improvement in mean serum levels of bilirubin, albumin, immunoglobulin M, serum aspartate aminotransferase activity, and hepatic inflammatory infiltrates. However, these outcomes are unvalidated surrogate outcomes for patient‐relevant outcomes. This means that improvement of these biochemistry measures cannot be taken as proof of improvement of patient‐relevant outcomes. It remains unclear whether chlorambucil can be supported or rejected for use in patients with primary biliary cirrhosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Li, WX; Yan, X; Shi, CR; Zhang, AP", "articleTypes": [], "doi": "10.1002/14651858.CD008714.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "72e835b8-6a3e-4728-8512-1244d53dbc69", "pmid": "", "title": "The Impact of Multivitamin Supplementation on Micronutrient Levels in GLP-1 Users: A Randomized, Double-Blind, Placebo-Controlled Trial", "imported": false, "abstract": "Rationale: Glucagon-Like Peptide-1 (GLP-1) receptor agonists have emerged as effective treatments for obesity and associated medical conditions. However, patients may be at risk of micronutrient deficiencies during therapy due to reduced appetite, altered gastrointestinal physiology, and weight loss. Multivitamin supplementation is commonly prescribed to mitigate these risks, but the necessity and efficacy of multivitamin use in GLP-1 users remain debatable, as some clinicians advocate for routine supplementation while others do not.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.152Z" }, { "id": "72f50f89-0701-4781-aeb3-24b3d09c56da", "pmid": "", "title": "Oral treatments for fungal infections of the skin of the foot", "imported": false, "abstract": "Abstract - Background About 15% of the world population have fungal infections of the feet (tinea pedis or athlete's foot). There are many clinical presentations of tinea pedis, and most commonly, tinea pedis is seen between the toes (interdigital) and on the soles, heels, and sides of the foot (plantar). Plantar tinea pedis is known as moccasin foot. Once acquired, the infection can spread to other sites including the nails, which can be a source of re‐infection. Oral therapy is usually used for chronic conditions or when topical treatment has failed. Objectives To assess the effects of oral treatments for fungal infections of the skin of the foot (tinea pedis). Search methods For this update we searched the following databases to July 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library , MEDLINE (from 1946), EMBASE (from 1974), and CINAHL (from 1981). We checked the bibliographies of retrieved trials for further references to relevant trials, and we searched online trials registers. Selection criteria Randomised controlled trials of oral treatments in participants who have a clinically diagnosed tinea pedis, confirmed by microscopy and growth of dermatophytes (fungi) in culture. Data collection and analysis Two review authors independently undertook study selection, 'Risk of bias' assessment, and data extraction. Main results We included 15 trials, involving 1438 participants. The 2 trials (71 participants) comparing terbinafine and griseofulvin produced a pooled risk ratio (RR) of 2.26 (95% confidence interval (CI) 1.49 to 3.44) in favour of terbinafine's ability to cure infection. No significant difference was detected between terbinafine and itraconazole, fluconazole and itraconazole, fluconazole and ketoconazole, or between griseofulvin and ketoconazole, although the trials were generally small. Two trials showed that terbinafine and itraconazole were effective compared with placebo: terbinafine (31 participants, RR 24.54, 95% CI 1.57 to 384.32) and itraconazole (72 participants, RR 6.67, 95% CI 2.17 to 20.48). All drugs reported adverse effects, with gastrointestinal effects most commonly reported. Ten of the trials were published over 15 years ago, and this is reflected by the poor reporting of information from which to make a clear 'Risk of bias' assessment. Only one trial was at low risk of bias overall. The majority of the remaining trials were judged as 'unclear' risk of bias because of the lack of clear statements with respect to methods of generating the randomisation sequence and allocation concealment. More trials achieved blinding of participants and personnel than blinding of the outcome assessors, which was again poorly reported. Authors' conclusions The evidence suggests that terbinafine is more effective than griseofulvin, and terbinafine and itraconazole are more effective than no treatment. In order to produce more reliable data, a rigorous evaluation of different drug therapies needs to be undertaken with larger sample sizes to ensure they are large enough to show any real difference when two treatments are being compared. It is also important to continue to follow up and collect data, preferably for six months after the end of the intervention period, to establish whether or not the infection recurred. Plain language summary Oral antifungal drugs for treating athlete's foot (tinea pedis) Athlete's foot (tinea pedis) is a fungal infection of the feet that is easily spread and difficult to get rid of. This review compared different oral antifungal drugs (i.e. drugs taken by mouth), and it included 15 trials, involving 1438 participants. There are several different kinds of oral treatments, and the trials we found considered all the oral drugs used to treat athlete's foot. We found terbinafine and itraconazole to be more effective than placebo. And we found terbinafine to be more effective than griseofulvin. Griseofulvin is a treatment that was developed much earlier than the new treatments, such as terbinafine and itraconazole; these newer treatments tend to be most evaluated. Trials of other drugs were not large enough to show differences between them. All drugs had side‐effects; gastrointestinal effects were the most common. In future clinical trials, larger numbers of participants are needed to test different treatments in order to produce more reliable data. Also, future research should consider the costs of the different treatment approaches.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Bell‐Syer, SEM; Khan, SM; Torgerson, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD003584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "73027131-767f-47ef-8240-f975119bb783", "pmid": "", "title": "A Randomized, Double-Blind, Placebo-Controlled Phase III Clinical Trial of Pembrolizumab (MK-3475) in Combination With Cisplatin and 5-Fluorouracil Versus Placebo in Combination With Cisplatin and 5-Fluorouracil as First-Line Treatment in Subjects With Advanced/Metastatic Esophageal Carcinoma (KEYNOTE-590)", "imported": false, "abstract": "The purpose of this trial is to evaluate efficacy and safety of pembrolizumab plus standard of care (SOC) chemotherapy with cisplatin and 5-fluorouracil (5-FU) versus placebo plus SOC chemotherapy with cisplatin and 5-FU as first-line treatment in participants with locally advanced or metastatic esophageal carcinoma.", "journal": "", "year": "2017", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.269Z" }, { "id": "730c4f54-29fe-4bea-be70-c1a214a4daaa", "pmid": "", "title": "Laxatives for the management of constipation in people receiving palliative care", "imported": false, "abstract": "Abstract - Background This article describes the second update of a Cochrane review on the effectiveness of laxatives for the management of constipation in people receiving palliative care. Previous versions were published in 2006 and 2010 where we also evaluated trials of methylnaltrexone; these trials have been removed as they are included in another review in press. In these earlier versions, we drew no conclusions on individual effectiveness of different laxatives because of the limited number of evaluations. This is despite constipation being common in palliative care, generating considerable suffering due to the unpleasant physical symptoms and the availability of a wide range of laxatives with known differences in effect in other populations. Objectives To determine the effectiveness and differential efficacy of laxatives used to manage constipation in people receiving palliative care. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library ), MEDLINE, EMBASE, CINAHL and Web of Science (SCI & CPCI‐S) for trials to September 2014. Selection criteria Randomised controlled trials (RCTs) evaluating laxatives for constipation in people receiving palliative care. Data collection and analysis Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity. Main results We identified five studies involving the laxatives lactulose, senna, co‐danthramer, misrakasneham, docusate and magnesium hydroxide with liquid paraffin. Overall, the study findings were at an unclear risk of bias. As all five studies compared different laxatives or combinations of laxatives, it was not possible to perform a meta‐analysis. There was no evidence on whether individual laxatives were more effective than others or caused fewer adverse effects. Authors' conclusions This second update found that laxatives were of similar effectiveness but the evidence remains limited due to insufficient data from a few small RCTs. None of the studies evaluated polyethylene glycol or any intervention given rectally. There is a need for more trials to evaluate the effectiveness of laxatives in palliative care populations. Extrapolating findings on the effectiveness of laxatives evaluated in other populations should proceed with caution. This is because of the differences inherent in people receiving palliative care that may impact, in a likely negative way, on the effect of a laxative. Plain language summary Laxatives for the management of constipation in people receiving palliative care Background People with an incurable illness may receive palliative care, which involves making the person as comfortable as possible by controlling pain and other distressing symptoms. People receiving palliative care commonly experience constipation. This is as a result of the use of medicines (e.g. morphine) for pain control, as well as disease, dietary and mobility factors. There is a wide range of laxatives available. The aim of this review was to determine what we know about the effectiveness of laxatives for the management of constipation in people receiving palliative care. Study characteristics We searched medical databases for clinical trials of the use of laxatives for constipation in people receiving palliative care. Two review authors assessed study quality and extracted data. Key results and quality of evidence We identified five studies involving 370 people. The laxatives evaluated were lactulose, senna, co‐danthramer combined with poloxamer, docusate and magnesium hydroxide combined with liquid paraffin. Misrakasneham was also evaluated; this is a traditional Indian medicine and is used as a laxative, containing castor oil, ghee, milk and 21 types of herbs. There was no evidence on which laxative provided the best treatment. However, the review was limited as the evidence was from only five small trials and patient preference and cost were under evaluated. Further rigorous, independent trials are needed to evaluate the effectiveness of laxatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Candy, B; Jones, L; Larkin, PJ; Vickerstaff, V; Tookman, A; Stone, P", "articleTypes": [], "doi": "10.1002/14651858.CD003448.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "731febbb-1554-4677-9830-39201be2bbc8", "pmid": "", "title": "Open versus closed surgical exposure of canine teeth that are displaced in the roof of the mouth", "imported": false, "abstract": "Abstract - Background Palatally displaced canines or PDCs are upper permanent canines, commonly known as 'eye' teeth, that are displaced in the roof of the mouth. This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. PDCs are a frequent dental anomaly, present in 2% to 3% of young people. Management of this problem is both time consuming and expensive. It involves surgical exposure (uncovering) followed by fixed braces for two to three years to bring the canine into alignment within the dental arch. Two techniques for exposing palatal canines are routinely used in the UK: the closed technique and the open technique. The closed technique involves uncovering the canine, attaching an eyelet and gold chain and then suturing the palatal mucosa back over the tooth. The tooth is then moved into position covered by the palatal mucosa. The open technique involves uncovering the canine tooth and removing the overlying palatal tissue to leave it uncovered. The orthodontist can then see the crown of the canine to align it. Objectives To assess the effects of using either an open or closed surgical method to expose canines that have become displaced in the roof of the mouth, in terms of success and other clinical and patient‐reported outcomes. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 24 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (in the Cochrane Library, 2017, Issue 1), MEDLINE Ovid (1946 to 24 February 2017), and Embase Ovid (1980 to 24 February 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised and quasi‐randomised controlled trials assessing young people receiving surgical treatment to correct upper PDCs. There was no restriction on age, presenting malocclusion or type of active orthodontic treatment undertaken. We included unilaterally and bilaterally displaced canines. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias in the included studies. We attempted to contact study authors for missing data or clarification where feasible. We followed statistical guidelines from the Cochrane Handbook for Systematic Reviews of Interventions for data synthesis. Main results We included three studies, involving 146 participants. Two studies were assessed as being at high risk of bias. The main finding of the review was that the two techniques may be equally successful at exposing PDCs (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.93 to 1.06; three studies, 141 participants analysed, low‐quality evidence). One surgical failure was due to detachment of the gold chain (closed group). One study reported on complications following surgery and found two in the closed group: a post‐operative infection requiring antibiotics and pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to pool data for dental aesthetics, patient‐reported pain and discomfort, periodontal health and treatment time; however, individual studies did not find any differences between the surgical techniques (low‐ to very low‐quality evidence). Authors' conclusions Currently, the evidence suggests that neither the open or closed surgical technique for exposing palatally displaced maxillary canine teeth is superior for any of the outcomes included in this review; however, we considered the evidence to be low quality, with two of the three included studies being at high risk of bias. This suggests the need for more high‐quality studies. Three ongoing clinical trials have been identified and it is hoped that these will produce data that can be pooled to increase the degree of certainty in these findings. Plain language summary Open versus closed surgical exposure of eye teeth that are displaced in the roof of the mouth Review question Is it better to use an open or closed surgical method to expose eye teeth ('canines') that have become displaced in the roof of the mouth? Background Permanent canine teeth in the upper jaw usually erupt into the mouth between the ages of 11 to 12 years. In 2% to 3% of young people, the canine teeth fail to erupt (grow down) and become displaced in the roof of the mouth (palate).This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. Management of this problem is both time consuming and expensive. It usually involves surgical exposure (uncovering), followed by fixed orthodontic braces for two to three years, to move the canine into the correct position. Two surgical techniques are routinely used in the UK: the closed technique involves uncovering the buried tooth, gluing an attachment onto the exposed tooth and repositioning the palatal flap. Shortly after surgery, an orthodontic brace is used to apply gentle forces to bring the canine into its correct position within the dental arch. The canine moves into position beneath the gum. An alternative method is the open technique, which involves surgically uncovering the canine tooth as before, but instead of placing an attachment onto the exposed tooth, a window of gum from around the tooth is removed and a dressing (pack) placed to cover the exposed area. Approximately 10 days later, this pack is removed and the canine is allowed to erupt naturally. Once the tooth has erupted sufficiently for an orthodontic attachment to be glued onto its surface, orthodontic braces are used to bring the tooth in line with the other teeth. Study characteristics The evidence in this review is up‐to‐date as of February 2017. Authors with Cochrane Oral Health found three relevant studies, involving 146 participants who had eye teeth displaced in the roof of the mouth, either on one or both sides. The majority of participants were female and the average age in the studies ranged from 14 to 17 years. Two studies were designed in a way that made them likely to be biased. Key results We combined results from three studies and found that one technique did not seem to have an advantage over the other for ensuring the movement of the tooth into the correct position without the need for repeat surgery. Five out of 141 participants analysed were surgical failures, one of which was due to the complication of detachment of the gold chain during surgery. One study reported complications after surgery and found one participant in the closed group had a post‐operative infection requiring antibiotics and another participant in the closed group experienced pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to combine results from studies for any other outcomes, but individual studies did not show evidence of a difference between the two techniques for pain, discomfort, appearance, gum health, length of treatment time or cost (low to very low quality evidence). Quality of the evidence Overall, we assessed the quality of the evidence as low, which means we cannot be certain of the findings. Author conclusions It does not seem that one surgical technique is better than the other for moving displaced eye teeth into the correct position, or for other outcomes, but this finding is uncertain because the quality of the evidence is low. This suggests the need for more high‐quality studies. Three studies are currently in process. When they are completed, we will include them in an update of this review and may be able to reach firmer conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Parkin, N; Benson, PE; Thind, B; Shah, A; Khalil, I; Ghafoor, S", "articleTypes": [], "doi": "10.1002/14651858.CD006966.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "733e710e-1712-43c9-9eac-07309ab0354e", "pmid": "", "title": "A Double-Blind, Placebo-Controlled, Randomized, Phase Ib/IIa Clinical Study of ApTOLL for the Treatment of Acute Ischemic Stroke", "imported": false, "abstract": "This is a prospective, multicenter, double-blind, randomized, placebo-controlled, Phase Ib/IIa clinical study to assess the administration of ApTOLL together with endovascular therapy in acute ischemic stroke patients who are candidates to receive reperfusion therapies.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.264Z" }, { "id": "734c9966-693b-40ad-b6b2-8aadee58a583", "pmid": "", "title": "Chinese medicinal herbs for asymptomatic carriers of hepatitis B virus infection", "imported": false, "abstract": "Abstract - Background About 350 million people are chronically infected carriers of hepatitis B virus and are at a higher risk of serious illness and death from cirrhosis of the liver and liver cancer. Chinese medicinal herbs have been used widely for more than 2000 years to treat chronic liver disease. Objectives To assess whether Chinese medicinal herbs are effective and safe for treating asymptomatic carriers of hepatitis B virus. Search methods The trials registers of The Cochrane Hepato‐Biliary Group , The Cochrane Library , and The Cochrane Complementary Medicine Field were searched in combination with MEDLINE , EMBASE , and handsearches of Chinese journals and conference proceedings (October 2000). Selection criteria Randomised or quasi‐randomised trials (minimum follow‐up three months) in asymptomatic carriers of hepatitis B virus. Chinese medicinal herbs (single herb or compound of herbs) compared with placebo, no intervention, general non‐specific treatment, or interferon treatment. Trials of Chinese medicinal herbs plus interferon versus interferon alone were also included. Data collection and analysis Data were extracted independently by two authors. Analysis was performed by intention‐to‐treat where possible. Pre‐specified subgroup analyses were: ethnic origin, age at time of infection, and single herb or compound of herbs. Main results Three randomised clinical trials (307 patients) that followed patients for three months or more after the end of treatment were included. The methodological quality was poor. The herbal compound 'Jianpi Wenshen recipe' had significant effects on viral markers compared to interferon: relative risk 2.40 (95% CI 1.01 to 5.72) for clearance of serum HBsAg, 2.03 (95% CI 0.98 to 4.20) for clearance of HBeAg, and 2.54 (95% CI 1.13 to 5.70) for seroconversion of HBeAg to anti‐HBe. Phyllanthus amarus and Astragalus membranaceus showed no significant antiviral effect compared with placebo. Analysis of pooling eight randomised clinical trials with less than three months follow‐up did not show a significant benefit of Chinese medicinal herbs on viral markers. Data on long‐term clinical outcomes and quality of life were lacking. Authors' conclusions Based on one low quality trial, the medicinal herb 'Jianpi Wenshen recipe' may have an antiviral activity in asymptomatic carriers of hepatitis B virus. However, rigorous randomised, double‐blind, placebo‐controlled trials are needed before herbs should be used for this condition. Plain language summary Firm evidence for effect of Chinese medicinal herbs for asymptomatic hepatitis B virus carriers is still awaited Chinese medicinal herbs have a long history in the treatment of liver diseases. Three randomised clinical trials were included. Due to their poor methodologic quality and the existing small number of trials, there is currently insufficient evidence for treating asymptomatic hepatitis B virus carriers with Chinese medicinal herbs like the herbal compound 'Jianpi Wenshen recipe', Phyllanthus amarus and Astragalus membranaceus. Methodologically better and larger randomised trials are needed comparing medicinal herbs versus placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Liu, JP, McIntosh, H, Lin, H", "articleTypes": [], "doi": "10.1002/14651858.CD002231", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.753Z" }, { "id": "736291e4-ecf6-4fe3-91c1-9a8cd80a39fc", "pmid": "", "title": "The Role of Bitter Taste Receptors Expressed in the Gastrointestinal Tract in Altering Food Intake and Gastrointestinal Motility", "imported": false, "abstract": "In this study, the investigators aimed at evaluating the role of bitter taste receptors in the gastrointestinal tract (GIT). Intragastric or intraduodenal administration of denatonium benzoate (DB) or quinine hydrochloride were compared with placebo administration for their effects on lingual sensitivity, gastrointestinal motility (both in the fasted and fed state), gut hormone release (motilin, ghrelin, glucagon-like peptide-1 (GLP-1) and cholecystokinin (CCK)) and food intake. Differences between lean and obese subjects will be evaluated.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.144Z" }, { "id": "7395bfe5-29d3-40d1-b8f8-9545b360ea4d", "pmid": "", "title": "Population‐level interventions in government jurisdictions for dietary sodium reduction", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McLaren, L, Sumar, N, Barberio, AM, Trieu, K, Lorenzetti, DL, Tarasuk, V, Webster, J, Campbell, NRC", "articleTypes": [], "doi": "10.1002/14651858.CD010166.pub2 AB - Abstract - Background Excess dietary sodium consumption is a risk factor for high blood pressure, stroke and cardiovascular disease. Currently, dietary sodium consumption in almost every country is too high. Excess sodium intake is associated with high blood pressure, which is common and costly and accounts for significant burden of disease. A large number of jurisdictions worldwide have implemented population‐level dietary sodium reduction initiatives. No systematic review has examined the impact of these initiatives. Objectives • To assess the impact of population‐level interventions for dietary sodium reduction in government jurisdictions worldwide. • To assess the differential impact of those initiatives by social and economic indicators. Search methods We searched the following electronic databases from their start date to 5 January 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); Cochrane Public Health Group Specialised Register; MEDLINE; MEDLINE In Process & Other Non‐Indexed Citations; EMBASE; Effective Public Health Practice Project Database; Web of Science; Trials Register of Promoting Health Interventions (TRoPHI) databases; and Latin American Caribbean Health Sciences Literature (LILACS). We also searched grey literature, other national sources and references of included studies. This review was conducted in parallel with a comprehensive review of national sodium reduction efforts under way worldwide ( Trieu 2015 ), through which we gained additional information directly from country contacts. We imposed no restrictions on language or publication status. Selection criteria We included population‐level initiatives (i.e. interventions that target whole populations, in this case, government jurisdictions, worldwide) for dietary sodium reduction, with at least one pre‐intervention data point and at least one post‐intervention data point of comparable jurisdiction. We included populations of all ages and the following types of study designs: cluster‐randomised, controlled pre‐post, interrupted time series and uncontrolled pre‐post. We contacted study authors at different points in the review to ask for missing information. Data collection and analysis Two review authors extracted data, and two review authors assessed risk of bias for each included initiative. We analysed the impact of initiatives by using estimates of sodium consumption from dietary surveys or urine samples. All estimates were converted to a common metric: salt intake in grams per day. We analysed impact by computing the mean change in salt intake (grams per day) from pre‐intervention to post‐intervention. Main results We reviewed a total of 881 full‐text documents. From these, we identified 15 national initiatives, including more than 260,000 people, that met the inclusion criteria. None of the initiatives were provided in lower‐middle‐income or low‐income countries. All initiatives except one used an uncontrolled pre‐post study design. Because of high levels of study heterogeneity (I 2 > 90%), we focused on individual initiatives rather than on pooled results. Ten initiatives provided sufficient data for quantitative analysis of impact (64,798 participants). As required by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) method, we graded the evidence as very low due to the risk of bias of the included studies, as well as variation in the direction and size of effect across the studies. Five of these showed mean decreases in average daily salt intake per person from pre‐intervention to post‐intervention, ranging from 1.15 grams/day less (Finland) to 0.35 grams/day less (Ireland). Two initiatives showed mean increase in salt intake from pre‐intervention to post‐intervention: Canada (1.66) and Switzerland (0.80 grams/day more per person); however in both countries the pre‐intervention data point was from several years prior to the initiation of the intervention. The remaining initiatives did not show a statistically significant mean change. Seven of the 10 initiatives were multi‐component and incorporated intervention activities of a structural nature (e.g. food product reformulation, food procurement policy in specific settings). Of those seven initiatives, four showed a statistically significant mean decrease in salt intake from pre‐intervention to post‐intervention, ranging from Finland to Ireland (see above), and one showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention (Switzerland; see above). Nine initiatives permitted quantitative analysis of differential impact by sex (men and women separately). For women, three initiatives (China, Finland, France) showed a statistically significant mean decrease, four (Austria, Netherlands, Switzerland, United Kingdom) showed no significant change and two (Canada, United States) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. For men, five initiatives (Austria, China, Finland, France, United Kingdom) showed a statistically significant mean decrease, three (Netherlands, Switzerland, United States) showed no significant change and one (Canada) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. Information was insufficient to indicate whether a differential change in mean salt intake occurred from pre‐intervention to post‐intervention by other axes of equity included in the PROGRESS framework (e.g. education, place of residence). We identified no adverse effects of these initiatives. The number of initiatives was insufficient to permit other subgroup analyses, including stratification by intervention type, economic status of country and duration (or start year) of the initiative. Many studies had methodological strengths, including large, nationally representative samples of the population and rigorous measurement of dietary sodium intake. However, all studies were scored as having high risk of bias, reflecting the observational nature of the research and the use of an uncontrolled study design. The quality of evidence for the main outcome was low. We could perform a sensitivity analysis only for impact. Authors' conclusions Population‐level interventions in government jurisdictions for dietary sodium reduction have the potential to result in population‐wide reductions in salt intake from pre‐intervention to post‐intervention, particularly if they are multi‐component (more than one intervention activity) and incorporate intervention activities of a structural nature (e.g. food product reformulation), and particularly amongst men. Heterogeneity across studies was significant, reflecting different contexts (population and setting) and initiative characteristics. Implementation of future initiatives should embed more effective means of evaluation to help us better understand the variation in the effects. Plain language summary National government initiatives to reduce salt intake in populations The problem 
 In almost all countries worldwide, most people eat too much salt. This is a problem because eating too much salt can cause high blood pressure, which can lead to health problems such as heart disease and stroke. To reduce the amount of salt eaten, governments in many countries have developed national salt reduction initiatives. The review question 
 Our aim was to examine whether national salt reduction initiatives have been effective in reducing the amount of salt consumed in those populations. Study characteristics 
 We searched research papers and government reports and had direct communication with individuals working in salt reduction in their respective countries. The evidence is current as of 5 January 2015, when we last searched electronic databases. Initiatives in 15 countries met the inclusion criteria. Ten of these countries provided sufficient data for quantitative analysis, gathered from studies that included 64,798 participants. Initiatives ranged from one activity (e.g. in Japan, which at the time of writing had a public information campaign) to many activities (e.g. in the United Kingdom, which provided five activities including on‐package nutrition information, restrictions on marketing to children and food product reformulation). Of the 15 countries that met inclusion criteria, seven provided information about funding source, of which six reported non‐industry funding. The other eight countries did not report a funding source for one or more data point(s). Key results and quality of the evidence 
 Five of the 10 countries included in the quantitative analysis (China, Finland, France, Ireland and England) showed a decrease in salt intake after the intervention. Two of the 10 countries (Canada, Switzerland) showed an increase in salt intake after the intervention, however, in both countries the only data available were from several years prior to the intervention starting. Because the initiatives were very different, we cannot present an overall finding of whether these types of initiatives work. When we focused on the subset of seven countries whose salt reduction initiatives included multiple components and were not focused solely on educating the public, we found that more than half (four of seven) showed a decrease in salt intake from pre‐intervention to post‐intervention. When we examined the nine initiatives that analysed men and women separately, we found that amongst men, more than half (five of nine) showed a decrease in salt intake after the intervention. Amongst women, the pattern of findings was less clear, with three of nine interventions showing a decrease, two showing an increase and four showing no change in salt intake. Low‐bias study designs, such as randomised controlled trials, typically are not suitable for evaluating complex initiatives such as these; therefore, we rated all of the studies included in this review as having low methodological quality. Large nationally representative samples of the population and careful measurement of dietary sodium intake were strengths of several studies. However, because of study design limitations, the trustworthiness of study results is not clear. Overall, our results show that national government initiatives have the potential to achieve population‐wide reductions in salt intake, especially amongst men, and particularly if they employ more than one strategy and include structural activities such as food product reformulation (i.e. food companies putting less salt in food products). The wide variation of results across the studies we found presents a challenge in interpreting the current evidence and this warrants more research to help us understand this.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.787Z" }, { "id": "739f2676-85db-42b0-8d94-ef6bfed9a1c7", "pmid": "", "title": "Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants", "imported": false, "abstract": "Abstract - Background It is important to institute an effective supportive therapy to maintain or recover soft tissue health around dental implants. Different maintenance regimens have been suggested, however it is unclear which are the most effective. Objectives To assess the effects of different interventions for 1) maintaining and 2) recovering soft tissue health around osseointegrated dental implants. Search methods We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and to an Internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 2 June 2010. Selection criteria All randomised controlled trials comparing agents or interventions for maintaining or recovering healthy tissues around dental implants. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random‐effects models using standardised mean differences for continuous data and risk ratios for dichotomous data with 95% confidence intervals. Main results Five trials compared interventions for maintaining soft tissue health around implants and a further six trials compared interventions to recover soft tissue health where there was evidence of peri‐implant mucositis. No statistically significant differences were found between the effectiveness of powered versus manual toothbrushes for either maintaining or recovering soft tissue health. There was no statistically significant difference found between different types of self administered antimicrobials for maintaining soft tissue health (hyaluronic acid gel compared to chlorhexidine gel, amine fluoride/stannous fluoride mouthwash compared to chlorhexidine mouthwash) and triclosan dentifrice compared to sodium fluoride dentifrice showed no statistically significant difference in recovering soft tissue health. However chlorhexidine irrigation was more effective in reducing plaque and marginal bleeding scores compared to chlorhexidine mouthwash and Listerine mouthwash was found to be statistically significantly better than placebo with regard to reducing mean plaque scores and marginal bleeding scores. When interventions administered by dental professional were compared there was no statistically significant difference found between chlorhexidine and physiologic solutions as irrigants at second stage surgery to maintain health of soft tissues. In patients with peri‐implant mucositis two trials evaluated interventions performed by dental professionals. There was no statistically significant difference between mechanical debridement followed by either minocycline or chlorhexidine gel, or between debridement with a titanium curette compared to an ultrasonic debridement tool. Authors' conclusions There was only low quality evidence for which are the most effective interventions for maintaining or recovering health of peri‐implant soft tissues. The included RCTs had short follow‐up periods and few subjects and although overall the risk of bias of the studies was either low or unclear, only single trials were available for each outcome. There was no reliable evidence as to which regimens are most effective for long term maintenance. This should not be interpreted as meaning that current maintenance regimens are ineffective. There was weak evidence that antibacterial mouthrinses are effective in reducing plaque and marginal bleeding around implants. More RCTs should be conducted in this area. In particular, there is a definite need for trials powered to find possible differences, using primary outcome measures and with much longer follow up. Such trials should be reported according to the CONSORT guidelines ( www.consort‐statement.org/ ). Plain language summary Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants Missing teeth can be replaced by dental implants. However, keeping the gums around the implants healthy is important, as they can be negatively affected by dental plaque and its induced inflammation. Prevention of this may include daily implant cleaning techniques by patients and regular cleaning by dental professionals. Antibacterial mouthrinses may help reduce plaque and bleeding around dental implants, but there is no evidence that powered toothbrushes are better than manual toothbrushes or that brushing with a certain gel or dentifrice is better than another. Among the professionally administered treatments there is no evidence that phosphoric acid is more effective than scaling and polishing, that chlorhexidine enclosed in the inner part of implants is superior to physiologic solution or that a topical antibiotic inserted submucosally is better than a chlorhexidine gel.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Grusovin, MG; Coulthard, P; Worthington, HV; George, P; Esposito, M", "articleTypes": [], "doi": "10.1002/14651858.CD003069.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "739faee7-381e-4ac5-b739-e5f86eadd6c6", "pmid": "", "title": "Probiotics for the prevention of Clostridioides difficile‐associated diarrhea in adults and children", "imported": false, "abstract": "Abstract - Rationale Antibiotics can disturb gastrointestinal microbiota, which may lead to reduced resistance to pathogens such as Clostridioides difficile . Probiotics are live microbial preparations that, when administered in adequate amounts, may confer a health benefit to the host, and are a potential C difficile infection prevention strategy. Objectives To assess the benefits and harms of probiotics for preventing C difficile ‐associated diarrhea (CDAD) in adults and children receiving an antibiotic for any reason. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, and Ovid Embase from 18 March 2017 (search date of the previous version of the review) to 3 March 2025. Eligibility criteria We included randomized controlled trials with a placebo, alternative prophylaxis, or no‐treatment control investigating probiotics (any strain or dose) for the prevention of CDAD in adults and children receiving an antibiotic for any reason. Outcomes The critical outcome was incidence of CDAD. Important outcomes included detection of C difficile in stool (i.e. colonization in absence of symptoms), adverse events, antibiotic‐associated diarrhea (AAD), and length of hospital stay. Risk of bias Two review authors independently assessed risk of bias using Cochrane's RoB 1 tool. Synthesis methods We pooled dichotomous outcomes (e.g . incidence of CDAD) using a random‐effects complete‐case model to calculate the risk ratio (RR) and absolute risk reduction (ARR) and corresponding 95% confidence interval (95% CI). We pooled continuous outcomes (e.g. length of hospital stay) using a random‐effects model to calculate the mean difference (MD) and corresponding 95% CI. We conducted sensitivity analyses to explore the impact of missing outcome data on benefits and harms outcomes. To investigate heterogeneity, we conducted a priori subgroup analyses on risk of bias, probiotic dose, probiotic species, adults versus children, inpatients versus outpatients, and the event rate in the control group for developing CDAD (low 0% to 2%; moderate 3% to 5%; high > 5%). The certainty of the evidence for each outcome was independently assessed using the GRADE approach. Included studies Eight new studies (n = 4595) met our inclusion criteria, for a total of 47 included studies (n = 15,260). Although we noted a high risk of bias in individual studies for sequence generation or allocation concealment, this did not impact our findings. Around 30% of studies lacked a published protocol or clinical trial registration, and in some cases there were inconsistencies between the reported methods and published results. We noted authors' affiliation with a probiotic company and financial support received from probiotic companies in 28 studies. Synthesis of results Evidence from 38 trials (13,179 participants) suggests that probiotics may result in a small absolute risk reduction (ARR) of 1.6% (incidence of 1.6% [110/6787] in the probiotic group versus 3.2% [203/6392] in the control group), and a relative risk reduction (RRR) of 50% (RR 0.50, 95% CI 0.38 to 0.64; P < 0.001; low‐certainty evidence) in incidence of CDAD. Twenty‐seven of 38 trials had missing CDAD data, ranging from 2% to 45%. Our complete‐case CDAD results proved robust to sensitivity analyses of plausible and worst‐plausible assumptions regarding missing outcome data. Pooled results from 16 trials (1302 participants) suggest that probiotics may result in a small absolute reduction in C difficile in stool (i.e. colonization in absence of symptoms) (ARR 2.1%; incidence of 14.9% [101/677] in the probiotic group versus 16.2% [101/625] in the control group; RR 0.87, 95% CI 0.68 to 1.11; P = 0.27; low‐certainty evidence). Thirty‐seven studies (11,911 participants) reported on adverse events. Our pooled analysis indicates that probiotics probably result in a small ARR of 1.7% (incidence of 10.9% [669/6148] in the probiotic group versus 12.2% [701/5763] in the control group), and an RRR of 14.0% (RR 0.86, 95% CI 0.72 to 1.01; P = 0.074; moderate‐certainty evidence). The most common adverse events in both the treatment and control groups were abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. Pooled results from 40 studies (13,419 participants) suggest that probiotics may result in a large ARR of 9% (incidence of 23% [1592/6901] in the probiotic group versus 27.4% [1787/6518] in the control group), and an RRR of 33% (RR 0.67, 95% CI 0.57 to 0.78; P < 0.001; low‐certainty evidence) in incidence of AAD. Only seven trials (6553 participants) investigated length of hospital stay. There is likely little to no difference in length of hospital stay between treatment and control groups (MD −0.07, 95% CI −0.35 to 0.21; P = 0.63; moderate‐certainty evidence). We downgraded the certainty of evidence for CDAD and AAD due to the low number of events or publication bias. We observed some variability in CDAD control group event rate (< 2% to > 5%) that may impact the applicability of evidence depending on clinical setting. We downgraded the certainty of evidence for adverse events due to variation between the results of the studies and for hospital stay due to selective reporting. Authors' conclusions The currently available evidence suggests that probiotics may be effective for preventing CDAD, suggesting that for every 65 people taking probiotics, one case of CDAD may be prevented (number needed to treat for an additional beneficial outcome of 65, 95% CI 48 to 97). There are probably fewer adverse events in the probiotic group. The short‐term use of probiotics may have a small absolute benefit, and is likely not associated with adverse effects when used in patient populations receiving systemic antibiotics who are not immunocompromised. Large trials comparing probiotics with placebo in people with a low baseline risk of CDAD are needed. Funding There was no source of funding for this update. Registration The original review was done in 2013 by Johnston and colleagues, for which the protocol was developed. We followed the methods specified in the 2017 review, while modifying the search strategy and risk of bias assessment for selective reporting for this update. Plain language summary What are the benefits and harms of probiotics for preventing Clostridioides difficile‐ associated diarrhea in adults and children receiving antibiotics for any reason? Key messages In people prescribed antibiotics, probiotics may be effective in preventing Clostridioides difficile ‐associated diarrhea (CDAD), and may reduce the risk of antibiotic‐associated diarrhea. Probiotics probably do not result in harm when taken with an antibiotic, with fewer mild to moderate unwanted effects in the group receiving probiotic than the group receiving placebo (dummy treatment) or no treatment. In those taking antibiotics who do not have a weakened immune system, the short‐term use of probiotics may offer a small benefit, and are likely not harmful. However, additional large studies comparing probiotics with placebo in people with a low risk of CDAD are needed. What is Clostridioides difficile ‐associated diarrhea (CDAD) ? Antibiotics are among the most prescribed medications worldwide. Antibiotic treatment may disturb the balance of organisms that normally populate the gut. This can result in a range of symptoms, most notably diarrhea. C difficile is a particularly dangerous organism that may colonize and infect the gut if the microbial balance has been disrupted. The effects of C difficile infection can vary, with some people having no symptoms, and others suffering diarrhea, severe inflammation, enlargement of the colon, or even death. The cost of treatment is expensive, and the financial burden on the medical system is substantial. What are probiotics? Probiotics are live microorganisms (bacteria or yeast) that provide health benefits when given in adequate amounts. They help to prevent potential disturbances to the gut microbial balance that are associated with antibiotic use, and to reduce the risk of growing harmful bacteria. Probiotics can be found in dietary supplements or yogurts and are widely available as capsules sold in health food stores and supermarkets. As 'functional food' or 'good bacteria,' probiotics have been suggested as a means of both preventing and treating CDAD. What did we want to find out? We wanted to know if probiotics prevent CDAD in adults and children receiving antibiotic therapy, and whether probiotics cause any unwanted effects. The researchers searched the medical literature extensively up to 3 March 2025. What did we do? We searched for studies that compared probiotics (any strain or dose) versus placebo (dummy treatment), alternative preventive treatment, or no treatment for the prevention of CDAD in adults and children receiving antibiotic therapy for any reason. We compared and summarized the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included 47 studies with a total of 15,260 adults and children who received antibiotic therapy along with probiotics, assessing CDAD or C difficile growth. Thirty‐eight studies (13,179 participants) assessed the effectiveness of probiotics for preventing CDAD. Our results suggest that probiotics may result in a small reduction in the risk of CDAD compared to placebo or no treatment. Probiotics may result in a small reduction in C difficile growth (16 studies, 1302 participants). Thirty‐seven studies (11,911 participants) looked at unwanted effects. Our results show that probiotics probably result in a small reduction in the risk of developing unwanted effects compared to placebo or no treatment. The most commonly reported unwanted effects included abdominal cramping, nausea, fever, soft stools, flatulence (gas), and taste disturbance, and were more common in the placebo or no‐treatment group. Forty studies (13,419 participants) reported on antibiotic‐associated diarrhea (AAD); probiotics may result in a large reduction in the risk of AAD compared to placebo or no treatment. Seven studies (6553 participants) reporting on length of hospital stay showed likely little to no difference between probiotics and placebo or no treatment. What are the limitations of the evidence? The studies we reviewed used different types of probiotics, but they didn't directly compare one probiotic to another. This lack of direct comparisons makes it harder to determine which probiotic works best. We have moderate to little confidence in the available evidence. Our confidence is limited because in some studies, people who dropped out of the study or were not followed up on resulted in missing information. The two largest studies in our analysis did not show a clear benefit of probiotics for preventing CDAD. How up‐to‐date is this evidence? The evidence is current to 3 March 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Esmaeilinezhad, Z, Ghosh, NR, Walsh, CM, Steen, JP, Burgman, AM, Mertz, D, Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD006095.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.750Z" }, { "id": "73b2a88f-b4b5-4c30-8e26-d75e586e91df", "pmid": "", "title": "Penicillamine for treating rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is a penicillin derived compound originally used to treat patients with rheumatoid arthritis (RA) in the 1950's. Although frequently used in the past, its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs) such as methotrexate. Objectives To estimate the short‐term effects of D‐penicillamine for the treatment of rheumatoid arthritis (RA). Search methods We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register (issue 3, 2000) and Medline up to and including August 2000 and Embase from 1988‐2000. We also carried out a handsearch of the reference lists of the trials retrieved from the electronic search. Selection criteria All randomized controlled trials and controlled clinical trials comparing D‐penicillamine against placebo in patients with rheumatoid arthritis. Data collection and analysis The methodological quality of the trials was assessed independently by two reviewers (CS, EB) and checked by a third (MS) using a validated quality assessment tool (Jadad 1996). Rheumatoid arthritis outcome measures were extracted from the publications for the six‐month endpoint and stratified according to D‐penicillamine dosages: low (<500mg/day), moderate (500 to <1000mg/day) and high (1000 mg/day or greater). Data was abstracted by one reviewer and checked by a second (CS, MS). The pooled analysis was performed using the standardized mean difference for joint counts, pain and global assessments. The weighted mean difference was used for erythrocyte sedimentation rate (ESR). Toxicity was evaluated with pooled odds ratios for withdrawals and adverse reactions. A chi‐square test was used to assess heterogeneity among trials. Fixed effects models were used throughout, since no statistical heterogeneity was found. Main results Six trials were identified, with 425 patients randomized to D‐penicillamine and 258 to placebo. A statistically significant benefit was observed for D‐penicillamine when compared to placebo for all three‐dose ranges and for most outcome measures including: tender joint counts, pain, physician's global assessments and ESR. The standardized weighted mean differences between treatment and placebo in moderate doses were ‐0.51 [95% CI ‐0.88, ‐0.14] for tender joint counts, ‐0.56 (95% CI ‐0.87, ‐0.26) for pain and ‐0.97 (95% CI ‐1.25, ‐0.70) for global assessment. The difference for ESR was ‐10.6 mm/hr. Similar results were observed for the higher dose group. Total withdrawals were significantly higher in the moderate and high dosage D‐penicillamine groups (OR=1.63 and 2.13 respectively), mostly due to increased adverse reactions (OR = 2.60 and 4.95 respectively), including renal and hematological abnormalities. Authors' conclusions D‐penicillamine appears to have a clinically and statistically significant benefit on the disease activity of patients with rheumatoid arthritis. Its efficacy appears to be similar to that of other disease modifying anti‐rheumatic drugs (DMARDs), but with a significantly higher toxicity. Its effects on long‐term functional status and radiological progression are not clear from this review. Plain language summary Penicillamine for treating rheumatoid arthritis Penicillamine is a penicillin derived compound. Studies showed that this could be used to treat rheumatoid arthritis originally in 1950. It was frequently used in the past, but its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs), such as methotrexate. The purpose of this summary was to find out if penicillamine is helpful in the treatment of rheumatoid arthritis. Penicillamine was seen to be beneficial for all ranges of dosages for disease activity on tender joint pain, physician global assessment and sed rate. No major differences were observed between placebo and low dose penicillamine (<500 mg/day). For higher dosages, patients on penicillamine were twice as likely to withdraw than those receiving placebo 500 to <1000 mg/day. D‐penicillamine appears be have a clinical and statistical benefit on the disease activity of patients with rheumatoid arthritis. Its benefit is similar to that of other such drugs, such as disease modifying anti‐rheumatic drugs (DMARDs). More adverse reactions are seen in patients being treated with D‐penicillamine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Suarez‐Almazor, ME; Belseck, E; Spooner, C", "articleTypes": [], "doi": "10.1002/14651858.CD001460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "73b5f8d6-c758-4fe8-8020-ac7528460333", "pmid": "", "title": "Fortification of condiments and seasonings with iron for preventing anaemia and improving health", "imported": false, "abstract": "Abstract - Background Anaemia affects approximately 1.8 billion people worldwide; over 60% of anaemia cases globally are due to iron deficiency (ID). Iron deficiency and anaemia contribute to the global burden of disease and affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortification of food with iron, alone or in combination with other nutrients, is an effective intervention to control ID. Condiments and seasonings are ideal food vehicles for iron fortification in countries where they are commonly used. Objectives To determine the effects and safety of condiment and seasoning fortification with iron alone or iron plus other micronutrients on iron deficiency, anaemia, and health‐related outcomes in the general population. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 24 January 2023. We also searched the International clinical trials registry platform (ICTRP) for any ongoing trials. Selection criteria We included randomised controlled trials (RCTs) (randomisation at individual or cluster level), non‐randomised controlled trials, interrupted time series with at least three measure points both before and after intervention, and controlled before‐after studies. Participants were populations of any age (including pregnant women), from any country, excluding those with critical illness or severe co‐morbidities. We included interventions in which condiments or seasonings have been fortified with any combination of iron and other vitamins and minerals, irrespective of the fortification technology used. Data collection and analysis Two review authors independently screened and assessed the eligibility of studies. Disagreements were resolved through discussion or input from a third review author. Two review authors extracted the data and assessed the risk of bias in all the included studies. We followed the methods laid out by Cochrane and used GRADE criteria for assessing certainty of the evidence. Main results Our search identified 15,902 records after removal of duplicates. We included 16 studies with 20,512 participants (18,410 participants after adjusting for clustering effects). They were all carried out in upper‐middle‐ and lower‐middle‐income countries. Three studies were controlled before‐after studies, one was non‐randomised trial, and 12 were RCTs (including three cluster RCTs). Six studies took place in schools; seven in communities; and one each in a nursery/kindergarten, tea estate, and factory. Three studies involved only women, one study involved both women and their children, and all other studies focused on children and/or adolescents. Nine studies used salt as a vehicle for iron fortification, three used fish sauce, two used soy sauce, one used curry powder, and one a \"seasoning powder\". The dose of iron received by participants ranged from 4.4 mg to 55 mg/day. The sample sizes in the trials ranged from 123 to 14,398, and study durations ranged from three months to two years. Twelve RCTs contributed data for meta‐analysis. Six trials compared iron‐fortified condiments versus the unfortified condiment, and six trials provided data comparing iron fortification in combination with other micronutrients versus the same condiment with other micronutrients, but no added iron. In one trial, the fortificant contained micronutrients that may have affected the absorption of iron. Overall no studies were assessed as having a low risk of bias. All included studies were assessed to have a high overall risk of bias, with the most concerns being around allocation concealment, blinding, and random sequence generation. There was very high heterogeneity amongst studies in almost all examined outcomes. Condiments/seasonings fortified with iron versus unfortified condiments/seasonings We are uncertain about whether consuming condiments/seasonings fortified with iron in comparison to the same unfortified condiment reduces anaemia at the end of intervention (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.18 to 0.65; 2328 participants; 4 studies; very low‐certainty of evidence). We are uncertain about whether consuming iron‐fortified condiments increases haemoglobin concentrations (mean difference (MD) 6.40 (g/L), 95% CI ‐0.62 to 13.41; 2808 participants; 5 studies; very low‐certainty evidence). Fortification of condiments/seasonings with iron probably slightly reduces ID (RR 0.33, 95% CI 0.11 to 1.01; 391 participants; 2 studies; moderate‐certainty evidence). We are uncertain about whether fortification with iron increases ferritin concentration (MD 14.81 (µg/L), 95% CI 5.14 to 24.48; 4459 participants; 6 studies; very low‐certainty evidence). Condiments/seasonings fortified with iron plus other micronutrients versus condiments/seasonings fortified with other micronutrients except iron Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia (RR 0.59, 95% CI 0.40 to 0.89; 1007 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification of condiments/seasonings with iron plus other micronutrients will improve haemoglobin concentration (MD 6.22 g/dL, 95% CI 1.60 to 10.83; 1270 participants; 5 studies; very low‐certainty evidence). It may reduce ID (RR 0.36, 95% CI 0.19 to 0.69; 1154 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification with iron plus other micronutrients improves ferritin concentration (MD 10.63 µg/L, 95% CI 2.40 to 18.85; 1251 participants; 5 studies; very low ‐certainty evidence). Condiments/seasonings fortified with iron versus no intervention No trial reported data on this comparison. No studies reported adverse effects. Funding sources do not appear to have distorted the results in any of the assessed trials. Authors' conclusions We are uncertain whether consuming iron‐fortified condiments/seasonings reduces anaemia, improves haemoglobin concentration, or improves ferritin concentration. It may reduce ID. Findings about ferritin should be interpreted with caution since its concentrations increase during inflammation. Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia, and we are uncertain whether this will improve haemoglobin concentration or ferritin concentration. More studies are needed to determine the true effect of iron‐fortified condiments/seasonings on preventing anaemia and improving health. The effects of this intervention on other health outcomes like malaria incidence, growth and development are unclear. Plain language summary Adding iron to condiments and seasonings for preventing anaemia and improving health Key messages ‐ Adding iron to condiments/seasonings may slightly improve iron status and reduce iron deficiency. When iron is added along with other micronutrients, it may reduce anaemia. Unwanted effects were not reported. ‐ There was a lot of variation between the studies included in this review, making it more difficult to draw definitive conclusions. The effects of fortifying condiments and seasonings with iron should continue to be examined in populations consuming them through well‐designed studies. What is anaemia? Iron deficiency is one of the most common nutritional deficiencies throughout the world and contributes significantly to the global burden of disease. Multiple factors cause anaemia, including insufficient iron intake (the most common cause of anaemia), and it affects approximately 1.8 billion people worldwide. In general, low‐income countries have more anaemia than higher‐income countries. Iron deficiency and anaemia have several lifetime consequences that can affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortifying condiments or seasonings with iron may be a useful and cost‐effective approach to help reduce iron deficiency. To date, there has been no systematic assessment of the safety and effectiveness of this intervention to inform policymaking. What did we want to find out? If fortifying condiments and seasonings with iron alone or iron plus other micronutrients improves measures of iron nutrition in the general population, in particular: ‐ anaemia; ‐ haemoglobin concentration; ‐ iron deficiency; ‐ iron status (including ferritin, transferrin saturation, and more). We also wanted to find out if consuming iron‐fortified condiments/seasonings was associated with any unwanted effects. What did we do? 
We searched for studies that provided iron‐fortified condiments/seasonings to one group, and condiments/seasonings not fortified with iron to another. We compared and summarised the results of the studies and rated our confidence in the evidence, based on study characteristics. What did we find? We identified 16 studies that involved 18,410 participants in middle‐income countries, most within schools or communities, with study durations ranging from three months to two years. The type of iron‐fortified condiments/seasonings used included salt, fish sauce, soy sauce, and seasoning powders. The dose of iron received by participants ranged from 4.4mg to 55 mg/day. Compared to unfortified condiments/seasonings, those which are iron‐fortified likely improve iron deficiency slightly. We are uncertain whether they reduce anaemia, improve haemoglobin, or other measures of iron status. Condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia; we are uncertain about whether they improve haemoglobin or ferritin concentrations. They may improve iron deficiency and total iron binding capacity. No studies reported adverse effects. More studies are needed to determine the effect of iron‐fortified condiments/seasonings on health such as malaria incidence, growth and development and any potential adverse effects. What are the limitations of the evidence? Our confidence in the evidence is very low to moderate; several factors reduced our confidence in the evidence. Firstly, we observed limitations in the way few studies were conducted with respect to the recruitment of people to assign interventions (this means that differences between the groups could be due to differences between people rather than between the treatments). Secondly, people in some studies may have been aware of which treatment they were getting. Also, not all the studies provided data about everything that were interested in, and results were inconsistent across the different studies. Finally, some studies were small. The results of future research could differ from the results of this review. How up to date is this evidence? The evidence is up‐to‐date to January 2023. What this means We judged the evidence in this review as very low to moderate certainty, which means we are not certain of the effect of condiments/seasonings with added iron on the reduction of anaemia and iron deficiency in people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jalal, CSB; De-Regil, LM; Pike, V; Mithra, P", "articleTypes": [], "doi": "10.1002/14651858.CD009604.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "73c2740c-d0e0-4b7f-905c-893a95ab2892", "pmid": "", "title": "Non‐nutritive sweeteners for diabetes mellitus", "imported": false, "abstract": "Abstract - Background Products sweetened with non‐nutritive sweeteners (NNS) are widely available. Many people with type 1 or type 2 diabetes use NNS as a replacement for nutritive sweeteners to control their carbohydrate and energy intake. Health outcomes associated with NNS use in diabetes are unknown. Objectives To assess the effects of non‐nutritive sweeteners in people with diabetes mellitus. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Scopus, the WHO ICTRP, and ClinicalTrials.gov. The date of the last search of all databases (except for Scopus) was May 2019. We last searched Scopus in January 2019. We did not apply any language restrictions. Selection criteria We included randomised controlled trials (RCTs) with a duration of four weeks or more comparing any type of NNS with usual diet, no intervention, placebo, water, a different NNS, or a nutritive sweetener in individuals with type 1 or type 2 diabetes. Trials with concomitant behaviour‐changing interventions, such as diet, exercise, or both, were eligible for inclusion, given that the concomitant interventions were the same in the intervention and comparator groups. Data collection and analysis Two review authors independently screened abstracts, full texts, and records retrieved from trials registries, assessed the certainty of the evidence, and extracted data. We used a random‐effects model to perform meta‐analysis, and calculated effect estimates as risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs). We assessed risk of bias using the Cochrane 'Risk of bias' tool and the certainty of evidence using the GRADE approach. Main results We included nine RCTs that randomised a total of 979 people with type 1 or type 2 diabetes. The intervention duration ranged from 4 to 10 months. We judged none of these trials as at low risk of bias for all ’Risk of bias’ domains; most of the included trials did not report the method of randomisation. Three trials compared the effects of a dietary supplement containing NNS with sugar: glycosylated haemoglobin A1c (HbA1c) was 0.4% higher in the NNS group (95% CI −0.5 to 1.2; P = 0.44; 3 trials; 72 participants; very low‐certainty evidence). The MD in weight change was −0.1 kg (95% CI −2.7 to 2.6; P = 0.96; 3 trials; 72 participants; very low‐certainty evidence). None of the trials with sugar as comparator reported on adverse events. Five trials compared NNS with placebo. The MD for HbA1c was 0%, 95% CI −0.1 to 0.1; P = 0.99; 4 trials; 360 participants; very low‐certainty evidence. The 95% prediction interval ranged between −0.3% and 0.3%. The comparison of NNS versus placebo showed a MD in body weight of −0.2 kg, 95% CI −1 to 0.6; P = 0.64; 2 trials; 184 participants; very low‐certainty evidence. Three trials reported the numbers of participants experiencing at least one non‐serious adverse event: 36/113 participants (31.9%) in the NNS group versus 42/118 participants (35.6%) in the placebo group (RR 0.78, 95% CI 0.39 to 1.56; P = 0.48; 3 trials; 231 participants; very low‐certainty evidence). One trial compared NNS with a nutritive low‐calorie sweetener (tagatose). HbA1c was 0.3% higher in the NNS group (95% CI 0.1 to 0.4; P = 0.01; 1 trial; 354 participants; very low‐certainty evidence). This trial did not report body weight data and adverse events. The included trials did not report data on health‐related quality of life, diabetes complications, all‐cause mortality, or socioeconomic effects. Authors' conclusions There is inconclusive evidence of very low certainty regarding the effects of NNS consumption compared with either sugar, placebo, or nutritive low‐calorie sweetener consumption on clinically relevant benefit or harm for HbA1c, body weight, and adverse events in people with type 1 or type 2 diabetes. Data on health‐related quality of life, diabetes complications, all‐cause mortality, and socioeconomic effects are lacking. Plain language summary Non‐nutritive sweeteners for diabetes mellitus Review question Are non‐nutritive sweeteners beneficial or harmful in people with diabetes? Background Non‐nutritive sweeteners are sweetening agents having higher sweetening intensity and lower calorie content per gram compared to caloric sweeteners like sucrose or corn syrups. Both the general population and diabetic people use non‐nutritive sweeteners as a caloric sweetener replacement to control their carbohydrate and energy intake. Most of the non‐nutritive sweeteners approved for human consumption are synthetic (artificial sweeteners); however, increasing numbers of natural non‐caloric sweeteners are becoming available for human consumption. Products sweetened with non‐nutritive sweeteners are widely available on the market: diet beverages, diet yoghourts, desserts, and chewing gums are the most common products containing non‐nutritive sweeteners. Non‐nutritive sweeteners are also available as table‐top sweeteners for use by consumers at home as a sweetening agent for beverages and for cooking and baking. There is very little information about the health consequences of this intensified non‐nutritive sweeteners consumption in people with diabetes. We wanted to find out whether non‐nutritive sweeteners consumption in people with diabetes has an effect on long‐term average blood sugar levels (glycosylated haemoglobin A1c ‐ HbA1c), body weight, side effects, diabetes complications (such as heart attack, eye or kidney disease), and health‐related quality of life. Study characteristics We found nine randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) that allocated people with diabetes to either a group that received a non‐nutritive sweetener or a comparator group. The comparator was usual diet with additional sugar in three studies; placebo (a dummy pill) in five studies; and tagatose (a nutritive low‐calorie sweetener) in one study. The studies included a total of 979 participants; most of the studies were small, with fewer than 100 participants. The length of the studies varied from 4 to 10 months. This evidence is up‐to‐date as of May 2019. Key results Data on health‐related quality of life, diabetes complications, death from any cause, and socioeconomic effects (such as absence from work, visits to general practitioner, medication consumption) were lacking, and data were generally sparse for all comparisons. The available data did not show a clear difference between non‐nutritive sweeteners and sugar, placebo, or the nutritive low‐calorie sweetener tagatose for HbA1c, body weight, and side effects. Certainty of the evidence We rated the overall certainty of the evidence as very low, mainly due to the small numbers of included studies and participants and methodological limitations of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lohner, S; Kuellenberg de Gaudry, D; Toews, I; Ferenci, T; Meerpohl, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD012885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "73d05be4-e941-4296-80eb-b2d4df7b5064", "pmid": "", "title": "Relief of pain due to uterine cramping/involution after birth", "imported": false, "abstract": "Abstract - Background Women may experience differing types of pain and discomfort following birth, including cramping pain (often called after‐birth pain) associated with uterine involution, where the uterus contracts to reduce blood loss and return the uterus to its non‐pregnant size. This is an update of a review first published in 2011. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological pain relief/analgesia for the relief of after‐birth pains following vaginal birth. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (31 October 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials comparing two different types of analgesia or analgesia versus placebo or analgesia versus no treatment, for the relief of after‐birth pains following vaginal birth. Types of analgesia included pharmacological and non‐pharmacological. Quasi‐randomised trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed trials for inclusion, conducted 'Risk of bias' assessment, extracted data and assessed the certainty of the evidence using the GRADE approach. Main results In this update, we include 28 studies (involving 2749 women). The evidence identified in this review comes from middle‐ to high‐income countries. Generally the trials were at low risk of selection bias, performance bias and attrition bias, but some trials were at high risk of bias due to selective reporting and lack of blinding. Our GRADE certainty of evidence assessments ranged from moderate to very low certainty, with downgrading decisions based on study limitations, imprecision, and (for one comparison) indirectness. Most studies reported our primary outcome of adequate pain relief as reported by the women. No studies reported data relating to neonatal adverse events, duration of hospital stay, or breastfeeding rates. Almost half of the included studies (11/28) excluded breastfeeding women from participating, making the evidence less generalisable to a broader group of women. Non‐steroidal anti‐inflammatory drugs (NSAIDs) compared to placebo NSAIDs are probably better than placebo for adequate pain relief as reported by the women (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.45 to 1.91; 11 studies, 946 women; moderate‐certainty evidence). NSAIDs may reduce the need for additional pain relief compared to placebo (RR 0.15, 95% CI 0.07 to 0.33; 4 studies, 375 women; low‐certainty evidence). There may be a similar risk of maternal adverse events (RR 1.05, 95% CI 0.78 to 1.41; 9 studies, 598 women; low‐certainty evidence). NSAIDs compared to opioids NSAIDs are probably better than opioids for adequate pain relief as reported by the women (RR 1.33, 95% CI 1.13 to 1.57; 5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of maternal adverse events (RR 0.62, 95% CI 0.43 to 0.89; 3 studies, 255 women; low‐certainty evidence). NSAIDs may be better than opioids for the need for additional pain relief, but the wide CIs include the possibility that the two classes of drugs are similarly effective or that opioids are better (RR 0.37, 95% CI 0.12 to 1.12; 2 studies, 232 women; low‐certainty evidence). Opioids compared to placebo Opioids may be better than placebo for adequate pain relief as reported by the women (RR 1.26, 95% CI 0.99 to 1.61; 5 studies, 299 women; low‐certainty evidence). Opioids may reduce the need for additional pain relief compared to placebo (RR 0.48, 95% CI 0.28 to 0.82; 3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of maternal adverse events compared with placebo, although the certainty of evidence is low (RR 1.59, 95% CI 0.99 to 2.55; 3 studies, 188 women; low‐certainty evidence). Paracetamol compared to placebo Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events (2 studies, 123 women). Paracetamol compared to NSAIDs Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events. No data were reported about the need for additional pain relief comparing paracetamol and NSAIDs (2 studies, 112 women). NSAIDs compared to herbal analgesia We are uncertain if there are any differences between NSAIDs and herbal analgesia for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events, because the certainty of evidence is very low (4 studies, 394 women). Transcutaneous nerve stimulation (TENS) compared to no TENS Very low‐certainty evidence means we are uncertain if TENS is better than no TENS for adequate pain relief as reported by the women. No other data were reported comparing TENS with no TENS (1 study, 32 women). Authors' conclusions NSAIDs may be better than placebo and are probably better than opioids at relieving pain from uterine cramping/involution following vaginal birth. NSAIDs and paracetamol may be as effective as each other, whereas opioids may be more effective than placebo. Due to low‐certainty evidence, we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater generalisability by including breastfeeding women. In addition, further research is required, including a survey of postpartum women to describe appropriately their experience of uterine cramping and involution. We identified nine ongoing studies, which may help to increase the level of certainty of the evidence around pain relief due to uterine cramping in future updates of this review. Plain language summary Relief of pain caused by uterine cramping or involution after giving birth This updated review investigates the effectiveness and safety of drug and non‐drug pain relief in women experiencing after‐birth pains following vaginal birth. Giving an agent for pain relief was compared to an inactive placebo, to no treatment, or to a different type of agent in randomised controlled trials. What is the issue? Women may experience cramping pain and discomfort following the birth of their baby, as the uterus contracts and returns to its normal pre‐pregnancy size. These pains usually last for two to three days after the birth. Women who have previously had a baby are more likely to experience after‐birth pains. Breastfeeding stimulates the uterus to contract and increases the severity of the pains. Types of pain relief used to treat the pain include paracetamol, non‐steroidal anti‐inflammatory drugs (NSAIDs) ibuprofen and naproxen, opioids including codeine, and non‐medicine methods such as herbal preparations and transcutaneous electrical nerve stimulation (TENS). Why is this important? Management of pain after birth is important, as the pain can affect a mother carrying out her normal activities as well as bonding with and caring for her baby. After‐pains can interfere with establishing breastfeeding. What evidence did we find? We searched for evidence from randomised controlled trials (October 2019) and identified 28 studies (2749 mothers) who were in hospital after uncomplicated single births. Most of the evidence is low‐certainty because the studies did not include sufficient numbers of women. Many of the studies excluded breastfeeding women.This makes the evidence less relevant to a broader group of women. No studies reported evidence on adverse events in the newborn infants. NSAIDs are probably better than placebo (a dummy treatment) in giving adequate pain relief as reported by the women (11 studies, 946 women; moderate‐certainty evidence), and they may reduce the need for additional pain relief (4 studies, 375 women; low‐certainty evidence). There may be little difference between NSAIDs and placebo in the risk of adverse events in the mother (9 studies, 598 women; low‐certainty evidence). NSAIDs are probably better than opioids in providing adequate pain relief as reported by the women (5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of adverse events in the mother (3 studies, 255 women; low‐certainty evidence). NSAIDs may slightly reduce the need for additional pain relief compared with opioids (2 studies, 232 women; low‐certainty evidence). Opioids may be better than placebo for adequate pain relief as reported by the women (5 studies, 299 women; low‐certainty evidence) and for the need for additional pain relief (3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of adverse events in the mother compared with placebo (3 studies, 188 women; low‐certainty evidence). Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional analgesia, or risk of maternal adverse events (2 studies, 123 women). Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events (2 studies, 112 women). Very low‐certainty evidence means we are uncertain if NSAIDs are better than herbal pain relief for adequate pain relief as reported by the women (4 studies, 394 women), the need for additional pain relief (1 study, 90 women) or risk of maternal adverse events (1 study, 108 women). Very low‐certainty evidence means we are uncertain if there is any difference between TENS and no TENS for adequate pain relief as reported by the women (1 study, 32 women). What does this mean? NSAIDs may be better than placebo and are probably better than opioids at relieving after‐birth pains following vaginal birth. The quality of the evidence was poor and we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater relevance by including breastfeeding women. Further research could also include a survey of women after delivery to capture their experience of after‐birth pains following vaginal birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Deussen, AR; Ashwood, P; Martis, R; Stewart, F; Grzeskowiak, LE", "articleTypes": [], "doi": "10.1002/14651858.CD004908.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "73d27bf3-6acc-4b73-976b-69baf9406d8e", "pmid": "", "title": "Interventions for bullous pemphigoid", "imported": false, "abstract": "Abstract - Background Bullous pemphigoid (BP) is the most common autoimmune blistering disease. Oral steroids are the standard treatment. We have updated this review, which was first published in 2002, because several new treatments have since been tried. Objectives To assess the effects of treatments for bullous pemphigoid. Search methods We updated searches of the following databases to November 2021: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched five trial databases to January 2022, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria RCTs of treatments for immunofluorescence‐confirmed bullous pemphigoid. Data collection and analysis At least two review authors, working independently, evaluated the studies against the review's inclusion criteria and extracted data from included studies. Using GRADE methodology, we assessed the certainty of the evidence for each outcome in each comparison. Our primary outcomes were healing of skin lesions and mortality. Main results We identified 14 RCTs (1442 participants). The main treatment modalities assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Most studies reported mortality but adverse events and quality of life were not well reported. We decided to look at the primary outcomes 'disease control' and 'mortality'. Almost all studies investigated different comparisons; two studies were placebo‐controlled. The results are therefore based on a single study for each comparison except azathioprine. Most studies involved only small numbers of participants. We assessed the risk of bias for all key outcomes as having 'some concerns' or high risk, due to missing data, inappropriate analysis, or insufficient information. Clobetasol propionate cream versus oral prednisone Compared to oral prednisone, clobetasol propionate cream applied over the whole body probably increases skin healing at day 21 (risk ratio (RR 1.08, 95% confidence interval (CI) 1.03 to 1.13; 1 study, 341 participants; moderate‐certainty evidence). Skin healing at 21 days was seen in 99.8% of participants assigned to clobetasol and 92.4% of participants assigned to prednisone. Clobetasol propionate cream applied over the whole body compared to oral prednisone may reduce mortality at one year (RR 0.73, 95% CI 0.53 to 1.01; 1 study, 341 participants; low‐certainty evidence). Death occurred in 26.5% (45/170) of participants assigned to clobetasol and 36.3% (62/171) of participants assigned to oral prednisone. This study did not measure quality of life. Clobetasol propionate cream may reduce risk of severe complications by day 21 compared with oral prednisone (RR 0.65, 95% CI 0.50 to 0.86; 1 study, 341 participants; low‐certainty evidence). Mild clobetasol propionate cream regimen (10 to 30 g/day) versus standard clobetasol propionate cream regimen (40 g/day) A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen probably does not change skin healing at day 21 (RR 1.00, 95% CI 0.97 to 1.03; 1 study, 312 participants; moderate‐certainty evidence). Both groups showed complete healing of lesions at day 21 in 98% participants. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change mortality at one year (RR 1.00, 95% CI 0.75 to 1.32; 1 study, 312 participants; low‐certainty evidence), which occurred in 118/312 (37.9%) participants. This study did not measure quality of life. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change adverse events at one year (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 309 participants; low‐certainty evidence). Doxycycline versus prednisolone Compared to prednisolone (0.5 mg/kg/day), doxycycline (200 mg/day) induces less skin healing at six weeks (RR 0.81, 95% CI 0.72 to 0.92; 1 study, 213 participants; high‐certainty evidence). Complete skin healing was reported in 73.8% of participants assigned to doxycycline and 91.1% assigned to prednisolone. Doxycycline compared to prednisolone probably decreases mortality at one year (RR 0.25, 95% CI 0.07 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 14; 1 study, 234 participants; moderate‐certainty evidence). Mortality occurred in 2.3% (3/132) of participants with doxycycline and 9.1% (11/121) with prednisolone. Compared to prednisolone, doxycycline improved quality of life at one year (mean difference 1.8 points lower, which is more favourable on the Dermatology Life Quality Index, 95% CI 1.02 to 2.58 lower; 1 study, 234 participants; high‐certainty evidence). Doxycycline compared to prednisolone probably reduces severe or life‐threatening treatment‐related adverse events at one year (RR 0.59, 95% CI 0.35 to 0.99; 1 study, 234 participants; moderate‐certainty evidence). Prednisone plus azathioprine versus prednisone It is unclear whether azathioprine plus prednisone compared to prednisone alone affects skin healing or mortality because there was only very low‐certainty evidence from two trials (98 participants). These studies did not measure quality of life. Adverse events were reported in a total of 20/48 (42%) participants assigned to azathioprine plus prednisone and 15/44 (34%) participants assigned to prednisone. Nicotinamide plus tetracycline versus prednisone It is unclear whether nicotinamide plus tetracycline compared to prednisone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (18 participants). This study did not measure quality of life. Fewer adverse events were reported in the nicotinamide group. Methylprednisolone plus azathioprine versus methylprednisolone plus dapsone It is unclear whether azathioprine plus methylprednisolone compared to dapsone plus methylprednisolone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (54 participants). This study did not measure quality of life. A total of 18 adverse events were reported in the azathioprine group and 13 in the dapsone group. Authors' conclusions Clobetasol propionate cream applied over the whole body is probably similarly effective as, and may cause less mortality than, oral prednisone for treating bullous pemphigoid. Lower‐dose clobetasol propionate cream applied over the whole body is probably similarly effective as standard‐dose clobetasol propionate cream and has similar mortality. Doxycycline is less effective but causes less mortality than prednisolone for treating bullous pemphigoid. Other treatments need further investigation. Plain language summary Treatments for bullous pemphigoid Which treatments work best for bullous pemphigoid (a rare, itchy skin disease that causes blisters)? Key messages • A cream, containing topical steroid clobetasol propionate, applied on the entire skin surface is as effective as oral steroids (prednisone), causes less severe unwanted or harmful effects, and may decrease deaths. • Initiating treatment with doxycycline (200 mg/day), an antibiotic with anti‐inflammatory effect, leads to an acceptable short‐term blister control compared to the oral steroid prednisolone (0.5 mg/kg/day), and is superior in long‐term safety aspects, including deaths. What is bullous pemphigoid? Bullous pemphigoid is the most common autoimmune blistering disease. In autoimmune diseases, the body's immune system mistakes its own tissues as foreign and attacks them. In bullous pemphigoid, this causes blisters on the skin. Bullous pemphigoid usually occurs in the elderly, but may also affect younger people. How is bullous pemphigoid treated? Until recently, the leading treatment for bullous pemphigoid was oral steroids which suppress inflammation and the body's own immune system. However, given over a long period of time, oral steroids will cause severe adverse (i.e. harmful) effects. This review assessed studies which investigated the effectiveness of other treatment options for bullous pemphigoid; for example, a steroid cream applied on the skin and the anti‐inflammatory antibiotic medicine, doxycycline. What did we want to find out? We wanted to find out which treatments work best for bullous pemphigoid with respect to the healing of blisters (efficacy) and reduction in adverse effects, such as death. What did we do? We searched for studies that looked at treatments for bullous pemphigoid. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 14 studies including 1442 people with bullous pemphigoid. The main treatments assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Other treatments tested were oral (i.e. taken by mouth) immunosuppressives (medicines that keep your immune system in check) and immunoglobulins (also called antibodies. Antibodies are proteins that your immune system makes to fight germs, for example). ‐ Topical steroid cream, clobetasol propionate, applied over the whole body (40 grams of cream applied per day, with the amount decreased over 12 months) is an effective and safe treatment for bullous pemphigoid. ‐ Treatment with a lower amount of clobetasol propionate cream (10 to 30 grams per day, decreased over 4 months) is equally effective and safe. ‐ Prednisolone, an oral corticosteroid, in the dose of 0.5 mg/kg/day, may be adequate to control disease in most people and reduces adverse effects compared to higher doses of oral corticosteroid. ‐ Initiating treatment with 200 mg/day of doxycycline leads to acceptable blister control compared to oral prednisolone (0.5 mg/kg/day) and is safer. ‐ A study with 20 participants suggests that nicotinamide (a form of vitamin B 3 )and tetracycline (an antibiotic used to treat a wide variety of infections) may be an effective alternative to prednisone and may decrease treatment‐associated death. ‐ Adding azathioprine, a drug which suppresses the immune system, to an oral corticosteroid does not improve disease control; it may lead to a reduced need for oral corticosteroid. ‐ Further research is needed to fully understand the effectiveness of alternatives to oral steroids (such as dapsone or immunoglobulins), as well as the effectiveness of giving other medicines alongside an oral steroid. What are the limitations of the evidence? Except for the studies on topical clobetasol cream and doxycycline, the studies included relatively few participants. The methodological quality of these studies was further limited because of unclear methods of allocating people to different treatment groups; lack of masking (participants and researchers knew which treatments were given to which people, which are not good conditions for fair assessment); and the exclusion of people who dropped out of the studies from treatment analysis. We are confident about the efficacy of initiating treatment with doxycycline and moderately confident about the efficacy of topical clobetasol cream for the treatment of bullous pemphigoid. How up to date is this evidence? The evidence is current to 11 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Singh, S, Kirtschig, G, Anchan, VN, Chi, C-C, Taghipour, K, Boyle, RJ, Murrell, DF", "articleTypes": [], "doi": "10.1002/14651858.CD002292.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.767Z" }, { "id": "73d74556-d671-4329-bb28-b6471fee393f", "pmid": "", "title": "Nasal decongestants in monotherapy for the common cold", "imported": false, "abstract": "Abstract - Background Many treatments for the common cold exist and are sold over‐the‐counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited. Objectives To assess the efficacy, and short‐ and long‐term safety, of nasal decongestants used in monotherapy to alleviate symptoms of the common cold in adults and children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6, June 2016), which contains the Cochrane Acute Respiratory Infections (ARI) Specialised Register, MEDLINE (1946 to July 2016), Embase (2010 to 15 July 2016), CINAHL (1981 to 15 July 2016), LILACS (1982 to July 2016), Web of Science (1955 to July 2016) and clinical trials registers. Selection criteria Randomised controlled trials (RCTs) and cluster‐RCTs investigating the effectiveness and adverse effects of nasal decongestants compared with placebo for treating the common cold in adults and children. We excluded quasi‐RCTs. Data collection and analysis Three review authors independently extracted and summarised data on subjective measures of nasal congestion, overall patient well‐being score, objective measures of nasal airway resistance, adverse effects and general recovery. One review author acted as arbiter in cases of disagreement. We categorised trials as single and multi‐dose and analysed data both separately and together. We also analysed studies using an oral or topical nasal decongestant separately and together. Main results We included 15 trials with 1838 participants. Fourteen studies included adult participants only (aged 18 years and over). In six studies the intervention was a single dose and in nine studies multiple doses were used. Nine studies used pseudoephedrine and three studies used oxymetazoline. Other decongestants included phenylpropanolamine, norephedrine and xylometazoline. Phenylpropanolamine (or norephedrine) is no longer available on the market therefore we did not include the results of these studies in the meta‐analyses. Eleven studies used oral decongestants; four studies used topical decongestants. Participants were included after contracting the common cold. The duration of symptoms differed among studies; in 10 studies participants had symptoms for less than three days, in three studies symptoms were present for less than five days, one study counted the number of colds over one year, and one study experimentally induced the common cold. In the single‐dose studies, the effectiveness of a nasal decongestant was measured on the same day, whereas the follow‐up in multi‐dose studies ranged between one and 10 days. Most studies were conducted in university settings (N = eight), six at a specific university common cold centre. Three studies were conducted at a university in collaboration with a hospital and two in a hospital only setting. In two studies the setting was unclear. There were large differences in the reporting of outcomes and the reporting of methods in most studies was limited. Therefore, we judged most studies to be at low or unclear risk of bias. Pooling was possible for a limited number of studies only; measures of effect are expressed as standardised mean differences (SMDs). A positive SMD represents an improvement in congestion. There is no defined minimal clinically important difference for measures of subjective improvement in nasal congestion, therefore we used the SMDs as a guide to assess whether an effect was small (0.2 to 0.49), moderate (0.5 to 0.79) or large (≥ 0.8). Single‐dose decongestant versus placebo: 10 studies compared a single dose of nasal decongestant with placebo and their effectiveness was tested between 15 minutes and 10 hours after dosing. Seven of 10 studies reported subjective symptom scores for nasal congestion; none reported overall patient well‐being. However, pooling was not possible due to the large diversity in the measurement and reporting of symptoms of congestion. Two studies recorded adverse events. Both studies used an oral decongestant and each of them showed that there was no statistical difference between the number of adverse events in the treatment group versus the placebo group. Multi‐dose decongestant versus placebo: nine studies compared multiple doses of nasal decongestants with placebo, but only five reported on the primary outcome, subjective symptom scores for nasal congestion. Only one study used a topical decongestant; none reported overall patient well‐being. Subjective measures of congestion were significantly better for the treatment group compared with placebo approximately three hours after the last dose (SMD 0.49, 95% confidence interval (CI) 0.07 to 0.92; P = 0.02; GRADE: low‐quality evidence). However, the SMD of 0.49 only indicates a small clinical effect. Pooling was based on two studies, one oral and one topical, therefore we were unable to assess the effects of oral and topical decongestants separately. Seven studies reported adverse events (six oral and one topical decongestant); meta‐analysis showed that there was no statistical difference between the number of adverse events in the treatment group (125 per 1000) compared to the placebo group (126 per 1000). The odds ratio (OR) for adverse events in the treatment group was 0.98 (95% CI 0.68 to 1.40; P = 0.90; GRADE: low‐quality evidence). The results remained the same when we only considered studies using an oral decongestant (OR 0.95, 95% CI 0.65 to 1.39; P = 0.80; GRADE: low‐quality evidence). Authors' conclusions We were unable to draw conclusions on the effectiveness of single‐dose nasal decongestants due to the limited evidence available. For multiple doses of nasal decongestants, the current evidence suggests that these may have a small positive effect on subjective measures of nasal congestion in adults with the common cold. However, the clinical relevance of this small effect is unknown and there is insufficient good‐quality evidence to draw any firm conclusions. Due to the small number of studies that used a topical nasal decongestant, we were also unable to draw conclusions on the effectiveness of oral versus topical decongestants. Nasal decongestants do not seem to increase the risk of adverse events in adults in the short term. The effectiveness and safety of nasal decongestants in children and the clinical relevance of their small effect in adults is yet to be determined. Plain language summary Do nasal decongestants used alone relieve cold symptoms? Review question We wanted to find out if nasal decongestants used alone can ease nasal congestion symptoms in people with colds. Background Colds, although not serious, are common illnesses responsible for many visits to family doctors and days lost from work and school. Cold symptoms include runny nose, sore throat and sneezing, and they can last up to two weeks. There is no cure for colds; treatments only ease the symptoms. Many people use over‐the‐counter medicines such as nasal decongestants to treat cold symptoms. However, there is little evidence that nasal decongestants actually work. We wanted to find out if nasal decongestants help ease congestion caused by colds. We considered studies that used a nasal decongestant as the only treatment for colds. We looked at subjective symptoms of congestion ‐ this means that symptoms and overall well‐being were self‐rated by patients. Search date We searched for studies in July 2016. Study characteristics We included 15 studies with 1838 participants; 14 included only adults aged 18 years or over. Six studies used a single‐dose nasal decongestant and measured the effects on the day it was administered. Nine studies used multiple doses and the effects were measured between one and 10 days after first administration. Eleven studies used tablets or syrup and four studies used nasal sprays. Eight studies were conducted at universities, three at universities in collaboration with hospitals and two in hospitals. The setting was unclear in two studies. Study funding sources Nine studies were funded by drug manufacturers or agencies with commercial interests in the study results. Funding sources were unclear in six studies. Key results We were unable to draw conclusions about single‐dose nasal decongestants. We found a small benefit in the relief of nasal congestion from multiple doses, but it was unclear if this was beneficial for patients. No studies reported overall patient well‐being. There was no difference in the numbers of adverse events between people who used a nasal decongestant and those who did not. We could not determine if there was a difference in effects between decongestant tablets and nasal sprays. The results relate to adults; there was no evidence on the effectiveness or safety of nasal decongestants for children. Quality of the evidence We assessed the quality of the evidence for subjective cold symptoms as low for the multi‐dose studies ‐ there were few data and reporting was unclear. We also assessed the quality of the evidence for adverse events as low because of unclear reporting and because the estimates were not precise (there were wide confidence intervals ‐ a measure of statistical uncertainty).", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Deckx, L, De Sutter, AIM, Guo, L, Mir, NA, van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009612.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.112Z" }, { "id": "73e4ed47-740f-48fd-b618-c149a3025da5", "pmid": "", "title": "Quinine for muscle cramps", "imported": false, "abstract": "Abstract - Background Muscle cramps can occur anywhere and for many reasons. Quinine has been used to treat cramps of all causes. However, controversy continues about its efficacy and safety. This review was first published in 2010 and searches were updated in 2014. Objectives To assess the efficacy and safety of quinine‐based agents in treating muscle cramps. Search methods On 27 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE. We searched reference lists of articles up to 2014. We also searched for ongoing trials in November 2014. Selection criteria Randomised controlled trials of people of all ages with muscle cramps in any location and of any cause, treated with quinine or its derivatives. Data collection and analysis Three review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We contacted study authors for additional information. For comparisons including more than one trial, we assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Main results We identified 23 trials with a total of 1586 participants. Fifty‐eight per cent of these participants were from five unpublished studies. Quinine was compared to placebo (20 trials, n = 1140), vitamin E (four trials, n = 543), a quinine‐vitamin E combination (three trials, n = 510), a quinine‐theophylline combination (one trial, n = 77), and xylocaine injections into the gastrocnemius muscle (one trial, n = 24). The most commonly used quinine dosage was 300 mg/day (range 200 to 500 mg). We found no new trials for inclusion when searches were updated in 2014. The risk of bias in the trials varied considerably. All 23 trials claimed to be randomised, but only a minority described randomisation and allocation concealment adequately. Compared to placebo, quinine significantly reduced cramp number over two weeks by 28%, cramp intensity by 10%, and cramp days by 20%. Cramp duration was not significantly affected. A significantly greater number of people suffered minor adverse events on quinine than placebo (risk difference (RD) 3%, 95% confidence interval (CI) 0% to 6%), mainly gastrointestinal symptoms. Overdoses of quinine have been reported elsewhere to cause potentially fatal adverse effects, but in the included trials there was no significant difference in major adverse events compared with placebo (RD 0%, 95% CI ‐1% to 2%). One participant suffered from thrombocytopenia (0.12% risk) on quinine. A quinine‐vitamin E combination, vitamin E alone, and xylocaine injections into gastrocnemius were not significantly different to quinine across all outcomes, including adverse effects. Based on a single trial comparison, quinine alone was significantly less effective than a quinine‐theophylline combination but with no significant differences in adverse events. Authors' conclusions There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that with use up to 60 days, the incidence of serious adverse events is not significantly greater than for placebo in the identified trials, but because serious adverse events can be rarely fatal, in some countries prescription of quinine is severely restricted. Evidence from single trials suggests that theophylline combined with quinine improves cramps more than quinine alone, and the effects of xylocaine injections into gastrocnemius are not significantly different to quinine across all outcomes. Low or moderate quality evidence shows no significant difference between quinine and vitamin E or quinine and quinine‐vitamin E mixture. Further research into these alternatives, as well other pharmacological and non‐pharmacological treatments, is thus warranted. There is no evidence to judge optimal dosage or duration of quinine treatment. Further studies using different dosages and measurement of serum quinine levels will allow a therapeutic range to be defined for muscle cramp. Because serious adverse events are not common, large population studies are required to more accurately inform incidence. Longer lengths of follow‐up in future trials will help determine the duration of action following cessation of quinine as well as long‐term adverse events. The search for new therapies, pharmacological and nonpharmacological, should continue and further trials should compare vitamin E, quinine‐vitamin E combination, and quinine‐theophylline mixture with quinine. Plain language summary Quinine for muscle cramps Review question We reviewed the evidence about the effect of quinine on muscle cramps. Background Muscle cramps can occur anywhere and in anyone; however, leg cramps are especially common in older people. Quinine is a medicine which has been used to treat cramps for many years. There is conflicting evidence for its ability to reduce cramps. Quinine can cause serious, even fatal adverse events, especially in overdosage. Study characteristics This review includes 23 trials, with 1586 participants. The trials compared quinine or quinine‐based medicines against inactive treatment (placebo) or other active treatments. We found no new studies when we searched the medical literature again and updated the review in 2014. Key results and quality of the evidence The risk of bias in the included trials varied considerably. All 23 trials claimed to be randomised, but many failed to clearly describe how participants were assigned to treatments. There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that there are more minor adverse events with quinine compared to placebo but no increase in major adverse events. However, there are reliable reports from other sources that an overdose of quinine can cause serious harm including death. Low or moderate quality evidence shows there is no significant difference when comparing quinine to vitamin E or to a quinine‐vitamin E mixture. There is evidence from one trial that theophylline combined with quinine improves cramps more than quinine alone. In a single trial there was no significant difference when comparing quinine to xylocaine injections. More research is needed to clarify the best dose and duration of treatment, as well as alternatives to quinine for cramps. The evidence is current to October 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El‐Tawil, S, Al Musa, T, Valli, H, Lunn, MPT, Brassington, R, El‐Tawil, T, Weber, M", "articleTypes": [], "doi": "10.1002/14651858.CD005044.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.096Z" }, { "id": "73f69018-ac4c-4800-a5ad-a18c9d6580a5", "pmid": "", "title": "Population‐level interventions in government jurisdictions for dietary sodium reduction", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McLaren, L, Sumar, N, Barberio, AM, Trieu, K, Lorenzetti, DL, Tarasuk, V, Webster, J, Campbell, NRC", "articleTypes": [], "doi": "10.1002/14651858.CD010166.pub2 AB - Abstract - Background Excess dietary sodium consumption is a risk factor for high blood pressure, stroke and cardiovascular disease. Currently, dietary sodium consumption in almost every country is too high. Excess sodium intake is associated with high blood pressure, which is common and costly and accounts for significant burden of disease. A large number of jurisdictions worldwide have implemented population‐level dietary sodium reduction initiatives. No systematic review has examined the impact of these initiatives. Objectives • To assess the impact of population‐level interventions for dietary sodium reduction in government jurisdictions worldwide. • To assess the differential impact of those initiatives by social and economic indicators. Search methods We searched the following electronic databases from their start date to 5 January 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); Cochrane Public Health Group Specialised Register; MEDLINE; MEDLINE In Process & Other Non‐Indexed Citations; EMBASE; Effective Public Health Practice Project Database; Web of Science; Trials Register of Promoting Health Interventions (TRoPHI) databases; and Latin American Caribbean Health Sciences Literature (LILACS). We also searched grey literature, other national sources and references of included studies. This review was conducted in parallel with a comprehensive review of national sodium reduction efforts under way worldwide ( Trieu 2015 ), through which we gained additional information directly from country contacts. We imposed no restrictions on language or publication status. Selection criteria We included population‐level initiatives (i.e. interventions that target whole populations, in this case, government jurisdictions, worldwide) for dietary sodium reduction, with at least one pre‐intervention data point and at least one post‐intervention data point of comparable jurisdiction. We included populations of all ages and the following types of study designs: cluster‐randomised, controlled pre‐post, interrupted time series and uncontrolled pre‐post. We contacted study authors at different points in the review to ask for missing information. Data collection and analysis Two review authors extracted data, and two review authors assessed risk of bias for each included initiative. We analysed the impact of initiatives by using estimates of sodium consumption from dietary surveys or urine samples. All estimates were converted to a common metric: salt intake in grams per day. We analysed impact by computing the mean change in salt intake (grams per day) from pre‐intervention to post‐intervention. Main results We reviewed a total of 881 full‐text documents. From these, we identified 15 national initiatives, including more than 260,000 people, that met the inclusion criteria. None of the initiatives were provided in lower‐middle‐income or low‐income countries. All initiatives except one used an uncontrolled pre‐post study design. Because of high levels of study heterogeneity (I 2 > 90%), we focused on individual initiatives rather than on pooled results. Ten initiatives provided sufficient data for quantitative analysis of impact (64,798 participants). As required by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) method, we graded the evidence as very low due to the risk of bias of the included studies, as well as variation in the direction and size of effect across the studies. Five of these showed mean decreases in average daily salt intake per person from pre‐intervention to post‐intervention, ranging from 1.15 grams/day less (Finland) to 0.35 grams/day less (Ireland). Two initiatives showed mean increase in salt intake from pre‐intervention to post‐intervention: Canada (1.66) and Switzerland (0.80 grams/day more per person); however in both countries the pre‐intervention data point was from several years prior to the initiation of the intervention. The remaining initiatives did not show a statistically significant mean change. Seven of the 10 initiatives were multi‐component and incorporated intervention activities of a structural nature (e.g. food product reformulation, food procurement policy in specific settings). Of those seven initiatives, four showed a statistically significant mean decrease in salt intake from pre‐intervention to post‐intervention, ranging from Finland to Ireland (see above), and one showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention (Switzerland; see above). Nine initiatives permitted quantitative analysis of differential impact by sex (men and women separately). For women, three initiatives (China, Finland, France) showed a statistically significant mean decrease, four (Austria, Netherlands, Switzerland, United Kingdom) showed no significant change and two (Canada, United States) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. For men, five initiatives (Austria, China, Finland, France, United Kingdom) showed a statistically significant mean decrease, three (Netherlands, Switzerland, United States) showed no significant change and one (Canada) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. Information was insufficient to indicate whether a differential change in mean salt intake occurred from pre‐intervention to post‐intervention by other axes of equity included in the PROGRESS framework (e.g. education, place of residence). We identified no adverse effects of these initiatives. The number of initiatives was insufficient to permit other subgroup analyses, including stratification by intervention type, economic status of country and duration (or start year) of the initiative. Many studies had methodological strengths, including large, nationally representative samples of the population and rigorous measurement of dietary sodium intake. However, all studies were scored as having high risk of bias, reflecting the observational nature of the research and the use of an uncontrolled study design. The quality of evidence for the main outcome was low. We could perform a sensitivity analysis only for impact. Authors' conclusions Population‐level interventions in government jurisdictions for dietary sodium reduction have the potential to result in population‐wide reductions in salt intake from pre‐intervention to post‐intervention, particularly if they are multi‐component (more than one intervention activity) and incorporate intervention activities of a structural nature (e.g. food product reformulation), and particularly amongst men. Heterogeneity across studies was significant, reflecting different contexts (population and setting) and initiative characteristics. Implementation of future initiatives should embed more effective means of evaluation to help us better understand the variation in the effects. Plain language summary National government initiatives to reduce salt intake in populations The problem 
 In almost all countries worldwide, most people eat too much salt. This is a problem because eating too much salt can cause high blood pressure, which can lead to health problems such as heart disease and stroke. To reduce the amount of salt eaten, governments in many countries have developed national salt reduction initiatives. The review question 
 Our aim was to examine whether national salt reduction initiatives have been effective in reducing the amount of salt consumed in those populations. Study characteristics 
 We searched research papers and government reports and had direct communication with individuals working in salt reduction in their respective countries. The evidence is current as of 5 January 2015, when we last searched electronic databases. Initiatives in 15 countries met the inclusion criteria. Ten of these countries provided sufficient data for quantitative analysis, gathered from studies that included 64,798 participants. Initiatives ranged from one activity (e.g. in Japan, which at the time of writing had a public information campaign) to many activities (e.g. in the United Kingdom, which provided five activities including on‐package nutrition information, restrictions on marketing to children and food product reformulation). Of the 15 countries that met inclusion criteria, seven provided information about funding source, of which six reported non‐industry funding. The other eight countries did not report a funding source for one or more data point(s). Key results and quality of the evidence 
 Five of the 10 countries included in the quantitative analysis (China, Finland, France, Ireland and England) showed a decrease in salt intake after the intervention. Two of the 10 countries (Canada, Switzerland) showed an increase in salt intake after the intervention, however, in both countries the only data available were from several years prior to the intervention starting. Because the initiatives were very different, we cannot present an overall finding of whether these types of initiatives work. When we focused on the subset of seven countries whose salt reduction initiatives included multiple components and were not focused solely on educating the public, we found that more than half (four of seven) showed a decrease in salt intake from pre‐intervention to post‐intervention. When we examined the nine initiatives that analysed men and women separately, we found that amongst men, more than half (five of nine) showed a decrease in salt intake after the intervention. Amongst women, the pattern of findings was less clear, with three of nine interventions showing a decrease, two showing an increase and four showing no change in salt intake. Low‐bias study designs, such as randomised controlled trials, typically are not suitable for evaluating complex initiatives such as these; therefore, we rated all of the studies included in this review as having low methodological quality. Large nationally representative samples of the population and careful measurement of dietary sodium intake were strengths of several studies. However, because of study design limitations, the trustworthiness of study results is not clear. Overall, our results show that national government initiatives have the potential to achieve population‐wide reductions in salt intake, especially amongst men, and particularly if they employ more than one strategy and include structural activities such as food product reformulation (i.e. food companies putting less salt in food products). The wide variation of results across the studies we found presents a challenge in interpreting the current evidence and this warrants more research to help us understand this.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.809Z" }, { "id": "7402d14e-da19-4138-80dc-184e14581d04", "pmid": "", "title": "Antihypertensive drug therapy for mild to moderate hypertension during pregnancy", "imported": false, "abstract": "Abstract - Background Antihypertensive drugs are often used in the belief that lowering blood pressure will prevent progression to more severe disease, and thereby improve pregnancy outcome. This Cochrane Review is an updated review, first published in 2001 and subsequently updated in 2007 and 2014. Objectives To assess the effects of antihypertensive drug treatments for women with mild to moderate hypertension during pregnancy. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (13 September 2017), and reference lists of retrieved studies. Selection criteria All randomised trials evaluating any antihypertensive drug treatment for mild to moderate hypertension during pregnancy, defined as systolic blood pressure 140 to 169 mmHg and/or diastolic blood pressure 90 to 109 mmHg. Comparisons were of one or more antihypertensive drug(s) with placebo, with no antihypertensive drug, or with another antihypertensive drug, and where treatment was planned to continue for at least seven days. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results For this update, we included 63 trials (data from 58 trials, 5909 women), with moderate to high risk of bias overall. We carried out GRADE assessments for the main 'antihypertensive drug versus placebo/no antihypertensive drug' comparison only. Evidence was graded from very low to moderate certainty, with downgrading mainly due to design limitations and imprecision.For many outcomes, trials contributing data evaluated different hypertensive drugs; while we did not downgrade for this indirectness, results should be interpreted with caution. Antihypertensive drug versus placebo/no antihypertensive drug (31 trials, 3485 women) Primary outcomes: moderate‐certainty evidence suggests that use of antihypertensive drug(s) probably halves the risk of developing severe hypertension (risk ratio (RR) 0.49; 95% confidence interval (CI) 0.40 to 0.60; 20 trials, 2558 women), but may have little or no effect on the risk of proteinuria/pre‐eclampsia (average risk ratio (aRR) 0.92; 95% CI 0.75 to 1.14; 23 trials, 2851 women; low‐certainty evidence). Moderate‐certainty evidence also shows that antihypertensive drug(s) probably have little or no effect in the risk of total reported fetal or neonatal death (including miscarriage) (aRR 0.72; 95% CI 0.50 to 1.04; 29 trials, 3365 women), small‐for‐gestational‐age babies (aRR 0.96; 95% CI 0.78 to 1.18; 21 trials, 2686 babies) or preterm birth less than 37 weeks (aRR 0.96; 95% CI 0.83 to 1.12; 15 trials, 2141 women). Secondary outcomes: we are uncertain of the effect of antihypertensive drug(s) on the risk of maternal death , severe pre‐eclampsia , or eclampsia, or impaired long‐term growth and development of the baby in infancy and childhood , because the certainty of this evidence is very low. There may be little or no effect on the risk of changed/stopped drugs due to maternal side‐effects, or admission to neonatal or intensive care nursery (low‐certainty evidence). There is probably little or no difference in the risk of elective delivery (moderate‐certainty evidence). Antihypertensive drug versus another antihypertensive drug (29 trials, 2774 women) Primary outcomes: beta blockers and calcium channel blockers together in the meta‐analysis appear to be more effective than methyldopa in avoiding an episode of severe hypertension (RR 0.70; 95% CI 0.56 to 0.88; 11 trials, 638 women). There was also an increase in this risk when other antihypertensive drugs were compared with calcium channel blockers (RR 1.86; 95% CI 1.09 to 3.15; 5 trials, 223 women), but no evidence of a difference when methyldopa and calcium channel blockers together were compared with beta blockers (RR1.18, 95% CI 0.95 to 1.48; 10 trials, 692 women). No evidence of a difference in the risk of proteinuria/pre‐eclampsia was found when alternative drugs were compared with methyldopa (aRR 0.78; 95% CI 0.58 to 1.06; 11 trials, 997 women), with calcium channel blockers (aRR: 1.24, 95% CI 0.70 to 2.19; 5 trials, 375 women), or with beta blockers (aRR 1.21, 95% CI 0.88 to 1.67; 12 trials, 1107 women). For the babies, we found no evidence of a difference in the risk of total reported fetal or neonatal death (including miscarriage) when comparing other antihypertensive drugs with methyldopa (aRR 0.77, 95% CI 0.52 to 1.14; 22 trials, 1791 babies), with calcium channel blockers (aRR 0.90, 95% CI 0.52 to 1.57; nine trials, 700 babies), or with beta blockers (aRR: 1.23, 95% CI 0.81 to 1.88; 19 trials, 1652 babies); nor in the risk for small‐for‐gestational age in the comparison with methyldopa (aRR 0.79, 95% CI 0.52 to 1.20; seven trials, 597 babies), with calcium channel blockers (aRR 1.05, 95% CI 0.64 to 1.73; four trials, 200 babies), or with beta blockers (average RR 1.13, 95% CI 0.80 to 1.60; 7 trials, 680 babies). No evidence of an overall difference among groups in the risk of preterm birth (less than 37 weeks) was found in the comparison with methyldopa (aRR: 0.91; 95% CI 0.68 to 1.22; 11 trials, 835 women), with calcium channel blockers (aRR 0.85, 95% CI 0.59 to 1.23; six trials, 330 women), or with beta blockers (aRR 1.22, 95% CI 0.90 to 1.66; 9 trials, 806 women). Secondary outcomes: There were no cases of maternal death and eclampsia. There is no evidence of a difference in the risk of severe pre‐eclampsia , changed/stopped drug due to maternal side‐effects , elective delivery, admission to neonatal or intensive care nursery when other antihypertensive drugs are compared with methyldopa, calcium channel blockers or beta blockers. Impaired long‐term growth and development in infancy and childhood was not reported for these comparisons. Authors' conclusions Antihypertensive drug therapy for mild to moderate hypertension during pregnancy reduces the risk of severe hypertension. The effect on other clinically important outcomes remains unclear. If antihypertensive drugs are used, beta blockers and calcium channel blockers appear to be more effective than the alternatives for preventing severe hypertension. High‐quality large sample‐sized randomised controlled trials are required in order to provide reliable estimates of the benefits and adverse effects of antihypertensive treatment for mild to moderate hypertension for both mother and baby, as well as costs to the health services, women and their families. Plain language summary Antihypertensive drug therapy for mild to moderate hypertension during pregnancy What is the issue? The aim of this review was to determine the benefits and adverse effects of blood pressure‐lowering drugs (antihypertensive drugs) for pregnant women with mild to moderate hypertension (high blood pressure). The other aim was to assess the benefits and adverse effects of these drugs for their babies. Why is this important? During pregnancy, up to one in 10 women have blood pressure readings that are above normal. For some women, their blood pressure remains slightly high (termed ‘mild to moderate high blood pressure’), with no apparent complications. Some of these women go on to develop very high blood pressure. Very high blood pressure can result in a medical emergency if it affects the woman’s organs (such as her liver, or brain in the form of a stroke). Also, it can seriously affect the growth and health of her baby. Drugs that lower blood pressure are used to treat mild to moderate high blood pressure, in the belief that this treatment will prevent the blood pressure from continuing to rise. Over the years, information from good quality research studies has been contradictory, so we cannot be sure if this drug treatment is worthwhile. What evidence did we find? This Cochrane Review is an update of a review that was first published in 2001 and updated in 2007 and 2014. We searched for randomised controlled trials in September 2017, and this review now includes data from 58 trials involving more than 5900 women. A total of 31 trials with 3485 women compared a number of different blood pressure‐lowering drugs to a placebo or no treatment. There were a further 29 trials involving 2774 women which compared one blood pressure‐lowering drug with another one. The evidence showed that treating pregnant women who had moderately raised blood pressure with blood pressure‐lowering drugs probably halved the number of the women developing severe high blood pressure (20 trials, 2558 women). However, blood pressure‐lowering drugs probably had little or no effect on the risk of the baby dying (29 trials, 3365 women), and there is insufficient data on maternal deaths to make a judgement on whether this risk is lowered (five trials, 525 women). The use of blood pressure‐lowering drugs may have little or no effect on the number of the women developing pre‐eclampsia (23 trials, 2851 women), or the number of women who had to change drugs because of side‐effects (16 trials, 1503 women). We found no difference in the number of babies born preterm, that is before 37 weeks (15 trials, 2141 women). There was also no difference in the number of babies born small for their gestational age (21 trials, 2686 babies). The quality of the evidence was mostly moderate (but for pre‐eclampsia it was low). This was due to a number of small studies, and problems with the way the studies were undertaken. The available evidence is still insufficient to demonstrate if there is any antihypertensive drug that is better than another. However, beta blockers and calcium channel blockers seem to be better than the alternative drugs for blood pressure control. What does this mean? More research is needed in order to confirm the true effect of antihypertensive drugs in mothers and in their babies, and to identify the drug which would be best.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abalos, E; Duley, L; Steyn, DW; Gialdini, C", "articleTypes": [], "doi": "10.1002/14651858.CD002252.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "744df142-5ce3-48d6-949d-d619791483fe", "pmid": "", "title": "Souvenaid for Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Souvenaid is a dietary supplement with a patented composition (Fortasyn Connect™)which is intended to be used by people with Alzheimer's disease (AD). It has been designed to support the formation and function of synapses in the brain, which are thought to be strongly correlated with cognitive function. If effective, it might improve symptoms of Alzheimer's disease and also prevent the progression from prodromal Alzheimer's disease to dementia. We sought in this review to examine the evidence for this proposition. Objectives To assess the effects of Souvenaid on incidence of dementia, cognition, functional performance, and safety in people with Alzheimer's disease. Search methods We searched ALOIS, i.e. the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science (ISI Web of Science), Cinahl (EBSCOhost), Lilacs (BIREME), and clinical trials registries up to 24 June 2020. We also reviewed citations of reference lists of landmark papers, reviews, and included studies for additional studies and assessed their suitability for inclusion in the review. Selection criteria We included randomised, placebo‐controlled trials which evaluated Souvenaid in people diagnosed with mild cognitive impairment (MCI) due to AD (also termed prodromal AD) or with dementia due to AD, and with a treatment duration of at least 16 weeks. Data collection and analysis Our primary outcome measures were incidence of dementia, global and specific cognitive function, functional performance, combined cognitive‐functional outcomes and adverse events. We selected studies, extracted data, assessed the quality of trials and intended to conduct meta‐analyses according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We present all outcomes grouped by stage of AD. Main results We included three randomised, placebo‐controlled trials investigating Souvenaid in 1097 community‐dwelling participants with Alzheimer's disease. One study each included participants with prodromal AD, mild AD dementia and mild‐to‐moderate AD dementia. We rated the risks of bias of all trials as low. One study (in prodromal AD) was funded by European grants. The other two studies were funded by the manufacturer of Souvenaid. One trial investigated the incidence of dementia in people with prodromal AD at baseline, and found little to no difference between the Souvenaid group and the placebo group after 24 months (RR 1.09, 95% CI 0.82 to 1.43; 1 trial, 311 participants; moderate quality of evidence). In prodromal AD, and in mild and mild‐to‐moderate Alzheimer's disease dementia, Souvenaid probably results in little or no difference in global or specific cognitive functions (moderate quality of evidence). Everyday function, or the ability to perform activities of daily living, were measured in mild and mild‐to‐moderate AD dementia. Neither study found evidence of a difference between the groups after 24 weeks of treatment (moderate quality of evidence). Two studies investigated combined cognitive‐functional outcomes with the Clinical Dementia Rating Sum of Boxes and observed conflicting results. Souvenaid probably results in slight improvement, which is below estimates of meaningful change, in participants with prodromal Alzheimer's disease after 24 months (moderate quality of evidence), but probably has little to no effect in mild‐to‐moderate Alzheimer's disease dementia after 24 weeks (moderate quality of evidence). Adverse effects observed were low in all trials, and the available data were insufficient to determine any connection with Souvenaid. Authors' conclusions Two years of treatment with Souvenaid probably does not reduce the risk of progression to dementia in people with prodromal AD. There is no convincing evidence that Souvenaid affects other outcomes important to people with AD in the prodromal stage or mild‐to‐moderate stages of dementia. Conflicting evidence on combined cognitive‐functional outcomes in prodromal AD and mild AD dementia warrants further investigation. Adverse effects of Souvenaid seem to be uncommon, but the evidence synthesised in this review does not permit us to make a definitive statement on the long‐term tolerability of Souvenaid. The effects of Souvenaid in more severe AD dementia or in people with AD at risk of nutritional deficiencies remain unclear. Plain language summary The dietary supplement Souvenaid for preventing dementia or delaying cognitive decline in people with Alzheimer's disease Review question We investigated whether people with mild cognitive impairment (MCI) due to Alzheimer's disease (AD) can reduce their risk of developing dementia with a patented dietary supplement called Souvenaid. We also investigated the effect of Souvenaid on memory or other thinking skills, ability to carry out daily activities, and side effects in people with MCI or any stage of dementia due to AD. Background Alzheimer's disease is a brain disease. It is the commonest cause of dementia among older people. A person is said to have dementia when there has been a decline in their memory and thinking skills which is severe enough to stop them being fully independent in all their daily activities. Because AD develops slowly, it is also possible to pick up symptoms before dementia is fully developed. This pre‐dementia stage, when people with AD have a detectable decline in memory and thinking skills but are still able to manage their usual activities independently, is known as mild cognitive impairment due to AD, or 'prodromal' AD. Souvenaid is a patented mix of vitamins and minerals (Fortasyn Connect™) which was designed to improve brain function in AD. It is a drink which is to be taken once a day. It is intended to be consumed under medical supervision, in addition to the usual diet. Search for evidence We systematically searched for randomised controlled trials (RCTs) which were published up to June 2020 and which compared treatment with Souvenaid for at least 16 weeks with treatment with a dummy supplement (a placebo). For the comparison to be fair, it had to be decided randomly whether each participant was given Souvenaid or the placebo. Key results We found three RCTs with a total of 1097 participants to include in the review. Two of the trials investigated Souvenaid in people with dementia over a treatment period of 24 weeks. One of these included 527 participants with mild‐to‐moderate dementia due to AD and the other included 259 participants with mild dementia due to AD. The third trial investigated the use of Souvenaid for two years in 311 people with prodromal AD. We considered all of the trials to be well‐designed, but because of differences between them in the severity of the participants' symptoms and in the way the researchers measured their results, we were not able to combine the data numerically from the single trials. All the results we report are therefore based on single trials, which leads us to have only moderate confidence in the findings of this review. This means that results could be changed by further research. We found that people with prodromal AD who took Souvenaid daily for two years were probably no more or less likely than those taking placebo to develop dementia. Souvenaid probably had little or no effect on measures of memory or other thinking skills in people with prodromal AD (after two years of treatment) or with mild or mild‐to‐moderate dementia due to AD (after 24 weeks of treatment). It also probably had little or no effect on the ability of people with mild or mild‐to‐moderate dementia due to AD to manage everyday activities (again after 24 weeks). Two studies used an outcome scale which combined memory and thinking skills with practical skills (described as a combined cognitive‐functional outcome). There was probably a small benefit of Souvenaid on this outcome among people with prodromal AD who took Souvenaid for two years. However, there was probably little or no effect of Souvenaid on this outcome among people with mild‐to‐moderate AD dementia who took it for 24 weeks. There were only a few adverse events reported in the trials, and it was not possible to know whether any of them were side effects of Souvenaid. Study funding sources Two studies were funded by the manufacturer of Souvenaid. The third study (in prodromal AD) was funded by European grants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Burckhardt, M; Watzke, S; Wienke, A; Langer, G; Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD011679.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "747f6224-e079-4074-af2b-fa675beb71a4", "pmid": "", "title": "Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people", "imported": false, "abstract": "Abstract - Background Folate deficiency can result in congenital neural tube defects and megaloblastic anaemia. Low folate levels may be due to insufficient dietary intake or inefficient absorption, but impaired metabolic utilization also occurs. Because B12 deficiency can produce a similar anaemia to folate deficiency, there is a risk that folate supplementation can delay the diagnosis of B12 deficiency, which can cause irreversible neurological damage. Folic acid supplements may sometimes therefore include vitamin B12 supplements with simultaneous administration of vitamin B12. Lesser degrees of folate inadequacy are associated with high blood levels of the amino acid homocysteine which has been linked with the risk of arterial disease, dementia and Alzheimer's disease. There is therefore interest in whether dietary supplementation can improve cognitive function in the elderly. However, any apparent benefit from folic acid which was given in combination with B12 needs to be \"corrected\" for any effect of vitamin B12 alone. A separate Cochrane review of vitamin B12 and cognitive function has therefore been published. Objectives To examine the effects of folic acid supplementation, with or without vitamin B12, on elderly healthy or demented people, in preventing cognitive impairment or retarding its progress. Search methods Trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 10 October 2007 using the terms: folic acid, folate, vitamin B9, leucovorin, methyltetrahydrofolate, vitamin B12, cobalamin and cyanocobalamin. This Register contains references from all major health care databases and many ongoing trials databases. In addition MEDLINE, EMBASE, CINAHL, PsychINFO and LILACS were searched (years 2003‐2007) for additional trials of folate with or without vitamin B12 on healthy elderly people. Selection criteria All double‐blind, placebo‐controlled, randomized trials, in which supplements of folic acid with or without vitamin B12 were compared with placebo for elderly healthy people or people with any type of dementia or cognitive impairment. Data collection and analysis The reviewers independently applied the selection criteria and assessed study quality. One reviewer extracted and analysed the data. In comparing intervention with placebo, weighted mean differences and standardized mean difference or odds ratios were estimated. Main results Eight randomized controlled trials fulfilled the inclusion criteria for this review. Four trials enrolled healthy older people, and four recruited participants with mild to moderate cognitive impairment or dementia with or without diagnosed folate deficiency. Pooling the data was not possible owing to heterogeneity in sample selections, outcomes, trial duration, and dosage. Two studies involved a combination of folic acid and vitamin B12. There is no adequate evidence of benefit from folic acid supplemententation with or without vitamin B12 on cognitive function and mood of unselected healthy elderly people. However, in one trial enrolling a selected group of healthy elderly people with high homocysteine levels, 800 mcg/day folic acid supplementation over three years was associated with significant benefit in terms of global functioning (WMD 0.05, 95% CI 0.004 to 0.096, P = 0.033); memory storage (WMD 0.14, 95% CI 0.04 to 0.24, P = 0.006) and information‐processing speed (WMD 0.09, 95% CI 0.02 to 0.16, P = 0.016). Four trials involved people with cognitive impairment. In one pilot trial enrolling people with Alzheimer's disease, the overall response to cholinesterase inhibitors significantly improved with folic acid at a dose of 1mg/day (odds ratio: 4.06, 95% CI 1.22 to 13.53; P = 0.02) and there was a significant improvement in scores on the Instrumental Activities of Daily Living and the Social Behaviour subscale of the Nurse's Observation Scale for Geriatric Patients (WMD 4.01, 95% CI 0.50 to 7.52, P = 0.02). Other trials involving people with cognitive impairment did not show any benefit in measures of cognitive function from folic acid, with or without vitamin B12. Folic acid plus vitamin B12 was effective in reducing serum homocysteine concentrations (WMD ‐5.90, 95% CI ‐8.43 to ‐3.37, P < 0.00001). Folic acid was well tolerated and no adverse effects were reported. Authors' conclusions The small number of studies which have been done provide no consistent evidence either way that folic acid, with or without vitamin B12, has a beneficial effect on cognitive function of unselected healthy or cognitively impaired older people. In a preliminary study, folic acid was associated with improvement in the response of people with Alzheimer's disease to cholinesterase inhibitors. In another, long‐term use appeared to improve the cognitive function of healthy older people with high homocysteine levels. More studies are needed on this important issue. Plain language summary No evidence that folic acid with or without vitamin B12 improves cognitive function of unselected elderly people with or without dementia. Long‐term supplementation may benefit cognitive function of healthy older people with high homocysteine levels In the economically developed world, folate deficiency is one of the commonest vitamin deficiencies. Several reports suggest a higher prevalence of various psychiatric disorders in elderly people with folate deficiency. There is interest in whether dietary supplements of folic acid (an artificial chemical analogue of naturally occurring folates) can improve cognitive function of people at risk of cognitive decline associated with ageing or dementia, whether by affecting homocysteine metabolism or through other mechanisms. Eight trials met the criteria for inclusion. It was not possible to pool the data because the trials studied different populations, tested folic acid in different doses, and used different outcome measures. There were two trials of folic acid in conjunction with B12. The analysis showed significant benefit of folic acid over placebo in some measures of cognition in a long‐term trial recruiting elderly people with high homocysteine levels from a general population. In one pilot trial, 1 mg/day of folic acid was associated with significant improvement in behavioural response to cholinesterase inhibitors in people with Alzheimer's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Malouf, R; Grimley Evans, J", "articleTypes": [], "doi": "10.1002/14651858.CD004514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "74db0267-7335-4db2-a433-3bfff3a865f8", "pmid": "", "title": "Treatment for recurrent vulvovaginal candidiasis (thrush)", "imported": false, "abstract": "Abstract - Background Recurrent vulvovaginal candidiasis (RVVC) affects up to 5% of women. No comprehensive systematic review of treatments for RVVC has been published. Objectives The primary objective was to assess the effectiveness and safety of pharmacological and non‐pharmacological treatments for RVVC. The secondary objective was to assess patient preference of treatment options. Search methods We conducted electronic searches of bibliographic databases, including CENTRAL, MEDLINE, Embase, and CINAHL (search date 6 October 2021). We also handsearched reference lists of identified trials and contacted authors of identified trials, experts in RVVC, and manufacturers of products for vulvovaginal candidiasis. Selection criteria We considered all published and unpublished randomised controlled trials evaluating RVVC treatments for at least six months, in women with four or more symptomatic episodes of vulvovaginal candidiasis in the past year. We excluded women with immunosuppressive disorders or taking immunosuppressant medication. We included women with diabetes mellitus and pregnant women. Diagnosis of RVVC must have been confirmed by presence of symptoms and a positive culture and/or microscopy. We included all drug and non‐drug therapies and partner treatment, assessing the following primary outcomes: • number of clinical recurrences per participant per year (recurrence defined as clinical signs and positive culture/microscopy);
• proportion of participants with at least one clinical recurrence during the treatment and follow‐up period; and
• adverse events. Data collection and analysis Two authors independently reviewed titles and abstracts to identify eligible trials. Duplicate data extraction was completed independently by two authors. We assessed risk of bias as described in the Cochrane Handbook for Systematic Reviews of Interventions . We used the fixed‐effects model for pooling and expressed the results as risk ratio (RR) with 95% confidence intervals (CI). Where important statistical heterogeneity was present we either did not pool data (I 2 > 70%) or used a random‐effects model (I 2 40‐70%). We used the GRADE tool to assess overall certainty of the evidence for the pooled primary outcomes. Main results Studies: Twenty‐three studies involving 2212 women aged 17 to 67 years met the inclusion criteria. Most studies excluded pregnant women and women with diabetes or immunosuppression. The predominant species found on culture at study entry was Candida albicans . Overall, the included studies were small (<100 participants). Six studies compared antifungal treatment with placebo (607 participants); four studies compared oral versus topical antifungals (543 participants); one study compared different oral antifungals (45 participants); two studies compared different dosing regimens for antifungals (100 participants); one study compared two different dosing regimens of the same topical agent (23 participants); one study compared short versus longer treatment duration (26 participants); two studies assessed the effect of partner treatment (98 participants); one study compared a complementary treatment (Lactobacillus vaginal tablets and probiotic oral tablets) with placebo (34 participants); three studies compared complementary medicine with antifungals (354 participants); two studies compared 'dermasilk' briefs with cotton briefs (130 participants); one study examined Lactobacillus vaccination versus heliotherapy versus ciclopyroxolamine (90 participants); one study compared CAM treatments to an antifungal treatment combined with CAM treatments (68 participants). We did not find any studies comparing different topical antifungals. Nine studies reported industry funding, three were funded by an independent source and eleven did not report their funding source. Risk of bias: Overall, the risk of bias was high or unclear due to insufficient blinding of allocation and participants and poor reporting. Primary outcomes: Meta‐analyses comparing drug treatments (oral and topical) with placebo or no treatment showed there may be a clinically relevant reduction in clinical recurrence at 6 months (RR 0.36, 95% CI 0.21 to 0.63; number needed to treat for an additional beneficial outcome (NNTB) = 2; participants = 607; studies = 6; I² = 82%; low‐certainty evidence) and 12 months (RR 0.80, 95% CI 0.72 to 0.89; NNTB = 6; participants = 585; studies = 6; I² = 21%; low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. We are very uncertain whether oral drug treatment compared to topical treatment increases the risk of clinical recurrence at 6 months (RR 1.66, 95% CI 0.83 to 3.31; participants = 206; studies = 3; I² = 0%; very low‐certainty evidence) and reduces the risk of clinical recurrence at 12 months (RR 0.95, 95% CI 0.71 to 1.27; participants = 206; studies = 3; I² = 10%; very low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. Adverse events were scarce across both treatment and control groups in both comparisons. The reporting of adverse events varied amongst studies, was generally of very low quality and could not be pooled. Overall the adverse event rate was low for both placebo and treatment arms and ranged from less than 5% to no side effects or complications. Authors' conclusions In women with RVVC, treatment with oral or topical antifungals may reduce symptomatic clinical recurrences when compared to placebo or no treatment. We were unable to find clear differences between different treatment options (e.g. oral versus topical treatment, different doses and durations). These findings are not applicable to pregnant or immunocompromised women and women with diabetes as the studies did not include or report on them. More research is needed to determine the optimal medication, dose and frequency. Plain language summary The effectiveness and safety of treatments for recurrent vulvovaginal candidiasis (thrush) Review question Cochrane authors set out to investigate the effectiveness and safety of drug treatments or non‐drug treatments (such as complementary and alternative medicines) for women with recurrent vulvovaginal candidiasis (thrush). Background Thrush of the vaginal/vulvar area is caused by Candida , a form of yeast that is commonly found in the vagina as part of normal flora without causing symptoms. For unknown reasons, Candida can start growing and cause symptoms of vulvovaginal candidiasis (commonly named thrush). Symptoms of vulvovaginal thrush include itching, swelling, and irritation of the vaginal and vulval areas. It is estimated that uncomplicated vulvovaginal thrush affects up to 75% of women at some time during their reproductive years. Recurrent vulvovaginal candidiasis (RVVC) occurs when a woman has four or more fungal infections during a 12‐month period. Up to 5% of women suffer from RVVC. Some doctors advise taking antifungals as a prevention, but there are no clear evidence‐based guidelines. Study characteristics We identified 23 studies involving 2212 participants between 17 and 67 years old with a diagnosis of RVVC confirmed by a positive test. The studies compared a range of antifungal medicines (taken by mouth or inserted into the vagina), and some complementary or alternative treatments (such as Lactobacillus vaccines or probiotics and special underwear). The studies reported the effects on recurrence of thrush after 6 and 12 months. Only one study reported the number of clinical recurrences at 12 months. Nine studies reported industry funding, three were funded by an independent source and nine studies did not report their funding source. The evidence is current to October 2021. Key results Six studies (607 participants) compared antifungal medication with placebo or no treatment. Based on low certainty evidence antifungal treatments may give a clinically relevant reduction in clinical recurrence at 6 and 12 months. We are uncertain if oral treatments are better than topical treatments (very low certainty evidence for no difference). Adverse effects of taking antifungal medication to prevent recurrence of thrush were not common. Studies reported on adverse effects differently, making comparisons difficult. More research is needed to determine the optimal medication, dose and frequency. We were unable to determine the effects in women who are pregnant or have diabetes. Certainty of the evidence Our confidence in the evidence was low to very low due to serious concerns about risk of bias, unclear reporting and the limited number of studies that could be combined. This means that new studies might change our confidence in the effects of treatments and our conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Cooke, G; Watson, C; Deckx, L; Pirotta, M; Smith, J; van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009151.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "74ea654d-b36c-4471-9690-2f1b648330ed", "pmid": "", "title": "Physical interventions to interrupt or reduce the spread of respiratory viruses", "imported": false, "abstract": "Abstract - Background Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID‐19) caused by SARS‐CoV‐2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID‐19 pandemic. Objectives To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. Search methods We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies. Selection criteria We included randomised controlled trials (RCTs) and cluster‐RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission. Data collection and analysis We used standard Cochrane methodological procedures. Main results We included 11 new RCTs and cluster‐RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID‐19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID‐19 pandemic. Many studies were conducted during non‐epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID‐19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high‐income countries; crowded inner city settings in low‐income countries; and an immigrant neighbourhood in a high‐income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster‐RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster‐RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza‐like illness (ILI)/COVID‐19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate‐certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory‐confirmed influenza/SARS‐CoV‐2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate‐certainty evidence). Harms were rarely measured and poorly reported (very low‐certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low‐certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low‐certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory‐confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate‐certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low‐certainty evidence). One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non‐inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID‐19 patients. Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta‐analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate‐certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory‐confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low‐certainty evidence), and laboratory‐confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low‐certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low‐certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low‐certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports. Authors' conclusions The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory‐confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under‐investigated. There is a need for large, well‐designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs. Plain language summary Do physical measures such as hand‐washing or wearing masks stop or slow down the spread of respiratory viruses? Key messages 
We are uncertain whether wearing masks or N95/P2 respirators helps to slow the spread of respiratory viruses based on the studies we assessed. Hand hygiene programmes may help to slow the spread of respiratory viruses. How do respiratory viruses spread? 
Respiratory viruses are viruses that infect the cells in your airways: nose, throat, and lungs. These infections can cause serious problems and affect normal breathing. They can cause flu (influenza), severe acute respiratory syndrome (SARS), and COVID‐19. People infected with a respiratory virus spread virus particles into the air when they cough or sneeze. Other people become infected if they come into contact with these virus particles in the air or on surfaces on which they land. Respiratory viruses can spread quickly through a community, through populations and countries (causing epidemics), and around the world (causing pandemics). Physical measures to try to prevent respiratory viruses spreading between people include: · washing hands often; · not touching your eyes, nose, or mouth; · sneezing or coughing into your elbow; · wiping surfaces with disinfectant; · wearing masks, eye protection, gloves, and protective gowns; · avoiding contact with other people (isolation or quarantine); · keeping a certain distance away from other people (distancing); and · examining people entering a country for signs of infection (screening). What did we want to find out? 
We wanted to find out whether physical measures stop or slow the spread of respiratory viruses from well‐controlled studies in which one intervention is compared to another, known as randomised controlled trials. What did we do? 
We searched for randomised controlled studies that looked at physical measures to stop people acquiring a respiratory virus infection. We were interested in how many people in the studies caught a respiratory virus infection, and whether the physical measures had any unwanted effects. What did we find? 
We identified 78 relevant studies. They took place in low‐, middle‐, and high‐income countries worldwide: in hospitals, schools, homes, offices, childcare centres, and communities during non‐epidemic influenza periods, the global H1N1 influenza pandemic in 2009, epidemic influenza seasons up to 2016, and during the COVID‐19 pandemic. We identified five ongoing, unpublished studies; two of them evaluate masks in COVID‐19. Five trials were funded by government and pharmaceutical companies, and nine trials were funded by pharmaceutical companies. No studies looked at face shields, gowns and gloves, or screening people when they entered a country. We assessed the effects of: · medical or surgical masks; · N95/P2 respirators (close‐fitting masks that filter the air breathed in, more commonly used by healthcare workers than the general public); and · hand hygiene (hand‐washing and using hand sanitiser). We obtained the following results: Medical or surgical masks Ten studies took place in the community, and two studies in healthcare workers. Compared with wearing no mask in the community studies only, wearing a mask may make little to no difference in how many people caught a flu‐like illness/COVID‐like illness (9 studies; 276,917 people); and probably makes little or no difference in how many people have flu/COVID confirmed by a laboratory test (6 studies; 13,919 people). Unwanted effects were rarely reported; discomfort was mentioned. N95/P2 respirators Four studies were in healthcare workers, and one small study was in the community. Compared with wearing medical or surgical masks, wearing N95/P2 respirators probably makes little to no difference in how many people have confirmed flu (5 studies; 8407 people); and may make little to no difference in how many people catch a flu‐like illness (5 studies; 8407 people), or respiratory illness (3 studies; 7799 people). Unwanted effects were not well‐reported; discomfort was mentioned. Hand hygiene Following a hand hygiene programme may reduce the number of people who catch a respiratory or flu‐like illness, or have confirmed flu, compared with people not following such a programme (19 studies; 71,210 people), although this effect was not confirmed as statistically significant reduction when ILI and laboratory‐confirmed ILI were analysed separately. Few studies measured unwanted effects; skin irritation in people using hand sanitiser was mentioned. What are the limitations of the evidence? 
Our confidence in these results is generally low to moderate for the subjective outcomes related to respiratory illness, but moderate for the more precisely defined laboratory‐confirmed respiratory virus infection, related to masks and N95/P2 respirators. The results might change when further evidence becomes available. Relatively low numbers of people followed the guidance about wearing masks or about hand hygiene, which may have affected the results of the studies. How up to date is this evidence? 
We included evidence published up to October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jefferson, T; Dooley, L; Ferroni, E; Al-Ansary, LA; van Driel, ML; Bawazeer, GA; Jones, MA; Hoffmann, TC; Clark, J; Beller, EM; Glasziou, PP; Conly, JM", "articleTypes": [], "doi": "10.1002/14651858.CD006207.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "74f3a4e2-1611-4b33-a366-d1c6b19c0ed0", "pmid": "", "title": "Systemic opioids versus other analgesics and sedatives for postoperative pain in neonates", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kinoshita, M, Stempel, KS, Borges do Nascimento, IJ, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD014876.pub2 AB - Abstract - Background Neonates may undergo surgery because of malformations such as diaphragmatic hernia, gastroschisis, congenital heart disease, and hypertrophic pyloric stenosis, or complications of prematurity, such as necrotizing enterocolitis, spontaneous intestinal perforation, and retinopathy of prematurity that require surgical treatment. Options for treatment of postoperative pain include opioids, non‐pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported. The assessment of the effects of opioids is of utmost importance, especially for neonates in substantial pain during the postoperative period. Objectives To evaluate the benefits and harms of systemic opioid analgesics in neonates who underwent surgery on all‐cause mortality, pain, and significant neurodevelopmental disability compared to no intervention, placebo, non‐pharmacological interventions, different types of opioids, or other drugs. Search methods We searched Cochrane CENTRAL, MEDLINE via PubMed and CINAHL in May 2021. We searched the WHO ICTRP, clinicaltrials.gov, and ICTRP trial registries. We searched conference proceedings, and the reference lists of retrieved articles for RCTs and quasi‐RCTs. Selection criteria We included randomized controlled trials (RCTs) conducted in preterm and term infants of a postmenstrual age up to 46 weeks and 0 days with postoperative pain where systemic opioids were compared to 1) placebo or no intervention; 2) non‐pharmacological interventions; 3) different types of opioids; or 4) other drugs. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods, all‐cause mortality during initial hospitalization, major neurodevelopmental disability, and cognitive and educational outcomes in children more than five years old. We used the fixed‐effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) for continuous data. We used GRADE to assess the certainty of evidence for each outcome. Main results We included four RCTs enrolling 331 infants in four countries across different continents. Most studies considered patients undergoing large or medium surgical procedures (including major thoracic or abdominal surgery), who potentially required pain control through opioid administration after surgery. The randomized trials did not consider patients undergoing minor surgery (including inguinal hernia repair) and those individuals exposed to opioids before the beginning of the trial. Two RCTs compared opioids with placebo; one fentanyl with tramadol; and one morphine with paracetamol. No meta‐analyses could be performed because the included RCTs reported no more than three outcomes within the prespecified comparisons. Certainty of the evidence was very low for all outcomes due to imprecision of the estimates (downgrade by two levels) and study limitations (downgrade by one level). Comparison 1: opioids versus no treatment or placebo Two trials were included in this comparison, comparing either tramadol or tapentadol with placebo. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of tramadol compared with placebo on all‐cause mortality during initial hospitalization (RR 0.32, 95% Confidence Interval (CI) 0.01 to 7.70; RD ‐0.03, 95% CI ‐0.10 to 0.05, 71 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 2: opioids versus non‐pharmacological interventions No trials were included in this comparison. Comparison 3: head‐to‐head comparisons of different opioids One trial comparing fentanyl with tramadol was included in this comparison. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of fentanyl compared with tramadol on all‐cause mortality during initial hospitalization (RR 0.99, 95% CI 0.59 to 1.64; RD 0.00, 95% CI ‐0.13 to 0.13, 171 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 4: opioids versus other analgesics and sedatives One trial comparing morphine with paracetamol was included in this comparison. The evidence is very uncertain about the effect of morphine compared with paracetamol on COMFORT pain scores (MD 0.10, 95% CI ‐0.85 to 1.05; 71 participants, 1 study; I² = not applicable). No data were reported on the other critical outcomes, i.e. major neurodevelopmental disability; cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization; retinopathy of prematurity; or intraventricular hemorrhage. Authors' conclusions Limited evidence is available on opioid administration for postoperative pain in newborn infants compared to either placebo, other opioids, or paracetamol. We are uncertain whether tramadol reduces mortality compared to placebo; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether fentanyl reduces mortality compared to tramadol; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether morphine reduces pain compared to paracetamol; none of the studies reported major neurodevelopmental disability, cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization, retinopathy of prematurity, or intraventricular hemorrhage. We identified no studies comparing opioids versus non‐pharmacological interventions. Plain language summary Are opioids the best choice for managing pain in babies after surgery? Key messages • We did not find enough good‐quality evidence about the benefits and risks of opioids (a group of pain‐relieving medicines) to manage pain after surgery in babies. We found only four studies and they had not enrolled enough babies to give reliable results. • Larger, well‐designed studies are needed to give better estimates of the benefits and potential harms of opioids, other medicines and non‐medicine‐based treatments. Why are opioids given to manage pain after surgery in babies? Babies (particularly in the first four weeks after birth) often have to have surgeries. Similar to adults, they need constant pain management after these operations and opioids are commonly used for post‐surgery pain relief in babies. What did we want to find out? We wanted to find out the impact of giving opioids to babies having surgery, compared to: 1) no treatment or placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested); 2) non‐medicine‐based treatments (such as sweet solutions); 3) other medicines; or 4) different types of opioids. What did we do? We searched for studies that compared opioids with the four treatments described above. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included four studies that involved 331 babies. The biggest study was in 171 babies and the smallest study was in 15 babies. • Two studies compared opioids with placebo: it is unclear if opioids have an effect on mortality; no studies reported pain, long‐term development, vision problems (retinopathy of prematurity) or bleeding to the brain (intraventricular hemorrhage). • One study compared one type of opioid to another type of opioid: it is unclear if fentanyl has an effect on mortality compared to tramadol; no studies reported pain, long‐term development, vision problems or bleeding to the brain. • One study compared an opioid to a different type of pain‐relieving medicine: it is unclear if the opioid morphine has an effect on pain compared with paracetamol; no studies reported long‐term development, mortality, vision problems or bleeding to the brain. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results of our outcomes. Also, it is possible that people in the studies were aware of what treatment they were given. Not all the studies provided data about everything that we were interested in. How up‐to‐date is this review? 
We searched for studies that were available up to May 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.128Z" }, { "id": "751cf44b-8356-4f5d-9130-a7887c5243d0", "pmid": "", "title": "Desmopressin for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐old children and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Desmopressin has been used to treat bedwetting since the 1970s. This is an update of a Cochrane review first published in 2000 and last updated in 2006. Objectives To assess the effects of desmopressin on treating nocturnal enuresis in children. Search methods We searched Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched January 2023) and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of desmopressin or desmopressin combined with another intervention for treating nocturnal enuresis in children between five and 16 years old. Data collection and analysis Three review authors independently extracted data and assessed the risk of bias in the eligible trials. We used standard methodological procedures expected by Cochrane. Main results We identified 50 new studies for this review, which now includes 95 studies (8473) participants, of whom 5434 received desmopressin. In this review we continued the assessment of the effect of combination therapy involving desmopressin. The majority of the trials were in children between the ages of five to 16 years in an outpatient setting. The quality of the evidence was assessed as low or very low. The first comparison was desmopressin versus placebo. Desmopressin may reduce the mean number of wet nights per week compared with placebo (MD ‐1.81, 95% CI ‐2.24 to ‐1.39; participants = 1267; studies = 16; low‐certainty evidence). Desmopressin probably leads to more children achieving 14 consecutive dry nights by the end of treatment compared with placebo (RR 3.18, 95% CI 1.75 to 5.80; participants = 922: studies = 11; moderate‐certainty evidence). There may be little to no difference in children experiencing adverse effects with desmopressin compared to placebo (RR 1.11, 95% CI 0.81 to 1.52; participants = 269; studies = 3; low‐certainty evidence). Desmopressin was compared with alarm therapy. It is uncertain if there is any difference between desmopressin compared with alarm training in reducing the number of wet nights per week (MD 0.63, 95% CI ‐0.49 to 1.75; participants = 285; studies = 4; I 2 = 82%; very low‐certainty evidence). There may be little or no difference between desmopressin and alarm therapy in the number of children achieving 14 consecutive dry nights (RR 0.98, 95% CI 0.88 to 1.09; participants = 1530; studies = 15; low‐certainty evidence). There may be little to no difference in children experiencing side effects with desmopressin therapy compared with alarm therapy (RR 1.50, 95% CI 0.33 to 6.78; participants = 461, studies = 4; low‐certainty evidence). We compared desmopressin with other medications, including tricyclics and anticholinergics. It is uncertain if there is any difference between desmopressin compared to tricyclics in reducing the mean number of wet nights per week (MD 0.23, 95% CI ‐ 0.88 to 1.33; participants = 331; studies = 4; I 2 = 79%; very low‐certainty evidence) or in the number of children achieving 14 consecutive dry nights at the end of treatment (RR 0.94, 95% CI 0.63 to 1.38; participants = 371; studies = 7; I 2 = 71%; very low‐certainty evidence). It is uncertain whether children experience more side effects with desmopressin compared with tricyclics (RR 0.29, 95%CI 0.06 to 1.39; participants = 351; studies = 4, very low‐certainty evidence). This review included studies with combination therapies. It is uncertain if desmopressin combined with alarm therapy reduces the mean number of wet nights at the end of treatment compared with alarm monotherapy (MD ‐0.80, 95% CI ‐1.34 to ‐0.25; participants = 528; studies = 6; I 2 = 84%; very low‐certainty evidence); or if it increases the number of children achieving 14 consecutive dry nights (RR 1.25, 95% CI 0.96 to 1.63; participants = 822; studies = 10; very low‐certainty evidence). Desmopressin plus alarm therapy may make little to no difference in children experiencing side effects compared with alarm therapy alone (RR 1.05 95% CI 0.07 to 16.56; participants = 207; studies = 1; low‐certainty evidence). Combining desmopressin with alarm therapy probably reduces the number of wet nights at the end of treatment (MD ‐0.88; 95%CI ‐1.38 to ‐0.38; participants = 156; studies = 2; moderate‐certainty evidence), and may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin monotherapy (RR 1.26, 95% CI 1.06 to 1.51; participants = 370; studies = 5; low‐certainty evidence). It is uncertain if combined desmopressin and anticholinergic therapy versus desmopressin monotherapy reduces the mean number of wet nights at the end of therapy (MD ‐0.50; 95% CI ‐1.05 to 0.06; participants = 188; studies = 3; I 2 = 66%; very low‐certainty evidence); or if it may increase the number of children achieving 14 consecutive dry nights at the end of treatment (RR 1.53, 95% CI 1.10 to 2.11; participants = 611; studies = 8; low‐certainty evidence). There may be little to no difference in adverse events between desmopressin plus anticholinergics and desmopressin monotherapy (RR 1.51 95% CI 0.73 to 3.09, participants = 187; studies =2; low‐certainty evidence). Minor adverse effects were common for desmopressin, including dizziness, headache, mood changes, gastrointestinal discomfort, nasal discomfort, hyponatraemia and one report of a convulsion. Authors' conclusions Desmopressin compared with placebo may increase the number of dry nights per week at the end of treatment in children. Desmopressin therapy may be as effective as alarm therapy at the end of treatment. However, the quality of evidence was assessed as low or very low. Alarm therapy compared to desmopressin may improve the number of children who are dry at follow‐up (moderate‐certainty evidence). Plain language summary Desmopressin for bedwetting in children Review question Is desmopressin an effective treatment for bedwetting in children? Key messages: Desmopressin may improve bedwetting. Only one study assessed quality of life. Further studies with good patient numbers are required. What is enuresis? What does desmopressin do ? Enuresis or bedwetting is involuntary wetting during sleep at an age when a child should be dry, usually at age five. The generally quoted prevalence rates (that is the proportion of a population with bedwetting in a given time period) are 15% to 20% of five‐year‐olds, 7% of seven‐year‐olds, 5% of 10‐year‐old children, and 2% to 3% of teenagers. Various treatments have been used to treat bedwetting. Desmopressin is a man‐made form of vasopressin, a chemical released from the brain that helps control the amount of urine made by the kidneys. Desmopressin is used to control bedwetting at night and reduces the number of bedwetting episodes. Why was it important to do this review? Although bedwetting is not a harmful condition and, with time, stops spontaneously, it is stigmatising and can impact the child’s quality of life, emotional and psychological wellbeing. It is a condition that unsettles the whole family and the affected children may suffer parental discontentment, teasing and may be at risk of physical or emotional abuse. Successful therapies that reduce bedwetting improve the child's self‐esteem and, therefore, it is important to see if desmopressin is as effective as other known treatments. How is the condition treated ? • Desmopressin therapy • Alarm therapy • Anticholinergic medications • Combination therapy – such as desmopressin and alarm therapy compared to desmopressin therapy There are several other therapies, such as behavioural therapies and laser therapy, though we have concentrated on the main therapies utilised. What did we want to find out? We wanted to see if desmopressin: • was effective in reducing the episodes of wet nights children may have; • was as effective as other treatments such as alarm therapy in treating bedwetting; • worked in combination with other treatments; • was associated with any unwanted effects. What did we do? We searched for studies where people were randomly placed into different treatment groups. We searched for and included studies that compared: • desmopressin with no treatment or placebo; • desmopressin and alarm therapy; • combination treatments of desmopressin and alarm. We compared and analysed our results, then rated our confidence in the evidence based on factors such as study methods and size of the studies. What did we find? We found 98 studies with 8699 participants, of whom 5616 received desmopressin. Main results • We found the use of desmopressin compared with placebo may improve wetting by giving children one more dry night a week while receiving treatment. This suggests that more children may stop wetting while using desmopressin (28% versus 1% who are given placebo or no treatment). • More children who received desmopressin therapy compared with placebo probably achieved 14 consecutive dry nights at the end of treatment. • We found that, when desmopressin was compared with alarm therapy, there was little to no difference in the number of children achieving 14 dry nights in a row. The evidence is also uncertain if desmopressin versus alarm therapy reduces the number of dry nights per week. • We found that combining desmopressin with alarm therapy may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin alone. • We found that side effects were commonly reported for desmopressin. These included dizziness, headache, mood changes, abdominal discomfort, nasal discomfort, hyponatraemia (low sodium level) and one report of a seizure. Thirty‐two studies reported no adverse effects occurring, and 25 studies omitted to report or mention adverse effects. What are the limitations of the evidence? We, however, have little confidence in the evidence as, in several studies, participants were aware of the therapy they were receiving, and several studies were very small. How up‐to‐date is this review? The evidence is current up to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hahn, D, Stewart, F, Raman, G", "articleTypes": [], "doi": "10.1002/14651858.CD002112.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.783Z" }, { "id": "7535fc2d-dd51-4050-9581-813c4a5c7632", "pmid": "", "title": "Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people", "imported": false, "abstract": "Abstract - Background Folate deficiency can result in congenital neural tube defects and megaloblastic anaemia. Low folate levels may be due to insufficient dietary intake or inefficient absorption, but impaired metabolic utilization also occurs. Because B12 deficiency can produce a similar anaemia to folate deficiency, there is a risk that folate supplementation can delay the diagnosis of B12 deficiency, which can cause irreversible neurological damage. Folic acid supplements may sometimes therefore include vitamin B12 supplements with simultaneous administration of vitamin B12. Lesser degrees of folate inadequacy are associated with high blood levels of the amino acid homocysteine which has been linked with the risk of arterial disease, dementia and Alzheimer's disease. There is therefore interest in whether dietary supplementation can improve cognitive function in the elderly. However, any apparent benefit from folic acid which was given in combination with B12 needs to be \"corrected\" for any effect of vitamin B12 alone. A separate Cochrane review of vitamin B12 and cognitive function has therefore been published. Objectives To examine the effects of folic acid supplementation, with or without vitamin B12, on elderly healthy or demented people, in preventing cognitive impairment or retarding its progress. Search methods Trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 10 October 2007 using the terms: folic acid, folate, vitamin B9, leucovorin, methyltetrahydrofolate, vitamin B12, cobalamin and cyanocobalamin. This Register contains references from all major health care databases and many ongoing trials databases. In addition MEDLINE, EMBASE, CINAHL, PsychINFO and LILACS were searched (years 2003‐2007) for additional trials of folate with or without vitamin B12 on healthy elderly people. Selection criteria All double‐blind, placebo‐controlled, randomized trials, in which supplements of folic acid with or without vitamin B12 were compared with placebo for elderly healthy people or people with any type of dementia or cognitive impairment. Data collection and analysis The reviewers independently applied the selection criteria and assessed study quality. One reviewer extracted and analysed the data. In comparing intervention with placebo, weighted mean differences and standardized mean difference or odds ratios were estimated. Main results Eight randomized controlled trials fulfilled the inclusion criteria for this review. Four trials enrolled healthy older people, and four recruited participants with mild to moderate cognitive impairment or dementia with or without diagnosed folate deficiency. Pooling the data was not possible owing to heterogeneity in sample selections, outcomes, trial duration, and dosage. Two studies involved a combination of folic acid and vitamin B12. There is no adequate evidence of benefit from folic acid supplemententation with or without vitamin B12 on cognitive function and mood of unselected healthy elderly people. However, in one trial enrolling a selected group of healthy elderly people with high homocysteine levels, 800 mcg/day folic acid supplementation over three years was associated with significant benefit in terms of global functioning (WMD 0.05, 95% CI 0.004 to 0.096, P = 0.033); memory storage (WMD 0.14, 95% CI 0.04 to 0.24, P = 0.006) and information‐processing speed (WMD 0.09, 95% CI 0.02 to 0.16, P = 0.016). Four trials involved people with cognitive impairment. In one pilot trial enrolling people with Alzheimer's disease, the overall response to cholinesterase inhibitors significantly improved with folic acid at a dose of 1mg/day (odds ratio: 4.06, 95% CI 1.22 to 13.53; P = 0.02) and there was a significant improvement in scores on the Instrumental Activities of Daily Living and the Social Behaviour subscale of the Nurse's Observation Scale for Geriatric Patients (WMD 4.01, 95% CI 0.50 to 7.52, P = 0.02). Other trials involving people with cognitive impairment did not show any benefit in measures of cognitive function from folic acid, with or without vitamin B12. Folic acid plus vitamin B12 was effective in reducing serum homocysteine concentrations (WMD ‐5.90, 95% CI ‐8.43 to ‐3.37, P < 0.00001). Folic acid was well tolerated and no adverse effects were reported. Authors' conclusions The small number of studies which have been done provide no consistent evidence either way that folic acid, with or without vitamin B12, has a beneficial effect on cognitive function of unselected healthy or cognitively impaired older people. In a preliminary study, folic acid was associated with improvement in the response of people with Alzheimer's disease to cholinesterase inhibitors. In another, long‐term use appeared to improve the cognitive function of healthy older people with high homocysteine levels. More studies are needed on this important issue. Plain language summary No evidence that folic acid with or without vitamin B12 improves cognitive function of unselected elderly people with or without dementia. Long‐term supplementation may benefit cognitive function of healthy older people with high homocysteine levels In the economically developed world, folate deficiency is one of the commonest vitamin deficiencies. Several reports suggest a higher prevalence of various psychiatric disorders in elderly people with folate deficiency. There is interest in whether dietary supplements of folic acid (an artificial chemical analogue of naturally occurring folates) can improve cognitive function of people at risk of cognitive decline associated with ageing or dementia, whether by affecting homocysteine metabolism or through other mechanisms. Eight trials met the criteria for inclusion. It was not possible to pool the data because the trials studied different populations, tested folic acid in different doses, and used different outcome measures. There were two trials of folic acid in conjunction with B12. The analysis showed significant benefit of folic acid over placebo in some measures of cognition in a long‐term trial recruiting elderly people with high homocysteine levels from a general population. In one pilot trial, 1 mg/day of folic acid was associated with significant improvement in behavioural response to cholinesterase inhibitors in people with Alzheimer's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Malouf, R; Grimley Evans, J", "articleTypes": [], "doi": "10.1002/14651858.CD004514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "753f68ed-53eb-4346-aa6c-e3088ea1f0a5", "pmid": "", "title": "Acupuncture for acute management and rehabilitation of traumatic brain injury", "imported": false, "abstract": "Abstract - Background Traumatic brain injury (TBI) can be life threatening depending on the severity of the insult to the brain. It can also cause a range of debilitating sequelae which require cognitive, motor, communication, emotional, or behavioral rehabilitation of varying intensity and duration. A number of studies conducted and published in China have suggested that acupuncture may be beneficial in the acute treatment and rehabilitation of TBI. Objectives To determine the efficacy and safety of acupuncture in the acute management or rehabilitation (or both) of patients with a TBI, including cognitive, neurological, motor, communication, emotional, or behavioral complications, or a combination of such complications. Search methods We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials ( The Cochrane Library ), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO and others. We also searched the Chinese Acupuncture Studies Register, the Studies Register of the Cochrane Complementary Medicine Field, NCCAM, and NIH Clinical Studies Database. Three major Mainland Chinese academic literature databases (CNKI, VIP and Wang Fang Data) were also searched using keywords in simplified Chinese. We searched all databases through December 2009, and some searches have been updated to October 2012. Selection criteria Randomized controlled studies evaluating different variants of acupuncture and involving participants of any age who had suffered a TBI. Included trials compared acupuncture with placebo or sham treatment, or acupuncture plus other treatments compared with the same other treatments. We excluded trials that only compared different variants of acupuncture or compared acupuncture alone against other treatments alone, as they did not yield the net effect of acupuncture. Data collection and analysis Two review authors identified potential articles from the literature search and extracted data independently using a data extraction form. We performed methodological assessment of included studies using the Cochrane Collaboration's tool for assessing risk of bias. We were unable to perform quantitative data analysis due to insufficient included studies and available data. Main results Four RCTs, including 294 participants, reported outcomes specified by this review. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The results seem to suggest that acupuncture is efficacious for these indications, however the low methodological quality of these studies renders the results questionable. No adverse effects of acupuncture were reported in any of the studies. Authors' conclusions The low methodological quality of the included studies does not allow us to make conclusive judgments on the efficacy and safety of acupuncture in either the acute treatment and/or rehabilitation of TBI. Its beneficial role for these indications remains uncertain. Further research with high quality trials is required. Plain language summary Acupuncture for acute management and rehabilitation of traumatic brain injury Acupuncture used for the acute treatment, rehabilitation (or both) of traumatic brain injury (TBI) has been studied in China. We conducted a systematic review to evaluate the efficacy and safety of acupuncture for these conditions. Four randomized controlled trials were eligible for inclusion in this review, involving 294 patients. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The studies were of low methodological quality and were diverse in their objectives, participant characteristics, acupuncture modalities and strategies, and outcome measures. The small number of studies together with their low methodological quality means that they are inadequate to allow any conclusion to be drawn about the efficacy and safety of acupuncture in the treatment of TBI. Further methodologically robust studies are needed to generate evidence‐based conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wong, V; Cheuk, DKL; Lee, S; Chu, V", "articleTypes": [], "doi": "10.1002/14651858.CD007700.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "7546d09b-1ba1-4518-8836-b440fc5c06e4", "pmid": "", "title": "Synbiotics, prebiotics and probiotics for people with chronic kidney disease", "imported": false, "abstract": "Abstract - Background Chronic kidney disease (CKD) is a major public health problem affecting 13% of the global population. Prior research has indicated that CKD is associated with gut dysbiosis. Gut dysbiosis may lead to the development and/or progression of CKD, which in turn may in turn lead to gut dysbiosis as a result of uraemic toxins, intestinal wall oedema, metabolic acidosis, prolonged intestinal transit times, polypharmacy (frequent antibiotic exposures) and dietary restrictions used to treat CKD. Interventions such as synbiotics, prebiotics, and probiotics may improve the balance of the gut flora by altering intestinal pH, improving gut microbiota balance and enhancing gut barrier function (i.e. reducing gut permeability). Objectives This review aimed to evaluate the benefits and harms of synbiotics, prebiotics, and probiotics for people with CKD. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria We included randomised controlled trials (RCTs) measuring and reporting the effects of synbiotics, prebiotics, or probiotics in any combination and any formulation given to people with CKD (CKD stages 1 to 5, including dialysis and kidney transplant). Two authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. Data collection and analysis Data extraction was independently carried out by two authors using a standard data extraction form. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross‐checked by another. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Forty‐five studies (2266 randomised participants) were included in this review. Study participants were adults (two studies in children) with CKD ranging from stages 1 to 5, with patients receiving and not receiving dialysis, of whom half also had diabetes and hypertension. No studies investigated the same synbiotic, prebiotic or probiotic of similar strains, doses, or frequencies. Most studies were judged to be low risk for selection bias, performance bias and reporting bias, unclear risk for detection bias and for control of confounding factors, and high risk for attrition and other biases. Compared to prebiotics, it is uncertain whether synbiotics improve estimated glomerular filtration rate (eGFR) at four weeks (1 study, 34 participants: MD ‐3.80 mL/min/1.73 m², 95% CI ‐17.98 to 10.38), indoxyl sulfate at four weeks (1 study, 42 participants: MD 128.30 ng/mL, 95% CI ‐242.77 to 499.37), change in gastrointestinal (GI) upset (borborymgi) at four weeks (1 study, 34 participants: RR 15.26, 95% CI 0.99 to 236.23), or change in GI upset (Gastrointestinal Symptom Rating Scale) at 12 months (1 study, 56 participants: MD 0.00, 95% CI ‐0.27 to 0.27), because the certainty of the evidence was very low. Compared to certain strains of prebiotics, it is uncertain whether a different strain of prebiotics improves eGFR at 12 weeks (1 study, 50 participants: MD 0.00 mL/min, 95% CI ‐1.73 to 1.73), indoxyl sulfate at six weeks (2 studies, 64 participants: MD ‐0.20 μg/mL, 95% CI ‐1.01 to 0.61; I² = 0%) or change in any GI upset, intolerance or microbiota composition, because the certainty of the evidence was very low. Compared to certain strains of probiotics, it is uncertain whether a different strain of probiotic improves eGFR at eight weeks (1 study, 30 participants: MD ‐0.64 mL/min, 95% CI ‐9.51 to 8.23; very low certainty evidence). Compared to placebo or no treatment, it is uncertain whether synbiotics improve eGFR at six or 12 weeks (2 studies, 98 participants: MD 1.42 mL/min, 95% CI 0.65 to 2.2) or change in any GI upset or intolerance at 12 weeks because the certainty of the evidence was very low. Compared to placebo or no treatment, it is uncertain whether prebiotics improves indoxyl sulfate at eight weeks (2 studies, 75 participants: SMD ‐0.14 mg/L, 95% CI ‐0.60 to 0.31; very low certainty evidence) or microbiota composition because the certainty of the evidence is very low. Compared to placebo or no treatment, it is uncertain whether probiotics improve eGFR at eight, 12 or 15 weeks (3 studies, 128 participants: MD 2.73 mL/min, 95% CI ‐2.28 to 7.75; I² = 78%), proteinuria at 12 or 24 weeks (1 study, 60 participants: MD ‐15.60 mg/dL, 95% CI ‐34.30 to 3.10), indoxyl sulfate at 12 or 24 weeks (2 studies, 83 participants: MD ‐4.42 mg/dL, 95% CI ‐9.83 to 1.35; I² = 0%), or any change in GI upset or intolerance because the certainty of the evidence was very low. Probiotics may have little or no effect on albuminuria at 12 or 24 weeks compared to placebo or no treatment (4 studies, 193 participants: MD 0.02 g/dL, 95% CI ‐0.08 to 0.13; I² = 0%; low certainty evidence). For all comparisons, adverse events were poorly reported and were minimal (flatulence, nausea, diarrhoea, abdominal pain) and non‐serious, and withdrawals were not related to the study treatment. Authors' conclusions We found very few studies that adequately test biotic supplementation as alternative treatments for improving kidney function, GI symptoms, dialysis outcomes, allograft function, patient‐reported outcomes, CVD, cancer, reducing uraemic toxins, and adverse effects. We are not certain whether synbiotics, prebiotics, or probiotics are more or less effective compared to one another, antibiotics, or standard care for improving patient outcomes in people with CKD. Adverse events were uncommon and mild. Plain language summary Prebiotics (dietary fibre), probiotics (good bacteria) or synbiotics (prebiotics plus probiotics) for people with chronic kidney disease Key messages Chronic kidney disease (CKD) is a serious health problem that affects over 850 million people worldwide. People with kidney disease have an unhealthy balance of good and bad bacteria in their guts, called 'gut dysbiosis'. This imbalance arises because of the effects of reduced kidney function (retained toxic waste products, fluid retention causing the gut wall to swell), drugs frequently used in people with CKD (especially antibiotics), and dietary restrictions placed on people with CKD. Gut dysbiosis can, in turn, cause or worsen CKD because bacteria can produce toxins that cross the bowel wall and damage the kidneys. Gut dysbiosis can also cause stomach problems (like bloating, cramping, constipation and diarrhoea) and reduce quality of life. To improve the balance of the gut flora, good bacteria can be taken in tablets of high doses of prebiotics and probiotics. Prebiotics, or indigestible plant fibre, can encourage the growth of good bacteria. Synbiotics are a combination of prebiotics and probiotics. Some research suggests that taking high doses of the good bacteria can re‐balance the good bacteria in people's gut, thereby improving bowel symptoms and the conditions that lead to worsening of CKD. What did we do? We reviewed all of the evidence on synbiotics, prebiotics and probiotics to see whether they can improve outcomes in people who have CKD (all stages 1 to 5). What did we find? We found 45 studies randomising 2266 participants. Half of these looked at participants receiving dialysis (mostly haemodialysis), and the other half not receiving dialysis. Half also had diabetes and hypertension. We are uncertain whether synbiotics, prebiotics, or probiotics improve bowel outcomes, quality of life, kidney toxin levels or kidney function. The quality of the evidence that we found is low quality and very low certainty. All studies were conducted using moderate to poor‐quality methods with too few patients. Summary Currently, we do not have enough information from trials to know whether synbiotics, prebiotics or probiotics work to improve bowel symptoms, quality of life, kidney toxin levels, or kidney function in people with CKD. Ten studies are currently ongoing; therefore, it is possible that findings may change with the inclusion of these studies in future updates. The evidence is up to date to 9 October 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Cooper, TE, Khalid, R, Chan, S, Craig, JC, Hawley, CM, Howell, M, Johnson, DW, Jaure, A, Teixeira-Pinto, A, Wong, G", "articleTypes": [], "doi": "10.1002/14651858.CD013631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.120Z" }, { "id": "754c5c3d-13ca-4acb-8676-b28845f7778f", "pmid": "", "title": "Folic acid supplementation and malaria susceptibility and severity among people taking antifolate antimalarial drugs in endemic areas", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Qi, YP, Crider, KS, Gutman, J, Centeno-Tablante, E, Fothergill, A, Daniels, K, Yeung, LF, Mai, CT, Mehta, S, Williams, JL, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014217.pub2 AB - Abstract - Background Malaria is an infectious disease transmitted by female Anopheles mosquitoes, with ongoing transmission in over 80 countries. The malaria parasite requires folate for survival and growth; antifolate antimalarial medications used for prevention and treatment target enzymes in folate metabolism as their mechanism of action. Periconceptional folic acid (synthetic form of folate) supplementation (400 μg/day) is the standard of care for neural tube defect prevention. Concerns have been raised about the potential effects of folic acid (including above the tolerable upper intake level (UL) > 1.0 mg/day) in the context of malaria prevention and treatment, including the efficacy of antimalarial medications. Examining the potential impact of folic acid on malaria risk and severity amongst people taking antifolate antimalarial medications may inform public health programmes in malaria‐endemic areas. Objectives To examine the effects of folic acid supplementation on the risk and severity of malaria infection amongst people taking antifolate antimalarials and living in areas with malaria endemicity. Prevention: Amongst uninfected people taking antifolate antimalarial medications for malaria prevention, does folic acid supplementation increase susceptibility or severity of malaria infection? Treatment: Amongst people with malaria infection who are being treated with antifolate antimalarial drugs, does folic acid supplementation reduce parasite clearance or increase the risk of treatment failure? Search methods We searched databases including CENTRAL, MEDLINE, Embase, CINAHL, Scopus, and trial registries (September 13, 2024), grey literature, and reference searches to identify additional studies. Selection criteria Randomised trials evaluating the effects of folic acid supplementation (alone or in combination with iron or other vitamins and minerals) amongst individuals taking antifolate antimalarial medications in malaria‐endemic areas. Data collection and analysis Primary outcomes included uncomplicated malaria or severe malaria, parasite clearance, and treatment failure. Cochrane RoB 2 was used to evaluate the risk of bias. Certainty of evidence was assessed using GRADE for primary outcomes. We performed meta‐analyses using random‐effects models for all outcomes. Main results Eight trials with 3486 participants were included: three malaria prevention trials and five malaria treatment trials. Most treatment trials included folic acid doses above the UL ( > 1.0 mg/d); one trial included 400 μg per day. Antifolate antimalarials included sulfadoxine‐pyrimethamine (SP; five trials), sulfisoxazole plus pyrimethamine (one trial), atovaquone‐proguanil (one trial), and proguanil (one trial). Some studies had unclear or high risk of bias due to missing outcome data. Malaria prevention Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medications. Data for primary outcomes, uncomplicated and severe malaria, were not reported. One trial reported laboratory parasitaemia; there was little to no difference in malaria parasitaemia amongst pregnant women receiving folic acid (with iron) and antifolate antimalarials compared to iron and antifolate antimalarials (Risk Ratio (RR) 1.21; 95% CI 0.56 to 2.62; P = 0.63; 1 trial, 643 individuals). Comparisons 2–4: No studies reported data for Comparisons 2–4. Malaria treatment 
 Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarial medications versus placebo/no folic acid with antifolate antimalarials. People receiving folic acid (alone or with iron) and antifolate antimalarials were less likely to clear malaria parasites (day 3) compared to individuals who did not receive folic acid (RR 0.89; 95% CI 0.84 to 0.95, 4 trials, 929 individuals, moderate‐certainty evidence); and had increased risk of treatment failure on day 7 (RR 2.12; 95% CI 1.41 to 3.19, 4 trials, 1062 individuals, moderate‐certainty evidence), day 14 (RR 1.97; 95% CI 1.44 to 2.70, 3 trials; 891 individuals; moderate‐certainty evidence), and day 28 (RR 1.35; 95% CI 1.21 to 1.51; 4 trials; 1012 individuals, moderate‐certainty evidence). Comparison 2: Folic acid alone + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medication. Folic acid supplementation with antifolate antimalarials likely had lower parasite clearance (day 3) (RR 0.87; 95% CI 0.79 to 0.96, 2 trials, 229 individuals, moderate certainty of the evidence), and increased treatment failure (day 7: RR 2.58; 95% CI 0.89 to 7.45; P = 0.08; 2 trials; 344 individuals, moderate‐certainty evidence; day 14: RR 4.15; 95% CI 0.92 to 18.65; P = 0.06; 1 trial; 173 individuals, moderate‐certainty evidence; and day 28: RR 1.47; 95% CI 0.86 to 2.49; P = 0.16; 2 trials; 294 individuals, moderate‐certainty evidence), compared to no folic acid and antifolate antimalarials. Comparison 3: Folic acid with iron + antifolate antimalarial medication versus placebo/no folic acid with iron + antifolate antimalarial medication. People receiving folic acid with iron and antifolate antimalarials were less likely to clear malaria parasites (day 3: RR 0.90; 95% CI 0.83 to 0.98; P = 0.02; 2 trials; 700 individuals, moderate‐certainty evidence), and had increased treatment failure (day 7: RR 1.96; 95% CI 1.05 to 3.65; P = 0.03; 2 trials; 718 individuals; day 14: RR 1.90; 95% CI 1.35 to 2.67; 2 trials; 718 individuals; day 28: RR 1.17; 95% CI 0.79 to 1.74; 2 trials; 578 individuals; all moderate‐certainty evidence), compared to iron and antifolate antimalarials. Comparison 4: No studies reported data. Authors' conclusions Malaria prevention: None of the included trials reported primary outcomes. Malaria treatment: People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to clear malaria parasitaemia (day 3), and had increased treatment failure (days 7, 14, 28). Most of the included trials provided folic acid with doses above the tolerable UL ( > 1.0 mg). One trial included folic acid at a dose of 400 μg/d (recommended dose for preventing neural tube defects) and showed little to no difference in parasite clearance or treatment failure. Plain language summary Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common? Review question 
Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common?

 Key messages 
° People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to eliminate malaria parasites and had increased treatment failure. 
° There were not enough studies to examine whether taking folic acid supplementation at a lower dose, like 400 μg, might affect the risk of malaria infection or health outcomes if infected. This low dose is currently recommended before and during early pregnancy for the prevention of neural tube defects. Malaria and the importance of folate 
Malaria is a disease spread by the bite of certain types of female mosquitoes and is found in over 80 countries. The malaria parasite needs folate to grow and survive, and some medicines used to prevent and treat malaria target folate. Folic acid (the synthetic form of folate) is recommended at a dose of 400 μg daily to prevent neural tube defects. There are some concerns that folic acid (particularly higher doses) may affect malaria and how well some medicines work to prevent and treat malaria. What did we want to find out? 
This review was done to see how folic acid affects malaria risk and severity amongst people taking antifolate antimalarial medications and living in areas where malaria is common. Specifically, we aimed to answer the following questions: Prevention: For people who do not have malaria and are taking antimalarial drugs to prevent malaria, do folic acid supplements increase their risk of getting malaria or having worse outcomes? Treatment: For people who have malaria and are being treated with antifolate antimalarial medications, does taking folic acid supplements affect how well the drugs work to treat malaria? What did we do? 
We searched for trials that looked at folic acid supplementation in people taking antifolate antimalarial medications to prevent or treat malaria. We compared and summarised the results of the trials and rated our confidence in the information based on how the study was done. What did we find? 
We included eight trials (3486 people); three were prevention trials and five were treatment trials. Most trials used higher folic acid doses ( > 1.0 mg) and included the medication sulfadoxine‐pyrimethamine (SP). The prevention studies did not include the main outcomes we were trying to assess. In the treatment studies, people who took folic acid and antifolate antimalarial drugs were less likely to clear malaria parasites from their bodies (day 3) and were more likely to have treatment failure (up to 28 days after treatment) compared to the same treatment but without folic acid. Most of the included trials provided the antimalarial SP and folic acid with doses above the tolerable upper intake level (upper limit; > 1.0 mg). Only one trial included folic acid at a dose of 400 μg per day (the recommended daily dose of folic acid for prevention of neural tube defects); there were no differences in parasite clearance or treatment failure between the arm with 400 μg per day of folic acid and the arm with no folic acid. What are the limitations of the evidence? 
The small number of trials and the size of the studies were limitations of this review, and no prevention studies reported main outcomes. How up to date is this evidence? 
The evidence is up‐to‐date as of September 13, 2024.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.810Z" }, { "id": "754cc224-e5f4-4a0e-a644-4dd82a313e07", "pmid": "", "title": "Anabolic‐androgenic steroids for alcoholic liver disease", "imported": false, "abstract": "Abstract - Background Alcohol is one of the most common causes of liver disease in the Western World. Randomised clinical trials have examined the effects of anabolic‐androgenic steroids for alcoholic liver disease. Objectives To assess the beneficial and harmful effects of anabolic‐androgenic steroids for patients with alcoholic liver disease based on the results of randomised clinical trials. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Controlled Trials Register in The Cochrane Library , MEDLINE , EMBASE, LILACS, and Science Citation Index Expanded until June 2006. Electronic searches were combined with full text searches. Manufacturers and researchers in the field were also contacted. Selection criteria Randomised clinical trials studying patients with alcoholic steatosis, alcoholic fibrosis, alcoholic hepatitis, and/or alcoholic cirrhosis were included. Interventions encompassed anabolic‐androgenic steroids at any dose or duration versus placebo or no intervention. The trials could be double blind, single blind, or unblinded. The trials could be unpublished or published, and no language limitations were applied. Data collection and analysis Outcomes are assessed at maximal follow‐up. All analyses were performed according to the intention‐to‐treat method. The statistical package RevMan Analyses was used. The methodological quality of the randomised clinical trials was assessed. Main results Combining the results of five randomised clinical trials randomising 499 patients with alcoholic hepatitis and/or cirrhosis demonstrated no significant effects of anabolic‐androgenic steroids on mortality (relative risk (RR) 1.01, 95% confidence interval (CI) 0.79 to 1.29), liver‐related mortality (RR 0.83, 95% CI 0.60 to 1.15), complications of liver disease (RR 1.25, 95% CI 0.74 to 2.10), and liver histology. Anabolic‐androgenic steroids did not significantly affect a number of other outcome measures, including sexual function and liver biochemistry. Anabolic‐androgenic steroids were not associated with a significantly increased risk of non‐serious adverse events (RR 1.14, 95% CI 0.50 to 2.59) or with serious adverse events (RR 4.54, 95% CI 0.57 to 36.30). Authors' conclusions This systematic review could not demonstrate any significant beneficial effects of anabolic‐androgenic steroids on any clinically important outcomes (mortality, liver‐related mortality, liver complications, and histology) of patients with alcoholic liver disease. Plain language summary No evidence to support anabolic‐androgenic steroids for alcoholic liver disease Alcohol causes a major part of the liver diseases in the Western World. Several trials have addressed the effects of anabolic‐androgenic steroids for alcoholic liver disease. This systematic review could not demonstrate any significant effects of anabolic‐androgenic steroids on mortality, liver‐related mortality, liver complications, and histology of patients with alcoholic liver disease. Anabolic‐androgenic steroid intervention is not associated with a significant increase in non‐serious adverse events, but with the seldom occurrence of serious adverse events. Accordingly, there is no evidence supporting the use of anabolic‐androgenic steroids for alcoholic liver disease, but further randomised clinical trials may be needed to settle the question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Rambaldi, A; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD003045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "757e62fb-dc2a-42a4-acdc-c5245f33b98a", "pmid": "", "title": "Antiamoebic drugs for treating amoebic colitis", "imported": false, "abstract": "Abstract - Background Infection with the protozoan Entamoeba histolytica is common in low‐ and middle‐income countries, and up to 100,000 people with severe disease die every year. Adequate therapy for amoebic colitis is necessary to reduce illness, prevent development of complicated disease and extraintestinal spread, and decrease transmission. Objectives To evaluate antiamoebic drugs for treating amoebic colitis. Search methods We searched the available literature up to 22 March 2018. We searched the Cochrane Infectious Diseases Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, m RCT, and conference proceedings. We contacted individual researchers, organizations, and pharmaceutical companies, and we checked reference lists. Selection criteria Randomized controlled trials of antiamoebic drugs given alone or in combination, compared with placebo or another antiamoebic drug, for treating adults and children with a diagnosis of amoebic colitis. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of trials and extracted and analysed the data. We calculated clinical and parasitological failure rates and rates of relapse and adverse events as risk ratios (RRs) with 95% confidence intervals (CIs), using a random‐effects model. We determined statistical heterogeneity and explored possible sources of heterogeneity using subgroup analyses. We carried out sensitivity analysis by using trial quality to assess the robustness of reported results. Main results In total, 41 trials (4999 participants) met the inclusion criteria of this review. In this update, we added four trials to the 37 trials included in the first published review version. Thirty trials were published over 20 years ago. Only one trial used adequate methods of randomization and allocation concealment, was blinded, and analysed all randomized participants. Only one trial used an E histolytica stool antigen test, and two trials used amoebic culture. Tinidazole may be more effective than metronidazole for reducing clinical failure (RR 0.28, 95% CI 0.15 to 0.51; 477 participants, eight trials; low‐certainty evidence) and is probably associated with fewer adverse events (RR 0.65, 95% CI 0.46 to 0.92; 477 participants, 8 trials; moderate‐certainty evidence). Compared with metronidazole, combination therapy may result in fewer parasitological failures (RR 0.36, 95% CI 0.15 to 0.86; 720 participants, 3 trials; low‐certainty evidence), but we are uncertain which combination is more effective than another. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Authors' conclusions Compared with metronidazole, tinidazole may be more effective in reducing clinical failure and may be associated with fewer adverse events. Combination drug therapy may be more effective for reducing parasitological failure compared with metronidazole alone. However, these results are based mostly on small trials conducted over 20 years ago with a variety of poorly defined outcomes. Tests that detect E histolytica more accurately are needed, particularly in countries where concomitant infection with other bacteria and parasites is common. 11 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (22 Mar, 2018) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Antiamoebic drugs for treating amoebic colitis What is the aim of this review? This Cochrane Review aims to determine the effectiveness and safety of drugs used to treat people with amoebic colitis, which is an infection of the large intestines caused by the parasite, Entamoeba histolytica . Cochrane researchers searched for all relevant studies to answer this question and included 41 relevant studies in this review. Key messages Tinidazole may be more effective than metronidazole for reducing clinical symptoms and may be associated with fewer adverse events. Combination therapy resulted in fewer parasitological failures than occurred with metronidazole alone. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Better quality randomized trials using accurate diagnostic methods and standardized outcomes are needed to evaluate the efficacy of drugs for treating individuals with amoebic colitis. What was studied in the review? Entamoeba histolytica is distributed throughout the world and is commonly acquired by ingestion of contaminated food or water. An estimated 40 to 50 million people infected with E histolytica develop amoebic colitis or extraintestinal abscesses, resulting in up to 100,000 deaths per year. Metronidazole is currently the standard therapy for treating adults and children with invasive amoebiasis, but it may not be sufficient to eliminate amoebic cysts from the intestine. Some unpleasant adverse effects have been associated with metronidazole, and the possibility of parasite resistance to metronidazole has led to the development of alternative drugs. Combinations of metronidazole with other drugs that eradicate surviving cysts in the intestines have been recommended, so evidence to support this approach needs to be assessed. This review compares different drugs used against amoebic colitis, alone or in combination, and also assesses single‐dose regimens versus longer regimens. What are the main results of the review? This review included 41 studies, most of which were conducted in countries considered to be highly endemic for amoebiasis. Most trials were old: 30 were conducted before 1998. Trials varied in the inclusion criteria used to enrol participants and in the definition and timing of measured outcomes. Stool microscopy with direct wet saline smear was the method used most often to detect the presence of E histolytica in stools. Study participants ranged in age from seven months to 80 years. Included trials reported a variety of comparisons and involved 25 individual drugs, two herbal products, and 15 different combinations. The review shows that in individuals with amoebic colitis, tinidazole may be better for reducing clinical symptoms (low‐certainty evidence) and probably results in fewer adverse events when compared with metronidazole (moderate‐certainty evidence). However, we do not know whether it is more effective for eradicating amoebae from the stools. Combination drug therapy may be more effective than metronidazole alone for eradicating amoebae (low‐certainty evidence), but we are uncertain which drug combination is most effective, and if combination treatment will lead to more rapid resolution of clinical symptoms or in more adverse events (very low‐certainty evidence). Evidence is insufficient to allow conclusions regarding efficacy of the other antiamoebic drugs. How up‐to‐date is this review? 
 The review authors searched for studies that had been published up to 22 March 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gonzales, MLM; Dans, LF; Sio‐Aguilar, J", "articleTypes": [], "doi": "10.1002/14651858.CD006085.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "75818748-713e-4349-a26d-1f210ef26372", "pmid": "", "title": "Diclofenac for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically cyclo‐oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain. Objectives To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled'). Search methods We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022. Selection criteria We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI). Main results We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low‐certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child‐reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD ‐0.45, 95% CI ‐0.74 to ‐0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD ‐0.64, 95% CI ‐0.89 to ‐0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low‐certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low‐certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results. Authors' conclusions We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non‐pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered. Plain language summary What are the benefits and harms of diclofenac for managing children's pain after they have had an operation? Key messages • Due to a lack of robust evidence, the benefits and harms of diclofenac for managing children's pain after they've had an operation are unclear. • Diclofenac probably reduces nausea and vomiting, but probably increases the risk of bleeding, compared to opioids (such as morphine). • Well‐designed and comprehensively‐reported studies are needed to shed light on the benefits and harms of diclofenac compared to opioids or other medicines, or for different ways of giving diclofenac to children. Postoperative pain management Pain after surgery or a procedure is common and can influence recovery and return to normal activities. There are many ways to reduce pain after an operation, including medicines such as diclofenac. Diclofenac is part of a class of medicines called non‐steroidal anti‐inflammatory drugs (NSAIDs) that can reduce inflammation and pain. They can be given by different routes, such as by mouth or through the anus into the rectum (back passage), and before, during, and after an operation. What did we want to find out? We wanted to find out the benefits and harms of diclofenac compared to other treatments, as well as the most effective way to deliver diclofenac to children. What did we do? We searched for studies that compared (a) diclofenac to other treatments for postoperative pain; or (b) different ways of delivering diclofenac to children. We summarised the results and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 32 studies that included 2250 children with postoperative pain. The largest study included 183 children and the smallest, 31 children. The studies were conducted in many countries around the world; the most common location was the United Kingdom (10 studies). The average age of the children was between 2 and 14 years. Diclofenac was used to manage postoperative pain in 12 different types of surgery; most commonly, ear, nose, and throat surgery (9 studies) or eye surgery (6 studies). Main results It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor and serious harms compared to a placebo (a 'dummy' or sham treatment that does not contain any medicine but looks or tastes identical to the medicine being tested). It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief or pain intensity compared to other medicines, such as opioids, paracetamol, or bupivacaine. Diclofenac probably results in less nausea and vomiting compared to opioids (7 studies involving 463 children), but probably increases the risk of any bleeding (2 studies involving 222 children), but we are very unsure about serious harms (death, long‐term disability, or hospitalisation). It is thus unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor or serious harms compared to placebo or other medicines other than opioids. It is also unclear which route (by mouth or rectal delivery) is the most effective way to manage pain after surgery in children. What are the limitations of the evidence? We are not confident in the evidence because of study design limitations, and none of the studies measured some of our main outcomes of interest. There were also not enough large studies to be certain about the results. How up to date is this evidence? The evidence is current to April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ringsten, M, Kredo, T, Ebrahim, S, Hohlfeld, A, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015087.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.823Z" }, { "id": "7584f565-87b8-45d4-afde-558a6fda6330", "pmid": "", "title": "Interventions for treating burning mouth syndrome", "imported": false, "abstract": "Abstract - Background Burning mouth syndrome (BMS) is a term used for oral mucosal pain (burning pain or discomfort in the tongue, lips or entire oral cavity) without identifiable cause. General population prevalence varies from 0.1% to 3.9%. Many BMS patients indicate anxiety, depression, personality disorders and impaired quality of life (QoL). This review updates the previous versions published in 2000 and 2005. Objectives To determine the effectiveness and safety of any intervention versus placebo for symptom relief and changes in QoL, taste, and feeling of dryness in people with BMS. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 31 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 11) in the Cochrane Library (searched 31 December 2015), MEDLINE Ovid (1946 to 31 December 2015), and Embase Ovid (1980 to 31 December 2015). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching the electronic databases Selection criteria Randomised controlled trials (RCTs) comparing any treatment against placebo in people with BMS. The primary outcomes were symptom relief (pain/burning) and change in QoL. Secondary outcomes included change in taste, feeling of dryness, and adverse effects. Data collection and analysis We used standard methodological procedures expected by Cochrane. Outcome data were analysed as short‐term (up to three months) or long‐term (three to six months). Main results We included 23 RCTs (1121 analysed participants; 83% female). Interventions were categorised as: antidepressants and antipsychotics, anticonvulsants, benzodiazepines, cholinergics, dietary supplements, electromagnetic radiation, physical barriers, psychological therapies, and topical treatments. Only one RCT was assessed at low risk of bias overall, four RCTs' risk of bias was unclear, and 18 studies were at high risk of bias. Overall quality of the evidence for effectiveness was very low for all interventions and all outcomes. Twenty‐one RCTs assessed short‐term symptom relief. There is very low‐quality evidence of benefit from electromagnetic radiation (one RCT, 58 participants), topical benzodiazepines (two RCTs, 111 participants), physical barriers (one RCT, 50 participants), and anticonvulsants (one RCT, 100 participants). We found insufficient/contradictory evidence regarding the effectiveness of antidepressants, cholinergics, systemic benzodiazepines, dietary supplements or topical treatments. No RCT assessing psychological therapies evaluated short‐term symptom relief. Four studies assessed long‐term symptom relief. There is very low‐quality evidence of a benefit from psychological therapies (one RCT, 30 participants), capsaicin oral rinse (topical treatment) (one RCT, 18 participants), and topical benzodiazepines (one RCT, 66 participants). We found no evidence of a difference for dietary supplements or lactoperoxidase oral rinse. No studies assessing antidepressants, anticonvulsants, cholinergics, electromagnetic radiation or physical barriers evaluated long‐term symptom relief. Short‐term change in QoL was assessed by seven studies (none long‐term).The quality of evidence was very low. A benefit was found for electromagnetic radiation (one RCT, 58 participants), however findings were inconclusive for antidepressants, benzodiazepines, dietary supplements and physical barriers. Secondary outcomes (change in taste and feeling of dryness) were only assessed short‐term, and the findings for both were also inconclusive. With regard to adverse effects, there is very low‐quality evidence that antidepressants increase dizziness and drowsiness (one RCT, 37 participants), and that alpha lipoic acid increased headache (two RCTs, 118 participants) and gastrointestinal complaints (3 RCTs, 138 participants). We found insufficient/contradictory evidence regarding adverse events for anticonvulsants or benzodiazepines. Adverse events were poorly reported or unreported for cholinergics, electromagnetic radiation, and psychological therapies. No adverse events occurred from physical barriers or topical therapy use. Authors' conclusions Given BMS' potentially disabling nature, the need to identify effective modes of treatment for sufferers is vital. Due to the limited number of clinical trials at low risk of bias, there is insufficient evidence to support or refute the use of any interventions in managing BMS. Further clinical trials, with improved methodology and standardised outcome sets are required in order to establish which treatments are effective. Future studies are encouraged to assess the role of treatments used in other neuropathic pain conditions and psychological therapies in the treatment of BMS. Plain language summary Interventions for treating burning mouth syndrome Review question Which treatments help to relieve symptoms for people with burning mouth syndrome (BMS)? Background BMS is a common painful condition. Symptoms include burning, dryness or uncomfortable sensations in the mouth and changes to taste, with no obvious underlying medical or dental cause. BMS is usually persistent and suffered long term, and can lead to a reduced quality of life (QoL). Currently, scientific research suggests that BMS is caused by underlying damage to the nerves. There are many treatments available including drugs for anxiety, other psychological conditions and increasing saliva production, protective barriers and treatments applied to the mouth surface amongst others. Study characteristics This review of studies was carried out through Cochrane Oral Health, and the evidence is current up to 31 December 2015. We found 23 studies (assessing 1121 people; 83% were women), published between 1995 and 2015 to include in this review. Twenty‐one studies assessed short‐term (up to three months) symptom relief, and four studies assessed long‐term (from three to six months) symptom relief. Seventeen studies provided information about side effect occurrence, seven studies assessed a measure of QoL, and two studies assessed changes in taste and feeling of dryness. All of the 23 treatments included in this review were compared to a placebo (fake treatment): antidepressants and antipsychotics (two studies), antiseizure drugs (one study), types of tranquillisers (four studies), saliva stimulants (one study), dietary supplements (12 studies), directed energy waves (one study), physical barriers (one study), psychological therapies (one study), and treatments applied to the mouth surface (five studies). Key results Short‐term symptom relief We found evidence of short‐term symptom relief for directed energy waves (one study, 58 participants), a type of tranquilliser used topically (that is held in the mouth before being removed, and which also acts as an antiseizure drug) called clonazepam (two studies, 111 participants), thin plastic tongue covers (one study, 50 participants), and an antiseizure drug called gabapentin (one study, 100 participants). There was no difference in short‐term symptom relief found for antidepressants, saliva stimulants, and another type of tranquilliser used systemically (one that is swallowed) also called clonazepam. We were unable to show whether dietary supplements or treatments applied to the mouth surface provide symptom relief in the short term or not. Short‐term relief was not reported for the single study that assessed a psychological therapy. Long‐term symptom relief We found evidence of long‐term symptom relief for psychological therapy (one study, 30 participants), chili pepper mouthrinse (one study, 18 participants) and the topical tranquilliser called clonazepam (one study, 66 participants). We found there was no difference in long‐term symptom relief for dietary supplements or treatments applied to the mouth surface. Studies which assessed antidepressants, directed energy waves, saliva stimulants, antiseizure drugs, or physical barriers did not evaluate long‐term symptom relief. Change in QoL There was evidence of short‐term improvement in QoL for directed energy waves (one study, 58 patients), although no difference was found for antidepressants, tranquillisers, dietary supplements and physical barriers. No study assessed long‐term QoL changes. Change in taste or feeling of dryness A few studies assessed short‐term change in taste or feeling of dryness (none evaluated these outcomes long‐term), but there was not enough evidence to judge the effects of treatment on these outcomes. Side effects Side effects were more likely to be experienced with antidepressants (dizziness and drowsiness more likely: one study, 37 people), and with a dietary supplement called alpha lipoic acid (also known as ALA) with or without other ingredients (headaches more likely: two studies, 118 people; and upset stomachs more likely: three studies, 138 people). Quality of the evidence 
 Overall, we found very low‐quality evidence for each short‐ and long‐term outcome we investigated (symptom relief; changes in QoL, taste and feeling of dryness; and side effects) in all types of assessed treatment: antidepressants and antipsychotics, antiseizure drugs, types of tranquillisers, saliva stimulants, dietary supplements, directed energy waves, physical barriers (except side effects, which was assessed as low quality), psychological therapies, and treatments applied to the mouth surface. As we found so few studies at low risk of bias, we are currently unable to prove or disprove the effectiveness of any treatments for managing BMS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McMillan, R; Forssell, H; Buchanan, JAG; Glenny, AM; Weldon, JC; Zakrzewska, JM", "articleTypes": [], "doi": "10.1002/14651858.CD002779.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "75c1ff10-6e0c-41d2-a961-da4148c2483e", "pmid": "", "title": "Alterations in Nutrient-sensing Mechanisms May Play a Role in Symptom Generation in Patients With IBS", "imported": false, "abstract": "Clinical data, fresh feces and intestinal mucosal tissues of patients with diarrheal IBS were collected. High performance liquid chromatography, immunohistochemistry and immunofluorescence were used to study the amino acid levels in feces of patients with IBS, the expression of taste receptors in intestinal mucosa, and the correlation between symptoms of abdominal pain and diarrhea and the expression of taste receptors, so as to obtain the conclusion that \"intestinal amino acid perception abnormalities exist in patients with IBS. And correlated with clinical symptoms.\"", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.231Z" }, { "id": "75c4c89d-b4f5-4831-9703-4f3dc86c5d0a", "pmid": "", "title": "Non‐immunosuppressive treatment for IgA nephropathy", "imported": false, "abstract": "Abstract - Background IgA nephropathy (IgAN) is the most common primary glomerular disease, with approximately 20% to 40% of patients progressing to kidney failure within 25 years. Non‐immunosuppressive treatment has become a mainstay in the management of IgAN by improving blood pressure (BP) management, decreasing proteinuria, and avoiding the risks of long‐term immunosuppressive management. Due to the slowly progressive nature of the disease, clinical trials are often underpowered, and conflicting information about management with non‐immunosuppressive treatment is common. This is an update of a Cochrane review, first published in 2011. Objectives To assess the benefits and harms of non‐immunosuppressive treatment for treating IgAN in adults and children. We aimed to examine all non‐immunosuppressive therapies (e.g. anticoagulants, antihypertensives, dietary restriction and supplementation, tonsillectomy, and herbal medicines) in the management of IgAN. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to December 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs of non‐immunosuppressive agents in adults and children with biopsy‐proven IgAN were included. Data collection and analysis Two authors independently reviewed search results, extracted data and assessed study quality. Results were expressed as mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI) using random‐effects meta‐analysis. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results This review includes 80 studies (4856 participants), of which 24 new studies (2018 participants) were included in this review update. The risk of bias within the included studies was mostly high or unclear for many of the assessed methodological domains, with poor reporting of important key clinical trial methods in most studies. Antihypertensive therapies were the most examined non‐immunosuppressive therapy (37 studies, 1799 participants). Compared to placebo or no treatment, renin‐angiotensin system (RAS) inhibition probably decreases proteinuria (3 studies, 199 participants: MD ‐ 0.71 g/24 h, 95% CI ‐1.04 to ‐0.39; moderate certainty evidence) but may result in little or no difference to kidney failure or doubling of serum creatinine (SCr), or complete remission of proteinuria (low certainty evidence). Death, remission of haematuria, relapse of proteinuria or > 50% increase in SCr were not reported. Compared to symptomatic treatment, RAS inhibition (3 studies, 168 participants) probably decreases proteinuria (MD ‐1.16 g/24 h, 95% CI ‐1.52 to ‐0.81) and SCr (MD ‐9.37 µmol/L, 95% CI ‐71.95 to ‐6.80) and probably increases creatinine clearance (2 studies, 127 participants: MD 23.26 mL/min, 95% CI 10.40 to 36.12) (all moderate certainty evidence); however, the risk of kidney failure is uncertain (1 study, 34 participants: RR 0.20, 95% CI 0.01 to 3.88; very low certainty evidence). Death, remission of proteinuria or haematuria, or relapse of proteinuria were not reported. The risk of adverse events may be no different with RAS inhibition compared to either placebo or symptomatic treatment (low certainty evidence). In low certainty evidence, tonsillectomy in people with IgAN in addition to standard care may increase remission of proteinuria compared to standard care alone (2 studies, 143 participants: RR 1.90, 95% CI 1.45 to 2.47) and remission of microscopic haematuria (2 studies, 143 participants: RR 1.93, 95% CI 1.47 to 2.53) and may decrease relapse of proteinuria (1 study, 73 participants: RR 0.70, 95% CI 0.57 to 0.85) and relapse of haematuria (1 study, 72 participants: RR 0.70, 95% CI 0.51 to 0.98). Death, kidney failure and a > 50% increase in SCr were not reported. These trials have only been conducted in Japanese people with IgAN, and the findings' generalisability is unclear. Anticoagulant therapy, fish oil, and traditional Chinese medicines exhibited small benefits to kidney function in patients with IgAN when compared to placebo or no treatment. However, compared to standard care, the kidney function benefits are no longer evident. Antimalarial therapy compared to placebo in one study reported an increase in a > 50% reduction of proteinuria (53 participants: RR 3.13 g/24 h, 95% CI 1.17 to 8.36; low certainty evidence). Although, there was uncertainty regarding adverse events from this study due to very few events. Authors' conclusions Available RCTs focused on a diverse range of interventions. They were few, small, and of insufficient duration to determine potential long‐term benefits on important kidney and cardiovascular outcomes and harms of treatment. Antihypertensive agents appear to be the most beneficial non‐immunosuppressive intervention for IgAN. The antihypertensives examined were predominantly angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers. The benefits of RAS inhibition appear to outweigh the harms in patients with IgAN. The certainty of the evidence of RCTs demonstrating a benefit of tonsillectomy to patients with Japanese patients with IgAN was low. In addition, these findings are inconsistent across observational studies in people with IgAN of other ethnicities; hence, tonsillectomy is not widely recommended, given the potential harm of therapy. The RCT evidence is insufficiently robust to demonstrate efficacy for the other non‐immunosuppressive treatments evaluated here. Plain language summary Non‐immunosuppressive treatment for IgA nephropathy Key messages Treatment with renin‐angiotensin system (RAS) inhibition, namely angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, is the most common first‐line, non‐immunosuppressive therapy used for managing patients with IgA nephropathy (IgAN). The role of other non‐immunosuppressive treatments in managing IgAN is unclear and warrants further clinical studies. Why treat IgA nephropathy with non‐immunosuppressive therapies? IgAN is one of the most common kidney diseases, leading to reduced kidney function and kidney failure for about 20% to 40% of patients within 20 to 25 years. The cause of IgAN is not widely understood, but most people have an abnormality in their immune system that leads to damage to the kidney. However, other non‐immune functions play a role in the disease's impact on the kidney. What did we want to find out? We wanted to find out if non‐immunosuppressive treatments (e.g. antihypertensive agents, anticoagulants, fish oil, tonsillectomy, herbal medicine) improved kidney function in adults and children with IgAN. What did we do? We searched for all trials that assessed the benefits and harms of randomly allocated non‐immunosuppressive treatment in people with IgAN. We compared and summarised the results of the trials and rated our confidence in the information based on factors such as trial methods and sizes. What did we find? We included 80 studies involving 4856 people with IgAN treated with a diverse collection of non‐immunosuppressive treatments. Patients in studies were given various therapies, including blood pressure lowering agents (antihypertensives), removal of participant's tonsils (tonsillectomy), antimalarials, traditional Chinese medicine, dietary supplements (e.g. fish oil), and vitamin D receptor agonists. Antihypertensive medication aimed at inhibiting the RAS appears to slow damage to the kidney with minimal side effects. However, its impact in preventing people from progressing to kidney failure is unclear. Other interventions, such as tonsillectomy, antimalarial medication, and low‐calorie restricted diets role in treating patients are still unclear. What are the limitations of the evidence? The small number of studies per comparison and the small size of the studies were limitations in this review. Not all the studies provided data about the outcomes we were interested in. We are unsure about the results. How up to date is the evidence? The evidence is up to date as of December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Tunnicliffe, DJ; Reid, S; Craig, JC; Samuels, JA; Molony, DA; Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD003962.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "75c52765-613d-4aa9-9e5d-c52358b66927", "pmid": "", "title": "Interventions for improving adherence to ocular hypotensive therapy", "imported": false, "abstract": "Abstract - Background Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open‐angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence. Objectives To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma. Data collection and analysis At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity. Main results Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow‐up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross‐over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive. Authors' conclusions Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes. Plain language summary Interventions for helping people use eye drops as prescribed for raised eye pressure or glaucoma A large number of people do not use eye drops as prescribed. Glaucoma is a slowly progressive eye disease, which can result in severe vision loss. Drops prescribed for raised eye pressure or glaucoma are aimed at lowering the pressure to assist in reducing the rate of progression, or preventing the conversion of raised eye pressure to glaucoma. It is important that these eye drops are used continually, usually for life. Approximately one‐third of people who are prescribed eye drops for the first time fail to continue collecting prescriptions within the first year and even when patients collect prescriptions they do not always use the drops as frequently as they should. A number of reasons are thought to be the cause, for example, forgetfulness, being prescribed a large number of medications, difficulties instilling drops, lack of knowledge about glaucoma, a busy lifestyle and seeing no benefit. This review is based on 16 studies (1565 participants) that tried out different methods to help people to use drops as prescribed. All the studies took place in industrialised countries (Belgium, Denmark, France, Greece, Iceland, Japan, Sweden, Switzerland, UK and USA) and recruited participants in outpatient clinics. The following interventions were included: simplifying drop routines, reminder devices, automated telephone service, providing information about glaucoma and offering advice regarding day to day issues with eye care. Those studies which combined the provision of information about glaucoma and eye drops with other interventions, such as helping people to fit instillation of eye drops into their daily routine, appear to be more successful. Unfortunately, not all of these studies were of high quality and, therefore, until more evidence is available we cannot recommend any particular method. Good quality research is needed in this area in order to develop a better understanding of patients' individual needs and to help us provide more effective eye care services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Waterman, H; Evans, JR; Gray, TA; Henson, D; Harper, R", "articleTypes": [], "doi": "10.1002/14651858.CD006132.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "75d1d088-8e01-46f6-85fd-3868b27543ff", "pmid": "", "title": "The Effects of the Dopamine Receptor Agonist Pramipexole on Reward and Emotion Related Information Processing in Healthy Volunteers", "imported": false, "abstract": "The dopamine agonist pramipexole has recently been suggested as a potential novel antidepressant drug. While preliminary clinical data hint at its efficacy in treating depressive symptoms, our current understanding of its impact on neurocognitive processes is relatively limited. This is in part because mechanistic studies have largely focused on the effects of single-dose treatments. However, such acute administration of dopaminergic drugs likely has different cognitive effects than the more prolonged administration that is used clinically. This study therefore aims to explore and characterise the neurocognitive effects of more prolonged pramipexole treatment. Forty healthy volunteers will be randomly allocated to 12 to 15 days of treatment with either pramipexole or placebo. Study participants as well as researchers will be blinded as to which treatment is used. Before and after treatment all participants will perform a set of psychological tasks and questionnaires evaluating reward-based learning, emotional information processing, motivational vigour and subjective experience. Furthermore, functional magnetic resonance imaging (fMRI) will be used to compare neural activity during emotion and reward processing between the two treatment groups. We hypothesises that pramipexole might enhance reward sensitivity, motivational vigour, and pleasure experience and could induce positive biases in emotional information processing.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "75d96c58-741d-47fa-bd8e-870b15e61e09", "pmid": "", "title": "Interventions for the prevention and management of oropharyngeal candidiasis associated with HIV infection in adults and children", "imported": false, "abstract": "Abstract - Background Oral candidiasis (OC) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Left untreated, these lesions contribute considerably to the morbidity associated with HIV infection. Interventions aimed at preventing and treating HIV‐associated oral candidal lesions form an integral component of maintaining the quality of life for affected individuals. Objectives To determine the effects of any intervention in preventing or treating OC in children and adults with HIV infection. Search methods The search strategy was based on that of the Cochrane HIV/AIDS Review Group. The following electronic databases were searched for randomised controlled trials for the years 1982 to 2005: Medline, AIDSearch, EMBASE and CINAHL. The Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectiveness, and the Cochrane Central Register of Controlled Trials (CENTRAL) were also searched through May 2005. The abstracts of relevant conferences, including the International Conferences on AIDS and the Conference on Retroviruses and Opportunistic Infections, as indexed by AIDSLINE, were also reviewed. The strategy was iterative, in that references of included studies were searched for additional references. All languages were included. The updated database search was done for the period 2005 up to 2009. The following databases were searched: Medline, EMBASE, the Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectivenes s and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library. AIDSearch was not searched for the updated search as it ceased publication during 2008. Selection criteria Randomised controlled trials (RCTs) of palliative, preventative or curative therapy were considered, irrespective of whether the control group received a placebo. Participants were HIV positive adults and children. Data collection and analysis Two authors independently assessed the methodological quality of the trials and extracted data. Study authors were contacted for additional data where necessary. Main results For the first publication of the review in 2006, forty studies were retrieved. Twenty eight trials (n=3225) met inclusion criteria. During the update search for the review a, further six studies were identified. Of these, five met the inclusion criteria and were included in the review. The review now includes 33 studies (n=3445): 22 assessing treatment and 11 assessing prevention of oropharyngeal candidiasis. Six studies were done in developing countries, 16 in the United States of America and the remainder in Europe. Treatment 
 Treatment was assessed in the majority of trials looking at both clinical and mycological cures. In the majority of comparisons there was only one trial. Compared to nystatin, fluconazole favoured clinical cure in adults (1 RCT; n=167; RR 1.69; 95% CI 1.27 to 2.23). There was no difference with regard to clinical cure between fluconazole compared to ketoconazole (2 RCTs; n=83; RR 1.27; 95% CI 0.97 to 1.66), itraconazole (2 RCTs; n=434; RR 1.05; 95% CI 0.94 to 1.16), clotrimazole (2 RCTs; n=358; RR 1.14; 95% CI 0.92 to 1.42) or posaconazole (1 RCT; n=366; RR1.32; 95% CI 0.36 to 4.83). Two trials compared different dosages of fluconazole with no difference in clinical cure. When compared with clotrimazole, both fluconazole (2 RCTs; n=358; RR 1.47; 95% CI 1.16 to 1.87) and itraconazole (1 RCT; n=123; RR 2.20; 95% CI 1.43 to3.39) proved to be better for mycological cure. Both gentian violet (1 RCT; n=96; RR 5.28; 95% CI 1.23 to 22.55) and ketoconazole (1 RCT; n=92; RR 5.22; 95% CI 1.21 to 22.53) were superior to nystatin in bringing about clinical cure. A single trial compared gentian violet with lemon juice and lemon grass with no significant difference in clinical cure between the groups. 
 
 Prevention 
 Successful prevention was defined as the prevention of a relapse while receiving prophylaxis. Fluconazole was compared with placebo in five studies (5 RCTs; n=599; RR 0.61; 95% CI 0.5 to 0.74) and with no treatment in another (1 RCT; n=65; RR 0.16; 95% CI 0.08 to 0.34). In both instances the prevention of clinical episodes was favoured by fluconazole. Comparing continuous fluconazole treatment with intermittent treatment (2 RCTs; n=891; RR 0.65; 95% CI 0.23 to 1.83), there was no significant difference between the two treatment arms. Chlorhexidine was compared with normal saline in a single study with no significant difference between the treatment arms. Authors' conclusions Five new studies were added to the review, but their results do not alter the final conclusion of the review. Implications for practice 
 Due to there being only one study in children, it is not possible to make recommendations for treatment or prevention of OC in children. Amongst adults, there were few studies per comparison. Due to insufficient evidence, no conclusion could be made about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole or ketoconazole with regard to OC prophylaxis. In comparison to placebo, fluconazole is an effective preventative intervention. However, the potential for resistant Candida organisms to develop, as well as the cost of prophylaxis, might impact the feasibility of implementation. No studies were found comparing fluconazole with other interventions. The direction of findings suggests that ketoconazole, fluconazole, itraconazole and clotrimazole improved the treatment outcomes. Implications for research 
 It is encouraging that low‐cost alternatives are being tested, but more research needs to be on in this area and on interventions like gentian violet and other less expensive anti‐fungal drugs to treat OC. More well‐designed treatment trials with larger samples are needed to allow for sufficient power to detect differences in not only clinical, but also mycological, response and relapse rates. There is also a strong need for more research to be done on the treatment and prevention of OC in children as it is reported that OC is the most frequent fungal infection in children and adolescents who are HIV positive. More research on the effectiveness of less expensive interventions also needs to be done in resource‐poor settings. Currently few trials report outcomes related to quality of life, nutrition, or survival. Future researchers should consider measuring these when planning trials. Development of resistance remains under‐studied and more work must be done in this area. It is recommended that trials be more standardised and conform more closely to CONSORT. Plain language summary Interventions for the prevention and management of oral thrush associated with HIV infection in adults and children Oral candidiasis (thrush) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Interventions aimed at preventing and treating HIV‐associated oral thrush form an integral component of maintaining the quality of life for affected individuals. This review evaluated the effects of interventions in preventing or treating oral thrush in children and adults with HIV infection. Thirty three trials (n=3445) were included. Twenty two trials investigated treatment and eleven trials investigate prevention. There was no difference with regard to clinical cure between fluconazole compared to ketoconazole, itraconazole, clotrimazole and posaconazole. Fluconazole, gentian violet and ketoconazole were superior to nystatin. Compared to placebo and no treatment, fluconazole was effective in preventing clinical episodes from occurring. Continuous fluconazole was better than intermittent treatment. Insufficient evidence was found to come to any conclusion about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole, ketoconazole or chlorhexidine with regard to OC prophylaxis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Pienaar, ED; Young, T; Holmes, H", "articleTypes": [], "doi": "10.1002/14651858.CD003940.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "75dad20c-25ec-4a09-b750-8f131fa042fd", "pmid": "", "title": "Intestinal Sweet Taste Receptor Function and Adaptation to Dietary Sugars and Sweeteners", "imported": false, "abstract": "The purpose of this study is to collect data that will help researchers better understand the various causes of obesity and diabetes; particularly to understand how consumption of NCASs affects the way the body uses nutrients.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.232Z" }, { "id": "75f87be3-ea1c-4a9d-bc8f-c7ede81b321c", "pmid": "", "title": "Omega‐3 fatty acids for the treatment of dementia", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) from fish and plant sources are commonly considered as a promising non‐medical alternative to improve brain functions and slow down the progression of dementia. This assumption is mostly based on findings of preclinical studies and epidemiological research. Resulting explanatory models aim at the role omega‐3 PUFAs play in the development and integrity of the brain's neurons, their protective antioxidative effect on cell membranes and potential neurochemical mechanisms directly related to Alzheimer‐specific pathology. Epidemiological research also found evidence of malnutrition in people with dementia. Considering this and the fact that omega‐3 PUFA cannot be synthesised by humans, omega‐3 PUFAs might be a promising treatment option for dementia. Objectives To assess the efficacy and safety of omega‐3 polyunsaturated fatty acid (PUFA) supplementation for the treatment of people with dementia. Search methods We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 10 December 2015. We contacted manufacturers of omega‐3 supplements and scanned reference lists of landmark papers and included articles. Selection criteria We included randomised controlled trials (RCTs) in which omega‐3 PUFA in the form of supplements or enriched diets were administered to people with Alzheimer's disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), Parkinson's disease dementia (PDD) or frontotemporal dementia (FTD). Data collection and analysis The primary outcome measures of interest were changes in global and specific cognitive functions, functional performance, dementia severity and adverse effects. Two review authors independently selected studies, extracted data and assessed the quality of trials according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We received unpublished data from the trial authors and collected adverse effects information from the published articles. We conducted meta‐analyses for available outcome measures at six months. Main results We included three comparable randomised, placebo‐controlled trials investigating omega‐3 PUFA supplements in 632 participants with mild to moderate AD over six, 12 and 18 months. We found no studies investigating other types of dementia. All trials were of high methodological quality. The overall quality of evidence for most of the outcomes was high. There was no evidence of a benefit from omega‐3 PUFAs on cognitive function when measured at six months with the Alzheimer's Disease Assessment Scale ‐ Cognitive subscale (standardised mean difference (SMD) ‐0.02, 95% confidence interval (CI) ‐0.19 to 0.15; 566 participants; 3 studies; high quality evidence) or Mini‐Mental State Examination (mean difference (MD) 0.18, 95% CI ‐1.05 to 1.41; 202 participants; 2 studies; high quality evidence) or on activities of daily living (SMD ‐0.02, 95% CI ‐0.19 to 0.16; 544 participants; 2 studies; high quality evidence). There was also no effect at six months of treatment on severity of dementia measured with the Clinical Dementia Rating ‐ Sum of Boxes (MD ‐0.00, 95% CI ‐0.58 to 0.57; 542 participants; 2 studies; high quality evidence) or on quality of life measured with the Quality of Life Alzheimer's Disease scale (MD ‐0.10, 95% CI ‐1.28 to 1.08; 322 participants; 1 study; high quality evidence). There was no difference at six months on mental health measured with the Montgomery‐Åsberg Depression Rating Scale (MD ‐0.10, 95% CI ‐0.74 to 0.54; 178 participants: 1 study; high quality of evidence) or the Neuropsychiatric Inventory (SMD 0.10, 95% CI ‐0.07 to 0.27; 543 participants; 2 studies; high quality of evidence). One very small study showed a benefit for omega‐3 PUFAs in instrumental activities of daily living after 12 months of treatment (MD ‐3.50, 95% CI ‐4.30 to ‐2.70; 22 participants; moderate quality evidence). The included studies did not measure specific cognitive function. The studies did not report adverse events well. Two studies stated that all adverse events were mild and that they did not differ in overall frequency between omega‐3 PUFA and placebo groups. Data from one study showed no difference between groups in frequency of any adverse event (risk ratio (RR) 1.02, 95% CI 0.95 to 1.10; 402 participants; 1 study; moderate quality evidence) or any serious adverse event (RR 1.05, 95% CI 0.78 to 1.41; 402 participants; 1 study; high quality evidence) at 18 months of treatment. Authors' conclusions We found no convincing evidence for the efficacy of omega‐3 PUFA supplements in the treatment of mild to moderate AD. This result was consistent for all outcomes relevant for people with dementia. Adverse effects of omega‐3 PUFAs seemed to be low, but based on the evidence synthesised in this review, we cannot make a final statement on tolerability. The effects on other populations remain unclear. Plain language summary Omega‐3 fatty acids for the treatment of dementia Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) are assumed to have a beneficial effect on the function of the brain. It has been suggested that they might improve or delay decline in memory and ability to carry out everyday tasks in people with dementia. In this review, we investigated randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) comparing omega‐3 PUFAs, given in the form of supplements or enriched diets, with placebo (a pretend treatment) in people with the most common types of dementia. Included trials We included three trials that investigated 632 people with Alzheimer's disease of mild to moderate severity. We found no trials on other types of dementia. In all trials participants took either placebo or omega‐3 PUFA supplements. The quality of the trials was good. The participants were allocated to the groups randomly. The participants and most of the investigators did not know which treatment was given. Results When we combined the results of the trials, we found that taking omega‐3 PUFA supplements for six months had no effect on cognition (learning and understanding), everyday functioning, quality of life or mental health. One very small study observed that omega‐3 PUFAs improved cognitively complex daily activities, such as shopping, when taken for a longer period of time. However, the quality of the evidence was only moderate, so this should be confirmed in further trials. Omega‐3 PUFAs also had no effect on ratings of the overall severity of the illness. The trials did not report side effects very well, but none of the studies reported significant harmful effects on health. Conclusion Altogether, the quality of the evidence was moderate or high for most of the effects that we measured, but we found no evidence for either benefit or harm from omega‐3 PUFA supplements in people with mild to moderate Alzheimer's disease. The effects on people with other types of dementia remain unclear.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Burckhardt, M, Herke, M, Wustmann, T, Watzke, S, Langer, G, Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD009002.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.780Z" }, { "id": "76332161-3ea9-418e-9f98-0557db5a8176", "pmid": "", "title": "Nutritional interventions for survivors of childhood cancer", "imported": false, "abstract": "Abstract - Background Childhood cancer survivors are at a higher risk of developing health conditions such as osteoporosis, and cardiovascular disease than their peers. Health‐promoting behaviour, such as consuming a healthy diet, could lessen the impact of these chronic issues, yet the prevalence rate of health‐protecting behaviour amongst survivors of childhood cancer is similar to that of the general population. Targeted nutritional interventions may prevent or reduce the incidence of these chronic diseases. Objectives The primary aim of this review was to assess the efficacy of a range of nutritional interventions designed to improve the nutritional intake of childhood cancer survivors, as compared to a control group of childhood cancer survivors who did not receive the intervention. Secondary objectives were to assess metabolic and cardiovascular risk factors, measures of weight and body fat distribution, behavioural change, changes in knowledge regarding disease risk and nutritional intake, participants' views of the intervention, measures of health status and quality of life, measures of harm associated with the process or outcomes of the intervention, and cost‐effectiveness of the intervention Search methods We searched the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 3), MEDLINE/PubMed (from 1945 to April 2013), and Embase/Ovid (from 1980 to April 2013). We ran the search again in August 2015; we have not yet fully assessed these results, but we have identified one ongoing trial. We conducted additional searching of ongoing trial registers ‐ the International Standard Randomised Controlled Trial Number register and the National Institutes of Health register (both screened in the first half of 2013) ‐ reference lists of relevant articles and reviews, and conference proceedings of the International Society for Paediatric Oncology and the International Conference on Long‐Term Complications of Treatment of Children and Adolescents for Cancer (both 2008 to 2012). Selection criteria We included all randomised controlled trials (RCTs) that compared the effects of a nutritional intervention with a control group which did not receive the intervention in this review. Participants were childhood cancer survivors of any age, diagnosed with any type of cancer when less than 18 years of age. Participating childhood cancer survivors had completed their treatment with curative intent prior to the intervention. Data collection and analysis Two review authors independently selected and extracted data from each identified study, using a standardised form. We assessed the validity of each identified study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Intervention s. We used the GRADE criteria to assess the quality of each trial. Main results Three RCTs were eligible for review. A total of 616 participants were included in the analysis. One study included participants who had been treated for acute lymphoblastic leukaemia (ALL) (275 participants). Two studies included participants who had all forms of paediatric malignancies (266 and 75 participants). All participants were less than 21 years of age at study entry. The follow‐up ranged from one month to 36 months from the initial assessment. All intended outcomes were not evaluated by each included study. All studies looked at different interventions, and so we were unable to pool results. We could not rule out the presence of bias in any of the studies. There was no clear evidence of a difference in calcium intake at one month between those who received the single, half‐day, group‐based education that focused on bone health, and those who received standard care (mean difference (MD) 111.60, 95% confidence interval (CI) ‐258.97 to 482.17; P = 0.56, low quality evidence). A regression analysis, adjusting for baseline calcium intake and changes in knowledge and self‐efficacy, showed a significantly greater calcium intake for the intervention as compared with the control group at the one‐month follow‐up (beta coefficient 4.92, 95% CI 0.33 to 9.52; P = 0.04). There was statistically significant higher, self‐reported milk consumption (MD 0.43, 95% CI 0.07 to 0.79; P = 0.02, low quality evidence), number of days on calcium supplementation (MD 11.42, 95% CI 7.11 to 15.73; P < 0.00001, low quality evidence), and use of any calcium supplementation (risk ratio (RR) 3.35, 95% CI 1.86 to 6.04; P < 0.0001, low quality evidence), with those who received this single, face‐to‐face, group‐based, health behaviour session. There was no clear evidence of a difference in bone density Z‐scores measured with a dual‐energy X‐ray absorptiometry (DEXA) scan at 36 months follow‐up (MD ‐0.05, 95% CI ‐0.26 to 0.16; P = 0.64, moderate quality evidence) between those who received calcium and vitamin D supplementation combined with nutrition education and those who received nutrition education alone. There was also no clear evidence of a difference in bone mineral density between the intervention and the control group at the 12‐month (median difference ‐0.17, P = 0.99) and 24‐month follow‐up (median difference ‐0.04, P = 0.54). A single multi‐component health behaviour change intervention, focusing on general healthy eating principles, with two telephone follow‐ups brought about a 0.17 lower score on the four‐point Likert scale of self‐reported junk food intake compared with the control group (MD ‐0.17, 95% CI ‐0.33 to ‐0.01; P = 0.04, low quality evidence); this result was statistically significant. There was no clear evidence of a difference between the groups in the self‐reported use of nutrition as a health protective behaviour (MD ‐0.05, 95% CI ‐0.24 to 0.14; P = 0.60, low quality evidence). Authors' conclusions Due to a paucity of studies, and the heterogeneity of the studies included in this review, we are unable to draw conclusions regarding the effectiveness of nutritional interventions for use with childhood cancer survivors. Although there is low quality evidence for the improvement in health behaviours using health behaviour change interventions, there remains no evidence as to whether this translates into an improvement in dietary intake. There was also no evidence that the studies reduced the risk of cardiovascular and metabolic disorders in childhood cancer survivors, although no evidence of effect is not the same as evidence of no effect. This review highlights the need for further well designed trials to be implemented in this population. Plain language summary Nutritional interventions for survivors of childhood cancer Background Survivors of childhood cancer are at a higher risk of chronic health conditions such as, osteoporosis, metabolic syndrome (including obesity and type II diabetes), and cardiovascular disease. These diseases have the potential to be reduced or prevented with targeted nutritional interventions. Objective This review looks at three randomised controlled trials that studied the effects of interventions designed to improve the dietary intake of children who have completed treatment for cancer. Study Characteristics The three studies included 616 participants who had completed their therapy for childhood cancer. All of the participants were less than 21 years of age at study entry. The interventions ranged from the promotion of health behaviours to vitamin and mineral supplementation. The follow‐up ranged from one month to 36 months from the initial assessment. Key results There was low quality evidence that those who received a health behaviour intervention decreased their self‐reported intake of “junk food”. They also increased their intake of dairy foods, as well as increasing their calcium supplementation. The interventions did not appear to translate to an improvement in their dietary intake, body composition, or bone mineral density. Quality of the evidence The results from this review do not provide enough evidence regarding the effectiveness of nutritional interventions for childhood cancer survivors. There was low quality evidence overall. Further well designed research is needed in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cohen, JE; Wakefield, CE; Cohn, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD009678.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "76572859-413c-4bad-b5e6-2f4c04d43683", "pmid": "", "title": "The Role of Bladder Cancer TAS2R38 Expression on Chemotherapy-Induced Bitter Taste", "imported": false, "abstract": "Alteration in the sense of taste is a frequent symptom that is closely linked to chemotherapy exposure, lowering quality of life and nutritional status. Malnutrition is of particular concern in muscle-invasive bladder cancer (MIBC), as malnutrition is associated with many negative outcomes from radical cystectomy (the surgical procedure in MIBC), which include higher morbidity, poor wound healing, and higher rate of infections after surgery.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.233Z" }, { "id": "765d8e11-69be-4c37-8afe-5893c519226b", "pmid": "", "title": "Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Soil‐transmitted helminth (STH) infections are amongst the most common infectious diseases worldwide, with an estimated 24% of the world’s population currently infected. Mass drug administration (MDA) is the periodic medicinal treatment, without prior individual diagnosis, of at‐risk people living in endemic areas. The World Health Organization currently recommends MDA for STHs. MDA programmes are complex health interventions; achieving adherence is important to their success. Adherence is influenced by the target population's perceptions of the drug, the programme, and those delivering it. Objectives To synthesize qualitative research evidence about community experiences and perceptions of mass drug administration programmes for soil‐transmitted helminths. To assess whether our findings confirm, extend, enrich, or conflict with those of a 2022 Cochrane qualitative evidence review of mass drug administration programmes for lymphatic filariasis. Search methods We searched CENTRAL, MEDLINE, Embase, and four other databases up to 11 November 2024, together with reference checking, and citation searching. Selection criteria We synthesized qualitative and mixed‐methods studies. We included studies exploring community experiences and perceptions of MDA programmes for STHs in any country, conducted between 2001 and 2024. We included all participants of MDA programmes, regardless of disease status, individual participation, or other demographic information. We also included lay healthcare workers and formally qualified healthcare workers, if their perspectives were clearly separated from those of the general population. Data collection and analysis We collected data on study characteristics and programme delivery, including country, endemicity, drug regimen, how the drugs were delivered, use of health education and sensitization, and adherence monitoring. We conducted thematic analysis using a 'best‐fit' framework synthesis based on a framework developed in a 2022 Cochrane review exploring community views on mass drug administration for filariasis (a parasitic infection caused by filarial worms). We conducted a deductive phase, accommodating our data within the existing model, followed by an inductive phase, during which we explored data not accommodated by the framework. We used the GRADE‐CERQual approach to assess our confidence in the findings, and updated the filariasis review's conceptual model to display our findings. Main results We included 17 studies, conducted in Bangladesh, Benin, India, Kenya, Malawi, Nigeria, the Philippines, and Turkey. Four themes emerged, three of which were identified in the review of MDA for lymphatic filariasis. People weigh up the benefits and harms in their decision to participate in MDA, though some may not have a choice. Outcomes of individual participation in MDA may be positive, negative, or both. The decision to partake is a careful balance of risk, benefit, and feasibility (high confidence). Unpleasant associations become part of the narrative and spread rapidly through the community (moderate confidence). Physical and social barriers prevent some people from being able to access MDA even if they want to participate (moderate confidence). Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical legacies, rumours, and mistrust of people involved in the programme affect overall trust in drug distribution and influence whether people choose to participate. Past experiences can have a profound effect on people, and negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background and in‐depth training around the drug or the disease itself (moderate confidence). Some community members prefer distribution from people they know or trust (high confidence). However, others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors (CDDs) cannot answer their programme‐related questions (moderate confidence). Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign, which includes improved sanitation, is necessary to tackle STH burden (moderate confidence). One theme that the filariasis review identified was not substantiated by the findings in this review (Programmes expect compliance: this can result in coercion and blame). Authors' conclusions Despite the prevalence and undoubted impact of MDA programmes over the past 10 years, endemic hotspots and continued transmission are common, due in part to poor community adherence. The 2022 Cochrane review outlined several key community concerns and doubts that hinder the effective implementation of MDA for lymphatic filariasis. This review shows that most of these concerns and doubts are shared by communities targeted for MDA for STHs, indicating that there are fundamental challenges in the overall conceptualization and design of MDA programmes that need to be addressed. Funding TF, MT, RK, and the Cochrane Infectious Diseases Group editorial base were funded by UK aid from the UK Government for the benefit of low‐ and middle‐income countries (project number 300342‐104). The views expressed do not necessarily reflect the UK Government’s official policies. Registration The protocol for this review was published in January 2024 on the Cochrane Database of Systematic Reviews. Available at doi.org/10.1002/14651858.CD015794. Plain language summary Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis Key messages People consider several personal, social, and historical factors before deciding to take medicine. Within one community, different individuals will experience benefits and harms associated with treatment, which shape their decision to participate. The decision to adhere depends on the perceived benefits compared to harms, the trust built between communities and the programme, the competency of people delivering the drugs to provide reassurance to the community members, and the perceived organisation of the delivery programme. Our findings are largely consistent with those of a 2022 Cochrane review exploring people's views and experiences of mass drug administration (MDA) programmes for lymphatic filariasis. This evidence overlap suggests that there are key challenges in the design of MDA programmes in general that need to be addressed to increase adherence. What was studied in this synthesis? Mass drug administration (MDA) involves the periodic delivery of drugs to treat entire communities or groups, regardless of whether an individual has a particular disease. This method aims to prevent onward transmission of infection within the population. MDA is currently recommended for some disease‐control programmes in low‐ and middle‐income countries, including for soil‐transmitted helminth (STH) infections. STHs are a group of parasitic worms, including roundworm, hookworm, whipworm, and threadworm. These MDA programmes are usually delivered within a community or as a school‐based programme. Successfully stopping STH infections through MDA depends on community members being willing and able to participate. In this review, we looked for studies that explored how people view and experience mass drug administration programmes for STHs. We identified 17 studies relevant to this synthesis. What was the aim of this synthesis? In this synthesis of qualitative research, we searched for studies that explored people's views on MDA programmes for treating STHs in low‐ and middle‐income countries. We wanted to understand how people view and experience mass drug administration programmes for soil‐transmitted helminths. We were also interested in whether our findings would support, extend, or conflict with findings from a 2022 Cochrane review which looked at MDA programmes for lymphatic filariasis, another infectious disease caused by worms. What were the main findings? We included 17 studies in our analysis. The studies covered several countries in Africa and South‐East Asia, and one country in the Eastern Mediterranean region. The included studies explored the views and experiences of community members and those distributing the medicines in low‐income countries where STH infection is a considerable problem. From the data, four themes emerged. The 2022 Cochrane review of MDA for lymphatic filariasis identified three of these themes, highlighting the similarities between these programmes. One new theme emerged. 1. People weigh up benefits and harms in their decision to participate in MDA, though some may not have a choice. There are many outcomes to participating in the MDA programme, both positive and negative. For community members, several of these may exist at once, and the decision to partake is a careful balance of risk, benefit, and feasibility (we have high confidence in the evidence). Unpleasant experiences can quickly spread through the community (moderate confidence). Physical and social barriers (e.g. travel distance or not attending school, respectively) prevent some people from accessing treatment through the MDA programme (moderate confidence). 2. Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical experiences, rumours, and mistrust of people involved in the programme affect overall trust in the programme. Past experiences can have a strong effect on people; negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). 3. The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background, and in‐depth training around the drug or the disease itself (moderate confidence). Whilst some community members prefer distribution from people who they know or trust (high confidence), others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors cannot answer their questions related to the programme (moderate confidence). 4. (New theme) Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign which includes improved sanitation is necessary to tackle STH burden (moderate confidence). How current is this evidence? The evidence is current to November 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fox, T, Shrestha, S, Kuehn, R, Taylor, M", "articleTypes": [], "doi": "10.1002/14651858.CD015794.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.119Z" }, { "id": "7660f9fe-47c6-45a1-87b8-541f5402b668", "pmid": "", "title": "Effects of Nutritional Supplementation With Amino Acids on Liver Lipid Content, Whole-body Protein Turnover, and Body Composition in Obese Pre-pubertal Children", "imported": false, "abstract": "The purpose of this study is to assess the effect of an eight-week dietary supplementation with essential amino acids plus arginine on liver and plasma lipid content, whole-body fat oxidation, whole-body insulin sensitivity, whole body protein metabolism, and body composition in obese pre-pubertal children.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.266Z" }, { "id": "7669d039-d0ec-4d1a-850d-b8ce7f5fdd69", "pmid": "", "title": "Antioxidant vitamin and mineral supplements for slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Age‐related macular degeneration (AMD) is a degenerative condition of the back of the eye that occurs in people over the age of 50 years. Antioxidants may prevent cellular damage in the retina by reacting with free radicals that are produced in the process of light absorption. Higher dietary levels of antioxidant vitamins and minerals may reduce the risk of progression of AMD. This is the third update of the review. Objectives To assess the effects of antioxidant vitamin and mineral supplements on the progression of AMD in people with AMD. Search methods We searched CENTRAL, MEDLINE, Embase, one other database, and three trials registers, most recently on 29 November 2022. Selection criteria We included randomised controlled trials (RCTs) that compared antioxidant vitamin or mineral supplementation to placebo or no intervention, in people with AMD. Data collection and analysis We used standard methods expected by Cochrane. Main results We included 26 studies conducted in the USA, Europe, China, and Australia. These studies enroled 11,952 people aged 65 to 75 years and included slightly more women (on average 56% women). We judged the studies that contributed data to the review to be at low or unclear risk of bias. Thirteen studies compared multivitamins with control in people with early and intermediate AMD. Most evidence came from the Age‐Related Eye Disease Study (AREDS) in the USA. People taking antioxidant vitamins were less likely to progress to late AMD (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.58 to 0.90; 3 studies, 2445 participants; moderate‐certainty evidence). In people with early AMD, who are at low risk of progression, this means there would be approximately four fewer cases of progression to late AMD for every 1000 people taking vitamins (one fewer to six fewer cases). In people with intermediate AMD at higher risk of progression, this corresponds to approximately 78 fewer cases of progression for every 1000 people taking vitamins (26 fewer to 126 fewer). AREDS also provided evidence of a lower risk of progression for both neovascular AMD (OR 0.62, 95% CI 0.47 to 0.82; moderate‐certainty evidence) and geographic atrophy (OR 0.75, 95% CI 0.51 to 1.10; moderate‐certainty evidence), and a lower risk of losing 3 or more lines of visual acuity (OR 0.77, 95% CI 0.62 to 0.96; moderate‐certainty evidence). Low‐certainty evidence from one study of 110 people suggested higher quality of life scores (measured with the Visual Function Questionnaire) in treated compared with non‐treated people after 24 months (mean difference (MD) 12.30, 95% CI 4.24 to 20.36). In exploratory subgroup analyses in the follow‐on study to AREDS (AREDS2), replacing beta‐carotene with lutein/zeaxanthin gave hazard ratios (HR) of 0.82 (95% CI 0.69 to 0.96), 0.78 (95% CI 0.64 to 0.94), 0.94 (95% CI 0.70 to 1.26), and 0.88 (95% CI 0.75 to 1.03) for progression to late AMD, neovascular AMD, geographic atrophy, and vision loss, respectively. Six studies compared lutein (with or without zeaxanthin) with placebo and one study compared a multivitamin including lutein/zeaxanthin with multivitamin alone. The duration of supplementation and follow‐up ranged from six months to five years. Most evidence came from the AREDS2 study in the USA; almost all participants in AREDS2 also took the original AREDS supplementation formula. People taking lutein/zeaxanthin may have similar or slightly reduced risk of progression to late AMD (RR 0.94, 95% CI 0.87 to 1.01), neovascular AMD (RR 0.92, 95% CI 0.84 to 1.02), and geographic atrophy (RR 0.92, 95% CI 0.80 to 1.05) compared with control (1 study, 4176 participants, 6891 eyes; low‐certainty evidence). A similar risk of progression to visual loss of 15 or more letters was seen in the lutein/zeaxanthin and control groups (RR 0.98, 95% CI 0.91 to 1.05; 6656 eyes; low‐certainty evidence). Quality of life (Visual Function Questionnaire) was similar between groups (MD 1.21, 95% CI ‐2.59 to 5.01; 2 studies, 308 participants; moderate‐certainty evidence).
One study in Australia randomised 1204 people to vitamin E or placebo with four years of follow‐up; 19% of participants had AMD. The number of late AMD events was low (N = 7) and the estimate of effect was uncertain (RR 1.36, 95% CI 0.31 to 6.05; very low‐certainty evidence). There was no evidence of any effect of treatment on visual loss (RR 1.04, 95% CI 0.74 to 1.47; low‐certainty evidence). There were no data on neovascular AMD, geographic atrophy, or quality of life.
Five studies compared zinc with placebo. Evidence largely drawn from the largest study (AREDS) found a lower progression to late AMD over six years (OR 0.83, 95% CI 0.70 to 0.98; 3 studies, 3790 participants; moderate‐certainty evidence), neovascular AMD (OR 0.76, 95% CI 0.62 to 0.93; moderate‐certainty evidence), geographic atrophy (OR 0.84, 95% CI 0.64 to 1.10; moderate‐certainty evidence), or visual loss (OR 0.87, 95% CI 0.75 to 1.00; 2 studies, 3791 participants; moderate‐certainty evidence). There were no data on quality of life. Gastrointestinal symptoms were the main reported adverse effect. In AREDS, zinc was associated with a higher risk of genitourinary problems in men, but no difference was seen between high‐ and low‐dose zinc groups in AREDS2. Most studies were too small to detect rare adverse effects. Data from larger studies (AREDS/AREDS2) suggested there may be little or no effect on mortality with multivitamin (HR 0.87, 95% CI 0.60 to 1.25; low‐certainty evidence) or lutein/zeaxanthin supplementation (HR 1.06, 95% CI 0.87 to 1.31; very low‐certainty evidence), but confirmed the increased risk of lung cancer with beta‐carotene, mostly in former smokers. Authors' conclusions Moderate‐certainty evidence suggests that antioxidant vitamin and mineral supplementation (AREDS: vitamin C, E, beta‐carotene, and zinc) probably slows down progression to late AMD. People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than people with early AMD. Although low‐certainty evidence suggested little effect with lutein/zeaxanthin alone compared with placebo, exploratory subgroup analyses from one large American study support the view that lutein/zeaxanthin may be a suitable replacement for the beta‐carotene used in the original AREDS formula. Plain language summary Do antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD)? Key messages 
‐ Taking an antioxidant multivitamin supplement may slow down the progression of age‐related macular degeneration (AMD), an eye disease that blurs your central vision. ‐ People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than for people with early AMD. ‐ Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence as to safety as they were generally too small. What is age‐related macular degeneration? Age‐related macular degeneration (AMD) is an eye disease that blurs your central vision. It is usually only diagnosed in people aged 50 years and above. AMD affects the central area (macula) of the back of the eye (retina), as the macula degenerates with age. In early AMD, yellow spots (called drusen) can be seen under the retina by an eye health professional. The affected person will probably be unaware that they have a problem. As the disease progresses, the drusen become larger (intermediate AMD). In the later stages of the disease, there may be loss of the cells – needed for vision – in the back of the eye. This is known as geographic atrophy. Sometimes, new (harmful) blood vessels grow in the macula. These new blood vessels may bleed and cause scarring. This is known as neovascular AMD. Neovascular AMD and geographic atrophy are known as late AMD. Why might antioxidant vitamins and minerals be helpful? Antioxidant vitamins and minerals may help to protect the macula against this deterioration and loss of vision. Antioxidants are natural molecules that may prevent or delay some types of cell damage. Vitamins C and E, beta‐carotene, lutein, zeaxanthin, and zinc are examples of antioxidants commonly found in dietary supplements. What did we want to find out? 
We wanted to find out whether antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD) and prevent visual loss. What did we do? We searched for studies that compared antioxidant vitamin and mineral supplements with placebo (a ‘dummy’ treatment not containing any supplements) or no treatment. We only looked at the effects of these supplements in people with AMD. There is another Cochrane Review on the effects of these supplements in people who do not already have AMD. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 26 studies from the USA, Europe, China, and Australia that enroled 11,952 people with AMD. These studies compared multivitamin supplements, zinc, vitamin E, lutein (with or without zeaxanthin) with placebo. Participants were aged 65 to 75 years and there were slightly more women than men in the studies. Main findings • Taking an antioxidant multivitamin supplement (AREDS formula containing vitamins E and C, beta‐carotene plus zinc) probably slows down the progression of AMD to late AMD and vision loss. This may result in a small improvement in quality of life. • People with intermediate AMD have a higher risk of progression to late AMD and so may be more likely to benefit from supplements (78 fewer cases of progression for every 1000 people taking supplements). People with early AMD have a low risk of progression and so may be less likely to benefit (4 fewer cases of progression to late AMD for every 1000 people taking supplements). • Lutein with or without zeaxanthin may have little or no effect on progression to late AMD but may be a suitable replacement for beta‐carotene in the AREDS formula. Beta‐carotene may increase the chance of lung cancer in people who have smoked. • The effects of vitamin E alone on the progression to late AMD and vision loss are uncertain. Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence about safety because most of the studies were small and reported on harmful effects inconsistently. What are the limitations of the evidence? Our confidence in the evidence ranged from moderate to very low. This is because most of the included studies were small, and they did not cover all the comparisons and outcomes we were interested in. How up to date is this review? 
This review updates our previous version. The evidence is up to date to 29 November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Evans, JR; Lawrenson, JG", "articleTypes": [], "doi": "10.1002/14651858.CD000254.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "766cc055-1459-4c91-ba1c-9cd3d20988fd", "pmid": "", "title": "Enteral tube feeding for people with severe dementia", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Davies, N, Barrado-Martín, Y, Vickerstaff, V, Rait, G, Fukui, A, Candy, B, Smith, CH, Manthorpe, J, Moore, KJ, Sampson, EL", "articleTypes": [], "doi": "10.1002/14651858.CD013503.pub2 AB - Abstract - Background The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing. Objectives To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021. Selection criteria We included randomised controlled trials (RCTs), or controlled non‐randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post‐pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers. Data collection and analysis Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non‐randomised Studies of Interventions' (ROBINS‐I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre‐agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta‐analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study. Main results We found no eligible RCTs. We included fourteen controlled, non‐randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low‐certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate‐certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very‐low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low‐certainty evidence. Five studies reported a variety of harm‐related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia. Authors' conclusions We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here. Plain language summary Enteral tube feeding for people with severe dementia What are the advantages and problems of tube feeding people with severe dementia? Key messages Tube feeding may not increase the length of time people with severe dementia live compared to no tube feeding. The risk of developing a pressure sore is probably higher with a feeding tube than with no tube. No studies looked at quality of life.We need more and better studies to investigate tube feeding people with severe dementia. Future studies should focus on a broader range of outcomes including, pain, quality of life and the impact on carers What is tube feeding? Somebody who can’t eat or drink through their mouth may be given liquid food through a tube into their stomach. This is called enteral tube feeding. The tube passes through their nose into their stomach (a nasogastric tube), or is inserted into the stomach through a small cut in their belly (percutaneous endoscopic gastrostomy or PEG). Why is this important for people with dementia? People with dementia often have difficulties eating and drinking. During the early stages of dementia, they may forget to eat, chew food without swallowing, or be confused at mealtimes. Some people experience changes in the taste and smell of food. In the later stages of dementia, people often have difficulties swallowing. It can be difficult to ensure they receive appropriate food and fluids. People with severe dementia need full‐time care, and it is often their families who care for them. It is difficult to decide whether or not to tube‐feed someone with dementia because the feeding tube can be uncomfortable or even painful, and may cause other unwanted effects such as pneumonia, worsen bowel or bladder control, as well as bleeding, swelling and infection. People with severe dementia may be confused or distressed by the tube and may try to remove it. What did we want to find out? We wanted to know whether tube feeding helps people with severe dementia who have problems with eating and swallowing. We were interested in the effect of tube feeding on: how long people lived; their quality of life (well‐being); and the development or healing of pressure sores (also known as bed sores). What did we do? 
We searched for studies that investigated whether: PEG compared to no tube; a nasogastric tube compared to no tube; orPEG, nasogastric and other types of tube feeding compared to no tube was effective and whether tube feeding caused any unwanted effects in adults of any age with severe dementia and poor intake of food and drink. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 14 studies that included 49,714 participants. Of these, 6203 were tube‐fed and 43,511 were not. Participants with no feeding tube were given standard care or standard care with extra treatments to encourage eating and drinking. Main results In people with severe dementia, compared to no tube feeding: PEG may make no difference to how long people live (4 studies, 36,816 people), and leads to a small increase in the chance of developing pressure sores (1 study, 4421 people). we don’t know if nasogastric tube feeding increases the length of time people live or increases their chance of developing pressure sores, because none of our included studies gave information about these points. Studies of people with either PEG or nasogastric tubes showed tube feeding may increase the length of time people live (4 studies, 1696 people), and may slightly increase the chance of developing pressure sores (3 studies, 351 people). None of our included studies reported quality of life. What are the limitations of the evidence? We have moderate confidence in our finding that pressure ulcers were more common in people who were fed with a PEG tube. However, we have little to very little confidence for our other findings. Three main factors reduced our confidence in the evidence. Firstly, people in the studies were not randomly placed into different treatment groups. This means that differences between the groups could be due to differences between people rather than between the treatments. However, due to ethical considerations it would be very difficult to do this in future studies. Secondly, results were very inconsistent across the different studies. Finally, some studies were very small. The results of further research could differ from the results of this review. How up to date is this evidence? The evidence is up to date to 14 April 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.803Z" }, { "id": "7686ba3e-d553-4981-81a7-1c28bd7eecfb", "pmid": "", "title": "Protein substitute for children and adults with phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria is an inherited metabolic disorder characterised by an absence or deficiency of the enzyme phenylalanine hydroxylase. The aim of treatment is to lower blood phenylalanine concentrations to the recommended therapeutic range to prevent developmental delay and support normal growth. Current treatment consists of a low‐phenylalanine diet in combination with a protein substitute which is free from or low in phenylalanine. Guidance regarding the use, dosage, and distribution of dosage of the protein substitute over a 24‐hour period is unclear, and there is variation in recommendations among treatment centres. This is an update of a Cochrane review first published in 2005, and previously updated in 2008. Objectives To assess the benefits and adverse effects of protein substitute, its dosage, and distribution of dose in children and adults with phenylketonuria who are adhering to a low‐phenylalanine diet. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which consists of references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. We also contacted manufacturers of the phenylalanine‐free and low‐phenylalanine protein substitutes for any data from published and unpublished randomised controlled trials. Date of the most recent search of the Group's Inborn Errors of Metabolism Trials Register: 03 April 2014. Selection criteria All randomised or quasi‐randomised controlled trials comparing: any dose of protein substitute with no protein substitute; an alternative dosage; or the same dose, but given as frequent small doses throughout the day compared with the same total daily dose given as larger boluses less frequently. Data collection and analysis Both authors independently extracted data and assessed trial quality. Main results Three trials (69 participants) are included in this review. One trial investigated the use of protein substitute in 16 participants, while a further two trials investigated the dosage of protein substitute in a total of 53 participants. Due to issues with data presentation in each trial, described in full in the review, formal statistical analyses of the data were impossible. Investigators will be contacted for further information. Authors' conclusions No conclusions could be drawn about the short‐ or long‐term use of protein substitute in phenylketonuria due to the lack of adequate or analysable trial data. Additional data and randomised controlled trials are needed to investigate the use of protein substitute in phenylketonuria. Until further evidence is available, current practice in the use of protein substitute should continue to be monitored with care. Plain language summary The impact of protein substitute on the nutrition status, growth, and neuropsychological performance of children and adults with phenylketonuria People with phenylketonuria (PKU) who follow a low‐phenylalanine diet are required to take protein substitute to ensure adequate consumption of protein, energy, and other nutrients. The need for protein substitute has been established through clinical experience and observational data. Randomised, controlled trials are needed to confirm this need as well as its proper dosage and frequency of use. We performed a systematic review of randomised control trials investigating the impact of the use, dosage, and distribution of protein substitute on physical and neuropsychological outcomes in the treatment of PKU. Trials of children and adults diagnosed with PKU in the newborn period who were treated early and continuously were included. We planned to pool the results of the trials to estimate treatment effect. Three trials met the inclusion criteria for the review. One trial evaluated the impact of protein substitute versus no protein substitute on neuropsychological status, plasma amino acid concentrations, and nutrient intake. The remaining two trials investigated the impact of differing dosages of protein substitute on plasma amino acid concentrations and nutrient intake. No trials investigating daily protein substitute distribution were eligible for inclusion in the review. Results are presented in text form only since adequate information for data pooling was not provided. The investigators will be contacted for further information. Currently data are insufficient to reach any conclusions regarding the use, dosage, and distribution of protein substitute in the treatment of PKU. Further randomized or controlled clinical trials are needed to provide evidence for the effectiveness, dosage, and distribution of protein substitute in the treatment of PKU.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Yi, SHL; Singh, RH", "articleTypes": [], "doi": "10.1002/14651858.CD004731.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "769b6071-5413-4ac3-a9c8-1ef04a09241a", "pmid": "", "title": "A Randomized, Multicenter, Adaptive Phase II/III Study To Evaluate The Efficacy And Safety Of Trastuzumab Emtansine (T-DM1) Versus Taxane (Docetaxel Or Paclitaxel) In Patients With Previously Treated Locally Advanced Or Metastatic HER2-Positive Gastric Cancer, Including Adenocarcinoma Of The Gastroesophageal Junction", "imported": false, "abstract": "This multicenter, randomized, adaptive Phase II/III study will evaluate the efficacy and safety of trastuzumab emtansine (T-DM1) compared to standard taxane (docetaxel or paclitaxel) treatment in participants with human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer. At the start of the trial (stage 1), participants will be randomized with a ratio 2:2:1 to one of three treatment arms: Arm A: trastuzumab emtansine 3.6 milligram per kilogram (mg/kg) per intravenous injection (IV) every 3 weeks; Arm B: trastuzumab emtansine 2.4 mg/kg IV every week; Arm C: standard taxane therapy (docetaxel 75 milligram per meter square [mg/m^2] IV every 3 weeks or paclitaxel 80 mg/m^2 kg IV every week per investigator choice). At the end of the first stage of the study, the dose and schedule of trastuzumab emtansine that will be used in the second stage of the study will be selected by an Independent Data Monitoring Committee (IDMC). The regimen selection analysis will be made after approximately 100 participants across all three study arms have been treated for at least 12 weeks.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.245Z" }, { "id": "76a8cdea-cc90-4577-901b-4431112237a0", "pmid": "", "title": "Preventive lipid‐based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes", "imported": false, "abstract": "Abstract - Background One nutritional intervention advocated to prevent malnutrition among children is lipid‐based nutrient supplements (LNS). LNS provide a range of vitamins and minerals, but unlike most other micronutrient supplements, LNS also provide energy, protein and essential fatty acids. Alternative recipes and formulations to LNS include fortified blended foods (FBF), which are foods fortified with vitamins and minerals, and micronutrient powders (MNP), which are a combination of vitamins and minerals, Objectives To assess the effects and safety of preventive LNS given with complementary foods on health, nutrition and developmental outcomes of non‐hospitalised infants and children six to 23 months of age, and whether or not they are more effective than other foods (including FBF or MNP). This review did not assess the effects of LNS as supplementary foods or therapeutic foods in the management of moderate and severe acute malnutrition. Search methods In October 2018, we searched CENTRAL, MEDLINE, Embase, 21 other databases and two trials registers for relevant studies. We also checked the reference lists of included studies and relevant reviews and contacted the authors of studies and other experts in the area for any ongoing and unpublished studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs that evaluated the impact of LNS plus complementary foods given at point‐of‐use (for any dose, frequency, duration) to non‐hospitalised infants and young children aged six to 23 months in stable or emergency settings and compared to no intervention, other supplementary foods (i.e. FBF), nutrition counselling or multiple micronutrient supplements or powders for point‐of‐use fortification of complementary foods. Data collection and analysis Two review authors independently screened studies for relevance and, for those studies included in the review, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software. We used a random‐effects meta‐analysis for combining data as the interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables,. Main results Our search identified a total of 8124 records, from which we included 17 studies (54 papers) with 23,200 children in the review. The included studies reported on one or more of the pre‐specified primary outcomes, and five studies included multiple comparison groups. Overall, the majority of trials were at low risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias, but at high risk of bias for blinding of participants and personnel due to the nature of the intervention. Using the GRADE approach, we judged the quality of the evidence for most outcomes as low or moderate. LNS+complementary feeding compared with no intervention Thirteen studies compared LNS plus complementary feeding with no intervention. LNS plus complementary feeding reduced the prevalence of moderate stunting by 7% (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.88 to 0.98; nine studies, 13,372 participants; moderate‐quality evidence), severe stunting by 15% (RR 0.85, 95% CI 0.74 to 0.98; five studies, 6151 participants; moderate‐quality evidence), moderate wasting by 18% (RR 0.82, 95% CI 0.74 to 0.91; eight studies; 13,172 participants; moderate‐quality evidence), moderate underweight by 15% (RR 0.85, 95% CI 0.80 to 0.91; eight studies, 13,073 participants; moderate‐quality evidence), and anaemia by 21% (RR 0.79, 95% CI 0.69 to 0.90; five studies, 2332 participants; low‐quality evidence). There was no impact of LNS plus complementary feeding on severe wasting (RR 1.27, 95% CI 0.66 to 2.46; three studies, 2329 participants) and severe underweight (RR 0.78, 95%CI 0.54 to 1.13; two studies, 1729 participants). Adverse effects did not differ between the groups (RR 0.86, 95% CI 0.74 to 1.01; three studies, 3382 participants). LNS+complementary feeding compared with FBF Five studies compared LNS plus complementary feeding with other FBF, including corn soy blend and UNIMIX. We pooled four of the five studies in meta‐analyses and found that, when compared to other FBF, LNS plus complementary feeding significantly reduced the prevalence of moderate stunting (RR 0.89, 95% CI 0.82 to 0.97; three studies, 2828 participants; moderate‐quality evidence), moderate wasting (RR 0.79, 95% CI 0.65 to 0.97; two studies, 2290 participants; moderate‐quality evidence), and moderate underweight (RR 0.81, 95% CI 0.73 to 0.91; two studies, 2280 participants; moderate‐quality evidence). We found no difference between LNS plus complementary feeding and FBF for severe stunting (RR 0.41, 95% CI 0.12 to 1.42; two studies, 729 participants; low‐quality evidence), severe wasting (RR 0.64, 95% CI 0.19 to 2.81; two studies, 735 participants; moderate‐quality evidence), and severe underweight (RR 1.23, 95% CI 0.67 to 2.25; one study, 173 participants; low‐quality evidence). LNS+complementary feeding compared with MNP Four studies compared LNS plus complementary feeding with MNP. We pooled data from three of the four studies in meta‐analyses and found that compared to MNP, LNS plus complementary feeding significantly reduced the prevalence of moderate underweight (RR 0.88, 95% CI 0.78 to 0.99; two studies, 2004 participants; moderate‐quality evidence) and anaemia (RR 0.38, 95% CI 0.21 to 0.68; two studies, 557 participants; low‐quality evidence). There was no difference between LNS plus complementary feeding and MNP for moderate stunting (RR 0.92, 95% CI 0.82 to 1.02; three studies, 2365 participants) and moderate wasting (RR 0.97, 95% CI 0.77 to 1.23; two studies, 2004 participants). Authors' conclusions The findings of this review suggest that LNS plus complementary feeding compared to no intervention is effective at improving growth outcomes and anaemia without adverse effects among children aged six to 23 months in low‐ and middle‐income countries (LMIC) in Asia and Africa, and more effective if provided over a longer duration of time (over 12 months). Limited evidence also suggests that LNS plus complementary feeding is more effective than FBF and MNP at improving growth outcomes. Plain language summary Effect of lipid‐based nutrient supplementation on infants and young children Review question What is the impact of lipid‐based nutrient supplements (LNS) plus complementary foods on health, nutrition and developmental outcomes among infants and young children? Background LNS are food products which contain energy, minerals and vitamins that can improve growth in children. LNS provide vitamins, minerals and energy in the form of protein and essential fatty acids. We sought to assess the effect of LNS given jointly with complementary feeding, compared to no intervention, micronutrient powders (MNP; a mixture of vitamins and minerals that is sprinkled onto food) and other fortified blended food (FBF) products in healthy children. Study characteristics This review includes 17 studies (from 54 reports) with 23,200 children. Four of the included studies were conducted in Malawi, three in Bangladesh, two in Ghana and one each in Burkina Faso, Haiti, Honduras, Chad, Congo, Kenya, Niger, Peru, Guatemala, and Indonesia. Four included studies enrolled pregnant women and provided LNS plus complementary feeding during pregnancy and post‐partum, followed by infant supplementation starting at six months of age. The other studies provided LNS plus complementary feeding to children after six months of age. None of the included studies were conducted in emergency settings. Key results Findings of this review suggest that LNS plus complementary feeding is probably an effective intervention for improving growth outcomes and reducing the occurrence of children who are of short stature for their age (stunting), have low weight for their age (moderate underweight), have low weight for their height (moderate wasting) and anaemia. Additionally, LNS plus complementary feeding probably improves height and weight for age as well as mid‐upper arm circumference without adverse effects among children aged six to 23 months. The intervention seems to be more effective if provided for a duration longer than 12 months. Evidence also suggests that LNS plus complementary probably reduces moderate stunting, moderate wasting and moderate underweight, compared to other FBF. Furthermore, LNS plus complementary feeding is probably more effective than MNP at reducing moderate underweight and improving height and weight. Quality of evidence Overall, we considered most studies to be at high risk of bias for blinding of participants and personnel due to the nature of intervention. We rated the quality of the evidence for most outcomes as either low or moderate. Currentness of evidence The evidence is current to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Das, JK; Salam, RA; Hadi, YB; Sadiq Sheikh, S; Bhutta, AZ; Weise Prinzo, Z; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD012611.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "76bb2e2e-29f3-4d1e-8f56-b763b43c030d", "pmid": "", "title": "Antioxidant supplementation for lung disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Airway infection leads to progressive damage of the lungs in cystic fibrosis (CF) and oxidative stress has been implicated in the etiology. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, beta‐carotene and selenium) or N‐acetylcysteine (NAC) as a source of glutathione, may therefore potentially help maintain an oxidant‐antioxidant balance. Glutathione or NAC can also be inhaled and if administered in this way can also have a mucolytic effect besides the antioxidant effect. Current literature suggests a relationship between oxidative status and lung function. This is an update of a previously published review. Objectives To synthesise existing knowledge on the effect of antioxidants such as vitamin C, vitamin E, beta‐carotene, selenium and glutathione (or NAC as precursor of glutathione) on lung function through inflammatory and oxidative stress markers in people with CF. Search methods The Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and PubMed were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies. We also searched online trials registries. Last search of Cystic Fibrosis Trials Register: 08 January 2019. Selection criteria Randomised and quasi‐randomised controlled studies comparing antioxidants as listed above (individually or in combination) in more than a single administration to placebo or standard care in people with CF. Data collection and analysis Two authors independently selected studies, extracted data and assessed the risk of bias in the included studies. We contacted study investigators to obtain missing information. If meta‐analysed, studies were subgrouped according to supplement, method of administration and the duration of supplementation. We assessed the quality of the evidence using GRADE. Main results One quasi‐randomised and 19 randomised controlled studies (924 children and adults) were included; 16 studies (n = 639) analysed oral antioxidant supplementation and four analysed inhaled supplements (n = 285). Only one of the 20 included studies was judged to be free of bias. Oral supplements versus control The change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted at three months and six months was only reported for the comparison of NAC to control. Four studies (125 participants) reported at three months; we are uncertain whether NAC improved FEV 1 % predicted as the quality of the evidence was very low, mean difference (MD) 2.83% (95% confidence interval (CI) ‐2.16 to 7.83). However, at six months two studies (109 participants) showed that NAC probably increased FEV 1 % predicted from baseline (moderate‐quality evidence), MD 4.38% (95% CI 0.89 to 7.87). A study of a combined vitamin and selenium supplement (46 participants) reported a greater change from baseline in FEV 1 % predicted in the control group at two months, MD ‐4.30% (95% CI ‐5.64 to ‐2.96). One study (61 participants) found that NAC probably makes little or no difference in the change from baseline in quality of life (QoL) at six months (moderate‐quality evidence), standardised mean difference (SMD) ‐0.03 (95% CI ‐0.53 to 0.47), but the two‐month combined vitamin and selenium study reported a small difference in QoL in favour of the control group, SMD ‐0.66 (95% CI ‐1.26 to ‐0.07). The NAC study reported on the change from baseline in body mass index (BMI) (62 participants) and similarly found that NAC probably made no difference between groups (moderate‐quality evidence). One study (69 participants) found that a mixed vitamin and mineral supplement may lead to a slightly lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) provided information on adverse events, but did not find any clear and consistent evidence of differences between treatment or control groups with the quality of the evidence ranging from low to moderate. Studies of β‐carotene and vitamin E consistently reported greater plasma levels of the respective antioxidants. Inhaled supplements versus control Two studies (258 participants) showed inhaled glutathione probably improves FEV 1 % predicted at three months, MD 3.50% (95% CI 1.38 to 5.62), but not at six months compared to placebo, MD 2.30% (95% CI ‐0.12 to 4.71) (moderate‐quality evidence). The same studies additionally reported an improvement in FEV 1 L in the treated group compared to placebo at both three and six months. One study (153 participants) reported inhaled glutathione probably made little or no difference to the change in QoL from baseline, MD 0.80 (95% CI ‐1.63 to 3.23) (moderate‐quality evidence). No study reported on the change from baseline in BMI at six months, but one study (16 participants) reported at two months and a further study (105 participants) at 12 months; neither study found any difference at either time point. One study (153 participants) reported no difference in the time to the first pulmonary exacerbation at six months. Two studies (223 participants) reported treatment may make little or no difference in adverse events (low‐quality evidence), a further study (153 participants) reported that the number of serious adverse events were similar across groups. Authors' conclusions With regards to micronutrients, there does not appear to be a positive treatment effect of antioxidant micronutrients on clinical end‐points; however, oral supplementation with glutathione showed some benefit to lung function and nutritional status. Based on the available evidence, inhaled and oral glutathione appear to improve lung function, while oral administration decreases oxidative stress; however, due to the very intensive antibiotic treatment and other concurrent treatments that people with CF take, the beneficial effect of antioxidants remains difficult to assess in those with chronic infection without a very large population sample and a long‐term study period. Further studies, especially in very young children, using outcome measures such as lung clearance index and the bronchiectasis scores derived from chest scans, with improved focus on study design variables (such as dose levels and timing), and elucidating clear biological pathways by which oxidative stress is involved in CF, are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn. The benefit of antioxidants in people with CF who receive CFTR modulators therapies should also be assessed in the future. Plain language summary How do vitamins E and C, beta‐carotene, selenium and glutathione affect lung disease in people with cystic fibrosis? Background Frequent chest infections cause long‐term lung inflammation; inflammation‐causing cells produce an oxygen molecule (reactive oxygen species (ROS)), which may harm body tissue (oxidative damage); the body uses antioxidants to protect itself. People with cystic fibrosis (CF) have high levels of ROS compared to low levels of antioxidants. Antioxidant supplements might reduce oxidative damage and build up levels of antioxidants. Given difficulties in absorbing fat, people with CF have low levels of fat‐soluble antioxidants (vitamin E and beta‐carotene). Water‐soluble vitamin C decreases with age in people with CF. Glutathione, one of the most abundant antioxidants in cells, is not released properly into the lungs of people with CF. Some enzymes that help antioxidants work depend on the mineral selenium, so selenium supplements aim to stimulate antioxidant action. Most supplements are swallowed, but glutathione and N‐acetylcysteine (NAC) (which the body uses to make glutathione) can also be inhaled; these may affect lung function as antioxidants, but also due to thinning mucus when inhaled (allowing easier mucus clearance). Search date Last search for this updated review: 08 January 2019. Study characteristics We included 20 studies (924 people with CF, almost equal gender split, aged six months to 59 years); 16 studies compared oral supplements to placebo ('dummy' treatment) and four compared inhaled supplements to placebo. Key results Oral supplements We are uncertain whether NAC changes lung function (forced expiratory volume in one second (FEV 1 ) % predicted) at three months (four studies, 125 participants, very low‐quality evidence), but at six months two studies (109 participants) reported NAC probably improved FEV 1 % predicted (moderate‐quality evidence). One study (46 participants) reported a greater change in FEV 1 % predicted with placebo than with a combined vitamin and selenium supplement after two months. One study (61 participants) reported little or no difference in quality of life (QoL) scores between NAC and control after six months (moderate‐quality evidence), but the two‐month combined vitamin and selenium study reported slightly better QoL scores in the control group. NAC probably made no difference to body mass index (BMI) (one study, 62 participants, moderate‐quality evidence). One study (69 participants) reported that a mixed vitamin and mineral supplement may lead to a lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) did not find any clear and consistent differences in side effects between groups (evidence ranged from low to moderate quality). Vitamin E and β‐carotene studies consistently reported greater levels of these antioxidants in blood samples. Inhaled supplements In two studies (258 participants), inhaled glutathione probably improved FEV 1 % predicted compared to placebo at three months but not at six months (moderate‐quality evidence); these studies also reported a greater improvement in FEV 1 litres with glutathione compared to placebo at both time points. Two studies (258 participants) found little or no difference in the change in QoL scores (moderate‐quality evidence). One two‐month study (16 participants) and a 12‐month study (105 participants) reported no difference between groups in the change in BMI. There was no difference in the time to the first pulmonary exacerbation in one six‐month study. Two studies (223 participants) reported no difference between groups in side effects (low‐quality evidence) and another study (153 participants) reported that the number of serious side effects were similar across groups. Conclusions Vitamin and mineral supplements do not seem to improve clinical outcomes. Inhaled glutathione appears to improve lung function, while oral administration lowers oxidative stress, with benefits to lung function and nutritional measures. Intensive antibiotic and other concurrent treatments for people with CF and chronic infection mean it is difficult to assess the effect of antioxidants without a very large and long study. Future research should look at how antioxidants affect people with CF taking CFTR modulator therapies. Quality of the evidence Evidence ranged from very low to moderate quality. All but one study had some bias; mostly because data were not fully reported (likely to affect our results). We were also largely unsure if participants knew which treatment they received, both in advance and once the studies started (unsure how this might affect our results).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ciofu, O; Smith, S; Lykkesfeldt, J", "articleTypes": [], "doi": "10.1002/14651858.CD007020.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "76c43c7c-fdd7-4a4b-8bfc-242e794bcc5e", "pmid": "", "title": "Zinc supplementation for the treatment of measles in children", "imported": false, "abstract": "Abstract - Background Measles is an important cause of childhood morbidity and mortality globally, despite increasing vaccine coverage. Zinc plays a significant role in the maintenance of normal immunological functions, therefore supplements given to zinc‐deficient children will increase the availability of zinc and could reduce measles‐related morbidity and mortality. This is an update of a review first published in 2015. Objectives To assess the effects of zinc supplementation in reducing morbidity and mortality in children with measles. Search methods We searched CENTRAL (03 February 2017, Issue 2), MEDLINE (1946 to 03 February 2017), Embase (1974 to 03 February 2017), CINAHL (1981 to 03 February 2017), LILACS (1982 to 03 February 2017), Web of Science (1985 to 03 February 2017), and BIOSIS Previews (1985 to 27 June 2014). We also searched ClinicalTrials.gov, the Australian New Zealand Clinical Trials Registry and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 03 February 2017 to identify unpublished and ongoing studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of zinc in reducing morbidity and mortality in children with measles. Data collection and analysis Two review authors independently assessed the studies for inclusion and extracted data on outcomes, details of the interventions, and other study characteristics using a standardised data extraction form. We used risk ratio (RR) and hazard ratio (HR) as measures of effect with 95% confidence intervals (CI). We included only one study, and did not conduct meta‐analysis. Main results We did not identify any new studies for inclusion in this update. One RCT met our inclusion criteria. The study was conducted in India and included 85 children diagnosed with measles and pneumonia. The trial showed no significant difference in mortality between children with measles and pneumonia who received zinc supplements and those who received placebo (RR 0.34, 95% CI 0.01 to 8.14). There was no significant difference in time to absence of fever between children who received zinc supplements and those who did not (HR 1.08, 95% CI 0.67 to 1.74). No treatment‐related side effects were reported in either group. We assessed the overall quality of the evidence as very low. Authors' conclusions We could not draw any definitive conclusions from this review about the effects of zinc supplementation on clinical outcomes of children with measles due to the very low quality of the evidence available. There is insufficient evidence to confirm or refute the effect of zinc supplementation in children with measles. Plain language summary Zinc supplementation for the treatment of measles in children Review question What is the effect of zinc supplementation in the treatment of children with measles? Background Measles infection has reduced globally over the last decade, but large outbreaks still occur, especially in low‐income countries. Zinc is one of the essential micronutrients necessary for the optimal functioning of the immune system. Zinc deficiency is particularly common in children in low‐ and middle‐income countries. It was therefore important to examine the potential role of zinc supplementation in controlling the symptoms of measles infection in children. We aimed to critically assess the current evidence from published studies on the effect of zinc supplementation for the treatment of measles in children. Search date We searched for evidence up to 03 February 2017. This is an update of a review first published in 2015. We did not include any new studies for this update. Study characteristics We found one small randomised trial (involving 85 children) that compared zinc supplements versus placebo administered to children with measles and pneumonia. All 85 children received supportive care and vitamin A. The study was conducted in India and funded by the Child Health Foundation USA and the Nestlé Foundation. Key results The included study was small and did not provide enough data to determine whether zinc had an effect on mortality when compared with placebo. Although no adverse effects were reported, there was insufficient evidence to draw any conclusions about the use of zinc supplements to improve measles symptoms in children. More research is needed to clarify any benefits or harms. Quality of the evidence We assessed the quality of the evidence as very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Awotiwon, AA, Oduwole, O, Sinha, A, Okwundu, CI", "articleTypes": [], "doi": "10.1002/14651858.CD011177.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.762Z" }, { "id": "76c62059-dcd7-46e5-bedc-945a3b94fae4", "pmid": "", "title": "Padma 28 for intermittent claudication", "imported": false, "abstract": "Abstract - Background Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease that develops in a limb during exercise and is relieved with rest. Most drug treatments of IC have a limited effect in improving walking distance. Padma 28, a Tibetan herbal preparation, has been used to treat IC, but there is debate as to whether Padma 28 produces a clinical benefit beyond the placebo effect. This is an update of a review first published in 2013. Objectives To determine whether Padma 28 is effective, compared with placebo or other medications, in increasing pain‐free and maximum walking distance for patients with intermittent claudication. Search methods For this update the Cochrane Vascular Trials Search Co‐ordinator searched the Specialised Register (September 2015), the Cochrane Register of Studies ((CENTRAL) (2015, Issue 8)) and clinical trials databases. Selection criteria Randomised controlled trials of Padma 28 compared with placebo or other pharmacological treatments in people suffering from IC. Data collection and analysis All review authors independently assessed the selected studies and extracted the data. Risk of bias was evaluated independently by two review authors. Depending on the data provided in the individual trials, we extracted mean or median walking distance at the end of the trial, or change in walking distance over the course of the trial, or both. Where not provided, and whenever possible, the statistical significance of differences in these parameters between treatment and placebo groups in individual trials was calculated. Where possible, data were combined by meta‐analysis. Main results No new trials were identified in the search for this review update. In total five trials involving 365 participants were included in this review. All trials compared Padma 28 with placebo for at least 16 weeks of follow‐up. Pain‐free and maximum walking distances both increased significantly in the groups treated with Padma 28, with no significant change in the placebo group. In general, the studies presented results comparing the treatment arms before and after treatment but made no comparisons between the Padma 28 and placebo groups. Pooled data of maximum walking distance after treatment with Padma 28 and placebo from two studies (193 participants) indicated a higher maximum walking distance (mean difference (MD) 95.97 m, 95% confidence interval (CI) 79.07 m to 112.88 m, P < 0.00001, very low quality evidence) in the Padma 28 group compared with placebo. The clinical importance of these observed changes in walking distance is unclear as no quality of life data were reported. There was no effect on ankle brachial index (ABI): change in ABI values between baseline and six months follow up MD ‐0.01, 95% CI ‐0.07 to 0.05, 1 study, 56 participants, P = 0.72, very low quality evidence). Mild side effects, especially gastrointestinal discomfort, tiredness and skin eruption, were reported but this outcome was not different between the Padma 28 and placebo groups (odds ratio 1.09, 95% CI 0.42 to 2.83, four studies, 231 participants, P = 0.86, very low quality evidence). Authors' conclusions Some evidence exists from individual trials to suggest that Padma 28 may be effective in increasing walking distances, at least in the short term (four months), in people with IC. Side effects do not appear to be a problem. However, the longer term effects of treatment are unknown and the clinical significance of the improvements in walking distance are questionable. Moreover, the quality of the evidence is limited by the small sample size of the available trials, limited reporting of statistical analyses that compared treatment groups, and relatively high withdrawal rates that were linked to the outcome. That is, patients were withdrawn if they failed to improve walking distance. There was also evidence of publication bias. We therefore feel there is currently insufficient evidence to draw conclusions regards the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation. Plain language summary Padma 28 for intermittent claudication Background Intermittent claudication (IC) is pain in the leg that occurs on exercise and is relieved by rest. It is caused by an inadequate blood supply to the legs due to blockage of arteries. Conservative drug treatment is commonly used in an attempt to improve walking distance in these patients. Padma 28 is a Tibetan herbal preparation used for treating intermittent claudication. Study characteristics and key results This review on the effects of Padma 28 includes five trials with a total of 365 participants (current until September 2015). The review showed that Padma 28 has some beneficial effects in improving maximum and pain‐free walking distance. The groups treated with placebo did not show an improved maximum and pain‐free walking distance. Unfortunately the studies reported insufficient data to allow the comparison of the change in walking distances in the Padma 28 group with the change in walking distances in the placebo group. Combining the data of maximum walking distance after treatment in two studies showed that there was a longer maximum walking distance in the Padma 28 group compared with the placebo group after 16 weeks of treatment. No change in ankle brachial pressure was observed. Mild side effects such as gastrointestinal discomfort, tiredness and skin eruption were also noted but these were not different between the Padma 28 and placebo groups. Quality of the evidence Overall, the quality of the studies was low, with evidence of publication bias, small number of trials, limited reporting of the analyses that compared treatment groups and bias due to a high percentage of withdrawals in the placebo groups because of lack of improvement or deterioration of the overall condition. We therefore feel there is currently insufficient evidence to draw conclusions about the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stewart, M, Morling, JR, Maxwell, H", "articleTypes": [], "doi": "10.1002/14651858.CD007371.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.768Z" }, { "id": "76c7a764-6093-4b2c-939d-5ec46b80a4d6", "pmid": "", "title": "Antipsychotics for fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue. It affects approximately 2% of the general population. Up to 70% of patients with fibromyalgia meet the criteria for a depressive or anxiety disorder. People often report high disability levels and poor health‐related quality of life. Drug therapy focuses on reducing key symptoms and disability, and improving health‐related quality of life. Antipsychotics might reduce fibromyalgia and associated mental health symptoms. Objectives To assess the efficacy, tolerability and safety of antipsychotics in fibromyalgia in adults. Search methods We searched CENTRAL (2016, Issue 4), MEDLINE and EMBASE to 20 May 2016, together with reference lists of retrieved papers and reviews and two clinical trial registries. We also contacted trial authors. Selection criteria We selected controlled trials of at least four weeks duration of any formulation of antipsychotics used for the treatment of fibromyalgia in adults. Data collection and analysis We extracted the data from all included studies and two review authors independently assessed study risks of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. We derived first tier evidence from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs, at least 200 participants in the comparison, eight to 12 weeks duration, parallel design), second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison, and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. We rated the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main results We included a total of four studies with 296 participants. Three studies with 206 participants compared quetiapine, an atypical (second‐generation) antipsychotic, with placebo. One study used a cross‐over design and two studies a parallel‐group design. Study duration was eight or 12 weeks. Quetiapine was used in all studies with a bedtime dosage between 50 and 300 mg/day. All studies had one or more sources of potential major bias and we judged them to be at moderate risk of bias overall. The primary outcomes in this review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Second tier evidence indicated that quetiapine was not statistically superior to placebo in the number of participants with a 50% or more pain reduction (very low quality evidence). No study reported data on PGIC. A greater proportion of participants on quetiapine reported a 30% or more pain reduction (risk difference (RD) 0.12, 95% confidence interval (CI) 0.00 to 0.23; number needed to treat for an additional benefit (NNTB) 8, 95% CI 5 to 100) (very low quality evidence). A greater proportion of participants on quetiapine reported a clinically relevant improvement of health‐related quality of life compared to placebo ( RD 0.18, 95% CI 0.05 to 0.31; NNTB 5, 95% CI 3 to 20) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing sleep problems (standardised mean difference (SMD) ‐0.67, 95% CI ‐1.10 to ‐0.23), depression (SMD ‐0.39, 95% CI ‐0.74 to ‐0.04) and anxiety (SMD ‐0.40, 95% CI ‐0.69 to ‐0.11) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing the risk of withdrawing from the study due to a lack of efficacy (RD ‐0.14, 95% CI ‐0.23 to ‐0.05) (very low quality evidence). There was no statistically significant difference between quetiapine and placebo in the proportion of participants withdrawing due to adverse events (tolerability) (very low quality evidence), in the frequency of serious adverse events (safety) (very low quality evidence) and in the proportion of participants reporting dizziness and somnolence as an adverse event (very low quality evidence). In more participants in the quetiapine group a substantial weight gain was noted (RD 0.08, 95% CI 0.02 to 0.15; number needed to treat for an additional harm (NNTH) 12, 95% CI 6 to 50) (very low quality evidence). We downgraded the quality of evidence by three levels to a very low quality rating because of limitations of study design, indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). One parallel design study with 90 participants compared quetiapine (50 to 300 mg/day flexible at bedtime) to amitriptyline (10 to 75 mg/day flexible at bedtime). The study had three major risks of bias and we judged it to be at moderate risk of bias overall. We downgraded the quality of evidence by two levels to a low quality rating because of indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). Third tier evidence indicated no statistically significant differences between the two drugs. Both drugs did not statistically significantly differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life and in the proportion of participants reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared to amitriptyline, more participants left the study due to adverse events (low quality evidence). No serious adverse events were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia. Authors' conclusions Very low quality evidence suggests that quetiapine may be considered for a time‐limited trial (4 to 12 weeks) to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits in shared decision making with the patient. Plain language summary Antipsychotics for fibromyalgia symptoms in adults Bottom line Quetiapine may be considered for 4 to 12 weeks to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as sleep problems, problems with thinking and exhaustion. They often report severe limitations of daily functioning and poor quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. In addition, many patients with fibromyalgia suffer from depression. Medicines used to treat depression can reduce the main symptoms in some people with fibromyalgia. Quetiapine is a drug for the treatment of psychosis (an abnormal condition of the mind described as involving a loss of contact with reality), which is also licensed for the treatment of major depression in some countries. Study characteristics In May 2016, we searched for clinical trials in which antipsychotics were used to treat symptoms of fibromyalgia in adults. We found a total of four studies with 298 participants. We found three studies with 208 participants, which were eight and 12 weeks long and compared quetiapine, an antipsychotic, against a fake medication (placebo). One hundred and sixty‐six participants were diagnosed with major depression. We also found one study comprising 90 patients that compared quetiapine to an antidepressant named amitriptyline, which is frequently used in the treatment of fibromyalgia. Five people in this study were diagnosed with major depression. Key results and quality of the evidence Quetiapine was not better than a fake medication in achieving a pain reduction of 50% or more (very low quality evidence). Quetiapine was better than the fake medication in achieving a pain reduction of 30% or more, reducing sleep problems, and improving depressed mood and anxiety (very low quality evidence). Quetiapine was better than the fake medication in improving health‐related quality of life. Fewer participants dropped out of the trial due to lack of efficacy with quetiapine than with fake medication (very low quality evidence). There was no difference in tolerability and safety between quetiapine and a fake medication (very low quality evidence). For some people, quetiapine led to substantial weight gain and somnolence (sleepiness). Quetiapine and amitriptyline (an antidepressant which is frequently used to improve sleep and reduce pain in people with fibromyalgia) did not differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life. Both drugs did not differ in the proportion of patients reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared with amitriptyline, more people experienced side effects and left the study due to side effects with quetiapine (low quality evidence). No serious side effects with either drug were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B, Klose, P, Üçeyler, N, Phillips, T, Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011804.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.771Z" }, { "id": "76dabf84-d098-4081-96c4-5e1147176b14", "pmid": "", "title": "Interventions for palliative symptom control in COVID‐19 patients", "imported": false, "abstract": "Abstract - Background Individuals dying of coronavirus disease 2019 (COVID‐19) may experience distressing symptoms such as breathlessness or delirium. Palliative symptom management can alleviate symptoms and improve the quality of life of patients. Various treatment options such as opioids or breathing techniques have been discussed for use in COVID‐19 patients. However, guidance on symptom management of COVID‐19 patients in palliative care has often been derived from clinical experiences and guidelines for the treatment of patients with other illnesses. An understanding of the effectiveness of pharmacological and non‐pharmacological palliative interventions to manage specific symptoms of COVID‐19 patients is required. Objectives To assess the efficacy and safety of pharmacological and non‐pharmacological interventions for palliative symptom control in individuals with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), Embase, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), medRxiv); Web of Science Core Collection (Science Citation Index Expanded, Emerging Sources); CINAHL; WHO COVID‐19 Global literature on coronavirus disease; and COAP Living Evidence on COVID‐19 to identify completed and ongoing studies without language restrictions until 23 March 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. Selection criteria We followed standard Cochrane methodology as outlined in the Cochrane Handbook for Systematic Reviews of Interventions . We included studies evaluating palliative symptom management for individuals with a confirmed diagnosis of COVID‐19 receiving interventions for palliative symptom control, with no restrictions regarding comorbidities, age, gender, or ethnicity. Interventions comprised pharmacological as well as non‐pharmacological treatment (e.g. acupressure, physical therapy, relaxation, or breathing techniques). We searched for the following types of studies: randomized controlled trials (RCT), quasi‐RCTs, controlled clinical trials, controlled before‐after studies, interrupted time series (with comparison group), prospective cohort studies, retrospective cohort studies, (nested) case‐control studies, and cross‐sectional studies. We searched for studies comparing pharmacological and non‐pharmacological interventions for palliative symptom control with standard care. We excluded studies evaluating palliative interventions for symptoms caused by other terminal illnesses. If studies enrolled populations with or exposed to multiple diseases, we would only include these if the authors provided subgroup data for individuals with COVID‐19. We excluded studies investigating interventions for symptom control in a curative setting, for example patients receiving life‐prolonging therapies such as invasive ventilation. Data collection and analysis We used a modified version of the Newcastle Ottawa Scale for non‐randomized studies of interventions (NRSIs) to assess bias in the included studies. We included the following outcomes: symptom relief (primary outcome); quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We rated the certainty of evidence using the GRADE approach. As meta‐analysis was not possible, we used tabulation to synthesize the studies and histograms to display the outcomes. Main results Overall, we identified four uncontrolled retrospective cohort studies investigating pharmacological interventions for palliative symptom control in hospitalized patients and patients in nursing homes. None of the studies included a comparator. We rated the risk of bias high across all studies. We rated the certainty of the evidence as very low for the primary outcome symptom relief, downgrading mainly for high risk of bias due to confounding and unblinded outcome assessors. Pharmacological interventions for palliative symptom control We identified four uncontrolled retrospective cohort studies (five references) investigating pharmacological interventions for palliative symptom control. Two references used the same register to form their cohorts, and study investigators confirmed a partial overlap of participants. We therefore do not know the exact number of participants, but individual reports included 61 to 2105 participants. Participants received multimodal pharmacological interventions: opioids, neuroleptics, anticholinergics, and benzodiazepines for relieving dyspnea (breathlessness), delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms. Primary outcome: symptom relief All identified studies reported this outcome. For all symptoms (dyspnea, delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms), a majority of interventions were rated as completely or partially effective by outcome assessors (treating clinicians or nursing staff). Interventions used in the studies were opioids, neuroleptics, anticholinergics, and benzodiazepines. We are very uncertain about the effect of pharmacological interventions on symptom relief (very low‐certainty evidence). The initial rating of the certainty of evidence was low since we only identified uncontrolled NRSIs. Our main reason for downgrading the certainty of evidence was high risk of bias due to confounding and unblinded outcome assessors. We therefore did not find evidence to confidently support or refute whether pharmacological interventions may be effective for palliative symptom relief in COVID‐19 patients. Secondary outcomes We planned to include the following outcomes: quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We did not find any data for these outcomes, or any other information on the efficacy and safety of used interventions. Non‐pharmacological interventions for palliative symptom control None of the identified studies used non‐pharmacological interventions for palliative symptom control. Authors' conclusions We found very low certainty evidence for the efficacy of pharmacological interventions for palliative symptom relief in COVID‐19 patients. We found no evidence on the safety of pharmacological interventions or efficacy and safety of non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. The evidence presented here has no specific implications for palliative symptom control in COVID‐19 patients because we cannot draw any conclusions about the effectiveness or safety based on the identified evidence. More evidence is needed to guide clinicians, nursing staff, and caregivers when treating symptoms of COVID‐19 patients at the end of life. Specifically, future studies ought to investigate palliative symptom control in prospectively registered studies, using an active‐controlled setting, assess patient‐reported outcomes, and clearly define interventions. The publication of the results of ongoing studies will necessitate an update of this review. The conclusions of an updated review could differ from those of the present review and may allow for a better judgement regarding pharmacological and non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. Plain language summary Which treatments are best for symptoms in COVID‐19 patients at the end of life? The burden of symptoms at the end of life of COVID‐19 patients and helpful treatments COVID‐19 patients may show symptoms such as breathlessness or delirium at the end of life. The goal of palliative medicine is to relieve such symptoms with specific treatments. Treatments can be drugs, for example opioids, or non‐drugs, such as breathing techniques or relaxation. What was the aim of our review? To explore how well different interventions (drugs and non‐drugs) work for the treatment of palliative symptoms in COVID‐19 patients at the end of life. We included patients of all ages and with all comorbidities (additional medical conditions). What type of studies did we search for? We searched selected medical databases and trial registries until 23 March 2021. We included studies looking at how well different palliative treatments work to relieve COVID‐19‐associated symptoms at the end of life. We wanted to compare studies investigating different medicines or therapies, but we only found studies without a comparison group. Only one study reported the specific drugs used for individual symptoms. Key results We found four studies that were published in five papers. Individual papers included between 61 and 2105 participants, and two papers partially reported on the same participants. All of the included studies investigated different drug treatments for palliative symptom management in people with COVID‐19. Drugs for symptom control at the end of life All of the included studies reported on the effectiveness of palliative care for symptom relief. In all studies, clinicians or nursing staff rated symptom relief rather than the patients themselves. Since the quality of the evidence was very low, we do not know the true effect of drug treatments on symptom relief and have very low confidence in the results of the studies. We did not find any data on quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; or safety of the drug treatments. Non‐drug therapies for symptom control at the end of life We did not find any data on the benefits and harms of non‐drug therapies for symptom control of COVID‐19 patients at the end of life. Conclusions Based on our findings, we could not draw any conclusions on palliative symptom control of people with COVID‐19. Future studies need to be designed better so that we can determine which treatments work for symptom control in people with COVID‐19.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Andreas, M, Piechotta, V, Skoetz, N, Grummich, K, Becker, M, Joos, L, Becker, G, Meissner, W, Boehlke, C", "articleTypes": [], "doi": "10.1002/14651858.CD015061", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.789Z" }, { "id": "76f45c99-5c2d-4bd1-b37c-e167e0cd951f", "pmid": "", "title": "Fortification of staple foods with vitamin A for vitamin A deficiency", "imported": false, "abstract": "Abstract - Background Vitamin A deficiency is a significant public health problem in many low‐ and middle‐income countries, especially affecting young children, women of reproductive age, and pregnant women. Fortification of staple foods with vitamin A has been used to increase vitamin A consumption among these groups. Objectives To assess the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving health‐related outcomes in the general population older than two years of age. Search methods We searched the following international databases with no language or date restrictions: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library; MEDLINE and MEDLINE In Process OVID; Embase OVID; CINAHL Ebsco; Web of Science (ISI) SCI, SSCI, CPCI‐exp and CPCI‐SSH; BIOSIS (ISI); POPLINE; Bibliomap; TRoPHI; ASSIA (Proquest); IBECS; SCIELO; Global Index Medicus ‐ AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched clinicaltrials.gov and the International Clinical Trials Registry Platform to identify ongoing and unpublished studies. The date of the last search was 19 July 2018. Selection criteria We included individually or cluster‐randomised controlled trials (RCTs) in this review. The intervention included fortification of staple foods (sugar, edible oils, edible fats, maize flour or corn meal, wheat flour, milk and dairy products, and condiments and seasonings) with vitamin A alone or in combination with other vitamins and minerals. We included the general population older than two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two authors independently screened and assessed eligibility of studies for inclusion, extracted data from included studies and assessed their risk of bias. We used standard Cochrane methodology to carry out the review. Main results We included 10 randomised controlled trials involving 4455 participants. All the studies were conducted in low‐ and upper‐middle income countries where vitamin A deficiency was a public health issue. One of the included trials did not contribute data to the outcomes of interest. Three trials compared provision of staple foods fortified with vitamin A versus unfortified staple food, five trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus unfortified staple foods, and two trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus no intervention. No studies compared staple foods fortified with vitamin A alone versus no intervention. The duration of interventions ranged from three to nine months. We assessed six studies at high risk of bias overall. Government organisations, non‐governmental organisations, the private sector, and academic institutions funded the included studies; funding source does not appear to have distorted the results. Staple food fortified with vitamin A versus unfortified staple food We are uncertain whether fortifying staple foods with vitamin A alone makes little or no difference for serum retinol concentration (mean difference (MD) 0.03 μmol/L, 95% CI −0.06 to 0.12; 3 studies, 1829 participants; I² = 90%, very low‐certainty evidence ). It is uncertain whether vitamin A alone reduces the risk of subclinical vitamin A deficiency (risk ratio (RR) 0.45, 95% CI 0.19 to 1.05; 2 studies; 993 participants; I² = 33%, very low‐certainty evidence ). The certainty of the evidence was mainly affected by risk of bias, imprecision and inconsistency. It is uncertain whether vitamin A fortification reduces clinical vitamin A deficiency, defined as night blindness (RR 0.11, 95% CI 0.01 to 1.98; 1 study, 581 participants, very low‐certainty evidence ). The certainty of the evidence was mainly affected by imprecision, inconsistency, and risk of bias. Staple foods fortified with vitamin A versus no intervention No studies provided data for this comparison. Staple foods fortified with vitamin A plus other micronutrients versus same unfortified staple foods Fortifying staple foods with vitamin A plus other micronutrients may not increase the serum retinol concentration (MD 0.08 μmol/L, 95% CI ‐0.06 to 0.22; 4 studies; 1009 participants; I² = 95%, low‐certainty evidence ). The certainty of the evidence was mainly affected by serious inconsistency and risk of bias. In comparison to unfortified staple foods, fortification with vitamin A plus other micronutrients probably reduces the risk of subclinical vitamin A deficiency (RR 0.27, 95% CI 0.16 to 0.49; 3 studies; 923 participants; I² = 0%; moderate‐certainty evidence ). The certainty of the evidence was mainly affected by serious risk of bias. Staple foods fortified with vitamin A plus other micronutrients versus no intervention Fortification of staple foods with vitamin A plus other micronutrients may increase serum retinol concentration (MD 0.22 μmol/L, 95% CI 0.15 to 0.30; 2 studies; 318 participants; I² = 0%; low‐certainty evidence ). When compared to no intervention, it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency (RR 0.71, 95% CI 0.52 to 0.98; 2 studies; 318 participants; I² = 0%; very low‐certainty evidence ) . The certainty of the evidence was affected mainly by serious imprecision and risk of bias. No trials reported on the outcomes of all‐cause morbidity, all‐cause mortality, adverse effects, food intake, congenital anomalies (for pregnant women), or breast milk concentration (for lactating women). Authors' conclusions Fortifying staple foods with vitamin A alone may make little or no difference to serum retinol concentrations or the risk of subclinical vitamin A deficiency. In comparison with provision of unfortified foods, provision of staple foods fortified with vitamin A plus other micronutrients may not increase serum retinol concentration but probably reduces the risk of subclinical vitamin A deficiency. Compared to no intervention, staple foods fortified with vitamin A plus other micronutrients may increase serum retinol concentration, although it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency as the certainty of the evidence has been assessed as very low. It was not possible to estimate the effect of staple food fortification on outcomes such as mortality, morbidity, adverse effects, congenital anomalies, or breast milk vitamin A, as no trials included these outcomes. The type of funding source for the studies did not appear to distort the results from the analysis. Plain language summary Fortification of staple foods with vitamin A for vitamin A deficiency What is the aim of the review? We wanted to investigate the effects of fortifying common staple foods with vitamin A, with or without other micronutrients, in populations two years of age and older. Staple foods used in public health fortification programmes have included refined sugar, edible vegetable oils and fats, rice, wheat flour, maize flours and corn meals, condiments and seasonings, and powdered or liquid milk. We searched for all the possible information on this question and found 10 eligible studies. Key messages Fortifiying staple foods with vitamin A plus other micronutrients may increase the serum retinol concentrations (an indicator of vitamin A stores in the body) and reduce the risk of subclinical vitamin A deficiency (those without clinical eye signs for risk of blinding undernutrition, detected through a serum/plasma retinol 70 μmol/L or less). However, adding vitamin A alone to the staple foods may have little or no effect on vitamin A status or deficiency. What was studied in this review? Vitamin A is an essential nutrient vital for good vision, cell growth, and immunity. Many people in low‐ and middle‐income countries have vitamin A deficiency, especially young children, pregnant women, and women of reproductive age, who may not get enough to eat to cover their increased nutritional demands. Long‐term deprivation of vitamin A could lead to visual impairment, blindness, common infections of the upper respiratory tract, diarrhoea, and measles. There are several strategies to combat the vitamin A deficiency, such as supplementing the diet with vitamin A capsules, adding vitamins and minerals in powder form to energy‐containing foods, eating more vitamin A‐rich foods, and fortifying staple foods with vitamin A during processing. This review focused on the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving the health of the general population older than two years of age. What are the main results of the review? We found 10 relevant studies (involving 4455 participants) from China, India, the Philippines, Bangladesh, Thailand, and Mexico. Three studies provided one study group with staple foods fortified with vitamin A alone, and another group with the same unfortified staple foods. Five studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus the same unfortified staple food, and two studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus no intervention. No studies compared staple foods fortified with vitamin A versus no intervention. Government agencies, private agencies, non‐governmental organisations, the private sector, and academic institutions funded the studies. The source of funding does not appear to have distorted the results. The effect of fortification of staple foods with vitamin A alone on vitamin A stores and on subclinical vitamin A deficiency is uncertain. It is uncertain whether this intervention might reduce clinical vitamin A deficiency (night blindness). We are moderately confident that fortifying staple foods with vitamin A and other micronutrients may not improve vitamin A status. However, children and adolescents in low‐ and middle‐income populations who eat foods fortified with vitamin A and other micronutrients may have a lower risk of subclinical vitamin A deficiency compared to those receiving unfortified staple foods. We do not know how vitamin A fortification affects other health indicators, such as the rate of disease in the population, mortality, adverse effects, food intake, birth defects (for pregnant women), or breast milk concentration for lactating women. We considered six of the included studies to be of poor methodological quality. The review authors searched for published studies up to July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hombali, AS, Solon, JA, Venkatesh, BT, Nair, NS, Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010068.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.126Z" }, { "id": "77122f7b-b12d-4959-85e0-421074ddcc06", "pmid": "", "title": "Relief of pain due to uterine cramping/involution after birth", "imported": false, "abstract": "Abstract - Background Women may experience differing types of pain and discomfort following birth, including cramping pain (often called after‐birth pain) associated with uterine involution, where the uterus contracts to reduce blood loss and return the uterus to its non‐pregnant size. This is an update of a review first published in 2011. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological pain relief/analgesia for the relief of after‐birth pains following vaginal birth. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (31 October 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials comparing two different types of analgesia or analgesia versus placebo or analgesia versus no treatment, for the relief of after‐birth pains following vaginal birth. Types of analgesia included pharmacological and non‐pharmacological. Quasi‐randomised trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed trials for inclusion, conducted 'Risk of bias' assessment, extracted data and assessed the certainty of the evidence using the GRADE approach. Main results In this update, we include 28 studies (involving 2749 women). The evidence identified in this review comes from middle‐ to high‐income countries. Generally the trials were at low risk of selection bias, performance bias and attrition bias, but some trials were at high risk of bias due to selective reporting and lack of blinding. Our GRADE certainty of evidence assessments ranged from moderate to very low certainty, with downgrading decisions based on study limitations, imprecision, and (for one comparison) indirectness. Most studies reported our primary outcome of adequate pain relief as reported by the women. No studies reported data relating to neonatal adverse events, duration of hospital stay, or breastfeeding rates. Almost half of the included studies (11/28) excluded breastfeeding women from participating, making the evidence less generalisable to a broader group of women. Non‐steroidal anti‐inflammatory drugs (NSAIDs) compared to placebo NSAIDs are probably better than placebo for adequate pain relief as reported by the women (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.45 to 1.91; 11 studies, 946 women; moderate‐certainty evidence). NSAIDs may reduce the need for additional pain relief compared to placebo (RR 0.15, 95% CI 0.07 to 0.33; 4 studies, 375 women; low‐certainty evidence). There may be a similar risk of maternal adverse events (RR 1.05, 95% CI 0.78 to 1.41; 9 studies, 598 women; low‐certainty evidence). NSAIDs compared to opioids NSAIDs are probably better than opioids for adequate pain relief as reported by the women (RR 1.33, 95% CI 1.13 to 1.57; 5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of maternal adverse events (RR 0.62, 95% CI 0.43 to 0.89; 3 studies, 255 women; low‐certainty evidence). NSAIDs may be better than opioids for the need for additional pain relief, but the wide CIs include the possibility that the two classes of drugs are similarly effective or that opioids are better (RR 0.37, 95% CI 0.12 to 1.12; 2 studies, 232 women; low‐certainty evidence). Opioids compared to placebo Opioids may be better than placebo for adequate pain relief as reported by the women (RR 1.26, 95% CI 0.99 to 1.61; 5 studies, 299 women; low‐certainty evidence). Opioids may reduce the need for additional pain relief compared to placebo (RR 0.48, 95% CI 0.28 to 0.82; 3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of maternal adverse events compared with placebo, although the certainty of evidence is low (RR 1.59, 95% CI 0.99 to 2.55; 3 studies, 188 women; low‐certainty evidence). Paracetamol compared to placebo Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events (2 studies, 123 women). Paracetamol compared to NSAIDs Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events. No data were reported about the need for additional pain relief comparing paracetamol and NSAIDs (2 studies, 112 women). NSAIDs compared to herbal analgesia We are uncertain if there are any differences between NSAIDs and herbal analgesia for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events, because the certainty of evidence is very low (4 studies, 394 women). Transcutaneous nerve stimulation (TENS) compared to no TENS Very low‐certainty evidence means we are uncertain if TENS is better than no TENS for adequate pain relief as reported by the women. No other data were reported comparing TENS with no TENS (1 study, 32 women). Authors' conclusions NSAIDs may be better than placebo and are probably better than opioids at relieving pain from uterine cramping/involution following vaginal birth. NSAIDs and paracetamol may be as effective as each other, whereas opioids may be more effective than placebo. Due to low‐certainty evidence, we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater generalisability by including breastfeeding women. In addition, further research is required, including a survey of postpartum women to describe appropriately their experience of uterine cramping and involution. We identified nine ongoing studies, which may help to increase the level of certainty of the evidence around pain relief due to uterine cramping in future updates of this review. Plain language summary Relief of pain caused by uterine cramping or involution after giving birth This updated review investigates the effectiveness and safety of drug and non‐drug pain relief in women experiencing after‐birth pains following vaginal birth. Giving an agent for pain relief was compared to an inactive placebo, to no treatment, or to a different type of agent in randomised controlled trials. What is the issue? Women may experience cramping pain and discomfort following the birth of their baby, as the uterus contracts and returns to its normal pre‐pregnancy size. These pains usually last for two to three days after the birth. Women who have previously had a baby are more likely to experience after‐birth pains. Breastfeeding stimulates the uterus to contract and increases the severity of the pains. Types of pain relief used to treat the pain include paracetamol, non‐steroidal anti‐inflammatory drugs (NSAIDs) ibuprofen and naproxen, opioids including codeine, and non‐medicine methods such as herbal preparations and transcutaneous electrical nerve stimulation (TENS). Why is this important? Management of pain after birth is important, as the pain can affect a mother carrying out her normal activities as well as bonding with and caring for her baby. After‐pains can interfere with establishing breastfeeding. What evidence did we find? We searched for evidence from randomised controlled trials (October 2019) and identified 28 studies (2749 mothers) who were in hospital after uncomplicated single births. Most of the evidence is low‐certainty because the studies did not include sufficient numbers of women. Many of the studies excluded breastfeeding women.This makes the evidence less relevant to a broader group of women. No studies reported evidence on adverse events in the newborn infants. NSAIDs are probably better than placebo (a dummy treatment) in giving adequate pain relief as reported by the women (11 studies, 946 women; moderate‐certainty evidence), and they may reduce the need for additional pain relief (4 studies, 375 women; low‐certainty evidence). There may be little difference between NSAIDs and placebo in the risk of adverse events in the mother (9 studies, 598 women; low‐certainty evidence). NSAIDs are probably better than opioids in providing adequate pain relief as reported by the women (5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of adverse events in the mother (3 studies, 255 women; low‐certainty evidence). NSAIDs may slightly reduce the need for additional pain relief compared with opioids (2 studies, 232 women; low‐certainty evidence). Opioids may be better than placebo for adequate pain relief as reported by the women (5 studies, 299 women; low‐certainty evidence) and for the need for additional pain relief (3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of adverse events in the mother compared with placebo (3 studies, 188 women; low‐certainty evidence). Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional analgesia, or risk of maternal adverse events (2 studies, 123 women). Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events (2 studies, 112 women). Very low‐certainty evidence means we are uncertain if NSAIDs are better than herbal pain relief for adequate pain relief as reported by the women (4 studies, 394 women), the need for additional pain relief (1 study, 90 women) or risk of maternal adverse events (1 study, 108 women). Very low‐certainty evidence means we are uncertain if there is any difference between TENS and no TENS for adequate pain relief as reported by the women (1 study, 32 women). What does this mean? NSAIDs may be better than placebo and are probably better than opioids at relieving after‐birth pains following vaginal birth. The quality of the evidence was poor and we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater relevance by including breastfeeding women. Further research could also include a survey of women after delivery to capture their experience of after‐birth pains following vaginal birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Deussen, AR, Ashwood, P, Martis, R, Stewart, F, Grzeskowiak, LE", "articleTypes": [], "doi": "10.1002/14651858.CD004908.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.781Z" }, { "id": "771b2d58-6f3b-4391-b4cc-35284a01d965", "pmid": "", "title": "A Placebo-Controlled, Randomized, Double-Blind Study to Assess the Safety, Tolerability and Efficacy of Folinic Acid Administered to Pediatric Subjects With Autism Spectrum Disorder (ASD)", "imported": false, "abstract": "Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by difficulties in social communication and the presence of restricted or repetitive behaviors. Although behavioral and educational interventions can be helpful, there is currently no established medication for the core symptoms of ASD. Medications approved for associated irritability may be effective in some children but are often associated with significant adverse effects.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.265Z" }, { "id": "77377495-ac22-45fa-b0c1-1c945193e128", "pmid": "", "title": "Management of gag reflex for patients undergoing dental treatment", "imported": false, "abstract": "Abstract - Background The gag reflex is an involuntary defence mechanism to protect the pharynx and throat from foreign objects. Gagging is a common problem encountered during dental treatment, making therapeutic procedures distressing and often difficult or even impossible to perform. Various interventions can be used to control the gag reflex: anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behavioural therapies, acupressure, acupuncture, laser, and prosthetic devices. This is an update of the Cochrane Review first published in 2015. Objectives To assess the effects of pharmacological and non‐pharmacological interventions for the management of gagging in people undergoing dental treatment. Search methods Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register (to 18 March 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2) in the Cochrane Library (searched 18 March 2019), MEDLINE Ovid (1946 to 18 March 2019), Embase Ovid (1980 to 18 March 2019), CINAHL EBSCO (1937 to 18 March 2019), AMED Ovid (1985 to 18 March 2019), and the proceedings of the International Association for Dental Research (IADR) online (2001 to 18 March 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We also conducted forwards citation searching on the included studies via Google Scholar. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs), involving people who were given a pharmacological or non‐pharmacological intervention to manage gagging that interfered with dental treatment. We excluded quasi‐RCTs. We excluded trials with participants who had central or peripheral nervous system disorders, who had oral lesions or were on systemic medications that might affect the gag sensation, or had undergone surgery which might alter anatomy permanently. Data collection and analysis We independently selected trials, extracted data, and assessed risk of bias. We followed Cochrane's statistical guidelines. We assessed the overall certainty of the evidence using GRADE. Main results We included four trials at unclear risk of bias with 328 participants (263 adults and 65 children who were four years or older), in which one trial compared acupuncture and acupressure (with thumb, device and sea band) at P6 (point located three‐finger breadths below the wrist on the inner forearm in between the two tendons) to sham acupuncture and acupressure with and without sedation. One trial compared acupuncture at P6 point to sham acupuncture. These trials reported both completion of dental procedure and reduction in gagging (assessor and patient reported) as their outcomes. One cross‐over and one split‐mouth trial studied the effect of laser at P6 point compared to control. One trial reported reduction in gagging and another reported presence or absence of gagging during dental procedure. Acupuncture at P6 showed uncertain evidence regarding the successful completion of dental procedure (RR 1.78, 95% CI 1.05 to 3.01; two trials, 59 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 2.57, 95% CI 1.12 to 5.89; one trial, 26 participants; very low‐certainty evidence) in comparison to sham acupuncture. Acupuncture at P6 with sedation did not show any difference when compared to sham acupuncture with sedation (RR 1.08, 95% CI 0.91 to 1.28; one trial, 34 participants; very low‐certainty evidence). Acupressure using thumb pressure with or without sedation showed no clear difference in completing dental procedure (RR 0.96, 95% CI 0.84 to 1.10; one trial, 39 participants; very low‐certainty evidence; and RR 0.85, 95% CI 0.50 to 1.46; one trial, 30 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 1.06, 95% CI 0.92 to 1.23; one trial, 39 participants; very low‐certainty evidence; and RR 0.92, 95% CI 0.60 to 1.41; one trial, 30 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Acupressure at P6 with device showed uncertain evidence regarding the successful completion of dental procedure (RR 2.63, 95% CI 1.33 to 5.18; one trial, 34 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 3.94, 95% CI 1.63 to 9.53; one trial, 34 participants; very low‐certainty evidence) when compared to sham acupressure. However, device combined with sedation showed no difference for either outcome (RR 1.16, 95% CI 0.90 to 1.48; one trial, 27 participants; very low‐certainty evidence; and RR 1.26, 95% CI 0.93 to 1.69; one trial, 27 participants; very low‐certainty evidence; respectively). Acupressure using a sea band with or without sedation showed no clear difference in completing dental procedure (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 1.80, 95% CI 0.63 to 5.16; one trial, 19 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 2.70, 95% CI 0.72 to 10.14; one trial, 19 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Laser at P6 showed a difference in absence of gagging (odds ratio (OR) 86.33, 95% CI 29.41 to 253.45; one trial, 40 participants; very low‐certainty evidence) and reduction in gagging (MD 1.80, 95% CI 1.53 to 2.07; one trial, 25 participants; very low‐certainty evidence) during dental procedure when compared to dummy laser application. No noteworthy adverse effects were reported. For acupuncture at P6, the trial authors were unsure whether the reported adverse effects were due to participant anxiety or due to the intervention. None of the trials on acupressure or laser reported on this outcome. We did not find trials evaluating any other interventions used to manage gagging in people undergoing dental treatment. Authors' conclusions We found very low‐certainty evidence from four trials that was insufficient to conclude if there is any benefit of acupuncture, acupressure or laser at P6 point in reducing gagging and allowing successful completion of dental procedures. We did not find any evidence on any other interventions for managing the gag reflex during dental treatment. More well‐designed and well‐reported trials evaluating different interventions are needed. Plain language summary Management of gagging in dental patients Review question With this Cochrane Review we tried to find out the best way to manage gagging in people having dental treatment. Background The gag reflex is a normal process to protect the throat and airway from foreign objects and prevent choking. Many people have an exaggerated gag reflex that causes distress during dental treatment. This can make it difficult or even impossible to perform the treatment. The interventions used to manage gagging include anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behaviour therapy and cognitive behaviour therapy, acupressure, acupuncture, laser, and prosthetic devices. We wanted to know how effective and safe these interventions are in helping people complete their dental treatment with less gagging. We compared them to no intervention or a placebo or to other interventions. Study characteristics This review is up‐to‐date as of 18 March 2019. We included four trials with 328 people (263 adults and 65 children who were 4 years or older). These people had nausea before when having dental treatment that caused the treatment to be stopped or not carried out properly. Key results Acupuncture at P6 point (a point located in the inside of the wrist) showed uncertain evidence regarding the successful completion of dental treatment and reduction in gagging when compared to sham (fake) acupuncture. The same intervention with sedation did not show a difference. Acupressure (with thumb or sea band (bands that fit around the wrist just like a sweat band with a pressure stud sewn inside)) at P6 point with or without sedation did not show any difference when compared to sham acupressure. Acupressure at P6 point with device showed a difference in completing dental treatment and reduction in gagging. It did not show a difference when combined with sedation. Laser at P6 point showed a difference in absence of gagging and reduction in gagging during dental treatment when compared to sham laser application. The included studies did not report any important harmful effects of the treatment. Certainty of the evidence The level of belief we have in these findings is very low. This was due to unclear risk of bias and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to manage gagging in people having dental treatment. We suggest that more well‐conducted studies should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Eachempati, P, Kumbargere Nagraj, S, Kiran Kumar Krishanappa, S, George, RP, Soe, HH, Karanth, L", "articleTypes": [], "doi": "10.1002/14651858.CD011116.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.760Z" }, { "id": "7740814e-3166-46f9-9b37-15575110ec45", "pmid": "", "title": "Genetic Variability in Taste Perception", "imported": false, "abstract": "This proposal describes a pilot study aimed at determining whether genetic variations in taste receptors determine differential taste tolerability of pediatric medications.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.230Z" }, { "id": "77432a05-aa2f-4b10-a0b9-4bcfc480afc4", "pmid": "", "title": "Folic acid supplementation and malaria susceptibility and severity among people taking antifolate antimalarial drugs in endemic areas", "imported": false, "abstract": "Abstract - Background Malaria is an infectious disease transmitted by female Anopheles mosquitoes, with ongoing transmission in over 80 countries. The malaria parasite requires folate for survival and growth; antifolate antimalarial medications used for prevention and treatment target enzymes in folate metabolism as their mechanism of action. Periconceptional folic acid (synthetic form of folate) supplementation (400 μg/day) is the standard of care for neural tube defect prevention. Concerns have been raised about the potential effects of folic acid (including above the tolerable upper intake level (UL) > 1.0 mg/day) in the context of malaria prevention and treatment, including the efficacy of antimalarial medications. Examining the potential impact of folic acid on malaria risk and severity amongst people taking antifolate antimalarial medications may inform public health programmes in malaria‐endemic areas. Objectives To examine the effects of folic acid supplementation on the risk and severity of malaria infection amongst people taking antifolate antimalarials and living in areas with malaria endemicity. Prevention: Amongst uninfected people taking antifolate antimalarial medications for malaria prevention, does folic acid supplementation increase susceptibility or severity of malaria infection? Treatment: Amongst people with malaria infection who are being treated with antifolate antimalarial drugs, does folic acid supplementation reduce parasite clearance or increase the risk of treatment failure? Search methods We searched databases including CENTRAL, MEDLINE, Embase, CINAHL, Scopus, and trial registries (September 13, 2024), grey literature, and reference searches to identify additional studies. Selection criteria Randomised trials evaluating the effects of folic acid supplementation (alone or in combination with iron or other vitamins and minerals) amongst individuals taking antifolate antimalarial medications in malaria‐endemic areas. Data collection and analysis Primary outcomes included uncomplicated malaria or severe malaria, parasite clearance, and treatment failure. Cochrane RoB 2 was used to evaluate the risk of bias. Certainty of evidence was assessed using GRADE for primary outcomes. We performed meta‐analyses using random‐effects models for all outcomes. Main results Eight trials with 3486 participants were included: three malaria prevention trials and five malaria treatment trials. Most treatment trials included folic acid doses above the UL ( > 1.0 mg/d); one trial included 400 μg per day. Antifolate antimalarials included sulfadoxine‐pyrimethamine (SP; five trials), sulfisoxazole plus pyrimethamine (one trial), atovaquone‐proguanil (one trial), and proguanil (one trial). Some studies had unclear or high risk of bias due to missing outcome data. Malaria prevention Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medications. Data for primary outcomes, uncomplicated and severe malaria, were not reported. One trial reported laboratory parasitaemia; there was little to no difference in malaria parasitaemia amongst pregnant women receiving folic acid (with iron) and antifolate antimalarials compared to iron and antifolate antimalarials (Risk Ratio (RR) 1.21; 95% CI 0.56 to 2.62; P = 0.63; 1 trial, 643 individuals). Comparisons 2–4: No studies reported data for Comparisons 2–4. Malaria treatment 
 Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarial medications versus placebo/no folic acid with antifolate antimalarials. People receiving folic acid (alone or with iron) and antifolate antimalarials were less likely to clear malaria parasites (day 3) compared to individuals who did not receive folic acid (RR 0.89; 95% CI 0.84 to 0.95, 4 trials, 929 individuals, moderate‐certainty evidence); and had increased risk of treatment failure on day 7 (RR 2.12; 95% CI 1.41 to 3.19, 4 trials, 1062 individuals, moderate‐certainty evidence), day 14 (RR 1.97; 95% CI 1.44 to 2.70, 3 trials; 891 individuals; moderate‐certainty evidence), and day 28 (RR 1.35; 95% CI 1.21 to 1.51; 4 trials; 1012 individuals, moderate‐certainty evidence). Comparison 2: Folic acid alone + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medication. Folic acid supplementation with antifolate antimalarials likely had lower parasite clearance (day 3) (RR 0.87; 95% CI 0.79 to 0.96, 2 trials, 229 individuals, moderate certainty of the evidence), and increased treatment failure (day 7: RR 2.58; 95% CI 0.89 to 7.45; P = 0.08; 2 trials; 344 individuals, moderate‐certainty evidence; day 14: RR 4.15; 95% CI 0.92 to 18.65; P = 0.06; 1 trial; 173 individuals, moderate‐certainty evidence; and day 28: RR 1.47; 95% CI 0.86 to 2.49; P = 0.16; 2 trials; 294 individuals, moderate‐certainty evidence), compared to no folic acid and antifolate antimalarials. Comparison 3: Folic acid with iron + antifolate antimalarial medication versus placebo/no folic acid with iron + antifolate antimalarial medication. People receiving folic acid with iron and antifolate antimalarials were less likely to clear malaria parasites (day 3: RR 0.90; 95% CI 0.83 to 0.98; P = 0.02; 2 trials; 700 individuals, moderate‐certainty evidence), and had increased treatment failure (day 7: RR 1.96; 95% CI 1.05 to 3.65; P = 0.03; 2 trials; 718 individuals; day 14: RR 1.90; 95% CI 1.35 to 2.67; 2 trials; 718 individuals; day 28: RR 1.17; 95% CI 0.79 to 1.74; 2 trials; 578 individuals; all moderate‐certainty evidence), compared to iron and antifolate antimalarials. Comparison 4: No studies reported data. Authors' conclusions Malaria prevention: None of the included trials reported primary outcomes. Malaria treatment: People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to clear malaria parasitaemia (day 3), and had increased treatment failure (days 7, 14, 28). Most of the included trials provided folic acid with doses above the tolerable UL ( > 1.0 mg). One trial included folic acid at a dose of 400 μg/d (recommended dose for preventing neural tube defects) and showed little to no difference in parasite clearance or treatment failure. Plain language summary Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common? Review question 
Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common?

 Key messages 
° People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to eliminate malaria parasites and had increased treatment failure. 
° There were not enough studies to examine whether taking folic acid supplementation at a lower dose, like 400 μg, might affect the risk of malaria infection or health outcomes if infected. This low dose is currently recommended before and during early pregnancy for the prevention of neural tube defects. Malaria and the importance of folate 
Malaria is a disease spread by the bite of certain types of female mosquitoes and is found in over 80 countries. The malaria parasite needs folate to grow and survive, and some medicines used to prevent and treat malaria target folate. Folic acid (the synthetic form of folate) is recommended at a dose of 400 μg daily to prevent neural tube defects. There are some concerns that folic acid (particularly higher doses) may affect malaria and how well some medicines work to prevent and treat malaria. What did we want to find out? 
This review was done to see how folic acid affects malaria risk and severity amongst people taking antifolate antimalarial medications and living in areas where malaria is common. Specifically, we aimed to answer the following questions: Prevention: For people who do not have malaria and are taking antimalarial drugs to prevent malaria, do folic acid supplements increase their risk of getting malaria or having worse outcomes? Treatment: For people who have malaria and are being treated with antifolate antimalarial medications, does taking folic acid supplements affect how well the drugs work to treat malaria? What did we do? 
We searched for trials that looked at folic acid supplementation in people taking antifolate antimalarial medications to prevent or treat malaria. We compared and summarised the results of the trials and rated our confidence in the information based on how the study was done. What did we find? 
We included eight trials (3486 people); three were prevention trials and five were treatment trials. Most trials used higher folic acid doses ( > 1.0 mg) and included the medication sulfadoxine‐pyrimethamine (SP). The prevention studies did not include the main outcomes we were trying to assess. In the treatment studies, people who took folic acid and antifolate antimalarial drugs were less likely to clear malaria parasites from their bodies (day 3) and were more likely to have treatment failure (up to 28 days after treatment) compared to the same treatment but without folic acid. Most of the included trials provided the antimalarial SP and folic acid with doses above the tolerable upper intake level (upper limit; > 1.0 mg). Only one trial included folic acid at a dose of 400 μg per day (the recommended daily dose of folic acid for prevention of neural tube defects); there were no differences in parasite clearance or treatment failure between the arm with 400 μg per day of folic acid and the arm with no folic acid. What are the limitations of the evidence? 
The small number of trials and the size of the studies were limitations of this review, and no prevention studies reported main outcomes. How up to date is this evidence? 
The evidence is up‐to‐date as of September 13, 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Qi, YP; Crider, KS; Gutman, J; Centeno-Tablante, E; Fothergill, A; Daniels, K; Yeung, LF; Mai, CT; Mehta, S; Williams, JL; Finkelstein, JL", "articleTypes": [], "doi": "10.1002/14651858.CD014217.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "77446a79-6d17-495d-83f3-0213124b0f90", "pmid": "", "title": "Cannabinoids for fibromyalgia", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue affecting approximately 2% of the general population. People often report high disability levels and poor health‐related quality of life (HRQoL). Drug therapy focuses on reducing key symptoms and disability, and improving HRQoL. Cannabis has been used for millennia to reduce pain and other somatic and psychological symptoms. Objectives To assess the efficacy, tolerability and safety of cannabinoids for fibromyalgia symptoms in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE to April 2016, together with reference lists of retrieved papers and reviews, three clinical trial registries, and contact with trial authors. Selection criteria We selected randomised controlled trials of at least four weeks' duration of any formulation of cannabis products used for the treatment of adults with fibromyalgia. Data collection and analysis Two review authors independently extracted the data of all included studies and assessed risk of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs; at least 200 participants in the comparison, eight to 12 weeks' duration, parallel design), second tier evidence from data that did not meet one or more of these criteria and were considered at some risk of bias but with adequate numbers (i.e. data from at least 200 participants) in the comparison, and third tier evidence from data involving small numbers of participants that were considered very likely to be biased or used outcomes of limited clinical utility, or both. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Main results We included two studies with 72 participants. Overall, the two studies were at moderate risk of bias. The evidence was derived from group mean data and completer analysis (very low quality evidence overall). We rated the quality of all outcomes according to GRADE as very low due to indirectness, imprecision and potential reporting bias. The primary outcomes in our review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Nabilone was compared to placebo and to amitriptyline in one study each. Study sizes were 32 and 40 participants. One study used a cross‐over design and one used a parallel group design; study duration was four or six weeks. Both studies used nabilone, a synthetic cannabinoid, with a bedtime dosage of 1 mg/day. No study reported the proportion of participants experiencing at least 30% or 50% pain relief or who were very much improved. No study provided first or second tier (high to moderate quality) evidence for an outcome of efficacy, tolerability and safety. Third tier (very low quality) evidence indicated greater reduction of pain and limitations of HRQoL compared to placebo in one study. There were no significant differences to placebo noted for fatigue and depression (very low quality evidence). Third tier evidence indicated better effects of nabilone on sleep than amitriptyline (very low quality evidence). There were no significant differences between the two drugs noted for pain, mood and HRQoL (very low quality evidence). More participants dropped out due to adverse events in the nabilone groups (4/52 participants) than in the control groups (1/20 in placebo and 0/32 in amitriptyline group). The most frequent adverse events were dizziness, nausea, dry mouth and drowsiness (six participants with nabilone). Neither study reported serious adverse events during the period of both studies. We planned to create a GRADE 'Summary of findings' table, but due to the scarcity of data we were unable to do this. We found no relevant study with herbal cannabis, plant‐based cannabinoids or synthetic cannabinoids other than nabilone in fibromyalgia. Authors' conclusions We found no convincing, unbiased, high quality evidence suggesting that nabilone is of value in treating people with fibromyalgia. The tolerability of nabilone was low in people with fibromyalgia. Plain language summary Cannabis products for people with fibromyalgia Background Fibromyalgia is characterised by chronic (longer than three months) widespread pain that often co‐exists with sleep problems, problems with thinking and fatigue (exhaustion). People often report severe limitations of daily functioning and poor health‐related quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. Cannabis has been used for 3000 years to reduce pain and other symptoms, such as loss of appetite and anxiety. Key results and quality of the evidence In April 2016 we searched for reports of clinical trials that used cannabis products to treat symptoms in adults with fibromyalgia. We found two small, moderate quality studies, of four and six weeks long, including 72 participants. Both studies tested nabilone, a synthetic (man‐made) cannabis product, comparing it with placebo (a dummy pill) or amitriptyline (an antidepressant frequently used in the treatment of fibromyalgia). Nabilone did not convincingly relieve fibromyalgia symptoms (pain, sleep, fatigue) better than placebo or amitriptyline (very low quality evidence). Compared with placebo and amitriptyline, more people experienced side effects and left the study due to side effects (very low quality evidence). There were no serious side effects reported. We found no relevant study with herbal cannabis, plant‐based cannabinoids or other synthetic cannabinoids than nabilone in fibromyalgia. There was not enough high quality evidence available to draw any robust conclusions. We found no studies on medical cannabis in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B; Klose, P; Fitzcharles, M-A; Phillips, T; Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "77584f97-a61b-4243-967d-e88c00da9edb", "pmid": "", "title": "Oral versus intravenous steroids for treatment of relapses in multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Burton, JM, O'Connor, PW, Hohol, M, Beyene, J", "articleTypes": [], "doi": "10.1002/14651858.CD006921.pub3 AB - Abstract - Background This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD006921. DOI: 10.1002/14651858.CD006921.pub2). Multiple sclerosis (MS), a chronic inflammatory and neurodegenerative disease of the central nervous system (CNS), is characterized by recurrent relapses of CNS inflammation ranging from mild to severely disabling. Relapses have long been treated with steroids to reduce inflammation and hasten recovery. However, the commonly used intravenous methylprednisolone (IVMP) requires repeated infusions with the added costs of homecare or hospitalization, and may interfere with daily responsibilities. Oral steroids have been used in place of intravenous steroids, with lower direct and indirect costs. Objectives The primary objective was to compare efficacy of oral versus intravenous steroids in promoting disability recovery in MS relapses <= six weeks. Secondary objectives included subsequent relapse rate, disability, ambulation, hospitalization, immunological markers, radiological markers, and quality of life. Search methods A literature search was performed using Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group's Trials Register (January 2012), abstracts from meetings of the American Academy of Neurology (2008‐2012), the European Federation of Neurological Sciences (2008‐2012), the European Committee for Treatment and Research in Multiple Sclerosis and American Committee for Treatment and Research in Multiple Sclerosis (2008‐2012) handsearching. No language restrictions were applied. Selection criteria Randomized or quasi‐randomized trials comparing oral versus intravenous steroids for acute relapses (<= six weeks) in patients with clinically definite MSover age 16 were eligible. Data collection and analysis Three review authors (JB, PO and MH) participated in the independent assessment of all published articles as potentially relevant to the review. Any disagreement was resolved by discussion among review authors. We contacted study authors for additional information. Methodological quality was assessed by the same three review authors. Relevant data were extracted, and effect size was reported as mean difference (MD), mean difference (MD), odds ratio (OR) and absolute risk difference (ARD). Main results With this current update, a total of five eligible studies (215 patients) were identified. Only one outcome, the proportion of patients with Expanded Disability Status Scale (EDSS) improvement at four weeks, was common to three trials, while two trials examined magnetic resonance imaging (MRI) outcomes. The results of this review shows there is no significant difference in relapse recovery at week four (MD ‐0.22, 95% confidence interval (95% CI), 0.71 to 0.26, P = 0.20) nor differences in magnetic resonance imaging (MRI) gadolinium enhancement activity based on oral versus intravenous steroid treatment. However, only two of the five studies employed more current and rigorous methodological techniques, so these results must be taken with some caution. The Oral Megadose Corticosteroid Therapy of Acute Exacerbations of Multiple Sclerosis (OMEGA) trial and the \"Efficacy and Safety of Methylprednisolone Per os Versus IV for the Treatment of Multiple Sclerosis (MS) Relapses\" (COPOUSEP) trial, designed to address such limitations, are currently underway. Authors' conclusions The analysis of the five included trials comparing intravenous versus oral steroid therapy for MS relapses do not demonstrate any significant differences in clinical (benefits and adverse events), radiological or pharmacological outcomes. Based on the evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy in the treatment of MS relapses. Plain language summary A comparison of the efficacy of oral versus intravenous steroids in relapsing‐remitting multiple sclerosis (RRMS) RRMS is characterized by periods of disability (relapse) due to inflammation in the central nervous system. All research has shown that a \"speeding up\" of recovery is obtained by use of corticosteroids, given most often in intravenous form. If oral steroids worked as well as intravenous ones for relapse events, they would be easier to take and are more affordable. 
 
 The objective of this review was to assess if oral and intravenous steroids are equally effective and safe in aiding in the recovery from relapses. Among the pertinent literature, only five studies met the inclusion criteria, comprising a total of 215 participants. Despite some limitations in the methods used to conduct the studies (i.e. incomplete reporting of the participants who dropped out the studies and appropriateness of the sample size) and in the analysis of the data, all five studies found that there were no significant differences in term of benefits and adverse events and in the pharmacological and radiological outcomes in patients taking oral or intravenous steroids. Both treatments appear to be equally effective and safe. Based on this evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy for the treatment of MS relapses.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.763Z" }, { "id": "776b87d0-476f-4aeb-ae69-3a02051094b0", "pmid": "", "title": "A Randomized, Double Blind, Placebo-controlled Study to Investigate the Safety, Pharmacodynamics and Effect on Allergic Reactivity of Repeat Intranasal Administration of the TLR7 Agonist GSK2245035 in Subjects With Respiratory Allergies", "imported": false, "abstract": "The purpose of this study is to examine the safety and effects on the immune system of treatment with GSK2245035 in subjects who suffer from nasal symptoms caused by an allergy to pollen or perennial allergen, with or without mild asthma. In addition, the effect of treatment with GSK2245035 on the body's allergic response in test situations will be explored. Approximately 28 subjects will receive GSK2245035 (up to 14 subjects each receiving 80 nanograms [ng] GSK2245035 and up to 14 subjects each receiving 20 ng GSK2245035) and 14 subjects will receive the dummy drug (placebo) during the study. Assignment of a subject to GSK2245035 or placebo will be done by chance, like flipping a coin. Neither the subjects nor the clinic staff will know whether a subject is being dosed with GSK2245035 or placebo during the course of the study. The study will include (a) Screening phase where the eligibility of subjects for enrolment will be assessed (b) Treatment phase during which subjects will receive either 8 nasal sprays of GSK2245035 80 ng or a matching placebo once weekly for 8 weeks (each dose will be split between the two nostrils). Subjects participating in this study in 2014 will receive a reduced dose of 20 ng i.n. of GSK2245035 once weekly for eight administrations (c) Follow-up period where any GSK2245035 induced changes to the immune system and the effect of treatment on the body's allergic response in test situations will be monitored. The maximum planned study duration for all subjects, including the screening, treatment and follow-up periods, is approximately 180 days.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.242Z" }, { "id": "776ea701-21ef-4c3f-ab78-06a72aca95a8", "pmid": "", "title": "Osmotic therapies added to antibiotics for acute bacterial meningitis", "imported": false, "abstract": "Abstract - Background Every day children and adults die from acute community‐acquired bacterial meningitis, particularly in low‐income countries, and survivors risk deafness, epilepsy and neurological disabilities. Osmotic therapies may attract extra‐vascular fluid and reduce cerebral oedema, and thus reduce death and improve neurological outcomes. This is an update of a Cochrane Review first published in 2013. Objectives To evaluate the effects of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults on mortality, deafness and neurological disability. Search methods We searched CENTRAL (2017, Issue 1), MEDLINE (1950 to 17 February 2017), Embase (1974 to 17 February 2017), CINAHL (1981 to 17 February 2017), LILACS (1982 to 17 February 2017) and registers of ongoing clinical trials (ClinicalTrials.com, WHO ICTRP) (21 February 2017). We also searched conference abstracts and contacted researchers in the field (up to 12 December 2015). Selection criteria Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis. Data collection and analysis Two review authors independently screened the search results and selected trials for inclusion. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not. We used the GRADE approach to assess the certainty of the evidence. Main results We included five trials with 1451 participants. Four trials evaluated glycerol against placebo, and one evaluated glycerol against 50% dextrose; in addition three trials evaluated dexamethasone and one trial evaluated acetaminophen (paracetamol) in a factorial design. Stratified analysis shows no effect modification with steroids; we present aggregate effect estimates. Compared to placebo, glycerol probably has little or no effect on death in people with bacterial meningitis (RR 1.08, 95% CI 0.90 to 1.30; 5 studies, 1272 participants; moderate‐certainty evidence ), but may reduce neurological disability (RR 0.73, 95% CI 0.53 to 1.00; 5 studies, 1270 participants; low‐certainty evidence ). Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30; 4 studies, 1090 participants; low‐certainty evidence ). Glycerol may reduce the risk of subsequent deafness (RR 0.64, 95% CI 0.44 to 0.93; 5 studies, 922 participants; low to moderate‐certainty evidence ). Glycerol probably has little or no effect on gastrointestinal bleeding (RR 0.93, 95% CI 0.39 to 2.19; 3 studies, 607 participants; moderate‐certainty evidence ). The evidence on nausea, vomiting and diarrhoea is uncertain (RR 1.09, 95% CI 0.81 to 1.47; 2 studies, 851 participants; very low‐certainty evidence ). Authors' conclusions Glycerol was the only osmotic therapy evaluated, and data from trials to date have not demonstrated an effect on death. Glycerol may reduce neurological deficiency and deafness. Plain language summary Osmotic therapies added to antibiotics for acute bacterial meningitis What is the aim of this review? The aim of this Cochrane Review is to collect and analyse trials evaluating osmotic therapies given orally or intravenously to people with acute bacterial meningitis. Cochrane authors collected and analysed all relevant studies to answer this question; they found five relevant studies. Key messages Giving glycerol, an osmotic diuretic, probably has little or no effect on death ( moderate‐certainty evidence ), but may reduce subsequent deafness ( moderate‐certainty evidence) or neurological disability ( low‐certainty evidence ). The evidence is current to 17 February 2017. What was studied in the review? In meningitis, the cerebrospinal fluid that surrounds the brain and spinal cord is infected, usually as a result of spread from the blood. Any form of meningitis can result in death or severe disability, but acute bacterial meningitis is rapidly fatal without treatment. Even with antibiotics, 10% to 15% of children with bacterial meningitis die in high‐income countries with much higher rates in low‐income settings. The infection causes the brain to swell, and this is thought to contribute to death and to long‐term brain damage in survivors. Osmotic therapies increase the concentration of the blood by exerting an osmotic pressure across a semi‐permeable membrane (such as a cell wall or blood vessel lining in the brain). This draws water from the brain into the blood, thereby reducing pressure in the brain. Potentially osmotic therapies could increase the rate of survival, or they could do harm. What are the main results of the review? We included five trials that compared glycerol with placebo in a total of 1451 patients with bacterial meningitis. In the studies steroids were often given as well, but this did not appear to modify any of the effects seen with glycerol. This review detected no benefit from glycerol relating to death. There appeared to be marginal protection against deafness and against neurological disability. No effect on epileptic seizures at follow‐up was noted. Glycerol was not associated with any severe adverse effects. The number of trials included was small and only two tested a large number of participants. All trials were from different healthcare settings and examined either adults or children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wall, ECB; Ajdukiewicz, KMB; Bergman, H; Heyderman, RS; Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD008806.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "7774144b-d267-4c73-bc34-d5cfeb9ce83e", "pmid": "", "title": "Multisensory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Multisensory stimulation is a structured, developmentally appropriate intervention that provides simultaneous or sequential stimulation of two or more senses (e.g. tactile, auditory, visual, or vestibular) in a controlled and non‐stressful manner, with the aim of supporting early neurodevelopment in preterm infants. It has the potential to enhance physiological regulation in preterm infants by stabilizing key functions, such as respiratory patterns, heart rate, and oxygen saturation; reducing the need for respiratory support; and improving feeding performance and sleep regulation. Targeted multisensory interventions have also been associated with improved neurodevelopmental outcomes, including enhanced psychomotor development and visual function. Objectives To assess the benefits and harms of multisensory stimulation compared to any single sensory intervention or standard care on major neurodevelopmental disability, mortality, and growth in preterm infants. Search methods We searched CENTRAL, MEDLINE, Embase, Emcare, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 28 November 2025. We checked reference lists of included trials, and systematic reviews on sensory interventions. Eligibility criteria We included 18 randomized controlled trials (RCTs) comparing multisensory stimulation in preterm infants with no intervention (placebo or standard care), and one RCT comparing multisensory stimulation with single‐sense stimulation (tactile stimulation). Outcomes Our critical outcomes were major neurodevelopmental disability at 18 to 24 months: cerebral palsy (CP), developmental delay, intellectual impairment, blindness, sensorineural deafness; death during initial hospitalization; and total weight gain (grams), assessed at discharge. When comparing multisensory stimulation with single‐sense intervention, we also included weight gain during the intervention, an outcome added during the post‐hoc analysis. Important outcomes were duration of hospital stay, of NICU stay, and of respiratory support; and time until full oral feeding. Risk of bias We used the Cochrane tool, RoB 2. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RR) for dichotomous data, and mean differences (MDs) for continuous data, each with its 95% confidence intervals (CIs). We assessed statistical heterogeneity by calculating the I 2 statistic when we included more than two trials in a meta‐analysis. We evaluated the certainty of evidence using GRADE. Included studies We included 19 trials (1554 newborn infants): 18 studies compared multisensory stimulation with standard care; one compared multisensory stimulation with single‐sensory stimulation (tactile). In 10 studies, the primary aim was to assess the neurobehavioral outcomes of multisensory stimulation on preterm neo­nates. The other nine studies aimed to assess the impact of multisensory stimulation on weight gain during the intervention, weight gain until hospital discharge, length of neonatal intensive care unit (NICU) stay, length of hospital stay, time until full oral feeding, length of respiratory support, or a combination. In the abstract we report results for the critical outcomes only. We identified 13 ongoing studies. Four studies are awaiting assessment. Synthesis of results Multisensory stimulation compared to standard care No studies reported on these major neurodevelopmental disabilities, assessed at 18 to 24 months' corrected age (CA): developmental delay, intellectual impairment, blindness, or sensorineural deafness. One study reported on rates of CP at 12 months of age. The evidence is very uncertain about the effect of multisensory stimulation on CP (RR 0.67, 95% CI 0.28 to 1.58; I² not applicable; 1 study, 18 participants; very low‐certainty evidence). The evidence suggests that multisensory stimulation may result in little to no difference in death during initial hospitalization (RR 0.97, 95% CI 0.54 to 1.73; I² not applicable; 1 study, 395 participants; low‐certainty evidence). Multisensory stimulation may increase total weight gain prior to discharge (MD 72.67, 95% CI 68.23 to 77.12; I² = 0%; 3 studies, 474 participants; low‐certainty evidence). Multisensory stimulation compared to single‐sense (tactile) stimulation No studies reported on major neurodevelopmental disability, assessed at 18 to 24 months' CA, or death during initial hospitalization. The evidence is very uncertain about the effect of multisensory stimulation compared to tactile stimulation on weight gain during the intervention (MD −175.00, 95% CI −376.60 to 26.60; I² not applicable; 1 study, 20 participants; very low‐certainty evidence). The certainty of the evidence was low to very low across outcomes, primarily due to risk of bias, imprecision from small sample sizes and wide CIs, and in some cases, inconsistency. The evidence base was also limited by the lack of reporting of relevant outcomes and reliance on surrogate outcomes or shorter follow‐up periods. Authors' conclusions The available evidence on multisensory stimulation in preterm infants is limited and of low to very low certainty. No included studies reported on major neurodevelopmental disabilities at 18 to 24 months’ CA, which represented a critical outcome for this review. Evidence regarding the effect of multisensory stimulation on CP is very uncertain, as it is based on a single small study reporting a surrogate outcome at 12 months. Multisensory stimulation may result in little to no difference in mortality during the initial hospitalization. It may increase total weight gain prior to discharge. However, the clinical significance of this finding is uncertain, particularly given the low certainty of the evidence and the multifactorial nature of growth in preterm infants. The evidence is very uncertain about the effect of multisensory stimulation compared to single‐sense (tactile) stimulation on weight gain during the intervention. The only included study did not report major neurodevelopmental disabilities at 18 to 24 months’ CA, mortality during the initial hospitalization, or total weight gain prior to discharge, which represented the critical outcomes for this review. Overall, the current evidence does not allow firm conclusions about the effectiveness of multisensory stimulation in promoting development or preventing morbidity in preterm infants. Future studies on multisensory stimulation should use more rigorous designs, larger samples, and report interventions using the template for intervention description and replication (TIDieR) checklist to ensure transparency. They should also report essential outcomes, such as neonatal death, major neurodevelopmental disabilities, length of hospital and NICU stay, time to full oral feeding, duration of respiratory support, and weight gain, to better assess the long‑term effects of multisensory stimulation in preterm infants. Funding This Cochrane review had no dedicated funding . Registration Protocol available via DOI: 10.1002/14651858.CD016073 Plain language summary Does stimulating multiple senses (such as hearing, touch, taste, smell) of premature babies improve growth and healthy development or reduce the risk of death? Key messages Multisensory stimulation (the stimulation of more than one sense at a time) may support growth in preterm infants by increasing weight gain before discharge from the hospital. However, it is unclear whether it improves longer‐term developmental outcomes or reduces the risk of death, as the available evidence is limited and uncertain. When compared with stimulation of a single sense (touch alone), it is uncertain whether multisensory stimulation is better than touch alone at increasing weight gain during the intervention. What is multisensory stimulation, and how does it work? Multisensory stimulation means giving premature babies experiences that activate two or more of their senses. The senses involved and the types of stimulation used include the sense of: hearing — a parent’s voice, singing, or calming music; touch — massage or passive movements; smell and taste — a mother’s scent or breast milk; balance — gentle rocking or changing the baby's position; sight — soft, cycled lighting and simple shapes, colors, or moving patterns. During the newborn period, the brain grows very quickly. Providing positive sensory experiences at this time may help premature babies in several ways, such as supporting their memory, helping them regulate emotions, and improving early learning and development. What did we want to find out? We wanted to find out whether multisensory stimulation compared with single‑sense stimulation or standard care helps premature babies survive, grow, stay healthy, and develop well. Specifically, we wanted to find out whether multisensory stimulation might: reduce the number of babies with severe developmental problems at 18 to 24 months' age, such as cerebral palsy, delay in development, limitations in mental abilities, blindness, or deafness; reduce the number of babies who die during the newborn period or before hospital discharge; increase the amount of weight the infants gained by the time they left the hospital. We also looked at other important measures of the babies’ health, including: how long they stayed in the hospital or in the neonatal intensive care unit (NICU); how long it took before they could feed fully by mouth; how many days they needed breathing support. What did we do? We searched for studies in which multisensory stimulation began before the baby was discharged from the hospital after birth, and which compared multisensory stimulation with: no intervention or standard care; single‐sense stimulation. We summarized the results of the studies and rated our confidence in the evidence, based on factors, such as the size of the study (number of babies enrolled) and the methods used. What did we find? We included 19 studies (1544 premature babies). Eighteen of these studies compared multisensory stimulation with standard care, and one study compared multisensory stimulation with a single‑sense intervention (touch only). In 10 studies, the main goal was to examine how multisensory stimulation affects babies’ brain and behavioral development. The remaining nine studies focused on weight gain during the intervention, weight gain prior to hospital discharge, length of stay in the NICU, total length of hospital stay, time until the baby could feed fully by mouth, number of days the baby needed breathing support, or a combination of these measures. We also found 13 ongoing studies and 4 studies that have not yet been fully assessed. They may give us more useful information in the future. Main results None of the studies that compared multisensory stimulation with no intervention reported on the critical outcome major developmental disability at 18 to 24 months' corrected age. Only one study assessed a related outcome, cerebral palsy at 12 months. Because this study was very small, the evidence is very uncertain about whether multisensory stimulation modifies the risk of cerebral palsy. Multisensory stimulation may result in little or no difference in death before hospital discharge, although it was reported in only one large study. It may increase total weight gain prior to discharge, but the observed effect is small, and its clinical significance remains uncertain. Compared with single‐sense stimulation (touch), we could not tell whether multisensory stimulation helped babies gain more weight during the intervention. The only study we found comparing a multi‐ to single‐sensory intervention did not report the critical outcomes, such as major developmental problems at 18 to 24 months' corrected age, death during the first hospital stay, or total weight gain prior to discharge. What are the limitations of the evidence? We have limited confidence in these findings because many of the studies were small or not well‐designed. Several studies did not report the outcomes we were most interested in or did not provide enough data for us to analyze. Because of these limitations, the true effects of multisensory stimulation may be different from what we found. How up‐to‐date is this evidence? The evidence is up‐to‐date to 28 November 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Wróblewska-Seniuk, K; Lenells, M; Prescott, MG; Fiander, M; Soll, RF; Bruschettini, M; supported by Cochrane Sweden and Cochrane Neonatal,", "articleTypes": [], "doi": "10.1002/14651858.CD016073.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "777494a4-a144-4e92-8866-43916cd889a8", "pmid": "", "title": "Interventions for the treatment of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "O'Byrne, L, Webster, KE, MacKeith, S, Philpott, C, Hopkins, C, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013876.pub3 AB - Abstract - Background Olfactory dysfunction is a common consequence of COVID‐19 infection and persistent symptoms can have a profound impact on quality of life. At present there is little guidance on how best to treat this condition. A variety of interventions have been suggested to promote recovery, including medication and olfactory training. However, it is uncertain whether any intervention is of benefit. This is an update of the 2021 review with one additional study added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with persisting olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance that had persisted for at least four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the recovery of sense of smell, disease‐related quality of life and serious adverse effects. Secondary outcomes were the change in sense of smell, general quality of life, prevalence of parosmia and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included two studies with 30 participants. The studies evaluated the following interventions: systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant and palmitoylethanolamide plus luteolin. Systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant compared to no intervention We included a single RCT with 18 participants who had anosmia for at least 30 days following COVID‐19 infection. Participants received a 15‐day course of oral corticosteroids combined with nasal irrigation (consisting of an intranasal corticosteroid/mucolytic/decongestant solution) or no intervention. Psychophysical testing was used to assess olfactory function at 40 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Palmitoylethanolamide plus luteolin compared to no intervention We included a single RCT with 12 participants who had anosmia or hyposmia for at least 90 days following COVID‐19 infection. Participants received a 30‐day course of palmitoylethanolamide and luteolin or no intervention. Psychophysical testing was used to assess olfactory function at 30 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the treatment of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important The sense of smell is critical to one's enjoyment of odours and tastes, and is important for safety. During the COVID‐19 pandemic there has been an increasing focus on change in sense of smell as one of the early symptoms associated with infection. This can be a reduction, change or complete loss of the sense of smell. For most people this is temporary, however for some this lasts weeks or even months. If a person has lost their sense of smell for a long time (over four weeks after having COVID‐19), we do not know if there are any treatments that might help it to recover. How we identified and assessed the evidence We searched the medical literature, identifying relevant studies and summarising the results. We assessed the quality of the studies as well as the certainty of the evidence. Factors influencing this included the size of the studies, the methods used to perform them and how results were reported by researchers. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found two small studies to include in the review, including a total of 30 people. All participants had problems with their sense of smell that had lasted for at least four weeks, and started after a COVID‐19 infection. Problems with the sense of smell were identified using special smell identification tests carried out by the research team. The patients were randomly divided into two groups: those who would receive treatment and those who would not. The treatment in one study was a course of corticosteroid tablets ('systemic') and nasal irrigation (with a wash consisting of a mix of corticosteroids, decongestant and an agent that breaks down mucus). The second study used a course of a supplement known as palmitoylethanolamide and luteolin. Systemic corticosteroids and nasal irrigation (intranasal corticosteroids/decongestant/mucolytic) compared to no treatment We do not know whether corticosteroid tablets with nasal irrigation is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 40 days;
 ‐ changing the sense of smell after 40 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. Palmitoylethanolamide and luteolin compared to no treatment We do not know whether palmitoylethanolamide and luteolin is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 30 days;
 ‐ changing the sense of smell after 30 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. We did find a number of other studies that are being carried out, but no results from these studies are yet available to be included in this review. What this means It is unclear whether using corticosteroids with nasal irrigation, or using a palmitoylethanolamide and luteolin supplement, might treat problems with the sense of smell after COVID‐19, or whether these treatments can potentially cause harm. Other treatments are under investigation. This review is a 'living systematic review', meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.765Z" }, { "id": "7784e53d-cf52-49a9-8064-7edaf149d608", "pmid": "", "title": "Interventions for preventing oral mucositis for patients with cancer receiving treatment", "imported": false, "abstract": "Abstract - Background Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers). Objectives To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment. Search methods Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL ( The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Selection criteria Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer. Data collection and analysis Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random‐effects models. Main results A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta‐analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte‐colony stimulating factor (G‐CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate. Authors' conclusions Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent. Plain language summary Interventions for preventing oral mucositis for patients with cancer receiving treatment Treatment for cancer (including bone marrow transplant) can cause oral mucositis (severe ulcers in the mouth). This painful condition can cause difficulties in eating, drinking and swallowing, and may also be associated with infections which may require the patient to stay longer in hospital. Different strategies are used to try and prevent this condition, and the review of trials found that some of these are effective. Two interventions, cryotherapy (ice chips) and keratinocyte growth factor (palifermin®) showed some benefit in preventing mucositis. Sucralfate is effective in reducing the severity of mucositis, and a further seven interventions, aloe vera, amifostine, intravenous glutamine, granulocyte‐colony stimulating factor (G‐CSF), honey, laser and antibiotic lozenges containing polymixin/tobramycin/amphotericin (PTA) showed weaker evidence of benefit. These were evaluated in patients with different types of cancer, undergoing different types of cancer treatment. Benefits may be restricted to the disease and treatment combinations evaluated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Worthington, HV; Clarkson, JE; Bryan, G; Furness, S; Glenny, A-M; Littlewood, A; McCabe, MG; Meyer, S; Khalid, T; Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD000978.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "77b59cbd-afa0-4bfd-ac48-d68b451f6ad8", "pmid": "", "title": "Nitrous oxide‐based techniques versus nitrous oxide‐free techniques for general anaesthesia", "imported": false, "abstract": "Abstract - Background Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise. Objectives To determine if nitrous oxide‐based anaesthesia results in similar outcomes to nitrous oxide‐free anaesthesia in adults undergoing surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites ( http://clinicaltrials.gov/ , http://controlled‐trials.com/ , and http://www.centerwatch.com ). Selection criteria We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol‐based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay. Data collection and analysis Two review authors independently assessed trial quality and extracted the outcome data. We used meta‐analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed‐effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random‐effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Main results We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta‐analyses showed that nitrous oxide‐based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta‐analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide‐based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low. Authors' conclusions Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review. Plain language summary Nitrous oxide (laughing gas)‐based techniques versus nitrous oxide‐free techniques for general anaesthesia Review question We reviewed the evidence about the harmful effects of nitrous oxide on people undergoing general anaesthesia. Background Nitrous oxide is an anaesthetic gas which has been used for more than 160 years for inducing anaesthesia and keeping patients anaesthetized throughout an operation. It is also known as 'laughing gas'. It is a colourless non‐flammable gas with a pleasant, faint sweet odour and taste. Its low cost and low toxicity have made nitrous oxide by far the most commonly used general anaesthetic. However, some studies have reported that adding nitrous oxide may lead to harmful effects. This has led many anaesthetists to question its continued routine use in a variety of operating room settings. We wanted to discover whether using nitrous oxide in general anaesthesia was better or worse than not using nitrous oxide. Study characteristics We examined the evidence available up to 17 October 2014. We included 35 trials involving 13,872 adult participants, all of whom were randomized to either receive nitrous oxide or no nitrous oxide. The trials covered a variety of situations during general anaesthesia. Key results We found that general anaesthesia with nitrous oxide increased the risk of pulmonary atelectasis (i.e. failure of the lungs to expand fully). When we restricted the results to the highest quality studies only, we found evidence that nitrous oxide may potentially increase the risk of pneumonia and severe nausea and vomiting. However, nitrous oxide had no effect on the patients' survival, the incidence of heart attack, stroke, wound infection, the occurrence of blood clots within veins, the length of hospital stay, or the length of intensive care unit stay. Quality of the evidence The evidence related to survival of participants was of moderate quality because we did not have enough data. The evidence related to some harmful effects, such as failure of the lungs to expand fully and heart attack, was of high quality, while for other harmful effects, such as stroke and the occurrence of blood clots within veins, the evidence was of moderate quality. For others, such as pneumonia, severe nausea and vomiting, and wound infection, the evidence was of low quality. The evidence related to the length of time spend in hospital was of moderate quality. Authors conclusions The avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Sun, R, Jia, WQ, Zhang, P, Yang, K, Tian, JH, Ma, B, Liu, Y, Jia, RH, Luo, XF, Kuriyama, A", "articleTypes": [], "doi": "10.1002/14651858.CD008984.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.762Z" }, { "id": "77c189a1-1fa1-4900-b5d5-2b8d7e08a69d", "pmid": "", "title": "Sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose or glucose with and without non‐nutritive sucking is frequently used as a non‐pharmacological intervention for needle‐related procedural pain relief in infants. Objectives To determine the effectiveness of sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet‐tasting solutions, or pharmacological or other non‐pharmacological pain‐relieving methods. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012); MEDLINE via Ovid (1966 to 2012); CINAHL via OVID (1982 to 2012). The World Health Organization International Clinical Trials Registry Platform was also searched for any ongoing trials. Clinical trial registries, conference proceedings and references for randomised controlled trials (RCTs) were also searched. An updated search was run to capture any new publications before finalising the review in April 2012 and no new included studies were identified. Two review authors (MK & JF) independently abstracted data and assessed quality using a standard form. Authors have been contacted for missing data. Selection criteria Randomised‐controlled trials using a sweet‐tasting solution to treat pain in healthy term infants (gestational age 37 weeks and over), between one month and 12 months of age who required needle‐related procedures. These procedures included but were not limited to: subcutaneous or intramuscular injections, venepuncture, and heel lance. Studies in which the painful procedure was circumcision, lumbar puncture or supra‐pubic bladder aspiration were not included as they are more severe and painful than needle‐related procedures. Control conditions included no treatment or placebo (water) or any other identical intervention (same appearance and consistency) without active ingredient, another sweet‐tasting solution, a pharmacological pain‐relieving method (e.g. paracetamol, topical anaesthetic cream), non‐pharmacological pain‐relieving method (e.g. distraction method, non‐nutritive sucking). Data collection and analysis Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Pain, Palliative and Supportive Care Group. We report mean differences (MD) with 95% confidence intervals (CI) using fixed‐effect models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. The Chi 2 test and I 2 statistic were used to assess between‐study heterogeneity. Main results Sixty‐five (65) studies were identified for possible inclusion in this review. Fourteen published RCTs with a total of 1551 participants met the inclusion criteria. Duration of cry was significantly reduced in infants who were administered a sweet‐tasting solution [MD ‐13.47 (95% CI ‐16.80 to ‐10.15)], P < 0.00001 compared with water. However, there was considerable heterogeneity between the studies (I 2 = 94%) that we were unable to explain. Meta‐analysis was not able to be undertaken for any of the other outcome measures, except for cry duration, because of differences in study design. However, most of the individual studies that measured pain found sucrose to significantly reduce pain compared with the control group. One study compared sucrose and Lidocaine‐prilocaine cream and no significant difference was found between the two treatments for the outcomes pain and cry duration. Due to the differences between the studies, we were unable to identify the optimal concentration, volume or method of administration of sweet‐tasting solutions in infants aged one to 12 months. Further large RCTs are needed. Authors' conclusions There is insufficient evidence to confidently judge the effectiveness of sweet‐tasting solutions in reducing needle‐related pain in infants (one month to 12 months of age). The treatments do, however, appear promising. Data from a series of individual trials are promising, as are the results from a subset meta‐analysis of studies measuring duration of crying. Further well controlled RCTs are warranted in this population to determine the optimal concentration, volume, method of administration, and possible adverse effects. Plain language summary Sweet‐tasting solutions for needle‐related pain in infants up to one year of age The use of needles that break the skin and cause pain is a common practice around the world with babies aged between one month and 12 months ( Appendix 4 ). In this review we were interested in whether giving babies sugar‐based solutions to taste when the needle breaks the skin will help reduce their pain. We found 14 separate studies that had asked this question. However, the differences between the studies were often too great to let us combine their findings. Overall, the studies show that different types of sugar‐based solutions were effective but we were not able to confidently assert that there is strong evidence for this treatment in reducing pain. We did find some evidence that babies may not cry for as long if given sugar‐based solutions. This review is broadly in agreement with two other reviews, one asking this question in younger children, and one in older children. There is a need for better studies in this field.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Kassab, M, Foster, JP, Foureur, M, Fowler, C", "articleTypes": [], "doi": "10.1002/14651858.CD008411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.747Z" }, { "id": "77c5d728-7c53-4549-8c6f-347bd34a2d6a", "pmid": "", "title": "Mechanisms Underlying Predictors of Success From Obesity Surgery", "imported": false, "abstract": "The goal of this project is to identify predictors of success in the treatment of obesity after bariatric surgery. The specific aims of this proposal are to:", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.248Z" }, { "id": "77c6b518-980a-42aa-af3b-c84e12950d45", "pmid": "", "title": "Glutamine for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Crohn's disease is a chronic relapsing condition of the alimentary tract with a high morbidity secondary to bowel inflammation. Glutamine plays a key role in maintaining the integrity of the intestinal mucosa and has been shown to reduce inflammation and disease activity in experimental models of Crohn's disease. Objectives To evaluate the efficacy and safety of glutamine supplementation for induction of remission in Crohn's disease. Search methods We searched the following databases from inception to November 15, 2015: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane IBD Group Specialised Register. Study references were also searched for additional trials. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) that compared glutamine supplementation administered by any route to a placebo, active comparator or no intervention in people with active Crohn's disease were considered for inclusion. Data collection and analysis Two authors independently extracted data and assessed the methodological quality of the included studies. The Cochrane risk of bias tool was used to assess methodological quality. The primary outcome measure was clinical or endoscopic remission. Secondary outcomes included intestinal permeability, clinical response, quality of life, growth in children and adverse events. Risk ratios and 95% confidence intervals were calculated for dichotomous outcomes. The overall quality of the evidence supporting the primary outcome was evaluated using the GRADE criteria. Main results Two small RCTs (total 42 patients) met the inclusion criteria and were included in the review. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. The other study (24 patients) compared glutamine‐supplemented total parenteral nutrition to non‐supplemented total parenteral nutrition in adult patients (> 18 years of age) with acute exacerbation of inflammatory bowel disease. The paediatric study was rated as low risk of bias. The study in adult patients was rated as unclear risk of bias for blinding and low risk of bias for all other items. It was not possible to pool data for meta‐analysis because of significant differences in study populations, nature of interventions, and the way outcomes were assessed. Data from one study showed no statistically significant difference in clinical remission rates at four weeks. Forty‐four per cent (4/9) of patients who received a glutamine‐enriched polymeric diet achieved remission compared to 56% (5/9) of patients who received a standard low‐glutamine polymeric diet (RR 0.80, 95% CI 0.31 to 2.04). A GRADE analysis indicated that the overall quality of evidence for this outcome was low due to serious imprecision (9 events). In both included studies, no statistically significant changes in intestinal permeability were found between patients who received glutamine supplementation and those who did not. Neither study reported on clinical response, quality of life or growth in children. Adverse event data were not well documented. There were no serious adverse events in the paediatric study. The study in adult patients reported three central catheter infections with positive blood cultures in the glutamine group compared to none in the control group (RR 7.00, 95% CI 0.40 to 122.44). Authors' conclusions Currently there is insufficient evidence to allow firm conclusions regarding the efficacy and safety of glutamine for induction of remission in Crohn's disease. Data from two small studies suggest that glutamine supplementation may not be beneficial in active Crohn's disease but these results need to be interpreted with caution as they are based on small numbers of patients. This review highlights the need for adequately powered randomised controlled trials to investigate the efficacy and safety of glutamine for induction of remission in Crohn's disease. Plain language summary Glutamine for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disorder of the intestines which has periods of inactivity and periods when it flares up. Crohn's disease can affect any part of the digestive tract, from the mouth to the anus. The most common symptoms of the disease include abdominal pain, non‐bloody diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms of the disease it is said to be ‘active’; periods when the symptoms stop are called ‘remission’. What is glutamine? Glutamine is an amino acid that plays a key role in maintaining the integrity of the intestinal mucosa (lining of the intestines) and has been shown to reduce inflammation and disease activity in animal models of Crohn's disease. It has therefore been suggested that glutamine may reduce intestinal inflammation in people with Crohn's disease. What did the researchers investigate? The researchers investigated whether glutamine is effective for inducing remission in people with active Crohn's disease and whether this treatment causes any harms (side effects). The researchers searched the medical literature up to November 15, 2015. What did the researchers find? The researchers identified two randomised controlled trials (total 42 participants) that investigated the role of glutamine for the treatment of active Crohn's disease. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. Participants were encouraged to consume the diet orally. If this was not possible the diet was administered via a fine‐bore nasogastric tube. The other study (24 participants) compared glutamine‐supplemented total parenteral nutrition (TPN) to non‐supplemented TPN in adult patients (> 18 years of age) with sudden worsening of inflammatory bowel disease. The TPN diet was administered intravenously via a central catheter (a thin tube) for at least one week. Both studies were generally high quality. Neither study demonstrated any beneficial effects for glutamine. Side effects were not well documented in the two studies. There were no serious side effects noted in the paediatric study. The study in adult patients reported three central catheter‐related blood infections in the glutamine group compared to none in the non‐glutamine control group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and harms of glutamine for the treatment of active Crohn's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Akobeng, AK; Elawad, M; Gordon, M", "articleTypes": [], "doi": "10.1002/14651858.CD007348.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "77d137c8-97d8-4026-a516-e2ee6e4afbe5", "pmid": "", "title": "Zinc supplementation for the promotion of growth and prevention of infections in infants less than six months of age", "imported": false, "abstract": "Abstract - Background Zinc is a vital micronutrient for humans and is essential for protein synthesis, cell growth, and differentiation. Severe zinc deficiency can lead to slower physical, cognitive and sexual growth, cause skin disorders, decrease immunity, increase incidence of acute illnesses in infants and children and contribute to childhood stunting. By estimation, 17.3% of the world population is at risk of inadequate zinc intake. Such nutritional impairment increases the risk of diarrhoea and pneumonia by 20%, as well as leads to a global loss of more than 16 million disability‐adjusted life years in children less than five years of age. Not only does zinc deficiency affect lives, it adds to the considerable financial burden on depleted resources in countries that are most affected. By preventing or curing this deficiency, we can improve childhood mortality, morbidity and growth. Objectives To assess the effectiveness of zinc supplementation for the promotion of growth, reduction in mortality, and the prevention of infections in infants less than six months of age. Search methods We used the standard search strategy of the Cochrane Neonatal Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 4), MEDLINE via PubMed (1966 to 18 May 2018), Embase (1980 to 18 May 2018), and CINAHL (1982 to 18 May 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials . An updated search from 1 January 2018 to 29 January 2020 was run in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria All randomised controlled (individual and cluster randomised) and quasi‐randomised trials of zinc supplementation in healthy, term infants, less than six months of age comparing infant mortality, incidence of diarrhoea or respiratory illnesses, growth and/or serum zinc levels were eligible. Data collection and analysis Two review authors screened search results (title and abstracts) and relevant full texts. Studies fulfilling prespecified inclusion criteria were included with any disagreements resolved by consensus. Extraction and analysis were then conducted. We used the GRADE approach to assess the quality of evidence as indicated by certainty in effect estimates. Main results Eight studies (with 85,629 infants) were included and five studies were meta‐analysed, out of which four studies compared zinc with placebo, and one compared zinc plus riboflavin versus riboflavin. Certain growth outcomes after six months of intervention (Weight for Age Z‐scores (WAZ) (standardised mean difference) (SMD) 0.16, 95% CI 0.03 to 0.29; three studies, n = 955; fixed‐effect; heterogeneity Chi² P = 0.96); I² = 0%); change in WAZ (SMD 0.16, 95% CI 0.07 to 0.25; one study, n = 386; fixed‐effect); (Weight‐for‐Length Z‐score (WLZ) (SMD 0.15, 95% CI 0.02 to 0.28; three studies, n = 955; fixed‐effect; heterogeneity: Chi² P = 0.81); I² = 0%); (change in WLZ (SMD 0.17, 95% CI 0.06 to 0.28; one study, n = 386; fixed‐effect)) were positively affected by zinc supplementation compared to placebo. A single study reported no difference in the incidence of diarrhoea and lower respiratory tract infection with zinc supplementation. Zinc had no effect on mortality in children younger than 12 months. When zinc plus riboflavin was compared to riboflavin only, significant improvement was observed in the incidence of wasting at 24 months (risk ratio (RR) 0.59, 95% CI 0.37 to 0.96; one study, n = 296; fixed‐effect), but significant worsening of incidence of stunting was present at 21 months (RR 1.53, 95% CI 1.09 to 2.16; one study, n = 298; fixed‐effect). Authors' conclusions There was a significant positive impact of zinc supplementation on WAZ and WLZ after six months of intervention in infants compared to placebo. When a combined supplement of zinc and riboflavin was compared to riboflavin, there was a significant reduction in wasting at 24 months, but stunting at 21 months was negatively affected. Although included trials were of good‐to‐moderate quality, evidence that could be meta‐analysed was based on a few studies which affected the overall quality of results. Regardless, there is a need for strong trials conducted in infants younger than six months before a strong recommendation can be made supporting zinc supplementation in this age group. Plain language summary Zinc supplementation for improving the health and survival of infants less than six months old Review question: does zinc supplementation reduce mortality, morbidity and increase growth in infants aged less than six months old? Background: zinc deficiency is prevalent in the world. Adequate zinc levels are linked to decreased deaths, illnesses and improved growth in all populations particularly in developing countries. Zinc supplementation in older children has shown some positive effects. Study characteristics: we searched for studies through January 2020 that enrolled healthy infants aged less than six months old and provided at least six months of zinc supplementation. We included eight studies that covered zinc supplementation compared with placebo, zinc and riboflavin compared with riboflavin only, zinc, riboflavin and B complex vitamins compared with riboflavin and B complex vitamins. Key results and certainty of evidence: zinc had no effect on decreasing deaths or illnesses in children younger than 12 months. Moderate‐ to good‐certainty evidence from three studies suggested an increase in weight‐for‐age Z‐scores and weight‐for‐length Z‐scores after zinc supplementation for six months compared to placebo only. Only one study could be analysed for zinc and riboflavin supplementation compared to riboflavin only, and the results suggested a decrease in wasting after 24 months of supplementation and an increase in stunting after 21 months. Conclusion: with this evidence, we cannot strongly recommend clinicians to prescribe zinc supplements to children under six months of age. We also encourage the development of trials that will provide zinc as well as other micronutrients in this age group and for such trials to evaluate outcomes such as death, disease, side effects and growth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lassi, ZS, Kurji, J, Oliveira, CSD, Moin, A, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD010205.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.743Z" }, { "id": "77dbeb23-cdbc-4563-aa90-565d9a03bb15", "pmid": "", "title": "Effects of Low-dose B-vitamins Supplementation on Plasma Homocysteine and Framingham Risk Score: Double Blind Randomized Controlled Trial in Healthy Chinese Elderly", "imported": false, "abstract": "The purpose of this study is to evaluate whether low dose complex B-vitamins (folic acid,vitamin B6 and vitamin B12) can lower the risk of developing hyperhomocysteinemia in an apparently healthy population with low folate/B12 and high Hcy status.", "journal": "", "year": "2008", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.248Z" }, { "id": "77e89b27-8ab5-4bb7-a369-256bcbd6adc0", "pmid": "", "title": "A Multicenter, Open-label, Randomized Study to Evaluate the Efficacy and Safety of Ropeginterferon Alfa-2b in the Treatment of Patients With Moderate COVID-19", "imported": false, "abstract": "To evaluate the efficacy of subcutaneous ropeginterferon alfa 2b ( P1101combined with standard of care (SOC) compared with standard care alone in hospitalized adults with moderate COVID 19.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.242Z" }, { "id": "77f64d1e-62fb-499d-95d8-6c9dd677ca91", "pmid": "", "title": "Evaluation of the Efficacy and Safety of a Drinkable Nutraceutical in Improving Hair Loss in Patients Treated With GLP-1/GIP Receptor Agonists: a Double-blind, 1:1 Randomized, Placebo-controlled Study.", "imported": false, "abstract": "The purpose of this clinical trial is to evaluate the efficacy of Olistic© Next Women, a nutraceutical supplement, compared with placebo in improving hair loss in patients undergoing treatment with GLP-1/GIP agonists. This 6-month, randomized, placebo-controlled clinical study investigates whether daily supplementation with Olistic© Next Women leads to significant improvements in hair loss in this patient population. In addition, the study assesses the safety and tolerability of the product throughout the treatment period.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.149Z" }, { "id": "77f8a33d-c5e4-4015-9d1b-212c820538b6", "pmid": "", "title": "Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Castillo, M, Scott, NW, Mustafa, MZ, Mustafa, MS, Azuara‐Blanco, A", "articleTypes": [], "doi": "10.1002/14651858.CD009566.pub2 AB - Abstract - Background Seasonal/perennial allergic conjunctivitis is the most common allergic conjunctivitis, usually with acute manifestations when a person is exposed to allergens and with typical signs and symptoms including itching, redness, and tearing. The clinical signs and symptoms of allergic conjunctivitis are mediated by the release of histamine by mast cells. Histamine antagonists (also called antihistamines) inhibit the action of histamine by blocking histamine H1 receptors, antagonising the vasoconstrictor, and to a lesser extent, the vasodilator effects of histamine. Mast cell stabilisers inhibit degranulation and consequently the release of histamine by interrupting the normal chain of intracellular signals.
 
 Topical treatments include eye drops with antihistamines, mast cell stabilisers, non‐steroidal anti‐inflammatory drugs, combinations of the previous treatments, and corticosteroids. Standard treatment is based on topical antihistamines alone or topical mast cell stabilisers alone or a combination of treatments. There is clinical uncertainty about the relative efficacy and safety of topical treatment. Objectives The objective of this review was to assess the effects of topical antihistamines and mast cell stabilisers, alone or in combination, for use in treating seasonal and perennial allergic conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2014, Issue 7), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2014), EMBASE (January 1980 to July 2014), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 July 2014. We also searched the reference lists of review articles and relevant trial reports for details of further relevant publications. Selection criteria We included randomised controlled trials (RCTs) comparing topical antihistamine and mast cell stabilisers, alone or in combination, with placebo, no treatment or to any other antihistamine or mast cell stabiliser, or both, that examined people with seasonal or perennial allergic conjunctivitis, or both. The primary outcome was any participant‐reported evaluation (by questionnaire) of severity of four main ocular symptoms: itching, irritation, watering eye (tearing), and photophobia (dislike of light), both separately and, if possible, by an overall symptom score. We considered any follow‐up time between one week and one year. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Disagreements were resolved by discussion among review authors and the involvement of a third review author. We followed standard methodological approaches used by Cochrane. Main results We identified 30 trials with a total of 4344 participants randomised, with 17 different drugs or treatment comparisons. The following antihistamines and mast cell stabilisers were evaluated in at least one RCT: nedocromil sodium or sodium cromoglycate, olopatadine, ketotifen, azelastine, emedastine, levocabastine (or levocabastine), mequitazine, bepotastine besilate, combination of antazoline and tetryzoline, combination of levocabastine and pemirolast potassium. The most common comparison was azelastine versus placebo (nine studies). We observed a large variability in reporting outcomes. The quality of the studies and reporting was variable, but overall the risk of bias was low. Trials evaluated only short‐term effects, with a range of treatment of one to eight weeks. Meta‐analysis was only possible in one comparison (olopatadine versus ketotifen). There was some evidence to support that topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo. There were no reported serious adverse events related to the use of topical antihistamine and mast cell stabilisers treatment. Authors' conclusions It seems that all reported topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo in the short term. However, there is no long‐term data on their efficacy. Direct comparisons of different antihistamines and mast cell stabilisers need to be interpreted with caution. Overall, topical antihistamines and mast cell stabilisers appear to be safe and well tolerated. We observed a large variability in outcomes reported. Poor quality of reporting challenged the synthesis of evidence. Plain language summary Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis Review question 
 Are treatments with eye drops of antihistamines and mast cell stabilisers, alone or in combination, effective and safe in people with seasonal and allergic conjunctivitis? The main outcome measure was eye symptoms reported by participants, including eye itching, irritation (burning sensation), watering eyes (tearing), and photophobia (dislike of light). We found 30 trials. Background 
 Conjunctivitis refers to inflammation of the conjunctiva, which is the thin tissue that covers the sclera (white part of the eye). Seasonal and perennial allergic conjunctivitis is the most common type of allergic conjunctivitis. Although this condition does not cause sight loss, it can cause intense itching and eye watering. Eye drops with antihistamines or mast cell stabilisers, or both are commonly used. Study characteristics 
 The evidence is current to July 2014. Among the 30 studies reviewed there were 17 different comparisons, including 4344 participants ranging in age between 4 and 85 years. The duration of treatment ranged from one to eight weeks. Ten out of 30 studies were funded by the drug manufacturer (8 totally and 2 partially funded); 20 studies did not report any source of funding. There was inconsistency in the way the effect of treatment was measured and reported. Overall risk of bias was low. Key results 
 Topical antihistamines and mast cell stabilisers, alone or in combination, are safe and effective for reducing symptoms of seasonal and perennial allergic conjunctivitis. We found insufficient evidence to discern which topical antihistamines and mast cell stabilisers are the most effective.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.755Z" }, { "id": "7870f0e4-41d5-4bfe-8eaa-5ecc8ab09aa0", "pmid": "", "title": "Prophylactic drug management for febrile seizures in children", "imported": false, "abstract": "Abstract - Background Febrile seizures occurring in a child older than one month during an episode of fever affect 2‐4% of children in Great Britain and the United States and recur in 30%. Rapid‐acting antiepileptics and antipyretics given during subsequent fever episodes have been used to avoid the adverse effects of continuous antiepileptic drugs. This is an updated version of a Cochrane Review previously published in 2017. Objectives To evaluate primarily the effectiveness and safety of antiepileptic and antipyretic drugs used prophylactically to treat children with febrile seizures; and also to evaluate any other drug intervention where there is a sound biological rationale for its use. Search methods For the latest update we searched the following databases on 3 February 2020: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to 31 January 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including the Cochrane Epilepsy Group. We imposed no language restrictions and contacted researchers to identify continuing or unpublished studies. Selection criteria Trials using randomised or quasi‐randomised participant allocation that compared the use of antiepileptics, antipyretics or recognised Central Nervous System active agents with each other, placebo, or no treatment. Data collection and analysis For the original review, two review authors independently applied predefined criteria to select trials for inclusion and extracted the predefined relevant data, recording methods for randomisation, blinding, and exclusions. For the 2016 update, a third review author checked all original inclusions, data analyses, and updated the search. For the 2020 update, one review author updated the search and performed the data analysis following a peer‐review process with the original review authors. We assessed seizure recurrence at 6, 12, 18, 24, 36, 48 months, and where data were available at age 5 to 6 years along with recorded adverse effects. We evaluated the presence of publication bias using funnel plots. Main results We included 42 articles describing 32 randomised trials, with 4431 randomised participants used in the analysis of this review. We analysed 15 interventions of continuous or intermittent prophylaxis and their control treatments. Methodological quality was moderate to poor in most studies. We found no significant benefit for intermittent phenobarbital, phenytoin, valproate, pyridoxine, ibuprofen, or zinc sulfate versus placebo or no treatment; nor for diclofenac versus placebo followed by ibuprofen, paracetamol, or placebo; nor for continuous phenobarbital versus diazepam, intermittent rectal diazepam versus intermittent valproate, or oral diazepam versus clobazam. There was a significant reduction of recurrent febrile seizures with intermittent diazepam versus placebo or no treatment at six months (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.48 to 0.85; 6 studies, 1151 participants; moderate‐certainty evidence), 12 months (RR 0.69, 95% CI 0.56 to 0.84; 8 studies, 1416 participants; moderate‐certainty evidence), 18 months (RR 0.37, 95% CI 0.23 to 0.60; 1 study, 289 participants; low‐certainty evidence), 24 months (RR 0.73, 95% CI 0.56 to 0.95; 4 studies, 739 participants; high‐certainty evidence), 36 months (RR 0.58, 95% CI 0.40 to 0.85; 1 study, 139 participants; low‐certainty evidence), 48 months (RR 0.36, 95% CI 0.15 to 0.89; 1 study, 110 participants; moderate‐certainty evidence), with no benefit at 60 to 72 months (RR 0.08, 95% CI 0.00 to 1.31; 1 study, 60 participants; very low‐certainty evidence). Phenobarbital versus placebo or no treatment reduced seizures at six months (RR 0.59, 95% CI 0.42 to 0.83; 6 studies, 833 participants; moderate‐certainty evidence), 12 months (RR 0.54, 95% CI 0.42 to 0.70; 7 studies, 807 participants; low‐certainty evidence), and 24 months (RR 0.69, 95% CI 0.53 to 0.89; 3 studies, 533 participants; moderate‐certainty evidence), but not at 18 months (RR 0.77, 95% CI 0.56 to 1.05; 2 studies, 264 participants) or 60 to 72 months follow‐up (RR 1.50, 95% CI 0.61 to 3.69; 1 study, 60 participants; very low‐certainty evidence). Intermittent clobazam compared to placebo at six months resulted in a RR of 0.36 (95% CI 0.20 to 0.64; 1 study, 60 participants; low‐certainty evidence), an effect found against an extremely high (83.3%) recurrence rate in the controls, a result that needs replication. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months (RR 0.45, 95% CI 0.18 to 1.15; 1 study, 60 participants; very‐low certainty evidence). When compared to placebo, intermittent oral levetiracetam significantly reduced recurrent seizures at 12 months (RR 0.27, 95% CI 0.15 to 0.52; 1 study, 115 participants; very low‐certainty evidence). The recording of adverse effects was variable. Two studies reported lower comprehension scores in phenobarbital‐treated children. Adverse effects were recorded in up to 30% of children in the phenobarbital‐treated groups and 36% in benzodiazepine‐treated groups. We found evidence of publication bias in the meta‐analyses of comparisons for phenobarbital versus placebo (seven studies) at 12 months but not at six months (six studies); and valproate versus placebo (four studies) at 12 months. There were too few studies to identify publication bias for the other comparisons. The methodological quality of most of the included studies was low or very low. Methods of randomisation and allocation concealment often did not meet current standards, and 'treatment versus no treatment' was more commonly seen than 'treatment versus placebo', leading to obvious risks of bias. Authors' conclusions We found reduced recurrence rates for intermittent diazepam and continuous phenobarbital, with adverse effects in up to 30% of children. The apparent benefit for clobazam treatment in one trial needs to be replicated. Levetiracetam also shows benefit with a good safety profile; however, further study is required. Given the benign nature of recurrent febrile seizures, and the high prevalence of adverse effects of these drugs, parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. Plain language summary Prophylactic drug management for febrile seizures in children Background Seizures occurring with a fever (febrile seizures) in children are common and affect about one in 30 children under the age of six years. On average, one out of three children who have had a febrile seizure will have at least one more. We reviewed the evidence about the effect of drugs to prevent seizures (antiepileptics), drugs to lower temperature (antipyretics), and zinc in children with febrile seizures. Objective We wanted to know in how many children these drugs would prevent a recurrence of febrile seizures or cause unwanted effects. Methods We included 32 studies with a total of 4431 children in the review. Children who had had at least one febrile seizure were assigned to one of two or more treatment groups. The studies recorded any further seizures at various time intervals between six months and up to six years of age in each group. Unwanted medication effects were also noted. Results The study design and evidence quality in the studies of antiepileptic drugs was often low or very low. Poor methods known to lead to obvious risks of bias were used. One issue was with the methods used to assign children to study groups and how random this allocation was. Other issues included whether the parents or doctors, or both, knew which group each child was in or if a treatment was compared to no treatment with no placebo (dummy pill) used. The quality of the trials of antipyretics or zinc was better, with the evidence assessed as moderate to high. Zinc therapy was found to provide no benefit. We also found no benefit in treating children just at the time of the fever with either antipyretic drugs or most antiepileptic drugs. A significant result was noted in some instances. For example, at times between 6 and 48 months follow‐up, intermittent diazepam (an antiepileptic drug) led to a reduction in the number of recurrent seizures by about a third. Continuous phenobarbital resulted in significantly fewer recurrences at 6, 12, and 24 months, but not at 18 and 60 to 72 months. One study showed that intermittent oral levetiracetam compared to placebo significantly reduced recurrent seizures at 12 months. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months. However, as recurrent seizures are only seen in about a third of children, this means that up to 16 children would have to be treated over a year or two to save just one child a further seizure. As febrile seizures are not harmful, we viewed these significant findings to be unimportant, in particular because adverse effects of the medications were common. Lower comprehension scores in phenobarbital‐treated children were found in two studies. In general, adverse effects were recorded in up to about a third of children in both the phenobarbital‐ and benzodiazepine‐treated groups. The benefit found for treatment with clobazam in one study published in 2011 needs to be repeated to test its reliability. Levetiracetam may be useful in treating children where family anxiety over possible seizure recurrence is high, but further study is required. Authors' conclusions There is currently insufficient evidence to support the use of continuous or intermittent treatment with zinc, antiepileptic or antipyretic drugs for children with febrile seizures. Febrile seizures can be frightening to witness. Parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. The evidence is current to February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Offringa, M; Newton, R; Nevitt, SJ; Vraka, K", "articleTypes": [], "doi": "10.1002/14651858.CD003031.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "788a5e58-4de6-48d4-9959-872ed3739c97", "pmid": "", "title": "Dissecting the Heterogeneity of Oral Cancer Pain", "imported": false, "abstract": "Oral squamous cell carcinoma (SCC) produces a higher prevalence and more severe pain than all other cancers. Orofacial pain is one of the most common initial symptoms of oral cancer and often leads to the diagnosis of oral cancer. However, the character, severity, and unique features of oral cancer widely differ between patients. There is currently no effective and lasting treatment available to alleviate suffering from oral cancer pain.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.153Z" }, { "id": "78b37784-29f8-4653-929f-b059a3d2ff42", "pmid": "", "title": "Interventions for dysphagia in oesophageal cancer", "imported": false, "abstract": "Abstract - Background Most patients with oesophageal and gastro‐oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009. Objectives The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro‐oesophageal carcinoma. Search methods To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Selection criteria Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, self‐expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head‐to‐head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30‐day mortality, adverse effects and quality of life. Data collection and analysis Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group. Main results We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re‐interventions and for adverse effects. Anti‐reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti‐reflux stents might have reduced gastro‐oesophageal reflux and complications. Newly‐designed double‐layered nitinol (Niti‐S) stents were preferable due to longer survival time and fewer complications compared to simple Niti‐S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy. Authors' conclusions Self‐expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high‐dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti‐reflux stents and newly‐designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self‐expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re‐interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia. Plain language summary Interventions for reducing difficulty in swallowing in people with oesophageal cancer Review question For most patients with unresectable or inoperable oesophageal cancer, providing clinical benefit with palliative treatment is highly desirable. However, the optimal palliative technique for dysphagia improvement and better quality of life is not established. Background Dysphagia (difficulty or discomfort in swallowing) is common among patients with unresectable or inoperable oesophageal cancer. There are five levels of dysphagia, ranging from the ability to eat a normal diet to some solids, semisolids, liquids and to complete dysphagia. Study characteristics The review included randomised controlled studies comparing the use of different interventions to improve dysphagia among patients with inoperable or unresectable primary oesophageal cancer. To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Key results The review updates the previous version but still fails to present any obvious superiority of one technique over another among the different kinds of interventions. Self‐expanding metal stents provided safer and more effective relief of dysphagia compared to rigid plastic stents. Other techniques like radiotherapy or brachytherapy were also suitable alternatives and might be favourable in improving quality of life and prolonging survival. Individual differences should be emphasised when the intervention type was determined. Quality of the evidence Half of the studies included in this review were of high quality. Most studies did not state the methods used to seek and report quality of life outcomes and adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Yang, C, Li, J, Fu, W, Xu, W, Yang, S", "articleTypes": [], "doi": "10.1002/14651858.CD005048.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.817Z" }, { "id": "78bee91b-d2b4-412e-ae33-3861e7b4c2c3", "pmid": "", "title": "Chinese medicinal herbs for influenza", "imported": false, "abstract": "Abstract - Background Influenza is a communicable acute respiratory infection which, during epidemics, can cause high morbidity and mortality rates. Traditional Chinese medicinal herbs, often administered following a particular Chinese medical theory, may be a potential treatment of choice. Objectives To assess the effect of Chinese medicinal herbs used to prevent and treat influenza and to estimate the frequency of adverse effects. Search methods We searched CENTRAL (2012, Issue 11), MEDLINE (January 1966 to November week 2, 2012), EMBASE (January 1988 to November 2012) and CNKI (January 1988 to 29 March 2012). We also searched reference lists of articles and the WHO ICTRP search portal (November 2012). Selection criteria Randomised controlled trials (RCTs) comparing traditional Chinese medicinal herbs with placebo, no treatment or conventional medicine normally used in preventing and treating uncomplicated influenza. Data collection and analysis Two review authors independently extracted data and assessed trial quality. Main results We included 18 studies involving 2521 participants. The methodological quality of 17 included studies was poor. Included RCTs separately compared medicinal herbs with different antiviral drugs, precluding any pooling of results. Only three indicated that compared with antiviral drugs, Chinese medicinal herbs may be effective in preventing influenza and alleviating influenza symptoms. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and speeding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. Ten studies reported mild adverse reactions. Authors' conclusions Most Chinese medical herbs in the included studies showed similar effects to antiviral drugs in preventing or treating influenza. Few were shown to be superior to antiviral drugs. No obvious adverse events were reported in the included studies. However, current evidence remains weak due to methodological limitations of the trials. More high‐quality RCTs with larger numbers of participants and clear reporting are needed. Plain language summary Chinese medicinal herbs for influenza Influenza is a viral respiratory infection that causes an acute febrile illness with myalgia, headache and cough, and can result in high morbidity and mortality rates during an epidemic. Annual epidemics are thought to result in between three and five million cases of severe influenza and between 250,000 and 500,000 deaths worldwide. Currently, annual vaccination is the primary strategy for preventing influenza, and four influenza antiviral agents (amantadine, rimantadine, zanamivir and oseltamivir) have been approved for treatment of influenza. However, high levels of drug resistance have been recorded. Many Chinese medicinal herbs are used to treat and prevent this condition. This updated review assessed the therapeutic effects and safety of Chinese medicinal herbs as an alternative and adjunctive therapy to other commonly used drugs for influenza. Eighteen studies involving 2521 participants were included in the review. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and aiding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. The remaining 17 Chinese herbal trials showed a similar effect to antiviral drugs in preventing or treating influenza. However, since these included studies were of poor quality, the evidence does not support or reject the use of any Chinese herbal preparations for influenza. High‐quality trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Jiang, L; Deng, L; Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD004559.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "78ddb2b2-161d-4176-b746-65f1be9e7030", "pmid": "", "title": "Micronutrient supplementation in pregnant women with HIV infection", "imported": false, "abstract": "Abstract - Background Micronutrient deficiencies are widespread and compound the effects of HIV disease; micronutrient supplements may be effective and safe in reducing this burden. Objectives To assess whether micronutrient supplements are effective and safe in reducing mortality and morbidity in pregnant and lactating women with HIV infection and their infants. Search methods The review has been updated three times since publication in 2005. In reviews prior to this update (2011), we searched the CENTRAL, EMBASE, PubMed, and GATEWAY databases to identify randomised controlled trials of micronutrient supplements using the search methods of the Cochrane HIV/AIDS Group. In the 2011 review the PubMed, EMBASE, and CENTRAL databases were searched in July 2011. As the GATEWAY database does not include conference abstracts after 2006, we also searched the AIDS‐specific conference database, www.aegis.org , and contacted researchers and organisations active in the field of research to identify additional unpublished trials. Selection criteria Randomised controlled trials were selected that compared the effects of micronutrient supplements (vitamins, trace elements, and combinations of these) with other supplements, placebo or no treatment on mortality, morbidity, pregnancy outcomes, immunologic indicators, and anthropometric measures in HIV‐positive pregnant and lactating women. Any adverse effects of supplementation were recorded. Data collection and analysis Two reviewer authors independently selected trials, appraised trial quality for risk of bias using standardised criteria, and extracted data using standardised forms. Where disagreements arose, a third author, acted as arbiter. Main results One additional trial is included in this update in addition to the three trials included in the 2010 update of the initial Cochrane review. Four relatively large, well‐conducted randomised controlled trials of the benefits of micronutrient supplementation have been conducted in pregnant and lactating women infected with HIV. Each of the trials evaluated a different micronutrient supplement and no direct comparisons or analyses can be made across the four trials. The four trials were conducted between 1995 and 2006. The trials have all been conducted by the same research team in Dar es Salaam in Tanzania, in an urban setting in hospital‐based antenatal clinics. Pregnant women were recruited with gestational age ranging from 12 to 27 weeks in each of the trials. Sample sizes range from 400 to 1129 with a median of 1000 participants. Three of the trials were placebo‐controlled. Different interventions have been evaluated in each trial, viz.:Vitamin A versus Vitamin A and multivitamins versus Multivitamins versus placebo; Selenium versus placebo; Zinc versus placebo; and Multiple RDA multivitamins versus Single RDA multivitamins. None of the women were receiving antiretrovrial therapy (ART). Multiple micronutrient supplements conferred multiple clinical benefits to pregnant women and their offspring. No significant adverse effects were reported. No significant clinical benefits were found from zinc supplementation of pregnant Tanzanian women. Selenium supplements given during and after pregnancy did not delay maternal HIV disease progression or improve pregnancy outcomes, but may improve child survival and decrease maternal diarrhoeal morbidity. There were no differences in maternal and infant outcomes when women received single RDA multivitamins or multiple RDA multivitamin supplementation. The evidence is lacking for the effects of micronutrient supplementation given concomitantly to pregnant women already initiated on antiretroviral therapy for treatment purposes. GRADE assessments were conducted on outcomes for each trial and included reviewing the data and the potential biases in each trial before grading the level of evidence. None of the trials were graded as providing high quality evidence primarily because there was no replication of results in other trials in other settings. Authors' conclusions In keeping with previous World Health Organization (WHO) recommendations everything possible should be done to promote and support adequate dietary intake of micronutrients, while recognising that this may not be sufficient to correct specific micronutrient deficiencies in all HIV‐infected individuals. Specific recommendations for pregnant and lactating women infected with HIV would be to include the provision of multivitamin supplements in single RDA formulations during the antenatal period and at least for 6 weeks post‐partum, especially for women who are breast‐feeding. There is no conclusive evidence to provide stand‐alone zinc or selenium supplementation to HIV‐infected pregnant and lactating women. Micronutrient supplementation should not be used as a substitute for provision of recommended antiretroviral medication for preventing mother‐to‐child transmission of HIV and treating maternal HIV infection when this is recommended. Further trials of single supplements are required to build the evidence base. The long‐term clinical benefits, adverse effects, and optimal formulation of multiple micronutrient supplements require further investigation in pregnant women at different stages of HIV infection. Plain language summary Micronutrient supplementation interventions to reduce harm in pregnant and lactating women living with HIV Micronutrients are vital components of a person’s daily food intake. Though only a small portion is necessary, a lack of micronutrients has been linked to tiredness, anaemia (low iron in blood), reduced learning ability, weaker immune system, and night blindness. In pregnant women, inadequate micronutrients have been shown to affect the development of the foetus and also the well‐being of the mother. In regions with high HIV prevalence, food availability may be scarce, which could lead to a double burden of disease in vulnerable/at‐risk populations. Specifically, pregnant and lactating women living with HIV may encounter the challenge of adequate food (including micronutrients) consumption, a weakened immune system, and the nutritional demands of a growing foetus or child. In this review, four randomised controlled trials, conducted between 1995 and 2006, assessed the benefits of micronutrient supplementation. The trials took place in an urban setting in hospital‐based antenatal clinics, with participants being pregnant women who ranged between 12‐27 weeks of their pregnancy, and sample sizes ranging from 400 to 1129 participants. Multiple micronutrient supplements improved the health of pregnant women and their offspring. No significant adverse effects were reported. Zinc supplementation did not show any significant beneficcial effects. Although it did not have any effect on the mother's pregnancy or her HIV disease, supplementation with selenium may increase the likelihood of a child surviving, and may reduce the likelihood of the mothers having diarrhoea. However, there is not enough evidence to determine the effect of micronutrient supplementation to pregnant women living with HIV who are being treated with antiretroviral medications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Siegfried, N; Irlam, JH; Visser, ME; Rollins, NN", "articleTypes": [], "doi": "10.1002/14651858.CD009755", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "78e536ce-c66a-4f26-93de-c6367084a769", "pmid": "", "title": "Cannabis‐based medicines and medical cannabis for adults with cancer pain", "imported": false, "abstract": "Abstract - Background Pain is a common symptom in people with cancer; 30% to 50% of people with cancer will experience moderate‐to‐severe pain. This can have a major negative impact on their quality of life. Opioid (morphine‐like) medications are commonly used to treat moderate or severe cancer pain, and are recommended for this purpose in the World Health Organization (WHO) pain treatment ladder. Pain is not sufficiently relieved by opioid medications in 10% to 15% of people with cancer. In people with insufficient relief of cancer pain, new analgesics are needed to effectively and safely supplement or replace opioids. Objectives To evaluate the benefits and harms of cannabis‐based medicines, including medical cannabis, for treating pain and other symptoms in adults with cancer compared to placebo or any other established analgesic for cancer pain. Search methods We used standard, extensive Cochrane search methods. The latest search date was 26 January 2023. Selection criteria We selected double‐blind randomised, controlled trials (RCT) of medical cannabis, plant‐derived and synthetic cannabis‐based medicines against placebo or any other active treatment for cancer pain in adults, with any treatment duration and at least 10 participants per treatment arm. Data collection and analysis We used standard Cochrane methods. The primary outcomes were 1. proportions of participants reporting no worse than mild pain; 2. Patient Global Impression of Change (PGIC) of much improved or very much improved and 3. withdrawals due to adverse events. Secondary outcomes were 4. number of participants who reported pain relief of 30% or greater and overall opioid use reduced or stable; 5. number of participants who reported pain relief of 30% or greater, or 50% or greater; 6. pain intensity; 7. sleep problems; 8. depression and anxiety; 9. daily maintenance and breakthrough opioid dosage; 10. dropouts due to lack of efficacy; 11. all central nervous system adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We identified 14 studies involving 1823 participants. No study assessed the proportions of participants reporting no worse than mild pain on treatment by 14 days after start of treatment. We found five RCTs assessing oromucosal nabiximols (tetrahydrocannabinol (THC) and cannabidiol (CBD)) or THC alone involving 1539 participants with moderate or severe pain despite opioid therapy. The double‐blind periods of the RCTs ranged between two and five weeks. Four studies with a parallel design and 1333 participants were available for meta‐analysis. There was moderate‐certainty evidence that there was no clinically relevant benefit for proportions of PGIC much or very much improved (risk difference (RD) 0.06, 95% confidence interval (CI) 0.01 to 0.12; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 8 to 100). There was moderate‐certainty evidence for no clinically relevant difference in the proportion of withdrawals due to adverse events (RD 0.04, 95% CI 0 to 0.08; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 16 to endless). There was moderate‐certainty evidence for no difference between nabiximols or THC and placebo in the frequency of serious adverse events (RD 0.02, 95% CI −0.03 to 0.07). There was moderate‐certainty evidence that nabiximols and THC used as add‐on treatment for opioid‐refractory cancer pain did not differ from placebo in reducing mean pain intensity (standardised mean difference (SMD) −0.19, 95% CI −0.40 to 0.02). There was low‐certainty evidence that a synthetic THC analogue (nabilone) delivered over eight weeks was not superior to placebo in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and non‐small cell lung cancer (2 studies, 89 participants, qualitative analysis). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that synthetic THC analogues were superior to placebo (SMD −0.98, 95% CI −1.36 to −0.60), but not superior to low‐dose codeine (SMD 0.03, 95% CI −0.25 to 0.32; 5 single‐dose trials; 126 participants) in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours (2 single‐dose trials; 66 participants). Analyses of tolerability and safety were not possible for these studies. There was low‐certainty evidence that CBD oil did not add value to specialist palliative care alone in the reduction of pain intensity in people with advanced cancer. There was no difference in the number of dropouts due to adverse events and serious adverse events (1 study, 144 participants, qualitative analysis). We found no studies using herbal cannabis. Authors' conclusions There is moderate‐certainty evidence that oromucosal nabiximols and THC are ineffective in relieving moderate‐to‐severe opioid‐refractory cancer pain. There is low‐certainty evidence that nabilone is ineffective in reducing pain associated with (radio‐) chemotherapy in people with head and neck cancer and non‐small cell lung cancer. There is low‐certainty evidence that a single dose of synthetic THC analogues is not superior to a single low‐dose morphine equivalent in reducing moderate‐to‐severe cancer pain. There is low‐certainty evidence that CBD does not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. Plain language summary Cannabis‐based medicines for cancer pain Do medicines based on cannabis help adults with cancer pain? Key messages Cannabis‐based medicines (CbMs) did not relieve cancer pain that did not respond to morphine‐like medicines. The studies analysed did not allow any statement to be made on the place of these medications in the World Health Organization (WHO) analgesic ladder for cancer pain. Trials with CbMs in cancer need to be very much better designed than those conducted so far. Pain in cancer and its treatment One person in two or three who gets cancer will have pain that becomes moderate or severe in intensity. The pain tends to get worse as the cancer progresses. The WHO recommends taking morphine‐like medicines for moderate‐to‐severe pain from cancer, but 1 in 6 to 10 people with cancer pain do not experience sufficient pain relief from morphine‐like medicines. Several products based on the cannabis plant have been suggested as treatment for cancer pain. These products include inhaled or orally ingested herbal cannabis, and various oils, sprays or tablets containing active cannabis ingredients obtained from the plant, or made synthetically. Some people with cancer pain have reported that CbMs are effective for them, and that is often highlighted in the media. What did we want to find out? If CbMs relieved cancer pain in people living with cancer. If CbMs were associated with any unwanted or harmful effects. What did we do? We searched for clinical trials that examined CbMs compared to other medications to treat cancer pain in adults. We summarised the results of the studies and rated our confidence in the evidence, based on factors such as the methods and size of studies. What did we find? We found 14 studies involving 1823 people. The biggest study included 399 people and the smallest study included 10 people. Studies were conducted in countries around the world; most (six) were based in North America. Five studies used one dose of CbM and lasted less than one day. Other studies lasted between two and eight weeks. Pharmaceutical companies funded seven studies. Six studies compared a mouth spray with a plant‐derived combination of tetrahydrocannabinol (THC), the principal psychoactive constituent of cannabis, and cannabidiol (CBD), an anti‐inflammatory ingredient of cannabis, against a fake medication (placebo). Seven studies compared an artificial cannabinoid mimicking the effects of THC against placebo. Of these seven studies, two studies compared against a morphine‐like medication (codeine), too. One study compared CBD against placebo. We did not find studies with herbal cannabis. Main results Mouth spray with a plant‐derived combination of THC and CBD was probably not better than placebo in reducing pain in people with moderate‐to‐severe cancer pain despite opioid treatment. Thirty‐two out of 100 people reported to be much or very much improved by cannabis‐based mouth spray and 23 out of 100 people with mouth spray with placebo. A total of 19 out of 100 people withdrew early because of side effects by cannabis‐based mouth spray and 16 out of 100 people by mouth spray with placebo. There was no difference in serious side effects between the cannabis‐based mouth spray and a placebo mouth spray. Artificial cannabinoid mimicking the effects of THC may not be better than a fake medication in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and a certain type of lung cancer. A single dose of an artificial cannabinoid mimicking the effects of THC may be better than a single dose of placebo, but may not differ from a single small dose of a morphine‐like medication in reducing moderate‐to‐severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours. CBD may not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer. We found no studies with medical cannabis. What are the limitations of the evidence? We are moderately confident in the evidence that a mouth spray with a plant‐derived combination of THC and CBD does not reduce severe cancer pain despite opioid treatment because studies did not provide information about everything that we could have used. We have little confidence in the evidence that an artificial cannabinoid mimicking the effects of THC (nabilone) does not reduce pain associated with chemotherapy or radiochemotherapy because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that artificial cannabinoids mimicking the effects of THC reduce cancer pain after the previous pain‐relieving medication was stopped some hours before because the studies did not provide data about everything that we could have used, and because the studies were small. We have little confidence in the evidence that CBD added to standard palliative care does not reduce cancer pain because there was only one study available. How up to date is the evidence? The evidence is up to date to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Häuser, W, Welsch, P, Radbruch, L, Fisher, E, Bell, RF, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD014915.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.088Z" }, { "id": "78efbed7-f6a9-40f9-85eb-21f9308a3a82", "pmid": "", "title": "Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Subcutaneous administration may be preferable to oral for individuals experiencing nausea and/or vomiting Objectives To determine the efficacy and tolerability of subcutaneous sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using subcutaneous sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Thirty‐five studies (9365 participants) compared subcutaneous sumatriptan with placebo or an active comparator. Most of the data were for the 6 mg dose. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 6 mg versus placebo the NNTs were 2.9, 2.3, 2.2, and 2.1 for pain‐free at one and two hours, and headache relief at one and two hours, respectively, and 6.1 for sustained pain‐free at 24 hours. Results for the 4 mg and 8 mg doses were similar to the 6 mg dose, with 6 mg significantly better than 4 mg only for pain‐free at one hour, and 8 mg significantly better than 6 mg only for headache relief at one hour. There was no evidence of increased migraine relief if a second dose of sumatriptan 6 mg was given after an inadequate response to the first. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Sumatriptan was compared directly with a number of active treatments, including other triptans, acetylsalicylic acid plus metoclopramide, and dihydroergotamine, but there were insufficient data for any pooled analyses. Authors' conclusions Subcutaneous sumatriptan is effective as an abortive treatment for acute migraine attacks, quickly relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a subcutaneous injection, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, or needing fast relief. This review found that a single subcutaneous dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in almost 6 in 10 people (59%) taking sumatriptan 6 mg, compared with about 1 in 7 (15%) taking placebo, and reduced from moderate or severe to no worse than mild pain by two hours in almost 8 in 10 people (79%) taking sumatriptan compared with about 3 in 10 (31%) taking placebo. Subcutaneous sumatriptan was fast‐acting, and the majority of people experiencing pain relief had done so by one hour. About 3 in 10 (31%) people had freedom from pain at two hours which was sustained during the 24 hours postdose without the use of rescue medication, compared with about 1 in 7 (15%) with placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events, most of which were of short duration and mild or moderate in severity, were more frequent with sumatriptan than with placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009665", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "791dfde3-b1df-498c-ad48-2e9719e35a2a", "pmid": "", "title": "Interventions for oropharyngeal dysphagia in children with neurological impairment", "imported": false, "abstract": "Abstract - Background Oropharyngeal dysphagia encompasses problems with the oral preparatory phase of swallowing (chewing and preparing the food), oral phase (moving the food or fluid posteriorly through the oral cavity with the tongue into the back of the throat) and pharyngeal phase (swallowing the food or fluid and moving it through the pharynx to the oesophagus). Populations of children with neurological impairment who commonly experience dysphagia include, but are not limited to, those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). Objectives To examine the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. Search methods We searched the following electronic databases in October 2011: CENTRAL 2011(3), MEDLINE (1948 to September Week 4 2011), EMBASE (1980 to 2011 Week 40)
, CINAHL (1937 to current)
, ERIC (1966 to current), PsycINFO (1806 to October Week 1 2011), Science Citation Index (1970 to 7 October 2011), Social Science Citation Index (1970 to 7 October 2011), Cochrane Database of Systematic Reviews, 2011(3), DARE 2011(3), Current Controlled Trials (ISRCTN Register) (15 October 2011), ClinicalTrials.gov (15 October 2011) and WHO ICTRP (15 October 2011). We searched for dissertations and theses using Networked Digital Library of Theses and Dissertations, Australasian Digital Theses Program and DART‐Europe E‐theses Portal (11 October 2011). Finally, additional references were also obtained from reference lists from articles. Selection criteria The review included randomised controlled trials and quasi‐randomised controlled trials for children with oropharyngeal dysphagia and neurological impairment. Data collection and analysis All three review authors (AM, PD and EW) independently screened titles and abstracts for inclusion and discussed results. In cases of uncertainty over whether an abstract met inclusion criterion, review authors obtained the full‐text article and independently evaluated each paper for inclusion. The data were categorised for comparisons depending on the nature of the control group (for example, oral sensorimotor treatment versus no treatment). Effectiveness of the oropharyngeal dysphagia intervention was assessed by considering primary outcomes of physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency a child is able to consume. Secondary outcomes were changes in growth, child’s level of participation in the mealtime routine and the level of parent or carer stress associated with feeding. Main results Three studies met the inclusion criteria for the review. Two studies were based on oral sensorimotor interventions for participants with cerebral palsy compared to standard care and a third study trialled lip strengthening exercises for children with myotonic dystrophy type 1 compared to no treatment ( Sjogreen 2010 ). A meta‐analysis combining results across the three studies was not possible because one of the studies had participants with a different condition, and the remaining two, although using oral sensorimotor treatments, used vastly different approaches with different intensities and durations. The decision not to combine these was in line with our protocol. In this review, we present the results from individual studies for four outcomes: physiological functions of the oropharyngeal mechanism for swallowing, the presence of chest infection and pneumonia, diet consistency, and changes in growth. However, it is not possible to reach definitive conclusions on the effectiveness of particular interventions for oropharyngeal dysphagia based on these studies. One study had a high risk of attrition bias owing to missing data, had statistically significant differences (in weight) across experimental and control groups at baseline, and did not describe other aspects of the trial sufficiently to enable assessment of other potential risks of bias. Another study was at high risk of detection bias as some outcomes were assessed by parents who knew whether their child was in the intervention or control group. The third study overall seemed to be at low risk of bias, but like the other two studies, suffered from a small sample size. Authors' conclusions The review demonstrates that there is currently insufficient high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials to provide conclusive results about the effectiveness of any particular type of oral‐motor therapy for children with neurological impairment. There is an urgent need for larger‐scale (appropriately statistically powered), randomised trials to evaluate the efficacy of interventions for oropharyngeal dysphagia. Plain language summary Interventions for swallowing difficulty in children with neurological impairment Oropharyngeal dysphagia, or swallowing difficulty, can be defined as problems with chewing and preparing food, difficulty moving food through the mouth to the back of the tongue, and difficulty with swallowing and movement of food through the 'throat' or pharynx. Many children with neurological impairment experience swallowing difficulties, including those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). This review examined the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. The three studies included in the review examined oral sensorimotor treatments and lip strengthening interventions. We were interested in three primary outcomes, which were physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency, and three secondary outcomes, which were changes in growth, child's level of participation in the mealtime routine, and the level of parent or carer stress associated with feeding. We concluded that there is currently not enough high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials for any particular type of oropharyngeal dysphagia intervention in this population of children. There is a need for larger‐scale randomised controlled trials to evaluate the effects of interventions for oropharyngeal dysphagia in children with neurological impairment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Morgan, AT; Dodrill, P; Ward, EC", "articleTypes": [], "doi": "10.1002/14651858.CD009456.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "79502ee4-04d1-4d1e-b6ab-b0dd0e278714", "pmid": "", "title": "Topical lidocaine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Lidocaine is a local anaesthetic that is sometimes used on the skin to treat neuropathic pain. Objectives To assess the analgesic efficacy of topical lidocaine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 1 July 2014, together with the reference lists of retrieved papers and other reviews. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal to identify additional published or unpublished data. Selection criteria We included randomised, double‐blind studies of at least two weeks' duration comparing any formulation of topical lidocaine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts; at least 200 participants in the comparison, 8 to 12 weeks' duration, parallel design); second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison; and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. Main results We included 12 studies (508 participants) in comparisons with placebo or an active control. Six studies enrolled participants with moderate or severe postherpetic neuralgia, and the remaining studies enrolled different, or mixed, neuropathic pain conditions, including trigeminal neuralgia and postsurgical or post‐traumatic neuralgia. Four different formulations were used: 5% medicated patch, 5% cream, 5% gel, and 8% spray. Most studies used a cross‐over design, and two used a parallel‐group design. Two studies used enriched enrolment with randomised withdrawal. Seven studies used multiple doses, with one to four‐week treatment periods, and five used single applications. We judged all of the studies at high risk of bias because of small size or incomplete outcome assessment, or both. There was no first or second tier evidence, and no pooling of data was possible for efficacy outcomes. Only one multiple‐dose study reported our primary outcome of participants with ≥ 50% or ≥ 30% pain intensity reduction. Three single‐dose studies reported participants who were pain‐free at a particular time point, or had a 2‐point (of 10) reduction in pain intensity. The two enriched enrolment, randomised withdrawal studies reported time to loss of efficacy. In all but one study, third tier (very low quality) evidence indicated that lidocaine was better than placebo for some measure of pain relief. Pooling multiple‐dose studies across conditions demonstrated no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals, but there were few events and the withdrawal phase of enriched enrolment designs is not suitable to assess the true impact of adverse events (very low quality evidence). Authors' conclusions This review found no evidence from good quality randomised controlled studies to support the use of topical lidocaine to treat neuropathic pain, although individual studies indicated that it was effective for relief of pain. Clinical experience also supports efficacy in some patients. Several large ongoing studies, of adequate duration, with clinically useful outcomes should provide more robust conclusions about both efficacy and harm. Plain language summary Topical lidocaine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It differs from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are usually not effective in neuropathic pain, while medicines that are sometimes used to treat epilepsy or depression can be very effective in some people with neuropathic pain. Other possible treatments include the use of local anaesthetic applied to the skin. Lidocaine is a local anaesthetic. It is available in plasters (or patches), sprays, and creams, as topical lidocaine. These contain high concentrations of lidocaine because it crosses the skin poorly. Treatment with plasters usually involves applying one, two, or three plasters for up to 12 hours a day. In July 2014 we performed searches to look for clinical trials where topical lidocaine was used to treat neuropathic pain. We found 12 small studies of modest quality that tested topical lidocaine against topical placebo for a number of weeks. One study also tested a cream containing amitriptyline, which is an antidepressant. The 508 people in the studies had different types of neuropathic pain, with pain after herpes zoster infection the most common. There was some indication that topical lidocaine was beneficial in these studies (very low quality evidence). There was no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals (very low quality evidence). A number of studies of topical lidocaine in neuropathic pain are ongoing. Several are large and of long duration. They will be of great help in working out the benefits of topical lidocaine when they are completed and results can be incorporated in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Derry, S, Wiffen, PJ, Moore, RA, Quinlan, J", "articleTypes": [], "doi": "10.1002/14651858.CD010958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.773Z" }, { "id": "7972ff17-e2ac-40cb-a65e-d64eeac80d06", "pmid": "", "title": "Vigabatrin add‐on therapy for drug‐resistant focal epilepsy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane Review published in 2008 and updated in 2013. Epilepsy is a common neurological condition which affects up to 1% of the population. Approximately 30% of people with epilepsy do not respond to treatment with currently available drugs. The majority of these people have focal epilepsy. Vigabatrin is an antiepileptic drug licensed for use in drug‐resistant epilepsy. Objectives To assess the efficacy and tolerability of vigabatrin as an add‐on therapy for people with drug‐resistant focal epilepsy. Search methods For the latest update of this review, we searched the following databases on 1 November 2018: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid 1946 to 31 October 2018), ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL) are both included in the Cochrane Register of Studies (CRS Web). We checked reference lists of retrieved studies for additional reports of relevant studies and contacted Hoechst Marion Roussel (manufacturers of vigabatrin) in 2000. Selection criteria We included randomised, double‐blind, placebo‐controlled, fully published trials of vigabatrin in people of any age with drug‐resistant focal epilepsy. Data collection and analysis Two review authors assessed trials for inclusion and extracted data using the standard methodological procedures expected by Cochrane. Primary analysis was by intention‐to‐treat (ITT). We evaluated: 50% or greater reduction in seizure frequency, treatment withdrawal, adverse effects, dose‐response analysis, cognitive outcomes and quality of life. We presented results as risk ratios (RR) with 95% or 99% confidence intervals (CI). Main results We identified 11 trials that included 756 participants (age range: 10 to 64 years). The trials tested vigabatrin doses between 1 g/day and 6 g/day. All 11 trials displayed a risk of bias across at least three risk of bias domains. Predominantly, the risk of bias was associated with: allocation concealment (selection bias), blinding of outcome assessment (detection bias) and incomplete outcome data (attrition bias). Participants treated with vigabatrin may be two to three times more likely to obtain a 50% or greater reduction in seizure frequency compared with those treated with placebo (RR 2.60, 95% CI 1.87 to 3.63; 4 studies; low‐certainty evidence). Those treated with vigabatrin may also be three times more likely to have treatment withdrawn although we are uncertain (RR 2.86, 95% CI 1.25 to 6.55; 4 studies; very low‐certainty evidence). Compared to placebo, participants given vigabatrin were more likely to experience adverse effects: dizziness/light‐headedness (RR 1.74, 95% CI 1.05 to 2.87; 9 studies; low‐certainty evidence), fatigue (RR 1.65, 95% CI 1.08 to 2.51; 9 studies; low‐certainty evidence), drowsiness (RR 1.70, 95% CI 1.18 to 2.44; 8 studies) and depression (RR 3.28, 95% CI 1.30 to 8.27; 6 studies). Although the incidence rates were higher among participants receiving vigabatrin compared to those receiving placebo, the effect was not significant for the following adverse effects: ataxia (RR 2.76, 95% CI 0.96 to 7.94; 7 studies; very low‐certainty evidence), nausea (RR 3.57, 95% CI 0.63 to 20.30; 4 studies), abnormal vision (RR 1.64, 95% CI 0.67 to 4.02; 5 studies; very low‐certainty evidence), headache (RR 1.23, 95% CI 0.79 to 1.92; 9 studies), diplopia (RR 1.76, 99% CI 0.94 to 3.30) and nystagmus (RR 1.53, 99% CI 0.62 to 3.76; 2 studies; low‐certainty evidence). Vigabatrin had little to no effect on cognitive outcomes or quality of life. Authors' conclusions Vigabatrin may significantly reduce seizure frequency in people with drug‐resistant focal epilepsy. The results largely apply to adults and should not be extrapolated to children under 10 years old. Short‐term follow‐up of participants showed that some adverse effects were associated with its use. Analysis of longer‐term observational studies elsewhere, however, has demonstrated that vigabatrin use can lead to the development of visual field defects. Plain language summary Vigabatrin add‐on for drug‐resistant focal epilepsy Background Epilepsy is a common neurological disorder affecting approximately 1 in 100 people. Around 30% of these people cannot control their epilepsy with currently available antiepileptic medication and are said to have drug‐resistant epilepsy. Most often, drug‐resistant epilepsy is focal in nature, meaning that the seizures start in one specific area of the brain. Vigabatrin is an antiepileptic medication that can be used as an add‐on treatment for drug‐resistant focal epilepsy, meaning that it is taken in addition to other antiepileptic medications. Main results We found 11 clinical trials, involving 756 people, which investigated vigabatrin as an add‐on for people with drug‐resistant focal epilepsy. The people in the trials were aged between 10 to 64 years and were given doses of 1 g/day to 6 g/day vigabatrin. We found that people given vigabatrin may be two to three times more likely to experience a 50% or greater reduction in seizure frequency than people given placebo (a non‐active treatment). We also suggest that people given vigabatrin may be up to three times more likely to stop treatment than people given placebo. People given vigabatrin were more likely to experience side effects: dizziness/light‐headedness, fatigue, drowsiness and depression, than people given placebo. However, the evidence suggested that they should not be more likely to experience: ataxia (disorders that affect co‐ordination, balance and speech), feeling sick (nausea), abnormal vision, headache, seeing double (diplopia), or involuntary movement of the eyes (nystagmus) than people given placebo. Reliability of the evidence We judged that all studies had significant risk of bias. The studies did not explain how people were allocated to treatment groups and did not say whether investigators knew which treatment people were receiving. Alongside other reasons, this reduced our confidence (certainty) in the results. Overall, we are uncertain to very uncertain whether the results we have reported are reliable. The true effect of vigabatrin could be significantly different to that reported here. Conclusions Vigabatrin may significantly reduce seizure frequency for people with drug‐resistant focal epilepsy but we are uncertain. Most of the evidence was gathered from adults, therefore, the effects of vigabatrin could be different in children. All of the included trials were of short duration; therefore, we cannot report any long‐term effects of vigabatrin. Importantly, reviews of long‐term studies have reported that long‐term vigabatrin use can lead to the development of visual problems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bresnahan, R; Gianatsi, M; Maguire, MJ; Tudur Smith, C; Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "7994d226-90c1-4869-a6dd-c6fbd5791ac8", "pmid": "", "title": "Antibiotics for community‐acquired pneumonia in adult outpatients", "imported": false, "abstract": "Abstract - Background Lower respiratory tract infection (LRTI) is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Community‐acquired pneumonia (CAP) is a common condition that causes a significant disease burden for the community, particularly in children younger than five years, the elderly and immunocompromised people. Antibiotics are the standard treatment for CAP. However, increasing antibiotic use is associated with the development of bacterial resistance and side effects for the patient. Several studies have been published regarding optimal antibiotic treatment for CAP but many of these data address treatments in hospitalised patients. This is an update of our 2009 Cochrane Review and addresses antibiotic therapies for CAP in outpatient settings. Objectives To compare the efficacy and safety of different antibiotic treatments for CAP in participants older than 12 years treated in outpatient settings with respect to clinical, radiological and bacteriological outcomes. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (January 1966 to March week 3, 2014), EMBASE (January 1974 to March 2014), CINAHL (2009 to March 2014), Web of Science (2009 to March 2014) and LILACS (2009 to March 2014). Selection criteria We looked for randomised controlled trials (RCTs), fully published in peer‐reviewed journals, of antibiotics versus placebo as well as antibiotics versus another antibiotic for the treatment of CAP in outpatient settings in participants older than 12 years of age. However, we did not find any studies of antibiotics versus placebo. Therefore, this review includes RCTs of one or more antibiotics, which report the diagnostic criteria and describe the clinical outcomes considered for inclusion in this review. Data collection and analysis Two review authors (LMB, TJMV) independently assessed study reports in the first publication. In the 2009 update, LMB performed study selection, which was checked by TJMV and MMK. In this 2014 update, two review authors (SP, SM) independently performed and checked study selection. We contacted trial authors to resolve any ambiguities in the study reports. We compiled and analysed the data. We resolved differences between review authors by discussion and consensus. Main results We included 11 RCTs in this review update (3352 participants older than 12 years with a diagnosis of CAP); 10 RCTs assessed nine antibiotic pairs (3321 participants) and one RCT assessed four antibiotics (31 participants) in people with CAP. The study quality was generally good, with some differences in the extent of the reporting. A variety of clinical, bacteriological and adverse events were reported. Overall, there was no significant difference in the efficacy of the various antibiotics. Studies evaluating clarithromycin and amoxicillin provided only descriptive data regarding the primary outcome. Though the majority of adverse events were similar between all antibiotics, nemonoxacin demonstrated higher gastrointestinal and nervous system adverse events when compared to levofloxacin, while cethromycin demonstrated significantly more nervous system side effects, especially dysgeusia, when compared to clarithromycin. Similarly, high‐dose amoxicillin (1 g three times a day) was associated with higher incidence of gastritis and diarrhoea compared to clarithromycin, azithromycin and levofloxacin. Authors' conclusions Available evidence from recent RCTs is insufficient to make new evidence‐based recommendations for the choice of antibiotic to be used for the treatment of CAP in outpatient settings. Pooling of study data was limited by the very low number of studies assessing the same antibiotic pairs. Individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups. However, two studies did find significantly more adverse events with use of cethromycin as compared to clarithromycin and nemonoxacin when compared to levofloxacin. Multi‐drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations. Further studies focusing on diagnosis, management, cost‐effectiveness and misuse of antibiotics in CAP and LRTI are warranted in high‐, middle‐ and low‐income countries. Plain language summary Antibiotics for community‐acquired pneumonia in adolescent and adult outpatients Review question This review studied the effects of antibiotics on adolescents and adults with pneumonia acquired and treated in the community (as opposed to acquiring pneumonia in hospital and/or being treated for pneumonia in hospital). The evidence is current to March 2014. Background Lower respiratory tract infection is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Pneumonia, or infection of the lungs, is a common condition representing a significant disease burden for the community. Pneumonia is especially life‐threatening in children younger than five years, in older people and in people with other illnesses that may affect their immune system (such as diabetes or HIV/AIDS, or solid organ transplant recipients). Antibiotics are the most common treatment for pneumonia and these can vary in their effectiveness and adverse effects. Study characteristics We identified 11 trials (with 3352 participants older than 12 years with a diagnosis of community‐acquired pneumonia), fully published in peer‐reviewed journals, focused on treatment of pneumonia in adolescents and adults treated in the community in outpatient settings. This included five new trials included since our last review published in 2009. None of the trials included antibiotics versus placebo; all trials included one or more antibiotics. All participants were diagnosed with pneumonia based upon clinical diagnosis by the physician and chest X‐ray. Study funding sources All included trials were well conducted; nine of the 11 trials were sponsored by bio‐pharmaceutical companies manufacturing the antibiotics used in the study, or their authors were closely linked with the company. Key results Nine of the included trials compared different antibiotics and, hence, we could not combine the results of the individual trials to present our overall conclusion. There were some notable adverse events in seven studies: 1) erythromycin demonstrated significant gastrointestinal side effects compared to clarithromycin in two studies; 2) nemonoxacin demonstrated higher gastrointestinal (nausea, diarrhoea) and nervous system (dizziness, headache) adverse events compared to levofloxacin; 3) cethromycin demonstrated more side effects, especially a distortion of the sense of taste, than clarithromycin; 4) gastritis and diarrhoea were more common in the high‐dose amoxicillin group (1 g three times a day) compared to the other three antibiotic groups (clarithromycin, azithromycin and levofloxacin). Conclusion Unfortunately, there were not enough trials to compare the effects of different antibiotics for pneumonia acquired and treated in the community.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Pakhale, S; Mulpuru, S; Verheij, TJM; Kochen, MM; Rohde, GGU; Bjerre, LM", "articleTypes": [], "doi": "10.1002/14651858.CD002109.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "799b6388-79d2-4deb-8ead-e747ee0cda37", "pmid": "", "title": "Surgical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Surgical treatment of chronic rhinosinusitis with nasal polyps is an established treatment for medically resistant nasal polyp disease. Whether a nasal polypectomy with additional sinus dissection offers any advantage over an isolated nasal polypectomy has not been systematically reviewed. Objectives To assess the effectiveness of simple polyp surgery versus more extensive surgical clearance in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 1); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised and quasi‐randomised controlled trials in patients over 16 with chronic rhinosinusitis with nasal polyps, who have failed a course of medical management and who have not previously undergone any previous surgical intervention for their nasal disease. Studies compared nasal polypectomy with more extensive sinus clearance in this patient cohort. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no trials which met our inclusion criteria. Six controlled trials (five randomised) met some but not all of the inclusion criteria and were therefore excluded from the review. Authors' conclusions We are unable to reach any conclusions as to whether isolated nasal polypectomy or more extensive sinus surgery is a superior surgical treatment modality for chronic rhinosinusitis with nasal polyps. There is a need for high‐quality randomised controlled trials to assess whether additional sinus surgery confers any benefit when compared to nasal polypectomy performed in isolation. Plain language summary Surgical interventions for chronic rhinosinusitis with nasal polyps Background Benign nasal polyps are abnormal tissue growths inside the nasal passages and sinuses, often on both sides of the nose. They can cause a wide array of symptoms including blocked nose, poor sense of smell that can lead to a loss of taste, runny nose and nasal congestion. Sinuses are air‐filled cavities in the bones of the face, which are in continuity with the nasal passages. The first‐line treatment for nasal polyps is usually medical therapy in the form of steroids ‐ as sprays (topically) or by mouth (orally). In patients where this treatment has failed to relieve the symptoms, the polyps can be removed surgically. These surgical procedures are often not curative and patients may need to continue medical therapy or undergo further surgeries. A number of well‐established surgical techniques can be used to remove polyps. What has not been established is whether removing the nasal polyps and clearing out the sinuses offers any advantage in the control of the disease when compared to simply removing the polyps and leaving the sinuses unchanged. We sought evidence in the literature to establish whether there was any difference in patients who underwent nasal polyp removal alone versus those who had nasal polyps removed as well as opening up of the sinuses. Study characteristics No trials met our inclusion criteria. We did identify six controlled trials (five of which were randomised) in which some but not all of our inclusion criteria were met, but we had to exclude these studies from the review. Key results No trials met our inclusion criteria. Quality of evidence At present, we cannot comment on whether taking nasal polyps out alone or also opening up the sinuses at the same time is a better treatment for patients with this disease. There is a need for high‐quality randomised controlled trials to answer this question. This evidence is current to February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Sharma, R, Lakhani, R, Rimmer, J, Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.775Z" }, { "id": "79a57bf0-6850-49aa-9bac-e9e1b9571baf", "pmid": "", "title": "Pharmacological interventions for preventing dry mouth and salivary gland dysfunction following radiotherapy", "imported": false, "abstract": "Abstract - Background Salivary gland dysfunction is an 'umbrella' term for the presence of either xerostomia (subjective sensation of dryness), or salivary gland hypofunction (reduction in saliva production). It is a predictable side effect of radiotherapy to the head and neck region, and is associated with a significant impairment of quality of life. A wide range of pharmacological interventions, with varying mechanisms of action, have been used for the prevention of radiation‐induced salivary gland dysfunction. Objectives To assess the effects of pharmacological interventions for the prevention of radiation‐induced salivary gland dysfunction. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 14 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 14 September 2016); MEDLINE Ovid (1946 to 14 September 2016); Embase Ovid (1980 to 14 September 2016); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 14 September 2016); LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 14 September 2016); Zetoc Conference Proceedings (1993 to 14 September 2016); and OpenGrey (1997 to 14 September 2016). We searched the US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials, irrespective of their language of publication or publication status. Trials included participants of all ages, ethnic origin and gender, scheduled to receive radiotherapy on its own or in addition to chemotherapy to the head and neck region. Participants could be outpatients or inpatients. We included trials comparing any pharmacological agent regimen, prescribed prophylactically for salivary gland dysfunction prior to or during radiotherapy, with placebo, no intervention or an alternative pharmacological intervention. Comparisons of radiation techniques were excluded. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 39 studies that randomised 3520 participants; the number of participants analysed varied by outcome and time point. The studies were ordered into 14 separate comparisons with meta‐analysis only being possible in three of those. We found low‐quality evidence to show that amifostine, when compared to a placebo or no treatment control, might reduce the risk of moderate to severe xerostomia (grade 2 or higher on a 0 to 4 scale) at the end of radiotherapy (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.19 to 0.67; P = 0.001, 3 studies, 119 participants), and up to three months after radiotherapy (RR 0.66, 95% CI 0.48 to 0.92; P = 0.01, 5 studies, 687 participants), but there is insufficient evidence that the effect is sustained up to 12 months after radiotherapy (RR 0.70, 95% CI 0.40 to 1.23; P = 0.21, 7 studies, 682 participants). We found very low‐quality evidence that amifostine increased unstimulated salivary flow rate up to 12 months after radiotherapy, both in terms of mg of saliva per 5 minutes (mean difference (MD) 0.32, 95% CI 0.09 to 0.55; P = 0.006, 1 study, 27 participants), and incidence of producing greater than 0.1 g of saliva over 5 minutes (RR 1.45, 95% CI 1.13 to 1.86; P = 0.004, 1 study, 175 participants). However, there was insufficient evidence to show a difference when looking at stimulated salivary flow rates. There was insufficient (very low‐quality) evidence to show that amifostine compromised the effects of cancer treatment when looking at survival measures. There was some very low‐quality evidence of a small benefit for amifostine in terms of quality of life (10‐point scale) at 12 months after radiotherapy (MD 0.70, 95% CI 0.20 to 1.20; P = 0.006, 1 study, 180 participants), but insufficient evidence at the end of and up to three months postradiotherapy. A further study showed no evidence of a difference at 6, 12, 18 and 24 months postradiotherapy. There was low‐quality evidence that amifostine is associated with increases in: vomiting (RR 4.90, 95% CI 2.87 to 8.38; P < 0.00001, 5 studies, 601 participants); hypotension (RR 9.20, 95% CI 2.84 to 29.83; P = 0.0002, 3 studies, 376 participants); nausea (RR 2.60, 95% CI 1.81 to 3.74; P < 0.00001, 4 studies, 556 participants); and allergic response (RR 7.51, 95% CI 1.40 to 40.39; P = 0.02, 3 studies, 524 participants). We found insufficient evidence (that was of very low quality) to determine whether or not pilocarpine performed better or worse than a placebo or no treatment control for the outcomes: xerostomia, salivary flow rate, survival, and quality of life. There was some low‐quality evidence that pilocarpine was associated with an increase in sweating (RR 2.98, 95% CI 1.43 to 6.22; P = 0.004, 5 studies, 389 participants). We found insufficient evidence to determine whether or not palifermin performed better or worse than placebo for: xerostomia (low quality); survival (moderate quality); and any adverse effects. There was also insufficient evidence to determine the effects of the following interventions: biperiden plus pilocarpine, Chinese medicines, bethanechol, artificial saliva, selenium, antiseptic mouthrinse, antimicrobial lozenge, polaprezinc, azulene rinse, and Venalot Depot (coumarin plus troxerutin). Authors' conclusions There is some low‐quality evidence to suggest that amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months postradiotherapy). However, it is less clear whether or not this effect is sustained to 12 months postradiotherapy. The benefits of amifostine should be weighed against its high cost and side effects. There was insufficient evidence to show that any other intervention is beneficial. Plain language summary Drugs for preventing dry mouth and problems with saliva after radiotherapy Review question To assess the effects of treatment with drugs in order to prevent damage to salivary glands following radiotherapy to the head and neck Background Problems with saliva production and salivary glands are a significant and mostly permanent side effect for people after radiotherapy treatment to the head and neck. When this occurs the condition is known as dry mouth or xerostomia. Dry mouth is not measurable and is a subjective or personal expression of how the mouth feels. It can have other causes and is a consequence of the production of less saliva or by the consistency of saliva. The rate of flow of saliva in an individual's mouth however can be measured. People who have dry mouth have a reduced quality of life. They can experience issues with taste and general discomfort, difficulties chewing, swallowing and speaking as well as tooth decay, thrush and other infections of the mouth. A wide range of drugs that work in different ways have been used to try and prevent problems with salivary glands caused by radiotherapy. Unfortunately there is currently not enough evidence to show which drugs or which type of drugs are most effective. Study characteristics The evidence in this review is current up to 14 September 2016. 39 studies were included with a total of 3520 participants. Participants were male and female, all ages and ethnic origins, out patients or in patients, who were scheduled to have radiation therapy with or without chemotherapy to the head and neck. Drugs included were any prescribed to prevent salivary gland problems and given before or during radiotherapy. Information was collected from the end of radiotherapy except for that about adverse effects. Different techniques for giving radiation treatment that might reduce damage were not included. The main outcomes measured were participant's own assessment of dry mouth and the measurement of salivary flow. Secondary outcomes measured included adverse or unwanted effects such as sweating, crying, watery discharge from the nose, diarrhoea and nausea. Key results There is some low‐quality evidence to suggest that the drug amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months after radiotherapy). However it is less clear whether or not this effect is sustained to 12 months after radiotherapy. The benefits of amifostine should be weighed against its high costs and side effects. Adverse effects of vomiting, low blood pressure, feeling of sickness and allergic response were all more frequent in those receiving amifostine. There was insufficient evidence to show that any other treatment is beneficial. Quality of the evidence The quality of evidence for amifostine was found to be low because of risk of bias, inconsistency and imprecision caused by the small number of studies in the comparison or sample size. A standardized scale for measuring participant's experience of dry mouth would in future allow comparison and pooling together of results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P, Glenny, AM, Hua, F, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD012744", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.756Z" }, { "id": "79a8294a-a1f0-4596-8984-14197b6f5444", "pmid": "", "title": "Lactobacillus Reuteri Versus Placebo in the Treatment and Prevention of Infantile Colic: a Clinical and Microbiological, Double-blind, Prospective, Randomised, Controlled Study", "imported": false, "abstract": "The purpose of this study is:", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "79b76b40-6186-4d60-9621-08b6868dff1b", "pmid": "", "title": "The Role of Sweet Taste Receptor Blockade on Intraduodenal Glucose- and Liquid Meal-stimulated Secretion of Satiation Peptides in Healthy Humans", "imported": false, "abstract": "The purpose of this study is to determine the functional significance of sweet taste receptors in the secretion of GI satiation peptides by using a specific sweet taste receptor antagonist to block sweet taste perception in the gastrointestinal tract.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.232Z" }, { "id": "79cee03e-cac9-4294-964b-935ea3fe8653", "pmid": "", "title": "Oral zinc for treating diarrhoea in children", "imported": false, "abstract": "Abstract - Background In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). Objectives To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, m RCT, and reference lists up to 30 September 2016. We also contacted researchers. Selection criteria Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery. Data collection and analysis Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses (using either a fixed‐effect or random‐effects model) and assessed heterogeneity. We assessed the certainty of the evidence using the GRADE approach. Main results Thirty‐three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoea There is currently not enough evidence from well‐conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized ( very low certainty evidence ). In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD −11.46 hours, 95% CI −19.72 to −3.19; 2581 children, 9 trials, low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD −26.39 hours, 95% CI −36.54 to −16.23; 419 children, 5 trials, high certainty evidence ). Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI −4.00 to 14.45; 1334 children, 2 trials, low certainty evidence ), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, low certainty evidence ). None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence ; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence ). Persistent diarrhoea In children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD −15.84 hours, 95% CI −25.43 to −6.24; 529 children, 5 trials, moderate certainty evidence ). Authors' conclusions In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency. 12 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (30 Sep, 2016) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Oral zinc supplementation for treating diarrhoea in children In low‐ and middle‐income countries, millions of children suffer from severe diarrhoea every year and many die from dehydration. Giving fluids by mouth (using an oral rehydration solution (ORS)) has been shown to save children's lives, but it has no effect on the length of time the children suffer with diarrhoea. Zinc supplementation could help reduce the duration and the severity of diarrhoea, and therefore have an additional benefit over ORS in reducing children mortality. What is oral zinc and how may it shorten the duration and severity of diarrhoea Zinc is usually given as zinc sulphate, zinc acetate, or zinc gluconate, which are all water‐soluble compounds. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend 10 mg to 20 mg of zinc per day for children with diarrhoea. There are several mechanism of action of zinc on acute diarrhoea, some of which are specific to the gastrointestinal system: zinc restores mucosal barrier integrity and enterocyte brush‐border enzyme activity, it promotes the production of antibodies and circulating lymphocytes against intestinal pathogens, and has a direct effect on ion channels, acting as a potassium channel blocker of adenosine 3‐5‐cyclic monophosphate‐mediated chlorine secretion. Cochrane researchers examined the evidence available up to 30 September 2016. What the evidence in the review suggests Thirty‐three trials that included 10,841 children met the inclusion criteria of this review. Among children with acute diarrhoea, we don't know if treating children with zinc has an effect on death or number of children hospitalized ( very low certainty evidence ). In children older than six months, zinc supplementation may shorten the average duration of diarrhoea by around half a day ( low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven ( moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day ( high certainty evidence ). Conversely, in children younger than six months, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea ( low certainty evidence ), or the number of children who still have diarrhoea on day seven ( low certainty evidence ). Zinc supplementation increased the risk of vomiting in both age groups ( moderate certainty evidence ). No other adverse effects were reported. Among children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours ( moderate certainty ) but it probably increases the risk of vomiting ( moderate certainty evidence ). In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lazzerini, M; Wanzira, H", "articleTypes": [], "doi": "10.1002/14651858.CD005436.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "79dec0a7-3d66-4ddb-a182-87d4a78eea90", "pmid": "", "title": "Antibiotics versus topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity. It is characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Antibiotics and antiseptics kill or inhibit the micro‐organisms that may be responsible for the infection. Antibiotics can be applied topically or administered systemically via the oral or injection route. Antiseptics are always directly applied to the ear (topically). Objectives To assess the benefits and harms of antibiotics versus antiseptics for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP). The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving adults and children who had chronic ear discharge of unknown cause or CSOM, where ear discharge had continued for more than two weeks. The intervention was any single, or combination of, antibiotic agent, whether applied topically (without steroids) or systemically. The comparison was any single, or combination of, topical antiseptic agent, applied as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The comparisons were 1. topical antiseptics compared to topical antibiotics, and 2. topical antiseptics compared to systemic antibiotics. We further separated these comparisons into those in which a. both groups of participants received aural toileting in addition to the intervention, or b. both groups received some other add‐on therapy treatment (such as systemic antibiotics) to both arms. Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This updated review included eight new studies. Overall, we identified 15 studies (2371 participants) across seven comparisons with antibiotics compared to acetic acid, aluminium acetate, boric acid, and povidone‐iodine. None of the included studies reported health‐related quality of life or serious complications. 1. Topical antibiotics (quinolones or aminoglycosides) versus topical antiseptic (acetic acid) We included seven studies (835 participants). Acetic acid may increase resolution of ear discharge when compared to aminoglycoside at one to two weeks (low‐certainty evidence). It is very uncertain whether acetic acid may increase resolution of ear discharge at one to two weeks when compared to topical quinolone. Results after four weeks were only presented narratively. It is very uncertain whether acetic acid may cause more ear pain, discomfort, local irritation, or combinations of these compared to topical antibiotics (aminoglycosides and quinolones) (risk ratio (RR) 0.20, 95% confidence interval (CI) 0.03 to 1.12; I 2 = 0%; 3 studies, 277 participants; very low‐certainty evidence). An additional two studies (350 participants) provided narrative results. There may be little to no difference in hearing between groups reported narratively (quinolones; low‐certainty evidence). The evidence is very uncertain for serious complications (aminoglycosides) or suspected ototoxicity (aminoglycosides) (very low‐certainty evidence). 2. Topical antibiotics (quinolones) versus topical antiseptic (boric acid) We included two studies (532 participants). Topical quinolones are likely to increase resolution of ear discharge at one to two weeks compared with boric acid ear drops (RR 1.86, 95% CI 1.48 to 2.35; 1 study, 411 participants; moderate‐certainty evidence). This means that one additional person will have resolution of ear discharge for every four people receiving topical antibiotics (compared with boric acid) at two weeks. No study reported results for ear discharge after four weeks. There may be less ear pain, discomfort, or irritation with quinolones compared with boric acid (RR 0.56, 95% CI 0.32 to 0.98; 2 studies, 510 participants; low‐certainty evidence). Suspected ototoxicity and serious complications were not reported. Topical quinolones may result in a greater improvement in mean hearing from baseline compared to topical boric acid (mean difference (MD) 2.79 decibels, 95% CI 0.48 to 5.10; 1 study, 390 participants; low‐certainty evidence), but this difference may not be clinically significant. 3. Topical antibiotics (quinolones) versus topical antiseptic (povidone‐iodine) We included one study (40 participants). It is very uncertain if there is a difference between quinolones and povidone‐iodine with respect to resolution of ear discharge at one to two weeks (RR 1.02, 95% CI 0.82 to 1.26; 1 RCT, 39 participants; very low‐certainty evidence). The study reported qualitatively that there were no differences between the groups for hearing and no participants developed ototoxic effects (very low‐certainty evidence). There were no results reported for resolution of ear discharge beyond four weeks; ear pain, discomfort, or irritation; or serious complications. 4. Topical antibiotics versus topical antiseptic (aluminium acetate) We included one study (51 participants; 60 ears) that presented results for resolution of ear discharge at two to four weeks results narratively. No other results were reported. 5. Other comparisons Five studies (966 participants) were assessed over an additional three comparisons; however, these results have not been included in the abstract. Authors' conclusions Treatment of CSOM with topical antibiotics (quinolones) likely results in an increase in resolution of ear discharge compared with boric acid at up to two weeks. There was limited evidence for the efficacy of other topical antibiotics or topical antiseptics and so we are unable to draw conclusions. Harmful effects were not well reported. Limitations of the review include lack of recent data, limitations in the quality of included studies, and limited information on certain population groups or interventions. Plain language summary Which are better, antibiotics or topical antiseptics, for treating chronic suppurative otitis media? Key message – There is limited evidence comparing topical antibiotics with topical antiseptics in people with swelling and infection of the middle ear (called chronic suppurative otitis media). The evidence is very uncertain whether antibiotics or topical antiseptics are more effective for reducing ear discharge, except that topical antibiotics are likely to be more effective than boric acid (an antiseptic). What is chronic suppurative otitis media? Chronic suppurative otitis media is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (where the eardrum has a hole or tear in it). The main symptoms of chronic suppurative otitis media are ear discharge (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Antibiotics (which kill bacteria) are the most commonly used treatment for chronic suppurative otitis media. Antibiotics can either be 'topical' (put into the ear canal as ear drops, ointments, sprays, or creams) or 'systemic' (taken either by mouth or by an injection into a muscle or vein). Topical antiseptics (antiseptics put directly into the ear as ear drops or powders) are a possible treatment for chronic suppurative otitis media. Both antibiotics and topical antiseptics kill or stop the growth of the germs that may be responsible for the infection. Antibiotics and topical antiseptics can be used on their own or added to other treatments for chronic suppurative otitis media, such as other antibiotics or ear cleaning (called aural toileting). It was important in this review to examine whether there were any unwanted effects from using antibiotics and antiseptics, such as irritation of the skin within the outer ear, which may cause discomfort, pain, or itching. Some antibiotics and antiseptics (such as alcohol) can also be toxic to the inner ear (called ototoxicity), which means that they may cause permanent hearing loss, dizziness, or ringing in the ear (called tinnitus). What was the aim of this review? We wanted to compare antibiotics and antiseptics for the treatment of chronic suppurative otitis media. In particular, we wanted to know whether they stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found 15 studies, which included 2371 people, that compared antibiotics to a variety of antiseptics (acetic acid, boric acid, povidone‐iodine, and aluminium acetate). One study recruited only children, two studies recruited only adults, and 12 studies included both adults and children. About 40 in every 100 people were females. We presented the main comparisons below. Comparison of antibiotics to acetic acid We included seven studies (835 people). We have little to no confidence in the evidence of whether topical antibiotics or acetic acid improved ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to boric acid We included two studies (532 people). Topical antibiotics (quinolones) are likely to be better than boric acid at reducing ear discharge after one to two weeks. There may also be less ear discomfort (pain, irritation, and bleeding). Topical quinolones may result in a greater improvement in hearing compared to topical boric acid, but this difference may be too small for the person to notice a difference. Comparison of antibiotics to povidone‐iodine We included one study (40 people). We have little to no confidence in the evidence of whether topical or systemic antibiotics or povidone‐iodine improve the resolution of ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to aluminium acetate We included one study (51 people) that stated there was improvement in ear discharge at two to four weeks, but they did not present their results in a way that we could use. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. What are the limitations of the evidence? The studies were small with many being poorly reported, and results varied widely between studies. We also need more information about harmful effects. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K, Chong, LY, Bhutta, MF, Daw, J, Veselinović, T, Morris, PS, Vijayasekaran, S, Schilder, AGM, Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013056.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.749Z" }, { "id": "79dfd885-44ef-466c-8bf5-ac603c1c60de", "pmid": "", "title": "Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is the most common life‐limiting autosomal recessive genetic disorder in white populations. Distal intestinal obstruction syndrome (DIOS) is an important morbidity in cystic fibrosis. It is the result of the accumulation of viscid faecal material within the bowel which combines with thick, sticky mucus produced in the intestines of people with cystic fibrosis. The intestine may be completely blocked (complete DIOS) or only partially blocked (incomplete DIOS). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the acute complete or incomplete faecal obstruction and ultimately prevent the need for surgical intervention . Objectives This review aimed to evaluate the effectiveness and safety of different treatment regimens for the treatment of DIOS (complete and incomplete) in children and adults with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials (including cross‐over trials (to be judged on an individual basis)) comparing the use of laxative agents or surgery for treating DIOS in children, young people and adults with cystic fibrosis to each other, placebo or no intervention. Data collection and analysis Two authors independently screened papers, extracted trial details and assessed for risk of bias. The authors assessed the quality of evidence using GRADE. Main results There was one trial with 20 participants (16 females) included in the review. The mean age of participants was 13.1 years. The trial was a double‐blinded, randomised cross‐over trial which had a duration of 12 months in total and compared high‐dose and low‐dose pancreatic enzyme therapy. As only the abstract of the trial was available, the overall risk of bias was judged to be unclear. The trial did not address either of our primary outcomes (time until resolution of DIOS and treatment failure rate), but reported episodes of acute DIOS, presence of abdominal mass and abdominal pain. There were no numerical data available for these outcomes, but the authors stated that there was no difference between treatment with high‐dose or low‐dose pancreatic enzymes. The overall certainty of the evidence was found to be very low. Authors' conclusions There is a clear lack of evidence for the treatment of DIOS in people with cystic fibrosis. The included abstract did not address our primary outcome measures and did not provide numerical data for the two secondary outcomes it did address. Therefore, we cannot justify the use of high‐dose pancreatic enzymes for treating DIOS, nor can we comment on the efficacy and safety of other laxative agents. From our findings, it is clear that more randomised controlled trials need to be conducted in this area. Plain language summary Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis Review question We reviewed the evidence about the effectiveness and safety of different treatments for distal intestinal obstruction syndrome (DIOS) in children and adults with cystic fibrosis. Background Cystic fibrosis is a common, life‐limiting, inherited disease. One of the main features of cystic fibrosis is the thick, sticky mucus produced by many organs including the lungs, pancreas and intestine. DIOS occurs when mucus in the intestine combines with faeces and builds up to produce a mass. This mass can partially or completely block the intestine and cause symptoms such as vomiting, severe abdominal pain and a swollen stomach (abdominal distension). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the complete or partial blockage and ultimately prevent the need for any surgical intervention. Search date The evidence is current to: 12 October 2021. Trial characteristics The review included one trial with 20 people with cystic fibrosis who were aged between 7.1 and 23.2 years of age (average 13.1 years old). The 12‐month trial compared a high dose of pancreatic enzymes with a low dose of pancreatic enzymes for treating chronic DIOS. Key results The trial did not report on our primary outcomes (time until DIOS successfully treated and treatment failure rate), but addressed two of our secondary outcomes; episodes of acute DIOS and the harmful effects that might occur in participants (the presence of an abdominal mass and abdominal pain). There were no numerical data available for these results, but the authors reported that there was no difference between high‐dose or low‐dose pancreatic enzymes. Certainty of the evidence We found the overall certainty of the evidence to be very low. The trial itself was only published as an abstract from a conference which did not include numerical data and it was not published as a full report. This meant that we do not know many details about the trial. We thought that the overall risk of bias was unclear, as the trial authors did not describe how participants were put into the treatment groups, whether any participants dropped out or whether the planned outcomes were the same as the reported outcomes. The trial also had a very small number of participants and a limited age range, making it difficult to draw conclusions about the relevance of the treatment for all people with cystic fibrosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gilchrist, FJ, Green, J, Carroll, W", "articleTypes": [], "doi": "10.1002/14651858.CD012798.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.737Z" }, { "id": "79f4560e-57e3-4e7b-973e-928ed3e7a408", "pmid": "", "title": "Neuraminidase inhibitors for preventing and treating influenza in adults and children", "imported": false, "abstract": "Abstract - Background Neuraminidase inhibitors (NIs) are stockpiled and recommended by public health agencies for treating and preventing seasonal and pandemic influenza. They are used clinically worldwide. Objectives To describe the potential benefits and harms of NIs for influenza in all age groups by reviewing all clinical study reports of published and unpublished randomised, placebo‐controlled trials and regulatory comments. Search methods We searched trial registries, electronic databases (to 22 July 2013) and regulatory archives, and corresponded with manufacturers to identify all trials. We also requested clinical study reports. We focused on the primary data sources of manufacturers but we checked that there were no published randomised controlled trials (RCTs) from non‐manufacturer sources by running electronic searches in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE (Ovid), EMBASE, Embase.com, PubMed (not MEDLINE), the Database of Reviews of Effects, the NHS Economic Evaluation Database and the Health Economic Evaluations Database. Selection criteria Randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Data collection and analysis We extracted clinical study reports and assessed risk of bias using purpose‐built instruments. We analysed the effects of zanamivir and oseltamivir on time to first alleviation of symptoms, influenza outcomes, complications, hospitalisations and adverse events in the intention‐to‐treat (ITT) population. All trials were sponsored by the manufacturers. Main results We obtained 107 clinical study reports from the European Medicines Agency (EMA), GlaxoSmithKline and Roche. We accessed comments by the US Food and Drug Administration (FDA), EMA and Japanese regulator. We included 53 trials in Stage 1 (a judgement of appropriate study design) and 46 in Stage 2 (formal analysis), including 20 oseltamivir (9623 participants) and 26 zanamivir trials (14,628 participants). Inadequate reporting put most of the zanamivir studies and half of the oseltamivir studies at a high risk of selection bias. There were inadequate measures in place to protect 11 studies of oseltamivir from performance bias due to non‐identical presentation of placebo. Attrition bias was high across the oseltamivir studies and there was also evidence of selective reporting for both the zanamivir and oseltamivir studies. The placebo interventions in both sets of trials may have contained active substances. Time to first symptom alleviation . For the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.8 hours (95% confidence interval (CI) 8.4 to 25.1 hours, P < 0.0001). This represents a reduction in the time to first alleviation of symptoms from 7 to 6.3 days. There was no effect in asthmatic children, but in otherwise healthy children there was (reduction by a mean difference of 29 hours, 95% CI 12 to 47 hours, P = 0.001). Zanamivir reduced the time to first alleviation of symptoms in adults by 0.60 days (95% CI 0.39 to 0.81 days, P < 0.00001), equating to a reduction in the mean duration of symptoms from 6.6 to 6.0 days. The effect in children was not significant. In subgroup analysis we found no evidence of a difference in treatment effect for zanamivir on time to first alleviation of symptoms in adults in the influenza‐infected and non‐influenza‐infected subgroups (P = 0.53). Hospitalisations . Treatment of adults with oseltamivir had no significant effect on hospitalisations: risk difference (RD) 0.15% (95% CI ‐0.78 to 0.91). There was also no significant effect in children or in prophylaxis. Zanamivir hospitalisation data were unreported. Serious influenza complications or those leading to study withdrawal . In adult treatment trials, oseltamivir did not significantly reduce those complications classified as serious or those which led to study withdrawal (RD 0.07%, 95% CI ‐0.78 to 0.44), nor in child treatment trials; neither did zanamivir in the treatment of adults or in prophylaxis. There were insufficient events to compare this outcome for oseltamivir in prophylaxis or zanamivir in the treatment of children. Pneumonia . Oseltamivir significantly reduced self reported, investigator‐mediated, unverified pneumonia (RD 1.00%, 95% CI 0.22 to 1.49); number needed to treat to benefit (NNTB) = 100 (95% CI 67 to 451) in the treated population. The effect was not significant in the five trials that used a more detailed diagnostic form for pneumonia. There were no definitions of pneumonia (or other complications) in any trial. No oseltamivir treatment studies reported effects on radiologically confirmed pneumonia. There was no significant effect on unverified pneumonia in children. There was no significant effect of zanamivir on either self reported or radiologically confirmed pneumonia. In prophylaxis, zanamivir significantly reduced the risk of self reported, investigator‐mediated, unverified pneumonia in adults (RD 0.32%, 95% CI 0.09 to 0.41); NNTB = 311 (95% CI 244 to 1086), but not oseltamivir. Bronchitis, sinusitis and otitis media . Zanamivir significantly reduced the risk of bronchitis in adult treatment trials (RD 1.80%, 95% CI 0.65 to 2.80); NNTB = 56 (36 to 155), but not oseltamivir. Neither NI significantly reduced the risk of otitis media and sinusitis in both adults and children. Harms of treatment . Oseltamivir in the treatment of adults increased the risk of nausea (RD 3.66%, 95% CI 0.90 to 7.39); number needed to treat to harm (NNTH) = 28 (95% CI 14 to 112) and vomiting (RD 4.56%, 95% CI 2.39 to 7.58); NNTH = 22 (14 to 42). The proportion of participants with four‐fold increases in antibody titre was significantly lower in the treated group compared to the control group (RR 0.92, 95% CI 0.86 to 0.97, I 2 statistic = 0%) (5% absolute difference between arms). Oseltamivir significantly decreased the risk of diarrhoea (RD 2.33%, 95% CI 0.14 to 3.81); NNTB = 43 (95% CI 27 to 709) and cardiac events (RD 0.68%, 95% CI 0.04 to 1.0); NNTB = 148 (101 to 2509) compared to placebo during the on‐treatment period. There was a dose‐response effect on psychiatric events in the two oseltamivir \"pivotal\" treatment trials, WV15670 and WV15671, at 150 mg (standard dose) and 300 mg daily (high dose) (P = 0.038). In the treatment of children, oseltamivir induced vomiting (RD 5.34%, 95% CI 1.75 to 10.29); NNTH = 19 (95% CI 10 to 57). There was a significantly lower proportion of children on oseltamivir with a four‐fold increase in antibodies (RR 0.90, 95% CI 0.80 to 1.00, I 2 = 0%). Prophylaxis . In prophylaxis trials, oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals (oseltamivir: RD 3.05% (95% CI 1.83 to 3.88); NNTB = 33 (26 to 55); zanamivir: RD 1.98% (95% CI 0.98 to 2.54); NNTB = 51 (40 to 103)) and in households (oseltamivir: RD 13.6% (95% CI 9.52 to 15.47); NNTB = 7 (6 to 11); zanamivir: RD 14.84% (95% CI 12.18 to 16.55); NNTB = 7 (7 to 9)). There was no significant effect on asymptomatic influenza (oseltamivir: RR 1.14 (95% CI 0.39 to 3.33); zanamivir: RR 0.97 (95% CI 0.76 to 1.24)). Non‐influenza, influenza‐like illness could not be assessed due to data not being fully reported. In oseltamivir prophylaxis studies, psychiatric adverse events were increased in the combined on‐ and off‐treatment periods (RD 1.06%, 95% CI 0.07 to 2.76); NNTH = 94 (95% CI 36 to 1538) in the study treatment population. Oseltamivir increased the risk of headaches whilst on treatment (RD 3.15%, 95% CI 0.88 to 5.78); NNTH = 32 (95% CI 18 to 115), renal events whilst on treatment (RD 0.67%, 95% CI ‐2.93 to 0.01); NNTH = 150 (NNTH 35 to NNTB > 1000) and nausea whilst on treatment (RD 4.15%, 95% CI 0.86 to 9.51); NNTH = 25 (95% CI 11 to 116). Authors' conclusions Oseltamivir and zanamivir have small, non‐specific effects on reducing the time to alleviation of influenza symptoms in adults, but not in asthmatic children. Using either drug as prophylaxis reduces the risk of developing symptomatic influenza. Treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced, because of a lack of diagnostic definitions. The use of oseltamivir increases the risk of adverse effects, such as nausea, vomiting, psychiatric effects and renal events in adults and vomiting in children. The lower bioavailability may explain the lower toxicity of zanamivir compared to oseltamivir. The balance between benefits and harms should be considered when making decisions about use of both NIs for either the prophylaxis or treatment of influenza. The influenza virus‐specific mechanism of action proposed by the producers does not fit the clinical evidence. Plain language summary Regulatory information on trials of oseltamivir (Tamiflu) and zanamivir (Relenza) for influenza in adults and children Oseltamivir and zanamivir have been stockpiled in many countries to treat and prevent seasonal and pandemic influenza, before an influenza vaccine matched to the circulating virus becomes available. Oseltamivir is classified by the World Health Organization as an essential medicine. How this review has been approached We have updated and combined our reviews on the antiviral drugs zanamivir and oseltamivir for influenza in adults and children on the basis of the manufacturers' reports to regulators (clinical study reports) and the regulators' comments. We have called these comments and reports 'regulatory information'. Clinical study reports are unpublished, extensive documents with great detail on the trials that formed the basis for market approval. They include the protocols, methods and results. Clinical study reports have until now been confidential, seen only by the manufacturers and regulators. Why we have taken this approach In previous versions of this review we identified unresolved discrepancies in the data presented in published trial reports and substantial publication bias. As a consequence, we elected not to use data from journal articles but included the documents generated during licensing processes. We have accessed such data from the UK, USA, European Medicines Agency (EMA), Japanese regulators and clinical study reports from the manufacturers (after a protracted media campaign). This has enabled us to verify information from the randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Based on our assessments of the regulatory documents (in excess of 160,000 pages), we came to the conclusion that there were substantial problems with the design, conduct, reporting and availability of information from many of the trials. What we have found We have used data from 46 trials (20 oseltamivir and 26 zanamivir studies) in this review. We identified problems in the design of many of the studies that we included, which affects our confidence in their results. We found that both drugs shorten the duration of symptoms of influenza‐like illness (unconfirmed influenza or 'the flu') by less than a day. Oseltamivir did not affect the number of hospitalisations, based on the data from all the people enrolled in treatment trials of oseltamivir. Zanamivir trials did not record this outcome. The effects on pneumonia and other complications of influenza, such as bronchitis, middle ear infection (otitis media) and sinusitis, were unreliably reported, as shown by the case report form in the trial documents. Some forms showed limitations in the diagnostic criteria for pneumonia. Regulatory comments noted problems with missing follow‐up diary cards from participants. In children with asthma there was no clear effect on the time to first alleviation of symptoms. Prophylaxis trials showed that oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals and households. There was no evidence of an effect on asymptomatic influenza or on non‐influenza, influenza‐like illness, but trial conduct problems prevent any definitive conclusion. Oseltamivir use was associated with nausea, vomiting, headaches, renal and psychiatric events; these last three were when it was used to prevent influenza (prophylaxis). Its effect on the heart is unclear: it may reduce cardiac symptoms, but may induce serious heart rhythm problems. In adult treatment trials of zanamivir there was no increased risk of reported adverse events. The evidence on the possible harms associated with the treatment of children with zanamivir was sparse. Agreement with other findings The lack of good evidence demonstrating an effect on complications agrees with the conservative conclusions on both drugs drawn by the US Food and Drug Administration (FDA). The FDA only allowed claims of effectiveness of both drugs for the prevention and treatment of symptoms of influenza and not for other effects (including the interruption of person‐to‐person spread of the influenza virus or prevention of pneumonia). The FDA described the overall performance of both drugs as 'modest'. Mechanism of action for beneficial effects These findings all suggest that the low immune response with low levels of pro‐inflammatory cytokines, which is induced by the action of oseltamivir carboxylate, may reduce the symptoms of influenza unrelated to an inhibition of influenza virus replication. The potential hypothermic or antipyretic effect of oseltamivir as a central nervous system depressant may also contribute to the apparent reduction of host symptoms. Statements made on the capacity of oseltamivir to interrupt viral transmission and reduce complications are not supported by any data we have been able to access. The mechanism of action proposed by the producers (influenza virus‐specific) does not fit the clinical evidence which suggests a multi‐system and central action.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Jefferson, T; Jones, MA; Doshi, P; Del Mar, CB; Hama, R; Thompson, MJ; Spencer, EA; Onakpoya, IJ; Mahtani, KR; Nunan, D; Howick, J; Heneghan, CJ", "articleTypes": [], "doi": "10.1002/14651858.CD008965.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "7a33ed26-35f9-4db1-84e7-27dca00d2686", "pmid": "", "title": "Hyperimmune immunoglobulin for people with COVID‐19", "imported": false, "abstract": "Abstract - Background Hyperimmune immunoglobulin (hIVIG) contains polyclonal antibodies, which can be prepared from large amounts of pooled convalescent plasma or prepared from animal sources through immunisation. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). This review was previously part of a parent review addressing convalescent plasma and hIVIG for people with COVID‐19 and was split to address hIVIG and convalescent plasma separately. Objectives To assess the benefits and harms of hIVIG therapy for the treatment of people with COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods To identify completed and ongoing studies, we searched the World Health Organization (WHO) COVID‐19 Research Database, the Cochrane COVID‐19 Study Register, the Epistemonikos COVID‐19 L*OVE Platform and Medline and Embase from 1 January 2019 onwards. We carried out searches on 31 March 2022. Selection criteria We included randomised controlled trials (RCTs) that evaluated hIVIG for COVID‐19, irrespective of disease severity, age, gender or ethnicity. We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)), as well as studies that evaluated standard immunoglobulin. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used RoB 2. We rated the certainty of evidence, using the GRADE approach, for the following outcomes: all‐cause mortality, improvement and worsening of clinical status (for individuals with moderate to severe disease), quality of life, adverse events, and serious adverse events. Main results We included five RCTs with 947 participants, of whom 688 received hIVIG prepared from humans, 18 received heterologous swine glyco‐humanised polyclonal antibody, and 241 received equine‐derived processed and purified F(ab’) 2 fragments. All participants were hospitalised with moderate‐to‐severe disease, most participants were not vaccinated (only 12 participants were vaccinated). The studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with mild COVID‐19. We identified a further 10 ongoing studies evaluating hIVIG. Benefits of hIVIG prepared from humans We included data on one RCT (579 participants) that assessed the benefits and harms of hIVIG 0.4 g/kg compared to saline placebo. hIVIG may have little to no impact on all‐cause mortality at 28 days (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.43 to 1.44; absolute effect 77 per 1000 with placebo versus 61 per 1000 (33 to 111) with hIVIG; low‐certainty evidence). The evidence is very uncertain about the effect on worsening of clinical status at day 7 (RR 0.85, 95% CI 0.58 to 1.23; very low‐certainty evidence). It probably has little to no impact on improvement of clinical status on day 28 (RR 1.02, 95% CI 0.97 to 1.08; moderate‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if hIVIG has any impact on quality of life. Harms of hIVIG prepared from humans hIVIG may have little to no impact on adverse events at any grade on day 1 (RR 0.98, 95% CI 0.81 to 1.18; 431 per 1000; 1 study 579 participants; low‐certainty evidence). Patients receiving hIVIG probably experience more adverse events at grade 3‐4 severity than patients who receive placebo (RR 4.09, 95% CI 1.39 to 12.01; moderate‐certainty evidence). hIVIG may have little to no impact on the composite outcome of serious adverse events or death up to day 28 (RR 0.72, 95% CI 0.45 to 1.14; moderate‐certainty evidence). We also identified additional results on the benefits and harms of other dose ranges of hIVIG, not included in the summary of findings table, but summarised in additional tables. Benefits of animal‐derived polyclonal antibodies We included data on one RCT (241 participants) to assess the benefits and harms of receptor‐binding domain‐specific polyclonal F(ab´) 2 fragments of equine antibodies (EpAbs) compared to saline placebo. EpAbs may reduce all‐cause mortality at 28 days (RR 0.60, 95% CI 0.26 to 1.37; absolute effect 114 per 1000 with placebo versus 68 per 1000 (30 to 156) ; low‐certainty evidence). EpAbs may reduce worsening of clinical status up to day 28 (RR 0.67, 95% CI 0.38 to 1.18; absolute effect 203 per 1000 with placebo versus 136 per 1000 (77 to 240); low‐certainty evidence). It may have some effect on improvement of clinical status on day 28 (RR 1.06, 95% CI 0.96 to 1.17; low‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if EpAbs have any impact on quality of life. Harms of animal‐derived polyclonal antibodies EpAbs may have little to no impact on the number of adverse events at any grade up to 28 days (RR 0.99, 95% CI 0.74 to 1.31; low‐certainty evidence). Adverse events at grade 3‐4 severity were not reported. Individuals receiving EpAbs may experience fewer serious adverse events than patients receiving placebo (RR 0.67, 95% CI 0.38 to 1.19; low‐certainty evidence). We also identified additional results on the benefits and harms of other animal‐derived polyclonal antibody doses, not included in the summary of findings table, but summarised in additional tables. Authors' conclusions We included data from five RCTs that evaluated hIVIG compared to standard therapy, with participants with moderate‐to‐severe disease. As the studies evaluated different preparations (from humans or from various animals) and doses, we could not pool them. hIVIG prepared from humans may have little to no impact on mortality, and clinical improvement and worsening. hIVIG may increase grade 3‐4 adverse events. Studies did not evaluate quality of life. RBD‐specific polyclonal F(ab´) 2 fragments of equine antibodies may reduce mortality and serious adverse events, and may reduce clinical worsening. However, the studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern and prior to widespread vaccine rollout. As no studies evaluated hIVIG for participants with asymptomatic infection or mild disease, benefits for these individuals remains uncertain. This is a living systematic review. We search monthly for new evidence and update the review when we identify relevant new evidence. Plain language summary Are concentrated antibodies from people who have recovered from COVID‐19 or animals an effective treatment for people with COVID‐19? Key messages • We do not know whether hyperimmune immunoglobulin (a preparation made with antibodies from people who have recovered from COVID‐19) reduces deaths or serious unwanted effects in people with moderate to severe COVID‐19. But a similar preparation made by injecting animals with certain antibodies may reduce deaths, and serious unwanted effects and may stop people’s condition getting worse. • We found no studies that investigated people with COVID‐19 but without symptoms or people with mild COVID‐19, so we do not know how effective human or animal hyperimmune immunoglobulin is for them. • We found 10 ongoing studies. We will update this review when their results become available. What is hyperimmune immunoglobulin? The body produces antibodies as one of its defences against infection. Antibodies, or 'immunoglobulins', are found in blood plasma. They act as a critical part of the immune response. Plasma from people who have recovered from COVID‐19 contains COVID‐19 antibodies, and can be used to make two preparations. Firstly, it can be used to make convalescent plasma, which is plasma that contains these antibodies. Secondly, it can be used to make hyperimmune immunoglobulin, which is more concentrated, and therefore contains more antibodies. The manufacturing process of hyperimmune immunoglobulin is complex and requires large pools of human plasma. Similar antibodies can be made from animal sources and used in humans. Why is hyperimmune immunoglobulin a possible treatment for COVID‐19? Hyperimmune immunoglobulin products contain high levels of antibodies that target SARS‐CoV‐2, the virus that causes COVID‐19. The products are thought to inactivate the virus particles. What did we want to find out? We wanted to know if hyperimmune immunoglobulin is an effective and helpful treatment for people with suspected or confirmed COVID‐19 in any setting (for example, home or hospital). We were interested in: • death from any cause up 30 days after treatment, 60 days, or longer if reported; • improvement or worsening of symptoms; • quality of life; • unwanted effects. What did we do? We searched for studies that investigated hyperimmune immunoglobulin and usual care compared to usual care only, or in addition to a dummy medicine that did not contain any active ingredients (placebo). To make a fair comparison, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the hyperimmune immunoglobulin or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies. We used a standardised method to rate our confidence in the evidence. The confidence is based on study features such as how it was designed and the number of people in them. What did we find? We found five studies with 957 people. Studies took place in Pakistan, India, France, and Argentina, and one study was conducted in multiple countries, including Denmark, Greece, Japan, Nigeria, Spain, the UK and the USA. The studies took place before or during the emergence of several new COVID‐19 variants and prior to widespread vaccine rollout. All the participants in four studies were unvaccinated. In one study, 12 from 579 participants were vaccinated. We also found 10 ongoing studies. Main results All studies compared hyperimmune immunoglobulin from human or animal sources with usual care or placebo. The studies included only hospitalised people with moderate to severe disease. No studies looked at people without COVID‐19 symptoms or mild COVID‐19. No studies reported on quality of life. We are uncertain whether or not hyperimmune immunoglobulin prepared from humans affects risk of death from any cause up to 28 days after treatment. It may have little to no impact on improvement or worsening of symptoms up to 28 days after treatment. We are uncertain about a possible difference in unwanted or serious unwanted effects. The individual studies decided which events to classify as serious unwanted effects, but this usually means something that may cause hospitalisation or permanent harm. Hyperimmune immunoglobulin from animals may reduce deaths up to 28 days after treatment, may reduce worsening of symptoms, may improve patients' condition and may reduce serious unwanted events. What are the limitations of the evidence? We are uncertain whether hyperimmune immunoglobulin is an effective treatment for people hospitalised with COVID‐19, and whether it affects the number of unwanted or serious unwanted effects because the studies were small and did not all provide evidence on all our points of interest. The studies were conducted predominantly in people from wealthy countries, before the widespread rollout of COVID‐19 vaccines and the emergence of the omicron variant, so the results may not apply to people with omicron variant infection, or people who were vaccinated before falling ill. There was no evidence for people without symptoms or with mild COVID‐19. How up to date is this evidence? Our evidence is up‐to‐date to 31st March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kimber, C; Valk, SJ; Chai, KL; Piechotta, V; Iannizzi, C; Monsef, I; Wood, EM; Lamikanra, AA; Roberts, DJ; McQuilten, Z; So-Osman, C; Estcourt, LJ; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015167.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "7a38b871-1b39-4f89-b8c1-925ee48d4999", "pmid": "", "title": "Breastfeeding for procedural pain in infants beyond the neonatal period", "imported": false, "abstract": "Abstract - Background Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin‐to‐skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk. Objectives To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin‐to‐skin contact, expressed breast milk, formula milk, bottle feeding, sweet‐tasting solutions (e.g. sucrose or glucose), distraction, or other interventions. Search methods We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In‐Process & Other Non‐Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials. Selection criteria We included RCTs and quasi‐RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet‐tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin‐to‐skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random‐effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information. Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38‐second reduction in cry time (MD ‐38, 95% CI ‐50 to ‐26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12‐month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7‐point reduction in standardised pain scores (SMD ‐1.7, 95% CI ‐2.2 to ‐1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD ‐3.6, ‐23 to 16). Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage. No included studies reported adverse events. Authors' conclusions We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin‐breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted. Plain language summary Does breastfeeding reduce vaccination pain in babies aged 1 to 12 months? Bottom line We found that breastfeeding before and during vaccination injections helped to reduce pain in most babies up to the age of one year. Background Needles are used for babies' early childhood vaccinations and medical care during childhood illnesses. These are essential, but painful. They cause distress for the babies and often their parents/caregivers, and can result in future anxiety and fear about needles. Breastfeeding during blood tests in newborn babies reduces pain. Breastfeeding when possible and feasible may also help to comfort babies and reduce their pain beyond the newborn period and throughout infancy. Study characteristics In February 2016 we searched the medical literature for studies examining the effectiveness of breastfeeding babies 1 to 12 months old during the use of needles. We compared effectiveness of breastfeeding in reducing pain (as scored by crying time and pain scores), to holding, babies lying flat, or the giving of water or sweet solutions. We found 10 studies with a total of 1066 infants. All studies examined if breastfeeding reduced pain during vaccinations. Key results Breastfeeding reduced crying in young babies having vaccinations. On average, breastfed babies cried for 38 seconds less than babies who were not breastfed (6 studies; 547 infants; moderate‐quality evidence), and pain scores were significantly lower (5 studies; 310 infants; moderate‐quality evidence). No studies reported on any harm (very low‐quality evidence). We could draw no conclusions on risk of harm while breastfeeding healthy babies during vaccination. Going forward: if mothers are breastfeeding, it could be considered when possible for babies during vaccinations. More evidence is needed to learn if breastfeeding helps older babies and babies in hospital during blood work or procedures such as insertion of drips. Quality of the evidence The quality of the evidence was moderate for crying time and pain scores. Most studies included younger infants aged 1 to 6 months. Further research including older infants up to 12 months of age may change our conclusions. In addition, the studies evaluated the effects of breastfeeding during vaccination. We do not know whether breastfeeding helps sick babies aged 1 to 12 months in hospital during blood sampling or drip insertion.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Harrison, D, Reszel, J, Bueno, M, Sampson, M, Shah, VS, Taddio, A, Larocque, C, Turner, L", "articleTypes": [], "doi": "10.1002/14651858.CD011248.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.757Z" }, { "id": "7a428970-58ce-417f-b6e1-a7858bd03aa7", "pmid": "", "title": "Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Etidronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts – bone cells that break down bone tissue. This is an update of a Cochrane review first published in 2008. For clinical relevance, we investigated etidronate's effects on postmenopausal women stratified by fracture risk (low versus high). Objectives To assess the benefits and harms of intermittent/cyclic etidronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE, Embase, two clinical trial registers, the websites of drug approval agencies, and the bibliographies of relevant systematic reviews. We identified eligible trials published between 1966 and February 2023. Selection criteria We included randomized controlled trials that assessed the benefits and harms of etidronate in the prevention of fractures for postmenopausal women. Women in the experimental arms must have received at least one year of etidronate, with or without other anti‐osteoporotic drugs and concurrent calcium/vitamin D. Eligible comparators were placebo (i.e. no treatment; or calcium, vitamin D, or both) or another anti‐osteoporotic drug. Major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. We classified a study as secondary prevention if its population fulfilled one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (≤ ‐2.5), or aged 75 years or older. If none of these criteria were met, we considered the study to be primary prevention. Data collection and analysis We used standard methodological procedures expected by Cochrane. The review has three main comparisons: (1) etidronate 400 mg/day versus placebo; (2) etidronate 200 mg/day versus placebo; (3) etidronate at any dosage versus another anti‐osteoporotic agent. We stratified the analyses for each comparison into primary and secondary prevention studies. For major outcomes in the placebo‐controlled studies of etidronate 400 mg/day, we followed our original review by defining a greater than 15% relative change as clinically important. For all outcomes of interest, we extracted outcome measurements at the longest time point in the study. Main results Thirty studies met the review's eligibility criteria. Of these, 26 studies, with a total of 2770 women, reported data that we could extract and quantitatively synthesize. There were nine primary and 17 secondary prevention studies. We had concerns about at least one risk of bias domain in each study. None of the studies described appropriate methods for allocation concealment, although 27% described adequate methods of random sequence generation. We judged that only 8% of the studies avoided performance bias, and provided adequate descriptions of appropriate blinding methods. One‐quarter of studies that reported efficacy outcomes were at high risk of attrition bias, whilst 23% of studies reporting safety outcomes were at high risk in this domain. The 30 included studies compared (1) etidronate 400 mg/day to placebo (13 studies: nine primary and four secondary prevention); (2) etidronate 200 mg/day to placebo (three studies, all secondary prevention); or (3) etidronate (both dosing regimens) to another anti‐osteoporotic agent (14 studies: one primary and 13 secondary prevention). We discuss only the etidronate 400 mg/day versus placebo comparison here. For primary prevention, we collected moderate‐ to very low‐certainty evidence from nine studies (one to four years in length) including 740 postmenopausal women at lower risk of fractures. Compared to placebo, etidronate 400 mg/day probably results in little to no difference in non‐vertebral fractures (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.20 to 1.61); absolute risk reduction (ARR) 4.8% fewer, 95% CI 8.9% fewer to 6.1% more) and serious adverse events (RR 0.90, 95% CI 0.52 to 1.54; ARR 1.1% fewer, 95% CI 4.9% fewer to 5.3% more), based on moderate‐certainty evidence. Etidronate 400 mg/day may result in little to no difference in clinical vertebral fractures (RR 3.03, 95% CI 0.32 to 28.44; ARR 0.02% more, 95% CI 0% fewer to 0% more) and withdrawals due to adverse events (RR 1.41, 95% CI 0.81 to 2.47; ARR 2.3% more, 95% CI 1.1% fewer to 8.4% more), based on low‐certainty evidence. We do not know the effect of etidronate on hip fractures because the evidence is very uncertain (RR not estimable based on very low‐certainty evidence). Wrist fractures were not reported in the included studies. For secondary prevention, four studies (two to four years in length) including 667 postmenopausal women at higher risk of fractures provided the evidence. Compared to placebo, etidronate 400 mg/day may make little or no difference to non‐vertebral fractures (RR 1.07, 95% CI 0.72 to 1.58; ARR 0.9% more, 95% CI 3.8% fewer to 8.1% more), based on low‐certainty evidence. The evidence is very uncertain about etidronate's effects on hip fractures (RR 0.93, 95% CI 0.17 to 5.19; ARR 0.0% fewer, 95% CI 1.2% fewer to 6.3% more), wrist fractures (RR 0.90, 95% CI 0.13 to 6.04; ARR 0.0% fewer, 95% CI 2.5% fewer to 15.9% more), withdrawals due to adverse events (RR 1.09, 95% CI 0.54 to 2.18; ARR 0.4% more, 95% CI 1.9% fewer to 4.9% more), and serious adverse events (RR not estimable), compared to placebo. Clinical vertebral fractures were not reported in the included studies. Authors' conclusions This update echoes the key findings of our previous review that etidronate probably makes or may make little to no difference to vertebral and non‐vertebral fractures for both primary and secondary prevention. Plain language summary Does etidronate prevent fractures caused by osteoporosis in postmenopausal women? Key messages • For women with close to normal bone density (bone strength) and no previous broken spinal bones, etidronate probably makes little or no difference to the likelihood of having a hip or wrist fracture or a serious adverse (unwanted/harmful) event.
 • For women who have low bone density and are at risk for or have had a previous broken spinal bone, etidronate may make little or no difference in preventing fractures in bones other than the spine. What is osteoporosis? Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow, and old bone cells break down to make room for new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break, even after a minor injury, such as a slight bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. What is etidronate? Etidronate belongs to the class of medicines called bisphosphonates, which slow down the cells that break down the old bone. It is given by mouth in an intermittent or cyclical schedule; for example, a 400 mg tablet daily for two weeks every 90 days, followed by calcium or no treatment for the remainder of each 90‐day treatment cycle. What did we want to find out? We wanted to find out if etidronate was better than placebo (inactive or 'dummy' medicine) or another medicine for osteoporosis in preventing broken bones in postmenopausal women. For clinical relevance, we looked at etidronate's effects on women, as grouped by their risk of fracture (lower versus higher risk). We also wanted to find out if etidronate was associated with any unwanted effects. What did we do? We searched for studies comparing etidronate to placebo or another medicine for preventing osteoporosis. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Overall, we found 30 studies, but 4 studies provided insufficient information about their results. Thus, we were able to analyse the results of 26 studies involving 2770 women. Nine studies were interested in 'primary prevention' of osteoporosis‐based fractures, meaning they focused on women at lower fracture risk, who had bones with near‐to‐normal density/strength and no previous broken spinal bones. Seventeen studies were interested in 'secondary prevention' with etidronate, meaning they focused on women at higher fracture risk, who already had weak bones (low bone density), had a broken spinal bone, or both. Most studies mainly included white women. The studies lasted between 1 and 4 years. Some studies gave the women 400 mg/day of etidronate, whilst other studies gave 200 mg/day. Main results for primary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate: • probably makes little or no difference to non‐vertebral (non‐spinal) fractures and serious adverse events; • may make little or no difference to clinical vertebral fractures (that is, spinal fractures suggested by clinical signs and symptoms) and the number of women who left the studies due to adverse events. The evidence is very uncertain about the effect of etidronate on hip fractures. None of the studies reported on the effect on wrist fractures. Main results for secondary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate may make little or no difference in preventing fractures in bones other than the spine. The evidence is very uncertain about the effect of etidronate on hip and wrist fractures, the number of women who left the studies due to adverse events, and serious adverse events. None of the studies reported on etidronate's effect on clinical vertebral fractures. What are the limitations of the evidence? Our confidence in the evidence ranged from very low to moderate. In general, we have little confidence in the evidence because it is possible that the women in the studies were aware of which treatment they were getting, which could influence the results, and because many of the studies were very small. How up to date is this evidence? The evidence is current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Wells, GA; Hsieh, S-C; Peterson, J; Zheng, C; Kelly, SE; Shea, B; Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD003376.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "7a4a3f66-6dcc-4c92-b335-40fe11662c4f", "pmid": "", "title": "Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer", "imported": false, "abstract": "Abstract - Background Radioactive iodine treatment for differentiated thyroid cancer possibly results in xerostomia. Amifostine has been used to prevent the effects of irradiation to salivary glands. To date, the effects of amifostine on salivary glands in radioactive iodine treated differentiated thyroid cancer remain uncertain. Objectives To assess the effects of amifostine on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer. Search methods Studies were obtained from computerized searches of MEDLINE, EMBASE, The Cochrane Library and paper collections of conferences held in Chinese. Selection criteria Randomised controlled clinical trials and quasi‐randomised controlled clinical trials comparing the effects of amifostine on salivary glands after radioactive iodine treatment for differentiated thyroid cancer with placebo and a duration of follow up of at least three months. Data collection and analysis Two authors independently assessed risk of bias and extracted data. Main results Two trials with 130 patients (67 and 63 patients randomised to intervention versus control) were included. Both studies had a low risk of bias. Amifostine versus placebo showed no statistically significant differences in the incidence of xerostomia (130 patients, two studies), the decrease of scintigraphically measured uptake of technetium‐99m by salivary or submandibular glands at twelve months (80 patients, one study), and the reduction of blood pressure (130 patients, two studies). Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Meta‐analysis was not performed on the function of salivary glands measured by technetium‐99m scintigraphy at three months after high dose radioactive iodine treatment due to the highly inconsistent findings across studies (I 2 statistic 99%). None of the included trials investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions Results from two randomised controlled clinical trials suggest that the amifostine has no significant radioprotective effects on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer patients. Moreover, no health‐related quality of life and other patient‐oriented outcomes were evaluated in the two included trials. Randomised controlled clinical trials with low risk of bias investigating patient‐oriented outcomes are needed to guide treatment choice. Plain language summary Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer Thyroid cancer is the most common malignancy of the endocrine system consisting of several subtypes like papillary carcinoma (accounting for 80% of cases) and follicular carcinoma (accounting for 11% of cases). These are collectively referred to as 'differentiated thyroid cancer'. Treatment with radioactive iodine after surgery (ablation of the thyroid gland or 'thyroidectomy') is important for the detection of metastatic disease and for the destruction of the remaining thyroid tissue with microscopic cancer. After radioactive iodine treatment, adverse effects may happen in the salivary glands and cause salivary gland swelling and pain, usually involving the parotid. The symptoms may develop immediately after a therapeutic dose of radioactive iodine or months later and progress in intensity with time. Secondary complications reported include dry mouth ('xerostomia') and taste alterations. Amifostine is thought to be a radioprotector of salivary glands used in conjunction with radioiodine therapy. This medication is administered intravenously and was reported to ameliorate the damage of salivary glands caused by radioactive iodine therapy. We found only two randomised controlled trials in which the effects of amifostine were compared with placebo. The two randomised clinical trials investigated 130 patients treated with high dose radioactive iodine for thyroid cancer. Altogether data from the two trials suggest that amifostine has no obvious protective effects on the salivary glands in these patients. Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Until better data become available, the use of sour candy or lemon juice to increase salivation might be more appropriate during radioactive iodine treatment for patients with differentiated thyroid cancer. Patients should be well informed of the importance of hydration, acid stimulation and glandular massage after radioactive iodine treatment. In addition, early recognition and treatment of xerostomia may improve outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Ma, C; Xie, J; Chen, Q; Wang, G; Zuo, S", "articleTypes": [], "doi": "10.1002/14651858.CD007956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "7a754613-b4d5-43bd-9672-b95a8fe671aa", "pmid": "", "title": "Listening to music for insomnia in adults", "imported": false, "abstract": "Abstract - Background Insomnia is a common problem in modern society. It is associated with reduced quality of life and impairments in physical and mental health. Listening to music is widely used as a sleep aid, but it remains unclear if it can actually improve insomnia in adults. This Cochrane Review is an update of a review published in 2015. Objectives To assess the effects of listening to music on sleep in adults with insomnia and to assess the influence of specific variables that may moderate the effect . Search methods For this update, we searched CENTRAL, MEDLINE, Embase, nine other databases and two trials registers up to December 2021. In addition, we handsearched reference lists of included studies, and contacted authors of published studies to identify additional studies eligible for inclusion, including any unpublished or ongoing trials. Selection criteria Randomised controlled trials comparing the effects of listening to music with no treatment or treatment as usual (TAU) in adults complaining of sleep difficulties. Data collection and analysis Two review authors independently screened records for eligibility, selected studies for inclusion, extracted data and assessed risk of bias of the included studies. We assessed the certainty of the evidence using GRADE. The primary outcomes were sleep quality, insomnia severity, sleep‐onset latency, total sleep time, sleep interruption, sleep efficiency and adverse events. Data on the predefined outcome measures were included in meta‐analyses when consistently reported by at least two studies that were homogeneous in terms of participants, interventions and outcomes. We undertook meta‐analyses using random‐effects models. Main results We included 13 studies (eight studies new to this update) comprising 1007 participants. The studies examined the effect of listening to prerecorded music daily, for 25 to 60 minutes, for a period of three days to three months. The risk of bias within the studies varied, with all studies being at high risk of performance bias, because of limited possibilities to blind participants to the music intervention. Some studies were at high risk of detection bias or other bias. Four studies reported funding from national research councils, three studies reported financial support from university sources and one study reported a grant from a private foundation. Five studies did not report any financial support. At the end of the intervention, we found moderate‐certainty evidence for improved sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI) in themusic groups compared to no intervention or TAU (mean difference (MD) −2.79, 95% confidence interval (CI) −3.86 to −1.72; 10 studies, 708 participants). The PSQI scale ranges from 0 to 21 with higher scores indicating poorer sleep. The size of the effect indicates an increase in sleep quality of the size of about one standard deviation in favour of the intervention. We found no clear evidence of a difference in the effects of listening to music compared to no treatment or TAU on insomnia severity (MD −6.96, 95% CI −15.21 to 1.28; 2 studies, 63 participants; very low‐certainty evidence). We found low‐certainty evidence that, compared to no treatment or TAU, listening to music may reduce problems with sleep‐onset latency (MD −0.60, 95% CI −0.83 to −0.37; 3 studies, 197 participants), total sleep time (MD −0.69, 95% CI −1.16 to −0.23; 3 studies, 197 participants) and sleep efficiency (MD −0.96, 95% CI −1.38 to −0.54; 3 studies, 197 participants), but may have no effect on perceived sleep interruption (MD −0.53, 95% CI −1.47 to 0.40; 3 studies, 197 participants). In addition, three studies (136 participants) included objective measures of sleep‐onset latency, total sleep time, sleep efficiency and sleep interruption and showed that listening to music may not improve these outcomes compared to no treatment or TAU. None of the included studies reported any adverse events. Authors' conclusions The findings of this review provide evidence that music may be effective for improving subjective sleep quality in adults with symptoms of insomnia. More research is needed to establish the effect of listening to music on other aspects of sleep as well as the daytime consequences of insomnia. Plain language summary Music for insomnia in adults Review question This review assessed the effects of listening to music on insomnia (sleep problems) in adults and the impact of factors that may influence the effect. Key messages We found a beneficial effect of music on sleep quality. For all the other outcomes, we did not find enough good‐quality evidence as there were too few participants and the people doing the scoring of the data were aware of the treatment. What is insomnia? Worldwide, millions of people experience insomnia. People can have difficulties getting to sleep, staying asleep or may experience poor sleep quality. Poor sleep affects people's physical and mental health. The consequences of poor sleep are costly, for both individuals and society. Many people listen to music to improve their sleep, but the effect of listening to music is unclear. What did we do? We searched electronic databases to identify relevant studies. We included 13 studies with 1007 participants. The studies compared the effect of listening to music to treatment as usual or no treatment. Treatment as usual could be sleep hygiene education (learning a set of rituals to help with sleep) or standard care for participants with insomnia related to chronic medical conditions. The studies examined the effect of listening to prerecorded music daily, for 25 to 50 minutes, for three days to three months. Seven of the included studies reported funding from national research councils or university sources, and one study reported funding from a private foundation. Five studies did not report any funding sources. What did we find? Ten studies measured sleep quality, and the results showed that music probably facilitates a large improvement in the quality of sleep compared to no treatment or treatment as usual. We do not know if listening to music has an effect on the severity of insomnia (difficulty in falling or staying asleep) or the number of times a person wakes up (broken sleep) compared to no treatment or treatment as usual. Listening to music may improve slightly sleep‐onset latency (how quickly a person falls asleep), sleep duration (length of time a person is asleep) and sleep efficiency (amount of a time a person is asleep compared to the total time spent in bed), compared to no treatment or treatment as usual. None of the studies reported any negative effects caused by listening to music. What are the limitations of the evidence? The quality of evidence from the 10 studies that examined sleep quality was moderate. Our confidence in the evidence for the quality of sleep is only moderate because the people in the studies were aware of which treatment they were getting and the people scoring the data were also sometimes aware of which treatment the participants were getting, which could introduce bias. We have little confidence in the evidence for the severity of insomnia because the studies were very small and were done in different types of people who knew which treatment they were getting. Our confidence in the evidence on sleep‐onset latency, sleep duration and sleep efficiency is low because the studies used very different methods to measure these outcomes, and the people in the studies were aware of the nature of the treatment. We have little confidence in the evidence on sleep interruption because the studies used different methods and showed different results. Furthermore, the participants in the studies knew which treatment they were getting. Future studies should assess other aspects of sleep as well as measures of daytime functioning, such as mood, fatigue, concentration, and quality of life. How up to date is this evidence? The evidence is current to 31 December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jespersen, KV; Pando-Naude, V; Koenig, J; Jennum, P; Vuust, P", "articleTypes": [], "doi": "10.1002/14651858.CD010459.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "7a89a44c-e5c9-40b5-b0c7-0c9949ed23a1", "pmid": "", "title": "Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents", "imported": false, "abstract": "Abstract - Background Vomiting is a common manifestation of acute gastroenteritis in children and adolescents. When untreated it can be a hindrance to oral rehydration therapy, which is the cornerstone in the management of acute gastroenteritis. Evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in acute gastroenteritis in children. Objectives To assess the safety and effectiveness of antiemetics on gastroenteritis induced vomiting in children and adolescents. Search methods We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conferences.The search was re‐run and is up to date as on 20 July 2010. Selection criteria Randomized controlled trials comparing antiemetics with placebo or no treatment, in children and adolescents under the age of 18, for vomiting due to gastroenteritis. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We included seven trials involving 1,020 participants. Mean time to cessation of vomiting in one study was 0.34 days less with dimenhydrinate suppository compared to placebo (P value = 0.036). Pooled data from three studies comparing oral ondansetron with placebo showed: a reduction in the immediate hospital admission rate (RR 0.40, NNT 17, 95% CI 10 to 100) but no difference between the hospitalization rates at 72 hours after discharge from the Emergency Department (ED); a reduction in IV rehydration rates both during the ED stay (RR 0.41, NNT 5, 95% CI 4 to 8), and in follow‐up to 72 hours after discharge from the ED stay (worst‐best scenario for ondansetron RR 0.57, NNT 6, 95% CI 4 to 13) and an increase in the proportion of patients with cessation of vomiting (RR 1.34, NNT 5, 95% CI 3 to 7)). No significant difference was noted in the revisit rates or adverse events, although diarrhea was reported as a side effect in four of the five ondansetron studies. In one study the proportion of patients with cessation of vomiting in 24 hours was (58%) with IV ondansetron, (17%) placebo and (33%) in the metoclopramide group (P value = 0.039). Authors' conclusions Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting. Plain language summary Anti‐sickness medication for vomiting in acute stomach upsets in children Vomiting caused by acute gastroenteritis is very common in children and adolescents. Treatment of vomiting in children with acute gastroenteritis can be problematic and there is lack of agreement among clinicians on the indications for the use of antiemetics. There have also been concerns expressed about apparently unacceptable levels of side effects with some of the older generation of antiemetics. The small number of included trials provided evidence which appeared to favour the use of antiemetics over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. A single oral dose of ondansetron given to children with mild to moderate dehydration can control vomiting, avoid hospitalization and intravenous fluid administration which would otherwise be needed. There were no major side effects other than a few reports of increased frequency of diarrhea.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fedorowicz, Z; Jagannath, VA; Carter, B", "articleTypes": [], "doi": "10.1002/14651858.CD005506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "7a933430-8f58-4c67-b4ed-fef057b5a8ed", "pmid": "", "title": "Anticoagulation for people receiving long‐term haemodialysis", "imported": false, "abstract": "Abstract - Background Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding. Objectives To assess the efficacy and safety of anticoagulation strategies (including both heparin and non‐heparin drugs) for long‐term HD in people with kidney failure. Any intervention preventing clotting within the extracorporeal circuit without establishing anticoagulation within the patient, such as regional citrate, citrate enriched dialysate, heparin‐coated dialysers, pre‐dilution haemodiafiltration (HDF), and saline flushes were also included. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to November 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐randomised controlled studies (quasi‐RCTs) evaluating anticoagulant agents administered during HD treatment in adults and children with kidney failure. Data collection and analysis Two authors independently assessed the risk of bias using the Cochrane tool and extracted data. Treatment effects were estimated using random effects meta‐analysis and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE). Main results We included 113 studies randomising 4535 participants. The risk of bias in each study was adjudicated as high or unclear for most risk domains. Compared to UFH, LMWH had uncertain effects on extracorporeal circuit thrombosis (3 studies, 91 participants: RR 1.58, 95% CI 0.46 to 5.42; I 2 = 8%; low certainty evidence), while major bleeding and minor bleeding were not adequately reported. Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH (2 studies, 82 participants: RR 0.34, 95% CI 0.14 to 0.85; I 2 = 0%; low certainty evidence). No studies reported data comparing regional citrate to UFH on risks of extracorporeal circuit thrombosis and major bleeding. The effects of very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors or heparin‐grafted membranes were uncertain due to insufficient data. The effects of different LMWH, different doses of LMWH, and the administration of LMWH anticoagulants using inlet versus outlet bloodline or bolus versus infusion were uncertain. Evidence to compare citrate to another citrate or control was scant. The effects of UFH compared to no anticoagulant therapy or different doses of UFH were uncertain. Death, dialysis vascular access outcomes, blood transfusions, measures of anticoagulation effect, and costs of interventions were rarely reported. No studies evaluated the effects of treatment on non‐fatal myocardial infarction, non‐fatal stroke and hospital admissions. Adverse events were inconsistently and rarely reported. Authors' conclusions Anticoagulant strategies, including UFH and LMWH, have uncertain comparative risks on extracorporeal circuit thrombosis, while major bleeding and minor bleeding were not adequately reported. Regional citrate may decrease minor bleeding, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported. Evidence supporting clinical decision‐making for different forms of anticoagulant strategies for HD is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes. Plain language summary Treatments to thin the blood during haemodialysis: which treatments reduce clotting problems without causing bleeding? What is the issue? When people have dialysis using a machine to clean their blood (called haemodialysis (HD)), blood‐thinning treatment helps prevent blood clots in the dialysis tubing. However, thinning the blood too much with treatment can lead to bleeding problems. There are several different medications to thin the blood, but it is not clear which is the best or the safest choice. What did we do? We searched for all the research trials that assessed the blood thinning treatments during HD for adults and children up until November 2023. We measured the certainty we could have about the results of this research using \"GRADE\". What did we find? We found 113 studies involving 4535 patients treated with HD. Patients were given different forms of blood thinning therapy. The treatment they got was decided by random chance (like the toss of a coin). Most of the studies looked at a treatment called \"low molecular weight heparin\" and compared this with standard blood thinning care (called \"standard heparin\"). Unfortunately, the studies included only a small number of patients and only looked for risks of clotting or bleeding during one or two months of therapy. Because of this short time frame, and other limitations of the research studies, we were very uncertain about the results. The current research doesn't tell us whether one blood thinning treatment is better or safer than another for patients during dialysis treatment. Conclusions We still can't be certain about the best way to thin the blood for HD treatment based on existing research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Natale, P; Palmer, SC; Ruospo, M; Longmuir, H; Dodds, B; Prasad, R; Batt, TJ; Jose, MD; Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD011858.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "7a9fb71c-607e-4c1a-8c64-3df226830390", "pmid": "", "title": "Vitamin B12 supplementation for growth, development, and cognition in children", "imported": false, "abstract": "Abstract - Rationale Vitamin B 12 deficiency is an important public health problem in children, and has been associated with anaemia and impaired growth, cognition, and development. Vitamin B 12 deficiency may develop in children due to lower content in breast milk, low dietary intake, and as requirements increase with age. Vitamin B 12 supplementation may confer benefits to child growth and development, due to its role in DNA synthesis and methylation, red blood cell formation, and folate metabolism. However, no systematic reviews have been conducted to examine the effects of vitamin B 12 supplementation in children. Objectives To determine the effects of vitamin B 12 supplementation on growth, development, and cognition in children less than 12 years of age. Search methods We searched CENTRAL, MEDLINE, Embase, 12 other databases, and two trial registries on 23 September 2025. We screened reference lists of studies. Eligibility criteria We included randomised controlled trials evaluating the effects of oral vitamin B 12 supplementation, alone or in combination with other micronutrients, in children < 12 years of age. We excluded cross‐over trials, trials targeting pregnant or breastfeeding women, or participants with critical illnesses, and interventions delivered by intravenous/intramuscular injections. Outcomes Critical outcomes were vitamin B 12 status, anaemia, haemoglobin, growth, cognitive function, developmental outcomes, and any adverse effects. Important outcomes included megaloblastic anaemia, body composition, health‐related quality of life, morbidity, and all‐cause mortality. Risk of bias We used Cochrane RoB 2 to evaluate bias. Synthesis methods We conducted meta‐analyses using fixed‐effect models. If there was substantial heterogeneity, we used random‐effect models. When meta‐analyses were not conducted, we described findings from individual trials, and considered synthesis and presentation of findings using other methods. We used GRADE to evaluate the certainty of evidence for critical outcomes. Included studies We included 16 trials (4083 children; 2 days to 11 years) in 10 countries, including India, Japan, Thailand, Nepal, United Kingdom, Italy, Spain, the United States, El Salvador, and Guatemala. Follow‐up periods for outcomes in most studies ranged from five weeks to 31 months, with one study extending follow‐up to nine years. Duration of vitamin B 12 supplementation varied, ranging from 28 days to 31 months, with doses from 0.9 µg/day to 150 µg/day. Nine trials, including 2391 children, contributed data to meta‐analyses. Synthesis of results Supplementation with vitamin B 12 alone versus placebo There may be little to no difference between groups in height/length (mean difference (MD) ‐0.19 cm, 95% confidence interval (CI) ‐2.44 to 2.06; 2 trials, 143 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (standardised mean difference (SMD) 0.09, 95% CI ‐0.10 to 0.28; 2 trials, 438 children, low‐certainty evidence). There may be little to no difference between groups in motor skill development (6 to 9 years, NEuroPSYchological assessment, Second Edition (NEPSY‐II); 1 trial, 403 children, low‐certainty evidence). Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency (absolute risk difference (ARD) 56 fewer per 1000, 95% CI 68 fewer to 24 fewer; 1.8% versus 7.6%; risk ratio (RR) 0.27, 95% CI 0.11 to 0.69; 3 trials, 642 children; high‐certainty evidence), and probably increases total vitamin B 12 concentrations (MD 68.53 pmol/L, 95% CI 41.83 to 95.23; 7 trials, 705 children; moderate‐certainty evidence), compared to placebo, with an average increase of 68.5 pmol/L. There may be little to no difference between groups in anaemia (ARD 21 more per 1000, 95% CI 26 fewer to 191 more; 9.1% versus 4.5%; RR 1.48, 95% CI 0.41 to 5.27; 2 trials, 144 children; low‐certainty evidence). No trials reported the occurrence of any adverse effects. Supplementation with vitamin B 12 alone versus no intervention The evidence is very uncertain about the effects of vitamin B 12 on height/length (2 trials, 70 children; very low‐certainty evidence), compared to no intervention. No trials reported data for the other critical outcomes. Supplementation with vitamin B 12 and other micronutrients, compared to the same formulation without vitamin B 12 There may be little to no difference between groups in height/length (MD ‐0.22 cm, 95% CI ‐0.65 to 0.20; 2 trials, 608 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (SMD 0.00, 95% CI ‐0.13 to 0.13; 3 trials, 956 children; low‐certainty evidence). There may be little to no difference between groups in development outcomes (e.g. motor skill development) (SMD ‐0.05, 95% CI ‐0.18 to 0.08; 2 trials, 960 children; low‐certainty evidence). Children who received vitamin B 12 supplementation and other micronutrients may have little to no difference in vitamin B 12 deficiency (ARD 2 fewer per 1000, 95% CI 7 fewer to 32 more; 0.7% versus 0.8%; RR 0.77, 95% CI 0.12 to 5.16; 2 trials, 534 children; low‐certainty evidence), or total vitamin B 12 concentrations (MD 34.32 pmol/L, 95% CI ‐31.13 to 99.77; 3 trials, 731 children; low‐certainty evidence), compared to supplements without vitamin B 12 . There may be little to no difference between groups in anaemia (21.7% versus 25.0%; 1 trial, 35 children; low‐certainty evidence). There may be little to no difference between groups in any adverse effects (9.2% versus 5.9%; 1 trial, 574 children; low‐certainty evidence). The certainty of evidence for critical outcomes ranged from high to very low; we downgraded for imprecision due to small sample sizes or few events, risk of bias in outcome measurement, randomisation methods, selective reporting bias, or inconsistency due to substantial statistical heterogeneity. Few studies reported growth, cognition, development, anaemia, or any adverse effects. Authors' conclusions Vitamin B 12 supplementation (alone or when supplemented with other micronutrients) in children may have little to no effect on growth (i.e. height/length), cognitive function (e.g. attention), development outcomes (e.g. motor skill development), or anaemia, compared to placebo, no intervention, or the same supplements without vitamin B 12 . Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency and probably improves total vitamin B 12 concentrations, compared to placebo. However, vitamin B 12 supplementation with other micronutrients may result in little to no difference in vitamin B 12 deficiency and total vitamin B 12 concentrations, compared to the same formulation without vitamin B 12 . Funding This review had no dedicated funding. Registration Protocol available via DOI 10.1002/14651858.CD015264. Plain language summary What are the effects of vitamin B 12 supplementation for children less than 12 years of age? Key messages Vitamin B 12 supplementation reduces the risk of vitamin B 12 deficiency, and probably improves vitamin B 12 levels in children less than 12 years of age, compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient) (that is, children who did not take vitamin B 12 supplements). Vitamin B 12 supplements, with other micronutrients (important vitamins and minerals the body needs in small amounts to function), may result in little to no difference in vitamin B 12 deficiency or total vitamin B 12 levels, compared to children who received the same supplements without vitamin B 12 . The impact of vitamin B 12 supplements on other health outcomes in children is less clear. What is vitamin B 12 ? Vitamin B 12 is an important nutrient that helps make red blood cells and keep the body's cells and nerves healthy. Vitamin B 12 deficiency is an important public health problem, including in children and in resource‐poor settings. Lower vitamin B 12 levels in children have been linked to anaemia (lower haemoglobin levels), and poorer growth, development, and cognition (a child's ability to gain knowledge through thought, understanding, and the senses). What did we want to find out? We wanted to find out if taking vitamin B 12 supplements would improve the nutrition and health of children less than 12 years of age. What did we do? We searched for studies that looked at the effects of vitamin B 12 compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient), no intervention, or the same supplements without vitamin B 12 . We summarised the results of the studies and our confidence in the evidence, based on information such as how the study was done. What did we find? We included 16 studies involving 4083 children less than 12 years of age (2 days to 11 years). Nine studies, including 2391 children, had data that we could analyse. The studies were conducted in 10 countries around the world. In most studies, the outcomes were assessed immediately after the intervention from five weeks to 31 months, with one study assessing outcomes after nine years. Vitamin B 12 supplements were provided from 28 days to 31 months in amounts from 0.9 to 150 micrograms a day. Supplementation with vitamin B 12 alone versus placebo There may be little to no difference in height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplements had less vitamin B 12 deficiency, and probably had higher vitamin B 12 levels, compared to placebo. There may be little to no difference between groups in anaemia. No studies provided data on any unwanted (adverse) effects. Vitamin B 12 alone versus no intervention The evidence is very uncertain for height/length. No studies reported data we could analyse for other outcomes. Vitamin B 12 and other micronutrients, compared to supplements with the same supplement without vitamin B 12 There may be little to no difference between groups for height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplementation (with other nutrients) may have little to no difference in vitamin B 12 deficiency, vitamin B 12 levels, anaemia, or any unwanted effects. What are the limitations of the evidence? The small number and the size of studies were limitations of this review. Few studies reported on health outcomes, including growth, cognition, development, anaemia, or any adverse effects. The different ages of children, and differences in the amount of vitamin B 12 and when the outcomes were measured, are also limitations of this review. How up to date is this evidence? The evidence is up to date as of 23 September 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Larvie, DY, Güitrón Leal, CE, Venkatramanan, S, Palma Molina, XE, Steel, LB, Kuriyan, R, Finkelstein, JL", "articleTypes": [], "doi": "10.1002/14651858.CD015264.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.764Z" }, { "id": "7ac4d5b9-e48a-4fd2-85ee-f0d5e7262c04", "pmid": "", "title": "Corticosteroids for idiopathic pulmonary fibrosis", "imported": false, "abstract": "Abstract - Background Idiopathic pulmonary fibrosis (IPF) is a disease with significant morbidity and mortality. Patients short survival time, high mortality and generally rapid decline raise the importance of early treatment. Current guidelines suggest a combination of corticosteroids and immunosuppressants as \"gold standard\" for IPF treatment, although the evidence for this recommendation is weak. Based on animal models, it has been hypothesized a central role for aberrant wound healing following repeated epithelial lung injury, weakening the rationale for using corticosteroids in IPF, previously thought to be a chronic inflammatory disease. Objectives The aim of the review is to determine the efficacy of corticosteroids in the treatment of adults with familial and sporadic IPF. Search methods We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2008), MEDLINE (January 1966 to June 2008) and EMBASE (January 1985 to June 2008) and reference lists of articles. We searched reference lists of published articles to identify clinical trials. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) using corticosteroids alone for the treatment of adults with IPF. Data collection and analysis Abstracts of identified articles were retrieved and articles possibly fulfilling inclusion criteria were retrieved in full. Two reviewers would have independently assessed trial quality if there had been any included study. Main results Seventeen articles were selected as potentially eligible for meta‐analysis. After further analysis of full text papers, no RCTs or CCTs were identified as suitable and therefore no data was available for inclusion in any meta‐analysis. All studies were excluded due to inadequate methodologies. Authors' conclusions At present, there is no evidence for an effect of corticosteroid treatment in patients with IPF. On the other hand, other fibrotic lung diseases, such as non‐specific interstitial pneumonia (NSIP), are reported to show a better response to corticosteroids. Making a clear distinction between IPF and other entities grouped under the umbrella term interstitial lung disease is, therefore, essential as this may have therapeutic and prognostic implications. Plain language summary Currently there is no evidence to support the routine use of corticosteroids alone in the management of idiopathic pulmonary fibrosis. Idiopathic pulmonary fibrosis (IPF) is a chronic disorder of unknown cause that is progressive and leads to death. Existing evidence about the treatment of IPF is difficult to interpret because of evolving diagnostic criteria and classification schemes, grouping together diverse entities with markedly different natural histories and responses to therapy. Therefore, because the old studies did not include only IPF patients, their results cannot be extended to IPF as they are currently defined. In addition, methodologic problems mainly related to the lack of randomized placebo‐controlled treatment trials have made evidence‐based conclusions difficult. A systematic search for high quality placebo‐controlled randomised trials comparing corticosteroid treatment with placebo in subjects with a diagnosis of IPF was unable to identify any studies suitable for inclusion in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Richeldi, L, Davies, HRHR, Spagnolo, P, Luppi, F", "articleTypes": [], "doi": "10.1002/14651858.CD002880", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.754Z" }, { "id": "7ad251a1-34c8-4ab6-a3ea-419ad2f3cc8b", "pmid": "", "title": "Antithyroid drug regimen for treating Graves' hyperthyroidism", "imported": false, "abstract": "Abstract - Background Antithyroid drugs are widely used in the therapy of hyperthyroidism. There are wide variations in the dose, regimen or duration of treatment used by health professionals. Objectives To assess the effects of dose, regimen and duration of antithyroid drug therapy for Graves' hyperthyroidism. Search methods We searched seven databases and reference lists. Selection criteria Randomised and quasi‐randomised trials of antithyroid medication for Graves' hyperthyroidism. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Pooling of data for primary outcomes, and select exploratory analyses were undertaken. Main results Twenty‐six randomised trials involving 3388 participants were included. Overall the quality of trials, as reported, was poor. None of the studies investigated incidence of hypothyroidism, changes in weight, health‐related quality of life, ophthalmopathy progression or economic outcomes. Four trials examined the effect of duration of therapy on relapse rates, and when using the titration regimen 12 months was superior to six months, but there was no benefit in extending treatment beyond 18 months. Twelve trials examined the effect of block‐replace versus titration block‐regimens. The relapse rates were similar in both groups at 51% in the block‐replace group and 54% in the titration block‐group (OR 0.86, 95% confidence interval (CI) 0.68 to1.08) though adverse effects (rashes (10% versus 6%) and withdrawing due to side effects (16% versus 9%)) were significantly higher in the block‐replace group. Three studies considered the addition of thyroxine with continued low dose antithyroid therapy after initial therapy with antithyroid drugs. There was significant heterogeneity between the studies and the difference between the two groups was not significant (OR 0.58, 95% CI 0.05 to 6.21). Four studies considered the addition of thyroxine alone after initial therapy with antithyroid drugs. There was no significant difference in the relapse rates between the groups after 12 months follow‐up (OR 1.15, 95% CI 0.79 to 1.67). Two studies considered the addition of immunosuppressive agents. The results which were in favour of the interventions would need to be validated in other populations. Authors' conclusions The evidence suggests that the optimal duration of antithyroid drug therapy for the titration regimen is 12 to 18 months. The titration (low dose) regimen had fewer adverse effects than the block‐replace (high dose) regimen and was no less effective. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Immunosuppressive therapies need further evaluation. Plain language summary Antithyroid drug regimen for treating Graves' hyperthyroidism People who have Graves' hyperthyroidism have thyroid glands which are releasing too much thyroid hormone. This can cause goitres (swelling in the neck around the thyroid gland), sweating, bowel or menstrual problems, and other, especially eye symptoms (ophthalmopathy). Treatments include anti‐thyroid drugs, surgery or radiation to reduce thyroid tissue. There are several choices to be made when considering the drug treatment of Graves' hyperthyroidism including the choice of drug, dose, duration of therapy, addition of thyroid hormone (thyroxine) and when to discontinue therapy. The antithyroid drugs which were used in the included randomised controlled trials (RCTs) comprised carbimazole, propylthiouracil and methimazole. Twenty‐six RCTs involving 3388 participants were identified. The majority of participants in all the studies were female (83% in the studies reporting sex distribution). The mean age was 40 years. The duration of follow up was between two to five years in eleven trials. In high dose ('block‐replace') versus low dose ('titration') studies the duration of therapy was six months in two studies, 18 months in four studies and 12 months in the remaining trials. The main outcome was the relapse rate of hyperthyroidism over one year after completion of drug treatment and this was the primary outcome in all the studies assessed. There were no deaths reported in any of the studies. None of the studies detailed incidence of hypothyroidism, changes in weight during the course of therapy, health‐related quality of life, ophthalmopathy progression or economic outcomes. The evidence (based on four studies) suggests that the optimal duration of antithyroid drug therapy for the low dose regimen is 12 to 18 months. The low dose regimen had fewer adverse effects than the high dose regimen and was no less effective in trials (based on 12 trials) of equal duration. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Studies using immunosuppressive agents need further validation of safety and efficacy in controlled trials among different populations. Data regarding side effects and number of participants withdrawn from therapy due to side effects were available in seven studies. The number of participants reporting rashes was significantly higher in the high versus low dose group (10% versus 6%). The number of participants withdrawing due to side effects were also significantly higher in the high versus low dose group (16% versus 9%).", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Abraham, P, Avenell, A, McGeoch, SC, Clark, LF, Bevan, JS", "articleTypes": [], "doi": "10.1002/14651858.CD003420.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.799Z" }, { "id": "7ae5618c-00c8-46c7-b0cf-c79e06852cf9", "pmid": "", "title": "Lactoferrin for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "Abstract - Background Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be due in part to disruption of the integrity of the gut and its altered intestinal microflora. Lactoferrin is a whey protein found in milk and is an important innate mammalian defence mechanism. Lactoferrin has been reported to have antimicrobial and anti‐inflammatory properties. It has also been reported to help establish a healthy gut microflora and aid in the intestinal immune system. Lactoferrin supplementation has been reported to decrease sepsis in preterm infants. There may be a role for lactoferrin to reduce the incidence of sepsis, thus reducing morbidity and mortality and improving enteral feeding in postoperative term neonates. Objectives The primary objective of this review was to evaluate the efficacy of administering lactoferrin on the incidence of sepsis and mortality in term neonates after gastrointestinal surgery. The secondary objective was to assess the impact of administering lactoferrin on time to full enteral feeds, the intestinal microflora, duration of hospital stay, and mortality before discharge in the same population. Search methods The Cochrane Neonatal Information Specialist searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase Ovid, CINAHL, the WHO ICTRP and ClinicalTrials.gov trials registries. The date of the last search was February 2023. There were no restrictions to language, publication year or publication type. We checked references of potentially relevant studies and systematic reviews. Selection criteria We planned to include randomised controlled trials that studied infants born at 37 or more weeks of gestation who had one or more episodes of gastrointestinal surgery within 28 days of birth, and compared administration of lactoferrin with a placebo. Data collection and analysis We used standard Cochrane methodological procedures. We planned to use the GRADE approach to assess the certainty of evidence for each outcome. Main results We identified no published randomised controlled studies that assessed the efficacy of lactoferrin for the postoperative management of term neonates following gastrointestinal surgery. Authors' conclusions There is currently no evidence available from randomised controlled trials to show whether lactoferrin is effective or ineffective for the postoperative management of term neonates after gastrointestinal surgery. There is a need for randomised controlled trials to be performed to assess the role of lactoferrin in this setting. Plain language summary What are the benefits and risks of giving lactoferrin to full‐term babies who had digestive tract surgery? Key message We found no medical studies that investigated the effects of giving lactoferrin (a protein found in milk) to babies born at full‐term (at or after 37 weeks of pregnancy) who had surgery of their digestive tract. What is lactoferrin? Lactoferrin is a protein found in milk that can protect against infection. Lactoferrin supplements are available and have been researched in premature babies. There is some evidence that lactoferrin can prevent infection in premature babies. What are some of the risks of digestive tract surgery in babies? Surgery of the digestive tract increases the risk of infection. Infections can increase the length of stay in hospital. Treatment with antibiotics (medicines that fight bacterial infections) and stress from surgery can disrupt good bacteria in the digestive tract. What did we want to find out? We wanted to find out if giving lactoferrin to full‐term babies, after digestive tract surgery, decreased rates of infection and death, and improved the presence of good bacteria in the digestive tract. What did we do? We searched for studies in which babies who had digestive tract surgery were assigned randomly to lactoferrin or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested). What did we find? We did not find any studies that compared giving lactoferrin to a placebo in full‐term babies who had digestive tract surgery. Well‐designed and large studies are needed to answer this question. How up to date is this evidence? The search is up‐to‐date as of February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Trivedi, A, Maheshwari, R, Tarnow-Mordi, WO, Saxena, N", "articleTypes": [], "doi": "10.1002/14651858.CD012218.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.775Z" }, { "id": "7ae97baf-89d6-4d39-8450-107a5e7c23dd", "pmid": "", "title": "Reduced dietary salt for the prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review that was first published in 2011 of the effects of reducing dietary salt intake, through advice to reduce salt intake or low‐sodium salt substitution, on mortality and cardiovascular events. Objectives 1. To assess the long‐term effects of advice and salt substitution, aimed at reducing dietary salt, on mortality and cardiovascular morbidity. 2. To investigate whether a reduction in blood pressure is an explanatory factor in the effect of such dietary interventions on mortality and cardiovascular outcomes. Search methods We updated the searches of CENTRAL (2013, Issue 4), MEDLINE (OVID, 1946 to April week 3 2013), EMBASE (OVID, 1947 to 30 April 2013) and CINAHL (EBSCO, inception to 1 April 2013) and last ran these on 1 May 2013. We also checked the references of included studies and reviews. We applied no language restrictions. Selection criteria Trials fulfilled the following criteria: (1) randomised, with follow‐up of at least six months, (2) the intervention was reduced dietary salt (through advice to reduce salt intake or low‐sodium salt substitution), (3) participants were adults and (4) mortality or cardiovascular morbidity data were available. Two review authors independently assessed whether studies met these criteria. Data collection and analysis A single author extracted data and assessed study validity, and a second author checked this. We contacted trial authors where possible to obtain missing information. We extracted events and calculated risk ratios (RRs) and 95% confidence intervals (CIs). Main results Eight studies met the inclusion criteria: three in normotensives (n = 3518) and five in hypertensives or mixed populations of normo‐ and hypertensives (n = 3766). End of trial follow‐up ranged from six to 36 months and the longest observational follow‐up (after trial end) was 12.7 years. The risk ratios (RR) for all‐cause mortality in normotensives were imprecise and showed no evidence of reduction (end of trial RR 0.67, 95% confidence interval (CI) 0.40 to 1.12, 60 deaths; longest follow‐up RR 0.90, 95% CI 0.58 to 1.40, 79 deaths n=3518) or in hypertensives (end of trial RR 1.00, 95% CI 0.86 to 1.15, 565 deaths; longest follow‐up RR 0.99, 95% CI 0.87 to 1.14, 674 deaths n=3085). There was weak evidence of benefit for cardiovascular mortality (hypertensives: end of trial RR 0.67, 95% CI 0.45 to 1.01, 106 events n=2656) and for cardiovascular events (hypertensives: end of trial RR 0.76, 95% CI 0.57 to 1.01, 194 events, four studies, n = 3397; normotensives: at longest follow‐up RR 0.84, 95% CI 0.64 to 1.10, 200 events; hypertensives: RR 0.77, 95% CI 0.58 to 1.02, 192 events; pooled analysis of six trials (RR 0.81, 95% CI 0.66 to 0.98; n = 5762). These findings were driven by one trial among retirement home residents that reduced salt intake in the kitchens of the homes, thereby not requiring individual behaviour change. Advice to reduce salt showed small reductions in systolic blood pressure (mean difference (MD) ‐1.15 mmHg, 95% CI ‐2.32 to 0.02 n=2079) and diastolic blood pressure (MD ‐0.80 mmHg, 95% CI ‐1.37 to ‐0.23 n=2079) in normotensives and greater reductions in systolic blood pressure in hypertensives (MD ‐4.14 mmHg, 95% CI ‐5.84 to ‐2.43 n=675), but no difference in diastolic blood pressure (MD ‐3.74 mmHg, 95% CI ‐8.41 to 0.93 n=675). Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Health‐related quality of life was assessed in one trial in normotensives, which reported significant improvements in well‐being but no data were presented. Authors' conclusions Despite collating more event data than previous systematic reviews of randomised controlled trials, there is insufficient power to confirm clinically important effects of dietary advice and salt substitution on cardiovascular mortality in normotensive or hypertensive populations. Our estimates of the clinical benefits from advice to reduce dietary salt are imprecise, but are larger than would be predicted from the small blood pressure reductions achieved. Further well‐powered studies would be needed to obtain more precise estimates. Our findings do not support individual dietary advice as a means of restricting salt intake. It is possible that alternative strategies that do not require individual behaviour change may be effective and merit further trials. Plain language summary Reduced dietary salt for the prevention of cardiovascular disease Cardiovascular disease includes heart attacks and strokes and is a major cause of premature death and disability. This is an update of a review first published in 2011. This review sets out to assess whether intensive support and encouragement to cut down on salt in foods, and substituting low‐sodium salt, reduces the risk of death or cardiovascular disease. This update includes two new studies and eliminates one problematic study, giving a total of eight trials with 7284 participants. Dietary advice and salt substitution did reduce the amount of salt eaten, which led to a small reduction in blood pressure by six months. There was weak evidence of benefit for cardiovascular events, but these findings were inconclusive and were driven by a single trial among retirement home residents, which reduced salt intake in the kitchens of the homes. The findings of our review do not mean that advising people to reduce salt should be stopped. However, additional measures ‐ reducing the amount of hidden salt in processed foods, for example – will make it much easier for people to achieve a lower salt diet. Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Further evidence of the effects of different ways of reducing dietary salt on clinical events is needed from experimental and observational studies to underpin public health policies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Adler, AJ; Taylor, F; Martin, N; Gottlieb, S; Taylor, RS; Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD009217.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "7ae9e6a5-cfc2-44f7-a368-f5279ebc0684", "pmid": "", "title": "Crave Crush: Sugar Cravings and ad Lib Candy Uptake", "imported": false, "abstract": "The purpose of the research is to determine if participants who take \"Crave Crush\" will report lower cravings and palatability ratings of candy as compared to subjects who receive the placebo. Participants are self-selected university students who pass our table and verbally agree to participate in a research study about taste preferences. Data will be recorded anonymously.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.147Z" }, { "id": "7b1d265d-f73b-4a40-a5a6-6016e58499ba", "pmid": "", "title": "Protein and energy supplementation in elderly people at risk from malnutrition", "imported": false, "abstract": "Abstract - Background Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. Objectives This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip‐feeds'. Search methods We searched The Cochrane Library , MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip‐feed' manufacturers. Selection criteria Randomised and quasi‐randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. Data collection and analysis Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. Main results Sixty‐two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97). The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (‐0.8 days, 95% CI ‐2.8 to 1.3). Adverse effects included nausea or diarrhoea. Authors' conclusions Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large‐scale multi‐centre trials are still required. Plain language summary Protein and energy supplementation in elderly people at risk from malnutrition Much emphasis is placed on the importance of good diet, usually in relation to concern about the health risks of obesity. However it has been generally agreed that the risk of undernutrition rather than overnutrition is the main cause for concern in elderly people, particularly those who are hospitalised or institutionalised. Malnutrition has been shown to have important effects on recovery in a broad range of patients and conditions. It has been associated strongly with impaired immune response, impaired muscle and respiratory function, delayed wound healing, overall increased complications, longer rehabilitation, greater length of hospital stay and increased mortality. Oral protein and energy supplements are potentially safer and easier to administer than nasogastric enteral feeds and are therefore particularly suited to elderly people and are also widely used. However, there may be problems with the willingness and ability of older people to consume oral supplements, and supplements may not be used effectively. Even if supplements are prescribed, they may not always be given, or are given but not consumed. In addition to taste, the composition and timing of administration in relation to meals may be important. Efforts also need to be made to provide normal meals and snacks which meet the needs of elderly people and to provide assistance with feeding if required. A total of 10,187 randomised participants from the 62 trials has been included. Maximum duration of intervention was 18 months. The reviewers suggest that supplementation appears to produce a small but consistent weight gain. There was no evidence in this updated review of a beneficial effect on mortality overall, but there may be a beneficial effect on mortality in people who are undernourished. Supplementation may also reduce the number of complications. The reported acceptance of supplements was variable between trials. Some adverse effects such as nausea or diarrhoea were reported. However, there were problems of study design and quality. More studies are required to confirm the beneficial effect on the number of complications, to establish whether there is a beneficial effect on mortality for undernourished elderly people and to provide evidence about whether protein and energy supplements can improve morbidity and functional status in frail older people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Milne, AC; Potter, J; Vivanti, A; Avenell, A", "articleTypes": [], "doi": "10.1002/14651858.CD003288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "7b228c5a-99bd-480d-afbf-ee81a5196e61", "pmid": "", "title": "Interventions for paracetamol (acetaminophen) overdose", "imported": false, "abstract": "Abstract - Background Paracetamol (acetaminophen) is the most widely used non‐prescription analgesic in the world. Paracetamol is commonly taken in overdose either deliberately or unintentionally. In high‐income countries, paracetamol toxicity is a common cause of acute liver injury. There are various interventions to treat paracetamol poisoning, depending on the clinical status of the person. These interventions include inhibiting the absorption of paracetamol from the gastrointestinal tract (decontamination), removal of paracetamol from the vascular system, and antidotes to prevent the formation of, or to detoxify, metabolites. Objectives To assess the benefits and harms of interventions for paracetamol overdosage irrespective of the cause of the overdose. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register (January 2017), CENTRAL (2016, Issue 11), MEDLINE (1946 to January 2017), Embase (1974 to January 2017), and Science Citation Index Expanded (1900 to January 2017). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov database (US National Institute of Health) for any ongoing or completed trials (January 2017). We examined the reference lists of relevant papers identified by the search and other published reviews. Selection criteria Randomised clinical trials assessing benefits and harms of interventions in people who have ingested a paracetamol overdose. The interventions could have been gastric lavage, ipecacuanha, or activated charcoal, or various extracorporeal treatments, or antidotes. The interventions could have been compared with placebo, no intervention, or to each other in differing regimens. Data collection and analysis Two review authors independently extracted data from the included trials. We used fixed‐effect and random‐effects Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of the review outcomes. We used the Cochrane 'Risk of bias' tool to assess the risks of bias (i.e. systematic errors leading to overestimation of benefits and underestimation of harms). We used Trial Sequential Analysis to control risks of random errors (i.e. play of chance) and GRADE to assess the quality of the evidence and constructed 'Summary of findings' tables using GRADE software. Main results We identified 11 randomised clinical trials (of which one acetylcysteine trial was abandoned due to low numbers recruited), assessing several different interventions in 700 participants. The variety of interventions studied included decontamination, extracorporeal measures, and antidotes to detoxify paracetamol's toxic metabolite; which included methionine, cysteamine, dimercaprol, or acetylcysteine. There were no randomised clinical trials of agents that inhibit cytochrome P‐450 to decrease the activation of the toxic metabolite N ‐acetyl‐ p ‐benzoquinone imine. Of the 11 trials, only two had two common outcomes, and hence, we could only meta‐analyse two comparisons. Each of the remaining comparisons included outcome data from one trial only and hence their results are presented as described in the trials. All trial analyses lack power to access efficacy. Furthermore, all the trials were at high risk of bias. Accordingly, the quality of evidence was low or very low for all comparisons. Interventions that prevent absorption, such as gastric lavage, ipecacuanha, or activated charcoal were compared with placebo or no intervention and with each other in one four‐armed randomised clinical trial involving 60 participants with an uncertain randomisation procedure and hence very low quality. The trial presented results on lowering plasma paracetamol levels. Activated charcoal seemed to reduce the absorption of paracetamol, but the clinical benefits were unclear. Activated charcoal seemed to have the best risk:benefit ratio among gastric lavage, ipecacuanha, or supportive treatment if given within four hours of ingestion. There seemed to be no difference between gastric lavage and ipecacuanha, but gastric lavage and ipecacuanha seemed more effective than no treatment (very low quality of evidence). Extracorporeal interventions included charcoal haemoperfusion compared with conventional treatment (supportive care including gastric lavage, intravenous fluids, and fresh frozen plasma) in one trial with 16 participants. The mean cumulative amount of paracetamol removed was 1.4 g. One participant from the haemoperfusion group who had ingested 135 g of paracetamol, died. There were no deaths in the conventional treatment group. Accordingly, we found no benefit of charcoal haemoperfusion (very low quality of evidence). Acetylcysteine appeared superior to placebo and had fewer adverse effects when compared with dimercaprol or cysteamine. Acetylcysteine superiority to methionine was unproven. One small trial (low quality evidence) found that acetylcysteine may reduce mortality in people with fulminant hepatic failure (Peto OR 0.29, 95% CI 0.09 to 0.94). The most recent randomised clinical trials studied different acetylcysteine regimens, with the primary outcome being adverse events. It was unclear which acetylcysteine treatment protocol offered the best efficacy, as most trials were underpowered to look at this outcome. One trial showed that a modified 12‐hour acetylcysteine regimen with a two‐hour acetylcysteine 100 mg/kg bodyweight loading dose was associated with significantly fewer adverse reactions compared with the traditional three‐bag 20.25‐hour regimen (low quality of evidence). All Trial Sequential Analyses showed lack of sufficient power. Children were not included in the majority of trials. Hence, the evidence pertains only to adults. Authors' conclusions These results highlight the paucity of randomised clinical trials comparing different interventions for paracetamol overdose and their routes of administration and the low or very low level quality of the evidence that is available. Evidence from a single trial found activated charcoal seemed the best choice to reduce absorption of paracetamol. Acetylcysteine should be given to people at risk of toxicity including people presenting with liver failure. Further randomised clinical trials with low risk of bias and adequate number of participants are required to determine which regimen results in the fewest adverse effects with the best efficacy. Current management of paracetamol poisoning worldwide involves the administration of intravenous or oral acetylcysteine which is based mainly on observational studies. Results from these observational studies indicate that treatment with acetylcysteine seems to result in a decrease in morbidity and mortality, However, further evidence from randomised clinical trials comparing different treatments are needed. Plain language summary Interventions for paracetamol (acetaminophen) overdose Review question: in this review, we looked at the evidence for the interventions (treatments) used to treat people with paracetamol (acetaminophen) poisoning. Mainly, we tried to assess what effects the interventions had on the number of deaths and the need for a liver transplant. Background: paracetamol is one of the most common drugs taken in overdose. Intentional or accidental poisoning with paracetamol is a common cause of liver injury. Search date: the evidence is current to January 2017. Study characteristics: randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) where participants had come to medical attention because they had taken a paracetamol overdose, intentionally or by accident, regardless of the amount of paracetamol taken or the age, sex, or other medical conditions of the person involved. There are many different interventions that can be used to try to treat people with paracetamol poisoning. These interventions include decreasing the absorption of the paracetamol ingested and hence decreasing the amount absorbed into the bloodstream. The agents include activated charcoal (that binds paracetamol together in the stomach), gastric lavage (stomach washout to remove as much paracetamol as possible), or ipecacuanha (a syrup that is swallowed and causes vomiting (being sick)). Paracetamol once absorbed into the bloodstream goes to the liver where the majority is broken down to harmless products. However, a small amount of the medicine is converted into a toxic product that the liver can normally handle but, when large amounts of paracetamol are taken, the liver is overwhelmed. As a consequence, the toxic product can damage the liver leading to liver failure, kidney failure, and in some cases death. Other interventions to treat paracetamol poisoning include medicines (antidotes) that may decrease the amount of the toxic products (such as a medicine called cimetidine) or breakdown the toxic products (including medicines called methionine, cysteamine, dimercaprol, or acetylcysteine). Finally, attempts can be made to remove paracetamol and its toxic products from the bloodstream using special blood cleansing equipment. All these treatments were examined. We found 11 randomised clinical trials with 700 participants. Most of these trials looked at different treatments. Key results: activated charcoal, gastric lavage, and ipecacuanha may reduce absorption of paracetamol if started within one to two hours of paracetamol ingestion, but the clinical benefit was unclear. Activated charcoal seems to be the best choice if the person is able to take it. People may not be able to take charcoal if they are drowsy and some may dislike its taste or texture (or both). Of the treatments that remove the toxic products of paracetamol, acetylcysteine seems to reduce the rate of liver injury from paracetamol poisoning. Furthermore, it has fewer side effects than some other antidotes such as dimercaprol and cysteamine; its superiority to methionine was unclear. Acetylcysteine should be given to people with paracetamol poisoning at risk of liver damage, risk is determined by the dose ingested, time of ingestion, and investigations. More recent clinical trials have looked at ways to decrease side effects of intravenous (into a vein) acetylcysteine treatment, by altering the way it is given. These trials have shown that by using a slower infusion and lower initial dose of acetylcysteine, the proportion of side effects such as nausea (feeling sick) and vomiting, and allergy (the body's bad reaction to the medicine such as a rash) may be lowered. Quality of the evidence: this review of interventions for paracetamol poisoning found surprisingly few published randomised clinical trials for this very common condition. Furthermore, the majority of trials had few participants and all were at high risk of bias. Accordingly, the quality of the evidence should be considered as low or very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Chiew, AL, Gluud, C, Brok, J, Buckley, NA", "articleTypes": [], "doi": "10.1002/14651858.CD003328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.796Z" }, { "id": "7b2e776e-0b3b-4273-813d-80d32b44f7c3", "pmid": "", "title": "Non‐nutritive sweeteners for diabetes mellitus", "imported": false, "abstract": "Abstract - Background Products sweetened with non‐nutritive sweeteners (NNS) are widely available. Many people with type 1 or type 2 diabetes use NNS as a replacement for nutritive sweeteners to control their carbohydrate and energy intake. Health outcomes associated with NNS use in diabetes are unknown. Objectives To assess the effects of non‐nutritive sweeteners in people with diabetes mellitus. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Scopus, the WHO ICTRP, and ClinicalTrials.gov. The date of the last search of all databases (except for Scopus) was May 2019. We last searched Scopus in January 2019. We did not apply any language restrictions. Selection criteria We included randomised controlled trials (RCTs) with a duration of four weeks or more comparing any type of NNS with usual diet, no intervention, placebo, water, a different NNS, or a nutritive sweetener in individuals with type 1 or type 2 diabetes. Trials with concomitant behaviour‐changing interventions, such as diet, exercise, or both, were eligible for inclusion, given that the concomitant interventions were the same in the intervention and comparator groups. Data collection and analysis Two review authors independently screened abstracts, full texts, and records retrieved from trials registries, assessed the certainty of the evidence, and extracted data. We used a random‐effects model to perform meta‐analysis, and calculated effect estimates as risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs). We assessed risk of bias using the Cochrane 'Risk of bias' tool and the certainty of evidence using the GRADE approach. Main results We included nine RCTs that randomised a total of 979 people with type 1 or type 2 diabetes. The intervention duration ranged from 4 to 10 months. We judged none of these trials as at low risk of bias for all ’Risk of bias’ domains; most of the included trials did not report the method of randomisation. Three trials compared the effects of a dietary supplement containing NNS with sugar: glycosylated haemoglobin A1c (HbA1c) was 0.4% higher in the NNS group (95% CI −0.5 to 1.2; P = 0.44; 3 trials; 72 participants; very low‐certainty evidence). The MD in weight change was −0.1 kg (95% CI −2.7 to 2.6; P = 0.96; 3 trials; 72 participants; very low‐certainty evidence). None of the trials with sugar as comparator reported on adverse events. Five trials compared NNS with placebo. The MD for HbA1c was 0%, 95% CI −0.1 to 0.1; P = 0.99; 4 trials; 360 participants; very low‐certainty evidence. The 95% prediction interval ranged between −0.3% and 0.3%. The comparison of NNS versus placebo showed a MD in body weight of −0.2 kg, 95% CI −1 to 0.6; P = 0.64; 2 trials; 184 participants; very low‐certainty evidence. Three trials reported the numbers of participants experiencing at least one non‐serious adverse event: 36/113 participants (31.9%) in the NNS group versus 42/118 participants (35.6%) in the placebo group (RR 0.78, 95% CI 0.39 to 1.56; P = 0.48; 3 trials; 231 participants; very low‐certainty evidence). One trial compared NNS with a nutritive low‐calorie sweetener (tagatose). HbA1c was 0.3% higher in the NNS group (95% CI 0.1 to 0.4; P = 0.01; 1 trial; 354 participants; very low‐certainty evidence). This trial did not report body weight data and adverse events. The included trials did not report data on health‐related quality of life, diabetes complications, all‐cause mortality, or socioeconomic effects. Authors' conclusions There is inconclusive evidence of very low certainty regarding the effects of NNS consumption compared with either sugar, placebo, or nutritive low‐calorie sweetener consumption on clinically relevant benefit or harm for HbA1c, body weight, and adverse events in people with type 1 or type 2 diabetes. Data on health‐related quality of life, diabetes complications, all‐cause mortality, and socioeconomic effects are lacking. Plain language summary Non‐nutritive sweeteners for diabetes mellitus Review question Are non‐nutritive sweeteners beneficial or harmful in people with diabetes? Background Non‐nutritive sweeteners are sweetening agents having higher sweetening intensity and lower calorie content per gram compared to caloric sweeteners like sucrose or corn syrups. Both the general population and diabetic people use non‐nutritive sweeteners as a caloric sweetener replacement to control their carbohydrate and energy intake. Most of the non‐nutritive sweeteners approved for human consumption are synthetic (artificial sweeteners); however, increasing numbers of natural non‐caloric sweeteners are becoming available for human consumption. Products sweetened with non‐nutritive sweeteners are widely available on the market: diet beverages, diet yoghourts, desserts, and chewing gums are the most common products containing non‐nutritive sweeteners. Non‐nutritive sweeteners are also available as table‐top sweeteners for use by consumers at home as a sweetening agent for beverages and for cooking and baking. There is very little information about the health consequences of this intensified non‐nutritive sweeteners consumption in people with diabetes. We wanted to find out whether non‐nutritive sweeteners consumption in people with diabetes has an effect on long‐term average blood sugar levels (glycosylated haemoglobin A1c ‐ HbA1c), body weight, side effects, diabetes complications (such as heart attack, eye or kidney disease), and health‐related quality of life. Study characteristics We found nine randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) that allocated people with diabetes to either a group that received a non‐nutritive sweetener or a comparator group. The comparator was usual diet with additional sugar in three studies; placebo (a dummy pill) in five studies; and tagatose (a nutritive low‐calorie sweetener) in one study. The studies included a total of 979 participants; most of the studies were small, with fewer than 100 participants. The length of the studies varied from 4 to 10 months. This evidence is up‐to‐date as of May 2019. Key results Data on health‐related quality of life, diabetes complications, death from any cause, and socioeconomic effects (such as absence from work, visits to general practitioner, medication consumption) were lacking, and data were generally sparse for all comparisons. The available data did not show a clear difference between non‐nutritive sweeteners and sugar, placebo, or the nutritive low‐calorie sweetener tagatose for HbA1c, body weight, and side effects. Certainty of the evidence We rated the overall certainty of the evidence as very low, mainly due to the small numbers of included studies and participants and methodological limitations of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lohner, S; Kuellenberg de Gaudry, D; Toews, I; Ferenci, T; Meerpohl, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD012885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "7b43bd12-b455-4639-918d-6b8dfae44a95", "pmid": "", "title": "The effects of antimicrobial therapy on bacterial vaginosis in non‐pregnant women", "imported": false, "abstract": "Abstract - Background Bacterial vaginosis (BV) is a very common cause of vaginitis that has been associated with a high incidence of obstetric and gynaecologic complications and increased risk of HIV‐1 transmission. This has led to renewed research interest in its treatment. Objectives To assess the effects of antimicrobial agents on BV in non‐pregnant women. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE, LILACS, and African Healthline (December 2007); and proceedings of relevant international conferences (from 1981 to date). Selection criteria Randomised controlled trials comparing any two or more antimicrobial agents, or antimicrobial agents with placebo or no treatment, in women with clinical or Gram‐stain criteria of BV. Data collection and analysis Two authors independently assessed trial quality and extracted data from the original publications while the third author cross checked the data. Main results Twenty‐four trials involving 4422 participants were reviewed. Most examined symptomatic women only. Only seven trials analysed results by intention to treat; we re‐analysed the remainder. Compared with placebo, clindamycin showed a lower rate of treatment failure (relative risk (RR) 0.25, 95% confidence interval (CI) 0.16 to 0.37). Clindamycin and metronidazole showed identical rates of treatment failure, irrespective of regimen type, at two and four‐week follow up (RR 1.01, 95% CI 0.69 to 1.46; RR 0.91, 95% CI 0.70 to 1.18, respectively). Clindamycin tended to cause a lower rate of adverse events (RR 0.75, 95% CI 0.56 to 1.02); metallic taste, and nausea and vomiting were more common in the metronidazole group (RR 0.08, 95% CI 0.1 to 0.59; RR 0.23, 95% CI 0.10 to 0.51, respectively). Given intravaginally as gelatin tablets, lactobacillus was more effective than oral metronidazole (RR 0.20, 95% CI 0.05 to 0.08). Similarly, oral lactobacillus combined with metronidazole was more effective than metronidazole alone (RR 0.33, 95% CI 0.14 to 0.77). Clindamycin showed a lower rate of clinical failure than triple sulfonamide cream (RR 0.46, 95% CI 0.29 to 0.72). Hydrogen peroxide douche showed a higher rate of clinical failure (RR 1.75, 95% CI 1.02 to 3.00) and adverse events (RR 2.33, 95% CI 1.21 to 4.52) than a single 2 g dose of metronidazole. Authors' conclusions Clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus were effective for bacterial vaginosis. Hydrogen peroxide douche and triple sulphonamide cream were ineffective. Metronidazole caused metallic taste, nausea and vomiting. We need better‐designed trials with larger sample sizes to test the effectiveness of promising drugs. Plain language summary The effects of antimicrobial treatment on bacterial vaginosis in non‐pregnant women Bacterial vaginosis (BV) is a very common cause of symptomatic and asymptomatic vaginal infection. It has been associated with a high incidence of obstetric and gynaecologic complications and an increased risk of transmission of HIV (human immunodeficiency virus). This review evaluated the effectiveness and adverse effects of antimicrobial agents used to treat BV in non‐pregnant women. Twenty‐four trials involving 4422 women were reviewed. With regard to less treatment failure, clindamycin was superior to placebo but comparable to metronidazole, irrespective of the dose regimen. Metronidazole tended to cause a higher rate of adverse events, such as metallic taste and nausea and vomiting, than did clindamycin. Oral lactobacillus combined with metronidazole was more effective than metronidazole alone. Administered in an intravaginal gelatin tablet, lactobacillus was also more effective than oral metronidazole. Triple sulfonamide cream was less effective compared with clindamycin. Hydrogen peroxide douche was not as effective as a single 2 g dose of metronidazole yet caused more harms. Only one trial involved asymptomatic women and the result was not conclusive. There was insufficient evidence to reach a conclusion on the effectiveness of other promising drugs. Drugs effective for bacterial vaginosis include clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus. Adverse effects of metronidazole include metallic taste, and nausea and vomiting. Information on possible side effects of lactobacillus preparations is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Oduyebo, OO; Anorlu, RI; Ogunsola, FT", "articleTypes": [], "doi": "10.1002/14651858.CD006055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "7b5258d3-a6b2-4f9d-ba00-c445498ebc77", "pmid": "", "title": "Sensory environment on health‐related outcomes of hospital patients", "imported": false, "abstract": "Abstract - Background Hospital environments have recently received renewed interest, with considerable investments into building and renovating healthcare estates. Understanding the effectiveness of environmental interventions is important for resource utilisation and providing quality care. Objectives To assess the effect of hospital environments on adult patient health‐related outcomes. Search methods We searched: the Cochrane Central Register of Controlled Trials (last searched January 2006); MEDLINE (1902 to December 2006); EMBASE (January 1980 to February 2006); 14 other databases covering health, psychology, and the built environment; reference lists; and organisation websites. This review is currently being updated (MEDLINE last search October 2010), see Studies awaiting classification. Selection criteria Randomised and non‐randomised controlled trials, controlled before‐and‐after studies, and interrupted times series of environmental interventions in adult hospital patients reporting health‐related outcomes. Data collection and analysis Two review authors independently undertook data extraction and 'Risk of bias' assessment. We contacted authors to obtain missing information. For continuous variables, we calculated a mean difference (MD) or standardized mean difference (SMD), and 95% confidence intervals (CI) for each study. For dichotomous variables, we calculated a risk ratio (RR) with 95% confidence intervals (95% CI). When appropriate, we used a random‐effects model of meta‐analysis. Heterogeneity was explored qualitatively and quantitatively based on risk of bias, case mix, hospital visit characteristics, and country of study. Main results Overall, 102 studies have been included in this review. Interventions explored were: 'positive distracters', to include aromas (two studies), audiovisual distractions (five studies), decoration (one study), and music (85 studies); interventions to reduce environmental stressors through physical changes, to include air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), and temperature (one study); and multifaceted interventions (two studies). We did not find any studies meeting the inclusion criteria to evaluate: art, access to nature for example, through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music may improve patient‐reported outcomes such as anxiety; however, the benefit for physiological outcomes, and medication consumption has less support. There are few studies to support or refute the implementation of physical changes, and except for air quality, the included studies demonstrated that physical changes to the hospital environment at least did no harm. Authors' conclusions Music may improve patient‐reported outcomes in certain circumstances, so support for this relatively inexpensive intervention may be justified. For some environmental interventions, well designed research studies have yet to take place. Plain language summary Sensory environment on health‐related outcomes of hospital patients The hospital environment (such as sounds, pictures, aromas, design, air quality, furnishings, architecture, and layout), may have an impact on the health of patients within it. This review aims to summarise the best available evidence on hospital environments, in order to help people involved in the design of hospital environments make decisions that will benefit patients' health. The review identified 102 relevant studies, 85 of which were on the use of music in hospital. Other environmental aspects considered were: aromas (two studies), audiovisual distractions (five studies), decoration (one study), air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), temperature (one study), and multiple design changes (two studies). No studies meeting the inclusion criteria were found to evaluate: art, access to nature for example through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music in hospital may help improve patient‐reported outcomes such as anxiety; however, there is less evidence to support the use of music for physiological outcomes (such as reducing heart rate and blood pressure) and for reducing the use of medications. For other aspects of hospital environments, there are not very many well designed studies to help with making evidence‐based design decisions. The studies that have been included in this review show that physical changes made to 'improve' the hospital environment on the whole do no harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Drahota, A, Ward, D, Mackenzie, H, Stores, R, Higgins, B, Gal, D, Dean, TP", "articleTypes": [], "doi": "10.1002/14651858.CD005315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.826Z" }, { "id": "7b56641d-c06b-40c7-bd6b-7d9e5eccfa6b", "pmid": "", "title": "Zolmitriptan for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a common, disabling condition and a burden for the individual, health services, and society. Zolmitriptan is an abortive medication for migraine attacks, belonging to the triptan family. These medicines work in a different way to analgesics such as paracetamol and ibuprofen. Objectives To determine the efficacy and tolerability of zolmitriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, and the Oxford Pain Relief Database, together with three online databases ( www.astrazenecaclinicaltrials.com , www.clinicaltrials.gov , and apps.who.int/trialsearch ) for studies to 12 March 2014. We also searched the reference lists of included studies and relevant reviews. Selection criteria We included randomised, double‐blind, placebo‐ or active‐controlled studies, with at least 10 participants per treatment arm, using zolmitriptan to treat a migraine headache episode. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate risk ratios and numbers needed to treat for an additional beneficial effect (NNT) or harmful effect (NNH) compared with placebo or a different active treatment. Main results Twenty‐five studies (20,162 participants) compared zolmitriptan with placebo or an active comparator. The evidence from placebo‐controlled studies was of high quality for all outcomes except 24 hour outcomes and serious adverse events where only limited data were available. The majority of included studies were at a low risk of performance, detection and attrition biases, but did not adequately describe methods of randomisation and concealment. Most of the data were for the 2.5 mg and 5 mg doses compared with placebo, for treatment of moderate to severe pain. For all efficacy outcomes, zolmitriptan surpassed placebo. For oral zolmitriptan 2.5 mg versus placebo, the NNTs were 5.0, 3.2, 7.7, and 4.1 for pain‐free at two hours, headache relief at two hours, sustained pain‐free during the 24 hours postdose, and sustained headache relief during the 24 hours postdose, respectively. Results for the oral 5 mg dose were similar to the 2.5 mg dose, while zolmitriptan 10 mg was significantly more effective than 5 mg for pain‐free and headache relief at two hours. For headache relief at one and two hours and sustained headache relief during the 24 hours postdose, but not pain‐free at two hours, zolmitriptan 5 mg nasal spray was significantly more effective than the 5 mg oral tablet. For the most part, adverse events were transient and mild and were more common with zolmitriptan than placebo, with a clear dose response relationship (1 mg to 10 mg). High quality evidence from two studies showed that oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people as oral sumatriptan 50 mg (66%, 67%, and 68% respectively), although not necessarily the same individuals. There was no significant difference in numbers experiencing adverse events. Single studies reported on other active treatment comparisons but are not described further because of the small amount of data. Authors' conclusions Zolmitriptan is effective as an abortive treatment for migraine attacks for some people, but is associated with increased adverse events compared to placebo. Zolmitriptan 2.5 mg and 5 mg benefited the same proportion of people as sumatriptan 50 mg, although not necessarily the same individuals, for headache relief at two hours. Plain language summary Zolmitriptan for acute migraine attacks in adults Migraine is a complex condition with a wide variety of symptoms. It affects about 1 person in 8, mainly women aged 30 to 50 years. For many people, the main feature is a painful, and often disabling, headache. Other symptoms include feeling sick, vomiting, disturbed vision, and sensitivity to light, sound, and smells. Zolmitriptan is one of the triptan family of drugs. It is used to treat migraine attacks when they occur, not to prevent attacks occurring. It is available as an oral tablet to swallow whole, an oral tablet to dissolve in the mouth, and a nasal spray. This review looked at 25 studies that involved over 20,000 participants reporting the effects of zolmitriptan on migraine attacks. Most information was for tablets taken by mouth. Overall methodological quality of the included studies was good, and treatment group sizes were large enough to avoid major bias. There were inconsistencies in the way use of rescue medication and adverse events were reported. A single oral dose of zolmitriptan relieved migraine headache pain in some people. Several different pain outcomes were reported. One outcome was pain reduced from moderate or severe to no pain at all two hours after taking treatment. An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 3 in 10 people (30%), compared with about 1 in 10 (10%) taking placebo. Another outcome was pain reduced from moderate or severe to no worse than mild pain two hours after taking treatment (called headache relief). An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 6 in 10 people (61%), compared with 3 in 10 (29%) taking placebo. Slightly better results were obtained with higher doses of 5 mg or 10 mg oral tablets, but the 10 mg dose was associated with more adverse events, most of which were of short duration and mild or moderate in severity. Results for the 5 mg nasal spray were generally similar to those for the oral tablet, but it was significantly better than the tablet at 1 hour. People with migraine want treatment that eliminates the headache and any associated symptoms quickly (maximum two hours) and prevents it returning (within 24 hours). Results indicate that with the 5 mg dose only 14% of those treated were pain‐free at 2 hours with no headache recurrence within 24 hours. Oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people (2 in 3) as oral sumatriptan 50 mg, with no difference in numbers experiencing adverse events. The individuals who respond to each drug may not be the same.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bird, S, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.080Z" }, { "id": "7b6fa68e-2275-408a-b2ce-4791daa75a68", "pmid": "", "title": "Triclosan/copolymer containing toothpastes for oral health", "imported": false, "abstract": "Abstract - Background Periodontal disease and dental caries are highly prevalent oral diseases that can lead to pain and discomfort, oral hygiene and aesthetic problems, and eventually tooth loss, all of which can be costly to treat and are a burden to healthcare systems. Triclosan is an antibacterial agent with low toxicity, which, along with a copolymer for aiding retention, can be added to toothpastes to reduce plaque and gingivitis (inflammation of the gums). It is important that these additional ingredients do not interfere with the anticaries effect of the fluoride present in toothpastes, and that they are safe. Objectives To assess the effects of triclosan/copolymer containing fluoride toothpastes, compared with fluoride toothpastes, for the long‐term control of caries, plaque and gingivitis in children and adults. Search methods We searched the Cochrane Oral Health's Trials Register (to 19 August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 7), MEDLINE via OVID (1946 to 19 August 2013), Embase via OVID (1980 to 19 August 2013), and the US National Institutes of Health Trials Register ( clinicaltrials.gov ) (to 19 August 2013). We applied no restrictions regarding language or date of publication in the searches of the electronic databases. Selection criteria We included randomised controlled trials (RCTs) assessing the effects triclosan/copolymer containing toothpastes on oral health. Data collection and analysis Two review authors independently assessed the search results against the inclusion criteria for this review, extracted data and carried out risk of bias assessments. We attempted to contact study authors for missing information or clarification when feasible. We combined sufficiently similar studies in meta‐analyses using random‐effects models when there were at least four studies (fixed‐effect models when fewer than four studies), reporting mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data. Main results We included 30 studies, analysing 14,835 participants, in this review. We assessed 10 studies (33%) as at low risk of bias, nine (30%) as at high risk of bias and 11 (37%) as unclear. Plaque Compared with control, after six to seven months of use, triclosan/copolymer toothpaste reduced plaque by 0.47 on a 0 to 5 scale (MD ‐0.47, 95% confidence interval (CI) ‐0.60 to ‐0.34, 20 studies, 2675 participants, moderate‐quality evidence). The control group mean was 2.17, representing a 22% reduction in plaque. After six to seven months of use, it also reduced the proportion of sites scoring 3 to 5 on a 0 to 5 scale by 0.15 (MD ‐0.15, 95% CI ‐0.20 to ‐0.10, 13 studies, 1850 participants, moderate‐quality evidence). The control group mean was 0.37, representing a 41% reduction in plaque severity. Gingivitis After six to nine months of use, triclosan/copolymer toothpaste reduced inflammation by 0.27 on a 0 to 3 scale (MD ‐0.27, 95% CI ‐0.33 to ‐0.21, 20 studies, 2743 participants, moderate‐quality evidence). The control group mean was 1.22, representing a 22% reduction in inflammation. After six to seven months of use, it reduced the proportion of bleeding sites (i.e. scoring 2 or 3 on the 0 to 3 scale) by 0.13 (MD ‐0.13, 95% CI ‐0.17 to ‐0.08, 15 studies, 1998 participants, moderate‐quality evidence). The control group mean was 0.27, representing a 48% reduction in bleeding. Periodontitis After 36 months of use, there was no evidence of a difference between triclosan/copolymer toothpaste and control in the development of periodontitis (attachment loss) (RR 0.92, 95% CI 0.67 to 1.27, one study, 480 participants, low‐quality evidence). Caries After 24 to 36 months of use, triclosan/copolymer toothpaste slightly reduced coronal caries when using the decayed and filled surfaces (DFS) index (MD ‐0.16, 95% CI ‐0.31 to ‐0.02, four studies, 9692 participants, high‐quality evidence). The control group mean was 3.44, representing a 5% reduction in coronal caries. After 36 months of use, triclosan/copolymer toothpaste probably reduced root caries (MD ‐0.31, 95% CI ‐0.39 to ‐0.23, one study, 1357 participants, moderate‐quality evidence). Calculus After six months of use, triclosan/copolymer toothpaste may have reduced the mean total calculus per participant by 2.12 mm (MD ‐2.12 mm, 95% CI ‐3.39 to ‐0.84, two studies, 415 participants, low‐quality evidence). The control group mean was 14.61 mm, representing a 15% reduction in calculus. Adverse effects There were no data available for meta‐analysis regarding adverse effects, but 22 studies (73%) reported that there were no adverse effects caused by either the experimental or control toothpaste. There was considerable heterogeneity present in the meta‐analyses for plaque, gingivitis and calculus. Plaque and gingivitis showed such consistent results that it did not affect our conclusions, but the reader may wish to interpret the results with more caution. Authors' conclusions There was moderate‐quality evidence showing that toothpastes containing triclosan/copolymer, in addition to fluoride, reduced plaque, gingival inflammation and gingival bleeding when compared with fluoride toothpastes without triclosan/copolymer. These reductions may or may not be clinically important, and are evident regardless of initial plaque and gingivitis levels, or whether a baseline oral prophylaxis had taken place or not. High‐quality evidence showed that triclosan/copolymer toothpastes lead to a small reduction in coronal caries. There was weaker evidence to show that triclosan/copolymer toothpastes may have reduced root caries and calculus, but insufficient evidence to show whether or not they prevented periodontitis. There do not appear to be any serious safety concerns regarding the use of triclosan/copolymer toothpastes in studies up to three years in duration. Plain language summary Triclosan/copolymer containing toothpastes for oral health Review question This Cochrane Review has been conducted to assess the effects of using a toothpaste containing triclosan (an antibacterial ingredient) plus copolymer (an ingredient to reduce the amount of triclosan that is washed away by rinsing or saliva) plus fluoride (a mineral that prevents tooth decay) compared with using a fluoride toothpaste (without triclosan/copolymer) for oral health. Background Gum disease and dental decay are the main reasons for tooth loss. Unless brushed away, plaque (a sticky film containing bacteria) can build up on the teeth. This can lead to gingivitis (a swelling and redness of the gums that affects most adults), which, if not treated, can then lead to a more serious form of gum disease called periodontitis (which affects up to one out of every five adults aged 35 to 44 years worldwide). Periodontitis can cause pain, eating difficulties, an unpleasant facial appearance and eventually tooth loss. Plaque build‐up can also lead to tooth decay, a problem affecting up to 90% of schoolchildren in industrialised countries, and the majority of adults. Vast healthcare resources are used worldwide to treat gum disease and tooth decay, which are both preventable. Currently there is a lot of ongoing research into possible links between periodontitis and other medical conditions such as diabetes, rheumatoid arthritis, heart disease and also to the premature (too early) birth of underweight babies. Adding an effective and safe antibacterial ingredient to toothpastes could be an easy and low‐cost answer to these problems. It is thought that triclosan could fight the harmful bacteria in plaque while also reducing the swelling that leads to serious gum disease. It is important that adding triclosan to fluoride toothpastes does not reduce the beneficial effects that fluoride has on preventing tooth decay. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 19 August 2013. It includes 30 studies published from 1990 to 2012 in which 14,835 participants were randomised to receive a triclosan/copolymer containing fluoride toothpaste or a fluoride toothpaste that did not include triclosan/copolymer. The toothpaste that was used in most of the studies is sold by the manufacturer Colgate. Key results The evidence produced shows benefits in using a triclosan/copolymer fluoride toothpaste when compared with a fluoride toothpaste (without triclosan/copolymer). There was a 22% reduction in plaque, a 22% reduction in gingivitis, a 48% reduction in bleeding gums and a 5% reduction in tooth decay. There was insufficient evidence to show a difference between either toothpaste in preventing periodontitis. There was no evidence of any harmful effects associated with the use of triclosan/copolymer toothpastes in studies up to three years in length. Quality of the evidence The evidence relating to plaque and gingivitis was considered to be of moderate quality. The evidence on tooth decay was high quality, while the evidence on periodontitis was low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Riley, P; Lamont, T", "articleTypes": [], "doi": "10.1002/14651858.CD010514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "7b73ddf7-79d4-4ca0-bc15-83c80fefb144", "pmid": "", "title": "Control interventions in randomised trials among people with mental health disorders", "imported": false, "abstract": "Abstract - Background Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated. Objectives To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait‐list versus no‐treatment, (ii) usual care versus wait‐list or no‐treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait‐list or no‐treatment. Wait‐list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. Search methods In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers. Selection criteria We included randomised trials assessing patients with a mental health disorder that compared wait‐list, usual care, or placebo interventions with wait‐list or no‐treatment . Data collection and analysis Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane’s risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre‐planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random‐effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed‐effect model). Main results We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep‐wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait‐list versus no‐treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait‐list or no‐treatment and found a SMD –0.33 (95% CI ‐0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait‐list or no‐treatment was SMD −0.37 (95% CI −0.49 to −0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger’s test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD ‐0.49 (95% CI −0.64 to −0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait‐list or no‐treatment on benefits was SMD ‐0.14 (95% CI −0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD −0.21 (95% CI −0.35 to −0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep‐wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed‐effect model in a sensitivity analysis on the comparison for usual care versus wait‐list and no‐treatment, the results were significant with an SMD of –0.46 (95 % CI –0.64 to –0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains. Authors' conclusions We found marked variations in effects between placebo versus no‐treatment and wait‐list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait‐list or no‐treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research. Plain language summary Control interventions in randomised trials for people with a mental health disorder This systematic review assesses the effects of different control interventions in randomised trials including patients with a mental health disorder. In randomised trials, patients are assigned by chance to one of two or more groups – usually an experimental intervention and a control intervention. There are many types of control interventions in mental health intervention research. Some of the most common are different types of placebos that lack what is assumed to be the active component in the experimental intervention, and usual care, where patients receive the standard treatment for their mental health disorder in the area where they live. Two other types of control interventions are wait‐list or no‐treatment where patients receive no trial‐related care during the study (although some patients may receive care outside the studies). Wait‐list patients are often offered the experimental intervention after the trial has been finalised if it is likely to provide more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. We searched for randomised trials with patients with mental health disorders where wait‐list, usual care, or placebo interventions were compared with either wait‐list or no‐treatment. We looked at differences between all the types of control interventions on beneficial effects and whether they caused any adverse effects. We included 96 trials with a total of 4200 participants. Only 83 trials (3614 participants) provided usable data. Fifteen different mental health disorders were included. We found that all the trials were at high risk of bias in how they had been conducted, which reduced the interpretability of our findings. However, the risk of bias was mostly due to lack of blinding in the placebo studies, which may be seen as an aspect of the review's methodological question rather than a flaw with the review itself. We found no clinically important differences for usual care or wait‐list control interventions in the main analyses, however in our secondary analyses we found a clinically important favourable difference for usual care. In general, placebo control interventions tended to be favourable over no‐treatment or wait‐list control interventions across mental health disorders. We found no clinically important differences on adverse events. This review suggests that different control interventions have a tendency to yield very different estimates for the effects of the experimental intervention and that the choice of control intervention has a large impact on how effective a mental health treatment appears to be. Control interventions in trials with patients with mental health disorders are often poorly reported upon, and guidelines are needed to inform researchers on how to properly design, report, and interpret these trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Faltinsen, E, Todorovac, A, Staxen Bruun, L, Hróbjartsson, A, Gluud, C, Kongerslev, MT, Simonsen, E, Storebø, OJ", "articleTypes": [], "doi": "10.1002/14651858.MR000050.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.136Z" }, { "id": "7b8803a1-9542-4528-b33d-55d3e31c0812", "pmid": "", "title": "Desipramine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Antidepressants are widely used to treat chronic neuropathic pain (pain due to nerve damage), usually in doses below those at which they exert antidepressant effects. An earlier review that included all antidepressants for neuropathic pain is being replaced by new reviews of individual drugs examining individual neuropathic pain conditions. Desipramine is a tricyclic antidepressant that is occasionally used for treating neuropathic pain. Objectives To assess the analgesic efficacy of desipramine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 29 April 2014, and the reference lists of retrieved papers and other reviews. We also used our own hand searched database to identify older studies, and two clinical trials databases for ongoing or unpublished studies. Selection criteria We included randomised, double‐blind studies of at least two weeks duration comparing desipramine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 years and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted the efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts, at least 200 participants in the comparison, 8 to 12 weeks duration, parallel design); second tier from data that failed to meet one or more of these criteria and were considered at some risk of bias but with adequate numbers in the comparison; and third tier from data involving small numbers of participants and considered very likely to be biased or that used outcomes of limited clinical utility, or both. Main results Five studies treated 177 participants with painful diabetic neuropathy (104) or postherpetic neuralgia (73). The mean or median ages in the studies were 55 to 72 years. Four studies used a cross‐over, and one a parallel group design; 145 participants were randomised to receive desipramine 12.5 mg to 250 mg daily, with most taking 100 mg to 150 mg daily following titration. Comparators were placebo in three studies (an 'active placebo' in two studies), fluoxetine, clomipramine (one study each), and amitriptyline (two studies), and treatment was for two to six weeks. All studies had one or more sources of potential major bias. No study provided first or second tier evidence for any outcome. No data were available on the proportion of people with at least 50% or 30% reduction in pain, but data were available from three studies for our other primary outcome of Patient Global Impression of Change, reported as patient evaluation of pain relief that was 'complete' or 'a lot'. No pooling of data was possible, but third tier evidence in individual studies indicated some improvement in pain relief with desipramine compared with placebo, although this was very low quality evidence, derived mainly from group mean data and completer analyses in small, short duration studies where major bias was possible. There were too few participants in comparisons of desipramine with another active treatment to draw any conclusions. All studies reported some information about adverse events, but reporting was inconsistent and fragmented. Participants taking desipramine experienced more adverse events, and a higher rate of withdrawal due to adverse events, than did participants taking placebo (very low quality evidence). Authors' conclusions This review found little evidence to support the use of desipramine to treat neuropathic pain. There was very low quality evidence of benefit and harm, but this came from studies that were methodologically flawed and potentially subject to major bias. Effective medicines with much greater supportive evidence are available. There may be a role for desipramine in patients who have not obtained pain relief from other treatments. Plain language summary Desipramine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not usually effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Desipramine is a tricyclic antidepressant from the same class of medicines as amitriptyline, which is widely recommended for treating neuropathic pain. Desipramine may also be useful in these painful conditions. In 2014, we performed searches to look for clinical trials where desipramine was used to treat neuropathic pain. Five small studies, each with 24 to 54 participants, included 177 participants in total with painful diabetic neuropathy or postherpetic neuralgia. Studies were randomised and double‐blind, but all had one or more sources of potential major bias that could lead to overestimation of efficacy. It was not possible to combine information from the different studies, but individually they indicated some benefit from desipramine (usually at a dose between 100 mg and 150 mg daily), compared with placebo, at the expense of increased adverse events. There was not enough information about other comparators to draw any conclusions. There was too little information, which was of inadequate quality, to be sure that desipramine works as a pain medicine in painful diabetic neuropathy or postherpetic neuralgia, and no information about other types of neuropathic pain. Other medicines have been shown to be effective as treatments of first choice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hearn, L; Moore, RA; Derry, S; Wiffen, PJ; Phillips, T", "articleTypes": [], "doi": "10.1002/14651858.CD011003.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "7b8e328d-7b02-432f-8c78-00f6bf0a0e11", "pmid": "", "title": "Interventions for increasing fruit and vegetable consumption in children aged five years and under", "imported": false, "abstract": "Abstract - Background Insufficient consumption of fruits and vegetables in childhood increases the risk of future non‐communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child‐feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden. Objectives To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. Search methods We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials. Selection criteria We included randomised controlled trials (RCTs), including cluster‐randomised controlled trials (C‐RCTs) and cross‐over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no‐intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random‐effects models in meta‐analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures. Main results We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child‐feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child‐focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate‐certainty evidence that child‐feeding practice interventions versus no‐intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as‐desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post‐intervention follow‐up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low‐certainty evidence). Multicomponent interventions versus no‐intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate‐certainty evidence; mean post‐intervention follow‐up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden‐based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low‐certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short‐term impact on child consumption of fruit and vegetables versus no‐intervention control (SMD 0.10, 95% CI ‐0.02 to 0.22; 14 trials, 4122 participants; low‐certainty evidence; mean post‐intervention follow‐up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low‐certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low‐certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding. Authors' conclusions There was moderate‐certainty evidence that child‐feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low‐ and middle‐income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. Plain language summary What are the benefits and harms of interventions to increase eating of fruit and vegetables among children aged five years and under? Key messages • Child‐feeding interventions probably lead to a small increase in eating of vegetables in children aged five years and under. • Multicomponent interventions probably lead to a small increase in eating of fruit and vegetables in children aged five years and under. • Parent nutrition education interventions may lead to little or no increase in eating of fruit and vegetables in children aged five years and under. Why is eating enough fruit and vegetables important? Not eating enough fruit and vegetables leads to a considerable health burden in developed countries. Eating adequate amounts of fruit and vegetables is associated with a reduced risk of future non‐communicable diseases (such as heart and circulatory disease) amongst other immediate health benefits. Early childhood is a critical period for the establishment of dietary habits that track into adulthood. Interventions to increase consumption of fruit and vegetables in early childhood may therefore be an effective strategy to reduce this disease burden. What did we want to find out? We wanted to know the benefits and harms of interventions designed to increase eating of fruit or vegetables or both amongst children aged five years and under. What did we do? We searched various electronic databases to find studies. We contacted the authors of the included studies for additional potentially relevant studies. Any randomised study (where participants have the same chance of being assigned to treatment or a no‐treatment control) of interventions aiming to increase the intake of fruit or vegetables or both by children aged five years and under, which measured intake, was eligible. Two review authors independently searched for and extracted information from studies. We searched up to March 2023. What did we find? We included 53 studies with 12,350 people taking part. Sixteen studies examined child‐feeding practice interventions (e.g. repeated exposure to vegetables); 20 examined multicomponent interventions (e.g. combining two or more interventions, such as preschool policy changes with parent nutrition education); 17 examined parent nutrition education interventions; two examined child nutrition education interventions; and one each examined child‐focused mindfulness or providing families with fruit and vegetable interventions. Child‐feeding practice interventions and multicomponent interventions probably lead to small increases in children's intake of fruit and vegetables in the short term (less than 12 months). Parent nutrition education interventions may lead to little to no increase in children's eating of fruit and vegetables. Limited information was available on cost and unintended harms. Of the studies that did report these, intervention costs ranged from 325 to 1500 US dollars (USD). No unintended harms were found in the two studies that reported assessing them. Studies reporting funding support received governmental or charitable funds, except for one study that received industry funding. What are the limitations of the evidence? No studies were conducted in low‐income countries and only one study was conducted in a middle‐income country. Our confidence in the current evidence is moderate for child feeding and multicomponent interventions, and low for parent nutrition education interventions. How up‐to‐date is this evidence? This evidence is up‐to‐date to March 2023. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Hodder, RK; O'Brien, KM; Wyse, RJ; Tzelepis, F; Yoong, S; Stacey, FG; Wolfenden, L", "articleTypes": [], "doi": "10.1002/14651858.CD008552.pub8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "7b8e40c0-13bf-4ebe-b328-ca7ee497fa72", "pmid": "", "title": "School feeding programs for improving the physical and psychological health of school children experiencing socioeconomic disadvantage", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kristjansson, E, Dignam, M, Rizvi, A, Osman, M, Magwood, O, Olarte, D, Cohen, JFW, Krasevec, J, Grover, T, Labelle, PR, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014794.pub2 AB - Abstract - Rationale School feeding aims to alleviate hunger and enhance child outcomes. Since the first Cochrane systematic review of school meals, there has been a marked increase in studies and reviews of school feeding programs. However, most systematic reviews are geographically limited and use qualitative analysis. We reviewed worldwide papers and performed several meta‐analyses, providing a more comprehensive picture of the effectiveness of school feeding. Objectives 1. To assess effectiveness of school feeding programs for improving the physical and psychological health of children experiencing socioeconomic disadvantage worldwide.
2. To assess effectiveness of school feeding programs for improving the health of children experiencing socioeconomic disadvantage compared with children who are more advantaged. Search methods We searched 17 subject‐specific and multidisciplinary databases and registries up to November 2023. In November 2024, two Information Specialists ran a top‐up search for randomized controlled trials (RCTs). We handsearched references of included studies and relevant reviews. Eligibility criteria We included individually randomized, cluster‐randomized, and cross‐over trials, as well as longitudinal non‐randomized studies of interventions (NRSIs). Studies had to compare the provision of free or reduced‐price food in schools versus no school feeding, focusing on socioeconomically disadvantaged children. The food had to contain at least 3% of the daily energy requirement and at least 10% of the daily protein requirement for the specified age group(s). Eligible participants were primary or secondary school students aged five to 19 years. Outcomes Our critical outcomes were change in: math achievement, reading achievement, attendance, enrollment, height‐for‐age z‐score (HAZ), weight‐for‐age z‐score (WAZ), and overweight/obesity. Our important outcomes were change in: overall academic achievement, fluid intelligence, working memory, behavioral/emotional outcomes, height, weight, and anemia. We planned to study changes between baseline and final outcomes. In one study with extreme contamination, we used the first follow‐up. Risk of bias We assessed the risk of bias for RCTs by outcome using the appropriate version of the Cochrane risk of bias tool (RoB 2): RoB 2 for individually randomized trials, for cluster‐RCTs, and for cross‐over trials. We evaluated the quality of NRSIs using the School‐based Measurement & Assessment of Results Tool (SMART), which is adapted from the Newcastle Ottawa Scale. Synthesis methods We used standardized mean differences (SMDs) with 95% confidence intervals (CIs) for educational and cognitive outcomes. We used mean differences (MDs), odds ratios (ORs), or incidence rate ratios (IRRs) for others. All meta‐analyses used random‐effects generic inverse variance. We conducted equity subgroup analyses by sex and socioeconomic status. We used GRADE to assess our confidence in the evidence for critical outcomes reported in RCTs. Included studies We included 40 studies with 83 reports. There were 13 RCTs (12 cluster‐randomized trials and one individually randomized trial) and 27 NRSIs. Most studies (34) were from low‐ and middle‐income countries (LMICs). In total, there were more than 91,885 students (four studies didn't report sample size). One study involved 59,613 students, while the others had between 60 and 6038 students. The studies included 48 outcomes; we meta‐analyzed or reported 14. Synthesis of results Low‐ and middle‐income countries (LMICs) School feeding compared to no school feeding improves math achievement slightly (SMD 0.14, 95% CI 0.06 to 0.23; P = 0.001; I² = 68%; 6 cluster‐RCTs, 5587 participants; high‐certainty evidence), but may have little to no effect on reading achievement (SMD 0.02, 95% CI −0.06 to 0.11; P = 0.61; I 2 = 54%; 3 cluster‐RCTs, 3417 participants; low‐certainty evidence). School feeding programs lead to a slight increase in enrollment rates (MD 3.44% increase, 95% CI 0.83 to 6.04; P = 0.01; I² = 0%; 2 cluster‐RCTs, 5200 participants, high‐certainty evidence) but may have little to no effect on attendance (MD 0.17%, 95% CI −2.64% to 2.97%; P = 0.91; I 2 = 81%; 3 cluster‐RCTs, 3566 participants; low‐certainty evidence). School feeding programs likely lead to a slight increase in HAZ (MD 0.06, 95% CI 0.03 to 0.09; P < 0.001; I 2 = 0%; 2 cluster‐RCTs, 3678 participants; moderate‐certainty evidence) and WAZ (MD 0.08, 95% CI 0.05 to 0.12; P < 0.001; I 2 = 0%; 3 cluster‐RCTs, 2132 participants; moderate‐certainty evidence). Two cluster‐RCTs assessed change in obesity/overweight. One 10‐month study found that the odds of being overweight/obese were 53% lower among adolescents receiving school meals compared to control adolescents (OR 0.47, 95% CI 0.30 to 0.72). Another study found no cases of overweight/obesity before or after the intervention. These findings are of very low certainty. Some researchers encountered implementation problems beyond their control, including conflicts, delays, and bureaucratic decisions. Heterogeneity in contexts, outcomes, child populations, and statistics was a limitation of this review. High‐income countries (HICs) One NRSI found very uncertain evidence that children assigned to a breakfast club increased their attendance by more than 1.6% on average compared to children in the control group. Equity analyses The equity (subgroup) analyses by sex and by socio‐economic status were all non‐significant. There were only two studies in each subgroup analysis; they were likely underpowered. Authors' conclusions In LMICs, school feeding programs lead to a slight improvement in math achievement, but may have little to no effect on reading achievement. School feeding programs lead to a slight increase in enrollment, but may have little to no impact on attendance. They likely lead to slight gains in HAZ and WAZ. There may be little to no association between school feeding and overweight/obesity, but the evidence is very uncertain. We recommend that researchers and policymakers view research as an integral part of the implementation process. To reduce heterogeneity in outcomes, we recommend even greater co‐ordination of research, and that researchers and interest holders work together to identify a core set of outcomes. Funding The authors would like to thank the following donors for their generous support in making this review possible: Dubai Cares, the World Food Programme's School Meals and Social Protection Service, and the Research Consortium for School Health and Nutrition. Registration Protocol (2022): https://doi.org/10.1002/14651858.CD014794 
Original review (2007): https://doi.org/10.1002/14651858.CD004676.pub2 
Original Campbell protocol (2006): doi.org/10.1002/CL2.12 Plain language summary Can school meal programs improve health and educational goals in children experiencing socioeconomic disadvantage? Key messages School meal programs in low‐ and middle‐income countries lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. Research should be a key part of planning and running school meal programs. To make it easier to compare results from different studies, researchers, parents, and policymakers should work together to agree on a list of the most important goals for children's health, development, and success in school. Why did we want to review studies on school meals? Worldwide, many children do not get enough nutritious food to keep them healthy and ready to learn in school. This affects their ability to enroll, attend school regularly, and learn there. School meals aim to reduce hunger and improve children's learning, focus, and overall health. School meals are one of the world's largest social safety nets. We sought to understand their effectiveness for children in disadvantaged circumstances across the globe. Most previous reviews of the evidence are limited in geographical scope, and many use narrative analyses. What did we want to find out? We asked the following two health equity (fairness) questions. Do school meals improve the physical health of socioeconomically disadvantaged children worldwide? Do school meals benefit children who are disadvantaged by sex and low family income more than they benefit less disadvantaged children? What did we do? We searched for studies that evaluated the effects of school meals for school students aged five to 19 years. We included randomized studies, which allocate students or schools to different study groups at random. However, because randomized studies are not always possible, we included non‐randomized studies that compared school meal groups with groups that received no school meals. These non‐randomized studies needed to measure outcomes at least twice; once at the beginning of the study and once at the end. We rated our confidence in the findings separately for each outcome. What did we find? We found 13 randomized studies and 27 non‐randomized studies, which collectively involved more than 91,995 students aged five to 19 years. One study included 59,613 students, while others had student populations ranging from 40 to 6038 students. Across all studies, there was a similar number of boys and girls, although three studies included only girls. Most studies took place in low‐ and middle‐income countries (34 studies), while six were from high‐income countries. In low‐ and middle‐income countries, school meals lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. In high‐income countries, one study presented very uncertain evidence that school meals may increase attendance slightly. What are the limitations of the evidence? Because we found very few eligible studies conducted in high‐income countries, we do not recommend applying our findings to this setting. We are confident in the results for math test scores and enrollment. We are moderately confident in the results for height and weight for age, because we had some concerns about the study methods. We have little confidence in the results for reading test scores and attendance, because we had some concerns about the study methods, and the results differed substantially among the trials. We are not confident in the results for overweight/obesity, because we have some concerns about the study methods, the two studies measured the outcome in different ways, and one of the studies was very small. Several studies faced barriers due to their context, such as conflict, droughts, bureaucratic delays, and difficulties in distributing funds to caterers, as well as eagerness to initiate school meal programs in control schools. We need more evidence on school meals and their impact on disadvantaged school students—especially those in secondary school—in countries of all income levels. We also need more studies that assess the difference between disadvantaged groups and more advantaged children in high‐income countries. We suggest that researchers, school feeding experts, teachers, and parents collaborate to develop a core set of key outcomes, and that these outcomes be put in an open‐access repository. How up‐to‐date is this evidence? This review updates and expands our 2007 review of school meal programs. The evidence is current to November 2024. Funding Dubai Cares funded this review through the World Food Program School Feeding Program. The London School of Hygiene and Tropical Medicine also funded this review. The funders had no influence on the review.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.112Z" }, { "id": "7b946c7c-e71b-4487-a2df-5db430a2ede6", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Omega‐3 fatty acids (n‐3, fish oil) have been shown to have anti‐inflammatory properties. Therefore, n‐3 therapy may be beneficial in chronic inflammatory disorders such as ulcerative colitis. Objectives To systematically review the efficacy and safety of n‐3 for maintaining remission in ulcerative colitis (UC). Search methods The following databases were searched from their inception without language restriction: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Healthstar, PubMed, and ACP journal club. Experts were contacted for unpublished data. Selection criteria Randomized placebo‐controlled trials (RCT) of fish oil for maintenance of remission in UC were included. Studies must have enrolled patients (of any age group) who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. The primary outcome was relapse rate and the secondary outcome was frequency of adverse events. Other outcomes to assess efficacy were change in disease activity scores and time to first relapse. Data collection and analysis Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality. Meta‐analysis weighted by the Mantel‐Haenszel method was performed using RevMan 4.2.8 software. Random or fixed effect models were used according to degree of heterogeneity and subgroup analyses were performed to explore heterogeneity. A sensitivity analysis was performed excluding a study of questionable quality . Main results The three studies that were included used different formulation and dosing of n‐3 but none used enteric coated capsules. The pooled analysis showed a similar relapse rate in the n‐3 treated patients and controls (RR 1.02; 95% CI 0.51 to 2.03; P = 0.96). Combining the studies resulted in virtually no statistical heterogeneity (P = 0.93, I 2 = 0%). Various subgroup and sensitivity analyses showed similar results. However, the total number of patients enrolled in these studies was small (n = 138). No significant adverse events were recorded in any of the studies and not enough data were available to pool the other secondary outcomes for meta‐analysis. Authors' conclusions No evidence was found that supports the use of omega 3 fatty acids for maintenance of remission in UC. Further studies using enteric coated capsules may be justified. Plain language summary Omega 3 fatty acids for maintenance of remission in ulcerative colitis Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of ulcerative colitis patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of omega‐3 fatty acids to maintain remission in ulcerative colitis were reviewed. Three studies were included of which none reported a reduction in the rate of disease relapse in comparison with placebo. When the studies were pooled for meta‐analysis there was no benefit for omega 3 fatty acids. There were no serious side effects in any of the studies. None of the studies used enteric coated capsules which allow release of the fish oil in the small bowel. Non‐enteric coated omega‐3 fatty acids (fish oil) seem safe but ineffective for maintaining remission in ulcerative colitis. Further studies of enteric coated capsules may be justified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Turner, D, Steinhart, AH, Griffiths, AM", "articleTypes": [], "doi": "10.1002/14651858.CD006443.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.065Z" }, { "id": "7b970690-43ba-4516-b83d-64d8bb389ee5", "pmid": "", "title": "Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia", "imported": false, "abstract": "Abstract - Background In a review and meta‐analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion‐focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect. Objectives To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic. Search methods We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the `awaiting classification' section of this review. Selection criteria We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion‐focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post‐surgery. Data collection and analysis One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion. Where possible we used random‐effects meta‐analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges' g) to combine data from different outcome measures. If data were not available in a form suitable for meta‐analysis we performed a narrative review. Main results Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty‐one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta‐analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD ‐0.20, 95% confidence interval (CI) ‐0.35 to ‐0.06), length of stay (mean difference ‐0.52 days, 95% CI ‐0.82 to ‐0.22) and negative affect (SMD ‐0.35, 95% CI ‐0.54 to ‐0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached. Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall,we rated the quality of evidence for each outcome as ‘low’ because of the high level of heterogeneity in meta‐analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta‐analysis, so we rated the quality of evidence as `very low'. Authors' conclusions The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well‐conducted and clearly reported research. Plain language summary The effect of psychological preparation on pain, behavioural recovery, negative emotion and length of stay after surgery Background The way people think and feel before surgery can affect how they feel and what they do after surgery. For example, research shows that people who feel more anxious before their surgery experience more pain after it. A review conducted in 1993 looked at the impact of psychological preparation on outcomes after surgery. The term `psychological preparation' includes a range of techniques that aim to change what people think, how they feel or what they do. This 1993 review found that psychological preparation techniques reduced pain after surgery, improved behavioural recovery (how quickly people return to activities), decreased length of stay in hospital and reduced negative emotion (e.g. feelings of anxiety or depression). We aimed to carry out an up‐to‐date review using Cochrane methodology to learn whether there are helpful (or harmful) effects of psychological preparation for people undergoing surgery, and which outcomes (pain after surgery, behavioural recovery, negative emotion or length of stay) are improved. Study characteristics We included studies of adults who received planned surgery with general anaesthesia. We looked at seven psychological preparation techniques: procedural information (information about what, when and how processes will happen); sensory information (what the experience will feel like and what other sensations they may have, e.g. taste, smell); behavioural instruction (telling patients what they need to do); cognitive intervention (techniques that aim to change how people think); relaxation techniques; hypnosis; and emotion‐focused interventions (techniques that aim to help people to manage their feelings). The psychological preparation had to be delivered before surgery for the study to be included in the review. We included studies that looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion after surgery (within one month). Studies were included in the review up to the search date of 4 May 2014. We updated the search on 7 July 2015 and will incorporate the 38 studies found in this later search when the review is updated. We included 105 studies from 115 papers, with 10,302 participants taking part. Sixty‐one studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative emotion. In accordance with the review protocol, we did not record details about funding sources. Key results In this review we included 105 studies, which were reported in 115 papers. A total of 10,302 participants were randomized in these studies. For pain, length of stay and negative emotion we combined numerical findings from the studies. We found that psychological preparation before surgery seemed to reduce pain and negative emotion after the operation and may reduce the time spent in hospital by around half a day but the quality of the evidence was low. Also, the studies used many different psychological preparation techniques (often in different combinations) so it was not possible to discover which techniques were better. We could not statistically combine numerical findings for behavioural recovery because few studies provided sufficient details and studies used different ways of measuring how quickly people returned to usual activities. In reviewing the studies, we found that psychological preparation, in particular behavioural instruction, may have the potential to improve behavioural recovery. However, the quality of this evidence was very low. We looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion in this review and did not find evidence to suggest that psychological preparation might lead to harm in these outcomes. However, as we did not look at other outcomes it is possible that we did not identify potential harm. Quality of the evidence Many studies were poorly reported, so we could not be confident that findings were reliable. For this reason and because of the large variation in psychological techniques, types of surgery and measures used, we graded the quality of the evidence as `low' for the outcomes pain, negative emotion and length of stay; we cannot be confident that these techniques help patients to recover from surgery. For behavioural recovery, we further downgraded the quality of the evidence to `very low' because of problems with measurement and reporting of the outcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, R, Scott, NW, Manyande, A, Bruce, J, Vögele, C, Byrne‐Davis, LMT, Unsworth, M, Osmer, C, Johnston, M", "articleTypes": [], "doi": "10.1002/14651858.CD008646.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.131Z" }, { "id": "7b97a403-9194-4445-87ec-f2062f0a9828", "pmid": "", "title": "The Effectiveness of Cerebrolycin, a Multi-modal Neurotrophic Factor, for Treatment of Post-covid-19 Persistent Olfactory, Gustatory and Trigeminal Chemosensory Dysfunctions: A Pilot Study", "imported": false, "abstract": "The loss of smell and taste is a prominent symptom of COVID-19. Studies found that patterns of smell loss due to Covid-19 infection differ from that of other respiratory viruses being much more profound in the Covid-19 patents and did not associate with runny, congested, or blocked-up nose. The researchers suggest that smell and taste testing can be used for fast COVID-19 screening. Studies found that the Covid-19 virus has similarities with severe acute respiratory syndrome coronavirus (SARS-CoV), which has been reported to enter the brain, via smell receptors in the nose. The sudden onset and relatively fast recovery in some patients suggest that COVID-19 anosmia is not caused by damage to the central nervous system but rather by the loss of smell information before it gets to the brain (smell receptors). They also found that it has different behavior from other respiratory viruses as it causes over-reaction of the immune system (or a cytokine storm). Trials to treat post-COVID anosmia using local steroid applications, sniffing of strong odors or scents or use of different vitamins (for several weeks to months) did not provide rapid, satisfactory or even significant recovery of olfactory dysfunction. Fortunately, the olfactory neurons can regenerate, however, studies reported variable prognoses, some patients recovered within weeks which others may have persistent deficits for months or even a year. In this study, the researchers hypothesize that cerebrolysin, a drug of neurotrophic and neuroprotective properties, can be used to treat patients with persistent post-COVID anosmia or ageusia or promote functional recovery of smell and taste deficits.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "7ba18b1d-ab43-487b-90e2-77e6e79a9d2e", "pmid": "", "title": "Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age", "imported": false, "abstract": "Abstract - Background Vitamin and mineral deficiencies, particularly those of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Multiple micronutrient powders (MNPs) are single‐dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi‐solid food for children six months of age or older. The use of MNPs for home or point‐of‐use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out‐of‐date. Objectives To assess the effects and safety of home (point‐of‐use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi‐solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point‐of‐use fortification. Search methods We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs with individual randomisation or cluster‐randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron‐containing supplements, which is standard practice. Data collection and analysis Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, and assessed the risk of bias of included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence. Main results We included 29 studies (33,147 children) conducted in low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty‐six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron‐only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate‐certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high‐certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low‐certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate‐certainty evidence) at follow‐up compared with children receiving the control intervention. We did not find an effect on weight‐for‐age (MD 0.02, 95% CI −0.03 to 0.07; 10 studies; 9287 children; moderate‐certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all‐cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low‐certainty evidence) and haemoglobin concentrations (MD −2.81 g/L, 95% CI −10.84 to 5.22; 2 studies; 278 children; very low‐certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low‐certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Authors' conclusions Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Plain language summary Using a vitamin and mineral powder, mixed into complementary foods, to improve health and nutrition in children under two years of age Review question Does using a vitamin and mineral powder, mixed into complementary foods, improve health and nutrition in children under two years of age? Background Deficiencies of vitamins and minerals, particularly of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Exclusive breastfeeding until six months of age, followed by complementary feeding combined with continued breastfeeding for at least two years, is recommended to maintain children's adequate health and nutrition. After six months of age, infants start to receive semi‐solid foods, but the quantities of vitamins and minerals can be insufficient to fulfil all of their requirements for growth and development. Multiple micronutrient powders (MNPs) are single‐dose packets of powder containing iron, vitamin A, zinc, and other vitamins and minerals that can be mixed into any semi‐solid food at home or at any other point of use, to increase the content of essential vitamins and minerals in the diet of infants and young children during this period. This is done without making any other changes to their usual diet. Study characteristics We searched up to July 2019 for all studies that assessed the use of MNP for improving the health and nutrition of children under two years of age. We included 29 studies that involved 33,147 infants and young children from low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean. Twenty‐six studies with 27,051 children contributed data. Of these 26 studies, 24 compared the use of MNP versus no intervention or placebo, and 2 compared the use of MNP versus an iron‐only supplement (iron drops) given daily. We found that a variety of MNP formulations containing between 5 and 22 vitamins and minerals were given for 2 to 44 months to infants and young children aged 6 to 23 months. Most studies were funded by government programmes or foundations; only 2 were funded by industry. Key results The use of MNP containing at least iron, zinc, and vitamin A for home fortification of foods was associated with reduced risk of anaemia of 18% and iron deficiency of 53% in children aged six months to two years compared with no intervention. Also, haemoglobin concentration and iron status improved. Studies did not find any effects on growth. There was no additional benefit in reducing risk of anaemia and improving haemoglobin concentration compared to usually recommended iron drops or syrups; however, only two studies compared these different interventions. No trials reported death attributable to the intervention. Information on deaths, side effects, and morbidity, including malaria and diarrhoea, was scarce. The use of MNP was beneficial for young children 6 to 23 months of age, independent of whether they lived in settings with different anaemia and malaria backgrounds and regardless of the length of the intervention. MNP is better than no intervention or placebo and may be comparable to daily iron supplementation.The benefits of this intervention as a child survival strategy or for developmental outcomes are still unclear, and further investigation is required. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Certainty of the evidence For the comparison of MNP versus no intervention or placebo, we judged the certainty of evidence to be moderate for anaemia and high for iron deficiency. The certainty of evidence for all other outcomes in this comparison was either low or moderate. Two trials that compared the use of MNP versus iron supplement showed similar effects on anaemia and haemoglobin but less diarrhoea; however, we judged the certainty of evidence as low for anaemia and very low for haemoglobin concentration due to the small number of study participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Suchdev, PS; Jefferds, MED; Ota, E; da Silva Lopes, K; De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD008959.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "7bae030d-da1a-43ee-a832-07a0828d58f3", "pmid": "", "title": "Antiemetics for adults for prevention of nausea and vomiting caused by moderately or highly emetogenic chemotherapy: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background About 70% to 80% of adults with cancer experience chemotherapy‐induced nausea and vomiting (CINV). CINV remains one of the most distressing symptoms associated with cancer therapy and is associated with decreased adherence to chemotherapy. Combining 5‐hydroxytryptamine‐3 (5‐HT₃) receptor antagonists with corticosteroids or additionally with neurokinin‐1 (NK₁) receptor antagonists is effective in preventing CINV among adults receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Various treatment options are available, but direct head‐to‐head comparisons do not allow comparison of all treatments versus another. Objectives • In adults with solid cancer or haematological malignancy receiving HEC ‐ To compare the effects of antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids on prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting in network meta‐analysis (NMA) ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy • In adults with solid cancer or haematological malignancy receiving MEC ‐ To compare whether antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids are superior for prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting to treatment combinations including 5‐HT₃ receptor antagonists and corticosteroids solely, in network meta‐analysis ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy Search methods We searched CENTRAL, MEDLINE, Embase, conference proceedings, and study registries from 1988 to February 2021 for randomised controlled trials (RCTs). Selection criteria We included RCTs including adults with any cancer receiving HEC or MEC (according to the latest definition) and comparing combination therapies of NK₁ and 5‐HT₃ inhibitors and corticosteroids for prevention of CINV. Data collection and analysis We used standard methodological procedures expected by Cochrane. We expressed treatment effects as risk ratios (RRs). Prioritised outcomes were complete control of vomiting during delayed and overall phases, complete control of nausea during the overall phase, quality of life, serious adverse events (SAEs), and on‐study mortality. We assessed GRADE and developed 12 'Summary of findings' tables. We report results of most crucial outcomes in the abstract, that is, complete control of vomiting during the overall phase and SAEs. For a comprehensive illustration of results, we randomly chose aprepitant plus granisetron as exemplary reference treatment for HEC, and granisetron as exemplary reference treatment for MEC. Main results Highly emetogenic chemotherapy ( HEC) We included 73 studies reporting on 25,275 participants and comparing 14 treatment combinations with NK₁ and 5‐HT₃ inhibitors. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 704 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with aprepitant + granisetron. Evidence from NMA (39 RCTs, 21,642 participants; 12 treatment combinations with NK₁ and 5‐HT₃ inhibitors) suggests that the following drug combinations are more efficacious than aprepitant + granisetron for completely controlling vomiting during the overall treatment phase (one to five days): fosnetupitant + palonosetron (810 of 1000; RR 1.15, 95% confidence interval (CI) 0.97 to 1.37; moderate certainty), aprepitant + palonosetron (753 of 1000; RR 1.07, 95% CI 1.98 to 1.18; low‐certainty), aprepitant + ramosetron (753 of 1000; RR 1.07, 95% CI 0.95 to 1.21; low certainty), and fosaprepitant + palonosetron (746 of 1000; RR 1.06, 95% CI 0.96 to 1.19; low certainty). Netupitant + palonosetron (704 of 1000; RR 1.00, 95% CI 0.93 to 1.08; high‐certainty) and fosaprepitant + granisetron (697 of 1000; RR 0.99, 95% CI 0.93 to 1.06; high‐certainty) have little to no impact on complete control of vomiting during the overall treatment phase (one to five days) when compared to aprepitant + granisetron, respectively. Evidence further suggests that the following drug combinations are less efficacious than aprepitant + granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): aprepitant + ondansetron (676 of 1000; RR 0.96, 95% CI 0.88 to 1.05; low certainty), fosaprepitant + ondansetron (662 of 1000; RR 0.94, 95% CI 0.85 to 1.04; low certainty), casopitant + ondansetron (634 of 1000; RR 0.90, 95% CI 0.79 to 1.03; low certainty), rolapitant + granisetron (627 of 1000; RR 0.89, 95% CI 0.78 to 1.01; moderate certainty), and rolapitant + ondansetron (598 of 1000; RR 0.85, 95% CI 0.65 to 1.12; low certainty). We could not include two treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 35 of 1000 participants experience any SAEs when treated with aprepitant + granisetron. Evidence from NMA (23 RCTs, 16,065 participants; 11 treatment combinations) suggests that fewer participants may experience SAEs when treated with the following drug combinations than with aprepitant + granisetron: fosaprepitant + ondansetron (8 of 1000; RR 0.23, 95% CI 0.05 to 1.07; low certainty), casopitant + ondansetron (8 of 1000; RR 0.24, 95% CI 0.04 to 1.39; low certainty), netupitant + palonosetron (9 of 1000; RR 0.27, 95% CI 0.05 to 1.58; low certainty), fosaprepitant + granisetron (13 of 1000; RR 0.37, 95% CI 0.09 to 1.50; low certainty), and rolapitant + granisetron (20 of 1000; RR 0.57, 95% CI 0.19 to 1.70; low certainty). Evidence is very uncertain about the effects of aprepitant + ondansetron (8 of 1000; RR 0.22, 95% CI 0.04 to 1.14; very low certainty), aprepitant + ramosetron (11 of 1000; RR 0.31, 95% CI 0.05 to 1.90; very low certainty), fosaprepitant + palonosetron (12 of 1000; RR 0.35, 95% CI 0.04 to 2.95; very low certainty), fosnetupitant + palonosetron (13 of 1000; RR 0.36, 95% CI 0.06 to 2.16; very low certainty), and aprepitant + palonosetron (17 of 1000; RR 0.48, 95% CI 0.05 to 4.78; very low certainty) on the risk of SAEs when compared to aprepitant + granisetron, respectively. We could not include three treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron, rolapitant + ondansetron) in NMA for this outcome because of missing direct comparisons. Moderately emetogenic chemotherapy (MEC) We included 38 studies reporting on 12,038 participants and comparing 15 treatment combinations with NK₁ and 5‐HT₃ inhibitors, or 5‐HT₃ inhibitors solely. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 555 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with granisetron. Evidence from NMA (22 RCTs, 7800 participants; 11 treatment combinations) suggests that the following drug combinations are more efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days): aprepitant + palonosetron (716 of 1000; RR 1.29, 95% CI 1.00 to 1.66; low certainty), netupitant + palonosetron (694 of 1000; RR 1.25, 95% CI 0.92 to 1.70; low certainty), and rolapitant + granisetron (660 of 1000; RR 1.19, 95% CI 1.06 to 1.33; high certainty). Palonosetron (588 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) and aprepitant + granisetron (577 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) may or may not increase complete response in the overall treatment phase (one to five days) when compared to granisetron, respectively. Azasetron (560 of 1000; RR 1.01, 95% CI 0.76 to 1.34; low certainty) may result in little to no difference in complete response in the overall treatment phase (one to five days) when compared to granisetron. Evidence further suggests that the following drug combinations are less efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): fosaprepitant + ondansetron (500 of 1000; RR 0.90, 95% CI 0.66 to 1.22; low certainty), aprepitant + ondansetron (477 of 1000; RR 0.86, 95% CI 0.64 to 1.17; low certainty), casopitant + ondansetron (461 of 1000; RR 0.83, 95% CI 0.62 to 1.12; low certainty), and ondansetron (433 of 1000; RR 0.78, 95% CI 0.59 to 1.04; low certainty). We could not include five treatment combinations (fosaprepitant + granisetron, azasetron, dolasetron, ramosetron, tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 153 of 1000 participants experience any SAEs when treated with granisetron. Evidence from pair‐wise comparison (1 RCT, 1344 participants) suggests that more participants may experience SAEs when treated with rolapitant + granisetron (176 of 1000; RR 1.15, 95% CI 0.88 to 1.50; low certainty). NMA was not feasible for this outcome because of missing direct comparisons. Certainty of evidence Our main reason for downgrading was serious or very serious imprecision (e.g. due to wide 95% CIs crossing or including unity, few events leading to wide 95% CIs, or small information size). Additional reasons for downgrading some comparisons or whole networks were serious study limitations due to high risk of bias or moderate inconsistency within networks. Authors' conclusions This field of supportive cancer care is very well researched. However, new drugs or drug combinations are continuously emerging and need to be systematically researched and assessed. For people receiving HEC, synthesised evidence does not suggest one superior treatment for prevention and control of chemotherapy‐induced nausea and vomiting. For people receiving MEC, synthesised evidence does not suggest superiority for treatments including both NK₁ and 5‐HT₃ inhibitors when compared to treatments including 5‐HT₃ inhibitors only. Rather, the results of our NMA suggest that the choice of 5‐HT₃ inhibitor may have an impact on treatment efficacy in preventing CINV. When interpreting the results of this systematic review, it is important for the reader to understand that NMAs are no substitute for direct head‐to‐head comparisons, and that results of our NMA do not necessarily rule out differences that could be clinically relevant for some individuals. Plain language summary Which drug combinations are best for prevention of nausea and vomiting caused by chemotherapy in adults with cancer? The burden of nausea and vomiting caused by chemotherapy and what helps to prevent it? In about 70% to 80% of adults with cancer, chemotherapy induces nausea and vomiting (CINV). Depending on the type of chemotherapy, treatment can cause strong or moderate sickness (hereafter referred to as HEC (highly emetogenic chemotherapy) and MEC (moderately emetogenic chemotherapy)). Multiple drug combinations have showed high benefit for CINV among adults receiving HEC or MEC. What was the aim of our review? Using a network meta‐analysis, we aimed to compare the benefits and harms of different drug combinations for prevention of CINV among people receiving HEC or MEC, and to identify treatment ranking. A network meta‐analysis is a technique used to compare different treatments described in already published trials, even when the original individual trial does not describe such comparisons. What studies did we look at? We searched selected medical databases and trial registries until February 2021. We included studies comparing multiple drug combinations for prevention of CINV among adults with any type of cancer receiving HEC or MEC that is commonly used in clinical practice. In particular, we looked at drugs inhibiting two specific biochemical receptors (neurokinin receptor and serotonin receptor) that trigger nausea and vomiting after chemotherapy. We looked at the preventative effects of these treatments over five days. This is the period during which the maximum intensity of CINV and further peaks of intensity are expected, after the start of chemotherapy. Our key results... ...for people receiving HEC We found 73 studies that reported on the experience of 25,275 participants and compared 14 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped to prevent any vomiting in 60% to 81% of people on average. Those individuals also had no need for rescue medicines, which are used in case nausea and vomiting occur even though prophylactic treatment has been given. The results of our analysis suggest some differences in effectiveness of different treatments, but overall we had little confidence that those differences would be reflected in real‐world observations. Harms. We estimated that 1% to 4% of people experience serious side effects. The differences between treatments were small. ...for people receiving MEC We found 38 studies that reported on the experience of 12,038 participants and compared 15 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped prevent any vomiting in 43% to 72% of people on average. Those individuals also had no need for rescue medicines. The results of our analysis suggest some differences in the effectiveness of different treatments, but overall, we had little confidence that those differences would be reflected in real‐world observations. Harms. Few studies reported serious side effects. The ones that did suggest that on average 15% to 18% of people experience such events. Differences between treatments were small. However, we think that future research is needed to rule out potential differences between treatments. Our confidence in the findings We assessed how confident we were that there are differences between compared treatments. We had low or very low confidence that one treatment is better or worse than another in preventing CINV. Our confidence in differences between statistical results was mainly limited because measures of variation were wide apart and included both potential advantages and disadvantages, although measures of precision showed no or little effect. We also identified limitations in some of the included studies, which further limited our confidence in the effects. This was mainly the case when study personnel and participants knew which treatments were given and therefore may not adhere to the planned intervention, or may perceive or report effects differently. Our conclusions The results of our analysis suggest that there is no superior drug combination for prevention of CINV for people receiving HEC or MEC. However, results suggest that the choice of drugs targeting the serotonin receptor may impact effectiveness, irrespective of whether given with or without a drug targeting the neurokinin receptor. However, when interpreting these results, it is important for the reader to understand that these kinds of multiple‐comparison analyses are no substitute for head‐to‐head comparisons, and that the results do not necessarily rule out differences that could be clinically relevant for some individuals. How up‐to‐date is this evidence? Evidence is up‐to‐date to 2 February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Piechotta, V, Adams, A, Haque, M, Scheckel, B, Kreuzberger, N, Monsef, I, Jordan, K, Kuhr, K, Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.822Z" }, { "id": "7bd4aadc-5355-4e3f-9ed8-29eb316ab7da", "pmid": "", "title": "Interventions to prevent obesity in children aged 5 to 11 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well‐being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review. Objectives To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta‐analyses. One hundred forty‐six studies were based in high‐income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0, 95% confidence interval (CI) ‐0.10 to 0.10; 5 studies, 2107 participants; low‐certainty evidence) and at medium‐term follow‐up (MD ‐0.01, 95% CI ‐0.15 to 0.12; 9 studies, 6815 participants; low‐certainty evidence) or zBMI at long‐term follow‐up (MD ‐0.05, 95% CI ‐0.10 to 0.01; 7 studies, 5285 participants; low‐certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long‐term follow‐up (MD ‐0.17, 95% CI ‐0.48 to 0.13; 2 studies, 945 participants; moderate‐certainty evidence) and zBMI at short‐ or medium‐term follow‐up (MD ‐0.06, 95% CI ‐0.13 to 0.01; 8 studies, 3695 participants; MD ‐0.04, 95% CI ‐0.10 to 0.02; 9 studies, 7048 participants; moderate‐certainty evidence). Five studies (1913 participants; very low‐certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short‐term or long‐term follow‐up (BMI short‐term: MD ‐0.02, 95% CI ‐0.17 to 0.13; 14 studies, 4069 participants; zBMI short‐term: MD ‐0.02, 95% CI ‐0.07 to 0.02; 6 studies, 3580 participants; low‐certainty evidence; BMI long‐term: MD ‐0.07, 95% CI ‐0.24 to 0.10; 8 studies, 8302 participants; zBMI long‐term: MD ‐0.02, 95% CI ‐0.09 to 0.04; 6 studies, 6940 participants; low‐certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.18 to ‐0.05; 16 studies, 21,286 participants; zBMI: MD ‐0.05, 95% CI ‐0.09 to ‐0.02; 13 studies, 20,600 participants; moderate‐certainty evidence). Eleven studies (21,278 participants; low‐certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to ‐0.01; 27 studies, 16,066 participants; zBMI: MD ‐0.03, 95% CI ‐0.06 to 0.00; 26 studies, 12,784 participants; low‐certainty evidence) and likely result in a reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD ‐0.05, 95% CI ‐0.07 to ‐0.02; 24 studies, 20,998 participants; moderate‐certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long‐term follow‐up (BMI: MD 0.03, 95% CI ‐0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD ‐0.02, 95% CI ‐0.06 to 0.01; 22 studies, 23,594 participants; low‐certainty evidence). Nineteen studies (27,882 participants; low‐certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow‐up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high‐income versus non‐high‐income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability. Authors' conclusions The body of evidence in this review demonstrates that a range of school‐based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short‐ and medium‐term, but not at long‐term follow‐up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community‐based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities. Plain language summary Do dietary and activity strategies help prevent obesity in children aged 5 to 11 years? Key messages ‐ Strategies for changing activity levels, or both activity levels and diet, of children to help prevent them developing overweight or obesity might be effective in making small reductions in body mass index (BMI) in children aged 5 to 11 years. ‐ There is very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but from what we found there appears to be little or no effect. ‐ This change in BMI, when provided to many children across a whole population, is useful for parents concerned about their children becoming overweight as they move into adulthood and for governments in trying to tackle the problems of obesity through the life course. Why is preventing obesity in children important? More children are developing overweight and obesity worldwide. Being overweight as a child can cause health problems, and people may be affected psychologically and in their social life. Children that are overweight are likely to be overweight as adults and continue to experience poor physical and mental health. Indeed, childhood obesity is associated with type 2 diabetes and heart disease in adulthood and middle‐age mortality. What did we want to find out? We wanted to find out if strategies to help people modify their diet or activity (or both) are effective at preventing obesity in children aged 5 to 11 years. We also wanted to find out if these strategies were associated with any serious adverse events. What did we do? We searched many scientific databases to find studies that looked at ways of preventing obesity in children. We included studies aimed at children aged 5 to 11 years. We did not include studies only aimed at children who were already overweight or were already living with obesity. However, we included studies in which children who were overweight or living with obesity were included in the analysis. We only included studies if the methods they used were aimed at changing children's diet, or their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed people into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 172 studies that involved 189,707 children. One hundred forty‐six studies were based in high‐income countries (e.g. the USA and in Europe). In 111 studies, the strategies were tried in schools, though 15 were based in the community, eight in the home and seven in clinical settings; one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six strategies were implemented for less than nine months, with the shortest being conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry (e.g. food suppliers, pharmaceutical industry and private healthcare services). Our statistical analyses included results from 149 studies of 160,267 children. We found that children who were helped with a strategy to change their activity levels alone or in combination with a strategy to change their diet may have their BMI reduced, compared with children who were not given any strategy. This means that these children may have been able to minimise their excess weight gain by a small amount which, for public health, is important. In contrast, children who were helped with a strategy to change their diet only did not have their BMI reduced. Only a few studies reported any possible harms of the strategies, and no serious harms were identified in these. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low. However, it is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. A lot of the studies had limitations in how they were done. 3. There were not enough studies reporting particular types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons, and also certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way such that we could include them in our analyses (e.g. without any detail of the difference between the strategies examined) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for children with disabilities, or whether those implemented in community settings are effective. How up‐to‐date is this evidence? This review updates our previous review. The evidence is up‐to‐date to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F; Davies, AL; Tomlinson, E; Moore, THM; Dawson, S; Breheny, K; Savović, J; Gao, Y; Phillips, SM; Hillier-Brown, F; Hodder, RK; Wolfenden, L; Higgins, JPT; Summerbell, CD", "articleTypes": [], "doi": "10.1002/14651858.CD015328.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "7bed4131-2e44-42d4-935b-9b37782940c9", "pmid": "", "title": "Sapropterin dihydrochloride for phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria results from a deficiency of the enzyme phenylalanine hydroxylase. Dietary restriction of phenylalanine keeps blood phenylalanine concentration low. Most natural foods are excluded from diet and supplements are used to supply other nutrients. Recent publications report a decrease in blood phenylalanine concentration in some patients treated with sapropterin dihydrochloride. We examined the evidence for the use of sapropterin dihydrochloride to treat phenylketonuria. This is an update of a previously published Cochrane Review. Objectives To assess the safety and efficacy of sapropterin dihydrochloride in lowering blood phenylalanine concentration in people with phenylketonuria. Search methods We identified relevant trials from the Group's Inborn Errors of Metabolism Trials Register. Date of last search: 11 August 2014. We also searched ClinicalTrials.gov and Current controlled trials. Last search: 4 September 2014 We contacted the manufacturers of the drug (BioMarin Pharmaceutical Inc.) for information regarding any unpublished trials. Selection criteria Randomized controlled trials comparing sapropterin with no supplementation or placebo in people with phenylketonuria due to phenylalanine hydroxylase deficiency. Data collection and analysis Two authors independently assessed trials and extracted outcome data. Main results Two placebo‐controlled trials were included. One trial administered 10 mg/kg/day sapropterin in 89 children and adults with phenylketonuria whose diets were not restricted and who had previously responded to saproterin.This trial measured change in blood phenylalanine concentration. The second trial screened 90 children (4 to 12 years) with phenylketonuria whose diet was restricted, for responsiveness to sapropterin. Forty‐six responders entered the placebo‐controlled part of the trial and received 20 mg/kg/day sapropterin. This trial measured change in both phenylalanine concentration and protein tolerance. Both trials reported adverse events. The trials showed an overall low risk of bias; but both are Biomarin‐sponsored. One trial showed a significant lowering in blood phenylalanine concentration in the sapropterin group (10 mg/kg/day), mean difference ‐238.80 μmol/L (95% confidence interval ‐343.09 to ‐134.51); a second trial (20 mg/kg/day sapropterin) showed a non‐significant difference, mean difference ‐51.90 μmol/L (95% confidence interval ‐197.27 to 93.47). The second trial also reported a significant increase in phenylalanine tolerance, mean difference18.00 mg/kg/day (95% confidence interval 12.28 to 23.72) in the 20 mg/kg/day sapropterin group. Authors' conclusions There is evidence of short‐term benefit from using sapropterin in some people with sapropterin‐responsive forms of phenylketonuria; blood phenylalanine concentration is lowered and protein tolerance increased. There are no serious adverse events associated with using sapropterin in the short term. There is no evidence on the long‐term effects of sapropterin and no clear evidence of effectiveness in severe phenylketonuria. Plain language summary The use of sapropterin to lower phenylalanine concentration in blood in people with phenylketonuria. Phenylketonuria occurs due to an inherited deficiency of the enzyme phenylalanine hydroxylase. If untreated it causes an excessive accumulation of the amino acid phenylalanine in the body which prevents normal brain development. The established treatment for phenylketonuria consists of dietary restriction of natural protein but with prescribed phenylalanine‐free amino acid, mineral and vitamin supplements. With this treatment the long‐term outcome for people with phenylketonuria is excellent but the diet is onerous. Sapropterin dihydrochloride, the cofactor for phenylalanine hydroxylase, could lower phenylalanine concentration significantly in phenylketonuria and might allow a relaxation of dietary restrictions. The review identified two trials of sapropterin dihydrochloride; one in children and adults with no restricted diet and one in just children whose diet was restricted. The trials used different doses of sapropterin dihydrochloride (10 mg/kg/day and 20 mg/kg/day). We could not combine any data due to different formats of presentation. We found evidence to show that some people with mild or moderate phenylketonuria can benefit from the use of sapropterin dihydrochloride in the short term; the concentration of blood phenylalanine was lowered after treatment in both trials. The trial with the higher dose also measured the outcome change in protein tolerance. It reported an increase in protein tolerance in response to sapropterin. There were no adverse effects associated with the use of sapropterin dihydrochloride in the short term. We found no evidence on the effects of long‐term treatment. We could not draw any conclusions on its benefits in severe phenylketonuria.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Somaraju, UR; Merrin, M", "articleTypes": [], "doi": "10.1002/14651858.CD008005.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "7bf5e2b1-7350-4390-97bd-1805202eec23", "pmid": "", "title": "Olfactory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Preterm infants, often gavage‐fed due to immaturity, may benefit from interventions that hasten the move to breastfeeding. Olfactory stimulation may increase appetite and speed up the transition to full oral feeding, potentially shortening hospital stay and improving outcomes for both infants and families. Objectives To evaluate the benefits and harms of olfactory stimulation for reducing morbidity and promoting development in hospitalized preterm infants. Search methods We searched MEDLINE, Embase, CENTRAL, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 2 April 2025. We checked the reference lists of included studies and systematic reviews on olfactory or sensory stimulation. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs evaluating olfactory stimulation with different odorants (maternal breast milk, food‐associated odors, or non‐food‐associated odors) in preterm infants (born before 37 weeks' gestation). Eligible controls were no intervention, placebo, or standard care (considered together) or another odorant. We excluded studies combining olfactory stimulation with taste, as another review will focus on combined sensory stimulation. Outcomes Our critical outcomes were apnea, intermittent hypoxemia, duration of hospital stay, time to full oral feeding, and exclusive breastfeeding. Our important outcomes included blindness and sensorineural deafness requiring amplification. Risk of bias We used the Cochrane risk of bias tool (RoB 2) to assess risk of bias in the included studies. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, each with its 95% confidence interval (CI). We assessed the certainty of evidence using GRADE. Included studies We included 14 trials enrolling 1087 neonates. The types of olfactory stimulation under investigation were maternal breast milk (9 studies); food‐associated odors such as cinnamon, vanilla, or anise (5 studies); and non‐food‐associated odors such as rose or parents' scent (3 studies). Three studies evaluated two different odorants. Gestational age and bodyweight varied widely. The comparators were placebo, no intervention, and standard care. Eleven studies aimed to assess the effect of olfactory stimulation on infant feeding outcomes such as time to full oral feeding, weight gain, length of hospital stay, or a combination of these outcomes. Three studies aimed to assess the effect of olfactory stimulation on apnea prevention, oxygen saturation, or both. We identified five ongoing trials. Synthesis of results No studies reported apnea as a dichotomous outcome, intermittent hypoxemia, exclusive breastfeeding, or major neurodevelopmental disability for any of the comparisons. We downgraded the certainty of evidence for limitations in study design, imprecision, and indirectness. Olfactory stimulation with maternal breast milk versus no intervention, placebo, or standard care The evidence is very uncertain about the effect of olfactory stimulation with maternal breast milk on the mean number of daily apnea episodes (MD −0.50, 95% CI −1.27 to 0.27; 1 study, 26 participants; very low‐certainty evidence) and duration of hospital stay in days (MD −0.18, 95% CI −0.64 to 0.27; I² = 0%; 4 studies, 270 participants; very low‐certainty evidence). Olfactory stimulation with maternal breast milk may result in a slight reduction in time to full oral feeding in days (MD −1.68, 95% CI −3.25 to −0.11; I² = 30%; 3 studies, 204 participants; low‐certainty evidence). Olfactory stimulation with food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with food‐associated odors may result in a slight reduction in the mean number of daily apnea episodes (MD −1.99, 95% CI −2.69 to −1.29; I² = 58%; 2 studies, 62 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with food‐associated odors on duration of hospital stay in days (MD −2.65, 95% CI −6.18 to 0.89; I² = 20%; 3 studies, 185 participants; very low‐certainty evidence) and time to full oral feeding in days (MD −2.06, 95% CI −5.16 to 1.04; I² = 36%; 3 studies, 185 participants; very low‐certainty evidence). Olfactory stimulation with non‐food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with non‐food‐associated odors may result in a slight reduction in duration of hospital stay in days (MD −3.23, 95% CI −5.50 to −0.97; I² = 0%; 2 studies, 94 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with non‐food‐associated odor on the mean number of daily apnea episodes (MD −2.13, 95% CI −2.28 to −1.98; 1 study, 60 participants; very low‐certainty evidence) and time to full oral feeding (mean 21 (standard deviation 3.1) days in the intervention group and mean 21 (standard deviation 15.6) days in the control group; 1 study, 27 participants; very low‐certainty evidence). Authors' conclusions Olfactory stimulation with maternal breast milk compared to no intervention, placebo, or standard care may result in a slight reduction in time to full oral feeding, but the evidence is very uncertain about its effect on frequency of apnea episodes and duration of hospital stay. Olfactory stimulation with food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in frequency of apnea episodes, but the evidence is very uncertain about its effect on duration of hospital stay and time to full oral feeding. Olfactory stimulation with non‐food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in duration of hospital stay, but the evidence is very uncertain about its effect on frequency of apnea episodes and time to full oral feeding. Future studies should be more rigorous in their design, report using TIDieR (Template for Intervention Description and Replication) checklists, have larger sample sizes, and measure outcomes such as apnea (number of infants with ≥ 1 episode), intermittent hypoxemia (number of infants with ≥ 1 episode), exclusive breastfeeding, and major neurodevelopmental disabilities. Funding Dedicated funding for this review can be found in the 'Sources of support' section. Registration Protocol: https://doi.org/10.1002/14651858.CD016074 . Plain language summary Does introducing smells to preterm infants improve their physical and mental development? Key messages Introducing preterm infants to the smell of maternal breast milk may slightly reduce the time it takes for them to feed fully by mouth. Introducing them to food smells such as vanilla and cinnamon may slightly reduce how often they stop breathing. Finally, introducing preterm babies to the smell of rose or a parent's scent may reduce slightly the time they have to stay in hospital. All other results are very uncertain. Future studies should include more infants, use more rigorous designs, and measure outcomes such as breathing problems, low blood oxygen levels, exclusive breastfeeding, and long‐term neurodevelopmental outcomes. What is preterm birth? A normal pregnancy usually lasts from 37 weeks to 42 weeks. Preterm birth is when a baby is born before 37 weeks of pregnancy. Babies born preterm have not had enough time to fully develop before birth. Their organs may not yet be ready to work on their own, which means they often need intensive medical care and are at greater risk of breathing and feeding difficulties, infection, and problems that can affect their long‐term development. What is olfactory stimulation, and how does it work? Preterm infants often take time to build up the skills or physical capacity to feed by mouth, and in the meantime are fed through a tube passed into the stomach. Olfactory stimulation involves introducing smells to preterm infants while they are in hospital to see if it helps them start breastfeeding more quickly. These smells include breast milk, food smells such as vanilla or cinnamon, and other smells such as a floral scent or a parent's scent. What did we want to find out? We wanted to find out whether introducing a smell to preterm infants in hospital could be helpful and safe for their short‐term and long‐term well‐being. More specifically, we wanted to find out whether introducing a smell to preterm infants is better than placebo (dummy treatment), no treatment, or usual care for: reducing the number of infants who have apnea (brief pauses in breathing); reducing the number of infants with low oxygen levels in the blood; reducing the time spent in hospital; reducing the time needed for the infants to learn to feed fully by mouth; increasing the number of infants that are fed only with breast milk; reducing the number of infants with blindness or deafness between 18 and 24 months of age. What did we do? We searched for studies that compared olfactory stimulation with placebo, no treatment, or usual care in preterm infants. We summarized the results of the studies and rated our confidence in the evidence based on factors such as study size (number of infants) and methods. What did we find? We included 14 studies with 1087 infants. Nine studies used the smell of maternal breast milk, five used food‐associated smells (vanilla, cinnamon, or anise), and three studies used other smells (rose or parents' scent). All studies compared these smells with no treatment, placebo, or usual care. Main results Introducing the smell of maternal breast milk may reduce slightly the time it takes infants to feed fully by mouth. It is unclear whether stimulation with this smell has any effect on how often infants have apnea episodes and how long they stay in hospital. Introducing the smell of cinnamon, vanilla, or anise may slightly reduce how often infants have apnea episodes. It is unclear whether stimulation with these smells has any effect on how long infants stay in hospital or how long it takes them to feed fully by mouth. Introducing the scent of rose or a parent's scent may slightly reduce how long infants spend in hospital. It is unclear whether stimulation with these smells has any effect on how often infants have apnea episodes or how long it takes them to feed fully by mouth. What are the limitations of the evidence? We have little confidence in these results, as the studies included could have been better designed and included more babies. Several studies did not report outcomes we were interested in. How up to date is this evidence? The evidence is current to 2 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lenells, M; Prescott, MG; Wróblewska-Seniuk, K; Fiander, M; Soll, RF; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD016074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "7c0b4e27-ce1f-45fb-a3d8-04277ceac224", "pmid": "", "title": "Finerenone and Empagliflozin Combination in Obesity With Hypertension: A 12-Week Prospective, Parallel-design, Double-blind, Randomized, Placebo-controlled Trial", "imported": false, "abstract": "The EFFORT Study (Empagliflozin and Finerenone Combination in Obesity with Hypertension) is a 12-week, randomized, double-blind, placebo-controlled trial that aims to test whether combining empagliflozin (10 mg/day) with finerenone (10 mg/day, up-titrated to 20 mg after 4 weeks) can significantly lower office systolic blood pressure in adults with obesity and stage 1 hypertension (systolic BP 140-160 mmHg) who are on up to two stable antihypertensives. The study will enroll 260 participants from community settings. Beyond blood pressure, the trial will also assess effects on diastolic pressure, cumulative BP exposure, urinary albumin-to-creatinine ratio, inflammation (hs-CRP), fasting glucose, body weight, and quality of life. Safety monitoring focuses on hyperkalemia, acute kidney injury, hypotension, and hypoglycemia. If positive, this research may offer a new, mechanism-based therapeutic strategy for the growing population with cardiometabolic risk, potentially providing better cardiovascular and kidney protection than conventional approaches.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.154Z" }, { "id": "7c0bb0b7-ae63-49c7-8cf4-d7511a785a5c", "pmid": "", "title": "Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age", "imported": false, "abstract": "Abstract - Background According to global prevalence analysis studies, acute upper respiratory tract infections (URTIs) are the most common acute infectious disease in children, especially in preschool children. Acute URTIs lead to an economic burden on families and society. Vitamin A refers to the fat‐soluble compound all‐trans‐retinol and also represents retinol and its active metabolites. Vitamin A interacts with both the innate immune system and the adaptive immune system and improves the host's defences against infections. Correlation studies show that serum retinol deficiency was associated with a higher risk of respiratory tract infections. Therefore, vitamin A supplementation may be important in preventing acute URTIs. Objectives To assess the effectiveness and safety of vitamin A supplements for preventing acute upper respiratory tract infections in children up to seven years of age. Search methods We searched CENTRAL, MEDLINE, Embase, the Chinese Biomedical Literature Database, and two trial registration platforms to 8 June 2023. We also checked the reference lists of all primary studies and reviewed relevant systematic reviews and trials for additional references. We imposed no language or publication restrictions. Selection criteria We included randomised controlled trials (RCTs), which evaluated the role of vitamin A supplementation in the prevention of acute URTIs in children up to seven years of age. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Main results We included six studies (27,351 participants). Four studies were RCTs and two were cluster‐RCTs. The included studies were all conducted in lower‐middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas with a high local prevalence of malnutrition and xerophthalmia. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. We judged the included studies to be at either a high or unclear risk of bias for random sequence generation, incomplete outcome data, and blinding. Primary outcomes Six studies reported the incidence of acute URTIs during the study period. Five studies reported the number of acute URTIs over a period of time, but there was population heterogeneity and the results were presented in different forms, therefore only three studies were meta‐analysed. We are uncertain of the effect of vitamin A supplementation on the number of acute URTIs over two weeks (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.92 to 1.09; I 2 = 44%; 3 studies, 22,668 participants; low‐certainty evidence). Two studies reported the proportion of participants with an acute URTI. We are uncertain of the effect of vitamin A supplementation on the proportion of participants with an acute URTI (2 studies, 15,535 participants; low‐certainty evidence). Only one study (116 participants) reported adverse events. No infant in either the placebo or vitamin A group was found to have feeding difficulties (failure to feed or vomiting), a bulging fontanelle, or neurological signs before or after vitamin A administration (very low‐certainty evidence). Secondary outcomes Two studies (296 participants) reported the severity of subjective symptoms, presented by the mean duration of acute URTI. Vitamin A may have little to no effect on the mean duration of acute URTI (very low‐certainty evidence). Authors' conclusions The evidence for the use of vitamin A supplementation to prevent acute URTI is uncertain, because population, dose and duration of interventions, and outcomes vary between studies. From generally very low‐ to low‐certainty evidence, we found that there may be no benefit in the use of vitamin A supplementation to prevent acute URTI in children up to seven years of age. More RCTs are needed to strengthen the current evidence. Future research should report over longer time frames using validated tools and consistent reporting, and ensure adequate power calculations, to allow for easier synthesis of data. Finally, it is important to assess vitamin A supplementation for preschool children with vitamin A deficiency. Plain language summary Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age Background Acute upper respiratory tract infections (URTIs) are the most common acute infectious diseases in children, especially in preschool children. Vitamin A has a positive role in the immune system and may improve the host's defences against infections. Studies show that children with vitamin deficiency are more likely to suffer from respiratory tract infections. Therefore, we assessed the role of vitamin A supplementation in the prevention of acute upper respiratory tract infections in preschool children (up to seven years of age). Review question What is the role of vitamin A supplementation in the prevention of acute URTIs in preschool children (up to seven years of age), compared to no supplementation? Search date We searched for evidence up to 8 June 2023. Study characteristics All included studies were conducted in lower‐ and middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas more likely to experience malnutrition and dry eye. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. Key results We included six studies involving 27,351 participants. We have very low to low confidence in the evidence provided by the studies. Five studies reported the number of acute URTIs over a period of time. The included studies varied by population and the results were presented in different forms, so we could only combine three studies together (meta‐analysis). We are uncertain if vitamin A supplementation lowers the number of acute URTIs over a two‐week period (three studies, 22,668 participants). Two studies reported the proportion of participants with acute URTI. The effect of vitamin A supplementation on the proportion of participants with acute URTI is uncertain (two studies, 15,535 participants). Only one study (116 participants) reported adverse events and none occurred in infants in the placebo or vitamin A groups. Two studies (296 participants) reported the severity of subjective symptoms, presented by the average duration of acute URTIs. Vitamin A may have little to no effect on the average duration of acute URTIs. Authors' conclusions From evidence in which we have very low to low confidence, we found that there may be no benefit in using vitamin A supplementation to prevent acute URTIs in children up to seven years of age. High‐quality studies focusing on preschool children with vitamin A deficiency are needed to identify whether vitamin A supplementation may be effective.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Cheng, X; Li, D; Yang, C; Chen, B; Xu, P; Zhang, L", "articleTypes": [], "doi": "10.1002/14651858.CD015306.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "7c52cfc1-36f2-4ffd-a475-39101d9289a0", "pmid": "", "title": "Postnatal phenobarbital for the prevention of intraventricular haemorrhage in preterm infants", "imported": false, "abstract": "Abstract - Background Intraventricular haemorrhage (IVH) is a major complication of preterm birth. Large haemorrhages are associated with a high risk of disability and hydrocephalus. Instability of blood pressure and cerebral blood in the newborn flow are postulated as causative factors. Another mechanism may involve reperfusion damage from oxygen free radicals. It has been suggested that phenobarbital stabilises blood pressure and may protect against free radicals. This is an update of a review first published in 2001 and updated in 2007 and 2013. Objectives To assess the benefits and harms of the postnatal administration of phenobarbital in preterm infants at risk of developing IVH compared to control (i.e. no intervention or placebo). Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL and clinical trial registries in January 2022. A new, more sensitive search strategy was developed, and searches were conducted without date limits. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs in which phenobarbital was given within the first 24 hours of life to preterm infants identified as being at risk of IVH because of gestational age below 34 weeks, birth weight below 1500 g or respiratory failure. Phenobarbital was compared to no intervention or placebo. We excluded infants with serious congenital malformations. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were all grades of IVH and severe IVH (i.e. grade III and IV); secondary outcomes were ventricular dilation or hydrocephalus, hypotension, pneumothorax, hypercapnia, acidosis, mechanical ventilation, neurodevelopmental impairment and death. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 10 RCTs (792 infants). The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH of any grade compared with control (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.84 to 1.19; risk difference (RD) 0.00, 95% CI ‐0.06 to 0.07; I² for RD = 65%; 10 RCTs, 792 participants; low certainty evidence) and in severe IVH (RR 0.88, 95% CI 0.64 to 1.21; 10 RCTs, 792 participants; low certainty evidence). The evidence is very uncertain about the effect of phenobarbital on posthaemorrhagic ventricular dilation or hydrocephalus (RR 0.62, 95% CI 0.31 to 1.26; 4 RCTs, 271 participants; very low certainty evidence), mild neurodevelopmental impairment (RR 0.57, 95% CI 0.15 to 2.17; 1RCT, 101 participants; very low certainty evidence), and severe neurodevelopmental impairment (RR 1.12, 95% CI 0.44 to 2.82; 2 RCTs, 153 participants; very low certainty evidence). Phenobarbital may result in little to no difference in death before discharge (RR 0.88, 95% CI 0.64 to 1.21; 9 RCTs, 740 participants; low certainty evidence) and mortality during study period (RR 0.98, 95% CI 0.72 to 1.33; 10 RCTs, 792 participants; low certainty evidence) compared with control. We identified no ongoing trials. Authors' conclusions The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH (any grade or severe) compared with control (i.e. no intervention or placebo). The evidence is very uncertain about the effects of phenobarbital on ventricular dilation or hydrocephalus and on neurodevelopmental impairment. The evidence suggests that phenobarbital results in little to no difference in death before discharge and all deaths during the study period compared with control. Since 1993, no randomised studies have been published on phenobarbital for the prevention of IVH in preterm infants, and no trials are ongoing. The effects of postnatal phenobarbital might be assessed in infants with both neonatal seizures and IVH, in both randomised and observational studies. The assessment of benefits and harms should include long‐term outcomes. Plain language summary What are the benefits and risks of phenobarbital for preventing bleeding to the brain in babies born too early? Key messages • Giving phenobarbital (a medicine used to control seizures) to babies born too early may have little to no effect in preventing intraventricular haemorrhage (bleeding to the brain) and death. • The evidence is very uncertain about the effect of phenobarbital on preventing ventricular dilation (enlarged spaces in the brain) and long‐term brain development. What is bleeding to the brain (intraventricular haemorrhage)? Large bleeds in the centre of the brain can cause disability or death in babies born too early. Unstable blood pressure and blood flow to the brain are believed to cause bleeding into the fluid‐filled cavities of the brain (ventricles). What did we want to find out? Phenobarbital is believed to stabilise blood pressure and therefore potentially help prevent bleeding to the brain. We wanted to find out whether phenobarbital was better than no medicine or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) to prevent bleeding to the brain. What did we do? We searched for studies that compared giving phenobarbital against no medicines. We compared and summarised the results of these studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We included 10 studies (792 babies). The evidence suggests that phenobarbital has little to no effect in preventing bleeding to the brain. The evidence is very uncertain about the effect of phenobarbital on dilation of the ventricles in the brain and long‐term development. The evidence suggests that phenobarbital has little to no effect in preventing deaths. We identified no ongoing trials. What are the limitations of the evidence? It is possible that people conducting the studies were aware of what treatment they were giving. Not all the studies provided data about everything that we were interested in. The studies were very small. How up to date is this evidence? This review updates our previous review. The evidence is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Romantsik, O, Smit, E, Odd, DE, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD001691.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.816Z" }, { "id": "7ca0347e-8d8f-4509-b41d-3537ec0e8c8d", "pmid": "", "title": "Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is the most common life‐limiting autosomal recessive genetic disorder in white populations. Distal intestinal obstruction syndrome (DIOS) is an important morbidity in cystic fibrosis. It is the result of the accumulation of viscid faecal material within the bowel which combines with thick, sticky mucus produced in the intestines of people with cystic fibrosis. The intestine may be completely blocked (complete DIOS) or only partially blocked (incomplete DIOS). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the acute complete or incomplete faecal obstruction and ultimately prevent the need for surgical intervention . Objectives This review aimed to evaluate the effectiveness and safety of different treatment regimens for the treatment of DIOS (complete and incomplete) in children and adults with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials (including cross‐over trials (to be judged on an individual basis)) comparing the use of laxative agents or surgery for treating DIOS in children, young people and adults with cystic fibrosis to each other, placebo or no intervention. Data collection and analysis Two authors independently screened papers, extracted trial details and assessed for risk of bias. The authors assessed the quality of evidence using GRADE. Main results There was one trial with 20 participants (16 females) included in the review. The mean age of participants was 13.1 years. The trial was a double‐blinded, randomised cross‐over trial which had a duration of 12 months in total and compared high‐dose and low‐dose pancreatic enzyme therapy. As only the abstract of the trial was available, the overall risk of bias was judged to be unclear. The trial did not address either of our primary outcomes (time until resolution of DIOS and treatment failure rate), but reported episodes of acute DIOS, presence of abdominal mass and abdominal pain. There were no numerical data available for these outcomes, but the authors stated that there was no difference between treatment with high‐dose or low‐dose pancreatic enzymes. The overall certainty of the evidence was found to be very low. Authors' conclusions There is a clear lack of evidence for the treatment of DIOS in people with cystic fibrosis. The included abstract did not address our primary outcome measures and did not provide numerical data for the two secondary outcomes it did address. Therefore, we cannot justify the use of high‐dose pancreatic enzymes for treating DIOS, nor can we comment on the efficacy and safety of other laxative agents. From our findings, it is clear that more randomised controlled trials need to be conducted in this area. Plain language summary Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis Review question We reviewed the evidence about the effectiveness and safety of different treatments for distal intestinal obstruction syndrome (DIOS) in children and adults with cystic fibrosis. Background Cystic fibrosis is a common, life‐limiting, inherited disease. One of the main features of cystic fibrosis is the thick, sticky mucus produced by many organs including the lungs, pancreas and intestine. DIOS occurs when mucus in the intestine combines with faeces and builds up to produce a mass. This mass can partially or completely block the intestine and cause symptoms such as vomiting, severe abdominal pain and a swollen stomach (abdominal distension). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the complete or partial blockage and ultimately prevent the need for any surgical intervention. Search date The evidence is current to: 12 October 2021. Trial characteristics The review included one trial with 20 people with cystic fibrosis who were aged between 7.1 and 23.2 years of age (average 13.1 years old). The 12‐month trial compared a high dose of pancreatic enzymes with a low dose of pancreatic enzymes for treating chronic DIOS. Key results The trial did not report on our primary outcomes (time until DIOS successfully treated and treatment failure rate), but addressed two of our secondary outcomes; episodes of acute DIOS and the harmful effects that might occur in participants (the presence of an abdominal mass and abdominal pain). There were no numerical data available for these results, but the authors reported that there was no difference between high‐dose or low‐dose pancreatic enzymes. Certainty of the evidence We found the overall certainty of the evidence to be very low. The trial itself was only published as an abstract from a conference which did not include numerical data and it was not published as a full report. This meant that we do not know many details about the trial. We thought that the overall risk of bias was unclear, as the trial authors did not describe how participants were put into the treatment groups, whether any participants dropped out or whether the planned outcomes were the same as the reported outcomes. The trial also had a very small number of participants and a limited age range, making it difficult to draw conclusions about the relevance of the treatment for all people with cystic fibrosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gilchrist, FJ, Green, J, Carroll, W", "articleTypes": [], "doi": "10.1002/14651858.CD012798.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.758Z" }, { "id": "7cb484f4-2c61-461d-b0cd-03414bd1e3af", "pmid": "", "title": "Xylitol for preventing acute otitis media in children up to 12 years of age", "imported": false, "abstract": "Abstract - Background Acute otitis media (AOM) is the most common bacterial infection among young children in the United States. There are limitations and concerns over its treatment with antibiotics and surgery and so effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk of dental decay. Xylitol can reduce the adherence of Streptococcus pneumoniae ( S pneumoniae ) and Haemophilus influenzae ( H influenzae ) to nasopharyngeal cells in vitro. This is an update of a review first published in 2011. Objectives To assess the efficacy and safety of xylitol to prevent AOM in children aged up to 12 years. Search methods We searched CENTRAL (to Issue 12, 2015), MEDLINE (1950 to January 2016), Embase (1974 to January 2016), CINAHL (1981 to January 2016), LILACS (1982 to January 2016), Web of Science (2011 to January 2016) and International Pharmaceutical Abstracts (2000 to January 2016). Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs of children aged 12 years or younger where xylitol supplementation was compared with placebo or no treatment to prevent AOM. Data collection and analysis Two review authors independently selected trials from search results, assessed and rated study quality and extracted relevant data for inclusion in the review. We contacted trial authors to request missing data. We noted data on any adverse events of xylitol. We extracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR), risk difference (RD) and associated 95% confidence intervals (CI). Main results We identified five clinical trials that involved 3405 children for inclusion. For this 2016 update, we identified one new trial for inclusion. This trial was systematically reviewed but due to several sources of heterogeneity, was not included in the meta‐analysis. The remaining four trials were of adequate methodological quality. In three RCTs that involved a total of 1826 healthy Finnish children attending daycare, there is moderate quality evidence that xylitol (in any form) can reduce the risk of AOM from 30% to around 22% compared with the control group (RR 0.75, 95% CI 0.65 to 0.88). Among the reasons for dropouts, there were no significant differences in abdominal discomfort and rash between the xylitol and the control groups. Xylitol was not effective in reducing AOM among healthy children during a respiratory infection (RR 1.13, 95% CI 0.83 to 1.53; moderate quality evidence) or among otitis‐prone healthy children (RR 0.90, 95% CI 0.67 to 1.21; low‐quality evidence). Authors' conclusions There is moderate quality evidence showing that the prophylactic administration of xylitol among healthy children attending daycare centres can reduce the occurrence of AOM. There is inconclusive evidence with regard to the efficacy of xylitol in preventing AOM among children with respiratory infection, or among otitis‐prone children. The meta‐analysis was limited because data came from a small number of studies, and most were from the same research group. Plain language summary Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age Review question 
 We reviewed the evidence about the effectiveness and safety of xylitol to prevent acute middle ear infection (acute otitis media; AOM) in children up to 12 years old. Background 
 AOM is the most common bacterial infection among young children in the United States. Although serious complications are rare, this common childhood ailment imposes a huge impact on the healthcare system. In the United States, it accounted for almost 20 million office visits. Antibiotic treatment of AOM is costly and raises concerns about the development of antibiotic‐resistant strains of bacteria. Surgery is invasive and costly, and because of these factors, effective measures for preventing AOM are sought. An alternative treatment is xylitol or birch sugar. Xylitol has been used for decades as a natural non‐sugar sweetener principally in chewing gums, confectionery, toothpaste and medicines, and can reduce the risk of tooth decay. Search date We searched the literature up to January 2016. This is an update of a review that was last published in 2011. Study characteristics 
 We identified five clinical trials that involved 3405 children, mostly from the same research group. Four trials were conducted in Finland and enrolled healthy children (three trials) or children with an acute respiratory infection (one trial). The fifth trial was conducted in the USA and enrolled otitis‐prone children who were recruited from attendance at general medical practices. Study funding sources All five trials received governmental funding; and the Finnish study investigators have a US patent for the use of xylitol to treat respiratory infections. Key results Xylitol, administered in chewing gum, lozenges or syrup, can reduce the occurrence of AOM among healthy children with no acute upper respiratory infection from 30% to 22%. There is no difference in side effects (namely, abdominal discomfort and rash). Based on these results we would expect that out of 1000 children up to 12 years of age, 299 would experience an AOM compared with between 194 and 263 children who would experience an AOM if they are provided with xylitol chewing gum. The preventive effect among healthy children with respiratory infection or among otitis‐prone children is inconclusive. Quality of the evidence 
 The quality of evidence was moderate for healthy children and children with respiratory infections but low for otitis‐prone children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Azarpazhooh, A; Lawrence, HP; Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD007095.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "7cb4fc3c-4aeb-473d-8bb4-f607ef40dcd0", "pmid": "", "title": "A MULTICENTER, GLOBAL, RANDOMIZED, DOUBLE-BLIND STUDY OF AXITINIB PLUS BEST SUPPORTIVE CARE VERSUS PLACEBO PLUS BEST SUPPORTIVE CARE IN PATIENTS WITH ADVANCED HEPATOCELLULAR CARCINOMA FOLLOWING FAILURE OF ONE PRIOR ANTIANGIOGENIC THERAPY", "imported": false, "abstract": "The study is designed to demonstrate that axitinib plus best supportive care is superior to placebo plus best supportive care in prolonging survival in patients with advanced hepatocellular carcinoma.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.251Z" }, { "id": "7cb5215b-390c-486e-9f7f-aad72e25c36e", "pmid": "", "title": "Prophylactic drug management for febrile seizures in children", "imported": false, "abstract": "Abstract - Background Febrile seizures occurring in a child older than one month during an episode of fever affect 2‐4% of children in Great Britain and the United States and recur in 30%. Rapid‐acting antiepileptics and antipyretics given during subsequent fever episodes have been used to avoid the adverse effects of continuous antiepileptic drugs. This is an updated version of a Cochrane Review previously published in 2017. Objectives To evaluate primarily the effectiveness and safety of antiepileptic and antipyretic drugs used prophylactically to treat children with febrile seizures; and also to evaluate any other drug intervention where there is a sound biological rationale for its use. Search methods For the latest update we searched the following databases on 3 February 2020: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to 31 January 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including the Cochrane Epilepsy Group. We imposed no language restrictions and contacted researchers to identify continuing or unpublished studies. Selection criteria Trials using randomised or quasi‐randomised participant allocation that compared the use of antiepileptics, antipyretics or recognised Central Nervous System active agents with each other, placebo, or no treatment. Data collection and analysis For the original review, two review authors independently applied predefined criteria to select trials for inclusion and extracted the predefined relevant data, recording methods for randomisation, blinding, and exclusions. For the 2016 update, a third review author checked all original inclusions, data analyses, and updated the search. For the 2020 update, one review author updated the search and performed the data analysis following a peer‐review process with the original review authors. We assessed seizure recurrence at 6, 12, 18, 24, 36, 48 months, and where data were available at age 5 to 6 years along with recorded adverse effects. We evaluated the presence of publication bias using funnel plots. Main results We included 42 articles describing 32 randomised trials, with 4431 randomised participants used in the analysis of this review. We analysed 15 interventions of continuous or intermittent prophylaxis and their control treatments. Methodological quality was moderate to poor in most studies. We found no significant benefit for intermittent phenobarbital, phenytoin, valproate, pyridoxine, ibuprofen, or zinc sulfate versus placebo or no treatment; nor for diclofenac versus placebo followed by ibuprofen, paracetamol, or placebo; nor for continuous phenobarbital versus diazepam, intermittent rectal diazepam versus intermittent valproate, or oral diazepam versus clobazam. There was a significant reduction of recurrent febrile seizures with intermittent diazepam versus placebo or no treatment at six months (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.48 to 0.85; 6 studies, 1151 participants; moderate‐certainty evidence), 12 months (RR 0.69, 95% CI 0.56 to 0.84; 8 studies, 1416 participants; moderate‐certainty evidence), 18 months (RR 0.37, 95% CI 0.23 to 0.60; 1 study, 289 participants; low‐certainty evidence), 24 months (RR 0.73, 95% CI 0.56 to 0.95; 4 studies, 739 participants; high‐certainty evidence), 36 months (RR 0.58, 95% CI 0.40 to 0.85; 1 study, 139 participants; low‐certainty evidence), 48 months (RR 0.36, 95% CI 0.15 to 0.89; 1 study, 110 participants; moderate‐certainty evidence), with no benefit at 60 to 72 months (RR 0.08, 95% CI 0.00 to 1.31; 1 study, 60 participants; very low‐certainty evidence). Phenobarbital versus placebo or no treatment reduced seizures at six months (RR 0.59, 95% CI 0.42 to 0.83; 6 studies, 833 participants; moderate‐certainty evidence), 12 months (RR 0.54, 95% CI 0.42 to 0.70; 7 studies, 807 participants; low‐certainty evidence), and 24 months (RR 0.69, 95% CI 0.53 to 0.89; 3 studies, 533 participants; moderate‐certainty evidence), but not at 18 months (RR 0.77, 95% CI 0.56 to 1.05; 2 studies, 264 participants) or 60 to 72 months follow‐up (RR 1.50, 95% CI 0.61 to 3.69; 1 study, 60 participants; very low‐certainty evidence). Intermittent clobazam compared to placebo at six months resulted in a RR of 0.36 (95% CI 0.20 to 0.64; 1 study, 60 participants; low‐certainty evidence), an effect found against an extremely high (83.3%) recurrence rate in the controls, a result that needs replication. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months (RR 0.45, 95% CI 0.18 to 1.15; 1 study, 60 participants; very‐low certainty evidence). When compared to placebo, intermittent oral levetiracetam significantly reduced recurrent seizures at 12 months (RR 0.27, 95% CI 0.15 to 0.52; 1 study, 115 participants; very low‐certainty evidence). The recording of adverse effects was variable. Two studies reported lower comprehension scores in phenobarbital‐treated children. Adverse effects were recorded in up to 30% of children in the phenobarbital‐treated groups and 36% in benzodiazepine‐treated groups. We found evidence of publication bias in the meta‐analyses of comparisons for phenobarbital versus placebo (seven studies) at 12 months but not at six months (six studies); and valproate versus placebo (four studies) at 12 months. There were too few studies to identify publication bias for the other comparisons. The methodological quality of most of the included studies was low or very low. Methods of randomisation and allocation concealment often did not meet current standards, and 'treatment versus no treatment' was more commonly seen than 'treatment versus placebo', leading to obvious risks of bias. Authors' conclusions We found reduced recurrence rates for intermittent diazepam and continuous phenobarbital, with adverse effects in up to 30% of children. The apparent benefit for clobazam treatment in one trial needs to be replicated. Levetiracetam also shows benefit with a good safety profile; however, further study is required. Given the benign nature of recurrent febrile seizures, and the high prevalence of adverse effects of these drugs, parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. Plain language summary Prophylactic drug management for febrile seizures in children Background Seizures occurring with a fever (febrile seizures) in children are common and affect about one in 30 children under the age of six years. On average, one out of three children who have had a febrile seizure will have at least one more. We reviewed the evidence about the effect of drugs to prevent seizures (antiepileptics), drugs to lower temperature (antipyretics), and zinc in children with febrile seizures. Objective We wanted to know in how many children these drugs would prevent a recurrence of febrile seizures or cause unwanted effects. Methods We included 32 studies with a total of 4431 children in the review. Children who had had at least one febrile seizure were assigned to one of two or more treatment groups. The studies recorded any further seizures at various time intervals between six months and up to six years of age in each group. Unwanted medication effects were also noted. Results The study design and evidence quality in the studies of antiepileptic drugs was often low or very low. Poor methods known to lead to obvious risks of bias were used. One issue was with the methods used to assign children to study groups and how random this allocation was. Other issues included whether the parents or doctors, or both, knew which group each child was in or if a treatment was compared to no treatment with no placebo (dummy pill) used. The quality of the trials of antipyretics or zinc was better, with the evidence assessed as moderate to high. Zinc therapy was found to provide no benefit. We also found no benefit in treating children just at the time of the fever with either antipyretic drugs or most antiepileptic drugs. A significant result was noted in some instances. For example, at times between 6 and 48 months follow‐up, intermittent diazepam (an antiepileptic drug) led to a reduction in the number of recurrent seizures by about a third. Continuous phenobarbital resulted in significantly fewer recurrences at 6, 12, and 24 months, but not at 18 and 60 to 72 months. One study showed that intermittent oral levetiracetam compared to placebo significantly reduced recurrent seizures at 12 months. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months. However, as recurrent seizures are only seen in about a third of children, this means that up to 16 children would have to be treated over a year or two to save just one child a further seizure. As febrile seizures are not harmful, we viewed these significant findings to be unimportant, in particular because adverse effects of the medications were common. Lower comprehension scores in phenobarbital‐treated children were found in two studies. In general, adverse effects were recorded in up to about a third of children in both the phenobarbital‐ and benzodiazepine‐treated groups. The benefit found for treatment with clobazam in one study published in 2011 needs to be repeated to test its reliability. Levetiracetam may be useful in treating children where family anxiety over possible seizure recurrence is high, but further study is required. Authors' conclusions There is currently insufficient evidence to support the use of continuous or intermittent treatment with zinc, antiepileptic or antipyretic drugs for children with febrile seizures. Febrile seizures can be frightening to witness. Parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. The evidence is current to February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Offringa, M, Newton, R, Nevitt, SJ, Vraka, K", "articleTypes": [], "doi": "10.1002/14651858.CD003031.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.805Z" }, { "id": "7cc06b77-a8d7-4b26-bb60-f211edd8fb95", "pmid": "", "title": "The effects of antimicrobial therapy on bacterial vaginosis in non‐pregnant women", "imported": false, "abstract": "Abstract - Background Bacterial vaginosis (BV) is a very common cause of vaginitis that has been associated with a high incidence of obstetric and gynaecologic complications and increased risk of HIV‐1 transmission. This has led to renewed research interest in its treatment. Objectives To assess the effects of antimicrobial agents on BV in non‐pregnant women. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE, LILACS, and African Healthline (December 2007); and proceedings of relevant international conferences (from 1981 to date). Selection criteria Randomised controlled trials comparing any two or more antimicrobial agents, or antimicrobial agents with placebo or no treatment, in women with clinical or Gram‐stain criteria of BV. Data collection and analysis Two authors independently assessed trial quality and extracted data from the original publications while the third author cross checked the data. Main results Twenty‐four trials involving 4422 participants were reviewed. Most examined symptomatic women only. Only seven trials analysed results by intention to treat; we re‐analysed the remainder. Compared with placebo, clindamycin showed a lower rate of treatment failure (relative risk (RR) 0.25, 95% confidence interval (CI) 0.16 to 0.37). Clindamycin and metronidazole showed identical rates of treatment failure, irrespective of regimen type, at two and four‐week follow up (RR 1.01, 95% CI 0.69 to 1.46; RR 0.91, 95% CI 0.70 to 1.18, respectively). Clindamycin tended to cause a lower rate of adverse events (RR 0.75, 95% CI 0.56 to 1.02); metallic taste, and nausea and vomiting were more common in the metronidazole group (RR 0.08, 95% CI 0.1 to 0.59; RR 0.23, 95% CI 0.10 to 0.51, respectively). Given intravaginally as gelatin tablets, lactobacillus was more effective than oral metronidazole (RR 0.20, 95% CI 0.05 to 0.08). Similarly, oral lactobacillus combined with metronidazole was more effective than metronidazole alone (RR 0.33, 95% CI 0.14 to 0.77). Clindamycin showed a lower rate of clinical failure than triple sulfonamide cream (RR 0.46, 95% CI 0.29 to 0.72). Hydrogen peroxide douche showed a higher rate of clinical failure (RR 1.75, 95% CI 1.02 to 3.00) and adverse events (RR 2.33, 95% CI 1.21 to 4.52) than a single 2 g dose of metronidazole. Authors' conclusions Clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus were effective for bacterial vaginosis. Hydrogen peroxide douche and triple sulphonamide cream were ineffective. Metronidazole caused metallic taste, nausea and vomiting. We need better‐designed trials with larger sample sizes to test the effectiveness of promising drugs. Plain language summary The effects of antimicrobial treatment on bacterial vaginosis in non‐pregnant women Bacterial vaginosis (BV) is a very common cause of symptomatic and asymptomatic vaginal infection. It has been associated with a high incidence of obstetric and gynaecologic complications and an increased risk of transmission of HIV (human immunodeficiency virus). This review evaluated the effectiveness and adverse effects of antimicrobial agents used to treat BV in non‐pregnant women. Twenty‐four trials involving 4422 women were reviewed. With regard to less treatment failure, clindamycin was superior to placebo but comparable to metronidazole, irrespective of the dose regimen. Metronidazole tended to cause a higher rate of adverse events, such as metallic taste and nausea and vomiting, than did clindamycin. Oral lactobacillus combined with metronidazole was more effective than metronidazole alone. Administered in an intravaginal gelatin tablet, lactobacillus was also more effective than oral metronidazole. Triple sulfonamide cream was less effective compared with clindamycin. Hydrogen peroxide douche was not as effective as a single 2 g dose of metronidazole yet caused more harms. Only one trial involved asymptomatic women and the result was not conclusive. There was insufficient evidence to reach a conclusion on the effectiveness of other promising drugs. Drugs effective for bacterial vaginosis include clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus. Adverse effects of metronidazole include metallic taste, and nausea and vomiting. Information on possible side effects of lactobacillus preparations is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Oduyebo, OO, Anorlu, RI, Ogunsola, FT", "articleTypes": [], "doi": "10.1002/14651858.CD006055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.066Z" }, { "id": "7cdb543f-47d4-44eb-94a7-6b47bb493996", "pmid": "", "title": "Triptans for acute cluster headache", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 ( Law 2010 ). Cluster headache is an uncommon, severely painful, and disabling condition, with rapid onset. Validated treatment options are limited; first‐line therapy includes inhaled oxygen. Other therapies such as intranasal lignocaine and ergotamine are not as commonly used and are less well studied. Triptans are successfully used to treat migraine attacks and they may also be useful for cluster headache. Objectives To assess the efficacy and tolerability of the triptan class of drugs compared to placebo and other active interventions in the acute treatment of episodic and chronic cluster headache in adult patients. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ClinicalTrials.gov, and reference lists for studies from inception to 22 January 2010 for the original review, and from 2009 to 4 April 2013 for this update. Selection criteria Randomised, double‐blind, placebo‐controlled studies of triptans for acute treatment of cluster headache episodes. Data collection and analysis Two review authors independently assessed study quality and extracted data. Numbers of participants with different levels of pain relief, requiring rescue medication, and experiencing adverse events and headache‐associated symptoms in treatment and control groups were used to calculate relative risk and numbers needed to treat for benefit (NNT) and harm (NNH). Main results New searches in 2013 did not identify any relevant new studies. All six included studies used a single dose of triptan to treat an attack of moderate to severe pain intensity. Subcutaneous sumatriptan was given to 131 participants at a 6 mg dose, and 88 at a 12 mg dose. Oral or intranasal zolmitriptan was given to 231 participants at a 5 mg dose, and 223 at a 10 mg dose. Placebo was given to 326 participants. Triptans were more effective than placebo for headache relief and pain‐free responses. By 15 minutes after treatment with subcutaneous sumatriptan 6 mg, 48% of participants were pain‐free and 75% had no pain or mild pain (17% and 32% respectively with placebo). NNTs for subcutaneous sumatriptan 6 mg were 3.3 (95% CI 2.4 to 5.0) and 2.4 (1.9 to 3.2) respectively. Intranasal zolmitriptan 10 mg was of less benefit, with 12% of participants pain‐free and 28% with no or mild pain (3% and 7% respectively with placebo). NNTs for intranasal zolmitriptan 10 mg were 11 (6.4 to 49) and 4.9 (3.3 to 9.2) respectively. Authors' conclusions Based on limited data, subcutaneous sumatriptan 6 mg was superior to intranasal zolmitriptan 5 mg or 10 mg for rapid (15 minute) responses, which are important in this condition. Oral routes of administration are not appropriate. Plain language summary Triptans for acute cluster headache Cluster headaches are excruciating headaches of extreme intensity. They can last for several hours, are usually on one side of the head only, and affect men more than women. Multiple headaches can occur over several days. Fast pain relief is important because of the intense nature of the pain with cluster headache. Triptans are a type of drug used to treat migraine. Although migraine is different from cluster headache, there are reasons to believe that some forms of these drugs could be useful in cluster headache. Triptans can be given by injection under the skin (subcutaneously) or by a spray into the nose (intranasally) to produce fast pain relief. The review found six studies examining two different triptans. The number of people in the studies was limited. Within 15 minutes of using subcutaneous sumatriptan 6 mg, almost 8 in 10 participants had no worse than mild pain, and 5 in 10 were pain‐free. Within 15 minutes of using intranasal zolmitriptan 5 mg, about 3 in 10 had no worse than mild pain, and 1 in 10 was pain‐free. Adverse events were more common with a triptan than with placebo but they were generally of mild to moderate severity. Cluster headache is an awful thing to have. More research on how to get better pain relief faster, and to more patients, would be welcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Law, S; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008042.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "7cfd066f-0df6-455c-a2b1-dac37fa50f54", "pmid": "", "title": "Interventions for bullous pemphigoid", "imported": false, "abstract": "Abstract - Background Bullous pemphigoid (BP) is the most common autoimmune blistering disease. Oral steroids are the standard treatment. We have updated this review, which was first published in 2002, because several new treatments have since been tried. Objectives To assess the effects of treatments for bullous pemphigoid. Search methods We updated searches of the following databases to November 2021: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched five trial databases to January 2022, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria RCTs of treatments for immunofluorescence‐confirmed bullous pemphigoid. Data collection and analysis At least two review authors, working independently, evaluated the studies against the review's inclusion criteria and extracted data from included studies. Using GRADE methodology, we assessed the certainty of the evidence for each outcome in each comparison. Our primary outcomes were healing of skin lesions and mortality. Main results We identified 14 RCTs (1442 participants). The main treatment modalities assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Most studies reported mortality but adverse events and quality of life were not well reported. We decided to look at the primary outcomes 'disease control' and 'mortality'. Almost all studies investigated different comparisons; two studies were placebo‐controlled. The results are therefore based on a single study for each comparison except azathioprine. Most studies involved only small numbers of participants. We assessed the risk of bias for all key outcomes as having 'some concerns' or high risk, due to missing data, inappropriate analysis, or insufficient information. Clobetasol propionate cream versus oral prednisone Compared to oral prednisone, clobetasol propionate cream applied over the whole body probably increases skin healing at day 21 (risk ratio (RR 1.08, 95% confidence interval (CI) 1.03 to 1.13; 1 study, 341 participants; moderate‐certainty evidence). Skin healing at 21 days was seen in 99.8% of participants assigned to clobetasol and 92.4% of participants assigned to prednisone. Clobetasol propionate cream applied over the whole body compared to oral prednisone may reduce mortality at one year (RR 0.73, 95% CI 0.53 to 1.01; 1 study, 341 participants; low‐certainty evidence). Death occurred in 26.5% (45/170) of participants assigned to clobetasol and 36.3% (62/171) of participants assigned to oral prednisone. This study did not measure quality of life. Clobetasol propionate cream may reduce risk of severe complications by day 21 compared with oral prednisone (RR 0.65, 95% CI 0.50 to 0.86; 1 study, 341 participants; low‐certainty evidence). Mild clobetasol propionate cream regimen (10 to 30 g/day) versus standard clobetasol propionate cream regimen (40 g/day) A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen probably does not change skin healing at day 21 (RR 1.00, 95% CI 0.97 to 1.03; 1 study, 312 participants; moderate‐certainty evidence). Both groups showed complete healing of lesions at day 21 in 98% participants. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change mortality at one year (RR 1.00, 95% CI 0.75 to 1.32; 1 study, 312 participants; low‐certainty evidence), which occurred in 118/312 (37.9%) participants. This study did not measure quality of life. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change adverse events at one year (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 309 participants; low‐certainty evidence). Doxycycline versus prednisolone Compared to prednisolone (0.5 mg/kg/day), doxycycline (200 mg/day) induces less skin healing at six weeks (RR 0.81, 95% CI 0.72 to 0.92; 1 study, 213 participants; high‐certainty evidence). Complete skin healing was reported in 73.8% of participants assigned to doxycycline and 91.1% assigned to prednisolone. Doxycycline compared to prednisolone probably decreases mortality at one year (RR 0.25, 95% CI 0.07 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 14; 1 study, 234 participants; moderate‐certainty evidence). Mortality occurred in 2.3% (3/132) of participants with doxycycline and 9.1% (11/121) with prednisolone. Compared to prednisolone, doxycycline improved quality of life at one year (mean difference 1.8 points lower, which is more favourable on the Dermatology Life Quality Index, 95% CI 1.02 to 2.58 lower; 1 study, 234 participants; high‐certainty evidence). Doxycycline compared to prednisolone probably reduces severe or life‐threatening treatment‐related adverse events at one year (RR 0.59, 95% CI 0.35 to 0.99; 1 study, 234 participants; moderate‐certainty evidence). Prednisone plus azathioprine versus prednisone It is unclear whether azathioprine plus prednisone compared to prednisone alone affects skin healing or mortality because there was only very low‐certainty evidence from two trials (98 participants). These studies did not measure quality of life. Adverse events were reported in a total of 20/48 (42%) participants assigned to azathioprine plus prednisone and 15/44 (34%) participants assigned to prednisone. Nicotinamide plus tetracycline versus prednisone It is unclear whether nicotinamide plus tetracycline compared to prednisone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (18 participants). This study did not measure quality of life. Fewer adverse events were reported in the nicotinamide group. Methylprednisolone plus azathioprine versus methylprednisolone plus dapsone It is unclear whether azathioprine plus methylprednisolone compared to dapsone plus methylprednisolone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (54 participants). This study did not measure quality of life. A total of 18 adverse events were reported in the azathioprine group and 13 in the dapsone group. Authors' conclusions Clobetasol propionate cream applied over the whole body is probably similarly effective as, and may cause less mortality than, oral prednisone for treating bullous pemphigoid. Lower‐dose clobetasol propionate cream applied over the whole body is probably similarly effective as standard‐dose clobetasol propionate cream and has similar mortality. Doxycycline is less effective but causes less mortality than prednisolone for treating bullous pemphigoid. Other treatments need further investigation. Plain language summary Treatments for bullous pemphigoid Which treatments work best for bullous pemphigoid (a rare, itchy skin disease that causes blisters)? Key messages • A cream, containing topical steroid clobetasol propionate, applied on the entire skin surface is as effective as oral steroids (prednisone), causes less severe unwanted or harmful effects, and may decrease deaths. • Initiating treatment with doxycycline (200 mg/day), an antibiotic with anti‐inflammatory effect, leads to an acceptable short‐term blister control compared to the oral steroid prednisolone (0.5 mg/kg/day), and is superior in long‐term safety aspects, including deaths. What is bullous pemphigoid? Bullous pemphigoid is the most common autoimmune blistering disease. In autoimmune diseases, the body's immune system mistakes its own tissues as foreign and attacks them. In bullous pemphigoid, this causes blisters on the skin. Bullous pemphigoid usually occurs in the elderly, but may also affect younger people. How is bullous pemphigoid treated? Until recently, the leading treatment for bullous pemphigoid was oral steroids which suppress inflammation and the body's own immune system. However, given over a long period of time, oral steroids will cause severe adverse (i.e. harmful) effects. This review assessed studies which investigated the effectiveness of other treatment options for bullous pemphigoid; for example, a steroid cream applied on the skin and the anti‐inflammatory antibiotic medicine, doxycycline. What did we want to find out? We wanted to find out which treatments work best for bullous pemphigoid with respect to the healing of blisters (efficacy) and reduction in adverse effects, such as death. What did we do? We searched for studies that looked at treatments for bullous pemphigoid. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 14 studies including 1442 people with bullous pemphigoid. The main treatments assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Other treatments tested were oral (i.e. taken by mouth) immunosuppressives (medicines that keep your immune system in check) and immunoglobulins (also called antibodies. Antibodies are proteins that your immune system makes to fight germs, for example). ‐ Topical steroid cream, clobetasol propionate, applied over the whole body (40 grams of cream applied per day, with the amount decreased over 12 months) is an effective and safe treatment for bullous pemphigoid. ‐ Treatment with a lower amount of clobetasol propionate cream (10 to 30 grams per day, decreased over 4 months) is equally effective and safe. ‐ Prednisolone, an oral corticosteroid, in the dose of 0.5 mg/kg/day, may be adequate to control disease in most people and reduces adverse effects compared to higher doses of oral corticosteroid. ‐ Initiating treatment with 200 mg/day of doxycycline leads to acceptable blister control compared to oral prednisolone (0.5 mg/kg/day) and is safer. ‐ A study with 20 participants suggests that nicotinamide (a form of vitamin B 3 )and tetracycline (an antibiotic used to treat a wide variety of infections) may be an effective alternative to prednisone and may decrease treatment‐associated death. ‐ Adding azathioprine, a drug which suppresses the immune system, to an oral corticosteroid does not improve disease control; it may lead to a reduced need for oral corticosteroid. ‐ Further research is needed to fully understand the effectiveness of alternatives to oral steroids (such as dapsone or immunoglobulins), as well as the effectiveness of giving other medicines alongside an oral steroid. What are the limitations of the evidence? Except for the studies on topical clobetasol cream and doxycycline, the studies included relatively few participants. The methodological quality of these studies was further limited because of unclear methods of allocating people to different treatment groups; lack of masking (participants and researchers knew which treatments were given to which people, which are not good conditions for fair assessment); and the exclusion of people who dropped out of the studies from treatment analysis. We are confident about the efficacy of initiating treatment with doxycycline and moderately confident about the efficacy of topical clobetasol cream for the treatment of bullous pemphigoid. How up to date is this evidence? The evidence is current to 11 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Singh, S, Kirtschig, G, Anchan, VN, Chi, C-C, Taghipour, K, Boyle, RJ, Murrell, DF", "articleTypes": [], "doi": "10.1002/14651858.CD002292.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.789Z" }, { "id": "7d0e4ef0-f535-4858-8f15-fdf5e0b3b79f", "pmid": "", "title": "Long‐acting muscarinic antagonists (LAMA) added to combination long‐acting beta₂‐agonists and inhaled corticosteroids (LABA/ICS) versus LABA/ICS for adults with asthma", "imported": false, "abstract": "Abstract - Background Maintenance treatment with long‐acting beta 2 ‐agonists and inhaled corticosteroids (LABA/ICS) can relieve asthma symptoms and reduce the frequency of exacerbations, but there are limited treatment options for people who do not gain control on combination LABA/ICS. Long‐acting muscarinic antagonists (LAMA) are a class of inhaled drug which have been effective for people with chronic obstructive pulmonary disease and are now becoming available for people with asthma to take alongside their LABA/ICS inhaler. Objectives To assess the effects of adding a long‐acting muscarinic antagonist (LAMA) to combination long‐acting beta 2 ‐agonists (LABA) and inhaled corticosteroids (ICS) in adults whose asthma is not well controlled by LABA/ICS. Search methods We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to January 2016. We also searched ClinicalTrials.gov, the WHO trials portal, and reference lists of other reviews, and we contacted trial authors for additional information. Selection criteria We included parallel randomised controlled trials (RCTs) of at least 12 weeks' duration. Studies met the inclusion criteria if they compared LAMA as an add‐on to LABA/ICS versus LABA/ICS alone for adults with asthma. We included studies reported as full text, those published as abstract only, and unpublished data. Primary outcomes were exacerbations requiring oral corticosteroids (OCS), validated measures of asthma control, and serious adverse events (including mortality). Data collection and analysis Two review authors screened searches and independently extracted details on risk of bias and numerical data. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MD) using a random‐effects model. We rated all outcomes using GRADE. Main results We found four double‐blind, double‐dummy trials comparing LAMA to placebo, including 1197 people with asthma taking combination LABA/ICS. One of the trials was designed to study glycopyrronium bromide but was withdrawn prior to enrolment, and the other three all studied tiotropium bromide (mostly 5 µg once daily via Respimat) over 48 to 52 weeks. People in the trials had a mean forced expiratory volume in one second (FEV 1 ) of 55% of their predicted value, indicating severe asthma. People randomised to take tiotropium add‐on had fewer exacerbations requiring oral corticosteroids than those continuing to take LABA/ICS alone, but the confidence intervals did not rule out no difference (OR 0.76, 95% CI 0.57 to 1.02; moderate quality evidence). Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS would have to take oral corticosteroids for an exacerbation compared with 271 if they took tiotropium as well (95% CI 218 to 333 per 1000). Analyses comparing the number of exacerbations per patient in each group (rate ratio) and the time until first exacerbation (hazard ratio) were in keeping with the main result. Quality of life, as measured by the Asthma Quality of Life Questionnaire (AQLQ) was no better for those taking tiotropium add‐on than for those taking LABA/ICS alone when considered in light of the 0.5 minimal clinically important difference on the scale (MD 0.09, 95% CI − 0.03 to 0.20), and evidence for whether tiotropium increased or decreased serious adverse events in this population was inconsistent (OR 0.60, 95% CI 0.24 to 1.47; I 2 = 76%). Within the secondary outcomes, exacerbations requiring hospital admission were too rare to tell whether tiotropium was beneficial over LABA/ICS alone. There was high quality evidence showing benefits to lung function (trough FEV 1 and forced vital capacity (FVC)) and potentially small benefits to asthma control. People taking tiotropium add‐on were less likely to experience non‐serious adverse events. Authors' conclusions Tiotropium add‐on may have additional benefits over LABA/ICS alone in reducing the need for rescue oral steroids in people with severe asthma. The effect was imprecise, and there was no evidence for other LAMA preparations. Possible benefits on quality of life were negligible, and evidence for the effect on serious adverse events was inconsistent. There are likely to be small added benefits for tiotropium Respimat 5 µg daily on lung function and asthma control over LABA/ICS alone and fewer non‐serious adverse events. The benefit of tiotropium add‐on on the frequency of hospital admission is still unknown, despite year‐long trials. Ongoing and future trials should clearly describe participants' background medications to help clinicians judge how the findings relate to stepwise care. If studies test LAMAs other than tiotropium Respimat for asthma, they should be at least six months long and use accepted and validated outcomes to allow comparisons of the safety and effectiveness between different preparations. Plain language summary Does adding tiotropium, a long‐acting muscarinic antagonist (LAMA), to combination therapy (LABA/ICS) help to control asthma? Adding the LAMA tiotropium Respimat inhaler to combination LABA/ICS inhaler may reduce the need for rescue oral steroids. A noticeable benefit on quality of life is unlikely, and we couldn't tell if it reduced hospital admissions, but adding tiotropium has some benefit on lung function, asthma control, and non‐serious side effects. More detail about the studies and results: Taking a daily inhaler containing a long‐acting beta 2 ‐agonist and an inhaled corticosteroid (LABA/ICS) can improve symptoms and reduce the likelihood of asthma attacks. If this doesn't help, another type of inhaled drug called a long‐acting muscarinic antagonist (LAMA), which has been effective for people with other breathing conditions, is now available for people with asthma to take as well as their LABA/ICS inhaler. We wanted to find out whether adding a LAMA to LABA/ICS is better than continuing LABA/ICS alone for adults with asthma. We found four relevant studies, but one was withdrawn before anyone was signed up. The other three compared a LAMA called tiotropium Respimat to placebo for around a year, with participants in both groups continuing to take their usual LABA/ICS inhaler. People generally had quite poor lung function when they entered the studies, suggesting their asthma was not well controlled ‐ in respiratory medicine, this is known as 'severe asthma'. Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS had to take a course of oral steroids compared with 271 if they took tiotropium as well. However, uncertainty in the results meant that rather than there being 271 people taking oral steroids, there could be anywhere from 218 to 333 people per 1000 who would have to take oral steroids, so we couldn't be sure of the benefit. Quality of life scores were not that different between those who took tiotropium and those who didn't. The studies showed different results for whether people taking tiotropium were more likely to suffer a serious side effect, but fewer people had non‐serious side effects if they took tiotropium. We couldn't tell whether taking tiotropium on top of LABA/ICS reduced the number of people who had to go to hospital for an asthma attack because it didn't happen often enough for us to have confidence in the result. There was high quality evidence that showed benefits to lung function and probably small benefits on measures of asthma control.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Kew, KM; Dahri, K", "articleTypes": [], "doi": "10.1002/14651858.CD011721.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "7d1b78c7-773e-4d59-a054-efc76776423f", "pmid": "", "title": "CD36 Involvement on Fat Taste Perception and Fat Hedonic Value in Humans", "imported": false, "abstract": "The purpose of this study is to determine the effect of common human variants in in taste related genes, such as CD36 gene, a putative fat taste receptor, affect fat taste perception.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "7d281adf-2307-4473-91b5-e7ac17c45d6a", "pmid": "", "title": "Fortification of staple foods with zinc for improving zinc status and other health outcomes in the general population", "imported": false, "abstract": "Abstract - Background Zinc deficiency is a global nutritional problem, particularly in children and women residing in settings where diets are cereal based and monotonous. It has several negative health consequences. Fortification of staple foods with zinc may be an effective strategy for preventing zinc deficiency and improving zinc‐related health outcomes. Objectives To evaluate the beneficial and adverse effects of fortification of staple foods with zinc on health‐related outcomes and biomarkers of zinc status in the general population. Search methods We searched the following databases in April 2015: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3 of 12, 2015, the Cochrane Library), MEDLINE & MEDLINE In Process (OVID) (1950 to 8 April 2015), EMBASE (OVID) (1974 to 8 April 2015), CINAHL (1982 to April 2015), Web of Science (1900 to 9 April 2015), BIOSIS (1969 to 9 April 2015), POPLINE (1970 to April 2015), AGRICOLA, OpenGrey, BiblioMap, and Trials Register of Promoting Health Interventions (TRoPHI), besides regional databases (April 2015) and theses. We also searched clinical trial registries (17 March 2015) and contacted relevant organisations (May 2014) in order to identify ongoing and unpublished studies. Selection criteria We included randomised controlled trials, randomised either at the level of the individual or cluster. We also included non‐randomised trials at the level of the individual if there was a concurrent comparison group. We included non‐randomised cluster trials and controlled before‐after studies only if there were at least two intervention sites and two control sites. Interventions included fortification (central/industrial) of staple foods (cereal flours, edible fats, sugar, condiments, seasonings, milk and beverages) with zinc for a minimum period of two weeks. Participants were members of the general population who were over two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies, and assessed the risk of bias of the included studies. Main results We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Four trials compared the effect of zinc‐fortified staple foods with unfortified foods (comparison 1), and four compared zinc‐fortified staple foods in combination with other nutrients/factors with the same foods containing other nutrients or factors without zinc (comparison 2). The interventions lasted between one and nine months. We categorised most trials as having unclear or high risk of bias for randomisation, but low risk of bias for blinding and attrition. None of the studies in comparison 1 reported data on zinc deficiency. Foods fortified with zinc increased the serum or plasma zinc levels in comparison to foods without added zinc (mean difference (MD) 2.12 µmol/L, 95% confidence interval (CI) 1.25 to 3.00 µmol/L; 3 studies; 158 participants; low‐quality evidence). Participants consuming foods fortified with zinc versus participants consuming the same food without zinc had similar risk of underweight (average risk ratio 3.10, 95% CI 0.52 to 18.38; 2 studies; 397 participants; low‐quality evidence) and stunting (risk ratio (RR) 0.88, 95% CI 0.36 to 2.13; 2 studies; 397 participants; low‐quality evidence). A single trial of addition of zinc to iron in wheat flour did not find a reduction in proportion of zinc deficiency (RR 0.17, 95% CI 0.01 to 3.94; very low‐quality evidence). We did not find a difference in serum or plasma zinc levels in participants consuming foods fortified with zinc plus other micronutrients when compared with participants consuming the same foods with micronutrients but no added zinc (MD 0.03 µmol/L, 95% CI ‐0.67 to 0.72 µmol/L; 4 studies; 250 participants; low‐quality evidence). No trial in comparison 2 provided information about underweight or stunting. There was no reported adverse effect of fortification of foods with zinc on indicators of iron or copper status. Authors' conclusions Fortification of foods with zinc may improve the serum zinc status of populations if zinc is the only micronutrient used for fortification. If zinc is added to food in combination with other micronutrients, it may make little or no difference to the serum zinc status. Effects of fortification of foods with zinc on other outcomes including zinc deficiency, children’s growth, cognition, work capacity of adults, or on haematological indicators are unknown. Given the small number of trials and participants in each trial, further investigation of these outcomes is required. Plain language summary The effects of fortification of common foods with zinc on health outcomes Background It is believed that zinc deficiency is widespread globally, particularly in children and women living in low‐ and middle‐income countries. Cereal‐based foods are rich in dietary fibre and phytates, which reduce absorption of zinc from the intestine. As people in low‐income households eat a lot of cereal‐based foods, they are more likely to develop zinc deficiency. Fortification of common staple foods with zinc alone or in combination with other vitamins and minerals has been proposed as an intervention to increase intake of zinc in populations who consume these foods. Review question We evaluated the effects of fortification of staple foods with zinc on blood zinc levels and health‐related outcomes in the general population above two years of age. Study characteristics We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Key results and quality of the evidence The effect of fortification of foods with zinc on incidence of zinc deficiency is uncertain. Fortification of foods with zinc may slightly improve the blood zinc levels of populations if zinc is the only micronutrient used for fortification. Zinc added to food in combination with other micronutrients may make little or no difference to blood zinc levels. The fortification of foods with zinc may make little or no difference on incidence of underweight or stunting. The effects of fortification of foods with zinc on other outcomes, including wasting and weight/height, are unknown. Fortification of foods with zinc does not seem to have any adverse effect on indicators of iron or copper status. Most studies included in this review involved a small number of participants and were judged to be at low or unclear risk of bias. There were also some inconsistencies in the results across different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Shah, D; Sachdev, HS; Gera, T; De‐Regil, LM; Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010697.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "7d2c0497-3824-4dfe-abe0-0560c00b0641", "pmid": "", "title": "The Molecular Basis for a Broad Range of Phenotypes Related to hTAS2R38", "imported": false, "abstract": "This single-site, within-subject, experimental study is designed to test the hypothesis that individuals express taste receptors differently and have different sensitivities to bitter taste samples, which results from uneven expression. Subjects will include 100 racially and ethnically diverse, healthy adults. All subjects will provide saliva samples for genetic analysis and undergo taste testing with common psychophysical stimuli. From the pool of 100 subjects, 36 subjects from the common heterozygous group (PAV/AVI) and two from each homozygous group (AVI/AVI, nontaster and PAV/PAV, taster) will be invited to return for two additional sessions. During both sessions the investigators will 1) measure bitterness thresholds for PROP, a common psychophysical stimulus; 2) measure bitterness perception of several vegetables; 3) obtain a saliva sample and 4) collect taste papillae. The investigators will then isolate DNA and RNA from the taste papillae and isolate DNA from saliva to evaluate molecular differences over time and between individuals and how it relates to taste psychophysics. All psychophysical and cellular measurements will be done during both sessions so that the investigators can determine how much variation is observed over a one-week time period in both cellular phenotype and psychophysical phenotype.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.236Z" }, { "id": "7d3c8503-afb9-4247-9945-e0b0b82c3954", "pmid": "", "title": "Short- and Long-term Effects of Once Weekly Semaglutide 2.4 mg on Appetite, Eating Behavior, and Psychosocial Status", "imported": false, "abstract": "This study will evaluate the effect of semaglutide on eating behavior, appetite (hunger/fullness), and food liking in the long-term, as compared to placebo. All participants will receive lifestyle modification (diet and exercise) counseling, and will be prescribed the FDA-approved weight loss medication, semaglutide, or placebo (an inactive saline solution) for 72 weeks.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "7d45e527-11ee-457f-9598-4ca9a6b24759", "pmid": "", "title": "Wheat flour fortification with iron and other micronutrients for reducing anaemia and improving iron status in populations", "imported": false, "abstract": "Abstract - Background Anaemia is a condition where the number of red blood cells (and consequently their oxygen‐carrying capacity) is insufficient to meet the body's physiological needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations. Objectives To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health‐related outcomes in populations over two years of age. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, 21 other databases and two trials registers up to 21 July 2020, together with contacting key organisations to identify additional studies. Selection criteria We included cluster‐ or individually‐randomised controlled trials (RCTs) carried out among the general population from any country, aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. We included trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat Data collection and analysis Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risks of bias. We followed Cochrane methods in this review. Main results Our search identified 3538 records, after removing duplicates. We included 10 trials, involving 3319 participants, carried out in Bangladesh, Brazil, India, Kuwait, Philippines, South Africa and Sri Lanka. We identified two ongoing studies and one study is awaiting classification. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, three trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial used various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta‐analyses. Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added may reduce by 27% the risk of anaemia in populations (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.55 to 0.97; 5 studies, 2315 participants; low‐certainty evidence). It is uncertain whether iron‐fortified wheat flour with or without other micronutrients reduces iron deficiency (RR 0.46, 95% CI 0.20 to 1.04; 3 studies, 748 participants; very low‐certainty evidence) or increases haemoglobin concentrations (in g/L) (mean difference MD 2.75, 95% CI 0.71 to 4.80; 8 studies, 2831 participants; very low‐certainty evidence). No trials reported data on adverse effects in children (including constipation, nausea, vomiting, heartburn or diarrhoea), except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to the risk of Infection or inflammation at individual level as measured by C‐reactive protein (CRP) (mean difference (MD) 0.04, 95% CI −0.02 to 0.11; 2 studies, 558 participants; moderate‐certainty evidence). Iron‐fortified wheat flour with other micronutrients added versus unfortified wheat flour (nil micronutrients added) It is unclear whether wheat flour fortified with iron, in combination with other micronutrients decreases anaemia (RR 0.77, 95% CI 0.41 to 1.46; 2 studies, 317 participants; very low‐certainty evidence). The intervention probably reduces the risk of iron deficiency (RR 0.73, 95% CI 0.54 to 0.99; 3 studies, 382 participants; moderate‐certainty evidence) and it is unclear whether it increases average haemoglobin concentrations (MD 2.53, 95% CI −0.39 to 5.45; 4 studies, 532 participants; very low‐certainty evidence). No trials reported data on adverse effects in children. Nine out of 10 trials reported sources of funding, with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials. Authors' conclusions Fortification of wheat flour with iron (in comparison to unfortified flour, or where both groups received the same other micronutrients) may reduce anaemia in the general population above two years of age, but its effects on other outcomes are uncertain. Iron‐fortified wheat flour in combination with other micronutrients, in comparison with unfortified flour, probably reduces iron deficiency, but its effects on other outcomes are uncertain. None of the included trials reported data on adverse side effects except for risk of infection or inflammation at the individual level. The effects of this intervention on other health outcomes are unclear. Future studies at low risk of bias should aim to measure all important outcomes, and to further investigate which variants of fortification, including the role of other micronutrients as well as types of iron fortification, are more effective, and for whom. Plain language summary Does adding iron to wheat flour reduce anaemia and increase iron levels in the general population? Why do we need iron in our diet? Iron is an essential mineral found in every cell of the body. It is needed to make haemoglobin, the oxygen‐carrying protein in the blood. Iron molecules in haemoglobin bind to oxygen and carry it from the lungs to all the cells and tissues in the body. Low levels of haemoglobin means the body does not get enough oxygen. Anaemia develops when haemoglobin levels in the blood fall too low. Symptoms of anaemia include: tiredness and lack of energy, getting out of breath quickly, pale skin and a greater susceptibility to infections. Low haemoglobin levels can be caused by blood loss, pregnancy or not eating enough foods containing iron (iron‐deficiency anaemia). Iron‐deficiency anaemia may be treated by taking iron tablets or eating foods rich in iron. Fortified foods Adding micronutrients (vitamins and minerals) to foods, whether those micronutrients were originally present or not, is called fortification. Fortifying foods is one way to improve nutrition in a population. People living in low‐income countries may not have enough iron in their diet, and may be at risk of anaemia. Adding iron and other nutrients to foods routinely eaten in large quantities, such as flour, is thought to help prevent iron‐deficiency anaemia. Why we did this Cochrane Review We wanted to find out how adding iron, and other minerals and vitamins, to wheat flour affected the blood iron levels of the general population, and whether fewer people developed anaemia or other health conditions. We also wanted to know if adding iron to wheat flour caused any unwanted effects. What did we do? We searched for studies that investigated eating any types of food made with wheat flour containing added iron, or foods made with wheat flour without added iron. We then compared the studies with each other, to find out the effects of adding iron to wheat flour on people's health and the levels of iron and haemoglobin in their blood. Search date: we included evidence published up to 21 July 2020. What we found We found 10 studies in 3319 people (aged 2 years and older). The studies lasted from 3 months to 24 months, and took place in Bangladesh, Brazil, India, Kuwait, the Philippines, Sri Lanka and South Africa. The studies looked at the effects of: · wheat flour containing added iron (with or without other minerals and vitamins) compared with wheat flour without added iron (but with the same other minerals and vitamins); · wheat flour containing added iron and other minerals and vitamins compared with wheat flour without any added minerals or vitamins. The wheat flours used in the studies contained different amounts of iron: from under 40 mg/kg to over 60 mg/kg. We were interested in: · how many people had anaemia (defined by low haemoglobin levels); · how many people had low levels of iron in their blood (iron deficiency; tested using a biomarker); · haemoglobin concentrations in people's blood; · how many children had diarrhoea or respiratory infections; · how many children died (of any cause); · signs of infection or inflammation (the body's response to injury) in children (by testing a biomarker in the blood); and · any unwanted effects. Most studies had multiple sources of funding; some were partly funded by companies involved in the food, chemical or pharmaceutical industries. What are the results of our review? Compared with flour without added iron (but with other minerals and vitamins) Flour containing added iron (with or without other minerals and vitamins): · may reduce anaemia, by 27% (evidence from 5 studies, 2315 people); and · probably makes no difference to children's risk of infection or inflammation (2 studies, 558 children). It was unclear how flour with added iron affected iron deficiency (3 studies, 748 people), or haemoglobin levels (8 studies, 2831 people ). Compared with flour without any added minerals or vitamins Flour containing added iron (with other minerals and vitamins) probably reduced iron deficiency (3 studies, 382 people). It was unclear from the studies how flour containing added iron affected anaemia (2 studies, 317 people) or haemoglobin levels (4 studies, 532 people). No studies reported information about unwanted effects, or how many children died, or had diarrhoea or respiratory infections. Our confidence in our results Our confidence is moderate to low that adding iron to flour probably reduces iron deficiency and anaemia. The studies appeared to show fewer people with iron deficiency and slightly higher haemoglobin levels associated with flour with added iron, but the results varied widely, so we are uncertain about the effect. These results might change if further evidence becomes available. We found limitations in the ways some of the studies were designed and conducted, and this could have affected their results. Key messages Adding iron to wheat flour may lead to fewer people with anaemia or low blood‐iron levels in the general population. We do not know if adding iron to wheat flour causes any unwanted effects, because no studies looked at these.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Field, MS, Mithra, P, Peña-Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD011302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.802Z" }, { "id": "7d4a791b-1f84-4e43-a70f-5ec63dec4d17", "pmid": "", "title": "Drugs for treating giardiasis", "imported": false, "abstract": "Abstract - Background Giardiasis infection may be asymptomatic, or can cause diarrhoea (sometimes severe), weight loss, malabsorption, and, in children, failure to thrive. It is usually treated with metronidazole given three times daily for five to 10 days. Objectives To evaluate the relative effectiveness of alternative antibiotic regimens for treating adults or children with symptomatic giardiasis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6 2012); MEDLINE, EMBASE, LILACS and the International Clinical Trials Registry Platform Search Portal (3 July 2012). Selection criteria We included randomized controlled trials (RCT) comparing metronidazole administered for five to 10 days with any of the following drugs: metronidazole (single dose), tinidazole, albendazole, mebendazole, and nitazoxanide. The primary outcomes were parasitological and clinical cure. Data collection and analysis Two authors independently assessed studies for inclusion, performed the risk of bias assessment, and extracted data. We summarized data using risk ratios and mean differences and we presented the results in forest plots and performed meta‐analyses where possible. We assessed heterogeneity using the Chi 2 test, I 2 statistic and visual inspection; and we explored this by using subgroup analyses.We assessed the quality of evidence by using the GRADE approach. Main results We included 19 trials, involving 1817 participants, of which 1441 were children. Studies were generally small, with poor methods reporting. . Most reported parasitological outcomes rather than clinical improvement. Ten trials, from India, Mexico, Peru, Iran, Cuba, and Turkey, compared albendazole (400 mg once daily for five to 10 days) with metronidazole (250 mg to 500 mg three times daily for five to 10 days). This once‐daily regimen of albendazole is probably equivalent to metronidazole at achieving parasitological cure (RR 0.99, 95% CI 0.95 to 1.03; 932 participants, 10 trials; moderate quality evidence ), and improving symptoms (RR 0.98, 95% confidence interval (CI) 0.93 to 1.04; 483 participants, five trials; moderate quality evidence ), but the duration of follow‐up was short (two to three weeks). Albendazole probably has fewer side effects than metronidazole (gastrointestinal side effects: RR 0.29, 95% CI 0.13 to 0.63; 717 participants, eight trials; moderate quality evidence ; neurological side effects: RR 0.34, 95% CI 0.18 to 0.64; 453 participants, five trials; low quality evidence ). Five trials from Turkey, Spain and the UK compared mebendazole (200 mg three times daily for five to 10 days) with metronidazole (5 mg/kg (or 250 mg) three times daily for five to 10 days). These trials were small in size, and at high risk of bias. Consequently, reliable conclusions on the relative effectiveness cannot be made ( very low quality evidence) . Five further trials, from Iran, Spain and Peru, have evaluated shortened regimens of tinidazole (single dose; 179 participants, three trials), metronidazole (single dose; 55 participants, one trial), and nitazoxanide (three days; 55 participants, one trial). Again, these trials were at high risk of bias and too small to reliably detect or exclude important differences ( very low quality evidence) . Authors' conclusions Albendazole may be of similar effectiveness to metronidazole, may have fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes (such as diarrhoea) will help assess further alternatives. 15 April 2019 Update pending Studies awaiting assessment The CIDG is currently examining a new search conducted in April 2019 for potentially relevant studies. These studies have not yet been incorporated into this Cochrane Review. Plain language summary Drugs for treating giardiasis Giardiasis is an infection of the small intestine caused by a microscopic organism called Giardia lamblia . The infection is passed from person to person by ingesting faecally contaminated water or food. Symptoms frequently include diarrhoea, abdominal pain, flatulence, bloating, vomiting, and weight loss. In this review, we assess alternatives to the most commonly used treatment for giardiasis; metronidazole given orally for five or more days. We identified 19 trials involving 1817 participants, of which 1441 were children. Most trials had a small number of participants and were at high risk of bias. Albendazole is probably of similar effectiveness to metronidazole, probably has fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes are required to assess further alternatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Granados, CE; Reveiz, L; Uribe, LG; Criollo, CP", "articleTypes": [], "doi": "10.1002/14651858.CD007787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "7d4aaa4e-98e4-4fbd-a1c5-090dd5ceb0e0", "pmid": "", "title": "Siponimod for multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Cao, L, Li, M, Yao, L, Yan, P, Wang, X, Yang, Z, Lao, Y, Li, H, Yang, K, Li, K", "articleTypes": [], "doi": "10.1002/14651858.CD013647.pub2 AB - Abstract - Background Multiple sclerosis (MS) is a chronic immune‐mediated disease of the central nervous system, with an unpredictable course. Current MS therapies such as disease‐modifying therapies focus on treating exacerbations, preventing new exacerbations and avoiding the progression of disability. Siponimod (BAF312) is an oral treatment, a selective sphingosine‐1‐phosphate (S1P) receptor modulator, for the treatment of adults with relapsing forms of MS including active, secondary progressive MS with relapses. Objectives To assess the benefits and adverse effects of siponimod as monotherapy or combination therapy versus placebo or any active comparator for people diagnosed with MS. Search methods We searched the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Trials Register, which contains studies from CENTRAL, MEDLINE and Embase, and the trials registry databases ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 10 September 2021. We also handsearched relevant journals and screened the reference lists of published reviews and retrieved articles and searched reports (2004 to September 2021) from the MS societies in Europe and America. Selection criteria We included randomised parallel controlled clinical trials (RCTs) that evaluated siponimod, as monotherapy or combination therapy, versus placebo or any active comparator in people with MS. There were no restrictions on dose or administration frequency. Data collection and analysis We used standard methodological procedures expected by Cochrane. We discussed disagreements and resolved them by consensus among the review authors. Our primary outcomes wereworsening disability , relapse and adverse events, and secondary outcomes were annualised relapse rate, gadolinium‐enhancing lesions, new lesions or enlarged pre‐existing lesions and mean change of brain volume. We independently evaluated the certainty of evidence using the GRADE approach. We contacted principal investigators of included studies for additional data or confirmation of data. Main results Two studies (1948 participants) met our selection criteria, 608 controls and 1334 treated with siponimod. The included studies compared siponimod with placebo. Overall, all studies had a high risk of bias due to selective reporting and attrition bias. Comparing siponimod administered at a dose of 2 mg to placebo, we found that siponimod may reduce the number of participants with disability progression at six months (56 fewer people per 1000; risk ratio (RR) 0.78, 95% confidence interval (CI) 0.65 to 0.94; 1 study, 1641 participants; low‐certainty evidence) and annualised relapse rate (RR 0.43, 95% CI 0.34 to 0.56; 2 studies, 1739 participants; low‐certainty evidence). But it might lead to little reduction in the number of participants with new relapse (166 fewer people per 1000; RR 0.38, 95% CI 0.15 to 1.00; 1 study, 94 participants; very low‐certainty evidence). We observed no evidence of a difference due to adverse events for siponimod at 2 mg compared to placebo (14 more people per 1000; RR 1.52, 95% CI 0.85 to 2.71; 2 studies, 1739 participants, low‐certainty evidence). In addition, due to the high risk of inaccurate magnetic resonance imaging (MRI) data in the two included studies, we could not combine data for active lesions on MRI scans. Both studies had high attrition bias resulting from the unbalanced reasons for dropouts among groups and high risk of bias due to conflicts of interest. Siponimod may reduce the number of gadolinium‐enhancing T1‐weighted lesions at two years of follow‐up (RR 0.14, 95% CI 0.10 to 0.19; P < 0.0001; 1 study, 1641 participants; very low‐certainty evidence). There may be no evidence of a difference between groups in the number of participants with at least one serious adverse event excluding relapses (113 more people per 1000; RR 1.80, 95% CI 0.37 to 8.77; 2 studies, 1739 participants; low‐certainty evidence) at six months. No data were available regarding cardiac adverse events. In terms of safety profile, the most common adverse events associated with siponimod were headache, back pain, bradycardia, dizziness, fatigue, influenza, urinary tract infection, lymphopenia, nausea, alanine amino transferase increase and upper respiratory tract infection. These adverse events have dose‐related effects and rarely led to discontinuation of treatment. Authors' conclusions Based on the findings of the RCTs included in this review, we are uncertain whether siponimod interventions are beneficial for people with MS. There was low‐certainty evidence to support that siponimod at a dose of 2 mg orally once daily as monotherapy compared with placebo may reduce the annualised relapse rate and the number of participants who experienced disability worsening, at 6 months. However, the certainty of the evidence to support the benefit in reducing the number of people with a relapse is very low. The risk of withdrawals due to adverse events requires careful monitoring of participants over time. The duration of all studies was less than 24 months, so the efficacy and safety of siponimod over 24 months are still uncertain, and further exploration is needed in the future. There is no high‐certainty data available to evaluate the benefit on MRI outcomes. We assessed the certainty of the body of evidence for all outcomes was low to very low, downgraded due to serious study limitations, imprecision and indirectness. We are uncertain whether siponimod is beneficial for people with MS. More new studies with robust methodology and longer follow‐up are needed to evaluate the benefit of siponimod for the management of MS and to observe long‐term adverse effects. Also, in addition to comparing with placebo, more new studies are needed to evaluate siponimod versus other therapeutic options. Plain language summary Is siponimod an effective treatment for multiple sclerosis (MS) and does it cause unwanted effects? Key messages · We don’t know whether siponimod is an effective treatment for people with multiple sclerosis (MS). At a dose of 2 mg once a day, siponimod may reduce recurrence of symptoms (relapse, calculated as an annual rate) after six months of treatment and may reduce the number of participants whose disability worsens after three months of treatment. · We don’t know if siponimod causes unwanted effects because studies did not last long enough to fully assess them. · Future studies should last longer in order to monitor unwanted and beneficial effects of siponimod better, and should use more robust methods. They should compare siponimod with other medicines. What is multiple sclerosis? Multiple sclerosis (MS) is a condition caused when the body’s immune system – which defends the body against disease and infection – mistakenly attacks parts of the central nervous system (the brain and spinal cord). Symptoms include problems with balance and walking, and blurred vision. MS is a lifelong condition that can cause serious disability. Some people’s symptoms may develop gradually. However, most people experience ‘attacks’ when new symptoms develop or existing symptoms worsen (called ‘relapse’), followed by periods with no changes to their symptoms (called ‘remittance’). This type of MS is called ‘relapsing remitting’ MS. Eventually, the course of their MS may change. These periods when there are no symptoms, or no worsening of symptoms, may stop and then symptoms may worsen continually. This is called ‘secondary progressive MS’. How does siponimod work? Siponimod is a medicine that attaches to the white blood cells (lymphocytes) that attack the central nervous system. This causes the lymphocytes to stay in the lymph glands instead of circulating in the blood to the brain. Fewer lymphocytes reach the brain so the attack by the immune system is reduced. Siponimod is a tablet taken once a day. What did we want to find out? We wanted to know if siponimod is an effective treatment for MS and whether it causes any unwanted effects. We were interested in the number of people: · who experienced relapses; · whose disability worsened; · who left the studies because of unwanted effects of siponimod; · who developed new or larger brain lesions (damage to the brain); and · who experienced serious unwanted effects, and which unwanted effects they experienced. What did we do? 
We searched for studies that investigated siponimod compared with placebo (a sham medicine that looks and tastes the same as siponimod but with no active ingredients) or another medicine to treat MS. Studies could investigate siponimod alone or combined with another treatment, at any dose over any length of time. Participants had to be aged over 18 years, with confirmed MS. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found two studies with 1948 participants. Both studies compared siponimod with placebo. One study included 1651 people with secondary progressive MS, who were given 2 mg siponimod for up to 3 years. The other study included 297 participants with relapsing remitting MS, who were given siponimod at doses of 10 mg, 2 mg or 0.5 mg for 6 months, or 1.25 mg or 0.25 mg for 3 months. We report the results for 2 mg daily because both studies looked at this dose. At 2 mg a day, compared to placebo: · siponimod may lead to a small reduction (166 fewer people per 1000) in the number of people with a new relapse up to six months after starting treatment, and may also reduce relapses when calculated at an annual rate; · siponimod may reduce the number of people whose disability worsened during the six months after starting treatment (by 56 people per 1000); · there may be no difference to the number of people (14 more per 1000) who left the studies in the six months after starting treatment due to unwanted effects; · siponimod may reduce the number of brain lesions of different types after six months and after two years of follow‐up. · siponimod may make no difference to the number of people with at least one serious unwanted effect in the six months after starting treatment. The most common unwanted effects associated with siponimod were headache, back pain, dizziness, tiredness, influenza, urinary tract infection, reduced white blood cells (lymphopenia), feeling sick, possible liver damage, and infections in the mouth and nose. No information was available about heart‐related unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only 2 studies. They did not provide information about everything we were interested and they included people with different types of MS. Also, they did not last long enough to judge the impact of unwanted effects. Both studies were funded by the company that makes siponimod.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.811Z" }, { "id": "7d4ab249-d4e2-4446-90f9-61416f9a0781", "pmid": "", "title": "Supplementation with multiple micronutrients for breastfeeding women for improving outcomes for the mother and baby", "imported": false, "abstract": "Abstract - Background Globally, more than two billion people are estimated to be deficient in key vitamins and minerals, particularly iodine, iron and zinc. The majority of these people live in low‐income settings and are typically deficient in more than one micronutrient. However, micronutrient deficiency among breastfeeding mothers and their infants also remains an issue in high‐income settings, specifically among women who avoid meat and/or milk, women who may lack sufficient supplies of vitamin B12 and vitamin D, and/or women who are iron‐deficient. Young children, pregnant and lactating women are particularly vulnerable to micronutrient deficiencies. They not only have a relatively greater need for vitamins and minerals because of their physiological state, but are also more susceptible to the harmful consequences of deficiencies. Multiple‐micronutrient supplementation might be an option to solve these problems. Objectives The objective of this review was to evaluate the effects of multiple‐micronutrient supplementation in breastfeeding mothers on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. Selection criteria Randomised controlled trials of multiple‐micronutrient supplementation of three or more micronutrients versus placebo, no supplementation or supplementation with two or fewer micronutrients, irrespective of dosage of micronutrients, in breastfeeding mothers. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We found no studies that compared multiple‐micronutrient supplementation (with three or more micronutrients) versus supplementation with two or fewer micronutrients. Two small studies (involving a total of 52 women) were included. One study compared multiple micronutrients with placebo and the other study compared multiple micronutrients with a group who received no supplementation. The studies were carried out in Brazil (36 adolescent mothers) and the USA (16 women) and included women with a low socioeconomic status. A lack of information in the study reports meant that risk of bias could not be adequately assessed (unclear risk of bias for many domains). There were no quantitative data for any of this review's outcomes so meta‐analysis was not possible. Neither of the studies reported on the primary outcomes of interest in this review: maternal morbidity (febrile illness, respiratory tract infection, diarrhoea) , adverse effects of micronutrients within three days of receiving the supplement , infant mortality (defined as a child dying before completing the first year of age) . One study reported qualitatively on maternal anaemia (a secondary outcome of this review) ‐ the study found that multiple‐micronutrient supplementation was effective for recuperating from anaemia but there were no data for inclusion in our analyses. Maternal satisfaction was not reported in the included studies. Similarly, none of this review's infant secondary outcomes were reported in the included studies: clinical micronutrient deficiency ; morbidity episodes (febrile illness, respiratory tract infection, diarrhoea, other) , adverse effects of micronutrients within three days of receiving the supplement . Authors' conclusions We found no evidence to quantitatively assess the effectiveness of multiple‐micronutrient supplementation in improving health outcomes in mother and baby. The results of this review are limited by the small numbers of studies available, small sample sizes and the studies not reporting on the outcomes of interest in this review. There is no evidence to evaluate potential adverse effects of multiple‐micronutrient supplements, particularly excess dosages. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Further research should focus on whether multiple‐micronutrient supplementation during lactation compared with none, a placebo or supplementation with fewer than two micronutrients is beneficial to maternal and infant health outcomes. Future studies should collect data on outcomes beyond micronutrient concentrations, for example: maternal and infant morbidity, adverse effects, maternal satisfaction, the risks of excess supplementation, and potential adverse interactions between the micronutrients and the other outcomes. This would help to bridge the gap between research on intermediary outcomes and health outcomes in order to develop sound policy in this field. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these affect maternal and infant health outcomes. Larger studies with longer follow‐up would improve the quality of studies and provide stronger evidence. In most of the included studies, bias could not be adequately assessed due to lack of information, therefore attention should be given to adequate methods of randomisation and allocation concealment, adequate methods of blinding of the participants, providers and the outcome assessors to improve the methodological quality of studies in this field. Plain language summary Multiple micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby The benefits and risks of multiple‐micronutrient supplementation during lactation are not clear from randomised controlled studies. Key vitamins and minerals, particularly iodine, iron and zinc, are required in small amounts to ensure normal body metabolism, physical growth and development. Nutrient deficiency affects nearly one third of the world’s population, especially in low‐ and middle‐income countries. Breastfeeding mothers need higher levels than usual in order to provide sufficient vitamins and minerals for their own health and that of their babies, particularly for normal functioning and the growth and development of the baby. Previous studies have assessed supplementation of individual micronutrients. This review looked at the use of multiple‐micronutrient supplements for breastfeeding women for improving outcomes for the mother and her baby. We searched for studies on 30 September 2015 and identified two small studies (involving 52 women) for inclusion in this review. The studies were carried out in Brazil and the USA and included women who had a low socioeconomic status. The studies were poorly reported and this lack of information made it difficult to determine whether the studies were at risk of bias. Neither of the studies provided data for any of this review's important outcomes: maternal illness (fever, respiratory infection, diarrhoea), adverse effects of micronutrients within three days of taking them, infant death (defined as a child dying before reaching one year of age). Similarly, there were no data for any of the other outcomes that we were interested in. For the mother, these outcomes were maternal anaemia, and women's satisfaction. For the baby, these outcomes were micronutrient deficiency; illness episodes (fever, respiratory infection, diarrhoea, other), adverse effects of micronutrients within three days of the woman receiving the supplement. However, one of the included studies reported that multiple‐micronutrient supplementation was effective for lactating women recuperating from anaemia. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Larger studies with longer‐term follow‐up would improve the quality of studies and provide stronger evidence. Further research should focus on whether multiple‐micronutrient supplementation during lactation (compared with no supplementation, a placebo or supplementation with fewer than two micronutrients) is beneficial to the mother and her baby and any associated adverse effects of the intervention. Futher studies should report on important outcomes such as those listed in this review and consider the risks of excess supplementation. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these effect outcomes for the mother and her baby.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Abe, SK, Balogun, OO, Ota, E, Takahashi, K, Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD010647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.101Z" }, { "id": "7d52280c-ae76-4383-814c-e67beee22d9a", "pmid": "", "title": "Systemic corticosteroids for acute otitis media in children", "imported": false, "abstract": "Abstract - Background Acute otitis media (AOM) is a common acute infection in children. Pain is its most prominent and distressing symptom. Antibiotics are commonly prescribed for AOM, although they have only a modest effect in reducing pain at two to three days. There is insufficient evidence for benefits of other treatment options, including systemic corticosteroids. However, systemic corticosteroids are potent anti‐inflammatory drugs, and so theoretically could be effective, either alone or as an addition to antibiotics. Objectives To assess the effects of systemic corticosteroids (oral or parenteral), with or without antibiotics, for AOM in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) which contains the Cochrane ARI Group's Specialised Register, MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), Web of Science (Thomson Reuters), and LILACS (BIREME) for published studies, and ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for completed and ongoing studies, to 20 February 2018. We checked the reference lists of all primary studies and review articles for additional references and contacted experts in the field to identify additional unpublished materials. Selection criteria We included randomised controlled trials of children with AOM that compared any systemic corticosteroid (oral or parenteral) with placebo, either with antibiotics (corticosteroid plus antibiotic versus placebo plus antibiotic) or without antibiotics (corticosteroid versus placebo). Data collection and analysis Three review authors (EDS, RR, YP) independently screened the titles and abstracts and retrieved the full texts of potentially relevant studies. We independently extracted study characteristics and outcome data from the included studies, and assessed the risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed study quality using the GRADE method. Main results We included two studies involving 252 children with AOM aged from three months to six years receiving hospital ambulatory care who were treated with intramuscular ceftriaxone, and who were then randomised to the corticosteroid group (corticosteroid and corticosteroid plus antihistamine) or the placebo group (antihistamine and double placebo). In one study, children also had a needle aspiration of middle ear fluid. Both studies were at unclear risk of bias for allocation concealment, and unclear to high risk of bias for selective reporting. One study (N = 179) included pain as an outcome, but we were unable to derive the proportion of children with persistent pain at Day 5 and Day 14. Reduction of overall or specific symptoms was presented as improvement in clinical symptoms and resolution of inflamed tympanic membranes without the need for additional antibiotic treatment: at Day 5 (94% of children in the treatment group (N = 89) versus 89% in the placebo group (N = 90); risk ratio (RR) 1.06, 95% confidence interval (CI) 0.97 to 1.16) and Day 14 (91% versus 87%; RR 1.05, 95% CI 0.95 to 1.17). Low‐quality evidence meant that we are uncertain of the effectiveness of corticosteroids for this outcome. The second study (N = 73) reported a reduction of overall or specific symptoms without additional antibiotic treatment during the first two weeks as a favourable outcome. Children in the treatment group had more favourable outcomes (adjusted odds ratio 65.9, 95% CI 1.28 to 1000; P = 0.037), although the numbers were small. We were unable to pool the results with the other study because it did not report the proportion of children with this outcome by treatment group. Only one study reported adverse effects of corticosteroids (e.g. drowsiness, nappy rash), but did not quantify incidence, so we were unable to draw conclusions about adverse effects. Neither study reported a reduction in overall or specific symptom duration. Authors' conclusions The evidence for the effect of systemic corticosteroids on AOM is of low to very low quality, meaning the effect of systemic corticosteroids on important clinical outcomes in AOM remains uncertain. Large, high‐quality studies are required to resolve the question . Plain language summary Systemic corticosteroids for improving symptoms in children with acute middle ear infection Review question We reviewed the evidence on the effects of corticosteroids given by mouth or injection for acute middle ear infection (acute otitis media (AOM)) in children, particularly in improving symptoms such as ear pain, fever, irritability, lack of sleep, and lack of appetite. We also looked at the side effects of corticosteroids. Background Acute otitis media is common in children and causes ear pain and non‐specific symptoms such as fever, irritability, and deafness. It is often treated with antibiotics, although ear pain generally resolves within two days, and antibiotics help symptoms only slightly. Other treatments (such as over‐the‐counter antihistamines and decongestants) do not help very much. Corticosteroids are often prescribed to reduce inflammation in children for other illnesses, and so may also help symptoms of AOM, which is an inflammatory process. We investigated whether using corticosteroids was better or worse than nothing in improving AOM‐related symptoms. Search date Our evidence is current to 20 February 2018. Study characteristics We included two studies involving 252 children with AOM, aged from three months to six years, receiving hospital ambulatory care. Children were treated with an antibiotic injection and either oral corticosteroid or a placebo (treatment with no effect). In one study, fluid from the middle ear was collected by inserting a needle through the eardrum to measure the level of inflammation. Study funding sources The National Institutes of Health (NIH) and the National Center for Research Resources, NIH, US Public Health Service funded both studies. Pharmaceutical companies provided the drug but did not contribute any other scientific or financial support. Key results and quality of evidence Corticosteroids did not make a significant difference in improving the symptoms and inflammation of the eardrum(s) at Day 5 and Day 14, but we are unsure of this effect due to the small numbers of children in the studies. There were no significant differences between the corticosteroid and placebo groups in terms of resolving fluid in children's middle ears (at 1, 2, and 3 months) and experiencing new episodes of AOM (at 1, 2, 3 months, and 4 and 6 months). Neither study reported a reduction in the duration of overall or specific symptoms, rupture of eardrum(s), the occurrence of middle ear inflammation in the other ear following the current ear infection, or serious complications. Only one study reported the overall side effects identified during the trial (e.g. drowsiness, dry mouth, diaper rash, nervousness). We could not draw any conclusions regarding the effects of corticosteroids for AOM in children. The quality of evidence included in this review was low to very low due to few children included in two small studies. We are uncertain about whether or not corticosteroids are useful in relieving pain from AOM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ranakusuma, RW; Pitoyo, Y; Safitri, ED; Thorning, S; Beller, EM; Sastroasmoro, S; Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD012289.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "7d80a1e1-fcb1-43e5-9993-6949d56045a4", "pmid": "", "title": "Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment", "imported": false, "abstract": "Abstract - Background Early dental decay or demineralised lesions (DLs, also known as white spot lesions) can appear on teeth during fixed orthodontic (brace) treatment. Fluoride reduces decay in susceptible individuals, including orthodontic patients. This review compared various forms of topical fluoride to prevent the development of DLs during orthodontic treatment. This is the second update of the Cochrane Review first published in 2004 and previously updated in 2013. Objectives The primary objective was to evaluate whether topical fluoride reduces the proportion of orthodontic patients with new DLs after fixed appliances. The secondary objectives were to examine the effectiveness of different modes of topical fluoride delivery in reducing the proportions of orthodontic patients with new DLs, as well as the severity of lesions, in terms of number, size and colour. Participant‐assessed outcomes, such as perception of DLs, and oral health‐related quality of life data were to be included, as would reports of adverse effects. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 1 February 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library (searched 1 February 2019), MEDLINE Ovid (1946 to 1 February 2019), and Embase Ovid (1980 to 1 February 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Parallel‐group, randomised controlled trials comparing the use of a fluoride‐containing product versus a placebo, no treatment or a different type of fluoride treatment, in which the outcome of enamel demineralisation was assessed at the start and at the end of orthodontic treatment. Data collection and analysis At least two review authors independently, in duplicate, conducted risk of bias assessments and extracted data. Authors of trials were contacted to obtain missing data or to ask for clarification of aspects of trial methodology. Cochrane's statistical guidelines were followed. Main results This update includes 10 studies and contains data from nine studies, comparing eight interventions, involving 1798 randomised participants (1580 analysed). One report contained insufficient information and the authors have been contacted. We assessed two studies as at low risk of bias, six at unclear risk of bias, and two at high risk of bias. Two placebo (non‐fluoride) controlled studies, at low risk of bias, investigated the professional application of varnish (7700 or 10,000 parts per million (ppm) fluoride (F)), every six weeks and found insufficient evidence of a difference regarding its effectiveness in preventing new DLs (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.14 to 1.93; 405 participants; low‐certainty evidence). One placebo (non‐fluoride) controlled study, at unclear risk of bias, provides a low level of certainty that fluoride foam (12,300 ppm F), professionally applied every two months, may reduce the incidence of new DLs (12% versus 49%) after fixed orthodontic treatment (RR 0.26, 95% CI 0.11 to 0.57; 95 participants). One study, at unclear risk of bias, also provides a low level of certainty that use of a high‐concentration fluoride toothpaste (5000 ppm F) by patients may reduce the incidence of new DLs (18% versus 27%) compared with a conventional fluoride toothpaste (1450 ppm F) (RR 0.68, 95% CI 0.46 to 1.00; 380 participants). There was no evidence for a difference in the proportions of orthodontic patients with new DLs on the teeth after treatment with fixed orthodontic appliances for the following comparisons:
 ‐ an amine fluoride and stannous fluoride toothpaste/mouthrinse combination versus a sodium fluoride toothpaste/mouthrinse,
 ‐ an amine fluoride gel versus a non‐fluoride placebo applied by participants at home once a week and by professional application every three months,
 ‐ resin‐modified glass ionomer cement versus light‐cured composite resin for bonding orthodontic brackets,
 ‐ a 250 ppm F mouthrinse versus 0 ppm F placebo mouthrinse,
 ‐ the use of an intraoral fluoride‐releasing glass bead device attached to the brace versus a daily fluoride mouthrinse. The last two comparisons involved studies that were assessed at high risk of bias, because a substantial number of participants were lost to follow‐up. Unfortunately, although the internal validity and hence the quality of the studies has improved since the first version of the review, they have compared different interventions; therefore, the findings are only considered to provide low level of certainty, because none has been replicated by follow‐up studies, in different settings, to confirm external validity. A patient‐reported outcome, such as concern about the aesthetics of any DLs, was still not included as an outcome in any study. Reports of adverse effects from topical fluoride applications were rare and unlikely to be significant. One study involving fluoride‐containing glass beads reported numerous breakages. Authors' conclusions This review found a low level of certainty that 12,300 ppm F foam applied by a professional every 6 to 8 weeks throughout fixed orthodontic treatment, might be effective in reducing the proportion of orthodontic patients with new DLs. In addition, there is a low level of certainty that the patient use of a high fluoride toothpaste (5000 ppm F) throughout orthodontic treatment, might be more effective than a conventional fluoride toothpaste. These two comparisons were based on single studies. There was insufficient evidence of a difference regarding the professional application of fluoride varnish (7700 or 10,000 ppm F). Further adequately powered, randomised controlled trials are required to increase the certainty of these findings and to determine the best means of preventing DLs in patients undergoing fixed orthodontic treatment. The most accurate means of assessing adherence with the use of fluoride products by patients and any possible adverse effects also need to be considered. Future studies should follow up participants beyond the end of orthodontic treatment to determine the effect of DLs on patient satisfaction with treatment. Plain language summary Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment Review question 
 Ugly white or brown marks sometimes appear on the teeth during treatment with braces to straighten teeth. These are due to early tooth decay and usually occur with fixed, glued‐on 'train track', braces, which make it more difficult to clean the teeth. We know that fluoride in toothpaste helps to prevent tooth decay and think that if extra fluoride is given to people wearing fixed braces, it will protect them from getting these marks. The aim of this Cochrane Oral Health's review was to look at how well fluorides help to prevent early tooth decay during fixed brace treatment and to find out the best way to get fluoride to the teeth. Background 
 Wearing a fixed brace makes it harder for people to keep their teeth clean and may also cause pain. Pain can make it more difficult for people to brush their teeth. This can lead to a build‐up of dental plaque around the brackets that attach the fixed brace to the teeth, and if the plaque stays on the tooth for long enough, it will cause early tooth decay, which looks like white or brown marks (demineralised lesions, also known as white spot lesions). People often wear braces for 18 months or longer and if the decay is left to progress, it can cause holes, which are sometimes bad enough to need fillings to be done in the teeth. Fluoride helps the tooth to heal, reducing tooth decay in people who are at risk of developing it. People receiving fixed brace treatment may be given different forms of fluoride treatment. It is important to think about how the fluoride gets to the teeth. Does the fluoride need to be placed by a dentist or dental nurse, or can people having treatment with braces apply the fluoride to their own teeth? Study characteristics 
 This review is up‐to‐date as of 1 February 2019. The review includes 10 studies but we could only use the information from nine studies involving 1798 randomised people. We have asked for more information about one study. The review looks at eight different ways of applying fluoride to the teeth. People taking part in the studies were all having treatment with fixed braces. The number of people with new decay on the teeth at end of fixed brace treatment, as well as the amount of decay in each person, were measured and counted. We compared the following treatments:
 ‐ dentist or nurse‐applied fluoride e.g. varnish, gel or foam,
 ‐ patient‐applied/used fluoride e.g. toothpaste, mouthwash, gel or foam, and
 ‐ materials that release fluoride over time e.g. glues, elastic bands. Key results 
 One study showed that when the dentist applies a foam with a high level of fluoride in it onto the teeth every time the patient is seen, this might reduce the risk of new decay. Another study found that if patients use a toothpaste with a higher level of fluoride than normal, then this might also reduce the risk of new marks on their teeth. No studies have shown that other ways of giving the teeth extra fluoride reduced the number and/or size of new decay on teeth in people wearing fixed braces. Harmful effects of the different ways of giving the teeth more fluoride were not reported in any of the included studies. Certainty of the evidence 
 The level of belief we have in these findings is low, due to the lack of studies testing the same fluorides and showing the same results. We suggest that more, well‐conducted studies should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Benson, PE; Parkin, N; Dyer, F; Millett, DT; Germain, P", "articleTypes": [], "doi": "10.1002/14651858.CD003809.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "7da28e6f-122b-4638-b6f5-1cec91131922", "pmid": "", "title": "Antiviral treatment for preventing postherpetic neuralgia", "imported": false, "abstract": "Abstract - Background Postherpetic neuralgia (PHN) is a painful and refractory complication of herpes zoster. Treatments are either partially or totally ineffective for many people with PHN. Antiviral agents, used at the time of the rash, have been proposed as an intervention to prevent the development of PHN. This is the first update since the first publication of the review in 2009. Objectives To assess the effectiveness of antiviral agents in preventing PHN. Search methods On 26 April 2013, we updated the searches in the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and the Chinese Biomedical Retrieval System. We checked the references of published studies to identify additional trials, and contacted authors to obtain additional data. We searched other databases in The Cochrane Library for information for the Discussion and two clinical trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) of antiviral treatment given within 72 hours after the onset of herpes zoster for preventing PHN. There were no language restrictions. Data collection and analysis Two authors independently selected trials, evaluated the risk of bias in included trials, and extracted and analysed data. Main results Six RCTs with a total of 1211 participants were eligible; five trials evaluated oral aciclovir, and one, with 419 participants, evaluated oral famciclovir. We were able to conduct meta‐analyses as there were sufficient similarities in the included studies, such as the reporting of the presence of PHN, duration of rash before treatment initiation and treatment regimen. For our primary outcome, based on three trials (609 participants) we found no significant difference between the aciclovir and control groups in the incidence of PHN four months after the onset of the acute herpetic rash (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.51 to 1.11), nor was there a significant difference at six months (RR 1.05, 95% CI 0.87 to 1.27, two trials, 476 participants). In four of the trials (692 participants), there was some evidence for a reduction in the incidence of pain four weeks after the onset of rash. In the trial of famciclovir versus placebo, neither 500 mg nor 750 mg doses of famciclovir reduced the incidence of herpetic neuralgia significantly. The most commonly reported adverse events were nausea, vomiting, diarrhoea and headache for aciclovir, and headache and nausea for famciclovir. For neither treatment was the incidence of adverse events significantly different from placebo. None of the studies were at high risk of bias, although the risk of bias was unclear in at least one domain for all but one study. We found no new RCTs when we updated the searches in April 2013. Authors' conclusions There is high quality evidence that oral aciclovir does not reduce the incidence of PHN significantly. In addition, there is insufficient evidence to determine the effect of other antiviral treatments; therefore, further well‐designed RCTs are needed to investigate famciclovir or other new antiviral agents in preventing PHN. Future trials should pay more attention to the severity of pain and quality of life of participants, and should be conducted among different subgroups of people, such as people who are immunocompromised. Plain language summary Antiviral treatment for preventing nerve pain after shingles (postherpetic neuralgia) Review question We reviewed the evidence about the effect of antiviral medicines for preventing postherpetic neuralgia (PHN). Background PHN is a painful condition that can occur after shingles (herpes zoster) in the area where the rash occurred. Many people with PHN find that treatments work only a little or not at all. Attention has therefore turned to stopping the development of PHN. Some people suggested that medicines that target the virus that causes shingles (antiviral medicines), given at the time of the rash, might prevent PHN. The aim of this review was to assess the whether antiviral medicines are able to prevent PHN. Study characteristics We identified six clinical trials that met our standards for inclusion in the review. They included a total of 1319 participants. We decided that our main measure of whether antiviral medicines work in preventing PHN would be whether or not PHN had developed six months after a first attack of shingles (some of the studies we included of aciclovir measured PHN at four months). Key results and quality of the evidence Aciclovir, which is an antiviral medicine, was used in five trials (900 participants) and was not better than a placebo (dummy pill) in preventing PHN. In the other trial (419 participants), famciclovir, which is another antiviral drug, was no better than placebo in preventing pain following healing of the shingles rash. The number of side effects with aciclovir and famciclovir was not very different from the number with placebo. The trials did not have any major problems of design or conduct that put the results in doubt, although most of the reports did not provide enough information to fully assess every aspect. We conclude that according to high quality evidence, oral aciclovir was ineffective in reducing the incidence of PHN and there is not enough evidence on other antiviral treatments. There need to be further well‐designed trials of famciclovir or other new antiviral agents with a greater number of participants. Future trials should pay more attention to the severity of pain and quality of life of participants, and should include different groups of people, such as those who have lowered immunity. The evidence is current to April 2013, when the searches were last updated. Because new evidence on this topic is slow to emerge, we have scheduled the next update of this review for 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Chen, N, Li, Q, Yang, J, Zhou, M, Zhou, D, He, L", "articleTypes": [], "doi": "10.1002/14651858.CD006866.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.111Z" }, { "id": "7db8542c-2f39-4186-8881-430593ef6254", "pmid": "", "title": "Ganoderma lucidum (Reishi mushroom) for cancer treatment", "imported": false, "abstract": "Abstract - Background Ganoderma lucidum is a natural medicine that is widely used and recommended by Asian physicians and naturopaths for its supporting effects on immune system. Laboratory research and a handful of preclinical trials have suggested that G. lucidum carries promising anticancer and immunomodulatory properties. The popularity of taking G. lucidum as an alternative medicine has been increasing in cancer patients. However, there is no systematic review that has been conducted to evaluate the actual benefits of G. lucidum in cancer treatment. Objectives To evaluate the clinical effects of G. lucidum on long‐term survival, tumour response, host immune functions and quality of life in cancer patients, as well as adverse events associated with its use. Search methods We searched an extensive set of databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, NIH, AMED, CBM, CNKI, CMCC and VIP Information/Chinese Scientific Journals Database was searched for randomised controlled trials (RCTs) in October 2011. Other strategies used were scanning the references of articles retrieved, handsearching of the International Journal of Medicinal Mushrooms and contact with herbal medicine experts and manufacturers of G. lucidum . For this update we updated the searches in February 2016. Selection criteria To be eligible for being included in this review, studies had to be RCTs comparing the efficacy of G. lucidum medications to active or placebo control in patients with cancer that had been diagnosed by pathology. All types and stages of cancer were eligible for inclusion. Trials were not restricted on the basis of language. Data collection and analysis Five RCTs met the inclusion criteria and were included in this review. Two independent review authors assessed the methodological quality of individual trials. Common primary outcomes were tumour response evaluated according to the World Health Organization (WHO) criteria, immune function parameters such as natural killer (NK)‐cell activity and T‐lymphocyte co‐receptor subsets, and quality of life measured by the Karnofsky scale score. No trial had recorded long‐term survival rates. Associated adverse events were reported in one study. A meta‐analysis was performed to pool available data from the primary trials. Results were gauged using relative risks (RR) and standard mean differences (SMD) for dichotomous and continuous data respectively, with a 95% confidence interval (CI). Main results The methodological quality of primary studies was generally unsatisfying and the results were reported inadequately in many aspects. Additional information was not available from primary trialists. The meta‐analysis results showed that patients who had been given G. lucidum alongside with chemo/radiotherapy were more likely to respond positively compared to chemo/radiotherapy alone (RR 1.50; 95% CI 0.90 to 2.51, P = 0.02). G. lucidum treatment alone did not demonstrate the same regression rate as that seen in combined therapy. The results for host immune function indicators suggested that G. lucidum simultaneously increases the percentage of CD3, CD4 and CD8 by 3.91% (95% CI 1.92% to 5.90%, P < 0.01), 3.05% (95% CI 1.00% to 5.11%, P < 0.01) and 2.02% (95% CI 0.21% to 3.84%, P = 0.03), respectively. In addition, leukocyte, NK‐cell activity and CD4/CD8 ratio were marginally elevated. Four studies showed that patients in the G. lucidum group had relatively improved quality of life in comparison to controls. One study recorded minimal side effects, including nausea and insomnia. No significant haematological or hepatological toxicity was reported. Authors' conclusions Our review did not find sufficient evidence to justify the use of G. lucidum as a first‐line treatment for cancer. It remains uncertain whether G. lucidum helps prolong long‐term cancer survival. However, G. lucidum could be administered as an alternative adjunct to conventional treatment in consideration of its potential of enhancing tumour response and stimulating host immunity. G. lucidum was generally well tolerated by most participants with only a scattered number of minor adverse events. No major toxicity was observed across the studies. Although there were few reports of harmful effect of G. lucidum , the use of its extract should be judicious, especially after thorough consideration of cost‐benefit and patient preference. Future studies should put emphasis on the improvement in methodological quality and further clinical research on the effect of G. lucidum on cancer long‐term survival are needed. An update to this review will be performed every two years. Plain language summary G. lucidum (Reishi mushroom) for cancer treatment There have been an increasing number of patients diagnosed with cancer each year. Certain malignancies have been a major cause of death in some populations. People who have been diagnosed with cancer want to do everything they can to combat the disease, manage its symptoms and cope with the side effects of radio/chemotherapy. Many turn to complementary and alternative medicine. G. lucidum extract is a medication that has been widely used by traditional Chinese medicine (TCM) practitioners for this regard. It is usually recommended as an immune system support supplement in cancer treatment. Latest laboratory research and preclinical trials of G. lucidum have shown promising results of its antitumour activity. However, clinical evidence of its efficacy is sparse and a systematic review is in need to provide collective information for health‐care consumers. Our review identified and subsequently included five relevant randomised controlled trials. A total of 373 subjects were analysed. A meta‐analysis was performed to pool available data from individual trials. Our results found that patients with G. lucidum extract in their anticancer regimen were 1.27 times more likely to respond to chemotherapy or radiotherapy than those without. However, the data failed to demonstrate significant effect on tumour shrinkage when it was used alone. In addition, G. lucidum could stimulate host immune functions by considerably increasing CD3, CD4 and CD8 lymphocyte percentages. Nevertheless, natural killer (NK)‐cell activity, which has been suggested to be an indicator of self‐defence against tumour cell, was marginally elevated. Patients in the G. lucidum group were found to have a relatively better quality of life after treatment than those in the control group. A few cases of minor side effect associated with G. lucidum treatment including nausea and insomnia were reported. There are limitations of the results from this systematic review. First, most included studies were small and there were concerns on the methodological quality of individual trials. Second, all participants in the individual trials were recruited from the Chinese population. Together, the robustness and applicability of the results were largely affected.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Jin, X, Ruiz Beguerie, J, Sze, DMY, Chan, GCF", "articleTypes": [], "doi": "10.1002/14651858.CD007731.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.763Z" }, { "id": "7dcc4dbe-b391-4a99-a47d-4d14f6eb0bcb", "pmid": "", "title": "Systemic corticosteroids for acute otitis media in children", "imported": false, "abstract": "Abstract - Background Acute otitis media (AOM) is a common acute infection in children. Pain is its most prominent and distressing symptom. Antibiotics are commonly prescribed for AOM, although they have only a modest effect in reducing pain at two to three days. There is insufficient evidence for benefits of other treatment options, including systemic corticosteroids. However, systemic corticosteroids are potent anti‐inflammatory drugs, and so theoretically could be effective, either alone or as an addition to antibiotics. Objectives To assess the effects of systemic corticosteroids (oral or parenteral), with or without antibiotics, for AOM in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) which contains the Cochrane ARI Group's Specialised Register, MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), Web of Science (Thomson Reuters), and LILACS (BIREME) for published studies, and ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for completed and ongoing studies, to 20 February 2018. We checked the reference lists of all primary studies and review articles for additional references and contacted experts in the field to identify additional unpublished materials. Selection criteria We included randomised controlled trials of children with AOM that compared any systemic corticosteroid (oral or parenteral) with placebo, either with antibiotics (corticosteroid plus antibiotic versus placebo plus antibiotic) or without antibiotics (corticosteroid versus placebo). Data collection and analysis Three review authors (EDS, RR, YP) independently screened the titles and abstracts and retrieved the full texts of potentially relevant studies. We independently extracted study characteristics and outcome data from the included studies, and assessed the risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed study quality using the GRADE method. Main results We included two studies involving 252 children with AOM aged from three months to six years receiving hospital ambulatory care who were treated with intramuscular ceftriaxone, and who were then randomised to the corticosteroid group (corticosteroid and corticosteroid plus antihistamine) or the placebo group (antihistamine and double placebo). In one study, children also had a needle aspiration of middle ear fluid. Both studies were at unclear risk of bias for allocation concealment, and unclear to high risk of bias for selective reporting. One study (N = 179) included pain as an outcome, but we were unable to derive the proportion of children with persistent pain at Day 5 and Day 14. Reduction of overall or specific symptoms was presented as improvement in clinical symptoms and resolution of inflamed tympanic membranes without the need for additional antibiotic treatment: at Day 5 (94% of children in the treatment group (N = 89) versus 89% in the placebo group (N = 90); risk ratio (RR) 1.06, 95% confidence interval (CI) 0.97 to 1.16) and Day 14 (91% versus 87%; RR 1.05, 95% CI 0.95 to 1.17). Low‐quality evidence meant that we are uncertain of the effectiveness of corticosteroids for this outcome. The second study (N = 73) reported a reduction of overall or specific symptoms without additional antibiotic treatment during the first two weeks as a favourable outcome. Children in the treatment group had more favourable outcomes (adjusted odds ratio 65.9, 95% CI 1.28 to 1000; P = 0.037), although the numbers were small. We were unable to pool the results with the other study because it did not report the proportion of children with this outcome by treatment group. Only one study reported adverse effects of corticosteroids (e.g. drowsiness, nappy rash), but did not quantify incidence, so we were unable to draw conclusions about adverse effects. Neither study reported a reduction in overall or specific symptom duration. Authors' conclusions The evidence for the effect of systemic corticosteroids on AOM is of low to very low quality, meaning the effect of systemic corticosteroids on important clinical outcomes in AOM remains uncertain. Large, high‐quality studies are required to resolve the question . Plain language summary Systemic corticosteroids for improving symptoms in children with acute middle ear infection Review question We reviewed the evidence on the effects of corticosteroids given by mouth or injection for acute middle ear infection (acute otitis media (AOM)) in children, particularly in improving symptoms such as ear pain, fever, irritability, lack of sleep, and lack of appetite. We also looked at the side effects of corticosteroids. Background Acute otitis media is common in children and causes ear pain and non‐specific symptoms such as fever, irritability, and deafness. It is often treated with antibiotics, although ear pain generally resolves within two days, and antibiotics help symptoms only slightly. Other treatments (such as over‐the‐counter antihistamines and decongestants) do not help very much. Corticosteroids are often prescribed to reduce inflammation in children for other illnesses, and so may also help symptoms of AOM, which is an inflammatory process. We investigated whether using corticosteroids was better or worse than nothing in improving AOM‐related symptoms. Search date Our evidence is current to 20 February 2018. Study characteristics We included two studies involving 252 children with AOM, aged from three months to six years, receiving hospital ambulatory care. Children were treated with an antibiotic injection and either oral corticosteroid or a placebo (treatment with no effect). In one study, fluid from the middle ear was collected by inserting a needle through the eardrum to measure the level of inflammation. Study funding sources The National Institutes of Health (NIH) and the National Center for Research Resources, NIH, US Public Health Service funded both studies. Pharmaceutical companies provided the drug but did not contribute any other scientific or financial support. Key results and quality of evidence Corticosteroids did not make a significant difference in improving the symptoms and inflammation of the eardrum(s) at Day 5 and Day 14, but we are unsure of this effect due to the small numbers of children in the studies. There were no significant differences between the corticosteroid and placebo groups in terms of resolving fluid in children's middle ears (at 1, 2, and 3 months) and experiencing new episodes of AOM (at 1, 2, 3 months, and 4 and 6 months). Neither study reported a reduction in the duration of overall or specific symptoms, rupture of eardrum(s), the occurrence of middle ear inflammation in the other ear following the current ear infection, or serious complications. Only one study reported the overall side effects identified during the trial (e.g. drowsiness, dry mouth, diaper rash, nervousness). We could not draw any conclusions regarding the effects of corticosteroids for AOM in children. The quality of evidence included in this review was low to very low due to few children included in two small studies. We are uncertain about whether or not corticosteroids are useful in relieving pain from AOM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ranakusuma, RW; Pitoyo, Y; Safitri, ED; Thorning, S; Beller, EM; Sastroasmoro, S; Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD012289.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "7dcd7c8d-99a0-4b1b-8d76-0af111459207", "pmid": "", "title": "High-dose Vitamin D Supplement for the Prevention of Acute Asthma-like Symptoms in Preschool Children - a Double-blind, Randomized, Controlled Trial", "imported": false, "abstract": "To investigate whether high-dose vitamin D supplementation may have a beneficial effect on secondary prevention in preschool children (1-5 years of age), with respiratory infections being the primary cause of acute exacerbations with asthma-like symptoms.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.264Z" }, { "id": "7dd4fb5f-d177-406b-90fb-6569b396cfb7", "pmid": "", "title": "Chinese medicinal herbs for measles", "imported": false, "abstract": "Abstract - Background Measles is an infectious disease caused by the Morbillivirus . Chinese physicians believe that medicinal herbs are effective in alleviating symptoms and preventing complications. Chinese herbal medicines are dispensed according to the particular symptoms. This is the second update of a Cochrane Review first published in 2006. Objectives To assess the effectiveness and possible adverse effects of Chinese medicinal herbs for measles. Search methods We searched the Cochrane Central Register of Controlled Clinical Trials (CENTRAL Issue 1, 2011) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to March week 5, 2011), EMBASE (1980 to April 2011), Web of Science (2005 to 30 April 2011), AMED (1985 to 30 April 2011), Chinese Biomedical Database (1976 to 30 June 2011), VIP Information (1989 to 30 June 2011), China National Knowledge Infrastructure (CNKI) (1976 to 30 June 2011), Chinese Journals full‐article database (1994 to 30 June 2011) and the meta Register of Controlled Trials for ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs in patients with measles (without complications). Data collection and analysis Two review authors (SC, TW) independently assessed trial quality and extracted data. We telephone interviewed the trial authors for missing information regarding participant allocation. Some trials allocated participants according to the sequence they were admitted to the trials, that is to say, by using a pseudo‐random allocation method. None of the trials concealed the allocation or used blinding methods. Main results We did not identify any suitable trials for inclusion. In this updated review we identified 80 trials which claimed to use random allocation. We contacted 32 trial authors by telephone and learned that the allocation methods used were not randomised. We excluded 34 studies because the participants experienced complications such as pneumonia. We excluded 10 trials because of non‐random allocation and complications experienced by the participants. We were unable to contact the remaining four trials' authors, so they require further assessment and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions There is no RCT evidence for or against Chinese medicinal herbs as a treatment for measles. We hope high‐quality, robust RCTs in this field will be conducted in the future. Plain language summary Chinese medicinal herbs for measles Measles (rubeola) is an infectious disease caused by multiplication of a single‐strand ribonucleic acid (RNA) virus of the genus Morbillivirus in the upper respiratory tract and conjunctiva. It can lead to serious complications and death. Chinese herbal medicines are believed to be effective in alleviating symptoms and shortening the duration of measles, and are widely used as the main or adjunctive therapy to treat measles in China and other countries. The review authors found a large number of clinical studies providing evidence of Chinese herbal medicines in the treatment of measles. Some of these reports claimed to be randomised controlled trials. However, after telephone interviewing 32 trial authors, we found that none of them used acceptable randomisation procedures to allocate participants and 34 studies included participants with measles complicated with other diseases, for example, pneumonia. Ten trials were non‐randomised controlled studies and four trials require further classification. In this update, we were unable to include any randomised controlled trial for assessment. Although no trials were included, the authors reviewed the articles and found no reports of adverse events in the use of Chinese herbal medicines for treating measles. High‐quality and large trials are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Chen, S; Wu, T; Kong, X; Yuan, H", "articleTypes": [], "doi": "10.1002/14651858.CD005531.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "7dda53da-998d-44d0-9555-5df24cee3629", "pmid": "", "title": "Serenoa repens for the treatment of lower urinary tract symptoms due to benign prostatic enlargement", "imported": false, "abstract": "Abstract - Background Benign prostatic hyperplasia (BPH) is a non‐malignant enlargement of the prostate, which can lead to obstructive and irritative lower urinary tract symptoms (LUTS). The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS associated with BPH is common. The extract of the berry of the American saw palmetto or dwarf palm plant, Serenoa repens (SR), which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of BPH. Objectives To assess the effects of Serenoa repens in the treatment of men with LUTS consistent with BPH. Search methods We performed a comprehensive search of multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to 16 September 2022, with no restrictions on language or publication status. Selection criteria We included randomized controlled trials of participants with BPH who were treated with Serenoa repens or placebo/no treatment. Data collection and analysis Two review authors independently assessed studies for inclusion at each stage and undertook data extraction and risk of bias assessment and GRADE assessment of the certainty of the evidence. We considered review outcomes measured up to 12 months after randomization as short term, and beyond 12 months as long term. Our main outcomes included urologic symptom scores, quality of life, and adverse events. Main results For this update, we narrowed the review question to only comparisons with placebo. We included 27 studies (of which 9 were new) involving a total of 4656 participants, 19 studies comparing Serenoa repens with placebo, and 8 studies comparing Serenoa repens in combination with other phytotherapeutic agents versus placebo. Most studies included men aged > 50 (mean age range 52 to 68) with moderate urologic symptoms (International Prostate Symptom Score [IPSS] range 8 to 19). Ten studies were funded by the pharmaceutical industry; two studies were funded by government agencies; and the remaining studies did not specify funding sources. Serenoa repens versus placebo or no intervention Results for this comparison are based on predefined sensitivity analyses limited to studies at low risk of bias. Serenoa repens results in little to no difference in urologic symptoms at short‐term follow‐up (3 to 6 months; IPSS score range 0 to 35, higher scores indicate worse symptoms; mean difference (MD) −0.90, 95% confidence interval (CI) −1.74 to −0.07; I 2 = 68%; 9 studies, 1681 participants; high‐certainty evidence). Serenoa repens results in little to no difference in the quality of life at short‐term follow‐up (3 to 6 months; IPSS quality of life domain range 0 to 6, higher scores indicate worse quality of life; MD −0.20, 95% CI −0.40 to −0.00; I 2 = 39%; 5 studies, 1001 participants; high‐certainty evidence). Serenoa repens probably results in little to no difference in adverse events (1 to 17 months; risk ratio (RR) 1.01, 95% CI 0.77 to 1.31; I 2 = 18%; 12 studies, 2399 participants; moderate‐certainty evidence). Based on 164 cases per 1000 men in the placebo group, this corresponds to 2 more (38 fewer to 51 more) per 1000 men in the Serenoa repens group. Serenoa repens results in little to no difference in urologic symptoms at long‐term follow‐up (12 to 17 months, IPSS score, MD 0.07, 95% CI −0.75 to 0.88; I 2 = 34%; 3 studies, 898 participants; high‐certainty evidence). Serenoa repens results in little to no difference in quality of life at long‐term follow‐up (12 to 17 months, IPSS quality of life, MD −0.11, 95% CI −0.41 to 0.19; I 2 = 65%; 3 studies, 882 participants; high‐certainty evidence). There were no data on long‐term adverse events for this comparison. Serenoa repens in combination with other phytotherapy versus placebo or no intervention Different phytotherapeutic agents that include Serenoa repens may result in little to no difference in urologic symptoms compared to placebo at short‐term follow‐up (12 to 24 weeks, IPSS score, MD −2.41, 95% CI −4.54 to −0.29; I 2 = 67%; 4 studies, 460 participants; low‐certainty evidence). We are very uncertain about the effects of these agents on quality of life (very low‐certainty evidence). These agents may result in little to no difference in the occurrence of adverse events; however, the CIs included substantial benefits and harms (12 to 48 weeks, RR 0.91, 95% CI 0.58 to 1.41; I 2 = 0%; 4 studies, 481 participants; low‐certainty evidence). Based on 132 cases per 1000 men in the placebo group, this corresponds to 12 fewer (55 fewer to 54 more) per 1000 men in the combined phytotherapeutic agents with Serenoa repens group. Authors' conclusions Serenoa repens alone provides little to no benefits for men with lower urinary tract symptoms due to benign prostatic enlargement. There is more uncertainty about the role of Serenoa repens in combination with other phytotherapeutic agents. Plain language summary Serenoa repens for benign prostatic hyperplasia Review question Does Serenoa repens alone or in combination with other phytotherapeutic agents improve symptoms in men with benign prostatic enlargement? Background An enlarged prostate may cause bothersome urinary tract symptoms, such as having to urinate often during the day or night, having a weak stream, and the feeling of not completely emptying the bladder. Besides other common drug interventions, using plants and herbs (phytotherapy) is common and has been growing steadily in most Western countries. The extract of the berry of the American saw palmetto, or dwarf palm plant, Serenoa repens , which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of this condition. Study characteristics We found 27 studies with 4656 men comparing Serenoa repens alone or in combination with other herbal products to a placebo (participants are made to believe they received treatment when in fact they did not). Most studies included men over 50 with moderate symptoms. Ten studies were funded by pharmaceutical organizations; two studies received government funding; and the remaining studies did not specify funding sources. Key results Based on the most trustworthy studies, Serenoa repens alone results in little to no difference in urinary tract symptoms or quality of life compared to placebo at three to six months. This treatment is also likely not associated with adverse events. Results were similar at 12 to 17 months. Serenoa repens in combination with other herbal products may result in little to no difference in urinary tract symptoms, but there is more uncertainty about effects on quality of life and adverse events. The findings of this review are current to 16 September 2022. Certainty of the evidence The certainty of the evidence is primarily high or moderate for Serenoa repens alone, but low for Serenoa repens in combination with other agents, meaning our confidence in the results is high, moderate, or low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Franco, JVA; Trivisonno, L; Sgarbossa, NJ; Alvez, GA; Fieiras, C; Escobar Liquitay, CM; Jung, JH", "articleTypes": [], "doi": "10.1002/14651858.CD001423.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "7df18cf4-511c-4311-a557-64f6849db11f", "pmid": "", "title": "Oral zinc for treating diarrhoea in children", "imported": false, "abstract": "Abstract - Background In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). Objectives To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, m RCT, and reference lists up to 30 September 2016. We also contacted researchers. Selection criteria Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery. Data collection and analysis Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses (using either a fixed‐effect or random‐effects model) and assessed heterogeneity. We assessed the certainty of the evidence using the GRADE approach. Main results Thirty‐three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoea There is currently not enough evidence from well‐conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized ( very low certainty evidence ). In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD −11.46 hours, 95% CI −19.72 to −3.19; 2581 children, 9 trials, low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD −26.39 hours, 95% CI −36.54 to −16.23; 419 children, 5 trials, high certainty evidence ). Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI −4.00 to 14.45; 1334 children, 2 trials, low certainty evidence ), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, low certainty evidence ). None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence ; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence ). Persistent diarrhoea In children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD −15.84 hours, 95% CI −25.43 to −6.24; 529 children, 5 trials, moderate certainty evidence ). Authors' conclusions In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency. 12 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (30 Sep, 2016) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Oral zinc supplementation for treating diarrhoea in children In low‐ and middle‐income countries, millions of children suffer from severe diarrhoea every year and many die from dehydration. Giving fluids by mouth (using an oral rehydration solution (ORS)) has been shown to save children's lives, but it has no effect on the length of time the children suffer with diarrhoea. Zinc supplementation could help reduce the duration and the severity of diarrhoea, and therefore have an additional benefit over ORS in reducing children mortality. What is oral zinc and how may it shorten the duration and severity of diarrhoea Zinc is usually given as zinc sulphate, zinc acetate, or zinc gluconate, which are all water‐soluble compounds. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend 10 mg to 20 mg of zinc per day for children with diarrhoea. There are several mechanism of action of zinc on acute diarrhoea, some of which are specific to the gastrointestinal system: zinc restores mucosal barrier integrity and enterocyte brush‐border enzyme activity, it promotes the production of antibodies and circulating lymphocytes against intestinal pathogens, and has a direct effect on ion channels, acting as a potassium channel blocker of adenosine 3‐5‐cyclic monophosphate‐mediated chlorine secretion. Cochrane researchers examined the evidence available up to 30 September 2016. What the evidence in the review suggests Thirty‐three trials that included 10,841 children met the inclusion criteria of this review. Among children with acute diarrhoea, we don't know if treating children with zinc has an effect on death or number of children hospitalized ( very low certainty evidence ). In children older than six months, zinc supplementation may shorten the average duration of diarrhoea by around half a day ( low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven ( moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day ( high certainty evidence ). Conversely, in children younger than six months, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea ( low certainty evidence ), or the number of children who still have diarrhoea on day seven ( low certainty evidence ). Zinc supplementation increased the risk of vomiting in both age groups ( moderate certainty evidence ). No other adverse effects were reported. Among children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours ( moderate certainty ) but it probably increases the risk of vomiting ( moderate certainty evidence ). In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lazzerini, M; Wanzira, H", "articleTypes": [], "doi": "10.1002/14651858.CD005436.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "7df7b7f7-1921-4fd5-8b59-1a6cf0e9dbb2", "pmid": "", "title": "Helicobacter pylori eradication for the prevention of gastric neoplasia", "imported": false, "abstract": "Abstract - Background Gastric cancer is the third most common cause of cancer death worldwide. Individuals infected with Helicobacter pylori have a higher likelihood of developing gastric cancer than individuals who are not infected. Eradication of H. pylori in healthy asymptomatic individuals in the general population may reduce the incidence of gastric cancer, but the magnitude of this effect is unclear. Objectives To assess the effectiveness of eradication of H. pylori in healthy asymptomatic individuals in the general population in reducing the incidence of gastric cancer. Search methods We identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 1), MEDLINE (1946 to February 2020), and EMBASE (1974 to February 2020). We handsearched reference lists from trials selected by electronic searching to identify further relevant trials. We handsearched published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ) between 2001 and 2019. We contacted members of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials comparing at least one week of H. pylori therapy with placebo or no treatment in preventing subsequent development of gastric cancer in otherwise healthy and asymptomatic H. pylori ‐positive adults. Trials had to follow up participants for at least two years and needed to have at least two participants with gastric cancer as an outcome. We defined gastric cancer as any gastric adenocarcinoma, including intestinal (differentiated) or diffuse (undifferentiated) type, with or without specified histology. Data collection and analysis We collected data on incidence of gastric cancer, incidence of oesophageal cancer, deaths from gastric cancer, deaths from any cause, and adverse effects arising due to therapy. Main results Six trials met all our eligibility criteria and provided extractable data in the previous version. Following our updated search, one new RCT was identified, meaning that seven trials were included in this updated review. In addition, one previously included trial provided fully published data out to 10 years, and another previously included trial provided fully published data out to 22 years of follow‐up. Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. Six trials were conducted in Asian populations. In preventing development of subsequent gastric cancer, H. pylori eradication therapy was superior to placebo or no treatment (RR 0.54, 95% confidence interval (CI) 0.40 to 0.72, 7 trials, 8323 participants, moderate certainty evidence). Only two trials reported the effect of eradication of H. pylori on the development of subsequent oesophageal cancer. Sixteen (0.8%) of 1947 participants assigned to eradication therapy subsequently developed oesophageal cancer compared with 13 (0.7%) of 1941 participants allocated to placebo (RR 1.22, 95% CI 0.59 to 2.54, moderate certainty evidence). H. pylori eradication reduced mortality from gastric cancer compared with placebo or no treatment (RR 0.61, 95% CI 0.40 to 0.92, 4 trials, 6301 participants, moderate certainty evidence). There was little or no evidence in all‐cause mortality (RR 0.97, 95% CI 0.85 to 1.12, 5 trials, 7079 participants, moderate certainty evidence). Adverse events data were poorly reported. Authors' conclusions We found moderate certainty evidence that searching for and eradicating H. pylori reduces the incidence of gastric cancer and death from gastric cancer in healthy asymptomatic infected Asian individuals, but we cannot necessarily extrapolate this data to other populations. Plain language summary Helicobacter pylori treatment for the prevention of stomach cancer Review question Whether testing healthy people for Helicobacter pylori and treating those infected with a course of antibiotics decreases the number of new cases of gastric cancer. Background Helicobacter pylori ( H. pylori ) is a bacteria that lives in the lining of the stomach with people usually not aware they are carrying the infection. People with H. pylori infection are more likely to develop gastric cancer than people who are not infected with the bacterium. For this reason, H. pylori is classed as carcinogenic (causing cancer) to humans. Many people worldwide die of gastric cancer every year, because by the time those affected seek the opinion of a doctor, the condition is often advanced. However, H. pylori infection is easily treatable with a one‐week course of antibiotics. Study characteristics A literature search up to 02 Feburary 2020 found seven trials (containing 8323 participants, four trials at low risk of bias). Six of the studies were based in Asia. Key results We found that antibiotics for H. pylori have a small benefit in preventing gastric cancer (68 (1.6%) of 4206 participants given treatment developed gastric cancer subsequently, compared with 125 (3.0%) of 4117 given no treatment or a placebo), and in decreasing the number of deaths from gastric cancer (36 (1.1%) of 3154, compared with 59 (1.9%) of 3147); but it is unclear whether or not they increase or decrease the number of deaths due to any cause, or increase or decrease the number of cases of oesophageal cancer. Data about side effects of treatment were poorly reported. Quality of the evidence Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. One study was at high risk of bias because no placebo was used for the active eradication therapy regimen, and so this part of the trial was unblinded, and the other study was at high risk of bias due to inconsistencies in data reporting at the two points of follow‐up. We were unable to resolve this discrepancy despite contacting the original authors. As a result, we downgraded the quality of evidence from high to moderate due to serious risk of bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ford, AC, Yuan, Y, Forman, D, Hunt, R, Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD005583.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.781Z" }, { "id": "7dfb9261-846f-48f5-82a5-072932d4b20c", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high risk patients. Ulceration can lead to severe pain and difficulty eating and drinking, which may necessitate opioid analgesics, hospitalisation and nasogastric or intravenous nutrition. These complications may lead to interruptions or alterations to cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Oral cryotherapy is a low‐cost, simple intervention which is unlikely to cause side‐effects. It has shown promise in clinical trials and warrants an up‐to‐date Cochrane review to assess and summarise the international evidence. Objectives To assess the effects of oral cryotherapy for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to 17 June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) ( Cochrane Library 2015, Issue 5), MEDLINE via Ovid (1946 to 17 June 2015), EMBASE via Ovid (1980 to 17 June 2015), CANCERLIT via PubMed (1950 to 17 June 2015) and CINAHL via EBSCO (1937 to 17 June 2015). We searched the US National Institutes of Health Trials Registry, and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching databases. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of oral cryotherapy in patients with cancer receiving treatment. We used outcomes from a published core outcome set registered on the COMET website. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. We contacted study authors for information where feasible. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 14 RCTs analysing 1280 participants. The vast majority of participants did not receive radiotherapy to the head and neck, so this review primarily assesses prevention of chemotherapy‐induced oral mucositis. All studies were at high risk of bias. The following results are for the main comparison: oral cryotherapy versus control (standard care or no treatment). Adults receiving fluorouracil‐based (5FU) chemotherapy for solid cancers Oral cryotherapy probably reduces oral mucositis of any severity (RR 0.61, 95% CI 0.52 to 0.72, 5 studies, 444 analysed, moderate quality evidence). In a population where 728 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 444 (95% CI 379 to 524). The number needed to treat to benefit one additional person (NNTB), i.e. to prevent them from developing oral mucositis, is 4 people (95% CI 3 to 5). The results were similar for moderate to severe oral mucositis (RR 0.52, 95% CI 0.41 to 0.65, 5 studies, 444 analysed, moderate quality evidence). NNTB 4 (95% CI 4 to 6). Severe oral mucositis is probably reduced (RR 0.40, 95% CI 0.27 to 0.61, 5 studies, 444 analysed, moderate quality evidence). Where 300 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 120 (95% CI 81 to 183), NNTB 6 (95% CI 5 to 9). Adults receiving high‐dose melphalan‐based chemotherapy before haematopoietic stem cell transplantation (HSCT) Oral cryotherapy may reduce oral mucositis of any severity (RR 0.59, 95% CI 0.35 to 1.01, 5 studies, 270 analysed, low quality evidence). Where 824 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 486 (95% CI reduced to 289 to increased to 833). The NNTB is 3, although the uncertainty surrounding the effect estimate means that the 95% CI ranges from 2 NNTB, to 111 NNTH (number needed to treat in order to harm one additional person, i.e. for one additional person to develop oral mucositis). The results were similar for moderate to severe oral mucositis (RR 0.43, 95% CI 0.17 to 1.09, 5 studies, 270 analysed, low quality evidence). NNTB 3 (95% CI 2 NNTB to 17 NNTH). Severe oral mucositis is probably reduced (RR 0.38, 95% CI 0.20 to 0.72, 5 studies, 270 analysed, moderate quality evidence). Where 427 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 162 (95% CI 85 to 308), NNTB 4 (95% CI 3 to 9). Oral cryotherapy was shown to be safe, with very low rates of minor adverse effects, such as headaches, chills, numbness/taste disturbance, and tooth pain. This appears to contribute to the high rates of compliance seen in the included studies. There was limited or no evidence on the secondary outcomes of this review, or on patients undergoing other chemotherapies, radiotherapy, targeted therapy, or on comparisons of oral cryotherapy with other interventions or different oral cryotherapy regimens. Therefore no further robust conclusions can be made. There was also no evidence on the effects of oral cryotherapy in children undergoing cancer treatment. Authors' conclusions We are confident that oral cryotherapy leads to large reductions in oral mucositis of all severities in adults receiving 5FU for solid cancers. We are less confident in the ability of oral cryotherapy to reduce oral mucositis in adults receiving high‐dose melphalan before HSCT. Evidence suggests that it does reduce oral mucositis in these adults, but we are less certain about the size of the reduction, which could be large or small. However, we are confident that there is an appreciable reduction in severe oral mucositis in these adults. This Cochrane review includes some very recent and currently unpublished data, and strengthens international guideline statements for adults receiving the above cancer treatments. Plain language summary Can keeping the mouth cold during cancer treatment help to prevent mouth soreness and ulcers in children and adults? Review question This review has been produced to assess whether or not keeping the mouth cold during cancer treatment, by using ice, ice‐cold water, ice cream or ice lollies/popsicles, can help prevent mouth soreness and ulcers in children and adults. Background People receiving treatment for cancer are at risk of developing a sore mouth and ulcers as a side effect. This side effect is called oral mucositis and affects over 75% of high‐risk patients (those receiving radiotherapy to the head and neck or high‐dose chemotherapy). The pain caused by this condition can be severe and can stop the person's ability to eat and drink, which may mean they need to take strong pain killers, stay in hospital and be fed through a tube into their stomach, or even into their veins. This in turn can lead to disruption to their cancer treatment, meaning they are not receiving the best possible treatment. The results may be a reduction in the patient's chances of survival, and increased costs to the healthcare system. Cancer patients have weakened immune systems due to their treatment, meaning that their bodies are less able to fight infections. This can be a problem if bacteria enter the body through the ulcer, which is an open wound. This can lead to sepsis (a dangerous inflammatory reaction of the body to infection), which requires antibiotics and hospitalisation, and can cause death. Oral cryotherapy is the cooling of the mouth using ice, ice‐cold water, ice cream or ice lollies/popsicles. It is thought to help prevent oral mucositis in people receiving certain types of chemotherapy because the coldness makes the blood vessels in the mouth more narrow, and this reduces the amount of blood containing chemotherapy drugs from reaching the mouth and causing oral mucositis. It is a low‐cost, natural treatment without serious side effects. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 17 June 2015. It includes 14 studies published from 1991 to 2015 in which 1316 participants were randomised (1280 of whom were included in the analyses) to receive oral cryotherapy versus standard care (usually saline mouthrinses) or no treatment or a different treatment or a different method of oral cryotherapy, and the number of people developing oral mucositis of different severities was compared. Nearly all the evidence was on adults receiving oral cryotherapy versus standard care or no treatment. This evidence fell into two main groups: 1) adults receiving fluorouracil‐based (5FU) treatment for solid cancers; or 2) adults receiving high‐dose melphalan‐based cancer treatment before haematopoietic stem cell transplantation (HSCT). HSCT is given to help the body to produce all types of blood cells, which are destroyed during cancer treatment. Key results There is evidence showing that oral cryotherapy can lead to large reductions in the numbers of adults who get oral mucositis of all severities after receiving 5FU‐based treatment for solid cancers. There is less certain evidence to suggest that oral cryotherapy may reduce the numbers of adults who get oral mucositis after receiving high‐dose melphalan‐based cancer treatment prior to HSCT. The evidence suggests that it does reduce oral mucositis in these adults, but the size of the reduction is much less certain. However, there is more certain evidence that there is a large reduction in severe oral mucositis in these adults. Oral cryotherapy did not cause any serious side effects in any of the participants of these studies, and most people seemed able to carry it out properly and complete it. Quality of the evidence The evidence presented, on the main outcome of whether or not people developed oral mucositis of all severities, is of moderate (because the nature of the oral cryotherapy treatment meant that the studies could not be 'blinded' which is a desirable characteristic of these studies) to low quality (because in addition to the above problem, the results of the individual studies were too different to give a precise result when they were combined).", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P; Glenny, AM; Worthington, HV; Littlewood, A; Clarkson, JE; McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011552.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "7e1eeb0a-9110-4db7-aa7f-18f1042641d9", "pmid": "", "title": "Helicobacter pylori eradication for the prevention of gastric neoplasia", "imported": false, "abstract": "Abstract - Background Gastric cancer is the third most common cause of cancer death worldwide. Individuals infected with Helicobacter pylori have a higher likelihood of developing gastric cancer than individuals who are not infected. Eradication of H. pylori in healthy asymptomatic individuals in the general population may reduce the incidence of gastric cancer, but the magnitude of this effect is unclear. Objectives To assess the effectiveness of eradication of H. pylori in healthy asymptomatic individuals in the general population in reducing the incidence of gastric cancer. Search methods We identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 1), MEDLINE (1946 to February 2020), and EMBASE (1974 to February 2020). We handsearched reference lists from trials selected by electronic searching to identify further relevant trials. We handsearched published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ) between 2001 and 2019. We contacted members of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials comparing at least one week of H. pylori therapy with placebo or no treatment in preventing subsequent development of gastric cancer in otherwise healthy and asymptomatic H. pylori ‐positive adults. Trials had to follow up participants for at least two years and needed to have at least two participants with gastric cancer as an outcome. We defined gastric cancer as any gastric adenocarcinoma, including intestinal (differentiated) or diffuse (undifferentiated) type, with or without specified histology. Data collection and analysis We collected data on incidence of gastric cancer, incidence of oesophageal cancer, deaths from gastric cancer, deaths from any cause, and adverse effects arising due to therapy. Main results Six trials met all our eligibility criteria and provided extractable data in the previous version. Following our updated search, one new RCT was identified, meaning that seven trials were included in this updated review. In addition, one previously included trial provided fully published data out to 10 years, and another previously included trial provided fully published data out to 22 years of follow‐up. Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. Six trials were conducted in Asian populations. In preventing development of subsequent gastric cancer, H. pylori eradication therapy was superior to placebo or no treatment (RR 0.54, 95% confidence interval (CI) 0.40 to 0.72, 7 trials, 8323 participants, moderate certainty evidence). Only two trials reported the effect of eradication of H. pylori on the development of subsequent oesophageal cancer. Sixteen (0.8%) of 1947 participants assigned to eradication therapy subsequently developed oesophageal cancer compared with 13 (0.7%) of 1941 participants allocated to placebo (RR 1.22, 95% CI 0.59 to 2.54, moderate certainty evidence). H. pylori eradication reduced mortality from gastric cancer compared with placebo or no treatment (RR 0.61, 95% CI 0.40 to 0.92, 4 trials, 6301 participants, moderate certainty evidence). There was little or no evidence in all‐cause mortality (RR 0.97, 95% CI 0.85 to 1.12, 5 trials, 7079 participants, moderate certainty evidence). Adverse events data were poorly reported. Authors' conclusions We found moderate certainty evidence that searching for and eradicating H. pylori reduces the incidence of gastric cancer and death from gastric cancer in healthy asymptomatic infected Asian individuals, but we cannot necessarily extrapolate this data to other populations. Plain language summary Helicobacter pylori treatment for the prevention of stomach cancer Review question Whether testing healthy people for Helicobacter pylori and treating those infected with a course of antibiotics decreases the number of new cases of gastric cancer. Background Helicobacter pylori ( H. pylori ) is a bacteria that lives in the lining of the stomach with people usually not aware they are carrying the infection. People with H. pylori infection are more likely to develop gastric cancer than people who are not infected with the bacterium. For this reason, H. pylori is classed as carcinogenic (causing cancer) to humans. Many people worldwide die of gastric cancer every year, because by the time those affected seek the opinion of a doctor, the condition is often advanced. However, H. pylori infection is easily treatable with a one‐week course of antibiotics. Study characteristics A literature search up to 02 Feburary 2020 found seven trials (containing 8323 participants, four trials at low risk of bias). Six of the studies were based in Asia. Key results We found that antibiotics for H. pylori have a small benefit in preventing gastric cancer (68 (1.6%) of 4206 participants given treatment developed gastric cancer subsequently, compared with 125 (3.0%) of 4117 given no treatment or a placebo), and in decreasing the number of deaths from gastric cancer (36 (1.1%) of 3154, compared with 59 (1.9%) of 3147); but it is unclear whether or not they increase or decrease the number of deaths due to any cause, or increase or decrease the number of cases of oesophageal cancer. Data about side effects of treatment were poorly reported. Quality of the evidence Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. One study was at high risk of bias because no placebo was used for the active eradication therapy regimen, and so this part of the trial was unblinded, and the other study was at high risk of bias due to inconsistencies in data reporting at the two points of follow‐up. We were unable to resolve this discrepancy despite contacting the original authors. As a result, we downgraded the quality of evidence from high to moderate due to serious risk of bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ford, AC, Yuan, Y, Forman, D, Hunt, R, Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD005583.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.098Z" }, { "id": "7e2168de-584a-4ca2-85d8-d34c64d1ee9b", "pmid": "", "title": "New generation antidepressants for depression in children and adolescents: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Major depressive disorders have a significant impact on children and adolescents, including on educational and vocational outcomes, interpersonal relationships, and physical and mental health and well‐being. There is an association between major depressive disorder and suicidal ideation, suicide attempts, and suicide. Antidepressant medication is used in moderate to severe depression; there is now a range of newer generations of these medications. Objectives To investigate, via network meta‐analysis (NMA), the comparative effectiveness and safety of different newer generation antidepressants in children and adolescents with a diagnosed major depressive disorder (MDD) in terms of depression, functioning, suicide‐related outcomes and other adverse outcomes. The impact of age, treatment duration, baseline severity, and pharmaceutical industry funding was investigated on clinician‐rated depression (CDRS‐R) and suicide‐related outcomes. Search methods We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR)), together with Ovid Embase, MEDLINE and PsycINFO till March 2020. Selection criteria Randomised trials of six to 18 year olds of either sex and any ethnicity with clinically diagnosed major depressive disorder were included. Trials that compared the effectiveness of newer generation antidepressants with each other or with a placebo were included. Newer generation antidepressants included: selective serotonin reuptake inhibitors; selective norepinephrine reuptake inhibitors (SNRIs); norepinephrine reuptake inhibitors; norepinephrine dopamine reuptake inhibitors; norepinephrine dopamine disinhibitors (NDDIs); and tetracyclic antidepressants (TeCAs). Data collection and analysis Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed risk of bias. We analysed dichotomous data as Odds Ratios (ORs), and continuous data as Mean Difference (MD) for the following outcomes: depression symptom severity (clinician rated), response or remission of depression symptoms, depression symptom severity (self‐rated), functioning, suicide related outcomes and overall adverse outcomes. Random‐effects network meta‐analyses were conducted in a frequentist framework using multivariate meta‐analysis. Certainty of evidence was assessed using Confidence in Network Meta‐analysis (CINeMA). We used \"informative statements\" to standardise the interpretation and description of the results. Main results Twenty‐six studies were included. There were no data for the two primary outcomes (depressive disorder established via clinical diagnostic interview and suicide), therefore, the results comprise only secondary outcomes. Most antidepressants may be associated with a \"small and unimportant\" reduction in depression symptoms on the CDRS‐R scale (range 17 to 113) compared with placebo (high certainty evidence: paroxetine: MD ‐1.43, 95% CI ‐3.90, 1.04; vilazodone: MD ‐0.84, 95% CI ‐3.03, 1.35; desvenlafaxine MD ‐0.07, 95% CI ‐3.51, 3.36; moderate certainty evidence: sertraline: MD ‐3.51, 95% CI ‐6.99, ‐0.04; fluoxetine: MD ‐2.84, 95% CI ‐4.12, ‐1.56; escitalopram: MD ‐2.62, 95% CI ‐5.29, 0.04; low certainty evidence: duloxetine: MD ‐2.70, 95% CI ‐5.03, ‐0.37; vortioxetine: MD 0.60, 95% CI ‐2.52, 3.72; very low certainty evidence for comparisons between other antidepressants and placebo). There were \"small and unimportant\" differences between most antidepressants in reduction of depression symptoms (high‐ or moderate‐certainty evidence). Results were similar across other outcomes of benefit. In most studies risk of self‐harm or suicide was an exclusion criterion for the study. Proportions of suicide‐related outcomes were low for most included studies and 95% confidence intervals were wide for all comparisons. The evidence is very uncertain about the effects of mirtazapine (OR 0.50, 95% CI 0.03, 8.04), duloxetine (OR 1.15, 95% CI 0.72, 1.82), vilazodone (OR 1.01, 95% CI 0.68, 1.48), desvenlafaxine (OR 0.94, 95% CI 0.59, 1.52), citalopram (OR 1.72, 95% CI 0.76, 3.87) or vortioxetine (OR 1.58, 95% CI 0.29, 8.60) on suicide‐related outcomes compared with placebo. There is low certainty evidence that escitalopram may \"at least slightly\" reduce odds of suicide‐related outcomes compared with placebo (OR 0.89, 95% CI 0.43, 1.84). There is low certainty evidence that fluoxetine (OR 1.27, 95% CI 0.87, 1.86), paroxetine (OR 1.81, 95% CI 0.85, 3.86), sertraline (OR 3.03, 95% CI 0.60, 15.22), and venlafaxine (OR 13.84, 95% CI 1.79, 106.90) may \"at least slightly\" increase odds of suicide‐related outcomes compared with placebo. There is moderate certainty evidence that venlafaxine probably results in an \"at least slightly\" increased odds of suicide‐related outcomes compared with desvenlafaxine (OR 0.07, 95% CI 0.01, 0.56) and escitalopram (OR 0.06, 95% CI 0.01, 0.56). There was very low certainty evidence regarding other comparisons between antidepressants. Authors' conclusions Overall, methodological shortcomings of the randomised trials make it difficult to interpret the findings with regard to the efficacy and safety of newer antidepressant medications. Findings suggest that most newer antidepressants may reduce depression symptoms in a small and unimportant way compared with placebo. Furthermore, there are likely to be small and unimportant differences in the reduction of depression symptoms between the majority of antidepressants. However, our findings reflect the average effects of the antidepressants, and given depression is a heterogeneous condition, some individuals may experience a greater response. Guideline developers and others making recommendations might therefore consider whether a recommendation for the use of newer generation antidepressants is warranted for some individuals in some circumstances. Our findings suggest sertraline, escitalopram, duloxetine, as well as fluoxetine (which is currently the only treatment recommended for first‐line prescribing) could be considered as a first option. Children and adolescents considered at risk of suicide were frequently excluded from trials, so that we cannot be confident about the effects of these medications for these individuals. If an antidepressant is being considered for an individual, this should be done in consultation with the child/adolescent and their family/caregivers and it remains critical to ensure close monitoring of treatment effects and suicide‐related outcomes (combined suicidal ideation and suicide attempt) in those treated with newer generation antidepressants, given findings that some of these medications may be associated with greater odds of these events. Consideration of psychotherapy, particularly cognitive behavioural therapy, as per guideline recommendations, remains important. Plain language summary Newer generation antidepressants for depression in children and adolescents: a network meta‐analysis How well do newer formulations of antidepressants work for children and adolescents with clinical depression? Children and adolescents (6 to 18 years) with depression (also called ‘major depressive disorder’) experience a range of negative impacts in all areas of their lives and have an increased risk of suicide, suicidal thinking and suicide attempts. Antidepressants have been shown to reduce symptoms of depression, but can also increase the risk of suicide‐related outcomes. Who will be interested in this research? The research in this Cochrane Review will interest: ‐ people who decide policy, and influence decisions about the prescription of antidepressant medicines to children and adolescents; ‐ people who prescribe these medicines to children and adolescents; ‐ children and adolescents with depression; and ‐ those who support and care for them (including their parents and caregivers and clinicians who provide treatment). What did we want to find out? We wanted to find out how well newer formulations (called ‘new generation’) antidepressants work to improve depression in children and adolescents aged 6 to 18 years. New generation antidepressants are those that have been developed recently. They are sometimes referred to as ‘second‐‘ and ‘third‐generation’ antidepressants; they do not include older formulations (tricyclic antidepressants or monoamine oxidase inhibitors). We wanted to know how these antidepressants affect: ‐ symptoms of depression; ‐ recovery: no longer meeting diagnostic criteria for major depressive disorder; ‐ response or remission: scores on a scale indicating an important reduction in depression or no longer experiencing depression; ‐ ability to function in daily life; ‐ suicide‐related outcomes; and ‐ whether they cause any unwanted effects in children and adolescents. What did we do? We searched for studies that tested new generation antidepressants on children or adolescents (or both) who had been diagnosed with a major depressive disorder. We identified 26 such studies. We then assessed the trustworthiness of those studies, and synthesized the findings across the studies. What does the evidence from the review tell us? Most newer antidepressants probably reduce depression symptoms better than a placebo (a 'dummy' treatment that does not contain any medicine but looks identical to the medicine being tested). However, the reduction is small and may not be experienced as important by children and adolescents, their parents and caregivers, or clinicians. When different medications are compared against each other, there may be only small and unimportant differences between most of them for the reduction of symptoms. Our findings reflect what happens on average to individuals, but some individuals may experience a greater response. This might lead to recommendations being made for the use of antidepressants for some individuals in some circumstances. Our findings suggest that sertraline, escitalopram, duloxetine and fluoxetine can be used if medication is being considered. The impact of medication on depression symptoms should be closely monitored by those prescribing the medication, especially as suicide‐related thinking and behaviour may be increased in those taking these medications. Close monitoring of suicide‐related behaviours is vital in those treated with new generation antidepressants. What should happen next? The studies that provided this evidence largely excluded children and adolescents who: ‐ were already thinking about suicide and wanting to take their own lives (i.e. had suicidal ideation); ‐ were self‐harming; ‐ had other mental health conditions; and ‐ had psychosocial difficulties. Future research should aim to understand the impacts of these medicines in children and adolescents with these problems, who are more typical of those who request clinical services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Hetrick, SE; McKenzie, JE; Bailey, AP; Sharma, V; Moller, CI; Badcock, PB; Cox, GR; Merry, SN; Meader, N", "articleTypes": [], "doi": "10.1002/14651858.CD013674.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "7e2bb8f2-58d4-4ced-9a50-4784812b175b", "pmid": "", "title": "Chinese herbal medicine for primary dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Conventional treatment for primary dysmenorrhoea has a failure rate of 20% to 25% and may be contraindicated or not tolerated by some women. Chinese herbal medicine may be a suitable alternative. Objectives To determine the efficacy and safety of Chinese herbal medicine for primary dysmenorrhoea when compared with placebo, no treatment, and other treatment. Search methods The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007), EMBASE (1980 to January 2007), CINAHL (1982 to January 2007), AMED (1985 to January 2007), CENTRAL (The Cochrane Library issue 4, 2006), China National Knowledge Infrastructure (CNKI, 1990 to January 2007), Traditional Chinese Medicine Database System (TCMDS, 1990 to December 2006), and the Chinese BioMedicine Database (CBM, 1990 to December 2006) were searched. Citation lists of included trials were also reviewed. Selection criteria Any randomised controlled trials involving Chinese herbal medicine versus placebo, no treatment, conventional therapy, heat compression, another type of Chinese herbal medicine, acupuncture or massage. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra‐uterine contraceptive device. Data collection and analysis Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Data were combined for meta‐analysis using either Peto odds ratios or relative risk (RR) for dichotomous data or weighted mean difference for continuous data. A fixed‐effect statistical model was used, where suitable. If data were not suitable for meta‐analysis, any available data from the trial were extracted and presented as descriptive data. Main results Thirty‐nine randomised controlled trials involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for Chinese herbal medicine compared to placebo were unclear as data could not be combined (3 RCTs). Chinese herbal medicine resulted in significant improvements in pain relief (14 RCTs; RR 1.99, 95% CI 1.52 to 2.60), overall symptoms (6 RCTs; RR 2.17, 95% CI 1.73 to 2.73) and use of additional medication (2 RCTs; RR 1.58, 95% CI 1.30 to 1.93) when compared to use of pharmaceutical drugs. Self‐designed Chinese herbal formulae resulted in significant improvements in pain relief (18 RCTs; RR 2.06, 95% CI 1.80 to 2.36), overall symptoms (14 RCTs; RR 1.99, 95% CI 1.65 to 2.40) and use of additional medication (5 RCTs; RR 1.58, 95% CI 1.34 to 1.87) after up to three months of follow‐up when compared to commonly used Chinese herbal health products. Chinese herbal medicine also resulted in better pain relief than acupuncture (2 RCTs; RR 1.75, 95% CI 1.09 to 2.82) and heat compression (1 RCT; RR 2.08, 95% CI 2.06 to 499.18). Authors' conclusions The review found promising evidence supporting the use of Chinese herbal medicine for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials. Plain language summary Chinese herbal medicine may help reduce menstrual pain. Dysmenorrhoea is a very common complaint that refers to painful menstrual cramps in abdomen. Primary dysmenorrhoea refers to pain of an unknown cause (i.e. no medical condition is identified). Nonsteroidal anti‐inflammatory drugs or the contraceptive pill have been used successfully for treatment but more women are looking for non‐drug therapies. Chinese herbal medicine has been used for centuries in China and it is currently used in public hospitals in China for the treatment of primary dysmenorrhoea. The review found promising evidence for the use of Chinese herbal medicine in reducing menstrual pain in the treatment of primary dysmenorrhoea, compared to conventional medicine such as NSAIDs and the oral contraceptive pill, acupuncture and heat compression. No significant adverse effects were identified in this review. However the findings should be interpreted with caution due to the generally low methodological quality of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Zhu, X; Proctor, M; Bensoussan, A; Wu, E; Smith, CA", "articleTypes": [], "doi": "10.1002/14651858.CD005288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "7e779df9-a21c-498c-9581-44372b2cf59d", "pmid": "", "title": "Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors", "imported": false, "abstract": "Abstract - Background Poor diet and insufficient physical activity are major risk factors for non‐communicable diseases. Developing healthy diet and physical activity behaviors early in life is important as these behaviors track between childhood and adulthood. Parents and other adult caregivers have important influences on children's health behaviors, but whether their involvement in children's nutrition and physical activity interventions contributes to intervention effectiveness is not known. Objectives • To assess effects of caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors, including those intended to prevent overweight and obesity • To describe intervention content and behavior change techniques employed, drawing from a behavior change technique taxonomy developed and advanced by Abraham, Michie, and colleagues (Abraham 2008; Michie 2011; Michie 2013; Michie 2015) • To identify content and techniques related to reported outcomes when such information was reported in included studies Search methods In January 2019, we searched CENTRAL, MEDLINE, Embase, 11 other databases, and three trials registers. We also searched the references lists of relevant reports and systematic reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of interventions to improve children's dietary intake or physical activity behavior, or both, with children aged 2 to 18 years as active participants and at least one component involving caregivers versus the same interventions but without the caregiver component(s). We excluded interventions meant as treatment or targeting children with pre‐existing conditions, as well as caregiver‐child units residing in orphanages and school hostel environments. Data collection and analysis We used standard methodological procedures outlined by Cochrane. Main results We included 23 trials with approximately 12,192 children in eligible intervention arms. With the exception of two studies, all were conducted in high‐income countries, with more than half performed in North America. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The specific intervention strategies used were not always reported completely. However, based on available reports, the behavior change techniques used most commonly in the child‐only arm were \"shaping knowledge,\" \"comparison of behavior,\" \"feedback and monitoring,\" and \"repetition and substitution.\" In the child + caregiver arm, the strategies used most commonly included additional \"shaping knowledge\" or \"feedback and monitoring\" techniques, as well as \"social support\" and \"natural consequences.\" We considered all trials to be at high risk of bias for at least one design factor. Seven trials did not contribute any data to analyses. The quality of reporting of intervention content varied between studies, and there was limited scope for meta‐analysis. Both validated and non‐validated instruments were used to measure outcomes of interest. Outcomes measured and reported differed between studies, with 16 studies contributing data to the meta‐analyses. About three‐quarters of studies reported their funding sources; no studies reported industry funding. We assessed the quality of evidence to be low or very low. Dietary behavior change interventions with a caregiver component versus interventions without a caregiver component Seven studies compared dietary behavior change interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (mean difference [MD] −0.42%, 95% confidence interval [CI] −1.25 to 0.41, 1 study, n = 207; low‐quality evidence) or from sodium intake (MD −0.12 g/d, 95% CI −0.36 to 0.12, 1 study, n = 207; low‐quality evidence). No trial in this comparison reported data for children's combined fruit and vegetable intake, sugar‐sweetened beverage (SSB) intake, or physical activity levels, nor for adverse effects of interventions. Physical activity interventions with a caregiver component versus interventions without a caregiver component Six studies compared physical activity interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's total physical activity (MD 0.20 min/h, 95% CI −1.19 to 1.59, 1 study, n = 54; low‐quality evidence) or moderate to vigorous physical activity (MVPA) (standard mean difference [SMD] 0.04, 95% CI −0.41 to 0.49, 2 studies, n = 80; moderate‐quality evidence). No trial in this comparison reported data for percentage of children's total energy intake from saturated fat, sodium intake, fruit and vegetable intake, or SSB intake, nor for adverse effects of interventions. Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component Ten studies compared dietary and physical activity interventions with and without a caregiver component. At the end of the intervention, we detected a small positive impact of a caregiver component on children's SSB intake (SMD −0.28, 95% CI −0.44 to −0.12, 3 studies, n = 651; moderate‐quality evidence). We did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (MD 0.06%, 95% CI −0.67 to 0.80, 2 studies, n = 216; very low‐quality evidence), sodium intake (MD 35.94 mg/d, 95% CI −322.60 to 394.47, 2 studies, n = 315; very low‐quality evidence), fruit and vegetable intake (MD 0.38 servings/d, 95% CI −0.51 to 1.27, 1 study, n = 134; very low‐quality evidence), total physical activity (MD 1.81 min/d, 95% CI −15.18 to 18.80, 2 studies, n = 573; low‐quality evidence), or MVPA (MD −0.05 min/d, 95% CI −18.57 to 18.47, 1 study, n = 622; very low‐quality evidence). One trial indicated that no adverse events were reported by study participants but did not provide data. Authors' conclusions Current evidence is insufficient to support the inclusion of caregiver involvement in interventions to improve children's dietary intake or physical activity behavior, or both. For most outcomes, the quality of the evidence is adversely impacted by the small number of studies with available data, limited effective sample sizes, risk of bias, and imprecision. To establish the value of caregiver involvement, additional studies measuring clinically important outcomes using valid and reliable measures, employing appropriate design and power, and following established reporting guidelines are needed, as is evidence on how such interventions might contribute to health equity. Plain language summary Effects of involving parents and other adult caregivers in children's diet and physical activity interventions Review question Does it make a difference if parents or other adult caregivers are involved in interventions to encourage children to eat healthier or be more physically active? Background Diet and physical activity behaviors are important determinants of health. Parents and other adult caregivers have an essential role in shaping children's health habits by controlling availability of and access to healthy foods and opportunities to be active; supporting, encouraging, and role‐modeling healthy behaviors; and adopting supportive feeding styles and practices. For these reasons, it often is argued that parent and caregiver involvement in children's diet and physical activity interventions is important; however, it remains unclear if involvement of parents and caregivers actually provides benefit. Objectives We assessed the effects of involving parents or other adult caregivers in children's healthy eating and physical activity interventions compared to the effects of the same child interventions without a parent or caregiver component. We were particularly interested in understanding effects on children's dietary intake, children's physical activity levels, and adverse effects of interventions. Study characteristics We found 23 studies, published between 1982 and 2019, that implemented diet interventions, physical activity interventions, or combined diet and physical activity interventions with children or adolescents, and evaluated the effects of adding an intervention component involving parents or other adult caregivers. Approximately 12,192 children aged 2 to 18 years were examined. More than half of studies took place in North America, and all but two were conducted in high‐income countries. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The breadth of information provided about intervention content varied between studies. The most commonly used intervention techniques were those aimed at shaping participants' knowledge, such as providing instruction about how to perform a behavior (e.g. dance, cooking lessons). About three‐quarters of studies reported their funding source; no studies reported industry funding. Key results The findings of this review suggest that adding a parent or caregiver component to dietary behavior change interventions or physical activity interventions may make little or no difference to children's dietary intake or physical activity levels. For interventions that target both diet and physical activity behaviors, involving a parent or caregiver probably slightly reduces children's sugar‐sweetened beverage intake by the end of the intervention. We do not know whether any of these types of interventions result in adverse effects because these data are not available. Quality of evidence Overall, the evidence from studies is of low or very low quality, which means that we are uncertain about study results. Currentness of evidence The evidence is current to January 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Morgan, EH; Schoonees, A; Sriram, U; Faure, M; Seguin‐Fowler, RA", "articleTypes": [], "doi": "10.1002/14651858.CD012547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "7e78e43e-c354-4c1d-9b8c-73d1135e206e", "pmid": "", "title": "Pain relief in hysterosalpingography", "imported": false, "abstract": "Abstract - Background Hysterosalpingography (HSG) is a method of testing for tubal patency. However, women struggle to tolerate the procedure, as it is associated with some discomfort. Various pharmacological strategies are available that may reduce pain during the procedure, though there is no consensus as to the best method. Objectives To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing HSG for investigation of subfertility. Search methods This review has drawn on the search strategy developed for the Cochrane Menstrual Disorders and Subfertility Group (MDSG). We searched the following databases to 15 April 2015: MDSG Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO. Selection criteria All identified randomised controlled trials investigating pharmacological interventions for pain relief during HSG were investigated for selection. Data collection and analysis Four review authors independently extracted data. We combined data to calculate mean differences (MDs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I² statistic. We assessed the overall quality of the evidence for the main comparisons using GRADE methods. Main results The search identified 23 trials (1272 women) that were eligible for inclusion into the study. Oral opioid analgesia versus placebo/no treatment There was no evidence of effect for oral opioid analgesia in reducing pain during the procedure (MD −0.91, 95% CI −1.88 to 0.06, 1 study, n = 128, low quality evidence) or more than 30 minutes after the procedure (MD −0.99, 95% CI −1.75 to −0.23, 1 study, n = 128, moderate quality evidence) No studies reported on the effect of oral opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes after the procedure There was insufficient evidence to reach conclusions regarding adverse effects. Intravenous opioid analgesia versus placebo/no treatment There was evidence that intravenous opioids may improve pain relief during the procedure compared to no treatment (MD −3.53, 95% CI −4.29 to −2.77, 1 study, n = 62, moderate quality evidence) No studies reported on the effect of intravenous opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes and more than 30 minutes after the procedure In terms of adverse effects, one trial reported 1/32 participants had apnoea with intravenous remifentanil. Recovery time was nearly 4 minutes longer in the remifentanil group compared to the control. Oral non‐opioid analgesia versus placebo/no treatment There was no evidence of effect for oral non‐opioid analgesia in reducing pain during the procedure (MD −0.13, 95% CI −0.48 to 0.23, 3 studies, n = 133, I² = 61%, low quality evidence), less than 30 minutes after the procedure (MD −0.30, 95% CI −1.03 to 0.43, 2 studies, n = 45, I² = 97%, very low quality evidence), or more than 30 minutes after the procedure (MD −0.36, 95% CI −1.06 to 0.34, 3 studies, n = 133, I² = 58%, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Topical anaesthesia versus placebo/no treatment There was evidence that topical anaesthetics may reduce pain during the procedure (MD −0.63, 95% CI −1.06 to −0.19, 9 studies, n = 613, I² = 66%, low quality evidence). There was no evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD 0.42, 95% CI ‐0.03 to 0.86, 5 studies, n = 373, I² = 59%, very low quality evidence). There was evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain more than 30 minutes after the procedure (MD −1.38, 95% CI ‐3.44 to −0.68, 2 studies, n = 166, I² = 92%, very low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Locally injected anaesthesia versus placebo/no treatment There was evidence of effect that locally injected anaesthetic can reduce pain during the procedure (MD −1.31, 95% CI −1.55 to −1.07, 2 studies, n = 125, I² = 0%, very low quality evidence). There was no evidence of effect for locally injected anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD −1.31, 95% CI −2.14 to −0.49, 2 studies, n = 125, I² = 46%, low quality evidence). No studies were included into the analysis of the effect of locally injected anaesthesia, when injected prior to the procedure, in reducing pain more than 30 minutes after the procedure. There was insufficient evidence to reach conclusions regarding adverse effects. Any analgesic versus any other analgesic There was no evidence of a difference between the groups when oral non‐opioid analgesia was compared to opioid analgesia for pain relief during the procedure (MD 1.10, 95% CI −0.26 to 2.46, 1 study, n = 91, low quality evidence); less than 30 minutes following the procedure (MD −0.30, 95% CI −1.00 to 0.40, 1 study, n = 91, low quality evidence); and more than 30 minutes following the procedure (MD −0.60, 95% CI −1.56 to 0.36, 1 study, n = 91, low quality evidence). Topical anaesthetics were found to be more effective than paracervical block for pain relief during HSG (MD −2.73, 95% CI −3.86 to −1.60, 1 study, n = 20, moderate quality evidence). This benefit did not extend to within 30 minutes following HSG (MD −1.03, 95% CI −2.52 to 0.46, 1 study, n = 20, low quality evidence); or 30 minutes or more after HSG (MD 0.31, 95% CI −0.87 to 1.49, 1 study, n = 20, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Authors' conclusions Topical anaesthetic applied before the procedure may be associated with effective pain relief during HSG, though the quality of this evidence is low. Intravenous opioids may also be effective in pain relief, though this must be weighed against their side effects and their effects on the recovery time. There is insufficient evidence to draw conclusions on the efficacy of other analgesics for HSG, or to reach any other conclusions regarding adverse effects. Plain language summary Drug treatments for pain relief in hysterosalpingography Review question: Which pain‐killers are effective at reducing the discomfort experienced with hysterosalpingography? Background: Hysterosalpingography (HSG) is a test used in investigating infertility in women. HSG involves a dye being introduced into the uterus and the connecting tubes, which enables them to be visualised using an x‐ray, allowing the clinician to assess how open the connecting tubes are. This can be a painful procedure. There is disagreement regarding the best form of pain relief during the procedure. Study characteristics: We identified 19 randomised controlled trials that compared a specific drug treatment to a placebo/no treatment. Four trials compared two different drug treatments to establish if one was better. All studies took place in a clinical setting. Age of participants ranged from 18 to 42 years. Studies took place in India, Australia, United Kingdom, United States of America, Turkey, Israel, Netherlands, Italy, Iran, Nigeria, Spain, Brazil, and Belgium (1272 women in total). We included 15 of these trials in a meta‐analysis. The remaining eight trials, while eligible for inclusion, did not have data in a format that could be entered into meta‐analysis (seven compared a specific drug to a placebo/no treatment, one compared two different drug treatments). The evidence is current to April 2015. Key results : Topical anaesthetic was associated with a mild reduction in the pain experienced during HSG (low quality evidence). However, it has no effect on the discomfort experienced by participants following the procedure (very low quality evidence). Locally injected anaesthetics, on the other hand, were not associated with any benefit. Only one study investigated this (moderate quality evidence). One study directly compared locally injected anaesthetics to topical anaesthetics. This study found that topical anaesthesia was associated with improved pain relief during the procedure (moderate quality evidence) No oral drug was found to be effective in reducing pain experienced during the procedure. This was true for both opioid (low quality evidence) and non‐opioid (low quality evidence) analgesia. One trial however reported that tramadol may be of benefit in reducing the pain experienced more than 30 minutes after the procedure (moderate quality evidence). Quality of the evidence: The quality of the combined results was mainly downgraded for two reasons: 1) studies having methods that may be at risk of bias/inaccuracy; 2) substantially different conclusions between studies that investigate the same drug. The included studies did not report side effects in large enough numbers to make definitive conclusions regarding the side effects of particular drugs during the procedure. Conclusions: Only topical anaesthetics and intravenous opioids were found to be of benefit in reducing pain during the procedure, though the quality of this evidence is low to moderate, and there is no evidence that these are effective at relieving pain following the procedure. There is insufficient evidence for other drug treatments in reducing pain during HSG. There was insufficient evidence to reach any conclusions regarding adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hindocha, A; Beere, L; O'Flynn, H; Watson, A; Ahmad, G", "articleTypes": [], "doi": "10.1002/14651858.CD006106.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "7e935984-aec2-46a2-a847-29fffbe12534", "pmid": "", "title": "Antithyroid drug regimen for treating Graves' hyperthyroidism", "imported": false, "abstract": "Abstract - Background Antithyroid drugs are widely used in the therapy of hyperthyroidism. There are wide variations in the dose, regimen or duration of treatment used by health professionals. Objectives To assess the effects of dose, regimen and duration of antithyroid drug therapy for Graves' hyperthyroidism. Search methods We searched seven databases and reference lists. Selection criteria Randomised and quasi‐randomised trials of antithyroid medication for Graves' hyperthyroidism. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Pooling of data for primary outcomes, and select exploratory analyses were undertaken. Main results Twenty‐six randomised trials involving 3388 participants were included. Overall the quality of trials, as reported, was poor. None of the studies investigated incidence of hypothyroidism, changes in weight, health‐related quality of life, ophthalmopathy progression or economic outcomes. Four trials examined the effect of duration of therapy on relapse rates, and when using the titration regimen 12 months was superior to six months, but there was no benefit in extending treatment beyond 18 months. Twelve trials examined the effect of block‐replace versus titration block‐regimens. The relapse rates were similar in both groups at 51% in the block‐replace group and 54% in the titration block‐group (OR 0.86, 95% confidence interval (CI) 0.68 to1.08) though adverse effects (rashes (10% versus 6%) and withdrawing due to side effects (16% versus 9%)) were significantly higher in the block‐replace group. Three studies considered the addition of thyroxine with continued low dose antithyroid therapy after initial therapy with antithyroid drugs. There was significant heterogeneity between the studies and the difference between the two groups was not significant (OR 0.58, 95% CI 0.05 to 6.21). Four studies considered the addition of thyroxine alone after initial therapy with antithyroid drugs. There was no significant difference in the relapse rates between the groups after 12 months follow‐up (OR 1.15, 95% CI 0.79 to 1.67). Two studies considered the addition of immunosuppressive agents. The results which were in favour of the interventions would need to be validated in other populations. Authors' conclusions The evidence suggests that the optimal duration of antithyroid drug therapy for the titration regimen is 12 to 18 months. The titration (low dose) regimen had fewer adverse effects than the block‐replace (high dose) regimen and was no less effective. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Immunosuppressive therapies need further evaluation. Plain language summary Antithyroid drug regimen for treating Graves' hyperthyroidism People who have Graves' hyperthyroidism have thyroid glands which are releasing too much thyroid hormone. This can cause goitres (swelling in the neck around the thyroid gland), sweating, bowel or menstrual problems, and other, especially eye symptoms (ophthalmopathy). Treatments include anti‐thyroid drugs, surgery or radiation to reduce thyroid tissue. There are several choices to be made when considering the drug treatment of Graves' hyperthyroidism including the choice of drug, dose, duration of therapy, addition of thyroid hormone (thyroxine) and when to discontinue therapy. The antithyroid drugs which were used in the included randomised controlled trials (RCTs) comprised carbimazole, propylthiouracil and methimazole. Twenty‐six RCTs involving 3388 participants were identified. The majority of participants in all the studies were female (83% in the studies reporting sex distribution). The mean age was 40 years. The duration of follow up was between two to five years in eleven trials. In high dose ('block‐replace') versus low dose ('titration') studies the duration of therapy was six months in two studies, 18 months in four studies and 12 months in the remaining trials. The main outcome was the relapse rate of hyperthyroidism over one year after completion of drug treatment and this was the primary outcome in all the studies assessed. There were no deaths reported in any of the studies. None of the studies detailed incidence of hypothyroidism, changes in weight during the course of therapy, health‐related quality of life, ophthalmopathy progression or economic outcomes. The evidence (based on four studies) suggests that the optimal duration of antithyroid drug therapy for the low dose regimen is 12 to 18 months. The low dose regimen had fewer adverse effects than the high dose regimen and was no less effective in trials (based on 12 trials) of equal duration. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Studies using immunosuppressive agents need further validation of safety and efficacy in controlled trials among different populations. Data regarding side effects and number of participants withdrawn from therapy due to side effects were available in seven studies. The number of participants reporting rashes was significantly higher in the high versus low dose group (10% versus 6%). The number of participants withdrawing due to side effects were also significantly higher in the high versus low dose group (16% versus 9%).", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Abraham, P; Avenell, A; McGeoch, SC; Clark, LF; Bevan, JS", "articleTypes": [], "doi": "10.1002/14651858.CD003420.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "7ea490de-5cf0-40b3-b71a-9f72e7927f27", "pmid": "", "title": "Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants)", "imported": false, "abstract": "Abstract - Background 'Immediate' implants are placed in dental sockets just after tooth extraction. 'Immediate‐delayed' implants are those implants inserted after weeks up to about a couple of months to allow for soft tissue healing. 'Delayed' implants are those placed thereafter in partially or completely healed bone. The potential advantages of immediate implants are that treatment time can be shortened and that bone volumes might be partially maintained thus possibly providing good aesthetic results. The potential disadvantages are an increased risk of infection and failures. After implant placement in postextractive sites, gaps can be present between the implant and the bony walls. It is possible to fill these gaps and to augment bone simultaneously to implant placement. There are many techniques to achieve this but it is unclear when augmentation is needed and which could be the best augmentation technique. Objectives To evaluate success, complications, aesthetics and patient satisfaction between 'immediate', 'immediate‐delayed' and 'delayed' implants. To evaluate whether and when augmentation procedures are necessary and which is the most effective technique. Search methods The Cochrane Oral Health Group's Trials Register (to 2 June 2010), CENTRAL ( The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 ‐ 2 June 2010) and EMBASE via OVID (1980 ‐ 2 June 2010) were searched. Several dental journals were handsearched. Selection criteria Randomised controlled trials (RCTs) comparing immediate, immediate‐delayed, and delayed implants, or comparing various bone augmentation procedures around the inserted implants, reporting the outcome of the interventions to at least 1 year after functional loading. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Trial authors were contacted for any missing information. Results were expressed as random‐effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). The statistical unit of the analysis was the patient. Main results Fourteen eligible RCTs were identified but only seven trials could be included. Four RCTs evaluated implant placement timing. Two RCTs compared immediate versus delayed implants in 126 patients and found no statistically significant differences. One RCT compared immediate‐delayed versus delayed implants in 46 patients. After 2 years patients in the immediate‐delayed group perceived the time to functional loading significantly shorter, were more satisfied and independent blinded assessor judged the level of the perimplant marginal mucosa in relation to that of the adjacent teeth as more appropriate (RR = 1.68; 95% CI 1.04 to 2.72). These differences disappeared 5 years after loading but significantly more complications occurred in the immediate‐delayed group (RR = 4.20; 95% CI 1.01 to 17.43). One RCT compared immediate with immediately delayed implants in 16 patients for 2 years and found no differences. Three RCTs evaluated different techniques of bone grafting for implants immediately placed in extraction sockets. No statistically significant difference was observed when evaluating whether autogenous bone is needed in postextractive sites (1 trial with 26 patients) or which was the most effective augmentation technique (2 trials with 56 patients). Authors' conclusions There is insufficient evidence to determine possible advantages or disadvantages of immediate, immediate‐delayed or delayed implants, therefore these preliminary conclusions are based on few underpowered trials often judged to be at high risk of bias. There is a suggestion that immediate and immediate‐delayed implants may be at higher risks of implant failures and complications than delayed implants on the other hand the aesthetic outcome might be better when placing implants just after teeth extraction. There is not enough reliable evidence supporting or refuting the need for augmentation procedures at immediate implants placed in fresh extraction sockets or whether any of the augmentation techniques is superior to the others. Plain language summary Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants) Dental implants can be placed in sockets just after tooth extraction (immediate implants) or after a couple of weeks up to a couple of months (immediate‐delayed implants) or thereafter (delayed implants). This review looked at which was the best time to place dental implants and whether it would be advantageous to augment sites with gaps present at implant placement. It also tried to determine the most effective bone augmentation procedure. The seven identified studies included too few patients to answer the questions. Four studies evaluated which is the best time to place implants. One study evaluated whether bone grafting is advantageous at implant placement and two studies evaluated which are the best grafting techniques. There is currently too little evidence to draw any reliable conclusions, however, the aesthetic outcome could be slightly better when placing implants early after tooth extraction, though early placed implants might be at a higher risk of failure. There is not enough evidence supporting or refusing the need of bone augmentation when extracted teeth are immediately replaced with dental implants, nor it is known whether any augmentation procedure is better than the others. Bone substitutes (anorganic bovine bone) can be used instead of self generated (autogenous) bone graft.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Esposito, M, Grusovin, MG, Polyzos, IP, Felice, P, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD005968.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.794Z" }, { "id": "7eaa5e9e-0e51-4a11-8d13-a5c914b1577f", "pmid": "", "title": "Omega‐3 fatty acid addition during pregnancy", "imported": false, "abstract": "Abstract - Background Higher intakes of foods containing omega‐3 long‐chain polyunsaturated fatty acids (LCPUFA), such as fish, during pregnancy have been associated with longer gestations and improved perinatal outcomes. This is an update of a review that was first published in 2006. Objectives To assess the effects of omega‐3 LCPUFA, as supplements or as dietary additions, during pregnancy on maternal, perinatal, and neonatal outcomes and longer‐term outcomes for mother and child. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (16 August 2018), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing omega‐3 fatty acids (as supplements or as foods, stand‐alone interventions, or with a co‐intervention) during pregnancy with placebo or no omega‐3, and studies or study arms directly comparing omega‐3 LCPUFA doses or types. Trials published in abstract form were eligible for inclusion. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, assessed risk of bias in trials and assessed quality of evidence for prespecified birth/infant, maternal, child/adult and health service outcomes using the GRADE approach. Main results In this update, we included 70 RCTs (involving 19,927 women at low, mixed or high risk of poor pregnancy outcomes) which compared omega‐3 LCPUFA interventions (supplements and food) compared with placebo or no omega‐3. Overall study‐level risk of bias was mixed, with selection and performance bias mostly at low risk, but there was high risk of attrition bias in some trials. Most trials were conducted in upper‐middle or high‐income countries; and nearly half the trials included women at increased/high risk for factors which might increase the risk of adverse maternal and birth outcomes. Preterm birth < 37 weeks (13.4% versus 11.9%; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.81 to 0.97; 26 RCTs, 10,304 participants; high‐quality evidence) and early preterm birth < 34 weeks (4.6% versus 2.7%; RR 0.58, 95% CI 0.44 to 0.77; 9 RCTs, 5204 participants; high‐quality evidence) were both lower in women who received omega‐3 LCPUFA compared with no omega‐3. Prolonged gestation > 42 weeks was probably increased from 1.6% to 2.6% in women who received omega‐3 LCPUFA compared with no omega‐3 (RR 1.61 95% CI 1.11 to 2.33; 5141 participants; 6 RCTs; moderate‐quality evidence ). For infants, there was a possibly reduced risk of perinatal death (RR 0.75, 95% CI 0.54 to 1.03; 10 RCTs, 7416 participants; moderate‐quality evidence: 62/3715 versus 83/3701 infants) and possibly fewer neonatal care admissions (RR 0.92, 95% CI 0.83 to 1.03; 9 RCTs, 6920 participants; moderate‐quality evidence ‐ 483/3475 infants versus 519/3445 infants). There was a reduced risk of low birthweight (LBW) babies (15.6% versus 14%; RR 0.90, 95% CI 0.82 to 0.99; 15 trials, 8449 participants; high‐quality evidence); but a possible small increase in large‐for‐gestational age (LGA) babies (RR 1.15, 95% CI 0.97 to 1.36; 6 RCTs, 3722 participants; moderate‐quality evidence, for omega‐3 LCPUFA compared with no omega‐3. Little or no difference in small‐for‐gestational age or intrauterine growth restriction (RR 1.01, 95% CI 0.90 to 1.13; 8 RCTs, 6907 participants; moderate‐quality evidence) was seen. For the maternal outcomes , there is insufficient evidence to determine the effects of omega‐3 on induction post‐term (average RR 0.82, 95% CI 0.22 to 2.98; 3 trials, 2900 participants; low‐quality evidence), maternal serious adverse events (RR 1.04, 95% CI 0.40 to 2.72; 2 trials, 2690 participants; low‐quality evidence), maternal admission to intensive care (RR 0.56, 95% CI 0.12 to 2.63; 2 trials, 2458 participants; low‐quality evidence), or postnatal depression (average RR 0.99, 95% CI 0.56 to 1.77; 2 trials, 2431 participants; low‐quality evidence). Mean gestational length was greater in women who received omega‐3 LCPUFA (mean difference (MD) 1.67 days, 95% CI 0.95 to 2.39; 41 trials, 12,517 participants; moderate‐quality evidence), and pre‐eclampsia may possibly be reduced with omega‐3 LCPUFA (RR 0.84, 95% CI 0.69 to 1.01; 20 trials, 8306 participants; low‐quality evidence). For the child/adult outcomes, very few differences between antenatal omega‐3 LCPUFA supplementation and no omega‐3 were observed in cognition, IQ, vision, other neurodevelopment and growth outcomes, language and behaviour (mostly low‐quality to very low‐quality evidence). The effect of omega‐3 LCPUFA on body mass index at 19 years (MD 0, 95% CI ‐0.83 to 0.83; 1 trial, 243 participants; very low‐quality evidence) was uncertain. No data were reported for development of diabetes in the children of study participants. Authors' conclusions In the overall analysis, preterm birth < 37 weeks and early preterm birth < 34 weeks were reduced in women receiving omega‐3 LCPUFA compared with no omega‐3. There was a possibly reduced risk of perinatal death and of neonatal care admission , a reduced risk of LBW babies; and possibly a small increased risk of LGA babies with omega‐3 LCPUFA. For our GRADE quality assessments, we assessed most of the important perinatal outcomes as high‐quality (e.g. preterm birth) or moderate‐quality evidence (e.g. perinatal death). For the other outcome domains (maternal, child/adult and health service outcomes) GRADE ratings ranged from moderate to very low, with over half rated as low. Reasons for downgrading across the domain were mostly due to design limitations and imprecision. Omega‐3 LCPUFA supplementation during pregnancy is an effective strategy for reducing the incidence of preterm birth, although it probably increases the incidence of post‐term pregnancies. More studies comparing omega‐3 LCPUFA and placebo (to establish causality in relation to preterm birth) are not needed at this stage. A further 23 ongoing trials are still to report on over 5000 women, so no more RCTs are needed that compare omega‐3 LCPUFA against placebo or no intervention. However, further follow‐up of completed trials is needed to assess longer‐term outcomes for mother and child, to improve understanding of metabolic, growth and neurodevelopment pathways in particular, and to establish if, and how, outcomes vary by different types of omega‐3 LCPUFA, timing and doses; or by characteristics of women. Plain language summary Omega‐3 fatty acid addition during pregnancy What is the issue? Do omega‐3 long chain polyunsaturated fatty acids (LCPUFA) taken during pregnancy ‐ either as supplements or as dietary additions in food (such as some types of fish) ‐ improve health outcomes for babies and their mothers? This is an update of a Cochrane Review that was first published in 2006. Why is this important? Preterm birth (babies born before 37 weeks pregnancy (gestation)) is a leading cause of disability or death in the first five years of life. Fish and fish oil contain omega‐3 LCPUFA (particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)) and have been associated with longer pregnancies. So it is suggested that additional omega‐3 LCPUFAs in pregnancy may reduce the number of babies born preterm and may improve outcomes for children and mothers. However, many pregnant women do not eat fish very often. Encouraging pregnant women to eat fatty fish (which generally have low toxin levels) or to use omega‐3 LCPUFA supplements may improve children’s and women's health. This is an update of a Cochrane Review that was first published in 2006. What evidence did we find? We searched for evidence in August 2018 and found 70 randomised controlled trials (RCTs; this type of trial provides the most reliable results) (involving 19,927 women). Most trials evaluated a group of women who received omega‐3 LCPUFA and compared them with a group of women who received something that looked like omega‐3 LCPUFA but did not contain it (placebo) or received no omega‐3. The trials were mostly undertaken in upper‐middle or high‐income countries. Some studies included women at increased risk of preterm birth. The quality of the evidence from the included studies ranged from high to very low; this affected the certainty of the findings for different outcomes. We found the incidence of preterm birth (before 37 weeks) and very preterm birth (before 34 weeks) was lower in women who received omega‐3 LCPUFA compared with no additional omega‐3. There were also fewer babies with low birthweight. However, omega‐3 LCPUFA probably increased the incidence of pregnancies continuing beyond 42 weeks, although there was no difference identified in induction of labour for post‐term pregnancies. The risk of the baby dying or being very sick and going to neonatal intensive care may be lower with omega‐3 LCPUFA compared with no omega‐3. We did not see any differences between groups for serious adverse events for mothers or in postnatal depression. Very few differences between the omega‐3 LCPUFA groups and no omega‐3 groups were observed in child development and growth. Eleven trials reported that they had received industry funding. When we omitted these trials from the main outcomes (such as preterm birth and very preterm birth) it made very little, or no difference, to the results. What does this mean? Increasing omega‐3 LCPUFA intake during pregnancy, either through supplements or in foods, may reduce the incidence of preterm birth (before 37 weeks and before 34 weeks) and there may be less chance of having a baby with a low birthweight. Women who take omega‐3 LCPUFA supplements during pregnancy may also be more likely to have longer pregnancies. More studies are underway and their results will be included in a further update of this review. Future studies could consider if and how outcomes may vary in different populations of women, and could test different ways of increasing omega‐3 LCPUFA during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Middleton, P; Gomersall, JC; Gould, JF; Shepherd, E; Olsen, SF; Makrides, M", "articleTypes": [], "doi": "10.1002/14651858.CD003402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "7ec19f71-ad65-4ad6-98da-ead04354c33d", "pmid": "", "title": "Serenoa repens for the treatment of lower urinary tract symptoms due to benign prostatic enlargement", "imported": false, "abstract": "Abstract - Background Benign prostatic hyperplasia (BPH) is a non‐malignant enlargement of the prostate, which can lead to obstructive and irritative lower urinary tract symptoms (LUTS). The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS associated with BPH is common. The extract of the berry of the American saw palmetto or dwarf palm plant, Serenoa repens (SR), which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of BPH. Objectives To assess the effects of Serenoa repens in the treatment of men with LUTS consistent with BPH. Search methods We performed a comprehensive search of multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to 16 September 2022, with no restrictions on language or publication status. Selection criteria We included randomized controlled trials of participants with BPH who were treated with Serenoa repens or placebo/no treatment. Data collection and analysis Two review authors independently assessed studies for inclusion at each stage and undertook data extraction and risk of bias assessment and GRADE assessment of the certainty of the evidence. We considered review outcomes measured up to 12 months after randomization as short term, and beyond 12 months as long term. Our main outcomes included urologic symptom scores, quality of life, and adverse events. Main results For this update, we narrowed the review question to only comparisons with placebo. We included 27 studies (of which 9 were new) involving a total of 4656 participants, 19 studies comparing Serenoa repens with placebo, and 8 studies comparing Serenoa repens in combination with other phytotherapeutic agents versus placebo. Most studies included men aged > 50 (mean age range 52 to 68) with moderate urologic symptoms (International Prostate Symptom Score [IPSS] range 8 to 19). Ten studies were funded by the pharmaceutical industry; two studies were funded by government agencies; and the remaining studies did not specify funding sources. Serenoa repens versus placebo or no intervention Results for this comparison are based on predefined sensitivity analyses limited to studies at low risk of bias. Serenoa repens results in little to no difference in urologic symptoms at short‐term follow‐up (3 to 6 months; IPSS score range 0 to 35, higher scores indicate worse symptoms; mean difference (MD) −0.90, 95% confidence interval (CI) −1.74 to −0.07; I 2 = 68%; 9 studies, 1681 participants; high‐certainty evidence). Serenoa repens results in little to no difference in the quality of life at short‐term follow‐up (3 to 6 months; IPSS quality of life domain range 0 to 6, higher scores indicate worse quality of life; MD −0.20, 95% CI −0.40 to −0.00; I 2 = 39%; 5 studies, 1001 participants; high‐certainty evidence). Serenoa repens probably results in little to no difference in adverse events (1 to 17 months; risk ratio (RR) 1.01, 95% CI 0.77 to 1.31; I 2 = 18%; 12 studies, 2399 participants; moderate‐certainty evidence). Based on 164 cases per 1000 men in the placebo group, this corresponds to 2 more (38 fewer to 51 more) per 1000 men in the Serenoa repens group. Serenoa repens results in little to no difference in urologic symptoms at long‐term follow‐up (12 to 17 months, IPSS score, MD 0.07, 95% CI −0.75 to 0.88; I 2 = 34%; 3 studies, 898 participants; high‐certainty evidence). Serenoa repens results in little to no difference in quality of life at long‐term follow‐up (12 to 17 months, IPSS quality of life, MD −0.11, 95% CI −0.41 to 0.19; I 2 = 65%; 3 studies, 882 participants; high‐certainty evidence). There were no data on long‐term adverse events for this comparison. Serenoa repens in combination with other phytotherapy versus placebo or no intervention Different phytotherapeutic agents that include Serenoa repens may result in little to no difference in urologic symptoms compared to placebo at short‐term follow‐up (12 to 24 weeks, IPSS score, MD −2.41, 95% CI −4.54 to −0.29; I 2 = 67%; 4 studies, 460 participants; low‐certainty evidence). We are very uncertain about the effects of these agents on quality of life (very low‐certainty evidence). These agents may result in little to no difference in the occurrence of adverse events; however, the CIs included substantial benefits and harms (12 to 48 weeks, RR 0.91, 95% CI 0.58 to 1.41; I 2 = 0%; 4 studies, 481 participants; low‐certainty evidence). Based on 132 cases per 1000 men in the placebo group, this corresponds to 12 fewer (55 fewer to 54 more) per 1000 men in the combined phytotherapeutic agents with Serenoa repens group. Authors' conclusions Serenoa repens alone provides little to no benefits for men with lower urinary tract symptoms due to benign prostatic enlargement. There is more uncertainty about the role of Serenoa repens in combination with other phytotherapeutic agents. Plain language summary Serenoa repens for benign prostatic hyperplasia Review question Does Serenoa repens alone or in combination with other phytotherapeutic agents improve symptoms in men with benign prostatic enlargement? Background An enlarged prostate may cause bothersome urinary tract symptoms, such as having to urinate often during the day or night, having a weak stream, and the feeling of not completely emptying the bladder. Besides other common drug interventions, using plants and herbs (phytotherapy) is common and has been growing steadily in most Western countries. The extract of the berry of the American saw palmetto, or dwarf palm plant, Serenoa repens , which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of this condition. Study characteristics We found 27 studies with 4656 men comparing Serenoa repens alone or in combination with other herbal products to a placebo (participants are made to believe they received treatment when in fact they did not). Most studies included men over 50 with moderate symptoms. Ten studies were funded by pharmaceutical organizations; two studies received government funding; and the remaining studies did not specify funding sources. Key results Based on the most trustworthy studies, Serenoa repens alone results in little to no difference in urinary tract symptoms or quality of life compared to placebo at three to six months. This treatment is also likely not associated with adverse events. Results were similar at 12 to 17 months. Serenoa repens in combination with other herbal products may result in little to no difference in urinary tract symptoms, but there is more uncertainty about effects on quality of life and adverse events. The findings of this review are current to 16 September 2022. Certainty of the evidence The certainty of the evidence is primarily high or moderate for Serenoa repens alone, but low for Serenoa repens in combination with other agents, meaning our confidence in the results is high, moderate, or low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Franco, JVA, Trivisonno, L, Sgarbossa, NJ, Alvez, GA, Fieiras, C, Escobar Liquitay, CM, Jung, JH", "articleTypes": [], "doi": "10.1002/14651858.CD001423.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.745Z" }, { "id": "7f08e7dc-3e8f-42b9-a0a7-6e0c49f1ae5b", "pmid": "", "title": "Optimisation of antiretroviral therapy in HIV‐infected children under 3 years of age", "imported": false, "abstract": "Abstract - Background In the absence of antiretroviral therapy (ART), over 50% of HIV‐infected infants progress to AIDS and death by 2 years of age. However, there are challenges to initiation of ART in early life, including the possibility of drug resistance in the context of prevention of mother‐to‐child transmission (PMTCT) programs, a paucity of drug choices , uncertain dosing for some medications and long‐term toxicities. Key management decisions include when to start ART, what regimen to start, and whether and when to substitute drugs or interrupt therapy. This review, an update of a previous review, aims to summarize the currently available evidence on this topic and inform the ART management in HIV‐infected children less than 3 years of age. Objectives To evaluate 1) when to start ART in young children (less than 3 years); 2) what ART to start with, comparing first‐line non‐nucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI)‐based regimens; and 3) whether alternative strategies should be used to optimize antiretroviral treatment in this population: induction (initiation with 4 drugs rather than 3 drugs) followed by maintenance ART, interruption of ART and substitution of PI with NNRTI drugs once virological suppression is achieved on a PI‐based regimen. Search methods Search methods We searched for published studies in the Cochrane HIV/AIDS Review Group Trials Register, The Cochrane Library, Pubmed, EMBASE and CENTRAL. We screened abstracts from relevant conference proceedings and searched for unpublished and ongoing trials in clinical trial registries (ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform). Selection criteria We identified RCTs that recruited perinatally HIV‐infected children under 3 years of age without restriction of setting. We rejected trials that did not include children less than 3 years of age, did not provide stratified outcomes for those less than 3 years or did not evaluate either timing of ART initiation, choice of drug regimen or treatment switch/interruption strategy. Data collection and analysis Two reviewers independently applied study selection criteria, assessed study quality and extracted data. Effects were assessed using the hazard ratio (HR) for time‐to‐event outcomes, relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes. Main results A search of the databases identified a total of 735 unique, previously unreviewed studies, of which 731 were excluded to leave 4 new studies to incorporate into the review. Four additional studies were identified in conference proceedings, for a total of 8 studies addressing when to start treatment (n=2), what to start (n=3), whether to substitute lopinavir/ritonavir (LPV/r) with nevirapine (NVP) (n=1), whether to use an induction‐maintenance ART strategy (n=1) and whether to interrupt treatment (n=1). Treatment initiation in asymptomatic infants with good immunological status was associated with a 75% reduction (HR=0.25; 95%CI 0.12‐0.51; p=0.0002) in mortality or disease progression in the one trial with sufficient power to address this question. In a smaller pilot trial, median CD4 cell count was not significantly different between early and deferred treatment groups 12 months after ART. Regardless of previous exposure to nevirapine for PMTCT, the hazard for treatment failure at 24 weeks was 1.79 (95%CI 1.33, 2.41) times higher in children starting ART with a NVP���based regimen compared to those starting with a LPV/r‐based regimen (p=0.0001) with no clear difference in the effect observed for children younger or older than 1 year. The hazard for virological failure at 24 weeks was overall 1.84 (95%CI 1.29, 2.63) times higher for children starting ART with a NVP‐based regimen compared to those starting with a LPV/r‐based regimen (p=0.0008) with a larger difference in time to virological failure (or death) between the NVP and LPV/r‐based regimens when ART was initiated in the first year of life. Infants starting a LPV/r regimen and achieving sustained virological suppression who then substituted LPV/r with NVP after median 9 months on LPV/r were less likely to develop virological failure (defined as at least one VL greater than 50 copies/mL) compared with infants who started and stayed on LPV/r (HR=0.62, 95%CI 0.41, 0.92, p=0.02). However the hazard for confirmed failure at a higher viral load (>1000 copies/mL) was greater among children who switched to NVP compared to those who remained on LPV/r (HR=10.19, 95% CI 2.36, 43.94, p=0.002). Children undergoing an induction‐maintenance ART approach with a 4‐drug NNRTI‐based regimen for 36 weeks, followed by 3‐drug ART, had significantly greater CD4 rise than children receiving a standard 3‐drug NNRTI‐based ART at 36 weeks (mean difference 1.70 [95%CI 0.61, 2.79] p=0.002) and significantly better viral load response at 24 weeks (OR 1.99 [95%CI 1.09, 3.62] p=0.02). However, the immunological and virological benefits were short‐term. The one trial of treatment interruption that compared children initiating continuous ART from infancy with children interrupting ART was terminated early because the duration of treatment interruption was less than 3 months in most infants. Children interrupting treatment had similar growth and occurrence of serious adverse events as those in the continuous arm. Authors' conclusions ART initiation in asymptomatic children under 1 year of age reduces morbidity and mortality, but it remains unclear whether there are clinical benefits to starting ART in asymptomatic children diagnosed with HIV infection between 1‐3 years. The available evidence shows that a LPV/r‐based first‐line regimen is more efficacious than a NVP‐based regimen, regardless of PMTCT exposure status. New formulations of LPV/r are urgently required to enable new WHO recommendations to be implemented. An alternative approach to long‐term LPV/r is substituting LPV/r with NVP once virological suppression is achieved. This strategy looked promising in the one trial undertaken, but may be difficult to implement in the absence of routine viral load testing. A 4‐drug induction‐maintenance approach showed short‐term virological and immunological benefits during the induction phase but, in the absence of sustained benefits, is not recommended as a routine treatment strategy. Treatment interruption following early ART initiation in infancy was challenging for children who were severely immunocompromised in the context of poor clinical immunological condition at ART initiation due to the short duration of interruption, and is therefore not practical in ART treatment programmes where close monitoring is not feasible. Plain language summary Using antiretroviral drugs to treat children under 3 years old who have HIV infection Children under 3 years of age who have HIV infection have a high risk of dying without antiretroviral therapy (ART). However, treatment in this age group is challenging because there are high levels of virus in the blood and few suitable drug choices. Results from this systematic review show that ART soon after birth is preferable to delaying treatment, because infants are less likely to die or become sick. Starting a first‐line treatment regimen that includes lopinavir/ritonavir rather than nevirapine is preferable, because infants and young children are less likely to have to stop treatment, whether or not they had previously been exposed to nevirapine. However, lopinavir/ritonavir is more expensive than nevirapine. It is also currently only available as an inconvenient liquid, which tastes bitter and has to be refrigerated, making it challenging to implement in all parts of the world. While waiting for better formulations to become available, it may be possible to switch from lopinavir/ritonavir to nevirapine once the HIV virus levels become undetectable. However, based on the evidence currently available, a viral load test would be required to identify those children who could safely substitute lopinavir/ritonavir with nevirapine. Viral loads are expensive and not widely available in most countries in sub‐Saharan Africa. An alternative treatment approach is to give a stronger drug combination (four different drugs together) when treatment is first started, then reduce down to three drugs after a short while. However, this strategy did not appear to have long‐term benefits. A 'treatment interruption' strategy, in which infants start ART soon after birth but then stop medication after 1‐2 years, is difficult to implement. Children stopping ART need to restart it very quickly to prevent them becoming sick, and monitoring a child off treatment is challenging in settings with few resources.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Penazzato, M; Prendergast, AJ; Muhe, LM; Tindyebwa, D; Abrams, E", "articleTypes": [], "doi": "10.1002/14651858.CD004772.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "7f1ba39a-76e7-4c48-a307-57199260ffe7", "pmid": "", "title": "Vitamin B12 supplementation for growth, development, and cognition in children", "imported": false, "abstract": "Abstract - Rationale Vitamin B 12 deficiency is an important public health problem in children, and has been associated with anaemia and impaired growth, cognition, and development. Vitamin B 12 deficiency may develop in children due to lower content in breast milk, low dietary intake, and as requirements increase with age. Vitamin B 12 supplementation may confer benefits to child growth and development, due to its role in DNA synthesis and methylation, red blood cell formation, and folate metabolism. However, no systematic reviews have been conducted to examine the effects of vitamin B 12 supplementation in children. Objectives To determine the effects of vitamin B 12 supplementation on growth, development, and cognition in children less than 12 years of age. Search methods We searched CENTRAL, MEDLINE, Embase, 12 other databases, and two trial registries on 23 September 2025. We screened reference lists of studies. Eligibility criteria We included randomised controlled trials evaluating the effects of oral vitamin B 12 supplementation, alone or in combination with other micronutrients, in children < 12 years of age. We excluded cross‐over trials, trials targeting pregnant or breastfeeding women, or participants with critical illnesses, and interventions delivered by intravenous/intramuscular injections. Outcomes Critical outcomes were vitamin B 12 status, anaemia, haemoglobin, growth, cognitive function, developmental outcomes, and any adverse effects. Important outcomes included megaloblastic anaemia, body composition, health‐related quality of life, morbidity, and all‐cause mortality. Risk of bias We used Cochrane RoB 2 to evaluate bias. Synthesis methods We conducted meta‐analyses using fixed‐effect models. If there was substantial heterogeneity, we used random‐effect models. When meta‐analyses were not conducted, we described findings from individual trials, and considered synthesis and presentation of findings using other methods. We used GRADE to evaluate the certainty of evidence for critical outcomes. Included studies We included 16 trials (4083 children; 2 days to 11 years) in 10 countries, including India, Japan, Thailand, Nepal, United Kingdom, Italy, Spain, the United States, El Salvador, and Guatemala. Follow‐up periods for outcomes in most studies ranged from five weeks to 31 months, with one study extending follow‐up to nine years. Duration of vitamin B 12 supplementation varied, ranging from 28 days to 31 months, with doses from 0.9 µg/day to 150 µg/day. Nine trials, including 2391 children, contributed data to meta‐analyses. Synthesis of results Supplementation with vitamin B 12 alone versus placebo There may be little to no difference between groups in height/length (mean difference (MD) ‐0.19 cm, 95% confidence interval (CI) ‐2.44 to 2.06; 2 trials, 143 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (standardised mean difference (SMD) 0.09, 95% CI ‐0.10 to 0.28; 2 trials, 438 children, low‐certainty evidence). There may be little to no difference between groups in motor skill development (6 to 9 years, NEuroPSYchological assessment, Second Edition (NEPSY‐II); 1 trial, 403 children, low‐certainty evidence). Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency (absolute risk difference (ARD) 56 fewer per 1000, 95% CI 68 fewer to 24 fewer; 1.8% versus 7.6%; risk ratio (RR) 0.27, 95% CI 0.11 to 0.69; 3 trials, 642 children; high‐certainty evidence), and probably increases total vitamin B 12 concentrations (MD 68.53 pmol/L, 95% CI 41.83 to 95.23; 7 trials, 705 children; moderate‐certainty evidence), compared to placebo, with an average increase of 68.5 pmol/L. There may be little to no difference between groups in anaemia (ARD 21 more per 1000, 95% CI 26 fewer to 191 more; 9.1% versus 4.5%; RR 1.48, 95% CI 0.41 to 5.27; 2 trials, 144 children; low‐certainty evidence). No trials reported the occurrence of any adverse effects. Supplementation with vitamin B 12 alone versus no intervention The evidence is very uncertain about the effects of vitamin B 12 on height/length (2 trials, 70 children; very low‐certainty evidence), compared to no intervention. No trials reported data for the other critical outcomes. Supplementation with vitamin B 12 and other micronutrients, compared to the same formulation without vitamin B 12 There may be little to no difference between groups in height/length (MD ‐0.22 cm, 95% CI ‐0.65 to 0.20; 2 trials, 608 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (SMD 0.00, 95% CI ‐0.13 to 0.13; 3 trials, 956 children; low‐certainty evidence). There may be little to no difference between groups in development outcomes (e.g. motor skill development) (SMD ‐0.05, 95% CI ‐0.18 to 0.08; 2 trials, 960 children; low‐certainty evidence). Children who received vitamin B 12 supplementation and other micronutrients may have little to no difference in vitamin B 12 deficiency (ARD 2 fewer per 1000, 95% CI 7 fewer to 32 more; 0.7% versus 0.8%; RR 0.77, 95% CI 0.12 to 5.16; 2 trials, 534 children; low‐certainty evidence), or total vitamin B 12 concentrations (MD 34.32 pmol/L, 95% CI ‐31.13 to 99.77; 3 trials, 731 children; low‐certainty evidence), compared to supplements without vitamin B 12 . There may be little to no difference between groups in anaemia (21.7% versus 25.0%; 1 trial, 35 children; low‐certainty evidence). There may be little to no difference between groups in any adverse effects (9.2% versus 5.9%; 1 trial, 574 children; low‐certainty evidence). The certainty of evidence for critical outcomes ranged from high to very low; we downgraded for imprecision due to small sample sizes or few events, risk of bias in outcome measurement, randomisation methods, selective reporting bias, or inconsistency due to substantial statistical heterogeneity. Few studies reported growth, cognition, development, anaemia, or any adverse effects. Authors' conclusions Vitamin B 12 supplementation (alone or when supplemented with other micronutrients) in children may have little to no effect on growth (i.e. height/length), cognitive function (e.g. attention), development outcomes (e.g. motor skill development), or anaemia, compared to placebo, no intervention, or the same supplements without vitamin B 12 . Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency and probably improves total vitamin B 12 concentrations, compared to placebo. However, vitamin B 12 supplementation with other micronutrients may result in little to no difference in vitamin B 12 deficiency and total vitamin B 12 concentrations, compared to the same formulation without vitamin B 12 . Funding This review had no dedicated funding. Registration Protocol available via DOI 10.1002/14651858.CD015264. Plain language summary What are the effects of vitamin B 12 supplementation for children less than 12 years of age? Key messages Vitamin B 12 supplementation reduces the risk of vitamin B 12 deficiency, and probably improves vitamin B 12 levels in children less than 12 years of age, compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient) (that is, children who did not take vitamin B 12 supplements). Vitamin B 12 supplements, with other micronutrients (important vitamins and minerals the body needs in small amounts to function), may result in little to no difference in vitamin B 12 deficiency or total vitamin B 12 levels, compared to children who received the same supplements without vitamin B 12 . The impact of vitamin B 12 supplements on other health outcomes in children is less clear. What is vitamin B 12 ? Vitamin B 12 is an important nutrient that helps make red blood cells and keep the body's cells and nerves healthy. Vitamin B 12 deficiency is an important public health problem, including in children and in resource‐poor settings. Lower vitamin B 12 levels in children have been linked to anaemia (lower haemoglobin levels), and poorer growth, development, and cognition (a child's ability to gain knowledge through thought, understanding, and the senses). What did we want to find out? We wanted to find out if taking vitamin B 12 supplements would improve the nutrition and health of children less than 12 years of age. What did we do? We searched for studies that looked at the effects of vitamin B 12 compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient), no intervention, or the same supplements without vitamin B 12 . We summarised the results of the studies and our confidence in the evidence, based on information such as how the study was done. What did we find? We included 16 studies involving 4083 children less than 12 years of age (2 days to 11 years). Nine studies, including 2391 children, had data that we could analyse. The studies were conducted in 10 countries around the world. In most studies, the outcomes were assessed immediately after the intervention from five weeks to 31 months, with one study assessing outcomes after nine years. Vitamin B 12 supplements were provided from 28 days to 31 months in amounts from 0.9 to 150 micrograms a day. Supplementation with vitamin B 12 alone versus placebo There may be little to no difference in height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplements had less vitamin B 12 deficiency, and probably had higher vitamin B 12 levels, compared to placebo. There may be little to no difference between groups in anaemia. No studies provided data on any unwanted (adverse) effects. Vitamin B 12 alone versus no intervention The evidence is very uncertain for height/length. No studies reported data we could analyse for other outcomes. Vitamin B 12 and other micronutrients, compared to supplements with the same supplement without vitamin B 12 There may be little to no difference between groups for height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplementation (with other nutrients) may have little to no difference in vitamin B 12 deficiency, vitamin B 12 levels, anaemia, or any unwanted effects. What are the limitations of the evidence? The small number and the size of studies were limitations of this review. Few studies reported on health outcomes, including growth, cognition, development, anaemia, or any adverse effects. The different ages of children, and differences in the amount of vitamin B 12 and when the outcomes were measured, are also limitations of this review. How up to date is this evidence? The evidence is up to date as of 23 September 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Larvie, DY; Güitrón Leal, CE; Venkatramanan, S; Palma Molina, XE; Steel, LB; Kuriyan, R; Finkelstein, JL", "articleTypes": [], "doi": "10.1002/14651858.CD015264.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "7f3fa0c5-d2cb-418a-96f3-a5c28f134ba3", "pmid": "", "title": "Antitumour antibiotic containing regimens for metastatic breast cancer", "imported": false, "abstract": "Abstract - Background Antitumour antibiotics are used in the management of metastatic breast cancer. Some of these agents have demonstrated higher tumour response rates than non‐antitumour antibiotic regimens, however a survival benefit has not been established in this setting. Objectives To review the randomised evidence comparing antitumour antibiotic containing chemotherapy regimens with regimens not containing an antitumour antibiotic in the management of women with metastatic breast cancer. Search methods The Specialised Register maintained by the Cochrane Breast Cancer Group was searched on 3rd October, 2006 using the codes for 'advanced breast cancer' and 'chemotherapy'. Details of the search strategy and coding applied by the Group to create the register are described in the Group's module on The Cochrane Library. Selection criteria Randomised trials comparing antitumour antibiotic containing regimens with regimens not containing antitumour antibiotics in women with metastatic breast cancer. Data collection and analysis Data were collected from published trials. Studies were assessed for eligibility and quality, and data were extracted by two independent reviewers. Hazard Ratios (HRs) were derived from time‐to‐event outcomes where possible, and a fixed effect model was used for meta‐analysis. Response rates were analysed as dichotomous variables. Quality of life and toxicity data were extracted where present. A primary analysis was conducted for all trials and by class of antitumour antibiotic. Main results Thirty‐four trials reporting on 46 treatment comparisons were identified. All trials published results for tumour response and 27 trials published time‐to‐event data for overall survival. The observed 4244 deaths in 5605 randomised women did not demonstrate a statistically significant difference in survival between regimens that contained antitumour antibiotics and those that did not (HR 0.96, 95% CI 0.90 to 1.02, P = 0.22) and no significant heterogeneity. Antitumour antibiotic regimens were favourably associated with time‐to‐progression (HR 0.84, 95% CI 0.77 to 0.91) and tumour response rates (odds ratio (OR) 1.33, 95% CI 1.21 to 1.48) although statistically significant heterogeneity was observed for these outcomes. These associations were consistent when the analysis was restricted to the 30 trials that reported on anthracyclines. Patients receiving anthracycline containing regimens were also more likely to experience toxic events compared to patients receiving non‐antitumour antibiotic regimens. No statistically significant difference was observed in any outcome between mitoxantrone containing and non‐antitumour antibiotic‐containing regimens. Authors' conclusions Compared to regimens without antitumour antibiotics, regimens that contained these agents showed a statistically significant advantage for tumour response and time to progression in women with metastatic breast cancer but were not associated with an improvement in overall survival. The favourable effect on tumour response and time to progression observed in anthracycline containing regimens was also associated with greater toxicity. Plain language summary Antitumour antibiotic containing regimens for metastatic breast cancer Advanced (metastatic) breast cancer is cancer that has spread beyond the breast. Treatment for metastatic disease usually involves some type of chemotherapy (anti‐cancer drugs) to try to reduce the cancer. Chemotherapy drugs can either be given as a single agent or in combination with other chemotherapy drugs. This is done according to a plan or a course of the drug referred to as a regimen. There are many types of chemotherapy drugs which work in various ways. Antitumour antibiotics work by damaging the cancer cells thereby preventing those cells from multiplying. Chemotherapy in general produces a range of side effects or adverse events related to the treatment. The known side effects of antitumour antibiotics include nausea, vomiting, a reduction in the number of white blood cells (known as leukopenia), and in some cases a toxic reaction which alters the working of the heart (called cardiotoxicity). This review sought to identify and review the randomised evidence comparing courses of chemotherapy containing antitumour antibiotics against courses not containing antitumour antibiotics. This review identified 34 eligible trials involving 5605 women. This review found that for women with advanced breast cancer, taking antitumour antibiotics did not result in better survival than women who took other types of chemotherapy drugs. Despite the lack of evidence of survival benefit, this review demonstrated that women taking these drugs had an advantage in time to progression (the length of time it takes for the cancer to progress after taking the drug) and tumour response (shrinking of the tumour) compared to women who did not take the antitumour antibiotic drugs. In addition however, the risks of side effects including cardiotoxicity, leukopenia and nausea/vomiting were all significantly increased in the women taking the antitumour antibiotics. Given that this review failed to show a benefit in survival for women taking this group of drugs but a higher rate of side effects, the use of these drugs in the management of metastatic breast cancer must be carefully weighed against the risk of these side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Lord, SJ, Ghersi, D, Gattellari, M, Wortley, S, Wilcken, N, Thornton, C, Simes, J", "articleTypes": [], "doi": "10.1002/14651858.CD003367.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.091Z" }, { "id": "7f619a34-1ff3-4b22-a1d6-e73e45f614ec", "pmid": "", "title": "Colchicine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Colchicine has been used for patients with primary biliary cirrhosis because of its immunomodulatory and antifibrotic potential. The therapeutical responses to colchicine in randomised clinical trials were inconsistent. Objectives To evaluate the beneficial and harmful effects of colchicine in patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials on The Cochrane Library , MEDLINE, EMBASE (September 2003) , and manual searches of bibliographies. We contacted authors of trials and pharmaceutical companies. Selection criteria Randomised clinical trials comparing colchicine with any kind of control therapy were included irrespective of language, year of publication, and publication status. Data collection and analysis The primary outcomes were the number of deaths and the number of death and/or patients who underwent liver transplantation. Dichotomous outcomes were reported as relative risk (RR) with 95% confidence interval (CI). We examined intervention effects by using both a fixed effect model and a random effects model. Heterogeneity was investigated by subgroup analyses and sensitivity analyses. Main results Eleven randomised clinical trials involving 716 patients with primary biliary cirrhosis fulfilled the inclusion criteria. No significant differences were detected between colchicine and placebo/no intervention on the number of deaths (RR 1.21, 95% CI 0.71 to 2.06), the number of deaths and/or patients who underwent liver transplantation (RR 1.00, 95% CI 0.67 to 1.49), liver complications, liver biochemical variables, liver histological measurements, and adverse events. Trial methodology was generally low and some trials had high drop‐out rate. A best‐worst‐case‐scenario analysis showed no significant effect of colchicine on mortality (RR 0.59, 95%CI 0.30 to 1.15), while a worst‐best‐case‐scenario analysis showed a significant detrimental effect of colchicine on mortality (RR 2.28, 95% CI 1.17 to 4.44). Colchicine significantly decreased the number of patients without improvement of pruritus (RR 0.75, 95% CI 0.65 to 0.87). However, this estimate was based on only 156 patients from three trials. The effect of the combined treatment with ursodeoxycholic acid was not significantly different from that of colchicine alone. Authors' conclusions We did not find evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis. As we are not able to exclude a detrimental effect of colchicine, we suggest that it is only used in randomised clinical trials. Plain language summary No convincing evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis Primary biliary cirrhosis is a rare, chronic liver disease of unknown etiology. Colchicine, a plant alkaloid, has been used to treat patients with primary biliary cirrhosis and was tested in randomised clinical trials. When all identified trials were combined, colchicine appeared to be not significantly different from placebo/no intervention in respect to mortality, mortality and/or patients who underwent liver transplantation, liver complications, liver biochemistry, liver histology, and the occurrences of adverse events. Colchicine may reduce pruritus, but this finding may be due to bias. The addition of ursodeoxycholic acid did not significantly influence the effect of colchicine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "7f645227-4dc5-4d66-816d-d8ca3b4db9ed", "pmid": "", "title": "Interventions for drooling in children with cerebral palsy", "imported": false, "abstract": "Abstract - Background Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation ( Blasco 1992 ; Van der Burg 2006 ). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP. Objectives (1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning. Search methods We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts. We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled‐trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts. Selection criteria Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included. Data collection and analysis Data were extracted independently by MW, MS and LP and differences resolved through discussion. Main results Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin‐A (BoNT‐A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro‐motor and oro‐sensory therapies, behavioural interventions, intra‐oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta‐analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies. Authors' conclusions It was not possible to reach a conclusion on the effectiveness and safety of either BoNT‐A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided. Plain language summary Interventions for drooling in children with cerebral palsy Many children with CP have difficulty controlling saliva. Drooling varies in severity and can be distressing for the children, families and caregivers. Excessive drooling can cause constant damp soiled clothing, unpleasant odour, irritated, chapped or sore skin around the mouth and chin, skin and mouth infections, dehydration, difficulties chewing, interference with speech, damage to books, communication aids, computer and audio equipment. There is also risk of social rejection and social isolation for these children. Many interventions are used to reduce or eliminate drooling. These include surgery, medications, botulinum toxin (BoNT‐A and BoNT‐B)), physical therapies, therapies to improve sensory function, behavioural therapies to assist the child in managing his/her own drooling, appliances placed in the mouth, and acupuncture. There is no clear consensus on which interventions are safe and effective in managing drooling in children with CP. This makes it hard to decide which intervention will be safest and most effective. Only RCTs and CCTs were included in this review. Trials were identified by electronic searches of databases, searches of clinical trials registers, peer reviewed journals, published conference proceedings and reference lists of relevant articles. Six trials were found. Four examined the safety and efficacy of BoNT‐A and two examined benztropine and glycopyrrolate. No trials were found on other interventions. The quality of trials was variable. The trials all differed in the children recruited, the product used, how the product was delivered and how its effectiveness was measured. All trials reported a positive reduction in drooling and all showed some statistically significant change for treatment groups up to 1 month post intervention. Few studies examined client and/or carer satisfaction with the intervention. Some looked at side effects of the intervention but no study examined the effect of interventions on the child's quality of life or psychological well being. There is insufficient evidence to support the use of one intervention over another. As trials on just two kinds of interventions were retrieved, and given the variation and quality of these studies, it is not possible to conclude that one intervention is more effective than another. The lack of trials on other interventions does not suggest that these interventions are ineffective. Adequately powered well designed trials are required across all interventions. In addition to using sensitive measures looking at change in salivary flow, measures are needed that examine client and carer satisfaction, changes in quality of life, psychological well being and in unwanted symptoms associated with drooling.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Walshe, M, Smith, M, Pennington, L", "articleTypes": [], "doi": "10.1002/14651858.CD008624.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.762Z" }, { "id": "7f64737d-25a8-4f5c-acc4-6d1231efa094", "pmid": "", "title": "Zinc supplementation for improving pregnancy and infant outcome", "imported": false, "abstract": "Abstract - Background It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy, such as prolonged labour, atonic postpartum haemorrhage, pregnancy‐induced hypertension, preterm labour and post‐term pregnancies, although these associations have not yet been established. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Objectives 1. To compare the effects on maternal, fetal, neonatal and infant outcomes in healthy pregnant women receiving zinc supplementation versus no zinc supplementation, or placebo.
2. To assess the above outcomes in a subgroup analysis reviewing studies performed in women who are, or are likely to be, zinc‐deficient. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (3 July 2020), and reference lists of retrieved studies. Selection criteria Randomised trials of zinc supplementation versus no zinc supplementation or placebo administration during pregnancy, earlier than 27 weeks' gestation. We excluded quasi‐randomised controlled trials. We intended to include studies presented only as abstracts, if they provided enough information or, if necessary, by contacting authors to analyse them against our criteria; we did not find any such studies. Data collection and analysis Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information. We assessed the certainty of the evidence using GRADE. Main results For this update, we included 25 randomised controlled trials (RCTs) involving over 18,000 women and their babies. The overall risk of bias was low in half of the studies. The evidence suggests that zinc supplementation may result in little or no difference in reducing preterm births (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.74 to 1.03; 21 studies, 9851 participants; low‐certainty evidence). Further, zinc supplementation may make little or no difference in reducing the risk of stillbirth (RR 1.22, 95% CI 0.80 to 1.88; 7 studies, 3295 participants; low‐certainty evidence), or perinatal deaths (RR 1.10, 95% CI 0.81 to 1.51; 2 studies, 2489 participants; low‐certainty evidence). It is unclear whether zinc supplementation reduces neonatal death, because the certainty of the evidence is very low. Finally, for other birth outcomes, zinc supplementation may make little or no difference to mean birthweight (MD 13.83, 95% CI ‐15.81 to 43.46; 22 studies, 7977 participants; low‐certainty evidence), and probably makes little or no difference in reducing the risk of low birthweight (RR 0.94, 95% CI 0.79 to 1.13; 17 studies, 7399 participants; moderate‐certainty evidence) and small‐for‐gestational age babies when compared to placebo or no zinc supplementation (RR 1.02, 95% CI 0.92 to 1.12; 9 studies, 5330 participants; moderate‐certainty evidence). We did not conduct subgroup analyses, as very few studies used normal zinc populations. Authors' conclusions There is not enough evidence that zinc supplementation during pregnancy results in improvements in maternal or neonatal outcomes. Future research to address ways of improving the overall nutritional status of pregnant women, particularly in low‐income regions, and not looking at zinc in isolation, should be an urgent priority. Plain language summary Zinc supplementation for improving pregnancy and infant outcome What is the issue? In low‐ and middle‐income countries, many women have poor diets and are deficient in key micronutrients that are required for good health. This is especially concerning during pregnancy, when energy and nutrient needs are greater for both the mother and the growing baby. Zinc plays a critical role in normal growth and development. Deficiency in zinc could lead to adverse health outcomes, such as being born too soon or too small. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Why is this important? Although severe zinc deficiency is rare, it is estimated that mild‐to‐moderate deficiency is common in several regions of the world. Studies of human pregnancy and zinc supplementation, including those from low‐ and middle‐income countries, have failed to document a consistent beneficial effect on fetal growth, length of gestation, and early newborn survival. What evidence did we find? We searched for studies in July 2020. This updated review now includes 25 randomised controlled trials, involving over 18,000 women and their babies. We found that zinc supplementation in pregnancy may make little to no difference in reducing the risk of preterm births, stillbirths, or deaths around the time of birth, when compared to no zinc supplementation or placebo. Zinc supplementation may make little or no difference to the birthweight of babies, and probably makes little or no difference to the number of babies born either with a low birthweight or small for their gestational age, when compared with no zinc supplementation, or with giving a placebo. We cannot be sure whether zinc supplementation reduces death in newborns, because the certainty of the evidence is very low. What does this mean? There is not enough evidence that zinc supplementation during pregnancy results in better outcomes for women and their babies. Finding ways to improve women's overall nutritional status, particularly in low‐income areas, will do more to improve the health of mothers and babies than supplementing pregnant women with zinc alone. This should be an urgent research priority for the future.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carducci, B; Keats, EC; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD000230.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "7f679c45-29d1-45bb-ba3b-3a17966aadd7", "pmid": "", "title": "Zinc supplementation for the treatment of measles in children", "imported": false, "abstract": "Abstract - Background Measles is an important cause of childhood morbidity and mortality globally, despite increasing vaccine coverage. Zinc plays a significant role in the maintenance of normal immunological functions, therefore supplements given to zinc‐deficient children will increase the availability of zinc and could reduce measles‐related morbidity and mortality. This is an update of a review first published in 2015. Objectives To assess the effects of zinc supplementation in reducing morbidity and mortality in children with measles. Search methods We searched CENTRAL (03 February 2017, Issue 2), MEDLINE (1946 to 03 February 2017), Embase (1974 to 03 February 2017), CINAHL (1981 to 03 February 2017), LILACS (1982 to 03 February 2017), Web of Science (1985 to 03 February 2017), and BIOSIS Previews (1985 to 27 June 2014). We also searched ClinicalTrials.gov, the Australian New Zealand Clinical Trials Registry and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 03 February 2017 to identify unpublished and ongoing studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of zinc in reducing morbidity and mortality in children with measles. Data collection and analysis Two review authors independently assessed the studies for inclusion and extracted data on outcomes, details of the interventions, and other study characteristics using a standardised data extraction form. We used risk ratio (RR) and hazard ratio (HR) as measures of effect with 95% confidence intervals (CI). We included only one study, and did not conduct meta‐analysis. Main results We did not identify any new studies for inclusion in this update. One RCT met our inclusion criteria. The study was conducted in India and included 85 children diagnosed with measles and pneumonia. The trial showed no significant difference in mortality between children with measles and pneumonia who received zinc supplements and those who received placebo (RR 0.34, 95% CI 0.01 to 8.14). There was no significant difference in time to absence of fever between children who received zinc supplements and those who did not (HR 1.08, 95% CI 0.67 to 1.74). No treatment‐related side effects were reported in either group. We assessed the overall quality of the evidence as very low. Authors' conclusions We could not draw any definitive conclusions from this review about the effects of zinc supplementation on clinical outcomes of children with measles due to the very low quality of the evidence available. There is insufficient evidence to confirm or refute the effect of zinc supplementation in children with measles. Plain language summary Zinc supplementation for the treatment of measles in children Review question What is the effect of zinc supplementation in the treatment of children with measles? Background Measles infection has reduced globally over the last decade, but large outbreaks still occur, especially in low‐income countries. Zinc is one of the essential micronutrients necessary for the optimal functioning of the immune system. Zinc deficiency is particularly common in children in low‐ and middle‐income countries. It was therefore important to examine the potential role of zinc supplementation in controlling the symptoms of measles infection in children. We aimed to critically assess the current evidence from published studies on the effect of zinc supplementation for the treatment of measles in children. Search date We searched for evidence up to 03 February 2017. This is an update of a review first published in 2015. We did not include any new studies for this update. Study characteristics We found one small randomised trial (involving 85 children) that compared zinc supplements versus placebo administered to children with measles and pneumonia. All 85 children received supportive care and vitamin A. The study was conducted in India and funded by the Child Health Foundation USA and the Nestlé Foundation. Key results The included study was small and did not provide enough data to determine whether zinc had an effect on mortality when compared with placebo. Although no adverse effects were reported, there was insufficient evidence to draw any conclusions about the use of zinc supplements to improve measles symptoms in children. More research is needed to clarify any benefits or harms. Quality of the evidence We assessed the quality of the evidence as very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Awotiwon, AA; Oduwole, O; Sinha, A; Okwundu, CI", "articleTypes": [], "doi": "10.1002/14651858.CD011177.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "7f7944ea-a295-4363-967c-a4b1606a3c99", "pmid": "", "title": "Modifying the consistency of food and fluids for swallowing difficulties in dementia", "imported": false, "abstract": "Abstract - Background People with dementia can have feeding and swallowing difficulties (dysphagia). Modification of the consistency of food or fluids, or both, is a common management strategy. However, diet modification can affect quality of life and may lead to dehydration and malnutrition. Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia. Objectives To determine the effectiveness and adverse effects associated with modifying the consistency of food and fluids in improving oral intake and eliminating aspiration in adults with dysphagia and dementia. Search methods We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE via Ovid SP, Embase via Ovid SP, PsycINFO via Ovid SP, CINAHL via EBSCOhost, LILACS via BIREME, ClinicalTrials.gov and the World Health Organization (WHO) Portal on 9 May 2018. We also checked the reference lists of relevant articles to identify any additional studies. Selection criteria We included randomised controlled trials (RCTs), quasi‐RCTs and cluster‐RCTs published in any language that measured any of the outcomes of interest. We included trials with adults with a clinical diagnosis of dementia with symptoms and signs of dysphagia confirmed on instrumental assessment. We included participants with all types, stages and severities of dementia. Control groups received either no intervention or interventions not involving diet modification or modification to sensory properties of food. Data collection and analysis Two review authors independently assessed for inclusion all potential studies identified. Data were extracted independently along with assessment of methodological quality using standard Cochrane methods. We contacted study authors for additional unpublished information. Main results No trials on modification of food met the inclusion criteria. We included two studies that examined modification to fluids. Both were part of the same large multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. Participation in the second trial was determined by results from the first trial. With unpublished data supplied by study authors, we examined data from participants with dementia only. The first study, a cross‐over trial, investigated the immediate effects on aspiration of two viscosities of liquids (nectar thick and honey thick) compared to regular liquids in 351 participants with dementia using videofluoroscopy. Regular liquids with a chin down head posture, as well as regular liquids without any intervention were also compared. The sequence of interventions during videofluoroscopy may have influenced response to intervention. The second study, a parallel designed RCT, compared the effect of nectar and honey thick liquids with a chin down head posture over a three‐month period in a subgroup of 260 participants with dementia. Outcomes were pneumonia and adverse intervention effects. Honey thick liquids, which are more consistent with descriptors for 'spoon thick' or 'extremely thick' liquids, showed a more positive impact on immediate elimination of aspiration during videofluoroscopy, but this consistency showed more adverse effects in the second follow‐up study. During the second three‐month follow‐up trial, there were a greater number of incidents of pneumonia in participants receiving honey thick liquids than those receiving nectar thick liquids or taking regular liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of fluids prescribed. Neither trial addressed quality of life. Risk of bias for both studies is high. The overall quality of evidence for outcomes in this review is low. Authors' conclusions We are uncertain about the immediate and long‐term effects of modifying the consistency of fluid for swallowing difficulties in dementia as too few studies have been completed. There may be differences in outcomes depending on the grade of thickness of fluids and the sequence of interventions trialled in videofluoroscopy for people with dementia. Clinicians should be aware that while thickening fluids may have an immediate positive effect on swallowing, the long‐term impact of thickened fluids on the health of the person with dementia should be considered. Further high‐quality clinical trials are required. Plain language summary Modifying the consistency of food and fluids for swallowing difficulties in dementia Background Individuals with dementia often present with swallowing difficulties (dysphagia). The consequences can include choking, dehydration, malnutrition, weight loss, pneumonia and death. Modification of food and liquid is a popular management strategy. It is believed that increasing the viscosity of liquids or altering the consistency of food allows individuals a better opportunity to swallow, with a reduced risk of choking or liquids entering the airway. However, there is growing evidence suggesting that this strategy can lead to dehydration, malnutrition, negative psychological/social consequences, and can affect quality of life for the person with dementia. Review question We wished to find out if changing the viscosity or consistency of food or fluids, or both, makes swallowing safer and has positive outcomes for people with dementia in terms of respiratory status, nutritional status and quality of life. We wanted to examine if modifying food or fluids, or both, also had any adverse effects for the person with dementia. Study characteristics We found two studies, which were both part of the same multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. We included data on people with dementia only. The first of the two studies looked at the immediate effects of two viscosities of liquids compared to regular thin liquids on aspiration (entry of food or fluid into the lungs) in 351 people with dementia. This study also compared drinking regular thin liquids using a chin down head posture as well as drinking regular thin liquids without any changes to head position; the main outcome was fluid entering the lungs. Using a subgroup of 260 people with dementia from the first study, the second study compared the effect of the same liquid viscosities with a chin down head posture. The effectiveness of these interventions on the incidence of pneumonia and adverse effects of these interventions was examined over a three‐month period. Study results Honey thick viscosity liquids, which clinically are similar to descriptions of 'very thick liquids', had a more positive immediate impact on preventing fluid entering the lungs when examined during videofluoroscopy (specialised swallow x‐ray) examination. However, during the three‐month follow‐up period there were a greater number of incidents of pneumonia in the group of people with dementia receiving these honey thick liquids, than those receiving nectar thick liquids and those receiving regular thin liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of liquids that the person with dementia was receiving. Conclusion There were a number of methodological flaws in both studies in this review and these were acknowledged by the authors. While thickening fluids may have an immediate positive effect on swallow function, clinicians should consider the effects of this intervention on the person with dementia in the longer‐term. People with dementia on thickened fluids require long‐term follow‐up. The overall risk of bias of included studies is high. The quality of evidence is low. Further well‐designed research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Flynn, E, Smith, CH, Walsh, CD, Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD011077.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.743Z" }, { "id": "7f7b6184-5ead-4966-a0bd-d1da1a5f54af", "pmid": "", "title": "Systemic antifungal therapy for tinea capitis in children", "imported": false, "abstract": "Abstract - Background Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread. This is an update of the original Cochrane review. Objectives To assess the effects of systemic antifungal drugs for tinea capitis in children. Search methods We updated our searches of the following databases to November 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and CINAHL (from 1981). We searched five trial registers and checked the reference lists of studies for references to relevant randomised controlled trials (RCTs). We obtained unpublished, ongoing trials and grey literature via correspondence with experts in the field and from pharmaceutical companies. Selection criteria RCTs of systemic antifungal therapy in children with normal immunity under the age of 18 with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 25 studies (N = 4449); 4 studies (N = 2637) were new to this update. Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy for the primary outcome of complete (i.e. clinical and mycological) cure in three studies involving 328 participants with Trichophyton species infections (84.2% versus 79.0%; risk ratio (RR) 1.06, 95% confidence interval (CI) 0.98 to 1.15; low quality evidence). Complete cure with itraconazole (two to six weeks) and griseofulvin (six weeks) was similar in two studies (83.6% versus 91.0%; RR 0.92, 95% CI 0.81 to 1.05; N = 134; very low quality evidence). In two studies, there was no difference between itraconazole and terbinafine for two to three weeks treatment (73.8% versus 78.8%; RR 0.93, 95% CI 0.72 to 1.19; N = 160; low quality evidence). In three studies, there was a similar proportion achieving complete cured with two to four weeks of fluconazole or six weeks of griseofulvin (41.4% versus 52.7%; RR 0.92, 95% CI 0.81 to 1.05; N = 615; moderate quality evidence). Current evidence for ketoconazole versus griseofulvin was limited. One study favoured griseofulvin (12 weeks) because ketoconazole (12 weeks) appeared less effective for complete cure (RR 0.76, 95% CI 0.62 to 0.94; low quality evidence). However, their effects appeared to be similar when the treatment lasted 26 weeks (RR 0.95, 95% CI 0.83 to 1.07; low quality evidence). Another study indicated that complete cure was similar for ketoconazole (12 weeks) and griseofulvin (12 weeks) (RR 0.89, 95% CI 0.57 to 1.39; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole (for two to three weeks) and terbinafine (for two to three weeks) (82.0% versus 94.0%; RR 0.87, 95% CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, we did not find a significant difference between fluconazole (for two to three weeks) and itraconazole (for two to three weeks) (82.0% versus 82.0%; RR 1.00, 95% CI 0.83 to 1.20; low quality evidence). This update provides new data: in children with Microsporum infections, a meta‐analysis of two studies found that the complete cure was lower for terbinafine (6 weeks) than for griseofulvin (6‐12 weeks) (34.7% versus 50.9%; RR 0.68, 95% CI 0.53 to 0.86; N = 334; moderate quality evidence). In the original review, there was no significant difference in complete cure between terbinafine (four weeks) and griseofulvin (eight weeks) in children with Microsporum infections in one small study (27.2% versus 60.0%; RR 0.45, 95% CI 0.15 to 1.35; N = 21; low quality evidence). One study provides new evidence that terbinafine and griseofulvin for six weeks show similar efficacy (49.5% versus 37.8%; RR 1.18, 95% CI 0.74 to 1.88; N = 1006; low quality evidence). However, in children infected with T. tonsurans , terbinafine was better than griseofulvin (52.1% versus 35.4%; RR 1.47, 95% CI 1.22 to 1.77; moderate quality evidence). For children infected with T. violaceum, these two regimens have similar effects (41.3% versus 45.1%; RR 0.91, 95% CI 0.68 to 1.24; low quality evidence). Additionally, three weeks of fluconazole was similar to six weeks of fluconazole in one study in 491 participants infected with T. tonsurans and M. canis (30.2% versus 34.1%; RR 0.88, 95% CI 0.68 to 1.14; low quality evidence). The frequency of adverse events attributed to the study drugs was similar for terbinafine and griseofulvin (9.2% versus 8.3%; RR 1.11, 95% CI 0.79 to 1.57; moderate quality evidence), and severe adverse events were rare (0.6% versus 0.6%; RR 0.97, 95% CI 0.24 to 3.88; moderate quality evidence). Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible. All of the included studies were at either high or unclear risk of bias in at least one domain. Using GRADE to rate the overall quality of the evidence, lower quality evidence resulted in lower confidence in the estimate of effect. Authors' conclusions Newer treatments including terbinafine, itraconazole and fluconazole are at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Limited evidence suggests that terbinafine, itraconazole and fluconazole have similar effects, whereas ketoconazole may be less effective than griseofulvin in children infected with Trichophyton . With some interventions the proportion achieving complete clinical cure was in excess of 90% (e.g. one study of terbinafine or griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. New evidence from this update suggests that terbinafine is more effective than griseofulvin in children with T. tonsurans infection. However, in children with Microsporum infections, new evidence suggests that the effect of griseofulvin is better than terbinafine. We did not find any evidence to support a difference in terms of adherence between four weeks of terbinafine versus eight weeks of griseofulvin. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles. Plain language summary Antifungal medicines for treating children with ringworm Background Tinea capitis, or ringworm, is a fungal infection of the scalp caused mainly by two species of fungi called Trichophyton and Microsporum . It is common in children. Most fungal infections can be treated with antifungal creams applied directly to the skin (topical treatments). However, because the fungal infection is found at the root of the hair follicles, where topical treatments cannot reach, tinea capitis always requires medication administered by mouth so that the treatment spreads throughout the entire body (systemic treatments). There are several different types of antifungal medicines available. Review question Which antifungal medicine is best for treating ringworm on the scalp in children? Study characteristics In November 2015, we searched for studies that used the gold standard design for clinical trials (randomised controlled trials) of antifungal treatments taken by mouth. We found 25 studies in which 4449 children under 18 years (4 studies with 2637 children were new to this update) had taken part. Key results With respect to complete cure (both cure of the infection and visible cure (i.e. fungal and clinical cure) low to moderate quality evidence suggests that newer treatments such as terbinafine, itraconazole and fluconazole are at least as good as griseofulvin, the usual treatment in children with tinea capitis caused by Trichophyton infections. However, new evidence in this update suggests that terbinafine may have better effects than griseofulvin for completely curing children with T. tonsurans infection. By contrast, in children with Microsporum infections, new evidence seems to indicate that griseofulvin is more effective than terbinafine. Terbinafine, itraconazole and fluconazole appear to have similar effects in terms of the proportion of participants achieving complete cure, whereas ketoconazole appears to be less effective than griseofulvin for children with tinea capitis caused by Trichophyton species. However, the quality of this evidence is low. With some interventions, the proportion with complete clinical cure was in excess of 90% (e.g. one study of terbinafine versus griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. The included studies reported on negative side effects, which were similarly mild and reversible for terbinafine, griseofulvin, itraconazole, ketoconazole and fluconazole. They included skin‐specific effects such as itching as well as abdominal discomfort, headache and nausea. Quality of the evidence The quality of the evidence in this review was generally low to moderate, so further research is likely to have an important effect on our confidence in these results. Some evidence was even of very low quality. We still need more and better evidence to help us understand the effectiveness and adverse events of systemic antifungal drugs for tinea capitis in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chen, X, Jiang, X, Yang, M, González, U, Lin, X, Hua, X, Xue, S, Zhang, M, Bennett, C", "articleTypes": [], "doi": "10.1002/14651858.CD004685.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.093Z" }, { "id": "7f8d6d83-bc94-4692-bd41-cd5bf297c3ab", "pmid": "", "title": "Investigating the Synergistic Potential of Music as an Adjunct to Ketamine Therapy for Chronic Noncancer Pain", "imported": false, "abstract": "Intravenous (IV) ketamine is a treatment option for patients with chronic pain that does not respond to standard therapies, primarily working by blocking NMDA receptors in the brain. Beyond pain relief, ketamine can produce dissociative sensations, classifying it as an atypical psychedelic or mind-altering drug, and may enable patients to reprocess their pain similarly to experiences with traditional psychedelics. At the Montreal General Hospital's pain clinic, the investigators have observed patients frequently listening to music during ketamine infusions, and recent research indicates that music-especially when self-selected by patients-might provide additional pain-relieving benefits by influencing central mechanisms related to pain perception and interpretation. This intersection of music and pain relief is garnering substantial scientific interest as recent advances provide more insight into the neuroscience of music and its effects on brain regions involved in emotion, sensation, memory, and pain.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.266Z" }, { "id": "7f8f7e29-5a27-4043-ac60-3fddce68fb28", "pmid": "", "title": "Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health services. Decay and gum disease can cause pain, eating and speaking difficulties, low self‐esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self‐administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area. Objectives To evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other. Search methods Cochrane Oral Health’s Information Specialist searched: Cochrane Oral Health’s Trials Register (to 16 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 12), MEDLINE Ovid (1946 to 16 January 2019), Embase Ovid (1980 to 16 January 2019) and CINAHL EBSCO (1937 to 16 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication. Selection criteria Randomised controlled trials (RCTs) that compared toothbrushing and a home‐use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks). Data collection and analysis At least two review authors independently screened searches, selected studies, extracted data, assessed studies' risk of bias, and assessed evidence certainty as high, moderate, low or very low, according to GRADE. We extracted indices measured on interproximal surfaces, where possible. We conducted random‐effects meta‐analyses, using mean differences (MDs) or standardised mean differences (SMDs). Main results We included 35 RCTs (3929 randomised adult participants). Studies were at high risk of performance bias as blinding of participants was not possible. Only two studies were otherwise at low risk of bias. Many participants had a low level of baseline gingival inflammation. Studies evaluated the following devices plus toothbrushing versus toothbrushing: floss (15 trials), interdental brushes (2 trials), wooden cleaning sticks (2 trials), rubber/elastomeric cleaning sticks (2 trials), oral irrigators (5 trials). Four devices were compared with floss: interdental brushes (9 trials), wooden cleaning sticks (3 trials), rubber/elastomeric cleaning sticks (9 trials) and oral irrigators (2 trials). Another comparison was rubber/elastomeric cleaning sticks versus interdental brushes (3 trials). No trials assessed interproximal caries, and most did not assess periodontitis. Gingivitis was measured by indices (most commonly, Löe‐Silness, 0 to 3 scale) and by proportion of bleeding sites. Plaque was measured by indices, most often Quigley‐Hein (0 to 5). Primary objective: comparisons against toothbrushing alone Low‐certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index (GI)) at one month (SMD ‐0.58, 95% confidence interval (CI) ‐1.12 to ‐0.04; 8 trials, 585 participants), three months or six months. The results for proportion of bleeding sites and plaque were inconsistent (very low‐certainty evidence). Very low‐certainty evidence suggested that using an interdental brush, plus toothbrushing, may reduce gingivitis (measured by GI) at one month (MD ‐0.53, 95% CI ‐0.83 to ‐0.23; 1 trial, 62 participants), though there was no clear difference in bleeding sites (MD ‐0.05, 95% CI ‐0.13 to 0.03; 1 trial, 31 participants). Low‐certainty evidence suggested interdental brushes may reduce plaque more than toothbrushing alone (SMD ‐1.07, 95% CI ‐1.51 to ‐0.63; 2 trials, 93 participants). Very low‐certainty evidence suggested that using wooden cleaning sticks, plus toothbrushing, may reduce bleeding sites at three months (MD ‐0.25, 95% CI ‐0.37 to ‐0.13; 1 trial, 24 participants), but not plaque (MD ‐0.03, 95% CI ‐0.13 to 0.07). Very low‐certainty evidence suggested that using rubber/elastomeric interdental cleaning sticks, plus toothbrushing, may reduce plaque at one month (MD ‐0.22, 95% CI ‐0.41 to ‐0.03), but this was not found for gingivitis (GI MD ‐0.01, 95% CI ‐0.19 to 0.21; 1 trial, 12 participants; bleeding MD 0.07, 95% CI ‐0.15 to 0.01; 1 trial, 30 participants). Very‐low certainty evidence suggested oral irrigators may reduce gingivitis measured by GI at one month (SMD ‐0.48, 95% CI ‐0.89 to ‐0.06; 4 trials, 380 participants), but not at three or six months. Low‐certainty evidence suggested that oral irrigators did not reduce bleeding sites at one month (MD ‐0.00, 95% CI ‐0.07 to 0.06; 2 trials, 126 participants) or three months, or plaque at one month (SMD ‐0.16, 95% CI ‐0.41 to 0.10; 3 trials, 235 participants), three months or six months, more than toothbrushing alone. Secondary objective: comparisons between devices Low‐certainty evidence suggested interdental brushes may reduce gingivitis more than floss at one and three months, but did not show a difference for periodontitis measured by probing pocket depth. Evidence for plaque was inconsistent. Low‐ to very low‐certainty evidence suggested oral irrigation may reduce gingivitis at one month compared to flossing, but very low‐certainty evidence did not suggest a difference between devices for plaque. Very low‐certainty evidence for interdental brushes or flossing versus interdental cleaning sticks did not demonstrate superiority of either intervention. Adverse events Studies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation. Authors' conclusions Using floss or interdental brushes in addition to toothbrushing may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low‐certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis. Plain language summary Home use of devices for cleaning between the teeth (in addition to toothbrushing) to prevent and control gum diseases and tooth decay Review question How effective are home‐use interdental cleaning devices, plus toothbrushing, compared with toothbrushing only or use of another device, for preventing and controlling periodontal (gum) diseases (gingivitis and periodontitis), tooth decay (dental caries) and plaque? Background Tooth decay and gum diseases affect most people. They can cause pain, difficulties with eating and speaking, low self‐esteem, and, in extreme cases, may lead to tooth loss and the need for surgery. The cost to health services of treating these diseases is very high. As dental plaque (a layer of bacteria in an organic matrix that forms on the teeth) is the root cause, it is important to remove plaque from teeth on a regular basis. While many people routinely brush their teeth to remove plaque up to the gum line, it is difficult for toothbrushes to reach into areas between teeth ('interdental'), so interdental cleaning is often recommended as an extra step in personal oral hygiene routines. Different tools can be used to clean interdentally, such as dental floss, interdental brushes, tooth cleaning sticks, and water pressure devices known as oral irrigators. Study characteristics Review authors working with Cochrane Oral Health searched for studies up to 16 January 2019. We identified 35 studies (3929 adult participants). Participants knew that they were in an experiment, which might have affected their teeth cleaning or eating behaviour. Some studies had other problems that might make their findings less reliable, such as people dropping out of the study or not using the assigned device. Studies evaluated the following devices plus toothbrushing compared to toothbrushing only: floss (15 studies), interdental brushes (2 studies), wooden cleaning sticks (2 studies), rubber/elastomeric cleaning sticks (2 studies) and oral irrigators (5 studies). Four devices were compared with floss: interdental brushes (9 studies), wooden cleaning sticks (3 studies), rubber/elastomeric cleaning sticks (9 studies), oral irrigators (2 studies). Three studies compared rubber/elastomeric cleaning sticks with interdental brushes. No studies evaluated decay, and few evaluated severe gum disease. Outcomes were measured at short (one month to six weeks) and medium term (three and six months). Key results We found that using floss, in addition to toothbrushing, may reduce gingivitis in the short and medium term. It is unclear if it reduces plaque. Using an interdental brush, in addition to a toothbrush, may reduce gingivitis and plaque in the short term. Using wooden tooth cleaning sticks may be better than toothbrushing only for reducing gingivitis (measured by bleeding sites) but not plaque in the medium term (only 24 participants). Using a tooth cleaning stick made of rubber or an elastomer may be better than toothbrushing only for reducing plaque but not gingivitis in the short term (only 30 participants). Toothbrushing plus oral irrigation (water pressure) may reduce gingivitis in the short term, but there was no evidence for this in the medium term. There was no evidence of a difference in plaque. Interdental brushes may be better than flossing for gingivitis at one and three months. The evidence for plaque is inconsistent. There was no evidence of a difference between the devices for periodontitis measured by probing pocket depth. There is some evidence that oral irrigation may be better than flossing for reducing gingivitis (but not plaque) in the short term. The available evidence for interdental cleaning sticks did not show them to be better or worse than floss or interdental brushes for controlling gingivitis or plaque. The studies that measured 'adverse events' found no serious effects and no evidence of differences between study groups in minor effects such as gum irritation. Certainty of the evidence The evidence is low to very low‐certainty. The effects observed may not be clinically important. Studies measured outcomes mostly in the short term and many participants had a low level of gum disease at the beginning of the studies. Future research Future studies should use the new periodontal diseases classification to describe the gum health of participants, and they should last long enough to measure periodontitis and tooth decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Worthington, HV; MacDonald, L; Poklepovic Pericic, T; Sambunjak, D; Johnson, TM; Imai, P; Clarkson, JE", "articleTypes": [], "doi": "10.1002/14651858.CD012018.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "7f995eec-f668-4004-8841-3909b8907c47", "pmid": "", "title": "The Role of Sweet Taste Receptor Blockade on Intragastric Liquid Meal-stimulated Secretion of Satiation Peptides in Healthy Humans", "imported": false, "abstract": "The purpose of this study is to determine the functional significance of sweet taste receptors in the secretion of gastrointestinal (GI) satiation peptides by using a specific sweet taste receptor antagonist to block sweet taste perception in the gastrointestinal tract.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.232Z" }, { "id": "7fb33de5-ca03-41b2-b429-3c5c0f152b06", "pmid": "", "title": "Colchicine for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The development of severe coronavirus disease 2019 (COVID‐19) and poor clinical outcomes are associated with hyperinflammation and a complex dysregulation of the immune response. Colchicine is an anti‐inflammatory medicine and is thought to improve disease outcomes in COVID‐19 through a wide range of anti‐inflammatory mechanisms. Patients and healthcare systems need more and better treatment options for COVID‐19 and a thorough understanding of the current body of evidence. Objectives To assess the effectiveness and safety of Colchicine as a treatment option for COVID‐19 in comparison to an active comparator, placebo, or standard care alone in any setting, and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising CENTRAL, MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv), Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index), and WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions to 21 May 2021. Selection criteria We included randomised controlled trials evaluating colchicine for the treatment of people with COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We excluded studies investigating the prophylactic effects of colchicine for people without severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection but at high risk of SARS‐CoV‐2 exposure. Data collection and analysis We followed standard Cochrane methodology. We used the Cochrane risk of bias tool (ROB 2) to assess bias in included studies and GRADE to rate the certainty of evidence for the following prioritised outcome categories considering people with moderate or severe COVID‐19: all‐cause mortality, worsening and improvement of clinical status, quality of life, adverse events, and serious adverse events and for people with asymptomatic infection or mild disease: all‐cause mortality, admission to hospital or death, symptom resolution, duration to symptom resolution, quality of life, adverse events, serious adverse events. Main results We included three RCTs with 11,525 hospitalised participants (8002 male) and one RCT with 4488 (2067 male) non‐hospitalised participants. Mean age of people treated in hospital was about 64 years, and was 55 years in the study with non‐hospitalised participants. Further, we identified 17 ongoing studies and 11 studies completed or terminated, but without published results. Colchicine plus standard care versus standard care (plus/minus placebo) Treatment of hospitalised people with moderate to severe COVID‐19 All‐cause mortality : colchicine plus standard care probably results in little to no difference in all‐cause mortality up to 28 days compared to standard care alone (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.93 to 1.08; 2 RCTs, 11,445 participants; moderate‐certainty evidence). Worsening of clinical status : colchicine plus standard care probably results in little to no difference in worsening of clinical status assessed as new need for invasive mechanical ventilation or death compared to standard care alone (RR 1.02, 95% CI 0.96 to 1.09; 2 RCTs, 10,916 participants; moderate‐certainty evidence). Improvement of clinical status : colchicine plus standard care probably results in little to no difference in improvement of clinical status, assessed as number of participants discharged alive up to day 28 without clinical deterioration or death compared to standard care alone (RR 0.99, 95% CI 0.96 to 1.01; 1 RCT, 11,340 participants; moderate‐certainty evidence). Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is very uncertain about the effect of colchicine on adverse events compared to placebo (RR 1.00, 95% CI 0.56 to 1.78; 1 RCT, 72 participants; very low‐certainty evidence). Serious adverse events : the evidence is very uncertain about the effect of colchicine plus standard care on serious adverse events compared to standard care alone (0 events observed in 1 RCT of 105 participants; very low‐certainty evidence). Treatment of non‐hospitalised people with asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 All‐cause mortality : the evidence is uncertain about the effect of colchicine on all‐cause mortality at 28 days (Peto odds ratio (OR) 0.57, 95% CI 0.20 to 1.62; 1 RCT, 4488 participants; low‐certainty evidence). Admission to hospital or death within 28 days : colchicine probably slightly reduces the need for hospitalisation or death within 28 days compared to placebo (RR 0.80, 95% CI 0.62 to 1.03; 1 RCT, 4488 participants; moderate‐certainty evidence). Symptom resolution : we identified no studies reporting this outcome. Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is uncertain about the effect of colchicine on adverse events compared to placebo . Results are from one RCT reporting treatment‐related events only in 4412 participants (low‐certainty evidence). Serious adverse events : colchicine probably slightly reduces serious adverse events (RR 0.78, 95% CI 0.61 to 1.00; 1 RCT, 4412 participants; moderate‐certainty evidence). Colchicine versus another active treatment (e.g. corticosteroids, anti‐viral drugs, monoclonal antibodies) No studies evaluated this comparison. Different formulations, doses, or schedules of colchicine No studies assessed this. Authors' conclusions Based on the current evidence, in people hospitalised with moderate to severe COVID‐19 the use of colchicine probably has little to no influence on mortality or clinical progression in comparison to placebo or standard care alone. We do not know whether colchicine increases the risk of (serious) adverse events. We are uncertain about the evidence of the effect of colchicine on all‐cause mortality for people with asymptomatic infection or mild disease. However, colchicine probably results in a slight reduction of hospital admissions or deaths within 28 days, and the rate of serious adverse events compared with placebo. None of the studies reported data on quality of life or compared the benefits and harms of colchicine versus other drugs, or different dosages of colchicine. We identified 17 ongoing and 11 completed but not published RCTs, which we expect to incorporate in future versions of this review as their results become available. Editorial note: due to the living approach of this work, we monitor newly published results of RCTs on colchicine on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Is colchicine an effective treatment for people with COVID‐19? Key messages ○ In hospitalised people with moderate to severe COVID‐19, colchicine probably has little to no benefit; we are uncertain about its side effects. ○In non‐hospitalised people with no symptoms or mild COVID‐19, we are uncertain whether colchicine prevents deaths or side effects, however it probably reduces the need for hospitalisation or death and serious side effects slightly. ○ Future studies should assess quality of life in people with no symptoms or mild COVID‐19 and non‐serious side effects and compare colchicine to other medicines for COVID‐19, such as corticosteroids. What is colchicine? Colchicine is a medicine used to reduce swelling and inflammation and may consequently relieve pain. It is often used to treat gout, a condition where people’s joints become swollen and painful. On the other hand, colchicine can be harmful to people with some health conditions, such as kidney or liver problems, or if you take too much of it. How might colchicine treat COVID‐19? Since colchicine is an anti‐inflammatory drug; researchers are interested in whether it might help with reducing inflammation caused by COVID‐19. What did we want to find out? We wanted to know whether colchicine is an effective treatment for people with COVID‐19 compared to placebo (a treatment that looks and tastes the same as colchicine but with no active ingredient) or usual care alone. We looked at people with moderate or severe disease being treated in hospital or with mild disease being treated in the community. We were particularly interested in the effects of colchicine on: ○ number of deaths; ○ whether people’s condition worsened or improved; ○ quality of life; ○ serious and non‐serious side effects What did we do? We searched for studies that compared colchicine together with usual care to usual care (plus/minus placebo). Studies could take place anywhere in the world and include people with mild or no symptoms, moderate or severe COVID‐19, of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our certainty in the evidence, based on factors such as study methods and sizes. What did we find? We identified four eligible randomised trials. Three included 11,525 hospitalised people and one included 4488 non‐hospitalised people. For hospitalised people, the average age was 64 years, and for non‐hospitalised people, the average age was 55 years. Two studies compared colchicine and usual care with usual care alone and 2 studies compared colchicine with usual care and placebo. None of the studies reported quality of life. We also found 17 ongoing studies and 11 completed but unpublished studies. Main results Hospitalised people with moderate to severe COVID‐19 (3 studies, 11,525 people) ○Colchicine probably does not reduce deaths in the 28 days after treatment (2 studies, 11,445 people). ○Colchicine probably does not prevent the worsening of patients’ condition (2 studies, 10,916 people) and probably does not improve it (1 study, 11,340 people). ○We are very uncertain about the effect of colchicine on side effects and serious side effects (2 studies, 177 people). Non‐hospitalised people with no symptoms or mild COVID‐19 (1 study, 4488 people) ○We are uncertain whether colchicine prevents deaths up to 28 days after treatment. ○Colchicine probably slightly reduces the risk of hospitalisation or death. ○We are uncertain about the effect of colchicine on side effects, but it probably slightly reduces serious side effects. What are the limitations of the evidence? Our certainty in the evidence is limited. Two studies did not use a placebo, so everybody knew who was treated with colchicine, which could influence the results. There were too few events for non‐hospitalised people, such as admissions to hospital and deaths, to be certain about the evidence. Studies used different ways to assess and report unwanted effects, so we could not combine studies into a single result to make a judgement. How up to date is this evidence? The evidence is up to date to 21 May 2021. Editorial note: this is a living systematic review. We search for new evidence every week and update the review when we identify relevant new evidence. Refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Mikolajewska, A, Fischer, A-L, Piechotta, V, Mueller, A, Metzendorf, M-I, Becker, M, Dorando, E, Pacheco, RL, Martimbianco, ALC, Riera, R, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015045", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.137Z" }, { "id": "7fc539fd-0054-439b-9495-c311718668da", "pmid": "", "title": "Treatments for intractable constipation in childhood", "imported": false, "abstract": "Abstract - Background Constipation that is prolonged and does not resolve with conventional therapeutic measures is called intractable constipation. The treatment of intractable constipation is challenging, involving pharmacological or non‐pharmacological therapies, as well as surgical approaches. Unresolved constipation can negatively impact quality of life, with additional implications for health systems. Consequently, there is an urgent need to identify treatments that are efficacious and safe. Objectives To evaluate the efficacy and safety of treatments used for intractable constipation in children. Search methods We searched CENTRAL, MEDLINE, Embase, and two trials registers up to 23 June 2023. We also searched reference lists of included studies for relevant studies. Selection criteria We included randomised controlled trials (RCTs) comparing any pharmacological, non‐pharmacological, or surgical treatment to placebo or another active comparator, in participants aged between 0 and 18 years with functional constipation who had not responded to conventional medical therapy. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were symptom resolution, frequency of defecation, treatment success, and adverse events; secondary outcomes were stool consistency, painful defecation, quality of life, faecal incontinence frequency, abdominal pain, hospital admission for disimpaction, and school absence. We used GRADE to assess the certainty of evidence for each primary outcome. Main results This review included 10 RCTs with 1278 children who had intractable constipation. We assessed one study as at low risk of bias across all domains. There were serious concerns about risk of bias in six studies. One study compared the injection of 160 units botulinum toxin A (n = 44) to unspecified oral stool softeners (n = 44). We are very uncertain whether botulinum toxin A injection improves treatment success (risk ratio (RR) 37.00, 95% confidence interval (CI) 5.31 to 257.94; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Frequency of defecation was reported only for the botulinum toxin A injection group (mean interval of 2.6 days). The study reported no data for the other primary outcomes. One study compared erythromycin estolate (n = 6) to placebo (n = 8). The only primary outcome reported was adverse events , which were 0 in both groups. The evidence is of very low certainty due to concerns with risk of bias and serious imprecision. One study compared 12 or 24 μg oral lubiprostone (n = 404) twice a day to placebo (n = 202) over 12 weeks. There may be little to no difference in treatment success (RR 1.29, 95% CI 0.87 to 1.92; low certainty evidence). We also found that lubiprostone probably results in little to no difference in adverse events (RR 1.05, 95% CI 0.91 to 1.21; moderate certainty evidence). The study reported no data for the other primary outcomes. One study compared three‐weekly rectal sodium dioctyl sulfosuccinate and sorbitol enemas (n = 51) to 0.5 g/kg/day polyethylene glycol laxatives (n = 51) over a 52‐week period. We are very uncertain whether rectal sodium dioctyl sulfosuccinate and sorbitol enemas improve treatment success (RR 1.33, 95% CI 0.83 to 2.14; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Results of defecation frequency per week was reported only as modelled means using a linear mixed model. The study reported no data for the other primary outcomes. One study compared biofeedback therapy (n = 12) to no intervention (n = 12). We are very uncertain whether biofeedback therapy improves symptom resolution (RR 2.50, 95% CI 1.08 to 5.79; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). The study reported no data for the other primary outcomes. One study compared 20 minutes of intrarectal electromotive botulinum toxin A using 2800 Hz frequency and botulinum toxin A dose 10 international units/kg (n = 30) to 10 international units/kg botulinum toxin A injection (n = 30). We are very uncertain whether intrarectal electromotive botulinum toxin A improves symptom resolution (RR 0.96, 95% CI 0.76 to 1.22; very low certainty evidence) or if it increases the frequency of defecation (mean difference (MD) 0.00, 95% CI −1.87 to 1.87; very low certainty evidence). We are also very uncertain whether intrarectal electromotive botulinum toxin A has an improved safety profile (RR 0.20, 95% CI 0.01 to 4.00; very low certainty evidence). The evidence for these results is of very low certainty due to serious concerns with risk of bias and imprecision. The study did not report data on treatment success. One study compared the injection of 60 units botulinum toxin A (n = 21) to myectomy of the internal anal sphincter (n = 21). We are very uncertain whether botulinum toxin A injection improves treatment success (RR 1.00, 95% CI 0.75 to 1.34; very low certainty evidence). No adverse events were recorded. The study reported no data for the other primary outcomes. One study compared 0.04 mg/kg oral prucalopride (n = 107) once daily to placebo (n = 108) over eight weeks. Oral prucalopride probably results in little or no difference in defecation frequency (MD 0.50, 95% CI −0.06 to 1.06; moderate certainty evidence); treatment success (RR 0.96, 95% CI 0.53 to 1.72; moderate certainty evidence); and adverse events (RR 1.15, 95% CI 0.94 to 1.39; moderate certainty evidence). The study did not report data on symptom resolution. One study compared transcutaneous electrical stimulation to sham stimulation, and another study compared dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. These studies did not report any of our predefined primary outcomes. Authors' conclusions We identified low to moderate certainty evidence that oral lubiprostone may result in little to no difference in treatment success and adverse events compared to placebo. Based on moderate certainty evidence, there is probably little or no difference between oral prucalopride and placebo in defecation frequency, treatment success, or adverse events. For all other comparisons, the certainty of the evidence for our predefined primary outcomes is very low due to serious concerns with study limitations and imprecision. Consequently, no robust conclusions could be drawn. Plain language summary Management of intractable constipation in children Key messages • There may be little to no difference between lubiprostone and placebo (dummy treatment) in achieving treatment success in children with intractable constipation. We also found that lubiprostone is probably as safe as placebo. • There is probably little or no difference between prucalopride, also a laxative, and placebo in frequency of defecation per day, treatment success, and safety. • It is unclear whether any of the other treatments we looked at are helpful. The evidence is uncertain because of the very low number of study participants and problems with how the research was reported. • Currently, there is not an agreed‐upon definition for intractable constipation. To develop further evidence on therapies for intractable constipation, researchers must use the same definition. We would encourage further work to come up with an agreed‐upon definition. What is intractable constipation? Constipation in children is a common problem. If doctors cannot find an underlying cause for the symptoms, it is called functional constipation. The symptoms of constipation include lower frequency of defecation, bowel incontinence or soiling, and stomach pain. Constipation can be mild and respond well to standard treatments, such as behavioural changes or laxatives. However, it can also be more severe or last for a long time. We defined intractable constipation as constipation that persists despite standard treatments. What did we want to find out? We wanted to find out which treatments are helpful and safe for treating children (between 0 and 18 years of age) with constipation that has not responded to standard medical treatments (intractable constipation). This extreme level of constipation can impact a child's life in very negative ways, such as keeping them away from school and other daily activities; causing them pain, discomfort, and general distress; and requiring hospital visits for treatment. Consequently, there is a need to investigate if the tested therapies can help resolve the problem. What did we do? We considered any medication, surgical procedure, or therapy to help children with intractable constipation. Each study compared a specific treatment to placebo, no treatment, or another treatment. We were interested in whether the treatments increased the frequency of defecation, improved symptoms, or led to treatment success. We also wanted to know if the treatments were safe, so we looked at whether they caused side effects. We searched for randomised controlled trials (studies in which people are randomly assigned to one of two or more treatment groups) comparing any medical, surgical, or complementary therapy versus no treatment, placebo, or another treatment in children with intractable constipation. What did we find? We found 10 studies involving a total of 1278 children. The average age of study participants ranged from around 5 to 10 years. The studies were conducted in Iran, Brazil, Colombia, the USA, Canada, Australia, and several European countries. Studies lasted from one to six months. The studies made the following comparisons: • botox injection versus stool softeners; • erythromycin versus placebo; • lubiprostone versus placebo; • rectal sodium dioctyl sulfosuccinate and sorbitol versus oral polyethylene glycol laxatives; • biofeedback therapy versus no treatment; • intrarectal electromotive botox injection versus a usual botox injection; • botox injection versus myectomy of the internal anal sphincter; • prucalopride versus placebo; • transcutaneous electrical stimulation versus sham stimulation; and • dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. Main results • There may be little to no difference between lubiprostone and placebo in achieving treatment success, and there is probably little to no difference in adverse events for this comparison. • There is probably little or no difference between prucalopride and placebo in defecation frequency, treatment success, and adverse events. • We do not know whether any of the other treatments looked at in this review are safer or more beneficial than others. What are the limitations of the evidence? The evidence is limited due to small participant numbers in the included studies, and because each study looked at a different comparison, both of which resulted in the evidence being imprecise. There were also issues with the way the studies were conducted, which led to concerns that study results might be biased. How up‐to‐date is this evidence? This review is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gordon, M; Grafton-Clarke, C; Rajindrajith, S; Benninga, M; Sinopoulou, V; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD014580.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "7fc99b04-2af4-4f73-bf9d-8d83d78e6f7a", "pmid": "", "title": "Antibiotics versus topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity. It is characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Antibiotics and antiseptics kill or inhibit the micro‐organisms that may be responsible for the infection. Antibiotics can be applied topically or administered systemically via the oral or injection route. Antiseptics are always directly applied to the ear (topically). Objectives To assess the benefits and harms of antibiotics versus antiseptics for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP). The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving adults and children who had chronic ear discharge of unknown cause or CSOM, where ear discharge had continued for more than two weeks. The intervention was any single, or combination of, antibiotic agent, whether applied topically (without steroids) or systemically. The comparison was any single, or combination of, topical antiseptic agent, applied as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The comparisons were 1. topical antiseptics compared to topical antibiotics, and 2. topical antiseptics compared to systemic antibiotics. We further separated these comparisons into those in which a. both groups of participants received aural toileting in addition to the intervention, or b. both groups received some other add‐on therapy treatment (such as systemic antibiotics) to both arms. Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This updated review included eight new studies. Overall, we identified 15 studies (2371 participants) across seven comparisons with antibiotics compared to acetic acid, aluminium acetate, boric acid, and povidone‐iodine. None of the included studies reported health‐related quality of life or serious complications. 1. Topical antibiotics (quinolones or aminoglycosides) versus topical antiseptic (acetic acid) We included seven studies (835 participants). Acetic acid may increase resolution of ear discharge when compared to aminoglycoside at one to two weeks (low‐certainty evidence). It is very uncertain whether acetic acid may increase resolution of ear discharge at one to two weeks when compared to topical quinolone. Results after four weeks were only presented narratively. It is very uncertain whether acetic acid may cause more ear pain, discomfort, local irritation, or combinations of these compared to topical antibiotics (aminoglycosides and quinolones) (risk ratio (RR) 0.20, 95% confidence interval (CI) 0.03 to 1.12; I 2 = 0%; 3 studies, 277 participants; very low‐certainty evidence). An additional two studies (350 participants) provided narrative results. There may be little to no difference in hearing between groups reported narratively (quinolones; low‐certainty evidence). The evidence is very uncertain for serious complications (aminoglycosides) or suspected ototoxicity (aminoglycosides) (very low‐certainty evidence). 2. Topical antibiotics (quinolones) versus topical antiseptic (boric acid) We included two studies (532 participants). Topical quinolones are likely to increase resolution of ear discharge at one to two weeks compared with boric acid ear drops (RR 1.86, 95% CI 1.48 to 2.35; 1 study, 411 participants; moderate‐certainty evidence). This means that one additional person will have resolution of ear discharge for every four people receiving topical antibiotics (compared with boric acid) at two weeks. No study reported results for ear discharge after four weeks. There may be less ear pain, discomfort, or irritation with quinolones compared with boric acid (RR 0.56, 95% CI 0.32 to 0.98; 2 studies, 510 participants; low‐certainty evidence). Suspected ototoxicity and serious complications were not reported. Topical quinolones may result in a greater improvement in mean hearing from baseline compared to topical boric acid (mean difference (MD) 2.79 decibels, 95% CI 0.48 to 5.10; 1 study, 390 participants; low‐certainty evidence), but this difference may not be clinically significant. 3. Topical antibiotics (quinolones) versus topical antiseptic (povidone‐iodine) We included one study (40 participants). It is very uncertain if there is a difference between quinolones and povidone‐iodine with respect to resolution of ear discharge at one to two weeks (RR 1.02, 95% CI 0.82 to 1.26; 1 RCT, 39 participants; very low‐certainty evidence). The study reported qualitatively that there were no differences between the groups for hearing and no participants developed ototoxic effects (very low‐certainty evidence). There were no results reported for resolution of ear discharge beyond four weeks; ear pain, discomfort, or irritation; or serious complications. 4. Topical antibiotics versus topical antiseptic (aluminium acetate) We included one study (51 participants; 60 ears) that presented results for resolution of ear discharge at two to four weeks results narratively. No other results were reported. 5. Other comparisons Five studies (966 participants) were assessed over an additional three comparisons; however, these results have not been included in the abstract. Authors' conclusions Treatment of CSOM with topical antibiotics (quinolones) likely results in an increase in resolution of ear discharge compared with boric acid at up to two weeks. There was limited evidence for the efficacy of other topical antibiotics or topical antiseptics and so we are unable to draw conclusions. Harmful effects were not well reported. Limitations of the review include lack of recent data, limitations in the quality of included studies, and limited information on certain population groups or interventions. Plain language summary Which are better, antibiotics or topical antiseptics, for treating chronic suppurative otitis media? Key message – There is limited evidence comparing topical antibiotics with topical antiseptics in people with swelling and infection of the middle ear (called chronic suppurative otitis media). The evidence is very uncertain whether antibiotics or topical antiseptics are more effective for reducing ear discharge, except that topical antibiotics are likely to be more effective than boric acid (an antiseptic). What is chronic suppurative otitis media? Chronic suppurative otitis media is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (where the eardrum has a hole or tear in it). The main symptoms of chronic suppurative otitis media are ear discharge (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Antibiotics (which kill bacteria) are the most commonly used treatment for chronic suppurative otitis media. Antibiotics can either be 'topical' (put into the ear canal as ear drops, ointments, sprays, or creams) or 'systemic' (taken either by mouth or by an injection into a muscle or vein). Topical antiseptics (antiseptics put directly into the ear as ear drops or powders) are a possible treatment for chronic suppurative otitis media. Both antibiotics and topical antiseptics kill or stop the growth of the germs that may be responsible for the infection. Antibiotics and topical antiseptics can be used on their own or added to other treatments for chronic suppurative otitis media, such as other antibiotics or ear cleaning (called aural toileting). It was important in this review to examine whether there were any unwanted effects from using antibiotics and antiseptics, such as irritation of the skin within the outer ear, which may cause discomfort, pain, or itching. Some antibiotics and antiseptics (such as alcohol) can also be toxic to the inner ear (called ototoxicity), which means that they may cause permanent hearing loss, dizziness, or ringing in the ear (called tinnitus). What was the aim of this review? We wanted to compare antibiotics and antiseptics for the treatment of chronic suppurative otitis media. In particular, we wanted to know whether they stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found 15 studies, which included 2371 people, that compared antibiotics to a variety of antiseptics (acetic acid, boric acid, povidone‐iodine, and aluminium acetate). One study recruited only children, two studies recruited only adults, and 12 studies included both adults and children. About 40 in every 100 people were females. We presented the main comparisons below. Comparison of antibiotics to acetic acid We included seven studies (835 people). We have little to no confidence in the evidence of whether topical antibiotics or acetic acid improved ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to boric acid We included two studies (532 people). Topical antibiotics (quinolones) are likely to be better than boric acid at reducing ear discharge after one to two weeks. There may also be less ear discomfort (pain, irritation, and bleeding). Topical quinolones may result in a greater improvement in hearing compared to topical boric acid, but this difference may be too small for the person to notice a difference. Comparison of antibiotics to povidone‐iodine We included one study (40 people). We have little to no confidence in the evidence of whether topical or systemic antibiotics or povidone‐iodine improve the resolution of ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to aluminium acetate We included one study (51 people) that stated there was improvement in ear discharge at two to four weeks, but they did not present their results in a way that we could use. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. What are the limitations of the evidence? The studies were small with many being poorly reported, and results varied widely between studies. We also need more information about harmful effects. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K; Chong, LY; Bhutta, MF; Daw, J; Veselinović, T; Morris, PS; Vijayasekaran, S; Schilder, AGM; Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013056.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "7feb29cd-5f17-4c60-84b7-5c6797238650", "pmid": "", "title": "Interventions for treating acute high altitude illness", "imported": false, "abstract": "Abstract - Background Acute high altitude illness is defined as a group of cerebral and pulmonary syndromes that can occur during travel to high altitudes. It is more common above 2500 metres, but can be seen at lower elevations, especially in susceptible people. Acute high altitude illness includes a wide spectrum of syndromes defined under the terms 'acute mountain sickness' (AMS), 'high altitude cerebral oedema' and 'high altitude pulmonary oedema'. There are several interventions available to treat this condition, both pharmacological and non‐pharmacological; however, there is a great uncertainty regarding their benefits and harms. Objectives To assess the clinical effectiveness, and safety of interventions (non‐pharmacological and pharmacological), as monotherapy or in any combination, for treating acute high altitude illness. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science, CINAHL, Wanfang database and the World Health Organization International Clinical Trials Registry Platform for ongoing studies on 10 August 2017. We did not apply any language restriction. Selection criteria We included randomized controlled trials evaluating the effects of pharmacological and non‐pharmacological interventions for individuals suffering from acute high altitude illness: acute mountain sickness, high altitude pulmonary oedema or high altitude cerebral oedema. Data collection and analysis Two review authors independently assessed the eligibility of study reports, the risk of bias for each and performed the data extraction. We resolved disagreements through discussion with a third author. We assessed the quality of evidence with GRADE. Main results We included 13 studies enrolling a total of 468 participants. We identified two ongoing studies. All studies included adults, and two studies included both teenagers and adults. The 13 studies took place in high altitude areas, mostly in the European Alps. Twelve studies included participants with acute mountain sickness, and one study included participants with high altitude pulmonary oedema. Follow‐up was usually less than one day. We downgraded the quality of the evidence in most cases due to risk of bias and imprecision. We report results for the main comparisons as follows. Non‐pharmacological interventions (3 studies, 124 participants) All‐cause mortality and complete relief of AMS symptoms were not reported in the three included trials. One study in 64 participants found that a simulated descent of 193 millibars versus 20 millibars may reduce the average of symptoms to 2.5 vs 3.1 units after 12 hours of treatment (clinical score ranged from 0 to 11 ‒ worse; reduction of 0.6 points on average with the intervention; low quality of evidence). In addition, no complications were found with use of hyperbaric chambers versus supplementary oxygen (one study; 29 participants; low‐quality evidence). Pharmacological interventions (11 trials, 375 participants) All‐cause mortality was not reported in the 11 included trials. One trial found a greater proportion of participants with complete relief of AMS symptoms after 12 and 16 hours when dexamethasone was administered in comparison with placebo (47.1% versus 0%, respectively; one study; 35 participants; low quality of evidence). Likewise, when acetazolamide was compared with placebo, the effects on symptom severity was uncertain (standardized mean difference (SMD) −1.15, 95% CI −2.56 to 0.27; 2 studies, 25 participants; low‐quality evidence). One trial of dexamethasone in comparison with placebo in 35 participants found a reduction in symptom severity (difference on change in the AMS score: 3.7 units reported by authors; moderate quality of evidence). The effects from two additional trials comparing gabapentin with placebo and magnesium with placebo on symptom severity at the end of treatment were uncertain. For gabapentin versus placebo: mean visual analogue scale (VAS) score of 2.92 versus 4.75, respectively; 24 participants; low quality of evidence. For magnesium versus placebo: mean scores of 9 and 10.3 units, respectively; 25 participants; low quality of evidence). The trials did not find adverse events from either treatment (low quality of evidence). One trial comparing magnesium sulphate versus placebo found that flushing was a frequent event in the magnesium sulphate arm (percentage of flushing: 75% versus 7.7%, respectively; one study; 25 participants; low quality of evidence). Authors' conclusions There is limited available evidence to determine the effects of non‐pharmacological and pharmacological interventions in treating acute high altitude illness. Low‐quality evidence suggests that dexamethasone and acetazolamide might reduce AMS score compared to placebo. However, the clinical benefits and harms related to these potential interventions remain unclear. Overall, the evidence is of limited practical significance in the clinical field. High‐quality research in this field is needed, since most trials were poorly conducted and reported. Plain language summary Treatments for high altitude (mountain) illness Background Acute high altitude illness, also known as acute mountain sickness, may present with a variety of symptoms. It is caused by the decreasing level of oxygen at increasingly high altitudes; and it can be experienced when reaching a high altitude when travelling, hiking or climbing mountains or other elevated areas. People going to altitudes over 4000 metres, females, people younger than mid‐adulthood , and people with a history of migraine are at greater risk of suffering from altitude sickness. The most common symptoms are headache, loss of appetite , insomnia, and nausea. However, severe forms can include confusion, difficulty walking, progressive cough, shortness of breath, and even death. Review question What are the benefits and risks of different treatments for people suffering from high altitude illness? Study characteristics We included 13 studies with a total of 468 participants. Most studies included participants with mild or moderate forms of mountain sickness, and only one study included the severe neurological (disorder of the nervous system) form. Follow‐up was usually less than one day. We also identified two ongoing studies. Key results We found studies evaluating the following interventions: simulated descent with a hyperbaric chamber (medical use of oxygen in a special chamber at greater than atmospheric pressure to increase the availability of oxygen in the body); oxygen; medicines: acetazolamide, dexamethasone, ibuprofen, paracetamol, gabapentin, sumatriptan, nitric oxide, and magnesium sulphate. None of the studies reported the effects of these interventions on all‐cause mortality. The report of complete relief from acute mountain sickness symptoms, and adverse events was infrequent. Studies related to simulated descent with the use of a hyperbaric chamber did not find additional benefits or harms related to this intervention (3 studies, 124 participants). In addition, studies related to administration of medicines found some benefits in terms of reduction of symptoms with the use of acetazolamide (2 studies, 25 participants), and dexamethasone (1 study, 35 participants), without an increase in side effects. Quality of the evidence The quality of the evidence we found was low, and thus our certainty in the findings is limited. There was insufficient information on how the studies were conducted, and in some cases there was evidence of tampering at some stages of the trials. Furthermore, the number of persons in each study was very small (< 30 participants), and therefore the results were not clear (imprecise). Some studies were not blinded (that is, participants knew what experimental treatment they were receiving), and this could have affected how the participants evaluated their own symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Simancas‐Racines, D; Arevalo‐Rodriguez, I; Osorio, D; Franco, JVA; Xu, Y; Hidalgo, R", "articleTypes": [], "doi": "10.1002/14651858.CD009567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "800f8a5c-e8c5-44cb-be58-1148f0cb6fb7", "pmid": "", "title": "Topical anaesthetics for pain control during repair of dermal laceration", "imported": false, "abstract": "Abstract - Background Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine‐free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017. Objectives To assess whether benefits of non‐invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single‐component or multi‐component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine. Search methods For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta‐registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010. Selection criteria We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence. Main results The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self‐reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine‐phenylephrine (PP) was higher than the mean self‐reported VAS (0 to 100 mm) score for topical tetracaine‐epinephrine‐cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine‐free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self‐limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine‐based or cocaine‐free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Authors' conclusions We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously. Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non‐invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine‐based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Plain language summary Local anaesthesia (numbing medicine) that is directly applied to the skin can provide pain control for repair of skin lacerations Background : Pain control during suturing of torn skin is generally achieved by injecting medication into the skin (infiltration) to numb the area. This injection itself may cause pain, but topical anaesthetics are applied directly to the skin and are painless to administer. Cocaine was one of the first anaesthetics to be successfully applied topically. Concerns over adverse effects of cocaine, its potential misuse and the administrative burden of dispensing a controlled substance led to the development of cocaine‐free topical anaesthetics. Multiple cocaine‐free topical anaesthetics have been found to provide effective anaesthesia for repair of dermal lacerations. Study characteristics : The evidence is current to December 2016. We included in this review 25 randomized controlled trials involving 3278 participants. Studies included both adults and children. Fifteen of the included trials used self‐reporting of pain intensity by trial participants to determine the effectiveness of local anaesthetics. Key results : Study results suggest that directly applying local anaesthetics to the skin is an effective, non‐invasive way of providing pain control during suturing or stapling of skin lacerations. Study findings on the efficacy of individual topical anaesthetics were limited by study design, and data on the efficacy of each topical agent were obtained mostly from single trials. Researchers reported no serious side effects following the use of cocaine‐containing or cocaine‐free topical anaesthetics. The overall broadly comparable effectiveness of cocaine‐free topical anaesthetics for skin laceration repair brings into question the necessity to include cocaine as a component of local anaesthetic solutions. The small number of trials in each comparison group and the range of outcome measures assessed prevented pooling and quantitative analysis of data for all but the single outcome of pain intensity. Additional studies are necessary to directly compare the effectiveness of different formulations of topical anaesthetics. Our review was limited to pain control for repair of superficial lacerations, and our results might not be generalizable to deeper lacerations or more complex procedures performed on intact skin. Further research is needed to strengthen the evidence and to overcome the weakness of the included studies. Quality of the evidence : The overall quality of the evidence was low owing to limitations in study design, ways that studies were carried out (implementation), imprecision of results and high probability of selective data reporting. Most of the trials that compared infiltrated and topical anaesthetics were at high risk of bias, and this was likely to influence measured effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tayeb, BO; Eidelman, A; Eidelman, CL; McNicol, ED; Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD005364.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "80112959-f08c-412d-9734-b2f7338c87f7", "pmid": "", "title": "Antibiotics prior to amniotomy for reducing infectious morbidity in mother and infant", "imported": false, "abstract": "Abstract - Background Amniotomy (the deliberate rupture of membranes) was described almost two centuries ago and since then has been used both for induction and augmentation of labour ‐ which are common obstetric practices. Trends have shown a rise in the induction rates over the last decade and data suggest that the rate of labour inductions is increasing faster than the rate of pregnancy complications. Recent years have seen the emergence of a variety of other methods of induction of labour but amniotomy combined with oxytocin infusion remains the most commonly used method of augmentation of labour. The newer agents for induction are expensive and in resource‐poor settings amniotomy is still the chosen method for both induction and augmentation. As with any invasive procedure amniotomy can lead to infection, ascending from the vagina into the uterine cavity and can contribute significantly to both maternal and neonatal infectious morbidity. Objectives The objective of this review was to evaluate the prophylactic use of antibiotics versus placebo or no treatment prior to amniotomy on maternal and neonatal infectious morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014), the International Clinical Trials Registry Platform ( ICTRP ) and ClinicalTrials.gov (12 September 2014). Selection criteria Randomised controlled trials or cluster‐randomised trials comparing antibiotics prior to amniotomy versus placebo (or no treatment) were eligible for inclusion in this review but none were identified. Quasi‐randomised trials or cross‐over trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed one trial report for inclusion. In future updates of this review, two review authors will independently assess risk of bias and carry out data extraction. Data will be checked for accuracy. Main results We identified one trial report but this was excluded. No studies met the inclusion criteria for this review. Authors' conclusions High‐quality trials are needed to justify or refute the routine use of antibiotics at amniotomy for prevention of infection in the mother and infant. Future studies should be conducted, especially in resource‐constrained settings where amniotomy is still used as a means of induction of labour, in order to evaluate the routine use of antibiotics at amniotomy in these settings. Future research in this area should include important maternal and infant outcomes listed in this review and also consider cost effectiveness and side effects of antibiotic use, including the emergence of antibiotic‐resistant strains. Plain language summary Antibiotic use before amniotomy (artificially rupturing the membranes) for reducing infections in mother and infant The artificial rupture of the membranes (amniotomy) is a common obstetrical procedure. It may be done to either initiate or to augment labour, with or without oxytocin. This invasive procedure allows vaginal micro‐organisms access into the uterine cavity, which can in turn lead to infections in both the mother and the infant. A greater time interval between rupture of membranes and delivery, as with induction of labour, increases the chances of an infection. The purpose of this review was to evaluate the routine use of antibiotics immediately prior to amniotomy for both initiation and augmentation of labour using randomised controlled trials. However, our search only identified one trial which did not meet the inclusion criteria for this review. Consequently, there is no evidence to support or refute the routine use of antibiotics prior to amniotomy. Randomised controlled trials on this topic are needed, especially in resource‐constrained settings where amniotomy is still used as a means of inducing labour, to evaluate the routine use of antibiotics at amniotomy in such settings. Future research in this area should also consider cost effectiveness and side effects of antibiotic use including the emergence of antibiotic‐resistant strains.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ray, A; Ray, S", "articleTypes": [], "doi": "10.1002/14651858.CD010626.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "8024dc1b-0a3b-44a3-becf-30b439240f95", "pmid": "", "title": "Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight", "imported": false, "abstract": "Abstract - Background The global prevalence of childhood and adolescent obesity is high. Lifestyle changes towards a healthy diet, increased physical activity and reduced sedentary activities are recommended to prevent and treat obesity. Evidence suggests that changing these health behaviours can benefit cognitive function and school achievement in children and adolescents in general. There are various theoretical mechanisms that suggest that children and adolescents with excessive body fat may benefit particularly from these interventions. Objectives To assess whether lifestyle interventions (in the areas of diet, physical activity, sedentary behaviour and behavioural therapy) improve school achievement, cognitive function (e.g. executive functions) and/or future success in children and adolescents with obesity or overweight, compared with standard care, waiting‐list control, no treatment, or an attention placebo control group. Search methods In February 2017, we searched CENTRAL, MEDLINE and 15 other databases. We also searched two trials registries, reference lists, and handsearched one journal from inception. We also contacted researchers in the field to obtain unpublished data. Selection criteria We included randomised and quasi‐randomised controlled trials (RCTs) of behavioural interventions for weight management in children and adolescents with obesity or overweight. We excluded studies in children and adolescents with medical conditions known to affect weight status, school achievement and cognitive function. We also excluded self‐ and parent‐reported outcomes. Data collection and analysis Four review authors independently selected studies for inclusion. Two review authors extracted data, assessed quality and risks of bias, and evaluated the quality of the evidence using the GRADE approach. We contacted study authors to obtain additional information. We used standard methodological procedures expected by Cochrane. Where the same outcome was assessed across different intervention types, we reported standardised effect sizes for findings from single‐study and multiple‐study analyses to allow comparison of intervention effects across intervention types. To ease interpretation of the effect size, we also reported the mean difference of effect sizes for single‐study outcomes. Main results We included 18 studies (59 records) of 2384 children and adolescents with obesity or overweight. Eight studies delivered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies delivered dietary interventions. We included five RCTs and 13 cluster‐RCTs. The studies took place in 10 different countries. Two were carried out in children attending preschool, 11 were conducted in primary/elementary school‐aged children, four studies were aimed at adolescents attending secondary/high school and one study included primary/elementary and secondary/high school‐aged children. The number of studies included for each outcome was low, with up to only three studies per outcome. The quality of evidence ranged from high to very low and 17 studies had a high risk of bias for at least one item. None of the studies reported data on additional educational support needs and adverse events. Compared to standard practice, analyses of physical activity‐only interventions suggested high‐quality evidence for improved mean cognitive executive function scores. The mean difference (MD) was 5.00 scale points higher in an after‐school exercise group compared to standard practice (95% confidence interval (CI) 0.68 to 9.32; scale mean 100, standard deviation 15; 116 children, 1 study). There was no statistically significant beneficial effect in favour of the intervention for mathematics, reading, or inhibition control. The standardised mean difference (SMD) for mathematics was 0.49 (95% CI ‐0.04 to 1.01; 2 studies, 255 children, moderate‐quality evidence) and for reading was 0.10 (95% CI ‐0.30 to 0.49; 2 studies, 308 children, moderate‐quality evidence). The MD for inhibition control was ‐1.55 scale points (95% CI ‐5.85 to 2.75; scale range 0 to 100; SMD ‐0.15, 95% CI ‐0.58 to 0.28; 1 study, 84 children, very low‐quality evidence). No data were available for average achievement across subjects taught at school. There was no evidence of a beneficial effect of physical activity interventions combined with healthy lifestyle education on average achievement across subjects taught at school, mathematics achievement, reading achievement or inhibition control. The MD for average achievement across subjects taught at school was 6.37 points lower in the intervention group compared to standard practice (95% CI ‐36.83 to 24.09; scale mean 500, scale SD 70; SMD ‐0.18, 95% CI ‐0.93 to 0.58; 1 study, 31 children, low‐quality evidence). The effect estimate for mathematics achievement was SMD 0.02 (95% CI ‐0.19 to 0.22; 3 studies, 384 children, very low‐quality evidence), for reading achievement SMD 0.00 (95% CI ‐0.24 to 0.24; 2 studies, 284 children, low‐quality evidence), and for inhibition control SMD ‐0.67 (95% CI ‐1.50 to 0.16; 2 studies, 110 children, very low‐quality evidence). No data were available for the effect of combined physical activity and healthy lifestyle education on cognitive executive functions. There was a moderate difference in the average achievement across subjects taught at school favouring interventions targeting the improvement of the school food environment compared to standard practice in adolescents with obesity (SMD 0.46, 95% CI 0.25 to 0.66; 2 studies, 382 adolescents, low‐quality evidence), but not with overweight. Replacing packed school lunch with a nutrient‐rich diet in addition to nutrition education did not improve mathematics (MD ‐2.18, 95% CI ‐5.83 to 1.47; scale range 0 to 69; SMD ‐0.26, 95% CI ‐0.72 to 0.20; 1 study, 76 children, low‐quality evidence) and reading achievement (MD 1.17, 95% CI ‐4.40 to 6.73; scale range 0 to 108; SMD 0.13, 95% CI ‐0.35 to 0.61; 1 study, 67 children, low‐quality evidence). Authors' conclusions Despite the large number of childhood and adolescent obesity treatment trials, we were only able to partially assess the impact of obesity treatment interventions on school achievement and cognitive abilities. School and community‐based physical activity interventions as part of an obesity prevention or treatment programme can benefit executive functions of children with obesity or overweight specifically. Similarly, school‐based dietary interventions may benefit general school achievement in children with obesity. These findings might assist health and education practitioners to make decisions related to promoting physical activity and healthy eating in schools. Future obesity treatment and prevention studies in clinical, school and community settings should consider assessing academic and cognitive as well as physical outcomes. Plain language summary Healthy weight interventions for improving thinking skills and school performance in children and teenagers with obesity What is the aim of this review? The aim of this Cochrane Review was to find out if healthy weight interventions can improve thinking skills and school performance in children and teenagers with obesity. Cochrane researchers collected and analysed all relevant studies to answer this question. What are the key messages? This updated review provides some evidence that school programmes that encourage healthier child weight may also provide ‘co‐benefits’ of thinking skills and school performance. However, we need more high‐quality healthy‐weight interventions that test thinking skills and school performance, as well as health outcomes. What was studied in this review? The number of children and teenagers with obesity is high worldwide. Some children and teenagers with obesity have health issues or are bullied because of their body weight. These experiences have been linked to problems in performing well in school, where they tend to perform less well in thinking tasks such as problem‐solving. Physical activity and healthy eating benefit a healthy body weight and improve thinking skills and school performance in children with a healthy weight. Studies found that healthy‐weight interventions can reduce obesity in children and teenagers, but it is unknown if and how well healthy‐weight interventions can improve thinking skills and school performance in children and teenagers with obesity. What are the main results of this review? The review authors found 18 studies which included a total of 2384 children and teenagers with obesity. Five studies assigned individual children to intervention or control groups. Thirteen studies allocated entire classes, school or school districts to the intervention and control group. Of the 18 studies, 11 involved children at primary/elementary‐school age. Eight studies offered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies offered dietary changes. The studies took place in 10 different countries. Seventeen studies had at least one flaw in how the study was done. This reduces the level of confidence we can have in the findings. Few studies shared the same type of school performance or thinking skills. Only three studies reported the same outcome. None of the studies reported on additional educational support needs and harmful events. We found that, compared with usual routine, physical activity interventions can lead to small improvements in problem‐solving skills. This finding was based on high‐quality evidence. Moderate‐quality findings showed that physical activity interventions do not improve mathematics and reading achievement in children with obesity. Very low‐quality evidence also suggested no benefits of physical activity interventions for improving uncontrolled behavioural responses. General school achievement was not reported in studies comparing physical activity interventions with standard practice. Studies that compared physical activity interventions plus healthy lifestyle education with standard practice were of low to very low quality. They showed no improvement in school achievement or uncontrolled behavioural responses in the intervention group compared to the control group. Problem‐solving skills were not reported in studies comparing physical activity plus healthy lifestyle education with standard practice. Our findings indicate that changing knowledge about nutrition, and changing the food offered in schools can lead to moderate improvements in general school achievement of teenagers with obesity, when compared to standard school practice. Replacing packed school lunch with a nutrient‐rich diet plus nutrition education did not improve mathematics and reading achievement of children with obesity. However, the quality of evidence for general school achievement, mathematics and reading was low. This means that future research is very likely to change the results, because included studies showed some methodological weaknesses (for example, small numbers of children and a high dropout of children from studies). Problem‐solving skills and uncontrolled behavioural responses were not reported for dietary intervention studies. How up‐to‐date is this review? The review authors searched the scientific literature for relevant studies in February 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Martin, A; Booth, JN; Laird, Y; Sproule, J; Reilly, JJ; Saunders, DH", "articleTypes": [], "doi": "10.1002/14651858.CD009728.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "802e2b64-10ac-42b6-ba53-51f0f09363b6", "pmid": "", "title": "Sapropterin dihydrochloride for phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria results from a deficiency of the enzyme phenylalanine hydroxylase. Dietary restriction of phenylalanine keeps blood phenylalanine concentration low. Most natural foods are excluded from diet and supplements are used to supply other nutrients. Recent publications report a decrease in blood phenylalanine concentration in some patients treated with sapropterin dihydrochloride. We examined the evidence for the use of sapropterin dihydrochloride to treat phenylketonuria. This is an update of a previously published Cochrane Review. Objectives To assess the safety and efficacy of sapropterin dihydrochloride in lowering blood phenylalanine concentration in people with phenylketonuria. Search methods We identified relevant trials from the Group's Inborn Errors of Metabolism Trials Register. Date of last search: 11 August 2014. We also searched ClinicalTrials.gov and Current controlled trials. Last search: 4 September 2014 We contacted the manufacturers of the drug (BioMarin Pharmaceutical Inc.) for information regarding any unpublished trials. Selection criteria Randomized controlled trials comparing sapropterin with no supplementation or placebo in people with phenylketonuria due to phenylalanine hydroxylase deficiency. Data collection and analysis Two authors independently assessed trials and extracted outcome data. Main results Two placebo‐controlled trials were included. One trial administered 10 mg/kg/day sapropterin in 89 children and adults with phenylketonuria whose diets were not restricted and who had previously responded to saproterin.This trial measured change in blood phenylalanine concentration. The second trial screened 90 children (4 to 12 years) with phenylketonuria whose diet was restricted, for responsiveness to sapropterin. Forty‐six responders entered the placebo‐controlled part of the trial and received 20 mg/kg/day sapropterin. This trial measured change in both phenylalanine concentration and protein tolerance. Both trials reported adverse events. The trials showed an overall low risk of bias; but both are Biomarin‐sponsored. One trial showed a significant lowering in blood phenylalanine concentration in the sapropterin group (10 mg/kg/day), mean difference ‐238.80 μmol/L (95% confidence interval ‐343.09 to ‐134.51); a second trial (20 mg/kg/day sapropterin) showed a non‐significant difference, mean difference ‐51.90 μmol/L (95% confidence interval ‐197.27 to 93.47). The second trial also reported a significant increase in phenylalanine tolerance, mean difference18.00 mg/kg/day (95% confidence interval 12.28 to 23.72) in the 20 mg/kg/day sapropterin group. Authors' conclusions There is evidence of short‐term benefit from using sapropterin in some people with sapropterin‐responsive forms of phenylketonuria; blood phenylalanine concentration is lowered and protein tolerance increased. There are no serious adverse events associated with using sapropterin in the short term. There is no evidence on the long‐term effects of sapropterin and no clear evidence of effectiveness in severe phenylketonuria. Plain language summary The use of sapropterin to lower phenylalanine concentration in blood in people with phenylketonuria. Phenylketonuria occurs due to an inherited deficiency of the enzyme phenylalanine hydroxylase. If untreated it causes an excessive accumulation of the amino acid phenylalanine in the body which prevents normal brain development. The established treatment for phenylketonuria consists of dietary restriction of natural protein but with prescribed phenylalanine‐free amino acid, mineral and vitamin supplements. With this treatment the long‐term outcome for people with phenylketonuria is excellent but the diet is onerous. Sapropterin dihydrochloride, the cofactor for phenylalanine hydroxylase, could lower phenylalanine concentration significantly in phenylketonuria and might allow a relaxation of dietary restrictions. The review identified two trials of sapropterin dihydrochloride; one in children and adults with no restricted diet and one in just children whose diet was restricted. The trials used different doses of sapropterin dihydrochloride (10 mg/kg/day and 20 mg/kg/day). We could not combine any data due to different formats of presentation. We found evidence to show that some people with mild or moderate phenylketonuria can benefit from the use of sapropterin dihydrochloride in the short term; the concentration of blood phenylalanine was lowered after treatment in both trials. The trial with the higher dose also measured the outcome change in protein tolerance. It reported an increase in protein tolerance in response to sapropterin. There were no adverse effects associated with the use of sapropterin dihydrochloride in the short term. We found no evidence on the effects of long‐term treatment. We could not draw any conclusions on its benefits in severe phenylketonuria.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Somaraju, UR, Merrin, M", "articleTypes": [], "doi": "10.1002/14651858.CD008005.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.078Z" }, { "id": "80464512-9888-401e-adb4-e78cde852ae8", "pmid": "", "title": "Zinc supplementation for the prevention of pneumonia in children aged 2 months to 59 months", "imported": false, "abstract": "Abstract - Background Pneumonia is a leading cause of morbidity and mortality in children younger than five years of age. Most deaths occur during infancy and in low‐income countries. Daily zinc supplements have been reported to prevent acute lower respiratory tract infection (LRTI) and reduce child mortality. This is an update of a review first published in 2010. Objectives To evaluate the effectiveness of zinc supplementation in the prevention of pneumonia in children aged two to 59 months. Search methods We searched CENTRAL (Issue 21 October 2016), MEDLINE (1966 to October 2016), Embase (1974 to October 2016), LILACS (1982 to October 2016), CINAHL (1981 to October 2016), Web of Science (1985 to October 2016) and IMSEAR (1980 to October 2016). Selection criteria Randomised controlled trials (RCTs) evaluating zinc supplementation for the prevention of pneumonia in children aged from 2 months to 59 months. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We did not identify any new studies for inclusion in this update. We included six studies that involved 5193 participants. Analysis showed that zinc supplementation reduced the incidence of pneumonia by 13% (fixed‐effect risk ratio (RR) 0.87; 95% confidence interval (CI) 0.81 to 0.94, six studies, low‐quality evidence) and prevalence of pneumonia by 41% (random‐effects RR 0.59; 95% CI 0.35 to 0.99, one study, n = 609, low‐quality evidence). On subgroup analysis, we found that zinc reduced the incidence of pneumonia defined by specific clinical criteria by 21% (i.e. confirmation by chest examination or chest radiograph) (fixed‐effect RR 0.79; 95% CI 0.71 to 0.88, four studies, n = 3261), but had no effect on lower specificity pneumonia case definition (i.e. age‐specific fast breathing with or without lower chest indrawing) (fixed‐effect RR 0.95; 95% CI 0.86 to 1.06, four studies, n = 1932). Authors' conclusions Zinc supplementation in children is associated with a reduction in the incidence and prevalence of pneumonia. Plain language summary Zinc supplementation for the prevention of pneumonia in children aged two to 59 months Review question We evaluated the effectiveness of zinc supplementation to prevent pneumonia in children aged from two to 59 months. Background Zinc is an essential element for children's growth and development. Too little zinc is associated with increased risk of infection, particularly diarrhoea and pneumonia. Children are more prone to zinc deficiency because they are less able to absorb dietary zinc and some children, especially in low‐income countries, may not have received enough zinc from their mothers before birth. Zinc supplements for children has been reported to prevent pneumonia. Search date We searched the literature up to October 2016. This is an update of a review published in 2010. We did not find any new studies for this update. Study characteristics We included six studies that investigated zinc supplements to prevent pneumonia. The studies were conducted in Bangladesh, India, Peru and South Africa and involved 5193 children aged from two to 59 months. Children received either zinc or a similar‐looking treatment that did not contain zinc. In two studies, children were also given vitamin A. Study funding sources All included studies were funded. Of these, three explicitly mentioned that funding agencies had no role in the design and results of the study. Key results Zinc supplementation was significantly associated with reducing the incidence and prevalence of pneumonia among children aged from two to 59 months. On subgroup analysis, we found that a more stringent diagnosis (radiological examination) increased the reduction in pneumonia incidence. Quality of the evidence Overall, evidence quality was assessed as low on GRADE assessment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lassi, ZS, Moin, A, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD005978.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.754Z" }, { "id": "804b8e0a-25cc-40f2-9deb-0fc05d45115c", "pmid": "", "title": "Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)", "imported": false, "abstract": "Abstract - Background Idiopathic acute vestibular dysfunction (vestibular neuritis) is the second most common cause of peripheral vertigo after benign paroxysmal positional vertigo (BPPV) and accounts for 7% of the patients who present at outpatient clinics specialising in the treatment of dizziness. The exact aetiology of the condition is unknown and the effects of corticosteroids on the condition and its recovery are uncertain. Objectives To assess the effectiveness of corticosteroids in the management of patients with idiopathic acute vestibular dysfunction (vestibular neuritis). Search methods We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 28 December 2010. Selection criteria Randomised controlled trials comparing corticosteroids with placebo, no treatment or other active treatments, for adults diagnosed with idiopathic acute vestibular dysfunction. Data collection and analysis Two authors independently selected studies from the search results and extracted data. Three authors independently assessed risk of bias. Main results Four trials, involving a total of 149 participants, compared the effectiveness of oral corticosteroids against placebo. All the trials were small and of low methodological quality. Although there was an overall significant effect of corticosteroids compared with placebo medication on complete caloric recovery at one month (risk ratio (RR) of 2.81; 95% confidence interval (CI) 1.32 to 6.00, P = 0.007), no significant effect was seen on complete caloric recovery at 12 months (RR 1.58; 95% CI 0.45 to 5.62, P = 0.48), or on the extent of caloric recovery at either one month (mean difference (MD) 9.60%; 95% CI ‐20.66 to 39.86, P = 0.53) or at 12 months (MD 6.83%; 95% CI ‐27.69 to 41.36, P = 0.70). In addition, there was no significant difference between corticosteroids and placebo medication in the symptomatic recovery of vestibular function following idiopathic acute vestibular dysfunction with respect to vertigo at 24 hours (RR 0.39; 95% CI 0.04 to 3.57, P = 0.40) and use of the Dizziness Handicap Inventory score at one, three, six and 12 months. Authors' conclusions Overall, there is currently insufficient evidence from these trials to support the administration of corticosteroids to patients with idiopathic acute vestibular dysfunction. We found no trials with a low risk of methodological bias that used the highest level of diagnostic criteria and outcome measures. We recommend that future studies should include health‐related quality of life and symptom‐based outcome measures, in addition to objective measures of vestibular improvement, such as caloric testing and electronystagmography. Plain language summary Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis) Idiopathic acute vestibular dysfunction (vestibular neuritis) is a common condition of unknown cause. Patients with the condition often experience dizziness, nausea or vomiting, and trouble with vision, balance or mobility, but have normal hearing and no tinnitus. It has been proposed that a course of corticosteroids, if given early on, may improve recovery from the condition and long‐term patient outcome. However, corticosteroids can cause adverse effects (e.g. bleeding stomach ulcer, mood changes, etc.). This review identified four randomised controlled trials including 149 adult patients with idiopathic acute vestibular dysfunction (vestibular neuritis) treated with either corticosteroids or placebo. The studies were varied in that they used different drugs and different treatment regimens. On the basis of these studies, there is currently insufficient evidence in favour of corticosteroids over placebo medication in the symptomatic recovery and objective testing of vestibular function, both in the short‐term and long‐term. Further studies of higher quality are needed to test the effectiveness of corticosteroids in patients with the condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fishman, JM, Burgess, C, Waddell, A", "articleTypes": [], "doi": "10.1002/14651858.CD008607.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.763Z" }, { "id": "80544bc9-7608-4cfb-bfa4-3e140f6d33b9", "pmid": "", "title": "Helminth therapy (worms) for allergic rhinitis", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a disorder of the nasal membranes and surrounding tissues, and a worldwide cause of illness and disability. Helminths are complex tissue‐dwelling or lumen‐dwelling organisms that inhabit larger organisms and are frequently asymptomatic. Helminths modulate the natural immune responses of their human hosts, and may prevent or cure immune‐mediated or allergic diseases (e.g. allergic rhinitis) in the host. Non‐randomised studies support this hypothesis. Objectives To assess the safety and effectiveness of helminth therapy in people with allergic rhinitis. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2011. Selection criteria All randomised controlled trials where the intervention was any helminth species or combination of helminth species, administered to people with allergic rhinitis in any dose, by any route and for any duration of exposure. We accepted both intermittent and persistent allergic rhinitis patients. Data collection and analysis We independently extracted data and assessed eligibility and risk of bias using a standardised data collection form. We resolved any disagreement through discussion. We combined dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), presenting both with 95% confidence intervals (CI). Main results We found five reports of two single‐centre, placebo‐controlled, double‐blinded studies (130 participants). Participants in both studies were a mix of adults with either intermittent or persistent allergic rhinitis. Both studies had a low risk of bias. One study, with 12 weeks’ follow‐up, used a single percutaneous application of 10 Necator americanus (i.e. human hookworm) larvae. The other study, with 24 weeks’ follow‐up, used three‐weekly oral dosing with 2500 Trichuris suis (i.e. pig whipworm) eggs in aqueous suspension. Of 17 outcomes evaluated in this review, eight were positive (i.e. favoured helminths). Participants taking helminths had no reduction in allergic rhinitis symptoms, percentage of well days (i.e. days with minimal symptoms and no use of medication for allergic rhinitis), lung function measures and quality of life scores. Total use of medication for allergic rhinitis (eye drops, nasal sprays, tablets) did not change; however, in the helminth group there was a statistically significant reduction in the percentage of days during the grass pollen season when participants needed to take tablets as rescue medication for their allergic rhinitis symptoms (MD –14.0%, 95% CI –26.6 to –1.40); in a typical 60‐day pollen season this 14% reduction translates into 19 days when tablets would be needed in the helminth group versus 27 days when tablets would be needed in the placebo group. Participants taking helminths percutaneously (i.e. as hookworm larvae) had local skin itching and redness in the first few days after administration. Participants taking helminths were more likely to report any gastrointestinal adverse event (RR 1.79, 95% CI 1.31 to 2.45), moderate or severe abdominal pain (RR 7.67, 95% CI 1.87 to 31.57), moderate or severe flatulence (RR 2.01, 95% CI 1.06 to 3.81) and moderate or severe diarrhoea (RR 1.99, 95% CI 1.18 to 3.37). There was no difference between the helminth and placebo groups in the incidence of serious adverse events, and in study withdrawals. Authors' conclusions There is currently insufficient evidence on the efficacy, tolerability and likely costs of helminth therapy to support its use in the routine management of allergic rhinitis. Administered to humans in carefully measured doses, helminths appear to be safe. More preclinical studies should be performed, before larger and extended duration trials of helminths for allergic rhinitis are carried out. Future studies should collect and report comparative data on the costs of helminth therapy versus conventional pharmacotherapy. Plain language summary Helminth therapy (worms) for allergic rhinitis Allergic rhinitis is a common health problem affecting about 500 million people worldwide; its prevalence is increasing. The symptoms of allergic rhinitis include sneezing, and an itchy, runny and blocked nose. Several classes of drugs are used to treat allergic rhinitis, but these drugs may be ineffective, and some drug classes have side effects after long‐term use. Drugs may also be relatively expensive. Helminths are complex multicellular organisms that inhabit larger organisms, and in humans are often symptomless. Helminths modulate (that is, optimally adjust) the immune systems of their hosts and it is thought that this property of helminths could be used therapeutically, to prevent or treat allergic diseases, such as allergic rhinitis. We included two well‐designed studies with a total of 130 adult participants, each study using a different species of gastrointestinal helminth (human hookworm in one study and pig whipworm in the other) as the intervention. Both studies found no significant efficacy from helminths, although one helminth species ( Trichuris suis , the pig whipworm) reduced the need for participants to take tablets as ‘rescue medication’ during the grass pollen season. Adverse events such as abdominal pain and flatulence were commoner in the helminth group, but the two helminths species studied did not cause serious adverse reactions. Currently there is insufficient evidence to support the use of helminths for allergic rhinitis in routine clinical practice. More preclinical studies are needed, before larger and extended duration clinical trials of helminths for allergic rhinitis are performed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Croft, AM; Bager, P; Garg, SK", "articleTypes": [], "doi": "10.1002/14651858.CD009238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "80894f20-07cf-44ae-88ba-f647684485f6", "pmid": "", "title": "Optimisation of antiretroviral therapy in HIV‐infected children under 3 years of age", "imported": false, "abstract": "Abstract - Background In the absence of antiretroviral therapy (ART), over 50% of HIV‐infected infants progress to AIDS and death by 2 years of age. However, there are challenges to initiation of ART in early life, including the possibility of drug resistance in the context of prevention of mother‐to‐child transmission (PMTCT) programs, a paucity of drug choices , uncertain dosing for some medications and long‐term toxicities. Key management decisions include when to start ART, what regimen to start, and whether and when to substitute drugs or interrupt therapy. This review, an update of a previous review, aims to summarize the currently available evidence on this topic and inform the ART management in HIV‐infected children less than 3 years of age. Objectives To evaluate 1) when to start ART in young children (less than 3 years); 2) what ART to start with, comparing first‐line non‐nucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI)‐based regimens; and 3) whether alternative strategies should be used to optimize antiretroviral treatment in this population: induction (initiation with 4 drugs rather than 3 drugs) followed by maintenance ART, interruption of ART and substitution of PI with NNRTI drugs once virological suppression is achieved on a PI‐based regimen. Search methods Search methods We searched for published studies in the Cochrane HIV/AIDS Review Group Trials Register, The Cochrane Library, Pubmed, EMBASE and CENTRAL. We screened abstracts from relevant conference proceedings and searched for unpublished and ongoing trials in clinical trial registries (ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform). Selection criteria We identified RCTs that recruited perinatally HIV‐infected children under 3 years of age without restriction of setting. We rejected trials that did not include children less than 3 years of age, did not provide stratified outcomes for those less than 3 years or did not evaluate either timing of ART initiation, choice of drug regimen or treatment switch/interruption strategy. Data collection and analysis Two reviewers independently applied study selection criteria, assessed study quality and extracted data. Effects were assessed using the hazard ratio (HR) for time‐to‐event outcomes, relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes. Main results A search of the databases identified a total of 735 unique, previously unreviewed studies, of which 731 were excluded to leave 4 new studies to incorporate into the review. Four additional studies were identified in conference proceedings, for a total of 8 studies addressing when to start treatment (n=2), what to start (n=3), whether to substitute lopinavir/ritonavir (LPV/r) with nevirapine (NVP) (n=1), whether to use an induction‐maintenance ART strategy (n=1) and whether to interrupt treatment (n=1). Treatment initiation in asymptomatic infants with good immunological status was associated with a 75% reduction (HR=0.25; 95%CI 0.12‐0.51; p=0.0002) in mortality or disease progression in the one trial with sufficient power to address this question. In a smaller pilot trial, median CD4 cell count was not significantly different between early and deferred treatment groups 12 months after ART. Regardless of previous exposure to nevirapine for PMTCT, the hazard for treatment failure at 24 weeks was 1.79 (95%CI 1.33, 2.41) times higher in children starting ART with a NVP���based regimen compared to those starting with a LPV/r‐based regimen (p=0.0001) with no clear difference in the effect observed for children younger or older than 1 year. The hazard for virological failure at 24 weeks was overall 1.84 (95%CI 1.29, 2.63) times higher for children starting ART with a NVP‐based regimen compared to those starting with a LPV/r‐based regimen (p=0.0008) with a larger difference in time to virological failure (or death) between the NVP and LPV/r‐based regimens when ART was initiated in the first year of life. Infants starting a LPV/r regimen and achieving sustained virological suppression who then substituted LPV/r with NVP after median 9 months on LPV/r were less likely to develop virological failure (defined as at least one VL greater than 50 copies/mL) compared with infants who started and stayed on LPV/r (HR=0.62, 95%CI 0.41, 0.92, p=0.02). However the hazard for confirmed failure at a higher viral load (>1000 copies/mL) was greater among children who switched to NVP compared to those who remained on LPV/r (HR=10.19, 95% CI 2.36, 43.94, p=0.002). Children undergoing an induction‐maintenance ART approach with a 4‐drug NNRTI‐based regimen for 36 weeks, followed by 3‐drug ART, had significantly greater CD4 rise than children receiving a standard 3‐drug NNRTI‐based ART at 36 weeks (mean difference 1.70 [95%CI 0.61, 2.79] p=0.002) and significantly better viral load response at 24 weeks (OR 1.99 [95%CI 1.09, 3.62] p=0.02). However, the immunological and virological benefits were short‐term. The one trial of treatment interruption that compared children initiating continuous ART from infancy with children interrupting ART was terminated early because the duration of treatment interruption was less than 3 months in most infants. Children interrupting treatment had similar growth and occurrence of serious adverse events as those in the continuous arm. Authors' conclusions ART initiation in asymptomatic children under 1 year of age reduces morbidity and mortality, but it remains unclear whether there are clinical benefits to starting ART in asymptomatic children diagnosed with HIV infection between 1‐3 years. The available evidence shows that a LPV/r‐based first‐line regimen is more efficacious than a NVP‐based regimen, regardless of PMTCT exposure status. New formulations of LPV/r are urgently required to enable new WHO recommendations to be implemented. An alternative approach to long‐term LPV/r is substituting LPV/r with NVP once virological suppression is achieved. This strategy looked promising in the one trial undertaken, but may be difficult to implement in the absence of routine viral load testing. A 4‐drug induction‐maintenance approach showed short‐term virological and immunological benefits during the induction phase but, in the absence of sustained benefits, is not recommended as a routine treatment strategy. Treatment interruption following early ART initiation in infancy was challenging for children who were severely immunocompromised in the context of poor clinical immunological condition at ART initiation due to the short duration of interruption, and is therefore not practical in ART treatment programmes where close monitoring is not feasible. Plain language summary Using antiretroviral drugs to treat children under 3 years old who have HIV infection Children under 3 years of age who have HIV infection have a high risk of dying without antiretroviral therapy (ART). However, treatment in this age group is challenging because there are high levels of virus in the blood and few suitable drug choices. Results from this systematic review show that ART soon after birth is preferable to delaying treatment, because infants are less likely to die or become sick. Starting a first‐line treatment regimen that includes lopinavir/ritonavir rather than nevirapine is preferable, because infants and young children are less likely to have to stop treatment, whether or not they had previously been exposed to nevirapine. However, lopinavir/ritonavir is more expensive than nevirapine. It is also currently only available as an inconvenient liquid, which tastes bitter and has to be refrigerated, making it challenging to implement in all parts of the world. While waiting for better formulations to become available, it may be possible to switch from lopinavir/ritonavir to nevirapine once the HIV virus levels become undetectable. However, based on the evidence currently available, a viral load test would be required to identify those children who could safely substitute lopinavir/ritonavir with nevirapine. Viral loads are expensive and not widely available in most countries in sub‐Saharan Africa. An alternative treatment approach is to give a stronger drug combination (four different drugs together) when treatment is first started, then reduce down to three drugs after a short while. However, this strategy did not appear to have long‐term benefits. A 'treatment interruption' strategy, in which infants start ART soon after birth but then stop medication after 1‐2 years, is difficult to implement. Children stopping ART need to restart it very quickly to prevent them becoming sick, and monitoring a child off treatment is challenging in settings with few resources.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Penazzato, M; Prendergast, AJ; Muhe, LM; Tindyebwa, D; Abrams, E", "articleTypes": [], "doi": "10.1002/14651858.CD004772.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "80b34ae2-b676-412b-bb02-f94c7cac4188", "pmid": "", "title": "Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Ethnic minority groups in upper‐middle‐income and high‐income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population. Objectives To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Search methods A systematic literature search was performed of the following databases: The Cochrane Library , MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well. Selection criteria We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper‐middle‐income or high‐income countries. Data collection and analysis Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification. Main results A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta‐analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education. Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) ‐0.4% (95% confidence interval (CI) ‐0.5 to ‐0.2); 14 trials; 1442 participants; high‐quality evidence) and at six months (MD ‐0.5% (95% CI ‐0.7 to ‐0.4); 14 trials; 1972 participants; high‐quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD ‐0.2% (95% CI ‐0.3 to ‐0.04); 9 trials; 1936 participants) and at 24 months (MD ‐0.3% (95% CI ‐0.6 to ‐0.1); 4 trials; 2268 participants; moderate‐quality evidence) post intervention. Neutral effects on health‐related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies — the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI ‐40 to ‐8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low‐density lipoprotein (LDL) cholesterol or high‐density lipoprotein (HDL) cholesterol were reported at any follow‐up point. Other outcome measures (blood pressure, body mass index, self‐efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient. Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self‐reported via questionnaires, leading to high bias in subjective outcome assessment. Authors' conclusions Culturally appropriate health education has short‐ to medium‐term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long‐term trials, and so clinically important long‐term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long‐term, standardised, multi‐centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium‐term effects could lead to clinically important health outcomes, if sustained. Plain language summary Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus Review question Does culturally appropriate diabetes health education lead to better outcomes than 'usual care' for people in ethnic minority groups with type 2 diabetes? Background In upper‐middle‐income and high‐income countries, minority ethnic groups often have a higher prevalence of type 2 diabetes mellitus than is seen in the local population. They also tend to come from lower socioeconomic backgrounds, with attendant difficulties in accessing good‐quality health care. In some cases, cultural and communication barriers increase the problems that minority ethnic communities experience when attempting to access good‐quality diabetes health education, which is vital for those who wish to understand diabetes and use available services to gain empowerment and bring about behaviour change toward a healthier lifestyle. In this review, 'culturally appropriate' health education is taken to mean any type of health education that has been specifically tailored to the cultural needs of a target minority group with type 2 diabetes mellitus. Study characteristics This updated review found in the world literature 33 randomised controlled trials (RCTs) of culturally appropriate health education on diabetes that met the selection criteria (participants from a defined ethnic minority group living in a upper‐middle‐income or high‐income country, over 16 years of age, diagnosed with type 2 diabetes mellitus and receiving a culturally tailored health education intervention). The median duration of the intervention was six months, and a total of 7453 participants were involved in the studies. Key results Culturally appropriate health education improved blood sugar control among participants, compared with those receiving 'usual' care, at three, six, 12 and 24 months after the intervention was provided. Knowledge about diabetes improved, and participants attained healthier lifestyles. No information was available regarding complications of diabetes and death from any cause, and there was a general lack of reporting of adverse effects in most studies. Neutral effects were observed for health‐related quality of life, blood lipids like cholesterol, blood pressure and weight. The costs of educational programmes were rarely analysed. Compared with the first review, performed in 2008 (11 studies), many more published studies were identified in this review (altogether 33 studies), strengthening the original findings that blood sugar control and knowledge of diabetes are improved when culturally appropriate health education is provided to people in ethnic minority groups diagnosed with diabetes. The effects of this improvement are shown in this update as lasting longer — up to 24 months after health education was provided in some trials. However, additional high‐quality standardised RCTs of longer duration are needed, along with full evaluation of costs. Quality of the evidence Heterogeneity of the studies, in terms of populations studied, type and duration of health education provided, variety of outcomes measured and differences in timing of assessment, limits interpretation of our findings. Also, risk of bias was judged to be high for many outcomes. Currentness of evidence This evidence is up‐to‐date as of September 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Attridge, M; Creamer, J; Ramsden, M; Cannings‐John, R; Hawthorne, K", "articleTypes": [], "doi": "10.1002/14651858.CD006424.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "80b6e2e6-2fa2-4914-9861-9c6e653e6066", "pmid": "", "title": "Padma 28 for intermittent claudication", "imported": false, "abstract": "Abstract - Background Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease that develops in a limb during exercise and is relieved with rest. Most drug treatments of IC have a limited effect in improving walking distance. Padma 28, a Tibetan herbal preparation, has been used to treat IC, but there is debate as to whether Padma 28 produces a clinical benefit beyond the placebo effect. This is an update of a review first published in 2013. Objectives To determine whether Padma 28 is effective, compared with placebo or other medications, in increasing pain‐free and maximum walking distance for patients with intermittent claudication. Search methods For this update the Cochrane Vascular Trials Search Co‐ordinator searched the Specialised Register (September 2015), the Cochrane Register of Studies ((CENTRAL) (2015, Issue 8)) and clinical trials databases. Selection criteria Randomised controlled trials of Padma 28 compared with placebo or other pharmacological treatments in people suffering from IC. Data collection and analysis All review authors independently assessed the selected studies and extracted the data. Risk of bias was evaluated independently by two review authors. Depending on the data provided in the individual trials, we extracted mean or median walking distance at the end of the trial, or change in walking distance over the course of the trial, or both. Where not provided, and whenever possible, the statistical significance of differences in these parameters between treatment and placebo groups in individual trials was calculated. Where possible, data were combined by meta‐analysis. Main results No new trials were identified in the search for this review update. In total five trials involving 365 participants were included in this review. All trials compared Padma 28 with placebo for at least 16 weeks of follow‐up. Pain‐free and maximum walking distances both increased significantly in the groups treated with Padma 28, with no significant change in the placebo group. In general, the studies presented results comparing the treatment arms before and after treatment but made no comparisons between the Padma 28 and placebo groups. Pooled data of maximum walking distance after treatment with Padma 28 and placebo from two studies (193 participants) indicated a higher maximum walking distance (mean difference (MD) 95.97 m, 95% confidence interval (CI) 79.07 m to 112.88 m, P < 0.00001, very low quality evidence) in the Padma 28 group compared with placebo. The clinical importance of these observed changes in walking distance is unclear as no quality of life data were reported. There was no effect on ankle brachial index (ABI): change in ABI values between baseline and six months follow up MD ‐0.01, 95% CI ‐0.07 to 0.05, 1 study, 56 participants, P = 0.72, very low quality evidence). Mild side effects, especially gastrointestinal discomfort, tiredness and skin eruption, were reported but this outcome was not different between the Padma 28 and placebo groups (odds ratio 1.09, 95% CI 0.42 to 2.83, four studies, 231 participants, P = 0.86, very low quality evidence). Authors' conclusions Some evidence exists from individual trials to suggest that Padma 28 may be effective in increasing walking distances, at least in the short term (four months), in people with IC. Side effects do not appear to be a problem. However, the longer term effects of treatment are unknown and the clinical significance of the improvements in walking distance are questionable. Moreover, the quality of the evidence is limited by the small sample size of the available trials, limited reporting of statistical analyses that compared treatment groups, and relatively high withdrawal rates that were linked to the outcome. That is, patients were withdrawn if they failed to improve walking distance. There was also evidence of publication bias. We therefore feel there is currently insufficient evidence to draw conclusions regards the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation. Plain language summary Padma 28 for intermittent claudication Background Intermittent claudication (IC) is pain in the leg that occurs on exercise and is relieved by rest. It is caused by an inadequate blood supply to the legs due to blockage of arteries. Conservative drug treatment is commonly used in an attempt to improve walking distance in these patients. Padma 28 is a Tibetan herbal preparation used for treating intermittent claudication. Study characteristics and key results This review on the effects of Padma 28 includes five trials with a total of 365 participants (current until September 2015). The review showed that Padma 28 has some beneficial effects in improving maximum and pain‐free walking distance. The groups treated with placebo did not show an improved maximum and pain‐free walking distance. Unfortunately the studies reported insufficient data to allow the comparison of the change in walking distances in the Padma 28 group with the change in walking distances in the placebo group. Combining the data of maximum walking distance after treatment in two studies showed that there was a longer maximum walking distance in the Padma 28 group compared with the placebo group after 16 weeks of treatment. No change in ankle brachial pressure was observed. Mild side effects such as gastrointestinal discomfort, tiredness and skin eruption were also noted but these were not different between the Padma 28 and placebo groups. Quality of the evidence Overall, the quality of the studies was low, with evidence of publication bias, small number of trials, limited reporting of the analyses that compared treatment groups and bias due to a high percentage of withdrawals in the placebo groups because of lack of improvement or deterioration of the overall condition. We therefore feel there is currently insufficient evidence to draw conclusions about the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stewart, M, Morling, JR, Maxwell, H", "articleTypes": [], "doi": "10.1002/14651858.CD007371.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.791Z" }, { "id": "80bbcd5b-d9f4-4e9c-b62e-0867265680ee", "pmid": "", "title": "Acupuncture for Bell's palsy", "imported": false, "abstract": "Abstract - Background Bell's palsy or idiopathic facial palsy is an acute facial paralysis due to inflammation of the facial nerve. A number of studies published in China have suggested acupuncture is beneficial for facial palsy. Objectives The objective of this review was to examine the efficacy of acupuncture in hastening recovery and reducing long‐term morbidity from Bell's palsy. Search methods We updated the searches of the Cochrane Neuromuscular Disease Group Trials Specialized Register (24 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2010), MEDLINE (January 1966 to May 2010), EMBASE (January 1980 to May 2010), AMED (January 1985 to May 2010), LILACS (from January 1982 to May 2010) and the Chinese Biomedical Retrieval System (January 1978 to May 2010) for randomised controlled trials using 'Bell's palsy' and its synonyms, 'idiopathic facial paralysis' or 'facial palsy' as well as search terms including 'acupuncture'. Chinese journals in which we thought we might find randomised controlled trials relevant to our study were handsearched. We reviewed the bibliographies of the randomised trials and contacted the authors and known experts in the field to identify additional published or unpublished data. Selection criteria We included all randomised controlled trials involving acupuncture by needle insertion in the treatment of Bell's palsy irrespective of any language restrictions. Data collection and analysis Two review authors identified potential articles from the literature search, extracted data and assessed quality of each trial independently. All disagreements were resolved by discussion between the review authors. Main results The literature search and handsearching identified 49 potentially relevant articles. Of these, six RCTs were included involving 537 participants with Bell's palsy. Two more possible trials were identified in the update than the previous version of this systematic review, but both were excluded because they were not real RCTs. Of the six included trials, five used acupuncture while the other one used acupuncture combined with drugs. No trial reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. Authors' conclusions The quality of the included trials was inadequate to allow any conclusion about the efficacy of acupuncture. More research with high quality trials is needed. Plain language summary Acupuncture for Bell's palsy Bell's palsy or idiopathic facial palsy is the most common disorder affecting the facial nerves and results in weakness or paralysis on one side of the face. The paralysis causes distortion of the face and interferes with normal functions, such as closing the eye and eating. It is thought to be caused by inflammation of the facial nerve. According to Traditional Chinese Medicine, facial paralysis is known as 'deviated mouth'. It was attributed to 'wind' by past dynasties. 'Qi' refers to the vital substances comprising the human body and the physiological functions of viscera and bowels, channels and collaterals. It maintains life activities and reflects the resistance of the human body. Deficiency of 'qi' allows the invasion of exogenous pathogenic wind. Acupuncture is part of Traditional Chinese Medicine and dates back thousands of years. It involves inserting fine needles into specific points on the skin or applying various other techniques to the acupuncture points to bring about healing. In Bell's palsy, acupuncture treatment might have numerous beneficial effects. This review aimed to review systematically all randomised controlled trials and controlled clinical trials, which examined the effectiveness of acupuncture by needle insertion for Bell's palsy. Six studies including a total of 537 participants met the inclusion criteria. Five studies used acupuncture while the other used acupuncture combined with drugs. No trials reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. More research with high quality trials is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, N; Zhou, M; He, L; Zhou, D; Li, N", "articleTypes": [], "doi": "10.1002/14651858.CD002914.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "80c2a6e3-d939-42b8-8a13-420e6b23c996", "pmid": "", "title": "Clonidine for pain in non‐ventilated infants", "imported": false, "abstract": "Abstract - Background Critically ill newborn infants undergo a variety of painful procedures or experience a variety of painful conditions during their early life in the neonatal unit. In the critically ill paediatric and neonatal population, clonidine is prescribed as an adjunct to opioids or benzodiazepines aiming to reduce the doses of these drugs that are required for analgesia or sedation, or to facilitate weaning from mechanical ventilation. It has been shown that clonidine premedication might have a positive effect on postoperative pain in children. Objectives To assess the benefit and harms of clonidine for the prevention or treatment of procedural pain; postoperative pain; or pain associated with clinical conditions in non‐ventilated neonates. Search methods We used the standard search strategy of Cochrane Neonatal to search the CENTRAL, MEDLINE via PubMed, Embase, and CINAHL to December 2018. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials. We ran an updated search from 1 January 2018 to 11 March 2020 in CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials, and cluster trials comparing clonidine to placebo or no treatment, opioids, paracetamol, dexmedetomidine, or non‐pharmacological pain‐reducing interventions for the management of procedural pain, postoperative pain, and pain associated with clinical conditions in preterm and term newborns. Data collection and analysis Two review authors independently planned to extract data (e.g. number of participants, birth weight, gestational age, modality of administration, and dose of clonidine) and assess the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow‐up). The primary outcome considered was pain: for procedural pain, the mean values of each analgesia scale assessed during the procedure and at one to two hours after the procedure; for postoperative pain and for pain associated with clinical conditions, the mean values of each analgesia scale assessed at 30 minutes, three hours, and 12 hours after the administration of the intervention. We planned to use the GRADE approach to assess the quality of evidence. Main results Our search strategy yielded 3383 references. Two review authors independently assessed all references for inclusion. We did not find any completed studies for inclusion. We excluded three trials where clonidine was administered for spinal anaesthesia. Authors' conclusions We did not find any studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of clonidine for the prevention or treatment of procedural or postoperative pain, or pain associated with clinical conditions in neonates. Plain language summary Clonidine for painful procedures and conditions in infants Review question: does clonidine administration reduce pain in newborns exposed to painful procedures or conditions? Background: newborns admitted to the hospital are exposed to a number of painful procedures which might include blood sampling, lumbar puncture (a medical procedure where a needle is inserted into the spinal canal, usually to collect cerebrospinal fluid for testing), tubes in the stomach, different types of catheters, and minor surgical procedures such as neonatal circumcision. In addition, newborns might have pain because of clinical conditions, such as, fractured bone, pain following traumatic vaginal birth, disease of the skin (open skin lesions from an inherited skin disorder), or intestines (necrotising enterocolitis (inflammation)). All babies, and especially those born too early (preterm), are very sensitive to pain. Moreover, the experience of repeated episodes of pain might cause problems, such as an altered development of the nervous system, in early life and an increased pain sensitivity when they grow up. Most of the medicines to manage pain and stress in babies have side effects, and might also harm the immature developing brain by inducing death of cells (apoptosis) in the brain. Study characteristics: we searched for studies up to 11 March 2020. The aim of this review was to assess if clonidine could reduce pain in newborns. This medicine can be given through injections, using a tube in the stomach (nasogastric tube), through the skin, and as spinal anaesthesia. However, the latter is not in the focus of this review as it is used for babies undergoing specific surgical procedures. Clonidine works on the brain modifying responses and reducing stress and agitation. Furthermore, clonidine may reduce pain, especially if used in combination with other medicines. Key results: we found no studies for our review. Three studies were excluded because clonidine was given for spinal anaesthesia, whereas our review focuses on other indications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Romantsik, O, Calevo, MG, Norman, E, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD013104.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.811Z" }, { "id": "80d24b35-3930-402e-92ea-b66068268d3a", "pmid": "", "title": "Corticosteroids for hospitalised children with acute asthma", "imported": false, "abstract": "Abstract - Background Systemic corticosteroids are used routinely in the management of children with severe acute asthma. There is a lack of consensus regarding the agent, dose and route of corticosteroid administration. Objectives To determine the benefit of systemic corticosteroids (oral, intravenous, or intramuscular) compared to placebo and inhaled steroids in acute paediatric asthma. Search methods All controlled trials were identified from the Cochrane Airways Review Group Register, hand searching of respiratory journals, reference lists and contacts with experts and pharmaceutical companies. Selection criteria Studies were included if they described a randomised controlled trial (RCT) involving children aged 1‐18 years with severe acute asthma who received oral, inhaled, intravenous or intramuscular corticosteroids. Only studies in which patients required hospital admission were included. Data collection and analysis Two reviewers using a standard form extracted all data. All data, numeric calculations and graphic extrapolations were independently confirmed. Main results Seven trials were included with a total of 426 children studied (274 with oral prednisone vs. placebo, 106 with intravenous steroids vs placebo and 46 with nebulised budesonide vs prednisolone). A significant number of steroid treated children were discharged early after admission (>4 hours) with an OR of 7.00 (95% CI: 2.98 to 16.45) and NNT of 3 (95%CI: 2 to 8). The length of stay was shorter in the steroid groups with a WMD of ‐8.75 hours (95% CI: ‐19.23 to 1.74). There were no significant differences between groups in pulmonary function or oxygen saturation measurements. Children treated with steroids in hospital were less likely to relapse within one to three months with OR 0.19 (95%CI: 0.07 to 0.55) and NNT of 3 (95%CI: 2 to 7). The single small study that compared nebulised budesonide to oral prednisone failed to demonstrate equivalence or a difference between each therapy. Authors' conclusions Systemic corticosteroids produce some improvements for children admitted to hospital with acute asthma. The benefits may include earlier discharge and fewer relapses. Inhaled or nebulised corticosteroids cannot be recommended as equivalent to systemic steroids at this time. Further studies examining differing doses and routes of administration for corticosteroids will clarify the optimal therapy. Plain language summary Corticosteroids for hospitalised children with acute asthma An acute asthma attack in a child often results in a trip to the hospital. In the emergency department steroid drugs are given which may improve the child's condition and allow them to be sent home after a few hours observation. However, some children require continued treatment in hospital. This review asked the question \"do steroid drugs help children admitted to hospital with asthma?\" We found that steroids given by mouth or through an intravenous tube help children recover from acute asthma. The benefits may include earlier discharge or a shorter stay in hospital. Children were less likely to come back to hospital in the one to three months following the admission. However, the evidence was not overwhelming due to the limited number of studies available and different medicines used. Further research needs to concentrate on the best medications to use and the best route of administration.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Smith, M, Iqbal, SMSI, Rowe, BH, N'Diaye, T", "articleTypes": [], "doi": "10.1002/14651858.CD002886", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.761Z" }, { "id": "80eb703f-047e-4a54-8ee7-2c06d6b82e73", "pmid": "", "title": "Antiemetics for adults for prevention of nausea and vomiting caused by moderately or highly emetogenic chemotherapy: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background About 70% to 80% of adults with cancer experience chemotherapy‐induced nausea and vomiting (CINV). CINV remains one of the most distressing symptoms associated with cancer therapy and is associated with decreased adherence to chemotherapy. Combining 5‐hydroxytryptamine‐3 (5‐HT₃) receptor antagonists with corticosteroids or additionally with neurokinin‐1 (NK₁) receptor antagonists is effective in preventing CINV among adults receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Various treatment options are available, but direct head‐to‐head comparisons do not allow comparison of all treatments versus another. Objectives • In adults with solid cancer or haematological malignancy receiving HEC ‐ To compare the effects of antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids on prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting in network meta‐analysis (NMA) ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy • In adults with solid cancer or haematological malignancy receiving MEC ‐ To compare whether antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids are superior for prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting to treatment combinations including 5‐HT₃ receptor antagonists and corticosteroids solely, in network meta‐analysis ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy Search methods We searched CENTRAL, MEDLINE, Embase, conference proceedings, and study registries from 1988 to February 2021 for randomised controlled trials (RCTs). Selection criteria We included RCTs including adults with any cancer receiving HEC or MEC (according to the latest definition) and comparing combination therapies of NK₁ and 5‐HT₃ inhibitors and corticosteroids for prevention of CINV. Data collection and analysis We used standard methodological procedures expected by Cochrane. We expressed treatment effects as risk ratios (RRs). Prioritised outcomes were complete control of vomiting during delayed and overall phases, complete control of nausea during the overall phase, quality of life, serious adverse events (SAEs), and on‐study mortality. We assessed GRADE and developed 12 'Summary of findings' tables. We report results of most crucial outcomes in the abstract, that is, complete control of vomiting during the overall phase and SAEs. For a comprehensive illustration of results, we randomly chose aprepitant plus granisetron as exemplary reference treatment for HEC, and granisetron as exemplary reference treatment for MEC. Main results Highly emetogenic chemotherapy ( HEC) We included 73 studies reporting on 25,275 participants and comparing 14 treatment combinations with NK₁ and 5‐HT₃ inhibitors. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 704 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with aprepitant + granisetron. Evidence from NMA (39 RCTs, 21,642 participants; 12 treatment combinations with NK₁ and 5‐HT₃ inhibitors) suggests that the following drug combinations are more efficacious than aprepitant + granisetron for completely controlling vomiting during the overall treatment phase (one to five days): fosnetupitant + palonosetron (810 of 1000; RR 1.15, 95% confidence interval (CI) 0.97 to 1.37; moderate certainty), aprepitant + palonosetron (753 of 1000; RR 1.07, 95% CI 1.98 to 1.18; low‐certainty), aprepitant + ramosetron (753 of 1000; RR 1.07, 95% CI 0.95 to 1.21; low certainty), and fosaprepitant + palonosetron (746 of 1000; RR 1.06, 95% CI 0.96 to 1.19; low certainty). Netupitant + palonosetron (704 of 1000; RR 1.00, 95% CI 0.93 to 1.08; high‐certainty) and fosaprepitant + granisetron (697 of 1000; RR 0.99, 95% CI 0.93 to 1.06; high‐certainty) have little to no impact on complete control of vomiting during the overall treatment phase (one to five days) when compared to aprepitant + granisetron, respectively. Evidence further suggests that the following drug combinations are less efficacious than aprepitant + granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): aprepitant + ondansetron (676 of 1000; RR 0.96, 95% CI 0.88 to 1.05; low certainty), fosaprepitant + ondansetron (662 of 1000; RR 0.94, 95% CI 0.85 to 1.04; low certainty), casopitant + ondansetron (634 of 1000; RR 0.90, 95% CI 0.79 to 1.03; low certainty), rolapitant + granisetron (627 of 1000; RR 0.89, 95% CI 0.78 to 1.01; moderate certainty), and rolapitant + ondansetron (598 of 1000; RR 0.85, 95% CI 0.65 to 1.12; low certainty). We could not include two treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 35 of 1000 participants experience any SAEs when treated with aprepitant + granisetron. Evidence from NMA (23 RCTs, 16,065 participants; 11 treatment combinations) suggests that fewer participants may experience SAEs when treated with the following drug combinations than with aprepitant + granisetron: fosaprepitant + ondansetron (8 of 1000; RR 0.23, 95% CI 0.05 to 1.07; low certainty), casopitant + ondansetron (8 of 1000; RR 0.24, 95% CI 0.04 to 1.39; low certainty), netupitant + palonosetron (9 of 1000; RR 0.27, 95% CI 0.05 to 1.58; low certainty), fosaprepitant + granisetron (13 of 1000; RR 0.37, 95% CI 0.09 to 1.50; low certainty), and rolapitant + granisetron (20 of 1000; RR 0.57, 95% CI 0.19 to 1.70; low certainty). Evidence is very uncertain about the effects of aprepitant + ondansetron (8 of 1000; RR 0.22, 95% CI 0.04 to 1.14; very low certainty), aprepitant + ramosetron (11 of 1000; RR 0.31, 95% CI 0.05 to 1.90; very low certainty), fosaprepitant + palonosetron (12 of 1000; RR 0.35, 95% CI 0.04 to 2.95; very low certainty), fosnetupitant + palonosetron (13 of 1000; RR 0.36, 95% CI 0.06 to 2.16; very low certainty), and aprepitant + palonosetron (17 of 1000; RR 0.48, 95% CI 0.05 to 4.78; very low certainty) on the risk of SAEs when compared to aprepitant + granisetron, respectively. We could not include three treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron, rolapitant + ondansetron) in NMA for this outcome because of missing direct comparisons. Moderately emetogenic chemotherapy (MEC) We included 38 studies reporting on 12,038 participants and comparing 15 treatment combinations with NK₁ and 5‐HT₃ inhibitors, or 5‐HT₃ inhibitors solely. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 555 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with granisetron. Evidence from NMA (22 RCTs, 7800 participants; 11 treatment combinations) suggests that the following drug combinations are more efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days): aprepitant + palonosetron (716 of 1000; RR 1.29, 95% CI 1.00 to 1.66; low certainty), netupitant + palonosetron (694 of 1000; RR 1.25, 95% CI 0.92 to 1.70; low certainty), and rolapitant + granisetron (660 of 1000; RR 1.19, 95% CI 1.06 to 1.33; high certainty). Palonosetron (588 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) and aprepitant + granisetron (577 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) may or may not increase complete response in the overall treatment phase (one to five days) when compared to granisetron, respectively. Azasetron (560 of 1000; RR 1.01, 95% CI 0.76 to 1.34; low certainty) may result in little to no difference in complete response in the overall treatment phase (one to five days) when compared to granisetron. Evidence further suggests that the following drug combinations are less efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): fosaprepitant + ondansetron (500 of 1000; RR 0.90, 95% CI 0.66 to 1.22; low certainty), aprepitant + ondansetron (477 of 1000; RR 0.86, 95% CI 0.64 to 1.17; low certainty), casopitant + ondansetron (461 of 1000; RR 0.83, 95% CI 0.62 to 1.12; low certainty), and ondansetron (433 of 1000; RR 0.78, 95% CI 0.59 to 1.04; low certainty). We could not include five treatment combinations (fosaprepitant + granisetron, azasetron, dolasetron, ramosetron, tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 153 of 1000 participants experience any SAEs when treated with granisetron. Evidence from pair‐wise comparison (1 RCT, 1344 participants) suggests that more participants may experience SAEs when treated with rolapitant + granisetron (176 of 1000; RR 1.15, 95% CI 0.88 to 1.50; low certainty). NMA was not feasible for this outcome because of missing direct comparisons. Certainty of evidence Our main reason for downgrading was serious or very serious imprecision (e.g. due to wide 95% CIs crossing or including unity, few events leading to wide 95% CIs, or small information size). Additional reasons for downgrading some comparisons or whole networks were serious study limitations due to high risk of bias or moderate inconsistency within networks. Authors' conclusions This field of supportive cancer care is very well researched. However, new drugs or drug combinations are continuously emerging and need to be systematically researched and assessed. For people receiving HEC, synthesised evidence does not suggest one superior treatment for prevention and control of chemotherapy‐induced nausea and vomiting. For people receiving MEC, synthesised evidence does not suggest superiority for treatments including both NK₁ and 5‐HT₃ inhibitors when compared to treatments including 5‐HT₃ inhibitors only. Rather, the results of our NMA suggest that the choice of 5‐HT₃ inhibitor may have an impact on treatment efficacy in preventing CINV. When interpreting the results of this systematic review, it is important for the reader to understand that NMAs are no substitute for direct head‐to‐head comparisons, and that results of our NMA do not necessarily rule out differences that could be clinically relevant for some individuals. Plain language summary Which drug combinations are best for prevention of nausea and vomiting caused by chemotherapy in adults with cancer? The burden of nausea and vomiting caused by chemotherapy and what helps to prevent it? In about 70% to 80% of adults with cancer, chemotherapy induces nausea and vomiting (CINV). Depending on the type of chemotherapy, treatment can cause strong or moderate sickness (hereafter referred to as HEC (highly emetogenic chemotherapy) and MEC (moderately emetogenic chemotherapy)). Multiple drug combinations have showed high benefit for CINV among adults receiving HEC or MEC. What was the aim of our review? Using a network meta‐analysis, we aimed to compare the benefits and harms of different drug combinations for prevention of CINV among people receiving HEC or MEC, and to identify treatment ranking. A network meta‐analysis is a technique used to compare different treatments described in already published trials, even when the original individual trial does not describe such comparisons. What studies did we look at? We searched selected medical databases and trial registries until February 2021. We included studies comparing multiple drug combinations for prevention of CINV among adults with any type of cancer receiving HEC or MEC that is commonly used in clinical practice. In particular, we looked at drugs inhibiting two specific biochemical receptors (neurokinin receptor and serotonin receptor) that trigger nausea and vomiting after chemotherapy. We looked at the preventative effects of these treatments over five days. This is the period during which the maximum intensity of CINV and further peaks of intensity are expected, after the start of chemotherapy. Our key results... ...for people receiving HEC We found 73 studies that reported on the experience of 25,275 participants and compared 14 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped to prevent any vomiting in 60% to 81% of people on average. Those individuals also had no need for rescue medicines, which are used in case nausea and vomiting occur even though prophylactic treatment has been given. The results of our analysis suggest some differences in effectiveness of different treatments, but overall we had little confidence that those differences would be reflected in real‐world observations. Harms. We estimated that 1% to 4% of people experience serious side effects. The differences between treatments were small. ...for people receiving MEC We found 38 studies that reported on the experience of 12,038 participants and compared 15 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped prevent any vomiting in 43% to 72% of people on average. Those individuals also had no need for rescue medicines. The results of our analysis suggest some differences in the effectiveness of different treatments, but overall, we had little confidence that those differences would be reflected in real‐world observations. Harms. Few studies reported serious side effects. The ones that did suggest that on average 15% to 18% of people experience such events. Differences between treatments were small. However, we think that future research is needed to rule out potential differences between treatments. Our confidence in the findings We assessed how confident we were that there are differences between compared treatments. We had low or very low confidence that one treatment is better or worse than another in preventing CINV. Our confidence in differences between statistical results was mainly limited because measures of variation were wide apart and included both potential advantages and disadvantages, although measures of precision showed no or little effect. We also identified limitations in some of the included studies, which further limited our confidence in the effects. This was mainly the case when study personnel and participants knew which treatments were given and therefore may not adhere to the planned intervention, or may perceive or report effects differently. Our conclusions The results of our analysis suggest that there is no superior drug combination for prevention of CINV for people receiving HEC or MEC. However, results suggest that the choice of drugs targeting the serotonin receptor may impact effectiveness, irrespective of whether given with or without a drug targeting the neurokinin receptor. However, when interpreting these results, it is important for the reader to understand that these kinds of multiple‐comparison analyses are no substitute for head‐to‐head comparisons, and that the results do not necessarily rule out differences that could be clinically relevant for some individuals. How up‐to‐date is this evidence? Evidence is up‐to‐date to 2 February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Piechotta, V, Adams, A, Haque, M, Scheckel, B, Kreuzberger, N, Monsef, I, Jordan, K, Kuhr, K, Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.139Z" }, { "id": "80f9a696-7d5c-47c6-8687-59389762a4a5", "pmid": "", "title": "Wheat flour fortification with iron and other micronutrients for reducing anaemia and improving iron status in populations", "imported": false, "abstract": "Abstract - Background Anaemia is a condition where the number of red blood cells (and consequently their oxygen‐carrying capacity) is insufficient to meet the body's physiological needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations. Objectives To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health‐related outcomes in populations over two years of age. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, 21 other databases and two trials registers up to 21 July 2020, together with contacting key organisations to identify additional studies. Selection criteria We included cluster‐ or individually‐randomised controlled trials (RCTs) carried out among the general population from any country, aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. We included trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat Data collection and analysis Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risks of bias. We followed Cochrane methods in this review. Main results Our search identified 3538 records, after removing duplicates. We included 10 trials, involving 3319 participants, carried out in Bangladesh, Brazil, India, Kuwait, Philippines, South Africa and Sri Lanka. We identified two ongoing studies and one study is awaiting classification. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, three trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial used various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta‐analyses. Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added may reduce by 27% the risk of anaemia in populations (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.55 to 0.97; 5 studies, 2315 participants; low‐certainty evidence). It is uncertain whether iron‐fortified wheat flour with or without other micronutrients reduces iron deficiency (RR 0.46, 95% CI 0.20 to 1.04; 3 studies, 748 participants; very low‐certainty evidence) or increases haemoglobin concentrations (in g/L) (mean difference MD 2.75, 95% CI 0.71 to 4.80; 8 studies, 2831 participants; very low‐certainty evidence). No trials reported data on adverse effects in children (including constipation, nausea, vomiting, heartburn or diarrhoea), except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to the risk of Infection or inflammation at individual level as measured by C‐reactive protein (CRP) (mean difference (MD) 0.04, 95% CI −0.02 to 0.11; 2 studies, 558 participants; moderate‐certainty evidence). Iron‐fortified wheat flour with other micronutrients added versus unfortified wheat flour (nil micronutrients added) It is unclear whether wheat flour fortified with iron, in combination with other micronutrients decreases anaemia (RR 0.77, 95% CI 0.41 to 1.46; 2 studies, 317 participants; very low‐certainty evidence). The intervention probably reduces the risk of iron deficiency (RR 0.73, 95% CI 0.54 to 0.99; 3 studies, 382 participants; moderate‐certainty evidence) and it is unclear whether it increases average haemoglobin concentrations (MD 2.53, 95% CI −0.39 to 5.45; 4 studies, 532 participants; very low‐certainty evidence). No trials reported data on adverse effects in children. Nine out of 10 trials reported sources of funding, with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials. Authors' conclusions Fortification of wheat flour with iron (in comparison to unfortified flour, or where both groups received the same other micronutrients) may reduce anaemia in the general population above two years of age, but its effects on other outcomes are uncertain. Iron‐fortified wheat flour in combination with other micronutrients, in comparison with unfortified flour, probably reduces iron deficiency, but its effects on other outcomes are uncertain. None of the included trials reported data on adverse side effects except for risk of infection or inflammation at the individual level. The effects of this intervention on other health outcomes are unclear. Future studies at low risk of bias should aim to measure all important outcomes, and to further investigate which variants of fortification, including the role of other micronutrients as well as types of iron fortification, are more effective, and for whom. Plain language summary Does adding iron to wheat flour reduce anaemia and increase iron levels in the general population? Why do we need iron in our diet? Iron is an essential mineral found in every cell of the body. It is needed to make haemoglobin, the oxygen‐carrying protein in the blood. Iron molecules in haemoglobin bind to oxygen and carry it from the lungs to all the cells and tissues in the body. Low levels of haemoglobin means the body does not get enough oxygen. Anaemia develops when haemoglobin levels in the blood fall too low. Symptoms of anaemia include: tiredness and lack of energy, getting out of breath quickly, pale skin and a greater susceptibility to infections. Low haemoglobin levels can be caused by blood loss, pregnancy or not eating enough foods containing iron (iron‐deficiency anaemia). Iron‐deficiency anaemia may be treated by taking iron tablets or eating foods rich in iron. Fortified foods Adding micronutrients (vitamins and minerals) to foods, whether those micronutrients were originally present or not, is called fortification. Fortifying foods is one way to improve nutrition in a population. People living in low‐income countries may not have enough iron in their diet, and may be at risk of anaemia. Adding iron and other nutrients to foods routinely eaten in large quantities, such as flour, is thought to help prevent iron‐deficiency anaemia. Why we did this Cochrane Review We wanted to find out how adding iron, and other minerals and vitamins, to wheat flour affected the blood iron levels of the general population, and whether fewer people developed anaemia or other health conditions. We also wanted to know if adding iron to wheat flour caused any unwanted effects. What did we do? We searched for studies that investigated eating any types of food made with wheat flour containing added iron, or foods made with wheat flour without added iron. We then compared the studies with each other, to find out the effects of adding iron to wheat flour on people's health and the levels of iron and haemoglobin in their blood. Search date: we included evidence published up to 21 July 2020. What we found We found 10 studies in 3319 people (aged 2 years and older). The studies lasted from 3 months to 24 months, and took place in Bangladesh, Brazil, India, Kuwait, the Philippines, Sri Lanka and South Africa. The studies looked at the effects of: · wheat flour containing added iron (with or without other minerals and vitamins) compared with wheat flour without added iron (but with the same other minerals and vitamins); · wheat flour containing added iron and other minerals and vitamins compared with wheat flour without any added minerals or vitamins. The wheat flours used in the studies contained different amounts of iron: from under 40 mg/kg to over 60 mg/kg. We were interested in: · how many people had anaemia (defined by low haemoglobin levels); · how many people had low levels of iron in their blood (iron deficiency; tested using a biomarker); · haemoglobin concentrations in people's blood; · how many children had diarrhoea or respiratory infections; · how many children died (of any cause); · signs of infection or inflammation (the body's response to injury) in children (by testing a biomarker in the blood); and · any unwanted effects. Most studies had multiple sources of funding; some were partly funded by companies involved in the food, chemical or pharmaceutical industries. What are the results of our review? Compared with flour without added iron (but with other minerals and vitamins) Flour containing added iron (with or without other minerals and vitamins): · may reduce anaemia, by 27% (evidence from 5 studies, 2315 people); and · probably makes no difference to children's risk of infection or inflammation (2 studies, 558 children). It was unclear how flour with added iron affected iron deficiency (3 studies, 748 people), or haemoglobin levels (8 studies, 2831 people ). Compared with flour without any added minerals or vitamins Flour containing added iron (with other minerals and vitamins) probably reduced iron deficiency (3 studies, 382 people). It was unclear from the studies how flour containing added iron affected anaemia (2 studies, 317 people) or haemoglobin levels (4 studies, 532 people). No studies reported information about unwanted effects, or how many children died, or had diarrhoea or respiratory infections. Our confidence in our results Our confidence is moderate to low that adding iron to flour probably reduces iron deficiency and anaemia. The studies appeared to show fewer people with iron deficiency and slightly higher haemoglobin levels associated with flour with added iron, but the results varied widely, so we are uncertain about the effect. These results might change if further evidence becomes available. We found limitations in the ways some of the studies were designed and conducted, and this could have affected their results. Key messages Adding iron to wheat flour may lead to fewer people with anaemia or low blood‐iron levels in the general population. We do not know if adding iron to wheat flour causes any unwanted effects, because no studies looked at these.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Field, MS, Mithra, P, Peña-Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD011302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.780Z" }, { "id": "80f9b0d7-05bf-481c-9869-e4024f6aacf3", "pmid": "", "title": "", "imported": false, "abstract": "The study aims at evaluating in normal weight and obese subjects those factors such as taste sensitivity and circulating endocannabinoids in influencing dietary choice and thereby lipid and energy metabolism in order to design personalized nutritional strategies.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.234Z" }, { "id": "8106875a-7c62-4be9-bac4-11277d0466ca", "pmid": "", "title": "", "imported": false, "abstract": "The study aims at evaluating in normal weight and obese subjects those factors such as taste sensitivity and circulating endocannabinoids in influencing dietary choice and thereby lipid and energy metabolism in order to design personalized nutritional strategies.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "81107646-ed45-4254-9f46-6cb1f19dd738", "pmid": "", "title": "Do Appetitive Gut Hormones Reduce Addictive and Eating Behaviours in Obesity, and Nicotine and Alcohol Dependence?", "imported": false, "abstract": "The \"Gut Hormones in Addiction\" study is a proof-of-concept experimental medicine human study to answer the following questions:", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.158Z" }, { "id": "8151c0a0-c5c2-4dbc-81e4-c57ad52e061a", "pmid": "", "title": "Surgical techniques for the removal of mandibular wisdom teeth", "imported": false, "abstract": "Abstract - Background Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short‐term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity. Objectives To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication. Selection criteria Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth. Data collection and analysis Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel‐group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross‐over or split‐mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split‐mouth studies in our analyses, and combined parallel‐group and split‐mouth studies using the generic inverse‐variance method. We used the fixed‐effect model for three studies or fewer, and random‐effects model for more than three studies. Main results We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low‐certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low‐certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low‐certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low‐certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand‐piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low‐certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low‐certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low‐certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low‐certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low‐certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported. Authors' conclusions In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future. Plain language summary Comparing different surgical techniques used to remove wisdom teeth from the lower jaw Background The removal of wisdom teeth is a common operation, but it can cause short‐ and long‐term side effects. People may have their wisdom teeth removed if they are causing pain or infection, or if they are damaging other teeth or not breaking through the gum properly. Surgery has a risk of complications. One of the most common is dry socket (also known as alveolar osteitis). This is when a blood clot fails to form in the socket that the tooth has come out of, or the clot is disturbed before the socket has properly healed. Because the bones and nerves underlying the socket are exposed, it can be a very painful condition. Review question We aimed to find out the benefits and harms of different surgical techniques used to remove wisdom teeth from the lower jaw, specifically how surgeons can reduce the risk of complications following surgery. We considered the most important outcomes to be: dry socket, wound infection, long‐term damage to the nerves supplying sensation to the tongue and skin of the lower lip and chin, and problems such as excessive bleeding or a broken jaw. Study characteristics We searched for relevant studies up to 8 July 2019. We included 62 studies with 4643 participants. Many studies excluded people who were not in excellent health so the participants in the trials may not be truly representative. Key results The available evidence is inconclusive. It is unclear if the position of the cut into the gum makes any difference to the outcomes. It is unclear whether it is possible to avoid damaging a nerve to the tongue by using a surgical instrument called a lingual retractor. It is unclear as to whether the type of surgical tool (a chisel or a rotating drill) used to remove bone from the jaw makes a difference to the likelihood of the wound becoming infected. It is unclear if the amount and method of delivering saltwater to clean the tooth socket after the extraction makes any difference to the outcomes. It is unclear whether different methods to stitch the gum after the tooth is removed makes any difference to the outcomes. Placing products that are derived from the patient’s own blood into the tooth socket may help to reduce the occurrence of dry socket (a condition that causes intense pain a few days after extraction). Another three surgical approaches were tested in the studies, but they did not measure the important outcomes. Certainty of the evidence None of the included studies were at low risk of bias. All of the studies were quite small. The quality of the studies varied, with most having flaws that could have biased their results. In addition, some of the results were very imprecise, with variation between them that could not be explained. For these reasons, we consider the available evidence to be uncertain. Future research may be able to provide dental surgeons and patients with clearer conclusions than those listed above.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bailey, E; Kashbour, W; Shah, N; Worthington, HV; Renton, TF; Coulthard, P", "articleTypes": [], "doi": "10.1002/14651858.CD004345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "8157fa72-97f7-422f-8baa-6f7acb015d7e", "pmid": "", "title": "Treatment for recurrent vulvovaginal candidiasis (thrush)", "imported": false, "abstract": "Abstract - Background Recurrent vulvovaginal candidiasis (RVVC) affects up to 5% of women. No comprehensive systematic review of treatments for RVVC has been published. Objectives The primary objective was to assess the effectiveness and safety of pharmacological and non‐pharmacological treatments for RVVC. The secondary objective was to assess patient preference of treatment options. Search methods We conducted electronic searches of bibliographic databases, including CENTRAL, MEDLINE, Embase, and CINAHL (search date 6 October 2021). We also handsearched reference lists of identified trials and contacted authors of identified trials, experts in RVVC, and manufacturers of products for vulvovaginal candidiasis. Selection criteria We considered all published and unpublished randomised controlled trials evaluating RVVC treatments for at least six months, in women with four or more symptomatic episodes of vulvovaginal candidiasis in the past year. We excluded women with immunosuppressive disorders or taking immunosuppressant medication. We included women with diabetes mellitus and pregnant women. Diagnosis of RVVC must have been confirmed by presence of symptoms and a positive culture and/or microscopy. We included all drug and non‐drug therapies and partner treatment, assessing the following primary outcomes: • number of clinical recurrences per participant per year (recurrence defined as clinical signs and positive culture/microscopy);
• proportion of participants with at least one clinical recurrence during the treatment and follow‐up period; and
• adverse events. Data collection and analysis Two authors independently reviewed titles and abstracts to identify eligible trials. Duplicate data extraction was completed independently by two authors. We assessed risk of bias as described in the Cochrane Handbook for Systematic Reviews of Interventions . We used the fixed‐effects model for pooling and expressed the results as risk ratio (RR) with 95% confidence intervals (CI). Where important statistical heterogeneity was present we either did not pool data (I 2 > 70%) or used a random‐effects model (I 2 40‐70%). We used the GRADE tool to assess overall certainty of the evidence for the pooled primary outcomes. Main results Studies: Twenty‐three studies involving 2212 women aged 17 to 67 years met the inclusion criteria. Most studies excluded pregnant women and women with diabetes or immunosuppression. The predominant species found on culture at study entry was Candida albicans . Overall, the included studies were small (<100 participants). Six studies compared antifungal treatment with placebo (607 participants); four studies compared oral versus topical antifungals (543 participants); one study compared different oral antifungals (45 participants); two studies compared different dosing regimens for antifungals (100 participants); one study compared two different dosing regimens of the same topical agent (23 participants); one study compared short versus longer treatment duration (26 participants); two studies assessed the effect of partner treatment (98 participants); one study compared a complementary treatment (Lactobacillus vaginal tablets and probiotic oral tablets) with placebo (34 participants); three studies compared complementary medicine with antifungals (354 participants); two studies compared 'dermasilk' briefs with cotton briefs (130 participants); one study examined Lactobacillus vaccination versus heliotherapy versus ciclopyroxolamine (90 participants); one study compared CAM treatments to an antifungal treatment combined with CAM treatments (68 participants). We did not find any studies comparing different topical antifungals. Nine studies reported industry funding, three were funded by an independent source and eleven did not report their funding source. Risk of bias: Overall, the risk of bias was high or unclear due to insufficient blinding of allocation and participants and poor reporting. Primary outcomes: Meta‐analyses comparing drug treatments (oral and topical) with placebo or no treatment showed there may be a clinically relevant reduction in clinical recurrence at 6 months (RR 0.36, 95% CI 0.21 to 0.63; number needed to treat for an additional beneficial outcome (NNTB) = 2; participants = 607; studies = 6; I² = 82%; low‐certainty evidence) and 12 months (RR 0.80, 95% CI 0.72 to 0.89; NNTB = 6; participants = 585; studies = 6; I² = 21%; low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. We are very uncertain whether oral drug treatment compared to topical treatment increases the risk of clinical recurrence at 6 months (RR 1.66, 95% CI 0.83 to 3.31; participants = 206; studies = 3; I² = 0%; very low‐certainty evidence) and reduces the risk of clinical recurrence at 12 months (RR 0.95, 95% CI 0.71 to 1.27; participants = 206; studies = 3; I² = 10%; very low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. Adverse events were scarce across both treatment and control groups in both comparisons. The reporting of adverse events varied amongst studies, was generally of very low quality and could not be pooled. Overall the adverse event rate was low for both placebo and treatment arms and ranged from less than 5% to no side effects or complications. Authors' conclusions In women with RVVC, treatment with oral or topical antifungals may reduce symptomatic clinical recurrences when compared to placebo or no treatment. We were unable to find clear differences between different treatment options (e.g. oral versus topical treatment, different doses and durations). These findings are not applicable to pregnant or immunocompromised women and women with diabetes as the studies did not include or report on them. More research is needed to determine the optimal medication, dose and frequency. Plain language summary The effectiveness and safety of treatments for recurrent vulvovaginal candidiasis (thrush) Review question Cochrane authors set out to investigate the effectiveness and safety of drug treatments or non‐drug treatments (such as complementary and alternative medicines) for women with recurrent vulvovaginal candidiasis (thrush). Background Thrush of the vaginal/vulvar area is caused by Candida , a form of yeast that is commonly found in the vagina as part of normal flora without causing symptoms. For unknown reasons, Candida can start growing and cause symptoms of vulvovaginal candidiasis (commonly named thrush). Symptoms of vulvovaginal thrush include itching, swelling, and irritation of the vaginal and vulval areas. It is estimated that uncomplicated vulvovaginal thrush affects up to 75% of women at some time during their reproductive years. Recurrent vulvovaginal candidiasis (RVVC) occurs when a woman has four or more fungal infections during a 12‐month period. Up to 5% of women suffer from RVVC. Some doctors advise taking antifungals as a prevention, but there are no clear evidence‐based guidelines. Study characteristics We identified 23 studies involving 2212 participants between 17 and 67 years old with a diagnosis of RVVC confirmed by a positive test. The studies compared a range of antifungal medicines (taken by mouth or inserted into the vagina), and some complementary or alternative treatments (such as Lactobacillus vaccines or probiotics and special underwear). The studies reported the effects on recurrence of thrush after 6 and 12 months. Only one study reported the number of clinical recurrences at 12 months. Nine studies reported industry funding, three were funded by an independent source and nine studies did not report their funding source. The evidence is current to October 2021. Key results Six studies (607 participants) compared antifungal medication with placebo or no treatment. Based on low certainty evidence antifungal treatments may give a clinically relevant reduction in clinical recurrence at 6 and 12 months. We are uncertain if oral treatments are better than topical treatments (very low certainty evidence for no difference). Adverse effects of taking antifungal medication to prevent recurrence of thrush were not common. Studies reported on adverse effects differently, making comparisons difficult. More research is needed to determine the optimal medication, dose and frequency. We were unable to determine the effects in women who are pregnant or have diabetes. Certainty of the evidence Our confidence in the evidence was low to very low due to serious concerns about risk of bias, unclear reporting and the limited number of studies that could be combined. This means that new studies might change our confidence in the effects of treatments and our conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Cooke, G; Watson, C; Deckx, L; Pirotta, M; Smith, J; van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009151.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "815c3f70-82ef-464a-b113-14fea0fa3c8f", "pmid": "", "title": "Antibiotics for community‐acquired pneumonia in adult outpatients", "imported": false, "abstract": "Abstract - Background Lower respiratory tract infection (LRTI) is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Community‐acquired pneumonia (CAP) is a common condition that causes a significant disease burden for the community, particularly in children younger than five years, the elderly and immunocompromised people. Antibiotics are the standard treatment for CAP. However, increasing antibiotic use is associated with the development of bacterial resistance and side effects for the patient. Several studies have been published regarding optimal antibiotic treatment for CAP but many of these data address treatments in hospitalised patients. This is an update of our 2009 Cochrane Review and addresses antibiotic therapies for CAP in outpatient settings. Objectives To compare the efficacy and safety of different antibiotic treatments for CAP in participants older than 12 years treated in outpatient settings with respect to clinical, radiological and bacteriological outcomes. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (January 1966 to March week 3, 2014), EMBASE (January 1974 to March 2014), CINAHL (2009 to March 2014), Web of Science (2009 to March 2014) and LILACS (2009 to March 2014). Selection criteria We looked for randomised controlled trials (RCTs), fully published in peer‐reviewed journals, of antibiotics versus placebo as well as antibiotics versus another antibiotic for the treatment of CAP in outpatient settings in participants older than 12 years of age. However, we did not find any studies of antibiotics versus placebo. Therefore, this review includes RCTs of one or more antibiotics, which report the diagnostic criteria and describe the clinical outcomes considered for inclusion in this review. Data collection and analysis Two review authors (LMB, TJMV) independently assessed study reports in the first publication. In the 2009 update, LMB performed study selection, which was checked by TJMV and MMK. In this 2014 update, two review authors (SP, SM) independently performed and checked study selection. We contacted trial authors to resolve any ambiguities in the study reports. We compiled and analysed the data. We resolved differences between review authors by discussion and consensus. Main results We included 11 RCTs in this review update (3352 participants older than 12 years with a diagnosis of CAP); 10 RCTs assessed nine antibiotic pairs (3321 participants) and one RCT assessed four antibiotics (31 participants) in people with CAP. The study quality was generally good, with some differences in the extent of the reporting. A variety of clinical, bacteriological and adverse events were reported. Overall, there was no significant difference in the efficacy of the various antibiotics. Studies evaluating clarithromycin and amoxicillin provided only descriptive data regarding the primary outcome. Though the majority of adverse events were similar between all antibiotics, nemonoxacin demonstrated higher gastrointestinal and nervous system adverse events when compared to levofloxacin, while cethromycin demonstrated significantly more nervous system side effects, especially dysgeusia, when compared to clarithromycin. Similarly, high‐dose amoxicillin (1 g three times a day) was associated with higher incidence of gastritis and diarrhoea compared to clarithromycin, azithromycin and levofloxacin. Authors' conclusions Available evidence from recent RCTs is insufficient to make new evidence‐based recommendations for the choice of antibiotic to be used for the treatment of CAP in outpatient settings. Pooling of study data was limited by the very low number of studies assessing the same antibiotic pairs. Individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups. However, two studies did find significantly more adverse events with use of cethromycin as compared to clarithromycin and nemonoxacin when compared to levofloxacin. Multi‐drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations. Further studies focusing on diagnosis, management, cost‐effectiveness and misuse of antibiotics in CAP and LRTI are warranted in high‐, middle‐ and low‐income countries. Plain language summary Antibiotics for community‐acquired pneumonia in adolescent and adult outpatients Review question This review studied the effects of antibiotics on adolescents and adults with pneumonia acquired and treated in the community (as opposed to acquiring pneumonia in hospital and/or being treated for pneumonia in hospital). The evidence is current to March 2014. Background Lower respiratory tract infection is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Pneumonia, or infection of the lungs, is a common condition representing a significant disease burden for the community. Pneumonia is especially life‐threatening in children younger than five years, in older people and in people with other illnesses that may affect their immune system (such as diabetes or HIV/AIDS, or solid organ transplant recipients). Antibiotics are the most common treatment for pneumonia and these can vary in their effectiveness and adverse effects. Study characteristics We identified 11 trials (with 3352 participants older than 12 years with a diagnosis of community‐acquired pneumonia), fully published in peer‐reviewed journals, focused on treatment of pneumonia in adolescents and adults treated in the community in outpatient settings. This included five new trials included since our last review published in 2009. None of the trials included antibiotics versus placebo; all trials included one or more antibiotics. All participants were diagnosed with pneumonia based upon clinical diagnosis by the physician and chest X‐ray. Study funding sources All included trials were well conducted; nine of the 11 trials were sponsored by bio‐pharmaceutical companies manufacturing the antibiotics used in the study, or their authors were closely linked with the company. Key results Nine of the included trials compared different antibiotics and, hence, we could not combine the results of the individual trials to present our overall conclusion. There were some notable adverse events in seven studies: 1) erythromycin demonstrated significant gastrointestinal side effects compared to clarithromycin in two studies; 2) nemonoxacin demonstrated higher gastrointestinal (nausea, diarrhoea) and nervous system (dizziness, headache) adverse events compared to levofloxacin; 3) cethromycin demonstrated more side effects, especially a distortion of the sense of taste, than clarithromycin; 4) gastritis and diarrhoea were more common in the high‐dose amoxicillin group (1 g three times a day) compared to the other three antibiotic groups (clarithromycin, azithromycin and levofloxacin). Conclusion Unfortunately, there were not enough trials to compare the effects of different antibiotics for pneumonia acquired and treated in the community.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Pakhale, S, Mulpuru, S, Verheij, TJM, Kochen, MM, Rohde, GGU, Bjerre, LM", "articleTypes": [], "doi": "10.1002/14651858.CD002109.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.787Z" }, { "id": "816fe794-c383-4273-a767-711f19801d18", "pmid": "", "title": "Ribavirin plus interferon versus interferon for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. Standard therapy is ribavirin plus pegylated interferon to achieve undetectable level of virus in the blood, but the effect on clinical outcomes is controversial. Objectives To assess the beneficial and harmful effects of ribavirin and interferon combination therapy versus interferon monotherapy for chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, approaching authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included randomised trials, irrespective of blinding, language, or publication status, comparing ribavirin plus interferon versus interferon for treatment of chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained loss of hepatitis C virus, liver‐related morbidity plus all‐cause mortality, and adverse events. We performed subgroup analyses of patients who were naive, relapsers, or non‐responders to previous antiviral treatment. All outcomes were analysed with the random‐effects model. We used Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of morbidity plus mortality. The remaining outcomes were presented as relative risks (RR). We used trial sequential analyses to examine the robustness of our findings. Main results We included 83 randomised trials with 12,707 patients. Most trials had unclear or high risk of bias. We did not find any significant influence of bias on our results but cannot exclude outcome measure reporting bias as many trials did not report on the primary outcomes of this review. Compared with interferon, ribavirin plus interferon had a significant beneficial effect on sustained virological response in subgroups of naive patients (RR 0.72, 95% confidence interval (CI) 0.68 to 0.75), relapsers (RR 0.62, 95% CI 0.54 to 0.70), non‐responders (RR 0.89, 95% CI 0.84 to 0.93), and in all patients (RR 0.75, 95% CI 0.71 to 0.79). Combination therapy significantly reduced morbidity plus mortality in all patients (Peto OR, 0.43, 95% CI 0.23 to 0.79), but not in naive, relapsers, or non‐responders individually. Combination therapy significantly increased the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous (cough, dyspnoea, fatigue) adverse reactions. Accordingly, combination therapy significantly increased the risk of treatment discontinuation and dose reductions. Trial sequential analyses confirmed our findings regarding virological effects, but not regarding liver‐related morbidity and all‐cause mortality. Authors' conclusions Compared with interferon alone, ribavirin plus interferon is more effective in clearing hepatitis C virus from the blood. Combination therapy may reduce liver‐related morbidity and all‐cause mortality, but we need more evidence. The number needed to treat to obtain a beneficial effect is considerable considering the increased risk of several severe adverse reactions and costs. Plain language summary Adding ribavirin to interferon increases the number of patients who clear hepatitis C virus but also leads to several adverse reactions Globally about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behavior, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die. It is known that treatment with the drug interferon clears hepatitis C virus from the blood in about 15% of patients. This review identified studies comparing ribavirin plus interferon with interferon alone in patients with chronic hepatitis C. This review shows, by combining the results from all trials, that adding ribavirin to interferon increases the number of patients who clear the hepatitis C virus to about 40% as well as the number of patients who demonstrate improved liver histology. Ribavirin and interferon may also reduce the risk of liver‐related morbidity or all‐cause mortality. However, the number needed to treat to prevent one patient developing morbidity or dying seems very large. Furthermore, combination therapy was associated with increased risk of anaemia and several other adverse reactions. The results gives rise to a dilemma ‐ should we, by adding ribavirin to interferon, increase the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous adverse reactions in a situation where it has not yet been clearly demonstrated that the antiviral effect of the intervention is directly linked to the reduction of all‐cause mortality? We, therefore, suggest that the combination intervention is applied only with stringent emphasis on the individual patients' well‐being. Furthermore, we suggest that all future trials within the area should focus more on adverse reactions and long‐term clinical outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Brok, J; Gluud, LL; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "8171bc0c-eadd-44cb-b0f5-5b094acd2cdf", "pmid": "", "title": "Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years", "imported": false, "abstract": "Abstract - Background Extensive evidence exists showing analgesic effects of sweet solutions for newborns and infants. It is less certain if the same analgesic effects exist for children one year to 16 years of age. This is an updated version of the original Cochrane review published in Issue 10, 2011 (Harrison 2011) titled Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. Objectives To determine the efficacy of sweet tasting solutions or substances for reducing needle‐related procedural pain in children beyond one year of age. Search methods Searches were run to the end of June 2014. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, the NHS Economic Evaluation Database, MEDLINE, EMBASE, PsycINFO, and ACP Journal Club (all via OvidSP), and CINAH (via EBSCOhost). We applied no language restrictions. Selection criteria Published or unpublished randomised controlled trials (RCT) in which children aged one year to 16 years, received a sweet tasting solution or substance for needle‐related procedural pain. Control conditions included water, non‐sweet tasting substances, pacifier, distraction, positioning/containment, breastfeeding, or no treatment. Data collection and analysis Outcome measures included crying duration, composite pain scores, physiological or behavioral pain indicators, self‐report of pain or parental or healthcare professional‐report of the child's pain. We reported mean differences (MD), weighted mean difference (WMD), or standardized mean difference (SMD) with 95% confidence intervals (CI) using fixed‐effect or random‐effects models as appropriate for continuous outcome measures. We reported risk ratio (RR), risk difference (RD), and the number needed to treat to benefit (NNTB) for dichotomous outcomes. We used the I 2 statistic to assess between‐study heterogeneity. Main results We included one unpublished and seven published studies (total of 808 participants); four more studies and 478 more participants than the 2011 review. Six trials included young children aged one to four years receiving sucrose or candy lollypops for immunisation pain compared with water or no treatment. Usual care included topical anaesthetics, upright parental holding, and distraction. All studies were well designed blinded RCTs, however, five of the six studies had a high risk of bias based on small sample sizes. Two studies included school‐aged children receiving sweet or unsweetened chewing gum before, or before and during, immunisation and blood collection. Both studies, conducted by the same author, had a high risk of bias based on small sample sizes. Results for the toddlers/pre‐school children were conflicting. Duration of cry, using a random‐effects model, was not significantly reduced by sweet taste (six trials, 520 children, WMD ‐15 seconds, 95% CI ‐54 to 24, I 2 = 94%). Composite pain score at time of first needle was reported in four studies (n = 121 children). The scores were not significantly different between the sucrose and control group (SMD ‐0.26, 95% CI ‐1.27 to 0.75, I 2 = 86%). A Children's Hospital of Eastern Ontario Pain Scale score > 4 was significantly less common in the sucrose group compared to the control group in one study (n = 472, RR 0.55, 95% CI 0.45 to 0.67; RD ‐0.29, 95% CI ‐0.37 to ‐0.20; NNTB 3, 95% CI 3 to 5; tests for heterogeneity not applicable. For school‐aged children, chewing sweet gum before needle‐related painful procedures (two studies, n = 111 children) or during the procedures (two studies, n = 103 children) did not significantly reduce pain scores. A comparison of the Faces Pain Scale scores in children chewing sweet gum before the procedures compared with scores of children chewing unsweetened gum revealed a WMD of ‐0.15 (95% CI ‐0.61 to 0.30). Similar results were found when comparing the chewing of sweet gum with unsweetened gum during the procedure (WMD 0.23, 95% CI ‐0.28 to 0.74). The Colored Analogue Scale for children chewing sweet gum compared to unsweetened gum before the procedure was not significantly different (WMD 0.24 (‐0.69 to 1.18)) nor was it different when children chewed the gum during the procedure (WMD 0.86 (95% CI ‐0.12 to 1.83)). There was no heterogeneity for any of these analyses in school‐aged children (I 2 = 0%). Authors' conclusions Based on the eight studies included in this systematic review update, two of which were subgroups of small numbers of eligible toddlers from larger studies, and three of which were pilot RCTs with small numbers of participants, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children between one and four years of age. Further rigorously conducted, adequately powered RCTs are warranted in this population. Based on the two studies by the same author, there was no evidence of analgesic effects of sweet taste in school‐aged children. As there are other effective evidence‐based strategies available to use in this age group, further trials are not warranted. Despite the addition of four studies in this review, conclusions have not changed since the last version of the review. Plain language summary Sweet taste to ease injection needle pain in children aged one to 16 years This is an updated version of the original Cochrane review published in Issue 10, 2011: Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. We re‐ran the search in October 2014. Review question: Do sweet tasting solutions reduce pain during needles in children aged from one to 16 years, compared to no treatment, water, other non‐sweet solutions, or other interventions such as non‐nutritive sucking (babies) or sweet foods or chewing gum (children), topical anaesthetics, music, and distraction? Background: Small amounts of sweet tasting sugar solutions given orally to babies before and during painful needles significantly reduces distress. However it was not known if the same pain‐reducing effects of sweet solutions occurred in children older than one year of age. We therefore examined studies looking at pain‐reducing effects of sweet solutions such as sucrose or glucose for painful needle procedures in children aged one to 16 years. Search date: We searched the literature for published and unpublished studies up to October 2014. Study characteristics : We found six studies focused on young children aged one to four years; two of these studies were included in the original review and four were new studies. The two studies included in the original review used a low concentration of sucrose, just 12%, which is not considered sweet enough for the pain reducing effects. Three of the four new studies were small pilot studies, conducted to inform full trials, and only one study of sweet solutions in young children included large numbers of children. When we compared results of all six studies, only two showed that sugar water (sucrose) reduced pain during injections. However, the four studies that showed no effect all included small numbers of children, therefore they were not considered large enough to detect significant differences in pain. Further well conducted trials with large enough numbers of young children are needed to work out if sweet taste effectively reduces their pain and distress during needles. For older school‐aged children, there were two studies published by the same author, both of which were included in the original review. Neither study showed that sweet taste helped to reduce pain. As other studies show that strategies such as distraction and topical anaesthetics can effectively reduce needle pain in school‐aged children, further studies of sweet taste for pain management in school‐aged children are not warranted. Study funding sources : Of the six studies including young children, two did not acknowledge receipt of research funding. For the remaining four: a state‐wide nursing fund supported two of the pilot studies, an internal research institute provided support for the remaining pilot study and another study was supported in part by a Maternal and Child Health grant. The two studies including school‐aged children, conducted by the same author, were supported by a grant from the Canadian Institutes of Health Research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Harrison, D; Yamada, J; Adams‐Webber, T; Ohlsson, A; Beyene, J; Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD008408.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "81990fe0-1cf2-4ceb-9dbb-f81413624219", "pmid": "", "title": "Interventions for treating iron deficiency anaemia in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease affects approximately seven million people globally. Iron deficiency anaemia can occur as a common systemic manifestation, with a prevalence of up to 90%, which can significantly affect quality of life, both during periods of active disease or in remission. It is important that iron deficiency anaemia is treated effectively and not be assumed to be a normal finding of inflammatory bowel disease. The various routes of iron administration, doses and preparations present varying advantages and disadvantages, and a significant proportion of people experience adverse effects with current therapies. Currently, no consensus has been reached amongst physicians as to which treatment path is most beneficial. Objectives The primary objective was to evaluate the efficacy and safety of the interventions for the treatment of iron deficiency anaemia in people with inflammatory bowel disease. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 21st November 2019. We also contacted experts in the field and searched references of trials for any additional trials. Selection criteria Randomised controlled trials investigating the effectiveness and safety of iron administration interventions compared to other iron administration interventions or placebo in the treatment of iron deficiency anaemia in inflammatory bowel disease. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors. Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We expressed dichotomous and continuous outcomes as risk ratios and mean differences with 95% confidence intervals. We assessed the certainty of the evidence using the GRADE methodology. Main results We included 11 studies (1670 randomised participants) that met the inclusion criteria. The studies compared intravenous iron sucrose vs oral iron sulphate (2 studies); oral iron sulphate vs oral iron hydroxide polymaltose complex (1 study); oral iron fumarate vs intravenous iron sucrose (1 study); intravenous ferric carboxymaltose vs intravenous iron sucrose (1 study); erythropoietin injection + intravenous iron sucrose vs intravenous iron sucrose + injection placebo (1 study); oral ferric maltol vs oral placebo (1 study); oral ferric maltol vs intravenous ferric carboxymaltose (1 study); intravenous ferric carboxymaltose vs oral iron sulphate (1 study); intravenous iron isomaltoside vs oral iron sulphate (1 study); erythropoietin injection vs oral placebo (1 study). All studies compared participants with CD and UC together, as well as considering a range of disease activity states. The primary outcome of number of responders, when defined, was stated to be an increase in haemoglobin of 20 g/L in all but two studies in which an increase in 10g/L was used. In one study comparing intravenous ferric carboxymaltose and intravenous iron sucrose, moderate‐certainty evidence was found that intravenous ferric carboxymaltose was probably superior to intravenous iron sucrose, although there were responders in both groups (150/244 versus 118/239, RR 1.25, 95% CI 1.06 to 1.46, number needed to treat for an additional beneficial outcome (NNTB) = 9). In one study comparing oral ferric maltol to placebo, there was low‐certainty evidence of superiority of the iron (36/64 versus 0/64, RR 73.00, 95% CI 4.58 to 1164.36). There were no other direct comparisons that found any difference in the primary outcomes, although certainty was low and very low for all outcomes, due to imprecision from sparse data and risk of bias varying between moderate and high risk. The reporting of secondary outcomes was inconsistent. The most common was the occurrence of serious adverse events or those requiring withdrawal of therapy. In no comparisons was there a difference seen between any of the intervention agents being studied, although the certainty was very low for all comparisons made, due to risk of bias and significant imprecision due to the low numbers of events. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes were reported in any of the studies. An analysis of all intravenous iron preparations to all oral iron preparations showed that intravenous administration may lead to more responders (368/554 versus 205/373, RR 1.17, 95% CI 1.05 to 1.31, NNTB = 11, low‐certainty due to risk of bias and inconsistency). Withdrawals due to adverse events may be greater in oral iron preparations vs intravenous (15/554 versus 31/373, RR 0.39, 95% CI 0.20 to 0.74, low‐certainty due to risk of bias, inconsistency and imprecision). Authors' conclusions Intravenous ferric carboxymaltose probably leads to more people having resolution of IDA (iron deficiency anaemia) than intravenous iron sucrose. Oral ferric maltol may lead to more people having resolution of IDA than placebo. We are unable to draw conclusions on which of the other treatments is most effective in IDA with IBD (inflammatory bowel disease) due to low numbers of studies in each comparison area and clinical heterogeneity within the studies. Therefore, there are no other conclusions regarding the treatments that can be made and certainty of all findings are low or very low. Overall, intravenous iron delivery probably leads to greater response in patients compared with oral iron, with a NNTB (number needed to treat) of 11. Whilst no serious adverse events were specifically elicited with any of the treatments studied, the numbers of reported events were low and the certainty of these findings very low for all comparisons, so no conclusions can be drawn. There may be more withdrawals due to such events when oral is compared with intravenous iron delivery. Other outcomes were poorly reported and once again no conclusions can be made as to the impact of IDA on any of these outcomes. Given the widespread use of many of these treatments in practice and the only guideline that exists recommending the use of intravenous iron in favour of oral iron, research to investigate this key issue is clearly needed. Considering the current ongoing trials identified in this review, these are more focussed on the impact in specific patient groups (young people) or on other symptoms (such as fatigue). Therefore, there is a need for studies to be performed to fill this evidence gap. Plain language summary Therapies for treating iron deficiency anaemia in Crohn's disease and ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether treatments in people with Crohn's disease and ulcerative colitis can improve iron deficiency anaemia. We analysed data from 11 studies to answer this question. Key messages Iron in the form of ferric carboxymaltose given intravenously is probably better than iron sucrose given intravenously in improving iron deficiency anaemia, although people improved taking both treatments. Oral iron in the form of ferric maltol may be better than placebo (dummy treatment). It is unclear whether any of the other treatments considered are better than each other, however, there is limited evidence due to low numbers of studies and issues due to low quality of the reporting of the research studies. What was studied in the review? People with both ulcerative colitis and Crohn's disease both commonly suffer with low iron levels that in turn lowers their haemoglobin (blood) levels (this is called anaemia). This can lead to a number of symptoms, including tiredness and pain. Several treatments exist to treat iron deficiency anaemia, consisting of delivering extra iron either orally or intravenously (through a vein). An additional treatment, erythropoietin, was also studied which stimulates the body to produce more blood itself. Currently, no consensus has been reached amongst physicians as to which treatment is better. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing any treatment with another or dummy treatment. We found 11 RCTs looking at 1670 participants. The trials looked at adult participants, with none considering children. 1) Intravenous iron in the form of ferric carboxymaltose probably leads to more people having an improvement in iron deficiency anaemia than intravenous iron sucrose (one extra person would improve for every 9 treated and five out of 10 people would improve with either therapy). 2) Oral iron as ferric maltol may lead to more people having resolution of iron deficiency than dummy treatment. 3) It is unclear whether there is any difference between any of the other treatments studied for treating iron deficiency anaemia. 4) It is unclear whether any therapy leads to a difference in adverse events (minor or serious) when compared to any other therapy. Conclusion Iron delivered via a vein as ferric carboxymaltose probably improves anaemia in more people that iron sucrose via a vein, although both groups of people improved. Oral iron as ferric maltol may improve more patients than dummy treatment. No conclusions can be drawn on other treatments due to lack of evidence and quality issues with the studies that were found. Further research is needed, particularly to investigate whether iron delivered through a vein is better than iron delivered orally and also how much treating anaemia in people with IBD makes a difference in terms of the symptoms they may experience. How up‐to‐date is this review? This review is up‐to‐date as of November 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gordon, M, Sinopoulou, V, Iheozor-Ejiofor, Z, Iqbal, T, Allen, P, Hoque, S, Engineer, J, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013529.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.811Z" }, { "id": "8199a51d-6394-4b69-962f-294c966399d4", "pmid": "", "title": "Effect of cocoa on blood pressure", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Ried, K, Fakler, P, Stocks, NP", "articleTypes": [], "doi": "10.1002/14651858.CD008893.pub3 AB - Abstract - Background High blood pressure is an important risk factor for cardiovascular disease, contributing to about 50% of cardiovascular events worldwide and 37% of cardiovascular‐related deaths in Western populations. Epidemiological studies suggest that cocoa‐rich products reduce the risk of cardiovascular disease. Flavanols found in cocoa have been shown to increase the formation of endothelial nitric oxide which promotes vasodilation and therefore blood pressure reduction. Here we update previous meta‐analyses on the effect of cocoa on blood pressure. Objectives To assess the effects on blood pressure of chocolate or cocoa products versus low‐flavanol products or placebo in adults with or without hypertension when consumed for two weeks or longer. Search methods This is an updated version of the review initially published in 2012. In this updated version, we searched the following electronic databases from inception to November 2016: Cochrane Hypertension Group Specialised Register, CENTRAL, MEDLINE and Embase. We also searched international trial registries, and the reference lists of review articles and included trials. Selection criteria Randomised controlled trials (RCTs) investigating the effects of chocolate or cocoa products on systolic and diastolic blood pressure in adults for a minimum of two weeks duration. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias in each trial. We conducted random‐effects meta‐analyses on the included studies using Review Manager 5. We explored heterogeneity with subgroup analyses by baseline blood pressure, flavanol content of control group, blinding, age and duration. Sensitivity analyses explored the influence of unusual study design. Main results Thirty‐five trials (including 40 treatment comparisons) met the inclusion criteria. Of these, we added 17 trials (20 treatment comparisons) to the 18 trials (20 treatment comparisons) in the previous version of this updated review. Trials provided participants with 30 to 1218 mg of flavanols (mean = 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. The control group received either a flavanol‐free product (n = 26 treatment comparisons) or a low‐flavanol‐containing cocoa powder (range 6.4 to 88 mg flavanols (mean = 55 mg, 13 treatment comparisons; 259 mg, 1 trial). Meta‐analyses of the 40 treatment comparisons involving 1804 mainly healthy participants revealed a small but statistically significant blood pressure‐reducing effect of flavanol‐rich cocoa products compared with control in trials of two to 18 weeks duration (mean nine weeks):
 Mean difference systolic blood pressure (SBP) (95% confidence interval (CI): ‐1.76 (‐3.09 to ‐0.43) mmHg, P = 0.009, n = 40 treatment comparisons, 1804 participants;
 Mean difference diastolic blood pressure (DBP) (95% CI): ‐1.76 (‐2.57 to ‐0.94) mmHg, P < 0.001, n = 39 treatment comparisons, 1772 participants. Baseline blood pressure may play a role in the effect of cocoa on blood pressure. While systolic blood pressure was reduced significantly by 4 mmHg in hypertensive people (n = 9 treatment comparisons, 401 participants), and tended to be lowered in prehypertensive people (n= 8 treatment comparisons, 340 participants), there was no significant difference in normotensive people (n = 23 treatment comparisons, 1063 participants); however, the test for subgroup differences was of borderline significance (P = 0.08; I 2 = 60%), requiring further research to confirm the findings. Subgroup meta‐analysis by blinding suggested a trend towards greater blood pressure reduction in unblinded trials compared to double‐blinded trials, albeit statistically not significant. Further research is needed to confirm whether participant expectation may influence blood pressure results. Subgroup analysis by type of control (flavanol‐free versus low‐flavanol control) did not reveal a significant difference. Whether the age of participants plays a role in the effect of cocoa on blood pressure, with younger participants responding with greater blood pressure reduction, needs to be further investigated. Sensitivity analysis excluding trials with authors employed by trials sponsoring industry (33 trials, 1482 participants) revealed a small reduction in effect size, indicating some reporting bias. Due to the remaining heterogeneity, which we could not explain in terms of blinding, flavanol content of the control groups, age of participants, or study duration, we downgraded the quality of the evidence from high to moderate. Results of subgroup analyses should be interpreted with caution and need to be confirmed or refuted in trials using direct randomised comparisons. Generally, cocoa products were highly tolerable, with adverse effects including gastrointestinal complaints and nausea being reported by 1% of participants in the active cocoa intervention group and 0.4% of participants in the control groups (moderate‐quality evidence). Authors' conclusions This review provides moderate‐quality evidence that flavanol‐rich chocolate and cocoa products cause a small (2 mmHg) blood pressure‐lowering effect in mainly healthy adults in the short term. These findings are limited by the heterogeneity between trials, which could not be explained by prespecified subgroup analyses, including blinding, flavanol content of the control groups, age of participants, or study duration. However, baseline blood pressure may play a role in the effect of cocoa on blood pressure; subgroup analysis of trials with (pre)hypertensive participants revealed a greater blood pressure‐reducing effect of cocoa compared to normotensive participants with borderline significance. Long‐term trials investigating the effect of cocoa on clinical outcomes are also needed to assess whether cocoa has an effect on cardiovascular events and to assess potential adverse effects associated with chronic ingestion of cocoa products. Plain language summary Effect of cocoa on blood pressure Review question We assessed the effect of cocoa products on blood pressure in adults when consumed daily for at least two weeks. We found 35 studies, covering 40 treatment comparisons. Background Dark chocolate and cocoa products are rich in chemical compounds called flavanols. Flavanols have attracted interest as they might help to reduce blood pressure, a known risk factor for cardiovascular disease (disorders of the heart and blood vessels). The blood pressure‐lowering properties of flavanols are thought to be related to widening of the blood vessels, caused by nitric oxide. Study characteristics Studies were short, mostly between two and12 weeks, with only one of 18 weeks. The studies involved 1804 mainly healthy adults. They provided participants with 30 to 1218 mg of flavanols (average of 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. Seven of the studies were funded by companies with a commercial interest in their results, and the reported effect was slightly larger in these studies, indicating possible bias. The evidence is current to November 2016. Key results Meta‐analysis of 40 treatment comparisons revealed a small but statistically significant lowering of blood pressure (systolic and diastolic) of 1.8 mmHg. This small reduction in blood pressure might complement other treatment options and might contribute to reducing the risk of cardiovascular disease. We investigated whether participants' blood pressure at the start of the study, their age, an awareness of group allocation (active or control), the flavanol content used in the control group, or how long the study lasted may explain variations between trials. While blood pressure status (high blood pressure or normal blood pressure) is a likely factor in the effect size of cocoa on blood pressure, the impact of other factors needs to be confirmed or rejected in further trials. Side effects including digestive complaints and dislike of the trial product were reported by only 1% of people in the active cocoa intervention group and 0.4% of people in the control groups. Longer‐term trials are needed to establish whether regularly eating flavanol‐rich cocoa products has a beneficial effect on blood pressure and cardiovascular health over time, and whether there are any side effects of long‐term use of cocoa products on a daily basis. Quality of evidence The evidence is of moderate quality. We were unable to identify any randomised controlled trials that tested the effect of long‐term daily use of cocoa products on blood pressure, and there were no trials that measured the health consequences of high blood pressure, such as heart attacks or strokes.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.761Z" }, { "id": "81a06128-bbd3-4fed-9872-eeb3886f2691", "pmid": "", "title": "Pharmacological interventions for prevention of weight gain in people with schizophrenia", "imported": false, "abstract": "Abstract - Background Antipsychotic‐induced weight gain is an extremely common problem in people with schizophrenia and is associated with increased morbidity and mortality. Adjunctive pharmacological interventions may be necessary to help manage antipsychotic‐induced weight gain. This review splits and updates a previous Cochrane Review that focused on both pharmacological and behavioural approaches to this problem. Objectives To determine the effectiveness of pharmacological interventions for preventing antipsychotic‐induced weight gain in people with schizophrenia. Search methods The Cochrane Schizophrenia Information Specialist searched Cochrane Schizophrenia's Register of Trials on 10 February 2021. There are no language, date, document type, or publication status limitations for inclusion of records in the register. Selection criteria We included all randomised controlled trials (RCTs) that examined any adjunctive pharmacological intervention for preventing weight gain in people with schizophrenia or schizophrenia‐like illnesses who use antipsychotic medications. Data collection and analysis At least two review authors independently extracted data and assessed the quality of included studies. For continuous outcomes, we combined mean differences (MD) in endpoint and change data in the analysis. For dichotomous outcomes, we calculated risk ratios (RR). We assessed risk of bias for included studies and used GRADE to judge certainty of evidence and create summary of findings tables. The primary outcomes for this review were clinically important change in weight, clinically important change in body mass index (BMI), leaving the study early, compliance with treatment, and frequency of nausea. The included studies rarely reported these outcomes, so, post hoc, we added two new outcomes, average endpoint/change in weight and average endpoint/change in BMI. Main results Seventeen RCTs, with a total of 1388 participants, met the inclusion criteria for the review. Five studies investigated metformin, three topiramate, three H2 antagonists, three monoamine modulators, and one each investigated monoamine modulators plus betahistine, melatonin and samidorphan. The comparator in all studies was placebo or no treatment (i.e. standard care alone). We synthesised all studies in a quantitative meta‐analysis. Most studies inadequately reported their methods of allocation concealment and blinding of participants and personnel. The resulting risk of bias and often small sample sizes limited the overall certainty of the evidence. Only one reboxetine study reported the primary outcome, number of participants with clinically important change in weight. Fewer people in the treatment condition experienced weight gains of more than 5% and more than 7% of their bodyweight than those in the placebo group (> 5% weight gain RR 0.27, 95% confidence interval (CI) 0.11 to 0.65; 1 study, 43 participants; > 7% weight gain RR 0.24, 95% CI 0.07 to 0.83; 1 study, 43 participants; very low‐certainty evidence). No studies reported the primary outcomes, 'clinically important change in BMI', or 'compliance with treatment'. However, several studies reported 'average endpoint/change in body weight' or 'average endpoint/change in BMI'. Metformin may be effective in preventing weight gain (MD −4.03 kg, 95% CI −5.78 to −2.28; 4 studies, 131 participants; low‐certainty evidence); and BMI increase (MD −1.63 kg/m2, 95% CI −2.96 to −0.29; 5 studies, 227 participants; low‐certainty evidence). Other agents that may be slightly effective in preventing weight gain include H2 antagonists such as nizatidine, famotidine and ranitidine (MD −1.32 kg, 95% CI −2.09 to −0.56; 3 studies, 248 participants; low‐certainty evidence) and monoamine modulators such as reboxetine and fluoxetine (weight: MD −1.89 kg, 95% CI −3.31 to −0.47; 3 studies, 103 participants; low‐certainty evidence; BMI: MD −0.66 kg/m2, 95% CI −1.05 to −0.26; 3 studies, 103 participants; low‐certainty evidence). Topiramate did not appear effective in preventing weight gain (MD −4.82 kg, 95% CI −9.99 to 0.35; 3 studies, 168 participants; very low‐certainty evidence ) . For all agents, there was no difference between groups in terms of individuals leaving the study or reports of nausea. However, the results of these outcomes are uncertain given the very low‐certainty evidence. Authors' conclusions There is low‐certainty evidence to suggest that metformin may be effective in preventing weight gain. Interpretation of this result and those for other agents, is limited by the small number of studies, small sample size, and short study duration. In future, we need studies that are adequately powered and with longer treatment durations to further evaluate the efficacy and safety of interventions for managing weight gain. Plain language summary How effective are medications given alongside antipsychotics at preventing weight gain in people with schizophrenia? Key messages ‐ Metformin may be effective in preventing weight gain caused by antipsychotics. ‐ H2 antagonists and monoamine modulators may be slightly effective in preventing weight gain caused by antipsychotics. ‐ Future studies should include more people and evaluate them for longer. What are antipsychotics? Antipsychotics are medications used to treat symptoms of psychosis, such as hallucinations, delusions and agitation. They are often used to treat people with schizophrenia. Examples of antipsychotics are haloperidol (Haldol), chlorpromazine (Thorazine), olanzapine (Zyprexa) and risperidone (Risperdal). Schizophrenia and weight gain People with schizophrenia are twice as likely as the general population to be overweight, perhaps due to a poor diet and an inactive lifestyle. Excess weight can lead to other health conditions, such as heart disease, stroke and diabetes. Unfortunately, an unwanted effect of antipsychotics is weight gain. Sometimes, people with schizophrenia are given medications alongside antipsychotics (‘add‐on’ medications) to prevent this additional weight gain. These add‐on medications may stop people feeling hungry or help them feel full. Usually, they are medications developed for other purposes, such as metformin, which is a medicine to treat diabetes, and fluoxetine, which is an antidepressant. What did we want to find out? We wanted to find out whether add‐on medications to prevent weight gain caused by antipsychotics were effective in people with schizophrenia. What did we do? We searched for studies that examined any medicine given alongside antipsychotics to prevent weight gain in people with schizophrenia. Study participants could be any age or sex but had to have a diagnosis of schizophrenia or a schizophrenia‐like illness. They had to be chosen at random to receive either the weight‐prevention medicine, or a placebo (a dummy medicine) or no add‐on medicine (standard treatment). We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 17 studies with 1388 people that examined the effects of add‐on medications to prevent weight gain caused by antipsychotics. The add‐on medications were metformin, topiramate, H2 antagonists, monoamine modulators, monoamine modulators plus betahistine, melatonin, and samidorphan. Studies were short, lasting between 6 and 24 weeks. And they were small, with only 63 people on average ‐ the smallest included only 14 people, the largest 561 people. Studies done to date suggest that: ‐ metformin may be effective in preventing weight gain and is well‐tolerated compared to standard treatment (5 studies, 232 participants); ‐ H2 antagonists, such as nizatidine, famotidine and ranitidine, or monoamine modulators, such as reboxetine and fluoxetine may be potentially effective in preventing weight gain caused by antipsychotics; ‐ topiramate is probably not effective in preventing weight gain caused by antipsychotics. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only a small number of studies for each add‐on medication. Studies included few people, and lasted only a short time. How up to date is this evidence? The evidence is up to date to February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Agarwal, SM, Stogios, N, Ahsan, ZA, Lockwood, JT, Duncan, MJ, Takeuchi, H, Cohn, T, Taylor, VH, Remington, G, Faulkner, GE J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.806Z" }, { "id": "81b5b828-6187-4e73-ac9d-a4a718cbd311", "pmid": "", "title": "Interventions for perceptual disorders following stroke", "imported": false, "abstract": "Abstract - Background Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non‐invasive brain stimulation, pharmacological and surgical approaches. Objectives To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living. Search methods We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors. Selection criteria We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain. Data collection and analysis One review author assessed titles, with two review authors independently screening abstracts and full‐text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB‐1 tool, and quality of evidence using GRADE. A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update. Main results We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch‐somatosensory disorders. None addressed stroke‐related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non‐invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL): Somatosensory disorders : one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure. Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention. Visual perception disorders : no trials measuring ADL compared an intervention with no treatment or control. In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials). Authors' conclusions Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high‐quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer‐term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines. Plain language summary Interventions for perceptual disorders following stroke Key messages Stroke can affect a person’s ability to process and understand information from their senses, including hearing, smell, somatosensation (sense of body temperature, position, and movement), taste, touch, and vision. Processing and understanding information from these senses is known as perception. Little research has been carried out to find out whether any treatments for stroke‐related problems with perception are helpful. People with stroke‐related problems with hearing, smell, somatosensation, taste, touch, and vision should continue to participate in rehabilitation as recommended by clinical guidelines. Healthcare professionals should continue to offer rehabilitation for stroke‐related perceptual problems in keeping with current clinical guidelines and recommendations. What is a perceptual disorder? Before a stroke, adults gather information about the world through their senses: hearing, smell, somatosensation, taste, touch, and vision. Somatosensation refers to sensation arising from the skin, muscles, or joints, and includes perception of pressure, vibration, temperature, and position. Information gathered might include the colour, shape, and size of objects that they see. Together with memories and cultural experiences, a person can understand how someone is feeling from seeing their facial expression. Other examples are how different odours can be identified through the sense of smell and how different textures can be felt through the sense of touch. A stroke can affect these abilities. How are perceptual disorders treated? Healthcare professionals, including occupational therapists, physiotherapists, and psychologists, may offer different therapies. Treatments might include medicine, stimulation of the brain, or perceptual rehabilitation through activities, puzzles, strategies, or intensive repetition of tasks. What did we want to find out? We wanted to find out whether receiving any perceptual disorder treatment was better than no treatment at all. We measured improvement by looking at how well people could carry out their daily activities. We measured whether treatments also helped other things, such as quality of life, mental health, and perception. We looked for information on when things did not go well. We also explored whether one treatment was more beneficial than another. What did we do? We searched for all relevant research. We assessed the quality of 18 studies and summarised their results. What did we find out? The studies we found were about different perceptual disorders: three studies looked at disorders of touch perception, seven looked at somatosensation, seven studies looked at vision, and one looked at several perceptual problems at the same time. The treatments used in these studies included paper‐and‐pencil copying tasks to improve visual memory and using robots to help improve a person’s sense of where their body is positioned. We found no information to show that any treatment worked. Why are we still uncertain? We found few studies. Each study included a small number of people with a perceptual problem after a stroke. With small numbers of people involved, the results were not clear. Each study looked at different interventions. Less than half the studies (seven) measured the ability to carry out everyday activities. How up to date is this information? Our information is up to date as of August 2021. Based on the information we gathered, we are still unclear about the benefits or harms of treatments for perceptual problems after stroke. People with perceptual problems after stroke should continue to be offered rehabilitation as recommended in clinical guidelines.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hazelton, C, Thomson, K, Todhunter-Brown, A, Campbell, P, Chung, CSY, Dorris, L, Gillespie, DC, Hunter, SM, McGill, K, Nicolson, DJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD007039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.747Z" }, { "id": "81dd6157-1893-42c2-a095-cdd4ef183a57", "pmid": "", "title": "Drug interventions for the treatment of obesity in children and adolescents", "imported": false, "abstract": "Abstract - Background Child and adolescent obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. Objectives To assess the efficacy of drug interventions for the treatment of obesity in children and adolescents. Search methods We searched CENTRAL , MEDLINE, Embase, PubMed (subsets not available on Ovid), LILACS as well as the trial registers ICTRP (WHO) and ClinicalTrials.gov. Searches were undertaken from inception to March 2016. We checked references and applied no language restrictions. Selection criteria We selected randomised controlled trials (RCTs) of pharmacological interventions for treating obesity (licensed and unlicensed for this indication) in children and adolescents (mean age under 18 years) with or without support of family members, with a minimum of three months' pharmacological intervention and six months' follow‐up from baseline. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. In addition, we excluded trials which included growth hormone therapies and pregnant participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data following standard Cochrane methodology. Where necessary we contacted authors for additional information. Main results We included 21 trials and identified eight ongoing trials. The included trials evaluated metformin (11 trials), sibutramine (six trials), orlistat (four trials), and one trial arm investigated the combination of metformin and fluoxetine. The ongoing trials evaluated metformin (four trials), topiramate (two trials) and exenatide (two trials). A total of 2484 people participated in the included trials, 1478 participants were randomised to drug intervention and 904 to comparator groups (91 participants took part in two cross‐over trials; 11 participants not specified). Eighteen trials used a placebo in the comparator group. Two trials had a cross‐over design while the remaining 19 trials were parallel RCTs. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up from baseline ranged from six months to 100 weeks. Trials generally had a low risk of bias for random sequence generation, allocation concealment and blinding (participants, personnel and assessors) for subjective and objective outcomes. We judged approximately half of the trials as having a high risk of bias in one or more domain such as selective reporting. The primary outcomes of this review were change in body mass index (BMI), change in weight and adverse events. All 21 trials measured these outcomes. The secondary outcomes were health‐related quality of life (only one trial reported results showing no marked differences; very low certainty evidence), body fat distribution (measured in 18 trials), behaviour change (measured in six trials), participants' views of the intervention (not reported), morbidity associated with the intervention (measured in one orlistat trial only reporting more new gallstones following the intervention; very low certainty evidence), all‐cause mortality (one suicide in the orlistat intervention group; low certainty evidence) and socioeconomic effects (not reported). Intervention versus comparator for mean difference (MD) in BMI change was ‐1.3 kg/m 2 (95% confidence interval (CI) ‐1.9 to ‐0.8; P < 0.00001; 16 trials; 1884 participants; low certainty evidence). When split by drug type, sibutramine, metformin and orlistat all showed reductions in BMI in favour of the intervention. Intervention versus comparator for change in weight showed a MD of ‐3.9 kg (95% CI ‐5.9 to ‐1.9; P < 0.00001; 11 trials; 1180 participants; low certainty evidence). As with BMI, when the trials were split by drug type, sibutramine, metformin and orlistat all showed reductions in weight in favour of the intervention. Five trials reported serious adverse events: 24/878 (2.7%) participants in the intervention groups versus 8/469 (1.7%) participants in the comparator groups (risk ratio (RR) 1.43, 95% CI 0.63 to 3.25; 1347 participants; low certainty evidence). A total 52/1043 (5.0%) participants in the intervention groups versus 17/621 (2.7%) in the comparator groups discontinued the trial because of adverse events (RR 1.45, 95% CI 0.83 to 2.52; 10 trials; 1664 participants; low certainty evidence). The most common adverse events in orlistat and metformin trials were gastrointestinal (such as diarrhoea, mild abdominal pain or discomfort, fatty stools). The most frequent adverse events in sibutramine trials included tachycardia, constipation and hypertension. The single fluoxetine trial reported dry mouth and loose stools. No trial investigated drug treatment for overweight children. Authors' conclusions This systematic review is part of a series of associated Cochrane reviews on interventions for obese children and adolescents and has shown that pharmacological interventions (metformin, sibutramine, orlistat and fluoxetine) may have small effects in reduction in BMI and bodyweight in obese children and adolescents. However, many of these drugs are not licensed for the treatment of obesity in children and adolescents, or have been withdrawn. Trials were generally of low quality with many having a short or no post‐intervention follow‐up period and high dropout rates (overall dropout of 25%). Future research should focus on conducting trials with sufficient power and long‐term follow‐up, to ensure the long‐term effects of any pharmacological intervention are comprehensively assessed. Adverse events should be reported in a more standardised manner specifying amongst other things the number of participants experiencing at least one adverse event. The requirement of regulatory authorities (US Food and Drug Administration and European Medicines Agency) for trials of all new medications to be used in children and adolescents should drive an increase in the number of high quality trials. Plain language summary Drug interventions for the treatment of obesity in children and adolescents Review question Do drug (medicine) interventions reduce weight in obese children and adolescents and are they safe? Background Across the world more children and adolescents are becoming overweight and obese. These children and adolescents are more likely to have health problems, both while as children or adolescents and in later life. More information is needed about what works best for treating this problem recognising that so‐called lifestyle changes (diet, exercise and counselling) have limited efficacy. Study characteristics We found 21 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) comparing various drugs plus a behaviour changing intervention such as diet, exercise or both (= intervention groups) usually with placebo (a pretend drug) plus a behaviour changing intervention (= control groups). We also identified eight ongoing studies (studies which are currently running but not completed yet). A total of 2484 children and adolescents took part in the included studies. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up ranged from six months to 100 weeks. Key results The included studies investigated metformin (10 studies), sibutramine (six studies), orlistat (four studies) and one study group evaluated the combination of metformin and fluoxetine. The ongoing studies are investigating metformin (four studies), topiramate (two studies) and exenatide (two studies). Most studies reported on body mass index (BMI) and bodyweight: BMI is a measure of body fat and is calculated from weight and height measurements (kg/m 2 ). In children, BMI is often measured in a way that takes into account sex, weight and height as children grow older (BMI z score). The average change in BMI across control groups was between a 1.8 kg/m 2 reduction to a 0.9 kg/m 2 increase, while across all intervention groups the average reduction was more pronounced (1.3 kg/m 2 reduction). The same effect was observed for weight change: on average, children and adolescents in the intervention groups lost 3.9 kg more weight than the children and adolescents in the control groups. Study authors reported an average of serious side effects in 24 per 1000 participants in the intervention groups compared with an average of 17 per 1000 participants in the control groups. The numbers of participants dropping out of the study because of side effects were 40 per 1000 in the intervention groups and 27 per 1000 in the control groups. The most common side effects in the orlistat and metformin studies were gut (such as diarrhoea and mild tummy pain). Common side effects in the sibutramine trials included increased heart rate (tachycardia), constipation and high blood pressure. The fluoxetine study reported dry mouth and loose stools. One study reported health‐related quality of life (a measure of physical, mental, emotional and social functioning) and found no marked differences between intervention and control. No study reported the participants' views of the intervention or socioeconomic effects. Only one study reported on morbidity (how often a disease occurs in a specific area) associated with the intervention, where there were more gallstones after the orlistat treatment. Study authors reported one suicide in the orlistat intervention group. However, studies were not long enough to reliably investigate death from any cause. No study investigated drug treatment for children who were only overweight (obese children have a much higher weight, BMI or BMI z score than children being overweight). This evidence is up to date to March 2016. Quality of the evidence The overall certainty of the evidence was low or very low, mainly because there were only a few studies per outcome measurement, the number of included children or adolescents was small, and due to variation in the results of the studies. In addition, many children or adolescents left the studies before the study had finished.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Axon, E; Atkinson, G; Richter, B; Metzendorf, MI; Baur, L; Finer, N; Corpeleijn, E; O'Malley, C; Ells, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012436", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "81f0b60e-5eae-4695-8ae8-afaed5171577", "pmid": "", "title": "Tranexamic acid for patients with nasal haemorrhage (epistaxis)", "imported": false, "abstract": "Abstract - Background Epistaxis (nosebleed) most commonly affects children and the elderly. The majority of episodes are managed at home with simple measures. In more severe cases medical intervention is required to either cauterise the bleeding vessel, or to pack the nose with various materials. Tranexamic acid is used in a number of clinical settings to stop bleeding by preventing clot breakdown (fibrinolysis). It may have a role in the management of epistaxis as an adjunct to standard treatments, reducing the need for further intervention. Objectives To determine the effects of tranexamic acid (oral, intravenous or topical) compared with placebo, no additional intervention or any other haemostatic agent in the management of patients with epistaxis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register (via CRS Web); Central Register of Controlled Trials (CENTRAL) (via CRS Web); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 October 2018. Selection criteria Randomised controlled trials (RCTs) of tranexamic acid (in addition to usual care) compared with usual care plus placebo, usual care alone or usual care plus any other haemostatic agent, to control epistaxis in adults or children. Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were control of epistaxis: re‐bleeding (as measured by the proportion of patients re‐bleeding within a period of up to 10 days) and significant adverse effects (seizures, thromboembolic events). Secondary outcomes were control of epistaxis as measured by the time to stop initial bleeding (the proportion of patients whose bleeding is controlled within a period of up to 30 minutes); severity of re‐bleeding (as measured by (a) the proportion of patients requiring any further intervention and (b) the proportion of patients requiring blood transfusion); length of hospital stay and other adverse effects. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included six RCTs (692 participants). The overall risk of bias in the studies was low. Two studies assessed oral administration of tranexamic acid, given regularly over several days, and compared it to placebo. In the other four studies, a single application of topical tranexamic acid was compared with placebo (one study) and a combination of epinephrine and lidocaine or phenylephrine (three studies). All participants were adults. Tranexamic acid versus placebo For our primary outcome, control of epistaxis: re‐bleeding (proportion re‐bleeding within 10 days), we were able to pool data from three studies. The pooled result demonstrated a benefit of tranexamic acid compared to placebo, the risk of re‐bleeding reducing from 67% to 47% (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; three studies; 225 participants; moderate‐quality evidence ). When we compared the effects of oral and topical tranexamic acid separately the risk of re‐bleeding with oral tranexamic acid reduced from 69% to 49%, RR 0.73 (95% CI 0.55 to 0.96; two studies, 157 participants; moderate‐quality evidence ) and with topical tranexamic acid it reduced from 66% to 43%, RR 0.66 (95% CI 0.41 to 1.05; single study, 68 participants). We rated the quality of evidence provided by the single study as low , therefore it is uncertain whether topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. No study specifically sought to identify and report our primary outcome: significant adverse effects (i.e. seizures, thromboembolic events). The secondary outcome time to stop initial bleeding (proportion with bleeding controlled within 30 minutes) was measured in one study using topical tranexamic acid and there was no evidence of a difference at 30 minutes (RR 0.79, 95% CI 0.56 to 1.11; 68 participants; low‐quality evidence ). No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery, embolisation). One study of oral tranexamic acid reported the proportion of patients requiring blood transfusion and found no difference between groups: 5/45 (11%) versus 6/44 (14%) (RR 0.81, 95% CI 0.27 to 2.48; 89 participants; low‐quality evidence ). Two studies reported hospital length of stay. One study reported a significantly shorter stay in the oral tranexamic acid group (mean difference (MD) ‐1.60 days, 95% CI ‐2.49 to ‐0.71; 68 participants). The other study found no evidence of a difference between the groups. Tranexamic acid versus other haemostatic agents When we pooled the data from three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the topical tranexamic acid group compared to the group receiving another haemostatic agent (70% versus 30%: RR 2.35, 95% CI 1.90 to 2.92; 460 participants) ( moderate‐quality evidence ). Adverse effects across all studies Five studies recorded 'adverse effects' in a general way. None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient developed a superficial thrombophlebitis of both legs following discharge, however it is not reported in which group this occurred. No \"other serious adverse effect\" was reported in any study. Authors' conclusions We found moderate‐quality evidence that there is probably a reduction in the risk of re‐bleeding with the use of either oral or topical tranexamic acid in addition to usual care in adult patients with epistaxis, compared to placebo with usual care. However, the quality of evidence relating solely to topical tranexamic acid was low (one study only), so we are uncertain whether or not topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. We found moderate‐quality evidence that topical tranexamic acid is probably better than other topical agents in stopping bleeding in the first 10 minutes. There have been only three RCTs on this subject since 1995. Since then there have been significant changes in nasal cauterisation and packing techniques (for example, techniques including nasal endoscopy and more invasive approaches such as endoscopic sphenopalatine artery ligation). New trials would inform us about the effectiveness of tranexamic acid in light of these developments. Plain language summary Tranexamic acid to help treat nosebleeds (epistaxis) Background Nosebleeds are a very common condition, with the majority of those affected either children or those over the age of 60. They usually stop on their own or by simply compressing the nose with fingers, although a small number require medical attention. This will involve either cauterising (sealing) the bleeding vessel, if it can be seen, or packing the inside of the nose with a material to cause pressure to build up and stop the bleeding ('usual care'). Occasionally bleeding continues despite these measures, or it restarts having initially been controlled. This can lead to a prolonged hospital stay and the possibility of further procedures such as repacking with a different type of nasal pack or an operation. Tranexamic acid is a drug that is known to help promote blood clotting by preventing a natural process called fibrinolysis (dissolution of a clot). It is already used in a number of situations where bleeding is a significant worry, such as after heart surgery or major trauma. It can be given by mouth (orally), directly to the bleeding site (topically) or by injection into a vein (intravenously). Study characteristics We searched for randomised controlled trials in patients of any age with nosebleed requiring intervention. Patients were treated with tranexamic acid (in addition to usual care) compared to placebo, no treatment or any other agent used to stop bleeding. We found six studies that met our inclusion criteria, with a total of 692 participants. Two studies used oral administration of tranexamic acid and four used topical administration. All participants in the studies were adults. Three of the six studies were conducted over 20 years ago. Key results Three studies measured re‐bleeding within 10 days. When we combined the results we found that fewer patients who were given either oral or topical tranexamic acid had further episodes of re‐bleeding following an initial nosebleed compared to those treated with usual care. The time to stop initial bleeding (control of bleeding within 30 minutes) was measured in four studies. In three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the group receiving topical tranexamic acid compared to the group receiving a different drug (topical epinephrine and lidocaine or phenylephrine). In the other study there was no significant difference at 30 minutes when topical tranexamic acid was compared with placebo. No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery). Only one study of oral tranexamic acid reported the proportion of patients requiring a blood transfusion and there was no evidence of a difference between the groups. Length of hospital stay was reported in two studies. One study reported a significantly shorter stay in the oral tranexamic acid group, while the other found no evidence of a difference. Five studies mention recording \"adverse effects\". None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient did develop a superficial thrombophlebitis (inflammation and a blood clot in a vein near the surface of the skin) of both legs following discharge, but the study did not report in which treatment group this happened. No serious adverse event was seen in any of the studies. Quality of the evidence and conclusions Overall, the risk of bias in the six studies was low. We graded the quality of the evidence for the main outcome (control of epistaxis: re‐bleeding within 10 days) as moderate, which means that further research is likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate. In light of this and the fact that 'usual care' has changed, with the development of more modern nasal cauterisation and packing techniques, since three of the included studies were carried out, there remains uncertainty about the role of tranexamic acid in the treatment of patients with epistaxis. Newer research into the effect of tranexamic acid as a treatment for nosebleeds would inform future management decisions for this condition. The evidence in this review is up to date to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Joseph, J; Martinez‐Devesa, P; Bellorini, J; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "82140858-cace-49f9-9ea0-ae9882036c14", "pmid": "", "title": "Zinc supplementation for the prevention of pneumonia in children aged 2 months to 59 months", "imported": false, "abstract": "Abstract - Background Pneumonia is a leading cause of morbidity and mortality in children younger than five years of age. Most deaths occur during infancy and in low‐income countries. Daily zinc supplements have been reported to prevent acute lower respiratory tract infection (LRTI) and reduce child mortality. This is an update of a review first published in 2010. Objectives To evaluate the effectiveness of zinc supplementation in the prevention of pneumonia in children aged two to 59 months. Search methods We searched CENTRAL (Issue 21 October 2016), MEDLINE (1966 to October 2016), Embase (1974 to October 2016), LILACS (1982 to October 2016), CINAHL (1981 to October 2016), Web of Science (1985 to October 2016) and IMSEAR (1980 to October 2016). Selection criteria Randomised controlled trials (RCTs) evaluating zinc supplementation for the prevention of pneumonia in children aged from 2 months to 59 months. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We did not identify any new studies for inclusion in this update. We included six studies that involved 5193 participants. Analysis showed that zinc supplementation reduced the incidence of pneumonia by 13% (fixed‐effect risk ratio (RR) 0.87; 95% confidence interval (CI) 0.81 to 0.94, six studies, low‐quality evidence) and prevalence of pneumonia by 41% (random‐effects RR 0.59; 95% CI 0.35 to 0.99, one study, n = 609, low‐quality evidence). On subgroup analysis, we found that zinc reduced the incidence of pneumonia defined by specific clinical criteria by 21% (i.e. confirmation by chest examination or chest radiograph) (fixed‐effect RR 0.79; 95% CI 0.71 to 0.88, four studies, n = 3261), but had no effect on lower specificity pneumonia case definition (i.e. age‐specific fast breathing with or without lower chest indrawing) (fixed‐effect RR 0.95; 95% CI 0.86 to 1.06, four studies, n = 1932). Authors' conclusions Zinc supplementation in children is associated with a reduction in the incidence and prevalence of pneumonia. Plain language summary Zinc supplementation for the prevention of pneumonia in children aged two to 59 months Review question We evaluated the effectiveness of zinc supplementation to prevent pneumonia in children aged from two to 59 months. Background Zinc is an essential element for children's growth and development. Too little zinc is associated with increased risk of infection, particularly diarrhoea and pneumonia. Children are more prone to zinc deficiency because they are less able to absorb dietary zinc and some children, especially in low‐income countries, may not have received enough zinc from their mothers before birth. Zinc supplements for children has been reported to prevent pneumonia. Search date We searched the literature up to October 2016. This is an update of a review published in 2010. We did not find any new studies for this update. Study characteristics We included six studies that investigated zinc supplements to prevent pneumonia. The studies were conducted in Bangladesh, India, Peru and South Africa and involved 5193 children aged from two to 59 months. Children received either zinc or a similar‐looking treatment that did not contain zinc. In two studies, children were also given vitamin A. Study funding sources All included studies were funded. Of these, three explicitly mentioned that funding agencies had no role in the design and results of the study. Key results Zinc supplementation was significantly associated with reducing the incidence and prevalence of pneumonia among children aged from two to 59 months. On subgroup analysis, we found that a more stringent diagnosis (radiological examination) increased the reduction in pneumonia incidence. Quality of the evidence Overall, evidence quality was assessed as low on GRADE assessment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lassi, ZS, Moin, A, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD005978.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.733Z" }, { "id": "821957ee-a018-4a3e-8cbf-393cf28b5afa", "pmid": "", "title": "Interventions for palliative symptom control in COVID‐19 patients", "imported": false, "abstract": "Abstract - Background Individuals dying of coronavirus disease 2019 (COVID‐19) may experience distressing symptoms such as breathlessness or delirium. Palliative symptom management can alleviate symptoms and improve the quality of life of patients. Various treatment options such as opioids or breathing techniques have been discussed for use in COVID‐19 patients. However, guidance on symptom management of COVID‐19 patients in palliative care has often been derived from clinical experiences and guidelines for the treatment of patients with other illnesses. An understanding of the effectiveness of pharmacological and non‐pharmacological palliative interventions to manage specific symptoms of COVID‐19 patients is required. Objectives To assess the efficacy and safety of pharmacological and non‐pharmacological interventions for palliative symptom control in individuals with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), Embase, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), medRxiv); Web of Science Core Collection (Science Citation Index Expanded, Emerging Sources); CINAHL; WHO COVID‐19 Global literature on coronavirus disease; and COAP Living Evidence on COVID‐19 to identify completed and ongoing studies without language restrictions until 23 March 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. Selection criteria We followed standard Cochrane methodology as outlined in the Cochrane Handbook for Systematic Reviews of Interventions . We included studies evaluating palliative symptom management for individuals with a confirmed diagnosis of COVID‐19 receiving interventions for palliative symptom control, with no restrictions regarding comorbidities, age, gender, or ethnicity. Interventions comprised pharmacological as well as non‐pharmacological treatment (e.g. acupressure, physical therapy, relaxation, or breathing techniques). We searched for the following types of studies: randomized controlled trials (RCT), quasi‐RCTs, controlled clinical trials, controlled before‐after studies, interrupted time series (with comparison group), prospective cohort studies, retrospective cohort studies, (nested) case‐control studies, and cross‐sectional studies. We searched for studies comparing pharmacological and non‐pharmacological interventions for palliative symptom control with standard care. We excluded studies evaluating palliative interventions for symptoms caused by other terminal illnesses. If studies enrolled populations with or exposed to multiple diseases, we would only include these if the authors provided subgroup data for individuals with COVID‐19. We excluded studies investigating interventions for symptom control in a curative setting, for example patients receiving life‐prolonging therapies such as invasive ventilation. Data collection and analysis We used a modified version of the Newcastle Ottawa Scale for non‐randomized studies of interventions (NRSIs) to assess bias in the included studies. We included the following outcomes: symptom relief (primary outcome); quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We rated the certainty of evidence using the GRADE approach. As meta‐analysis was not possible, we used tabulation to synthesize the studies and histograms to display the outcomes. Main results Overall, we identified four uncontrolled retrospective cohort studies investigating pharmacological interventions for palliative symptom control in hospitalized patients and patients in nursing homes. None of the studies included a comparator. We rated the risk of bias high across all studies. We rated the certainty of the evidence as very low for the primary outcome symptom relief, downgrading mainly for high risk of bias due to confounding and unblinded outcome assessors. Pharmacological interventions for palliative symptom control We identified four uncontrolled retrospective cohort studies (five references) investigating pharmacological interventions for palliative symptom control. Two references used the same register to form their cohorts, and study investigators confirmed a partial overlap of participants. We therefore do not know the exact number of participants, but individual reports included 61 to 2105 participants. Participants received multimodal pharmacological interventions: opioids, neuroleptics, anticholinergics, and benzodiazepines for relieving dyspnea (breathlessness), delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms. Primary outcome: symptom relief All identified studies reported this outcome. For all symptoms (dyspnea, delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms), a majority of interventions were rated as completely or partially effective by outcome assessors (treating clinicians or nursing staff). Interventions used in the studies were opioids, neuroleptics, anticholinergics, and benzodiazepines. We are very uncertain about the effect of pharmacological interventions on symptom relief (very low‐certainty evidence). The initial rating of the certainty of evidence was low since we only identified uncontrolled NRSIs. Our main reason for downgrading the certainty of evidence was high risk of bias due to confounding and unblinded outcome assessors. We therefore did not find evidence to confidently support or refute whether pharmacological interventions may be effective for palliative symptom relief in COVID‐19 patients. Secondary outcomes We planned to include the following outcomes: quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We did not find any data for these outcomes, or any other information on the efficacy and safety of used interventions. Non‐pharmacological interventions for palliative symptom control None of the identified studies used non‐pharmacological interventions for palliative symptom control. Authors' conclusions We found very low certainty evidence for the efficacy of pharmacological interventions for palliative symptom relief in COVID‐19 patients. We found no evidence on the safety of pharmacological interventions or efficacy and safety of non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. The evidence presented here has no specific implications for palliative symptom control in COVID‐19 patients because we cannot draw any conclusions about the effectiveness or safety based on the identified evidence. More evidence is needed to guide clinicians, nursing staff, and caregivers when treating symptoms of COVID‐19 patients at the end of life. Specifically, future studies ought to investigate palliative symptom control in prospectively registered studies, using an active‐controlled setting, assess patient‐reported outcomes, and clearly define interventions. The publication of the results of ongoing studies will necessitate an update of this review. The conclusions of an updated review could differ from those of the present review and may allow for a better judgement regarding pharmacological and non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. Plain language summary Which treatments are best for symptoms in COVID‐19 patients at the end of life? The burden of symptoms at the end of life of COVID‐19 patients and helpful treatments COVID‐19 patients may show symptoms such as breathlessness or delirium at the end of life. The goal of palliative medicine is to relieve such symptoms with specific treatments. Treatments can be drugs, for example opioids, or non‐drugs, such as breathing techniques or relaxation. What was the aim of our review? To explore how well different interventions (drugs and non‐drugs) work for the treatment of palliative symptoms in COVID‐19 patients at the end of life. We included patients of all ages and with all comorbidities (additional medical conditions). What type of studies did we search for? We searched selected medical databases and trial registries until 23 March 2021. We included studies looking at how well different palliative treatments work to relieve COVID‐19‐associated symptoms at the end of life. We wanted to compare studies investigating different medicines or therapies, but we only found studies without a comparison group. Only one study reported the specific drugs used for individual symptoms. Key results We found four studies that were published in five papers. Individual papers included between 61 and 2105 participants, and two papers partially reported on the same participants. All of the included studies investigated different drug treatments for palliative symptom management in people with COVID‐19. Drugs for symptom control at the end of life All of the included studies reported on the effectiveness of palliative care for symptom relief. In all studies, clinicians or nursing staff rated symptom relief rather than the patients themselves. Since the quality of the evidence was very low, we do not know the true effect of drug treatments on symptom relief and have very low confidence in the results of the studies. We did not find any data on quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; or safety of the drug treatments. Non‐drug therapies for symptom control at the end of life We did not find any data on the benefits and harms of non‐drug therapies for symptom control of COVID‐19 patients at the end of life. Conclusions Based on our findings, we could not draw any conclusions on palliative symptom control of people with COVID‐19. Future studies need to be designed better so that we can determine which treatments work for symptom control in people with COVID‐19.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Andreas, M; Piechotta, V; Skoetz, N; Grummich, K; Becker, M; Joos, L; Becker, G; Meissner, W; Boehlke, C", "articleTypes": [], "doi": "10.1002/14651858.CD015061", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "821b3f90-6da3-4d85-9065-3bf9dfa40a59", "pmid": "", "title": "Dietary supplements for dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Dysmenorrhoea refers to painful menstrual cramps and is a common gynaecological complaint. Conventional treatments include non‐steroidal anti‐inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs), which both reduce myometrial activity (contractions of the uterus). A suggested alternative approach is dietary supplements. We used the term 'dietary supplement' to include herbs or other botanical, vitamins, minerals, enzymes, and amino acids. We excluded traditional Chinese medicines. Objectives To determine the efficacy and safety of dietary supplements for treating dysmenorrhoea. Search methods We searched sources including the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, PsycINFO (all from inception to 23 March 2015), trial registries, and the reference lists of relevant articles. Selection criteria We included randomised controlled trials (RCTs) of dietary supplements for moderate or severe primary or secondary dysmenorrhoea. We excluded studies of women with an intrauterine device. Eligible comparators were other dietary supplements, placebo, no treatment, or conventional analgesia. Data collection and analysis Two review authors independently performed study selection, performed data extraction and assessed the risk of bias in the included trials. The primary outcomes were pain intensity and adverse effects. We used a fixed‐effect model to calculate odds ratios (ORs) for dichotomous data, and mean differences (MDs) or standardised mean differences (SMDs) for continuous data, with 95% confidence intervals (CIs). We presented data that were unsuitable for analysis either descriptively or in additional tables. We assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods. Main results We included 27 RCTs (3101 women). Most included studies were conducted amongst cohorts of students with primary dysmenorrhoea in their late teens or early twenties. Twenty‐two studies were conducted in Iran and the rest were performed in other middle‐income countries. Only one study addressed secondary dysmenorrhoea. Interventions included 12 different herbal medicines (German chamomile ( Matricaria chamomilla, M recutita, Chamomilla recutita) , cinnamon ( Cinnamomum zeylanicum, C. verum) , Damask rose ( Rosa damascena), dill ( Anethum graveolens ), fennel ( Foeniculum vulgare ), fenugreek ( Trigonella foenum‐graecum ), ginger ( Zingiber officinale ), guava ( Psidium guajava ), rhubarb ( Rheum emodi ), uzara ( Xysmalobium undulatum ), valerian ( Valeriana officinalis ), and zataria ( Zataria multiflora )) and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Comparators included other supplements, placebo, no treatment, and NSAIDs. We judged all the evidence to be of low or very low quality. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few studies reported adverse effects. Effectiveness of supplements for primary dysmenorrhoea We have presented pain scores (all on a visual analogue scale (VAS) 0 to 10 point scale) or rates of pain relief, or both, at the first post‐treatment follow‐up. Supplements versus placebo or no treatment There was no evidence of effectiveness for vitamin E (MD 0.00 points, 95% CI −0.34 to 0.34; two RCTs, 135 women). There was no consistent evidence of effectiveness for dill (MD ‐1.15 points, 95% CI −2.22 to −0.08, one RCT, 46 women), guava (MD 0.59, 95% CI −0.13 to 1.31; one RCT, 151 women); one RCT, 73 women), or fennel (MD −0.34 points, 95% CI −0.74 to 0.06; one RCT, 43 women). There was very limited evidence of effectiveness for fenugreek (MD −1.71 points, 95% CI −2.35 to −1.07; one RCT, 101 women), fish oil (MD 1.11 points, 95% CI 0.45 to 1.77; one RCT, 120 women), fish oil plus vitamin B1 (MD −1.21 points, 95% CI −1.79 to −0.63; one RCT, 120 women), ginger (MD −1.55 points, 95% CI −2.43 to −0.68; three RCTs, 266 women; OR 5.44, 95% CI 1.80 to 16.46; one RCT, 69 women), valerian (MD −0.76 points, 95% CI −1.44 to −0.08; one RCT, 100 women), vitamin B1 alone (MD −2.70 points, 95% CI −3.32 to −2.08; one RCT, 120 women), zataria (OR 6.66, 95% CI 2.66 to 16.72; one RCT, 99 women), and zinc sulphate (MD −0.95 points, 95% CI −1.54 to −0.36; one RCT, 99 women). Data on chamomile and cinnamon versus placebo were unsuitable for analysis. Supplements versus NSAIDS There was no evidence of any difference between NSAIDs and dill (MD 0.13 points, 95% CI −1.01 to 1.27; one RCT, 47 women), fennel (MD −0.70 points, 95% CI −1.81 to 0.41; one RCT, 59 women), guava (MD 1.19, 95% CI 0.42 to 1.96; one RCT, 155 women), rhubarb (MD −0.20 points, 95% CI −0.44 to 0.04; one RCT, 45 women), or valerian (MD points 0.62 , 95% CI 0.03 to 1.21; one RCT, 99 women), There was no consistent evidence of a difference between Damask rose and NSAIDs (MD −0.15 points, 95% CI −0.55 to 0.25; one RCT, 92 women). There was very limited evidence that chamomile was more effective than NSAIDs (MD −1.42 points, 95% CI −1.69 to −1.15; one RCT, 160 women). Supplements versus other supplements There was no evidence of a difference in effectiveness between ginger and zinc sulphate (MD 0.02 points, 95% CI −0.58 to 0.62; one RCT, 101 women). Vitamin B1 may be more effective than fish oil (MD −1.59 points, 95% CI −2.25 to −0.93; one RCT, 120 women). Effectiveness of supplements for secondary dysmenorrhoea There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis (data were unsuitable for analysis). Safety of supplements Only four of the 27 included studies reported adverse effects in both treatment groups. There was no evidence of a difference between the groups but data were too scanty to reach any conclusions about safety. Authors' conclusions There is no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety is lacking. However for several supplements there was some low quality evidence of effectiveness and more research is justified. Plain language summary Dietary supplements for pain during menstruation Review question Cochrane authors reviewed the evidence of the effect of dietary supplements (e.g. vitamins, minerals, herbs) on period pain (dysmenorrhoea). Background Dietary supplements have been used in the treatment of period pain. It is important to explore their benefits and harms. We investigated the effectiveness of dietary supplements compared to other supplements, placebo, no treatment or conventional analgesics (pain relief) in women with either primary dysmenorrhoea (not related to any other diagnosis) or secondary dysmenorrhoea (related to other causes, such as endometriosis). The evidence is current to 23 March 2015. Study characteristics We included 27 randomised controlled trials (3101 women). Most participants were students in their late teens or early twenties with primary dysmenorrhoea. Most studies were conducted in Iran. Interventions included 12 different herbal medicines (chamomile, cinnamon, Damask rose, dill, fennel, fenugreek, ginger, guava, rhubarb, uzara, valerian, and zataria), and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Supplements were compared with other supplements, placebo, no treatment, and non‐steroidal anti‐inflammatory drugs (NSAIDs). Key results There was no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety was lacking. However, for several supplements there was some low quality evidence of effectiveness. Supplements for which there was some very limited evidence to suggest a potential benefit were fenugreek, ginger, valerian, zataria, zinc sulphate, fish oil, and vitamin B1. There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis. Quality of the evidence The evidence was of low or very low quality for all comparisons. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few included studies reported adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pattanittum, P, Kunyanone, N, Brown, J, Sangkomkamhang, US, Barnes, J, Seyfoddin, V, Marjoribanks, J", "articleTypes": [], "doi": "10.1002/14651858.CD002124.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.779Z" }, { "id": "823b7e3e-4a34-4de2-bd25-bb457afa819c", "pmid": "", "title": "Antibiotics for acute rhinosinusitis in adults", "imported": false, "abstract": "Abstract - Background Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear. We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging. Objectives To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings. Search methods We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines. Selection criteria Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis‐like signs or symptoms or sinusitis confirmed by imaging. Data collection and analysis Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required. Main results We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I² = 0%; 8 trials; high‐quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I² = 0%; 3 trials; moderate‐quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate‐quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I² = 0%; 3 trials; high‐quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I² = 16%; 10 trials; high‐quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I² = 21%; 12 trials; high‐quality evidence). A disease‐related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group). Authors' conclusions The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high‐quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate‐quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials. Plain language summary Antibiotics for sinus infection of short duration in adults Review question Do antibiotics cure sinus infection faster than no antibiotics in adults? Background A sinus is a cavity situated in the head. Adults with short‐duration sinus infection experience stuffy nose and thick, yellow discharge from the nose. People with sinus infection can feel slime in the back of the throat, facial pain, pain when bending forward, and pain in the upper teeth or when chewing. A short‐duration sinus infection may be suspected following physical examination and questions about symptoms. Blood examination or images of the sinuses can support diagnosis, but are not routinely recommended in most countries. Short‐duration sinus infections are mostly caused by viruses. Nevertheless, physicians tend to prescribe antibiotics, which should only be used to treat bacterial infections. Taking antibiotics unnecessarily results in antibiotic resistance against bacterial infections. We investigated whether antibiotics cure adults with short‐duration sinus infection faster than a dummy drug (placebo) or no treatment. Search date 18 January 2018. Study characteristics We included 15 studies in which adults with short‐duration sinus infection, whether or not confirmed by imaging, randomly received antibiotics, or a dummy drug or no treatment, in ambulatory care settings. The studies included a total of 3057 adults whose average age was 36 years; about 60% were female. Participants were followed until they were cured. Trial duration ranged from 8 to 28 days. Study funding sources Seven studies received financial support from government or academic institutions; six received grants from the pharmaceutical industry; and five did not state sources of support. Key results Without antibiotics, almost half of all participants were cured after one week, and two out of three were cured after 14 days. Five (diagnosis based on symptoms described to a doctor) to 11 (diagnosis confirmed by x‐ray) more people per 100 were cured faster with antibiotics. A computed tomography (CT) scan could better predict who would benefit from antibiotics, but routine use would cause health problems related to radiation exposure. Ten more people per 100 were relieved faster of thick, yellow discharge from the nose with antibiotics compared to a dummy drug or no treatment. Thirteen more people per 100 experienced side effects (mostly concerning stomach or intestines) with antibiotics compared to a dummy drug or no treatment. Compared with people who initially started antibiotics, five more people per 100 in the dummy drug or no treatment group had to start antibiotics because their condition worsened. Serious complications (e.g. brain abscess) were rare. We found that antibiotics are not a first‐choice treatment for adults with short‐duration sinus infection. We found no evidence relating to adults with severe sinusitis or with reduced immunity, or to children. Quality of evidence We found high‐quality evidence when the diagnosis was based on symptoms described to a doctor. We downgraded evidence quality to moderate when diagnosis was confirmed by x‐ray or CT scan because the number of participants was small, which makes the estimates less reliable.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Lemiengre, MB, van Driel, ML, Merenstein, D, Liira, H, Mäkelä, M, De Sutter, AIM", "articleTypes": [], "doi": "10.1002/14651858.CD006089.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.097Z" }, { "id": "823c7d97-4f21-4fc3-bbb7-6f9fa2612e38", "pmid": "", "title": "Nedocromil sodium for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Exercise‐induced bronchoconstriction (EIB) following strenuous physical exertion afflicts many people. It can be the cause of sub‐optimal performance, symptoms such as cough, dyspnea, wheeze and chest tightness, and can lead people to avoid physical activity. Management of EIB focuses on prevention through pharmacotherapy and alternate strategies. Single use, pre‐exercise, beta‐agonists and non‐steroidal antiinflammatory agents are recommended. Objectives Bronchodilator medications have been commonly used to prevent narrowing of airways after exercise, but anti‐inflammatory drugs such as nedocromil sodium have also been used. The objective of this review was to assess the effects of a single dose of nedocromil sodium to prevent exercise‐induced bronchoconstriction. Search methods We searched the Cochrane Airways Group Specialised Regsiter, the Cochrane Central Register of Controlled Trials, Current Contents, review articles, textbooks and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. Searches have been updated to August 2008. Selection criteria Randomised trials comparing a single dose of nedocromil sodium with placebo to prevent exercise‐induced bronchoconstriction in patients with EIB over six years of age. Data collection and analysis Trial quality assessment and data extraction were conducted independently by two reviewers. Study authors were contacted for confirmation of data. No new studies were identified in an update search conducted in August 2008. Main results The combined results from 20 randomised controlled trials involving 280 participants, show that 4 mg, of nedocromil sodium inhaled 15 to 60 minutes prior to exercise significantly reduce the severity and duration of EIB in both adults and children, when compared to placebo. The maximum percentage fall in FEV1 was improved significantly compared to placebo (weighted mean difference 15.5 %; 95% confidence interval:13.2 to 18.1). For the maximum percentage fall in peak expiratory flow rate (PEFR) the improvement was similar: WMD 15.0%, (95% CI 8.3 to 21.6). Nedocromil shortened the time to recover lung normal function from more than 30 minutes with placebo to less than 10 minutes with the drug. It had a greater effect on those patients with more severe exercise‐induced bronchoconstriction (defined as an exercise‐induced fall in lung function > 30% from baseline). There were no significant adverse effects reported with the short term use of nedocromil. A further search conducted in August 2005 did not yield any further studies. Authors' conclusions Nedocromil sodium used before exercise reduces the severity and duration of exercise‐induced bronchoconstriction. This effect appears to be more pronounced in people with severe exercise‐induced bronchoconstriction. Plain language summary Nedocromil sodium for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. The review of trials found that nedocromil sodium (Tilade) inhaled 15 to 60 minutes before exercise may reduce the severity and length of this kind of asthma for both adults and children, particularly those who have severe episodes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Spooner, C, Saunders, LD, Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD001183", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.766Z" }, { "id": "825780cd-8c5c-4172-b988-eb43c730a841", "pmid": "", "title": "Medically Utilized Tailored Traditional Meals to Optimize Nutrition in Heart Failure Pilot Trial", "imported": false, "abstract": "Study subjects with heart failure will receive either pre-prepared, home-delivered DASH/SRD-compliant meals incorporating local Navajo traditional foods or usual care for 30 days (14 meals weekly).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.161Z" }, { "id": "82779ec1-d8ca-47c6-be9e-909f9c1b4e0a", "pmid": "", "title": "Omega‐3 fatty acid addition during pregnancy", "imported": false, "abstract": "Abstract - Background Higher intakes of foods containing omega‐3 long‐chain polyunsaturated fatty acids (LCPUFA), such as fish, during pregnancy have been associated with longer gestations and improved perinatal outcomes. This is an update of a review that was first published in 2006. Objectives To assess the effects of omega‐3 LCPUFA, as supplements or as dietary additions, during pregnancy on maternal, perinatal, and neonatal outcomes and longer‐term outcomes for mother and child. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (16 August 2018), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing omega‐3 fatty acids (as supplements or as foods, stand‐alone interventions, or with a co‐intervention) during pregnancy with placebo or no omega‐3, and studies or study arms directly comparing omega‐3 LCPUFA doses or types. Trials published in abstract form were eligible for inclusion. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, assessed risk of bias in trials and assessed quality of evidence for prespecified birth/infant, maternal, child/adult and health service outcomes using the GRADE approach. Main results In this update, we included 70 RCTs (involving 19,927 women at low, mixed or high risk of poor pregnancy outcomes) which compared omega‐3 LCPUFA interventions (supplements and food) compared with placebo or no omega‐3. Overall study‐level risk of bias was mixed, with selection and performance bias mostly at low risk, but there was high risk of attrition bias in some trials. Most trials were conducted in upper‐middle or high‐income countries; and nearly half the trials included women at increased/high risk for factors which might increase the risk of adverse maternal and birth outcomes. Preterm birth < 37 weeks (13.4% versus 11.9%; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.81 to 0.97; 26 RCTs, 10,304 participants; high‐quality evidence) and early preterm birth < 34 weeks (4.6% versus 2.7%; RR 0.58, 95% CI 0.44 to 0.77; 9 RCTs, 5204 participants; high‐quality evidence) were both lower in women who received omega‐3 LCPUFA compared with no omega‐3. Prolonged gestation > 42 weeks was probably increased from 1.6% to 2.6% in women who received omega‐3 LCPUFA compared with no omega‐3 (RR 1.61 95% CI 1.11 to 2.33; 5141 participants; 6 RCTs; moderate‐quality evidence ). For infants, there was a possibly reduced risk of perinatal death (RR 0.75, 95% CI 0.54 to 1.03; 10 RCTs, 7416 participants; moderate‐quality evidence: 62/3715 versus 83/3701 infants) and possibly fewer neonatal care admissions (RR 0.92, 95% CI 0.83 to 1.03; 9 RCTs, 6920 participants; moderate‐quality evidence ‐ 483/3475 infants versus 519/3445 infants). There was a reduced risk of low birthweight (LBW) babies (15.6% versus 14%; RR 0.90, 95% CI 0.82 to 0.99; 15 trials, 8449 participants; high‐quality evidence); but a possible small increase in large‐for‐gestational age (LGA) babies (RR 1.15, 95% CI 0.97 to 1.36; 6 RCTs, 3722 participants; moderate‐quality evidence, for omega‐3 LCPUFA compared with no omega‐3. Little or no difference in small‐for‐gestational age or intrauterine growth restriction (RR 1.01, 95% CI 0.90 to 1.13; 8 RCTs, 6907 participants; moderate‐quality evidence) was seen. For the maternal outcomes , there is insufficient evidence to determine the effects of omega‐3 on induction post‐term (average RR 0.82, 95% CI 0.22 to 2.98; 3 trials, 2900 participants; low‐quality evidence), maternal serious adverse events (RR 1.04, 95% CI 0.40 to 2.72; 2 trials, 2690 participants; low‐quality evidence), maternal admission to intensive care (RR 0.56, 95% CI 0.12 to 2.63; 2 trials, 2458 participants; low‐quality evidence), or postnatal depression (average RR 0.99, 95% CI 0.56 to 1.77; 2 trials, 2431 participants; low‐quality evidence). Mean gestational length was greater in women who received omega‐3 LCPUFA (mean difference (MD) 1.67 days, 95% CI 0.95 to 2.39; 41 trials, 12,517 participants; moderate‐quality evidence), and pre‐eclampsia may possibly be reduced with omega‐3 LCPUFA (RR 0.84, 95% CI 0.69 to 1.01; 20 trials, 8306 participants; low‐quality evidence). For the child/adult outcomes, very few differences between antenatal omega‐3 LCPUFA supplementation and no omega‐3 were observed in cognition, IQ, vision, other neurodevelopment and growth outcomes, language and behaviour (mostly low‐quality to very low‐quality evidence). The effect of omega‐3 LCPUFA on body mass index at 19 years (MD 0, 95% CI ‐0.83 to 0.83; 1 trial, 243 participants; very low‐quality evidence) was uncertain. No data were reported for development of diabetes in the children of study participants. Authors' conclusions In the overall analysis, preterm birth < 37 weeks and early preterm birth < 34 weeks were reduced in women receiving omega‐3 LCPUFA compared with no omega‐3. There was a possibly reduced risk of perinatal death and of neonatal care admission , a reduced risk of LBW babies; and possibly a small increased risk of LGA babies with omega‐3 LCPUFA. For our GRADE quality assessments, we assessed most of the important perinatal outcomes as high‐quality (e.g. preterm birth) or moderate‐quality evidence (e.g. perinatal death). For the other outcome domains (maternal, child/adult and health service outcomes) GRADE ratings ranged from moderate to very low, with over half rated as low. Reasons for downgrading across the domain were mostly due to design limitations and imprecision. Omega‐3 LCPUFA supplementation during pregnancy is an effective strategy for reducing the incidence of preterm birth, although it probably increases the incidence of post‐term pregnancies. More studies comparing omega‐3 LCPUFA and placebo (to establish causality in relation to preterm birth) are not needed at this stage. A further 23 ongoing trials are still to report on over 5000 women, so no more RCTs are needed that compare omega‐3 LCPUFA against placebo or no intervention. However, further follow‐up of completed trials is needed to assess longer‐term outcomes for mother and child, to improve understanding of metabolic, growth and neurodevelopment pathways in particular, and to establish if, and how, outcomes vary by different types of omega‐3 LCPUFA, timing and doses; or by characteristics of women. Plain language summary Omega‐3 fatty acid addition during pregnancy What is the issue? Do omega‐3 long chain polyunsaturated fatty acids (LCPUFA) taken during pregnancy ‐ either as supplements or as dietary additions in food (such as some types of fish) ‐ improve health outcomes for babies and their mothers? This is an update of a Cochrane Review that was first published in 2006. Why is this important? Preterm birth (babies born before 37 weeks pregnancy (gestation)) is a leading cause of disability or death in the first five years of life. Fish and fish oil contain omega‐3 LCPUFA (particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)) and have been associated with longer pregnancies. So it is suggested that additional omega‐3 LCPUFAs in pregnancy may reduce the number of babies born preterm and may improve outcomes for children and mothers. However, many pregnant women do not eat fish very often. Encouraging pregnant women to eat fatty fish (which generally have low toxin levels) or to use omega‐3 LCPUFA supplements may improve children’s and women's health. This is an update of a Cochrane Review that was first published in 2006. What evidence did we find? We searched for evidence in August 2018 and found 70 randomised controlled trials (RCTs; this type of trial provides the most reliable results) (involving 19,927 women). Most trials evaluated a group of women who received omega‐3 LCPUFA and compared them with a group of women who received something that looked like omega‐3 LCPUFA but did not contain it (placebo) or received no omega‐3. The trials were mostly undertaken in upper‐middle or high‐income countries. Some studies included women at increased risk of preterm birth. The quality of the evidence from the included studies ranged from high to very low; this affected the certainty of the findings for different outcomes. We found the incidence of preterm birth (before 37 weeks) and very preterm birth (before 34 weeks) was lower in women who received omega‐3 LCPUFA compared with no additional omega‐3. There were also fewer babies with low birthweight. However, omega‐3 LCPUFA probably increased the incidence of pregnancies continuing beyond 42 weeks, although there was no difference identified in induction of labour for post‐term pregnancies. The risk of the baby dying or being very sick and going to neonatal intensive care may be lower with omega‐3 LCPUFA compared with no omega‐3. We did not see any differences between groups for serious adverse events for mothers or in postnatal depression. Very few differences between the omega‐3 LCPUFA groups and no omega‐3 groups were observed in child development and growth. Eleven trials reported that they had received industry funding. When we omitted these trials from the main outcomes (such as preterm birth and very preterm birth) it made very little, or no difference, to the results. What does this mean? Increasing omega‐3 LCPUFA intake during pregnancy, either through supplements or in foods, may reduce the incidence of preterm birth (before 37 weeks and before 34 weeks) and there may be less chance of having a baby with a low birthweight. Women who take omega‐3 LCPUFA supplements during pregnancy may also be more likely to have longer pregnancies. More studies are underway and their results will be included in a further update of this review. Future studies could consider if and how outcomes may vary in different populations of women, and could test different ways of increasing omega‐3 LCPUFA during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Middleton, P, Gomersall, JC, Gould, JF, Shepherd, E, Olsen, SF, Makrides, M", "articleTypes": [], "doi": "10.1002/14651858.CD003402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.785Z" }, { "id": "8289953f-1bed-4d9a-b56e-d9da0a47945a", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 1. Commonly‐used classes of drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres ( ˜ 8200 feet ). Acute hypoxia, acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude. In this review, the first in a series of three about preventive strategies for HAI, we assess the effectiveness of six of the most recommended classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of commonly‐used pharmacological interventions for preventing acute HAI. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), LILACS and trial registries in January 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text terms to search. Selection criteria We included randomized‐controlled and cross‐over trials conducted in any setting where commonly‐used classes of drugs were used to prevent acute HAI. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Main results We included 64 studies (78 references) and 4547 participants in this review, and classified 12 additional studies as ongoing. A further 12 studies await classification, as we were unable to obtain the full texts. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. Risks of bias were unclear for several domains, and a considerable number of studies did not report adverse events of the evaluated interventions. We found 26 comparisons, 15 of them comparing commonly‐used drugs versus placebo. We report results for the three most important comparisons: Acetazolamide versus placebo (28 parallel studies; 2345 participants) The risk of AMS was reduced with acetazolamide (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.56; I 2 = 0%; 16 studies; 2301 participants; moderate quality of evidence). No events of HAPE were reported and only one event of HACE (RR 0.32, 95% CI 0.01 to 7.48; 6 parallel studies; 1126 participants; moderate quality of evidence). Few studies reported side effects for this comparison, and they showed an increase in the risk of paraesthesia with the intake of acetazolamide (RR 5.53, 95% CI 2.81 to 10.88, I 2 = 60%; 5 studies, 789 participants; low quality of evidence). Budenoside versus placebo (2 parallel studies; 132 participants) Data on budenoside showed a reduction in the incidence of AMS compared with placebo (RR 0.37, 95% CI 0.23 to 0.61; I 2 = 0%; 2 studies, 132 participants; low quality of evidence). Studies included did not report events of HAPE or HACE, and they did not find side effects (low quality of evidence). Dexamethasone versus placebo (7 parallel studies; 205 participants) For dexamethasone, the data did not show benefits at any dosage (RR 0.60, 95% CI 0.36 to 1.00; I2 = 39%; 4 trials, 176 participants; low quality of evidence). Included studies did not report events of HAPE or HACE, and we rated the evidence about adverse events as of very low quality. Authors' conclusions Our assessment of the most commonly‐used pharmacological interventions suggests that acetazolamide is an effective pharmacological agent to prevent acute HAI in dosages of 250 to 750 mg/day. This information is based on evidence of moderate quality. Acetazolamide is associated with an increased risk of paraesthesia, although there are few reports about other adverse events from the available evidence. The clinical benefits and harms of other pharmacological interventions such as ibuprofen, budenoside and dexamethasone are unclear. Large multicentre studies are needed for most of the pharmacological agents evaluated in this review, to evaluate their effectiveness and safety. Plain language summary Drugs commonly‐used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and breathing conditions that can occur while travelling to altitudes above 2500 metres ( ˜ 8200 feet ). HAI is generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but may affect the brain or the lungs in different individuals. In this review, we assessed the most commonly‐used drugs to prevent the onset of this illness. Study characteristics The evidence is current to January 2017. We included 64 studies related to six different types of drugs recommended for HAI prevention. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. The participants' ages ranged between 16 and 65 years. Eleven studies included people at a high risk of this condition due to their history of HAI or other illnesses such as asthma. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. In 23 of the included studies, the source of funding was unclear. Only 18 studies declared their possible conflicts of interests. We classed 24 more studies as still ongoing or waiting for assessment. Key results Our findings suggest that acetazolamide is an effective treatment for the prevention of acute HAI in dosages of 250 to 750 mg/day, when this drug is compared to a placebo (i.e. a pill with no active agent). Most of the available information relates to the prevention of uncomplicated HAI (headache, nausea, vomiting and tiredness) rather than to more serious brain or lung problems. We also found that acetazolamide is associated with an increased risk of paraesthesia in the fingers (i.e. a sensation of tingling, tickling, pricking, or burning of the skin), although this outcome is not well reported in the available evidence. The benefits and harms of other drugs such as ibuprofen, budenoside and dexamethasone are unclear, due to the small number of studies. Quality of the evidence We rated the quality of the evidence as moderate to very low. Several studies had quality shortcomings, including their use of small numbers of participants and a lack of reporting of important outcomes such as side effects. For most of the drugs covered by the studies, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Nieto Estrada, VH, Molano Franco, D, Medina, RD, Gonzalez Garay, AG, Martí‐Carvajal, AJ, Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD009761.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.089Z" }, { "id": "828ba530-90a9-48d5-bffd-87670d99cd77", "pmid": "", "title": "Modafinil for people with schizophrenia or related disorders", "imported": false, "abstract": "Abstract - Background People with schizophrenia have a range of different symptoms, including positive symptoms (hallucinations and delusions), negative symptoms (such as social withdrawal and lack of affect), and cognitive impairment. The standard medication for people with schizophrenia is antipsychotics. However, these medications may not be effective for all symptoms of schizophrenia, as cognitive and negative symptoms are usually hard to treat. Additional therapies or medications are available for the management of these symptoms. Modafinil, a wakefulness‐promoting agent most frequently used in narcolepsy or shift work sleep disorder, is one intervention that is theorised to have an effect of these symptoms. Objectives The primary objective of this review was to assess the effects of modafinil for people with schizophrenia or related disorders. Search methods On 27 April 2015, 24 May 2017, and 31 October 2019, we searched the Cochrane Schizophrenia Group's register of trials, which is based on regular searches of CENTRAL, MEDLINE, Embase, AMED, BIOSIS, CINAHL, PsycINFO, PubMed, and registries of clinical trials. There are no language, time, document type, or publication status limitations for the inclusion of records in the register. Selection criteria We selected all randomised controlled trials comparing modafinil with placebo or other treatments for people with schizophrenia or schizophrenia‐spectrum disorders. Data collection and analysis We independently extracted data from the included studies. We analysed dichotomous data using risk ratios (RR) and 95% confidence intervals (CI). We analysed continuous data using mean difference (MD) with a 95% CI. We used a random‐effects model for the meta‐analysis. We used GRADE to complete a 'Summary of findings' table and assessed risk of bias for the included studies. Main results Eleven studies including a total of 422 participants contributed to data analyses. Most studies had a small population size (average 38 people per study) and were of short duration. We also detected a high risk of bias for selective outcome reporting in just under 50% of the trials. We therefore rated the overall methodological quality of the included studies as low. We considered seven main outcomes of interest: clinically important change in overall mental state, clinically important change in cognitive functioning, incidence of a clinically important adverse effect/event, clinically important change in global state, leaving the study early for any reason, clinically important change in quality of life, and hospital admission. All studies assessed the effects of adding modafinil to participants' usual antipsychotic treatment compared to adding placebo to usual antipsychotic treatment. Six studies found that adding modafinil to antipsychotic treatment may have little or no effect on overall mental state of people with schizophrenia, specifically the risk of worsening psychosis (RR 0.91, 95% CI 0.28 to 2.98; participants = 209; studies = 6, low‐quality evidence ). Regarding the effect of modafinil on cognitive function, the trials did not report clinically important change data, but one study reported endpoint scores on the MATRICS Consensus Cognitive Battery (MCCB): in this study we found no clear difference in scores between modafinil and placebo treatment groups (MD −3.10, 95% CI −10.9 to 4.7; participants = 48; studies = 1, very low‐quality evidence ). Only one study (N = 35) reported adverse effect/event data. In this study one serious adverse event occurred in each group (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). One study measured change in global state using the Clinical Global Impression ‐ Improvement Scale. This study found that adding modafinil to antipsychotic treatment may have little or no effect on global state (RR 6.36, 95% CI 0.94 to 43.07, participants = 21; studies = 1, very low‐quality evidence ). Nine studies found that modafinil has no effect on numbers of participants leaving the study early (RR 1.26, 95% CI 0.63 to 2.52 participants = 357; studies = 9, moderate‐quality evidence ). None of the trials reported clinically important change in quality of life, but one study did report quality of life using endpoint scores on the Quality of Life Inventory, finding no clear difference between treatment groups (MD −0.2, 95% CI −1.18 to 0.78; participants = 20; studies = 1, very low‐quality evidence ). Finally, one study reported data for number of participants needing hospitalisation: one participant in each group was hospitalised (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). Authors' conclusions Due to methodological issues, low sample size, and short duration of the clinical trials as well as high risk of bias for outcome reporting, most of the evidence available for this review is of very low or low quality. For results where quality is low or very low, we are uncertain or very uncertain if the effect estimates are true effects, limiting our conclusions. Specifically, we found that modafinil is no better or worse than placebo at preventing worsening of psychosis; however, we are uncertain about this result. We have more confidence that participants receiving modafinil are no more likely to leave a trial early than participants receiving placebo. However, we are very uncertain about the remaining equivocal results between modafinil and placebo for outcomes such as improvement in global state or cognitive function, incidence of adverse events, and changes in quality of life. More high‐quality data are needed before firm conclusions regarding the effects of modafinil for people with schizophrenia or related disorders can be made. Plain language summary Modafinil for schizophrenia Review question: Is adding modafinil to antipsychotic treatment effective and safe for people with schizophrenia? Background Schizophrenia is a complicated and chronic mental disorder that usually presents with a wide range of symptoms. The standard treatment (antipsychotics) is considered to be effective for the positive symptoms (such as delusions and hallucinations or bizarre thoughts). However, there are negative and cognitive symptoms (such as social withdrawal, lack of affect, problems with memory) that are not adequately treated with these medications. These symptoms tend to be chronic and can therefore have a long‐term impact on an individual's quality of life. Additional treatments are often added to antipsychotic treatment, of which one is modafinil, a wakefulness‐promoting medication usually used for sleep disorders. Searching for evidence We ran an electronic search of Cochrane Schizophrenia's register of trials in April 2015, May 2017, and October 2019 for trials that randomised (allocated participants to treatment groups using a random method) people with schizophrenia to receive add‐on modafinil (modafinil added to their standard care) or to receive add‐on placebo. We identified 67 records that referred to 25 studies. Evidence found Eleven studies met the review requirements and reported data that could be used in analyses. However, the trials included small numbers of participants and were of short duration; schizophrenia is a long‐term health problem that ideally requires studies of longer duration. Our analysis of the data showed there is no clear difference between add‐on modafinil and add‐on placebo for improving mental state or global state, changing cognitive functioning, causing participants to leave a study early, producing adverse effects, or affecting rates of hospitalisation. However, most of these results were based on very low‐ or low‐quality data, therefore it is uncertain if these statistical effect sizes found by our data analyses are true effects. Conclusions The results of this review indicate no clear difference in effectiveness and safety between add‐on modafinil and add‐on placebo, however these results are not conclusive as they are based low‐ or very low‐quality evidence. Based on the current evidence we were unable to provide an answer to our review question as to whether modafinil is better than placebo for improving the symptoms of schizophrenia, or if it is safe to use for people with schizophrenia. More high‐quality research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ortiz-Orendain, J, Covarrubias-Castillo, SA, Vazquez-Alvarez, AO, Castiello-de Obeso, S, Arias Quiñones, GE, Seegers, M, Colunga-Lozano, LE", "articleTypes": [], "doi": "10.1002/14651858.CD008661.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.784Z" }, { "id": "829e4ac3-536c-47fb-a72f-adc2c18a5a68", "pmid": "", "title": "Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment", "imported": false, "abstract": "Abstract - Background Vitamins and minerals have many functions in the nervous system which are important for brain health. It has been suggested that various different vitamin and mineral supplements might be useful in maintaining cognitive function and delaying the onset of dementia. In this review, we sought to examine the evidence for this in people who already had mild cognitive impairment (MCI). Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function and the incidence of dementia in people with mild cognitive impairment. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CENTRAL, CINAHL, LILACs, Web of Science Core Collection, ClinicalTrials.gov, and the WHO Portal/ICTRP, from inception to 25 January 2018. Selection criteria We included randomised or quasi‐randomised, placebo‐controlled trials which evaluated orally administered vitamin or mineral supplements in participants with a diagnosis of mild cognitive impairment and which assessed the incidence of dementia or cognitive outcomes, or both. We were interested in studies applicable to the general population of older people and therefore excluded studies in which participants had severe vitamin or mineral deficiencies. Data collection and analysis We sought data on our primary outcomes of dementia incidence and overall cognitive function and on secondary outcomes of episodic memory, executive function, speed of processing, quality of life, functional performance, clinical global impression, adverse events, and mortality. We conducted data collection and analysis according to standard Cochrane systematic review methods. We assessed the risk of bias of included studies using the Cochrane 'Risk of bias' assessment tool. We grouped vitamins and minerals according to their putative mechanism of action and, where we considered it to be clinically appropriate, we pooled data using random‐effects methods. We used GRADE methods to assess the overall quality of evidence for each comparison and outcome. Main results We included five trials with 879 participants which investigated B vitamin supplements. In four trials, the intervention was a combination of vitamins B6, B12, and folic acid; in one, it was folic acid only. Doses varied. We considered there to be some risks of performance and attrition bias and of selective outcome reporting among these trials. Our primary efficacy outcomes were the incidence of dementia and scores on measures of overall cognitive function. None of the trials reported the incidence of dementia and the evidence on overall cognitive function was of very low‐quality. There was probably little or no effect of B vitamins taken for six to 24 months on episodic memory, executive function, speed of processing, or quality of life. The evidence on our other secondary clinical outcomes, including harms, was very sparse or very low‐quality. There was evidence from one study that there may be a slower rate of brain atrophy over two years in participants taking B vitamins. The same study reported subgroup analyses based on the level of serum homocysteine (tHcy) at baseline and found evidence that B vitamins may improve episodic memory in those with tHcy above the median at baseline. We included one trial (n = 516) of vitamin E supplementation. Vitamin E was given as 1000 IU of alpha‐tocopherol twice daily. We considered this trial to be at risk of attrition and selective reporting bias. There was probably no effect of vitamin E on the probability of progression from MCI to Alzheimer's dementia over three years (HR 1.02; 95% CI 0.74 to 1.41; n = 516; 1 study, moderate‐quality evidence). There was also no evidence of an effect at intermediate time points. The available data did not allow us to conduct analyses, but the authors reported no significant effect of three years of supplementation with vitamin E on overall cognitive function, episodic memory, speed of processing, clinical global impression, functional performance, adverse events, or mortality (five deaths in each group). We considered this to be low‐quality evidence. We included one trial (n = 256) of combined vitamin E and vitamin C supplementation and one trial (n = 26) of supplementation with chromium picolinate. In both cases, there was a single eligible cognitive outcome, but we considered the evidence to be very low‐quality and so could not be sure of any effects. Authors' conclusions The evidence on vitamin and mineral supplements as treatments for MCI is very limited. Three years of treatment with high‐dose vitamin E probably does not reduce the risk of progression to dementia, but we have no data on this outcome for other supplements. Only B vitamins have been assessed in more than one RCT. There is no evidence for beneficial effects on cognition of supplementation with B vitamins for six to 24 months. Evidence from a single study of a reduced rate of brain atrophy in participants taking vitamin B and a beneficial effect of vitamin B on episodic memory in those with higher tHcy at baseline warrants attempted replication. Plain language summary Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment Review question This review investigated whether people with mild cognitive impairment can reduce their risk of developing dementia, or can prevent their memory or other thinking skills from deteriorating further, by taking vitamin or mineral supplements. Background Slight changes in memory and thinking skills are common as people get older. When these changes are worse than can be expected in normal ageing, but are not bad enough to make a person's usual activities difficult to manage, then the person is said to have mild cognitive impairment (MCI). People with MCI are at increased risk of developing dementia in the future. Vitamins and minerals are naturally occurring substances which are needed in the diet to maintain health. They have lots of different functions in the body and many are essential to keep the brain working properly. It has been suggested that supplementing a person's normal diet with extra doses of these vitamins or minerals might help to maintain thinking skills or prevent dementia. Study characteristics We found eight randomised controlled trials (RCTs), which investigated four different types of vitamin or mineral pills by comparing them to a placebo (a dummy pill). The vitamins tested were B vitamins (vitamin B6, vitamin B12 and folic acid), vitamin E, and vitamin E and C given together. The only mineral tested was chromium. Key results and quality of the evidence Vitamin B combination versus placebo Five trials with a total of 879 participants compared B vitamins with placebo. Four used combinations of vitamin B6, vitamin B12, and folic acid; one small study tested folic acid on its own. None of these studies reported whether or not participants developed dementia. These studies did not find that memory or thinking skills differed between the group of people who took vitamin B supplements and those who took placebo after treatment lasting six months to two years. Our confidence in the results on different tests used in the studies varied from moderate to very low. Two years of vitamin B supplements did seem to help memory in a small subgroup of participants in one study who could be identified by a particular blood test at the start of the trial. One study found that there was probably no effect on participants' quality of life. One study scanned the brains of some participants and reported that B vitamins may slow the rate of brain shrinkage. Harmful effects and deaths were reported in very few participants and we cannot conclude whether or not there are harms from taking these or similar combinations of B vitamins. Vitamin E versus placebo. One study with 516 participants compared a relatively high dose of vitamin E (2000 IU a day) to placebo in people who were also taking a multivitamin containing 15 IU of vitamin E (the daily requirement for vitamin E is approximately 30 IU). The risk of developing dementia due to Alzheimer’s disease (the commonest form of dementia) is probably not affected by three years of treatment with high‐dose vitamin E. The quality of the evidence for other outcomes was lower, but there may also be no effect of this dose of vitamin E on specific memory or thinking skills or on how well people could manage their daily activities. Vitamin E and C versus placebo One study with 256 participants compared a combination of vitamins C and E with placebo. It found no effect on overall memory and thinking skills, but we had little confidence in this result because of the quality of the evidence. Chromium picolinate versus placebo Only one very small study with 26 participants investigated the effect of chromium supplements. This study was too small for us to be able to draw any conclusions. Conclusions The amount and quality of research evidence about vitamin and mineral supplements for treating MCI in people without nutritional deficiency is limited. At the moment, it is not possible to identify any supplements which can reduce the risk of people with MCI developing dementia or which can effectively treat their symptoms. More research is needed before we can answer our review question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "McCleery, J; Abraham, RP; Denton, DA; Rutjes, AWS; Chong, LY; Al‐Assaf, AS; Griffith, DJ; Rafeeq, S; Yaman, H; Malik, MA; Di Nisio, M; Martínez, G; Vernooij, RWM; Tabet, N", "articleTypes": [], "doi": "10.1002/14651858.CD011905.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "82ac0153-4b36-4d2f-8edf-17e34cb56644", "pmid": "", "title": "Desipramine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Antidepressants are widely used to treat chronic neuropathic pain (pain due to nerve damage), usually in doses below those at which they exert antidepressant effects. An earlier review that included all antidepressants for neuropathic pain is being replaced by new reviews of individual drugs examining individual neuropathic pain conditions. Desipramine is a tricyclic antidepressant that is occasionally used for treating neuropathic pain. Objectives To assess the analgesic efficacy of desipramine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 29 April 2014, and the reference lists of retrieved papers and other reviews. We also used our own hand searched database to identify older studies, and two clinical trials databases for ongoing or unpublished studies. Selection criteria We included randomised, double‐blind studies of at least two weeks duration comparing desipramine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 years and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted the efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts, at least 200 participants in the comparison, 8 to 12 weeks duration, parallel design); second tier from data that failed to meet one or more of these criteria and were considered at some risk of bias but with adequate numbers in the comparison; and third tier from data involving small numbers of participants and considered very likely to be biased or that used outcomes of limited clinical utility, or both. Main results Five studies treated 177 participants with painful diabetic neuropathy (104) or postherpetic neuralgia (73). The mean or median ages in the studies were 55 to 72 years. Four studies used a cross‐over, and one a parallel group design; 145 participants were randomised to receive desipramine 12.5 mg to 250 mg daily, with most taking 100 mg to 150 mg daily following titration. Comparators were placebo in three studies (an 'active placebo' in two studies), fluoxetine, clomipramine (one study each), and amitriptyline (two studies), and treatment was for two to six weeks. All studies had one or more sources of potential major bias. No study provided first or second tier evidence for any outcome. No data were available on the proportion of people with at least 50% or 30% reduction in pain, but data were available from three studies for our other primary outcome of Patient Global Impression of Change, reported as patient evaluation of pain relief that was 'complete' or 'a lot'. No pooling of data was possible, but third tier evidence in individual studies indicated some improvement in pain relief with desipramine compared with placebo, although this was very low quality evidence, derived mainly from group mean data and completer analyses in small, short duration studies where major bias was possible. There were too few participants in comparisons of desipramine with another active treatment to draw any conclusions. All studies reported some information about adverse events, but reporting was inconsistent and fragmented. Participants taking desipramine experienced more adverse events, and a higher rate of withdrawal due to adverse events, than did participants taking placebo (very low quality evidence). Authors' conclusions This review found little evidence to support the use of desipramine to treat neuropathic pain. There was very low quality evidence of benefit and harm, but this came from studies that were methodologically flawed and potentially subject to major bias. Effective medicines with much greater supportive evidence are available. There may be a role for desipramine in patients who have not obtained pain relief from other treatments. Plain language summary Desipramine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not usually effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Desipramine is a tricyclic antidepressant from the same class of medicines as amitriptyline, which is widely recommended for treating neuropathic pain. Desipramine may also be useful in these painful conditions. In 2014, we performed searches to look for clinical trials where desipramine was used to treat neuropathic pain. Five small studies, each with 24 to 54 participants, included 177 participants in total with painful diabetic neuropathy or postherpetic neuralgia. Studies were randomised and double‐blind, but all had one or more sources of potential major bias that could lead to overestimation of efficacy. It was not possible to combine information from the different studies, but individually they indicated some benefit from desipramine (usually at a dose between 100 mg and 150 mg daily), compared with placebo, at the expense of increased adverse events. There was not enough information about other comparators to draw any conclusions. There was too little information, which was of inadequate quality, to be sure that desipramine works as a pain medicine in painful diabetic neuropathy or postherpetic neuralgia, and no information about other types of neuropathic pain. Other medicines have been shown to be effective as treatments of first choice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hearn, L; Moore, RA; Derry, S; Wiffen, PJ; Phillips, T", "articleTypes": [], "doi": "10.1002/14651858.CD011003.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "82b2b4ec-083b-4d2b-8161-ff6f9f7061ef", "pmid": "", "title": "Bile acids for liver‐transplanted patients", "imported": false, "abstract": "Abstract - Background Liver transplantation has become a widely accepted form of treatment for numerous end‐stage liver diseases. Bile acids may decrease allograft rejection after liver transplantation by changing the expression of major histocompatibility complex class molecules in bile duct epithelium and central vein endothelium. Objectives To assess the beneficial and harmful effects of bile acids for liver‐transplanted patients. Search methods We performed searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials in The Cochrane Library , MEDLINE , EMBASE , and Science Citation Expanded to September, 2009. Selection criteria Randomised clinical trials comparing any dose of bile acids or duration of treatment in liver‐transplanted patients versus placebo, no intervention, or another intervention. We included randomised clinical trials irrespective of blinding, language, and publication status. Data collection and analysis Two review authors extracted and checked data independently. We evaluated the risk of bias of the trials from the method of allocation sequence generation, allocation concealment, blinding, outcome data analysis, outcome data reporting, and other potential sources of bias. We used the intention‐to‐treat principle to perform meta‐analyses and presented the outcomes as relative risks (RR) or mean differences (MD), both with 95% confidence intervals (CI). Main results The updated search resulted in no new trials meeting the inclusion criteria of this review, thus leaving it to the seven already included randomised trials (six evaluating ursodeoxycholic acid versus placebo or no intervention, and one evaluating tauro‐ursodeoxycholic acid versus no intervention) enrolling a total of 335 participants. The administration of bile acids began one day or more after liver transplantation. All patients received the standard triple‐drug immunosuppressive regimen (steroids, azathioprine, and cyclosporine or tacrolimus) to suppress the allograft rejection response after liver transplantation. Bile acids compared with placebo or no intervention did not significantly change all‐cause mortality (RR 0.85, 95% CI 0.53 to 1.36), mortality related to allograft rejection (RR 0.30, 95% CI 0.01 to 7.12), retransplantation (RR 0.76, 95% CI 0.20 to 2.86), acute cellular rejection, or number of patients with steroid‐resistant rejection. Bile acids significantly reduced the number of patients who had chronic rejection in a fixed‐effect model but not in a random‐effects model meta‐analysis. Bile acids were safe and well tolerated by liver‐transplanted patients. However, this observation is based on data analysis from three trials with only 187 patients. Authors' conclusions We did not find evidence to support or refute bile acids for liver‐transplanted patients. Further randomised trials are necessary before bile acids can be recommended to liver‐transplanted patients. Plain language summary Bile acids for liver‐transplanted patients Liver transplantation is a major surgical procedure that has been practiced for more than forty years and has nowadays become a generally accepted treatment option in patients with end‐stage liver disease. The most common cause for liver transplantation in adults is cirrhosis caused by various types of liver injuries such as infections (hepatitis B and C), alcohol, autoimmune liver diseases, early‐stage liver cancer, metabolic and hereditary disorders, but also diseases of unknown aetiology. All transplant recipients need lifetime immunosuppressive therapy to prevent transplant rejection. Bile acids are being used for a variety of chronic liver diseases, mainly primary biliary cirrhosis and primary sclerosing cholangitis. However, their mechanisms of action and beneficial and harmful effects are poorly understood. This has led to the idea of the potential use of bile acids to prevent rejection in liver‐transplanted patients. Results of the seven randomised clinical trials included in the review in which patients received standard immunosuppressive treatment (steroids, azathioprine, and cyclosporine or tacrolimus) with or without bile acids after liver transplantation, did not show any significant effects of bile acids on all‐cause mortality, mortality related to rejection, acute cellular rejection, steroid resistant rejection, or need for retransplantation. One analysis suggested that bile acids might beneficially influence number of patients with chronic rejection, but was contradicted by the analyses. The evidence that the use of ursodeoxycholic acid might have beneficial effects on chronic rejection and length of hospitalisation is weak as it is produced from trials with high risk of bias and insufficient number of included patients. That bile acids seemed well tolerated, with no reports of serious adverse events, is good knowledge, but much more research is needed before their use is acquitted. None of the randomised clinical trials assessed the effects of bile acids on quality of life or cost‐effectiveness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Poropat, G, Giljaca, V, Stimac, D, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005442.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.777Z" }, { "id": "82c55a8c-c4bd-471a-a69a-8e6f9e86e2d9", "pmid": "", "title": "Oral nutritional interventions in hospitalised older people at nutritional risk: a network meta‐analysis of individual participant data", "imported": false, "abstract": "Abstract - Rationale Malnutrition affects 35% to 64% of hospitalised older people, and is associated with adverse health outcomes such as disease complications and hospital readmission. Identifying effective nutritional interventions is essential to improve clinical outcomes and reduce healthcare costs in this population. Objectives To evaluate the effects of various nutritional interventions, compared with either a control group (standard care or placebo) or each other, on patient‐relevant outcomes in hospitalised older people at risk of or with established malnutrition, and to rank the effects of these different interventions using network meta‐analysis (NMA) based on individual participant data (IPD). Search methods We searched CENTRAL, MEDLINE, five other databases, and two trial registries to 2 July 2024, and checked the reference lists of included studies and relevant systematic reviews. Eligibility criteria We included older people (≥ 65 years) hospitalised for different acute conditions at risk of or with malnutrition enrolled in randomised controlled trials (RCTs) comparing oral nutritional interventions with control or each other. For RCTs that met our inclusion criteria, either fully or partially, we requested IPD from the study authors. If we did not receive a response or IPD were unavailable, we used published aggregated data. We excluded RCTs that only partially met the eligibility criteria if neither IPD nor sufficient aggregated data were obtainable. Outcomes Critical outcomes were all‐cause mortality, serious adverse events (SAEs), and functional status (e.g. activities of daily living). Important outcomes were health‐related quality of life (HRQoL), length of hospital stay (LOS), body weight, and fat‐free mass. The main outcome assessment time point was at hospital discharge or 30 days after randomisation. Risk of bias We used the Cochrane risk of bias 2 (RoB 2) tool. Synthesis methods For each outcome, we first analysed IPD within each study. Second, we pooled results in an NMA which also included the aggregated data from RCTs without available IPD. We performed random‐effects NMAs based on the frequentist approach and ranked treatments by P‐scores. We rated the certainty of evidence using the GRADE approach. Included studies We included 21 RCTs (72 reports; 12 RCTs with IPD) with 3309 older participants (mean age ranged from 75 to 85 years; 1863 participants with IPD) with different acute conditions. Interventions included the provision of additional protein (three studies), energy supplements (two studies), oral nutritional supplements (ONS; eight studies), individualised feeding support (two studies), and comprehensive individualised nutritional care (eight studies). In all but two RCTs, interventions were compared to control (standard care with or without a placebo). We judged 16.1% of outcome assessments to be at low risk of bias and 16.8% at high risk. Synthesis of results ONS may reduce all‐cause mortality (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.25 to 0.84; absolute risk difference 57 fewer deaths per 1000 people, 95% CI 79 fewer to 17 fewer; low‐certainty evidence) compared to control, while comprehensive individualised nutritional care may show little to no effect (RR 0.98, 95% CI 0.55 to 1.73; 1 fewer per 1000 people, 95% CI 26 fewer to 46 more; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 13 RCTs, 2728 participants; Q between designs: not applicable (NA)). ONS may reduce SAEs compared to control (RR 0.56, 95% CI 0.32 to 0.95; 84 fewer SAEs per 1000 people, 95% CI 131 fewer to 10 fewer; Q between designs: Q 1.95, df 2, P = 0.3772; low‐certainty evidence ). For all other treatment comparisons, the evidence is very uncertain (NMA with 14 RCTs, 2184 participants). Comprehensive individualised nutritional care may make little to no difference in activities of daily living compared to control (standardised mean difference (SMD) 0.06, 95% CI −0.08 to 0.20; low‐certainty evidence) and ONS compared to energy supplements (SMD −0.15, 95% CI −0.53 to 0.23; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 5 RCTs, 1128 participants; Q between designs: NA). Energy supplements probably make little to no difference in HRQoL compared with ONS (mean difference (MD) 0.01, 95% CI −0.06 to 0.08; Q between designs: NA; moderate‐certainty evidence). All other comparisons of different nutritional interventions may make little to no difference to HRQoL (NMA with 3 RCTs, 1513 participants). The provision of additional protein, energy supplements, ONS, and comprehensive individualised nutritional care may make little to no difference in LOS compared to control (18 RCTs, 3013 participants; Q between designs: Q 2.86, df 3, P = 0.4145). Body weight (16 RCTs, 2114 participants; Q between designs: Q 2.03, df 3, P = 0.5655) may increase with ONS when compared to control (MD 0.9 kg, 95% CI 0.37 to 1.42) or comprehensive individualised nutritional care (MD 1.00 kg, 95% CI 0.12 to 1.87), but the evidence is very uncertain. Energy supplements and ONS probably have similar effects on body weight (MD 0.11 kg, 95% CI −0.85 to 0.63; moderate‐certainty evidence). For fat‐free mass, no meta‐analysis was possible. One RCT (102 participants) compared ONS with energy supplements and found little or no difference between groups (MD 0.13 kg, 95% CI −0.63 to 0.90; low‐certainty evidence), while evidence regarding the effects of additional protein compared with control was very uncertain (1 RCT, 19 participants). Rankings of treatments by P‐scores were not consistent across outcomes. Authors' conclusions In older hospitalised people at risk of or with malnutrition, oral nutritional supplements may reduce mortality and SAEs compared to control 30 days after randomisation . For other outcomes, there may be little or no differences in results. Overall, the evidence was of low to very low certainty, primarily due to a limited number of studies and participants per comparison. The comparison of treatment effects across outcomes was constrained by variations in network structure. When interpreting the results, the heterogeneity of the population in terms of acute and chronic conditions needs to be considered. To improve certainty, adequately powered studies with robust methodologies should compare interventions with controls as well as against each other. Funding The German Federal Ministry of Education and Research funded this work (grant number: 01KG2102). Registration Protocol (2022) doi.org/10.1002/14651858.CD015468 Plain language summary What are the benefits and risks of different types of nutritional support for older, hospitalised people who are malnourished or at risk of malnutrition? Key messages Compared to standard hospital care, specialised foods and drinks may reduce the chances of dying and of having a serious negative health event one month after hospital admission. In terms of people's ability to perform basic daily activities, their quality of life, length of hospital stay, and body weight, we are either very uncertain about the benefits and risks of the different types of nutritional support, or evidence shows they may make little or no difference compared to standard hospital care. Larger and well‐designed studies comparing different types of nutritional support may increase our confidence in these findings. What is malnutrition? People become malnourished when their intake of energy and protein is not enough to meet their body's needs. This condition can reduce someone's fat and muscle stores. Being malnourished threatens people's health and compromises the immune system's ability to fight infections. Older people who are malnourished are at higher risk of disease complications, losing their independence, and dying than non‐malnourished older people. They also experience a lower quality of life. Older people may become malnourished or be at risk of malnutrition for several reasons, including having a reduced appetite, chewing problems, physical limitations (e.g. unable to stand for long periods to prepare meals), and loneliness. Older people in hospital are particularly prone to malnutrition. They may not eat enough at a time when their illness increases their energy and protein needs. Malnutrition affects roughly one‐third to two‐thirds of hospitalised older people. How is malnutrition treated? There is a wide range of treatments for malnutrition, including: specialised foods and beverages that provide extra energy, protein, and other nutrients; practical help with eating and drinking; additional snacks, protein‐rich foods or supplements; nutritional counselling; or tailored combinations of these approaches. What did we want to find out? In older, hospitalised people who are malnourished or at risk of malnutrition, we wanted to know if different types of nutritional support are better than standard care at: reducing the risk of dying and serious negative health events (e.g. complications such as infections or wound healing); improving people's ability to perform basic daily activities and their quality of life; reducing time spent in hospital; and boosting people's body weight and muscle mass. We also wanted to know which type of nutritional support works best. What did we do? We searched for studies in people 65 years and older who were in hospital and malnourished or at risk of malnutrition. We included studies that compared one type of nutritional support to another type, or compared nutritional support to standard hospital care (i.e. usual hospital food service), sometimes in combination with a 'dummy treatment' that looked identical to the supplements tested. We summarised and compared all treatments, and rated our confidence in the results based on factors such as study methods and the numbers of people included. What did we find? We found 21 studies involving 3309 hospitalised older people with different acute conditions. We grouped the treatments they received into five categories: specialised foods and drinks; protein‐enriched foods or supplements; energy supplements; personalised feeding support from an assistant (who would, for example, accommodate food preferences, adjust someone's position, and help with eating); multi‐component personalised nutritional care from a dietitian or nutritionist (who would, for example, modify foods or offer counselling). Main findings Compared to standard hospital care, after a month in hospital, specialised foods and drinks may: reduce the chance of death: they may lead to 57 fewer deaths per 1000 people; reduce serious negative health events: they may lead to 84 fewer events per 1000 people. Compared to standard hospital care, we are either very uncertain about the effects of specialised foods and drinks, protein‐enriched foods or supplements, energy supplements, personalised feeding support, and multi‐component personalised nutritional care, or these treatments may make little or no difference to people's: ability to perform basic daily activities; quality of life; length of hospital stay; body weight and muscle mass. When we compared the different types of nutritional support to each other, we did not find that any one approach worked better than all others in improving the results we measured. What are the limitations of the evidence? Our confidence in the findings is low or very low for several reasons. Some studies used methods that may have led to errors in the results. Studies often involved too few people, or did not look at everything we were interested in, such as muscle mass as outcome or comparisons of different types of nutritional support. Moreover, older people in hospital have different illnesses and functional abilities, and we could not assess how the different types of nutritional support work for different people. How current is this evidence? The evidence is current to 2 July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E; Schwarzer, G; Stadelmaier, J; Lohner, S; Grummich, K; Dagnelie, PC; Beck, AM; Beelen, J; Botella-Carretero, JI; Faxén-Irving, G; Hickson, M; Iff, S; Johansen, A; Sharma, Y; Sorensen, JM; Kaegi-Braun, N; Wunderle, C; Bongaerts, B; Meerpohl, JJ; Norman, K; Schuetz, P; Torbahn, G; Visser, M; Volkert, D; Schwingshackl, L", "articleTypes": [], "doi": "10.1002/14651858.CD015468.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "82d999a8-fa0d-4cc4-ab4c-9306c4a2a2eb", "pmid": "", "title": "Interventions for managing halitosis", "imported": false, "abstract": "Abstract - Background Halitosis or bad breath is a symptom in which a noticeably unpleasant breath odour is present due to an underlying oral or systemic disease. 50% to 60% of the world population has experienced this problem which can lead to social stigma and loss of self‐confidence. Multiple interventions have been tried to control halitosis ranging from mouthwashes and toothpastes to lasers. This new Cochrane Review incorporates Cochrane Reviews previously published on tongue scraping and mouthrinses for halitosis. Objectives The objectives of this review were to assess the effects of various interventions used to control halitosis due to oral diseases only. We excluded studies including patients with halitosis secondary to systemic disease and halitosis‐masking interventions. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 April 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3) in the Cochrane Library (searched 8 April 2019), MEDLINE Ovid (1946 to 8 April 2019), and Embase Ovid (1980 to 8 April 2019). We also searched LILACS BIREME (1982 to 19 April 2019), the National Database of Indian Medical Journals (1985 to 19 April 2019), OpenGrey (1992 to 19 April 2019), and CINAHL EBSCO (1937 to 19 April 2019). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (8 April 2019), the World Health Organization International Clinical Trials Registry Platform (8 April 2019), the ISRCTN Registry (19 April 2019), the Clinical Trials Registry ‐ India (19 April 2019), were searched for ongoing trials. We also searched the cross‐references of included studies and systematic reviews published on the topic. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs) which involved adults over the age of 16, and any intervention for managing halitosis compared to another or placebo, or no intervention. The active interventions or controls were administered over a minimum of one week and with no upper time limit. We excluded quasi‐randomised trials, trials comparing the results for less than one week follow‐up, and studies including advanced periodontitis. Data collection and analysis Two pairs of review authors independently selected trials, extracted data, and assessed risk of bias. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach. Main results We included 44 trials in the review with 1809 participants comparing an intervention with a placebo or a control. The age of participants ranged from 17 to 77 years. Most of the trials reported on short‐term follow‐up (ranging from one week to four weeks). Only one trial reported long‐term follow‐up (three months). Three studies were at low overall risk of bias, 16 at high overall risk of bias, and the remaining 25 at unclear overall risk of bias. We compared different types of interventions which were categorised as mechanical debridement, chewing gums, systemic deodorising agents, topical agents, toothpastes, mouthrinse/mouthwash, tablets, and combination methods. Mechanical debridement: for mechanical tongue cleaning versus no tongue cleaning, the evidence was very uncertain for the outcome dentist‐reported organoleptic test (OLT) scores (MD ‐0.20, 95% CI ‐0.34 to ‐0.07; 2 trials, 46 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Chewing gums: for 0.6% eucalyptus chewing gum versus placebo chewing gum, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.10, 95% CI ‐0.31 to 0.11; 1 trial, 65 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Systemic deodorising agents: for 1000 mg champignon versus placebo, the evidence was very uncertain for the outcome patient‐reported visual analogue scale (VAS) scores (MD ‐1.07, 95% CI ‐14.51 to 12.37; 1 trial, 40 participants; very low‐certainty evidence). No data were reported for dentist‐reported OLT score or adverse events. Topical agents: for hinokitiol gel versus placebo gel, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.27, 95% CI ‐1.26 to 0.72; 1 trial, 18 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Toothpastes: for 0.3% triclosan toothpaste versus control toothpaste, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐3.48, 95% CI ‐3.77 to ‐3.19; 1 trial, 81 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Mouthrinse/mouthwash: for mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.20, 95% CI ‐0.58 to 0.18; 1 trial, 44 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Tablets: no data were reported on key outcomes for this comparison. Combination methods: for brushing plus cetylpyridium mouthwash versus brushing, the evidence was uncertain for the outcome dentist‐reported OLT scores (MD ‐0.48, 95% CI ‐0.72 to ‐0.24; 1 trial, 70 participants; low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Authors' conclusions We found low‐ to very low‐certainty evidence to support the effectiveness of interventions for managing halitosis compared to placebo or control for the OLT and patient‐reported outcomes tested. We were unable to draw any conclusions regarding the superiority of any intervention or concentration. Well‐planned RCTs need to be conducted by standardising the interventions and concentrations. Plain language summary Interventions for managing bad breath Review question With this Cochrane Review we tried to find out the best way to control bad breath, also called halitosis, due to a disease within the mouth in adults. Background Bad breath or halitosis is caused by too much bacteria or small food parts left inside the mouth, most commonly at the back of the tongue. It can be a sign of a disease within the mouth or other body diseases. People with bad breath can have low self‐esteem and feel embarrassed. It can affect their personal relationships and work. In this review, we looked at treatments for bad breath due to a disease within the mouth and at treatments that aim to control not just mask bad breath. Study characteristics This review is up‐to‐date as of 8 April 2019. The review includes 44 studies involving 1809 people who were 17 to 77 years old. The review compared an intervention with another intervention, a placebo or a control. It looked at eight different ways to control bad breath: mechanical cleaning (e.g. tongue cleaners and toothbrushes), chewing gums, systemic deodorising agents (e.g. mushroom extract that you eat), topical agents (e.g. gel that you apply), toothpastes, mouthrinse/mouthwash, tablets, and combination of different treatments. Key results The evidence was very uncertain for mechanical tongue cleaning versus no tongue cleaning, 0.6% eucalyptus chewing gum versus placebo chewing gum, 1000 mg mushroom extract versus placebo, hinokitiol gel versus placebo gel, 0.3% triclosan toothpaste versus control toothpaste, mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, and brushing plus cetylpyridium mouthwash versus brushing. Harmful effects of the different interventions were not reported or were not important. Certainty of the evidence The level of certainty we have in these findings is low to very low. This was due mainly to risk of bias and the small number of people studied in the included trials. Conclusion We do not have enough evidence to say which intervention works better to control bad breath.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kumbargere Nagraj, S; Eachempati, P; Uma, E; Singh, VP; Ismail, NM; Varghese, E", "articleTypes": [], "doi": "10.1002/14651858.CD012213.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "82ef9c0c-91f6-4f47-a3b1-55459c75a930", "pmid": "", "title": "Corticosteroids for the long‐term treatment in multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Ciccone, A, Beretta, S, Brusaferri, F, Galea, I, Protti, A, Spreafico, C", "articleTypes": [], "doi": "10.1002/14651858.CD006264.pub2 AB - Abstract - Background Short term high dose corticosteroid treatment improves symptoms and short term disability after an acute exacerbation of multiple sclerosis (MS) but it is unknown whether its long‐term use can reduce the accumulation of disability. Objectives To determine the efficacy and safety of long‐term corticosteroid use in MS. Search methods We searched The Cochrane MS Group Trials Register (February 2007),the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to February 2007) and EMBASE (1980 to February 2007). In an effort to identify further published, unpublished and ongoing trials we searched reference lists and contacted trial authors and one pharmaceutical company. Selection criteria We considered controlled, randomised trials (RCTs), with or without blinding, of long term treatment (i.e. longer than 6 months) of any type of corticosteroid in MS, irrespective of disease course. Data collection and analysis Reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Three trials, all classified at high risk of bias, contributed to this review (Miller 1961; BPSM 1995; Zivadinov 2001) resulting in a total of 183 participants (91 treated). Corticosteroid therapy did not reduce the risk of being worse at the end of follow‐up (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.26 to 1.02) but there was a substantial heterogeneity between studies (I 2 : 78.4%). I. v. periodic high dose methylprednisolone (MP) was associated with a significant reduction in the risk of disability progression at 5 years in relapsing‐remitting (RR) MS (OR 0.26, 95% CI 0.10 to 0.66), while oral continuous low dose prednisolone was not associated with any risk reduction in disability progression at 18 months (OR 1.23, 95% CI 0.43 to 3.56). Risk of experiencing at least one exacerbation at end of follow‐up was not significantly reduced with corticosteroid treatment (OR 0.36; 95% CI 0.10 to 1.25). 
 Only one study recorded adverse events: in one patient i. v. MP was discontinued after the fourth pulse when he developed acute glomerulonephritis; a second patient was removed from the study after the fifth i. v. MP pulse because of severe osteoporosis. Authors' conclusions There is no enough evidence that long‐term corticosteroid treatment delays progression of long term disability in patients with MS. Since one study at high risk of bias showed that the administration of pulsed high dose i. v. MP is associated with a significant reduction in the risk of long term disability progression in patients with RR MS, an adequately powered, high quality RCT is needed to investigate this finding. Plain language summary The long‐term use of anti‐inflammatory corticosteroids for treating multiple sclerosis Multiple sclerosis is an inflammatory disease affecting the brain and spinal cord. It results in episodes of neurological deficit which recover (relapses) as well as accumulation of sustained disability with the passage of time. Corticosteroids are potent anti‐inflammatory drugs. It is postulated that long‐term use of steroids may reduce the accumulation of disability. The reviewers found three studies addressing this issue. A meta‐analysis showed a trend towards a beneficial effect of long‐term corticosteroids on accumulation of disability; however only two small studies contributed to this result. It was not possible to reliably comment on the effect of long‐term corticosteroids on the frequency of relapses. Side effects were poorly documented. Therefore rigorous randomised controlled trials of this treatment are warranted.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.741Z" }, { "id": "83091dff-631f-4c87-a22d-624a19580368", "pmid": "", "title": "Acute and Repeated Impact of Sweeteners and Sweetness Enhancers on Food Behaviour, Physiology & Health (SWEET Work Package 2 Phase 2)", "imported": false, "abstract": "This study aims to evaluate the acute (1-day) and repeated (2-week) effects of combinations of Sweeteners & Sweetness Enhancer blends on metabolic, sensory, neuro-behavioural and microbiota-mediated processes involved in satiety, consumer preferences and health.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.251Z" }, { "id": "833efb72-0cd2-4277-b571-afc75cbe700b", "pmid": "", "title": "Sensory Study: Taste and Tongue Biology", "imported": false, "abstract": "Researchers will investigate the correlation between a) self-reported dietary intake of foods and beverages, b) intensity of sucrose stimuli, and c) liking rating of sweet stimuli, with the relative expression of the taste receptor genes from human fungiform papillae (TAS1R2 and TAS1R3).", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.141Z" }, { "id": "83472ec4-a7f3-442c-bbf5-385c3f91ec53", "pmid": "", "title": "Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Hip and knee replacement surgery is a well‐established means of improving quality of life, but is associated with a significant risk of bleeding. One‐third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care. Objectives To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta‐analysis (NMA) methodology. Search methods We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO host ), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). Selection criteria We included RCTs of people undergoing elective hip or knee surgery only. We excluded non‐elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon‐aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non‐fibrin sealants. Data collection and analysis We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all‐cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received. Main results We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra‐articularly and orally at a total dose of greater than 3 g pre‐incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate‐certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre‐incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low‐certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low‐certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low‐certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low‐certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low‐certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all‐cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low‐certainty evidence). This was followed by TXA given intravenously and intra‐articularly at a total dose of 2 g pre‐incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low‐certainty evidence) and TXA given intravenously and intra‐articularly, total dose greater than 3 g pre‐incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low‐certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low‐certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials). Authors' conclusions We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra‐articular, oral and intravenous, or intravenous and intra‐articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review. Plain language summary What is the best medication to stop bleeding in those having non‐emergency hip or knee surgery? Key messages • Tranexamic acid may be an effective medicine to help blood to clot during hip or knee replacement surgery, which reduces bleeding and the need for a blood transfusion (replacing lost blood with donated blood). • A high dose of this medicine and administering it in more than one way (for example, as a tablet and injected into the joint at the end of surgery) appears to work best. • Tranexamic acid is potentially as effective when given as a tablet as when injected into a vein. • There is little to no evidence to indicate that higher doses of tranexamic acid increase the risk of blood clots in the leg or other harms. Background Why is it important to stop bleeding during hip or knee surgery? Controlling bleeding during surgery reduces the likelihood of the person developing anaemia and requiring a blood transfusion, which carries the risk of complications. Anaemia occurs when the number of red blood cells (haemoglobin) available to carry oxygen is lower than normal. This causes symptoms such as fatigue, weakness, dizziness, shortness of breath and, in severe cases, can be life‐threatening. Preventing blood loss during surgery improves patient outcomes, decreases healthcare costs and preserves the limited supplies of donated blood. Is there a medication that helps control bleeding? Many research studies have investigated whether certain medication, such as tranexamic acid, can help minimise blood loss during surgery. Most of the studies test different doses of medications, different methods of administration and different times of use, either before, during or after an operation. What did we want to find out? We wanted to find out whether medication can reduce blood loss and the need for blood transfusions in people having hip or knee replacement surgery. We also wanted to know the most effective way of giving this medication to patients. What did we do? We searched for studies comparing different medications that could help reduce bleeding in adults undergoing planned hip or knee replacement surgery. We also searched for studies comparing medication with a placebo. A placebo is a 'dummy' medication that looks or tastes identical to the medication being tested. What did we find? We found 102 studies. Twelve studies did not report the number of included participants; in the other 90 studies, there were 8418 included participants. On average, people were between 50 and 77 years of age and 64% were women. The smallest study included 16 people and the largest involved 300. Studies took place around the globe, with the highest number in Europe and Asia. Of those studies that reported a source of funding, seven were fully funded and five partly funded by pharmaceutical (medication) companies. All studies investigated medications that helped the blood to clot. However, most studies assessed the effectiveness and safety of tranexamic acid administered intravenously (injected into a vein), orally (swallowing a tablet or liquid), injected into the joint during surgery, or with a combination of these methods. Main results Our review of the studies showed the following: • Tranexamic acid was the most effective at controlling bleeding compared to other medications. • Adults who underwent hip or knee replacement surgery required fewer blood transfusions if they were given tranexamic acid. • Tranexamic acid given in higher doses using multiple methods of administration, such as orally and injected into the joint during surgery, may be more likely to prevent bleeding. • Taking tranexamic acid orally is probably as effective at preventing a blood transfusion as injecting the medication into a vein. We were unable to decide on the optimal dose, which combination of methods are best to administer tranexamic acid and when it is most beneficial to use it (before, during and after surgery). We did not find evidence to suggest that higher doses of tranexamic acid increase the risk of developing a blood clot, or any other harms. What are the limitations of the evidence? We are not able to definitively draw conclusions based on the trials included within this review. We have little confidence in the evidence for some outcomes, and are not confident about the evidence for others. This is because it is possible that people in the studies were aware of which treatment they were getting. Also, the studies were small and did not all provide data about everything in which we were interested. Ongoing studies and future updates Thirty studies with a planned total of 3776 participants are currently ongoing. These studies should be completed and published within the next few years. Once the authors publish their data, we may update our analyses and provide stronger answers than we can at present. How up‐to‐date is this evidence? The evidence is current to 18 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gibbs, VN; Champaneria, R; Sandercock, J; Welton, NJ; Geneen, LJ; Brunskill, SJ; Dorée, C; Kimber, C; Palmer, AJR; Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD013295.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "835510d1-41e1-42b1-8907-c4b18852f393", "pmid": "", "title": "Polyunsaturated fatty acid supplementation for schizophrenia", "imported": false, "abstract": "Abstract - Background Limited evidence supports a hypothesis suggesting that the symptoms of schizophrenia may be the result of altered neuronal membrane structure and metabolism. The structure and metabolism is dependent on blood plasma levels of certain essential fatty acids and their metabolites. Objectives To assess the effects of polyunsaturated fatty acids for people with schizophrenia. Search methods We have updated the initial searches of 1998, 2002 and 2005 with a search of the Cochrane Schizophrenia Group's Register, November 2008, which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. Where necessary, we contacted authors and relevant pharmaceutical companies for additional information. Selection criteria We included all randomised controlled trials of polyunsaturated fatty acid treatment for schizophrenia. Data collection and analysis Working independently, we selected studies for quality assessment and extracted relevant data. We analysed on an intention‐to‐treat basis. Where possible and appropriate we calculated the Relative Risk (RR) and their 95% confidence intervals (CI) and estimated the number needed to treat (NNT). For continuous data we calculated weighted mean differences (WMD) and their 95% confidence intervals. We also inspected the data for heterogeneity. Main results Eight studies are now included in this review. When any dose omega‐3 (E‐EPA or EPA) is compared with placebo, small short trials suggest that the need for neuroleptics appears to be reduced for people allocated omega‐3 supplementation (n=30, 1 RCT, RR 0.73 CI 0.54 to 1.00) and mental state may improve (n=30, 1 RCT, RR not gaining 25% change in PANSS scores 0.54 CI 0.30 to 0.96, NNT 3 CI 2 to 29). There are no differences in the number of people leaving the study early (n=595, 6 RCTs, RR 0.86 CI 0.50 to 1.48). There are few data on the comparison of any dose omega‐6 (GLA) with placebo. For movement disorder outcomes, the one small study we found does not show any difference for average short‐term endpoint AIMS score (n=16, 1 RCT, WMD 1.30 CI ‐1.96 to 4.56). When any dose omega‐3 (E‐EPA or EPA) is compared with any dose omega‐3 (DHA) there is no significant difference for mental state outcome of not gaining 25% change in PANSS scores (n=31, 1 RCT, RR 0.66 CI 0.39 to 1.11). When different doses of omega‐3 (E‐EPA) are compared with placebo there are no differences in measures of global and mental state between the studies. For the outcome of 'experiencing at least one adverse effect' no differences between groups are found for any dose (1 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.97 CI 0.60 to 1.56; 2 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.67 CI 0.37 to 1.20; 4 g/day E‐EPA vs placebo n=58, 1 RCT, RR 1.15 CI 0.72 to 1.82). Authors' conclusions Three updates of this review have resulted in more included studies and more people randomised but still relatively little useful additional data. The results remain inconclusive. The new trials all compare the omega‐3 polyunsaturated fatty acids, in particular eicosapentaenoic acid and its ester, ethyl‐eicosapentaenoic acid. The use of omega‐3 polyunsaturated fatty acids for schizophrenia still remains experimental and this review highlights the need for large, well designed, conducted and reported studies. Plain language summary Polyunsaturated fatty acid supplementation for schizophrenia Schizophrenia is a serious mental health problem that affects about one percent of any population. For some people it can become an illness that they have to live with for their entire life. Early research has suggested that supplementing the diet with omega 3 or omega 6 fatty acids may have a positive effect on the symptoms of schizophrenia. This review looks at randomised control trials where omega 3 or omega 6 were used in combination with antipsychotic medication, or as a treatment in their own right for schizophrenia. Eight studies were found which included a total of 517 people who had a diagnosis of schizophrenia or schizoaffective disorder (combined symptoms of schizophrenia and a mood disorder). They ranged from six to 16 weeks in length and were in both hospital and community settings. The majority of the trials compared two different types of omega 3 fatty acids, EPA (usually as E‐EPA) and DHA with placebo, in people with schizophrenia who are stable on antipsychotic medication. Some of these trials show some improvement in general functioning and in mental state but not to a statistically significant degree. In the longest trial there was no difference between the two groups at the end of the study. One trial compared E‐EPA with DHA and found a suggestion that E‐EPA works better than DHA, but again it was not statistically significant. Where EPA was compared to placebo as a first line treatment for schizophrenia (30 people), those taking EPA had a better overall outcome and improvement in mental state. However, this was a short trial with few people. Finally, one trial compared a type of omega 6 with placebo in men who had the movement disorder tardive dykinesia (16 people). There was no improvement in the symptoms of movement adverse effects in either group at the end of six weeks. These trials were both small and short. In addition most of the data they reported were not able to be used, and half of the trials were funded by the group supplying the trial medication. Therefore it is still not clear whether taking manufactured omega 3 or 6 improves overall functioning or mental state in people with schizophrenia. (Plain language summary prepared for this review by Janey Antoniou of RETHINK, UK www.rethink.org )", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Irving, CB; Mumby‐Croft, R; Joy, LA", "articleTypes": [], "doi": "10.1002/14651858.CD001257.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "83643828-b833-40ff-a4c6-6e46efcc5e18", "pmid": "", "title": "Evaluating the Effect of a Food for Special Medical Purposes Containing Essential Amino Acids (EAA), Carnitine, Arginine, and Sucrosomial Minerals on the Preservation of Appendicular Skeletal Muscle Mass (ASMM) During a Weight Loss Program With GLP-1 Receptor Agonists", "imported": false, "abstract": "This study evaluates whether a Food for Special Medical Purposes (FSMP) can help to preserve appendicular skeletal muscle mass (ASMM) in adults undergoing weight loss treatment with GLP-1 receptor agonists or dual GIP/GLP-1 receptor agonists. Participants will receive the FSMP or a matching placebo for 24 weeks while continuing standard GLP-1-based therapy. ASMM will be measured using Bioelectrical Impedance Vector Analysis (BIVA).", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "837693b0-46e3-460b-bde9-32c115dbd1f4", "pmid": "", "title": "Interventions to improve adherence to antiretroviral therapy in children with HIV infection", "imported": false, "abstract": "Abstract - Background Achieving and maintaining high levels of medication adherence are required to achieve the full benefits of antiretroviral therapy (ART), yet suboptimal adherence among children is common in both developed and developing countries. Objectives To conduct a systematic review of the literature of evaluations of interventions for improving paediatric ART adherence. Search methods We created a comprehensive search strategy in order to identify all studies relevant to this topic. In July 2010, we searched the following electronic databases: EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, LILACS, Web of Science, Web of Social Science, NLM Gateway (supplemented by a manual search of the most recent abstracts not included in the Gateway database). We searched abstracts from the International AIDS Conference from 2002 to 2010, the International AIDS Society Conference on Pathogenesis, Treatment and Prevention from 2003 to 2009, and from the Conference on Retroviruses and Opportunistic Infections from 1997 to 2010. We used search strategies determined by the Cochrane Review Group on HIV/AIDS. We also contacted researchers who work in this field and checked reference lists of related systematic reviews and of all included studies. Selection criteria Randomised and non‐randomised controlled trials of interventions to improve adherence to ART among children and adolescents (age ≤18 years) were included. Studies had to report adherence to ART as an outcome. Data collection and analysis After one author performed an initial screening to exclude citations that did not meet the inclusion criteria, two authors did a second screening of those citations that likely met the criteria. For all articles that passed the second screening, full articles were pulled in order to make a final determination. Two authors then extracted data and graded methodological quality independently. Differences were resolved through discussion. Main results Four studies met the inclusion criteria. No single intervention was evaluated by more than one trial. Two studies were conducted in low‐income countries. Two studies were randomised controlled trials (RCT), and two were non‐randomised trials. An RCT of a home‐based nursing programme showed a positive effect of the intervention on knowledge and medication refills (p=.002), but no effect on CD4 count and viral load. A second RCT of caregiver medication diaries showed that the intervention group had fewer participants reporting no missed doses compared to the control group (85% vs. 92%, respectively), although this difference was not statistically significant (p=.08). The intervention had no effect on CD4 percentage or viral load. A non‐randomised trial of peer support group therapy for adolescents demonstrated no change in self‐reported adherence, yet the percentage of participants with suppressed viral load increased from 30% to 80% (p=.06). The second non‐randomised trial found that the percentage of children achieving >80% adherence was no different between children on a lopinavir‐ritonavir (LPV/r) regimen compared to children on a non‐nucleoside reverse transcriptase regimen (p=.781). However, the proportion of children achieving virological suppression was significantly greater for children on the LPV/r regimen than for children on the NNRTI‐containing regimen (p=.002). Authors' conclusions A home‐based nursing intervention has the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence or disease outcomes. Two interventions, an LPV/r‐containing regimen and peer support therapy for adolescents, did not demonstrate improvements in adherence, yet demonstrated greater viral load suppression compared to control groups, suggesting a different mechanism for improved health outcomes. Well‐designed evaluations of interventions to improve paediatric adherence to ART are needed. Plain language summary Interventions to improve adherence to ART in children and adolescents Achieving and maintaining high levels of medication adherence are required to realise the full benefits of antiretroviral therapy (ART). We identified four studies that evaluated interventions designed to improve adherence to ART among children and adolescents age 18 years and younger. These studies showed that home‐based nursing, peer support for adolescents and LPV/r‐containing regimens have the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence. There is a need for well‐designed evaluations of interventions to improve paediatric adherence to ART.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Bain‐Brickley, D; Butler, LM; Kennedy, GE; Rutherford, GW", "articleTypes": [], "doi": "10.1002/14651858.CD009513", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "8377c31f-8459-44ec-b3dc-3e771da13819", "pmid": "", "title": "Interventions for the cessation of non‐nutritive sucking habits in children", "imported": false, "abstract": "Abstract - Background Comforting behaviours, such as the use of pacifiers (dummies, soothers), blankets and finger or thumb sucking, are common in babies and young children. These comforting habits, which can be referred to collectively as 'non‐nutritive sucking habits' (NNSHs), tend to stop as children get older, under their own impetus or with support from parents and carers. However, if the habit continues whilst the permanent dentition is becoming established, it can contribute to, or cause, development of a malocclusion (abnormal bite). A diverse variety of approaches has been used to help children with stopping a NNSH. These include advice, removal of the comforting object, fitting an orthodontic appliance to interfere with the habit, application of an aversive taste to the digit or behaviour modification techniques. Some of these interventions are easier to apply than others and less disturbing for the child and their parent; some are more applicable to a particular type of habit. Objectives The primary objective of the review was to evaluate the effects of different interventions for cessation of NNSHs in children. The secondary objectives were to determine which interventions work most quickly and are the most effective in terms of child and parent‐ or carer‐centred outcomes of least discomfort and psychological distress from the intervention, as well as the dental measures of malocclusion (reduction in anterior open bite, overjet and correction of posterior crossbite) and cost‐effectiveness. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 8 October 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 9), MEDLINE via OVID (1946 to 8 October 2014), EMBASE via OVID (1980 to 8 October 2014), PsycINFO via OVID (1980 to 8 October 2014) and CINAHL via EBSCO (1937 to 8 October 2014), the US National Institutes of Health Trials Register (Clinical Trials.gov) (to 8 October 2014) and the WHO International Clinical Trials Registry Platform (to 8 October 2014). There were no restrictions regarding language or date of publication in the searches of the electronic databases. We screened reference lists from relevant articles and contacted authors of eligible studies for further information where necessary. Selection criteria Randomised or quasi‐randomised controlled trials in children with a non‐nutritive sucking habit that compared one intervention with another intervention or a no‐intervention control group. The primary outcome of interest was cessation of the habit. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Three review authors were involved in screening the records identified; two undertook data extraction, two assessed risk of bias and two assessed overall quality of the evidence base. Most of the data could not be combined and only one meta‐analysis could be carried out. Main results We included six trials, which recruited 252 children (aged 2 and a half to 18 years), but presented follow‐up data on only 246 children. Digit sucking was the only NNSH assessed in the studies. Five studies compared single or multiple interventions with a no‐intervention or waiting list control group and one study made a head‐to‐head comparison. All the studies were at high risk of bias due to major limitations in methodology and reporting. There were small numbers of participants in the studies (20 to 38 participants per study) and follow‐up times ranged from 1 to 36 months. Short‐term outcomes were observed under one year post‐intervention and long‐term outcomes were observed at one year or more post‐intervention. Orthodontics appliance (with or without psychological intervention) versus no treatment Two trials that assessed this comparison evaluated our primary outcome of cessation of habit. One of the trials evaluated palatal crib and one used a mix of palatal cribs and arches. Both trials were at high risk of bias. The orthodontic appliance was more likely to stop digit sucking than no treatment, whether it was used over the short term (risk ratio (RR) 6.53, 95% confidence interval (CI) 1.67 to 25.53; 2 trials, 70 participants) or long term (RR 5.81, 95% CI 1.49 to 22.66; 1 trial, 37 participants) or used in combination with a psychological intervention (RR 6.36, 95% CI 0.97 to 41.96; 1 trial, 32 participants). Psychological intervention versus no treatment Two trials (78 participants) at high risk of bias evaluated positive reinforcement (alone or in combination with gaining the child's co‐operation) or negative reinforcement compared with no treatment. Pooling of data showed a statistically significant difference in favour of the psychological interventions in the short term (RR 6.16, 95% CI 1.18 to 32.10; I 2 = 0%). One study, with data from 57 participants, reported on the long‐term effect of positive and negative reinforcement on sucking cessation and found a statistically significant difference in favour of the psychological interventions (RR 6.25, 95% CI 1.65 to 23.65). Head‐to‐head comparisons Only one trial demonstrated a clear difference in effectiveness between different active interventions. This trial, which had only 22 participants, found a higher likelihood of cessation of habit with palatal crib than palatal arch (RR 0.13, 95% CI 0.03 to 0.59). Authors' conclusions This review found low‐quality evidence that orthodontic appliances (palatal arch and palatal crib) and psychological interventions (including positive and negative reinforcement) are effective at improving sucking cessation in children. There is very low‐quality evidence that palatal crib is more effective than palatal arch. This review has highlighted the need for high‐quality trials evaluating interventions to stop non‐nutritive sucking habits to be conducted and the need for a consolidated, standardised approach to reporting outcomes in these trials. Plain language summary Interventions for stopping dummy or finger or thumb sucking habits in children Review question This review has been produced to assess the effects of interventions to stop sucking habits in children, which are not linked to food. Important considerations are: which treatment or combination of treatments work most effectively, when should treatment be started, what is the optimum length of time for the intervention and what causes least upset to children and their parents? Background Often babies and children develop a habit of sucking objects to comfort and calm them. They frequently suck dummies (known as pacifiers in the USA), fingers, thumbs or other items like blankets. Eventually, most children grow out of the habit, or stop due to encouragement from their parents. Some children, however, continue sucking as a habit. If they continue to do so as their adult teeth start to grow through (around the age of six), there is a risk that these adult teeth will grow into the wrong position causing them to stick out too far or not meet properly when biting. As a result these children often need dental treatment to fix the problems caused by their sucking habit. Possible treatments to help children break their sucking habits examined in studies in this review include the use of two different braces in the mouth; giving advice and incentives for changing behaviour (known as psychological advice/treatment); applying a bitter, nasty tasting substance to the children’s thumbs/fingers or combinations of these treatments. None of the studies included looked at barrier methods, for example the use of gloves or plasters or withdrawal of dummies. Study characteristics Review authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 8 October 2014. The review includes six studies published from 1967 to 1997, which involved 252 children as participants (although data were supplied on only 246 of the children). Three of the studies were carried out in the USA, one in Canada, one in Sweden and one in Australia. Not all of the studies gave the ages of children involved; in four of the studies children were aged from two and a half to 18 years old, in one study they were aged four years and over and in another nine years and over. Results Use of an orthodontic brace (such as a palatal crib or arch) or a psychological intervention (such as use of positive or negative reinforcement), or both, was more likely to lead to cessation of the habit than no treatment. Most of the trials that compared two different interventions were inconclusive but one study suggested that, of two different types of braces,a palatal crib is more effective than a palatal arch design. Quality of the evidence The evidence presented is of low quality due to the small number of participants in the few available studies and problems with the way in which the studies were conducted. There was a high risk of bias across the studies. Conclusion Orthodontic braces or psychological intervention seems to be effective to help children stop sucking that does not have a feeding purpose but the evidence is low quality. Further high quality clinical trials are required to guide decision making for what is a common problem that can require lengthy and expensive dental treatment to correct.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Borrie, FRP; Bearn, DR; Innes, NPT; Iheozor-Ejiofor, Z", "articleTypes": [], "doi": "10.1002/14651858.CD008694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "837eafe6-3060-48bd-8c7a-e79683a250fc", "pmid": "", "title": "Chlorhexidine mouthrinse as an adjunctive treatment for gingival health", "imported": false, "abstract": "Abstract - Background Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build‐up of plaque thereby reducing gingivitis. Objectives To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day). To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs. Data collection and analysis Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random‐effects models for all meta‐analyses. Main results We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high‐quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high‐quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate‐quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies). Authors' conclusions There is high‐quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high‐quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies. Plain language summary Chlorhexidine mouthrinse to reduce gingivitis and plaque build‐up Review question Does the use of chlorhexidine mouthrinse (a broad spectrum antiseptic) in addition to other conventional tooth cleaning help to control and improve gingivitis (inflammation of the gums)? Does the frequency of rinsing or the concentration of the solution affect the result and are there any undesirable side effects? Background Gingivitis is a reversible condition when gums become red, swollen and can bleed easily. Gingivitis is also very common ‐ studies suggest that as many as 50% to 90% of adults in the UK and USA suffer from it. In susceptible people gingivitis may lead to periodontitis, which is not reversible. In periodontitis inflammation is accompanied by loss of ligaments and bone supporting the teeth. If untreated it may eventually lead to tooth loss. Severe periodontitis is the sixth most widespread disease globally. It is recognised that maintaining a high standard of oral hygiene is important for the prevention and treatment of gingivitis. Toothbrushing is the main method for maintaining good oral hygiene. Other cleaning methods commonly used include dental floss, interdental brushes and scaling and polishing carried out by a dental professional. Some people have difficulty controlling plaque build‐up and preventing gingivitis using only conventional tooth cleaning. Therefore people sometimes use mouthrinses containing chlorhexidine in addition to conventional tooth cleaning. These mouthrinses are readily available over the counter; prescriptions generally not being required outside the USA. Study characteristics We included 51 studies that analysed a total of 5345 participants. The evidence in this review is up to date as of 28 September 2016. Generally study participants were children and adults who had gingivitis or periodontitis, were able to use usual tooth cleaning methods and were healthy. We did not exclude studies where some or all participants had medical conditions or special care needs as we considered the use of mouthrinses with chlorhexidine to be particularly relevant to them. The included studies assessed the effects of chlorhexidine mouthrinse used for at least 4 weeks in addition to conventional tooth cleaning on gingivitis in children and adults. Key results There is high‐quality evidence that the use of mouthrinses containing chlorhexidine in addition to usual toothbrushing and cleaning for 4 to 6 weeks or 6 months leads to a large reduction in the build‐up of plaque. There is also high‐quality evidence of a moderate reduction in gingivitis in people with a mild level of it, although because the level of disease was already low this is not considered clinically important. The nature of the available evidence does not allow us to determine the level of reduction of gingivitis in people with moderate to severe levels of it. There was no evidence that one concentration or strength of chlorhexidine rinse was more effective than another. Rinsing for 4 weeks or longer causes tooth staining, which requires scaling and polishing carried out by a dental professional. Other side effects have been reported, including build‐up of calculus (tartar), temporary taste disturbance and temporary shedding of/damage to the lining of the mouth. Quality of the evidence One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "James, P; Worthington, HV; Parnell, C; Harding, M; Lamont, T; Cheung, A; Whelton, H; Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD008676.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "83889d32-c792-4dd5-af4e-c7d4ee5336be", "pmid": "", "title": "Drugs for preventing malaria in pregnant women in endemic areas: any drug regimen versus placebo or no treatment", "imported": false, "abstract": "Abstract - Background Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. To reduce these effects, the World Health Organization recommends that pregnant women living in malaria endemic areas sleep under insecticide‐treated bednets, are treated for malaria illness and anaemia, and receive chemoprevention with an effective antimalarial drug during the second and third trimesters. Objectives To assess the effects of malaria chemoprevention given to pregnant women living in malaria endemic areas on substantive maternal and infant health outcomes. We also summarised the effects of intermittent preventive treatment with sulfadoxine‐pyrimethamine (SP) alone, and preventive regimens for Plasmodium vivax. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and reference lists up to 1 June 2014. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs of any antimalarial drug regimen for preventing malaria in pregnant women living in malaria‐endemic areas compared to placebo or no intervention. In the mother, we sought outcomes that included mortality, severe anaemia, and severe malaria; anaemia, haemoglobin values, and malaria episodes; indicators of malaria infection, and adverse events. In the baby, we sought foetal loss, perinatal, neonatal and infant mortality; preterm birth and birthweight measures; and indicators of malaria infection. We included regimens that were known to be effective against the malaria parasite at the time but may no longer be used because of parasite drug resistance. Data collection and analysis Two review authors applied inclusion criteria, assessed risk of bias and extracted data. Dichotomous outcomes were compared using risk ratios (RR), and continuous outcomes using mean differences (MD); both are presented with 95% confidence intervals (CI). We assessed the quality of evidence using the GRADE approach. Main results Seventeen trials enrolling 14,481 pregnant women met our inclusion criteria. These trials were conducted between 1957 and 2008, in Nigeria (three trials), The Gambia (three trials), Kenya (three trials), Mozambique (two trials), Uganda (two trials), Cameroon (one trial), Burkina Faso (one trial), and Thailand (two trials). Six different antimalarials were evaluated against placebo or no intervention; chloroquine (given weekly), pyrimethamine (weekly or monthly), proguanil (daily), pyrimethamine‐dapsone (weekly or fortnightly), and mefloquine (weekly), or intermittent preventive therapy with SP (given twice, three times or monthly). Trials recruited women in their first or second pregnancy (eight trials); only multigravid women (one trial); or all women (eight trials). Only six trials had adequate allocation concealment. For women in their first or second pregnancy, malaria chemoprevention reduces the risk of moderate to severe anaemia by around 40% (RR 0.60, 95% CI 0.47 to 0.75; three trials, 2503 participants, high quality evidence ), and the risk of any anaemia by around 17% (RR 0.83, 95% CI 0.74 to 0.93; five trials,, 3662 participants, high quality evidence ). Malaria chemoprevention reduces the risk of antenatal parasitaemia by around 61% (RR 0.39, 95% CI 0.26 to 0.58; seven trials, 3663 participants, high quality evidence ), and two trials reported a reduction in febrile illness ( low quality evidence ). There were only 16 maternal deaths and these trials were underpowered to detect an effect on maternal mortality ( very low quality evidence ). For infants of women in their first and second pregnancies, malaria chemoprevention probably increases mean birthweight by around 93 g (MD 92.72 g, 95% CI 62.05 to 123.39; nine trials, 3936 participants, moderate quality evidence ), reduces low birthweight by around 27% (RR 0.73, 95% CI 0.61 to 0.87; eight trials, 3619 participants, moderate quality evidence ), and reduces placental parasitaemia by around 46% (RR 0.54, 95% CI 0.43 to 0.69; seven trials, 2830 participants, high quality evidence ). Fewer trials evaluated spontaneous abortions, still births, perinatal deaths, or neonatal deaths, and these analyses were underpowered to detect clinically important differences. In multigravid women, chemoprevention has similar effects on antenatal parasitaemia (RR 0.38, 95% CI 0.28 to 0.50; three trials, 977 participants, high quality evidence )but there are too few trials to evaluate effects on other outcomes. In trials giving chemoprevention to all pregnant women irrespective of parity, the average effects of chemoprevention measured in all women indicated it may prevent severe anaemia (defined by authors, but at least < 8 g/L: RR 0.19, 95% CI 0.05 to 0.75; two trials, 1327 participants, low quality evidence), but consistent benefits have not been shown for other outcomes. In an analysis confined only to intermittent preventive therapy with SP, the estimates of effect and the quality of the evidence were similar. A summary of a single trial in Thailand of prophylaxis against P. vivax showed chloroquine prevented vivax infection (RR 0.01, 95% CI 0.00 to 0.20; one trial, 942 participants). Authors' conclusions Routine chemoprevention to prevent malaria and its consequences has been extensively tested in RCTs, with clinically important benefits on anaemia and parasitaemia in the mother, and on birthweight in infants. 8 May 2019 No update planned Review superseded The intervention is clearly effective. The questions now are around head‐to‐head comparisons not included in this review. Plain language summary The effect of taking antimalarial drugs routinely to prevent malaria in pregnancy Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. For this reason, women are encouraged to try and prevent malaria infection during pregnancy by sleeping under mosquito bed‐nets, and by taking drugs effective against malaria throughout pregnancy as chemoprevention. This Cochrane Review looked at all drug regimens compared to placebo. The review authors sought to summarise and quantify the overall effects of chemoprevention. Seventeen trials were included, all conducted between 1957 and 2008, and all but two in countries of Africa. For women in their first or second pregnancy, malaria chemoprevention prevents moderate to severe anaemia ( high quality evidence ); and prevents malaria parasites being detected in the blood ( high quality evidence ). It may also prevent malaria illness. We don't know if it prevents maternal deaths, as this would require very large studies to detect an effect. In their infants, malaria chemoprevention improves the average birthweight ( moderate quality evidence ), and reduces the number of low birthweight infants ( moderate quality evidence ). We are not sure if chemoprevention reduces mortality of babies in the first week, month and year, as again studies would need to be very large to show these effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Radeva‐Petrova, D; Kayentao, K; ter Kuile, FO; Sinclair, D; Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD000169.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "839f08a6-c4df-478d-b355-cf415b1ddb38", "pmid": "", "title": "Exploring the Use of Genetic and Behavioural Data in Tailoring Dietary and Lifestyle Support: An n=1 Randomised Trial", "imported": false, "abstract": "Personalised nutrition approaches typically rely on static information such as health status, lifestyle and genetic data. However, adherence often remains low because daily behaviours are influenced by psychological states, motivation and real-time barriers. There is growing interest in whether integrating behavioural signals and timely prompts could strengthen engagement. The purpose of this study is to explore whether incorporating psychological adaptation and just-in-time behavioural prompts leads to better adherence to a personalised nutrition programme compared with commonly used personalised approach (combining health, lifestyle and genetics data without psycho-behavioural adaptation). Using a six-week n-of-1 randomised trial design implemented across multiple participants, the research will also assess the feasibility of delivering this adaptive support in a free-living environment, as well as participants' engagement, acceptability and perceived usefulness. Following completion of the 6-week intervention, an optional focus group will be conducted with a subset of participants (maximum 8) within four weeks of the final study day. The focus group will last approximately 60-90 minutes and will be conducted in person or via video call. Qualitative data from the focus group will be analysed using reflexive thematic analysis (Braun & Clarke, 2021). These findings will inform the development of an adaptive personalised nutrition AI agent.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.248Z" }, { "id": "83a7b138-cdca-46c6-9f08-e4b389d0fc2e", "pmid": "", "title": "Local interventions for the management of alveolar osteitis (dry socket)", "imported": false, "abstract": "Abstract - Background Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012. Objectives To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction. Search methods An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies. Selection criteria We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews. Data collection and analysis We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random‐effects models. For some of the split‐mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence. Main results We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate‐certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively. Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate‐certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low‐certainty evidence). The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low‐certainty evidence). A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) ‐1.40, 95% CI ‐1.75 to ‐1.04; P < 0.00001; 2 studies, 80 participants; very low‐certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects. Authors' conclusions Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate‐certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. Plain language summary What treatments can be used to prevent and treat alveolar osteitis (dry socket)? Key messages ‐ Rinsing with chlorhexidine mouthwash before a dental extraction or beginning 24 hours after may help to prevent a dry socket.
‐ Placing a chlorhexidine gel directly into the socket immediately after tooth extraction may help to prevent a dry socket.
‐ Chlorhexidine rinses cause some minor adverse (unwanted) effects; chlorhexidine intrasocket gels do not appear to cause adverse effects.
‐ Alvogyl reduces the pain of a dry socket when compared to zinc oxide eugenol, but the evidence for this is very uncertain.
‐ Alvogyl does not appear to cause unwanted effects.
‐ We need future studies to strengthen the evidence and investigate the best ways to prevent and treat dry socket in all teeth. What is dry socket? Dry socket is a painful condition that sometimes arises after a tooth has been extracted and is more likely to occur following extraction of wisdom teeth in the lower jaw. What causes dry socket? It is thought to be linked to the loss of some or all of the blood clot that forms at the bottom of a tooth socket after a tooth is taken out. How can we prevent dry socket? An option for prevention of dry socket is to reduce debris and the bacterial load in the mouth, though dry socket is not bacterial in origin. People with poor oral hygiene (food debris and plaque) are at greater risk of dry socket. Improved oral hygiene and rinsing before a dental extraction or beginning 24 hours after may reduce the likelihood of dry socket. How can we treat dry socket ? Options for treating dry socket largely focus on reducing pain locally around the tooth extraction site by placing an obtundent (a soothing medicated dressing). What did we want to find out ? We wanted to find out if antiseptic rinses, gels, or healing patches could help to prevent dry socket. We also wanted to find out if placing a medicated dressing could treat a dry socket and whether any unwanted side effects were produced. What did we do? We searched for studies that compared antiseptic rinses or intrasocket gels with a placebo (dummy) rinse or nothing and a placebo (dummy) intrasocket gel or nothing. To find the best way to treat dry socket we searched for studies that compared different soothing agents with a placebo (dummy) with other soothing agents or with nothing. We compared the results of the studies and summarised the findings. We made an assessment of our confidence in the evidence based on the design of the study and the number of patients recruited. What did we find? We identified 49 trials; 39 trials (6219 participants) investigated prevention of dry socket and 10 trials (552 participants) investigated the treatment of dry socket. We found that: ‐ rinsing both before and after tooth extraction (commencing 24 hours after extraction) with chlorhexidine gluconate rinse (at 0.12% and 0.2% strength) probably results in a reduction in dry socket;
‐ placing chlorhexidine gel (0.2% strength) in the socket of an extracted tooth probably results in a reduction in dry socket;
‐ chlorhexidine rinses and gels are equally effective at reducing dry socket, but the evidence for this comparison is very uncertain;
‐ chlorhexidine rinses produced some minor unwanted effects; chlorhexidine intrasocket gels appeared to produce no unwanted effects;
‐ there was a small amount of evidence of very low certainty from two studies that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. This evidence relates to the old formulation of Alvogyl which is no longer available. It should be noted that the formulation of Alvogyl has changed, it is now called Alveogyl. Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. What are the limitations of the evidence? The main limitation of the evidence are that studies: ‐ reported mostly on tooth extractions involving lower wisdom teeth;
‐ were undertaken in ways that introduced errors in the conduct of the study leading to errors in the results; and
‐ produced imprecise results when they were combined. Due to these errors we have some confidence in the results relating to chlorhexidine rinses and gels but further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. How up to date is this evidence? The search for existing studies was completed by 28 September 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Daly, BJM; Sharif, MO; Jones, K; Worthington, HV; Beattie, A", "articleTypes": [], "doi": "10.1002/14651858.CD006968.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "83ba9a59-9348-4be2-9e89-87370deba7bb", "pmid": "", "title": "Melatonin and agomelatine for preventing seasonal affective disorder", "imported": false, "abstract": "Abstract - Background Seasonal affective disorder (SAD) is a seasonal pattern of recurrent major depressive episodes that most commonly starts in autumn or winter and remits in spring. The prevalence of SAD depends on latitude and ranges from 1.5% to 9%. The predictable seasonal aspect of SAD provides a promising opportunity for prevention in people who have a history of SAD. This is one of four reviews on the efficacy and safety of interventions to prevent SAD; we focus on agomelatine and melatonin as preventive interventions. Objectives To assess the efficacy and safety of agomelatine and melatonin (in comparison with each other, placebo, second‐generation antidepressants, light therapy, psychological therapy or lifestyle interventions) in preventing SAD and improving person‐centred outcomes among adults with a history of SAD. Search methods We searched Ovid MEDLINE (1950‐ ), Embase (1974‐ ), PsycINFO (1967‐ ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 19 June 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD‐CTR) (all years to 11 August 2015). Furthermore, we searched the Cumulative Index to Nursing and Allied Health Literature, Web of Science, the Cochrane Library , the Allied and Complementary Medicine Database and international trial registers (to 19 June 2018). We also conducted a grey literature search and handsearched the reference lists of included studies and pertinent review articles. Selection criteria To examine efficacy, we included randomised controlled trials (RCTs) on adults with a history of winter‐type SAD who were free of symptoms at the beginning of the study. For adverse events, we intended also to include non‐randomised studies. We planned to include studies that compared agomelatine versus melatonin, or agomelatine or melatonin versus placebo, any second‐generation antidepressant, light therapy, psychological therapies or lifestyle changes. We also intended to compare melatonin or agomelatine in combination with any of the comparator interventions mentioned above versus the same comparator intervention as monotherapy. Data collection and analysis Two review authors screened abstracts and full‐text publications, abstracted data and assessed risk of bias of included studies independently. We intended to pool data in a meta‐analysis using a random‐effects model, but included only one study. Main results We identified 3745 citations through electronic searches and reviews of reference lists after deduplication of search results. We excluded 3619 records during title and abstract review and assessed 126 full‐text papers for inclusion in the review. Only one study, providing data of 225 participants, met our eligibility criteria and compared agomelatine (25 mg/day) with placebo. We rated it as having high risk of attrition bias because nearly half of the participants left the study before completion. We rated the certainty of the evidence as very low for all outcomes, because of high risk of bias, indirectness, and imprecision. The main analysis based on data of 199 participants rendered an indeterminate result with wide confidence intervals (CIs) that may encompass both a relevant reduction as well as a relevant increase of SAD incidence by agomelatine (risk ratio (RR) 0.83, 95% CI 0.51 to 1.34; 199 participants; very low‐certainty evidence). Also the severity of SAD may be similar in both groups at the end of the study with a mean SIGH‐SAD (Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders) score of 8.3 (standard deviation (SD) 9.4) in the agomelatine group and 10.1 (SD 10.6) in the placebo group (mean difference (MD) ‐1.80, 95% CI ‐4.58 to 0.98; 199 participants; very low‐certainty evidence). The incidence of adverse events and serious adverse events may be similar in both groups. In the agomelatine group, 64 out of 112 participants experienced at least one adverse event, while 61 out of 113 did in the placebo group (RR 1.06, 95% CI 0.84 to 1.34; 225 participants; very low‐certainty evidence). Three out of 112 patients experienced serious adverse events in the agomelatine group, compared to 4 out of 113 in the placebo group (RR 0.76, 95% CI 0.17 to 3.30; 225 participants; very low‐certainty evidence). No data on quality of life or interpersonal functioning were reported. We did not identify any studies on melatonin. Authors' conclusions Given the uncertain evidence on agomelatine and the absence of studies on melatonin, no conclusion about efficacy and safety of agomelatine and melatonin for prevention of SAD can currently be drawn. The decision for or against initiating preventive treatment of SAD and the treatment selected should consider patient preferences and reflect on the evidence base of all available treatment options. Plain language summary Melatonin and agomelatine for prevention of winter depression Why is this review important? Many people in northern latitudes suffer from seasonal affective disorder (SAD), which occurs as a reaction to reduced sunlight. Three‐quarters of those affected are women. Lethargy, overeating, craving for carbohydrates and depressed mood are common symptoms. In some people, SAD becomes depression that seriously affects their daily lives. Up to two‐thirds experience depressive symptoms every winter. Who might be interested in this review? General practitioners, psychiatrists, pharmacists, other health professionals working in adult mental health services, and researchers could be interested in the results of this review. Anyone who has experienced winter depression, or who has friends or relatives who have experienced winter depression might also be interested. What questions does this review aim to answer? Because of the seasonal pattern and high recurrence of SAD, melatonin or agomelatine could be used to prevent the onset of depressed mood. The goal of this report is to examine whether benefits outweigh harms of melatonin or agomelatine when used to prevent onset of a new depressive episode in people with a history of SAD who were free of symptoms when the preventive intervention started. To date, this question has not been examined in a systematic way. This is one of four reviews on the efficacy and potential harms of interventions to prevent SAD. Which studies were included in the review? We searched databases up to June 2018 for studies on melatonin or agomelatine for prevention of winter depression. Among 3745 records, we found one randomised controlled study comparing agomelatine with placebo for one year. All 225 participants had a history of winter depression but were not depressed when the prevention study started. What does evidence from the review reveal? The included study showed neither a clear effect in favour nor against agomelatine as a preventive treatment. In addition, the certainty of evidence for all outcomes was very low, making it impossible to draw any conclusions about the efficacy and safety of agomelatine for the prevention of winter depression. No evidence on melatonin for prevention of SAD was identified. Doctors need to discuss with persons with a history of SAD that currently evidence on agomelatine or melatonin for preventive treatment options for SAD is inconclusive, therefore treatment selection should be strongly based on peoples' preferences and reflect on the evidence base of all available treatment options. What should happen next? Review authors recommend that future studies should evaluate the efficacy of agomelatine or melatonin in preventing SAD and should directly compare these interventions against other treatment options, such as light therapy, antidepressants, or psychological therapies to determine the best treatment option for prevention of SAD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nussbaumer‐Streit, B; Greenblatt, A; Kaminski‐Hartenthaler, A; Van Noord, MG; Forneris, CA; Morgan, LC; Gaynes, BN; Wipplinger, J; Lux, LJ; Winkler, D; Gartlehner, G", "articleTypes": [], "doi": "10.1002/14651858.CD011271.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "83bddb75-bb3d-4ff7-b919-f424999e9907", "pmid": "", "title": "Effect of adrenergic agonist oral decongestants on blood pressure", "imported": false, "abstract": "Abstract - Background Adrenergic agonist oral decongestants are commonly taken daily over long periods of time to relieve sinus and nasal congestion. The mechanism of action of decongestants potentially increases blood pressure, and these effects may be acute or chronic. However, no systematic reviews to date have comprehensively assessed the chronic blood pressure effects of adrenergic agonist oral decongestants as a drug class, despite their widespread non‐prescription availability. Objectives Primary objective To assess the effects of adrenergic agonist oral decongestants on systolic and diastolic blood pressure compared to placebo. Secondary objective To assess the effects of adrenergic agonist oral decongestants on heart rate and withdrawals due to adverse effects. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCT) up to July 2024: Cochrane Hypertension Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Register of Studies, Ovid MEDLINE, Ovid Embase, and ClinicalTrials.gov. There were no language, publication year, or publication status restrictions. Selection criteria We included RCTs of at least seven days' duration with parallel groups (intervention and placebo) comparing adrenergic agonist oral decongestants versus placebo on blood pressure in people aged over six years. Data collection and analysis Two review authors (JJC and MC) independently assessed the trials for inclusion, extracted the data, and assessed the risk of bias from the included trials. In cases where there were disagreements, the third review author (JMW) adjudicated. For any missing or unclear information in the studies, we contacted the study author to request the missing information or seek clarification. The primary outcomes were systolic blood pressure and diastolic blood pressure. Secondary outcomes were heart rate and withdrawal due to adverse effects. We used a fixed‐effect model to combine the effect sizes from all studies. We assessed the certainty of the evidence using GRADE. Main results Five RCTs randomizing 882 participants met the inclusion criteria. The shortest study duration was one week, and the longest study duration was 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The largest study included 568 people, and the smallest study included 18 people. The mean age of participants was 20.0 years, with 326 males and 591 females. The studies were conducted in the USA and Europe; most were set in the USA. Pharmaceutical companies funded three of the five included studies. The findings are relevant to all people using adrenergic agonist oral decongestants for seven days or longer regardless of comorbidities or pre‐existing conditions. The adrenergic agonist oral decongestants included were ephedrine (one RCT), pseudoephedrine (one RCT), and phenylpropanolamine (three RCTs). Compared to placebo, adrenergic agonist oral decongestants may have little to no effect on systolic blood pressure , but the evidence is very uncertain (mean difference [MD] 0.91 mmHg, 95% confidence interval [CI] −0.57 to 2.38; 4 RCTs, 784 participants; I 2 = 54%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on diastolic blood pressure (MD 0.44 mmHg, 95% CI −0.59 to 1.48; 5 RCTs, 882 participants; I 2 = 30%; low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on heart rate, but the evidence is very uncertain (MD 1.92 beats per minute, 95% CI −0.62 to 4.47; 2 RCTs, 190 participants; I 2 = 79%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on the number of withdrawals due to adverse effects (risk ratio [RR] 1.20, 95% CI 0.37 to 3.88; 4 RCTs, 806 participants; low‐certainty evidence; note 1 study reported withdrawals due to adverse effects but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 3 studies rather than 4). Four studies were at overall high risk of bias, and one study was at overall low risk of bias. Authors' conclusions In this systematic review, chronic daily intake of adrenergic agonist oral decongestants had little to no effect on blood pressure, heart rate, and withdrawals due to adverse effects. People making decisions about using these medicines should consider the very low certainty of evidence and the theoretical risk of increased blood pressure. Independent trials free from biases that are designed to answer this question are required. The evidence was limited due to the small number of studies, and the blood pressure and heart rate not being measured at the optimal time after drug ingestion. Plain language summary What are the effects of oral decongestants on blood pressure? Key messages – We found no evidence that taking oral decongestants (medicine taken by mouth to relieve a stuffy nose) daily for a week or more changes blood pressure or heart rate or causes people to stop taking them due to unwanted effects. – There were only a few studies, and they were not well designed. More well‐conducted studies are needed. – Given that oral decongestants are sometimes taken daily for weeks or months, and have the potential to increase blood pressure, people should consider this potential risk alongside the limited evidence from this review when deciding whether to use these medicines. What are oral decongestants? Oral decongestants are medications taken by mouth to relieve nasal congestion (stuffy or blocked nose), often caused by colds, allergies, or sinus infections (small, empty spaces behind the cheekbones and forehead that are connected to the nose). They typically include medicines called pseudoephedrine or phenylephrine. How do oral decongestants work? These medicines shrink swollen blood vessels in the nasal passages. This reduces swelling and allows air to flow more freely, helping you breathe easier. What is hypertension? Hypertension (high blood pressure) is when resting blood pressure is consistently above 140/90 mmHg. It can lead to unwanted effects such as stroke (where the blood supply to parts of the brain is reduced or stopped) and heart attack (where the blood supply to the heart is reduced or stopped). Lowering blood pressure is the easiest way to reduce these diseases. How is hypertension treated? Treating hypertension involves lifestyle measures and taking blood pressure‐lowering medicines. Here, we focused on the effects of daily intake of oral decongestants. While these medicines help with nasal congestion, they may also increase blood pressure. What do we want to find out? We wanted to find out whether long‐term use of oral decongestants (for seven days or longer) increases blood pressure and has any unwanted effects. We also evaluated their effectiveness in relieving nasal congestion. This provides essential insights into their benefits and risks to guide informed use. What did we do? We searched for studies that compared the blood pressure effects of oral decongestants with placebo. A placebo is a substance or treatment with no active ingredients that is used in medical research to compare against the effects of real medications. We then compared and summarized the results, and rated our confidence in the evidence depending on the study design and methods. What did we find? We found five studies involving 882 children and adults (326 males and 591 females). The shortest study lasted one week, with the longest study lasting 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The size of the studies ranged from 18 to 568 people, and most were done in the USA. Pharmaceutical companies funded three studies. We found no clear evidence that taking oral decongestants daily changes blood pressure or heart rate, or causes people to stop taking them due to unwanted effects. What are the limitations of the evidence? There was a limited number of studies, and they were not well designed. None of the studies were primarily designed to assess the long‐term effects of oral decongestants on blood pressure. Trials designed to answer this question are needed. How up to date is the evidence? The evidence is up to date to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Chan, JJ; Chan, M; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007895.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "83c43a7b-9dba-43dd-9c91-537ceea7af05", "pmid": "", "title": "Interventions for recurrent idiopathic epistaxis (nosebleeds) in children", "imported": false, "abstract": "Abstract - Background Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified. Although nosebleeds are very common in children, and most cases are self limiting or settle with simple measures (such as pinching the nose), more severe recurrent cases can require treatment from a healthcare professional. However, there is no consensus on the effectiveness of the different clinical interventions currently used in managing this condition. Objectives To assess the effects of different interventions for the management of recurrent idiopathic epistaxis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 5 March 2012. Selection criteria We identified all randomised controlled trials (RCTs) (with or without blinding) in which any surgical or medical intervention for the treatment of recurrent idiopathic epistaxis in children was evaluated in comparison with either no treatment, a placebo or another intervention, and in which the frequency and severity of episodes of nasal bleeding following treatment was stated or calculable. The two authors reviewed the full‐text articles of all retrieved trials of possible relevance and applied the inclusion criteria independently. Data collection and analysis We graded trials for risk of bias using the Cochrane approach. One author performed data extraction in a standardised manner and this was rechecked by the other author. Where necessary we contacted investigators to obtain missing information. We did not undertake a meta‐analysis because of the heterogeneity of the treatments, procedures and quality of the included trials. A narrative overview of the results is therefore presented. Main results Five studies (four RCTs and one quasi‐randomised controlled trial) involving 468 participants satisfied the inclusion criteria. The identified RCTs compared 0.5% neomycin + 0.1% chlorhexidine (Naseptin®) cream with no treatment, Vaseline® petroleum jelly with no treatment, 75% with 95% silver nitrate nasal cautery, and silver nitrate cautery combined with Naseptin® against Naseptin® alone; the quasi‐randomised controlled trial compared Naseptin® antiseptic cream with silver nitrate cautery. Overall results were inconclusive, with no statistically significant difference found between the compared treatments upon completion of the trials, however 75% silver nitrate was more effective than 95% silver nitrate at two weeks following application. The group treated with 75% silver nitrate had 88% complete resolution of epistaxis compared to 65% in the group treated with 95% silver nitrate (P = 0.01). No serious adverse effects were reported from any of the interventions, although children receiving silver nitrate cautery reported that it was a painful experience (despite the use of local anaesthetic). The pain scores were significantly less in those treated with 75% silver nitrate, the mean score being 1 compared to a mean score of 5 in those treated with 95% silver nitrate; this was statistically significant (P = 0.001). We carried out a 'Risk of bias' assessment of each study according to the Cochrane methodology and judged that two randomised controlled trials had a low risk of bias, two had an unclear risk of bias and the quasi‐randomised controlled trial had a high risk of bias. Authors' conclusions The optimal management of children with recurrent idiopathic epistaxis is unknown, however if silver nitrate nasal cautery is undertaken 75% is preferable to 95% as it is more effective in the short term and causes less pain. High‐quality randomised controlled trials comparing interventions either with placebo or no treatment, and with a follow‐up period of at least a year, are needed to assess the relative merits of the various treatments currently in use. Plain language summary Interventions for recurrent nosebleeds of unknown cause in children Nosebleeds in children usually just stop by themselves or after pinching the nose. However, some children get repeated nosebleeds with no specific cause (recurrent idiopathic epistaxis). The most common treatments are cautery or antiseptic cream, or both. Cautery (a method of sealing) can be painful even with local anaesthetic, and usually involves using a silver nitrate stick to seal off a visible blood vessel inside the nose that may be rupturing. Other options include ointments and nasal sprays. The review of trials found that there is not enough evidence to compare the effectiveness of different treatment options, however using a lower concentration of silver nitrate cautery is more effective in the short term and less painful. More research is needed to show the best options for reducing recurrent nosebleeds of unknown cause in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Qureishi, A; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004461.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "83e5f048-9650-4a20-8b5b-90fe4f739dd0", "pmid": "", "title": "Endometrial preparation for women undergoing embryo transfer with frozen embryos or embryos derived from donor oocytes", "imported": false, "abstract": "Abstract - Background A frozen embryo transfer (FET) cycle is when one or more embryos (frozen during a previous treatment cycle) are thawed and transferred to the uterus. Some women undergo fresh embryo transfer (ET) cycles with embryos derived from donated oocytes. In both situations, the endometrium is primed with oestrogen and progestogen in different doses and routes of administration. Objectives To evaluate the most effective endometrial preparation for women undergoing transfer with frozen embryos or embryos from donor oocytes with regard to the subsequent live birth rate (LBR). Search methods The Cochrane Gynaecology and Fertility Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, LILACS, trials registers and abstracts of reproductive societies' meetings were searched in June 2020 together with reference checking and contact with study authors and experts in the field to identify additional studies. Selection criteria Randomised controlled trials (RCTs) evaluating endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. Data collection and analysis We used standard methodological procedures recommended by Cochrane. We analysed all available interventions versus placebo, no treatment, or between each other. The primary review outcome was live birth rate. Secondary outcomes were clinical and multiple pregnancy, miscarriage, cycle cancellation, endometrial thickness and adverse effects. Main results Thirty‐one RCTs (5426 women) were included. Evidence was moderate to very low‐quality: the main limitations were serious risk of bias due to poor reporting of methods, and serious imprecision. Stimulated versus programmed cycle We are uncertain whether a letrozole‐stimulated cycle compared to a programmed cycle, for endometrial preparation, improves LBR (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.49 to 3.26; 100 participants; one study; very low‐quality evidence). Stimulating with follicle stimulating hormone (FSH), letrozole or clomiphene citrate may improve clinical pregnancy rate (CPR) (OR 1.63, 95% CI 1.12 to 2.38; 656 participants; five studies; I 2 = 11%; low‐quality evidence). We are uncertain if they reduce miscarriage rate (MR) (OR 0.79, 95% CI 0.36 to 1.71; 355 participants; three studies; I 2 = 0%; very low‐quality evidence). Endometrial thickness (ET) may be reduced with clomiphene citrate (mean difference(MD) ‐1.04, 95% CI ‐1.59 to ‐0.49; 92 participants; one study; low‐quality evidence). Other outcomes were not reported. Natural versus programmed cycle We are uncertain of the effect from a natural versus programmed cycle for LBR (OR 0.97, 95% CI 0.74 to 1.28; 1285 participants; four studies; I 2 = 0%; very low‐quality evidence) and CPR (OR 0.79, 95% CI 0.62 to 1.01; 1249 participants; five studies; I 2 = 60%; very low‐quality evidence), while a natural cycle probably reduces the cycle cancellation rate (CCR) (OR 0.60, 95% CI 0.44 to 0.82; 734 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and ET. No study reported other outcomes. Transdermal versus oral oestrogens From low‐quality evidence we are uncertain of the effect transdermal compared to oral oestrogens has on CPR (OR 0.86, 95% CI 0.59 to 1.25; 504 participants; three studies; I 2 = 58%) or MR (OR 0.55, 95% CI 0.27 to 1.09; 414 participants; two studies; I 2 = 0%). Other outcomes were not reported. Day of starting administration of progestogen When doing a fresh ET using donated oocytes in a synchronised cycle starting progestogen on the day of oocyte pick‐up (OPU) or the day after OPU, in comparison with recipients that start progestogen the day prior to OPU, probably increases the CPR (OR 1.87, 95% CI 1.13 to 3.08; 282 participants; one study, moderate‐quality evidence). We are uncertain of the effect on multiple pregnancy rate (MPR) or MR. It probably reduces the CCR (OR 0.28, 95% CI 0.11 to 0.74; 282 participants; one study; moderate‐quality evidence). No study reported other outcomes. Gonadotropin‐releasing hormone (GnRH) agonist versus control A cycle with GnRH agonist compared to without may improve LBR (OR 2.62, 95% CI 1.19 to 5.78; 234 participants; one study; low‐quality evidence). From low‐quality evidence we are uncertain of the effect on CPR (OR 1.08, 95% CI 0.82 to 1.43; 1289 participants; eight studies; I 2 = 20%), MR (OR 0.85, 95% CI 0.36 to 2.00; 828 participants; four studies; I 2 = 0%), CCR (OR 0.49, 95% CI 0.21 to 1.17; 530 participants; two studies; I 2 = 0%) and ET (MD ‐0.08, 95% CI ‐0.33 to 0.16; 697 participants; four studies; I 2 = 4%). No study reported other outcomes. Among different GnRH agonists From very low‐quality evidence we are uncertain if cycles among different GnRH agonists improves CPR or MR. No study reported other outcomes. GnRH agonists versus GnRH antagonists GnRH antagonists compared to agonists probably improves CPR (OR 0.62, 95% CI 0.42 to 0.90; 473 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and MPR. No study reported other outcomes. Aspirin versus control From very low‐quality evidence we are uncertain whether a cycle with aspirin versus without improves LBR, CPR, or ET. Steroids versus control From very low‐quality evidence we are uncertain whether a cycle with steroids compared to without improves LBR, CPR or MR. No study reported other outcomes. Authors' conclusions There is insufficient evidence on the use of any particular intervention for endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. In frozen embryo transfers, low‐quality evidence showed that clinical pregnancy rates may be improved in a stimulated cycle compared to a programmed one, and we are uncertain of the effect when comparing a programmed cycle to a natural cycle. Cycle cancellation rates are probably reduced in a natural cycle. Although administering a GnRH agonist, compared to without, may improve live birth rates, clinical pregnancy rates will probably be improved in a GnRH antagonist cycle over an agonist cycle. In fresh synchronised oocyte donor cycles, the clinical pregnancy rate is probably improved and cycle cancellation rates are probably reduced when starting progestogen the day of or day after donor oocyte retrieval. Adequately powered studies are needed to evaluate each treatment more accurately. Plain language summary Endometrial preparation for egg donor recipients or for frozen embryo transfers Review question What is the most effective method for endometrial preparation in women undergoing embryo transfers with frozen embryos or embryos derived from donor oocytes? Background Couples undergo infertility treatments due to male factor, female factors or unexplained infertility. After an unsuccessful fresh embryo transfer cycle, a frozen‐thawed embryo transfer can be performed when frozen embryos are available. Adequate hormonal preparation of the endometrium is of utmost importance for both egg donor and frozen embryo replacement cycles to provide the optimal chances of pregnancy. Many drugs and various modes of administration have been tried by several investigators in order to optimise implantation rates and consequently improve the success rates of the embryo transfer procedures: stimulated cycles (to generate endogenous oestradiol), programmed cycles (administering exogenous oestradiol) or natural cycles (allowing the ovaries to produce oestradiol without stimulation) are some of the options; avoiding spontaneous ovulation with gonadotropin‐releasing hormone (GnRH) agonists and antagonists could have some impact; or using some other drugs such as aspirin or steroids that could potentially enhance the endometrial receptivity were also evaluated. Study characteristics We found 31 randomised controlled trials comparing different interventions such as the dose and route of administration of oestrogens and progestogen, the use of drugs that stop the patient from ovulating prematurely (GnRH agonists), and the use of other medications to improve the endometrium in a total of 5426 women. The evidence is current to June 2020. Key results We are uncertain whether a stimulated cycle (with letrozole) compared to a programmed cycle, for endometrial preparation, improves live birth. The evidence suggests that if the chance of live birth following a programmed cycle is assumed to be 24%, the chance following a stimulated cycle would be between 13% and 51%. We are also uncertain of the impact on miscarriage rate and endometrial thickness. A stimulated cycle may improve clinical pregnancy rate. Data were lacking on multiple pregnancy, cycle cancellation and other adverse effects. We are uncertain whether a natural cycle improves the live birth rate, pregnancy rate, miscarriage rate and endometrial thickness in comparison with a programmed cycle. Data were lacking for all other outcomes. We are uncertain if transdermal (delivered via the skin) oestrogens compared with oral (by mouth) oestrogens improve clinical pregnancy rate and miscarriage rate. Data were lacking for all other outcomes in this comparison. Starting progestogen on the day of the donor oocyte retrieval or the day after probably increases the clinical pregnancy rate and probably reduces the cycle cancellation rate. We are uncertain if it reduces the miscarriage rate. Data were lacking for all other outcomes. A cycle with GnRH agonist compared to without may improve live birth rate. We are uncertain of the effect of a GnRH cycle compared to no GnRH for the outcomes of clinical pregnancy rate, miscarriage rate, and endometrial thickness. No study reported on the other outcomes for this comparison. We are uncertain if any GnRH agonist is better than other: a cycle with daily leuprolide or with deposit tryptorelin improves clinical pregnancy rate, or if daily acetate leuprolide or daily nafarelin reduces the miscarriage rate. Other outcomes were not reported. GnRH antagonists compared to agonists probably improve clinical pregnancy rate. We are uncertain of the effect on miscarriage rate and multiple pregnancy rate. No study reported the other outcomes. We are uncertain whether a cycle with aspirin compared to a cycle without improves live birth, clinical pregnancy rate or endometrial thickness. Data were lacking for all other outcomes. We are also uncertain whether a cycle with steroids compared to a cycle without steroids improves live birth rate, clinical pregnancy rate or miscarriage rate. No study reported on the other outcomes. Quality of the evidence The evidence was of moderate to very low‐quality. The main limitations in the evidence were poor reporting of study methods, and lack of precision in the findings for live birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Glujovsky, D; Pesce, R; Sueldo, C; Quinteiro Retamar, AM; Hart, RJ; Ciapponi, A", "articleTypes": [], "doi": "10.1002/14651858.CD006359.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "83ecf981-9d06-4263-bf84-12386be019aa", "pmid": "", "title": "Protein and energy supplementation in elderly people at risk from malnutrition", "imported": false, "abstract": "Abstract - Background Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. Objectives This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip‐feeds'. Search methods We searched The Cochrane Library , MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip‐feed' manufacturers. Selection criteria Randomised and quasi‐randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. Data collection and analysis Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. Main results Sixty‐two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97). The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (‐0.8 days, 95% CI ‐2.8 to 1.3). Adverse effects included nausea or diarrhoea. Authors' conclusions Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large‐scale multi‐centre trials are still required. Plain language summary Protein and energy supplementation in elderly people at risk from malnutrition Much emphasis is placed on the importance of good diet, usually in relation to concern about the health risks of obesity. However it has been generally agreed that the risk of undernutrition rather than overnutrition is the main cause for concern in elderly people, particularly those who are hospitalised or institutionalised. Malnutrition has been shown to have important effects on recovery in a broad range of patients and conditions. It has been associated strongly with impaired immune response, impaired muscle and respiratory function, delayed wound healing, overall increased complications, longer rehabilitation, greater length of hospital stay and increased mortality. Oral protein and energy supplements are potentially safer and easier to administer than nasogastric enteral feeds and are therefore particularly suited to elderly people and are also widely used. However, there may be problems with the willingness and ability of older people to consume oral supplements, and supplements may not be used effectively. Even if supplements are prescribed, they may not always be given, or are given but not consumed. In addition to taste, the composition and timing of administration in relation to meals may be important. Efforts also need to be made to provide normal meals and snacks which meet the needs of elderly people and to provide assistance with feeding if required. A total of 10,187 randomised participants from the 62 trials has been included. Maximum duration of intervention was 18 months. The reviewers suggest that supplementation appears to produce a small but consistent weight gain. There was no evidence in this updated review of a beneficial effect on mortality overall, but there may be a beneficial effect on mortality in people who are undernourished. Supplementation may also reduce the number of complications. The reported acceptance of supplements was variable between trials. Some adverse effects such as nausea or diarrhoea were reported. However, there were problems of study design and quality. More studies are required to confirm the beneficial effect on the number of complications, to establish whether there is a beneficial effect on mortality for undernourished elderly people and to provide evidence about whether protein and energy supplements can improve morbidity and functional status in frail older people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Milne, AC; Potter, J; Vivanti, A; Avenell, A", "articleTypes": [], "doi": "10.1002/14651858.CD003288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "83efc1e9-3662-401e-90ce-231531ae5fc4", "pmid": "", "title": "Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Benson, PE, Parkin, N, Dyer, F, Millett, DT, Germain, P", "articleTypes": [], "doi": "10.1002/14651858.CD003809.pub4 AB - Abstract - Background Early dental decay or demineralised lesions (DLs, also known as white spot lesions) can appear on teeth during fixed orthodontic (brace) treatment. Fluoride reduces decay in susceptible individuals, including orthodontic patients. This review compared various forms of topical fluoride to prevent the development of DLs during orthodontic treatment. This is the second update of the Cochrane Review first published in 2004 and previously updated in 2013. Objectives The primary objective was to evaluate whether topical fluoride reduces the proportion of orthodontic patients with new DLs after fixed appliances. The secondary objectives were to examine the effectiveness of different modes of topical fluoride delivery in reducing the proportions of orthodontic patients with new DLs, as well as the severity of lesions, in terms of number, size and colour. Participant‐assessed outcomes, such as perception of DLs, and oral health‐related quality of life data were to be included, as would reports of adverse effects. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 1 February 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library (searched 1 February 2019), MEDLINE Ovid (1946 to 1 February 2019), and Embase Ovid (1980 to 1 February 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Parallel‐group, randomised controlled trials comparing the use of a fluoride‐containing product versus a placebo, no treatment or a different type of fluoride treatment, in which the outcome of enamel demineralisation was assessed at the start and at the end of orthodontic treatment. Data collection and analysis At least two review authors independently, in duplicate, conducted risk of bias assessments and extracted data. Authors of trials were contacted to obtain missing data or to ask for clarification of aspects of trial methodology. Cochrane's statistical guidelines were followed. Main results This update includes 10 studies and contains data from nine studies, comparing eight interventions, involving 1798 randomised participants (1580 analysed). One report contained insufficient information and the authors have been contacted. We assessed two studies as at low risk of bias, six at unclear risk of bias, and two at high risk of bias. Two placebo (non‐fluoride) controlled studies, at low risk of bias, investigated the professional application of varnish (7700 or 10,000 parts per million (ppm) fluoride (F)), every six weeks and found insufficient evidence of a difference regarding its effectiveness in preventing new DLs (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.14 to 1.93; 405 participants; low‐certainty evidence). One placebo (non‐fluoride) controlled study, at unclear risk of bias, provides a low level of certainty that fluoride foam (12,300 ppm F), professionally applied every two months, may reduce the incidence of new DLs (12% versus 49%) after fixed orthodontic treatment (RR 0.26, 95% CI 0.11 to 0.57; 95 participants). One study, at unclear risk of bias, also provides a low level of certainty that use of a high‐concentration fluoride toothpaste (5000 ppm F) by patients may reduce the incidence of new DLs (18% versus 27%) compared with a conventional fluoride toothpaste (1450 ppm F) (RR 0.68, 95% CI 0.46 to 1.00; 380 participants). There was no evidence for a difference in the proportions of orthodontic patients with new DLs on the teeth after treatment with fixed orthodontic appliances for the following comparisons:
 ‐ an amine fluoride and stannous fluoride toothpaste/mouthrinse combination versus a sodium fluoride toothpaste/mouthrinse,
 ‐ an amine fluoride gel versus a non‐fluoride placebo applied by participants at home once a week and by professional application every three months,
 ‐ resin‐modified glass ionomer cement versus light‐cured composite resin for bonding orthodontic brackets,
 ‐ a 250 ppm F mouthrinse versus 0 ppm F placebo mouthrinse,
 ‐ the use of an intraoral fluoride‐releasing glass bead device attached to the brace versus a daily fluoride mouthrinse. The last two comparisons involved studies that were assessed at high risk of bias, because a substantial number of participants were lost to follow‐up. Unfortunately, although the internal validity and hence the quality of the studies has improved since the first version of the review, they have compared different interventions; therefore, the findings are only considered to provide low level of certainty, because none has been replicated by follow‐up studies, in different settings, to confirm external validity. A patient‐reported outcome, such as concern about the aesthetics of any DLs, was still not included as an outcome in any study. Reports of adverse effects from topical fluoride applications were rare and unlikely to be significant. One study involving fluoride‐containing glass beads reported numerous breakages. Authors' conclusions This review found a low level of certainty that 12,300 ppm F foam applied by a professional every 6 to 8 weeks throughout fixed orthodontic treatment, might be effective in reducing the proportion of orthodontic patients with new DLs. In addition, there is a low level of certainty that the patient use of a high fluoride toothpaste (5000 ppm F) throughout orthodontic treatment, might be more effective than a conventional fluoride toothpaste. These two comparisons were based on single studies. There was insufficient evidence of a difference regarding the professional application of fluoride varnish (7700 or 10,000 ppm F). Further adequately powered, randomised controlled trials are required to increase the certainty of these findings and to determine the best means of preventing DLs in patients undergoing fixed orthodontic treatment. The most accurate means of assessing adherence with the use of fluoride products by patients and any possible adverse effects also need to be considered. Future studies should follow up participants beyond the end of orthodontic treatment to determine the effect of DLs on patient satisfaction with treatment. Plain language summary Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment Review question 
 Ugly white or brown marks sometimes appear on the teeth during treatment with braces to straighten teeth. These are due to early tooth decay and usually occur with fixed, glued‐on 'train track', braces, which make it more difficult to clean the teeth. We know that fluoride in toothpaste helps to prevent tooth decay and think that if extra fluoride is given to people wearing fixed braces, it will protect them from getting these marks. The aim of this Cochrane Oral Health's review was to look at how well fluorides help to prevent early tooth decay during fixed brace treatment and to find out the best way to get fluoride to the teeth. Background 
 Wearing a fixed brace makes it harder for people to keep their teeth clean and may also cause pain. Pain can make it more difficult for people to brush their teeth. This can lead to a build‐up of dental plaque around the brackets that attach the fixed brace to the teeth, and if the plaque stays on the tooth for long enough, it will cause early tooth decay, which looks like white or brown marks (demineralised lesions, also known as white spot lesions). People often wear braces for 18 months or longer and if the decay is left to progress, it can cause holes, which are sometimes bad enough to need fillings to be done in the teeth. Fluoride helps the tooth to heal, reducing tooth decay in people who are at risk of developing it. People receiving fixed brace treatment may be given different forms of fluoride treatment. It is important to think about how the fluoride gets to the teeth. Does the fluoride need to be placed by a dentist or dental nurse, or can people having treatment with braces apply the fluoride to their own teeth? Study characteristics 
 This review is up‐to‐date as of 1 February 2019. The review includes 10 studies but we could only use the information from nine studies involving 1798 randomised people. We have asked for more information about one study. The review looks at eight different ways of applying fluoride to the teeth. People taking part in the studies were all having treatment with fixed braces. The number of people with new decay on the teeth at end of fixed brace treatment, as well as the amount of decay in each person, were measured and counted. We compared the following treatments:
 ‐ dentist or nurse‐applied fluoride e.g. varnish, gel or foam,
 ‐ patient‐applied/used fluoride e.g. toothpaste, mouthwash, gel or foam, and
 ‐ materials that release fluoride over time e.g. glues, elastic bands. Key results 
 One study showed that when the dentist applies a foam with a high level of fluoride in it onto the teeth every time the patient is seen, this might reduce the risk of new decay. Another study found that if patients use a toothpaste with a higher level of fluoride than normal, then this might also reduce the risk of new marks on their teeth. No studies have shown that other ways of giving the teeth extra fluoride reduced the number and/or size of new decay on teeth in people wearing fixed braces. Harmful effects of the different ways of giving the teeth more fluoride were not reported in any of the included studies. Certainty of the evidence 
 The level of belief we have in these findings is low, due to the lack of studies testing the same fluorides and showing the same results. We suggest that more, well‐conducted studies should be done in this area.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.097Z" }, { "id": "83ff8125-6320-44d0-885d-1e7b3468c7bb", "pmid": "", "title": "Systemic interventions for recurrent aphthous stomatitis (mouth ulcers)", "imported": false, "abstract": "Abstract - Background Recurrent aphthous stomatitis (RAS) is the most frequent form of oral ulceration, characterised by recurrent oral mucosal ulceration in an otherwise healthy individual. At its worst RAS can cause significant difficulties in eating and drinking. Treatment is primarily aimed at pain relief and the promotion of healing to reduce the duration of the disease or reduce the rate of recurrence. A variety of topical and systemic therapies have been utilised. Objectives To determine the clinical effect of systemic interventions in the reduction of pain associated with RAS, a reduction in episode duration or frequency. Search methods We undertook electronic searches of: Cochrane Oral Health Group and PaPaS Trials Registers (to 6 June 2012); CENTRAL via The Cochrane Library (to Issue 4, 2012); MEDLINE via OVID (1950 to 6 June 2012); EMBASE via OVID (1980 to 6 June 2012); CINAHL via EBSCO (1980 to 6 June 2012); and AMED via PubMed (1950 to 6 June 2012). We searched reference lists from relevant articles and contacted the authors of eligible trials to identify further trials and obtain additional information. Selection criteria We included randomised controlled trials (RCTs) in which the primary outcome measures assess a reduction of pain associated with RAS, a reduction in episode duration or a reduction in episode frequency. Trials were not restricted by outcome alone. We also included RCTs of a cross‐over design. Data collection and analysis Two review authors independently extracted data in duplicate. We contacted trial authors for details of randomisation, blindness and withdrawals. We carried out risk of bias assessment on six domains. We followed The Cochrane Collaboration statistical guidelines and risk ratio (RR) values were to be calculated using fixed‐effect models (if two or three trials in each meta‐analysis) or random‐effects models (if four or more trials in each meta‐analysis). Main results A total of 25 trials were included, 22 of which were placebo controlled and eight made head‐to‐head comparisons (five trials had more than two treatment arms). Twenty‐one different interventions were assessed. The interventions were grouped into two categories: immunomodulatory/anti‐inflammatory and uncertain. Only one study was assessed as being at low risk of bias. There was insufficient evidence to support or refute the use of any intervention. Authors' conclusions No single treatment was found to be effective and therefore the results remain inconclusive in regard to the best systemic intervention for RAS. This is likely to reflect the poor methodological rigour of trials, and lack of studies for certain drugs, rather than the true effect of the intervention. It is also recognised that in clinical practice, individual drugs appear to work for individual patients and so the interventions are likely to be complex in nature. In addition, it is acknowledged that systemic interventions are often reserved for those patients who have been unresponsive to topical treatments, and therefore may represent a select group of patients. Plain language summary Systemic interventions for recurrent aphthous stomatitis (mouth ulcers) Mouth ulcers (sores) are one of the most common oral problems and many people suffer with them repeatedly. These can be painful and slow to heal. At its worst, this can cause significant difficulties in eating and drinking. This review found that many different treatments were used to manage this condition, although the evidence of their effectiveness remains inconclusive.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Brocklehurst, P, Tickle, M, Glenny, AM, Lewis, MA, Pemberton, MN, Taylor, J, Walsh, T, Riley, P, Yates, JM", "articleTypes": [], "doi": "10.1002/14651858.CD005411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.772Z" }, { "id": "84016dc6-a808-45d2-89b6-258d5fe9efe9", "pmid": "", "title": "Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015. Objectives To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate. Selection criteria We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non‐serious, general behaviour, and quality of life. Data collection and analysis Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel‐group trials and first‐period data from cross‐over trials formed the basis of our primary analyses. We undertook separate analyses using end‐of‐last period data from cross‐over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach. Main results We included 212 trials (16,302 participants randomised); 55 parallel‐group trials (8104 participants randomised), and 156 cross‐over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross‐over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male‐female ratio was 3:1. Most trials were carried out in high‐income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias. Primary outcomes: methylphenidate versus placebo or no intervention may improve teacher‐rated ADHD symptoms (standardised mean difference (SMD) −0.74, 95% confidence interval (CI) −0.88 to −0.61; I² = 38%; 21 trials; 1728 participants; very low‐certainty evidence). This corresponds to a mean difference (MD) of −10.58 (95% CI −12.58 to −8.72) on the ADHD Rating Scale (ADHD‐RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD‐RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68). Secondary outcomes: methylphenidate may cause more adverse events considered non‐serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher‐rated general behaviour versus placebo (SMD −0.62, 95% CI −0.91 to −0.33; I² = 68%; 7 trials 792 participants; very low‐certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI −0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low‐certainty evidence). Authors' conclusions The majority of our conclusions from the 2015 version of this review still apply. Our updated meta‐analyses suggest that methylphenidate versus placebo or no‐intervention may improve teacher‐rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non‐serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non‐serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes. Plain language summary Is methylphenidate an effective treatment for children and adolescents with attention deficit hyperactivity disorder (ADHD) and does it cause unwanted effects? Key messages ‐ Methylphenidate might reduce hyperactivity and impulsivity and might help children to concentrate. Methylphenidate might also help to improve general behaviour, but does not seem to affect quality of life. ‐ Methylphenidate does not seem to increase the risk of serious (life‐threatening) unwanted effects when used for periods of up to six months. However, it is associated with an increased risk of non‐serious unwanted effects like sleeping problems and decreased appetite. ‐ Future studies should focus more on reporting unwanted effects and should take place over longer periods of time. What is attention deficit hyperactivity disorder (ADHD)? ADHD is one of the most commonly diagnosed and treated childhood psychiatric disorders. Children with ADHD find it hard to concentrate. They are often hyperactive (fidgety, unable to sit still for long periods) and impulsive (doing things without stopping to think). ADHD can make it difficult for children to do well at school, because they find it hard to follow instructions and to concentrate. Their behavioural problems can interfere with their ability to get on well with family and friends, and they often get into more trouble than other children. How is ADHD treated? Methylphenidate (for example, Ritalin) is the medication most often prescribed to children and adolescents with ADHD. Methylphenidate is a stimulant that helps to increase activity in parts of the brain, such as those involved with concentration. Methylphenidate can be taken as a tablet or given as a skin patch. It can be formulated to have an immediate effect, or be delivered slowly, over a period of hours. Methylphenidate may cause unwanted effects, such as headaches, stomachaches and problems sleeping. It sometimes causes serious unwanted effects like heart problems, hallucinations, or facial 'tics' (twitches). What did we want to find out? We wanted to find out if methylphenidate improves children's ADHD symptoms (attention, hyperactivity) based mainly on teachers' ratings using various scales, and whether it causes serious unwanted effects, like death, hospitalisation, or disability. We were also interested in less serious unwanted effects like sleep problems and loss of appetite, and its effects on children's general behaviour and quality of life. What did we do? We searched for studies that investigated the use of methylphenidate in children and adolescents with ADHD. Participants in the studies had to be aged 18 years or younger and have a diagnosis of ADHD. They could have other disorders or illnesses and be taking other medication or undergoing behavioural treatments. They had to have a normal IQ (intelligence quotient). Studies could compare methylphenidate with placebo (something designed to look and taste the same as methylphenidate but with no active ingredient) or no treatment. Participants had to be randomly chosen to receive methylphenidate or not. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 212 studies with 16,302 children or adolescents with ADHD. Most of the trials compared methylphenidate with placebo. Most studies were small with around 70 children, with an average age of 10 years (ages ranged from 3 to 18 years). Most studies were short, lasting an average of around a month; the shortest study lasted just one day and the longest 425 days. Most studies were in the USA. Based on teachers' ratings, compared with placebo or no treatment, methylphenidate: ‐ may improve ADHD symptoms (21 studies, 1728 children) ‐ may make no difference to serious unwanted effects (26 studies, 3673 participants) ‐ may cause more non‐serious unwanted effects (35 studies, 5342 participants) ‐ may improve general behaviour (7 trials 792 participants) ‐ may not affect quality of life (4 trials, 608 participants) Limitations of the evidence Our confidence in the results of the review is limited for several reasons. It was often possible for people in the studies to know which treatment the children were taking, which could influence the results. The reporting of the results was not complete in many studies and for some outcomes the results varied across studies. Studies were small and they used different scales for measuring symptoms. And most of the studies only lasted for a short period of time, making it impossible to assess the long‐term effects of methylphenidate. Around 41% of studies were funded or partly funded by the pharmaceutical industry. How up to date is this evidence? This is an update of a review conducted in 2015. The evidence is current to March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Storebø, OJ, Storm, MR, Pereira Ribeiro, J, Skoog, M, Groth, C, Callesen, HE, Schaug, JP, Darling, P, Huus, C-ML, Zwi, M, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD009885.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.826Z" }, { "id": "8409f8c3-4d36-4783-b2c0-93f50755253f", "pmid": "", "title": "Outpatient Administration of Teclistamab or Talquetamab for Multiple Myeloma", "imported": false, "abstract": "This is a phase II study to evaluate the outpatient administration of Teclistamab or Talquetamab in Multiple Myeloma patients", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.157Z" }, { "id": "8416cb85-afd1-47fb-bb12-2b33b91918c5", "pmid": "", "title": "Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users", "imported": false, "abstract": "Abstract - Background Prolonged treatment with benzodiazepines is common practice despite clinical recommendations of short‐term use. Benzodiazepines are used by approximately 4% of the general population, with increased prevalence in psychiatric populations and the elderly. After long‐term use it is often difficult to discontinue benzodiazepines due to psychological and physiological dependence. This review investigated if pharmacological interventions can facilitate benzodiazepine tapering. Objectives To assess the benefits and harms of pharmacological interventions to facilitate discontinuation of chronic benzodiazepine use. Search methods We searched the following electronic databases up to October 2017: Cochrane Drugs and Alcohol Group's Specialised Register of Trials, CENTRAL, PubMed, Embase, CINAHL, and ISI Web of Science. We also searched ClinicalTrials.gov, the WHO ICTRP, and ISRCTN registry, and checked the reference lists of included studies for further references to relevant randomised controlled trials. Selection criteria We included randomised controlled trials comparing pharmacological treatment versus placebo or no intervention or versus another pharmacological intervention in adults who had been treated with benzodiazepines for at least two months and/or fulfilled criteria for benzodiazepine dependence (any criteria). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 38 trials (involving 2543 participants), but we could only extract data from 35 trials with 2295 participants. Many different interventions were studied, and no single intervention was assessed in more than four trials. We extracted data on 18 different comparisons. The risk of bias was high in all trials but one. Trial Sequential Analysis showed imprecision for all comparisons. For benzodiazepine discontinuation, we found a potential benefit of valproate at end of intervention (1 study, 27 participants; risk ratio (RR) 2.55, 95% confidence interval (CI) 1.08 to 6.03; very low‐quality evidence) and of tricyclic antidepressants at longest follow���up (1 study, 47 participants; RR 2.20, 95% CI 1.27 to 3.82; low‐quality evidence). We found potentially positive effects on benzodiazepine withdrawal symptoms of pregabalin (1 study, 106 participants; mean difference (MD) ‐3.10 points, 95% CI ‐3.51 to ‐2.69; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐1.00 points, 95% CI ‐1.13 to ‐0.87; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐3.57 points, 95% CI ‐5.34 to ‐1.80; very low‐quality evidence), tricyclic antidepressants (1 study, 38 participants; MD ‐19.78 points, 95% CI ‐20.25 to ‐19.31; very low‐quality evidence), and flumazenil (3 studies, 58 participants; standardised mean difference ‐0.95, 95% CI ‐1.71 to ‐0.19; very low‐quality evidence) at end of intervention. However, the positive effect of paroxetine on benzodiazepine withdrawal symptoms did not persist until longest follow‐up (1 study, 54 participants; MD ‐0.13 points, 95% CI ‐4.03 to 3.77; very low‐quality evidence). The following pharmacological interventions reduced symptoms of anxiety at end of intervention: carbamazepine (1 study, 36 participants; MD ‐6.00 points, 95% CI ‐9.58 to ‐2.42; very low‐quality evidence), pregabalin (1 study, 106 participants; MD ‐4.80 points, 95% CI ‐5.28 to ‐4.32; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐5.70 points, 95% CI ‐6.05 to ‐5.35; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐6.75 points, 95% CI ‐9.64 to ‐3.86; very low‐quality evidence), and flumazenil (1 study, 18 participants; MD ‐1.30 points, 95% CI ‐2.28 to ‐0.32; very low‐quality evidence). Two pharmacological treatments seemed to reduce the proportion of participants that relapsed to benzodiazepine use: valproate (1 study, 27 participants; RR 0.31, 95% CI 0.11 to 0.90; very low‐quality evidence) and cyamemazine (1 study, 124 participants; RR 0.33, 95% CI 0.14 to 0.78; very low‐quality evidence). Alpidem decreased the proportion of participants with benzodiazepine discontinuation (1 study, 25 participants; RR 0.41, 95% CI 0.17 to 0.99; number needed to treat for an additional harmful outcome (NNTH) 2.3 participants; low‐quality evidence) and increased the occurrence of withdrawal syndrome (1 study, 145 participants; RR 4.86, 95% CI 1.12 to 21.14; NNTH 5.9 participants; low‐quality evidence). Likewise, magnesium aspartate decreased the proportion of participants discontinuing benzodiazepines (1 study, 144 participants; RR 0.80, 95% CI 0.66 to 0.96; NNTH 5.8; very low‐quality evidence). Generally, adverse events were insufficiently reported. Specifically, one of the flumazenil trials was discontinued due to severe panic reactions. Authors' conclusions Given the low or very low quality of the evidence for the reported outcomes, and the small number of trials identified with a limited number of participants for each comparison, it is not possible to draw firm conclusions regarding pharmacological interventions to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Due to poor reporting, adverse events could not be reliably assessed across trials. More randomised controlled trials are required with less risk of systematic errors ('bias') and of random errors ('play of chance') and better and full reporting of patient‐centred and long‐term clinical outcomes. Such trials ought to be conducted independently of industry involvement. Plain language summary Medications for discontinuation of long‐term benzodiazepine use Background Benzodiazepines are widely prescribed for long‐term use despite recommendations of only short‐term use. It is often difficult to discontinue benzodiazepines after more than a few weeks of treatment due to the development of physical and psychological dependence. This review aimed to assess the effect and safety of medications to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Search date The evidence is current to October 2017. Study characteristics We identified 38 randomised controlled trials involving 2543 participants who had either been treated for more than two months with benzodiazepines, or who had been diagnosed with benzodiazepine dependence. We included studies irrespective of whether benzodiazepines were prescribed for anxiety, insomnia, or any other condition. The average age of participants was around 50 years, and the majority of participants were women in most studies. Twenty‐four trials were conducted in Europe; eight trials in the US or Canada; and six trials in Asia. The trials involved a wide range of medications to facilitate reduction or discontinuation of benzodiazepine use. Fourteen of the 38 included studies were partly funded by the drug manufacturer; nine studies were funded by government agencies; and 15 studies did not state the source of funding. The duration of the trials ranged between 1 and 24 weeks; the average trial duration was 9 weeks. Key results We extracted data on 18 different comparisons in a total of 2295 participants. We are uncertain whether valproate and tricyclic antidepressants increase the chance of discontinuing benzodiazepines, and whether benzodiazepine withdrawal symptoms are reduced by pregabalin, captodiame, paroxetine, tricyclic antidepressants, and flumazenil, as we assessed the quality of the evidence as very low. We are uncertain as to whether symptoms of anxiety after withdrawal of benzodiazepines are reduced by carbamazepine, pregabalin, captodiame, paroxetine, and flumazenil, as we assessed the quality of the evidence as very low. The effects of the evaluated medications were too uncertain to inform clinical practice due to risk of bias (systematic errors with overestimation of benefits and underestimation of harms) and risk of chance occurrence (random errors giving any result). Tolerability and safety were poorly reported across the included studies, making it impossible to assess the balance between possible benefits and adverse effects. Consequently, no conclusions can be drawn about the effectiveness of the interventions. Quality of the evidence The quality of the evidence was generally low or very low due to the small number of trials including a limited number of participants for each comparison; dissimilar results across studies; poor study design; and pronounced financial involvement of the pharmaceutical industry. Randomised controlled trials are therefore needed without risk of bias and random significant results involving long‐term assessments of participants conducted without involvement of industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Baandrup, L; Ebdrup, BH; Rasmussen, JØ; Lindschou, J; Gluud, C; Glenthøj, BY", "articleTypes": [], "doi": "10.1002/14651858.CD011481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "841ca9bb-2255-41ad-92ed-0393b9c6e653", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background The anti‐inflammatory effects of n‐3 (omega‐3 fatty acids, fish oil) have been suggested to be beneficial in chronic inflammatory disorders such as inflammatory bowel disease. This review is an update of a previously published Cochrane review. Objectives To systematically review the efficacy and safety of n‐3 for maintenance of remission in Crohn's disease (CD). Search methods The following databases were searched from inception to November 2013 without language restriction: CENTRAL, MEDLINE, EMBASE, HealthSTAR, PubMed, and ACP journal club. Selection criteria Randomized placebo‐controlled trials (RCT) of n‐3 for maintenance of remission in CD were included. Studies must have enrolled patients of any age group, who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil or n‐3 given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. Data collection and analysis The primary outcome was the relapse rate and secondary outcomes included change in disease activity scores, time to first relapse and adverse events. Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality using the Cochrane risk of bias tool. The overall quality of the evidence supporting the primary and selected secondary outcomes was reassessed for the current update using the GRADE system. We used the RevMan software for analyses. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the hazard ratio and 95% CI for time‐to‐event outcomes. Random‐effects or fixed‐effect models were used according to degree of heterogeneity and sensitivity analyses were performed in an attempt to explore possible sources of heterogeneity. Main results Six studies with a total of 1039 patients were eligible for inclusion. The two largest studies were rated as low risk of bias for all assessed items. Four studies were rated as unclear risk of bias for randomization and allocation concealment. Two studies were rated as high risk of bias for incomplete outcome data and selective reporting. There was a marginal significant benefit of n‐3 therapy for maintenance of remission. Thirty‐nine per cent of patients in the n‐3 group relapsed at 12 months compared to 47% of placebo patients (6 studies, 1039 patients; RR 0.77, 95% CI 0.61 to 0.98). A GRADE analysis rated the overall quality of the evidence for the primary outcome (i.e. relapse) as very low due to unexplained heterogeneity (I 2 = 58%), publication bias, and a high or unknown risk of bias in four studies in the pooled analysis. When two large studies at low risk of bias were considered the benefit was no longer statistically significant. Thirty‐seven per cent of patients in the n‐3 group relapsed at 12 months compared to 42% of placebo patients (2 studies, 738 patients; RR 0.88, 95% CI 0.74 to 1.05). No significant heterogeneity was identified for this pooled analysis ( I 2 = 0%). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was moderate due to sparse data (294 events). No serious adverse events were recorded in any of the studies but in a pooled analyses there was a significantly higher rate of diarrhea (4 studies, 862 patients; RR 1.36 95% CI 1.01 to 1.84) and upper gastrointestinal tract symptoms (5 studies, 999 patients; RR 1.65, 95% CI 1.25 to 2.18) in the n‐3 treatment group. Authors' conclusions Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms. Plain language summary Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of Crohn's disease patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of capsules containing omega‐3 fatty acids to maintain remission in Crohn's disease were reviewed. Six studies including 1039 patients were included in the review. A pooled analysis of six studies suggests a marginal benefit for omega 3 fatty acids over placebo (i.e. fake medicine) in preventing relapse of disease at one year. However, these results need to be interpreted with caution due to differences across the studies in terms of induction of remission regimens (e.g. surgical remission versus drug therapy) patients (e.g. adult versus pediatric patients) and medication regimens (e.g. some studies used different placebos), the possibility of publication bias (i.e. only studies with positive results are published) and low methodological quality in four studies in the pooled analysis. When the two largest and highest quality studies were pooled the results showed no benefit to omega‐3 treatment over placebo. There were no serious side effects in any of the studies. Common side effects included unpleasant taste, bad breath, heartburn, nausea and diarrhea. Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Lev‐Tzion, R, Griffiths, AM, Ledder, O, Turner, D", "articleTypes": [], "doi": "10.1002/14651858.CD006320.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.745Z" }, { "id": "843d2d29-49ef-4264-8475-8a508c5b64bf", "pmid": "", "title": "Systemic corticosteroids for acute otitis media in children", "imported": false, "abstract": "Abstract - Background Acute otitis media (AOM) is a common acute infection in children. Pain is its most prominent and distressing symptom. Antibiotics are commonly prescribed for AOM, although they have only a modest effect in reducing pain at two to three days. There is insufficient evidence for benefits of other treatment options, including systemic corticosteroids. However, systemic corticosteroids are potent anti‐inflammatory drugs, and so theoretically could be effective, either alone or as an addition to antibiotics. Objectives To assess the effects of systemic corticosteroids (oral or parenteral), with or without antibiotics, for AOM in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) which contains the Cochrane ARI Group's Specialised Register, MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), Web of Science (Thomson Reuters), and LILACS (BIREME) for published studies, and ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for completed and ongoing studies, to 20 February 2018. We checked the reference lists of all primary studies and review articles for additional references and contacted experts in the field to identify additional unpublished materials. Selection criteria We included randomised controlled trials of children with AOM that compared any systemic corticosteroid (oral or parenteral) with placebo, either with antibiotics (corticosteroid plus antibiotic versus placebo plus antibiotic) or without antibiotics (corticosteroid versus placebo). Data collection and analysis Three review authors (EDS, RR, YP) independently screened the titles and abstracts and retrieved the full texts of potentially relevant studies. We independently extracted study characteristics and outcome data from the included studies, and assessed the risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed study quality using the GRADE method. Main results We included two studies involving 252 children with AOM aged from three months to six years receiving hospital ambulatory care who were treated with intramuscular ceftriaxone, and who were then randomised to the corticosteroid group (corticosteroid and corticosteroid plus antihistamine) or the placebo group (antihistamine and double placebo). In one study, children also had a needle aspiration of middle ear fluid. Both studies were at unclear risk of bias for allocation concealment, and unclear to high risk of bias for selective reporting. One study (N = 179) included pain as an outcome, but we were unable to derive the proportion of children with persistent pain at Day 5 and Day 14. Reduction of overall or specific symptoms was presented as improvement in clinical symptoms and resolution of inflamed tympanic membranes without the need for additional antibiotic treatment: at Day 5 (94% of children in the treatment group (N = 89) versus 89% in the placebo group (N = 90); risk ratio (RR) 1.06, 95% confidence interval (CI) 0.97 to 1.16) and Day 14 (91% versus 87%; RR 1.05, 95% CI 0.95 to 1.17). Low‐quality evidence meant that we are uncertain of the effectiveness of corticosteroids for this outcome. The second study (N = 73) reported a reduction of overall or specific symptoms without additional antibiotic treatment during the first two weeks as a favourable outcome. Children in the treatment group had more favourable outcomes (adjusted odds ratio 65.9, 95% CI 1.28 to 1000; P = 0.037), although the numbers were small. We were unable to pool the results with the other study because it did not report the proportion of children with this outcome by treatment group. Only one study reported adverse effects of corticosteroids (e.g. drowsiness, nappy rash), but did not quantify incidence, so we were unable to draw conclusions about adverse effects. Neither study reported a reduction in overall or specific symptom duration. Authors' conclusions The evidence for the effect of systemic corticosteroids on AOM is of low to very low quality, meaning the effect of systemic corticosteroids on important clinical outcomes in AOM remains uncertain. Large, high‐quality studies are required to resolve the question . Plain language summary Systemic corticosteroids for improving symptoms in children with acute middle ear infection Review question We reviewed the evidence on the effects of corticosteroids given by mouth or injection for acute middle ear infection (acute otitis media (AOM)) in children, particularly in improving symptoms such as ear pain, fever, irritability, lack of sleep, and lack of appetite. We also looked at the side effects of corticosteroids. Background Acute otitis media is common in children and causes ear pain and non‐specific symptoms such as fever, irritability, and deafness. It is often treated with antibiotics, although ear pain generally resolves within two days, and antibiotics help symptoms only slightly. Other treatments (such as over‐the‐counter antihistamines and decongestants) do not help very much. Corticosteroids are often prescribed to reduce inflammation in children for other illnesses, and so may also help symptoms of AOM, which is an inflammatory process. We investigated whether using corticosteroids was better or worse than nothing in improving AOM‐related symptoms. Search date Our evidence is current to 20 February 2018. Study characteristics We included two studies involving 252 children with AOM, aged from three months to six years, receiving hospital ambulatory care. Children were treated with an antibiotic injection and either oral corticosteroid or a placebo (treatment with no effect). In one study, fluid from the middle ear was collected by inserting a needle through the eardrum to measure the level of inflammation. Study funding sources The National Institutes of Health (NIH) and the National Center for Research Resources, NIH, US Public Health Service funded both studies. Pharmaceutical companies provided the drug but did not contribute any other scientific or financial support. Key results and quality of evidence Corticosteroids did not make a significant difference in improving the symptoms and inflammation of the eardrum(s) at Day 5 and Day 14, but we are unsure of this effect due to the small numbers of children in the studies. There were no significant differences between the corticosteroid and placebo groups in terms of resolving fluid in children's middle ears (at 1, 2, and 3 months) and experiencing new episodes of AOM (at 1, 2, 3 months, and 4 and 6 months). Neither study reported a reduction in the duration of overall or specific symptoms, rupture of eardrum(s), the occurrence of middle ear inflammation in the other ear following the current ear infection, or serious complications. Only one study reported the overall side effects identified during the trial (e.g. drowsiness, dry mouth, diaper rash, nervousness). We could not draw any conclusions regarding the effects of corticosteroids for AOM in children. The quality of evidence included in this review was low to very low due to few children included in two small studies. We are uncertain about whether or not corticosteroids are useful in relieving pain from AOM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ranakusuma, RW, Pitoyo, Y, Safitri, ED, Thorning, S, Beller, EM, Sastroasmoro, S, Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD012289.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.090Z" }, { "id": "8446bc78-fc89-4b79-9135-cc80a651e71e", "pmid": "", "title": "Melatonin in cancer treatment", "imported": false, "abstract": "Abstract - Rationale Preserving health‐related quality of life is an aspect of care that requires constant attention from the time of cancer diagnosis. Melatonin has been used to diminish treatment‐related side effects and cancer symptoms, and as a medication to regulate circadian rhythm. An up‐to‐date systematic review is needed to investigate the current evidence concerning possible beneficial effects of melatonin on quality of life and sleep in cancer patients. Objectives To evaluate the benefits and harms of melatonin for preserving health‐related quality of life and sleep in cancer patients. Search methods To identify studies for inclusion in this review, we used CENTRAL, MEDLINE, 10 other databases, and four trial registers, together with reference checking, citation searching, and contact with study authors. The latest search date was 10 September 2024. Eligibility criteria We included randomised controlled trials (RCTs) of adults (18 years or over) with histologically proven cancer of any stage that evaluated melatonin (alone or in combination with standard anticancer treatment) versus no treatment or placebo (alone or in combination with standard anticancer treatment), or standard anticancer treatment. Standard anticancer treatment refers to treatments to stop or prevent cancer, including chemotherapy, radiation therapy, surgery, immunotherapy, and hormonal therapies (such as androgen deprivation therapy). Outcomes The primary outcomes of interest were quality of life and sleep quality within three months, and melatonin‐related adverse events. Other outcomes included survival, disease‐free survival, progression‐free survival, tumour response, and anticancer treatment‐related harms. Risk of bias We used Cochrane's risk of bias tool (RoB 1) to assess the risk of bias in the studies included in the review. Synthesis methods We synthesised results for each outcome using random‐effects meta‐analysis. The effect size was presented as risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CI). If this was not possible, due to the nature of the data, we synthesised results in a narrative format. We used GRADE to assess the certainty of evidence for each outcome. Included studies We identified 30 RCTs (reported in 49 publications) involving 5093 adult participants with cancer (2470 males, 2228 females, 395 not reported). Studies were conducted in a hospital setting and took place in at least 10 countries. We assessed two studies at low risk of bias and the other 28 at high risk of bias. Synthesis of results Melatonin plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life score (MD 2.60, 95% CI −14.53 to 19.73; 1 study, 126 participants; very low certainty evidence), and sleep score (MD 2.80, 95% CI 0.18 to 5.42; 1 study, 50 participants; very low certainty evidence) within three months. We are also very uncertain about potential adverse effects of melatonin: headache (RR 2.77, 95% CI 0.33 to 23.14; 1 study, 25 participants; very low certainty evidence); fatigue (RR 1.02, 95% CI 0.90 to 1.17; 2 studies, 170 participants; very low certainty evidence); and nausea (RR 1.01, 95% CI 0.66 to 1.56; 1 study, 146 participants; very low certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of high risk of bias, small sample size, the width of the 95% confidence interval, and indirectness due to inadequate reporting of cancer type. Melatonin plus standard treatment versus standard treatment No data are available relating to quality of life and sleep within three months. The evidence is very uncertain about headaches (experienced by 15 of 820 participants in melatonin groups, with no data available for control groups; 2 studies, 1640 participants; very low certainty evidence). Melatonin likely reduces the incidence of fatigue (RR 0.46, 95% CI 0.39 to 0.55; 10 studies, 1359 participants; moderate‐certainty evidence) and may reduce nausea (RR 0.85, 95% CI 0.72 to 1.00; 6 studies, 710 participants; low‐certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of the high risk of bias and the width of the 95% confidence interval. Melatonin (topical use) plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life (one study reported no difference between groups, both having the same median score of 66.7; 48 participants; very low certainty evidence). No data are available relating to sleep and adverse events (including headache, dizziness, fatigue, and nausea). We downgraded the certainty of the evidence because of the high risk of bias, small sample size, and insufficient data. Authors' conclusions The available evidence is of very low certainty, so we are unable to draw conclusions about the effects of melatonin on quality of life and sleep at three months in people receiving treatment for cancer. There may be no difference in adverse events between melatonin plus standard treatment and placebo plus standard treatment, but the evidence is very uncertain. Data were lacking for some outcomes, such as dizziness. Melatonin used alongside standard treatment probably reduces the risk of fatigue and may reduce nausea when compared to standard treatment alone. Since the evidence base for melatonin in people with cancer is limited due to insufficient data and risks of bias in study design, the decision for or against using melatonin as an adjunct to cancer treatment cannot easily be made at the current time. Funding This Cochrane Review was partially funded by AG Biologische Krebstherapie, Deutsche Krebshilfe (grant numbers 70‐301 and 109863). The funding agency had no role in the design or conduct of the study. Registration The protocol for this review is available via DOI 10.1002/14651858.CD010145. Plain language summary For cancer patients, what are the benefits and risks of taking the hormone melatonin? Key messages Due to a lack of robust evidence, the effects of melatonin on quality of life and sleep quality in people receiving treatment for cancer are unclear. Melatonin might not increase the risk of adverse events, but the available evidence is not strong enough for us to be certain. Well designed studies using melatonin over a period of up to three months are needed to give better estimates of the benefits and risks. What is melatonin? Melatonin is a hormone produced in the body to regulate the daily sleep and wakefulness cycle. It has been suggested that melatonin may improve sleep quality and quality of life, which are very important in cancer treatment. Moreover, there is research suggesting that melatonin is effective against solid tumours and may be effective for the treatment of cancer. What did we want to find out? We wanted to find out if melatonin can be used in cancer treatment, particularly for preserving the quality of life and sleep quality of cancer patients. We also wanted to find out if melatonin causes any unwanted side effects ('adverse events'). What did we do? We searched for studies that looked at melatonin used with other standard cancer treatments compared with standard cancer treatments used alone or with placebo (fake treatment). What did we find? We found 30 studies that involved 5093 cancer patients, both men and women, with cancer of any type. The studies were conducted in 10 countries around the world. We focused on the effects of melatonin over a period of three months. When compared to placebo plus standard cancer treatments, it is unclear if melatonin has an effect on quality of life and sleep. Melatonin may have little to no effect on potential adverse events like headache, fatigue, and nausea, but we are very uncertain about these results. No results are available for dizziness. We found no studies to help us answer our questions about quality of life and sleep quality when melatonin is used with standard cancer treatments compared to the standard treatment alone. However, the studies did evaluate potential adverse events that might be related to melatonin, and they found that melatonin probably reduces the risk of tiredness (fatigue), and may reduce the risk of feeling sick (nausea). It is unclear if melatonin has an effect on headaches. No results are available for dizziness. When melatonin is used topically, such as in a cream to put on the skin or in a mouth wash, it is unclear if it has an effect on quality of life. We found no studies to help us answer our questions about sleep quality. No data are available for adverse events like headache, fatigue, nausea, and dizziness, as these are not relevant if the melatonin is used topically. It is unclear if melatonin has any other unwanted effects when used topically. What are the limitations of the evidence? We are not confident in the evidence because it is possible that people in the studies were aware of which treatment they were getting. The evidence relating to some benefits and risks we are interested in does not cover all cancer types, or it is based on only a few cases. How up to date is this evidence? The evidence is up‐to‐date to September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Yu, ZY, Peng, RY, Cheng, N, Wang, RT, Nan, MD, Milazzo, S, Pilkington, K, Seely, D, Horneber, M, Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010145.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.091Z" }, { "id": "84497616-cc15-4212-bb07-9fff13abcf62", "pmid": "", "title": "Chlorhexidine treatment for the prevention of dental caries in children and adolescents", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) is a common disease that is preventable by reducing the dietary intake of free sugars and using topical sodium fluoride products. An antibacterial agent known as chlorhexidine may also help prevent caries. A number of over‐the‐counter and professionally administered chlorhexidine‐based preparations are available in a variety of formulations and in a range of strengths. Although previous reviews have concluded that some formulations of chlorhexidine may be effective in inhibiting the progression of established caries in children, there is currently a lack of evidence to either claim or refute a benefit for its use in preventing dental caries. Objectives To assess the effects of chlorhexidine‐containing oral products (toothpastes, mouthrinses, varnishes, gels, gums and sprays) on the prevention of dental caries in children and adolescents. Search methods We searched the Cochrane Oral Health Group Trials Register (25 February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 12), MEDLINE via OVID (1946 to 25 February 2015), EMBASE via OVID (1980 to 25 February 2015) and CINAHL via EBSCO (1937 to 25 February 2015). We handsearched several journals placed no language restrictions on our search. After duplicate citations were removed, the electronic searches retrieved 1075 references to studies. Selection criteria We included parallel‐group, randomised controlled trials (RCTs) that compared the caries preventive effects of chlorhexidine gels, toothpastes, varnishes, mouthrinses, chewing gums or sprays with each other, placebo or no intervention in children and adolescents. We excluded trials with combined interventions of chlorhexidine and fluoride or comparisons between chlorhexidine and fluoride interventions. Data collection and analysis Two review authors independently extracted trial data and assessed risk of bias. We resolved disagreements by consensus. We contacted trial authors for clarification or additional study details when necessary. The number of included studies that were suitable for meta‐analysis was limited due to the clinical diversity of the included studies with respect to age, composition of intervention, and variation in outcome measures and follow‐up. Where we were unable to conduct meta‐analysis, we elected to present a narrative synthesis of the results. Main results We included eight RCTs that evaluated the effects of chlorhexidine varnishes (1%, 10% or 40% concentration) and chlorhexidine gel (0.12%) on the primary or permanent teeth, or both, of children from birth to 15 years of age at the start of the study. The studies randomised a total of 2876 participants, of whom 2276 (79%) were evaluated. We assessed six studies as being at high risk of bias overall and two studies as being at unclear risk of bias overall. Follow‐up assessment ranged from 6 to 36 months. Six trials compared chlorhexidine varnish with placebo or no treatment. It was possible to pool the data from two trials in the permanent dentition (one study using 10% chlorhexidine and the other, 40%). This led to an increase in the DMFS increment in the varnish group of 0.53 (95% confidence interval (CI) ‐0.47 to 1.53; two trials, 690 participants; very low quality evidence). Only one trial (10% concentration chlorhexidine varnish) provided usable data for elevated mutans streptococci levels > 4 with RR 0.93 (95% CI 0.80 to 1.07, 496 participants; very low quality evidence). One trial measured adverse effects (for example, ulcers or tooth staining) and reported that there were none; another trial reported that no side effects of the treatment were noted. No trials reported on pain, quality of life, patient satisfaction or costs. Two trials compared chlorhexidine gel (0.12% concentration) with no treatment in the primary dentition. The presence of new caries gave rise to a 95% confidence interval that was compatible with either an increase or a decrease in caries incidence (RR 1.00, 95% CI 0.36 to 2.77; 487 participants; very low quality evidence). Similarly, data for the effects of chlorhexidine gel on the prevalence of mutans streptococci were inconclusive (RR 1.26, 95% CI 0.95 to 1.66; two trials, 490 participants; very low quality evidence). Both trials measured adverse effects and did not observe any. Neither of these trials reported on the other secondary outcomes such as measures of pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Authors' conclusions We found little evidence from the eight trials on varnishes and gels included in this review to either support or refute the assertion that chlorhexidine is more effective than placebo or no treatment in the prevention of caries or the reduction of mutans streptococci levels in children and adolescents. There were no trials on other products containing chlorhexidine such as sprays, toothpastes, chewing gums or mouthrinses. Further high quality research is required, in particular evaluating the effects on both the primary and permanent dentition and using other chlorhexidine‐containing oral products. Plain language summary Antiseptic treatment (chlorhexidine) to prevent tooth decay in children and young people Review question This review examined the effectiveness of varnishes and gels containing chlorhexidine in preventing tooth decay in children and young people. Background Tooth decay is a very common disease that over time destroys the tooth surface. It has been estimated to affect up to 80% of people in high‐income countries and, despite being preventable through oral hygiene and dietary measures and the use of agents such as fluoride that reduce risk of decay, it is likely to remain a problem, especially in low‐income countries. Tooth decay can result in pain and infection, and in young children may require treatment in hospital under a general anaesthetic. As well as causing anxiety and pain, this may mean the child or young person missing time at school and their parents or carers having to take time off work, possibly losing income and incurring extra costs. Prevention of tooth decay is simpler and possibly cheaper than waiting until it occurs and then requires extensive treatment. Tooth decay is largely preventable, and a range of things may assist this: twice‐daily toothbrushing with a fluoride toothpaste, reducing both the amount of and number of times per day sugar is eaten, and drinking water that contains fluoride (bottled or tap, depending on where you live). Tooth decay occurs when certain types of bacteria (germs) in the mouth, such as Streptococcus mutans, produce acids from the sugar we eat, which dissolve the hard enamel coating on our teeth. The chemical antiseptic treatment chlorhexidine is highly successful at destroying these bacteria and can be used safely at home in the form of a gel, spray, chewing gum, toothpaste or mouthrinse. Alternatively, chlorhexidine can be applied as a varnish to the surface of teeth by a dentist. Study characteristics The evidence in this review, carried out through the Cochrane Oral Health Group, is up‐to‐date at 25 February 2015. We found eight studies that were suitable to include in this review. The studies involved a total of 2876 children from birth to 15 years of age who were at moderate to high risk of tooth decay. Six of the studies looked at the effects of dental professionals applying different strengths of chlorhexidine varnishes to the baby teeth, permanent teeth or both types of teeth in children and adolescents. The other two studies looked at the effects of parents placing chlorhexidine gel on their children's baby teeth. There were no studies that examined other products containing chlorhexidine, such as sprays, toothpastes, chewing gums or mouthrinses. Key results The results did not provide evidence that chlorhexidine varnish or gel reduces tooth decay or reduces the bacteria that encourage tooth decay. The studies did not evaluate other outcomes such as pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Four studies measured side effects and found none were observed. Quality of the evidence Due to the lack of suitable studies and concerns about possible bias in the included studies, the evidence is very low quality. As a result, we are not able to conclude whether or not chlorhexidine is effective in preventing tooth decay in children or adolescents, when compared to placebo (an inactive substitute for chlorhexidine) or no treatment. Future research on the use of chlorhexidine to prevent tooth decay is needed and should consider both primary and permanent teeth and should assess other chlorhexidine‐containing products that can be used at home, such as toothpastes or mouthrinses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Walsh, T, Oliveira‐Neto, JM, Moore, D", "articleTypes": [], "doi": "10.1002/14651858.CD008457.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.768Z" }, { "id": "84551afe-e614-4e48-a78b-d8b6e9ba183d", "pmid": "", "title": "Chinese herbal medicine for primary dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Conventional treatment for primary dysmenorrhoea has a failure rate of 20% to 25% and may be contraindicated or not tolerated by some women. Chinese herbal medicine may be a suitable alternative. Objectives To determine the efficacy and safety of Chinese herbal medicine for primary dysmenorrhoea when compared with placebo, no treatment, and other treatment. Search methods The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007), EMBASE (1980 to January 2007), CINAHL (1982 to January 2007), AMED (1985 to January 2007), CENTRAL (The Cochrane Library issue 4, 2006), China National Knowledge Infrastructure (CNKI, 1990 to January 2007), Traditional Chinese Medicine Database System (TCMDS, 1990 to December 2006), and the Chinese BioMedicine Database (CBM, 1990 to December 2006) were searched. Citation lists of included trials were also reviewed. Selection criteria Any randomised controlled trials involving Chinese herbal medicine versus placebo, no treatment, conventional therapy, heat compression, another type of Chinese herbal medicine, acupuncture or massage. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra‐uterine contraceptive device. Data collection and analysis Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Data were combined for meta‐analysis using either Peto odds ratios or relative risk (RR) for dichotomous data or weighted mean difference for continuous data. A fixed‐effect statistical model was used, where suitable. If data were not suitable for meta‐analysis, any available data from the trial were extracted and presented as descriptive data. Main results Thirty‐nine randomised controlled trials involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for Chinese herbal medicine compared to placebo were unclear as data could not be combined (3 RCTs). Chinese herbal medicine resulted in significant improvements in pain relief (14 RCTs; RR 1.99, 95% CI 1.52 to 2.60), overall symptoms (6 RCTs; RR 2.17, 95% CI 1.73 to 2.73) and use of additional medication (2 RCTs; RR 1.58, 95% CI 1.30 to 1.93) when compared to use of pharmaceutical drugs. Self‐designed Chinese herbal formulae resulted in significant improvements in pain relief (18 RCTs; RR 2.06, 95% CI 1.80 to 2.36), overall symptoms (14 RCTs; RR 1.99, 95% CI 1.65 to 2.40) and use of additional medication (5 RCTs; RR 1.58, 95% CI 1.34 to 1.87) after up to three months of follow‐up when compared to commonly used Chinese herbal health products. Chinese herbal medicine also resulted in better pain relief than acupuncture (2 RCTs; RR 1.75, 95% CI 1.09 to 2.82) and heat compression (1 RCT; RR 2.08, 95% CI 2.06 to 499.18). Authors' conclusions The review found promising evidence supporting the use of Chinese herbal medicine for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials. Plain language summary Chinese herbal medicine may help reduce menstrual pain. Dysmenorrhoea is a very common complaint that refers to painful menstrual cramps in abdomen. Primary dysmenorrhoea refers to pain of an unknown cause (i.e. no medical condition is identified). Nonsteroidal anti‐inflammatory drugs or the contraceptive pill have been used successfully for treatment but more women are looking for non‐drug therapies. Chinese herbal medicine has been used for centuries in China and it is currently used in public hospitals in China for the treatment of primary dysmenorrhoea. The review found promising evidence for the use of Chinese herbal medicine in reducing menstrual pain in the treatment of primary dysmenorrhoea, compared to conventional medicine such as NSAIDs and the oral contraceptive pill, acupuncture and heat compression. No significant adverse effects were identified in this review. However the findings should be interpreted with caution due to the generally low methodological quality of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Zhu, X; Proctor, M; Bensoussan, A; Wu, E; Smith, CA", "articleTypes": [], "doi": "10.1002/14651858.CD005288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "845b059d-3d69-4a1a-82e9-b71ff015248e", "pmid": "", "title": "Vitamin D supplementation for chronic liver diseases in adults", "imported": false, "abstract": "Abstract - Background Vitamin D deficiency is often reported in people with chronic liver diseases. Improving vitamin D status could therefore be beneficial for people with chronic liver diseases. Objectives To assess the beneficial and harmful effects of vitamin D supplementation in adults with chronic liver diseases. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index‐Science. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We scanned bibliographies of relevant publications and enquired experts and pharmaceutical companies as to additional trials. All searches were up to November 2020. Selection criteria Randomised clinical trials that compared vitamin D at any dose, duration, and route of administration versus placebo or no intervention in adults with chronic liver diseases. Vitamin D could have been administered as supplemental vitamin D (vitamin D 3 (cholecalciferol) or vitamin D 2 (ergocalciferol)), or an active form of vitamin D (1α‐hydroxyvitamin D (alfacalcidol), 25‐hydroxyvitamin D (calcidiol), or 1,25‐dihydroxyvitamin D (calcitriol)). Data collection and analysis We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of evidence. Main results We included 27 randomised clinical trials with 1979 adult participants. This review update added 12 trials with 945 participants. We assessed all trials at high risk of bias. All trials had a parallel‐group design. Eleven trials were conducted in high‐income countries and 16 trials in middle‐income countries. Ten trials included participants with chronic hepatitis C, five trials participants with liver cirrhosis, 11 trials participants with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. All of the included trials reported the baseline vitamin D status of participants. Participants in nine trials had baseline serum 25‐hydroxyvitamin D levels at or above vitamin D adequacy (20 ng/mL), whilst participants in the remaining 18 trials were vitamin D insufficient (less than 20 ng/mL). Twenty‐four trials administered vitamin D orally, two trials intramuscularly, and one trial intramuscularly and orally. In all 27 trials, the mean duration of vitamin D supplementation was 6 months, and the mean follow‐up of participants from randomisation was 7 months. Twenty trials (1592 participants; 44% women; mean age 48 years) tested vitamin D 3 (cholecalciferol); three trials (156 participants; 28% women; mean age 54 years) tested vitamin D 2 ; four trials (291 participants; 60% women; mean age 52 years) tested 1,25‐dihydroxyvitamin D; and one trial (18 participants; 0% women; mean age 52 years) tested 25‐hydroxyvitamin D. One trial did not report the form of vitamin D. Twelve trials used a placebo, whilst the other 15 trials used no intervention in the control group. Fourteen trials appeared to be free of vested interest. Eleven trials did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on all‐cause mortality (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.51 to 1.45; 27 trials; 1979 participants). The mean follow‐up was 7 months (range 1 to 18 months). We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on liver‐related mortality (RR 1.62, 95% CI 0.08 to 34.66; 1 trial; 18 participants) (follow‐up: 12 months); serious adverse events such as hypercalcaemia (RR 5.00, 95% CI 0.25 to 100.8; 1 trial; 76 participants); myocardial infarction (RR 0.75, 95% CI 0.08 to 6.81; 2 trials; 86 participants); thyroiditis (RR 0.33, 95% CI 0.01 to 7.91; 1 trial; 68 participants); circular haemorrhoidal prolapse (RR 3.00, 95% CI 0.14 to 65.9; 1 trial; 20 participants); bronchopneumonia (RR 0.33, 95% CI 0.02 to 7.32; 1 trial 20 participants); and non‐serious adverse events. The certainty of evidence for all outcomes is very low. We found no data on liver‐related morbidity such as gastrointestinal bleeding, hepatic encephalopathy, hepatorenal syndrome, ascites, or liver cancer. There were also no data on health‐related quality of life. The evidence is also very uncertain regarding the effect of vitamin D versus placebo or no intervention on rapid, early, and sustained virological response in people with chronic hepatitis C. Authors' conclusions Given the high risk of bias and insufficient power of the included trials and the very low certainty of the available evidence, vitamin D supplementation versus placebo or no intervention may increase or reduce all‐cause mortality, liver‐related mortality, serious adverse events, or non‐serious adverse events in adults with chronic liver diseases. There is a lack of data on liver‐related morbidity and health‐related quality of life. Further evidence on clinically important outcomes analysed in this review is needed. Plain language summary Vitamin D supplementation for chronic liver diseases Review question Is vitamin D supplementation beneficial or harmful for adults with chronic liver diseases? Background The available evidence on vitamin D and chronic liver diseases in adults is inconclusive. The aim of this systematic review (a summary of results of available healthcare trials) was to analyse the benefits and harms of the different forms of vitamin D in people with chronic liver diseases. Study characteristics Twenty‐seven trials with 1979 adult participants provided data for this review. This review update added 12 trials with 945 participants. The 1979 trial participants were randomly assigned to vitamin D compared with placebo (dummy pill) or no treatment. Eleven trials were conducted in high‐income countries, and 16 trials in middle‐income countries. The age range of the participants was 28 years to 61 years, and on average 44% were women. Ten trials included people with chronic hepatitis C, five trials people with liver cirrhosis, 11 trials people with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. There were no trials including people with chronic hepatitis B or inherited liver diseases. All of the included trials reported the baseline vitamin D status of participants. Vitamin D administration lasted on average six months, and most trials used the cholecalciferol (vitamin D 3 ) form. Funding Fourteen trials appeared to be free of vested interest that could bias the trial results. Eleven trials may not have been free of vested interest, as they did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We found no difference between trials without industry support compared to trials at risk of industry support in our analysis. Key results There is not enough evidence to determine whether vitamin D has beneficial or harmful effects, or has little to no effect on chronic liver diseases in adults. There were too few participants in the individual trials as well as in our evidence synthesis. The trials were at high risk of bias so we lack fair assessments of the benefits and harms of vitamin D in this population. Neither benefits nor harms of vitamin D supplementation in people with chronic liver diseases can be excluded. There were no trials including people with chronic hepatitis B and inherited liver diseases. Quality of the evidence We judged all trials to be at high risk of bias (that is an underestimation or overestimation of the true intervention effect). The certainty of evidence is very low. Currentness of evidence The evidence is current to November 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Bjelakovic, M; Nikolova, D; Bjelakovic, G; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD011564.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "847c4100-bef1-4121-b498-9c54265cd0c3", "pmid": "", "title": "Topical anaesthetics for pain control during repair of dermal laceration", "imported": false, "abstract": "Abstract - Background Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine‐free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017. Objectives To assess whether benefits of non‐invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single‐component or multi‐component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine. Search methods For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta‐registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010. Selection criteria We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence. Main results The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self‐reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine‐phenylephrine (PP) was higher than the mean self‐reported VAS (0 to 100 mm) score for topical tetracaine‐epinephrine‐cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine‐free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self‐limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine‐based or cocaine‐free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Authors' conclusions We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously. Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non‐invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine‐based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Plain language summary Local anaesthesia (numbing medicine) that is directly applied to the skin can provide pain control for repair of skin lacerations Background : Pain control during suturing of torn skin is generally achieved by injecting medication into the skin (infiltration) to numb the area. This injection itself may cause pain, but topical anaesthetics are applied directly to the skin and are painless to administer. Cocaine was one of the first anaesthetics to be successfully applied topically. Concerns over adverse effects of cocaine, its potential misuse and the administrative burden of dispensing a controlled substance led to the development of cocaine‐free topical anaesthetics. Multiple cocaine‐free topical anaesthetics have been found to provide effective anaesthesia for repair of dermal lacerations. Study characteristics : The evidence is current to December 2016. We included in this review 25 randomized controlled trials involving 3278 participants. Studies included both adults and children. Fifteen of the included trials used self‐reporting of pain intensity by trial participants to determine the effectiveness of local anaesthetics. Key results : Study results suggest that directly applying local anaesthetics to the skin is an effective, non‐invasive way of providing pain control during suturing or stapling of skin lacerations. Study findings on the efficacy of individual topical anaesthetics were limited by study design, and data on the efficacy of each topical agent were obtained mostly from single trials. Researchers reported no serious side effects following the use of cocaine‐containing or cocaine‐free topical anaesthetics. The overall broadly comparable effectiveness of cocaine‐free topical anaesthetics for skin laceration repair brings into question the necessity to include cocaine as a component of local anaesthetic solutions. The small number of trials in each comparison group and the range of outcome measures assessed prevented pooling and quantitative analysis of data for all but the single outcome of pain intensity. Additional studies are necessary to directly compare the effectiveness of different formulations of topical anaesthetics. Our review was limited to pain control for repair of superficial lacerations, and our results might not be generalizable to deeper lacerations or more complex procedures performed on intact skin. Further research is needed to strengthen the evidence and to overcome the weakness of the included studies. Quality of the evidence : The overall quality of the evidence was low owing to limitations in study design, ways that studies were carried out (implementation), imprecision of results and high probability of selective data reporting. Most of the trials that compared infiltrated and topical anaesthetics were at high risk of bias, and this was likely to influence measured effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tayeb, BO, Eidelman, A, Eidelman, CL, McNicol, ED, Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD005364.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.095Z" }, { "id": "8482db6c-6180-4e31-80c7-b906dad20b64", "pmid": "", "title": "Effects of Gymnemic Acids Lozenge on Reward Region Response to Receipt and Anticipated Receipt of High-Sugar Food, High-Sugar Food Pictures, and Ad Lib Candy Intake", "imported": false, "abstract": "The purpose of the research is to test whether a gymnemic acids (GA) lozenge will reduce reward region response to intake of high-sugar food and ad lib candy intake and whether the GA lozenge reduced reward region response to anticipated intake of high-sugar food and high-sugar food pictures relative to a placebo lozenge.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.256Z" }, { "id": "8487bb5b-f7e7-451c-ab64-6de5d382e69c", "pmid": "", "title": "Sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose or glucose with and without non‐nutritive sucking is frequently used as a non‐pharmacological intervention for needle‐related procedural pain relief in infants. Objectives To determine the effectiveness of sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet‐tasting solutions, or pharmacological or other non‐pharmacological pain‐relieving methods. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012); MEDLINE via Ovid (1966 to 2012); CINAHL via OVID (1982 to 2012). The World Health Organization International Clinical Trials Registry Platform was also searched for any ongoing trials. Clinical trial registries, conference proceedings and references for randomised controlled trials (RCTs) were also searched. An updated search was run to capture any new publications before finalising the review in April 2012 and no new included studies were identified. Two review authors (MK & JF) independently abstracted data and assessed quality using a standard form. Authors have been contacted for missing data. Selection criteria Randomised‐controlled trials using a sweet‐tasting solution to treat pain in healthy term infants (gestational age 37 weeks and over), between one month and 12 months of age who required needle‐related procedures. These procedures included but were not limited to: subcutaneous or intramuscular injections, venepuncture, and heel lance. Studies in which the painful procedure was circumcision, lumbar puncture or supra‐pubic bladder aspiration were not included as they are more severe and painful than needle‐related procedures. Control conditions included no treatment or placebo (water) or any other identical intervention (same appearance and consistency) without active ingredient, another sweet‐tasting solution, a pharmacological pain‐relieving method (e.g. paracetamol, topical anaesthetic cream), non‐pharmacological pain‐relieving method (e.g. distraction method, non‐nutritive sucking). Data collection and analysis Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Pain, Palliative and Supportive Care Group. We report mean differences (MD) with 95% confidence intervals (CI) using fixed‐effect models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. The Chi 2 test and I 2 statistic were used to assess between‐study heterogeneity. Main results Sixty‐five (65) studies were identified for possible inclusion in this review. Fourteen published RCTs with a total of 1551 participants met the inclusion criteria. Duration of cry was significantly reduced in infants who were administered a sweet‐tasting solution [MD ‐13.47 (95% CI ‐16.80 to ‐10.15)], P < 0.00001 compared with water. However, there was considerable heterogeneity between the studies (I 2 = 94%) that we were unable to explain. Meta‐analysis was not able to be undertaken for any of the other outcome measures, except for cry duration, because of differences in study design. However, most of the individual studies that measured pain found sucrose to significantly reduce pain compared with the control group. One study compared sucrose and Lidocaine‐prilocaine cream and no significant difference was found between the two treatments for the outcomes pain and cry duration. Due to the differences between the studies, we were unable to identify the optimal concentration, volume or method of administration of sweet‐tasting solutions in infants aged one to 12 months. Further large RCTs are needed. Authors' conclusions There is insufficient evidence to confidently judge the effectiveness of sweet‐tasting solutions in reducing needle‐related pain in infants (one month to 12 months of age). The treatments do, however, appear promising. Data from a series of individual trials are promising, as are the results from a subset meta‐analysis of studies measuring duration of crying. Further well controlled RCTs are warranted in this population to determine the optimal concentration, volume, method of administration, and possible adverse effects. Plain language summary Sweet‐tasting solutions for needle‐related pain in infants up to one year of age The use of needles that break the skin and cause pain is a common practice around the world with babies aged between one month and 12 months ( Appendix 4 ). In this review we were interested in whether giving babies sugar‐based solutions to taste when the needle breaks the skin will help reduce their pain. We found 14 separate studies that had asked this question. However, the differences between the studies were often too great to let us combine their findings. Overall, the studies show that different types of sugar‐based solutions were effective but we were not able to confidently assert that there is strong evidence for this treatment in reducing pain. We did find some evidence that babies may not cry for as long if given sugar‐based solutions. This review is broadly in agreement with two other reviews, one asking this question in younger children, and one in older children. There is a need for better studies in this field.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Kassab, M; Foster, JP; Foureur, M; Fowler, C", "articleTypes": [], "doi": "10.1002/14651858.CD008411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "848ea7c6-0c94-435d-adfb-0814ef9e09c2", "pmid": "", "title": "Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Romero, L, Huerfano, C, Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD012492.pub2 AB - Abstract - Background Chancroid is a genital ulcerative disease caused by Haemophilus ducreyi . This microorganism is endemic in Africa, where it can cause up to 10% of genital ulcers. Macrolides may be an effective alternative to treat chancroid and, based on their oral administration and duration of therapy, could be considered as first line therapy. Objectives To assess the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults. Search methods We searched the Cochrane STI Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, WHO ICTRP, ClinicalTrials.gov and Web of Science to 30 October 2017. We also handsearched conference proceedings and reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) comparing macrolides in different regimens or with other therapeutic alternatives for chancroid. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We resolved disagreements through consensus. We used the GRADE approach to assess the quality of the evidence. Main results Seven RCTs (875 participants) met our inclusion criteria, of which four were funded by industry. Five studies (664 participants) compared macrolides with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Low quality evidence suggested there was no difference between the groups after treatment in terms of clinical cure (risk ratio (RR) 1.09, 95% confidence interval (CI) 0.97 to 1.21; 2 studies, 340 participants with syndromic approach and RR 1.06, 95% CI 0.98 to 1.15; 5 studies, 348 participants with aetiological diagnosis) or improvement (RR 0.89, 95% CI 0.52 to 1.52; 2 studies, 340 participants with syndromic approach and RR 0.80, 95% CI 0.42 to 1.51; 3 studies, 187 participants with aetiological diagnosis). Based on low and very low quality evidence, there was no difference between macrolides and any other antibiotic treatments for microbiological cure (RR 0.93, 95% CI 0.74 to 1.16; 1 study, 45 participants) and minor adverse effects (RR 1.34, 95% CI 0.24 to 7.51; 3 studies, 412 participants). Two trials (269 participants) compared erythromycin with any other macrolide type. Low quality evidence suggested that, compared with azithromycin or rosaramicin, long courses of erythromycin did not increase clinical cure (RR 1.00, 95% CI 0.91 to 1.10; 2 studies, 269 participants with syndromic approach and RR 1.04, 95% CI 0.93 to 1.16; 2 studies, 211 participants with aetiological diagnosis), with a similar frequency of minor adverse effects between the groups (RR 1.14, 95% CI 0.63 to 2.06; 1 trial, 101 participants). For this comparison, subgroup analysis found no difference between HIV‐positive participants (RR 1.02, 95% CI 0.73 to 1.43; 1 study, 38 participants) and HIV‐negative participants (RR 1.04, 95% CI 0.94 to 1.14; 1 study, 89 participants). We downgraded the quality of evidence to low, because of imprecision, some limitations on risk of bias and heterogeneity. None of the trials reported serious adverse events, cost effectiveness and participant satisfaction. Authors' conclusions At present, the quality of the evidence on the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults is low, implying that we are uncertain about the estimated treatment effect. There is no statistically significant difference between the available therapeutic alternatives for the treatment of sexually active adults with genital ulcers compatible with chancroid. Low quality evidence suggests that azithromycin could be considered as the first therapeutic alternative, based on their mono‐dose oral administration, with a similar safety and effectiveness profile, when it is compared with long‐term erythromycin use. Due to sparse available evidence about the safety and effectiveness of macrolides to treat H ducreyi infection in people with HIV, these results should be taken with caution. Plain language summary Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults Review question 
 In this Cochrane Review, we assess the effectiveness and safety of macrolides in different regimens or with other treatments for H ducreyi infection in adults. Background Chancroid is a sexually transmitted infection (STI) caused by infection with a bacteria called Haemophilus ducreyi . It causes ulcers in the genital area and is endemic in some low‐income countries. Control and eradication of chancroid could reduce transmission of the STI from one sexual partner to another. Macrolides are antibiotics that could be effective and safe for treating H ducreyi infection. Trial characteristics We searched the available literature up to 30 October 2017 and we included seven trials with 875 participants. The trials recruited men and non‐pregnant women over the age of 16 years who presented with genital ulcers compatible with chancroid. Three studies included people with high‐risk sexual behaviour as migrant mine workers, sex workers and men with prostitute contact. All the trials tested for other STIs, and discarded people who were also infected with syphilis and herpes simple virus. One study included people with HIV. The most frequent antibiotic treatment was erythromycin with azithromycin as an alternative. They were compared with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Five studies compared two types of antibiotic and two studies compared different ways of treating with macrolides. Four trials were funded by pharmaceutical companies. Key results There was no difference between the types of antibiotics in sexually active adults with genital ulcers compatible with chancroid. Erythromycin is usually the first choice for treatment but low quality evidence suggested that azithromycin (as a single dose, oral (by mouth) administration) had similar safety and effectiveness. Because of sparse evidence about the safety and effectiveness of macrolides to treat Haemophilus ducreyi infection in people with HIV, these results should be taken with caution. Quality of evidence The quality of evidence was low as there was a risk of bias due to poor methods, people dropping out of the study and pharmaceutical companies sponsored four studies.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.771Z" }, { "id": "849a80a6-eb50-4be6-a887-65b8687be7c4", "pmid": "", "title": "Interventions for treating acute high altitude illness", "imported": false, "abstract": "Abstract - Background Acute high altitude illness is defined as a group of cerebral and pulmonary syndromes that can occur during travel to high altitudes. It is more common above 2500 metres, but can be seen at lower elevations, especially in susceptible people. Acute high altitude illness includes a wide spectrum of syndromes defined under the terms 'acute mountain sickness' (AMS), 'high altitude cerebral oedema' and 'high altitude pulmonary oedema'. There are several interventions available to treat this condition, both pharmacological and non‐pharmacological; however, there is a great uncertainty regarding their benefits and harms. Objectives To assess the clinical effectiveness, and safety of interventions (non‐pharmacological and pharmacological), as monotherapy or in any combination, for treating acute high altitude illness. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science, CINAHL, Wanfang database and the World Health Organization International Clinical Trials Registry Platform for ongoing studies on 10 August 2017. We did not apply any language restriction. Selection criteria We included randomized controlled trials evaluating the effects of pharmacological and non‐pharmacological interventions for individuals suffering from acute high altitude illness: acute mountain sickness, high altitude pulmonary oedema or high altitude cerebral oedema. Data collection and analysis Two review authors independently assessed the eligibility of study reports, the risk of bias for each and performed the data extraction. We resolved disagreements through discussion with a third author. We assessed the quality of evidence with GRADE. Main results We included 13 studies enrolling a total of 468 participants. We identified two ongoing studies. All studies included adults, and two studies included both teenagers and adults. The 13 studies took place in high altitude areas, mostly in the European Alps. Twelve studies included participants with acute mountain sickness, and one study included participants with high altitude pulmonary oedema. Follow‐up was usually less than one day. We downgraded the quality of the evidence in most cases due to risk of bias and imprecision. We report results for the main comparisons as follows. Non‐pharmacological interventions (3 studies, 124 participants) All‐cause mortality and complete relief of AMS symptoms were not reported in the three included trials. One study in 64 participants found that a simulated descent of 193 millibars versus 20 millibars may reduce the average of symptoms to 2.5 vs 3.1 units after 12 hours of treatment (clinical score ranged from 0 to 11 ‒ worse; reduction of 0.6 points on average with the intervention; low quality of evidence). In addition, no complications were found with use of hyperbaric chambers versus supplementary oxygen (one study; 29 participants; low‐quality evidence). Pharmacological interventions (11 trials, 375 participants) All‐cause mortality was not reported in the 11 included trials. One trial found a greater proportion of participants with complete relief of AMS symptoms after 12 and 16 hours when dexamethasone was administered in comparison with placebo (47.1% versus 0%, respectively; one study; 35 participants; low quality of evidence). Likewise, when acetazolamide was compared with placebo, the effects on symptom severity was uncertain (standardized mean difference (SMD) −1.15, 95% CI −2.56 to 0.27; 2 studies, 25 participants; low‐quality evidence). One trial of dexamethasone in comparison with placebo in 35 participants found a reduction in symptom severity (difference on change in the AMS score: 3.7 units reported by authors; moderate quality of evidence). The effects from two additional trials comparing gabapentin with placebo and magnesium with placebo on symptom severity at the end of treatment were uncertain. For gabapentin versus placebo: mean visual analogue scale (VAS) score of 2.92 versus 4.75, respectively; 24 participants; low quality of evidence. For magnesium versus placebo: mean scores of 9 and 10.3 units, respectively; 25 participants; low quality of evidence). The trials did not find adverse events from either treatment (low quality of evidence). One trial comparing magnesium sulphate versus placebo found that flushing was a frequent event in the magnesium sulphate arm (percentage of flushing: 75% versus 7.7%, respectively; one study; 25 participants; low quality of evidence). Authors' conclusions There is limited available evidence to determine the effects of non‐pharmacological and pharmacological interventions in treating acute high altitude illness. Low‐quality evidence suggests that dexamethasone and acetazolamide might reduce AMS score compared to placebo. However, the clinical benefits and harms related to these potential interventions remain unclear. Overall, the evidence is of limited practical significance in the clinical field. High‐quality research in this field is needed, since most trials were poorly conducted and reported. Plain language summary Treatments for high altitude (mountain) illness Background Acute high altitude illness, also known as acute mountain sickness, may present with a variety of symptoms. It is caused by the decreasing level of oxygen at increasingly high altitudes; and it can be experienced when reaching a high altitude when travelling, hiking or climbing mountains or other elevated areas. People going to altitudes over 4000 metres, females, people younger than mid‐adulthood , and people with a history of migraine are at greater risk of suffering from altitude sickness. The most common symptoms are headache, loss of appetite , insomnia, and nausea. However, severe forms can include confusion, difficulty walking, progressive cough, shortness of breath, and even death. Review question What are the benefits and risks of different treatments for people suffering from high altitude illness? Study characteristics We included 13 studies with a total of 468 participants. Most studies included participants with mild or moderate forms of mountain sickness, and only one study included the severe neurological (disorder of the nervous system) form. Follow‐up was usually less than one day. We also identified two ongoing studies. Key results We found studies evaluating the following interventions: simulated descent with a hyperbaric chamber (medical use of oxygen in a special chamber at greater than atmospheric pressure to increase the availability of oxygen in the body); oxygen; medicines: acetazolamide, dexamethasone, ibuprofen, paracetamol, gabapentin, sumatriptan, nitric oxide, and magnesium sulphate. None of the studies reported the effects of these interventions on all‐cause mortality. The report of complete relief from acute mountain sickness symptoms, and adverse events was infrequent. Studies related to simulated descent with the use of a hyperbaric chamber did not find additional benefits or harms related to this intervention (3 studies, 124 participants). In addition, studies related to administration of medicines found some benefits in terms of reduction of symptoms with the use of acetazolamide (2 studies, 25 participants), and dexamethasone (1 study, 35 participants), without an increase in side effects. Quality of the evidence The quality of the evidence we found was low, and thus our certainty in the findings is limited. There was insufficient information on how the studies were conducted, and in some cases there was evidence of tampering at some stages of the trials. Furthermore, the number of persons in each study was very small (< 30 participants), and therefore the results were not clear (imprecise). Some studies were not blinded (that is, participants knew what experimental treatment they were receiving), and this could have affected how the participants evaluated their own symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Simancas‐Racines, D; Arevalo‐Rodriguez, I; Osorio, D; Franco, JVA; Xu, Y; Hidalgo, R", "articleTypes": [], "doi": "10.1002/14651858.CD009567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "849e35a0-216b-4b7a-966e-ce411b28acc6", "pmid": "", "title": "Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Wells, GA, Hsieh, S-C, Peterson, J, Zheng, C, Kelly, SE, Shea, B, Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD003376.pub4 AB - Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Etidronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts – bone cells that break down bone tissue. This is an update of a Cochrane review first published in 2008. For clinical relevance, we investigated etidronate's effects on postmenopausal women stratified by fracture risk (low versus high). Objectives To assess the benefits and harms of intermittent/cyclic etidronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE, Embase, two clinical trial registers, the websites of drug approval agencies, and the bibliographies of relevant systematic reviews. We identified eligible trials published between 1966 and February 2023. Selection criteria We included randomized controlled trials that assessed the benefits and harms of etidronate in the prevention of fractures for postmenopausal women. Women in the experimental arms must have received at least one year of etidronate, with or without other anti‐osteoporotic drugs and concurrent calcium/vitamin D. Eligible comparators were placebo (i.e. no treatment; or calcium, vitamin D, or both) or another anti‐osteoporotic drug. Major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. We classified a study as secondary prevention if its population fulfilled one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (≤ ‐2.5), or aged 75 years or older. If none of these criteria were met, we considered the study to be primary prevention. Data collection and analysis We used standard methodological procedures expected by Cochrane. The review has three main comparisons: (1) etidronate 400 mg/day versus placebo; (2) etidronate 200 mg/day versus placebo; (3) etidronate at any dosage versus another anti‐osteoporotic agent. We stratified the analyses for each comparison into primary and secondary prevention studies. For major outcomes in the placebo‐controlled studies of etidronate 400 mg/day, we followed our original review by defining a greater than 15% relative change as clinically important. For all outcomes of interest, we extracted outcome measurements at the longest time point in the study. Main results Thirty studies met the review's eligibility criteria. Of these, 26 studies, with a total of 2770 women, reported data that we could extract and quantitatively synthesize. There were nine primary and 17 secondary prevention studies. We had concerns about at least one risk of bias domain in each study. None of the studies described appropriate methods for allocation concealment, although 27% described adequate methods of random sequence generation. We judged that only 8% of the studies avoided performance bias, and provided adequate descriptions of appropriate blinding methods. One‐quarter of studies that reported efficacy outcomes were at high risk of attrition bias, whilst 23% of studies reporting safety outcomes were at high risk in this domain. The 30 included studies compared (1) etidronate 400 mg/day to placebo (13 studies: nine primary and four secondary prevention); (2) etidronate 200 mg/day to placebo (three studies, all secondary prevention); or (3) etidronate (both dosing regimens) to another anti‐osteoporotic agent (14 studies: one primary and 13 secondary prevention). We discuss only the etidronate 400 mg/day versus placebo comparison here. For primary prevention, we collected moderate‐ to very low‐certainty evidence from nine studies (one to four years in length) including 740 postmenopausal women at lower risk of fractures. Compared to placebo, etidronate 400 mg/day probably results in little to no difference in non‐vertebral fractures (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.20 to 1.61); absolute risk reduction (ARR) 4.8% fewer, 95% CI 8.9% fewer to 6.1% more) and serious adverse events (RR 0.90, 95% CI 0.52 to 1.54; ARR 1.1% fewer, 95% CI 4.9% fewer to 5.3% more), based on moderate‐certainty evidence. Etidronate 400 mg/day may result in little to no difference in clinical vertebral fractures (RR 3.03, 95% CI 0.32 to 28.44; ARR 0.02% more, 95% CI 0% fewer to 0% more) and withdrawals due to adverse events (RR 1.41, 95% CI 0.81 to 2.47; ARR 2.3% more, 95% CI 1.1% fewer to 8.4% more), based on low‐certainty evidence. We do not know the effect of etidronate on hip fractures because the evidence is very uncertain (RR not estimable based on very low‐certainty evidence). Wrist fractures were not reported in the included studies. For secondary prevention, four studies (two to four years in length) including 667 postmenopausal women at higher risk of fractures provided the evidence. Compared to placebo, etidronate 400 mg/day may make little or no difference to non‐vertebral fractures (RR 1.07, 95% CI 0.72 to 1.58; ARR 0.9% more, 95% CI 3.8% fewer to 8.1% more), based on low‐certainty evidence. The evidence is very uncertain about etidronate's effects on hip fractures (RR 0.93, 95% CI 0.17 to 5.19; ARR 0.0% fewer, 95% CI 1.2% fewer to 6.3% more), wrist fractures (RR 0.90, 95% CI 0.13 to 6.04; ARR 0.0% fewer, 95% CI 2.5% fewer to 15.9% more), withdrawals due to adverse events (RR 1.09, 95% CI 0.54 to 2.18; ARR 0.4% more, 95% CI 1.9% fewer to 4.9% more), and serious adverse events (RR not estimable), compared to placebo. Clinical vertebral fractures were not reported in the included studies. Authors' conclusions This update echoes the key findings of our previous review that etidronate probably makes or may make little to no difference to vertebral and non‐vertebral fractures for both primary and secondary prevention. Plain language summary Does etidronate prevent fractures caused by osteoporosis in postmenopausal women? Key messages • For women with close to normal bone density (bone strength) and no previous broken spinal bones, etidronate probably makes little or no difference to the likelihood of having a hip or wrist fracture or a serious adverse (unwanted/harmful) event.
 • For women who have low bone density and are at risk for or have had a previous broken spinal bone, etidronate may make little or no difference in preventing fractures in bones other than the spine. What is osteoporosis? Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow, and old bone cells break down to make room for new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break, even after a minor injury, such as a slight bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. What is etidronate? Etidronate belongs to the class of medicines called bisphosphonates, which slow down the cells that break down the old bone. It is given by mouth in an intermittent or cyclical schedule; for example, a 400 mg tablet daily for two weeks every 90 days, followed by calcium or no treatment for the remainder of each 90‐day treatment cycle. What did we want to find out? We wanted to find out if etidronate was better than placebo (inactive or 'dummy' medicine) or another medicine for osteoporosis in preventing broken bones in postmenopausal women. For clinical relevance, we looked at etidronate's effects on women, as grouped by their risk of fracture (lower versus higher risk). We also wanted to find out if etidronate was associated with any unwanted effects. What did we do? We searched for studies comparing etidronate to placebo or another medicine for preventing osteoporosis. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Overall, we found 30 studies, but 4 studies provided insufficient information about their results. Thus, we were able to analyse the results of 26 studies involving 2770 women. Nine studies were interested in 'primary prevention' of osteoporosis‐based fractures, meaning they focused on women at lower fracture risk, who had bones with near‐to‐normal density/strength and no previous broken spinal bones. Seventeen studies were interested in 'secondary prevention' with etidronate, meaning they focused on women at higher fracture risk, who already had weak bones (low bone density), had a broken spinal bone, or both. Most studies mainly included white women. The studies lasted between 1 and 4 years. Some studies gave the women 400 mg/day of etidronate, whilst other studies gave 200 mg/day. Main results for primary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate: • probably makes little or no difference to non‐vertebral (non‐spinal) fractures and serious adverse events; • may make little or no difference to clinical vertebral fractures (that is, spinal fractures suggested by clinical signs and symptoms) and the number of women who left the studies due to adverse events. The evidence is very uncertain about the effect of etidronate on hip fractures. None of the studies reported on the effect on wrist fractures. Main results for secondary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate may make little or no difference in preventing fractures in bones other than the spine. The evidence is very uncertain about the effect of etidronate on hip and wrist fractures, the number of women who left the studies due to adverse events, and serious adverse events. None of the studies reported on etidronate's effect on clinical vertebral fractures. What are the limitations of the evidence? Our confidence in the evidence ranged from very low to moderate. In general, we have little confidence in the evidence because it is possible that the women in the studies were aware of which treatment they were getting, which could influence the results, and because many of the studies were very small. How up to date is this evidence? The evidence is current to February 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.812Z" }, { "id": "84c7bfc7-f244-447a-b3f8-fe61abd709c9", "pmid": "", "title": "Chloroquine or hydroxychloroquine for prevention and treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The coronavirus disease 2019 (COVID‐19) pandemic has resulted in substantial mortality. Some specialists proposed chloroquine (CQ) and hydroxychloroquine (HCQ) for treating or preventing the disease. The efficacy and safety of these drugs have been assessed in randomized controlled trials. Objectives To evaluate the effects of chloroquine (CQ) or hydroxychloroquine (HCQ) for 1) treating people with COVID‐19 on death and time to clearance of the virus; 2) preventing infection in people at risk of SARS‐CoV‐2 exposure; 3) preventing infection in people exposed to SARS‐CoV‐2. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Current Controlled Trials (www.controlled‐trials.com), and the COVID‐19‐specific resources www.covid‐nma.com and covid‐19.cochrane.org, for studies of any publication status and in any language. We performed all searches up to 15 September 2020. We contacted researchers to identify unpublished and ongoing studies. Selection criteria We included randomized controlled trials (RCTs) testing chloroquine or hydroxychloroquine in people with COVID‐19, people at risk of COVID‐19 exposure, and people exposed to COVID‐19. Adverse events (any, serious, and QT‐interval prolongation on electrocardiogram) were also extracted. Data collection and analysis Two review authors independently assessed eligibility of search results, extracted data from the included studies, and assessed risk of bias using the Cochrane ‘Risk of bias’ tool. We contacted study authors for clarification and additional data for some studies. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). We performed meta‐analysis using a random‐effects model for outcomes where pooling of effect estimates was appropriate. Main results 1. Treatment of COVID‐19 disease We included 12 trials involving 8569 participants, all of whom were adults. Studies were from China (4); Brazil, Egypt, Iran, Spain, Taiwan, the UK, and North America (each 1 study); and a global study in 30 countries (1 study). Nine were in hospitalized patients, and three from ambulatory care. Disease severity, prevalence of comorbidities, and use of co‐interventions varied substantially between trials. We found potential risks of bias across all domains for several trials. Nine trials compared HCQ with standard care (7779 participants), and one compared HCQ with placebo (491 participants); dosing schedules varied. HCQ makes little or no difference to death due to any cause (RR 1.09, 95% CI 0.99 to 1.19; 8208 participants; 9 trials; high‐certainty evidence). A sensitivity analysis using modified intention‐to‐treat results from three trials did not influence the pooled effect estimate. HCQ may make little or no difference to the proportion of people having negative PCR for SARS‐CoV‐2 on respiratory samples at day 14 from enrolment (RR 1.00, 95% CI 0.91 to 1.10; 213 participants; 3 trials; low‐certainty evidence). HCQ probably results in little to no difference in progression to mechanical ventilation (RR 1.11, 95% CI 0.91 to 1.37; 4521 participants; 3 trials; moderate‐certainty evidence). HCQ probably results in an almost three‐fold increased risk of adverse events (RR 2.90, 95% CI 1.49 to 5.64; 1394 participants; 6 trials; moderate‐certainty evidence), but may make little or no difference to the risk of serious adverse events (RR 0.82, 95% CI 0.37 to 1.79; 1004 participants; 6 trials; low‐certainty evidence). We are very uncertain about the effect of HCQ on time to clinical improvement or risk of prolongation of QT‐interval on electrocardiogram (very low‐certainty evidence). One trial (22 participants) randomized patients to CQ versus lopinavir/ritonavir, a drug with unknown efficacy against SARS‐CoV‐2, and did not report any difference for clinical recovery or adverse events. One trial compared HCQ combined with azithromycin against standard care (444 participants). This trial did not detect a difference in death, requirement for mechanical ventilation, length of hospital admission, or serious adverse events. A higher risk of adverse events was reported in the HCQ‐and‐azithromycin arm; this included QT‐interval prolongation, when measured. One trial compared HCQ with febuxostat, another drug with unknown efficacy against SARS‐CoV‐2 (60 participants). There was no difference detected in risk of hospitalization or change in computed tomography (CT) scan appearance of the lungs; no deaths were reported. 2. Preventing COVID‐19 disease in people at risk of exposure to SARS‐CoV‐2 Ongoing trials are yet to report results for this objective. 3. Preventing COVID‐19 disease in people who have been exposed to SARS‐CoV‐2 One trial (821 participants) compared HCQ with placebo as a prophylactic agent in the USA (around 90% of participants) and Canada. Asymptomatic adults (66% healthcare workers; mean age 40 years; 73% without comorbidity) with a history of exposure to people with confirmed COVID‐19 were recruited. We are very uncertain about the effect of HCQ on the primary outcomes, for which few events were reported: 20/821 (2.4%) developed confirmed COVID‐19 at 14 days from enrolment, and 2/821 (0.2%) were hospitalized due to COVID‐19 (very low‐certainty evidence). HCQ probably increases the risk of adverse events compared with placebo (RR 2.39, 95% CI 1.83 to 3.11; 700 participants; 1 trial; moderate‐certainty evidence). HCQ may result in little or no difference in serious adverse events (no RR: no participants experienced serious adverse events; low‐certainty evidence). One cluster‐randomized trial (2525 participants) compared HCQ with standard care for the prevention of COVID‐19 in people with a history of exposure to SARS‐CoV‐2 in Spain. Most participants were working or residing in nursing homes; mean age was 49 years. There was no difference in the risk of symptomatic confirmed COVID‐19 or production of antibodies to SARS‐CoV‐2 between the two study arms. Authors' conclusions HCQ for people infected with COVID‐19 has little or no effect on the risk of death and probably no effect on progression to mechanical ventilation. Adverse events are tripled compared to placebo, but very few serious adverse events were found. No further trials of hydroxychloroquine or chloroquine for treatment should be carried out. These results make it less likely that the drug is effective in protecting people from infection, although this is not excluded entirely. It is probably sensible to complete trials examining prevention of infection, and ensure these are carried out to a high standard to provide unambiguous results. Plain language summary Is chloroquine or hydroxychloroquine useful in treating people with COVID‐19, or in preventing infection in people who have been exposed to the virus? What is the aim of this review? COVID‐19 is an infectious respiratory disease caused by a coronavirus called SARS‐CoV‐2. If the infection becomes severe, people may need intensive care and support in hospital, including mechanical ventilation. Drugs used for other diseases were tried out in COVID‐19, and this included chloroquine, used for malaria; and hydroxychloroquine used for rheumatic diseases, such as rheumatoid arthritis or systemic lupus erythematosus. We sought evidence of the effects of these drugs in treating people ill with the disease; in preventing the disease in people at risk of getting the disease, such as health workers; and people exposed to the virus developing the disease. Key messages Hydroxychloroquine does not reduce deaths from COVID‐19, and probably does not reduce the number of people needing mechanical ventilation. Hydroxychloroquine caused more unwanted effects than a placebo treatment, though it did not appear to increase the number of serious unwanted effects. We do not think new studies of hydroxychloroquine should be started for treatment of COVID‐19. What was studied in the review? We searched for studies that looked at giving chloroquine and hydroxychloroquine to people with COVID‐19; people at risk of being exposed to the virus; and people who have been exposed to the virus. We found 14 relevant studies: 12 studies of chloroquine or hydroxychloroquine used to treat COVID‐19 in 8569 adults; two studies of hydroxychloroquine to stop COVID‐19 in 3346 adults who had been exposed to the virus but had no symptoms of infection. We did not find any completed studies of these medicines to stop COVID‐19 in people who were at risk of exposure to the virus; studies are still under way. The studies took place in China, Brazil, Egypt, Iran, Taiwan, North America, and Europe; one study was worldwide. Some studies were partly funded by pharmaceutical companies that manufacture hydroxychloroquine. What are the main results of our review? Treating COVID‐19 Compared with usual care or placebo, hydroxychloroquine: · clearly did not affect how many people died (of any cause; 9 studies in 8208 people); · probably did not affect how many people needed mechanical ventilation (3 studies; 4521 people); · may not affect how many people still tested positive for the virus after 14 days (3 studies; 213 people). We are uncertain whether hydroxychloroquine affected the number of people whose symptoms improved after 28 days. Compared with other antiviral treatment (lopinavir plus ritonavir), chloroquine made little or no difference to the time taken for symptoms to improve (1 study; 22 people). Compared with usual care in one study in 444 people, hydroxychloroquine given with azithromycin (an antibiotic) made no difference to: · how many people died; · how many needed mechanical ventilation; or · time spent in hospital. Compared with febuxostat (a medicine to treat gout), hydroxychloroquine made no difference to how many people were admitted to hospital or to changes seen on scans of people's lungs; no deaths were reported (1 study; 60 people). Preventing COVID‐19 in people exposed to it We are uncertain whether hydroxychloroquine affected how many people developed COVID‐19, or how many people were admitted to hospital with COVID‐19, compared with those receiving a placebo treatment (1 study; 821 people). Compared with usual care, hydroxychloroquine made no difference to the risk of developing COVID‐19, or antibodies to the virus, in people exposed to it (1 study; 2525 people). Unwanted effects When used for treating COVID‐19, compared with usual care or placebo, hydroxychloroquine: · probably increases the risk of mild unwanted effects (6 studies; 1394 people); · may not increase the risk of serious harmful effects (6 studies; 1004 people). When given along with azithromycin, hydroxychloroquine increased the risk of any unwanted effects, but made no difference to the risk of serious unwanted effects (1 study; 444 people). Compared with lopinavir plus ritonavir, chloroquine made little or no difference to the risk of unwanted effects (1 study; 22 people). When used for preventing COVID‐19, hydroxychloroquine probably causes more unwanted effects than placebo, but may not increase the risk of serious, harmful unwanted effects (1 study; 700 people). How confident are we in our results? We are confident about our results for how many people died and moderately confident about how many needed mechanical ventilation. We are moderately confident about the unwanted effects of hydroxychloroquine treatment, but less confident about our results for serious unwanted effects; these results might change with further evidence. How up‐to‐date is this review? We included evidence published up to 15 September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Singh, B, Ryan, H, Kredo, T, Chaplin, M, Fletcher, T", "articleTypes": [], "doi": "10.1002/14651858.CD013587.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.122Z" }, { "id": "84d94493-a21b-4eb6-98a6-b1162c664748", "pmid": "", "title": "Rituximab for people with multiple sclerosis", "imported": false, "abstract": "Abstract - Background Multiple sclerosis (MS) is the most common neurological cause of disability in young adults. Off‐label rituximab for MS is used in most countries surveyed by the International Federation of MS, including high‐income countries where on‐label disease‐modifying treatments (DMTs) are available. This updates the 2021 version of the review. Objectives To assess the benefits and harms of rituximab as 'first choice' and 'switching' treatment for adults with any form of MS. Search methods We searched CENTRAL , MEDLINE, Embase, CINAHL, and three trials registers on 31 December 2023, together with reference checking and contacting study authors to identify unpublished studies. Selection criteria We included randomised controlled trials (RCTs) and controlled non‐randomised studies of interventions (NRSIs) comparing rituximab with placebo or another DMT for adults with any form of MS. Data collection and analysis We followed standard Cochrane methods. We used RoB 1 to assess risk of bias in RCTs and ROBINS‐I in NRSIs. We assessed the certainty of evidence for critical and important prioritised outcomes using GRADE: disability worsening, relapse, serious adverse events (SAEs), health‐related quality of life (HRQoL), common infections, cancer, and mortality. We conducted separate analyses for rituximab as 'first choice' or as 'switching' treatment, relapsing or progressive MS, comparison with placebo or another DMT, and RCTs or NRSIs. Main results In this update, the number of study participants increased from 16,429 (15 studies) to 37,443 (28 studies; 13 new studies: 1 RCT and 12 NRSIs). The studies were conducted worldwide; most originated from high‐income countries (25 studies). Public institutions funded 22 (79%) of the studies. Most studies investigated the effects of rituximab on people with relapsing MS (19 studies; 27,500 (73%) participants). We identified 12 ongoing studies. Rituximab as 'first choice' for active relapsing MS None of the included studies compared rituximab to placebo. One RCT compared rituximab to dimethyl fumarate, with 24 months' follow‐up. Rituximab may reduce the recurrence of relapse (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.04 to 0.57; 195 participants; low‐certainty evidence). The evidence is very uncertain on disability worsening and SAEs. Rituximab may result in little to no difference in upper respiratory tract infections (rate ratio (RR) 1.03, 95% CI 0.79 to 1.34; low‐certainty evidence). The evidence is very uncertain for urinary tract, skin, and viral infections. HRQoL, cancer, and mortality were not reported. One NRSI compared rituximab to other DMTs, with 24 months' follow‐up. Disability worsening was not reported. Compared with interferon beta or glatiramer acetate, rituximab likely delays relapse (hazard ratio (HR) 0.14, 95% CI 0.05 to 0.39; 1 study, 335 participants; moderate‐certainty evidence). Compared with dimethyl fumarate and natalizumab, rituximab may delay relapse (dimethyl fumarate: HR 0.29, 95% CI 0.08 to 1.00; 1 study, 206 participants; low‐certainty evidence; natalizumab: HR 0.24, 95% CI 0.06 to 1.00; 1 study, 170 participants; low‐certainty evidence). The evidence for relapse is very uncertain when comparing rituximab to fingolimod. The effect on SAEs is uncertain due to very few events in all the comparison groups. No deaths were reported. HRQoL, common infections, and cancer were not reported. Rituximab as 'first choice' for primary progressive MS One RCT compared rituximab to placebo, with 24 months' follow‐up. Rituximab likely results in little or no difference in disability worsening (OR 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate‐certainty evidence). The evidence is very uncertain on relapse, SAEs, common infections, cancer, and mortality. HRQoL was not reported. None of the included studies compared rituximab as 'first choice' treatment to other DMTs for primary or secondary progressive MS. Rituximab as 'switching' treatment for relapsing MS One small RCT compared rituximab to placebo, with 12 months' follow‐up. Disability worsening was not reported. Rituximab may reduce recurrence of relapses (OR 0.38, 95% CI 0.16 to 0.93; 1 study, 104 participants; low‐certainty evidence). The evidence is very uncertain regarding SAEs, common infections, cancer, and mortality. HRQoL was not reported. Twelve NRSIs compared rituximab to other DMTs, with 24 months' follow‐up. The evidence on disability worsening is very uncertain in comparison with interferons or glatiramer acetate, natalizumab, alemtuzumab, and ocrelizumab. Rituximab likely delays time to relapse in comparison with interferons or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 study, 1383 participants; moderate‐certainty evidence), fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 study, 256 participants; moderate‐certainty evidence), and may result in little or no difference compared with natalizumab (HR 0.96, 95% CI 0.83 to 1.10; 3 studies, 1922 participants; low‐certainty evidence). The evidence is very uncertain on relapse in comparison with alemtuzumab. There is uncertainty regarding SAEs when comparing rituximab to natalizumab and fingolimod. Rituximab likely increases serious common infections when compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 study, 5477 participants; moderate‐certainty evidence) and natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 studies, 5001 participants; moderate‐certainty evidence). The evidence for common infections is very uncertain when comparing rituximab to fingolimod and ocrelizumab. Rituximab may slightly reduce the risk of cancer compared with natalizumab (HR 0.79, 95% CI 0.62 to 0.99; 2 studies, 6202 participants; low‐certainty evidence), whereas the evidence is very uncertain in comparison with fingolimod. The effect of rituximab on mortality is very uncertain due to very few events in all the comparison groups. HRQoL was not reported. Authors' conclusions For preventing relapses in relapsing MS, rituximab as 'first choice' and 'switching' treatment compares favourably with a wide range of approved DMTs. The protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab on primary progressive MS. There is limited evidence for long‐term adverse events of rituximab in people with MS. Evidence for serious adverse events, cancer, and mortality was of very low certainty due to few events. There is an increased risk of serious (hospital‐treated) infections with rituximab compared with other DMTs, although the absolute risk is low. High‐quality (prospectively registered) NRSIs should be conducted to draw more reliable conclusions about the potential benefits and harms of rituximab in people with MS. Plain language summary Is rituximab better for people with multiple sclerosis than other disease‐modifying medicines? Key messages • We are uncertain whether rituximab prevents disability worsening in people with any form of multiple sclerosis (MS). 
• Rituximab may offer moderate‐to‐large benefit against a range of other medicines in preventing relapses in relapsing MS, both in people treated with rituximab for the first time and in those given rituximab after other medicines failed to work or became unsuitable.
• Very few people given rituximab in the studies had serious unwanted/harmful events, developed cancer, or died over 24 months' follow‐up. What is multiple sclerosis (MS)? MS is a disease affecting the central nervous system, in which the body’s immune system mistakenly attacks the protective covering of nerve fibres, which leads to inflammation and damage. Communication between the brain and the rest of the body is affected, resulting in a wide range of symptoms. There are two main types: (1) relapsing MS, where someone has periods of relapse (worsening of symptoms) followed by remissions (improvement or complete recovery); and (2) progressive MS, where symptoms worsen over time, without distinct periods of improvement. Relapsing MS is more common. How is MS treated? There is no cure for MS, so the goal of treatment is to manage symptoms, reduce disease activity, slow progression, and improve quality of life. This involves giving people with MS disease‐modifying treatments (DMTs), in contrast to treatments which only manage symptoms. There are different kinds of disease‐modifying treatments for MS, including rituximab. Rituximab is: • a medicine given slowly via a needle in a vein (intravenous infusion) that can suppress certain immune cells;
• included in the World Health Organization (WHO) Model List of Essential Medicines for MS, which makes rituximab available worldwide. Rituximab is not always reimbursed by health systems because it is not licensed for MS by marketing authorities;
• a highly effective treatment. It's cheaper and is given less often than other approved medicines for MS. Treatment with rituximab requires specialist care and infusion facilities, but other approved medicines do too. What did we want to find out? We wanted to find out the effects of rituximab on people with any form of MS on: • disability worsening, relapse, and quality of life;
• unwanted effects, such as serious harmful effects, serious common infections, cancer, and death. What did we do? We searched for studies that compared rituximab with other infused medicines (e.g. natalizumab), injectable medicines (e.g. interferon beta, glatiramer acetate), and oral medicines (e.g. fingolimod, dimethyl fumarate). We compared and summarised the results of the included studies, and rated our confidence in the evidence, based on factors such as study methods and quality. What did we find? We found 28 studies that involved 37,443 people with MS and lasted one or two years. The biggest study involved 8600 people and the smallest, 27 people. Most people (27,500, 73% of all participants) had a relapsing form of MS, while only 813 (2%) had a progressive form. Three studies included 9130 (24%) people with all forms of MS. Most studies originated from high‐income countries. Public institutions funded 22 (79%) of the studies. MAIN RESULTS Relapsing forms of MS • We do not know if rituximab has an effect on long‐term disability worsening due to the short follow‐up period of the studies.
• For people treated with rituximab for the first time as well as those given rituximab after other medicines failed to work or became unsuitable, rituximab may reduce the risk of relapses compared with interferon beta or glatiramer acetate, dimethyl fumarate, fingolimod, and natalizumab (evidence from 16 studies). 
• Serious unwanted effects of rituximab are very few. However, we do not know if rituximab has an effect on long‐term serious unwanted effects due to the short follow‐up period of the studies.
• Rituximab likely increases serious common infections (i.e. hospital‐treated infections) compared with other approved medicines for MS. However, the likelihood of serious common infections occurring is low in terms of the total number of people being considered. Progressive forms of MS We do not know if rituximab has benefits for people with primary progressive MS. What are the main limitations of the evidence? Our confidence in the evidence is limited because of three main factors. First, people were not randomly placed into different treatment groups in most of the studies. This means that differences between the groups could be due to differences between participants rather than between the comparison treatments. Second, we found few studies in which participants were assigned randomly to different treatment groups. These studies were small and used methods likely to introduce errors in their results. Third, results originated from short‐term studies. This is an important issue for people with a lifelong disease such as MS, who need to know the long‐term benefits and unwanted effects of a medicine. How current is the evidence? This review updates our previous review. The evidence is current to 31 December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Filippini, G; Kruja, J; Del Giovane, C", "articleTypes": [], "doi": "10.1002/14651858.CD013874.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "84fc9225-4ade-4fbf-8c33-6681ea3cadb1", "pmid": "", "title": "Intranasal fentanyl for the management of acute pain in children", "imported": false, "abstract": "Abstract - Background Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula. Objectives We identified and evaluated all randomized controlled trials (RCTs) and quasi‐randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of \"rescue analgesia,\" patient/parental satisfaction and patient mortality. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014). Selection criteria We included RCTs comparing INF versus any other pharmacological/non‐pharmacological intervention for the treatment of children in acute pain (aged < 18 years). Data collection and analysis Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions. Main results Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a “bad taste” and vomiting with INF. Overall the risk of bias in all studies was considered low. Authors' conclusions INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non‐inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause. Plain language summary Intranasal fentanyl for the treatment of children in acute pain Background Pain is the most common reason why patients are seen in emergency departments (EDs). The challenging nature of treating children in acute severe pain is reflected in the medical literature by poor pain management in this population. We reviewed evidence on the effect of intranasal fentanyl (INF) (a strong pain relief drug, similar to morphine) compared with any other pain‐relieving technique for treatment of children in acute severe pain. Study characteristics We included studies with children (younger than 18 years of age) suffering from acute severe pain as a result of injury or medical illness. The target intervention was INF administered for pain relief compared with any other drug intervention for pain relief (e.g. intravenous morphine) or non‐drug intervention (e.g. limb splinting, wound dressing) provided in the emergency setting. The evidence is current to January 2014. Key results We identified three studies that included 313 children with acute severe pain resulting from broken bones of the upper and lower limbs. These trials compared INF versus morphine administered by a needle into a muscle (intramuscular morphine) or via a drip into a vein (intravenous morphine), as well as standard concentration INF versus high concentration INF. The collective study population in these trials consisted of children three to 15 years of age. Males accounted for approximately two‐thirds of the overall study population. The review concluded that INF may be an effective analgesic for the treatment of children in acute moderate to severe pain, and its administration appears to cause minimal distress to children; however, the evidence is insufficient to permit judgement of the effects of INF compared with intramuscular or intravenous morphine. No serious adverse events (e.g. opiate toxicity, death) were reported. Limitations Limitations of this review include the following: Few studies (three) were eligible for inclusion; no study examined the use of INF in children younger than three years of age; no study included children with pain resulting from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Murphy, A, O'Sullivan, R, Wakai, A, Grant, TS, Barrett, MJ, Cronin, J, McCoy, SC, Hom, J, Kandamany, N", "articleTypes": [], "doi": "10.1002/14651858.CD009942.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.068Z" }, { "id": "84fd45d7-19e6-4e7a-aec5-4e28b04650c8", "pmid": "", "title": "Pharmacological interventions for cognitive decline in people with Down syndrome", "imported": false, "abstract": "Abstract - Background People with Down syndrome are vulnerable to developing dementia at an earlier age than the general population. Alzheimer's disease and cognitive decline in people with Down syndrome can place a significant burden on both the person with Down syndrome and their family and carers. Various pharmacological interventions, including donepezil, galantamine, memantine and rivastigmine, appear to have some effect in treating cognitive decline in people without Down syndrome, but their effectiveness for those with Down syndrome remains unclear. Objectives To assess the effectiveness of anti‐dementia pharmacological interventions and nutritional supplements for treating cognitive decline in people with Down syndrome. Search methods In January 2015, we searched CENTRAL, ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), Ovid MEDLINE, Embase, PsycINFO, seven other databases, and two trials registers. In addition, we checked the references of relevant reviews and studies and contacted study authors, other researchers and relevant drug manufacturers to identify additional studies. Selection criteria Randomised controlled trials (RCTs) of anti‐dementia pharmacological interventions or nutritional supplements for adults (aged 18 years and older) with Down syndrome, in which treatment was administered and compared with either placebo or no treatment. Data collection and analysis Two review authors independently assessed the risk of bias of included trials and extracted the relevant data. Review authors contacted study authors to obtain missing information where necessary. Main results Only nine studies (427 participants) met the inclusion criteria for this review. Four of these (192 participants) assessed the effectiveness of donepezil, two (139 participants) assessed memantine, one (21 participants) assessed simvastatin, one study (35 participants) assessed antioxidants, and one study (40 participants) assessed acetyl‐L‐carnitine. Five studies focused on adults aged 45 to 55 years, while the remaining four studies focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one between Norway and the UK, and one in Japan. Follow‐up periods in studies ranged from four weeks to two years. The reviewers judged all included studies to be at low or unclear risk of bias. Analyses indicate that for participants who received donepezil, scores in measures of cognitive functioning (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) ‐0.27 to 1.13) and measures of behaviour (SMD 0.42, 95% CI ‐0.06 to 0.89) were similar to those who received placebo. However, participants who received donepezil were significantly more likely to experience an adverse event (odds ratio (OR) 0.32, 95% CI 0.16 to 0.62). The quality of this body of evidence was low. None of the included donepezil studies reported data for carer stress, institutional/home care, or death. For participants who received memantine, scores in measures of cognitive functioning (SMD 0.05, 95% CI ‐0.43 to 0.52), behaviour (SMD ‐0.17, 95% CI ‐0.46 to 0.11), and occurrence of adverse events (OR 0.45, 95% CI 0.18 to 1.17) were similar to those who received placebo. The quality of this body of evidence was low. None of the included memantine studies reported data for carer stress, institutional/home care, or death. Due to insufficient data, it was possible to provide a narrative account only of the outcomes for simvastatin, antioxidants, and acetyl‐L‐carnitine. Results from one pilot study suggest that participants who received simvastatin may have shown a slight improvement in cognitive measures. Authors' conclusions Due to the low quality of the body of evidence in this review, it is difficult to draw conclusions about the effectiveness of any pharmacological intervention for cognitive decline in people with Down syndrome. Plain language summary Medications for cognitive decline in people with Down syndrome People with Down syndrome often experience cognitive decline (a deterioration in memory, language, thinking and judgment that are greater than normal age‐related changes) at a younger age and in greater numbers than the general population. Various medicines have been shown to improve, or at least slow down the progression of these symptoms in people without Down syndrome. Review question Do adults (18 years and older) with Down syndrome benefit from treatment with medicine to prevent cognitive decline, compared with other adults with Down syndrome who receive either fake medicine (placebos) or no medicine? Study characteristics In January 2015, we, a team of Cochrane researchers, searched for all medical studies that investigated the effect of any medicine or nutritional supplement on cognitive decline in adults with Down syndrome. We found nine relevant randomised controlled trials (this design produces the most reliable results) that we could include in this overview. These studies tested: ‐ donepezil, a medicine used to treat Alzheimer's disease (four studies); ‐ memantine, a medicine used to treat Alzheimer's disease (two studies); ‐ simvastatin, a (statin) medicine used to prevent heart disease (one study); ‐ a mixture of antioxidants, including forms of vitamins C and E, and alpha‐lipoic acid (one study); and ‐ acetyl‐L‐carnitine, a dietary supplement that has previously been used to treat dementia (one study). Five of the studies focused on adults aged 45 to 55 years and four focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one took place in Norway and the UK, and one study was conducted in Japan. Key results The nine studies we found examined the effects of five medicines that are, or have been, used to prevent cognitive decline. All the studies compared the medicine being tested with a placebo (a tablet or capsule that looked and tasted like the medicine, but which contained no medicine). Generally, those who received the medicine did no better than those who received the placebo in any of the areas assessed in the studies. The areas assessed included general functioning (including memory and thinking, speech, mood and behaviour); cognitive functioning (including memory, following what’s going on around you); adaptive behaviours (being able to do day‐to‐day tasks); or behaviour problems (such as being irritable or aggressive). The only medicine to show any positive effect was the statin, simvastatin. Preliminary findings from a very small study showed that simvastin had some benefit on improving memory compared to placebo. In the four donepezil studies, those participants given donepezil reported more headaches, dizziness, and nausea than participants given placebo. In the two memantine studies, there was no difference between participants given memantine or placebo for reports of headaches, dizziness, and nausea. Quality of the evidence Although the included studies were well conducted, most involved small numbers of participants and for many of the areas assessed we could not combine results from two or more studies. Overall, the quality of this evidence is low. We cannot be certain whether any of these medicines are effective. Running more trials with more people over a longer period of time would allow us answer this question with greater certainty. We could not find any trials that investigated many of the medicines used to prevent cognitive decline, and so research is needed to explore the effectiveness of these medications in the Down syndrome population.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Livingstone, N, Hanratty, J, McShane, R, Macdonald, G", "articleTypes": [], "doi": "10.1002/14651858.CD011546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.133Z" }, { "id": "8510500e-1d5a-462c-80de-905225f129d6", "pmid": "", "title": "Dissecting the Heterogeneity of Oral Cancer Pain", "imported": false, "abstract": "Oral squamous cell carcinoma (SCC) produces a higher prevalence and more severe pain than all other cancers. Orofacial pain is one of the most common initial symptoms of oral cancer and often leads to the diagnosis of oral cancer. However, the character, severity, and unique features of oral cancer widely differ between patients. There is currently no effective and lasting treatment available to alleviate suffering from oral cancer pain.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.242Z" }, { "id": "85249eb4-12b9-4054-9e4c-ba3ef9d5ef16", "pmid": "", "title": "Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low‐ and middle‐income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid‐based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition. Objectives To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low‐ and middle‐income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective. Search methods In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. Selection criteria We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before‐and‐after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low‐ and middle‐income countries. Data collection and analysis Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses using the random‐effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods. Main results Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care ‐ the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight‐for‐height (MD 0.20 z‐score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid‐based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses ‐ there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid‐based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non‐recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight‐for‐height, and mid‐upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid‐based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses ‐ no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid‐based nutrient supplements versus specific types of blended foods ‐ a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods ‐ in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet ‐ no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. Authors' conclusions In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short‐term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent. Plain language summary Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries Moderate acute malnutrition (MAM) affects around 10% of children under five years of age in low‐ and middle‐income countries. Different food strategies have been used for the nutritional recovery of children with MAM, such as lipid‐based nutrient supplements or blended foods, which can be provided in full dose or in a low dose as a complement to the usual diet. However, there is no definitive consensus on the most effective way to treat children with MAM. We searched eight electronic databases and three trials registers (in October 2012 for all except Embase, which was searched in August 2012). We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. We found eight relevant randomised controlled trials, enrolling 10,037 children under five years of age. All but one study was conducted in Africa. The risk of bias in the studies was generally low, though two studies had a high dropout rate. The participants were aware which intervention group they were in and this may have influenced their behaviour but we thought it unlikely it would have influenced the results since the outcomes measured were objective ones. For four of the studies, we were unable to assess if the study authors reported all the outcomes they intended to measure. When any type of specially formulated food was compared to standard care (medical care and counselling without foods), the children treated with foods had a higher chance of recovering from moderate malnutrition (two studies), greater improvement in nutritional status (two studies), and a lower number of dropouts (one study). A reduction in mortality was not shown. When lipid‐based nutrient supplements (which are food with high energy density and high lipid content) at full dose were compared to blended foods at full dose (which are dry food mixtures without high lipid content), there was no difference between these two types of foods in terms of number of deaths (five studies), children progressing to severe acute malnutrition (three studies), and children dropping out (four studies). However, lipid‐based nutrient supplements increased the number recovered by 10% (five studies), decreased the number of children non‐recovering (three studies), and slightly improved the nutritional status among the recovered. One study observed more children vomiting when given lipid‐based nutrient supplements compared to blended foods, but this was not reported by the other studies. No other side effects were reported. Few studies evaluated foods at complementary dosage (i.e. foods given in low quantity, just to complement the diet and not to fully substitute it), and no conclusion could be drawn from these studies. When specific foods were compared to each other, a type of corn‐soy blended food called CSB++ compared to lipid‐based nutrient supplements resulted in similar outcomes, while results of another blended food (CSB pre‐mix) versus lipid‐based nutrient supplements were unclear. In one study, CSB++ did not show any significant benefit over locally‐made blended foods, for example, Misola. No study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with moderate acute malnutrition. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. There are no studies evaluating special recipes to improve the adequacy of the usual home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lazzerini, M; Rubert, L; Pani, P", "articleTypes": [], "doi": "10.1002/14651858.CD009584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "852f5a89-f176-4257-b429-662801f7198a", "pmid": "", "title": "Preoperative fasting for preventing perioperative complications in children", "imported": false, "abstract": "Abstract - Background Children, like adults, are required to fast before general anaesthesia with the aim of reducing the volume and acidity of their stomach contents. It is thought that fasting reduces the risk of regurgitation and aspiration of gastric contents during surgery. Recent developments have encouraged a shift from the standard 'nil‐by‐mouth‐from‐midnight' fasting policy to more relaxed regimens. Practice has been slow to change due to questions relating to the duration of a total fast, the type and amount of intake permitted. Objectives To systematically assess the effects of different fasting regimens (duration, type and volume of permitted intake) and the impact on perioperative complications and patient well being (aspiration, regurgitation, related morbidity, thirst, hunger, pain, comfort, behaviour, nausea and vomiting) in children. Search methods We searched Cochrane Wounds Group Specialised Register (searched 25/6/09), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 2 2009), Ovid MEDLINE (1950 to June Week 2 2009), Ovid EMBASE (1980 to 2009 Week 25), EBSCO CINAHL (1982 to June Week 3 2009), the National Research Register, relevant conference proceedings and article reference lists and contacted experts. Selection criteria Randomised and quasi randomised controlled trials of preoperative fasting regimens for children were identified. Data collection and analysis Data extraction and trial quality assessment was conducted independently by three authors. Trial authors were contacted for additional information including adverse events. Main results This first update of the review identified two additional eligible studies, bringing the total number of included studies to 25 (forty seven randomised controlled comparisons involving 2543 children considered to be at normal risk of regurgitation or aspiration during anaesthesia). Only one incidence of aspiration and regurgitation was reported. Children permitted fluids up to 120 minutes preoperatively were not found to experience higher gastric volumes or lower gastric pH values than those who fasted. The children permitted fluids were less thirsty and hungry, better behaved and more comfortable than those who fasted. Clear fluids preoperatively did not result in a clinically important difference in children's gastric volume or pH. Evidence relating to the preoperative intake of milk was sparse. The volume of fluid permitted during the preoperative period did not appear to impact on children's intraoperative gastric volume or pH contents. Authors' conclusions There is no evidence that children who are denied oral fluids for more than six hours preoperatively benefit in terms of intraoperative gastric volume and pH compared with children permitted unlimited fluids up to two hours preoperatively. Children permitted fluids have a more comfortable preoperative experience in terms of thirst and hunger. This evidence applies only to children who are considered to be at normal risk of aspiration/regurgitation during anaesthesia. Plain language summary Preoperative fasting for children to prevent complications during surgery General anaesthetics inhibit the protective reflexes that stop the stomach contents reaching the lungs. In order to prevent the inadvertent inhalation of stomach contents, children are often advised to have nothing to eat or drink from the midnight before surgery. However, the review of trials found that drinking clear fluids up to a few hours before surgery did not increase the risk of regurgitation during or after surgery. Indeed there is an added benefit of a more comfortable preoperative experience in terms of thirst and hunger. Some children are considered more likely to regurgitate under anaesthetic, including those who are obese or have stomach disorders. More research is needed to determine whether these children can also safely drink up to a few hours before surgery.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brady, MC; Kinn, S; Ness, V; O'Rourke, K; Randhawa, N; Stuart, P", "articleTypes": [], "doi": "10.1002/14651858.CD005285.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "854d6368-40d6-4288-b811-1d1223858fd2", "pmid": "", "title": "Open versus closed surgical exposure of canine teeth that are displaced in the roof of the mouth", "imported": false, "abstract": "Abstract - Background Palatally displaced canines or PDCs are upper permanent canines, commonly known as 'eye' teeth, that are displaced in the roof of the mouth. This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. PDCs are a frequent dental anomaly, present in 2% to 3% of young people. Management of this problem is both time consuming and expensive. It involves surgical exposure (uncovering) followed by fixed braces for two to three years to bring the canine into alignment within the dental arch. Two techniques for exposing palatal canines are routinely used in the UK: the closed technique and the open technique. The closed technique involves uncovering the canine, attaching an eyelet and gold chain and then suturing the palatal mucosa back over the tooth. The tooth is then moved into position covered by the palatal mucosa. The open technique involves uncovering the canine tooth and removing the overlying palatal tissue to leave it uncovered. The orthodontist can then see the crown of the canine to align it. Objectives To assess the effects of using either an open or closed surgical method to expose canines that have become displaced in the roof of the mouth, in terms of success and other clinical and patient‐reported outcomes. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 24 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (in the Cochrane Library, 2017, Issue 1), MEDLINE Ovid (1946 to 24 February 2017), and Embase Ovid (1980 to 24 February 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised and quasi‐randomised controlled trials assessing young people receiving surgical treatment to correct upper PDCs. There was no restriction on age, presenting malocclusion or type of active orthodontic treatment undertaken. We included unilaterally and bilaterally displaced canines. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias in the included studies. We attempted to contact study authors for missing data or clarification where feasible. We followed statistical guidelines from the Cochrane Handbook for Systematic Reviews of Interventions for data synthesis. Main results We included three studies, involving 146 participants. Two studies were assessed as being at high risk of bias. The main finding of the review was that the two techniques may be equally successful at exposing PDCs (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.93 to 1.06; three studies, 141 participants analysed, low‐quality evidence). One surgical failure was due to detachment of the gold chain (closed group). One study reported on complications following surgery and found two in the closed group: a post‐operative infection requiring antibiotics and pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to pool data for dental aesthetics, patient‐reported pain and discomfort, periodontal health and treatment time; however, individual studies did not find any differences between the surgical techniques (low‐ to very low‐quality evidence). Authors' conclusions Currently, the evidence suggests that neither the open or closed surgical technique for exposing palatally displaced maxillary canine teeth is superior for any of the outcomes included in this review; however, we considered the evidence to be low quality, with two of the three included studies being at high risk of bias. This suggests the need for more high‐quality studies. Three ongoing clinical trials have been identified and it is hoped that these will produce data that can be pooled to increase the degree of certainty in these findings. Plain language summary Open versus closed surgical exposure of eye teeth that are displaced in the roof of the mouth Review question Is it better to use an open or closed surgical method to expose eye teeth ('canines') that have become displaced in the roof of the mouth? Background Permanent canine teeth in the upper jaw usually erupt into the mouth between the ages of 11 to 12 years. In 2% to 3% of young people, the canine teeth fail to erupt (grow down) and become displaced in the roof of the mouth (palate).This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts. Management of this problem is both time consuming and expensive. It usually involves surgical exposure (uncovering), followed by fixed orthodontic braces for two to three years, to move the canine into the correct position. Two surgical techniques are routinely used in the UK: the closed technique involves uncovering the buried tooth, gluing an attachment onto the exposed tooth and repositioning the palatal flap. Shortly after surgery, an orthodontic brace is used to apply gentle forces to bring the canine into its correct position within the dental arch. The canine moves into position beneath the gum. An alternative method is the open technique, which involves surgically uncovering the canine tooth as before, but instead of placing an attachment onto the exposed tooth, a window of gum from around the tooth is removed and a dressing (pack) placed to cover the exposed area. Approximately 10 days later, this pack is removed and the canine is allowed to erupt naturally. Once the tooth has erupted sufficiently for an orthodontic attachment to be glued onto its surface, orthodontic braces are used to bring the tooth in line with the other teeth. Study characteristics The evidence in this review is up‐to‐date as of February 2017. Authors with Cochrane Oral Health found three relevant studies, involving 146 participants who had eye teeth displaced in the roof of the mouth, either on one or both sides. The majority of participants were female and the average age in the studies ranged from 14 to 17 years. Two studies were designed in a way that made them likely to be biased. Key results We combined results from three studies and found that one technique did not seem to have an advantage over the other for ensuring the movement of the tooth into the correct position without the need for repeat surgery. Five out of 141 participants analysed were surgical failures, one of which was due to the complication of detachment of the gold chain during surgery. One study reported complications after surgery and found one participant in the closed group had a post‐operative infection requiring antibiotics and another participant in the closed group experienced pain during alignment of the canine as the gold chain penetrated through the gum tissue of the palate. We were unable to combine results from studies for any other outcomes, but individual studies did not show evidence of a difference between the two techniques for pain, discomfort, appearance, gum health, length of treatment time or cost (low to very low quality evidence). Quality of the evidence Overall, we assessed the quality of the evidence as low, which means we cannot be certain of the findings. Author conclusions It does not seem that one surgical technique is better than the other for moving displaced eye teeth into the correct position, or for other outcomes, but this finding is uncertain because the quality of the evidence is low. This suggests the need for more high‐quality studies. Three studies are currently in process. When they are completed, we will include them in an update of this review and may be able to reach firmer conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Parkin, N, Benson, PE, Thind, B, Shah, A, Khalil, I, Ghafoor, S", "articleTypes": [], "doi": "10.1002/14651858.CD006966.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.741Z" }, { "id": "854f101d-3668-40e4-83ec-4bb019a59826", "pmid": "", "title": "Silver acetate for smoking cessation", "imported": false, "abstract": "Abstract - Background Silver acetate produces an unpleasant taste when combined with cigarettes, thereby producing an aversive stimulus. It has been marketed in various forms with the aim of extinguishing the urge to smoke, by pairing the urge with an unpleasant stimulus. Objectives The aim of this review was to determine the effectiveness of silver acetate products (gum, lozenge, spray) in promoting smoking cessation. Search methods We searched the Cochrane Tobacco Addiction Group specialised trials register. Most recent search was in July 2012. Selection criteria We included randomised trials of silver acetate for smoking cessation with reports of smoking status at least six months after the beginning of treatment. Data collection and analysis We extracted data in duplicate on the type of subjects, the dose and form of silver acetate, the outcome measures, method of randomisation, and completeness of follow‐up. The main outcome measure was biochemically validated abstinence from smoking after at least six months follow‐up in patients smoking at baseline. Subjects lost to follow‐up were counted as continuing smokers. Where appropriate, we performed meta‐analysis using a fixed effects model. Main results Two studies provided long‐term follow‐up data on patients randomised to silver acetate or placebo. In one of these studies, there was a third arm, randomised to 2mg nicotine gum. The pooled risk ratio for quitting for silver acetate vs placebo was 1.04 (95% confidence interval 0.69 to 1.57). Authors' conclusions Existing trials show little evidence for a specific effect of silver acetate in promoting smoking cessation. The confidence intervals for the ratio are quite wide. However, the upper limit of the confidence intervals for a positive effect equates to an absolute increase in the smoking cessation rate of about 4%. Any effect of this agent is therefore likely to be smaller than nicotine replacement therapy. The lack of effect of silver acetate may reflect poor compliance with a treatment whose rationale is to create an unpleasant stimulus. Plain language summary Does silver acetate help people stop smoking Silver acetate products (gum, lozenge, and spray) produce an unpleasant metallic taste when combined with cigarettes, so they are used as a form of aversion therapy for smoking. However, the review of trials found little evidence to show that silver acetate helps smokers quit. Any beneficial effect of silver acetate is likely to be very small, and less than the effect already proven for nicotine replacement therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lancaster, T, Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000191.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.061Z" }, { "id": "854f459c-85af-44a1-a61f-2c62fcfe1c7b", "pmid": "", "title": "Effects of Infant Formula Composition on Infant Feeding Behaviors", "imported": false, "abstract": "There is a paucity of information on whether and how the composition of formulas fed to infants influences their short-term feeding behaviors during the first few months of life. The purpose of this study is to investigate whether the composition of infant formula affects infants' feeding behaviors, in particular, how much formula is consumed within a given feed (i.e., measure of satiation) and how much time elapses after the feed until the infant exhibits signs of hunger (i.e., measure of satiety). The investigators will also examine the relationship between the composition of infant formula consumed and infant temperature, activity, sleep, and mothers' perceptions of infants' intake and regulatory behaviors.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.245Z" }, { "id": "85a99dc9-140a-4137-943f-a0b55c00efa9", "pmid": "", "title": "Advice to reduce dietary salt for prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Restricting sodium intake in hypertensive patients over short periods of time reduces blood pressure. Long term effects (on mortality, morbidity or blood pressure) of advice to reduce salt in patients with elevated or normal blood pressure are unclear. Objectives To assess in adults the long term effects (mortality, cardiovascular events, blood pressure, quality of life, weight, urinary sodium excretion, other nutrients and use of anti‐hypertensive medications) of advice to restrict dietary sodium using all relevant randomised controlled trials. Search methods The Cochrane Library, MEDLINE, EMBASE, bibliographies of included studies and related systematic reviews were searched for unconfounded randomised trials in healthy adults aiming to reduce sodium intake over at least 6 months. Attempts were made to trace unpublished or missed studies and authors of all included trials were contacted. There were no language restrictions. Selection criteria Inclusion decisions were independently duplicated and based on the following criteria: 1) randomisation was adequate; 2) there was a usual or control diet group; 3) the intervention aimed to reduce sodium intake; 4) the intervention was not multifactorial; 5) the participants were not children, acutely ill, pregnant or institutionalised; 6) follow‐up was at least 26 weeks; 7) data on any of the outcomes of interest were available. Data collection and analysis Decisions on validity and data extraction were made independently by two reviewers, disagreements were resolved by discussion or if necessary by a third reviewer. Random effects meta‐analysis, sub‐grouping, sensitivity analysis and meta‐regression were performed. Main results Three trials in normotensives (n=2326), five in untreated hypertensives (n=387) and three in treated hypertensives (n=801) were included, with follow up from six months to seven years. The large, high quality (and therefore most informative) studies used intensive behavioural interventions. Deaths and cardiovascular events were inconsistently defined and reported; only 17 deaths equally distributed between intervention and control groups occurred. Systolic and diastolic blood pressures were reduced at 13 to 60 months in those given low sodium advice as compared with controls (systolic by 1.1 mm Hg, 95% CI 1.8 to 0.4, diastolic by 0.6 mm hg, 95% CI 1.5 to ‐0.3), as was urinary 24 hour sodium excretion (by 35.5 mmol/ 24 hours, 95% CI 47.2 to 23.9). Degree of reduction in sodium intake and change in blood pressure were not related. People on anti‐hypertensive medications were able to stop their medication more often on a reduced sodium diet as compared with controls, while maintaining similar blood pressure control. Authors' conclusions Intensive interventions, unsuited to primary care or population prevention programmes, provide only minimal reductions in blood pressure during long‐term trials. Further evaluations to assess effects on morbidity and mortality outcomes are needed for populations as a whole and for patients with elevated blood pressure. A low sodium diet may help in maintenance of lower blood pressure following withdrawal of antihypertensives. If this is confirmed, with no increase in cardiovascular events, then targeting of comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. Plain language summary The long term effects of advice to cut down on salt in food on deaths, cardiovascular disease and blood pressure in adults Intensive support and encouragement to reduce salt intake did lead to reduction in salt eaten. It also lowered blood pressure but only by a small amount (about 1 mmHg for systolic blood pressure, less for diastolic) after more than a year. This reduction was not enough to expect an important health benefit. It was also very hard to keep to a low salt diet. However, the reduction in blood pressure appeared larger for people with higher blood pressure. There was not enough information to assess the effect of these changes in salt intake on health or deaths. Evidence from a large and small trial showed that advice to reduce salt helps to maintain lower blood pressure following withdrawal of antihypertensive medication. If this is confirmed, with no increase in cardiovascular events, then comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. See also the Cochrane review of short‐term salt reduction trials: Jurgens 2003 .", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Hooper, L, Bartlett, C, Davey Smith, G, Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD003656.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.060Z" }, { "id": "85b027ae-9377-4b82-b0ba-eaf6811f5e15", "pmid": "", "title": "Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors", "imported": false, "abstract": "Abstract - Background Poor diet and insufficient physical activity are major risk factors for non‐communicable diseases. Developing healthy diet and physical activity behaviors early in life is important as these behaviors track between childhood and adulthood. Parents and other adult caregivers have important influences on children's health behaviors, but whether their involvement in children's nutrition and physical activity interventions contributes to intervention effectiveness is not known. Objectives • To assess effects of caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors, including those intended to prevent overweight and obesity • To describe intervention content and behavior change techniques employed, drawing from a behavior change technique taxonomy developed and advanced by Abraham, Michie, and colleagues (Abraham 2008; Michie 2011; Michie 2013; Michie 2015) • To identify content and techniques related to reported outcomes when such information was reported in included studies Search methods In January 2019, we searched CENTRAL, MEDLINE, Embase, 11 other databases, and three trials registers. We also searched the references lists of relevant reports and systematic reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of interventions to improve children's dietary intake or physical activity behavior, or both, with children aged 2 to 18 years as active participants and at least one component involving caregivers versus the same interventions but without the caregiver component(s). We excluded interventions meant as treatment or targeting children with pre‐existing conditions, as well as caregiver‐child units residing in orphanages and school hostel environments. Data collection and analysis We used standard methodological procedures outlined by Cochrane. Main results We included 23 trials with approximately 12,192 children in eligible intervention arms. With the exception of two studies, all were conducted in high‐income countries, with more than half performed in North America. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The specific intervention strategies used were not always reported completely. However, based on available reports, the behavior change techniques used most commonly in the child‐only arm were \"shaping knowledge,\" \"comparison of behavior,\" \"feedback and monitoring,\" and \"repetition and substitution.\" In the child + caregiver arm, the strategies used most commonly included additional \"shaping knowledge\" or \"feedback and monitoring\" techniques, as well as \"social support\" and \"natural consequences.\" We considered all trials to be at high risk of bias for at least one design factor. Seven trials did not contribute any data to analyses. The quality of reporting of intervention content varied between studies, and there was limited scope for meta‐analysis. Both validated and non‐validated instruments were used to measure outcomes of interest. Outcomes measured and reported differed between studies, with 16 studies contributing data to the meta‐analyses. About three‐quarters of studies reported their funding sources; no studies reported industry funding. We assessed the quality of evidence to be low or very low. Dietary behavior change interventions with a caregiver component versus interventions without a caregiver component Seven studies compared dietary behavior change interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (mean difference [MD] −0.42%, 95% confidence interval [CI] −1.25 to 0.41, 1 study, n = 207; low‐quality evidence) or from sodium intake (MD −0.12 g/d, 95% CI −0.36 to 0.12, 1 study, n = 207; low‐quality evidence). No trial in this comparison reported data for children's combined fruit and vegetable intake, sugar‐sweetened beverage (SSB) intake, or physical activity levels, nor for adverse effects of interventions. Physical activity interventions with a caregiver component versus interventions without a caregiver component Six studies compared physical activity interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's total physical activity (MD 0.20 min/h, 95% CI −1.19 to 1.59, 1 study, n = 54; low‐quality evidence) or moderate to vigorous physical activity (MVPA) (standard mean difference [SMD] 0.04, 95% CI −0.41 to 0.49, 2 studies, n = 80; moderate‐quality evidence). No trial in this comparison reported data for percentage of children's total energy intake from saturated fat, sodium intake, fruit and vegetable intake, or SSB intake, nor for adverse effects of interventions. Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component Ten studies compared dietary and physical activity interventions with and without a caregiver component. At the end of the intervention, we detected a small positive impact of a caregiver component on children's SSB intake (SMD −0.28, 95% CI −0.44 to −0.12, 3 studies, n = 651; moderate‐quality evidence). We did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (MD 0.06%, 95% CI −0.67 to 0.80, 2 studies, n = 216; very low‐quality evidence), sodium intake (MD 35.94 mg/d, 95% CI −322.60 to 394.47, 2 studies, n = 315; very low‐quality evidence), fruit and vegetable intake (MD 0.38 servings/d, 95% CI −0.51 to 1.27, 1 study, n = 134; very low‐quality evidence), total physical activity (MD 1.81 min/d, 95% CI −15.18 to 18.80, 2 studies, n = 573; low‐quality evidence), or MVPA (MD −0.05 min/d, 95% CI −18.57 to 18.47, 1 study, n = 622; very low‐quality evidence). One trial indicated that no adverse events were reported by study participants but did not provide data. Authors' conclusions Current evidence is insufficient to support the inclusion of caregiver involvement in interventions to improve children's dietary intake or physical activity behavior, or both. For most outcomes, the quality of the evidence is adversely impacted by the small number of studies with available data, limited effective sample sizes, risk of bias, and imprecision. To establish the value of caregiver involvement, additional studies measuring clinically important outcomes using valid and reliable measures, employing appropriate design and power, and following established reporting guidelines are needed, as is evidence on how such interventions might contribute to health equity. Plain language summary Effects of involving parents and other adult caregivers in children's diet and physical activity interventions Review question Does it make a difference if parents or other adult caregivers are involved in interventions to encourage children to eat healthier or be more physically active? Background Diet and physical activity behaviors are important determinants of health. Parents and other adult caregivers have an essential role in shaping children's health habits by controlling availability of and access to healthy foods and opportunities to be active; supporting, encouraging, and role‐modeling healthy behaviors; and adopting supportive feeding styles and practices. For these reasons, it often is argued that parent and caregiver involvement in children's diet and physical activity interventions is important; however, it remains unclear if involvement of parents and caregivers actually provides benefit. Objectives We assessed the effects of involving parents or other adult caregivers in children's healthy eating and physical activity interventions compared to the effects of the same child interventions without a parent or caregiver component. We were particularly interested in understanding effects on children's dietary intake, children's physical activity levels, and adverse effects of interventions. Study characteristics We found 23 studies, published between 1982 and 2019, that implemented diet interventions, physical activity interventions, or combined diet and physical activity interventions with children or adolescents, and evaluated the effects of adding an intervention component involving parents or other adult caregivers. Approximately 12,192 children aged 2 to 18 years were examined. More than half of studies took place in North America, and all but two were conducted in high‐income countries. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The breadth of information provided about intervention content varied between studies. The most commonly used intervention techniques were those aimed at shaping participants' knowledge, such as providing instruction about how to perform a behavior (e.g. dance, cooking lessons). About three‐quarters of studies reported their funding source; no studies reported industry funding. Key results The findings of this review suggest that adding a parent or caregiver component to dietary behavior change interventions or physical activity interventions may make little or no difference to children's dietary intake or physical activity levels. For interventions that target both diet and physical activity behaviors, involving a parent or caregiver probably slightly reduces children's sugar‐sweetened beverage intake by the end of the intervention. We do not know whether any of these types of interventions result in adverse effects because these data are not available. Quality of evidence Overall, the evidence from studies is of low or very low quality, which means that we are uncertain about study results. Currentness of evidence The evidence is current to January 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Morgan, EH; Schoonees, A; Sriram, U; Faure, M; Seguin‐Fowler, RA", "articleTypes": [], "doi": "10.1002/14651858.CD012547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "85b2c4de-4f4c-4670-af8f-744d40695117", "pmid": "", "title": "Oral stimulation for promoting oral feeding in preterm infants", "imported": false, "abstract": "Abstract - Background Preterm infants (< 37 weeks' post‐menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co‐ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review. Objectives To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA. Search methods Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi‐randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis. Selection criteria Randomised and quasi‐randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non‐oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes. Data collection and analysis Following the updated search, two review authors screened the titles and abstracts of studies and full‐text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non‐oral or sham intervention. We performed meta‐analysis using a fixed‐effect model. Main results We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) ‐4.07 days, 95% confidence interval (CI) ‐4.81 to ‐3.32 days, 6 studies, 292 infants; I 2 =85%, very low‐certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD ‐4.33, 95% CI ‐5.97 to ‐2.68 days, 5 studies, 249 infants; i 2 =68%, very low‐certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non‐oral intervention Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non‐oral intervention (MD ‐7.17, 95% CI ‐8.04 to ‐6.29 days, 10 studies, 574 infants; I 2 =80%, very low‐certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD ‐6.15, 95% CI ‐8.63 to ‐3.66 days, 10 studies, 591 infants; I 2 =0%, low‐certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD ‐2.85, 95% CI ‐6.13 to 0.42, 3 studies, 268 infants; very low‐certainty evidence due to serious risk of bias, inconsistency and imprecision). Authors' conclusions There remains uncertainty about the effects of oral stimulation (versus either standard care or a non‐oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta‐analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well‐designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions. Plain language summary Effects of oral stimulation for oral feeding in preterm infants Review questions Do oral stimulation interventions that involve finger stimulation protocols in preterm infants born before 37 weeks' gestation: Reduce time (days) taken to achieve exclusive oral feeding? Reduce time (days) spent in Neonatal Intensive Care (NICU)? Reduce length of time (days) spent in hospital? Reduce length of time (days) that an infant spends on tube feeding (parenteral nutrition)? Background This is an update of the 2016 review. Many preterm infants have delayed establishment of oral (suck) feeding and are fed at first with feeding tubes or with intravenous (parenteral) nutrition. Development of oral feeding skills needs careful co‐ordination of sucking, swallowing and breathing. In preterm infants, the development of oral feeding can be challenging because of long hospitalisations, breathing difficulties and other medical conditions associated with preterm birth. Unpleasant and invasive procedures such as ventilation or frequent suctioning of secretions from the mouth or nose can negatively impact feeding skills. International guidelines for the transition from tube feeding to oral feeding vary widely. Healthcare providers use a range of interventions to improve sucking and feeding skills in preterm infants, and studies report faster transition time from tube feeds to oral feeds, reduced length of stay in hospital and improvement in infants' sucking skills. The first review in 2016 showed that while oral stimulation interventions appear to reduce length of hospital stay, reduce need for tube feeding and accelerate time to oral feeding, the studies were of poor methodological quality leaving some uncertainty about overall effects. This update assessed whether current research supports these findings and if the quality of studies has improved, leading to increased certainty of results. Study characteristics This review included randomised controlled trials (RCTs) that explored oral stimulation by finger stimulation only in preterm infants. Review authors identified studies to be included by searching electronic databases, clinical trials registers, peer‐reviewed journals and published conference proceedings. Search is up‐to‐date as of March 2022. Key results For this update, we added 12 new studies of variable quality with small numbers of participants, making a total of 28 included studies. As the certainty of evidence was considered 'low' to 'very low', it remains uncertain whether oral stimulation interventions can shorten the transition to oral feeding, reduce length of hospital stay and decrease time spent on parenteral nutrition, although there may be some potential benefit. No studies reported length of stay in NICU. No studies looked at longer‐term outcomes of the interventions (i.e. beyond six months). Certainty of evidence The numbers of infants in these studies were small, the methods employed by researchers varied in quality and the certainty of evidence is estimated to be 'low' to 'very low'.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, Z; O'Donnell, CPF; Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD009720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "85bfe562-2364-48de-81e6-586d8d8ffbd6", "pmid": "", "title": "Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years", "imported": false, "abstract": "Abstract - Background Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health. Objectives To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non‐dietary intervention. Secondary objectives were to assess the impact of ECEC‐based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality‐of‐life outcomes. We also report on cost and adverse consequences of ECEC‐based healthy eating interventions. Search methods We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers. Selection criteria We included randomised controlled trials (RCTs), including cluster‐RCTs, stepped‐wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross‐over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both. Data collection and analysis Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta‐analyses using a random‐effects model; otherwise, we described findings using vote‐counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes. Main results We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster‐RCTs. Twenty‐nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty‐eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC‐based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I 2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I 2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC‐based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI −0.01 to 0.25; P =0.08, I 2 = 70%; 13 studies, 3335 children). There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely result in little to no difference in children's consumption of non‐core (i.e. less healthy/discretionary) foods (SMD −0.05, 95% CI −0.17 to 0.08; P = 0.48, I 2 = 16%; 7 studies, 1369 children) or consumption of sugar‐sweetened beverages (SMD −0.10, 95% CI −0.34 to 0.14; P = 0.41, I 2 = 45%; 3 studies, 522 children). Thirty‐six studies measured BMI, BMI z‐score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC‐based healthy eating interventions may result in little to no difference in child BMI (MD −0.08, 95% CI −0.23 to 0.07; P = 0.30, I 2 = 65%; 15 studies, 3932 children) or in child BMI z‐score (MD −0.03, 95% CI −0.09 to 0.03; P = 0.36, I 2 = 0%; 17 studies; 4766 children). ECEC‐based healthy eating interventions may decrease child weight (MD −0.23, 95% CI −0.49 to 0.03; P = 0.09, I 2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I 2 = 0%; 5 studies, 1070 children). ECEC‐based healthy eating interventions may be cost‐effective but the evidence is very uncertain (6 studies). ECEC‐based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3). Authors' conclusions ECEC‐based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC‐based healthy eating interventions on vegetable consumption. ECEC‐based healthy eating interventions may result in little to no difference in child consumption of non‐core foods and sugar‐sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z‐scores. Future studies exploring the impact of specific intervention components, and describing cost‐effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC‐based healthy eating interventions. Plain language summary How successful are healthy eating programmes in preschools, kindergartens and childcare settings? Key messages • Healthy eating programmes delivered in early childhood education and care (ECEC) settings (e.g. preschools, kindergarten, family day care) may improve child diet quality, likely increase fruit consumption, may have favourable effects on vegetable consumption, and likely have no impact on consumption of less healthy foods and sugar‐sweetened drinks. They may have favourable effects on child weight and may reduce the risk of being overweight or obese. • We don't know if healthy eating interventions save money or cause unwanted effects because very few studies provided information about these points. • We found little evidence from low‐ and middle‐income countries, but healthy eating programmes in high‐income countries may benefit child health. We don't know how to support educators and staff to implement these programmes in practice. We need more research about delivering programmes and about their effect in low‐income countries. Why is it important to improve young children's diet? Having a poor diet puts people at risk of many long‐term diseases including heart disease, type 2 diabetes and certain types of cancers. Research estimates that over 11 million deaths worldwide are caused by having an unhealthy diet. Dietary behaviours and preferences are established early in life and persist into adulthood. What are healthy eating programmes? Healthy eating programmes aim to encourage children to eat a healthier diet. They may involve changes to lessons and the culture in preschools, kindergartens and day care centres (early childhood education and care (ECEC) settings), and working with children's families, teachers and healthcare staff. For example, introducing new fruits and vegetables to children, changing the menu to include healthier options or providing families with information about child healthy eating. Healthy eating programmes may establish lifelong healthy eating patterns, reduce excessive weight gain and improve overall health. What did we want to find out? We wanted to find out what impact healthy eating interventions have on child diet and health. We were interested in changes to diet, weight, language and cognitive performance, social, emotional and quality of life outcomes in children aged six months to six years attending preschool, long day care, nurseries, kindergartens and family day care services. We also wanted to know the cost of interventions and whether they had any potential unwanted effects. What did we do? We searched for studies that compared healthy eating programmes against no action, delayed delivery of the programme, or a programme that did not aim to change child diet. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 52 studies that looked at the effects of 58 healthy eating programmes in ECEC settings for children aged six months to six years. All studies were published in high and high‐middle‐income countries. The programmes were very different from each other. They: • lasted from 4 weeks to 3 years; • were delivered by a range of people including healthcare providers, ECEC staff, and researchers; • used different delivery methods (telephone, face‐to‐face, online, printed materials); and • measured results in a variety of ways (e.g. parent or staff surveys, observations of children's eating, and weighing foods before and after meals). Overall, the programmes aimed to: • change the ECEC environment (e.g. staff demonstrated healthy eating to children, and provided healthier foods); • change the curriculum (e.g. they provided lessons about foods and healthy eating); and • establish partnerships (e.g. they provided educational resources to families); and • increase children's physical activity (e.g. by structured physical activity lessons and encouraging less screen time). Healthy eating programmes may lead to small improvements in child diet quality, increase fruit consumption by 0.11 servings, potentially improve vegetable consumption by 0.12 servings and may have no effect on consumption of less healthy foods and sugar‐sweetened drinks. Further, we found child weight is potentially reduced by 230 g and for every 100 children, 19 would have better weight status. However, we found no evidence of impact on body mass index. The programmes may be cost‐effective and likely to have no unwanted effects, although few studies reported these points. Few studies reported on other learning, social and developmental outcomes. What are the limitations of the evidence? Our confidence in the evidence is low because the healthy eating programmes were conducted, delivered and assessed in different ways. Also, many of the people who received the healthy eating programmes were aware that they were being assessed and this can sometimes influence how they report their effects. For example, parents who reported their child's diet may have been more inclined to give positive answers because they felt they were doing what society expected or because they were grateful for the support and wanted to please the researchers. Also, not all studies provided information about everything we were interested in and there was often missing data when children were followed up after the study. How up‐to‐date is the evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yoong, SL; Lum, M; Wolfenden, L; Jackson, J; Barnes, C; Hall, AE; McCrabb, S; Pearson, N; Lane, C; Jones, JZ; Nolan, E; Dinour, L; McDonnell, T; Booth, D; Grady, A", "articleTypes": [], "doi": "10.1002/14651858.CD013862.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "85c50f6e-4320-4a9e-9f7e-0d243e02a995", "pmid": "", "title": "Immunostimulants for preventing respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are a major cause of childhood morbidity and mortality. Immunostimulants (IS) may reduce the incidence of ARTIs. Objectives To determine the efficacy and safety of IS in preventing ARTIs in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 1, which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to February week 4, 2011), EMBASE (1990 to February 2011), Google Scholar (2009 to February 2011), Scopus (2009 to February 2011), PASCAL (1990 to February 2010), SciSearch (1990 to February 2010) and IPA (1990 to February 2010). Selection criteria We included all comparative randomized controlled trials (RCTs) which enrolled participants less than 18 years of age. The intervention was IS medication, administered by any method, compared to placebo to prevent ARTIs. Data collection and analysis We analyzed the outcome on ARTIs both as the mean number of ARTIs by group and as a percent change in the rate of ARTIs. We undertook meta‐analyses using a random‐effects model and presented results as mean differences (MD) with 95% confidence intervals (CI). Two review authors independently assessed the search results and risk of bias, and extracted data. A funnel plot suggested there may be publication bias in the identified trials. Main results Thirty‐five placebo‐controlled trials (4060 participants) provided data in a form suitable for inclusion in the meta‐analyses. When compared with placebo, the use of IS was shown to reduce ARTIs measured as the total numbers of ARTIs (MD ‐1.24; 95% CI ‐1.54 to ‐0.94) and the difference in ARTI rates (MD ‐38.84%; 95% CI ‐46.37% to ‐31.31%). Trial quality was generally poor and a high level of statistical heterogeneity was evident. The subgroup analysis of bacterial IS, D53 and OM‐85 studies produced similar results, with lower heterogeneity. No difference in adverse events was evident between the placebo and IS groups. Authors' conclusions This review shows that IS reduce the incidence of ARTIs by 40% on average in susceptible children. Studies in healthy children are not available. Although the safety profile in the studies was good, some IS may be unsafe. ARTI‐susceptible children may benefit from IS treatment. Further high‐quality trials are needed and we encourage national health authorities to conduct large, multicentre, double‐blind, placebo‐controlled RCTs on the role of IS in preventing ARTIs in children. Plain language summary Immunostimulants to prevent acute respiratory tract infections in children Acute respiratory tract infections (ARTIs) are responsible for 19% of all deaths in children younger than five years of age, mainly in low‐income countries in Africa, Asia and Latin America. In high‐income countries ARTIs are among the most frequent illnesses, leading to 20% of medical consultations, 30% of days lost from work and 75% of antibiotic prescriptions. In the USA the total cost of non‐influenza‐related viral ARTIs is around $40 billion annually, while the corresponding cost for influenza is US $87.1 billion. The main signs and symptoms of ARTIs include sneezing, runny nose, sore throat, cough and malaise. Children living in rural communities, not attending daycare centres, suffer about seven ARTI episodes in the first year of life; eight ARTIs per year from the ages of one to four; six per year aged five to nine; and five per year aged 10 to 19. Children exposed to risks factors, such as attendance at daycare centres, overcrowding, contact with older siblings, smoking at home and lack of breast feeding, may suffer more ARTIs. Several treatments have been used to reduce the incidence of ARTIs (vitamin A, vitamin C, zinc, antibiotics). Among them are immunostimulants (herbal extracts, bacterial extracts, synthetic compounds), which aim to increase the immune defences of the respiratory tract. We searched for clinical trials of immunostimulants to prevent ARTIs in children compared to placebo. Our review includes 35 studies with 4060 participants. However, the quality of many of the studies was poor and the results were very diverse. By combining results, immunostimulants reduced 1.24 ARTIs in a six‐month period, equivalent to a 39% reduction in ARTIs compared to the placebo group. Only 20 studies provided adequate data on adverse events: the most frequent were rash, nausea, vomiting, abdominal pain and diarrhea. The main limitations of this review were the poor methodological quality and diverse trial results. We conclude that ARTI‐susceptible children may benefit from immunostimulants, but more high‐quality studies are needed. We suggest that national health authorities conduct high‐quality randomized controlled trials to assess the true effects of immunostimulant preparations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Del‐Rio‐Navarro, BE; Espinosa‐Rosales, FJ; Flenady, V; Sienra‐Monge, JJL", "articleTypes": [], "doi": "10.1002/14651858.CD004974.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "85cd2504-8b5d-4e1b-8fe7-ce78bad43d20", "pmid": "", "title": "Topical anaesthetic or vasoconstrictor preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy", "imported": false, "abstract": "Abstract - Background Nasal pharyngolaryngoscopy (NPL) is performed as an outpatient and inpatient procedure on a daily basis, for a variety of indications. It frequently causes some degree of discomfort to the patient. Various different topical agents, which are intended to reduce this discomfort, are in common use. This review aimed to assess the effectiveness of the various agents. Objectives To assess the effectiveness of topical preparations used to reduce discomfort and facilitate NPL in adults. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 14 April 2010. Selection criteria Randomised controlled trials (RCTs) looking at the effect of topical anaesthetic or vasoconstrictor agents used reduce discomfort and facilitate NPL in adult patients. Data collection and analysis Two review authors independently selected studies, extracted data and assessed risk of bias. We contacted trial authors for further information where necessary. The primary outcome measured was pain/discomfort. Secondary outcomes that were looked at included side effects of the topical medications, ease of the procedure and the quality of the view from the operator's perspective. Main results We included eight RCTs (746 participants) in the review. The risk of bias in the studies was generally low. Five studies did not demonstrate any advantage in using a topical treatment prior to endoscopy. One study suggested that a vasoconstrictor alone should be used to reduce the general level of unpleasantness. Two studies did not compare treatment against placebo or no treatment, so it was not possible to draw meaningful conclusions from them. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. There was variation in the format of the outcome data and a lack of complete data; none of the included studies reported their results in a way that would allow pooling and we could not therefore perform meta‐analysis. Authors' conclusions The included studies do not demonstrate any evidence to support the use of topical treatments prior to the use of a fibre‐optic nasal endoscope. Some go as far as to suggest that these agents should not be used due to cost and unpleasant side effects. Five studies did not demonstrate any advantage in terms of reducing pain or discomfort when using a topical treatment prior to endoscopy. The absence of demonstrable effect may be due to relatively small patient groups. It is therefore possible that there is a small effect of using these sprays. Further research using standardised reporting methods is needed. Plain language summary Topical anaesthetic or vasoconstrictor (blood vessel narrowing) preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy Topical medications are often applied to the inside of a patient's nose prior to examining the nose, sinuses and throat with a flexible nasopharyngolaryngoscope. The aim of this is to reduce any discomfort the patient may feel and also to improve the adequacy of the examination. Types of preparation include lidocaine, phenylephrine and lidocaine, oxymetazoline, xylometazoline and cocaine and they are usually administered as a spray, although they may also be in the form of a solution which can be applied to cotton wool and placed in the nasal cavity, or as gels, pastes or creams. We looked for randomised controlled trials comparing any of these topical treatments with placebo, no treatment or another topical treatment in adult patients undergoing nasal pharyngolaryngoscopy (NPL). We included eight studies in the review (with a total of 746 patients). It was not possible to combine data from any of the studies, therefore we assessed the individual study results. Five of the studies did not demonstrate any advantage, in terms of reducing pain or discomfort, of using a topical treatment prior to endoscopy. One of these suggested that a vasoconstrictor (xylometazoline) alone reduced the level of \"general unpleasantness\". Two studies did not compare the treatment against placebo or no treatment. A final study actually suggested an increase in pain with the use of topical agents. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. Further standardised research is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Sunkaraneni, VS; Jones, SEM", "articleTypes": [], "doi": "10.1002/14651858.CD005606.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "85cee801-0ec7-4dc7-a586-22ba47e21c64", "pmid": "", "title": "Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status", "imported": false, "abstract": "Abstract - Background Iron deficiency is an important micronutrient deficiency contributing to the global burden of disease, and particularly affects children, premenopausal women, and people in low‐resource settings. Anaemia is a possible consequence of iron deficiency, although clinical and functional manifestations of anemia can occur without iron deficiency (e.g. from other nutritional deficiencies, inflammation, and parasitic infections). Direct nutritional interventions, such as large‐scale food fortification, can improve micronutrient status, especially in vulnerable populations. Given the highly successful delivery of iodine through salt iodisation, fortifying salt with iodine and iron has been proposed as a method for preventing iron deficiency anaemia. Further investigation of the effect of double‐fortified salt (i.e. with iron and iodine) on iron deficiency and related outcomes is warranted. Objectives To assess the effect of double‐fortified salt (DFS) compared to iodised salt (IS) on measures of iron and iodine status in all age groups. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases, and two trial registries up to April 2021. We also searched relevant websites, reference lists, and contacted the authors of included studies. Selection criteria All prospective randomised controlled trials (RCTs), including cluster‐randomised controlled trials (cRCTs), and controlled before‐after (CBA) studies, comparing DFS with IS on measures of iron and iodine status were eligible, irrespective of language or publication status. Study reports published as abstracts were also eligible. Data collection and analysis Three review authors applied the study selection criteria, extracted data, and assessed risk of bias. Two review authors rated the certainty of the evidence using GRADE. When necessary, we contacted study authors for additional information. We assessed RCTs, cRCTs and CBA studies using the Cochrane RoB 1 tool and Cochrane Effective Practice and Organisation of Care (EPOC) tool across the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other potential sources of bias due to similar baseline characteristics, similar baseline outcome assessments, and declarations of conflicts of interest and funding sources. We also assessed cRCTs for recruitment bias, baseline imbalance, loss of clusters, incorrect analysis, and comparability with individually randomised studies. We assigned studies an overall risk of bias judgement (low risk, high risk, or unclear). Main results We included 18 studies (7 RCTs, 7 cRCTs, 4 CBA studies), involving over 8800 individuals from five countries. One study did not contribute to analyses. All studies used IS as the comparator and measured and reported outcomes at study endpoint. With regards to risk of bias, five RCTs had unclear risk of bias, with some concerns in random sequence generation and allocation concealment, while we assessed two RCTs to have a high risk of bias overall, whereby high risk was noted in at least one or more domain(s). Of the seven cRCTs, we assessed six at high risk of bias overall, with one or more domain(s) judged as high risk and one cRCT had an unclear risk of bias with concerns around allocation and blinding. The four CBA studies had high or unclear risk of bias for most domains. The RCT evidence suggested that, compared to IS, DFS may slightly improve haemoglobin concentration (mean difference (MD) 0.43 g/dL, 95% confidence interval (CI) 0.23 to 0.63; 13 studies, 4564 participants; low‐certainty evidence), but DFS may reduce urinary iodine concentration compared to IS (MD −96.86 μg/L, 95% CI −164.99 to −28.73; 7 studies, 1594 participants; low‐certainty evidence), although both salts increased mean urinary iodine concentration above the cut‐off deficiency. For CBA studies, we found DFS made no difference in haemoglobin concentration (MD 0.26 g/dL, 95% CI −0.10 to 0.63; 4 studies, 1397 participants) or urinary iodine concentration (MD −17.27 µg/L, 95% CI −49.27 to 14.73; 3 studies, 1127 participants). No studies measured blood pressure. For secondary outcomes reported in RCTs, DFS may result in little to no difference in ferritin concentration (MD −3.94 µg/L, 95% CI −20.65 to 12.77; 5 studies, 1419 participants; low‐certainty evidence) or transferrin receptor concentration (MD −4.68 mg/L, 95% CI −11.67 to 2.31; 5 studies, 1256 participants; low‐certainty evidence) compared to IS . However, DFS may reduce zinc protoporphyrin concentration (MD −27.26 µmol/mol, 95% CI −47.49 to −7.03; 3 studies, 921 participants; low‐certainty evidence) and result in a slight increase in body iron stores (MD 1.77 mg/kg, 95% CI 0.79 to 2.74; 4 studies, 847 participants; low‐certainty evidence). In terms of prevalence of anaemia, DFS may reduce the risk of anaemia by 21% (risk ratio (RR) 0.79, 95% CI 0.66 to 0.94; P = 0.007; 8 studies, 2593 participants; moderate‐certainty evidence). Likewise, DFS may reduce the risk of iron deficiency anaemia by 65% (RR 0.35, 95% CI 0.24 to 0.52; 5 studies, 1209 participants; low‐certainty evidence). Four studies measured salt intake at endline, although only one study reported this for both groups. Two studies reported prevalence of goitre, while one CBA study measured and reported serum iron concentration. One study reported adverse effects. No studies measured hepcidin concentration. Authors' conclusions Our findings suggest DFS may have a small positive impact on haemoglobin concentration and the prevalence of anaemia compared to IS, particularly when considering efficacy studies. Future research should prioritise studies that incorporate robust study designs and outcome measures (e.g. anaemia, iron status measures) to better understand the effect of DFS provision to a free‐living population (non‐research population), where there could be an added cost to purchase double‐fortified salt. Adequately measuring salt intake, both at baseline and endline, and adjusting for inflammation will be important to understanding the true effect on measures of iron status. Plain language summary Fortification of salt with iron and iodine compared to salt fortified with iodine only for improving iron and iodine status Key messages Compared to iodised salt, double‐fortified salt (salt fortified with iron and iodine) may improve some measures of iron and iodine nutrition, such as haemoglobin (i.e. the substance that gives red blood cells their colour) concentrations and body iron stores. However, it may reduce urinary iodine concentration and may make little or no difference to ferritin (i.e. iron‐storage protein) concentrations and transferrin receptor (i.e. protein that affects the uptake of iron) concentrations. It probably also reduces the prevalence of anaemia (lack of haemoglobin), and may reduce the prevalence of iron deficiency anaemia (lack of iron), compared to iodised salt. Well‐designed studies that assess the effects of double‐fortified salt within non‐research populations (i.e. real‐life settings), and that measure salt intake, including changes in salt consumption, are needed. What is iron deficiency? Almost two billion people experience a deficiency in a vitamin or mineral (or both), with women and children in resource‐limited settings most frequently affected. Iron‐related deficiencies are among the most common deficiencies in the world and have important short‐ and long‐term health consequences. Interventions to provide iron frequently include iron supplementation, including iron tablets, powders, or syrups. However, these have known barriers, and food fortification strategies may be attractive alternatives. Salt is one of few universally consumed food vehicles. Iodised salt is fortified to provide 100% of a person's iodine requirements and is highly effective. Double‐fortified salt was developed to provide 30% of a person's daily dietary iron requirement and 100% of their iodine requirement. In some resource‐limited settings, where iron‐related deficiencies are a common problem, there has been interest in making double‐fortified salt more available to the public. This calls for further understanding of the effect of double‐fortified salt on related outcomes. What did we want to find out? If double‐fortified salt is better than salt fortified with iodine alone for improving measures of iron and iodine‐related nutrition, in particular: ‐ haemoglobin concentration; ‐ urinary iodine concentration; ‐ blood pressure; ‐ ferritin concentration; ‐ transferrin receptor concentration; ‐ prevalence of anaemia; ‐ prevalence of iron deficiency anaemia. What did we do? We looked for studies that provided double‐fortified salt to one group of participants and iodised salt to another. We compared their results, and rated our confidence in the evidence, based on factors such as study methods and sample size. What did we find? We identified 18 studies, involving over 8800 individuals from five countries; 13 studies were conducted in India. In 13 studies the intervention lasted between 6 and 12 months; in two studies it lasted 3 months, and in single studies it lasted for 18 months, 24 months, or the duration was unclear. Nine studies were conducted in children and adolescents (5 to 17 years), four in adults (18 years and older), and five included multiple age groups. All studies compared double‐fortified salt to iodised salt. Most studies were funded by non‐profit organisations, university grants or academic institutes. In four studies, double‐fortified salt was provided by a commercial organisation, and in three studies the funding source unclear. Compared to iodised salt, double‐fortified salt may improve haemoglobin concentration and body iron stores slightly, and probably reduces the prevalence of anaemia by 21%. However, double‐fortified salt may also reduce urinary iodine concentration compared to iodised salt and may make little or no difference in ferritin and transferrin receptor concentration. Double‐fortified salt may reduce the prevalence of iron deficiency anaemia by 65%, compared to iodised salt, although this conclusion is uncertain because of some problems with the way the studies were conducted. Very few studies measured zinc protoporphyrin concentration, adverse effects, prevalence of goitre and salt intake. One study measured serum iron concentration. No studies measured blood pressure or hepcidin concentration. What are the limitations of the evidence? We have relatively low confidence in the evidence for the outcomes: haemoglobin, urinary iodine, ferritin, and transferrin receptor concentration, and prevalence of iron deficiency anaemia. Not all studies provided data about all outcomes of interest; studies delivered the intervention differently; and studies were small, both in number and size. For the prevalence of anaemia, we are moderately confident in the evidence because studies used different ways of delivering the intervention. Care should be taken in interpreting our findings in relation to public health policy and programmes. Most studies were conducted in monitored research settings and double‐fortified salt was provided without an added cost. We are unsure if the effect we observed would be the same in real‐life (i.e. non‐research population), where purchasing double‐fortified salt could increase the cost. More studies looking at the effect of double‐fortified salt within real‐life settings are needed to understand the true effects of double‐fortified salt with greater certainty. Given the changing guidelines for salt intake, future studies should measure salt intake to understand if double‐fortified salt should be considered to prevent anaemia at the population level and how to integrate double‐fortified salt into the supply chain. How up to date is this evidence? The evidence is up to date to April 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Baxter, J-AB, Carducci, B, Kamali, M, Zlotkin, SH, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD013463.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.782Z" }, { "id": "85db9f64-7022-48dd-9305-de8a3d22542f", "pmid": "", "title": "Fish oil for induction of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Fish oil supplements, which are rich in n‐3 fatty acids, may reduce inflammation, decrease the need for anti‐inflammatory drugs, and promote normal weight gain in people with ulcerative colitis. Objectives This review evaluates the efficacy of fish oil for induction of remission in ulcerative colitis using all available randomised controlled trials. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, EMBASE, CINAHL, the database of ongoing trials and the reference lists of all publications of included or excluded trials were searched. Selection criteria Randomised controlled trials and quasi‐randomised controlled trials with active ulcerative colitis patients who were treated with fish oil. Data collection and analysis The reviewers performed study selection, assessment of methodological quality by using different approaches: including Cochrane assessment of allocation concealment and Jadad quality assessment score. Data extraction forms were used by the two reviewers to extract the data independently. Authors were contacted for additional information. Main results Six studies were included. Three were of cross‐over design and three were of parallel design. No data were pooled for analysis due to differences in outcomes and methodology among the included studies. One small study shows a positive benefit for induction of remission (RR 19.00; 95% CI 1.27 to 284.24). Some of the other included studies show some positive benefits for secondary outcomes. However, these results need to be interpreted with caution due to small study size and poor study quality. Authors' conclusions The current data does not allow for a definitive conclusion regarding the efficacy of fish oil. There is no adequate information to make recommendations for clinical practice. More research is required. Plain language summary Fish oil for the treatment of active ulcerative colitis Ulcerative colitis is an inflammation of the large intestine that causes diarrhea, abdominal pain, rectal bleeding and fever. Since there is no cure for the disease the aim of treatment is to cause a reduction of the unpleasant and painful signs and symptoms. Current, proven, treatment options for active ulcerative colitis include corticosteroids, aminosalicylates, immunosuppressive and biological agents. However, these drugs can cause side effects. New treatments which cause fewer side effects are being sought. Fish oil, which is rich in omega‐3 fatty acids may reduce inflammation and decrease the need for anti‐inflammatory drugs in patients with ulcerative colitis. Six studies looking at the effects of fish oil in active ulcerative colitis were included in the review. Study quality was mostly poor. One small study showed a positive benefit for the treatment of active ulcerative colitis. However, this result should be interpreted with caution due to small study size and poor study quality. Due to limited data there is not enough information available to determine whether fish oil treatment is effective for induction of remission in ulcerative colitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "De Ley, M, de Vos, R, Hommes, DW, Stokkers, PC", "articleTypes": [], "doi": "10.1002/14651858.CD005986.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.069Z" }, { "id": "85dc4fd7-8487-439e-9d0a-bef7f32f23a5", "pmid": "", "title": "Fortification of staple foods with zinc for improving zinc status and other health outcomes in the general population", "imported": false, "abstract": "Abstract - Background Zinc deficiency is a global nutritional problem, particularly in children and women residing in settings where diets are cereal based and monotonous. It has several negative health consequences. Fortification of staple foods with zinc may be an effective strategy for preventing zinc deficiency and improving zinc‐related health outcomes. Objectives To evaluate the beneficial and adverse effects of fortification of staple foods with zinc on health‐related outcomes and biomarkers of zinc status in the general population. Search methods We searched the following databases in April 2015: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3 of 12, 2015, the Cochrane Library), MEDLINE & MEDLINE In Process (OVID) (1950 to 8 April 2015), EMBASE (OVID) (1974 to 8 April 2015), CINAHL (1982 to April 2015), Web of Science (1900 to 9 April 2015), BIOSIS (1969 to 9 April 2015), POPLINE (1970 to April 2015), AGRICOLA, OpenGrey, BiblioMap, and Trials Register of Promoting Health Interventions (TRoPHI), besides regional databases (April 2015) and theses. We also searched clinical trial registries (17 March 2015) and contacted relevant organisations (May 2014) in order to identify ongoing and unpublished studies. Selection criteria We included randomised controlled trials, randomised either at the level of the individual or cluster. We also included non‐randomised trials at the level of the individual if there was a concurrent comparison group. We included non‐randomised cluster trials and controlled before‐after studies only if there were at least two intervention sites and two control sites. Interventions included fortification (central/industrial) of staple foods (cereal flours, edible fats, sugar, condiments, seasonings, milk and beverages) with zinc for a minimum period of two weeks. Participants were members of the general population who were over two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies, and assessed the risk of bias of the included studies. Main results We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Four trials compared the effect of zinc‐fortified staple foods with unfortified foods (comparison 1), and four compared zinc‐fortified staple foods in combination with other nutrients/factors with the same foods containing other nutrients or factors without zinc (comparison 2). The interventions lasted between one and nine months. We categorised most trials as having unclear or high risk of bias for randomisation, but low risk of bias for blinding and attrition. None of the studies in comparison 1 reported data on zinc deficiency. Foods fortified with zinc increased the serum or plasma zinc levels in comparison to foods without added zinc (mean difference (MD) 2.12 µmol/L, 95% confidence interval (CI) 1.25 to 3.00 µmol/L; 3 studies; 158 participants; low‐quality evidence). Participants consuming foods fortified with zinc versus participants consuming the same food without zinc had similar risk of underweight (average risk ratio 3.10, 95% CI 0.52 to 18.38; 2 studies; 397 participants; low‐quality evidence) and stunting (risk ratio (RR) 0.88, 95% CI 0.36 to 2.13; 2 studies; 397 participants; low‐quality evidence). A single trial of addition of zinc to iron in wheat flour did not find a reduction in proportion of zinc deficiency (RR 0.17, 95% CI 0.01 to 3.94; very low‐quality evidence). We did not find a difference in serum or plasma zinc levels in participants consuming foods fortified with zinc plus other micronutrients when compared with participants consuming the same foods with micronutrients but no added zinc (MD 0.03 µmol/L, 95% CI ‐0.67 to 0.72 µmol/L; 4 studies; 250 participants; low‐quality evidence). No trial in comparison 2 provided information about underweight or stunting. There was no reported adverse effect of fortification of foods with zinc on indicators of iron or copper status. Authors' conclusions Fortification of foods with zinc may improve the serum zinc status of populations if zinc is the only micronutrient used for fortification. If zinc is added to food in combination with other micronutrients, it may make little or no difference to the serum zinc status. Effects of fortification of foods with zinc on other outcomes including zinc deficiency, children’s growth, cognition, work capacity of adults, or on haematological indicators are unknown. Given the small number of trials and participants in each trial, further investigation of these outcomes is required. Plain language summary The effects of fortification of common foods with zinc on health outcomes Background It is believed that zinc deficiency is widespread globally, particularly in children and women living in low‐ and middle‐income countries. Cereal‐based foods are rich in dietary fibre and phytates, which reduce absorption of zinc from the intestine. As people in low‐income households eat a lot of cereal‐based foods, they are more likely to develop zinc deficiency. Fortification of common staple foods with zinc alone or in combination with other vitamins and minerals has been proposed as an intervention to increase intake of zinc in populations who consume these foods. Review question We evaluated the effects of fortification of staple foods with zinc on blood zinc levels and health‐related outcomes in the general population above two years of age. Study characteristics We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Key results and quality of the evidence The effect of fortification of foods with zinc on incidence of zinc deficiency is uncertain. Fortification of foods with zinc may slightly improve the blood zinc levels of populations if zinc is the only micronutrient used for fortification. Zinc added to food in combination with other micronutrients may make little or no difference to blood zinc levels. The fortification of foods with zinc may make little or no difference on incidence of underweight or stunting. The effects of fortification of foods with zinc on other outcomes, including wasting and weight/height, are unknown. Fortification of foods with zinc does not seem to have any adverse effect on indicators of iron or copper status. Most studies included in this review involved a small number of participants and were judged to be at low or unclear risk of bias. There were also some inconsistencies in the results across different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Shah, D, Sachdev, HS, Gera, T, De‐Regil, LM, Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010697.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.110Z" }, { "id": "85f01dd8-c964-43bf-be51-dc7eb9496461", "pmid": "", "title": "Intranasal fentanyl for the management of acute pain in children", "imported": false, "abstract": "Abstract - Background Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula. Objectives We identified and evaluated all randomized controlled trials (RCTs) and quasi‐randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of \"rescue analgesia,\" patient/parental satisfaction and patient mortality. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014). Selection criteria We included RCTs comparing INF versus any other pharmacological/non‐pharmacological intervention for the treatment of children in acute pain (aged < 18 years). Data collection and analysis Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions. Main results Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a “bad taste” and vomiting with INF. Overall the risk of bias in all studies was considered low. Authors' conclusions INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non‐inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause. Plain language summary Intranasal fentanyl for the treatment of children in acute pain Background Pain is the most common reason why patients are seen in emergency departments (EDs). The challenging nature of treating children in acute severe pain is reflected in the medical literature by poor pain management in this population. We reviewed evidence on the effect of intranasal fentanyl (INF) (a strong pain relief drug, similar to morphine) compared with any other pain‐relieving technique for treatment of children in acute severe pain. Study characteristics We included studies with children (younger than 18 years of age) suffering from acute severe pain as a result of injury or medical illness. The target intervention was INF administered for pain relief compared with any other drug intervention for pain relief (e.g. intravenous morphine) or non‐drug intervention (e.g. limb splinting, wound dressing) provided in the emergency setting. The evidence is current to January 2014. Key results We identified three studies that included 313 children with acute severe pain resulting from broken bones of the upper and lower limbs. These trials compared INF versus morphine administered by a needle into a muscle (intramuscular morphine) or via a drip into a vein (intravenous morphine), as well as standard concentration INF versus high concentration INF. The collective study population in these trials consisted of children three to 15 years of age. Males accounted for approximately two‐thirds of the overall study population. The review concluded that INF may be an effective analgesic for the treatment of children in acute moderate to severe pain, and its administration appears to cause minimal distress to children; however, the evidence is insufficient to permit judgement of the effects of INF compared with intramuscular or intravenous morphine. No serious adverse events (e.g. opiate toxicity, death) were reported. Limitations Limitations of this review include the following: Few studies (three) were eligible for inclusion; no study examined the use of INF in children younger than three years of age; no study included children with pain resulting from a \"medical\" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a \"medical\" cause.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Murphy, A; O'Sullivan, R; Wakai, A; Grant, TS; Barrett, MJ; Cronin, J; McCoy, SC; Hom, J; Kandamany, N", "articleTypes": [], "doi": "10.1002/14651858.CD009942.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "8603ebd0-068c-410b-80bd-b993fca8b370", "pmid": "", "title": "Inhaled corticosteroids for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Inhaled corticosteroids are well established for the long‐term treatment of inflammatory respiratory diseases such as asthma or chronic obstructive pulmonary disease. They have been investigated for the treatment of coronavirus disease 2019 (COVID‐19). The anti‐inflammatory action of inhaled corticosteroids might have the potential to reduce the risk of severe illness resulting from hyperinflammation in COVID‐19. Objectives To assess whether inhaled corticosteroids are effective and safe in the treatment of COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (which includes CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO ICTRP, and medRxiv), Web of Science (Science Citation Index, Emerging Citation Index), and the WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies to 7 October 2021. Selection criteria We included randomised controlled trials (RCTs) evaluating inhaled corticosteroids for COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We included the following interventions: any type or dose of inhaled corticosteroids. We included the following comparison: inhaled corticosteroids plus standard care versus standard care (with or without placebo). We excluded studies examining nasal or topical steroids. Data collection and analysis We followed standard Cochrane methodology. For risk of bias assessment, we used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the outcomes of mortality, admission to hospital or death, symptom resolution, time to symptom resolution, serious adverse events, adverse events, and infections. Main results Inhaled corticosteroids plus standard care versus standard care (with/without placebo) People with a confirmed diagnosis of moderate‐to‐severe COVID‐19 We found no studies that included people with a confirmed diagnosis of moderate‐to‐severe COVID‐19. People with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included three RCTs allocating 3607 participants, of whom 2490 had confirmed mild COVID‐19. We analysed a subset of the total number of participants recruited to the studies (2171, 52% female) as some trials had a platform design where not all participants were allocated to treatment groups simultaneously. The included studies were community‐based, recruiting people who were able to use inhaler devices to deliver steroids and relied on remote assessment and self‐reporting of outcomes. Most people were older than 50 years and had co‐morbidities such as hypertension, lung disease, or diabetes. The studies were conducted in high‐income countries prior to wide‐scale vaccination programmes. A total of 1057 participants were analysed in the inhaled corticosteroid arm (budesonide: 860 participants; ciclesonide: 197 participants), and 1075 participants in the control arm. No studies included people with asymptomatic SARS‐CoV‐2 infection. With respect to the following outcomes, inhaled corticosteroids compared to standard care: – may result in little to no difference in all‐cause mortality (at up to day 30) (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.22 to 1.67; 2132 participants; low‐certainty evidence). In absolute terms, this means that for every nine deaths per 1000 people not receiving inhaled corticosteroids, there were six deaths per 1000 people who did receive the intervention (95% CI 2 to 16 per 1000 people); – probably reduces admission to hospital or death (at up to 30 days) (RR 0.72, 95% CI 0.51 to 0.99; 2025 participants; moderate‐certainty evidence); – probably increases resolution of all initial symptoms at day 14 (RR 1.19, 95% CI 1.09 to 1.30; 1986 participants; moderate‐certainty evidence); – may reduce the duration to symptom resolution (at up to day 30) (by −4.00 days, 95% CI −6.22 to −1.78 less than control group rate of 12 days; 139 participants; low‐certainty evidence); – the evidence is very uncertain about the effect on serious adverse events (during study period) (RR 0.51, 95% CI 0.09 to 2.76; 1586 participants; very low‐certainty evidence); – may result in little to no difference in adverse events (at up to day 30) (RR 0.78, 95% CI 0.47 to 1.31; 400 participants; low‐certainty evidence); – may result in little to no difference in infections (during study period) (RR 0.88, 95% CI 0.30 to 2.58; 400 participants; low‐certainty evidence). As studies did not report outcomes for subgroups (e.g. age, ethnicity, sex), we did not perform subgroup analyses. Authors' conclusions In people with confirmed COVID‐19 and mild symptoms who are able to use inhaler devices, we found moderate‐certainty evidence that inhaled corticosteroids probably reduce the combined endpoint of admission to hospital or death and increase the resolution of all initial symptoms at day 14. Low‐certainty evidence suggests that corticosteroids make little to no difference in all‐cause mortality up to day 30 and may decrease the duration to symptom resolution. We do not know whether inhaled corticosteroids increase or decrease serious adverse events due to heterogeneity in the way they were reported across the studies. There is low‐certainty evidence that inhaled corticosteroids may decrease infections. The evidence we identified came from studies in high‐income settings using budesonide and ciclesonide prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, serious adverse events, and people with asymptomatic infection or with moderate‐to‐severe COVID‐19. The 10 ongoing and four completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. We monitor newly published results of RCTs on inhaled corticosteroids on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Are inhaled corticosteroids an effective treatment for people with mild COVID‐19? Key messages Inhaled corticosteroids (anti‐inflammatory medicines) given via the oral inhaled route are evaluated for treatment of coronavirus disease 2019 (COVID‐19). We identified three published studies for people with mild disease. Inhaled corticosteroids probably reduce the risk of people going to hospital or death (admission to hospital or death before hospital admission). Inhaled corticosteroids may lower the number of days people have symptoms of mild COVID‐19 and probably increase resolution of COVID‐19 symptoms at day 14. They may make little to no difference in death from any cause, and we do not have enough evidence to know whether they cause serious harms. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with moderate‐to‐severe COVID‐19. We found 10 ongoing and four completed unpublished studies. We will update this review when their results become available. What are inhaled corticosteroids? Inhaled corticosteroids are medicines that are breathed into the lower airways through an inhaler where they reduce inflammation in the lungs. They are commonly used to treat respiratory diseases like asthma and chronic obstructive pulmonary disease. Long‐term use and incorrect inhaler technique may lead to side effects that include a mouth infection called thrush, a change in voice, and an increased risk of lung infections. Good inhaler technique means the medicine does not stay in the mouth and throat. Why are inhaled corticosteroids possible treatments for COVID‐19? COVID‐19 mainly affects the lungs and airways. When the immune system fights the virus, the lungs and airways become inflamed. This inflammation causes breathing difficulties, and the lungs cannot easily move oxygen into the blood and remove carbon dioxide from the blood. What did we want to find out? People need more and better treatment options for asymptomatic SARS‐CoV‐2 infection (the virus that causes COVID‐19) or mild, moderate, or severe COVID‐19. We wanted to know if inhaled corticosteroids are an effective and helpful treatment option for COVID‐19 in any setting (for example, home or hospital) and whether they cause unwanted effects. We were interested in: – death from any cause up to day 30, day 60, or longer if reported; – admission to hospital or death within 30 days; – whether symptoms resolved and how fast; – quality of life; – unwanted effects. What did we do? We looked for studies where the investigators compared inhaled corticosteroids and usual care to usual care only, sometimes in addition to a dummy medicine that did not contain any active ingredients (placebo) but was given in the same way. To make the comparison least skewed and more fair, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the inhaled corticosteroids or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Three studies compared inhaled corticosteroids plus usual care compared to usual care with or without placebo in people with a confirmed diagnosis of mild COVID‐19. These studies analysed 2171 participants mostly older than 50 years and with other medical problems, 52% of them were female, of whom 1057 received inhaled corticosteroids in our analyses. We found no studies that included people with asymptomatic infection or confirmed diagnosis of moderate‐to‐severe COVID‐19. We also found 10 ongoing studies, and four completed studies without published results. Main results All studies compared inhaled corticosteroids with usual care or placebo. The studies included only people with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease. No studies looked at hospitalised people or people with asymptomatic SARS‐CoV‐2 infection. Inhaled corticosteroids – may make little to no difference in death from any cause up to day 30; – probably reduce the risk of admission to hospital or occurrence of death up to day 30; – probably increase resolution of COVID‐19 symptoms at day 14 and may reduce time to symptom resolution. We are very uncertain about a possible difference in serious unwanted effects. Moreover, inhaled corticosteroids may result in little to no difference in the number of any unwanted effects or additional infections. What are the limitations of the evidence? The studies were conducted in populations from wealthy countries, prior to the roll‐out of COVID‐19 vaccination programmes. We have moderate confidence in the evidence for the outcomes of symptom resolution at day 14 and hospital admission. We have low confidence in the evidence for the effects on deaths from any cause for people with mild COVID‐19 and time to symptom resolution. The confidence in the unwanted or serious unwanted effects and infections is low or very low, because of the differences in the way investigators recorded and reported results. There was no evidence for people with asymptomatic infection or moderate‐to‐severe COVID‐19 who were hospitalised. How up to date is this evidence? Our evidence is up‐to‐date to 7 October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Griesel, M, Wagner, C, Mikolajewska, A, Stegemann, M, Fichtner, F, Metzendorf, M-I, Nair, AAnil, Daniel, J, Fischer, A-L, Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015125", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.092Z" }, { "id": "862be8e0-1c56-4306-a353-0a33f2510139", "pmid": "", "title": "Sapropterin dihydrochloride for phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria results from a deficiency of the enzyme phenylalanine hydroxylase. Dietary restriction of phenylalanine keeps blood phenylalanine concentration low. Most natural foods are excluded from diet and supplements are used to supply other nutrients. Recent publications report a decrease in blood phenylalanine concentration in some patients treated with sapropterin dihydrochloride. We examined the evidence for the use of sapropterin dihydrochloride to treat phenylketonuria. This is an update of a previously published Cochrane Review. Objectives To assess the safety and efficacy of sapropterin dihydrochloride in lowering blood phenylalanine concentration in people with phenylketonuria. Search methods We identified relevant trials from the Group's Inborn Errors of Metabolism Trials Register. Date of last search: 11 August 2014. We also searched ClinicalTrials.gov and Current controlled trials. Last search: 4 September 2014 We contacted the manufacturers of the drug (BioMarin Pharmaceutical Inc.) for information regarding any unpublished trials. Selection criteria Randomized controlled trials comparing sapropterin with no supplementation or placebo in people with phenylketonuria due to phenylalanine hydroxylase deficiency. Data collection and analysis Two authors independently assessed trials and extracted outcome data. Main results Two placebo‐controlled trials were included. One trial administered 10 mg/kg/day sapropterin in 89 children and adults with phenylketonuria whose diets were not restricted and who had previously responded to saproterin.This trial measured change in blood phenylalanine concentration. The second trial screened 90 children (4 to 12 years) with phenylketonuria whose diet was restricted, for responsiveness to sapropterin. Forty‐six responders entered the placebo‐controlled part of the trial and received 20 mg/kg/day sapropterin. This trial measured change in both phenylalanine concentration and protein tolerance. Both trials reported adverse events. The trials showed an overall low risk of bias; but both are Biomarin‐sponsored. One trial showed a significant lowering in blood phenylalanine concentration in the sapropterin group (10 mg/kg/day), mean difference ‐238.80 μmol/L (95% confidence interval ‐343.09 to ‐134.51); a second trial (20 mg/kg/day sapropterin) showed a non‐significant difference, mean difference ‐51.90 μmol/L (95% confidence interval ‐197.27 to 93.47). The second trial also reported a significant increase in phenylalanine tolerance, mean difference18.00 mg/kg/day (95% confidence interval 12.28 to 23.72) in the 20 mg/kg/day sapropterin group. Authors' conclusions There is evidence of short‐term benefit from using sapropterin in some people with sapropterin‐responsive forms of phenylketonuria; blood phenylalanine concentration is lowered and protein tolerance increased. There are no serious adverse events associated with using sapropterin in the short term. There is no evidence on the long‐term effects of sapropterin and no clear evidence of effectiveness in severe phenylketonuria. Plain language summary The use of sapropterin to lower phenylalanine concentration in blood in people with phenylketonuria. Phenylketonuria occurs due to an inherited deficiency of the enzyme phenylalanine hydroxylase. If untreated it causes an excessive accumulation of the amino acid phenylalanine in the body which prevents normal brain development. The established treatment for phenylketonuria consists of dietary restriction of natural protein but with prescribed phenylalanine‐free amino acid, mineral and vitamin supplements. With this treatment the long‐term outcome for people with phenylketonuria is excellent but the diet is onerous. Sapropterin dihydrochloride, the cofactor for phenylalanine hydroxylase, could lower phenylalanine concentration significantly in phenylketonuria and might allow a relaxation of dietary restrictions. The review identified two trials of sapropterin dihydrochloride; one in children and adults with no restricted diet and one in just children whose diet was restricted. The trials used different doses of sapropterin dihydrochloride (10 mg/kg/day and 20 mg/kg/day). We could not combine any data due to different formats of presentation. We found evidence to show that some people with mild or moderate phenylketonuria can benefit from the use of sapropterin dihydrochloride in the short term; the concentration of blood phenylalanine was lowered after treatment in both trials. The trial with the higher dose also measured the outcome change in protein tolerance. It reported an increase in protein tolerance in response to sapropterin. There were no adverse effects associated with the use of sapropterin dihydrochloride in the short term. We found no evidence on the effects of long‐term treatment. We could not draw any conclusions on its benefits in severe phenylketonuria.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Somaraju, UR, Merrin, M", "articleTypes": [], "doi": "10.1002/14651858.CD008005.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.762Z" }, { "id": "8637e102-e0d5-4a69-9c9f-37c34b5f04c0", "pmid": "", "title": "Investigating the Synergistic Potential of Music as an Adjunct to Ketamine Therapy for Chronic Noncancer Pain", "imported": false, "abstract": "Intravenous (IV) ketamine is a treatment option for patients with chronic pain that does not respond to standard therapies, primarily working by blocking NMDA receptors in the brain. Beyond pain relief, ketamine can produce dissociative sensations, classifying it as an atypical psychedelic or mind-altering drug, and may enable patients to reprocess their pain similarly to experiences with traditional psychedelics. At the Montreal General Hospital's pain clinic, the investigators have observed patients frequently listening to music during ketamine infusions, and recent research indicates that music-especially when self-selected by patients-might provide additional pain-relieving benefits by influencing central mechanisms related to pain perception and interpretation. This intersection of music and pain relief is garnering substantial scientific interest as recent advances provide more insight into the neuroscience of music and its effects on brain regions involved in emotion, sensation, memory, and pain.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.247Z" }, { "id": "863e6c9e-81ce-497c-8b5e-da1f189cfbe2", "pmid": "", "title": "Preoperative statin therapy for adults undergoing cardiac surgery", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Marques Antunes, M, Nunes-Ferreira, A, Duarte, GS, Gouveia e Melo, R, Sucena Rodrigues, B, Guerra, NC, Nobre, A, Pinto, FJ, Costa, J, Caldeira, D", "articleTypes": [], "doi": "10.1002/14651858.CD008493.pub5 AB - Abstract - Background Despite significant advances in surgical techniques and perioperative care, people undertaking cardiac surgery due to cardiovascular disease are more prone to the development of postoperative adverse events. Statins (5‐hydroxy‐3‐methylglutaryl‐co‐enzyme A (HMG‐CoA) reductase inhibitors) are well‐known for their anti‐inflammatory and antioxidant effects and are established for primary and secondary prevention of coronary artery disease. In addition, statins are thought to have clinical benefits in perioperative outcomes in people undergoing cardiac surgery. This review is an update of a review that was first published in 2012 and updated in 2015. Objectives To evaluate the benefits and harms of preoperative statin therapy in adults undergoing cardiac surgery compared to standard of care or placebo. Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2023), Ovid MEDLINE (1980 to 14 September 2023), and Ovid Embase (1980 to 2023 (week 36)). We applied no language restrictions. Selection criteria We included all randomised controlled trials (RCTs) comparing any statin treatment before cardiac surgery, for any given duration and dose, versus no preoperative statin therapy (standard of care) or placebo. We excluded trials without a registered trial protocol and trials without approval by an institutional ethics committee. Data collection and analysis We used standard Cochrane methodology. Primary outcomes were short‐term mortality and major adverse cardiovascular events. Secondary outcomes were myocardial infarction, atrial fibrillation, stroke, renal failure, length of intensive care unit (ICU) stay, length of hospital stay and adverse effects related to statin therapy. We reported effect measures as risk ratios (RRs) or mean differences (MDs) with corresponding 95% confidence intervals (CIs). We used the RoB 1 tool to assess the risk of bias in included trials, and GRADE to assess the certainty of the evidence. Main results We identified eight RCTs (five new to this review) including 5592 participants. Pooled analysis showed that statin treatment before surgery may result in little to no difference in the risk of postoperative short‐term mortality (RR 1.36, 95% CI 0.72 to 2.59; I 2 = 0%; 6 RCTs, 5260 participants; low‐certainty evidence; note 2 RCTs reported 0 events in both groups so RR calculated from 4 RCTs with 5143 participants). We are very uncertain about the effect of statins on major adverse cardiovascular events (RR 0.93, 95% CI 0.77 to 1.13; 1 RCT, 2406 participants; very low‐certainty evidence). Statins probably result in little to no difference in myocardial infarction (RR 0.88, 95% CI 0.73 to 1.06; I 2 = 0%; 5 RCTs, 4645 participants; moderate‐certainty evidence), may result in little to no difference in atrial fibrillation (RR 0.87, 95% CI 0.72 to 1.05; I 2 = 60%; 8 RCTs, 5592 participants; low‐certainty evidence), and may result in little to no difference in stroke (RR 1.47, 95% CI 0.90 to 2.40; I 2 = 0%; 4 RCTs, 5143 participants; low‐certainty evidence). We are very uncertain about the effect of statins on renal failure (RR 1.04, 95% CI 0.80 to 1.34; I 2 = 57%; 4 RCTs, 4728 participants; very low‐certainty evidence). Additionally, statins probably result in little to no difference in length of ICU stay (MD 1.40 hours, 95% CI −1.62 to 4.41; I 2 = 43%; 3 RCTs, 4528 participants; moderate‐certainty evidence) and overall hospital stay (MD −0.31 days, 95% CI −0.64 to 0.03; I 2 = 84%; 5 RCTs, 4788 participants; moderate‐certainty evidence). No study had any individual risk of bias domain classified as high. However, two studies were at high risk of bias overall given the classification of unclear risk of bias in three domains. Authors' conclusions In this updated Cochrane review, we found no evidence that statin use in the perioperative period of elective cardiac surgery was associated with any clinical benefit or worsening, when compared with placebo or standard of care. Compared with placebo or standard of care, statin use probably results in little to no difference in MIs, length of ICU stay and overall hospital stay; and may make little to no difference to mortality, atrial fibrillation and stroke. We are very uncertain about the effects of statins on major harmful cardiac events and renal failure. The certainty of the evidence validating this finding varied from moderate to very low, depending on the outcome. Future trials should focus on assessing the impact of statin therapy on mortality and major adverse cardiovascular events. Plain language summary Is it better to take statins before undergoing heart‐related surgery? Key messages – Taking statins may make little to no difference to death within 30 days of surgery, irregular heart rhythms and stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off); and probably results in little to no difference in heart attacks, length of intensive care unit stay and overall hospital stay. We are very uncertain about the effects of statins on kidney failure and harmful effects from statin treatment. – Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. What are the dangers of cardiac surgery and how may statins help? Cardiac surgeries can effectively treat people with heart and circulation problems. However, undergoing cardiac surgery also increases the risk of death, heart attack, stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off), irregular heart rhythms and kidney failure. This is partly because more than half of people undergoing cardiac surgery are over 70 years of age. To reduce these risks, we should try to improve recovery rates by preventing these problems from occurring before, during and after surgery. Statins are medications used throughout the world to lower blood cholesterol (a fatty substance found in the blood that may block blood vessels) levels and reduce the chances of cardiovascular issues becoming worse. Studies have shown that fewer people who had built up dangerous amounts of cholesterol in their blood vessels (arteries) died while taking statins. However, the potential benefits of taking statins in people undergoing cardiac surgery are unclear. What did we want to find out? We wanted to find out whether taking statins before undergoing cardiac surgery could help reduce the risk of: – death occurring shortly after surgery; or
– developing other heart or kidney problems. We also wanted to find out if there were any changes in the quality of care associated with cardiac surgeries for people who had been taking statins, such as reducing the length of hospital stay or intensive care unit stay, or if there were any harmful effects from statin treatment. What did we do? We searched for studies published up to September 2023 that compared treatment with statins to treatment with a placebo (a pretend medicine that looks or tastes identical to the medicine being tested) or usual care in people undergoing cardiac surgeries. Contrary to previous versions of this review, we only included trials that we were sure were approved by an ethical review board. What did we find? We found eight studies involving 5592 people with an average age of 63 years and 79% were men. Of these, 2798 people were treated with statins and 2794 people were not treated with statins before cardiac surgery. The smallest study included 57 people and the largest involved 2406 people. All studies were conducted in hospitals affiliated with universities in Asia, Europe and North America. Each study used different statin types (atorvastatin, fluvastatin, simvastatin, pravastatin or rosuvastatin) and doses (between 20 mg and 80 mg). Main results In people undergoing cardiac surgery, compared to no statin treatment, statin treatment: – probably results in little to no difference in heart attacks (5 studies, 4645 people), length of intensive care unit stay (3 studies, 4528 people) and overall hospital stay (5 studies, 4788 people); – may make little to no difference to death within 30 days of surgery (6 studies, 5260 people), irregular heart rhythm (8 studies, 5592 people) and stroke (4 studies, 5143 people). We are very uncertain about the effects of statins on major harmful cardiac events (1 study, 2406 people) and kidney failure (4 studies, 4728 people). What are the limitations of the evidence? We are moderately confident in our findings that there were probably little to no differences in the risk of heart attack, length of hospital and intensive care unit stay. However, we have little to very little confidence about our other findings, namely the most important finding we were looking for, which was a reduction in death. This is because most of the studies had many differences between them, there were fewer comparative cases than expected, and the studies did not always provide information about the statin intervention or treatment outcomes we were interested in. In addition, all studies used a different approach to statin treatment, which made them difficult to compare. Overall, this lowered our confidence in the evidence. Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. How up to date is this evidence? This is an update of a Cochrane review. The evidence is up to date to September 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.793Z" }, { "id": "8672f2ac-e3d2-476f-b4a0-75af786124db", "pmid": "", "title": "Dual antibiotics for bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is a chronic respiratory disease characterised by abnormal and irreversible dilatation of the smaller airways and associated with a mortality rate greater than twice that of the general population. Antibiotics serve as front‐line therapy for managing bacterial load, but their use is weighed against the development of antibiotic resistance. Dual antibiotic therapy has the potential to suppress infection from multiple strains of bacteria, leading to more successful treatment of exacerbations, reduced symptoms, and improved quality of life. Further evidence is required on the efficacy of dual antibiotics in terms of management of exacerbations and extent of antibiotic resistance. Objectives To evaluate the effects of dual antibiotics in the treatment of adults and children with bronchiectasis. Search methods We identified studies from the Cochrane Airways Group Specialised Register (CAGR), which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED), and PsycINFO, as well as studies obtained by handsearching of journals/abstracts. We also searched the following trial registries: US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. We imposed no restriction on language of publication. We conducted our search in October 2017. Selection criteria We searched for randomised controlled trials comparing dual antibiotics versus a single antibiotic for short‐term (< 4 weeks) or long‐term management of bronchiectasis diagnosed in adults and/or children by bronchography, plain film chest radiography, or high‐resolution computed tomography. Primary outcomes included exacerbations, length of hospitalisation, and serious adverse events. Secondary outcomes were response rates, emergence of resistance to antibiotics, systemic markers of infection, sputum volume and purulence, measures of lung function, adverse events/effects, deaths, exercise capacity, and health‐related quality of life. We did not apply outcome measures as selection criteria. Data collection and analysis Two review authors independently screened the titles and abstracts of 287 records, along with the full text of seven reports. Two studies met review inclusion criteria. Two review authors independently extracted outcome data and assessed risk of bias . We extracted data from only one study and conducted GRADE assessments for the following outcomes: successful treatment of exacerbation; response rates; and serious adverse events. Main results Two randomised trials assessed the effectiveness of oral plus inhaled dual therapy versus oral monotherapy in a total of 118 adults with a mean age of 62.8 years. One multi‐centre trial compared inhaled tobramycin plus oral ciprofloxacin versus ciprofloxacin alone, and one single‐centre trial compared nebulised gentamicin plus systemic antibiotics versus a systemic antibiotic alone. Published papers did not report study funding sources. Effect estimates from one small study with 53 adults showed no evidence of treatment benefit with oral plus inhaled dual therapy for the following primary outcomes at the end of the study: successful management of exacerbation ‐ cure at day 42 (odds ratio (OR) 0.66, 95% confidence interval (CI) 0.22 to 2.01; 53 participants; one study; very low‐quality evidence); number of participants with Pseudomonas aeruginosa eradication at day 21 (OR 2.33, 95% CI 0.66 to 8.24; 53 participants; one study; very low‐quality evidence); and serious adverse events (OR 0.48, 95% CI 0.08 to 2.87; 53 participants; one study; very low‐quality evidence). Similarly, researchers provided no evidence of treatment benefit for the following secondary outcomes: clinical response rates ‐ relapse at day 42 (OR 0.57, 95% CI 0.12 to 2.69; 53 participants; one study; very low‐quality evidence); microbiological response rate at day 21 ‐ eradicated (OR 2.40, 95% CI 0.67 to 8.65; 53 participants; one study; very low‐quality evidence); and adverse events ‐ incidence of wheeze (OR 5.75, 95% CI 1.55 to 21.33). Data show no evidence of benefit in terms of sputum volume, lung function, or antibiotic resistance. Outcomes from a second small study with 65 adults, available only as an abstract, were not included in the quantitative data synthesis. The included studies did not report our other primary outcomes: duration; frequency; and time to next exacerbation; nor our secondary outcomes: systemic markers of infection; exercise capacity; and quality of life. We did not identify any trials that included children. Authors' conclusions A small number of studies in adults have generated high‐quality evidence that is insufficient to inform robust conclusions, and studies in children have provided no evidence. We identified only one dual‐therapy combination of oral and inhaled antibiotics. Results from this single trial of 53 adults that we were able to include in the quantitative synthesis showed no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, serious adverse events, sputum volume, lung function, and antibiotic resistance. Further high‐quality research is required to determine the efficacy and safety of other combinations of dual antibiotics for both adults and children with bronchiectasis, particularly in terms of antibiotic resistance. Plain language summary Dual antibiotics for bronchiectasis Background to the question Bronchiectasis is a lung disease involving abnormal airways, leading to repeated chest infections, and associated with a mortality rate more than twice that of the general population. Although previously considered a relatively rare disease, numbers appear to be increasing, particularly for those over 75 years in low/middle‐income countries. Antibiotics are the main therapy for chest infection, but their use must be weighed against potential side effects and the risk of increasing resistance to antibiotic therapy. One strategy to improve response and/or reduce antibiotic resistance involves giving two antibiotic agents at the same time: dual antibiotic therapy. This review therefore aimed to evaluate the effects of dual antibiotics for treatment of adults and children with bronchiectasis. Study characteristics In October 2017, we identified two relevant studies comparing oral plus inhaled dual therapy versus oral therapy alone. They included a total of 118 adults with an average age of 62.8 years. One study compared inhaled tobramycin plus oral ciprofloxacin with oral ciprofloxacin, and the second study compared inhaled gentamicin plus a systemic (affecting the whole body, rather than just the lungs) antibiotic with a systemic antibiotic alone. Only a research summary was available for the latter. Published papers did not report study funding sources Main results Results from one small trial of 53 adults show no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, the occurrence of serious unwanted events, amount of phlegm, lung function, or resistance to antibiotic treatment. However, we found insufficient evidence to permit confident conclusions about their use. Quality of the evidence The overall quality of the evidence was very poor, largely because one of the studies was not well described and included few participants. Information on exacerbations, exercise ability, and quality of life was not reported. We did not identify any trials that compared other types of dual antibiotic therapy, and we found none that included children. Therefore uncertainty remains concerning the use of dual antibiotics, and further high‐quality studies are needed to examine the role of dual antibiotics in the treatment of adults and children with bronchiectasis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Felix, LM, Grundy, S, Milan, SJ, Armstrong, R, Harrison, H, Lynes, D, Spencer, S", "articleTypes": [], "doi": "10.1002/14651858.CD012514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.755Z" }, { "id": "86a3cedd-8151-411e-a46d-543e7047b1b5", "pmid": "", "title": "Effects of Single-dose Semaglutide on Cognition and Energy in Healthy Volunteers", "imported": false, "abstract": "Semaglutide is a glucagon-like peptide 1 receptor agonist (GLP-1RA). It is a safe medication approved for use in type-2 diabetes mellitus (T2DM) and obesity. Primarily, it works by counteracting insulin-resistance and inducing weight loss. It also acts on several other interconnected neurobiological, immunological (esp. inflammatory), endocrine-metabolic, and gut-brain axis processes that play a role in depressive symptoms. Its effects on cognition and energy are currently unknown. In this study we are using semaglutide as an experimental tool to further investigate these relationships.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "86b52c84-f138-41a3-b39b-c5d13523d014", "pmid": "", "title": "Glutamatergic drugs for schizophrenia", "imported": false, "abstract": "Abstract - Background It has been shown that central nervous system dopamine can play a major role in the pathophysiology of schizophrenia. Brain glutamate is thought to mediate symptoms in schizophrenia due to the influence of glutamate neurons on the dopaminergic transmission in the brain. It might be possible to decrease negative symptoms and the cognitive impairment of people with schizophrenia by treatment with glutamatergic drugs. Objectives To determine the efficacy of glutamatergic drugs in the treatment of schizophrenia. Search methods We searched the Cochrane Schizophrenia Group's Trials Register (May 2002 and October 2003), inspected references of all identified studies and contacted relevant authors. Selection criteria We included all randomised controlled trials in which glutamatergic medication was administered to people with schizophrenia. Data collection and analysis We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results We included eighteen short‐term trials with 358 randomised participants. The single studies were small with numbers of participants ranging between six and 51. All trials were short‐term trials with a maximum duration of 12 weeks. In all of these trials, glycine, D‐serine, D‐cycloserine, or ampakine CX516 was used to augment the effect of antipsychotic drugs. D‐cycloserine, a partial agonist of NMDA receptors' glycine site, seemed ineffective towards the symptoms of schizophrenia. NMDA receptor co‐agonists glycine and D‐serine showed some effects in reducing the negative symptoms of schizophrenia (n=132, SMD ‐0.66, CI ‐1.0 to ‐0.3, p=0.0004), but the magnitude of the effect was moderate. Furthermore, when responder rates rather than mean scores of negative symptoms were analysed the data were inconsistent: There was no difference in responder rates between glycine and the control in terms of more than 20% improvement of negative symptoms (n=62, RR 0.70, CI 0.3 to 1.71) and only a borderline significant superiority in terms of more than 50% improvement (n=62, RR 0.87, CI 0.8 to 1.00). There were also some effects in favour of glycine and/or D‐serine in terms of overall and general symptoms, but the results were again inconsistent and depended on the response definition applied. Available rating scale data on positive symptoms and cognitive functioning did not indicate a statistically significant effect of glycine or D‐serine. Authors' conclusions In general, all glutamatergic drugs appeared to be ineffective in further reducing positive symptoms of the disease when added to the existing antipsychotic treatment. Glycine and D‐serine may somewhat improve negative symptoms when added to regular antipsychotic medication, but the results were not fully consistent and data are too few to allow any firm conclusions. Many participants in the included trials were treatment‐resistant which may have reduced treatment response. Additional research on glutamatergic mechanisms of schizophrenia is needed. Plain language summary Glutamatergic drugs for schizophrenia Schizophrenia is a severe psychiatric disease characterised by positive symptoms such as hallucinations and delusions and negative symptoms such as blunted affect and emotional withdrawal. People with schizophrenia may also suffer from cognitive deficits. Current medication is effective in reducing positive symptoms, but negative and cognitive symptoms are fairly resistant to treatment. Antipsychotic drugs act mainly on the dopamine system in the brain, although other neurotransmitter systems may also play a role in schizophrenia. We sought to review all randomised trials that used glutamatergic drugs in the treatment of schizophrenia. This review shows that substances acting on the glutamate system may improve symptoms when added to regular antipsychotic medication, although the available evidence base is too limited to allow for any firm conclusions. Presently, glutamatergic drugs are not available for clinical use. Additional research is needed to determine their ultimate role in the treatment of schizophrenia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Tiihonen, J; Wahlbeck, K", "articleTypes": [], "doi": "10.1002/14651858.CD003730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "86bad5f9-236c-486a-b79d-3e975b2083d0", "pmid": "", "title": "Interventions for fatigue in people with kidney failure requiring dialysis", "imported": false, "abstract": "Abstract - Background Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD). Objectives We aimed to evaluate the effects of pharmacological and non‐pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Studies evaluating pharmacological and non‐pharmacological interventions affecting levels of fatigue or fatigue‐related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue‐related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered. Data collection and analysis Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta‐analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Ninety‐four studies involving 8191 randomised participants were eligible. Pharmacological and non‐pharmacological interventions were compared either to placebo or control, or to another pharmacological or non‐pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis‐Related Fatigue scale score): SMD ‐1.18, 95% CI ‐2.04 to ‐0.31; I 2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD ‐1.23, 95% CI ‐1.96 to ‐0.50; I 2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD ‐1.06, 95% CI ‐1.47, ‐0.65; I 2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I 2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD ‐0.64, 95% CI ‐1.03 to ‐0.25; I 2 = 75%) in HD. A wide range of heterogenous interventions and fatigue‐related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non‐pharmacological interventions on fatigue or fatigue‐related outcomes, including non‐physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive‐behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta‐blockers, anabolic steroids, glucose‐enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non‐pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported. Authors' conclusions Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non‐pharmacological interventions had uncertain effects on fatigue or fatigue‐related outcomes in people receiving dialysis. Future adequately powered, high‐quality studies are likely to change the estimated effects of interventions for fatigue and fatigue‐related outcomes in people receiving dialysis. Plain language summary Are interventions for fatigue effective among people with kidney failure requiring dialysis? What is the issue? Fatigue is a frequent and debilitating symptom that can limit life participation in people receiving dialysis. Fatigue is linked to impaired quality of life, cardiovascular disease, death and depression in people on dialysis. Several potential interventions, including drugs or other non‐pharmacological treatments (e.g. exercise, diet, massage, aromatherapy, acupressure), have been evaluated for their effect on fatigue in people on dialysis. What did we do? We evaluated whether drugs or other non‐pharmacological interventions are beneficial for adults and children receiving haemodialysis or peritoneal dialysis to manage fatigue. We evaluated all clinical studies available and summarised the results. We evaluated how certain we could be about the evidence related to interventions for fatigue using a system called \"GRADE\". What did we find? Ninety‐four studies involving 8191 randomised participants were available. Patients in the studies were given a drug, non‐pharmacological intervention, standard care or a sugar pill (placebo). The treatment they received was decided by random chance. The studies were generally short‐term (over a few months). There were no studies in children. Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. Drugs or other non‐pharmacological interventions have uncertain effects on fatigue in people on dialysis. Conclusions Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. It remains uncertain whether drugs or other non‐pharmacological interventions have any impact on fatigue in people on dialysis when compared to a sugar pill, standard care or other treatments for fatigue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Natale, P; Ju, A; Strippoli, GFM; Craig, JC; Saglimbene, VM; Unruh, ML; Stallone, G; Jaure, A", "articleTypes": [], "doi": "10.1002/14651858.CD013074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "86c98057-635f-4a18-9d29-a9224817cb6a", "pmid": "", "title": "Probiotics for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Trivedi, A, Teo, E, Walker, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012265.pub2 AB - Abstract - Background The intestinal microflora has an essential role in providing a barrier against colonisation of pathogens, facilitating important metabolic functions, stimulating the development of the immune system, and maintaining intestinal motility. Probiotics are live microorganisms that can be administered to supplement the gut flora. Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be partly due to a disruption of the integrity of the gut and its intestinal microflora. There may be a role for probiotics in reducing the incidence of sepsis and improving intestinal motility, thus reducing morbidity and mortality and improving enteral feeding in neonates in the postoperative period. Objectives To evaluate the efficacy and safety of administering probiotics after gastrointestinal surgery for the postoperative management of neonates born from 35 weeks of gestation. Search methods We searched CENTRAL, MEDLINE, Embase, and trial registries in August 2023. We checked reference lists of included studies and relevant systematic reviews for additional studies. Selection criteria We included randomised controlled trials (RCTs) that investigated the postoperative administration of oral probiotics versus placebo or no treatment in neonates born from 35 weeks of gestation who had one or more gastrointestinal surgical procedures. We applied no restrictions regarding the type or dosage of probiotics or the duration of treatment. Data collection and analysis We used standard Cochrane methods, and we used GRADE to assess the certainty of evidence. Main results We identified one RCT that recruited 61 neonates with a gestational age of 35 weeks or more. All infants were admitted to a neonatal intensive care unit and had surgery for gastrointestinal pathologies. There may be little or no difference in proven sepsis (positive bacterial culture, local or systemic) between infants who receive probiotics compared with those who receive placebo (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.16 to 2.55; 61 infants; low‐certainty evidence). Probiotics compared to placebo may have little or no effect on time to full enteral feeds (mean difference (MD) 0.63 days, 95% CI −4.02 to 5.28; 61 infants; low‐certainty evidence). There were no reported deaths prior to discharge from hospital in either study arm. Two weeks after supplementation, the infants who received probiotics had a substantially higher relative abundance of non‐pathogenic intestinal microflora (Bifidobacteriaceae) than those who received placebo (MD 38.22, 95% CI 28.40 to 48.04; 39 infants; low‐certainty evidence). Authors' conclusions This review provides low‐certainty evidence from one small RCT that probiotics compared to placebo have little or no effect on the risk of proven sepsis (positive bacterial culture, local or systemic) or time to full‐enteral feeds in neonates who have undergone gastrointestinal surgery. Probiotics may substantially increase the abundance of beneficial bacterial in the intestine of these neonates, but the clinical implications of this finding are unknown. There is a need for adequately powered RCTs to assess the role of probiotics in this population. We identified two ongoing studies. As neither reported the gestational age of prospective study participants, we are unsure if they will be eligible for inclusion in this review. Plain language summary Benefits and harms of giving probiotics to newborns after digestive tract surgery Key message • Probiotics may have little or no effect on the risk of blood infection in infants born from 35 weeks of pregnancy who have undergone surgery of the digestive tract (food pipe, stomach, or bowel).
• Probiotics may increase the proportion of 'good' bacteria in the bowel, but we do not know if this has any real benefit for the infant. What are probiotics? Probiotics are live bacteria that may offer health benefits when consumed. There is evidence that probiotics can prevent an inflammatory disease of the bowel (necrotising enterocolitis) and infection in premature babies. What are some of the risks of bowel surgery in babies? Surgery of the digestive tract increases the risk of infection, and infection can increase the length of hospital stay. Treatment with antibiotics (medicines that treat bacterial infection) and the stress of surgery can diminish the 'good' bacteria in the bowel. What did we want to find out? We wanted to find out if giving probiotics to babies born from 35 weeks of pregnancy who underwent stomach or bowel surgery could improve rates of infection, length of hospital stay, rates of death, feeding, and the proportion of 'good' bacteria in the stomach and bowel. What did we do? We searched for studies that randomly assigned babies to experimental treatment (probiotics) or a control, which could be placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested) or no treatment. What did we find? We found one small study of 61 babies born from 35 weeks of pregnancy who had digestive tract surgery. Thirty babies received probiotics after the surgery, and 30 received a placebo. In the probiotics group, 13% of babies had a blood infection, compared with 19% in the placebo group. This difference is too small to be significant. On average, the babies in the probiotic group were receiving food into their stomach about 15 hours sooner than those in the placebo group. Again, this difference is not important. Among 39 infants who were tested, those in the probiotics group had considerably more 'good' bacteria in their bowel compared to the placebo group. What are the limitations of the evidence? We have little confidence in the evidence because it is based on a single study with few participants. The evidence is not strong enough to support giving probiotics routinely. Well‐designed and large studies are needed to determine the benefits and harms of giving probiotics to newborns after digestive tract surgery. How up to date is this evidence? The evidence is up to date to August 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.811Z" }, { "id": "86e120b0-6aa6-45a0-803f-ff93009f7a36", "pmid": "", "title": "Chlorhexidine treatment for the prevention of dental caries in children and adolescents", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) is a common disease that is preventable by reducing the dietary intake of free sugars and using topical sodium fluoride products. An antibacterial agent known as chlorhexidine may also help prevent caries. A number of over‐the‐counter and professionally administered chlorhexidine‐based preparations are available in a variety of formulations and in a range of strengths. Although previous reviews have concluded that some formulations of chlorhexidine may be effective in inhibiting the progression of established caries in children, there is currently a lack of evidence to either claim or refute a benefit for its use in preventing dental caries. Objectives To assess the effects of chlorhexidine‐containing oral products (toothpastes, mouthrinses, varnishes, gels, gums and sprays) on the prevention of dental caries in children and adolescents. Search methods We searched the Cochrane Oral Health Group Trials Register (25 February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 12), MEDLINE via OVID (1946 to 25 February 2015), EMBASE via OVID (1980 to 25 February 2015) and CINAHL via EBSCO (1937 to 25 February 2015). We handsearched several journals placed no language restrictions on our search. After duplicate citations were removed, the electronic searches retrieved 1075 references to studies. Selection criteria We included parallel‐group, randomised controlled trials (RCTs) that compared the caries preventive effects of chlorhexidine gels, toothpastes, varnishes, mouthrinses, chewing gums or sprays with each other, placebo or no intervention in children and adolescents. We excluded trials with combined interventions of chlorhexidine and fluoride or comparisons between chlorhexidine and fluoride interventions. Data collection and analysis Two review authors independently extracted trial data and assessed risk of bias. We resolved disagreements by consensus. We contacted trial authors for clarification or additional study details when necessary. The number of included studies that were suitable for meta‐analysis was limited due to the clinical diversity of the included studies with respect to age, composition of intervention, and variation in outcome measures and follow‐up. Where we were unable to conduct meta‐analysis, we elected to present a narrative synthesis of the results. Main results We included eight RCTs that evaluated the effects of chlorhexidine varnishes (1%, 10% or 40% concentration) and chlorhexidine gel (0.12%) on the primary or permanent teeth, or both, of children from birth to 15 years of age at the start of the study. The studies randomised a total of 2876 participants, of whom 2276 (79%) were evaluated. We assessed six studies as being at high risk of bias overall and two studies as being at unclear risk of bias overall. Follow‐up assessment ranged from 6 to 36 months. Six trials compared chlorhexidine varnish with placebo or no treatment. It was possible to pool the data from two trials in the permanent dentition (one study using 10% chlorhexidine and the other, 40%). This led to an increase in the DMFS increment in the varnish group of 0.53 (95% confidence interval (CI) ‐0.47 to 1.53; two trials, 690 participants; very low quality evidence). Only one trial (10% concentration chlorhexidine varnish) provided usable data for elevated mutans streptococci levels > 4 with RR 0.93 (95% CI 0.80 to 1.07, 496 participants; very low quality evidence). One trial measured adverse effects (for example, ulcers or tooth staining) and reported that there were none; another trial reported that no side effects of the treatment were noted. No trials reported on pain, quality of life, patient satisfaction or costs. Two trials compared chlorhexidine gel (0.12% concentration) with no treatment in the primary dentition. The presence of new caries gave rise to a 95% confidence interval that was compatible with either an increase or a decrease in caries incidence (RR 1.00, 95% CI 0.36 to 2.77; 487 participants; very low quality evidence). Similarly, data for the effects of chlorhexidine gel on the prevalence of mutans streptococci were inconclusive (RR 1.26, 95% CI 0.95 to 1.66; two trials, 490 participants; very low quality evidence). Both trials measured adverse effects and did not observe any. Neither of these trials reported on the other secondary outcomes such as measures of pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Authors' conclusions We found little evidence from the eight trials on varnishes and gels included in this review to either support or refute the assertion that chlorhexidine is more effective than placebo or no treatment in the prevention of caries or the reduction of mutans streptococci levels in children and adolescents. There were no trials on other products containing chlorhexidine such as sprays, toothpastes, chewing gums or mouthrinses. Further high quality research is required, in particular evaluating the effects on both the primary and permanent dentition and using other chlorhexidine‐containing oral products. Plain language summary Antiseptic treatment (chlorhexidine) to prevent tooth decay in children and young people Review question This review examined the effectiveness of varnishes and gels containing chlorhexidine in preventing tooth decay in children and young people. Background Tooth decay is a very common disease that over time destroys the tooth surface. It has been estimated to affect up to 80% of people in high‐income countries and, despite being preventable through oral hygiene and dietary measures and the use of agents such as fluoride that reduce risk of decay, it is likely to remain a problem, especially in low‐income countries. Tooth decay can result in pain and infection, and in young children may require treatment in hospital under a general anaesthetic. As well as causing anxiety and pain, this may mean the child or young person missing time at school and their parents or carers having to take time off work, possibly losing income and incurring extra costs. Prevention of tooth decay is simpler and possibly cheaper than waiting until it occurs and then requires extensive treatment. Tooth decay is largely preventable, and a range of things may assist this: twice‐daily toothbrushing with a fluoride toothpaste, reducing both the amount of and number of times per day sugar is eaten, and drinking water that contains fluoride (bottled or tap, depending on where you live). Tooth decay occurs when certain types of bacteria (germs) in the mouth, such as Streptococcus mutans, produce acids from the sugar we eat, which dissolve the hard enamel coating on our teeth. The chemical antiseptic treatment chlorhexidine is highly successful at destroying these bacteria and can be used safely at home in the form of a gel, spray, chewing gum, toothpaste or mouthrinse. Alternatively, chlorhexidine can be applied as a varnish to the surface of teeth by a dentist. Study characteristics The evidence in this review, carried out through the Cochrane Oral Health Group, is up‐to‐date at 25 February 2015. We found eight studies that were suitable to include in this review. The studies involved a total of 2876 children from birth to 15 years of age who were at moderate to high risk of tooth decay. Six of the studies looked at the effects of dental professionals applying different strengths of chlorhexidine varnishes to the baby teeth, permanent teeth or both types of teeth in children and adolescents. The other two studies looked at the effects of parents placing chlorhexidine gel on their children's baby teeth. There were no studies that examined other products containing chlorhexidine, such as sprays, toothpastes, chewing gums or mouthrinses. Key results The results did not provide evidence that chlorhexidine varnish or gel reduces tooth decay or reduces the bacteria that encourage tooth decay. The studies did not evaluate other outcomes such as pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Four studies measured side effects and found none were observed. Quality of the evidence Due to the lack of suitable studies and concerns about possible bias in the included studies, the evidence is very low quality. As a result, we are not able to conclude whether or not chlorhexidine is effective in preventing tooth decay in children or adolescents, when compared to placebo (an inactive substitute for chlorhexidine) or no treatment. Future research on the use of chlorhexidine to prevent tooth decay is needed and should consider both primary and permanent teeth and should assess other chlorhexidine‐containing products that can be used at home, such as toothpastes or mouthrinses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Walsh, T; Oliveira‐Neto, JM; Moore, D", "articleTypes": [], "doi": "10.1002/14651858.CD008457.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "86e6e9bf-69ba-48ae-b227-88272c73d400", "pmid": "", "title": "Individualized Computational Assessment of the Effects of GABA Receptor Modulation in Posttraumatic Stress Disorder", "imported": false, "abstract": "A substantial majority of Veterans with posttraumatic stress disorder (PTSD) continue to suffer even with the best current medications. Progress in developing more effective medications is hampered by the substantial variability within Veterans with PTSD, meaning the most effective medication likely varies from individual to individual. New scientific tools to help identify distinct subgroups of Veterans with PTSD who are likely to respond to specific medications could help improve treatment in this population. Research has indicated that a specific subgroup of Veterans with PTSD with a high level of anxious arousal may benefit from medications which boost signaling of the neurotransmitter gamma-aminobutyric acid (GABA). This project aims to validate a clinical test to identify these individuals using new computational and neuroimaging methods combined with the medication lorazepam, a positive GABA modulator. The ultimate goal is to use these methods in future clinical trials of new medications to target the best treatments to individual Veterans with PTSD.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.148Z" }, { "id": "86f42e5c-3fc2-4baa-b887-de2ef4df92c0", "pmid": "", "title": "Zinc supplementation for tinnitus", "imported": false, "abstract": "Abstract - Background Tinnitus is the perception of sound without external acoustic stimuli. Patients with severe tinnitus may have physical and psychological complaints and their tinnitus can cause deterioration in their quality of life. At present no specific therapy for tinnitus has been found to be satisfactory in all patients. In recent decades, a number of reports have suggested that oral zinc supplementation may be effective in the management of tinnitus. Since zinc has a role in cochlear physiology and in the synapses of the auditory system, there is a plausible mechanism of action for this treatment. Objectives To evaluate the effectiveness and safety of oral zinc supplementation in the management of patients with tinnitus. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 6); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 July 2016. Selection criteria Randomised controlled trials comparing zinc supplementation versus placebo in adults (18 years and over) with tinnitus. Data collection and analysis We used the standard methodological procedures recommended by Cochrane. Our primary outcome measures were improvement in tinnitus severity and disability, measured by a validated tinnitus‐specific questionnaire, and adverse effects. Secondary outcomes were quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters, change in tinnitus loudness, change in overall severity of tinnitus and change in thresholds on pure tone audiometry. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included three trials involving a total of 209 participants. The studies were at moderate to high risk of bias. All included studies had differences in participant selection criteria, length of follow‐up and outcome measurement, precluding a meta‐analysis. The participants were all adults over 18 years with subjective tinnitus, but one study conducted in 2013 (n = 109) included only elderly patients. Improvement in tinnitus severity and disability Only the study in elderly patients used a validated instrument (Tinnitus Handicap Questionnaire) for this primary outcome. The authors of this cross‐over study did not report the results of the two phases separately and found no significant differences in the proportion of patients reporting tinnitus improvement at four months of follow‐up: 5% (5/93) versus 2% (2/94) in the zinc and placebo groups, respectively (risk ratio (RR) 2.53, 95% confidence interval (CI) 0.50 to 12.70; very low‐quality evidence ). None of the included studies reported any significant adverse effects. Secondary outcomes For the secondary outcome change in tinnitus loudness, one study reported no significant difference between the zinc and placebo groups after eight weeks: mean difference in tinnitus loudness ‐9.71 dB (95% CI ‐25.53 to 6.11; very low‐quality evidence ). Another study also measured tinnitus loudness but used a 0‐ to 100‐point scale. The authors of this second study reported no significant difference between the zinc and placebo groups after four months: mean difference in tinnitus loudness rating scores 0.50 (95% CI ‐5.08 to 6.08; very low‐quality evidence ). Two studies used unvalidated instruments to assess tinnitus severity. One (with 50 participants) reported the severity of tinnitus using a non‐validated scale (0 to 7 points) and found no significant difference in subjective tinnitus scores between the zinc and placebo groups at the end of eight weeks of follow‐up (mean difference (MD) ‐1.41, 95% CI ‐2.97 to 0.15; very low‐quality evidence ). A third trial (n = 50) also evaluated the improvement of tinnitus using a non‐validated instrument (a 0 to 10 scale: 10 = severe and unbearable tinnitus). In this study, after eight weeks there was no difference in the proportion of patients with improvement in their tinnitus, 8.7% (2/23) treated with zinc versus 8% (2/25) of those who received a placebo (RR 1.09, 95% CI 0.17 to 7.10, very low‐quality evidence ). None of the included studies reported any of our other secondary outcomes (quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters or change in thresholds on pure tone audiometry). Authors' conclusions We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. Plain language summary Zinc supplements for tinnitus Background Tinnitus is the perceived sensation of sound in the ear or head. Severe tinnitus affects 1% to 2% of the population. People with severe tinnitus frequently have psychological changes and a decrease in their quality of life. Tinnitus is difficult to control and many doctors are testing new treatments to improve the quality of life of people who suffer from this problem. This review looked for high‐quality studies in the literature that involved zinc supplements as a possible treatment for tinnitus in adults. The aim was to evaluate whether oral zinc is effective in the treatment of tinnitus. Study characteristics We included a total of three trials involving 209 participants who were treated with oral zinc pills or placebo. All patients were adults over 18 years who had subjective tinnitus. All three studies investigated improvement in tinnitus as their primary outcome. One study assessed adverse effects and our secondary outcome 'change in overall severity of tinnitus'. Two studies assessed tinnitus loudness. Only one study, which enrolled only elderly patients, used a validated instrument (the Tinnitus Handicap Questionnaire (THQ)) to measure the primary outcome. The other two studies measured tinnitus using scales (from 0 to 7 and from 0 to 10), but these scales were not validated instruments for studying tinnitus. Key results All three included studies had differences in their participant selection, length of follow‐up and outcome measurement, which prevented a meta‐analysis (combining of results). Only one trial (conducted in 2013) used a validated instrument (the THQ) to measure improvement in tinnitus, our primary outcome. The authors reported no significant difference between the groups. Another study (2003) reported the severity of tinnitus using a non‐validated scale (0 to 7) and found a significant difference in the subjective tinnitus scores, which favoured the zinc group. However, this result may be biased because the losses were unbalanced and higher in the placebo group. A third study (1991) also evaluated improvement of tinnitus using a non‐validated instrument (a scale of 0 to 10) and found no significant difference between groups. There were no severe adverse effects associated with zinc. Three cases of mild adverse effects were reported in different participants (e.g. mild gastric symptoms). Two studies (2003 and 2013) assessed change in tinnitus loudness (one of our secondary outcomes), but did not find a difference between patients treated with zinc compared to those who took a placebo. Two studies assessed change in the overall severity of tinnitus. One study, published in 1991, did not find any difference for this outcome between the groups. The second study, published in 2003, reported a significant reduction in subjective tinnitus score in the zinc group and no difference in the placebo group. However, both studies used a non‐validated scale. Quality of the evidence The quality of the evidence is very low. We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. This evidence is up to date to 14 July 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Person, OC, Puga, MES, da Silva, EMK, Torloni, MR", "articleTypes": [], "doi": "10.1002/14651858.CD009832.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.094Z" }, { "id": "86fae1b4-9938-4aae-8b89-d7ca72ece82a", "pmid": "", "title": "Oral nicotine pouches for cessation or reduction of use of other tobacco or nicotine products", "imported": false, "abstract": "Abstract - Rationale Oral nicotine pouches (ONP) emerged in the late 2000s, but have gained popularity since their introduction to the global market in 2016, with claims about their harm reduction potential. Objectives Primary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from combustible tobacco use (smoking). • To evaluate the impact of ONP on the prevalence of combustible tobacco use. Secondary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from other non‐combustible tobacco/commercial nicotine product use. • To evaluate the impact of ONP on the prevalence of use of other non‐combustible tobacco/commercial nicotine products. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO from 2000 to 13 January 2025. We also covered ClinicalTrials.gov and the WHO ICTRP through our search of CENTRAL. Eligibility criteria We included randomised controlled trials (RCTs) of ONP in people using tobacco or other non‐combustible tobacco/non‐pharmaceutical nicotine products. RCTs must have reported tobacco/nicotine use at 4+ weeks or biomarkers or adverse events at 1+ weeks. We also sought interrupted/multiple time‐series studies of ONP's population‐level effects on the prevalence of use of other tobacco/nicotine products. Outcomes Our critical outcomes were: smoking abstinence at 4+ weeks; number of people reporting serious adverse events (SAEs) at 1+ weeks; and change in the prevalence of smoking. Important outcomes included tobacco‐specific nitrosamines (TSNAs), carboxyhaemoglobin (COHb), metals, and inflammatory markers detected in human biosamples. Risk of bias We used the Cochrane RoB 1 tool to assess risk of bias. Synthesis methods We synthesised results using random‐effects meta‐analysis where possible. We used I 2 to quantify statistical heterogeneity. Where meta‐analysis was not possible, we graphically plotted available data in forest plots. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CI). We assessed the certainty of evidence using GRADE. Included studies We included four small studies (n < 150 for each, total n = 284; 3 independent, 1 industry‐funded; 3 at high risk of bias and 1 at unclear risk of bias). All were RCTs in people who smoked combustible cigarettes at baseline. Three were conducted in the USA, and one in New Zealand. Two compared higher‐ versus lower‐nicotine dose ONP. Two compared ONP to instructions to continue smoking as usual. One each compared ONP to electronic cigarettes (e‐cigarettes), snus, and pharmaceutical nicotine replacement therapy (NRT). Synthesis of results Smoking abstinence Smoking abstinence may be slightly higher in people randomised to ONP compared to no intervention at eight‐week follow‐up (RR 1.58, 95% CI 0.07 to 35.32; 1 study, 27 participants; very low‐certainty evidence (risk of bias and imprecision; CI incorporated possibility of no difference)), but the evidence is very uncertain. Low‐certainty evidence (serious imprecision; CI incorporated possibility of no difference) suggests there may be lower abstinence rates in those randomised to ONP compared to e‐cigarettes (RR 0.25, 95% CI 0.03 to 2.02; 1 study, 36 participants). Evidence from one study (n = 30) comparing higher‐ versus lower‐dose ONP found a higher quit rate in the higher‐dose arm, but again with wide CI encompassing the possibility of no difference and of higher quit rates in the lower‐dose arm (RR 5.00, 95% CI 0.26 to 96.13; evidence certainty not assessed). Serious adverse events No SAEs occurred in the three studies reporting this outcome. Data were available for the comparisons ONP versus minimal control (2 studies, 124 participants; very low‐certainty evidence (risk of bias and serious imprecision)) and ONP versus e‐cigarettes (1 study, 26 participants; low‐certainty evidence (serious imprecision)). TSNA One study reported on a TSNA (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol (NNAL)) comparing ONP with instructions to continue smoking. There may be lower levels with ONP (MD −265.30 ng/g creatinine, 95% CI −350.64 to −179.96; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. Data from two studies suggested no difference in NNAL levels between higher‐ and lower‐dose ONP (SMD −0.16, 95% CI −1.87 to 1.56; I 2 = 0%; 77 participants; evidence certainty not assessed). COHb Based on one study, there may be lower levels of COHb with ONP compared to instructions to continue smoking (MD −6.7%, 95% CI −8.33 to −5.07; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. When comparing higher‐ versus lower‐dose ONP, the same study found very slightly lower levels in the higher‐dose group, with the 95% CI incorporating the possibility of no difference (MD −0.40%, 95% CI −1.19 to 0.39; evidence certainty not assessed). No studies reported on prevalence, inflammatory markers, metals, or use of tobacco/nicotine products other than cigarettes. Authors' conclusions There is limited evidence on the use of ONP for cessation or reduction of cigarette use. There is no evidence on the use of ONP for cessation or reduction of other tobacco or nicotine products or on the effects of ONP on prevalence of tobacco use/nicotine vaping. Low‐certainty evidence suggests that people randomised to ONP may be slightly less likely to quit smoking than those randomised to e‐cigarettes, but data were from one small study and therefore imprecise. Limited, short‐term data did not identify any serious health harms from ONP when used to help people transition away from tobacco smoking. More research on the effects of ONP for cessation or reduction of use of other tobacco or non‐pharmaceutical nicotine products is urgently needed. Future trials should prioritise comparing ONP to other active interventions (e.g. NRT and e‐cigarettes). Funding This Cochrane review was funded by the National Cancer Institute of the National Institutes of Health (NIH) and FDA Center for Tobacco Products (CTP) under Award Number 2U54CA229974. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food & Drug Administration. Registration Registration: Cochrane, via protocol available via DOI:10.1002/14651858.CD016220. Plain language summary What are the benefits and risks of oral nicotine pouches when used to help people stop smoking, vaping nicotine, or using other forms of tobacco? Key messages Limited evidence from three small studies found no short‐term serious health harms of oral nicotine pouches in people who smoke. We are uncertain if oral nicotine pouches help people quit smoking compared to instructions to continue smoking as usual or no support to quit. Future research is needed, in particular comparing oral nicotine pouches to other active treatments (e.g. nicotine replacement therapy and e‐cigarettes). What are oral nicotine pouches? Oral nicotine pouches are preportioned pouches containing nicotine, sold in various flavours and nicotine strengths. They are similar in appearance and use to snus. Snus is a form of smokeless tobacco placed between the gum and lip that is popular in Nordic countries, but whose sale is banned in the UK and European Union countries excluding Sweden. Unlike snus, nicotine pouches do not contain tobacco leaf. Like nicotine e‐cigarettes and pharmaceutical forms of nicotine replacement therapy (such as nicotine patches and gums), oral nicotine pouches may be able to help people transition away from harmful forms of tobacco/nicotine product use by replacing them with a product that does not contain tobacco leaf and which, unlike e‐cigarettes, does not involve inhaling vapour into the lungs. Common brand names of oral nicotine pouches include Zyn, Velo, and Nordic Spirit. What did we want to find out? We wanted to find out if oral nicotine pouches can help people transition away from smoking, nicotine vaping, or other forms of tobacco use. We also wanted to know if oral nicotine pouches caused any unwanted effects when used for this purpose. What did we do? We searched for studies where people who smoked, vaped, or used other tobacco products were given oral nicotine pouches as a way to quit. We included studies if they tracked tobacco use or vaping for at least four weeks or looked at unwanted effects or chemical changes in the blood, breath, or urine for at least one week. What did we find? We found four studies including a total of 284 people who were smokers at study start. The studies were conducted between 2006 and 2023, and in those that reported race or ethnicity, were conducted in majority white populations. The average age across studies ranged from 34 to 50 years. The average number of cigarettes smoked by participants at study start was between 14 and 23 per day. The longest study ran for eight weeks. Three studies were independently funded, and one was funded by a tobacco manufacturer. Based on two small studies, it was not clear whether using nicotine pouches helped more people to quit smoking compared to instructions to continue smoking as usual or no support to quit, and there may be lower quit rates in those using nicotine pouches compared to those using a nicotine e‐cigarette (vaping). No serious health harms occurred in any group in the three studies that reported this information, so it is unclear if using nicotine pouches affects the chances of experiencing a serious health harm. We also looked at certain chemicals measured in blood, breath, or urine that can signal exposures to harmful substances. Tobacco use exposes the body to cancer‐causing chemicals. NNAL (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol), a chemical formed when these cancer‐causing chemicals enter the body, measures exposure to harmful ingredients in tobacco smoke. One small study reported lower levels of NNAL in people using oral nicotine pouches compared to those given no specific treatment to stop smoking. Combined evidence from two studies suggested no difference in NNAL levels between people receiving higher‐ versus lower‐dose nicotine pouches. Carbon monoxide is a poisonous gas present in tobacco smoke. When carbon monoxide binds with blood haemoglobin, it forms a substance called carboxyhaemoglobin. Carboxyhaemoglobin measures how much carbon monoxide a person has been exposed to in their blood. One study found lower levels of carboxyhaemoglobin in people using oral nicotine pouches compared to those who continued smoking. When comparing higher‐ versus lower‐dose nicotine pouches, the same study found very slightly lower carboxyhaemoglobin levels in the higher‐dose group. What are the limitations of the evidence? We have little to very low confidence in the evidence because the studies were relatively small, and there are not enough studies to be certain about the results. Also, some studies had issues with the way they were designed that could have affected their results. Many studies are currently underway, and we plan to update this review when their findings become available. How up‐to‐date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hartmann-Boyce, J, Tattan-Birch, H, Brown, J, Shahab, L, Goniewicz, ML, Ma, CL, Wu, AD, Travis, N, Jarman, H, Livingstone-Banks, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD016220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.075Z" }, { "id": "87003515-473e-4684-a2af-191bdb58f497", "pmid": "", "title": "Topical anaesthetic or vasoconstrictor preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy", "imported": false, "abstract": "Abstract - Background Nasal pharyngolaryngoscopy (NPL) is performed as an outpatient and inpatient procedure on a daily basis, for a variety of indications. It frequently causes some degree of discomfort to the patient. Various different topical agents, which are intended to reduce this discomfort, are in common use. This review aimed to assess the effectiveness of the various agents. Objectives To assess the effectiveness of topical preparations used to reduce discomfort and facilitate NPL in adults. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 14 April 2010. Selection criteria Randomised controlled trials (RCTs) looking at the effect of topical anaesthetic or vasoconstrictor agents used reduce discomfort and facilitate NPL in adult patients. Data collection and analysis Two review authors independently selected studies, extracted data and assessed risk of bias. We contacted trial authors for further information where necessary. The primary outcome measured was pain/discomfort. Secondary outcomes that were looked at included side effects of the topical medications, ease of the procedure and the quality of the view from the operator's perspective. Main results We included eight RCTs (746 participants) in the review. The risk of bias in the studies was generally low. Five studies did not demonstrate any advantage in using a topical treatment prior to endoscopy. One study suggested that a vasoconstrictor alone should be used to reduce the general level of unpleasantness. Two studies did not compare treatment against placebo or no treatment, so it was not possible to draw meaningful conclusions from them. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. There was variation in the format of the outcome data and a lack of complete data; none of the included studies reported their results in a way that would allow pooling and we could not therefore perform meta‐analysis. Authors' conclusions The included studies do not demonstrate any evidence to support the use of topical treatments prior to the use of a fibre‐optic nasal endoscope. Some go as far as to suggest that these agents should not be used due to cost and unpleasant side effects. Five studies did not demonstrate any advantage in terms of reducing pain or discomfort when using a topical treatment prior to endoscopy. The absence of demonstrable effect may be due to relatively small patient groups. It is therefore possible that there is a small effect of using these sprays. Further research using standardised reporting methods is needed. Plain language summary Topical anaesthetic or vasoconstrictor (blood vessel narrowing) preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy Topical medications are often applied to the inside of a patient's nose prior to examining the nose, sinuses and throat with a flexible nasopharyngolaryngoscope. The aim of this is to reduce any discomfort the patient may feel and also to improve the adequacy of the examination. Types of preparation include lidocaine, phenylephrine and lidocaine, oxymetazoline, xylometazoline and cocaine and they are usually administered as a spray, although they may also be in the form of a solution which can be applied to cotton wool and placed in the nasal cavity, or as gels, pastes or creams. We looked for randomised controlled trials comparing any of these topical treatments with placebo, no treatment or another topical treatment in adult patients undergoing nasal pharyngolaryngoscopy (NPL). We included eight studies in the review (with a total of 746 patients). It was not possible to combine data from any of the studies, therefore we assessed the individual study results. Five of the studies did not demonstrate any advantage, in terms of reducing pain or discomfort, of using a topical treatment prior to endoscopy. One of these suggested that a vasoconstrictor (xylometazoline) alone reduced the level of \"general unpleasantness\". Two studies did not compare the treatment against placebo or no treatment. A final study actually suggested an increase in pain with the use of topical agents. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. Further standardised research is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Sunkaraneni, VS, Jones, SEM", "articleTypes": [], "doi": "10.1002/14651858.CD005606.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.063Z" }, { "id": "87044949-5031-421a-a10a-7c7b30e41f72", "pmid": "", "title": "Systemic corticosteroids for acute otitis media in children", "imported": false, "abstract": "Abstract - Background Acute otitis media (AOM) is a common acute infection in children. Pain is its most prominent and distressing symptom. Antibiotics are commonly prescribed for AOM, although they have only a modest effect in reducing pain at two to three days. There is insufficient evidence for benefits of other treatment options, including systemic corticosteroids. However, systemic corticosteroids are potent anti‐inflammatory drugs, and so theoretically could be effective, either alone or as an addition to antibiotics. Objectives To assess the effects of systemic corticosteroids (oral or parenteral), with or without antibiotics, for AOM in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) which contains the Cochrane ARI Group's Specialised Register, MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), Web of Science (Thomson Reuters), and LILACS (BIREME) for published studies, and ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for completed and ongoing studies, to 20 February 2018. We checked the reference lists of all primary studies and review articles for additional references and contacted experts in the field to identify additional unpublished materials. Selection criteria We included randomised controlled trials of children with AOM that compared any systemic corticosteroid (oral or parenteral) with placebo, either with antibiotics (corticosteroid plus antibiotic versus placebo plus antibiotic) or without antibiotics (corticosteroid versus placebo). Data collection and analysis Three review authors (EDS, RR, YP) independently screened the titles and abstracts and retrieved the full texts of potentially relevant studies. We independently extracted study characteristics and outcome data from the included studies, and assessed the risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed study quality using the GRADE method. Main results We included two studies involving 252 children with AOM aged from three months to six years receiving hospital ambulatory care who were treated with intramuscular ceftriaxone, and who were then randomised to the corticosteroid group (corticosteroid and corticosteroid plus antihistamine) or the placebo group (antihistamine and double placebo). In one study, children also had a needle aspiration of middle ear fluid. Both studies were at unclear risk of bias for allocation concealment, and unclear to high risk of bias for selective reporting. One study (N = 179) included pain as an outcome, but we were unable to derive the proportion of children with persistent pain at Day 5 and Day 14. Reduction of overall or specific symptoms was presented as improvement in clinical symptoms and resolution of inflamed tympanic membranes without the need for additional antibiotic treatment: at Day 5 (94% of children in the treatment group (N = 89) versus 89% in the placebo group (N = 90); risk ratio (RR) 1.06, 95% confidence interval (CI) 0.97 to 1.16) and Day 14 (91% versus 87%; RR 1.05, 95% CI 0.95 to 1.17). Low‐quality evidence meant that we are uncertain of the effectiveness of corticosteroids for this outcome. The second study (N = 73) reported a reduction of overall or specific symptoms without additional antibiotic treatment during the first two weeks as a favourable outcome. Children in the treatment group had more favourable outcomes (adjusted odds ratio 65.9, 95% CI 1.28 to 1000; P = 0.037), although the numbers were small. We were unable to pool the results with the other study because it did not report the proportion of children with this outcome by treatment group. Only one study reported adverse effects of corticosteroids (e.g. drowsiness, nappy rash), but did not quantify incidence, so we were unable to draw conclusions about adverse effects. Neither study reported a reduction in overall or specific symptom duration. Authors' conclusions The evidence for the effect of systemic corticosteroids on AOM is of low to very low quality, meaning the effect of systemic corticosteroids on important clinical outcomes in AOM remains uncertain. Large, high‐quality studies are required to resolve the question . Plain language summary Systemic corticosteroids for improving symptoms in children with acute middle ear infection Review question We reviewed the evidence on the effects of corticosteroids given by mouth or injection for acute middle ear infection (acute otitis media (AOM)) in children, particularly in improving symptoms such as ear pain, fever, irritability, lack of sleep, and lack of appetite. We also looked at the side effects of corticosteroids. Background Acute otitis media is common in children and causes ear pain and non‐specific symptoms such as fever, irritability, and deafness. It is often treated with antibiotics, although ear pain generally resolves within two days, and antibiotics help symptoms only slightly. Other treatments (such as over‐the‐counter antihistamines and decongestants) do not help very much. Corticosteroids are often prescribed to reduce inflammation in children for other illnesses, and so may also help symptoms of AOM, which is an inflammatory process. We investigated whether using corticosteroids was better or worse than nothing in improving AOM‐related symptoms. Search date Our evidence is current to 20 February 2018. Study characteristics We included two studies involving 252 children with AOM, aged from three months to six years, receiving hospital ambulatory care. Children were treated with an antibiotic injection and either oral corticosteroid or a placebo (treatment with no effect). In one study, fluid from the middle ear was collected by inserting a needle through the eardrum to measure the level of inflammation. Study funding sources The National Institutes of Health (NIH) and the National Center for Research Resources, NIH, US Public Health Service funded both studies. Pharmaceutical companies provided the drug but did not contribute any other scientific or financial support. Key results and quality of evidence Corticosteroids did not make a significant difference in improving the symptoms and inflammation of the eardrum(s) at Day 5 and Day 14, but we are unsure of this effect due to the small numbers of children in the studies. There were no significant differences between the corticosteroid and placebo groups in terms of resolving fluid in children's middle ears (at 1, 2, and 3 months) and experiencing new episodes of AOM (at 1, 2, 3 months, and 4 and 6 months). Neither study reported a reduction in the duration of overall or specific symptoms, rupture of eardrum(s), the occurrence of middle ear inflammation in the other ear following the current ear infection, or serious complications. Only one study reported the overall side effects identified during the trial (e.g. drowsiness, dry mouth, diaper rash, nervousness). We could not draw any conclusions regarding the effects of corticosteroids for AOM in children. The quality of evidence included in this review was low to very low due to few children included in two small studies. We are uncertain about whether or not corticosteroids are useful in relieving pain from AOM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ranakusuma, RW, Pitoyo, Y, Safitri, ED, Thorning, S, Beller, EM, Sastroasmoro, S, Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD012289.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.773Z" }, { "id": "871ff73d-a194-439d-9f87-b770fc4b2dac", "pmid": "", "title": "Dornase alfa for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Dornase alfa is currently used as a mucolytic to treat pulmonary disease (the major cause of morbidity and mortality) in cystic fibrosis. It reduces mucus viscosity in the lungs, promoting improved clearance of secretions. This is an update of a previously published review. Objectives To determine whether the use of dornase alfa in cystic fibrosis is associated with improved mortality and morbidity compared to placebo or other medications that improve airway clearance, and to identify any adverse events associated with its use. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstracts from conferences. Date of the most recent search of the Group's Cystic Fibrosis Register: 12 October 2020. Clinicaltrials.gov and the International Clinical Trials Registry Platform were also searched to identify unpublished or ongoing trials. Date of most recent search: 08 February 2021. Selection criteria All randomised and quasi‐randomised controlled trials comparing dornase alfa to placebo, standard therapy or other medications that improve airway clearance. Data collection and analysis Authors independently assessed trials against the inclusion criteria; two authors carried out analysis of methodological quality and data extraction. GRADE was used to assess the level of evidence. Main results The searches identified 74 trials, of which 19 (2565 participants) met our inclusion criteria. 15 trials compared dornase alfa to placebo or no dornase alfa (2447 participants); two compared daily dornase to hypertonic saline (32 participants); one compared daily dornase alfa to hypertonic saline and alternate day dornase alfa (48 participants); one compared dornase alfa to mannitol and the combination of both drugs (38 participants). Trial duration varied from six days to three years. Dornase alfa compared to placebo or no treatment Dornase alfa probably improved forced expiratory volume at one second (FEV 1 ) at one month (four trials, 248 participants), three months (one trial, 320 participants; moderate‐quality evidence), six months (one trial, 647 participants; high‐quality evidence) and two years (one trial, 410 participants). Limited low‐quality evidence showed treatment may make little or no difference in quality of life. Dornase alfa probably reduced the number of pulmonary exacerbations in trials of up to two years (moderate‐quality evidence). One trial that examined the cost of care, including the cost of dornase alfa, found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa: daily versus alternate day One cross‐over trial (43 children) found little or no difference between treatment regimens for lung function, quality of life or pulmonary exacerbations (low‐quality evidence). Dornase alfa compared to other medications that improve airway clearance Results for these comparisons were mixed. One trial (43 children) showed dornase alfa may lead to a greater improvement in FEV 1 compared to hypertonic saline (low‐quality evidence), and one trial (23 participants) reported little or no differences in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol (low‐quality evidence). One trial (23 participants) found dornase alfa may improve quality of life compared to dornase alfa plus mannitol (low‐quality evidence); other comparisons found little or no difference in this outcome (low‐quality evidence). No trials in any comparison reported any difference between groups in the number of pulmonary exacerbations (low‐quality evidence). When all comparisons are assessed, dornase alfa did not cause significantly more adverse effects than other treatments, except voice alteration and rash. Authors' conclusions There is evidence to show that, compared with placebo, therapy with dornase alfa may improve lung function in people with cystic fibrosis in trials lasting from one month to two years. There was a decrease in pulmonary exacerbations in trials of six months or longer, probably due to treatment. Voice alteration and rash appear to be the only adverse events reported with increased frequency in randomised controlled trials. There is not enough evidence to firmly conclude if dornase alfa is superior to other hyperosmolar agents in improving lung function. Plain language summary Dornase alfa, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of using inhaled dornase alfa for treating lung disease in people with cystic fibrosis. Background Cystic fibrosis is an inherited condition which affects the movement of salt across cells in the body and affects, for example, the sweat glands, airways, pancreas and male reproductive system. Lung disease is the most common cause of death in people with cystic fibrosis and although the average life expectancy has increased over the last 30 years, it is still only 48.5 years in high‐income countries. People with cystic fibrosis develop chronic lung disease because of thick mucus that builds up in the lungs which causes infections and inflammation. Dornase alfa was developed to thin out this mucus, so it is easier for people to cough it up from their lungs; this in turn should decrease the number of infections and amount of inflammation and prevent chronic lung disease. Search date The evidence is current to: 12 October 2020. Study characteristics We included 19 trials with 2565 people with cystic fibrosis; 15 trials (2447 people) compared dornase alfa to placebo (a dummy treatment with no active medication) or no dornase alfa treatment; two trials (32 people) compared daily dornase to hypertonic saline; one trial (48 people) compared daily dornase alfa with hypertonic saline and alternate day dornase alfa; and one trial (38 people) compared dornase alfa to mannitol and the combination of both drugs. People from all age groups (infants through to adults) took part in the trials which lasted from six days to three years. Key results Dornase alfa compared to placebo or no treatment We found that dornase alfa probably improves lung function within one month when compared to a placebo or no treatment and this improvement was also seen in longer trials lasting from six months to two years (eight trials; 1708 participants). There were also fewer pulmonary exacerbations (flare up of lung inflammation) in these longer trials. One trial found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa ‐ daily versus alternate day One trial (43 children) found no differences between treatment schedules for lung function, quality of life or pulmonary exacerbations. Dornase alfa compared to other medications that improve airway clearance The results from trials comparing dornase alfa to hypertonic saline or mannitol were mixed. One trial (43 children) showed a greater improvement in lung function with dornase alfa compared to hypertonic saline and one trial (23 participants) reported no difference in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol. In one trial (23 participants) quality of life scores were better with dornase alfa alone than with dornase alfa plus mannitol; other drug comparisons found no difference between treatments for quality of life. No trials in any comparison of treatments reported any difference between groups in the number of pulmonary exacerbations. Overall, no serious side effects were reported, with only rash and a change in voice seen more frequently in those people taking dornase alfa. However, it is not definitively clear from the current evidence if dornase alfa is better than other medications such as hypertonic saline or mannitol. Quality of the evidence The quality of evidence from the trials comparing dornase alfa to placebo or no treatment was moderate to high for lung function results, but only one trial reported any changes in quality of life so the evidence for this outcome is limited. Also, there were few trials comparing different treatment schedules of dornase alfa (e.g. once a day versus twice a day) or comparing dornase alfa to other medications which help with clearing secretions, so current evidence from these trials is limited and of low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Yang, C, Montgomery, M", "articleTypes": [], "doi": "10.1002/14651858.CD001127.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.098Z" }, { "id": "8720ecac-c8ef-49ce-93f3-7a1bd9f6f152", "pmid": "", "title": "Treatment of periodontitis for glycaemic control in people with diabetes mellitus", "imported": false, "abstract": "Abstract - Background Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontitis. Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus, and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement, or non‐surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe. This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care. Objectives To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis. Search methods An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. Selection criteria We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment or adjunctive antimicrobial therapy or both) to no active intervention or 'usual care' (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least 3 months and have measured HbA1c (glycated haemoglobin). Data collection and analysis At least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials, and assessed included trials for risk of bias. Where necessary and possible, we attempted to contact study authors. Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol). Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index, and probing pocket depth), quality of life, cost implications, and diabetic complications. Main results We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel‐RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 diabetes, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair, or poor. Most studies were carried out in secondary care. We assessed two studies as being at low risk of bias, 14 studies at high risk of bias, and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings. Moderate‐certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) ‐0.59% to ‐0.28%; ‐6.4 mmol/mol to ‐3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI ‐0.52% to ‐0.08%; ‐5.7 mmol/mol to ‐0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI ‐0.55% to ‐0.45%; ‐6.0 mmol/mol to ‐4.9 mmol/mol; 1 study, 264 participants). Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, adverse effects of periodontal treatments were not evaluated in most studies. Authors' conclusions Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate‐certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in this review. Plain language summary Does treatment for gum disease help people with diabetes control blood sugar levels? Review question The main question addressed by this review is: how effective is gum disease (periodontitis) treatment for controlling blood sugar levels (known as glycaemic control) in people with diabetes, compared to no active treatment or usual care? Background The aim of treating periodontitis is to reduce swelling and infection and stabilise the condition of the gums and supporting bone. The level of sugar in the blood is too high in people with diabetes, so keeping blood sugar levels under control is a key issue. Some clinical research suggests a relationship exists between gum disease treatment and glycaemic control. Glycaemic control can be measured in different ways. For this review, we focused on HbA1c, which shows average blood glucose levels over the preceding 3 months. It can be reported as a percentage (of total haemoglobin) or as mmol/mol (millimoles per mole). Excellent glycaemic control in a diabetic person might be around 6.5% or 48 mmol/mol. This review was carried out by authors working with the Cochrane Oral Health and is part one of an update of a review previously published in 2010 and 2015. This review evaluates gum disease treatment versus no active treatment or usual care. Part two of the review will compare different types of periodontal treatment. We carried out this review as it is important to discover if gum disease treatment does improve glycaemic control in order to ensure best use of clinical resources. Study characteristics We searched six research databases and found 35 relevant trials where people with diabetes and periodontitis were randomly allocated to an experimental group or a control group. The experimental groups received gum disease treatment called 'subgingival instrumentation', also known as scaling and root planing or deep cleaning. In some experimental groups, the deep cleaning was supplemented with instructions for cleaning teeth properly ('oral hygiene instruction'), or other gum treatments, for example, antimicrobials, which are used to treat infections. Control groups received no active treatment or 'usual care', which was oral hygiene instruction, support with oral hygiene, and/or removal of plaque above the gumline. The trials randomised 3249 participants in total. Almost all participants had type 2 diabetes, with a mix of good, fair, and poor diabetic control. Most of the studies were carried out in hospitals. The studies followed up participants for between 3 and 12 months. Key results Evidence from 30 trials (results from 2443 participants) showed that periodontitis treatment reduces blood sugar levels (measured by HbA1c) in diabetic patients on average by 0.43 percentage points (e.g. from 7.43% to 7%; 4.7 mmol/mol) 3 to 4 months after receiving the treatment compared with no active treatment or usual care. A difference of 0.30% (3.3 mmol/mol) was seen after 6 months (12 studies), and 0.50% (5.4 mmol/mol) at 12 months (one study). There were not enough studies measuring side effects to be able to evaluate the risk of harm from gum disease treatments. Certainty of the evidence Most of the studies were conducted in a way that meant they were at a high risk of bias or did not provide enough information for us to make a judgement on this. However, the consistency of our findings suggests they are reliable and future research is not likely to change them. In summary, currently there is moderate‐certainty evidence to support gum disease treatment (known as subgingival instrumentation) for controlling blood sugar levels in people with periodontitis (gum disease) and diabetes up to 12 months after the start of the periodontal treatment. Date of the search The evidence is current up to 7 September 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Simpson, TC, Clarkson, JE, Worthington, HV, MacDonald, L, Weldon, JC, Needleman, I, Iheozor-Ejiofor, Z, Wild, SH, Qureshi, A, Walker, A, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD004714.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.122Z" }, { "id": "872b37ec-8903-4ea1-b1f7-20a620873669", "pmid": "", "title": "Topical anaesthetics for pain control during repair of dermal laceration", "imported": false, "abstract": "Abstract - Background Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine‐free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017. Objectives To assess whether benefits of non‐invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single‐component or multi‐component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine. Search methods For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta‐registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010. Selection criteria We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence. Main results The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self‐reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine‐phenylephrine (PP) was higher than the mean self‐reported VAS (0 to 100 mm) score for topical tetracaine‐epinephrine‐cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine‐free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self‐limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine‐based or cocaine‐free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Authors' conclusions We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously. Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non‐invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine‐based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Plain language summary Local anaesthesia (numbing medicine) that is directly applied to the skin can provide pain control for repair of skin lacerations Background : Pain control during suturing of torn skin is generally achieved by injecting medication into the skin (infiltration) to numb the area. This injection itself may cause pain, but topical anaesthetics are applied directly to the skin and are painless to administer. Cocaine was one of the first anaesthetics to be successfully applied topically. Concerns over adverse effects of cocaine, its potential misuse and the administrative burden of dispensing a controlled substance led to the development of cocaine‐free topical anaesthetics. Multiple cocaine‐free topical anaesthetics have been found to provide effective anaesthesia for repair of dermal lacerations. Study characteristics : The evidence is current to December 2016. We included in this review 25 randomized controlled trials involving 3278 participants. Studies included both adults and children. Fifteen of the included trials used self‐reporting of pain intensity by trial participants to determine the effectiveness of local anaesthetics. Key results : Study results suggest that directly applying local anaesthetics to the skin is an effective, non‐invasive way of providing pain control during suturing or stapling of skin lacerations. Study findings on the efficacy of individual topical anaesthetics were limited by study design, and data on the efficacy of each topical agent were obtained mostly from single trials. Researchers reported no serious side effects following the use of cocaine‐containing or cocaine‐free topical anaesthetics. The overall broadly comparable effectiveness of cocaine‐free topical anaesthetics for skin laceration repair brings into question the necessity to include cocaine as a component of local anaesthetic solutions. The small number of trials in each comparison group and the range of outcome measures assessed prevented pooling and quantitative analysis of data for all but the single outcome of pain intensity. Additional studies are necessary to directly compare the effectiveness of different formulations of topical anaesthetics. Our review was limited to pain control for repair of superficial lacerations, and our results might not be generalizable to deeper lacerations or more complex procedures performed on intact skin. Further research is needed to strengthen the evidence and to overcome the weakness of the included studies. Quality of the evidence : The overall quality of the evidence was low owing to limitations in study design, ways that studies were carried out (implementation), imprecision of results and high probability of selective data reporting. Most of the trials that compared infiltrated and topical anaesthetics were at high risk of bias, and this was likely to influence measured effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tayeb, BO; Eidelman, A; Eidelman, CL; McNicol, ED; Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD005364.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "876b9582-9760-42f2-9ebb-19c466dccc2e", "pmid": "", "title": "Antioxidant vitamin and mineral supplements for slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Evans, JR, Lawrenson, JG", "articleTypes": [], "doi": "10.1002/14651858.CD000254.pub5 AB - Abstract - Background Age‐related macular degeneration (AMD) is a degenerative condition of the back of the eye that occurs in people over the age of 50 years. Antioxidants may prevent cellular damage in the retina by reacting with free radicals that are produced in the process of light absorption. Higher dietary levels of antioxidant vitamins and minerals may reduce the risk of progression of AMD. This is the third update of the review. Objectives To assess the effects of antioxidant vitamin and mineral supplements on the progression of AMD in people with AMD. Search methods We searched CENTRAL, MEDLINE, Embase, one other database, and three trials registers, most recently on 29 November 2022. Selection criteria We included randomised controlled trials (RCTs) that compared antioxidant vitamin or mineral supplementation to placebo or no intervention, in people with AMD. Data collection and analysis We used standard methods expected by Cochrane. Main results We included 26 studies conducted in the USA, Europe, China, and Australia. These studies enroled 11,952 people aged 65 to 75 years and included slightly more women (on average 56% women). We judged the studies that contributed data to the review to be at low or unclear risk of bias. Thirteen studies compared multivitamins with control in people with early and intermediate AMD. Most evidence came from the Age‐Related Eye Disease Study (AREDS) in the USA. People taking antioxidant vitamins were less likely to progress to late AMD (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.58 to 0.90; 3 studies, 2445 participants; moderate‐certainty evidence). In people with early AMD, who are at low risk of progression, this means there would be approximately four fewer cases of progression to late AMD for every 1000 people taking vitamins (one fewer to six fewer cases). In people with intermediate AMD at higher risk of progression, this corresponds to approximately 78 fewer cases of progression for every 1000 people taking vitamins (26 fewer to 126 fewer). AREDS also provided evidence of a lower risk of progression for both neovascular AMD (OR 0.62, 95% CI 0.47 to 0.82; moderate‐certainty evidence) and geographic atrophy (OR 0.75, 95% CI 0.51 to 1.10; moderate‐certainty evidence), and a lower risk of losing 3 or more lines of visual acuity (OR 0.77, 95% CI 0.62 to 0.96; moderate‐certainty evidence). Low‐certainty evidence from one study of 110 people suggested higher quality of life scores (measured with the Visual Function Questionnaire) in treated compared with non‐treated people after 24 months (mean difference (MD) 12.30, 95% CI 4.24 to 20.36). In exploratory subgroup analyses in the follow‐on study to AREDS (AREDS2), replacing beta‐carotene with lutein/zeaxanthin gave hazard ratios (HR) of 0.82 (95% CI 0.69 to 0.96), 0.78 (95% CI 0.64 to 0.94), 0.94 (95% CI 0.70 to 1.26), and 0.88 (95% CI 0.75 to 1.03) for progression to late AMD, neovascular AMD, geographic atrophy, and vision loss, respectively. Six studies compared lutein (with or without zeaxanthin) with placebo and one study compared a multivitamin including lutein/zeaxanthin with multivitamin alone. The duration of supplementation and follow‐up ranged from six months to five years. Most evidence came from the AREDS2 study in the USA; almost all participants in AREDS2 also took the original AREDS supplementation formula. People taking lutein/zeaxanthin may have similar or slightly reduced risk of progression to late AMD (RR 0.94, 95% CI 0.87 to 1.01), neovascular AMD (RR 0.92, 95% CI 0.84 to 1.02), and geographic atrophy (RR 0.92, 95% CI 0.80 to 1.05) compared with control (1 study, 4176 participants, 6891 eyes; low‐certainty evidence). A similar risk of progression to visual loss of 15 or more letters was seen in the lutein/zeaxanthin and control groups (RR 0.98, 95% CI 0.91 to 1.05; 6656 eyes; low‐certainty evidence). Quality of life (Visual Function Questionnaire) was similar between groups (MD 1.21, 95% CI ‐2.59 to 5.01; 2 studies, 308 participants; moderate‐certainty evidence).
One study in Australia randomised 1204 people to vitamin E or placebo with four years of follow‐up; 19% of participants had AMD. The number of late AMD events was low (N = 7) and the estimate of effect was uncertain (RR 1.36, 95% CI 0.31 to 6.05; very low‐certainty evidence). There was no evidence of any effect of treatment on visual loss (RR 1.04, 95% CI 0.74 to 1.47; low‐certainty evidence). There were no data on neovascular AMD, geographic atrophy, or quality of life.
Five studies compared zinc with placebo. Evidence largely drawn from the largest study (AREDS) found a lower progression to late AMD over six years (OR 0.83, 95% CI 0.70 to 0.98; 3 studies, 3790 participants; moderate‐certainty evidence), neovascular AMD (OR 0.76, 95% CI 0.62 to 0.93; moderate‐certainty evidence), geographic atrophy (OR 0.84, 95% CI 0.64 to 1.10; moderate‐certainty evidence), or visual loss (OR 0.87, 95% CI 0.75 to 1.00; 2 studies, 3791 participants; moderate‐certainty evidence). There were no data on quality of life. Gastrointestinal symptoms were the main reported adverse effect. In AREDS, zinc was associated with a higher risk of genitourinary problems in men, but no difference was seen between high‐ and low‐dose zinc groups in AREDS2. Most studies were too small to detect rare adverse effects. Data from larger studies (AREDS/AREDS2) suggested there may be little or no effect on mortality with multivitamin (HR 0.87, 95% CI 0.60 to 1.25; low‐certainty evidence) or lutein/zeaxanthin supplementation (HR 1.06, 95% CI 0.87 to 1.31; very low‐certainty evidence), but confirmed the increased risk of lung cancer with beta‐carotene, mostly in former smokers. Authors' conclusions Moderate‐certainty evidence suggests that antioxidant vitamin and mineral supplementation (AREDS: vitamin C, E, beta‐carotene, and zinc) probably slows down progression to late AMD. People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than people with early AMD. Although low‐certainty evidence suggested little effect with lutein/zeaxanthin alone compared with placebo, exploratory subgroup analyses from one large American study support the view that lutein/zeaxanthin may be a suitable replacement for the beta‐carotene used in the original AREDS formula. Plain language summary Do antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD)? Key messages 
‐ Taking an antioxidant multivitamin supplement may slow down the progression of age‐related macular degeneration (AMD), an eye disease that blurs your central vision. ‐ People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than for people with early AMD. ‐ Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence as to safety as they were generally too small. What is age‐related macular degeneration? Age‐related macular degeneration (AMD) is an eye disease that blurs your central vision. It is usually only diagnosed in people aged 50 years and above. AMD affects the central area (macula) of the back of the eye (retina), as the macula degenerates with age. In early AMD, yellow spots (called drusen) can be seen under the retina by an eye health professional. The affected person will probably be unaware that they have a problem. As the disease progresses, the drusen become larger (intermediate AMD). In the later stages of the disease, there may be loss of the cells – needed for vision – in the back of the eye. This is known as geographic atrophy. Sometimes, new (harmful) blood vessels grow in the macula. These new blood vessels may bleed and cause scarring. This is known as neovascular AMD. Neovascular AMD and geographic atrophy are known as late AMD. Why might antioxidant vitamins and minerals be helpful? Antioxidant vitamins and minerals may help to protect the macula against this deterioration and loss of vision. Antioxidants are natural molecules that may prevent or delay some types of cell damage. Vitamins C and E, beta‐carotene, lutein, zeaxanthin, and zinc are examples of antioxidants commonly found in dietary supplements. What did we want to find out? 
We wanted to find out whether antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD) and prevent visual loss. What did we do? We searched for studies that compared antioxidant vitamin and mineral supplements with placebo (a ‘dummy’ treatment not containing any supplements) or no treatment. We only looked at the effects of these supplements in people with AMD. There is another Cochrane Review on the effects of these supplements in people who do not already have AMD. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 26 studies from the USA, Europe, China, and Australia that enroled 11,952 people with AMD. These studies compared multivitamin supplements, zinc, vitamin E, lutein (with or without zeaxanthin) with placebo. Participants were aged 65 to 75 years and there were slightly more women than men in the studies. Main findings • Taking an antioxidant multivitamin supplement (AREDS formula containing vitamins E and C, beta‐carotene plus zinc) probably slows down the progression of AMD to late AMD and vision loss. This may result in a small improvement in quality of life. • People with intermediate AMD have a higher risk of progression to late AMD and so may be more likely to benefit from supplements (78 fewer cases of progression for every 1000 people taking supplements). People with early AMD have a low risk of progression and so may be less likely to benefit (4 fewer cases of progression to late AMD for every 1000 people taking supplements). • Lutein with or without zeaxanthin may have little or no effect on progression to late AMD but may be a suitable replacement for beta‐carotene in the AREDS formula. Beta‐carotene may increase the chance of lung cancer in people who have smoked. • The effects of vitamin E alone on the progression to late AMD and vision loss are uncertain. Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence about safety because most of the studies were small and reported on harmful effects inconsistently. What are the limitations of the evidence? Our confidence in the evidence ranged from moderate to very low. This is because most of the included studies were small, and they did not cover all the comparisons and outcomes we were interested in. How up to date is this review? 
This review updates our previous version. The evidence is up to date to 29 November 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.804Z" }, { "id": "877b9d65-3641-4279-be8f-bb405b16b0b3", "pmid": "", "title": "Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010. For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established. Objectives To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications. Search methods Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012. Selection criteria Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Data collection and analysis Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information. Main results One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012. Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study. Weight loss was greater for the NG group at six weeks post‐treatment than for the PEG group (P = 0.001). At six months post‐treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post‐treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively. We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review. Authors' conclusions There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required. Plain language summary Artificial tube feeding methods for use with patients with head and neck cancer who are receiving treatment with radiotherapy, chemotherapy or both Patients with cancer of the head and neck are at risk of malnutrition during radiotherapy treatment due to the side effects of this treatment and they may need tube feeding to meet their nutritional needs. Tube feeding can either be delivered via a nasogastric feeding tube, which is a fine tube inserted through the nose into the stomach, or a gastrostomy tube which is inserted through the skin of the abdomen directly into the stomach. Both of these methods allow the delivery of nutrients directly into the stomach. Tube feeding is essential to meet the nutritional needs of head and neck cancer patients as malnutrition can lead to a poorer prognosis for this patient group. There is debate over which method of tube feeding provides the most benefit to the patient for outcomes such as nutritional benefit and quality of life, as well as avoiding delays in radiotherapy treatment. Following our analysis of the available literature, only one clinical trial was eligible to be included in this review. The authors of this review found no evidence to support the use of any one method of tube feeding over another.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Nugent, B; Lewis, S; O'Sullivan, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007904.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "87817121-2771-4fb3-bf44-104bf1dfff5b", "pmid": "", "title": "Zinc supplementation for the promotion of growth and prevention of infections in infants less than six months of age", "imported": false, "abstract": "Abstract - Background Zinc is a vital micronutrient for humans and is essential for protein synthesis, cell growth, and differentiation. Severe zinc deficiency can lead to slower physical, cognitive and sexual growth, cause skin disorders, decrease immunity, increase incidence of acute illnesses in infants and children and contribute to childhood stunting. By estimation, 17.3% of the world population is at risk of inadequate zinc intake. Such nutritional impairment increases the risk of diarrhoea and pneumonia by 20%, as well as leads to a global loss of more than 16 million disability‐adjusted life years in children less than five years of age. Not only does zinc deficiency affect lives, it adds to the considerable financial burden on depleted resources in countries that are most affected. By preventing or curing this deficiency, we can improve childhood mortality, morbidity and growth. Objectives To assess the effectiveness of zinc supplementation for the promotion of growth, reduction in mortality, and the prevention of infections in infants less than six months of age. Search methods We used the standard search strategy of the Cochrane Neonatal Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 4), MEDLINE via PubMed (1966 to 18 May 2018), Embase (1980 to 18 May 2018), and CINAHL (1982 to 18 May 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials . An updated search from 1 January 2018 to 29 January 2020 was run in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria All randomised controlled (individual and cluster randomised) and quasi‐randomised trials of zinc supplementation in healthy, term infants, less than six months of age comparing infant mortality, incidence of diarrhoea or respiratory illnesses, growth and/or serum zinc levels were eligible. Data collection and analysis Two review authors screened search results (title and abstracts) and relevant full texts. Studies fulfilling prespecified inclusion criteria were included with any disagreements resolved by consensus. Extraction and analysis were then conducted. We used the GRADE approach to assess the quality of evidence as indicated by certainty in effect estimates. Main results Eight studies (with 85,629 infants) were included and five studies were meta‐analysed, out of which four studies compared zinc with placebo, and one compared zinc plus riboflavin versus riboflavin. Certain growth outcomes after six months of intervention (Weight for Age Z‐scores (WAZ) (standardised mean difference) (SMD) 0.16, 95% CI 0.03 to 0.29; three studies, n = 955; fixed‐effect; heterogeneity Chi² P = 0.96); I² = 0%); change in WAZ (SMD 0.16, 95% CI 0.07 to 0.25; one study, n = 386; fixed‐effect); (Weight‐for‐Length Z‐score (WLZ) (SMD 0.15, 95% CI 0.02 to 0.28; three studies, n = 955; fixed‐effect; heterogeneity: Chi² P = 0.81); I² = 0%); (change in WLZ (SMD 0.17, 95% CI 0.06 to 0.28; one study, n = 386; fixed‐effect)) were positively affected by zinc supplementation compared to placebo. A single study reported no difference in the incidence of diarrhoea and lower respiratory tract infection with zinc supplementation. Zinc had no effect on mortality in children younger than 12 months. When zinc plus riboflavin was compared to riboflavin only, significant improvement was observed in the incidence of wasting at 24 months (risk ratio (RR) 0.59, 95% CI 0.37 to 0.96; one study, n = 296; fixed‐effect), but significant worsening of incidence of stunting was present at 21 months (RR 1.53, 95% CI 1.09 to 2.16; one study, n = 298; fixed‐effect). Authors' conclusions There was a significant positive impact of zinc supplementation on WAZ and WLZ after six months of intervention in infants compared to placebo. When a combined supplement of zinc and riboflavin was compared to riboflavin, there was a significant reduction in wasting at 24 months, but stunting at 21 months was negatively affected. Although included trials were of good‐to‐moderate quality, evidence that could be meta‐analysed was based on a few studies which affected the overall quality of results. Regardless, there is a need for strong trials conducted in infants younger than six months before a strong recommendation can be made supporting zinc supplementation in this age group. Plain language summary Zinc supplementation for improving the health and survival of infants less than six months old Review question: does zinc supplementation reduce mortality, morbidity and increase growth in infants aged less than six months old? Background: zinc deficiency is prevalent in the world. Adequate zinc levels are linked to decreased deaths, illnesses and improved growth in all populations particularly in developing countries. Zinc supplementation in older children has shown some positive effects. Study characteristics: we searched for studies through January 2020 that enrolled healthy infants aged less than six months old and provided at least six months of zinc supplementation. We included eight studies that covered zinc supplementation compared with placebo, zinc and riboflavin compared with riboflavin only, zinc, riboflavin and B complex vitamins compared with riboflavin and B complex vitamins. Key results and certainty of evidence: zinc had no effect on decreasing deaths or illnesses in children younger than 12 months. Moderate‐ to good‐certainty evidence from three studies suggested an increase in weight‐for‐age Z‐scores and weight‐for‐length Z‐scores after zinc supplementation for six months compared to placebo only. Only one study could be analysed for zinc and riboflavin supplementation compared to riboflavin only, and the results suggested a decrease in wasting after 24 months of supplementation and an increase in stunting after 21 months. Conclusion: with this evidence, we cannot strongly recommend clinicians to prescribe zinc supplements to children under six months of age. We also encourage the development of trials that will provide zinc as well as other micronutrients in this age group and for such trials to evaluate outcomes such as death, disease, side effects and growth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lassi, ZS, Kurji, J, Oliveira, CSD, Moin, A, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD010205.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.764Z" }, { "id": "878fa7c2-49bd-4146-a6e8-963523b8d765", "pmid": "", "title": "Pine bark (Pinus spp.) extract for treating chronic disorders", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Robertson, NU, Schoonees, A, Brand, A, Visser, J", "articleTypes": [], "doi": "10.1002/14651858.CD008294.pub5 AB - Abstract - Background Pine bark ( Pinus spp.) extract is rich in bioflavonoids, predominantly proanthocyanidins, which are antioxidants. Commercially‐available extract supplements are marketed for preventing or treating various chronic conditions associated with oxidative stress. This is an update of a previously published review. Objectives To assess the efficacy and safety of pine bark extract supplements for treating chronic disorders. Search methods We searched three databases and three trial registries; latest search: 30 September 2019. We contacted the manufacturers of pine bark extracts to identify additional studies and hand‐searched bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) evaluating pine bark extract supplements in adults or children with any chronic disorder. Data collection and analysis Two authors independently assessed trial eligibility, extracted data and assessed risk of bias. Where possible, we pooled data in meta‐analyses. We used GRADE to evaluate the certainty of evidence. Primary outcomes were participant‐ and investigator‐reported clinical outcomes directly related to each disorder and all‐cause mortality. We also assessed adverse events and biomarkers of oxidative stress. Main results This review included 27 RCTs (22 parallel and five cross‐over designs; 1641 participants) evaluating pine bark extract supplements across 10 chronic disorders: asthma (two studies; 86 participants); attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), cardiovascular disease (CVD) and risk factors (seven studies; 338 participants), chronic venous insufficiency (CVI) (two studies; 60 participants), diabetes mellitus (DM) (six studies; 339 participants), erectile dysfunction (three studies; 277 participants), female sexual dysfunction (one study; 83 participants), osteoarthritis (three studies; 293 participants), osteopenia (one study; 44 participants) and traumatic brain injury (one study; 60 participants). Two studies exclusively recruited children; the remainder recruited adults. Trials lasted between four weeks and six months. Placebo was the control in 24 studies. Overall risk of bias was low for four, high for one and unclear for 22 studies. In adults with asthma, we do not know whether pine bark extract increases change in forced expiratory volume in one second (FEV 1 ) % predicted/forced vital capacity (FVC) (mean difference (MD) 7.70, 95% confidence interval (CI) 3.19 to 12.21; one study; 44 participants; very low‐certainty evidence), increases change in FEV 1 % predicted (MD 7.00, 95% CI 0.10 to 13.90; one study; 44 participants; very low‐certainty evidence), improves asthma symptoms (risk ratio (RR) 1.85, 95% CI 1.32 to 2.58; one study; 60 participants; very low‐certainty evidence) or increases the number of people able to stop using albuterol inhalers (RR 6.00, 95% CI 1.97 to 18.25; one study; 60 participants; very low‐certainty evidence). In children with ADHD, we do not know whether pine bark extract decreases inattention and hyperactivity assessed by parent‐ and teacher‐rating scales (narrative synthesis; one study; 57 participants; very low‐certainty evidence) or increases the change in visual‐motoric coordination and concentration (MD 3.37, 95% CI 2.41 to 4.33; one study; 57 participants; very low‐certainty evidence). In participants with CVD, we do not know whether pine bark extract decreases diastolic blood pressure (MD ‐3.00 mm Hg, 95% CI ‐4.51 to ‐1.49; one study; 61 participants; very low‐certainty evidence); increases HDL cholesterol (MD 0.05 mmol/L, 95% CI ‐0.01 to 0.11; one study; 61 participants; very low‐certainty evidence) or decreases LDL cholesterol (MD ‐0.03 mmol/L, 95% CI ‐0.05 to 0.00; one study; 61 participants; very low‐certainty evidence). In participants with CVI, we do not know whether pine bark extract decreases pain scores (MD ‐0.59, 95% CI ‐1.02 to ‐0.16; one study; 40 participants; very low‐certainty evidence), increases the disappearance of pain (RR 25.0, 95% CI 1.58 to 395.48; one study; 40 participants; very low‐certainty evidence) or increases physician‐judged treatment efficacy (RR 4.75, 95% CI 1.97 to 11.48; 1 study; 40 participants; very low‐certainty evidence). In type 2 DM, we do not know whether pine bark extract leads to a greater reduction in fasting blood glucose (MD 1.0 mmol/L, 95% CI 0.91 to 1.09; one study; 48 participants;very low‐certainty evidence) or decreases HbA1c (MD ‐0.90 %, 95% CI ‐1.78 to ‐0.02; 1 study; 48 participants; very low‐certainty evidence). In a mixed group of participants with type 1 and type 2 DM we do not know whether pine bark extract decreases HbA1c (MD ‐0.20 %, 95% CI ‐1.83 to 1.43; one study; 67 participants; very low‐certainty evidence). In men with erectile dysfunction, we do not know whether pine bark extract supplements increase International Index of Erectile Function‐5 scores (not pooled; two studies; 147 participants; very low‐certainty evidence). In women with sexual dysfunction, we do not know whether pine bark extract increases satisfaction as measured by the Female Sexual Function Index (MD 5.10, 95% CI 3.49 to 6.71; one study; 75 participants; very low‐certainty evidence) or leads to a greater reduction of pain scores (MD 4.30, 95% CI 2.69 to 5.91; one study; 75 participants; very low‐certainty evidence). In adults with osteoarthritis of the knee, we do not know whether pine bark extract decreases composite Western Ontario and McMaster Universities Osteoarthritis Index scores (MD ‐730.00, 95% CI ‐1011.95 to ‐448.05; one study; 37 participants; very low‐certainty evidence) or the use of non‐steroidal anti‐inflammatory medication (MD ‐18.30, 95% CI ‐25.14 to ‐11.46; one study; 35 participants; very low‐certainty evidence). We do not know whether pine bark extract increases bone alkaline phosphatase in post‐menopausal women with osteopenia (MD 1.16 ug/L, 95% CI ‐2.37 to 4.69; one study; 40 participants; very low‐certainty evidence). In individuals with traumatic brain injury, we do not know whether pine bark extract decreases cognitive failure scores (MD ‐2.24, 95% CI ‐11.17 to 6.69; one study; 56 participants; very low‐certainty evidence) or post‐concussion symptoms (MD ‐0.76, 95% CI ‐5.39 to 3.87; one study; 56 participants; very low‐certainty evidence). For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. Authors' conclusions Small sample sizes, limited numbers of RCTs per condition, variation in outcome measures, and poor reporting of the included RCTs mean no definitive conclusions regarding the efficacy or safety of pine bark extract supplements are possible. Plain language summary Using pine bark supplements to help treat a variety of chronic diseases Review question Can pine bark antioxidant supplements help to treat chronic diseases? Background The main ingredients in pine bark extract supplements are proanthocyanidins, which are antioxidants. These supplements are marketed to prevent or treat a wide range of chronic diseases. This is an update of a previously published review, where we assessed how well these supplements work for treating chronic diseases, as well as their safety. Search date The evidence is current to 30 September 2019. Study characteristics We included 27 studies (1641 participants) across 10 chronic diseases. These included: asthma (two studies; 86 participants), attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), heart disease and risk factors (seven studies; 332 participants), chronic venous insufficiency (leg veins not working effectively; two studies; 60 participants), diabetes (six studies; 336 participants), erectile dysfunction (three studies; 227 participants), female sexual dysfunction (one study; 75 participants), osteoarthritis (cartilage damage in joints; three studies; 293 participants), osteopenia (beginning of bone mass loss; one study; 44 participants) and traumatic brain injury (one study; 56 participants). Two of the studies were conducted exclusively in children; the others were in adults. Studies compared pine bark supplements with placebo (i.e. a dummy supplement) or non‐antioxidant interventions and participants were randomly selected for one treatment or the other. The duration of treatment ranged from four weeks to six months. Key results For most outcomes across the different chronic diseases we only included one study with a small number of participants. In adults with asthma, we do not know whether pine bark extract increases lung function, improves asthma symptoms or increases the number of people able to stop using albuterol inhalers (a specific type of asthma pump).
In children with ADHD, we do not know whether pine bark supplements decrease inattention and hyperactivity (assessed by parents and teachers) or whether it increases co‐ordination and concentration.
In people with heart disease we do not know if pine bark supplements decrease blood pressure and LDL cholesterol (the bad type) or whether it increases HDL cholesterol (the good type).
In adults with chronic venous insufficiency we do not know whether pine bark supplements decrease pain, increase the number of people free of pain, or how well doctors think the treatment works. In people with type 2 diabetes, we do not know whether pine bark supplements improve blood sugar levels or HbA1c levels (the long‐term marker for measuring blood sugar control); we also do not know if pine bark supplements decrease HbA1c in people with type 1 or type 2 diabetes.
In men with erectile dysfunction, we do not know if pine bark supplements increase erectile function. Similarly, in women with sexual dysfunction, we do not know if pine bark supplements increase sexual satisfaction or reduce pain.
In adults with osteoarthritis, it is not clear if pine bark supplements improve pain, swelling or stiffness in the knee, or whether it decreases the use of anti‐inflammatory drugs. We also do not know if pine bark supplements increase bone formation in postmenopausal women with weakened bones. Lastly, in people with a traumatic brain injury, it is not clear if pine bark supplements improve memory and post‐concussion symptoms . For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. With the available studies, we cannot clearly say how well (or not) pine bark supplements work and whether they are safe. Quality of the evidence The overall risk of bias was low for four studies, high for one and unclear for 22 studies. By this we mean the extent to which the methods used in a study enable it to determine the truth. The certainty of evidence was very low for all outcomes across all chronic diseases in the included studies.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.822Z" }, { "id": "87b2e537-0500-403c-8d30-26c142b36572", "pmid": "", "title": "Chlorambucil for patients with primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. But it is unknown whether it benefits or harms these patients. Objectives To evaluate the beneficial and any harmful effects of chlorambucil for primary biliary cirrhosis patients. Search methods Eligible trials were identified by searching the Cochrane Hepato‐Biliary Group Controlled Trials Register (March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2012, Issue 2), MEDLINE (1946 to March 2012), EMBASE (1974 to March 2012), Science Citation Index EXPANDED (1900 to March 2012), The Chinese Biomedical Database (1976 to March 2012), The Chinese Medical Current Contents (1994 to March 2012), The China Hospital Knowledge Database (1994 to March 2012), and a database of ongoing trials (http://www.controlled‐trials.com/mrct/) (accessed 6 March 2012). The reference lists of the retrieved publications and review articles were also read through, and pharmaceutical companies known to produce chlorambucil were contacted. Selection criteria Randomised clinical trials, irrespective of language, year of publication, and publication status, comparing chlorambucil at any dose versus placebo, no intervention, another active drug, or one dose of chlorambucil with another dose. Data collection and analysis We planned to assess continuous data with mean differences (MD), and dichotomous outcomes with relative risk (RR), both with 95% confidence intervals (CI). As we only identified one trial, Fisher's exact tests were employed. Main results Only one randomised trial was identified and included in the review. The bias risk in the trial was high. The trial compared chlorambucil versus no intervention in 24 patients with primary biliary cirrhosis. Fisher's exact test did not show a significant reduction of mortality when comparing chlorambucil with no treatment (0/13 (0%) versus (2/11 (18.2%); P = 0.20). There was no significant difference regarding adverse events for chlorambucil compared with no treatment, but all patients receiving chlorambucil experienced adverse events (13/13 (100%) versus (3/11 (27%); P = 0.1). According to the authors of the trial, chlorambucil led to a significant improvement in mean serum levels of bilirubin (P < 0.05), albumin (P < 0.05), immunoglobulin M (P < 0.01), serum aspartate aminotransferase activity (P < 0.01), and hepatic inflammatory infiltrates (P < 0.01). Authors' conclusions There is not sufficient evidence to support or reject the use of chlorambucil for patients with primary biliary cirrhosis. Chlorambucil may show benefit in some unvalidated surrogate outcome measures (for example, serum bilirubin and immunoglobulin M levels). Chlorambucil is, however, connected with a number of adverse events. Bone marrow suppression should be noted in particular. Further randomised clinical trials are necessary to assess the benefits and harms of chlorambucil in this indication. Plain language summary Chlorambucil for patients with primary biliary cirrhosis Primary biliary cirrhosis is an autoimmune disease of the liver. Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. This review aimed to assess the beneficial or harmful effects of chlorambucil for primary biliary cirrhosis. The authors identified only one randomised trial, with 24 participants included. This trial compared chlorambucil with no intervention. The trial is small and at a high risk of bias, which suggests that the results may not be reliable. Meta‐analyses were not possible because of the inclusion of one trial only. Fisher's exact test and t‐test were used instead. Chlorambucil was not associated with significantly lower mortality when compared with no intervention. All patients on chlorambucil experienced adverse events, especially bone marrow suppression. Chlorambucil led to a significant improvement in mean serum levels of bilirubin, albumin, immunoglobulin M, serum aspartate aminotransferase activity, and hepatic inflammatory infiltrates. However, these outcomes are unvalidated surrogate outcomes for patient‐relevant outcomes. This means that improvement of these biochemistry measures cannot be taken as proof of improvement of patient‐relevant outcomes. It remains unclear whether chlorambucil can be supported or rejected for use in patients with primary biliary cirrhosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Li, WX, Yan, X, Shi, CR, Zhang, AP", "articleTypes": [], "doi": "10.1002/14651858.CD008714.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.097Z" }, { "id": "87ce9d07-677f-48a3-96a0-674e08a739eb", "pmid": "", "title": "Folic acid supplementation and malaria susceptibility and severity among people taking antifolate antimalarial drugs in endemic areas", "imported": false, "abstract": "Abstract - Background Malaria is an infectious disease transmitted by female Anopheles mosquitoes, with ongoing transmission in over 80 countries. The malaria parasite requires folate for survival and growth; antifolate antimalarial medications used for prevention and treatment target enzymes in folate metabolism as their mechanism of action. Periconceptional folic acid (synthetic form of folate) supplementation (400 μg/day) is the standard of care for neural tube defect prevention. Concerns have been raised about the potential effects of folic acid (including above the tolerable upper intake level (UL) > 1.0 mg/day) in the context of malaria prevention and treatment, including the efficacy of antimalarial medications. Examining the potential impact of folic acid on malaria risk and severity amongst people taking antifolate antimalarial medications may inform public health programmes in malaria‐endemic areas. Objectives To examine the effects of folic acid supplementation on the risk and severity of malaria infection amongst people taking antifolate antimalarials and living in areas with malaria endemicity. Prevention: Amongst uninfected people taking antifolate antimalarial medications for malaria prevention, does folic acid supplementation increase susceptibility or severity of malaria infection? Treatment: Amongst people with malaria infection who are being treated with antifolate antimalarial drugs, does folic acid supplementation reduce parasite clearance or increase the risk of treatment failure? Search methods We searched databases including CENTRAL, MEDLINE, Embase, CINAHL, Scopus, and trial registries (September 13, 2024), grey literature, and reference searches to identify additional studies. Selection criteria Randomised trials evaluating the effects of folic acid supplementation (alone or in combination with iron or other vitamins and minerals) amongst individuals taking antifolate antimalarial medications in malaria‐endemic areas. Data collection and analysis Primary outcomes included uncomplicated malaria or severe malaria, parasite clearance, and treatment failure. Cochrane RoB 2 was used to evaluate the risk of bias. Certainty of evidence was assessed using GRADE for primary outcomes. We performed meta‐analyses using random‐effects models for all outcomes. Main results Eight trials with 3486 participants were included: three malaria prevention trials and five malaria treatment trials. Most treatment trials included folic acid doses above the UL ( > 1.0 mg/d); one trial included 400 μg per day. Antifolate antimalarials included sulfadoxine‐pyrimethamine (SP; five trials), sulfisoxazole plus pyrimethamine (one trial), atovaquone‐proguanil (one trial), and proguanil (one trial). Some studies had unclear or high risk of bias due to missing outcome data. Malaria prevention Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medications. Data for primary outcomes, uncomplicated and severe malaria, were not reported. One trial reported laboratory parasitaemia; there was little to no difference in malaria parasitaemia amongst pregnant women receiving folic acid (with iron) and antifolate antimalarials compared to iron and antifolate antimalarials (Risk Ratio (RR) 1.21; 95% CI 0.56 to 2.62; P = 0.63; 1 trial, 643 individuals). Comparisons 2–4: No studies reported data for Comparisons 2–4. Malaria treatment 
 Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarial medications versus placebo/no folic acid with antifolate antimalarials. People receiving folic acid (alone or with iron) and antifolate antimalarials were less likely to clear malaria parasites (day 3) compared to individuals who did not receive folic acid (RR 0.89; 95% CI 0.84 to 0.95, 4 trials, 929 individuals, moderate‐certainty evidence); and had increased risk of treatment failure on day 7 (RR 2.12; 95% CI 1.41 to 3.19, 4 trials, 1062 individuals, moderate‐certainty evidence), day 14 (RR 1.97; 95% CI 1.44 to 2.70, 3 trials; 891 individuals; moderate‐certainty evidence), and day 28 (RR 1.35; 95% CI 1.21 to 1.51; 4 trials; 1012 individuals, moderate‐certainty evidence). Comparison 2: Folic acid alone + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medication. Folic acid supplementation with antifolate antimalarials likely had lower parasite clearance (day 3) (RR 0.87; 95% CI 0.79 to 0.96, 2 trials, 229 individuals, moderate certainty of the evidence), and increased treatment failure (day 7: RR 2.58; 95% CI 0.89 to 7.45; P = 0.08; 2 trials; 344 individuals, moderate‐certainty evidence; day 14: RR 4.15; 95% CI 0.92 to 18.65; P = 0.06; 1 trial; 173 individuals, moderate‐certainty evidence; and day 28: RR 1.47; 95% CI 0.86 to 2.49; P = 0.16; 2 trials; 294 individuals, moderate‐certainty evidence), compared to no folic acid and antifolate antimalarials. Comparison 3: Folic acid with iron + antifolate antimalarial medication versus placebo/no folic acid with iron + antifolate antimalarial medication. People receiving folic acid with iron and antifolate antimalarials were less likely to clear malaria parasites (day 3: RR 0.90; 95% CI 0.83 to 0.98; P = 0.02; 2 trials; 700 individuals, moderate‐certainty evidence), and had increased treatment failure (day 7: RR 1.96; 95% CI 1.05 to 3.65; P = 0.03; 2 trials; 718 individuals; day 14: RR 1.90; 95% CI 1.35 to 2.67; 2 trials; 718 individuals; day 28: RR 1.17; 95% CI 0.79 to 1.74; 2 trials; 578 individuals; all moderate‐certainty evidence), compared to iron and antifolate antimalarials. Comparison 4: No studies reported data. Authors' conclusions Malaria prevention: None of the included trials reported primary outcomes. Malaria treatment: People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to clear malaria parasitaemia (day 3), and had increased treatment failure (days 7, 14, 28). Most of the included trials provided folic acid with doses above the tolerable UL ( > 1.0 mg). One trial included folic acid at a dose of 400 μg/d (recommended dose for preventing neural tube defects) and showed little to no difference in parasite clearance or treatment failure. Plain language summary Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common? Review question 
Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common?

 Key messages 
° People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to eliminate malaria parasites and had increased treatment failure. 
° There were not enough studies to examine whether taking folic acid supplementation at a lower dose, like 400 μg, might affect the risk of malaria infection or health outcomes if infected. This low dose is currently recommended before and during early pregnancy for the prevention of neural tube defects. Malaria and the importance of folate 
Malaria is a disease spread by the bite of certain types of female mosquitoes and is found in over 80 countries. The malaria parasite needs folate to grow and survive, and some medicines used to prevent and treat malaria target folate. Folic acid (the synthetic form of folate) is recommended at a dose of 400 μg daily to prevent neural tube defects. There are some concerns that folic acid (particularly higher doses) may affect malaria and how well some medicines work to prevent and treat malaria. What did we want to find out? 
This review was done to see how folic acid affects malaria risk and severity amongst people taking antifolate antimalarial medications and living in areas where malaria is common. Specifically, we aimed to answer the following questions: Prevention: For people who do not have malaria and are taking antimalarial drugs to prevent malaria, do folic acid supplements increase their risk of getting malaria or having worse outcomes? Treatment: For people who have malaria and are being treated with antifolate antimalarial medications, does taking folic acid supplements affect how well the drugs work to treat malaria? What did we do? 
We searched for trials that looked at folic acid supplementation in people taking antifolate antimalarial medications to prevent or treat malaria. We compared and summarised the results of the trials and rated our confidence in the information based on how the study was done. What did we find? 
We included eight trials (3486 people); three were prevention trials and five were treatment trials. Most trials used higher folic acid doses ( > 1.0 mg) and included the medication sulfadoxine‐pyrimethamine (SP). The prevention studies did not include the main outcomes we were trying to assess. In the treatment studies, people who took folic acid and antifolate antimalarial drugs were less likely to clear malaria parasites from their bodies (day 3) and were more likely to have treatment failure (up to 28 days after treatment) compared to the same treatment but without folic acid. Most of the included trials provided the antimalarial SP and folic acid with doses above the tolerable upper intake level (upper limit; > 1.0 mg). Only one trial included folic acid at a dose of 400 μg per day (the recommended daily dose of folic acid for prevention of neural tube defects); there were no differences in parasite clearance or treatment failure between the arm with 400 μg per day of folic acid and the arm with no folic acid. What are the limitations of the evidence? 
The small number of trials and the size of the studies were limitations of this review, and no prevention studies reported main outcomes. How up to date is this evidence? 
The evidence is up‐to‐date as of September 13, 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Qi, YP; Crider, KS; Gutman, J; Centeno-Tablante, E; Fothergill, A; Daniels, K; Yeung, LF; Mai, CT; Mehta, S; Williams, JL; Finkelstein, JL", "articleTypes": [], "doi": "10.1002/14651858.CD014217.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "87d23295-053e-4e93-a3c2-92222aff9309", "pmid": "", "title": "Glutamine for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Crohn's disease is a chronic relapsing condition of the alimentary tract with a high morbidity secondary to bowel inflammation. Glutamine plays a key role in maintaining the integrity of the intestinal mucosa and has been shown to reduce inflammation and disease activity in experimental models of Crohn's disease. Objectives To evaluate the efficacy and safety of glutamine supplementation for induction of remission in Crohn's disease. Search methods We searched the following databases from inception to November 15, 2015: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane IBD Group Specialised Register. Study references were also searched for additional trials. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) that compared glutamine supplementation administered by any route to a placebo, active comparator or no intervention in people with active Crohn's disease were considered for inclusion. Data collection and analysis Two authors independently extracted data and assessed the methodological quality of the included studies. The Cochrane risk of bias tool was used to assess methodological quality. The primary outcome measure was clinical or endoscopic remission. Secondary outcomes included intestinal permeability, clinical response, quality of life, growth in children and adverse events. Risk ratios and 95% confidence intervals were calculated for dichotomous outcomes. The overall quality of the evidence supporting the primary outcome was evaluated using the GRADE criteria. Main results Two small RCTs (total 42 patients) met the inclusion criteria and were included in the review. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. The other study (24 patients) compared glutamine‐supplemented total parenteral nutrition to non‐supplemented total parenteral nutrition in adult patients (> 18 years of age) with acute exacerbation of inflammatory bowel disease. The paediatric study was rated as low risk of bias. The study in adult patients was rated as unclear risk of bias for blinding and low risk of bias for all other items. It was not possible to pool data for meta‐analysis because of significant differences in study populations, nature of interventions, and the way outcomes were assessed. Data from one study showed no statistically significant difference in clinical remission rates at four weeks. Forty‐four per cent (4/9) of patients who received a glutamine‐enriched polymeric diet achieved remission compared to 56% (5/9) of patients who received a standard low‐glutamine polymeric diet (RR 0.80, 95% CI 0.31 to 2.04). A GRADE analysis indicated that the overall quality of evidence for this outcome was low due to serious imprecision (9 events). In both included studies, no statistically significant changes in intestinal permeability were found between patients who received glutamine supplementation and those who did not. Neither study reported on clinical response, quality of life or growth in children. Adverse event data were not well documented. There were no serious adverse events in the paediatric study. The study in adult patients reported three central catheter infections with positive blood cultures in the glutamine group compared to none in the control group (RR 7.00, 95% CI 0.40 to 122.44). Authors' conclusions Currently there is insufficient evidence to allow firm conclusions regarding the efficacy and safety of glutamine for induction of remission in Crohn's disease. Data from two small studies suggest that glutamine supplementation may not be beneficial in active Crohn's disease but these results need to be interpreted with caution as they are based on small numbers of patients. This review highlights the need for adequately powered randomised controlled trials to investigate the efficacy and safety of glutamine for induction of remission in Crohn's disease. Plain language summary Glutamine for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disorder of the intestines which has periods of inactivity and periods when it flares up. Crohn's disease can affect any part of the digestive tract, from the mouth to the anus. The most common symptoms of the disease include abdominal pain, non‐bloody diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms of the disease it is said to be ‘active’; periods when the symptoms stop are called ‘remission’. What is glutamine? Glutamine is an amino acid that plays a key role in maintaining the integrity of the intestinal mucosa (lining of the intestines) and has been shown to reduce inflammation and disease activity in animal models of Crohn's disease. It has therefore been suggested that glutamine may reduce intestinal inflammation in people with Crohn's disease. What did the researchers investigate? The researchers investigated whether glutamine is effective for inducing remission in people with active Crohn's disease and whether this treatment causes any harms (side effects). The researchers searched the medical literature up to November 15, 2015. What did the researchers find? The researchers identified two randomised controlled trials (total 42 participants) that investigated the role of glutamine for the treatment of active Crohn's disease. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. Participants were encouraged to consume the diet orally. If this was not possible the diet was administered via a fine‐bore nasogastric tube. The other study (24 participants) compared glutamine‐supplemented total parenteral nutrition (TPN) to non‐supplemented TPN in adult patients (> 18 years of age) with sudden worsening of inflammatory bowel disease. The TPN diet was administered intravenously via a central catheter (a thin tube) for at least one week. Both studies were generally high quality. Neither study demonstrated any beneficial effects for glutamine. Side effects were not well documented in the two studies. There were no serious side effects noted in the paediatric study. The study in adult patients reported three central catheter‐related blood infections in the glutamine group compared to none in the non‐glutamine control group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and harms of glutamine for the treatment of active Crohn's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Akobeng, AK, Elawad, M, Gordon, M", "articleTypes": [], "doi": "10.1002/14651858.CD007348.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.085Z" }, { "id": "87e18ebd-c9dd-48dd-8e72-5ebc952f329b", "pmid": "", "title": "Honey and lozenges for children with non‐specific cough", "imported": false, "abstract": "Abstract - Background Chronic non‐specific cough is a chronic, dry cough of in the absence of identifiable respiratory disease or known aetiology. Although it is usually not reflective of an underlying severe illness, it does cause significant morbidity, and as such relief from it is often sought. The use of honey and lozenges to soothe upper respiratory tract irritation is common, inexpensive, and potentially more effective in treating the symptoms than pharmacological interventions. Objectives To evaluate the efficacy of honey and/or lozenges in the management of children with chronic non‐specific cough. Search methods The Cochrane Airways Group searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, OLDMEDLINE, and EMBASE databases in October 2010. Selection criteria All randomised controlled trials comparing honey or lozenges with a placebo in treating children with chronic non‐specific cough. Data collection and analysis The results of the searches were assessed according to the pre‐determined criteria. None of the trials identified by the searches were eligible for inclusion, leaving no data available for analysis in this review. Main results The search did not provide any applicable randomised controlled trials that investigated the efficacy of honey and lozenges in treating children with non‐specific chronic cough. Data from acute studies suggest a potential role for honey in relieving cough, but whether this is applicable to chronic cough is unknown. Authors' conclusions Clinically, this review was unable to provide any justifiable recommendation for or against honey and/or lozenges due to the lack of evidence. The absence of applicable studies highlights the need for further research into the area of treating children with chronic non‐specific coughs with honey and/or lozenges. These treatments are not recommended when managing very young children (as lozenges are a potential choking hazard, and honey may cause infant botulism in children under one year of age). Plain language summary Honey and lozenges for children with non‐specific cough Symptomatic relief is often sought for children with chronic non‐specific cough (which is defined as a dry, non‐productive cough with no known cause lasting longer than four consecutive weeks). This review aimed to assess the efficacy of treating children with such coughs using honey or lozenges, as these options are inexpensive. No randomised controlled trials were found to be applicable to this review, primarily due to the participants in the studies not fulfilling the inclusion criteria. However, studies on the efficacy of these treatments in treating acute cough in children showed that honey has the potential to be beneficial in children over a year old. Further research evaluating the efficacy of honey and lozenges in treating chronic non‐specific coughs in children is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Mulholland, S, Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD007523.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.083Z" }, { "id": "87ee0f43-bf20-4238-b295-990fad60ac6a", "pmid": "", "title": "Progestin‐only pills for contraception", "imported": false, "abstract": "Abstract - Background The introduction of a new progestin‐only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. Objectives This review examined randomized controlled trials of progestin‐only pills for differences in efficacy, acceptability, and continuation rates. Search methods Through October 2013, we searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, and LILACS for studies of progestin‐only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. Selection criteria We included all randomized controlled trials in any language that included progestin‐only pills for contraception. We incorporated any comparison with a progestin‐only pill; this could include different doses, other progestin‐only pills, combined oral contraceptives, or other contraceptives. Data collection and analysis The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry. We attempted to extract life‐table rates (actuarial or continuous) and used the rate difference as the effect measure. Where life‐table rates were not published, we used the incidence rate ratio (ratio of Pearl rates). Where only the crude number of events was published, we calculated the Peto odds ratio with 95% confidence interval (CI) using a fixed‐effect model. For continuous variables, the mean difference (MD) was computed with 95% CI. Because of disparate exposures, we were not able to combine studies in meta‐analysis. Main results Six trials met the inclusion criteria. We have not found any new studies since the initial review. In the trial comparing the desogestrel versus levonorgestrel progestin‐only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin‐only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low‐dose mifepristone versus a levonorgestrel progestin‐only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin‐only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin‐only and two combined oral contraceptives, the progestin‐only pill containing levonorgestrel 30 μg had higher efficacy than did the pill containing norethisterone 350 μg. An early trial found megestrol acetate inferior to other progestin‐only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. Authors' conclusions Evidence is insufficient to compare progestin‐only pills to each other or to combined oral contraceptives. Plain language summary Progestin‐only pills for contraception Progestin‐only pills, as their name implies, contain just one hormone. The more common birth control pills combine two hormones. How these one‐hormone pills compare to each other or to two‐hormone pills is not clear. Hence, we did this review to compare progestin‐only pills to other similar pills or to combined (two‐hormone) pills. Through October 2013, we did a computer search and literature search to find randomized trials of progestin‐only pills. We found six trials for the initial review. We have not found any more studies since then. Some studies are several decades old and not very relevant to pills available today. A newer pill containing the progestin desogestrel may work better to prevent pregnancy than an older pill with levonorgestrel. The newer pill caused more bleeding problems. Pills with levonorgestrel may be more effective than pills with other progestins that are no longer used. These studies are not adequate to tell how progestin‐only pills compare to each other or to combined (two‐hormone) pills. Larger studies with currently used pills are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grimes, DA, Lopez, LM, O'Brien, PA, Raymond, EG", "articleTypes": [], "doi": "10.1002/14651858.CD007541.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.762Z" }, { "id": "87f4c87d-54f6-4ab8-a80d-bc076dabbd52", "pmid": "", "title": "Interventions for dysphagia in oesophageal cancer", "imported": false, "abstract": "Abstract - Background Most patients with oesophageal and gastro‐oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009. Objectives The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro‐oesophageal carcinoma. Search methods To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Selection criteria Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, self‐expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head‐to‐head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30‐day mortality, adverse effects and quality of life. Data collection and analysis Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group. Main results We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re‐interventions and for adverse effects. Anti‐reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti‐reflux stents might have reduced gastro‐oesophageal reflux and complications. Newly‐designed double‐layered nitinol (Niti‐S) stents were preferable due to longer survival time and fewer complications compared to simple Niti‐S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy. Authors' conclusions Self‐expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high‐dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti‐reflux stents and newly‐designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self‐expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re‐interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia. Plain language summary Interventions for reducing difficulty in swallowing in people with oesophageal cancer Review question For most patients with unresectable or inoperable oesophageal cancer, providing clinical benefit with palliative treatment is highly desirable. However, the optimal palliative technique for dysphagia improvement and better quality of life is not established. Background Dysphagia (difficulty or discomfort in swallowing) is common among patients with unresectable or inoperable oesophageal cancer. There are five levels of dysphagia, ranging from the ability to eat a normal diet to some solids, semisolids, liquids and to complete dysphagia. Study characteristics The review included randomised controlled studies comparing the use of different interventions to improve dysphagia among patients with inoperable or unresectable primary oesophageal cancer. To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). Key results The review updates the previous version but still fails to present any obvious superiority of one technique over another among the different kinds of interventions. Self‐expanding metal stents provided safer and more effective relief of dysphagia compared to rigid plastic stents. Other techniques like radiotherapy or brachytherapy were also suitable alternatives and might be favourable in improving quality of life and prolonging survival. Individual differences should be emphasised when the intervention type was determined. Quality of the evidence Half of the studies included in this review were of high quality. Most studies did not state the methods used to seek and report quality of life outcomes and adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Yang, C; Li, J; Fu, W; Xu, W; Yang, S", "articleTypes": [], "doi": "10.1002/14651858.CD005048.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "87f8b133-8981-4e5f-a683-37d11d446f47", "pmid": "", "title": "Needle size for vaccination procedures in children and adolescents", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane Review first published in 2015. The conclusions have not changed. Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller the diameter of the needle (e.g. a 23 G needle is 0.6 mm in diameter, whereas a 25 G needle is 0.5 mm in diameter). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. Guidelines conflict regarding the sizes of needles that should be used for vaccinating children and adolescents. Objectives To assess the effects of using needles of different sizes for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration). Search methods We updated our searches of CENTRAL, MEDLINE, Embase, and CINAHL to October 2017. We also searched proceedings of vaccine conferences and two trials registers. Selection criteria Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years. Data collection and analysis Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system. Main results We included five trials involving 1350 participants in the original review. The updated review identified no new trials. The evidence from two small trials (one trial including infants and one including adolescents) was insufficient to allow any definitive statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity. The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials included infants predominantly aged from two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole‐cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP‐Hib) and hepatitis B (DTwP‐Hib‐Hep B) antigen components. Primary outcomes Incidence of vaccine‐preventable diseases: No trials reported this outcome. Procedural pain and crying: Using a wider gauge 23 G 25 mm needle may slightly reduce procedural pain (low‐quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate‐quality evidence) compared with a narrower gauge 25 G 25 mm needle (one trial, 320 participants). The effects are probably not large enough to be clinically relevant. Secondary outcomes Immune response: There is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between use of 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP‐Hib vaccine at ages two, three, and four months (moderate‐quality evidence, one trial, numbers of participants in analyses range from 309 to 402. The immune response to the pertussis antigen was not measured). Severe and non‐severe local reactions: 25 mm needles (either 25 G or 23 G) probably lead to fewer severe and non‐severe local reactions after DTwP‐Hib vaccination compared with 25 G 16 mm needles (moderate‐quality evidence, one trial, 447 to 458 participants in analyses). We estimate that one fewer infant will experience a severe local reaction (extensive redness and swelling) after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat for an additional beneficial outcome (NNTB) with a 25 G 25 mm needle: 25 (95% confidence interval (CI) 15 to 100); NNTB with a 23 G 25 mm needle: 25 (95% CI 17 to 100)). We estimate that one fewer infant will experience a non‐severe local reaction (any redness, swelling, tenderness, or hardness (composite outcome)) at 24 hours after the first vaccine dose for every 5 or 6 infants vaccinated with a 25 mm rather than a 16 mm needle (NNTB with a 25 G 25 mm needle: 5 (95% CI 4 to 10); NNTB with a 23 G 25 mm needle: 6 (95% CI 4 to 13)). The results are similar after the second and third vaccine doses. Using a narrow gauge 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with a wider gauge 23 G 25 mm needle, but the effect estimates are imprecise (low‐quality evidence, two trials, 100 to 459 participants in analyses). Systemic reactions: The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of postvaccination fever and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence. Authors' conclusions Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole‐cell pertussis antigen component. These vaccines are predominantly used in low‐ and middle‐income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain. Plain language summary Needle size for vaccination procedures in children and adolescents Background Vaccines contain antigens that make the body's immune system produce antibodies that can protect against disease, which is known as an immune response. Antigens are modified or partial forms of the virus, bacteria, or toxin that cause the disease that the vaccine protects against. Because the antigen is altered from its original form, it cannot cause disease, but it can produce an immune response. Vaccines can be injected using needles of different lengths and gauges. The needle gauge (G) refers to the width (diameter) of the needle. The higher the gauge number, the narrower the needle. For example, a 25 G needle is approximately 0.5 mm in diameter and is narrower than a 23 G needle, which has a diameter of 0.6 mm. Guidelines conflict regarding the lengths and gauges of needles that should be used for vaccinating children and adolescents. Review question We wanted to find out if the length and gauge of needles used to vaccinate children and adolescents has an influence on the: 1) immune response to the injected vaccine; 2) pain experienced during the vaccination procedure; 3) occurrence of reactions such as swelling, tenderness, and redness at the site where the vaccine is given; fever (high temperature); and other side effects that can occur after vaccination. Quality of the evidence We included five studies involving 1350 people. We rated the quality of the evidence from studies as very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. There were problems with the design of some studies, and data were insufficient to answer some parts of our review question. The quality of the evidence from two studies was too low to allow us to draw any conclusions about the effects of the needles compared in the studies. However, there was sufficient evidence from the remaining three studies to allow us to reach conclusions. Study characteristics The three studies that allowed us to reach conclusions involved 1135 healthy infants aged mostly between two and six months. The infants were vaccinated in the thigh with either 25 G 25 mm (narrow, long needles), 23 G 25 mm (wide, long needles), or 25 G 16 mm needles (narrow, short needles). The needles were inserted at right angles (90° angle) into the skin and pushed down into the muscle of the thigh. The vaccines injected were combination vaccines designed to protect against several diseases including diphtheria (D), tetanus (T), whooping cough (pertussis), and Haemophilus influenzae type b disease (Hib). The vaccines all contained whole‐cell pertussis (wP) vaccine antigens. These vaccines are commonly used in low‐ and middle‐income countries but not in high‐income countries. Our review findings are therefore most relevant to low‐ and middle‐income countries. Key findings We found moderate‐quality evidence that infants vaccinated in the thigh with 25 mm needles probably have fewer severe reactions (extensive redness and swelling in the thigh) after DTwP‐Hib vaccination than infants vaccinated with 16 mm needles. We also found that the longer needles probably lead to fewer non‐severe reactions such as mild swelling, tenderness, and redness after vaccination. The immune response to the vaccine is probably similar with the long and the short needles. We found low‐quality evidence that the wide, long needle may slightly reduce the pain of the vaccination procedure compared with the narrow, long needle. We found moderate‐quality evidence that the wide, long needle probably slightly reduces the duration of crying immediately following vaccination compared with the narrow, long needle. The differences in pain and crying between use of the wide and narrow needles are probably too small to be of any practical importance. We found low‐quality evidence that infants vaccinated with the narrow, long needle may have slightly fewer non‐severe reactions than infants vaccinated with the wide, long needle. We do not know if needle size has an effect on fever or other reactions that sometimes occur after vaccination including drowsiness, loss of appetite, and vomiting due to the very low quality of the evidence. The evidence in our review is current to October 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Beirne, PV; Hennessy, S; Cadogan, SL; Shiely, F; Fitzgerald, T; MacLeod, F", "articleTypes": [], "doi": "10.1002/14651858.CD010720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "882d7fc9-0e34-4d6a-92fa-3814ff1996ed", "pmid": "", "title": "Investigating the Potential Role of Aerosolized Retinoic Acid, a Potent Vitamin A Metabolite for Treating COVID-19 Anosmia and Retinoic Acid Insufficiency .A Novel Approach for Regaining Sense of Smell.", "imported": false, "abstract": "Investigating the potential role of Aerosolized retinoic acid, a potent Vitamin A metabolite for treating COVID-19 Anosmia and retinoic acid insufficiency .A novel approach for regaining Sense of Smell.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.268Z" }, { "id": "883644d6-6ae5-4982-a098-ba46980d10e3", "pmid": "", "title": "Systemic corticosteroids for acute otitis media in children", "imported": false, "abstract": "Abstract - Background Acute otitis media (AOM) is a common acute infection in children. Pain is its most prominent and distressing symptom. Antibiotics are commonly prescribed for AOM, although they have only a modest effect in reducing pain at two to three days. There is insufficient evidence for benefits of other treatment options, including systemic corticosteroids. However, systemic corticosteroids are potent anti‐inflammatory drugs, and so theoretically could be effective, either alone or as an addition to antibiotics. Objectives To assess the effects of systemic corticosteroids (oral or parenteral), with or without antibiotics, for AOM in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) which contains the Cochrane ARI Group's Specialised Register, MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), Web of Science (Thomson Reuters), and LILACS (BIREME) for published studies, and ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for completed and ongoing studies, to 20 February 2018. We checked the reference lists of all primary studies and review articles for additional references and contacted experts in the field to identify additional unpublished materials. Selection criteria We included randomised controlled trials of children with AOM that compared any systemic corticosteroid (oral or parenteral) with placebo, either with antibiotics (corticosteroid plus antibiotic versus placebo plus antibiotic) or without antibiotics (corticosteroid versus placebo). Data collection and analysis Three review authors (EDS, RR, YP) independently screened the titles and abstracts and retrieved the full texts of potentially relevant studies. We independently extracted study characteristics and outcome data from the included studies, and assessed the risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed study quality using the GRADE method. Main results We included two studies involving 252 children with AOM aged from three months to six years receiving hospital ambulatory care who were treated with intramuscular ceftriaxone, and who were then randomised to the corticosteroid group (corticosteroid and corticosteroid plus antihistamine) or the placebo group (antihistamine and double placebo). In one study, children also had a needle aspiration of middle ear fluid. Both studies were at unclear risk of bias for allocation concealment, and unclear to high risk of bias for selective reporting. One study (N = 179) included pain as an outcome, but we were unable to derive the proportion of children with persistent pain at Day 5 and Day 14. Reduction of overall or specific symptoms was presented as improvement in clinical symptoms and resolution of inflamed tympanic membranes without the need for additional antibiotic treatment: at Day 5 (94% of children in the treatment group (N = 89) versus 89% in the placebo group (N = 90); risk ratio (RR) 1.06, 95% confidence interval (CI) 0.97 to 1.16) and Day 14 (91% versus 87%; RR 1.05, 95% CI 0.95 to 1.17). Low‐quality evidence meant that we are uncertain of the effectiveness of corticosteroids for this outcome. The second study (N = 73) reported a reduction of overall or specific symptoms without additional antibiotic treatment during the first two weeks as a favourable outcome. Children in the treatment group had more favourable outcomes (adjusted odds ratio 65.9, 95% CI 1.28 to 1000; P = 0.037), although the numbers were small. We were unable to pool the results with the other study because it did not report the proportion of children with this outcome by treatment group. Only one study reported adverse effects of corticosteroids (e.g. drowsiness, nappy rash), but did not quantify incidence, so we were unable to draw conclusions about adverse effects. Neither study reported a reduction in overall or specific symptom duration. Authors' conclusions The evidence for the effect of systemic corticosteroids on AOM is of low to very low quality, meaning the effect of systemic corticosteroids on important clinical outcomes in AOM remains uncertain. Large, high‐quality studies are required to resolve the question . Plain language summary Systemic corticosteroids for improving symptoms in children with acute middle ear infection Review question We reviewed the evidence on the effects of corticosteroids given by mouth or injection for acute middle ear infection (acute otitis media (AOM)) in children, particularly in improving symptoms such as ear pain, fever, irritability, lack of sleep, and lack of appetite. We also looked at the side effects of corticosteroids. Background Acute otitis media is common in children and causes ear pain and non‐specific symptoms such as fever, irritability, and deafness. It is often treated with antibiotics, although ear pain generally resolves within two days, and antibiotics help symptoms only slightly. Other treatments (such as over‐the‐counter antihistamines and decongestants) do not help very much. Corticosteroids are often prescribed to reduce inflammation in children for other illnesses, and so may also help symptoms of AOM, which is an inflammatory process. We investigated whether using corticosteroids was better or worse than nothing in improving AOM‐related symptoms. Search date Our evidence is current to 20 February 2018. Study characteristics We included two studies involving 252 children with AOM, aged from three months to six years, receiving hospital ambulatory care. Children were treated with an antibiotic injection and either oral corticosteroid or a placebo (treatment with no effect). In one study, fluid from the middle ear was collected by inserting a needle through the eardrum to measure the level of inflammation. Study funding sources The National Institutes of Health (NIH) and the National Center for Research Resources, NIH, US Public Health Service funded both studies. Pharmaceutical companies provided the drug but did not contribute any other scientific or financial support. Key results and quality of evidence Corticosteroids did not make a significant difference in improving the symptoms and inflammation of the eardrum(s) at Day 5 and Day 14, but we are unsure of this effect due to the small numbers of children in the studies. There were no significant differences between the corticosteroid and placebo groups in terms of resolving fluid in children's middle ears (at 1, 2, and 3 months) and experiencing new episodes of AOM (at 1, 2, 3 months, and 4 and 6 months). Neither study reported a reduction in the duration of overall or specific symptoms, rupture of eardrum(s), the occurrence of middle ear inflammation in the other ear following the current ear infection, or serious complications. Only one study reported the overall side effects identified during the trial (e.g. drowsiness, dry mouth, diaper rash, nervousness). We could not draw any conclusions regarding the effects of corticosteroids for AOM in children. The quality of evidence included in this review was low to very low due to few children included in two small studies. We are uncertain about whether or not corticosteroids are useful in relieving pain from AOM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ranakusuma, RW, Pitoyo, Y, Safitri, ED, Thorning, S, Beller, EM, Sastroasmoro, S, Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD012289.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.751Z" }, { "id": "883c23d5-e49a-4a30-afa5-506d4a6c359b", "pmid": "", "title": "Complementary therapies for acne vulgaris", "imported": false, "abstract": "Abstract - Background Acne is a chronic skin disease characterised by inflamed spots and blackheads on the face, neck, back, and chest. Cysts and scarring can also occur, especially in more severe disease. People with acne often turn to complementary and alternative medicine (CAM), such as herbal medicine, acupuncture, and dietary modifications, because of their concerns about the adverse effects of conventional medicines. However, evidence for CAM therapies has not been systematically assessed. Objectives To assess the effects and safety of any complementary therapies in people with acne vulgaris. Search methods We searched the following databases from inception up to 22 January 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 , Issue 1 ), MEDLINE (from 1946), Embase (from 1974), PsycINFO (from 1806), AMED (from 1985), CINAHL (from 1981), Scopus (from 1966), and a number of other databases listed in the Methods section of the review. The Cochrane CAM Field Specialised Register was searched up to May 2014. We also searched five trials registers and checked the reference lists of articles for further references to relevant trials. Selection criteria We included parallel‐group randomised controlled trials (or the first phase data of randomised cross‐over trials) of any kind of CAM, compared with no treatment, placebo, or other active therapies, in people with a diagnosis of acne vulgaris. Data collection and analysis Three authors collected data from each included trial and evaluated the methodological quality independently. They resolved disagreements by discussion and, as needed, arbitration by another author. Main results We included 35 studies, with a total of 3227 participants. We evaluated the majority as having unclear risk of selection, attrition, reporting, detection, and other biases. Because of the clinical heterogeneity between trials and the incomplete data reporting, we could only include four trials in two meta‐analyses, with two trials in each meta‐analysis. The categories of CAM included herbal medicine, acupuncture, cupping therapy, diet, purified bee venom (PBV), and tea tree oil. A pharmaceutical company funded one trial; the other trials did not report their funding sources. Our main primary outcome was 'Improvement of clinical signs assessed through skin lesion counts', which we have reported as 'Change in inflammatory and non‐inflammatory lesion counts', 'Change of total skin lesion counts', 'Skin lesion scores', and 'Change of acne severity score'. For 'Change in inflammatory and non‐inflammatory lesion counts', we combined 2 studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD) at 12 weeks and found no clear evidence of a difference between the groups in change in non‐inflammatory lesion counts (mean difference (MD) ‐3.89, 95% confidence interval (CI) ‐10.07 to 2.29, P = 0.10, 75 participants, 2 trials, low quality of evidence). However, although data from 1 of these 2 trials showed benefit of LGLD for reducing inflammatory lesions (MD ‐7.60, 95% CI ‐13.52 to ‐1.68, 43 participants, 1 trial) and total skin lesion counts (MD ‐8.10, 95% CI ‐14.89 to ‐1.31, 43 participants, 1 trial) for people with acne vulgaris, data regarding inflammatory and total lesion counts from the other study were incomplete and unusable in synthesis. Data from a single trial showed potential benefit of tea tree oil compared with placebo in improving total skin lesion counts (MD ‐7.53, 95% CI ‐10.40 to ‐4.66, 60 participants, 1 trial, low quality of evidence) and acne severity scores (MD ‐5.75, 95% CI ‐9.51 to ‐1.99, 60 participants, 1 trial). Another trial showed pollen bee venom to be better than control in reducing numbers of skin lesions (MD ‐1.17, 95% CI ‐2.06 to ‐0.28, 12 participants, 1 trial). Results from the other 31 trials showed inconsistent effects in terms of whether acupuncture, herbal medicine, or wet‐cupping therapy were superior to controls in increasing remission or reducing skin lesions. Twenty‐six of the 35 included studies reported adverse effects; they did not report any severe adverse events, but specific included trials reported mild adverse effects from herbal medicines, wet‐cupping therapy, and tea tree oil gel. Thirty trials measured two of our secondary outcomes, which we combined and expressed as 'Number of participants with remission'. We were able to combine 2 studies (low quality of evidence), which compared Ziyin Qinggan Xiaocuo Granule and the antibiotic, minocycline (100 mg daily) (worst case = risk ratio (RR) 0.49, 95% CI 0.09 to 2.53, 2 trials, 206 participants at 4 weeks; best case = RR 2.82, 95% CI 0.82 to 9.06, 2 trials, 206 participants at 4 weeks), but there was no clear evidence of a difference between the groups. None of the included studies assessed 'Psychosocial function'. Two studies assessed 'Quality of life', and significant differences in favour of the complementary therapy were found in both of them on 'feelings of self‐worth' (MD 1.51, 95% CI 0.88 to 2.14, P < 0.00001, 1 trial, 70 participants; MD 1.26, 95% CI 0.20 to 2.32, 1 trial, 46 participants) and emotional functionality (MD 2.20, 95% CI 1.75 to 2.65, P < 0.00001, 1 trial, 70 participants; MD 0.93, 95% CI 0.17 to 1.69, 1 trial, 46 participants). Because of limitations and concerns about the quality of the included studies, we could not draw a robust conclusion for consistency, size, and direction of outcome effects in this review. Authors' conclusions There is some low‐quality evidence from single trials that LGLD, tea tree oil, and bee venom may reduce total skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs, such as herbal medicine, acupuncture, or wet‐cupping therapy, for the treatment of this condition. There is a potential for adverse effects from herbal medicines; however, future studies need to assess the safety of all of these CAM therapies. Methodological and reporting quality limitations in the included studies weakened any evidence. Future studies should be designed to ensure low risk of bias and meet current reporting standards for clinical trials. Plain language summary Complementary therapies for acne vulgaris Background Acne is a chronic skin disease, which causes spots to occur simultaneously on several areas of the body, including the face, neck, back, and chest. Besides the current commonly used treatments, complementary and alternative medicines (CAM) are of increasing interest to people who often use them in addition to conventional treatments as additive or single therapies to treat acne. The review question Can any complementary therapies improve the clinical symptoms of acne vulgaris? Study characteristics We searched relevant databases and trials registers up to 22 January 2014. We identified 35 randomised controlled trials, with 3227 participants, which used 6 kinds of CAM (herbal medicine, acupuncture, wet cupping, diet, purified bee venom, and tea tree oil). A pharmaceutical company funded one trial; the other trials did not report their funding sources. Key results For our primary outcome, we combined two studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD), but found no clear evidence of a difference between the 2 groups at 12 weeks for a change in non‐inflammatory lesion counts. Only one of these two trials provided usable data to show potential benefit of LGLD for reducing inflammatory and total skin lesion counts. Tea tree oil and pollen bee venom were found to reduce total skin lesion counts in single trials, respectively. The remaining 31 included trials gave mixed results about whether complementary therapies might reduce the total number of skin lesion counts. Twenty‐six trials reported adverse events. The herbal medicine group found some mild side‐effects, such as nausea, diarrhoea, and stomach upset. The acupuncture group found some itch or redness and pain following needle insertion. Participants who used tea tree oil reported itchiness, dryness, and flaking of the skin. None of the trials reported severe adverse effects. For our secondary outcome, there was no clear evidence of a difference in the number of participants with remission between Ziyin Qinggan Xiaocuo Granule and minocycline according to a meta‐analysis of two studies. Quality of the evidence There is some low‐quality evidence from single trials that a low‐glycaemic‐load diet, tea tree oil, and bee venom may reduce skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs. Methodological and reporting quality limitations in the included studies weakened any evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Cao, H; Yang, G; Wang, Y; Liu, JP; Smith, CA; Luo, H; Liu, Y", "articleTypes": [], "doi": "10.1002/14651858.CD009436.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "88642652-49de-45a1-ab0e-b7fc788e3b73", "pmid": "", "title": "Inhaled anti‐pseudomonal antibiotics for long‐term therapy in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review. Objectives To evaluate the effects of long‐term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug‐sensitivity reactions and survival). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022. Selection criteria We selected trials where people with cystic fibrosis received inhaled anti‐pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi‐randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). Data collection and analysis Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system. Main results The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta‐analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low‐certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) ‐5.30 days, 95% CI ‐8.59 to ‐2.01; 1 trial, 245 participants; low‐certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta‐analyses. We are uncertain of the effect of the intervention on adverse events (very low‐certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEV 1 ) % predicted compared to tobramycin (MD ‐3.40%, 95% CI ‐6.63 to ‐0.17; 1 trial, 273 participants; moderate‐certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate‐certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high‐certainty evidence). Important treatment‐related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high. Authors' conclusions Long‐term treatment with inhaled anti‐pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer‐term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes. Plain language summary Inhaling antibiotics to treat lung infection in people with cystic fibrosis Review question Are inhaled antibiotics helpful against persistent infection with Pseudomonas aeruginosa in people with cystic fibrosis (CF)? Key messages As people with CF get older, they are more likely to become infected on a long‐term basis with Pseudomonas aeruginosa. This is the most common cause of chronic lung infection in people with CF . We wanted to find out whether antibiotics targeting Pseudomonas aeruginosa would reduce the effects of infection when they are breathed into the lungs. We wanted to learn whether this treatment would improve lung function, quality of life and survival. We also looked for any harmful effects. What is CF? Cystic fibrosis is an inherited disease which results in abnormal mucus in several parts of the body and mainly affects the lungs, which are susceptible to infection by certain bacteria. Infection causes inflammation which results in progressive damage to the lungs. What did we find? The review includes 18 trials with 3042 people with CF aged between five and 45 years of age . The trials lasted from three to 33 months. In 11 trials investigators compared inhaled antibiotics with a placebo (an inhaled substance without the medication in it) and people were selected for one treatment or the other randomly. Eight trials compared one inhaled antibiotic with either a different inhaled antibiotic or a different schedule of the same inhaled antibiotic. One of the trials compared an antibiotic both to placebo and to a different antibiotic and so fell into both groups. Main results Results from four trials showed that when compared to placebo, inhaled antibiotics may improve lung function and reduce the number of times the people with CF had a worsening of symptoms (exacerbation). Inhaled antibiotics may also mean fewer days off school or work (a measure of quality of life). They did not seem to have an effect on survival. We are not sure of the side effects of inhaled antibiotics, but tinnitus and changes in voice were reported more often in people inhaling antibiotics rather than the placebo. We did not find enough evidence to be able to comment on how inhaled antibiotics affect height and weight. Where the trials compared different inhaled antibiotics or schedules, there was only one trial in each of the eight different comparisons. The only differences we found in all these comparisons were for two outcomes. In one trial we found that aztreonam lysine probably improved lung function more than tobramycin, but no important differences were found in the other trials with regard to lung function. Aztreonam lysine also probably led to fewer people needing additional courses of antibiotics than tobramycin and there were fewer hospitalisations after levofloxacin compared to placebo. We noted that important side effects that were related to the treatment were not very common in the trials, but they were less common with tobramycin than with other antibiotics. What are the limitations of the evidence? The trials that we included in this review measured lung function in different ways and also how often people experienced a sudden worsening of symptoms. That made it difficult for us to combine the results of different trials to strengthen our evidence. We thought the overall certainty of evidence was low for most outcomes, mainly due to risks of bias within the trials and low event rates meaning results were not precise. How up to date is this evidence? The evidence is current to: 28 June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Smith, S, Rowbotham, NJ", "articleTypes": [], "doi": "10.1002/14651858.CD001021.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.088Z" }, { "id": "886b9473-3726-4fde-a524-7481445b6da4", "pmid": "", "title": "Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Hip and knee replacement surgery is a well‐established means of improving quality of life, but is associated with a significant risk of bleeding. One‐third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care. Objectives To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta‐analysis (NMA) methodology. Search methods We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO host ), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). Selection criteria We included RCTs of people undergoing elective hip or knee surgery only. We excluded non‐elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon‐aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non‐fibrin sealants. Data collection and analysis We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all‐cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received. Main results We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra‐articularly and orally at a total dose of greater than 3 g pre‐incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate‐certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre‐incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low‐certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low‐certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low‐certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low‐certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low‐certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all‐cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low‐certainty evidence). This was followed by TXA given intravenously and intra‐articularly at a total dose of 2 g pre‐incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low‐certainty evidence) and TXA given intravenously and intra‐articularly, total dose greater than 3 g pre‐incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low‐certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low‐certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials). Authors' conclusions We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra‐articular, oral and intravenous, or intravenous and intra‐articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review. Plain language summary What is the best medication to stop bleeding in those having non‐emergency hip or knee surgery? Key messages • Tranexamic acid may be an effective medicine to help blood to clot during hip or knee replacement surgery, which reduces bleeding and the need for a blood transfusion (replacing lost blood with donated blood). • A high dose of this medicine and administering it in more than one way (for example, as a tablet and injected into the joint at the end of surgery) appears to work best. • Tranexamic acid is potentially as effective when given as a tablet as when injected into a vein. • There is little to no evidence to indicate that higher doses of tranexamic acid increase the risk of blood clots in the leg or other harms. Background Why is it important to stop bleeding during hip or knee surgery? Controlling bleeding during surgery reduces the likelihood of the person developing anaemia and requiring a blood transfusion, which carries the risk of complications. Anaemia occurs when the number of red blood cells (haemoglobin) available to carry oxygen is lower than normal. This causes symptoms such as fatigue, weakness, dizziness, shortness of breath and, in severe cases, can be life‐threatening. Preventing blood loss during surgery improves patient outcomes, decreases healthcare costs and preserves the limited supplies of donated blood. Is there a medication that helps control bleeding? Many research studies have investigated whether certain medication, such as tranexamic acid, can help minimise blood loss during surgery. Most of the studies test different doses of medications, different methods of administration and different times of use, either before, during or after an operation. What did we want to find out? We wanted to find out whether medication can reduce blood loss and the need for blood transfusions in people having hip or knee replacement surgery. We also wanted to know the most effective way of giving this medication to patients. What did we do? We searched for studies comparing different medications that could help reduce bleeding in adults undergoing planned hip or knee replacement surgery. We also searched for studies comparing medication with a placebo. A placebo is a 'dummy' medication that looks or tastes identical to the medication being tested. What did we find? We found 102 studies. Twelve studies did not report the number of included participants; in the other 90 studies, there were 8418 included participants. On average, people were between 50 and 77 years of age and 64% were women. The smallest study included 16 people and the largest involved 300. Studies took place around the globe, with the highest number in Europe and Asia. Of those studies that reported a source of funding, seven were fully funded and five partly funded by pharmaceutical (medication) companies. All studies investigated medications that helped the blood to clot. However, most studies assessed the effectiveness and safety of tranexamic acid administered intravenously (injected into a vein), orally (swallowing a tablet or liquid), injected into the joint during surgery, or with a combination of these methods. Main results Our review of the studies showed the following: • Tranexamic acid was the most effective at controlling bleeding compared to other medications. • Adults who underwent hip or knee replacement surgery required fewer blood transfusions if they were given tranexamic acid. • Tranexamic acid given in higher doses using multiple methods of administration, such as orally and injected into the joint during surgery, may be more likely to prevent bleeding. • Taking tranexamic acid orally is probably as effective at preventing a blood transfusion as injecting the medication into a vein. We were unable to decide on the optimal dose, which combination of methods are best to administer tranexamic acid and when it is most beneficial to use it (before, during and after surgery). We did not find evidence to suggest that higher doses of tranexamic acid increase the risk of developing a blood clot, or any other harms. What are the limitations of the evidence? We are not able to definitively draw conclusions based on the trials included within this review. We have little confidence in the evidence for some outcomes, and are not confident about the evidence for others. This is because it is possible that people in the studies were aware of which treatment they were getting. Also, the studies were small and did not all provide data about everything in which we were interested. Ongoing studies and future updates Thirty studies with a planned total of 3776 participants are currently ongoing. These studies should be completed and published within the next few years. Once the authors publish their data, we may update our analyses and provide stronger answers than we can at present. How up‐to‐date is this evidence? The evidence is current to 18 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gibbs, VN; Champaneria, R; Sandercock, J; Welton, NJ; Geneen, LJ; Brunskill, SJ; Dorée, C; Kimber, C; Palmer, AJR; Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD013295.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "88732aeb-9190-4877-98ee-f4d1c36f2e58", "pmid": "", "title": "Genital ulcer disease treatment for reducing sexual acquisition of HIV", "imported": false, "abstract": "Abstract - Background Genital ulcer disease by virtue of disruption of the mucosal surfaces may enhance HIV acquisition. Genital ulcer disease treatment with resolution of the ulcers may therefore contribute in reducing the sexual acquisition of HIV. Objectives To determine the effects of treatment of genital ulcer disease on sexual acquisition of HIV. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, LILACS, NLM Gateway, Web of Science, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and reference lists of relevant publications for eligible studies published between 1980 and August 2011. Selection criteria Randomized controlled trials of any treatment intervention aimed at curing genital ulcer disease compared with an alternative treatment, placebo, or no treatment. We included only trials whose unit of randomization was the individual with confirmed genital ulcer. Data collection and analysis We independently selected studies and extracted data in duplicate; resolving discrepancies by discussion, consensus, and arbitration by third review author. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI). Main results There were three randomized controlled trials that met our inclusion criteria recruited HIV‐negative participants with chancroid (two trials with 143 participants) and primary syphilis (one trial with 30 participants). The syphilis study, carried out in the US between 1995 and 1997, randomized participants to receive a single 2.0 g oral dose of azithromycin (11 participants); two 2.0 g oral doses of azithromycin administered six to eight days apart (eight participants); or benzathine penicillin G administered as either 2.4 million units intramuscular injection once or twice seven days apart (11 participants). No participant in the trial seroconverted during 12 months of follow‐up. The chancroid trials, conducted in Kenya by 1990, found no significant differences in HIV seroconversion rates during four to 12 weeks of follow‐up between 400 and 200 mg single oral doses of fleroxacin (one trial, 45 participants; RR 3.00; 95% CI 0.29 to 30.69), or between 400 mg fleroxacin and 800 mg sulfamethoxazole plus 160 mg trimethoprim (one trial, 98 participants; RR 0.33; 95% CI 0.04 to 3.09). Adverse events reported were mild to moderate in severity, and included Jarisch‐Herxheimer reactions and gastrointestinal symptoms. The differences between the treatment arms in the incidence of adverse events were not significant. The quality of this evidence on the effectiveness of genital ulcer disease treatment in reducing sexual acquisition of HIV, according to GRADE methodology, is of very low quality. Authors' conclusions At present, there is insufficient evidence to determine whether curative treatment of genital ulcer disease would reduce the risk of HIV acquisition. The very low quality of the evidence implies that the true effect of genital ulcer disease treatment on sexual acquisition of HIV may be substantially different from the effect estimated from currently available data. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not. Plain language summary Genital ulcer disease treatment for reducing sexual acquisition of HIV The presence of a genital ulcer would provide an entry point for the HIV virus if an HIV‐negative individual with an ulcer has unprotected sexual intercourse with an HIV‐infected person. Treatment of the condition causing the genital ulcer would allow the ulcer to heal and therefore reduce the chances of HIV acquisition. This review assessed whether giving treatment for diseases that present with ulcers in the genital region would reduce sexual acquisition of HIV. Three studies were identified involving 173 HIV‐negative patients with genital ulcers. These studies did not provide sufficient evidence that treatment of genital ulcer diseases reduces sexual acquisition of HIV infection. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mutua, FM, M'Imunya, JM, Wiysonge, CS", "articleTypes": [], "doi": "10.1002/14651858.CD007933.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.762Z" }, { "id": "88a1c220-ff30-4d42-8f8f-889b1efb4aaa", "pmid": "", "title": "Alpha‐blockers as medical expulsive therapy for ureteral stones", "imported": false, "abstract": "Abstract - Background Ureteral colic is a common reason for patients to seek medical care. Alpha‐blockers are commonly used to improve stone passage through so‐called medical expulsive therapy (MET), but their effectiveness remains controversial. This is an update of a 2014 Cochrane review; since that time, several large randomised controlled trials (RCTs) have been reported, making this update relevant. Objectives To assess effects of alpha‐blockers compared with standard therapy for ureteral stones 1 cm or smaller confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease. Search methods On 18 November 2017, we searched CENTRAL, MEDLINE Ovid, and Embase. We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials. We checked all references of included and review articles and conference proceedings for articles relevant to this review. We sent letters to investigators to request information about unpublished or incomplete studies. Selection criteria We included RCTs of ureteral stone passage in adult patients that compared alpha‐blockers versus standard therapy. Data collection and analysis Two review authors screened studies for inclusion and extracted data using standard methodological procedures. We performed meta‐analysis using a random‐effects model. Primary outcomes were stone clearance and major adverse events; secondary outcomes were stone expulsion time, number of pain episodes, use of diclofenac, hospitalisation, and surgical intervention. We assessed the quality of evidence on a per‐outcome basis using the GRADE approach. Main results We included 67 studies with 10,509 participants overall. Of these, 15 studies with 5787 participants used a placebo. Stone clearance: Based on the overall analysis, treatment with an alpha‐blocker may result in a large increase in stone clearance (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.36 to 1.55; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that the likely effect is probably smaller (RR 1.16, 95% CI 1.07 to 1.25; moderate‐quality evidence), corresponding to 116 more (95% CI 51 more to 182 more) stone clearances per 1000 participants. Major adverse events: Based on the overall analysis, treatment with an alpha‐blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that alpha‐blockers likely increase the risk of major adverse events slightly (RR 2.09, 95% CI 1.13 to 3.86), corresponding to 29 more (95% CI 3 more to 75 more) major adverse events per 1000 participants. Patients treated with alpha‐blockers may experience shorter stone expulsion times (mean difference (MD) ‐3.40 days, 95% CI ‐4.17 to ‐2.63; low‐quality evidence), may use less diclofenac (MD ‐82.41, 95% CI ‐122.51 to ‐42.31; low‐quality evidence), and likely require fewer hospitalisations (RR 0.51, 95% CI 0.34 to 0.77; moderate‐quality evidence), corresponding to 69 fewer hospitalisations (95% CI 93 fewer to 32 fewer) per 1000 participants. Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI 0.53 to 1.02; low‐quality evidence), corresponding to 28 fewer surgical interventions (95% CI 51 fewer to 2 more) per 1000 participants. A predefined subgroup analysis (test for subgroup differences; P = 0.002) suggests that effects of alpha‐blockers may vary with stone size, with RR of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or smaller versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones larger than 5 mm. We found no evidence suggesting possible subgroup effects based on stone location or alpha‐blocker type. Authors' conclusions For patients with ureteral stones, alpha‐blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha‐blockers may be less effective for smaller (5 mm or smaller) than for larger stones (greater than 5 mm). Plain language summary Alpha‐blockers for ureteral stones in adult patients with symptoms of stone disease Review question Does medical treatment with alpha‐blockers improve the outcomes of patients with stones stuck in their ureter? Background Stones stuck in the ureter, which is the tube that transports urine from the kidney to the bladder, often cause pain and make people see a doctor. Depending on which part of the ureter the stone is stuck in and the size of the stone, it will often pass into the bladder on its own over the course of weeks. If the stone does not come out by itself, people often need to have procedures done to remove the stone. Alpha‐blockers are medications that relax muscles in the urinary tract and may make the stone pass into the bladder faster. However, they can cause unwanted effects. We updated an existing Cochrane Review from 2014 to look into the effects of alpha‐blockers. Study characteristics Based on our latest search of the literature from November 2017, we included 64 studies with 10,509 participants. Of these, 15 studies compared alpha‐blockers with placebo with 5787 participants. A placebo is a pill that looks and tastes exactly like the real medication, so participants did not know what they were getting. These were the higher‐quality studies, which we trusted more. Key results Based on the subset of higher‐quality studies that used a placebo, alpha‐blockers likely resulted in more people passing their stones. However, these patients are likely to experience slightly more serious unwanted effects of this medication. People taking alpha‐blockers may pass their stones in a shorter time, may use less diclofenac (which is a type of pain medication), and are likely to be admitted to the hospital less often. Meanwhile, the need for surgery for their stones was similar. Upon completing additional analyses, we found that effects of alpha‐blockers may be different in people with small (5 mm or smaller) versus larger (larger than 5 mm) stones. It appears that this medication works better in people with larger stones. We could find no difference in how well alpha‐blockers work, no matter where in the ureter the stone is stuck or what type of alpha‐blocker is used. Authors' conclusions For patients with stones stuck in the ureter, alpha‐blockers likely make passing the stone easier but cause slightly more unwanted effects. It appears that alpha‐blockers work better in people with larger (greater than 5 mm) rather than smaller (5 mm or smaller) stones. Quality of the evidence The quality of the evidence for most outcomes was moderate or low, meaning that we have moderate or low confidence in most of the reported results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Campschroer, T, Zhu, X, Vernooij, RWM, Lock, MTWT", "articleTypes": [], "doi": "10.1002/14651858.CD008509.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.793Z" }, { "id": "88ae3184-59d8-41b5-bf0f-1fb7370c75ff", "pmid": "", "title": "Sumatriptan (oral route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Objectives To determine the efficacy and tolerability of oral sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using oral sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Sixty‐one studies (37,250 participants) compared oral sumatriptan with placebo or an active comparator. Most of the data were for the 50 mg and 100 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 50 mg versus placebo the NNTs were 6.1, 7.5, and 4.0 for pain‐free at two hours and headache relief at one and two hours, respectively. NNTs for sustained pain‐free and sustained headache relief during the 24 hours postdose were 9.5 and 6.0, respectively. For sumatriptan 100 mg versus placebo the NNTs were 4.7, 6.8, 3.5, 6.5, and 5.2, respectively, for the same outcomes. Results for the 25 mg dose were similar to the 50 mg dose, while sumatriptan 100 mg was significantly better than 50 mg for pain‐free and headache relief at two hours, and for sustained pain‐free during 24 hours. Treating early, during the mild pain phase, gave significantly better NNTs for pain‐free at two hours and sustained pain‐free during 24 hours than did treating established attacks with moderate or severe pain intensity. Relief of associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than with placebo. For the most part, adverse events were transient and mild and were more common with the sumatriptan than with placebo, with a clear dose response relationship (25 mg to 100 mg). Sumatriptan was compared directly with a number of active treatments, including other triptans, paracetamol (acetaminophen), acetylsalicylic acid, non‐steroidal anti‐inflammatory drugs (NSAIDs), and ergotamine combinations. Authors' conclusions Oral sumatriptan is effective as an abortive treatment for migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (oral route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is widely available as an oral tablet. This review found that a single dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in about 3 in 10 people (32%) taking sumatriptan 100 mg, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 6 in 10 people (61%) taking sumatriptan 100 mg, compared with about 3 in 10 (32%) taking placebo. Almost a quarter (24%) of people taking sumatriptan 100 mg had freedom from pain at two hours which was sustained during 24 hours without the use of rescue medication, compared with fewer than 1 in 10 (8%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events were mostly of short duration and mild or moderate in severity, and were experienced by about 4 in 10 (43%) of people taking sumatriptan 100 mg, and by 2 in 10 (23%) taking placebo. The 50 mg dose had slightly lower efficacy, but was associated with fewer adverse events. Treating attacks while pain was still mild was more effective than treating established attacks with moderate or severe pain intensity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008615.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.076Z" }, { "id": "88b30716-341a-4268-a48d-5d2b12129f35", "pmid": "", "title": "Triptans for acute cluster headache", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 ( Law 2010 ). Cluster headache is an uncommon, severely painful, and disabling condition, with rapid onset. Validated treatment options are limited; first‐line therapy includes inhaled oxygen. Other therapies such as intranasal lignocaine and ergotamine are not as commonly used and are less well studied. Triptans are successfully used to treat migraine attacks and they may also be useful for cluster headache. Objectives To assess the efficacy and tolerability of the triptan class of drugs compared to placebo and other active interventions in the acute treatment of episodic and chronic cluster headache in adult patients. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ClinicalTrials.gov, and reference lists for studies from inception to 22 January 2010 for the original review, and from 2009 to 4 April 2013 for this update. Selection criteria Randomised, double‐blind, placebo‐controlled studies of triptans for acute treatment of cluster headache episodes. Data collection and analysis Two review authors independently assessed study quality and extracted data. Numbers of participants with different levels of pain relief, requiring rescue medication, and experiencing adverse events and headache‐associated symptoms in treatment and control groups were used to calculate relative risk and numbers needed to treat for benefit (NNT) and harm (NNH). Main results New searches in 2013 did not identify any relevant new studies. All six included studies used a single dose of triptan to treat an attack of moderate to severe pain intensity. Subcutaneous sumatriptan was given to 131 participants at a 6 mg dose, and 88 at a 12 mg dose. Oral or intranasal zolmitriptan was given to 231 participants at a 5 mg dose, and 223 at a 10 mg dose. Placebo was given to 326 participants. Triptans were more effective than placebo for headache relief and pain‐free responses. By 15 minutes after treatment with subcutaneous sumatriptan 6 mg, 48% of participants were pain‐free and 75% had no pain or mild pain (17% and 32% respectively with placebo). NNTs for subcutaneous sumatriptan 6 mg were 3.3 (95% CI 2.4 to 5.0) and 2.4 (1.9 to 3.2) respectively. Intranasal zolmitriptan 10 mg was of less benefit, with 12% of participants pain‐free and 28% with no or mild pain (3% and 7% respectively with placebo). NNTs for intranasal zolmitriptan 10 mg were 11 (6.4 to 49) and 4.9 (3.3 to 9.2) respectively. Authors' conclusions Based on limited data, subcutaneous sumatriptan 6 mg was superior to intranasal zolmitriptan 5 mg or 10 mg for rapid (15 minute) responses, which are important in this condition. Oral routes of administration are not appropriate. Plain language summary Triptans for acute cluster headache Cluster headaches are excruciating headaches of extreme intensity. They can last for several hours, are usually on one side of the head only, and affect men more than women. Multiple headaches can occur over several days. Fast pain relief is important because of the intense nature of the pain with cluster headache. Triptans are a type of drug used to treat migraine. Although migraine is different from cluster headache, there are reasons to believe that some forms of these drugs could be useful in cluster headache. Triptans can be given by injection under the skin (subcutaneously) or by a spray into the nose (intranasally) to produce fast pain relief. The review found six studies examining two different triptans. The number of people in the studies was limited. Within 15 minutes of using subcutaneous sumatriptan 6 mg, almost 8 in 10 participants had no worse than mild pain, and 5 in 10 were pain‐free. Within 15 minutes of using intranasal zolmitriptan 5 mg, about 3 in 10 had no worse than mild pain, and 1 in 10 was pain‐free. Adverse events were more common with a triptan than with placebo but they were generally of mild to moderate severity. Cluster headache is an awful thing to have. More research on how to get better pain relief faster, and to more patients, would be welcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Law, S, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008042.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.745Z" }, { "id": "88c57375-b211-4609-bcd2-ebd6ce8fe553", "pmid": "", "title": "Supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults", "imported": false, "abstract": "Abstract - Background Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy. Objectives To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults. Search methods We identified publications from comprehensive searches of the Cochrane Library , MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016. Selection criteria Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care. Data collection and analysis Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta‐analyses for the outcome measures, 'all‐cause mortality', 'hospitalisation' and 'nutritional status (weight change)'. Main results Forty‐one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow‐up ranged from ‘duration of hospital stay’ to 12 months. The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all‐cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate‐quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low‐quality evidence). Only five trials (4451 participants) investigated health‐related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of ‐0.5 days (95% CI ‐2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low‐quality evidence. Only three of 41 included trials (4108 participants; very low‐quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta‐analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate‐quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low‐quality evidence). Authors' conclusions There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all‐cause mortality for supportive interventions comes from hospital‐based trials and more research is needed to confirm this effect. There is very low‐quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient‐important outcomes in future research. Plain language summary Supportive interventions for improving dietary intake in nutritionally vulnerable groups Review question Are supportive interventions for improving dietary intake in nutritionally vulnerable groups (malnourished or nutritionally at‐risk individuals) effective? Background Serving meals in a dining room, or the use of assistance to help feed people in need and other similar methods are often recommended to help especially sick and elderly people who have lost or are likely to lose weight (nutritionally vulnerable groups). Such supportive interventions are implemented in the health care in many countries but their effects are not well investigated. Study characteristics We included 41 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 10,681 people in our review. There were five different interventions which we call 'supportive interventions': changes to the organisation of nutritional care (13 studies, 3456 people), changes to the feeding environment (5 studies, 351 people), modification of the meal profile or pattern (12 studies, 649 people), additional supplementation of meals (10 studies, 6022 people) and home meal delivery systems (1 study, 203 people). Monitoring participants over time (follow‐up) ranged from ‘duration of hospital stay’ to 12 months. The comparator groups received 'usual' care. More than half of all participants took part in studies investigating the additional supplementation of meals (for example a protein‐energy oral nutritional supplement in addition to the usual diet). Key results It is possible that supportive interventions for enhancing dietary intake in nutritionally vulnerable groups reduce death from any cause (approximately 23 fewer cases of death per 1000 participants in favour of supportive interventions). However, this has to be confirmed by more evidence from high‐quality randomised controlled studies. The number of participants experiencing any medical complication did not differ substantially between the supportive interventions and the comparator groups. The same was found for health‐related quality of life (which is physical, mental, emotional and social health attributed to health), patient satisfaction, nutritional or energy intake and days spent in hospital. Economic costs were not well investigated. Only three studies reported on side effects, describing intolerance to the nutritional supplement (such as diarrhoea or vomiting in 5 of 34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567 of 2017 participants). After analysing 15 studies in 1945 participants we found a beneficial effect of supportive interventions compared with comparators on weight: on average people in the supportive interventions groups increased their weight 0.6 kg more than people in the comparator groups. This evidence is up to date as of September 2016. Quality of evidence The overall quality of evidence ranged between moderate to very low, mainly because for most of our outcomes there was only a small number of studies and participants to achieve reliable information, or because risk of bias made results uncertain. However, if some randomised controlled studies with low risk of bias for our patient‐important outcomes and a good number of participants were performed, this review could quickly provide good guidance for better health care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Baldwin, C; Kimber, KL; Gibbs, M; Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD009840.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "88c611ab-8a9a-4441-a0cd-d9264d041471", "pmid": "", "title": "Tartrazine exclusion for allergic asthma", "imported": false, "abstract": "Abstract - Background Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There has been conflicting evidence as to whether tartrazine causes exacerbations of asthma with some studies finding a positive association especially in individuals with cross‐sensitivity to aspirin. Objectives To assess the overall effect of tartrazine (exclusion or challenge) in the management of asthma. Search methods A search was carried out on the Cochrane Airways Group Specialised Register. Bibliographies of each RCT was searched for additional papers. Authors of identified RCTs were contacted for further information. Searches are updated annually and are current as of February 2006. Selection criteria RCTs of oral administration of tartrazine (as a challenge) versus placebo or dietary avoidance of tartrazine versus normal diet were considered. Studies which focused upon allergic asthma, were also included. Studies of tartrazine exclusion for other allergic conditions such as hay fever, allergic rhinitis and eczema were only considered if the results for subjects with asthma were separately identified. Trials could be in either adults or children with asthma or allergic asthma (e.g. sensitivity to aspirin or food items known to contain tartrazine). Data collection and analysis Study quality was assessed and data abstracted by two reviewers independently. Outcomes were analysed using RevMan 4.1.1. Main results Ninety four abstracts were found, of which 20 were potentially relevant. Six? met the inclusion criteria, but only three presented results in a format that permitted analysis and none could be combined in a meta‐analysis. In none of the studies did tartrazine challenge or avoidance in diet significantly alter asthma outcomes. Authors' conclusions Due to the paucity of available evidence, it is not possible to provide firm conclusions as to the effects of tartrazine on asthma control. However, the six RCTs that could be included in this review all arrived at the same conclusion. Routine tartrazine exclusion may not benefit most patients, except those very few individuals with proven sensitivity. Plain language summary Tartrazine exclusion for allergic asthma Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There is no evidence that tartrazine makes asthma worse or avoiding it makes asthma patients any better.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Ardern, K", "articleTypes": [], "doi": "10.1002/14651858.CD000460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.754Z" }, { "id": "88d205fe-a986-4e6c-a637-dcab5b253797", "pmid": "", "title": "Nebulized and oral thiol derivatives for pulmonary disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is an inherited condition resulting in thickened, sticky respiratory secretions. Respiratory failure, due to recurrent pulmonary infection and inflammation, is the most common cause of mortality. Muco‐active therapies (e.g. dornase alfa and nebulized hypertonic saline) may decrease sputum viscosity, increase airway clearance of sputum, reduce infection and inflammation and improve lung function. Thiol derivatives, either oral or nebulized, have shown benefit in other respiratory diseases. Their mode of action is likely to differ according to the route of administration. There are several thiol derivatives, and it is unclear which of these may be beneficial in cystic fibrosis. Objectives To evaluate the efficacy and safety of nebulized and oral thiol derivatives in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches, hand searches of relevant journals, abstract books and conference proceedings. Most recent search: 13 June 2013. We also conducted a PubMed search on 26 February 2013 for relevant published articles. Selection criteria Randomized and quasi‐randomized controlled trials comparing nebulized or oral thiol derivatives to placebo or another thiol derivative in people with cystic fibrosis. Data collection and analysis The authors independently assessed trials for inclusion, analysed risk of bias and extracted data. Main results Searches identified 23 trials; nine trials (255 participants) are included, of these seven trials are more than 10 years old. Three trials of nebulized thiol derivatives were identified (one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and another compared glutathione to 4% hypertonic saline). Although generally well‐tolerated with no significant adverse effects, there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Six trials of oral thiol derivatives were identified. Three trials compared N‐acetylcysteine to placebo; one compared N‐acetylcysteine, ambroxol and placebo; one compared carbocysteine to ambroxol; and one compared low and high‐dose N‐acetylcysteine. Oral thiol derivatives were generally well‐tolerated with no significant adverse effects, however there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Authors' conclusions We found no evidence to recommend the use of either nebulized or oral thiol derivatives in people with cystic fibrosis. There are very few good quality trials investigating the effect of these medications in cystic fibrosis, and further research is required to investigate the potential role of these medications in improving the outcomes of people with cystic fibrosis. Plain language summary Compounds which can break down the structure of mucus for lung disease in cystic fibrosis Cystic fibrosis is a genetic disorder which mainly affects the lungs. Chest infections recur in people with cystic fibrosis due to a build up of thick sputum (phlegm) in the air passages. Several treatments, including thiol derivatives, aim to loosen this sputum and so improve lung function and reduce the frequency of chest infections. Thiol derivatives may be either nebulized (breathed in) or oral (by mouth). They have been shown to help in other lung conditions, such as chronic obstructive pulmonary disease. This review aims to find out if there is enough evidence to recommend the use of nebulized or oral thiol derivatives for people with cystic fibrosis. We included nine trials; three assessed the effect of nebulized thiol derivatives. Of the nebulized trials, one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and the other compared glutathione to 4% hypertonic saline. Nebulized thiol derivatives were generally well‐tolerated with no major adverse effects. However they showed no significant improvements in any of our outcome measures. Six included trials assessed the effects of oral thiol derivatives.Three of these trials compared oral N‐acetylcysteine to placebo; one compared oral N‐acetylcysteine, oral ambroxol and placebo; and one compared oral carbocysteine and oral ambroxol (no placebo). None of the trials showed an overall significant benefit in any of the outcome measures of this review. Oral thiol derivatives were generally well‐tolerated with no major adverse effects. In summary, the trials included in the review did not provide any evidence that nebulized or oral thiol derivatives were either beneficial or harmful to people with cystic fibrosis. Further research investigating the effects of thiol derivatives in people with cystic fibrosis is required before their use can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Tam, J; Nash, EF; Ratjen, F; Tullis, E; Stephenson, A", "articleTypes": [], "doi": "10.1002/14651858.CD007168.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "88dd6725-090f-468c-8fba-65514d12ee22", "pmid": "", "title": "Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wells, GA, Hsieh, S-C, Zheng, C, Peterson, J, Liu, W, Kelly, SE, Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD004523.pub4 AB - Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration leading to increased fracture risk. Risedronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts. This is an update of a Cochrane Review that was originally published in 2003. Objectives We assessed the benefits and harms of risedronate in the primary and secondary prevention of osteoporotic fractures for postmenopausal women at lower and higher risk for fractures, respectively. Search methods With broader and updated strategies, we searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE and Embase. A grey literature search, including the online databases ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), and drug approval agencies, as well as bibliography checks of relevant systematic reviews was also performed. Eligible trials published between 1966 to 24 March 2021 were identified. Selection criteria We included randomised controlled trials that assessed the benefits and harms of risedronate in the prevention of fractures for postmenopausal women. Participants must have received at least one year of risedronate, placebo or other anti‐osteoporotic drugs, with or without concurrent calcium/vitamin D. Major outcomes were clinical vertebral, non‐vertebral, hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. In the interest of clinical relevance and applicability, we classified a study as secondary prevention if its population fulfilled more than one of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, low bone mineral density (BMD)T score ≤ ‐2.5, and age ≥ 75 years old. If none of these criteria was met, the study was considered to be primary prevention. Data collection and analysis We used standard methodology expected by Cochrane. We pooled the relative risk (RR) of fractures using a fixed‐effect model based on the expectation that the clinical and methodological characteristics of the respective primary and secondary prevention studies would be homogeneous, and the experience from the previous review suggesting that there would be a small number of studies. The base case included the data available for the longest treatment period in each placebo‐controlled trial and a >15% relative change was considered clinically important. The main findings of the review were presented in summary of findings tables, using the GRADE approach. In addition, we looked at benefit and harm comparisons between different dosage regimens for risedronate and between risedronate and other anti‐osteoporotic drugs. Main results Forty‐three trials fulfilled the eligibility criteria, among which 33 studies (27,348 participants) reported data that could be extracted and quantitatively synthesized. We had concerns about particular domains of risk of bias in each trial. Selection bias was the most frequent concern, with only 24% of the studies describing appropriate methods for both sequence generation and allocation concealment. Fifty per cent and 39% of the studies reporting benefit and harm outcomes, respectively, were subject to high risk. None of the studies included in the quantitative syntheses were judged to be at low risk of bias in all seven domains. The results described below pertain to the comparisons for daily risedronate 5 mg versus placebo which reported major outcomes. Other comparisons are described in the full text. For primary prevention, low‐ to very low‐certainty evidence was collected from four studies (one to two years in length) including 989 postmenopausal women at lower risk of fractures. Risedronate 5 mg/day may make little or no difference to wrist fractures [RR 0.48 ( 95% CI 0.03 to 7.50; two studies, 243 participants); absolute risk reduction (ARR) 0.6% fewer (95% CI 1% fewer to 7% more)] and withdrawals due to adverse events [RR 0.67 (95% CI 0.38 to 1.18; three studies, 748 participants); ARR 2% fewer (95% CI 5% fewer to 1% more)], based on low‐certainty evidence. However, its preventive effects on non‐vertebral fractures and serious adverse events are not known due to the very low‐certainty evidence. There were zero clinical vertebral and hip fractures reported therefore the effects of risedronate for these outcomes are not estimable. For secondary prevention, nine studies (one to three years in length) including 14,354 postmenopausal women at higher risk of fractures provided evidence. Risedronate 5 mg/day probably prevents non‐vertebral fractures [RR 0.80 (95% CI 0.72 to 0.90; six studies, 12,173 participants); RRR 20% (95% CI 10% to 28%) and ARR 2% fewer (95% CI 1% fewer to 3% fewer), moderate certainty], and may reduce hip fractures [RR 0.73 (95% CI 0.56 to 0.94); RRR 27% (95% CI 6% to 44%) and ARR 1% fewer (95% CI 0.2% fewer to 1% fewer), low certainty]. Both of these effects are probably clinically important. However, risedronate's effects are not known for wrist fractures [RR 0.64 (95% CI 0.33 to 1.24); three studies,1746 participants); ARR 1% fewer (95% CI 2% fewer to 1% more), very‐low certainty] and not estimable for clinical vertebral fractures due to zero events reported (low certainty). Risedronate results in little to no difference in withdrawals due to adverse events [RR 0.98 (95% CI 0.90 to 1.07; eight studies, 9529 participants); ARR 0.3% fewer (95% CI 2% fewer to 1% more); 16.9% in risedronate versus 17.2% in control, high certainty] and probably results in little to no difference in serious adverse events [RR 1.00 (95% CI 0.94 to 1.07; six studies, 9435 participants); ARR 0% fewer (95% CI 2% fewer to 2% more; 29.2% in both groups, moderate certainty). Authors' conclusions This update recaps the key findings from our previous review that, for secondary prevention, risedronate 5 mg/day probably prevents non‐vertebral fracture, and may reduce the risk of hip fractures. We are uncertain on whether risedronate 5mg/day reduces clinical vertebral and wrist fractures. Compared to placebo, risedronate probably does not increase the risk of serious adverse events. For primary prevention, the benefit and harms of risedronate were supported by limited evidence with high uncertainty. Plain language summary Risedronate for preventing fractures caused by osteoporosis in postmenopausal women This summary of a Cochrane Review presents what we know from the evidence up to 24 March 2021 about the effect of risedronate for preventing fractures (broken bones) caused by osteoporosis. What is osteoporosis and what is risedronate? 
Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow and old bone cells break down to make room for the new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break even after a minor injury, like a little bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. Risedronate belongs to the class of drugs called bisphosphonates. It is a type of medication that slows down the cells that break down the old bone. In postmenopausal women whose bone density is closer to normal or who may not yet have had a fracture in the bones of their spine therefore putting them at lower risk for fractures: ‐ there is insufficient evidence to tell us if risedronate leads to any reduction in the number of women sustaining bone fractures; ‐ based on limited data there is no evidence of an increase in adverse events for postmenopausal women at lower risk for fractures. In postmenopausal women who have already been diagnosed with osteoporosis (who have low bone density, or who have already had a fracture in the bones of their spine) putting them at higher risk for fractures, risedronate: ‐ probably prevents fractures in the bones of the hip and in bones other than in the spine; ‐ may not lead to any difference in preventing wrist fractures; ‐ does not have enough evidence to show if it may prevent fractures in the bones of the spine suggested by clinical signs and symptoms; ‐ might make little or no difference in adverse events for postmenopausal women at higher risk for fractures. Best estimate of what happens to postmenopausal women at lower risk for fractures who take risedronate or placebo: ‐ for spine fractures suggested by clinical signs and symptoms and hip fractures, it was not possible to calculate the effect because none of these fractures were reported in any of the studies; ‐ compared to placebo, there is not enough information to tell if risedronate prevents fractures in wrist and bones other than in the spine. Best estimate of what happens to postmenopausal women at higher risk for fractures who take risedronate or placebo: Fractures of the spine suggested by clinical signs and symptoms were not reported in any of the studies. Fractures in bones other than the spine: ‐ 10 out of 100 women had a fracture when taking a placebo; ‐ 8 out of 100 women had a fracture when taking risedronate; Fractures of the hip ‐ 3 out of 100 women had a fracture when taking a placebo; ‐ 2 out of 100 women had a fracture when taking risedronate. Fractures of the wrist: ‐ there is not enough information to tell if risedronate prevents wrist fractures.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.789Z" }, { "id": "88de2667-bb01-4f86-a43e-507639f95ba5", "pmid": "", "title": "Community‐based supplementary feeding for food insecure, vulnerable and malnourished populations – an overview of systematic reviews", "imported": false, "abstract": "Abstract - Background Supplementary feeding may help food insecure and vulnerable people by optimising the nutritional value and adequacy of the diet, improving quality of life and improving various health parameters of disadvantaged families. In low‐ and middle‐income countries (LMIC), the problems supplementary feeding aims to address are entangled with poverty and deprivation, the programmes are expensive and delivery is complicated. Objectives 1. To summarise the evidence from systematic reviews of supplementary feeding for food insecure, vulnerable and malnourished populations, including children under five years of age, school‐aged children, pregnant and lactating women, people with HIV or tuberculosis (or both), and older populations. 2. To describe and explore the effects of supplementary feeding given to people in these groups, and to describe the range of outcomes between reviews and range of effects in the different groups. Methods In January 2017, we searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase and nine other databases. We included systematic reviews evaluating community‐based supplementary feeding, and concerning food insecure, vulnerable and malnourished populations. Two review authors independently undertook selection of systematic reviews, data extraction and 'Risk of bias' assessment. We assessed review quality using the AMSTAR tool, and used GRADEpro 'Summary of findings' tables from each review to indicate the certainty of the evidence for the main comparisons. We summarised review findings in the text and reported the data for each outcome in additional tables. We also used forest plots to display results graphically. Main results This overview included eight systematic reviews (with last search dates between May 2006 and February 2016). Seven were Cochrane Reviews evaluating interventions in pregnant women; children (aged from birth to five years) from LMIC; disadvantaged infants and young children (aged three months to five years); children with moderate acute malnutrition (MAM); disadvantaged school children; adults and children who were HIV positive or with active tuberculosis (with or without HIV). One was a non‐Cochrane systematic review in older people with Alzheimer's disease. These reviews included 95 trials relevant to this overview, with the majority (74%) of participants from LMIC. The number of included participants varied between 91 and 7940 adults, and 271 and more than 12,595 children. Trials included a wide array of nutritional interventions that varied in duration, frequency and format, with micronutrients often reported as cointerventions. Follow‐up ranged from six weeks to two years; three trials investigated outcomes at four to 17 years of age. All reviews were rated as high quality (AMSTAR score between eight and 11). The GRADE certainty ratings ranged from very low to moderate for individual comparisons, with the evidence often comprising only one or two small trials, thereby resulting in many underpowered analyses (too small to detect small but important differences). The main outcome categories reported across reviews were death, anthropometry (adults and children) and other markers of nutritional status, disease‐related outcomes, neurocognitive development and psychosocial outcomes, and adverse events. Mortality data were limited and underpowered in meta‐analysis in all populations (children with MAM, in children with HIV, and in adults with tuberculosis) with the exception of balanced energy and protein supplementation in pregnancy, which may have reduced the risk of stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94; 5 trials, 3408 women). Supplementation in pregnancy also improved infant birth weight (mean difference (MD) 40.96 g, 95% CI 4.66 to 77.26; 11 trials, 5385 participants) and reduced risk of infants born small‐for‐gestational age (RR 0.79, 95% CI 0.69 to 0.90; 7 trials, 4408 participants). These effects did not translate into demonstrable long‐term benefits for children in terms of growth and neurocognitive development in the one to two trials reporting on longer‐term outcomes. In one study (505 participants), high‐protein supplementation was associated with increased risk of small‐for‐gestational age babies. Effects on growth in children were mixed. In children under five years of age from LMIC, one review found that supplementary feeding had a little or no effect on child growth; however, a more recent review in a similar population found that those who received food supplementation gained an average of 0.12 kg more in weight (MD 0.12 kg, 95% CI 0.05 to 0.18; 9 trials, 1057 participants) and 0.27 cm more in height (MD 0.27 cm, 95% CI 0.07 to 0.48; 9 trials, 1463 participants) than those who were not supplemented. Supplementary food was generally more effective for younger children (younger than two years of age) and for those who were poorer or less well‐nourished. In children with MAM, the provision of specially formulated food improved their weight, weight‐for‐height z scores and other key outcomes such as recovery rate (by 29%), as well as reducing the number of participants dropping out (by 70%). In LMIC, school meals seemed to lead to small benefits for children, including improvements in weight z scores, especially in children from lower‐income countries, height z scores, cognition or intelligence quotient tests, and maths and spelling performance. Supplementary feeding in adults who were HIV positive increased the daily energy and protein intake compared to nutritional counselling alone. Supplementation led to an initial improvement in weight gain or body mass index but did not seem to confer long‐term benefit. In adults with tuberculosis, one small trial found a significant benefit on treatment completion and sputum conversion rate. There were also significant but modest benefits in terms of weight gain (up to 2.60 kg) during active tuberculosis. The one study included in the Alzheimer's disease review found that three months of daily oral nutritional supplements improved nutritional outcomes in the intervention group. There was little or no evidence regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes. Authors' conclusions Considering the current evidence base included, supplementary food effects are modest at best, with inconsistent and limited mortality evidence. The trials reflected in the reviews mostly reported on short‐term outcomes and across the whole of the supplementation trial literature it appears important outcomes, such as quality of life and cost of programmes, are not systematically reported or summarised. Plain language summary Supplementary feeding for groups of people that are food insecure, vulnerable and malnourished What was the aim of this review? To summarise the effect of supplementary feeding on populations that were food insecure, vulnerable and malnourished. The overview authors found eight systematic reviews examining supplementary feeding in a variety of populations. Key messages Across a range of vulnerable populations, supplementary feeding programmes sometimes show modest benefit in nutritional outcomes. In a few studies examining mortality (death), effects were either small or absent, and research mostly looked at short‐term effects. What was studied in the review? Supplementary feeding means providing extra food to people or families over and above their home diet and has been used in populations that are food insecure (limited access to adequate and nutritious food) and vulnerable (including women and young children; school‐aged children; people living with diseases such as tuberculosis, HIV, and Alzheimer's disease; and older people) to improve their health and quality of life. What are the main results of the review? The evidence presented here was current to January 2017. We found eight systematic reviews to include in this summary. These reviews included 95 studies (including up to 7940 adults, and more than 12,595 children in a few studies). Most of the included studies lasted from six weeks to two years, with only three studies following people for longer periods of time (up to 17 years). In these reviews, there were a wide range of different types of supplementary feeding given to vulnerable groups over different periods of time, and often in combination with vitamins or minerals. In pregnancy, we found that energy and protein supplements that were balanced (i.e. providing adequate amounts of energy and nutrients, in this case protein) may have decreased the rate of stillbirth (death or loss of a baby before or during delivery), improved infant birth weight and reduced the risk of infants born small‐for‐gestational age (infants that are smaller than expected). We observed no long‐term benefits for children in terms of growth and cognitive (intellectual) development (although very few studies reported long‐term effects). High‐protein supplements (containing protein in higher amounts) were associated with risk and harm (increased risk of small‐for‐gestational age babies). We found that the effects of supplementary feeding on growth in children were varied. In children under five years of age from low‐ and middle‐income countries, supplementary feeding had a small impact on child growth. We observed some benefits in terms of weight and height gains, especially in younger children (those younger than two years of age) and in those who were poorer or less well‐nourished (or both). Some benefit could be seen in children with moderate acute malnutrition in terms of weight gain, other growth factors and recovery rate. School meals seemed to lead to a number of small benefits in school children (including improvements in weight, height, intelligence tests, and maths and spelling performance). Supplementary feeding in adults who were HIV positive increased the daily intake of energy and protein and led to an early improvement in weight gain or body mass index (measure of whether someone is overweight or underweight), or both, but did not seem to lead to long‐term benefits (although few studies reported long‐term effects). In adults with tuberculosis (serious infectious lung disease), we observed small benefits in terms of weight gain during active tuberculosis. In Alzheimer's disease (a type of dementia), providing a daily oral nutrition supplement for three months improved nutritional outcomes (such as weight and energy intake). There was little or no evidence available regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Visser, J; McLachlan, MH; Maayan, N; Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD010578.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "8942a8b6-4631-46b0-aedf-9b62fcea6613", "pmid": "", "title": "Ribavirin monotherapy for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. A high proportion of patients never experience symptoms. Peginterferon plus ribavirin is the recommended treatment for chronic hepatitis C. However, ribavirin monotherapy may be considered for some patients. Objectives To assess the beneficial and harmful effects of ribavirin monotherapy for patients with chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included all randomised trials irrespective of blinding, language, or publication status comparing ribavirin versus no intervention, placebo, or interferon for chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained virological response (loss of hepatitis C virus RNA at least six months after treatment), liver‐related morbidity plus all‐cause mortality, and adverse events. Secondary outcome measures were end of treatment virological response, biochemical response (transaminase activity), and histological response. Randomisation methods, blinding, data handling, and funding were extracted as measures of bias control. Random‐effects and fixed‐effect meta‐analyses were performed for all outcomes. We only present the results of the fixed‐effect model if both models provide the same result regarding statistical significance. We present data as risk difference (RD) with 95% confidence intervals (CI). Main results We included 14 randomised trials with 657 patients. The majority of trials had unclear control of bias. Compared with placebo or no intervention, ribavirin had no significant effect on the sustained virological response (RD 0%, 95% CI ‐2% to 3%, five trials) or end of treatment virological response (RD 0% 95% CI ‐3% to 3%, ten trials). Ribavirin had no significant effect on liver‐related morbidity plus mortality (RD 0%, 95% CI ‐2% to 3%, 11 trials). Ribavirin significantly increased the risk of adverse reactions, including anaemia. Ribavirin significantly improved end of treatment biochemical and histological response but not the sustained biochemical response. Ribavirin was significantly inferior to interferon regarding virological and biochemical responses (five trials). Authors' conclusions Ribavirin seems without beneficial effects on serum virological response and liver‐related morbidity or mortality, and significantly increased the risk of adverse reactions. Ribavirin monotherapy seems significantly inferior to interferon monotherapy. The total number of included patients is small, and more trials are perhaps needed. The use of ribavirin monotherapy for chronic hepatitis C cannot be recommended outside randomised trials. Plain language summary Treatment of patients infected with hepatitis C virus Globally, about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behaviour, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die from it. Treatment with interferon clears hepatitis C virus from the blood in about 15% of the patients. Adding ribavirin to interferon (combination therapy) significantly improves the number that clears hepatitis C from the blood to about 40%. Not all patients are tolerant to interferon, and also interferon is costly. This is why ribavirin given as a single drug may be considered as an option for patients with chronic hepatitis C. This review identified 11 randomised trials comparing ribavirin with no antiviral treatment in patient with chronic hepatitis C. Combining the results from all identified trials ribavirin alone seemed without beneficial effects for patients with chronic hepatitis C. Moreover, ribavirin given alone was significantly inferior compared with interferon regarding clearing hepatitis C from the blood and regarding reducing liver enzymes activity in the blood. Furthermore, ribavirin given alone increased the risk of anaemia. Thus, ribavirin given alone cannot be recommended, but more trials may be needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brok, J; Gluud, LL; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005527.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "895f5efd-d90f-4385-97d8-d191b8033044", "pmid": "", "title": "Brexpiprazole versus placebo or other antidepressive agents for treating depression", "imported": false, "abstract": "Abstract - Background Brexpiprazole is the newest antipsychotic drug approved as an adjunctive for treatment‐resistant depression. This systematic review provides comprehensive, high‐quality evidence for the effects of brexpiprazole in major depressive disorder (MDD) based on existing and emerging randomised controlled trials (RCTs). Objectives To evaluate the benefits and harms of brexpiprazole as monotherapy or adjunct treatment in the acute and longer‐term treatment of MDD compared to placebo or other antidepressive agents. Search methods We used standard, extensive Cochrane search methods. The latest search date was November 2021. Selection criteria We included RCTs in people with a history of non‐response to one or more antidepressant monotherapies comparing brexpiprazole as monotherapy or adjunct treatment with placebo or other antidepressive agents. Data collection and analysis We used standard Cochrane methods. Primary outcomes were 1. response to treatment, measured as number of participants who achieved 50% or more reduction of the score on a validated scale for depression, 2. dropouts due to any reason, and 3. dropouts due to adverse effects, all measured at eight weeks (acute treatment). Our secondary outcomes were 4. number of participants who responded to treatment after two and 18 weeks, number of participants who achieved remission after eight weeks, 5. total number of participants with any adverse events, 6. social functioning or adjustment, and 7. health‐related quality of life. We used GRADE to assess certainty of evidence for each outcome. Main results We retrieved nine studies with 3424 participants with treatment‐resistant depression, defined as lack of response to at least two trials of antidepressant monotherapy. The age of participants was 18 to 65 years in seven studies, 18 to 75 years in one study, and older than 65 years in one study. Inclusion criteria for all studies required a diagnosis of MDD with a current major depressive episode per Diagnostic and Statistical Manual of Mental Disorders Text Revision Fourth Edition criteria and additional criteria on minimal scores on Montgomery–Åsberg Depression Rating Scale (MADRS) and Hamilton Depression Rating Scale which varied across studies. Eight studies compared brexpiprazole as adjunctive treatment to an antidepressant versus placebo as adjunctive treatment to an antidepressant. One study added brexpiprazole or placebo to a combination of antidepressant and ketamine. Four studies used fixed dosages and five studies used flexible dosages of brexpiprazole. The manufacturer sponsored eight studies and one study was independently funded. Brexpiprazole was superior in achieving response at eight weeks (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.23 to 1.75; 8 studies, 3409 participants; high‐certainty evidence). More participants randomised to brexpiprazole dropped out due to any cause at eight weeks (OR 1.37, 95% CI 1.02 to 1.83; 7 studies, 2523 participants; high‐certainty evidence) or due to adverse effects (OR 2.88, 95% CI 1.37 to 6.05; 6 studies, 2472 participants; high‐certainty evidence). Brexpiprazole was superior to placebo when added to an antidepressant for achieving remission at eight weeks (OR 1.46, 95% CI 1.19 to 1.79; 7 studies, 3358 participants; high‐certainty evidence). When response was defined based on a change in the score on MADRS, brexpiprazole also demonstrated better efficacy than placebo (mean difference (MD) –1.39, 95% CI –1.96 to –0.82; 8 studies, 3263 participants; high‐certainty evidence). Compared to placebo, add‐on brexpiprazole is probably more likely to result in akathisia (OR 2.95, 95% CI 2.06 to 4.21; 7 studies, 3358 participants; moderate‐certainty evidence) and weight gain (OR 3.14, 95% CI 2.19 to 4.49; 9 studies, 3424 participants; moderate‐certainty evidence). The risk of bias varied between low and unclear for most studies. Only one study was at high risk of selective reporting bias and other bias; however, this study had a small sample size and its impact on overall risk of bias was not considered significant. The certainty of the evidence on five of the main outcomes (response to treatment, measured as number of participants who achieved response and change in depressive symptoms, remission, dropouts due to any cause, dropouts due to adverse effects) was high. The certainty of evidence for akathisia and weight gain was downgraded one level to moderate due to indirectness. Authors' conclusions Our review supports the superior efficacy of add‐on brexpiprazole in comparison to placebo in adults with treatment‐resistant depression for the short‐term and acute treatment of depression. Our findings were limited by the small number of studies and the moderate‐certainty evidence for the most common adverse effects (akathisia and weight gain). There was insufficient evidence for the effects of brexpiprazole for depression in older people or children. In addition, we found no studies that compared brexpiprazole to other antidepressants or where brexpiprazole was added after lack of response to only one antidepressant. We also lacked sufficient data to establish the long‐term efficacy of brexpiprazole as adjunctive treatment. Active comparators, long‐term studies in different age groups and cost‐effect analyses are needed to more precisely establish the clinical role of brexpiprazole in the treatment of MDD. Plain language summary What are the benefits and harms of brexpiprazole, a new antipsychotic medication, for the treatment of depression when compared to dummy tablets or antidepressants? Key messages – Brexpiprazole added to an antidepressant is better at reducing the symptoms of depression than placebo (dummy tablet) added to an antidepressant. – Brexpiprazole might be more commonly associated with weight gain and akathisia (a feeling of restlessness that causes a compelling need to move all the time). What is depression? Depression is a common mental health condition which leads to low mood, inability to experience pleasure, sleep disruption, weight loss, fatigue or low energy, slower speech and movements, feeling worthless or excessively guilty, being unable to concentrate and having thoughts of committing suicide. To be diagnosed with depression, a person should experience five or more of these symptoms, including low mood or loss of sense of pleasure for at least two weeks. How is the condition treated? Unless the symptoms of depression are mild, the first option for treatment is an antidepressant medication, but antidepressants only help in half of cases when prescribed for the first time. When an antidepressant is not enough to treat depression, one available option is to add another medication to help the effects of the antidepressant. Other options include changing the antidepressant to another antidepressant, talking therapy or stimulation of the brain through electrical pulses. Brexpiprazole is a new medication which can be added to an antidepressant that has not worked by itself. Brexpiprazole can be prescribed in doses from 0.5 mg to 3 mg for the treatment of depression. It has also been approved for the treatment of schizophrenia. What did we want to find out? We wanted to examine the effects of brexpiprazole in the treatment of depression when prescribed by itself or when added to another antidepressant and how its effects compare to the effects of antidepressants or placebo. To do so we explored several effects. First, we looked into how well brexpiprazole decreased the symptoms of depression. Second, we explored how many participants gave up taking part in the studies for any reason. Third, we investigated how many stopped participating because of the unwanted effects they experienced. Fourth, we explored what unwanted effects emerged with the use of brexpiprazole. We also wanted to know how brexpiprazole affected the quality of life of the participants and how it affected the way they functioned in their everyday lives. What did we do? We searched scientific databases for studies that reported the effects of brexpiprazole versus placebo or antidepressants for depression. We included only studies in which the participants were assigned randomly to one or the other treatment. Neither them nor the team that was evaluating the effects of the treatment knew what was prescribed and this helped to objectively evaluate the results without the knowledge of what was prescribed impacting on the outcome. We compared and summarised the results and evaluated how confident we were that the results of the studies represented the real effects of the medication. We based our confidence on different factors such as the size of the effects, the methods used, and what and how the results were reported. What did we find and what were the limitations of our findings? We found nine studies, which included 3424 participants; two‐thirds of them were women and one‐third were men. We only found studies in which brexpiprazole was added after the participants had tried treatment with two or more antidepressants on their own. We have a high level of confidence that brexpiprazole added to an antidepressant reduced the symptoms of depression more after eight weeks of treatment than placebo added to an antidepressant. Brexpiprazole was also more likely to lead to no symptoms of depression than placebo when either of them was added to an antidepressant. We are moderately confident that brexpiprazole caused weight gain or subjective feelings of restlessness more often than placebo. We are less confident about the results around these unwanted effects as we could not find information about how they were measured and whether all studies used the same methods to measure them. What did we fail to find? We found no studies that explored how brexpiprazole would work for children or older people who have depression. We wanted to find how brexpiprazole would work when given for depression for longer periods of time, such as 18 to 24 weeks, but we found only one study and its results were not enough to draw a conclusion. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 1 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ralovska, S, Koychev, I, Marinov, P, Furukawa, TA, Mulsant, B, Cipriani, A", "articleTypes": [], "doi": "10.1002/14651858.CD013866.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.790Z" }, { "id": "89a00aee-de66-41d7-8932-8b1599c3ac10", "pmid": "", "title": "Preventive lipid‐based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes", "imported": false, "abstract": "Abstract - Background One nutritional intervention advocated to prevent malnutrition among children is lipid‐based nutrient supplements (LNS). LNS provide a range of vitamins and minerals, but unlike most other micronutrient supplements, LNS also provide energy, protein and essential fatty acids. Alternative recipes and formulations to LNS include fortified blended foods (FBF), which are foods fortified with vitamins and minerals, and micronutrient powders (MNP), which are a combination of vitamins and minerals, Objectives To assess the effects and safety of preventive LNS given with complementary foods on health, nutrition and developmental outcomes of non‐hospitalised infants and children six to 23 months of age, and whether or not they are more effective than other foods (including FBF or MNP). This review did not assess the effects of LNS as supplementary foods or therapeutic foods in the management of moderate and severe acute malnutrition. Search methods In October 2018, we searched CENTRAL, MEDLINE, Embase, 21 other databases and two trials registers for relevant studies. We also checked the reference lists of included studies and relevant reviews and contacted the authors of studies and other experts in the area for any ongoing and unpublished studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs that evaluated the impact of LNS plus complementary foods given at point‐of‐use (for any dose, frequency, duration) to non‐hospitalised infants and young children aged six to 23 months in stable or emergency settings and compared to no intervention, other supplementary foods (i.e. FBF), nutrition counselling or multiple micronutrient supplements or powders for point‐of‐use fortification of complementary foods. Data collection and analysis Two review authors independently screened studies for relevance and, for those studies included in the review, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software. We used a random‐effects meta‐analysis for combining data as the interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables,. Main results Our search identified a total of 8124 records, from which we included 17 studies (54 papers) with 23,200 children in the review. The included studies reported on one or more of the pre‐specified primary outcomes, and five studies included multiple comparison groups. Overall, the majority of trials were at low risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias, but at high risk of bias for blinding of participants and personnel due to the nature of the intervention. Using the GRADE approach, we judged the quality of the evidence for most outcomes as low or moderate. LNS+complementary feeding compared with no intervention Thirteen studies compared LNS plus complementary feeding with no intervention. LNS plus complementary feeding reduced the prevalence of moderate stunting by 7% (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.88 to 0.98; nine studies, 13,372 participants; moderate‐quality evidence), severe stunting by 15% (RR 0.85, 95% CI 0.74 to 0.98; five studies, 6151 participants; moderate‐quality evidence), moderate wasting by 18% (RR 0.82, 95% CI 0.74 to 0.91; eight studies; 13,172 participants; moderate‐quality evidence), moderate underweight by 15% (RR 0.85, 95% CI 0.80 to 0.91; eight studies, 13,073 participants; moderate‐quality evidence), and anaemia by 21% (RR 0.79, 95% CI 0.69 to 0.90; five studies, 2332 participants; low‐quality evidence). There was no impact of LNS plus complementary feeding on severe wasting (RR 1.27, 95% CI 0.66 to 2.46; three studies, 2329 participants) and severe underweight (RR 0.78, 95%CI 0.54 to 1.13; two studies, 1729 participants). Adverse effects did not differ between the groups (RR 0.86, 95% CI 0.74 to 1.01; three studies, 3382 participants). LNS+complementary feeding compared with FBF Five studies compared LNS plus complementary feeding with other FBF, including corn soy blend and UNIMIX. We pooled four of the five studies in meta‐analyses and found that, when compared to other FBF, LNS plus complementary feeding significantly reduced the prevalence of moderate stunting (RR 0.89, 95% CI 0.82 to 0.97; three studies, 2828 participants; moderate‐quality evidence), moderate wasting (RR 0.79, 95% CI 0.65 to 0.97; two studies, 2290 participants; moderate‐quality evidence), and moderate underweight (RR 0.81, 95% CI 0.73 to 0.91; two studies, 2280 participants; moderate‐quality evidence). We found no difference between LNS plus complementary feeding and FBF for severe stunting (RR 0.41, 95% CI 0.12 to 1.42; two studies, 729 participants; low‐quality evidence), severe wasting (RR 0.64, 95% CI 0.19 to 2.81; two studies, 735 participants; moderate‐quality evidence), and severe underweight (RR 1.23, 95% CI 0.67 to 2.25; one study, 173 participants; low‐quality evidence). LNS+complementary feeding compared with MNP Four studies compared LNS plus complementary feeding with MNP. We pooled data from three of the four studies in meta‐analyses and found that compared to MNP, LNS plus complementary feeding significantly reduced the prevalence of moderate underweight (RR 0.88, 95% CI 0.78 to 0.99; two studies, 2004 participants; moderate‐quality evidence) and anaemia (RR 0.38, 95% CI 0.21 to 0.68; two studies, 557 participants; low‐quality evidence). There was no difference between LNS plus complementary feeding and MNP for moderate stunting (RR 0.92, 95% CI 0.82 to 1.02; three studies, 2365 participants) and moderate wasting (RR 0.97, 95% CI 0.77 to 1.23; two studies, 2004 participants). Authors' conclusions The findings of this review suggest that LNS plus complementary feeding compared to no intervention is effective at improving growth outcomes and anaemia without adverse effects among children aged six to 23 months in low‐ and middle‐income countries (LMIC) in Asia and Africa, and more effective if provided over a longer duration of time (over 12 months). Limited evidence also suggests that LNS plus complementary feeding is more effective than FBF and MNP at improving growth outcomes. Plain language summary Effect of lipid‐based nutrient supplementation on infants and young children Review question What is the impact of lipid‐based nutrient supplements (LNS) plus complementary foods on health, nutrition and developmental outcomes among infants and young children? Background LNS are food products which contain energy, minerals and vitamins that can improve growth in children. LNS provide vitamins, minerals and energy in the form of protein and essential fatty acids. We sought to assess the effect of LNS given jointly with complementary feeding, compared to no intervention, micronutrient powders (MNP; a mixture of vitamins and minerals that is sprinkled onto food) and other fortified blended food (FBF) products in healthy children. Study characteristics This review includes 17 studies (from 54 reports) with 23,200 children. Four of the included studies were conducted in Malawi, three in Bangladesh, two in Ghana and one each in Burkina Faso, Haiti, Honduras, Chad, Congo, Kenya, Niger, Peru, Guatemala, and Indonesia. Four included studies enrolled pregnant women and provided LNS plus complementary feeding during pregnancy and post‐partum, followed by infant supplementation starting at six months of age. The other studies provided LNS plus complementary feeding to children after six months of age. None of the included studies were conducted in emergency settings. Key results Findings of this review suggest that LNS plus complementary feeding is probably an effective intervention for improving growth outcomes and reducing the occurrence of children who are of short stature for their age (stunting), have low weight for their age (moderate underweight), have low weight for their height (moderate wasting) and anaemia. Additionally, LNS plus complementary feeding probably improves height and weight for age as well as mid‐upper arm circumference without adverse effects among children aged six to 23 months. The intervention seems to be more effective if provided for a duration longer than 12 months. Evidence also suggests that LNS plus complementary probably reduces moderate stunting, moderate wasting and moderate underweight, compared to other FBF. Furthermore, LNS plus complementary feeding is probably more effective than MNP at reducing moderate underweight and improving height and weight. Quality of evidence Overall, we considered most studies to be at high risk of bias for blinding of participants and personnel due to the nature of intervention. We rated the quality of the evidence for most outcomes as either low or moderate. Currentness of evidence The evidence is current to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Das, JK, Salam, RA, Hadi, YB, Sadiq Sheikh, S, Bhutta, AZ, Weise Prinzo, Z, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD012611.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.127Z" }, { "id": "89a2b87a-4ced-401c-928f-eb8bde46d3f2", "pmid": "", "title": "Donepezil for dementia due to Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Alzheimer's disease is the most common cause of dementia in older people. One approach to symptomatic treatment of Alzheimer's disease is to enhance cholinergic neurotransmission in the brain by blocking the action of the enzyme responsible for the breakdown of the neurotransmitter acetylcholine. This can be done by a group of drugs known as cholinesterase inhibitors. Donepezil is a cholinesterase inhibitor. This review is an updated version of a review first published in 1998. Objectives To assess the clinical efficacy and safety of donepezil in people with mild, moderate or severe dementia due to Alzheimer's disease; to compare the efficacy and safety of different doses of donepezil; and to assess the effect of donepezil on healthcare resource use and costs. Search methods We searched Cochrane Dementia and Cognitive Improvement’s Specialized Register, MEDLINE, Embase, PsycINFO and a number of other sources on 20 May 2017 to ensure that the search was as comprehensive and up‐to‐date as possible. In addition, we contacted members of the Donepezil Study Group and Eisai Inc. Selection criteria We included all double‐blind, randomised controlled trials in which treatment with donepezil was administered to people with mild, moderate or severe dementia due to Alzheimer's disease for 12 weeks or more and its effects compared with those of placebo in a parallel group of patients, or where two different doses of donepezil were compared. Data collection and analysis One reviewer (JSB) extracted data on cognitive function, activities of daily living, behavioural symptoms, global clinical state, quality of life, adverse events, deaths and healthcare resource costs. Where appropriate and possible, we estimated pooled treatment effects. We used GRADE methods to assess the quality of the evidence for each outcome. Main results Thirty studies involving 8257 participants met the inclusion criteria of the review, of which 28 studies reported results in sufficient detail for the meta‐analyses. Most studies were of six months' duration or less. Only one small trial lasted 52 weeks. The studies tested mainly donepezil capsules at a dose of 5 mg/day or 10 mg/day. Two studies tested a slow‐release oral formulation that delivered 23 mg/day. Participants in 21 studies had mild to moderate disease, in five studies moderate to severe, and in four severe disease. Seventeen studies were industry funded or sponsored, four studies were funded independently of industry and for nine studies there was no information on source of funding. Our main analysis compared the safety and efficacy of donepezil 10 mg/day with placebo at 24 to 26 weeks of treatment. Thirteen studies contributed data from 3396 participants to this analysis. Eleven of these studies were multicentre studies. Seven studies recruited patients with mild to moderate Alzheimer's disease, two with moderate to severe, and four with severe Alzheimer's disease, with a mean age of about 75 years. Almost all evidence was of moderate quality, downgraded due to study limitations. After 26 weeks of treatment, donepezil compared with placebo was associated with better outcomes for cognitive function measured with the Alzheimer's Disease Assessment Scale‐Cognitive (ADAS‐Cog, range 0 to 70) (mean difference (MD) ‐2.67, 95% confidence interval (CI) ‐3.31 to ‐2.02, 1130 participants, 5 studies), the Mini‐Mental State Examination (MMSE) score (MD 1.05, 95% CI 0.73 to 1.37, 1757 participants, 7 studies) and the Severe Impairment Battery (SIB, range 0 to 100) (MD 5.92, 95% CI 4.53 to 7.31, 1348 participants, 5 studies). Donepezil was also associated with better function measured with the Alzheimer's Disease Cooperative Study activities of daily living score for severe Alzheimer's disease (ADCS‐ADL‐sev) (MD 1.03, 95% CI 0.21 to 1.85, 733 participants, 3 studies). A higher proportion of participants treated with donepezil experienced improvement on the clinician‐rated global impression of change scale (odds ratio (OR) 1.92, 95% CI 1.54 to 2.39, 1674 participants, 6 studies). There was no difference between donepezil and placebo for behavioural symptoms measured by the Neuropsychiatric Inventory (NPI) (MD ‐1.62, 95% CI ‐3.43 to 0.19, 1035 participants, 4 studies) or by the Behavioural Pathology in Alzheimer's Disease (BEHAVE‐AD) scale (MD 0.4, 95% CI ‐1.28 to 2.08, 194 participants, 1 study). There was also no difference between donepezil and placebo for Quality of Life (QoL) (MD ‐2.79, 95% CI ‐8.15 to 2.56, 815 participants, 2 studies). Participants receiving donepezil were more likely to withdraw from the studies before the end of treatment (24% versus 20%, OR 1.25, 95% CI 1.05 to 1.50, 2846 participants, 12 studies) or to experience an adverse event during the studies (72% vs 65%, OR 1.59, 95% 1.31 to 1.95, 2500 participants, 10 studies). There was no evidence of a difference between donepezil and placebo for patient total healthcare resource utilisation. Three studies compared donepezil 10 mg/day to donepezil 5 mg/day over 26 weeks. The 5 mg dose was associated with slightly worse cognitive function on the ADAS‐Cog, but not on the MMSE or SIB, with slightly better QoL and with fewer adverse events and withdrawals from treatment. Two studies compared donepezil 10 mg/day to donepezil 23 mg/day. There were no differences on efficacy outcomes, but fewer participants on 10 mg/day experienced adverse events or withdrew from treatment. Authors' conclusions There is moderate‐quality evidence that people with mild, moderate or severe dementia due to Alzheimer's disease treated for periods of 12 or 24 weeks with donepezil experience small benefits in cognitive function, activities of daily living and clinician‐rated global clinical state. There is some evidence that use of donepezil is neither more nor less expensive compared with placebo when assessing total healthcare resource costs. Benefits on 23 mg/day were no greater than on 10 mg/day, and benefits on the 10 mg/day dose were marginally larger than on the 5 mg/day dose, but the rates of withdrawal and of adverse events before end of treatment were higher the higher the dose. Plain language summary Donepezil for people with dementia due to Alzheimer's disease Review question What effects (benefits or harms) does donepezil have on people with dementia due to Alzheimer's disease? Background Alzheimer's disease is the most common cause of dementia. As the disease progresses, people lose the ability to remember, communicate, think clearly and perform the activities of daily living. Their behaviour may also change. In severe Alzheimer's disease people lose the ability to care for themselves. The most commonly used treatment for Alzheimer's disease are medicines known as acetylcholinesterase inhibitors. Donepezil is one of these medicines. It is taken as a pill once a day. In Alzheimer's disease, one of the changes in the brain is a reduced number of nerve cells called cholinergic neurones. These are nerve cells that signal to other cells using a chemical called acetylcholine. Acetylcholinesterase inhibitors, such as donepezil, work by preventing acetylcholine from being broken down. This may improve the symptoms of dementia. However, acetylcholine is also found elsewhere in the body and so drugs of this type may have unwanted effects. Review methods In this review we examined evidence about benefits and harms from studies that compared donepezil, taken for at least 12 weeks, to placebo (a dummy pill), or that compared different doses of donepezil. The studies had to be double‐blind and randomised, that is, the decision whether people taking part got donepezil or placebo had to be made randomly and neither they nor the researchers should have known which treatment they were getting while the trial was going on. This was to make the comparison as unbiased, or fair, as possible. We searched for studies up to May 2017. We assessed the quality of all the studies we included. When it was sensible to do so, we analysed the results of studies together to get an overall result. Key results We included 30 studies with 8257 participants. Most of the people in the studies had mild or moderate dementia due to Alzheimer's disease, but in nine studies they had moderate or severe dementia. Almost all of the studies lasted six months or less. The majority of the studies were known to have been funded by the manufacturer of donepezil. We found that people with Alzheimer's disease who took 10 mg of donepezil a day for six months did slightly better than people taking placebo, on scales measuring their cognitive function (e.g. thinking and remembering), how well they could manage their daily activities, and the overall impression of a trained researcher. We did not find any effect on behaviour or quality of life. People taking donepezil were more likely than those taking placebo to report side effects and to drop out of the studies. Most side effects were described as mild. Nausea, vomiting and diarrhoea were most common. Comparing 5 mg of donepezil a day with 10 mg/day, people on 5 mg had fewer side effects, but did slightly less well on cognitive function tests. A higher dose (23 mg/day) offered no advantages and was associated with more side effects. There is some evidence that use of donepezil is neither more nor less expensive than placebo when total health care costs are taken into account. Quality of the evidence In general, we thought that the quality of the evidence was moderate. The main factor reducing our confidence was concern that the results of some studies might have been biased by the way they were done. We cannot be sure that the results apply to treatment longer than six months. Conclusions After six months of treatment, there are benefits of donepezil that are large enough to measure in studies. It is associated with side effects that are mainly mild, but that may cause people to stop treatment. Being able to stabilise cognitive performance or ability to maintain activities of daily living may be important clinically. In terms of total healthcare costs the use of donepezil appears cost neutral. However, there does not appear to be an effect on quality of life. More data are still required from longer‐term clinical studies examining measures of disease progression or time to needing full time care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Birks, JS, Harvey, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD001190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.760Z" }, { "id": "89a7c368-2524-43bd-bcaf-da2bfd7d4db2", "pmid": "", "title": "The effect of sample site and collection procedure on identification of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Sample collection is a key driver of accuracy in the diagnosis of SARS‐CoV‐2 infection. Viral load may vary at different anatomical sampling sites and accuracy may be compromised by difficulties obtaining specimens and the expertise of the person taking the sample. It is important to optimise sampling accuracy within cost, safety and accessibility constraints. Objectives To compare the sensitivity of different sampling collection sites and methods for the detection of current SARS‐CoV‐2 infection with any molecular or antigen‐based test. Search methods Electronic searches of the Cochrane COVID‐19 Study Register and the COVID‐19 Living Evidence Database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) were undertaken on 22 February 2022. We included independent evaluations from national reference laboratories, FIND and the Diagnostics Global Health website. We did not apply language restrictions. Selection criteria We included studies of symptomatic or asymptomatic people with suspected SARS‐CoV‐2 infection undergoing testing. We included studies of any design that compared results from different sample types (anatomical location, operator, collection device) collected from the same participant within a 24‐hour period. Data collection and analysis Within a sample pair, we defined a reference sample and an index sample collected from the same participant within the same clinical encounter (within 24 hours). Where the sample comparison was different anatomical sites, the reference standard was defined as a nasopharyngeal or combined naso/oropharyngeal sample collected into the same sample container and the index sample as the alternative anatomical site. Where the sample comparison was concerned with differences in the sample collection method from the same site, we defined the reference sample as that closest to standard practice for that sample type. Where the sample pair comparison was concerned with differences in personnel collecting the sample, the more skilled or experienced operator was considered the reference sample. Two review authors independently assessed the risk of bias and applicability concerns using the QUADAS‐2 and QUADAS‐C checklists, tailored to this review. We present estimates of the difference in the sensitivity (reference sample (%) minus index sample sensitivity (%)) in a pair and as an average across studies for each index sampling method using forest plots and tables. We examined heterogeneity between studies according to population (age, symptom status) and index sample (time post‐symptom onset, operator expertise, use of transport medium) characteristics. Main results This review includes 106 studies reporting 154 evaluations and 60,523 sample pair comparisons, of which 11,045 had SARS‐CoV‐2 infection. Ninety evaluations were of saliva samples, 37 nasal, seven oropharyngeal, six gargle, six oral and four combined nasal/oropharyngeal samples. Four evaluations were of the effect of operator expertise on the accuracy of three different sample types. The majority of included evaluations (146) used molecular tests, of which 140 used RT‐PCR (reverse transcription polymerase chain reaction). Eight evaluations were of nasal samples used with Ag‐RDTs (rapid antigen tests). The majority of studies were conducted in Europe (35/106, 33%) or the USA (27%) and conducted in dedicated COVID‐19 testing clinics or in ambulatory hospital settings (53%). Targeted screening or contact tracing accounted for only 4% of evaluations. Where reported, the majority of evaluations were of adults (91/154, 59%), 28 (18%) were in mixed populations with only seven (4%) in children. The median prevalence of confirmed SARS‐CoV‐2 was 23% (interquartile (IQR) 13%‐40%). Risk of bias and applicability assessment were hampered by poor reporting in 77% and 65% of included studies, respectively. Risk of bias was low across all domains in only 3% of evaluations due to inappropriate inclusion or exclusion criteria, unclear recruitment, lack of blinding, nonrandomised sampling order or differences in testing kit within a sample pair. Sixty‐eight percent of evaluation cohorts were judged as being at high or unclear applicability concern either due to inflation of the prevalence of SARS‐CoV‐2 infection in study populations by selectively including individuals with confirmed PCR‐positive samples or because there was insufficient detail to allow replication of sample collection. When used with RT‐PCR • There was no evidence of a difference in sensitivity between gargle and nasopharyngeal samples (on average ‐1 percentage points, 95% CI ‐5 to +2, based on 6 evaluations, 2138 sample pairs, of which 389 had SARS‐CoV‐2). • There was no evidence of a difference in sensitivity between saliva collection from the deep throat and nasopharyngeal samples (on average +10 percentage points, 95% CI ‐1 to +21, based on 2192 sample pairs, of which 730 had SARS‐CoV‐2). • There was evidence that saliva collection using spitting, drooling or salivating was on average ‐12 percentage points less sensitive (95% CI ‐16 to ‐8, based on 27,253 sample pairs, of which 4636 had SARS‐CoV‐2) compared to nasopharyngeal samples. We did not find any evidence of a difference in the sensitivity of saliva collected using spitting, drooling or salivating (sensitivity difference: range from ‐13 percentage points (spit) to –21 percentage points (salivate)). • Nasal samples (anterior and mid‐turbinate collection combined) were, on average, 12 percentage points less sensitive compared to nasopharyngeal samples (95% CI ‐17 to ‐7), based on 9291 sample pairs, of which 1485 had SARS‐CoV‐2. We did not find any evidence of a difference in sensitivity between nasal samples collected from the mid‐turbinates (3942 sample pairs) or from the anterior nares (8272 sample pairs). • There was evidence that oropharyngeal samples were, on average, 17 percentage points less sensitive than nasopharyngeal samples (95% CI ‐29 to ‐5), based on seven evaluations, 2522 sample pairs, of which 511 had SARS‐CoV‐2. A much smaller volume of evidence was available for combined nasal/oropharyngeal samples and oral samples. Age, symptom status and use of transport media do not appear to affect the sensitivity of saliva samples and nasal samples. When used with Ag‐RDTs • There was no evidence of a difference in sensitivity between nasal samples compared to nasopharyngeal samples (sensitivity, on average, 0 percentage points ‐0.2 to +0.2, based on 3688 sample pairs, of which 535 had SARS‐CoV‐2). Authors' conclusions When used with RT‐PCR, there is no evidence for a difference in sensitivity of self‐collected gargle or deep‐throat saliva samples compared to nasopharyngeal samples collected by healthcare workers when used with RT‐PCR. Use of these alternative, self‐collected sample types has the potential to reduce cost and discomfort and improve the safety of sampling by reducing risk of transmission from aerosol spread which occurs as a result of coughing and gagging during the nasopharyngeal or oropharyngeal sample collection procedure. This may, in turn, improve access to and uptake of testing. Other types of saliva, nasal, oral and oropharyngeal samples are, on average, less sensitive compared to healthcare worker‐collected nasopharyngeal samples, and it is unlikely that sensitivities of this magnitude would be acceptable for confirmation of SARS‐CoV‐2 infection with RT‐PCR. When used with Ag‐RDTs, there is no evidence of a difference in sensitivity between nasal samples and healthcare worker‐collected nasopharyngeal samples for detecting SARS‐CoV‐2. The implications of this for self‐testing are unclear as evaluations did not report whether nasal samples were self‐collected or collected by healthcare workers. Further research is needed in asymptomatic individuals, children and in Ag‐RDTs, and to investigate the effect of operator expertise on accuracy. Quality assessment of the evidence base underpinning these conclusions was restricted by poor reporting. There is a need for further high‐quality studies, adhering to reporting standards for test accuracy studies. Plain language summary How accurate are different types of sample collection for diagnosing COVID‐19 infection? Key messages • When used with RT‐PCR tests (a molecular test that detects genetic material in COVID‐19 using a technique called reverse transcription polymerase chain reaction), self‐collected gargle and deep throat saliva samples have a similar sensitivity compared to trained healthcare worker‐collected nasopharyngeal samples (taken from the back of the throat through the nose) in detecting COVID‐19. • When used with RT‐PCR, samples collected from the nose, oropharynx (throat via the mouth), oral cavity, and other saliva collection methods are less sensitive for detecting COVID‐19 compared to healthcare worker‐collected nasopharyngeal samples. • When used with rapid antigen tests (Ag‐RDTs; at‐home/self‐tests), samples collected from the nose have a similar sensitivity to healthcare worker‐collected nasopharyngeal samples in detecting COVID‐19. Why is improving the diagnosis of COVID‐19 important? Coronavirus disease (COVID‐19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). People with suspected COVID‐19 may decide to take a test to know whether they are infected, so that they can receive treatment, and follow recommended guidance to self‐isolate and inform close contacts. Not detecting COVID‐19 when it is present (a false negative result) risks spreading infection and results in missed opportunities for treatment. Types of sample collection methods for diagnosing COVID‐19? The type and quality of sample taken for confirmation of COVID‐19 affects the reliability of diagnosis. The most accurate type of sample to diagnose COVID‐19 is that taken by a trained healthcare worker from the back of the throat through the nose (a nasopharyngeal sample). This type of test detects genetic material in the virus using a technique called reverse transcription polymerase chain reaction (RT‐PCR). However, this sample is difficult to obtain correctly, causes discomfort and risks spreading infection if individuals cough or sneeze when the sample is taken. Alternative sample types, particularly those that can be self‐collected using rapid antigen tests (Ag‐RDTs; i.e. self‐tests), may reduce cost and discomfort and improve the safety of sampling. This may, in turn, improve access to and uptake of testing. What did we want to find out? We wanted to compare the sensitivity of different sample sites and collection methods in detecting COVID‐19 with molecular tests (RT‐PCR tests) or self‐based tests (Ag‐RDT tests). What did we do? We searched for studies that had compared the accuracy of nasopharyngeal samples to any alternative that could be used in patients outside of hospital, including nose (nasal) samples, throat samples taken through the mouth (oropharyngeal), gargle samples and saliva samples. We looked at the use of samples with either RT‐PCR or Ag‐RDTs. We also searched for studies that had compared different methods for taking samples, such as samples collected by a healthcare worker compared to those collected by individuals with no or minimal instructions. What did we find? The review included 106 studies with a total of 60,523 participants, of whom 11,045 had COVID‐19 infection. Fifty‐nine per cent of studies were conducted on adults and 79% on symptomatic or mixed symptomatic and asymptomatic participants. Sixty per cent of studies took place in Europe or the USA; just over half (55%) took place in dedicated COVID‐19 testing centres or in outpatient settings. Main results With RT‐PCR, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also test positive on self‐collected gargle samples or saliva samples (collected by coughing and then spitting (deep throat saliva)); ‐ 88% of positive nasopharyngeal samples collected by healthcare workers would also test positive with self‐ or healthcare worker‐collected nose samples; ‐ 87% of positive nasopharyngeal samples collected by healthcare workers would also be detected by saliva self‐collected using spitting, 84% by saliva self‐collected using drooling and 79% by saliva self‐collected by sucking on a swab; and ‐ 83% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐ or healthcare worker‐collected oropharyngeal samples. With Ag‐RDTs, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐collected or healthcare worker‐collected nose samples. Summary results The results of these studies indicate that in a group of 1000 people, of whom 230 (23%) have COVID‐19, then: when used with PCR, compared to healthcare worker‐collected nasopharyngeal samples: ‐ no cases of COVID‐19 would be missed using self‐collected gargle samples (12 less to 5 more) or deep throat saliva samples (2 less to 48 more); ‐ 28 (16 to 39) fewer cases of COVID‐19 infection would be detected using healthcare worker‐ or self‐collected nose sample; ‐ 30 (18 to 41) fewer cases of COVID‐19 infection would be detected by saliva self‐collected using spitting, 37 (12 to 62) fewer by saliva collected by drooling and 48 (12 to 85) fewer by saliva collected by sucking on a swab; ‐ 39 (12 to 67) fewer cases of COVID‐19 infection would be detected by healthcare worker‐ or self‐collected oropharyngeal samples; and when used with Ag‐RDTs, compared to healthcare worker‐collected nasopharyngeal samples: no cases of COVID‐19 infection would be missed using healthcare worker‐ or self‐collected nose samples. What are the limitations of the evidence? It was often not clear whether included studies deliberately excluded inadequate samples or whether the results of the more accurate nasopharyngeal sample were known when alternative samples were interpreted. This may have resulted in alternative sample types appearing more accurate than they are in practice, decreasing the number of missed cases of COVID‐19 infection. More than half of studies did not give information about how long participants had had symptoms at the time of sampling. This reduces our confidence in the comparison of different sample types. Most studies evaluated self‐collected samples by adults with symptoms for use with RT‐PCR; therefore, the findings of this review may not be applicable to asymptomatic individuals or children. For studies conducted with Ag‐RDTs, it is unclear whether sensitivity estimates of nose samples are applicable to home use (self‐collected and self‐interpreted). How up to date is this review? The evidence is current to 22 February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Davenport, C; Arevalo-Rodriguez, I; Mateos-Haro, M; Berhane, S; Dinnes, J; Spijker, R; Buitrago-Garcia, D; Ciapponi, A; Takwoingi, Y; Deeks, JJ; Emperador, D; Leeflang, MM. G.; Van den Bruel, A", "articleTypes": [], "doi": "10.1002/14651858.CD014780", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "89aa0b6b-34bd-4a95-b19f-939e3cb46aa4", "pmid": "", "title": "Altered dietary salt for preventing pre‐eclampsia, and its complications", "imported": false, "abstract": "Abstract - Background In the past, women have been advised that lowering their salt intake might reduce their risk of developing pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of altered dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of altered dietary salt during pregnancy on the risk of developing pre‐eclampsia and its complications. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (8 April 2005), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2005), and EMBASE (2002 to May 2005). We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 1 October 2009 and added the results to the awaiting classification section. Selection criteria Randomised trials evaluating either reduced or increased dietary salt intake during pregnancy. Data collection and analysis Two review authors selected trials for inclusion and extracted data independently. Data were entered on Review Manager software for analysis, and double‐checked for accuracy. Main results Two trials were included, with 603 women. Both compared advice to reduce dietary salt intake with advice to continue a normal diet. The confidence intervals were wide and crossed the no‐effect line for all the reported outcomes, including pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). In other words, there was insufficient evidence for reliable conclusions about the effects of advice to reduce dietary salt. Authors' conclusions In the absence of evidence that advice to alter salt intake during pregnancy has any beneficial effect for prevention of pre‐eclampsia or any other outcome, salt consumption during pregnancy should remain a matter of personal preference. [Note: The citation in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Altered dietary salt for preventing pre‐eclampsia, and its complications Low salt intake in pregnancy is unlikely to prevent pre‐eclampsia. Pre‐eclampsia is a serious complication of pregnancy associated with poor health, or even death, for the mother and baby. Pre‐eclampsia is identified by raised blood pressure and protein in the urine during the second half of pregnancy. In the past, a low‐salt diet was often recommended, in the belief that it would help to prevent pre‐eclampsia. However, the review found just two trials that did not show any evidence of benefit for the mother or baby. Salt intake in pregnancy should be a matter of personal preference.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Duley, L; Henderson‐Smart, DJ; Meher, S", "articleTypes": [], "doi": "10.1002/14651858.CD005548", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "89ab8d7e-a568-45e9-9260-1f4039f0e7b9", "pmid": "", "title": "Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Subcutaneous administration may be preferable to oral for individuals experiencing nausea and/or vomiting Objectives To determine the efficacy and tolerability of subcutaneous sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using subcutaneous sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Thirty‐five studies (9365 participants) compared subcutaneous sumatriptan with placebo or an active comparator. Most of the data were for the 6 mg dose. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 6 mg versus placebo the NNTs were 2.9, 2.3, 2.2, and 2.1 for pain‐free at one and two hours, and headache relief at one and two hours, respectively, and 6.1 for sustained pain‐free at 24 hours. Results for the 4 mg and 8 mg doses were similar to the 6 mg dose, with 6 mg significantly better than 4 mg only for pain‐free at one hour, and 8 mg significantly better than 6 mg only for headache relief at one hour. There was no evidence of increased migraine relief if a second dose of sumatriptan 6 mg was given after an inadequate response to the first. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Sumatriptan was compared directly with a number of active treatments, including other triptans, acetylsalicylic acid plus metoclopramide, and dihydroergotamine, but there were insufficient data for any pooled analyses. Authors' conclusions Subcutaneous sumatriptan is effective as an abortive treatment for acute migraine attacks, quickly relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a subcutaneous injection, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, or needing fast relief. This review found that a single subcutaneous dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in almost 6 in 10 people (59%) taking sumatriptan 6 mg, compared with about 1 in 7 (15%) taking placebo, and reduced from moderate or severe to no worse than mild pain by two hours in almost 8 in 10 people (79%) taking sumatriptan compared with about 3 in 10 (31%) taking placebo. Subcutaneous sumatriptan was fast‐acting, and the majority of people experiencing pain relief had done so by one hour. About 3 in 10 (31%) people had freedom from pain at two hours which was sustained during the 24 hours postdose without the use of rescue medication, compared with about 1 in 7 (15%) with placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events, most of which were of short duration and mild or moderate in severity, were more frequent with sumatriptan than with placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009665", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "89b86172-541d-419d-8a62-1efaed5f8dc7", "pmid": "", "title": "Community‐based supplementary feeding for food insecure, vulnerable and malnourished populations – an overview of systematic reviews", "imported": false, "abstract": "Abstract - Background Supplementary feeding may help food insecure and vulnerable people by optimising the nutritional value and adequacy of the diet, improving quality of life and improving various health parameters of disadvantaged families. In low‐ and middle‐income countries (LMIC), the problems supplementary feeding aims to address are entangled with poverty and deprivation, the programmes are expensive and delivery is complicated. Objectives 1. To summarise the evidence from systematic reviews of supplementary feeding for food insecure, vulnerable and malnourished populations, including children under five years of age, school‐aged children, pregnant and lactating women, people with HIV or tuberculosis (or both), and older populations. 2. To describe and explore the effects of supplementary feeding given to people in these groups, and to describe the range of outcomes between reviews and range of effects in the different groups. Methods In January 2017, we searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase and nine other databases. We included systematic reviews evaluating community‐based supplementary feeding, and concerning food insecure, vulnerable and malnourished populations. Two review authors independently undertook selection of systematic reviews, data extraction and 'Risk of bias' assessment. We assessed review quality using the AMSTAR tool, and used GRADEpro 'Summary of findings' tables from each review to indicate the certainty of the evidence for the main comparisons. We summarised review findings in the text and reported the data for each outcome in additional tables. We also used forest plots to display results graphically. Main results This overview included eight systematic reviews (with last search dates between May 2006 and February 2016). Seven were Cochrane Reviews evaluating interventions in pregnant women; children (aged from birth to five years) from LMIC; disadvantaged infants and young children (aged three months to five years); children with moderate acute malnutrition (MAM); disadvantaged school children; adults and children who were HIV positive or with active tuberculosis (with or without HIV). One was a non‐Cochrane systematic review in older people with Alzheimer's disease. These reviews included 95 trials relevant to this overview, with the majority (74%) of participants from LMIC. The number of included participants varied between 91 and 7940 adults, and 271 and more than 12,595 children. Trials included a wide array of nutritional interventions that varied in duration, frequency and format, with micronutrients often reported as cointerventions. Follow‐up ranged from six weeks to two years; three trials investigated outcomes at four to 17 years of age. All reviews were rated as high quality (AMSTAR score between eight and 11). The GRADE certainty ratings ranged from very low to moderate for individual comparisons, with the evidence often comprising only one or two small trials, thereby resulting in many underpowered analyses (too small to detect small but important differences). The main outcome categories reported across reviews were death, anthropometry (adults and children) and other markers of nutritional status, disease‐related outcomes, neurocognitive development and psychosocial outcomes, and adverse events. Mortality data were limited and underpowered in meta‐analysis in all populations (children with MAM, in children with HIV, and in adults with tuberculosis) with the exception of balanced energy and protein supplementation in pregnancy, which may have reduced the risk of stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94; 5 trials, 3408 women). Supplementation in pregnancy also improved infant birth weight (mean difference (MD) 40.96 g, 95% CI 4.66 to 77.26; 11 trials, 5385 participants) and reduced risk of infants born small‐for‐gestational age (RR 0.79, 95% CI 0.69 to 0.90; 7 trials, 4408 participants). These effects did not translate into demonstrable long‐term benefits for children in terms of growth and neurocognitive development in the one to two trials reporting on longer‐term outcomes. In one study (505 participants), high‐protein supplementation was associated with increased risk of small‐for‐gestational age babies. Effects on growth in children were mixed. In children under five years of age from LMIC, one review found that supplementary feeding had a little or no effect on child growth; however, a more recent review in a similar population found that those who received food supplementation gained an average of 0.12 kg more in weight (MD 0.12 kg, 95% CI 0.05 to 0.18; 9 trials, 1057 participants) and 0.27 cm more in height (MD 0.27 cm, 95% CI 0.07 to 0.48; 9 trials, 1463 participants) than those who were not supplemented. Supplementary food was generally more effective for younger children (younger than two years of age) and for those who were poorer or less well‐nourished. In children with MAM, the provision of specially formulated food improved their weight, weight‐for‐height z scores and other key outcomes such as recovery rate (by 29%), as well as reducing the number of participants dropping out (by 70%). In LMIC, school meals seemed to lead to small benefits for children, including improvements in weight z scores, especially in children from lower‐income countries, height z scores, cognition or intelligence quotient tests, and maths and spelling performance. Supplementary feeding in adults who were HIV positive increased the daily energy and protein intake compared to nutritional counselling alone. Supplementation led to an initial improvement in weight gain or body mass index but did not seem to confer long‐term benefit. In adults with tuberculosis, one small trial found a significant benefit on treatment completion and sputum conversion rate. There were also significant but modest benefits in terms of weight gain (up to 2.60 kg) during active tuberculosis. The one study included in the Alzheimer's disease review found that three months of daily oral nutritional supplements improved nutritional outcomes in the intervention group. There was little or no evidence regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes. Authors' conclusions Considering the current evidence base included, supplementary food effects are modest at best, with inconsistent and limited mortality evidence. The trials reflected in the reviews mostly reported on short‐term outcomes and across the whole of the supplementation trial literature it appears important outcomes, such as quality of life and cost of programmes, are not systematically reported or summarised. Plain language summary Supplementary feeding for groups of people that are food insecure, vulnerable and malnourished What was the aim of this review? To summarise the effect of supplementary feeding on populations that were food insecure, vulnerable and malnourished. The overview authors found eight systematic reviews examining supplementary feeding in a variety of populations. Key messages Across a range of vulnerable populations, supplementary feeding programmes sometimes show modest benefit in nutritional outcomes. In a few studies examining mortality (death), effects were either small or absent, and research mostly looked at short‐term effects. What was studied in the review? Supplementary feeding means providing extra food to people or families over and above their home diet and has been used in populations that are food insecure (limited access to adequate and nutritious food) and vulnerable (including women and young children; school‐aged children; people living with diseases such as tuberculosis, HIV, and Alzheimer's disease; and older people) to improve their health and quality of life. What are the main results of the review? The evidence presented here was current to January 2017. We found eight systematic reviews to include in this summary. These reviews included 95 studies (including up to 7940 adults, and more than 12,595 children in a few studies). Most of the included studies lasted from six weeks to two years, with only three studies following people for longer periods of time (up to 17 years). In these reviews, there were a wide range of different types of supplementary feeding given to vulnerable groups over different periods of time, and often in combination with vitamins or minerals. In pregnancy, we found that energy and protein supplements that were balanced (i.e. providing adequate amounts of energy and nutrients, in this case protein) may have decreased the rate of stillbirth (death or loss of a baby before or during delivery), improved infant birth weight and reduced the risk of infants born small‐for‐gestational age (infants that are smaller than expected). We observed no long‐term benefits for children in terms of growth and cognitive (intellectual) development (although very few studies reported long‐term effects). High‐protein supplements (containing protein in higher amounts) were associated with risk and harm (increased risk of small‐for‐gestational age babies). We found that the effects of supplementary feeding on growth in children were varied. In children under five years of age from low‐ and middle‐income countries, supplementary feeding had a small impact on child growth. We observed some benefits in terms of weight and height gains, especially in younger children (those younger than two years of age) and in those who were poorer or less well‐nourished (or both). Some benefit could be seen in children with moderate acute malnutrition in terms of weight gain, other growth factors and recovery rate. School meals seemed to lead to a number of small benefits in school children (including improvements in weight, height, intelligence tests, and maths and spelling performance). Supplementary feeding in adults who were HIV positive increased the daily intake of energy and protein and led to an early improvement in weight gain or body mass index (measure of whether someone is overweight or underweight), or both, but did not seem to lead to long‐term benefits (although few studies reported long‐term effects). In adults with tuberculosis (serious infectious lung disease), we observed small benefits in terms of weight gain during active tuberculosis. In Alzheimer's disease (a type of dementia), providing a daily oral nutrition supplement for three months improved nutritional outcomes (such as weight and energy intake). There was little or no evidence available regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Visser, J; McLachlan, MH; Maayan, N; Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD010578.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "89d4ee96-14fa-4a06-8912-1951b5b6c1aa", "pmid": "", "title": "Carbetocin for preventing postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Postpartum haemorrhage (PPH) is one of the major contributors to maternal mortality and morbidity worldwide. Active management of the third stage of labour has been proven to be effective in the prevention of PPH. Syntometrine is more effective than oxytocin but is associated with more side effects. Carbetocin, a long‐acting oxytocin agonist, appears to be a promising agent for the prevention of PPH. Objectives To determine if the use of oxytocin agonist is as effective as conventional uterotonic agents for the prevention of PPH, and assess the best routes of administration and optimal doses of oxytocin agonist. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2011, Issue 1 of 4), MEDLINE (1966 to 1 March 2011) and EMBASE (1974 to 1 March 2011). We checked references of articles and communicated with authors and pharmaceutical industry contacts. Selection criteria Randomised controlled trials which compared oxytocin agonist (carbetocin) with other uterotonic agents or with placebo or no treatment for the prevention of PPH. Data collection and analysis Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Main results We included 11 studies (2635 women) in the review. Six trials compared carbetocin with oxytocin; four of these were conducted for women undergoing caesarean deliveries, one was for women following vaginal deliveries and one did not state the mode of delivery clearly. The carbetocin was administered as 100 µg intravenous dosage across the trials, while oxytocin was administered intravenously but at varied dosages. Four trials compared intramuscular carbetocin and intramuscular syntometrine for women undergoing vaginal deliveries. Three of the trials were on women with no risk factor for PPH, while one trial was on women with risk factors for PPH. One trial compared the use of intravenous carbetocin with placebo. Use of carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics (risk ratio (RR) 0.62; 95% confidence interval (CI) 0.44 to 0.88; four trials, 1173 women) compared to oxytocin for those who underwent caesarean section, but not for vaginal delivery. Compared to oxytocin, carbetocin was associated with a reduced need for uterine massage following both caesarean delivery (RR 0.54; 95% CI 0.37 to 0.79; two trials, 739 women) and vaginal delivery (RR 0.70; 95% CI 0.51 to 0.94; one trial, 160 women). There were no statistically significant differences between carbetocin and oxytocin in terms of risk of any PPH (blood loss greater than 500 ml) or in risk of severe PPH (blood loss greater than 1000 ml). Comparison between carbetocin and syntometrine showed a lower mean blood loss in women who received carbetocin compared to syntometrine (mean difference (MD) ‐48.84 ml; 95% CI ‐94.82 to ‐2.85; four trials, 1030 women). There was no statistically significant difference in terms of the need for therapeutic uterotonic agents, but the risk of adverse effects such as nausea and vomiting were significantly lower in the carbetocin group: nausea (RR 0.24; 95% CI 0.15 to 0.40; four trials, 1030 women); vomiting (RR 0.21; 95% CI 0.11 to 0.39; four trials, 1030 women). The incidence of postpartum hypertension was also significantly lower in women who received carbetocin compared to those who received syntometrine. Cost‐effectiveness of carbetocin was investigated by one study published as an abstract, with limited data. Authors' conclusions For women who undergo caesarean section, carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics compared to oxytocin, but there is no difference in the incidence of postpartum haemorrhage. Carbetocin is associated with less blood loss compared to syntometrine in the prevention of PPH for women who have vaginal deliveries and is associated with significantly fewer adverse effects. Further research is needed to analyse the cost‐effectiveness of carbetocin as a uterotonic agent. Plain language summary Carbetocin for preventing postpartum haemorrhage In low‐ and middle‐income countries, postpartum haemorrhage is a major cause of maternal deaths and ill health. In high‐income countries, the problems are much less but there is still a small risk of major bleeding problems for women after giving birth. Active management of the third stage of labour, which is generally used to reduce blood loss at birth, consists of giving the mother a drug that helps the uterus to contract, early cord clamping and controlled cord traction to deliver the placenta. Different drugs have been tried and generally either intramuscular oxytocin or intramuscular syntometrine is given. Carbetocin is an oxytocin agonist. Oxytocin agonists are a group of drugs that mimic the oxytocin action, oxytocin being the natural hormone that helps to reduce blood loss at birth. This review includes 11 randomised controlled trials involving 2635 women. The trials compared carbetocin against either oxytocin or syntometrine given after delivery, vaginally or by caesarean section. The comparison between intramuscular carbetocin and oxytocin showed that there was no difference in the risk of heavy bleeding, but that women who received carbetocin were less likely to require other medications to produce uterine contractions following caesarean sections. Comparisons between carbetocin and syntometrine showed that women who received carbetocin had less blood loss compared to women who received syntometrine after vaginal delivery, and were much less likely to experience side effects such as nausea and vomiting. The incidence of hypertension at 30 and 60 minutes post delivery was also significantly lower in women who received carbetocin compared to those who received syntometrine. Five of the 11 studies were known to be supported by a pharmaceutical company.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Su, LL, Chong, YS, Samuel, M", "articleTypes": [], "doi": "10.1002/14651858.CD005457.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.116Z" }, { "id": "8a0bce04-6b89-46e9-88bd-3ecfdf3f9462", "pmid": "", "title": "Fortification of maize flour with iron for controlling anaemia and iron deficiency in populations", "imported": false, "abstract": "Abstract - Background Approximately 800 million women and children have anaemia, a condition thought to cause almost 9% of the global burden of years lived with disability. Around half this burden could be amenable to interventions that involve the provision of iron. Maize (corn) is one of the world's most important cereal grains and is cultivated across most of the globe. Several programmes around the world have fortified maize flour and other maize‐derived foodstuffs with iron and other vitamins and minerals to combat anaemia and iron deficiency. Objectives To assess the effects of iron fortification of maize flour, corn meal and fortified maize flour products for anaemia and iron status in the general population. Search methods We searched the following international and regional sources in December 2017 and January 2018: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE (R) In Process; Embase; Web of Science (both the Social Science Citation Index and the Science Citation Index); CINAHL Ebsco; POPLINE; AGRICOLA ( agricola.nal.usda.gov ); BIOSIS (ISI); Bibliomap and TRoPHI; IBECS; Scielo; Global Index Medicus ‐ AFRO (includes African Index Medicus); EMRO (includes Index Medicus for the Eastern Mediterranean Region); LILACS; PAHO (Pan American Health Library); WHOLIS (WHO Library); WPRO (includes Western Pacific Region Index Medicus); IMSEAR, Index Medicus for the South‐East Asian Region; IndMED, Indian medical journals; and the Native Health Research Database. We searched clinicaltrials.gov and the International Clinical Trials Registry Platform ( ICTRP ) for any ongoing or planned studies on 17 January 2018 and contacted authors of such studies to obtain further information or eligible data if available. For assistance in identifying ongoing or unpublished studies, we also contacted relevant international organisations and agencies working in food fortification on 9 August 2016. Selection criteria We included cluster‐ or individually randomised controlled trials and observational studies. Interventions included (central/industrial) fortification of maize flour or corn meal with iron alone or with other vitamins and minerals and provided to individuals over 2 years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies and assessed the risk of bias of the included studies. Trial designs with a comparison group were included to assess the effects of interventions. Trial designs without a control or comparison group (uncontrolled before‐and‐after studies) were included for completeness but were not considered in assessments of the overall effectiveness of interventions or used to draw conclusions regarding the effects of interventions in the review. Main results Our search yielded 4529 records. After initial screening of titles and abstracts, we reviewed the full text of 75 studies (80 records). We included 5 studies and excluded 70. All the included studies assessed the effects of providing maize products fortified with iron plus other vitamins and minerals versus unfortified maize flour. No studies compared this intervention to no intervention or looked at the relative effect of flour and products fortified with iron alone (without other vitamins and minerals). Three were randomised trials involving 2610 participants, and two were uncontrolled before‐and‐after studies involving 849 participants. Only three studies contributed data for the meta‐analysis and included children aged 2 to 11.9 years and women. Compared to unfortified maize flour, it is uncertain whether fortifying maize flour or corn meal with iron and other vitamins and minerals has any effect on anaemia (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.58 to 1.40; 2 studies; 1027 participants; very low‐certainty evidence), or on the risk of iron deficiency (RR 0.75, 95% CI 0.49 to 1.15; 2 studies; 1102 participants; very low‐certainty evidence), haemoglobin concentration (mean difference (MD) 1.25 g/L, 95% CI −2.36 to 4.86 g/L; 3 studies; 1144 participants; very low‐certainty evidence) or ferritin concentrations (MD 0.48 µg/L, 95% CI −0.37 to 1.33 µg/L; 1 study; 584 participants; very low‐certainty evidence). None of the studies reported on any adverse effects. We judged the certainty of the evidence to be very low based on GRADE, so we are uncertain whether the results reflect the true effect of the intervention. We downgraded evidence due to high risk of selection bias and unclear risk of performance bias in one of two included studies, high heterogeneity and wide CIs crossing the line of no effect for anaemia prevalence and haemoglobin concentration. Authors' conclusions It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of anaemia or iron deficiency in children aged over 2 years or in adults. Moreover, the evidence is too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population, as the certainty of the evidence is very low. No studies reported on any adverse effects. Public organisations funded three of the five included studies, while the private sector gave grants to universities to perform the other two. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. The reduced number of studies, including only two age groups (children and women of reproductive age), as well as the limited number of comparisons (only one out of the four planned) constitute the main limitations of this review. Plain language summary Fortification of maize flour with iron for preventing anaemia and iron deficiency What is the aim of this review? The aim of this Cochrane Review was to determine the effects of fortifying maize flour, corn meal and fortified‐maize flour products with iron for anaemia and iron status in the general population. We searched for relevant published studies to answer this question and analysed all relevant information. Key messages It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We do not know whether fortifying maize flour with iron reduces anaemia in the general population, as the evidence was very unreliable. No studies reported on any harmful effects. What was studied in the review? Approximately 496 million non‐pregnant women, 32 million pregnant women, and 273 million children were thought to be anaemic as of 2011. Iron deficiency is considered to be the single most prevalent nutrient deficiency worldwide, but at least half this burden is considered responsive to interventions that involve providing people with iron. Fortification means adding vitamins and minerals to foods to increase their nutritional value. In public health, fortifying staple foods is considered one way of reducing micronutrient deficiencies without changing usual and culturally acceptable diets. Maize (corn) is one of the world's most important cereal grains. In sub‐Saharan Africa, some parts of Southeast Asia and Latin America, where iron deficiency is endemic, maize is a dietary staple for more than 200 million people. Fortification of maize flour with iron (and in some cases, other nutrients) is mandatory in Brazil, Costa Rica, El Salvador, Kenya, Mexico, Nigeria, Rwanda, South Africa, Tanzania, Uganda, the USA and Venezuela. What are the main results of the review? We found five relevant studies, but none looked at the effects of maize flour or maize flour products fortified with iron alone. Five studies compared the effects of maize flour or maize‐flour products fortified with iron plus other vitamins and minerals versus unfortified maize flours or maize‐flour products (not containing iron or any other vitamin and minerals). Three of these five studies randomly divided a collective total of 2302 children aged 2 to 12 years and 130 indigenous women into groups receiving fortified versus unfortified maize flour or corn flour. One study was from Kenya and the other two took place in Mexico. The remaining two studies did not provide data to assess the effects of fortification relative to a comparison group. Three of five of the included studies were funded by public organisations and two by funds granted by private sector to universities. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency in the general population. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population. How up‐to‐date is this review? We searched for studies that had been published up to 17 January 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Garcia‐Casal, MN; Peña‐Rosas, JP; De‐Regil, LM; Gwirtz, JA; Pasricha, SR", "articleTypes": [], "doi": "10.1002/14651858.CD010187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "8a0c699b-cf0b-402e-8dfc-d6afd6bd096e", "pmid": "", "title": "Cranberries for preventing urinary tract infections", "imported": false, "abstract": "Abstract - Background Cranberries contain proanthocyanidins (PACs), which inhibit the adherence of p‐fimbriated Escherichia coli to the urothelial cells lining the bladder. Cranberry products have been used widely for several decades to prevent urinary tract infections (UTIs). This is the fifth update of a review first published in 1998 and updated in 2003, 2004, 2008, and 2012. Objectives To assess the effectiveness of cranberry products in preventing UTIs in susceptible populations. Search methods We searched the Cochrane Kidney and Transplant Specialised Register up to 13 March 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria All randomised controlled trials (RCTs) or quasi‐RCTs of cranberry products compared with placebo, no specific treatment or other intervention (antibiotics, probiotics) for the prevention of UTIs were included. Data collection and analysis At least two authors independently assessed and extracted data. Information was collected on methods, participants, interventions and outcomes (incidence of symptomatic UTIs, positive culture results, side effects, adherence to therapy). Risk ratios (RR) with 95% confidence intervals (CI) were calculated where appropriate. Study quality was assessed using the Cochrane risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results For this update, 26 new studies were added, bringing the total number of included studies to 50 (8857 randomised participants). The risk of bias for sequence generation and allocation concealment was low for 29 and 28 studies, respectively. Thirty‐six studies were at low risk of performance bias, and 23 studies were at low risk of detection bias. Twenty‐seven, 41, and 17 studies were at low risk of attrition bias, reporting bias and other bias, respectively. Forty‐five studies compared cranberry products with placebo, water or no specific treatment in six different groups of participants. Twenty‐six of these 45 studies could be meta‐analysed for the outcome of symptomatic, culture‐verified UTIs. In moderate certainty evidence, cranberry products reduced the risk of UTIs (6211 participants: RR 0.70, 95% CI 0.58 to 0.84; I² = 69%). When studies were divided into groups according to the treatment indication, cranberry products probably reduced the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs (8 studies, 1555 participants: RR 0.74, 95% CI 0.55 to 0.99; I² = 54%), in children (5 studies, 504 participants: RR 0.46, 95% CI 0.32 to 0.68; I² = 21%) and in people with a susceptibility to UTIs due to an intervention (6 studies, 1434 participants: RR 0.47, 95% CI 0.37 to 0.61; I² = 0%). However, there may be little or no benefit in elderly institutionalised men and women (3 studies, 1489 participants: RR 0.93, 95% CI 0.67 to 1.30; I² = 9%; moderate certainty evidence), pregnant women (3 studies, 765 participants: RR 1.06, 95% CI 0.75 to 1.50; I² = 3%; moderate certainty evidence), or adults with neuromuscular bladder dysfunction with incomplete bladder emptying (3 studies, 464 participants: RR 0.97, 95% CI 0.78 to 1.19; I² = 0%; low certainty evidence). Other comparisons were cranberry products with probiotics (three studies) or antibiotics (six studies), cranberry tablets with cranberry liquid (one study), and different doses of PACs (two studies). Compared to antibiotics, cranberry products may make little or no difference to the risk of symptomatic, culture‐verified UTIs (2 studies, 385 participants: RR 1.03, 95% CI 0.80 to 1.33; I² = 0%) or the risk of clinical symptoms without culture (2 studies, 336 participants: RR 1.30, 95% CI 0.79 to 2.14; I² = 68%). Compared to probiotics, cranberry products may reduce the risk of symptomatic, culture‐verified UTIs (3 studies, 215 participants: RR 0.39, 95% CI 0.27 to 0.56; I = 0%). It is unclear whether efficacy differs between cranberry juice and tablets or between different doses of PACs, as the certainty of the evidence was very low. The number of participants with gastrointestinal side effects probably does not differ between those taking cranberry products and those receiving a placebo or no specific treatment (10 studies, 2166 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%; moderate certainty evidence). There was no clear relationship between compliance with therapy and the risk for repeat UTIs. No difference in the risk for UTIs could be demonstrated between low, moderate and high doses of PACs. Authors' conclusions This update adds a further 26 studies, taking the total number of studies to 50 with 8857 participants. These data support the use of cranberry products to reduce the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs, in children, and in people susceptible to UTIs following interventions. The evidence currently available does not support its use in the elderly, patients with bladder emptying problems, or pregnant women. Plain language summary Cranberries for preventing urinary tract infections What is the issue? Cranberries (as cranberry juice, tablets or capsules) have been used for many years to prevent urinary tract infections (UTIs). Cranberries contain proanthocyanidins (PACs), substances that can prevent bacteria from sticking to the walls of the bladder. This may help prevent infections and reduce the need for working people to take time for medical appointments. However, there is currently no established regimen for what PACs dose to use and no formal regulation by health authorities of cranberry products. In particular, the dose suggested may not be included on the package. What did we do? We analysed the results of randomised controlled trials (RCTs), which compared the occurrence of UTIs in people taking a cranberry product with those taking a placebo or no treatment. We also analysed the results of RCTs comparing a cranberry product with other treatments such as antibiotics or probiotics. What did we find? We found 50 RCTs involving 8857 people. Forty‐five RCTs compared cranberry with a placebo or no treatment. Taking cranberries as a juice, tablets or capsules reduced the number of UTIs in women with recurrent UTIs, in children with UTIs and in people susceptible to UTIs following an intervention such as bladder radiotherapy. However, UTIs did not appear to be reduced in elderly institutionalised men and women, in adults with neuromuscular bladder dysfunction and incomplete bladder emptying, or in pregnant women. Few people reported any side effects with the most common being tummy pain. We did not find enough information to determine if cranberry products are more or less effective compared with antibiotics or probiotics in preventing further UTIs. Conclusions Cranberry products may help to prevent UTIs which cause symptoms in women with frequent UTIs, in children with UTIs and in people who have undergone an intervention involving the bladder. However, further assessment is required in well‐designed and prospectively registered RCTs to clarify further who with UTIs would benefit from cranberry products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Williams, G; Stothart, CI; Hahn, D; Stephens, JH; Craig, JC; Hodson, EM", "articleTypes": [], "doi": "10.1002/14651858.CD001321.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "8a14ce6e-4bc4-428d-85b6-506eae3478d5", "pmid": "", "title": "Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide and its prevalence among children has significantly increased over the last two decades. Prevalence and severity are related to age, with children of school age most commonly affected. Objectives To assess the effectiveness and adverse event profile of antihistamines (oral or topical) used as an adjunct to topical nasal steroids for intermittent and persistent allergic rhinitis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 21 September 2009. Selection criteria Randomised controlled trials (RCTs) in children under the age of 18 with a history of allergic rhinitis, with or without allergic conjunctivitis or asthma, comparing topical nasal steroids with antihistamines to topical nasal steroids only. Data collection and analysis Two review authors independently screened studies, extracted data and assessed risk of bias. Main results One study including 24 participants met the inclusion criteria for this review. This study compared the administration of topical nasal steroids with oral antihistamines to topical nasal steroids only in children, but it did not provide sufficient data to address the clinical question of this review. Authors' conclusions In view of the lack of evidence for the benefit or lack of benefit of antihistamine add‐on therapy with topical nasal steroids for children with intermittent or persistent allergic rhinitis, it is important that clinicians are mindful of the adverse effects of antihistamines and the additional costs that may be incurred. Plain language summary Antihistamines as an addition to topical nasal steroids for allergic rhinitis in children Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide. Seasonal allergic rhinitis (hay fever) is most common around springtime. The symptoms are mostly sneezing, a runny nose and watery eyes. We looked for trials that compared antihistamines (either oral or topical) in addition to a topical nasal steroid with a topical nasal steroid alone in children who had allergic rhinitis. We wanted to know whether adding antihistamines (oral or topical) in the therapy of children with allergic rhinitis who already use topical nasal steroids would have additional benefits for them. We found one trial that had been carried out in children comparing oral antihistamines in addition to topical nasal steroids with topical nasal steroids alone but it did not provide sufficient data to draw any conclusions. Most of the trials focused only on adults or included a small number of children. Unfortunately, the trials which included children along with adults did not report whether there were any differences in the effect of treatment or adverse effects in children in comparison with adults. We are therefore unable to draw a conclusion as to whether or not this combination therapy has beneficial effect in children with allergic rhinitis or whether the benefits are acceptable in terms of the adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Nasser, M, Fedorowicz, Z, Aljufairi, H, McKerrow, W", "articleTypes": [], "doi": "10.1002/14651858.CD006989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.821Z" }, { "id": "8a1ed9d1-0b55-49aa-aa36-eb96e21d8f41", "pmid": "", "title": "Investigating the Potential Role of Aerosolized Retinoic Acid, a Potent Vitamin A Metabolite for Treating COVID-19 Anosmia and Retinoic Acid Insufficiency .A Novel Approach for Regaining Sense of Smell.", "imported": false, "abstract": "Investigating the potential role of Aerosolized retinoic acid, a potent Vitamin A metabolite for treating COVID-19 Anosmia and retinoic acid insufficiency .A novel approach for regaining Sense of Smell.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.249Z" }, { "id": "8a1f774f-f15c-44cd-b981-0d1cbbfa99b6", "pmid": "", "title": "Melatonin for the prevention and treatment of jet lag", "imported": false, "abstract": "Abstract - Background Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Objectives To assess the effectiveness of oral melatonin taken in different dosage regimens for alleviating jet lag after air travel across several time zones. Search methods We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsychLit and Science Citation Index electronically, and the journals 'Aviation, Space and Environmental Medicine' and 'Sleep' by hand. We searched citation lists of relevant studies for other relevant trials. We asked principal authors of relevant studies to tell us about unpublished trials. Reports of adverse events linked to melatonin use outside randomised trials were searched for systematically in 'Side Effects of Drugs' (SED) and SED Annuals, 'Reactions Weekly', MEDLINE, and the adverse drug reactions databases of the WHO Uppsala Monitoring Centre (UMC) and the US Food & Drug Administration. An updating search was carried out on 12/2/2008 but no new studies were identified. Selection criteria Randomised trials in airline passengers, airline staff or military personnel given oral melatonin, compared with placebo or other medication. Outcome measures should consist of subjective rating of jet lag or related components, such as subjective well being, daytime tiredness, onset and quality of sleep, psychological functioning, duration of return to normal, or indicators of circadian rhythms. Data collection and analysis Ten trials met the inclusion criteria. All compared melatonin with placebo; one in addition compared it with a hypnotic, zolpidem. Nine of the trials were of adequate quality to contribute to the assessment, one had a design fault and could not be used in the assessment. 
 Reports of adverse events outside trials were found through MEDLINE, 'Reactions Weekly', and in the WHO UMC database. Main results Eight of the ten trials found that melatonin, taken close to the target bedtime at the destination (10pm to midnight), decreased jet‐lag from flights crossing five or more time zones. Daily doses of melatonin between 0.5 and 5mg are similarly effective, except that people fall asleep faster and sleep better after 5mg than 0.5mg. Doses above 5mg appear to be no more effective. The relative ineffectiveness of 2mg slow‐release melatonin suggests that a short‐lived higher peak concentration of melatonin works better. The estimated number needed to treat (NNT) is 2, based on the only two trials that gave the necessary data. The benefit is likely to be greater the more time zones are crossed, and less for westward flights. The timing of the melatonin dose is important: if it is taken at the wrong time, early in the day, it is liable to cause sleepiness and delay adaptation to local time. The incidence of other side effects is low. Case reports suggest that people with epilepsy, and patients taking warfarin may come to harm from melatonin. Authors' conclusions Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be. The pharmacology and toxicology of melatonin needs systematic study, and routine pharmaceutical quality control of melatonin products must be established. The effects of melatonin in people with epilepsy, and a possible interaction with warfarin, need investigation. Plain language summary Melatonin for the prevention and treatment of jet lag Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Herxheimer, A; Petrie, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD001520", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "8a3f64b6-99f0-4654-af82-ce72c0194d42", "pmid": "", "title": "Chlorhexidine treatment for the prevention of dental caries in children and adolescents", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) is a common disease that is preventable by reducing the dietary intake of free sugars and using topical sodium fluoride products. An antibacterial agent known as chlorhexidine may also help prevent caries. A number of over‐the‐counter and professionally administered chlorhexidine‐based preparations are available in a variety of formulations and in a range of strengths. Although previous reviews have concluded that some formulations of chlorhexidine may be effective in inhibiting the progression of established caries in children, there is currently a lack of evidence to either claim or refute a benefit for its use in preventing dental caries. Objectives To assess the effects of chlorhexidine‐containing oral products (toothpastes, mouthrinses, varnishes, gels, gums and sprays) on the prevention of dental caries in children and adolescents. Search methods We searched the Cochrane Oral Health Group Trials Register (25 February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 12), MEDLINE via OVID (1946 to 25 February 2015), EMBASE via OVID (1980 to 25 February 2015) and CINAHL via EBSCO (1937 to 25 February 2015). We handsearched several journals placed no language restrictions on our search. After duplicate citations were removed, the electronic searches retrieved 1075 references to studies. Selection criteria We included parallel‐group, randomised controlled trials (RCTs) that compared the caries preventive effects of chlorhexidine gels, toothpastes, varnishes, mouthrinses, chewing gums or sprays with each other, placebo or no intervention in children and adolescents. We excluded trials with combined interventions of chlorhexidine and fluoride or comparisons between chlorhexidine and fluoride interventions. Data collection and analysis Two review authors independently extracted trial data and assessed risk of bias. We resolved disagreements by consensus. We contacted trial authors for clarification or additional study details when necessary. The number of included studies that were suitable for meta‐analysis was limited due to the clinical diversity of the included studies with respect to age, composition of intervention, and variation in outcome measures and follow‐up. Where we were unable to conduct meta‐analysis, we elected to present a narrative synthesis of the results. Main results We included eight RCTs that evaluated the effects of chlorhexidine varnishes (1%, 10% or 40% concentration) and chlorhexidine gel (0.12%) on the primary or permanent teeth, or both, of children from birth to 15 years of age at the start of the study. The studies randomised a total of 2876 participants, of whom 2276 (79%) were evaluated. We assessed six studies as being at high risk of bias overall and two studies as being at unclear risk of bias overall. Follow‐up assessment ranged from 6 to 36 months. Six trials compared chlorhexidine varnish with placebo or no treatment. It was possible to pool the data from two trials in the permanent dentition (one study using 10% chlorhexidine and the other, 40%). This led to an increase in the DMFS increment in the varnish group of 0.53 (95% confidence interval (CI) ‐0.47 to 1.53; two trials, 690 participants; very low quality evidence). Only one trial (10% concentration chlorhexidine varnish) provided usable data for elevated mutans streptococci levels > 4 with RR 0.93 (95% CI 0.80 to 1.07, 496 participants; very low quality evidence). One trial measured adverse effects (for example, ulcers or tooth staining) and reported that there were none; another trial reported that no side effects of the treatment were noted. No trials reported on pain, quality of life, patient satisfaction or costs. Two trials compared chlorhexidine gel (0.12% concentration) with no treatment in the primary dentition. The presence of new caries gave rise to a 95% confidence interval that was compatible with either an increase or a decrease in caries incidence (RR 1.00, 95% CI 0.36 to 2.77; 487 participants; very low quality evidence). Similarly, data for the effects of chlorhexidine gel on the prevalence of mutans streptococci were inconclusive (RR 1.26, 95% CI 0.95 to 1.66; two trials, 490 participants; very low quality evidence). Both trials measured adverse effects and did not observe any. Neither of these trials reported on the other secondary outcomes such as measures of pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Authors' conclusions We found little evidence from the eight trials on varnishes and gels included in this review to either support or refute the assertion that chlorhexidine is more effective than placebo or no treatment in the prevention of caries or the reduction of mutans streptococci levels in children and adolescents. There were no trials on other products containing chlorhexidine such as sprays, toothpastes, chewing gums or mouthrinses. Further high quality research is required, in particular evaluating the effects on both the primary and permanent dentition and using other chlorhexidine‐containing oral products. Plain language summary Antiseptic treatment (chlorhexidine) to prevent tooth decay in children and young people Review question This review examined the effectiveness of varnishes and gels containing chlorhexidine in preventing tooth decay in children and young people. Background Tooth decay is a very common disease that over time destroys the tooth surface. It has been estimated to affect up to 80% of people in high‐income countries and, despite being preventable through oral hygiene and dietary measures and the use of agents such as fluoride that reduce risk of decay, it is likely to remain a problem, especially in low‐income countries. Tooth decay can result in pain and infection, and in young children may require treatment in hospital under a general anaesthetic. As well as causing anxiety and pain, this may mean the child or young person missing time at school and their parents or carers having to take time off work, possibly losing income and incurring extra costs. Prevention of tooth decay is simpler and possibly cheaper than waiting until it occurs and then requires extensive treatment. Tooth decay is largely preventable, and a range of things may assist this: twice‐daily toothbrushing with a fluoride toothpaste, reducing both the amount of and number of times per day sugar is eaten, and drinking water that contains fluoride (bottled or tap, depending on where you live). Tooth decay occurs when certain types of bacteria (germs) in the mouth, such as Streptococcus mutans, produce acids from the sugar we eat, which dissolve the hard enamel coating on our teeth. The chemical antiseptic treatment chlorhexidine is highly successful at destroying these bacteria and can be used safely at home in the form of a gel, spray, chewing gum, toothpaste or mouthrinse. Alternatively, chlorhexidine can be applied as a varnish to the surface of teeth by a dentist. Study characteristics The evidence in this review, carried out through the Cochrane Oral Health Group, is up‐to‐date at 25 February 2015. We found eight studies that were suitable to include in this review. The studies involved a total of 2876 children from birth to 15 years of age who were at moderate to high risk of tooth decay. Six of the studies looked at the effects of dental professionals applying different strengths of chlorhexidine varnishes to the baby teeth, permanent teeth or both types of teeth in children and adolescents. The other two studies looked at the effects of parents placing chlorhexidine gel on their children's baby teeth. There were no studies that examined other products containing chlorhexidine, such as sprays, toothpastes, chewing gums or mouthrinses. Key results The results did not provide evidence that chlorhexidine varnish or gel reduces tooth decay or reduces the bacteria that encourage tooth decay. The studies did not evaluate other outcomes such as pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Four studies measured side effects and found none were observed. Quality of the evidence Due to the lack of suitable studies and concerns about possible bias in the included studies, the evidence is very low quality. As a result, we are not able to conclude whether or not chlorhexidine is effective in preventing tooth decay in children or adolescents, when compared to placebo (an inactive substitute for chlorhexidine) or no treatment. Future research on the use of chlorhexidine to prevent tooth decay is needed and should consider both primary and permanent teeth and should assess other chlorhexidine‐containing products that can be used at home, such as toothpastes or mouthrinses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Walsh, T, Oliveira‐Neto, JM, Moore, D", "articleTypes": [], "doi": "10.1002/14651858.CD008457.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.746Z" }, { "id": "8a419921-20ed-471e-aa3b-173dd5559abd", "pmid": "", "title": "Exposure to the smell and taste of milk to accelerate feeding in preterm infants", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Delgado Paramo, L, Bronnert, A, Lin, L, Bloomfield, FH, Muelbert, M, Harding, JE", "articleTypes": [], "doi": "10.1002/14651858.CD013038.pub3 AB - Abstract - Background Preterm infants (born before 37 weeks' gestation) are often unable to co‐ordinate sucking, swallowing, and breathing for oral feeding because of their immaturity. In such cases, initial nutrition is provided by orogastric or nasogastric tube feeding. Feeding intolerance is common and can delay attainment of full enteral and sucking feeds, prolonging the need for nutritional support and the hospital stay. Smell and taste play an important role in the activation of physiological pre‐absorptive processes that contribute to food digestion and absorption. However, during tube feeding, milk bypasses the nasal and oral cavities, limiting exposure to the smell and taste of milk. Provision of the smell and taste of milk with tube feeds offers a non‐invasive and low‐cost intervention that, if effective in accelerating the transition to enteral feeds and subsequently to sucking feeds, would bring considerable advantages to infants, their families, and healthcare systems. Objectives To assess whether exposure to the smell or taste (or both) of breastmilk or formula administered with tube feeds can accelerate the transition to full sucking feeds without adverse effects in preterm infants. Search methods We conducted searches in CENTRAL, MEDLINE, Embase, CINAHL, and Epistemonikos to 26 April 2023. We also searched clinical trial databases and conference proceedings. Selection criteria We included randomised and quasi‐randomised studies that evaluated exposure versus no exposure to the smell or taste of milk (or both) immediately before or at the time of tube feeds. Data collection and analysis Two review authors independently selected studies, assessed risk of bias, and extracted data according to Cochrane Neonatal methodology. We performed meta‐analyses using risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence. Main results We included eight studies (1277 preterm infants). Seven studies (1244 infants) contributed data for meta‐analysis. The evidence suggests that exposure to the smell and taste of milk with tube feeds has little to no effect on time taken to reach full sucking feeds (MD −1.07 days, 95% CI −2.63 to 0.50; 3 studies, 662 infants; very low‐certainty evidence). Two studies reported no adverse effects related to the intervention. The intervention may have little to no effect on duration of parenteral nutrition (MD 0.23 days, 95% CI −0.24 to 0.71; 3 studies, 977 infants; low‐certainty evidence), time to reach full enteral feeds (MD −0.16 days, 95% CI −0.45 to 0.12; 1 study, 736 infants; very low‐certainty evidence) or risk of necrotising enterocolitis (RR 0.93, 95% CI 0.47 to 1.84; 2 studies, 435 infants; low‐certainty evidence), although the evidence for time to reach full enteral feeds is very uncertain. Exposure to the smell and taste of milk with tube feeds probably has little to no effect on risk of late infection (RR 1.14, 95% CI 0.74 to 1.75; 2 studies, 436 infants; moderate‐certainty evidence). There were no data available to assess feeding intolerance. The included studies had small sample sizes and methodological limitations, including unclear or lack of randomisation (four studies), lack of blinding of participants and personnel (five studies), unclear or lack of blinding of the outcome assessor (all eight studies), and different inclusion criteria and methods of administering the interventions. Authors' conclusions The results of our meta‐analyses suggest that exposure to the smell and taste of milk with tube feeds may have little to no effect on time to reach full sucking feeds and time to reach full enteral feeds. We found no clear difference between exposure and no exposure to the smell or taste of milk on safety outcomes (adverse effects, necrotising enterocolitis, and late infection). Results from one ongoing study and two studies awaiting classification may alter the conclusions of this review. Future research should examine the effect of exposing preterm infants to the smell and taste of milk with tube feeds on health outcomes during hospitalisation, such as attainment of feeding skills, safety, feed tolerance, infection, and growth. Future studies should be powered to detect the effect of the intervention in infants of different gestational ages and on each sex separately. It is also important to determine the optimal method, frequency, and duration of exposure. Plain language summary Does exposure to the smell and taste of milk accelerate feeding in tube‐fed preterm infants? Key messages • Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time it takes preterm infants to reach full sucking feeds.
• We found no evidence of any unwanted effects of exposure to the smell and taste of milk with tube feeds in newborn infants. What is tube feeding? Infants born preterm (before 37 weeks of pregnancy) often need to be fed via a thin tube inserted through the mouth (orogastric tube) or nose (nasogastric tube) into the stomach until they are able to suck all of their feeds. Why is the smell and taste of milk important for tube‐fed babies? Initially, only small volumes of milk are given, and this is gradually increased depending on how well the babies tolerate the milk. Smell and taste have a significant role in helping with digestion and absorption of food, and since infants being fed by a tube may not experience the smell or taste of milk, they might be taking longer to tolerate larger volumes of milk. What did we want to find out? We wanted to find out if exposing infants to the smell and taste of milk before or while they were being fed through a tube could help them tolerate greater volumes of milk more quickly and improve their overall growth and development. We also wanted to know if this method had any unwanted effects. What did we do? We searched for studies that investigated exposing preterm infants to the smell or taste (or both) of milk with tube feeds, compared to no such exposure. We compared and summarised the results of the studies and rated the certainty of the evidence, based on factors such as study methods and number of infants included. What did we find? We identified eight completed studies involving 1277 preterm infants admitted to a neonatal intensive care unit. Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time to reach full sucking feeds, but the results are very uncertain. Two studies reported that no infants had any unwanted effects related to exposure to the smell and taste of milk with tube feeds. Exposure to the smell and taste of milk may have little to no effect on duration of intravenous nutrition (feeding through a vein), time to reach full enteral feeds (feeds though a tube into the stomach), or on the risk of necrotising enterocolitis (a serious intestinal disease), although the results for time to full enteral feeds are very uncertain. Exposure to the smell and taste of milk probably has little or no effect on the risk of developing an infection more than two days after birth. What are the limitations of the evidence? We have little confidence in the evidence because: • we identified few studies;
• most studies were small and provided different types of exposure to smell and taste;
• in many studies, clinicians and parents were aware of which treatment the infant was receiving; and
• the studies did not investigate all the outcomes we were interested in. How up‐to‐date is this evidence? This review is current to April 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.059Z" }, { "id": "8a4996e1-99f0-4c2c-9760-f2c1a4d7a487", "pmid": "", "title": "Intranasal corticosteroids for non‐allergic rhinitis", "imported": false, "abstract": "Abstract - Background Non‐allergic rhinitis is defined as dysfunction and non‐infectious inflammation of the nasal mucosa that is caused by provoking agents other than allergens or microbes. It is common, with an estimated prevalence of around 10% to 20%. Patients experience symptoms of nasal obstruction, anterior rhinorrhoea/post‐nasal drip and sneezing. Several subgroups of non‐allergic rhinitis can be distinguished, depending on the trigger responsible for symptoms; these include occupation, cigarette smoke, hormones, medication, food and age. On a cellular molecular level different disease mechanisms can also be identified. People with non‐allergic rhinitis often lack an effective treatment as a result of poor understanding and lack of recognition of the underlying disease mechanism. Intranasal corticosteroids are one of the most common types of medication prescribed in patients with rhinitis or rhinosinusitis symptoms, including those with non‐allergic rhinitis. However, it is unclear whether intranasal corticosteroids are truly effective in these patients. Objectives To assess the effects of intranasal corticosteroids in the management of non‐allergic rhinitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 7); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 July 2019. Selection criteria Randomised controlled trials (RCTs) comparing intranasal corticosteroids, delivered by any means and in any volume, with (a) placebo/no intervention or (b) other active treatments in adults and children (aged ≥ 12 years). Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were patient‐reported disease severity and a
 significant adverse effect ‐ epistaxis. Secondary outcomes were (disease‐specific) health‐related quality of life, objective measurements of airflow and other adverse events. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 34 studies (4452 participants); however, only 13 studies provided data for our main comparison, intranasal corticosteroids versus placebo. The participants were mainly defined as patients with perennial rhinitis symptoms and negative allergy tests. No distinction between different pheno‐ and endotypes could be made, although a few studies only included a specific phenotype such as pregnancy rhinitis, vasomotor rhinitis, rhinitis medicamentosa or senile rhinitis. Most studies were conducted in a secondary or tertiary healthcare setting. No studies reported outcomes beyond three months follow‐up. Intranasal corticosteroid dosage in the review ranged from 50 µg to 2000 µg daily. Intranasal corticosteroids versus placebo Thirteen studies (2045 participants) provided data for this comparison. These studies used different scoring systems for patient‐reported disease severity, so we pooled the data in each analysis using the standardised mean difference (SMD). Intranasal corticosteroid treatment may improve patient‐reported disease severity as measured by total nasal symptom score compared with placebo at up to four weeks (SMD ‐0.74, 95% confidence interval (CI) ‐1.15 to ‐0.33; 4 studies; 131 participants; I 2 = 22%) (low‐certainty evidence). However, between four weeks and three months the evidence is very uncertain (SMD ‐0.24, 95% CI ‐0.67 to 0.20; 3 studies; 85 participants; I 2 = 0%) (very low‐certainty evidence). Intranasal corticosteroid treatment may slightly improve patient‐reported disease severity as measured by total nasal symptom score change from baseline when compared with placebo at up to four weeks (SMD ‐0.15, 95% CI ‐0.25 to ‐0.05; 4 studies; 1465 participants; I 2 = 35%) (low‐certainty evidence) . All four studies evaluating the risk of epistaxis showed that there is probably a higher risk in the intranasal corticosteroids group (65 per 1000) compared to placebo (31 per 1000) (risk ratio (RR) 2.10, 95% CI 1.24 to 3.57; 4 studies; 1174 participants; I 2 = 0%) (moderate‐certainty evidence). The absolute risk difference (RD) was 0.04 with a number needed to treat for an additional harmful outcome (NNTH) of 25 (95% CI 16.7 to 100). Only one study reported numerical data for quality of life. It did report a higher quality of life score in the intranasal corticosteroids group (152.3 versus 145.6; SF‐12v2 range 0 to 800); however, this disappeared at longer‐term follow‐up (148.4 versus 145.6) (low‐certainty evidence). Only two studies provided data for the outcome objective measurements of airflow. These data could not be pooled because they used different methods of outcome measurement. Neither found a significant difference between the intranasal corticosteroids and placebo group (rhinomanometry SMD ‐0.46, 95% CI ‐1.06 to 0.14; 44 participants; peak expiratory flow rate SMD 0.78, 95% CI ‐0.47 to 2.03; 11 participants) (very low‐certainty evidence). Intranasal corticosteroids probably resulted in little or no difference in the risk of other adverse events compared to placebo (RR 0.99, 95% CI 0.87 to 1.12; 3 studies; 1130 participants; I 2 = 0%) (moderate‐certainty evidence) . Intranasal corticosteroids versus other treatments Only one or a few studies assessed each of the other comparisons (intranasal corticosteroids versus saline irrigation, intranasal antihistamine, capsaicin, cromoglycate sodium, ipratropium bromide, intranasal corticosteroids combined with intranasal antihistamine, intranasal corticosteroids combined with intranasal antihistamine and intranasal corticosteroids with saline compared to saline alone). It is therefore uncertain whether there are differences between intranasal corticosteroids and other active treatments for any of the outcomes reported. Authors' conclusions Overall, the certainty of the evidence for most outcomes in this review was low or very low. It is unclear whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. However, intranasal corticosteroids probably have a higher risk of the adverse effect epistaxis. There are very few studies comparing intranasal corticosteroids to other treatment modalities making it difficult to draw conclusions. Plain language summary Intranasal corticosteroids for non‐allergic rhinitis Review question We wanted to find out whether intranasal corticosteroids (steroids applied into the nose) are effective for the treatment of rhinitis that is not caused by allergy. Background Non‐allergic rhinitis is a chronic disease of the nose, which is not caused by infection or allergies. People with non‐allergic rhinitis experience symptoms that affect their quality of life, such as nasal obstruction, runny nose and sneezing. Non‐allergic rhinitis patients can be divided into different subgroups who have different underlying causes for their disease. The underlying causes of non‐allergic rhinitis are not fully understood, therefore treatment is often unsuccessful in these patients. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation. They are the most commonly prescribed drug in other chronic diseases of the nose and sinuses, such as allergic rhinitis and chronic rhinosinusitis. Intranasal corticosteroid treatment can be delivered with sprays or drops and for different time periods. Study characteristics We included 34 randomised controlled trials (RCTs) with a total of 4452 participants in this review. Most of the studies were relatively small, although the largest study had 983 patients in total. All of the patients were either adults or adolescents (aged between 12 and 18 years old) with non‐allergic rhinitis. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Nine studies were sponsored by the pharmaceutical industry or had commercial sponsors. One study was funded by the government. In several studies, the pharmaceutical industry or commercial sponsor may have provided medications, but the funding role was unclear. Funding was not reported in eight studies. Key results Intranasal corticosteroids compared with placebo It is uncertain whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. They may improve patient‐reported disease severity compared with placebo at up to four weeks, however this evidence is of low certainty. Treatment with intranasal corticosteroids probably increases the risk of epistaxis (nosebleed) but there is no difference in the risk of other adverse effects. It is not possible to tell from this review whether there is a difference between the different concentrations, delivery methods or treatment plans of intranasal corticosteroids. There are no good‐quality studies assessing changes in quality of life with intranasal corticosteroids. Intranasal corticosteroids compared with other treatments There is not enough evidence to know whether intranasal corticosteroid treatment is better, worse or the same as using other treatment strategies such as saline irrigation, intranasal antihistamines, capsaicin or ipratropium bromide for non‐allergic rhinitis. Certainty of the evidence Overall, the evidence for intranasal corticosteroids compared with placebo for most outcomes was either low‐certainty (our confidence in the effect estimate is low) or very low‐certainty (our confidence in the effect estimate is very low). This was because most studies were very small and used different methods to measure the same outcome. This evidence is up to date to July 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Segboer, C; Gevorgyan, A; Avdeeva, K; Chusakul, S; Kanjanaumporn, J; Aeumjaturapat, S; Reeskamp, LF; Snidvongs, K; Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010592.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "8a5bd81a-a2f1-4fd2-ad8a-2bb8641ce2e6", "pmid": "", "title": "A Randomized, Double Blinded, Placebo-controlled, Multicenter, Phase III Study to Evaluate the Efficacy and Safety of Losartan in Early Immunoglobulin A Nephropathy (IgAN) Patients", "imported": false, "abstract": "Immunoglobulin A nephropathy (IgAN) is the most common glomerulonephritis worldwide. IgAN is progressive, particularly when patients have a significant proteinuria (proteinuria >1g/g creatinine), impaired kidney function, or elevated blood pressure. In 10 years, nearly 20-40% of these IgAN patients progress to end-stage renal disease (ESRD). Early IgAN is tentatively defined when proteinuria is insignificant and kidney function and blood pressure are normal. Patients with early IgAN rarely progress to ESRD. However, 30-40% of patients with early IgAN ultimately developed a significant proteinuria and hypertension in 10 years. Therefore, earlier intervention may be needed if it can prevent the development of a significant proteinuria and hypertension. Since angiotensin ll receptor blocker (ARB) is drug of choice in reducing proteinuria and controlling blood pressure, the investigators hypothesized that early introduction of ARB may be beneficial in preventing the significant proteinuria development in early IgAN patients. To prove the hypothesis, the investigators plan the current interventional study.", "journal": "", "year": "2017", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.151Z" }, { "id": "8a5d81be-cd1f-40e8-859f-5684d5f08098", "pmid": "", "title": "Melatonin in cancer treatment", "imported": false, "abstract": "Abstract - Rationale Preserving health‐related quality of life is an aspect of care that requires constant attention from the time of cancer diagnosis. Melatonin has been used to diminish treatment‐related side effects and cancer symptoms, and as a medication to regulate circadian rhythm. An up‐to‐date systematic review is needed to investigate the current evidence concerning possible beneficial effects of melatonin on quality of life and sleep in cancer patients. Objectives To evaluate the benefits and harms of melatonin for preserving health‐related quality of life and sleep in cancer patients. Search methods To identify studies for inclusion in this review, we used CENTRAL, MEDLINE, 10 other databases, and four trial registers, together with reference checking, citation searching, and contact with study authors. The latest search date was 10 September 2024. Eligibility criteria We included randomised controlled trials (RCTs) of adults (18 years or over) with histologically proven cancer of any stage that evaluated melatonin (alone or in combination with standard anticancer treatment) versus no treatment or placebo (alone or in combination with standard anticancer treatment), or standard anticancer treatment. Standard anticancer treatment refers to treatments to stop or prevent cancer, including chemotherapy, radiation therapy, surgery, immunotherapy, and hormonal therapies (such as androgen deprivation therapy). Outcomes The primary outcomes of interest were quality of life and sleep quality within three months, and melatonin‐related adverse events. Other outcomes included survival, disease‐free survival, progression‐free survival, tumour response, and anticancer treatment‐related harms. Risk of bias We used Cochrane's risk of bias tool (RoB 1) to assess the risk of bias in the studies included in the review. Synthesis methods We synthesised results for each outcome using random‐effects meta‐analysis. The effect size was presented as risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CI). If this was not possible, due to the nature of the data, we synthesised results in a narrative format. We used GRADE to assess the certainty of evidence for each outcome. Included studies We identified 30 RCTs (reported in 49 publications) involving 5093 adult participants with cancer (2470 males, 2228 females, 395 not reported). Studies were conducted in a hospital setting and took place in at least 10 countries. We assessed two studies at low risk of bias and the other 28 at high risk of bias. Synthesis of results Melatonin plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life score (MD 2.60, 95% CI −14.53 to 19.73; 1 study, 126 participants; very low certainty evidence), and sleep score (MD 2.80, 95% CI 0.18 to 5.42; 1 study, 50 participants; very low certainty evidence) within three months. We are also very uncertain about potential adverse effects of melatonin: headache (RR 2.77, 95% CI 0.33 to 23.14; 1 study, 25 participants; very low certainty evidence); fatigue (RR 1.02, 95% CI 0.90 to 1.17; 2 studies, 170 participants; very low certainty evidence); and nausea (RR 1.01, 95% CI 0.66 to 1.56; 1 study, 146 participants; very low certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of high risk of bias, small sample size, the width of the 95% confidence interval, and indirectness due to inadequate reporting of cancer type. Melatonin plus standard treatment versus standard treatment No data are available relating to quality of life and sleep within three months. The evidence is very uncertain about headaches (experienced by 15 of 820 participants in melatonin groups, with no data available for control groups; 2 studies, 1640 participants; very low certainty evidence). Melatonin likely reduces the incidence of fatigue (RR 0.46, 95% CI 0.39 to 0.55; 10 studies, 1359 participants; moderate‐certainty evidence) and may reduce nausea (RR 0.85, 95% CI 0.72 to 1.00; 6 studies, 710 participants; low‐certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of the high risk of bias and the width of the 95% confidence interval. Melatonin (topical use) plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life (one study reported no difference between groups, both having the same median score of 66.7; 48 participants; very low certainty evidence). No data are available relating to sleep and adverse events (including headache, dizziness, fatigue, and nausea). We downgraded the certainty of the evidence because of the high risk of bias, small sample size, and insufficient data. Authors' conclusions The available evidence is of very low certainty, so we are unable to draw conclusions about the effects of melatonin on quality of life and sleep at three months in people receiving treatment for cancer. There may be no difference in adverse events between melatonin plus standard treatment and placebo plus standard treatment, but the evidence is very uncertain. Data were lacking for some outcomes, such as dizziness. Melatonin used alongside standard treatment probably reduces the risk of fatigue and may reduce nausea when compared to standard treatment alone. Since the evidence base for melatonin in people with cancer is limited due to insufficient data and risks of bias in study design, the decision for or against using melatonin as an adjunct to cancer treatment cannot easily be made at the current time. Funding This Cochrane Review was partially funded by AG Biologische Krebstherapie, Deutsche Krebshilfe (grant numbers 70‐301 and 109863). The funding agency had no role in the design or conduct of the study. Registration The protocol for this review is available via DOI 10.1002/14651858.CD010145. Plain language summary For cancer patients, what are the benefits and risks of taking the hormone melatonin? Key messages Due to a lack of robust evidence, the effects of melatonin on quality of life and sleep quality in people receiving treatment for cancer are unclear. Melatonin might not increase the risk of adverse events, but the available evidence is not strong enough for us to be certain. Well designed studies using melatonin over a period of up to three months are needed to give better estimates of the benefits and risks. What is melatonin? Melatonin is a hormone produced in the body to regulate the daily sleep and wakefulness cycle. It has been suggested that melatonin may improve sleep quality and quality of life, which are very important in cancer treatment. Moreover, there is research suggesting that melatonin is effective against solid tumours and may be effective for the treatment of cancer. What did we want to find out? We wanted to find out if melatonin can be used in cancer treatment, particularly for preserving the quality of life and sleep quality of cancer patients. We also wanted to find out if melatonin causes any unwanted side effects ('adverse events'). What did we do? We searched for studies that looked at melatonin used with other standard cancer treatments compared with standard cancer treatments used alone or with placebo (fake treatment). What did we find? We found 30 studies that involved 5093 cancer patients, both men and women, with cancer of any type. The studies were conducted in 10 countries around the world. We focused on the effects of melatonin over a period of three months. When compared to placebo plus standard cancer treatments, it is unclear if melatonin has an effect on quality of life and sleep. Melatonin may have little to no effect on potential adverse events like headache, fatigue, and nausea, but we are very uncertain about these results. No results are available for dizziness. We found no studies to help us answer our questions about quality of life and sleep quality when melatonin is used with standard cancer treatments compared to the standard treatment alone. However, the studies did evaluate potential adverse events that might be related to melatonin, and they found that melatonin probably reduces the risk of tiredness (fatigue), and may reduce the risk of feeling sick (nausea). It is unclear if melatonin has an effect on headaches. No results are available for dizziness. When melatonin is used topically, such as in a cream to put on the skin or in a mouth wash, it is unclear if it has an effect on quality of life. We found no studies to help us answer our questions about sleep quality. No data are available for adverse events like headache, fatigue, nausea, and dizziness, as these are not relevant if the melatonin is used topically. It is unclear if melatonin has any other unwanted effects when used topically. What are the limitations of the evidence? We are not confident in the evidence because it is possible that people in the studies were aware of which treatment they were getting. The evidence relating to some benefits and risks we are interested in does not cover all cancer types, or it is based on only a few cases. How up to date is this evidence? The evidence is up‐to‐date to September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Yu, ZY; Peng, RY; Cheng, N; Wang, RT; Nan, MD; Milazzo, S; Pilkington, K; Seely, D; Horneber, M; Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010145.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "8a66ebda-f48f-4ba5-ba77-60061f2ca353", "pmid": "", "title": "Salty Taste: Assessing a Strategy to Reduce Children's Preference", "imported": false, "abstract": "The goals of the proposed research are to determine whether repeated exposure to a low sodium food will result in reduced preference for salt in that food among children; and to determine whether such reductions in preference are related to dietary intake of salt, taste receptor genotype, and anthropometric and physiological measures.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.233Z" }, { "id": "8a7afc0f-01b0-47f3-9af4-e17ebb9331a4", "pmid": "", "title": "Zinc supplements for preventing otitis media", "imported": false, "abstract": "Abstract - Background Otitis media is inflammation of the middle ear and is usually caused by infection. It affects people of all ages but is particularly common in young children. Around 164 million people worldwide have long‐term hearing loss caused by this condition, 90% of them in low‐income countries. As zinc supplements prevent pneumonia in disadvantaged children, we wanted to investigate whether zinc supplements could also prevent otitis media. Objectives To evaluate whether zinc supplements prevent otitis media in adults and children of different ages. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (1950 to February week 4, 2014) and EMBASE (1974 to March 2014). Selection criteria Randomised, placebo‐controlled trials of zinc supplements given at least once a week for at least a month for preventing otitis media. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of the included trials and extracted and analysed data. We summarised results using risk ratios (RRs) or rate ratios for dichotomous data and mean differences (MDs) for continuous data. We combined trial results where appropriate. Main results No new trials were identified for inclusion in this update. We identified 12 trials for inclusion, 10 of which contributed outcomes data. There were a total of 6820 participants. In trials of healthy children living in low‐income communities, two trials did not demonstrate a significant difference between the zinc‐supplemented and placebo groups in the numbers of participants experiencing an episode of definite otitis media during follow‐up (3191 participants); another trial showed a significantly lower incidence rate of otitis media in the zinc group (rate ratio 0.69, 95% confidence interval (CI) 0.61 to 0.79, n = 1621). A small trial of 39 infants undergoing treatment for severe malnutrition suggested a benefit of zinc for the mean number of episodes of otitis media (mean difference (MD) ‐1.12 episodes, 95% CI ‐2.21 to ‐0.03). Zinc supplements did not seem to cause any serious adverse events but a small minority of children were reported to have vomited shortly after ingestion of the supplements. The trial evidence included is generally of good quality, with a low risk of bias. Authors' conclusions Evidence on whether zinc supplementation can reduce the incidence of otitis media in healthy children under the age of five years living in low‐ and middle‐income countries is mixed. There is some evidence of benefit in children being treated for marasmus (severe malnutrition), but this is based on one small trial and should therefore be treated with caution. Plain language summary Zinc supplements for preventing middle ear infections Background Middle ear infections are common, especially among young children, usually causing earache and some temporary (occasionally permanent) hearing loss. Zinc is an essential micronutrient, which has a role in the optimal functioning of the immune system and resistance to infection. It must be consumed regularly as it cannot be stored in the body. Some people, especially children in low‐ and middle‐income countries, may not have adequate zinc intake from food alone. Researchers have examined the potential role of zinc supplements in preventing infective illnesses. Therefore we wanted to discover whether zinc supplements have any role in preventing middle ear infections. Study characteristics The review authors searched the medical literature for studies up to March 2014. We searched for trials which compared middle ear infections in people randomly selected to receive zinc supplements or who did not receive supplements. We found 10 eligible studies, all conducted amongst young children. The total number of participants was 6820. Nine trials were conducted in low‐ and middle‐income countries. Seven trials were conducted on healthy children. Participants included both males and females. Results The results of the trials provided no convincing evidence that zinc supplements reduce the occurrence of middle ear infections in healthy children. However, in one small study of severely malnourished children, those receiving zinc supplements had fewer middle ear infections. The only adverse effect was vomiting. Quality of evidence The trial evidence included is generally of good quality, with a low risk of bias. All the included trials included otitis media only as a secondary outcome. Therefore, there was a potential to miss trials which were less publicised or less well indexed within the electronic databases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Gulani, A; Sachdev, HS", "articleTypes": [], "doi": "10.1002/14651858.CD006639.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "8a7ff769-4c10-4560-8158-c9fad748a356", "pmid": "", "title": "Colchicine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Colchicine has been used for patients with primary biliary cirrhosis because of its immunomodulatory and antifibrotic potential. The therapeutical responses to colchicine in randomised clinical trials were inconsistent. Objectives To evaluate the beneficial and harmful effects of colchicine in patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials on The Cochrane Library , MEDLINE, EMBASE (September 2003) , and manual searches of bibliographies. We contacted authors of trials and pharmaceutical companies. Selection criteria Randomised clinical trials comparing colchicine with any kind of control therapy were included irrespective of language, year of publication, and publication status. Data collection and analysis The primary outcomes were the number of deaths and the number of death and/or patients who underwent liver transplantation. Dichotomous outcomes were reported as relative risk (RR) with 95% confidence interval (CI). We examined intervention effects by using both a fixed effect model and a random effects model. Heterogeneity was investigated by subgroup analyses and sensitivity analyses. Main results Eleven randomised clinical trials involving 716 patients with primary biliary cirrhosis fulfilled the inclusion criteria. No significant differences were detected between colchicine and placebo/no intervention on the number of deaths (RR 1.21, 95% CI 0.71 to 2.06), the number of deaths and/or patients who underwent liver transplantation (RR 1.00, 95% CI 0.67 to 1.49), liver complications, liver biochemical variables, liver histological measurements, and adverse events. Trial methodology was generally low and some trials had high drop‐out rate. A best‐worst‐case‐scenario analysis showed no significant effect of colchicine on mortality (RR 0.59, 95%CI 0.30 to 1.15), while a worst‐best‐case‐scenario analysis showed a significant detrimental effect of colchicine on mortality (RR 2.28, 95% CI 1.17 to 4.44). Colchicine significantly decreased the number of patients without improvement of pruritus (RR 0.75, 95% CI 0.65 to 0.87). However, this estimate was based on only 156 patients from three trials. The effect of the combined treatment with ursodeoxycholic acid was not significantly different from that of colchicine alone. Authors' conclusions We did not find evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis. As we are not able to exclude a detrimental effect of colchicine, we suggest that it is only used in randomised clinical trials. Plain language summary No convincing evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis Primary biliary cirrhosis is a rare, chronic liver disease of unknown etiology. Colchicine, a plant alkaloid, has been used to treat patients with primary biliary cirrhosis and was tested in randomised clinical trials. When all identified trials were combined, colchicine appeared to be not significantly different from placebo/no intervention in respect to mortality, mortality and/or patients who underwent liver transplantation, liver complications, liver biochemistry, liver histology, and the occurrences of adverse events. Colchicine may reduce pruritus, but this finding may be due to bias. The addition of ursodeoxycholic acid did not significantly influence the effect of colchicine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "8a8a7860-e285-41e4-9554-b89bd7129295", "pmid": "", "title": "Supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults", "imported": false, "abstract": "Abstract - Background Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy. Objectives To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults. Search methods We identified publications from comprehensive searches of the Cochrane Library , MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016. Selection criteria Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care. Data collection and analysis Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta‐analyses for the outcome measures, 'all‐cause mortality', 'hospitalisation' and 'nutritional status (weight change)'. Main results Forty‐one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow‐up ranged from ‘duration of hospital stay’ to 12 months. The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all‐cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate‐quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low‐quality evidence). Only five trials (4451 participants) investigated health‐related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of ‐0.5 days (95% CI ‐2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low‐quality evidence. Only three of 41 included trials (4108 participants; very low‐quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta‐analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate‐quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low‐quality evidence). Authors' conclusions There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all‐cause mortality for supportive interventions comes from hospital‐based trials and more research is needed to confirm this effect. There is very low‐quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient‐important outcomes in future research. Plain language summary Supportive interventions for improving dietary intake in nutritionally vulnerable groups Review question Are supportive interventions for improving dietary intake in nutritionally vulnerable groups (malnourished or nutritionally at‐risk individuals) effective? Background Serving meals in a dining room, or the use of assistance to help feed people in need and other similar methods are often recommended to help especially sick and elderly people who have lost or are likely to lose weight (nutritionally vulnerable groups). Such supportive interventions are implemented in the health care in many countries but their effects are not well investigated. Study characteristics We included 41 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 10,681 people in our review. There were five different interventions which we call 'supportive interventions': changes to the organisation of nutritional care (13 studies, 3456 people), changes to the feeding environment (5 studies, 351 people), modification of the meal profile or pattern (12 studies, 649 people), additional supplementation of meals (10 studies, 6022 people) and home meal delivery systems (1 study, 203 people). Monitoring participants over time (follow‐up) ranged from ‘duration of hospital stay’ to 12 months. The comparator groups received 'usual' care. More than half of all participants took part in studies investigating the additional supplementation of meals (for example a protein‐energy oral nutritional supplement in addition to the usual diet). Key results It is possible that supportive interventions for enhancing dietary intake in nutritionally vulnerable groups reduce death from any cause (approximately 23 fewer cases of death per 1000 participants in favour of supportive interventions). However, this has to be confirmed by more evidence from high‐quality randomised controlled studies. The number of participants experiencing any medical complication did not differ substantially between the supportive interventions and the comparator groups. The same was found for health‐related quality of life (which is physical, mental, emotional and social health attributed to health), patient satisfaction, nutritional or energy intake and days spent in hospital. Economic costs were not well investigated. Only three studies reported on side effects, describing intolerance to the nutritional supplement (such as diarrhoea or vomiting in 5 of 34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567 of 2017 participants). After analysing 15 studies in 1945 participants we found a beneficial effect of supportive interventions compared with comparators on weight: on average people in the supportive interventions groups increased their weight 0.6 kg more than people in the comparator groups. This evidence is up to date as of September 2016. Quality of evidence The overall quality of evidence ranged between moderate to very low, mainly because for most of our outcomes there was only a small number of studies and participants to achieve reliable information, or because risk of bias made results uncertain. However, if some randomised controlled studies with low risk of bias for our patient‐important outcomes and a good number of participants were performed, this review could quickly provide good guidance for better health care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Baldwin, C, Kimber, KL, Gibbs, M, Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD009840.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.732Z" }, { "id": "8aa37c93-b545-4647-8f9a-46555b9dd612", "pmid": "", "title": "Sodium channel blockers for cystic fibrosis", "imported": false, "abstract": "Abstract - Background People with cystic fibrosis (CF) have increased transport of the salt, sodium across their airway lining. Over‐absorption of sodium results in the dehydration of the liquid that lines the airway surface and (along with defective chloride secretion) is a primary defect in people with CF. Objectives To determine whether the topical administration of drugs that block sodium transport improves the respiratory condition of people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We contacted principal investigators known to work in the field, previous authors and pharmaceutical companies who manufacture ion transport agents for unpublished or follow‐up data. Most recent search of the Group's register: 19 December 2013. Selection criteria Published or unpublished randomised controlled trials (RCTs) or quasi‐randomised controlled trials of sodium channel blockers compared to placebo or another sodium channel blocker or the same sodium channel blocker at a different dosing regimen. Data collection and analysis Two authors independently extracted data. Meta‐analysis was limited due to differing study designs. Main results Five RCTs, with a total of 226 participants, examining the topical administration of the short‐acting sodium channel blocker, amiloride, compared to placebo were identified as eligible for inclusion in the review. In three studies over six months, there was a significant difference found in the difference in relative change in FVC in favour of placebo (weighted mean difference 1.51% (95% confidence interval ‐2.77 to ‐0.25), although heterogeneity was evident. A two‐week study demonstrated that hypertonic saline with amiloride pre‐treatment did not result in a significant improvement in respiratory function or mucus clearance, in contrast to pre‐treatment with placebo. There were no significant differences identified in other clinically relevant outcomes. Authors' conclusions We found no evidence that the topical administration of a short‐acting sodium channel blocker improves respiratory condition in people with cystic fibrosis and some limited evidence of deterioration in lung function. Plain language summary Drugs to control the movement of salt in the lungs of people with cystic fibrosis Usually salt is absorbed from liquid on the surface of the lungs to stop fluid building up there. In cystic fibrosis too much salt is absorbed and there is little liquid left on the airway surfaces. As a result people with cystic fibrosis have problems clearing their lungs of sticky secretions. Thus the lungs are left open to infection. Drugs applied directly to the lungs may prevent too much salt being absorbed. This may lead to better clearance of mucus and less lung infection and damage. The review includes five studies with a total of 226 participants. All studies looked at short‐acting drugs applied directly to the lungs compared to placebo. When the results from three studies over six months were combined, the placebo group showed a slower rate of decline in forced vital capacity than the treatment group. However, each of these differed in their results. A further study showed that people receiving a sodium channel blocker before receiving hypertonic saline did not achieve better lung function or mucus clearance than those receiving placebo before hypertonic saline. We found no evidence that short‐acting sodium channel blockers administered directly to the lungs improve respiratory status in people with cystic fibrosis. There was even some limited evidence of a decline in lung function. Trials of long‐acting sodium channel blockers are ongoing.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Burrows, EF, Southern, KW, Noone, PG", "articleTypes": [], "doi": "10.1002/14651858.CD005087.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.755Z" }, { "id": "8acfae17-7255-4da8-9ded-f740671219f3", "pmid": "", "title": "Antibiotics to prevent complications following tooth extractions", "imported": false, "abstract": "Abstract - Background The most frequent indications for tooth extractions, generally performed by general dental practitioners, are dental caries and periodontal infections. Systemic antibiotics may be prescribed to patients undergoing extractions to prevent complications due to infection. This is an update of a review first published in 2012. Objectives To determine the effect of systemic antibiotic prophylaxis on the prevention of infectious complications following tooth extractions. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 16 April 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 3), MEDLINE Ovid (1946 to 16 April 2020), Embase Ovid (1980 to 16 April 2020), and LILACS (1982 to 16 April 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised, double‐blind, placebo‐controlled trials of systemic antibiotic prophylaxis in patients undergoing tooth extraction(s) for any indication. Data collection and analysis At least two review authors independently performed data extraction and 'Risk of bias' assessment for the included studies. We contacted trial authors for further details where these were unclear. For dichotomous outcomes, we calculated risk ratios (RR) and 95% confidence intervals (CI) using random‐effects models. For continuous outcomes, we used mean differences (MD) with 95% CI using random‐effects models. We examined potential sources of heterogeneity. We assessed the certainty of the body of evidence for key outcomes as high, moderate, low, or very low, using the GRADE approach. Main results We included 23 trials that randomised approximately 3206 participants (2583 analysed) to prophylactic antibiotics or placebo. Although general dentists perform dental extractions because of severe dental caries or periodontal infection, only one of the trials evaluated the role of antibiotic prophylaxis in groups of patients affected by those clinical conditions. We assessed 16 trials as being at high risk of bias, three at low risk, and four as unclear. Compared to placebo, antibiotics may reduce the risk of postsurgical infectious complications in patients undergoing third molar extractions by approximately 66% (RR 0.34, 95% CI 0.19 to 0.64; 1728 participants; 12 studies; low‐certainty evidence), which means that 19 people (95% CI 15 to 34) need to be treated with antibiotics to prevent one infection following extraction of impacted wisdom teeth. Antibiotics may also reduce the risk of dry socket by 34% (RR 0.66, 95% CI 0.45 to 0.97; 1882 participants; 13 studies; low‐certainty evidence), which means that 46 people (95% CI 29 to 62) need to take antibiotics to prevent one case of dry socket following extraction of impacted wisdom teeth. The evidence for our other outcomes is uncertain: pain, whether measured dichotomously as presence or absence (RR 0.59, 95% CI 0.31 to 1.12; 675 participants; 3 studies) or continuously using a visual analogue scale (0‐to‐10‐centimetre scale, where 0 is no pain) (MD −0.26, 95% CI −0.59 to 0.07; 422 participants; 4 studies); fever (RR 0.66, 95% CI 0.24 to 1.79; 475 participants; 4 studies); and adverse effects, which were mild and transient (RR 1.46, 95% CI 0.81 to 2.64; 1277 participants; 8 studies) (very low‐certainty evidence). We found no clear evidence that the timing of antibiotic administration (preoperative, postoperative, or both) was important. The included studies enrolled a subset of patients undergoing dental extractions, that is healthy people who had surgical extraction of third molars. Consequently, the results of this review may not be generalisable to all people undergoing tooth extractions. Authors' conclusions The vast majority (21 out of 23) of the trials included in this review included only healthy patients undergoing extraction of impacted third molars, often performed by oral surgeons. None of the studies evaluated tooth extraction in immunocompromised patients. We found low‐certainty evidence that prophylactic antibiotics may reduce the risk of infection and dry socket following third molar extraction when compared to placebo, and very low‐certainty evidence of no increase in the risk of adverse effects. On average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection. It is unclear whether the evidence in this review is generalisable to patients with concomitant illnesses or patients at a higher risk of infection. Due to the increasing prevalence of bacteria that are resistant to antibiotic treatment, clinicians should evaluate if and when to prescribe prophylactic antibiotic therapy before a dental extraction for each patient on the basis of the patient's clinical conditions (healthy or affected by systemic pathology) and level of risk from infective complications. Immunocompromised patients, in particular, need an individualised approach in consultation with their treating medical specialist. Plain language summary Are antibiotics an effective way to prevent infection following tooth removal? What is the problem? Teeth that are affected by decay or gum disease or painful wisdom teeth are often removed (extracted) by dentists. Tooth extraction is a surgical procedure that leaves a wound in the mouth that can become infected. Infection can lead to swelling, pain, development of pus, fever, as well as ‘dry socket’ (where the tooth socket is not filled by a blood clot, and there is severe pain and bad odour). These complications are unpleasant for patients and may cause difficulty with chewing, speaking, and teeth cleaning, and may even result in days off work or study. Treatment of infection is generally simple and involves drainage of the infection from the wound and patients receiving antibiotics. Why is this question important? Antibiotics work by killing the bacteria that cause infections, or by slowing their growth. However, some infections clear up by themselves. Taking antibiotics unnecessarily may stop them working effectively in future. This ‘antimicrobial resistance’ is a growing problem throughout the world. Antibiotics may also cause unwanted effects such as diarrhoea and nausea. Some patients may be allergic to antibiotics, and antibiotics may not mix well with other medicines. Dentists frequently give patients antibiotics at the time of the extraction as a precaution in order to prevent infection occurring in the first place. This may be unnecessary and may lead to unwanted effects. What did we want to find out? We wanted to know whether giving antibiotics as a preventive measure reduces infection and other complications after tooth extraction. We also wanted to understand whether antibiotics work differently in healthy people compared with people with health conditions such as diabetes or HIV. What did we do? We searched for studies that assessed the effectiveness of antibiotics compared to placebo (sham medicine), given when no infection was present in order to prevent infection following tooth extraction. Studies could include people of any age undergoing tooth extraction. Where possible, we pooled the studies’ results and analysed them together. We also assessed the quality of each study to judge the reliability (certainty) of evidence of individual studies and the body of evidence. What we found We found 23 included studies with a total of more than 3200 participants, who received either antibiotics (of different kinds and dosages) or placebo immediately before or just after tooth extraction, or both. Four studies were conducted in Spain, three each in Brazil, Sweden, and the UK, two in India, and one each in Colombia, Denmark, Finland, France, Poland, New Zealand, Nigeria, and the USA. All but one study included healthy patients in their 20s. Twenty‐one studies assessed the removal of wisdom teeth in hospital dental departments, one assessed the removal of other teeth and one assessed complex oral surgery. None of the included studies assessed tooth extraction in general dental practice for the removal of decayed teeth. Main results Antibiotics given just before or just after surgery (or both) may reduce the risk of infection and dry socket after the removal of wisdom teeth by oral surgeons. However, antibiotics may cause more (generally brief and minor) unwanted effects for these patients. We found no evidence that antibiotics prevent pain, fever, swelling, or problems with restricted mouth opening in patients who have had wisdom teeth removed. There was no evidence to judge the effects of preventive antibiotics for extractions of severely decayed teeth, teeth in diseased gums, or extractions in patients who are sick or have low immunity to infection. How reliable are the results? Our confidence in the results is limited because we had concerns about aspects of the design and reporting of all of the included studies. What does this mean? We did not find studies in patients with depressed immune systems, other illnesses, or in young children or older patients, therefore the results of our review probably do not apply to people who may be at high risk of infection. Also, extractions were mainly carried out by oral surgeons, so the review may not apply to dentists working in general practice. Another concern, which cannot be assessed by clinical studies (i.e. studies testing new medical approaches in people), is that widespread use of antibiotics by people who do not have an infection is likely to contribute to the development of antimicrobial resistance. We concluded that antibiotics given to healthy people when they are having teeth extracted may help prevent infection, but the decision to use an antibiotic should be judged on an individual patient basis based on their state of health and possible complications of getting an infection. How up‐to‐date is this review? This is an updated review. The evidence is current to April 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lodi, G, Azzi, L, Varoni, EM, Pentenero, M, Del Fabbro, M, Carrassi, A, Sardella, A, Manfredi, M", "articleTypes": [], "doi": "10.1002/14651858.CD003811.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.768Z" }, { "id": "8ad49cdc-0021-44df-aa01-954545280194", "pmid": "", "title": "Physical interventions to interrupt or reduce the spread of respiratory viruses", "imported": false, "abstract": "Abstract - Background Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID‐19) caused by SARS‐CoV‐2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID‐19 pandemic. Objectives To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. Search methods We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies. Selection criteria We included randomised controlled trials (RCTs) and cluster‐RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission. Data collection and analysis We used standard Cochrane methodological procedures. Main results We included 11 new RCTs and cluster‐RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID‐19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID‐19 pandemic. Many studies were conducted during non‐epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID‐19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high‐income countries; crowded inner city settings in low‐income countries; and an immigrant neighbourhood in a high‐income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster‐RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster‐RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza‐like illness (ILI)/COVID‐19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate‐certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory‐confirmed influenza/SARS‐CoV‐2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate‐certainty evidence). Harms were rarely measured and poorly reported (very low‐certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low‐certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low‐certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory‐confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate‐certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low‐certainty evidence). One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non‐inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID‐19 patients. Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta‐analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate‐certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory‐confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low‐certainty evidence), and laboratory‐confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low‐certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low‐certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low‐certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports. Authors' conclusions The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory‐confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under‐investigated. There is a need for large, well‐designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs. Plain language summary Do physical measures such as hand‐washing or wearing masks stop or slow down the spread of respiratory viruses? Key messages 
We are uncertain whether wearing masks or N95/P2 respirators helps to slow the spread of respiratory viruses based on the studies we assessed. Hand hygiene programmes may help to slow the spread of respiratory viruses. How do respiratory viruses spread? 
Respiratory viruses are viruses that infect the cells in your airways: nose, throat, and lungs. These infections can cause serious problems and affect normal breathing. They can cause flu (influenza), severe acute respiratory syndrome (SARS), and COVID‐19. People infected with a respiratory virus spread virus particles into the air when they cough or sneeze. Other people become infected if they come into contact with these virus particles in the air or on surfaces on which they land. Respiratory viruses can spread quickly through a community, through populations and countries (causing epidemics), and around the world (causing pandemics). Physical measures to try to prevent respiratory viruses spreading between people include: · washing hands often; · not touching your eyes, nose, or mouth; · sneezing or coughing into your elbow; · wiping surfaces with disinfectant; · wearing masks, eye protection, gloves, and protective gowns; · avoiding contact with other people (isolation or quarantine); · keeping a certain distance away from other people (distancing); and · examining people entering a country for signs of infection (screening). What did we want to find out? 
We wanted to find out whether physical measures stop or slow the spread of respiratory viruses from well‐controlled studies in which one intervention is compared to another, known as randomised controlled trials. What did we do? 
We searched for randomised controlled studies that looked at physical measures to stop people acquiring a respiratory virus infection. We were interested in how many people in the studies caught a respiratory virus infection, and whether the physical measures had any unwanted effects. What did we find? 
We identified 78 relevant studies. They took place in low‐, middle‐, and high‐income countries worldwide: in hospitals, schools, homes, offices, childcare centres, and communities during non‐epidemic influenza periods, the global H1N1 influenza pandemic in 2009, epidemic influenza seasons up to 2016, and during the COVID‐19 pandemic. We identified five ongoing, unpublished studies; two of them evaluate masks in COVID‐19. Five trials were funded by government and pharmaceutical companies, and nine trials were funded by pharmaceutical companies. No studies looked at face shields, gowns and gloves, or screening people when they entered a country. We assessed the effects of: · medical or surgical masks; · N95/P2 respirators (close‐fitting masks that filter the air breathed in, more commonly used by healthcare workers than the general public); and · hand hygiene (hand‐washing and using hand sanitiser). We obtained the following results: Medical or surgical masks Ten studies took place in the community, and two studies in healthcare workers. Compared with wearing no mask in the community studies only, wearing a mask may make little to no difference in how many people caught a flu‐like illness/COVID‐like illness (9 studies; 276,917 people); and probably makes little or no difference in how many people have flu/COVID confirmed by a laboratory test (6 studies; 13,919 people). Unwanted effects were rarely reported; discomfort was mentioned. N95/P2 respirators Four studies were in healthcare workers, and one small study was in the community. Compared with wearing medical or surgical masks, wearing N95/P2 respirators probably makes little to no difference in how many people have confirmed flu (5 studies; 8407 people); and may make little to no difference in how many people catch a flu‐like illness (5 studies; 8407 people), or respiratory illness (3 studies; 7799 people). Unwanted effects were not well‐reported; discomfort was mentioned. Hand hygiene Following a hand hygiene programme may reduce the number of people who catch a respiratory or flu‐like illness, or have confirmed flu, compared with people not following such a programme (19 studies; 71,210 people), although this effect was not confirmed as statistically significant reduction when ILI and laboratory‐confirmed ILI were analysed separately. Few studies measured unwanted effects; skin irritation in people using hand sanitiser was mentioned. What are the limitations of the evidence? 
Our confidence in these results is generally low to moderate for the subjective outcomes related to respiratory illness, but moderate for the more precisely defined laboratory‐confirmed respiratory virus infection, related to masks and N95/P2 respirators. The results might change when further evidence becomes available. Relatively low numbers of people followed the guidance about wearing masks or about hand hygiene, which may have affected the results of the studies. How up to date is this evidence? 
We included evidence published up to October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jefferson, T; Dooley, L; Ferroni, E; Al-Ansary, LA; van Driel, ML; Bawazeer, GA; Jones, MA; Hoffmann, TC; Clark, J; Beller, EM; Glasziou, PP; Conly, JM", "articleTypes": [], "doi": "10.1002/14651858.CD006207.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "8ae6c56f-80e2-4838-bbcf-e3631b40f6ae", "pmid": "", "title": "Pharmacological interventions for preventing dry mouth and salivary gland dysfunction following radiotherapy", "imported": false, "abstract": "Abstract - Background Salivary gland dysfunction is an 'umbrella' term for the presence of either xerostomia (subjective sensation of dryness), or salivary gland hypofunction (reduction in saliva production). It is a predictable side effect of radiotherapy to the head and neck region, and is associated with a significant impairment of quality of life. A wide range of pharmacological interventions, with varying mechanisms of action, have been used for the prevention of radiation‐induced salivary gland dysfunction. Objectives To assess the effects of pharmacological interventions for the prevention of radiation‐induced salivary gland dysfunction. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 14 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 14 September 2016); MEDLINE Ovid (1946 to 14 September 2016); Embase Ovid (1980 to 14 September 2016); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 14 September 2016); LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 14 September 2016); Zetoc Conference Proceedings (1993 to 14 September 2016); and OpenGrey (1997 to 14 September 2016). We searched the US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials, irrespective of their language of publication or publication status. Trials included participants of all ages, ethnic origin and gender, scheduled to receive radiotherapy on its own or in addition to chemotherapy to the head and neck region. Participants could be outpatients or inpatients. We included trials comparing any pharmacological agent regimen, prescribed prophylactically for salivary gland dysfunction prior to or during radiotherapy, with placebo, no intervention or an alternative pharmacological intervention. Comparisons of radiation techniques were excluded. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 39 studies that randomised 3520 participants; the number of participants analysed varied by outcome and time point. The studies were ordered into 14 separate comparisons with meta‐analysis only being possible in three of those. We found low‐quality evidence to show that amifostine, when compared to a placebo or no treatment control, might reduce the risk of moderate to severe xerostomia (grade 2 or higher on a 0 to 4 scale) at the end of radiotherapy (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.19 to 0.67; P = 0.001, 3 studies, 119 participants), and up to three months after radiotherapy (RR 0.66, 95% CI 0.48 to 0.92; P = 0.01, 5 studies, 687 participants), but there is insufficient evidence that the effect is sustained up to 12 months after radiotherapy (RR 0.70, 95% CI 0.40 to 1.23; P = 0.21, 7 studies, 682 participants). We found very low‐quality evidence that amifostine increased unstimulated salivary flow rate up to 12 months after radiotherapy, both in terms of mg of saliva per 5 minutes (mean difference (MD) 0.32, 95% CI 0.09 to 0.55; P = 0.006, 1 study, 27 participants), and incidence of producing greater than 0.1 g of saliva over 5 minutes (RR 1.45, 95% CI 1.13 to 1.86; P = 0.004, 1 study, 175 participants). However, there was insufficient evidence to show a difference when looking at stimulated salivary flow rates. There was insufficient (very low‐quality) evidence to show that amifostine compromised the effects of cancer treatment when looking at survival measures. There was some very low‐quality evidence of a small benefit for amifostine in terms of quality of life (10‐point scale) at 12 months after radiotherapy (MD 0.70, 95% CI 0.20 to 1.20; P = 0.006, 1 study, 180 participants), but insufficient evidence at the end of and up to three months postradiotherapy. A further study showed no evidence of a difference at 6, 12, 18 and 24 months postradiotherapy. There was low‐quality evidence that amifostine is associated with increases in: vomiting (RR 4.90, 95% CI 2.87 to 8.38; P < 0.00001, 5 studies, 601 participants); hypotension (RR 9.20, 95% CI 2.84 to 29.83; P = 0.0002, 3 studies, 376 participants); nausea (RR 2.60, 95% CI 1.81 to 3.74; P < 0.00001, 4 studies, 556 participants); and allergic response (RR 7.51, 95% CI 1.40 to 40.39; P = 0.02, 3 studies, 524 participants). We found insufficient evidence (that was of very low quality) to determine whether or not pilocarpine performed better or worse than a placebo or no treatment control for the outcomes: xerostomia, salivary flow rate, survival, and quality of life. There was some low‐quality evidence that pilocarpine was associated with an increase in sweating (RR 2.98, 95% CI 1.43 to 6.22; P = 0.004, 5 studies, 389 participants). We found insufficient evidence to determine whether or not palifermin performed better or worse than placebo for: xerostomia (low quality); survival (moderate quality); and any adverse effects. There was also insufficient evidence to determine the effects of the following interventions: biperiden plus pilocarpine, Chinese medicines, bethanechol, artificial saliva, selenium, antiseptic mouthrinse, antimicrobial lozenge, polaprezinc, azulene rinse, and Venalot Depot (coumarin plus troxerutin). Authors' conclusions There is some low‐quality evidence to suggest that amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months postradiotherapy). However, it is less clear whether or not this effect is sustained to 12 months postradiotherapy. The benefits of amifostine should be weighed against its high cost and side effects. There was insufficient evidence to show that any other intervention is beneficial. Plain language summary Drugs for preventing dry mouth and problems with saliva after radiotherapy Review question To assess the effects of treatment with drugs in order to prevent damage to salivary glands following radiotherapy to the head and neck Background Problems with saliva production and salivary glands are a significant and mostly permanent side effect for people after radiotherapy treatment to the head and neck. When this occurs the condition is known as dry mouth or xerostomia. Dry mouth is not measurable and is a subjective or personal expression of how the mouth feels. It can have other causes and is a consequence of the production of less saliva or by the consistency of saliva. The rate of flow of saliva in an individual's mouth however can be measured. People who have dry mouth have a reduced quality of life. They can experience issues with taste and general discomfort, difficulties chewing, swallowing and speaking as well as tooth decay, thrush and other infections of the mouth. A wide range of drugs that work in different ways have been used to try and prevent problems with salivary glands caused by radiotherapy. Unfortunately there is currently not enough evidence to show which drugs or which type of drugs are most effective. Study characteristics The evidence in this review is current up to 14 September 2016. 39 studies were included with a total of 3520 participants. Participants were male and female, all ages and ethnic origins, out patients or in patients, who were scheduled to have radiation therapy with or without chemotherapy to the head and neck. Drugs included were any prescribed to prevent salivary gland problems and given before or during radiotherapy. Information was collected from the end of radiotherapy except for that about adverse effects. Different techniques for giving radiation treatment that might reduce damage were not included. The main outcomes measured were participant's own assessment of dry mouth and the measurement of salivary flow. Secondary outcomes measured included adverse or unwanted effects such as sweating, crying, watery discharge from the nose, diarrhoea and nausea. Key results There is some low‐quality evidence to suggest that the drug amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months after radiotherapy). However it is less clear whether or not this effect is sustained to 12 months after radiotherapy. The benefits of amifostine should be weighed against its high costs and side effects. Adverse effects of vomiting, low blood pressure, feeling of sickness and allergic response were all more frequent in those receiving amifostine. There was insufficient evidence to show that any other treatment is beneficial. Quality of the evidence The quality of evidence for amifostine was found to be low because of risk of bias, inconsistency and imprecision caused by the small number of studies in the comparison or sample size. A standardized scale for measuring participant's experience of dry mouth would in future allow comparison and pooling together of results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P; Glenny, AM; Hua, F; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD012744", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "8aef6e79-4ab5-46f0-a90c-5d49bac6e596", "pmid": "", "title": "Interventions for the prevention and management of oropharyngeal candidiasis associated with HIV infection in adults and children", "imported": false, "abstract": "Abstract - Background Oral candidiasis (OC) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Left untreated, these lesions contribute considerably to the morbidity associated with HIV infection. Interventions aimed at preventing and treating HIV‐associated oral candidal lesions form an integral component of maintaining the quality of life for affected individuals. Objectives To determine the effects of any intervention in preventing or treating OC in children and adults with HIV infection. Search methods The search strategy was based on that of the Cochrane HIV/AIDS Review Group. The following electronic databases were searched for randomised controlled trials for the years 1982 to 2005: Medline, AIDSearch, EMBASE and CINAHL. The Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectiveness, and the Cochrane Central Register of Controlled Trials (CENTRAL) were also searched through May 2005. The abstracts of relevant conferences, including the International Conferences on AIDS and the Conference on Retroviruses and Opportunistic Infections, as indexed by AIDSLINE, were also reviewed. The strategy was iterative, in that references of included studies were searched for additional references. All languages were included. The updated database search was done for the period 2005 up to 2009. The following databases were searched: Medline, EMBASE, the Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectivenes s and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library. AIDSearch was not searched for the updated search as it ceased publication during 2008. Selection criteria Randomised controlled trials (RCTs) of palliative, preventative or curative therapy were considered, irrespective of whether the control group received a placebo. Participants were HIV positive adults and children. Data collection and analysis Two authors independently assessed the methodological quality of the trials and extracted data. Study authors were contacted for additional data where necessary. Main results For the first publication of the review in 2006, forty studies were retrieved. Twenty eight trials (n=3225) met inclusion criteria. During the update search for the review a, further six studies were identified. Of these, five met the inclusion criteria and were included in the review. The review now includes 33 studies (n=3445): 22 assessing treatment and 11 assessing prevention of oropharyngeal candidiasis. Six studies were done in developing countries, 16 in the United States of America and the remainder in Europe. Treatment 
 Treatment was assessed in the majority of trials looking at both clinical and mycological cures. In the majority of comparisons there was only one trial. Compared to nystatin, fluconazole favoured clinical cure in adults (1 RCT; n=167; RR 1.69; 95% CI 1.27 to 2.23). There was no difference with regard to clinical cure between fluconazole compared to ketoconazole (2 RCTs; n=83; RR 1.27; 95% CI 0.97 to 1.66), itraconazole (2 RCTs; n=434; RR 1.05; 95% CI 0.94 to 1.16), clotrimazole (2 RCTs; n=358; RR 1.14; 95% CI 0.92 to 1.42) or posaconazole (1 RCT; n=366; RR1.32; 95% CI 0.36 to 4.83). Two trials compared different dosages of fluconazole with no difference in clinical cure. When compared with clotrimazole, both fluconazole (2 RCTs; n=358; RR 1.47; 95% CI 1.16 to 1.87) and itraconazole (1 RCT; n=123; RR 2.20; 95% CI 1.43 to3.39) proved to be better for mycological cure. Both gentian violet (1 RCT; n=96; RR 5.28; 95% CI 1.23 to 22.55) and ketoconazole (1 RCT; n=92; RR 5.22; 95% CI 1.21 to 22.53) were superior to nystatin in bringing about clinical cure. A single trial compared gentian violet with lemon juice and lemon grass with no significant difference in clinical cure between the groups. 
 
 Prevention 
 Successful prevention was defined as the prevention of a relapse while receiving prophylaxis. Fluconazole was compared with placebo in five studies (5 RCTs; n=599; RR 0.61; 95% CI 0.5 to 0.74) and with no treatment in another (1 RCT; n=65; RR 0.16; 95% CI 0.08 to 0.34). In both instances the prevention of clinical episodes was favoured by fluconazole. Comparing continuous fluconazole treatment with intermittent treatment (2 RCTs; n=891; RR 0.65; 95% CI 0.23 to 1.83), there was no significant difference between the two treatment arms. Chlorhexidine was compared with normal saline in a single study with no significant difference between the treatment arms. Authors' conclusions Five new studies were added to the review, but their results do not alter the final conclusion of the review. Implications for practice 
 Due to there being only one study in children, it is not possible to make recommendations for treatment or prevention of OC in children. Amongst adults, there were few studies per comparison. Due to insufficient evidence, no conclusion could be made about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole or ketoconazole with regard to OC prophylaxis. In comparison to placebo, fluconazole is an effective preventative intervention. However, the potential for resistant Candida organisms to develop, as well as the cost of prophylaxis, might impact the feasibility of implementation. No studies were found comparing fluconazole with other interventions. The direction of findings suggests that ketoconazole, fluconazole, itraconazole and clotrimazole improved the treatment outcomes. Implications for research 
 It is encouraging that low‐cost alternatives are being tested, but more research needs to be on in this area and on interventions like gentian violet and other less expensive anti‐fungal drugs to treat OC. More well‐designed treatment trials with larger samples are needed to allow for sufficient power to detect differences in not only clinical, but also mycological, response and relapse rates. There is also a strong need for more research to be done on the treatment and prevention of OC in children as it is reported that OC is the most frequent fungal infection in children and adolescents who are HIV positive. More research on the effectiveness of less expensive interventions also needs to be done in resource‐poor settings. Currently few trials report outcomes related to quality of life, nutrition, or survival. Future researchers should consider measuring these when planning trials. Development of resistance remains under‐studied and more work must be done in this area. It is recommended that trials be more standardised and conform more closely to CONSORT. Plain language summary Interventions for the prevention and management of oral thrush associated with HIV infection in adults and children Oral candidiasis (thrush) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Interventions aimed at preventing and treating HIV‐associated oral thrush form an integral component of maintaining the quality of life for affected individuals. This review evaluated the effects of interventions in preventing or treating oral thrush in children and adults with HIV infection. Thirty three trials (n=3445) were included. Twenty two trials investigated treatment and eleven trials investigate prevention. There was no difference with regard to clinical cure between fluconazole compared to ketoconazole, itraconazole, clotrimazole and posaconazole. Fluconazole, gentian violet and ketoconazole were superior to nystatin. Compared to placebo and no treatment, fluconazole was effective in preventing clinical episodes from occurring. Continuous fluconazole was better than intermittent treatment. Insufficient evidence was found to come to any conclusion about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole, ketoconazole or chlorhexidine with regard to OC prophylaxis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Pienaar, ED; Young, T; Holmes, H", "articleTypes": [], "doi": "10.1002/14651858.CD003940.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "8afc70ef-a933-4bd4-8324-239791c484e4", "pmid": "", "title": "Interventions for preventing osteoradionecrosis of the jaws in adults receiving head and neck radiotherapy", "imported": false, "abstract": "Abstract - Background Osteoradionecrosis (ORN) of the jaws is among the most serious oral complications of head and neck cancer radiotherapy, arising from radiation‐induced fibro‐atrophic tissue injury, manifested by necrosis of osseous tissues and failure to heal, often secondary to operative interventions in the oral cavity. It is associated with considerable morbidity and has important quality of life ramifications. Since ORN is very difficult to treat effectively, preventive measures to limit the onset of this disease are needed; however, the effects of various preventive interventions has not been adequately quantified. Objectives To assess the effects of interventions for preventing ORN of the jaws in adult patients with head and neck cancer undergoing curative or adjuvant (i.e. non‐palliative) radiotherapy. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 5 November 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 10) in the Cochrane Library (searched 5 November 2019), MEDLINE Ovid (1946 to 5 November 2019), Embase Ovid (1980 to 5 November 2019), Allied and Complementary Medicine (AMED) Ovid (1985 to 5 November 2019), Scopus (1966 to 5 November 2019), Proquest Dissertations and Theses International (1861 to 5 November 2019) and Web of Science Conference Proceedings (1990 to 5 November 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We selected randomised controlled trials (RCTs) or quasi‐RCTs of adult patients 18 years or older with head and neck cancer who had undergone curative or adjuvant radiotherapy to the head and neck, who had received an intervention to prevent the onset of ORN. Eligible patients were those subjected to pre‐ or post‐irradiation dental evaluation. Management of these patients was to be with interventions independent of their cancer therapy, including but not limited to local, systemic, or behavioural interventions. Data collection and analysis Two review authors independently selected trials from search results, assessed risk of bias, and extracted relevant data for inclusion in the review. Authors of included studies were contacted to request missing data. We used standard methodological procedures expected by Cochrane. Main results Four studies were identified that met pre‐determined eligibility criteria, evaluating a total of 342 adults. From the four studies, all assessed as at high risk of bias, three broad interventions were identified that may potentially reduce the risk of ORN development: one study showed no reduction in ORN when using platelet‐rich plasma placed in the extraction sockets of prophylactically removed healthy mandibular molar teeth prior to radiotherapy (odds ratio (OR) 3.32, 95% confidence interval (CI) 0.58 to 19.09; one trial, 44 participants; very low‐certainty evidence). Another study involved comparing fluoride gel and high‐content fluoride toothpaste (1350 parts per million (ppm)) in prevention of post‐radiation caries, and found no difference between their use as no cases of ORN were reported (one trial, 220 participants; very low‐certainty evidence). The other two studies involved the use of perioperative hyperbaric oxygen (HBO) therapy and antibiotics. One study showed that treatment with HBO caused a reduction in the development of ORN in comparison to patients treated with antibiotics following dental extractions (risk ratio (RR) 0.18, 95% CI 0.43 to 0.76; one trial, 74 participants; very low‐certainty evidence). Another study found no difference between combined HBO and antibiotics compared to antibiotics alone prior to dental implant placement (RR 3.00, 95% CI 0.14 to 65.16; one trial, 26 participants; very low‐certainty evidence). Adverse effects of the different interventions were not reported clearly or were not important. Authors' conclusions Given the suboptimal reporting and inadequate sample sizes of the included studies, evidence regarding the interventions evaluated by the trials included in this review is uncertain. More well‐designed RCTs with larger samples are required to make conclusive statements regarding the efficacy of these interventions. Plain language summary Dental treatments for preventing damage to the jawbones in people with cancer receiving radiotherapy to the head and neck Review question With this Cochrane Review we tried to find out the best way to prevent the death and exposure of bone in the jaws of people who have had radiotherapy for head and neck cancer. This is a condition called osteoradionecrosis (ORN). Background ORN of the jaws is a serious problem which can happen after people have radiotherapy as part of their treatment for head and neck cancer. ORN refers to the death and exposure of bone that result from damage to the tissues due to being exposed to radiation. ORN is very difficult to treat and it is important that steps are taken to prevent it. In this review, we looked at any treatments that have been used to prevent ORN. Study characteristics This review is up‐to‐date as of 5 November 2019. The review includes four studies involving 342 adults who had received radiotherapy for the treatment of head and neck cancer. The review looks at three different ways to prevent ORN: ‐ the use of platelet‐rich plasma (PRP) in bone after removal of healthy teeth prior to radiotherapy. Plasma is a part of blood that contains special proteins that help the blood to clot, and PRP is concentrated plasma which supports cell growth. Injecting PRP into damaged tissue may stimulate the body to grow new, healthy cells to make it heal more quickly; ‐ taking out teeth because of tooth decay makes the risk of developing ORN greater. Preventing tooth decay in people having radiotherapy is very important. We looked at a study comparing using fluoride gel with a toothpaste with a higher level of fluoride than normal to prevent tooth decay after radiotherapy; ‐ hyperbaric oxygen therapy is breathing oxygen in a pressurized chamber to improve blood supply, which may help heal damaged tissue. Two studies compared the use of hyperbaric oxygen therapy for taking out teeth or placing dental implants with antibiotics. Antibiotics are drugs which stop or slow the growth of bacteria. Key results One study showed no reduction in ORN when using platelet‐rich plasma in bone after the removal of healthy teeth. Another study found no difference between fluoride gel and toothpaste with a higher level of fluoride than normal as no cases of ORN were reported. A third study showed that treatment with hyperbaric oxygen therapy caused a reduction in the development of ORN in comparison to patients treated with antibiotics following the removal of teeth. The fourth study found no difference between combined hyperbaric oxygen therapy and antibiotics compared to antibiotics alone. Harmful effects of the different interventions were not reported clearly or were not important. Certainty of the evidence The level of certainty we have in these findings is very low. This was due to high risk of bias, not all studies mentioning important details, and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to stop ORN of the jaws from happening or making it less severe in adults receiving head and neck radiotherapy. We suggest that more, well‐conducted, and bigger studies including more people, should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "El‐Rabbany, M, Duchnay, M, Raziee, HR, Zych, M, Tenenbaum, H, Shah, PS, Azarpazhooh, A", "articleTypes": [], "doi": "10.1002/14651858.CD011559.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.764Z" }, { "id": "8b21297e-635c-4669-a5de-64f65559c1b7", "pmid": "", "title": "Sapropterin dihydrochloride for phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria results from a deficiency of the enzyme phenylalanine hydroxylase. Dietary restriction of phenylalanine keeps blood phenylalanine concentration low. Most natural foods are excluded from diet and supplements are used to supply other nutrients. Recent publications report a decrease in blood phenylalanine concentration in some patients treated with sapropterin dihydrochloride. We examined the evidence for the use of sapropterin dihydrochloride to treat phenylketonuria. This is an update of a previously published Cochrane Review. Objectives To assess the safety and efficacy of sapropterin dihydrochloride in lowering blood phenylalanine concentration in people with phenylketonuria. Search methods We identified relevant trials from the Group's Inborn Errors of Metabolism Trials Register. Date of last search: 11 August 2014. We also searched ClinicalTrials.gov and Current controlled trials. Last search: 4 September 2014 We contacted the manufacturers of the drug (BioMarin Pharmaceutical Inc.) for information regarding any unpublished trials. Selection criteria Randomized controlled trials comparing sapropterin with no supplementation or placebo in people with phenylketonuria due to phenylalanine hydroxylase deficiency. Data collection and analysis Two authors independently assessed trials and extracted outcome data. Main results Two placebo‐controlled trials were included. One trial administered 10 mg/kg/day sapropterin in 89 children and adults with phenylketonuria whose diets were not restricted and who had previously responded to saproterin.This trial measured change in blood phenylalanine concentration. The second trial screened 90 children (4 to 12 years) with phenylketonuria whose diet was restricted, for responsiveness to sapropterin. Forty‐six responders entered the placebo‐controlled part of the trial and received 20 mg/kg/day sapropterin. This trial measured change in both phenylalanine concentration and protein tolerance. Both trials reported adverse events. The trials showed an overall low risk of bias; but both are Biomarin‐sponsored. One trial showed a significant lowering in blood phenylalanine concentration in the sapropterin group (10 mg/kg/day), mean difference ‐238.80 μmol/L (95% confidence interval ‐343.09 to ‐134.51); a second trial (20 mg/kg/day sapropterin) showed a non‐significant difference, mean difference ‐51.90 μmol/L (95% confidence interval ‐197.27 to 93.47). The second trial also reported a significant increase in phenylalanine tolerance, mean difference18.00 mg/kg/day (95% confidence interval 12.28 to 23.72) in the 20 mg/kg/day sapropterin group. Authors' conclusions There is evidence of short‐term benefit from using sapropterin in some people with sapropterin‐responsive forms of phenylketonuria; blood phenylalanine concentration is lowered and protein tolerance increased. There are no serious adverse events associated with using sapropterin in the short term. There is no evidence on the long‐term effects of sapropterin and no clear evidence of effectiveness in severe phenylketonuria. Plain language summary The use of sapropterin to lower phenylalanine concentration in blood in people with phenylketonuria. Phenylketonuria occurs due to an inherited deficiency of the enzyme phenylalanine hydroxylase. If untreated it causes an excessive accumulation of the amino acid phenylalanine in the body which prevents normal brain development. The established treatment for phenylketonuria consists of dietary restriction of natural protein but with prescribed phenylalanine‐free amino acid, mineral and vitamin supplements. With this treatment the long‐term outcome for people with phenylketonuria is excellent but the diet is onerous. Sapropterin dihydrochloride, the cofactor for phenylalanine hydroxylase, could lower phenylalanine concentration significantly in phenylketonuria and might allow a relaxation of dietary restrictions. The review identified two trials of sapropterin dihydrochloride; one in children and adults with no restricted diet and one in just children whose diet was restricted. The trials used different doses of sapropterin dihydrochloride (10 mg/kg/day and 20 mg/kg/day). We could not combine any data due to different formats of presentation. We found evidence to show that some people with mild or moderate phenylketonuria can benefit from the use of sapropterin dihydrochloride in the short term; the concentration of blood phenylalanine was lowered after treatment in both trials. The trial with the higher dose also measured the outcome change in protein tolerance. It reported an increase in protein tolerance in response to sapropterin. There were no adverse effects associated with the use of sapropterin dihydrochloride in the short term. We found no evidence on the effects of long‐term treatment. We could not draw any conclusions on its benefits in severe phenylketonuria.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Somaraju, UR; Merrin, M", "articleTypes": [], "doi": "10.1002/14651858.CD008005.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "8b3d923f-4f44-42c2-9443-34409efcd1fb", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high risk patients. Ulceration can lead to severe pain and difficulty eating and drinking, which may necessitate opioid analgesics, hospitalisation and nasogastric or intravenous nutrition. These complications may lead to interruptions or alterations to cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Oral cryotherapy is a low‐cost, simple intervention which is unlikely to cause side‐effects. It has shown promise in clinical trials and warrants an up‐to‐date Cochrane review to assess and summarise the international evidence. Objectives To assess the effects of oral cryotherapy for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to 17 June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) ( Cochrane Library 2015, Issue 5), MEDLINE via Ovid (1946 to 17 June 2015), EMBASE via Ovid (1980 to 17 June 2015), CANCERLIT via PubMed (1950 to 17 June 2015) and CINAHL via EBSCO (1937 to 17 June 2015). We searched the US National Institutes of Health Trials Registry, and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching databases. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of oral cryotherapy in patients with cancer receiving treatment. We used outcomes from a published core outcome set registered on the COMET website. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. We contacted study authors for information where feasible. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 14 RCTs analysing 1280 participants. The vast majority of participants did not receive radiotherapy to the head and neck, so this review primarily assesses prevention of chemotherapy‐induced oral mucositis. All studies were at high risk of bias. The following results are for the main comparison: oral cryotherapy versus control (standard care or no treatment). Adults receiving fluorouracil‐based (5FU) chemotherapy for solid cancers Oral cryotherapy probably reduces oral mucositis of any severity (RR 0.61, 95% CI 0.52 to 0.72, 5 studies, 444 analysed, moderate quality evidence). In a population where 728 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 444 (95% CI 379 to 524). The number needed to treat to benefit one additional person (NNTB), i.e. to prevent them from developing oral mucositis, is 4 people (95% CI 3 to 5). The results were similar for moderate to severe oral mucositis (RR 0.52, 95% CI 0.41 to 0.65, 5 studies, 444 analysed, moderate quality evidence). NNTB 4 (95% CI 4 to 6). Severe oral mucositis is probably reduced (RR 0.40, 95% CI 0.27 to 0.61, 5 studies, 444 analysed, moderate quality evidence). Where 300 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 120 (95% CI 81 to 183), NNTB 6 (95% CI 5 to 9). Adults receiving high‐dose melphalan‐based chemotherapy before haematopoietic stem cell transplantation (HSCT) Oral cryotherapy may reduce oral mucositis of any severity (RR 0.59, 95% CI 0.35 to 1.01, 5 studies, 270 analysed, low quality evidence). Where 824 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 486 (95% CI reduced to 289 to increased to 833). The NNTB is 3, although the uncertainty surrounding the effect estimate means that the 95% CI ranges from 2 NNTB, to 111 NNTH (number needed to treat in order to harm one additional person, i.e. for one additional person to develop oral mucositis). The results were similar for moderate to severe oral mucositis (RR 0.43, 95% CI 0.17 to 1.09, 5 studies, 270 analysed, low quality evidence). NNTB 3 (95% CI 2 NNTB to 17 NNTH). Severe oral mucositis is probably reduced (RR 0.38, 95% CI 0.20 to 0.72, 5 studies, 270 analysed, moderate quality evidence). Where 427 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 162 (95% CI 85 to 308), NNTB 4 (95% CI 3 to 9). Oral cryotherapy was shown to be safe, with very low rates of minor adverse effects, such as headaches, chills, numbness/taste disturbance, and tooth pain. This appears to contribute to the high rates of compliance seen in the included studies. There was limited or no evidence on the secondary outcomes of this review, or on patients undergoing other chemotherapies, radiotherapy, targeted therapy, or on comparisons of oral cryotherapy with other interventions or different oral cryotherapy regimens. Therefore no further robust conclusions can be made. There was also no evidence on the effects of oral cryotherapy in children undergoing cancer treatment. Authors' conclusions We are confident that oral cryotherapy leads to large reductions in oral mucositis of all severities in adults receiving 5FU for solid cancers. We are less confident in the ability of oral cryotherapy to reduce oral mucositis in adults receiving high‐dose melphalan before HSCT. Evidence suggests that it does reduce oral mucositis in these adults, but we are less certain about the size of the reduction, which could be large or small. However, we are confident that there is an appreciable reduction in severe oral mucositis in these adults. This Cochrane review includes some very recent and currently unpublished data, and strengthens international guideline statements for adults receiving the above cancer treatments. Plain language summary Can keeping the mouth cold during cancer treatment help to prevent mouth soreness and ulcers in children and adults? Review question This review has been produced to assess whether or not keeping the mouth cold during cancer treatment, by using ice, ice‐cold water, ice cream or ice lollies/popsicles, can help prevent mouth soreness and ulcers in children and adults. Background People receiving treatment for cancer are at risk of developing a sore mouth and ulcers as a side effect. This side effect is called oral mucositis and affects over 75% of high‐risk patients (those receiving radiotherapy to the head and neck or high‐dose chemotherapy). The pain caused by this condition can be severe and can stop the person's ability to eat and drink, which may mean they need to take strong pain killers, stay in hospital and be fed through a tube into their stomach, or even into their veins. This in turn can lead to disruption to their cancer treatment, meaning they are not receiving the best possible treatment. The results may be a reduction in the patient's chances of survival, and increased costs to the healthcare system. Cancer patients have weakened immune systems due to their treatment, meaning that their bodies are less able to fight infections. This can be a problem if bacteria enter the body through the ulcer, which is an open wound. This can lead to sepsis (a dangerous inflammatory reaction of the body to infection), which requires antibiotics and hospitalisation, and can cause death. Oral cryotherapy is the cooling of the mouth using ice, ice‐cold water, ice cream or ice lollies/popsicles. It is thought to help prevent oral mucositis in people receiving certain types of chemotherapy because the coldness makes the blood vessels in the mouth more narrow, and this reduces the amount of blood containing chemotherapy drugs from reaching the mouth and causing oral mucositis. It is a low‐cost, natural treatment without serious side effects. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 17 June 2015. It includes 14 studies published from 1991 to 2015 in which 1316 participants were randomised (1280 of whom were included in the analyses) to receive oral cryotherapy versus standard care (usually saline mouthrinses) or no treatment or a different treatment or a different method of oral cryotherapy, and the number of people developing oral mucositis of different severities was compared. Nearly all the evidence was on adults receiving oral cryotherapy versus standard care or no treatment. This evidence fell into two main groups: 1) adults receiving fluorouracil‐based (5FU) treatment for solid cancers; or 2) adults receiving high‐dose melphalan‐based cancer treatment before haematopoietic stem cell transplantation (HSCT). HSCT is given to help the body to produce all types of blood cells, which are destroyed during cancer treatment. Key results There is evidence showing that oral cryotherapy can lead to large reductions in the numbers of adults who get oral mucositis of all severities after receiving 5FU‐based treatment for solid cancers. There is less certain evidence to suggest that oral cryotherapy may reduce the numbers of adults who get oral mucositis after receiving high‐dose melphalan‐based cancer treatment prior to HSCT. The evidence suggests that it does reduce oral mucositis in these adults, but the size of the reduction is much less certain. However, there is more certain evidence that there is a large reduction in severe oral mucositis in these adults. Oral cryotherapy did not cause any serious side effects in any of the participants of these studies, and most people seemed able to carry it out properly and complete it. Quality of the evidence The evidence presented, on the main outcome of whether or not people developed oral mucositis of all severities, is of moderate (because the nature of the oral cryotherapy treatment meant that the studies could not be 'blinded' which is a desirable characteristic of these studies) to low quality (because in addition to the above problem, the results of the individual studies were too different to give a precise result when they were combined).", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P, Glenny, AM, Worthington, HV, Littlewood, A, Clarkson, JE, McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011552.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.768Z" }, { "id": "8b4eb754-d28c-4620-b20e-10bdca39e913", "pmid": "", "title": "Protein substitute for children and adults with phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria is an inherited metabolic disorder characterised by an absence or deficiency of the enzyme phenylalanine hydroxylase. The aim of treatment is to lower blood phenylalanine concentrations to the recommended therapeutic range to prevent developmental delay and support normal growth. Current treatment consists of a low‐phenylalanine diet in combination with a protein substitute which is free from or low in phenylalanine. Guidance regarding the use, dosage, and distribution of dosage of the protein substitute over a 24‐hour period is unclear, and there is variation in recommendations among treatment centres. This is an update of a Cochrane review first published in 2005, and previously updated in 2008. Objectives To assess the benefits and adverse effects of protein substitute, its dosage, and distribution of dose in children and adults with phenylketonuria who are adhering to a low‐phenylalanine diet. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which consists of references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. We also contacted manufacturers of the phenylalanine‐free and low‐phenylalanine protein substitutes for any data from published and unpublished randomised controlled trials. Date of the most recent search of the Group's Inborn Errors of Metabolism Trials Register: 03 April 2014. Selection criteria All randomised or quasi‐randomised controlled trials comparing: any dose of protein substitute with no protein substitute; an alternative dosage; or the same dose, but given as frequent small doses throughout the day compared with the same total daily dose given as larger boluses less frequently. Data collection and analysis Both authors independently extracted data and assessed trial quality. Main results Three trials (69 participants) are included in this review. One trial investigated the use of protein substitute in 16 participants, while a further two trials investigated the dosage of protein substitute in a total of 53 participants. Due to issues with data presentation in each trial, described in full in the review, formal statistical analyses of the data were impossible. Investigators will be contacted for further information. Authors' conclusions No conclusions could be drawn about the short‐ or long‐term use of protein substitute in phenylketonuria due to the lack of adequate or analysable trial data. Additional data and randomised controlled trials are needed to investigate the use of protein substitute in phenylketonuria. Until further evidence is available, current practice in the use of protein substitute should continue to be monitored with care. Plain language summary The impact of protein substitute on the nutrition status, growth, and neuropsychological performance of children and adults with phenylketonuria People with phenylketonuria (PKU) who follow a low‐phenylalanine diet are required to take protein substitute to ensure adequate consumption of protein, energy, and other nutrients. The need for protein substitute has been established through clinical experience and observational data. Randomised, controlled trials are needed to confirm this need as well as its proper dosage and frequency of use. We performed a systematic review of randomised control trials investigating the impact of the use, dosage, and distribution of protein substitute on physical and neuropsychological outcomes in the treatment of PKU. Trials of children and adults diagnosed with PKU in the newborn period who were treated early and continuously were included. We planned to pool the results of the trials to estimate treatment effect. Three trials met the inclusion criteria for the review. One trial evaluated the impact of protein substitute versus no protein substitute on neuropsychological status, plasma amino acid concentrations, and nutrient intake. The remaining two trials investigated the impact of differing dosages of protein substitute on plasma amino acid concentrations and nutrient intake. No trials investigating daily protein substitute distribution were eligible for inclusion in the review. Results are presented in text form only since adequate information for data pooling was not provided. The investigators will be contacted for further information. Currently data are insufficient to reach any conclusions regarding the use, dosage, and distribution of protein substitute in the treatment of PKU. Further randomized or controlled clinical trials are needed to provide evidence for the effectiveness, dosage, and distribution of protein substitute in the treatment of PKU.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Yi, SHL; Singh, RH", "articleTypes": [], "doi": "10.1002/14651858.CD004731.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "8b510668-5be0-457d-8d97-de78506404c8", "pmid": "", "title": "Topiramate for the prophylaxis of episodic migraine in adults", "imported": false, "abstract": "Abstract - Background Some antiepileptic drugs but not others are useful in clinical practice for the prophylaxis of migraine. This might be explained by the variety of actions of these drugs in the central nervous system. The present review is part of an update of a Cochrane review first published in 2004, and previously updated (conclusions not changed) in 2007. Objectives To describe and assess the evidence from controlled trials on the efficacy and tolerability of topiramate for preventing migraine attacks in adult patients with episodic migraine. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2012, Issue 12), PubMed/MEDLINE (1966 to 15 January 2013), MEDLINE In‐Process (current week, 15 January 2013), and EMBASE (1974 to 15 January 2013) and handsearched Headache and Cephalalgia through January 2013. Selection criteria Studies were required to be prospective, controlled trials of topiramate taken regularly to prevent the occurrence of migraine attacks, to improve migraine‐related quality of life, or both. Data collection and analysis Two review authors independently selected studies and extracted data. For headache frequency data, we calculated mean differences (MDs) between topiramate and comparator (placebo, active control, or topiramate in a different dose) for individual studies and pooled these across studies. For dichotomous data on responders (patients with ≥ 50% reduction in headache frequency), we calculated odds ratios (ORs) and, in select cases, risk ratios (RRs); we also calculated numbers needed to treat (NNTs). We calculated MDs for selected quality of life instruments. Finally, we summarised data on adverse events from placebo‐controlled trials and calculated risk differences (RDs) and numbers needed to harm (NNHs). Main results Twenty papers describing 17 unique trials met the inclusion criteria. Analysis of data from nine trials (1737 participants) showed that topiramate reduced headache frequency by about 1.2 attacks per 28 days as compared to placebo (MD ‐1.20; 95% confidence interval (CI) ‐1.59 to ‐0.80). Data from nine trials (1190 participants) show that topiramate approximately doubled the proportion of responders relative to placebo (RR 2.02; 95% CI 1.57 to 2.60; NNT 4; 95% CI 3 to 6). Separate analysis of different topiramate doses produced similar MDs versus placebo at 50 mg (‐0.95; 95% CI ‐1.95 to 0.04; three studies; 520 participants), 100 mg (‐1.15; 95% CI ‐1.58 to ‐0.71; six studies; 1620 participants), and 200 mg (‐0.94; 95% CI ‐1.53 to ‐0.36; five studies; 804 participants). All three doses significantly increased the proportion of responders relative to placebo; ORs were as follows: for 50 mg, 2.35 (95% CI 1.60 to 3.44; three studies; 519 participants); for 100 mg, 3.49 (95% CI 2.23 to 5.45; five studies; 852 participants); and for 200 mg, 2.49 (95% CI 1.61 to 3.87; six studies; 1025 participants). All three doses also significantly improved three or more domains of quality of life as compared to placebo. Meta‐analysis of the three studies that included more than one dose of topiramate suggests that 200 mg is no more effective than 100 mg. With regard to mean headache frequency and/or responder rate, seven trials using active comparators found (a) no significant difference between topiramate and amitriptyline (one study, 330 participants); (b) no significant difference between topiramate and flunarizine (one study, 83 participants); (c) no significant difference between topiramate and propranolol (two studies, 342 participants); (d) no significant difference between topiramate and relaxation (one study, 61 participants); but (e) a slight significant advantage of topiramate over valproate (two studies, 120 participants). Relaxation improved migraine‐specific quality of life significantly more than topiramate. In trials of topiramate against placebo, seven adverse events (AEs) were reported by at least three studies. These were usually mild and of a non‐serious nature. Except for taste disturbance and weight loss, there were no significant differences in the frequency of AEs in general, or of the seven specific AEs, between placebo and topiramate 50 mg. AEs in general and all of the specific AEs except nausea were significantly more common on topiramate 100 mg than on placebo, with NNHs varying from 3 to 25, and the RDs versus placebo were even higher for topiramate 200 mg, with NNHs varying from 2 to 17. Authors' conclusions Meta‐analysis demonstrates that topiramate in a 100 mg/day dosage is effective in reducing headache frequency and reasonably well‐tolerated in adult patients with episodic migraine. This provides good evidence to support its use in routine clinical management. More studies designed specifically to compare the efficacy or safety of topiramate versus other interventions with proven efficacy in the prophylaxis of migraine are needed. Plain language summary Topiramate for preventing migraine attacks in adults Various medicines, collectively termed 'antiepileptics', are used to treat epilepsy. For several years, some of these drugs have also been used for preventing migraine attacks. For the present review, researchers in The Cochrane Collaboration reviewed the evidence about the effects of topiramate in adult patients (≥ 16 years of age) with 'episodic' migraine (headache on < 15 days per month). They examined research published up to 15 January 2013 and found 17 relevant studies. Compared with placebo, topiramate reduced the frequency of migraine headaches by approximately 1.2 per month (nine studies, 1737 participants). Patients were also about twice as likely to reduce the number of their migraine headaches by 50% or more with topiramate than with placebo (nine studies, 1190 participants). Side effects associated with topiramate were common but generally mild; topiramate can, however, cause birth defects and so should be used with caution in women of childbearing age. Further research is needed comparing topiramate with other active drugs used for preventing migraine attacks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Linde, M, Mulleners, WM, Chronicle, EP, McCrory, DC", "articleTypes": [], "doi": "10.1002/14651858.CD010610", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.071Z" }, { "id": "8b5ae866-9a64-427a-86d8-428d278bf0ff", "pmid": "", "title": "Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration leading to increased fracture risk. Risedronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts. This is an update of a Cochrane Review that was originally published in 2003. Objectives We assessed the benefits and harms of risedronate in the primary and secondary prevention of osteoporotic fractures for postmenopausal women at lower and higher risk for fractures, respectively. Search methods With broader and updated strategies, we searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE and Embase. A grey literature search, including the online databases ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), and drug approval agencies, as well as bibliography checks of relevant systematic reviews was also performed. Eligible trials published between 1966 to 24 March 2021 were identified. Selection criteria We included randomised controlled trials that assessed the benefits and harms of risedronate in the prevention of fractures for postmenopausal women. Participants must have received at least one year of risedronate, placebo or other anti‐osteoporotic drugs, with or without concurrent calcium/vitamin D. Major outcomes were clinical vertebral, non‐vertebral, hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. In the interest of clinical relevance and applicability, we classified a study as secondary prevention if its population fulfilled more than one of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, low bone mineral density (BMD)T score ≤ ‐2.5, and age ≥ 75 years old. If none of these criteria was met, the study was considered to be primary prevention. Data collection and analysis We used standard methodology expected by Cochrane. We pooled the relative risk (RR) of fractures using a fixed‐effect model based on the expectation that the clinical and methodological characteristics of the respective primary and secondary prevention studies would be homogeneous, and the experience from the previous review suggesting that there would be a small number of studies. The base case included the data available for the longest treatment period in each placebo‐controlled trial and a >15% relative change was considered clinically important. The main findings of the review were presented in summary of findings tables, using the GRADE approach. In addition, we looked at benefit and harm comparisons between different dosage regimens for risedronate and between risedronate and other anti‐osteoporotic drugs. Main results Forty‐three trials fulfilled the eligibility criteria, among which 33 studies (27,348 participants) reported data that could be extracted and quantitatively synthesized. We had concerns about particular domains of risk of bias in each trial. Selection bias was the most frequent concern, with only 24% of the studies describing appropriate methods for both sequence generation and allocation concealment. Fifty per cent and 39% of the studies reporting benefit and harm outcomes, respectively, were subject to high risk. None of the studies included in the quantitative syntheses were judged to be at low risk of bias in all seven domains. The results described below pertain to the comparisons for daily risedronate 5 mg versus placebo which reported major outcomes. Other comparisons are described in the full text. For primary prevention, low‐ to very low‐certainty evidence was collected from four studies (one to two years in length) including 989 postmenopausal women at lower risk of fractures. Risedronate 5 mg/day may make little or no difference to wrist fractures [RR 0.48 ( 95% CI 0.03 to 7.50; two studies, 243 participants); absolute risk reduction (ARR) 0.6% fewer (95% CI 1% fewer to 7% more)] and withdrawals due to adverse events [RR 0.67 (95% CI 0.38 to 1.18; three studies, 748 participants); ARR 2% fewer (95% CI 5% fewer to 1% more)], based on low‐certainty evidence. However, its preventive effects on non‐vertebral fractures and serious adverse events are not known due to the very low‐certainty evidence. There were zero clinical vertebral and hip fractures reported therefore the effects of risedronate for these outcomes are not estimable. For secondary prevention, nine studies (one to three years in length) including 14,354 postmenopausal women at higher risk of fractures provided evidence. Risedronate 5 mg/day probably prevents non‐vertebral fractures [RR 0.80 (95% CI 0.72 to 0.90; six studies, 12,173 participants); RRR 20% (95% CI 10% to 28%) and ARR 2% fewer (95% CI 1% fewer to 3% fewer), moderate certainty], and may reduce hip fractures [RR 0.73 (95% CI 0.56 to 0.94); RRR 27% (95% CI 6% to 44%) and ARR 1% fewer (95% CI 0.2% fewer to 1% fewer), low certainty]. Both of these effects are probably clinically important. However, risedronate's effects are not known for wrist fractures [RR 0.64 (95% CI 0.33 to 1.24); three studies,1746 participants); ARR 1% fewer (95% CI 2% fewer to 1% more), very‐low certainty] and not estimable for clinical vertebral fractures due to zero events reported (low certainty). Risedronate results in little to no difference in withdrawals due to adverse events [RR 0.98 (95% CI 0.90 to 1.07; eight studies, 9529 participants); ARR 0.3% fewer (95% CI 2% fewer to 1% more); 16.9% in risedronate versus 17.2% in control, high certainty] and probably results in little to no difference in serious adverse events [RR 1.00 (95% CI 0.94 to 1.07; six studies, 9435 participants); ARR 0% fewer (95% CI 2% fewer to 2% more; 29.2% in both groups, moderate certainty). Authors' conclusions This update recaps the key findings from our previous review that, for secondary prevention, risedronate 5 mg/day probably prevents non‐vertebral fracture, and may reduce the risk of hip fractures. We are uncertain on whether risedronate 5mg/day reduces clinical vertebral and wrist fractures. Compared to placebo, risedronate probably does not increase the risk of serious adverse events. For primary prevention, the benefit and harms of risedronate were supported by limited evidence with high uncertainty. Plain language summary Risedronate for preventing fractures caused by osteoporosis in postmenopausal women This summary of a Cochrane Review presents what we know from the evidence up to 24 March 2021 about the effect of risedronate for preventing fractures (broken bones) caused by osteoporosis. What is osteoporosis and what is risedronate? 
Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow and old bone cells break down to make room for the new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break even after a minor injury, like a little bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. Risedronate belongs to the class of drugs called bisphosphonates. It is a type of medication that slows down the cells that break down the old bone. In postmenopausal women whose bone density is closer to normal or who may not yet have had a fracture in the bones of their spine therefore putting them at lower risk for fractures: ‐ there is insufficient evidence to tell us if risedronate leads to any reduction in the number of women sustaining bone fractures; ‐ based on limited data there is no evidence of an increase in adverse events for postmenopausal women at lower risk for fractures. In postmenopausal women who have already been diagnosed with osteoporosis (who have low bone density, or who have already had a fracture in the bones of their spine) putting them at higher risk for fractures, risedronate: ‐ probably prevents fractures in the bones of the hip and in bones other than in the spine; ‐ may not lead to any difference in preventing wrist fractures; ‐ does not have enough evidence to show if it may prevent fractures in the bones of the spine suggested by clinical signs and symptoms; ‐ might make little or no difference in adverse events for postmenopausal women at higher risk for fractures. Best estimate of what happens to postmenopausal women at lower risk for fractures who take risedronate or placebo: ‐ for spine fractures suggested by clinical signs and symptoms and hip fractures, it was not possible to calculate the effect because none of these fractures were reported in any of the studies; ‐ compared to placebo, there is not enough information to tell if risedronate prevents fractures in wrist and bones other than in the spine. Best estimate of what happens to postmenopausal women at higher risk for fractures who take risedronate or placebo: Fractures of the spine suggested by clinical signs and symptoms were not reported in any of the studies. Fractures in bones other than the spine: ‐ 10 out of 100 women had a fracture when taking a placebo; ‐ 8 out of 100 women had a fracture when taking risedronate; Fractures of the hip ‐ 3 out of 100 women had a fracture when taking a placebo; ‐ 2 out of 100 women had a fracture when taking risedronate. Fractures of the wrist: ‐ there is not enough information to tell if risedronate prevents wrist fractures.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wells, GA; Hsieh, S-C; Zheng, C; Peterson, J; Liu, W; Kelly, SE; Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD004523.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "8b7625ec-6ec0-4d57-a725-94f5622fbbdb", "pmid": "", "title": "Salty Taste: Assessing a Strategy to Reduce Children's Preference", "imported": false, "abstract": "The goals of the proposed research are to determine whether repeated exposure to a low sodium food will result in reduced preference for salt in that food among children; and to determine whether such reductions in preference are related to dietary intake of salt, taste receptor genotype, and anthropometric and physiological measures.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "8b7d52b4-fb00-4da3-bde3-a0f69e57009d", "pmid": "", "title": "Multiple micronutrient powders for home (point‐of‐use) fortification of foods in pregnant women", "imported": false, "abstract": "Abstract - Background It is estimated that 32 million pregnant women suffer from anaemia worldwide. Due to increased metabolic demands, pregnant women are particularly vulnerable to anaemia and vitamin and mineral deficiencies, leading to adverse health effects in both the mother and her baby. Despite the demonstrated benefits of prenatal supplementation with iron and folic acid or multiple micronutrients, poor adherence to routine supplementation has limited the effectiveness of this intervention in many settings. Micronutrient powders for point‐of‐use fortification are packed, single‐dose sachets containing vitamins and minerals that can be added onto prepared food to improve its nutrient profile. The use of multiple micronutrient powders for point‐of‐use fortification of foods in pregnant women could be an alternative intervention to prenatal micronutrient supplementation. Objectives To assess the effects of prenatal home (point‐of‐use) fortification of foods with multiple micronutrient powders on maternal and newborn health. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and the International Clinical Trials Registry Platform ( ICTRP ) (31 January 2015). We also contacted relevant agencies to identify ongoing and unpublished studies. Selection criteria Randomised controlled trials (both individual and cluster randomisation) and quasi‐randomised trials, irrespective of language or publication status. The intervention was micronutrient powders for point‐of‐use fortification of foods, containing at least three micronutrients with one of them being iron, provided to pregnant women of any gestational age and parity. Five comparison groups were considered: no intervention/placebo, iron and folic acid supplements, iron‐only supplements, folic‐acid only supplements, and multiple micronutrients in supplements. Data collection and analysis Two review authors independently assessed the eligibility of studies, extracted and checked data accuracy, and assessed the risk of bias of included studies. Main results Our search identified 12 reports (relating to six studies). We included two cluster‐randomised controlled trials (involving 1172 women) ‐ these trials were considered to be at a moderate to high risk of bias due to methodological limitations. One trial is ongoing, and three studies were excluded. Micronutrient powders for point‐of‐use fortification of foods versus iron and folic acid supplements One trial (involving 478 pregnant women attending 42 antenatal care centres) compared micronutrient powders containing iron, folic acid, vitamin C and zinc with iron and folic acid tablets provided daily from 14 to 22 weeks to 32 weeks' gestation. The trial did not report on any of this review's primary outcomes: maternal anaemia at or near term, maternal iron deficiency, maternal mortality, adverse effects, low birthweight, preterm births. Nor did the trial report on the majority of this review's secondary outcomes, with the exception of maternal adherence. Adherence to micronutrient powders was lower than adherence to iron and folic acid supplements (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.66 to 0.87, one study, n = 405). Micronutrient powders for point‐of‐use fortification of foods versus same multiple micronutrients in supplements One study (involving 694 pregnant women from 18 communities), compared micronutrient powders containing iron, folic acid, vitamin C, zinc, iodine, vitamin E and vitamin B 12 with tablets containing the same seven micronutrients. There was no difference in maternal anaemia at 37 weeks of gestation (RR 0.92, 95% CI 0.53 to 1.59, one study, n = 470, very low quality evidence ). The trial did not report on any of this review's other primary outcomes in relation to maternal iron deficiency, maternal mortality, adverse effects, low birthweight, or preterm birth. In terms of this review's secondary outcomes, the included trial did not report on the majority of this review's prespecified secondary outcomes with one exception ‐ there was no clear difference in maternal haemoglobin Hb or near term (mean difference (MD) 1.0 g/L, 95% CI ‐1.77 to 3.77, one study, n = 470). Authors' conclusions Limited evidence suggests that micronutrient powders for point‐of‐use fortification of foods have no clear difference as multiple micronutrient supplements on maternal anaemia ( very low quality evidence ) and Hb at or near term. There is limited evidence to suggest that women were more likely to adhere to taking tablets than using micronutrient powders. The overall quality of evidence was judged very low (due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes. Therefore, more evidence is needed to assess the potential benefits or harms of the use of micronutrient powders in pregnant women on maternal and infant health outcomes. Future trials should also assess adherence to micronutrient powders and be adequately powered to evaluate the effects on birth outcomes and morbidity. Plain language summary Powders of iron plus other micronutrients for home (point‐of‐use) fortification of foods consumed by pregnant women Pregnant women are particularly vulnerable to nutrient deficiencies due to the requirements of the growing baby during the pregnancy. In low‐income countries, many women have diets with low content of vitamins and minerals, and they participate in long hours of physical labour. They are also exposed to recurrent infections, which make nutritional deficiencies worse. Thus, lack of adequate nutrition can contribute to the poor health of these women their babies. Iron and folic acid supplements in pregnancy are widely recommended. However, getting the supplements to the women and encouraging them to take them is particularly challenging. Micronutrient powders containing iron, vitamin A, zinc and other vitamins and minerals are usually packaged in single‐use sachets and can be sprinkled onto any semi‐solid food at home or in any other place where meals are to be consumed. The use of micronutrient powders to fortify foods may overcome this problem with micronutrient supplements. Micronutrient powders have already been shown to be effective in reducing anaemia and iron deficiency in young children and so may be useful for pregnant women. This review looked at the use of micronutrient powders in pregnancy, compared with micronutrient supplements or with no additional micronutrients. We found only two studies involving a total of 1172 women, undertaken in Bangladesh and Mexico. The overall quality of evidence was judged very low (with a high risk of bias due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes of this review. One trial compared micronutrient powders with iron and folate supplements, and the other trial compared micronutrient powders with the same nutrients but given as supplements. Overall, micronutrient powders fortification of foods had a similar effect as multiple micronutrient supplements on anaemia in mothers at or near term ( very low quality evidence ) or the mother's haemoglobin (Hb) at or near term. The study that compared micronutrient powders with iron and folic acid supplements reported that women were more likely to take iron and folic acid tablets than micronutrient powders. Nearly all of the review's important outcomes were not reported in the included studies. Therefore, more evidence is needed for both mother and infant health outcomes in order to adequately evaluate the use of micronutrient powders in pregnant women.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Suchdev, PS; Peña‐Rosas, JP; De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD011158.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "8b9216e3-9c17-46c0-8b9c-741b3def02e5", "pmid": "", "title": "Effect of Non-nutritive Sweeteners on Vascular Function in Humans", "imported": false, "abstract": "In recent decades, low-to-null caloric, non-nutritive sweeteners (NNS) have been increasingly used, replacing and offering an alternative to food and beverages sweetened by high-energy, added sugars. Indeed, by providing consumers with products that have a sweet taste with low energy content, NNS appear to be the magic bullet to enhance weight loss and reduce cardio-metabolic diseases. However, a recent meta-analysis of randomized trials does not show any benefit of NNS consumption on body weight loss. Moreover, epidemiological, descriptive and experimental studies have recently reported that NNS consumption is paradoxically associated with weight gain, glucose intolerance and increased risk of type 2 diabetes and/or cardiovascular events. Among the approved NNS, sucralose and AceK, both high intensity (respectively ~500-600 and 200 times sweeter than sugar) are the most widely used in foods and drinks, accounting more than 62 % of the global artificial sweetener market. Recent experimental data show an effect of sucralose and AceK (and other NNS) consumption on vascular reactivity in response to a physiological stress (hyperglycemic load) in rats. Since sweet taste receptors (T1R) have been recently found in the endothelium, investigators hypothesize that NNS, and especially sucralose and AceK, a potent T1R agonist, impairs micro- and macrovascular reactivity in humans, which, to the best of our knowledge, has never been explored.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.151Z" }, { "id": "8b9924b5-f74b-4531-9197-2232d738a7c1", "pmid": "", "title": "Systemic administration of local anesthetic agents to relieve neuropathic pain", "imported": false, "abstract": "Abstract - Background Lidocaine, mexiletine, tocainide, and flecainide are local anesthetics which give an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain. Interest reappeared decades later when patient series and clinical trials reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients. With the recent publication of clinical trials with high quality standards, we have reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to update our knowledge, to measure their benefit and harm, and to better define their role in therapy. Objectives To evaluate pain relief and adverse effect rates between systemic local anesthetic‐type drugs and other control interventions. Search methods We searched MEDLINE (1966 through 15 May 2004), EMBASE (January 1980 to December 2002), Cancer Lit (through 15 December 2002), Cochrane Central Register of Controlled Trials (2nd Quarter, 2004), System for Information on Grey Literature in Europe (SIGLE), and LILACS, from January 1966 through March 2001. We also hand searched conference proceedings, textbooks, original articles and reviews. Selection criteria We included trials with random allocation, that were double blinded, with a parallel or crossover design. The control intervention was a placebo or an analgesic drug for neuropathic pain from any cause. Data collection and analysis We collected efficacy and safety data from all published and unpublished trials. We calculated combined effect sizes using continuous and binary data for pain relief and adverse effects as primary and secondary outcome measurements, respectively. Main results Thirty‐two controlled clinical trials met the selection criteria; two were duplicate articles. The treatment drugs were intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (one trial), and tocainide (one trial). Twenty‐one trials were crossover studies, and nine were parallel. Lidocaine and mexiletine were superior to placebo [weighted mean difference (WMD) = ‐11; 95% CI: ‐15 to ‐7; P < 0.00001], and limited data showed no difference in efficacy (WMD = ‐0.6; 95% CI: ‐7 to 6), or adverse effects versus carbamazepine, amantadine, gabapentin or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life‐threatening toxicities. Sensitivity analysis identified data distribution in three trials as a probable source of heterogeneity. There was no publication bias. Authors' conclusions Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. Future trials should enroll specific diseases and test novel lidocaine analogs with better toxicity profiles. More emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful. Plain language summary Systemic administration of local anesthetic agents to relieve neuropathic pain Intravenous lidocaine and oral derivatives relieve pain from damage to the nervous system (neuropathic pain). In early reports, intravenous lidocaine and its oral analogs mexiletine and tocainide relieved neuropathic pain, a type of pain caused by disease in the nervous system. However, the evidence was conflicting. The authors reviewed all randomized studies comparing these drugs with placebo or with other analgesics and found that: local anesthetics were superior to placebo in decreasing intensity of neuropathic pain; limited data showed no difference in efficacy or adverse effects between local anesthetics and carbamazepine, amantadine, gabapentin or morphine; local anesthetics had more adverse effects than placebo; and local anesthetics were safe.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Challapalli, V, Tremont-Lukats, IW, McNicol, ED, Lau, J, Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD003345.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.778Z" }, { "id": "8ba09c9d-0f66-407a-80da-373dbce8250c", "pmid": "", "title": "Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age", "imported": false, "abstract": "Abstract - Background According to global prevalence analysis studies, acute upper respiratory tract infections (URTIs) are the most common acute infectious disease in children, especially in preschool children. Acute URTIs lead to an economic burden on families and society. Vitamin A refers to the fat‐soluble compound all‐trans‐retinol and also represents retinol and its active metabolites. Vitamin A interacts with both the innate immune system and the adaptive immune system and improves the host's defences against infections. Correlation studies show that serum retinol deficiency was associated with a higher risk of respiratory tract infections. Therefore, vitamin A supplementation may be important in preventing acute URTIs. Objectives To assess the effectiveness and safety of vitamin A supplements for preventing acute upper respiratory tract infections in children up to seven years of age. Search methods We searched CENTRAL, MEDLINE, Embase, the Chinese Biomedical Literature Database, and two trial registration platforms to 8 June 2023. We also checked the reference lists of all primary studies and reviewed relevant systematic reviews and trials for additional references. We imposed no language or publication restrictions. Selection criteria We included randomised controlled trials (RCTs), which evaluated the role of vitamin A supplementation in the prevention of acute URTIs in children up to seven years of age. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Main results We included six studies (27,351 participants). Four studies were RCTs and two were cluster‐RCTs. The included studies were all conducted in lower‐middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas with a high local prevalence of malnutrition and xerophthalmia. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. We judged the included studies to be at either a high or unclear risk of bias for random sequence generation, incomplete outcome data, and blinding. Primary outcomes Six studies reported the incidence of acute URTIs during the study period. Five studies reported the number of acute URTIs over a period of time, but there was population heterogeneity and the results were presented in different forms, therefore only three studies were meta‐analysed. We are uncertain of the effect of vitamin A supplementation on the number of acute URTIs over two weeks (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.92 to 1.09; I 2 = 44%; 3 studies, 22,668 participants; low‐certainty evidence). Two studies reported the proportion of participants with an acute URTI. We are uncertain of the effect of vitamin A supplementation on the proportion of participants with an acute URTI (2 studies, 15,535 participants; low‐certainty evidence). Only one study (116 participants) reported adverse events. No infant in either the placebo or vitamin A group was found to have feeding difficulties (failure to feed or vomiting), a bulging fontanelle, or neurological signs before or after vitamin A administration (very low‐certainty evidence). Secondary outcomes Two studies (296 participants) reported the severity of subjective symptoms, presented by the mean duration of acute URTI. Vitamin A may have little to no effect on the mean duration of acute URTI (very low‐certainty evidence). Authors' conclusions The evidence for the use of vitamin A supplementation to prevent acute URTI is uncertain, because population, dose and duration of interventions, and outcomes vary between studies. From generally very low‐ to low‐certainty evidence, we found that there may be no benefit in the use of vitamin A supplementation to prevent acute URTI in children up to seven years of age. More RCTs are needed to strengthen the current evidence. Future research should report over longer time frames using validated tools and consistent reporting, and ensure adequate power calculations, to allow for easier synthesis of data. Finally, it is important to assess vitamin A supplementation for preschool children with vitamin A deficiency. Plain language summary Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age Background Acute upper respiratory tract infections (URTIs) are the most common acute infectious diseases in children, especially in preschool children. Vitamin A has a positive role in the immune system and may improve the host's defences against infections. Studies show that children with vitamin deficiency are more likely to suffer from respiratory tract infections. Therefore, we assessed the role of vitamin A supplementation in the prevention of acute upper respiratory tract infections in preschool children (up to seven years of age). Review question What is the role of vitamin A supplementation in the prevention of acute URTIs in preschool children (up to seven years of age), compared to no supplementation? Search date We searched for evidence up to 8 June 2023. Study characteristics All included studies were conducted in lower‐ and middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas more likely to experience malnutrition and dry eye. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. Key results We included six studies involving 27,351 participants. We have very low to low confidence in the evidence provided by the studies. Five studies reported the number of acute URTIs over a period of time. The included studies varied by population and the results were presented in different forms, so we could only combine three studies together (meta‐analysis). We are uncertain if vitamin A supplementation lowers the number of acute URTIs over a two‐week period (three studies, 22,668 participants). Two studies reported the proportion of participants with acute URTI. The effect of vitamin A supplementation on the proportion of participants with acute URTI is uncertain (two studies, 15,535 participants). Only one study (116 participants) reported adverse events and none occurred in infants in the placebo or vitamin A groups. Two studies (296 participants) reported the severity of subjective symptoms, presented by the average duration of acute URTIs. Vitamin A may have little to no effect on the average duration of acute URTIs. Authors' conclusions From evidence in which we have very low to low confidence, we found that there may be no benefit in using vitamin A supplementation to prevent acute URTIs in children up to seven years of age. High‐quality studies focusing on preschool children with vitamin A deficiency are needed to identify whether vitamin A supplementation may be effective.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Cheng, X; Li, D; Yang, C; Chen, B; Xu, P; Zhang, L", "articleTypes": [], "doi": "10.1002/14651858.CD015306.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "8bc67c54-f185-487a-ad5b-720c5e3c4883", "pmid": "", "title": "Surgical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Surgical treatment of chronic rhinosinusitis with nasal polyps is an established treatment for medically resistant nasal polyp disease. Whether a nasal polypectomy with additional sinus dissection offers any advantage over an isolated nasal polypectomy has not been systematically reviewed. Objectives To assess the effectiveness of simple polyp surgery versus more extensive surgical clearance in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 1); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised and quasi‐randomised controlled trials in patients over 16 with chronic rhinosinusitis with nasal polyps, who have failed a course of medical management and who have not previously undergone any previous surgical intervention for their nasal disease. Studies compared nasal polypectomy with more extensive sinus clearance in this patient cohort. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no trials which met our inclusion criteria. Six controlled trials (five randomised) met some but not all of the inclusion criteria and were therefore excluded from the review. Authors' conclusions We are unable to reach any conclusions as to whether isolated nasal polypectomy or more extensive sinus surgery is a superior surgical treatment modality for chronic rhinosinusitis with nasal polyps. There is a need for high‐quality randomised controlled trials to assess whether additional sinus surgery confers any benefit when compared to nasal polypectomy performed in isolation. Plain language summary Surgical interventions for chronic rhinosinusitis with nasal polyps Background Benign nasal polyps are abnormal tissue growths inside the nasal passages and sinuses, often on both sides of the nose. They can cause a wide array of symptoms including blocked nose, poor sense of smell that can lead to a loss of taste, runny nose and nasal congestion. Sinuses are air‐filled cavities in the bones of the face, which are in continuity with the nasal passages. The first‐line treatment for nasal polyps is usually medical therapy in the form of steroids ‐ as sprays (topically) or by mouth (orally). In patients where this treatment has failed to relieve the symptoms, the polyps can be removed surgically. These surgical procedures are often not curative and patients may need to continue medical therapy or undergo further surgeries. A number of well‐established surgical techniques can be used to remove polyps. What has not been established is whether removing the nasal polyps and clearing out the sinuses offers any advantage in the control of the disease when compared to simply removing the polyps and leaving the sinuses unchanged. We sought evidence in the literature to establish whether there was any difference in patients who underwent nasal polyp removal alone versus those who had nasal polyps removed as well as opening up of the sinuses. Study characteristics No trials met our inclusion criteria. We did identify six controlled trials (five of which were randomised) in which some but not all of our inclusion criteria were met, but we had to exclude these studies from the review. Key results No trials met our inclusion criteria. Quality of evidence At present, we cannot comment on whether taking nasal polyps out alone or also opening up the sinuses at the same time is a better treatment for patients with this disease. There is a need for high‐quality randomised controlled trials to answer this question. This evidence is current to February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Sharma, R; Lakhani, R; Rimmer, J; Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "8bdb41b9-33cf-4895-95c9-58df6705b6af", "pmid": "", "title": "Iodised salt for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency is the main cause for potentially preventable mental retardation in childhood, as well as causing goitre and hypothyroidism in people of all ages. It is still prevalent in large parts of the world. Objectives To assess the effects of iodised salt in comparison with other forms of iodine supplementation or placebo in the prevention of iodine deficiency disorders. Search methods We searched The Cochrane Library , MEDLINE, the Register of Chinese trials developed by the Chinese Cochrane Centre, and the Chinese Med Database, China National knowledge Infrastructure, and searched reference lists, databases of ongoing trials and the Internet. Selection criteria We included prospective controlled studies of iodised salt versus other forms of iodine supplementation or placebo in people living in areas of iodine deficiency. Studies reported mainly goitre rates and urinary iodine excretion as outcome measures. Data collection and analysis The initial data selection and quality assessment of trials was done independently by two reviewers. Subsequently, after the scope of the review was slightly widened from including only randomised controlled trials to including non‐randomised prospective comparative studies, a third reviewer repeated the trials selection and quality assessment. As the studies identified were not sufficiently similar and not of sufficient quality, we did not do a meta‐analysis but summarised the data in a narrative format. Main results We found six prospective controlled trials relating to our question. Four of these were described as randomised controlled trials, one was a prospective controlled trial that did not specify allocation to comparison groups, and one was a repeated cross‐sectional study comparing different interventions. Comparison interventions included non‐iodised salt, iodised water, iodised oil, and salt iodisation with potassium iodide versus potassium iodate. Numbers of participants in the trials ranged from 35 to 334; over 20,000 people were included in the cross‐sectional study. Three studies were in children only, two investigated both groups of children and adults and one investigated pregnant women. There was a tendency towards goitre reduction with iodised salt, although this was not significant in all studies. There was also an improved iodine status in most studies (except in small children in one of the studies), although urinary iodine excretion did not always reach the levels recommended by the WHO. None of the studies observed any adverse effects of iodised salt. Authors' conclusions The results suggest that iodised salt is an effective means of improving iodine status. No conclusions can be made about improvements in other, more patient‐oriented outcomes, such as physical and mental development in children and mortality. None of the studies specifically investigated development of iodine‐induced hyperthyroidism, which can be easily overlooked if just assessed on the basis of symptoms. High quality controlled studies investigating relevant long term outcome measures are needed to address questions of dosage and best means of iodine supplementation in different population groups and settings. Plain language summary Iodised salt for preventing iodine deficiency disorders Iodine deficiency causes mental retardation in children as well as enlarged thyroid glands (goitre) and deficiencies in thyroid hormones in people of all ages. It still exists in large parts of the world. This review looked at studies of iodised salt in the diet that included a comparison group. Six studies, most of them in children but some also in adults, were included. Iodine in the urine increased in all but one studies, but there was some concern that small children did not eat enough salt to achieve adequate iodine status. Some studies, but not all, also showed a reduction in the enlargement of the thyroid gland (goitre) that can accompany lack of iodine in the diet. Adverse effects were not reported, but these may not have been studied adequately. More high quality long term studies measuring outcomes related to child development, to deaths associated with iodine‐deficiency and to adverse effects are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Wu, T, Liu, GJ, Li, P, Clar, C", "articleTypes": [], "doi": "10.1002/14651858.CD003204", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.782Z" }, { "id": "8be50f2b-d723-4a2b-bee1-2258ec6c5768", "pmid": "", "title": "Effect of a Dual Orexin Receptor Antagonist, Lemborexant, on Total Sleep Time in Shift Workers: a Randomized Controlled Trial", "imported": false, "abstract": "Insomnia and daytime sleepiness are common complaints among night shift workers, but effective sleep treatments in shift workers are lacking. The aim of this Phase IV double-blind, placebo-controlled, randomized study is to test whether a dual orexin antagonist, Lemborexant (5mg or 10mg), which would be expected to block the clock-driven orexin-mediated wakefulness during the day, will increase daytime sleep time in shift workers who complain of difficulty sleeping during the daytime compared to placebo.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "8bfa5396-2484-458d-8f5e-9b6252b12024", "pmid": "", "title": "Endometrial preparation for women undergoing embryo transfer with frozen embryos or embryos derived from donor oocytes", "imported": false, "abstract": "Abstract - Background A frozen embryo transfer (FET) cycle is when one or more embryos (frozen during a previous treatment cycle) are thawed and transferred to the uterus. Some women undergo fresh embryo transfer (ET) cycles with embryos derived from donated oocytes. In both situations, the endometrium is primed with oestrogen and progestogen in different doses and routes of administration. Objectives To evaluate the most effective endometrial preparation for women undergoing transfer with frozen embryos or embryos from donor oocytes with regard to the subsequent live birth rate (LBR). Search methods The Cochrane Gynaecology and Fertility Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, LILACS, trials registers and abstracts of reproductive societies' meetings were searched in June 2020 together with reference checking and contact with study authors and experts in the field to identify additional studies. Selection criteria Randomised controlled trials (RCTs) evaluating endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. Data collection and analysis We used standard methodological procedures recommended by Cochrane. We analysed all available interventions versus placebo, no treatment, or between each other. The primary review outcome was live birth rate. Secondary outcomes were clinical and multiple pregnancy, miscarriage, cycle cancellation, endometrial thickness and adverse effects. Main results Thirty‐one RCTs (5426 women) were included. Evidence was moderate to very low‐quality: the main limitations were serious risk of bias due to poor reporting of methods, and serious imprecision. Stimulated versus programmed cycle We are uncertain whether a letrozole‐stimulated cycle compared to a programmed cycle, for endometrial preparation, improves LBR (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.49 to 3.26; 100 participants; one study; very low‐quality evidence). Stimulating with follicle stimulating hormone (FSH), letrozole or clomiphene citrate may improve clinical pregnancy rate (CPR) (OR 1.63, 95% CI 1.12 to 2.38; 656 participants; five studies; I 2 = 11%; low‐quality evidence). We are uncertain if they reduce miscarriage rate (MR) (OR 0.79, 95% CI 0.36 to 1.71; 355 participants; three studies; I 2 = 0%; very low‐quality evidence). Endometrial thickness (ET) may be reduced with clomiphene citrate (mean difference(MD) ‐1.04, 95% CI ‐1.59 to ‐0.49; 92 participants; one study; low‐quality evidence). Other outcomes were not reported. Natural versus programmed cycle We are uncertain of the effect from a natural versus programmed cycle for LBR (OR 0.97, 95% CI 0.74 to 1.28; 1285 participants; four studies; I 2 = 0%; very low‐quality evidence) and CPR (OR 0.79, 95% CI 0.62 to 1.01; 1249 participants; five studies; I 2 = 60%; very low‐quality evidence), while a natural cycle probably reduces the cycle cancellation rate (CCR) (OR 0.60, 95% CI 0.44 to 0.82; 734 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and ET. No study reported other outcomes. Transdermal versus oral oestrogens From low‐quality evidence we are uncertain of the effect transdermal compared to oral oestrogens has on CPR (OR 0.86, 95% CI 0.59 to 1.25; 504 participants; three studies; I 2 = 58%) or MR (OR 0.55, 95% CI 0.27 to 1.09; 414 participants; two studies; I 2 = 0%). Other outcomes were not reported. Day of starting administration of progestogen When doing a fresh ET using donated oocytes in a synchronised cycle starting progestogen on the day of oocyte pick‐up (OPU) or the day after OPU, in comparison with recipients that start progestogen the day prior to OPU, probably increases the CPR (OR 1.87, 95% CI 1.13 to 3.08; 282 participants; one study, moderate‐quality evidence). We are uncertain of the effect on multiple pregnancy rate (MPR) or MR. It probably reduces the CCR (OR 0.28, 95% CI 0.11 to 0.74; 282 participants; one study; moderate‐quality evidence). No study reported other outcomes. Gonadotropin‐releasing hormone (GnRH) agonist versus control A cycle with GnRH agonist compared to without may improve LBR (OR 2.62, 95% CI 1.19 to 5.78; 234 participants; one study; low‐quality evidence). From low‐quality evidence we are uncertain of the effect on CPR (OR 1.08, 95% CI 0.82 to 1.43; 1289 participants; eight studies; I 2 = 20%), MR (OR 0.85, 95% CI 0.36 to 2.00; 828 participants; four studies; I 2 = 0%), CCR (OR 0.49, 95% CI 0.21 to 1.17; 530 participants; two studies; I 2 = 0%) and ET (MD ‐0.08, 95% CI ‐0.33 to 0.16; 697 participants; four studies; I 2 = 4%). No study reported other outcomes. Among different GnRH agonists From very low‐quality evidence we are uncertain if cycles among different GnRH agonists improves CPR or MR. No study reported other outcomes. GnRH agonists versus GnRH antagonists GnRH antagonists compared to agonists probably improves CPR (OR 0.62, 95% CI 0.42 to 0.90; 473 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and MPR. No study reported other outcomes. Aspirin versus control From very low‐quality evidence we are uncertain whether a cycle with aspirin versus without improves LBR, CPR, or ET. Steroids versus control From very low‐quality evidence we are uncertain whether a cycle with steroids compared to without improves LBR, CPR or MR. No study reported other outcomes. Authors' conclusions There is insufficient evidence on the use of any particular intervention for endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. In frozen embryo transfers, low‐quality evidence showed that clinical pregnancy rates may be improved in a stimulated cycle compared to a programmed one, and we are uncertain of the effect when comparing a programmed cycle to a natural cycle. Cycle cancellation rates are probably reduced in a natural cycle. Although administering a GnRH agonist, compared to without, may improve live birth rates, clinical pregnancy rates will probably be improved in a GnRH antagonist cycle over an agonist cycle. In fresh synchronised oocyte donor cycles, the clinical pregnancy rate is probably improved and cycle cancellation rates are probably reduced when starting progestogen the day of or day after donor oocyte retrieval. Adequately powered studies are needed to evaluate each treatment more accurately. Plain language summary Endometrial preparation for egg donor recipients or for frozen embryo transfers Review question What is the most effective method for endometrial preparation in women undergoing embryo transfers with frozen embryos or embryos derived from donor oocytes? Background Couples undergo infertility treatments due to male factor, female factors or unexplained infertility. After an unsuccessful fresh embryo transfer cycle, a frozen‐thawed embryo transfer can be performed when frozen embryos are available. Adequate hormonal preparation of the endometrium is of utmost importance for both egg donor and frozen embryo replacement cycles to provide the optimal chances of pregnancy. Many drugs and various modes of administration have been tried by several investigators in order to optimise implantation rates and consequently improve the success rates of the embryo transfer procedures: stimulated cycles (to generate endogenous oestradiol), programmed cycles (administering exogenous oestradiol) or natural cycles (allowing the ovaries to produce oestradiol without stimulation) are some of the options; avoiding spontaneous ovulation with gonadotropin‐releasing hormone (GnRH) agonists and antagonists could have some impact; or using some other drugs such as aspirin or steroids that could potentially enhance the endometrial receptivity were also evaluated. Study characteristics We found 31 randomised controlled trials comparing different interventions such as the dose and route of administration of oestrogens and progestogen, the use of drugs that stop the patient from ovulating prematurely (GnRH agonists), and the use of other medications to improve the endometrium in a total of 5426 women. The evidence is current to June 2020. Key results We are uncertain whether a stimulated cycle (with letrozole) compared to a programmed cycle, for endometrial preparation, improves live birth. The evidence suggests that if the chance of live birth following a programmed cycle is assumed to be 24%, the chance following a stimulated cycle would be between 13% and 51%. We are also uncertain of the impact on miscarriage rate and endometrial thickness. A stimulated cycle may improve clinical pregnancy rate. Data were lacking on multiple pregnancy, cycle cancellation and other adverse effects. We are uncertain whether a natural cycle improves the live birth rate, pregnancy rate, miscarriage rate and endometrial thickness in comparison with a programmed cycle. Data were lacking for all other outcomes. We are uncertain if transdermal (delivered via the skin) oestrogens compared with oral (by mouth) oestrogens improve clinical pregnancy rate and miscarriage rate. Data were lacking for all other outcomes in this comparison. Starting progestogen on the day of the donor oocyte retrieval or the day after probably increases the clinical pregnancy rate and probably reduces the cycle cancellation rate. We are uncertain if it reduces the miscarriage rate. Data were lacking for all other outcomes. A cycle with GnRH agonist compared to without may improve live birth rate. We are uncertain of the effect of a GnRH cycle compared to no GnRH for the outcomes of clinical pregnancy rate, miscarriage rate, and endometrial thickness. No study reported on the other outcomes for this comparison. We are uncertain if any GnRH agonist is better than other: a cycle with daily leuprolide or with deposit tryptorelin improves clinical pregnancy rate, or if daily acetate leuprolide or daily nafarelin reduces the miscarriage rate. Other outcomes were not reported. GnRH antagonists compared to agonists probably improve clinical pregnancy rate. We are uncertain of the effect on miscarriage rate and multiple pregnancy rate. No study reported the other outcomes. We are uncertain whether a cycle with aspirin compared to a cycle without improves live birth, clinical pregnancy rate or endometrial thickness. Data were lacking for all other outcomes. We are also uncertain whether a cycle with steroids compared to a cycle without steroids improves live birth rate, clinical pregnancy rate or miscarriage rate. No study reported on the other outcomes. Quality of the evidence The evidence was of moderate to very low‐quality. The main limitations in the evidence were poor reporting of study methods, and lack of precision in the findings for live birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Glujovsky, D, Pesce, R, Sueldo, C, Quinteiro Retamar, AM, Hart, RJ, Ciapponi, A", "articleTypes": [], "doi": "10.1002/14651858.CD006359.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.119Z" }, { "id": "8bfee868-0fe8-45d1-aa95-43732aa5bddf", "pmid": "", "title": "Interventions for palliative symptom control in COVID‐19 patients", "imported": false, "abstract": "Abstract - Background Individuals dying of coronavirus disease 2019 (COVID‐19) may experience distressing symptoms such as breathlessness or delirium. Palliative symptom management can alleviate symptoms and improve the quality of life of patients. Various treatment options such as opioids or breathing techniques have been discussed for use in COVID‐19 patients. However, guidance on symptom management of COVID‐19 patients in palliative care has often been derived from clinical experiences and guidelines for the treatment of patients with other illnesses. An understanding of the effectiveness of pharmacological and non‐pharmacological palliative interventions to manage specific symptoms of COVID‐19 patients is required. Objectives To assess the efficacy and safety of pharmacological and non‐pharmacological interventions for palliative symptom control in individuals with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), Embase, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), medRxiv); Web of Science Core Collection (Science Citation Index Expanded, Emerging Sources); CINAHL; WHO COVID‐19 Global literature on coronavirus disease; and COAP Living Evidence on COVID‐19 to identify completed and ongoing studies without language restrictions until 23 March 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. Selection criteria We followed standard Cochrane methodology as outlined in the Cochrane Handbook for Systematic Reviews of Interventions . We included studies evaluating palliative symptom management for individuals with a confirmed diagnosis of COVID‐19 receiving interventions for palliative symptom control, with no restrictions regarding comorbidities, age, gender, or ethnicity. Interventions comprised pharmacological as well as non‐pharmacological treatment (e.g. acupressure, physical therapy, relaxation, or breathing techniques). We searched for the following types of studies: randomized controlled trials (RCT), quasi‐RCTs, controlled clinical trials, controlled before‐after studies, interrupted time series (with comparison group), prospective cohort studies, retrospective cohort studies, (nested) case‐control studies, and cross‐sectional studies. We searched for studies comparing pharmacological and non‐pharmacological interventions for palliative symptom control with standard care. We excluded studies evaluating palliative interventions for symptoms caused by other terminal illnesses. If studies enrolled populations with or exposed to multiple diseases, we would only include these if the authors provided subgroup data for individuals with COVID‐19. We excluded studies investigating interventions for symptom control in a curative setting, for example patients receiving life‐prolonging therapies such as invasive ventilation. Data collection and analysis We used a modified version of the Newcastle Ottawa Scale for non‐randomized studies of interventions (NRSIs) to assess bias in the included studies. We included the following outcomes: symptom relief (primary outcome); quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We rated the certainty of evidence using the GRADE approach. As meta‐analysis was not possible, we used tabulation to synthesize the studies and histograms to display the outcomes. Main results Overall, we identified four uncontrolled retrospective cohort studies investigating pharmacological interventions for palliative symptom control in hospitalized patients and patients in nursing homes. None of the studies included a comparator. We rated the risk of bias high across all studies. We rated the certainty of the evidence as very low for the primary outcome symptom relief, downgrading mainly for high risk of bias due to confounding and unblinded outcome assessors. Pharmacological interventions for palliative symptom control We identified four uncontrolled retrospective cohort studies (five references) investigating pharmacological interventions for palliative symptom control. Two references used the same register to form their cohorts, and study investigators confirmed a partial overlap of participants. We therefore do not know the exact number of participants, but individual reports included 61 to 2105 participants. Participants received multimodal pharmacological interventions: opioids, neuroleptics, anticholinergics, and benzodiazepines for relieving dyspnea (breathlessness), delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms. Primary outcome: symptom relief All identified studies reported this outcome. For all symptoms (dyspnea, delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms), a majority of interventions were rated as completely or partially effective by outcome assessors (treating clinicians or nursing staff). Interventions used in the studies were opioids, neuroleptics, anticholinergics, and benzodiazepines. We are very uncertain about the effect of pharmacological interventions on symptom relief (very low‐certainty evidence). The initial rating of the certainty of evidence was low since we only identified uncontrolled NRSIs. Our main reason for downgrading the certainty of evidence was high risk of bias due to confounding and unblinded outcome assessors. We therefore did not find evidence to confidently support or refute whether pharmacological interventions may be effective for palliative symptom relief in COVID‐19 patients. Secondary outcomes We planned to include the following outcomes: quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We did not find any data for these outcomes, or any other information on the efficacy and safety of used interventions. Non‐pharmacological interventions for palliative symptom control None of the identified studies used non‐pharmacological interventions for palliative symptom control. Authors' conclusions We found very low certainty evidence for the efficacy of pharmacological interventions for palliative symptom relief in COVID‐19 patients. We found no evidence on the safety of pharmacological interventions or efficacy and safety of non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. The evidence presented here has no specific implications for palliative symptom control in COVID‐19 patients because we cannot draw any conclusions about the effectiveness or safety based on the identified evidence. More evidence is needed to guide clinicians, nursing staff, and caregivers when treating symptoms of COVID‐19 patients at the end of life. Specifically, future studies ought to investigate palliative symptom control in prospectively registered studies, using an active‐controlled setting, assess patient‐reported outcomes, and clearly define interventions. The publication of the results of ongoing studies will necessitate an update of this review. The conclusions of an updated review could differ from those of the present review and may allow for a better judgement regarding pharmacological and non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. Plain language summary Which treatments are best for symptoms in COVID‐19 patients at the end of life? The burden of symptoms at the end of life of COVID‐19 patients and helpful treatments COVID‐19 patients may show symptoms such as breathlessness or delirium at the end of life. The goal of palliative medicine is to relieve such symptoms with specific treatments. Treatments can be drugs, for example opioids, or non‐drugs, such as breathing techniques or relaxation. What was the aim of our review? To explore how well different interventions (drugs and non‐drugs) work for the treatment of palliative symptoms in COVID‐19 patients at the end of life. We included patients of all ages and with all comorbidities (additional medical conditions). What type of studies did we search for? We searched selected medical databases and trial registries until 23 March 2021. We included studies looking at how well different palliative treatments work to relieve COVID‐19‐associated symptoms at the end of life. We wanted to compare studies investigating different medicines or therapies, but we only found studies without a comparison group. Only one study reported the specific drugs used for individual symptoms. Key results We found four studies that were published in five papers. Individual papers included between 61 and 2105 participants, and two papers partially reported on the same participants. All of the included studies investigated different drug treatments for palliative symptom management in people with COVID‐19. Drugs for symptom control at the end of life All of the included studies reported on the effectiveness of palliative care for symptom relief. In all studies, clinicians or nursing staff rated symptom relief rather than the patients themselves. Since the quality of the evidence was very low, we do not know the true effect of drug treatments on symptom relief and have very low confidence in the results of the studies. We did not find any data on quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; or safety of the drug treatments. Non‐drug therapies for symptom control at the end of life We did not find any data on the benefits and harms of non‐drug therapies for symptom control of COVID‐19 patients at the end of life. Conclusions Based on our findings, we could not draw any conclusions on palliative symptom control of people with COVID‐19. Future studies need to be designed better so that we can determine which treatments work for symptom control in people with COVID‐19.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Andreas, M, Piechotta, V, Skoetz, N, Grummich, K, Becker, M, Joos, L, Becker, G, Meissner, W, Boehlke, C", "articleTypes": [], "doi": "10.1002/14651858.CD015061", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.107Z" }, { "id": "8c0361bb-1675-4dae-b73e-77315a8f8af9", "pmid": "", "title": "Vigabatrin add‐on therapy for drug‐resistant focal epilepsy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane Review published in 2008 and updated in 2013. Epilepsy is a common neurological condition which affects up to 1% of the population. Approximately 30% of people with epilepsy do not respond to treatment with currently available drugs. The majority of these people have focal epilepsy. Vigabatrin is an antiepileptic drug licensed for use in drug‐resistant epilepsy. Objectives To assess the efficacy and tolerability of vigabatrin as an add‐on therapy for people with drug‐resistant focal epilepsy. Search methods For the latest update of this review, we searched the following databases on 1 November 2018: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid 1946 to 31 October 2018), ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL) are both included in the Cochrane Register of Studies (CRS Web). We checked reference lists of retrieved studies for additional reports of relevant studies and contacted Hoechst Marion Roussel (manufacturers of vigabatrin) in 2000. Selection criteria We included randomised, double‐blind, placebo‐controlled, fully published trials of vigabatrin in people of any age with drug‐resistant focal epilepsy. Data collection and analysis Two review authors assessed trials for inclusion and extracted data using the standard methodological procedures expected by Cochrane. Primary analysis was by intention‐to‐treat (ITT). We evaluated: 50% or greater reduction in seizure frequency, treatment withdrawal, adverse effects, dose‐response analysis, cognitive outcomes and quality of life. We presented results as risk ratios (RR) with 95% or 99% confidence intervals (CI). Main results We identified 11 trials that included 756 participants (age range: 10 to 64 years). The trials tested vigabatrin doses between 1 g/day and 6 g/day. All 11 trials displayed a risk of bias across at least three risk of bias domains. Predominantly, the risk of bias was associated with: allocation concealment (selection bias), blinding of outcome assessment (detection bias) and incomplete outcome data (attrition bias). Participants treated with vigabatrin may be two to three times more likely to obtain a 50% or greater reduction in seizure frequency compared with those treated with placebo (RR 2.60, 95% CI 1.87 to 3.63; 4 studies; low‐certainty evidence). Those treated with vigabatrin may also be three times more likely to have treatment withdrawn although we are uncertain (RR 2.86, 95% CI 1.25 to 6.55; 4 studies; very low‐certainty evidence). Compared to placebo, participants given vigabatrin were more likely to experience adverse effects: dizziness/light‐headedness (RR 1.74, 95% CI 1.05 to 2.87; 9 studies; low‐certainty evidence), fatigue (RR 1.65, 95% CI 1.08 to 2.51; 9 studies; low‐certainty evidence), drowsiness (RR 1.70, 95% CI 1.18 to 2.44; 8 studies) and depression (RR 3.28, 95% CI 1.30 to 8.27; 6 studies). Although the incidence rates were higher among participants receiving vigabatrin compared to those receiving placebo, the effect was not significant for the following adverse effects: ataxia (RR 2.76, 95% CI 0.96 to 7.94; 7 studies; very low‐certainty evidence), nausea (RR 3.57, 95% CI 0.63 to 20.30; 4 studies), abnormal vision (RR 1.64, 95% CI 0.67 to 4.02; 5 studies; very low‐certainty evidence), headache (RR 1.23, 95% CI 0.79 to 1.92; 9 studies), diplopia (RR 1.76, 99% CI 0.94 to 3.30) and nystagmus (RR 1.53, 99% CI 0.62 to 3.76; 2 studies; low‐certainty evidence). Vigabatrin had little to no effect on cognitive outcomes or quality of life. Authors' conclusions Vigabatrin may significantly reduce seizure frequency in people with drug‐resistant focal epilepsy. The results largely apply to adults and should not be extrapolated to children under 10 years old. Short‐term follow‐up of participants showed that some adverse effects were associated with its use. Analysis of longer‐term observational studies elsewhere, however, has demonstrated that vigabatrin use can lead to the development of visual field defects. Plain language summary Vigabatrin add‐on for drug‐resistant focal epilepsy Background Epilepsy is a common neurological disorder affecting approximately 1 in 100 people. Around 30% of these people cannot control their epilepsy with currently available antiepileptic medication and are said to have drug‐resistant epilepsy. Most often, drug‐resistant epilepsy is focal in nature, meaning that the seizures start in one specific area of the brain. Vigabatrin is an antiepileptic medication that can be used as an add‐on treatment for drug‐resistant focal epilepsy, meaning that it is taken in addition to other antiepileptic medications. Main results We found 11 clinical trials, involving 756 people, which investigated vigabatrin as an add‐on for people with drug‐resistant focal epilepsy. The people in the trials were aged between 10 to 64 years and were given doses of 1 g/day to 6 g/day vigabatrin. We found that people given vigabatrin may be two to three times more likely to experience a 50% or greater reduction in seizure frequency than people given placebo (a non‐active treatment). We also suggest that people given vigabatrin may be up to three times more likely to stop treatment than people given placebo. People given vigabatrin were more likely to experience side effects: dizziness/light‐headedness, fatigue, drowsiness and depression, than people given placebo. However, the evidence suggested that they should not be more likely to experience: ataxia (disorders that affect co‐ordination, balance and speech), feeling sick (nausea), abnormal vision, headache, seeing double (diplopia), or involuntary movement of the eyes (nystagmus) than people given placebo. Reliability of the evidence We judged that all studies had significant risk of bias. The studies did not explain how people were allocated to treatment groups and did not say whether investigators knew which treatment people were receiving. Alongside other reasons, this reduced our confidence (certainty) in the results. Overall, we are uncertain to very uncertain whether the results we have reported are reliable. The true effect of vigabatrin could be significantly different to that reported here. Conclusions Vigabatrin may significantly reduce seizure frequency for people with drug‐resistant focal epilepsy but we are uncertain. Most of the evidence was gathered from adults, therefore, the effects of vigabatrin could be different in children. All of the included trials were of short duration; therefore, we cannot report any long‐term effects of vigabatrin. Importantly, reviews of long‐term studies have reported that long‐term vigabatrin use can lead to the development of visual problems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bresnahan, R, Gianatsi, M, Maguire, MJ, Tudur Smith, C, Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.103Z" }, { "id": "8c104eb8-0aef-40b8-bc3a-8cd6ce319d6e", "pmid": "", "title": "Sensory stimulation for brain injured individuals in coma or vegetative state", "imported": false, "abstract": "Abstract - Background Coma and vegetative state follow traumatic brain injury in about one out of eight patients, and in patients with non traumatic injury the prognosis is worse. The use of sensory stimulation for coma and vegetative state has gained popularity during the 1980's but beliefs and opinions about its effectiveness vary substantially among health professionals. Objectives To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. Search methods We searched the Injuries Group specialised register, the Cochrane Controlled trials register, EMBASE, MEDLINE, CINAHL and PSYCHLIT from 1966 to January 2002, without language restriction. Reference lists of articles were scanned and we contacted experts in the area to find other relevant studies. Selection criteria Randomised or controlled trials that compared sensory stimulation programmes with standard rehabilitation in patients in coma or vegetative state. Data collection and analysis Abstracts and papers found were screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality resolving disagreement by consensus. Main results Three studies were identified with 68 patients in total. The overall methodological quality was poor and studies differed widely in terms of outcomes measures, study design and conduct. We therefore did not carry out any quantitative synthesis but reviewed results of available studies qualitatively. Authors' conclusions This systematic review indicates that there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state. Plain language summary No strong evidence about the effects of sensory stimulation for a brain‐injured person in a coma About half of people in a coma (deep unconsciousness) because of traumatic brain injury will wake within a year of the accident. Speeding recovery to allow people to wake sooner is a priority for them and their family. One type of treatment uses sensory stimulation to try to keep the person's brain working normally. Sensory stimulation methods vary greatly, from one or two hourly sessions of a day, through to shorter sessions every hour for 12 to 14 hours a day. The review found there is no strong evidence to determine whether sensory stimulation benefits people in comas.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Lombardi, FFL, Taricco, M, De Tanti, A, Telaro, E, Liberati, A", "articleTypes": [], "doi": "10.1002/14651858.CD001427", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.748Z" }, { "id": "8c13cfa5-58fb-44f0-b75e-9fc276f93f15", "pmid": "", "title": "Prophylactic drug management for febrile seizures in children", "imported": false, "abstract": "Abstract - Background Febrile seizures occurring in a child older than one month during an episode of fever affect 2‐4% of children in Great Britain and the United States and recur in 30%. Rapid‐acting antiepileptics and antipyretics given during subsequent fever episodes have been used to avoid the adverse effects of continuous antiepileptic drugs. This is an updated version of a Cochrane Review previously published in 2017. Objectives To evaluate primarily the effectiveness and safety of antiepileptic and antipyretic drugs used prophylactically to treat children with febrile seizures; and also to evaluate any other drug intervention where there is a sound biological rationale for its use. Search methods For the latest update we searched the following databases on 3 February 2020: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to 31 January 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including the Cochrane Epilepsy Group. We imposed no language restrictions and contacted researchers to identify continuing or unpublished studies. Selection criteria Trials using randomised or quasi‐randomised participant allocation that compared the use of antiepileptics, antipyretics or recognised Central Nervous System active agents with each other, placebo, or no treatment. Data collection and analysis For the original review, two review authors independently applied predefined criteria to select trials for inclusion and extracted the predefined relevant data, recording methods for randomisation, blinding, and exclusions. For the 2016 update, a third review author checked all original inclusions, data analyses, and updated the search. For the 2020 update, one review author updated the search and performed the data analysis following a peer‐review process with the original review authors. We assessed seizure recurrence at 6, 12, 18, 24, 36, 48 months, and where data were available at age 5 to 6 years along with recorded adverse effects. We evaluated the presence of publication bias using funnel plots. Main results We included 42 articles describing 32 randomised trials, with 4431 randomised participants used in the analysis of this review. We analysed 15 interventions of continuous or intermittent prophylaxis and their control treatments. Methodological quality was moderate to poor in most studies. We found no significant benefit for intermittent phenobarbital, phenytoin, valproate, pyridoxine, ibuprofen, or zinc sulfate versus placebo or no treatment; nor for diclofenac versus placebo followed by ibuprofen, paracetamol, or placebo; nor for continuous phenobarbital versus diazepam, intermittent rectal diazepam versus intermittent valproate, or oral diazepam versus clobazam. There was a significant reduction of recurrent febrile seizures with intermittent diazepam versus placebo or no treatment at six months (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.48 to 0.85; 6 studies, 1151 participants; moderate‐certainty evidence), 12 months (RR 0.69, 95% CI 0.56 to 0.84; 8 studies, 1416 participants; moderate‐certainty evidence), 18 months (RR 0.37, 95% CI 0.23 to 0.60; 1 study, 289 participants; low‐certainty evidence), 24 months (RR 0.73, 95% CI 0.56 to 0.95; 4 studies, 739 participants; high‐certainty evidence), 36 months (RR 0.58, 95% CI 0.40 to 0.85; 1 study, 139 participants; low‐certainty evidence), 48 months (RR 0.36, 95% CI 0.15 to 0.89; 1 study, 110 participants; moderate‐certainty evidence), with no benefit at 60 to 72 months (RR 0.08, 95% CI 0.00 to 1.31; 1 study, 60 participants; very low‐certainty evidence). Phenobarbital versus placebo or no treatment reduced seizures at six months (RR 0.59, 95% CI 0.42 to 0.83; 6 studies, 833 participants; moderate‐certainty evidence), 12 months (RR 0.54, 95% CI 0.42 to 0.70; 7 studies, 807 participants; low‐certainty evidence), and 24 months (RR 0.69, 95% CI 0.53 to 0.89; 3 studies, 533 participants; moderate‐certainty evidence), but not at 18 months (RR 0.77, 95% CI 0.56 to 1.05; 2 studies, 264 participants) or 60 to 72 months follow‐up (RR 1.50, 95% CI 0.61 to 3.69; 1 study, 60 participants; very low‐certainty evidence). Intermittent clobazam compared to placebo at six months resulted in a RR of 0.36 (95% CI 0.20 to 0.64; 1 study, 60 participants; low‐certainty evidence), an effect found against an extremely high (83.3%) recurrence rate in the controls, a result that needs replication. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months (RR 0.45, 95% CI 0.18 to 1.15; 1 study, 60 participants; very‐low certainty evidence). When compared to placebo, intermittent oral levetiracetam significantly reduced recurrent seizures at 12 months (RR 0.27, 95% CI 0.15 to 0.52; 1 study, 115 participants; very low‐certainty evidence). The recording of adverse effects was variable. Two studies reported lower comprehension scores in phenobarbital‐treated children. Adverse effects were recorded in up to 30% of children in the phenobarbital‐treated groups and 36% in benzodiazepine‐treated groups. We found evidence of publication bias in the meta‐analyses of comparisons for phenobarbital versus placebo (seven studies) at 12 months but not at six months (six studies); and valproate versus placebo (four studies) at 12 months. There were too few studies to identify publication bias for the other comparisons. The methodological quality of most of the included studies was low or very low. Methods of randomisation and allocation concealment often did not meet current standards, and 'treatment versus no treatment' was more commonly seen than 'treatment versus placebo', leading to obvious risks of bias. Authors' conclusions We found reduced recurrence rates for intermittent diazepam and continuous phenobarbital, with adverse effects in up to 30% of children. The apparent benefit for clobazam treatment in one trial needs to be replicated. Levetiracetam also shows benefit with a good safety profile; however, further study is required. Given the benign nature of recurrent febrile seizures, and the high prevalence of adverse effects of these drugs, parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. Plain language summary Prophylactic drug management for febrile seizures in children Background Seizures occurring with a fever (febrile seizures) in children are common and affect about one in 30 children under the age of six years. On average, one out of three children who have had a febrile seizure will have at least one more. We reviewed the evidence about the effect of drugs to prevent seizures (antiepileptics), drugs to lower temperature (antipyretics), and zinc in children with febrile seizures. Objective We wanted to know in how many children these drugs would prevent a recurrence of febrile seizures or cause unwanted effects. Methods We included 32 studies with a total of 4431 children in the review. Children who had had at least one febrile seizure were assigned to one of two or more treatment groups. The studies recorded any further seizures at various time intervals between six months and up to six years of age in each group. Unwanted medication effects were also noted. Results The study design and evidence quality in the studies of antiepileptic drugs was often low or very low. Poor methods known to lead to obvious risks of bias were used. One issue was with the methods used to assign children to study groups and how random this allocation was. Other issues included whether the parents or doctors, or both, knew which group each child was in or if a treatment was compared to no treatment with no placebo (dummy pill) used. The quality of the trials of antipyretics or zinc was better, with the evidence assessed as moderate to high. Zinc therapy was found to provide no benefit. We also found no benefit in treating children just at the time of the fever with either antipyretic drugs or most antiepileptic drugs. A significant result was noted in some instances. For example, at times between 6 and 48 months follow‐up, intermittent diazepam (an antiepileptic drug) led to a reduction in the number of recurrent seizures by about a third. Continuous phenobarbital resulted in significantly fewer recurrences at 6, 12, and 24 months, but not at 18 and 60 to 72 months. One study showed that intermittent oral levetiracetam compared to placebo significantly reduced recurrent seizures at 12 months. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months. However, as recurrent seizures are only seen in about a third of children, this means that up to 16 children would have to be treated over a year or two to save just one child a further seizure. As febrile seizures are not harmful, we viewed these significant findings to be unimportant, in particular because adverse effects of the medications were common. Lower comprehension scores in phenobarbital‐treated children were found in two studies. In general, adverse effects were recorded in up to about a third of children in both the phenobarbital‐ and benzodiazepine‐treated groups. The benefit found for treatment with clobazam in one study published in 2011 needs to be repeated to test its reliability. Levetiracetam may be useful in treating children where family anxiety over possible seizure recurrence is high, but further study is required. Authors' conclusions There is currently insufficient evidence to support the use of continuous or intermittent treatment with zinc, antiepileptic or antipyretic drugs for children with febrile seizures. Febrile seizures can be frightening to witness. Parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. The evidence is current to February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Offringa, M, Newton, R, Nevitt, SJ, Vraka, K", "articleTypes": [], "doi": "10.1002/14651858.CD003031.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.122Z" }, { "id": "8c28ce98-e35a-4212-90f9-577c3195f08d", "pmid": "", "title": "Green tea for weight loss and weight maintenance in overweight or obese adults", "imported": false, "abstract": "Abstract - Background Preparations of green tea are used as aids in weight loss and weight maintenance. Catechins and caffeine, both contained in green tea, are each believed to have a role in increasing energy metabolism, which may lead to weight loss. A number of randomised controlled trials (RCTs) evaluating the role of green tea in weight loss have been published; however, the efficacy of green tea preparations in weight loss remains unclear. Objectives To assess the efficacy and safety of green tea preparations for weight loss and weight maintenance in overweight or obese adults. Search methods We searched the following databases from inception to specified date as well as reference lists of relevant articles: The Cochrane Library (Issue 12, 2011), MEDLINE (December 2011), EMBASE (December 2011), CINAHL (January 2012), AMED (January 2012), Biological Abstracts (January 2012), IBIDS (August 2010), Obesity+ (January 2012), IPA (January 2012) and Web of Science (December 2011). Current Controlled Trials with links to other databases of ongoing trials was also searched. Selection criteria RCTs of at least 12 weeks' duration comparing green tea preparations to a control in overweight or obese adults. Data collection and analysis Three authors independently extracted data, assessed studies for risk of bias and quality, with differences resolved by consensus. Heterogeneity of included studies was assessed visually using forest plots and quantified using the I 2 statistic. We synthesised data using meta‐analysis and descriptive analysis as appropriate; subgroup and sensitivity analyses were conducted. Adverse effects reported in studies were recorded. Main results Due to the level of heterogeneity among studies, studies were divided into two groups; those conducted in Japan and those conducted outside Japan. Study length ranged between 12 and 13 weeks. Meta‐analysis of six studies conducted outside Japan showed a mean difference (MD) in weight loss of ‐0.04 kg (95% CI ‐0.5 to 0.4; P = 0.88; I 2 = 18%; 532 participants). The eight studies conducted in Japan were not similar enough to allow pooling of results and MD in weight loss ranged from ‐0.2 kg to ‐3.5 kg (1030 participants) in favour of green tea preparations. Meta‐analysis of studies measuring change in body mass index (BMI) conducted outside Japan showed a MD in BMI of ‐0.2 kg/m 2 (95% CI ‐0.5 to 0.1; P = 0.21; I 2 = 38%; 222 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed a reduction in BMI ranging from no effect to ‐1.3 kg/m 2 (1030 participants), in favour of green tea preparations over control. Meta‐analysis of five studies conducted outside Japan and measuring waist circumference reported a MD of ‐0.2 cm (95% CI ‐1.4 to 0.9; P = 0.70; I 2 = 58%; 404 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed effects on waist circumference ranging from a gain of 1 cm to a loss of 3.3 cm (1030 participants). Meta‐analysis for three weight loss studies, conducted outside Japan, with waist‐to‐hip ratio data (144 participants) yielded no significant change (MD 0; 95% CI ‐0.02 to 0.01). Analysis of two studies conducted to determine if green tea could help to maintain weight after a period of weight loss (184 participants) showed a change in weight loss of 0.6 to ‐1.6 kg, a change in BMI from 0.2 to ‐0.5 kg/m 2 and a change in waist circumference from 0.3 to ‐1.7 cm. In the eight studies that recorded adverse events, four reported adverse events that were mild to moderate, with the exception of two (green tea preparations group) that required hospitalisation (reported as not associated with the intervention). Nine studies reported on compliance/adherence, one study assessed attitude towards eating as part of the health‐related quality of life outcome. No studies reported on patient satisfaction, morbidity or cost. Authors' conclusions Green tea preparations appear to induce a small, statistically non‐significant weight loss in overweight or obese adults. Because the amount of weight loss is small, it is not likely to be clinically important. Green tea had no significant effect on the maintenance of weight loss. Of those studies recording information on adverse events, only two identified an adverse event requiring hospitalisation. The remaining adverse events were judged to be mild to moderate. Plain language summary Green tea for weight loss and weight maintenance in overweight or obese adults Green tea has a long history of many uses, one of which is helping overweight people to lose weight and to maintain weight loss. Believed to be able to increase a person's energy output, green tea weight loss preparations are extracts of green tea that contain a higher concentration of ingredients (catechins and caffeine) than the typical green tea beverage prepared from a tea bag and boiling water. This review looked at 15 weight loss studies and three studies measuring weight maintenance where some form of a green tea preparation was given to one group and results compared to a group receiving a control. Neither group knew whether they were receiving the green tea preparation or the control. A total of 1945 participants completed the studies, ranging in length from 12 to 13 weeks. In summary, the loss in weight in adults who had taken a green tea preparation was statistically not significant, was very small and is not likely to be clinically important. Similar results were found in studies that used other ways to measure loss in weight (body mass index, waist circumference). Studies examining the effect of green tea preparations on weight maintenance did not show any benefit compared to the use of a control preparation. Most adverse effects, such as nausea, constipation, abdominal discomfort and increased blood pressure, were judged to be mild to moderate and to be unrelated to the green tea or control intervention. No deaths were reported, although adverse events required hospitalisation. One study attempted to look at health‐related quality of life by asking participants about their attitudes towards eating. Nine studies tracked participants' compliance with green tea preparations. Studies did not include any information about the effects of green tea preparations on morbidity, costs or patient satisfaction.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Jurgens, TM; Whelan, AM; Killian, L; Doucette, S; Kirk, S; Foy, E", "articleTypes": [], "doi": "10.1002/14651858.CD008650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "8c424189-c11e-48d6-ba0a-91a9059303f8", "pmid": "", "title": "Oral zinc for the prevention of hyperbilirubinaemia in neonates", "imported": false, "abstract": "Abstract - Background Between 6% and 15% of neonates develop hyperbilirubinaemia requiring treatment. Successful management of neonatal hyperbilirubinaemia relies on prevention and early treatment, with phototherapy being the mainstay of treatment. Oral zinc has been reported to decrease the serum total bilirubin (STB), presumably by decreasing the enterohepatic circulation. Objectives To determine the effect of oral zinc supplementation compared to placebo or no treatment on the incidence of hyperbilirubinaemia in neonates during the first week of life and to assess the safety of oral zinc in enrolled neonates. Search methods We searched CENTRAL (The Cochrane Library 2014, Issue 1), MEDLINE (1966 to November 30, 2014), and EMBASE (1990 to November 30, 2014). Selection criteria Randomised controlled trials were eligible for inclusion if they enrolled neonates (term and preterm) to whom oral zinc, in a dose of 10 to 20 mg/day, was initiated within the first 96 hours of life, for any duration until day seven, compared with no treatment or placebo. Data collection and analysis We used the standard methods of The Cochrane Collaboration and its Neonatal Review Group for data collection and analysis. Main results Only one study met the criteria of inclusion in the review. This study compared oral zinc with placebo. Oral zinc was administered in a dose of 5 mL twice daily from day 2 to day 7 postpartum. The drug was administered into the mouth of the infant by the plastic measure provided with the bottle or with a spoon. Incidence of hyperbilirubinaemia, defined as serum total bilirubin (STB) ≥ 15 mg/dL, was similar between groups (N = 286; risk ratio (RR) 0.94, 95% confidence interval (CI) 0.58 to 1.52). Mean STB levels, mg/dL, at 72 ± 12 hours were comparable in both the groups (N = 286; mean difference (MD) ‐0.20; 95% CI ‐1.03 to 0.63). Although the duration of phototherapy in the zinc group was significantly shorter compared to the placebo group (N = 286; MD ‐12.80, 95% CI ‐16.93 to ‐8.67), the incidence of need for phototherapy was comparable across both the groups (N = 286; RR 1.20; 95% CI 0.66 to 2.18). Incidences of side effects like vomiting (N = 286; RR 0.65, 95% CI 0.19 to 2.25), diarrhoea (N = 286; RR 2.92, 95% CI 0.31 to 27.71), and rash (N = 286; RR 2.92, 95% CI 0.12 to 71.03) were found to be rare and statistically comparable between groups. Authors' conclusions The limited evidence available has not shown that oral zinc supplementation given to infants up to one week old reduces the incidence of hyperbilirubinaemia or need for phototherapy. Plain language summary Oral zinc for the prevention of hyperbilirubinaemia in neonates Review question In newborn infants less than one week old, does oral zinc salt supplementation compared to placebo or no treatment decrease the incidence of hyperbilirubinaemia (jaundice)? Background Jaundice, or yellowish discolouration of the skin, can occur due to an increased amount of bilirubin pigment in the blood. It is a commonly observed and usually harmless condition in newborn infants during the first week after birth. However, in some babies, the amount of bilirubin pigment can increase to dangerous levels and necessitate treatment. Bilirubin is metabolised in the liver and is excreted via the intestine in faeces. Increased reabsorption of bilirubin from the intestine is one of the major factors inducing hyperbilirubinaemia in newborn infants. Oral zinc salt, a relatively harmless medicine, can reduce the bilirubin level in newborn infants by decreasing its reabsorption from the intestine. Study characteristics Researchers from Cochrane searched for all available literature up to 30 November 2014. One randomised controlled trial met our inclusion criteria. Results In this review, the efficacy of oral zinc salt was compared with placebo. One study enrolling 294 infants was identified. This study evaluated oral zinc salt, given in a dose of 5 mg twice daily to infants between 25 and 168 hours old. The administration of oral zinc salt did not affect the incidence of jaundice (hyperbilirubinaemia) in these infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mishra, S; Cheema, A; Agarwal, R; Deorari, A; Paul, V", "articleTypes": [], "doi": "10.1002/14651858.CD008432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "8c481a68-faf4-4fa2-bfa6-fe55d1132603", "pmid": "", "title": "Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five‐year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis. Objectives To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions. Search methods We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi‐randomised trials. The reference lists of relevant articles were also searched. Selection criteria All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded. Data collection and analysis Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author. Main results A total of 40 randomised or quasi‐randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials. For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights. Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects. Authors' conclusions There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials. Plain language summary Drug treatment for children with bedwetting (nocturnal enuresis) but not including the drug types desmopressin or tricyclics Bedwetting (nocturnal enuresis) is the involuntary loss of urine at night without an underlying organic disease as the cause. It can result in social problems, sibling teasing and lowered self esteem. It affects around 15% to 20% of five‐year olds, and up to 2% of adults. Many different types of drugs have been used to treat children with bed wetting. There is not enough reliable evidence to show that drugs other than desmopressin or tricyclics reduce bedwetting in children during treatment when used in isolation, despite their risk of unwanted side effects. In other Cochrane reviews, alarms triggered by wetting, desmopressin and tricyclic drugs have been shown to work during treatment. However, alarms have a more sustained effect than desmopressin and tricyclics after treatment has finished. The adverse effects of alarm therapy (tiredness and waking other members of the family) are relatively benign and self limiting compared with the adverse effects of drugs. One class of drugs (anticholinergic drugs) appears to improve the efficacy of other established treatments such as tricyclics, bedwetting alarms and desmopressin. The cost of treating children with bedwetting with alarm therapy or drugs may vary in different countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Deshpande, AV; Caldwell, PHY; Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "8c4f9280-9d32-4830-bf94-ab14f40a9037", "pmid": "", "title": "External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion). Objectives To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. Search methods We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index‐Science (CPCI‐S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. Selection criteria We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. Data collection and analysis We used standard Cochrane methodology to collect data and performed a network meta‐analysis using the standard frequentist graph‐theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption. Main results We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy‐nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow‐up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low‐certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled. Authors' conclusions Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method. Plain language summary Electrical shocks (electrical cardioversion) and drugs (pharmacological cardioversion) for restoring normal rhythm in patients with atrial fibrillation or atrial flutter Key Messages ‐ Electrical cardioversion and some drugs can be used to restore the normal rhythm in patients with atrial fibrillation (AF) and atrial flutter. While electrical cardioversion is highly effective in dealing with all arrhythmias, the efficacy of drugs varies, with some being only moderately effective or not working at all in persistent AF and atrial flutter. ‐ Electrical cardioversion seems to be a very safe option. The risk of severe complications with cardioversion using drugs was low, but additional precautions are needed. ‐ We need further studies to find out if these treatment options also have a positive effect on quality of life, or if they lead to relevant differences in the duration of hospital stay. What is atrial fibrillation? AF is the most frequent abnormal heart rhythm seen in the world. Patients with this condition may feel their heart beating rapidly and irregularly. This can occur for separate brief or long episodes (paroxysmal AF) or it may become continuous (persistent AF). Atrial flutter is a similar abnormal rhythm that causes similar symptoms, can cause episodes of variable duration and can also become continuous. What is cardioversion? Cardioversion is a treatment to restore the rhythm of the heart back to normal (sinus rhythm). What did we want to find out? We wanted to know if delivering a controlled electrical shock (i.e. electrical cardioversion) and drugs (i.e. pharmacological cardioversion) are effective and safe when restoring heart rhythm back to normal. What did we do? We searched for studies that investigated electrical and pharmacological cardioversion compared to each other or placebo (a medicine that looks like the real medicine but that has no active ingredient). We compared and summarised the results of the studies and rated our trust in these results, based on factors such as study methods and size. What did we find? We found 112 studies. We were able to combine and analyse the results from 72 studies, with 15,968 participants aged between 47 and 72 years. Thirty‐five studies included patients with paroxysmal AF (AF that terminates spontaneously or with intervention within 7 days of onset), 26 studies of patients with persistent AF (AF that is continuously sustained beyond seven days, including episodes terminated by cardioversion after ≥ 7 days), and 14 trials included patients with atrial flutter. The remaining included a mix of paroxysmal, persistent AF and atrial flutter. Main results For patients with paroxysmal AF, electrical cardioversion with biphasic incremental energy, fast‐acting drugs like intravenous vernakalant, flecainide, ibutilide and antazoline, and slower‐acting and/or oral drugs such as quinidine, propafenone, amiodarone and sotalol are effective at restoring sinus rhythm. For patients with persistent AF, electrical cardioversion with biphasic energy seems to be the most effective option; bepridil, quinidine and amiodarone tablets may also be effective in selected cases. For patients with atrial flutter, electrical cardioversion followed by dofetilide are the most effective options. The risk of death and stroke is very low for patients having cardioversion procedures. Malignant arrhythmias (torsade de pointes, sustained ventricular tachycardia or ventricular fibrillation, all of which are associated with high 1‐year mortality rate) were observed for dofetilide, ibutilide, sotalol, quinidine and vernakalant, justifying the need for special care and closer monitoring when using these drugs. Duration of hospitalisation data was available in three studies but, as there were variable timings in these studies, we could not combine them to assess their joint effectiveness. These studies suggest that the duration of hospitalisation may be lower with electrical cardioversion. Heart failure was observed in some patients treated with propafenone, flecainide, sotalol, amiodarone, vernakalant, and placebo, and was not observed in patients receiving electrical cardioversion, suggesting that the latter approach should be the preferred one if concerns exist regarding the occurrence of this outcome. Phlebitis (i.e. inflammation of the vein caused by using injectable drugs) occurred frequently in patients treated with amiodarone, and dysgeusia (i.e. impairment of the sense of taste) and sneezing occurred frequently in patients receiving vernakalant. What are the limitations of the observed results? We are sure or moderately sure of the results for the efficacy of treatments available for persistent AF and atrial flutter. We are less sure about the results for some of the treatment options for paroxysmal AF. Not enough data are available regarding quality of life, and data were limited regarding duration of hospital stay. The risk of stroke or dying was very low. How up to date are the studies and information on this review? The included studies and information are current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Kukendrarajah, K; Ahmad, M; Carrington, M; Ioannou, A; Taylor, J; Razvi, Y; Papageorgiou, N; Mead, GE; Nevis, IF; D'Ascenzo, F; Wilton, SB; Lambiase, PD; Morillo, CA; Kwong, JSW; Providencia, R", "articleTypes": [], "doi": "10.1002/14651858.CD013255.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "8c64dbce-3eb7-4da0-8be2-3eb6414d2c9a", "pmid": "", "title": "Interventions for iatrogenic inferior alveolar and lingual nerve injury", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Coulthard, P, Kushnerev, E, Yates, JM, Walsh, T, Patel, N, Bailey, E, Renton, TF", "articleTypes": [], "doi": "10.1002/14651858.CD005293.pub2 AB - Abstract - Background Iatrogenic injury of the inferior alveolar or lingual nerve or both is a known complication of oral and maxillofacial surgery procedures. Injury to these two branches of the mandibular division of the trigeminal nerve may result in altered sensation associated with the ipsilateral lower lip or tongue or both and may include anaesthesia, paraesthesia, dysaesthesia, hyperalgesia, allodynia, hypoaesthesia and hyperaesthesia. Injury to the lingual nerve may also affect taste perception on the affected side of the tongue. The vast majority (approximately 90%) of these injuries are temporary in nature and resolve within eight weeks. However, if the injury persists beyond six months it is deemed to be permanent. Surgical, medical and psychological techniques have been used as a treatment for such injuries, though at present there is no consensus on the preferred intervention, or the timing of the intervention. Objectives To evaluate the effects of different interventions and timings of interventions to treat iatrogenic injury of the inferior alveolar or lingual nerves. Search methods We searched the following electronic databases: the Cochrane Oral Health Group's Trial Register (to 9 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 9 October 2013) and EMBASE via OVID (1980 to 9 October 2013). No language restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials (RCTs) involving interventions to treat patients with neurosensory defect of the inferior alveolar or lingual nerve or both as a sequela of iatrogenic injury. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. We performed data extraction and assessment of the risk of bias independently and in duplicate. We contacted authors to clarify the inclusion criteria of the studies. Main results Two studies assessed as at high risk of bias, reporting data from 26 analysed participants were included in this review. The age range of participants was from 17 to 55 years. Both trials investigated the effectiveness of low‐level laser treatment compared to placebo laser therapy on inferior alveolar sensory deficit as a result of iatrogenic injury. Patient‐reported altered sensation was partially reported in one study and fully reported in another. Following treatment with laser therapy, there was some evidence of an improvement in the subjective assessment of neurosensory deficit in the lip and chin areas compared to placebo, though the estimates were imprecise: a difference in mean change in neurosensory deficit of the chin of 8.40 cm (95% confidence interval (CI) 3.67 to 13.13) and a difference in mean change in neurosensory deficit of the lip of 21.79 cm (95% CI 5.29 to 38.29). The overall quality of the evidence for this outcome was very low; the outcome data were fully reported in one small study of 13 patients, with differential drop‐out in the control group, and patients suffered only partial loss of sensation. No studies reported on the effects of the intervention on the remaining primary outcomes of pain, difficulty eating or speaking or taste. No studies reported on quality of life or adverse events. The overall quality of the evidence was very low as a result of limitations in the conduct and reporting of the studies, indirectness of the evidence and the imprecision of the results. Authors' conclusions There is clearly a need for randomised controlled clinical trials to investigate the effectiveness of surgical, medical and psychological interventions for iatrogenic inferior alveolar and lingual nerve injuries. Primary outcomes of this research should include: patient‐focused morbidity measures including altered sensation and pain, pain, quantitative sensory testing and the effects of delayed treatment. Plain language summary Treatments for accidental damage during surgery to the nerves supplying sensation to the tongue, lower lip and chin Review question The main question addressed by this review is how effective are different treatments and what are the best timings for these treatments following accidental damage during surgery to the nerves that supply sensation to the tongue, lower lip and chin. Background The nerves (alveolar and lingual) supplying sensation to the tongue, lower lip and chin, may be injured as a result of surgical treatments to the mouth and face, including surgery to remove lower wisdom teeth. The vast majority (90%) of these injuries are temporary and get better within eight weeks. However if they last for longer than six months they are considered to be permanent. Damage to these nerves can lead to altered sensation in the region of the lower lip and chin, or tongue or both. Furthermore, damage to the nerve supplying the tongue may lead to altered taste perception. These injuries can affect people's quality of life leading to emotional problems, problems with socialising and disabilities. Accidental injury after surgery can also give rise to legal action. There are many interventions or treatments available, surgical and non‐surgical, that may enhance recovery, including improving sensation. They can be grouped as. 1. Surgical – a variety of procedures.
 2. Laser treatment – low‐level laser treatment has been used to treat partial loss of sensation.
 3. Medical – treatment with drugs including antiepileptics, antidepressants and painkillers.
 4. Counselling – including cognitive behavioural and relaxation therapy, changing behaviour and hypnosis. Study characteristics The Cochrane Oral Health Group carried out this review, and the evidence is current as of 9 October 2013. There are two studies included, both published in 1996, which compared low‐level laser treatment to placebo or fake treatment for partial loss of sensation following surgery to the lower jaw. There were 15 participants in one study and 16 in the other, their ages ranging from 17 to 55 years. All had suffered accidental damage to nerves of the lower jaw and tongue causing some loss of sensation following surgery. Key results Low‐level laser therapy was the only treatment to be evaluated in the included studies and this was compared to fake or placebo laser therapy. No studies were found that evaluated other surgical, medical or counselling treatments. There was some evidence of an improvement when participants reported whether or not sensation was better in the lip and chin areas with low‐level laser therapy. This is based on the results of a single, small study, so the results should be interpreted with caution. No studies reported on the effects of the treatment on other outcomes such as pain, difficulty eating or speaking or taste. No studies reported on quality of life or harm. Quality of the evidence The overall quality of the evidence is very low as a result of limitations in the conduct and reporting of the two included studies and the low number of participants, and evidence from participants with only partial sensory loss.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.062Z" }, { "id": "8c7213ca-cefb-4153-b3a3-e14dfa9975ff", "pmid": "", "title": "Aspirin with or without an antiemetic for acute migraine headaches in adults", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010). Migraine is a common, disabling condition and a burden for the individual, health services and society. Many sufferers choose not to, or are unable to, seek professional help and rely on over‐the‐counter analgesics. Co‐therapy with an antiemetic should help to reduce nausea and vomiting commonly associated with migraine headaches. Objectives To determine the efficacy and tolerability of aspirin, alone or in combination with an antiemetic, compared to placebo and other active interventions in the treatment of acute migraine headaches in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, ClinicalTrials.gov, and reference lists for studies through 10 March 2010 for the original review and to 31 January 2013 for the update. Selection criteria We included randomised, double‐blind, placebo‐controlled or active‐controlled studies, or both, using aspirin to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and numbers needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment. Main results No new studies were found for this update. Thirteen studies (4222 participants) compared aspirin 900 mg or 1000 mg, alone or in combination with metoclopramide 10 mg, with placebo or other active comparators, mainly sumatriptan 50 mg or 100 mg. For all efficacy outcomes, all active treatments were superior to placebo, with NNTs of 8.1, 4.9 and 6.6 for 2‐hour pain‐free, 2‐hour headache relief, and 24‐hour headache relief with aspirin alone versus placebo, and 8.8, 3.3 and 6.2 with aspirin plus metoclopramide versus placebo. Sumatriptan 50 mg did not differ from aspirin alone for 2‐hour pain‐free and headache relief, while sumatriptan 100 mg was better than the combination of aspirin plus metoclopramide for 2‐hour pain‐free, but not headache relief; there were no data for 24‐hour headache relief. Adverse events were mostly mild and transient, occurring slightly more often with aspirin than placebo. Additional metoclopramide significantly reduced nausea (P < 0.00006) and vomiting (P = 0.002) compared with aspirin alone. Authors' conclusions We found no new studies since the last version of this review. Aspirin 1000 mg is an effective treatment for acute migraine headaches, similar to sumatriptan 50 mg or 100 mg. Addition of metoclopramide 10 mg improves relief of nausea and vomiting. Adverse events were mainly mild and transient, and were slightly more common with aspirin than placebo, but less common than with sumatriptan 100 mg. Plain language summary Aspirin with or without an antiemetic for acute migraine headaches in adults This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010); no new studies were found. A single oral dose of 1000 mg of aspirin reduced pain from moderate or severe to none by two hours in approximately 1 in 4 people (24%) taking aspirin, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (52%) taking aspirin compared with approximately 1 in 3 (32%) taking placebo. Of those who experienced effective headache relief at two hours, more had that relief sustained over 24 hours with aspirin than with placebo. Addition of 10 mg of the antiemetic metoclopramide substantially increased relief of nausea and vomiting compared with aspirin alone, but made little difference to pain. Oral sumatriptan 100 mg was better than aspirin plus metoclopramide for pain‐free response at two hours, but otherwise there were no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short‐term use were mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Kirthi, V, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008041.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.754Z" }, { "id": "8c8af220-ffaa-48a1-9cd6-5cbd0b916669", "pmid": "", "title": "Diclofenac for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically cyclo‐oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain. Objectives To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled'). Search methods We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022. Selection criteria We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI). Main results We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low‐certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child‐reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD ‐0.45, 95% CI ‐0.74 to ‐0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD ‐0.64, 95% CI ‐0.89 to ‐0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low‐certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low‐certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results. Authors' conclusions We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non‐pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered. Plain language summary What are the benefits and harms of diclofenac for managing children's pain after they have had an operation? Key messages • Due to a lack of robust evidence, the benefits and harms of diclofenac for managing children's pain after they've had an operation are unclear. • Diclofenac probably reduces nausea and vomiting, but probably increases the risk of bleeding, compared to opioids (such as morphine). • Well‐designed and comprehensively‐reported studies are needed to shed light on the benefits and harms of diclofenac compared to opioids or other medicines, or for different ways of giving diclofenac to children. Postoperative pain management Pain after surgery or a procedure is common and can influence recovery and return to normal activities. There are many ways to reduce pain after an operation, including medicines such as diclofenac. Diclofenac is part of a class of medicines called non‐steroidal anti‐inflammatory drugs (NSAIDs) that can reduce inflammation and pain. They can be given by different routes, such as by mouth or through the anus into the rectum (back passage), and before, during, and after an operation. What did we want to find out? We wanted to find out the benefits and harms of diclofenac compared to other treatments, as well as the most effective way to deliver diclofenac to children. What did we do? We searched for studies that compared (a) diclofenac to other treatments for postoperative pain; or (b) different ways of delivering diclofenac to children. We summarised the results and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 32 studies that included 2250 children with postoperative pain. The largest study included 183 children and the smallest, 31 children. The studies were conducted in many countries around the world; the most common location was the United Kingdom (10 studies). The average age of the children was between 2 and 14 years. Diclofenac was used to manage postoperative pain in 12 different types of surgery; most commonly, ear, nose, and throat surgery (9 studies) or eye surgery (6 studies). Main results It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor and serious harms compared to a placebo (a 'dummy' or sham treatment that does not contain any medicine but looks or tastes identical to the medicine being tested). It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief or pain intensity compared to other medicines, such as opioids, paracetamol, or bupivacaine. Diclofenac probably results in less nausea and vomiting compared to opioids (7 studies involving 463 children), but probably increases the risk of any bleeding (2 studies involving 222 children), but we are very unsure about serious harms (death, long‐term disability, or hospitalisation). It is thus unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor or serious harms compared to placebo or other medicines other than opioids. It is also unclear which route (by mouth or rectal delivery) is the most effective way to manage pain after surgery in children. What are the limitations of the evidence? We are not confident in the evidence because of study design limitations, and none of the studies measured some of our main outcomes of interest. There were also not enough large studies to be certain about the results. How up to date is this evidence? The evidence is current to April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ringsten, M; Kredo, T; Ebrahim, S; Hohlfeld, A; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015087.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "8cc54b72-3cd7-40fb-9656-ee3580914c1f", "pmid": "", "title": "Short‐course oral steroids as an adjunct therapy for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of a short course of oral corticosteroids as an adjunct ('add‐on') therapy in people with chronic rhinosinusitis who are already on standard treatments. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids to placebo or no treatment, where all patients were also receiving pharmacological treatment for chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score, and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results Two trials with a total of 78 participants met the inclusion criteria. Both the populations and the 'standard' treatments differed in the two studies. Oral steroids as an adjunct to intranasal corticosteroids One trial in adults with nasal polyps included 30 participants. All participants used intranasal corticosteroids and were randomised to either short‐course oral steroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 21‐day treatment course) or no additional treatment. None of the primary outcome measures of interest in this review were reported by the study. There may have been an important reduction in the size of the polyps (measured by the nasal polyps score, a secondary outcome measure) in patients receiving oral steroids and intranasal corticosteroids, compared to intranasal corticosteroids alone (mean difference (MD) ‐0.46, 95% confidence interval (CI) ‐0.87 to ‐0.05; 30 participants; scale 1 to 4) at the end of treatment (21 days). This corresponds to a large effect size, but we are very uncertain about this estimate as we judged the study to be at high risk of bias. Moreover, longer‐term data were not available and the other outcomes of interest were not reported. Oral steroids as an adjunct to antibiotics One trial in children (mean age of eight years) without nasal polyps included 48 participants. The trial compared oral corticosteroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 15‐day treatment course) with placebo in participants who also received a 30‐day course of antibiotics. This study addressed one of the primary outcome measures (disease severity) and one secondary outcome (CT score). For disease severity the four key symptoms used to define chronic rhinosinusitis in children (nasal blockage, nasal discharge, facial pressure, cough) were combined into one score. There was a greater improvement in symptom severity 30 days after the start of treatment in patients who received oral steroids and antibiotics compared with placebo and antibiotics (MD ‐7.10, 95% CI ‐9.59 to ‐4.61; 45 participants; scale 0 to 40). The observed mean difference corresponds to a large effect size. At the same time point there was a difference in CT scan score (MD ‐2.90, 95% CI ‐4.91 to ‐0.89; 45 participants; scale 0 to 24). We assessed the quality of the evidence to be low . There were no data available for the longer term (three months). Authors' conclusions There might be an improvement in symptom severity, polyps size and condition of the sinuses when assessed using CT scans in patients taking oral corticosteroids when these are used as an adjunct therapy to antibiotics or intranasal corticosteroids, but the quality of the evidence supporting this is low or very low (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). It is unclear whether the benefits of oral corticosteroids as an adjunct therapy are sustained beyond the short follow‐up period reported (up to 30 days), as no longer‐term data were available. There were no data in this review about the adverse effects associated with short courses of oral corticosteroids as an adjunct therapy. More research in this area, particularly research evaluating longer‐term outcomes and adverse effects, is required. Plain language summary Short‐term oral corticosteroids in addition to other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of adding a short course (typically up to 14 days) of corticosteroid given by mouth to people with chronic rhinosinusitis who were also receiving another type of treatment (such as corticosteroids delivered through the nose). Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling inflammation and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included two randomised controlled trials with a total of 78 participants. One trial involved 30 adults with nasal polyps. Participants received either intranasal corticosteroids and oral corticosteroids or only intranasal corticosteroids. The only result reported of interest to this review was whether the size of the nasal polyps was reduced, when these treatments were completed (three weeks). One trial involved 48 children (mean age of eight years) with chronic rhinosinusitis but no nasal polyps. Participants received either antibiotics and oral corticosteroids or only antibiotics and a placebo (sugar pill). The oral corticosteroids and placebo were given for 15 days and the antibiotics were given for 30 days. The trial reported findings when the antibiotic treatment was completed (at one month). Key results At the end of a three‐week treatment course, people who took both intranasal corticosteroids and oral steroids may have had smaller nasal polyps than people who just received intranasal corticosteroids. The trial did not follow up people to determine whether the polyp size increased after the end of the trial. The trial did not provide information on adverse events or other outcomes important to patients, such as symptom severity or quality of life. Children who received both antibiotics and oral corticosteroids seemed to have a lower total symptom score and better computerised tomography (CT) scan score after treatment compared with children who received antibiotics and control treatment. The reporting of adverse effects in this trial was not very clear and so is difficult to tell if any participant experienced gastrointestinal disturbances, mood changes or difficulty in sleeping. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be very low (we are very uncertain about the estimate) as the evidence comes from one trial that has a low number of participants. The trial had a high risk of bias due to the way it was conducted. The trial did not report adverse events and did not report results after the end of treatment. We judged the quality of the evidence for oral steroids plus antibiotics for children to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate) as the evidence comes from one small trial. The trial did not have a high risk of bias, but it only included children without nasal polyps, who might not have the same results as adults with nasal polyps. The trial did not report results after the end of treatment and the adverse effects of treatment were not well reported.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K, Chong, LY, Hopkins, C, Philpott, C, Schilder, AGM, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.746Z" }, { "id": "8ccbf390-857a-4d21-b9ca-f8890fabe3db", "pmid": "", "title": "Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega‐3 PUFA and plant oils in omega‐6 PUFA. Evidence suggests that increasing PUFA‐rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear. Objectives To assess effects of increasing total PUFA intake on cardiovascular disease and all‐cause mortality, lipids and adiposity in adults. Search methods We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all‐cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions. Data collection and analysis Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta‐analyses used random‐effects analysis, sensitivity analyses included fixed‐effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence. Main results We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA. Increasing PUFA intake probably has little or no effect on all‐cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate‐quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) and stroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low‐quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality. Increasing PUFA intake probably slightly decreases triglycerides (by 15%, MD ‐0.12 mmol/L, 95% CI ‐0.20 to ‐0.04, 20 trials, 3905 participants), but has little or no effect on total cholesterol (mean difference (MD) ‐0.12 mmol/L, 95% CI ‐0.23 to ‐0.02, 26 trials, 8072 participants), high‐density lipoprotein (HDL) (MD ‐0.01 mmol/L, 95% CI ‐0.02 to 0.01, 18 trials, 4674 participants) or low‐density lipoprotein (LDL) (MD ‐0.01 mmol/L, 95% CI ‐0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably has little or no effect on adiposity (body weight MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants). Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality. Authors' conclusions This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all‐cause or cardiovascular disease mortality. The mechanism may be via TG reduction. Plain language summary Polyunsaturated fatty acids for prevention and treatment of diseases of the heart and circulation Review question We reviewed randomised trials (participants have an equal chance to be assigned to either treatment) examining effects of increasing intake of polyunsaturated fatty acids (PUFA) on deaths and diseases of the heart and circulation (cardiovascular diseases), including heart attacks and stroke. Background We eat PUFA in our usual food, but quantities of PUFA eaten vary. There is some evidence that increasing the amount of PUFA we eat can reduce our blood cholesterol and make us less likely to develop cardiovascular disease, particularly if PUFAs are eaten instead of saturated fats (fats from animal sources such as meat and cheese). But eating more PUFA may increase our body weight, and omega‐6 fats (one component of PUFA) may worsen cardiovascular risk by increasing inflammation. Evidence on the benefits or harms of increasing PUFA intake on diseases of the heart and circulation, or on other health outcomes, is inconclusive. Trial characteristics Evidence in this Cochrane Review is current to 27 April 2017. We included 49 trials randomising 24,272 participants, for one to eight years. These trials assessed effects of eating more, compared to less PUFA, on diseases of the heart and circulation, and deaths. Twelve trials were very trustworthy (had low risk of bias overall). Participants were men and women, some with existing illnesses and some not. Trials took place in North America, Asia, Europe and Australia, and sixteen were funded only by national or charitable agencies. Key results Increasing PUFA probably makes little or no difference (neither benefit nor harm) to our risk of death (moderate‐quality evidence), and may make little or no difference to our risk of dying from cardiovascular disease (low‐quality evidence). However, increasing PUFA probably slightly reduces our risk of heart disease events and of combined heart and stroke events (moderate‐quality evidence). Fifty three people would need to eat more PUFA to prevent one person experiencing a heart disease event, and 63 people to prevent one person experiencing a heart or stroke event. Increasing PUFA may very slightly reduce risk of death due to heart disease, as well as stroke, but harm is possible (low‐quality evidence). PUFA probably slightly reduces fats circulating in the blood (triglycerides, moderate‐quality evidence but without effects on other lipids or adiposity). The evidence mainly comes from dietary‐advice trials of men living in high‐income countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abdelhamid, AS; Martin, N; Bridges, C; Brainard, JS; Wang, X; Brown, TJ; Hanson, S; Jimoh, OF; Ajabnoor, SM; Deane, KHO; Song, F; Hooper, L", "articleTypes": [], "doi": "10.1002/14651858.CD012345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "8ccf4457-7ad8-48fd-bd4a-6b964897a3f3", "pmid": "", "title": "Altered dietary salt for preventing pre‐eclampsia, and its complications", "imported": false, "abstract": "Abstract - Background In the past, women have been advised that lowering their salt intake might reduce their risk of developing pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of altered dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of altered dietary salt during pregnancy on the risk of developing pre‐eclampsia and its complications. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (8 April 2005), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2005), and EMBASE (2002 to May 2005). We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 1 October 2009 and added the results to the awaiting classification section. Selection criteria Randomised trials evaluating either reduced or increased dietary salt intake during pregnancy. Data collection and analysis Two review authors selected trials for inclusion and extracted data independently. Data were entered on Review Manager software for analysis, and double‐checked for accuracy. Main results Two trials were included, with 603 women. Both compared advice to reduce dietary salt intake with advice to continue a normal diet. The confidence intervals were wide and crossed the no‐effect line for all the reported outcomes, including pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). In other words, there was insufficient evidence for reliable conclusions about the effects of advice to reduce dietary salt. Authors' conclusions In the absence of evidence that advice to alter salt intake during pregnancy has any beneficial effect for prevention of pre‐eclampsia or any other outcome, salt consumption during pregnancy should remain a matter of personal preference. [Note: The citation in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Altered dietary salt for preventing pre‐eclampsia, and its complications Low salt intake in pregnancy is unlikely to prevent pre‐eclampsia. Pre‐eclampsia is a serious complication of pregnancy associated with poor health, or even death, for the mother and baby. Pre‐eclampsia is identified by raised blood pressure and protein in the urine during the second half of pregnancy. In the past, a low‐salt diet was often recommended, in the belief that it would help to prevent pre‐eclampsia. However, the review found just two trials that did not show any evidence of benefit for the mother or baby. Salt intake in pregnancy should be a matter of personal preference.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Duley, L; Henderson‐Smart, DJ; Meher, S", "articleTypes": [], "doi": "10.1002/14651858.CD005548", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "8cd1223b-d998-4dee-a608-2259b32f42fc", "pmid": "", "title": "Desipramine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Antidepressants are widely used to treat chronic neuropathic pain (pain due to nerve damage), usually in doses below those at which they exert antidepressant effects. An earlier review that included all antidepressants for neuropathic pain is being replaced by new reviews of individual drugs examining individual neuropathic pain conditions. Desipramine is a tricyclic antidepressant that is occasionally used for treating neuropathic pain. Objectives To assess the analgesic efficacy of desipramine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 29 April 2014, and the reference lists of retrieved papers and other reviews. We also used our own hand searched database to identify older studies, and two clinical trials databases for ongoing or unpublished studies. Selection criteria We included randomised, double‐blind studies of at least two weeks duration comparing desipramine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 years and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted the efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts, at least 200 participants in the comparison, 8 to 12 weeks duration, parallel design); second tier from data that failed to meet one or more of these criteria and were considered at some risk of bias but with adequate numbers in the comparison; and third tier from data involving small numbers of participants and considered very likely to be biased or that used outcomes of limited clinical utility, or both. Main results Five studies treated 177 participants with painful diabetic neuropathy (104) or postherpetic neuralgia (73). The mean or median ages in the studies were 55 to 72 years. Four studies used a cross‐over, and one a parallel group design; 145 participants were randomised to receive desipramine 12.5 mg to 250 mg daily, with most taking 100 mg to 150 mg daily following titration. Comparators were placebo in three studies (an 'active placebo' in two studies), fluoxetine, clomipramine (one study each), and amitriptyline (two studies), and treatment was for two to six weeks. All studies had one or more sources of potential major bias. No study provided first or second tier evidence for any outcome. No data were available on the proportion of people with at least 50% or 30% reduction in pain, but data were available from three studies for our other primary outcome of Patient Global Impression of Change, reported as patient evaluation of pain relief that was 'complete' or 'a lot'. No pooling of data was possible, but third tier evidence in individual studies indicated some improvement in pain relief with desipramine compared with placebo, although this was very low quality evidence, derived mainly from group mean data and completer analyses in small, short duration studies where major bias was possible. There were too few participants in comparisons of desipramine with another active treatment to draw any conclusions. All studies reported some information about adverse events, but reporting was inconsistent and fragmented. Participants taking desipramine experienced more adverse events, and a higher rate of withdrawal due to adverse events, than did participants taking placebo (very low quality evidence). Authors' conclusions This review found little evidence to support the use of desipramine to treat neuropathic pain. There was very low quality evidence of benefit and harm, but this came from studies that were methodologically flawed and potentially subject to major bias. Effective medicines with much greater supportive evidence are available. There may be a role for desipramine in patients who have not obtained pain relief from other treatments. Plain language summary Desipramine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not usually effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Desipramine is a tricyclic antidepressant from the same class of medicines as amitriptyline, which is widely recommended for treating neuropathic pain. Desipramine may also be useful in these painful conditions. In 2014, we performed searches to look for clinical trials where desipramine was used to treat neuropathic pain. Five small studies, each with 24 to 54 participants, included 177 participants in total with painful diabetic neuropathy or postherpetic neuralgia. Studies were randomised and double‐blind, but all had one or more sources of potential major bias that could lead to overestimation of efficacy. It was not possible to combine information from the different studies, but individually they indicated some benefit from desipramine (usually at a dose between 100 mg and 150 mg daily), compared with placebo, at the expense of increased adverse events. There was not enough information about other comparators to draw any conclusions. There was too little information, which was of inadequate quality, to be sure that desipramine works as a pain medicine in painful diabetic neuropathy or postherpetic neuralgia, and no information about other types of neuropathic pain. Other medicines have been shown to be effective as treatments of first choice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hearn, L, Moore, RA, Derry, S, Wiffen, PJ, Phillips, T", "articleTypes": [], "doi": "10.1002/14651858.CD011003.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.763Z" }, { "id": "8cd15751-c217-4cfc-b12b-844ecfe48ba2", "pmid": "", "title": "Impact of active placebo controls on estimated drug effects in randomised trials: a systematic review of trials with both active placebo and standard placebo", "imported": false, "abstract": "Abstract - Background An estimated 60% of pharmacological randomised trials use placebo control interventions to blind (i.e. mask) participants. However, standard placebos do not control for perceptible non‐therapeutic effects (i.e. side effects) of the experimental drug, which may unblind participants. Trials rarely use active placebo controls, which contain pharmacological compounds designed to mimic the non‐therapeutic experimental drug effects in order to reduce the risk of unblinding. A relevant improvement in the estimated effects of active placebo compared with standard placebo would imply that trials with standard placebo may overestimate experimental drug effects. Objectives We aimed to estimate the difference in drug effects when an experimental drug is compared with an active placebo versus a standard placebo control intervention, and to explore causes for heterogeneity. In the context of a randomised trial, this difference in drug effects can be estimated by directly comparing the effect difference between the active placebo and standard placebo intervention. Search methods We searched PubMed, CENTRAL, Embase, two other databases, and two trial registries up to October 2020. We also searched reference lists and citations and contacted trial authors. Selection criteria We included randomised trials that compared an active placebo versus a standard placebo intervention. We considered trials both with and without a matching experimental drug arm. Data collection and analysis We extracted data, assessed risk of bias, scored active placebos for adequacy and risk of unintended therapeutic effect, and categorised active placebos as unpleasant, neutral, or pleasant. We requested individual participant data from the authors of four cross‐over trials published after 1990 and one unpublished trial registered after 1990. Our primary inverse‐variance, random‐effects meta‐analysis used standardised mean differences (SMDs) of active versus standard placebo for participant‐reported outcomes at earliest post‐treatment assessment. A negative SMD favoured the active placebo. We stratified analyses by trial type (clinical or preclinical) and supplemented with sensitivity and subgroup analyses and meta‐regression. In secondary analyses, we investigated observer‐reported outcomes, harms, attrition, and co‐intervention outcomes. Main results We included 21 trials (1462 participants). We obtained individual participant data from four trials. Our primary analysis of participant‐reported outcomes at earliest post‐treatment assessment resulted in a pooled SMD of −0.08 (95% confidence interval (CI) −0.20 to 0.04; I 2 = 31%; 14 trials), with no clear difference between clinical and preclinical trials. Individual participant data contributed 43% of the weight of this analysis. Two of seven sensitivity analyses found more pronounced and statistically significant differences; for example, in the five trials with low overall risk of bias, the pooled SMD was −0.24 (95% CI −0.34 to −0.13). The pooled SMD of observer‐reported outcomes was similar to the primary analysis. The pooled odds ratio (OR) for harms was 3.08 (95% CI 1.56 to 6.07), and for attrition, 1.22 (95% CI 0.74 to 2.03). Co‐intervention data were limited. Meta‐regression found no statistically significant association with adequacy of the active placebo or risk of unintended therapeutic effect. Authors' conclusions We did not find a statistically significant difference between active and standard placebo control interventions in our primary analysis, but the result was imprecise and the CI compatible with a difference ranging from important to irrelevant. Furthermore, the result was not robust, because two sensitivity analyses produced a more pronounced and statistically significant difference. We suggest that trialists and users of information from trials carefully consider the type of placebo control intervention in trials with high risk of unblinding, such as those with pronounced non‐therapeutic effects and participant‐reported outcomes. Plain language summary Do treatment effects in randomised trials differ when using active placebo compared to standard placebo? Key messages 1. We found no clear difference in effect between active and standard placebos, but we are very uncertain about the results. 2. We suggest that researchers carefully consider the type of placebo when investigating medicines with clear side effects. What are standard placebos and active placebos? Blinding (or masking) is an important part of randomised trials and ensures that participants and healthcare providers are not influenced by knowing whether the participant is receiving the experimental treatment. If they had this knowledge, they might unintentionally overestimate (or underestimate) the effect of the treatment. One method of blinding is to give the non‐treated group of participants a placebo, which looks like the medicine (e.g. a tablet of similar shape, colour, smell, taste, and texture) but does not contain its active ingredients. Blinding with a placebo may not always be successful. The treatment may have side effects that distinguish it from the placebo so that the treatment effect is still not measured accurately. For this reason, some trials use active placebos, which mimic some of the side effects of the experimental medicine. However, it is unclear whether the choice of placebo type actually makes a difference to the treatment effects. What did we want to find out? We wanted to find out whether treatment effects in randomised trials differ when using active placebos compared to standard placebos. What did we do? We collected and analysed trials that directly compared the two types of placebo, or that compared both placebos with an experimental medicine. If people receiving active placebo experience better results than those receiving standard placebo, this difference might be due to them believing that they are receiving the experimental medicine. It would also mean that in trials that compare a medicine with standard placebo, the beneficial effect of the medicine is exaggerated. This is important if the measured benefits of the treatment are small or moderate and thus especially sensitive to changes in the methods used for the trial. What did we find? We included 21 trials in this review, covering subjects such as pain and psychiatry. We found no clear difference between the two types of placebo in participant‐reported outcomes (such as pain intensity). However, because the result was uncertain, the possible range of this result included both no difference and a potentially important difference in favour of active placebo. When we limited our analysis to higher‐quality trials, active placebos were more beneficial than standard placebos, but these trials were not typical clinical trials and might not be applicable to clinical scenarios.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Laursen, DRT; Nejstgaard, CH; Bjørkedal, E; Frost, AD; Hansen, MR; Paludan-Müller, AS; Prosenz, J; Werner, CP; Hróbjartsson, A", "articleTypes": [], "doi": "10.1002/14651858.MR000055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "8cd65880-e7c1-411b-acb6-5accce9b0c47", "pmid": "", "title": "Progestin‐only pills for contraception", "imported": false, "abstract": "Abstract - Background The introduction of a new progestin‐only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. Objectives This review examined randomized controlled trials of progestin‐only pills for differences in efficacy, acceptability, and continuation rates. Search methods Through October 2013, we searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, and LILACS for studies of progestin‐only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. Selection criteria We included all randomized controlled trials in any language that included progestin‐only pills for contraception. We incorporated any comparison with a progestin‐only pill; this could include different doses, other progestin‐only pills, combined oral contraceptives, or other contraceptives. Data collection and analysis The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry. We attempted to extract life‐table rates (actuarial or continuous) and used the rate difference as the effect measure. Where life‐table rates were not published, we used the incidence rate ratio (ratio of Pearl rates). Where only the crude number of events was published, we calculated the Peto odds ratio with 95% confidence interval (CI) using a fixed‐effect model. For continuous variables, the mean difference (MD) was computed with 95% CI. Because of disparate exposures, we were not able to combine studies in meta‐analysis. Main results Six trials met the inclusion criteria. We have not found any new studies since the initial review. In the trial comparing the desogestrel versus levonorgestrel progestin‐only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin‐only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low‐dose mifepristone versus a levonorgestrel progestin‐only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin‐only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin‐only and two combined oral contraceptives, the progestin‐only pill containing levonorgestrel 30 μg had higher efficacy than did the pill containing norethisterone 350 μg. An early trial found megestrol acetate inferior to other progestin‐only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. Authors' conclusions Evidence is insufficient to compare progestin‐only pills to each other or to combined oral contraceptives. Plain language summary Progestin‐only pills for contraception Progestin‐only pills, as their name implies, contain just one hormone. The more common birth control pills combine two hormones. How these one‐hormone pills compare to each other or to two‐hormone pills is not clear. Hence, we did this review to compare progestin‐only pills to other similar pills or to combined (two‐hormone) pills. Through October 2013, we did a computer search and literature search to find randomized trials of progestin‐only pills. We found six trials for the initial review. We have not found any more studies since then. Some studies are several decades old and not very relevant to pills available today. A newer pill containing the progestin desogestrel may work better to prevent pregnancy than an older pill with levonorgestrel. The newer pill caused more bleeding problems. Pills with levonorgestrel may be more effective than pills with other progestins that are no longer used. These studies are not adequate to tell how progestin‐only pills compare to each other or to combined (two‐hormone) pills. Larger studies with currently used pills are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grimes, DA; Lopez, LM; O'Brien, PA; Raymond, EG", "articleTypes": [], "doi": "10.1002/14651858.CD007541.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "8cd6a8ed-af9b-4b06-9924-396d8250dfe5", "pmid": "", "title": "Acupuncture for acute management and rehabilitation of traumatic brain injury", "imported": false, "abstract": "Abstract - Background Traumatic brain injury (TBI) can be life threatening depending on the severity of the insult to the brain. It can also cause a range of debilitating sequelae which require cognitive, motor, communication, emotional, or behavioral rehabilitation of varying intensity and duration. A number of studies conducted and published in China have suggested that acupuncture may be beneficial in the acute treatment and rehabilitation of TBI. Objectives To determine the efficacy and safety of acupuncture in the acute management or rehabilitation (or both) of patients with a TBI, including cognitive, neurological, motor, communication, emotional, or behavioral complications, or a combination of such complications. Search methods We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials ( The Cochrane Library ), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO and others. We also searched the Chinese Acupuncture Studies Register, the Studies Register of the Cochrane Complementary Medicine Field, NCCAM, and NIH Clinical Studies Database. Three major Mainland Chinese academic literature databases (CNKI, VIP and Wang Fang Data) were also searched using keywords in simplified Chinese. We searched all databases through December 2009, and some searches have been updated to October 2012. Selection criteria Randomized controlled studies evaluating different variants of acupuncture and involving participants of any age who had suffered a TBI. Included trials compared acupuncture with placebo or sham treatment, or acupuncture plus other treatments compared with the same other treatments. We excluded trials that only compared different variants of acupuncture or compared acupuncture alone against other treatments alone, as they did not yield the net effect of acupuncture. Data collection and analysis Two review authors identified potential articles from the literature search and extracted data independently using a data extraction form. We performed methodological assessment of included studies using the Cochrane Collaboration's tool for assessing risk of bias. We were unable to perform quantitative data analysis due to insufficient included studies and available data. Main results Four RCTs, including 294 participants, reported outcomes specified by this review. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The results seem to suggest that acupuncture is efficacious for these indications, however the low methodological quality of these studies renders the results questionable. No adverse effects of acupuncture were reported in any of the studies. Authors' conclusions The low methodological quality of the included studies does not allow us to make conclusive judgments on the efficacy and safety of acupuncture in either the acute treatment and/or rehabilitation of TBI. Its beneficial role for these indications remains uncertain. Further research with high quality trials is required. Plain language summary Acupuncture for acute management and rehabilitation of traumatic brain injury Acupuncture used for the acute treatment, rehabilitation (or both) of traumatic brain injury (TBI) has been studied in China. We conducted a systematic review to evaluate the efficacy and safety of acupuncture for these conditions. Four randomized controlled trials were eligible for inclusion in this review, involving 294 patients. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The studies were of low methodological quality and were diverse in their objectives, participant characteristics, acupuncture modalities and strategies, and outcome measures. The small number of studies together with their low methodological quality means that they are inadequate to allow any conclusion to be drawn about the efficacy and safety of acupuncture in the treatment of TBI. Further methodologically robust studies are needed to generate evidence‐based conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wong, V; Cheuk, DKL; Lee, S; Chu, V", "articleTypes": [], "doi": "10.1002/14651858.CD007700.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "8cda676c-234e-437e-9e96-7d0970e42432", "pmid": "", "title": "Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega‐3 PUFA and plant oils in omega‐6 PUFA. Evidence suggests that increasing PUFA‐rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear. Objectives To assess effects of increasing total PUFA intake on cardiovascular disease and all‐cause mortality, lipids and adiposity in adults. Search methods We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all‐cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions. Data collection and analysis Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta‐analyses used random‐effects analysis, sensitivity analyses included fixed‐effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence. Main results We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA. Increasing PUFA intake probably has little or no effect on all‐cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate‐quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) and stroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low‐quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality. Increasing PUFA intake probably slightly decreases triglycerides (by 15%, MD ‐0.12 mmol/L, 95% CI ‐0.20 to ‐0.04, 20 trials, 3905 participants), but has little or no effect on total cholesterol (mean difference (MD) ‐0.12 mmol/L, 95% CI ‐0.23 to ‐0.02, 26 trials, 8072 participants), high‐density lipoprotein (HDL) (MD ‐0.01 mmol/L, 95% CI ‐0.02 to 0.01, 18 trials, 4674 participants) or low‐density lipoprotein (LDL) (MD ‐0.01 mmol/L, 95% CI ‐0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably has little or no effect on adiposity (body weight MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants). Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality. Authors' conclusions This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all‐cause or cardiovascular disease mortality. The mechanism may be via TG reduction. Plain language summary Polyunsaturated fatty acids for prevention and treatment of diseases of the heart and circulation Review question We reviewed randomised trials (participants have an equal chance to be assigned to either treatment) examining effects of increasing intake of polyunsaturated fatty acids (PUFA) on deaths and diseases of the heart and circulation (cardiovascular diseases), including heart attacks and stroke. Background We eat PUFA in our usual food, but quantities of PUFA eaten vary. There is some evidence that increasing the amount of PUFA we eat can reduce our blood cholesterol and make us less likely to develop cardiovascular disease, particularly if PUFAs are eaten instead of saturated fats (fats from animal sources such as meat and cheese). But eating more PUFA may increase our body weight, and omega‐6 fats (one component of PUFA) may worsen cardiovascular risk by increasing inflammation. Evidence on the benefits or harms of increasing PUFA intake on diseases of the heart and circulation, or on other health outcomes, is inconclusive. Trial characteristics Evidence in this Cochrane Review is current to 27 April 2017. We included 49 trials randomising 24,272 participants, for one to eight years. These trials assessed effects of eating more, compared to less PUFA, on diseases of the heart and circulation, and deaths. Twelve trials were very trustworthy (had low risk of bias overall). Participants were men and women, some with existing illnesses and some not. Trials took place in North America, Asia, Europe and Australia, and sixteen were funded only by national or charitable agencies. Key results Increasing PUFA probably makes little or no difference (neither benefit nor harm) to our risk of death (moderate‐quality evidence), and may make little or no difference to our risk of dying from cardiovascular disease (low‐quality evidence). However, increasing PUFA probably slightly reduces our risk of heart disease events and of combined heart and stroke events (moderate‐quality evidence). Fifty three people would need to eat more PUFA to prevent one person experiencing a heart disease event, and 63 people to prevent one person experiencing a heart or stroke event. Increasing PUFA may very slightly reduce risk of death due to heart disease, as well as stroke, but harm is possible (low‐quality evidence). PUFA probably slightly reduces fats circulating in the blood (triglycerides, moderate‐quality evidence but without effects on other lipids or adiposity). The evidence mainly comes from dietary‐advice trials of men living in high‐income countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abdelhamid, AS, Martin, N, Bridges, C, Brainard, JS, Wang, X, Brown, TJ, Hanson, S, Jimoh, OF, Ajabnoor, SM, Deane, KHO, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.142Z" }, { "id": "8cec4903-18e4-437e-a088-865b5f023266", "pmid": "", "title": "Adhesives for fixed orthodontic bands", "imported": false, "abstract": "Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. It has been shown that the quality of treatment result obtained with fixed appliances is much better than with removable appliances. Fixed appliances are, therefore, favoured by most orthodontists for treatment. The success of a fixed orthodontic appliance depends on the metal attachments (brackets and bands) being attached securely to the teeth so that they do not become loose during treatment. Brackets are usually attached to the front and side teeth, whereas bands (metal rings that go round the teeth) are more commonly used on the back teeth (molars). A number of adhesives are available to attach bands to teeth and it is important to understand which group of adhesives bond most reliably, as well as reducing or preventing dental decay during the treatment period. Objectives To evaluate the effectiveness of the adhesives used to attach bands to teeth during fixed appliance treatment, in terms of:
 (1) how often the bands come off during treatment; and
 (2) whether they protect the banded teeth against decay during fixed appliance treatment. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (searched 2 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 2 June 2016), MEDLINE Ovid (1946 to 2 June 2016) and EMBASE Ovid (1980 to 2 June 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised and controlled clinical trials (RCTs and CCTs) (including split‐mouth studies) of adhesives used to attach orthodontic bands to molar teeth were selected. Patients with full arch fixed orthodontic appliance(s) who had bands attached to molars were included. Data collection and analysis All review authors were involved in study selection, validity assessment and data extraction without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Five RCTs and three CCTs were identified as meeting the review's inclusion criteria. All the included trials were of split‐mouth design. Four trials compared chemically cured zinc phosphate and chemically cured glass ionomer; three trials compared chemically cured glass ionomer cement with light cured compomer; one trial compared chemically cured glass ionomer with a chemically cured glass phosphonate. Data analysis was often inappropriate within the studies meeting the inclusion criteria. Authors' conclusions There is insufficient high quality evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth. Further RCTs are required. Plain language summary Adhesives for fixed orthodontic bands There is insufficient evidence to determine the most effective adhesive for attaching orthodontic bands to molar teeth in patients with full arch fixed orthodontic appliances.
 Orthodontic treatment involves using fixed or removable appliances (braces) on teeth to correct their position. It has been shown that the quality of treatment result obtained with fixed dental appliances is much better than with removable appliances. The success of a fixed dental appliance depends on the metal attachments (brackets and bands) being securely attached to the teeth so that they do not become loose during treatment. Brackets are usually attached to teeth other than molars, where bands (metal rings that go round the teeth) are more commonly used. There is insufficient evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Millett, DT; Glenny, AM; Mattick, RCR; Hickman, J; Mandall, NA", "articleTypes": [], "doi": "10.1002/14651858.CD004485.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "8cf34db0-d09b-48be-a7c2-58bab09ca476", "pmid": "", "title": "Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment", "imported": false, "abstract": "Abstract - Background Vitamins and minerals have many functions in the nervous system which are important for brain health. It has been suggested that various different vitamin and mineral supplements might be useful in maintaining cognitive function and delaying the onset of dementia. In this review, we sought to examine the evidence for this in people who already had mild cognitive impairment (MCI). Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function and the incidence of dementia in people with mild cognitive impairment. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CENTRAL, CINAHL, LILACs, Web of Science Core Collection, ClinicalTrials.gov, and the WHO Portal/ICTRP, from inception to 25 January 2018. Selection criteria We included randomised or quasi‐randomised, placebo‐controlled trials which evaluated orally administered vitamin or mineral supplements in participants with a diagnosis of mild cognitive impairment and which assessed the incidence of dementia or cognitive outcomes, or both. We were interested in studies applicable to the general population of older people and therefore excluded studies in which participants had severe vitamin or mineral deficiencies. Data collection and analysis We sought data on our primary outcomes of dementia incidence and overall cognitive function and on secondary outcomes of episodic memory, executive function, speed of processing, quality of life, functional performance, clinical global impression, adverse events, and mortality. We conducted data collection and analysis according to standard Cochrane systematic review methods. We assessed the risk of bias of included studies using the Cochrane 'Risk of bias' assessment tool. We grouped vitamins and minerals according to their putative mechanism of action and, where we considered it to be clinically appropriate, we pooled data using random‐effects methods. We used GRADE methods to assess the overall quality of evidence for each comparison and outcome. Main results We included five trials with 879 participants which investigated B vitamin supplements. In four trials, the intervention was a combination of vitamins B6, B12, and folic acid; in one, it was folic acid only. Doses varied. We considered there to be some risks of performance and attrition bias and of selective outcome reporting among these trials. Our primary efficacy outcomes were the incidence of dementia and scores on measures of overall cognitive function. None of the trials reported the incidence of dementia and the evidence on overall cognitive function was of very low‐quality. There was probably little or no effect of B vitamins taken for six to 24 months on episodic memory, executive function, speed of processing, or quality of life. The evidence on our other secondary clinical outcomes, including harms, was very sparse or very low‐quality. There was evidence from one study that there may be a slower rate of brain atrophy over two years in participants taking B vitamins. The same study reported subgroup analyses based on the level of serum homocysteine (tHcy) at baseline and found evidence that B vitamins may improve episodic memory in those with tHcy above the median at baseline. We included one trial (n = 516) of vitamin E supplementation. Vitamin E was given as 1000 IU of alpha‐tocopherol twice daily. We considered this trial to be at risk of attrition and selective reporting bias. There was probably no effect of vitamin E on the probability of progression from MCI to Alzheimer's dementia over three years (HR 1.02; 95% CI 0.74 to 1.41; n = 516; 1 study, moderate‐quality evidence). There was also no evidence of an effect at intermediate time points. The available data did not allow us to conduct analyses, but the authors reported no significant effect of three years of supplementation with vitamin E on overall cognitive function, episodic memory, speed of processing, clinical global impression, functional performance, adverse events, or mortality (five deaths in each group). We considered this to be low‐quality evidence. We included one trial (n = 256) of combined vitamin E and vitamin C supplementation and one trial (n = 26) of supplementation with chromium picolinate. In both cases, there was a single eligible cognitive outcome, but we considered the evidence to be very low‐quality and so could not be sure of any effects. Authors' conclusions The evidence on vitamin and mineral supplements as treatments for MCI is very limited. Three years of treatment with high‐dose vitamin E probably does not reduce the risk of progression to dementia, but we have no data on this outcome for other supplements. Only B vitamins have been assessed in more than one RCT. There is no evidence for beneficial effects on cognition of supplementation with B vitamins for six to 24 months. Evidence from a single study of a reduced rate of brain atrophy in participants taking vitamin B and a beneficial effect of vitamin B on episodic memory in those with higher tHcy at baseline warrants attempted replication. Plain language summary Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment Review question This review investigated whether people with mild cognitive impairment can reduce their risk of developing dementia, or can prevent their memory or other thinking skills from deteriorating further, by taking vitamin or mineral supplements. Background Slight changes in memory and thinking skills are common as people get older. When these changes are worse than can be expected in normal ageing, but are not bad enough to make a person's usual activities difficult to manage, then the person is said to have mild cognitive impairment (MCI). People with MCI are at increased risk of developing dementia in the future. Vitamins and minerals are naturally occurring substances which are needed in the diet to maintain health. They have lots of different functions in the body and many are essential to keep the brain working properly. It has been suggested that supplementing a person's normal diet with extra doses of these vitamins or minerals might help to maintain thinking skills or prevent dementia. Study characteristics We found eight randomised controlled trials (RCTs), which investigated four different types of vitamin or mineral pills by comparing them to a placebo (a dummy pill). The vitamins tested were B vitamins (vitamin B6, vitamin B12 and folic acid), vitamin E, and vitamin E and C given together. The only mineral tested was chromium. Key results and quality of the evidence Vitamin B combination versus placebo Five trials with a total of 879 participants compared B vitamins with placebo. Four used combinations of vitamin B6, vitamin B12, and folic acid; one small study tested folic acid on its own. None of these studies reported whether or not participants developed dementia. These studies did not find that memory or thinking skills differed between the group of people who took vitamin B supplements and those who took placebo after treatment lasting six months to two years. Our confidence in the results on different tests used in the studies varied from moderate to very low. Two years of vitamin B supplements did seem to help memory in a small subgroup of participants in one study who could be identified by a particular blood test at the start of the trial. One study found that there was probably no effect on participants' quality of life. One study scanned the brains of some participants and reported that B vitamins may slow the rate of brain shrinkage. Harmful effects and deaths were reported in very few participants and we cannot conclude whether or not there are harms from taking these or similar combinations of B vitamins. Vitamin E versus placebo. One study with 516 participants compared a relatively high dose of vitamin E (2000 IU a day) to placebo in people who were also taking a multivitamin containing 15 IU of vitamin E (the daily requirement for vitamin E is approximately 30 IU). The risk of developing dementia due to Alzheimer’s disease (the commonest form of dementia) is probably not affected by three years of treatment with high‐dose vitamin E. The quality of the evidence for other outcomes was lower, but there may also be no effect of this dose of vitamin E on specific memory or thinking skills or on how well people could manage their daily activities. Vitamin E and C versus placebo One study with 256 participants compared a combination of vitamins C and E with placebo. It found no effect on overall memory and thinking skills, but we had little confidence in this result because of the quality of the evidence. Chromium picolinate versus placebo Only one very small study with 26 participants investigated the effect of chromium supplements. This study was too small for us to be able to draw any conclusions. Conclusions The amount and quality of research evidence about vitamin and mineral supplements for treating MCI in people without nutritional deficiency is limited. At the moment, it is not possible to identify any supplements which can reduce the risk of people with MCI developing dementia or which can effectively treat their symptoms. More research is needed before we can answer our review question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "McCleery, J; Abraham, RP; Denton, DA; Rutjes, AWS; Chong, LY; Al‐Assaf, AS; Griffith, DJ; Rafeeq, S; Yaman, H; Malik, MA; Di Nisio, M; Martínez, G; Vernooij, RWM; Tabet, N", "articleTypes": [], "doi": "10.1002/14651858.CD011905.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "8cf62acf-41b5-48a7-9f54-545e76096156", "pmid": "", "title": "Local interventions for the management of alveolar osteitis (dry socket)", "imported": false, "abstract": "Abstract - Background Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012. Objectives To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction. Search methods An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies. Selection criteria We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews. Data collection and analysis We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random‐effects models. For some of the split‐mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence. Main results We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate‐certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively. Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate‐certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low‐certainty evidence). The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low‐certainty evidence). A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) ‐1.40, 95% CI ‐1.75 to ‐1.04; P < 0.00001; 2 studies, 80 participants; very low‐certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects. Authors' conclusions Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate‐certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. Plain language summary What treatments can be used to prevent and treat alveolar osteitis (dry socket)? Key messages ‐ Rinsing with chlorhexidine mouthwash before a dental extraction or beginning 24 hours after may help to prevent a dry socket.
‐ Placing a chlorhexidine gel directly into the socket immediately after tooth extraction may help to prevent a dry socket.
‐ Chlorhexidine rinses cause some minor adverse (unwanted) effects; chlorhexidine intrasocket gels do not appear to cause adverse effects.
‐ Alvogyl reduces the pain of a dry socket when compared to zinc oxide eugenol, but the evidence for this is very uncertain.
‐ Alvogyl does not appear to cause unwanted effects.
‐ We need future studies to strengthen the evidence and investigate the best ways to prevent and treat dry socket in all teeth. What is dry socket? Dry socket is a painful condition that sometimes arises after a tooth has been extracted and is more likely to occur following extraction of wisdom teeth in the lower jaw. What causes dry socket? It is thought to be linked to the loss of some or all of the blood clot that forms at the bottom of a tooth socket after a tooth is taken out. How can we prevent dry socket? An option for prevention of dry socket is to reduce debris and the bacterial load in the mouth, though dry socket is not bacterial in origin. People with poor oral hygiene (food debris and plaque) are at greater risk of dry socket. Improved oral hygiene and rinsing before a dental extraction or beginning 24 hours after may reduce the likelihood of dry socket. How can we treat dry socket ? Options for treating dry socket largely focus on reducing pain locally around the tooth extraction site by placing an obtundent (a soothing medicated dressing). What did we want to find out ? We wanted to find out if antiseptic rinses, gels, or healing patches could help to prevent dry socket. We also wanted to find out if placing a medicated dressing could treat a dry socket and whether any unwanted side effects were produced. What did we do? We searched for studies that compared antiseptic rinses or intrasocket gels with a placebo (dummy) rinse or nothing and a placebo (dummy) intrasocket gel or nothing. To find the best way to treat dry socket we searched for studies that compared different soothing agents with a placebo (dummy) with other soothing agents or with nothing. We compared the results of the studies and summarised the findings. We made an assessment of our confidence in the evidence based on the design of the study and the number of patients recruited. What did we find? We identified 49 trials; 39 trials (6219 participants) investigated prevention of dry socket and 10 trials (552 participants) investigated the treatment of dry socket. We found that: ‐ rinsing both before and after tooth extraction (commencing 24 hours after extraction) with chlorhexidine gluconate rinse (at 0.12% and 0.2% strength) probably results in a reduction in dry socket;
‐ placing chlorhexidine gel (0.2% strength) in the socket of an extracted tooth probably results in a reduction in dry socket;
‐ chlorhexidine rinses and gels are equally effective at reducing dry socket, but the evidence for this comparison is very uncertain;
‐ chlorhexidine rinses produced some minor unwanted effects; chlorhexidine intrasocket gels appeared to produce no unwanted effects;
‐ there was a small amount of evidence of very low certainty from two studies that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. This evidence relates to the old formulation of Alvogyl which is no longer available. It should be noted that the formulation of Alvogyl has changed, it is now called Alveogyl. Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. What are the limitations of the evidence? The main limitation of the evidence are that studies: ‐ reported mostly on tooth extractions involving lower wisdom teeth;
‐ were undertaken in ways that introduced errors in the conduct of the study leading to errors in the results; and
‐ produced imprecise results when they were combined. Due to these errors we have some confidence in the results relating to chlorhexidine rinses and gels but further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. How up to date is this evidence? The search for existing studies was completed by 28 September 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Daly, BJM; Sharif, MO; Jones, K; Worthington, HV; Beattie, A", "articleTypes": [], "doi": "10.1002/14651858.CD006968.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "8cfb8361-da89-4d2d-bbc1-a823895b0f9d", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Omega‐3 fatty acids (n‐3, fish oil) have been shown to have anti‐inflammatory properties. Therefore, n‐3 therapy may be beneficial in chronic inflammatory disorders such as ulcerative colitis. Objectives To systematically review the efficacy and safety of n‐3 for maintaining remission in ulcerative colitis (UC). Search methods The following databases were searched from their inception without language restriction: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Healthstar, PubMed, and ACP journal club. Experts were contacted for unpublished data. Selection criteria Randomized placebo‐controlled trials (RCT) of fish oil for maintenance of remission in UC were included. Studies must have enrolled patients (of any age group) who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. The primary outcome was relapse rate and the secondary outcome was frequency of adverse events. Other outcomes to assess efficacy were change in disease activity scores and time to first relapse. Data collection and analysis Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality. Meta‐analysis weighted by the Mantel‐Haenszel method was performed using RevMan 4.2.8 software. Random or fixed effect models were used according to degree of heterogeneity and subgroup analyses were performed to explore heterogeneity. A sensitivity analysis was performed excluding a study of questionable quality . Main results The three studies that were included used different formulation and dosing of n‐3 but none used enteric coated capsules. The pooled analysis showed a similar relapse rate in the n‐3 treated patients and controls (RR 1.02; 95% CI 0.51 to 2.03; P = 0.96). Combining the studies resulted in virtually no statistical heterogeneity (P = 0.93, I 2 = 0%). Various subgroup and sensitivity analyses showed similar results. However, the total number of patients enrolled in these studies was small (n = 138). No significant adverse events were recorded in any of the studies and not enough data were available to pool the other secondary outcomes for meta‐analysis. Authors' conclusions No evidence was found that supports the use of omega 3 fatty acids for maintenance of remission in UC. Further studies using enteric coated capsules may be justified. Plain language summary Omega 3 fatty acids for maintenance of remission in ulcerative colitis Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of ulcerative colitis patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of omega‐3 fatty acids to maintain remission in ulcerative colitis were reviewed. Three studies were included of which none reported a reduction in the rate of disease relapse in comparison with placebo. When the studies were pooled for meta‐analysis there was no benefit for omega 3 fatty acids. There were no serious side effects in any of the studies. None of the studies used enteric coated capsules which allow release of the fish oil in the small bowel. Non‐enteric coated omega‐3 fatty acids (fish oil) seem safe but ineffective for maintaining remission in ulcerative colitis. Further studies of enteric coated capsules may be justified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Turner, D, Steinhart, AH, Griffiths, AM", "articleTypes": [], "doi": "10.1002/14651858.CD006443.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.729Z" }, { "id": "8d1cc335-631a-48de-b8d7-262a1f7c9165", "pmid": "", "title": "Interventions for American cutaneous and mucocutaneous leishmaniasis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Pinart, M, Rueda, J-R, Romero, GAS, Pinzón-Flórez, CE, Osorio-Arango, K, Silveira Maia-Elkhoury, AN, Reveiz, L, Elias, VM, Tweed, JA", "articleTypes": [], "doi": "10.1002/14651858.CD004834.pub3 AB - Abstract - Background On the American continent, cutaneous and mucocutaneous leishmaniasis (CL and MCL) are diseases associated with infection by several species of Leishmania parasites. Pentavalent antimonials remain the first‐choice treatment. There are alternative interventions, but reviewing their effectiveness and safety is important as availability is limited. This is an update of a Cochrane Review first published in 2009. Objectives To assess the effects of interventions for all immuno‐competent people who have American cutaneous and mucocutaneous leishmaniasis (ACML). Search methods We updated our database searches of the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and CINAHL to August 2019. We searched five trials registers. Selection criteria Randomised controlled trials (RCTs) assessing either single or combination treatments for ACML in immuno‐competent people, diagnosed by clinical presentation and Leishmania infection confirmed by smear, culture, histology, or polymerase chain reaction on a biopsy specimen. The comparators were either no treatment, placebo only, or another active compound. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our key outcomes were the percentage of participants 'cured' at least three months after the end of treatment, adverse effects, and recurrence. We used GRADE to assess evidence certainty for each outcome. Main results We included 75 studies (37 were new), totalling 6533 randomised participants with ATL. The studies were mainly conducted in Central and South America at regional hospitals, local healthcare clinics, and research centres. More male participants were included (mean age: roughly 28.9 years (SD: 7.0)). The most common confirmed species were L. braziliensis , L. panamensis , and L. mexicana . The most assessed interventions and comparators were non‐antimonial systemics (particularly oral miltefosine) and antimonials (particularly meglumine antimoniate (MA), which was also a common intervention), respectively. Three studies included moderate‐to‐severe cases of mucosal leishmaniasis but none included cases with diffuse cutaneous or disseminated CL, considered the severe cutaneous form. Lesions were mainly ulcerative and located in the extremities and limbs. The follow‐up (FU) period ranged from 28 days to 7 years. All studies had high or unclear risk of bias in at least one domain (especially performance bias). None of the studies reported the degree of functional or aesthetic impairment, scarring, or quality of life. Compared to placebo, at one‐year FU, intramuscular (IM) MA given for 20 days to treat L. braziliensis and L. panamensis infections in ACML may increase the likelihood of complete cure (risk ratio (RR) 4.23, 95% confidence interval (CI) 0.84 to 21.38; 2 RCTs, 157 participants; moderate‐certainty evidence), but may also make little to no difference, since the 95% CI includes the possibility of both increased and reduced healing (cure rates), and IMMA probably increases severe adverse effects such as myalgias and arthralgias (RR 1.51, 95% CI 1.17 to 1.96; 1 RCT, 134 participants; moderate‐certainty evidence). IMMA may make little to no difference to the recurrence risk, but the 95% CI includes the possibility of both increased and reduced risk (RR 1.79, 95% CI 0.17 to 19.26; 1 RCT, 127 participants; low‐certainty evidence). Compared to placebo, at six‐month FU, oral miltefosine given for 28 days to treat L. mexicana , L. panamensis and L. braziliensis infections in American cutaneous leishmaniasis (ACL) probably improves the likelihood of complete cure (RR 2.25, 95% CI 1.42 to 3.38), and probably increases nausea rates (RR 3.96, 95% CI 1.49 to 10.48) and vomiting (RR 6.92, 95% CI 2.68 to 17.86) (moderate‐certainty evidence). Oral miltefosine may make little to no difference to the recurrence risk (RR 2.97, 95% CI 0.37 to 23.89; low‐certainty evidence), but the 95% CI includes the possibility of both increased and reduced risk (all based on 1 RCT, 133 participants). Compared to IMMA, at 6 to 12 months FU, oral miltefosine given for 28 days to treat L. braziliensis , L. panamensis , L. guyanensis and L. amazonensis infections in ACML may make little to no difference to the likelihood of complete cure (RR 1.05, 95% CI 0.90 to 1.23; 7 RCTs, 676 participants; low‐certainty evidence). Based on moderate‐certainty evidence (3 RCTs, 464 participants), miltefosine probably increases nausea rates (RR 2.45, 95% CI 1.72 to 3.49) and vomiting (RR 4.76, 95% CI 1.82 to 12.46) compared to IMMA. Recurrence risk was not reported. For the rest of the key comparisons, recurrence risk was not reported, and risk of adverse events could not be estimated. Compared to IMMA, at 6 to 12 months FU, oral azithromycin given for 20 to 28 days to treat L. braziliensis infections in ACML probably reduces the likelihood of complete cure (RR 0.51, 95% CI 0.34 to 0.76; 2 RCTs, 93 participants; moderate‐certainty evidence). Compared to intravenous MA (IVMA) and placebo, at 12 month FU, adding topical imiquimod to IVMA, given for 20 days to treat L. braziliensis , L. guyanensis and L. peruviana infections in ACL probably makes little to no difference to the likelihood of complete cure (RR 1.30, 95% CI 0.95 to 1.80; 1 RCT, 80 participants; moderate‐certainty evidence). Compared to MA, at 6 months FU, one session of local thermotherapy to treat L. panamensis and L. braziliensis infections in ACL reduces the likelihood of complete cure (RR 0.80, 95% CI 0.68 to 0.95; 1 RCT, 292 participants; high‐certainty evidence). Compared to IMMA and placebo, at 26 weeks FU, adding oral pentoxifylline to IMMA to treat CL (species not stated) probably makes little to no difference to the likelihood of complete cure (RR 0.86, 95% CI 0.63 to 1.18; 1 RCT, 70 participants; moderate‐certainty evidence). Authors' conclusions Evidence certainty was mostly moderate or low, due to methodological shortcomings, which precluded conclusive results. Overall, both IMMA and oral miltefosine probably result in an increase in cure rates, and nausea and vomiting are probably more common with miltefosine than with IMMA. Future trials should investigate interventions for mucosal leishmaniasis and evaluate recurrence rates of cutaneous leishmaniasis and its progression to mucosal disease. Plain language summary What are the benefits and risks of different treatments for American (muco)cutaneous leishmaniasis (a parasitic disease of the skin and mucous membranes)? Why this question is important American (muco)cutaneous leishmaniasis (ACML) is a disfiguring disease that affects people in Central and South America. It is caused by parasites that are transmitted to humans by sandflies. Different forms of ACML have different symptoms. People with the cutaneous form develop skin sores that often heal within a few months without treatment, but can leave scars. In people with mucosal or mucocutaneous leishmaniasis, destructive sores develop in the protective lining (mucous membranes) of the nose, mouth and throat. To compare the effectiveness and risks of the many treatments for ACML, we reviewed evidence from research studies (randomised controlled trials). We looked for information on the proportion of people whose sores had healed three months or more after treatment, unwanted effects, quality of life, re‐appearance of sores, damage associated with the disease and prevention of scarring. How we identified and assessed the evidence First, we searched for all relevant studies. We then compared the results, summarised the evidence, and assessed the certainty of the evidence. What we found We found 75 studies on 6533 people (approximately 75% male; average age: 29 years). ‐ One study investigated children (2 to 12 years).
‐ Most studies (67) involved people with cutaneous leishmaniasis.
‐ Eight studies investigated people with mucosal or mucocutaneous leishmaniasis.
‐ The parasite Leishmania braziliensis caused the disease in 52 studies.
‐ Studies were conducted at regional hospitals, local clinics, and research centres.
‐ Studies lasted between 28 days and seven years.
‐ Most studies reported their funding source: the US army funded eight studies, industry funded 10, and institutional grants funded 33 (five of these also reported industry funding). Treatments were mainly compared to a placebo (fake treatment) or meglumine antimoniate (an antimonial). Here we report this review's main results. We were only able to report the risk of recurrence and side effects for the comparisons of meglumine antimoniate (MA) or miltefosine versus placebo and miltefosine versus MA. Main results Antimonials Compared to placebo, MA may increase chances of complete healing of ACML, but treatment effects vary, so it is possible that it may make little to no difference. MA probably increases the likelihood of pain in the muscles or joints. There may be little to no difference in the risk of developing the disease again, but there is also a possibility of increased or reduced risk due to the wide range of effects seen. Non‐antimonials Miltefosine probably improves chances of complete healing of American cutaneous leishmaniasis (ACL) compared to placebo, but there may be little to no difference compared to treatment with MA in ACML. Miltefosine may make little to no difference to the risk of developing ACL again when compared to placebo, but treatment effects on recurrence varied, so it may also increase or decrease the risk. Miltefosine probably increases the likelihood of vomiting or nausea when compared to either placebo or MA in ACML. We do not know the effect on recurrence of miltefosine compared to MA. Azithromycin probably reduces chances of complete healing of ACML compared to MA. Imiquimod in combination with MA probably makes little to no difference to the chance of complete healing of ACL compared to MA in combination with placebo. Physical therapies Thermotherapy lowers the chance of complete healing of ACL compared to MA. Immuno‐chemotherapy Pentoxifylline plus MA probably makes little to no difference to chances of complete healing of ACML compared with MA plus placebo. No study reported information about damage, prevention of scarring, or quality of life. What this means The main findings of this review suggest that: ‐ MA and miltefosine probably increase chances of complete healing; and
‐ vomiting or nausea are probably more common with miltefosine, and joint or muscle ache is probably more common with MA. The evidence was mostly of moderate certainty, so the true results are likely close to what we found. Evidence was limited by the inclusion of very few people in some studies, and participants or investigators knowing which treatments they were receiving. How‐up‐to date is this review? The evidence in this Cochrane Review is current to August 2019.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.808Z" }, { "id": "8d264050-893f-40c7-8d92-4a0d3f15a5d1", "pmid": "", "title": "Prolonged Overnight Fasting and/or Exercise on Fatigue and Other Patient Reported Outcomes in Women With Hormone Receptor Positive Advanced Breast Cancer (FastER)", "imported": false, "abstract": "The purpose of this study is to test whether four different supportive care programs can reduce fatigue in women with advanced or metastatic breast cancer who are receiving a medication called a CDK4/6 inhibitor (palbociclib, ribociclib, or abemaciclib) alongwith endocrine therapy with or without a PI3K or AKT inhibitor.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.243Z" }, { "id": "8d39671e-fdd7-4841-add8-22a633974149", "pmid": "", "title": "The Role of Bitter Taste Receptors Expressed in the Gastrointestinal Tract in Altering Food Intake and Gastrointestinal Motility", "imported": false, "abstract": "In this study, the investigators aimed at evaluating the role of bitter taste receptors in the gastrointestinal tract (GIT). Intragastric or intraduodenal administration of denatonium benzoate (DB) or quinine hydrochloride were compared with placebo administration for their effects on lingual sensitivity, gastrointestinal motility (both in the fasted and fed state), gut hormone release (motilin, ghrelin, glucagon-like peptide-1 (GLP-1) and cholecystokinin (CCK)) and food intake. Differences between lean and obese subjects will be evaluated.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "8d50007b-49a6-4f06-898d-2fba9010c965", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background The anti‐inflammatory effects of n‐3 (omega‐3 fatty acids, fish oil) have been suggested to be beneficial in chronic inflammatory disorders such as inflammatory bowel disease. This review is an update of a previously published Cochrane review. Objectives To systematically review the efficacy and safety of n‐3 for maintenance of remission in Crohn's disease (CD). Search methods The following databases were searched from inception to November 2013 without language restriction: CENTRAL, MEDLINE, EMBASE, HealthSTAR, PubMed, and ACP journal club. Selection criteria Randomized placebo‐controlled trials (RCT) of n‐3 for maintenance of remission in CD were included. Studies must have enrolled patients of any age group, who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil or n‐3 given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. Data collection and analysis The primary outcome was the relapse rate and secondary outcomes included change in disease activity scores, time to first relapse and adverse events. Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality using the Cochrane risk of bias tool. The overall quality of the evidence supporting the primary and selected secondary outcomes was reassessed for the current update using the GRADE system. We used the RevMan software for analyses. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the hazard ratio and 95% CI for time‐to‐event outcomes. Random‐effects or fixed‐effect models were used according to degree of heterogeneity and sensitivity analyses were performed in an attempt to explore possible sources of heterogeneity. Main results Six studies with a total of 1039 patients were eligible for inclusion. The two largest studies were rated as low risk of bias for all assessed items. Four studies were rated as unclear risk of bias for randomization and allocation concealment. Two studies were rated as high risk of bias for incomplete outcome data and selective reporting. There was a marginal significant benefit of n‐3 therapy for maintenance of remission. Thirty‐nine per cent of patients in the n‐3 group relapsed at 12 months compared to 47% of placebo patients (6 studies, 1039 patients; RR 0.77, 95% CI 0.61 to 0.98). A GRADE analysis rated the overall quality of the evidence for the primary outcome (i.e. relapse) as very low due to unexplained heterogeneity (I 2 = 58%), publication bias, and a high or unknown risk of bias in four studies in the pooled analysis. When two large studies at low risk of bias were considered the benefit was no longer statistically significant. Thirty‐seven per cent of patients in the n‐3 group relapsed at 12 months compared to 42% of placebo patients (2 studies, 738 patients; RR 0.88, 95% CI 0.74 to 1.05). No significant heterogeneity was identified for this pooled analysis ( I 2 = 0%). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was moderate due to sparse data (294 events). No serious adverse events were recorded in any of the studies but in a pooled analyses there was a significantly higher rate of diarrhea (4 studies, 862 patients; RR 1.36 95% CI 1.01 to 1.84) and upper gastrointestinal tract symptoms (5 studies, 999 patients; RR 1.65, 95% CI 1.25 to 2.18) in the n‐3 treatment group. Authors' conclusions Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms. Plain language summary Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of Crohn's disease patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of capsules containing omega‐3 fatty acids to maintain remission in Crohn's disease were reviewed. Six studies including 1039 patients were included in the review. A pooled analysis of six studies suggests a marginal benefit for omega 3 fatty acids over placebo (i.e. fake medicine) in preventing relapse of disease at one year. However, these results need to be interpreted with caution due to differences across the studies in terms of induction of remission regimens (e.g. surgical remission versus drug therapy) patients (e.g. adult versus pediatric patients) and medication regimens (e.g. some studies used different placebos), the possibility of publication bias (i.e. only studies with positive results are published) and low methodological quality in four studies in the pooled analysis. When the two largest and highest quality studies were pooled the results showed no benefit to omega‐3 treatment over placebo. There were no serious side effects in any of the studies. Common side effects included unpleasant taste, bad breath, heartburn, nausea and diarrhea. Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Lev‐Tzion, R; Griffiths, AM; Ledder, O; Turner, D", "articleTypes": [], "doi": "10.1002/14651858.CD006320.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "8d68c3ac-3d7a-4656-97f9-14d4cb9baf07", "pmid": "", "title": "Perioperative nutrition interventions for women with ovarian cancer", "imported": false, "abstract": "Abstract - Background Women with ovarian cancer have been shown to be at significant risk of malnutrition with incidence rates described as being between 28% to 67%. Nutrition interventions may improve clinical outcomes positively, nutritional status or quality of life measures in this patient group. Objectives This review was conducted to assess the effects of nutrition interventions during the perioperative period for women with ovarian cancer. Search methods Electronic searches were conducted of the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 7), Medline (1946 to July week 4 2012), Embase (1980 to 2012 week 31), DARE (to 7th August 2012) AMED (1985 to April 2012), BNI (1992 to April 2012), CINAHL (to April 2012). We also searched trials databases, conference proceedings and related citation lists. Reference listings were handsearched. No restrictions were applied on language or date. Selection criteria Randomised controlled trials (RCTs) in which women 18 years and over with any stage of ovarian cancer, including recurrent cancer, were in the perioperative phase of treatment and received any type of nutrition intervention. Data collection and analysis Titles and abstracts were screened by two review authors with study selection discussed by a team. Pairs of review authors worked independently on data collection and compared findings. Main results A total of 4092 titles were screened and 14 full text reports reviewed; a single small study met the inclusion criteria. In the included RCT, 40 women (35 with ovarian cancer) had extensive elective surgery including bowel resection for treatment of gynaecological malignancy. Randomisation was made to either early oral feeding (oral fluids in the first 24 hours, solid foods on the following day) or to a 'traditional' feeding regimen where oral fluids and foods were delayed until there was evidence of bowel function. Most women in the early feeding group (14/18) were able to resume eating solid food one day after surgery. This resulted in a significantly shorter hospital stay with no increase in postoperative complications or change in quality of life measures in comparison with the women on the 'traditional' feeding regimen. The incidence of nausea and vomiting during the postoperative stay was similar in both groups and was noted in slightly more than half of the women. Overall survival was evaluated until 30 days following discharge from hospital; in this period, there was one death of a woman who had been in the 'traditional oral feeding' group, cause of death was not noted. We assessed risk of bias and found no high risk of bias was identified in the methodology and reporting of the included study, although there was an increased risk of bias due to the small size of the study in which not all of the women had ovarian cancer. Authors' conclusions Although women with ovarian cancer have been shown to be at risk of malnutrition, there is a lack of evidence derived from RCTs evaluating the identification, assessment and treatment of malnutrition during the perioperative phase of treatment. There is evidence from one small study that some women with ovarian cancer undergoing surgery with associated bowel resection may safely commence oral fluids within 24 hours of surgery and solid foods on the following day. Further research is required, including a RCT, to generate guidance concerning the treatment of malnutrition in this patient group. Plain language summary Nutrition for women who are having surgery for ovarian cancer Women who have ovarian cancer, (a cancer which develops in the two organs (ovaries) that produce eggs in women) are more likely to have difficulties with food and with eating a nourishing diet in comparison to women with other types of gynaecological cancers. One reason may be because the symptoms of ovarian cancer can be difficult to recognise. Women may have a lack of interest in food, feel full, feel sick or have a painful or swollen abdomen. Some women become thinner in parts of their bodies while becoming bigger around their abdomen due to an abnormal build up of fluid or large tumours. There may be no change in body weight or weight may increase, this can make it difficult to know which women are developing problems due to a poor food intake. Women who are unable to eat and drink well are at risk of becoming malnourished and may then have more complications from the treatments for ovarian cancer than women who are not malnourished. It is recommended that people who are having difficulties with eating and drinking should be identified and helped when they receive hospital care. Currently, there is no agreed method for finding and treating nutritional problems for women with ovarian cancer. In this review, the authors looked for studies (randomised controlled trials (RCTs)) from around the world to find out how women with ovarian cancer were assessed to see if they were eating and drinking well and what help they may be given with nutrition before or after surgery. A lack of information was found on this topic. One RCT was found where a small group of women (40 including 35 with ovarian cancer) requiring extensive elective surgery for gynaecological cancer including surgery to the gut, were able to restart eating normal foods on the day after surgery. They were able to leave hospital earlier and did not have more complications in the month after surgery than women who were not allowed to resume eating normal foods until at least three days after the operation. More studies are needed to confirm whether restarting normal eating one day after surgery can be recommended for women having surgery for ovarian cancer. More research is needed to provide information about how to identify and treat problems of malnutrition in women with ovarian cancer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Billson, HA, Holland, C, Curwell, J, Davey, VL, Kinsey, L, Lawton, LJ, Whitworth, AJ, Burden, S", "articleTypes": [], "doi": "10.1002/14651858.CD009884.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.761Z" }, { "id": "8d713490-e266-48a5-9f07-954f70a4725a", "pmid": "", "title": "Gut microbiome‐based interventions for the management of obesity in children and adolescents aged up to 19 years", "imported": false, "abstract": "Abstract - Background The epidemic of overweight and obesity affects more than 390 million children and adolescents aged 5 to 19 years and 37 million children under five years of age. Overweight and obesity are associated with both short‐ and long‐term consequences, including chronic inflammation, metabolic diseases, as well as alterations in the gut microbiome composition. Gut microbiome‐based approaches may impact microbiome‐related metrics such as diversity or the abundance of intestinal bacteria, which may be linked to obesity‐related outcomes. However, evidence regarding the effect of gut microbiome‐based interventions for the management of obesity is limited. Objectives To assess the effects of gut microbiome‐based interventions in the management of overweight or obesity in children and adolescents in all their diversity aged 0 to 19 years. Search methods We searched CENTRAL, MEDLINE, CINAHL, Web of Science Core Collection, BIOSIS Previews, Global Index Medicus (all regions), IBECS, SciELO, PAHO, PAHO IRIS, WHO IRIS, WHOLIS, Bibliomap, TRoPHI as well as ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 24 January 2025. We did not apply any language restrictions. Selection criteria We included randomised controlled trials that evaluated gut microbiome‐based interventions [i.e. prebiotics, probiotics, synbiotics, short‐chain fatty acids (SCFAs), and faecal microbiota transplantation (FMT)] compared to standard‐of‐care, placebo, or control interventions in children and adolescents aged 0 to 19 years with overweight or obesity. Data collection and analysis Two review authors independently screened titles and abstracts and full texts, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias 2 tool and certainty of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE), a framework for assessing the certainty of evidence and making recommendations in systematic reviews. Random‐effects meta‐analyses were performed unless only one study per outcome was available, for which fixed‐effect analyses were performed. Main results We found 17 studies (838 participants) from various countries, evaluating the effects of prebiotics, probiotics, synbiotics, SCFAs, and FMT on body mass index (BMI), body weight, waist circumference, total body fat percentage (%TBF), systolic and diastolic blood pressure, and adverse events. Of the 17 studies included, five studies were in adolescents aged 10 to 19 years, and 12 studies were in children and adolescents spanning both age groups, 0 to 19 years. Upon contacting authors for data grouped by age of the participants, no studies provided separate outcomes data for children and adolescents. The included studies were funded by either academic funding sources or grants from the public and private sectors. Additionally, 15 studies were classified as currently being conducted ('ongoing'). The certainty of evidence throughout was very low. In adolescents 10 to 19 years of age, probiotics compared to placebo or no intervention may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events. Similarly, FMT compared to placebo may have little to no effect on waist circumference, %TBF, blood pressure, and adverse events in this age group. According to one study with 41 participants and in children and adolescents 0 to 19 years of age, intervention with prebiotics compared to placebo may result in a small reduction in BMI (mean difference = ‐0.70, 95% CI = ‐1.25 to ‐0.15) and body weight (mean difference = ‐1.5, 95% CI = ‐2.61 to ‐0.39). Prebiotics compared to placebo may have little to no effect on waist circumference, %TBF, systolic blood pressure, and adverse events. No data were available on the effect of prebiotics on diastolic blood pressure. Probiotics compared to placebo may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events in children and adolescents (0 to 19 years). Synbiotics compared to placebo may result in a reduction in systolic blood pressure (mean difference = ‐40.00, 95% CI = ‐50.63 to ‐29.37) in children and adolescents (0 to 19 years); according to one study with 56 participants. The evidence is very uncertain about the effects of synbiotics compared to a placebo on BMI, body weight, waist circumference, blood pressure, and adverse events. No data were available on the effect of synbiotics compared to placebo on %TBF. Synbiotics, compared to probiotics, may have little to no effect on waist circumference, %TBF, and adverse events. No data were available on the effect of synbiotics compared to probiotics on BMI, body weight, and blood pressure. According to one study with 48 participants and very low‐certainty of evidence, SCFAs compared to placebo may result in a reduction in waist circumference (mean difference = ‐5.08, 95% CI = ‐7.40 to ‐2.76) and BMI (mean difference = ‐2.26, 95% CI = ‐3.24 to ‐1.28) in children and adolescents (0–19 years). SCFAs compared to placebo may have little to no effect on adverse events. No data were available on the effect of SCFAs on body weight, %TBF, and blood pressure. Adverse events, i.e. abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine, were reported in the prebiotics group but with very low incidence. Additionally, adverse events such as nausea and headache were reported in the SCFAs group, but with low incidence. Authors' conclusions In adolescents aged 10 to 19 years, gut microbiome‐based interventions may result in little to no difference in obesity‐related outcomes. In children and adolescents aged 0 to 19 years, prebiotics may result in a small reduction in BMI and body weight; synbiotics may result in a reduction in systolic blood pressure, and SCFAs may result in a reduction in BMI and waist circumference, albeit the certainty of evidence was very low. The evidence was of very low certainty due to few studies per comparison, small sample sizes, short intervention durations, and insufficient reporting of adverse events. More rigorous research examining different types of gut microbiome‐based interventions for the management of obesity is required in children and adolescents, both in clinical and community settings. Future trials should also report methods related to randomisation, blinding, and compliance, as well as include prespecified analysis plans. Plain language summary Review question How effective are the gut microbiome‐based interventions for the management of overweight or obesity in children and adolescents in all their diversity, aged 0 to 19 years? Key messages • It is unclear if gut microbiome‐based interventions (nutrition interventions targeting intestinal microbes) have an effect on body mass index (BMI), body weight, waist size, body fat percentage, measures of blood pressure, and adverse events in children and adolescents with overweight and obesity. • Further research, including larger trials, is required to understand the effects of gut microbiome‐based interventions for the management of overweight and obesity in children and adolescents. What is overweight or obesity? Overweight is a condition of excessive fat deposits, and obesity is a chronic disease characterised by excessive fat deposits that can affect most body systems, impair quality of life, and reduce life expectancy. BMI, calculated by dividing a person's weight in kilograms by their height in metres, squared, is often used to define overweight and obesity. How is overweight or obesity managed? Overweight or obesity may be managed through changes in diet, behavioural counselling for lifestyle modifications, medications, or surgery. Despite these approaches, this global epidemic affects more than 390 million children and adolescents aged 5 to 19 years, and 37 million children under five years of age as of 2022. Overweight or obesity is linked to abnormal metabolism and an imbalance in the gut microbiome. Published works have shown that nutrition interventions targeting the \"gut microbiome\" may have beneficial effects on body weight and body fat percentage. The gut microbiome is the community of harmless bacteria and other microorganisms in the human intestine needed for optimal health. What did we want to find out? We wanted to find out the effect of various nutritional interventions targeting the intestinal microbial community on BMI, body weight, waist circumference, total body fat percentage, blood pressure, and adverse events associated with the interventions amongst children and adolescents in all their diversity, aged 0 to 19 years. What did we do? We searched for studies that examined the effects of gut microbiome‐based interventions, including prebiotics (food ingredients that promote beneficial microbes in the gut), probiotics (live microbes that are good for health), synbiotics (a combination of both prebiotics and probiotics), short‐chain fatty acids (i.e. small fat molecules produced by intestinal bacteria by fermenting dietary fibre and non‐digestible carbohydrates), and faecal microbiota transplantation (i.e. a capsule containing stool microbes from a healthy donor), compared to standard‐of‐care (usual care), placebo, control, or no interventions in children and adolescents up to 19 years of age. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 17 studies involving 838 children and adolescents with overweight and obesity. The studies were conducted in different countries, including Spain, China, Taiwan, Canada, Mexico, Italy, Poland, Turkey, Iran, Thailand, Denmark, New Zealand, and the USA. Adolescents aged 10 to 19 years Nutrition interventions targeting intestinal microbes may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. Children and adolescents aged 0 to 19 years It is unclear if prebiotics have an effect on waist size, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that prebiotics compared to a dummy treatment (i.e. an intervention that does not contain any medicine but looks or tastes identical to the intervention being tested) may result in a small reduction in BMI and body weight, but the evidence is very uncertain. Probiotics compared to a dummy treatment may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. It is unclear if synbiotics have an effect on BMI, body weight, waist size, body fat percentage, diastolic blood pressure, and adverse events compared with a dummy treatment. One study found that synbiotics may result in a reduction in systolic blood pressure, but the evidence is very uncertain. It is unclear if short‐chain fatty acids have an effect on body weight, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that short‐chain fatty acids may result in a reduction in BMI and waist circumference, but the evidence is very uncertain. Side effects of the interventions were generally not reported in the included studies, but one study noted potential side effects such as abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine in the prebiotics group; however, the occurrence was very low. Nausea and headache were reported in another study in the short‐chain fatty acids group, but were minimal. What are the limitations of the evidence? The review's findings are limited by the small number of participants, the low number of available studies for each of the comparisons, the lack of long‐term data, and insufficient reporting of adverse effects. How up to date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fahim, SM; Huey, SL; Palma Molina, XE; Agarwal, N; Ridwan, P; Ji, N; Kibbee, M; Kuriyan, R; Finkelstein, JL; Mehta, S", "articleTypes": [], "doi": "10.1002/14651858.CD015875", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "8d9ff7a7-decc-4f1d-8288-8d907305374e", "pmid": "", "title": "Effect of a Dual Orexin Receptor Antagonist, Lemborexant, on Total Sleep Time in Shift Workers: a Randomized Controlled Trial", "imported": false, "abstract": "Insomnia and daytime sleepiness are common complaints among night shift workers, but effective sleep treatments in shift workers are lacking. The aim of this Phase IV double-blind, placebo-controlled, randomized study is to test whether a dual orexin antagonist, Lemborexant (5mg or 10mg), which would be expected to block the clock-driven orexin-mediated wakefulness during the day, will increase daytime sleep time in shift workers who complain of difficulty sleeping during the daytime compared to placebo.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.237Z" }, { "id": "8da0166b-e723-4db1-9820-5efeeedb6713", "pmid": "", "title": "Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Rationale Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Alendronate belongs to the bisphosphonate class of drugs, which inhibit bone resorption by interfering with the activity of osteoclasts (bone cells that break down bone tissue). This is an update of a Cochrane review first published in 2008. Objectives To assess the benefits and harms of alendronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched Evidence‐Based Medicine Reviews (which includes CENTRAL), MEDLINE, Embase, two trial registers, drug approval agency websites, and the bibliographies of relevant systematic reviews to identify the studies included in this review. The latest search date was 01 February 2023. We imposed no restrictions on language, date, form of publication, or reported outcomes. Eligibility criteria We included only randomized controlled trials that assessed the effects of alendronate on postmenopausal women. Targeted participants must have received at least one year of alendronate. We classified a study as secondary prevention if its population met one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (‐2.5 or lower), and 75 years old or older. If a study population met none of those criteria, we classified it as a primary prevention study. Outcomes Our major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. Risk of bias We used the Cochrane risk of bias 1 tool. Synthesis methods We used standard methodological procedures expected by Cochrane. Based on the previous review experience, in which the clinical and methodological characteristics in the primary and secondary prevention studies were homogeneous, we used a fixed‐effect model for meta‐analysis and estimated effects using the risk ratio (RR) for dichotomous outcomes. Our base case analyses included all eligible placebo‐controlled studies with usable data. We selected the data available for the longest treatment period. We consider a relative change exceeding 15% as clinically important. Included studies We included 119 studies, of which 102 studies provided data for quantitative synthesis. Of these, we classified 34 studies (15,188 participants) as primary prevention and 68 studies (29,577 participants) as secondary prevention. We had concerns about risks of bias in most studies. Selection bias was the most frequently overlooked domain, with only 20 studies (19%) describing appropriate methods for both sequence generation and allocation concealment. Eight studies (8%) were at low risk of bias in all seven domains. Synthesis of results The base case analyses included 16 primary prevention studies (one to five years in length; 10,057 women) and 20 secondary prevention studies (one to three years in length; 7375 women) which compared alendronate 10 mg/day (or 70 mg/week) to placebo, no treatment, or both. Indirectness, imprecision, and risk of bias emerged as the main factors contributing to the downgrading of the certainty of the evidence. For primary prevention, alendronate may lead to a clinically important reduction in clinical vertebral fractures (16/1190 in the alendronate group versus 24/926 in the placebo group; RR 0.45, 95% confidence interval [CI] 0.25 to 0.84; absolute risk reduction [ARR] 1.4% fewer, 95% CI 1.9% fewer to 0.4% fewer; low‐certainty evidence) and non‐vertebral fractures (RR 0.83, 95% CI 0.72 to 0.97; ARR 1.6% fewer, 95% CI 2.6% fewer to 0.3% fewer; low‐certainty evidence). However, clinically important differences were not observed for the following outcomes: hip fractures (RR 0.76, 95% CI 0.43 to 1.32; ARR 0.2% fewer, 95% CI 0.4% fewer to 0.2% more; low‐certainty evidence); wrist fractures (RR 1.12, 95% CI 0.84 to 1.49; ARR 0.3% more, 95% CI 0.4% fewer to 1.1% more; low‐certainty evidence); withdrawals due to adverse events (RR 1.03, 95% CI 0.89 to 1.18; ARR 0.2% more, 95% CI 0.9% fewer to 1.5% more; low‐certainty evidence); and serious adverse events (RR 1.08, 95% CI 0.82 to 1.43; ARR 0.5% more, 95% CI 1.2% fewer to 2.8% more; low‐certainty evidence). For secondary prevention, alendronate probably results in a clinically important reduction in clinical vertebral fractures (24/1114 in the alendronate group versus 51/1055 in the placebo group; RR 0.45, 95% CI 0.28 to 0.73; ARR 2.7% fewer, 95% CI 3.5% fewer to 1.3% fewer; moderate‐certainty evidence). It may lead to a clinically important reduction in non‐vertebral fractures (RR 0.80, 95% CI 0.64 to 0.99; ARR 2.8% fewer, 95% CI 5.1% fewer to 0.1% fewer; low‐certainty evidence); hip fractures (RR 0.49, 95% CI 0.25 to 0.96; ARR 1.0% fewer, 95% CI 1.5% fewer to 0.1% fewer; low‐certainty evidence); wrist fractures (RR 0.54, 95% CI 0.33 to 0.90; ARR 1.8% fewer, 95% CI 2.6% fewer to 0.4% fewer; low‐certainty evidence); and serious adverse events (RR 0.75, 95% CI 0.59 to 0.96; ARR 3.5% fewer, 95% CI 5.8% fewer to 0.6% fewer; low‐certainty evidence). However, the effects of alendronate for withdrawals due to adverse events are uncertain (RR 0.95, 95% CI 0.78 to 1.16; ARR 0.4% fewer, 95% CI 1.7% fewer to 1.3% more; very low‐certainty evidence). Furthermore, the updated evidence for the safety risks of alendronate suggests that, irrespective of participants' risk of fracture, alendronate may lead to little or no difference for gastrointestinal adverse events. Zero incidents of osteonecrosis of the jaw and atypical femoral fracture were observed. Authors' conclusions For primary prevention, compared to placebo, alendronate 10 mg/day may reduce clinical vertebral and non‐vertebral fractures, but it might make little or no difference to hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. For secondary prevention, alendronate probably reduces clinical vertebral fractures, and may reduce non‐vertebral, hip, and wrist fractures, and serious adverse events, compared to placebo. The evidence is very uncertain about the effect of alendronate on withdrawals due to adverse events. Funding This Cochrane review had no dedicated funding. Registration This review is an update of the previous review (DOI: 10.1002/14651858.CD001155). Plain language summary Does alendronate help prevent fractures caused by osteoporosis in postmenopausal women? Key messages • Alendronate used for up to five years may prevent spinal fractures in women who are at lower risk for fractures, or in those who have not yet had a fracture of the spine. • Alendronate used for up to three years in women diagnosed with osteoporosis, with low bone density, or who have already had a fracture of the spine, probably prevents fractures of the spine. What is osteoporosis? Osteoporosis is a disease which makes bones weak and fragile. Bone is living tissue that is constantly being broken down and replaced. In osteoporosis, old bone breaks down faster than new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones more likely to break even after a minor injury, such as a bump or fall. Women are more likely to get osteoporosis after menopause. What is alendronate? Alendronate is a bisphosphonate, a type of medicine which slows down the cells that break down the old bone. What did we want to find out? We aimed to find out if alendronate is better than placebo (an inactive or 'dummy' medicine) or other medicines in preventing or reducing fractures in postmenopausal women. What did we do? We searched for studies that compared alendronate with placebo or other anti‐osteoporotic medicines for osteoporosis in postmenopausal women. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 119 eligible studies. Of these, 102 studies provided usable data, and 40 studies compared alendronate to placebo (dummy pill). Key findings In women who are at a lower risk for fractures because they have bone density closer to normal, or they may not yet have a fracture in the bones of their spine, alendronate used for up to five years: may prevent clinical spinal fractures – that is, fractures indicated by clinical signs and symptoms, without radiographic evidence; may prevent fractures in bones other than the spine. However, specifically in hip and wrist fractures, alendronate may make no difference; may make no difference to the number of women who withdrew from the study due to adverse events – that is, unwanted, harmful events; may make no difference to the number of women experiencing serious adverse events. In women who are at a higher risk for fractures because they have already been diagnosed with osteoporosis, have low bone density, or have already had a spinal fracture, alendronate used for up to three years: probably prevents clinical spinal fractures; may prevent fractures in bones other than the spine; may prevent hip and wrist fractures; may reduce serious adverse events; We do not know if alendronate reduces withdrawals due to adverse events in this group of women. The best estimates for women at lower fracture risk taking alendronate or placebo are as follows. For clinical spinal fractures, evidence suggests that if 3 out of 100 women taking placebo experience a fracture, only 1 out of 100 women taking alendronate will. If 10 out of 100 women on placebo have a fracture in bones other than the spine, only 8 out of 100 on alendronate are likely to. For hip and wrist fractures, there may be no difference between the two groups in the number of women experiencing fractures. The best estimates for women at higher fracture risk taking alendronate or placebo are as follows. If 5 out of 100 women on placebo have a clinical spinal fracture, only 2 out of 100 women on alendronate are likely to. If 14 out of 100 women on placebo have a fracture in bones other than the spine, only 11 out of 100 on alendronate are likely to. If 2 out of 100 women on placebo have a hip fracture, only 1 out of 100 on alendronate are likely to. If 4 out of 100 women on placebo have a wrist fracture, only 2 out of 100 on alendronate are likely to. What are the limitations of the evidence? For most findings, our confidence in the evidence was low, because it is possible that the women in the studies, and the researchers assessing outcomes, were aware of which treatment the women received. Additionally, some of the evidence focused on specific alendronate doses, whereas the question we wanted to answer was broader. Finally, for some fracture outcomes, the evidence was based on few cases. How current is the evidence? The evidence is current to 1 February 2023. This is an update of a Cochrane review originally published in 2008.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Wells, GA; Hsieh, SC; Peterson, J; Zheng, C; Kelly, SE; Shea, B; Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD001155.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "8da4047d-91ff-42d7-a3f6-4fc580a7f79b", "pmid": "", "title": "Hyperimmune immunoglobulin for people with COVID‐19", "imported": false, "abstract": "Abstract - Background Hyperimmune immunoglobulin (hIVIG) contains polyclonal antibodies, which can be prepared from large amounts of pooled convalescent plasma or prepared from animal sources through immunisation. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). This review was previously part of a parent review addressing convalescent plasma and hIVIG for people with COVID‐19 and was split to address hIVIG and convalescent plasma separately. Objectives To assess the benefits and harms of hIVIG therapy for the treatment of people with COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods To identify completed and ongoing studies, we searched the World Health Organization (WHO) COVID‐19 Research Database, the Cochrane COVID‐19 Study Register, the Epistemonikos COVID‐19 L*OVE Platform and Medline and Embase from 1 January 2019 onwards. We carried out searches on 31 March 2022. Selection criteria We included randomised controlled trials (RCTs) that evaluated hIVIG for COVID‐19, irrespective of disease severity, age, gender or ethnicity. We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)), as well as studies that evaluated standard immunoglobulin. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used RoB 2. We rated the certainty of evidence, using the GRADE approach, for the following outcomes: all‐cause mortality, improvement and worsening of clinical status (for individuals with moderate to severe disease), quality of life, adverse events, and serious adverse events. Main results We included five RCTs with 947 participants, of whom 688 received hIVIG prepared from humans, 18 received heterologous swine glyco‐humanised polyclonal antibody, and 241 received equine‐derived processed and purified F(ab’) 2 fragments. All participants were hospitalised with moderate‐to‐severe disease, most participants were not vaccinated (only 12 participants were vaccinated). The studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with mild COVID‐19. We identified a further 10 ongoing studies evaluating hIVIG. Benefits of hIVIG prepared from humans We included data on one RCT (579 participants) that assessed the benefits and harms of hIVIG 0.4 g/kg compared to saline placebo. hIVIG may have little to no impact on all‐cause mortality at 28 days (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.43 to 1.44; absolute effect 77 per 1000 with placebo versus 61 per 1000 (33 to 111) with hIVIG; low‐certainty evidence). The evidence is very uncertain about the effect on worsening of clinical status at day 7 (RR 0.85, 95% CI 0.58 to 1.23; very low‐certainty evidence). It probably has little to no impact on improvement of clinical status on day 28 (RR 1.02, 95% CI 0.97 to 1.08; moderate‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if hIVIG has any impact on quality of life. Harms of hIVIG prepared from humans hIVIG may have little to no impact on adverse events at any grade on day 1 (RR 0.98, 95% CI 0.81 to 1.18; 431 per 1000; 1 study 579 participants; low‐certainty evidence). Patients receiving hIVIG probably experience more adverse events at grade 3‐4 severity than patients who receive placebo (RR 4.09, 95% CI 1.39 to 12.01; moderate‐certainty evidence). hIVIG may have little to no impact on the composite outcome of serious adverse events or death up to day 28 (RR 0.72, 95% CI 0.45 to 1.14; moderate‐certainty evidence). We also identified additional results on the benefits and harms of other dose ranges of hIVIG, not included in the summary of findings table, but summarised in additional tables. Benefits of animal‐derived polyclonal antibodies We included data on one RCT (241 participants) to assess the benefits and harms of receptor‐binding domain‐specific polyclonal F(ab´) 2 fragments of equine antibodies (EpAbs) compared to saline placebo. EpAbs may reduce all‐cause mortality at 28 days (RR 0.60, 95% CI 0.26 to 1.37; absolute effect 114 per 1000 with placebo versus 68 per 1000 (30 to 156) ; low‐certainty evidence). EpAbs may reduce worsening of clinical status up to day 28 (RR 0.67, 95% CI 0.38 to 1.18; absolute effect 203 per 1000 with placebo versus 136 per 1000 (77 to 240); low‐certainty evidence). It may have some effect on improvement of clinical status on day 28 (RR 1.06, 95% CI 0.96 to 1.17; low‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if EpAbs have any impact on quality of life. Harms of animal‐derived polyclonal antibodies EpAbs may have little to no impact on the number of adverse events at any grade up to 28 days (RR 0.99, 95% CI 0.74 to 1.31; low‐certainty evidence). Adverse events at grade 3‐4 severity were not reported. Individuals receiving EpAbs may experience fewer serious adverse events than patients receiving placebo (RR 0.67, 95% CI 0.38 to 1.19; low‐certainty evidence). We also identified additional results on the benefits and harms of other animal‐derived polyclonal antibody doses, not included in the summary of findings table, but summarised in additional tables. Authors' conclusions We included data from five RCTs that evaluated hIVIG compared to standard therapy, with participants with moderate‐to‐severe disease. As the studies evaluated different preparations (from humans or from various animals) and doses, we could not pool them. hIVIG prepared from humans may have little to no impact on mortality, and clinical improvement and worsening. hIVIG may increase grade 3‐4 adverse events. Studies did not evaluate quality of life. RBD‐specific polyclonal F(ab´) 2 fragments of equine antibodies may reduce mortality and serious adverse events, and may reduce clinical worsening. However, the studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern and prior to widespread vaccine rollout. As no studies evaluated hIVIG for participants with asymptomatic infection or mild disease, benefits for these individuals remains uncertain. This is a living systematic review. We search monthly for new evidence and update the review when we identify relevant new evidence. Plain language summary Are concentrated antibodies from people who have recovered from COVID‐19 or animals an effective treatment for people with COVID‐19? Key messages • We do not know whether hyperimmune immunoglobulin (a preparation made with antibodies from people who have recovered from COVID‐19) reduces deaths or serious unwanted effects in people with moderate to severe COVID‐19. But a similar preparation made by injecting animals with certain antibodies may reduce deaths, and serious unwanted effects and may stop people’s condition getting worse. • We found no studies that investigated people with COVID‐19 but without symptoms or people with mild COVID‐19, so we do not know how effective human or animal hyperimmune immunoglobulin is for them. • We found 10 ongoing studies. We will update this review when their results become available. What is hyperimmune immunoglobulin? The body produces antibodies as one of its defences against infection. Antibodies, or 'immunoglobulins', are found in blood plasma. They act as a critical part of the immune response. Plasma from people who have recovered from COVID‐19 contains COVID‐19 antibodies, and can be used to make two preparations. Firstly, it can be used to make convalescent plasma, which is plasma that contains these antibodies. Secondly, it can be used to make hyperimmune immunoglobulin, which is more concentrated, and therefore contains more antibodies. The manufacturing process of hyperimmune immunoglobulin is complex and requires large pools of human plasma. Similar antibodies can be made from animal sources and used in humans. Why is hyperimmune immunoglobulin a possible treatment for COVID‐19? Hyperimmune immunoglobulin products contain high levels of antibodies that target SARS‐CoV‐2, the virus that causes COVID‐19. The products are thought to inactivate the virus particles. What did we want to find out? We wanted to know if hyperimmune immunoglobulin is an effective and helpful treatment for people with suspected or confirmed COVID‐19 in any setting (for example, home or hospital). We were interested in: • death from any cause up 30 days after treatment, 60 days, or longer if reported; • improvement or worsening of symptoms; • quality of life; • unwanted effects. What did we do? We searched for studies that investigated hyperimmune immunoglobulin and usual care compared to usual care only, or in addition to a dummy medicine that did not contain any active ingredients (placebo). To make a fair comparison, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the hyperimmune immunoglobulin or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies. We used a standardised method to rate our confidence in the evidence. The confidence is based on study features such as how it was designed and the number of people in them. What did we find? We found five studies with 957 people. Studies took place in Pakistan, India, France, and Argentina, and one study was conducted in multiple countries, including Denmark, Greece, Japan, Nigeria, Spain, the UK and the USA. The studies took place before or during the emergence of several new COVID‐19 variants and prior to widespread vaccine rollout. All the participants in four studies were unvaccinated. In one study, 12 from 579 participants were vaccinated. We also found 10 ongoing studies. Main results All studies compared hyperimmune immunoglobulin from human or animal sources with usual care or placebo. The studies included only hospitalised people with moderate to severe disease. No studies looked at people without COVID‐19 symptoms or mild COVID‐19. No studies reported on quality of life. We are uncertain whether or not hyperimmune immunoglobulin prepared from humans affects risk of death from any cause up to 28 days after treatment. It may have little to no impact on improvement or worsening of symptoms up to 28 days after treatment. We are uncertain about a possible difference in unwanted or serious unwanted effects. The individual studies decided which events to classify as serious unwanted effects, but this usually means something that may cause hospitalisation or permanent harm. Hyperimmune immunoglobulin from animals may reduce deaths up to 28 days after treatment, may reduce worsening of symptoms, may improve patients' condition and may reduce serious unwanted events. What are the limitations of the evidence? We are uncertain whether hyperimmune immunoglobulin is an effective treatment for people hospitalised with COVID‐19, and whether it affects the number of unwanted or serious unwanted effects because the studies were small and did not all provide evidence on all our points of interest. The studies were conducted predominantly in people from wealthy countries, before the widespread rollout of COVID‐19 vaccines and the emergence of the omicron variant, so the results may not apply to people with omicron variant infection, or people who were vaccinated before falling ill. There was no evidence for people without symptoms or with mild COVID‐19. How up to date is this evidence? Our evidence is up‐to‐date to 31st March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kimber, C, Valk, SJ, Chai, KL, Piechotta, V, Iannizzi, C, Monsef, I, Wood, EM, Lamikanra, AA, Roberts, DJ, McQuilten, Z, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015167.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.789Z" }, { "id": "8dad6e86-d573-4933-b376-aaa6f9030a91", "pmid": "", "title": "Altered dietary salt for preventing pre‐eclampsia, and its complications", "imported": false, "abstract": "Abstract - Background In the past, women have been advised that lowering their salt intake might reduce their risk of developing pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of altered dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of altered dietary salt during pregnancy on the risk of developing pre‐eclampsia and its complications. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (8 April 2005), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2005), and EMBASE (2002 to May 2005). We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 1 October 2009 and added the results to the awaiting classification section. Selection criteria Randomised trials evaluating either reduced or increased dietary salt intake during pregnancy. Data collection and analysis Two review authors selected trials for inclusion and extracted data independently. Data were entered on Review Manager software for analysis, and double‐checked for accuracy. Main results Two trials were included, with 603 women. Both compared advice to reduce dietary salt intake with advice to continue a normal diet. The confidence intervals were wide and crossed the no‐effect line for all the reported outcomes, including pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). In other words, there was insufficient evidence for reliable conclusions about the effects of advice to reduce dietary salt. Authors' conclusions In the absence of evidence that advice to alter salt intake during pregnancy has any beneficial effect for prevention of pre‐eclampsia or any other outcome, salt consumption during pregnancy should remain a matter of personal preference. [Note: The citation in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Altered dietary salt for preventing pre‐eclampsia, and its complications Low salt intake in pregnancy is unlikely to prevent pre‐eclampsia. Pre‐eclampsia is a serious complication of pregnancy associated with poor health, or even death, for the mother and baby. Pre‐eclampsia is identified by raised blood pressure and protein in the urine during the second half of pregnancy. In the past, a low‐salt diet was often recommended, in the belief that it would help to prevent pre‐eclampsia. However, the review found just two trials that did not show any evidence of benefit for the mother or baby. Salt intake in pregnancy should be a matter of personal preference.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Duley, L, Henderson‐Smart, DJ, Meher, S", "articleTypes": [], "doi": "10.1002/14651858.CD005548", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.767Z" }, { "id": "8dc32945-30a9-46dc-8f94-4e78a725f33a", "pmid": "", "title": "Sensory environment on health‐related outcomes of hospital patients", "imported": false, "abstract": "Abstract - Background Hospital environments have recently received renewed interest, with considerable investments into building and renovating healthcare estates. Understanding the effectiveness of environmental interventions is important for resource utilisation and providing quality care. Objectives To assess the effect of hospital environments on adult patient health‐related outcomes. Search methods We searched: the Cochrane Central Register of Controlled Trials (last searched January 2006); MEDLINE (1902 to December 2006); EMBASE (January 1980 to February 2006); 14 other databases covering health, psychology, and the built environment; reference lists; and organisation websites. This review is currently being updated (MEDLINE last search October 2010), see Studies awaiting classification. Selection criteria Randomised and non‐randomised controlled trials, controlled before‐and‐after studies, and interrupted times series of environmental interventions in adult hospital patients reporting health‐related outcomes. Data collection and analysis Two review authors independently undertook data extraction and 'Risk of bias' assessment. We contacted authors to obtain missing information. For continuous variables, we calculated a mean difference (MD) or standardized mean difference (SMD), and 95% confidence intervals (CI) for each study. For dichotomous variables, we calculated a risk ratio (RR) with 95% confidence intervals (95% CI). When appropriate, we used a random‐effects model of meta‐analysis. Heterogeneity was explored qualitatively and quantitatively based on risk of bias, case mix, hospital visit characteristics, and country of study. Main results Overall, 102 studies have been included in this review. Interventions explored were: 'positive distracters', to include aromas (two studies), audiovisual distractions (five studies), decoration (one study), and music (85 studies); interventions to reduce environmental stressors through physical changes, to include air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), and temperature (one study); and multifaceted interventions (two studies). We did not find any studies meeting the inclusion criteria to evaluate: art, access to nature for example, through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music may improve patient‐reported outcomes such as anxiety; however, the benefit for physiological outcomes, and medication consumption has less support. There are few studies to support or refute the implementation of physical changes, and except for air quality, the included studies demonstrated that physical changes to the hospital environment at least did no harm. Authors' conclusions Music may improve patient‐reported outcomes in certain circumstances, so support for this relatively inexpensive intervention may be justified. For some environmental interventions, well designed research studies have yet to take place. Plain language summary Sensory environment on health‐related outcomes of hospital patients The hospital environment (such as sounds, pictures, aromas, design, air quality, furnishings, architecture, and layout), may have an impact on the health of patients within it. This review aims to summarise the best available evidence on hospital environments, in order to help people involved in the design of hospital environments make decisions that will benefit patients' health. The review identified 102 relevant studies, 85 of which were on the use of music in hospital. Other environmental aspects considered were: aromas (two studies), audiovisual distractions (five studies), decoration (one study), air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), temperature (one study), and multiple design changes (two studies). No studies meeting the inclusion criteria were found to evaluate: art, access to nature for example through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music in hospital may help improve patient‐reported outcomes such as anxiety; however, there is less evidence to support the use of music for physiological outcomes (such as reducing heart rate and blood pressure) and for reducing the use of medications. For other aspects of hospital environments, there are not very many well designed studies to help with making evidence‐based design decisions. The studies that have been included in this review show that physical changes made to 'improve' the hospital environment on the whole do no harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Drahota, A; Ward, D; Mackenzie, H; Stores, R; Higgins, B; Gal, D; Dean, TP", "articleTypes": [], "doi": "10.1002/14651858.CD005315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "8dd48280-0280-4f1f-ab10-0bf4f4b6ba1a", "pmid": "", "title": "Interventions for chronic kidney disease in people with sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD), one of the commonest severe monogenic disorders, is caused by the inheritance of two abnormal haemoglobin (beta‐globin) genes. SCD can cause severe pain, significant end‐organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD. Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD. Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, with increased prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end‐stage renal disease. This is an update of a review first published in 2017. Objectives To assess the effectiveness of any intervention for preventing or reducing kidney complications or chronic kidney disease in people with sickle cell disease. Possible interventions include red blood cell transfusions, hydroxyurea, and angiotensin‐converting enzyme inhibitors (ACEIs), either alone or in combination. Search methods We searched for relevant trials in the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, CENTRAL, MEDLINE, Embase, seven other databases, and two other trials registers. Selection criteria Randomised controlled trials (RCTs) comparing interventions to prevent or reduce kidney complications or CKD in people with SCD. We applied no restrictions related to outcomes examined, language, or publication status. Data collection and analysis Two review authors independently assessed trial eligibility, extracted data, assessed the risk of bias, and assessed the certainty of the evidence (GRADE). Main results We included three RCTs with 385 participants. We rated the certainty of the evidence as low to very low across different outcomes according to GRADE methodology, downgrading for risk of bias concerns, indirectness, and imprecision. Hydroxyurea versus placebo One RCT published in 2011 compared hydroxyurea to placebo in 193 children aged nine to 18 months. We are unsure if hydroxyurea compared to placebo reduces or prevents progression of kidney disease assessed by change in glomerular filtration rate (mean difference (MD) 0.58 mL/min /1.73 m 2 , 95% confidence interval (CI) −14.60 to 15.76; 142 participants; very low certainty). Hydroxyurea compared to placebo may improve the ability to concentrate urine (MD 42.23 mOsm/kg, 95% CI 12.14 to 72.32; 178 participants; low certainty), and may make little or no difference to SCD‐related serious adverse events, including acute chest syndrome (risk ratio (RR) 0.39, 99% CI 0.13 to 1.16; 193 participants; low certainty), painful crisis (RR 0.68, 99% CI 0.45 to 1.02; 193 participants; low certainty); and hospitalisations (RR 0.83, 99% CI 0.68 to 1.01; 193 participants; low certainty). No deaths occurred in either trial arm and the RCT did not report quality of life. Angiotensin‐converting enzyme inhibitors versus placebo One RCT published in 1998 compared an ACEI (captopril) to placebo in 22 adults with normal blood pressure and microalbuminuria. We are unsure if captopril compared to placebo reduces proteinuria (MD −49.00 mg/day, 95% CI −124.10 to 26.10; 22 participants; very low certainty). We are unsure if captopril reduces or prevents kidney disease as measured by creatinine clearance; the trial authors stated that creatinine clearance remained constant over six months in both groups, but provided no comparative data (very low certainty). The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Angiotensin‐converting enzyme inhibitors versus vitamin C One RCT published in 2020 compared an ACEI (lisinopril) with vitamin C in 170 children aged one to 18 years with normal blood pressure and microalbuminuria. It reported no data we could analyse. We are unsure if lisinopril compared to vitamin C reduces proteinuria in this population: the large drop in microalbuminuria in both arms of the trial after only one month on treatment may have been due to an overestimation of microalbuminuria at baseline rather than a true effect. The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Authors' conclusions We are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. We are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. We are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria. No RCTs assessed red blood cell transfusions or any combined interventions to prevent or reduce kidney complications. Due to lack of evidence, we cannot comment on the management of children aged over 18 months or adults with any known genotype of SCD. We have identified a lack of adequately designed and powered studies, although we found four ongoing trials since the last version of this review. Only one ongoing trial addresses renal function as a primary outcome in the short term, but such interventions have long‐term effects. Trials of hydroxyurea, ACEIs or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction of kidney complications in people with SCD. Plain language summary Interventions to prevent or reduce kidney complications in people with sickle cell disease Review question Are there any safe and effective interventions that prevent or reduce kidney complications in people with sickle cell disease (SCD)? Background SCD is a serious inherited blood disorder where the red blood cells, which carry oxygen around the body, develop abnormally. Normal red blood cells are flexible and disc‐shaped, but sickled cells are rigid and crescent‐shaped, and stickier than normal red blood cells. This can lead to blockage of blood vessels, resulting in tissue and organ damage and episodes of severe pain. The abnormal cells are fragile and break apart easily, which leads to a decreased number of red blood cells, known as anaemia. Kidney complications can start at an early age in children with SCD and are common in adults with the condition. Kidney complications leading to kidney protein leak and chronic kidney disease can be severe, with serious effects on health. Severe complications include the need for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) or a kidney transplant. Identifying therapies that can prevent or slow down the decline in kidney function in people with SCD is critical for improving health outcomes. Search date The evidence is current to 22 September 2022. Study characteristics We found three randomised controlled trials, which enroled a total of 385 people. One trial, published in 2011, compared the drug hydroxyurea (which helps to maintain the shape and flexibility of red blood cells), to placebo (dummy treatment) in 193 children aged nine to 18 months. The second trial, published in 1998, compared captopril (a drug used to treat high blood pressure) to placebo in 22 adults with normal blood pressure and microalbuminuria (high levels of protein in the urine). The third trial, published in 2020, compared lisinopril (a drug used to treat high blood pressure) to vitamin C in 170 children aged one to 18 years. Two trials received government funding; it was unclear how the third trial was funded. Key results In children aged nine to 18 months, hydroxyurea may increase the ability to produce normal urine, but we are unsure if it has any effect on the glomerular filtration rate (network of filters in the kidney that filter waste from the blood). Hydroxyurea may make little or no difference to the occurrence of serious complications including acute chest syndrome (pain, cough, fever, low oxygen levels, and abnormal substances in the lungs), painful crises, and hospitalisations. We are unsure if giving captopril to adults with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. We are unsure if giving lisinopril to children aged one to 18 years with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. No trials reported quality of life. Limitations of the evidence We have little or very little confidence in the evidence because we only found three trials, and they had specific populations (only children or only adults), few participants, and wide variations in results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Roy, NBA; Carpenter, A; Dale-Harris, I; Dorée, C; Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012380.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "8df354a1-535a-4880-a149-1f839d45e794", "pmid": "", "title": "Pharmacological interventions for prevention of weight gain in people with schizophrenia", "imported": false, "abstract": "Abstract - Background Antipsychotic‐induced weight gain is an extremely common problem in people with schizophrenia and is associated with increased morbidity and mortality. Adjunctive pharmacological interventions may be necessary to help manage antipsychotic‐induced weight gain. This review splits and updates a previous Cochrane Review that focused on both pharmacological and behavioural approaches to this problem. Objectives To determine the effectiveness of pharmacological interventions for preventing antipsychotic‐induced weight gain in people with schizophrenia. Search methods The Cochrane Schizophrenia Information Specialist searched Cochrane Schizophrenia's Register of Trials on 10 February 2021. There are no language, date, document type, or publication status limitations for inclusion of records in the register. Selection criteria We included all randomised controlled trials (RCTs) that examined any adjunctive pharmacological intervention for preventing weight gain in people with schizophrenia or schizophrenia‐like illnesses who use antipsychotic medications. Data collection and analysis At least two review authors independently extracted data and assessed the quality of included studies. For continuous outcomes, we combined mean differences (MD) in endpoint and change data in the analysis. For dichotomous outcomes, we calculated risk ratios (RR). We assessed risk of bias for included studies and used GRADE to judge certainty of evidence and create summary of findings tables. The primary outcomes for this review were clinically important change in weight, clinically important change in body mass index (BMI), leaving the study early, compliance with treatment, and frequency of nausea. The included studies rarely reported these outcomes, so, post hoc, we added two new outcomes, average endpoint/change in weight and average endpoint/change in BMI. Main results Seventeen RCTs, with a total of 1388 participants, met the inclusion criteria for the review. Five studies investigated metformin, three topiramate, three H2 antagonists, three monoamine modulators, and one each investigated monoamine modulators plus betahistine, melatonin and samidorphan. The comparator in all studies was placebo or no treatment (i.e. standard care alone). We synthesised all studies in a quantitative meta‐analysis. Most studies inadequately reported their methods of allocation concealment and blinding of participants and personnel. The resulting risk of bias and often small sample sizes limited the overall certainty of the evidence. Only one reboxetine study reported the primary outcome, number of participants with clinically important change in weight. Fewer people in the treatment condition experienced weight gains of more than 5% and more than 7% of their bodyweight than those in the placebo group (> 5% weight gain RR 0.27, 95% confidence interval (CI) 0.11 to 0.65; 1 study, 43 participants; > 7% weight gain RR 0.24, 95% CI 0.07 to 0.83; 1 study, 43 participants; very low‐certainty evidence). No studies reported the primary outcomes, 'clinically important change in BMI', or 'compliance with treatment'. However, several studies reported 'average endpoint/change in body weight' or 'average endpoint/change in BMI'. Metformin may be effective in preventing weight gain (MD −4.03 kg, 95% CI −5.78 to −2.28; 4 studies, 131 participants; low‐certainty evidence); and BMI increase (MD −1.63 kg/m2, 95% CI −2.96 to −0.29; 5 studies, 227 participants; low‐certainty evidence). Other agents that may be slightly effective in preventing weight gain include H2 antagonists such as nizatidine, famotidine and ranitidine (MD −1.32 kg, 95% CI −2.09 to −0.56; 3 studies, 248 participants; low‐certainty evidence) and monoamine modulators such as reboxetine and fluoxetine (weight: MD −1.89 kg, 95% CI −3.31 to −0.47; 3 studies, 103 participants; low‐certainty evidence; BMI: MD −0.66 kg/m2, 95% CI −1.05 to −0.26; 3 studies, 103 participants; low‐certainty evidence). Topiramate did not appear effective in preventing weight gain (MD −4.82 kg, 95% CI −9.99 to 0.35; 3 studies, 168 participants; very low‐certainty evidence ) . For all agents, there was no difference between groups in terms of individuals leaving the study or reports of nausea. However, the results of these outcomes are uncertain given the very low‐certainty evidence. Authors' conclusions There is low‐certainty evidence to suggest that metformin may be effective in preventing weight gain. Interpretation of this result and those for other agents, is limited by the small number of studies, small sample size, and short study duration. In future, we need studies that are adequately powered and with longer treatment durations to further evaluate the efficacy and safety of interventions for managing weight gain. Plain language summary How effective are medications given alongside antipsychotics at preventing weight gain in people with schizophrenia? Key messages ‐ Metformin may be effective in preventing weight gain caused by antipsychotics. ‐ H2 antagonists and monoamine modulators may be slightly effective in preventing weight gain caused by antipsychotics. ‐ Future studies should include more people and evaluate them for longer. What are antipsychotics? Antipsychotics are medications used to treat symptoms of psychosis, such as hallucinations, delusions and agitation. They are often used to treat people with schizophrenia. Examples of antipsychotics are haloperidol (Haldol), chlorpromazine (Thorazine), olanzapine (Zyprexa) and risperidone (Risperdal). Schizophrenia and weight gain People with schizophrenia are twice as likely as the general population to be overweight, perhaps due to a poor diet and an inactive lifestyle. Excess weight can lead to other health conditions, such as heart disease, stroke and diabetes. Unfortunately, an unwanted effect of antipsychotics is weight gain. Sometimes, people with schizophrenia are given medications alongside antipsychotics (‘add‐on’ medications) to prevent this additional weight gain. These add‐on medications may stop people feeling hungry or help them feel full. Usually, they are medications developed for other purposes, such as metformin, which is a medicine to treat diabetes, and fluoxetine, which is an antidepressant. What did we want to find out? We wanted to find out whether add‐on medications to prevent weight gain caused by antipsychotics were effective in people with schizophrenia. What did we do? We searched for studies that examined any medicine given alongside antipsychotics to prevent weight gain in people with schizophrenia. Study participants could be any age or sex but had to have a diagnosis of schizophrenia or a schizophrenia‐like illness. They had to be chosen at random to receive either the weight‐prevention medicine, or a placebo (a dummy medicine) or no add‐on medicine (standard treatment). We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 17 studies with 1388 people that examined the effects of add‐on medications to prevent weight gain caused by antipsychotics. The add‐on medications were metformin, topiramate, H2 antagonists, monoamine modulators, monoamine modulators plus betahistine, melatonin, and samidorphan. Studies were short, lasting between 6 and 24 weeks. And they were small, with only 63 people on average ‐ the smallest included only 14 people, the largest 561 people. Studies done to date suggest that: ‐ metformin may be effective in preventing weight gain and is well‐tolerated compared to standard treatment (5 studies, 232 participants); ‐ H2 antagonists, such as nizatidine, famotidine and ranitidine, or monoamine modulators, such as reboxetine and fluoxetine may be potentially effective in preventing weight gain caused by antipsychotics; ‐ topiramate is probably not effective in preventing weight gain caused by antipsychotics. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only a small number of studies for each add‐on medication. Studies included few people, and lasted only a short time. How up to date is this evidence? The evidence is up to date to February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Agarwal, SM; Stogios, N; Ahsan, ZA; Lockwood, JT; Duncan, MJ; Takeuchi, H; Cohn, T; Taylor, VH; Remington, G; Faulkner, GE J; Hahn, M", "articleTypes": [], "doi": "10.1002/14651858.CD013337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "8dfe196b-9bac-4bf0-aa11-54eaf6738f58", "pmid": "", "title": "Oral immunotherapy for milk allergy", "imported": false, "abstract": "Abstract - Background The mainstay of treatment of IgE‐mediated cow milk allergy (IMCMA) is an avoidance diet, which is especially difficult with a ubiquitous food like milk. Milk oral immunotherapy (MOIT) may be an alternative treatment, through desensitization or induction of tolerance. Objectives We aim to assess the clinical efficacy and safety of MOIT in children and adults with IMCMA as compared to a placebo treatment or avoidance strategy. Search methods We searched 13 databases for journal articles, conference proceedings, theses and unpublished trials, without language or date restrictions, using a combination of subject headings and text words. The search is up‐to‐date as of October 1, 2012. Selection criteria Only randomised controlled trials (RCT) were considered for inclusion. Blinded and open trial designs were included. Children and adults with IMCMA were included. MOIT administered by any protocol were included. Data collection and analysis A total of 2111 unique records were identified and screened for potential inclusion. Studies were selected, data extracted and methodological quality assessed independently by two reviewers. We attempted to contact the study investigators to inquire about data not published that was required for the analysis. Statistical heterogeneity was assessed using the I² test. We estimated a pooled risk ratio (RR) for each outcome using a Mantel‐Haenzel fixed‐effect model if statistical heterogeneity was low as evaluated by an I² value less than 50%. Main results Of 157 records reviewed, 16 were included, representing five trials. In general, the studies were small and had inconsistent methodological rigor. Overall, the quality of evidence was rated as low. Each study used a different MOIT protocol. A total of 196 patients were studied (106 MOIT, 90 control) and all were children. Three studies were blinded and two used an avoidance diet control. Sixty‐six patients (62%) in the MOIT group were able to tolerate a full serving of milk (about 200 mL) compared to seven (8%) of the control group (RR 6.61, 95% CI 3.51 to 12.44). In addition, 27 (25%) in the MOIT group could ingest a partial serving of milk (10 to 184 mL) while none could in the control group (RR 9.34, 95% CI 2.72 to 32.09). None of the studies assessed the patients following a period off immunotherapy. Adverse reactions were common (97 of 106 MOIT patients had at least one symptom), although most were local and mild. Because of variability in reporting methods, adverse effects could not be combined quantitatively. For every 11 patients receiving MOIT, one required intramuscular epinephrine. One patient required it on two occasions. Authors' conclusions Studies to date have involved small numbers of patients and the quality of evidence is generally low. The current evidence shows that MOIT can lead to desensitization in the majority of individuals with IMCMA although the development of long‐term tolerance has not been established. A major drawback of MOIT is the frequency of adverse effects, although most are mild and self‐limited. The use of parenteral epinephrine is not infrequent. Because there are no standardized protocols, guidelines would be required prior to incorporating desensitization into clinical practice. Plain language summary Repetitive, increasing doses of daily milk for treatment of milk allergy To date, the only option to treat food allergy is strict avoidance of the food and carrying an epinephrine injector (Epipen/Twinject) in case of an allergic reaction. For a food like cow's milk, avoidance is very difficult because it is found in many foods. The constant fear of accidentally eating or drinking cow's milk and anxiety related to carrying an injector has negative effects on quality of life. Accidentally having milk can cause life‐threatening reactions. Oral immunotherapy involves initially taking a very small amount of the allergen, in the case of milk allergy, cow's milk, and slowly increasing the amount each day until a full serving is reached. This may change the way the body's immune system sees the allergen, thereby increasing the amount of milk that can be eaten or drunk with no reaction. We identified randomized controlled trials that compared oral immunotherapy to placebo or continued avoidance diet in children and adults with cow's milk allergy. Five studies satisfied our inclusion criteria. In total there were 196 participants (106 in the treatment group and 90 in the control), all of whom were children. In general, the quality of the studies was low. Because the trials involved small numbers and there were problems with the way they were done, further research is needed. The current evidence shows that oral immunotherapy can help a majority of allergic children tolerate a full serving of milk, as long as they continue drinking this amount each day. However, it is not known if this protection is continued if the immunotherapy is stopped for some time. Side effects during oral immunotherapy are frequent and most patients will have at least some mild symptoms. In the studies we included, for every 11 patients who received oral immunotherapy, one needed to be treated with epinephrine injection at some point for a serious allergic reaction to the therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Yeung, JP; Kloda, LA; McDevitt, J; Ben‐Shoshan, M; Alizadehfar, R", "articleTypes": [], "doi": "10.1002/14651858.CD009542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "8e0c74b9-68de-411b-832a-a7fc3e94b643", "pmid": "", "title": "Antitumour antibiotic containing regimens for metastatic breast cancer", "imported": false, "abstract": "Abstract - Background Antitumour antibiotics are used in the management of metastatic breast cancer. Some of these agents have demonstrated higher tumour response rates than non‐antitumour antibiotic regimens, however a survival benefit has not been established in this setting. Objectives To review the randomised evidence comparing antitumour antibiotic containing chemotherapy regimens with regimens not containing an antitumour antibiotic in the management of women with metastatic breast cancer. Search methods The Specialised Register maintained by the Cochrane Breast Cancer Group was searched on 3rd October, 2006 using the codes for 'advanced breast cancer' and 'chemotherapy'. Details of the search strategy and coding applied by the Group to create the register are described in the Group's module on The Cochrane Library. Selection criteria Randomised trials comparing antitumour antibiotic containing regimens with regimens not containing antitumour antibiotics in women with metastatic breast cancer. Data collection and analysis Data were collected from published trials. Studies were assessed for eligibility and quality, and data were extracted by two independent reviewers. Hazard Ratios (HRs) were derived from time‐to‐event outcomes where possible, and a fixed effect model was used for meta‐analysis. Response rates were analysed as dichotomous variables. Quality of life and toxicity data were extracted where present. A primary analysis was conducted for all trials and by class of antitumour antibiotic. Main results Thirty‐four trials reporting on 46 treatment comparisons were identified. All trials published results for tumour response and 27 trials published time‐to‐event data for overall survival. The observed 4244 deaths in 5605 randomised women did not demonstrate a statistically significant difference in survival between regimens that contained antitumour antibiotics and those that did not (HR 0.96, 95% CI 0.90 to 1.02, P = 0.22) and no significant heterogeneity. Antitumour antibiotic regimens were favourably associated with time‐to‐progression (HR 0.84, 95% CI 0.77 to 0.91) and tumour response rates (odds ratio (OR) 1.33, 95% CI 1.21 to 1.48) although statistically significant heterogeneity was observed for these outcomes. These associations were consistent when the analysis was restricted to the 30 trials that reported on anthracyclines. Patients receiving anthracycline containing regimens were also more likely to experience toxic events compared to patients receiving non‐antitumour antibiotic regimens. No statistically significant difference was observed in any outcome between mitoxantrone containing and non‐antitumour antibiotic‐containing regimens. Authors' conclusions Compared to regimens without antitumour antibiotics, regimens that contained these agents showed a statistically significant advantage for tumour response and time to progression in women with metastatic breast cancer but were not associated with an improvement in overall survival. The favourable effect on tumour response and time to progression observed in anthracycline containing regimens was also associated with greater toxicity. Plain language summary Antitumour antibiotic containing regimens for metastatic breast cancer Advanced (metastatic) breast cancer is cancer that has spread beyond the breast. Treatment for metastatic disease usually involves some type of chemotherapy (anti‐cancer drugs) to try to reduce the cancer. Chemotherapy drugs can either be given as a single agent or in combination with other chemotherapy drugs. This is done according to a plan or a course of the drug referred to as a regimen. There are many types of chemotherapy drugs which work in various ways. Antitumour antibiotics work by damaging the cancer cells thereby preventing those cells from multiplying. Chemotherapy in general produces a range of side effects or adverse events related to the treatment. The known side effects of antitumour antibiotics include nausea, vomiting, a reduction in the number of white blood cells (known as leukopenia), and in some cases a toxic reaction which alters the working of the heart (called cardiotoxicity). This review sought to identify and review the randomised evidence comparing courses of chemotherapy containing antitumour antibiotics against courses not containing antitumour antibiotics. This review identified 34 eligible trials involving 5605 women. This review found that for women with advanced breast cancer, taking antitumour antibiotics did not result in better survival than women who took other types of chemotherapy drugs. Despite the lack of evidence of survival benefit, this review demonstrated that women taking these drugs had an advantage in time to progression (the length of time it takes for the cancer to progress after taking the drug) and tumour response (shrinking of the tumour) compared to women who did not take the antitumour antibiotic drugs. In addition however, the risks of side effects including cardiotoxicity, leukopenia and nausea/vomiting were all significantly increased in the women taking the antitumour antibiotics. Given that this review failed to show a benefit in survival for women taking this group of drugs but a higher rate of side effects, the use of these drugs in the management of metastatic breast cancer must be carefully weighed against the risk of these side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Lord, SJ, Ghersi, D, Gattellari, M, Wortley, S, Wilcken, N, Thornton, C, Simes, J", "articleTypes": [], "doi": "10.1002/14651858.CD003367.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.753Z" }, { "id": "8e15ba29-be3b-4804-aa1e-2d89c0ddc71a", "pmid": "", "title": "Individualized Computational Assessment of the Effects of GABA Receptor Modulation in Posttraumatic Stress Disorder", "imported": false, "abstract": "A substantial majority of Veterans with posttraumatic stress disorder (PTSD) continue to suffer even with the best current medications. Progress in developing more effective medications is hampered by the substantial variability within Veterans with PTSD, meaning the most effective medication likely varies from individual to individual. New scientific tools to help identify distinct subgroups of Veterans with PTSD who are likely to respond to specific medications could help improve treatment in this population. Research has indicated that a specific subgroup of Veterans with PTSD with a high level of anxious arousal may benefit from medications which boost signaling of the neurotransmitter gamma-aminobutyric acid (GABA). This project aims to validate a clinical test to identify these individuals using new computational and neuroimaging methods combined with the medication lorazepam, a positive GABA modulator. The ultimate goal is to use these methods in future clinical trials of new medications to target the best treatments to individual Veterans with PTSD.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.237Z" }, { "id": "8e1fd1d7-a37f-4bff-8e54-e065cc789c74", "pmid": "", "title": "Vitamin and mineral supplementation for maintaining cognitive function in cognitively healthy people in mid and late life", "imported": false, "abstract": "Abstract - Background Vitamins and minerals play multiple functions within the central nervous system which may help to maintain brain health and optimal cognitive functioning. Supplementation of the diet with various vitamins and minerals has been suggested as a means of maintaining cognitive function, or even of preventing dementia, in later life. Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function in cognitively healthy people aged 40 years or more. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov and the WHO Portal/ICTRP from inception to 26th January 2018. Selection criteria We included randomised controlled trials that evaluated the cognitive effects on people aged 40 years or more of any vitamin or mineral supplements taken by mouth for at least three months. Data collection and analysis Study selection, data extraction, and quality assessments were done in duplicate. Vitamins were considered broadly in the categories of B vitamins, antioxidant vitamins, and combinations of both. Minerals were considered separately, where possible. If interventions and outcomes were considered sufficiently similar, then data were pooled. In order to separate short‐term cognitive effects from possible longer‐term effects on the trajectory of cognitive decline, data were pooled for various treatment durations from 3 months to 12 months and up to 10 years or more. Main results In total, we included 28 studies with more than 83,000 participants. There were some general limitations of the evidence. Most participants were enrolled in studies which were not designed primarily to assess cognition. These studies often had no baseline cognitive assessment and used only brief cognitive assessments at follow‐up. Very few studies assessed the incidence of dementia. Most study reports did not mention adverse events or made only very general statements about them. Only 10 studies had a mean follow‐up > 5 years. Only two studies had participants whose mean age was < 60 years at baseline. The risk of bias in the included studies was generally low, other than a risk of attrition bias for longer‐term outcomes. We considered the certainty of the evidence behind almost all results to be moderate or low. We included 14 studies with 27,882 participants which compared folic acid, vitamin B12, vitamin B6, or a combination of these to placebo. The majority of participants were aged over 60 years and had a history of cardio‐ or cerebrovascular disease. We found that giving B vitamin supplements to cognitively healthy adults, mainly in their 60s and 70s, probably has little or no effect on global cognitive function at any time point up to 5 years (SMD values from ‐0.03 to 0.06) and may also have no effect at 5‐10 years (SMD ‐0.01). There were very sparse data on adverse effects or on incidence of cognitive impairment or dementia. We included 8 studies with 47,840 participants in which the active intervention was one or more of the antioxidant vitamins: ß‐carotene, vitamin C or vitamin E. Results were mixed. For overall cognitive function, there was low‐certainty evidence of benefit associated with ß‐carotene after a mean of 18 years of treatment (MD 0.18 TICS points, 95% CI 0.01 to 0.35) and of vitamin C after 5 years to 10 years (MD 0.46 TICS points, 95% CI 0.14 to 0.78), but not at earlier time points. From two studies which reported on dementia incidence, there was low‐certainty evidence of no effect of an antioxidant vitamin combination or of vitamin E, either alone or combined with selenium. One of the included studies had been designed to look for effects on the incidence of prostate cancer; it found a statistically significant increase in prostate cancer diagnoses among men taking vitamin E. One trial with 4143 participants compared vitamin D3 (400 IU/day) and calcium supplements to placebo. We found low‐ to moderate‐certainty evidence of no effect of vitamin D3 and calcium supplements at any time‐point up to 10 years on overall cognitive function (MD after a mean of 7.8 years ‐0.1 MMSE points, 95% CI ‐0.81 to 0.61) or the incidence of dementia (HR 0.94, 95% CI 0.72 to 1.24). A pilot study with 60 participants used a higher dose of vitamin D3 (4000 IU on alternate days) and found preliminary evidence that this dose probably has no effect on cognitive function over six months. We included data from one trial of zinc and copper supplementation with 1072 participants. There was moderate‐certainty evidence of little or no effect on overall cognitive function (MD 0.6 MMSE points, 95% CI ‐0.19 to 1.39) or on the incidence of cognitive impairment after 5 years to 10 years. A second smaller trial provided no usable data, but reported no cognitive effects of six months of supplementation with zinc gluconate. From one study with 3711 participants, there was low‐certainty evidence of no effect of approximately five years of selenium supplementation on the incidence of dementia (HR 0.83, 95% CI 0.61 to 1.13). Finally, we included three trials of complex supplements (combinations of B vitamins, antioxidant vitamins, and minerals) with 6306 participants. From the one trial which assessed overall cognitive function, there was low‐certainty evidence of little or no effect on the TICS (MD after a mean of 8.5 years 0.12, 95% CI ‐0.14 to 0.38). Authors' conclusions We did not find evidence that any vitamin or mineral supplementation strategy for cognitively healthy adults in mid or late life has a meaningful effect on cognitive decline or dementia, although the evidence does not permit definitive conclusions. There were very few data on supplementation starting in midlife (< 60 years); studies designed to assess cognitive outcomes tended to be too short to assess maintenance of cognitive function; longer studies often had other primary outcomes and used cognitive measures which may have lacked sensitivity. The only positive signals of effect came from studies of long‐term supplementation with antioxidant vitamins. These may be the most promising for further research. Plain language summary Vitamin and mineral supplementation for preventing cognitive deterioration in cognitively healthy people in mid and late life Review question This review aimed to find out whether people aged 40 years or older could maintain their mental abilities or reduce their risk of dementia by taking vitamin or mineral supplements. Background There is great interest in anything people might do to keep themselves mentally healthy as they age and, especially, to reduce their risk of developing dementia. Various vitamin and mineral supplements have been suggested as ways to do this. Vitamins and minerals have many functions in the body and the ways they might affect brain health are not well understood. Therefore, we were interested in the effects of any vitamins or minerals, either alone or in combination. What we did We searched up to January 2018 for all trials which had studied the effect on cognition (thinking and remembering) of any vitamin or mineral supplements in people aged 40 years or more who had no cognitive problems at the beginning of the study. The studies had to include a comparison group which had not taken the supplement being studied and, to be sure the comparison was fair, it should have been decided at random whether people got the supplement or not. What we found We grouped the 28 included trials according to the kind of supplement they used and how it might work. Most of the trials were not originally designed to study cognition or dementia and used only simple measures of cognition. Very few studies investigated whether participants developed dementia. Long‐term studies are probably needed to find effects on the risk of dementia or cognitive decline but only 10 studies had an average length of follow‐up longer than five years. The studies were generally well‐conducted although the longer trials had difficulty following up all of the participants and this could have biased some of the longer‐term results. There were 14 trials of B vitamins (folic acid, vitamin B6, vitamin B12) with nearly 28,000 participants, mainly in their 60s and 70s. Most of these trials were quite short (less than two years). We found no evidence that B vitamins had any effect on cognition. There were 8 trials of antioxidant vitamins (beta‐carotene/vitamin A, vitamin C, vitamin E) with approximately 47,000 participants. These trials tended to be longer than the B vitamin trials so may have had more chance of detecting effects on dementia and cognitive decline. The results were mixed. We found low‐certainty evidence of better overall cognitive function after an average of 18 years taking beta‐carotene and after five years to 10 years taking vitamin C, but no effects after shorter periods of treatment. There were also small benefits of beta‐carotene, vitamin C, and antioxidant combinations on memory at some time points but not others. There was no evidence of any benefits from vitamin E alone. Two studies examined the risk of developing dementia. One found no effect of a combination of antioxidant vitamins and the other found no effect of vitamin E, either alone or combined with the mineral selenium. Most of the studies did not report any information about harmful effects. One included trial was designed to look for an effect on the risk of prostate cancer; it found a higher risk among the men taking vitamin E. There was a small trial of vitamin D supplements which found they probably had no effect on cognition over six months. There were longer trials of vitamin D with calcium (one trial), zinc and copper (one trial), and complex multivitamins (three trials). All lasted between five and 10 years, but none of them found any evidence of beneficial effects on cognition. One trial found no effect of selenium taken for approximately five years on the risk of developing dementia. Conclusions We found no good evidence to suggest that middle‐aged or older people can preserve cognitive function or prevent dementia by taking vitamin or mineral supplements. There were a few positive results associated with long‐term use of antioxidant vitamins, particularly beta‐carotene and vitamin C, although the effects were small. Further research into the effects of these vitamins may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rutjes, AWS; Denton, DA; Di Nisio, M; Chong, LY; Abraham, RP; Al‐Assaf, AS; Anderson, JL; Malik, MA; Vernooij, RWM; Martínez, G; Tabet, N; McCleery, J", "articleTypes": [], "doi": "10.1002/14651858.CD011906.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "8e2bd33d-68b1-4fc6-96d8-83bd6b31774c", "pmid": "", "title": "Effect of a Dual Orexin Receptor Antagonist, Lemborexant, on Total Sleep Time in Shift Workers: a Randomized Controlled Trial", "imported": false, "abstract": "Insomnia and daytime sleepiness are common complaints among night shift workers, but effective sleep treatments in shift workers are lacking. The aim of this Phase IV double-blind, placebo-controlled, randomized study is to test whether a dual orexin antagonist, Lemborexant (5mg or 10mg), which would be expected to block the clock-driven orexin-mediated wakefulness during the day, will increase daytime sleep time in shift workers who complain of difficulty sleeping during the daytime compared to placebo.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.148Z" }, { "id": "8e2c7ea7-2c52-4bb3-8889-b7bdff553673", "pmid": "", "title": "Could Docosahexaenoic Acid (DHA), Contained in Breast Milk and Artificial Baby Milks, Protect Infants and Children From COVID-19 and Make Them Less Prone to COVID-19-related Severe Illness Than Adults?", "imported": false, "abstract": "Could Docosahexaenoic Acid (DHA) Protect Infants and Children From COVID-19 and Make Them Less Susceptible to COVID-19-related Severe Illness Than Adults?", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.269Z" }, { "id": "8e3b0b43-7fe8-4cfc-bdf5-75c0246d78c2", "pmid": "", "title": "Lifestyle interventions for chronic gout", "imported": false, "abstract": "Abstract - Background Although lifestyle interventions are commonly recommended in the management of patients with chronic gout, the evidence from trial data for their benefits and safety has not been previously examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with chronic gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies on 5 April 2013. We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials (RCTs or CCTs) which compared lifestyle interventions to another therapy (active or placebo) in patients with chronic gout. Outcomes of interest were changes in gout attack frequency, joint pain, serum urate levels, tophus size, function, quality of life and adverse effects. Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (120 participants), at moderate risk of bias, was included in the review. Patients were randomised to one of three interventions: either skim milk powder (SMP) enriched with glycomacropeptide (GMP) and G600, non‐enriched SMP or lactose powder, over a three‐month period. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the three‐month study period. Low quality evidence indicated that there was no difference between the SMP/GMP/G600 group and combined control groups (SMP and lactose powder) at three months (mean difference (MD) ‐0.21, 95% confidence interval (CI) ‐0.76 to 0.34). There were no significant between‐group differences in terms of withdrawals due to adverse effects (risk ratio (RR) 1.27, 95% CI 0.53 to 3.03), and serious adverse events resulting in hospitalisation (2/40 SMP/GMP/G600 group versus 3/80 controls; RR 1.33, 95% CI 0.23 to 7.66). Gastrointestinal adverse effects were the most commonly reported. Pain from self reported gout flares, measured on a 10‐point Likert scale, improved more in the SMP/GMP/G600 group compared to controls (MD ‐1.03, 95% CI ‐1.96 to ‐0.10), an absolute difference of 10% (absolute risk difference ‐0.10, 95% CI ‐0.20 to ‐0.01). This is unlikely to be of clinical significance. There was no significant difference in physical function between SMP/GMP/G600 and the control groups at three‐month followup (MD ‐0.03, 95% CI ‐0.14 to 0.08). Tophus regression and serum urate normalisation were not reported in this study. Authors' conclusions While there is good evidence from observational studies of an association between various lifestyle risk factors and gout development, there is a paucity of high‐quality evidence from randomised controlled trials to either support or refute the use of lifestyle modifications for improving outcomes in people with chronic gout. Plain language summary Lifestyle interventions for chronic gout This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with chronic gout. There was one study included in this review which looked at the benefits and safety of consuming skim milk powder (SMP) enriched with two components of dairy products (glycomacropeptide (GMP) and G600 milk fat extract) compared to standard skim milk or lactose powder in reducing the frequency of gout attacks over a three‐month period. The review shows that, in people with chronic gout : Compared with standard skim milk or lactose powder, SMP enriched with GMP and G600 may not reduce the frequency of gout attacks, may not improve physical function, but may reduce pain. We do not know if consuming these dairy preparations improves tophus size (tophi are gout crystal deposits commonly found in skin, on the surface of joints or in cartilage) or blood uric acid levels, as these were not reported. We do not have precise information about side effects and complications. Possible side effects may include nausea or diarrhoea. What is gout and what are lifestyle interventions? Gout is a very common form of painful joint inflammation (arthritis) caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness and swelling of affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic makeup, being overweight, ingesting certain medications (e.g. diuretics), having impaired kidney function and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Although medications are the mainstay of gout treatment, given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as losing weight, stopping smoking, exercising more, drinking more coffee and dairy products, and consuming less sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout. Best estimate of what happens to people with gout who consume enriched skim milk powder: Gout attacks People who consumed enriched skim milk powder had 0.21 fewer gout attacks per month at 3 months (or 2.5 fewer gout attacks per year) . ‐ People who consumed enriched skim milk powder had 0.49 gout attacks per month (or 6 gout attacks per year). ‐ People who consumed standard skim milk powder or lactose had 0.70 gout attacks per month (or 8 gout attacks per year). Withdrawals due to adverse events 4 more people out of 100 who consumed enriched skim milk powder discontinued the supplement at 3 months (4% more withdrawals absolute change, from 10% fewer to 18% more). ‐ 18 out of 100 stopped consuming enriched skim milk powder. ‐ 14 out of 100 stopped consuming standard skim milk powder or lactose. Pain (lower score means less pain) People who consumed enriched skim milk powder rated their pain 1 point lower on a 0 to 10 point pain scale (10% absolute improvement; 20% to 1% improvement) at 3 months. ‐ People who consumed enriched skim milk powder rated their pain to be 0.67 points on a scale of 0 to 10. ‐ People who consumed standard skim milk powder or lactose rated their pain to be 1.7 points on a scale of 0 to 10. Physical function (lower score means better function) People who consumed enriched skim milk powder rated their function 0.03 better (0.14 better to 0.08 worse) on a 0 to 3 point scale (1% absolute improvement; 5% improvement to 3% worse) at 3 months. ‐ People who consumed enriched skim milk powder rated their function to be 0.08 points on a scale of 0 to 3. ‐ People who consumed standard skim milk powder or lactose rated their function to be 0.11 points on a scale of 0 to 3. Serious adverse events 1 more person out of 100 who consumed enriched skim milk powder reported a serious adverse event. ‐ 5 out of 100 who consumed enriched skim milk powder had a serious adverse event. ‐ 4 out of 100 who consumed standard skim milk powder or lactose had a serious adverse event.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY, Sriranganathan, MK, Edwards, CJ, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.086Z" }, { "id": "8e492db9-8ae6-4e63-848a-f94582de23ae", "pmid": "", "title": "A Phase 1, Randomized, Double-blinded, Placebo-controlled, Dose-escalation and Dose-expansion Study to Evaluate the Safety and Immunogenicity of DelNS1-nCoV-RBD LAIV for COVID-19 in Healthy Adults", "imported": false, "abstract": "To investigate the safety and immunogenicity profile of of a novel nasal spray investigational vaccine, which is a potential prophylactic vaccine for current pandemic disease COVID-19.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.151Z" }, { "id": "8e59b38b-dbb7-49dd-aedc-5b1a799b87f4", "pmid": "", "title": "Interventions for fatigue in people with kidney failure requiring dialysis", "imported": false, "abstract": "Abstract - Background Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD). Objectives We aimed to evaluate the effects of pharmacological and non‐pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Studies evaluating pharmacological and non‐pharmacological interventions affecting levels of fatigue or fatigue‐related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue‐related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered. Data collection and analysis Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta‐analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Ninety‐four studies involving 8191 randomised participants were eligible. Pharmacological and non‐pharmacological interventions were compared either to placebo or control, or to another pharmacological or non‐pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis‐Related Fatigue scale score): SMD ‐1.18, 95% CI ‐2.04 to ‐0.31; I 2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD ‐1.23, 95% CI ‐1.96 to ‐0.50; I 2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD ‐1.06, 95% CI ‐1.47, ‐0.65; I 2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I 2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD ‐0.64, 95% CI ‐1.03 to ‐0.25; I 2 = 75%) in HD. A wide range of heterogenous interventions and fatigue‐related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non‐pharmacological interventions on fatigue or fatigue‐related outcomes, including non‐physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive‐behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta‐blockers, anabolic steroids, glucose‐enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non‐pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported. Authors' conclusions Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non‐pharmacological interventions had uncertain effects on fatigue or fatigue‐related outcomes in people receiving dialysis. Future adequately powered, high‐quality studies are likely to change the estimated effects of interventions for fatigue and fatigue‐related outcomes in people receiving dialysis. Plain language summary Are interventions for fatigue effective among people with kidney failure requiring dialysis? What is the issue? Fatigue is a frequent and debilitating symptom that can limit life participation in people receiving dialysis. Fatigue is linked to impaired quality of life, cardiovascular disease, death and depression in people on dialysis. Several potential interventions, including drugs or other non‐pharmacological treatments (e.g. exercise, diet, massage, aromatherapy, acupressure), have been evaluated for their effect on fatigue in people on dialysis. What did we do? We evaluated whether drugs or other non‐pharmacological interventions are beneficial for adults and children receiving haemodialysis or peritoneal dialysis to manage fatigue. We evaluated all clinical studies available and summarised the results. We evaluated how certain we could be about the evidence related to interventions for fatigue using a system called \"GRADE\". What did we find? Ninety‐four studies involving 8191 randomised participants were available. Patients in the studies were given a drug, non‐pharmacological intervention, standard care or a sugar pill (placebo). The treatment they received was decided by random chance. The studies were generally short‐term (over a few months). There were no studies in children. Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. Drugs or other non‐pharmacological interventions have uncertain effects on fatigue in people on dialysis. Conclusions Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. It remains uncertain whether drugs or other non‐pharmacological interventions have any impact on fatigue in people on dialysis when compared to a sugar pill, standard care or other treatments for fatigue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Natale, P, Ju, A, Strippoli, GFM, Craig, JC, Saglimbene, VM, Unruh, ML, Stallone, G, Jaure, A", "articleTypes": [], "doi": "10.1002/14651858.CD013074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.800Z" }, { "id": "8e5b6491-b430-42eb-b4f6-dc82c9738b20", "pmid": "", "title": "Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve due to viral infection by the herpes zoster virus are implicated in the aetiology and clinical manifestation of Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Corticosteroids, with their powerful anti‐inflammatory effect, have a potential role to play in the reduction or minimisation of nerve damage when administered together with antiviral therapy, and therefore may improve the outcome for patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of corticosteroids as an adjuvant to antiviral therapy in adult patients with Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Search methods We searched the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 4, 2007), MEDLINE (1950 to December 2007) and EMBASE (1974 to December 2007), CINAHL (1982 to December 2007), LILACS, KoreaMed, IndMed, PakMediNet, ZETOC, Cambridge Scientific Abstracts (Conference Proceedings Database), ISI Proceedings (Web of Science), the National Research Register (NRR), the UK Clinical Research Network Portfolio Database (UKCRN), the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Research Findings Register (ReFeR) and the metaRegister of Controlled Trials (mRCT). Selection criteria All randomised controlled trials in which corticosteroids (by any route of administration at any dosage) were given as an adjuvant to antiviral agents in the treatment of Ramsay Hunt syndrome. Data collection and analysis Two reviewers independently assessed eligibility and trial quality of the available studies, whether they were published or unpublished. No trials were found and therefore no data were analysed. Main results This is an empty review as no trials were found that fulfilled the inclusion criteria. Authors' conclusions Since no randomised controlled trials investigating the use of corticosteroids as an adjuvant to antiviral treatment in Ramsay Hunt syndrome were identified, such studies are needed to assess the effects of such therapy. Plain language summary Corticosteroids used in addition to antiviral drugs in patients with Ramsay Hunt syndrome Ramsay Hunt syndrome (also known as herpes zoster oticus) consists of weakness of the face due to infection with the varicella zoster virus. Five cases arise per 100,000 of the population per year in the US. It is more common among those over 60 and rare in children. Other symptoms may include severe ear pain and small blisters on the outer ear or in the mouth. Prompt diagnosis and treatment (ideally within 72 hours of the onset of symptoms) are crucial to secure the best outcomes. In cases where treatment has been started within this time period, facial weakness recovers in up to 75% of patients. Standard treatment is with antiviral therapy (most commonly acyclovir). Corticosteroids are known for their anti‐inflammatory properties and are commonly used together with antivirals to reduce the inflammation in the facial nerve. This is thought to be the cause of the facial weakness. The aim of the review was to see if corticosteroids, used at the same time as antiviral drugs, improved outcomes in patients with Ramsay Hunt syndrome. However the review found no trials matching the inclusion criteria, and no conclusions can be drawn about the effectiveness of using corticosteroids in this way. It is recommended that high‐quality randomised controlled trials be undertaken to address this issue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T, Doree, C, Chamberlain, IJ, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006852.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.074Z" }, { "id": "8e5b6c8e-b06f-40e8-8e7c-a4326b2d3045", "pmid": "", "title": "Cannabinoids for Tourette's Syndrome", "imported": false, "abstract": "Abstract - Background Gilles de la Tourette Syndrome (GTS) is a developmental neuropsychiatric disorder characterised by the presence of chronic motor and phonic tics. Drugs currently used in the treatment of GTS either lack efficacy or are associated with intolerable side effects. There is some anecdotal and experimental evidence that cannabinoids may be effective in treating tics and compulsive behaviour in patients with GTS. There are currently no systematic Cochrane reviews of treatments used in GTS. There is one other Cochrane review being undertaken at present, on the use of fluoxetine for tics in GTS. Objectives To evaluate the efficacy and safety of cannabinoids as compared to placebo or other drugs in treating tics, premonitory urges and obsessive compulsive symptoms (OCS), in patients with GTS. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (in The Cochrane Library Issue 4 2008) , MEDLINE (January 1996 to date), EMBASE (January 1974 to date), PsycINFO (January 1887 to date), CINAHL (January 1982 to date), AMED (January 1985 to date), British Nursing Index (January 1994 to date) and DH DATA (January 1994 to date). 
 
 We also searched the reference lists of located trials and review articles for further information. Selection criteria We included randomised controlled trials (RCTs) comparing any cannabinoid preparation with placebo or other drugs used in the treatment of tics and OCS in patients with GTS. Data collection and analysis Two authors abstracted data independently and settled any differences by discussion. Main results Only two trials were found that met the inclusion criteria. Both compared a cannabinoid, delta‐9‐Tetrahydrocannabinol (Δ 9 THC), either as monotherapy or as adjuvant therapy, with placebo. One was a double blind, single dose crossover trial and the other was a double blind, parallel group study. A total of 28 different patients were studied. Although both trials reported a positive effect from Δ 9 THC, the improvements in tic frequency and severity were small and were only detected by some of the outcome measures. Authors' conclusions Not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome. Plain language summary Cannabinoids for Tourette syndrome Cannabinoid medication might be useful in the treatment of the symptoms in patients with Tourette's syndrome. At the present time only two relevant studies have been conducted. Both studies used tetrahydrocannabinol (Δ 9 THC). In both studies Δ 9 THC was associated with tic reduction. However the sample size was small and a large number of multiple comparisons were made . There were only 28 participants in total, since eight participants took part in both studies. Possibly the patients who derived the greatest benefit and experienced the least adverse effects would be the most inclined to participate in further studies. There were a high number of drop outs/exclusions in the six week study and it is unclear whether intention to treat analysis (ITT) was performed. The results that are reported are analyses done on the patients who remained in the study on the study medication at the correct dose. In reality, patients do opt not to continue treatment if there is limited efficacy or unpalatable side effects. This introduces attrition bias. Whilst there were some significant results, the authors themselves accept that very few of these results are significant if a Bonferroni correction is performed. It is possible that cannabinoid medication has a beneficial effect which is too weak to be detected using ITT and such a small sample size. There is some weak evidence that cannabinoid medication may have an effect on obsessive compulsive behaviour but the measure used was an addition to the TSSL which has not been validated.There were no data on the effect of Δ 9 THC on quality of life.There is not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Curtis, A; Clarke, CE; Rickards, HE", "articleTypes": [], "doi": "10.1002/14651858.CD006565.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "8e66048b-032b-4e16-93be-879ec46a5da6", "pmid": "", "title": "Evaluation of the Efficacy of Serotoninergic Antidepressants in Bulimia Nervosa, According to Brain Serotonin Profile Determined by Positron Emission Tomography With [18F] MPPF - a Multicenter Study", "imported": false, "abstract": "Bulimia nervosa (BN) is a serious mental illness characterized by massive food crises followed by anxiety and compensatory behaviours (vomiting more often). Recent data show an increasing prevalence and a serious prognosis, due to excess mortality by suicide but also somatic complications.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.247Z" }, { "id": "8e7e8735-387e-466e-bcdc-99d1cdfa62cb", "pmid": "", "title": "Buspirone for Early Satiety and Symptoms of Gastroparesis: A Multicenter, Randomized, Placebo-Controlled, Double-Masked Trial (BESST)", "imported": false, "abstract": "This study evaluates whether the study medication, buspirone, an antianxiety drug, improves the symptoms of gastroparesis in patients with gastroparesis symptoms and at least moderately severe symptoms of fullness and/or inability to eat a full meal. Half the patients will receive buspirone and half the patients will receive a placebo.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.158Z" }, { "id": "8e86211f-dc0b-4b77-a508-6f437e33d1b6", "pmid": "", "title": "Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Hip and knee replacement surgery is a well‐established means of improving quality of life, but is associated with a significant risk of bleeding. One‐third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care. Objectives To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta‐analysis (NMA) methodology. Search methods We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO host ), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). Selection criteria We included RCTs of people undergoing elective hip or knee surgery only. We excluded non‐elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon‐aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non‐fibrin sealants. Data collection and analysis We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all‐cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received. Main results We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra‐articularly and orally at a total dose of greater than 3 g pre‐incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate‐certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre‐incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low‐certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low‐certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low‐certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low‐certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low‐certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all‐cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low‐certainty evidence). This was followed by TXA given intravenously and intra‐articularly at a total dose of 2 g pre‐incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low‐certainty evidence) and TXA given intravenously and intra‐articularly, total dose greater than 3 g pre‐incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low‐certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low‐certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials). Authors' conclusions We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra‐articular, oral and intravenous, or intravenous and intra‐articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review. Plain language summary What is the best medication to stop bleeding in those having non‐emergency hip or knee surgery? Key messages • Tranexamic acid may be an effective medicine to help blood to clot during hip or knee replacement surgery, which reduces bleeding and the need for a blood transfusion (replacing lost blood with donated blood). • A high dose of this medicine and administering it in more than one way (for example, as a tablet and injected into the joint at the end of surgery) appears to work best. • Tranexamic acid is potentially as effective when given as a tablet as when injected into a vein. • There is little to no evidence to indicate that higher doses of tranexamic acid increase the risk of blood clots in the leg or other harms. Background Why is it important to stop bleeding during hip or knee surgery? Controlling bleeding during surgery reduces the likelihood of the person developing anaemia and requiring a blood transfusion, which carries the risk of complications. Anaemia occurs when the number of red blood cells (haemoglobin) available to carry oxygen is lower than normal. This causes symptoms such as fatigue, weakness, dizziness, shortness of breath and, in severe cases, can be life‐threatening. Preventing blood loss during surgery improves patient outcomes, decreases healthcare costs and preserves the limited supplies of donated blood. Is there a medication that helps control bleeding? Many research studies have investigated whether certain medication, such as tranexamic acid, can help minimise blood loss during surgery. Most of the studies test different doses of medications, different methods of administration and different times of use, either before, during or after an operation. What did we want to find out? We wanted to find out whether medication can reduce blood loss and the need for blood transfusions in people having hip or knee replacement surgery. We also wanted to know the most effective way of giving this medication to patients. What did we do? We searched for studies comparing different medications that could help reduce bleeding in adults undergoing planned hip or knee replacement surgery. We also searched for studies comparing medication with a placebo. A placebo is a 'dummy' medication that looks or tastes identical to the medication being tested. What did we find? We found 102 studies. Twelve studies did not report the number of included participants; in the other 90 studies, there were 8418 included participants. On average, people were between 50 and 77 years of age and 64% were women. The smallest study included 16 people and the largest involved 300. Studies took place around the globe, with the highest number in Europe and Asia. Of those studies that reported a source of funding, seven were fully funded and five partly funded by pharmaceutical (medication) companies. All studies investigated medications that helped the blood to clot. However, most studies assessed the effectiveness and safety of tranexamic acid administered intravenously (injected into a vein), orally (swallowing a tablet or liquid), injected into the joint during surgery, or with a combination of these methods. Main results Our review of the studies showed the following: • Tranexamic acid was the most effective at controlling bleeding compared to other medications. • Adults who underwent hip or knee replacement surgery required fewer blood transfusions if they were given tranexamic acid. • Tranexamic acid given in higher doses using multiple methods of administration, such as orally and injected into the joint during surgery, may be more likely to prevent bleeding. • Taking tranexamic acid orally is probably as effective at preventing a blood transfusion as injecting the medication into a vein. We were unable to decide on the optimal dose, which combination of methods are best to administer tranexamic acid and when it is most beneficial to use it (before, during and after surgery). We did not find evidence to suggest that higher doses of tranexamic acid increase the risk of developing a blood clot, or any other harms. What are the limitations of the evidence? We are not able to definitively draw conclusions based on the trials included within this review. We have little confidence in the evidence for some outcomes, and are not confident about the evidence for others. This is because it is possible that people in the studies were aware of which treatment they were getting. Also, the studies were small and did not all provide data about everything in which we were interested. Ongoing studies and future updates Thirty studies with a planned total of 3776 participants are currently ongoing. These studies should be completed and published within the next few years. Once the authors publish their data, we may update our analyses and provide stronger answers than we can at present. How up‐to‐date is this evidence? The evidence is current to 18 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gibbs, VN, Champaneria, R, Sandercock, J, Welton, NJ, Geneen, LJ, Brunskill, SJ, Dorée, C, Kimber, C, Palmer, AJR, Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD013295.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.825Z" }, { "id": "8e86fda0-1e1f-4918-aa4a-3b24b799ff1d", "pmid": "", "title": "Transitional discharge interventions for people with schizophrenia", "imported": false, "abstract": "Abstract - Background Schizophrenia is a chronic mental illness characterized by delusions, hallucinations, and important functional and social disability. Interventions labeled as 'transitional' add to care plans made during the hospital stay in preparation for discharge. They also include interventions developed after discharge to support people with serious mental illness as they make the transition from the hospital to the community. Transitional discharge interventions may anticipate the future needs of the patient after discharge by co‐ordinating the different levels of the health system that can effectively guarantee continuity of care in the community. This occurs through the provision of therapeutic relationships which give a safety net throughout the discharge and community reintegration processes to improve the general condition of users, level of functioning, use of health resources, and satisfaction with care. Objectives To assess the effects of transitional discharge interventions for people with schizophrenia. Search methods On 7 December 2022, we searched the Cochrane Schizophrenia Group's Study‐Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, PubMed, CINAHL, ClinicalTrials.gov, ISRCTN, PsycINFO, and WHO ICTRP. Selection criteria Randomized controlled trials (RCTs) evaluating the effects of transitional discharge interventions in people with schizophrenia and schizophrenia‐related disorders. Eligible interventions included three key elements: predischarge planning, co‐ordination of care and follow‐up, and postdischarge support. Data collection and analysis We used standard Cochrane methods. Outcomes of this review included global state (relapse), service use (hospitalization), general functioning, satisfaction with care, adverse effects/events, quality of life, and direct costs. For binary outcomes, we calculated risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardized mean difference (SMD) and their 95% CIs. We used GRADE to assess certainty of evidence. Main results We found 12 studies with 1748 participants comparing transitional discharge interventions to usual care. All were parallel‐group RCTs. No studies assessed global state (relapse) or reported data about adverse events/effects. All studies had a high risk of bias, mainly due to serious concerns about allocation concealment, deviations from intended interventions, measurement of the outcomes, and missing outcome data. Transitional discharge interventions may make little to no difference in service use (hospitalization) at short‐ and long‐term follow‐ups, but the evidence is very uncertain (RR 1.18, 95% CI 0.55 to 2.50; I 2 = 54%; 4 studies, 462 participants; very low‐certainty evidence). Transitional discharge intervention may increase the levels of functioning after discharge (clinically important change in general functioning) (SMD 0.95, 95% CI −0.06 to 1.97; I² = 95%; 4 studies, 437 participants; very low‐certainty evidence) and may increase the proportion of participants who are satisfied with the intervention (clinically important change in satisfaction) (RR 1.96, 95% CI 1.37 to 2.80; 1 study, 76 participants; very low‐certainty evidence), but for both outcomes the evidence is very uncertain. Transitional discharge intervention may make little to no difference in quality of life compared to treatment as usual (SMD 0.24, 95% CI −0.30 to 0.78; I² = 90%; 4 studies, 748 participants; very low‐certainty evidence), but we are very uncertain. For direct costs, one study with 124 participants did not report full details and thus the results were inconclusive. Authors' conclusions There is currently no clear evidence for or against implementing transitional discharge interventions for people with schizophrenia. Transitional discharge interventions may improve patient satisfaction and functionality, but this evidence is also very uncertain. For future research, it is important to improve the quality of the conduct and reporting of these trials, including using validated tools for measuring their outcomes. Plain language summary What are the benefits of transitional discharge care for people with schizophrenia? Key messages – Transitional discharge care (an intervention that supports a person move from a stay in hospital to the community) may make little to no difference in admissions to hospital and quality of life, and may improve how well a person functions in day‐to‐day life and how happy they are with their treatment when they return home, but we are very uncertain about the results. – The results on costs of running the transitional discharge care program are inconclusive, and the studies provided no information on relapse (a new mental health crisis) or unwanted effects. – We need more and better studies to investigate how to support people with schizophrenia or schizophrenia‐related disorders during the transition from hospital to community. What is schizophrenia? Schizophrenia is a persistent and severe mental health condition where people have hallucinations (where they hear, see, smell, taste, or feel things that appear to be real but only exist in their mind) and delusions (a strong belief in something that is untrue), among other debilitating symptoms, leading to poor quality of life. People with schizophrenia‐related disorders have symptoms that are similar to those of schizophrenia. The illness varies, with people having different symptoms at different times, often with them requiring admission to hospital for treatment. What happens when a person with schizophrenia or schizophrenia‐related disorders is discharged from hospital? People with schizophrenia or schizophrenia‐related disorders are sometimes admitted to hospital to improve their health, and afterward, they are discharged to their homes or other care facilities. This transition might be difficult and frightening for them and their carers, and they may need help to adapt. There are some interventions to support people with schizophrenia or schizophrenia‐related disorders after they leave the hospital, such as case management with an expert guide or continuous care with a nurse. What is transitional discharge care? Transitional discharge care is an intervention which provides support to people leaving hospital to cover their medical, practical, and emotional needs. This starts before hospital discharge and continues until people are confident in their homes or care facilities. This may include help with housing; communicating and co‐ordinating among healthcare staff, patients, and families; planning meetings; sessions with families; visits to the neighborhood; talking therapy sessions; telephone and face‐to‐face support; and support groups focusing on recreation, medication, shopping, cooking, and financial responsibilities. What did we want to find out? We wanted to know whether transitional discharge care helps people with schizophrenia or schizophrenia‐related disorders when leaving the hospital, especially if it reduces the rate of a new mental health crisis (relapse), repeat admissions to hospital, overall functioning in day‐to‐day life, satisfaction with the care they receive, quality of life, unwanted effects, and costs. What did we do? We searched for studies that investigated whether transitional discharge care, compared to no transitional discharge care or usual care, was effective in adults with schizophrenia or schizophrenia‐related disorders. What did we find? We found 12 studies with 1748 people that compared transitional discharge care to usual care. Transitional discharge care may make little to no difference to admissions to hospital (4 studies, 462 people). Transitional discharge care may improve functioning (4 studies, 437 people) and may increase people's satisfaction with care (1 study, 76 people), but we are very uncertain about the results. Transitional discharge care may make little to no difference to quality of life (4 studies, 748 people). The results on costs were inconclusive as the study did not fully report the methods (1 study, 124 people). ​​ None of the included studies provided data for relapse or unwanted effects of transitional discharge care. What are the limitations of the evidence? All 12 studies had problems with their methods and results were inconsistent. Some studies included people with other mental disorders, so the results might not apply directly to people with schizophrenia or schizophrenia‐related disorders. Therefore, we have very low confidence in our findings. How up to date is this evidence? The evidence is up to date to December 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Roson Rodriguez, P, Chen, X, Arancibia, M, Garegnani, L, Escobar Liquitay, CM, Mohammad, HA, Franco, JVA", "articleTypes": [], "doi": "10.1002/14651858.CD009788.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.815Z" }, { "id": "8e9b7b6d-efdb-46d6-96e9-125d6d1edba9", "pmid": "", "title": "Interventions for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is the most common, life‐limiting, genetically inherited disease. It affects multiple organs, particularly the respiratory system. However, gastrointestinal problems such as constipation and distal intestinal obstruction syndrome (DIOS) are also important and well‐recognised complications in CF. They share similar symptoms e.g. bloating, abdominal pain, but are distinct conditions. Constipation occurs when there is gradual faecal impaction of the colon, but DIOS occurs when there is an accumulation of faeces and sticky mucus, forming a mass in the distal part of the small intestine. The mass may partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). Symptoms of DIOS can affect quality of life and other aspects of CF health, such as airway clearance, exercise, sleep and nutritional status. Treatment of constipation and prevention of complete bowel obstruction are required for gastrointestinal management in CF. However, many different strategies are used in clinical practice and there is a lack of consensus. The importance of this topic was highlighted in a recent research priority setting exercise by the James Lind Alliance. Objectives To evaluate the effectiveness and safety of laxative agents of differing types for preventing DIOS (complete and incomplete) in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised and quasi‐randomised controlled parallel trials comparing laxative therapy for preventing DIOS (including osmotic agents, stimulants, mucolytics and substances with more than one action) at any dose to placebo, no treatment or an alternative laxative therapy, in people of any age with pancreatic sufficient or insufficient CF and any stage of lung disease. Randomised cross‐over trials were judged on an individual basis. Data collection and analysis Two authors independently assessed trials for inclusion, extracted outcome data and performed a risk of bias assessment for the included data. We judged the certainty of the evidence using GRADE criteria. Main results We included one cross‐over trial (17 participants) with a duration of 12 months, in which participants were randomly allocated to either cisapride (a gastro‐prokinetic agent) or placebo for six months each. The trial had an unclear risk of bias for most domains but had a high risk of reporting bias. Radiograph scores revealed no difference in occurrence of DIOS between cisapride and placebo (narrative report, no data provided). There were no adverse effects. Symptom scores were the only secondary outcome within the review that were reported. Total gastrointestinal symptom scores favoured cisapride with a statistically significant mean difference (MD) of ‐7.60 (95% confidence interval (CI) ‐14.73 to ‐0.47). There was no significant difference at six months between cisapride and placebo for abdominal distension, MD ‐0.90 (95% CI ‐2.39 to 0.59) or abdominal pain, MD ‐0.4 (95% CI ‐2.05 to 1.25). The global symptom scores (whether individuals felt better or worse) were reported in the paper to favour cisapride and be statistically significant (P < 0.05). We assessed the available data to be very low certainty. There was a great deal of missing data from the included trial and the investigators failed to report numerical data for many outcomes. The overall risk of bias of the trial was unclear and it had a high risk for reporting bias. There was also indirectness; the trial drug (cisapride) has since been removed from the market in several countries due to adverse effects, thus it has no current applicability for preventing DIOS. The included trial also had very few participants, which downgraded the certainty a further level for precision. Authors' conclusions There is an absence of evidence for interventions for the prevention of DIOS. As there was only one included trial, we could not perform a meta‐analysis of the data. Furthermore, the included trial compared a prokinetic agent (cisapride) that is no longer licensed for use in a number of countries due to the risk of serious cardiac events, a finding that came to light after the trial was conducted. Therefore, the limited findings from the trial are not applicable in current clinical practice. Overall, a great deal more research needs to be undertaken on gastrointestinal complications in CF, as this is a very poorly studied area compared to respiratory complications in CF. Plain language summary Which interventions are effective and safe for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis? Background Cystic fibrosis (CF) is an inherited, life‐long condition that causes organ systems in the body to produce large amounts of thick and sticky mucus. The most commonly affected area is the lungs, in which thick mucus leads to recurrent chest infections and breathing difficulties. Another commonly affected area is the digestive system. Many people with CF suffer from bloating and abdominal pain which may be caused by constipation or distal intestinal obstruction syndrome (DIOS). In DIOS, overproduction of thick mucus combines with stool and sticks to the intestinal wall. This mass can partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). The latter causes severe pain, vomiting and is treated as a medical emergency. As part of effective care for people with CF, constipation should therefore be treated and complete bowel obstruction be prevented. It is also important to recognise that constipation and DIOS impact on other aspects of CF health. Bloating, abdominal pain and nausea may affect airway clearance, exercise and sleep. Nutritional status may also be affected due to decreased appetite and malabsorption. DIOS may affect the absorption of other medications taken by people with CF. Overall, DIOS can significantly impair quality of life. Different laxatives are currently used in clinics, but prescribing practices differ and there is no consensus on optimal treatment strategies. Hence, this review aimed to analyse the evidence for the preventing DIOS. Search date We last searched for evidence: 12 October 2021. Trial characteristics We included one trial in the review, which included 17 people aged between 13 to 35 years. These people were randomly put into groups to take either a placebo drug (with no active medication) or cisapride for six months each and then to cross over and take the alternative treatment for a further six months. Key results The trial used radiography to diagnose DIOS, but did not provide any data and only stated that there was no difference between cisapride and placebo. The trial also stated that there were no adverse effects from the cisapride. The trial assessed participant‐reported total and individual gastrointestinal symptom scores. People in the cisapride group reported an improvement in total gastrointestinal symptom scores compared to those in the placebo group. However, there were no differences reported between groups for the individual symptom scores of abdominal pain and abdominal distension (swelling). Participants also reported global symptom scores, which showed that most people felt better taking cisapride compared to placebo. Certainty of the evidence The overall certainty of the evidence was very low. With one trial in this review, we could not combine data from different trials. The trial did not provide enough information about the methods used for allocating participants or about missing data and did not fully report certain results. The small number of participants also lowered the precision of the results. Since this trial was conducted, cisapride has been removed from the market in a number of countries due to rare but serious heart complications, therefore it has no applicability to current clinical practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carroll, W; Green, J; Gilchrist, FJ", "articleTypes": [], "doi": "10.1002/14651858.CD012619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "8e9bd0a2-c297-4331-8700-58135a3e6e03", "pmid": "", "title": "Interventions for preventing oral mucositis for patients with cancer receiving treatment", "imported": false, "abstract": "Abstract - Background Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers). Objectives To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment. Search methods Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL ( The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Selection criteria Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer. Data collection and analysis Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random‐effects models. Main results A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta‐analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte‐colony stimulating factor (G‐CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate. Authors' conclusions Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent. Plain language summary Interventions for preventing oral mucositis for patients with cancer receiving treatment Treatment for cancer (including bone marrow transplant) can cause oral mucositis (severe ulcers in the mouth). This painful condition can cause difficulties in eating, drinking and swallowing, and may also be associated with infections which may require the patient to stay longer in hospital. Different strategies are used to try and prevent this condition, and the review of trials found that some of these are effective. Two interventions, cryotherapy (ice chips) and keratinocyte growth factor (palifermin®) showed some benefit in preventing mucositis. Sucralfate is effective in reducing the severity of mucositis, and a further seven interventions, aloe vera, amifostine, intravenous glutamine, granulocyte‐colony stimulating factor (G‐CSF), honey, laser and antibiotic lozenges containing polymixin/tobramycin/amphotericin (PTA) showed weaker evidence of benefit. These were evaluated in patients with different types of cancer, undergoing different types of cancer treatment. Benefits may be restricted to the disease and treatment combinations evaluated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Worthington, HV, Clarkson, JE, Bryan, G, Furness, S, Glenny, A-M, Littlewood, A, McCabe, MG, Meyer, S, Khalid, T, Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD000978.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.127Z" }, { "id": "8ea5c162-4914-4835-8729-a1a4dc2f0a15", "pmid": "", "title": "Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether metformin can prevent or delay T2DM and its complications in people with increased risk of developing T2DM is unknown. Objectives To assess the effects of metformin for the prevention or delay of T2DM and its associated complications in persons at increased risk for the T2DM. Search methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was March 2019. Selection criteria We included randomised controlled trials (RCTs) with a duration of one year or more comparing metformin with any pharmacological glucose‐lowering intervention, behaviour‐changing intervention, placebo or standard care in people with impaired glucose tolerance, impaired fasting glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or combinations of these. Data collection and analysis Two review authors read all abstracts and full‐text articles and records, assessed risk of bias and extracted outcome data independently. We used a random‐effects model to perform meta‐analysis and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using GRADE. Main results We included 20 RCTs randomising 6774 participants. One trial contributed 48% of all participants. The duration of intervention in the trials varied from one to five years. We judged none of the trials to be at low risk of bias in all 'Risk of bias' domains. Our main outcome measures were all‐cause mortality, incidence of T2DM, serious adverse events (SAEs), cardiovascular mortality, non‐fatal myocardial infarction or stroke, health‐related quality of life and socioeconomic effects.The following comparisons mostly reported only a fraction of our main outcome set.
 Fifteen RCTs compared metformin with diet and exercise with or without placebo: all‐cause mortality was 7/1353 versus 7/1480 (RR 1.11, 95% CI 0.41 to 3.01; P = 0.83; 2833 participants, 5 trials; very low‐quality evidence); incidence of T2DM was 324/1751 versus 529/1881 participants (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 3632 participants, 12 trials; moderate‐quality evidence); the reporting of SAEs was insufficient and diverse and meta‐analysis could not be performed (reported numbers were 4/118 versus 2/191; 309 participants; 4 trials; very low‐quality evidence); cardiovascular mortality was 1/1073 versus 4/1082 (2416 participants; 2 trials; very low‐quality evidence). One trial reported no clear difference in health‐related quality of life after 3.2 years of follow‐up (very low‐quality evidence). Two trials estimated the direct medical costs (DMC) per participant for metformin varying from $220 to $1177 versus $61 to $184 in the comparator group (2416 participants; 2 trials; low‐quality evidence). Eight RCTs compared metformin with intensive diet and exercise: all‐cause mortality was 7/1278 versus 4/1272 (RR 1.61, 95% CI 0.50 to 5.23; P = 0.43; 2550 participants, 4 trials; very low‐quality evidence); incidence of T2DM was 304/1455 versus 251/1505 (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 2960 participants, 7 trials; moderate‐quality evidence); the reporting of SAEs was sparse and meta‐analysis could not be performed (one trial reported 1/44 in the metformin group versus 0/36 in the intensive exercise and diet group with SAEs). One trial reported that 1/1073 participants in the metformin group compared with 2/1079 participants in the comparator group died from cardiovascular causes. One trial reported that no participant died due to cardiovascular causes (very low‐quality evidence). Two trials estimated the DMC per participant for metformin varying from $220 to $1177 versus $225 to $3628 in the comparator group (2400 participants; 2 trials; very low‐quality evidence). Three RCTs compared metformin with acarbose: all‐cause mortality was 1/44 versus 0/45 (89 participants; 1 trial; very low‐quality evidence); incidence of T2DM was 12/147 versus 7/148 (RR 1.72, 95% CI 0.72 to 4.14; P = 0.22; 295 participants; 3 trials; low‐quality evidence); SAEs were 1/51 versus 2/50 (101 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin with thiazolidinediones: incidence of T2DM was 9/161 versus 9/159 (RR 0.99, 95% CI 0.41 to 2.40; P = 0.98; 320 participants; 3 trials; low‐quality evidence). SAEs were 3/45 versus 0/41 (86 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin plus intensive diet and exercise with identical intensive diet and exercise: all‐cause mortality was 1/121 versus 1/120 participants (450 participants; 2 trials; very low‐quality evidence); incidence of T2DM was 48/166 versus 53/166 (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; 332 participants; 2 trials; very low‐quality evidence). One trial estimated the DMC of metformin plus intensive diet and exercise to be $270 per participant compared with $225 in the comparator group (94 participants; 1 trial; very‐low quality evidence). One trial in 45 participants compared metformin with a sulphonylurea. The trial reported no patient‐important outcomes. For all comparisons there were no data on non‐fatal myocardial infarction, non‐fatal stroke or microvascular complications. We identified 11 ongoing trials which potentially could provide data of interest for this review. These trials will add a total of 17,853 participants in future updates of this review. Authors' conclusions Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate‐quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate‐quality evidence). Likewise, the combination of metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of T2DM (very low‐quality evidence). Data on patient‐important outcomes such as mortality, macrovascular and microvascular diabetic complications and health‐related quality of life were sparse or missing. Plain language summary Metformin for prevention/delay of type 2 diabetes mellitus (T2DM) and associated complications in persons at increased risk for development of T2DM Review question Is the antidiabetic drug metformin able to prevent or delay the development of type 2 diabetes and its associated complications in people with moderately elevated blood sugar levels? Background People with moderately elevated blood sugar levels (often referred to as 'prediabetes') are said to have an increased risk for developing diabetes. Metformin is a blood sugar‐lowering medicine which has been used for a long time to treat people with type 2 diabetes. Type 2 diabetes, also known as adult‐onset diabetes, is the most common type of diabetes and prevents the body from using insulin properly (insulin resistance). Type 2 diabetes can have bad effects on health in the long term (diabetic complications), such as severe eye or kidney disease or 'diabetic feet', eventually resulting in foot ulcers. We investigated whether metformin can also be used to prevent or delay type 2 diabetes in people at increased risk. We examined the effects of metformin on patient‐important outcomes, such as complications of diabetes, death from any cause, health‐related quality of life and side effects of the drug. Study characteristics To be included, people had to have blood sugar levels higher than normal, but below the levels that are used to diagnose diabetes. We found 20 randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 6774 participants. The comparator group consisted of diet and exercise, intensive diet and exercise or another blood sugar‐lowering drug. One study dominated the evidence (48% of the total number of all participants). Twelve studies were performed in China. We only included studies with a treatment duration of one year or more. The treatment duration in the included studies varied from one to five years. This evidence is up to date as of March 2019. Key results Fifteen studies compared metformin against diet and exercise. Eight studies compared metformin against intensive diet and exercise and three studies compared metformin plus intensive diet and exercise against intensive diet and exercise only. When compared to standard diet and exercise metformin slightly reduces or delays development of diabetes. However, when compared to intensive diet and exercise, metformin does not provide an additional benefit in reducing or delaying development of diabetes. Seven studies compared metformin with another glucose‐lowering drug: three studies compared metformin with acarbose. Three studies compared metformin with a thiazolidinedione (such as pioglitazone). There was neither an advantage or disadvantage when comparing metformin with these drugs with respect to the development of diabetes. One study compared metformin with a sulphonylurea (glimepiride). The trial did not report patient‐important outcomes. In general, the reporting of serious side effects was sparse. Few participants died and we did not detect a clear difference between the intervention and comparator groups. We also did not detect an advantage or disadvantage of metformin in relation to health‐related quality of life. Our included studies did not report on non‐fatal heart attacks, strokes or complications of diabetes such as kidney or eye disease. Few studies estimated the direct medical costs. When compared to diet and exercise, metformin was more expensive. When compared to intensive diet and exercise, metformin was less expensive. We identified 11 ongoing studies which potentially could provide data for this review. These studies will add a total of 17,853 participants in future updates of our review. Future studies should investigate more patient‐important outcomes such as complications of diabetes and especially the side effects of the drugs. We do not know whether 'prediabetes' is just a condition defined by laboratory measurements, or whether it is in fact a real risk factor for diabetes. It is also unknown whether treatment of this condition translates into better patient‐important outcomes. Certainty of the evidence All included studies had problems in the way they were conduced or reported.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Madsen, KS; Chi, Y; Metzendorf, MI; Richter, B; Hemmingsen, B", "articleTypes": [], "doi": "10.1002/14651858.CD008558.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "8eae75ca-ae9f-4b70-a060-bb873fcbc09d", "pmid": "", "title": "Cannabis and cannabinoids for symptomatic treatment for people with multiple sclerosis", "imported": false, "abstract": "Abstract - Background Spasticity and chronic neuropathic pain are common and serious symptoms in people with multiple sclerosis (MS). These symptoms increase with disease progression and lead to worsening disability, impaired activities of daily living and quality of life. Anti‐spasticity medications and analgesics are of limited benefit or poorly tolerated. Cannabinoids may reduce spasticity and pain in people with MS. Demand for symptomatic treatment with cannabinoids is high. A thorough understanding of the current body of evidence regarding benefits and harms of these drugs is required. Objectives To assess benefit and harms of cannabinoids, including synthetic, or herbal and plant‐derived cannabinoids, for reducing symptoms for adults with MS. Search methods We searched the following databases from inception to December 2021: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), CINAHL (EBSCO host), LILACS, the Physiotherapy Evidence Database (PEDro), the World Health Organisation International Clinical Trials Registry Platform, the US National Institutes of Health clinical trial register, the European Union Clinical Trials Register, the International Association for Cannabinoid Medicines databank. We hand searched citation lists of included studies and relevant reviews. Selection criteria We included randomised parallel or cross‐over trials (RCTs) evaluating any cannabinoid (including herbal C annabis, C annabis flowers, plant‐based cannabinoids, or synthetic cannabinoids) irrespective of dose, route, frequency, or duration of use for adults with MS. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane Risk of bias 2 tool for parallel RCTs and crossover trials. We rated the certainty of evidence using the GRADE approach for the following outcomes: reduction of 30% in the spasticity Numeric Rating Scale, pain relief of 50% or greater in the Numeric Rating Scale‐Pain Intensity, much or very much improvement in the Patient Global Impression of Change (PGIC), Health‐Related Quality of Life (HRQoL), withdrawals due to adverse events (AEs) (tolerability), serious adverse events (SAEs), nervous system disorders, psychiatric disorders, physical dependence. Main results We included 25 RCTs with 3763 participants of whom 2290 received cannabinoids. Age ranged from 18 to 60 years, and between 50% and 88% participants across the studies were female. The included studies were 3 to 48 weeks long and compared nabiximols, an oromucosal spray with a plant derived equal (1:1) combination of tetrahydrocannabinol (THC) and cannabidiol (CBD) (13 studies), synthetic cannabinoids mimicking THC (7 studies), an oral THC extract of C annabis sativa (2 studies), inhaled herbal C annabis (1 study) against placebo. One study compared dronabinol, THC extract of C annabis sativa and placebo, one compared inhaled herbal C annabis , dronabinol and placebo. We identified eight ongoing studies. Critical outcomes • Spasticity: nabiximols probably increases the number of people who report an important reduction of perceived severity of spasticity compared with placebo (odds ratio (OR) 2.51, 95% confidence interval (CI) 1.56 to 4.04; 5 RCTs, 1143 participants; I 2 = 67%; moderate‐certainty evidence). The absolute effect was 216 more people (95% CI 99 more to 332 more) per 1000 reporting benefit with cannabinoids than with placebo. • Chronic neuropathic pain: we found only one small trial that measured the number of participants reporting substantial pain relief with a synthetic cannabinoid compared with placebo (OR 4.23, 95% CI 1.11 to 16.17; 1 study, 48 participants; very low‐certainty evidence). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity. • Treatment discontinuation due to AEs: cannabinoids may increase slightly the number of participants who discontinue treatment compared with placebo (OR 2.41, 95% CI 1.51 to 3.84; 21 studies, 3110 participants; I² = 17%; low‐certainty evidence); the absolute effect is 39 more people (95% CI 15 more to 76 more) per 1000 people. Important outcomes • PGIC: cannabinoids probably increase the number of people who report 'very much' or 'much' improvement in health status compared with placebo (OR 1.80, 95% CI 1.37 to 2.36; 8 studies, 1215 participants; I² = 0%; moderate‐certainty evidence). The absolute effect is 113 more people (95% CI 57 more to 175 more) per 1000 people reporting improvement. • HRQoL: cannabinoids may have little to no effect on HRQoL (SMD ‐0.08, 95% CI ‐0.17 to 0.02; 8 studies, 1942 participants; I 2 = 0%; low‐certainty evidence); • SAEs: cannabinoids may result in little to no difference in the number of participants who have SAEs compared with placebo (OR 1.38, 95% CI 0.96 to 1.99; 20 studies, 3124 participants; I² = 0%; low‐certainty evidence); • AEs of the nervous system: cannabinoids may increase nervous system disorders compared with placebo (OR 2.61, 95% CI 1.53 to 4.44; 7 studies, 1154 participants; I² = 63%; low‐certainty evidence); • Psychiatric disorders: cannabinoids may increase psychiatric disorders compared with placebo (OR 1.94, 95% CI 1.31 to 2.88; 6 studies, 1122 participants; I² = 0%; low‐certainty evidence); • Drug tolerance: the evidence is very uncertain about the effect of cannabinoids on drug tolerance (OR 3.07, 95% CI 0.12 to 75.95; 2 studies, 458 participants; very low‐certainty evidence). Authors' conclusions Compared with placebo, nabiximols probably reduces the severity of spasticity in the short‐term in people with MS. We are uncertain about the effect on chronic neurological pain and health‐related quality of life. Cannabinoids may increase slightly treatment discontinuation due to AEs, nervous system and psychiatric disorders compared with placebo. We are uncertain about the effect on drug tolerance. The overall certainty of evidence is limited by short‐term duration of the included studies. Plain language summary Cannabis and cannabinoids for people with multiple sclerosis Key messages 
• Treatment with nabiximols likely results in improvement of spasticity and may not increase serious harmful effects compared with placebo • Compared with placebo, cannabinoids (nabiximols, C annabis extract, synthetic cannabinoids) likely improve well‐being when measured with patient‐reported outcomes • Due to a lack of robust evidence, the benefit of these medicines for treating chronic neuropathic pain is unclear. What is the issue? Many people with multiple sclerosis (MS) experience spasticity that causes also pain and impacts on the ability to carry out daily activities. Spasticity is a form of increased muscle tone. Cannabis ‐based medicines refer to the use of Cannabis , or its ingredients called cannabinoids, as medical therapies to alleviate spasticity, chronic pain and other symptoms in MS. An international survey found that MS was one of the five medical conditions for which C annabis was most often used. Another survey conducted in the UK found that more than one in five people with MS reported they had used C annabis to try to manage their symptoms. What did we want to find out? We wanted to find out if cannabinoids were better than placebo in adults with MS to improve: • spasticity; • chronic neuropathic pain; • well‐being, We also wanted to find out if cannabinoids were associated with: • treatment discontinuation due to unwanted effects; • serious harmful effects; • nervous system disorders or psychiatric disorders; • drug tolerance defined as a condition that occurs when the body gets used to a medicine so that more medicine is needed. What did we do? 
We searched for studies that compared cannabinoids against placebo in adult people with MS. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and certainty of evidence. What did we find? We found 25 studies that involved 3763 people with MS, 2290 of whom received cannabinoids. Fifteen studies were very short term or short‐term studies (two to 12 weeks), seven were intermediate term (12 to 26 weeks), and two were long term (50 and 156 weeks). One study reported results at three days only. The biggest study was conducted in 657 people and the smallest study involved 14 people. Most studies were done in European countries. Thirteen studies evaluated an oral spray (nabiximols) containing two compounds derived from the C annabis plant. The other studies compared different cannabinoids with placebo. Pharmaceutical companies funded 15 of the studies. Main results Compared with placebo, cannabinoids: • probably increase the number of people who report an important reduction of perceived severity of spasticity for up to 14 weeks (evidence from five studies in 1143 people); • may increase the number of people who report an important reduction of perceived severity of chronic neuropathic pain, but the evidence is very uncertain (evidence from one study in 48 people). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity: • probably increase the number of people who perceive their well‐being as 'very much' or 'much' improved (evidence from eight studies in 1215 people); • may increase slightly the number of people who discontinue treatment due to unwanted effects (evidence from 21 studies in 3110 people); • may result in little to no difference in the number of people who have serious harmful effects (evidence from 20 studies in 3124 people); • may increase nervous system disorders (evidence from seven studies in 1154 people) or psychiatric disorders (evidence from six studies in 1122 people); • may have little to no effect on the number of people who have drug tolerance, but the evidence is very uncertain (two studies in 458 people). What are the limitations of the evidence? There is no high‐quality evidence. We are moderately confident that cannabinoids work better versus no cannabinoids to improve severity of spasticity and well‐being in adults with MS. We have little confidence in our results for the effect on chronic neuropathic pain because the available evidence is limited. There is limited evidence to determine the effects of cannabinoids on serious harmful effects, nervous system or psychiatric disorders, and drug tolerance. How up to date is the evidence? 
The evidence is up‐to‐date to December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Filippini, G; Minozzi, S; Borrelli, F; Cinquini, M; Dwan, K", "articleTypes": [], "doi": "10.1002/14651858.CD013444.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "8eaf7ee5-879e-4c69-be92-0e5c8b2854f6", "pmid": "", "title": "Optimum duration of regimens for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background The optimal duration for Helicobacter pylori (H. pylori) eradication therapy is controversial, with recommendations ranging from 7 to 14 days. Several systematic reviews have attempted to address this issue but have given conflicting results and limited their analysis to proton pump inhibitor (PPI), two antibiotics (PPI triple) therapy. We performed a systematic review and meta‐analysis to investigate the optimal duration of multiple H. pylori eradication regimens. Objectives The primary objective was to assess the relative effectiveness of different durations (7, 10 or 14 days) of a variety of regimens for eradicating H. pylori . The primary outcome was H. pylori persistence. The secondary outcome was adverse events. Search methods The Cochrane Library , MEDLINE, EMBASE, and CINAHL were searched up to December 2011 to identify eligible randomised controlled trials (RCTs). We also searched the proceedings of six conferences from 1995 to 2011, dissertations and theses, and grey literature. There were no language restrictions applied to any search. Selection criteria Only parallel group RCTs assessing the efficacy of one to two weeks duration of first line H. pylori eradication regimens in adults were eligible. Within each regimen, the same combinations of drugs at the same dose were compared over different durations. Studies with at least two arms comparing 7, 10, or 14 days were eligible. Enrolled participants needed to be diagnosed with at least one positive test for H. pylori on the basis of a rapid urease test (RUT), histology, culture, urea breath test (UBT), or a stool antigen test (HpSA) before treatment. Eligible trials needed to confirm eradication of H. pylori as their primary outcome at least 28 days after completion of eradication treatment. Trials using only serology or a polymerase chain reaction (PCR) to determine H. pylori infection or eradication were excluded. Data collection and analysis Study eligibility and data extraction were performed by two independent review authors. Data analyses were performed within each type of intervention, for both primary and secondary outcomes. The relative risk (RR) and number needed to treat (NNT)/number needed to harm (NNTH) according to duration of therapy were calculated using the outcomes of H. pylori persistence and adverse events. A random‐effects model was used. Subgroup analyses and sensitivity analyses were planned a priori. Main results In total, 75 studies met the inclusion criteria. Eight types of regimens were reported with at least two comparative eligible durations. They included: PPI + two antibiotics triple therapy (n = 59), PPI bismuth‐based quadruple therapy (n = 6), PPI + three antibiotics quadruple therapy (n = 1), PPI dual therapy (n = 2), histamine H 2 ‐receptor antagonist (H 2 RA) bismuth quadruple therapy (n = 3), H 2 RA bismuth‐based triple therapy (n = 2), H 2 RA + two antibiotics triple therapy (n = 3), and bismuth + two antibiotics triple therapy (n = 2). Some studies provided data for more than one regimen or more than two durations. For the PPI triple therapy, 59 studies with five regimens were reported: PPI + clarithromycin + amoxicillin (PCA); PPI + clarithromycin + a nitroimidazole (PCN); PPI + amoxicillin + nitroimidazole (PAN); PPI + amoxicillin + a quinolone (PAQ); and PPI + amoxicillin + a nitrofuran (PANi). Regardless of type and dose of antibiotics, increased duration of PPI triple therapy from 7 to 14 days significantly increased the H. pylor i eradication rate (45 studies, 72.9% versus 81.9%), the RR for H. pylori persistence was 0.66 (95% CI 0.60 to 0.74), NNT was 11 (95% CI 9 to 14). Significant effects were seen in the subgroup of PCA (34 studies, RR 0.65, 95% CI 0.57 to 0.75; NNT 12, 95% CI 9 to 16); PAN (10 studies, RR 0.67, 95% CI 0.52 to 0.86; NNT = 11, 95% CI 8 to 25); and in PAQ (2 studies, RR 0.37, 95% CI 0.16 to 0.83; NNT 3, 95% CI 2 to 10); but not in PCN triple therapy (4 studies, RR 0.87, 95% CI 0.71 to 1.07). Significantly increased eradication rates were also seen for PPI triple therapy with 10 versus 7 days (24 studies, 79.9% versus 75.7%; RR 0.80, 95% CI 0.72 to 0.89; NNT 21, 95% CI 15 to 38) and 14 versus 10 days (12 studies, 84.4% versus 78.5%; RR 0.72, 95% CI 0.58 to 0.90; NNT 17, 95% CI 11 to 46); especially in the subgroup of PAC for 10 versus 7 days (17 studies, RR 0.80, 95% CI 0.70 to 0.91) and for 14 versus 10 days (10 studies, RR 0.69, 95% CI 0.52 to 0.91). A trend towards increased H. pylori eradication rates was seen with increased duration of PCN for 10 versus 7 days, and of PAN for 10 versus 7 days and 14 versus 10 days, though this was not statistical significant. The proportion of patients with adverse events, defined by authors, was marginally significantly increased only between 7 days and 14 days (15.5% versus 19.4%; RR 1.21, 95% CI 1.06 to 1.37; NNTH 31, 95% CI 18 to 104) but not for other duration comparisons. The proportion of patients discontinuing treatment due to adverse events was not significantly different between treatment durations. Only limited data were reported for different durations of regimens other than PPI triple therapy. No significant difference of the eradication rate was seen for all regimens according to different durations except for H 2 RA bismuth quadruple therapy, where a significantly higher eradication rate was seen for 14 days versus 7 days, however only one study reported outcome data. Authors' conclusions Increasing the duration of PPI‐based triple therapy increases H. pylori eradication rates. For PCA, prolonging treatment duration from 7 to 10 or from 10 to 14 days is associated with a significantly higher eradication rate. The optimal duration of therapy for PCA and PAN is at least 14 days. More data are needed to confirm if there is any benefit of increasing the duration of therapy for PCN therapy. Information is limited for regimens other than PPI triple therapy; more studies are needed to draw meaningful conclusions for optimal duration of other H. pylori eradication regimens. Plain language summary Ideal length of treatment for Helicobacter pylori ( H. pylori ) eradication The ideal duration of therapy for H. pylori eradication is controversial, with recommendations ranging from 7 to 14 days. A proton pump inhibitor (PPI) plus two antibiotics is the most commonly used first treatment to remove H. pylori infection. Current data suggest that increasing the length of treatment to 14 days of a PPI plus amoxicillin and clarithromycin or amoxicillin and a nitroimidazole significantly increases the eradication rate, while increasing the adverse events by a small amount. Based on the overall evidence, the ideal length of treatment with a PPI plus amoxicillin and clarithromycin is at least 14 days.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Yuan, Y, Ford, AC, Khan, KJ, Gisbert, JP, Forman, D, Leontiadis, GI, Tse, F, Calvet, X, Fallone, C, Fischbach, L, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD008337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.727Z" }, { "id": "8eb8a091-fe91-484e-9ba0-401259e01d4a", "pmid": "", "title": "Vitamin B12 supplementation for growth, development, and cognition in children", "imported": false, "abstract": "Abstract - Rationale Vitamin B 12 deficiency is an important public health problem in children, and has been associated with anaemia and impaired growth, cognition, and development. Vitamin B 12 deficiency may develop in children due to lower content in breast milk, low dietary intake, and as requirements increase with age. Vitamin B 12 supplementation may confer benefits to child growth and development, due to its role in DNA synthesis and methylation, red blood cell formation, and folate metabolism. However, no systematic reviews have been conducted to examine the effects of vitamin B 12 supplementation in children. Objectives To determine the effects of vitamin B 12 supplementation on growth, development, and cognition in children less than 12 years of age. Search methods We searched CENTRAL, MEDLINE, Embase, 12 other databases, and two trial registries on 23 September 2025. We screened reference lists of studies. Eligibility criteria We included randomised controlled trials evaluating the effects of oral vitamin B 12 supplementation, alone or in combination with other micronutrients, in children < 12 years of age. We excluded cross‐over trials, trials targeting pregnant or breastfeeding women, or participants with critical illnesses, and interventions delivered by intravenous/intramuscular injections. Outcomes Critical outcomes were vitamin B 12 status, anaemia, haemoglobin, growth, cognitive function, developmental outcomes, and any adverse effects. Important outcomes included megaloblastic anaemia, body composition, health‐related quality of life, morbidity, and all‐cause mortality. Risk of bias We used Cochrane RoB 2 to evaluate bias. Synthesis methods We conducted meta‐analyses using fixed‐effect models. If there was substantial heterogeneity, we used random‐effect models. When meta‐analyses were not conducted, we described findings from individual trials, and considered synthesis and presentation of findings using other methods. We used GRADE to evaluate the certainty of evidence for critical outcomes. Included studies We included 16 trials (4083 children; 2 days to 11 years) in 10 countries, including India, Japan, Thailand, Nepal, United Kingdom, Italy, Spain, the United States, El Salvador, and Guatemala. Follow‐up periods for outcomes in most studies ranged from five weeks to 31 months, with one study extending follow‐up to nine years. Duration of vitamin B 12 supplementation varied, ranging from 28 days to 31 months, with doses from 0.9 µg/day to 150 µg/day. Nine trials, including 2391 children, contributed data to meta‐analyses. Synthesis of results Supplementation with vitamin B 12 alone versus placebo There may be little to no difference between groups in height/length (mean difference (MD) ‐0.19 cm, 95% confidence interval (CI) ‐2.44 to 2.06; 2 trials, 143 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (standardised mean difference (SMD) 0.09, 95% CI ‐0.10 to 0.28; 2 trials, 438 children, low‐certainty evidence). There may be little to no difference between groups in motor skill development (6 to 9 years, NEuroPSYchological assessment, Second Edition (NEPSY‐II); 1 trial, 403 children, low‐certainty evidence). Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency (absolute risk difference (ARD) 56 fewer per 1000, 95% CI 68 fewer to 24 fewer; 1.8% versus 7.6%; risk ratio (RR) 0.27, 95% CI 0.11 to 0.69; 3 trials, 642 children; high‐certainty evidence), and probably increases total vitamin B 12 concentrations (MD 68.53 pmol/L, 95% CI 41.83 to 95.23; 7 trials, 705 children; moderate‐certainty evidence), compared to placebo, with an average increase of 68.5 pmol/L. There may be little to no difference between groups in anaemia (ARD 21 more per 1000, 95% CI 26 fewer to 191 more; 9.1% versus 4.5%; RR 1.48, 95% CI 0.41 to 5.27; 2 trials, 144 children; low‐certainty evidence). No trials reported the occurrence of any adverse effects. Supplementation with vitamin B 12 alone versus no intervention The evidence is very uncertain about the effects of vitamin B 12 on height/length (2 trials, 70 children; very low‐certainty evidence), compared to no intervention. No trials reported data for the other critical outcomes. Supplementation with vitamin B 12 and other micronutrients, compared to the same formulation without vitamin B 12 There may be little to no difference between groups in height/length (MD ‐0.22 cm, 95% CI ‐0.65 to 0.20; 2 trials, 608 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (SMD 0.00, 95% CI ‐0.13 to 0.13; 3 trials, 956 children; low‐certainty evidence). There may be little to no difference between groups in development outcomes (e.g. motor skill development) (SMD ‐0.05, 95% CI ‐0.18 to 0.08; 2 trials, 960 children; low‐certainty evidence). Children who received vitamin B 12 supplementation and other micronutrients may have little to no difference in vitamin B 12 deficiency (ARD 2 fewer per 1000, 95% CI 7 fewer to 32 more; 0.7% versus 0.8%; RR 0.77, 95% CI 0.12 to 5.16; 2 trials, 534 children; low‐certainty evidence), or total vitamin B 12 concentrations (MD 34.32 pmol/L, 95% CI ‐31.13 to 99.77; 3 trials, 731 children; low‐certainty evidence), compared to supplements without vitamin B 12 . There may be little to no difference between groups in anaemia (21.7% versus 25.0%; 1 trial, 35 children; low‐certainty evidence). There may be little to no difference between groups in any adverse effects (9.2% versus 5.9%; 1 trial, 574 children; low‐certainty evidence). The certainty of evidence for critical outcomes ranged from high to very low; we downgraded for imprecision due to small sample sizes or few events, risk of bias in outcome measurement, randomisation methods, selective reporting bias, or inconsistency due to substantial statistical heterogeneity. Few studies reported growth, cognition, development, anaemia, or any adverse effects. Authors' conclusions Vitamin B 12 supplementation (alone or when supplemented with other micronutrients) in children may have little to no effect on growth (i.e. height/length), cognitive function (e.g. attention), development outcomes (e.g. motor skill development), or anaemia, compared to placebo, no intervention, or the same supplements without vitamin B 12 . Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency and probably improves total vitamin B 12 concentrations, compared to placebo. However, vitamin B 12 supplementation with other micronutrients may result in little to no difference in vitamin B 12 deficiency and total vitamin B 12 concentrations, compared to the same formulation without vitamin B 12 . Funding This review had no dedicated funding. Registration Protocol available via DOI 10.1002/14651858.CD015264. Plain language summary What are the effects of vitamin B 12 supplementation for children less than 12 years of age? Key messages Vitamin B 12 supplementation reduces the risk of vitamin B 12 deficiency, and probably improves vitamin B 12 levels in children less than 12 years of age, compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient) (that is, children who did not take vitamin B 12 supplements). Vitamin B 12 supplements, with other micronutrients (important vitamins and minerals the body needs in small amounts to function), may result in little to no difference in vitamin B 12 deficiency or total vitamin B 12 levels, compared to children who received the same supplements without vitamin B 12 . The impact of vitamin B 12 supplements on other health outcomes in children is less clear. What is vitamin B 12 ? Vitamin B 12 is an important nutrient that helps make red blood cells and keep the body's cells and nerves healthy. Vitamin B 12 deficiency is an important public health problem, including in children and in resource‐poor settings. Lower vitamin B 12 levels in children have been linked to anaemia (lower haemoglobin levels), and poorer growth, development, and cognition (a child's ability to gain knowledge through thought, understanding, and the senses). What did we want to find out? We wanted to find out if taking vitamin B 12 supplements would improve the nutrition and health of children less than 12 years of age. What did we do? We searched for studies that looked at the effects of vitamin B 12 compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient), no intervention, or the same supplements without vitamin B 12 . We summarised the results of the studies and our confidence in the evidence, based on information such as how the study was done. What did we find? We included 16 studies involving 4083 children less than 12 years of age (2 days to 11 years). Nine studies, including 2391 children, had data that we could analyse. The studies were conducted in 10 countries around the world. In most studies, the outcomes were assessed immediately after the intervention from five weeks to 31 months, with one study assessing outcomes after nine years. Vitamin B 12 supplements were provided from 28 days to 31 months in amounts from 0.9 to 150 micrograms a day. Supplementation with vitamin B 12 alone versus placebo There may be little to no difference in height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplements had less vitamin B 12 deficiency, and probably had higher vitamin B 12 levels, compared to placebo. There may be little to no difference between groups in anaemia. No studies provided data on any unwanted (adverse) effects. Vitamin B 12 alone versus no intervention The evidence is very uncertain for height/length. No studies reported data we could analyse for other outcomes. Vitamin B 12 and other micronutrients, compared to supplements with the same supplement without vitamin B 12 There may be little to no difference between groups for height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplementation (with other nutrients) may have little to no difference in vitamin B 12 deficiency, vitamin B 12 levels, anaemia, or any unwanted effects. What are the limitations of the evidence? The small number and the size of studies were limitations of this review. Few studies reported on health outcomes, including growth, cognition, development, anaemia, or any adverse effects. The different ages of children, and differences in the amount of vitamin B 12 and when the outcomes were measured, are also limitations of this review. How up to date is this evidence? The evidence is up to date as of 23 September 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Larvie, DY; Güitrón Leal, CE; Venkatramanan, S; Palma Molina, XE; Steel, LB; Kuriyan, R; Finkelstein, JL", "articleTypes": [], "doi": "10.1002/14651858.CD015264.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "8ebda8be-5272-4769-9da6-c8b4499af1f7", "pmid": "", "title": "ATATURK UNİVERSITY", "imported": false, "abstract": "'Pandemic' is a medical term that has become a ubiquitous part of the global vocabulary over the last year. Although pandemics have occurred throughout human history, their sociocultural, economic, and psychological impact can leave lasting damage. In the current COVID-19 pandemic, more than 200 million confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported to date. While most people present with mild symptoms such as loss of taste and smell, sore throat, joint pain, and headache, it can cause serious morbidity and mortality, especially in individuals over 65 years of age and those with comorbidities .", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.269Z" }, { "id": "8eddb99a-c6fb-4f11-8033-54dd3d549372", "pmid": "", "title": "Interventions for protecting renal function in the perioperative period", "imported": false, "abstract": "Abstract - Background Various methods have been used to try to protect kidney function in patients undergoing surgery. These most often include pharmacological interventions such as dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants and erythropoietin (EPO). Objectives This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period. We considered the following questions: (1) Are any specific measures known to protect kidney function during the perioperative period? (2) Of measures used to protect the kidneys during the perioperative period, does any one method appear to be more effective than the others? (3) Of measures used to protect the kidneys during the perioperative period,does any one method appear to be safer than the others? Search methods In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 2, 2012), MEDLINE (Ovid SP) (1966 to August 2012) and EMBASE (Ovid SP) (1988 to August 2012). We originally handsearched six journals ( Anesthesia and Analgesi a, Anesthesiology , Annals of Surgery , British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery) (1985 to 2004). However, because these journals are properly indexed in MEDLINE, we decided to rely on electronic searches only without handsearching the journals from 2004 onwards. Selection criteria We selected all randomized controlled trials in adults undergoing surgery for which a treatment measure was used for the purpose of providing renal protection during the perioperative period. Data collection and analysis We selected 72 studies for inclusion in this review. Two review authors extracted data from all selected studies and entered them into RevMan 5.1; then the data were appropriately analysed. We performed subgroup analyses for type of intervention, type of surgical procedure and pre‐existing renal dysfunction. We undertook sensitivity analyses for studies with high and moderately good methodological quality. Main results The updated review included data from 72 studies, comprising a total of 4378 participants. Of these, 2291 received some form of treatment and 2087 acted as controls. The interventions consisted most often of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, NAC, ANP, sodium bicarbonate, antioxidants and EPO or selected hydration fluids. Some clinical heterogeneity and varying risk of bias were noted amongst the studies, although we were able to meaningfully interpret the data. Results showed significant heterogeneity and indicated that most interventions provided no benefit. Data on perioperative mortality were reported in 41 studies and data on acute renal injury in 44 studies (all interventions combined). Because of considerable clinical heterogeneity (different clinical scenarios, as well as considerable methodological variability amongst the studies), we did not perform a meta‐analysis on the combined data. Subgroup analysis of major interventions and surgical procedures showed no significant influence of interventions on reported mortality and acute renal injury. For the subgroup of participants who had pre‐existing renal damage, the risk of mortality from 10 trials (959 participants) was estimated as odds ratio (OR) 0.76, 95% confidence interval (CI) 0.38 to 1.52; the risk of acute renal injury (as reported in the trials) was estimated from 11 trials (979 participants) as OR 0.43, 95% CI 0.23 to 0.80. Subgroup analysis of studies that were rated as having low risk of bias revealed that 19 studies reported mortality numbers (1604 participants); OR was 1.01, 95% CI 0.54 to 1.90. Fifteen studies reported data on acute renal injury (criteria chosen by the individual studies; 1600 participants); OR was 1.03, 95% CI 0.54 to 1.97. Authors' conclusions No reliable evidence from the available literature suggests that interventions during surgery can protect the kidneys from damage. However, the criteria used to diagnose acute renal damage varied in many of the older studies selected for inclusion in this review, many of which suffered from poor methodological quality such as insufficient participant numbers and poor definitions of end points such as acute renal failure and acute renal injury. Recent methods of detecting renal damage such as the use of specific biomarkers and better defined criteria for identifying renal damage (RIFLE (risk, injury, failure, loss of kidney function and end‐stage renal failure) or AKI (acute kidney injury)) may have to be explored further to determine any possible benefit derived from interventions used to protect the kidneys during the perioperative period. Plain language summary No evidence indicates that any of the measures used to protect patients' kidneys during the perioperative period are beneficial The kidneys may be damaged during an operation as a result of direct and indirect insult. The reasons for this are multiple and include changes to physiology brought on by the surgery and by the body’s response to such insult. Damage to kidneys during the perioperative period is associated with significant morbidity and mortality. This updated Cochrane review looked at 72 randomized controlled trials (RCTs) with 4378 participants (search data until August 2012); interventions most often included pharmacological interventions (administration of dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine, atrial natriuretic peptide, sodium bicarbonate, antioxidants and erythropoietin) or selected hydration fluids. We attempted to identify any possible damage to the kidneys by evaluating kidney function up to seven days after the operation. No clear evidence from available RCTs suggests that any of the measures used to protect the kidneys during the perioperative period are beneficial. These findings held true in 14 studies of patients with pre‐existing renal damage and in 24 studies that were considered of good methodological quality. The primary outcomes of these studies were mortality and acute renal injury. Reported mortality in studies with low risk of bias was not different between intervention and control groups (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.52 to 1.97) or for acute renal injury (OR 1.05, 95% CI 0.55 to 2.03). The summary of findings revealed a similar picture. So we conclude that evidence suggests that none of the interventions used currently are helpful in protecting the kidneys during the perioperative period, nor do they cause increased harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zacharias, M, Mugawar, M, Herbison, GP, Walker, RJ, Hovhannisyan, K, Sivalingam, P, Conlon, NP", "articleTypes": [], "doi": "10.1002/14651858.CD003590.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.100Z" }, { "id": "8f104824-df75-4dc5-ac9e-80f4b866304e", "pmid": "", "title": "The Effects of Genetic Variation in the Bitter and Fat Taste Receptor Genes on Taste Perception, Dietary Behaviour and Obesity Status", "imported": false, "abstract": "Obesity is an increasing problem for adults in the UK. Diets high in fat and sugar are the major contributors to weight gain. Individual differences in taste perception are a crucial factor in determining the investigator's choice of foods and an individual's sensitivity to the either bitter or fat taste compounds has been linked to a preference for different foods including sweet and high fat foods. Previous research has not comprehensively explored the effect of both fat and bitter taste sensitivity on dietary intake and obesity status. Therefore, the aim of this study is to explore the associations between genetics, fat and bitter taste sensitivity, food preference, dietary intake and obesity measures in the adult UK population.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.231Z" }, { "id": "8f12ff3f-1921-4226-8b6d-f285df81fd4b", "pmid": "", "title": "Chewing gum for postoperative recovery of gastrointestinal function", "imported": false, "abstract": "Abstract - Background Ileus commonly occurs after abdominal surgery, and is associated with complications and increased length of hospital stay (LOHS). Onset of ileus is considered to be multifactorial, and a variety of preventative methods have been investigated. Chewing gum (CG) is hypothesised to reduce postoperative ileus by stimulating early recovery of gastrointestinal (GI) function, through cephalo‐vagal stimulation. There is no comprehensive review of this intervention in abdominal surgery. Objectives To examine whether chewing gum after surgery hastens the return of gastrointestinal function. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), MEDLINE (via PubMed), EMBASE (via Ovid), CINAHL (via EBSCO) and ISI Web of Science (June 2014). We hand‐searched reference lists of identified studies and previous reviews and systematic reviews, and contacted CG companies to ask for information on any studies using their products. We identified proposed and ongoing studies from clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform and meta Register of Controlled Trials. Selection criteria We included completed randomised controlled trials (RCTs) that used postoperative CG as an intervention compared to a control group. Data collection and analysis Two authors independently collected data and assessed study quality using an adapted Cochrane risk of bias (ROB) tool, and resolved disagreements by discussion. We assessed overall quality of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Studies were split into subgroups: colorectal surgery (CRS), caesarean section (CS) and other surgery (OS). We assessed the effect of CG on time to first flatus (TFF), time to bowel movement (TBM), LOHS and time to bowel sounds (TBS) through meta‐analyses using a random‐effects model. We investigated the influence of study quality, reviewers’ methodological estimations and use of Enhanced Recovery After Surgery (ERAS) programmes using sensitivity analyses. We used meta‐regression to explore if surgical site or ROB scores predicted the extent of the effect estimate of the intervention on continuous outcomes. We reported frequency of complications, and descriptions of tolerability of gum and cost. Main results We identified 81 studies that comprised 9072 participants for inclusion in our review. We categorised many studies at high or unclear risk of the bias' assessed. There was statistical evidence that use of CG reduced TFF [overall reduction of 10.4 hours (95% CI: ‐11.9, ‐8.9): 12.5 hours (95% CI: ‐17.2, ‐7.8) in CRS, 7.9 hours (95% CI: –10.0, ‐5.8) in CS, 10.6 hours (95% CI: ‐12.7, ‐8.5) in OS]. There was also statistical evidence that use of CG reduced TBM [overall reduction of 12.7 hours (95% CI: ‐14.5, ‐10.9): 18.1 hours (95% CI: ‐25.3, ‐10.9) in CRS, 9.1 hours (95% CI: ‐11.4, ‐6.7) in CS, 12.3 hours (95% CI: ‐14.9, ‐9.7) in OS]. There was statistical evidence that use of CG slightly reduced LOHS [overall reduction of 0.7 days (95% CI: ‐0.8, ‐0.5): 1.0 days in CRS (95% CI: ‐1.6, ‐0.4), 0.2 days (95% CI: ‐0.3, ‐0.1) in CS, 0.8 days (95% CI: ‐1.1, ‐0.5) in OS]. There was statistical evidence that use of CG slightly reduced TBS [overall reduction of 5.0 hours (95% CI: ‐6.4, ‐3.7): 3.21 hours (95% CI: ‐7.0, 0.6) in CRS, 4.4 hours (95% CI: ‐5.9, ‐2.8) in CS, 6.3 hours (95% CI: ‐8.7, ‐3.8) in OS]. Effect sizes were largest in CRS and smallest in CS. There was statistical evidence of heterogeneity in all analyses other than TBS in CRS. There was little difference in mortality, infection risk and readmission rate between the groups. Some studies reported reduced nausea and vomiting and other complications in the intervention group. CG was generally well‐tolerated by participants. There was little difference in cost between the groups in the two studies reporting this outcome. Sensitivity analyses by quality of studies and robustness of review estimates revealed no clinically important differences in effect estimates. Sensitivity analysis of ERAS studies showed a smaller effect size on TFF, larger effect size on TBM, and no difference between groups for LOHS. Meta‐regression analyses indicated that surgical site is associated with the extent of the effect size on LOHS (all surgical subgroups), and TFF and TBM (CS and CRS subgroups only). There was no evidence that ROB score predicted the extent of the effect size on any outcome. Neither variable explained the identified heterogeneity between studies. Authors' conclusions This review identified some evidence for the benefit of postoperative CG in improving recovery of GI function. However, the research to date has primarily focussed on CS and CRS, and largely consisted of small, poor quality trials. Many components of the ERAS programme also target ileus, therefore the benefit of CG alongside ERAS may be reduced, as we observed in this review. Therefore larger, better quality RCTS in an ERAS setting in wider surgical disciplines would be needed to improve the evidence base for use of CG after surgery. Plain language summary Chewing gum after surgery to help recovery of the digestive system Background When people have surgery on their abdomen, the digestive system can stop working for a few days. This is called ileus, and can be painful and uncomfortable. There are different causes of ileus, and several ways of treating or preventing it. One possible way of preventing ileus is by chewing gum. The idea is that chewing gum tricks the body into thinking it is eating, causing the digestive system to start working again. It is important to do this review because ileus is common: it is estimated that up to a third of people having bowel surgery suffer from ileus. Main Findings This review found 81 relevant studies that recruited over 9000 participants in total. The studies mainly focussed on people having bowel surgery or caesarean section, but there were some studies of other surgery types. There were few studies of children. Most studies were of poor quality, which may mean their results are less reliable. We found some evidence that people who chewed gum after an operation were able to pass wind and have bowel movements sooner than people who did not chew gum. We also found some evidence that people who chewed gum after an operation had bowel sounds (gurgling sounds heard using a stethoscope held to the abdomen) slightly sooner than people who did not chew gum. There was a small difference in how long people stayed in hospital between people who did or did not chew gum. There were no differences in complications (such as infection or death) between people who did or did not chew gum. There was also no difference in the overall cost of treatment between people who did or did not chew gum. Conclusions There is some evidence that chewing gum after surgery may help the digestive system to recover. However, the studies included in this review are generally of poor quality, which meant that their results may not be reliable. We also know that there are many factors affecting ileus, and that modern treatment plans attempt to reduce risk of ileus. Therefore to further explore using chewing gum after surgery, more studies would be needed which are larger, of better quality, include different types of surgery, and consider recent changes in health care systems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Short, V, Herbert, G, Perry, R, Atkinson, C, Ness, AR, Penfold, C, Thomas, S, Andersen, HK, Lewis, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD006506.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.753Z" }, { "id": "8f13772b-f89b-4fb2-8a87-3db2d47e9579", "pmid": "", "title": "Zolmitriptan for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a common, disabling condition and a burden for the individual, health services, and society. Zolmitriptan is an abortive medication for migraine attacks, belonging to the triptan family. These medicines work in a different way to analgesics such as paracetamol and ibuprofen. Objectives To determine the efficacy and tolerability of zolmitriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, and the Oxford Pain Relief Database, together with three online databases ( www.astrazenecaclinicaltrials.com , www.clinicaltrials.gov , and apps.who.int/trialsearch ) for studies to 12 March 2014. We also searched the reference lists of included studies and relevant reviews. Selection criteria We included randomised, double‐blind, placebo‐ or active‐controlled studies, with at least 10 participants per treatment arm, using zolmitriptan to treat a migraine headache episode. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate risk ratios and numbers needed to treat for an additional beneficial effect (NNT) or harmful effect (NNH) compared with placebo or a different active treatment. Main results Twenty‐five studies (20,162 participants) compared zolmitriptan with placebo or an active comparator. The evidence from placebo‐controlled studies was of high quality for all outcomes except 24 hour outcomes and serious adverse events where only limited data were available. The majority of included studies were at a low risk of performance, detection and attrition biases, but did not adequately describe methods of randomisation and concealment. Most of the data were for the 2.5 mg and 5 mg doses compared with placebo, for treatment of moderate to severe pain. For all efficacy outcomes, zolmitriptan surpassed placebo. For oral zolmitriptan 2.5 mg versus placebo, the NNTs were 5.0, 3.2, 7.7, and 4.1 for pain‐free at two hours, headache relief at two hours, sustained pain‐free during the 24 hours postdose, and sustained headache relief during the 24 hours postdose, respectively. Results for the oral 5 mg dose were similar to the 2.5 mg dose, while zolmitriptan 10 mg was significantly more effective than 5 mg for pain‐free and headache relief at two hours. For headache relief at one and two hours and sustained headache relief during the 24 hours postdose, but not pain‐free at two hours, zolmitriptan 5 mg nasal spray was significantly more effective than the 5 mg oral tablet. For the most part, adverse events were transient and mild and were more common with zolmitriptan than placebo, with a clear dose response relationship (1 mg to 10 mg). High quality evidence from two studies showed that oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people as oral sumatriptan 50 mg (66%, 67%, and 68% respectively), although not necessarily the same individuals. There was no significant difference in numbers experiencing adverse events. Single studies reported on other active treatment comparisons but are not described further because of the small amount of data. Authors' conclusions Zolmitriptan is effective as an abortive treatment for migraine attacks for some people, but is associated with increased adverse events compared to placebo. Zolmitriptan 2.5 mg and 5 mg benefited the same proportion of people as sumatriptan 50 mg, although not necessarily the same individuals, for headache relief at two hours. Plain language summary Zolmitriptan for acute migraine attacks in adults Migraine is a complex condition with a wide variety of symptoms. It affects about 1 person in 8, mainly women aged 30 to 50 years. For many people, the main feature is a painful, and often disabling, headache. Other symptoms include feeling sick, vomiting, disturbed vision, and sensitivity to light, sound, and smells. Zolmitriptan is one of the triptan family of drugs. It is used to treat migraine attacks when they occur, not to prevent attacks occurring. It is available as an oral tablet to swallow whole, an oral tablet to dissolve in the mouth, and a nasal spray. This review looked at 25 studies that involved over 20,000 participants reporting the effects of zolmitriptan on migraine attacks. Most information was for tablets taken by mouth. Overall methodological quality of the included studies was good, and treatment group sizes were large enough to avoid major bias. There were inconsistencies in the way use of rescue medication and adverse events were reported. A single oral dose of zolmitriptan relieved migraine headache pain in some people. Several different pain outcomes were reported. One outcome was pain reduced from moderate or severe to no pain at all two hours after taking treatment. An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 3 in 10 people (30%), compared with about 1 in 10 (10%) taking placebo. Another outcome was pain reduced from moderate or severe to no worse than mild pain two hours after taking treatment (called headache relief). An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 6 in 10 people (61%), compared with 3 in 10 (29%) taking placebo. Slightly better results were obtained with higher doses of 5 mg or 10 mg oral tablets, but the 10 mg dose was associated with more adverse events, most of which were of short duration and mild or moderate in severity. Results for the 5 mg nasal spray were generally similar to those for the oral tablet, but it was significantly better than the tablet at 1 hour. People with migraine want treatment that eliminates the headache and any associated symptoms quickly (maximum two hours) and prevents it returning (within 24 hours). Results indicate that with the 5 mg dose only 14% of those treated were pain‐free at 2 hours with no headache recurrence within 24 hours. Oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people (2 in 3) as oral sumatriptan 50 mg, with no difference in numbers experiencing adverse events. The individuals who respond to each drug may not be the same.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bird, S, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.764Z" }, { "id": "8f1390e8-05b7-48a5-b0e2-2c9ffb16e107", "pmid": "", "title": "Ribavirin monotherapy for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. A high proportion of patients never experience symptoms. Peginterferon plus ribavirin is the recommended treatment for chronic hepatitis C. However, ribavirin monotherapy may be considered for some patients. Objectives To assess the beneficial and harmful effects of ribavirin monotherapy for patients with chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included all randomised trials irrespective of blinding, language, or publication status comparing ribavirin versus no intervention, placebo, or interferon for chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained virological response (loss of hepatitis C virus RNA at least six months after treatment), liver‐related morbidity plus all‐cause mortality, and adverse events. Secondary outcome measures were end of treatment virological response, biochemical response (transaminase activity), and histological response. Randomisation methods, blinding, data handling, and funding were extracted as measures of bias control. Random‐effects and fixed‐effect meta‐analyses were performed for all outcomes. We only present the results of the fixed‐effect model if both models provide the same result regarding statistical significance. We present data as risk difference (RD) with 95% confidence intervals (CI). Main results We included 14 randomised trials with 657 patients. The majority of trials had unclear control of bias. Compared with placebo or no intervention, ribavirin had no significant effect on the sustained virological response (RD 0%, 95% CI ‐2% to 3%, five trials) or end of treatment virological response (RD 0% 95% CI ‐3% to 3%, ten trials). Ribavirin had no significant effect on liver‐related morbidity plus mortality (RD 0%, 95% CI ‐2% to 3%, 11 trials). Ribavirin significantly increased the risk of adverse reactions, including anaemia. Ribavirin significantly improved end of treatment biochemical and histological response but not the sustained biochemical response. Ribavirin was significantly inferior to interferon regarding virological and biochemical responses (five trials). Authors' conclusions Ribavirin seems without beneficial effects on serum virological response and liver‐related morbidity or mortality, and significantly increased the risk of adverse reactions. Ribavirin monotherapy seems significantly inferior to interferon monotherapy. The total number of included patients is small, and more trials are perhaps needed. The use of ribavirin monotherapy for chronic hepatitis C cannot be recommended outside randomised trials. Plain language summary Treatment of patients infected with hepatitis C virus Globally, about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behaviour, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die from it. Treatment with interferon clears hepatitis C virus from the blood in about 15% of the patients. Adding ribavirin to interferon (combination therapy) significantly improves the number that clears hepatitis C from the blood to about 40%. Not all patients are tolerant to interferon, and also interferon is costly. This is why ribavirin given as a single drug may be considered as an option for patients with chronic hepatitis C. This review identified 11 randomised trials comparing ribavirin with no antiviral treatment in patient with chronic hepatitis C. Combining the results from all identified trials ribavirin alone seemed without beneficial effects for patients with chronic hepatitis C. Moreover, ribavirin given alone was significantly inferior compared with interferon regarding clearing hepatitis C from the blood and regarding reducing liver enzymes activity in the blood. Furthermore, ribavirin given alone increased the risk of anaemia. Thus, ribavirin given alone cannot be recommended, but more trials may be needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brok, J, Gluud, LL, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005527.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.100Z" }, { "id": "8f196e42-80e7-42fc-baef-35327e12a4e5", "pmid": "", "title": "Probiotics for the prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wei, D, Heus, P, van de Wetering, FT, van Tienhoven, G, Verleye, L, Scholten, RJPM", "articleTypes": [], "doi": "10.1002/14651858.CD008831.pub3 AB - Abstract - Background Treament‐related diarrhoea is one of the most common and troublesome adverse effects related to chemotherapy or radiotherapy in people with cancer. Its reported incidence has been as high as 50% to 80%. Severe treatment‐related diarrhoea can lead to fluid and electrolyte losses and nutritional deficiencies and could adversely affect quality of life (QoL). It is also associated with increased risk of infection in people with neutropenia due to anticancer therapy and often leads to treatment delays, dose reductions, or treatment discontinuation. Probiotics may be effective in preventing or treating chemotherapy‐ or radiotherapy‐induced diarrhoea. Objectives To evaluate the clinical effectiveness and side effects of probiotics used alone or combined with other agents for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 7), MEDLINE (1946 to July week 2, 2017), and Embase (1980 to 2017, week 30). We also searched prospective clinical trial registers and the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) investigating the effects of probiotics for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Data collection and analysis Two review authors independently selected studies, extracted data, and assessed risk of bias. We used random‐effects models for all meta‐analyses. If meta‐analysis was not possible, we summarised the results narratively. Main results We included 12 studies involving 1554 participants. Eleven studies were prevention studies, of which seven compared probiotics with placebo (887 participants), one compared two doses of probiotics with each other and with placebo (246 participants), and three compared probiotics with another active agent (216 participants).The remaining study assessed the effectiveness of probiotics compared with placebo for treatment of radiotherapy‐related diarrhoea (205 participants). For prevention of radiotherapy (with or without chemotherapy)‐induced diarrhoea, review authors identified five heterogeneous placebo‐controlled studies (with 926 participants analysed). Owing to heterogeneity, we could not carry out a meta‐analysis, except for two outcomes. For occurrence of any diarrhoea, risk ratios (RRs) ranged from 0.35 (95% confidence interval (CI) 0.26 to 0.47) to 1.0 (95% CI 0.94 to 1.06) (three studies; low‐certainty evidence). A beneficial effect of probiotics on quality of life could neither be demonstrated nor refuted (two studies; low‐certainty evidence). For occurrence of grade 2 or higher diarrhoea, the pooled RR was 0.75 (95% CI 0.55 to 1.03; four studies; 420 participants; low‐certainty evidence), and for grade 3 or higher diarrhoea, RRs ranged from 0.11 (95% CI 0.06 to 0.23) to 1.24 (95% CI 0.74 to 2.08) (three studies; low‐certainty evidence). For probiotic users, time to rescue medication was 36 hours longer in one study (95% CI 34.7 to 37.3), but another study reported no difference (moderate‐certainty evidence). For the need for rescue medication, the pooled RR was 0.50 (95% CI 0.15 to 1.66; three studies; 194 participants; very low‐certainty evidence). No study reported major differences between groups with respect to adverse effects. Although not mentioned explicitly, no studies reported deaths, except one in which one participant in the probiotics group died of myocardial infarction after three sessions of radiotherapy. Three placebo‐controlled studies, with 128 analysed participants, addressed prevention of chemotherapy‐induced diarrhoea. For occurrence of any diarrhoea, the pooled RR was 0.59 (95% CI 0.36 to 0.96; two studies; 106 participants; low‐certainty evidence). For all other outcomes, a beneficial effect of probiotics could be neither demonstrated nor refuted (one to two studies; 46 to 106 participants; all low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. Three studies compared probiotics with another intervention in 213 participants treated with radiotherapy (with or without chemotherapy). One very small study (21 participants) reported less diarrhoea six weeks after treatment when dietary counselling was provided (RR 0.30, 95% CI 0.11 to 0.81; very low‐certainty evidence). In another study (148 participants), grade 3 or 4 diarrhoea occurred less often in the probiotics group than in the control group (guar gum containing nutritional supplement) (odds ratio (OR) 0.38, 95% CI 0.16 to 0.89; low‐certainty evidence), and two studies (63 participants) found less need for rescue medication of probiotics versus another active treatment (RR 0.44, 95% CI 0.22 to 0.86; very low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. One placebo‐controlled study with 205 participants addressed treatment for radiotherapy‐induced diarrhoea and could not demonstrate or refute a beneficial effect of probiotics on average diarrhoea grade, time to rescue medication for diarrhoea (13 hours longer in the probiotics group; 95% CI ‐0.9 to 26.9 hours), or need for rescue medication (RR 0.74, 95% CI 0.53 to 1.03; moderate‐certainty evidence). This study did not address quality of life. No studies reported serious adverse events or diarrhoea‐related deaths. Authors' conclusions This review presents limited low‐ or very low‐certainty evidence supporting the effects of probiotics for prevention and treatment of diarrhoea related to radiotherapy (with or without chemotherapy) or chemotherapy alone, need for rescue medication, or occurrence of adverse events. All studies were underpowered and heterogeneous. Severe side effects were absent from all studies. Robust evidence on this topic must be provided by future methodologically well‐designed trials. Plain language summary Live micro‐organisms for prevention or treatment of diarrhoea in people with cancer who are treated with chemotherapy or radiotherapy Background 
 Up to 80% of people treated with chemotherapy or radiotherapy for cancer suffer from diarrhoea ‐ one of the most common and troublesome side effects. Severe diarrhoea can lead to dehydration (fluid and salts loss) and malnutrition from changes to digestion and bowel habits and could adversely affect quality of life. It is also associated with increased risk of infection in people with low white cell blood count related to cancer treatment. Diarrhoea often leads to delays in cancer treatment or the need to lower the dose or even discontinue cancer treatment. Foods containing live bacteria or yeast (probiotics) might have a beneficial effect on the occurrence and severity of diarrhoea. Aim of the review 
 To evaluate the effects of live micro‐organisms (probiotics) in preventing the occurrence or reducing the severity of diarrhoea in people with cancer who are receiving chemotherapy or radiotherapy. Main findings 
 Overall, the studies we found do not give a clear answer on whether probiotics reduce the occurrence or severity of diarrhoea, improve quality of life, or reduce the need for other medication. However, an analysis of only well‐performed studies demonstrated a beneficial effect for some outcomes. With regard to prevention of diarrhoea compared with placebo in participants treated with radiotherapy with or without chemotherapy, we are not able to conclude whether use of probiotics would be beneficial based on the five relevant studies. For prevention of diarrhoea due to chemotherapy alone, three studies suggested that use of probiotics may not reduce diarrhoea, and one study reported use of less rescue medication for diarrhoea. Three studies that compared probiotics with another agent for preventing diarrhoea in patients treated with radiotherapy with or without chemotherapy found beneficial effects of probiotics for the occurrence and severity of diarrhoea and the need for rescue medication. With respect to treatment of diarrhoea due to radiotherapy, we found only one study that did not demonstrate a clear effect of probiotics compared with placebo. No study reported serious adverse events nor deaths related to diarrhoea. Certainty of the evidence 
 The quality (certainty) of the evidence in prevention studies was low to very low. For the only study that assessed the effects of probiotics on treatment for diarrhoea, the certainty of the evidence was moderate. What are the conclusions? 
 Evidence supporting the effects of probiotics in preventing or treating diarrhoea related to cancer treatment is insufficient. However, probiotics appear to be safe, as no studies have found severe side effects.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.119Z" }, { "id": "8f1f8796-fb89-441e-bcae-796888c18de5", "pmid": "", "title": "Preprocedural mouth rinses for preventing transmission of infectious diseases through aerosols in dental healthcare providers", "imported": false, "abstract": "Abstract - Background Aerosols and spatter are generated in a dental clinic during aerosol‐generating procedures (AGPs) that use high‐speed hand pieces. Dental healthcare providers can be at increased risk of transmission of diseases such as tuberculosis, measles and severe acute respiratory syndrome (SARS) through droplets on mucosae, inhalation of aerosols or through fomites on mucosae, which harbour micro‐organisms. There are ways to mitigate and contain spatter and aerosols that may, in turn, reduce any risk of disease transmission. In addition to personal protective equipment (PPE) and aerosol‐reducing devices such as high‐volume suction, it has been hypothesised that the use of mouth rinse by patients before dental procedures could reduce the microbial load of aerosols that are generated during dental AGPs. Objectives To assess the effects of preprocedural mouth rinses used in dental clinics to minimise incidence of infection in dental healthcare providers and reduce or neutralise contamination in aerosols. Search methods We used standard, extensive Cochrane search methods. The latest search date was 4 February 2022. Selection criteria We included randomised controlled trials and excluded laboratory‐based studies. Study participants were dental patients undergoing AGPs. Studies compared any preprocedural mouth rinse used to reduce contaminated aerosols versus placebo, no mouth rinse or another mouth rinse. Our primary outcome was incidence of infection of dental healthcare providers and secondary outcomes were reduction in the level of contamination of the dental operatory environment, cost, change in mouth microbiota, adverse events, and acceptability and feasibility of the intervention. Data collection and analysis Two review authors screened search results, extracted data from included studies, assessed the risk of bias in the studies and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random‐effects meta‐analysis to combine data Main results We included 17 studies with 830 participants aged 18 to 70 years. We judged three trials at high risk of bias, two at low risk and 12 at unclear risk of bias. None of the studies measured our primary outcome of the incidence of infection in dental healthcare providers. The primary outcome in the studies was reduction in the level of bacterial contamination measured in colony‐forming units (CFUs) at distances of less than 2 m (intended to capture larger droplets) and 2 m or more (to capture droplet nuclei from aerosols arising from the participant's oral cavity). It is unclear what size of CFU reduction represents a clinically significant amount. There is low‐ to very low‐certainty evidence that chlorhexidine (CHX) may reduce bacterial contamination, as measured by CFUs, compared with no rinsing or rinsing with water. There were similar results when comparing cetylpyridinium chloride (CPC) with no rinsing and when comparing CPC, essential oils/herbal mouthwashes or boric acid with water. There is very low‐certainty evidence that tempered mouth rinses may provide a greater reduction in CFUs than cold mouth rinses. There is low‐certainty evidence that CHX may reduce CFUs more than essential oils/herbal mouthwashes. The evidence for other head‐to‐head comparisons was limited and inconsistent. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or adverse events such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess acceptability of the intervention to patients or feasibility of implementation for dentists. Authors' conclusions None of the included studies measured the incidence of infection among dental healthcare providers. The studies measured only reduction in level of bacterial contamination in aerosols. None of the studies evaluated viral or fungal contamination. We have only low to very low certainty for all findings. We are unable to draw conclusions regarding whether there is a role for preprocedural mouth rinses in reducing infection risk or the possible superiority of one preprocedural rinse over another. Studies are needed that measure the effect of rinses on infectious disease risk among dental healthcare providers and on contaminated aerosols at larger distances with standardised outcome measurement. Plain language summary Does use of mouth rinse before a dental procedure reduce the risk of infection transmission from patient to health professional? Why is this question important? Many dental procedures generate droplets that settle on a surface quickly. If high‐speed instruments, such as a drill, are used, aerosols are generated, which consist of tiny particles that remain suspended in the air and that can be inhaled or that settle farther away on surfaces. These aerosols contain a variety of micro‐organisms and may transmit infections either through direct contact or indirectly through the contaminated surfaces. To prevent the spread of infection, it may help to reduce the number of micro‐organisms that are present in these aerosols. The use of mouth rinses before a dental procedure ('preprocedural mouth rinse') has been suggested as a possible way to reduce the amount of contamination of these aerosols. Chlorhexidine, povidone iodine and cetylpyridinium chloride (CPC) are some of the commonly used mouth rinses. They act by killing or inactivating the micro‐organisms in the mouth and thereby reducing the level of contamination in the aerosol that is generated. We wanted to find out whether rinsing the mouth before a dental procedure reduces the contamination of aerosols produced during dental procedures in practice and helps prevent the transmission of infectious diseases. How did we identify and evaluate the evidence? We searched for all relevant studies that compared mouth rinses used before dental procedures against placebo (fake treatment), no intervention or another mouth rinse considered to be inactive. We then compared the results, and summarised the evidence from all the studies. Finally, we assessed our confidence in the evidence. To do this, we considered factors such as the way studies were conducted, study sizes and consistency of findings across studies. What did we find? We found 17 studies that met our inclusion criteria. These studies used chlorhexidine, CPC, essential oil/herbal mouth rinses, povidone iodine and boric acid in comparison to no rinsing, or rinsing with water, saline (salt water) or another mouth rinse. None of the studies measured the how often dental healthcare providers became infected with micro‐organisms. All the included studies measured the level of bacterial contamination in droplets or aerosols in the dental clinic. They did not examine contamination with viruses or fungi. Most rinses decreased bacterial contamination in aerosols to some extent, but there was considerable variation in the effects and we do not know what size of reduction is necessary to reduce infection risk. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or side effects such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess whether patients were happy to use a mouth rinse or whether it was easy for dentists to implement. Overall, the results suggest that using a preprocedural mouth rinse may reduce the level of bacterial contamination in aerosols compared with no rinsing or rinsing with water, but we have only low or very low certainty that the evidence is reliable and we do not know how this reduction in contamination relates to the risk of infection. What does this mean? We have very little confidence in the evidence, and further studies may change the findings of our review. No studies measured infection risk or investigated viral or fungal contamination. How up‐to‐date is this review? The evidence in this Cochrane Review is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kumbargere Nagraj, S; Eachempati, P; Paisi, M; Nasser, M; Sivaramakrishnan, G; Francis, T; Verbeek, JH", "articleTypes": [], "doi": "10.1002/14651858.CD013826.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "8f3ca604-c68c-4743-8aef-9b2e1e9b938f", "pmid": "", "title": "Pharmacological interventions for self‐harm in adults", "imported": false, "abstract": "Abstract - Background Self‐harm (SH; intentional self‐poisoning or self‐injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm. Objectives To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta‐analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients. Search methods For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co‐ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013. Selection criteria We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services. Data collection and analysis We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta‐analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow‐up. For this analysis, we pooled data using a random‐effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach. Main results We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low‐dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported. Authors' conclusions Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment. Plain language summary Drugs and natural products for self‐harm in adults We have reviewed the international literature regarding pharmacological (drug) and natural product (dietary supplementation) treatment trials in this field. A total of seven trials meeting our inclusion criteria were identified. There is little evidence of beneficial effects of either pharmacological or natural product treatments. However, few trials have been conducted and those that have are small, meaning that possible beneficial effects of some therapies cannot be ruled out. Why is this review important? Self‐harm (SH), which includes intentional self‐poisoning/overdose and self‐injury, is a major problem in many countries and is strongly linked to suicide. It is therefore important that effective treatments for SH patients are developed. Whilst there has been an increase in the use of psychosocial interventions for SH in adults (which is the focus of a separate review), drug treatments are frequently used in clinical practice. It is therefore important to assess the evidence for their effectiveness. Who will be interested in this review? Clinicians working with patients who engage in SH, patients themselves, and their relatives. What questions does this review aim to answer? This review is an update of a previous Cochrane review from 1999 which found little evidence of beneficial effects of drug treatments on repetition of SH apart from for flupenthixol. This update aims to further evaluate the evidence for effectiveness of drugs and natural products for patients with SH with a broader range of outcomes. Which studies were included in the review? To be included in the review, studies had to be randomised controlled trials of drug treatments for adults who had recently engaged in SH. What does the evidence from the review tell us? There is currently no clear evidence for the effectiveness of antidepressants, antipsychotics, mood stabilisers, or natural products in preventing repetition of SH. What should happen next? We recommend further trials of drugs for SH patients, possibly in combination with psychological treatment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hawton, K, Witt, KG, Taylor Salisbury, TL, Arensman, E, Gunnell, D, Hazell, P, Townsend, E, van Heeringen, K", "articleTypes": [], "doi": "10.1002/14651858.CD011777", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.798Z" }, { "id": "8f44f146-5906-4baf-bb9a-89bcda8c2929", "pmid": "", "title": "Antipsychotics for fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue. It affects approximately 2% of the general population. Up to 70% of patients with fibromyalgia meet the criteria for a depressive or anxiety disorder. People often report high disability levels and poor health‐related quality of life. Drug therapy focuses on reducing key symptoms and disability, and improving health‐related quality of life. Antipsychotics might reduce fibromyalgia and associated mental health symptoms. Objectives To assess the efficacy, tolerability and safety of antipsychotics in fibromyalgia in adults. Search methods We searched CENTRAL (2016, Issue 4), MEDLINE and EMBASE to 20 May 2016, together with reference lists of retrieved papers and reviews and two clinical trial registries. We also contacted trial authors. Selection criteria We selected controlled trials of at least four weeks duration of any formulation of antipsychotics used for the treatment of fibromyalgia in adults. Data collection and analysis We extracted the data from all included studies and two review authors independently assessed study risks of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. We derived first tier evidence from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs, at least 200 participants in the comparison, eight to 12 weeks duration, parallel design), second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison, and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. We rated the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main results We included a total of four studies with 296 participants. Three studies with 206 participants compared quetiapine, an atypical (second‐generation) antipsychotic, with placebo. One study used a cross‐over design and two studies a parallel‐group design. Study duration was eight or 12 weeks. Quetiapine was used in all studies with a bedtime dosage between 50 and 300 mg/day. All studies had one or more sources of potential major bias and we judged them to be at moderate risk of bias overall. The primary outcomes in this review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Second tier evidence indicated that quetiapine was not statistically superior to placebo in the number of participants with a 50% or more pain reduction (very low quality evidence). No study reported data on PGIC. A greater proportion of participants on quetiapine reported a 30% or more pain reduction (risk difference (RD) 0.12, 95% confidence interval (CI) 0.00 to 0.23; number needed to treat for an additional benefit (NNTB) 8, 95% CI 5 to 100) (very low quality evidence). A greater proportion of participants on quetiapine reported a clinically relevant improvement of health‐related quality of life compared to placebo ( RD 0.18, 95% CI 0.05 to 0.31; NNTB 5, 95% CI 3 to 20) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing sleep problems (standardised mean difference (SMD) ‐0.67, 95% CI ‐1.10 to ‐0.23), depression (SMD ‐0.39, 95% CI ‐0.74 to ‐0.04) and anxiety (SMD ‐0.40, 95% CI ‐0.69 to ‐0.11) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing the risk of withdrawing from the study due to a lack of efficacy (RD ‐0.14, 95% CI ‐0.23 to ‐0.05) (very low quality evidence). There was no statistically significant difference between quetiapine and placebo in the proportion of participants withdrawing due to adverse events (tolerability) (very low quality evidence), in the frequency of serious adverse events (safety) (very low quality evidence) and in the proportion of participants reporting dizziness and somnolence as an adverse event (very low quality evidence). In more participants in the quetiapine group a substantial weight gain was noted (RD 0.08, 95% CI 0.02 to 0.15; number needed to treat for an additional harm (NNTH) 12, 95% CI 6 to 50) (very low quality evidence). We downgraded the quality of evidence by three levels to a very low quality rating because of limitations of study design, indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). One parallel design study with 90 participants compared quetiapine (50 to 300 mg/day flexible at bedtime) to amitriptyline (10 to 75 mg/day flexible at bedtime). The study had three major risks of bias and we judged it to be at moderate risk of bias overall. We downgraded the quality of evidence by two levels to a low quality rating because of indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). Third tier evidence indicated no statistically significant differences between the two drugs. Both drugs did not statistically significantly differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life and in the proportion of participants reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared to amitriptyline, more participants left the study due to adverse events (low quality evidence). No serious adverse events were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia. Authors' conclusions Very low quality evidence suggests that quetiapine may be considered for a time‐limited trial (4 to 12 weeks) to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits in shared decision making with the patient. Plain language summary Antipsychotics for fibromyalgia symptoms in adults Bottom line Quetiapine may be considered for 4 to 12 weeks to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as sleep problems, problems with thinking and exhaustion. They often report severe limitations of daily functioning and poor quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. In addition, many patients with fibromyalgia suffer from depression. Medicines used to treat depression can reduce the main symptoms in some people with fibromyalgia. Quetiapine is a drug for the treatment of psychosis (an abnormal condition of the mind described as involving a loss of contact with reality), which is also licensed for the treatment of major depression in some countries. Study characteristics In May 2016, we searched for clinical trials in which antipsychotics were used to treat symptoms of fibromyalgia in adults. We found a total of four studies with 298 participants. We found three studies with 208 participants, which were eight and 12 weeks long and compared quetiapine, an antipsychotic, against a fake medication (placebo). One hundred and sixty‐six participants were diagnosed with major depression. We also found one study comprising 90 patients that compared quetiapine to an antidepressant named amitriptyline, which is frequently used in the treatment of fibromyalgia. Five people in this study were diagnosed with major depression. Key results and quality of the evidence Quetiapine was not better than a fake medication in achieving a pain reduction of 50% or more (very low quality evidence). Quetiapine was better than the fake medication in achieving a pain reduction of 30% or more, reducing sleep problems, and improving depressed mood and anxiety (very low quality evidence). Quetiapine was better than the fake medication in improving health‐related quality of life. Fewer participants dropped out of the trial due to lack of efficacy with quetiapine than with fake medication (very low quality evidence). There was no difference in tolerability and safety between quetiapine and a fake medication (very low quality evidence). For some people, quetiapine led to substantial weight gain and somnolence (sleepiness). Quetiapine and amitriptyline (an antidepressant which is frequently used to improve sleep and reduce pain in people with fibromyalgia) did not differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life. Both drugs did not differ in the proportion of patients reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared with amitriptyline, more people experienced side effects and left the study due to side effects with quetiapine (low quality evidence). No serious side effects with either drug were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B; Klose, P; Üçeyler, N; Phillips, T; Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011804.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "8f4eecf1-87e1-4edf-a98a-45afcfe03858", "pmid": "", "title": "Zinc supplementation for improving pregnancy and infant outcome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carducci, B, Keats, EC, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD000230.pub6 AB - Abstract - Background It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy, such as prolonged labour, atonic postpartum haemorrhage, pregnancy‐induced hypertension, preterm labour and post‐term pregnancies, although these associations have not yet been established. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Objectives 1. To compare the effects on maternal, fetal, neonatal and infant outcomes in healthy pregnant women receiving zinc supplementation versus no zinc supplementation, or placebo.
2. To assess the above outcomes in a subgroup analysis reviewing studies performed in women who are, or are likely to be, zinc‐deficient. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (3 July 2020), and reference lists of retrieved studies. Selection criteria Randomised trials of zinc supplementation versus no zinc supplementation or placebo administration during pregnancy, earlier than 27 weeks' gestation. We excluded quasi‐randomised controlled trials. We intended to include studies presented only as abstracts, if they provided enough information or, if necessary, by contacting authors to analyse them against our criteria; we did not find any such studies. Data collection and analysis Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information. We assessed the certainty of the evidence using GRADE. Main results For this update, we included 25 randomised controlled trials (RCTs) involving over 18,000 women and their babies. The overall risk of bias was low in half of the studies. The evidence suggests that zinc supplementation may result in little or no difference in reducing preterm births (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.74 to 1.03; 21 studies, 9851 participants; low‐certainty evidence). Further, zinc supplementation may make little or no difference in reducing the risk of stillbirth (RR 1.22, 95% CI 0.80 to 1.88; 7 studies, 3295 participants; low‐certainty evidence), or perinatal deaths (RR 1.10, 95% CI 0.81 to 1.51; 2 studies, 2489 participants; low‐certainty evidence). It is unclear whether zinc supplementation reduces neonatal death, because the certainty of the evidence is very low. Finally, for other birth outcomes, zinc supplementation may make little or no difference to mean birthweight (MD 13.83, 95% CI ‐15.81 to 43.46; 22 studies, 7977 participants; low‐certainty evidence), and probably makes little or no difference in reducing the risk of low birthweight (RR 0.94, 95% CI 0.79 to 1.13; 17 studies, 7399 participants; moderate‐certainty evidence) and small‐for‐gestational age babies when compared to placebo or no zinc supplementation (RR 1.02, 95% CI 0.92 to 1.12; 9 studies, 5330 participants; moderate‐certainty evidence). We did not conduct subgroup analyses, as very few studies used normal zinc populations. Authors' conclusions There is not enough evidence that zinc supplementation during pregnancy results in improvements in maternal or neonatal outcomes. Future research to address ways of improving the overall nutritional status of pregnant women, particularly in low‐income regions, and not looking at zinc in isolation, should be an urgent priority. Plain language summary Zinc supplementation for improving pregnancy and infant outcome What is the issue? In low‐ and middle‐income countries, many women have poor diets and are deficient in key micronutrients that are required for good health. This is especially concerning during pregnancy, when energy and nutrient needs are greater for both the mother and the growing baby. Zinc plays a critical role in normal growth and development. Deficiency in zinc could lead to adverse health outcomes, such as being born too soon or too small. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Why is this important? Although severe zinc deficiency is rare, it is estimated that mild‐to‐moderate deficiency is common in several regions of the world. Studies of human pregnancy and zinc supplementation, including those from low‐ and middle‐income countries, have failed to document a consistent beneficial effect on fetal growth, length of gestation, and early newborn survival. What evidence did we find? We searched for studies in July 2020. This updated review now includes 25 randomised controlled trials, involving over 18,000 women and their babies. We found that zinc supplementation in pregnancy may make little to no difference in reducing the risk of preterm births, stillbirths, or deaths around the time of birth, when compared to no zinc supplementation or placebo. Zinc supplementation may make little or no difference to the birthweight of babies, and probably makes little or no difference to the number of babies born either with a low birthweight or small for their gestational age, when compared with no zinc supplementation, or with giving a placebo. We cannot be sure whether zinc supplementation reduces death in newborns, because the certainty of the evidence is very low. What does this mean? There is not enough evidence that zinc supplementation during pregnancy results in better outcomes for women and their babies. Finding ways to improve women's overall nutritional status, particularly in low‐income areas, will do more to improve the health of mothers and babies than supplementing pregnant women with zinc alone. This should be an urgent research priority for the future.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.073Z" }, { "id": "8f5446fa-aed7-41ff-bcea-ded2fb7e89c3", "pmid": "", "title": "Metabolic and bariatric surgery in adults with obesity and diabetes mellitus: a network meta‐analysis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E, Gorenflo, L, Schwarzer, G, Stadelmaier, J, Wallerer, S, Marjanovic, G, Fink, JM, Lehane, C, Metzendorf, MI, Meerpohl, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015622.pub2 AB - Abstract - Rationale Obesity and its associated comorbidities, particularly type 2 diabetes (T2D), have reached epidemic dimensions globally. Both conditions are related to an increased risk of serious health outcomes and impose a substantial burden on those affected. Metabolic and bariatric surgery (MBS) may offer a therapeutic option for achieving sustained weight loss, improving comorbidities and thereby enhancing long���term quality of life. Objectives To investigate the medium‐ and long‐term benefits and harms of different MBS procedures compared with each other and to non‐surgical treatment on outcomes relevant to adults with obesity and T2D, and to obtain a clinically meaningful ranking of these interventions by considering both randomised controlled trials (RCTs) and cohort studies. Search methods We searched MEDLINE, Cochrane CENTRAL, CINAHL, LILACS, BASE as well as the WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 25 June 2024. We did not apply any language restrictions. Eligibility criteria We included RCTs and both prospective and retrospective cohort studies with a minimum follow‐up of three years in adults (≥ 18 years) with obesity (body mass index ≥ 30 kg/m² or ethnic‐specific cut‐off values) and T2D. Eligible interventions include MBS procedures (i.e. laparoscopic adjustable gastric banding [LAGB], sleeve gastrectomy [SG], Roux‐en‐Y gastric bypass [RYGB], one‐anastomosis gastric bypass [OAGB], gastric plication [GCP], biliopancreatic diversion with duodenal switch, and their variations) or non‐surgical treatment (i.e. lifestyle intervention, medical treatment [LI/MT]). Outcomes Critical outcomes were medium‐ (≥ 3 to < 5 years) and long‐term (≥ 5 years) weight loss (%), waist circumference (cm), T2D remission (complete, partial), and serious adverse events (SAE). Important outcomes included all‐cause mortality, T2D complications, glycaemic control (glycated haemoglobin (HbA1c) in %) and health‐related quality of life (HRQoL). Risk of bias We used the Risk of Bias 2 (RoB 2) tool for RCTs and Risk Of Bias In Non‐randomized Studies – of Interventions (ROBINS‐I) for cohort studies. Synthesis methods We performed random‐effects network meta‐analyses based on the frequentist approach and ranked treatments by P scores. We rated the certainty of evidence according to the GRADE approach for long‐term outcomes (≥ 5 years). Included studies We included 18 studies (with 70 reports) with 15,282 participants in this review. Of these, 13 studies were RCTs (n = 911) and five were cohort studies (n = 14,371). Two RCTs compared MBS with LI/MT, ten compared two or three different MBS procedures and one with a 3‐arm design investigated two different MBS procedures as well as LI/MT. All cohort studies compared different MBS procedures. The networks were based on the following MBS procedures: RYGB, SG, OAGB, LAGB, GCP, and LI/MT. Synthesis of results NMA results (8 RCTs; n = 491) suggest greater long‐term weight loss after RYGB compared to LI/MT (MD ‐16.95%; 95% CI ‐24.19 to ‐9.71). OAGB (MD ‐12.10%; 95% CI ‐22.85 to ‐1.34) and SG (MD ‐9.40 %; 95% CI ‐17.45 to ‐1.34) may also result in greater weight loss compared to LI/MT, but the evidence is very uncertain. A reduction in waist circumference at long‐term follow‐up (6 RCTs; n = 348) is likely higher after RYGB compared to LI/MT (MD ‐12.34 cm; 95% CI ‐17.88 to ‐6.81). OAGB (MD: ‐13.28 cm; 95% CI ‐22.04 to ‐4.53) and SG (MD‐9.08 cm; 95% CI ‐15.74 to ‐2.43) may also lead to a higher reduction in waist circumference compared to LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effects of MBS procedures compared to LI/MT on long‐term complete T2D remission (9 RCTs; n = 536). All MBS procedures (8 RCTs; n = 588) may result more often in partial T2D remissions than LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effect of all MBS procedures compared to LI/MT on SAE (9 RCTs; n = 598) and all‐cause mortality in the long term (7 RCTs; n = 520). RYGB may reduce total long‐term T2D complications compared to LI/MT (Rate ratio (RaR) 0.17; 95% CI 0.03 to 0.89; 5 RCTs; n = 356), but the evidence is very uncertain. Based on NMA results (10 RCTs; n = 612), RYGB may reduce HbA1c compared to LI/MT (MD ‐1.44%; 95% CI ‐2.26 to ‐0.63). OAGB (MD ‐2.01%; 95%CI ‐3.42 to ‐0.60) and SG (MD ‐1.01%; 95%CI ‐1.94 to ‐0.08) may also reduce HbA1c compared to LI/MT, but the evidence is every uncertain. Both RYGB and SG may increase mental and physical components of HRQoL compared to LI/MT (both 2 RCTs; n = 118), but evidence is very uncertain. The inclusion of cohort studies in the analyses of percentage weight loss, partial type 2 diabetes remission, SAE, and all‐cause mortality confirmed the main findings. For most outcomes, the main reasons for downgrading certainty of evidence were related to risk of bias and imprecision. Authors' conclusions In people with obesity and T2D, RYGB, OAGB and, to a lesser extent, SG may lead to long‐term improvements in body weight, waist circumference, partial T2D remission, and HbA1c compared with LI/MT. However, due to imprecise results, the magnitude of the effects often remains uncertain or very uncertain. For other outcomes, especially complete T2D remission, SAE, all‐cause mortality and T2D complications, the evidence is mainly very uncertain, due to a low numbers of participants and events. When interpreting these findings, it should be noted that cohort studies were not, as originally planned, included in the certainty of evidence assessment, as these studies were judged to have a high or critical risk of bias. Larger and well‐designed studies may contribute to diminishing the existing uncertainties and enhancing our confidence in the findings. Funding This Cochrane review was funded by the German Federal Ministry of Education and Research (BMBF) (grant number: 01KG2201). Registration Protocol (2024) DOI: https://doi.org/10.1002/14651858.CD015622 PROSPERO ID: CRD42023457363 Plain language summary Review question What are the long‐term benefits and risks of different types of weight loss surgery (also called metabolic and bariatric surgery) to treat obesity and type 2 diabetes in adults? Key messages In people with obesity and type 2 diabetes, gastric (stomach) bypass (i.e. Roux‐en‐Y gastric bypass and one‐anastomosis gastric bypass) may be most beneficial for improving body weight, waist circumference, type 2 diabetes status and long‐term blood sugar levels at least five years after surgery, but for one‐anastomosis gastric bypass, we are very uncertain about the results. It is unclear whether the different surgical procedures have an effect on risks such as serious unwanted health effects and death from any cause at least five years after surgery. Larger and well‐designed studies may help reduce the existing uncertainties and increase our confidence in the findings. What are obesity and type 2 diabetes? 
Obesity is a condition with too many fat deposits that can damage health. In type 2 diabetes, the body has difficulty controlling blood sugar levels because the hormone insulin does not work properly. Type 2 diabetes often occurs in people with obesity, and both conditions increase the risk of premature death and other health problems, such as cardiovascular disease. How are obesity and type 2 diabetes treated? Lifestyle interventions such as nutrition, exercise, and behavioural programmes, along with medicines, are often used first for weight loss and improvement of diabetes status. When these do not work well, metabolic and bariatric surgery may be considered as an additional treatment option. There are a number of different types of bariatric surgery: gastric (stomach) banding; gastric sleeve (removal of a part of the stomach); Roux‐en‐Y gastric bypass (RYGB); one‐anastomosis gastric bypass, or mini‐gastric bypass; gastric plication (folding to make the stomach smaller); biliopancreatic diversion with duodenal switch. What did we want to find out? Which of the different types of surgery are the safest and most beneficial ones by comparing them with each other and with lifestyle and medication therapy regarding their long‐term (at least 5 years follow‐up) benefits and risks. Whether these surgical procedures improve body weight, waist circumference, type 2 diabetes status, long‐term blood sugar levels, and quality of life at least five years after surgery. Whether surgery affects serious unwanted health effects, death from any cause, and type 2 diabetes complications over this period. What did we do? 
We searched for studies involving people with obesity and type 2 diabetes. We included studies that compared at least two different surgical procedures, or surgery with lifestyle and medication treatment. We summarised and compared all treatments using a method called network meta‐analysis, and we rated our confidence in the results based on factors such as study methods and sample size. What did we find? 
We found 18 studies, including 15,282 people with obesity and type 2 diabetes. In 13 of these studies (including 911 people), participants were assigned randomly to two or more treatment groups. This is the best way to ensure that groups of people are similar. Five studies (with 14,371 people) used ‘real‐life’ observational data. The studies investigated surgical procedures such as gastric band, gastric sleeve, Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, and gastric plication. We found that: Roux‐en‐Y gastric bypass, may improve body weight and likely reduce waist circumference compared with lifestyle and medication treatment in the long term. One‐anastomosis gastric bypass and, to a lesser extent, gastric sleeve, may also improve body weight and waist circumference, but we are very uncertain about the results. Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, gastric sleeve, and gastric band may improve type 2 diabetes status, but we are very uncertain about the results. It is unclear whether the types of surgery have an effect on serious unwanted health effects or death from any cause. Roux‐en‐Y gastric bypass may reduce type 2 diabetes complications in the long term compared to non‐surgical treatments, but we are very uncertain about the results. Roux‐en‐Y gastric bypass may improve blood sugar levels compared to non‐surgical treatments. One‐anastomosis gastric bypass and gastric sleeve may also improve blood sugar levels, but we are very uncertain about the results. RYGB and SG may lead to a greater increase in health‐related quality of life than non‐surgical treatments, but again, we are very uncertain about the results. What are the limitations of the evidence? 
Our confidence in the evidence is often low to very low because the studies included only small numbers of people, and the results for some outcomes, especially serious unwanted health effects, death from any cause, and type 2 diabetes complications, were based on very few events. Moreover, for several surgical procedures, there were not enough studies to be certain about the outcomes. It is important to note that rating our confidence in findings was based only on studies in which participants were randomly assigned to groups and did not include observational studies. How up to date is this evidence? 
This evidence is up to date as of June 2024.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.796Z" }, { "id": "8f5701d0-3dde-4b7b-ba85-a1f3705dba00", "pmid": "", "title": "Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Soil‐transmitted helminth (STH) infections are amongst the most common infectious diseases worldwide, with an estimated 24% of the world’s population currently infected. Mass drug administration (MDA) is the periodic medicinal treatment, without prior individual diagnosis, of at‐risk people living in endemic areas. The World Health Organization currently recommends MDA for STHs. MDA programmes are complex health interventions; achieving adherence is important to their success. Adherence is influenced by the target population's perceptions of the drug, the programme, and those delivering it. Objectives To synthesize qualitative research evidence about community experiences and perceptions of mass drug administration programmes for soil‐transmitted helminths. To assess whether our findings confirm, extend, enrich, or conflict with those of a 2022 Cochrane qualitative evidence review of mass drug administration programmes for lymphatic filariasis. Search methods We searched CENTRAL, MEDLINE, Embase, and four other databases up to 11 November 2024, together with reference checking, and citation searching. Selection criteria We synthesized qualitative and mixed‐methods studies. We included studies exploring community experiences and perceptions of MDA programmes for STHs in any country, conducted between 2001 and 2024. We included all participants of MDA programmes, regardless of disease status, individual participation, or other demographic information. We also included lay healthcare workers and formally qualified healthcare workers, if their perspectives were clearly separated from those of the general population. Data collection and analysis We collected data on study characteristics and programme delivery, including country, endemicity, drug regimen, how the drugs were delivered, use of health education and sensitization, and adherence monitoring. We conducted thematic analysis using a 'best‐fit' framework synthesis based on a framework developed in a 2022 Cochrane review exploring community views on mass drug administration for filariasis (a parasitic infection caused by filarial worms). We conducted a deductive phase, accommodating our data within the existing model, followed by an inductive phase, during which we explored data not accommodated by the framework. We used the GRADE‐CERQual approach to assess our confidence in the findings, and updated the filariasis review's conceptual model to display our findings. Main results We included 17 studies, conducted in Bangladesh, Benin, India, Kenya, Malawi, Nigeria, the Philippines, and Turkey. Four themes emerged, three of which were identified in the review of MDA for lymphatic filariasis. People weigh up the benefits and harms in their decision to participate in MDA, though some may not have a choice. Outcomes of individual participation in MDA may be positive, negative, or both. The decision to partake is a careful balance of risk, benefit, and feasibility (high confidence). Unpleasant associations become part of the narrative and spread rapidly through the community (moderate confidence). Physical and social barriers prevent some people from being able to access MDA even if they want to participate (moderate confidence). Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical legacies, rumours, and mistrust of people involved in the programme affect overall trust in drug distribution and influence whether people choose to participate. Past experiences can have a profound effect on people, and negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background and in‐depth training around the drug or the disease itself (moderate confidence). Some community members prefer distribution from people they know or trust (high confidence). However, others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors (CDDs) cannot answer their programme‐related questions (moderate confidence). Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign, which includes improved sanitation, is necessary to tackle STH burden (moderate confidence). One theme that the filariasis review identified was not substantiated by the findings in this review (Programmes expect compliance: this can result in coercion and blame). Authors' conclusions Despite the prevalence and undoubted impact of MDA programmes over the past 10 years, endemic hotspots and continued transmission are common, due in part to poor community adherence. The 2022 Cochrane review outlined several key community concerns and doubts that hinder the effective implementation of MDA for lymphatic filariasis. This review shows that most of these concerns and doubts are shared by communities targeted for MDA for STHs, indicating that there are fundamental challenges in the overall conceptualization and design of MDA programmes that need to be addressed. Funding TF, MT, RK, and the Cochrane Infectious Diseases Group editorial base were funded by UK aid from the UK Government for the benefit of low‐ and middle‐income countries (project number 300342‐104). The views expressed do not necessarily reflect the UK Government’s official policies. Registration The protocol for this review was published in January 2024 on the Cochrane Database of Systematic Reviews. Available at doi.org/10.1002/14651858.CD015794. Plain language summary Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis Key messages People consider several personal, social, and historical factors before deciding to take medicine. Within one community, different individuals will experience benefits and harms associated with treatment, which shape their decision to participate. The decision to adhere depends on the perceived benefits compared to harms, the trust built between communities and the programme, the competency of people delivering the drugs to provide reassurance to the community members, and the perceived organisation of the delivery programme. Our findings are largely consistent with those of a 2022 Cochrane review exploring people's views and experiences of mass drug administration (MDA) programmes for lymphatic filariasis. This evidence overlap suggests that there are key challenges in the design of MDA programmes in general that need to be addressed to increase adherence. What was studied in this synthesis? Mass drug administration (MDA) involves the periodic delivery of drugs to treat entire communities or groups, regardless of whether an individual has a particular disease. This method aims to prevent onward transmission of infection within the population. MDA is currently recommended for some disease‐control programmes in low‐ and middle‐income countries, including for soil‐transmitted helminth (STH) infections. STHs are a group of parasitic worms, including roundworm, hookworm, whipworm, and threadworm. These MDA programmes are usually delivered within a community or as a school‐based programme. Successfully stopping STH infections through MDA depends on community members being willing and able to participate. In this review, we looked for studies that explored how people view and experience mass drug administration programmes for STHs. We identified 17 studies relevant to this synthesis. What was the aim of this synthesis? In this synthesis of qualitative research, we searched for studies that explored people's views on MDA programmes for treating STHs in low‐ and middle‐income countries. We wanted to understand how people view and experience mass drug administration programmes for soil‐transmitted helminths. We were also interested in whether our findings would support, extend, or conflict with findings from a 2022 Cochrane review which looked at MDA programmes for lymphatic filariasis, another infectious disease caused by worms. What were the main findings? We included 17 studies in our analysis. The studies covered several countries in Africa and South‐East Asia, and one country in the Eastern Mediterranean region. The included studies explored the views and experiences of community members and those distributing the medicines in low‐income countries where STH infection is a considerable problem. From the data, four themes emerged. The 2022 Cochrane review of MDA for lymphatic filariasis identified three of these themes, highlighting the similarities between these programmes. One new theme emerged. 1. People weigh up benefits and harms in their decision to participate in MDA, though some may not have a choice. There are many outcomes to participating in the MDA programme, both positive and negative. For community members, several of these may exist at once, and the decision to partake is a careful balance of risk, benefit, and feasibility (we have high confidence in the evidence). Unpleasant experiences can quickly spread through the community (moderate confidence). Physical and social barriers (e.g. travel distance or not attending school, respectively) prevent some people from accessing treatment through the MDA programme (moderate confidence). 2. Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical experiences, rumours, and mistrust of people involved in the programme affect overall trust in the programme. Past experiences can have a strong effect on people; negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). 3. The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background, and in‐depth training around the drug or the disease itself (moderate confidence). Whilst some community members prefer distribution from people who they know or trust (high confidence), others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors cannot answer their questions related to the programme (moderate confidence). 4. (New theme) Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign which includes improved sanitation is necessary to tackle STH burden (moderate confidence). How current is this evidence? The evidence is current to November 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fox, T; Shrestha, S; Kuehn, R; Taylor, M", "articleTypes": [], "doi": "10.1002/14651858.CD015794.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "8f57453f-a6b8-46f8-9d4a-6784305ade92", "pmid": "", "title": "Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery", "imported": false, "abstract": "Abstract - Background In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete. Objectives To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Date of the last search: 20 November 2014. Selection criteria Randomised and quasi‐randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention. Data collection and analysis Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta‐analyses were performed on available and relevant data. Main results Of the 16 identified trials, four (112 participants) were eligible for inclusion. Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon‐aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post‐operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re‐intervention was not reported by either trial. Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re‐intervention). In one trial a high‐dose rFVIIa regimen (90 μg/kg) was compared with a low‐dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety. Authors' conclusions There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well‐designed randomised controlled trials would be needed, in particular to address the cost‐effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies. Plain language summary Preventing bleeding in people with congenital bleeding disorders during and after surgery In haemophilia and other congenital bleeding disorders blood does not clot properly, which can cause excessive bleeding. This is particularly relevant during surgery, when the risk of bleeding depends on the type and severity of the clotting disorder and on the type of surgery. Therefore, during and after surgery, these individuals should receive treatment to improve the ability of their blood to clot and so prevent bleeding. Clotting factor concentrates (when available and appropriate in those individuals missing specific clotting proteins) or other non‐specific drugs for clotting, or a combination of both, are administered. It is not known what is the optimal dose or duration or method of administration of these treatments in these circumstances. We searched for randomised controlled trials comparing the efficacy (mortality, blood loss, need for re‐intervention, subjective assessment of efficacy, duration and dose of therapy) and the safety of any type of treatment given to people with congenital bleeding disorders during any type of surgery. We found four trials to be included in this review. Two trials evaluated 59 people with haemophilia A or B receiving antifibrinolytic drugs (agents that reduce the breakdown of clots) or placebo in addition to the initial standard treatment before dental extractions. The remaining two trials evaluated 53 people with haemophilia A or B and inhibitors (antibodies that act against the factor concentrate therapy) receiving an different clotting concentrate, recombinant activated factor VII, both during and after surgery. These two trials evaluated different treatment options: high‐dose compared with low‐dose and a single large (bolus) infusion compared with continuous infusion. The trials included in this review provide some information in two specific situations in people with congenital bleeding disorders undergoing surgery. However, on the whole, there is not enough evidence from trials to define the best treatments for the various types of disease and types of surgery. Further trials would be useful to improve our knowledge but are difficult to carry out and currently do not appear to be a clinical priority. Indeed, both major and minor surgery are safely performed in clinical practice in these individuals based on local experience and data from uncontrolled studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Coppola, A, Windyga, J, Tufano, A, Yeung, C, Di Minno, MND", "articleTypes": [], "doi": "10.1002/14651858.CD009961.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.794Z" }, { "id": "8f7b318b-3b4c-4f08-ac42-07b5bacf3889", "pmid": "", "title": "Carbetocin for preventing postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Postpartum haemorrhage (PPH) is one of the major contributors to maternal mortality and morbidity worldwide. Active management of the third stage of labour has been proven to be effective in the prevention of PPH. Syntometrine is more effective than oxytocin but is associated with more side effects. Carbetocin, a long‐acting oxytocin agonist, appears to be a promising agent for the prevention of PPH. Objectives To determine if the use of oxytocin agonist is as effective as conventional uterotonic agents for the prevention of PPH, and assess the best routes of administration and optimal doses of oxytocin agonist. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2011, Issue 1 of 4), MEDLINE (1966 to 1 March 2011) and EMBASE (1974 to 1 March 2011). We checked references of articles and communicated with authors and pharmaceutical industry contacts. Selection criteria Randomised controlled trials which compared oxytocin agonist (carbetocin) with other uterotonic agents or with placebo or no treatment for the prevention of PPH. Data collection and analysis Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Main results We included 11 studies (2635 women) in the review. Six trials compared carbetocin with oxytocin; four of these were conducted for women undergoing caesarean deliveries, one was for women following vaginal deliveries and one did not state the mode of delivery clearly. The carbetocin was administered as 100 µg intravenous dosage across the trials, while oxytocin was administered intravenously but at varied dosages. Four trials compared intramuscular carbetocin and intramuscular syntometrine for women undergoing vaginal deliveries. Three of the trials were on women with no risk factor for PPH, while one trial was on women with risk factors for PPH. One trial compared the use of intravenous carbetocin with placebo. Use of carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics (risk ratio (RR) 0.62; 95% confidence interval (CI) 0.44 to 0.88; four trials, 1173 women) compared to oxytocin for those who underwent caesarean section, but not for vaginal delivery. Compared to oxytocin, carbetocin was associated with a reduced need for uterine massage following both caesarean delivery (RR 0.54; 95% CI 0.37 to 0.79; two trials, 739 women) and vaginal delivery (RR 0.70; 95% CI 0.51 to 0.94; one trial, 160 women). There were no statistically significant differences between carbetocin and oxytocin in terms of risk of any PPH (blood loss greater than 500 ml) or in risk of severe PPH (blood loss greater than 1000 ml). Comparison between carbetocin and syntometrine showed a lower mean blood loss in women who received carbetocin compared to syntometrine (mean difference (MD) ‐48.84 ml; 95% CI ‐94.82 to ‐2.85; four trials, 1030 women). There was no statistically significant difference in terms of the need for therapeutic uterotonic agents, but the risk of adverse effects such as nausea and vomiting were significantly lower in the carbetocin group: nausea (RR 0.24; 95% CI 0.15 to 0.40; four trials, 1030 women); vomiting (RR 0.21; 95% CI 0.11 to 0.39; four trials, 1030 women). The incidence of postpartum hypertension was also significantly lower in women who received carbetocin compared to those who received syntometrine. Cost‐effectiveness of carbetocin was investigated by one study published as an abstract, with limited data. Authors' conclusions For women who undergo caesarean section, carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics compared to oxytocin, but there is no difference in the incidence of postpartum haemorrhage. Carbetocin is associated with less blood loss compared to syntometrine in the prevention of PPH for women who have vaginal deliveries and is associated with significantly fewer adverse effects. Further research is needed to analyse the cost‐effectiveness of carbetocin as a uterotonic agent. Plain language summary Carbetocin for preventing postpartum haemorrhage In low‐ and middle‐income countries, postpartum haemorrhage is a major cause of maternal deaths and ill health. In high‐income countries, the problems are much less but there is still a small risk of major bleeding problems for women after giving birth. Active management of the third stage of labour, which is generally used to reduce blood loss at birth, consists of giving the mother a drug that helps the uterus to contract, early cord clamping and controlled cord traction to deliver the placenta. Different drugs have been tried and generally either intramuscular oxytocin or intramuscular syntometrine is given. Carbetocin is an oxytocin agonist. Oxytocin agonists are a group of drugs that mimic the oxytocin action, oxytocin being the natural hormone that helps to reduce blood loss at birth. This review includes 11 randomised controlled trials involving 2635 women. The trials compared carbetocin against either oxytocin or syntometrine given after delivery, vaginally or by caesarean section. The comparison between intramuscular carbetocin and oxytocin showed that there was no difference in the risk of heavy bleeding, but that women who received carbetocin were less likely to require other medications to produce uterine contractions following caesarean sections. Comparisons between carbetocin and syntometrine showed that women who received carbetocin had less blood loss compared to women who received syntometrine after vaginal delivery, and were much less likely to experience side effects such as nausea and vomiting. The incidence of hypertension at 30 and 60 minutes post delivery was also significantly lower in women who received carbetocin compared to those who received syntometrine. Five of the 11 studies were known to be supported by a pharmaceutical company.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Su, LL; Chong, YS; Samuel, M", "articleTypes": [], "doi": "10.1002/14651858.CD005457.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "8f8d5614-c3ad-4366-9ffc-519b17a7608c", "pmid": "", "title": "Colchicine for pericarditis", "imported": false, "abstract": "Abstract - Background Pericarditis is the inflammation of the pericardium, the membranous sac surrounding the heart. Recurrent pericarditis is the most common complication of acute pericarditis, causing severe and disabling chest pains. Recurrent pericarditis affects one in three patients with acute pericarditis within the first 18 months. Colchicine has been suggested to be beneficial in preventing recurrent pericarditis. Objectives To review all randomised controlled trials (RCTs) that assess the effects of colchicine alone or combined, compared to any other intervention to prevent further recurrences of pericarditis, in people with acute or recurrent pericarditis. Search methods We searched the following bibliographic databases on 4 August 2014: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2014 on The Cochrane Library ), MEDLINE (OVID, 1946 to July week 4, 2014), EMBASE (OVID, 1947 to 2014 week 31), and the Conference Proceedings Citation Index ‐ Science on Web of Science (Thomson Reuters) 1990 to 1 Aug 2014. We did not apply any language or time restrictions. Selection criteria RCTs of people with acute or recurrent pericarditis who are receiving colchicine compared to any other treatment, in order to prevent recurrences. Data collection and analysis Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The first primary outcome was the time to recurrence, measured by calculating the hazard ratios (HRs). The second primary outcome was the adverse effects of colchicine. Secondary outcomes were the rate of recurrences at 6, 12 and 18 months, and symptom relief. Main results We included four RCTs, involving 564 participants in this review. We compared the effects of colchicine in addition to a non‐steroidal anti‐inflammatory drug (NSAID) such as ibuprofen, aspirin or indomethacin to the effects of the NSAID alone. Two comparable trials studied the effects of colchicine in 204 participants with recurrent pericarditis and two trials studied 360 people with acute pericarditis. All trials had a moderate quality for the primary outcomes. We identified two on‐going trials; one of these trials examines acute pericarditis and the other assesses recurrent pericarditis. There was moderate quality evidence that colchicine reduces episodes of pericarditis in people with recurrent pericarditis over 18 months follow‐up (HR 0.37; 95% confidence interval (CI) 0.24 to 0.58). It is expected that at 18 months, the number needed to treat (NNT) is 4. In people with acute pericarditis, there was moderate quality evidence that colchicine reduces recurrence (HR 0.40; 95% CI 0.27 to 0.61) at 18 months follow‐up. Colchicine led to a greater chance of symptom relief at 72 hours (risk ratio (RR) 1.4; 95% CI 1.26 to 1.56; low quality evidence). Adverse effects were mainly gastrointestinal and included abdominal pain and diarrhoea. The pooled RR for adverse events was 1.26 (95% CI 0.75 to 2.12). While the number of people experiencing adverse effects was higher in the colchicine than the control groups (9% versus 7%), the quality of evidence was low owing to imprecision, and there was no statistically significant difference between the treatment groups (P = 0.42). There was moderate quality evidence that treatment with colchicine led to more people stopping treatment due to adverse events (RR 1.87; 95% CI 1.02 to 3.41). Authors' conclusions Colchicine, as adjunctive therapy to NSAIDs, is effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis. However, evidence is based on a limited number of small trials. Patients with multiple resistant recurrences were not represented in any published or on‐going trials, and it is these patients that are in the most need for treatment. Plain language summary Systematic review of randomised controlled trials about the efficacy and safety of colchicine in people with pericarditis Pericarditis is the inflammation and swelling of the tissue covering the outer layer of the heart. Pericarditis causes severe and disabling chest pain and fever, however the main issue is the repeated recurrence of pericarditis attacks. Colchicine is an ancient medication that has been used in the treatment of other inflammatory diseases such as gout. We wanted to discover whether colchicine alone or added to other medications is better or worse than alternative therapies in preventing pericarditis. We have reviewed all randomised controlled trials about the effect of colchicine in preventing recurrence of pericarditis in people with pericarditis. We found four trials involving 564 participants, who were followed up for at least 18 months. Two studies examined the use of colchicine in people with recurrent pericarditis and two examined the use of colchicine in people with a first episode of pericarditis. The evidence is current to August 2014. The trials showed that people taking colchicine have a lower risk of developing pericarditis recurrence and a higher proportion experience symptom relief. It is expected that at 18 months, one pericarditis recurrence can be avoided for every four people receiving colchicine with NSAIDs rather than NSAIDs alone. Adverse effects were reported in all trials and affected 15 people (9%) of the 162 taking colchicine. Adverse effects included abdominal pain, nausea and vomiting. Two studies were designed so that participants knew the type of intervention they were taking and people in the comparison group had no dummy pill. The results of these studies could exaggerate the effects of the drug. The evidence suggests beneficial effects of colchicine in preventing recurrence of pericarditis, however this is based on a limited number of small trials. More trials are currently being done and we await their results to see if the benefits of colchicine can be further confirmed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Alabed, S, Cabello, JB, Irving, GJ, Qintar, M, Burls, A", "articleTypes": [], "doi": "10.1002/14651858.CD010652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.772Z" }, { "id": "8f911c41-ee89-4782-b943-9ecff6b0f1e6", "pmid": "", "title": "Aversive smoking for smoking cessation", "imported": false, "abstract": "Abstract - Background Aversion therapy pairs the pleasurable stimulus of smoking a cigarette with some unpleasant stimulus. The objective is to extinguish the urge to smoke. Objectives This review has two aims: First, to determine the efficacy of rapid smoking and other aversive methods in helping smokers to stop smoking; Second, to determine whether there is a dose‐response effect on smoking cessation at different levels of aversive stimulation. Search methods We searched the Cochrane Tobacco Addiction Group specialised register (latest search date October 2009) for studies which evaluated any technique of aversive smoking. Selection criteria Randomized trials which compared aversion treatments with 'inactive' procedures or which compared aversion treatments of different intensity for smoking cessation. Trials must have reported follow up of least six months from beginning of treatment. Data collection and analysis We extracted data in duplicate on the study population, the type of aversion treatment, the outcome measure, method of randomization and completeness of follow up. The outcome measure was abstinence from smoking at maximum follow up, using the strictest measure reported by the authors. Subjects lost to follow up were regarded as smokers. Where appropriate, we performed meta‐analysis using a fixed effect model. Main results Twenty‐five trials met the inclusion criteria. Twelve included rapid smoking and nine used other aversion methods. Ten trials included two or more conditions allowing assessment of a dose‐response to aversive stimulation. The odds ratio (OR) for abstinence following rapid smoking compared to control was 2.01 (95% confidence intervals (CI): 1.36 to 2.95). Several factors suggest that this finding should be interpreted cautiously. A funnel plot of included studies was asymmetric, due to the relative absence of small studies with negative results. Most trials had a number of serious methodological problems likely to lead to spurious positive results. The only trial using biochemical validation of all self reported cessation gave a non‐significant result. Other aversion methods were not shown to be effective (OR 1.15, 95% CI 0.73 to 1.82). There was a borderline dose‐response to the level of aversive stimulation (OR 1.67, 95% CI 0.99 to 2.81). Authors' conclusions The existing studies provide insufficient evidence to determine the efficacy of rapid smoking, or whether there is a dose‐response to aversive stimulation. Milder versions of aversive smoking seem to lack specific efficacy. Rapid smoking is an unproven method with sufficient indications of promise to warrant evaluation using modern rigorous methodology. Plain language summary Does smoking in a way that is unpleasant help smokers to quit Aversion treatments pair undesirable behaviours with negative sensations. In smoking cessation, several approaches have been suggested such as rapid smoking, which requires smokers to take a puff every few seconds to make smoking unpleasant. The results of the existing trials suggest that this may be effective, but the evidence is not conclusive because most of the studies of this approach have methodological problems. A recent laboratory study also suggests that the method has an active ingredient. Further research may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Hajek, P, Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.072Z" }, { "id": "8f957474-641b-4b1c-b161-823971452c51", "pmid": "", "title": "Antibiotic strategies for eradicating Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Respiratory tract infections with Pseudomonas aeruginosa occur in most people with cystic fibrosis (CF). Established chronic P aeruginosa infection is virtually impossible to eradicate and is associated with increased mortality and morbidity. Early infection may be easier to eradicate. This is an updated review. Objectives Does giving antibiotics for P aeruginosa infection in people with CF at the time of new isolation improve clinical outcomes (e.g. mortality, quality of life and morbidity), eradicate P aeruginosa infection, and delay the onset of chronic infection, but without adverse effects, compared to usual treatment or an alternative antibiotic regimen? We also assessed cost‐effectiveness. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings. Latest search: 24 March 2022. We searched ongoing trials registries. Latest search: 6 April 2022. Selection criteria We included randomised controlled trials (RCTs) of people with CF, in whom P aeruginosa had recently been isolated from respiratory secretions. We compared combinations of inhaled, oral or intravenous (IV) antibiotics with placebo, usual treatment or other antibiotic combinations. We excluded non‐randomised trials and cross‐over trials. Data collection and analysis Two authors independently selected trials, assessed risk of bias and extracted data. We assessed the certainty of the evidence using GRADE. Main results We included 11 trials (1449 participants) lasting between 28 days and 27 months; some had few participants and most had relatively short follow‐up periods. Antibiotics in this review are: oral – ciprofloxacin and azithromycin; inhaled – tobramycin nebuliser solution for inhalation (TNS), aztreonam lysine (AZLI) and colistin; IV – ceftazidime and tobramycin. There was generally a low risk of bias from missing data. In most trials it was difficult to blind participants and clinicians to treatment. Two trials were supported by the manufacturers of the antibiotic used. TNS versus placebo TNS may improve eradication; fewer participants were still positive for P aeruginosa at one month (odds ratio (OR) 0.06, 95% confidence interval (CI) 0.02 to 0.18; 3 trials, 89 participants; low‐certainty evidence) and two months (OR 0.15, 95% CI 0.03 to 0.65; 2 trials, 38 participants). We are uncertain whether the odds of a positive culture decrease at 12 months (OR 0.02, 95% CI 0.00 to 0.67; 1 trial, 12 participants). TNS (28 days) versus TNS (56 days) One trial (88 participants) comparing 28 days to 56 days TNS treatment found duration of treatment may make little or no difference in time to next isolation (hazard ratio (HR) 0.81, 95% CI 0.37 to 1.76; low‐certainty evidence). Cycled TNS versus culture‐based TNS One trial (304 children, one to 12 years old) compared cycled TNS to culture‐based therapy and also ciprofloxacin to placebo. We found moderate‐certainty evidence of an effect favouring cycled TNS therapy (OR 0.51, 95% CI 0.31 to 0.82), although the trial publication reported age‐adjusted OR and no difference between groups. Ciprofloxacin versus placebo added to cycled and culture‐based TNS therapy One trial (296 participants) examined the effect of adding ciprofloxacin versus placebo to cycled and culture‐based TNS therapy. There is probably no difference between ciprofloxacin and placebo in eradicating P aeruginosa (OR 0.89, 95% CI 0.55 to 1.44; moderate‐certainty evidence). Ciprofloxacin and colistin versus TNS We are uncertain whether there is any difference between groups in eradication of P aeruginosa at up to six months (OR 0.43, 95% CI 0.15 to 1.23; 1 trial, 58 participants) or up to 24 months (OR 0.76, 95% CI 0.24 to 2.42; 1 trial, 47 participants); there was a low rate of short‐term eradication in both groups. Ciprofloxacin plus colistin versus ciprofloxacin plus TNS One trial (223 participants) found there may be no difference in positive respiratory cultures at 16 months between ciprofloxacin with colistin versus TNS with ciprofloxacin (OR 1.28, 95% CI 0.72 to 2.29; low‐certainty evidence). TNS plus azithromycin compared to TNS plus oral placebo Adding azithromycin may make no difference to the number of participants eradicating P aeruginosa after a three‐month treatment phase (risk ratio (RR) 1.01, 95% CI 0.75 to 1.35; 1 trial, 91 participants; low‐certainty evidence); there was also no evidence of any difference in the time to recurrence. Ciprofloxacin and colistin versus no treatment A single trial only reported one of our planned outcomes; there were no adverse effects in either group. AZLI for 14 days plus placebo for 14 days compared to AZLI for 28 days We are uncertain whether giving 14 or 28 days of AZLI makes any difference to the proportion of participants having a negative respiratory culture at 28 days (mean difference (MD) ‐7.50, 95% CI ‐24.80 to 9.80; 1 trial, 139 participants; very low‐certainty evidence). Ceftazidime with IV tobramycin compared with ciprofloxacin (both regimens in conjunction with three months colistin) IV ceftazidime with tobramycin compared with ciprofloxacin may make little or no difference to eradication of P aeruginosa at three months, sustained to 15 months, provided that inhaled antibiotics are also used (RR 0.84, 95 % CI 0.65 to 1.09; P = 0.18; 1 trial, 255 participants; high‐certainty evidence). The results do not support using IV antibiotics over oral therapy to eradicate P aeruginosa , based on both eradication rate and financial cost. Authors' conclusions We found that nebulised antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with P aeruginosa . Eradication may be sustained in the short term. There is insufficient evidence to determine whether these antibiotic strategies decrease mortality or morbidity, improve quality of life, or are associated with adverse effects compared to placebo or standard treatment. Four trials comparing two active treatments have failed to show differences in rates of eradication of P aeruginosa . One large trial showed that intravenous ceftazidime with tobramycin is not superior to oral ciprofloxacin when inhaled antibiotics are also used. There is still insufficient evidence to state which antibiotic strategy should be used for the eradication of early P aeruginosa infection in CF, but there is now evidence that intravenous therapy is not superior to oral antibiotics. Plain language summary Different ways of giving antibiotics to clear Pseudomonas aeruginosa infection in people with cystic fibrosis Key messages ‐ Cystic fibrosis (CF) is an inherited condition where the airways often become blocked with mucus, and people with CF are more likely to get chest infections which cause more damage to the lungs. ‐ Pseudomonas aeruginosa ( P aeruginosa ) is often the cause of infection and is difficult to get rid of; antibiotics are the main treatment, but there are many different antibiotics, and they can be given in different ways. ‐ Inhaled antibiotics may be better than no treatment allowing most people to remain free of P aeruginosa after one month. ‐ There seems to be little difference in the other treatments we compared regarding how well they clear P aeruginosa from the lungs. What is cystic fibrosis? CF is the most common inherited condition that is life‐limiting. Sticky mucus builds up in the lungs of people with CF, which makes it difficult to breathe and can lead to chest infections. These chest infections can cause further lung damage and lead to breathing failure and death. A germ called P aeruginosa is often the cause of infection and is difficult to treat successfully, once it has persisted for longer than six months. What did we want to find out? We wanted to compare different combinations of inhaled, oral and intravenous (IV) antibiotics for clearing P aeruginosa in people with CF, to see if any single treatment works best and is more cost‐effective. What did we find? The review includes 11 studies with a total of 1449 people with CF, of any age or sex, who had mild to severe lung disease. The studies lasted from 28 days to 27 months. We could not combine many results as studies used different treatments. There were 10 different comparisons of antibiotic treatments: three studies compared inhaled antibiotics with a placebo (dummy treatment); two studies compared inhaled antibiotics for different lengths of time; two studies compared inhaled tobramycin with or without oral antibiotics depending on how the infection was detected; two studies compared inhaled antibiotics plus an oral antibiotic with inhaled antibiotics plus a placebo; one study compared two different inhaled antibiotics plus an oral antibiotic; and one study compared IV antibiotics with oral antibiotics. Most of the studies showed how well the treatments got rid of P aeruginosa as well as how they affected lung function, other germs, worsening of flare‐ups, and side effects. Main results Three small studies (of 89 people) treating early infection showed that after one month, inhaled antibiotics were better than no treatment and cleared P aeruginosa in most people, but our confidence in the evidence is low. There is likely to be little difference in the other treatments regarding how well they clear P aeruginosa from the lungs, although we found that inhaled antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with Pseudomonas aeruginosa. A study of IV ceftazidime with tobramycin in comparison with oral ciprofloxacin also showed neither group was better at getting rid of P aeruginosa, but we are more certain of the results and this means that it may be just as effective to treat with oral antibiotics. What are the limitations of the evidence? Some studies were carried out up to 30 years ago and the results may not apply today, and some studies were small. Most studies were quite short, so we could not show whether treatment made people with CF feel better or live longer. Given the treatments used in most of the studies, it would have been easy for people to guess which treatment they were receiving, which might have influenced some of the results. Two studies were supported by the pharmaceutical industry. Further research is needed to see whether clearing the infection completely improves the well‐being and quality of life in people with CF and to establish which antibiotic combination is best at clearing P aeruginosa . Overall our confidence in the evidence was moderate to very low, so further research is likely to change our confidence in the results. However, we have higher confidence in one recently published study, which means we can be more sure of the results. How up to date is this evidence? The studies we have reported on are the most up‐to‐date we could find. We last searched the literature in April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Langton Hewer, SC, Smith, S, Rowbotham, NJ, Yule, A, Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD004197.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.789Z" }, { "id": "8f96ba0e-8f03-4db0-8a61-62be57f276ef", "pmid": "", "title": "Foetal haemoglobin inducers for reducing blood transfusion in non‐transfusion‐dependent beta‐thalassaemias", "imported": false, "abstract": "Abstract - Background Non‐transfusion‐dependent β‐thalassaemia (NTDβT) is a subset of inherited haemoglobin disorders characterised by reduced production of the β‐globin chain of haemoglobin leading to anaemia of varying severity. Although blood transfusion is not a necessity for survival, it may be required to prevent complications of chronic anaemia, such as impaired growth and hypercoagulability. People with NTDβT also experience iron overload due to increased iron absorption from food sources which becomes more pronounced in those requiring blood transfusion. People with a higher foetal haemoglobin (HbF) level have been found to require fewer blood transfusions, thus leading to the emergence of treatments that could increase its level. HbF inducers stimulate HbF production without altering any gene structures. Evidence for the possible benefits and harms of these inducers is important for making an informed decision on their use. Objectives To compare the effectiveness and safety of the following for reducing blood transfusion for people with NTDβT: 1. HbF inducers versus usual care or placebo; 2. single HbF inducer with another HbF inducer, and single dose with another dose; and 3. combination of HbF inducers versus usual care or placebo, or single HbF inducer. Search methods We used standard, extensive Cochrane search methods. The latest search date was 21 August 2022. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs comparing single HbF inducer with placebo or usual care, with another single HbF inducer or with a combination of HbF inducers; or comparing different doses of the same HbF inducer. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were blood transfusion and haemoglobin levels. Our secondary outcomes were HbF levels, the long‐term sequelae of NTDβT, quality of life and adverse events. Main results We included seven RCTs involving 291 people with NTDβT, aged two to 49 years, from five countries. We reported 10 comparisons using eight different HbF inducers (four pharmacological and four natural): three RCTs compared a single HbF inducer to placebo and seven to another HbF inducer. The duration of the intervention lasted from 56 days to six months. Most studies did not adequately report the randomisation procedures or whether and how blinding was achieved. HbF inducer against placebo or usual care Three HbF inducers, HQK‐1001, Radix Astragali or a 3‐in‐1 combined natural preparation (CNP), were compared with a placebo. None of the comparisons reported the frequency of blood transfusion. We are uncertain whether Radix Astragali and CNP increase haemoglobin at three months (mean difference (MD) 1.33 g/dL, 95% confidence interval (CI) 0.54 to 2.11; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). We are uncertain whether Radix Astragali and CNP have any effect on HbF (MD 12%, 95% CI −0.74% to 24.75%; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). Only medians on haemoglobin and HbF levels were reported for HQK‐1001. Adverse effects reported for HQK‐1001 were nausea, vomiting, dizziness and suprapubic pain. There were no prespecified adverse effects for Radix Astragali and CNP. HbF inducer versus another HbF inducer Four studies compared a single inducer with another over three to six months. Comparisons included hydroxyurea versus resveratrol, hydroxyurea versus thalidomide, hydroxyurea versus decitabine and Radix Astragali versus CNP. No study reported our prespecified outcomes on blood transfusion. Haemoglobin and HbF were reported for the comparison Radix Astragali versus CNP, but we are uncertain whether there were any differences (1 study, 24 participants; low‐certainty evidence). Different doses of the same HbF inducer Two studies compared two different types of HbF inducers at different doses over two to six months. Comparisons included hydroxyurea 20 mg/kg/day versus 10 mg/kg/day and HQK‐1001 10 mg/kg/day, 20 mg/kg/day, 30 mg/kg/day and 40 mg/kg/day. Blood transfusion, as prespecified, was not reported. In one study (61 participants) we are uncertain whether the lower levels of both haemoglobin and HbF at 24 weeks were due to the higher dose of hydroxyurea (haemoglobin: MD −2.39 g/dL, 95% CI −2.80 to −1.98; very low‐certainty evidence; HbF: MD −10.20%, 95% CI −16.28% to −4.12%; very low‐certainty evidence). The study of the four different doses of HQK‐1001 did not report results for either haemoglobin or HbF. We are not certain if major adverse effects may be more common with higher hydroxyurea doses (neutropenia: risk ratio (RR) 9.93, 95% CI 1.34 to 73.97; thrombocytopenia: RR 3.68, 95% CI 1.12 to 12.07; very low‐certainty evidence). Taking HQK‐1001 20 mg/kg/day may result in the fewest adverse effects. A combination of HbF inducers versus a single HbF inducer Two studies compared three combinations of two inducers with a single inducer over six months: hydroxyurea plus resveratrol versus resveratrol or hydroxyurea alone, and hydroxyurea plus l‐carnitine versus hydroxyurea alone. Blood transfusion was not reported. Hydroxyurea plus resveratrol may reduce haemoglobin compared with either resveratrol or hydroxyurea alone (MD −0.74 g/dL, 95% CI −1.45 to −0.03; 1 study, 54 participants; low‐certainty evidence). We are not certain whether the gastrointestinal disturbances, headache and malaise more commonly reported with hydroxyurea plus resveratrol than resveratrol alone were due to the interventions. We are uncertain whether hydroxyurea plus l‐carnitine compared with hydroxyurea alone may increase mean haemoglobin, and reduce pulmonary hypertension (1 study, 60 participants; very low‐certainty evidence). Adverse events were reported but not in the intervention group. None of the comparisons reported the outcome of HbF. Authors' conclusions We are uncertain whether any of the eight HbF inducers in this review have a beneficial effect on people with NTDβT. For each of these HbF inducers, we found only one or at the most two small studies. There is no information on whether any of these HbF inducers have an effect on our primary outcome, blood transfusion. For the second primary outcome, haemoglobin, there may be small differences between intervention groups, but these may not be clinically meaningful and are of low‐ to very low‐certainty evidence. Data on adverse effects and optimal doses are limited. Five studies are awaiting classification, but none are ongoing. Plain language summary Medicines to increase foetal haemoglobin levels and reduce the need for blood transfusion in people with non‐transfusion‐dependent thalassaemia Review question Do medicines that increase foetal haemoglobin (HbF) levels in people with non‐transfusion‐dependent β‐thalassaemia (NTDβT) reduce their need for blood transfusion? What is thalassaemia? Thalassaemia is a genetic (inherited) blood disorder that causes defects in adult haemoglobin (the oxygen carrying component of red blood cells) leading to destruction of the red blood cells and anaemia with different degrees of severity. Persistent anaemia can affect general health and reduce quality of life. People with NTDβT may require periodic blood transfusion to replace the red blood cells and this could lead to excess iron being deposited in various organs in the body, affecting their function. People with NTDβT have higher levels of HbF (the main form of haemoglobin found during the development of a baby before birth) which persists after birth. The amount of HbF that persists varies and people with a higher HbF level require less frequent blood transfusions. What are HbF inducers? HbF inducers are substances which increase HbF levels without alteration to the gene. They may reduce the need for blood transfusion in people with NTDβT. However, it is not known which HbF inducers are effective and safe, and if so, what the optimal dose is and at what age treatment should be started. What did we do? We searched medical databases for studies comparing single HbF inducer with placebo (dummy treatment) or usual care, with another inducer or with a combination of inducers; or comparing different doses for a same inducer. What did we find? We found seven very small randomised controlled trials (where people taking part in the trial had equal chances of being in the treatment or the control group), involving 291 people with NTDβT, aged between two and 49 years, from five countries. These studies varied widely in the type of HbF inducers investigated and their comparison, the doses and how outcomes were reported. The duration of the trials ranged from two to six months. The inducers used include hydroxyurea, decitabine, HQK‐1001, thalidomide, Radix Astragali, resveratrol, l‐carnitine and combined natural preparation (CNP). Main results None of the studies reported our main outcome of changes to the frequency of blood transfusion. All inducers may have caused a small increase in haemoglobin and HbF when compared to placebo, but we are very uncertain about this. Four studies compared a single HbF inducer against another, for three to six months. There were changes to haemoglobin and HbF, but we cannot be certain if a single HbF inducer or a combination of HbF inducers would work better than another. Two studies, each compared a different dose of the same inducer. Lower doses of hydroxyurea appeared to increase haemoglobin and HbF levels more than the higher doses, but we are very uncertain. The other study used four different doses of HQK‐1001 but did not actually look for a difference in the effect of these four different doses on haemoglobin or HbF. Two studies compared a combination of two HbF inducers with a single HbF inducer for six months. We are very uncertain whether the combination or a single inducer improves haemoglobin. None of the studies reported whether HbF inducers have any effect on quality of life. Adverse (unwanted) drug effects were reported for each HbF inducer, but there was little information available to guide us on the safety of these substances. What are the limitations of the evidence? The main reason we are very uncertain about the effects of HbF inducers are because the studies were all very small and had weaknesses in their design. None of the studies lasted long enough to provide meaningful information for many of the outcomes we measured. How up to date is this evidence? The evidence is current to 21 August 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Foong, WC; Loh, CK; Ho, JJ; Lau, DSC", "articleTypes": [], "doi": "10.1002/14651858.CD013767.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "8fb454c4-613e-49ae-8a8c-5f58cc4fede1", "pmid": "", "title": "Zinc for prevention and treatment of the common cold", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Nault, D, Machingo, TA, Shipper, AG, Antiporta, DA, Hamel, C, Nourouzpour, S, Konstantinidis, M, Phillips, E, Lipski, EA, Wieland, LS", "articleTypes": [], "doi": "10.1002/14651858.CD014914.pub2 AB - Abstract - Background The common cold is an acute, self‐limiting viral respiratory illness. Symptoms include nasal congestion and mucus discharge, sneezing, sore throat, cough, and general malaise. Given the frequency of colds, they are a public health burden and a significant cause of lost work productivity and school absenteeism. There are no established interventions to prevent colds or shorten their duration. However, zinc supplements are commonly recommended and taken for this purpose. Objectives To assess the effectiveness and safety of zinc for the prevention and treatment of the common cold. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and LILACS to 22 May 2023, and searched Web of Science Core Collection and two trials registries to 14 June 2023. We also used reference checking, citation searching, and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) in children or adults that tested any form of zinc against placebo to prevent or treat the common cold or upper respiratory infection (URTI). We excluded zinc interventions in which zinc was combined with other minerals, vitamins, or herbs (e.g. a multivitamin, or mineral supplement containing zinc). Data collection and analysis We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We independently extracted data. When necessary, we contacted study authors for additional information. We assessed zinc (type and route) with placebo in the prevention and treatment of the common cold. Primary outcomes included the proportion of participants developing colds (for analyses of prevention trials only), duration of cold (measured in days from start to resolution of the cold), adverse events potentially due to zinc supplements (e.g. unpleasant taste, loss of smell, vomiting, stomach cramps, and diarrhoea), and adverse events considered to be potential complications of the common cold (e.g. respiratory bacterial infections). Main results We included 34 studies (15 prevention, 19 treatment) involving 8526 participants. Twenty‐two studies were conducted on adults and 12 studies were conducted on children. Most trials were conducted in the USA (n = 18), followed by India, Indonesia, Iran, and Turkey (two studies each), and Australia, Burkina Faso, Colombia, Denmark, Finland, Tanzania, Thailand, and the UK (one study each). The 15 prevention studies identified the condition as either common cold (n = 8) or URTI (n = 7). However, almost all therapeutic studies (17/19) focused on the common cold. Most studies (17/34) evaluated the effectiveness of zinc administered as lozenges (3 prevention; 14 treatment) in acetate, gluconate, and orotate forms; gluconate lozenges were the most common (9/17). Zinc gluconate was given at doses between 45 and 276 mg/day for between 4.5 and 21 days. Five (5/17) lozenge studies gave acetate lozenges and two (2/17) gave both acetate and gluconate lozenges. One (1/17) lozenge study administered intranasal ( gluconate ) and lozenge ( orotate ) zinc in tandem for cold treatment. Of the 17/34 studies that did not use lozenges, 1/17 gave capsules, 3/17 administered dissolved powders, 5/17 gave tablets, 4/17 used syrups, and 4/17 used intranasal administration. Most studies were at unclear or high risk of bias in at least one domain. There may be little or no reduction in the risk of developing a cold with zinc compared to placebo (risk ratio (RR) 0.93, 95% CI 0.85 to 1.01; I 2 = 20%; 9 studies, 1449 participants; low‐certainty evidence). There may be little or no reduction in the mean number of colds that occur over five to 18 months of follow‐up (mean difference (MD) ‐0.90, 95% CI ‐1.93 to 0.12; I 2 = 96%; 2 studies, 1284 participants; low‐certainty evidence). When colds occur, there is probably little or no difference in the duration of colds in days (MD ‐0.63, 95% CI ‐1.29 to 0.04; I² = 77%; 3 studies, 740 participants; moderate‐certainty evidence), and there may be little or no difference in global symptom severity (standardised mean difference (SMD) 0.04, 95% CI ‐0.35 to 0.43; I² = 0%; 2 studies, 101 participants; low‐certainty evidence). When zinc is used for cold treatment, there may be a reduction in the mean duration of the cold in days (MD ‐2.37, 95% CI ‐4.21 to ‐0.53; I² = 97%; 8 studies, 972 participants; low‐certainty evidence), although it is uncertain whether there is a reduction in the risk of having an ongoing cold at the end of follow‐up (RR 0.52, 95% CI 0.21 to 1.27; I² = 65%; 5 studies, 357 participants; very low‐certainty evidence), or global symptom severity (SMD ‐0.03, 95% CI ‐0.56 to 0.50; I² = 78%; 2 studies, 261 participants; very low‐certainty evidence), and there may be little or no difference in the risk of a change in global symptom severity (RR 1.02, 95% CI 0.85 to 1.23; 1 study, 114 participants; low‐certainty evidence). Thirty‐one studies reported non‐serious adverse events (2422 participants). It is uncertain whether there is a difference in the risk of adverse events with zinc used for cold prevention (RR 1.11, 95% CI 0.84 to 1.47; I 2 = 0%; 7 studies, 1517 participants; very low‐certainty evidence) or an increase in the risk of serious adverse events (RR 1.67, 95% CI 0.78 to 3.57; I 2 = 0%; 3 studies, 1563 participants; low‐certainty evidence). There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment (RR 1.34, 95% CI 1.15 to 1.55; I 2 = 44%; 2084 participants, 16 studies; moderate‐certainty evidence); no treatment study provided information on serious adverse events. No study provided clear information about adverse events considered to be potential complications of the common cold. Authors' conclusions The findings suggest that zinc supplementation may have little or no effect on the prevention of colds but may reduce the duration of ongoing colds, with an increase in non‐serious adverse events. Overall, there was wide variation in interventions (including concomitant therapy) and outcomes across the studies, as well as incomplete reporting of several domains, which should be considered when making conclusions about the efficacy of zinc for the common cold. Plain language summary Zinc for the prevention and treatment of the common cold Key messages 
‐ There may be little or no reduction in the risk of developing a cold with zinc supplements compared to placebo. ‐ For people who already have a cold, there may be a reduction in how long the cold lasts with zinc supplements compared to placebo. ‐ There is probably an increase in the risk of non‐serious adverse events when zinc is used for cold treatment. What is the common cold? 
The common cold is primarily a viral infection of the upper respiratory tract. There is no specific combination of symptoms that defines a cold, but symptoms can include nasal congestion, sneezing, sore throat, cough, fatigue, and runny nose, with or without fever. Most people usually recover from this illness without medical treatment; however, there are no definitive treatments to prevent colds or shorten their duration. Given the frequency of colds in adults and children, they are a public health burden and a significant cause of lost work productivity and school absenteeism. Prevention and treatment for the common cold with zinc is an ongoing interest. What did we want to find out? 
We wanted to find out if zinc was better than placebo at reducing the risk of developing a cold and shortening the duration of existing colds. A placebo is a substance similar in appearance to a treatment, but that has no known therapeutic effect. Placebos help assess the effects of the belief that a treatment has been received versus treatment actually being received. We also wanted to find out if zinc was associated with any adverse effects (e.g. harms), especially harms considered to be potential complications of the common cold. Additionally, we looked at self‐reported overall cold severity, individual symptom severity, individual symptom duration, and days missed from work or school. What did we do? 
We searched six databases and two clinical trials registers for studies comparing zinc with placebo for the treatment or prevention of the common cold in adults and children. We compared and summarised the results of the studies, and we found and rated our confidence in the evidence based on specific factors such as risk of bias and study methods. What did we find? 
We found 34 studies of cold prevention or treatment. The studies were conducted in 13 countries, a majority taking place in the USA. Twelve studies were conducted on children (aged under 18 years) and 22 studies were conducted on adults. Most treatments ended with self‐reported resolution of symptoms, and the minimum treatment period was five days with a maximum period of 540 days. Most of the studies were funded by an organisation with ties to related commerce/industry or did not report their funding. The remainder were funded by private clinics, non‐government foundations, universities, or governmental entities. We assessed the effects of: ‐ zinc as a preventative measure; and ‐ zinc as a treatment measure. We obtained the following results: Zinc for prevention Compared with placebo, taking zinc may make little to no difference in preventing people from catching a cold (9 studies, 1449 people). Preventative zinc also probably makes little to no difference to the length of the cold if one has been caught (3 studies, 740 participants) and may make little to no difference to the severity of the symptoms experienced (2 studies, 101 people). Negative side effects were reported by people taking either zinc or placebo; irregularities in taste and stomach upset were the most common. Zinc for treatment Zinc taken for treatment of a cold may reduce the length of time that symptoms are present, by approximately two days, when compared with placebo (8 studies, 972 people). However, we have little confidence in the evidence supporting this conclusion. It is unclear whether zinc makes a difference to the severity of the cold symptoms experienced (2 studies, 261 people). Negative side effects were reported more frequently for those taking zinc as a cold treatment when compared to those taking placebo; irregularities in taste and stomach upset were the most common. Studies administering intranasal zinc did not report any cases of anosmia (loss of sense of smell) but information about specific side effects is uncertain. What are the limitations of the evidence? 
Our confidence in the evidence is mostly low to very low, and the results of further research could differ from the results of this review. Several factors reduced our confidence in the evidence. Firstly, some studies did not report adequately on how people in the studies were randomly placed into treatment groups, meaning that differences between the study groups could be due to differences between the participants and not the treatments. Secondly, some studies used widely different ways of delivering treatments. Finally, due to the large differences between studies in the approaches used to test the effectiveness of zinc, it is likely that additional studies are required before any firm conclusions can be drawn. How up‐to‐date is this evidence? 
The evidence is current to 22 May 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.069Z" }, { "id": "8fcb50a6-f79f-46cd-b282-b2db4c15940e", "pmid": "", "title": "Probiotics for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "Abstract - Background The intestinal microflora has an essential role in providing a barrier against colonisation of pathogens, facilitating important metabolic functions, stimulating the development of the immune system, and maintaining intestinal motility. Probiotics are live microorganisms that can be administered to supplement the gut flora. Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be partly due to a disruption of the integrity of the gut and its intestinal microflora. There may be a role for probiotics in reducing the incidence of sepsis and improving intestinal motility, thus reducing morbidity and mortality and improving enteral feeding in neonates in the postoperative period. Objectives To evaluate the efficacy and safety of administering probiotics after gastrointestinal surgery for the postoperative management of neonates born from 35 weeks of gestation. Search methods We searched CENTRAL, MEDLINE, Embase, and trial registries in August 2023. We checked reference lists of included studies and relevant systematic reviews for additional studies. Selection criteria We included randomised controlled trials (RCTs) that investigated the postoperative administration of oral probiotics versus placebo or no treatment in neonates born from 35 weeks of gestation who had one or more gastrointestinal surgical procedures. We applied no restrictions regarding the type or dosage of probiotics or the duration of treatment. Data collection and analysis We used standard Cochrane methods, and we used GRADE to assess the certainty of evidence. Main results We identified one RCT that recruited 61 neonates with a gestational age of 35 weeks or more. All infants were admitted to a neonatal intensive care unit and had surgery for gastrointestinal pathologies. There may be little or no difference in proven sepsis (positive bacterial culture, local or systemic) between infants who receive probiotics compared with those who receive placebo (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.16 to 2.55; 61 infants; low‐certainty evidence). Probiotics compared to placebo may have little or no effect on time to full enteral feeds (mean difference (MD) 0.63 days, 95% CI −4.02 to 5.28; 61 infants; low‐certainty evidence). There were no reported deaths prior to discharge from hospital in either study arm. Two weeks after supplementation, the infants who received probiotics had a substantially higher relative abundance of non‐pathogenic intestinal microflora (Bifidobacteriaceae) than those who received placebo (MD 38.22, 95% CI 28.40 to 48.04; 39 infants; low‐certainty evidence). Authors' conclusions This review provides low‐certainty evidence from one small RCT that probiotics compared to placebo have little or no effect on the risk of proven sepsis (positive bacterial culture, local or systemic) or time to full‐enteral feeds in neonates who have undergone gastrointestinal surgery. Probiotics may substantially increase the abundance of beneficial bacterial in the intestine of these neonates, but the clinical implications of this finding are unknown. There is a need for adequately powered RCTs to assess the role of probiotics in this population. We identified two ongoing studies. As neither reported the gestational age of prospective study participants, we are unsure if they will be eligible for inclusion in this review. Plain language summary Benefits and harms of giving probiotics to newborns after digestive tract surgery Key message • Probiotics may have little or no effect on the risk of blood infection in infants born from 35 weeks of pregnancy who have undergone surgery of the digestive tract (food pipe, stomach, or bowel).
• Probiotics may increase the proportion of 'good' bacteria in the bowel, but we do not know if this has any real benefit for the infant. What are probiotics? Probiotics are live bacteria that may offer health benefits when consumed. There is evidence that probiotics can prevent an inflammatory disease of the bowel (necrotising enterocolitis) and infection in premature babies. What are some of the risks of bowel surgery in babies? Surgery of the digestive tract increases the risk of infection, and infection can increase the length of hospital stay. Treatment with antibiotics (medicines that treat bacterial infection) and the stress of surgery can diminish the 'good' bacteria in the bowel. What did we want to find out? We wanted to find out if giving probiotics to babies born from 35 weeks of pregnancy who underwent stomach or bowel surgery could improve rates of infection, length of hospital stay, rates of death, feeding, and the proportion of 'good' bacteria in the stomach and bowel. What did we do? We searched for studies that randomly assigned babies to experimental treatment (probiotics) or a control, which could be placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested) or no treatment. What did we find? We found one small study of 61 babies born from 35 weeks of pregnancy who had digestive tract surgery. Thirty babies received probiotics after the surgery, and 30 received a placebo. In the probiotics group, 13% of babies had a blood infection, compared with 19% in the placebo group. This difference is too small to be significant. On average, the babies in the probiotic group were receiving food into their stomach about 15 hours sooner than those in the placebo group. Again, this difference is not important. Among 39 infants who were tested, those in the probiotics group had considerably more 'good' bacteria in their bowel compared to the placebo group. What are the limitations of the evidence? We have little confidence in the evidence because it is based on a single study with few participants. The evidence is not strong enough to support giving probiotics routinely. Well‐designed and large studies are needed to determine the benefits and harms of giving probiotics to newborns after digestive tract surgery. How up to date is this evidence? The evidence is up to date to August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Trivedi, A; Teo, E; Walker, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012265.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "8fd7e477-b562-45ac-a69b-8f21d72779bb", "pmid": "", "title": "The Real-world Treatment Satisfaction by Gefapixiant in Patients with Refractory Chronic Cough in Terms of Cough Improvement and Taste Disturbance. (The RESTORE Study)", "imported": false, "abstract": "Chronic cough has a high global prevalence and it is refractory to such treatments by approximately 20% of patients. Gafapixant is a P2X3 receptor antagonist that has demonstrated the reduction of cough in patients with refractory chronic cough(RCC). Taste disturbance is the most frequent adverse event by gefapixant (approximately 60-70%). Although gefapixant is well-tolerated even if taste disturbance has occurred, the impact of taste disturbance on cough-specific QoL remains to be unclear. Therefore, the investigator would like to evaluate factors related to treatment satisfaction by gefapixant in RCC patients. the investigator hypothesize that taste disturbance will be associated with the improvement of cough specific QoL and treatment satisfaction in RCC patients.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.146Z" }, { "id": "8fefdd3f-b838-4b9e-978f-c02ba2fc1249", "pmid": "", "title": "Oral stimulation for promoting oral feeding in preterm infants", "imported": false, "abstract": "Abstract - Background Preterm infants (< 37 weeks' post‐menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co‐ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review. Objectives To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA. Search methods Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi‐randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis. Selection criteria Randomised and quasi‐randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non‐oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes. Data collection and analysis Following the updated search, two review authors screened the titles and abstracts of studies and full‐text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non‐oral or sham intervention. We performed meta‐analysis using a fixed‐effect model. Main results We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) ‐4.07 days, 95% confidence interval (CI) ‐4.81 to ‐3.32 days, 6 studies, 292 infants; I 2 =85%, very low‐certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD ‐4.33, 95% CI ‐5.97 to ‐2.68 days, 5 studies, 249 infants; i 2 =68%, very low‐certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non‐oral intervention Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non‐oral intervention (MD ‐7.17, 95% CI ‐8.04 to ‐6.29 days, 10 studies, 574 infants; I 2 =80%, very low‐certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD ‐6.15, 95% CI ‐8.63 to ‐3.66 days, 10 studies, 591 infants; I 2 =0%, low‐certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD ‐2.85, 95% CI ‐6.13 to 0.42, 3 studies, 268 infants; very low‐certainty evidence due to serious risk of bias, inconsistency and imprecision). Authors' conclusions There remains uncertainty about the effects of oral stimulation (versus either standard care or a non‐oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta‐analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well‐designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions. Plain language summary Effects of oral stimulation for oral feeding in preterm infants Review questions Do oral stimulation interventions that involve finger stimulation protocols in preterm infants born before 37 weeks' gestation: Reduce time (days) taken to achieve exclusive oral feeding? Reduce time (days) spent in Neonatal Intensive Care (NICU)? Reduce length of time (days) spent in hospital? Reduce length of time (days) that an infant spends on tube feeding (parenteral nutrition)? Background This is an update of the 2016 review. Many preterm infants have delayed establishment of oral (suck) feeding and are fed at first with feeding tubes or with intravenous (parenteral) nutrition. Development of oral feeding skills needs careful co‐ordination of sucking, swallowing and breathing. In preterm infants, the development of oral feeding can be challenging because of long hospitalisations, breathing difficulties and other medical conditions associated with preterm birth. Unpleasant and invasive procedures such as ventilation or frequent suctioning of secretions from the mouth or nose can negatively impact feeding skills. International guidelines for the transition from tube feeding to oral feeding vary widely. Healthcare providers use a range of interventions to improve sucking and feeding skills in preterm infants, and studies report faster transition time from tube feeds to oral feeds, reduced length of stay in hospital and improvement in infants' sucking skills. The first review in 2016 showed that while oral stimulation interventions appear to reduce length of hospital stay, reduce need for tube feeding and accelerate time to oral feeding, the studies were of poor methodological quality leaving some uncertainty about overall effects. This update assessed whether current research supports these findings and if the quality of studies has improved, leading to increased certainty of results. Study characteristics This review included randomised controlled trials (RCTs) that explored oral stimulation by finger stimulation only in preterm infants. Review authors identified studies to be included by searching electronic databases, clinical trials registers, peer‐reviewed journals and published conference proceedings. Search is up‐to‐date as of March 2022. Key results For this update, we added 12 new studies of variable quality with small numbers of participants, making a total of 28 included studies. As the certainty of evidence was considered 'low' to 'very low', it remains uncertain whether oral stimulation interventions can shorten the transition to oral feeding, reduce length of hospital stay and decrease time spent on parenteral nutrition, although there may be some potential benefit. No studies reported length of stay in NICU. No studies looked at longer‐term outcomes of the interventions (i.e. beyond six months). Certainty of evidence The numbers of infants in these studies were small, the methods employed by researchers varied in quality and the certainty of evidence is estimated to be 'low' to 'very low'.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, Z, O'Donnell, CPF, Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD009720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.134Z" }, { "id": "8ff1f661-27fd-4d46-9ca2-f68415c19b5b", "pmid": "", "title": "Physical interventions to interrupt or reduce the spread of respiratory viruses", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jefferson, T, Dooley, L, Ferroni, E, Al-Ansary, LA, van Driel, ML, Bawazeer, GA, Jones, MA, Hoffmann, TC, Clark, J, Beller, EM, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD006207.pub6 AB - Abstract - Background Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID‐19) caused by SARS‐CoV‐2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID‐19 pandemic. Objectives To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. Search methods We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies. Selection criteria We included randomised controlled trials (RCTs) and cluster‐RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission. Data collection and analysis We used standard Cochrane methodological procedures. Main results We included 11 new RCTs and cluster‐RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID‐19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID‐19 pandemic. Many studies were conducted during non‐epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID‐19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high‐income countries; crowded inner city settings in low‐income countries; and an immigrant neighbourhood in a high‐income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster‐RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster‐RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza‐like illness (ILI)/COVID‐19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate‐certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory‐confirmed influenza/SARS‐CoV‐2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate‐certainty evidence). Harms were rarely measured and poorly reported (very low‐certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low‐certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low‐certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory‐confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate‐certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low‐certainty evidence). One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non‐inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID‐19 patients. Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta‐analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate‐certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory‐confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low‐certainty evidence), and laboratory‐confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low‐certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low‐certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low‐certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports. Authors' conclusions The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory‐confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under‐investigated. There is a need for large, well‐designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs. Plain language summary Do physical measures such as hand‐washing or wearing masks stop or slow down the spread of respiratory viruses? Key messages 
We are uncertain whether wearing masks or N95/P2 respirators helps to slow the spread of respiratory viruses based on the studies we assessed. Hand hygiene programmes may help to slow the spread of respiratory viruses. How do respiratory viruses spread? 
Respiratory viruses are viruses that infect the cells in your airways: nose, throat, and lungs. These infections can cause serious problems and affect normal breathing. They can cause flu (influenza), severe acute respiratory syndrome (SARS), and COVID‐19. People infected with a respiratory virus spread virus particles into the air when they cough or sneeze. Other people become infected if they come into contact with these virus particles in the air or on surfaces on which they land. Respiratory viruses can spread quickly through a community, through populations and countries (causing epidemics), and around the world (causing pandemics). Physical measures to try to prevent respiratory viruses spreading between people include: · washing hands often; · not touching your eyes, nose, or mouth; · sneezing or coughing into your elbow; · wiping surfaces with disinfectant; · wearing masks, eye protection, gloves, and protective gowns; · avoiding contact with other people (isolation or quarantine); · keeping a certain distance away from other people (distancing); and · examining people entering a country for signs of infection (screening). What did we want to find out? 
We wanted to find out whether physical measures stop or slow the spread of respiratory viruses from well‐controlled studies in which one intervention is compared to another, known as randomised controlled trials. What did we do? 
We searched for randomised controlled studies that looked at physical measures to stop people acquiring a respiratory virus infection. We were interested in how many people in the studies caught a respiratory virus infection, and whether the physical measures had any unwanted effects. What did we find? 
We identified 78 relevant studies. They took place in low‐, middle‐, and high‐income countries worldwide: in hospitals, schools, homes, offices, childcare centres, and communities during non‐epidemic influenza periods, the global H1N1 influenza pandemic in 2009, epidemic influenza seasons up to 2016, and during the COVID‐19 pandemic. We identified five ongoing, unpublished studies; two of them evaluate masks in COVID‐19. Five trials were funded by government and pharmaceutical companies, and nine trials were funded by pharmaceutical companies. No studies looked at face shields, gowns and gloves, or screening people when they entered a country. We assessed the effects of: · medical or surgical masks; · N95/P2 respirators (close‐fitting masks that filter the air breathed in, more commonly used by healthcare workers than the general public); and · hand hygiene (hand‐washing and using hand sanitiser). We obtained the following results: Medical or surgical masks Ten studies took place in the community, and two studies in healthcare workers. Compared with wearing no mask in the community studies only, wearing a mask may make little to no difference in how many people caught a flu‐like illness/COVID‐like illness (9 studies; 276,917 people); and probably makes little or no difference in how many people have flu/COVID confirmed by a laboratory test (6 studies; 13,919 people). Unwanted effects were rarely reported; discomfort was mentioned. N95/P2 respirators Four studies were in healthcare workers, and one small study was in the community. Compared with wearing medical or surgical masks, wearing N95/P2 respirators probably makes little to no difference in how many people have confirmed flu (5 studies; 8407 people); and may make little to no difference in how many people catch a flu‐like illness (5 studies; 8407 people), or respiratory illness (3 studies; 7799 people). Unwanted effects were not well‐reported; discomfort was mentioned. Hand hygiene Following a hand hygiene programme may reduce the number of people who catch a respiratory or flu‐like illness, or have confirmed flu, compared with people not following such a programme (19 studies; 71,210 people), although this effect was not confirmed as statistically significant reduction when ILI and laboratory‐confirmed ILI were analysed separately. Few studies measured unwanted effects; skin irritation in people using hand sanitiser was mentioned. What are the limitations of the evidence? 
Our confidence in these results is generally low to moderate for the subjective outcomes related to respiratory illness, but moderate for the more precisely defined laboratory‐confirmed respiratory virus infection, related to masks and N95/P2 respirators. The results might change when further evidence becomes available. Relatively low numbers of people followed the guidance about wearing masks or about hand hygiene, which may have affected the results of the studies. How up to date is this evidence? 
We included evidence published up to October 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.140Z" }, { "id": "902bf7d7-7e1c-4cf9-af6b-7619f8cb4b97", "pmid": "", "title": "Supplementation with multiple micronutrients for breastfeeding women for improving outcomes for the mother and baby", "imported": false, "abstract": "Abstract - Background Globally, more than two billion people are estimated to be deficient in key vitamins and minerals, particularly iodine, iron and zinc. The majority of these people live in low‐income settings and are typically deficient in more than one micronutrient. However, micronutrient deficiency among breastfeeding mothers and their infants also remains an issue in high‐income settings, specifically among women who avoid meat and/or milk, women who may lack sufficient supplies of vitamin B12 and vitamin D, and/or women who are iron‐deficient. Young children, pregnant and lactating women are particularly vulnerable to micronutrient deficiencies. They not only have a relatively greater need for vitamins and minerals because of their physiological state, but are also more susceptible to the harmful consequences of deficiencies. Multiple‐micronutrient supplementation might be an option to solve these problems. Objectives The objective of this review was to evaluate the effects of multiple‐micronutrient supplementation in breastfeeding mothers on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. Selection criteria Randomised controlled trials of multiple‐micronutrient supplementation of three or more micronutrients versus placebo, no supplementation or supplementation with two or fewer micronutrients, irrespective of dosage of micronutrients, in breastfeeding mothers. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We found no studies that compared multiple‐micronutrient supplementation (with three or more micronutrients) versus supplementation with two or fewer micronutrients. Two small studies (involving a total of 52 women) were included. One study compared multiple micronutrients with placebo and the other study compared multiple micronutrients with a group who received no supplementation. The studies were carried out in Brazil (36 adolescent mothers) and the USA (16 women) and included women with a low socioeconomic status. A lack of information in the study reports meant that risk of bias could not be adequately assessed (unclear risk of bias for many domains). There were no quantitative data for any of this review's outcomes so meta‐analysis was not possible. Neither of the studies reported on the primary outcomes of interest in this review: maternal morbidity (febrile illness, respiratory tract infection, diarrhoea) , adverse effects of micronutrients within three days of receiving the supplement , infant mortality (defined as a child dying before completing the first year of age) . One study reported qualitatively on maternal anaemia (a secondary outcome of this review) ‐ the study found that multiple‐micronutrient supplementation was effective for recuperating from anaemia but there were no data for inclusion in our analyses. Maternal satisfaction was not reported in the included studies. Similarly, none of this review's infant secondary outcomes were reported in the included studies: clinical micronutrient deficiency ; morbidity episodes (febrile illness, respiratory tract infection, diarrhoea, other) , adverse effects of micronutrients within three days of receiving the supplement . Authors' conclusions We found no evidence to quantitatively assess the effectiveness of multiple‐micronutrient supplementation in improving health outcomes in mother and baby. The results of this review are limited by the small numbers of studies available, small sample sizes and the studies not reporting on the outcomes of interest in this review. There is no evidence to evaluate potential adverse effects of multiple‐micronutrient supplements, particularly excess dosages. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Further research should focus on whether multiple‐micronutrient supplementation during lactation compared with none, a placebo or supplementation with fewer than two micronutrients is beneficial to maternal and infant health outcomes. Future studies should collect data on outcomes beyond micronutrient concentrations, for example: maternal and infant morbidity, adverse effects, maternal satisfaction, the risks of excess supplementation, and potential adverse interactions between the micronutrients and the other outcomes. This would help to bridge the gap between research on intermediary outcomes and health outcomes in order to develop sound policy in this field. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these affect maternal and infant health outcomes. Larger studies with longer follow‐up would improve the quality of studies and provide stronger evidence. In most of the included studies, bias could not be adequately assessed due to lack of information, therefore attention should be given to adequate methods of randomisation and allocation concealment, adequate methods of blinding of the participants, providers and the outcome assessors to improve the methodological quality of studies in this field. Plain language summary Multiple micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby The benefits and risks of multiple‐micronutrient supplementation during lactation are not clear from randomised controlled studies. Key vitamins and minerals, particularly iodine, iron and zinc, are required in small amounts to ensure normal body metabolism, physical growth and development. Nutrient deficiency affects nearly one third of the world’s population, especially in low‐ and middle‐income countries. Breastfeeding mothers need higher levels than usual in order to provide sufficient vitamins and minerals for their own health and that of their babies, particularly for normal functioning and the growth and development of the baby. Previous studies have assessed supplementation of individual micronutrients. This review looked at the use of multiple‐micronutrient supplements for breastfeeding women for improving outcomes for the mother and her baby. We searched for studies on 30 September 2015 and identified two small studies (involving 52 women) for inclusion in this review. The studies were carried out in Brazil and the USA and included women who had a low socioeconomic status. The studies were poorly reported and this lack of information made it difficult to determine whether the studies were at risk of bias. Neither of the studies provided data for any of this review's important outcomes: maternal illness (fever, respiratory infection, diarrhoea), adverse effects of micronutrients within three days of taking them, infant death (defined as a child dying before reaching one year of age). Similarly, there were no data for any of the other outcomes that we were interested in. For the mother, these outcomes were maternal anaemia, and women's satisfaction. For the baby, these outcomes were micronutrient deficiency; illness episodes (fever, respiratory infection, diarrhoea, other), adverse effects of micronutrients within three days of the woman receiving the supplement. However, one of the included studies reported that multiple‐micronutrient supplementation was effective for lactating women recuperating from anaemia. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Larger studies with longer‐term follow‐up would improve the quality of studies and provide stronger evidence. Further research should focus on whether multiple‐micronutrient supplementation during lactation (compared with no supplementation, a placebo or supplementation with fewer than two micronutrients) is beneficial to the mother and her baby and any associated adverse effects of the intervention. Futher studies should report on important outcomes such as those listed in this review and consider the risks of excess supplementation. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these effect outcomes for the mother and her baby.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Abe, SK; Balogun, OO; Ota, E; Takahashi, K; Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD010647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "903572e4-dc71-452b-9e15-9ccf2d811597", "pmid": "", "title": "Anticholinergic therapy for chronic asthma in children over two years of age", "imported": false, "abstract": "Abstract - Background In the intrinsic system of controlling airway calibre, the cholinergic (muscarinic) sympathetic nervous system has an important role. Anticholinergic, anti muscarinic bronchodilators such as ipratropium bromide are frequently used in the management of childhood airway disease. In asthma, ipratropium is a less potent bronchodilator than beta‐2 adrenergic agents but it is known to be a useful adjunct to other therapies, particularly in status asthmaticus. What remains unclear is the role of anticholinergic drugs in the maintenance treatment of chronic asthma. Objectives To determine the effectiveness of anticholinergic drugs in chronic asthma in children over the age of 2 years. Search methods The Cochrane Airways Group Specialised Register and reference lists of articles were searched. The most recent search was carried out in Febuary 2010. Selection criteria Randomised controlled trials in which anticholinergic drugs were given for chronic asthma in children over 2 years of age were included. Studies including comparison of: anticholinergics with placebo, and anticholinergics with any other drug were included. Data collection and analysis Eligibility for inclusion and quality of trials were assessed independently by two reviewers. Main results Eight studies met the inclusion criteria. Three papers compared the effects of anticholinergic drugs with placebo, and a meta‐analysis of these results demonstrated no statistically significant benefit of the use of anticholinergic drugs over placebo in any of the outcome measures used. The results of one of these trials could not be included in the meta‐analysis but the authors did report significantly lower symptom scores with inhaled anticholinergics compared with placebo. However, there was no significant difference between ipratropium bromide and placebo in the percentage of symptom‐free nights or days. Two trials studied the effects of anticholinergics on bronchial hyper responsiveness to histamine, by measuring the provocation dose of histamine needed to cause a fall of 20 % in FEV1 (PD 20). One study (comparing anticholinergics with placebo) reported a statistically significant increase in PD 20 but this was not found in another study (comparing anticholinergics with a beta‐2 agonist). Both trials also examined the effect of anticholinergic drugs on diurnal variation in peak expiratory flow rate (PEFR) and reported no significant effect. Two studies compared the addition of an anticholinergic drug to a beta‐2 agonist with the beta‐2 agonist alone. Both trials failed to show any significant benefit from the long term use of combined anticholinergics with beta‐2 agonists compared with beta‐2 agonists alone. One trial compared the effects of oral and inhaled anticholinergic drugs with placebo. No statistically significant differences were found in any of the outcome measures except for a higher FEV1 / VC ratio and RV / TLC ratio with oral anticholinergic therapy when compared with placebo. Authors' conclusions The present review summarises the best evidence available to date. Although there were some small beneficial findings in favour of anticholinergic therapy, there is insufficient data to support the use of anticholinergic drugs in the maintenance treatment of chronic asthma in children. Plain language summary Anticholinergic drugs versus either placebo or other medications for children over two years of age with asthma Anticholinergic drugs are widely used in the management of both acute and chronic asthma in children. Their effect is achieved through relief of narrowing of the airways that occurs in asthma. Current guidelines for the management of chronic asthma advise that anticholinergic drugs may be used if children are already on high dose inhaled steroids. This study undertook a comprehensive search of the literature unrestricted by country of publication or language. Unfortunately small numbers of relevant trials were found and these were of variable quality. This review found that although anticholinergic drugs are well tolerated, in children over two years of age, there is not enough data to be sure if they are better than placebo in terms of effects on lung function or symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "McDonald, N; Bara, A; McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD003535", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "90568157-7fb7-44b8-aee0-a99807459c48", "pmid": "", "title": "Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Harmful alcohol use is defined as unhealthy alcohol use that results in adverse physical, psychological, social, or societal consequences and is among the leading risk factors for disease, disability and premature mortality globally. The burden of harmful alcohol use is increasing in low‐ and middle‐income countries (LMICs) and there remains a large unmet need for indicated prevention and treatment interventions to reduce harmful alcohol use in these settings. Evidence regarding which interventions are effective and feasible for addressing harmful and other patterns of unhealthy alcohol use in LMICs is limited, which contributes to this gap in services. Objectives To assess the efficacy and safety of psychosocial and pharmacologic treatment and indicated prevention interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs. Search methods We searched for randomized controlled trials (RCTs) indexed in the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, the Cochrane Clinical Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, and the Latin American and Caribbean Health Sciences Literature (LILACS) through 12 December 2021. We searched clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, Web of Science, and Opengrey database to identify unpublished or ongoing studies. We searched the reference lists of included studies and relevant review articles for eligible studies. Selection criteria All RCTs comparing an indicated prevention or treatment intervention (pharmacologic or psychosocial) versus a control condition for people with harmful alcohol use in LMICs were included. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 66 RCTs with 17,626 participants. Sixty‐two of these trials contributed to the meta‐analysis. Sixty‐three studies were conducted in middle‐income countries (MICs), and the remaining three studies were conducted in low‐income countries (LICs). Twenty‐five trials exclusively enrolled participants with alcohol use disorder. The remaining 51 trials enrolled participants with harmful alcohol use, some of which included both cases of alcohol use disorder and people reporting hazardous alcohol use patterns that did not meet criteria for disorder. Fifty‐two RCTs assessed the efficacy of psychosocial interventions; 27 were brief interventions primarily based on motivational interviewing and were compared to brief advice, information, or assessment only. We are uncertain whether a reduction in harmful alcohol use is attributable to brief interventions given the high levels of heterogeneity among included studies (Studies reporting continuous outcomes: Tau² = 0.15, Q =139.64, df =16, P<.001, I² = 89%, 3913 participants, 17 trials, very low certainty; Studies reporting dichotomous outcomes: Tau²=0.18, Q=58.26, df=3, P<.001, I² =95%, 1349 participants, 4 trials, very low certainty). The other types of psychosocial interventions included a range of therapeutic approaches such as behavioral risk reduction, cognitive‐behavioral therapy, contingency management, rational emotive therapy, and relapse prevention. These interventions were most commonly compared to usual care involving varying combinations of psychoeducation, counseling, and pharmacotherapy. We are uncertain whether a reduction in harmful alcohol use is attributable to psychosocial treatments due to high levels of heterogeneity among included studies (Heterogeneity: Tau² = 1.15; Q = 444.32, df = 11, P<.001; I²=98%, 2106 participants, 12 trials, very low certainty). Eight trials compared combined pharmacologic and psychosocial interventions with placebo, psychosocial intervention alone, or another pharmacologic treatment. The active pharmacologic study conditions included disulfiram, naltrexone, ondansetron, or topiramate. The psychosocial components of these interventions included counseling, encouragement to attend Alcoholics Anonymous, motivational interviewing, brief cognitive‐behavioral therapy, or other psychotherapy (not specified). Analysis of studies comparing a combined pharmacologic and psychosocial intervention to psychosocial intervention alone found that the combined approach may be associated with a greater reduction in harmful alcohol use (standardized mean difference (standardized mean difference (SMD))=‐0.43, 95% confidence interval (CI): ‐0.61 to ‐0.24; 475 participants; 4 trials; low certainty). Four trials compared pharmacologic intervention alone with placebo and three with another pharmacotherapy. Drugs assessed were: acamprosate, amitriptyline, baclofen disulfiram, gabapentin, mirtazapine, and naltrexone. None of these trials evaluated the primary clinical outcome of interest, harmful alcohol use. Thirty‐one trials reported rates of retention in the intervention. Meta‐analyses revealed that rates of retention between study conditions did not differ in any of the comparisons (pharmacologic risk ratio (RR) = 1.13, 95% CI: 0.89 to 1.44, 247 participants, 3 trials, low certainty; pharmacologic in addition to psychosocial intervention: RR = 1.15, 95% CI: 0.95 to 1.40, 363 participants, 3 trials, moderate certainty). Due to high levels of heterogeneity, we did not calculate pooled estimates comparing retention in brief (Heterogeneity: Tau² = 0.00; Q = 172.59, df = 11, P<.001; I 2 = 94%; 5380 participants; 12 trials, very low certainty) or other psychosocial interventions (Heterogeneity: Tau² = 0.01; Q = 34.07, df = 8, P<.001; I 2 = 77%; 1664 participants; 9 trials, very low certainty). Two pharmacologic trials and three combined pharmacologic and psychosocial trials reported on side effects. These studies found more side effects attributable to amitriptyline relative to mirtazapine, naltrexone and topiramate relative to placebo, yet no differences in side effects between placebo and either acamprosate or ondansetron. Across all intervention types there was substantial risk of bias. Primary threats to validity included lack of blinding and differential/high rates of attrition. Authors' conclusions In LMICs there is low‐certainty evidence supporting the efficacy of combined psychosocial and pharmacologic interventions on reducing harmful alcohol use relative to psychosocial interventions alone. There is insufficient evidence to determine the efficacy of pharmacologic or psychosocial interventions on reducing harmful alcohol use largely due to the substantial heterogeneity in outcomes, comparisons, and interventions that precluded pooling of these data in meta‐analyses. The majority of studies are brief interventions, primarily among men, and using measures that have not been validated in the target population. Confidence in these results is reduced by the risk of bias and significant heterogeneity among studies as well as the heterogeneity of results on different outcome measures within studies. More evidence on the efficacy of pharmacologic interventions, specific types of psychosocial interventions are needed to increase the certainty of these results. Plain language summary Interventions to reduce harmful alcohol use in low‐ and middle‐income countries Why is this review important? Harmful alcohol use is one of the main contributors to the global burden of disease. In low‐ and middle‐income countries, harmful alcohol use is increasing. However, services to prevent and treat harmful alcohol use are limited. One contributor to the lack of available services is the limited information about which intervention approaches are effective in reducing harmful alcohol use and whether these approaches are feasible and acceptable in low‐resource settings. In order to prevent the physical, psychological, and societal burden of harmful alcohol use, it is important that effective interventions are available to reduce alcohol‐related harm. What is the goal of this review? The goal of this review is to summarize evidence on whether psychosocial and pharmacologic interventions are able to reduce harmful alcohol use in low‐ and middle‐income countries. We also aim to evaluate the safety of treatments and how many people remain in treatment until its completion. What does the research say? We identified 66 randomized controlled trials that evaluated the effect of interventions on reducing harmful alcohol use. Most of these studies assessed psychosocial interventions (n = 52 studies), six assessed pharmacologic interventions alone, and eight assessed combined pharmacologic and psychosocial interventions. The majority of included trials were funded by government agencies (36 trials) followed by multiple public and private funders (8 trials) or private foundations (5 trials). Seventeen trials did not report the funding source. We are uncertain whether brief psychosocial interventions and other psychosocial interventions reduce harmful alcohol use. Combined pharmacologic and psychosocial interventions may reduce harmful alcohol use relative to psychosocial interventions combined with placebo, yet the certainty of the evidence has been assessed as low. No studies were found that looked at the effect of pharmacologic interventions alone on harmful alcohol use. We did not find evidence that rates of retention differed between study conditions for any of the intervention types. Certainty of evidence: The certainty of evidence on the effect of brief and other psychosocial interventions on harmful alcohol use was very low due to lack of masking, differential attrition and missing data, selective outcome reporting, high heterogeneity, and differences in patient populations. The certainty of evidence on the effect of combined pharmacologic and psychosocial interventions on harmful alcohol use was low due to lack of blinding, incomplete outcome data, and heterogeneity in the pharmacologic interventions under investigation. No studies evaluated the effect of pharmacologic interventions alone on harmful alcohol use. The evidence is current to 12 December 2021. What are the next steps? Future research on interventions to reduce harmful alcohol use is needed to address some of the limitations described in this review. Studies evaluating similar interventions across studies and contexts are needed to improve generalizability and understand the necessary characteristics of and conditions for effective intervention. Studies must utilize measurement tools that are valid in the population they are studying. Lastly, studies must be designed to reduce the risk of bias leading to the high degree of uncertainty in the results reported in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, MC; Kane, J; Alto, M; Giusto, A; Lovero, K; Stockton, M; McClendon, J; Nicholson, T; Wainberg, ML.; Johnson, RM; Tol, WAnton", "articleTypes": [], "doi": "10.1002/14651858.CD013350.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "90572eac-e95f-44a0-af9b-722464762087", "pmid": "", "title": "Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen‐ultraviolet A photochemotherapy for psoriasis", "imported": false, "abstract": "Abstract - Background The most commonly used types of phototherapy for treating psoriasis are narrow‐band ultraviolet B (NB‐UVB); broad‐band ultraviolet B (BB‐UVB), which includes selective (delivering radiation with a wavelength range of 305 to 325 nm) and conventional BB‐UVB (280 to 320 nm); and psoralen ultraviolet A photochemotherapy (oral or bath PUVA). There is substantial controversy regarding their efficacy when compared with each other. Objectives To assess the effects of narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for psoriasis. Search methods We searched the following databases up to August 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 7), MEDLINE (from 1946), and EMBASE (from 1974). We searched the following databases up to November 2012: CNKI (from 1974) and CBM (from 1978). We also searched trials registers and the OpenGrey database. Selection criteria We included all randomised controlled trials (RCTs) that compared NB‐UVB phototherapy with BB‐UVB or PUVA for treating psoriasis, which included chronic plaque psoriasis (CPP), guttate psoriasis (GP), and palmoplantar psoriasis (PPP). Data collection and analysis Two review authors independently conducted the study selection, 'Risk of bias' assessment, and data extraction. Main results We included 13 RCTs, with a total of 662 participants. We report the results of intention‐to‐treat analyses (ITT) here. Our primary outcomes of interest were as follows: Participant‐rated global improvement, Percentage of participants reaching Psoriasis Area and Severity Index (PASI) 75 (which meant equal to or more than 75% reduction in PASI score), Withdrawal due to side‐effects, and Clearance rate. In one RCT of NB‐UVB compared with oral PUVA in participants with CPP, the difference in PASI 75 was not statistically significant (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.63 to 1.32; N = 51; low quality). In three other RCTs of CPP, the clearance rates were inconsistent because in one, there was no difference between the groups (RR 1.01, 95% CI 0.91 to 1.12; N = 54), and in the other two, the clearance rates were statistically significantly in favour of oral PUVA: RR 0.66, 95% CI 0.47 to 0.93; N = 93 and RR 0.75, 95% CI 0.59 to 0.96; N = 100, respectively. Pooled data from these three studies indicated that withdrawals due to adverse events were not significantly different between either group (RR 0.71, 95% CI 0.20 to 2.54; N = 247; low quality). The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate for CPP was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the NB‐UVB and bath PUVA groups (RR 1.79, 95% CI 0.46 to 6.91; N = 92; low quality), while a parallel RCT favoured bath PUVA (RR 0.18, 95% CI 0.05 to 0.71; N = 36; low quality). In participants with PPP, one RCT found there were no significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate (RR 0.09, 95% CI 0.01 to 1.56; N = 50; low quality). Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or GP in terms of clearance rate (RR 0.93, 95% CI 0.79 to 1.10; N = 90; low quality). One RCT in people with CPP found no significant differences between NB‐UVB and selective BB‐UVB in terms of clearance rate (RR 1.40, 95% CI 0.92 to 2.13; N = 100; low quality) and withdrawals due to adverse events (RR 3.00, 95% CI 0.32 to 27.87; N = 100; low quality). No studies reported our primary outcomes for NB‐UVB compared with conventional BB‐UVB. Authors' conclusions Current evidence is very heterogeneous and needs to be interpreted with caution. The clearance rate between oral PUVA and NB‐UVB is inconsistent among the included studies. Evidence regarding NB‐UVB versus bath PUVA is also inconsistent. Re‐NB‐UVB and re‐PUVA are similarly effective for treating people with CPP or GP. In practice, NB‐UVB may be more convenient to use since exogenous photosensitiser is not required before phototherapy. NB‐UVB is considered ineffective for PPP in clinical practice, and a small RCT did not detect a statistically significant difference between NB‐UVB and topical PUVA for clearing PPP. NB‐UVB seemed to be similar to selective BB‐UVB for clearing CPP. Larger prospective studies are needed to confirm the long‐term safety of NB‐UVB. Plain language summary Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for treating psoriasis Psoriasis is a common, chronic inflammatory skin disease, with an estimated global prevalence ranging from 0.5% to 4.6%. Based on clinical features, psoriasis is generally divided into the following: chronic plaque psoriasis (CPP); psoriasis associated with psoriatic arthritis; and pustular, erythrodermic, or guttate psoriasis. We also considered psoriasis affecting the palms and soles (palmoplantar psoriasis, or PPP). Although psoriasis is rarely life‐threatening, it can affect a person's quality of life significantly. Phototherapy is an essential treatment option for people with psoriasis. The most commonly used types of phototherapy are narrow‐band ultraviolet B (NB‐UVB), broad‐band ultraviolet B (BB‐UVB), and psoralen ultraviolet A photochemotherapy (PUVA). PUVA can be further divided into oral, bath, and topical PUVA according to the administrative route of psoralen. NB‐UVB delivers almost exclusively 311 nm radiation, whereas BB‐UVB can be divided into two types: selective BB‐UVB (305 to 325 nm radiation) and conventional BB‐UVB (280 to 320 nm radiation). This review included 13 small randomised controlled trials (RCT), with a total of 662 participants. Most of these were of poor methodological quality. For treating CPP, the clearance rate between the NB‐UVB and oral PUVA groups were inconsistent in three RCTs. In one, there was no difference between the groups, and in the other two, the clearance rate was in favour of oral PUVA. The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the two groups, while another RCT favoured bath PUVA. Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or guttate psoriasis. One RCT found no significant differences between NB‐UVB and selective BB‐UVB for clearing CPP or in the number of withdrawals due to side‐effects. In participants with PPP, one RCT found there were no statistically significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate. In summary, NB‐UVB may be preferred to oral or bath PUVA because it is more convenient to use. NB‐UVB seemed to be equal to selective BB‐UVB for clearing CPP. Evidence regarding NB‐UVB and conventional BB‐UVB is limited. The long‐term safety of NB‐UVB needs to be confirmed. The efficacy of NB‐UVB for clearing PPP needs to be confirmed in future studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Chen, X, Yang, M, Cheng, Y, Liu, GJ, Zhang, M", "articleTypes": [], "doi": "10.1002/14651858.CD009481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.118Z" }, { "id": "9073d2f4-3f0f-4995-969c-777459b35565", "pmid": "", "title": "Topical silver diamine fluoride (SDF) for preventing and managing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is the world's most prevalent disease. Untreated caries can cause pain and negatively impact psychosocial health, functioning, and nutrition. It is important to identify cost‐effective, easy‐to‐use agents, which can prevent or arrest caries. This review evaluates silver diamine fluoride (SDF). Objectives To assess the effects of silver diamine fluoride for preventing and managing caries in primary and permanent teeth (coronal and root caries) compared to any other intervention including placebo or no treatment. Search methods We searched CENTRAL, MEDLINE, Embase, Cochrane Oral Health's Trial Register and two clinical trials registers in June 2023. Selection criteria We included randomised controlled trials (RCTs), with parallel‐group or split‐mouth design, in children and adults (with or without carious lesions) that compared SDF with placebo or no treatment; different frequencies, concentrations or duration of SDF; or any other intervention. Data collection and analysis We used standard methodological procedures expected by Cochrane, and GRADE to assess the certainty of the evidence. We collected data for primary caries prevention (change in caries increment), arrest of carious lesions, secondary prevention of caries (lesions do not progress from initial classification), adverse effects, dental pain or sensitivity, and aesthetics at the end of study follow‐up. Main results We included 29 RCTs (13,036 participants; 12,020 children, 1016 older adults). We summarise outcome data for the five most clinically relevant comparisons. All studies included high risks of bias, and some findings were imprecise (e.g. because of small sample sizes). SDF versus placebo or no treatment (14 studies; 2695 children, 905 older adults) Compared to placebo or no treatment, SDF may help prevent new caries in the primary dentition (1 study, 373 participants), or on the coronal surfaces of permanent dentition (1 study, 373 participants) but the evidence is very uncertain. SDF likely prevents new root caries (mean difference (MD) −0.79 surfaces, 95% confidence interval (CI) −1.40 to −0.17; 3 studies, 439 participants; moderate‐certainty evidence). SDF may help arrest caries in the primary dentition (MD 0.86 surfaces, 95% CI 0.39 to 1.33; 2 studies, 841 participants; low‐certainty evidence) and the permanent dentition (coronal: 1 study, 373 participants; root: 1 study, 158 participants) but the evidence is very uncertain. The evidence is very uncertain for secondary prevention of caries (primary dentition: 1 study, 128 participants; permanent dentition (coronal): 1 study, 663 participants), for adverse effects (5 studies, 1299 participants), and aesthetics (1 study, 43 participants). Different approaches to SDF application (5 studies, 1808 children) Studies compared different frequencies or intervals of application, different concentrations of SDF, and different durations of treatment. Some studies included multiple comparisons of different approaches. Because of the different approaches, we could not combine findings from these studies. Due to very low‐certainty evidence, we were unsure whether any approach to SDF application was better than another for caries arrest (4 studies, including 8 comparisons of different approaches, 1360 participants); secondary prevention of caries (1 study, 203 participants), or led to differences in adverse effects (3 studies, 1121 children) or aesthetics (1 study, 119 children). SDF versus fluoride varnish (8 studies, 2868 children, 223 older adults) Compared to flouride varnish, SDF may result in little or no difference to the prevention of new caries in the primary dentition (MD 0.00, 95% CI ‐0.26 to 0.26; 1 study, 434 participants; low‐certainty evidence). The evidence is very uncertain for this outcome measure in the permanent dentition (coronal: 1 study, 237 participants; root: 1 study, 100 participants; very low‐certainty evidence). Due to very low‐certainty evidence, we were unsure whether or not there were any differences between flouride varnish (applied weekly for three applications) and SDF for caries arrest and secondary prevention of caries in the primary dentition (1 study, 309 participants). Similarly, we were unsure of adverse effects (3 studies, 980 children), dental pain or sensitivity (1 study, 62 children), or aesthetics (1 study, 263 children). SDF versus sealants and resin infiltration (2 studies, 343 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other for primary prevention of caries in permanent dentition (coronal: 1 study, 242 participants), or adverse effects (2 studies, 336 participants). SDF versus atraumatic restorative treatment (ART) with glass ionomer cement (GIC) or GI material (4 studies, 610 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other at arresting caries in the primary dentition (1 study, 143 participants). We were also unsure whether there were any differences between treatments in adverse effects (3 studies, 482 participants), dental pain or sensitivity (1 study, 234 participants), or aesthetics (2 studies, 248 participants). Authors' conclusions In the primary dentition, evidence remains uncertain whether SDF prevents new caries or progression of existing caries compared to placebo or no treatment, but it may offer benefit over placebo or no treatment in caries arrest. Compared to placebo or no treatment, SDF probably also helps prevent new root caries. However, the evidence is uncertain for other caries outcome measures in this dentition and in all caries outcomes for coronal surfaces of permanent dentition. Compared to flouride varnish, SDF may offer little or no benefit in preventing new caries in the primary dentition, but the evidence is very uncertain for other caries outcome measures in the primary dentition and for preventing new caries in the permanent dentition. We were unable to establish whether one SDF treatment approach was better than another, or how SDF compared to other treatments, because of very low‐certainty evidence. The impact of SDF staining of teeth was poorly reported and the evidence for adverse effects is very uncertain. Additional well‐conducted studies are needed. These should measure the impact of staining and be analysed to take account of clustering issues within participants. Plain language summary Is silver diamine fluoride varnish an effective treatment for preventing and managing tooth decay in children and adults? Key messages ‐ We can't tell if silver diamine fluoride (SDF) is better than no treatment at preventing or treating tooth decay. ‐ We can't tell if SDF is better or worse than other treatments at preventing or treating tooth decay. ‐ New studies could help to find out about the unwanted effects of SDF, whether people are bothered by the staining on the teeth caused by SDF, and the best treatment approach. What is tooth decay? Tooth decay happens when bacteria in your mouth break down sugars from food, producing acids that damage tooth enamel (hard surfaces). This can lead to holes, or cavities, in the teeth. Tooth decay affects the crown of the tooth (the part above the gum) of baby teeth, and the crown and root of permanent teeth. If it is not prevented or treated it can cause toothache, infections and tooth loss. How is tooth decay treated? Treatments for tooth decay include liquids, gels (varnishes) and sealants. These treatments are painted onto the tooth to protect against bacteria. Treatment may also include fillings in larger cavities. Silver diamine fluoride (SDF) is a low‐cost liquid that can be painted on a tooth by a dentist or another trained person. It is suitable for people of all ages, including people with special health needs. However, SDF can permanently stain the treated tooth surface black or dark brown. What did we want to find out? We wanted to find out: ‐ if SDF was better than no treatment or other treatments at preventing new tooth decay, stopping existing tooth decay or preventing tooth decay from progressing; ‐ if there were benefits to applying SDF for different numbers of times, strengths of solution, or durations; ‐ if SDF caused unwanted effects, toothache, or if people were bothered by staining. What did we do? We searched for studies that compared SDF with no treatment or placebo (a dummy treatment), other treatments, or different application approaches. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 29 studies, with 12,020 children and 1016 older adults. Main results Compared with no treatment or placebo, we can't tell if SDF prevents new tooth decay in baby teeth or crown surfaces of permanent teeth. SDF is likely to prevent new tooth decay on root surfaces of permanent teeth. It may also completely stop existing tooth decay in baby teeth. However, we are unsure if it completely stops existing tooth decay on crown and root surfaces of permanent teeth, prevents existing tooth decay from progressing in any types of teeth, increases the risk of unwanted effects, or if people are bothered by the appearance of staining. Studies used different combinations of treatment approaches (number of times SDF is applied and how often, the strength of solution, and duration of treatment). We can't tell if one approach is better than another at stopping or preventing further decay, unwanted effects, or bother with appearance of staining. When SDF is compared with fluoride varnish, neither treatment may be better than the other at preventing new tooth decay in baby teeth. We are unsure about the effect on crown and root surfaces of permanent teeth. We also can't tell if either treatment is better than the other at stopping existing tooth decay or preventing further decay in baby teeth, or if there are any differences in unwanted effects, toothache, or bother with appearance of staining. When SDF is compared with sealants, we can't tell if there are any differences between treatments in preventing new tooth decay on the crown surfaces of permanent teeth, or whether there are any differences between these treatments in unwanted effects. When SDF is compared with fillings (with tooth decay first removed using only hand tools), we can't tell if there were any differences between treatments in stopping existing decay in baby teeth, unwanted effects, toothache, or bother with appearance of staining. What are the limitations of the evidence? Often we were very unsure of the evidence for the following reasons. ‐ SDF stains the teeth. Everyone in the studies would have known what treatment they were given. This might affect their usual teeth‐brushing routine. In most studies, the person checking teeth for new or existing decay would also have known this information. ‐ When we compared different approaches to SDF, the studies were too different from one another to allow us to compare them. ‐ Although we found 29 studies, most evidence was from individual (or few) studies, which were very small. How current is this evidence? The evidence is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Worthington, HV, Lewis, SR, Glenny, A-M, Huang, SS, Innes, NPT, O'Malley, L, Riley, P, Walsh, T, Wong, MC, Clarkson, JE, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012718.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.069Z" }, { "id": "907efeaa-9c56-4b48-b286-12c9dc19131e", "pmid": "", "title": "Pharmacological interventions for self‐harm in adults", "imported": false, "abstract": "Abstract - Background Self‐harm (SH; intentional self‐poisoning or self‐injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm. Objectives To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta‐analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients. Search methods For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co‐ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013. Selection criteria We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services. Data collection and analysis We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta‐analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow‐up. For this analysis, we pooled data using a random‐effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach. Main results We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low‐dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported. Authors' conclusions Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment. Plain language summary Drugs and natural products for self‐harm in adults We have reviewed the international literature regarding pharmacological (drug) and natural product (dietary supplementation) treatment trials in this field. A total of seven trials meeting our inclusion criteria were identified. There is little evidence of beneficial effects of either pharmacological or natural product treatments. However, few trials have been conducted and those that have are small, meaning that possible beneficial effects of some therapies cannot be ruled out. Why is this review important? Self‐harm (SH), which includes intentional self‐poisoning/overdose and self‐injury, is a major problem in many countries and is strongly linked to suicide. It is therefore important that effective treatments for SH patients are developed. Whilst there has been an increase in the use of psychosocial interventions for SH in adults (which is the focus of a separate review), drug treatments are frequently used in clinical practice. It is therefore important to assess the evidence for their effectiveness. Who will be interested in this review? Clinicians working with patients who engage in SH, patients themselves, and their relatives. What questions does this review aim to answer? This review is an update of a previous Cochrane review from 1999 which found little evidence of beneficial effects of drug treatments on repetition of SH apart from for flupenthixol. This update aims to further evaluate the evidence for effectiveness of drugs and natural products for patients with SH with a broader range of outcomes. Which studies were included in the review? To be included in the review, studies had to be randomised controlled trials of drug treatments for adults who had recently engaged in SH. What does the evidence from the review tell us? There is currently no clear evidence for the effectiveness of antidepressants, antipsychotics, mood stabilisers, or natural products in preventing repetition of SH. What should happen next? We recommend further trials of drugs for SH patients, possibly in combination with psychological treatment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hawton, K; Witt, KG; Taylor Salisbury, TL; Arensman, E; Gunnell, D; Hazell, P; Townsend, E; van Heeringen, K", "articleTypes": [], "doi": "10.1002/14651858.CD011777", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "907f968b-7e1f-4c16-b2c3-35283b276b40", "pmid": "", "title": "Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco", "imported": false, "abstract": "Abstract - Background Overeating and harmful alcohol and tobacco use have been linked to the aetiology of various non‐communicable diseases, which are among the leading global causes of morbidity and premature mortality. As people are repeatedly exposed to varying sizes and shapes of food, alcohol and tobacco products in environments such as shops, restaurants, bars and homes, this has stimulated public health policy interest in product size and shape as potential targets for intervention. Objectives 1) To assess the effects of interventions involving exposure to different sizes or sets of physical dimensions of a portion, package, individual unit or item of tableware on unregulated selection or consumption of food, alcohol or tobacco products in adults and children. 2) To assess the extent to which these effects may be modified by study, intervention and participant characteristics. Search methods We searched CENTRAL, MEDLINE, EMBASE, PsycINFO, eight other published or grey literature databases, trial registries and key websites up to November 2012, followed by citation searches and contacts with study authors. This original search identified eligible studies published up to July 2013, which are fully incorporated into the review. We conducted an updated search up to 30 January 2015 but further eligible studies are not yet fully incorporated due to their minimal potential to change the conclusions. Selection criteria Randomised controlled trials with between‐subjects (parallel‐group) or within‐subjects (cross‐over) designs, conducted in laboratory or field settings, in adults or children. Eligible studies compared at least two groups of participants, each exposed to a different size or shape of a portion of a food (including non‐alcoholic beverages), alcohol or tobacco product, its package or individual unit size, or of an item of tableware used to consume it, and included a measure of unregulated selection or consumption of food, alcohol or tobacco. Data collection and analysis We applied standard Cochrane methods to select eligible studies for inclusion and to collect data and assess risk of bias. We calculated study‐level effect sizes as standardised mean differences (SMDs) between comparison groups, measured as quantities selected or consumed. We combined these results using random‐effects meta‐analysis models to estimate summary effect sizes (SMDs with 95% confidence intervals (CIs)) for each outcome for size and shape comparisons. We rated the overall quality of evidence using the GRADE system. Finally, we used meta‐regression analysis to investigate statistical associations between summary effect sizes and variant study, intervention or participant characteristics. Main results The current version of this review includes 72 studies, published between 1978 and July 2013, assessed as being at overall unclear or high risk of bias with respect to selection and consumption outcomes. Ninety‐six per cent of included studies (69/72) manipulated food products and 4% (3/72) manipulated cigarettes. No included studies manipulated alcohol products. Forty‐nine per cent (35/72) manipulated portion size, 14% (10/72) package size and 21% (15/72) tableware size or shape. More studies investigated effects among adults (76% (55/72)) than children and all studies were conducted in high‐income countries ‐ predominantly in the USA (81% (58/72)). Sources of funding were reported for the majority of studies, with no evidence of funding by agencies with possible commercial interests in their results. A meta‐analysis of 86 independent comparisons from 58 studies (6603 participants) found a small to moderate effect of portion, package, individual unit or tableware size on consumption of food (SMD 0.38, 95% CI 0.29 to 0.46), providing moderate quality evidence that exposure to larger sizes increased quantities of food consumed among children (SMD 0.21, 95% CI 0.10 to 0.31) and adults (SMD 0.46, 95% CI 0.40 to 0.52). The size of this effect suggests that, if sustained reductions in exposure to larger‐sized food portions, packages and tableware could be achieved across the whole diet, this could reduce average daily energy consumed from food by between 144 and 228 kcal (8.5% to 13.5% from a baseline of 1689 kcal) among UK children and adults. A meta‐analysis of six independent comparisons from three studies (108 participants) found low quality evidence for no difference in the effect of cigarette length on consumption (SMD 0.25, 95% CI ‐0.14 to 0.65). One included study (50 participants) estimated a large effect on consumption of exposure to differently shaped tableware (SMD 1.17, 95% CI 0.57 to 1.78), rated as very low quality evidence that exposure to shorter, wider bottles (versus taller, narrower bottles) increased quantities of water consumed by young adult participants. A meta‐analysis of 13 independent comparisons from 10 studies (1164 participants) found a small to moderate effect of portion or tableware size on selection of food (SMD 0.42, 95% CI 0.24 to 0.59), rated as moderate quality evidence that exposure to larger sizes increased the quantities of food people selected for subsequent consumption. This effect was present among adults (SMD 0.55, 95% CI 0.35 to 0.75) but not children (SMD 0.14, 95% CI ‐0.06 to 0.34). In addition, a meta‐analysis of three independent comparisons from three studies (232 participants) found a very large effect of exposure to differently shaped tableware on selection of non‐alcoholic beverages (SMD 1.47, 95% CI 0.52 to 2.43), rated as low quality evidence that exposure to shorter, wider (versus taller, narrower) glasses or bottles increased the quantities selected for subsequent consumption among adults (SMD 2.31, 95% CI 1.79 to 2.83) and children (SMD 1.03, 95% CI 0.41 to 1.65). Authors' conclusions This review found that people consistently consume more food and drink when offered larger‐sized portions, packages or tableware than when offered smaller‐sized versions. This suggests that policies and practices that successfully reduce the size, availability and appeal of larger‐sized portions, packages, individual units and tableware can contribute to meaningful reductions in the quantities of food (including non‐alcoholic beverages) people select and consume in the immediate and short term. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. We are unable to highlight clear implications for tobacco or alcohol policy due to identified gaps in the current evidence base. Plain language summary Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco Review question We reviewed the evidence to establish by how much the amounts of food, alcohol or tobacco adults and children select or consume change in response to being presented with larger or smaller‐sized (or differently shaped) portions or packages of these products, or of items of tableware (such as plates or glasses) used to consume them. Study characteristics This review includes 72 randomised controlled trials (RCTs) published up to July 2013 that compared at least two groups of participants, each presented with a different size of a portion, package or item of tableware. Included studies measured the amounts of food, alcohol or tobacco selected and/or consumed by participants, typically over a period of one day or less. Almost all of the included studies investigated food, with only three tobacco studies and no alcohol studies found. Almost all assessed participants' responses to different sizes rather than different shapes. The average age of participants in the different studies ranged from three to 55 years, with more studies involving adults than children and most conducted in the USA. Sources of funding were reported for the majority of studies and there was no evidence of study funding by agencies with commercial interests in their results. Key findings and quality of evidence Effects of size on consumption: We found evidence that people consistently ate more food or drank more non‐alcoholic drinks when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. We estimate the size of this effect to be small to moderate among both children and adults. If an effect of this size were sustained across the whole diet it would be equivalent to around a 12% to 16% change in average daily energy intake from food among UK adults. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations arising from incomplete or unclear reporting of methods and procedures. From three tobacco studies, we found no effect of longer compared with shorter cigarettes on the amounts of tobacco consumed. We rated the overall quality of evidence for this effect as low due to concerns about study limitations and not having enough evidence. Effects of shape on consumption: One study found that adults provided with shorter, wider bottles drank larger amounts of water from them, having already poured more, compared with those provided with taller, narrower bottles. However, we rated the quality of this evidence as very low, due to very serious concerns about study limitations and not having enough evidence (only one study with outcome data from 50 participants). Effects of size on selection: We further found that adults, but not children, consistently chose (selected) more food (including non‐alcoholic drinks) when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. The estimated size of this effect was again small to moderate. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations. Effects of shape on selection: Evidence from three studies suggested that adults and children provided with shorter, wider bottles or glasses selected increased quantities of non‐alcoholic beverages for subsequent consumption, compared with those provided with taller, narrower bottles or glasses. We rated the quality of this evidence as low, again due to concerns about study limitations and unexplained variation in effects between the three studies. Conclusions Overall, this review provides the most conclusive evidence to date that acting to reduce the size, availability and appeal of larger‐sized portions, packages and tableware has potential to reduce the quantities of food that people select and consume by meaningful amounts. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. Our findings highlight the need for further research that aims to reduce uncertainties about these effects and address identified gaps in the evidence base, including not having enough evidence for longer‐term effects and the absence of evidence about alcohol products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hollands, GJ; Shemilt, I; Marteau, TM; Jebb, SA; Lewis, HB; Wei, Y; Higgins, JPT; Ogilvie, D", "articleTypes": [], "doi": "10.1002/14651858.CD011045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "908f21bf-1593-4f11-a5fd-843fd39e2307", "pmid": "", "title": "Chinese herbal medicine for primary dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Conventional treatment for primary dysmenorrhoea has a failure rate of 20% to 25% and may be contraindicated or not tolerated by some women. Chinese herbal medicine may be a suitable alternative. Objectives To determine the efficacy and safety of Chinese herbal medicine for primary dysmenorrhoea when compared with placebo, no treatment, and other treatment. Search methods The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007), EMBASE (1980 to January 2007), CINAHL (1982 to January 2007), AMED (1985 to January 2007), CENTRAL (The Cochrane Library issue 4, 2006), China National Knowledge Infrastructure (CNKI, 1990 to January 2007), Traditional Chinese Medicine Database System (TCMDS, 1990 to December 2006), and the Chinese BioMedicine Database (CBM, 1990 to December 2006) were searched. Citation lists of included trials were also reviewed. Selection criteria Any randomised controlled trials involving Chinese herbal medicine versus placebo, no treatment, conventional therapy, heat compression, another type of Chinese herbal medicine, acupuncture or massage. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra‐uterine contraceptive device. Data collection and analysis Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Data were combined for meta‐analysis using either Peto odds ratios or relative risk (RR) for dichotomous data or weighted mean difference for continuous data. A fixed‐effect statistical model was used, where suitable. If data were not suitable for meta‐analysis, any available data from the trial were extracted and presented as descriptive data. Main results Thirty‐nine randomised controlled trials involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for Chinese herbal medicine compared to placebo were unclear as data could not be combined (3 RCTs). Chinese herbal medicine resulted in significant improvements in pain relief (14 RCTs; RR 1.99, 95% CI 1.52 to 2.60), overall symptoms (6 RCTs; RR 2.17, 95% CI 1.73 to 2.73) and use of additional medication (2 RCTs; RR 1.58, 95% CI 1.30 to 1.93) when compared to use of pharmaceutical drugs. Self‐designed Chinese herbal formulae resulted in significant improvements in pain relief (18 RCTs; RR 2.06, 95% CI 1.80 to 2.36), overall symptoms (14 RCTs; RR 1.99, 95% CI 1.65 to 2.40) and use of additional medication (5 RCTs; RR 1.58, 95% CI 1.34 to 1.87) after up to three months of follow‐up when compared to commonly used Chinese herbal health products. Chinese herbal medicine also resulted in better pain relief than acupuncture (2 RCTs; RR 1.75, 95% CI 1.09 to 2.82) and heat compression (1 RCT; RR 2.08, 95% CI 2.06 to 499.18). Authors' conclusions The review found promising evidence supporting the use of Chinese herbal medicine for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials. Plain language summary Chinese herbal medicine may help reduce menstrual pain. Dysmenorrhoea is a very common complaint that refers to painful menstrual cramps in abdomen. Primary dysmenorrhoea refers to pain of an unknown cause (i.e. no medical condition is identified). Nonsteroidal anti‐inflammatory drugs or the contraceptive pill have been used successfully for treatment but more women are looking for non‐drug therapies. Chinese herbal medicine has been used for centuries in China and it is currently used in public hospitals in China for the treatment of primary dysmenorrhoea. The review found promising evidence for the use of Chinese herbal medicine in reducing menstrual pain in the treatment of primary dysmenorrhoea, compared to conventional medicine such as NSAIDs and the oral contraceptive pill, acupuncture and heat compression. No significant adverse effects were identified in this review. However the findings should be interpreted with caution due to the generally low methodological quality of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Zhu, X, Proctor, M, Bensoussan, A, Wu, E, Smith, CA", "articleTypes": [], "doi": "10.1002/14651858.CD005288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.116Z" }, { "id": "90cda096-a8e1-465c-b144-de5aa1a1530b", "pmid": "", "title": "Chewing gum for postoperative recovery of gastrointestinal function", "imported": false, "abstract": "Abstract - Background Ileus commonly occurs after abdominal surgery, and is associated with complications and increased length of hospital stay (LOHS). Onset of ileus is considered to be multifactorial, and a variety of preventative methods have been investigated. Chewing gum (CG) is hypothesised to reduce postoperative ileus by stimulating early recovery of gastrointestinal (GI) function, through cephalo‐vagal stimulation. There is no comprehensive review of this intervention in abdominal surgery. Objectives To examine whether chewing gum after surgery hastens the return of gastrointestinal function. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), MEDLINE (via PubMed), EMBASE (via Ovid), CINAHL (via EBSCO) and ISI Web of Science (June 2014). We hand‐searched reference lists of identified studies and previous reviews and systematic reviews, and contacted CG companies to ask for information on any studies using their products. We identified proposed and ongoing studies from clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform and meta Register of Controlled Trials. Selection criteria We included completed randomised controlled trials (RCTs) that used postoperative CG as an intervention compared to a control group. Data collection and analysis Two authors independently collected data and assessed study quality using an adapted Cochrane risk of bias (ROB) tool, and resolved disagreements by discussion. We assessed overall quality of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Studies were split into subgroups: colorectal surgery (CRS), caesarean section (CS) and other surgery (OS). We assessed the effect of CG on time to first flatus (TFF), time to bowel movement (TBM), LOHS and time to bowel sounds (TBS) through meta‐analyses using a random‐effects model. We investigated the influence of study quality, reviewers’ methodological estimations and use of Enhanced Recovery After Surgery (ERAS) programmes using sensitivity analyses. We used meta‐regression to explore if surgical site or ROB scores predicted the extent of the effect estimate of the intervention on continuous outcomes. We reported frequency of complications, and descriptions of tolerability of gum and cost. Main results We identified 81 studies that comprised 9072 participants for inclusion in our review. We categorised many studies at high or unclear risk of the bias' assessed. There was statistical evidence that use of CG reduced TFF [overall reduction of 10.4 hours (95% CI: ‐11.9, ‐8.9): 12.5 hours (95% CI: ‐17.2, ‐7.8) in CRS, 7.9 hours (95% CI: –10.0, ‐5.8) in CS, 10.6 hours (95% CI: ‐12.7, ‐8.5) in OS]. There was also statistical evidence that use of CG reduced TBM [overall reduction of 12.7 hours (95% CI: ‐14.5, ‐10.9): 18.1 hours (95% CI: ‐25.3, ‐10.9) in CRS, 9.1 hours (95% CI: ‐11.4, ‐6.7) in CS, 12.3 hours (95% CI: ‐14.9, ‐9.7) in OS]. There was statistical evidence that use of CG slightly reduced LOHS [overall reduction of 0.7 days (95% CI: ‐0.8, ‐0.5): 1.0 days in CRS (95% CI: ‐1.6, ‐0.4), 0.2 days (95% CI: ‐0.3, ‐0.1) in CS, 0.8 days (95% CI: ‐1.1, ‐0.5) in OS]. There was statistical evidence that use of CG slightly reduced TBS [overall reduction of 5.0 hours (95% CI: ‐6.4, ‐3.7): 3.21 hours (95% CI: ‐7.0, 0.6) in CRS, 4.4 hours (95% CI: ‐5.9, ‐2.8) in CS, 6.3 hours (95% CI: ‐8.7, ‐3.8) in OS]. Effect sizes were largest in CRS and smallest in CS. There was statistical evidence of heterogeneity in all analyses other than TBS in CRS. There was little difference in mortality, infection risk and readmission rate between the groups. Some studies reported reduced nausea and vomiting and other complications in the intervention group. CG was generally well‐tolerated by participants. There was little difference in cost between the groups in the two studies reporting this outcome. Sensitivity analyses by quality of studies and robustness of review estimates revealed no clinically important differences in effect estimates. Sensitivity analysis of ERAS studies showed a smaller effect size on TFF, larger effect size on TBM, and no difference between groups for LOHS. Meta‐regression analyses indicated that surgical site is associated with the extent of the effect size on LOHS (all surgical subgroups), and TFF and TBM (CS and CRS subgroups only). There was no evidence that ROB score predicted the extent of the effect size on any outcome. Neither variable explained the identified heterogeneity between studies. Authors' conclusions This review identified some evidence for the benefit of postoperative CG in improving recovery of GI function. However, the research to date has primarily focussed on CS and CRS, and largely consisted of small, poor quality trials. Many components of the ERAS programme also target ileus, therefore the benefit of CG alongside ERAS may be reduced, as we observed in this review. Therefore larger, better quality RCTS in an ERAS setting in wider surgical disciplines would be needed to improve the evidence base for use of CG after surgery. Plain language summary Chewing gum after surgery to help recovery of the digestive system Background When people have surgery on their abdomen, the digestive system can stop working for a few days. This is called ileus, and can be painful and uncomfortable. There are different causes of ileus, and several ways of treating or preventing it. One possible way of preventing ileus is by chewing gum. The idea is that chewing gum tricks the body into thinking it is eating, causing the digestive system to start working again. It is important to do this review because ileus is common: it is estimated that up to a third of people having bowel surgery suffer from ileus. Main Findings This review found 81 relevant studies that recruited over 9000 participants in total. The studies mainly focussed on people having bowel surgery or caesarean section, but there were some studies of other surgery types. There were few studies of children. Most studies were of poor quality, which may mean their results are less reliable. We found some evidence that people who chewed gum after an operation were able to pass wind and have bowel movements sooner than people who did not chew gum. We also found some evidence that people who chewed gum after an operation had bowel sounds (gurgling sounds heard using a stethoscope held to the abdomen) slightly sooner than people who did not chew gum. There was a small difference in how long people stayed in hospital between people who did or did not chew gum. There were no differences in complications (such as infection or death) between people who did or did not chew gum. There was also no difference in the overall cost of treatment between people who did or did not chew gum. Conclusions There is some evidence that chewing gum after surgery may help the digestive system to recover. However, the studies included in this review are generally of poor quality, which meant that their results may not be reliable. We also know that there are many factors affecting ileus, and that modern treatment plans attempt to reduce risk of ileus. Therefore to further explore using chewing gum after surgery, more studies would be needed which are larger, of better quality, include different types of surgery, and consider recent changes in health care systems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Short, V; Herbert, G; Perry, R; Atkinson, C; Ness, AR; Penfold, C; Thomas, S; Andersen, HK; Lewis, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD006506.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "90e61c80-7ec6-41ef-8188-161a6da2a1a0", "pmid": "", "title": "Tranexamic acid for patients with nasal haemorrhage (epistaxis)", "imported": false, "abstract": "Abstract - Background Epistaxis (nosebleed) most commonly affects children and the elderly. The majority of episodes are managed at home with simple measures. In more severe cases medical intervention is required to either cauterise the bleeding vessel, or to pack the nose with various materials. Tranexamic acid is used in a number of clinical settings to stop bleeding by preventing clot breakdown (fibrinolysis). It may have a role in the management of epistaxis as an adjunct to standard treatments, reducing the need for further intervention. Objectives To determine the effects of tranexamic acid (oral, intravenous or topical) compared with placebo, no additional intervention or any other haemostatic agent in the management of patients with epistaxis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register (via CRS Web); Central Register of Controlled Trials (CENTRAL) (via CRS Web); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 October 2018. Selection criteria Randomised controlled trials (RCTs) of tranexamic acid (in addition to usual care) compared with usual care plus placebo, usual care alone or usual care plus any other haemostatic agent, to control epistaxis in adults or children. Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were control of epistaxis: re‐bleeding (as measured by the proportion of patients re‐bleeding within a period of up to 10 days) and significant adverse effects (seizures, thromboembolic events). Secondary outcomes were control of epistaxis as measured by the time to stop initial bleeding (the proportion of patients whose bleeding is controlled within a period of up to 30 minutes); severity of re‐bleeding (as measured by (a) the proportion of patients requiring any further intervention and (b) the proportion of patients requiring blood transfusion); length of hospital stay and other adverse effects. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included six RCTs (692 participants). The overall risk of bias in the studies was low. Two studies assessed oral administration of tranexamic acid, given regularly over several days, and compared it to placebo. In the other four studies, a single application of topical tranexamic acid was compared with placebo (one study) and a combination of epinephrine and lidocaine or phenylephrine (three studies). All participants were adults. Tranexamic acid versus placebo For our primary outcome, control of epistaxis: re‐bleeding (proportion re‐bleeding within 10 days), we were able to pool data from three studies. The pooled result demonstrated a benefit of tranexamic acid compared to placebo, the risk of re‐bleeding reducing from 67% to 47% (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; three studies; 225 participants; moderate‐quality evidence ). When we compared the effects of oral and topical tranexamic acid separately the risk of re‐bleeding with oral tranexamic acid reduced from 69% to 49%, RR 0.73 (95% CI 0.55 to 0.96; two studies, 157 participants; moderate‐quality evidence ) and with topical tranexamic acid it reduced from 66% to 43%, RR 0.66 (95% CI 0.41 to 1.05; single study, 68 participants). We rated the quality of evidence provided by the single study as low , therefore it is uncertain whether topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. No study specifically sought to identify and report our primary outcome: significant adverse effects (i.e. seizures, thromboembolic events). The secondary outcome time to stop initial bleeding (proportion with bleeding controlled within 30 minutes) was measured in one study using topical tranexamic acid and there was no evidence of a difference at 30 minutes (RR 0.79, 95% CI 0.56 to 1.11; 68 participants; low‐quality evidence ). No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery, embolisation). One study of oral tranexamic acid reported the proportion of patients requiring blood transfusion and found no difference between groups: 5/45 (11%) versus 6/44 (14%) (RR 0.81, 95% CI 0.27 to 2.48; 89 participants; low‐quality evidence ). Two studies reported hospital length of stay. One study reported a significantly shorter stay in the oral tranexamic acid group (mean difference (MD) ‐1.60 days, 95% CI ‐2.49 to ‐0.71; 68 participants). The other study found no evidence of a difference between the groups. Tranexamic acid versus other haemostatic agents When we pooled the data from three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the topical tranexamic acid group compared to the group receiving another haemostatic agent (70% versus 30%: RR 2.35, 95% CI 1.90 to 2.92; 460 participants) ( moderate‐quality evidence ). Adverse effects across all studies Five studies recorded 'adverse effects' in a general way. None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient developed a superficial thrombophlebitis of both legs following discharge, however it is not reported in which group this occurred. No \"other serious adverse effect\" was reported in any study. Authors' conclusions We found moderate‐quality evidence that there is probably a reduction in the risk of re‐bleeding with the use of either oral or topical tranexamic acid in addition to usual care in adult patients with epistaxis, compared to placebo with usual care. However, the quality of evidence relating solely to topical tranexamic acid was low (one study only), so we are uncertain whether or not topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. We found moderate‐quality evidence that topical tranexamic acid is probably better than other topical agents in stopping bleeding in the first 10 minutes. There have been only three RCTs on this subject since 1995. Since then there have been significant changes in nasal cauterisation and packing techniques (for example, techniques including nasal endoscopy and more invasive approaches such as endoscopic sphenopalatine artery ligation). New trials would inform us about the effectiveness of tranexamic acid in light of these developments. Plain language summary Tranexamic acid to help treat nosebleeds (epistaxis) Background Nosebleeds are a very common condition, with the majority of those affected either children or those over the age of 60. They usually stop on their own or by simply compressing the nose with fingers, although a small number require medical attention. This will involve either cauterising (sealing) the bleeding vessel, if it can be seen, or packing the inside of the nose with a material to cause pressure to build up and stop the bleeding ('usual care'). Occasionally bleeding continues despite these measures, or it restarts having initially been controlled. This can lead to a prolonged hospital stay and the possibility of further procedures such as repacking with a different type of nasal pack or an operation. Tranexamic acid is a drug that is known to help promote blood clotting by preventing a natural process called fibrinolysis (dissolution of a clot). It is already used in a number of situations where bleeding is a significant worry, such as after heart surgery or major trauma. It can be given by mouth (orally), directly to the bleeding site (topically) or by injection into a vein (intravenously). Study characteristics We searched for randomised controlled trials in patients of any age with nosebleed requiring intervention. Patients were treated with tranexamic acid (in addition to usual care) compared to placebo, no treatment or any other agent used to stop bleeding. We found six studies that met our inclusion criteria, with a total of 692 participants. Two studies used oral administration of tranexamic acid and four used topical administration. All participants in the studies were adults. Three of the six studies were conducted over 20 years ago. Key results Three studies measured re‐bleeding within 10 days. When we combined the results we found that fewer patients who were given either oral or topical tranexamic acid had further episodes of re‐bleeding following an initial nosebleed compared to those treated with usual care. The time to stop initial bleeding (control of bleeding within 30 minutes) was measured in four studies. In three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the group receiving topical tranexamic acid compared to the group receiving a different drug (topical epinephrine and lidocaine or phenylephrine). In the other study there was no significant difference at 30 minutes when topical tranexamic acid was compared with placebo. No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery). Only one study of oral tranexamic acid reported the proportion of patients requiring a blood transfusion and there was no evidence of a difference between the groups. Length of hospital stay was reported in two studies. One study reported a significantly shorter stay in the oral tranexamic acid group, while the other found no evidence of a difference. Five studies mention recording \"adverse effects\". None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient did develop a superficial thrombophlebitis (inflammation and a blood clot in a vein near the surface of the skin) of both legs following discharge, but the study did not report in which treatment group this happened. No serious adverse event was seen in any of the studies. Quality of the evidence and conclusions Overall, the risk of bias in the six studies was low. We graded the quality of the evidence for the main outcome (control of epistaxis: re‐bleeding within 10 days) as moderate, which means that further research is likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate. In light of this and the fact that 'usual care' has changed, with the development of more modern nasal cauterisation and packing techniques, since three of the included studies were carried out, there remains uncertainty about the role of tranexamic acid in the treatment of patients with epistaxis. Newer research into the effect of tranexamic acid as a treatment for nosebleeds would inform future management decisions for this condition. The evidence in this review is up to date to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Joseph, J; Martinez‐Devesa, P; Bellorini, J; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "90f25555-4300-43e5-bfe4-563b669cc071", "pmid": "", "title": "Aversive smoking for smoking cessation", "imported": false, "abstract": "Abstract - Background Aversion therapy pairs the pleasurable stimulus of smoking a cigarette with some unpleasant stimulus. The objective is to extinguish the urge to smoke. Objectives This review has two aims: First, to determine the efficacy of rapid smoking and other aversive methods in helping smokers to stop smoking; Second, to determine whether there is a dose‐response effect on smoking cessation at different levels of aversive stimulation. Search methods We searched the Cochrane Tobacco Addiction Group specialised register (latest search date October 2009) for studies which evaluated any technique of aversive smoking. Selection criteria Randomized trials which compared aversion treatments with 'inactive' procedures or which compared aversion treatments of different intensity for smoking cessation. Trials must have reported follow up of least six months from beginning of treatment. Data collection and analysis We extracted data in duplicate on the study population, the type of aversion treatment, the outcome measure, method of randomization and completeness of follow up. The outcome measure was abstinence from smoking at maximum follow up, using the strictest measure reported by the authors. Subjects lost to follow up were regarded as smokers. Where appropriate, we performed meta‐analysis using a fixed effect model. Main results Twenty‐five trials met the inclusion criteria. Twelve included rapid smoking and nine used other aversion methods. Ten trials included two or more conditions allowing assessment of a dose‐response to aversive stimulation. The odds ratio (OR) for abstinence following rapid smoking compared to control was 2.01 (95% confidence intervals (CI): 1.36 to 2.95). Several factors suggest that this finding should be interpreted cautiously. A funnel plot of included studies was asymmetric, due to the relative absence of small studies with negative results. Most trials had a number of serious methodological problems likely to lead to spurious positive results. The only trial using biochemical validation of all self reported cessation gave a non‐significant result. Other aversion methods were not shown to be effective (OR 1.15, 95% CI 0.73 to 1.82). There was a borderline dose‐response to the level of aversive stimulation (OR 1.67, 95% CI 0.99 to 2.81). Authors' conclusions The existing studies provide insufficient evidence to determine the efficacy of rapid smoking, or whether there is a dose‐response to aversive stimulation. Milder versions of aversive smoking seem to lack specific efficacy. Rapid smoking is an unproven method with sufficient indications of promise to warrant evaluation using modern rigorous methodology. Plain language summary Does smoking in a way that is unpleasant help smokers to quit Aversion treatments pair undesirable behaviours with negative sensations. In smoking cessation, several approaches have been suggested such as rapid smoking, which requires smokers to take a puff every few seconds to make smoking unpleasant. The results of the existing trials suggest that this may be effective, but the evidence is not conclusive because most of the studies of this approach have methodological problems. A recent laboratory study also suggests that the method has an active ingredient. Further research may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Hajek, P; Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "90f3bc71-a479-4e8f-a41d-a73aa4a3e922", "pmid": "", "title": "Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults", "imported": false, "abstract": "Abstract - Background The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non‐opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. Objectives To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. Selection criteria We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. Data collection and analysis We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. Main results We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after). The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies. IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) −0.50, 95% confidence interval (CI) −0.72 to −0.28; 29 studies, 1656 participants; very low‐quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD −0.14, 95% CI −0.25 to −0.04; 33 studies, 1847 participants; moderate‐quality evidence), and at late time points (48 hours) (SMD −0.11, 95% CI −0.25 to 0.04; 24 studies, 1404 participants; moderate‐quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures. We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) −7.92 hours, 95% CI −12.71 to −3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD −4.52 mg morphine equivalents , 95% CI −6.25 to −2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes. The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low‐quality evidence). IV Lidocaine compared to TEA The effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI −0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI −1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD −1.66, 95% CI −10.88 to 7.56; 2 studies, 102 participants); all very low‐quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low‐quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low‐quality evidence). Authors' conclusions We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review. Plain language summary Intravenous infusion of lidocaine starting at the time of surgery for reduction of pain and improvement of recovery after surgery Background The most common problems immediately following surgery under general anaesthesia are pain, nausea and vomiting, delirium and slow or no movement of food through the digestive system. Opioid medications given to reduce postoperative pain may also be associated with nausea and constipation, also preventing a smooth recovery. It is of interest for patients and clinicians to reduce or prevent these complications leading to an early recovery so that patients can leave hospital earlier. One option for pain relief after surgery is epidural analgesia, where an opioid or local anaesthetic such as lidocaine is injected into the space surrounding the spinal cord. Not all patients may be suited to epidural analgesia, and so additional options such as intravenous non‐opioid analgesic medications that enable a rapid recovery are required. The aim of this review was to assess the benefits and risks of intravenous infusion of lidocaine in patients undergoing various surgical procedures. Lidocaine is a medication used to numb tissue in a specific area. Study characteristics This review was published in 2015, and updated in 2017. We found 68 randomized controlled studies (RCTs), (clinical studies where people are randomly put into one of two or more treatment groups), with results from a total of 4525 participants. RCTs are used because they provide the most reliable evidence. Intravenous lidocaine was compared with placebo or standard care in 66 of the studies, and with thoracic (chest area of spine) epidural analgesia in two studies. (A placebo is an inactive substance or procedure given to a participant in a medical trial to compare its effects with those of a real drug or other intervention). Lidocaine infusion was started during the surgery, before the first cut, and continued to at least the end of surgery. The included studies were moderately well conducted. Key results We are uncertain whether lidocaine infusion reduces pain, one to four hours after surgery when compared to placebo or usual care (29 studies, over 1600 participants). There was probably no difference in pain at 24 hours (33 studies, 1847 participants) and at 48 hours (24 studies, 1404 participants) between participants in the lidocaine and the placebo group. We are uncertain whether lidocaine infusion improves recovery of bowel function, with a reduction in the time to first defaecation or bowel movements (12 studies, 684 participants), and reduced risk of stopping the passage of food in the gut (4 studies, 273 participants). We are also uncertain whether lidocaine reduces postoperative nausea (35 studies, 1903 participants), and the requirement for opioids for pain relief (40 studies, 2201 participants). Only a limited number of studies systematically analysed adverse effects of intravenous lidocaine infusion. The side effects of intravenous lidocaine were unclear. In the two studies that investigated intravenous lidocaine compared to epidural analgesia (102 participants), the effect on pain at 24 and 48 hours, and on the time to first bowel movement, remains unclear. The effect of lidocaine on the risk of stopping the passage of food in the gut and for postoperative nausea is also unclear, as only one small trial assessed these outcomes. Neither study investigated the effect on pain immediately after surgery, or on opioid consumption. Both studies looked at adverse effects associated with lidocaine, but the effect is uncertain. Quality of the evidence We rated the quality of evidence for most outcomes as very low. This was because of inconsistent findings across studies and the fact that the evidence came from small studies that were of moderate design quality or a limited number of studies. The quality of the evidence for minimal or no effect on pain at 24 and 48 hours was moderate quality. The studies involved a variety of surgical procedures. The dose of lidocaine used, and how long it was delivered for after the end of surgery, also varied between studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Weibel, S, Jelting, Y, Pace, NL, Helf, A, Eberhart, LHJ, Hahnenkamp, K, Hollmann, MW, Poepping, DM, Schnabel, A, Kranke, P", "articleTypes": [], "doi": "10.1002/14651858.CD009642.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.751Z" }, { "id": "90ff9b2b-55c6-4c93-8d35-0f90a1e189f0", "pmid": "", "title": "Effect of adrenergic agonist oral decongestants on blood pressure", "imported": false, "abstract": "Abstract - Background Adrenergic agonist oral decongestants are commonly taken daily over long periods of time to relieve sinus and nasal congestion. The mechanism of action of decongestants potentially increases blood pressure, and these effects may be acute or chronic. However, no systematic reviews to date have comprehensively assessed the chronic blood pressure effects of adrenergic agonist oral decongestants as a drug class, despite their widespread non‐prescription availability. Objectives Primary objective To assess the effects of adrenergic agonist oral decongestants on systolic and diastolic blood pressure compared to placebo. Secondary objective To assess the effects of adrenergic agonist oral decongestants on heart rate and withdrawals due to adverse effects. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCT) up to July 2024: Cochrane Hypertension Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Register of Studies, Ovid MEDLINE, Ovid Embase, and ClinicalTrials.gov. There were no language, publication year, or publication status restrictions. Selection criteria We included RCTs of at least seven days' duration with parallel groups (intervention and placebo) comparing adrenergic agonist oral decongestants versus placebo on blood pressure in people aged over six years. Data collection and analysis Two review authors (JJC and MC) independently assessed the trials for inclusion, extracted the data, and assessed the risk of bias from the included trials. In cases where there were disagreements, the third review author (JMW) adjudicated. For any missing or unclear information in the studies, we contacted the study author to request the missing information or seek clarification. The primary outcomes were systolic blood pressure and diastolic blood pressure. Secondary outcomes were heart rate and withdrawal due to adverse effects. We used a fixed‐effect model to combine the effect sizes from all studies. We assessed the certainty of the evidence using GRADE. Main results Five RCTs randomizing 882 participants met the inclusion criteria. The shortest study duration was one week, and the longest study duration was 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The largest study included 568 people, and the smallest study included 18 people. The mean age of participants was 20.0 years, with 326 males and 591 females. The studies were conducted in the USA and Europe; most were set in the USA. Pharmaceutical companies funded three of the five included studies. The findings are relevant to all people using adrenergic agonist oral decongestants for seven days or longer regardless of comorbidities or pre‐existing conditions. The adrenergic agonist oral decongestants included were ephedrine (one RCT), pseudoephedrine (one RCT), and phenylpropanolamine (three RCTs). Compared to placebo, adrenergic agonist oral decongestants may have little to no effect on systolic blood pressure , but the evidence is very uncertain (mean difference [MD] 0.91 mmHg, 95% confidence interval [CI] −0.57 to 2.38; 4 RCTs, 784 participants; I 2 = 54%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on diastolic blood pressure (MD 0.44 mmHg, 95% CI −0.59 to 1.48; 5 RCTs, 882 participants; I 2 = 30%; low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on heart rate, but the evidence is very uncertain (MD 1.92 beats per minute, 95% CI −0.62 to 4.47; 2 RCTs, 190 participants; I 2 = 79%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on the number of withdrawals due to adverse effects (risk ratio [RR] 1.20, 95% CI 0.37 to 3.88; 4 RCTs, 806 participants; low‐certainty evidence; note 1 study reported withdrawals due to adverse effects but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 3 studies rather than 4). Four studies were at overall high risk of bias, and one study was at overall low risk of bias. Authors' conclusions In this systematic review, chronic daily intake of adrenergic agonist oral decongestants had little to no effect on blood pressure, heart rate, and withdrawals due to adverse effects. People making decisions about using these medicines should consider the very low certainty of evidence and the theoretical risk of increased blood pressure. Independent trials free from biases that are designed to answer this question are required. The evidence was limited due to the small number of studies, and the blood pressure and heart rate not being measured at the optimal time after drug ingestion. Plain language summary What are the effects of oral decongestants on blood pressure? Key messages – We found no evidence that taking oral decongestants (medicine taken by mouth to relieve a stuffy nose) daily for a week or more changes blood pressure or heart rate or causes people to stop taking them due to unwanted effects. – There were only a few studies, and they were not well designed. More well‐conducted studies are needed. – Given that oral decongestants are sometimes taken daily for weeks or months, and have the potential to increase blood pressure, people should consider this potential risk alongside the limited evidence from this review when deciding whether to use these medicines. What are oral decongestants? Oral decongestants are medications taken by mouth to relieve nasal congestion (stuffy or blocked nose), often caused by colds, allergies, or sinus infections (small, empty spaces behind the cheekbones and forehead that are connected to the nose). They typically include medicines called pseudoephedrine or phenylephrine. How do oral decongestants work? These medicines shrink swollen blood vessels in the nasal passages. This reduces swelling and allows air to flow more freely, helping you breathe easier. What is hypertension? Hypertension (high blood pressure) is when resting blood pressure is consistently above 140/90 mmHg. It can lead to unwanted effects such as stroke (where the blood supply to parts of the brain is reduced or stopped) and heart attack (where the blood supply to the heart is reduced or stopped). Lowering blood pressure is the easiest way to reduce these diseases. How is hypertension treated? Treating hypertension involves lifestyle measures and taking blood pressure‐lowering medicines. Here, we focused on the effects of daily intake of oral decongestants. While these medicines help with nasal congestion, they may also increase blood pressure. What do we want to find out? We wanted to find out whether long‐term use of oral decongestants (for seven days or longer) increases blood pressure and has any unwanted effects. We also evaluated their effectiveness in relieving nasal congestion. This provides essential insights into their benefits and risks to guide informed use. What did we do? We searched for studies that compared the blood pressure effects of oral decongestants with placebo. A placebo is a substance or treatment with no active ingredients that is used in medical research to compare against the effects of real medications. We then compared and summarized the results, and rated our confidence in the evidence depending on the study design and methods. What did we find? We found five studies involving 882 children and adults (326 males and 591 females). The shortest study lasted one week, with the longest study lasting 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The size of the studies ranged from 18 to 568 people, and most were done in the USA. Pharmaceutical companies funded three studies. We found no clear evidence that taking oral decongestants daily changes blood pressure or heart rate, or causes people to stop taking them due to unwanted effects. What are the limitations of the evidence? There was a limited number of studies, and they were not well designed. None of the studies were primarily designed to assess the long‐term effects of oral decongestants on blood pressure. Trials designed to answer this question are needed. How up to date is the evidence? The evidence is up to date to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Chan, JJ; Chan, M; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007895.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "9101eec4-bddf-4b09-80fb-35c09142562a", "pmid": "", "title": "Drugs for the acute treatment of migraine in children and adolescents", "imported": false, "abstract": "Abstract - Background Numerous medications are available for the acute treatment of migraine in adults, and some have now been approved for use in children and adolescents in the ambulatory setting. A systematic review of acute treatment of migraine medication trials in children and adolescents will help clinicians make evidence‐informed management choices. Objectives To assess the effects of pharmacological interventions by any route of administration versus placebo for migraine in children and adolescents 17 years of age or less. For the purposes of this review, children were defined as under 12 years of age and adolescents 12 to 17 years of age. Search methods We searched seven bibliographic databases and four clinical trial registers as well as gray literature for studies through February 2016. Selection criteria We included prospective randomized controlled clinical trials of children and adolescents with migraine, comparing acute symptom relieving migraine medications with placebo in the ambulatory setting. Data collection and analysis Two reviewers screened titles and abstracts and reviewed the full text of potentially eligible studies. Two independent reviewers extracted data for studies meeting inclusion criteria. We calculated the risk ratios (RRs) and number needed to treat for an additional beneficial outcome (NNTB) for dichotomous data. We calculated the risk difference (RD) and number needed to treat for an additional harmful outcome (NNTH) for proportions of adverse events. The percentage of pain‐free patients at two hours was the primary efficacy outcome measure. We used adverse events to evaluate safety and tolerability. Secondary outcome measures included headache relief, use of rescue medication, headache recurrence, presence of nausea, and presence of vomiting. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables. Main results We identified a total of 27 randomized controlled trials (RCTs) of migraine symptom‐relieving medications, in which 9158 children and adolescents were enrolled and 7630 (range of mean age between 8.2 and 14.7 years) received medication. Twenty‐four studies focused on drugs in the triptan class, including almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, sumatriptan + naproxen sodium, and zolmitriptan. Other medications studied included paracetamol (acetaminophen), ibuprofen, and dihydroergotamine (DHE). More than half of the studies evaluated sumatriptan. All but one study reported adverse event data. Most studies presented a low or unclear risk of bias, and the overall quality of evidence, according to GRADE criteria, was low to moderate, downgraded mostly due to imprecision and inconsistency. Ibuprofen was more effective than placebo for producing pain freedom at two hours in two small studies that included 162 children (RR 1.87, 95% confidence interval (CI) 1.15 to 3.04) with low quality evidence (due to imprecision). Paracetamol was not superior to placebo in one small study of 80 children. Triptans as a class of medication were superior to placebo in producing pain freedom in 3 studies involving 273 children (RR 1.67, 95% CI 1.06 to 2.62, NNTB 13) (moderate quality evidence) and 21 studies involving 7026 adolescents (RR 1.32, 95% CI 1.19 to 1.47, NNTB 6) (moderate quality evidence). There was no significant difference in the effect sizes between studies involving children versus adolescents. Triptans were associated with an increased risk of minor (non‐serious) adverse events in adolescents (RD 0.13, 95% CI 0.08 to 0.18, NNTH 8), but studies did not report any serious adverse events. The risk of minor adverse events was not significant in children (RD 0.06, 95% CI − 0.04 to 0.17, NNTH 17). Sumatriptan plus naproxen sodium was superior to placebo in one study involving 490 adolescents (RR 3.25, 95% CI 1.78 to 5.94, NNTB 6) (moderate quality evidence). Oral dihydroergotamine was not superior to placebo in one small study involving 13 children. Authors' conclusions Low quality evidence from two small trials shows that ibuprofen appears to improve pain freedom for the acute treatment of children with migraine. We have only limited information on adverse events associated with ibuprofen in the trials included in this review. Triptans as a class are also effective at providing pain freedom in children and adolescents but are associated with higher rates of minor adverse events. Sumatriptan plus naproxen sodium is also effective in treating adolescents with migraine. Plain language summary Drugs for the acute treatment of migraine in children and adolescents Background and review question Migraine is a painful and debilitating disorder that is common in children (under 12 years of age) and adolescents (12 to 17 years of age). Common symptoms reported during a migraine attack are headache, nausea, vomiting, and sensitivity to light and sound. Many treatments for migraine are available, of which the most common are paracetamol (also known as acetaminophen), ibuprofen and other anti‐inflammatories, and triptans. Not all triptan medications are approved for use in children or adolescents, and approvals vary from country to country. Study characteristics In our review, we looked at 27 randomized controlled trials of drugs compared to placebo to find out which treatments were effective at providing pain freedom two hours after treatment. We also wanted to know what side effects might be caused by the treatments. A total of 7630 children received medication in the studies. The evidence is current to February 2016. Each study had between 13 and 888 participants. Their average age was 12.9 years and ranged from 8.2 to 14.7 years. Nineteen of the studies were funded by the drug manufacturer. Key results Ibuprofen appears to be effective in treating children with migraine, but the evidence is limited to only two small trials. Ibuprofen is readily available and inexpensive, making it an excellent first choice for migraine treatment. Paracetamol was not shown to be effective in providing pain freedom in children, but we only found one small study. Triptans are a type of medication designed specifically to treat migraine and are often effective at providing greater pain freedom in children and adolescents. The triptans examined in children included rizatriptan and sumatriptan, while almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan were examined in adolescents. The combination of sumatriptan plus naproxen sodium is also effective at treating adolescents with migraine. Overall, there is a risk that the triptan medications may cause minor unwanted side effects like taste disturbance, nasal symptoms, dizziness, fatigue, low energy, nausea, or vomiting. The studies did not report any serious side effects. Quality of the evidence The overall quality of the evidence provided by the review was moderate for the triptans, but low for paracetamol and ibuprofen, as we only identified a few studies. More studies need to look at the effects of each of the migraine treatments in children and adolescents separately.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Richer, L, Billinghurst, L, Linsdell, MA, Russell, K, Vandermeer, B, Crumley, ET, Durec, T, Klassen, TP, Hartling, L", "articleTypes": [], "doi": "10.1002/14651858.CD005220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.748Z" }, { "id": "910256f3-a850-4163-ba03-ba6eb7876218", "pmid": "", "title": "Interventions for oropharyngeal dysphagia in children with neurological impairment", "imported": false, "abstract": "Abstract - Background Oropharyngeal dysphagia encompasses problems with the oral preparatory phase of swallowing (chewing and preparing the food), oral phase (moving the food or fluid posteriorly through the oral cavity with the tongue into the back of the throat) and pharyngeal phase (swallowing the food or fluid and moving it through the pharynx to the oesophagus). Populations of children with neurological impairment who commonly experience dysphagia include, but are not limited to, those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). Objectives To examine the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. Search methods We searched the following electronic databases in October 2011: CENTRAL 2011(3), MEDLINE (1948 to September Week 4 2011), EMBASE (1980 to 2011 Week 40)
, CINAHL (1937 to current)
, ERIC (1966 to current), PsycINFO (1806 to October Week 1 2011), Science Citation Index (1970 to 7 October 2011), Social Science Citation Index (1970 to 7 October 2011), Cochrane Database of Systematic Reviews, 2011(3), DARE 2011(3), Current Controlled Trials (ISRCTN Register) (15 October 2011), ClinicalTrials.gov (15 October 2011) and WHO ICTRP (15 October 2011). We searched for dissertations and theses using Networked Digital Library of Theses and Dissertations, Australasian Digital Theses Program and DART‐Europe E‐theses Portal (11 October 2011). Finally, additional references were also obtained from reference lists from articles. Selection criteria The review included randomised controlled trials and quasi‐randomised controlled trials for children with oropharyngeal dysphagia and neurological impairment. Data collection and analysis All three review authors (AM, PD and EW) independently screened titles and abstracts for inclusion and discussed results. In cases of uncertainty over whether an abstract met inclusion criterion, review authors obtained the full‐text article and independently evaluated each paper for inclusion. The data were categorised for comparisons depending on the nature of the control group (for example, oral sensorimotor treatment versus no treatment). Effectiveness of the oropharyngeal dysphagia intervention was assessed by considering primary outcomes of physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency a child is able to consume. Secondary outcomes were changes in growth, child’s level of participation in the mealtime routine and the level of parent or carer stress associated with feeding. Main results Three studies met the inclusion criteria for the review. Two studies were based on oral sensorimotor interventions for participants with cerebral palsy compared to standard care and a third study trialled lip strengthening exercises for children with myotonic dystrophy type 1 compared to no treatment ( Sjogreen 2010 ). A meta‐analysis combining results across the three studies was not possible because one of the studies had participants with a different condition, and the remaining two, although using oral sensorimotor treatments, used vastly different approaches with different intensities and durations. The decision not to combine these was in line with our protocol. In this review, we present the results from individual studies for four outcomes: physiological functions of the oropharyngeal mechanism for swallowing, the presence of chest infection and pneumonia, diet consistency, and changes in growth. However, it is not possible to reach definitive conclusions on the effectiveness of particular interventions for oropharyngeal dysphagia based on these studies. One study had a high risk of attrition bias owing to missing data, had statistically significant differences (in weight) across experimental and control groups at baseline, and did not describe other aspects of the trial sufficiently to enable assessment of other potential risks of bias. Another study was at high risk of detection bias as some outcomes were assessed by parents who knew whether their child was in the intervention or control group. The third study overall seemed to be at low risk of bias, but like the other two studies, suffered from a small sample size. Authors' conclusions The review demonstrates that there is currently insufficient high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials to provide conclusive results about the effectiveness of any particular type of oral‐motor therapy for children with neurological impairment. There is an urgent need for larger‐scale (appropriately statistically powered), randomised trials to evaluate the efficacy of interventions for oropharyngeal dysphagia. Plain language summary Interventions for swallowing difficulty in children with neurological impairment Oropharyngeal dysphagia, or swallowing difficulty, can be defined as problems with chewing and preparing food, difficulty moving food through the mouth to the back of the tongue, and difficulty with swallowing and movement of food through the 'throat' or pharynx. Many children with neurological impairment experience swallowing difficulties, including those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). This review examined the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. The three studies included in the review examined oral sensorimotor treatments and lip strengthening interventions. We were interested in three primary outcomes, which were physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency, and three secondary outcomes, which were changes in growth, child's level of participation in the mealtime routine, and the level of parent or carer stress associated with feeding. We concluded that there is currently not enough high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials for any particular type of oropharyngeal dysphagia intervention in this population of children. There is a need for larger‐scale randomised controlled trials to evaluate the effects of interventions for oropharyngeal dysphagia in children with neurological impairment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Morgan, AT; Dodrill, P; Ward, EC", "articleTypes": [], "doi": "10.1002/14651858.CD009456.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "91082cb0-d644-4272-bfa1-201bb021926f", "pmid": "", "title": "Using Fenfluramine to Test the Serotonin Deficiency Theory of Depression", "imported": false, "abstract": "Clinical depression is a common and disabling condition characterised by persistent low mood and loss of interest that interferes with daily functioning. Serotonin is a key brain neurotransmitter involved in mood regulation, and a leading theory proposes that depression is associated with impaired serotonin function (the serotonin deficiency hypothesis), which underpins the use of selective serotonin reuptake inhibitors (SSRIs) as first-line antidepressant treatments. However, the strength and specificity of the link between serotonin dysfunction and depressive symptoms in humans remains uncertain and requires direct evidence in living human brains.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.247Z" }, { "id": "910bc9a9-f7cf-42ff-95d2-c2a7c1ce03f2", "pmid": "", "title": "Antiviral treatment for preventing postherpetic neuralgia", "imported": false, "abstract": "Abstract - Background Postherpetic neuralgia (PHN) is a painful and refractory complication of herpes zoster. Treatments are either partially or totally ineffective for many people with PHN. Antiviral agents, used at the time of the rash, have been proposed as an intervention to prevent the development of PHN. This is the first update since the first publication of the review in 2009. Objectives To assess the effectiveness of antiviral agents in preventing PHN. Search methods On 26 April 2013, we updated the searches in the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and the Chinese Biomedical Retrieval System. We checked the references of published studies to identify additional trials, and contacted authors to obtain additional data. We searched other databases in The Cochrane Library for information for the Discussion and two clinical trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) of antiviral treatment given within 72 hours after the onset of herpes zoster for preventing PHN. There were no language restrictions. Data collection and analysis Two authors independently selected trials, evaluated the risk of bias in included trials, and extracted and analysed data. Main results Six RCTs with a total of 1211 participants were eligible; five trials evaluated oral aciclovir, and one, with 419 participants, evaluated oral famciclovir. We were able to conduct meta‐analyses as there were sufficient similarities in the included studies, such as the reporting of the presence of PHN, duration of rash before treatment initiation and treatment regimen. For our primary outcome, based on three trials (609 participants) we found no significant difference between the aciclovir and control groups in the incidence of PHN four months after the onset of the acute herpetic rash (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.51 to 1.11), nor was there a significant difference at six months (RR 1.05, 95% CI 0.87 to 1.27, two trials, 476 participants). In four of the trials (692 participants), there was some evidence for a reduction in the incidence of pain four weeks after the onset of rash. In the trial of famciclovir versus placebo, neither 500 mg nor 750 mg doses of famciclovir reduced the incidence of herpetic neuralgia significantly. The most commonly reported adverse events were nausea, vomiting, diarrhoea and headache for aciclovir, and headache and nausea for famciclovir. For neither treatment was the incidence of adverse events significantly different from placebo. None of the studies were at high risk of bias, although the risk of bias was unclear in at least one domain for all but one study. We found no new RCTs when we updated the searches in April 2013. Authors' conclusions There is high quality evidence that oral aciclovir does not reduce the incidence of PHN significantly. In addition, there is insufficient evidence to determine the effect of other antiviral treatments; therefore, further well‐designed RCTs are needed to investigate famciclovir or other new antiviral agents in preventing PHN. Future trials should pay more attention to the severity of pain and quality of life of participants, and should be conducted among different subgroups of people, such as people who are immunocompromised. Plain language summary Antiviral treatment for preventing nerve pain after shingles (postherpetic neuralgia) Review question We reviewed the evidence about the effect of antiviral medicines for preventing postherpetic neuralgia (PHN). Background PHN is a painful condition that can occur after shingles (herpes zoster) in the area where the rash occurred. Many people with PHN find that treatments work only a little or not at all. Attention has therefore turned to stopping the development of PHN. Some people suggested that medicines that target the virus that causes shingles (antiviral medicines), given at the time of the rash, might prevent PHN. The aim of this review was to assess the whether antiviral medicines are able to prevent PHN. Study characteristics We identified six clinical trials that met our standards for inclusion in the review. They included a total of 1319 participants. We decided that our main measure of whether antiviral medicines work in preventing PHN would be whether or not PHN had developed six months after a first attack of shingles (some of the studies we included of aciclovir measured PHN at four months). Key results and quality of the evidence Aciclovir, which is an antiviral medicine, was used in five trials (900 participants) and was not better than a placebo (dummy pill) in preventing PHN. In the other trial (419 participants), famciclovir, which is another antiviral drug, was no better than placebo in preventing pain following healing of the shingles rash. The number of side effects with aciclovir and famciclovir was not very different from the number with placebo. The trials did not have any major problems of design or conduct that put the results in doubt, although most of the reports did not provide enough information to fully assess every aspect. We conclude that according to high quality evidence, oral aciclovir was ineffective in reducing the incidence of PHN and there is not enough evidence on other antiviral treatments. There need to be further well‐designed trials of famciclovir or other new antiviral agents with a greater number of participants. Future trials should pay more attention to the severity of pain and quality of life of participants, and should include different groups of people, such as those who have lowered immunity. The evidence is current to April 2013, when the searches were last updated. Because new evidence on this topic is slow to emerge, we have scheduled the next update of this review for 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Chen, N; Li, Q; Yang, J; Zhou, M; Zhou, D; He, L", "articleTypes": [], "doi": "10.1002/14651858.CD006866.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "912d1ccd-6ed1-4490-a134-40d18cc078e5", "pmid": "", "title": "Pharmacological and nutritional treatment for McArdle disease (Glycogen Storage Disease type V)", "imported": false, "abstract": "Abstract - Background McArdle disease (Glycogen Storage Disease type V) is caused by an absence of muscle phosphorylase leading to exercise intolerance, myoglobinuria rhabdomyolysis and acute renal failure. This is an update of a review first published in 2004. Objectives To review systematically the evidence from randomised controlled trials (RCTs) of pharmacological or nutritional treatments for improving exercise performance and quality of life in McArdle disease. Search methods We searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE on 11 August 2014. Selection criteria We included RCTs (including cross‐over studies) and quasi‐RCTs. We included unblinded open trials and individual patient studies in the discussion. Interventions included any pharmacological agent or nutritional supplement. Primary outcome measures included any objective assessment of exercise endurance (for example aerobic capacity (VO 2 ) max, walking speed, muscle force or power and fatigability). Secondary outcome measures included metabolic changes (such as reduced plasma creatine kinase and a reduction in the frequency of myoglobinuria), subjective measures (including quality of life scores and indices of disability) and serious adverse events. Data collection and analysis Three review authors checked the titles and abstracts identified by the search and reviewed the manuscripts. Two review authors independently assessed the risk of bias of relevant studies, with comments from a third author. Two authors extracted data onto a specially designed form. Main results We identified 31 studies, and 13 fulfilled the criteria for inclusion. We described trials that were not eligible for the review in the Discussion. The included studies involved a total of 85 participants, but the number in each individual trial was small; the largest treatment trial included 19 participants and the smallest study included only one participant. There was no benefit with: D‐ribose, glucagon, verapamil, vitamin B 6 , branched chain amino acids, dantrolene sodium, and high‐dose creatine. Minimal subjective benefit was found with low dose creatine and ramipril only for patients with a polymorphism known as the D/D angiotensin converting enzyme (ACE) phenotype. A carbohydrate‐rich diet resulted in better exercise performance compared with a protein‐rich diet. Two studies of oral sucrose given at different times and in different amounts before exercise showed an improvement in exercise performance. Four studies reported adverse effects. Oral ribose caused diarrhoea and symptoms suggestive of hypoglycaemia including light‐headedness and hunger. In one study, branched chain amino acids caused a deterioration of functional outcomes. Dantrolene was reported to cause a number of adverse effects including tiredness, somnolence, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of myalgia. Authors' conclusions Although there was low quality evidence of improvement in some parameters with creatine, oral sucrose, ramipril and a carbohydrate‐rich diet, none was sufficiently strong to indicate significant clinical benefit. Plain language summary Drug and nutritional treatment for McArdle disease Review question We reviewed the evidence about the effects of drug and nutritional treatment for McArdle disease. Background McArdle disease (also known as glycogen storage disease type V) is a disorder affecting muscle metabolism. The condition is caused by the lack of an enzyme called muscle phosphorylase. This results in an inability to break down glycogen 'fuel' stores. McArdle disease leads to pain and fatigue with strenuous exercise. Sometimes severe muscle damage develops and occasionally this results in acute reversible kidney failure. Study characteristics After a wide search, we identified 13 randomised studies that included 85 participants with McArdle disease. This is an update of a review first published in 2004. We found no new trials at this update. Key results and quality of the evidence The review found no benefit compared with placebo with the following treatments: D‐ribose, glucagon, verapamil, vitamin B 6 , oral branched chain amino acids, dantrolene sodium, high‐dose creatine and ramipril. Low dose creatine and ramipril produced minimal benefit for patients who also have the D/D angiotensin converting enzyme (ACE) phenotype. Taking low dose creatine supplements had a minor benefit in improving exercise tolerance in a small number of people with the condition. Taking a sugary drink before planned strenuous exercise can improve performance but this treatment is not practical for day‐to‐day living. A diet rich in carbohydrate may be superior to a diet rich in protein. Adverse effects were reported in four studies. Oral ribose caused symptoms suggestive of a low blood sugar including light‐headedness, hunger and diarrhoea. One study of branched chain amino acids resulted in a deterioration in participants. Dantrolene was reported to cause a number of side‐effects including tiredness, sleepiness, dizziness and muscle weakness. Low dose creatine (60 mg/kg/day) did not cause any side‐effects but high‐dose creatine (150 mg/kg/day) worsened the symptoms of muscle pain. The quality of these studies was low due to the small number of participants; the largest number in one trial was 19 and one trial had only one participant. The evidence is current to August 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Quinlivan, R, Martinuzzi, A, Schoser, B", "articleTypes": [], "doi": "10.1002/14651858.CD003458.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.745Z" }, { "id": "91348079-25bf-4780-b407-eb535f33152b", "pmid": "", "title": "Systemic opioids versus other analgesics and sedatives for postoperative pain in neonates", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kinoshita, M, Stempel, KS, Borges do Nascimento, IJ, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD014876.pub2 AB - Abstract - Background Neonates may undergo surgery because of malformations such as diaphragmatic hernia, gastroschisis, congenital heart disease, and hypertrophic pyloric stenosis, or complications of prematurity, such as necrotizing enterocolitis, spontaneous intestinal perforation, and retinopathy of prematurity that require surgical treatment. Options for treatment of postoperative pain include opioids, non‐pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported. The assessment of the effects of opioids is of utmost importance, especially for neonates in substantial pain during the postoperative period. Objectives To evaluate the benefits and harms of systemic opioid analgesics in neonates who underwent surgery on all‐cause mortality, pain, and significant neurodevelopmental disability compared to no intervention, placebo, non‐pharmacological interventions, different types of opioids, or other drugs. Search methods We searched Cochrane CENTRAL, MEDLINE via PubMed and CINAHL in May 2021. We searched the WHO ICTRP, clinicaltrials.gov, and ICTRP trial registries. We searched conference proceedings, and the reference lists of retrieved articles for RCTs and quasi‐RCTs. Selection criteria We included randomized controlled trials (RCTs) conducted in preterm and term infants of a postmenstrual age up to 46 weeks and 0 days with postoperative pain where systemic opioids were compared to 1) placebo or no intervention; 2) non‐pharmacological interventions; 3) different types of opioids; or 4) other drugs. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods, all‐cause mortality during initial hospitalization, major neurodevelopmental disability, and cognitive and educational outcomes in children more than five years old. We used the fixed‐effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) for continuous data. We used GRADE to assess the certainty of evidence for each outcome. Main results We included four RCTs enrolling 331 infants in four countries across different continents. Most studies considered patients undergoing large or medium surgical procedures (including major thoracic or abdominal surgery), who potentially required pain control through opioid administration after surgery. The randomized trials did not consider patients undergoing minor surgery (including inguinal hernia repair) and those individuals exposed to opioids before the beginning of the trial. Two RCTs compared opioids with placebo; one fentanyl with tramadol; and one morphine with paracetamol. No meta‐analyses could be performed because the included RCTs reported no more than three outcomes within the prespecified comparisons. Certainty of the evidence was very low for all outcomes due to imprecision of the estimates (downgrade by two levels) and study limitations (downgrade by one level). Comparison 1: opioids versus no treatment or placebo Two trials were included in this comparison, comparing either tramadol or tapentadol with placebo. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of tramadol compared with placebo on all‐cause mortality during initial hospitalization (RR 0.32, 95% Confidence Interval (CI) 0.01 to 7.70; RD ‐0.03, 95% CI ‐0.10 to 0.05, 71 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 2: opioids versus non‐pharmacological interventions No trials were included in this comparison. Comparison 3: head‐to‐head comparisons of different opioids One trial comparing fentanyl with tramadol was included in this comparison. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of fentanyl compared with tramadol on all‐cause mortality during initial hospitalization (RR 0.99, 95% CI 0.59 to 1.64; RD 0.00, 95% CI ‐0.13 to 0.13, 171 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 4: opioids versus other analgesics and sedatives One trial comparing morphine with paracetamol was included in this comparison. The evidence is very uncertain about the effect of morphine compared with paracetamol on COMFORT pain scores (MD 0.10, 95% CI ‐0.85 to 1.05; 71 participants, 1 study; I² = not applicable). No data were reported on the other critical outcomes, i.e. major neurodevelopmental disability; cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization; retinopathy of prematurity; or intraventricular hemorrhage. Authors' conclusions Limited evidence is available on opioid administration for postoperative pain in newborn infants compared to either placebo, other opioids, or paracetamol. We are uncertain whether tramadol reduces mortality compared to placebo; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether fentanyl reduces mortality compared to tramadol; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether morphine reduces pain compared to paracetamol; none of the studies reported major neurodevelopmental disability, cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization, retinopathy of prematurity, or intraventricular hemorrhage. We identified no studies comparing opioids versus non‐pharmacological interventions. Plain language summary Are opioids the best choice for managing pain in babies after surgery? Key messages • We did not find enough good‐quality evidence about the benefits and risks of opioids (a group of pain‐relieving medicines) to manage pain after surgery in babies. We found only four studies and they had not enrolled enough babies to give reliable results. • Larger, well‐designed studies are needed to give better estimates of the benefits and potential harms of opioids, other medicines and non‐medicine‐based treatments. Why are opioids given to manage pain after surgery in babies? Babies (particularly in the first four weeks after birth) often have to have surgeries. Similar to adults, they need constant pain management after these operations and opioids are commonly used for post‐surgery pain relief in babies. What did we want to find out? We wanted to find out the impact of giving opioids to babies having surgery, compared to: 1) no treatment or placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested); 2) non‐medicine‐based treatments (such as sweet solutions); 3) other medicines; or 4) different types of opioids. What did we do? We searched for studies that compared opioids with the four treatments described above. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included four studies that involved 331 babies. The biggest study was in 171 babies and the smallest study was in 15 babies. • Two studies compared opioids with placebo: it is unclear if opioids have an effect on mortality; no studies reported pain, long‐term development, vision problems (retinopathy of prematurity) or bleeding to the brain (intraventricular hemorrhage). • One study compared one type of opioid to another type of opioid: it is unclear if fentanyl has an effect on mortality compared to tramadol; no studies reported pain, long‐term development, vision problems or bleeding to the brain. • One study compared an opioid to a different type of pain‐relieving medicine: it is unclear if the opioid morphine has an effect on pain compared with paracetamol; no studies reported long‐term development, mortality, vision problems or bleeding to the brain. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results of our outcomes. Also, it is possible that people in the studies were aware of what treatment they were given. Not all the studies provided data about everything that we were interested in. How up‐to‐date is this review? 
We searched for studies that were available up to May 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.810Z" }, { "id": "9135f7c1-3788-40d8-b161-d10b24676278", "pmid": "", "title": "Treatments for iron‐deficiency anaemia in pregnancy", "imported": false, "abstract": "Abstract - Background Iron deficiency, the most common cause of anaemia in pregnancy worldwide, can be mild, moderate or severe. Severe anaemia can have very serious consequences for mothers and babies, but there is controversy about whether treating mild or moderate anaemia provides more benefit than harm. Objectives To assess the effects of different treatments for anaemia in pregnancy attributed to iron deficiency (defined as haemoglobin less than 11 g/dL or other equivalent parameters) on maternal and neonatal morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2011), CENTRAL (2011, Issue 5), PubMed (1966 to June 2011), the International Clinical Trials Registry Platform (ICTRP) (2 May 2011), Health Technology Assessment Program (HTA) (2 May 2011) and LATINREC (Colombia) (2 May 2011). Selection criteria Randomised controlled trials comparing treatments for anaemia in pregnancy attributed to iron deficiency. Data collection and analysis We identified 23 trials, involving 3.198 women. We assessed their risk of bias. Three further studies identified are awaiting classification. Main results Many of the trials were from low‐income countries; they were generally small and frequently methodologically poor. They covered a very wide range of differing drugs, doses and routes of administration, making it difficult to pool data. Oral iron in pregnancy showed a reduction in the incidence of anaemia (risk ratio 0.38, 95% confidence interval 0.26 to 0.55, one trial, 125 women) and better haematological indices than placebo (two trials). It was not possible to assess the effects of treatment by severity of anaemia. A trend was found between dose and reported adverse effects. Most trials reported no clinically relevant outcomes nor adverse effects. Although the intramuscular and intravenous routes produced better haematological indices in women than the oral route, no clinical outcomes were assessed and there were insufficient data on adverse effects, for example, on venous thrombosis and severe allergic reactions. Daily low‐dose iron supplements may be effective at treating anaemia in pregnancy with less gastrointestinal side effects compared with higher doses. Authors' conclusions Despite the high incidence and burden of disease associated with this condition, there is a paucity of good quality trials assessing clinical maternal and neonatal effects of iron administration in women with anaemia. Daily oral iron treatment improves haematological indices but causes frequent gastrointestinal adverse effects. Parenteral (intramuscular and intravenous) iron enhances haematological response, compared with oral iron, but there are concerns about possible important adverse effects (for intravenous treatment venous thrombosis and allergic reactions and for intramuscular treatment important pain, discolouration and allergic reactions). Large, good quality trials, assessing clinical outcomes (including adverse effects) as well as the effects of treatment by severity of anaemia are required. Plain language summary Treatments for anaemia in pregnancy thought to be due to iron deficiency When the blood has insufficient red cells, or the red cells carry insufficient haemoglobin to deliver adequate oxygen to the tissues, this is called anaemia. There is normally a reduction in the haemoglobin concentrations in the mother's blood during pregnancy, and this allows a better blood flow around the womb (uterus) and to the baby. This is sometime called physiological anaemia and needs no treatment. True anaemia, however, can be mild, moderate or severe and can cause weakness, tiredness and dizziness. Severe anaemia makes women at risk of cardiac failure and is very common in low‐income countries Anaemia has many causes including a shortage or iron, folic acid or vitamin B 12 . These are all required for making red cells and are available in a good diet. Iron shortage, however, is the most common cause of anaemia during pregnancy. Iron treatment can be given by mouth (oral), by injection into the muscle (intramuscular) or injection into the vein (intravenous). Blood transfusion or giving something which stimulates the body to produce more red cells (erythropoietin) are also possible treatments. In this review, we identified 23 trials involving 3198 pregnant women. Many of the trials were in low‐income countries and many treatment variations were studied. Oral iron reduced the incidence of anaemia but is known to sometimes cause constipation and nausea. Although the intramuscular and intravenous routes produced better levels of red cells and iron stores than the oral route, no clinical outcomes (such as pre‐eclampsia, preterm births, postpartum haemorrhage) were assessed and there were insufficient data on adverse effects. Intravenous treatment can cause venous thrombosis (blockages in the veins) and intramuscular treatment causes important pain and discolouration at the injection site. It was unclear if women and babies were healthier when women were given iron for mild or moderate anaemia during pregnancy. There were no studies on using blood transfusions. Overall, there was insufficient evidence to say when or how anaemia in pregnancy needs to or should be treated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Reveiz, L, Gyte, GML, Cuervo, LG, Casasbuenas, A", "articleTypes": [], "doi": "10.1002/14651858.CD003094.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.069Z" }, { "id": "914be5b0-3162-4bb4-9fbb-fe842cd6f755", "pmid": "", "title": "Sensory Study: Taste and Tongue Biology", "imported": false, "abstract": "Researchers will investigate the correlation between a) self-reported dietary intake of foods and beverages, b) intensity of sucrose stimuli, and c) liking rating of sweet stimuli, with the relative expression of the taste receptor genes from human fungiform papillae (TAS1R2 and TAS1R3).", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.230Z" }, { "id": "914d2740-2641-4290-8bcb-666b14483e66", "pmid": "", "title": "Immunosuppressive agents for myasthenia gravis", "imported": false, "abstract": "Abstract - Background The benefits of different immunosuppressants for myasthenia gravis (MG) are unclear. Objectives Assessment of immunosuppressant drug efficacy in MG. Search methods We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to July 2007), EMBASE (from January 1980 to July 2007), review and trial bibliographies and contacted trial authors. Selection criteria Types of studies: Randomised and quasi‐randomised controlled trials. Types of participants: Any age, any type or severity of MG regardless of concomitant treatment. Types of interventions: Any immunosuppressive agent. Types of outcome measures: Primary: 
 (1) Improvement or not at six months Secondary: 
 (1) Improvement or not at one year 
 (2) Need for other treatment, for example corticosteroid dose, at six months 
 (3) Number of exacerbations during the first year 
 (4) Acetylcholine receptor antibody titre after at least six months 
 (5) Occurrence of one or more adverse events at any time after the introduction of treatment. Data collection and analysis One author extracted and two checked the data. Main results Seven trials are included but few reported the outcomes selected for this review. A meta‐analysis of ciclosporin versus placebo from two trials (59 participants) ‐ one as monotherapy (20 participants) and the other with corticosteroids (39 participants) ‐ showed that it resulted in improvement of participants in the ciclosporin group compared with those in the placebo group, with a relative rate of improvement of 2.44 (95% confidence interval (CI) 1.13 to 5.27). In addition the weighted mean difference in QMG score between the ciclosporin and placebo groups was ‐0.34 (95% CI ‐0.52 to ‐0.17). Azathioprine (plus prednisolone for first month) had no significant benefit over prednisolone alone (41 participants). The effects of azathioprine plus prednisolone versus prednisolone plus placebo were similar (34 participants). Cyclophosphamide was reported to be statistically more efficacious than placebo at 12 months in corticosteroid‐dependent participants (23 participants), but no raw data were available. Trials of mycophenolate mofetil and tacrolimus did not provide relevant endpoint data for this review. All trials had low numbers of participants. Adverse event reporting was variable. Trial protocol heterogeneity prevented comparison of the different immunosuppressants. Authors' conclusions In generalised MG, limited evidence from small RCTs suggests that ciclosporin, as monotherapy or with corticosteroids, or cyclophosphamide with corticosteroids, significantly improve MG. 
 Limited evidence from RCTs shows no significant benefit from azathioprine (as monotherapy or with steroids), mycophenolate mofetil (as monotherapy or with either corticosteroids or ciclosporin) or tacrolimus (with corticosteroids or plasma exchange). Bigger, better‐designed, longer trials are needed. Plain language summary A review of the use of drugs that suppress the immune system (immunosuppressants) in myasthenia gravis. Myasthenia gravis (MG) is caused by antibodies produced by the immune system that impair the transmission of nerve impulses to muscles. This results in muscle weakness that characteristically fluctuates. About one person in every 10 000 ‐ 50 000 develops MG each year. The natural history of the disorder is typically a series of exacerbations and remissions. Severe attacks can be life‐threatening because of weakness of muscles involved in swallowing causing choking, and chest muscles causing difficulty with breathing. In MG, immunosuppressant drugs act mainly by reducing the production of antibodies. There were seven randomised controlled trials to include in this review. Each trial compared different interventions in generalised MG: (1) azathioprine plus initial prednisolone versus prednisolone ‐ 41 participants; (2) azathioprine plus prednisolone versus prednisolone plus placebo (dummy treatment) ‐ 34 participants; (3) ciclosporin monotherapy versus placebo ‐ 20 participants; (4) ciclosporin plus prednisolone versus prednisolone plus placebo ‐ 39 participants; (5) cyclophosphamide plus prednisolone versus prednisolone plus placebo ‐ 23 participants; (6) mycophenolate mofetil plus either ciclosporin or prednisolone or no immunosuppressants versus placebo plus either ciclosporin or prednisolone or no immunosuppressants trial ‐ 14 participants; (7) tacrolimus plus corticosteroids with or without plasma exchange versus no tacrolimus plus corticosteroids with or without plasma exchange trial ‐ 34 participants. It is difficult to draw useful clinical conclusions from this small number of often short‐term, randomised controlled trials. Each trial had relatively few participants and different trials used different study designs. The limited evidence available found that MG improved significantly with either ciclosporin (alone or in combination with corticosteroids) or cyclophosphamide (in combination with corticosteroids) compared with placebo. There is no clear evidence from randomised controlled trials of benefit for any of the immunosuppressant drugs used more commonly in MG ‐ azathioprine (alone or in combination with corticosteroids), mycophenolate mofetil (as monotherapy or in combination with either corticosteroids or ciclosporin) or tacrolimus (in combination with corticosteroids or plasma exchange or both). There is no randomised controlled trial of methotrexate in MG. Long‐term studies of the potentially formidable toxic effects of all of these drugs are lacking in MG.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Hart, IK; Sathasivam, S; Sharshar, T", "articleTypes": [], "doi": "10.1002/14651858.CD005224.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "914d2f73-86a1-43a8-b241-005b091b2770", "pmid": "", "title": "Topical antibiotics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection (involving more than one micro‐organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms are ear discharge and hearing loss. Topical antibiotics, the most common treatment for CSOM, aim to kill or inhibit the growth of micro‐organisms that may be responsible for the infection. Antibiotics can be used alone or with other treatments for CSOM, such as antiseptics or ear cleaning (aural toileting). This is an update of a Cochrane review first published in 2020 and one of a suite of seven reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To evaluate the benefits and harms of topical antibiotics (without steroids) for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials with at least a one week of follow‐up involving adults and children with chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antibiotic(s) of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic compared to placebo or no intervention, and compared to another topical antibiotic (e.g. topical antibiotic A versus topical antibiotic B). Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks and up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This update found one new study (100 participants). Overall, we included 18 studies with 1783 participants (in 16 studies), plus 108 ears that could not be accounted for in participant numbers (in two studies). 1. Topical antibiotics versus placebo or no treatment (with aural toilet in both arms and no other background treatment) One study (50 participants, data unavailable for 15 participants) compared a topical antibiotic (ciprofloxacin) with placebo (saline). All participants received aural toilet. Topical ciprofloxacin may increase resolution of discharge at one to up to two weeks compared with placebo (84% with antibiotic versus 12% with placebo; risk ratio (RR) 6.74, 95% confidence interval (CI) 1.82 to 24.99; 35 participants; very low‐certainty evidence). The study authors reported \"no medical side‐effects and worsening of audiological measurements related to this topical medication were detected.\" 2. Topical antibiotics versus placebo or no treatment (with use of oral antibiotics in both arms) Four studies (438 participants) compared topical antibiotics versus no treatment, with oral antibiotics in both arms. These compared topical ciprofloxacin to no treatment (3 studies, 190 participants) or topical ceftizoxime to no treatment (1 study, 248 participants). In each study, all participants received the same antibiotic systemically (oral ciprofloxacin or injected ceftizoxime). In at least one study, all participants received aural toilet. There were no useable data comparing topical ceftizoxime to no treatment. Topical antibiotics in addition to systemic antibiotics may increase resolution of ear discharge at one to up to two weeks compared with systemic antibiotics alone (resolution of discharge occurring in 88% with topical antibiotics versus 60% without topical antibiotics; RR 1.47, 95% CI 1.14 to 1.88; 1 study, 100 participants; low‐certainty evidence). One study (40 participants) stated \"no side effect was recorded in any patient\" (low‐certainty evidence). 3. Comparisons of different topical antibiotics Eight studies (794 participants, plus 40 ears) compared aminoglycosides (gentamicin, neomycin, or tobramycin) with quinolones (ciprofloxacin or ofloxacin). Resolution of discharge at one to up to two weeks may be higher in the quinolones group, but the evidence is very uncertain (RR 1.92, 95% CI 1.00 to 3.67; 7 studies, 794 participants; very low‐certainty evidence). There was considerable heterogeneity (I 2 = 97%). One study (308 participants) stated there were no differences between the different groups for resolution of ear discharge after four weeks (low‐certainty evidence). The evidence is very uncertain about the effects of topical antibiotics on ear pain (1 study reported no differences between groups). The evidence is very uncertain about the effects of topical antibiotics on hearing loss (2 studies reported no differences between groups). 4. Other comparisons We assessed five studies (501 participants, plus 68 ears) over the following three additional comparisons: quinolones versus aminoglycosides/polymyxin B with/without gramicidin, aminoglycosides versus trimethoprim‐sulphacetamide‐polymixin B, and rifampicin versus chloramphenicol. However, these results have not been included in the abstract. Authors' conclusions We are very uncertain about the effectiveness of topical antibiotics in improving resolution of ear discharge in people with CSOM because of the limited amount of low‐ or very low‐certainty evidence available. This was mostly due to risk of bias and imprecision. However, amongst this uncertainty, there is some evidence to suggest that the use of topical antibiotics may be effective when compared to placebo, or when used in addition to a systemic antibiotic. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine whether quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, harmful effects were poorly reported. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and harms of using topical antibiotics to treat chronic suppurative otitis media? Key messages – We are uncertain whether topical antibiotics reduce ear discharge of people with swelling and infection of the middle ear (called chronic suppurative otitis media). – Topical antibiotics may reduce ear discharge compared to placebo (a salt solution), but we are very uncertain. Topical antibiotics used in addition to an antibiotic given by mouth may reduce ear discharge. – Overall, we are very uncertain which type of topical antibiotic is the most effective. What is chronic suppurative otitis media? Chronic suppurative otitis media, also known as chronic otitis media, is a swelling and infection of the middle ear that lasts for two weeks or more. People with chronic suppurative otitis media usually have ear discharge that is difficult to get rid of or keeps coming back (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Topical antibiotics (administered into the ear canal as ear drops, ointments, sprays, or creams) are the most commonly used treatment for chronic suppurative otitis media. Topical antibiotics kill or stop the growth of the bacteria (germs) that may be responsible for the infection. Topical antibiotics can be used on their own or be added to other treatments for chronic suppurative otitis media, such as antiseptics (which also kill germs) or ear cleaning (aural toileting) or systemic antibiotics (antibiotics taken either by mouth or by an injection into a muscle or vein). What was the aim of this review? We wanted to find out how effective topical antibiotics are for people with chronic suppurative otitis media, and whether they cause unwanted effects. We also wanted to know whether one type of topical antibiotic was more beneficial or harmful than any other. In particular, we wanted to know whether topical antibiotics stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found one new study (100 participants). Overall, we found 18 studies examining at least 1783 people, but it was difficult to determine precisely how many people were included as some studies did not clearly report the number. Two studies included \"mainly children,\" three included only adults, whilst the remainder appeared to include both children and adults. None of the studies reported the inclusion of people considered at high risk of having chronic suppurative otitis media (for example, people with cleft palate (where the roof of the mouth of a baby does not join together during pregnancy) or Down's syndrome; or people whose immune system does not work well enough to fight germs). The studies used different types of antibiotics and combinations of antibiotics. Comparison of topical antibiotics to placebo or no treatment One study (50 people) compared topical antibiotics to a saline (salt water) ear wash. Topical antibiotics may reduce ear discharge more than the saline ear wash when assessed one to up to two weeks after treatment, but we are very uncertain. The evidence is very uncertain about unwanted effects and worsening of hearing measurements. The study did not measure quality of life and reported that there were no serious complications. Comparison of topical antibiotics in addition to systemic (oral or injected) antibiotics Four studies (438 people) compared treatment with topical antibiotic (ciprofloxacin) drops in addition to a systemic (oral or injected) antibiotic, but one study did not contribute data. Topical plus oral antibiotics may reduce ear discharge more than oral antibiotics alone at one to up to two weeks and two to up to four weeks. One study stated there were no unwanted effects. The studies did not measure quality of life and did not report any serious complications. Comparisons of different topical antibiotics Eight studies (794 participants plus 40 ears) compared an aminoglycoside antibiotic (gentamicin, neomycin, or tobramycin) with a quinolone antibiotic (ciprofloxacin or ofloxacin). Quinolones may reduce ear discharge better than aminoglycosides, but the evidence is very uncertain. One study (100 people) measured ear pain and reported no difference between the groups, but the evidence is very uncertain. Two studies measured hearing loss, but the evidence is very uncertain. What are the limitations of the evidence? There were several limitations with the studies. For example, the results varied widely between studies, there were small numbers of people included, there was a lack of recent data, and limited information on groups of people who are more likely to have chronic suppurative otitis media. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Brennan-Jones, CG, Head, K, Chong, LY, Daw, J, Veselinović, T, Schilder, AGM, Bhutta, MF", "articleTypes": [], "doi": "10.1002/14651858.CD013051.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.767Z" }, { "id": "917225b2-dd25-4670-91bb-3b939449ee61", "pmid": "", "title": "Population‐level interventions in government jurisdictions for dietary sodium reduction", "imported": false, "abstract": "Abstract - Background Excess dietary sodium consumption is a risk factor for high blood pressure, stroke and cardiovascular disease. Currently, dietary sodium consumption in almost every country is too high. Excess sodium intake is associated with high blood pressure, which is common and costly and accounts for significant burden of disease. A large number of jurisdictions worldwide have implemented population‐level dietary sodium reduction initiatives. No systematic review has examined the impact of these initiatives. Objectives • To assess the impact of population‐level interventions for dietary sodium reduction in government jurisdictions worldwide. • To assess the differential impact of those initiatives by social and economic indicators. Search methods We searched the following electronic databases from their start date to 5 January 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); Cochrane Public Health Group Specialised Register; MEDLINE; MEDLINE In Process & Other Non‐Indexed Citations; EMBASE; Effective Public Health Practice Project Database; Web of Science; Trials Register of Promoting Health Interventions (TRoPHI) databases; and Latin American Caribbean Health Sciences Literature (LILACS). We also searched grey literature, other national sources and references of included studies. This review was conducted in parallel with a comprehensive review of national sodium reduction efforts under way worldwide ( Trieu 2015 ), through which we gained additional information directly from country contacts. We imposed no restrictions on language or publication status. Selection criteria We included population‐level initiatives (i.e. interventions that target whole populations, in this case, government jurisdictions, worldwide) for dietary sodium reduction, with at least one pre‐intervention data point and at least one post‐intervention data point of comparable jurisdiction. We included populations of all ages and the following types of study designs: cluster‐randomised, controlled pre‐post, interrupted time series and uncontrolled pre‐post. We contacted study authors at different points in the review to ask for missing information. Data collection and analysis Two review authors extracted data, and two review authors assessed risk of bias for each included initiative. We analysed the impact of initiatives by using estimates of sodium consumption from dietary surveys or urine samples. All estimates were converted to a common metric: salt intake in grams per day. We analysed impact by computing the mean change in salt intake (grams per day) from pre‐intervention to post‐intervention. Main results We reviewed a total of 881 full‐text documents. From these, we identified 15 national initiatives, including more than 260,000 people, that met the inclusion criteria. None of the initiatives were provided in lower‐middle‐income or low‐income countries. All initiatives except one used an uncontrolled pre‐post study design. Because of high levels of study heterogeneity (I 2 > 90%), we focused on individual initiatives rather than on pooled results. Ten initiatives provided sufficient data for quantitative analysis of impact (64,798 participants). As required by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) method, we graded the evidence as very low due to the risk of bias of the included studies, as well as variation in the direction and size of effect across the studies. Five of these showed mean decreases in average daily salt intake per person from pre‐intervention to post‐intervention, ranging from 1.15 grams/day less (Finland) to 0.35 grams/day less (Ireland). Two initiatives showed mean increase in salt intake from pre‐intervention to post‐intervention: Canada (1.66) and Switzerland (0.80 grams/day more per person); however in both countries the pre‐intervention data point was from several years prior to the initiation of the intervention. The remaining initiatives did not show a statistically significant mean change. Seven of the 10 initiatives were multi‐component and incorporated intervention activities of a structural nature (e.g. food product reformulation, food procurement policy in specific settings). Of those seven initiatives, four showed a statistically significant mean decrease in salt intake from pre‐intervention to post‐intervention, ranging from Finland to Ireland (see above), and one showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention (Switzerland; see above). Nine initiatives permitted quantitative analysis of differential impact by sex (men and women separately). For women, three initiatives (China, Finland, France) showed a statistically significant mean decrease, four (Austria, Netherlands, Switzerland, United Kingdom) showed no significant change and two (Canada, United States) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. For men, five initiatives (Austria, China, Finland, France, United Kingdom) showed a statistically significant mean decrease, three (Netherlands, Switzerland, United States) showed no significant change and one (Canada) showed a statistically significant mean increase in salt intake from pre‐intervention to post‐intervention. Information was insufficient to indicate whether a differential change in mean salt intake occurred from pre‐intervention to post‐intervention by other axes of equity included in the PROGRESS framework (e.g. education, place of residence). We identified no adverse effects of these initiatives. The number of initiatives was insufficient to permit other subgroup analyses, including stratification by intervention type, economic status of country and duration (or start year) of the initiative. Many studies had methodological strengths, including large, nationally representative samples of the population and rigorous measurement of dietary sodium intake. However, all studies were scored as having high risk of bias, reflecting the observational nature of the research and the use of an uncontrolled study design. The quality of evidence for the main outcome was low. We could perform a sensitivity analysis only for impact. Authors' conclusions Population‐level interventions in government jurisdictions for dietary sodium reduction have the potential to result in population‐wide reductions in salt intake from pre‐intervention to post‐intervention, particularly if they are multi‐component (more than one intervention activity) and incorporate intervention activities of a structural nature (e.g. food product reformulation), and particularly amongst men. Heterogeneity across studies was significant, reflecting different contexts (population and setting) and initiative characteristics. Implementation of future initiatives should embed more effective means of evaluation to help us better understand the variation in the effects. Plain language summary National government initiatives to reduce salt intake in populations The problem 
 In almost all countries worldwide, most people eat too much salt. This is a problem because eating too much salt can cause high blood pressure, which can lead to health problems such as heart disease and stroke. To reduce the amount of salt eaten, governments in many countries have developed national salt reduction initiatives. The review question 
 Our aim was to examine whether national salt reduction initiatives have been effective in reducing the amount of salt consumed in those populations. Study characteristics 
 We searched research papers and government reports and had direct communication with individuals working in salt reduction in their respective countries. The evidence is current as of 5 January 2015, when we last searched electronic databases. Initiatives in 15 countries met the inclusion criteria. Ten of these countries provided sufficient data for quantitative analysis, gathered from studies that included 64,798 participants. Initiatives ranged from one activity (e.g. in Japan, which at the time of writing had a public information campaign) to many activities (e.g. in the United Kingdom, which provided five activities including on‐package nutrition information, restrictions on marketing to children and food product reformulation). Of the 15 countries that met inclusion criteria, seven provided information about funding source, of which six reported non‐industry funding. The other eight countries did not report a funding source for one or more data point(s). Key results and quality of the evidence 
 Five of the 10 countries included in the quantitative analysis (China, Finland, France, Ireland and England) showed a decrease in salt intake after the intervention. Two of the 10 countries (Canada, Switzerland) showed an increase in salt intake after the intervention, however, in both countries the only data available were from several years prior to the intervention starting. Because the initiatives were very different, we cannot present an overall finding of whether these types of initiatives work. When we focused on the subset of seven countries whose salt reduction initiatives included multiple components and were not focused solely on educating the public, we found that more than half (four of seven) showed a decrease in salt intake from pre‐intervention to post‐intervention. When we examined the nine initiatives that analysed men and women separately, we found that amongst men, more than half (five of nine) showed a decrease in salt intake after the intervention. Amongst women, the pattern of findings was less clear, with three of nine interventions showing a decrease, two showing an increase and four showing no change in salt intake. Low‐bias study designs, such as randomised controlled trials, typically are not suitable for evaluating complex initiatives such as these; therefore, we rated all of the studies included in this review as having low methodological quality. Large nationally representative samples of the population and careful measurement of dietary sodium intake were strengths of several studies. However, because of study design limitations, the trustworthiness of study results is not clear. Overall, our results show that national government initiatives have the potential to achieve population‐wide reductions in salt intake, especially amongst men, and particularly if they employ more than one strategy and include structural activities such as food product reformulation (i.e. food companies putting less salt in food products). The wide variation of results across the studies we found presents a challenge in interpreting the current evidence and this warrants more research to help us understand this.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McLaren, L; Sumar, N; Barberio, AM; Trieu, K; Lorenzetti, DL; Tarasuk, V; Webster, J; Campbell, NRC", "articleTypes": [], "doi": "10.1002/14651858.CD010166.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "91972c6d-9dd0-484f-bbaf-6aa747d98baf", "pmid": "", "title": "Short courses of antibiotics for children and adults with bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is an important cause of respiratory morbidity in both developing and developed countries. Antibiotics are considered standard therapy in the treatment of this condition but it is unknown whether short courses (four weeks or less) are efficacious. Objectives To determine whether short courses of antibiotics (i.e. less than or equal to four weeks) for treatment of acute and stable state bronchiectasis, in adults and children, are efficacious when compared to placebo or usual care. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library ), MEDLINE, EMBASE, OLDMEDLINE, CINAHL, AMED and PsycINFO and handsearching of respiratory journals and meeting abstracts were performed by the Cochrane Airways Group up to February 2011. Selection criteria Only randomised controlled trials were considered. Adults and children with bronchiectasis (defined clinically or radiologically) were included. Patients with cystic fibrosis were excluded. Data collection and analysis Two review authors independently reviewed the titles, abstracts and citations to assess eligibility for inclusion. Only one study fulfilled the inclusion criteria and thus meta‐analysis could not be performed. Main results The single eligible study showed a small benefit, when compared to placebo, of four weeks of inhaled antibiotic therapy in adults with bronchiectasis and pseudomonas in their sputum. There were no studies in children and no studies on oral or intravenous antibiotics. Authors' conclusions There is insufficient evidence in the current literature to make reasonable conclusions about the efficacy of short course antibiotics in the management of adults and children with bronchiectasis. Until further evidence is available, adherence to current treatment guidelines is recommended. Plain language summary Short courses of antibiotics for children and adults with bronchiectasis There is a paucity of evidence to conclude whether short courses of antibiotics (i.e. less than or equal to four weeks) are equivalent or superior to placebo in the treatment of stable or exacerbation state bronchiectasis. One single study showed some benefit of short‐course inhaled antibiotics over placebo, in terms of microbiological response and subjective improvement in medical condition, although this was balanced against an increase in adverse effects and antimicrobial resistance in the treatment group. Given the potential benefits of shorter duration antibiotic therapy in bronchiectasis, further RCTs are clearly needed to answer this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Wurzel, D, Marchant, JM, Yerkovich, ST, Upham, JW, Masters, IB, Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD008695.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.776Z" }, { "id": "91a0e80a-0eea-4b3c-a59e-d699e29ef2ea", "pmid": "", "title": "Rituximab for people with multiple sclerosis", "imported": false, "abstract": "Abstract - Background Multiple sclerosis (MS) is the most common neurological cause of disability in young adults. Off‐label rituximab for MS is used in most countries surveyed by the International Federation of MS, including high‐income countries where on‐label disease‐modifying treatments (DMTs) are available. This updates the 2021 version of the review. Objectives To assess the benefits and harms of rituximab as 'first choice' and 'switching' treatment for adults with any form of MS. Search methods We searched CENTRAL , MEDLINE, Embase, CINAHL, and three trials registers on 31 December 2023, together with reference checking and contacting study authors to identify unpublished studies. Selection criteria We included randomised controlled trials (RCTs) and controlled non‐randomised studies of interventions (NRSIs) comparing rituximab with placebo or another DMT for adults with any form of MS. Data collection and analysis We followed standard Cochrane methods. We used RoB 1 to assess risk of bias in RCTs and ROBINS‐I in NRSIs. We assessed the certainty of evidence for critical and important prioritised outcomes using GRADE: disability worsening, relapse, serious adverse events (SAEs), health‐related quality of life (HRQoL), common infections, cancer, and mortality. We conducted separate analyses for rituximab as 'first choice' or as 'switching' treatment, relapsing or progressive MS, comparison with placebo or another DMT, and RCTs or NRSIs. Main results In this update, the number of study participants increased from 16,429 (15 studies) to 37,443 (28 studies; 13 new studies: 1 RCT and 12 NRSIs). The studies were conducted worldwide; most originated from high‐income countries (25 studies). Public institutions funded 22 (79%) of the studies. Most studies investigated the effects of rituximab on people with relapsing MS (19 studies; 27,500 (73%) participants). We identified 12 ongoing studies. Rituximab as 'first choice' for active relapsing MS None of the included studies compared rituximab to placebo. One RCT compared rituximab to dimethyl fumarate, with 24 months' follow‐up. Rituximab may reduce the recurrence of relapse (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.04 to 0.57; 195 participants; low‐certainty evidence). The evidence is very uncertain on disability worsening and SAEs. Rituximab may result in little to no difference in upper respiratory tract infections (rate ratio (RR) 1.03, 95% CI 0.79 to 1.34; low‐certainty evidence). The evidence is very uncertain for urinary tract, skin, and viral infections. HRQoL, cancer, and mortality were not reported. One NRSI compared rituximab to other DMTs, with 24 months' follow‐up. Disability worsening was not reported. Compared with interferon beta or glatiramer acetate, rituximab likely delays relapse (hazard ratio (HR) 0.14, 95% CI 0.05 to 0.39; 1 study, 335 participants; moderate‐certainty evidence). Compared with dimethyl fumarate and natalizumab, rituximab may delay relapse (dimethyl fumarate: HR 0.29, 95% CI 0.08 to 1.00; 1 study, 206 participants; low‐certainty evidence; natalizumab: HR 0.24, 95% CI 0.06 to 1.00; 1 study, 170 participants; low‐certainty evidence). The evidence for relapse is very uncertain when comparing rituximab to fingolimod. The effect on SAEs is uncertain due to very few events in all the comparison groups. No deaths were reported. HRQoL, common infections, and cancer were not reported. Rituximab as 'first choice' for primary progressive MS One RCT compared rituximab to placebo, with 24 months' follow‐up. Rituximab likely results in little or no difference in disability worsening (OR 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate‐certainty evidence). The evidence is very uncertain on relapse, SAEs, common infections, cancer, and mortality. HRQoL was not reported. None of the included studies compared rituximab as 'first choice' treatment to other DMTs for primary or secondary progressive MS. Rituximab as 'switching' treatment for relapsing MS One small RCT compared rituximab to placebo, with 12 months' follow‐up. Disability worsening was not reported. Rituximab may reduce recurrence of relapses (OR 0.38, 95% CI 0.16 to 0.93; 1 study, 104 participants; low‐certainty evidence). The evidence is very uncertain regarding SAEs, common infections, cancer, and mortality. HRQoL was not reported. Twelve NRSIs compared rituximab to other DMTs, with 24 months' follow‐up. The evidence on disability worsening is very uncertain in comparison with interferons or glatiramer acetate, natalizumab, alemtuzumab, and ocrelizumab. Rituximab likely delays time to relapse in comparison with interferons or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 study, 1383 participants; moderate‐certainty evidence), fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 study, 256 participants; moderate‐certainty evidence), and may result in little or no difference compared with natalizumab (HR 0.96, 95% CI 0.83 to 1.10; 3 studies, 1922 participants; low‐certainty evidence). The evidence is very uncertain on relapse in comparison with alemtuzumab. There is uncertainty regarding SAEs when comparing rituximab to natalizumab and fingolimod. Rituximab likely increases serious common infections when compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 study, 5477 participants; moderate‐certainty evidence) and natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 studies, 5001 participants; moderate‐certainty evidence). The evidence for common infections is very uncertain when comparing rituximab to fingolimod and ocrelizumab. Rituximab may slightly reduce the risk of cancer compared with natalizumab (HR 0.79, 95% CI 0.62 to 0.99; 2 studies, 6202 participants; low‐certainty evidence), whereas the evidence is very uncertain in comparison with fingolimod. The effect of rituximab on mortality is very uncertain due to very few events in all the comparison groups. HRQoL was not reported. Authors' conclusions For preventing relapses in relapsing MS, rituximab as 'first choice' and 'switching' treatment compares favourably with a wide range of approved DMTs. The protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab on primary progressive MS. There is limited evidence for long‐term adverse events of rituximab in people with MS. Evidence for serious adverse events, cancer, and mortality was of very low certainty due to few events. There is an increased risk of serious (hospital‐treated) infections with rituximab compared with other DMTs, although the absolute risk is low. High‐quality (prospectively registered) NRSIs should be conducted to draw more reliable conclusions about the potential benefits and harms of rituximab in people with MS. Plain language summary Is rituximab better for people with multiple sclerosis than other disease‐modifying medicines? Key messages • We are uncertain whether rituximab prevents disability worsening in people with any form of multiple sclerosis (MS). 
• Rituximab may offer moderate‐to‐large benefit against a range of other medicines in preventing relapses in relapsing MS, both in people treated with rituximab for the first time and in those given rituximab after other medicines failed to work or became unsuitable.
• Very few people given rituximab in the studies had serious unwanted/harmful events, developed cancer, or died over 24 months' follow‐up. What is multiple sclerosis (MS)? MS is a disease affecting the central nervous system, in which the body’s immune system mistakenly attacks the protective covering of nerve fibres, which leads to inflammation and damage. Communication between the brain and the rest of the body is affected, resulting in a wide range of symptoms. There are two main types: (1) relapsing MS, where someone has periods of relapse (worsening of symptoms) followed by remissions (improvement or complete recovery); and (2) progressive MS, where symptoms worsen over time, without distinct periods of improvement. Relapsing MS is more common. How is MS treated? There is no cure for MS, so the goal of treatment is to manage symptoms, reduce disease activity, slow progression, and improve quality of life. This involves giving people with MS disease‐modifying treatments (DMTs), in contrast to treatments which only manage symptoms. There are different kinds of disease‐modifying treatments for MS, including rituximab. Rituximab is: • a medicine given slowly via a needle in a vein (intravenous infusion) that can suppress certain immune cells;
• included in the World Health Organization (WHO) Model List of Essential Medicines for MS, which makes rituximab available worldwide. Rituximab is not always reimbursed by health systems because it is not licensed for MS by marketing authorities;
• a highly effective treatment. It's cheaper and is given less often than other approved medicines for MS. Treatment with rituximab requires specialist care and infusion facilities, but other approved medicines do too. What did we want to find out? We wanted to find out the effects of rituximab on people with any form of MS on: • disability worsening, relapse, and quality of life;
• unwanted effects, such as serious harmful effects, serious common infections, cancer, and death. What did we do? We searched for studies that compared rituximab with other infused medicines (e.g. natalizumab), injectable medicines (e.g. interferon beta, glatiramer acetate), and oral medicines (e.g. fingolimod, dimethyl fumarate). We compared and summarised the results of the included studies, and rated our confidence in the evidence, based on factors such as study methods and quality. What did we find? We found 28 studies that involved 37,443 people with MS and lasted one or two years. The biggest study involved 8600 people and the smallest, 27 people. Most people (27,500, 73% of all participants) had a relapsing form of MS, while only 813 (2%) had a progressive form. Three studies included 9130 (24%) people with all forms of MS. Most studies originated from high‐income countries. Public institutions funded 22 (79%) of the studies. MAIN RESULTS Relapsing forms of MS • We do not know if rituximab has an effect on long‐term disability worsening due to the short follow‐up period of the studies.
• For people treated with rituximab for the first time as well as those given rituximab after other medicines failed to work or became unsuitable, rituximab may reduce the risk of relapses compared with interferon beta or glatiramer acetate, dimethyl fumarate, fingolimod, and natalizumab (evidence from 16 studies). 
• Serious unwanted effects of rituximab are very few. However, we do not know if rituximab has an effect on long‐term serious unwanted effects due to the short follow‐up period of the studies.
• Rituximab likely increases serious common infections (i.e. hospital‐treated infections) compared with other approved medicines for MS. However, the likelihood of serious common infections occurring is low in terms of the total number of people being considered. Progressive forms of MS We do not know if rituximab has benefits for people with primary progressive MS. What are the main limitations of the evidence? Our confidence in the evidence is limited because of three main factors. First, people were not randomly placed into different treatment groups in most of the studies. This means that differences between the groups could be due to differences between participants rather than between the comparison treatments. Second, we found few studies in which participants were assigned randomly to different treatment groups. These studies were small and used methods likely to introduce errors in their results. Third, results originated from short‐term studies. This is an important issue for people with a lifelong disease such as MS, who need to know the long‐term benefits and unwanted effects of a medicine. How current is the evidence? This review updates our previous review. The evidence is current to 31 December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Filippini, G; Kruja, J; Del Giovane, C", "articleTypes": [], "doi": "10.1002/14651858.CD013874.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "91a83625-446c-46cc-a073-2544bb377617", "pmid": "", "title": "Eszopiclone for insomnia", "imported": false, "abstract": "Abstract - Background Insomnia is a major public health issue affecting between 6% to 10% of the adult population in Western countries. Eszopiclone is a hypnotic drug belonging to a newer group of hypnotic agents, known as new generation hypnotics, which was marketed as being just as effective as benzodiazepines for this condition, while being safer and having a lower risk for abuse and dependence. It is the aim of the review to integrate evidence from randomised controlled trials and to draw conclusions on eszopiclone's efficacy and safety profile, while taking methodological features and bias risks into consideration. Objectives To assess the efficacy and safety of eszopiclone for the treatment of insomnia compared to placebo or active control. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, Embase, PsycINFO, PSYNDEX and registry databases (WHO trials portal, ClinicalTrials.gov) with results incorporated from searches to 10 February 2016. To identify trials not registered in electronic databases, we contacted key informants and searched reference lists of identified studies. We ran an update search (21 February 2018) and have placed studies of interest in awaiting classification/ongoing studies. These will be incorporated into the next version of the review, as appropriate. Selection criteria Parallel group randomised controlled trials (RCTs) comparing eszopiclone with either placebo or active control were included in the review. Participants were adults with insomnia, as diagnosed with a standardised diagnostic system, including primary insomnia and comorbid insomnia. Data collection and analysis Two authors independently extracted outcome data; one reviewer assessed trial quality and the second author cross‐checked it. Main results A total of 14 RCTs, with 4732 participants, were included in this review covering short‐term (≤ 4 weeks; 6 studies), medium‐term (> 4 weeks ≤ 6 months; 6 studies) and long‐term treatment (> 6 months; 2 studies) with eszopiclone. Most RCTs included in the review included participants aged between 18 and 64 years, three RCTs only included elderly participants (64 to 85 years) and one RCT included participants with a broader age range (35 to 85 years). Seven studies considered primary insomnia; the remaining studies considered secondary insomnia comorbid with depression (2), generalised anxiety (1), back pain (1), Parkinson's disease (1), rheumatoid arthritis (1) and menopausal transition (1). Meta‐analytic integrations of participant‐reported data on sleep efficacy outcomes demonstrated better results for eszopiclone compared to placebo: a 12‐minute decrease of sleep onset latency (mean difference (MD) ‐11.94 min, 95% confidence interval (CI) ‐16.03 to ‐7.86; 9 studies, 2890 participants, moderate quality evidence), a 17‐minute decrease of wake time after sleep onset (MD ‐17.02 min, 95% CI ‐24.89 to ‐9.15; 8 studies, 2295 participants, moderate quality evidence) and a 28‐minute increase of total sleep time (MD 27.70 min, 95% CI 20.30 to 35.09; 10 studies, 2965 participants, moderate quality evidence). There were no significant changes from baseline to the first three nights after drug discontinuation for sleep onset latency (MD 17.00 min, 95% CI ‐4.29 to 38.29; 1 study, 291 participants, low quality evidence) and wake time after sleep onset (MD ‐6.71 min, 95% CI ‐21.25 to 7.83; 1 study, 291 participants, low quality evidence). Adverse events during treatment that were documented more frequently under eszopiclone compared to placebo included unpleasant taste (risk difference (RD) 0.18, 95% CI 0.14 to 0.21; 9 studies, 3787 participants), dry mouth (RD 0.04, 95% CI 0.02 to 0.06; 6 studies, 2802 participants), somnolence (RD 0.04, 95% CI 0.02 to 0.06; 8 studies, 3532 participants) and dizziness (RD 0.03, 95% CI 0.01 to 0.05; 7 studies, 2933 participants). According to the GRADE criteria, evidence was rated as being of moderate quality for sleep efficacy outcomes and adverse events and of low quality for rebound effects and next‐day functioning. Authors' conclusions Eszopiclone appears to be an efficient drug with moderate effects on sleep onset and maintenance. There was no or little evidence of harm if taken as recommended. However, as certain patient subgroups were underrepresented in RCTs included in the review, findings might not have displayed the entire spectrum of possible adverse events. Further, increased caution is required in elderly individuals with cognitive and motor impairments and individuals who are at increased risk of using eszopiclone in a non‐recommended way. Plain language summary Eszopiclone (Lunesta) for sleep difficulty Why is this review important? Insomnia is the medical term for sleep difficulty covering trouble falling asleep, difficulties staying asleep, waking up too early or experiencing sleep as non‐restorative. Insomnia can be treated with different methods including behaviour modification, relaxation techniques, or sleeping medication. Eszopiclone (Lunesta) is a sleeping medication that belongs to a class of sleeping tablets known as non‐benzodiazepine hypnotics. Who will be interested in this review? People who are affected by insomnia, general practitioners, professionals working in health services, and addiction treatment and health policy makers. What questions does this review aim to answer? The review aimed to find out more about the wanted effects and unwanted effects of eszopiclone. Wanted effects included the immediate effects eszopiclone has on sleep; unwanted effects included side effects, effects on next‐day functioning, but also addictive properties of the drug. Which studies were included in the review? The review summarised findings from 14 clinical studies with 4732 people, either receiving eszopiclone or an identically‐appearing, but inert substance (placebo). What does the evidence from the review tell us? On average, people taking eszopiclone fell asleep 12 minutes faster than those taking placebo, were 17 minutes less awake during the night and had, in total, about half an hour more sleep than people in the placebo group. As side effects, eszopiclone can cause unpleasant taste, dizziness, dry mouth, and tiredness during the day. Clinical studies did not find evidence that eszopiclone was causing serious harm or withdrawal symptoms or whether it was addictive if it was stopped and not taken after several weeks or months of treatment. Nevertheless, as clinical studies included in the review did not cover certain groups (e.g. elderly people with cognitive or motor problems or certain conditions of medication intake), it is important for patients to consult their doctor who knows their medical history and condition. What should happen next? Future research needs to compare eszopiclone with other sleep medications to help physicians and patients decide which of the available treatment options to prefer. In addition, sleep medications that are also well tolerated by elderly individuals and individuals with alcohol or drug problems need to be identified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rösner, S, Englbrecht, C, Wehrle, R, Hajak, G, Soyka, M", "articleTypes": [], "doi": "10.1002/14651858.CD010703.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.063Z" }, { "id": "91cb1a57-675b-42e9-b0ac-fbdd3730a5df", "pmid": "", "title": "Nirmatrelvir combined with ritonavir for preventing and treating COVID‐19", "imported": false, "abstract": "Abstract - Background Oral nirmatrelvir/ritonavir (Paxlovid) aims to avoid severe COVID‐19 in asymptomatic people or those with mild symptoms, thereby decreasing hospitalization and death. It remains to be evaluated for which indications and patient populations the drug is suitable. Objectives To assess the efficacy and safety of nirmatrelvir/ritonavir plus standard of care (SoC) compared to SoC with or without placebo, or any other intervention for treating COVID‐19 or preventing SARS‐CoV‐2 infection. To explore equity aspects in subgroup analyses. To keep up to date with the evolving evidence base using a living systematic review (LSR) approach and make new relevant studies available to readers in‐between publication of review updates. Search methods We searched the Cochrane COVID‐19 Study Register, Scopus, and World Health Organization COVID‐19 Research Database, identifying completed and ongoing studies without language restrictions and incorporating studies up to 15 May 2023. This is a LSR. We conduct update searches every two months and make them publicly available on the open science framework (OSF) platform. Selection criteria We included randomized controlled trials (RCTs) comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo, or any other intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. We screened all studies for research integrity. Studies were ineligible if they had been retracted, or if they were not prospectively registered including appropriate ethics approval. Data collection and analysis We followed standard Cochrane methodology and used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the following outcomes: 1. to treat outpatients with mild COVID‐19; 2. to treat inpatients with moderate to severe COVID‐19: mortality, clinical worsening or improvement, quality of life, (serious) adverse events, and viral clearance; 3. to prevent SARS‐CoV‐2 infection in postexposure prophylaxis (PEP); and 4. pre‐exposure prophylaxis (PrEP) scenarios: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, mortality, admission to hospital, quality of life, and (serious) adverse events. We explored inequity by subgroup analysis for elderly people, socially‐disadvantaged people with comorbidities, populations from low‐income countries and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. Main results As of 15 May 2023, we included two RCTs with 2510 participants with mild and mild to moderate symptomatic COVID‐19 in outpatient and inpatient settings comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo. All trial participants were without previous confirmed SARS‐CoV‐2 infection and at high risk for progression to severe disease. Randomization coincided with the Delta wave for outpatients and Omicron wave for inpatients. Outpatient trial participants and 73% of inpatients were unvaccinated. Symptom onset in outpatients was no more than five days before randomisation and prior or concomitant therapies including medications highly dependent on CYP3A4 were not allowed. We excluded two studies due to concerns with research integrity. We identified 13 ongoing studies. Three studies are currently awaiting classification. Nirmatrelvir/ritonavir for treating people with asymptomatic or mild COVID‐19 in outpatient settings Nirmatrelvir/ritonavir plus SoC compared to SoC plus placebo may reduce all‐cause mortality at 28 days (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.68; 1 study, 2224 participants; low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.13, 95% CI 0.07 to 0.27; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC may reduce serious adverse events during the study period compared to SoC plus placebo (RR 0.24, 95% CI 0.15 to 0.41; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably has little or no effect on treatment‐emergent adverse events (RR 0.95, 95% CI 0.82 to 1.10; 1 study, 2224 participants; moderate‐certainty evidence), and probably increases treatment‐related adverse events such as dysgeusia and diarrhoea during the study period compared to SoC plus placebo (RR 2.06, 95% CI 1.44 to 2.95; 1 study, 2224 participants; moderate‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably decreases discontinuation of study drug due to adverse events compared to SoC plus placebo (RR 0.49, 95% CI 0.30 to 0.80; 1 study, 2224 participants; moderate‐certainty evidence). No studies reported improvement of clinical status, quality of life, or viral clearance. Nirmatrelvir/ritonavir for treating people with moderate to severe COVID‐19 in inpatient settings We are uncertain whether nirmatrelvir/ritonavir plus SoC compared to SoC reduces all‐cause mortality at 28 days (RR 0.63, 95% CI 0.21 to 1.86; 1 study, 264 participants; very low‐certainty evidence), or increases viral clearance at seven days (RR 1.06, 95% CI 0.71 to 1.58; 1 study, 264 participants; very low‐certainty evidence) and 14 days (RR 1.05, 95% CI 0.92 to 1.20; 1 study, 264 participants; very low‐certainty evidence). No studies reported improvement or worsening of clinical status and quality of life. We did not include data for safety outcomes due to insufficient and inconsistent information. Subgroup analyses for equity For outpatients, the outcome 'admission to hospital or death' was investigated for equity regarding age (less than 65 years versus 65 years or greater) and ethnicity. There were no subgroup differences for age or ethnicity. For inpatients, the outcome 'all‐cause mortality' was investigated for equity regarding age (65 years or less versus greater than 65 years). There was no difference between subgroups of age. No further equity‐related subgroups were reported, and no subgroups were reported for other outcomes. Nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection (PrEP and PEP) No studies available. Authors' conclusions Low‐certainty evidence suggests nirmatrelvir/ritonavir reduces the risk of all‐cause mortality and hospital admission or death in high‐risk, unvaccinated COVID‐19 outpatients infected with the Delta variant of SARS‐CoV‐2. There is low‐ to moderate‐certainty evidence of the safety of nirmatrelvir/ritonavir. Very low‐certainty evidence exists regarding the effects of nirmatrelvir/ritonavir on all‐cause mortality and viral clearance in mildly to moderately affected, mostly unvaccinated COVID‐19 inpatients infected with the Omicron variant of SARS‐CoV‐2. Insufficient and inconsistent information prevents the assessment of safety outcomes. No reliable differences in effect size and direction were found regarding equity aspects. There is no available evidence supporting the use of nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection. We are continually updating our search and making search results available on the OSF platform. Plain language summary Is the combination of nirmatrelvir plus ritonavir effective for treating or preventing COVID‐19? Key messages Nirmatrelvir/ritonavir (Paxlovid) is evaluated for the treatment of coronavirus disease 2019 (COVID‐19). Nirmatrelvir/ritonavir may lead to fewer deaths and improve patient condition, as assessed by need for hospitalization or death within 28 days for unvaccinated outpatients at increased risk for disease progression receiving treatment within five days of symptom onset. We are very uncertain about the effectiveness of nirmatrelvir/ritonavir in inpatients. We excluded two studies due to concerns with research integrity. We found 13 ongoing studies. What is nirmatrelvir/ritonavir? The combination of nirmatrelvir with ritonavir is a new medicine developed to treat infection with the SARS‐CoV‐2 virus and aims to avoid severe COVID‐19 in people without symptoms, or those with mild symptoms. Ritonavir increases the effectiveness of nirmatrelvir but it can interact with many other medicines, which can increase side effects. What did we want to find out? We wanted to know if nirmatrelvir/ritonavir reduces death, illness, and length of infection in people with COVID‐19, or if it is useful in prevention of the disease. We included studies comparing the medicine with placebo (dummy treatment), no treatment, usual care, or any other treatments for COVID‐19. We addressed equity and wanted to know whether there are certain groups of people for which nirmatrelvir/ritonavir works best or is less effective. We looked at elderly people, socially disadvantaged people with other illnesses (comorbidities), people from low‐income and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. We evaluated the effects of nirmatrelvir/ritonavir in people with COVID‐19 regarding: – people dying; – whether COVID‐19 symptoms got better or worse; – quality of life; – unwanted effects of the medicine; – virus elimination. For prevention, we sought the effect on preventing COVID‐19 and SARS‐CoV‐2 infection. What did we do? We searched for randomized controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that investigated nirmatrelvir/ritonavir to prevent or treat COVID‐19. People receiving nirmatrelvir/ritonavir as treatment had to have laboratory‐confirmed COVID‐19 and be treated in hospital or as outpatients. People receiving nirmatrelvir/ritonavir to prevent an infection had to have a high risk of contracting the disease or had to have had a high‐risk contact with a person with confirmed COVID‐19. We summarized the results of the studies and rated our confidence in the evidence, based on common criteria as to how reliable the evidence was. We examined differences with respect to age, level of comorbidity, country according to the World Bank country classification by income level, and ethnicity. What did we find? We found two studies with 2510 participants that investigated nirmatrelvir/ritonavir compared to placebo or standard of care for the treatment of COVID‐19 in people without previous confirmed SARS‐CoV‐2 infection and at increased risk for progression to severe disease due to a comorbidity or risk factor such as current smoking. Included outpatients were enrolled during the Delta wave, unvaccinated, and had a symptom onset of up to five days before starting treatment. Included inpatients were enrolled during the Omicron wave, mostly unvaccinated, and mildly to moderately affected. We found 13 ongoing studies that have not yet been completed, and three studies are currently awaiting classification. Main results Treating outpatients with COVID‐19 For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir may: – lead to fewer deaths; – improve patients' condition assessed by need for admission to hospital or death within 28 days; – reduce serious unwanted events. For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir probably: – has little effect on any unwanted events; – increases any treatment‐related unwanted events (mostly taste disturbance and diarrhoea); – decreases discontinuation of study medicine due to unwanted events. Equity aspects Most study participants were younger than 65 years and of white ethnicity. There was no difference in effectiveness between younger and older participants and participants from different ethnic groups. No subgroups were reported for different levels of comorbidity and World Bank country classification by income level. Treating inpatients with COVID‐19 We are uncertain whether, for the specific population of mildly to moderately affected, high‐risk patients, nirmatrelvir/ritonavir: – leads to fewer deaths; and – increases virus elimination Equity aspects Most study participants were older than 65 years. There was no difference in effectiveness between younger and older participants. No subgroups were reported for different levels of comorbidity, ethnicity, and World Bank country classification by income level. No subgroups were reported for other outcomes. What are the limitations of the evidence? Our confidence in the evidence is low to moderate for outpatients and very low for inpatients. The studies did not report everything we were interested in, such as quality of life and symptom resolution, and had a highly specific population of people at high risk of progression to severe COVID‐19. How up to date is this evidence? The evidence is up to date to 15 May 2023. According to this review's living approach, we will update our search every two months. We are making search results and new relevant studies publicly available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Reis, S; Metzendorf, M-I; Kuehn, R; Popp, M; Gagyor, I; Kranke, P; Meybohm, P; Skoetz, N; Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015395.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "91e18066-cfb7-40a9-956b-7a5c0a8d7471", "pmid": "", "title": "Effect of cocoa on blood pressure", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Ried, K, Fakler, P, Stocks, NP", "articleTypes": [], "doi": "10.1002/14651858.CD008893.pub3 AB - Abstract - Background High blood pressure is an important risk factor for cardiovascular disease, contributing to about 50% of cardiovascular events worldwide and 37% of cardiovascular‐related deaths in Western populations. Epidemiological studies suggest that cocoa‐rich products reduce the risk of cardiovascular disease. Flavanols found in cocoa have been shown to increase the formation of endothelial nitric oxide which promotes vasodilation and therefore blood pressure reduction. Here we update previous meta‐analyses on the effect of cocoa on blood pressure. Objectives To assess the effects on blood pressure of chocolate or cocoa products versus low‐flavanol products or placebo in adults with or without hypertension when consumed for two weeks or longer. Search methods This is an updated version of the review initially published in 2012. In this updated version, we searched the following electronic databases from inception to November 2016: Cochrane Hypertension Group Specialised Register, CENTRAL, MEDLINE and Embase. We also searched international trial registries, and the reference lists of review articles and included trials. Selection criteria Randomised controlled trials (RCTs) investigating the effects of chocolate or cocoa products on systolic and diastolic blood pressure in adults for a minimum of two weeks duration. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias in each trial. We conducted random‐effects meta‐analyses on the included studies using Review Manager 5. We explored heterogeneity with subgroup analyses by baseline blood pressure, flavanol content of control group, blinding, age and duration. Sensitivity analyses explored the influence of unusual study design. Main results Thirty‐five trials (including 40 treatment comparisons) met the inclusion criteria. Of these, we added 17 trials (20 treatment comparisons) to the 18 trials (20 treatment comparisons) in the previous version of this updated review. Trials provided participants with 30 to 1218 mg of flavanols (mean = 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. The control group received either a flavanol‐free product (n = 26 treatment comparisons) or a low‐flavanol‐containing cocoa powder (range 6.4 to 88 mg flavanols (mean = 55 mg, 13 treatment comparisons; 259 mg, 1 trial). Meta‐analyses of the 40 treatment comparisons involving 1804 mainly healthy participants revealed a small but statistically significant blood pressure‐reducing effect of flavanol‐rich cocoa products compared with control in trials of two to 18 weeks duration (mean nine weeks):
 Mean difference systolic blood pressure (SBP) (95% confidence interval (CI): ‐1.76 (‐3.09 to ‐0.43) mmHg, P = 0.009, n = 40 treatment comparisons, 1804 participants;
 Mean difference diastolic blood pressure (DBP) (95% CI): ‐1.76 (‐2.57 to ‐0.94) mmHg, P < 0.001, n = 39 treatment comparisons, 1772 participants. Baseline blood pressure may play a role in the effect of cocoa on blood pressure. While systolic blood pressure was reduced significantly by 4 mmHg in hypertensive people (n = 9 treatment comparisons, 401 participants), and tended to be lowered in prehypertensive people (n= 8 treatment comparisons, 340 participants), there was no significant difference in normotensive people (n = 23 treatment comparisons, 1063 participants); however, the test for subgroup differences was of borderline significance (P = 0.08; I 2 = 60%), requiring further research to confirm the findings. Subgroup meta‐analysis by blinding suggested a trend towards greater blood pressure reduction in unblinded trials compared to double‐blinded trials, albeit statistically not significant. Further research is needed to confirm whether participant expectation may influence blood pressure results. Subgroup analysis by type of control (flavanol‐free versus low‐flavanol control) did not reveal a significant difference. Whether the age of participants plays a role in the effect of cocoa on blood pressure, with younger participants responding with greater blood pressure reduction, needs to be further investigated. Sensitivity analysis excluding trials with authors employed by trials sponsoring industry (33 trials, 1482 participants) revealed a small reduction in effect size, indicating some reporting bias. Due to the remaining heterogeneity, which we could not explain in terms of blinding, flavanol content of the control groups, age of participants, or study duration, we downgraded the quality of the evidence from high to moderate. Results of subgroup analyses should be interpreted with caution and need to be confirmed or refuted in trials using direct randomised comparisons. Generally, cocoa products were highly tolerable, with adverse effects including gastrointestinal complaints and nausea being reported by 1% of participants in the active cocoa intervention group and 0.4% of participants in the control groups (moderate‐quality evidence). Authors' conclusions This review provides moderate‐quality evidence that flavanol‐rich chocolate and cocoa products cause a small (2 mmHg) blood pressure‐lowering effect in mainly healthy adults in the short term. These findings are limited by the heterogeneity between trials, which could not be explained by prespecified subgroup analyses, including blinding, flavanol content of the control groups, age of participants, or study duration. However, baseline blood pressure may play a role in the effect of cocoa on blood pressure; subgroup analysis of trials with (pre)hypertensive participants revealed a greater blood pressure‐reducing effect of cocoa compared to normotensive participants with borderline significance. Long‐term trials investigating the effect of cocoa on clinical outcomes are also needed to assess whether cocoa has an effect on cardiovascular events and to assess potential adverse effects associated with chronic ingestion of cocoa products. Plain language summary Effect of cocoa on blood pressure Review question We assessed the effect of cocoa products on blood pressure in adults when consumed daily for at least two weeks. We found 35 studies, covering 40 treatment comparisons. Background Dark chocolate and cocoa products are rich in chemical compounds called flavanols. Flavanols have attracted interest as they might help to reduce blood pressure, a known risk factor for cardiovascular disease (disorders of the heart and blood vessels). The blood pressure‐lowering properties of flavanols are thought to be related to widening of the blood vessels, caused by nitric oxide. Study characteristics Studies were short, mostly between two and12 weeks, with only one of 18 weeks. The studies involved 1804 mainly healthy adults. They provided participants with 30 to 1218 mg of flavanols (average of 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. Seven of the studies were funded by companies with a commercial interest in their results, and the reported effect was slightly larger in these studies, indicating possible bias. The evidence is current to November 2016. Key results Meta‐analysis of 40 treatment comparisons revealed a small but statistically significant lowering of blood pressure (systolic and diastolic) of 1.8 mmHg. This small reduction in blood pressure might complement other treatment options and might contribute to reducing the risk of cardiovascular disease. We investigated whether participants' blood pressure at the start of the study, their age, an awareness of group allocation (active or control), the flavanol content used in the control group, or how long the study lasted may explain variations between trials. While blood pressure status (high blood pressure or normal blood pressure) is a likely factor in the effect size of cocoa on blood pressure, the impact of other factors needs to be confirmed or rejected in further trials. Side effects including digestive complaints and dislike of the trial product were reported by only 1% of people in the active cocoa intervention group and 0.4% of people in the control groups. Longer‐term trials are needed to establish whether regularly eating flavanol‐rich cocoa products has a beneficial effect on blood pressure and cardiovascular health over time, and whether there are any side effects of long‐term use of cocoa products on a daily basis. Quality of evidence The evidence is of moderate quality. We were unable to identify any randomised controlled trials that tested the effect of long‐term daily use of cocoa products on blood pressure, and there were no trials that measured the health consequences of high blood pressure, such as heart attacks or strokes.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.739Z" }, { "id": "91f1d969-d094-4891-b7ab-d0a99b141b52", "pmid": "", "title": "Interventions for treating burning mouth syndrome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McMillan, R, Forssell, H, Buchanan, JAG, Glenny, AM, Weldon, JC, Zakrzewska, JM", "articleTypes": [], "doi": "10.1002/14651858.CD002779.pub3 AB - Abstract - Background Burning mouth syndrome (BMS) is a term used for oral mucosal pain (burning pain or discomfort in the tongue, lips or entire oral cavity) without identifiable cause. General population prevalence varies from 0.1% to 3.9%. Many BMS patients indicate anxiety, depression, personality disorders and impaired quality of life (QoL). This review updates the previous versions published in 2000 and 2005. Objectives To determine the effectiveness and safety of any intervention versus placebo for symptom relief and changes in QoL, taste, and feeling of dryness in people with BMS. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 31 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 11) in the Cochrane Library (searched 31 December 2015), MEDLINE Ovid (1946 to 31 December 2015), and Embase Ovid (1980 to 31 December 2015). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching the electronic databases Selection criteria Randomised controlled trials (RCTs) comparing any treatment against placebo in people with BMS. The primary outcomes were symptom relief (pain/burning) and change in QoL. Secondary outcomes included change in taste, feeling of dryness, and adverse effects. Data collection and analysis We used standard methodological procedures expected by Cochrane. Outcome data were analysed as short‐term (up to three months) or long‐term (three to six months). Main results We included 23 RCTs (1121 analysed participants; 83% female). Interventions were categorised as: antidepressants and antipsychotics, anticonvulsants, benzodiazepines, cholinergics, dietary supplements, electromagnetic radiation, physical barriers, psychological therapies, and topical treatments. Only one RCT was assessed at low risk of bias overall, four RCTs' risk of bias was unclear, and 18 studies were at high risk of bias. Overall quality of the evidence for effectiveness was very low for all interventions and all outcomes. Twenty‐one RCTs assessed short‐term symptom relief. There is very low‐quality evidence of benefit from electromagnetic radiation (one RCT, 58 participants), topical benzodiazepines (two RCTs, 111 participants), physical barriers (one RCT, 50 participants), and anticonvulsants (one RCT, 100 participants). We found insufficient/contradictory evidence regarding the effectiveness of antidepressants, cholinergics, systemic benzodiazepines, dietary supplements or topical treatments. No RCT assessing psychological therapies evaluated short‐term symptom relief. Four studies assessed long‐term symptom relief. There is very low‐quality evidence of a benefit from psychological therapies (one RCT, 30 participants), capsaicin oral rinse (topical treatment) (one RCT, 18 participants), and topical benzodiazepines (one RCT, 66 participants). We found no evidence of a difference for dietary supplements or lactoperoxidase oral rinse. No studies assessing antidepressants, anticonvulsants, cholinergics, electromagnetic radiation or physical barriers evaluated long‐term symptom relief. Short‐term change in QoL was assessed by seven studies (none long‐term).The quality of evidence was very low. A benefit was found for electromagnetic radiation (one RCT, 58 participants), however findings were inconclusive for antidepressants, benzodiazepines, dietary supplements and physical barriers. Secondary outcomes (change in taste and feeling of dryness) were only assessed short‐term, and the findings for both were also inconclusive. With regard to adverse effects, there is very low‐quality evidence that antidepressants increase dizziness and drowsiness (one RCT, 37 participants), and that alpha lipoic acid increased headache (two RCTs, 118 participants) and gastrointestinal complaints (3 RCTs, 138 participants). We found insufficient/contradictory evidence regarding adverse events for anticonvulsants or benzodiazepines. Adverse events were poorly reported or unreported for cholinergics, electromagnetic radiation, and psychological therapies. No adverse events occurred from physical barriers or topical therapy use. Authors' conclusions Given BMS' potentially disabling nature, the need to identify effective modes of treatment for sufferers is vital. Due to the limited number of clinical trials at low risk of bias, there is insufficient evidence to support or refute the use of any interventions in managing BMS. Further clinical trials, with improved methodology and standardised outcome sets are required in order to establish which treatments are effective. Future studies are encouraged to assess the role of treatments used in other neuropathic pain conditions and psychological therapies in the treatment of BMS. Plain language summary Interventions for treating burning mouth syndrome Review question Which treatments help to relieve symptoms for people with burning mouth syndrome (BMS)? Background BMS is a common painful condition. Symptoms include burning, dryness or uncomfortable sensations in the mouth and changes to taste, with no obvious underlying medical or dental cause. BMS is usually persistent and suffered long term, and can lead to a reduced quality of life (QoL). Currently, scientific research suggests that BMS is caused by underlying damage to the nerves. There are many treatments available including drugs for anxiety, other psychological conditions and increasing saliva production, protective barriers and treatments applied to the mouth surface amongst others. Study characteristics This review of studies was carried out through Cochrane Oral Health, and the evidence is current up to 31 December 2015. We found 23 studies (assessing 1121 people; 83% were women), published between 1995 and 2015 to include in this review. Twenty‐one studies assessed short‐term (up to three months) symptom relief, and four studies assessed long‐term (from three to six months) symptom relief. Seventeen studies provided information about side effect occurrence, seven studies assessed a measure of QoL, and two studies assessed changes in taste and feeling of dryness. All of the 23 treatments included in this review were compared to a placebo (fake treatment): antidepressants and antipsychotics (two studies), antiseizure drugs (one study), types of tranquillisers (four studies), saliva stimulants (one study), dietary supplements (12 studies), directed energy waves (one study), physical barriers (one study), psychological therapies (one study), and treatments applied to the mouth surface (five studies). Key results Short‐term symptom relief We found evidence of short‐term symptom relief for directed energy waves (one study, 58 participants), a type of tranquilliser used topically (that is held in the mouth before being removed, and which also acts as an antiseizure drug) called clonazepam (two studies, 111 participants), thin plastic tongue covers (one study, 50 participants), and an antiseizure drug called gabapentin (one study, 100 participants). There was no difference in short‐term symptom relief found for antidepressants, saliva stimulants, and another type of tranquilliser used systemically (one that is swallowed) also called clonazepam. We were unable to show whether dietary supplements or treatments applied to the mouth surface provide symptom relief in the short term or not. Short‐term relief was not reported for the single study that assessed a psychological therapy. Long‐term symptom relief We found evidence of long‐term symptom relief for psychological therapy (one study, 30 participants), chili pepper mouthrinse (one study, 18 participants) and the topical tranquilliser called clonazepam (one study, 66 participants). We found there was no difference in long‐term symptom relief for dietary supplements or treatments applied to the mouth surface. Studies which assessed antidepressants, directed energy waves, saliva stimulants, antiseizure drugs, or physical barriers did not evaluate long‐term symptom relief. Change in QoL There was evidence of short‐term improvement in QoL for directed energy waves (one study, 58 patients), although no difference was found for antidepressants, tranquillisers, dietary supplements and physical barriers. No study assessed long‐term QoL changes. Change in taste or feeling of dryness A few studies assessed short‐term change in taste or feeling of dryness (none evaluated these outcomes long‐term), but there was not enough evidence to judge the effects of treatment on these outcomes. Side effects Side effects were more likely to be experienced with antidepressants (dizziness and drowsiness more likely: one study, 37 people), and with a dietary supplement called alpha lipoic acid (also known as ALA) with or without other ingredients (headaches more likely: two studies, 118 people; and upset stomachs more likely: three studies, 138 people). Quality of the evidence 
 Overall, we found very low‐quality evidence for each short‐ and long‐term outcome we investigated (symptom relief; changes in QoL, taste and feeling of dryness; and side effects) in all types of assessed treatment: antidepressants and antipsychotics, antiseizure drugs, types of tranquillisers, saliva stimulants, dietary supplements, directed energy waves, physical barriers (except side effects, which was assessed as low quality), psychological therapies, and treatments applied to the mouth surface. As we found so few studies at low risk of bias, we are currently unable to prove or disprove the effectiveness of any treatments for managing BMS.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.726Z" }, { "id": "9200bb59-7593-4e49-9c7d-22726b5e1bee", "pmid": "", "title": "Impacts of Sugar-Sweetened Beverage Consumption on Body Weight Regulation", "imported": false, "abstract": "The obesity epidemic is a major public health problem. Weight gain is strongly associated with an increase in the incidence of complex health conditions such as type 2 diabetes (T2D), cardiovascular disease, stroke, and cancers. Behaviours linked to food and beverage consumption can greatly affect body weight. Frequent consumption of sugar-sweetened beverages such as carbonated soft-drinks, energy and sport drinks, fruit juices from concentrate, soda and flavoured milk and water is considered to be an unhealthy dietary behaviour.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.146Z" }, { "id": "920ea7b0-5d32-4758-bb7b-32363e5a2f61", "pmid": "", "title": "Eliciting adverse effects data from participants in clinical trials", "imported": false, "abstract": "Abstract - Background Analysis of drug safety in clinical trials involves assessing adverse events (AEs) individually or by aggregate statistical synthesis to provide evidence of likely adverse drug reactions (ADR). While some AEs may be ascertained from physical examinations or tests, there is great reliance on reports from participants to detect subjective symptoms, where he/she is often the only source of information. There is no consensus on how these reports should be elicited, although it is known that questioning methods influence the extent and nature of data detected. This leaves room for measurement error and undermines comparisons between studies and pooled analyses. This review investigated comparisons of methods used in trials to elicit participant‐reported AEs. This should contribute to knowledge about the methodological challenges and possible solutions for achieving better, or more consistent, AE ascertainment in trials. Objectives To systematically review the research that has compared methods used within clinical drug trials (or methods that would be specific for such trials) to elicit information about AEs defined in the protocol or in the planning for the trial. Search methods Databases (searched to March 2015 unless indicated otherwise) included: Embase; MEDLINE; MEDLINE in Process and Other Non‐Indexed Citations; Cochrane Methodology Register (July 2012); Cochrane Central Register of Controlled Trials (February 2015); Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects (January 2015); Health Technology Assessment database (January 2015); CINAHL; CAB Abstracts; BIOSIS (July 2013); Science Citation Index; Social Science Citation Index; Conference Proceedings Citation Index – Science. The search used thesaurus headings and synonyms for the following concepts: (A): Adverse events AND measurement; (B): Participants AND elicitation (also other synonyms for extraction of information about adverse effects from people); (C): Participants AND checklists (also other synonyms as for B). Pragmatic ways were used to limit the results whilst trying to maintain sensitivity. There were no date or sample size restrictions but only reports published in English were included fully, because of resource constraints as regards translation. Selection criteria Two types of studies were included: drug trials comparing two or more methods within‐ or between‐participants to elicit participant‐reported AEs, and research studies performed outside the context of a trial to compare methods which could be used in trials (evidenced by reference to such applicability). Primary outcome data included AEs elicited from participants taking part in any such clinical trial. We included any participant‐reported data relevant for an assessment of drug‐related harm, using the original authors' terminology (and definition, where available), with comment on whether the data were likely to be treatment‐emergent AEs or not. Data collection and analysis Titles and abstracts were independently reviewed for eligibility. Full texts of potentially eligible citations were independently reviewed for final eligibility. Relevant data were extracted and subjected to a 100% check. Disagreements were resolved by discussion, involving a third author. The risk of bias was independently assessed by two authors. The Cochrane 'Risk of bias' tool was used for reports comparing outcomes between participants, while for within‐participant comparisons, each study was critically evaluated in terms of potential impact of the design and conduct on findings using the framework of selection, performance, detection, attrition, reporting, and other biases. An attempt was made to contact authors to retrieve protocols or specific relevant missing information. Reports were not excluded on the basis of quality unless data for outcomes were impossible to compare (e.g. where denominators differed). A narrative synthesis was conducted because differences in study design and presentation meant that a quantitative meta‐analysis was not possible. Main results The 33 eligible studies largely compared open questions with checklist‐type questions or rating scales. Two included participant interviews. Despite different designs, populations and details of questioning methods, the narrative review showed that more specific questioning of participants led to more AEs detected compared to a more general enquiry. A subset of six studies suggested that more severe, bothersome, or otherwise clinically relevant AEs were reported when an initial open enquiry was used, while some less severe, bothersome, or clinically relevant AEs were only reported with a subsequent specific enquiry. However, two studies showed that quite severe or debilitating AEs were only detected by an interview, while other studies did not find a difference in the nature of AEs between elicitation methods. No conclusions could be made regarding the impact of question method on the ability to detect a statistically significant difference between study groups. There was no common statistical rubric, but we were able to represent some effect measures as a risk ratio of the proportion of participants with at least one AE. This showed a lower level of reporting for open questions (O) compared to checklists (CL), with a range for the risk ratios of 0.12 to 0.64. Authors' conclusions This review supports concerns that methods to elicit participant‐reported AEs influence the detection of these data. There was a risk for under‐detection of AEs in studies using a more general elicitation method compared to those using a comprehensive method. These AEs may be important from a clinical perspective or for patients. This under‐detection could compromise ability to pool AE data. However, the impact on the nature of the AE detected by different methods is unclear. The wide variety and low quality of methods to compare elicitation strategies limited this review. Future studies would be improved by using and reporting clear definitions and terminology for AEs (and other important variables), frequency and time period over which they were ascertained, how they were graded, assessed for a relationship to the study drug, coded, and tabulated/reported. While the many potential AE endpoints in a trial may preclude the development of general AE patient‐reported outcome measurement instruments, much could also be learnt from how these employ both quantitative and qualitative methods to better understand data elicited. Any chosen questioning method needs to be feasible for use by both staff and participants. Plain language summary Questioning clinical trial participants about their health in order to collect information on adverse effects of drugs Clinical drug trials or studies are usually conducted to assess how well the drug works but also whether it causes any harm (side effects or adverse effects). Adverse effects can be detected by the trial doctor examining participants or taking some blood samples or doing other kinds of tests. The trial staff can also ask participants about how they are feeling after taking the trial drug. However, the way participants are asked about their health can vary from trial to trial, or even within a trial. In some trials, participants may be asked a simple open question such as 'how have you been feeling?', while in other trials, participants may be asked about whether they have had any of a long list of possible symptoms (such as 'have you had a headache, stomach ache, or sore muscles?'). There has been concern that these different kinds of questions and how they are phrased will impact on what participants report about their health during a trial. This might then affect the trial's results and what we know about the side effects of drugs. We did this review to look at studies that compared different types of participant questioning methods in order to investigate these issues. We found 33 studies comparing mainly open questions with checklist‐type questions, but also some ratings scales and participant interviews. While the studies were all very different in terms of the types of disease, drugs, and patients studied, we found in general that, as would be expected, when a more specific type of question was asked (like a checklist), participants reported more symptoms. What is interesting is that, in those studies that looked more closely at the types of symptoms reported, it seems that an open question picks up the more severe or bothersome symptoms compared to a checklist‐type question. However, some studies found that even quite severe or bothersome symptoms were not reported when a participant is asked an open question and these severe symptoms will only be reported with the more specific question. This makes it difficult to say whether one method is better than any other and the different questioning methods may, in fact, be complementary and therefore should be used together. It is also difficult to say what a specific question should include, as it might take too long for a participant to have to answer a very long list. While more research is needed to resolve the remaining uncertainties, it is very important for trials to be clear about which kind of questioning was used when they publish their results. This will help readers understand the trial's findings about the side effects and make it easier to make accurate comparisons between trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Allen, EN; Chandler, CIR; Mandimika, N; Leisegang, C; Barnes, K", "articleTypes": [], "doi": "10.1002/14651858.MR000039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "9218a470-27bd-4b92-9dbb-6fa9c4a7afa6", "pmid": "", "title": "Nebulized and oral thiol derivatives for pulmonary disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is an inherited condition resulting in thickened, sticky respiratory secretions. Respiratory failure, due to recurrent pulmonary infection and inflammation, is the most common cause of mortality. Muco‐active therapies (e.g. dornase alfa and nebulized hypertonic saline) may decrease sputum viscosity, increase airway clearance of sputum, reduce infection and inflammation and improve lung function. Thiol derivatives, either oral or nebulized, have shown benefit in other respiratory diseases. Their mode of action is likely to differ according to the route of administration. There are several thiol derivatives, and it is unclear which of these may be beneficial in cystic fibrosis. Objectives To evaluate the efficacy and safety of nebulized and oral thiol derivatives in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches, hand searches of relevant journals, abstract books and conference proceedings. Most recent search: 13 June 2013. We also conducted a PubMed search on 26 February 2013 for relevant published articles. Selection criteria Randomized and quasi‐randomized controlled trials comparing nebulized or oral thiol derivatives to placebo or another thiol derivative in people with cystic fibrosis. Data collection and analysis The authors independently assessed trials for inclusion, analysed risk of bias and extracted data. Main results Searches identified 23 trials; nine trials (255 participants) are included, of these seven trials are more than 10 years old. Three trials of nebulized thiol derivatives were identified (one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and another compared glutathione to 4% hypertonic saline). Although generally well‐tolerated with no significant adverse effects, there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Six trials of oral thiol derivatives were identified. Three trials compared N‐acetylcysteine to placebo; one compared N‐acetylcysteine, ambroxol and placebo; one compared carbocysteine to ambroxol; and one compared low and high‐dose N‐acetylcysteine. Oral thiol derivatives were generally well‐tolerated with no significant adverse effects, however there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Authors' conclusions We found no evidence to recommend the use of either nebulized or oral thiol derivatives in people with cystic fibrosis. There are very few good quality trials investigating the effect of these medications in cystic fibrosis, and further research is required to investigate the potential role of these medications in improving the outcomes of people with cystic fibrosis. Plain language summary Compounds which can break down the structure of mucus for lung disease in cystic fibrosis Cystic fibrosis is a genetic disorder which mainly affects the lungs. Chest infections recur in people with cystic fibrosis due to a build up of thick sputum (phlegm) in the air passages. Several treatments, including thiol derivatives, aim to loosen this sputum and so improve lung function and reduce the frequency of chest infections. Thiol derivatives may be either nebulized (breathed in) or oral (by mouth). They have been shown to help in other lung conditions, such as chronic obstructive pulmonary disease. This review aims to find out if there is enough evidence to recommend the use of nebulized or oral thiol derivatives for people with cystic fibrosis. We included nine trials; three assessed the effect of nebulized thiol derivatives. Of the nebulized trials, one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and the other compared glutathione to 4% hypertonic saline. Nebulized thiol derivatives were generally well‐tolerated with no major adverse effects. However they showed no significant improvements in any of our outcome measures. Six included trials assessed the effects of oral thiol derivatives.Three of these trials compared oral N‐acetylcysteine to placebo; one compared oral N‐acetylcysteine, oral ambroxol and placebo; and one compared oral carbocysteine and oral ambroxol (no placebo). None of the trials showed an overall significant benefit in any of the outcome measures of this review. Oral thiol derivatives were generally well‐tolerated with no major adverse effects. In summary, the trials included in the review did not provide any evidence that nebulized or oral thiol derivatives were either beneficial or harmful to people with cystic fibrosis. Further research investigating the effects of thiol derivatives in people with cystic fibrosis is required before their use can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Tam, J, Nash, EF, Ratjen, F, Tullis, E, Stephenson, A", "articleTypes": [], "doi": "10.1002/14651858.CD007168.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.083Z" }, { "id": "9226f952-2cd0-47cc-8261-a61ccfa7792d", "pmid": "", "title": "Prophylactic drug management for febrile seizures in children", "imported": false, "abstract": "Abstract - Background Febrile seizures occurring in a child older than one month during an episode of fever affect 2‐4% of children in Great Britain and the United States and recur in 30%. Rapid‐acting antiepileptics and antipyretics given during subsequent fever episodes have been used to avoid the adverse effects of continuous antiepileptic drugs. This is an updated version of a Cochrane Review previously published in 2017. Objectives To evaluate primarily the effectiveness and safety of antiepileptic and antipyretic drugs used prophylactically to treat children with febrile seizures; and also to evaluate any other drug intervention where there is a sound biological rationale for its use. Search methods For the latest update we searched the following databases on 3 February 2020: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to 31 January 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including the Cochrane Epilepsy Group. We imposed no language restrictions and contacted researchers to identify continuing or unpublished studies. Selection criteria Trials using randomised or quasi‐randomised participant allocation that compared the use of antiepileptics, antipyretics or recognised Central Nervous System active agents with each other, placebo, or no treatment. Data collection and analysis For the original review, two review authors independently applied predefined criteria to select trials for inclusion and extracted the predefined relevant data, recording methods for randomisation, blinding, and exclusions. For the 2016 update, a third review author checked all original inclusions, data analyses, and updated the search. For the 2020 update, one review author updated the search and performed the data analysis following a peer‐review process with the original review authors. We assessed seizure recurrence at 6, 12, 18, 24, 36, 48 months, and where data were available at age 5 to 6 years along with recorded adverse effects. We evaluated the presence of publication bias using funnel plots. Main results We included 42 articles describing 32 randomised trials, with 4431 randomised participants used in the analysis of this review. We analysed 15 interventions of continuous or intermittent prophylaxis and their control treatments. Methodological quality was moderate to poor in most studies. We found no significant benefit for intermittent phenobarbital, phenytoin, valproate, pyridoxine, ibuprofen, or zinc sulfate versus placebo or no treatment; nor for diclofenac versus placebo followed by ibuprofen, paracetamol, or placebo; nor for continuous phenobarbital versus diazepam, intermittent rectal diazepam versus intermittent valproate, or oral diazepam versus clobazam. There was a significant reduction of recurrent febrile seizures with intermittent diazepam versus placebo or no treatment at six months (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.48 to 0.85; 6 studies, 1151 participants; moderate‐certainty evidence), 12 months (RR 0.69, 95% CI 0.56 to 0.84; 8 studies, 1416 participants; moderate‐certainty evidence), 18 months (RR 0.37, 95% CI 0.23 to 0.60; 1 study, 289 participants; low‐certainty evidence), 24 months (RR 0.73, 95% CI 0.56 to 0.95; 4 studies, 739 participants; high‐certainty evidence), 36 months (RR 0.58, 95% CI 0.40 to 0.85; 1 study, 139 participants; low‐certainty evidence), 48 months (RR 0.36, 95% CI 0.15 to 0.89; 1 study, 110 participants; moderate‐certainty evidence), with no benefit at 60 to 72 months (RR 0.08, 95% CI 0.00 to 1.31; 1 study, 60 participants; very low‐certainty evidence). Phenobarbital versus placebo or no treatment reduced seizures at six months (RR 0.59, 95% CI 0.42 to 0.83; 6 studies, 833 participants; moderate‐certainty evidence), 12 months (RR 0.54, 95% CI 0.42 to 0.70; 7 studies, 807 participants; low‐certainty evidence), and 24 months (RR 0.69, 95% CI 0.53 to 0.89; 3 studies, 533 participants; moderate‐certainty evidence), but not at 18 months (RR 0.77, 95% CI 0.56 to 1.05; 2 studies, 264 participants) or 60 to 72 months follow‐up (RR 1.50, 95% CI 0.61 to 3.69; 1 study, 60 participants; very low‐certainty evidence). Intermittent clobazam compared to placebo at six months resulted in a RR of 0.36 (95% CI 0.20 to 0.64; 1 study, 60 participants; low‐certainty evidence), an effect found against an extremely high (83.3%) recurrence rate in the controls, a result that needs replication. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months (RR 0.45, 95% CI 0.18 to 1.15; 1 study, 60 participants; very‐low certainty evidence). When compared to placebo, intermittent oral levetiracetam significantly reduced recurrent seizures at 12 months (RR 0.27, 95% CI 0.15 to 0.52; 1 study, 115 participants; very low‐certainty evidence). The recording of adverse effects was variable. Two studies reported lower comprehension scores in phenobarbital‐treated children. Adverse effects were recorded in up to 30% of children in the phenobarbital‐treated groups and 36% in benzodiazepine‐treated groups. We found evidence of publication bias in the meta‐analyses of comparisons for phenobarbital versus placebo (seven studies) at 12 months but not at six months (six studies); and valproate versus placebo (four studies) at 12 months. There were too few studies to identify publication bias for the other comparisons. The methodological quality of most of the included studies was low or very low. Methods of randomisation and allocation concealment often did not meet current standards, and 'treatment versus no treatment' was more commonly seen than 'treatment versus placebo', leading to obvious risks of bias. Authors' conclusions We found reduced recurrence rates for intermittent diazepam and continuous phenobarbital, with adverse effects in up to 30% of children. The apparent benefit for clobazam treatment in one trial needs to be replicated. Levetiracetam also shows benefit with a good safety profile; however, further study is required. Given the benign nature of recurrent febrile seizures, and the high prevalence of adverse effects of these drugs, parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. Plain language summary Prophylactic drug management for febrile seizures in children Background Seizures occurring with a fever (febrile seizures) in children are common and affect about one in 30 children under the age of six years. On average, one out of three children who have had a febrile seizure will have at least one more. We reviewed the evidence about the effect of drugs to prevent seizures (antiepileptics), drugs to lower temperature (antipyretics), and zinc in children with febrile seizures. Objective We wanted to know in how many children these drugs would prevent a recurrence of febrile seizures or cause unwanted effects. Methods We included 32 studies with a total of 4431 children in the review. Children who had had at least one febrile seizure were assigned to one of two or more treatment groups. The studies recorded any further seizures at various time intervals between six months and up to six years of age in each group. Unwanted medication effects were also noted. Results The study design and evidence quality in the studies of antiepileptic drugs was often low or very low. Poor methods known to lead to obvious risks of bias were used. One issue was with the methods used to assign children to study groups and how random this allocation was. Other issues included whether the parents or doctors, or both, knew which group each child was in or if a treatment was compared to no treatment with no placebo (dummy pill) used. The quality of the trials of antipyretics or zinc was better, with the evidence assessed as moderate to high. Zinc therapy was found to provide no benefit. We also found no benefit in treating children just at the time of the fever with either antipyretic drugs or most antiepileptic drugs. A significant result was noted in some instances. For example, at times between 6 and 48 months follow‐up, intermittent diazepam (an antiepileptic drug) led to a reduction in the number of recurrent seizures by about a third. Continuous phenobarbital resulted in significantly fewer recurrences at 6, 12, and 24 months, but not at 18 and 60 to 72 months. One study showed that intermittent oral levetiracetam compared to placebo significantly reduced recurrent seizures at 12 months. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months. However, as recurrent seizures are only seen in about a third of children, this means that up to 16 children would have to be treated over a year or two to save just one child a further seizure. As febrile seizures are not harmful, we viewed these significant findings to be unimportant, in particular because adverse effects of the medications were common. Lower comprehension scores in phenobarbital‐treated children were found in two studies. In general, adverse effects were recorded in up to about a third of children in both the phenobarbital‐ and benzodiazepine‐treated groups. The benefit found for treatment with clobazam in one study published in 2011 needs to be repeated to test its reliability. Levetiracetam may be useful in treating children where family anxiety over possible seizure recurrence is high, but further study is required. Authors' conclusions There is currently insufficient evidence to support the use of continuous or intermittent treatment with zinc, antiepileptic or antipyretic drugs for children with febrile seizures. Febrile seizures can be frightening to witness. Parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. The evidence is current to February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Offringa, M, Newton, R, Nevitt, SJ, Vraka, K", "articleTypes": [], "doi": "10.1002/14651858.CD003031.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.782Z" }, { "id": "92460f39-d80c-4ad6-8f37-122c487cfab6", "pmid": "", "title": "Interventions for deliberately altering blood pressure in acute stroke", "imported": false, "abstract": "Abstract - Background It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001 and 2008. Objectives To assess the clinical effectiveness of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke. Search methods We searched the Cochrane Stroke Group Trials Register (last searched in February 2014), the Cochrane Database of Systematic reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 2), MEDLINE (Ovid) (1966 to May 2014), EMBASE (Ovid) (1974 to May 2014), Science Citation Index (ISI, Web of Science, 1981 to May 2014) and the Stroke Trials Registry (searched May 2014). Selection criteria Randomised controlled trials of interventions that aimed to alter blood pressure compared with control in participants within one week of acute ischaemic or haemorrhagic stroke. Data collection and analysis Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data. The review authors cross‐checked data and resolved discrepancies by discussion to reach consensus. We obtained published and unpublished data where available. Main results We included 26 trials involving 17,011 participants (8497 participants were assigned active therapy and 8514 participants received placebo/control). Not all trials contributed to each outcome. Most data came from trials that had a wide time window for recruitment; four trials gave treatment within six hours and one trial within eight hours. The trials tested alpha‐2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide‐like diuretics, and target‐driven blood pressure lowering. One trial tested phenylephrine. At 24 hours after randomisation oral ACEIs reduced systolic blood pressure (SBP, mean difference (MD) ‐8 mmHg, 95% confidence interval (CI) ‐17 to 1) and diastolic blood pressure (DBP, MD ‐3 mmHg, 95% CI ‐9 to 2), sublingual ACEIs reduced SBP (MD ‐12.00 mm Hg, 95% CI ‐26 to 2) and DBP (MD ‐2, 95%CI ‐10 to 6), oral ARA reduced SBP (MD ‐1 mm Hg, 95% CI ‐3 to 2) and DBP (MD ‐1 mm Hg, 95% CI ‐3 to 1), oral beta blockers reduced SBP (MD ‐14 mm Hg; 95% CI ‐27 to ‐1) and DBP (MD ‐1 mm Hg, 95% CI ‐9 to 7), intravenous (iv) beta blockers reduced SBP (MD ‐5 mm Hg, 95% CI ‐18 to 8) and DBP (‐5 mm Hg, 95% CI ‐13 to 3), oral CCBs reduced SBP (MD ‐13 mmHg, 95% CI ‐43 to 17) and DBP (MD ‐6 mmHg, 95% CI ‐14 to 2), iv CCBs reduced SBP (MD ‐32 mmHg, 95% CI ‐65 to 1) and DBP (MD ‐13, 95% CI ‐31 to 6), NO donors reduced SBP (MD ‐12 mmHg, 95% CI ���19 to ‐5) and DBP (MD ‐3, 95% CI ‐4 to ‐2) while phenylephrine, non‐significantly increased SBP (MD 21 mmHg, 95% CI ‐13 to 55) and DBP (MD 1 mmHg, 95% CI ‐15 to 16). Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05), stroke type (OR 0.98, 95% CI 0.92 to 1.05) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05). Treatment within six hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99) but not death (OR 0.70, 95% CI 0.38 to 1.26) at the end of the trial. Although death or dependency did not differ between people who continued pre‐stroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24), disability scores at the end of the trial were worse in participants randomised to continue treatment (Barthel Index, MD ‐3.2, 95% CI ‐5.8, ‐0.6). Authors' conclusions There is insufficient evidence that lowering blood pressure during the acute phase of stroke improves functional outcome. It is reasonable to withhold blood pressure‐lowering drugs until patients are medically and neurologically stable, and have suitable oral or enteral access, after which drugs can than be reintroduced. In people with acute stroke, CCBs, ACEI, ARA, beta blockers and NO donors each lower blood pressure while phenylephrine probably increases blood pressure. Further trials are needed to identify which people are most likely to benefit from early treatment, in particular whether treatment started very early is beneficial. Plain language summary Drug interventions for deliberately altering blood pressure in acute stroke Background: In people who have just had a stroke (a sudden brain attack due to either blockage or rupture of an artery in the brain), very high and very low blood pressures may be harmful. Therefore, drugs that raise low blood pressure or lower high blood pressure might be beneficial. Up to 50% of people admitted with acute stroke are taking blood pressure tablets on hospital admission and it is not clear whether these medications should be continued or discontinued in the acute situation. This review looked at those trials that deliberately altered blood pressure or compared continuing or stopping blood pressure‐lowering tablets taken before stroke. Study characteristics: This review is up‐to‐date to May 2014. We included 26 trials involving 17,011 participants: 24 trials assessed lowering blood pressure, one trial tested raising blood pressure, and two trials assessed what to do with drugs taken before stroke. All studies took place in hospitals that were used to treating people with stroke. Not all trials contributed information to all outcomes, and we have used data that were available in publications. Key results: There is insufficient evidence to say that lowering blood pressure saves lives or reduces disability in people with acute stroke. Immediately restarting blood pressure‐lowering drugs taken before the stroke may increase disability. Conclusion: More research is needed to identify those people who are most likely to benefit from altering blood pressure in acute stroke, the time window in which the treatment is likely to be of benefit, what types of stroke are likely to respond favourably, and the environment in which such treatment may be best given in routine practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bath, PMW, Krishnan, K", "articleTypes": [], "doi": "10.1002/14651858.CD000039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.750Z" }, { "id": "92602ec6-7500-480f-a727-298238c102a4", "pmid": "", "title": "Silver acetate for smoking cessation", "imported": false, "abstract": "Abstract - Background Silver acetate produces an unpleasant taste when combined with cigarettes, thereby producing an aversive stimulus. It has been marketed in various forms with the aim of extinguishing the urge to smoke, by pairing the urge with an unpleasant stimulus. Objectives The aim of this review was to determine the effectiveness of silver acetate products (gum, lozenge, spray) in promoting smoking cessation. Search methods We searched the Cochrane Tobacco Addiction Group specialised trials register. Most recent search was in July 2012. Selection criteria We included randomised trials of silver acetate for smoking cessation with reports of smoking status at least six months after the beginning of treatment. Data collection and analysis We extracted data in duplicate on the type of subjects, the dose and form of silver acetate, the outcome measures, method of randomisation, and completeness of follow‐up. The main outcome measure was biochemically validated abstinence from smoking after at least six months follow‐up in patients smoking at baseline. Subjects lost to follow‐up were counted as continuing smokers. Where appropriate, we performed meta‐analysis using a fixed effects model. Main results Two studies provided long‐term follow‐up data on patients randomised to silver acetate or placebo. In one of these studies, there was a third arm, randomised to 2mg nicotine gum. The pooled risk ratio for quitting for silver acetate vs placebo was 1.04 (95% confidence interval 0.69 to 1.57). Authors' conclusions Existing trials show little evidence for a specific effect of silver acetate in promoting smoking cessation. The confidence intervals for the ratio are quite wide. However, the upper limit of the confidence intervals for a positive effect equates to an absolute increase in the smoking cessation rate of about 4%. Any effect of this agent is therefore likely to be smaller than nicotine replacement therapy. The lack of effect of silver acetate may reflect poor compliance with a treatment whose rationale is to create an unpleasant stimulus. Plain language summary Does silver acetate help people stop smoking Silver acetate products (gum, lozenge, and spray) produce an unpleasant metallic taste when combined with cigarettes, so they are used as a form of aversion therapy for smoking. However, the review of trials found little evidence to show that silver acetate helps smokers quit. Any beneficial effect of silver acetate is likely to be very small, and less than the effect already proven for nicotine replacement therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lancaster, T, Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000191.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.746Z" }, { "id": "92613497-3a9d-4964-8383-161e27f8edff", "pmid": "", "title": "Paracetamol (acetaminophen) for prevention or treatment of pain in newborns", "imported": false, "abstract": "Abstract - Background Newborn infants have the ability to experience pain. Hospitalised infants are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Objectives To determine the efficacy and safety of paracetamol for the prevention or treatment of procedural/postoperative pain or pain associated with clinical conditions in neonates. To review the effects of various doses and routes of administration (enteral, intravenous or rectal) of paracetamol for the prevention or treatment of pain in neonates. Search methods We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 4), MEDLINE via PubMed (1966 to 9 May 2016), Embase (1980 to 9 May 2016), and CINAHL (1982 to 9 May 2016). We searched clinical trials' databases, Google Scholar, conference proceedings, and the reference lists of retrieved articles. Selection criteria We included randomised and quasi‐randomised controlled trials of paracetamol for the prevention/treatment of pain in neonates (≤ 28 days of age). Data collection and analysis Two review authors independently extracted data from the articles using pre‐designed forms. We used this form to decide trial inclusion/exclusion, to extract data from eligible trials and to request additional published information from authors of the original reports. We entered and cross‐checked data using RevMan 5 software. When noted, we resolved differences by mutual discussion and consensus. We used the GRADE approach to assess the quality of evidence. Main results We included nine trials with low risk of bias, which assessed paracetamol for the treatment of pain in 728 infants. Painful procedures studied included heel lance, assisted vaginal birth, eye examination for retinopathy of prematurity assessment and postoperative care. Results of individual studies could not be combined in meta‐analyses as the painful conditions, the use of paracetamol and comparison interventions and the outcome measures differed. Paracetamol compared with water, cherry elixir or EMLA cream (eutectic mixture of lidocaine and prilocaine) did not significantly reduce pain following heel lance. The Premature Infant Pain Profile score (PIPP) within three minutes following lancing was higher in the paracetamol group than in the oral glucose group (mean difference (MD) 2.21, 95% confidence interval (CI) 0.72 to 3.70; one study, 38 infants). Paracetamol did not reduce \"modified facies scores\" after assisted vaginal birth (one study, 119 infants). In another study (n = 123), the Échelle de Douleur et d'Inconfort du Nouveau‐Né score at two hours of age was significantly higher in the group that received paracetamol suppositories than in the placebo suppositories group (MD 1.00, 95% CI 0.60 to 1.40). In that study, when infants were subjected to a heel lance at two to three days of age, Bernese Pain Scale for Neonates scores were higher in the paracetamol group than in the placebo group, and infants spent a longer time crying (MD 19 seconds, 95% CI 14 to 24). For eye examinations, no significant reduction in PIPP scores in the first or last 45 seconds of eye examination was reported, nor at five minutes after the eye examination. In one study (n = 81), the PIPP score was significantly higher in the paracetamol group than in the 24% sucrose group (MD 3.90, 95% CI 2.92 to 4.88). In one study (n = 114) the PIPP score during eye examination was significantly lower in the paracetamol group than in the water group (MD −2.70, 95% CI −3.55 to 1.85). For postoperative care following major surgery, the total amount of morphine (µg/kg) administered over 48 hours was significantly less among infants assigned to the paracetamol group than to the morphine group (MD −157 µg/kg, 95% CI −27 to −288). No adverse events were noted in any study. The quality of evidence according to GRADE was low. Authors' conclusions The paucity and low quality of existing data do not provide sufficient evidence to establish the role of paracetamol in reducing the effects of painful procedures in neonates. Paracetamol given after assisted vaginal birth may increase the response to later painful exposures. Paracetamol may reduce the total need for morphine following major surgery, and for this aspect of paracetamol use, further research is needed. Plain language summary Paracetamol (acetaminophen) for prevention or treatment of pain in newborns Review question: Is paracetamol effective and safe for the prevention or treatment of procedural or postoperative pain or pain associated with clinical conditions in newborn infants? Background: Newborn infants have the ability to experience pain. Newborns treated in neonatal intensive care units are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Study characteristics: We identified nine studies that reported comparisons in 728 infants of paracetamol versus placebo or other pain‐reducing interventions. The literature search was updated in May 2016. Key results: Paracetamol for heel lance did not reduce pain compared with placebo (water or cherry elixir) or compared with EMLA cream (eutectic mixture of lidocaine and prilocaine). Paracetamol use was associated with a stronger response to pain than was seen with glucose. Paracetamol did not reduce pain in infants exposed to vacuum extraction or forceps at birth, and their response to a subsequent heel lance at two to three days of life was increased compared with placebo. For eye examination, paracetamol was effective in reducing pain compared with water in one study, but the pain response was stronger among paracetamol‐treated infants than in infants given 24% sucrose. In infants treated with paracetamol and morphine compared with morphine alone, the total amount of morphine required during the first 48 hours following major surgery to the chest or the abdomen was less in the paracetamol group. Paracetamol did not significantly reduce pain during heel lance. Paracetamol following assisted birth may increase the response to later exposure to painful interventions. Paraetamol may reduce the total need for morphine following major surgery, and further research is needed into this aspect of paracetamol use. Quality of evidence: In general the studies were of good quality but the numbers of infants enrolled in the different studies were small. The overall quality of evidence was low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ohlsson, A, Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD011219.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.824Z" }, { "id": "9272f838-3a3a-4a0d-b542-a166a1198ab3", "pmid": "", "title": "Topiramate for neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background Topiramate is an antiepileptic drug with multiple possible mechanisms of action. Antiepileptic drugs are widely used to treat chronic neuropathic pain (pain due to nerve damage) and fibromyalgia, and many guidelines recommend them. Objectives To assess the analgesic efficacy and associated adverse events of topiramate for chronic neuropathic pain and fibromyalgia in adults (aged 18 years and above). Search methods On 8 May 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We reviewed the bibliographies of all randomised trials identified and review articles, and also searched two clinical trial databases, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform, to identify additional published or unpublished data. Selection criteria We included randomised controlled trials (RCTs) with double‐blind assessment of participant outcomes following two weeks of treatment or longer (though the emphasis of the review was on studies of eight weeks or longer) that used a placebo or active comparator. Data collection and analysis We extracted efficacy and adverse event data, and two study authors examined issues of study quality independently. We performed analysis using two tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First tier studies did not use last‐observation‐carried‐forward (LOCF) or other imputation methods for dropouts. The second tier used data that failed to meet this standard; second tier results were therefore subject to potential bias. Main results We included four studies with 1684 participants. Three parallel‐group placebo comparisons were in painful diabetic neuropathy (1643 participants), and one cross‐over study with diphenhydramine as an active placebo (41 participants) was in lumbar radiculopathy. Doses of topiramate were titrated up to 200 mg/day or 400 mg/day. All studies had one or more sources of potential major bias, as they either used LOCF imputation or were of small size. No study provided first tier evidence for an efficacy outcome. There was no convincing evidence for efficacy of topiramate at 200 to 400 mg/day over placebo. Eighty‐two per cent of participants taking topiramate 200 to 400 mg/day experienced at least one adverse event, as did 71% with placebo, and the number needed to treat for an additional harmful effect (NNTH) was 8.6 (95% confidence interval (CI) 4.9 to 35). There was no difference in serious adverse events recorded (6.6% versus 7.5%). Adverse event withdrawals with 400 mg daily were much more common with topiramate (27%) than with placebo (8%), with an NNTH of 5.4 (95% CI 4.3 to 7.1). Lack of efficacy withdrawal was less frequent with topiramate (12%) than placebo (18%). Weight loss was a common event in most studies. No deaths attributable to treatment were reported. Authors' conclusions Topiramate is without evidence of efficacy in diabetic neuropathic pain, the only neuropathic condition in which it has been adequately tested. The data we have includes the likelihood of major bias due to LOCF imputation, where adverse event withdrawals are much higher with active treatment than placebo control. Despite the strong potential for bias, no difference in efficacy between topiramate and placebo was apparent. Plain language summary Topiramate for treating neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (for example from a fall, a cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in treating neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our knowledge about fibromyalgia is even less advanced, but fibromyalgia can respond to the same medicines as neuropathic pain. Topiramate is a medicine used to treat epilepsy, and so it might be a useful medicine for neuropathic pain or fibromyalgia. On 8 May 2013, we performed searches to look for clinical trials on the use of topiramate to treat neuropathic pain or fibromyalgia. We found four studies of reasonable quality that tested topiramate against placebo for a number of weeks. Almost all of the 1684 people in the studies had painful limbs because of damaged nerves caused by diabetes. Topiramate did not help the pain and was no different from placebo except in causing more side‐effects, which made many more people withdraw from the studies early. About 3 people in 10 withdrew because of side‐effects with topiramate compared with 1 in 10 with placebo. Topiramate has not been shown to work as a pain medicine in diabetic neuropathy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ; Derry, S; Lunn, MPT; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008314.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "9277aeb4-e593-44c0-b882-a95cc406b3b1", "pmid": "", "title": "Interventions for the eradication of meticillin‐resistant Staphylococcus aureus (MRSA) in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a genetic disorder characterised by recurrent and persistent pulmonary infections from resistant organisms, resulting in deterioration of lung function and early mortality. Meticillin‐resistant Staphylococcus aureus (MRSA) is an important infection in hospital patients and harmful to people with CF (pwCF). Chronic pulmonary MRSA infection may confer a worse clinical outcome on pwCF and result in a faster decline in lung function. Robust evidence clearly guiding MRSA eradication in CF is urgently needed. This is an updated review. Objectives To evaluate the effectiveness of antibiotic treatment designed to eradicate MRSA, to determine whether eradication confers better clinical and microbiological outcomes for pwCF, and to ascertain whether attempts at eradicating MRSA lead to increased acquisition of other resistant organisms (including Pseudomonas aeruginosa ), increased adverse effects from drugs, or both. Search methods We searched the Cochrane CF's Trials Register, PubMed, MEDLINE and three trials registries; handsearched article reference lists; and contacted experts in the field. We last searched Cochrane CF's Trials Register and the trials registries on 28 April 2026. Eligibility criteria Randomised controlled trials (RCTs) or quasi‐RCTs of any combination of topical, inhaled, oral or intravenous antibiotics for treating MRSA compared with placebo, standard treatment or no treatment in pwCF, regardless of age or disease severity. Outcomes We planned to assess these outcomes at up to 12 months following therapy: eradication of MRSA from respiratory cultures, time until next positive MRSA isolate, quality of life (QoL), change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted, change in weight (kg), frequency of pulmonary exacerbations and adverse effects of treatment. Risk of bias Using the original Cochrane risk of bias tool, we assessed individual domains and produced an overall risk of bias for each trial. Synthesis methods We followed Cochrane's standard methodology, conducting fixed‐effect meta‐analyses or reporting narratively. We assessed evidence certainty using GRADE. Included studies We included five RCTs (410 participants). Synthesis of results Oral antibiotics versus no treatment Two trials (106 participants) compared observation to oral trimethoprim plus sulfamethoxazole combined with rifampicin; in one trial for two weeks alongside topical decontamination and a three‐week environmental decontamination, and in a second for 21 days alongside intranasal mupirocin (five days); 29 participants withdrew from the second trial by the end of follow‐up. Oral antibiotics have little or no effect on any outcome reported below, in contrast to one study (45 participants) which was terminated early due to results clearly favouring treatment. In one trial defining eradication as negative MRSA respiratory cultures at day 28 and remaining so at day 168 (45 participants), treatment may result in more negative cultures than observation (odds ratio (OR) 12.6 (95% confidence interval (CI) 2.84 to 55.84; low‐certainty). There may be little to no difference between groups by day 168 of follow‐up (OR 1.17, 95% CI 0.31 to 4.42), and also in one trial defining successful eradication as no MRSA in at least three cultures over six months follow‐up (OR 2.74, 95% CI 0.64 to 11.75; low‐certainty). Treatment may result in an increase in FEV 1 % predicted from baseline (MD 5.67%, 95% CI 1.43 to 9.90; 2 trials, 58 participants; low‐certainty evidence). There may be little to no differences between groups in QoL, frequency of pulmonary exacerbations (although one study reported a lower hospitalisation rate through day 168 with treatment (P = 0.01)), adverse effects, or weight (all low‐certainty evidence). Nebulised antibiotics versus placebo Two trials (275 participants randomised, 251 analysed) compared a standard dose of vancomycin (one trial additionally compared a high dose) to placebo. The multi‐arm trial reported a decrease in MRSA colony forming units (CFUs) at each time point, up to one month. There were no differences in most lung function results in either trial, but treatment probably increased FEV 1 % predicted at 20 weeks (MD 3.55%, 95% CI 0.33 to 6.77; P = 0.03; 1 trial, 133 participants; moderate‐certainty evidence). This trial also reported no difference in pulmonary exacerbation frequency, while the multi‐arm trial reported a longer time to the next exacerbation with the lower vancomycin dose (no placebo data available). Evidence from both trials suggests that nebulised antibiotics may make little or no difference in QoL (high to low‐certainty), or frequency of adverse outcomes or of exacerbations (low‐to‐moderate‐certainty evidence). Oral antibiotics plus nebulised antibiotics (vancomycin) versus oral antibiotics plus placebo One trial (29 participants randomised, 25 participants analysed) compared combination antibiotic treatment (inhaled plus oral) to oral antibiotics plus inhaled placebo, defining eradication as a negative MRSA respiratory sample at one month following treatment. Combination antibiotic treatment may result in little or no difference in MRSA eradication at three months (OR 1.63, 95% CI 0.19 to 13.93; low‐certainty evidence), lung function (no data available for analysis) or adverse effects (low‐certainty evidence), in QoL (very low‐certainty evidence) or nasal colonisation with MRSA. Authors' conclusions Early eradication of MRSA is possible in pwCF; evidence from one trial suggested active MRSA treatment may result in a higher proportion of MRSA‐negative respiratory cultures after one month compared with observation. However, longer follow‐up showed treatment may make little or no difference in the proportion of participants remaining MRSA‐negative. One trial of nebulised antibiotics alone compared to placebo reported a decrease in MRSA CFUs with a higher antibiotic dose. The longer‐term clinical consequences of any treatment option – in terms of lung function, mortality and cost of care – remain unclear. We judged the evidence to range from high to very low‐certainty, due to potential biases from trial design, high attrition rates and small sample sizes. While early eradication of respiratory MRSA in pwCF may be possible, the currently available evidence does not demonstrate that routine treatment of respiratory MRSA in pwCF is effective. Research is needed to assess MRSA infection and treatment in the age of modulator therapies. Funding The 2025 update was undertaken as part of Cochrane CF funding from the UK CF Trust and the CF Foundation. Registration Protocol (2012) DOI: 10.1002/14651858.CD009650. Original review (2013) DOI: 10.1002/14651858.CD009650.pub2. Review updates: (2015) DOI: 10.1002/14651858.CD009650.pub3; (2018) DOI: 10.1002/14651858.CD123456.pub4; (2022) DOI: 10.1002/14651858.CD009650.pub5. Plain language summary Can treatment with antibiotics clear the 'superbug' MRSA from the lungs of people with cystic fibrosis? Key messages Early treatment of meticillin‐resistant Staphylococcus aureus (MRSA) (a type of bacteria which are resistant to some antibiotics) infection in people with cystic fibrosis (CF) seems possible, but we are unsure about the effectiveness of current routine treatment. Longer‐term implications of treatment are not clear. Research is needed to assess MRSA infection and treatment in the age of cystic fibrosis transmembrane conductance regulator (CFTR) modulators (drugs that fix the broken protein made by the CF gene so salt and water can move correctly across cells and help move mucus from the lungs). What is cystic fibrosis (CF)? CF is an inherited condition which causes thick mucus to build up in the lungs and other organs. It is very difficult for people with CF to cough up this thick mucus, making it an ideal breeding ground for germs (including MRSA), and making them more prone to chest infections. CF worsens over time. Although there is currently no cure, many people with CF can lead active and full lives. What is MRSA and how is it treated? MRSA (meticillin‐resistant Staphyloccocus aureus) are bacteria which cause infection that is treated with antibiotics. However, MRSA are resistant to some types of antibiotics, making the infection hard to treat. They are sometimes called 'superbugs' and infection with MRSA is particularly worrying for people with CF, as it is thought that MRSA can cause more damage than other bacteria which are not resistant to antibiotics. MRSA is usually treated with a combination of antibiotics, taken orally (by mouth) or inhaled, alongside decontamination treatment (antibiotic creams applied to the skin and nasal cavities). What did we want to find out? We wanted to know whether treatment with antibiotics: can get rid of MRSA infection in the lungs of children or adults with CF; does not cause infection with other resistant bacteria; does not cause unwanted effects. What did we do? We looked for studies that investigated antibiotics (oral or inhaled) to treat MRSA infections in people with CF. Studies had to compare antibiotic treatment with either no treatment, placebo (sham treatment) or other type of antibiotics. People had to have CF and current infection with MRSA. What did we find? We found five studies which recruited 410 people with CF and a diagnosed MRSA infection. Studies took place in Italy or North America and lasted from eight weeks to six months. People in the studies (equal numbers of males and females) were young (average age ranged from 11 to 25 years). Oral antibiotics compared to no treatment (2 studies, 106 people) One group of people with CF were treated with oral antibiotics (trimethoprim, sulfamethoxazole and rifampicin or co‐trimoxazole and rifampicin), plus decontamination treatment; the other group received no treatment. Oral antibiotics may clear MRSA. One trial stopped early due to clear benefits of antibiotics, but some people cleared the infection with no treatment. In six months, there was no difference between groups in the number of people who still had MRSA. Antibiotics may increase lung function. There may be little to no difference between groups in quality of life, frequency of flare‐ups of the disease (although one study reported fewer people taking antibiotics were admitted to hospital in the first six months), unwanted effects of treatment, or changes in weight. Inhaled antibiotics compared to placebo (2 studies, 251 people) Both studies compared a standard dose of vancomycin (an inhaled antibiotic) to placebo (a dummy drug) and one study also compared a standard dose of vancomycin to a high dose. Inhaled antibiotics probably make no difference to lung function compared to placebo (2 studies), but results from one study indicated that inhaled antibiotics probably lead to a small increase after 20 weeks. A standard dose of vancomycin probably makes no difference to the frequency of flare‐ups compared to placebo (2 studies); One study reported a longer time to the next flare‐up with the lower dose of vancomycin; One study reported a decrease in MRSA bacteria levels with a higher dose of vancomycin for up to one month; Neither study reported any differences in quality of life or unwanted effects. Oral plus inhaled antibiotics compared to oral antibiotics plus placebo (1 study, 25 people) One study compared a combination of oral plus inhaled antibiotics to inhaled antibiotics plus placebo. We are uncertain if either treatment made any difference to MRSA clearance; There may be few or no differences between groups in lung function, quality of life or unwanted effects; The study did not report changes in weight or frequency of flare‐ups. What are the limitations of the evidence? Our confidence in the results ranged from high to very low. This was due to potential issues with the trial designs (people knew which treatment they were receiving), or because there were small numbers of people in each trial and many of them dropped out. How up to date is this evidence? This review updates our previous review published in 2022. The evidence is current to 28 April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lo, DKH; Jahnke, N; Smith, S; Muhlebach, MS; Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD009650.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "92b0b7a9-287f-42ff-9641-2265c044f10b", "pmid": "", "title": "Fortification of condiments and seasonings with iron for preventing anaemia and improving health", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jalal, CSB, De-Regil, LM, Pike, V, Mithra, P", "articleTypes": [], "doi": "10.1002/14651858.CD009604.pub2 AB - Abstract - Background Anaemia affects approximately 1.8 billion people worldwide; over 60% of anaemia cases globally are due to iron deficiency (ID). Iron deficiency and anaemia contribute to the global burden of disease and affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortification of food with iron, alone or in combination with other nutrients, is an effective intervention to control ID. Condiments and seasonings are ideal food vehicles for iron fortification in countries where they are commonly used. Objectives To determine the effects and safety of condiment and seasoning fortification with iron alone or iron plus other micronutrients on iron deficiency, anaemia, and health‐related outcomes in the general population. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 24 January 2023. We also searched the International clinical trials registry platform (ICTRP) for any ongoing trials. Selection criteria We included randomised controlled trials (RCTs) (randomisation at individual or cluster level), non‐randomised controlled trials, interrupted time series with at least three measure points both before and after intervention, and controlled before‐after studies. Participants were populations of any age (including pregnant women), from any country, excluding those with critical illness or severe co‐morbidities. We included interventions in which condiments or seasonings have been fortified with any combination of iron and other vitamins and minerals, irrespective of the fortification technology used. Data collection and analysis Two review authors independently screened and assessed the eligibility of studies. Disagreements were resolved through discussion or input from a third review author. Two review authors extracted the data and assessed the risk of bias in all the included studies. We followed the methods laid out by Cochrane and used GRADE criteria for assessing certainty of the evidence. Main results Our search identified 15,902 records after removal of duplicates. We included 16 studies with 20,512 participants (18,410 participants after adjusting for clustering effects). They were all carried out in upper‐middle‐ and lower‐middle‐income countries. Three studies were controlled before‐after studies, one was non‐randomised trial, and 12 were RCTs (including three cluster RCTs). Six studies took place in schools; seven in communities; and one each in a nursery/kindergarten, tea estate, and factory. Three studies involved only women, one study involved both women and their children, and all other studies focused on children and/or adolescents. Nine studies used salt as a vehicle for iron fortification, three used fish sauce, two used soy sauce, one used curry powder, and one a \"seasoning powder\". The dose of iron received by participants ranged from 4.4 mg to 55 mg/day. The sample sizes in the trials ranged from 123 to 14,398, and study durations ranged from three months to two years. Twelve RCTs contributed data for meta‐analysis. Six trials compared iron‐fortified condiments versus the unfortified condiment, and six trials provided data comparing iron fortification in combination with other micronutrients versus the same condiment with other micronutrients, but no added iron. In one trial, the fortificant contained micronutrients that may have affected the absorption of iron. Overall no studies were assessed as having a low risk of bias. All included studies were assessed to have a high overall risk of bias, with the most concerns being around allocation concealment, blinding, and random sequence generation. There was very high heterogeneity amongst studies in almost all examined outcomes. Condiments/seasonings fortified with iron versus unfortified condiments/seasonings We are uncertain about whether consuming condiments/seasonings fortified with iron in comparison to the same unfortified condiment reduces anaemia at the end of intervention (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.18 to 0.65; 2328 participants; 4 studies; very low‐certainty of evidence). We are uncertain about whether consuming iron‐fortified condiments increases haemoglobin concentrations (mean difference (MD) 6.40 (g/L), 95% CI ‐0.62 to 13.41; 2808 participants; 5 studies; very low‐certainty evidence). Fortification of condiments/seasonings with iron probably slightly reduces ID (RR 0.33, 95% CI 0.11 to 1.01; 391 participants; 2 studies; moderate‐certainty evidence). We are uncertain about whether fortification with iron increases ferritin concentration (MD 14.81 (µg/L), 95% CI 5.14 to 24.48; 4459 participants; 6 studies; very low‐certainty evidence). Condiments/seasonings fortified with iron plus other micronutrients versus condiments/seasonings fortified with other micronutrients except iron Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia (RR 0.59, 95% CI 0.40 to 0.89; 1007 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification of condiments/seasonings with iron plus other micronutrients will improve haemoglobin concentration (MD 6.22 g/dL, 95% CI 1.60 to 10.83; 1270 participants; 5 studies; very low‐certainty evidence). It may reduce ID (RR 0.36, 95% CI 0.19 to 0.69; 1154 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification with iron plus other micronutrients improves ferritin concentration (MD 10.63 µg/L, 95% CI 2.40 to 18.85; 1251 participants; 5 studies; very low ‐certainty evidence). Condiments/seasonings fortified with iron versus no intervention No trial reported data on this comparison. No studies reported adverse effects. Funding sources do not appear to have distorted the results in any of the assessed trials. Authors' conclusions We are uncertain whether consuming iron‐fortified condiments/seasonings reduces anaemia, improves haemoglobin concentration, or improves ferritin concentration. It may reduce ID. Findings about ferritin should be interpreted with caution since its concentrations increase during inflammation. Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia, and we are uncertain whether this will improve haemoglobin concentration or ferritin concentration. More studies are needed to determine the true effect of iron‐fortified condiments/seasonings on preventing anaemia and improving health. The effects of this intervention on other health outcomes like malaria incidence, growth and development are unclear. Plain language summary Adding iron to condiments and seasonings for preventing anaemia and improving health Key messages ‐ Adding iron to condiments/seasonings may slightly improve iron status and reduce iron deficiency. When iron is added along with other micronutrients, it may reduce anaemia. Unwanted effects were not reported. ‐ There was a lot of variation between the studies included in this review, making it more difficult to draw definitive conclusions. The effects of fortifying condiments and seasonings with iron should continue to be examined in populations consuming them through well‐designed studies. What is anaemia? Iron deficiency is one of the most common nutritional deficiencies throughout the world and contributes significantly to the global burden of disease. Multiple factors cause anaemia, including insufficient iron intake (the most common cause of anaemia), and it affects approximately 1.8 billion people worldwide. In general, low‐income countries have more anaemia than higher‐income countries. Iron deficiency and anaemia have several lifetime consequences that can affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortifying condiments or seasonings with iron may be a useful and cost‐effective approach to help reduce iron deficiency. To date, there has been no systematic assessment of the safety and effectiveness of this intervention to inform policymaking. What did we want to find out? If fortifying condiments and seasonings with iron alone or iron plus other micronutrients improves measures of iron nutrition in the general population, in particular: ‐ anaemia; ‐ haemoglobin concentration; ‐ iron deficiency; ‐ iron status (including ferritin, transferrin saturation, and more). We also wanted to find out if consuming iron‐fortified condiments/seasonings was associated with any unwanted effects. What did we do? 
We searched for studies that provided iron‐fortified condiments/seasonings to one group, and condiments/seasonings not fortified with iron to another. We compared and summarised the results of the studies and rated our confidence in the evidence, based on study characteristics. What did we find? We identified 16 studies that involved 18,410 participants in middle‐income countries, most within schools or communities, with study durations ranging from three months to two years. The type of iron‐fortified condiments/seasonings used included salt, fish sauce, soy sauce, and seasoning powders. The dose of iron received by participants ranged from 4.4mg to 55 mg/day. Compared to unfortified condiments/seasonings, those which are iron‐fortified likely improve iron deficiency slightly. We are uncertain whether they reduce anaemia, improve haemoglobin, or other measures of iron status. Condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia; we are uncertain about whether they improve haemoglobin or ferritin concentrations. They may improve iron deficiency and total iron binding capacity. No studies reported adverse effects. More studies are needed to determine the effect of iron‐fortified condiments/seasonings on health such as malaria incidence, growth and development and any potential adverse effects. What are the limitations of the evidence? Our confidence in the evidence is very low to moderate; several factors reduced our confidence in the evidence. Firstly, we observed limitations in the way few studies were conducted with respect to the recruitment of people to assign interventions (this means that differences between the groups could be due to differences between people rather than between the treatments). Secondly, people in some studies may have been aware of which treatment they were getting. Also, not all the studies provided data about everything that were interested in, and results were inconsistent across the different studies. Finally, some studies were small. The results of future research could differ from the results of this review. How up to date is this evidence? The evidence is up‐to‐date to January 2023. What this means We judged the evidence in this review as very low to moderate certainty, which means we are not certain of the effect of condiments/seasonings with added iron on the reduction of anaemia and iron deficiency in people.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.766Z" }, { "id": "92b791ff-954a-43d1-8d0f-321a5e97e677", "pmid": "", "title": "Statins for children with familial hypercholesterolemia", "imported": false, "abstract": "Abstract - Background Familial hypercholesterolemia is one of the most common inherited metabolic diseases and is an autosomal dominant disorder meaning heterozygotes, or carriers, are affected. Those who are homozygous have severe disease. The average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500, although recent genetic epidemiological data from Denmark and next generation sequencing data suggest the frequency may be closer to 1 in 250. Diagnosis of familial hypercholesterolemia in children is based on elevated total cholesterol and low‐density lipoprotein cholesterol levels or DNA‐based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong treatment, started in childhood, is needed to reduce the risk of cardiovascular disease. In children with the disease, diet was the cornerstone of treatment but the addition of lipid‐lowering medications has resulted in a significant improvement in treatment. Anion exchange resins, such as cholestyramine and colestipol, were found to be effective, but they are poorly tolerated. Since the 1990s studies carried out on children aged 6 to 17 years with heterozygous familial hypercholesterolemia have demonstrated significant reductions in their serum total and low‐density lipoprotein cholesterol levels. While statins seem to be safe and well‐tolerated in children, their long‐term safety in this age group is not firmly established. This is an update of a previously published version of this Cochane Review. Objectives To assess the effectiveness and safety of statins in children with heterozygous familial hypercholesterolemia. Search methods Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline. Date of most recent search: 04 November 2019. Selection criteria Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. Data collection and analysis Two authors independently assessed studies for inclusion and extracted data. Main results We found 26 potentially eligible studies, of which we included nine randomized placebo‐controlled studies (1177 participants). In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). There may be little or no difference in liver function (serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations) between treated and placebo groups at any time point (low‐quality evidence). There may be little or no difference in myopathy (as measured in change in creatinine levels) (low‐quality evidence) or clinical adverse events (moderate‐quality evidence) with statins compared to placebo. One study on simvastatin showed that this may slightly improve flow‐mediated dilatation of the brachial artery (low‐quality evidence), and on pravastatin for two years may have induced a regression in carotid intima media thickness (low‐quality evidence). No studies reported rhabdomyolysis (degeneration of skeletal muscle tissue) or death due to rhabdomyolysis, quality of life or compliance to study medication. Authors' conclusions Statin treatment is an effective lipid‐lowering therapy in children with familial hypercholesterolemia. Few or no safety issues were identified. Statin treatment seems to be safe in the short term, but long‐term safety remains unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians and their care transferred to an adult lipidologist once they reach 18 years of age. Large long‐term randomized controlled trials are needed to establish the long‐term safety issues of statins. Plain language summary Statins for children with inherited high blood cholesterol Review question We reviewed the evidence for the effectiveness and safety of statins in children with inherited high blood cholesterol. Background Familial hypercholesterolemia is an inherited disease in which the blood cholesterol level is high. Vascular disease, i.e. furring up of the blood vessels, often occurs at an earlier age than usual, especially amongst men. Thus lifelong therapies, started in childhood, to reduce blood cholesterol are needed. In children with familial hypercholesterolemia, diet has been the main treatment option. Medications, such as cholestyramine and colestipol, have been used effectively, but due to their unpleasant taste they are poorly tolerated and treatment plans are not followed. The advent of statin therapy for children has improved treatment and this review updates the previous published version. Search date The evidence is current to: 04 November 2019. Study characteristics The review included 9 studies with 1177 people with heterozygous familial hypercholesterolemia aged between 4 and 18 years of age. Studies compared different statin treatments with a substance which contains no medication (termed placebo) and people were selected for one treatment or the other randomly. The studies lasted from 12 weeks to 104 weeks. Key results In general, the intervention and follow‐up time was short (median 24 weeks; range from six weeks to two years). Statins probably reduced the mean low‐density lipoprotein cholesterol concentration at all time points (high‐quality evidence). The levels of the liver enzymes, serum aspartate and alanine aminotransferase, and the muscle enzyme, creatinine kinase, did not differ between treated and placebo groups at any time point (low‐quality evidence). The risks of myopathy (disease of muscle tissue) and side‐effects were very low and similar in both groups (low‐quality evidence). Two of the statins, simvastatin and pravastatin may have a positive effect on two of the major blood vessels typically affected by raised cholesterol levels (low‐quality evidence). Quality of the evidence Information regarding blinding (performance bias and detection bias), was available for all nine studies; each was described as double blind, indicating that participants and those participating in treatment procedures were blinded to treatment. In two studies information on how the participants were allocated to treatment groups (selection bias) was clearly presented, but this information was not clearly stated in the remaining seven studies. There is a lack of information whether investigators knew which treatment group participants would be put into (selection bias) and or whether selective reporting (reporting bias) occurred, but it is very unlikely. In conclusion, it can be stated all the studies appeared to be well run and we do not think any of the above‐mentioned factors influenced the results in a negative way. Quality of evidence varied from high (change in serum low‐density lipoprotein (LDL) cholesterol) through moderate (adverse events) to low (change in blood vessel wall (carotid intima‐media) thickness, change in measures if growth and maturation, liver dysfunction, myopathy and change in blood wall (endothelial) function).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Vuorio, A, Kuoppala, J, Kovanen, PT, Humphries, SE, Tonstad, S, Wiegman, A, Drogari, E, Ramaswami, U", "articleTypes": [], "doi": "10.1002/14651858.CD006401.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.761Z" }, { "id": "92b87fc4-8845-4627-a616-b962988e97ab", "pmid": "", "title": "Evaluation of the Efficacy of CANNABIDIOL on the Pruritus in Children With Hereditary Epidermolysis Bullosa", "imported": false, "abstract": "Hereditary epidermolysis bullosa (HEB) is a heterogeneous group of rare genetic diseases, characterized by fragility of the skin and mucous membranes, which results in the appearance of mucocutaneous bullae and erosions during minimal trauma. Pruritus is a neuropathic pain mainly related to activation of unmyelinated cutaneous C nerve fibers and is very common in patients with HEB. It is the cause of trophic disorders, aggravation of certain wounds, appearance of new bubbles. In addition, this chronic pruritus can also have a major psychological impact on the patient and his family. However, these therapies used in the pruritus of patients with HEB have often proven to be ineffective.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.156Z" }, { "id": "92bc81f6-4f43-41d5-86c8-f4401aab49c2", "pmid": "", "title": "Nutritional interventions for reducing morbidity and mortality in people with HIV", "imported": false, "abstract": "Abstract - Background Adequate nutrition is important for optimal immune and metabolic function. Dietary support may, therefore, improve clinical outcomes in HIV‐infected individuals by reducing the incidence of HIV‐associated complications and attenuating progression of HIV disease, improving quality of life and ultimately reducing disease‐related mortality. Objectives To evaluate the effectiveness of various macronutrient interventions, given orally, in reducing morbidity and mortality in adults and children living with HIV infection. Search methods We searched CENTRAL (up to August 2011), MEDLINE (1966 to August 2011), EMBASE (1988 to August 2011), LILACS (up to February 2012), and Gateway (March 2006‐February 2010). We also scanned reference lists of articles and contacted authors of relevant studies and other researchers. Selection criteria Randomised controlled trials evaluating the effectiveness of macronutrient interventions compared with no nutritional supplements or placebo in the management of adults and children infected with HIV. Data collection and analysis Three reviewers independently applied study selection criteria, assessed study quality, and extracted data. Effects were assessed using mean difference and 95% confidence intervals. Homogenous studies were combined wherever it was clinically meaningful to do so and a meta‐analysis using the random effects model was conducted. Main results Fourteen trials (including 1725 HIV positive adults and 271 HIV positive children), were included in this review. Neither supplementary food nor daily supplement of Spirulina significantly altered the risk of death compared with no supplement or placebo in malnourished, ART naive adult participants in the two studies which reported on this outcome. A nutritional supplement enhanced with protein did not significantly alter the risk of death compared to standard nutritional care in children with prolonged diarrhoea. Supplementation with macronutrient formulas given to provide protein and/or energy and fortified with micronutrients, in conjunction with nutrition counselling, significantly improved energy intake (3 trials; n=131; MD 393.57 kcal/day; 95% CI: 224.66 to 562.47;p<0.00001) and protein intake (2 trials; n=81; MD 23.5 g/day; 95% CI: 12.68, 34.01; p<0.00001) compared with no nutritional supplementation or nutrition counselling alone in adult participants with weight loss. In general supplementation with specific macronutrients such as amino acids, whey protein concentration or Spirulina did not significantly alter clinical, anthropometric or immunological outcomes compared with placebo in HIV‐infected adults and children. Authors' conclusions Given the current evidence base, which is limited to fourteen relatively small trials all evaluating different macronutrient supplements in different populations at different stages of HIV infection and with varying treatment status, no firm conclusions can be drawn about the effects of macronutrient supplementation on morbidity and mortality in people living with HIV. It is, however, promising to see more studies being conducted in low‐income countries, and particularly in children, where macronutrient supplementation both pre‐antiretroviral treatment and in conjunction with antiretroviral treatment might prove to be beneficial. Plain language summary Nutritional interventions for reducing morbidity and mortality in people with HIV Achieving and maintaining optimal nutrition is considered an important adjunct in the clinical care of patients infected with HIV, as good nutrition can improve an individual's immune function, limit disease‐specific complications, and improve quality of life and survival. We sought to determine whether macronutrient interventions, either given to provide protein and/or energy or test the effect of specific macronutrients (i.e. ch as amino acids, whey protein concentrate or Spirulina), given orally, influence morbidity and mortality in adults and children living with HIV infection. Our review, based on fourteen small trials, evaluating different macronutrient supplements, found limited evidence that balanced macronutrient formulas increase protein and energy intake. However, we found no evidence that such supplementation translates into reductions in disease progression or HIV‐related complications, such as opportunistic infections or death.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grobler, L, Siegfried, N, Visser, ME, Mahlungulu, SSN, Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD004536.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.079Z" }, { "id": "92ceeb90-3db4-4753-bb02-da5d7917a846", "pmid": "", "title": "Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions", "imported": false, "abstract": "Abstract - Background Individuals on continuous treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) are at increased risk of bleeding complications during and after oral or dental procedures. Anticoagulant treatment is preferably continued at the same dose, since dose reduction or discontinuation of treatment is associated with an increased risk of thromboembolism. The use of haemostatic measures during or after the procedure (or both) could enable continuation of the oral anticoagulant treatment. Objectives We aimed to assess the efficacy of antifibrinolytic agents for preventing bleeding complications in people on oral anticoagulants undergoing minor oral surgery or dental extractions. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and the Cochrane Library. Additional searches were performed using ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), the CINAHL database of nursing and allied health services, the open access ProQuest dissertation database, papers and reports from the American College of Clinical Pharmacy (ACCP) and abstract books from annual scientific conferences. Date of last search: 04 January 2018. Selection criteria Randomised and quasi‐randomised controlled trials in people on continuous treatment with VKAs or DOACs undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid (TXA) or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. Data collection and analysis Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained from potentially relevant abstracts and two authors independently assessed these for inclusion based of the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. The quality of the evidence was assessed using GRADE. Main results No eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures were identified. Three randomised trials and one quasi‐randomised trial (follow‐up in all was seven days) in people on continuous treatment with VKAs were included with a total of 253 participants (mean age 60 years). Two trials published in 1989 and 1993 compared the antifibrinolytic agent TXA with placebo in people using VKAs. Two other trials were published in 1999 and 2015 and compared TXA with gelatin sponge and sutures, and dry gauze compression, respectively. In all included trials, those who were treated with VKAs had international normalised ratio (INR) values within the therapeutic range and TXA was applied locally, not systemically. The two trials from 1989 and 1993 comparing TXA with placebo showed a statistically significant beneficial effect regarding the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) of ‐0.25 (95% confidence interval (CI) ‐0.36 to ‐0.14) (128 participants) (moderate‐quality evidence). For the two trials that compared TXA with either gelatin sponge and sutures or with dry gauze compression, there was no difference between the TXA and the standard care group, RD 0.02 (95% CI ‐0.07 to 0.11) (125 participants) (moderate‐quality evidence). The combined RD of all included trials was ‐0.13 (95% CI ‐0.30 to 0.05) (moderate‐quality evidence). There were no side effects of antifibrinolytic therapy that required treatment withdrawal (128 participants) (moderate‐quality evidence). Despite heterogeneity between trials with respect to the different haemostatic measures used in the control groups, the trials were comparable regarding design and baseline participant characteristics. Overall, we considered the risk of bias to be low in the trials comparing TXA with placebo and moderate in the trials comparing TXA with alternative haemostatic measures. Authors' conclusions Based on the results of this Cochrane Review, there seems to be a beneficial effect of locally applied TXA in preventing oral bleeding in people on continuous treatment with VKAs undergoing minor oral surgery or dental extractions. However, the small number of identified randomised controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population. We were unable to identify any eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures. Therefore, a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs. Plain language summary Drugs that prevent oral bleeding in people using oral anticoagulants undergoing minor oral surgery or dental extractions Review question We reviewed the evidence about whether antifibrinolytic medicine (drugs that prevent breakdown of a blood clot), such as tranexamic acid or epsilon aminocaproic acid, can prevent oral bleeding after minor oral surgery or dental extractions in people using oral anticoagulants (blood thinners that are taken by mouth) without interruption during the procedure. Background People on continuous oral anticoagulant treatment are at an increased risk of bleeding complications during and after oral surgery or dental extractions. There are two types of oral anticoagulant treatment: vitamin K antagonists (VKAs) (e.g. warfarin and coumarin) and direct oral anticoagulants (DOACs) (e.g. dabigatran, rivaroxaban, apixaban, edoxaban). DOACs are becoming an increasingly popular alternative for VKAs, traditionally used for preventing blood clotting in people at risk of thrombosis. The number of bleeds and the severity of each bleed depend on medication‐related factors (such as the degree of anticoagulation, measured by the international normalised ratio (INR)), surgery‐related factors (such as the size of the wound or the number of roots extracted), as well as patient‐related factors (such as inflammation of the gums or blood vessel diseases). The INR level is important to determine how well the anticoagulant treatment is preventing blood clots. Within the desired range of the INR level, a person has both the least risk of blood clotting complications and the least risk of excessive bleeding. In routine practice antifibrinolytic medicine is often used before, during and after minor oral surgery or dental extractions for people using oral anticoagulants. The question is whether there is reliable scientific evidence for this practice. Search date The evidence is current to: 04 January 2018. Study characteristics We did not find any trials of antifibrinolytic medicine for preventing bleeding after minor oral surgery or dental extractions in people using DOACs. This review includes four trials (253 participants) in people continuously treated with VKAs during minor oral surgery or dental extractions. The earliest included trial was published in 1989 and the most recent one in 2015. The mean age of all participants was 60 years. The follow‐up time in all trials was seven days. Key results Overall, the included trials showed a reduction in the number of bleeds after dental extraction when using tranexamic acid solution in the mouth. Combining the results of the separate trials it appeared that antifibrinolytic medication reduces the bleeding rate after dental extractions by 25% when compared to placebo ('dummy' treatment). However, there was no difference in bleeding rate between people treated with tranexamic acid and those treated with standard care (e.g. gauze compression or stitches). Side effects of the antifibrinolytic medication rarely occurred and did not lead to individuals discontinuing tranexamic acid treatment. No evidence was found for people being treated with DOACs. It could, however, be argued that, if antifibrinolytic medicine is effective in people on continuous treatment with VKAs, it might also work for people receiving other comparable anticoagulant drugs. Quality of evidence In relation to the review's two primary outcomes of number of postoperative bleeds and side effects of therapy, we judged there to be moderate‐quality evidence. In the two trials comparing tranexamic acid with placebo, the risk of bias, in relation to trial design, was considered to be low, in the two trials comparing tranexamic acid to standard care (gelatin sponge and sutures; or dry gauze compression) the risk of bias was considered to be moderate. This was mainly due to the lack of blinding (a way of making sure that the people involved in the trial do not know which trial arm they are assigned to) and inadequate allocation concealment (using the play of chance to assign participants to comparison groups to prevent selection bias) in two of these trials. There were differences between the trials with regards to different standard care treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Engelen, ET; Schutgens, REG; Mauser‐Bunschoten, EP; van Es, RJJ; van Galen, KPM", "articleTypes": [], "doi": "10.1002/14651858.CD012293.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "92d41864-d569-473c-bf2c-2995a065cbf9", "pmid": "", "title": "Inhaled sodium cromoglycate for asthma in children", "imported": false, "abstract": "Abstract - Background Sodium cromoglycate has been recommended as maintenance treatment for childhood asthma for many years. Its use has decreased since 1990, when inhaled corticosteroids became popular, but it is still used in many countries. Objectives To determine the efficacy of sodium cromoglycate compared to placebo in the prophylactic treatment of children with asthma. Search methods We searched the Cochrane Airways Group Trials Register (October 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library Issue 3, 2009), MEDLINE (January 1966 to October 2009), EMBASE (January 1985 to October 2009) and reference lists of articles. We also contacted the pharmaceutical company manufacturing sodium cromoglycate. Selection criteria All double‐blind, placebo‐controlled randomised trials, which addressed the effectiveness of inhaled sodium cromoglycate as maintenance therapy, studying children aged 0 up to 18 years with asthma. Data collection and analysis Two authors independently assessed trial quality and extracted data. We pooled study results. Main results Of 3500 titles retrieved from the literature, 24 papers reporting on 23 studies could be included in the review. The studies were published between 1970 and 1997 and together included 1026 participants. Most were cross‐over studies. Few studies provided sufficient information to judge the concealment of allocation. Four studies provided results for the percentage of symptom‐free days. Pooling the results did not reveal a statistically significant difference between sodium cromoglycate and placebo. For the other pooled outcomes, most of the symptom‐related outcomes and bronchodilator use showed statistically significant results, but treatment effects were small. Considering the confidence intervals of the outcome measures, a clinically relevant effect of sodium cromoglycate cannot be excluded. The funnel plot showed an under‐representation of small studies with negative results, suggesting publication bias. Authors' conclusions There is insufficient evidence to be sure about the efficacy of sodium cromoglycate over placebo. Publication bias is likely to have overestimated the beneficial effects of sodium cromoglycate as maintenance therapy in childhood asthma. Plain language summary The effects of sodium cromoglycate compared with placebo for chronic asthma in children In this review we aimed to determine whether there is evidence for the effectiveness of inhaled sodium cromoglycate as maintenance treatment in children with chronic asthma. Most of the studies were carried out in small groups of patients. Furthermore, we suspect that not all studies undertaken have been published. The results show that there is insufficient evidence to be sure about the beneficial effect of sodium cromoglycate compared to placebo. However, for several outcome measures the results favoured sodium cromoglycate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "van der Wouden, JC; Uijen, JHJM; Bernsen, RMD; Tasche, MJA; de Jongste, JC; Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002173.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "92dcd60f-7a28-4640-9d4c-b18fb65498a4", "pmid": "", "title": "Vitamin D for the treatment of inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Vitamin D possesses immunomodulatory properties and has been implicated in the pathogenesis and severity of inflammatory bowel disease (IBD). Animal studies and emerging epidemiological evidence have demonstrated an association between vitamin D deficiency and worse disease activity. However, the role of vitamin D for the treatment of IBD is unclear. Objectives To evaluate the benefits and harms of vitamin D supplementation as a treatment for IBD. Search methods We used standard, extensive Cochrane search methods. The latest search date was Jun 2023. Selection criteria We included randomised controlled trials (RCTs) in people of all ages with active or inactive IBD comparing any dose of vitamin D with another dose of vitamin D, another intervention, placebo, or no intervention. We defined doses as: vitamin D (all doses), any‐treatment‐dose vitamin D (greater than 400 IU/day), high‐treatment‐dose vitamin D (greater than 1000 IU/day), low‐treatment‐dose vitamin D (400 IU/day to 1000 IU/day), and supplemental‐dose vitamin D (less than 400 IU/day). Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. clinical response for people with active disease, 2. clinical relapse for people in remission, 3. quality of life, and 4. withdrawals due to adverse events. Our secondary outcomes were 5. disease activity at end of study, 6. normalisation of vitamin D levels at end of study, and 7. total serious adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We included 22 RCTs with 1874 participants. Study duration ranged from four to 52 weeks. Ten studies enroled people with Crohn's disease (CD), five enroled people with ulcerative colitis (UC), and seven enroled people with CD and people with UC. Seventeen studies included adults, three included children, and two included both. Four studies enroled people with active disease, six enroled people in remission, and 12 enroled both. We assessed each study for risk of bias across seven individual domains. Five studies were at low risk of bias across all seven domains. Ten studies were at unclear risk of bias in at least one domain but with no areas of high risk of bias. Seven studies were at high risk of bias for blinding of participants and assessors. Vitamin D (all doses) versus placebo or no treatment Thirteen studies compared vitamin D against placebo or no treatment. We could not draw any conclusions on clinical response for UC as the certainty of the evidence was very low (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.51 to 10.57; 1 study, 60 participants). There were no data on CD. There may be fewer clinical relapses for IBD when using vitamin D compared to placebo or no treatment (RR 0.57, 95% CI 0.34 to 0.96; 3 studies, 310 participants). The certainty of the evidence was low. We could not draw any conclusions on quality of life for IBD (standardised mean difference (SMD) −0.13, 95% CI −3.10 to 2.83 (the SMD value indicates a negligent decrease in quality of life, and the corresponding CIs indicate that the effect can range from a large decrease to a large increase in quality of life); 2 studies, 243 participants) or withdrawals due to adverse events for IBD (RR 1.97, 95% CI 0.18 to 21.27; 12 studies, 1251 participants; note 11 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 12). The certainty of the evidence was very low. High‐treatment‐dose vitamin D versus low‐treatment‐dose vitamin D Five studies compared high treatment vitamin D doses against low treatment vitamin D doses. There were no data on clinical response. There may be no difference in clinical relapse for CD (RR 0.48, 95% CI 0.23 to 1.01; 1 study, 34 participants). The certainty of the evidence was low. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 0.89, 95% CI 0.06 to 13.08; 3 studies, 104 participants; note 2 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 3). The data on quality of life and disease activity could not be meta‐analysed, were of very low certainty, and no conclusions could be drawn. Any‐treatment‐dose vitamin D versus supplemental‐dose vitamin D Four studies compared treatment doses of vitamin D against supplemental doses. There were no data on clinical response and relapse. There were no data on quality of life that could be meta‐analysed. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 3.09, 95% CI 0.13 to 73.17; 4 studies, 233 participants; note 3 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 4). Authors' conclusions There may be fewer clinical relapses when comparing vitamin D with placebo, but we cannot draw any conclusions on differences in clinical response, quality of life, or withdrawals, due to very low‐certainty evidence. When comparing high and low doses of vitamin D, there were no data for clinical response, but there may be no difference in relapse for CD. We cannot draw conclusions on the other outcomes due to very low certainty evidence. Finally, comparing vitamin D (all doses) to supplemental‐dose vitamin D, there were no data on clinical relapse or response, and we could not draw conclusions on other outcomes due to very low certainty evidence or missing data. It is difficult to make any clear recommendations for future research on the basis of the findings of this review. Future studies must be clear on the baseline populations, the purpose of vitamin D treatment, and, therefore, study an appropriate dosing strategy. Stakeholders in the field may wish to reach consensus on such issues prior to new studies. Plain language summary Vitamin D for the treatment of inflammatory bowel disease Key messages The data we presently have for the use of vitamin D for the treatment of inflammatory bowel disease are of very low quality, and we do not know whether it works or if it is safe. What is inflammatory bowel disease? Inflammatory bowel disease is a life‐long disease that affects the gut. Its two main types are ulcerative colitis and Crohn's disease. Ulcerative colitis only affects the large intestine. Crohn's disease can affect any part of the gut, from mouth to bottom. Common symptoms include bloody poo, diarrhoea, stomach ache, fever, weight loss, and fatigue. We do not know exactly what causes it, but it is probably a mix of genes, problems with the immune system, bacteria in the gut, and something in the environment. There is no known cure, but the symptoms are usually managed with medicines, such as steroids and immune system medications, and sometimes surgery. Most people with inflammatory bowel disease have times when they have symptoms (called active disease) and other times when their symptoms are under control (called remission). When symptoms reappear after being in remission, it is called relapse. What did we want to find out? We wanted to find out if vitamin D works for the treatment of inflammatory bowel disease, and whether it is safe to use. Specifically, we looked at improvement of symptoms for people with active disease; relapse for people in remission; quality of life; and withdrawals from the trial because of side effects. What did we do? We searched for randomised controlled trials (studies where people are assigned to one of two or more treatment groups using a random method) comparing vitamin D with any other treatment, standard treatment, or different doses of vitamin D. What did we find? We found 22 trials with 1874 participants with inflammatory bowel disease. The studies lasted from four to 52 weeks. Ten studies were on Crohn's disease, five on ulcerative colitis, and seven on participants who had either of these. Seventeen studies were on adults, three on children, and two on both. Four included people with active disease, six in remission, and 12 on a mix of both. The studies included doses of vitamin D used to treat deficiency and doses given as supplements. Thirteen studies compared vitamin D (all doses) against placebo (dummy treatment) or no other treatment. There was low‐quality evidence that there may be fewer clinical relapses when using vitamin D compared to placebo or no treatment. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Five studies compared high‐treatment‐doses to low‐treatment‐doses of vitamin D. There were no data on improvement of symptoms. There was low‐quality evidence that there may be no difference on relapse in Crohn's disease, but there were no data on ulcerative colitis. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Four studies compared treatment doses to supplement doses of vitamin D. There were no data on improvement of symptoms, relapses, or quality of life changes. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. What are the limitations of the evidence? The evidence is mostly of very low and low quality. This is because of problems with the way the studies were carried out, and problems with how the results were reported. Additionally, the individual studies did not make the same measurements, meaning that we did not have enough numbers of people to strengthen the results of the measures we looked for. How up‐to‐date is this review? This review is up‐to‐date to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wallace, C; Gordon, M; Sinopoulou, V; Limketkai, BN", "articleTypes": [], "doi": "10.1002/14651858.CD011806.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "92e4516f-df68-4dee-b61c-f4bed7d9cdfb", "pmid": "", "title": "Nutritional support in children and young people with cancer undergoing chemotherapy", "imported": false, "abstract": "Abstract - Background It is well documented that malnutrition is a common complication of paediatric malignancy and its treatment. Malnutrition can often be a consequence of cancer itself or a result of chemotherapy. Nutritional support aims to reverse malnutrition seen at diagnosis, prevent malnutrition associated with treatment and promote weight gain and growth. The most effective and safe forms of nutritional support in children and young people with cancer are not known. Objectives To determine the effects of any form of parenteral (PN) or enteral (EN) nutritional support, excluding vitamin supplementation and micronutrient supplementation, in children and young people with cancer undergoing chemotherapy and to determine the effect of the nutritional content of PN and EN. This is an update of a previous Cochrane review. Search methods We searched the following databases for the initial review: CENTRAL ( The Cochrane Library , Issue 2, 2009), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), CINAHL (1982 to 2006), the National Research Register (2007) and Dissertations & Theses (2007). Experts in the field were also contacted for information on relevant trials. For this update, we searched the same electronic databases from 2006 to September 2013. We also scrutinised the reference lists of included articles to identify additional trials. Selection criteria Randomised or quasi‐randomised controlled trials comparing any form of nutritional support with another, or control, in children or young people with cancer undergoing chemotherapy. Data collection and analysis Two authors independently selected trials. At least two authors independently assessed quality and extracted data. We contacted trialists for missing information. Main results The current review included the eight trials from the initial review and six new trials which randomised 595 participants (< 21 years of age) with leukaemias or solid tumours undergoing chemotherapy. The trials were all of low quality with the exception of two of the trials looking at glutamine supplementation. One small trial found that compared to EN, PN significantly increased weight (mean difference (MD) 4.12, 95% CI 1.91 to 6.33), serum albumin levels (MD 0.70, 95% CI 0.14 to 1.26), calorie intake (MD 22.00, 95% CI 5.12 to 38.88) and protein intake (MD 0.80, 95% CI 0.45 to 1.15). One trial comparing peripheral PN and EN with central PN found that mean daily weight gain (MD ‐27.00, 95% CI ‐43.32 to ‐10.68) and energy intake (MD ‐15.00, 95% CI ‐26.81 to ‐3.19) were significantly less for the peripheral PN and EN group, whereas mean change in serum albumin was significantly greater for that group (MD 0.47, 95% CI 0.13 to 0.81, P = 0.008). Another trial with few participants found an increase in mean energy intake (% recommended daily amount) in children fed an energy dense feed compared to a standard calorie feed (MD +28%, 95% CI 17% to 39%). Three studies looked at glutamine supplementation. The evidence suggesting that glutamine reduces severity of mucositis was not statistically significant in two studies (RR 0.64, 95% CI 0.19 to 2.2 and RR 0.85, 95% CI 0.66 to 1.1) and differences in reduction of infection rates were also not significant in two studies (RR 1.0, 95% CI 0.72 to 1.4 and RR 0.98, 95% CI 0.63 to 1.51). Only one study compared olive oil based PN to standard lipid containing PN. Despite similar calorie contents in both feeds, the standard lipid formula lead to greater weight gain (MD ‐0.34 z‐scores, 95% CI ‐0.68 to 0.00). A single study compared standard EN with fructooligosaccharide containing EN. There was no difference in weight gain between groups (mean difference ‐0.12, 95% CI ‐0.57 to 0.33), with adverse effects (nausea) occurring equally between the groups (RR 0.92, 95% CI 0.48 to 1.74). Authors' conclusions There is limited evidence from individual trials to suggest that PN is more effective than EN in well‐nourished children and young people with cancer undergoing chemotherapy. The evidence for other methods of nutritional support remains unclear. Limited evidence suggests an energy dense feed increases mean daily energy intake and has a positive effect on weight gain. Evidence suggesting glutamine supplementation reduces incidence and severity of mucositis, infection rates and length of hospital stay is not statistically significant. Further research, incorporating larger sample sizes and rigorous methodology utilising valid and reliable outcome measures, is essential. Plain language summary Nutritional support in children and young people with cancer undergoing chemotherapy The provision of safe, appropriate and effective nutritional support for children and young people undergoing treatment for cancer is now well recognised as an important part of their care. It may help to reverse malnutrition seen at diagnosis, prevent malnutrition associated with the cancer, promote weight gain and growth and improve quality of life. Nutritional support may be provided by one of two methods: intravenous nutritional liquids delivered through a central or peripheral vein which bypass the gut (parenteral nutrition); or nutritional liquids or solids that pass through any part of the gut, regardless of method of delivery (e.g. orally or via a tube; enteral nutrition). We found evidence from one small trial to suggest that parenteral nutrition may result in an increase in weight, serum albumin levels and calorie and protein intake when compared to enteral nutrition (usual food intake). However, the effect of other methods of delivery of nutritional support remains unclear. Results from another small study suggested that the use of energy dense enteral feeds resulted in greater average daily energy intake and subsequently improved weight gain. Three studies looked at glutamine supplementation and did not show a benefit from its use. One study looked at the effect of using olive oil based parenteral feeds rather than those containing standard fats and found that it lead to less weight gain. One study considered the effect of adding fructooligosaccharide to enteral feeds and found that it did not effect the amount of weight gained or how often participants felt nauseated. No studies were identified that compared the nutritional content in either the PN or EN groups of studies. The trials were all of low quality and very different in terms of outcome measures used. In the future, much larger, rigorously conducted trials are needed in order to address this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Ward, EJ, Henry, LM, Friend, AJ, Wilkins, S, Phillips, RS", "articleTypes": [], "doi": "10.1002/14651858.CD003298.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.103Z" }, { "id": "92f5532a-7cab-4b89-912c-b23b81e8c4df", "pmid": "", "title": "Interventions for chronic kidney disease in people with sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD), one of the commonest severe monogenic disorders, is caused by the inheritance of two abnormal haemoglobin (beta‐globin) genes. SCD can cause severe pain, significant end‐organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD. Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD. Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, with increased prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end‐stage renal disease. This is an update of a review first published in 2017. Objectives To assess the effectiveness of any intervention for preventing or reducing kidney complications or chronic kidney disease in people with sickle cell disease. Possible interventions include red blood cell transfusions, hydroxyurea, and angiotensin‐converting enzyme inhibitors (ACEIs), either alone or in combination. Search methods We searched for relevant trials in the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, CENTRAL, MEDLINE, Embase, seven other databases, and two other trials registers. Selection criteria Randomised controlled trials (RCTs) comparing interventions to prevent or reduce kidney complications or CKD in people with SCD. We applied no restrictions related to outcomes examined, language, or publication status. Data collection and analysis Two review authors independently assessed trial eligibility, extracted data, assessed the risk of bias, and assessed the certainty of the evidence (GRADE). Main results We included three RCTs with 385 participants. We rated the certainty of the evidence as low to very low across different outcomes according to GRADE methodology, downgrading for risk of bias concerns, indirectness, and imprecision. Hydroxyurea versus placebo One RCT published in 2011 compared hydroxyurea to placebo in 193 children aged nine to 18 months. We are unsure if hydroxyurea compared to placebo reduces or prevents progression of kidney disease assessed by change in glomerular filtration rate (mean difference (MD) 0.58 mL/min /1.73 m 2 , 95% confidence interval (CI) −14.60 to 15.76; 142 participants; very low certainty). Hydroxyurea compared to placebo may improve the ability to concentrate urine (MD 42.23 mOsm/kg, 95% CI 12.14 to 72.32; 178 participants; low certainty), and may make little or no difference to SCD‐related serious adverse events, including acute chest syndrome (risk ratio (RR) 0.39, 99% CI 0.13 to 1.16; 193 participants; low certainty), painful crisis (RR 0.68, 99% CI 0.45 to 1.02; 193 participants; low certainty); and hospitalisations (RR 0.83, 99% CI 0.68 to 1.01; 193 participants; low certainty). No deaths occurred in either trial arm and the RCT did not report quality of life. Angiotensin‐converting enzyme inhibitors versus placebo One RCT published in 1998 compared an ACEI (captopril) to placebo in 22 adults with normal blood pressure and microalbuminuria. We are unsure if captopril compared to placebo reduces proteinuria (MD −49.00 mg/day, 95% CI −124.10 to 26.10; 22 participants; very low certainty). We are unsure if captopril reduces or prevents kidney disease as measured by creatinine clearance; the trial authors stated that creatinine clearance remained constant over six months in both groups, but provided no comparative data (very low certainty). The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Angiotensin‐converting enzyme inhibitors versus vitamin C One RCT published in 2020 compared an ACEI (lisinopril) with vitamin C in 170 children aged one to 18 years with normal blood pressure and microalbuminuria. It reported no data we could analyse. We are unsure if lisinopril compared to vitamin C reduces proteinuria in this population: the large drop in microalbuminuria in both arms of the trial after only one month on treatment may have been due to an overestimation of microalbuminuria at baseline rather than a true effect. The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Authors' conclusions We are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. We are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. We are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria. No RCTs assessed red blood cell transfusions or any combined interventions to prevent or reduce kidney complications. Due to lack of evidence, we cannot comment on the management of children aged over 18 months or adults with any known genotype of SCD. We have identified a lack of adequately designed and powered studies, although we found four ongoing trials since the last version of this review. Only one ongoing trial addresses renal function as a primary outcome in the short term, but such interventions have long‐term effects. Trials of hydroxyurea, ACEIs or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction of kidney complications in people with SCD. Plain language summary Interventions to prevent or reduce kidney complications in people with sickle cell disease Review question Are there any safe and effective interventions that prevent or reduce kidney complications in people with sickle cell disease (SCD)? Background SCD is a serious inherited blood disorder where the red blood cells, which carry oxygen around the body, develop abnormally. Normal red blood cells are flexible and disc‐shaped, but sickled cells are rigid and crescent‐shaped, and stickier than normal red blood cells. This can lead to blockage of blood vessels, resulting in tissue and organ damage and episodes of severe pain. The abnormal cells are fragile and break apart easily, which leads to a decreased number of red blood cells, known as anaemia. Kidney complications can start at an early age in children with SCD and are common in adults with the condition. Kidney complications leading to kidney protein leak and chronic kidney disease can be severe, with serious effects on health. Severe complications include the need for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) or a kidney transplant. Identifying therapies that can prevent or slow down the decline in kidney function in people with SCD is critical for improving health outcomes. Search date The evidence is current to 22 September 2022. Study characteristics We found three randomised controlled trials, which enroled a total of 385 people. One trial, published in 2011, compared the drug hydroxyurea (which helps to maintain the shape and flexibility of red blood cells), to placebo (dummy treatment) in 193 children aged nine to 18 months. The second trial, published in 1998, compared captopril (a drug used to treat high blood pressure) to placebo in 22 adults with normal blood pressure and microalbuminuria (high levels of protein in the urine). The third trial, published in 2020, compared lisinopril (a drug used to treat high blood pressure) to vitamin C in 170 children aged one to 18 years. Two trials received government funding; it was unclear how the third trial was funded. Key results In children aged nine to 18 months, hydroxyurea may increase the ability to produce normal urine, but we are unsure if it has any effect on the glomerular filtration rate (network of filters in the kidney that filter waste from the blood). Hydroxyurea may make little or no difference to the occurrence of serious complications including acute chest syndrome (pain, cough, fever, low oxygen levels, and abnormal substances in the lungs), painful crises, and hospitalisations. We are unsure if giving captopril to adults with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. We are unsure if giving lisinopril to children aged one to 18 years with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. No trials reported quality of life. Limitations of the evidence We have little or very little confidence in the evidence because we only found three trials, and they had specific populations (only children or only adults), few participants, and wide variations in results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Roy, NBA; Carpenter, A; Dale-Harris, I; Dorée, C; Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012380.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "92fcb6d3-f582-44da-97db-28f53230f726", "pmid": "", "title": "Wheat flour fortification with iron and other micronutrients for reducing anaemia and improving iron status in populations", "imported": false, "abstract": "Abstract - Background Anaemia is a condition where the number of red blood cells (and consequently their oxygen‐carrying capacity) is insufficient to meet the body's physiological needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations. Objectives To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health‐related outcomes in populations over two years of age. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, 21 other databases and two trials registers up to 21 July 2020, together with contacting key organisations to identify additional studies. Selection criteria We included cluster‐ or individually‐randomised controlled trials (RCTs) carried out among the general population from any country, aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. We included trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat Data collection and analysis Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risks of bias. We followed Cochrane methods in this review. Main results Our search identified 3538 records, after removing duplicates. We included 10 trials, involving 3319 participants, carried out in Bangladesh, Brazil, India, Kuwait, Philippines, South Africa and Sri Lanka. We identified two ongoing studies and one study is awaiting classification. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, three trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial used various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta‐analyses. Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added may reduce by 27% the risk of anaemia in populations (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.55 to 0.97; 5 studies, 2315 participants; low‐certainty evidence). It is uncertain whether iron‐fortified wheat flour with or without other micronutrients reduces iron deficiency (RR 0.46, 95% CI 0.20 to 1.04; 3 studies, 748 participants; very low‐certainty evidence) or increases haemoglobin concentrations (in g/L) (mean difference MD 2.75, 95% CI 0.71 to 4.80; 8 studies, 2831 participants; very low‐certainty evidence). No trials reported data on adverse effects in children (including constipation, nausea, vomiting, heartburn or diarrhoea), except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to the risk of Infection or inflammation at individual level as measured by C‐reactive protein (CRP) (mean difference (MD) 0.04, 95% CI −0.02 to 0.11; 2 studies, 558 participants; moderate‐certainty evidence). Iron‐fortified wheat flour with other micronutrients added versus unfortified wheat flour (nil micronutrients added) It is unclear whether wheat flour fortified with iron, in combination with other micronutrients decreases anaemia (RR 0.77, 95% CI 0.41 to 1.46; 2 studies, 317 participants; very low‐certainty evidence). The intervention probably reduces the risk of iron deficiency (RR 0.73, 95% CI 0.54 to 0.99; 3 studies, 382 participants; moderate‐certainty evidence) and it is unclear whether it increases average haemoglobin concentrations (MD 2.53, 95% CI −0.39 to 5.45; 4 studies, 532 participants; very low‐certainty evidence). No trials reported data on adverse effects in children. Nine out of 10 trials reported sources of funding, with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials. Authors' conclusions Fortification of wheat flour with iron (in comparison to unfortified flour, or where both groups received the same other micronutrients) may reduce anaemia in the general population above two years of age, but its effects on other outcomes are uncertain. Iron‐fortified wheat flour in combination with other micronutrients, in comparison with unfortified flour, probably reduces iron deficiency, but its effects on other outcomes are uncertain. None of the included trials reported data on adverse side effects except for risk of infection or inflammation at the individual level. The effects of this intervention on other health outcomes are unclear. Future studies at low risk of bias should aim to measure all important outcomes, and to further investigate which variants of fortification, including the role of other micronutrients as well as types of iron fortification, are more effective, and for whom. Plain language summary Does adding iron to wheat flour reduce anaemia and increase iron levels in the general population? Why do we need iron in our diet? Iron is an essential mineral found in every cell of the body. It is needed to make haemoglobin, the oxygen‐carrying protein in the blood. Iron molecules in haemoglobin bind to oxygen and carry it from the lungs to all the cells and tissues in the body. Low levels of haemoglobin means the body does not get enough oxygen. Anaemia develops when haemoglobin levels in the blood fall too low. Symptoms of anaemia include: tiredness and lack of energy, getting out of breath quickly, pale skin and a greater susceptibility to infections. Low haemoglobin levels can be caused by blood loss, pregnancy or not eating enough foods containing iron (iron‐deficiency anaemia). Iron‐deficiency anaemia may be treated by taking iron tablets or eating foods rich in iron. Fortified foods Adding micronutrients (vitamins and minerals) to foods, whether those micronutrients were originally present or not, is called fortification. Fortifying foods is one way to improve nutrition in a population. People living in low‐income countries may not have enough iron in their diet, and may be at risk of anaemia. Adding iron and other nutrients to foods routinely eaten in large quantities, such as flour, is thought to help prevent iron‐deficiency anaemia. Why we did this Cochrane Review We wanted to find out how adding iron, and other minerals and vitamins, to wheat flour affected the blood iron levels of the general population, and whether fewer people developed anaemia or other health conditions. We also wanted to know if adding iron to wheat flour caused any unwanted effects. What did we do? We searched for studies that investigated eating any types of food made with wheat flour containing added iron, or foods made with wheat flour without added iron. We then compared the studies with each other, to find out the effects of adding iron to wheat flour on people's health and the levels of iron and haemoglobin in their blood. Search date: we included evidence published up to 21 July 2020. What we found We found 10 studies in 3319 people (aged 2 years and older). The studies lasted from 3 months to 24 months, and took place in Bangladesh, Brazil, India, Kuwait, the Philippines, Sri Lanka and South Africa. The studies looked at the effects of: · wheat flour containing added iron (with or without other minerals and vitamins) compared with wheat flour without added iron (but with the same other minerals and vitamins); · wheat flour containing added iron and other minerals and vitamins compared with wheat flour without any added minerals or vitamins. The wheat flours used in the studies contained different amounts of iron: from under 40 mg/kg to over 60 mg/kg. We were interested in: · how many people had anaemia (defined by low haemoglobin levels); · how many people had low levels of iron in their blood (iron deficiency; tested using a biomarker); · haemoglobin concentrations in people's blood; · how many children had diarrhoea or respiratory infections; · how many children died (of any cause); · signs of infection or inflammation (the body's response to injury) in children (by testing a biomarker in the blood); and · any unwanted effects. Most studies had multiple sources of funding; some were partly funded by companies involved in the food, chemical or pharmaceutical industries. What are the results of our review? Compared with flour without added iron (but with other minerals and vitamins) Flour containing added iron (with or without other minerals and vitamins): · may reduce anaemia, by 27% (evidence from 5 studies, 2315 people); and · probably makes no difference to children's risk of infection or inflammation (2 studies, 558 children). It was unclear how flour with added iron affected iron deficiency (3 studies, 748 people), or haemoglobin levels (8 studies, 2831 people ). Compared with flour without any added minerals or vitamins Flour containing added iron (with other minerals and vitamins) probably reduced iron deficiency (3 studies, 382 people). It was unclear from the studies how flour containing added iron affected anaemia (2 studies, 317 people) or haemoglobin levels (4 studies, 532 people). No studies reported information about unwanted effects, or how many children died, or had diarrhoea or respiratory infections. Our confidence in our results Our confidence is moderate to low that adding iron to flour probably reduces iron deficiency and anaemia. The studies appeared to show fewer people with iron deficiency and slightly higher haemoglobin levels associated with flour with added iron, but the results varied widely, so we are uncertain about the effect. These results might change if further evidence becomes available. We found limitations in the ways some of the studies were designed and conducted, and this could have affected their results. Key messages Adding iron to wheat flour may lead to fewer people with anaemia or low blood‐iron levels in the general population. We do not know if adding iron to wheat flour causes any unwanted effects, because no studies looked at these.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Field, MS, Mithra, P, Peña-Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD011302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.120Z" }, { "id": "930af227-2074-4c79-846d-e38dd3e23b4f", "pmid": "", "title": "Zinc supplementation for improving pregnancy and infant outcome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carducci, B, Keats, EC, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD000230.pub6 AB - Abstract - Background It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy, such as prolonged labour, atonic postpartum haemorrhage, pregnancy‐induced hypertension, preterm labour and post‐term pregnancies, although these associations have not yet been established. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Objectives 1. To compare the effects on maternal, fetal, neonatal and infant outcomes in healthy pregnant women receiving zinc supplementation versus no zinc supplementation, or placebo.
2. To assess the above outcomes in a subgroup analysis reviewing studies performed in women who are, or are likely to be, zinc‐deficient. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (3 July 2020), and reference lists of retrieved studies. Selection criteria Randomised trials of zinc supplementation versus no zinc supplementation or placebo administration during pregnancy, earlier than 27 weeks' gestation. We excluded quasi‐randomised controlled trials. We intended to include studies presented only as abstracts, if they provided enough information or, if necessary, by contacting authors to analyse them against our criteria; we did not find any such studies. Data collection and analysis Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information. We assessed the certainty of the evidence using GRADE. Main results For this update, we included 25 randomised controlled trials (RCTs) involving over 18,000 women and their babies. The overall risk of bias was low in half of the studies. The evidence suggests that zinc supplementation may result in little or no difference in reducing preterm births (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.74 to 1.03; 21 studies, 9851 participants; low‐certainty evidence). Further, zinc supplementation may make little or no difference in reducing the risk of stillbirth (RR 1.22, 95% CI 0.80 to 1.88; 7 studies, 3295 participants; low‐certainty evidence), or perinatal deaths (RR 1.10, 95% CI 0.81 to 1.51; 2 studies, 2489 participants; low‐certainty evidence). It is unclear whether zinc supplementation reduces neonatal death, because the certainty of the evidence is very low. Finally, for other birth outcomes, zinc supplementation may make little or no difference to mean birthweight (MD 13.83, 95% CI ‐15.81 to 43.46; 22 studies, 7977 participants; low‐certainty evidence), and probably makes little or no difference in reducing the risk of low birthweight (RR 0.94, 95% CI 0.79 to 1.13; 17 studies, 7399 participants; moderate‐certainty evidence) and small‐for‐gestational age babies when compared to placebo or no zinc supplementation (RR 1.02, 95% CI 0.92 to 1.12; 9 studies, 5330 participants; moderate‐certainty evidence). We did not conduct subgroup analyses, as very few studies used normal zinc populations. Authors' conclusions There is not enough evidence that zinc supplementation during pregnancy results in improvements in maternal or neonatal outcomes. Future research to address ways of improving the overall nutritional status of pregnant women, particularly in low‐income regions, and not looking at zinc in isolation, should be an urgent priority. Plain language summary Zinc supplementation for improving pregnancy and infant outcome What is the issue? In low‐ and middle‐income countries, many women have poor diets and are deficient in key micronutrients that are required for good health. This is especially concerning during pregnancy, when energy and nutrient needs are greater for both the mother and the growing baby. Zinc plays a critical role in normal growth and development. Deficiency in zinc could lead to adverse health outcomes, such as being born too soon or too small. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Why is this important? Although severe zinc deficiency is rare, it is estimated that mild‐to‐moderate deficiency is common in several regions of the world. Studies of human pregnancy and zinc supplementation, including those from low‐ and middle‐income countries, have failed to document a consistent beneficial effect on fetal growth, length of gestation, and early newborn survival. What evidence did we find? We searched for studies in July 2020. This updated review now includes 25 randomised controlled trials, involving over 18,000 women and their babies. We found that zinc supplementation in pregnancy may make little to no difference in reducing the risk of preterm births, stillbirths, or deaths around the time of birth, when compared to no zinc supplementation or placebo. Zinc supplementation may make little or no difference to the birthweight of babies, and probably makes little or no difference to the number of babies born either with a low birthweight or small for their gestational age, when compared with no zinc supplementation, or with giving a placebo. We cannot be sure whether zinc supplementation reduces death in newborns, because the certainty of the evidence is very low. What does this mean? There is not enough evidence that zinc supplementation during pregnancy results in better outcomes for women and their babies. Finding ways to improve women's overall nutritional status, particularly in low‐income areas, will do more to improve the health of mothers and babies than supplementing pregnant women with zinc alone. This should be an urgent research priority for the future.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.736Z" }, { "id": "933009a1-55c3-4622-ae1f-446e7b7a933d", "pmid": "", "title": "Janus kinase inhibitors for the treatment of COVID‐19", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kramer, A, Prinz, C, Fichtner, F, Fischer, A-L, Thieme, V, Grundeis, F, Spagl, M, Seeber, C, Piechotta, V, Metzendorf, M-I, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015209 AB - Abstract - Background With potential antiviral and anti‐inflammatory properties, Janus kinase (JAK) inhibitors represent a potential treatment for symptomatic severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. They may modulate the exuberant immune response to SARS‐CoV‐2 infection. Furthermore, a direct antiviral effect has been described. An understanding of the current evidence regarding the efficacy and safety of JAK inhibitors as a treatment for coronavirus disease 2019 (COVID‐19) is required. Objectives To assess the effects of systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo) on clinical outcomes in individuals (outpatient or in‐hospital) with any severity of COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising MEDLINE, Embase, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform, medRxiv, and Cochrane Central Register of Controlled Trials), Web of Science, WHO COVID‐19 Global literature on coronavirus disease, and the US Department of Veterans Affairs Evidence Synthesis Program (VA ESP) Covid‐19 Evidence Reviews to identify studies up to February 2022. We monitor newly published randomised controlled trials (RCTs) weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials from this source until the first week of April 2022. Selection criteria We included RCTs that compared systemic JAK inhibitors plus standard of care to standard of care alone (plus/minus placebo) for the treatment of individuals with COVID‐19. We used the WHO definitions of illness severity for COVID‐19. Data collection and analysis We assessed risk of bias of primary outcomes using Cochrane's Risk of Bias 2 (RoB 2) tool. We used GRADE to rate the certainty of evidence for the following primary outcomes: all‐cause mortality (up to day 28), all‐cause mortality (up to day 60), improvement in clinical status: alive and without need for in‐hospital medical care (up to day 28), worsening of clinical status: new need for invasive mechanical ventilation or death (up to day 28), adverse events (any grade), serious adverse events, secondary infections. Main results We included six RCTs with 11,145 participants investigating systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo). Standard of care followed local protocols and included the application of glucocorticoids (five studies reported their use in a range of 70% to 95% of their participants; one study restricted glucocorticoid use to non‐COVID‐19 specific indications), antibiotic agents, anticoagulants, and antiviral agents, as well as non‐pharmaceutical procedures. At study entry, about 65% of participants required low‐flow oxygen, about 23% required high‐flow oxygen or non‐invasive ventilation, about 8% did not need any respiratory support, and only about 4% were intubated. We also identified 13 ongoing studies, and 9 studies that are completed or terminated and where classification is pending. Individuals with moderate to severe disease Four studies investigated the single agent baricitinib (10,815 participants), one tofacitinib (289 participants), and one ruxolitinib (41 participants). Systemic JAK inhibitors probably decrease all‐cause mortality at up to day 28 (95 of 1000 participants in the intervention group versus 131 of 1000 participants in the control group; risk ratio (RR) 0.72, 95% confidence interval (CI) 0.57 to 0.91; 6 studies, 11,145 participants; moderate‐certainty evidence), and decrease all‐cause mortality at up to day 60 (125 of 1000 participants in the intervention group versus 181 of 1000 participants in the control group; RR 0.69, 95% CI 0.56 to 0.86; 2 studies, 1626 participants; high‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in improvement in clinical status (discharged alive or hospitalised, but no longer requiring ongoing medical care) (801 of 1000 participants in the intervention group versus 778 of 1000 participants in the control group; RR 1.03, 95% CI 1.00 to 1.06; 4 studies, 10,802 participants; moderate‐certainty evidence). They probably decrease the risk of worsening of clinical status (new need for invasive mechanical ventilation or death at day 28) (154 of 1000 participants in the intervention group versus 172 of 1000 participants in the control group; RR 0.90, 95% CI 0.82 to 0.98; 2 studies, 9417 participants; moderate‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in the rate of adverse events (any grade) (427 of 1000 participants in the intervention group versus 441 of 1000 participants in the control group; RR 0.97, 95% CI 0.88 to 1.08; 3 studies, 1885 participants; moderate‐certainty evidence), and probably decrease the occurrence of serious adverse events (160 of 1000 participants in the intervention group versus 202 of 1000 participants in the control group; RR 0.79, 95% CI 0.68 to 0.92; 4 studies, 2901 participants; moderate‐certainty evidence). JAK inhibitors may make little or no difference to the rate of secondary infection (111 of 1000 participants in the intervention group versus 113 of 1000 participants in the control group; RR 0.98, 95% CI 0.89 to 1.09; 4 studies, 10,041 participants; low‐certainty evidence). Subgroup analysis by severity of COVID‐19 disease or type of JAK inhibitor did not identify specific subgroups which benefit more or less from systemic JAK inhibitors. Individuals with asymptomatic or mild disease We did not identify any trial for this population. Authors' conclusions In hospitalised individuals with moderate to severe COVID‐19, moderate‐certainty evidence shows that systemic JAK inhibitors probably decrease all‐cause mortality. Baricitinib was the most often evaluated JAK inhibitor. Moderate‐certainty evidence suggests that they probably make little or no difference in improvement in clinical status. Moderate‐certainty evidence indicates that systemic JAK inhibitors probably decrease the risk of worsening of clinical status and make little or no difference in the rate of adverse events of any grade, whilst they probably decrease the occurrence of serious adverse events. Based on low‐certainty evidence, JAK inhibitors may make little or no difference in the rate of secondary infection. Subgroup analysis by severity of COVID‐19 or type of agent failed to identify specific subgroups which benefit more or less from systemic JAK inhibitors. Currently, there is no evidence on the efficacy and safety of systemic JAK inhibitors for individuals with asymptomatic or mild disease (non‐hospitalised individuals). Plain language summary Are systemic Janus kinase inhibitors an effective treatment for people with COVID‐19? Key messages We found moderate‐ to high‐certainty evidence from 6 studies to conclude that systemic Janus kinase (JAK) inhibitors are an effective treatment for coronavirus disease 2019 (COVID‐19) in hospitalised people, because they resulted in fewer deaths and a lower rate of clinical deterioration. Evaluation of systemic JAK inhibitors is ongoing in 13 studies whilst the results of 9 further studies are awaiting publication. We will update this review and may adapt our conclusions when their results become available. What are JAK inhibitors? JAK inhibitors are medicines that block the activity of certain parts of the immune system that are sometimes problematic. They are taken orally (systemic) and usually are taken by people who suffer from autoimmune diseases, where the immune system attacks the body itself. JAK inhibitors might also be administered by inhalation but since this was not our focus, we refer to 'systemic JAK inhibitors' throughout the review. How might JAK inhibitors treat COVID‐19? In COVID‐19, the immune system sometimes overreacts, which can lead to a severe course of disease. JAK inhibitors can block parts of the immune system and counteract any clinical deteriorations. What did we want to find out? We wanted to know whether systemic JAK inhibitors, in addition to usual care, are effective for people with COVID‐19 when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in:
• number of deaths from any cause up to 60 days after treatment, or longer if reported;
• whether people got better or worse after treatment, based on their need for breathing support;
• unwanted effects of the treatment and infections acquired in hospital. What did we do? We searched for studies that reported on people with COVID‐19 who received systemic JAK inhibitors together with usual care, or usual care alone (plus/minus placebo). We compared and summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We found 6 suitable studies involving 11,145 people with COVID‐19. All studies compared systemic JAK inhibitors (baricitinib in 4 studies, tofacitinib in 1 study and ruxolitinib in 1 study) to usual care (in addition to placebo), and were performed in hospitalised people. We did not find studies performed in outpatients. Most participants needed oxygen supplementation through low‐flow devices (7220 participants) and few (463 participants) were mechanically ventilated at the study entry. We also identified 13 ongoing studies and 9 studies that are completed/terminated but unpublished yet. Main results Systemic JAK inhibitors plus usual care compared to usual care alone probably lead to fewer deaths from all causes at up to day 28 and lead to fewer deaths from all causes up to day 60 in the studies. It was not possible to identify subgroups of participants (according to severity of illness) who might benefit most from treatment with JAK inhibitors. Systemic JAK inhibitors probably make little or no difference in improvement in clinical status. They probably decrease the risk of worsening of clinical status. Systemic JAK inhibitors probably make little or no difference in the rate of unwanted effects, and probably decrease slightly the occurrence of serious unwanted effects. Systemic JAK inhibitors may result in little or no difference in the rate of infections acquired in hospital. What are the limitations of the evidence? As current studies on systemic JAK inhibitors in outpatients are lacking, evidence is limited in this group of people with COVID‐19. Studies used different ways to assess and report unwanted effects, especially in regard to infections acquired in hospital. In accordance with the living approach of this review, we will continually update our search and include eligible trials to fill this evidence gap. How up to date is this evidence? The evidence is up to date to February 2022. We monitor newly published studies weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials identified from this source until the first week of April 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.797Z" }, { "id": "93388766-337b-42b8-a37b-8aa4c4cbabab", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: cytokines and growth factors", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulceration can lead to severe pain and difficulty with eating and drinking, which may necessitate opioid analgesics, hospitalisation and supplemental nutrition. These complications may disrupt cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining of the mouth, thus preventing or reducing oral mucositis and its negative effects. Objectives To assess the effects of cytokines and growth factors for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (searched 10 May 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4) in the Cochrane Library (searched 10 May 2017); MEDLINE Ovid (1946 to 10 May 2017); Embase Ovid (7 December 2015 to 10 May 2017); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 10 May 2017); and CANCERLIT PubMed (1950 to 10 May 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of cytokines and growth factors in patients with cancer receiving treatment. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 35 RCTs analysing 3102 participants. Thirteen studies were at low risk of bias, 12 studies were at unclear risk of bias, and 10 studies were at high risk of bias. Our main findings were regarding keratinocyte growth factor (KGF) and are summarised as follows. There might be a reduction in the risk of moderate to severe oral mucositis in adults receiving bone marrow/stem cell transplantation after conditioning therapy for haematological cancers (RR 0.89, 95% CI 0.80 to 0.99; 6 studies; 852 participants; low‐quality evidence). We would need to treat 11 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 6 to 112). There might be a reduction in the risk of severe oral mucositis in this population, but there is also some possibility of an increase in risk (RR 0.85, 95% CI 0.65 to 1.11; 6 studies; 852 participants; low‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to prevent the outcome to 14 to cause the outcome). There is probably a reduction in the risk of moderate to severe oral mucositis in adults receiving radiotherapy to the head and neck with cisplatin or fluorouracil (RR 0.91, 95% CI 0.83 to 1.00; 3 studies; 471 participants; moderate‐quality evidence). We would need to treat 12 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 7 to infinity). It is very likely that there is a reduction in the risk of severe oral mucositis in this population (RR 0.79, 95% CI 0.69 to 0.90; 3 studies; 471 participants; high‐quality evidence). We would need to treat 7 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to 15). It is likely that there is a reduction in the risk of moderate to severe oral mucositis in adults receiving chemotherapy alone for mixed solid and haematological cancers (RR 0.56, 95% CI 0.45 to 0.70; 4 studies; 344 participants; moderate‐quality evidence). We would need to treat 4 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 3 to 6). There might be a reduction in the risk of severe oral mucositis in this population (RR 0.30, 95% CI 0.14 to 0.65; 3 studies; 263 participants; low ‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 8 to 19). Due to the low volume of evidence, single‐study comparisons and insufficient sample sizes, we found no compelling evidence of a benefit for any other cytokines or growth factors and there was no evidence on children. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Authors' conclusions We are confident that KGF is beneficial in the prevention of oral mucositis in adults who are receiving: a) radiotherapy to the head and neck with cisplatin or fluorouracil; or b) chemotherapy alone for mixed solid and haematological cancers. We are less confident about a benefit for KGF in adults receiving bone marrow/stem cell transplant after conditioning therapy for haematological cancers because of multiple factors involved in that population, such as whether or not they received total body irradiation (TBI) and whether the transplant was autologous (the patients' own cells) or allogeneic (cells from a donor). KGF appears to be a relatively safe intervention. Due to limited research, we are not confident that there are any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Plain language summary Can cytokines and growth factors help prevent mouth soreness and ulcers (oral mucositis) in patients being treated for cancer? Review question This review has been produced to assess whether or not the use of cytokines and growth factors during cancer treatment, can help prevent mouth soreness and ulcers. Background Sore mouth and ulcers (oral mucositis) is a side effect of treatment for cancer including chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulcers can lead to severe pain and difficulty with eating and drinking. Sufferers may need strong painkillers, possibly have to go into hospital and even be fed through a tube into their stomach or their veins. These complications may disrupt their cancer therapy, meaning they are not receiving the best treatment, which may reduce survival. Cancer patients have weakened immune systems due to their treatment and are less able to fight infections. An ulcer is an open wound and there is a risk that bacteria can enter the body leading to infection or sepsis (a dangerous inflammatory reaction of the body to infection). Mouth soreness and ulcers can be costly to healthcare systems, yet there are few preventive interventions or treatments proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining the mouth, thus preventing or reducing oral mucositis and its negative effects. Study characteristics Authors from Cochrane Oral Health carried out this review of existing studies and the evidence is current up to 10 May 2017. It includes 35 studies (published between 1993 and 2017) with 3102 participants, all patients being treated for cancer, aged from 1 to 87 years old. Review authors included studies comparing cytokines and growth factors for the prevention of oral mucositis. The studies were carried out all over the world and often featured multiple sites, although most took place in high‐income countries. Main results The main findings were regarding keratinocyte growth factor (KGF). KGF is likely to reduce the risk of oral mucositis in adults who are receiving either radiotherapy to the head and neck with chemotherapy (cisplatin or fluorouracil), or chemotherapy alone for mixed solid and blood cancers. KGF may also reduce the risk of oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, but these results are less clear because of multiple complicating factors. KGF appears to be a relatively safe intervention. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Due to limited research, review authors are uncertain of any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Quality of the evidence For reducing oral mucositis in adults receiving radiotherapy to the head and neck with chemotherapy, review authors rated the evidence for KGF as moderate to high quality. For reducing oral mucositis in adults receiving chemotherapy alone for mixed solid and blood cancers, they rated the evidence for KGF as low to moderate quality. This evidence was downgraded due to there not being enough data and because some results have not yet been published. For reducing oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, they rated the evidence for KGF as low quality because results were not similar across the studies and some results have not yet been published. Evidence on side effects of KGF was poorly reported and inconsistent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P, Glenny, AM, Worthington, HV, Littlewood, A, Fernandez Mauleffinch, LM, Clarkson, JE, McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.070Z" }, { "id": "9358f0a5-315f-4f04-b145-e0a2bde22009", "pmid": "", "title": "Over the counter (OTC) artificial tear drops for dry eye syndrome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pucker, AD, Ng, SM, Nichols, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD009729.pub2 AB - Abstract - Background Over the counter (OTC) artificial tears historically have been the first line of treatment for dry eye syndrome and dry eye‐related conditions like contact lens discomfort, yet currently we know little regarding the overall efficacy of individual, commercially available artificial tears. This review provides a much needed meta‐analytical look at all randomized and quasi‐randomized clinical trials that have analyzed head‐to‐head comparisons of OTC artificial tears. Objectives To evaluate the effectiveness and toxicity of OTC artificial tear applications in the treatment of dry eye syndrome compared with another class of OTC artificial tears, no treatment, or placebo. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 12), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2015), EMBASE (January 1980 to December 2015), Latin American and Caribbean Health Sciences (LILACS) (January 1982 to December 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) and the US Food and Drugs Administration (FDA) website ( www.fda.gov ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 December 2015. We searched reference lists of included trials for any additional trials not identified by the electronic searches. Selection criteria This review includes randomized controlled trials with adult participants who were diagnosed with dry eye, regardless of race and gender. We included trials in which the age of participants was not reported, and clinical trials comparing OTC artificial tears with another class of OTC artificial tears, placebo, or no treatment. This review did not consider head‐to‐head comparisons of artificial tears with another type of dry‐eye therapy. Data collection and analysis We followed the standard methodological procedures expected by Cochrane. Two authors independently screened the search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. We performed meta‐analysis for trials that compared similar interventions and reported comparable outcomes with sufficient data. We summarized all other included trial results in the text. Main results We included 43 randomized controlled trials (3497 participants with dry eye). Due to the heterogeneity of study characteristics among the included trials with respect to types of diagnostic criteria, interventions, comparisons, and measurements taken, our ability to perform meta‐analyses was limited. The review found that, in general, there was uncertainty whether different OTC artificial tears provide similar relief of signs and symptoms when compared with each other or placebo. Nevertheless, we found that 0.2% polyacrylic acid‐based artificial tears were consistently more effective at treating dry eye symptoms than 1.4% polyvinyl alcohol‐based artificial tears in two trials assessing this comparison (175 participants). All other included artificial tears produced contradictory between‐group results or found no between‐group differences. Our review also found that OTC artificial tears may be generally safe, but not without adverse events. Overall, we assessed the quality of evidence as low due to high risks of bias among included trials and poor reporting of outcome measures which were insufficient for quantitative analysis. Furthermore, we identified an additional 18 potentially eligible trials that were reported only in clinical trial registers with no associated results or publications. These trials reportedly enrolled 2079 total participants for whom no data are available. Such lack of reporting of trial results represents a high risk of publication bias. Authors' conclusions OTC artificial tears may be safe and effective means for treating dry eye syndrome; the literature indicates that the majority of OTC artificial tears may have similar efficacies. This conclusion could be greatly skewed by the inconsistencies in study designs and inconsistencies in reporting trial results. Additional research is therefore needed before we can draw robust conclusions about the effectiveness of individual OTC artificial tear formulations. Plain language summary Efficacy of over the counter (OTC) artificial tears for dry eye syndrome Research question What is the effect of over the counter (OTC) artificial tears on dry eye syndrome? Background 
 Dry eye syndrome is a long‐term condition that is known to cause eye discomfort and visual disturbances like blurred vision. This condition affects millions of people around the world, and the first‐line treatment for dry eye is typically over the counter (OTC) artificial tears. OTC artificial tears are meant to replace or supplement the tears (fluid) that naturally cover the eye’s front surface (cornea and conjunctiva). There are a great number of commercially available artificial tears, yet there is currently no agreement about whether one formulation works better than another at treating dry eye. Our review attempts to bridge this knowledge gap. Study characteristics 
 This review included 43 randomized controlled trials (3497 people with dry eye) that compared OTC artificial tears with other OTC artificial tears, with no treatment, or with placebo. We considered participant symptoms to be the primary outcome for this review. We recorded other commonly performed dry eye tests as secondary outcomes (e.g. vision, tear stability). We measured primary and secondary outcomes at two and four weeks, although we also considered other time points in this review. We searched for trials up to December 2015. Key results 
 This review analyzed many OTC artificial tear formulations, and most of the literature indicates uncertainty as to which OTC artificial tear works best. The literature also shows that OTC artificial tears may be effective at treating dry eye symptoms and that OTC artificial tears are generally safe, although not without side effects. We also identified an additional 18 potentially eligible trials that were registered, but did not provide any results or publications. These trials may have enrolled 2079 total participants for whom no data are available. Without the results of these trials, the effects of the OTC artificial tears that they evaluated are unknown. Quality of the evidence The overall quality of the evidence was low for the various OTC artificial tear formulations compared in this review. This finding indicates that future published research may have an important impact on the conclusions currently provided in this review.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.793Z" }, { "id": "937857ad-730b-43a3-a3bf-964d1a8930df", "pmid": "", "title": "Opioids for restless legs syndrome", "imported": false, "abstract": "Abstract - Background Restless legs syndrome (RLS) is a distressing and common neurological disorder that may have a huge impact in the quality of life of those with frequent and intense symptoms. Patients complain of unpleasant sensations in the legs, at or before bedtime, and feel an urge to move the legs, which improves with movement, such as walking. Symptoms start with the patient at rest (e.g. sitting or lying down), and follow a circadian pattern, increasing during the evening or at night. Many pharmacological intervention are available for RLS, including drugs used to treat Parkinson's disease (L‐Dopa and dopaminergic agonists), epilepsy (anticonvulsants), anxiety (benzodiazepines), and pain (opioids). Dopaminergic drugs are those most frequently used for treatment of RLS, but some patients do not respond effectively and require other medication. Opioids, a class of medications used to treat severe pain, seem to be effective in treating RLS symptoms, and are recommended for patients with severe symptoms, because RLS and pain appear to share the same mechanism in the central nervous system. All available drugs are associated to some degree with side effects, which can impede treatment. Opioids are associated with adverse events such as constipation, tolerance, and dependence. This justifies the conduct of a systematic review to ascertain whether opioids are safe and effective for treatment of RLS. Objectives To asses the effects of opioids compared to placebo treatment for restless legs syndrome in adults. Search methods We searched the Cochrane Central Register of Controlled trials, CENTRAL 2016, issue 4 and MEDLINE, EMBASE, and LILACS up to April 2016, using a search strategy adapted by Cochraneto identify randomised clinical trials. We checked the references of each study and established personal communication with other authors to identify any additional studies. We considered publications in all languages. Selection criteria Randomised controlled clinical trials of opioid treatment in adults with idiopathic RLS. Data collection and analysis Two review authors independently screened articles, independently extracted data into a standard form, and assessed for risk of bias. If necessary, they discussed discrepancies with a third researcher to resolve any doubts. Main results We included one randomised clinical trial (N = 304 randomised; 204 completed; 276 analysed) that evaluated opioids (prolonged release oxycodone/naloxone) versus placebo. After 12 weeks, RSL symptoms had improved more in the drug group than in the placebo group (using the IRLSSS: MD ‐7.0; 95% CI ‐9.69 to ‐4.31 and the CGI: MD ‐1.11; 95% CI ‐1.49 to ‐0.73). More patients in the drug group than in the placebo group were drug responders (using the IRLSSS: RR 1.82; 95% CI 1.37 to 2.42 and the CGI: RR1.92; 95% ICI 1.49 to 2.48). The proportion of remitters was greater in the drug group than in the placebo group (using the IRLSSS: RR 2.14; 95% CI 1.45 to 3.16). Quality of life scores also improved more in the drug group than in the placebo group (MD ‐0.73; 95% CI ‐1.1 to ‐0.36). Quality of sleep was improved more in the drug group measured by sleep adequacy (MD ‐0.74; 95% CI ‐1.15 to ‐0.33), and sleep quantity (MD 0.89; 95% CI 0.52 to 1.26). There was no difference between groups for daytime somnolence, trouble staying awake during the day, or naps during the day. More adverse events were reported in the drug group (RR 1.22; 95% CI 1.07 to 1.39). The major adverse events were gastrointestinal problems, fatigue, and headache. Authors' conclusions Opioids seem to be effective for treating RLS symptoms, but there are no definitive data regarding the important problem of safety. This conclusion is based on only one study with a high dropout rate (low quality evidence). Plain language summary Opiods for restless legs syndrome Background Restless legs syndrome (RLS) is a very common neurological disorder in which patients complain of an intense need to move their legs, and unpleasant sensations felt deep in their legs, all occurring while at rest, mostly at bedtime. The number of patients complaining of RLS varies according to race, gender, age, country, and health status. About 5% to 10% of people are affected; , and, among these, 2% to 5% need continual pharmacological treatment (medication). When RLS does not respond to medications generally used for Parkinsons Disease and epilepsy, their doctors often prescribe opioids. Question Are opioids effective and safe for people with RLS? Methods We searched the literature for studies in any language, published or not, that considered opioids for the treatment of RLS Results We included one randomised controlled clinical trial with moderate risk of bias that tested a combination of oxycodone and naloxone against placebo capsules, taken twice daily in participants whodid not respond to more usual medications. Researchers used the International RLS severity scale to find out if patients were improved after 12 weeks of treatment. Particpants receiving the combined oxycodone and naloxone reported improvement in RLS symptoms, Quality of life, and sleep quality; 42% of the drug group were symptom‐free. Discussion The study was well designed overall, but was at a high risk of bias due to the high percentage of participants who withdrew from treatment (attrition bias). Eighty‐four percent of the drug group developed adverse events, which were mostly related to the gastrointestinal system, headache, fatigue, and sleepiness (somnolence); 9.8% left the study because of the adverse events. Conclusion The use of opioids for the treatment of RLS in patients resistant to conventional treatment is supported by low‐quality evidence. Prescription of these medications should be based on clinical experience, and caution used due to the potential for abuse, dependency, and adverse events. No patient on opioids complained that their symptoms worsened.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "de Oliveira, CO; Carvalho, LBC; Carlos, K; Conti, C; de Oliveira, MM; Prado, LBF; Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006941.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "9380cbe5-273f-410b-acee-e65b9cca40af", "pmid": "", "title": "Omega‐3 fatty acids for depression in adults", "imported": false, "abstract": "Abstract - Background Major depressive disorder (MDD) is highly debilitating, difficult to treat, has a high rate of recurrence, and negatively impacts the individual and society as a whole. One potential treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, some other seafood, and some nuts and seeds. Various lines of evidence suggest a role for n‐3PUFAs in MDD, but the evidence is far from conclusive. Reviews and meta‐analyses clearly demonstrate heterogeneity between studies. Investigations of heterogeneity suggest different effects of n‐3PUFAs, depending on the severity of depressive symptoms, where no effects of n‐3PUFAs are found in studies of individuals with mild depressive symptomology, but possible benefit may be suggested in studies of individuals with more severe depressive symptomology. Hence it is important to establish their effectiveness in treating MDD. This review updates and incorporates an earlier review with the same research objective (Appleton 2015). Objectives To assess the effects of n‐3 polyunsaturated fatty acids (also known as omega‐3 fatty acids) versus a comparator (e.g. placebo, antidepressant treatment, standard care, no treatment, wait‐list control) for major depressive disorder (MDD) in adults. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO together with trial registries and grey literature sources (to 9 January 2021). We checked reference lists and contacted authors of included studies for additional information when necessary. Selection criteria We included studies in the review if they: used a randomised controlled trial design; provided n‐3PUFAs as an intervention; used a comparator; measured depressive symptomology as an outcome; and were conducted in adults with MDD. Primary outcomes were depressive symptomology (continuous data collected using a validated rating scale) and adverse events. Secondary outcomes were depressive symptomology (dichotomous data on remission and response), quality of life, and non‐completion of studies. Data collection and analysis We used standard methodological procedures as expected by Cochrane. We assessed the certainty of the evidence using GRADE criteria. Main results The review includes 35 relevant studies: 34 studies involving a total of 1924 participants investigated the impact of n‐3PUFA supplementation compared to placebo, and one study involving 40 participants investigated the impact of n‐3PUFA supplementation compared to antidepressant treatment. For the placebo comparison, n‐3PUFA supplementation resulted in a small to modest benefit for depressive symptomology, compared to placebo: standardised mean difference (SMD) (random‐effects model) −0.40 (95% confidence interval (CI) −0.64 to −0.16; 33 studies, 1848 participants; very low‐certainty evidence), but this effect is unlikely to be clinically meaningful. An SMD of 0.40 represents a difference between groups in scores on the HDRS (17‐item) of approximately 2.5 points (95% CI 1.0 to 4.0), where the minimal clinically important change score on this scale is 3.0 points. The confidence intervals include both a possible clinically important effect and a possible negligible effect, and there is considerable heterogeneity between studies. Sensitivity analyses, funnel plot inspection and comparison of our results with those of large well‐conducted trials also suggest that this effect estimate may be biased towards a positive finding for n‐3PUFAs. Although the numbers of individuals experiencing adverse events were similar in intervention and placebo groups (odds ratio (OR) 1.27, 95% CI 0.99 to 1.64; 24 studies, 1503 participants; very low‐certainty evidence), the confidence intervals include a small decrease to a modest increase in adverse events with n‐3PUFAs. There was no evidence for a difference between n‐3PUFA and placebo groups in remission rates (OR 1.13, 95% CI 0.74 to 1.72; 8 studies, 609 participants, low‐certainty evidence), response rates (OR 1.20, 95% CI 0.80 to 1.79; 17 studies, 794 participants; low‐certainty evidence), quality of life (SMD −0.38 (95% CI −0.82 to 0.06), 12 studies, 476 participants, very low‐certainty evidence), or trial non‐completion (OR 0.92, 95% CI 0.70 to 1.22; 29 studies, 1777 participants, very low‐certainty evidence). The evidence on which these results are based was also very limited, highly heterogeneous, and potentially biased. Only one study, involving 40 participants, was available for the antidepressant comparison. This study found no differences between treatment with n‐3PUFAs and treatment with antidepressants in depressive symptomology (mean difference (MD) −0.70, 95% CI −5.88 to 4.48), rates of response to treatment (OR 1.23, 95% CI 0.35 to 4.31), or trial non‐completion (OR 1.00, 95% CI 0.21 to 4.71). Confidence intervals are however very wide in all analyses, and do not rule out important beneficial or detrimental effects of n‐3PUFAs compared to antidepressants. Adverse events were not reported in a manner suitable for analysis, and rates of depression remission and quality of life were not reported. Authors' conclusions At present, we do not have sufficient high‐certainty evidence to determine the effects of n‐3PUFAs as a treatment for MDD. Our primary analyses may suggest a small‐to‐modest, non‐clinically beneficial effect of n‐3PUFAs on depressive symptomology compared to placebo; however the estimate is imprecise, and we judged the certainty of the evidence on which this result is based to be low to very low. Our data may also suggest similar rates of adverse events and trial non‐completion in n‐3PUFA and placebo groups, but again our estimates are very imprecise. Effects of n‐3PUFAs compared to antidepressants are very imprecise and uncertain. More complete evidence is required for both the potential positive and negative effects of n‐3PUFAs for MDD. Plain language summary Omega‐3 fatty acids for depression in adults Why is this review important? Major depressive disorder (MDD) is characterised by depressed mood or a markedly decreased pleasure or interest in all activities, or both. It has negative impacts on the individual and on society, often over the long term. One possible treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, in some other seafood and in some nuts and seeds. Various lines of evidence suggest that n‐3PUFAs may impact on depressive symptoms, but a lot of studies have different findings, making it difficult to draw conclusions. Who will be interested in this review? Health professionals, including general practitioners, mental health and psychiatric specialists; individuals with MDD; and the people around them. What questions does this review aim to answer? Do n‐3PUFAs, compared to an alternative, have an effect on depressive symptoms, negative side effects, rates of recovery, quality of life, and rates of study non‐completion, in individuals with MDD? Which studies were included in the review? This review is an update of earlier work (Appleton 2015), using the same methods. We searched scientific databases for all randomised controlled trials in adults with MDD, where individuals received either n‐3PUFAs or an alternative, that were completed up to January 2021. We have included 35 relevant studies: 34 of them involving 1924 people compared the effects of n‐3PUFAs with those of placebo, and one study involving 40 people compared the effects of n‐3PUFAs with those of antidepressants. All studies were of direct relevance to our review, but we considered the certainty of the evidence to be low to very low. What does the evidence from the review tell us? At present, we do not have enough high quality evidence to determine the effects of n‐3PUFAs as a treatment for MDD. We found a small‐to‐modest positive effect of n‐3PUFAs compared to placebo, but the size of this effect is unlikely to be meaningful to people with MDD, and we considered the evidence to be of low or very low certainty, with many differences between studies. There was also insufficient high quality evidence to determine the effects of n‐3PUFAs on negative side effects or numbers not completing studies. What should happen next? We need more evidence, particularly to explain the differences between study findings, e.g. by looking at individuals who may or may not benefit from n‐3PUFAs. Future studies should also compare n‐3PUFAs with usual antidepressant treatment, and investigate the way these treatments may work.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Appleton, KM, Voyias, PD, Sallis, HM, Dawson, S, Ness, AR, Churchill, R, Perry, R", "articleTypes": [], "doi": "10.1002/14651858.CD004692.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.081Z" }, { "id": "93878570-4d60-4b2a-914b-d3edc791dd90", "pmid": "", "title": "Glucocorticoids for croup in children", "imported": false, "abstract": "Abstract - Background Glucocorticoids are the mainstay for the treatment of croup. The existing evidence demonstrates that glucocorticoids are effective in the treatment of croup in children. However, updating the evidence on their clinical relevance in croup is imperative. This is an update to a review first published in 1999, and updated in 2004, 2011, and 2018. Objectives To investigate the effects and safety of glucocorticoids in the treatment of croup in children aged 18 years and below. Search methods We searched the Cochrane Library, which includes the Cochrane Central Register of Controlled Trials (CENTRAL; 2022 Issue 9), Ovid MEDLINE Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations and Ovid MEDLINE (1946 to 4 March 2022), Embase (Ovid) (1974 to 4 March 2022). We also searched the WHO ICTRP and ClinicalTrials.gov on 4 March 2022. Selection criteria We included randomised controlled trials (RCTs) in children (aged 18 years and below) with croup. We assessed the effect of glucocorticoids compared to the following: placebo, any other pharmacologic agents, any other glucocorticoids, any combination of other glucocorticoids, given by different modes of administration, or given in different doses. The included studies must have assessed at least one of our primary outcomes (defined as the change in croup score or return visits, (re)admissions to the hospital or both) or secondary outcomes (defined as the length of stay in hospital or emergency departments, patient improvement, use of additional treatments, or adverse events). Data collection and analysis Review authors independently extracted data, with another review author verified. We entered the data into Review Manager 5 for meta‐analysis. Two review authors independently assessed studies for risk of bias using the Cochrane risk of bias tool. Two review authors assessed the certainty of the evidence for the primary outcomes using the GRADE approach. Main results This updated review includes 45 RCTs with a total of 5888 children, an increase of two RCTs with 1323 children since the last update. We also identified one ongoing study and one study awaiting classification. We assessed most studies (98%) as at high or unclear risk of bias. Any glucocorticoid compared to placebo Compared to placebo, glucocorticoids may result in greater reductions in croup score after two hours (standardised mean difference (SMD) −0.65, 95% confidence interval (CI) −1.13 to −0.18; 7 RCTs, 426 children; low‐certainty evidence); six hours (SMD −0.76, 95% CI −1.12 to −0.40; 11 RCTs, 959 children; low‐certainty evidence); and 12 hours (SMD −1.03, 95% CI −1.53 to ‐0.53; 8 RCTs, 571 children; low‐certainty evidence). The evidence for change in croup score after 24 hours is very uncertain (SMD −0.86, 95% CI −1.40 to −0.31; 8 RCTs, 351 children; very low‐certainty evidence). One glucocorticoid compared to another glucocorticoid There was little to no difference between prednisolone and dexamethasone for reduction in croup score at two‐hour post‐baseline score (SMD 0.06, 95% CI −0.06 to 0.18; 1 RCT, 1231 children; high‐certainty evidence). There was likely little to no difference between prednisolone and dexamethasone for reduction in croup score at six‐hour post‐baseline score (SMD 0.21, 95% CI −0.21 to 0.62; 1 RCT, 99 children; moderate‐certainty evidence). However, dexamethasone probably reduced the return visits or (re)admissions for croup by almost half (risk ratio (RR) 0.55, 95% CI 0.28 to 1.11; 4 RCTs, 1537 children; moderate‐certainty evidence), and showed a 28% reduction in the use of supplemental glucocorticoids as an additional treatment (RR 0.72, 95% CI 0.53 to 0.97; 2 RCTs, 926 children). Dexamethasone given in different doses Compared to 0.15 mg/kg, 0.60 mg/kg dexamethasone probably reduced the severity of croup as assessed by the croup scoring scale at 24‐hour postbaseline score (SMD 0.63, 95% CI 0.16 to 1.10; 1 RCT, 72 children; moderate‐certainty evidence); however, this was not the case at two hours (SMD −0.27, 95% CI −0.76 to 0.22; 2 RCTs, 861 children; high‐certainty evidence). There was probably no reduction at six hours (SMD −0.45, 95% CI −1.26 to 0.35; 3 RCTs, 178 children; moderate‐certainty evidence), and the evidence at 12 hours is very uncertain (SMD −0.60, 95% CI −4.39 to 3.19; 2 RCTs, 113 children; very low‐certainty evidence). There was little to no difference between doses of dexamethasone in return visits or (re)admissions of children or both (RR 0.91, 95% CI 0.71 to 1.17; 3 RCTs, 949 children; high‐certainty evidence) or length of stay in the hospital or emergency department (mean difference 0.12, 95% CI −0.32 to 0.56; 2 RCTs, 892 children). The need for additional treatments, such as epinephrine (RR 0.78, 95% CI 0.34 to 1.75; 2 RCTs, 885 children); intubation (risk difference 0.00, 95% CI −0.00 to 0.00; 2 RCTs, 861 children); or use of supplemental glucocorticoids (RR 0.77, 95% CI 0.51 to 1.15; 2 RCTs, 617 children), also did not differ between doses of dexamethasone. There were moderate to high levels of heterogeneity in the analyses for most comparisons. Adverse events were observed for some of the comparisons reported in the review. Authors' conclusions The evidence that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions has not changed in this update. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg. More RCTs are needed to strengthen the evidence for effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. Plain language summary Glucocorticoids for croup in children Review question What is the effectiveness and safety of glucocorticoids when treating children with croup? Background Respiratory viruses are the main cause of croup in children. Croup leads to a swelling of the throat and airway, which can make breathing difficult. Children also present with a special type of cough called a barking cough. Glucocorticoids are types of steroids that help reduce the swelling, thereby making it easier for children with croup to breathe. This is an update of a review first published in 1999 and updated in 2004, 2011, and 2018. Search date The evidence is current to 4 March 2022. Study characteristics We included 2 new studies with 1323 children, for a total of 45 studies with 5888 children aged 0 to 18 years published between 1964 and 2021. The three types of glucocorticoids used in the new studies were budesonide, dexamethasone, and prednisolone. The most recent study compared the effectiveness of budesonide and dexamethasone. The other new study compared the effectiveness of dexamethasone and prednisolone, as well as a small dose of dexamethasone (0.15 mg/kg) versus 0.60 mg/kg dexamethasone. We added the data from the new study that compared the doses of dexamethasone to previously included studies looking at the same comparison. Study funding sources Funding sources included government (11%), academic or research institute (7%), industry (18%), or foundations (9%). More than half of the studies (55%) did not report funding sources. Key results Compared to prednisolone, dexamethasone showed no improvement in croup score at two and six hours after presenting to the hospital or emergency department, and probably reduced return visits or (re)admissions for croup by almost half. The addition of supplemental glucocorticoid favoured dexamethasone versus prednisolone. Compared to 0.15 mg/kg dexamethasone, the standard dose of 0.60 mg/kg probably reduced the severity of croup as assessed by the croup scoring scale at 24 hours after presenting to the hospital or emergency department. However, we did not find any important difference between groups in croup scoring scale at 2, 6, or 12 hours, return visits or (re)admissions of children, or length of stay in the hospital or emergency department. The need for additional treatments such as the use of other drugs like epinephrine, supplemental glucocorticoid, or the use of a tube to help breathing did not differ between 0.15 mg/kg and 0.60 mg/kg dexamethasone. No serious adverse events from the use of the glucocorticoids were reported in the newly included studies. Conclusions The evidence has not changed that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions compared to placebo (dummy treatment). A small dose of dexamethasone at 0.15 mg/kg may be as effective as the standard dose of 0.60 mg/kg. More studies are needed to strengthen the evidence for the effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. We conclude that glucocorticoids are effective in the treatment of croup in children. Certainty of evidence Most studies (98%) had problems related to their methods, reporting issues, or both. For any glucocorticoid compared to placebo, we downgraded the certainty of the evidence for change in croup score after 2, 6, 12, and 24 hours and return visits or (re)admissions due to study variability, imprecision and inconsistency of study results, and risk of bias. There is little evidence that reporting bias influenced our results for return visits or (re)admissions, or both. Similar threats to the certainty of the evidence were present in the other comparisons in this review, including concerns related to risk of bias and inconsistency and imprecision of study results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aregbesola, A, Tam, CM, Kothari, A, Le, M-L, Ragheb, M, Klassen, TP", "articleTypes": [], "doi": "10.1002/14651858.CD001955.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.060Z" }, { "id": "9394a287-c098-43ab-a43c-c939c73ded14", "pmid": "", "title": "Systemic antifungal therapy for tinea capitis in children", "imported": false, "abstract": "Abstract - Background Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread. This is an update of the original Cochrane review. Objectives To assess the effects of systemic antifungal drugs for tinea capitis in children. Search methods We updated our searches of the following databases to November 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and CINAHL (from 1981). We searched five trial registers and checked the reference lists of studies for references to relevant randomised controlled trials (RCTs). We obtained unpublished, ongoing trials and grey literature via correspondence with experts in the field and from pharmaceutical companies. Selection criteria RCTs of systemic antifungal therapy in children with normal immunity under the age of 18 with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 25 studies (N = 4449); 4 studies (N = 2637) were new to this update. Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy for the primary outcome of complete (i.e. clinical and mycological) cure in three studies involving 328 participants with Trichophyton species infections (84.2% versus 79.0%; risk ratio (RR) 1.06, 95% confidence interval (CI) 0.98 to 1.15; low quality evidence). Complete cure with itraconazole (two to six weeks) and griseofulvin (six weeks) was similar in two studies (83.6% versus 91.0%; RR 0.92, 95% CI 0.81 to 1.05; N = 134; very low quality evidence). In two studies, there was no difference between itraconazole and terbinafine for two to three weeks treatment (73.8% versus 78.8%; RR 0.93, 95% CI 0.72 to 1.19; N = 160; low quality evidence). In three studies, there was a similar proportion achieving complete cured with two to four weeks of fluconazole or six weeks of griseofulvin (41.4% versus 52.7%; RR 0.92, 95% CI 0.81 to 1.05; N = 615; moderate quality evidence). Current evidence for ketoconazole versus griseofulvin was limited. One study favoured griseofulvin (12 weeks) because ketoconazole (12 weeks) appeared less effective for complete cure (RR 0.76, 95% CI 0.62 to 0.94; low quality evidence). However, their effects appeared to be similar when the treatment lasted 26 weeks (RR 0.95, 95% CI 0.83 to 1.07; low quality evidence). Another study indicated that complete cure was similar for ketoconazole (12 weeks) and griseofulvin (12 weeks) (RR 0.89, 95% CI 0.57 to 1.39; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole (for two to three weeks) and terbinafine (for two to three weeks) (82.0% versus 94.0%; RR 0.87, 95% CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, we did not find a significant difference between fluconazole (for two to three weeks) and itraconazole (for two to three weeks) (82.0% versus 82.0%; RR 1.00, 95% CI 0.83 to 1.20; low quality evidence). This update provides new data: in children with Microsporum infections, a meta‐analysis of two studies found that the complete cure was lower for terbinafine (6 weeks) than for griseofulvin (6‐12 weeks) (34.7% versus 50.9%; RR 0.68, 95% CI 0.53 to 0.86; N = 334; moderate quality evidence). In the original review, there was no significant difference in complete cure between terbinafine (four weeks) and griseofulvin (eight weeks) in children with Microsporum infections in one small study (27.2% versus 60.0%; RR 0.45, 95% CI 0.15 to 1.35; N = 21; low quality evidence). One study provides new evidence that terbinafine and griseofulvin for six weeks show similar efficacy (49.5% versus 37.8%; RR 1.18, 95% CI 0.74 to 1.88; N = 1006; low quality evidence). However, in children infected with T. tonsurans , terbinafine was better than griseofulvin (52.1% versus 35.4%; RR 1.47, 95% CI 1.22 to 1.77; moderate quality evidence). For children infected with T. violaceum, these two regimens have similar effects (41.3% versus 45.1%; RR 0.91, 95% CI 0.68 to 1.24; low quality evidence). Additionally, three weeks of fluconazole was similar to six weeks of fluconazole in one study in 491 participants infected with T. tonsurans and M. canis (30.2% versus 34.1%; RR 0.88, 95% CI 0.68 to 1.14; low quality evidence). The frequency of adverse events attributed to the study drugs was similar for terbinafine and griseofulvin (9.2% versus 8.3%; RR 1.11, 95% CI 0.79 to 1.57; moderate quality evidence), and severe adverse events were rare (0.6% versus 0.6%; RR 0.97, 95% CI 0.24 to 3.88; moderate quality evidence). Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible. All of the included studies were at either high or unclear risk of bias in at least one domain. Using GRADE to rate the overall quality of the evidence, lower quality evidence resulted in lower confidence in the estimate of effect. Authors' conclusions Newer treatments including terbinafine, itraconazole and fluconazole are at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Limited evidence suggests that terbinafine, itraconazole and fluconazole have similar effects, whereas ketoconazole may be less effective than griseofulvin in children infected with Trichophyton . With some interventions the proportion achieving complete clinical cure was in excess of 90% (e.g. one study of terbinafine or griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. New evidence from this update suggests that terbinafine is more effective than griseofulvin in children with T. tonsurans infection. However, in children with Microsporum infections, new evidence suggests that the effect of griseofulvin is better than terbinafine. We did not find any evidence to support a difference in terms of adherence between four weeks of terbinafine versus eight weeks of griseofulvin. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles. Plain language summary Antifungal medicines for treating children with ringworm Background Tinea capitis, or ringworm, is a fungal infection of the scalp caused mainly by two species of fungi called Trichophyton and Microsporum . It is common in children. Most fungal infections can be treated with antifungal creams applied directly to the skin (topical treatments). However, because the fungal infection is found at the root of the hair follicles, where topical treatments cannot reach, tinea capitis always requires medication administered by mouth so that the treatment spreads throughout the entire body (systemic treatments). There are several different types of antifungal medicines available. Review question Which antifungal medicine is best for treating ringworm on the scalp in children? Study characteristics In November 2015, we searched for studies that used the gold standard design for clinical trials (randomised controlled trials) of antifungal treatments taken by mouth. We found 25 studies in which 4449 children under 18 years (4 studies with 2637 children were new to this update) had taken part. Key results With respect to complete cure (both cure of the infection and visible cure (i.e. fungal and clinical cure) low to moderate quality evidence suggests that newer treatments such as terbinafine, itraconazole and fluconazole are at least as good as griseofulvin, the usual treatment in children with tinea capitis caused by Trichophyton infections. However, new evidence in this update suggests that terbinafine may have better effects than griseofulvin for completely curing children with T. tonsurans infection. By contrast, in children with Microsporum infections, new evidence seems to indicate that griseofulvin is more effective than terbinafine. Terbinafine, itraconazole and fluconazole appear to have similar effects in terms of the proportion of participants achieving complete cure, whereas ketoconazole appears to be less effective than griseofulvin for children with tinea capitis caused by Trichophyton species. However, the quality of this evidence is low. With some interventions, the proportion with complete clinical cure was in excess of 90% (e.g. one study of terbinafine versus griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. The included studies reported on negative side effects, which were similarly mild and reversible for terbinafine, griseofulvin, itraconazole, ketoconazole and fluconazole. They included skin‐specific effects such as itching as well as abdominal discomfort, headache and nausea. Quality of the evidence The quality of the evidence in this review was generally low to moderate, so further research is likely to have an important effect on our confidence in these results. Some evidence was even of very low quality. We still need more and better evidence to help us understand the effectiveness and adverse events of systemic antifungal drugs for tinea capitis in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chen, X; Jiang, X; Yang, M; González, U; Lin, X; Hua, X; Xue, S; Zhang, M; Bennett, C", "articleTypes": [], "doi": "10.1002/14651858.CD004685.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "939c2ce0-b943-4260-8c9c-d519a36fb353", "pmid": "", "title": "Combination Therapies to Reduce the Nasopharyngeal Carriage of SARS-CoV-2 and Improve the Outcome of COVID-19 Infection in Ivory Coast (INTENSE-COV): a Phase IIb Randomized Clinical Trial", "imported": false, "abstract": "In January 2020, the new SARS-CoV-2 coronavirus was identified in China. The disease caused by this coronavirus was named COVID-19 by the World Health Organization (WHO). Since March 11, 2020, the WHO has described the global situation of COVID-19 as a pandemic. In Côte d'Ivoire, as in other African countries, the number of cases is increasing exponentially.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.160Z" }, { "id": "93a1d49b-b907-4d07-9b6b-16dc74b74b90", "pmid": "", "title": "Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia", "imported": false, "abstract": "Abstract - Background In a review and meta‐analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion‐focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect. Objectives To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic. Search methods We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the `awaiting classification' section of this review. Selection criteria We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion‐focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post‐surgery. Data collection and analysis One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion. Where possible we used random‐effects meta‐analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges' g) to combine data from different outcome measures. If data were not available in a form suitable for meta‐analysis we performed a narrative review. Main results Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty‐one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta‐analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD ‐0.20, 95% confidence interval (CI) ‐0.35 to ‐0.06), length of stay (mean difference ‐0.52 days, 95% CI ‐0.82 to ‐0.22) and negative affect (SMD ‐0.35, 95% CI ‐0.54 to ‐0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached. Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall,we rated the quality of evidence for each outcome as ‘low’ because of the high level of heterogeneity in meta‐analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta‐analysis, so we rated the quality of evidence as `very low'. Authors' conclusions The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well‐conducted and clearly reported research. Plain language summary The effect of psychological preparation on pain, behavioural recovery, negative emotion and length of stay after surgery Background The way people think and feel before surgery can affect how they feel and what they do after surgery. For example, research shows that people who feel more anxious before their surgery experience more pain after it. A review conducted in 1993 looked at the impact of psychological preparation on outcomes after surgery. The term `psychological preparation' includes a range of techniques that aim to change what people think, how they feel or what they do. This 1993 review found that psychological preparation techniques reduced pain after surgery, improved behavioural recovery (how quickly people return to activities), decreased length of stay in hospital and reduced negative emotion (e.g. feelings of anxiety or depression). We aimed to carry out an up‐to‐date review using Cochrane methodology to learn whether there are helpful (or harmful) effects of psychological preparation for people undergoing surgery, and which outcomes (pain after surgery, behavioural recovery, negative emotion or length of stay) are improved. Study characteristics We included studies of adults who received planned surgery with general anaesthesia. We looked at seven psychological preparation techniques: procedural information (information about what, when and how processes will happen); sensory information (what the experience will feel like and what other sensations they may have, e.g. taste, smell); behavioural instruction (telling patients what they need to do); cognitive intervention (techniques that aim to change how people think); relaxation techniques; hypnosis; and emotion‐focused interventions (techniques that aim to help people to manage their feelings). The psychological preparation had to be delivered before surgery for the study to be included in the review. We included studies that looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion after surgery (within one month). Studies were included in the review up to the search date of 4 May 2014. We updated the search on 7 July 2015 and will incorporate the 38 studies found in this later search when the review is updated. We included 105 studies from 115 papers, with 10,302 participants taking part. Sixty‐one studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative emotion. In accordance with the review protocol, we did not record details about funding sources. Key results In this review we included 105 studies, which were reported in 115 papers. A total of 10,302 participants were randomized in these studies. For pain, length of stay and negative emotion we combined numerical findings from the studies. We found that psychological preparation before surgery seemed to reduce pain and negative emotion after the operation and may reduce the time spent in hospital by around half a day but the quality of the evidence was low. Also, the studies used many different psychological preparation techniques (often in different combinations) so it was not possible to discover which techniques were better. We could not statistically combine numerical findings for behavioural recovery because few studies provided sufficient details and studies used different ways of measuring how quickly people returned to usual activities. In reviewing the studies, we found that psychological preparation, in particular behavioural instruction, may have the potential to improve behavioural recovery. However, the quality of this evidence was very low. We looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion in this review and did not find evidence to suggest that psychological preparation might lead to harm in these outcomes. However, as we did not look at other outcomes it is possible that we did not identify potential harm. Quality of the evidence Many studies were poorly reported, so we could not be confident that findings were reliable. For this reason and because of the large variation in psychological techniques, types of surgery and measures used, we graded the quality of the evidence as `low' for the outcomes pain, negative emotion and length of stay; we cannot be confident that these techniques help patients to recover from surgery. For behavioural recovery, we further downgraded the quality of the evidence to `very low' because of problems with measurement and reporting of the outcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, R, Scott, NW, Manyande, A, Bruce, J, Vögele, C, Byrne‐Davis, LMT, Unsworth, M, Osmer, C, Johnston, M", "articleTypes": [], "doi": "10.1002/14651858.CD008646.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.791Z" }, { "id": "93a91e89-f408-4f46-ad1c-1bb60b1b6d57", "pmid": "", "title": "Vitamin D supplementation for chronic liver diseases in adults", "imported": false, "abstract": "Abstract - Background Vitamin D deficiency is often reported in people with chronic liver diseases. Improving vitamin D status could therefore be beneficial for people with chronic liver diseases. Objectives To assess the beneficial and harmful effects of vitamin D supplementation in adults with chronic liver diseases. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index‐Science. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We scanned bibliographies of relevant publications and enquired experts and pharmaceutical companies as to additional trials. All searches were up to November 2020. Selection criteria Randomised clinical trials that compared vitamin D at any dose, duration, and route of administration versus placebo or no intervention in adults with chronic liver diseases. Vitamin D could have been administered as supplemental vitamin D (vitamin D 3 (cholecalciferol) or vitamin D 2 (ergocalciferol)), or an active form of vitamin D (1α‐hydroxyvitamin D (alfacalcidol), 25‐hydroxyvitamin D (calcidiol), or 1,25‐dihydroxyvitamin D (calcitriol)). Data collection and analysis We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of evidence. Main results We included 27 randomised clinical trials with 1979 adult participants. This review update added 12 trials with 945 participants. We assessed all trials at high risk of bias. All trials had a parallel‐group design. Eleven trials were conducted in high‐income countries and 16 trials in middle‐income countries. Ten trials included participants with chronic hepatitis C, five trials participants with liver cirrhosis, 11 trials participants with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. All of the included trials reported the baseline vitamin D status of participants. Participants in nine trials had baseline serum 25‐hydroxyvitamin D levels at or above vitamin D adequacy (20 ng/mL), whilst participants in the remaining 18 trials were vitamin D insufficient (less than 20 ng/mL). Twenty‐four trials administered vitamin D orally, two trials intramuscularly, and one trial intramuscularly and orally. In all 27 trials, the mean duration of vitamin D supplementation was 6 months, and the mean follow‐up of participants from randomisation was 7 months. Twenty trials (1592 participants; 44% women; mean age 48 years) tested vitamin D 3 (cholecalciferol); three trials (156 participants; 28% women; mean age 54 years) tested vitamin D 2 ; four trials (291 participants; 60% women; mean age 52 years) tested 1,25‐dihydroxyvitamin D; and one trial (18 participants; 0% women; mean age 52 years) tested 25‐hydroxyvitamin D. One trial did not report the form of vitamin D. Twelve trials used a placebo, whilst the other 15 trials used no intervention in the control group. Fourteen trials appeared to be free of vested interest. Eleven trials did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on all‐cause mortality (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.51 to 1.45; 27 trials; 1979 participants). The mean follow‐up was 7 months (range 1 to 18 months). We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on liver‐related mortality (RR 1.62, 95% CI 0.08 to 34.66; 1 trial; 18 participants) (follow‐up: 12 months); serious adverse events such as hypercalcaemia (RR 5.00, 95% CI 0.25 to 100.8; 1 trial; 76 participants); myocardial infarction (RR 0.75, 95% CI 0.08 to 6.81; 2 trials; 86 participants); thyroiditis (RR 0.33, 95% CI 0.01 to 7.91; 1 trial; 68 participants); circular haemorrhoidal prolapse (RR 3.00, 95% CI 0.14 to 65.9; 1 trial; 20 participants); bronchopneumonia (RR 0.33, 95% CI 0.02 to 7.32; 1 trial 20 participants); and non‐serious adverse events. The certainty of evidence for all outcomes is very low. We found no data on liver‐related morbidity such as gastrointestinal bleeding, hepatic encephalopathy, hepatorenal syndrome, ascites, or liver cancer. There were also no data on health‐related quality of life. The evidence is also very uncertain regarding the effect of vitamin D versus placebo or no intervention on rapid, early, and sustained virological response in people with chronic hepatitis C. Authors' conclusions Given the high risk of bias and insufficient power of the included trials and the very low certainty of the available evidence, vitamin D supplementation versus placebo or no intervention may increase or reduce all‐cause mortality, liver‐related mortality, serious adverse events, or non‐serious adverse events in adults with chronic liver diseases. There is a lack of data on liver‐related morbidity and health‐related quality of life. Further evidence on clinically important outcomes analysed in this review is needed. Plain language summary Vitamin D supplementation for chronic liver diseases Review question Is vitamin D supplementation beneficial or harmful for adults with chronic liver diseases? Background The available evidence on vitamin D and chronic liver diseases in adults is inconclusive. The aim of this systematic review (a summary of results of available healthcare trials) was to analyse the benefits and harms of the different forms of vitamin D in people with chronic liver diseases. Study characteristics Twenty‐seven trials with 1979 adult participants provided data for this review. This review update added 12 trials with 945 participants. The 1979 trial participants were randomly assigned to vitamin D compared with placebo (dummy pill) or no treatment. Eleven trials were conducted in high‐income countries, and 16 trials in middle‐income countries. The age range of the participants was 28 years to 61 years, and on average 44% were women. Ten trials included people with chronic hepatitis C, five trials people with liver cirrhosis, 11 trials people with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. There were no trials including people with chronic hepatitis B or inherited liver diseases. All of the included trials reported the baseline vitamin D status of participants. Vitamin D administration lasted on average six months, and most trials used the cholecalciferol (vitamin D 3 ) form. Funding Fourteen trials appeared to be free of vested interest that could bias the trial results. Eleven trials may not have been free of vested interest, as they did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We found no difference between trials without industry support compared to trials at risk of industry support in our analysis. Key results There is not enough evidence to determine whether vitamin D has beneficial or harmful effects, or has little to no effect on chronic liver diseases in adults. There were too few participants in the individual trials as well as in our evidence synthesis. The trials were at high risk of bias so we lack fair assessments of the benefits and harms of vitamin D in this population. Neither benefits nor harms of vitamin D supplementation in people with chronic liver diseases can be excluded. There were no trials including people with chronic hepatitis B and inherited liver diseases. Quality of the evidence We judged all trials to be at high risk of bias (that is an underestimation or overestimation of the true intervention effect). The certainty of evidence is very low. Currentness of evidence The evidence is current to November 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Bjelakovic, M; Nikolova, D; Bjelakovic, G; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD011564.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "93b0b176-e42b-49b8-af9f-9f32836771b2", "pmid": "", "title": "Penicillamine for treating rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is a penicillin derived compound originally used to treat patients with rheumatoid arthritis (RA) in the 1950's. Although frequently used in the past, its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs) such as methotrexate. Objectives To estimate the short‐term effects of D‐penicillamine for the treatment of rheumatoid arthritis (RA). Search methods We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register (issue 3, 2000) and Medline up to and including August 2000 and Embase from 1988‐2000. We also carried out a handsearch of the reference lists of the trials retrieved from the electronic search. Selection criteria All randomized controlled trials and controlled clinical trials comparing D‐penicillamine against placebo in patients with rheumatoid arthritis. Data collection and analysis The methodological quality of the trials was assessed independently by two reviewers (CS, EB) and checked by a third (MS) using a validated quality assessment tool (Jadad 1996). Rheumatoid arthritis outcome measures were extracted from the publications for the six‐month endpoint and stratified according to D‐penicillamine dosages: low (<500mg/day), moderate (500 to <1000mg/day) and high (1000 mg/day or greater). Data was abstracted by one reviewer and checked by a second (CS, MS). The pooled analysis was performed using the standardized mean difference for joint counts, pain and global assessments. The weighted mean difference was used for erythrocyte sedimentation rate (ESR). Toxicity was evaluated with pooled odds ratios for withdrawals and adverse reactions. A chi‐square test was used to assess heterogeneity among trials. Fixed effects models were used throughout, since no statistical heterogeneity was found. Main results Six trials were identified, with 425 patients randomized to D‐penicillamine and 258 to placebo. A statistically significant benefit was observed for D‐penicillamine when compared to placebo for all three‐dose ranges and for most outcome measures including: tender joint counts, pain, physician's global assessments and ESR. The standardized weighted mean differences between treatment and placebo in moderate doses were ‐0.51 [95% CI ‐0.88, ‐0.14] for tender joint counts, ‐0.56 (95% CI ‐0.87, ‐0.26) for pain and ‐0.97 (95% CI ‐1.25, ‐0.70) for global assessment. The difference for ESR was ‐10.6 mm/hr. Similar results were observed for the higher dose group. Total withdrawals were significantly higher in the moderate and high dosage D‐penicillamine groups (OR=1.63 and 2.13 respectively), mostly due to increased adverse reactions (OR = 2.60 and 4.95 respectively), including renal and hematological abnormalities. Authors' conclusions D‐penicillamine appears to have a clinically and statistically significant benefit on the disease activity of patients with rheumatoid arthritis. Its efficacy appears to be similar to that of other disease modifying anti‐rheumatic drugs (DMARDs), but with a significantly higher toxicity. Its effects on long‐term functional status and radiological progression are not clear from this review. Plain language summary Penicillamine for treating rheumatoid arthritis Penicillamine is a penicillin derived compound. Studies showed that this could be used to treat rheumatoid arthritis originally in 1950. It was frequently used in the past, but its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs), such as methotrexate. The purpose of this summary was to find out if penicillamine is helpful in the treatment of rheumatoid arthritis. Penicillamine was seen to be beneficial for all ranges of dosages for disease activity on tender joint pain, physician global assessment and sed rate. No major differences were observed between placebo and low dose penicillamine (<500 mg/day). For higher dosages, patients on penicillamine were twice as likely to withdraw than those receiving placebo 500 to <1000 mg/day. D‐penicillamine appears be have a clinical and statistical benefit on the disease activity of patients with rheumatoid arthritis. Its benefit is similar to that of other such drugs, such as disease modifying anti‐rheumatic drugs (DMARDs). More adverse reactions are seen in patients being treated with D‐penicillamine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Suarez‐Almazor, ME; Belseck, E; Spooner, C", "articleTypes": [], "doi": "10.1002/14651858.CD001460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "93cd4b52-cf6c-44ce-bc98-7cdacbc013dc", "pmid": "", "title": "Paroxetine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Paroxetine is the most potent inhibitor of the reuptake of serotonin of all selective serotonin reuptake inhibitors (SSRIs) and has been studied in many randomised controlled trials (RCTs). However, these comparative studies provided contrasting findings and systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to paroxetine alone. The present systematic review assessed the efficacy and tolerability profile of paroxetine in comparison with tricyclics (TCAs), SSRIs and newer or non‐conventional agents. Objectives 1. To determine the efficacy of paroxetine in comparison with other anti‐depressive agents in alleviating the acute symptoms of Major Depressive Disorder. 2. To review acceptability of treatment with paroxetine in comparison with other anti‐depressive agents. 3. To investigate the adverse effects of paroxetine in comparison with other anti‐depressive agents. Search methods We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR, to 30 September 2012), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Reference lists of relevant papers and previous systematic reviews were handsearched. Pharmaceutical companies marketing paroxetine and experts in this field were contacted for supplemental data. Selection criteria All randomised controlled trials allocating participants with major depression to paroxetine versus any other antidepressants (ADs), both conventional (such as TCAs, SSRIs) and newer or non‐conventional (such as hypericum). For trials which had a cross‐over design, only results from the first randomisation period were considered. Data collection and analysis Two review authors independently checked eligibility and extracted data using a standard form. Data were then entered in RevMan 5.2 with a double‐entry procedure. Information extracted included study and participant characteristics, intervention details, settings and efficacy, acceptability and tolerability measures. Main results A total of 115 randomised controlled trials (26,134 participants) were included. In 54 studies paroxetine was compared with older ADs, in 21 studies with another SSRI, and in 40 studies with a newer or non‐conventional antidepressant other than SSRIs. For the primary outcome (patients who responded to treatment), paroxetine was more effective than reboxetine at increasing patients who responded early to treatment (Odds Ratio (OR): 0.66, 95% Confidence Interval (CI) 0.50 to 0.87, number needed to treat to provide benefit (NNTb) = 16, 95% CI 10 to 50, at one to four weeks, 3 RCTs, 1375 participants, moderate quality of evidence), and less effective than mirtazapine (OR: 2.39, 95% CI 1.42 to 4.02, NNTb = 8, 95% CI 5 to 14, at one to four weeks, 3 RCTs, 726 participants, moderate quality of evidence). Paroxetine was less effective than citalopram in improving response to treatment (OR: 1.54, 95% CI 1.04 to 2.28, NNTb = 9, 95% CI 5 to 102, at six to 12 weeks, 1 RCT, 406 participants, moderate quality of evidence). We found no clear evidence that paroxetine was more or less effective compared with other antidepressants at increasing response to treatment at acute (six to 12 weeks), early (one to four weeks), or longer term follow‐up (four to six months). Paroxetine was associated with a lower rate of adverse events than amitriptyline, imipramine and older ADs as a class, but was less well tolerated than agomelatine and hypericum. Included studies were generally at unclear or high risk of bias due to poor reporting of allocation concealment and blinding of outcome assessment, and incomplete reporting of outcomes. Authors' conclusions Some possibly clinically meaningful differences between paroxetine and other ADs exist, but no definitive conclusions can be drawn from these findings. In terms of response, there was a moderate quality of evidence that citalopram was better than paroxetine in the acute phase (six to 12 weeks), although only one study contributed data. In terms of early response to treatment (one to four weeks) there was moderate quality of evidence that mirtazapine was better than paroxetine and that paroxetine was better than reboxetine. However there was no clear evidence that paroxetine was better or worse compared with other antidepressants at increasing response to treatment at any time point. Even if some differences were identified, the findings from this review are better thought as hypothesis forming rather than hypothesis testing and it would be reassuring to see the conclusions replicated in future trials. Finally, most of included studies were at unclear or high risk of bias, and were sponsored by the drug industry. The potential for overestimation of treatment effect due to sponsorship bias should be borne in mind. Plain language summary Paroxetine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms such as appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, inappropriate guilt and morbid thoughts of death. Although medication and psychological treatments are both effective for major depression, antidepressant drugs remain the mainstay of treatment in moderate to severe major depression. However, head‐to‐head comparisons of such drugs provide contrasting findings as to whether they are effective. This review of the research on the effect of an antidepressant drug called paroxetine was conducted to shed light on the field of drug treatment for depression. In September 2012 we searched, in a wide ranging way, for all the useful studies (randomised controlled trials) which had been completed which compared paroxetine with any other antidepressant in treating people with depression. One hundred and fifteen studies were included in this review, with a total of 26,134 people. We grouped the studies according to the types of drug they compared paroxetine against; we then analysed the combined findings of these groups of studies. For the primary outcome (number of people who responded to treatment) paroxetine was more effective than reboxetine, but less effective than mirtazapine (in the early phase: one to four weeks follow‐up) and probably citalopram (at endpoint: six weeks follow‐up). There was some evidence that paroxetine is less well tolerated than agomelatine and St John's Wort, as more patients allocated to paroxetine experienced at least some side effects (though this finding for St John's Wort was only based on one study). In conclusion, some possibly meaningful differences between paroxetine and other antidepressants exist, but no definitive concluions can be drawn due to the limited number of studies per comparison. In addition, most of included studies were sponsored by the drug industry, which means they might potentially have overestimated the effect of paroxetine. Therefore, the results of this review should be interpreted with caution.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Purgato, M; Papola, D; Gastaldon, C; Trespidi, C; Magni, LR; Rizzo, C; Furukawa, TA; Watanabe, N; Cipriani, A; Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006531.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "93d09839-978e-4cbb-99f6-e084edb7ff2e", "pmid": "", "title": "Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users", "imported": false, "abstract": "Abstract - Background Prolonged treatment with benzodiazepines is common practice despite clinical recommendations of short‐term use. Benzodiazepines are used by approximately 4% of the general population, with increased prevalence in psychiatric populations and the elderly. After long‐term use it is often difficult to discontinue benzodiazepines due to psychological and physiological dependence. This review investigated if pharmacological interventions can facilitate benzodiazepine tapering. Objectives To assess the benefits and harms of pharmacological interventions to facilitate discontinuation of chronic benzodiazepine use. Search methods We searched the following electronic databases up to October 2017: Cochrane Drugs and Alcohol Group's Specialised Register of Trials, CENTRAL, PubMed, Embase, CINAHL, and ISI Web of Science. We also searched ClinicalTrials.gov, the WHO ICTRP, and ISRCTN registry, and checked the reference lists of included studies for further references to relevant randomised controlled trials. Selection criteria We included randomised controlled trials comparing pharmacological treatment versus placebo or no intervention or versus another pharmacological intervention in adults who had been treated with benzodiazepines for at least two months and/or fulfilled criteria for benzodiazepine dependence (any criteria). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 38 trials (involving 2543 participants), but we could only extract data from 35 trials with 2295 participants. Many different interventions were studied, and no single intervention was assessed in more than four trials. We extracted data on 18 different comparisons. The risk of bias was high in all trials but one. Trial Sequential Analysis showed imprecision for all comparisons. For benzodiazepine discontinuation, we found a potential benefit of valproate at end of intervention (1 study, 27 participants; risk ratio (RR) 2.55, 95% confidence interval (CI) 1.08 to 6.03; very low‐quality evidence) and of tricyclic antidepressants at longest follow‐up (1 study, 47 participants; RR 2.20, 95% CI 1.27 to 3.82; low‐quality evidence). We found potentially positive effects on benzodiazepine withdrawal symptoms of pregabalin (1 study, 106 participants; mean difference (MD) ‐3.10 points, 95% CI ‐3.51 to ‐2.69; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐1.00 points, 95% CI ‐1.13 to ‐0.87; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐3.57 points, 95% CI ‐5.34 to ‐1.80; very low‐quality evidence), tricyclic antidepressants (1 study, 38 participants; MD ‐19.78 points, 95% CI ‐20.25 to ‐19.31; very low‐quality evidence), and flumazenil (3 studies, 58 participants; standardised mean difference ‐0.95, 95% CI ‐1.71 to ‐0.19; very low‐quality evidence) at end of intervention. However, the positive effect of paroxetine on benzodiazepine withdrawal symptoms did not persist until longest follow‐up (1 study, 54 participants; MD ‐0.13 points, 95% CI ‐4.03 to 3.77; very low‐quality evidence). The following pharmacological interventions reduced symptoms of anxiety at end of intervention: carbamazepine (1 study, 36 participants; MD ‐6.00 points, 95% CI ‐9.58 to ‐2.42; very low‐quality evidence), pregabalin (1 study, 106 participants; MD ‐4.80 points, 95% CI ‐5.28 to ‐4.32; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐5.70 points, 95% CI ‐6.05 to ‐5.35; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐6.75 points, 95% CI ‐9.64 to ‐3.86; very low‐quality evidence), and flumazenil (1 study, 18 participants; MD ‐1.30 points, 95% CI ‐2.28 to ‐0.32; very low‐quality evidence). Two pharmacological treatments seemed to reduce the proportion of participants that relapsed to benzodiazepine use: valproate (1 study, 27 participants; RR 0.31, 95% CI 0.11 to 0.90; very low‐quality evidence) and cyamemazine (1 study, 124 participants; RR 0.33, 95% CI 0.14 to 0.78; very low‐quality evidence). Alpidem decreased the proportion of participants with benzodiazepine discontinuation (1 study, 25 participants; RR 0.41, 95% CI 0.17 to 0.99; number needed to treat for an additional harmful outcome (NNTH) 2.3 participants; low‐quality evidence) and increased the occurrence of withdrawal syndrome (1 study, 145 participants; RR 4.86, 95% CI 1.12 to 21.14; NNTH 5.9 participants; low‐quality evidence). Likewise, magnesium aspartate decreased the proportion of participants discontinuing benzodiazepines (1 study, 144 participants; RR 0.80, 95% CI 0.66 to 0.96; NNTH 5.8; very low‐quality evidence). Generally, adverse events were insufficiently reported. Specifically, one of the flumazenil trials was discontinued due to severe panic reactions. Authors' conclusions Given the low or very low quality of the evidence for the reported outcomes, and the small number of trials identified with a limited number of participants for each comparison, it is not possible to draw firm conclusions regarding pharmacological interventions to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Due to poor reporting, adverse events could not be reliably assessed across trials. More randomised controlled trials are required with less risk of systematic errors ('bias') and of random errors ('play of chance') and better and full reporting of patient‐centred and long‐term clinical outcomes. Such trials ought to be conducted independently of industry involvement. Plain language summary Medications for discontinuation of long‐term benzodiazepine use Background Benzodiazepines are widely prescribed for long‐term use despite recommendations of only short‐term use. It is often difficult to discontinue benzodiazepines after more than a few weeks of treatment due to the development of physical and psychological dependence. This review aimed to assess the effect and safety of medications to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Search date The evidence is current to October 2017. Study characteristics We identified 38 randomised controlled trials involving 2543 participants who had either been treated for more than two months with benzodiazepines, or who had been diagnosed with benzodiazepine dependence. We included studies irrespective of whether benzodiazepines were prescribed for anxiety, insomnia, or any other condition. The average age of participants was around 50 years, and the majority of participants were women in most studies. Twenty‐four trials were conducted in Europe; eight trials in the US or Canada; and six trials in Asia. The trials involved a wide range of medications to facilitate reduction or discontinuation of benzodiazepine use. Fourteen of the 38 included studies were partly funded by the drug manufacturer; nine studies were funded by government agencies; and 15 studies did not state the source of funding. The duration of the trials ranged between 1 and 24 weeks; the average trial duration was 9 weeks. Key results We extracted data on 18 different comparisons in a total of 2295 participants. We are uncertain whether valproate and tricyclic antidepressants increase the chance of discontinuing benzodiazepines, and whether benzodiazepine withdrawal symptoms are reduced by pregabalin, captodiame, paroxetine, tricyclic antidepressants, and flumazenil, as we assessed the quality of the evidence as very low. We are uncertain as to whether symptoms of anxiety after withdrawal of benzodiazepines are reduced by carbamazepine, pregabalin, captodiame, paroxetine, and flumazenil, as we assessed the quality of the evidence as very low. The effects of the evaluated medications were too uncertain to inform clinical practice due to risk of bias (systematic errors with overestimation of benefits and underestimation of harms) and risk of chance occurrence (random errors giving any result). Tolerability and safety were poorly reported across the included studies, making it impossible to assess the balance between possible benefits and adverse effects. Consequently, no conclusions can be drawn about the effectiveness of the interventions. Quality of the evidence The quality of the evidence was generally low or very low due to the small number of trials including a limited number of participants for each comparison; dissimilar results across studies; poor study design; and pronounced financial involvement of the pharmaceutical industry. Randomised controlled trials are therefore needed without risk of bias and random significant results involving long‐term assessments of participants conducted without involvement of industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Baandrup, L, Ebdrup, BH, Rasmussen, JØ, Lindschou, J, Gluud, C, Glenthøj, BY", "articleTypes": [], "doi": "10.1002/14651858.CD011481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.809Z" }, { "id": "93df7f5d-4bf9-4d50-83b1-8724075ba6d6", "pmid": "", "title": "Ipilimumab or FOLFOX in Combination With Nivolumab and Trastuzumab in Previously Untreated HER2 Positive Locally Advanced or Metastatic EsophagoGastric Adenocarcinoma", "imported": false, "abstract": "The INTEGA study assesses therapy Options for advanced or metastatic esophagogastric Adenocarcinoma in patients overexpressing human epidermal receptor type 2 (HER2 positive patients). Current treatment options in this situation include chemotherapy based palliative treatment in combination withTrastuzumab.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.266Z" }, { "id": "93e1ccc4-9850-411d-8498-fbfa9dfa6b7c", "pmid": "", "title": "Antibiotics versus placebo for acute bacterial conjunctivitis", "imported": false, "abstract": "Abstract - Background Acute bacterial conjunctivitis is an infection of the conjunctiva and is one of the most common ocular disorders in primary care. Antibiotics are generally prescribed on the basis that they may speed recovery, reduce persistence, and prevent keratitis. However, many cases of acute bacterial conjunctivitis are self‐limited, resolving without antibiotic therapy. This Cochrane Review was first published in The Cochrane Library in 1999, then updated in 2006, 2012, and 2022. Objectives To assess the benefits and side effects of antibiotic therapy in the management of acute bacterial conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2022, Issue 5), MEDLINE (January 1950 to May 2022), Embase (January 1980 to May 2022), the meta Register of Controlled Trials ( m RCT) ( www.controlled-trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ), and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases in May 2022. Selection criteria We included randomized controlled trials (RCTs) in which any form of antibiotic treatment, with or without steroid, had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical and systemic antibiotic treatments. Data collection and analysis Two authors independently reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies and determined the included RCTs, which were further assessed for risk of bias using Cochrane methodology. We performed data extraction in a standardized manner and conducted random‐effects meta‐analyses using RevMan Web. Main results We included 21 eligible RCTs, 10 of which were newly identified in this update. A total of 8805 participants were randomized. All treatments were topical in the form of drops or ointment. The trials were heterogeneous in terms of their eligibility criteria, the nature of the intervention (antibiotic drug class, which included fluoroquinolones [FQs] and non‐FQs; dosage frequency; duration of treatment), the outcomes assessed and the time points of assessment. We judged one trial to be of high risk of bias, four as low risk of bias, and the others as raising some concerns. Based on intention‐to‐treat (ITT) population, antibiotics likely improved clinical cure (resolution of clinical symptoms or signs) by 26% (RR 1.26, 95% CI 1.09 to 1.46; 5 trials, 1474 participants; moderate certainty) as compared with placebo. Subgroup analysis showed no differences by antibiotic class (P = 0.67) or treatment duration (P = 0.60). In the placebo group, 55.5% (408/735) of participants had spontaneous clinical resolution by days 4 to 9 versus 68.2% (504/739) of participants treated with an antibiotic. Based on modified ITT population, in which participants were analyzed after randomization on the basis of positive microbiological culture, antibiotics likely increased microbiological cure (RR 1.53, 95% CI 1.34 to 1.74; 10 trials, 2827 participants) compared with placebo at the end of therapy; there were no subgroup differences by drug class (P = 0.60). No study evaluated the cost‐effectiveness of antibiotic treatment. Patients receiving antibiotics had a lower risk of treatment incompletion than those in the placebo group (RR 0.64, 95% CI 0.52 to 0.78; 13 trials, 5573 participants; moderate certainty) and were 27% less likely to have persistent clinical infection (RR 0.73, 95% CI 0.65 to 0.81; 19 trials, 5280 participants; moderate certainty). There was no evidence of serious systemic side effects reported in either the antibiotic or placebo group (very low certainty). When compared with placebo, FQs (RR 0.70, 95% CI 0.54 to 0.90) but not non‐FQs (RR 4.05, 95% CI 1.36 to 12.00) may result in fewer participants with ocular side effects. However, the estimated effects were of very low certainty. Authors' conclusions The findings of this update suggest that the use of topical antibiotics is associated with a modestly improved chance of resolution in comparison to the use of placebo. Since no evidence of serious side effects was reported, use of antibiotics may therefore be considered to achieve better clinical and microbiologic efficacy than placebo. Increasing the proportion of participants with clinical cure or increasing the speed of recovery or both are important for individual return to work or school, allowing people to regain quality of life. Future studies may examine antiseptic treatments with topical antibiotics for reasons of cost and growing antibiotic resistance. Plain language summary What are the benefits and harms of antibiotics for acute bacterial conjunctivitis? Key messages Topical antibiotics may improve signs and symptoms as well as bacterial clearance in participants with acute bacterial conjunctivitis. However, some antibiotics can cause unwanted effects on the eyes or eyelids; no evidence suggests that antibiotics cause unwanted effects in other parts of the body. What is acute bacterial conjunctivitis? Acute bacterial conjunctivitis is a condition in which the thin layer over the white areas and the inside lining of the eyelids of one or both eyes becomes red and inflamed from a bacterial infection. Acute bacterial conjunctivitis is usually contagious and hence children and working adults are advised to avoid going to school or work when affected. Fortunately, it resolves spontaneously in most cases. How is acute bacterial conjunctivitis treated? People with acute bacterial conjunctivitis are often given treatment at the site of the infection, usually as antibiotic eye drops or ointment, to speed recovery. However, the benefits of antibiotics have been questioned when considering they can cause irritation or allergic reaction in and around the eyes or surrounding skin. What did we want to find out? We examined whether antibiotics alone or in combination with steroid, can improve signs and symptoms of conjunctivitis or help clear the associated bacteria. We also evaluated whether antibiotics would result in undesirable effects on the eyes. What did we do? We performed a systematic review by searching for studies that compared antibiotics in eyedrop, ointment, or tablet form with inactive controls. We summarized these study findings and reported the results together with our level of confidence in them based on how studies were conducted. What did we find? We found that antibiotics likely increase clinical cure and microbiological cure after a course of treatment in comparison with placebo. Antibiotic use also is associated with fewer participants stopping their treatment earlier than they are supposed to. However, for some individuals, non‐fluroquinolone but not fluoroquinolone antibiotics, may result in more unwanted effects on the eyes or eyelids than placebo though we were very uncertain about the relevant evidence. There was no evidence that antibiotics were associated with systemic side effects such as headache or altered sense of smell. What are the limitations of the evidence? The current update focused on adults and children aged one month or older. Therefore, the evidence does not pertain to antibiotic treatment for neonatal conjunctivitis in neonates younger than one month old. We did not find studies that compared effects of the same antibiotics used in short versus long duration. Therefore, the current review was unable to suggest for or against the prescription duration for acute bacterial conjunctivitis. How up‐to‐date is this evidence? The evidence is up‐to‐date as of April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Chen, Y-Y; Liu, A-HS; Nurmatov, U; van Schayck, OCP; Kuo, IC", "articleTypes": [], "doi": "10.1002/14651858.CD001211.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "93e7a7ac-9af0-4a40-b1f0-a6aca2af45e0", "pmid": "", "title": "Treatment for recurrent vulvovaginal candidiasis (thrush)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Cooke, G, Watson, C, Deckx, L, Pirotta, M, Smith, J, van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009151.pub2 AB - Abstract - Background Recurrent vulvovaginal candidiasis (RVVC) affects up to 5% of women. No comprehensive systematic review of treatments for RVVC has been published. Objectives The primary objective was to assess the effectiveness and safety of pharmacological and non‐pharmacological treatments for RVVC. The secondary objective was to assess patient preference of treatment options. Search methods We conducted electronic searches of bibliographic databases, including CENTRAL, MEDLINE, Embase, and CINAHL (search date 6 October 2021). We also handsearched reference lists of identified trials and contacted authors of identified trials, experts in RVVC, and manufacturers of products for vulvovaginal candidiasis. Selection criteria We considered all published and unpublished randomised controlled trials evaluating RVVC treatments for at least six months, in women with four or more symptomatic episodes of vulvovaginal candidiasis in the past year. We excluded women with immunosuppressive disorders or taking immunosuppressant medication. We included women with diabetes mellitus and pregnant women. Diagnosis of RVVC must have been confirmed by presence of symptoms and a positive culture and/or microscopy. We included all drug and non‐drug therapies and partner treatment, assessing the following primary outcomes: • number of clinical recurrences per participant per year (recurrence defined as clinical signs and positive culture/microscopy);
• proportion of participants with at least one clinical recurrence during the treatment and follow‐up period; and
• adverse events. Data collection and analysis Two authors independently reviewed titles and abstracts to identify eligible trials. Duplicate data extraction was completed independently by two authors. We assessed risk of bias as described in the Cochrane Handbook for Systematic Reviews of Interventions . We used the fixed‐effects model for pooling and expressed the results as risk ratio (RR) with 95% confidence intervals (CI). Where important statistical heterogeneity was present we either did not pool data (I 2 > 70%) or used a random‐effects model (I 2 40‐70%). We used the GRADE tool to assess overall certainty of the evidence for the pooled primary outcomes. Main results Studies: Twenty‐three studies involving 2212 women aged 17 to 67 years met the inclusion criteria. Most studies excluded pregnant women and women with diabetes or immunosuppression. The predominant species found on culture at study entry was Candida albicans . Overall, the included studies were small (<100 participants). Six studies compared antifungal treatment with placebo (607 participants); four studies compared oral versus topical antifungals (543 participants); one study compared different oral antifungals (45 participants); two studies compared different dosing regimens for antifungals (100 participants); one study compared two different dosing regimens of the same topical agent (23 participants); one study compared short versus longer treatment duration (26 participants); two studies assessed the effect of partner treatment (98 participants); one study compared a complementary treatment (Lactobacillus vaginal tablets and probiotic oral tablets) with placebo (34 participants); three studies compared complementary medicine with antifungals (354 participants); two studies compared 'dermasilk' briefs with cotton briefs (130 participants); one study examined Lactobacillus vaccination versus heliotherapy versus ciclopyroxolamine (90 participants); one study compared CAM treatments to an antifungal treatment combined with CAM treatments (68 participants). We did not find any studies comparing different topical antifungals. Nine studies reported industry funding, three were funded by an independent source and eleven did not report their funding source. Risk of bias: Overall, the risk of bias was high or unclear due to insufficient blinding of allocation and participants and poor reporting. Primary outcomes: Meta‐analyses comparing drug treatments (oral and topical) with placebo or no treatment showed there may be a clinically relevant reduction in clinical recurrence at 6 months (RR 0.36, 95% CI 0.21 to 0.63; number needed to treat for an additional beneficial outcome (NNTB) = 2; participants = 607; studies = 6; I² = 82%; low‐certainty evidence) and 12 months (RR 0.80, 95% CI 0.72 to 0.89; NNTB = 6; participants = 585; studies = 6; I² = 21%; low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. We are very uncertain whether oral drug treatment compared to topical treatment increases the risk of clinical recurrence at 6 months (RR 1.66, 95% CI 0.83 to 3.31; participants = 206; studies = 3; I² = 0%; very low‐certainty evidence) and reduces the risk of clinical recurrence at 12 months (RR 0.95, 95% CI 0.71 to 1.27; participants = 206; studies = 3; I² = 10%; very low‐certainty evidence). No study reported on the number of clinical recurrences per participant per year. Adverse events were scarce across both treatment and control groups in both comparisons. The reporting of adverse events varied amongst studies, was generally of very low quality and could not be pooled. Overall the adverse event rate was low for both placebo and treatment arms and ranged from less than 5% to no side effects or complications. Authors' conclusions In women with RVVC, treatment with oral or topical antifungals may reduce symptomatic clinical recurrences when compared to placebo or no treatment. We were unable to find clear differences between different treatment options (e.g. oral versus topical treatment, different doses and durations). These findings are not applicable to pregnant or immunocompromised women and women with diabetes as the studies did not include or report on them. More research is needed to determine the optimal medication, dose and frequency. Plain language summary The effectiveness and safety of treatments for recurrent vulvovaginal candidiasis (thrush) Review question Cochrane authors set out to investigate the effectiveness and safety of drug treatments or non‐drug treatments (such as complementary and alternative medicines) for women with recurrent vulvovaginal candidiasis (thrush). Background Thrush of the vaginal/vulvar area is caused by Candida , a form of yeast that is commonly found in the vagina as part of normal flora without causing symptoms. For unknown reasons, Candida can start growing and cause symptoms of vulvovaginal candidiasis (commonly named thrush). Symptoms of vulvovaginal thrush include itching, swelling, and irritation of the vaginal and vulval areas. It is estimated that uncomplicated vulvovaginal thrush affects up to 75% of women at some time during their reproductive years. Recurrent vulvovaginal candidiasis (RVVC) occurs when a woman has four or more fungal infections during a 12‐month period. Up to 5% of women suffer from RVVC. Some doctors advise taking antifungals as a prevention, but there are no clear evidence‐based guidelines. Study characteristics We identified 23 studies involving 2212 participants between 17 and 67 years old with a diagnosis of RVVC confirmed by a positive test. The studies compared a range of antifungal medicines (taken by mouth or inserted into the vagina), and some complementary or alternative treatments (such as Lactobacillus vaccines or probiotics and special underwear). The studies reported the effects on recurrence of thrush after 6 and 12 months. Only one study reported the number of clinical recurrences at 12 months. Nine studies reported industry funding, three were funded by an independent source and nine studies did not report their funding source. The evidence is current to October 2021. Key results Six studies (607 participants) compared antifungal medication with placebo or no treatment. Based on low certainty evidence antifungal treatments may give a clinically relevant reduction in clinical recurrence at 6 and 12 months. We are uncertain if oral treatments are better than topical treatments (very low certainty evidence for no difference). Adverse effects of taking antifungal medication to prevent recurrence of thrush were not common. Studies reported on adverse effects differently, making comparisons difficult. More research is needed to determine the optimal medication, dose and frequency. We were unable to determine the effects in women who are pregnant or have diabetes. Certainty of the evidence Our confidence in the evidence was low to very low due to serious concerns about risk of bias, unclear reporting and the limited number of studies that could be combined. This means that new studies might change our confidence in the effects of treatments and our conclusions.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.780Z" }, { "id": "93efe24a-bcd3-44bb-841a-6737e4c8416e", "pmid": "", "title": "Corticosteroids for idiopathic pulmonary fibrosis", "imported": false, "abstract": "Abstract - Background Idiopathic pulmonary fibrosis (IPF) is a disease with significant morbidity and mortality. Patients short survival time, high mortality and generally rapid decline raise the importance of early treatment. Current guidelines suggest a combination of corticosteroids and immunosuppressants as \"gold standard\" for IPF treatment, although the evidence for this recommendation is weak. Based on animal models, it has been hypothesized a central role for aberrant wound healing following repeated epithelial lung injury, weakening the rationale for using corticosteroids in IPF, previously thought to be a chronic inflammatory disease. Objectives The aim of the review is to determine the efficacy of corticosteroids in the treatment of adults with familial and sporadic IPF. Search methods We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2008), MEDLINE (January 1966 to June 2008) and EMBASE (January 1985 to June 2008) and reference lists of articles. We searched reference lists of published articles to identify clinical trials. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) using corticosteroids alone for the treatment of adults with IPF. Data collection and analysis Abstracts of identified articles were retrieved and articles possibly fulfilling inclusion criteria were retrieved in full. Two reviewers would have independently assessed trial quality if there had been any included study. Main results Seventeen articles were selected as potentially eligible for meta‐analysis. After further analysis of full text papers, no RCTs or CCTs were identified as suitable and therefore no data was available for inclusion in any meta‐analysis. All studies were excluded due to inadequate methodologies. Authors' conclusions At present, there is no evidence for an effect of corticosteroid treatment in patients with IPF. On the other hand, other fibrotic lung diseases, such as non‐specific interstitial pneumonia (NSIP), are reported to show a better response to corticosteroids. Making a clear distinction between IPF and other entities grouped under the umbrella term interstitial lung disease is, therefore, essential as this may have therapeutic and prognostic implications. Plain language summary Currently there is no evidence to support the routine use of corticosteroids alone in the management of idiopathic pulmonary fibrosis. Idiopathic pulmonary fibrosis (IPF) is a chronic disorder of unknown cause that is progressive and leads to death. Existing evidence about the treatment of IPF is difficult to interpret because of evolving diagnostic criteria and classification schemes, grouping together diverse entities with markedly different natural histories and responses to therapy. Therefore, because the old studies did not include only IPF patients, their results cannot be extended to IPF as they are currently defined. In addition, methodologic problems mainly related to the lack of randomized placebo‐controlled treatment trials have made evidence‐based conclusions difficult. A systematic search for high quality placebo‐controlled randomised trials comparing corticosteroid treatment with placebo in subjects with a diagnosis of IPF was unable to identify any studies suitable for inclusion in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Richeldi, L, Davies, HRHR, Spagnolo, P, Luppi, F", "articleTypes": [], "doi": "10.1002/14651858.CD002880", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.776Z" }, { "id": "93fb60bf-27a9-4cef-a5f1-c5cc08e57ad0", "pmid": "", "title": "Sucrose and Non Nutritive Suck as Analgesia for Babies Undergoing Retinopathy of Prematurity Screening; a Randomised Placebo Controlled Trial", "imported": false, "abstract": "Retinopathy of Prematurity (ROP) screening is one of many potentially painful diagnostic and therapeutic procedures performed routinely on preterm infants in the Neonatal Intensive Care Unit. Therefore strategies for stress reduction and pain management are essential to promote growth and development and minimize long-term sequelae. Procedural analgesia should include concepts of developmental care, non nutritive suck (NNS), pharmacological and non-pharmacological agents. Sucrose is thought to stimulate the body's activation of lingual sweet taste receptors and release of endogenous opioids, when combined with NNS, non-opioid mechanisms are also activated. The administration of sucrose or the combination of sucrose and non-nutritive sucking is one of the most frequently studied non-pharmacological interventions for relief of pain in neonates and oral sucrose has been shown to be an effective and safe therapy for common neonatal procedures such as heal lance, blood-letting and venepuncture. There is conflicting evidence on the benefit of sucrose in ROP screening. Therefore the purpose of this study is to determine the efficacy of sucrose combined with NNS as a potential regime for reduction of pain associated with retinopathy of prematurity screening.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.154Z" }, { "id": "940378b1-bb9c-40b4-979b-cbbb3a4ce876", "pmid": "", "title": "Serenoa repens for the treatment of lower urinary tract symptoms due to benign prostatic enlargement", "imported": false, "abstract": "Abstract - Background Benign prostatic hyperplasia (BPH) is a non‐malignant enlargement of the prostate, which can lead to obstructive and irritative lower urinary tract symptoms (LUTS). The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS associated with BPH is common. The extract of the berry of the American saw palmetto or dwarf palm plant, Serenoa repens (SR), which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of BPH. Objectives To assess the effects of Serenoa repens in the treatment of men with LUTS consistent with BPH. Search methods We performed a comprehensive search of multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to 16 September 2022, with no restrictions on language or publication status. Selection criteria We included randomized controlled trials of participants with BPH who were treated with Serenoa repens or placebo/no treatment. Data collection and analysis Two review authors independently assessed studies for inclusion at each stage and undertook data extraction and risk of bias assessment and GRADE assessment of the certainty of the evidence. We considered review outcomes measured up to 12 months after randomization as short term, and beyond 12 months as long term. Our main outcomes included urologic symptom scores, quality of life, and adverse events. Main results For this update, we narrowed the review question to only comparisons with placebo. We included 27 studies (of which 9 were new) involving a total of 4656 participants, 19 studies comparing Serenoa repens with placebo, and 8 studies comparing Serenoa repens in combination with other phytotherapeutic agents versus placebo. Most studies included men aged > 50 (mean age range 52 to 68) with moderate urologic symptoms (International Prostate Symptom Score [IPSS] range 8 to 19). Ten studies were funded by the pharmaceutical industry; two studies were funded by government agencies; and the remaining studies did not specify funding sources. Serenoa repens versus placebo or no intervention Results for this comparison are based on predefined sensitivity analyses limited to studies at low risk of bias. Serenoa repens results in little to no difference in urologic symptoms at short‐term follow‐up (3 to 6 months; IPSS score range 0 to 35, higher scores indicate worse symptoms; mean difference (MD) −0.90, 95% confidence interval (CI) −1.74 to −0.07; I 2 = 68%; 9 studies, 1681 participants; high‐certainty evidence). Serenoa repens results in little to no difference in the quality of life at short‐term follow‐up (3 to 6 months; IPSS quality of life domain range 0 to 6, higher scores indicate worse quality of life; MD −0.20, 95% CI −0.40 to −0.00; I 2 = 39%; 5 studies, 1001 participants; high‐certainty evidence). Serenoa repens probably results in little to no difference in adverse events (1 to 17 months; risk ratio (RR) 1.01, 95% CI 0.77 to 1.31; I 2 = 18%; 12 studies, 2399 participants; moderate‐certainty evidence). Based on 164 cases per 1000 men in the placebo group, this corresponds to 2 more (38 fewer to 51 more) per 1000 men in the Serenoa repens group. Serenoa repens results in little to no difference in urologic symptoms at long‐term follow‐up (12 to 17 months, IPSS score, MD 0.07, 95% CI −0.75 to 0.88; I 2 = 34%; 3 studies, 898 participants; high‐certainty evidence). Serenoa repens results in little to no difference in quality of life at long‐term follow‐up (12 to 17 months, IPSS quality of life, MD −0.11, 95% CI −0.41 to 0.19; I 2 = 65%; 3 studies, 882 participants; high‐certainty evidence). There were no data on long‐term adverse events for this comparison. Serenoa repens in combination with other phytotherapy versus placebo or no intervention Different phytotherapeutic agents that include Serenoa repens may result in little to no difference in urologic symptoms compared to placebo at short‐term follow‐up (12 to 24 weeks, IPSS score, MD −2.41, 95% CI −4.54 to −0.29; I 2 = 67%; 4 studies, 460 participants; low‐certainty evidence). We are very uncertain about the effects of these agents on quality of life (very low‐certainty evidence). These agents may result in little to no difference in the occurrence of adverse events; however, the CIs included substantial benefits and harms (12 to 48 weeks, RR 0.91, 95% CI 0.58 to 1.41; I 2 = 0%; 4 studies, 481 participants; low‐certainty evidence). Based on 132 cases per 1000 men in the placebo group, this corresponds to 12 fewer (55 fewer to 54 more) per 1000 men in the combined phytotherapeutic agents with Serenoa repens group. Authors' conclusions Serenoa repens alone provides little to no benefits for men with lower urinary tract symptoms due to benign prostatic enlargement. There is more uncertainty about the role of Serenoa repens in combination with other phytotherapeutic agents. Plain language summary Serenoa repens for benign prostatic hyperplasia Review question Does Serenoa repens alone or in combination with other phytotherapeutic agents improve symptoms in men with benign prostatic enlargement? Background An enlarged prostate may cause bothersome urinary tract symptoms, such as having to urinate often during the day or night, having a weak stream, and the feeling of not completely emptying the bladder. Besides other common drug interventions, using plants and herbs (phytotherapy) is common and has been growing steadily in most Western countries. The extract of the berry of the American saw palmetto, or dwarf palm plant, Serenoa repens , which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of this condition. Study characteristics We found 27 studies with 4656 men comparing Serenoa repens alone or in combination with other herbal products to a placebo (participants are made to believe they received treatment when in fact they did not). Most studies included men over 50 with moderate symptoms. Ten studies were funded by pharmaceutical organizations; two studies received government funding; and the remaining studies did not specify funding sources. Key results Based on the most trustworthy studies, Serenoa repens alone results in little to no difference in urinary tract symptoms or quality of life compared to placebo at three to six months. This treatment is also likely not associated with adverse events. Results were similar at 12 to 17 months. Serenoa repens in combination with other herbal products may result in little to no difference in urinary tract symptoms, but there is more uncertainty about effects on quality of life and adverse events. The findings of this review are current to 16 September 2022. Certainty of the evidence The certainty of the evidence is primarily high or moderate for Serenoa repens alone, but low for Serenoa repens in combination with other agents, meaning our confidence in the results is high, moderate, or low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Franco, JVA, Trivisonno, L, Sgarbossa, NJ, Alvez, GA, Fieiras, C, Escobar Liquitay, CM, Jung, JH", "articleTypes": [], "doi": "10.1002/14651858.CD001423.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.724Z" }, { "id": "9407fcce-109e-4158-80d4-523b349e0544", "pmid": "", "title": "Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Subcutaneous administration may be preferable to oral for individuals experiencing nausea and/or vomiting Objectives To determine the efficacy and tolerability of subcutaneous sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using subcutaneous sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Thirty‐five studies (9365 participants) compared subcutaneous sumatriptan with placebo or an active comparator. Most of the data were for the 6 mg dose. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 6 mg versus placebo the NNTs were 2.9, 2.3, 2.2, and 2.1 for pain‐free at one and two hours, and headache relief at one and two hours, respectively, and 6.1 for sustained pain‐free at 24 hours. Results for the 4 mg and 8 mg doses were similar to the 6 mg dose, with 6 mg significantly better than 4 mg only for pain‐free at one hour, and 8 mg significantly better than 6 mg only for headache relief at one hour. There was no evidence of increased migraine relief if a second dose of sumatriptan 6 mg was given after an inadequate response to the first. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Sumatriptan was compared directly with a number of active treatments, including other triptans, acetylsalicylic acid plus metoclopramide, and dihydroergotamine, but there were insufficient data for any pooled analyses. Authors' conclusions Subcutaneous sumatriptan is effective as an abortive treatment for acute migraine attacks, quickly relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a subcutaneous injection, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, or needing fast relief. This review found that a single subcutaneous dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in almost 6 in 10 people (59%) taking sumatriptan 6 mg, compared with about 1 in 7 (15%) taking placebo, and reduced from moderate or severe to no worse than mild pain by two hours in almost 8 in 10 people (79%) taking sumatriptan compared with about 3 in 10 (31%) taking placebo. Subcutaneous sumatriptan was fast‐acting, and the majority of people experiencing pain relief had done so by one hour. About 3 in 10 (31%) people had freedom from pain at two hours which was sustained during the 24 hours postdose without the use of rescue medication, compared with about 1 in 7 (15%) with placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events, most of which were of short duration and mild or moderate in severity, were more frequent with sumatriptan than with placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009665", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.738Z" }, { "id": "940bbb3d-916e-4b03-b483-8970aa851fd7", "pmid": "", "title": "Herbal medicines for fatty liver diseases", "imported": false, "abstract": "Abstract - Background Fatty liver disease is potentially a reversible condition that may lead to end‐stage liver disease. Since herbal medicines such as Crataegus pinnatifida and Salvia miltiorrhiza have increasingly been used in the management of fatty liver disease, a systematic review on herbal medicine for fatty liver disease is needed. Objectives To assess the beneficial and harmful effects of herbal medicines for people with alcoholic or non‐alcoholic fatty liver disease. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2012), MEDLINE, EMBASE, and Science Citation Index Expanded to 1 March 2012. We also searched the Chinese BioMedical Database, Traditional Chinese Medical Literature Analysis and Retrieval System, China National Knowledge Infrastructure, Chinese VIP Information, Chinese Academic Conference Papers Database and Chinese Dissertation Database, and the Allied and Complementary Medicine Database to 2 March 2012. Selection criteria We included randomised clinical trials comparing herbal medicines with placebo, no treatment, a pharmacological intervention, or a non‐pharmacological intervention such as diet or lifestyle, or Western interventions in participants with fatty liver disease. Data collection and analysis Two review authors extracted data independently. We used the 'risk of bias' tool to assess the risk of bias of the included trials. We assessed the following domains: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. We presented the effects estimates as risk ratios (RR) with 95% confidence intervals (CI) or as mean differences (MD) with 95% CI, depending on the variables of the outcome measures. Main results We included 77 randomised clinical trials, which included 6753 participants with fatty liver disease. The risks of bias (overestimation of benefits and underestimation of harms) was high in all trials. The mean sample size was 88 participants (ranging from 40 to 200 participants) per trial. Seventy‐five different herbal medicine products were tested. Herbal medicines tested in the randomised trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca) , proprietary herbal medicines commercially available, and combination formulas prescribed by practitioners. The most commonly used herbs were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia, Astragalus membranaceous, and Rheum palmatum . None of the trials reported death, hepatic‐related morbidity, quality of life, or costs. A large number of trials reported positive effects on putative surrogate outcomes such as serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases, ultrasound, and computed tomography scan. Twenty‐seven trials reported adverse effects and found no significant difference between herbal medicines versus control. However, the risk of bias of the included trials was high. The outcomes were ultrasound findings in 22 trials, liver computed tomography findings in eight trials, aspartate aminotransferase levels in 64 trials, alanine aminotransferase activity in 77 trials, and glutamyltransferase activities in 44 trials. Six herbal medicines showed statistically significant beneficial effects on ultrasound, four on liver computed tomography, 42 on aspartate aminotransferase activity, 49 on alanine aminotransferase activity, three on alkaline phosphatases activity, and 32 on glutamyltransferase activity compared with control interventions. Authors' conclusions Some herbal medicines seemed to have positive effects on aspartate aminotransferase, alanine aminotransferase, ultrasound, and computed tomography. We found no significant difference on adverse effects between herbal medicine and control groups. The findings are not conclusive due to the high risk of bias of the included trials and the limited number of trials testing individual herbal medicines. Accordingly, there is also high risk of random errors. Plain language summary Herbal medicines for fatty liver diseases Fatty liver disease is a potentially reversible illness where fat builds up within the cells of the liver. It may lead to the liver no longer being able to function properly; this is called end‐stage liver disease. This systematic review evaluated the effects and safety of herbal medicines (single herbs, branded herbal medicines, and prescribed formulas) for treating fatty liver disease. We included 77 randomised clinical trials in this review, which tested 75 herbal medicines. All trials had high risk of systematic errors (ie, bias or risk of overestimation of benefits and overestimation of harms) as well as high risks of random errors (ie, play of chance) due to the small number of people in the trials. Herbal medicines tested in the randomised clinical trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca ), commercially available branded herbal medicines, and combination formulas prescribed by practitioners. Herbs most commonly included as an ingredient in different products were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia , Astragalus membranaceous , and Rheum palmatum . We could not combine the results of the trials due to the range of different herbs used. We could not reach any conclusions about the use of herbal medicines for people with fatty liver disease as none of the trials reported results on death, liver‐related illnesses, quality of life, or costs. A number of trials showed positive effects of herbal medicines compared with control interventions on enzyme activity (enzymes are proteins that cause chemical reactions in the body; eg, serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases), ultrasound scan findings, and computed tomography scan findings. No serious adverse effects were reported for herbal medicines. However, the methodology of the trials had high risk of systematic errors (bias). Furthermore, the individual herbs were seldomly retested, and all trials had relatively low numbers of people, which increases the risk of random errors (play of chance). Therefore, the findings are inconclusive, and rigorously conducted randomised clinical trials are required to establish the benefits and harms of herbal medicines for fatty liver disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Liu, ZL, Xie, LZ, Zhu, J, Li, GQ, Grant, SJ, Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009059.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.773Z" }, { "id": "940e8b19-702a-4e7d-844d-567846a76783", "pmid": "", "title": "Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Rationale Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Alendronate belongs to the bisphosphonate class of drugs, which inhibit bone resorption by interfering with the activity of osteoclasts (bone cells that break down bone tissue). This is an update of a Cochrane review first published in 2008. Objectives To assess the benefits and harms of alendronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched Evidence‐Based Medicine Reviews (which includes CENTRAL), MEDLINE, Embase, two trial registers, drug approval agency websites, and the bibliographies of relevant systematic reviews to identify the studies included in this review. The latest search date was 01 February 2023. We imposed no restrictions on language, date, form of publication, or reported outcomes. Eligibility criteria We included only randomized controlled trials that assessed the effects of alendronate on postmenopausal women. Targeted participants must have received at least one year of alendronate. We classified a study as secondary prevention if its population met one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (‐2.5 or lower), and 75 years old or older. If a study population met none of those criteria, we classified it as a primary prevention study. Outcomes Our major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. Risk of bias We used the Cochrane risk of bias 1 tool. Synthesis methods We used standard methodological procedures expected by Cochrane. Based on the previous review experience, in which the clinical and methodological characteristics in the primary and secondary prevention studies were homogeneous, we used a fixed‐effect model for meta‐analysis and estimated effects using the risk ratio (RR) for dichotomous outcomes. Our base case analyses included all eligible placebo‐controlled studies with usable data. We selected the data available for the longest treatment period. We consider a relative change exceeding 15% as clinically important. Included studies We included 119 studies, of which 102 studies provided data for quantitative synthesis. Of these, we classified 34 studies (15,188 participants) as primary prevention and 68 studies (29,577 participants) as secondary prevention. We had concerns about risks of bias in most studies. Selection bias was the most frequently overlooked domain, with only 20 studies (19%) describing appropriate methods for both sequence generation and allocation concealment. Eight studies (8%) were at low risk of bias in all seven domains. Synthesis of results The base case analyses included 16 primary prevention studies (one to five years in length; 10,057 women) and 20 secondary prevention studies (one to three years in length; 7375 women) which compared alendronate 10 mg/day (or 70 mg/week) to placebo, no treatment, or both. Indirectness, imprecision, and risk of bias emerged as the main factors contributing to the downgrading of the certainty of the evidence. For primary prevention, alendronate may lead to a clinically important reduction in clinical vertebral fractures (16/1190 in the alendronate group versus 24/926 in the placebo group; RR 0.45, 95% confidence interval [CI] 0.25 to 0.84; absolute risk reduction [ARR] 1.4% fewer, 95% CI 1.9% fewer to 0.4% fewer; low‐certainty evidence) and non‐vertebral fractures (RR 0.83, 95% CI 0.72 to 0.97; ARR 1.6% fewer, 95% CI 2.6% fewer to 0.3% fewer; low‐certainty evidence). However, clinically important differences were not observed for the following outcomes: hip fractures (RR 0.76, 95% CI 0.43 to 1.32; ARR 0.2% fewer, 95% CI 0.4% fewer to 0.2% more; low‐certainty evidence); wrist fractures (RR 1.12, 95% CI 0.84 to 1.49; ARR 0.3% more, 95% CI 0.4% fewer to 1.1% more; low‐certainty evidence); withdrawals due to adverse events (RR 1.03, 95% CI 0.89 to 1.18; ARR 0.2% more, 95% CI 0.9% fewer to 1.5% more; low‐certainty evidence); and serious adverse events (RR 1.08, 95% CI 0.82 to 1.43; ARR 0.5% more, 95% CI 1.2% fewer to 2.8% more; low‐certainty evidence). For secondary prevention, alendronate probably results in a clinically important reduction in clinical vertebral fractures (24/1114 in the alendronate group versus 51/1055 in the placebo group; RR 0.45, 95% CI 0.28 to 0.73; ARR 2.7% fewer, 95% CI 3.5% fewer to 1.3% fewer; moderate‐certainty evidence). It may lead to a clinically important reduction in non‐vertebral fractures (RR 0.80, 95% CI 0.64 to 0.99; ARR 2.8% fewer, 95% CI 5.1% fewer to 0.1% fewer; low‐certainty evidence); hip fractures (RR 0.49, 95% CI 0.25 to 0.96; ARR 1.0% fewer, 95% CI 1.5% fewer to 0.1% fewer; low‐certainty evidence); wrist fractures (RR 0.54, 95% CI 0.33 to 0.90; ARR 1.8% fewer, 95% CI 2.6% fewer to 0.4% fewer; low‐certainty evidence); and serious adverse events (RR 0.75, 95% CI 0.59 to 0.96; ARR 3.5% fewer, 95% CI 5.8% fewer to 0.6% fewer; low‐certainty evidence). However, the effects of alendronate for withdrawals due to adverse events are uncertain (RR 0.95, 95% CI 0.78 to 1.16; ARR 0.4% fewer, 95% CI 1.7% fewer to 1.3% more; very low‐certainty evidence). Furthermore, the updated evidence for the safety risks of alendronate suggests that, irrespective of participants' risk of fracture, alendronate may lead to little or no difference for gastrointestinal adverse events. Zero incidents of osteonecrosis of the jaw and atypical femoral fracture were observed. Authors' conclusions For primary prevention, compared to placebo, alendronate 10 mg/day may reduce clinical vertebral and non‐vertebral fractures, but it might make little or no difference to hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. For secondary prevention, alendronate probably reduces clinical vertebral fractures, and may reduce non‐vertebral, hip, and wrist fractures, and serious adverse events, compared to placebo. The evidence is very uncertain about the effect of alendronate on withdrawals due to adverse events. Funding This Cochrane review had no dedicated funding. Registration This review is an update of the previous review (DOI: 10.1002/14651858.CD001155). Plain language summary Does alendronate help prevent fractures caused by osteoporosis in postmenopausal women? Key messages • Alendronate used for up to five years may prevent spinal fractures in women who are at lower risk for fractures, or in those who have not yet had a fracture of the spine. • Alendronate used for up to three years in women diagnosed with osteoporosis, with low bone density, or who have already had a fracture of the spine, probably prevents fractures of the spine. What is osteoporosis? Osteoporosis is a disease which makes bones weak and fragile. Bone is living tissue that is constantly being broken down and replaced. In osteoporosis, old bone breaks down faster than new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones more likely to break even after a minor injury, such as a bump or fall. Women are more likely to get osteoporosis after menopause. What is alendronate? Alendronate is a bisphosphonate, a type of medicine which slows down the cells that break down the old bone. What did we want to find out? We aimed to find out if alendronate is better than placebo (an inactive or 'dummy' medicine) or other medicines in preventing or reducing fractures in postmenopausal women. What did we do? We searched for studies that compared alendronate with placebo or other anti‐osteoporotic medicines for osteoporosis in postmenopausal women. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 119 eligible studies. Of these, 102 studies provided usable data, and 40 studies compared alendronate to placebo (dummy pill). Key findings In women who are at a lower risk for fractures because they have bone density closer to normal, or they may not yet have a fracture in the bones of their spine, alendronate used for up to five years: may prevent clinical spinal fractures – that is, fractures indicated by clinical signs and symptoms, without radiographic evidence; may prevent fractures in bones other than the spine. However, specifically in hip and wrist fractures, alendronate may make no difference; may make no difference to the number of women who withdrew from the study due to adverse events – that is, unwanted, harmful events; may make no difference to the number of women experiencing serious adverse events. In women who are at a higher risk for fractures because they have already been diagnosed with osteoporosis, have low bone density, or have already had a spinal fracture, alendronate used for up to three years: probably prevents clinical spinal fractures; may prevent fractures in bones other than the spine; may prevent hip and wrist fractures; may reduce serious adverse events; We do not know if alendronate reduces withdrawals due to adverse events in this group of women. The best estimates for women at lower fracture risk taking alendronate or placebo are as follows. For clinical spinal fractures, evidence suggests that if 3 out of 100 women taking placebo experience a fracture, only 1 out of 100 women taking alendronate will. If 10 out of 100 women on placebo have a fracture in bones other than the spine, only 8 out of 100 on alendronate are likely to. For hip and wrist fractures, there may be no difference between the two groups in the number of women experiencing fractures. The best estimates for women at higher fracture risk taking alendronate or placebo are as follows. If 5 out of 100 women on placebo have a clinical spinal fracture, only 2 out of 100 women on alendronate are likely to. If 14 out of 100 women on placebo have a fracture in bones other than the spine, only 11 out of 100 on alendronate are likely to. If 2 out of 100 women on placebo have a hip fracture, only 1 out of 100 on alendronate are likely to. If 4 out of 100 women on placebo have a wrist fracture, only 2 out of 100 on alendronate are likely to. What are the limitations of the evidence? For most findings, our confidence in the evidence was low, because it is possible that the women in the studies, and the researchers assessing outcomes, were aware of which treatment the women received. Additionally, some of the evidence focused on specific alendronate doses, whereas the question we wanted to answer was broader. Finally, for some fracture outcomes, the evidence was based on few cases. How current is the evidence? The evidence is current to 1 February 2023. This is an update of a Cochrane review originally published in 2008.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Wells, GA, Hsieh, SC, Peterson, J, Zheng, C, Kelly, SE, Shea, B, Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD001155.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.819Z" }, { "id": "941b710b-dd67-4aa5-9586-d0d777257bcc", "pmid": "", "title": "Coblation versus other surgical techniques for tonsillectomy", "imported": false, "abstract": "Abstract - Background Tonsillectomy is a very common operation and is performed using various surgical methods. Coblation is a popular method because it purportedly causes less pain than other surgical methods. However, the superiority of coblation is unproven. Objectives To compare the effects of coblation tonsillectomy for chronic tonsillitis or tonsillar hypertrophy with other surgical techniques, both hot and cold, on intraoperative morbidity, postoperative morbidity and procedural cost. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2017, Issue 3); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 April 2017. Selection criteria Randomised controlled trials (RCTs) of children and adults undergoing tonsillectomy with coblation compared with any other surgical technique. This review is limited to trials of extracapsular (traditional) tonsillectomy and excludes trials of intracapsular tonsil removal (tonsillotomy). Data collection and analysis We used the standard Cochrane methods. Our primary outcomes were: patient‐reported pain using a validated pain scale at postoperative days 1, 3 and 7; intraoperative blood loss; primary postoperative bleeding (within 24 hours) and secondary postoperative bleeding (more than 24 hours after surgery). Secondary outcomes were: time until resumption of normal diet, time until resumption of normal activity, duration of surgery and adverse effects including blood transfusion and the need for reoperation. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 29 studies, with a total of 2561 participants. All studies had moderate or high risk of bias. Sixteen studies used an adequate randomisation technique, however the inability to mask the surgical teams and/or provide adequate methods to mitigate the risk of bias put nearly all studies at moderate or high risk of detection and measurement bias for intraoperative blood loss, and primary and secondary bleeding. In contrast most studies (20) were at low risk of bias for pain assessment. Most studies did not report data in a manner permitting meta‐analysis. Most studies did not clearly report the participant characteristics, surgical indications or whether patients underwent tonsillectomy or adenotonsillectomy. Most studies reported that tonsillitis (infection) and/or tonsillar hypertrophy (obstruction) were the indication for surgery. Seven studies included only adults, 16 studies included only children and six studies included both. Pain At postoperative day 1 there is very low quality evidence that patients in the coblation group had less pain, with a standardised mean difference (SMD) of ‐0.79 (95% confidence interval (CI) ‐1.38 to ‐0.19; 538 participants; six studies). This effect is reduced a SMD of ‐0.44 (95% CI ‐0.97 to 0.09; 401 participants; five studies; very low‐quality evidence ) at day 3, and at day 7 there is low quality evidence of little or no difference in pain (SMD ‐0.01, 95% CI ‐0.22 to 0.19; 420 participants; five studies). Although this suggests that pain may be slightly less in the coblation group between days 1 and 3, the clinical significance is unclear. Intraoperative blood loss Methodological differences between studies in the measurement of intraoperative blood loss precluded meta‐analysis. Primary and secondary bleeding The risk of primary bleeding was similar (risk ratio (RR) 0.99, 95% CI 0.48 to 2.05; 2055 participants; 25 studies; low‐quality evidence ). The risk of secondary bleeding was greater in the coblation group with a risk ratio of 1.36 (95% CI 0.95 to 1.95; 2118 participants; 25 studies; low‐quality evidence ). Using the median of the control group as the baseline risk, the absolute risk in the coblation group was 5% versus 3.6% in the control group. The difference of 1.3% has a 95% CI of 0.2% lower in the coblation group to 3.5% higher. Secondary outcomes Differences in study design and data reporting precluded the identification of differences in the time to resumption of normal diet or activity, or whether there was a difference in the duration of surgery. Although we could not feasibly compare the costs of equipment or operative facility, anaesthetic and surgical fees across different healthcare systems we used duration of surgery as a proxy for cost. Although this outcome was commonly reported in studies, it was not possible to pool the data to determine whether there was a difference. Adverse events other than bleeding were not well reported. It is unclear whether there is a difference in postoperative infections or the need for reoperation. Authors' conclusions The coblation technique may cause less pain on postoperative day 1, but the difference is small and may be clinically meaningless. By postoperative day 3, the difference decreases further and by postoperative day 7 there appears to be little or no difference. We found similar rates of primary bleeding but we cannot rule out a small increased risk of secondary bleeding with coblation. The evidence supporting these findings is of low or very low quality , i.e. there is a very high degree of uncertainty about the results. Moreover, for most outcomes data were only available from a few of the 29 included studies. The current evidence is of very low quality, therefore it is uncertain whether or not the coblation technique has any advantages over traditional tonsillectomy techniques. Despite the large number of studies, failure to use standardised or validated outcome measures precludes the ability to pool data across studies. Therefore, well‐conducted RCTs using consistent, validated outcome measures are needed to establish whether the coblation technique has a benefit over other methods. In the included studies we identified no clear difference in adverse events. However, given the rarity of these events, randomised trials lack the power to detect a difference. Data from large‐scale registries will provide a better estimate of any difference in these rare outcomes. Plain language summary Surgical removal of the tonsils (tonsillectomy) with coblation or another surgical method Review question This review compared the coblation method with other methods of tonsil removal to assess recovery following tonsillectomy or adenotonsillectomy. Background Surgical removal of the tonsils (tonsillectomy) is a very common operation. Patients may have pain for up to two weeks after surgery. Bleeding may occur either immediately after surgery ('primary bleeding' within 24 hours of surgery) or later ('secondary bleeding' more than 24 hours after surgery). There are many methods of tonsillectomy; the traditional method is with metal surgical instruments. Coblation is a new method where the surgeon uses an electrically powered handpiece that 'burns' tissues using low temperatures. Study characteristics This review included evidence available up to April 2017. We included 29 studies, with a total of 2561 participants. All studies had a moderate or high risk of bias. Seven studies included adults, 16 studies included children and six included both adults and children. Most studies measured pain using a patient‐reported scale (for example, asking people to rate their pain on a scale of 1 to 10). Key results The coblation technique may cause slightly less pain one day after surgery and three days after surgery, but it is unlikely that there is a difference in pain seven days after surgery. We are very uncertain whether the amount of pain reduction observed in days 1 to 3 after surgery would be important to patients. There is little or no difference in the risk of bleeding in the first day after surgery, but there may be a small increased risk of bleeding with coblation after the first day. For every 1000 patients having a tonsillectomy, 50 patients would have a bleed with coblation, compared to 36 with traditional surgical techniques. Quality of the evidence The evidence for the difference in pain is of low or very low quality and for the difference in bleeding after surgery it is of low quality . This means that we have little confidence in the results; the true effect may be very different ‐ we simply do not know at this stage.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Pynnonen, M, Brinkmeier, JV, Thorne, MC, Chong, LY, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.761Z" }, { "id": "9428a620-3b29-4502-9851-c3ac79ff8d78", "pmid": "", "title": "Corrector therapies (with or without potentiators) for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR variant F508del is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF)). The F508del variant lacks meaningful CFTR function ‐ faulty protein is degraded before reaching the cell membrane, where it needs to be to effect transepithelial salt transport. Corrective therapy could benefit many pwCF. This review evaluates single correctors (monotherapy) and any combination of correctors (most commonly lumacaftor, tezacaftor, elexacaftor, VX‐659, VX‐440 or VX‐152) and a potentiator (e.g. ivacaftor) (dual and triple therapies). Objectives To evaluate the effects of CFTR correctors (with or without potentiators) on clinically important benefits and harms in pwCF of any age with class II CFTR mutations (most commonly F508del). Search methods We searched the Cochrane CF Trials Register (28 November 2022), reference lists of relevant articles and online trials registries (3 December 2022). Selection criteria Randomised controlled trials (RCTs) (parallel design) comparing CFTR correctors to control in pwCF with class II mutations. Data collection and analysis Two authors independently extracted data, assessed risk of bias and judged evidence certainty (GRADE); we contacted investigators for additional data. Main results We included 34 RCTs (4781 participants), lasting between 1 day and 48 weeks; an extension of two lumacaftor‐ivacaftor studies provided additional 96‐week safety data (1029 participants). We assessed eight monotherapy RCTs (344 participants) (4PBA, CPX, lumacaftor, cavosonstat and FDL169), 16 dual‐therapy RCTs (2627 participants) (lumacaftor‐ivacaftor or tezacaftor‐ivacaftor) and 11 triple‐therapy RCTs (1804 participants) (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor). Participants in 21 RCTs had the genotype F508del/F508del, in seven RCTs they had F508del/minimal function (MF), in one RCT F508del/gating genotypes, in one RCT either F508del/F508del genotypes or F508del/residual function genotypes, in one RCT either F508del/gating or F508del/residual function genotypes, and in three RCTs either F508del/F508del genotypes or F508del/MF genotypes. Risk of bias judgements varied across different comparisons. Results from 16 RCTs may not be applicable to all pwCF due to age limits (e.g. adults only) or non‐standard designs (converting from monotherapy to combination therapy). Monotherapy Investigators reported no deaths or clinically relevant improvements in quality of life (QoL). There was insufficient evidence to determine effects on lung function. No placebo‐controlled monotherapy RCT demonstrated differences in mild, moderate or severe adverse effects (AEs); the clinical relevance of these events is difficult to assess due to their variety and few participants (all F508del/F508del). Dual therapy In a tezacaftor‐ivacaftor group there was one death (deemed unrelated to the study drug). QoL scores (respiratory domain) favoured both lumacaftor‐ivacaftor and tezacaftor‐ivacaftor therapy compared to placebo at all time points (moderate‐certainty evidence). At six months, relative change in forced expiratory volume in one second (FEV 1 ) % predicted improved with all dual combination therapies compared to placebo (high‐ to moderate‐certainty evidence). More pwCF reported early transient breathlessness with lumacaftor‐ivacaftor (odds ratio (OR) 2.05, 99% confidence interval (CI) 1.10 to 3.83; I 2 = 0%; 2 studies, 739 participants; high‐certainty evidence). Over 120 weeks (initial study period and follow‐up), systolic blood pressure rose by 5.1 mmHg and diastolic blood pressure by 4.1 mmHg with twice‐daily 400 mg lumacaftor‐ivacaftor (80 participants). The tezacaftor‐ivacaftor RCTs did not report these adverse effects. Pulmonary exacerbation rates decreased in pwCF receiving additional therapies to ivacaftor compared to placebo (all moderate‐certainty evidence): lumacaftor 600 mg (hazard ratio (HR) 0.70, 95% CI 0.57 to 0.87; I 2 = 0%; 2 studies, 739 participants); lumacaftor 400 mg (HR 0.61, 95% CI 0.49 to 0.76; I 2 = 0%; 2 studies, 740 participants); and tezacaftor (HR 0.64, 95% CI 0.46 to 0.89; 1 study, 506 participants). Triple therapy No study reported any deaths (high‐certainty evidence). All other evidence was low‐ to moderate‐certainty. QoL respiratory domain scores probably improved with triple therapy compared to control at six months (six studies). There was probably a greater relative and absolute change in FEV 1 % predicted with triple therapy (four studies each across all combinations). The absolute change in FEV 1 % predicted was probably greater for F508del/MF participants taking elexacaftor‐tezacaftor‐ivacaftor compared to placebo (mean difference 14.30, 95% CI 12.76 to 15.84; 1 study, 403 participants; moderate‐certainty evidence), with similar results for other drug combinations and genotypes. There was little or no difference in adverse events between triple therapy and control (10 studies). No study reported time to next pulmonary exacerbation, but fewer F508del/F508del participants experienced a pulmonary exacerbation with elexacaftor‐tezacaftor‐ivacaftor at four weeks (OR 0.17, 99% CI 0.06 to 0.45; 1 study, 175 participants) and 24 weeks (OR 0.29, 95% CI 0.14 to 0.60; 1 study, 405 participants); similar results were seen across other triple therapy and genotype combinations. Authors' conclusions There is insufficient evidence of clinically important effects from corrector monotherapy in pwCF with F508del/F508del. Additional data in this review reduced the evidence for efficacy of dual therapy; these agents can no longer be considered as standard therapy. Their use may be appropriate in exceptional circumstances (e.g. if triple therapy is not tolerated or due to age). Both dual therapies (lumacaftor‐ivacaftor, tezacaftor‐ivacaftor) result in similar small improvements in QoL and respiratory function with lower pulmonary exacerbation rates. While the effect sizes for QoL and FEV 1 still favour treatment, they have reduced compared to our previous findings. Lumacaftor‐ivacaftor was associated with an increase in early transient shortness of breath and longer‐term increases in blood pressure (not observed for tezacaftor‐ivacaftor). Tezacaftor‐ivacaftor has a better safety profile, although data are lacking in children under 12 years. In this population, lumacaftor‐ivacaftor had an important impact on respiratory function with no apparent immediate safety concerns, but this should be balanced against the blood pressure increase and shortness of breath seen in longer‐term adult data when considering lumacaftor‐ivacaftor. Data from triple therapy trials demonstrate improvements in several key outcomes, including FEV 1 and QoL. There is probably little or no difference in adverse events for triple therapy (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor) in pwCF with one or two F508del variants aged 12 years or older (moderate‐certainty evidence). Further RCTs are required in children under 12 years and those with more severe lung disease. Plain language summary CFTR correctors, a therapy for cystic fibrosis targeted at specific variants (most commonly F508del) Review question How do drugs (or drug combinations) for correcting the basic defect in the most common cystic fibrosis (CF)‐causing gene variant (F508del) impact on outcomes important to people with CF (pwCF), e.g. survival, quality of life (QoL), lung function and safety? Key messages There is a lack of evidence to support monotherapy and limited evidence to support dual therapy for pwCF who have the gene variant F508del. We found important differences across key outcomes, with fewer unwanted side effects in the triple therapy studies when compared to one dual therapy drug combination (lumacaftor plus ivacaftor). More research is needed to assess triple therapy combinations in children and to monitor their safety profiles over the longer term. How would drugs (or drug combinations) correct the basic defect in the most common CF‐causing gene variant (F508del)? The CF gene makes a protein that helps salts move across cells in many parts of the body. Over 80% of pwCF have at least one copy of the genetic variant F508del, meaning they make a full length of this protein, but it cannot move through the cell correctly. Laboratory experiments suggest that if this protein reaches the cell wall, it may be able to function, restore salt movement and correct the chronic problems that pwCF experience. What did we want to find out? How do drugs (or drug combinations) used to treat people of any age who have the genetic variant F508del impact their lives? Are these drugs associated with any unwanted side effects? What did we do? We searched for and included studies that looked at drugs (and drug combinations) used to treat pwCF who had at least one copy of the most common CF‐causing gene variant (F508del) compared to control medications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 34 studies that involved 4781 pwCF and which lasted between 1 day and 48 weeks; all studies compared an active drug treatment to a placebo (drug containing no active treatment). We do not have enough information to decide if 14 studies should be included or not and eight studies have not yet been completed. Eight studies looked at treatment with a single drug (monotherapy). These studies did not report any deaths or clinically relevant improvements in quality of life (QoL) scores. There was not enough evidence to show an effect on lung function. All studies reported side effects; there were a wide range of side effects each reported by a small number of participants in the studies. There were 16 studies assessing a combination of two drugs (dual therapy), either tezacaftor plus ivacaftor or lumacaftor plus ivacaftor. One participant taking tezacaftor plus ivacaftor died, but this was not thought to be related to the treatment. Both dual therapies resulted in improvements in QoL and lung function; rates of pulmonary exacerbations (a flare‐up of symptoms) were also lower. Neither dual therapy was linked to severe side effects, although people starting treatment with lumacaftor plus ivacaftor experienced shortness of breath for one to two weeks; this usually stopped without further treatment . More concerningly, in longer studies some people taking lumacaftor plus ivacaftor experienced a rise in blood pressure. Two people (out of over 500) even stopped lumacaftor plus ivacaftor treatment because of high blood pressure. These side effects were not reported for tezacaftor plus ivacaftor. There were 11 studies assessing different combinations of three drugs (triple therapy). The combinations were based on tezacaftor with ivacaftor (or deutivacaftor, which is a similar but chemically altered version of ivacaftor) and investigators then added either elexacaftor, VX‐659, VX‐440 or VX‐152 and compared these to either triple placebo, or tezacaftor with ivacaftor and one placebo. Some studies split groups by treatment and also by different genetic variants. No study reported any deaths. Triple therapies improved QoL scores and lung function in all comparisons, with no difference in the number or severity of side effects. Fewer people with two copies of F508del taking elexacaftor plus tezacaftor plus ivacaftor experienced a pulmonary exacerbation than those taking the control treatment. What are the limitations of the evidence? Our certainty in the evidence ranged from uncertain to very certain, but we were quite certain of the evidence for most results. While studies generally provided few details about their design, so we could not make clear judgements on potential biases, we had fewer concerns with the larger, more recent studies. Some of our findings are based on studies that were too small to show important effects and for 16 studies the results may not be applicable to all pwCF due to them only including people of certain ages (i.e. only adults or only children). Also, one study had an unusual design where people were given monotherapy and then later a dual therapy. How up‐to‐date is this evidence? This review updates our earlier review. We last looked for evidence on 28 November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Heneghan, M; Southern, KW; Murphy, J; Sinha, IP; Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD010966.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "9429b624-35e6-4f51-8dcd-a5568eef4d34", "pmid": "", "title": "Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults", "imported": false, "abstract": "Abstract - Background Acetylcholinesterase inhibitors, such as neostigmine, have traditionally been used for reversal of non‐depolarizing neuromuscular blocking agents. However, these drugs have significant limitations, such as indirect mechanisms of reversal, limited and unpredictable efficacy, and undesirable autonomic responses. Sugammadex is a selective relaxant‐binding agent specifically developed for rapid reversal of non‐depolarizing neuromuscular blockade induced by rocuronium. Its potential clinical benefits include fast and predictable reversal of any degree of block, increased patient safety, reduced incidence of residual block on recovery, and more efficient use of healthcare resources. Objectives The main objective of this review was to compare the efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade caused by non‐depolarizing neuromuscular agents in adults. Search methods We searched the following databases on 2 May 2016: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (WebSPIRS Ovid SP), Embase (WebSPIRS Ovid SP), and the clinical trials registries www.controlled‐trials.com , clinicaltrials.gov , and www.centerwatch.com . We re‐ran the search on 10 May 2017. Selection criteria We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published, or language. We included adults, classified as American Society of Anesthesiologists (ASA) I to IV, who received non‐depolarizing neuromuscular blocking agents for an elective in‐patient or day‐case surgical procedure. We included all trials comparing sugammadex versus neostigmine that reported recovery times or adverse events. We included any dose of sugammadex and neostigmine and any time point of study drug administration. Data collection and analysis Two review authors independently screened titles and abstracts to identify trials for eligibility, examined articles for eligibility, abstracted data, assessed the articles, and excluded obviously irrelevant reports. We resolved disagreements by discussion between review authors and further disagreements through consultation with the last review author. We assessed risk of bias in 10 methodological domains using the Cochrane risk of bias tool and examined risk of random error through trial sequential analysis. We used the principles of the GRADE approach to prepare an overall assessment of the quality of evidence. For our primary outcomes (recovery times to train‐of‐four ratio (TOFR) > 0.9), we presented data as mean differences (MDs) with 95 % confidence intervals (CIs), and for our secondary outcomes (risk of adverse events and risk of serious adverse events), we calculated risk ratios (RRs) with CIs. Main results We included 41 studies (4206 participants) in this updated review, 38 of which were new studies. Twelve trials were eligible for meta‐analysis of primary outcomes (n = 949), 28 trials were eligible for meta‐analysis of secondary outcomes (n = 2298), and 10 trials (n = 1647) were ineligible for meta‐analysis. We compared sugammadex 2 mg/kg and neostigmine 0.05 mg/kg for reversal of rocuronium‐induced moderate neuromuscular blockade (NMB). Sugammadex 2 mg/kg was 10.22 minutes (6.6 times) faster then neostigmine 0.05 mg/kg (1.96 vs 12.87 minutes) in reversing NMB from the second twitch (T2) to TOFR > 0.9 (MD 10.22 minutes, 95% CI 8.48 to 11.96; I 2 = 84%; 10 studies, n = 835; GRADE: moderate quality). We compared sugammadex 4 mg/kg and neostigmine 0.07 mg/kg for reversal of rocuronium‐induced deep NMB. Sugammadex 4 mg/kg was 45.78 minutes (16.8 times) faster then neostigmine 0.07 mg/kg (2.9 vs 48.8 minutes) in reversing NMB from post‐tetanic count (PTC) 1 to 5 to TOFR > 0.9 (MD 45.78 minutes, 95% CI 39.41 to 52.15; I 2 = 0%; two studies, n = 114; GRADE: low quality). For our secondary outcomes, we compared sugammadex, any dose, and neostigmine, any dose, looking at risk of adverse and serious adverse events. We found significantly fewer composite adverse events in the sugammadex group compared with the neostigmine group (RR 0.60, 95% CI 0.49 to 0.74; I 2 = 40%; 28 studies, n = 2298; GRADE: moderate quality). Risk of adverse events was 28% in the neostigmine group and 16% in the sugammadex group, resulting in a number needed to treat for an additional beneficial outcome (NNTB) of 8. When looking at specific adverse events, we noted significantly less risk of bradycardia (RR 0.16, 95% CI 0.07 to 0.34; I 2 = 0%; 11 studies, n = 1218; NNTB 14; GRADE: moderate quality), postoperative nausea and vomiting (PONV) (RR 0.52, 95% CI 0.28 to 0.97; I 2 = 0%; six studies, n = 389; NNTB 16; GRADE: low quality) and overall signs of postoperative residual paralysis (RR 0.40, 95% CI 0.28 to 0.57; I 2 = 0%; 15 studies, n = 1474; NNTB 13; GRADE: moderate quality) in the sugammadex group when compared with the neostigmine group. Finally, we found no significant differences between sugammadex and neostigmine regarding risk of serious adverse events (RR 0.54, 95% CI 0.13 to 2.25; I 2 = 0%; 10 studies, n = 959; GRADE: low quality). Application of trial sequential analysis (TSA) indicates superiority of sugammadex for outcomes such as recovery time from T2 to TOFR > 0.9, adverse events, and overall signs of postoperative residual paralysis. Authors' conclusions Review results suggest that in comparison with neostigmine, sugammadex can more rapidly reverse rocuronium‐induced neuromuscular block regardless of the depth of the block. Sugammadex 2 mg/kg is 10.22 minutes (˜ 6.6 times) faster in reversing moderate neuromuscular blockade (T2) than neostigmine 0.05 mg/kg (GRADE: moderate quality), and sugammadex 4 mg/kg is 45.78 minutes (˜ 16.8 times) faster in reversing deep neuromuscular blockade (PTC 1 to 5) than neostigmine 0.07 mg/kg (GRADE: low quality). With an NNTB of 8 to avoid an adverse event, sugammadex appears to have a better safety profile than neostigmine. Patients receiving sugammadex had 40% fewer adverse events compared with those given neostigmine. Specifically, risks of bradycardia (RR 0.16, NNTB 14; GRADE: moderate quality), PONV (RR 0.52, NNTB 16; GRADE: low quality), and overall signs of postoperative residual paralysis (RR 0.40, NNTB 13; GRADE: moderate quality) were reduced. Both sugammadex and neostigmine were associated with serious adverse events in less than 1% of patients, and data showed no differences in risk of serious adverse events between groups (RR 0.54; GRADE: low quality). Plain language summary Benefits and harms of sugammadex versus neostigmine in reversing induced paralysis Background Different levels of induced paralysis are sometimes necessary when patients are put to sleep or are prepared for operations. When the operation is finished, paralysis should be reversed in a fast, reliable, and safe way. Neostigmine is a medication that is traditionally used to reverse induced paralysis. However, its use can be associated with incomplete or slow reversal as well as changes in lung function, heart function, and vomiting and nausea. Sugammadex is a relatively new medication specifically designed to reverse rocuronium‐induced paralysis in a faster, more reliable, and safer way when compared with neostigmine. Objective This review systematically sets out to compare the benefits and harms of sugammadex and neostigmine. The evidence is current up to May 2017. Study characteristics We identified 41 randomized controlled trials comparing sugammadex with neostigmine that provided suitable data on efficacy and safety. All of these trials included adults undergoing surgery and involved a total of 4206 participants. Key results Data indicate that sugammadex was 10.22 minutes (6.6 times) faster than neostigmine (1.96 vs 12.87 minutes) in reversing moderate induced paralysis. Sugammadex was 45.78 minutes (16.8 times) faster than neostigmine (2.9 vs 48.8 minutes) in reversing deep induced paralysis. Participants receiving sugammadex appeared to have a 40% reduced risk of experiencing harmful events than those given neostigmine. Statistically, eight persons can be treated with sugammadex as opposed to neostigmine to avoid one person experiencing a single random harmful event. The occurrence of serious harmful events was nearly non‐existent and data show no differences between compared groups. Conclusion Sugammadex is more efficient and safer than neostigmine for reversing moderate and deep induced paralysis. Quality of evidence We consider our overall findings on benefits and harms to provide evidence of moderate quality in favour of sugammadex.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Hristovska, AM; Duch, P; Allingstrup, M; Afshari, A", "articleTypes": [], "doi": "10.1002/14651858.CD012763", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "94328d14-2bbe-4a99-91dc-0fc45f063f4e", "pmid": "", "title": "Green tea for weight loss and weight maintenance in overweight or obese adults", "imported": false, "abstract": "Abstract - Background Preparations of green tea are used as aids in weight loss and weight maintenance. Catechins and caffeine, both contained in green tea, are each believed to have a role in increasing energy metabolism, which may lead to weight loss. A number of randomised controlled trials (RCTs) evaluating the role of green tea in weight loss have been published; however, the efficacy of green tea preparations in weight loss remains unclear. Objectives To assess the efficacy and safety of green tea preparations for weight loss and weight maintenance in overweight or obese adults. Search methods We searched the following databases from inception to specified date as well as reference lists of relevant articles: The Cochrane Library (Issue 12, 2011), MEDLINE (December 2011), EMBASE (December 2011), CINAHL (January 2012), AMED (January 2012), Biological Abstracts (January 2012), IBIDS (August 2010), Obesity+ (January 2012), IPA (January 2012) and Web of Science (December 2011). Current Controlled Trials with links to other databases of ongoing trials was also searched. Selection criteria RCTs of at least 12 weeks' duration comparing green tea preparations to a control in overweight or obese adults. Data collection and analysis Three authors independently extracted data, assessed studies for risk of bias and quality, with differences resolved by consensus. Heterogeneity of included studies was assessed visually using forest plots and quantified using the I 2 statistic. We synthesised data using meta‐analysis and descriptive analysis as appropriate; subgroup and sensitivity analyses were conducted. Adverse effects reported in studies were recorded. Main results Due to the level of heterogeneity among studies, studies were divided into two groups; those conducted in Japan and those conducted outside Japan. Study length ranged between 12 and 13 weeks. Meta‐analysis of six studies conducted outside Japan showed a mean difference (MD) in weight loss of ‐0.04 kg (95% CI ‐0.5 to 0.4; P = 0.88; I 2 = 18%; 532 participants). The eight studies conducted in Japan were not similar enough to allow pooling of results and MD in weight loss ranged from ‐0.2 kg to ‐3.5 kg (1030 participants) in favour of green tea preparations. Meta‐analysis of studies measuring change in body mass index (BMI) conducted outside Japan showed a MD in BMI of ‐0.2 kg/m 2 (95% CI ‐0.5 to 0.1; P = 0.21; I 2 = 38%; 222 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed a reduction in BMI ranging from no effect to ‐1.3 kg/m 2 (1030 participants), in favour of green tea preparations over control. Meta‐analysis of five studies conducted outside Japan and measuring waist circumference reported a MD of ‐0.2 cm (95% CI ‐1.4 to 0.9; P = 0.70; I 2 = 58%; 404 participants). Differences among the eight studies conducted in Japan did not allow pooling of results and showed effects on waist circumference ranging from a gain of 1 cm to a loss of 3.3 cm (1030 participants). Meta‐analysis for three weight loss studies, conducted outside Japan, with waist‐to‐hip ratio data (144 participants) yielded no significant change (MD 0; 95% CI ‐0.02 to 0.01). Analysis of two studies conducted to determine if green tea could help to maintain weight after a period of weight loss (184 participants) showed a change in weight loss of 0.6 to ‐1.6 kg, a change in BMI from 0.2 to ‐0.5 kg/m 2 and a change in waist circumference from 0.3 to ‐1.7 cm. In the eight studies that recorded adverse events, four reported adverse events that were mild to moderate, with the exception of two (green tea preparations group) that required hospitalisation (reported as not associated with the intervention). Nine studies reported on compliance/adherence, one study assessed attitude towards eating as part of the health‐related quality of life outcome. No studies reported on patient satisfaction, morbidity or cost. Authors' conclusions Green tea preparations appear to induce a small, statistically non‐significant weight loss in overweight or obese adults. Because the amount of weight loss is small, it is not likely to be clinically important. Green tea had no significant effect on the maintenance of weight loss. Of those studies recording information on adverse events, only two identified an adverse event requiring hospitalisation. The remaining adverse events were judged to be mild to moderate. Plain language summary Green tea for weight loss and weight maintenance in overweight or obese adults Green tea has a long history of many uses, one of which is helping overweight people to lose weight and to maintain weight loss. Believed to be able to increase a person's energy output, green tea weight loss preparations are extracts of green tea that contain a higher concentration of ingredients (catechins and caffeine) than the typical green tea beverage prepared from a tea bag and boiling water. This review looked at 15 weight loss studies and three studies measuring weight maintenance where some form of a green tea preparation was given to one group and results compared to a group receiving a control. Neither group knew whether they were receiving the green tea preparation or the control. A total of 1945 participants completed the studies, ranging in length from 12 to 13 weeks. In summary, the loss in weight in adults who had taken a green tea preparation was statistically not significant, was very small and is not likely to be clinically important. Similar results were found in studies that used other ways to measure loss in weight (body mass index, waist circumference). Studies examining the effect of green tea preparations on weight maintenance did not show any benefit compared to the use of a control preparation. Most adverse effects, such as nausea, constipation, abdominal discomfort and increased blood pressure, were judged to be mild to moderate and to be unrelated to the green tea or control intervention. No deaths were reported, although adverse events required hospitalisation. One study attempted to look at health‐related quality of life by asking participants about their attitudes towards eating. Nine studies tracked participants' compliance with green tea preparations. Studies did not include any information about the effects of green tea preparations on morbidity, costs or patient satisfaction.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Jurgens, TM; Whelan, AM; Killian, L; Doucette, S; Kirk, S; Foy, E", "articleTypes": [], "doi": "10.1002/14651858.CD008650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "9438ccd6-f70f-40ce-889c-ab6e9e5bdd7f", "pmid": "", "title": "Interventions for fatigue in people with kidney failure requiring dialysis", "imported": false, "abstract": "Abstract - Background Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD). Objectives We aimed to evaluate the effects of pharmacological and non‐pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Studies evaluating pharmacological and non‐pharmacological interventions affecting levels of fatigue or fatigue‐related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue‐related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered. Data collection and analysis Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta‐analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Ninety‐four studies involving 8191 randomised participants were eligible. Pharmacological and non‐pharmacological interventions were compared either to placebo or control, or to another pharmacological or non‐pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis‐Related Fatigue scale score): SMD ‐1.18, 95% CI ‐2.04 to ‐0.31; I 2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD ‐1.23, 95% CI ‐1.96 to ‐0.50; I 2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD ‐1.06, 95% CI ‐1.47, ‐0.65; I 2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I 2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD ‐0.64, 95% CI ‐1.03 to ‐0.25; I 2 = 75%) in HD. A wide range of heterogenous interventions and fatigue‐related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non‐pharmacological interventions on fatigue or fatigue‐related outcomes, including non‐physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive‐behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta‐blockers, anabolic steroids, glucose‐enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non‐pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported. Authors' conclusions Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non‐pharmacological interventions had uncertain effects on fatigue or fatigue‐related outcomes in people receiving dialysis. Future adequately powered, high‐quality studies are likely to change the estimated effects of interventions for fatigue and fatigue‐related outcomes in people receiving dialysis. Plain language summary Are interventions for fatigue effective among people with kidney failure requiring dialysis? What is the issue? Fatigue is a frequent and debilitating symptom that can limit life participation in people receiving dialysis. Fatigue is linked to impaired quality of life, cardiovascular disease, death and depression in people on dialysis. Several potential interventions, including drugs or other non‐pharmacological treatments (e.g. exercise, diet, massage, aromatherapy, acupressure), have been evaluated for their effect on fatigue in people on dialysis. What did we do? We evaluated whether drugs or other non‐pharmacological interventions are beneficial for adults and children receiving haemodialysis or peritoneal dialysis to manage fatigue. We evaluated all clinical studies available and summarised the results. We evaluated how certain we could be about the evidence related to interventions for fatigue using a system called \"GRADE\". What did we find? Ninety‐four studies involving 8191 randomised participants were available. Patients in the studies were given a drug, non‐pharmacological intervention, standard care or a sugar pill (placebo). The treatment they received was decided by random chance. The studies were generally short‐term (over a few months). There were no studies in children. Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. Drugs or other non‐pharmacological interventions have uncertain effects on fatigue in people on dialysis. Conclusions Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. It remains uncertain whether drugs or other non‐pharmacological interventions have any impact on fatigue in people on dialysis when compared to a sugar pill, standard care or other treatments for fatigue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Natale, P, Ju, A, Strippoli, GFM, Craig, JC, Saglimbene, VM, Unruh, ML, Stallone, G, Jaure, A", "articleTypes": [], "doi": "10.1002/14651858.CD013074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.777Z" }, { "id": "944ae95d-d89f-4e47-bef6-b2161a8fd8e7", "pmid": "", "title": "Efficacy of Cannabidiol in Combination With Red Algae (CBDRA60) to Prevent or Reduce Symptoms of COVID-19 and Post-Acute Sequelae of SARS-CoV-2 Infection PASC", "imported": false, "abstract": "Coronavirus disease (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents a major threat to human health. SARS-CoV-2 is highly infectious and is associated with extensive morbidity and mortality. Our study shares important features with other clinical trials using supplements or other widely available medications (e.g., Ascorbic Acid, Zinc, Vitamin D, Vitamin C). Our study shares two important elements with these previous studies, including:", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.248Z" }, { "id": "945f03fc-2b8e-4365-a856-90ee432d6051", "pmid": "", "title": "Progesterone receptor modulators for endometriosis", "imported": false, "abstract": "Abstract - Rationale Endometriosis is defined as the presence of endometrium‐like tissue developing outside the uterine cavity. This condition is oestrogen‐dependent and thus is seen primarily during the reproductive years. Owing to their antiproliferative effects on the endometrium, progesterone receptor modulators (PRMs) have been advocated for the treatment of endometriosis. This is an update of a Cochrane review previously published in 2017. Objectives To assess the effectiveness and safety of progesterone receptor modulators (PRMs) in the management of endometriosis. Search methods To identify studies, we searched online sources, including the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, ClinicalTrials.gov and the WHO (World Health Organization) trial registry up to 16 April 2026. We also checked reference lists and contacted study authors and experts. Eligibility criteria We included randomised controlled trials (RCTs) comparing PRMs with placebo, no treatment or other medical treatment, in women with symptomatic endometriosis. Outcomes Our critical outcomes were overall pain; improvement in the most troublesome symptom, including dysmenorrhoea and dyspareunia; and adverse events resulting from the PRM intervention. Our important outcomes included quality of life (QoL) and patient satisfaction with treatment. Risk of bias We used the Cochrane tool RoB 2 to assess the risk of bias in the outcomes of this review. Synthesis methods Two review authors independently assessed studies against the inclusion criteria, extracted data and assessed risk of bias, consulting a third review author where required. We analysed dichotomous outcomes using Mantel‐Haenszel odds ratios (ORs), 95% confidence intervals (CIs) and the fixed‐effect model. We analysed continuous outcomes using the mean difference (MD) between groups, presented with 95% CIs. We employed the GRADE approach to assess the certainty of the evidence as high, moderate, low or very low. Included studies No new studies were eligible for inclusion in this update. Of the nine studies (922 women) already included in the review, two compared mifepristone versus placebo or compared different doses of mifepristone, and four either compared gestrinone versus danazol, gestrinone versus gonadotropin‐releasing hormone (GnRH) analogues or compared different doses of gestrinone. One study compared asoprisnil versus placebo. The asoprisnil study did not provide extractable numerical data and was included in the narrative synthesis only. Two of the studies did not report any of the review's prespecified outcomes. Synthesis of results Certainty of the evidence We judged the certainty of evidence as low to very low. The main limitations of the evidence were serious risk of bias (associated with poor reporting of methods and high or unclear rates of attrition), very serious imprecision (associated with low event rates and wide confidence intervals, with some large effect estimates) and serious indirectness (outcomes assessed in selected subgroups). PRM versus placebo Mifepristone versus placebo These results are based on one study (360 participants) that measured outcomes after three months. The study did not report overall pain. At three months, mifepristone may improve dysmenorrhoea (OR 0.07, 95% CI 0.03 to 0.15; 1 study, 342 participants; low‐certainty evidence), suggesting that if 40% of women taking placebo experience dysmenorrhoea, then between 3% and 10% of women taking mifepristone will do so. We are uncertain whether mifepristone improves dyspareunia (OR 0.23, 95% CI 0.10 to 0.51; 1 study, 223 participants; very low‐certainty evidence). However, mifepristone may increase hot flushes (OR 28.79, 95% CI 3.93 to 210.73; 1 study, 360 participants; low‐certainty evidence). Mifepristone may make little or no difference after three months of treatment to the prevalence of nausea (OR 1.72, 95% CI 0.20 to 15.03; 1 study, 360 participants; low‐certainty evidence). PRM versus other medical treatment Gestrinone versus danazol These results are based on two studies (302 participants) that measured outcomes after six months. We are uncertain of the effects of gestrinone relative to danazol on the improvement of overall pain (dichotomous outcome: participants reporting no or mild pelvic pain counted as 'improved') (OR 0.47, 95% CI 0.04 to 5.70; 1 study, 38 participants), dysmenorrhoea (Not estimable; 1 study, 38 participants), or dyspareunia (OR 1.00, 95% CI 0.13 to 7.94; 1 study, 38 participants (all very low‐certainty evidence). We are uncertain about the effects of gestrinone relative to danazol on hot flushes (OR 0.79, 95% CI 0.50 to 1.26; 2 studies, 302 participants; very low‐certainty evidence). There may be little or no difference between gestrinone and danazol in rates of nausea (OR 1.36, 95% CI 0.84 to 2.19; 2 studies, 302 participants; low‐certainty evidence). Gestrinone versus a GnRH analogue (leuprorelin) These results are based on one study (55 participants) that measured outcomes after six months. There may be little to no difference between gestrinone and leuprorelin in non‐menstrual pain (MD −0.41, 95% CI −1.76 to 0.94; 1 study, 55 participants; low‐certainty evidence). Women taking gestrinone may have higher dysmenorrhoea scores than those taking leuprorelin (MD 0.82, 95% CI 0.15 to 1.49; 1 study, 55 participants; low‐certainty evidence), but gestrinone may improve dyspareunia more than leuprorelin (MD −1.16, 95% CI −2.08 to −0.24; 1 study, 52 participants; low‐certainty evidence). There may be lower rates of hot flushes with gestrinone than leuprorelin (OR 0.20, 95% CI 0.06 to 0.63; 1 study, 55 participants; low‐certainty evidence). There may be little or no difference between gestrinone and leuprorelin in rates of nausea (OR 1.04, 95% CI 0.06 to 17.49; 1 study, 55 participants; low‐certainty evidence). Authors' conclusions Mifepristone may improve dysmenorrhoea in women with endometriosis, but it might increase the prevalence of adverse events, such as hot flushes. The evidence is very uncertain regarding its effect on dyspareunia. Gestrinone may be less effective than leuprorelin in treating dysmenorrhoea, but it may improve dyspareunia. It may be associated with lower rates of hot flushes and similar rates of nausea. We are uncertain about the effect of gestrinone compared to danazol. We found insufficient evidence to permit firm conclusions about the safety and effectiveness of other progesterone receptor modulators. Funding This Cochrane review had no dedicated funding. Registration Protocol (2012) DOI: 10.1002/14651858.CD009881 Review (2017) DOI: 10.1002/14651858.CD009881.pub2 Plain language summary What are the benefits and risks of medicines called progesterone receptor modulators (PRMs) for treating endometriosis (a condition where tissue grows outside the womb)? Key messages In the management of endometriosis (a condition where tissue grows outside the womb), studies that compared a progesterone receptor modulator (PRM; a medicine that changes how the hormone progesterone acts in the body) against placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested) found that a PRM called mifepristone may improve painful periods. However, it may cause hot flushes. A PRM called gestrinone may be less effective than medicines known as gonadotropin‐releasing hormone (GnRH) analogues (which reduce the amount of oestrogen made by the ovaries) for treating painful periods, but may improve pain during sex. Gestrinone may also cause fewer hot flushes. We do not know how gestrinone compares to a treatment called danazol in terms of pain not related to periods, painful periods or pain during sex. We do not know whether gestrinone or danazol causes more unwanted effects. Future studies should compare progesterone receptor modulators with medicines currently used to treat endometriosis symptoms and focus on assessing pain using recognised and reliable methods. Larger, well‐designed studies are also needed to assess the benefits and unwanted effects of progesterone receptor modulators other than mifepristone and gestrinone. What is endometriosis? Endometriosis is a condition where tissue similar to the lining of the womb (uterus) grows outside the womb. Endometriosis is oestrogen‐dependent and thus is seen mainly during the reproductive years. It can cause pain in the tummy area (abdomen), generally during periods (menstruation) or associated with sexual intercourse. Endometriosis is treated through different types of medical or surgical treatment. Progesterone receptor modulators (PRMs) are medicines that change how the hormone progesterone acts in the body. PRMs include mifepristone, gestrinone, ulipristal acetate, vilaprisan and asoprisnil. Because they can slow down or stop the growth of tissue in the lining of the uterus, they have been suggested as a treatment for endometriosis. What did we want to find out? We wanted to know whether, in patients with endometriosis, PRMs are better than placebo ('dummy' treatment), no treatment or other medical treatment for improving overall pain, pain during periods and pain during sexual intercourse. We also wanted to know if these medications were safe by assessing unwanted effects experienced by patients, such as hot flushes and feeling sick (nausea). What did we do? We searched for studies that investigated the effectiveness of PRMs for symptoms associated with endometriosis and whether they caused unwanted effects. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included nine studies involving 922 women aged 18 to 45 years. Most studies tested the PRMs mifepristone or gestrinone. One study tested asoprisnil, but the study was published only as a short summary without results that we could use. Two of the studies did not measure any of the effects we were interested in. Main results Progesterone receptor modulators versus placebo When compared to a placebo, mifepristone: may reduce painful periods after three months of treatment (based on 1 study of 342 women); may cause more unwanted effects, such as hot flushes (1 study, 360 women); may make little or no difference to nausea (1 study, 360 women); and we are uncertain whether mifepristone reduces pain during sex (1 study, 223 women). Progesterone receptor modulators versus other medical treatment When compared to danazol, one study of 38 women showed that: we do not know whether gestrinone improves pain symptoms after six months of treatment (1 study, 38 women); we do not know whether gestrinone causes more or fewer hot flushes or makes no difference (2 studies, 302 women); and gestrinone and danazol may cause similar rates of nausea, but the results are very uncertain (2 studies, 302 women). When compared to a GnRH analogue (leuprorelin), one study of 55 women found that: gestrinone may be less efficient in treating painful periods after six months of treatment (1 study, 55 women); but gestrinone may reduce pain during sex (1 study, 52 women); gestrinone may be similar to leuprorelin in terms of general pain experienced (1 study, 55 women); gestrinone may cause fewer hot flushes and similar levels of nausea (1 study, 55 women). What are the limitations of the evidence? Our confidence in the evidence is low to very low, mainly because some studies had one or more of these problems: they did not have many people taking part; they focused on specific settings or populations; they used methods likely to introduce errors in their results; they did not clearly report how they were conducted; they did not clearly report whether the people taking part knew which treatment they had received, which could have affected the study results. How up to date is this evidence? This review updates a previous review. The evidence is up to date to April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Grammatis, AL, Gibbons, T, Anucha, EN, Becker, CM", "articleTypes": [], "doi": "10.1002/14651858.CD009881.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.797Z" }, { "id": "947b399a-2121-4411-abb9-a4de7de0ea2c", "pmid": "", "title": "External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion). Objectives To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. Search methods We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index‐Science (CPCI‐S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. Selection criteria We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. Data collection and analysis We used standard Cochrane methodology to collect data and performed a network meta‐analysis using the standard frequentist graph‐theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption. Main results We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy‐nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow‐up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low‐certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled. Authors' conclusions Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method. Plain language summary Electrical shocks (electrical cardioversion) and drugs (pharmacological cardioversion) for restoring normal rhythm in patients with atrial fibrillation or atrial flutter Key Messages ‐ Electrical cardioversion and some drugs can be used to restore the normal rhythm in patients with atrial fibrillation (AF) and atrial flutter. While electrical cardioversion is highly effective in dealing with all arrhythmias, the efficacy of drugs varies, with some being only moderately effective or not working at all in persistent AF and atrial flutter. ‐ Electrical cardioversion seems to be a very safe option. The risk of severe complications with cardioversion using drugs was low, but additional precautions are needed. ‐ We need further studies to find out if these treatment options also have a positive effect on quality of life, or if they lead to relevant differences in the duration of hospital stay. What is atrial fibrillation? AF is the most frequent abnormal heart rhythm seen in the world. Patients with this condition may feel their heart beating rapidly and irregularly. This can occur for separate brief or long episodes (paroxysmal AF) or it may become continuous (persistent AF). Atrial flutter is a similar abnormal rhythm that causes similar symptoms, can cause episodes of variable duration and can also become continuous. What is cardioversion? Cardioversion is a treatment to restore the rhythm of the heart back to normal (sinus rhythm). What did we want to find out? We wanted to know if delivering a controlled electrical shock (i.e. electrical cardioversion) and drugs (i.e. pharmacological cardioversion) are effective and safe when restoring heart rhythm back to normal. What did we do? We searched for studies that investigated electrical and pharmacological cardioversion compared to each other or placebo (a medicine that looks like the real medicine but that has no active ingredient). We compared and summarised the results of the studies and rated our trust in these results, based on factors such as study methods and size. What did we find? We found 112 studies. We were able to combine and analyse the results from 72 studies, with 15,968 participants aged between 47 and 72 years. Thirty‐five studies included patients with paroxysmal AF (AF that terminates spontaneously or with intervention within 7 days of onset), 26 studies of patients with persistent AF (AF that is continuously sustained beyond seven days, including episodes terminated by cardioversion after ≥ 7 days), and 14 trials included patients with atrial flutter. The remaining included a mix of paroxysmal, persistent AF and atrial flutter. Main results For patients with paroxysmal AF, electrical cardioversion with biphasic incremental energy, fast‐acting drugs like intravenous vernakalant, flecainide, ibutilide and antazoline, and slower‐acting and/or oral drugs such as quinidine, propafenone, amiodarone and sotalol are effective at restoring sinus rhythm. For patients with persistent AF, electrical cardioversion with biphasic energy seems to be the most effective option; bepridil, quinidine and amiodarone tablets may also be effective in selected cases. For patients with atrial flutter, electrical cardioversion followed by dofetilide are the most effective options. The risk of death and stroke is very low for patients having cardioversion procedures. Malignant arrhythmias (torsade de pointes, sustained ventricular tachycardia or ventricular fibrillation, all of which are associated with high 1‐year mortality rate) were observed for dofetilide, ibutilide, sotalol, quinidine and vernakalant, justifying the need for special care and closer monitoring when using these drugs. Duration of hospitalisation data was available in three studies but, as there were variable timings in these studies, we could not combine them to assess their joint effectiveness. These studies suggest that the duration of hospitalisation may be lower with electrical cardioversion. Heart failure was observed in some patients treated with propafenone, flecainide, sotalol, amiodarone, vernakalant, and placebo, and was not observed in patients receiving electrical cardioversion, suggesting that the latter approach should be the preferred one if concerns exist regarding the occurrence of this outcome. Phlebitis (i.e. inflammation of the vein caused by using injectable drugs) occurred frequently in patients treated with amiodarone, and dysgeusia (i.e. impairment of the sense of taste) and sneezing occurred frequently in patients receiving vernakalant. What are the limitations of the observed results? We are sure or moderately sure of the results for the efficacy of treatments available for persistent AF and atrial flutter. We are less sure about the results for some of the treatment options for paroxysmal AF. Not enough data are available regarding quality of life, and data were limited regarding duration of hospital stay. The risk of stroke or dying was very low. How up to date are the studies and information on this review? The included studies and information are current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Kukendrarajah, K; Ahmad, M; Carrington, M; Ioannou, A; Taylor, J; Razvi, Y; Papageorgiou, N; Mead, GE; Nevis, IF; D'Ascenzo, F; Wilton, SB; Lambiase, PD; Morillo, CA; Kwong, JSW; Providencia, R", "articleTypes": [], "doi": "10.1002/14651858.CD013255.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "948668ba-8cdf-409f-ab08-ed9355d562c0", "pmid": "", "title": "Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health services. Decay and gum disease can cause pain, eating and speaking difficulties, low self‐esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self‐administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area. Objectives To evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other. Search methods Cochrane Oral Health’s Information Specialist searched: Cochrane Oral Health’s Trials Register (to 16 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 12), MEDLINE Ovid (1946 to 16 January 2019), Embase Ovid (1980 to 16 January 2019) and CINAHL EBSCO (1937 to 16 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication. Selection criteria Randomised controlled trials (RCTs) that compared toothbrushing and a home‐use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks). Data collection and analysis At least two review authors independently screened searches, selected studies, extracted data, assessed studies' risk of bias, and assessed evidence certainty as high, moderate, low or very low, according to GRADE. We extracted indices measured on interproximal surfaces, where possible. We conducted random‐effects meta‐analyses, using mean differences (MDs) or standardised mean differences (SMDs). Main results We included 35 RCTs (3929 randomised adult participants). Studies were at high risk of performance bias as blinding of participants was not possible. Only two studies were otherwise at low risk of bias. Many participants had a low level of baseline gingival inflammation. Studies evaluated the following devices plus toothbrushing versus toothbrushing: floss (15 trials), interdental brushes (2 trials), wooden cleaning sticks (2 trials), rubber/elastomeric cleaning sticks (2 trials), oral irrigators (5 trials). Four devices were compared with floss: interdental brushes (9 trials), wooden cleaning sticks (3 trials), rubber/elastomeric cleaning sticks (9 trials) and oral irrigators (2 trials). Another comparison was rubber/elastomeric cleaning sticks versus interdental brushes (3 trials). No trials assessed interproximal caries, and most did not assess periodontitis. Gingivitis was measured by indices (most commonly, Löe‐Silness, 0 to 3 scale) and by proportion of bleeding sites. Plaque was measured by indices, most often Quigley‐Hein (0 to 5). Primary objective: comparisons against toothbrushing alone Low‐certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index (GI)) at one month (SMD ‐0.58, 95% confidence interval (CI) ‐1.12 to ‐0.04; 8 trials, 585 participants), three months or six months. The results for proportion of bleeding sites and plaque were inconsistent (very low‐certainty evidence). Very low‐certainty evidence suggested that using an interdental brush, plus toothbrushing, may reduce gingivitis (measured by GI) at one month (MD ‐0.53, 95% CI ‐0.83 to ‐0.23; 1 trial, 62 participants), though there was no clear difference in bleeding sites (MD ‐0.05, 95% CI ‐0.13 to 0.03; 1 trial, 31 participants). Low‐certainty evidence suggested interdental brushes may reduce plaque more than toothbrushing alone (SMD ‐1.07, 95% CI ‐1.51 to ‐0.63; 2 trials, 93 participants). Very low‐certainty evidence suggested that using wooden cleaning sticks, plus toothbrushing, may reduce bleeding sites at three months (MD ‐0.25, 95% CI ‐0.37 to ‐0.13; 1 trial, 24 participants), but not plaque (MD ‐0.03, 95% CI ‐0.13 to 0.07). Very low‐certainty evidence suggested that using rubber/elastomeric interdental cleaning sticks, plus toothbrushing, may reduce plaque at one month (MD ‐0.22, 95% CI ‐0.41 to ‐0.03), but this was not found for gingivitis (GI MD ‐0.01, 95% CI ‐0.19 to 0.21; 1 trial, 12 participants; bleeding MD 0.07, 95% CI ‐0.15 to 0.01; 1 trial, 30 participants). Very‐low certainty evidence suggested oral irrigators may reduce gingivitis measured by GI at one month (SMD ‐0.48, 95% CI ‐0.89 to ‐0.06; 4 trials, 380 participants), but not at three or six months. Low‐certainty evidence suggested that oral irrigators did not reduce bleeding sites at one month (MD ‐0.00, 95% CI ‐0.07 to 0.06; 2 trials, 126 participants) or three months, or plaque at one month (SMD ‐0.16, 95% CI ‐0.41 to 0.10; 3 trials, 235 participants), three months or six months, more than toothbrushing alone. Secondary objective: comparisons between devices Low‐certainty evidence suggested interdental brushes may reduce gingivitis more than floss at one and three months, but did not show a difference for periodontitis measured by probing pocket depth. Evidence for plaque was inconsistent. Low‐ to very low‐certainty evidence suggested oral irrigation may reduce gingivitis at one month compared to flossing, but very low‐certainty evidence did not suggest a difference between devices for plaque. Very low‐certainty evidence for interdental brushes or flossing versus interdental cleaning sticks did not demonstrate superiority of either intervention. Adverse events Studies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation. Authors' conclusions Using floss or interdental brushes in addition to toothbrushing may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low‐certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis. Plain language summary Home use of devices for cleaning between the teeth (in addition to toothbrushing) to prevent and control gum diseases and tooth decay Review question How effective are home‐use interdental cleaning devices, plus toothbrushing, compared with toothbrushing only or use of another device, for preventing and controlling periodontal (gum) diseases (gingivitis and periodontitis), tooth decay (dental caries) and plaque? Background Tooth decay and gum diseases affect most people. They can cause pain, difficulties with eating and speaking, low self‐esteem, and, in extreme cases, may lead to tooth loss and the need for surgery. The cost to health services of treating these diseases is very high. As dental plaque (a layer of bacteria in an organic matrix that forms on the teeth) is the root cause, it is important to remove plaque from teeth on a regular basis. While many people routinely brush their teeth to remove plaque up to the gum line, it is difficult for toothbrushes to reach into areas between teeth ('interdental'), so interdental cleaning is often recommended as an extra step in personal oral hygiene routines. Different tools can be used to clean interdentally, such as dental floss, interdental brushes, tooth cleaning sticks, and water pressure devices known as oral irrigators. Study characteristics Review authors working with Cochrane Oral Health searched for studies up to 16 January 2019. We identified 35 studies (3929 adult participants). Participants knew that they were in an experiment, which might have affected their teeth cleaning or eating behaviour. Some studies had other problems that might make their findings less reliable, such as people dropping out of the study or not using the assigned device. Studies evaluated the following devices plus toothbrushing compared to toothbrushing only: floss (15 studies), interdental brushes (2 studies), wooden cleaning sticks (2 studies), rubber/elastomeric cleaning sticks (2 studies) and oral irrigators (5 studies). Four devices were compared with floss: interdental brushes (9 studies), wooden cleaning sticks (3 studies), rubber/elastomeric cleaning sticks (9 studies), oral irrigators (2 studies). Three studies compared rubber/elastomeric cleaning sticks with interdental brushes. No studies evaluated decay, and few evaluated severe gum disease. Outcomes were measured at short (one month to six weeks) and medium term (three and six months). Key results We found that using floss, in addition to toothbrushing, may reduce gingivitis in the short and medium term. It is unclear if it reduces plaque. Using an interdental brush, in addition to a toothbrush, may reduce gingivitis and plaque in the short term. Using wooden tooth cleaning sticks may be better than toothbrushing only for reducing gingivitis (measured by bleeding sites) but not plaque in the medium term (only 24 participants). Using a tooth cleaning stick made of rubber or an elastomer may be better than toothbrushing only for reducing plaque but not gingivitis in the short term (only 30 participants). Toothbrushing plus oral irrigation (water pressure) may reduce gingivitis in the short term, but there was no evidence for this in the medium term. There was no evidence of a difference in plaque. Interdental brushes may be better than flossing for gingivitis at one and three months. The evidence for plaque is inconsistent. There was no evidence of a difference between the devices for periodontitis measured by probing pocket depth. There is some evidence that oral irrigation may be better than flossing for reducing gingivitis (but not plaque) in the short term. The available evidence for interdental cleaning sticks did not show them to be better or worse than floss or interdental brushes for controlling gingivitis or plaque. The studies that measured 'adverse events' found no serious effects and no evidence of differences between study groups in minor effects such as gum irritation. Certainty of the evidence The evidence is low to very low‐certainty. The effects observed may not be clinically important. Studies measured outcomes mostly in the short term and many participants had a low level of gum disease at the beginning of the studies. Future research Future studies should use the new periodontal diseases classification to describe the gum health of participants, and they should last long enough to measure periodontitis and tooth decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Worthington, HV, MacDonald, L, Poklepovic Pericic, T, Sambunjak, D, Johnson, TM, Imai, P, Clarkson, JE", "articleTypes": [], "doi": "10.1002/14651858.CD012018.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.130Z" }, { "id": "94b3f33c-0188-4c1f-ad65-38e625e5d9de", "pmid": "", "title": "Micronutrient supplementation in pregnant women with HIV infection", "imported": false, "abstract": "Abstract - Background Micronutrient deficiencies are widespread and compound the effects of HIV disease; micronutrient supplements may be effective and safe in reducing this burden. Objectives To assess whether micronutrient supplements are effective and safe in reducing mortality and morbidity in pregnant and lactating women with HIV infection and their infants. Search methods The review has been updated three times since publication in 2005. In reviews prior to this update (2011), we searched the CENTRAL, EMBASE, PubMed, and GATEWAY databases to identify randomised controlled trials of micronutrient supplements using the search methods of the Cochrane HIV/AIDS Group. In the 2011 review the PubMed, EMBASE, and CENTRAL databases were searched in July 2011. As the GATEWAY database does not include conference abstracts after 2006, we also searched the AIDS‐specific conference database, www.aegis.org , and contacted researchers and organisations active in the field of research to identify additional unpublished trials. Selection criteria Randomised controlled trials were selected that compared the effects of micronutrient supplements (vitamins, trace elements, and combinations of these) with other supplements, placebo or no treatment on mortality, morbidity, pregnancy outcomes, immunologic indicators, and anthropometric measures in HIV‐positive pregnant and lactating women. Any adverse effects of supplementation were recorded. Data collection and analysis Two reviewer authors independently selected trials, appraised trial quality for risk of bias using standardised criteria, and extracted data using standardised forms. Where disagreements arose, a third author, acted as arbiter. Main results One additional trial is included in this update in addition to the three trials included in the 2010 update of the initial Cochrane review. Four relatively large, well‐conducted randomised controlled trials of the benefits of micronutrient supplementation have been conducted in pregnant and lactating women infected with HIV. Each of the trials evaluated a different micronutrient supplement and no direct comparisons or analyses can be made across the four trials. The four trials were conducted between 1995 and 2006. The trials have all been conducted by the same research team in Dar es Salaam in Tanzania, in an urban setting in hospital‐based antenatal clinics. Pregnant women were recruited with gestational age ranging from 12 to 27 weeks in each of the trials. Sample sizes range from 400 to 1129 with a median of 1000 participants. Three of the trials were placebo‐controlled. Different interventions have been evaluated in each trial, viz.:Vitamin A versus Vitamin A and multivitamins versus Multivitamins versus placebo; Selenium versus placebo; Zinc versus placebo; and Multiple RDA multivitamins versus Single RDA multivitamins. None of the women were receiving antiretrovrial therapy (ART). Multiple micronutrient supplements conferred multiple clinical benefits to pregnant women and their offspring. No significant adverse effects were reported. No significant clinical benefits were found from zinc supplementation of pregnant Tanzanian women. Selenium supplements given during and after pregnancy did not delay maternal HIV disease progression or improve pregnancy outcomes, but may improve child survival and decrease maternal diarrhoeal morbidity. There were no differences in maternal and infant outcomes when women received single RDA multivitamins or multiple RDA multivitamin supplementation. The evidence is lacking for the effects of micronutrient supplementation given concomitantly to pregnant women already initiated on antiretroviral therapy for treatment purposes. GRADE assessments were conducted on outcomes for each trial and included reviewing the data and the potential biases in each trial before grading the level of evidence. None of the trials were graded as providing high quality evidence primarily because there was no replication of results in other trials in other settings. Authors' conclusions In keeping with previous World Health Organization (WHO) recommendations everything possible should be done to promote and support adequate dietary intake of micronutrients, while recognising that this may not be sufficient to correct specific micronutrient deficiencies in all HIV‐infected individuals. Specific recommendations for pregnant and lactating women infected with HIV would be to include the provision of multivitamin supplements in single RDA formulations during the antenatal period and at least for 6 weeks post‐partum, especially for women who are breast‐feeding. There is no conclusive evidence to provide stand‐alone zinc or selenium supplementation to HIV‐infected pregnant and lactating women. Micronutrient supplementation should not be used as a substitute for provision of recommended antiretroviral medication for preventing mother‐to‐child transmission of HIV and treating maternal HIV infection when this is recommended. Further trials of single supplements are required to build the evidence base. The long‐term clinical benefits, adverse effects, and optimal formulation of multiple micronutrient supplements require further investigation in pregnant women at different stages of HIV infection. Plain language summary Micronutrient supplementation interventions to reduce harm in pregnant and lactating women living with HIV Micronutrients are vital components of a person’s daily food intake. Though only a small portion is necessary, a lack of micronutrients has been linked to tiredness, anaemia (low iron in blood), reduced learning ability, weaker immune system, and night blindness. In pregnant women, inadequate micronutrients have been shown to affect the development of the foetus and also the well‐being of the mother. In regions with high HIV prevalence, food availability may be scarce, which could lead to a double burden of disease in vulnerable/at‐risk populations. Specifically, pregnant and lactating women living with HIV may encounter the challenge of adequate food (including micronutrients) consumption, a weakened immune system, and the nutritional demands of a growing foetus or child. In this review, four randomised controlled trials, conducted between 1995 and 2006, assessed the benefits of micronutrient supplementation. The trials took place in an urban setting in hospital‐based antenatal clinics, with participants being pregnant women who ranged between 12‐27 weeks of their pregnancy, and sample sizes ranging from 400 to 1129 participants. Multiple micronutrient supplements improved the health of pregnant women and their offspring. No significant adverse effects were reported. Zinc supplementation did not show any significant beneficcial effects. Although it did not have any effect on the mother's pregnancy or her HIV disease, supplementation with selenium may increase the likelihood of a child surviving, and may reduce the likelihood of the mothers having diarrhoea. However, there is not enough evidence to determine the effect of micronutrient supplementation to pregnant women living with HIV who are being treated with antiretroviral medications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Siegfried, N; Irlam, JH; Visser, ME; Rollins, NN", "articleTypes": [], "doi": "10.1002/14651858.CD009755", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "94d02f00-f0bf-4e6e-a9ac-82ed808f0a77", "pmid": "", "title": "Laxatives for the management of constipation in people receiving palliative care", "imported": false, "abstract": "Abstract - Background This article describes the second update of a Cochrane review on the effectiveness of laxatives for the management of constipation in people receiving palliative care. Previous versions were published in 2006 and 2010 where we also evaluated trials of methylnaltrexone; these trials have been removed as they are included in another review in press. In these earlier versions, we drew no conclusions on individual effectiveness of different laxatives because of the limited number of evaluations. This is despite constipation being common in palliative care, generating considerable suffering due to the unpleasant physical symptoms and the availability of a wide range of laxatives with known differences in effect in other populations. Objectives To determine the effectiveness and differential efficacy of laxatives used to manage constipation in people receiving palliative care. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library ), MEDLINE, EMBASE, CINAHL and Web of Science (SCI & CPCI‐S) for trials to September 2014. Selection criteria Randomised controlled trials (RCTs) evaluating laxatives for constipation in people receiving palliative care. Data collection and analysis Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity. Main results We identified five studies involving the laxatives lactulose, senna, co‐danthramer, misrakasneham, docusate and magnesium hydroxide with liquid paraffin. Overall, the study findings were at an unclear risk of bias. As all five studies compared different laxatives or combinations of laxatives, it was not possible to perform a meta‐analysis. There was no evidence on whether individual laxatives were more effective than others or caused fewer adverse effects. Authors' conclusions This second update found that laxatives were of similar effectiveness but the evidence remains limited due to insufficient data from a few small RCTs. None of the studies evaluated polyethylene glycol or any intervention given rectally. There is a need for more trials to evaluate the effectiveness of laxatives in palliative care populations. Extrapolating findings on the effectiveness of laxatives evaluated in other populations should proceed with caution. This is because of the differences inherent in people receiving palliative care that may impact, in a likely negative way, on the effect of a laxative. Plain language summary Laxatives for the management of constipation in people receiving palliative care Background People with an incurable illness may receive palliative care, which involves making the person as comfortable as possible by controlling pain and other distressing symptoms. People receiving palliative care commonly experience constipation. This is as a result of the use of medicines (e.g. morphine) for pain control, as well as disease, dietary and mobility factors. There is a wide range of laxatives available. The aim of this review was to determine what we know about the effectiveness of laxatives for the management of constipation in people receiving palliative care. Study characteristics We searched medical databases for clinical trials of the use of laxatives for constipation in people receiving palliative care. Two review authors assessed study quality and extracted data. Key results and quality of evidence We identified five studies involving 370 people. The laxatives evaluated were lactulose, senna, co‐danthramer combined with poloxamer, docusate and magnesium hydroxide combined with liquid paraffin. Misrakasneham was also evaluated; this is a traditional Indian medicine and is used as a laxative, containing castor oil, ghee, milk and 21 types of herbs. There was no evidence on which laxative provided the best treatment. However, the review was limited as the evidence was from only five small trials and patient preference and cost were under evaluated. Further rigorous, independent trials are needed to evaluate the effectiveness of laxatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Candy, B, Jones, L, Larkin, PJ, Vickerstaff, V, Tookman, A, Stone, P", "articleTypes": [], "doi": "10.1002/14651858.CD003448.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.099Z" }, { "id": "94d06888-2521-40cd-bb94-7fd0621183f8", "pmid": "", "title": "Antibiotics versus placebo for acute bacterial conjunctivitis", "imported": false, "abstract": "Abstract - Background Acute bacterial conjunctivitis is an infection of the conjunctiva and is one of the most common ocular disorders in primary care. Antibiotics are generally prescribed on the basis that they may speed recovery, reduce persistence, and prevent keratitis. However, many cases of acute bacterial conjunctivitis are self‐limited, resolving without antibiotic therapy. This Cochrane Review was first published in The Cochrane Library in 1999, then updated in 2006, 2012, and 2022. Objectives To assess the benefits and side effects of antibiotic therapy in the management of acute bacterial conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2022, Issue 5), MEDLINE (January 1950 to May 2022), Embase (January 1980 to May 2022), the meta Register of Controlled Trials ( m RCT) ( www.controlled-trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ), and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases in May 2022. Selection criteria We included randomized controlled trials (RCTs) in which any form of antibiotic treatment, with or without steroid, had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical and systemic antibiotic treatments. Data collection and analysis Two authors independently reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies and determined the included RCTs, which were further assessed for risk of bias using Cochrane methodology. We performed data extraction in a standardized manner and conducted random‐effects meta‐analyses using RevMan Web. Main results We included 21 eligible RCTs, 10 of which were newly identified in this update. A total of 8805 participants were randomized. All treatments were topical in the form of drops or ointment. The trials were heterogeneous in terms of their eligibility criteria, the nature of the intervention (antibiotic drug class, which included fluoroquinolones [FQs] and non‐FQs; dosage frequency; duration of treatment), the outcomes assessed and the time points of assessment. We judged one trial to be of high risk of bias, four as low risk of bias, and the others as raising some concerns. Based on intention‐to‐treat (ITT) population, antibiotics likely improved clinical cure (resolution of clinical symptoms or signs) by 26% (RR 1.26, 95% CI 1.09 to 1.46; 5 trials, 1474 participants; moderate certainty) as compared with placebo. Subgroup analysis showed no differences by antibiotic class (P = 0.67) or treatment duration (P = 0.60). In the placebo group, 55.5% (408/735) of participants had spontaneous clinical resolution by days 4 to 9 versus 68.2% (504/739) of participants treated with an antibiotic. Based on modified ITT population, in which participants were analyzed after randomization on the basis of positive microbiological culture, antibiotics likely increased microbiological cure (RR 1.53, 95% CI 1.34 to 1.74; 10 trials, 2827 participants) compared with placebo at the end of therapy; there were no subgroup differences by drug class (P = 0.60). No study evaluated the cost‐effectiveness of antibiotic treatment. Patients receiving antibiotics had a lower risk of treatment incompletion than those in the placebo group (RR 0.64, 95% CI 0.52 to 0.78; 13 trials, 5573 participants; moderate certainty) and were 27% less likely to have persistent clinical infection (RR 0.73, 95% CI 0.65 to 0.81; 19 trials, 5280 participants; moderate certainty). There was no evidence of serious systemic side effects reported in either the antibiotic or placebo group (very low certainty). When compared with placebo, FQs (RR 0.70, 95% CI 0.54 to 0.90) but not non‐FQs (RR 4.05, 95% CI 1.36 to 12.00) may result in fewer participants with ocular side effects. However, the estimated effects were of very low certainty. Authors' conclusions The findings of this update suggest that the use of topical antibiotics is associated with a modestly improved chance of resolution in comparison to the use of placebo. Since no evidence of serious side effects was reported, use of antibiotics may therefore be considered to achieve better clinical and microbiologic efficacy than placebo. Increasing the proportion of participants with clinical cure or increasing the speed of recovery or both are important for individual return to work or school, allowing people to regain quality of life. Future studies may examine antiseptic treatments with topical antibiotics for reasons of cost and growing antibiotic resistance. Plain language summary What are the benefits and harms of antibiotics for acute bacterial conjunctivitis? Key messages Topical antibiotics may improve signs and symptoms as well as bacterial clearance in participants with acute bacterial conjunctivitis. However, some antibiotics can cause unwanted effects on the eyes or eyelids; no evidence suggests that antibiotics cause unwanted effects in other parts of the body. What is acute bacterial conjunctivitis? Acute bacterial conjunctivitis is a condition in which the thin layer over the white areas and the inside lining of the eyelids of one or both eyes becomes red and inflamed from a bacterial infection. Acute bacterial conjunctivitis is usually contagious and hence children and working adults are advised to avoid going to school or work when affected. Fortunately, it resolves spontaneously in most cases. How is acute bacterial conjunctivitis treated? People with acute bacterial conjunctivitis are often given treatment at the site of the infection, usually as antibiotic eye drops or ointment, to speed recovery. However, the benefits of antibiotics have been questioned when considering they can cause irritation or allergic reaction in and around the eyes or surrounding skin. What did we want to find out? We examined whether antibiotics alone or in combination with steroid, can improve signs and symptoms of conjunctivitis or help clear the associated bacteria. We also evaluated whether antibiotics would result in undesirable effects on the eyes. What did we do? We performed a systematic review by searching for studies that compared antibiotics in eyedrop, ointment, or tablet form with inactive controls. We summarized these study findings and reported the results together with our level of confidence in them based on how studies were conducted. What did we find? We found that antibiotics likely increase clinical cure and microbiological cure after a course of treatment in comparison with placebo. Antibiotic use also is associated with fewer participants stopping their treatment earlier than they are supposed to. However, for some individuals, non‐fluroquinolone but not fluoroquinolone antibiotics, may result in more unwanted effects on the eyes or eyelids than placebo though we were very uncertain about the relevant evidence. There was no evidence that antibiotics were associated with systemic side effects such as headache or altered sense of smell. What are the limitations of the evidence? The current update focused on adults and children aged one month or older. Therefore, the evidence does not pertain to antibiotic treatment for neonatal conjunctivitis in neonates younger than one month old. We did not find studies that compared effects of the same antibiotics used in short versus long duration. Therefore, the current review was unable to suggest for or against the prescription duration for acute bacterial conjunctivitis. How up‐to‐date is this evidence? The evidence is up‐to‐date as of April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Chen, Y-Y; Liu, A-HS; Nurmatov, U; van Schayck, OCP; Kuo, IC", "articleTypes": [], "doi": "10.1002/14651858.CD001211.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "9500848c-2438-4f46-8eac-0dab1b6f49a9", "pmid": "", "title": "Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Ethnic minority groups in upper‐middle‐income and high‐income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population. Objectives To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Search methods A systematic literature search was performed of the following databases: The Cochrane Library , MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well. Selection criteria We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper‐middle‐income or high‐income countries. Data collection and analysis Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification. Main results A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta‐analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education. Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) ‐0.4% (95% confidence interval (CI) ‐0.5 to ‐0.2); 14 trials; 1442 participants; high‐quality evidence) and at six months (MD ‐0.5% (95% CI ‐0.7 to ‐0.4); 14 trials; 1972 participants; high‐quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD ‐0.2% (95% CI ‐0.3 to ‐0.04); 9 trials; 1936 participants) and at 24 months (MD ‐0.3% (95% CI ‐0.6 to ‐0.1); 4 trials; 2268 participants; moderate‐quality evidence) post intervention. Neutral effects on health‐related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies — the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI ‐40 to ‐8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low‐density lipoprotein (LDL) cholesterol or high‐density lipoprotein (HDL) cholesterol were reported at any follow‐up point. Other outcome measures (blood pressure, body mass index, self‐efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient. Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self‐reported via questionnaires, leading to high bias in subjective outcome assessment. Authors' conclusions Culturally appropriate health education has short‐ to medium‐term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long‐term trials, and so clinically important long‐term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long‐term, standardised, multi‐centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium‐term effects could lead to clinically important health outcomes, if sustained. Plain language summary Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus Review question Does culturally appropriate diabetes health education lead to better outcomes than 'usual care' for people in ethnic minority groups with type 2 diabetes? Background In upper‐middle‐income and high‐income countries, minority ethnic groups often have a higher prevalence of type 2 diabetes mellitus than is seen in the local population. They also tend to come from lower socioeconomic backgrounds, with attendant difficulties in accessing good‐quality health care. In some cases, cultural and communication barriers increase the problems that minority ethnic communities experience when attempting to access good‐quality diabetes health education, which is vital for those who wish to understand diabetes and use available services to gain empowerment and bring about behaviour change toward a healthier lifestyle. In this review, 'culturally appropriate' health education is taken to mean any type of health education that has been specifically tailored to the cultural needs of a target minority group with type 2 diabetes mellitus. Study characteristics This updated review found in the world literature 33 randomised controlled trials (RCTs) of culturally appropriate health education on diabetes that met the selection criteria (participants from a defined ethnic minority group living in a upper‐middle‐income or high‐income country, over 16 years of age, diagnosed with type 2 diabetes mellitus and receiving a culturally tailored health education intervention). The median duration of the intervention was six months, and a total of 7453 participants were involved in the studies. Key results Culturally appropriate health education improved blood sugar control among participants, compared with those receiving 'usual' care, at three, six, 12 and 24 months after the intervention was provided. Knowledge about diabetes improved, and participants attained healthier lifestyles. No information was available regarding complications of diabetes and death from any cause, and there was a general lack of reporting of adverse effects in most studies. Neutral effects were observed for health‐related quality of life, blood lipids like cholesterol, blood pressure and weight. The costs of educational programmes were rarely analysed. Compared with the first review, performed in 2008 (11 studies), many more published studies were identified in this review (altogether 33 studies), strengthening the original findings that blood sugar control and knowledge of diabetes are improved when culturally appropriate health education is provided to people in ethnic minority groups diagnosed with diabetes. The effects of this improvement are shown in this update as lasting longer — up to 24 months after health education was provided in some trials. However, additional high‐quality standardised RCTs of longer duration are needed, along with full evaluation of costs. Quality of the evidence Heterogeneity of the studies, in terms of populations studied, type and duration of health education provided, variety of outcomes measured and differences in timing of assessment, limits interpretation of our findings. Also, risk of bias was judged to be high for many outcomes. Currentness of evidence This evidence is up‐to‐date as of September 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Attridge, M, Creamer, J, Ramsden, M, Cannings‐John, R, Hawthorne, K", "articleTypes": [], "doi": "10.1002/14651858.CD006424.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.823Z" }, { "id": "95118cf6-ac69-441a-b039-0e59ea80b77e", "pmid": "", "title": "Chlorambucil for patients with primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. But it is unknown whether it benefits or harms these patients. Objectives To evaluate the beneficial and any harmful effects of chlorambucil for primary biliary cirrhosis patients. Search methods Eligible trials were identified by searching the Cochrane Hepato‐Biliary Group Controlled Trials Register (March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2012, Issue 2), MEDLINE (1946 to March 2012), EMBASE (1974 to March 2012), Science Citation Index EXPANDED (1900 to March 2012), The Chinese Biomedical Database (1976 to March 2012), The Chinese Medical Current Contents (1994 to March 2012), The China Hospital Knowledge Database (1994 to March 2012), and a database of ongoing trials (http://www.controlled‐trials.com/mrct/) (accessed 6 March 2012). The reference lists of the retrieved publications and review articles were also read through, and pharmaceutical companies known to produce chlorambucil were contacted. Selection criteria Randomised clinical trials, irrespective of language, year of publication, and publication status, comparing chlorambucil at any dose versus placebo, no intervention, another active drug, or one dose of chlorambucil with another dose. Data collection and analysis We planned to assess continuous data with mean differences (MD), and dichotomous outcomes with relative risk (RR), both with 95% confidence intervals (CI). As we only identified one trial, Fisher's exact tests were employed. Main results Only one randomised trial was identified and included in the review. The bias risk in the trial was high. The trial compared chlorambucil versus no intervention in 24 patients with primary biliary cirrhosis. Fisher's exact test did not show a significant reduction of mortality when comparing chlorambucil with no treatment (0/13 (0%) versus (2/11 (18.2%); P = 0.20). There was no significant difference regarding adverse events for chlorambucil compared with no treatment, but all patients receiving chlorambucil experienced adverse events (13/13 (100%) versus (3/11 (27%); P = 0.1). According to the authors of the trial, chlorambucil led to a significant improvement in mean serum levels of bilirubin (P < 0.05), albumin (P < 0.05), immunoglobulin M (P < 0.01), serum aspartate aminotransferase activity (P < 0.01), and hepatic inflammatory infiltrates (P < 0.01). Authors' conclusions There is not sufficient evidence to support or reject the use of chlorambucil for patients with primary biliary cirrhosis. Chlorambucil may show benefit in some unvalidated surrogate outcome measures (for example, serum bilirubin and immunoglobulin M levels). Chlorambucil is, however, connected with a number of adverse events. Bone marrow suppression should be noted in particular. Further randomised clinical trials are necessary to assess the benefits and harms of chlorambucil in this indication. Plain language summary Chlorambucil for patients with primary biliary cirrhosis Primary biliary cirrhosis is an autoimmune disease of the liver. Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. This review aimed to assess the beneficial or harmful effects of chlorambucil for primary biliary cirrhosis. The authors identified only one randomised trial, with 24 participants included. This trial compared chlorambucil with no intervention. The trial is small and at a high risk of bias, which suggests that the results may not be reliable. Meta‐analyses were not possible because of the inclusion of one trial only. Fisher's exact test and t‐test were used instead. Chlorambucil was not associated with significantly lower mortality when compared with no intervention. All patients on chlorambucil experienced adverse events, especially bone marrow suppression. Chlorambucil led to a significant improvement in mean serum levels of bilirubin, albumin, immunoglobulin M, serum aspartate aminotransferase activity, and hepatic inflammatory infiltrates. However, these outcomes are unvalidated surrogate outcomes for patient‐relevant outcomes. This means that improvement of these biochemistry measures cannot be taken as proof of improvement of patient‐relevant outcomes. It remains unclear whether chlorambucil can be supported or rejected for use in patients with primary biliary cirrhosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Li, WX, Yan, X, Shi, CR, Zhang, AP", "articleTypes": [], "doi": "10.1002/14651858.CD008714.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.758Z" }, { "id": "9514397f-75ae-494f-a53d-889793391b8f", "pmid": "", "title": "Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long‐term central venous catheters in infants and children", "imported": false, "abstract": "Abstract - Background Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015. Objectives To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long‐term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC). Data collection and analysis Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random‐effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review. Main results We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin. Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC‐associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC‐associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low‐certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate‐certainty evidence), and not reported in the remaining studies. Authors' conclusions The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC‐associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains. Plain language summary Replacing heparin flushing with saline flushing to prevent complications in long‐term central venous catheters in children Background A central venous catheter (CVC) is a long, thin, flexible tube which is inserted into a large central vein. This enables access to the blood stream for people with serious medical conditions to receive medications and fluids, as well as the collection of blood specimens. Long‐term CVCs are used to access the blood system in children with complex medical conditions like cancer. To stop the catheter from becoming blocked it is usual to use heparin, a drug that prevents clots forming, to flush the catheter. However, some studies have shown that heparin is not necessary, and that normal saline (a sterile salt water solution) can be safely used instead. Heparin may be associated with complications, such as bleeding and infection, along with higher costs for healthcare providers. While the complications such as infections and occlusions are uncommon, practices vary around the world and there are many inconsistencies regarding the best flush solution to use to prevent complications in long‐term catheters. Study characteristics and key results This review included randomised controlled trials (clinical studies where people were randomly assigned into one of two or more treatment groups) that compared the use of saline and heparin to prevent blockage, and other complications related to long‐term catheters. The evidence is current to 9 April 2019. Two review authors independently reviewed the studies. We included four studies with a total of 255 participants in the review. The four trials were all undertaken in large teaching (tertiary) hospitals, and directly compared the use of saline and heparin. The studies were, however, very different in the way they compared saline and heparin, with different concentrations of heparin and different frequencies of flushes reported. We were able to combine the results of two studies: the analysis showed imprecise results for the blocking of catheters and blood stream infections for normal saline versus heparin. One study reported the duration of catheter placement to be similar between the two study arms. Certainty of the evidence The overall certainty of the evidence ranged from moderate to very low. There was high risk of bias for blinding, there were differences between the studies methods and interventions, inconsistent results between the studies, and not all studies reported all outcomes of interest. We found there was not enough evidence to determine which solution, saline or heparin, is more effective for reducing complications. Further research is required and is likely to have an important impact in this area. This review is an update of a review first published in 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bradford, NK; Edwards, RM; Chan, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD010996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "951fe4a2-652f-4a7c-be21-b8c5c26ed544", "pmid": "", "title": "Interventions for managing taste disturbances", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kumbargere Nagraj, S, George, RP, Shetty, N, Levenson, D, Ferraiolo, DM, Shrestha, A", "articleTypes": [], "doi": "10.1002/14651858.CD010470.pub3 AB - Abstract - Background The sense of taste is very much essential to the overall health of an individual. It is a necessary component to enjoy one's food, which in turn provides nutrition to an individual. Any disturbance in taste perception can hamper quality of life in such patients by influencing their appetite, body weight and psychological well‐being. Taste disorders have been treated using different modalities of treatment and there is no consensus for the best intervention. Hence this Cochrane Review was undertaken. This is an update of the Cochrane Review first published in November 2014. Objectives To assess the effects of interventions for the management of patients with taste disturbances. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 4 July 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017 Issue 6) in the Cochrane Library (searched 4 July 2017); MEDLINE Ovid (1946 to 4 July 2017); Embase Ovid (1980 to 4 July 2017); CINAHL EBSCO (1937 to 4 July 2017); and AMED Ovid (1985 to 4 July 2017). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for trials. Abstracts from scientific meetings and conferences were searched on 25 September 2017. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included all randomised controlled trials (RCTs) comparing any pharmacological agent with a control intervention or any non‐pharmacological agent with a control intervention. We also included cross‐over trials in the review. Data collection and analysis Two pairs of review authors independently, and in duplicate, assessed the quality of trials and extracted data. Wherever possible, we contacted trial authors for additional information. We collected adverse events information from the trials. Main results We included 10 trials (581 participants), nine of which we were able to include in the quantitative analyses (566 participants). We assessed three trials (30%) as having a low risk of bias, four trials (40%) at high risk of bias and three trials (30%) as having an unclear risk of bias. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Of these, nine trials with 544 people compared zinc supplements to placebo for patients with taste disorders. The participants in two trials were children and adolescents with respective mean ages of 10 and 11.2 years and the other seven trials had adult participants. Out of these nine, two trials assessed the patient‐reported outcome for improvement in taste acuity using zinc supplements (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.94 to 2.09; 119 participants, very low‐quality evidence). We meta‐analysed for taste acuity improvement using objective outcome (continuous data) in idiopathic and zinc‐deficient taste disorder patients (standardised mean difference (SMD) 0.44, 95% CI 0.23 to 0.65; 366 participants, three trials, very low‐quality evidence). We also analysed one cross‐over trial separately using the first half of the results for taste detection (mean difference (MD) 2.50, 95% CI 0.93 to 4.07; 14 participants, very low‐quality evidence), and taste recognition (MD 3.00, 95% CI 0.66 to 5.34; 14 participants, very low‐quality evidence). We meta‐analysed taste acuity improvement using objective outcome (dichotomous data) in idiopathic and zinc‐deficient taste disorder patients (RR 1.42, 95% 1.09 to 1.84; 292 participants, two trials, very low‐quality evidence). Out of the nine trials using zinc supplementation, four reported adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase, and minor increase in blood triglycerides. One trial tested taste discrimination using acupuncture (MD 2.80, 95% CI ‐1.18 to 6.78; 37 participants, very low‐quality evidence). No adverse events were reported in the acupuncture trial. None of the included trials could be included in the meta‐analysis for health‐related quality of life in taste disorder patients. Authors' conclusions We found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders. We did not find any evidence to conclude the role of zinc supplements for improving taste discrimination, or any evidence addressing health‐related quality of life due to taste disorders. We found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste). We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. Plain language summary Interventions for managing taste disturbances What is the aim of this review? The aim of this Cochrane Review was to find out what is the best method for the management of zinc‐deficient/idiopathic (of unknown cause) taste disorders and taste disorders secondary to chronic renal failure in children and adults. Key messages Giving zinc supplements or acupuncture may have some benefit in treating taste disorders. However, we still need more high‐quality studies to ascertain the role of zinc supplements and acupuncture in treating taste disorders. What was studied in the review? The sense of taste is essential to the health and psychological well‐being of an individual. Taste disorders can range from lack of taste, to distortion of taste, to reduced ability to taste. Any disorder in taste perception can lead to conditions like malnutrition and consumption of poisonous food substances. The cause may be due to disease, drugs, radiation treatment, or ageing; or it may result from unknown causes. Various treatment methods have been used to improve taste sensation. These include the use of zinc compounds, pilocarpine, alpha lipoic acid, transcranial magnetic stimulation, ginkgo biloba and acupuncture. What are the main results of the review? We collected and analysed all relevant studies to answer this question and found 10 trials in which a total of 581 subjects received different treatments. Nine trials assessed the benefits of zinc compounds and one trial assessed the effects of acupuncture. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Two trials were from Germany, three from Japan, two from the UK, and three from the US. These studies compared zinc with placebo or acupuncture with sham procedure for patients with taste disorders. Two were government funded, three were privately funded, two were funded by a pharmaceutical company and three trials did not mention funding details. When patients with taste disorders are given zinc, compared to placebo: ‐ we found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders;
 ‐ zinc supplementation showed adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase and minor increase in blood triglycerides;
 ‐ no studies were found that looked at improvement in taste discrimination or quality of life. When patients with taste disorders are given acupuncture, compared to sham procedure: ‐ we found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste);
 ‐ acupuncture trial did not show adverse events;
 ‐ no studies were found that looked at improvement in taste acuity or quality of life. We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. How up‐to‐date is this review? We searched for studies that had been published up to 4 July 2017.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.725Z" }, { "id": "952a959e-aaf6-4610-b71a-5cba92ec20aa", "pmid": "", "title": "Bile acids for liver‐transplanted patients", "imported": false, "abstract": "Abstract - Background Liver transplantation has become a widely accepted form of treatment for numerous end‐stage liver diseases. Bile acids may decrease allograft rejection after liver transplantation by changing the expression of major histocompatibility complex class molecules in bile duct epithelium and central vein endothelium. Objectives To assess the beneficial and harmful effects of bile acids for liver‐transplanted patients. Search methods We performed searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials in The Cochrane Library , MEDLINE , EMBASE , and Science Citation Expanded to September, 2009. Selection criteria Randomised clinical trials comparing any dose of bile acids or duration of treatment in liver‐transplanted patients versus placebo, no intervention, or another intervention. We included randomised clinical trials irrespective of blinding, language, and publication status. Data collection and analysis Two review authors extracted and checked data independently. We evaluated the risk of bias of the trials from the method of allocation sequence generation, allocation concealment, blinding, outcome data analysis, outcome data reporting, and other potential sources of bias. We used the intention‐to‐treat principle to perform meta‐analyses and presented the outcomes as relative risks (RR) or mean differences (MD), both with 95% confidence intervals (CI). Main results The updated search resulted in no new trials meeting the inclusion criteria of this review, thus leaving it to the seven already included randomised trials (six evaluating ursodeoxycholic acid versus placebo or no intervention, and one evaluating tauro‐ursodeoxycholic acid versus no intervention) enrolling a total of 335 participants. The administration of bile acids began one day or more after liver transplantation. All patients received the standard triple‐drug immunosuppressive regimen (steroids, azathioprine, and cyclosporine or tacrolimus) to suppress the allograft rejection response after liver transplantation. Bile acids compared with placebo or no intervention did not significantly change all‐cause mortality (RR 0.85, 95% CI 0.53 to 1.36), mortality related to allograft rejection (RR 0.30, 95% CI 0.01 to 7.12), retransplantation (RR 0.76, 95% CI 0.20 to 2.86), acute cellular rejection, or number of patients with steroid‐resistant rejection. Bile acids significantly reduced the number of patients who had chronic rejection in a fixed‐effect model but not in a random‐effects model meta‐analysis. Bile acids were safe and well tolerated by liver‐transplanted patients. However, this observation is based on data analysis from three trials with only 187 patients. Authors' conclusions We did not find evidence to support or refute bile acids for liver‐transplanted patients. Further randomised trials are necessary before bile acids can be recommended to liver‐transplanted patients. Plain language summary Bile acids for liver‐transplanted patients Liver transplantation is a major surgical procedure that has been practiced for more than forty years and has nowadays become a generally accepted treatment option in patients with end‐stage liver disease. The most common cause for liver transplantation in adults is cirrhosis caused by various types of liver injuries such as infections (hepatitis B and C), alcohol, autoimmune liver diseases, early‐stage liver cancer, metabolic and hereditary disorders, but also diseases of unknown aetiology. All transplant recipients need lifetime immunosuppressive therapy to prevent transplant rejection. Bile acids are being used for a variety of chronic liver diseases, mainly primary biliary cirrhosis and primary sclerosing cholangitis. However, their mechanisms of action and beneficial and harmful effects are poorly understood. This has led to the idea of the potential use of bile acids to prevent rejection in liver‐transplanted patients. Results of the seven randomised clinical trials included in the review in which patients received standard immunosuppressive treatment (steroids, azathioprine, and cyclosporine or tacrolimus) with or without bile acids after liver transplantation, did not show any significant effects of bile acids on all‐cause mortality, mortality related to rejection, acute cellular rejection, steroid resistant rejection, or need for retransplantation. One analysis suggested that bile acids might beneficially influence number of patients with chronic rejection, but was contradicted by the analyses. The evidence that the use of ursodeoxycholic acid might have beneficial effects on chronic rejection and length of hospitalisation is weak as it is produced from trials with high risk of bias and insufficient number of included patients. That bile acids seemed well tolerated, with no reports of serious adverse events, is good knowledge, but much more research is needed before their use is acquitted. None of the randomised clinical trials assessed the effects of bile acids on quality of life or cost‐effectiveness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Poropat, G, Giljaca, V, Stimac, D, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005442.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.117Z" }, { "id": "952cbdb2-1e27-44b5-aae1-340f6ee04e83", "pmid": "", "title": "Omega‐6 fats for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐6 fats are polyunsaturated fats vital for many physiological functions, but their effect on cardiovascular disease (CVD) risk is debated. Objectives To assess effects of increasing omega‐6 fats (linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA)) on CVD and all‐cause mortality. Search methods We searched CENTRAL, MEDLINE and Embase to May 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher versus lower omega‐6 fat intake in adults with or without CVD, assessing effects over at least 12 months. We included full texts, abstracts, trials registry entries and unpublished studies. Outcomes were all‐cause mortality, CVD mortality, CVD events, risk factors (blood lipids, adiposity, blood pressure), and potential adverse events. We excluded trials where we could not separate omega‐6 fat effects from those of other dietary, lifestyle or medication interventions. Data collection and analysis Two authors independently screened titles/abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias of included trials. We wrote to authors of included studies. Meta‐analyses used random‐effects analysis, while sensitivity analyses used fixed‐effects and limited analyses to trials at low summary risk of bias. We assessed GRADE quality of evidence for 'Summary of findings' tables. Main results We included 19 RCTs in 6461 participants who were followed for one to eight years. Seven trials assessed the effects of supplemental GLA and 12 of LA, none DGLA or AA; the omega‐6 fats usually displaced dietary saturated or monounsaturated fats. We assessed three RCTs as being at low summary risk of bias. Primary outcomes : we found low‐quality evidence that increased intake of omega‐6 fats may make little or no difference to all‐cause mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.88 to 1.12, 740 deaths, 4506 randomised, 10 trials) or CVD events (RR 0.97, 95% CI 0.81 to 1.15, 1404 people experienced events of 4962 randomised, 7 trials). We are uncertain whether increasing omega‐6 fats affects CVD mortality (RR 1.09, 95% CI 0.76 to 1.55, 472 deaths, 4019 randomised, 7 trials), coronary heart disease events (RR 0.88, 95% CI 0.66 to 1.17, 1059 people with events of 3997 randomised, 7 trials), major adverse cardiac and cerebrovascular events (RR 0.84, 95% CI 0.59 to 1.20, 817 events, 2879 participants, 2 trials) or stroke (RR 1.36, 95% CI 0.45 to 4.11, 54 events, 3730 participants, 4 trials), as we assessed the evidence as being of very low quality. We found no evidence of dose‐response or duration effects for any primary outcome, but there was a suggestion of greater protection in participants with lower baseline omega‐6 intake across outcomes. Additional key outcomes : we found increased intake of omega‐6 fats may reduce myocardial infarction (MI) risk (RR 0.88, 95% CI 0.76 to 1.02, 609 events, 4606 participants, 7 trials, low‐quality evidence). High‐quality evidence suggests increasing omega‐6 fats reduces total serum cholesterol a little in the long term (mean difference (MD) −0.33 mmol/L, 95% CI −0.50 to −0.16, I 2 = 81%; heterogeneity partially explained by dose, 4280 participants, 10 trials). Increasing omega‐6 fats probably has little or no effect on adiposity (body mass index (BMI) MD −0.20 kg/m 2 , 95% CI −0.56 to 0.16, 371 participants, 1 trial, moderate‐quality evidence). It may make little or no difference to serum triglycerides (MD −0.01 mmol/L, 95% CI −0.23 to 0.21, 834 participants, 5 trials), HDL (MD −0.01 mmol/L, 95% CI −0.03 to 0.02, 1995 participants, 4 trials) or low‐density lipoprotein (MD −0.04 mmol/L, 95% CI −0.21 to 0.14, 244 participants, 2 trials, low‐quality evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐6 fats on cardiovascular health, mortality, lipids and adiposity to date, using previously unpublished data. We found no evidence that increasing omega‐6 fats reduces cardiovascular outcomes other than MI, where 53 people may need to increase omega‐6 fat intake to prevent 1 person from experiencing MI. Although benefits of omega‐6 fats remain to be proven, increasing omega‐6 fats may be of benefit in people at high risk of MI. Increased omega‐6 fats reduce serum total cholesterol but not other blood fat fractions or adiposity. Plain language summary Omega‐6 fats to prevent and treat heart and circulatory diseases Review question We reviewed randomised trials (participants had an equal chance to be assigned to either treatment) examining effects of higher omega‐6 fats compared to lower omega‐6 fats on deaths and heart and circulatory diseases (cardiovascular diseases (CVD), which include heart attacks and strokes). Background Omega‐6 fats are essential, we must obtain some from food. They are important for regulating energy production (part of metabolism), bone, skin and hair health. Many foods contain omega‐6 fats, particularly vegetable oils and nuts. Omega‐6 fats include linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA). Some evidence suggests that a higher intake of omega‐6 fats, along with a lower intake of saturated fat (from animal sources such as meat and cheese) can reduce coronary heart disease. In contrast, there is concern that high levels of omega‐6 fats may worsen cardiovascular risk by increasing inflammation. Overall, there is no conclusive evidence on the benefits or harms of omega‐6 fat intake on heart and circulatory diseases or on other health outcomes. Study characteristics Evidence in this review is current to May 2017. We found 19 studies recruiting 6461 adults. These studies assessed the effects of higher compared to lower omega‐6 fat intake on heart and circulatory diseases as well as deaths. We found that three trials were highly trustworthy (with good designs that produce reliable evidence). Studies took place in North America, Asia, Europe and Australia, and eight were funded only by national or charitable agencies. Participants increased their omega‐6 fats or maintained their usual fats for at least one year and up to eight years. Key results We found that increasing omega‐6 fats may make little or no difference to deaths or cardiovascular events but may reduce risk of heart attacks (low‐quality evidence). Evidence was weakened by study design problems, small numbers of events, low numbers of participants from developing countries, and few women. Evidence suggests that increasing omega‐6 fats reduces blood cholesterol (high‐quality evidence), probably has little or no effect on body weight adjusted for height (all moderate‐quality evidence), and may make little or no difference to triglycerides, high‐density lipoprotein (HDL, the 'good' cholesterol) or low‐density lipoprotein (LDL, the 'bad' cholesterol, low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hooper, L, Al‐Khudairy, L, Abdelhamid, AS, Rees, K, Brainard, JS, Brown, TJ, Ajabnoor, SM, O'Brien, AT, Winstanley, LE, Donaldson, DH, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011094.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.825Z" }, { "id": "953837de-21eb-4d56-a014-ea1296f6d4da", "pmid": "", "title": "Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Chronic infection with Pseudomonas aeruginosa (PA) in cystic fibrosis (CF) is a source of much morbidity and mortality. Eradication of early PA infection is possible, but can recur in many individuals. We sought to examine strategies to delay the time to PA recurrence in people with CF. Objectives To establish whether secondary prevention strategies, using antibiotics or other therapies, increase the chances of people with CF remaining free from PA infection following successful eradication therapy. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries and the reference lists of relevant articles and reviews. Date of last search: 21 August 2019. Selection criteria Randomised controlled trials (and quasi‐randomised trials where the risk of bias was low) comparing any treatment modality aimed at preventing recurrence of PA infection with placebo, standard therapy or any other treatment modality in people with CF who have undergone successful eradication of PA. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias. Quality of the evidence was assessed using GRADE. Conflicts were resolved by discussion and the opinion of a third review author was sought where necessary. Only a subset of participants in the included trial were eligible, therefore individual participant data were requested and obtained from the trial investigators. Main results We included one trial (n = 306) in the review; however, only 253 participants had undergone successful eradication of PA, so fulfilling the inclusion criteria for our review. Information presented relates only to the included subset of participants. The trial recruited children aged one to 12 years (mean (standard deviation (SD)) age of 5.8 (3.5) years), 129 participants (51.0%) were female and the median follow‐up was 494 days. We compared cycled therapy with tobramycin inhalation solution (TIS), in which participants underwent 28 days of TIS every three months, with culture‐based therapy, in which participants were only prescribed medication when a quarterly sputum sample was positive for PA. Reasons for downgrading the quality of the evidence included applicability (only included children), incomplete outcome data and a small number of participants. The time to next isolation of PA was probably shorter with cycled TIS therapy than with culture‐based therapy, hazard ratio (HR) 2.04 days (95% confidence interval (CI) 1.28 to 3.26) (moderate‐quality evidence). This is in contrast to the main publication of the only included trial, which examined rate of PA positivity rather than time to PA infection and included participants not eligible for inclusion in this review. At the end of the trial, there was no difference between the cycled and culture‐based groups in the change from baseline in forced expiratory volume in one second (FEV 1 ) L, mean difference (MD) 0.0 L (95% CI ‐0.09 to 0.09) or in FEV 1 % predicted, MD 0.70% (95% CI ‐4.33 to 5.73) (both very low‐quality evidence). There was no difference in the change from baseline for FVC between the groups. There was also no difference in the frequency of pulmonary exacerbations between groups, MD ‐0.18 (95% CI ‐0.51 to 0.14) (moderate‐quality evidence). Similarly, there was no difference between groups in the risk of participants developing novel resistant bacteria, RR 1.00 (95% CI 0.67 to 1.5) (moderate‐quality evidence). There were more severe adverse events in the cycled group, but the type of treatment probably makes little or no difference to the results, RR 0.65 (95% CI 0.39 to 1.11) (moderate‐quality evidence). There was no difference between groups in the change in weight or height from baseline or in rates of adherence to tobramycin or all trial medicines. The included trial did not assess changes in quality of life, the time to chronic infection with PA or the cost‐effectiveness of treatment. Authors' conclusions Cycled TIS therapy may be beneficial in prolonging the time to recurrence of PA after successful eradication, but further trials are required, specifically addressing this question and in both adults and children. Plain language summary Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis Review question We reviewed evidence about the effect of treatments given to people with cystic fibrosis (CF) to prevent recurrence of infection with bacteria called Pseudomonas aeruginosa (PA) after it has been successfully treated. Background People with CF experience frequent, severe chest infections. These infections may be caused by bacteria that do not cause disease in healthy people, such as PA. PA is an important infection in CF since if it is not treated early it cannot be cleared from the lungs (termed chronic PA). When it cannot be cleared from the lungs, it causes ongoing damage to the lung tissue as well as worse chest infections. People with CF who have chronic PA may be more unwell than those without it. Early treatment can remove PA from the lungs of people with CF, but infection can happen again and is difficult to prevent. We want to know if giving extra treatment after the PA has been successfully treated, can prolong the time to the next infection. The treatment could be antibiotics or another treatment, for example something that helps the person's immune system fight the PA. Search date The evidence is current to: 21 August 2019. Trial characteristics We included one trial with 306 participants. Only 253 of these people had had successful treatment of PA and so could be included in our review. There were only children in the trial who were aged between one and 12 years old; 51% were girls. The trial compared treatment with one month of an inhaled antibiotic every three months ('cycled treatment') with antibiotic treatment given only when the person was found to have PA ('culture‐based treatment'). People were selected randomly to have either cycled or culture‐based treatment. The trial followed people up for an average of 70 weeks. Key results Taking into the account the certainty of the evidence, we believe that the time to the next isolation of PA was probably shorter with cycled therapy than with culture‐based therapy. We found that PA recurred in a quarter of participants in the culture‐based group by 249 days but in the cycled group it took 505 days; giving cycled treatment doubled the time to a new infection with PA compared with culture‐based treatment. This is in contrast to the main publication of the only included trial, which looked at the rate of positive PA cultures rather than the time to a new infection of PA and included participants not eligible for inclusion in this review. There was no difference between the groups in: pulmonary function (a measure of how well someone's lungs are working); in the number of people having chest infections; in the change in height and weight from the beginning to th end of the trial; in how many people took all the doses of the medications; in how many people developed infections with new bacteria; or in how many people had a serious complication. The trial did not give information about the effect of the two treatments on individuals' quality of life, the time until the development of chronic PA or the cost‐effectiveness of the treatment. Quality of the evidence The quality of most of the evidence was moderate. As the trial only included children, we cannot be sure if the cycled treatment would have the same effect in teenagers or adults with CF. Further trials including both adults and children are needed to help answer the question. Trials designed to specifically answer this question are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Palser, S; Smith, S; Nash, EF; Agarwal, A; Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD012300.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "9538f68a-e4e1-4fb9-8309-f30b92a1b924", "pmid": "", "title": "Interventions for hyperthyroidism pre‐pregnancy and during pregnancy", "imported": false, "abstract": "Abstract - Background Women with hyperthyroidism in pregnancy have increased risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction; and they can develop severe pre‐eclampsia or placental abruption. Objectives To identify interventions used in the management of hyperthyroidism pre‐pregnancy or during pregnancy and to ascertain the impact of these interventions on important maternal, fetal, neonatal and childhood outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 September 2013). Selection criteria We planned to include randomised controlled trials, quasi‐randomised controlled trials, and cluster‐randomised trials comparing antithyroid interventions for hyperthyroidism pre‐pregnancy or during pregnancy with another intervention or no intervention (placebo or no treatment). Data collection and analysis Two review authors assessed trial eligibility and planned to assess trial quality and extract the data independently. Main results No trials were included in the review. Authors' conclusions As we did not identify any eligible trials, we are unable to comment on implications for practice, although early identification of hyperthyroidism before pregnancy may allow a woman to choose radioactive iodine therapy or surgery before planning to have a child. Designing and conducting a trial of antithyroid interventions for pregnant women with hyperthyroidism presents formidable challenges. Not only is hyperthyroidism a relatively rare condition, both of the two main drugs used have potential for harm, one for the mother and the other for the child. More observational research is required about the potential harms of methimazole in early pregnancy and about the potential liver damage from propylthiouracil. Plain language summary No evidence found from randomised trials for drugs to treat pregnant women with hyperthyroidism Hyperthyroidism in pregnancy is a rare, serious condition which can increase the risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction. Pregnant women who are hyperthyroid may also develop severe pre‐eclampsia or placental abruption. Most of these women have Graves' disease, an autoimmune disease most common in women aged 20 to 40 years. Most pregnant women with hyperthyroidism are diagnosed with thyroid disease prior to conception and will have previously received treatment for the condition. Generally only drug therapy is considered for treating pregnant women with hyperthyroidism. Radioiodine treatment is not used in pregnancy because it destroys the fetal thyroid gland, resulting in permanent hypothyroidism in the newborn. The main antithyroid drugs used are the thionamides, propylthiouracil (PTU), methimazole and carbimazole. PTU is currently the favoured drug for use in pregnancy, as it is associated with fewer teratogenic effects (scalp lesions) than methimazole. However, since there have been reports of liver damage in people taking PTU, it may be reasonable for pregnant hyperthyroid women to be treated with PTU in the first trimester (to reduce any teratogenic effects of methimazole) and then to change to methimazole. We did not identify any randomised trials to help inform women and their doctors about which antithyroid drugs are most effective, with the lowest potential for harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Earl, R; Crowther, CA; Middleton, P", "articleTypes": [], "doi": "10.1002/14651858.CD008633.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "954210ee-c961-4b35-92a7-a7f2b57a2a5b", "pmid": "", "title": "Effects of Gymnemic Acids Lozenge on Reward Region Response to Receipt and Anticipated Receipt of High-Sugar Food, High-Sugar Food Pictures, and Ad Lib Candy Intake", "imported": false, "abstract": "The purpose of the research is to test whether a gymnemic acids (GA) lozenge will reduce reward region response to intake of high-sugar food and ad lib candy intake and whether the GA lozenge reduced reward region response to anticipated intake of high-sugar food and high-sugar food pictures relative to a placebo lozenge.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.234Z" }, { "id": "9561e32c-6fb6-4d40-a35a-2105ad0a1756", "pmid": "", "title": "Antioxidant supplementation for lung disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Airway infection leads to progressive damage of the lungs in cystic fibrosis (CF) and oxidative stress has been implicated in the etiology. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, beta‐carotene and selenium) or N‐acetylcysteine (NAC) as a source of glutathione, may therefore potentially help maintain an oxidant‐antioxidant balance. Glutathione or NAC can also be inhaled and if administered in this way can also have a mucolytic effect besides the antioxidant effect. Current literature suggests a relationship between oxidative status and lung function. This is an update of a previously published review. Objectives To synthesise existing knowledge on the effect of antioxidants such as vitamin C, vitamin E, beta‐carotene, selenium and glutathione (or NAC as precursor of glutathione) on lung function through inflammatory and oxidative stress markers in people with CF. Search methods The Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and PubMed were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies. We also searched online trials registries. Last search of Cystic Fibrosis Trials Register: 08 January 2019. Selection criteria Randomised and quasi‐randomised controlled studies comparing antioxidants as listed above (individually or in combination) in more than a single administration to placebo or standard care in people with CF. Data collection and analysis Two authors independently selected studies, extracted data and assessed the risk of bias in the included studies. We contacted study investigators to obtain missing information. If meta‐analysed, studies were subgrouped according to supplement, method of administration and the duration of supplementation. We assessed the quality of the evidence using GRADE. Main results One quasi‐randomised and 19 randomised controlled studies (924 children and adults) were included; 16 studies (n = 639) analysed oral antioxidant supplementation and four analysed inhaled supplements (n = 285). Only one of the 20 included studies was judged to be free of bias. Oral supplements versus control The change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted at three months and six months was only reported for the comparison of NAC to control. Four studies (125 participants) reported at three months; we are uncertain whether NAC improved FEV 1 % predicted as the quality of the evidence was very low, mean difference (MD) 2.83% (95% confidence interval (CI) ‐2.16 to 7.83). However, at six months two studies (109 participants) showed that NAC probably increased FEV 1 % predicted from baseline (moderate‐quality evidence), MD 4.38% (95% CI 0.89 to 7.87). A study of a combined vitamin and selenium supplement (46 participants) reported a greater change from baseline in FEV 1 % predicted in the control group at two months, MD ‐4.30% (95% CI ‐5.64 to ‐2.96). One study (61 participants) found that NAC probably makes little or no difference in the change from baseline in quality of life (QoL) at six months (moderate‐quality evidence), standardised mean difference (SMD) ‐0.03 (95% CI ‐0.53 to 0.47), but the two‐month combined vitamin and selenium study reported a small difference in QoL in favour of the control group, SMD ‐0.66 (95% CI ‐1.26 to ‐0.07). The NAC study reported on the change from baseline in body mass index (BMI) (62 participants) and similarly found that NAC probably made no difference between groups (moderate‐quality evidence). One study (69 participants) found that a mixed vitamin and mineral supplement may lead to a slightly lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) provided information on adverse events, but did not find any clear and consistent evidence of differences between treatment or control groups with the quality of the evidence ranging from low to moderate. Studies of β‐carotene and vitamin E consistently reported greater plasma levels of the respective antioxidants. Inhaled supplements versus control Two studies (258 participants) showed inhaled glutathione probably improves FEV 1 % predicted at three months, MD 3.50% (95% CI 1.38 to 5.62), but not at six months compared to placebo, MD 2.30% (95% CI ‐0.12 to 4.71) (moderate‐quality evidence). The same studies additionally reported an improvement in FEV 1 L in the treated group compared to placebo at both three and six months. One study (153 participants) reported inhaled glutathione probably made little or no difference to the change in QoL from baseline, MD 0.80 (95% CI ‐1.63 to 3.23) (moderate‐quality evidence). No study reported on the change from baseline in BMI at six months, but one study (16 participants) reported at two months and a further study (105 participants) at 12 months; neither study found any difference at either time point. One study (153 participants) reported no difference in the time to the first pulmonary exacerbation at six months. Two studies (223 participants) reported treatment may make little or no difference in adverse events (low‐quality evidence), a further study (153 participants) reported that the number of serious adverse events were similar across groups. Authors' conclusions With regards to micronutrients, there does not appear to be a positive treatment effect of antioxidant micronutrients on clinical end‐points; however, oral supplementation with glutathione showed some benefit to lung function and nutritional status. Based on the available evidence, inhaled and oral glutathione appear to improve lung function, while oral administration decreases oxidative stress; however, due to the very intensive antibiotic treatment and other concurrent treatments that people with CF take, the beneficial effect of antioxidants remains difficult to assess in those with chronic infection without a very large population sample and a long‐term study period. Further studies, especially in very young children, using outcome measures such as lung clearance index and the bronchiectasis scores derived from chest scans, with improved focus on study design variables (such as dose levels and timing), and elucidating clear biological pathways by which oxidative stress is involved in CF, are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn. The benefit of antioxidants in people with CF who receive CFTR modulators therapies should also be assessed in the future. Plain language summary How do vitamins E and C, beta‐carotene, selenium and glutathione affect lung disease in people with cystic fibrosis? Background Frequent chest infections cause long‐term lung inflammation; inflammation‐causing cells produce an oxygen molecule (reactive oxygen species (ROS)), which may harm body tissue (oxidative damage); the body uses antioxidants to protect itself. People with cystic fibrosis (CF) have high levels of ROS compared to low levels of antioxidants. Antioxidant supplements might reduce oxidative damage and build up levels of antioxidants. Given difficulties in absorbing fat, people with CF have low levels of fat‐soluble antioxidants (vitamin E and beta‐carotene). Water‐soluble vitamin C decreases with age in people with CF. Glutathione, one of the most abundant antioxidants in cells, is not released properly into the lungs of people with CF. Some enzymes that help antioxidants work depend on the mineral selenium, so selenium supplements aim to stimulate antioxidant action. Most supplements are swallowed, but glutathione and N‐acetylcysteine (NAC) (which the body uses to make glutathione) can also be inhaled; these may affect lung function as antioxidants, but also due to thinning mucus when inhaled (allowing easier mucus clearance). Search date Last search for this updated review: 08 January 2019. Study characteristics We included 20 studies (924 people with CF, almost equal gender split, aged six months to 59 years); 16 studies compared oral supplements to placebo ('dummy' treatment) and four compared inhaled supplements to placebo. Key results Oral supplements We are uncertain whether NAC changes lung function (forced expiratory volume in one second (FEV 1 ) % predicted) at three months (four studies, 125 participants, very low‐quality evidence), but at six months two studies (109 participants) reported NAC probably improved FEV 1 % predicted (moderate‐quality evidence). One study (46 participants) reported a greater change in FEV 1 % predicted with placebo than with a combined vitamin and selenium supplement after two months. One study (61 participants) reported little or no difference in quality of life (QoL) scores between NAC and control after six months (moderate‐quality evidence), but the two‐month combined vitamin and selenium study reported slightly better QoL scores in the control group. NAC probably made no difference to body mass index (BMI) (one study, 62 participants, moderate‐quality evidence). One study (69 participants) reported that a mixed vitamin and mineral supplement may lead to a lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) did not find any clear and consistent differences in side effects between groups (evidence ranged from low to moderate quality). Vitamin E and β‐carotene studies consistently reported greater levels of these antioxidants in blood samples. Inhaled supplements In two studies (258 participants), inhaled glutathione probably improved FEV 1 % predicted compared to placebo at three months but not at six months (moderate‐quality evidence); these studies also reported a greater improvement in FEV 1 litres with glutathione compared to placebo at both time points. Two studies (258 participants) found little or no difference in the change in QoL scores (moderate‐quality evidence). One two‐month study (16 participants) and a 12‐month study (105 participants) reported no difference between groups in the change in BMI. There was no difference in the time to the first pulmonary exacerbation in one six‐month study. Two studies (223 participants) reported no difference between groups in side effects (low‐quality evidence) and another study (153 participants) reported that the number of serious side effects were similar across groups. Conclusions Vitamin and mineral supplements do not seem to improve clinical outcomes. Inhaled glutathione appears to improve lung function, while oral administration lowers oxidative stress, with benefits to lung function and nutritional measures. Intensive antibiotic and other concurrent treatments for people with CF and chronic infection mean it is difficult to assess the effect of antioxidants without a very large and long study. Future research should look at how antioxidants affect people with CF taking CFTR modulator therapies. Quality of the evidence Evidence ranged from very low to moderate quality. All but one study had some bias; mostly because data were not fully reported (likely to affect our results). We were also largely unsure if participants knew which treatment they received, both in advance and once the studies started (unsure how this might affect our results).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ciofu, O, Smith, S, Lykkesfeldt, J", "articleTypes": [], "doi": "10.1002/14651858.CD007020.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.079Z" }, { "id": "9567229a-1326-4739-995a-f224e2e749b4", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high risk patients. Ulceration can lead to severe pain and difficulty eating and drinking, which may necessitate opioid analgesics, hospitalisation and nasogastric or intravenous nutrition. These complications may lead to interruptions or alterations to cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Oral cryotherapy is a low‐cost, simple intervention which is unlikely to cause side‐effects. It has shown promise in clinical trials and warrants an up‐to‐date Cochrane review to assess and summarise the international evidence. Objectives To assess the effects of oral cryotherapy for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to 17 June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) ( Cochrane Library 2015, Issue 5), MEDLINE via Ovid (1946 to 17 June 2015), EMBASE via Ovid (1980 to 17 June 2015), CANCERLIT via PubMed (1950 to 17 June 2015) and CINAHL via EBSCO (1937 to 17 June 2015). We searched the US National Institutes of Health Trials Registry, and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching databases. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of oral cryotherapy in patients with cancer receiving treatment. We used outcomes from a published core outcome set registered on the COMET website. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. We contacted study authors for information where feasible. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 14 RCTs analysing 1280 participants. The vast majority of participants did not receive radiotherapy to the head and neck, so this review primarily assesses prevention of chemotherapy‐induced oral mucositis. All studies were at high risk of bias. The following results are for the main comparison: oral cryotherapy versus control (standard care or no treatment). Adults receiving fluorouracil‐based (5FU) chemotherapy for solid cancers Oral cryotherapy probably reduces oral mucositis of any severity (RR 0.61, 95% CI 0.52 to 0.72, 5 studies, 444 analysed, moderate quality evidence). In a population where 728 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 444 (95% CI 379 to 524). The number needed to treat to benefit one additional person (NNTB), i.e. to prevent them from developing oral mucositis, is 4 people (95% CI 3 to 5). The results were similar for moderate to severe oral mucositis (RR 0.52, 95% CI 0.41 to 0.65, 5 studies, 444 analysed, moderate quality evidence). NNTB 4 (95% CI 4 to 6). Severe oral mucositis is probably reduced (RR 0.40, 95% CI 0.27 to 0.61, 5 studies, 444 analysed, moderate quality evidence). Where 300 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 120 (95% CI 81 to 183), NNTB 6 (95% CI 5 to 9). Adults receiving high‐dose melphalan‐based chemotherapy before haematopoietic stem cell transplantation (HSCT) Oral cryotherapy may reduce oral mucositis of any severity (RR 0.59, 95% CI 0.35 to 1.01, 5 studies, 270 analysed, low quality evidence). Where 824 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 486 (95% CI reduced to 289 to increased to 833). The NNTB is 3, although the uncertainty surrounding the effect estimate means that the 95% CI ranges from 2 NNTB, to 111 NNTH (number needed to treat in order to harm one additional person, i.e. for one additional person to develop oral mucositis). The results were similar for moderate to severe oral mucositis (RR 0.43, 95% CI 0.17 to 1.09, 5 studies, 270 analysed, low quality evidence). NNTB 3 (95% CI 2 NNTB to 17 NNTH). Severe oral mucositis is probably reduced (RR 0.38, 95% CI 0.20 to 0.72, 5 studies, 270 analysed, moderate quality evidence). Where 427 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 162 (95% CI 85 to 308), NNTB 4 (95% CI 3 to 9). Oral cryotherapy was shown to be safe, with very low rates of minor adverse effects, such as headaches, chills, numbness/taste disturbance, and tooth pain. This appears to contribute to the high rates of compliance seen in the included studies. There was limited or no evidence on the secondary outcomes of this review, or on patients undergoing other chemotherapies, radiotherapy, targeted therapy, or on comparisons of oral cryotherapy with other interventions or different oral cryotherapy regimens. Therefore no further robust conclusions can be made. There was also no evidence on the effects of oral cryotherapy in children undergoing cancer treatment. Authors' conclusions We are confident that oral cryotherapy leads to large reductions in oral mucositis of all severities in adults receiving 5FU for solid cancers. We are less confident in the ability of oral cryotherapy to reduce oral mucositis in adults receiving high‐dose melphalan before HSCT. Evidence suggests that it does reduce oral mucositis in these adults, but we are less certain about the size of the reduction, which could be large or small. However, we are confident that there is an appreciable reduction in severe oral mucositis in these adults. This Cochrane review includes some very recent and currently unpublished data, and strengthens international guideline statements for adults receiving the above cancer treatments. Plain language summary Can keeping the mouth cold during cancer treatment help to prevent mouth soreness and ulcers in children and adults? Review question This review has been produced to assess whether or not keeping the mouth cold during cancer treatment, by using ice, ice‐cold water, ice cream or ice lollies/popsicles, can help prevent mouth soreness and ulcers in children and adults. Background People receiving treatment for cancer are at risk of developing a sore mouth and ulcers as a side effect. This side effect is called oral mucositis and affects over 75% of high‐risk patients (those receiving radiotherapy to the head and neck or high‐dose chemotherapy). The pain caused by this condition can be severe and can stop the person's ability to eat and drink, which may mean they need to take strong pain killers, stay in hospital and be fed through a tube into their stomach, or even into their veins. This in turn can lead to disruption to their cancer treatment, meaning they are not receiving the best possible treatment. The results may be a reduction in the patient's chances of survival, and increased costs to the healthcare system. Cancer patients have weakened immune systems due to their treatment, meaning that their bodies are less able to fight infections. This can be a problem if bacteria enter the body through the ulcer, which is an open wound. This can lead to sepsis (a dangerous inflammatory reaction of the body to infection), which requires antibiotics and hospitalisation, and can cause death. Oral cryotherapy is the cooling of the mouth using ice, ice‐cold water, ice cream or ice lollies/popsicles. It is thought to help prevent oral mucositis in people receiving certain types of chemotherapy because the coldness makes the blood vessels in the mouth more narrow, and this reduces the amount of blood containing chemotherapy drugs from reaching the mouth and causing oral mucositis. It is a low‐cost, natural treatment without serious side effects. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 17 June 2015. It includes 14 studies published from 1991 to 2015 in which 1316 participants were randomised (1280 of whom were included in the analyses) to receive oral cryotherapy versus standard care (usually saline mouthrinses) or no treatment or a different treatment or a different method of oral cryotherapy, and the number of people developing oral mucositis of different severities was compared. Nearly all the evidence was on adults receiving oral cryotherapy versus standard care or no treatment. This evidence fell into two main groups: 1) adults receiving fluorouracil‐based (5FU) treatment for solid cancers; or 2) adults receiving high‐dose melphalan‐based cancer treatment before haematopoietic stem cell transplantation (HSCT). HSCT is given to help the body to produce all types of blood cells, which are destroyed during cancer treatment. Key results There is evidence showing that oral cryotherapy can lead to large reductions in the numbers of adults who get oral mucositis of all severities after receiving 5FU‐based treatment for solid cancers. There is less certain evidence to suggest that oral cryotherapy may reduce the numbers of adults who get oral mucositis after receiving high‐dose melphalan‐based cancer treatment prior to HSCT. The evidence suggests that it does reduce oral mucositis in these adults, but the size of the reduction is much less certain. However, there is more certain evidence that there is a large reduction in severe oral mucositis in these adults. Oral cryotherapy did not cause any serious side effects in any of the participants of these studies, and most people seemed able to carry it out properly and complete it. Quality of the evidence The evidence presented, on the main outcome of whether or not people developed oral mucositis of all severities, is of moderate (because the nature of the oral cryotherapy treatment meant that the studies could not be 'blinded' which is a desirable characteristic of these studies) to low quality (because in addition to the above problem, the results of the individual studies were too different to give a precise result when they were combined).", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P, Glenny, AM, Worthington, HV, Littlewood, A, Clarkson, JE, McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011552.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.747Z" }, { "id": "9577f0bd-927a-4df8-a567-760ca4453e60", "pmid": "", "title": "A Phase 1, Randomised, Single-blind, Placebo-controlled, Single-centre Study to Investigate the Safety, Tolerability and Pharmacokinetics of Single and Multiple Doses of Elarekibep Given Twice Daily as Inhaled or a Single IV Formulation in Healthy Japanese Subjects", "imported": false, "abstract": "This study will assess the safety, tolerability and pharmacokinetics (PK) of elarekibep after single and multiple doses given twice daily (BID) by inhalation or intravenous (IV) in healthy Japanese subjects compared with placebo.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "957f2630-8b48-4c8b-a936-6c21caa7c04c", "pmid": "", "title": "Interventions for the prevention of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "Abstract - Background Loss of olfactory function is well recognised as a symptom of COVID‐19 infection, and the pandemic has resulted in a large number of individuals with abnormalities in their sense of smell. For many, the condition is temporary and resolves within two to four weeks. However, in a significant minority the symptoms persist. At present, it is not known whether early intervention with any form of treatment (such as medication or olfactory training) can promote recovery and prevent persisting olfactory disturbance. This is an update of the 2021 review with four studies added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with acute olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance, which had been present for less than four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the presence of normal olfactory function, serious adverse effects and change in sense of smell. Secondary outcomes were the prevalence of parosmia, change in sense of taste, disease‐related quality of life and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included five studies with 691 participants. The studies evaluated the following interventions: intranasal corticosteroid sprays, intranasal corticosteroid drops, intranasal hypertonic saline and zinc sulphate. Intranasal corticosteroid spray compared to no intervention/placebo We included three studies with 288 participants who had olfactory dysfunction for less than four weeks following COVID‐19. Presence of normal olfactory function The evidence is very uncertain about the effect of intranasal corticosteroid spray on both self‐rated recovery of olfactory function and recovery of olfactory function using psychophysical tests at up to four weeks follow‐up ( self‐rated : risk ratio (RR) 1.19, 95% confidence interval (CI) 0.85 to 1.68; 1 study; 100 participants; psychophysical testing : RR 2.3, 95% CI 1.16 to 4.63; 1 study; 77 participants; very low‐certainty evidence). Change in sense of smell The evidence is also very uncertain about the effect of intranasal corticosteroid spray on self‐rated change in the sense of smell ( at less than 4 weeks : mean difference (MD) 0.5 points lower, 95% CI 1.38 lower to 0.38 higher; 1 study; 77 participants; at > 4 weeks to 3 months : MD 2.4 points higher, 95% CI 1.32 higher to 3.48 higher; 1 study; 100 participants; very low‐certainty evidence, rated on a scale of 1 to 10, higher scores mean better olfactory function). Intranasal corticosteroids may make little or no difference to the change in sense of smell when assessed with psychophysical testing (MD 0.2 points, 95% CI 2.06 points lower to 2.06 points higher; 1 study; 77 participants; low‐certainty evidence, 0‐ to 24‐point scale, higher scores mean better olfactory function). Serious adverse effects The authors of one study reported no adverse effects, but their intention to collect these data was not pre‐specified so we are uncertain if these were systematically sought and identified. The remaining two studies did not report on adverse effects. Intranasal corticosteroid drops compared to no intervention/placebo We included one study with 248 participants who had olfactory dysfunction for ≤ 15 days following COVID‐19. Presence of normal olfactory function Intranasal corticosteroid drops may make little or no difference to self‐rated recovery at > 4 weeks to 3 months (RR 1.00, 95% CI 0.89 to 1.11; 1 study; 248 participants; low‐certainty evidence). No other outcomes were assessed by this study. Data on the use of hypertonic saline nasal irrigation and the use of zinc sulphate to prevent persistent olfactory dysfunction are included in the full text of the review. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for preventing persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the prevention of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important COVID‐19 has been found to cause problems with the sense of smell. Sometimes this is a reduction in the ability to smell things, and sometimes it is a complete loss of the sense of smell. For many people this recovers in a short time, but for others it may last for weeks or months. This review considers whether there are treatments that people might take as soon as they have lost their sense of smell (within four weeks of the symptoms starting), to try and stop this becoming a long‐standing problem. How we identified and assessed the evidence We searched for all relevant studies in the medical literature to summarise the results. We also looked at how certain the evidence was, considering things like the size of the studies and how they were carried out. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found five studies that had been completed. Intranasal corticosteroids compared to no treatment Three studies looked at this treatment. Nasal corticosteroid spray might make little or no difference to the sense of smell when measured with specific tests (rather than when asking people about their sense of smell). The rest of the evidence was of very low certainty, so we do not know whether a nasal corticosteroid spray is better or worse than no treatment at: ‐ helping the sense of smell get back to normal (either people feeling that their sense of smell is back to normal, or having a normal sense of smell according to specific tests); ‐ making people feel that their sense of smell has improved; ‐ causing any unwanted side effects. Intranasal corticosteroid drops compared to placebo (dummy treatment) One study looked at this treatment. Intranasal corticosteroid drops might not make any difference to the number of people who think their sense of smell has recovered at 30 days. We did find a number of other studies that are being carried out, but no results from these studies were available yet to be included in this review. What this means We do not know whether using a nasal corticosteroid spray or nasal drops has any benefit in preventing longer‐term loss of the sense of smell that is related to COVID‐19, or whether they may cause any harm. This review is a 'living systematic review' ‐ meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Webster, KE, O'Byrne, L, MacKeith, S, Philpott, C, Hopkins, C, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013877.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.727Z" }, { "id": "958f3d3c-ea13-4d2a-906f-0193026a6d23", "pmid": "", "title": "Pharmacological interventions for the treatment of depression in chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Studies report that up to 80% of individuals with chronic obstructive pulmonary disease (COPD) may struggle with symptoms of depression. However, this major comorbidity in COPD is rarely managed effectively. A number of recent studies indicate that left untreated, COPD‐related depression is associated with worse quality of life, worse compliance with COPD treatment plan, increased exacerbations, hospital admissions, and healthcare costs when compared to individuals with COPD without depression. Regrettably, COPD practice guidelines do not provide conclusive treatment recommendations for the use of antidepressants in patients with COPD, and base their guidelines on findings from trials in the general population. This may be problematic, as there is an elevated risk of respiratory issues associated with antidepressant treatment and COPD. Evaluating effectiveness and safety of pharmacological interventions specifically for patients with COPD and depression was therefore paramount. Objectives To assess the effectiveness and safety of pharmacological interventions for the treatment of depression in patients with COPD. Search methods The last search was performed on 26 November 2018. We initially searched the following databases via the Specialised Trials Registers of the Cochrane Airways and Common Mental Disorders Groups (to June 2016): MEDLINE, Embase, PsycINFO, CINAHL, AMED, and the Cochrane Library trials register (CENTRAL). Searches from June 2016 to November 2018 were performed directly on Ovid MEDLINE, Embase, PsycINFO and the Cochrane Library (Issue 11, 2018). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform to 26 November 2018. We searched the grey literature databases to identify studies not indexed in major databases and the reference lists of studies initially identified for full‐text screening. Selection criteria All published and unpublished randomised controlled trials (RCTs) comparing the efficacy of pharmacological interventions with no intervention, placebo or co‐intervention in adults with diagnosed COPD and depression were eligible for inclusion. Data collection and analysis Two review authors independently assessed articles identified by the search for eligibility. Our primary outcomes were change in depressive symptoms and adverse events. The secondary outcomes were: change in quality of life, change in dyspnoea, change in forced expiratory volume in one second (FEV 1 ), change in exercise tolerance, change in hospital utilisation (length of stay and readmission rates), and cost‐effectiveness. For continuous outcomes, we calculated the pooled mean difference (MD) or standardised mean difference (SMD) with 95% confidence interval (CI) as appropriate. For dichotomous outcomes, we calculated the pooled odds ratio (OR) and corresponding 95% CI using a random‐effects model. We assessed the quality of evidence using the GRADE framework. Main results Of the 1125 records screened for eligibility, four RCTs (N = 201 participants), and one on‐going study, met the inclusion criteria. Two classes of antidepressants were investigated in two separate comparisons with placebo: a tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitors (SSRIs). TCA versus placebo Only one RCT (N = 30 participants) provided results for this comparison. Primary outcomes The TCA (nortriptyline) reduced depressive symptoms post‐treatment compared to placebo (MD ‐10.20, 95% CI ‐16.75 to ‐3.65; P = 0.007; very low‐quality evidence), as measured by the Hamilton Depression Rating Scale (HAM‐D). Three participants withdrew from the trial due to adverse events related to the tested antidepressant (dry mouth, sedation, orthostatic hypotension). Secondary outcomes The overall results post‐treatment indicated that nortriptyline was not effective in improving the quality of life of individuals with COPD, as measured by the Sickness Impact Profile (MD ‐2.80, 95% CI ‐11.02 to 5.42; P = 0.50; very low‐quality evidence). The results for the change in dyspnoea for the domains examined (e.g. dyspnoea scores for 'most day‐to‐day activities') post‐treatment showed no improvement in the intervention group (MD 9.80, 95% CI ‐6.20 to 25.80; P = 0.23; very low‐quality evidence). No data were reported for change in FEV 1 , change in exercise tolerance, change in hospital utilisation, or cost‐effectiveness. The TCA study provided short‐term results, with the last follow‐up data collection at 12 weeks. The quality of the evidence for all the outcomes evaluated was very low due to a small sample size, imprecision, attrition, and selection and reporting bias. SSRIs versus placebo Three RCTs (N = 171 participants) provided results for this comparison. Primary outcomes The pooled results for two studies showed no difference for the change in depressive symptoms post‐intervention (SMD 0.75, 95% CI ‐1.14 to 2.64; 148 participants; 2 studies; P = 0.44; very low‐quality evidence). High heterogeneity was observed (I² = 95%), limiting the reliability of these findings. While it was not possible to meta‐analyse the total adverse events rates across the studies, it was possible to combine the results for two medication‐specific adverse effects: nausea and dizziness. There were no significant post‐treatment group differences for nausea (OR 2.32, 95% CI 0.66 to 8.12; 171 participants; 3 studies; P = 0.19; very low‐quality evidence) or dizziness (OR 0.61, 95% CI 0.09 to 4.06; 143 participants; 2 studies; P = 0.61; very low‐quality evidence). Secondary outcomes The pooled analysis of two trials reporting data for the change in quality of life did not show improvement post‐treatment in the intervention group compared to placebo (SMD 1.17, 95% CI ‐0.80 to 3.15; 148 participants; 2 studies; P = 0.25; very low‐quality evidence). There was no difference between groups in change in FEV 1 post‐treatment (MD 0.01, 95% CI ‐0.03 to 0.05; 148 participants; 2 studies; P = 0.60; low‐quality evidence). However, two trials reported improvement in exercise tolerance in the SSRI group versus the placebo group (MD 13.88, 95% CI 11.73 to 16.03; 148 participants; 2 studies; P < 0.001; very low‐quality evidence). The trials included in this comparison did not report data related to the change in dyspnoea, hospital utilisation rates, or cost‐effectiveness. Authors' conclusions There is insufficient evidence to make definitive statements about the efficacy or safety of antidepressants for treating COPD‐related depression. New RCTs are needed; with better methodological quality and more accurate reporting of the methods used. Moreover, longer‐term follow‐up data collection is needed, including outcomes such as adverse events, hospital utilisation and cost‐effectiveness. Plain language summary Medication for the treatment of depression in chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a term that mainly describes two lung conditions: chronic bronchitis and emphysema. The main symptoms of COPD include shortness of breath, persistent cough, wheezing, and/or frequent chest infections. There is no cure for COPD, but treatment can help slow the disease progress and relieve symptoms. Depression is very common in patients with COPD, but is often untreated. Studies show that untreated depression in patients with COPD can worsen quality of life, increase COPD exacerbations and hospital admissions, and make following a COPD treatment plan difficult. Treatment for depression can include antidepressant medication, psychological therapy, or both. However, evidence‐based recommendations regarding antidepressant medication use specifically for patients with COPD are not currently available. Why is this review important? There is currently no clear overview of existing evidence showing whether antidepressants can effectively and safely reduce depressive symptoms in patients with COPD, therefore it was important to assess the existing experimental studies. Who will be interested in this review? Healthcare professionals, people with COPD and depression, researchers, and policymakers will be interested in the findings of this review. What questions does this review aim to answer? Our main aim was to assess whether pharmacological treatment (e.g. antidepressants) could effectively and safely treat COPD‐related depression. Which studies were included in the review? This review included experimental studies called randomised controlled trials (studies in which participants are assigned to a treatment group based on a random method) that compared the effectiveness of pharmacological interventions (antidepressants) to placebo (inactive treatment in the same form as the active treatment, e.g. a pill). Study participants were adults diagnosed with COPD and depression. What does the evidence from the review tell us? We have identified only four studies worldwide that were eligible for inclusion in our review. This means limited evidence to support the use of antidepressants for the treatment of depression in patients with COPD. Only one study evaluated a tricyclic antidepressant, nortriptyline, finding that it reduced depressive symptoms when compared to a placebo. Three studies evaluated a newer generation class of antidepressants called selective serotonin reuptake inhibitors (SSRIs), finding no evidence for their effectiveness in improving depressive symptoms. Due to the limited evidence, we are unable to make definitive statements about the effectiveness but also safety of antidepressants when used for COPD‐related depression. However, SSRIs may increase exercise capacity in patients with COPD. Given that the current findings were based on only four small studies with evidence rated as of very low quality, it is important to interpret our results with caution. What should happen next? Insufficient evidence prevented us from making clear recommendations for doctors, other healthcare professionals, researchers, or policymakers. More studies with better methodological quality and a larger number of participants are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pollok, J, van Agteren, JEM, Carson‐Chahhoud, KV", "articleTypes": [], "doi": "10.1002/14651858.CD012346.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.773Z" }, { "id": "959ef097-23c2-4c07-9c1e-38f445ed1e5a", "pmid": "", "title": "Folic acid for fragile X syndrome", "imported": false, "abstract": "Abstract - Background It has been argued that individuals with fragile X syndrome could have low folate levels in their bodies and that supplementing their dietary intake might remediate the adverse developmental and behavioural effects of the condition. Objectives To review the efficacy and safety of folic acid in the treatment of people with fragile X syndrome. Search methods We searched four databases in November 2010: CENTRAL, PubMed, EMBASE and PsycINFO. Selection criteria Randomised controlled trials. Data collection and analysis Two review authors independently extracted data and assessed risk of bias using the Cochrane 'Risk of bias' tool. Main results We included five trials, which were published between 1986 and 1992. Overall, they included 67 patients, all male, with ages ranging from one to 54 years. Intellectual disability in participants varied from borderline to severe and some studies included patients with an additional diagnosis of autism or autistic behaviour. Four of the studies were placebo‐controlled cross‐over trials and one study was a parallel design. The duration of follow‐up ranged from two months to 12 months and the period on folic acid or placebo ranged from two to eight months. Doses of folic acid ranged from 10 mg to 250 mg per day, 10 mg per day being the most common. Most of the younger patients involved were also taking part in special education programmes (usually involving language and occupational therapy). We were not able to perform meta‐analysis to combine results but none of the individual studies found evidence of clinical benefit with the use of folic acid medication in fragile X syndrome patients on any of the areas of interest, either psychological and learning capabilities or behaviour and social performance, as measured with standardised tools. Separate analysis of evidence for patients of different age groups, i.e. prepubertal children and postpubertal young people, found some statistically significant results, but did not show clear evidence of benefit for either group. Adverse effects of folic acid treatment were rare, not serious and transient. Studies were generally poorly reported and we classified only one study as being at low risk of bias. Authors' conclusions The quality of available evidence is low and not suitable for drawing conclusions about the effect of folic acid on fragile X syndrome patients. It consists of few studies with small samples of patients, all of them male, with little statistical power to detect anything other than huge effects. Plain language summary Folic acid for fragile X syndrome People with fragile X syndrome (or FXS) have intellectual limitations that can range from mild to severe. Fragile X syndrome is considered the most common form of inherited intellectual disability and it has been estimated that it affects approximately 1 in 4000 males and 1 in 8000 females. Folate is particularly important during the early development of the brain and in later life is involved in methylation processes that are essential for the maintenance of normal brain function. It was observed that cells from patients with fragile X syndrome cultured in solutions deficient in folic acid revealed a fragile site at the X chromosome; consequently it was thought that individuals with fragile X syndrome had low folate levels in their bodies, which may be due to insufficient dietary intake, inefficient absorption or impaired metabolic utilisation. It was argued that supplementing their dietary intake might help improve the adverse developmental and behavioural effects of the condition. This review asks whether folic acid helps improve symptoms in people with fragile X syndrome and whether it has any side effects. We found five randomised controlled trials, all of which were published between 1986 and 1992. These studies included 69 people, all male. One of the studies compared a folic acid group with a control group; the other four used a cross‐over design (i.e. participants received first one treatment and then the other). The quality of reporting of the trials was generally poor, particularly the methods used, which made it difficult to assess the risk of bias in the studies. The results of the few published studies did not find significant differences in the effects of folic acid or placebo on psychological or learning capabilities, behaviour or social performance, as measured by standardised tools. There is therefore no evidence to support the recommendation of supplementing dietary intake with folic acid medication for people with fragile X syndrome. However, due to the number and quality of the studies, it is not possible to conclude with any certainty that folic acid does not help. Given that intellectual, behavioural, emotional and/or learning performance in people with fragile X syndrome are strongly influenced by different social factors, future studies should also pay attention to the evaluation of non‐pharmacological interventions, such as modifications in the home environment, tailored behavioural interventions and classroom environments, or language and occupational therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Rueda, JR; Ballesteros, J; Guillen, V; Tejada, MI; Solà, I", "articleTypes": [], "doi": "10.1002/14651858.CD008476.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "95a0b95b-9424-4c53-91a6-c0a586154bc4", "pmid": "", "title": "Taste Changes With Bariatric Surgery", "imported": false, "abstract": "It is commonly believed that a link exists between BMI and taste perception. One group of researchers observed that women who are obese experience reduced taste sensitivity when compared to normal-weight controls. Others have compared taste sensitivity between lean and obese subjects and found no significant differences. The inconsistencies in these studies demonstrate how much variation in taste sensitivity is possible when different factors are applied in research. Throughout several studies, one element remains constant - bariatric surgery causes appetite aversions. These changes in appetite and food preference likely have a large influence on the overall magnitude of post-surgical weight loss. Although many studies have investigated the changes in taste preference after bariatric surgery, few, if any, have focused on changes in sweet taste perception.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.231Z" }, { "id": "95a954b7-e613-47c8-b39c-bc2ab02ff542", "pmid": "", "title": "Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications", "imported": false, "abstract": "Abstract - Background Radiotherapy as part of head and neck cancer treatment leaves patients requiring much dental rehabilitation in a compromised environment that is difficult for the patient and the dental team to manage. Objectives To assess the effects of maintaining the patient's natural dentition during radiotherapy in comparison to extracting teeth before radiotherapy in areas that are difficult to access by the patient and the dentist, should reduction in mouth opening occur after radiotherapy to the jaws. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 22 November 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 22 November 2012), EMBASE via OVID (1980 to 22 November 2012), CANCERLIT via PubMed (1950 to 22 November 2012), CINAHL via EBSCO (1980 to 22 November 2012) and reference lists of articles. We advertised for currently ongoing studies via the Cochrane Oral Health Group website and the Cochrane Oral Health Group Twitter feed. Selection criteria Randomised controlled trials comparing extraction of teeth prior to radiotherapy with leaving teeth in situ during radiotherapy to the jaws. Data collection and analysis Three review authors independently assessed the results of the searches for inclusion in the review. Main results No randomised controlled trials were found. Authors' conclusions There are no randomised controlled trials to assess the effect of extracting teeth prior to radiotherapy compared to leaving teeth in the mouth during radiotherapy to the jaws. Plain language summary Dental extractions prior to radiotherapy to the jaws for reducing post‐radiotherapy dental complications This review aimed to assess if removing the back teeth before radiotherapy would mean that patients had fewer tooth‐related problems after radiotherapy as part of head and neck cancer treatment, when compared to not removing the teeth. Electronic and handsearching found 357 titles of studies but none of them met the inclusion criteria for the review. There is currently no evidence available to answer this complex question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Eliyas, S, Al‐Khayatt, A, Porter, RWJ, Briggs, P", "articleTypes": [], "doi": "10.1002/14651858.CD008857.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.769Z" }, { "id": "95bb6e06-3868-4454-a392-da974198f31a", "pmid": "", "title": "Iodine fortification of foods and condiments, other than salt, for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency disorders (IDD) affect close to 1.9 billion people worldwide, and are a major public health concern in many countries. Among children, iodine deficiency is the main cause of potentially preventable deficits of central nervous system development and impairment of cognitive function, as well as goitre and hypothyroidism in people of all ages. Salt iodisation is the preferred strategy for IDD prevention and control, however, in some instances where salt is not the major condiment, alternate vehicles for iodine fortification have been considered. Objectives To assess the effects of fortifying foods, beverages, condiments, or seasonings other than salt with iodine alone or in conjunction with other micronutrients, on iodine status and health‐related outcomes in all populations. Search methods Studies were identified through systematic searches of the following databases from their start date to January 2018: Cochrane Public Health Group Specialised Register; CENTRAL; MEDLINE; MEDLINE in Process; Embase; Web of Science; CINAHL; POPLINE; AGRICOLA; BIOSIS; Food Science and Technology Abstracts; OpenGrey; Bibliomap and TRoPHI; AGRIS; IBECS; Scielo; Global Index Medicus‐AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched reference list of relevant articles, conference proceedings, and databases of ongoing trials, and contacted experts and relevant organisations to identify any unpublished work. We applied no language or date restrictions. Selection criteria Studies were eligible if they were randomised or quasi‐randomised controlled trials (RCT) with randomisation at either the individual or cluster level (including cross‐over trials), non‐randomised RCTs, or prospective observational studies with a control group, such as cohort studies, controlled before‐and‐after studies, and interrupted time series. We included studies that examined the effects of fortification of food, beverage, condiment, or seasoning with iodine alone, or in combination with other micronutrients versus the same unfortified food, or no intervention. We considered the following measures: death (all‐cause), goitre, physical development, mental development, cognitive function and motor skill development, cretinism, hypothyroidism, adverse effects (any reported by trialists), urinary iodine concentration, thyroid‐stimulating hormone (TSH) concentration, and serum thyroglobulin concentration. We included all populations, including pregnant women, from any country. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias of included studies. We used random‐effects meta‐analyses to combine data and generate an overall estimate of treatment effect, when more than one study examined the same outcome measure. The overall effect estimate was calculated as the mean difference (MD) or standardised mean difference (SMD) between the intervention group and the comparison group for continuous outcomes, and as odds ratio (OR) for dichotomous outcomes. We assessed the level of heterogeneity through the I² statistic. We conducted post‐hoc subgroup analyses to explore possible sources of heterogeneity, and sensitivity analyses to check the robustness of the findings from the primary analyses. We assessed the quality of the evidence for each outcome using the GRADE framework. Where it was not possible to pool the results in a meta‐analysis, we provided a narrative summary of the outcomes. Main results Eleven studies met the criteria, providing 14 comparisons, and capturing data on 4317 participants. Seven studies were RCTs, three were cluster non‐RCTs, and one was a randomised cross‐over design. Seven studies were carried out among school children (N = 3636), three among women of reproductive age (N = 648), and one among infants (N = 33). The studies used diverse types of food as vehicle for iodine delivery: biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. Daily amounts of iodine provided ranged from 35 µg/day to 220 µg/day; trial duration ranged from 11 days to 48 weeks. Five studies examined the effect of iodine fortification alone, two against the same unfortified food, and three against no intervention. Six studies evaluated the effect of cofortification of iodine with other micronutrients versus the same food without iodine but with different levels of other micronutrients. We assessed one study to be at low risk of bias for all bias domains, three at low risk of bias for all domains apart from selective reporting, and seven at an overall rating of high risk of bias. No study assessed the primary outcomes of death, mental development, cognitive function, cretinism, or hypothyroidism, or secondary outcomes of TSH or serum thyroglobulin concentration. Two studies reported the effects on goitre, one on physical development measures, and one on adverse effects. All studies assessed urinary iodine concentration. The effects of iodine fortification compared to control on goitre prevalence (OR 1.60, 95% CI 0.60 to 4.31; 1 non‐RCT, 83 participants; very low‐quality evidence), and five physical development measures were uncertain (1 non‐RCT, 83 participants; very low‐quality evidence): weight (MD 0.23 kg, 95% CI ‐6.30 to 6.77); height (MD ‐0.66 cm, 95% CI ‐4.64 to 3.33); weight‐for‐age (MD 0.05, 95% CI ‐0.59 to 0.69); height‐for‐age (MD ‐0.30, 95% CI ‐0.75 to 0.15); and weight‐for‐height (MD ‐0.21, 95% CI ‐0.51 to 0.10). One study reported that there were no adverse events observed during the cross‐over trial (low‐quality evidence). Pooled results from RCTs showed that urinary iodine concentration significantly increased following iodine fortification (SMD 0.59, 95% CI 0.37 to 0.81; 6 RCTs, 2032 participants; moderate‐quality evidence). This is equivalent to an increase of 38.32 µg/L (95% CI 24.03 to 52.61 µg/L). This effect was not observed in the meta‐analysis of non‐RCTs (SMD 0.25, 95% CI ‐0.16 to 0.66; 3 non‐RCTs, 262 participants; very low‐quality evidence). Sensitivity analyses did not change the effect observed in the primary analyses. Authors' conclusions The evidence on the effect of iodine fortification of foods, beverages, condiments, or seasonings other than salt on reducing goitre, improving physical development measures, and any adverse effects is uncertain. However, our findings suggest that the intervention likely increases urinary iodine concentration. Additional, adequately powered, high‐quality studies on the effects of iodine fortification of foods on these, and other important outcomes, as well as its efficacy and safety, are required. Plain language summary Adding iodine to foods, other than salt, to prevent diseases caused by inadequate iodine intake Background and review question Many people around the world do not consume enough iodine. This is a problem because iodine is important for normal childhood growth and brain development, and for ensuring a healthy adult population. Inadequate intake of iodine can lead to health problems, such as intellectual disability and goitre (enlargement of the thyroid gland). Currently, the main strategy to increase the amount of iodine consumed in populations recommended by the World Health Organization is adding iodine to salt. However, in some areas where salt is not the major condiment, adding iodine to other foods has also been explored. The aim of our study was to examine the effect of adding iodine to foods, beverages, condiments, or seasonings, other than salt, on iodine nutrition status and health‐related outcomes in all populations. Study characteristics We searched for articles from different sources including published research papers, unpublished reports, and through direct communication with experts and organisations working to address iodine and micronutrient deficiency. We last searched the databases in January 2018. Eleven studies, which captured data on 4317 participants (3636 children, 648 women of reproductive age, and 33 infants), met our inclusion criteria. The type of foods used as vehicle to deliver iodine differed between the studies, and included biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. The amount of iodine provided to participants ranged from 35 µg/day to 220 µg/day, and study duration ranged from 11 days to 48 weeks. Of the 11 studies included, five examined the effect of adding iodine alone to foods compared to either no intervention or the same foods without iodine; while six evaluated the effect of adding iodine plus other micronutrients to foods compared to the same foods without iodine, but with different levels of other micronutrients. Key results No study evaluated the effect of adding iodine to foods on death, mental development, cognitive function, cretinism (a condition characterized by impaired control of physical movement and intellectual disability), hypothyroidism (underactive thyroid), thyroid‐stimulating hormone concentration, or serum thyroglobulin concentration (these are biological markers that indicate the presence of iodine deficiency when concentration in the blood is high). Two studies reported on the effect of the intervention on goitre, one study assessed five physical development measures (weight, height, weight‐for‐age, height‐for‐age, and weight‐for‐height scores), and one examined adverse effects. All studies assessed urinary iodine concentration (the concentration of iodine secreted in the urine, which indicates the presence of iodine deficiency when concentration is low in a population group, rather than in an individual). We combined the data that met our requirements in these studies in a meta‐analysis. We are uncertain of the effects of iodine fortification on the proportion of participants with goitre, or on any of the five physical development measures. One study reported narratively that no adverse effects were observed during the trial. We found a significant increase of 38.32 µg/L in urinary iodine concentration after adding iodine to foods, compared to the groups that did not have iodine added, from studies of higher quality. Quality of the evidence Using GRADE, we rated the quality of the evidence as very low for goitre and physical development measures, due to study limitations (risk of bias) and imprecise results, and low for adverse events due to indirectness and imprecise results. We rated the quality of the evidence for urinary iodine concentration, from studies in which participants were allocated to treatment groups at random (gold standard design for clinical research), as moderate. On the other hand, quality of the evidence for urinary iodine concentration from studies without this random element was rated as very low, due to study limitations and imprecise results. Conclusion Overall, there is no clear evidence on the effect of the intervention on reducing the proportion of people with goitre, improving physical growth, or adverse events. However, our results show that adding iodine to foods likely increases urinary iodine concentration. Additional studies to better quantify the effect of the intervention on these outcomes, as well as other outcomes, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Santos, JAR, Christoforou, A, Trieu, K, McKenzie, BL, Downs, S, Billot, L, Webster, J, Li, M", "articleTypes": [], "doi": "10.1002/14651858.CD010734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.778Z" }, { "id": "95c30717-8142-4449-bece-caca8b423fbe", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies for treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). Objectives To assess the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for treating patients with COVID‐19, compared to an active comparator, placebo, or no intervention. To maintain the currency of the evidence, we will use a living systematic review approach. A secondary objective is to track newly developed SARS‐CoV‐2‐targeting mAbs from first tests in humans onwards. Search methods We searched MEDLINE, Embase, the Cochrane COVID‐19 Study Register, and three other databases on 17 June 2021. We also checked references, searched citations, and contacted study authors to identify additional studies. Between submission and publication, we conducted a shortened randomised controlled trial (RCT)‐only search on 30 July 2021. Selection criteria We included studies that evaluated SARS‐CoV‐2‐neutralising mAbs, alone or combined, compared to an active comparator, placebo, or no intervention, to treat people with COVID‐19. We excluded studies on prophylactic use of SARS‐CoV‐2‐neutralising mAbs. Data collection and analysis Two authors independently assessed search results, extracted data, and assessed risk of bias using the Cochrane risk of bias tool (RoB2). Prioritised outcomes were all‐cause mortality by days 30 and 60, clinical progression, quality of life, admission to hospital, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We identified six RCTs that provided results from 17,495 participants with planned completion dates between July 2021 and December 2031. Target sample sizes varied from 1020 to 10,000 participants. Average age was 42 to 53 years across four studies of non‐hospitalised participants, and 61 years in two studies of hospitalised participants. Non‐hospitalised individuals with COVID‐19 Four studies evaluated single agents bamlanivimab (N = 465), sotrovimab (N = 868), regdanvimab (N = 307), and combinations of bamlanivimab/etesevimab (N = 1035), and casirivimab/imdevimab (N = 799). We did not identify data for mortality at 60 days or quality of life. Our certainty of the evidence is low for all outcomes due to too few events (very serious imprecision). Bamlanivimab compared to placebo No deaths occurred in the study by day 29. There were nine people admitted to hospital by day 29 out of 156 in the placebo group compared with one out of 101 in the group treated with 0.7 g bamlanivimab (risk ratio (RR) 0.17, 95% confidence interval (CI) 0.02 to 1.33), 2 from 107 in the group treated with 2.8 g (RR 0.32, 95% CI 0.07 to 1.47) and 2 from 101 in the group treated with 7.0 g (RR 0.34, 95% CI 0.08 to 1.56). Treatment with 0.7 g, 2.8 g and 7.0 g bamlanivimab may have similar rates of AEs as placebo (RR 0.99, 95% CI 0.66 to 1.50; RR 0.90, 95% CI 0.59 to 1.38; RR 0.81, 95% CI 0.52 to 1.27). The effect on SAEs is uncertain. Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Bamlanivimab/etesevimab compared to placebo There were 10 deaths in the placebo group and none in bamlanivimab/etesevimab group by day 30 (RR 0.05, 95% CI 0.00 to 0.81). Bamlanivimab/etesevimab may decrease hospital admission by day 29 (RR 0.30, 95% CI 0.16 to 0.59), may result in a slight increase in any grade AEs (RR 1.15, 95% CI 0.83 to 1.59) and may increase SAEs (RR 1.40, 95% CI 0.45 to 4.37). Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Casirivimab/imdevimab compared to placebo Casirivimab/imdevimab may reduce hospital admissions or death (2.4 g: RR 0.43, 95% CI 0.08 to 2.19; 8.0 g: RR 0.21, 95% CI 0.02 to 1.79). We are uncertain of the effect on grades 3‐4 AEs (2.4 g: RR 0.76, 95% CI 0.17 to 3.37; 8.0 g: RR 0.50, 95% CI 0.09 to 2.73) and SAEs (2.4 g: RR 0.68, 95% CI 0.19 to 2.37; 8.0 g: RR 0.34, 95% CI 0.07 to 1.65). Mortality by day 30 and clinical progression/improvement of symptoms or development of severe symptoms were not reported. Sotrovimab compared to placebo We are uncertain whether sotrovimab has an effect on mortality (RR 0.33, 95% CI 0.01 to 8.18) and invasive mechanical ventilation (IMV) requirement or death (RR 0.14, 95% CI 0.01 to 2.76). Treatment with sotrovimab may reduce the number of participants with oxygen requirement (RR 0.11, 95 % CI 0.02 to 0.45), hospital admission or death by day 30 (RR 0.14, 95% CI 0.04 to 0.48), grades 3‐4 AEs (RR 0.26, 95% CI 0.12 to 0.60), SAEs (RR 0.27, 95% CI 0.12 to 0.63) and may have little or no effect on any grade AEs (RR 0.87, 95% CI 0.66 to 1.16). Regdanvimab compared to placebo Treatment with either dose (40 or 80 mg/kg) compared with placebo may decrease hospital admissions or death (RR 0.45, 95% CI 0.14 to 1.42; RR 0.56, 95% CI 0.19 to 1.60, 206 participants), but may increase grades 3‐4 AEs (RR 2.62, 95% CI 0.52 to 13.12; RR 2.00, 95% CI 0.37 to 10.70). 80 mg/kg may reduce any grade AEs (RR 0.79, 95% CI 0.52 to 1.22) but 40 mg/kg may have little to no effect (RR 0.96, 95% CI 0.64 to 1.43). There were too few events to allow meaningful judgment for the outcomes mortality by 30 days, IMV requirement, and SAEs. Hospitalised individuals with COVID‐19 Two studies evaluating bamlanivimab as a single agent (N = 314) and casirivimab/imdevimab as a combination therapy (N = 9785) were included. Bamlanivimab compared to placebo We are uncertain whether bamlanivimab has an effect on mortality by day 30 (RR 1.39, 95% CI 0.40 to 4.83) and SAEs by day 28 (RR 0.93, 95% CI 0.27 to 3.14). Bamlanivimab may have little to no effect on time to hospital discharge (HR 0.97, 95% CI 0.78 to 1.20) and mortality by day 90 (HR 1.09, 95% CI 0.49 to 2.43). The effect of bamlanivimab on the development of severe symptoms at day 5 (RR 1.17, 95% CI 0.75 to 1.85) is uncertain. Bamlanivimab may increase grades 3‐4 AEs at day 28 (RR 1.27, 95% CI 0.81 to 1.98). We assessed the evidence as low certainty for all outcomes due to serious imprecision, and very low certainty for severe symptoms because of additional concerns about indirectness. Casirivimab/imdevimab with usual care compared to usual care alone Treatment with casirivimab/imdevimab compared to usual care probably has little or no effect on mortality by day 30 (RR 0.94, 95% CI 0.87 to 1.02), IMV requirement or death (RR 0.96, 95% CI 0.90 to 1.04), nor alive at hospital discharge by day 30 (RR 1.01, 95% CI 0.98 to 1.04). We assessed the evidence as moderate certainty due to study limitations (lack of blinding). AEs and SAEs were not reported. Authors' conclusions The evidence for each comparison is based on single studies. None of these measured quality of life. Our certainty in the evidence for all non‐hospitalised individuals is low, and for hospitalised individuals is very low to moderate. We consider the current evidence insufficient to draw meaningful conclusions regarding treatment with SARS‐CoV‐2‐neutralising mAbs. Further studies and long‐term data from the existing studies are needed to confirm or refute these initial findings, and to understand how the emergence of SARS‐CoV‐2 variants may impact the effectiveness of SARS‐CoV‐2‐neutralising mAbs. Publication of the 36 ongoing studies may resolve uncertainties about the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for the treatment of COVID‐19 and possible subgroup differences. Plain language summary Are laboratory‐made, COVID‐19‐specific monoclonal antibodies an effective treatment for COVID‐19? Key messages ‐ We do not know whether antibodies (the body’s natural defence against disease) made in a laboratory and all the same as one another (monoclonal) and designed to target COVID‐19, are an effective treatment for COVID‐19 because we assessed only six studies exploring different treatments in different types of patients. ‐ We identified 36 ongoing studies that will provide more evidence when completed. ‐ We will update this review regularly as more evidence becomes available. What are ‘monoclonal’ antibodies? Antibodies are made by the body as a defence against disease. However, they can also be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that are designed to target only one specific protein – in this case, a protein on the virus that causes COVID‐19 – are ‘monoclonal’. They attach to the COVID‐19 virus and stop it from entering and replicating in human cells, which helps to fight the infection. Monoclonal antibodies have been used successfully to treat other viruses. They are thought to cause fewer unwanted effects than convalescent plasma, which contains a variety of different antibodies. What did we want to find out? We wanted to know if COVID‐19 specific monoclonal antibodies are an effective treatment for COVID‐19. We looked at whether they: ‐ reduced the number of deaths from any cause; ‐ improved symptoms or made them worse; ‐ increased admissions to hospital; and ‐ caused any serious or other unwanted effects. What did we do? We searched for studies that investigated one or more monoclonal antibodies to treat people with confirmed COVID‐19 compared with placebo (sham treatment), another treatment or no treatment. Studies could take place anywhere globally and include participants of any age, gender or ethnicity, with mild, moderate or severe COVID‐19. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found six active studies including a total of 17,495 people. Four studies investigated non‐hospitalised people with no symptoms or mild COVID‐19. Two studies investigated hospitalised people with moderate to severe COVID‐19. Studies took place across the world. Three studies were funded by pharmaceutical companies. The monoclonal antibodies they studied were bamlanivimab, etesevimab, casirivimab and imdevimab, sotrovimab, regdanvimab. We did not identify data for mortality at 60 days and quality of life. Non‐hospitalised people, with no symptoms or mild COVID‐19 (four studies) One study investigated different doses of bamlanivimab (465 people), compared to placebo. We don’t know whether bamlanivimab: ‐ increases or reduces the number of deaths because no participants died within 30 days of treatment; ‐ causes more or fewer serious unwanted effects because there were few events. Bamlanivimab may reduce the number of admissions to hospital within 30 days of treatment compared to placebo. ‐ May cause slightly fewer unwanted effects than placebo. ‐ We did not find data for improved symptoms or worsened symptoms. One study investigated a combination of bamlanivimab and etesevimab (1035 people), compared to placebo. ‐ Bamlanivimab and etesevimab may reduce the number of deaths and admissions to hospital. ‐ May cause slightly more unwanted effects. ‐ May cause more serious unwanted effects. For treatment with bamlanivimab alone or in combination with etesevimab we did not find data for improved symptoms or worsened symptoms. One study (phase 1/2 with 799 people) investigated different doses of casirivimab combined with imdevimab, compared to placebo. ‐ Casirivimab combined with imdevimab may reduce the number of hospital admissions or death. ‐ We don't know whether casirivimab and imdevimab causes more unwanted (grades 3 and 4) and serious unwanted effects than placebo because there were too few deaths to allow us to make a judgment. ‐ We did not find data for the number of people who died at day 30 and development of severe symptoms. ‐ We did not include results from phase 3 (5607 people) of this study, because of high risk of bias, as it was not clear which participants were included in the analysis. One study (583 people) investigated sotrovimab, compared to placebo. We don't know whether sotrovimab: ‐ increases or reduces the number of deaths and people requiring invasive mechanical ventilation or dying, because there were too few deaths to allow us to make a judgment. ‐ Sotrovimab may reduce the number of people requiring oxygen, unwanted (grades 3 to 4) and serious unwanted effects; ‐ may have little or no effect on unwanted effects (all grades). Another study (327 people) investigated different doses of regdanvimab (40 mg/kg and 80 mg/kg), compared to placebo. ‐ Regdanvimab at either dose may reduce the number of admissions to hospital or death. ‐ May increase unwanted events (grades 3 to 4). ‐ Regdanvimab at a dose of 80 mg/kg may reduce unwanted effects (all grades) and 40 mg/kg may have little to no effect. ‐ We don't know whether regdanvimab increases or decreases the number of deaths, requirement for invasive mechanical ventilation, and serious unwanted effects, because there were too few events to allow us to make a judgment. Hospitalised people with moderate to severe COVID‐19 (2 studies) One study (314 people) investigated bamlanivimab compared to placebo. ‐ We don’t know whether bamlanivimab increases or decreases the number of deaths due to any cause up to 30 or 90 days after treatment because there were too few deaths to allow us to make a judgment (6 deaths with bamlanivimab and 4 deaths with placebo in 314 people). ‐ Bamlanivimab may slightly increase the development of severe COVID‐19 symptoms five days after treatment and the number of people with unwanted effects. ‐ Bamlanivimab may have little to no effect on time until discharge from hospital. ‐ We don’t know whether bamlanivimab causes serious unwanted effects by day 30 because the study was small and reported few serious unwanted effects. Another study (9785 people) investigated casirivimab combined with imdevimab, compared to standard of care. ‐ Casirivimab combined with imdevimab has probably little to no effect on the number of deaths, requirement for invasive mechanical ventilation or death, and hospital discharge alive. ‐ We did not find data for unwanted and serious unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is low because we found only six studies, and they did not report everything we were interested in, such as the number of deaths within 60 days and quality of life. We found 36 ongoing studies. When they are published, we will add their results to our review. These results are likely to change our conclusions and will also help us understand how new variants affect how well monoclonal antibodies work. How up to date is this evidence? The evidence is up to date to 17 June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Kreuzberger, N, Hirsch, C, Chai, KL, Tomlinson, E, Khosravi, Z, Popp, M, Neidhardt, M, Piechotta, V, Salomon, S, Valk, SJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.124Z" }, { "id": "95c6cd10-6377-4038-a71c-12f50ae0c3f7", "pmid": "", "title": "Fish oil for induction of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Fish oil supplements, which are rich in n‐3 fatty acids, may reduce inflammation, decrease the need for anti‐inflammatory drugs, and promote normal weight gain in people with ulcerative colitis. Objectives This review evaluates the efficacy of fish oil for induction of remission in ulcerative colitis using all available randomised controlled trials. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, EMBASE, CINAHL, the database of ongoing trials and the reference lists of all publications of included or excluded trials were searched. Selection criteria Randomised controlled trials and quasi‐randomised controlled trials with active ulcerative colitis patients who were treated with fish oil. Data collection and analysis The reviewers performed study selection, assessment of methodological quality by using different approaches: including Cochrane assessment of allocation concealment and Jadad quality assessment score. Data extraction forms were used by the two reviewers to extract the data independently. Authors were contacted for additional information. Main results Six studies were included. Three were of cross‐over design and three were of parallel design. No data were pooled for analysis due to differences in outcomes and methodology among the included studies. One small study shows a positive benefit for induction of remission (RR 19.00; 95% CI 1.27 to 284.24). Some of the other included studies show some positive benefits for secondary outcomes. However, these results need to be interpreted with caution due to small study size and poor study quality. Authors' conclusions The current data does not allow for a definitive conclusion regarding the efficacy of fish oil. There is no adequate information to make recommendations for clinical practice. More research is required. Plain language summary Fish oil for the treatment of active ulcerative colitis Ulcerative colitis is an inflammation of the large intestine that causes diarrhea, abdominal pain, rectal bleeding and fever. Since there is no cure for the disease the aim of treatment is to cause a reduction of the unpleasant and painful signs and symptoms. Current, proven, treatment options for active ulcerative colitis include corticosteroids, aminosalicylates, immunosuppressive and biological agents. However, these drugs can cause side effects. New treatments which cause fewer side effects are being sought. Fish oil, which is rich in omega‐3 fatty acids may reduce inflammation and decrease the need for anti‐inflammatory drugs in patients with ulcerative colitis. Six studies looking at the effects of fish oil in active ulcerative colitis were included in the review. Study quality was mostly poor. One small study showed a positive benefit for the treatment of active ulcerative colitis. However, this result should be interpreted with caution due to small study size and poor study quality. Due to limited data there is not enough information available to determine whether fish oil treatment is effective for induction of remission in ulcerative colitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "De Ley, M; de Vos, R; Hommes, DW; Stokkers, PC", "articleTypes": [], "doi": "10.1002/14651858.CD005986.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "95efe6aa-5311-419a-9b9f-a3c08d3744f8", "pmid": "", "title": "Interventions for fatigue management after traumatic brain injury", "imported": false, "abstract": "Abstract - Rationale Despite the high prevalence and medico‐social significance of fatigue in post‐traumatic brain injury (post‐TBI) populations, there are no validated management strategies to control this condition. It is timely to provide clinicians and patients with the best available evidence of the efficacy of current pharmacological and non‐pharmacological fatigue management practices. Objectives To assess the effectiveness of pharmacological and non‐pharmacological interventions for fatigue in people who have experienced a TBI. Search methods For this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO. We also searched relevant conference proceedings, and we searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for ongoing trials. The most recent searches were conducted on 12 February 2025. Eligibility criteria Eligible study designs were randomised controlled trials (RCTs) and randomised cross‐over trials (for pharmacological interventions only). Studies with participants of all ages (children and adults) with a TBI (of any severity) were included, where at least 75% of participants had a TBI. Any type of treatment for fatigue was considered. Four categories of interventions were prioritised: pharmacological, cognitive, stimulation/biofeedback, and psychoeducational. These interventions were compared to placebo groups, no treatment, or groups receiving other interventions. Outcomes The critical outcome was fatigue. Important outcomes include fatigue‐related outcomes of psychological functioning (depression and anxiety), cognitive functioning (processing speed), general quality of life, and daytime sleepiness. Risk of bias We assessed risk of bias using the original Cochrane risk of bias tool for RCTs (RoB 1). Synthesis methods We synthesised the results for each outcome by meta‐analysis where possible using mean differences (MDs) and standardised mean differences (SMDs) and a fixed‐effect model. Where meta‐analysis was not possible due to the nature of the data , we narratively reported the results. We used GRADE to assess the certainty of evidence for each outcome . We performed all statistical analyses using RevMan and presented results with 95% confidence intervals (CI). Included studies We included a total of 3518 trial participants (at baseline) across 40 studies, described in 49 publications. The 40 included studies are grouped by type of intervention. There were seven categories of interventions: pharmacological, cognitive, physical activity, stimulation/biofeedback, health visits, psychoeducational, and a final category for trials with multiple interventions (multi‐interventions). Four published studies identified in the most recent search are awaiting classification. Synthesis of results Pharmacological interventions (melatonin; recombinant human growth hormones (rhGH); psychostimulants; atorvastatin; monoaminergic stabiliser (‐)‐OSU6162) likely reduce fatigue slightly (SMD ‐0.25, 95% CI ‐0.44 to ‐0.06; 8 studies, 395 participants; moderate‐certainty evidence). Cognitive interventions (cognitive rehabilitation; technology‐enhanced training; functional skills training) may reduce fatigue slightly (MD ‐0.32, 95% CI ‐0.59 to ‐0.06; 6 studies, 222 participants; low‐certainty evidence). Stimulation/biofeedback interventions (light therapy; electrical/magnetic stimulation; acupressure) may reduce fatigue slightly, but the evidence is very uncertain (SMD ‐0.23, 95% CI ‐0.47 to 0.01; 8 studies, 295 participants; very low‐certainty evidence). Psychoeducation interventions (cognitive behavioural therapy; acceptance and commitment therapy; individualised occupational therapy; novel therapies) may reduce fatigue, but the evidence is very uncertain (SMD ‐0.55, 95% CI ‐0.74 to ‐0.35; 8 studies, 474 participants; very low‐certainty evidence). There may be little to no difference in psychological functioning (depression), psychological functioning (anxiety), cognitive functioning (processing speed), or daytime sleepiness. However, these results are very uncertain. Authors' conclusions There is very limited and moderate to very low‐certainty evidence from RCTs about treatments to reduce fatigue after TBI. Despite the prevalence of fatigue post‐TBI, we lack high‐quality studies that evaluate interventions to improve this disabling, but potentially treatable, symptom. There is a need for considerable further work to identify an effective treatment for fatigue in people with TBI. Funding This Cochrane review had no dedicated funding. Registration Protocol available via DOI: 10.1002/14651858.CD006448 Plain language summary Which treatments are effective for fatigue after traumatic brain injury? Key messages Medications (such as melatonin, growth hormones, brain stimulants, atorvastatin, or dopamine and serotonin regulators) likely reduce fatigue after a traumatic brain injury. Other treatments, such as talking therapies, sensory stimulation, and counselling, may reduce fatigue after a traumatic brain injury. Future studies should involve more people, including children and young people. They should investigate different kinds of treatments in different settings, and the severity and causes of traumatic brain injury. What is traumatic brain injury? Traumatic brain injury is damage to the brain following a bump or blow to the head. The injury might result from a traffic accident, fall, assault, sports injury, or an explosion. People with traumatic brain injury might experience headaches, become forgetful, and have difficulties sleeping and moving. They may also experience fatigue, which is defined as an overwhelming sense of tiredness unrelated to previous effort, which does not usually improve with rest. Fatigue makes it hard for people to concentrate and perform everyday activities, which affects their quality of life. How is fatigue after traumatic brain injury treated? Treatments for fatigue vary because the causes and symptoms of fatigue may be very different. Treatments include medication to stimulate or protect the brain, and hormones and antidepressants to help people sleep and improve their mood. Treatments that don’t involve medication include counselling, education, behavioural therapy and exercise. What did we want to find out? We mainly wanted to find out if different treatments reduce fatigue in people with traumatic brain injury. We were also interested in the effect of the treatments on people’s mood, memory or attention, quality of life, and sleepiness. What did we do? We searched for studies that randomly assigned people to receive treatment for fatigue, usual care (that is, no specific treatment for fatigue), or a placebo (dummy) treatment. We also looked at studies that compared different treatments. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 40 studies with 3518 adults and children living with traumatic brain injury. The studies took place in 12, mainly high‐income, countries in Europe, North America, and Oceania. They were conducted in different settings, including medical centres, rehabilitation clinics, military bases, clinical research facilities, and hospitals. Main results Fatigue Medications likely reduce fatigue after a traumatic brain injury (8 studies, 395 people). Medications included melatonin, growth hormones, psychostimulants, statins, and dopamine regulators. Other treatments (without medication) may reduce fatigue after a traumatic brain injury (31 studies, 2203 people). Treatments included cognitive behavioural therapy, technical‐enhanced training, functional skills training, sensory stimulation, electrical/magnetic stimulation, acupressure, counselling, acceptance and commitment therapy, individualised occupational therapy, cognitive symptom management rehabilitation therapy, aerobic exercise, prescribed light exercise, location of exercise, vestibular rehabilitation, health visits, and multi‐interventional therapies. For treatments with medication, there were some reported adverse (unwanted or harmful) events that are specific to particular studies. For other treatments (without medication), adverse events were often not reported. Fatigue‐related symptoms Medications may make little or no difference to depression, anxiety, processing speed, quality of life, and daytime sleepiness (21 studies, 1016 people). Of the treatments without medication, only cognitive therapy showed any noticeable effect; it may reduce anxiety (2 studies, 57 people). What are the limitations of the evidence? We have limited confidence in the evidence due to the small numbers of people in the different studies, and the variation in settings, treatments, ages of participants, and the severity and causes of traumatic brain injury. How up to date is this evidence? We searched for studies up to 12 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Senior, HE, Leung, JH, Meehan, B, Leao, S, Jordan, V, Barker-Collo, S, Crummey, S, Purdy, SC", "articleTypes": [], "doi": "10.1002/14651858.CD006448.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.794Z" }, { "id": "960499f6-d59c-445f-b8b4-0bd54cc241ff", "pmid": "", "title": "Effect of cocoa on blood pressure", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Ried, K, Fakler, P, Stocks, NP", "articleTypes": [], "doi": "10.1002/14651858.CD008893.pub3 AB - Abstract - Background High blood pressure is an important risk factor for cardiovascular disease, contributing to about 50% of cardiovascular events worldwide and 37% of cardiovascular‐related deaths in Western populations. Epidemiological studies suggest that cocoa‐rich products reduce the risk of cardiovascular disease. Flavanols found in cocoa have been shown to increase the formation of endothelial nitric oxide which promotes vasodilation and therefore blood pressure reduction. Here we update previous meta‐analyses on the effect of cocoa on blood pressure. Objectives To assess the effects on blood pressure of chocolate or cocoa products versus low‐flavanol products or placebo in adults with or without hypertension when consumed for two weeks or longer. Search methods This is an updated version of the review initially published in 2012. In this updated version, we searched the following electronic databases from inception to November 2016: Cochrane Hypertension Group Specialised Register, CENTRAL, MEDLINE and Embase. We also searched international trial registries, and the reference lists of review articles and included trials. Selection criteria Randomised controlled trials (RCTs) investigating the effects of chocolate or cocoa products on systolic and diastolic blood pressure in adults for a minimum of two weeks duration. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias in each trial. We conducted random‐effects meta‐analyses on the included studies using Review Manager 5. We explored heterogeneity with subgroup analyses by baseline blood pressure, flavanol content of control group, blinding, age and duration. Sensitivity analyses explored the influence of unusual study design. Main results Thirty‐five trials (including 40 treatment comparisons) met the inclusion criteria. Of these, we added 17 trials (20 treatment comparisons) to the 18 trials (20 treatment comparisons) in the previous version of this updated review. Trials provided participants with 30 to 1218 mg of flavanols (mean = 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. The control group received either a flavanol‐free product (n = 26 treatment comparisons) or a low‐flavanol‐containing cocoa powder (range 6.4 to 88 mg flavanols (mean = 55 mg, 13 treatment comparisons; 259 mg, 1 trial). Meta‐analyses of the 40 treatment comparisons involving 1804 mainly healthy participants revealed a small but statistically significant blood pressure‐reducing effect of flavanol‐rich cocoa products compared with control in trials of two to 18 weeks duration (mean nine weeks):
 Mean difference systolic blood pressure (SBP) (95% confidence interval (CI): ‐1.76 (‐3.09 to ‐0.43) mmHg, P = 0.009, n = 40 treatment comparisons, 1804 participants;
 Mean difference diastolic blood pressure (DBP) (95% CI): ‐1.76 (‐2.57 to ‐0.94) mmHg, P < 0.001, n = 39 treatment comparisons, 1772 participants. Baseline blood pressure may play a role in the effect of cocoa on blood pressure. While systolic blood pressure was reduced significantly by 4 mmHg in hypertensive people (n = 9 treatment comparisons, 401 participants), and tended to be lowered in prehypertensive people (n= 8 treatment comparisons, 340 participants), there was no significant difference in normotensive people (n = 23 treatment comparisons, 1063 participants); however, the test for subgroup differences was of borderline significance (P = 0.08; I 2 = 60%), requiring further research to confirm the findings. Subgroup meta‐analysis by blinding suggested a trend towards greater blood pressure reduction in unblinded trials compared to double‐blinded trials, albeit statistically not significant. Further research is needed to confirm whether participant expectation may influence blood pressure results. Subgroup analysis by type of control (flavanol‐free versus low‐flavanol control) did not reveal a significant difference. Whether the age of participants plays a role in the effect of cocoa on blood pressure, with younger participants responding with greater blood pressure reduction, needs to be further investigated. Sensitivity analysis excluding trials with authors employed by trials sponsoring industry (33 trials, 1482 participants) revealed a small reduction in effect size, indicating some reporting bias. Due to the remaining heterogeneity, which we could not explain in terms of blinding, flavanol content of the control groups, age of participants, or study duration, we downgraded the quality of the evidence from high to moderate. Results of subgroup analyses should be interpreted with caution and need to be confirmed or refuted in trials using direct randomised comparisons. Generally, cocoa products were highly tolerable, with adverse effects including gastrointestinal complaints and nausea being reported by 1% of participants in the active cocoa intervention group and 0.4% of participants in the control groups (moderate‐quality evidence). Authors' conclusions This review provides moderate‐quality evidence that flavanol‐rich chocolate and cocoa products cause a small (2 mmHg) blood pressure‐lowering effect in mainly healthy adults in the short term. These findings are limited by the heterogeneity between trials, which could not be explained by prespecified subgroup analyses, including blinding, flavanol content of the control groups, age of participants, or study duration. However, baseline blood pressure may play a role in the effect of cocoa on blood pressure; subgroup analysis of trials with (pre)hypertensive participants revealed a greater blood pressure‐reducing effect of cocoa compared to normotensive participants with borderline significance. Long‐term trials investigating the effect of cocoa on clinical outcomes are also needed to assess whether cocoa has an effect on cardiovascular events and to assess potential adverse effects associated with chronic ingestion of cocoa products. Plain language summary Effect of cocoa on blood pressure Review question We assessed the effect of cocoa products on blood pressure in adults when consumed daily for at least two weeks. We found 35 studies, covering 40 treatment comparisons. Background Dark chocolate and cocoa products are rich in chemical compounds called flavanols. Flavanols have attracted interest as they might help to reduce blood pressure, a known risk factor for cardiovascular disease (disorders of the heart and blood vessels). The blood pressure‐lowering properties of flavanols are thought to be related to widening of the blood vessels, caused by nitric oxide. Study characteristics Studies were short, mostly between two and12 weeks, with only one of 18 weeks. The studies involved 1804 mainly healthy adults. They provided participants with 30 to 1218 mg of flavanols (average of 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. Seven of the studies were funded by companies with a commercial interest in their results, and the reported effect was slightly larger in these studies, indicating possible bias. The evidence is current to November 2016. Key results Meta‐analysis of 40 treatment comparisons revealed a small but statistically significant lowering of blood pressure (systolic and diastolic) of 1.8 mmHg. This small reduction in blood pressure might complement other treatment options and might contribute to reducing the risk of cardiovascular disease. We investigated whether participants' blood pressure at the start of the study, their age, an awareness of group allocation (active or control), the flavanol content used in the control group, or how long the study lasted may explain variations between trials. While blood pressure status (high blood pressure or normal blood pressure) is a likely factor in the effect size of cocoa on blood pressure, the impact of other factors needs to be confirmed or rejected in further trials. Side effects including digestive complaints and dislike of the trial product were reported by only 1% of people in the active cocoa intervention group and 0.4% of people in the control groups. Longer‐term trials are needed to establish whether regularly eating flavanol‐rich cocoa products has a beneficial effect on blood pressure and cardiovascular health over time, and whether there are any side effects of long‐term use of cocoa products on a daily basis. Quality of evidence The evidence is of moderate quality. We were unable to identify any randomised controlled trials that tested the effect of long‐term daily use of cocoa products on blood pressure, and there were no trials that measured the health consequences of high blood pressure, such as heart attacks or strokes.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.076Z" }, { "id": "962a2ef5-8aa7-4031-857f-74ef12eb8359", "pmid": "", "title": "Vitamin and mineral supplementation for maintaining cognitive function in cognitively healthy people in mid and late life", "imported": false, "abstract": "Abstract - Background Vitamins and minerals play multiple functions within the central nervous system which may help to maintain brain health and optimal cognitive functioning. Supplementation of the diet with various vitamins and minerals has been suggested as a means of maintaining cognitive function, or even of preventing dementia, in later life. Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function in cognitively healthy people aged 40 years or more. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov and the WHO Portal/ICTRP from inception to 26th January 2018. Selection criteria We included randomised controlled trials that evaluated the cognitive effects on people aged 40 years or more of any vitamin or mineral supplements taken by mouth for at least three months. Data collection and analysis Study selection, data extraction, and quality assessments were done in duplicate. Vitamins were considered broadly in the categories of B vitamins, antioxidant vitamins, and combinations of both. Minerals were considered separately, where possible. If interventions and outcomes were considered sufficiently similar, then data were pooled. In order to separate short‐term cognitive effects from possible longer‐term effects on the trajectory of cognitive decline, data were pooled for various treatment durations from 3 months to 12 months and up to 10 years or more. Main results In total, we included 28 studies with more than 83,000 participants. There were some general limitations of the evidence. Most participants were enrolled in studies which were not designed primarily to assess cognition. These studies often had no baseline cognitive assessment and used only brief cognitive assessments at follow‐up. Very few studies assessed the incidence of dementia. Most study reports did not mention adverse events or made only very general statements about them. Only 10 studies had a mean follow‐up > 5 years. Only two studies had participants whose mean age was < 60 years at baseline. The risk of bias in the included studies was generally low, other than a risk of attrition bias for longer‐term outcomes. We considered the certainty of the evidence behind almost all results to be moderate or low. We included 14 studies with 27,882 participants which compared folic acid, vitamin B12, vitamin B6, or a combination of these to placebo. The majority of participants were aged over 60 years and had a history of cardio‐ or cerebrovascular disease. We found that giving B vitamin supplements to cognitively healthy adults, mainly in their 60s and 70s, probably has little or no effect on global cognitive function at any time point up to 5 years (SMD values from ‐0.03 to 0.06) and may also have no effect at 5‐10 years (SMD ‐0.01). There were very sparse data on adverse effects or on incidence of cognitive impairment or dementia. We included 8 studies with 47,840 participants in which the active intervention was one or more of the antioxidant vitamins: ß‐carotene, vitamin C or vitamin E. Results were mixed. For overall cognitive function, there was low‐certainty evidence of benefit associated with ß‐carotene after a mean of 18 years of treatment (MD 0.18 TICS points, 95% CI 0.01 to 0.35) and of vitamin C after 5 years to 10 years (MD 0.46 TICS points, 95% CI 0.14 to 0.78), but not at earlier time points. From two studies which reported on dementia incidence, there was low‐certainty evidence of no effect of an antioxidant vitamin combination or of vitamin E, either alone or combined with selenium. One of the included studies had been designed to look for effects on the incidence of prostate cancer; it found a statistically significant increase in prostate cancer diagnoses among men taking vitamin E. One trial with 4143 participants compared vitamin D3 (400 IU/day) and calcium supplements to placebo. We found low‐ to moderate‐certainty evidence of no effect of vitamin D3 and calcium supplements at any time‐point up to 10 years on overall cognitive function (MD after a mean of 7.8 years ‐0.1 MMSE points, 95% CI ‐0.81 to 0.61) or the incidence of dementia (HR 0.94, 95% CI 0.72 to 1.24). A pilot study with 60 participants used a higher dose of vitamin D3 (4000 IU on alternate days) and found preliminary evidence that this dose probably has no effect on cognitive function over six months. We included data from one trial of zinc and copper supplementation with 1072 participants. There was moderate‐certainty evidence of little or no effect on overall cognitive function (MD 0.6 MMSE points, 95% CI ‐0.19 to 1.39) or on the incidence of cognitive impairment after 5 years to 10 years. A second smaller trial provided no usable data, but reported no cognitive effects of six months of supplementation with zinc gluconate. From one study with 3711 participants, there was low‐certainty evidence of no effect of approximately five years of selenium supplementation on the incidence of dementia (HR 0.83, 95% CI 0.61 to 1.13). Finally, we included three trials of complex supplements (combinations of B vitamins, antioxidant vitamins, and minerals) with 6306 participants. From the one trial which assessed overall cognitive function, there was low‐certainty evidence of little or no effect on the TICS (MD after a mean of 8.5 years 0.12, 95% CI ‐0.14 to 0.38). Authors' conclusions We did not find evidence that any vitamin or mineral supplementation strategy for cognitively healthy adults in mid or late life has a meaningful effect on cognitive decline or dementia, although the evidence does not permit definitive conclusions. There were very few data on supplementation starting in midlife (< 60 years); studies designed to assess cognitive outcomes tended to be too short to assess maintenance of cognitive function; longer studies often had other primary outcomes and used cognitive measures which may have lacked sensitivity. The only positive signals of effect came from studies of long‐term supplementation with antioxidant vitamins. These may be the most promising for further research. Plain language summary Vitamin and mineral supplementation for preventing cognitive deterioration in cognitively healthy people in mid and late life Review question This review aimed to find out whether people aged 40 years or older could maintain their mental abilities or reduce their risk of dementia by taking vitamin or mineral supplements. Background There is great interest in anything people might do to keep themselves mentally healthy as they age and, especially, to reduce their risk of developing dementia. Various vitamin and mineral supplements have been suggested as ways to do this. Vitamins and minerals have many functions in the body and the ways they might affect brain health are not well understood. Therefore, we were interested in the effects of any vitamins or minerals, either alone or in combination. What we did We searched up to January 2018 for all trials which had studied the effect on cognition (thinking and remembering) of any vitamin or mineral supplements in people aged 40 years or more who had no cognitive problems at the beginning of the study. The studies had to include a comparison group which had not taken the supplement being studied and, to be sure the comparison was fair, it should have been decided at random whether people got the supplement or not. What we found We grouped the 28 included trials according to the kind of supplement they used and how it might work. Most of the trials were not originally designed to study cognition or dementia and used only simple measures of cognition. Very few studies investigated whether participants developed dementia. Long‐term studies are probably needed to find effects on the risk of dementia or cognitive decline but only 10 studies had an average length of follow‐up longer than five years. The studies were generally well‐conducted although the longer trials had difficulty following up all of the participants and this could have biased some of the longer‐term results. There were 14 trials of B vitamins (folic acid, vitamin B6, vitamin B12) with nearly 28,000 participants, mainly in their 60s and 70s. Most of these trials were quite short (less than two years). We found no evidence that B vitamins had any effect on cognition. There were 8 trials of antioxidant vitamins (beta‐carotene/vitamin A, vitamin C, vitamin E) with approximately 47,000 participants. These trials tended to be longer than the B vitamin trials so may have had more chance of detecting effects on dementia and cognitive decline. The results were mixed. We found low‐certainty evidence of better overall cognitive function after an average of 18 years taking beta‐carotene and after five years to 10 years taking vitamin C, but no effects after shorter periods of treatment. There were also small benefits of beta‐carotene, vitamin C, and antioxidant combinations on memory at some time points but not others. There was no evidence of any benefits from vitamin E alone. Two studies examined the risk of developing dementia. One found no effect of a combination of antioxidant vitamins and the other found no effect of vitamin E, either alone or combined with the mineral selenium. Most of the studies did not report any information about harmful effects. One included trial was designed to look for an effect on the risk of prostate cancer; it found a higher risk among the men taking vitamin E. There was a small trial of vitamin D supplements which found they probably had no effect on cognition over six months. There were longer trials of vitamin D with calcium (one trial), zinc and copper (one trial), and complex multivitamins (three trials). All lasted between five and 10 years, but none of them found any evidence of beneficial effects on cognition. One trial found no effect of selenium taken for approximately five years on the risk of developing dementia. Conclusions We found no good evidence to suggest that middle‐aged or older people can preserve cognitive function or prevent dementia by taking vitamin or mineral supplements. There were a few positive results associated with long‐term use of antioxidant vitamins, particularly beta‐carotene and vitamin C, although the effects were small. Further research into the effects of these vitamins may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rutjes, AWS; Denton, DA; Di Nisio, M; Chong, LY; Abraham, RP; Al‐Assaf, AS; Anderson, JL; Malik, MA; Vernooij, RWM; Martínez, G; Tabet, N; McCleery, J", "articleTypes": [], "doi": "10.1002/14651858.CD011906.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "963821da-254b-4cf1-aaf5-d2f877a22575", "pmid": "", "title": "Cannabinoids for fibromyalgia", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue affecting approximately 2% of the general population. People often report high disability levels and poor health‐related quality of life (HRQoL). Drug therapy focuses on reducing key symptoms and disability, and improving HRQoL. Cannabis has been used for millennia to reduce pain and other somatic and psychological symptoms. Objectives To assess the efficacy, tolerability and safety of cannabinoids for fibromyalgia symptoms in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE to April 2016, together with reference lists of retrieved papers and reviews, three clinical trial registries, and contact with trial authors. Selection criteria We selected randomised controlled trials of at least four weeks' duration of any formulation of cannabis products used for the treatment of adults with fibromyalgia. Data collection and analysis Two review authors independently extracted the data of all included studies and assessed risk of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs; at least 200 participants in the comparison, eight to 12 weeks' duration, parallel design), second tier evidence from data that did not meet one or more of these criteria and were considered at some risk of bias but with adequate numbers (i.e. data from at least 200 participants) in the comparison, and third tier evidence from data involving small numbers of participants that were considered very likely to be biased or used outcomes of limited clinical utility, or both. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Main results We included two studies with 72 participants. Overall, the two studies were at moderate risk of bias. The evidence was derived from group mean data and completer analysis (very low quality evidence overall). We rated the quality of all outcomes according to GRADE as very low due to indirectness, imprecision and potential reporting bias. The primary outcomes in our review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Nabilone was compared to placebo and to amitriptyline in one study each. Study sizes were 32 and 40 participants. One study used a cross‐over design and one used a parallel group design; study duration was four or six weeks. Both studies used nabilone, a synthetic cannabinoid, with a bedtime dosage of 1 mg/day. No study reported the proportion of participants experiencing at least 30% or 50% pain relief or who were very much improved. No study provided first or second tier (high to moderate quality) evidence for an outcome of efficacy, tolerability and safety. Third tier (very low quality) evidence indicated greater reduction of pain and limitations of HRQoL compared to placebo in one study. There were no significant differences to placebo noted for fatigue and depression (very low quality evidence). Third tier evidence indicated better effects of nabilone on sleep than amitriptyline (very low quality evidence). There were no significant differences between the two drugs noted for pain, mood and HRQoL (very low quality evidence). More participants dropped out due to adverse events in the nabilone groups (4/52 participants) than in the control groups (1/20 in placebo and 0/32 in amitriptyline group). The most frequent adverse events were dizziness, nausea, dry mouth and drowsiness (six participants with nabilone). Neither study reported serious adverse events during the period of both studies. We planned to create a GRADE 'Summary of findings' table, but due to the scarcity of data we were unable to do this. We found no relevant study with herbal cannabis, plant‐based cannabinoids or synthetic cannabinoids other than nabilone in fibromyalgia. Authors' conclusions We found no convincing, unbiased, high quality evidence suggesting that nabilone is of value in treating people with fibromyalgia. The tolerability of nabilone was low in people with fibromyalgia. Plain language summary Cannabis products for people with fibromyalgia Background Fibromyalgia is characterised by chronic (longer than three months) widespread pain that often co‐exists with sleep problems, problems with thinking and fatigue (exhaustion). People often report severe limitations of daily functioning and poor health‐related quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. Cannabis has been used for 3000 years to reduce pain and other symptoms, such as loss of appetite and anxiety. Key results and quality of the evidence In April 2016 we searched for reports of clinical trials that used cannabis products to treat symptoms in adults with fibromyalgia. We found two small, moderate quality studies, of four and six weeks long, including 72 participants. Both studies tested nabilone, a synthetic (man‐made) cannabis product, comparing it with placebo (a dummy pill) or amitriptyline (an antidepressant frequently used in the treatment of fibromyalgia). Nabilone did not convincingly relieve fibromyalgia symptoms (pain, sleep, fatigue) better than placebo or amitriptyline (very low quality evidence). Compared with placebo and amitriptyline, more people experienced side effects and left the study due to side effects (very low quality evidence). There were no serious side effects reported. We found no relevant study with herbal cannabis, plant‐based cannabinoids or other synthetic cannabinoids than nabilone in fibromyalgia. There was not enough high quality evidence available to draw any robust conclusions. We found no studies on medical cannabis in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B, Klose, P, Fitzcharles, M-A, Phillips, T, Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.765Z" }, { "id": "965fb4d6-6a3b-4284-849d-2f1b49d316cb", "pmid": "", "title": "Modafinil for people with schizophrenia or related disorders", "imported": false, "abstract": "Abstract - Background People with schizophrenia have a range of different symptoms, including positive symptoms (hallucinations and delusions), negative symptoms (such as social withdrawal and lack of affect), and cognitive impairment. The standard medication for people with schizophrenia is antipsychotics. However, these medications may not be effective for all symptoms of schizophrenia, as cognitive and negative symptoms are usually hard to treat. Additional therapies or medications are available for the management of these symptoms. Modafinil, a wakefulness‐promoting agent most frequently used in narcolepsy or shift work sleep disorder, is one intervention that is theorised to have an effect of these symptoms. Objectives The primary objective of this review was to assess the effects of modafinil for people with schizophrenia or related disorders. Search methods On 27 April 2015, 24 May 2017, and 31 October 2019, we searched the Cochrane Schizophrenia Group's register of trials, which is based on regular searches of CENTRAL, MEDLINE, Embase, AMED, BIOSIS, CINAHL, PsycINFO, PubMed, and registries of clinical trials. There are no language, time, document type, or publication status limitations for the inclusion of records in the register. Selection criteria We selected all randomised controlled trials comparing modafinil with placebo or other treatments for people with schizophrenia or schizophrenia‐spectrum disorders. Data collection and analysis We independently extracted data from the included studies. We analysed dichotomous data using risk ratios (RR) and 95% confidence intervals (CI). We analysed continuous data using mean difference (MD) with a 95% CI. We used a random‐effects model for the meta‐analysis. We used GRADE to complete a 'Summary of findings' table and assessed risk of bias for the included studies. Main results Eleven studies including a total of 422 participants contributed to data analyses. Most studies had a small population size (average 38 people per study) and were of short duration. We also detected a high risk of bias for selective outcome reporting in just under 50% of the trials. We therefore rated the overall methodological quality of the included studies as low. We considered seven main outcomes of interest: clinically important change in overall mental state, clinically important change in cognitive functioning, incidence of a clinically important adverse effect/event, clinically important change in global state, leaving the study early for any reason, clinically important change in quality of life, and hospital admission. All studies assessed the effects of adding modafinil to participants' usual antipsychotic treatment compared to adding placebo to usual antipsychotic treatment. Six studies found that adding modafinil to antipsychotic treatment may have little or no effect on overall mental state of people with schizophrenia, specifically the risk of worsening psychosis (RR 0.91, 95% CI 0.28 to 2.98; participants = 209; studies = 6, low‐quality evidence ). Regarding the effect of modafinil on cognitive function, the trials did not report clinically important change data, but one study reported endpoint scores on the MATRICS Consensus Cognitive Battery (MCCB): in this study we found no clear difference in scores between modafinil and placebo treatment groups (MD −3.10, 95% CI −10.9 to 4.7; participants = 48; studies = 1, very low‐quality evidence ). Only one study (N = 35) reported adverse effect/event data. In this study one serious adverse event occurred in each group (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). One study measured change in global state using the Clinical Global Impression ‐ Improvement Scale. This study found that adding modafinil to antipsychotic treatment may have little or no effect on global state (RR 6.36, 95% CI 0.94 to 43.07, participants = 21; studies = 1, very low‐quality evidence ). Nine studies found that modafinil has no effect on numbers of participants leaving the study early (RR 1.26, 95% CI 0.63 to 2.52 participants = 357; studies = 9, moderate‐quality evidence ). None of the trials reported clinically important change in quality of life, but one study did report quality of life using endpoint scores on the Quality of Life Inventory, finding no clear difference between treatment groups (MD −0.2, 95% CI −1.18 to 0.78; participants = 20; studies = 1, very low‐quality evidence ). Finally, one study reported data for number of participants needing hospitalisation: one participant in each group was hospitalised (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). Authors' conclusions Due to methodological issues, low sample size, and short duration of the clinical trials as well as high risk of bias for outcome reporting, most of the evidence available for this review is of very low or low quality. For results where quality is low or very low, we are uncertain or very uncertain if the effect estimates are true effects, limiting our conclusions. Specifically, we found that modafinil is no better or worse than placebo at preventing worsening of psychosis; however, we are uncertain about this result. We have more confidence that participants receiving modafinil are no more likely to leave a trial early than participants receiving placebo. However, we are very uncertain about the remaining equivocal results between modafinil and placebo for outcomes such as improvement in global state or cognitive function, incidence of adverse events, and changes in quality of life. More high‐quality data are needed before firm conclusions regarding the effects of modafinil for people with schizophrenia or related disorders can be made. Plain language summary Modafinil for schizophrenia Review question: Is adding modafinil to antipsychotic treatment effective and safe for people with schizophrenia? Background Schizophrenia is a complicated and chronic mental disorder that usually presents with a wide range of symptoms. The standard treatment (antipsychotics) is considered to be effective for the positive symptoms (such as delusions and hallucinations or bizarre thoughts). However, there are negative and cognitive symptoms (such as social withdrawal, lack of affect, problems with memory) that are not adequately treated with these medications. These symptoms tend to be chronic and can therefore have a long‐term impact on an individual's quality of life. Additional treatments are often added to antipsychotic treatment, of which one is modafinil, a wakefulness‐promoting medication usually used for sleep disorders. Searching for evidence We ran an electronic search of Cochrane Schizophrenia's register of trials in April 2015, May 2017, and October 2019 for trials that randomised (allocated participants to treatment groups using a random method) people with schizophrenia to receive add‐on modafinil (modafinil added to their standard care) or to receive add‐on placebo. We identified 67 records that referred to 25 studies. Evidence found Eleven studies met the review requirements and reported data that could be used in analyses. However, the trials included small numbers of participants and were of short duration; schizophrenia is a long‐term health problem that ideally requires studies of longer duration. Our analysis of the data showed there is no clear difference between add‐on modafinil and add‐on placebo for improving mental state or global state, changing cognitive functioning, causing participants to leave a study early, producing adverse effects, or affecting rates of hospitalisation. However, most of these results were based on very low‐ or low‐quality data, therefore it is uncertain if these statistical effect sizes found by our data analyses are true effects. Conclusions The results of this review indicate no clear difference in effectiveness and safety between add‐on modafinil and add‐on placebo, however these results are not conclusive as they are based low‐ or very low‐quality evidence. Based on the current evidence we were unable to provide an answer to our review question as to whether modafinil is better than placebo for improving the symptoms of schizophrenia, or if it is safe to use for people with schizophrenia. More high‐quality research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ortiz-Orendain, J; Covarrubias-Castillo, SA; Vazquez-Alvarez, AO; Castiello-de Obeso, S; Arias Quiñones, GE; Seegers, M; Colunga-Lozano, LE", "articleTypes": [], "doi": "10.1002/14651858.CD008661.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "966ce460-3429-4269-8e4d-cf08ffabddb3", "pmid": "", "title": "Nutritional support in children and young people with cancer undergoing chemotherapy", "imported": false, "abstract": "Abstract - Background It is well documented that malnutrition is a common complication of paediatric malignancy and its treatment. Malnutrition can often be a consequence of cancer itself or a result of chemotherapy. Nutritional support aims to reverse malnutrition seen at diagnosis, prevent malnutrition associated with treatment and promote weight gain and growth. The most effective and safe forms of nutritional support in children and young people with cancer are not known. Objectives To determine the effects of any form of parenteral (PN) or enteral (EN) nutritional support, excluding vitamin supplementation and micronutrient supplementation, in children and young people with cancer undergoing chemotherapy and to determine the effect of the nutritional content of PN and EN. This is an update of a previous Cochrane review. Search methods We searched the following databases for the initial review: CENTRAL ( The Cochrane Library , Issue 2, 2009), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), CINAHL (1982 to 2006), the National Research Register (2007) and Dissertations & Theses (2007). Experts in the field were also contacted for information on relevant trials. For this update, we searched the same electronic databases from 2006 to September 2013. We also scrutinised the reference lists of included articles to identify additional trials. Selection criteria Randomised or quasi‐randomised controlled trials comparing any form of nutritional support with another, or control, in children or young people with cancer undergoing chemotherapy. Data collection and analysis Two authors independently selected trials. At least two authors independently assessed quality and extracted data. We contacted trialists for missing information. Main results The current review included the eight trials from the initial review and six new trials which randomised 595 participants (< 21 years of age) with leukaemias or solid tumours undergoing chemotherapy. The trials were all of low quality with the exception of two of the trials looking at glutamine supplementation. One small trial found that compared to EN, PN significantly increased weight (mean difference (MD) 4.12, 95% CI 1.91 to 6.33), serum albumin levels (MD 0.70, 95% CI 0.14 to 1.26), calorie intake (MD 22.00, 95% CI 5.12 to 38.88) and protein intake (MD 0.80, 95% CI 0.45 to 1.15). One trial comparing peripheral PN and EN with central PN found that mean daily weight gain (MD ‐27.00, 95% CI ‐43.32 to ‐10.68) and energy intake (MD ‐15.00, 95% CI ‐26.81 to ‐3.19) were significantly less for the peripheral PN and EN group, whereas mean change in serum albumin was significantly greater for that group (MD 0.47, 95% CI 0.13 to 0.81, P = 0.008). Another trial with few participants found an increase in mean energy intake (% recommended daily amount) in children fed an energy dense feed compared to a standard calorie feed (MD +28%, 95% CI 17% to 39%). Three studies looked at glutamine supplementation. The evidence suggesting that glutamine reduces severity of mucositis was not statistically significant in two studies (RR 0.64, 95% CI 0.19 to 2.2 and RR 0.85, 95% CI 0.66 to 1.1) and differences in reduction of infection rates were also not significant in two studies (RR 1.0, 95% CI 0.72 to 1.4 and RR 0.98, 95% CI 0.63 to 1.51). Only one study compared olive oil based PN to standard lipid containing PN. Despite similar calorie contents in both feeds, the standard lipid formula lead to greater weight gain (MD ‐0.34 z‐scores, 95% CI ‐0.68 to 0.00). A single study compared standard EN with fructooligosaccharide containing EN. There was no difference in weight gain between groups (mean difference ‐0.12, 95% CI ‐0.57 to 0.33), with adverse effects (nausea) occurring equally between the groups (RR 0.92, 95% CI 0.48 to 1.74). Authors' conclusions There is limited evidence from individual trials to suggest that PN is more effective than EN in well‐nourished children and young people with cancer undergoing chemotherapy. The evidence for other methods of nutritional support remains unclear. Limited evidence suggests an energy dense feed increases mean daily energy intake and has a positive effect on weight gain. Evidence suggesting glutamine supplementation reduces incidence and severity of mucositis, infection rates and length of hospital stay is not statistically significant. Further research, incorporating larger sample sizes and rigorous methodology utilising valid and reliable outcome measures, is essential. Plain language summary Nutritional support in children and young people with cancer undergoing chemotherapy The provision of safe, appropriate and effective nutritional support for children and young people undergoing treatment for cancer is now well recognised as an important part of their care. It may help to reverse malnutrition seen at diagnosis, prevent malnutrition associated with the cancer, promote weight gain and growth and improve quality of life. Nutritional support may be provided by one of two methods: intravenous nutritional liquids delivered through a central or peripheral vein which bypass the gut (parenteral nutrition); or nutritional liquids or solids that pass through any part of the gut, regardless of method of delivery (e.g. orally or via a tube; enteral nutrition). We found evidence from one small trial to suggest that parenteral nutrition may result in an increase in weight, serum albumin levels and calorie and protein intake when compared to enteral nutrition (usual food intake). However, the effect of other methods of delivery of nutritional support remains unclear. Results from another small study suggested that the use of energy dense enteral feeds resulted in greater average daily energy intake and subsequently improved weight gain. Three studies looked at glutamine supplementation and did not show a benefit from its use. One study looked at the effect of using olive oil based parenteral feeds rather than those containing standard fats and found that it lead to less weight gain. One study considered the effect of adding fructooligosaccharide to enteral feeds and found that it did not effect the amount of weight gained or how often participants felt nauseated. No studies were identified that compared the nutritional content in either the PN or EN groups of studies. The trials were all of low quality and very different in terms of outcome measures used. In the future, much larger, rigorously conducted trials are needed in order to address this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Ward, EJ, Henry, LM, Friend, AJ, Wilkins, S, Phillips, RS", "articleTypes": [], "doi": "10.1002/14651858.CD003298.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.786Z" }, { "id": "96843888-d4ec-4b83-89ac-565b4145b5f9", "pmid": "", "title": "Coblation versus other surgical techniques for tonsillectomy", "imported": false, "abstract": "Abstract - Background Tonsillectomy is a very common operation and is performed using various surgical methods. Coblation is a popular method because it purportedly causes less pain than other surgical methods. However, the superiority of coblation is unproven. Objectives To compare the effects of coblation tonsillectomy for chronic tonsillitis or tonsillar hypertrophy with other surgical techniques, both hot and cold, on intraoperative morbidity, postoperative morbidity and procedural cost. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2017, Issue 3); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 April 2017. Selection criteria Randomised controlled trials (RCTs) of children and adults undergoing tonsillectomy with coblation compared with any other surgical technique. This review is limited to trials of extracapsular (traditional) tonsillectomy and excludes trials of intracapsular tonsil removal (tonsillotomy). Data collection and analysis We used the standard Cochrane methods. Our primary outcomes were: patient‐reported pain using a validated pain scale at postoperative days 1, 3 and 7; intraoperative blood loss; primary postoperative bleeding (within 24 hours) and secondary postoperative bleeding (more than 24 hours after surgery). Secondary outcomes were: time until resumption of normal diet, time until resumption of normal activity, duration of surgery and adverse effects including blood transfusion and the need for reoperation. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 29 studies, with a total of 2561 participants. All studies had moderate or high risk of bias. Sixteen studies used an adequate randomisation technique, however the inability to mask the surgical teams and/or provide adequate methods to mitigate the risk of bias put nearly all studies at moderate or high risk of detection and measurement bias for intraoperative blood loss, and primary and secondary bleeding. In contrast most studies (20) were at low risk of bias for pain assessment. Most studies did not report data in a manner permitting meta‐analysis. Most studies did not clearly report the participant characteristics, surgical indications or whether patients underwent tonsillectomy or adenotonsillectomy. Most studies reported that tonsillitis (infection) and/or tonsillar hypertrophy (obstruction) were the indication for surgery. Seven studies included only adults, 16 studies included only children and six studies included both. Pain At postoperative day 1 there is very low quality evidence that patients in the coblation group had less pain, with a standardised mean difference (SMD) of ‐0.79 (95% confidence interval (CI) ‐1.38 to ‐0.19; 538 participants; six studies). This effect is reduced a SMD of ‐0.44 (95% CI ‐0.97 to 0.09; 401 participants; five studies; very low‐quality evidence ) at day 3, and at day 7 there is low quality evidence of little or no difference in pain (SMD ‐0.01, 95% CI ‐0.22 to 0.19; 420 participants; five studies). Although this suggests that pain may be slightly less in the coblation group between days 1 and 3, the clinical significance is unclear. Intraoperative blood loss Methodological differences between studies in the measurement of intraoperative blood loss precluded meta‐analysis. Primary and secondary bleeding The risk of primary bleeding was similar (risk ratio (RR) 0.99, 95% CI 0.48 to 2.05; 2055 participants; 25 studies; low‐quality evidence ). The risk of secondary bleeding was greater in the coblation group with a risk ratio of 1.36 (95% CI 0.95 to 1.95; 2118 participants; 25 studies; low‐quality evidence ). Using the median of the control group as the baseline risk, the absolute risk in the coblation group was 5% versus 3.6% in the control group. The difference of 1.3% has a 95% CI of 0.2% lower in the coblation group to 3.5% higher. Secondary outcomes Differences in study design and data reporting precluded the identification of differences in the time to resumption of normal diet or activity, or whether there was a difference in the duration of surgery. Although we could not feasibly compare the costs of equipment or operative facility, anaesthetic and surgical fees across different healthcare systems we used duration of surgery as a proxy for cost. Although this outcome was commonly reported in studies, it was not possible to pool the data to determine whether there was a difference. Adverse events other than bleeding were not well reported. It is unclear whether there is a difference in postoperative infections or the need for reoperation. Authors' conclusions The coblation technique may cause less pain on postoperative day 1, but the difference is small and may be clinically meaningless. By postoperative day 3, the difference decreases further and by postoperative day 7 there appears to be little or no difference. We found similar rates of primary bleeding but we cannot rule out a small increased risk of secondary bleeding with coblation. The evidence supporting these findings is of low or very low quality , i.e. there is a very high degree of uncertainty about the results. Moreover, for most outcomes data were only available from a few of the 29 included studies. The current evidence is of very low quality, therefore it is uncertain whether or not the coblation technique has any advantages over traditional tonsillectomy techniques. Despite the large number of studies, failure to use standardised or validated outcome measures precludes the ability to pool data across studies. Therefore, well‐conducted RCTs using consistent, validated outcome measures are needed to establish whether the coblation technique has a benefit over other methods. In the included studies we identified no clear difference in adverse events. However, given the rarity of these events, randomised trials lack the power to detect a difference. Data from large‐scale registries will provide a better estimate of any difference in these rare outcomes. Plain language summary Surgical removal of the tonsils (tonsillectomy) with coblation or another surgical method Review question This review compared the coblation method with other methods of tonsil removal to assess recovery following tonsillectomy or adenotonsillectomy. Background Surgical removal of the tonsils (tonsillectomy) is a very common operation. Patients may have pain for up to two weeks after surgery. Bleeding may occur either immediately after surgery ('primary bleeding' within 24 hours of surgery) or later ('secondary bleeding' more than 24 hours after surgery). There are many methods of tonsillectomy; the traditional method is with metal surgical instruments. Coblation is a new method where the surgeon uses an electrically powered handpiece that 'burns' tissues using low temperatures. Study characteristics This review included evidence available up to April 2017. We included 29 studies, with a total of 2561 participants. All studies had a moderate or high risk of bias. Seven studies included adults, 16 studies included children and six included both adults and children. Most studies measured pain using a patient‐reported scale (for example, asking people to rate their pain on a scale of 1 to 10). Key results The coblation technique may cause slightly less pain one day after surgery and three days after surgery, but it is unlikely that there is a difference in pain seven days after surgery. We are very uncertain whether the amount of pain reduction observed in days 1 to 3 after surgery would be important to patients. There is little or no difference in the risk of bleeding in the first day after surgery, but there may be a small increased risk of bleeding with coblation after the first day. For every 1000 patients having a tonsillectomy, 50 patients would have a bleed with coblation, compared to 36 with traditional surgical techniques. Quality of the evidence The evidence for the difference in pain is of low or very low quality and for the difference in bleeding after surgery it is of low quality . This means that we have little confidence in the results; the true effect may be very different ‐ we simply do not know at this stage.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Pynnonen, M; Brinkmeier, JV; Thorne, MC; Chong, LY; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "968ad0f5-5d22-49ce-8af1-6117869bd287", "pmid": "", "title": "Oral Astragalus (Huang qi) for preventing frequent episodes of acute respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common in children and can involve both upper and lower airways. Many children experience frequent ARTI episodes or recurrent respiratory tract infections (RRTIs) in early life, which creates challenges for paediatricians, primary care physicians, parents and carers of children. In China, Astragalus (Huang qi), alone or in combination with other herbs, is used by Traditional Chinese Medicine (TCM) practitioners in the form of a water extract, to reduce the risk of ARTIs; it is believed to stimulate the immune system. Better understanding of the therapeutic mechanisms of Astragalus may provide insights into ARTI prevention, and consequently reduced antibiotic use. Objectives To assess the effectiveness and safety of oral Astragalus for preventing frequent episodes of acute respiratory tract infections (ARTIs) in children in community settings. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2015), MEDLINE (Ovid) (1946 to 31 December 2015), Embase (Elsevier) (1974 to 31 December 2015), AMED (Ovid) (1985 to 31 December 2015), Chinese National Knowledge Infrastructure (CNKI) (1979 to 31 December 2015) and Chinese Scientific Journals full text database (CQVIP) (1989 to 31 December 2015), China Biology Medicine disc (CBM 1976 to 31 December 2015) and Wanfang Data Knowledge Service Platform (WanFang) (1998 to 31 December 2015). Selection criteria We included randomised controlled trials (RCTs) comparing oral Astragalus as a sole Chinese herbal preparation with placebo to prevent frequent episodes of ARTIs in children. Data collection and analysis We used standard Cochrane methodological procedures for this review. We assessed search results to identify relevant studies. We planned to extract data using standardised forms. Disagreements were to be resolved through discussion. Risk of bias was to be assessed using the Cochrane 'Risk of bias' tool. We planned to use mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) or odds ratio (OR) to analyse dichotomous data, both with 95% confidence intervals (CIs). Main results We identified 6080 records: 3352 from English language databases, 2724 from Chinese databases, and four from other sources. Following initial screening and deduplication, we obtained 120 full‐text papers for assessment. Of these, 21 were not RCTs; 55 did not meet the inclusion criteria because: participants were aged over 14 years; definition was not included for recurrent or frequent episodes; Astragalus preparation was not an intervention; Astragalus preparation was in the formula but was not the sole agent; the Astragalus preparation was not administered orally; or Astragalus was used for treatment rather than prevention of ARTI. A further 44 studies were excluded because they were not placebo‐controlled, although other inclusion criteria were fulfilled. No RCTs met our inclusion criteria. Authors' conclusions We found insufficient evidence to enable assessment of the effectiveness and safety of oral Astragalus as a sole intervention to prevent frequent ARTIs in children aged up to 14 years. Plain language summary Can oral Astragalus (Huang qi) prevent frequent acute respiratory tract infections in children? Review question We assessed evidence for the benefits and harms of oral Astragalus used alone to prevent frequent episodes of acute respiratory infections (ARTIs) in children aged up to 14 years, compared to a dummy treatment. ARTIs include colds, sore throats, laryngitis, influenza, bronchitis and pneumonia. Background Many therapies are used to prevent ARTIs, especially in children. Astragalus, is a widely used and available herbal therapy that has been used for thousands of years in China to help prevent ARTIs. It is thought to boost immunity. Almost one in five children experience frequent ARTIs and treatment accounts for up to 75% of all prescribed antibiotics for children. Because most ARTIs are caused by viruses, antibiotics are not effective in treating these illnesses. Search date We searched the literature up to 31 December 2015. Study characteristics We identified 6080 potentially relevant records. After removing duplicate records, and those that did not meet our inclusion criteria, we obtained 120 full‐text studies. We carefully assessed these studies for possible inclusion. We excluded most studies because: they presented unclear diagnosis criteria; Astragalus preparation was used with other agents; or Astragalus was not compared with a dummy treatment. No studies met our inclusion criteria and so we were unable to analyse any results. Study funding sources We could not assess study funding sources. Key results We did not find any studies that compared use of oral Astragalus alone with a dummy treatment to prevent frequent episodes of ARTI in children aged up to 14 years. Well‐designed, conducted and reported studies investigating this issue are needed to enable assessment in the future. Quality of the evidence We could not assess evidence quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Su, G, Chen, X, Liu, Z, Yang, L, Zhang, L, Stålsby Lundborg, C, Wen, Z, Guo, X, Qin, X, Liang, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.765Z" }, { "id": "96978532-73f8-4097-a8a1-0880c0fdf477", "pmid": "", "title": "Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve due to viral infection by the herpes zoster virus are implicated in the aetiology and clinical manifestation of Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Corticosteroids, with their powerful anti‐inflammatory effect, have a potential role to play in the reduction or minimisation of nerve damage when administered together with antiviral therapy, and therefore may improve the outcome for patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of corticosteroids as an adjuvant to antiviral therapy in adult patients with Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Search methods We searched the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 4, 2007), MEDLINE (1950 to December 2007) and EMBASE (1974 to December 2007), CINAHL (1982 to December 2007), LILACS, KoreaMed, IndMed, PakMediNet, ZETOC, Cambridge Scientific Abstracts (Conference Proceedings Database), ISI Proceedings (Web of Science), the National Research Register (NRR), the UK Clinical Research Network Portfolio Database (UKCRN), the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Research Findings Register (ReFeR) and the metaRegister of Controlled Trials (mRCT). Selection criteria All randomised controlled trials in which corticosteroids (by any route of administration at any dosage) were given as an adjuvant to antiviral agents in the treatment of Ramsay Hunt syndrome. Data collection and analysis Two reviewers independently assessed eligibility and trial quality of the available studies, whether they were published or unpublished. No trials were found and therefore no data were analysed. Main results This is an empty review as no trials were found that fulfilled the inclusion criteria. Authors' conclusions Since no randomised controlled trials investigating the use of corticosteroids as an adjuvant to antiviral treatment in Ramsay Hunt syndrome were identified, such studies are needed to assess the effects of such therapy. Plain language summary Corticosteroids used in addition to antiviral drugs in patients with Ramsay Hunt syndrome Ramsay Hunt syndrome (also known as herpes zoster oticus) consists of weakness of the face due to infection with the varicella zoster virus. Five cases arise per 100,000 of the population per year in the US. It is more common among those over 60 and rare in children. Other symptoms may include severe ear pain and small blisters on the outer ear or in the mouth. Prompt diagnosis and treatment (ideally within 72 hours of the onset of symptoms) are crucial to secure the best outcomes. In cases where treatment has been started within this time period, facial weakness recovers in up to 75% of patients. Standard treatment is with antiviral therapy (most commonly acyclovir). Corticosteroids are known for their anti‐inflammatory properties and are commonly used together with antivirals to reduce the inflammation in the facial nerve. This is thought to be the cause of the facial weakness. The aim of the review was to see if corticosteroids, used at the same time as antiviral drugs, improved outcomes in patients with Ramsay Hunt syndrome. However the review found no trials matching the inclusion criteria, and no conclusions can be drawn about the effectiveness of using corticosteroids in this way. It is recommended that high‐quality randomised controlled trials be undertaken to address this issue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T; Doree, C; Chamberlain, IJ; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006852.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "96a21e37-0ca1-4a67-987b-05bcfcf473c8", "pmid": "", "title": "Using Fenfluramine to Test the Serotonin Deficiency Theory of Depression", "imported": false, "abstract": "Clinical depression is a common and disabling condition characterised by persistent low mood and loss of interest that interferes with daily functioning. Serotonin is a key brain neurotransmitter involved in mood regulation, and a leading theory proposes that depression is associated with impaired serotonin function (the serotonin deficiency hypothesis), which underpins the use of selective serotonin reuptake inhibitors (SSRIs) as first-line antidepressant treatments. However, the strength and specificity of the link between serotonin dysfunction and depressive symptoms in humans remains uncertain and requires direct evidence in living human brains.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.266Z" }, { "id": "96a506fb-53ed-4f6b-b2f2-3bb54b9889ee", "pmid": "", "title": "Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non‐hospitalised term infants", "imported": false, "abstract": "Abstract - Background Many women express concern about their ability to produce enough milk, and insufficient milk is frequently cited as the reason for supplementation and early termination of breastfeeding. When addressing this concern, it is important first to consider the influence of maternal and neonatal health, infant suck, proper latch, and feeding frequency on milk production, and that steps be taken to correct or compensate for any contributing issues. Oral galactagogues are substances that stimulate milk production. They may be pharmacological or non‐pharmacological (natural). Natural galactagogues are usually botanical or other food agents. The choice between pharmacological or natural galactagogues is often influenced by familiarity and local customs. Evidence for the possible benefits and harms of galactagogues is important for making an informed decision on their use. Objectives To assess the effect of oral galactagogues for increasing milk production in non‐hospitalised breastfeeding mother‐term infant pairs. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov , the World Health Organization (WHO) International Clinical Trials Registry Platform ( ICTRP ), Health Research and Development Network ‐ Phillippines ( HERDIN ), Natural Products Alert ( Napralert ), the personal reference collection of author LM, and reference lists of retrieved studies (4 November 2019). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs (including published abstracts) comparing oral galactagogues with placebo, no treatment, or another oral galactagogue in mothers breastfeeding healthy term infants. We also included cluster‐randomised trials but excluded cross‐over trials. Data collection and analysis We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two to four review authors independently selected the studies, assessed the risk of bias, extracted data for analysis and checked accuracy. Where necessary, we contacted the study authors for clarification. Main results Forty‐one RCTs involving 3005 mothers and 3006 infants from at least 17 countries met the inclusion criteria. Studies were conducted either in hospitals immediately postpartum or in the community. There was considerable variation in mothers, particularly in parity and whether or not they had lactation insufficiency. Infants' ages at commencement of the studies ranged from newborn to 6 months. The overall certainty of evidence was low to very low because of high risk of biases (mainly due to lack of blinding), substantial clinical and statistical heterogeneity, and imprecision of measurements. Pharmacological galactagogues Nine studies compared a pharmacological galactagogue (domperidone, metoclopramide, sulpiride, thyrotropin‐releasing hormone) with placebo or no treatment. The primary outcome of proportion of mothers who continued breastfeeding at 3, 4 and 6 months was not reported. Only one study (metoclopramide) reported on the outcome of infant weight, finding little or no difference (mean difference (MD) 23.0 grams, 95% confidence interval (CI) ‐47.71 to 93.71; 1 study, 20 participants; low‐certainty evidence). Three studies (metoclopramide, domperidone, sulpiride) reported on milk volume, finding pharmacological galactagogues may increase milk volume (MD 63.82 mL, 95% CI 25.91 to 101.72; I² = 34%; 3 studies, 151 participants; low‐certainty evidence). Subgroup analysis indicates there may be increased milk volume with each drug, but with varying CIs. There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints, such as tiredness, nausea, headache and dry mouth (very low‐certainty evidence). No adverse effects were reported for infants. Natural galactagogues Twenty‐seven studies compared natural oral galactagogues (banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves or other natural mixtures) with placebo or no treatment. One study (Mother's Milk Tea) reported breastfeeding rates at six months with a concluding statement of \"no significant difference\" (no data and no measure of significance provided, 60 participants, very low‐certainty evidence). Three studies (fennel, fenugreek, moringa, mixed botanical tea) reported infant weight but could not be meta‐analysed due to substantial clinical and statistical heterogeneity (I 2 = 60%, 275 participants, very low‐certainty evidence). Subgroup analysis shows we are very uncertain whether fennel or fenugreek improves infant weight, whereas moringa and mixed botanical tea may increase infant weight compared to placebo. Thirteen studies (Bu Xue Sheng Ru, Chanbao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants) reported on milk volume, but meta‐analysis was not possible due to substantial heterogeneity (I 2 = 99%). The subgroup analysis for each intervention suggested either benefit or little or no difference (very low‐certainty evidence). There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints such as mothers with urine that smelled like maple syrup and urticaria in infants (very low‐certainty evidence). Galactagogue versus galactagogue Eight studies (Chanbao; Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one oral galactagogue with another. We were unable to perform meta‐analysis because there was only one small study for each match‐up, so we do not know if one galactagogue is better than another for any outcome. Authors' conclusions Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low‐certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High‐quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used. Plain language summary Milk boosters (galactagogues) for mothers breastfeeding their healthy infants born at term What is the issue? We set out to determine the ability of milk boosters taken by mouth (medicine, herb or food) to increase milk production in breastfeeding mothers of healthy infants born at term. Poor milk supply is often given as the reason for early supplementation and weaning sooner than desired. A range of factors, including mother's and baby's health, baby's sucking skills, proper latch and frequency of feeds, can affect milk production. Every attempt should first be made to identify and correct the causes for low milk production before trying a milk booster. Why is this important? Inadequate milk production can be distressing for mothers and threatening to babies' health. The choice of milk booster is often influenced by familiarity or local customs. Some mothers may prefer medications, while others prefer natural remedies. Evidence for the possible benefits and harms of milk boosters is important to assist mothers in making informed decisions. What evidence did we find? We searched for evidence from randomised controlled studies up to 4 November 2019 and identified 41 eligible studies involving 3005 mothers and 3006 infants from at least 17 countries. The studies varied widely in babies ages, type of milk boosters investigated, how long they were taken, and how outcomes were reported. Medications included sulpiride, metoclopramide, domperidone and thyrotropin‐releasing hormone. Natural interventions included banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves, and a variety of natural mixtures as teas or soups. Milk‐boosting medication Nine studies compared a milk‐boosting medication with placebo or no treatment. None reported exclusive breastfeeding rates at 3. 4 or 6 months and only one (metoclopramide, 20 participants) reported on weight gain in infants receiving only their mothers' own milk, with better results in the milk booster group. Three studies that tracked milk volume (domperidone, metoclopramide, sulpiride; 151 participants) reported more milk in the booster groups, though the certainty of the evidence was low. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as tiredness, nausea, decreased appetite, headache and dry mouth. Natural milk boosters Twenty‐seven studies compared natural milk boosters with placebo or no treatment. Only one (Mother’s Milk Tea; 60 participants) examined the impact on breastfeeding rates, reporting \"no significant difference at 6 months\" without providing any data (very low‐certainty evidence). Three studies (275 participants) reported infant weight, two of which (moringa, mixed botanical tea) reported higher gains in the milk booster group, while the other study (fennel and fenugreek) was inconclusive on whether infant weight gain improved with the milk boosters. In the 13 studies tracking changes in milk volume (Bu Xue Sheng Ru, Chan Bao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants), some showed benefits and others little or no difference, so we are very uncertain about the results for milk volume. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as mothers with urine that smells like maple syrup and rash in infants (very low‐certainty evidence). One milk booster compared with another Eight studies (Chanbao, Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one milk booster with another. There was only one small study for each particular match‐up, hence we cannot be certain if any one milk booster truly worked better than another. What does this mean? There is limited evidence that milk‐boosting medications may increase milk volume and that natural milk boosters may improve milk volume and infants' weight, but we are very uncertain about the supporting evidence. Due to limited information, we are also uncertain if there are any risks to the mother or baby in taking any particular milk booster. More high‐quality studies are needed to increase our certainty about the effects of milk boosters.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Foong, SC; Tan, ML; Foong, WC; Marasco, LA; Ho, JJ; Ong, JH", "articleTypes": [], "doi": "10.1002/14651858.CD011505.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "96bd9318-51f6-4c80-8029-aae1bb706017", "pmid": "", "title": "Enteral nutrition for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Prevention of relapse is a major issue in the management of quiescent Crohn's disease (CD). Current therapies (e.g. methotrexate, biologics, 6‐mercaptopurine and azathioprine) may be effective for maintaining remission in CD, but these drugs may cause significant adverse events. Interventions that are effective and safe for maintenance of remission in CD are desirable. Objectives The primary objectives were to evaluate the efficacy and safety of enteral nutrition for the maintenance of remission in CD and to assess the impact of formula composition on effectiveness. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and clinicaltrials.gov from inception to 27 July 2018. We also searched references of retrieved studies and reviews. Selection criteria Randomised controlled trials (RCTs) including participants of any age with quiescent CD were considered for inclusion. Studies that compared enteral nutrition with no intervention, placebo or any other intervention were selected for review. Data collection and analysis Two authors independently screened studies for inclusion, extracted data and assessed methodological quality using the Cochrane risk of bias tool. The primary outcome was clinical or endoscopic relapse as defined by the primary studies. Secondary outcomes included anthropometric measures (i.e. height and weight), quality of life (QoL), adverse events, serious adverse events and withdrawal due to adverse events. We calculated the risk ratio and 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated the mean difference and 95% CI. A random‐effects model was used for the statistical analysis. We used the GRADE criteria to assess the overall certainty of the evidence supporting the primary outcome and selected secondary outcomes. Main results Four RCTs (262 adult participants) met the inclusion criteria. One study (N = 33) compared an elemental diet to a non‐elemental (polymeric) diet. One study (N = 51) compared a half elemental diet to a regular free diet. Another study (N = 95) compared an elemental diet to 6‐mercaptopurine (6‐MP) or a no treatment control group. One study (N= 83) compared a polymeric diet to mesalamine. Two studies were rated as high risk of bias due to lack of blinding or incomplete outcome data. The other two studies were judged to have an unclear risk of bias. The studies were not pooled due to differences in control interventions and the way outcomes were assessed. The effect of an elemental diet compared to a polymeric diet on remission rates or withdrawal due to adverse events is uncertain. Fifty‐eight per cent (11/19) of participants in the elemental diet group relapsed at 12 months compared to 57% (8/14) of participants in the polymeric diet group (RR 1.01, 95% CI 0.56 to 1.84; very low certainty evidence). Thirty‐two per cent (6/19) of participants in the elemental diet group were intolerant to the enteral nutritional formula because of taste or smell and were withdrawn from the study in the first 2 weeks compared to zero participants (0/14) in the polymeric diet group (RR 9.75, 95% CI 0.59 to 159.93; low certainty evidence). Anthropometric measures, QoL, adverse events and serious adverse events were not reported as outcomes. The effect of an elemental diet (half of total daily calorie requirements) compared to a normal free diet on relapse rates is uncertain. Thirty‐five per cent (9/26) of participants in the elemental diet group relapsed at 12 months compared to 64% (16/25) of participants in the free diet group (RR 0.54, 95% CI 0.30 to 0.99; very low certainty evidence). No adverse events were reported. This study reported no differences in weight change between the two diet groups. Height and QoL were not reported as outcomes. The effect of an elemental diet compared to 6‐MP on relapse rates or adverse events is uncertain. Thirty‐eight per cent (12/32) of participants in the elemental diet group relapsed at 12 months compared to 23% (7/30) of participants in the 6‐MP group (RR 1.61; 95% CI 0.73 to 3.53; very low certainty evidence). Three per cent (1/32) of participants in the elemental diet group had an adverse event compared to 13% (4/30) of participants in the 6‐MP group (RR 0.23, 95% CI 0.03 to 1.98; low certainty evidence). Adverse events in the elemental diet group included surgery due to worsening CD. Adverse events in the 6‐MP group included liver injury (n = 2), hair loss (n = 1) and surgery due to an abscess (n = 1). No serious adverse events or withdrawals due to adverse events were reported. Weight, height and QoL were not reported as outcomes The effect of a polymeric diet compared to mesalamine on relapse rates and weight is uncertain. Forty‐two per cent (18/43) of participants in the polymeric diet group relapsed at 6 months compared to 55% (22/40) of participants in the mesalamine group (RR 0.76; 95% CI 0.49 to 1.19; low certainty evidence). The mean difference in weight gain over the study period was 1.9 kg higher in the polymeric diet group compared to mesalamine (95% CI ‐4.62 to 8.42; low certainty evidence). Two participants in the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had an adverse event. Height, QoL, serious adverse events and withdrawal due to adverse events were not reported as outcomes. Authors' conclusions The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the efficacy and safety of enteral nutrition in quiescent CD can be drawn. More research is needed to determine the efficacy and safety of using enteral nutrition as maintenance therapy in CD. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available. Plain language summary Enteral nutrition (liquid feeds) for maintenance of remission in Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disease of the intestines that frequently occurs in the lower part of the small intestine (ileum). Symptoms include abdominal pain, diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms the disease is considered 'active'. When the symptoms stop, it is called 'remission'. When people in remission experience symptoms it is called a 'relapse'. What is enteral nutrition? Enteral nutrition is a feeding method where a person's daily caloric intake is delivered via a liquid diet using the GI tract. Enteral nutrition can be administered by mouth or by tube feeding, where a tube is inserted through the nose or abdomen into the stomach to deliver the liquid feed. Enteral nutrition is a form of nutritional therapy for Crohn's disease patients. The mechanism by which enteral nutrition may influence inflammation is unknown and is being studied. Enteral nutrition can be classified as elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets are composed of amino‐acids (organic compounds), fats, sugars, vitamins and minerals. Elemental diets are easily absorbed and digested. Non‐elemental diets are based on oligopeptide (organic compounds composed of 2 to 20 amino‐acids) or whole protein sources. Non‐elemental diets are best for people who can digest and absorb nutrients without difficulty. What is 6‐mercaptopurine? 6‐Mercaptopurine is an immunosuppressive drug that is thought to reduce inflammation in people with Crohn's disease by blocking the immune system. What is mesalamine? Mesalamine is a 5‐aminosalicylic acid drug. 5‐Aminosalicylic drugs are thought to treat Crohn's disease by reducing inflammation in the gastrointestinal tract. These drugs are usually taken by mouth. What did the researchers investigate? The researchers studied whether enteral nutrition helps to maintain remission in people with Crohn's disease. The researchers also investigated whether one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) for maintaining remission in people with Crohn's disease. What did the researchers find? Four studies including 262 adult participants with Crohn's disease in remission were included. One study (33 participants) compared an elemental diet to a non‐elemental (polymeric) diet. One study (51 participants) compared an elemental diet to a normal diet (no supplements). One study (95 participants) compared an elemental diet to 6‐mercaptopurine or a no treatment control group. One study (83 participants) compared a non‐elemental polymeric diet to mesalamine. The researchers searched the medical literature extensively up to 27 July 2018. The study comparing an elemental diet to a polymeric diet found no difference in remission rates at 12 months. Six elemental diet participants were not able to tolerate the enteral nutritional formula because of taste or smell and were withdrawn from the study. Participants who received half of their total daily calorie requirements as elemental diet and the remaining half by normal diet had a lower chance of relapse at 12 months compared to participants who received a free diet. No side effects were reported in this study. The study comparing an elemental diet to 6‐mercaptopurine did not show any difference in relapse rates at 12 months. There was no difference in side effect rates. The only side effect reported in the elemental diet group was surgery due to worsening Crohn's disease. Side effects in the 6‐mercaptopurine group included liver injury in two participants, hair loss in one participant and surgery to treat an abscess in one participant. The study comparing a polymeric diet to mesalamine found no difference in relapse rates at six months. Two participants the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had side effects. No serious side effects were reported in any of the studies. The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the effectiveness and safety of enteral nutrition for maintenance of remission in Crohn's disease can be drawn. More research is needed to determine the effectiveness and safety of using enteral nutrition as maintenance therapy in Crohn's disease. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Akobeng, AK, Zhang, D, Gordon, M, MacDonald, JK", "articleTypes": [], "doi": "10.1002/14651858.CD005984.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.749Z" }, { "id": "96dfefc0-fe18-429e-a4cb-9dd78bb51802", "pmid": "", "title": "Effects of Nutritional Supplementation With Amino Acids on Liver Lipid Content, Whole-body Protein Turnover, and Body Composition in Obese Pre-pubertal Children", "imported": false, "abstract": "The purpose of this study is to assess the effect of an eight-week dietary supplementation with essential amino acids plus arginine on liver and plasma lipid content, whole-body fat oxidation, whole-body insulin sensitivity, whole body protein metabolism, and body composition in obese pre-pubertal children.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.157Z" }, { "id": "96e5c54d-22db-4885-93bc-c54cde6cf381", "pmid": "", "title": "Interventions for hirsutism (excluding laser and photoepilation therapy alone)", "imported": false, "abstract": "Abstract - Background Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen‐sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective. Objectives To assess the effects of interventions (except laser and light‐based therapies alone) for hirsutism. Search methods We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014. Selection criteria Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism. Data collection and analysis Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses. Main results We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty‐eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow‐up above 40%. Primary outcomes, 'participant‐reported improvement of hirsutism' and 'change in health‐related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin‐releasing hormone (GnRH) analogues)). Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one‐third of studies. The quality of evidence was moderate to very low for most outcomes. There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman‐Gallwey scores. The mean difference (MD) was ‐1.84 (95% confidence interval (CI) ‐3.86 to 0.18). There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman‐Gallwey scores more effectively than placebo (MD ‐7.60, 95% CI ‐10.53 to ‐4.67 and MD ‐7.20, 95% CI ‐10.15 to ‐4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87). Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman‐Gallwey scores (MD ‐7.69, 95% CI ‐10.12 to ‐5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD ‐1.90, 95% CI ‐5.01 to 1.21 and MD 0.49, 95% CI ‐1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI ‐0.58 to 3.56 and MD 0.40, 95% CI ‐1.18 to 1.98) (low quality evidence). Although there was very low quality evidence of a difference in reduction of Ferriman‐Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD ‐5.73, 95% CI ‐6.87 to ‐4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached. Metformin demonstrated no benefit over placebo in reduction of Ferriman‐Gallwey scores (MD 0.05, 95% CI ‐1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements. We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman‐Gallwey scores. Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman‐Gallwey scores (low quality evidence). Ferriman‐Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD ‐6.30, 95% CI ‐9.83 to ‐2.77) (very low quality evidence). Data showing reductions in Ferriman‐Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%). Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman‐Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs. Authors' conclusions Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision‐making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects. Further research should consist of well‐designed, rigorously reported, head‐to‐head trials examining OCPs combined with antiandrogens or 5α‐reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α‐reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment. Plain language summary Treatments for unwanted male pattern hair growth in women Background 
 Up to 5% to 10% of women are hirsute (hair in areas where normally only men have hairs such as moustache, beard area, chest, belly, back etc). The most common cause is polycystic ovary syndrome. Hirsutism can lead to psychological distress, low self esteem, decreased self image, depression, feelings of shame and social difficulties. Review question 
 Which treatments (except laser and light‐based therapies alone) work best for hirsutism? Study characteristics 
 We included 157 studies published up to June 2014, which examined 10,550 people. Participants included women with a mean age of 25 years. There was considerable variation in the quality of how the studies were conducted; more than half were not blinded and this may have had an impact on the reporting of the outcomes. Most studies were carried out in single centres in Europe and lasted six to 12 months. A range of treatments were evaluated, mostly in single studies. These included a few topical treatments, lifestyle modification, oral contraceptive pills (OCPs), medication to inhibit the effect of hormones that are responsible for male traits, and combination therapies. Participant‐assessed improvement and impact on quality of life were evaluated in a minority of the studies, whilst the majority of the studies measured physician‐assessed reduction in hirsutism, as well as androgen levels in the blood. Half of the studies reported adverse events and around one‐third other signs and symptoms, e.g. oily skin and menstrual irregularities that might be due to an increase of androgen levels in the blood. Key results 
 Oral contraceptive pills reduced the amount of hairs, but the reduction was not consistent across the studies, although two OCPs (ethinyl estradiol 35 µg + cyproterone acetate 2 mg compared to ethinyl estradiol 30 µg + desogestrel 0.15 mg) appeared to be effective in a way that can be considered important for women with hirsutism. Of the antiandrogen drugs, flutamide was considered to be more effective than placebo by both the women and the doctors. Spironolactone was also effective, but data were only available for the physicians' assessments. Finasteride did not show convincing effectiveness based on the evaluations of the hirsute women and those made by the investigators. The addition of cyproterone acetate (an antiandrogen) to OCP seemed to enhance the beneficial effect of OCPs on hair reduction. Insulin sensitisers (antidiabetic drugs) and lifestyle modification did not have any demonstrable benefit in terms of the severity of hirsutism. Unfortunately, the self assessments by the women, as well as the impact of hirsutism on their quality of life, were outcomes that were insufficiently addressed in the studies. The adverse events reported with the different drugs are well known, i.e. pain in the stomach and intestines, breast tenderness, reduced libido and dry skin with flutamide and finasteride; irregular bleeding with spironolactone; nausea, diarrhoea and abdominal bloating with metformin; and hot flushes, decreased libido, vaginal dryness, breast tenderness and headaches with the GnRH analogues. There were no important differences in blood androgen levels between the different treatment groups, OCPs had a positive effect on acne, and similarly insulin sensitisers improved the menstrual pattern. We were expecting to find evidence that combined therapies of an OCP with an antiandrogen were more effective than, for example, OCPs alone, but the lack of studies did not allow us to draw these conclusions. Overall we concluded that OCPs (especially with antiandrogenic activity), OCPs combined with cyproterone acetate, flutamide and spironolactone are effective in treating hirsutism. However, additional cosmetic measures (epilating, waxing, bleaching, electrolysis, laser and photoepilation) are generally required because all treatments need at least six to 12 months to reach the optimum effect. In addition, because of the distress associated with hirsutism and its impact on quality of life psychological support should be part of the treatment approach. Quality of the evidence 
 The overall quality of the evidence for the different outcomes was on average rated as moderate to very low. Important reasons for this were that studies were not blinded, or had a small sample size.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "van Zuuren, EJ; Fedorowicz, Z; Carter, B; Pandis, N", "articleTypes": [], "doi": "10.1002/14651858.CD010334.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "971ad182-c579-4ba5-a6e0-47a1ff90b1a1", "pmid": "", "title": "Chinese medicinal herbs for influenza", "imported": false, "abstract": "Abstract - Background Influenza is a communicable acute respiratory infection which, during epidemics, can cause high morbidity and mortality rates. Traditional Chinese medicinal herbs, often administered following a particular Chinese medical theory, may be a potential treatment of choice. Objectives To assess the effect of Chinese medicinal herbs used to prevent and treat influenza and to estimate the frequency of adverse effects. Search methods We searched CENTRAL (2012, Issue 11), MEDLINE (January 1966 to November week 2, 2012), EMBASE (January 1988 to November 2012) and CNKI (January 1988 to 29 March 2012). We also searched reference lists of articles and the WHO ICTRP search portal (November 2012). Selection criteria Randomised controlled trials (RCTs) comparing traditional Chinese medicinal herbs with placebo, no treatment or conventional medicine normally used in preventing and treating uncomplicated influenza. Data collection and analysis Two review authors independently extracted data and assessed trial quality. Main results We included 18 studies involving 2521 participants. The methodological quality of 17 included studies was poor. Included RCTs separately compared medicinal herbs with different antiviral drugs, precluding any pooling of results. Only three indicated that compared with antiviral drugs, Chinese medicinal herbs may be effective in preventing influenza and alleviating influenza symptoms. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and speeding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. Ten studies reported mild adverse reactions. Authors' conclusions Most Chinese medical herbs in the included studies showed similar effects to antiviral drugs in preventing or treating influenza. Few were shown to be superior to antiviral drugs. No obvious adverse events were reported in the included studies. However, current evidence remains weak due to methodological limitations of the trials. More high‐quality RCTs with larger numbers of participants and clear reporting are needed. Plain language summary Chinese medicinal herbs for influenza Influenza is a viral respiratory infection that causes an acute febrile illness with myalgia, headache and cough, and can result in high morbidity and mortality rates during an epidemic. Annual epidemics are thought to result in between three and five million cases of severe influenza and between 250,000 and 500,000 deaths worldwide. Currently, annual vaccination is the primary strategy for preventing influenza, and four influenza antiviral agents (amantadine, rimantadine, zanamivir and oseltamivir) have been approved for treatment of influenza. However, high levels of drug resistance have been recorded. Many Chinese medicinal herbs are used to treat and prevent this condition. This updated review assessed the therapeutic effects and safety of Chinese medicinal herbs as an alternative and adjunctive therapy to other commonly used drugs for influenza. Eighteen studies involving 2521 participants were included in the review. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and aiding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. The remaining 17 Chinese herbal trials showed a similar effect to antiviral drugs in preventing or treating influenza. However, since these included studies were of poor quality, the evidence does not support or reject the use of any Chinese herbal preparations for influenza. High‐quality trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Jiang, L; Deng, L; Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD004559.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "974b4f58-be52-484e-bb93-f0b2877b2753", "pmid": "", "title": "Control interventions in randomised trials among people with mental health disorders", "imported": false, "abstract": "Abstract - Background Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated. Objectives To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait‐list versus no‐treatment, (ii) usual care versus wait‐list or no‐treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait‐list or no‐treatment. Wait‐list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. Search methods In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers. Selection criteria We included randomised trials assessing patients with a mental health disorder that compared wait‐list, usual care, or placebo interventions with wait‐list or no‐treatment . Data collection and analysis Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane’s risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre‐planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random‐effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed‐effect model). Main results We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep‐wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait‐list versus no‐treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait‐list or no‐treatment and found a SMD –0.33 (95% CI ‐0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait‐list or no‐treatment was SMD −0.37 (95% CI −0.49 to −0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger’s test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD ‐0.49 (95% CI −0.64 to −0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait‐list or no‐treatment on benefits was SMD ‐0.14 (95% CI −0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD −0.21 (95% CI −0.35 to −0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep‐wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed‐effect model in a sensitivity analysis on the comparison for usual care versus wait‐list and no‐treatment, the results were significant with an SMD of –0.46 (95 % CI –0.64 to –0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains. Authors' conclusions We found marked variations in effects between placebo versus no‐treatment and wait‐list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait‐list or no‐treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research. Plain language summary Control interventions in randomised trials for people with a mental health disorder This systematic review assesses the effects of different control interventions in randomised trials including patients with a mental health disorder. In randomised trials, patients are assigned by chance to one of two or more groups – usually an experimental intervention and a control intervention. There are many types of control interventions in mental health intervention research. Some of the most common are different types of placebos that lack what is assumed to be the active component in the experimental intervention, and usual care, where patients receive the standard treatment for their mental health disorder in the area where they live. Two other types of control interventions are wait‐list or no‐treatment where patients receive no trial‐related care during the study (although some patients may receive care outside the studies). Wait‐list patients are often offered the experimental intervention after the trial has been finalised if it is likely to provide more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. We searched for randomised trials with patients with mental health disorders where wait‐list, usual care, or placebo interventions were compared with either wait‐list or no‐treatment. We looked at differences between all the types of control interventions on beneficial effects and whether they caused any adverse effects. We included 96 trials with a total of 4200 participants. Only 83 trials (3614 participants) provided usable data. Fifteen different mental health disorders were included. We found that all the trials were at high risk of bias in how they had been conducted, which reduced the interpretability of our findings. However, the risk of bias was mostly due to lack of blinding in the placebo studies, which may be seen as an aspect of the review's methodological question rather than a flaw with the review itself. We found no clinically important differences for usual care or wait‐list control interventions in the main analyses, however in our secondary analyses we found a clinically important favourable difference for usual care. In general, placebo control interventions tended to be favourable over no‐treatment or wait‐list control interventions across mental health disorders. We found no clinically important differences on adverse events. This review suggests that different control interventions have a tendency to yield very different estimates for the effects of the experimental intervention and that the choice of control intervention has a large impact on how effective a mental health treatment appears to be. Control interventions in trials with patients with mental health disorders are often poorly reported upon, and guidelines are needed to inform researchers on how to properly design, report, and interpret these trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Faltinsen, E; Todorovac, A; Staxen Bruun, L; Hróbjartsson, A; Gluud, C; Kongerslev, MT; Simonsen, E; Storebø, OJ", "articleTypes": [], "doi": "10.1002/14651858.MR000050.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "97575c8d-73e6-45e3-aecb-856e95274657", "pmid": "", "title": "Ribavirin plus interferon versus interferon for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. Standard therapy is ribavirin plus pegylated interferon to achieve undetectable level of virus in the blood, but the effect on clinical outcomes is controversial. Objectives To assess the beneficial and harmful effects of ribavirin and interferon combination therapy versus interferon monotherapy for chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, approaching authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included randomised trials, irrespective of blinding, language, or publication status, comparing ribavirin plus interferon versus interferon for treatment of chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained loss of hepatitis C virus, liver‐related morbidity plus all‐cause mortality, and adverse events. We performed subgroup analyses of patients who were naive, relapsers, or non‐responders to previous antiviral treatment. All outcomes were analysed with the random‐effects model. We used Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of morbidity plus mortality. The remaining outcomes were presented as relative risks (RR). We used trial sequential analyses to examine the robustness of our findings. Main results We included 83 randomised trials with 12,707 patients. Most trials had unclear or high risk of bias. We did not find any significant influence of bias on our results but cannot exclude outcome measure reporting bias as many trials did not report on the primary outcomes of this review. Compared with interferon, ribavirin plus interferon had a significant beneficial effect on sustained virological response in subgroups of naive patients (RR 0.72, 95% confidence interval (CI) 0.68 to 0.75), relapsers (RR 0.62, 95% CI 0.54 to 0.70), non‐responders (RR 0.89, 95% CI 0.84 to 0.93), and in all patients (RR 0.75, 95% CI 0.71 to 0.79). Combination therapy significantly reduced morbidity plus mortality in all patients (Peto OR, 0.43, 95% CI 0.23 to 0.79), but not in naive, relapsers, or non‐responders individually. Combination therapy significantly increased the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous (cough, dyspnoea, fatigue) adverse reactions. Accordingly, combination therapy significantly increased the risk of treatment discontinuation and dose reductions. Trial sequential analyses confirmed our findings regarding virological effects, but not regarding liver‐related morbidity and all‐cause mortality. Authors' conclusions Compared with interferon alone, ribavirin plus interferon is more effective in clearing hepatitis C virus from the blood. Combination therapy may reduce liver‐related morbidity and all‐cause mortality, but we need more evidence. The number needed to treat to obtain a beneficial effect is considerable considering the increased risk of several severe adverse reactions and costs. Plain language summary Adding ribavirin to interferon increases the number of patients who clear hepatitis C virus but also leads to several adverse reactions Globally about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behavior, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die. It is known that treatment with the drug interferon clears hepatitis C virus from the blood in about 15% of patients. This review identified studies comparing ribavirin plus interferon with interferon alone in patients with chronic hepatitis C. This review shows, by combining the results from all trials, that adding ribavirin to interferon increases the number of patients who clear the hepatitis C virus to about 40% as well as the number of patients who demonstrate improved liver histology. Ribavirin and interferon may also reduce the risk of liver‐related morbidity or all‐cause mortality. However, the number needed to treat to prevent one patient developing morbidity or dying seems very large. Furthermore, combination therapy was associated with increased risk of anaemia and several other adverse reactions. The results gives rise to a dilemma ‐ should we, by adding ribavirin to interferon, increase the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous adverse reactions in a situation where it has not yet been clearly demonstrated that the antiviral effect of the intervention is directly linked to the reduction of all‐cause mortality? We, therefore, suggest that the combination intervention is applied only with stringent emphasis on the individual patients' well‐being. Furthermore, we suggest that all future trials within the area should focus more on adverse reactions and long‐term clinical outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Brok, J, Gluud, LL, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.798Z" }, { "id": "97595b15-9d55-41dd-a0e7-43885b7be2ec", "pmid": "", "title": "Altered dietary salt for preventing pre‐eclampsia, and its complications", "imported": false, "abstract": "Abstract - Background In the past, women have been advised that lowering their salt intake might reduce their risk of developing pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of altered dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of altered dietary salt during pregnancy on the risk of developing pre‐eclampsia and its complications. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (8 April 2005), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2005), and EMBASE (2002 to May 2005). We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 1 October 2009 and added the results to the awaiting classification section. Selection criteria Randomised trials evaluating either reduced or increased dietary salt intake during pregnancy. Data collection and analysis Two review authors selected trials for inclusion and extracted data independently. Data were entered on Review Manager software for analysis, and double‐checked for accuracy. Main results Two trials were included, with 603 women. Both compared advice to reduce dietary salt intake with advice to continue a normal diet. The confidence intervals were wide and crossed the no‐effect line for all the reported outcomes, including pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). In other words, there was insufficient evidence for reliable conclusions about the effects of advice to reduce dietary salt. Authors' conclusions In the absence of evidence that advice to alter salt intake during pregnancy has any beneficial effect for prevention of pre‐eclampsia or any other outcome, salt consumption during pregnancy should remain a matter of personal preference. [Note: The citation in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Altered dietary salt for preventing pre‐eclampsia, and its complications Low salt intake in pregnancy is unlikely to prevent pre‐eclampsia. Pre‐eclampsia is a serious complication of pregnancy associated with poor health, or even death, for the mother and baby. Pre‐eclampsia is identified by raised blood pressure and protein in the urine during the second half of pregnancy. In the past, a low‐salt diet was often recommended, in the belief that it would help to prevent pre‐eclampsia. However, the review found just two trials that did not show any evidence of benefit for the mother or baby. Salt intake in pregnancy should be a matter of personal preference.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Duley, L, Henderson‐Smart, DJ, Meher, S", "articleTypes": [], "doi": "10.1002/14651858.CD005548", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.083Z" }, { "id": "975ccf84-12a8-4b4d-a00e-63f5e15c7862", "pmid": "", "title": "Physical interventions to interrupt or reduce the spread of respiratory viruses", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jefferson, T, Dooley, L, Ferroni, E, Al-Ansary, LA, van Driel, ML, Bawazeer, GA, Jones, MA, Hoffmann, TC, Clark, J, Beller, EM, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD006207.pub6 AB - Abstract - Background Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID‐19) caused by SARS‐CoV‐2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID‐19 pandemic. Objectives To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. Search methods We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies. Selection criteria We included randomised controlled trials (RCTs) and cluster‐RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission. Data collection and analysis We used standard Cochrane methodological procedures. Main results We included 11 new RCTs and cluster‐RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID‐19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID‐19 pandemic. Many studies were conducted during non‐epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID‐19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high‐income countries; crowded inner city settings in low‐income countries; and an immigrant neighbourhood in a high‐income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster‐RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster‐RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza‐like illness (ILI)/COVID‐19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate‐certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory‐confirmed influenza/SARS‐CoV‐2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate‐certainty evidence). Harms were rarely measured and poorly reported (very low‐certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low‐certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low‐certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory‐confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate‐certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low‐certainty evidence). One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non‐inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID‐19 patients. Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta‐analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate‐certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory‐confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low‐certainty evidence), and laboratory‐confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low‐certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low‐certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low‐certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports. Authors' conclusions The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory‐confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under‐investigated. There is a need for large, well‐designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs. Plain language summary Do physical measures such as hand‐washing or wearing masks stop or slow down the spread of respiratory viruses? Key messages 
We are uncertain whether wearing masks or N95/P2 respirators helps to slow the spread of respiratory viruses based on the studies we assessed. Hand hygiene programmes may help to slow the spread of respiratory viruses. How do respiratory viruses spread? 
Respiratory viruses are viruses that infect the cells in your airways: nose, throat, and lungs. These infections can cause serious problems and affect normal breathing. They can cause flu (influenza), severe acute respiratory syndrome (SARS), and COVID‐19. People infected with a respiratory virus spread virus particles into the air when they cough or sneeze. Other people become infected if they come into contact with these virus particles in the air or on surfaces on which they land. Respiratory viruses can spread quickly through a community, through populations and countries (causing epidemics), and around the world (causing pandemics). Physical measures to try to prevent respiratory viruses spreading between people include: · washing hands often; · not touching your eyes, nose, or mouth; · sneezing or coughing into your elbow; · wiping surfaces with disinfectant; · wearing masks, eye protection, gloves, and protective gowns; · avoiding contact with other people (isolation or quarantine); · keeping a certain distance away from other people (distancing); and · examining people entering a country for signs of infection (screening). What did we want to find out? 
We wanted to find out whether physical measures stop or slow the spread of respiratory viruses from well‐controlled studies in which one intervention is compared to another, known as randomised controlled trials. What did we do? 
We searched for randomised controlled studies that looked at physical measures to stop people acquiring a respiratory virus infection. We were interested in how many people in the studies caught a respiratory virus infection, and whether the physical measures had any unwanted effects. What did we find? 
We identified 78 relevant studies. They took place in low‐, middle‐, and high‐income countries worldwide: in hospitals, schools, homes, offices, childcare centres, and communities during non‐epidemic influenza periods, the global H1N1 influenza pandemic in 2009, epidemic influenza seasons up to 2016, and during the COVID‐19 pandemic. We identified five ongoing, unpublished studies; two of them evaluate masks in COVID‐19. Five trials were funded by government and pharmaceutical companies, and nine trials were funded by pharmaceutical companies. No studies looked at face shields, gowns and gloves, or screening people when they entered a country. We assessed the effects of: · medical or surgical masks; · N95/P2 respirators (close‐fitting masks that filter the air breathed in, more commonly used by healthcare workers than the general public); and · hand hygiene (hand‐washing and using hand sanitiser). We obtained the following results: Medical or surgical masks Ten studies took place in the community, and two studies in healthcare workers. Compared with wearing no mask in the community studies only, wearing a mask may make little to no difference in how many people caught a flu‐like illness/COVID‐like illness (9 studies; 276,917 people); and probably makes little or no difference in how many people have flu/COVID confirmed by a laboratory test (6 studies; 13,919 people). Unwanted effects were rarely reported; discomfort was mentioned. N95/P2 respirators Four studies were in healthcare workers, and one small study was in the community. Compared with wearing medical or surgical masks, wearing N95/P2 respirators probably makes little to no difference in how many people have confirmed flu (5 studies; 8407 people); and may make little to no difference in how many people catch a flu‐like illness (5 studies; 8407 people), or respiratory illness (3 studies; 7799 people). Unwanted effects were not well‐reported; discomfort was mentioned. Hand hygiene Following a hand hygiene programme may reduce the number of people who catch a respiratory or flu‐like illness, or have confirmed flu, compared with people not following such a programme (19 studies; 71,210 people), although this effect was not confirmed as statistically significant reduction when ILI and laboratory‐confirmed ILI were analysed separately. Few studies measured unwanted effects; skin irritation in people using hand sanitiser was mentioned. What are the limitations of the evidence? 
Our confidence in these results is generally low to moderate for the subjective outcomes related to respiratory illness, but moderate for the more precisely defined laboratory‐confirmed respiratory virus infection, related to masks and N95/P2 respirators. The results might change when further evidence becomes available. Relatively low numbers of people followed the guidance about wearing masks or about hand hygiene, which may have affected the results of the studies. How up to date is this evidence? 
We included evidence published up to October 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.822Z" }, { "id": "976db165-b1c9-4a9a-a2b7-5c823658d0cd", "pmid": "", "title": "Short‐course oral steroids alone for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of oral corticosteroids compared with placebo/no intervention or other pharmacological interventions (intranasal corticosteroids, antibiotics, antifungals) for chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids with placebo or no treatment or compared with other pharmacological interventions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included eight RCTs (474 randomised participants), which compared oral corticosteroids with placebo or no intervention. All trials only recruited adults with chronic rhinosinusitis with nasal polyps. All trials reported outcomes at two to three weeks, at the end of the short‐course oral steroid treatment period. Three trials additionally reported outcomes at three to six months. Two of these studies prescribed intranasal steroids to patients in both arms of the trial at the end of the oral steroid treatment period. Oral steroids versus placebo or no intervention Disease‐specific health‐related quality of life was reported by one study. This study reported improved quality of life after treatment (two to three weeks) in the group receiving oral steroids compared with the group who received placebo (standardised mean difference (SMD) ‐1.24, 95% confidence interval (CI) ‐1.92 to ‐0.56, 40 participants, modified RSOM‐31), which corresponds to a large effect size. We assessed the evidence to be low quality (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). Disease severity as measured by patient‐reported symptom scores was reported by two studies, which allowed the four key symptoms used to define chronic rhinosinusitis (nasal blockage, nasal discharge, facial pressure, hyposmia) to be combined into one score. The results at the end of treatment (two to three weeks) showed an improvement in patients receiving oral steroids compared to placebo, both when presented as a mean final value (SMD ‐2.84, 95% CI ‐4.09 to ‐1.59, 22 participants) and as a change from baseline (SMD ‐2.28, 95% CI ‐2.76 to ‐1.80, 114 participants). These correspond to large effect sizes but we assessed the evidence to be low quality. One study (114 participants) followed patients for 10 weeks after the two‐week treatment period. All patients in both arms received intranasal steroids at the end of the oral steroid treatment period. The results showed that the initial results after treatment were not sustained (SMD ‐0.22, 95% CI ‐0.59 to 0.15, 114 participants, percentage improvement from baseline). This corresponds to a small effect size and we assessed the evidence to be low quality. There was an increase in adverse events in people receiving orals steroids compared with placebo for gastrointestinal disturbances (risk ratio (RR) 3.45, 95% CI 1.11 to 10.78; 187 participants; three studies) and insomnia (RR 3.63, 95% CI 1.10 to 11.95; 187 participants; three studies). There was no significant impact of oral steroids on mood disturbances at the dosage used in the included study (risk ratio (RR) 2.50, 95% CI 0.55 to 11.41; 40 participants; one study). We assessed the evidence to be low quality due to the lack of definitions of the adverse events and the small number of events or sample size, or both). Other comparisons No studies that compared short‐course oral steroids with other treatment for chronic rhinosinusitis met the inclusion criteria. Authors' conclusions At the end of the treatment course (two to three weeks) there is an improvement in health‐related quality of life and symptom severity in patients with chronic rhinosinusitis with nasal polyps taking oral corticosteroids compared with placebo or no treatment. The quality of the evidence supporting this finding is low. At three to six months after the end of the oral steroid treatment period, there is little or no improvement in health‐related quality of life or symptom severity for patients taking an initial course of oral steroids compared with placebo or no treatment. The data on the adverse effects associated with short courses of oral corticosteroids indicate that there may be an increase in insomnia and gastrointestinal disturbances but it is not clear whether there is an increase in mood disturbances. All of the adverse events results are based on low quality evidence. More research in this area, particularly research evaluating patients with chronic rhinosinusitis without nasal polyps, longer‐term outcomes and adverse effects, is required. There is no evidence for oral steroids compared with other treatments. Plain language summary Short‐term oral corticosteroids compared with no treatment or other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of a short course (typically up to 21 days) of corticosteroid given by mouth to people with chronic rhinosinusitis compared with giving a placebo or no treatment, or another type of treatment. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling the inflammatory response and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included eight randomised controlled trials with a total of 474 participants. All of the patients were adults who had chronic rhinosinusitis with nasal polyps. All of the studies followed patients until the end of treatment (two to three weeks) and three studies (210 participants) followed up people for three to six months after the initial treatment had ended. Five of the eight reports mentioned how the trial was funded. None of the funding sources were pharmaceutical companies. Key results At the end of a two‐ or three‐week treatment course, people who took oral steroids may have had a better quality of life, less severe symptoms and smaller nasal polyps than people who had placebo or did not receive any treatment. After three to six months, there was little or no difference in quality of life, symptom severity or nasal polyps between the people who had oral steroids and the people who had placebo or no intervention. The people who took oral steroids may have had more gastrointestinal disturbances and insomnia than the people who had placebo or no intervention. It is not clear if the people who took oral steroids had more mood disturbances than the people who had placebo or no intervention. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate), as the some of the results are only from one or two studies, which do not have a lot of participants. Most of the trials do not have a high risk of bias, but only people with nasal polyps were included in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K, Chong, LY, Hopkins, C, Philpott, C, Burton, MJ, Schilder, AGM", "articleTypes": [], "doi": "10.1002/14651858.CD011991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.742Z" }, { "id": "97716d18-4360-4fb9-a04e-4665c37b3cb7", "pmid": "", "title": "Effect of cocoa on blood pressure", "imported": false, "abstract": "Abstract - Background High blood pressure is an important risk factor for cardiovascular disease, contributing to about 50% of cardiovascular events worldwide and 37% of cardiovascular‐related deaths in Western populations. Epidemiological studies suggest that cocoa‐rich products reduce the risk of cardiovascular disease. Flavanols found in cocoa have been shown to increase the formation of endothelial nitric oxide which promotes vasodilation and therefore blood pressure reduction. Here we update previous meta‐analyses on the effect of cocoa on blood pressure. Objectives To assess the effects on blood pressure of chocolate or cocoa products versus low‐flavanol products or placebo in adults with or without hypertension when consumed for two weeks or longer. Search methods This is an updated version of the review initially published in 2012. In this updated version, we searched the following electronic databases from inception to November 2016: Cochrane Hypertension Group Specialised Register, CENTRAL, MEDLINE and Embase. We also searched international trial registries, and the reference lists of review articles and included trials. Selection criteria Randomised controlled trials (RCTs) investigating the effects of chocolate or cocoa products on systolic and diastolic blood pressure in adults for a minimum of two weeks duration. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias in each trial. We conducted random‐effects meta‐analyses on the included studies using Review Manager 5. We explored heterogeneity with subgroup analyses by baseline blood pressure, flavanol content of control group, blinding, age and duration. Sensitivity analyses explored the influence of unusual study design. Main results Thirty‐five trials (including 40 treatment comparisons) met the inclusion criteria. Of these, we added 17 trials (20 treatment comparisons) to the 18 trials (20 treatment comparisons) in the previous version of this updated review. Trials provided participants with 30 to 1218 mg of flavanols (mean = 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. The control group received either a flavanol‐free product (n = 26 treatment comparisons) or a low‐flavanol‐containing cocoa powder (range 6.4 to 88 mg flavanols (mean = 55 mg, 13 treatment comparisons; 259 mg, 1 trial). Meta‐analyses of the 40 treatment comparisons involving 1804 mainly healthy participants revealed a small but statistically significant blood pressure‐reducing effect of flavanol‐rich cocoa products compared with control in trials of two to 18 weeks duration (mean nine weeks):
 Mean difference systolic blood pressure (SBP) (95% confidence interval (CI): ‐1.76 (‐3.09 to ‐0.43) mmHg, P = 0.009, n = 40 treatment comparisons, 1804 participants;
 Mean difference diastolic blood pressure (DBP) (95% CI): ‐1.76 (‐2.57 to ‐0.94) mmHg, P < 0.001, n = 39 treatment comparisons, 1772 participants. Baseline blood pressure may play a role in the effect of cocoa on blood pressure. While systolic blood pressure was reduced significantly by 4 mmHg in hypertensive people (n = 9 treatment comparisons, 401 participants), and tended to be lowered in prehypertensive people (n= 8 treatment comparisons, 340 participants), there was no significant difference in normotensive people (n = 23 treatment comparisons, 1063 participants); however, the test for subgroup differences was of borderline significance (P = 0.08; I 2 = 60%), requiring further research to confirm the findings. Subgroup meta‐analysis by blinding suggested a trend towards greater blood pressure reduction in unblinded trials compared to double‐blinded trials, albeit statistically not significant. Further research is needed to confirm whether participant expectation may influence blood pressure results. Subgroup analysis by type of control (flavanol‐free versus low‐flavanol control) did not reveal a significant difference. Whether the age of participants plays a role in the effect of cocoa on blood pressure, with younger participants responding with greater blood pressure reduction, needs to be further investigated. Sensitivity analysis excluding trials with authors employed by trials sponsoring industry (33 trials, 1482 participants) revealed a small reduction in effect size, indicating some reporting bias. Due to the remaining heterogeneity, which we could not explain in terms of blinding, flavanol content of the control groups, age of participants, or study duration, we downgraded the quality of the evidence from high to moderate. Results of subgroup analyses should be interpreted with caution and need to be confirmed or refuted in trials using direct randomised comparisons. Generally, cocoa products were highly tolerable, with adverse effects including gastrointestinal complaints and nausea being reported by 1% of participants in the active cocoa intervention group and 0.4% of participants in the control groups (moderate‐quality evidence). Authors' conclusions This review provides moderate‐quality evidence that flavanol‐rich chocolate and cocoa products cause a small (2 mmHg) blood pressure‐lowering effect in mainly healthy adults in the short term. These findings are limited by the heterogeneity between trials, which could not be explained by prespecified subgroup analyses, including blinding, flavanol content of the control groups, age of participants, or study duration. However, baseline blood pressure may play a role in the effect of cocoa on blood pressure; subgroup analysis of trials with (pre)hypertensive participants revealed a greater blood pressure‐reducing effect of cocoa compared to normotensive participants with borderline significance. Long‐term trials investigating the effect of cocoa on clinical outcomes are also needed to assess whether cocoa has an effect on cardiovascular events and to assess potential adverse effects associated with chronic ingestion of cocoa products. Plain language summary Effect of cocoa on blood pressure Review question We assessed the effect of cocoa products on blood pressure in adults when consumed daily for at least two weeks. We found 35 studies, covering 40 treatment comparisons. Background Dark chocolate and cocoa products are rich in chemical compounds called flavanols. Flavanols have attracted interest as they might help to reduce blood pressure, a known risk factor for cardiovascular disease (disorders of the heart and blood vessels). The blood pressure‐lowering properties of flavanols are thought to be related to widening of the blood vessels, caused by nitric oxide. Study characteristics Studies were short, mostly between two and12 weeks, with only one of 18 weeks. The studies involved 1804 mainly healthy adults. They provided participants with 30 to 1218 mg of flavanols (average of 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. Seven of the studies were funded by companies with a commercial interest in their results, and the reported effect was slightly larger in these studies, indicating possible bias. The evidence is current to November 2016. Key results Meta‐analysis of 40 treatment comparisons revealed a small but statistically significant lowering of blood pressure (systolic and diastolic) of 1.8 mmHg. This small reduction in blood pressure might complement other treatment options and might contribute to reducing the risk of cardiovascular disease. We investigated whether participants' blood pressure at the start of the study, their age, an awareness of group allocation (active or control), the flavanol content used in the control group, or how long the study lasted may explain variations between trials. While blood pressure status (high blood pressure or normal blood pressure) is a likely factor in the effect size of cocoa on blood pressure, the impact of other factors needs to be confirmed or rejected in further trials. Side effects including digestive complaints and dislike of the trial product were reported by only 1% of people in the active cocoa intervention group and 0.4% of people in the control groups. Longer‐term trials are needed to establish whether regularly eating flavanol‐rich cocoa products has a beneficial effect on blood pressure and cardiovascular health over time, and whether there are any side effects of long‐term use of cocoa products on a daily basis. Quality of evidence The evidence is of moderate quality. We were unable to identify any randomised controlled trials that tested the effect of long‐term daily use of cocoa products on blood pressure, and there were no trials that measured the health consequences of high blood pressure, such as heart attacks or strokes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Ried, K; Fakler, P; Stocks, NP", "articleTypes": [], "doi": "10.1002/14651858.CD008893.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "97778fb4-948c-4e06-b58d-e4af71cc58ee", "pmid": "", "title": "Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common, life‐shortening, genetic disorder in populations of Northern European descent caused by the mutation of a single gene that codes for the production of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. This protein coordinates the transport of salt (and bicarbonate) across cell surfaces, and the mutation most notably affects the airways. In the lungs of people with CF, the defective protein compromises mucociliary clearance and makes the airway prone to chronic infection and inflammation, damaging the structure of the airways and eventually leading to respiratory failure. In addition, abnormalities in the truncated CFTR protein lead to other systemic complications, including malnutrition, diabetes and subfertility. Five classes of mutation have been described, depending on the impact of the mutation on the processing of the CFTR protein in the cell. In class I mutations, premature termination codons prevent the production of any functional protein, resulting in severe CF. Therapies targeting class I mutations aim to enable the normal cellular mechanism to read through the mutation, potentially restoring the production of the CFTR protein. This could, in turn, normalise salt transport in the cells and decrease the chronic infection and inflammation that characterises lung disease in people with CF. This is an update of a previously published review. Objectives To evaluate the benefits and harms of ataluren and similar compounds on clinically important outcomes in people with CF with class I mutations (premature termination codons). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles. The last search of the Cochrane Cystic Fibrosis Trials Register was conducted on 7 March 2022. We searched clinical trial registries maintained by the European Medicines Agency, the US National Institutes of Health and the World Health Organization. The last search of the clinical trials registries was conducted on 4 October 2022. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing ataluren and similar compounds (specific therapies for class I mutations) with placebo in people with CF who have at least one class I mutation. Data collection and analysis For the included trials, the review authors independently extracted data, assessed the risk of bias and evaluated the certainty of the evidence using GRADE; trial authors were contacted for additional data. Main results Our searches identified 56 references to 20 trials; of these, 18 trials were excluded. Both the included parallel RCTs compared ataluren to placebo for 48 weeks in 517 participants (males and females; age range six to 53 years) with CF who had at least one nonsense mutation (a type of class I mutation). The certainty of evidence and risk of bias assessments for the trials were moderate overall. Random sequence generation, allocation concealment and blinding of trial personnel were well documented; participant blinding was less clear. Some participant data were excluded from the analysis in one trial that also had a high risk of bias for selective outcome reporting. PTC Therapeutics Incorporated sponsored both trials with grant support from the Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the National Institutes of Health. The trials reported no difference between treatment groups in terms of quality of life, and no improvement in respiratory function measures. Ataluren was associated with a higher rate of episodes of renal impairment (risk ratio 12.81, 95% confidence interval 2.46 to 66.65; P = 0.002; I 2 = 0%; 2 trials, 517 participants). The trials reported no treatment effect for ataluren for the review's secondary outcomes of pulmonary exacerbation, computed tomography score, weight, body mass index and sweat chloride. No deaths were reported in the trials. The earlier trial performed a post hoc subgroup analysis of participants not receiving concomitant chronic inhaled tobramycin (n = 146). This analysis demonstrated favourable results for ataluren (n = 72) for the relative change in forced expiratory volume in one second (FEV 1 ) per cent (%) predicted and pulmonary exacerbation rate. The later trial aimed to prospectively assess the efficacy of ataluren in participants not concomitantly receiving inhaled aminoglycosides, and found no difference between ataluren and placebo in FEV 1 % predicted and pulmonary exacerbation rate. Authors' conclusions There is currently insufficient evidence to determine the effect of ataluren as a therapy for people with CF with class I mutations. One trial reported favourable results for ataluren in a post hoc subgroup analysis of participants not receiving chronic inhaled aminoglycosides, but these were not reproduced in the later trial, suggesting that the earlier results may have occurred by chance. Future trials should carefully assess for adverse events, notably renal impairment, and consider the possibility of drug interactions. Cross‐over trials should be avoided, given the potential for the treatment to change the natural history of CF. Plain language summary Ataluren and similar compounds (specific therapies for premature termination codon class I mutations) for cystic fibrosis Review question Can ataluren (and similar compounds specifically targeting class I mutations in cystic fibrosis (CF)) improve the quality of life and lung function of people with CF without having adverse effects? Key messages What is CF? In people with CF, the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. This especially affects the airways, causing the airway surface to dry out and making it difficult to clear thick mucus. This leads to progressive infection and damages the lungs, shortening life expectancy. How will ataluren treat CF? In people with certain CF genetic mutations where the genetic instructions for producing the CFTR protein are interrupted (known as premature termination codon or class I mutations), ataluren (and similar medicines) may be able to skip over the break in the faulty gene sequence and allow the body to produce a corrected version of the CFTR protein. By correcting the protein, the airway surface should remain hydrated, allowing people with CF to better clear their mucus and so develop fewer lung infections. What did we want to find out? We wanted to know whether ataluren can improve the quality of life and lung function of people with CF, and whether it can do so without any side effects. We also wanted to measure the effects on lung infections (need for hospital visits or additional antibiotics), survival, nutritional status (weight, body mass index and height) and whether treatment was cost‐effective. What did we do? We searched for trials that directly compared drugs such as ataluren to placebo (treatment not containing an active drug) or to a different treatment for these specific genetic mutations in any people with CF. What did we find? We found two trials including 517 people (males and females between 6 and 53 years of age) comparing ataluren to a placebo. The trials lasted 48 weeks and everyone taking part in the trials had at least one gene with a class I mutation. Key results In people taking ataluren, there was no improvement in clinical outcomes such as quality of life, lung function, exacerbations (flare up of disease), sweat chloride (salt) levels or weight compared with people taking placebo. The trials found that kidney damage was more common in people taking ataluren. The earlier trial analysed their results in a way not originally planned to see whether the effects of ataluren and placebo were different in people using inhaled tobramycin (an antibiotic) on a long‐term basis compared with people not taking the inhaled antibiotic. In people taking ataluren but not using inhaled tobramycin, lung function declined at a slower rate and there were fewer exacerbations than in people in the placebo group also not using inhaled tobramycin. The later trial specifically recruited people not taking tobramycin to see whether this really was an effect of the antibiotic, but the investigators did not find any difference between the ataluren and placebo groups for changes in lung function or exacerbations. This suggests that the earlier results occurred by chance. There were no deaths and we did not find any differences between ataluren and placebo in side effects or nutritional status. Neither trial reported on hospitalisations, extra courses of antibiotics or cost‐effectiveness. We have not found enough high‐quality evidence to determine the effect of ataluren for treating CF. We recommend that future trials are designed and reported clearly so that their results can be included in a systematic review. What are the limitations of the evidence? We are moderately confident in our findings, but there is some uncertainty due to how widely the results varied between participants. We are satisfied that everyone taking part had an equal chance of being in either group (ataluren or placebo) and that no one could work out which group the next person would be put into (so that healthier people did not receive the treatment and make the results seem better). We believe that the clinicians running the trials and those taking part in the trials did not know which treatment each person was receiving. We have some concerns about the emphasis the investigators of one trial placed on the results of a comparison they had not planned (the use of long‐term inhaled tobramycin). Unfortunately, that trial did not report all its results clearly. Sometimes, the results were reported in a way that meant they could not be used in this review, and sometimes the information was not reported at all. This affected our confidence in the overall results. Trial funding sources Both trials were sponsored by PTC Therapeutics Incorporated, who make ataluren. The Cystic Fibrosis Foundation, the US Food and Drug Administration's Office of Orphan Products Development and the US National Institutes of Health also supported the trials. How up to date is this evidence? We last searched for evidence on 4 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aslam, AA, Sinha, IP, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD012040.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.082Z" }, { "id": "977e0138-0b49-4a34-87ba-920168a19b7b", "pmid": "", "title": "Multimodal interventions for cachexia management", "imported": false, "abstract": "Abstract - Background Cachexia (disease‐related wasting) is a complex metabolic syndrome which occurs in people with chronic illnesses, including cancer, HIV/AIDS, kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People with cachexia experience unintentional weight loss, muscle loss, fatigue, loss of appetite, and reduced quality of life. Multimodal interventions which work synergistically to treat the syndrome could lead to benefits. Objectives To assess the benefits and harms of multimodal interventions aimed at alleviating or stabilising cachexia in people with a chronic illness. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers in July 2024, together with reference checking, citation searching, and contact with study authors to identify studies. Selection criteria We included randomised controlled trials (RCTs) in adults with or at risk of cachexia, comparing multimodal interventions combining two or more modalities (of pharmacology, nutrition, exercise) to treatment as usual, variation of the intervention, or unimodal intervention. Data collection and analysis Two review authors independently screened potentially eligible studies, extracted data, and assessed risk of bias (RoB 1). Primary outcomes were physical function, strength, and adverse events. Secondary outcomes were body composition and weight, quality of life (QoL), appetite, fatigue, and biochemical markers. We assessed the certainty of evidence with GRADE. Main results We included nine studies with 926 adults (mean age: 63 years). Study sample sizes ranged from 20 to 332 participants. Six studies were conducted in Europe, and one each in Turkey, New Zealand, and the USA. There were six studies in people with cancer, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. We judged four studies to be at an overall high risk of bias, and five at an overall unclear risk. All outcomes in all comparisons had very low‐certainty evidence, downgraded once for risk of bias and/or indirectness and twice for imprecision. Multimodal intervention (pharmacological, nutritional, and/or exercise) compared to treatment as usual One cancer study randomised 46 participants, with 41 included in all analyses except adverse events. The study assessed outcomes immediately after treatment, lasting six weeks. Compared to treatment as usual, there is no clear evidence for an effect of a multimodal intervention on: physical function (mean difference (MD) −16.10 m, 95% confidence interval (CI) −79.06 to 46.86; 41 participants); strength (MD 3.80 kg, 95% CI −3.21 to 10.81; 41 participants); adverse events (risk ratio (RR) 1.36, 95% CI 0.70 to 2.65; 46 participants); body composition (MD 7.89 cm 2 , 95% CI −10.43 to 26.21; 41 participants); weight (MD 5.89 kg, 95% CI −1.45 to 13.23; 41 participants); appetite (MD 0.68 points, 95% CI −0.60 to 1.96; 41 participants); fatigue (MD 0.12, 95% CI −1.05 to 1.29; 41 participants); and biochemical markers (MD 2%, 95% CI 0.99 to 3.01; 41 participants), but the evidence was very uncertain; QoL was not reported. Multimodal intervention compared to variation of the intervention Three cancer studies and one HIV/AIDS study randomised 192 participants. We could not use the available data, nor obtain additional data, from two studies (one in cancer, one in HIV/AIDS). The studies assessed outcomes immediately after treatment, ranging from three to seven months. Compared to a variation of the intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (MD 10.0 m, 95% CI −36.27 to 56.27; 1 study, 56 participants); strength (MD 0.7 kg, 95% CI −3.75 to 5.15; 1 study, 56 participants); adverse events (RR 0.87, 95% CI 0.38 to 2.02; P = 0.75, I 2 = 0%; 2 studies, 95 participants); body composition (MD −2.67 kg, 95% CI −5.89 to 0.54; P = 0.10, I 2 = 0%; 2 studies, 95 participants); weight (MD −2.47 kg, 95% CI −7.11 to 2.16; P = 0.30, I 2 = 0%; 2 studies, 95 participants); QoL (standardised mean difference (SMD) −0.15, 95% CI −0.55 to 0.26; P = 0.47, I 2 = 0%; 2 studies, 95 participants); appetite (SMD −0.34, 95% CI −1.27 to 0.59; P = 0.48, I 2 = 79%; 2 studies, 95 participants); fatigue (MD 6.40 points, 95% CI −1.10 to 13.90; 1 study, 56 participants); or biochemical markers (MD 9.80 pg/mL, 95% CI −6.25 to 25.85; P = 0.23, I 2 = 73%; 2 studies, 95 participants), but the evidence is very uncertain. Multimodal intervention compared to unimodal intervention We included six studies (802 participants) in this comparison: three cancer studies, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. The studies assessed outcomes immediately after treatment, ranging from three to seven months. We could not use the available data, nor obtain additional data, from the HIV/AIDS study. Compared to a unimodal intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (SMD 0.02, 95% CI −0.22 to 0.26; P = 0.86, I 2 = 0%; 2 studies, 348 participants); strength (SMD 0.23, 95% CI −0.81 to 1.27; P = 0.66, I 2 = 0%; 2 studies, 348 participants); adverse events (RR 0.87, 95% CI −0.43 to 1.73; P = 0.68, I 2 = 45%; 2 studies, 395 participants); body composition (SMD 0.11, 95% CI −0.28 to 0.50; P = 0.58, I 2 = 74%; 5 studies, 742 participants); body weight (SMD −0.02, 95% CI −0.38 to 0.33; P = 0.90, I 2 = 49%; 4 studies, 431 participants); QoL (SMD 0.22, 95% CI −0.29 to 0.73; P = 0.39, I 2 = 61%; 3 studies, 411 participants); appetite (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.72, I 2 = 58%; 2 studies, 395 participants); fatigue (MD −6.80 points, 95% CI −12.44 to −1.17; 1 study, 244 participants); and biochemical markers (SMD 0.11, 95% CI −0.59 to 0.80; P = 0.76, I 2 = 79%; 3 studies, 411 participants), but the evidence is very uncertain. Authors' conclusions The review found insufficient evidence to support or refute the use of multimodal interventions in managing cachexia. The certainty of the evidence was very low. Methodologically rigorous, well‐powered RCTs with adequate interaction times are needed to assess the effectiveness of multimodal interventions in managing cachexia across chronic illnesses. Plain language summary What are the benefits and risks of using a combination of treatments to manage cachexia (disease‐related wasting)? Key messages: • We do not know if combinations of two or more treatments (of medication, diet, and exercise) benefit people who have or are at risk of developing cachexia (disease‐related wasting). This is because there are currently not enough robust studies in this area. • We need future research to increase our confidence in the evidence by conducting better designed and larger studies. What is cachexia? Cachexia is a complex metabolic syndrome that occurs in people with long‐term illnesses (known as chronic illnesses), such as cancer, HIV/AIDS, chronic kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People who have cachexia may: • lose weight unintentionally;
• lose muscle;
• feel tired, weak, or both; 
• lose their appetite. Cachexia affects well‐being and can be life‐threatening. How is cachexia treated? Studies are investigating how to best manage cachexia with different treatments. These treatments can include medications, diet, and exercise, provided in a single (unimodal) or combined (multimodal) treatment. It is thought that due to the complex biology of cachexia, a combination of treatments may work in a complementary way (synergistically) to help improve the symptoms associated with cachexia and people's well‐being, extend life, or both. What did we want to find out? We wanted to find out if combining at least two treatments (out of diet, exercise, and medication) helped to improve: physical function and strength; muscle loss; weight; well‐being; appetite; fatigue; and biological indicators within the blood (biochemical markers). We also wanted to find out if these interventions were associated with any unwanted or harmful (adverse) effects. What did we do? We searched for studies that compared treatment combinations of diet, exercise and/or medication (where at least two treatments were used together) to: different combinations of treatments; a single treatment; or treatment as usual (standard care) in adults with cachexia or at risk of developing cachexia. We compared and summarised the results of the included studies. We rated our confidence in the evidence based on factors such as study methods and the number of people included. What did we find? We found nine studies that included a total of 926 adults, with an average age of 63 years. Just over half of participants (57%) were men. Studies took place around the world, including Europe (six studies), Turkey (one study), New Zealand (one study), and the USA (one study). One study included people with HIV/AIDS (average age 43 years; 35 of 50 people in the study were men); one study included people with COPD (average age 72 years; 20 of 28 people in the study were men); and one study included people with chronic kidney disease (average age 70 years; 11 of 21 in the study were men). Six studies included people with cancer (average age 64 years; 461 of 893 people in the studies were men). The studies lasted six weeks to two years. The studies used combinations of treatments which could have included diet, exercise, and/or medication, where at least two treatments were used together, and compared these to: • treatment as usual (1 study, 46 people);
• different combinations of treatments (4 studies, 192 people);
• a single treatment (6 studies, 802 people). The studies did not provide enough robust evidence to determine if multimodal interventions are associated with benefits or harms in people with or at risk of cachexia. What are the limitations of the evidence? We are not confident in the evidence because not all the studies provided information about everything that we were interested in. Additionally, the studies used different ways of measuring results, and most of the studies included only small numbers of people. Importantly, future studies may change the conclusions of this review. How current is this review? The evidence is current to June 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Reid, J; Blair, C; Dempster, M; McKeaveney, C; Slee, A; Fitzsimons, D", "articleTypes": [], "doi": "10.1002/14651858.CD015749.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "978ab29b-917d-4097-965f-13280da7c552", "pmid": "", "title": "Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco", "imported": false, "abstract": "Abstract - Background Overeating and harmful alcohol and tobacco use have been linked to the aetiology of various non‐communicable diseases, which are among the leading global causes of morbidity and premature mortality. As people are repeatedly exposed to varying sizes and shapes of food, alcohol and tobacco products in environments such as shops, restaurants, bars and homes, this has stimulated public health policy interest in product size and shape as potential targets for intervention. Objectives 1) To assess the effects of interventions involving exposure to different sizes or sets of physical dimensions of a portion, package, individual unit or item of tableware on unregulated selection or consumption of food, alcohol or tobacco products in adults and children. 2) To assess the extent to which these effects may be modified by study, intervention and participant characteristics. Search methods We searched CENTRAL, MEDLINE, EMBASE, PsycINFO, eight other published or grey literature databases, trial registries and key websites up to November 2012, followed by citation searches and contacts with study authors. This original search identified eligible studies published up to July 2013, which are fully incorporated into the review. We conducted an updated search up to 30 January 2015 but further eligible studies are not yet fully incorporated due to their minimal potential to change the conclusions. Selection criteria Randomised controlled trials with between‐subjects (parallel‐group) or within‐subjects (cross‐over) designs, conducted in laboratory or field settings, in adults or children. Eligible studies compared at least two groups of participants, each exposed to a different size or shape of a portion of a food (including non‐alcoholic beverages), alcohol or tobacco product, its package or individual unit size, or of an item of tableware used to consume it, and included a measure of unregulated selection or consumption of food, alcohol or tobacco. Data collection and analysis We applied standard Cochrane methods to select eligible studies for inclusion and to collect data and assess risk of bias. We calculated study‐level effect sizes as standardised mean differences (SMDs) between comparison groups, measured as quantities selected or consumed. We combined these results using random‐effects meta‐analysis models to estimate summary effect sizes (SMDs with 95% confidence intervals (CIs)) for each outcome for size and shape comparisons. We rated the overall quality of evidence using the GRADE system. Finally, we used meta‐regression analysis to investigate statistical associations between summary effect sizes and variant study, intervention or participant characteristics. Main results The current version of this review includes 72 studies, published between 1978 and July 2013, assessed as being at overall unclear or high risk of bias with respect to selection and consumption outcomes. Ninety‐six per cent of included studies (69/72) manipulated food products and 4% (3/72) manipulated cigarettes. No included studies manipulated alcohol products. Forty‐nine per cent (35/72) manipulated portion size, 14% (10/72) package size and 21% (15/72) tableware size or shape. More studies investigated effects among adults (76% (55/72)) than children and all studies were conducted in high‐income countries ‐ predominantly in the USA (81% (58/72)). Sources of funding were reported for the majority of studies, with no evidence of funding by agencies with possible commercial interests in their results. A meta‐analysis of 86 independent comparisons from 58 studies (6603 participants) found a small to moderate effect of portion, package, individual unit or tableware size on consumption of food (SMD 0.38, 95% CI 0.29 to 0.46), providing moderate quality evidence that exposure to larger sizes increased quantities of food consumed among children (SMD 0.21, 95% CI 0.10 to 0.31) and adults (SMD 0.46, 95% CI 0.40 to 0.52). The size of this effect suggests that, if sustained reductions in exposure to larger‐sized food portions, packages and tableware could be achieved across the whole diet, this could reduce average daily energy consumed from food by between 144 and 228 kcal (8.5% to 13.5% from a baseline of 1689 kcal) among UK children and adults. A meta‐analysis of six independent comparisons from three studies (108 participants) found low quality evidence for no difference in the effect of cigarette length on consumption (SMD 0.25, 95% CI ‐0.14 to 0.65). One included study (50 participants) estimated a large effect on consumption of exposure to differently shaped tableware (SMD 1.17, 95% CI 0.57 to 1.78), rated as very low quality evidence that exposure to shorter, wider bottles (versus taller, narrower bottles) increased quantities of water consumed by young adult participants. A meta‐analysis of 13 independent comparisons from 10 studies (1164 participants) found a small to moderate effect of portion or tableware size on selection of food (SMD 0.42, 95% CI 0.24 to 0.59), rated as moderate quality evidence that exposure to larger sizes increased the quantities of food people selected for subsequent consumption. This effect was present among adults (SMD 0.55, 95% CI 0.35 to 0.75) but not children (SMD 0.14, 95% CI ‐0.06 to 0.34). In addition, a meta‐analysis of three independent comparisons from three studies (232 participants) found a very large effect of exposure to differently shaped tableware on selection of non‐alcoholic beverages (SMD 1.47, 95% CI 0.52 to 2.43), rated as low quality evidence that exposure to shorter, wider (versus taller, narrower) glasses or bottles increased the quantities selected for subsequent consumption among adults (SMD 2.31, 95% CI 1.79 to 2.83) and children (SMD 1.03, 95% CI 0.41 to 1.65). Authors' conclusions This review found that people consistently consume more food and drink when offered larger‐sized portions, packages or tableware than when offered smaller‐sized versions. This suggests that policies and practices that successfully reduce the size, availability and appeal of larger‐sized portions, packages, individual units and tableware can contribute to meaningful reductions in the quantities of food (including non‐alcoholic beverages) people select and consume in the immediate and short term. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. We are unable to highlight clear implications for tobacco or alcohol policy due to identified gaps in the current evidence base. Plain language summary Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco Review question We reviewed the evidence to establish by how much the amounts of food, alcohol or tobacco adults and children select or consume change in response to being presented with larger or smaller‐sized (or differently shaped) portions or packages of these products, or of items of tableware (such as plates or glasses) used to consume them. Study characteristics This review includes 72 randomised controlled trials (RCTs) published up to July 2013 that compared at least two groups of participants, each presented with a different size of a portion, package or item of tableware. Included studies measured the amounts of food, alcohol or tobacco selected and/or consumed by participants, typically over a period of one day or less. Almost all of the included studies investigated food, with only three tobacco studies and no alcohol studies found. Almost all assessed participants' responses to different sizes rather than different shapes. The average age of participants in the different studies ranged from three to 55 years, with more studies involving adults than children and most conducted in the USA. Sources of funding were reported for the majority of studies and there was no evidence of study funding by agencies with commercial interests in their results. Key findings and quality of evidence Effects of size on consumption: We found evidence that people consistently ate more food or drank more non‐alcoholic drinks when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. We estimate the size of this effect to be small to moderate among both children and adults. If an effect of this size were sustained across the whole diet it would be equivalent to around a 12% to 16% change in average daily energy intake from food among UK adults. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations arising from incomplete or unclear reporting of methods and procedures. From three tobacco studies, we found no effect of longer compared with shorter cigarettes on the amounts of tobacco consumed. We rated the overall quality of evidence for this effect as low due to concerns about study limitations and not having enough evidence. Effects of shape on consumption: One study found that adults provided with shorter, wider bottles drank larger amounts of water from them, having already poured more, compared with those provided with taller, narrower bottles. However, we rated the quality of this evidence as very low, due to very serious concerns about study limitations and not having enough evidence (only one study with outcome data from 50 participants). Effects of size on selection: We further found that adults, but not children, consistently chose (selected) more food (including non‐alcoholic drinks) when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. The estimated size of this effect was again small to moderate. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations. Effects of shape on selection: Evidence from three studies suggested that adults and children provided with shorter, wider bottles or glasses selected increased quantities of non‐alcoholic beverages for subsequent consumption, compared with those provided with taller, narrower bottles or glasses. We rated the quality of this evidence as low, again due to concerns about study limitations and unexplained variation in effects between the three studies. Conclusions Overall, this review provides the most conclusive evidence to date that acting to reduce the size, availability and appeal of larger‐sized portions, packages and tableware has potential to reduce the quantities of food that people select and consume by meaningful amounts. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. Our findings highlight the need for further research that aims to reduce uncertainties about these effects and address identified gaps in the evidence base, including not having enough evidence for longer‐term effects and the absence of evidence about alcohol products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hollands, GJ; Shemilt, I; Marteau, TM; Jebb, SA; Lewis, HB; Wei, Y; Higgins, JPT; Ogilvie, D", "articleTypes": [], "doi": "10.1002/14651858.CD011045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "979b2af9-5135-4abd-8869-c8da7f76d54a", "pmid": "", "title": "Dietary Peanut Intake and Nutrition-Related Outcomes in Individuals Using GLP-1 Receptor Agonists: A Randomized Controlled Trial", "imported": false, "abstract": "This study will look at how eating peanuts every day might affect participants weight, how healthy their diet is, and how they feel when eating. Investigators want to see if adding peanuts to meals for 12 weeks helps participants feel fuller, have more energy, and improve body composition. The study will include adults who have been taking GLP-1 medicines like semaglutide or tirzepatide for at least three months. Investigators also want to see if eating peanuts improves overall diet quality and health markers like tiredness and certain levels in blood.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.151Z" }, { "id": "97a79472-c440-4632-8f43-644dba92ff91", "pmid": "", "title": "Helminth therapy (worms) for induction of remission in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease (IBD) is a chronic, globally‐occurring gastrointestinal disorder and a major cause of illness and disability. It is conventionally classified into Crohn’s disease (CD) and ulcerative colitis (UC). Helminths are parasitic worms with complex life cycles involving tissue‐ or lumen‐dwelling stages in their hosts, and causing long‐lasting or chronic infections that are frequently asymptomatic. Helminths modulate immune responses of their hosts, and many observational and experimental studies support the hypothesis that helminths suppress immune‐mediated chronic inflammation that occurs in asthma, allergy and IBD. Objectives The objective was to evaluate the efficacy and safety of helminth treatment for induction of remission in IBD. Search methods We searched the following databases from inception to 13 July 2013: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Inflammatory Bowel Disease Group Specialized Trials Register. We also searched four online trials registries, and abstracts from major meetings. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) where the intervention was any helminth species or combination of helminth species, administered in any dose and by any route and for any duration of exposure to people with active CD or UC, confirmed through any combination of clinical, endoscopic and histological criteria were eligible for inclusion. Data collection and analysis Two authors independently extracted data and assessed eligibility using a standardized data collection form. We used the RevMan software for analyses. The primary outcome was induction of remission as defined by the included studies. Secondary outcomes included clinical, histologic, or endoscopic improvement as defined by the authors, endoscopic mucosal healing, change in disease activity index score, change in quality of life score, hospital admissions, requirement for intravenous corticosteroids, surgery, study withdrawal and the incidence of adverse events. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. We calculated the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria. Main results Two RCTs (90 participants) were included. One trial assessed the efficacy and safety of Trichuris suis ( T. suis ) ova in patients with UC (n = 54). The other RCT was a phase one that assessed the safety and tolerability of T. suis ova in patients with CD (n = 36). The risk of bias in both studies was judged to be low. In the UC study, during the 12‐week study period, participants in the active arm received 2‐weekly aliquots of 2500 T. suis eggs, added to 0.8 mL of saline; those in the placebo arm received 0.8 mL saline only. There were sparse data available for the outcomes clinical remission and clinical improvement. Ten per cent (3/30) of patients in the T. suis arm entered remission compared to 4% (1/24) of patients in the placebo arm (RR 2.40, 95% CI 0.27 to 21.63). Forty‐three per cent (13/30) of patients in the T. suis group achieved clinical improvement compared to 17% (4/24) of placebo patients (RR 2.60, 95% CI 0.97 to 6.95). The mean ulcerative colitis disease activity index (UCDAI) score was lower in the T. suis group (6.1 +/‐ 0.61) compared to the placebo group (7.5 +/‐ 0.66) after 12 weeks of treatment (MD ‐1.40, 95% CI ‐1.75 to ‐1.05). There was only limited evidence relating to the proportion of patients who experienced an adverse event. Three per cent (1/30) of patients in the T. suis group experienced at least one adverse event compared to 12% (3/24) of placebo patients (RR 0.27, 95% CI 0.03 to 2.40). None of the adverse events reported in this study were judged to be related to the study treatment. GRADE analyses rated the overall quality of the evidence for the primary and secondary outcomes (i.e. clinical remission and improvement) as low due to serious imprecision. In the CD study, participants received a single treatment of T. suis ova at a dosage of 500 (n = 9), 2500 (n = 9), or 7500 (n = 9) embryonated eggs or matching placebo (n = 9). The CD study did not assess clinical remission or improvement as outcomes. There were sparse data on adverse events at two weeks. Thirty‐seven per cent (10/27) of patients in the T. suis group experienced at least one adverse event compared to 44% (4/9) of placebo patients (RR 0.83, 95% CI 0.35 to 2.01). Only one adverse event (dysgeusia) was judged to be possibly related to treatment in this study. Dysgeusia was reported in one patient in the T. suis group and in one patient in the placebo group. Authors' conclusions Currently, there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of helminths used to treat patients with IBD. The evidence for our primary efficacy outcomes in this review comes from one small study and is of low quality due to serious imprecision. We do not have enough evidence to determine whether helminths are safe when used in patients with UC and CD. Further RCTs are required to assess the efficacy and safety of helminth therapy in IBD. Plain language summary Helminth therapy (worms) for induction of remission in inflammatory bowel disease Inflammatory bowel disease (IBD) is comprised of two disorders: ulcerative colitis and Crohn’s disease. These disorders have both distinct and overlapping symptoms, but the underlying cause remains incompletely understood. Standard therapy for IBD includes sulfasalazine, 5‐ASA drugs, steroids, immunosuppressives such as azathioprine, 6‐mercaptopurine and methotrexate and biological agents such as infliximab. Helminths are worm‐like parasites, that inhabit larger organisms. Helminths cause changes in the immune systems of their hosts including an altered immunological response to antigens and this has implications for the treatment of inflammatory bowel disease which is thought to be caused by immune dysregulation. The purpose of this systematic review was to examine the effectiveness and safety of helminth therapy for inducing remission in people with IBD. This review identified two randomised controlled trials including a total of 90 participants. One study compared twice weekly treatment with helminths (an 0.8 mL solution containing 2500 live eggs of the helminth Trichuris suis ) for 12 weeks to a matching placebo (an 0.8 ml identical looking solution with no Trichuris suis eggs) in 54 patients with active ulcerative colitis. Few remissions occurred during the trial and helminth treatment had no detectable effect on these remissions. Ten per cent (3/30) of patients in the helminth group achieved remission compared to four per cent (1/24) of placebo patients. A higher proportion of patients in the helminth group (43% or 13/30) improved clinically compared to the placebo group (17% or 4/24). However, this difference could be a chance effect. We could not determine whether the proportion of patients who had a side effect was higher in either group. No observed side effects were thought to be related to treatment were reported in this study. The other study compared one treatment with various doses of helminths (a solution of 500, 2500 or 7500 Trichuris suis eggs) to a matching placebo in 36 patients with Crohn's disease. This study was designed to assess side effects and did not measure clinical remission or improvement. There amount of information available on side‐effects at two weeks was limited and the results were uncertain due to the small number of participants in the study. The only side effect that was judged to be possibly related to the study treatment was dysgeusia (a distortion of the sense of taste). This was reported in one patient in the helminth group and in one patient in the placebo group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and safety of helminths used to treat patients with IBD. The only information available relating to clinical improvement in patients with active ulcerative colitis comes from one small study. We do not know how safe helminths are when used in patients with ulcerative colitis and Crohn's disease. Further randomised controlled trials are required to assess the efficacy and safety of helminth therapy in IBD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Garg, SK, Croft, AM, Bager, P", "articleTypes": [], "doi": "10.1002/14651858.CD009400.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.810Z" }, { "id": "97e1118b-c2d2-4e89-be4a-327593b63cd3", "pmid": "", "title": "Interventions for fatigue in peripheral neuropathy", "imported": false, "abstract": "Abstract - Background Persistent feelings of fatigue (or subjective fatigue), which may be experienced in the absence of physiological factors, affect many people with peripheral neuropathy. A variety of interventions for subjective fatigue are available, but little is known about their efficacy or the likelihood of any adverse effects for people with peripheral neuropathy. Objectives To assess the effects of drugs and physical, psychological or behavioural interventions for fatigue in adults or children with peripheral neuropathy. Search methods On 5 November 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, CINAHL Plus, LILACS and AMED. We also searched reference lists of all studies identified for inclusion and relevant reviews, and contacted the authors of included studies and known experts in the field to identify additional published or unpublished data. We also searched trials registries for ongoing studies. Selection criteria We considered for inclusion randomised controlled trials (RCTs) and quasi‐RCTs comparing any form of intervention for fatigue management in adults with peripheral neuropathy with placebo, no intervention or an alternative form of intervention for fatigue. Interventions considered included drugs, pacing and grading of physical activity, general or specific exercise, compensatory strategies such as orthotics, relaxation, counselling, cognitive and educational strategies. Data collection and analysis Two review authors independently assessed risk of bias and extracted study data. We contacted study authors for additional information. We collected information on adverse events from the included trials. Main results The review includes three trials, which were all at low risk of bias, involving 530 people with peripheral neuropathy. The effects of amantadine from one randomised, double‐blind, placebo‐controlled, cross‐over trial comparing amantadine with placebo for the treatment of fatigue in 80 people with Guillain‐Barré syndrome (GBS) were uncertain for the proportion of people achieving a favourable outcome six weeks post‐intervention (odds ratio (OR) 0.56 (95% confidence interval (CI) 0.22 to 1.35, N = 74, P = 0.16). We assessed the quality of this evidence as low. Two parallel‐group randomised double‐blind, placebo‐controlled trials comparing the effects of two doses of ascorbic acid with placebo for reducing fatigue in adults with Charcot‐Marie‐Tooth disease type 1A (CMT1A) showed that the effects of ascorbic acid at either dose are probably small (standardised mean difference (SMD) ‐0.12 (95% CI ‐0.32 to 0.08, n = 404, P = 0.25)) for change in fatigue after 12 to 24 months (moderate quality evidence). Neither ascorbic acid study measured fatigue at four to 12 weeks, which was our primary outcome measure. No serious adverse events were reported with amantadine. Serious adverse events were reported in the trials of ascorbic acid. However,risk of serious adverse events was similar with ascorbic acid and placebo. Authors' conclusions One small imprecise study in people with GBS showed uncertain effects of amantadine on fatigue. In two studies in people with CMT1A there is moderate‐quality evidence that ascorbic acid has little meaningful benefit on fatigue. Information about adverse effects was limited, although both treatments appear to be well tolerated and safe in these conditions. There was no evidence available from RCTs to evaluate the effect of other drugs or other interventions for fatigue in either GBS, CMT1A or other causes of peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future randomised clinical trials. Plain language summary Treatments for fatigue in peripheral neuropathy Review question To assess the effects of treatments for fatigue in people with peripheral neuropathy. Background Peripheral neuropathy is damage to the nerves outside the brain and spinal cord. Many people with peripheral neuropathy have feelings of severe tiredness (fatigue) that are not necessarily related to physical problems such as muscle weakness. Evidence in other long‐term illnesses where fatigue is a problem suggests that medicines and other forms of treatment may help. The aim of this review was to assess the effect of drugs and other treatments, such as general or specific exercise, orthotics (devices such as braces), relaxation, counselling and cognitive, behavioural and educational strategies on feelings of fatigue in people with peripheral neuropathy. Study characteristics From a wide search, we identified three RCTs that met our selection criteria. The trials involved a total of 530 adults with peripheral neuropathy. Treatments were ascorbic acid (vitamin C) in people with Charcot‐Marie‐Tooth disease in two trials, and amantadine in Guillain‐Barré syndrome in the third. Charcot‐Marie‐Tooth disease is an inherited nerve disease and Guillain‐Barré syndrome is a condition where there is inflammation of the peripheral nerves. We chose measures of fatigue at four to 12 weeks as our preferred measure of the effects of treatment. The amantadine trial but not the ascorbic acid trials provided data at this time point; the ascorbic acid trials provided data more than 12 months after the start of the intervention. Key results and quality of the evidence There was insufficient evidence to determine the effects of amantadine when compared with an inactive treatment (placebo) for fatigue. and there were no major unwanted effects. We found evidence that ascorbic acid probably has little meaningful benefit for fatigue. No major unwanted effects were identified, but the trials were small. We assessed the quality of this evidence as moderate because the results were imprecise, which means they do not rule out the possibility that the drugs could have an effect. We found no evidence from RCTs on other medicines or treatments for fatigue in peripheral neuropathy. There is insufficient evidence to determine the effect of amantadine for fatigue in GBS and ascorbic acid for fatigue in CMT1A. More high‐quality studies are needed to provide evidence on which to base management of feelings of fatigue in peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future RCTs. The evidence in this review is current to November 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "White, CM, van Doorn, PA, Garssen, MPJ, Stockley, RC", "articleTypes": [], "doi": "10.1002/14651858.CD008146.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.782Z" }, { "id": "97e7edd4-927c-48b7-bdd1-a4ddc00ef82b", "pmid": "", "title": "Omega‐3 fatty acids for bipolar disorder", "imported": false, "abstract": "Abstract - Background Bipolar disorder is a complex psychiatric disorder and is amongst the top thirty causes of worldwide disability. Mood stabilisers are the primary pharmacological intervention, both in the treatment of acute episodes and in prophylaxis. There is, however, mounting evidence that dietary supplementation with omega‐3 fatty acids may be beneficial in psychiatric conditions, particularly those involving disturbances of mood. Objectives To review the efficacy of omega‐3 fatty acids as either a monotherapy or an adjunctive treatment for bipolar disorder. Search methods Electronic searches of the following databases were performed: CCDANCTR‐Studies and CCDANCTR‐References were searched on 12/2/2008, Supplementary searches were carried out on Biological Abstracts, CINAHL, The Cochrane Library, CCDAN Register, EMBASE, MEDLINE, and PsycINFO. The search strategy also included cited reference searching, personal contact with all authors of studies initially included and contact with the omega‐3 producing pharmaceutical companies. Selection criteria All relevant randomised controlled trials were included in the review. Studies involving males and females of all ages with a diagnosis of bipolar disorder qualified for inclusion. Studies using any type or dose of omega‐3 fatty acid treatment as monotherapy or in addition to standard pharmacotherapy were eligible. The primary outcome was symptom severity; and secondary outcomes were adverse effects, dropout and satisfaction with treatment. Data collection and analysis Two review authors independently inspected the citations identified from the search. Potentially relevant abstracts were identified and full papers ordered and reassessed for inclusion and methodological quality. All relevant data were extracted. The weighted mean difference (WMD) was used for continuous outcome data, with 95% confidence intervals (CI). Main results Five studies met inclusion criteria for the review, however, methodological quality was highly variable. Only one study, involving 75 participants, provided data for analysis, and showed a benefit of active treatment over control for depression symptom levels (WMD ‐3.93, 95% CI ‐7.00 to ‐0.86)and Clinical Global Impression scores (WMD ‐0.75, 95% CI ‐1.33 to ‐0.17) but not for mania (WMD ‐2.81, 95% CI ‐7.68 to 1.90). No serious adverse effects were reported in the five studies. The pattern of dropout was highly variable between studies. Authors' conclusions Results from one study showed positive effects of omega‐3 as an adjunctive treatment for depressive but not manic symptoms in bipolar disorder. These findings must be regarded with caution owing to the limited data available. There is an acute need for well‐designed and executed randomised controlled trials in this field. Plain language summary Omega‐3 fatty acids for bipolar disorder This systematic review investigated the efficacy of omega‐3 fatty acids for bipolar disorder. Five randomised controlled trials met inclusion criteria for the review. Only one trial provided data that could be analysed, investigating ethyl‐EPA as an adjunctive treatment in a mixed outpatient population. Some positive benefits were found for depressive symptoms but not for mania, and no adverse events were reported. There is currently insufficient evidence on which to base any clear recommendations concerning omega‐3 fatty acids for bipolar disorder. However, given the general health benefits and safety of omega‐3, the preliminary evidence from this review provides a strong case for well‐powered, high‐quality trials in specific index populations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Montgomery, P, Richardson, AJ", "articleTypes": [], "doi": "10.1002/14651858.CD005169.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.766Z" }, { "id": "980df697-d2f8-48f6-8d19-8440574cead2", "pmid": "", "title": "Interventions for chronic kidney disease in people with sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD), one of the commonest severe monogenic disorders, is caused by the inheritance of two abnormal haemoglobin (beta‐globin) genes. SCD can cause severe pain, significant end‐organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD. Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD. Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, with increased prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end‐stage renal disease. This is an update of a review first published in 2017. Objectives To assess the effectiveness of any intervention for preventing or reducing kidney complications or chronic kidney disease in people with sickle cell disease. Possible interventions include red blood cell transfusions, hydroxyurea, and angiotensin‐converting enzyme inhibitors (ACEIs), either alone or in combination. Search methods We searched for relevant trials in the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, CENTRAL, MEDLINE, Embase, seven other databases, and two other trials registers. Selection criteria Randomised controlled trials (RCTs) comparing interventions to prevent or reduce kidney complications or CKD in people with SCD. We applied no restrictions related to outcomes examined, language, or publication status. Data collection and analysis Two review authors independently assessed trial eligibility, extracted data, assessed the risk of bias, and assessed the certainty of the evidence (GRADE). Main results We included three RCTs with 385 participants. We rated the certainty of the evidence as low to very low across different outcomes according to GRADE methodology, downgrading for risk of bias concerns, indirectness, and imprecision. Hydroxyurea versus placebo One RCT published in 2011 compared hydroxyurea to placebo in 193 children aged nine to 18 months. We are unsure if hydroxyurea compared to placebo reduces or prevents progression of kidney disease assessed by change in glomerular filtration rate (mean difference (MD) 0.58 mL/min /1.73 m 2 , 95% confidence interval (CI) −14.60 to 15.76; 142 participants; very low certainty). Hydroxyurea compared to placebo may improve the ability to concentrate urine (MD 42.23 mOsm/kg, 95% CI 12.14 to 72.32; 178 participants; low certainty), and may make little or no difference to SCD‐related serious adverse events, including acute chest syndrome (risk ratio (RR) 0.39, 99% CI 0.13 to 1.16; 193 participants; low certainty), painful crisis (RR 0.68, 99% CI 0.45 to 1.02; 193 participants; low certainty); and hospitalisations (RR 0.83, 99% CI 0.68 to 1.01; 193 participants; low certainty). No deaths occurred in either trial arm and the RCT did not report quality of life. Angiotensin‐converting enzyme inhibitors versus placebo One RCT published in 1998 compared an ACEI (captopril) to placebo in 22 adults with normal blood pressure and microalbuminuria. We are unsure if captopril compared to placebo reduces proteinuria (MD −49.00 mg/day, 95% CI −124.10 to 26.10; 22 participants; very low certainty). We are unsure if captopril reduces or prevents kidney disease as measured by creatinine clearance; the trial authors stated that creatinine clearance remained constant over six months in both groups, but provided no comparative data (very low certainty). The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Angiotensin‐converting enzyme inhibitors versus vitamin C One RCT published in 2020 compared an ACEI (lisinopril) with vitamin C in 170 children aged one to 18 years with normal blood pressure and microalbuminuria. It reported no data we could analyse. We are unsure if lisinopril compared to vitamin C reduces proteinuria in this population: the large drop in microalbuminuria in both arms of the trial after only one month on treatment may have been due to an overestimation of microalbuminuria at baseline rather than a true effect. The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Authors' conclusions We are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. We are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. We are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria. No RCTs assessed red blood cell transfusions or any combined interventions to prevent or reduce kidney complications. Due to lack of evidence, we cannot comment on the management of children aged over 18 months or adults with any known genotype of SCD. We have identified a lack of adequately designed and powered studies, although we found four ongoing trials since the last version of this review. Only one ongoing trial addresses renal function as a primary outcome in the short term, but such interventions have long‐term effects. Trials of hydroxyurea, ACEIs or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction of kidney complications in people with SCD. Plain language summary Interventions to prevent or reduce kidney complications in people with sickle cell disease Review question Are there any safe and effective interventions that prevent or reduce kidney complications in people with sickle cell disease (SCD)? Background SCD is a serious inherited blood disorder where the red blood cells, which carry oxygen around the body, develop abnormally. Normal red blood cells are flexible and disc‐shaped, but sickled cells are rigid and crescent‐shaped, and stickier than normal red blood cells. This can lead to blockage of blood vessels, resulting in tissue and organ damage and episodes of severe pain. The abnormal cells are fragile and break apart easily, which leads to a decreased number of red blood cells, known as anaemia. Kidney complications can start at an early age in children with SCD and are common in adults with the condition. Kidney complications leading to kidney protein leak and chronic kidney disease can be severe, with serious effects on health. Severe complications include the need for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) or a kidney transplant. Identifying therapies that can prevent or slow down the decline in kidney function in people with SCD is critical for improving health outcomes. Search date The evidence is current to 22 September 2022. Study characteristics We found three randomised controlled trials, which enroled a total of 385 people. One trial, published in 2011, compared the drug hydroxyurea (which helps to maintain the shape and flexibility of red blood cells), to placebo (dummy treatment) in 193 children aged nine to 18 months. The second trial, published in 1998, compared captopril (a drug used to treat high blood pressure) to placebo in 22 adults with normal blood pressure and microalbuminuria (high levels of protein in the urine). The third trial, published in 2020, compared lisinopril (a drug used to treat high blood pressure) to vitamin C in 170 children aged one to 18 years. Two trials received government funding; it was unclear how the third trial was funded. Key results In children aged nine to 18 months, hydroxyurea may increase the ability to produce normal urine, but we are unsure if it has any effect on the glomerular filtration rate (network of filters in the kidney that filter waste from the blood). Hydroxyurea may make little or no difference to the occurrence of serious complications including acute chest syndrome (pain, cough, fever, low oxygen levels, and abnormal substances in the lungs), painful crises, and hospitalisations. We are unsure if giving captopril to adults with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. We are unsure if giving lisinopril to children aged one to 18 years with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. No trials reported quality of life. Limitations of the evidence We have little or very little confidence in the evidence because we only found three trials, and they had specific populations (only children or only adults), few participants, and wide variations in results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Roy, NBA, Carpenter, A, Dale-Harris, I, Dorée, C, Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012380.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.797Z" }, { "id": "9820917a-9059-452a-967f-a875af045ebb", "pmid": "", "title": "Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age", "imported": false, "abstract": "Abstract - Background According to global prevalence analysis studies, acute upper respiratory tract infections (URTIs) are the most common acute infectious disease in children, especially in preschool children. Acute URTIs lead to an economic burden on families and society. Vitamin A refers to the fat‐soluble compound all‐trans‐retinol and also represents retinol and its active metabolites. Vitamin A interacts with both the innate immune system and the adaptive immune system and improves the host's defences against infections. Correlation studies show that serum retinol deficiency was associated with a higher risk of respiratory tract infections. Therefore, vitamin A supplementation may be important in preventing acute URTIs. Objectives To assess the effectiveness and safety of vitamin A supplements for preventing acute upper respiratory tract infections in children up to seven years of age. Search methods We searched CENTRAL, MEDLINE, Embase, the Chinese Biomedical Literature Database, and two trial registration platforms to 8 June 2023. We also checked the reference lists of all primary studies and reviewed relevant systematic reviews and trials for additional references. We imposed no language or publication restrictions. Selection criteria We included randomised controlled trials (RCTs), which evaluated the role of vitamin A supplementation in the prevention of acute URTIs in children up to seven years of age. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Main results We included six studies (27,351 participants). Four studies were RCTs and two were cluster‐RCTs. The included studies were all conducted in lower‐middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas with a high local prevalence of malnutrition and xerophthalmia. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. We judged the included studies to be at either a high or unclear risk of bias for random sequence generation, incomplete outcome data, and blinding. Primary outcomes Six studies reported the incidence of acute URTIs during the study period. Five studies reported the number of acute URTIs over a period of time, but there was population heterogeneity and the results were presented in different forms, therefore only three studies were meta‐analysed. We are uncertain of the effect of vitamin A supplementation on the number of acute URTIs over two weeks (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.92 to 1.09; I 2 = 44%; 3 studies, 22,668 participants; low‐certainty evidence). Two studies reported the proportion of participants with an acute URTI. We are uncertain of the effect of vitamin A supplementation on the proportion of participants with an acute URTI (2 studies, 15,535 participants; low‐certainty evidence). Only one study (116 participants) reported adverse events. No infant in either the placebo or vitamin A group was found to have feeding difficulties (failure to feed or vomiting), a bulging fontanelle, or neurological signs before or after vitamin A administration (very low‐certainty evidence). Secondary outcomes Two studies (296 participants) reported the severity of subjective symptoms, presented by the mean duration of acute URTI. Vitamin A may have little to no effect on the mean duration of acute URTI (very low‐certainty evidence). Authors' conclusions The evidence for the use of vitamin A supplementation to prevent acute URTI is uncertain, because population, dose and duration of interventions, and outcomes vary between studies. From generally very low‐ to low‐certainty evidence, we found that there may be no benefit in the use of vitamin A supplementation to prevent acute URTI in children up to seven years of age. More RCTs are needed to strengthen the current evidence. Future research should report over longer time frames using validated tools and consistent reporting, and ensure adequate power calculations, to allow for easier synthesis of data. Finally, it is important to assess vitamin A supplementation for preschool children with vitamin A deficiency. Plain language summary Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age Background Acute upper respiratory tract infections (URTIs) are the most common acute infectious diseases in children, especially in preschool children. Vitamin A has a positive role in the immune system and may improve the host's defences against infections. Studies show that children with vitamin deficiency are more likely to suffer from respiratory tract infections. Therefore, we assessed the role of vitamin A supplementation in the prevention of acute upper respiratory tract infections in preschool children (up to seven years of age). Review question What is the role of vitamin A supplementation in the prevention of acute URTIs in preschool children (up to seven years of age), compared to no supplementation? Search date We searched for evidence up to 8 June 2023. Study characteristics All included studies were conducted in lower‐ and middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas more likely to experience malnutrition and dry eye. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. Key results We included six studies involving 27,351 participants. We have very low to low confidence in the evidence provided by the studies. Five studies reported the number of acute URTIs over a period of time. The included studies varied by population and the results were presented in different forms, so we could only combine three studies together (meta‐analysis). We are uncertain if vitamin A supplementation lowers the number of acute URTIs over a two‐week period (three studies, 22,668 participants). Two studies reported the proportion of participants with acute URTI. The effect of vitamin A supplementation on the proportion of participants with acute URTI is uncertain (two studies, 15,535 participants). Only one study (116 participants) reported adverse events and none occurred in infants in the placebo or vitamin A groups. Two studies (296 participants) reported the severity of subjective symptoms, presented by the average duration of acute URTIs. Vitamin A may have little to no effect on the average duration of acute URTIs. Authors' conclusions From evidence in which we have very low to low confidence, we found that there may be no benefit in using vitamin A supplementation to prevent acute URTIs in children up to seven years of age. High‐quality studies focusing on preschool children with vitamin A deficiency are needed to identify whether vitamin A supplementation may be effective.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Cheng, X, Li, D, Yang, C, Chen, B, Xu, P, Zhang, L", "articleTypes": [], "doi": "10.1002/14651858.CD015306.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.805Z" }, { "id": "983351c4-60e9-4b88-8af3-b1eba254f9e6", "pmid": "", "title": "Statins for asthma", "imported": false, "abstract": "Abstract - Background Asthma is a common chronic respiratory disease. People with asthma have inflammation of their airways that causes recurrent episodes of wheezing, breathlessness and chest tightness, with or without a cough. Statins possess multiple therapeutic effects, including lowering lipid levels in the blood. Statins are reported to have a potential role as an adjunct treatment in asthma. However, comprehensive evidence of the benefits and harms of using statins is required to facilitate decision making. Objectives To assess the benefits and harms of statins as an adjunct therapy for asthma in adults and children. Search methods We searched for studies in the Cochrane Airways Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid SP and Embase Ovid SP, from their inception dates We handsearched the proceedings of major respiratory conferences. We also searched clinical trials registries for completed, ongoing and unpublished studies, and scanned the reference lists of included studies and relevant reviews to identify additional studies. The search is current to 7 February 2020. Selection criteria We included randomised controlled trials (RCTs) with a parallel‐group design that assessed statins for at least 12 weeks' duration. We considered all participants with a clinical diagnosis of asthma to be eligible, regardless of age, sex, disease severity and previous or current treatment. We planned to include studies reported as full text, those published as abstract only, and unpublished data. Data collection and analysis Two review authors independently screened and selected the studies, extracted outcome data and intervention characteristics from included studies, and assessed risk of bias according to standard Cochrane methodological procedures. We resolved any disagreement through discussion. Main results We found only one trial involving a total of 60 people living with asthma. The trial compared the effect of atorvastatin with a placebo (dummy treatment containing lactose) in treating people with chronic asthma. The trial did not report data for the primary outcomes or adverse events. There was uncertainty about the relative effect on forced expiratory volume in one second (FEV 1 ) and peak expiratory flow (PEF) in the atorvastatin group compared with the placebo group. The study did not report serious adverse effects for the interventions. The included study had internal discrepancies in its reported data. Authors' conclusions The evidence was of very low certainty, so we are unable to draw conclusions about the effectiveness and safety of statins to treat asthma. High‐quality RCTs are needed to assess the effect of statins on people with asthma. Well‐designed multicentre trials with larger samples and longer duration of treatment are required, which assess outcomes such as adverse events, hospital utilisation and costs, to provide better quality evidence. Future studies that include subgroups of obese people with asthma are also required. Plain language summary Statins for asthma Review question We reviewed the evidence about the effect of statins in people with asthma. Background Asthma is a common chronic (persistent) airway disease. Asthma is caused by inflammation in the lungs and bronchoconstriction (tightening of the small tubes in the lungs in response to a trigger such as pollen or cold air). Inflammation and bronchoconstriction cause airflow obstruction (narrowing and blockage). People with asthma experience recurrent attacks of wheezing, difficultly in breathing, and chest tightness, with or without a cough. Statins are anti‐inflammatory medicines. We wanted to review the evidence for statins because the theory is that their anti‐inflammatory properties will help people with asthma. We wanted to discover whether using statin therapy was better or worse than other alternatives, such as usual care alone or different types of statins (atorvastatin, simvastatin). Study characteristics We found only one trial that assessed atorvastatin (a type of statin drug) and placebo (dummy treatment) in 60 adults with asthma over a period of 12 weeks. These people had chronic asthma (persistent airway disease) when they started treatment. Key results We found that the statin (atorvastatin) did not result in any clear improvement in lung function in people with asthma, but may be better in asthma control than the dummy drug. However, because there is only one trial, we cannot draw firm conclusions. The trial did not report on adverse effects or severe adverse effects (harms). We are uncertain whether statins may have beneficial effects on relieving asthma or whether they may increase the risk of adverse events or non‐serious adverse events. Quality of the evidence The evidence was of very low certainty, so we cannot draw firm conclusions about whether statins are helpful and safe to be used by people with asthma. The evidence is current to 7 February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Naing, C; Ni, H", "articleTypes": [], "doi": "10.1002/14651858.CD013268.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "9843bc2d-f6e7-4e58-b5bb-6ed364215b32", "pmid": "", "title": "Community‐based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries", "imported": false, "abstract": "Abstract - Background Supplementary feeding is defined as the provision of extra food to children or families beyond the normal ration of their home diets. The impact of food supplementation on child growth merits careful evaluation in view of the reliance of many states and non‐governmental organisations on this intervention to improve child health in low and middle income countries (LMIC). This is an update of a Cochrane review first published in 2005. Objectives To evaluate the effectiveness of community‐based supplementary feeding for promoting the physical growth of children under five years of age in LMIC. Search methods For this updated review we searched the following databases on 31 January 2011: CENTRAL ( The Cochrane Library ), MEDLINE (1948 to January week 3, 2011), EMBASE (1980 to week 3, 2011), CINAHL (1937 to 27 January 2011), LILACS (all years), WorldCat for dissertations and theses (all years) and ClinicalTrials.gov (all years). Selection criteria Randomised controlled trials (RCTs) evaluating supplementary feeding in comparison to a control group (no intervention or a placebo such as food with a very low number of nutrients and calories) in children from birth to five years of age in LMIC. Data collection and analysis Two review authors independently extracted and analysed the data. Main results We included eight RCTs (n = 1243 children) that were at relatively high risk of bias. We found high levels of clinical heterogeneity in the participants, interventions and outcome measures across studies. Nevertheless, in order to quantify pooled effects of supplementary feeding, we decided to combine studies according to prespecified characteristics. These were the children's age (younger or older than 24 months), their nutritional status at baseline (stunted or wasted, or not stunted or wasted) and the duration of the intervention (less or more than 12 months). A statistically significant difference of effect was only found for length during the intervention in children aged less than 12 months (two studies; 795 children; mean difference 0.19 cm; 95% confidence interval (CI) 0.07 to 0.31). Based on the summary statistic calculated for each study, the mean difference (MD) between intervention and control groups ranged from 0.48 cm (95% CI 0.07 to 0.89) to 1.3 cm (95% CI 0.03 to 2.57) after 3 and 12 months of intervention, respectively. Data on potential adverse effects were lacking. Authors' conclusions The scarcity of available studies and their heterogeneity makes it difficult to reach any firm conclusions. The review findings suggest supplementary feeding has a negligible impact on child growth; however, the pooled results should be interpreted with great caution because the studies included in the review are clinically diverse. Future studies should address issues of research design, including sample size calculation, to detect meaningful clinical effects and adequate intervention allocation concealment. In the meantime, families and children in need should be provided appropriate feeding, health care and sanitation without waiting for new RCTs to establish a research basis for feeding children. Plain language summary Providing extra food for children under five years of age in low and middle income countries Undernutrition is one of the underlying causes of childhood illness and death in low‐ and middle‐income countries. Providing extra food to children or families beyond what they normally have at home is an intervention aimed at supporting the nutritional wellbeing of the target population. We included eight studies where the participants were randomly assigned to two groups: one group received the extra food and the other group was a control, either receiving no food or food with very low nutritional content. Although the impact of supplementary feeding on child growth appeared to be negligible, it is not possible to draw any conclusions until we have studies that involve larger numbers and do not allow assessors to know who is receiving the intervention. Although it is difficult to determine whether community‐based supplementary feeding helps to promote the growth of children from birth to five years in low‐ and middle‐income countries, it is obviously vital to continue to provide food, health care and sanitation to those who need them.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Sguassero, Y; de Onis, M; Bonotti, AM; Carroli, G", "articleTypes": [], "doi": "10.1002/14651858.CD005039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "98468a1d-eb0c-4dbb-8307-60d166ed0b57", "pmid": "", "title": "Chinese medicinal herbs for influenza", "imported": false, "abstract": "Abstract - Background Influenza is a communicable acute respiratory infection which, during epidemics, can cause high morbidity and mortality rates. Traditional Chinese medicinal herbs, often administered following a particular Chinese medical theory, may be a potential treatment of choice. Objectives To assess the effect of Chinese medicinal herbs used to prevent and treat influenza and to estimate the frequency of adverse effects. Search methods We searched CENTRAL (2012, Issue 11), MEDLINE (January 1966 to November week 2, 2012), EMBASE (January 1988 to November 2012) and CNKI (January 1988 to 29 March 2012). We also searched reference lists of articles and the WHO ICTRP search portal (November 2012). Selection criteria Randomised controlled trials (RCTs) comparing traditional Chinese medicinal herbs with placebo, no treatment or conventional medicine normally used in preventing and treating uncomplicated influenza. Data collection and analysis Two review authors independently extracted data and assessed trial quality. Main results We included 18 studies involving 2521 participants. The methodological quality of 17 included studies was poor. Included RCTs separately compared medicinal herbs with different antiviral drugs, precluding any pooling of results. Only three indicated that compared with antiviral drugs, Chinese medicinal herbs may be effective in preventing influenza and alleviating influenza symptoms. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and speeding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. Ten studies reported mild adverse reactions. Authors' conclusions Most Chinese medical herbs in the included studies showed similar effects to antiviral drugs in preventing or treating influenza. Few were shown to be superior to antiviral drugs. No obvious adverse events were reported in the included studies. However, current evidence remains weak due to methodological limitations of the trials. More high‐quality RCTs with larger numbers of participants and clear reporting are needed. Plain language summary Chinese medicinal herbs for influenza Influenza is a viral respiratory infection that causes an acute febrile illness with myalgia, headache and cough, and can result in high morbidity and mortality rates during an epidemic. Annual epidemics are thought to result in between three and five million cases of severe influenza and between 250,000 and 500,000 deaths worldwide. Currently, annual vaccination is the primary strategy for preventing influenza, and four influenza antiviral agents (amantadine, rimantadine, zanamivir and oseltamivir) have been approved for treatment of influenza. However, high levels of drug resistance have been recorded. Many Chinese medicinal herbs are used to treat and prevent this condition. This updated review assessed the therapeutic effects and safety of Chinese medicinal herbs as an alternative and adjunctive therapy to other commonly used drugs for influenza. Eighteen studies involving 2521 participants were included in the review. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and aiding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. The remaining 17 Chinese herbal trials showed a similar effect to antiviral drugs in preventing or treating influenza. However, since these included studies were of poor quality, the evidence does not support or reject the use of any Chinese herbal preparations for influenza. High‐quality trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Jiang, L, Deng, L, Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD004559.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.097Z" }, { "id": "9866f6e6-7be5-40d5-acad-a0830cc3a804", "pmid": "", "title": "Drugs for the acute treatment of migraine in children and adolescents", "imported": false, "abstract": "Abstract - Background Numerous medications are available for the acute treatment of migraine in adults, and some have now been approved for use in children and adolescents in the ambulatory setting. A systematic review of acute treatment of migraine medication trials in children and adolescents will help clinicians make evidence‐informed management choices. Objectives To assess the effects of pharmacological interventions by any route of administration versus placebo for migraine in children and adolescents 17 years of age or less. For the purposes of this review, children were defined as under 12 years of age and adolescents 12 to 17 years of age. Search methods We searched seven bibliographic databases and four clinical trial registers as well as gray literature for studies through February 2016. Selection criteria We included prospective randomized controlled clinical trials of children and adolescents with migraine, comparing acute symptom relieving migraine medications with placebo in the ambulatory setting. Data collection and analysis Two reviewers screened titles and abstracts and reviewed the full text of potentially eligible studies. Two independent reviewers extracted data for studies meeting inclusion criteria. We calculated the risk ratios (RRs) and number needed to treat for an additional beneficial outcome (NNTB) for dichotomous data. We calculated the risk difference (RD) and number needed to treat for an additional harmful outcome (NNTH) for proportions of adverse events. The percentage of pain‐free patients at two hours was the primary efficacy outcome measure. We used adverse events to evaluate safety and tolerability. Secondary outcome measures included headache relief, use of rescue medication, headache recurrence, presence of nausea, and presence of vomiting. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables. Main results We identified a total of 27 randomized controlled trials (RCTs) of migraine symptom‐relieving medications, in which 9158 children and adolescents were enrolled and 7630 (range of mean age between 8.2 and 14.7 years) received medication. Twenty‐four studies focused on drugs in the triptan class, including almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, sumatriptan + naproxen sodium, and zolmitriptan. Other medications studied included paracetamol (acetaminophen), ibuprofen, and dihydroergotamine (DHE). More than half of the studies evaluated sumatriptan. All but one study reported adverse event data. Most studies presented a low or unclear risk of bias, and the overall quality of evidence, according to GRADE criteria, was low to moderate, downgraded mostly due to imprecision and inconsistency. Ibuprofen was more effective than placebo for producing pain freedom at two hours in two small studies that included 162 children (RR 1.87, 95% confidence interval (CI) 1.15 to 3.04) with low quality evidence (due to imprecision). Paracetamol was not superior to placebo in one small study of 80 children. Triptans as a class of medication were superior to placebo in producing pain freedom in 3 studies involving 273 children (RR 1.67, 95% CI 1.06 to 2.62, NNTB 13) (moderate quality evidence) and 21 studies involving 7026 adolescents (RR 1.32, 95% CI 1.19 to 1.47, NNTB 6) (moderate quality evidence). There was no significant difference in the effect sizes between studies involving children versus adolescents. Triptans were associated with an increased risk of minor (non‐serious) adverse events in adolescents (RD 0.13, 95% CI 0.08 to 0.18, NNTH 8), but studies did not report any serious adverse events. The risk of minor adverse events was not significant in children (RD 0.06, 95% CI − 0.04 to 0.17, NNTH 17). Sumatriptan plus naproxen sodium was superior to placebo in one study involving 490 adolescents (RR 3.25, 95% CI 1.78 to 5.94, NNTB 6) (moderate quality evidence). Oral dihydroergotamine was not superior to placebo in one small study involving 13 children. Authors' conclusions Low quality evidence from two small trials shows that ibuprofen appears to improve pain freedom for the acute treatment of children with migraine. We have only limited information on adverse events associated with ibuprofen in the trials included in this review. Triptans as a class are also effective at providing pain freedom in children and adolescents but are associated with higher rates of minor adverse events. Sumatriptan plus naproxen sodium is also effective in treating adolescents with migraine. Plain language summary Drugs for the acute treatment of migraine in children and adolescents Background and review question Migraine is a painful and debilitating disorder that is common in children (under 12 years of age) and adolescents (12 to 17 years of age). Common symptoms reported during a migraine attack are headache, nausea, vomiting, and sensitivity to light and sound. Many treatments for migraine are available, of which the most common are paracetamol (also known as acetaminophen), ibuprofen and other anti‐inflammatories, and triptans. Not all triptan medications are approved for use in children or adolescents, and approvals vary from country to country. Study characteristics In our review, we looked at 27 randomized controlled trials of drugs compared to placebo to find out which treatments were effective at providing pain freedom two hours after treatment. We also wanted to know what side effects might be caused by the treatments. A total of 7630 children received medication in the studies. The evidence is current to February 2016. Each study had between 13 and 888 participants. Their average age was 12.9 years and ranged from 8.2 to 14.7 years. Nineteen of the studies were funded by the drug manufacturer. Key results Ibuprofen appears to be effective in treating children with migraine, but the evidence is limited to only two small trials. Ibuprofen is readily available and inexpensive, making it an excellent first choice for migraine treatment. Paracetamol was not shown to be effective in providing pain freedom in children, but we only found one small study. Triptans are a type of medication designed specifically to treat migraine and are often effective at providing greater pain freedom in children and adolescents. The triptans examined in children included rizatriptan and sumatriptan, while almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan were examined in adolescents. The combination of sumatriptan plus naproxen sodium is also effective at treating adolescents with migraine. Overall, there is a risk that the triptan medications may cause minor unwanted side effects like taste disturbance, nasal symptoms, dizziness, fatigue, low energy, nausea, or vomiting. The studies did not report any serious side effects. Quality of the evidence The overall quality of the evidence provided by the review was moderate for the triptans, but low for paracetamol and ibuprofen, as we only identified a few studies. More studies need to look at the effects of each of the migraine treatments in children and adolescents separately.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Richer, L, Billinghurst, L, Linsdell, MA, Russell, K, Vandermeer, B, Crumley, ET, Durec, T, Klassen, TP, Hartling, L", "articleTypes": [], "doi": "10.1002/14651858.CD005220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.086Z" }, { "id": "987c0c55-86ca-43f4-bde7-ee966da4c62b", "pmid": "", "title": "Intranasal corticosteroids for non‐allergic rhinitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Segboer, C, Gevorgyan, A, Avdeeva, K, Chusakul, S, Kanjanaumporn, J, Aeumjaturapat, S, Reeskamp, LF, Snidvongs, K, Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010592.pub2 AB - Abstract - Background Non‐allergic rhinitis is defined as dysfunction and non‐infectious inflammation of the nasal mucosa that is caused by provoking agents other than allergens or microbes. It is common, with an estimated prevalence of around 10% to 20%. Patients experience symptoms of nasal obstruction, anterior rhinorrhoea/post‐nasal drip and sneezing. Several subgroups of non‐allergic rhinitis can be distinguished, depending on the trigger responsible for symptoms; these include occupation, cigarette smoke, hormones, medication, food and age. On a cellular molecular level different disease mechanisms can also be identified. People with non‐allergic rhinitis often lack an effective treatment as a result of poor understanding and lack of recognition of the underlying disease mechanism. Intranasal corticosteroids are one of the most common types of medication prescribed in patients with rhinitis or rhinosinusitis symptoms, including those with non‐allergic rhinitis. However, it is unclear whether intranasal corticosteroids are truly effective in these patients. Objectives To assess the effects of intranasal corticosteroids in the management of non‐allergic rhinitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 7); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 July 2019. Selection criteria Randomised controlled trials (RCTs) comparing intranasal corticosteroids, delivered by any means and in any volume, with (a) placebo/no intervention or (b) other active treatments in adults and children (aged ≥ 12 years). Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were patient‐reported disease severity and a
 significant adverse effect ‐ epistaxis. Secondary outcomes were (disease‐specific) health‐related quality of life, objective measurements of airflow and other adverse events. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 34 studies (4452 participants); however, only 13 studies provided data for our main comparison, intranasal corticosteroids versus placebo. The participants were mainly defined as patients with perennial rhinitis symptoms and negative allergy tests. No distinction between different pheno‐ and endotypes could be made, although a few studies only included a specific phenotype such as pregnancy rhinitis, vasomotor rhinitis, rhinitis medicamentosa or senile rhinitis. Most studies were conducted in a secondary or tertiary healthcare setting. No studies reported outcomes beyond three months follow‐up. Intranasal corticosteroid dosage in the review ranged from 50 µg to 2000 µg daily. Intranasal corticosteroids versus placebo Thirteen studies (2045 participants) provided data for this comparison. These studies used different scoring systems for patient‐reported disease severity, so we pooled the data in each analysis using the standardised mean difference (SMD). Intranasal corticosteroid treatment may improve patient‐reported disease severity as measured by total nasal symptom score compared with placebo at up to four weeks (SMD ‐0.74, 95% confidence interval (CI) ‐1.15 to ‐0.33; 4 studies; 131 participants; I 2 = 22%) (low‐certainty evidence). However, between four weeks and three months the evidence is very uncertain (SMD ‐0.24, 95% CI ‐0.67 to 0.20; 3 studies; 85 participants; I 2 = 0%) (very low‐certainty evidence). Intranasal corticosteroid treatment may slightly improve patient‐reported disease severity as measured by total nasal symptom score change from baseline when compared with placebo at up to four weeks (SMD ‐0.15, 95% CI ‐0.25 to ‐0.05; 4 studies; 1465 participants; I 2 = 35%) (low‐certainty evidence) . All four studies evaluating the risk of epistaxis showed that there is probably a higher risk in the intranasal corticosteroids group (65 per 1000) compared to placebo (31 per 1000) (risk ratio (RR) 2.10, 95% CI 1.24 to 3.57; 4 studies; 1174 participants; I 2 = 0%) (moderate‐certainty evidence). The absolute risk difference (RD) was 0.04 with a number needed to treat for an additional harmful outcome (NNTH) of 25 (95% CI 16.7 to 100). Only one study reported numerical data for quality of life. It did report a higher quality of life score in the intranasal corticosteroids group (152.3 versus 145.6; SF‐12v2 range 0 to 800); however, this disappeared at longer‐term follow‐up (148.4 versus 145.6) (low‐certainty evidence). Only two studies provided data for the outcome objective measurements of airflow. These data could not be pooled because they used different methods of outcome measurement. Neither found a significant difference between the intranasal corticosteroids and placebo group (rhinomanometry SMD ‐0.46, 95% CI ‐1.06 to 0.14; 44 participants; peak expiratory flow rate SMD 0.78, 95% CI ‐0.47 to 2.03; 11 participants) (very low‐certainty evidence). Intranasal corticosteroids probably resulted in little or no difference in the risk of other adverse events compared to placebo (RR 0.99, 95% CI 0.87 to 1.12; 3 studies; 1130 participants; I 2 = 0%) (moderate‐certainty evidence) . Intranasal corticosteroids versus other treatments Only one or a few studies assessed each of the other comparisons (intranasal corticosteroids versus saline irrigation, intranasal antihistamine, capsaicin, cromoglycate sodium, ipratropium bromide, intranasal corticosteroids combined with intranasal antihistamine, intranasal corticosteroids combined with intranasal antihistamine and intranasal corticosteroids with saline compared to saline alone). It is therefore uncertain whether there are differences between intranasal corticosteroids and other active treatments for any of the outcomes reported. Authors' conclusions Overall, the certainty of the evidence for most outcomes in this review was low or very low. It is unclear whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. However, intranasal corticosteroids probably have a higher risk of the adverse effect epistaxis. There are very few studies comparing intranasal corticosteroids to other treatment modalities making it difficult to draw conclusions. Plain language summary Intranasal corticosteroids for non‐allergic rhinitis Review question We wanted to find out whether intranasal corticosteroids (steroids applied into the nose) are effective for the treatment of rhinitis that is not caused by allergy. Background Non‐allergic rhinitis is a chronic disease of the nose, which is not caused by infection or allergies. People with non‐allergic rhinitis experience symptoms that affect their quality of life, such as nasal obstruction, runny nose and sneezing. Non‐allergic rhinitis patients can be divided into different subgroups who have different underlying causes for their disease. The underlying causes of non‐allergic rhinitis are not fully understood, therefore treatment is often unsuccessful in these patients. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation. They are the most commonly prescribed drug in other chronic diseases of the nose and sinuses, such as allergic rhinitis and chronic rhinosinusitis. Intranasal corticosteroid treatment can be delivered with sprays or drops and for different time periods. Study characteristics We included 34 randomised controlled trials (RCTs) with a total of 4452 participants in this review. Most of the studies were relatively small, although the largest study had 983 patients in total. All of the patients were either adults or adolescents (aged between 12 and 18 years old) with non‐allergic rhinitis. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Nine studies were sponsored by the pharmaceutical industry or had commercial sponsors. One study was funded by the government. In several studies, the pharmaceutical industry or commercial sponsor may have provided medications, but the funding role was unclear. Funding was not reported in eight studies. Key results Intranasal corticosteroids compared with placebo It is uncertain whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. They may improve patient‐reported disease severity compared with placebo at up to four weeks, however this evidence is of low certainty. Treatment with intranasal corticosteroids probably increases the risk of epistaxis (nosebleed) but there is no difference in the risk of other adverse effects. It is not possible to tell from this review whether there is a difference between the different concentrations, delivery methods or treatment plans of intranasal corticosteroids. There are no good‐quality studies assessing changes in quality of life with intranasal corticosteroids. Intranasal corticosteroids compared with other treatments There is not enough evidence to know whether intranasal corticosteroid treatment is better, worse or the same as using other treatment strategies such as saline irrigation, intranasal antihistamines, capsaicin or ipratropium bromide for non‐allergic rhinitis. Certainty of the evidence Overall, the evidence for intranasal corticosteroids compared with placebo for most outcomes was either low‐certainty (our confidence in the effect estimate is low) or very low‐certainty (our confidence in the effect estimate is very low). This was because most studies were very small and used different methods to measure the same outcome. This evidence is up to date to July 2019.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.753Z" }, { "id": "988987aa-4c23-4900-849e-c75f0a9a2098", "pmid": "", "title": "Melatonin in cancer treatment", "imported": false, "abstract": "Abstract - Rationale Preserving health‐related quality of life is an aspect of care that requires constant attention from the time of cancer diagnosis. Melatonin has been used to diminish treatment‐related side effects and cancer symptoms, and as a medication to regulate circadian rhythm. An up‐to‐date systematic review is needed to investigate the current evidence concerning possible beneficial effects of melatonin on quality of life and sleep in cancer patients. Objectives To evaluate the benefits and harms of melatonin for preserving health‐related quality of life and sleep in cancer patients. Search methods To identify studies for inclusion in this review, we used CENTRAL, MEDLINE, 10 other databases, and four trial registers, together with reference checking, citation searching, and contact with study authors. The latest search date was 10 September 2024. Eligibility criteria We included randomised controlled trials (RCTs) of adults (18 years or over) with histologically proven cancer of any stage that evaluated melatonin (alone or in combination with standard anticancer treatment) versus no treatment or placebo (alone or in combination with standard anticancer treatment), or standard anticancer treatment. Standard anticancer treatment refers to treatments to stop or prevent cancer, including chemotherapy, radiation therapy, surgery, immunotherapy, and hormonal therapies (such as androgen deprivation therapy). Outcomes The primary outcomes of interest were quality of life and sleep quality within three months, and melatonin‐related adverse events. Other outcomes included survival, disease‐free survival, progression‐free survival, tumour response, and anticancer treatment‐related harms. Risk of bias We used Cochrane's risk of bias tool (RoB 1) to assess the risk of bias in the studies included in the review. Synthesis methods We synthesised results for each outcome using random‐effects meta‐analysis. The effect size was presented as risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CI). If this was not possible, due to the nature of the data, we synthesised results in a narrative format. We used GRADE to assess the certainty of evidence for each outcome. Included studies We identified 30 RCTs (reported in 49 publications) involving 5093 adult participants with cancer (2470 males, 2228 females, 395 not reported). Studies were conducted in a hospital setting and took place in at least 10 countries. We assessed two studies at low risk of bias and the other 28 at high risk of bias. Synthesis of results Melatonin plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life score (MD 2.60, 95% CI −14.53 to 19.73; 1 study, 126 participants; very low certainty evidence), and sleep score (MD 2.80, 95% CI 0.18 to 5.42; 1 study, 50 participants; very low certainty evidence) within three months. We are also very uncertain about potential adverse effects of melatonin: headache (RR 2.77, 95% CI 0.33 to 23.14; 1 study, 25 participants; very low certainty evidence); fatigue (RR 1.02, 95% CI 0.90 to 1.17; 2 studies, 170 participants; very low certainty evidence); and nausea (RR 1.01, 95% CI 0.66 to 1.56; 1 study, 146 participants; very low certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of high risk of bias, small sample size, the width of the 95% confidence interval, and indirectness due to inadequate reporting of cancer type. Melatonin plus standard treatment versus standard treatment No data are available relating to quality of life and sleep within three months. The evidence is very uncertain about headaches (experienced by 15 of 820 participants in melatonin groups, with no data available for control groups; 2 studies, 1640 participants; very low certainty evidence). Melatonin likely reduces the incidence of fatigue (RR 0.46, 95% CI 0.39 to 0.55; 10 studies, 1359 participants; moderate‐certainty evidence) and may reduce nausea (RR 0.85, 95% CI 0.72 to 1.00; 6 studies, 710 participants; low‐certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of the high risk of bias and the width of the 95% confidence interval. Melatonin (topical use) plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life (one study reported no difference between groups, both having the same median score of 66.7; 48 participants; very low certainty evidence). No data are available relating to sleep and adverse events (including headache, dizziness, fatigue, and nausea). We downgraded the certainty of the evidence because of the high risk of bias, small sample size, and insufficient data. Authors' conclusions The available evidence is of very low certainty, so we are unable to draw conclusions about the effects of melatonin on quality of life and sleep at three months in people receiving treatment for cancer. There may be no difference in adverse events between melatonin plus standard treatment and placebo plus standard treatment, but the evidence is very uncertain. Data were lacking for some outcomes, such as dizziness. Melatonin used alongside standard treatment probably reduces the risk of fatigue and may reduce nausea when compared to standard treatment alone. Since the evidence base for melatonin in people with cancer is limited due to insufficient data and risks of bias in study design, the decision for or against using melatonin as an adjunct to cancer treatment cannot easily be made at the current time. Funding This Cochrane Review was partially funded by AG Biologische Krebstherapie, Deutsche Krebshilfe (grant numbers 70‐301 and 109863). The funding agency had no role in the design or conduct of the study. Registration The protocol for this review is available via DOI 10.1002/14651858.CD010145. Plain language summary For cancer patients, what are the benefits and risks of taking the hormone melatonin? Key messages Due to a lack of robust evidence, the effects of melatonin on quality of life and sleep quality in people receiving treatment for cancer are unclear. Melatonin might not increase the risk of adverse events, but the available evidence is not strong enough for us to be certain. Well designed studies using melatonin over a period of up to three months are needed to give better estimates of the benefits and risks. What is melatonin? Melatonin is a hormone produced in the body to regulate the daily sleep and wakefulness cycle. It has been suggested that melatonin may improve sleep quality and quality of life, which are very important in cancer treatment. Moreover, there is research suggesting that melatonin is effective against solid tumours and may be effective for the treatment of cancer. What did we want to find out? We wanted to find out if melatonin can be used in cancer treatment, particularly for preserving the quality of life and sleep quality of cancer patients. We also wanted to find out if melatonin causes any unwanted side effects ('adverse events'). What did we do? We searched for studies that looked at melatonin used with other standard cancer treatments compared with standard cancer treatments used alone or with placebo (fake treatment). What did we find? We found 30 studies that involved 5093 cancer patients, both men and women, with cancer of any type. The studies were conducted in 10 countries around the world. We focused on the effects of melatonin over a period of three months. When compared to placebo plus standard cancer treatments, it is unclear if melatonin has an effect on quality of life and sleep. Melatonin may have little to no effect on potential adverse events like headache, fatigue, and nausea, but we are very uncertain about these results. No results are available for dizziness. We found no studies to help us answer our questions about quality of life and sleep quality when melatonin is used with standard cancer treatments compared to the standard treatment alone. However, the studies did evaluate potential adverse events that might be related to melatonin, and they found that melatonin probably reduces the risk of tiredness (fatigue), and may reduce the risk of feeling sick (nausea). It is unclear if melatonin has an effect on headaches. No results are available for dizziness. When melatonin is used topically, such as in a cream to put on the skin or in a mouth wash, it is unclear if it has an effect on quality of life. We found no studies to help us answer our questions about sleep quality. No data are available for adverse events like headache, fatigue, nausea, and dizziness, as these are not relevant if the melatonin is used topically. It is unclear if melatonin has any other unwanted effects when used topically. What are the limitations of the evidence? We are not confident in the evidence because it is possible that people in the studies were aware of which treatment they were getting. The evidence relating to some benefits and risks we are interested in does not cover all cancer types, or it is based on only a few cases. How up to date is this evidence? The evidence is up‐to‐date to September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Yu, ZY; Peng, RY; Cheng, N; Wang, RT; Nan, MD; Milazzo, S; Pilkington, K; Seely, D; Horneber, M; Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010145.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "98919b32-8f2d-41d8-bab7-bd280c951958", "pmid": "", "title": "Pharmacological interventions for promoting smoking cessation during pregnancy", "imported": false, "abstract": "Abstract - Background Tobacco smoking in pregnancy causes serious health problems for the developing fetus and mother. When used by non‐pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion, and varenicline) are effective for increasing smoking cessation, however their efficacy and safety in pregnancy remains unknown. Electronic cigarettes (ECs) are becoming widely used, but their efficacy and safety when used for smoking cessation in pregnancy are also unknown. Objectives To determine the efficacy and safety of smoking cessation pharmacotherapies and ECs used during pregnancy for smoking cessation in later pregnancy and after childbirth, and to determine adherence to smoking cessation pharmacotherapies and ECs for smoking cessation during pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2019), trial registers, and grey literature, and checked references of retrieved studies. Selection criteria Randomised controlled trials (RCTs) conducted in pregnant women, comparing smoking cessation pharmacotherapy or EC use with either placebo or no pharmacotherapy/EC control. We excluded quasi‐randomised, cross‐over, and within‐participant designs, and RCTs with additional intervention components not matched between trial arms. Data collection and analysis We followed standard Cochrane methods. The primary efficacy outcome was smoking cessation in later pregnancy; safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well‐being. We also collated data on adherence to trial treatments. We calculated the risk ratio (RR) or mean difference (MD) and the 95% confidence intervals (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta‐analyses where appropriate. Main results We included 11 trials that enrolled a total of 2412 pregnant women who smoked at enrolment, nine trials of NRT and two trials of bupropion as adjuncts to behavioural support, with comparable behavioural support provided in the control arms. No trials investigated varenicline or ECs. We assessed four trials as at low risk of bias overall. The overall certainty of the evidence was low across outcomes and comparisons as assessed using GRADE, with reductions in confidence due to risk of bias, imprecision, and inconsistency. Compared to placebo and non‐placebo (behavioural support only) controls, there was low‐certainty evidence that NRT increased the likelihood of smoking abstinence in later pregnancy (RR 1.37, 95% CI 1.08 to 1.74; I² = 34%, 9 studies, 2336 women). However, in subgroup analysis by comparator type, there was a subgroup difference between placebo‐controlled and non‐placebo controlled RCTs (test for subgroup differences P = 0.008). There was unclear evidence of an effect in placebo‐controlled RCTs (RR 1.21, 95% CI 0.95 to 1.55; I² = 0%, 6 studies, 2063 women), whereas non‐placebo‐controlled trials showed clearer evidence of a benefit (RR 8.55, 95% CI 2.05 to 35.71; I² = 0%, 3 studies, 273 women). An additional subgroup analysis in which studies were grouped by the type of NRT used found no difference in the effectiveness of NRT in those using patches or fast‐acting NRT (test for subgroup differences P = 0.08). There was no evidence of a difference between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities, or neonatal death. In one study infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' at two years of age compared to the placebo group. Non‐serious adverse effects observed with NRT included headache, nausea, and local reactions (e.g. skin irritation from patches or foul taste from gum), but data could not be pooled. Adherence to NRT treatment regimens was generally low. We identified low‐certainty evidence that there was no difference in smoking abstinence rates observed in later pregnancy in women using bupropion when compared to placebo control (RR 0.74, 95% CI 0.21 to 2.64; I² = 0%, 2 studies, 76 women). Evidence investigating the safety outcomes of bupropion use was sparse, but the existing evidence showed no difference between the bupropion and control group. Authors' conclusions NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy. However, this evidence is of low certainty, as the effect was not evident when potentially biased, non‐placebo‐controlled RCTs were excluded from the analysis. Future studies may therefore change this conclusion. We found no evidence that NRT has either positive or negative impacts on birth outcomes; however, the evidence for some of these outcomes was also judged to be of low certainty due to imprecision and inconsistency. We found no evidence that bupropion may be an effective aid for smoking cessation during pregnancy, and there was little evidence evaluating its safety in this population. Further research evidence on the efficacy and safety of pharmacotherapy and EC use for smoking cessation in pregnancy is needed, ideally from placebo‐controlled RCTs that achieve higher adherence rates and that monitor infants' outcomes into childhood. Future RCTs of NRT should investigate higher doses than those tested in the studies included in this review. Plain language summary Drug treatments and electronic cigarettes for stopping smoking in pregnancy What is the issue? Smoking during pregnancy harms women and infants. However, many women who smoke struggle to stop whilst pregnant. Medication for smoking cessation reduces the intensity of cravings, meaning that people trying to stop smoking are more likely to succeed in the long term. Providing pregnant women who smoke with these treatments could help them to stop smoking and have a positive impact on both their own health and the health of their infants. Why is this important? Medications commonly used to help people to stop smoking include nicotine replacement therapy (NRT), bupropion, and varenicline. Electronic cigarettes containing nicotine are also used by some who smoke to help avoid smoking. However, the safety and effectiveness of smoking cessation drugs and electronic cigarettes in pregnant women is unknown. We searched for studies looking at how good these aids were at helping pregnant women stop smoking and how safe they were when used during pregnancy. What evidence did we find? We searched for evidence on 20 May 2019 and identified 11 randomised studies (studies in which participants are assigned to one of two or more treatment groups using a random method) that enrolled a total of 2412 women. Nine studies tested NRT used alongside counselling to stop smoking, whilst the other two studies tested bupropion. Low‐quality evidence suggests that NRT combined with behavioural support might help women to stop smoking in later pregnancy more than behavioural support alone. Medication trials often use placebos, that is tablets or patches that look like the drug but do not actually include it, so that each comparison group has equal expectation of success and there is a fairer test of the benefits of the medicine itself. When just the higher‐quality, placebo‐controlled trials were analysed, the evidence suggested that NRT was more effective than placebo NRT. There was no evidence that either nicotine patches or fast‐acting NRT (such as gum or lozenge) was more effective than the other. Low‐quality evidence suggests that bupropion may be no more effective than placebo in helping women quit smoking later in pregnancy. We found no trials investigating other smoking cessation pharmacotherapies or electronic cigarettes. There was insufficient evidence to conclude whether NRT had either positive or negative impacts on rates of miscarriage, stillbirth, preterm birth (less than 37 weeks), mean birthweight, low birthweight (less than 2500 g), admissions of babies to neonatal intensive care, or newborn deaths. However, in one trial where infants were followed until two years of age, those infants born to women who had been randomised to NRT were more likely to have healthy development. Similarly, it is unclear whether bupropion had a positive or negative impact on birth outcomes. Studies that looked at whether women used their stop smoking medications as instructed found that use was generally low, and the majority of women used little of the NRT they were given. What does this mean? More research evidence is needed, in particular placebo‐controlled trials that test higher doses of NRT, encourage women to use sufficient medication, and follow infants into childhood. Furthermore, more studies are required investigating the effect and safety of bupropion, electronic cigarettes, and varenicline for giving up smoking during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Claire, R, Chamberlain, C, Davey, MA, Cooper, SE, Berlin, I, Leonardi‐Bee, J, Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD010078.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.743Z" }, { "id": "989bc57a-7cd3-414c-98d7-e981efe3709d", "pmid": "", "title": "Chinese medicinal herbs for the common cold", "imported": false, "abstract": "Abstract - Background Chinese medicinal herbs are frequently used to treat the common cold in China. Until now, their efficacy has not been systematically reviewed. Objectives To assess the effectiveness and safety of Chinese medicinal herbs for the common cold. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2008, issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to May 2008); EMBASE (1980 to May 2008); AMED (1985 to May 2008); the Chinese Biomedical Database (CBMdisc) (1978 to May 2008); and China National Knowledge Infrastructure (CNKI) (1994 to May 2008). Selection criteria Randomised controlled trials (RCTs) studying the efficacy of Chinese medicinal herb(s) for the treatment of the common cold. Data collection and analysis Four review authors telephoned the original trial authors of the RCTs identified by our searches to verify the randomisation procedure. Two review authors extracted and analysed data from trials which met the inclusion criteria. Main results We found17 studies involving 3212 patients. The methods of 15 studies were at high risk of bias. In only two studies was the risk of bias low. Trials used \"positive drugs\", of which the efficacy was not known, as controls. Different Chinese herbal preparations were tested in nearly all trials. In only one trial was a Chinese herbal preparation tested twice. In seven trials, six herbal preparations were found to be more effective at enhancing recovery than the control preparations. In the other 10 studies, seven herbal preparations were not shown to be significantly different from the control. One study did not describe the difference between the intervention and control groups. Authors' conclusions Chinese herbal medicines may shorten the symptomatic phase in patients with the common cold. However, the lack of trials of low enough risk of bias, or using a placebo or a drug clearly identified as a control, means that we are uncertain enough to be unable to recommend any kind of Chinese medicinal herbs for the common cold. Plain language summary Chinese medicinal herbs to treat the common cold The common cold is the most widespread acute respiratory tract illness affecting all age groups. Many Chinese herbal medicines are used to treat this illness in China. Although we included 17 trials, involving 3212 patients, in this review, the risk of bias was so high that the evidence did not support using any Chinese herbal preparation(s) for the common cold. Well‐designed clinical trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Zhang, X, Wu, T, Zhang, J, Yan, Q, Xie, L, Liu, GJ", "articleTypes": [], "doi": "10.1002/14651858.CD004782.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.765Z" }, { "id": "98b906d8-83b3-4a81-900e-ad276955a2a5", "pmid": "", "title": "Souvenaid for Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Souvenaid is a dietary supplement with a patented composition (Fortasyn Connect™)which is intended to be used by people with Alzheimer's disease (AD). It has been designed to support the formation and function of synapses in the brain, which are thought to be strongly correlated with cognitive function. If effective, it might improve symptoms of Alzheimer's disease and also prevent the progression from prodromal Alzheimer's disease to dementia. We sought in this review to examine the evidence for this proposition. Objectives To assess the effects of Souvenaid on incidence of dementia, cognition, functional performance, and safety in people with Alzheimer's disease. Search methods We searched ALOIS, i.e. the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science (ISI Web of Science), Cinahl (EBSCOhost), Lilacs (BIREME), and clinical trials registries up to 24 June 2020. We also reviewed citations of reference lists of landmark papers, reviews, and included studies for additional studies and assessed their suitability for inclusion in the review. Selection criteria We included randomised, placebo‐controlled trials which evaluated Souvenaid in people diagnosed with mild cognitive impairment (MCI) due to AD (also termed prodromal AD) or with dementia due to AD, and with a treatment duration of at least 16 weeks. Data collection and analysis Our primary outcome measures were incidence of dementia, global and specific cognitive function, functional performance, combined cognitive‐functional outcomes and adverse events. We selected studies, extracted data, assessed the quality of trials and intended to conduct meta‐analyses according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We present all outcomes grouped by stage of AD. Main results We included three randomised, placebo‐controlled trials investigating Souvenaid in 1097 community‐dwelling participants with Alzheimer's disease. One study each included participants with prodromal AD, mild AD dementia and mild‐to‐moderate AD dementia. We rated the risks of bias of all trials as low. One study (in prodromal AD) was funded by European grants. The other two studies were funded by the manufacturer of Souvenaid. One trial investigated the incidence of dementia in people with prodromal AD at baseline, and found little to no difference between the Souvenaid group and the placebo group after 24 months (RR 1.09, 95% CI 0.82 to 1.43; 1 trial, 311 participants; moderate quality of evidence). In prodromal AD, and in mild and mild‐to‐moderate Alzheimer's disease dementia, Souvenaid probably results in little or no difference in global or specific cognitive functions (moderate quality of evidence). Everyday function, or the ability to perform activities of daily living, were measured in mild and mild‐to‐moderate AD dementia. Neither study found evidence of a difference between the groups after 24 weeks of treatment (moderate quality of evidence). Two studies investigated combined cognitive‐functional outcomes with the Clinical Dementia Rating Sum of Boxes and observed conflicting results. Souvenaid probably results in slight improvement, which is below estimates of meaningful change, in participants with prodromal Alzheimer's disease after 24 months (moderate quality of evidence), but probably has little to no effect in mild‐to‐moderate Alzheimer's disease dementia after 24 weeks (moderate quality of evidence). Adverse effects observed were low in all trials, and the available data were insufficient to determine any connection with Souvenaid. Authors' conclusions Two years of treatment with Souvenaid probably does not reduce the risk of progression to dementia in people with prodromal AD. There is no convincing evidence that Souvenaid affects other outcomes important to people with AD in the prodromal stage or mild‐to‐moderate stages of dementia. Conflicting evidence on combined cognitive‐functional outcomes in prodromal AD and mild AD dementia warrants further investigation. Adverse effects of Souvenaid seem to be uncommon, but the evidence synthesised in this review does not permit us to make a definitive statement on the long‐term tolerability of Souvenaid. The effects of Souvenaid in more severe AD dementia or in people with AD at risk of nutritional deficiencies remain unclear. Plain language summary The dietary supplement Souvenaid for preventing dementia or delaying cognitive decline in people with Alzheimer's disease Review question We investigated whether people with mild cognitive impairment (MCI) due to Alzheimer's disease (AD) can reduce their risk of developing dementia with a patented dietary supplement called Souvenaid. We also investigated the effect of Souvenaid on memory or other thinking skills, ability to carry out daily activities, and side effects in people with MCI or any stage of dementia due to AD. Background Alzheimer's disease is a brain disease. It is the commonest cause of dementia among older people. A person is said to have dementia when there has been a decline in their memory and thinking skills which is severe enough to stop them being fully independent in all their daily activities. Because AD develops slowly, it is also possible to pick up symptoms before dementia is fully developed. This pre‐dementia stage, when people with AD have a detectable decline in memory and thinking skills but are still able to manage their usual activities independently, is known as mild cognitive impairment due to AD, or 'prodromal' AD. Souvenaid is a patented mix of vitamins and minerals (Fortasyn Connect™) which was designed to improve brain function in AD. It is a drink which is to be taken once a day. It is intended to be consumed under medical supervision, in addition to the usual diet. Search for evidence We systematically searched for randomised controlled trials (RCTs) which were published up to June 2020 and which compared treatment with Souvenaid for at least 16 weeks with treatment with a dummy supplement (a placebo). For the comparison to be fair, it had to be decided randomly whether each participant was given Souvenaid or the placebo. Key results We found three RCTs with a total of 1097 participants to include in the review. Two of the trials investigated Souvenaid in people with dementia over a treatment period of 24 weeks. One of these included 527 participants with mild‐to‐moderate dementia due to AD and the other included 259 participants with mild dementia due to AD. The third trial investigated the use of Souvenaid for two years in 311 people with prodromal AD. We considered all of the trials to be well‐designed, but because of differences between them in the severity of the participants' symptoms and in the way the researchers measured their results, we were not able to combine the data numerically from the single trials. All the results we report are therefore based on single trials, which leads us to have only moderate confidence in the findings of this review. This means that results could be changed by further research. We found that people with prodromal AD who took Souvenaid daily for two years were probably no more or less likely than those taking placebo to develop dementia. Souvenaid probably had little or no effect on measures of memory or other thinking skills in people with prodromal AD (after two years of treatment) or with mild or mild‐to‐moderate dementia due to AD (after 24 weeks of treatment). It also probably had little or no effect on the ability of people with mild or mild‐to‐moderate dementia due to AD to manage everyday activities (again after 24 weeks). Two studies used an outcome scale which combined memory and thinking skills with practical skills (described as a combined cognitive‐functional outcome). There was probably a small benefit of Souvenaid on this outcome among people with prodromal AD who took Souvenaid for two years. However, there was probably little or no effect of Souvenaid on this outcome among people with mild‐to‐moderate AD dementia who took it for 24 weeks. There were only a few adverse events reported in the trials, and it was not possible to know whether any of them were side effects of Souvenaid. Study funding sources Two studies were funded by the manufacturer of Souvenaid. The third study (in prodromal AD) was funded by European grants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Burckhardt, M, Watzke, S, Wienke, A, Langer, G, Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD011679.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.778Z" }, { "id": "98e031bc-aebb-4f6e-b924-4d14c675e702", "pmid": "", "title": "Replacing salt with low‐sodium salt substitutes (LSSS) for cardiovascular health in adults, children and pregnant women", "imported": false, "abstract": "Abstract - Background Elevated blood pressure, or hypertension, is the leading cause of preventable deaths globally. Diets high in sodium (predominantly sodium chloride) and low in potassium contribute to elevated blood pressure. The WHO recommends decreasing mean population sodium intake through effective and safe strategies to reduce hypertension and its associated disease burden. Incorporating low‐sodium salt substitutes (LSSS) into population strategies has increasingly been recognised as a possible sodium reduction strategy, particularly in populations where a substantial proportion of overall sodium intake comes from discretionary salt. The LSSS contain lower concentrations of sodium through its displacement with potassium predominantly, or other minerals. Potassium‐containing LSSS can potentially simultaneously decrease sodium intake and increase potassium intake. Benefits of LSSS include their potential blood pressure‐lowering effect and relatively low cost. However, there are concerns about potential adverse effects of LSSS, such as hyperkalaemia, particularly in people at risk, for example, those with chronic kidney disease (CKD) or taking medications that impair potassium excretion. Objectives To assess the effects and safety of replacing salt with LSSS to reduce sodium intake on cardiovascular health in adults, pregnant women and children. Search methods We searched MEDLINE (PubMed), Embase (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection (Clarivate Analytics), Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCOhost), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) up to 18 August 2021, and screened reference lists of included trials and relevant systematic reviews. No language or publication restrictions were applied. Selection criteria We included randomised controlled trials (RCTs) and prospective analytical cohort studies in participants of any age in the general population, from any setting in any country. This included participants with non‐communicable diseases and those taking medications that impair potassium excretion. Studies had to compare any type and method of implementation of LSSS with the use of regular salt, or no active intervention, at an individual, household or community level, for any duration. Data collection and analysis Two review authors independently screened titles, abstracts and full‐text articles to determine eligibility; and extracted data, assessed risk of bias (RoB) using the Cochrane RoB tool, and assessed the certainty of the evidence using GRADE. We stratified analyses by adults, children (≤ 18 years) and pregnant women. Primary effectiveness outcomes were change in diastolic and systolic blood pressure (DBP and SBP), hypertension and blood pressure control; cardiovascular events and cardiovascular mortality were additionally assessed as primary effectiveness outcomes in adults. Primary safety outcomes were change in blood potassium, hyperkalaemia and hypokalaemia. Main results We included 26 RCTs, 16 randomising individual participants and 10 randomising clusters (families, households or villages). A total of 34,961 adult participants and 92 children were randomised to either LSSS or regular salt, with the smallest trial including 10 and the largest including 20,995 participants. No studies in pregnant women were identified. Studies included only participants with hypertension (11/26), normal blood pressure (1/26), pre‐hypertension (1/26), or participants with and without hypertension (11/26). This was unknown in the remaining studies. The largest study included only participants with an elevated risk of stroke at baseline. Seven studies included adult participants possibly at risk of hyperkalaemia. All 26 trials specifically excluded participants in whom an increased potassium intake is known to be potentially harmful. The majority of trials were conducted in rural or suburban settings, with more than half (14/26) conducted in low‐ and middle‐income countries. The proportion of sodium chloride replacement in the LSSS interventions varied from approximately 3% to 77%. The majority of trials (23/26) investigated LSSS where potassium‐containing salts were used to substitute sodium. In most trials, LSSS implementation was discretionary (22/26). Trial duration ranged from two months to nearly five years. We assessed the overall risk of bias as high in six trials and unclear in 12 trials. LSSS compared to regular salt in adults: LSSS compared to regular salt probably reduce DBP on average (mean difference (MD) ‐2.43 mmHg, 95% confidence interval (CI) ‐3.50 to ‐1.36; 20,830 participants, 19 RCTs, moderate‐certainty evidence) and SBP (MD ‐4.76 mmHg, 95% CI ‐6.01 to ‐3.50; 21,414 participants, 20 RCTs, moderate‐certainty evidence) slightly. On average, LSSS probably reduce non‐fatal stroke (absolute effect (AE) 20 fewer/100,000 person‐years, 95% CI ‐40 to 2; 21,250 participants, 3 RCTs, moderate‐certainty evidence), non‐fatal acute coronary syndrome (AE 150 fewer/100,000 person‐years, 95% CI ‐250 to ‐30; 20,995 participants, 1 RCT, moderate‐certainty evidence) and cardiovascular mortality (AE 180 fewer/100,000 person‐years, 95% CI ‐310 to 0; 23,200 participants, 3 RCTs, moderate‐certainty evidence) slightly, and probably increase blood potassium slightly (MD 0.12 mmol/L, 95% CI 0.07 to 0.18; 784 participants, 6 RCTs, moderate‐certainty evidence), compared to regular salt. LSSS may result in little to no difference, on average, in hypertension (AE 17 fewer/1000, 95% CI ‐58 to 17; 2566 participants, 1 RCT, low‐certainty evidence) and hyperkalaemia (AE 4 more/100,000, 95% CI ‐47 to 121; 22,849 participants, 5 RCTs, moderate‐certainty evidence) compared to regular salt. The evidence is very uncertain about the effects of LSSS on blood pressure control, various cardiovascular events, stroke mortality, hypokalaemia, and other adverse events (very‐low certainty evidence). LSSS compared to regular salt in children: The evidence is very uncertain about the effects of LSSS on DBP and SBP in children. We found no evidence about the effects of LSSS on hypertension, blood pressure control, blood potassium, hyperkalaemia and hypokalaemia in children. Authors' conclusions When compared to regular salt, LSSS probably reduce blood pressure, non‐fatal cardiovascular events and cardiovascular mortality slightly in adults. However, LSSS also probably increase blood potassium slightly in adults. These small effects may be important when LSSS interventions are implemented at the population level. Evidence is limited for adults without elevated blood pressure, and there is a lack of evidence in pregnant women and people in whom an increased potassium intake is known to be potentially harmful, limiting conclusions on the safety of LSSS in the general population. We also cannot draw firm conclusions about effects of non‐discretionary LSSS implementations. The evidence is very uncertain about the effects of LSSS on blood pressure in children. Plain language summary Does using low‐sodium salt substitutes (LSSS) instead of regular salt reduce blood pressure and heart disease risks, and is it safe? Key messages • In adults, using LSSS instead of regular salt in food probably lowers blood pressure slightly. Adults using LSSS instead of regular salt probably have a slightly lower risk of non‐fatal heart conditions, such as stroke or a sudden reduced blood flow to the heart, and death from heart disease. • Using LSSS instead of regular salt probably also slightly increases the level of blood potassium (a mineral that keeps your heart beating at the right pace) in adults. This could be harmful for people who cannot effectively regulate the potassium in their bodies. Other evidence on safety is very limited. • We are not certain about effects of using LSSS instead of regular salt on blood pressure in children, or whether using LSSS is safe in children. • This evidence may not directly apply to people known to be at risk of high blood potassium, such as people with kidney problems or on certain medications. What are low‐sodium salt substitutes (LSSS)? LSSS are products with less sodium than regular salt. Amounts of sodium in LSSS are lowered by replacing some of the sodium with potassium or other minerals. LSSS may help lower risks of using regular salt, since eating lots of sodium and not enough potassium contributes to high blood pressure. Globally, high blood pressure is the largest cause of preventable deaths, mainly because it causes stroke, acute coronary syndrome (ACS; where less blood flows to the heart), and kidney problems. However, LSSS also has potential health risks. Using LSSS may lead to higher than normal blood potassium (hyperkalaemia), which causes problems with the heartbeat speed and rhythm, or can cause the heart to stop. These risks are greater in certain people, for example, those whose kidneys do not work properly to remove potassium. What did we want to find out? We wanted to find out what the effects of using LSSS instead of regular salt are on blood pressure as well as on events (stroke and ACS) and heart disease death. We also wanted to know if using LSSS instead of regular salt is safe, both in the general population and in people who are known to be at risk of high blood potassium levels. We wanted to find this out for adults, children and pregnant women. What did we do? 
We searched five electronic databases and trial registries for studies that compared using LSSS with using regular salt. We compared and summarised the results of the studies and rated our confidence in the combined evidence, based on factors such as study methods and sizes. What did we find? We found 26 trials* involving 34,961 adults and 92 children. No studies in pregnant women were found. Most trials were undertaken in rural or suburban areas, with more than half done in low‐ and middle‐income countries. Most trials included some people with high blood pressure (22); the largest included only people with a high risk of stroke. Seven trials were done in people at possible risk of high blood potassium. All trials excluded people where high potassium intake is known to be harmful, such as people with kidney problems or on certain medications. Nearly all trials (23) examined LSSS types where some sodium was replaced with potassium. The amount of sodium replaced in the various LSSS used in the trials ranged from very small (3%) to large (77%). *Trials are types of studies in which participants are assigned randomly to two or more treatment groups. This is the best way to ensure similar groups of participants. Main results In adults, LSSS probably lowers blood pressure (diastolic and systolic) slightly when compared to regular salt. Using LSSS also probably lowers risk of non‐fatal stroke, non‐fatal ACS and heart disease death slightly when compared to regular salt. However, using LSSS instead of regular salt probably also slightly increases the level of potassium in the blood. Compared to regular salt, LSSS may result in little to no difference in high blood pressure and hyperkalaemia. We could not draw any conclusions about effects of LSSS on blood pressure control, various heart disease events, death caused by stroke, lower than normal blood potassium (hypokalaemia), and other adverse events. We could not draw any conclusions about the effects or safety of using LSSS instead of regular salt in children. What are the limitations of the evidence? We are moderately confident in the evidence. Our confidence was lowered mainly because of concerns about how some trials were conducted, and whether the results apply to the general population. We are not sure about the effects and safety of LSSS in children, pregnant women, people known to have a risk of high blood potassium, or those who do not have high blood pressure. We are also unsure about the effects of LSSS when used in foods not prepared at home. Further research may change these results. How up to date is this evidence? The evidence is up‐to‐date to August 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Brand, A; Visser, ME; Schoonees, A; Naude, CE", "articleTypes": [], "doi": "10.1002/14651858.CD015207", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "9901ca9a-62da-47f9-a41f-5aa4f0eaff7f", "pmid": "", "title": "Control interventions in randomised trials among people with mental health disorders", "imported": false, "abstract": "Abstract - Background Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated. Objectives To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait‐list versus no‐treatment, (ii) usual care versus wait‐list or no‐treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait‐list or no‐treatment. Wait‐list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. Search methods In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers. Selection criteria We included randomised trials assessing patients with a mental health disorder that compared wait‐list, usual care, or placebo interventions with wait‐list or no‐treatment . Data collection and analysis Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane’s risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre‐planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random‐effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed‐effect model). Main results We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep‐wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait‐list versus no‐treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait‐list or no‐treatment and found a SMD –0.33 (95% CI ‐0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait‐list or no‐treatment was SMD −0.37 (95% CI −0.49 to −0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger’s test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD ‐0.49 (95% CI −0.64 to −0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait‐list or no‐treatment on benefits was SMD ‐0.14 (95% CI −0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD −0.21 (95% CI −0.35 to −0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep‐wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed‐effect model in a sensitivity analysis on the comparison for usual care versus wait‐list and no‐treatment, the results were significant with an SMD of –0.46 (95 % CI –0.64 to –0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains. Authors' conclusions We found marked variations in effects between placebo versus no‐treatment and wait‐list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait‐list or no‐treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research. Plain language summary Control interventions in randomised trials for people with a mental health disorder This systematic review assesses the effects of different control interventions in randomised trials including patients with a mental health disorder. In randomised trials, patients are assigned by chance to one of two or more groups – usually an experimental intervention and a control intervention. There are many types of control interventions in mental health intervention research. Some of the most common are different types of placebos that lack what is assumed to be the active component in the experimental intervention, and usual care, where patients receive the standard treatment for their mental health disorder in the area where they live. Two other types of control interventions are wait‐list or no‐treatment where patients receive no trial‐related care during the study (although some patients may receive care outside the studies). Wait‐list patients are often offered the experimental intervention after the trial has been finalised if it is likely to provide more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. We searched for randomised trials with patients with mental health disorders where wait‐list, usual care, or placebo interventions were compared with either wait‐list or no‐treatment. We looked at differences between all the types of control interventions on beneficial effects and whether they caused any adverse effects. We included 96 trials with a total of 4200 participants. Only 83 trials (3614 participants) provided usable data. Fifteen different mental health disorders were included. We found that all the trials were at high risk of bias in how they had been conducted, which reduced the interpretability of our findings. However, the risk of bias was mostly due to lack of blinding in the placebo studies, which may be seen as an aspect of the review's methodological question rather than a flaw with the review itself. We found no clinically important differences for usual care or wait‐list control interventions in the main analyses, however in our secondary analyses we found a clinically important favourable difference for usual care. In general, placebo control interventions tended to be favourable over no‐treatment or wait‐list control interventions across mental health disorders. We found no clinically important differences on adverse events. This review suggests that different control interventions have a tendency to yield very different estimates for the effects of the experimental intervention and that the choice of control intervention has a large impact on how effective a mental health treatment appears to be. Control interventions in trials with patients with mental health disorders are often poorly reported upon, and guidelines are needed to inform researchers on how to properly design, report, and interpret these trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Faltinsen, E, Todorovac, A, Staxen Bruun, L, Hróbjartsson, A, Gluud, C, Kongerslev, MT, Simonsen, E, Storebø, OJ", "articleTypes": [], "doi": "10.1002/14651858.MR000050.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.819Z" }, { "id": "9919d36d-6ea5-40c1-a323-d4098ebf80eb", "pmid": "", "title": "Pharmacotherapy for hypertension‐induced left ventricular hypertrophy", "imported": false, "abstract": "Abstract - Background Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension‐induced LVH. Objectives To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension‐induced LVH. Search methods Cochrane Hypertension’s Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) with at least 12 months’ follow‐up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension‐induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all‐cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. Data collection and analysis Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. Main results We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow‐up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention‐to‐treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add‐on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low‐certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low‐certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low‐certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low‐certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low‐certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. Authors' conclusions We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low‐certainty evidence requires that caution be used when interpreting the findings. High‐quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension‐induced LVH are warranted. Plain language summary What are the main benefits and risks of drugs for reducing blood pressure in the treatment of people with thickening of the heart muscle caused by high blood pressure? Key messages Given the lack of robust evidence, the benefits and risks of adding additional drugs for reducing blood pressure to treat people with thickening of the heart muscle and high blood pressure are unclear. It is unclear if adding drugs for reducing blood pressure causes more serious harms in patients than placebo (dummy treatment) or no treatment; however, it may increase treatment discontinuation due to unwanted effects. There is a need for future studies to better understand the benefits and harms of adding drugs for reducing blood pressure in people with thickening of the heart muscle caused by high blood pressure. What is thickening of the heart muscle? Thickening of the heart muscle is a condition where the muscle gets bigger and affects the function of the heart. This can happen when the heart has worked too hard over time and is mainly caused by high blood pressure. People with thickening of the heart muscle can experience shortness of breath, fatigue, chest pain, heart palpitations, and dizziness or fainting. How is thickening of the heart muscle treated? Thickening of the heart muscle can be treated with drugs for reducing blood pressure. What did we want to find out? We wanted to find out if adding drugs for reducing blood pressure was better than placebo or no drug treatment at preventing illness and death in people with thickening of the heart muscle and high blood pressure. We also wanted to learn if the addition of drugs for reducing blood pressure was associated with any unwanted or harmful effects. What did we do? We searched for studies that investigated the addition of drugs for reducing blood pressure compared with placebo or no drug treatment. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as methods and sizes of participant groups. What did we find? We found 3 studies that involved 930 people with thickening of the heart muscle and high blood pressure. The largest study was in 692 people, and the smallest study was in 15 people. Study participants were of both genders and on average between 66 and 75 years old. Participants were followed for between three and four years. The studies were conducted in several countries in Europe, Asia, and North and South America. One study received pharmaceutical industry funding. It is uncertain if adding drugs for reducing blood pressure has an effect on death, development of heart and blood vessel diseases, or on hospitalisation for heart failure. It is unclear if adding drugs for reducing blood pressure causes more serious harms than placebo or no drug treatment, but it may increase treatment discontinuations due to unwanted effects. It is unclear if adding drugs for reducing blood pressure has an effect on heart muscle mass. What are the limitations of the evidence? Our confidence in the evidence is lacking because of the small number of identified studies. The available evidence is based on a small percentage of people with thickening of the heart muscle and high blood pressure identified from larger populations in the included studies. Further evidence may change our results. How up‐to‐date is the evidence? The evidence is current to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Leache, L; Gutiérrez-Valencia, M; Finizola, RM; Infante, E; Finizola, B; Pardo Pardo, J; Flores, Y; Granero, R; Arai, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD012039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "991fe3d4-f2b6-4a9c-adcc-b34717746f52", "pmid": "", "title": "Inhaled hyperosmolar agents for bronchiectasis", "imported": false, "abstract": "Abstract - Background Mucus retention in the lungs is a prominent feature of bronchiectasis. The stagnant mucus becomes chronically colonised with bacteria, which elicit a host neutrophilic response. This fails to eliminate the bacteria, and the large concentration of host‐derived protease may contribute to the airway damage. The sensation of retained mucus is itself a cause of suffering, and the failure to maintain airway sterility probably contributes to the frequent respiratory infections experienced by many patients. Hypertonic saline inhalation is known to accelerate tracheobronchial clearance in many conditions, probably by inducing a liquid flux into the airway surface, which alters mucus rheology in a way favourable to mucociliary clearance. Inhaled dry powder mannitol has a similar effect. Such agents are an attractive approach to the problem of mucostasis, and deserve further clinical evaluation. Objectives To determine whether inhaled hyperosmolar substances are effective in the treatment of bronchiectasis. Search methods We searched the Cochrane Airways Group Specialised Register, trials registries, and the reference lists of included studies and review articles. Searches are current up to April 2014. Selection criteria Any randomised controlled trial (RCT) using hyperosmolar inhalation in patients with bronchiectasis not caused by cystic fibrosis. Data collection and analysis Two review authors assessed studies for suitability. We used standard methods recommended by The Cochrane Collaboration. Main results Eleven studies met the inclusion criteria of the review (1021 participants). Five studies on 833 participants compared inhaled mannitol with placebo but poor outcome reporting meant we could pool very little data and most outcomes were reported by only one study. One 12‐month trial on 461 participants provided results for exacerbations and demonstrated an advantage for mannitol in terms of time to first exacerbation (median time to exacerbation 165 versus 124 days for mannitol and placebo respectively (hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.63 to 0.96, P = 0.022) and number of days on antibiotics for bronchiectasis exacerbations was significantly better with mannitol (risk ratio (RR) 0.76, 95%CI 0.58 to 1.00, P = 0.0496). However, exacerbation rate per year was not significantly different between mannitol and placebo (RR 0.92 95% CI 0.78 to 1.08). The quality of this evidence was rated as moderate. There was also an indication, from only three trials, again based on moderate quality evidence, that mannitol improves health‐related quality of life (mean difference (MD) ‐2.05; 95% CI ‐3.69 to ‐0.40). An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo (OR 0.96; 95% CI 0.61 to 1.51). Two additional small trials on 25 participants compared mannitol versus no treatment and the data from these studies were inconclusive. Four studies (combined N = 113) compared hypertonic saline versus isotonic saline. On most outcomes there were conflicting results and the opportunities for the statistical aggregation of data from studies was very limited. It is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Authors' conclusions There is an indication from a single, large, unpublished study that inhaled mannitol increases time to first exacerbation in patients with bronchiectasis. In patients with near normal lung function, spirometry does not change dramatically with mannitol and adverse events are not more frequent than placebo. Further investigation is required in a patient population with impaired lung function. It is not possible to draw firm conclusions regarding the effect of nebulised hypertonic saline due to significant differences in the methodology, patient groups, and findings amongst the limited data available. The data suggest that it is unlikely to have benefit over isotonic saline in patients with milder disease, and hence future studies should test its use in those with more severe disease Plain language summary Inhaled hyperosmolar agents for bronchiectasis Review question We wanted to know if inhaled hyperosmolar agents ‐ treatments which help people cough up sputum ‐ may be helpful for people with bronchiectasis. We only included trials on people who had bronchiectasis and who did not have cystic fibrosis. Therefore we are unable to draw any conclusions for people with cystic fibrosis. Background Bronchiectasis is a lung condition that usually develops after a series of lung problems (such as childhood infections, problems in the lung structure, tuberculosis, and cystic fibrosis). A lot of mucus (phlegm) collects in the lungs, causing discomfort and the need to cough it up. The phlegm also collects bacteria, which can add to breathing difficulties and make people very ill by causing recurring lung infections that are difficult to clear with antibiotics. Breathing in (inhaling) hypertonic saline (salt solutions with a greater salt content than blood) liquids may help clear this mucus, as may the drug mannitol (inhaled in dry powder form). This is because the concentrated salt or sugar (mannitol) draws water into the mucus in the lung and makes it thinner and easier to cough out. Study characteristics We found 11 randomised controlled trials on 1021 participants that compared inhaled hyperosmolar agents versus no mucolytic treatment. Five studies compared inhaled mannitol versus placebo (with a total of 883 participants) and two very small studies (with a total of just 25 participants) compared inhaled mannitol with no treatment. We also found four studies (with a total of 113 participants) that compared hypertonic saline with isotonic (normal) saline. Key results For the comparison between mannitol and placebo only one study (a 12‐month trial with 461 participants) provided information on the number of people who had an exacerbation (or flare up) over the course of a year. This study showed that people who were treated with mannitol had 8% fewer exacerbations on average compared with placebo. Overall, we felt the quality of this evidence was moderate and new trials would be likely to change either how effective we think the treatment is or how confident we are about it. Three trials assessed the effect of mannitol on health‐related quality of life, and again the quality of the evidence was rated as moderate. An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo The trials comparing hypertonic saline with isotonic saline had conflicting results for most of the outcomes of interest. Because we were unable to combine the data, it is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Our analysis of adverse events between hypertonic saline versus isotonic saline showed no significant difference however this was based on a single study and the quality of the evidence was moderate. Quality of the evidence Details of how the patients in the trials were allocated to receive mannitol or not was clearly described in only one of the studies, and similarly only one of the hypertonic saline versus isotonic saline studies provided this information. The general lack of information on this point was considered carefully in the review in relation to our level of uncertainty in interpreting the results. Taking this into account, the quality of evidence was generally regarded as moderate both for the mannitol and hypertonic saline studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hart, A, Sugumar, K, Milan, SJ, Fowler, SJ, Crossingham, I", "articleTypes": [], "doi": "10.1002/14651858.CD002996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.109Z" }, { "id": "992b98ed-7ff4-4932-b8b6-00824703816f", "pmid": "", "title": "Colchicine for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The development of severe coronavirus disease 2019 (COVID‐19) and poor clinical outcomes are associated with hyperinflammation and a complex dysregulation of the immune response. Colchicine is an anti‐inflammatory medicine and is thought to improve disease outcomes in COVID‐19 through a wide range of anti‐inflammatory mechanisms. Patients and healthcare systems need more and better treatment options for COVID‐19 and a thorough understanding of the current body of evidence. Objectives To assess the effectiveness and safety of Colchicine as a treatment option for COVID‐19 in comparison to an active comparator, placebo, or standard care alone in any setting, and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising CENTRAL, MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv), Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index), and WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions to 21 May 2021. Selection criteria We included randomised controlled trials evaluating colchicine for the treatment of people with COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We excluded studies investigating the prophylactic effects of colchicine for people without severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection but at high risk of SARS‐CoV‐2 exposure. Data collection and analysis We followed standard Cochrane methodology. We used the Cochrane risk of bias tool (ROB 2) to assess bias in included studies and GRADE to rate the certainty of evidence for the following prioritised outcome categories considering people with moderate or severe COVID‐19: all‐cause mortality, worsening and improvement of clinical status, quality of life, adverse events, and serious adverse events and for people with asymptomatic infection or mild disease: all‐cause mortality, admission to hospital or death, symptom resolution, duration to symptom resolution, quality of life, adverse events, serious adverse events. Main results We included three RCTs with 11,525 hospitalised participants (8002 male) and one RCT with 4488 (2067 male) non‐hospitalised participants. Mean age of people treated in hospital was about 64 years, and was 55 years in the study with non‐hospitalised participants. Further, we identified 17 ongoing studies and 11 studies completed or terminated, but without published results. Colchicine plus standard care versus standard care (plus/minus placebo) Treatment of hospitalised people with moderate to severe COVID‐19 All‐cause mortality : colchicine plus standard care probably results in little to no difference in all‐cause mortality up to 28 days compared to standard care alone (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.93 to 1.08; 2 RCTs, 11,445 participants; moderate‐certainty evidence). Worsening of clinical status : colchicine plus standard care probably results in little to no difference in worsening of clinical status assessed as new need for invasive mechanical ventilation or death compared to standard care alone (RR 1.02, 95% CI 0.96 to 1.09; 2 RCTs, 10,916 participants; moderate‐certainty evidence). Improvement of clinical status : colchicine plus standard care probably results in little to no difference in improvement of clinical status, assessed as number of participants discharged alive up to day 28 without clinical deterioration or death compared to standard care alone (RR 0.99, 95% CI 0.96 to 1.01; 1 RCT, 11,340 participants; moderate‐certainty evidence). Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is very uncertain about the effect of colchicine on adverse events compared to placebo (RR 1.00, 95% CI 0.56 to 1.78; 1 RCT, 72 participants; very low‐certainty evidence). Serious adverse events : the evidence is very uncertain about the effect of colchicine plus standard care on serious adverse events compared to standard care alone (0 events observed in 1 RCT of 105 participants; very low‐certainty evidence). Treatment of non‐hospitalised people with asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 All‐cause mortality : the evidence is uncertain about the effect of colchicine on all‐cause mortality at 28 days (Peto odds ratio (OR) 0.57, 95% CI 0.20 to 1.62; 1 RCT, 4488 participants; low‐certainty evidence). Admission to hospital or death within 28 days : colchicine probably slightly reduces the need for hospitalisation or death within 28 days compared to placebo (RR 0.80, 95% CI 0.62 to 1.03; 1 RCT, 4488 participants; moderate‐certainty evidence). Symptom resolution : we identified no studies reporting this outcome. Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is uncertain about the effect of colchicine on adverse events compared to placebo . Results are from one RCT reporting treatment‐related events only in 4412 participants (low‐certainty evidence). Serious adverse events : colchicine probably slightly reduces serious adverse events (RR 0.78, 95% CI 0.61 to 1.00; 1 RCT, 4412 participants; moderate‐certainty evidence). Colchicine versus another active treatment (e.g. corticosteroids, anti‐viral drugs, monoclonal antibodies) No studies evaluated this comparison. Different formulations, doses, or schedules of colchicine No studies assessed this. Authors' conclusions Based on the current evidence, in people hospitalised with moderate to severe COVID‐19 the use of colchicine probably has little to no influence on mortality or clinical progression in comparison to placebo or standard care alone. We do not know whether colchicine increases the risk of (serious) adverse events. We are uncertain about the evidence of the effect of colchicine on all‐cause mortality for people with asymptomatic infection or mild disease. However, colchicine probably results in a slight reduction of hospital admissions or deaths within 28 days, and the rate of serious adverse events compared with placebo. None of the studies reported data on quality of life or compared the benefits and harms of colchicine versus other drugs, or different dosages of colchicine. We identified 17 ongoing and 11 completed but not published RCTs, which we expect to incorporate in future versions of this review as their results become available. Editorial note: due to the living approach of this work, we monitor newly published results of RCTs on colchicine on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Is colchicine an effective treatment for people with COVID‐19? Key messages ○ In hospitalised people with moderate to severe COVID‐19, colchicine probably has little to no benefit; we are uncertain about its side effects. ○In non‐hospitalised people with no symptoms or mild COVID‐19, we are uncertain whether colchicine prevents deaths or side effects, however it probably reduces the need for hospitalisation or death and serious side effects slightly. ○ Future studies should assess quality of life in people with no symptoms or mild COVID‐19 and non‐serious side effects and compare colchicine to other medicines for COVID‐19, such as corticosteroids. What is colchicine? Colchicine is a medicine used to reduce swelling and inflammation and may consequently relieve pain. It is often used to treat gout, a condition where people’s joints become swollen and painful. On the other hand, colchicine can be harmful to people with some health conditions, such as kidney or liver problems, or if you take too much of it. How might colchicine treat COVID‐19? Since colchicine is an anti‐inflammatory drug; researchers are interested in whether it might help with reducing inflammation caused by COVID‐19. What did we want to find out? We wanted to know whether colchicine is an effective treatment for people with COVID‐19 compared to placebo (a treatment that looks and tastes the same as colchicine but with no active ingredient) or usual care alone. We looked at people with moderate or severe disease being treated in hospital or with mild disease being treated in the community. We were particularly interested in the effects of colchicine on: ○ number of deaths; ○ whether people’s condition worsened or improved; ○ quality of life; ○ serious and non‐serious side effects What did we do? We searched for studies that compared colchicine together with usual care to usual care (plus/minus placebo). Studies could take place anywhere in the world and include people with mild or no symptoms, moderate or severe COVID‐19, of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our certainty in the evidence, based on factors such as study methods and sizes. What did we find? We identified four eligible randomised trials. Three included 11,525 hospitalised people and one included 4488 non‐hospitalised people. For hospitalised people, the average age was 64 years, and for non‐hospitalised people, the average age was 55 years. Two studies compared colchicine and usual care with usual care alone and 2 studies compared colchicine with usual care and placebo. None of the studies reported quality of life. We also found 17 ongoing studies and 11 completed but unpublished studies. Main results Hospitalised people with moderate to severe COVID‐19 (3 studies, 11,525 people) ○Colchicine probably does not reduce deaths in the 28 days after treatment (2 studies, 11,445 people). ○Colchicine probably does not prevent the worsening of patients’ condition (2 studies, 10,916 people) and probably does not improve it (1 study, 11,340 people). ○We are very uncertain about the effect of colchicine on side effects and serious side effects (2 studies, 177 people). Non‐hospitalised people with no symptoms or mild COVID‐19 (1 study, 4488 people) ○We are uncertain whether colchicine prevents deaths up to 28 days after treatment. ○Colchicine probably slightly reduces the risk of hospitalisation or death. ○We are uncertain about the effect of colchicine on side effects, but it probably slightly reduces serious side effects. What are the limitations of the evidence? Our certainty in the evidence is limited. Two studies did not use a placebo, so everybody knew who was treated with colchicine, which could influence the results. There were too few events for non‐hospitalised people, such as admissions to hospital and deaths, to be certain about the evidence. Studies used different ways to assess and report unwanted effects, so we could not combine studies into a single result to make a judgement. How up to date is this evidence? The evidence is up to date to 21 May 2021. Editorial note: this is a living systematic review. We search for new evidence every week and update the review when we identify relevant new evidence. Refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Mikolajewska, A; Fischer, A-L; Piechotta, V; Mueller, A; Metzendorf, M-I; Becker, M; Dorando, E; Pacheco, RL; Martimbianco, ALC; Riera, R; Skoetz, N; Stegemann, M", "articleTypes": [], "doi": "10.1002/14651858.CD015045", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "993536bc-830a-4f20-bac8-af7b860db6a3", "pmid": "", "title": "Short courses of antibiotics for children and adults with bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is an important cause of respiratory morbidity in both developing and developed countries. Antibiotics are considered standard therapy in the treatment of this condition but it is unknown whether short courses (four weeks or less) are efficacious. Objectives To determine whether short courses of antibiotics (i.e. less than or equal to four weeks) for treatment of acute and stable state bronchiectasis, in adults and children, are efficacious when compared to placebo or usual care. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library ), MEDLINE, EMBASE, OLDMEDLINE, CINAHL, AMED and PsycINFO and handsearching of respiratory journals and meeting abstracts were performed by the Cochrane Airways Group up to February 2011. Selection criteria Only randomised controlled trials were considered. Adults and children with bronchiectasis (defined clinically or radiologically) were included. Patients with cystic fibrosis were excluded. Data collection and analysis Two review authors independently reviewed the titles, abstracts and citations to assess eligibility for inclusion. Only one study fulfilled the inclusion criteria and thus meta‐analysis could not be performed. Main results The single eligible study showed a small benefit, when compared to placebo, of four weeks of inhaled antibiotic therapy in adults with bronchiectasis and pseudomonas in their sputum. There were no studies in children and no studies on oral or intravenous antibiotics. Authors' conclusions There is insufficient evidence in the current literature to make reasonable conclusions about the efficacy of short course antibiotics in the management of adults and children with bronchiectasis. Until further evidence is available, adherence to current treatment guidelines is recommended. Plain language summary Short courses of antibiotics for children and adults with bronchiectasis There is a paucity of evidence to conclude whether short courses of antibiotics (i.e. less than or equal to four weeks) are equivalent or superior to placebo in the treatment of stable or exacerbation state bronchiectasis. One single study showed some benefit of short‐course inhaled antibiotics over placebo, in terms of microbiological response and subjective improvement in medical condition, although this was balanced against an increase in adverse effects and antimicrobial resistance in the treatment group. Given the potential benefits of shorter duration antibiotic therapy in bronchiectasis, further RCTs are clearly needed to answer this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Wurzel, D, Marchant, JM, Yerkovich, ST, Upham, JW, Masters, IB, Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD008695.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.754Z" }, { "id": "99593b20-f018-4cb9-9ec7-4396436d5f53", "pmid": "", "title": "Impact of active placebo controls on estimated drug effects in randomised trials: a systematic review of trials with both active placebo and standard placebo", "imported": false, "abstract": "Abstract - Background An estimated 60% of pharmacological randomised trials use placebo control interventions to blind (i.e. mask) participants. However, standard placebos do not control for perceptible non‐therapeutic effects (i.e. side effects) of the experimental drug, which may unblind participants. Trials rarely use active placebo controls, which contain pharmacological compounds designed to mimic the non‐therapeutic experimental drug effects in order to reduce the risk of unblinding. A relevant improvement in the estimated effects of active placebo compared with standard placebo would imply that trials with standard placebo may overestimate experimental drug effects. Objectives We aimed to estimate the difference in drug effects when an experimental drug is compared with an active placebo versus a standard placebo control intervention, and to explore causes for heterogeneity. In the context of a randomised trial, this difference in drug effects can be estimated by directly comparing the effect difference between the active placebo and standard placebo intervention. Search methods We searched PubMed, CENTRAL, Embase, two other databases, and two trial registries up to October 2020. We also searched reference lists and citations and contacted trial authors. Selection criteria We included randomised trials that compared an active placebo versus a standard placebo intervention. We considered trials both with and without a matching experimental drug arm. Data collection and analysis We extracted data, assessed risk of bias, scored active placebos for adequacy and risk of unintended therapeutic effect, and categorised active placebos as unpleasant, neutral, or pleasant. We requested individual participant data from the authors of four cross‐over trials published after 1990 and one unpublished trial registered after 1990. Our primary inverse‐variance, random‐effects meta‐analysis used standardised mean differences (SMDs) of active versus standard placebo for participant‐reported outcomes at earliest post‐treatment assessment. A negative SMD favoured the active placebo. We stratified analyses by trial type (clinical or preclinical) and supplemented with sensitivity and subgroup analyses and meta‐regression. In secondary analyses, we investigated observer‐reported outcomes, harms, attrition, and co‐intervention outcomes. Main results We included 21 trials (1462 participants). We obtained individual participant data from four trials. Our primary analysis of participant‐reported outcomes at earliest post‐treatment assessment resulted in a pooled SMD of −0.08 (95% confidence interval (CI) −0.20 to 0.04; I 2 = 31%; 14 trials), with no clear difference between clinical and preclinical trials. Individual participant data contributed 43% of the weight of this analysis. Two of seven sensitivity analyses found more pronounced and statistically significant differences; for example, in the five trials with low overall risk of bias, the pooled SMD was −0.24 (95% CI −0.34 to −0.13). The pooled SMD of observer‐reported outcomes was similar to the primary analysis. The pooled odds ratio (OR) for harms was 3.08 (95% CI 1.56 to 6.07), and for attrition, 1.22 (95% CI 0.74 to 2.03). Co‐intervention data were limited. Meta‐regression found no statistically significant association with adequacy of the active placebo or risk of unintended therapeutic effect. Authors' conclusions We did not find a statistically significant difference between active and standard placebo control interventions in our primary analysis, but the result was imprecise and the CI compatible with a difference ranging from important to irrelevant. Furthermore, the result was not robust, because two sensitivity analyses produced a more pronounced and statistically significant difference. We suggest that trialists and users of information from trials carefully consider the type of placebo control intervention in trials with high risk of unblinding, such as those with pronounced non‐therapeutic effects and participant‐reported outcomes. Plain language summary Do treatment effects in randomised trials differ when using active placebo compared to standard placebo? Key messages 1. We found no clear difference in effect between active and standard placebos, but we are very uncertain about the results. 2. We suggest that researchers carefully consider the type of placebo when investigating medicines with clear side effects. What are standard placebos and active placebos? Blinding (or masking) is an important part of randomised trials and ensures that participants and healthcare providers are not influenced by knowing whether the participant is receiving the experimental treatment. If they had this knowledge, they might unintentionally overestimate (or underestimate) the effect of the treatment. One method of blinding is to give the non‐treated group of participants a placebo, which looks like the medicine (e.g. a tablet of similar shape, colour, smell, taste, and texture) but does not contain its active ingredients. Blinding with a placebo may not always be successful. The treatment may have side effects that distinguish it from the placebo so that the treatment effect is still not measured accurately. For this reason, some trials use active placebos, which mimic some of the side effects of the experimental medicine. However, it is unclear whether the choice of placebo type actually makes a difference to the treatment effects. What did we want to find out? We wanted to find out whether treatment effects in randomised trials differ when using active placebos compared to standard placebos. What did we do? We collected and analysed trials that directly compared the two types of placebo, or that compared both placebos with an experimental medicine. If people receiving active placebo experience better results than those receiving standard placebo, this difference might be due to them believing that they are receiving the experimental medicine. It would also mean that in trials that compare a medicine with standard placebo, the beneficial effect of the medicine is exaggerated. This is important if the measured benefits of the treatment are small or moderate and thus especially sensitive to changes in the methods used for the trial. What did we find? We included 21 trials in this review, covering subjects such as pain and psychiatry. We found no clear difference between the two types of placebo in participant‐reported outcomes (such as pain intensity). However, because the result was uncertain, the possible range of this result included both no difference and a potentially important difference in favour of active placebo. When we limited our analysis to higher‐quality trials, active placebos were more beneficial than standard placebos, but these trials were not typical clinical trials and might not be applicable to clinical scenarios.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Laursen, DRT; Nejstgaard, CH; Bjørkedal, E; Frost, AD; Hansen, MR; Paludan-Müller, AS; Prosenz, J; Werner, CP; Hróbjartsson, A", "articleTypes": [], "doi": "10.1002/14651858.MR000055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "995a68ed-d3ef-4bb1-afd2-af6109515e48", "pmid": "", "title": "Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide and its prevalence among children has significantly increased over the last two decades. Prevalence and severity are related to age, with children of school age most commonly affected. Objectives To assess the effectiveness and adverse event profile of antihistamines (oral or topical) used as an adjunct to topical nasal steroids for intermittent and persistent allergic rhinitis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 21 September 2009. Selection criteria Randomised controlled trials (RCTs) in children under the age of 18 with a history of allergic rhinitis, with or without allergic conjunctivitis or asthma, comparing topical nasal steroids with antihistamines to topical nasal steroids only. Data collection and analysis Two review authors independently screened studies, extracted data and assessed risk of bias. Main results One study including 24 participants met the inclusion criteria for this review. This study compared the administration of topical nasal steroids with oral antihistamines to topical nasal steroids only in children, but it did not provide sufficient data to address the clinical question of this review. Authors' conclusions In view of the lack of evidence for the benefit or lack of benefit of antihistamine add‐on therapy with topical nasal steroids for children with intermittent or persistent allergic rhinitis, it is important that clinicians are mindful of the adverse effects of antihistamines and the additional costs that may be incurred. Plain language summary Antihistamines as an addition to topical nasal steroids for allergic rhinitis in children Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide. Seasonal allergic rhinitis (hay fever) is most common around springtime. The symptoms are mostly sneezing, a runny nose and watery eyes. We looked for trials that compared antihistamines (either oral or topical) in addition to a topical nasal steroid with a topical nasal steroid alone in children who had allergic rhinitis. We wanted to know whether adding antihistamines (oral or topical) in the therapy of children with allergic rhinitis who already use topical nasal steroids would have additional benefits for them. We found one trial that had been carried out in children comparing oral antihistamines in addition to topical nasal steroids with topical nasal steroids alone but it did not provide sufficient data to draw any conclusions. Most of the trials focused only on adults or included a small number of children. Unfortunately, the trials which included children along with adults did not report whether there were any differences in the effect of treatment or adverse effects in children in comparison with adults. We are therefore unable to draw a conclusion as to whether or not this combination therapy has beneficial effect in children with allergic rhinitis or whether the benefits are acceptable in terms of the adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Nasser, M; Fedorowicz, Z; Aljufairi, H; McKerrow, W", "articleTypes": [], "doi": "10.1002/14651858.CD006989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "996e2dd2-6a20-4bce-ad34-9405f477a2a5", "pmid": "", "title": "Zinc supplements for preventing otitis media", "imported": false, "abstract": "Abstract - Background Otitis media is inflammation of the middle ear and is usually caused by infection. It affects people of all ages but is particularly common in young children. Around 164 million people worldwide have long‐term hearing loss caused by this condition, 90% of them in low‐income countries. As zinc supplements prevent pneumonia in disadvantaged children, we wanted to investigate whether zinc supplements could also prevent otitis media. Objectives To evaluate whether zinc supplements prevent otitis media in adults and children of different ages. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (1950 to February week 4, 2014) and EMBASE (1974 to March 2014). Selection criteria Randomised, placebo‐controlled trials of zinc supplements given at least once a week for at least a month for preventing otitis media. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of the included trials and extracted and analysed data. We summarised results using risk ratios (RRs) or rate ratios for dichotomous data and mean differences (MDs) for continuous data. We combined trial results where appropriate. Main results No new trials were identified for inclusion in this update. We identified 12 trials for inclusion, 10 of which contributed outcomes data. There were a total of 6820 participants. In trials of healthy children living in low‐income communities, two trials did not demonstrate a significant difference between the zinc‐supplemented and placebo groups in the numbers of participants experiencing an episode of definite otitis media during follow‐up (3191 participants); another trial showed a significantly lower incidence rate of otitis media in the zinc group (rate ratio 0.69, 95% confidence interval (CI) 0.61 to 0.79, n = 1621). A small trial of 39 infants undergoing treatment for severe malnutrition suggested a benefit of zinc for the mean number of episodes of otitis media (mean difference (MD) ‐1.12 episodes, 95% CI ‐2.21 to ‐0.03). Zinc supplements did not seem to cause any serious adverse events but a small minority of children were reported to have vomited shortly after ingestion of the supplements. The trial evidence included is generally of good quality, with a low risk of bias. Authors' conclusions Evidence on whether zinc supplementation can reduce the incidence of otitis media in healthy children under the age of five years living in low‐ and middle‐income countries is mixed. There is some evidence of benefit in children being treated for marasmus (severe malnutrition), but this is based on one small trial and should therefore be treated with caution. Plain language summary Zinc supplements for preventing middle ear infections Background Middle ear infections are common, especially among young children, usually causing earache and some temporary (occasionally permanent) hearing loss. Zinc is an essential micronutrient, which has a role in the optimal functioning of the immune system and resistance to infection. It must be consumed regularly as it cannot be stored in the body. Some people, especially children in low‐ and middle‐income countries, may not have adequate zinc intake from food alone. Researchers have examined the potential role of zinc supplements in preventing infective illnesses. Therefore we wanted to discover whether zinc supplements have any role in preventing middle ear infections. Study characteristics The review authors searched the medical literature for studies up to March 2014. We searched for trials which compared middle ear infections in people randomly selected to receive zinc supplements or who did not receive supplements. We found 10 eligible studies, all conducted amongst young children. The total number of participants was 6820. Nine trials were conducted in low‐ and middle‐income countries. Seven trials were conducted on healthy children. Participants included both males and females. Results The results of the trials provided no convincing evidence that zinc supplements reduce the occurrence of middle ear infections in healthy children. However, in one small study of severely malnourished children, those receiving zinc supplements had fewer middle ear infections. The only adverse effect was vomiting. Quality of evidence The trial evidence included is generally of good quality, with a low risk of bias. All the included trials included otitis media only as a secondary outcome. Therefore, there was a potential to miss trials which were less publicised or less well indexed within the electronic databases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Gulani, A; Sachdev, HS", "articleTypes": [], "doi": "10.1002/14651858.CD006639.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "99784b5a-fb68-49c2-94c0-84ab87006aba", "pmid": "", "title": "Community‐based supplementary feeding for food insecure, vulnerable and malnourished populations – an overview of systematic reviews", "imported": false, "abstract": "Abstract - Background Supplementary feeding may help food insecure and vulnerable people by optimising the nutritional value and adequacy of the diet, improving quality of life and improving various health parameters of disadvantaged families. In low‐ and middle‐income countries (LMIC), the problems supplementary feeding aims to address are entangled with poverty and deprivation, the programmes are expensive and delivery is complicated. Objectives 1. To summarise the evidence from systematic reviews of supplementary feeding for food insecure, vulnerable and malnourished populations, including children under five years of age, school‐aged children, pregnant and lactating women, people with HIV or tuberculosis (or both), and older populations. 2. To describe and explore the effects of supplementary feeding given to people in these groups, and to describe the range of outcomes between reviews and range of effects in the different groups. Methods In January 2017, we searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase and nine other databases. We included systematic reviews evaluating community‐based supplementary feeding, and concerning food insecure, vulnerable and malnourished populations. Two review authors independently undertook selection of systematic reviews, data extraction and 'Risk of bias' assessment. We assessed review quality using the AMSTAR tool, and used GRADEpro 'Summary of findings' tables from each review to indicate the certainty of the evidence for the main comparisons. We summarised review findings in the text and reported the data for each outcome in additional tables. We also used forest plots to display results graphically. Main results This overview included eight systematic reviews (with last search dates between May 2006 and February 2016). Seven were Cochrane Reviews evaluating interventions in pregnant women; children (aged from birth to five years) from LMIC; disadvantaged infants and young children (aged three months to five years); children with moderate acute malnutrition (MAM); disadvantaged school children; adults and children who were HIV positive or with active tuberculosis (with or without HIV). One was a non‐Cochrane systematic review in older people with Alzheimer's disease. These reviews included 95 trials relevant to this overview, with the majority (74%) of participants from LMIC. The number of included participants varied between 91 and 7940 adults, and 271 and more than 12,595 children. Trials included a wide array of nutritional interventions that varied in duration, frequency and format, with micronutrients often reported as cointerventions. Follow‐up ranged from six weeks to two years; three trials investigated outcomes at four to 17 years of age. All reviews were rated as high quality (AMSTAR score between eight and 11). The GRADE certainty ratings ranged from very low to moderate for individual comparisons, with the evidence often comprising only one or two small trials, thereby resulting in many underpowered analyses (too small to detect small but important differences). The main outcome categories reported across reviews were death, anthropometry (adults and children) and other markers of nutritional status, disease‐related outcomes, neurocognitive development and psychosocial outcomes, and adverse events. Mortality data were limited and underpowered in meta‐analysis in all populations (children with MAM, in children with HIV, and in adults with tuberculosis) with the exception of balanced energy and protein supplementation in pregnancy, which may have reduced the risk of stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94; 5 trials, 3408 women). Supplementation in pregnancy also improved infant birth weight (mean difference (MD) 40.96 g, 95% CI 4.66 to 77.26; 11 trials, 5385 participants) and reduced risk of infants born small‐for‐gestational age (RR 0.79, 95% CI 0.69 to 0.90; 7 trials, 4408 participants). These effects did not translate into demonstrable long‐term benefits for children in terms of growth and neurocognitive development in the one to two trials reporting on longer‐term outcomes. In one study (505 participants), high‐protein supplementation was associated with increased risk of small‐for‐gestational age babies. Effects on growth in children were mixed. In children under five years of age from LMIC, one review found that supplementary feeding had a little or no effect on child growth; however, a more recent review in a similar population found that those who received food supplementation gained an average of 0.12 kg more in weight (MD 0.12 kg, 95% CI 0.05 to 0.18; 9 trials, 1057 participants) and 0.27 cm more in height (MD 0.27 cm, 95% CI 0.07 to 0.48; 9 trials, 1463 participants) than those who were not supplemented. Supplementary food was generally more effective for younger children (younger than two years of age) and for those who were poorer or less well‐nourished. In children with MAM, the provision of specially formulated food improved their weight, weight‐for‐height z scores and other key outcomes such as recovery rate (by 29%), as well as reducing the number of participants dropping out (by 70%). In LMIC, school meals seemed to lead to small benefits for children, including improvements in weight z scores, especially in children from lower‐income countries, height z scores, cognition or intelligence quotient tests, and maths and spelling performance. Supplementary feeding in adults who were HIV positive increased the daily energy and protein intake compared to nutritional counselling alone. Supplementation led to an initial improvement in weight gain or body mass index but did not seem to confer long‐term benefit. In adults with tuberculosis, one small trial found a significant benefit on treatment completion and sputum conversion rate. There were also significant but modest benefits in terms of weight gain (up to 2.60 kg) during active tuberculosis. The one study included in the Alzheimer's disease review found that three months of daily oral nutritional supplements improved nutritional outcomes in the intervention group. There was little or no evidence regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes. Authors' conclusions Considering the current evidence base included, supplementary food effects are modest at best, with inconsistent and limited mortality evidence. The trials reflected in the reviews mostly reported on short‐term outcomes and across the whole of the supplementation trial literature it appears important outcomes, such as quality of life and cost of programmes, are not systematically reported or summarised. Plain language summary Supplementary feeding for groups of people that are food insecure, vulnerable and malnourished What was the aim of this review? To summarise the effect of supplementary feeding on populations that were food insecure, vulnerable and malnourished. The overview authors found eight systematic reviews examining supplementary feeding in a variety of populations. Key messages Across a range of vulnerable populations, supplementary feeding programmes sometimes show modest benefit in nutritional outcomes. In a few studies examining mortality (death), effects were either small or absent, and research mostly looked at short‐term effects. What was studied in the review? Supplementary feeding means providing extra food to people or families over and above their home diet and has been used in populations that are food insecure (limited access to adequate and nutritious food) and vulnerable (including women and young children; school‐aged children; people living with diseases such as tuberculosis, HIV, and Alzheimer's disease; and older people) to improve their health and quality of life. What are the main results of the review? The evidence presented here was current to January 2017. We found eight systematic reviews to include in this summary. These reviews included 95 studies (including up to 7940 adults, and more than 12,595 children in a few studies). Most of the included studies lasted from six weeks to two years, with only three studies following people for longer periods of time (up to 17 years). In these reviews, there were a wide range of different types of supplementary feeding given to vulnerable groups over different periods of time, and often in combination with vitamins or minerals. In pregnancy, we found that energy and protein supplements that were balanced (i.e. providing adequate amounts of energy and nutrients, in this case protein) may have decreased the rate of stillbirth (death or loss of a baby before or during delivery), improved infant birth weight and reduced the risk of infants born small‐for‐gestational age (infants that are smaller than expected). We observed no long‐term benefits for children in terms of growth and cognitive (intellectual) development (although very few studies reported long‐term effects). High‐protein supplements (containing protein in higher amounts) were associated with risk and harm (increased risk of small‐for‐gestational age babies). We found that the effects of supplementary feeding on growth in children were varied. In children under five years of age from low‐ and middle‐income countries, supplementary feeding had a small impact on child growth. We observed some benefits in terms of weight and height gains, especially in younger children (those younger than two years of age) and in those who were poorer or less well‐nourished (or both). Some benefit could be seen in children with moderate acute malnutrition in terms of weight gain, other growth factors and recovery rate. School meals seemed to lead to a number of small benefits in school children (including improvements in weight, height, intelligence tests, and maths and spelling performance). Supplementary feeding in adults who were HIV positive increased the daily intake of energy and protein and led to an early improvement in weight gain or body mass index (measure of whether someone is overweight or underweight), or both, but did not seem to lead to long‐term benefits (although few studies reported long‐term effects). In adults with tuberculosis (serious infectious lung disease), we observed small benefits in terms of weight gain during active tuberculosis. In Alzheimer's disease (a type of dementia), providing a daily oral nutrition supplement for three months improved nutritional outcomes (such as weight and energy intake). There was little or no evidence available regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Visser, J; McLachlan, MH; Maayan, N; Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD010578.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "99860fd9-1227-40f7-b00c-d89e70bd80cd", "pmid": "", "title": "Management of gag reflex for patients undergoing dental treatment", "imported": false, "abstract": "Abstract - Background The gag reflex is an involuntary defence mechanism to protect the pharynx and throat from foreign objects. Gagging is a common problem encountered during dental treatment, making therapeutic procedures distressing and often difficult or even impossible to perform. Various interventions can be used to control the gag reflex: anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behavioural therapies, acupressure, acupuncture, laser, and prosthetic devices. This is an update of the Cochrane Review first published in 2015. Objectives To assess the effects of pharmacological and non‐pharmacological interventions for the management of gagging in people undergoing dental treatment. Search methods Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register (to 18 March 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2) in the Cochrane Library (searched 18 March 2019), MEDLINE Ovid (1946 to 18 March 2019), Embase Ovid (1980 to 18 March 2019), CINAHL EBSCO (1937 to 18 March 2019), AMED Ovid (1985 to 18 March 2019), and the proceedings of the International Association for Dental Research (IADR) online (2001 to 18 March 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We also conducted forwards citation searching on the included studies via Google Scholar. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs), involving people who were given a pharmacological or non‐pharmacological intervention to manage gagging that interfered with dental treatment. We excluded quasi‐RCTs. We excluded trials with participants who had central or peripheral nervous system disorders, who had oral lesions or were on systemic medications that might affect the gag sensation, or had undergone surgery which might alter anatomy permanently. Data collection and analysis We independently selected trials, extracted data, and assessed risk of bias. We followed Cochrane's statistical guidelines. We assessed the overall certainty of the evidence using GRADE. Main results We included four trials at unclear risk of bias with 328 participants (263 adults and 65 children who were four years or older), in which one trial compared acupuncture and acupressure (with thumb, device and sea band) at P6 (point located three‐finger breadths below the wrist on the inner forearm in between the two tendons) to sham acupuncture and acupressure with and without sedation. One trial compared acupuncture at P6 point to sham acupuncture. These trials reported both completion of dental procedure and reduction in gagging (assessor and patient reported) as their outcomes. One cross‐over and one split‐mouth trial studied the effect of laser at P6 point compared to control. One trial reported reduction in gagging and another reported presence or absence of gagging during dental procedure. Acupuncture at P6 showed uncertain evidence regarding the successful completion of dental procedure (RR 1.78, 95% CI 1.05 to 3.01; two trials, 59 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 2.57, 95% CI 1.12 to 5.89; one trial, 26 participants; very low‐certainty evidence) in comparison to sham acupuncture. Acupuncture at P6 with sedation did not show any difference when compared to sham acupuncture with sedation (RR 1.08, 95% CI 0.91 to 1.28; one trial, 34 participants; very low‐certainty evidence). Acupressure using thumb pressure with or without sedation showed no clear difference in completing dental procedure (RR 0.96, 95% CI 0.84 to 1.10; one trial, 39 participants; very low‐certainty evidence; and RR 0.85, 95% CI 0.50 to 1.46; one trial, 30 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 1.06, 95% CI 0.92 to 1.23; one trial, 39 participants; very low‐certainty evidence; and RR 0.92, 95% CI 0.60 to 1.41; one trial, 30 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Acupressure at P6 with device showed uncertain evidence regarding the successful completion of dental procedure (RR 2.63, 95% CI 1.33 to 5.18; one trial, 34 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 3.94, 95% CI 1.63 to 9.53; one trial, 34 participants; very low‐certainty evidence) when compared to sham acupressure. However, device combined with sedation showed no difference for either outcome (RR 1.16, 95% CI 0.90 to 1.48; one trial, 27 participants; very low‐certainty evidence; and RR 1.26, 95% CI 0.93 to 1.69; one trial, 27 participants; very low‐certainty evidence; respectively). Acupressure using a sea band with or without sedation showed no clear difference in completing dental procedure (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 1.80, 95% CI 0.63 to 5.16; one trial, 19 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 2.70, 95% CI 0.72 to 10.14; one trial, 19 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Laser at P6 showed a difference in absence of gagging (odds ratio (OR) 86.33, 95% CI 29.41 to 253.45; one trial, 40 participants; very low‐certainty evidence) and reduction in gagging (MD 1.80, 95% CI 1.53 to 2.07; one trial, 25 participants; very low‐certainty evidence) during dental procedure when compared to dummy laser application. No noteworthy adverse effects were reported. For acupuncture at P6, the trial authors were unsure whether the reported adverse effects were due to participant anxiety or due to the intervention. None of the trials on acupressure or laser reported on this outcome. We did not find trials evaluating any other interventions used to manage gagging in people undergoing dental treatment. Authors' conclusions We found very low‐certainty evidence from four trials that was insufficient to conclude if there is any benefit of acupuncture, acupressure or laser at P6 point in reducing gagging and allowing successful completion of dental procedures. We did not find any evidence on any other interventions for managing the gag reflex during dental treatment. More well‐designed and well‐reported trials evaluating different interventions are needed. Plain language summary Management of gagging in dental patients Review question With this Cochrane Review we tried to find out the best way to manage gagging in people having dental treatment. Background The gag reflex is a normal process to protect the throat and airway from foreign objects and prevent choking. Many people have an exaggerated gag reflex that causes distress during dental treatment. This can make it difficult or even impossible to perform the treatment. The interventions used to manage gagging include anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behaviour therapy and cognitive behaviour therapy, acupressure, acupuncture, laser, and prosthetic devices. We wanted to know how effective and safe these interventions are in helping people complete their dental treatment with less gagging. We compared them to no intervention or a placebo or to other interventions. Study characteristics This review is up‐to‐date as of 18 March 2019. We included four trials with 328 people (263 adults and 65 children who were 4 years or older). These people had nausea before when having dental treatment that caused the treatment to be stopped or not carried out properly. Key results Acupuncture at P6 point (a point located in the inside of the wrist) showed uncertain evidence regarding the successful completion of dental treatment and reduction in gagging when compared to sham (fake) acupuncture. The same intervention with sedation did not show a difference. Acupressure (with thumb or sea band (bands that fit around the wrist just like a sweat band with a pressure stud sewn inside)) at P6 point with or without sedation did not show any difference when compared to sham acupressure. Acupressure at P6 point with device showed a difference in completing dental treatment and reduction in gagging. It did not show a difference when combined with sedation. Laser at P6 point showed a difference in absence of gagging and reduction in gagging during dental treatment when compared to sham laser application. The included studies did not report any important harmful effects of the treatment. Certainty of the evidence The level of belief we have in these findings is very low. This was due to unclear risk of bias and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to manage gagging in people having dental treatment. We suggest that more well‐conducted studies should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Eachempati, P; Kumbargere Nagraj, S; Kiran Kumar Krishanappa, S; George, RP; Soe, HH; Karanth, L", "articleTypes": [], "doi": "10.1002/14651858.CD011116.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "99970f9f-a411-4dc5-82e6-a7601c213cde", "pmid": "", "title": "Dietary Pistachio Intake and Nutrition-Related Outcomes in Individuals Using GLP-1 Receptor Agonists: A Randomized Controlled Trial", "imported": false, "abstract": "In this study will look at how eating pistachios every day might affect participants weight, how healthy their diet is, and how they feel when eating. Investigators want to see if adding pistachios to meals for 12 weeks helps participants feel fuller, have more energy, and improve body composition. The study will include adults who have been taking GLP-1 medicines like semaglutide or tirzepatide for at least three months. Investigators also want to see if eating pistachios improves overall diet quality and health markers like tiredness and certain levels in blood.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "99a63df8-f760-422a-b848-387272a0097a", "pmid": "", "title": "Homeopathic Oscillococcinum® for preventing and treating influenza and influenza‐like illness", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mathie, RT, Frye, J, Fisher, P", "articleTypes": [], "doi": "10.1002/14651858.CD001957.pub6 AB - Abstract - Background Influenza is a highly infectious viral disease that is particularly common in the winter months. Oscillococcinum ® is a patented homeopathic medicine that is made from a 1% solution of wild duck heart and liver extract, which is then serially diluted 200 times with water and alcohol. Objectives To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Search methods We searched CENTRAL (2014, Issue 8), MEDLINE (1966 to August week 4, 2014), MEDLINE In‐Process & Other Non‐Indexed Citations (4 September 2014), AMED (2006 to September 2014), Web of Science (1985 to September 2014), LILACS (1985 to September 2014) and EMBASE (1980 to September 2014). We contacted the manufacturers of Oscillococcinum ® for information on further trials. Selection criteria Randomised, placebo‐controlled trials of Oscillococcinum ® in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Data collection and analysis Three review authors independently extracted data and assessed risk of bias in the eligible trials. Main results No new trials were included in this 2014 update. We included six studies: two prophylaxis trials (327 young to middle‐aged adults in Russia) and four treatment trials (1196 teenagers and adults in France and Germany). The overall standard of trial reporting was poor and hence many important methodological aspects of the trials had unclear risk of bias. There was no statistically significant difference between the effects of Oscillococcinum ® and placebo in the prevention of influenza‐like illness: risk ratio (RR) 0.48, 95% confidence interval (CI) 0.17 to 1.34, P value = 0.16. Two treatment trials (judged as 'low quality') reported sufficient information to allow full data extraction: 48 hours after commencing treatment, there was an absolute risk reduction of 7.7% in the frequency of symptom relief with Oscillococcinum ® compared with that of placebo (risk difference (RD) 0.077, 95% CI 0.03 to 0.12); the RR was 1.86 (95% CI 1.27 to 2.73; P value = 0.001). A significant but lesser effect was observed at three days (RR 1.27, 95% CI 1.03 to 1.56; P value = 0.03), and no significant difference between the groups was noted at four days (RR 1.11, 95% CI 0.98 to 1.27; P value = 0.10) or at five days (RR 1.06, 95% CI 0.96 to 1.16; P value = 0.25). One of the six studies reported one patient who suffered an adverse effect (headache) from taking Oscillococcinum ® . Authors' conclusions There is insufficient good evidence to enable robust conclusions to be made about Oscillococcinum ® in the prevention or treatment of influenza and influenza‐like illness. Our findings do not rule out the possibility that Oscillococcinum ® could have a clinically useful treatment effect but, given the low quality of the eligible studies, the evidence is not compelling. There was no evidence of clinically important harms due to Oscillococcinum ® . Plain language summary Homeopathic Oscillococcinum ® for preventing and treating influenza and influenza‐like illness Review question 
 To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Background 
 Influenza ('the flu') is a highly infectious viral respiratory disease. Other than treatments for complications (such as pneumonia), the conventional medical strategies for the prevention or treatment of flu are not entirely effective or satisfactory. Oscillococcinum ® is a highly diluted homeopathic preparation manufactured from wild duck heart and liver, which may be reservoirs of flu viruses. Some people take Oscillococcinum ® regularly over the winter months either to prevent flu or as a treatment for flu symptoms. Study characteristics 
 We included six studies, which comprised two prevention trials (a total of 327 young to middle‐aged adults in Russia) and four treatment trials (a total of 1196 teenagers and adults in France and Germany). Key results 
 The findings from the two prevention trials did not show that Oscillococcinum ® can prevent the onset of flu. Although the results from the four other clinical trials suggested that Oscillococcinum ® relieved flu symptoms at 48 hours, this might be due to bias in the trial methods. One patient reported headache after taking Oscillococcinum ® . The evidence is current to September 2014. Quality of the evidence 
 The overall standard of research reporting was poor, and thus many aspects of the trials' methods and results were at unclear risk of bias. We therefore judged the evidence overall as low quality, preventing clear conclusions from being made about Oscillococcinum ® in the prevention or treatment of flu and flu‐like illness.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.755Z" }, { "id": "99a82247-f36d-4b58-b0a8-2c61dbd7a55b", "pmid": "", "title": "Preoperative carbohydrate treatment for enhancing recovery after elective surgery", "imported": false, "abstract": "Abstract - Background Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast‐track surgery protocols. Although fast‐track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis. Objectives To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data. Selection criteria We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time. Data collection and analysis Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis. Main results We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I‐II or I‐III. A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding. In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low‐quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference ‐0.13 days; 95% CI ‐0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high‐quality evidence). As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low‐quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation. Authors' conclusions Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases. Plain language summary Does giving patients carbohydrate supplements before planned surgery lead to improved recovery? Review question We reviewed the evidence on effects of carbohydrate supplements on the recovery of people undergoing planned surgical procedures. We found 27 studies investigating this question. Background Carbohydrate (sugar‐containing) nutritional supplements have become a routine part of the package of care for people undergoing planned surgical procedures. We wanted to discover whether carbohydrate supplements are a useful part of care packages used by doctors to improve recovery after planned surgical procedures. Study characteristics The evidence is current up to March 2014. We identified 27 studies and included the outcomes of 1976 participants. Studies investigated the outcomes of patients undergoing planned surgical procedures on the abdomen (18), the bones or joints (4), the heart (4) or the thyroid gland (1). Eighteen studies compared carbohydrate supplements versus an identical appearing placebo drink that did not contain carbohydrates; in six of these studies, an additional group of patients had nothing to eat or drink for at least six hours before surgery. In nine studies, taking carbohydrate supplements was compared with having nothing to eat or drink for six hours before surgery. The primary outcomes of length of hospital stay and complication rate were reported by 19 and 14 studies, respectively. Key results Patients given carbohydrates before planned surgical procedures went home between 0.04 and 0.56 days sooner than those receiving a placebo drink or having nothing to eat or drink before surgery. Carbohydrate supplements had little or no effect on complication rate or on how people feel in‐hospital during recovery from surgery. Quality of the evidence The overall quality of the evidence varied from very low to high. The quality of evidence in support of carbohydrate supplements resulting in a shorter hospital stay was very low because the included studies had important flaws in their design, a very wide range of results was described and evidence revealed that studies showing no differences in length of hospital stay may not have been published. When we looked only at well‐conducted studies, we found that carbohydrate supplements had little or no effect on length of hospital stay. The quality of evidence to support the effects of carbohydrate supplements on complication rate was low because issues with study design were identified and results were not similar across studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Smith, MD, McCall, J, Plank, L, Herbison, GP, Soop, M, Nygren, J", "articleTypes": [], "doi": "10.1002/14651858.CD009161.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.774Z" }, { "id": "99aeac72-2920-47c0-868e-cd0d4442085e", "pmid": "", "title": "Statins for Smith‐Lemli‐Opitz syndrome", "imported": false, "abstract": "Abstract - Background Smith‐Lemli‐Opitz syndrome (SLOS) is a multiple congenital malformations syndrome caused by defective cholesterol biosynthesis. Affected individuals show cholesterol deficiency and accumulation of various precursor molecules, mainly 7‐dehydrocholesterol and 8‐dehydrocholesterol. There is currently no cure for SLOS, with cholesterol supplementation being primarily a biochemical therapy of limited evidence. However, several anecdotal reports and preclinical studies have highlighted statins as a potential therapy for SLOS. Objectives To evaluate the effects of statins, either alone or in combination with other non‐statin therapies (e.g. cholesterol, bile acid, or vitamin co‐supplementation), compared to cholesterol supplementation alone or in combination with other non‐statin therapies (e.g. bile acid or vitamin supplementation) on several important outcomes including overall survival, neurobehavioral features, and adverse effects in individuals with SLOS. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and three trials registers on 15 February 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs with parallel or cross‐over designs, and non‐randomized studies of interventions (NRSIs) including non‐randomized trials, cohort studies, and controlled before‐and‐after studies, were eligible for inclusion in this review if they met our prespecified inclusion criteria, i.e. involved human participants with biochemically or genetically diagnosed SLOS receiving statin therapy or cholesterol supplementation, or both. Data collection and analysis Two authors screened titles and abstracts and subsequently full‐texts for all potentially‐relevant references. Both authors independently extracted relevant data from included studies and assessed the risks of bias. We analyzed the data extracted from the included NRSIs and cohort studies separately from the data extracted from the single included RCT. We used a random‐effects model to account for the inherent heterogeneity and methodological variation between these different study designs. We used GRADE to assess the certainty of evidence. Main results We included six studies (61 participants with SLOS); one RCT (N = 18), three prospective NRSIs (N = 20), and two retrospective NRSIs (N = 22). Five studies included only children, and two limited their participant inclusion by disease severity. Overall, there were nearly twice as many males as females. All six studies compared add‐on statin therapy to cholesterol supplementation alone. However, the dosages, formulations, and durations of treatment were highly variable across studies. We judged the RCT as having a high risk of bias due to missing data and selective reporting. All included NRSIs had a serious or critical overall risk of bias assessed by the Risk Of Bias In Non‐randomized Studies of Interventions tool (ROBINS‐I). None of the included studies evaluated survival or reported quality of life (QoL). Only the included RCT formally assessed changes in the neurobehavioral manifestations of SLOS, and we are uncertain whether statin therapy improves this outcome (very low‐certainty evidence). We are also uncertain whether the adverse events reported in the RCT were statin‐related (very low‐certainty evidence). In contrast, the adverse events reported in the NRSIs seem to be possibly due to statin therapy (risk ratio 13.00, 95% confidence interval 1.85 to 91.49; P = 0.01; low‐certainty evidence), with only one of the NRSIs retrospectively mentioning changes in the irritability of two of their participants. We are uncertain whether statins affect growth based on the RCT or NRSI results (very low‐certainty evidence). The RCT showed that statins may make little or no difference to plasma biomarker levels (low‐certainty evidence), while we are uncertain of their effects on such parameters in the NRSIs (very low‐certainty evidence). Authors' conclusions Currently, there is no evidence on the potential effects of statin therapy in people with SLOS regarding survival or QoL, and very limited evidence on the effects on neurobehavioral manifestations. Likewise, current evidence is insufficient and of very low certainty regarding the effects of statins on growth parameters in children with SLOS and plasma or cerebrospinal fluid (CSF) levels of various disease biomarkers. Despite these limitations, current evidence seemingly suggests that statins may increase the risk of adverse reactions in individuals with SLOS receiving statins compared to those who are not. Given the insufficient evidence on potential benefits of statins in individuals with SLOS, and their potential for causing adverse reactions, anyone considering this therapy should take these findings into consideration. Future studies should address the highlighted gaps in evidence on the use of statins in individuals with SLOS by collecting prospective data on survival and performing serial standardized assessments of neurobehavioral features, QoL, anthropometric measures, and plasma and CSF biomarker levels after statin introduction. Future studies should also attempt to use consistent dosages, formulations and durations of cholesterol and statin therapy. Plain language summary Statins for Smith‐Lemli‐Opitz syndrome Review question Is statin therapy, either alone or combined with cholesterol therapy, linked to better outcomes (e.g. survival, quality of life, severity or frequency of neurobehavioral abnormalities, changes in growth parameters or biomarker levels) compared to cholesterol therapy alone for people with Smith‐Lemli‐Opitz syndrome (SLOS), and what are the risks of harmful effects for either option? Background Smith‐Lemli‐Opitz syndrome is a genetic malformation syndrome, which occurs when cholesterol is not able to be produced by the body and there is a build up of several toxic molecules that would, under normal circumstances, go on to become cholesterol, such as 7DHC and 8DHC. This means that people with SLOS may fail to achieve normal physical growth, show various degrees of intellectual disability or developmental delay (or both), and show a range of possible behavioral abnormalities (e.g. irritability, aggressiveness, anxiety, attention‐deficit hyperactivity disorder (ADHD), impulsivity and sleep disturbances, among others). It is also notable that SLOS may cause various possible physical abnormalities and disability. There is currently no cure for SLOS, but cholesterol supplementation remains common practice among clinicians caring for people with SLOS. This is based solely on our current understanding of the underlying biochemistry of the disease itself. However, there has been evidence from studies in the laboratory and in single individuals suggesting that statins may be helpful for treating people with SLOS. Search date We conducted our latest search on 15 February 2022. Study characteristics In this review, we included six studies of different designs that included a total of 61 people with SLOS, mostly males. Five of the studies only included children (18 years old or younger). All studies compared a combination of statin and cholesterol therapy to cholesterol supplementation alone. However, the studies used different doses and formulations of statin or cholesterol therapy (or both), as well as different durations of treatment. Key results We found no evidence for the effects of combined statin and cholesterol supplementation, compared to cholesterol supplementation alone, on survival or quality of life in people with SLOS. We are also not sure if combined statin and cholesterol therapy has positive effects on neurobehavioral manifestations or growth in individuals with SLOS compared with cholesterol therapy alone, as we have low confidence in the evidence. We think people with SLOS receiving statin therapy in addition to cholesterol supplementation are more likely to experience adverse events that are usually associated with using statins, compared to those who are only receiving cholesterol supplementation. Finally, we are uncertain about the effects of statin therapy on the levels of various biomarkers usually measured in the blood of people with SLOS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ballout, RA, Livinski, A, Fu, Y-P, Steiner, RD, Remaley, AT", "articleTypes": [], "doi": "10.1002/14651858.CD013521.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.114Z" }, { "id": "99b16dcc-dd3b-4990-b2d4-29e631d8e060", "pmid": "", "title": "Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015. Objectives To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate. Selection criteria We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non‐serious, general behaviour, and quality of life. Data collection and analysis Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel‐group trials and first‐period data from cross‐over trials formed the basis of our primary analyses. We undertook separate analyses using end‐of‐last period data from cross‐over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach. Main results We included 212 trials (16,302 participants randomised); 55 parallel‐group trials (8104 participants randomised), and 156 cross‐over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross‐over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male‐female ratio was 3:1. Most trials were carried out in high‐income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias. Primary outcomes: methylphenidate versus placebo or no intervention may improve teacher‐rated ADHD symptoms (standardised mean difference (SMD) −0.74, 95% confidence interval (CI) −0.88 to −0.61; I² = 38%; 21 trials; 1728 participants; very low‐certainty evidence). This corresponds to a mean difference (MD) of −10.58 (95% CI −12.58 to −8.72) on the ADHD Rating Scale (ADHD‐RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD‐RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68). Secondary outcomes: methylphenidate may cause more adverse events considered non‐serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher‐rated general behaviour versus placebo (SMD −0.62, 95% CI −0.91 to −0.33; I² = 68%; 7 trials 792 participants; very low‐certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI −0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low‐certainty evidence). Authors' conclusions The majority of our conclusions from the 2015 version of this review still apply. Our updated meta‐analyses suggest that methylphenidate versus placebo or no‐intervention may improve teacher‐rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non‐serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non‐serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes. Plain language summary Is methylphenidate an effective treatment for children and adolescents with attention deficit hyperactivity disorder (ADHD) and does it cause unwanted effects? Key messages ‐ Methylphenidate might reduce hyperactivity and impulsivity and might help children to concentrate. Methylphenidate might also help to improve general behaviour, but does not seem to affect quality of life. ‐ Methylphenidate does not seem to increase the risk of serious (life‐threatening) unwanted effects when used for periods of up to six months. However, it is associated with an increased risk of non‐serious unwanted effects like sleeping problems and decreased appetite. ‐ Future studies should focus more on reporting unwanted effects and should take place over longer periods of time. What is attention deficit hyperactivity disorder (ADHD)? ADHD is one of the most commonly diagnosed and treated childhood psychiatric disorders. Children with ADHD find it hard to concentrate. They are often hyperactive (fidgety, unable to sit still for long periods) and impulsive (doing things without stopping to think). ADHD can make it difficult for children to do well at school, because they find it hard to follow instructions and to concentrate. Their behavioural problems can interfere with their ability to get on well with family and friends, and they often get into more trouble than other children. How is ADHD treated? Methylphenidate (for example, Ritalin) is the medication most often prescribed to children and adolescents with ADHD. Methylphenidate is a stimulant that helps to increase activity in parts of the brain, such as those involved with concentration. Methylphenidate can be taken as a tablet or given as a skin patch. It can be formulated to have an immediate effect, or be delivered slowly, over a period of hours. Methylphenidate may cause unwanted effects, such as headaches, stomachaches and problems sleeping. It sometimes causes serious unwanted effects like heart problems, hallucinations, or facial 'tics' (twitches). What did we want to find out? We wanted to find out if methylphenidate improves children's ADHD symptoms (attention, hyperactivity) based mainly on teachers' ratings using various scales, and whether it causes serious unwanted effects, like death, hospitalisation, or disability. We were also interested in less serious unwanted effects like sleep problems and loss of appetite, and its effects on children's general behaviour and quality of life. What did we do? We searched for studies that investigated the use of methylphenidate in children and adolescents with ADHD. Participants in the studies had to be aged 18 years or younger and have a diagnosis of ADHD. They could have other disorders or illnesses and be taking other medication or undergoing behavioural treatments. They had to have a normal IQ (intelligence quotient). Studies could compare methylphenidate with placebo (something designed to look and taste the same as methylphenidate but with no active ingredient) or no treatment. Participants had to be randomly chosen to receive methylphenidate or not. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 212 studies with 16,302 children or adolescents with ADHD. Most of the trials compared methylphenidate with placebo. Most studies were small with around 70 children, with an average age of 10 years (ages ranged from 3 to 18 years). Most studies were short, lasting an average of around a month; the shortest study lasted just one day and the longest 425 days. Most studies were in the USA. Based on teachers' ratings, compared with placebo or no treatment, methylphenidate: ‐ may improve ADHD symptoms (21 studies, 1728 children) ‐ may make no difference to serious unwanted effects (26 studies, 3673 participants) ‐ may cause more non‐serious unwanted effects (35 studies, 5342 participants) ‐ may improve general behaviour (7 trials 792 participants) ‐ may not affect quality of life (4 trials, 608 participants) Limitations of the evidence Our confidence in the results of the review is limited for several reasons. It was often possible for people in the studies to know which treatment the children were taking, which could influence the results. The reporting of the results was not complete in many studies and for some outcomes the results varied across studies. Studies were small and they used different scales for measuring symptoms. And most of the studies only lasted for a short period of time, making it impossible to assess the long‐term effects of methylphenidate. Around 41% of studies were funded or partly funded by the pharmaceutical industry. How up to date is this evidence? This is an update of a review conducted in 2015. The evidence is current to March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Storebø, OJ, Storm, MR, Pereira Ribeiro, J, Skoog, M, Groth, C, Callesen, HE, Schaug, JP, Darling, P, Huus, C-ML, Zwi, M, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD009885.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.802Z" }, { "id": "99b24733-d7c2-4a9a-b0ec-8dbbaaa61dd6", "pmid": "", "title": "Music‐based therapeutic interventions for people with dementia", "imported": false, "abstract": "Abstract - Background Dementia is a clinical syndrome with a number of different causes. It is characterised by deterioration in cognitive, behavioural, social and emotional functioning. Pharmacological interventions are available but have limited effect on many of the syndrome's features. However, receptivity to music may remain until the late phases of dementia, and music‐based therapeutic interventions (which include, but are not limited to, music therapy) are suitable for people with advanced dementia. As there is uncertainty about the effectiveness of music‐based therapeutic interventions, trials are being conducted to evaluate this. This review updates one last published in 2018 and examines the current evidence for the effects of music‐based interventions for people with dementia. Objectives To assess the effects of music‐based therapeutic interventions for people with dementia on emotional well‐being (including quality of life), mood disturbance or negative affect (i.e. depressive symptoms and anxiety), behavioural problems (i.e. overall behavioural problems or neuropsychiatric symptoms, and more specifically agitation or aggression), social behaviour and cognition, at the end of therapy and four or more weeks after the end of treatment, and to assess any adverse effects. Search methods We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organisation's meta‐register‐the International Clinical Trials Registry Platform on 30 November 2023. Selection criteria We included randomised controlled trials of music‐based therapeutic interventions (of at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music. Data collection and analysis Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data from included studies and assess their risk of bias. If necessary, we contacted trial authors to ask for additional data, such as relevant subscales. We pooled data using the random‐effects model. We assessed the certainty of the evidence for our two comparisons and our main outcomes of interest using GRADE. Main results We included 30 studies with 1720 randomised participants that were conducted in 15 countries. Twenty‐eight studies with 1366 participants contributed data to meta‐analyses. Ten studies contributed data to long‐term outcomes. Participants had dementia of varying degrees of severity and resided in institutions in most of the studies. Seven studies delivered an individual intervention; the other studies delivered the intervention to groups. Most interventions involved both active and receptive elements of musical experience. The studies were at high risk of performance bias and some were at high risk of detection or other bias. For music‐based therapeutic interventions compared to usual care, we found moderate‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions probably improved depressive symptoms slightly (standardised mean difference (SMD) −0.23, 95% confidence interval (CI) −0.42 to −0.04; 9 studies, 441 participants), and we found low‐certainty evidence that it may have improved overall behavioural problems (SMD −0.31, 95% CI −0.60 to −0.02; 10 studies, 385 participants). We found moderate‐certainty evidence that music‐based therapeutic interventions likely did not improve agitation or aggression (SMD −0.05, 95% CI −0.27 to 0.17; 11 studies, 503 participants). Low to very low certainty evidence showed that they did not improve emotional well‐being (SMD 0.14, 95% CI ‐0.29 to 0.56; 4 studies, 154 participants), anxiety (SMD −0.15, 95% CI −0.39 to 0.09; 7 studies, 282 participants), social behaviour (SMD 0.22, 95% CI −0.14 to 0.57; 2 studies; 121 participants) or cognition (SMD 0.19, 95% CI −0.02 to 0.41; 7 studies, 353 participants). Low or very‐low ‐certainty evidence showed that music‐based therapeutic interventions may not have been more effective than usual care in the long term (four weeks or more after the end of treatment) for any of the outcomes. For music‐based therapeutic interventions compared to other interventions, we found low‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions may have been more effective than the other activities for social behaviour (SMD 0.52, 95% CI 0.08 to 0.96; 4 studies, 84 participants). We found very low‐certainty evidence of a positive effect on anxiety (SMD −0.75, 95% CI −1.27 to −0.24; 10 studies, 291 participants). For all other outcomes, low‐certainty evidence showed no evidence of an effect: emotional well‐being (SMD 0.20, 95% CI −0.09 to 0.49; 9 studies, 298 participants); depressive symptoms (SMD −0.14, 95% CI ‐0.36 to 0.08; 10 studies, 359 participants); agitation or aggression (SMD 0.01, 95% CI −0.31 to 0.32; 6 studies, 168 participants); overall behavioural problems (SMD −0.08, 95% CI −0.33 to 0.17; 8 studies, 292 participants) and cognition (SMD 0.12, 95% CI −0.21 to 0.45; 5 studies; 147 participants). We found low or very‐low certainty evidence that music‐based therapeutic interventions may not have been more effective than other interventions in the long term (four weeks or more after the end of treatment) for any of the outcomes. Adverse effects were inconsistently measured or recorded, but no serious adverse events were reported. Authors' conclusions When compared to usual care, providing people with dementia with at least five sessions of a music‐based therapeutic intervention probably improves depressive symptoms and may improve overall behavioural problems at the end of treatment. When compared to other activities, music‐based therapeutic interventions may improve social behaviour at the end of treatment. No conclusions can be reached about the outcome of anxiety as the certainty of the evidence is very low. There may be no effects on other outcomes at the end of treatment. There was no evidence of long‐term effects from music‐based therapeutic interventions. Adverse effects may be rare, but the studies were inconsistent in their reporting of adverse effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions. Plain language summary Does music‐based therapy help people with dementia? Key messages · Compared to usual care (i.e. without specific activities), providing people with dementia with music‐based therapy sessions probably improves depression, and may improve overall behavioural problems. · Compared to other activities, music‐based therapy may improve social behaviour, but we are unsure if it improves anxiety. · These effects may not last beyond the end of treatment. · There is no evidence that music‐based therapy makes a difference to the emotional well‐being, agitation or cognition (e.g. thinking and remembering) of people with dementia, although there is uncertainty about this. · There is uncertainty in the evidence for long‐term effects, but no long‐term effects were observed in the studies. · Adverse effects (unwanted side effects) may be rare, but the studies were inconsistent in their reporting, so we need more evidence before we can reach reliable conclusions. Why offer music‐based therapy to people with dementia? People with dementia gradually develop increasing difficulty with thinking and daily activities. Dementia is often associated with emotional and behavioural problems and may decrease a person's quality of life. In the later stages of dementia, it may be difficult for people to communicate with words, but even when they can no longer speak, they may still be able to hum or play along with music. Therapy involving music may therefore be especially suitable for people with dementia to improve their lives. Who provides music‐based therapy? Music therapists are certified to work with individuals or groups of people, using music to try to help meet their physical, psychological and social needs. Other professionals may also be trained to provide similar therapies. What did we want to find out? We wanted to find out if, for people with dementia, music‐based therapy works better than usual care or other activities, such as painting. We were interested in whether the therapy changed these outcomes at the end of treatment: · emotional well‐being including quality of life; · depression and anxiety; · agitation or aggression and overall behavioural problems; · social behaviour; and · cognition (e.g. thinking and remembering). We also wanted to find out if there were any long‐term effects after therapy ended or any unwanted effects. What did we do? We searched for studies in which people with dementia were randomly allocated to receive music‐based therapy (of at least five sessions) or to a comparison group with no activities or different activities. We combined the results of the studies to estimate the effects of music‐based therapy as accurately as possible. We also rated our level of confidence in the findings. What did we find? We found 30 studies performed in 15 countries. The studies involved 1720 people with dementia of varying severity. In most of the studies, the participants lived in nursing homes. Seven studies delivered the music‐based therapy to individuals; the other studies delivered the intervention to groups. We were able to use results from 28 studies involving 1366 people with dementia for one or more outcomes at the end of treatment. Ten studies contributed information about long‐term results. Main results At the end of treatment Music‐based therapy probably improves depression and may improve overall behavioural problems, compared with providing usual care. Music‐based therapy may improve social behaviour compared to other activities. We were less confident about the effects of music‐based therapy on anxiety compared to other activities. The available evidence does not suggest any benefit of music‐based therapy for emotional well‐being (including quality of life), agitation and aggression, or cognition, but the evidence is limited and there is uncertainty about this. In the longer term Some studies measured outcomes four weeks or more after treatment ended. We did not find any lasting effects, but there were fewer results measured in the longer term, and we are uncertain about this evidence. Further studies are likely to have a significant impact on what we know about the effects of music‐based therapy for people with dementia, so it is important that research continues. What are the limitations of the evidence? There was variation in the quality of the studies and how well they were reported. In all studies, participants and personnel might have known which treatment participants were getting, and in some, the assessors might have known this as well. This could have affected the results. Regarding effects at the end of music‐based therapy, we are moderately confident in the evidence for the beneficial effect on depression compared to usual care. We have little confidence in the effects or lack of effects on any of the other outcomes. Adverse effects were rarely reported. How up to date is this evidence? This review updates our previous review. We added eight new studies and reached new conclusions. The evidence is current to 30 November 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "van der Steen, JT; van der Wouden, JC; Methley, AM; Smaling, HJ A; Vink, AC; Bruinsma, MS", "articleTypes": [], "doi": "10.1002/14651858.CD003477.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "99b7cfc1-143c-472c-b9d5-4f558dab9ddc", "pmid": "", "title": "Cranberries for preventing urinary tract infections", "imported": false, "abstract": "Abstract - Background Cranberries contain proanthocyanidins (PACs), which inhibit the adherence of p‐fimbriated Escherichia coli to the urothelial cells lining the bladder. Cranberry products have been used widely for several decades to prevent urinary tract infections (UTIs). This is the fifth update of a review first published in 1998 and updated in 2003, 2004, 2008, and 2012. Objectives To assess the effectiveness of cranberry products in preventing UTIs in susceptible populations. Search methods We searched the Cochrane Kidney and Transplant Specialised Register up to 13 March 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria All randomised controlled trials (RCTs) or quasi‐RCTs of cranberry products compared with placebo, no specific treatment or other intervention (antibiotics, probiotics) for the prevention of UTIs were included. Data collection and analysis At least two authors independently assessed and extracted data. Information was collected on methods, participants, interventions and outcomes (incidence of symptomatic UTIs, positive culture results, side effects, adherence to therapy). Risk ratios (RR) with 95% confidence intervals (CI) were calculated where appropriate. Study quality was assessed using the Cochrane risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results For this update, 26 new studies were added, bringing the total number of included studies to 50 (8857 randomised participants). The risk of bias for sequence generation and allocation concealment was low for 29 and 28 studies, respectively. Thirty‐six studies were at low risk of performance bias, and 23 studies were at low risk of detection bias. Twenty‐seven, 41, and 17 studies were at low risk of attrition bias, reporting bias and other bias, respectively. Forty‐five studies compared cranberry products with placebo, water or no specific treatment in six different groups of participants. Twenty‐six of these 45 studies could be meta‐analysed for the outcome of symptomatic, culture‐verified UTIs. In moderate certainty evidence, cranberry products reduced the risk of UTIs (6211 participants: RR 0.70, 95% CI 0.58 to 0.84; I² = 69%). When studies were divided into groups according to the treatment indication, cranberry products probably reduced the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs (8 studies, 1555 participants: RR 0.74, 95% CI 0.55 to 0.99; I² = 54%), in children (5 studies, 504 participants: RR 0.46, 95% CI 0.32 to 0.68; I² = 21%) and in people with a susceptibility to UTIs due to an intervention (6 studies, 1434 participants: RR 0.47, 95% CI 0.37 to 0.61; I² = 0%). However, there may be little or no benefit in elderly institutionalised men and women (3 studies, 1489 participants: RR 0.93, 95% CI 0.67 to 1.30; I² = 9%; moderate certainty evidence), pregnant women (3 studies, 765 participants: RR 1.06, 95% CI 0.75 to 1.50; I² = 3%; moderate certainty evidence), or adults with neuromuscular bladder dysfunction with incomplete bladder emptying (3 studies, 464 participants: RR 0.97, 95% CI 0.78 to 1.19; I² = 0%; low certainty evidence). Other comparisons were cranberry products with probiotics (three studies) or antibiotics (six studies), cranberry tablets with cranberry liquid (one study), and different doses of PACs (two studies). Compared to antibiotics, cranberry products may make little or no difference to the risk of symptomatic, culture‐verified UTIs (2 studies, 385 participants: RR 1.03, 95% CI 0.80 to 1.33; I² = 0%) or the risk of clinical symptoms without culture (2 studies, 336 participants: RR 1.30, 95% CI 0.79 to 2.14; I² = 68%). Compared to probiotics, cranberry products may reduce the risk of symptomatic, culture‐verified UTIs (3 studies, 215 participants: RR 0.39, 95% CI 0.27 to 0.56; I = 0%). It is unclear whether efficacy differs between cranberry juice and tablets or between different doses of PACs, as the certainty of the evidence was very low. The number of participants with gastrointestinal side effects probably does not differ between those taking cranberry products and those receiving a placebo or no specific treatment (10 studies, 2166 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%; moderate certainty evidence). There was no clear relationship between compliance with therapy and the risk for repeat UTIs. No difference in the risk for UTIs could be demonstrated between low, moderate and high doses of PACs. Authors' conclusions This update adds a further 26 studies, taking the total number of studies to 50 with 8857 participants. These data support the use of cranberry products to reduce the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs, in children, and in people susceptible to UTIs following interventions. The evidence currently available does not support its use in the elderly, patients with bladder emptying problems, or pregnant women. Plain language summary Cranberries for preventing urinary tract infections What is the issue? Cranberries (as cranberry juice, tablets or capsules) have been used for many years to prevent urinary tract infections (UTIs). Cranberries contain proanthocyanidins (PACs), substances that can prevent bacteria from sticking to the walls of the bladder. This may help prevent infections and reduce the need for working people to take time for medical appointments. However, there is currently no established regimen for what PACs dose to use and no formal regulation by health authorities of cranberry products. In particular, the dose suggested may not be included on the package. What did we do? We analysed the results of randomised controlled trials (RCTs), which compared the occurrence of UTIs in people taking a cranberry product with those taking a placebo or no treatment. We also analysed the results of RCTs comparing a cranberry product with other treatments such as antibiotics or probiotics. What did we find? We found 50 RCTs involving 8857 people. Forty‐five RCTs compared cranberry with a placebo or no treatment. Taking cranberries as a juice, tablets or capsules reduced the number of UTIs in women with recurrent UTIs, in children with UTIs and in people susceptible to UTIs following an intervention such as bladder radiotherapy. However, UTIs did not appear to be reduced in elderly institutionalised men and women, in adults with neuromuscular bladder dysfunction and incomplete bladder emptying, or in pregnant women. Few people reported any side effects with the most common being tummy pain. We did not find enough information to determine if cranberry products are more or less effective compared with antibiotics or probiotics in preventing further UTIs. Conclusions Cranberry products may help to prevent UTIs which cause symptoms in women with frequent UTIs, in children with UTIs and in people who have undergone an intervention involving the bladder. However, further assessment is required in well‐designed and prospectively registered RCTs to clarify further who with UTIs would benefit from cranberry products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Williams, G, Stothart, CI, Hahn, D, Stephens, JH, Craig, JC, Hodson, EM", "articleTypes": [], "doi": "10.1002/14651858.CD001321.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.774Z" }, { "id": "99defb24-0cb4-4d32-b75b-e77b94da0301", "pmid": "", "title": "Ginkgo biloba extract for age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Ginkgo is used in the treatment of peripheral vascular disease and 'cerebral insufficiency'. It is thought to have several potential mechanisms of action including increased blood flow, platelet activating factor antagonism, and prevention of membrane damage caused by free radicals. Vascular factors and oxidative damage are thought to be two potential mechanisms in the pathology of age‐related macular degeneration (AMD). Objectives The objective of this review was to determine the effect of Ginkgo biloba extract on the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2012), EMBASE (January 1980 to October 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to October 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 5 October 2012. We searched the reference lists of identified reports and the Science Citation Index. We also contacted investigators of included studies for additional information. Selection criteria All randomised trials in people with AMD where Ginkgo biloba extract had been compared to control were included. Data collection and analysis The review author extracted data using a standardised form. The data were verified with the trial investigators. Trial quality was assessed. Main results Two published trials were identified that randomised a total of 119 people. In one study conducted in France, 20 people were randomly allocated to Gingko biloba extract EGb 761 80 mg twice daily or placebo. In the other study conducted in Germany, 99 people were randomly allocated to two different doses of Ginkgo biloba extract EGb 761 (240 mg per day and 60 mg per day). Treatment duration in both studies was six months. Both trials reported some positive effects of Ginkgo biloba on vision however their results could not be pooled. Adverse effects and quality of life for people with AMD were not reported. Authors' conclusions The question as to whether people with AMD should take Ginkgo biloba extract to prevent progression of the disease has not been answered by research to date. Two small trials have suggested possible benefit of Gingko biloba on vision and further trials are warranted. Ginkgo biloba is widely used in China, Germany, and France. Future trials should be larger, and last longer, in order to provide a more robust measure of the effect of Gingko biloba extract on AMD. Plain language summary Use of Gingko biloba, an extract from the leaves of the maidenhair tree, for slowing the progression of age‐related macular degeneration Age‐related macular degeneration (AMD) is a condition affecting the central area of the retina (the back of the eye). The retina can deteriorate with age and some people get lesions that lead to loss of central vision. Gingko biloba, extracted from the leaves of the maidenhair tree, is used in Chinese herbal medicine to treat a variety of medical conditions, in particular circulatory problems. Ginkgo biloba extract contains two constituents (flavonoids and terpenoids) which have antioxidant properties. It is believed these may help to slow down the progression of AMD. The author identified two small randomised controlled studies (with a total of 119 participants); one in France and one in Germany. One trial compared Gingko biloba to placebo and the other compared two different doses of the extract. Although both trials reported some positive effects of Ginkgo biloba on vision, the trials were small and of short duration. Adverse effects and quality of life were not assessed. The overall conclusion of this review is that current research has not answered the question as to whether Ginkgo biloba is of benefit to people with AMD. Future trials need to include a larger number of participants and be conducted over a longer time.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD001775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "9a1ebf38-6178-4443-8c0c-2f33d08702cf", "pmid": "", "title": "Diet-induced Modification of Sweet Taste Perception and Preference", "imported": false, "abstract": "Overconsumption of carbohydrates has been implicated as a cause of significant public health problems including obesity and diabetes. The most effective approach to alter dietary pattern and improve public health is unknown. Gradual and abrupt changes in dietary pattern have been tried in small, uncontrolled trials, but it is not clear which approach is most effective. The primary objective of this study is to evaluate different approaches to changing dietary pattern for altering flavor perception in foods and beverages and for altering preference for flavor.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.145Z" }, { "id": "9a221859-f3f9-43d7-97f9-2a50350e4df4", "pmid": "", "title": "Efficacy Of Bovine Colostrum In The Treatment Of Severe Alcohol-Associated Hepatitis: A Randomized Controlled Trial", "imported": false, "abstract": "Severe alcohol-associated hepatitis (sAH)is associated with hepatocellular necrosis, inflammation, hyperactivated immune system, paradoxical immune exhaustion, leaky gut, and alteration in the gut microbiome. The leading cause of mortality is a bacterial infection with multi-organ failure.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.160Z" }, { "id": "9a2d13d3-b8a3-4ce2-a8f0-67da8e3a2cf1", "pmid": "", "title": "Pharmacological treatments for Friedreich ataxia", "imported": false, "abstract": "Abstract - Rationale Friedreich ataxia (FRDA) is a rare inherited autosomal recessive neurological disorder, characterised initially by unsteadiness in standing and walking, and slowly progressing to wheelchair dependency, usually in the late teens or early twenties. Scoliosis, pes cavus and cardiomyopathy are often present at diagnosis. As the disease progresses, individuals usually develop slurred speech, auditory impairment (especially in a noisy environment), urinary tract morbidity, diabetes, anxiety, depression, muscle spasticity and visual disturbances. Cardiac abnormalities cause premature death in 60% of people with FRDA. There is no easily defined clinical or biochemical marker to assess progression and no known curative treatment. This is the third update of a review published in 2009 and updated in 2012 and 2016. Objectives To assess the effects of pharmacological treatments for people with Friedreich ataxia (FRDA) after 12 months of treatment. Search methods To identify studies for inclusion in this review, we searched CENTRAL, MEDLINE, Embase, CINAHL Plus, TRIP, Orphanet, WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. We also checked reference lists of relevant studies and contacted study authors. The most recent search was on 4 February 2025. Eligibility criteria We were interested in randomised controlled trials (RCTs) and quasi‐RCTs of pharmacological treatments (including vitamins) in people with genetically‐confirmed FRDA. To be included in the review, studies had to last at least 12 months. Outcomes We assessed the following outcomes after 12 months of treatment: change in score on a validated ataxia rating scale; change in interventricular septal thickness in diastole (IVSTd) by cardiac magnetic resonance imaging or echocardiogram; change in activities of daily living (ADL) using a validated questionnaire; change in upper limb dexterity; and change in cardiopulmonary exercise testing (CPET). We also assessed treatment‐related adverse events with medication continued for the study period, and treatment‐emergent adverse events leading to cessation of medication or death during the study period. Risk of bias Using the Cochrane risk of bias tool RoB 2, we assessed the risk of bias in the seven outcomes reported in our summary of findings tables. Synthesis methods We synthesised the results of the studies for each outcome using meta‐analysis, where possible. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and the risk ratio (RR) for dichotomous outcomes, all with 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for our prespecified outcomes as high, moderate, low or very low. Included studies We included eight RCTs in this updated review. We included seven of them in meta‐analysis, and these studies enroled a total of 574 participants, with sample sizes ranging from 29 to 232 participants per study. One study was international, with centres in North America, Europe and Australia. There were four other multicentre studies (three in Europe and one in North America). Single‐centre studies were conducted in the UK, Italy and France. Participants in the studies ranged from eight to 70 years of age at enrolment, with the mean age in each study being between 18 years and 35 years (with an unweighted pooled mean age across studies of 25.9 years). All of the studies enroled both males and females, with the proportion of female participants ranging from 21% to 58%. Sixty‐eight per cent of participants had severe ataxia, while the other 32% had moderate ataxia. The studies tested epoetin alpha, CoQ10 and vitamin E, idebenone, leriglitazone, omaveloxolone, and RT001. One study tested pioglitazone but has not published any results. Four of the studies were pharmaceutical‐industry‐controlled. Synthesis of results Meta‐analysis of seven studies demonstrated that pharmacological treatment probably makes little or no difference to scores on the ataxia rating scale after 12 months of treatment (SMD 0.02, 95% CI −0.23 to 0.26; I² = 42%; 7 studies, 513 participants; moderate‐certainty evidence). The evidence was very uncertain about the effects of treatment on IVSTd (MD −0.51, 95% CI −1.10 to 0.09; I² = 80%; 2 studies, 72 participants; very low‐certainty evidence) and on ADL (MD −0.59, 95% CI −1.39 to 0.21; I² = 24%; 3 studies, 167 participants; very low‐certainty evidence). Meta‐analysis of three studies showed that treatment probably improves upper limb dexterity (SMD −0.42, 95% CI −0.73 to −0.11; I² = 0%; 3 studies, 166 participants; moderate‐certainty evidence). We are very uncertain about the effect of pharmacological treatment on CPET (SMD −0.16, 95% CI −0.46 to 0.13; I² = 0%; 3 studies, 181 participants; very low‐certainty evidence). We are very uncertain whether pharmacological treatment has any effect on treatment‐related adverse events (RR 0.88, 95% CI 0.63 to 1.22; I² = 0%; 2 studies, 104 participants; very low‐certainty evidence). There were only 104 participants in this analysis out of a total of 545 participants, so the result may have little relevance. Meta‐analysis of six studies found that there may be little to no difference between pharmacological treatment and placebo in treatment‐emergent adverse events leading to cessation of medication or death (RR 1.24, 95% CI 0.44 to 3.48; I² = 0%; 6 studies, 313 participants; low‐certainty evidence). Our certainty in the evidence ranged from very low to moderate. We downgraded all outcomes by one or two levels for imprecision, with further downgrades for inconsistency (for the outcomes of IVSTd, ADL, CPET) and suspected publication bias (for the outcomes of IVSTd, ADL, CPET and adverse events). Authors' conclusions In this updated Cochrane systematic review, meta‐analysis of results on the ataxia rating scale showed that pharmacological treatments probably make little or no difference compared with placebo after 12 months of treatment. Given this result, the probable improvement that we found in upper limb dexterity was unexpected. Treatment‐emergent adverse events leading to cessation of medication or death may be no more common in treatment groups than placebo groups as there were few adverse events detected in the treated groups. However, the studies may not have detected all rare and serious adverse events. Funding The authors in this review received no funding. Registration Protocol (2009) DOI: 10.1002/14651858.CD007791 Original review (2009) DOI: 10.1002/14651858.CD99791.pub2 Update (2012) DOI: 10.1002/14651858.CD007791.pub3 Update (2016) DOI: 10.1002/14651858.CD007791.pub4 Plain language summary Does taking medicine help people with Friedreich ataxia? Key messages For people with a progressive genetic condition called Friedreich ataxia, which affects nerves and muscles, taking medicine for a year probably has little to no effect on measures of ataxia (problems with co‐ordination and balance) or speech, although it probably improves upper limb dexterity (the ability to co‐ordinate the action of the arms, hands and fingers). We are uncertain whether taking medicine has any effect on heart health, the ability to perform daily tasks, or the body's response to exercise in people with Friedreich ataxia. From the available evidence, it is very uncertain whether the medicines cause any unwanted effects. What is Friedreich ataxia? Friedreich ataxia is a rare inherited condition affecting the nerves and muscles, which usually appears in childhood, at between 5 and 15 years of age. It causes clumsiness of movement, which progresses to unsteadiness in standing and walking, and to being dependent on a wheelchair by the late teens or early twenties. It can be associated with a curved spine (scoliosis), foot deformity (a high arch) and heart problems. As the disease progresses, slurred speech, hearing difficulties, problems going to the toilet, muscle spasticity, depression, anxiety and visual disturbances are common. Heart problems are a cause of early death in nearly two‐thirds of people with Friedreich ataxia. Clinical examination and laboratory tests are not very useful for judging the progression of the disease, which makes it difficult to understand the results of studies with Friedreich ataxia patients. What are the possible options for treating Friedreich ataxia? There is currently no cure for Friedreich ataxia. Various medicines have been tried. A new medicine, omaveloxolone, was recently approved in the USA and Europe for people over 16 years of age with Friedreich ataxia. What did we want to find out? We wanted to know if any of the medicines tested in randomised clinical trials help improve the lives of people with Friedreich ataxia. Randomised clinical trials are studies where some people take medicine and others take placebo, which is a substance that has no medical benefit but looks the same as the active medicine. No‐one involved with the study knows who is taking medicine and who is taking placebo. This is the third update of a Cochrane review that was first published in 2009. What did we do? We searched for randomised clinical trials that compared medicine to placebo in people with Friedreich ataxia and lasted at least 12 months. We combined the results of the studies and rated our confidence in this evidence, based on factors such as study methods and the number of people involved. What did we find? We found eight studies, seven of which reported results after taking medicine or placebo for 12 months. The studies included a total of 574 people, whose average ages were between 18 and 35 years. Most of the participants (68%) had severe ataxia, while 32% had moderate ataxia. The studies took place in Europe, North America and Australia. Four of them were carried out by the pharmaceutical industry (i.e. by companies who make the medicines). Two studies used a medicine called idebenone, and each of the others used a different medicine: co‐Q10 with vitamin E, epoetin alpha, omaveloxolone, leriglitazone, pioglitazone, and RT001. We found that, after one year, there was probably little to no difference in the level of ataxia that people experienced, regardless of whether they took medicine or placebo (7 studies, 513 people). We are very uncertain whether medicine has any effect on heart health (based on measuring the thickness of the heart muscle) or the ability to do daily tasks or how people score on special tests designed to measure the body's response to exercise. We found that medicine probably improves upper limb dexterity after one year (3 studies (testing leriglitazone, epoetin alpha and omaveloxolone), 166 people). With regard to safety, we are very uncertain whether the medicines cause any more unwanted effects than placebo. We found that there may be little to no difference between people taking medicine and people taking placebo in terms of the number of who either stopped taking the medicine or placebo, or the number of who died during the study years (6 studies, 313 people). What are the limitations of the evidence? Our confidence in the effect of medicine on ataxia is only moderate. This is because the results were not very precise. We are only moderately confident about the effect of medicine on upper limb dexterity because this was only reported in small studies. We had very little confidence in the other outcomes because of the small numbers of people in the studies. The studies reported varied results, and some studies did not publish the results for all the assessments that were carried out. It is difficult to measure an individual's perceptions of the positive effects of any new medicine, which may vary depending on their expectations prior to starting the medicine and whether their illness is early or advanced. How up to date is this evidence? The evidence is current to 4 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lyons, S; Kearney, M; Fahey, MC; Janjal, P; Pandolfo, M; Patton, P", "articleTypes": [], "doi": "10.1002/14651858.CD007791.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "9a354559-a7d4-431f-9646-f9770cec6dc9", "pmid": "", "title": "Ivermectin for preventing and treating COVID‐19", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Popp, M, Reis, S, Schießer, S, Hausinger, RIlona, Stegemann, M, Metzendorf, M-I, Kranke, P, Meybohm, P, Skoetz, N, Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015017.pub3 AB - Abstract - Background Ivermectin, an antiparasitic agent, inhibits the replication of viruses in vitro. The molecular hypothesis of ivermectin's antiviral mode of action suggests an inhibitory effect on severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) replication in early stages of infection. Currently, evidence on ivermectin for prevention of SARS‐CoV‐2 infection and COVID‐19 treatment is conflicting. Objectives To assess the efficacy and safety of ivermectin plus standard of care compared to standard of care plus/minus placebo, or any other proven intervention for people with COVID‐19 receiving treatment as inpatients or outpatients, and for prevention of an infection with SARS‐CoV‐2 (postexposure prophylaxis). Search methods We searched the Cochrane COVID‐19 Study Register, Web of Science (Emerging Citation Index and Science Citation Index), WHO COVID‐19 Global literature on coronavirus disease, and HTA database weekly to identify completed and ongoing trials without language restrictions to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022. Selection criteria We included randomized controlled trials (RCTs) comparing ivermectin to standard of care, placebo, or another proven intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. Co‐interventions had to be the same in both study arms. For this review update, we reappraised eligible trials for research integrity: only RCTs prospectively registered in a trial registry according to WHO guidelines for clinical trial registration were eligible for inclusion. Data collection and analysis We assessed RCTs for bias, using the Cochrane RoB 2 tool. We used GRADE to rate the certainty of evidence for outcomes in the following settings and populations: 1) to treat inpatients with moderate‐to‐severe COVID‐19, 2) to treat outpatients with mild COVID‐19 (outcomes: mortality, clinical worsening or improvement, (serious) adverse events, quality of life, and viral clearance), and 3) to prevent SARS‐CoV‐2 infection (outcomes: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, admission to hospital, mortality, adverse events and quality of life). Main results We excluded seven of the 14 trials included in the previous review version; six were not prospectively registered and one was non‐randomized. This updated review includes 11 trials with 3409 participants investigating ivermectin plus standard of care compared to standard of care plus/minus placebo. No trial investigated ivermectin for prevention of infection or compared ivermectin to an intervention with proven efficacy. Five trials treated participants with moderate COVID‐19 (inpatient settings); six treated mild COVID‐19 (outpatient settings). Eight trials were double‐blind and placebo‐controlled, and three were open‐label. We assessed around 50% of the trial results as low risk of bias. We identified 31 ongoing trials. In addition, there are 28 potentially eligible trials without publication of results, or with disparities in the reporting of the methods and results, held in ‘awaiting classification’ until the trial authors clarify questions upon request. Ivermectin for treating COVID‐19 in inpatient settings with moderate‐to‐severe disease We are uncertain whether ivermectin plus standard of care compared to standard of care plus/minus placebo reduces or increases all‐cause mortality at 28 days (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.14 to 2.51; 3 trials, 230 participants; very low‐certainty evidence); or clinical worsening, assessed by participants with new need for invasive mechanical ventilation or death at day 28 (RR 0.82, 95% CI 0.33 to 2.04; 2 trials, 118 participants; very low‐certainty evidence); or serious adverse events during the trial period (RR 1.55, 95% CI 0.07 to 35.89; 2 trials, 197 participants; very low‐certainty evidence). Ivermectin plus standard of care compared to standard of care plus placebo may have little or no effect on clinical improvement, assessed by the number of participants discharged alive at day 28 (RR 1.03, 95% CI 0.78 to 1.35; 1 trial, 73 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.04, 95% CI 0.61 to 1.79; 3 trials, 228 participants; low‐certainty evidence); and on viral clearance at 7 days (RR 1.12, 95% CI 0.80 to 1.58; 3 trials, 231 participants; low‐certainty evidence). No trial investigated quality of life at any time point. Ivermectin for treating COVID‐19 in outpatient settings with asymptomatic or mild disease Ivermectin plus standard of care compared to standard of care plus/minus placebo probably has little or no effect on all‐cause mortality at day 28 (RR 0.77, 95% CI 0.47 to 1.25; 6 trials, 2860 participants; moderate‐certainty evidence) and little or no effect on quality of life, measured with the PROMIS Global‐10 scale (physical component mean difference (MD) 0.00, 95% CI ‐0.98 to 0.98; and mental component MD 0.00, 95% CI ‐1.08 to 1.08; 1358 participants; high‐certainty evidence). Ivermectin may have little or no effect on clinical worsening, assessed by admission to hospital or death within 28 days (RR 1.09, 95% CI 0.20 to 6.02; 2 trials, 590 participants; low‐certainty evidence); on clinical improvement, assessed by the number of participants with all initial symptoms resolved up to 14 days (RR 0.90, 95% CI 0.60 to 1.36; 2 trials, 478 participants; low‐certainty evidence); on serious adverse events (RR 2.27, 95% CI 0.62 to 8.31; 5 trials, 1502 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.24, 95% CI 0.87 to 1.76; 5 trials, 1502 participants; low‐certainty evidence); and on viral clearance at day 7 compared to placebo(RR 1.01, 95% CI 0.69 to 1.48; 2 trials, 331 participants; low‐certainty evidence). None of the trials reporting duration of symptoms were eligible for meta‐analysis. Authors' conclusions For outpatients, there is currently low‐ to high‐certainty evidence that ivermectin has no beneficial effect for people with COVID‐19. Based on the very low‐certainty evidence for inpatients, we are still uncertain whether ivermectin prevents death or clinical worsening or increases serious adverse events, while there is low‐certainty evidence that it has no beneficial effect regarding clinical improvement, viral clearance and adverse events. No evidence is available on ivermectin to prevent SARS‐CoV‐2 infection. In this update, certainty of evidence increased through higher quality trials including more participants. According to this review's living approach, we will continually update our search. Plain language summary Ivermectin for preventing and treating COVID‐19 Is ivermectin effective for COVID‐19? Key messages We found no evidence to support the use of ivermectin for treating COVID‐19 or preventing SARS‐CoV‐2 infection. The evidence base improved slightly in this update, but is still limited. Evaluation of ivermectin is continuing in 31 ongoing trials, and we will update this review again when their results become available. What is ivermectin? Ivermectin is a medicine used to treat parasites, such as intestinal parasites in animals, and scabies in humans. It is inexpensive and is widely used in regions of the world where parasitic infestations are common. It has few unwanted effects. Medical regulators have not approved ivermectin for COVID‐19. What did we want to find out? We wanted to update our knowledge of whether ivermectin reduces death, illness, and length of infection in people with COVID‐19, or is useful in prevention of the infection. We included trials comparing the medicine to placebo (dummy treatment), usual care, or treatments for COVID‐19 that are known to work to some extent, such as dexamethasone. We excluded trials comparing ivermectin to other medicines that do not work, like hydroxychloroquine, or whose effectiveness against COVID‐19 is uncertain. We evaluated the effects of ivermectin in infected people on: – people dying;
– whether people's COVID‐19 got better or worse;
– quality of life;
– serious and non‐serious unwanted effects;
– viral clearance. For prevention, we sought the effect on preventing SARS‐CoV‐2 infection and COVID‐19 disease. What did we do? We searched for randomized controlled trials that investigated ivermectin to prevent or treat COVID‐19. People treated in hospital or as outpatients had to have laboratory‐confirmed COVID‐19. In this update, we also investigated the trustworthiness of the trials and only included them if they fulfilled clear ethical and scientific criteria. We compared and summarized the results of the trials and rated our confidence in the evidence, based on common criteria such as trial methods and sizes. What did we find? We excluded seven of the 14 trials included in the previous review as these trials did not fulfil the expected ethical and scientific criteria. Together with four new trials, we included 11 trials with 3409 participants that investigated ivermectin combined with any usual care compared to the same usual care or placebo. For treatment, there were five trials of people in hospital with moderate COVID‐19 and six trials of outpatients with mild COVID‐19. The trials used different doses of ivermectin and different durations of treatment. No trial investigated ivermectin to prevent SARS‐CoV‐2 infection. We also found 31 ongoing trials, and an additional 28 trials still requiring clarification from the authors or not yet published. Main results Treating people in hospital with COVID‐19 We do not know whether ivermectin compared with placebo or usual care 28 days after treatment: – leads to more or fewer deaths (3 trials, 230 people); 
– worsens or improves patients' condition, assessed by need for ventilation or death (2 trials, 118 people);
– increases or reduces serious unwanted events (2 trials, 197 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – improving patients' condition, assessed by discharge from hospital (1 trial, 73 people);
– non‐serious unwanted events (3 trials, 228 participants). Seven days after treatment, ivermectin may make little or no difference to reduction of negative COVID‐19 tests (3 trials, 231 participants) compared with placebo or usual care. Treating outpatients with COVID‐19 Ivermectin compared with placebo or usual care 28 days after treatment, probably makes little or no difference to people dying (6 trials, 2860 people). Ivermectin compared with placebo or usual care 28 days after treatment, makes little or no difference to quality of life (1 trial, 1358 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – worsening patients' condition, assessed by admission to hospital or death (2 trials, 590 people);
– serious unwanted events (5 trials, 1502 people); 
– non‐serious unwanted events (5 trials, 1502 participants); 
– improving people's COVID‐19 symptoms in the 14 days after treatment (2 trials, 478 people);
– number of people with negative COVID‐19 tests 7 days after treatment (2 trials, 331 people). What are the limitations of the evidence? Our confidence in the evidence, especially for outpatients, improved since the last review version, because we could look at more participants included in high‐quality trials. Although we are quite certain regarding our results on risk of people dying and quality of life, the confidence in the evidence is still low for many other outpatient and inpatient outcomes because there were only few events measured. The methods differed between trials, and they did not report everything we were interested in, such as relevant outcomes. How up to date is this evidence? The systematic literature search is up to date to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.790Z" }, { "id": "9a378d2f-1aec-49de-88c7-dbb7348d1ea9", "pmid": "", "title": "Interventions for managing taste disturbances", "imported": false, "abstract": "Abstract - Background The sense of taste is very much essential to the overall health of an individual. It is a necessary component to enjoy one's food, which in turn provides nutrition to an individual. Any disturbance in taste perception can hamper quality of life in such patients by influencing their appetite, body weight and psychological well‐being. Taste disorders have been treated using different modalities of treatment and there is no consensus for the best intervention. Hence this Cochrane Review was undertaken. This is an update of the Cochrane Review first published in November 2014. Objectives To assess the effects of interventions for the management of patients with taste disturbances. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 4 July 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017 Issue 6) in the Cochrane Library (searched 4 July 2017); MEDLINE Ovid (1946 to 4 July 2017); Embase Ovid (1980 to 4 July 2017); CINAHL EBSCO (1937 to 4 July 2017); and AMED Ovid (1985 to 4 July 2017). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for trials. Abstracts from scientific meetings and conferences were searched on 25 September 2017. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included all randomised controlled trials (RCTs) comparing any pharmacological agent with a control intervention or any non‐pharmacological agent with a control intervention. We also included cross‐over trials in the review. Data collection and analysis Two pairs of review authors independently, and in duplicate, assessed the quality of trials and extracted data. Wherever possible, we contacted trial authors for additional information. We collected adverse events information from the trials. Main results We included 10 trials (581 participants), nine of which we were able to include in the quantitative analyses (566 participants). We assessed three trials (30%) as having a low risk of bias, four trials (40%) at high risk of bias and three trials (30%) as having an unclear risk of bias. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Of these, nine trials with 544 people compared zinc supplements to placebo for patients with taste disorders. The participants in two trials were children and adolescents with respective mean ages of 10 and 11.2 years and the other seven trials had adult participants. Out of these nine, two trials assessed the patient‐reported outcome for improvement in taste acuity using zinc supplements (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.94 to 2.09; 119 participants, very low‐quality evidence). We meta‐analysed for taste acuity improvement using objective outcome (continuous data) in idiopathic and zinc‐deficient taste disorder patients (standardised mean difference (SMD) 0.44, 95% CI 0.23 to 0.65; 366 participants, three trials, very low‐quality evidence). We also analysed one cross‐over trial separately using the first half of the results for taste detection (mean difference (MD) 2.50, 95% CI 0.93 to 4.07; 14 participants, very low‐quality evidence), and taste recognition (MD 3.00, 95% CI 0.66 to 5.34; 14 participants, very low‐quality evidence). We meta‐analysed taste acuity improvement using objective outcome (dichotomous data) in idiopathic and zinc‐deficient taste disorder patients (RR 1.42, 95% 1.09 to 1.84; 292 participants, two trials, very low‐quality evidence). Out of the nine trials using zinc supplementation, four reported adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase, and minor increase in blood triglycerides. One trial tested taste discrimination using acupuncture (MD 2.80, 95% CI ‐1.18 to 6.78; 37 participants, very low‐quality evidence). No adverse events were reported in the acupuncture trial. None of the included trials could be included in the meta‐analysis for health‐related quality of life in taste disorder patients. Authors' conclusions We found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders. We did not find any evidence to conclude the role of zinc supplements for improving taste discrimination, or any evidence addressing health‐related quality of life due to taste disorders. We found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste). We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. Plain language summary Interventions for managing taste disturbances What is the aim of this review? The aim of this Cochrane Review was to find out what is the best method for the management of zinc‐deficient/idiopathic (of unknown cause) taste disorders and taste disorders secondary to chronic renal failure in children and adults. Key messages Giving zinc supplements or acupuncture may have some benefit in treating taste disorders. However, we still need more high‐quality studies to ascertain the role of zinc supplements and acupuncture in treating taste disorders. What was studied in the review? The sense of taste is essential to the health and psychological well‐being of an individual. Taste disorders can range from lack of taste, to distortion of taste, to reduced ability to taste. Any disorder in taste perception can lead to conditions like malnutrition and consumption of poisonous food substances. The cause may be due to disease, drugs, radiation treatment, or ageing; or it may result from unknown causes. Various treatment methods have been used to improve taste sensation. These include the use of zinc compounds, pilocarpine, alpha lipoic acid, transcranial magnetic stimulation, ginkgo biloba and acupuncture. What are the main results of the review? We collected and analysed all relevant studies to answer this question and found 10 trials in which a total of 581 subjects received different treatments. Nine trials assessed the benefits of zinc compounds and one trial assessed the effects of acupuncture. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure. Two trials were from Germany, three from Japan, two from the UK, and three from the US. These studies compared zinc with placebo or acupuncture with sham procedure for patients with taste disorders. Two were government funded, three were privately funded, two were funded by a pharmaceutical company and three trials did not mention funding details. When patients with taste disorders are given zinc, compared to placebo: ‐ we found very low‐quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low‐quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders;
 ‐ zinc supplementation showed adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase and minor increase in blood triglycerides;
 ‐ no studies were found that looked at improvement in taste discrimination or quality of life. When patients with taste disorders are given acupuncture, compared to sham procedure: ‐ we found very low‐quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste);
 ‐ acupuncture trial did not show adverse events;
 ‐ no studies were found that looked at improvement in taste acuity or quality of life. We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions. How up‐to‐date is this review? We searched for studies that had been published up to 4 July 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kumbargere Nagraj, S; George, RP; Shetty, N; Levenson, D; Ferraiolo, DM; Shrestha, A", "articleTypes": [], "doi": "10.1002/14651858.CD010470.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "9a395801-c8a0-4e04-b9eb-a6f16b21b2f5", "pmid": "", "title": "Pain relief in hysterosalpingography", "imported": false, "abstract": "Abstract - Background Hysterosalpingography (HSG) is a method of testing for tubal patency. However, women struggle to tolerate the procedure, as it is associated with some discomfort. Various pharmacological strategies are available that may reduce pain during the procedure, though there is no consensus as to the best method. Objectives To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing HSG for investigation of subfertility. Search methods This review has drawn on the search strategy developed for the Cochrane Menstrual Disorders and Subfertility Group (MDSG). We searched the following databases to 15 April 2015: MDSG Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO. Selection criteria All identified randomised controlled trials investigating pharmacological interventions for pain relief during HSG were investigated for selection. Data collection and analysis Four review authors independently extracted data. We combined data to calculate mean differences (MDs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I² statistic. We assessed the overall quality of the evidence for the main comparisons using GRADE methods. Main results The search identified 23 trials (1272 women) that were eligible for inclusion into the study. Oral opioid analgesia versus placebo/no treatment There was no evidence of effect for oral opioid analgesia in reducing pain during the procedure (MD −0.91, 95% CI −1.88 to 0.06, 1 study, n = 128, low quality evidence) or more than 30 minutes after the procedure (MD −0.99, 95% CI −1.75 to −0.23, 1 study, n = 128, moderate quality evidence) No studies reported on the effect of oral opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes after the procedure There was insufficient evidence to reach conclusions regarding adverse effects. Intravenous opioid analgesia versus placebo/no treatment There was evidence that intravenous opioids may improve pain relief during the procedure compared to no treatment (MD −3.53, 95% CI −4.29 to −2.77, 1 study, n = 62, moderate quality evidence) No studies reported on the effect of intravenous opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes and more than 30 minutes after the procedure In terms of adverse effects, one trial reported 1/32 participants had apnoea with intravenous remifentanil. Recovery time was nearly 4 minutes longer in the remifentanil group compared to the control. Oral non‐opioid analgesia versus placebo/no treatment There was no evidence of effect for oral non‐opioid analgesia in reducing pain during the procedure (MD −0.13, 95% CI −0.48 to 0.23, 3 studies, n = 133, I² = 61%, low quality evidence), less than 30 minutes after the procedure (MD −0.30, 95% CI −1.03 to 0.43, 2 studies, n = 45, I² = 97%, very low quality evidence), or more than 30 minutes after the procedure (MD −0.36, 95% CI −1.06 to 0.34, 3 studies, n = 133, I² = 58%, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Topical anaesthesia versus placebo/no treatment There was evidence that topical anaesthetics may reduce pain during the procedure (MD −0.63, 95% CI −1.06 to −0.19, 9 studies, n = 613, I² = 66%, low quality evidence). There was no evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD 0.42, 95% CI ‐0.03 to 0.86, 5 studies, n = 373, I² = 59%, very low quality evidence). There was evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain more than 30 minutes after the procedure (MD −1.38, 95% CI ‐3.44 to −0.68, 2 studies, n = 166, I² = 92%, very low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Locally injected anaesthesia versus placebo/no treatment There was evidence of effect that locally injected anaesthetic can reduce pain during the procedure (MD −1.31, 95% CI −1.55 to −1.07, 2 studies, n = 125, I² = 0%, very low quality evidence). There was no evidence of effect for locally injected anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD −1.31, 95% CI −2.14 to −0.49, 2 studies, n = 125, I² = 46%, low quality evidence). No studies were included into the analysis of the effect of locally injected anaesthesia, when injected prior to the procedure, in reducing pain more than 30 minutes after the procedure. There was insufficient evidence to reach conclusions regarding adverse effects. Any analgesic versus any other analgesic There was no evidence of a difference between the groups when oral non‐opioid analgesia was compared to opioid analgesia for pain relief during the procedure (MD 1.10, 95% CI −0.26 to 2.46, 1 study, n = 91, low quality evidence); less than 30 minutes following the procedure (MD −0.30, 95% CI −1.00 to 0.40, 1 study, n = 91, low quality evidence); and more than 30 minutes following the procedure (MD −0.60, 95% CI −1.56 to 0.36, 1 study, n = 91, low quality evidence). Topical anaesthetics were found to be more effective than paracervical block for pain relief during HSG (MD −2.73, 95% CI −3.86 to −1.60, 1 study, n = 20, moderate quality evidence). This benefit did not extend to within 30 minutes following HSG (MD −1.03, 95% CI −2.52 to 0.46, 1 study, n = 20, low quality evidence); or 30 minutes or more after HSG (MD 0.31, 95% CI −0.87 to 1.49, 1 study, n = 20, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Authors' conclusions Topical anaesthetic applied before the procedure may be associated with effective pain relief during HSG, though the quality of this evidence is low. Intravenous opioids may also be effective in pain relief, though this must be weighed against their side effects and their effects on the recovery time. There is insufficient evidence to draw conclusions on the efficacy of other analgesics for HSG, or to reach any other conclusions regarding adverse effects. Plain language summary Drug treatments for pain relief in hysterosalpingography Review question: Which pain‐killers are effective at reducing the discomfort experienced with hysterosalpingography? Background: Hysterosalpingography (HSG) is a test used in investigating infertility in women. HSG involves a dye being introduced into the uterus and the connecting tubes, which enables them to be visualised using an x‐ray, allowing the clinician to assess how open the connecting tubes are. This can be a painful procedure. There is disagreement regarding the best form of pain relief during the procedure. Study characteristics: We identified 19 randomised controlled trials that compared a specific drug treatment to a placebo/no treatment. Four trials compared two different drug treatments to establish if one was better. All studies took place in a clinical setting. Age of participants ranged from 18 to 42 years. Studies took place in India, Australia, United Kingdom, United States of America, Turkey, Israel, Netherlands, Italy, Iran, Nigeria, Spain, Brazil, and Belgium (1272 women in total). We included 15 of these trials in a meta‐analysis. The remaining eight trials, while eligible for inclusion, did not have data in a format that could be entered into meta‐analysis (seven compared a specific drug to a placebo/no treatment, one compared two different drug treatments). The evidence is current to April 2015. Key results : Topical anaesthetic was associated with a mild reduction in the pain experienced during HSG (low quality evidence). However, it has no effect on the discomfort experienced by participants following the procedure (very low quality evidence). Locally injected anaesthetics, on the other hand, were not associated with any benefit. Only one study investigated this (moderate quality evidence). One study directly compared locally injected anaesthetics to topical anaesthetics. This study found that topical anaesthesia was associated with improved pain relief during the procedure (moderate quality evidence) No oral drug was found to be effective in reducing pain experienced during the procedure. This was true for both opioid (low quality evidence) and non‐opioid (low quality evidence) analgesia. One trial however reported that tramadol may be of benefit in reducing the pain experienced more than 30 minutes after the procedure (moderate quality evidence). Quality of the evidence: The quality of the combined results was mainly downgraded for two reasons: 1) studies having methods that may be at risk of bias/inaccuracy; 2) substantially different conclusions between studies that investigate the same drug. The included studies did not report side effects in large enough numbers to make definitive conclusions regarding the side effects of particular drugs during the procedure. Conclusions: Only topical anaesthetics and intravenous opioids were found to be of benefit in reducing pain during the procedure, though the quality of this evidence is low to moderate, and there is no evidence that these are effective at relieving pain following the procedure. There is insufficient evidence for other drug treatments in reducing pain during HSG. There was insufficient evidence to reach any conclusions regarding adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hindocha, A; Beere, L; O'Flynn, H; Watson, A; Ahmad, G", "articleTypes": [], "doi": "10.1002/14651858.CD006106.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "9a405456-8702-44e2-b7a3-9183744b3aeb", "pmid": "", "title": "Thoracic imaging tests for the diagnosis of COVID‐19", "imported": false, "abstract": "Abstract - Background Our March 2021 edition of this review showed thoracic imaging computed tomography (CT) to be sensitive and moderately specific in diagnosing COVID‐19 pneumonia. This new edition is an update of the review. Objectives Our objectives were to evaluate the diagnostic accuracy of thoracic imaging in people with suspected COVID‐19; assess the rate of positive imaging in people who had an initial reverse transcriptase polymerase chain reaction (RT‐PCR) negative result and a positive RT‐PCR result on follow‐up; and evaluate the accuracy of thoracic imaging for screening COVID‐19 in asymptomatic individuals. The secondary objective was to assess threshold effects of index test positivity on accuracy. Search methods We searched the COVID‐19 Living Evidence Database from the University of Bern, the Cochrane COVID‐19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID‐19 publications through to 17 February 2021. We did not apply any language restrictions. Selection criteria We included diagnostic accuracy studies of all designs, except for case‐control, that recruited participants of any age group suspected to have COVID‐19. Studies had to assess chest CT, chest X‐ray, or ultrasound of the lungs for the diagnosis of COVID‐19, use a reference standard that included RT‐PCR, and report estimates of test accuracy or provide data from which we could compute estimates. We excluded studies that used imaging as part of the reference standard and studies that excluded participants with normal index test results. Data collection and analysis The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using QUADAS‐2. We presented sensitivity and specificity per study on paired forest plots, and summarized pooled estimates in tables. We used a bivariate meta‐analysis model where appropriate. Main results We included 98 studies in this review. Of these, 94 were included for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eight studies were included for assessing the rate of positive imaging in individuals with initial RT‐PCR negative results and positive RT‐PCR results on follow‐up, and 10 studies were included for evaluating the accuracy of thoracic imaging for imagining asymptomatic individuals. For all 98 included studies, risk of bias was high or unclear in 52 (53%) studies with respect to participant selection, in 64 (65%) studies with respect to reference standard, in 46 (47%) studies with respect to index test, and in 48 (49%) studies with respect to flow and timing. Concerns about the applicability of the evidence to: participants were high or unclear in eight (8%) studies; index test were high or unclear in seven (7%) studies; and reference standard were high or unclear in seven (7%) studies. Imaging in people with suspected COVID‐19 We included 94 studies. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All studies used RT‐PCR alone or in combination with other criteria (for example, clinical signs and symptoms, positive contacts) as the reference standard for the diagnosis of COVID‐19. For chest CT (69 studies, 28285 participants, 14,342 (51%) cases), sensitivities ranged from 45% to 100%, and specificities from 10% to 99%. The pooled sensitivity of chest CT was 86.9% (95% confidence interval (CI) 83.6 to 89.6), and pooled specificity was 78.3% (95% CI 73.7 to 82.3). Definition for index test positivity was a source of heterogeneity for sensitivity, but not specificity. Reference standard was not a source of heterogeneity. For chest X‐ray (17 studies, 8529 participants, 5303 (62%) cases), the sensitivity ranged from 44% to 94% and specificity from 24 to 93%. The pooled sensitivity of chest X‐ray was 73.1% (95% CI 64.1 to 80.5), and pooled specificity was 73.3% (95% CI 61.9 to 82.2). Definition for index test positivity was not found to be a source of heterogeneity. Definition for index test positivity and reference standard were not found to be sources of heterogeneity. For ultrasound of the lungs (15 studies, 2410 participants, 1158 (48%) cases), the sensitivity ranged from 73% to 94% and the specificity ranged from 21% to 98%. The pooled sensitivity of ultrasound was 88.9% (95% CI 84.9 to 92.0), and the pooled specificity was 72.2% (95% CI 58.8 to 82.5). Definition for index test positivity and reference standard were not found to be sources of heterogeneity. Indirect comparisons of modalities evaluated across all 94 studies indicated that chest CT and ultrasound gave higher sensitivity estimates than X‐ray (P = 0.0003 and P = 0.001, respectively). Chest CT and ultrasound gave similar sensitivities (P = 0.42). All modalities had similar specificities (CT versus X‐ray P = 0.36; CT versus ultrasound P = 0.32; X‐ray versus ultrasound P = 0.89). Imaging in PCR‐negative people who subsequently became positive For rate of positive imaging in individuals with initial RT‐PCR negative results, we included 8 studies (7 CT, 1 ultrasound) with a total of 198 participants suspected of having COVID‐19, all of whom had a final diagnosis of COVID‐19. Most studies (7/8) evaluated CT. Of 177 participants with initially negative RT‐PCR who had positive RT‐PCR results on follow‐up testing, 75.8% (95% CI 45.3 to 92.2) had positive CT findings. Imaging in asymptomatic PCR‐positive people For imaging asymptomatic individuals, we included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with a total of 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. For chest CT (7 studies, 3134 participants, 315 (10%) cases), the pooled sensitivity was 55.7% (95% CI 35.4 to 74.3) and the pooled specificity was 91.1% (95% CI 82.6 to 95.7). Authors' conclusions Chest CT and ultrasound of the lungs are sensitive and moderately specific in diagnosing COVID‐19. Chest X‐ray is moderately sensitive and moderately specific in diagnosing COVID‐19. Thus, chest CT and ultrasound may have more utility for ruling out COVID‐19 than for differentiating SARS‐CoV‐2 infection from other causes of respiratory illness. The uncertainty resulting from high or unclear risk of bias and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results. Plain language summary How accurate is chest imaging for diagnosing COVID‐19? Why is this question important? People with suspected COVID‐19 need to know quickly whether they are infected, so they can receive appropriate treatment, self‐isolate, and inform close contacts. Currently, a formal diagnosis of COVID‐19 requires a laboratory test (RT‐PCR) of nose and throat samples. RT‐PCR requires specialist equipment and takes at least 24 hours to produce a result. It is not completely accurate, and may require a second RT‐PCR or a different test to confirm diagnosis. Clinicians may use chest imaging to diagnose people who have COVID‐19 symptoms, while awaiting RT‐PCR results or when RT‐PCR results are negative, and the person has COVID‐19 symptoms. This is the fourth version of this review. What did we want to find out? We wanted to know whether chest imaging is accurate enough to diagnose COVID‐19 in people with suspected infection; we included studies in people with suspected COVID‐19 only and excluded studies in people with confirmed COVID‐19. We also wanted to assess the accuracy of chest imaging for screening asymptomatic people. The evidence is up to date to 17 February 2021. What are chest imaging tests? X‐rays or scans produce an image of the organs and structures in the chest. ‐ X‐rays (radiography) use radiation to produce a 2‐D image. Usually done in hospitals, using fixed equipment by a radiographer; they can also be done on portable machines. ‐ Computed tomography (CT) scans use a computer to merge 2‐D X‐ray images and convert them to a 3‐D image. They require highly‐specialized equipment and are done in hospital by a specialist radiographer. ‐ Ultrasound scans use high‐frequency sound waves to produce an image. They can be done in hospitals or other healthcare settings, such as a doctor’s office. What did we do? We searched for studies that assessed the accuracy of chest imaging to diagnose COVID‐19 in people of any age with suspected COVID‐19. We included studies with ‘symptomatic' or 'mixed populations'. What did we find? We found 94 studies with 37,631 participants (of whom 19,768 (53%) had a final diagnosis of COVID‐19) for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All 94 studies used RT‐PCR either alone or in combination with other criteria (such as clinical signs and symptoms, or positive contacts) as the reference standard for the diagnosis of COVID‐19. Chest CT: suspected people Pooled results showed that chest CT (69 studies) correctly diagnosed COVID‐19 in 87% of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 21% of people who did not have COVID‐19. Chest X‐ray: suspected people Pooled results showed that chest X‐ray (17 studies) correctly diagnosed COVID‐19 in 73 % of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 27% of people who did not have COVID‐19. Lung ultrasound: suspected people Pooled results showed that lung ultrasound (15 studies) correctly diagnosed COVID‐19 in 87% of people with COVID‐19. However, it incorrectly diagnosed COVID‐19 in 24% of people who did not have COVID‐19. Screening asymptomatic people We included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. Pooled results of seven studies, showed that CT correctly diagnosed COVID‐19 in 56% of people who had COVID‐19, and incorrectly identified COVID‐19 in 8% of people who did not have COVID‐19. How reliable are the results? The studies differed from each other and used different methods to report their results. Very few studies directly compared one type of imaging test with another. Also, the risk of bias was high or unclear in about half of all included studies. Therefore, it is difficult to draw confident conclusions. What does this mean? The evidence suggests that chest CT and ultrasound are better at ruling out COVID‐19 infection than distinguishing it from other respiratory problems. So, their usefulness may be limited to excluding COVID‐19 infection rather than differentiating it from other causes of lung infection. In addition, chest CT imaging had poor sensitivity and high specificity for detecting asymptomatic individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ebrahimzadeh, S; Islam, N; Dawit, H; Salameh, J-P; Kazi, S; Fabiano, N; Treanor, L; Absi, M; Ahmad, F; Rooprai, P; Al Khalil, A; Harper, K; Kamra, N; Leeflang, MMG; Hooft, L; van der Pol, CB; Prager, R; Hare, SS; Dennie, C; Spijker, R; Deeks, JJ; Dinnes, J; Jenniskens, K; Korevaar, DA; Cohen, JF; Van den Bruel, A; Takwoingi, Y; van de Wijgert, J; Wang, J; Pena, E; Sabongui, S; McInnes, MDF", "articleTypes": [], "doi": "10.1002/14651858.CD013639.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "9a51eb45-2db4-4fc5-92ab-240f4e80108b", "pmid": "", "title": "Diet or exercise, or both, for weight reduction in women after childbirth", "imported": false, "abstract": "Abstract - Background Weight retention after pregnancy may contribute to obesity. It is known that diet and exercise are recommended components of any weight loss programme in the general population. However, strategies to achieve healthy body weight among postpartum women have not been adequately evaluated. Objectives The objectives of this review were to evaluate the effect of diet, exercise or both for weight reduction in women after childbirth, and to assess the impact of these interventions on maternal body composition, cardiorespiratory fitness, breastfeeding performance and other child and maternal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012) and LILACS (31 January 2012). We scanned secondary references and contacted experts in the field. We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 30 April 2013 and added the results to the awaiting classification section of the review. Selection criteria All published and unpublished randomised controlled trials (RCTs) and quasi‐randomised trials of diet or exercise or both, among women during the postpartum period. Data collection and analysis Both review authors independently assessed trial quality and extracted data. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data. Data were analysed with a fixed‐effect model. A random‐effects model was used in the presence of heterogeneity. Main results Fourteen trials were included, but only 12 trials involving 910 women contributed data to outcome analysis. Women who exercised did not lose significantly more weight than women in the usual care group (two trials; n = 53; MD ‐0.10 kg; 95% confidence interval (CI) ‐1.90 to 1.71). Women who took part in a diet (one trial; n = 45; MD ‐1.70 kg; 95% CI ‐2.08 to ‐1.32), or diet plus exercise programme (seven trials; n = 573; MD ‐1.93 kg; 95% CI ‐2.96 to ‐0.89; random‐effects, T² = 1.09, I² = 71%), lost significantly more weight than women in the usual care group. There was no difference in the magnitude of weight loss between diet alone and diet plus exercise group (one trial; n = 43; MD 0.30 kg; 95% CI ‐0.06 to 0.66). The interventions seemed not to affect breastfeeding performance adversely. Authors' conclusions Evidence from this review suggests that both diet and exercise together and diet alone help women to lose weight after childbirth. Nevertheless, it may be preferable to lose weight through a combination of diet and exercise as this improves maternal cardiorespiratory fitness and preserves fat‐free mass, while diet alone reduces fat‐free mass. This needs confirmation in large trials of high methodological quality. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby. Plain language summary Diet or exercise, or both, for weight reduction in women carrying excess weight after childbirth Women naturally gain weight during pregnancy and many gradually lose it afterwards. Some women, though, find it difficult to lose the gained weight in the year or two following the birth of the baby and there is concern that this may be a health risk for them. The retention of weight gained during pregnancy may contribute to obesity, which can increase the risk of diabetes, heart disease and high blood pressure. It is suggested that women who return to their pre‐pregnancy weight by about six months have a lower risk of being overweight 10 years later. The review looked for randomised studies to assess the impact of dieting or exercise, or both, on women's weight loss in the months after giving birth. It paid particular attention to breastfeeding women to be sure that breastfeeding was not compromised. The review of trials found 14 studies, with 12 studies involving 910 women carrying excess weight after childbirth that contributed data for analysis. The findings suggest that diet combined with exercise or diet alone compared with usual care seemed to help with weight loss after giving birth. There is potential for these interventions to play a role in preventing future maternal obesity. There was not sufficient evidence to be sure that exercise or diet did not interfere with breastfeeding though it appeared not to in the included studies. It seems preferable to lose weight through a combination of dieting and exercise, compared to dieting alone, because exercise is thought to improve circulation and heart fitness, and to preserve lean body mass. Further research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Amorim Adegboye, AR, Linne, YM", "articleTypes": [], "doi": "10.1002/14651858.CD005627.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.773Z" }, { "id": "9a671beb-a0a5-436a-bb44-0c886c4cd281", "pmid": "", "title": "Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under", "imported": false, "abstract": "Abstract - Background Although complementary feeding is a universal practice, the methods and manner in which it is practiced vary between cultures, individuals and socioeconomic classes. The period of complementary feeding is a critical time of transition in the life of an infant, and inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. Educational interventions are widely acknowledged as effective in promoting public health strategy, and those aimed at improving complementary feeding practices provide information about proper complementary feeding practices to caregivers of infants/children. It is therefore important to summarise evidence on the effectiveness of educational interventions to improve the complementary feeding practices of caregivers of infants. Objectives To assess the effectiveness of educational interventions for improving the complementary feeding (weaning) practices of primary caregivers of children of complementary feeding age, and related health and growth outcomes in infants. Search methods In November 2017, we searched CENTRAL, MEDLINE, Embase, 10 other databases and two trials registers. We also searched the reference lists of relevant studies and reviews to identify any additional studies. We did not limit the searches by date, language or publication status. Selection criteria Randomised controlled trials (RCTs), comparing educational interventions to no intervention, usual practice, or educational interventions provided in conjunction with another intervention, so long as the educational intervention was only available in the experimental group and the adjunctive intervention was available to the control group. Study participants included caregivers of infants aged 4 to 24 months undergoing complementary feeding. Pregnant women who were expected to give birth and commence complementary feeding during the period of the study were also included. Data collection and analysis Two review authors independently extracted data on participants, settings, interventions, methodology and outcomes using a specifically‐developed and piloted data extraction form. We calculated risk ratios (RR) and 95% confidence intervals (CIs) for dichotomous data, and mean differences (MD) and 95% CIs for continuous data. Where data permitted, we conducted a meta‐analysis using a random‐effects model. We assessed the included studies for risk of bias and also assessed the quality of evidence using the GRADE approach. Main results We included 23 studies (from 35 reports) with a total of 11,170 caregiver‐infant pairs who were randomly assigned to receive an educational intervention delivered to the caregiver or usual care. Nineteen of the included studies were community‐based studies while four were facility‐based studies. In addition, 13 of the included studies were cluster‐randomised while the others were individually randomised. Generally, the interventions were focused on the introduction of complementary feeding at the appropriate time, the types and amount of complementary foods to be fed to infants, and hygiene. Using the GRADE criteria, we assessed the quality of the evidence as moderate, mostly due to inadequate allocation concealment and insufficient blinding. Educational interventions led to improvements in complementary feeding practices for age at introduction of complementary foods (average RR 0.88, 95% CI 0.83 to 0.94; 4 studies, 1738 children; moderate‐quality evidence) and hygiene practices (average RR 1.38, 95% CI 1.23 to 1.55; 4 studies, 2029 participants; moderate‐quality evidence). For duration of exclusive breastfeeding, pooled results were compatible with both a reduction and an increase in the outcome (average RR 1.58, 95% CI 0.77 to 3.22; 3 studies, 1544 children; very low‐quality evidence). There was limited (low to very low‐quality) evidence of an effect for all growth outcomes. Quality of evidence There is moderate to very low‐quality evidence that educational interventions can improve complementary feeding practices but insufficient evidence to conclude that it impacts growth outcomes. Authors' conclusions Overall, we found evidence that education improves complementary feeding practices. Plain language summary Educational interventions for improving complementary feeding practices Background Complementary feeding is the period when an infant moves from taking only breast milk or breast‐milk substitutes (such as infant formula) to family food. It is a critical period in the life of an infant. Inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. This is because inappropriate complementary feeding practices, such as introduction of semi‐solid foods too early (before six months of age), poor hygiene or giving foods that do not contain adequate nutrients, are all major causes of illness. Such illnesses include malnutrition, diarrhoea, poor growth, infections and poor mental development of children. Education has been proposed as an effective means of improving complementary feeding practices. Review question Does education improve complementary feeding practices of caregivers of infants as well as the health and growth of the infants? Study characteristics We searched for randomised controlled trials (a type of experiment in which people are randomly allocated to one or more treatment groups) up until November 2017. The search identified 23 studies involving a total of 11,170 caregivers and their children. The ages of the children ranged from birth to 24 months. The caregivers received educational interventions alone while the control group received no intervention, usual care or any other non‐educational intervention. The educational methods included printed materials such as leaflets, counselling, teaching sessions, peer support, videos and practical demonstrations. Generally, the education messages were focused on the introduction of semi‐solid foods at the appropriate age, the types and amount of complementary foods to be fed to infants, and hygiene. Key results Education reduced the number of caregivers that introduced semi‐solid foods to their infants before six months of age by up to 12% (moderate‐quality evidence). Hygiene practices of caregivers who received education also showed some improvement compared to those that did not (moderate‐quality evidence). In studies conducted in the community, education increased the duration of exclusive breastfeeding, but not in studies conducted in health facilities. There was no convincing evidence of an effect of education on the growth of children (low to very low‐quality evidence). We could not combine the results from different studies for diarrhoea, knowledge of caregivers and adequacy of complementary food. However, from the individual reports of the study authors, education led to a reduction in diarrhoea and an improvement in the knowledge of caregivers. It also led to improvement in the quality and quantity of complementary foods fed to infants. Overall, we found evidence that education improves complementary feeding practices.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Arikpo, D, Edet, ES, Chibuzor, MT, Odey, F, Caldwell, DM", "articleTypes": [], "doi": "10.1002/14651858.CD011768.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.802Z" }, { "id": "9a6ac076-91d7-4a9d-bb6b-244c4f21862b", "pmid": "", "title": "Lasers for caries removal in deciduous and permanent teeth", "imported": false, "abstract": "Abstract - Background Despite considerable improvements in oral health, dental caries continue to be a public health issue. The most frequently used, and universally accepted technique, to remove caries is through mechanical ablation of decayed tissues by means of rotating drills (diamond or tungsten carbide, or both). In the past few decades, the introduction of adhesive filling materials (resin composites) has affected cavity filling procedures by reducing its retention needs, with advantages for dental tissue conservation. Consequently, new minimally invasive strategies were introduced into dental practice, such as the use of lasers to perform highly controlled tissue ablation. Laser use has also raised expectations of limiting pain and discomfort compared to using drills, as well as overcoming drill phobia. Objectives The main objective of the review was to compare the effects of laser‐based methods to conventional mechanical methods for removing dental caries in deciduous and permanent teeth. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (searched 22 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 22 June 2016), MEDLINE Ovid (1946 to 22 June 2016), Embase Ovid (1980 to 22 June 2016), ProQuest Dissertations and Theses (1980 to 22 June 2016), Zetoc (limited to conference proceedings) (1993 to 22 June 2016), and ISI Web of Knowledge (limited to conference proceedings) (1990 to 22 June 2016). We checked the reference lists of relevant articles to identify additional studies. We searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. Selection criteria We included randomised controlled trials, split‐mouth trials and cluster‐randomised trials (irrespective of their language) comparing laser therapy to drill ablation of caries. We included participants of any age (children, adolescents and adults). Data collection and analysis Two review authors independently screened titles and abstracts of citations identified by the review search strategy. Two review authors independently evaluated the full text of relevant primary studies, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. Main results We included nine randomised trials, published between 1998 and 2014, involving 662 participants. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Four studies examined only permanent teeth, and five studies evaluated both deciduous and permanent teeth. Six trials used Er:YAG (erbium‐doped yttrium aluminium garnet) lasers, two trials employed Er,Cr:YSGG (erbium, chromium: yttrium‐scandium‐gallium‐garnet) lasers, and one trial used Nd:YAG (neodymium‐doped yttrium aluminium garnet) laser. Overall, the trials had small sample sizes, and the majority were at unclear or high risk of bias. The primary outcomes were evaluated in a limited number of trials (removal of caries (four trials (but only two reported quantitative data)); episodes of pain (five studies)). There was insufficient evidence to suggest that either lasers or drill were better at caries removal (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.99 to 1.01; 2 studies; 256 treated caries; P = 0.75; I 2 = 0%; low‐quality evidence). The incidence of moderate or high pain was greater in the drill group compared to the laser group (RR 0.40, 95% CI 0.28 to 0.57; 2 studies; 143 participants; P < 0.001; I 2 = 50%). Similarly, the need for anaesthesia was significantly higher in the drill group than in the laser group (RR 0.25, 95% CI 0.10 to 0.65; 3 studies; 217 children/adolescents; P = 0.004; I 2 = 0%). In terms of marginal integrity of restoration, there was no evidence of a difference between laser and drill comparisons evaluated at 6 months (RR 1.00, 95% CI 0.21 to 4.78; 3 studies), 1 year (RR 1.59, 95% CI 0.34 to 7.38; 2 studies), or 2 years (RR 1.00, 95% CI 0.21 to 4.74; 1 study). There was no evidence of a difference for durability of restoration between laser therapy or drill at 6 months' follow‐up (RR 2.40, 95% CI 0.65 to 8.77; 4 studies), at 1 year (RR 1.40, 95% CI 0.29 to 6.78; 2 studies) or at 2 years' follow‐up (RR 0.50, 95% CI 0.02 to 14.60; 1 study). Only two trials investigated the recurrence of caries, but no events occurred during 6 months' follow‐up. There was insufficient evidence of a difference between laser or drill in terms of pulpal inflammation or necrosis at 1 week (RR 1.51, 95% CI 0.26 to 8.75; 3 studies) and at 6 months (RR 0.99, 95% CI 0.10 to 9.41; 2 studies). Authors' conclusions Given the low quality of the body of evidence, we concluded that evidence was insufficient to support the use of laser as an alternative to traditional drill therapy for caries removal. We found some evidence in favour of laser therapy for pain control, need of anaesthesia and patient discomfort, but, again, the body of evidence was of low quality. Additional well‐designed, randomised trials investigating the most relevant outcomes are needed. Plain language summary Lasers for the removal of decay in first and permanent teeth Review question This review addressed the issue of whether there is an advantage to laser therapy for the removal of decay in teeth and patient pain, compared to a traditional drill, in children, adolescents and adults. Background Dental decay is a cavity formation in teeth resulting from the destruction of dental tissue caused by bacteria under certain conditions, including poor oral hygiene and excessive sugar intake. Symptoms may include pain and difficulty with eating, and complications may include tooth loss, infection or inflammation of the gum. Rotating drills are traditionally used to remove decay. However, this mechanical tool may have unexpected side effects, such as the removal of too much or too little decay, in addition to discomfort due to pain, noise and vibration. Laser therapy is a potential alternative to a mechanical drill. Study characteristics Cochrane Oral Health provided the search strategies and carried out the search in several electronic databases. We selected nine randomised trials for inclusion in this review that were conducted between 1998 and 2014. The evidence in the review is up to date as of 22 June 2016. The trials involved a total of 662 participants, with 1498 teeth treated. Three studies were conducted in the USA, one in Taiwan, one in China, one in Bulgaria, one in Germany, one in Turkey and one in the UK. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Key results Despite the number of included studies, only a few trials adequately and completely reported information on the primary outcomes. Two trials reported on removal of decay, and there was not enough evidence to conclude that either lasers or drills were better at decay removal. Only five trials reported on episodes of pain, which was significantly reduced in people treated with lasers. There was no difference in terms of side effects, such as inflammation or death of dental pulp, between the two interventions. Quality of the evidence The overall quality of the evidence for the nine studies was low. Only one study adequately randomised participants, and none of the included studies was at low risk of bias. This review highlights the need for high‐quality studies comparing laser therapy and mechanical drills in the treatment of dental decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Montedori, A; Abraha, I; Orso, M; D'Errico, PG; Pagano, S; Lombardo, G", "articleTypes": [], "doi": "10.1002/14651858.CD010229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "9a77fd90-96ae-4c86-88d1-efb68574156d", "pmid": "", "title": "Sucrose for analgesia in newborn infants undergoing painful procedures", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose with and without non‐nutritive sucking is the most frequently studied non‐pharmacological intervention for procedural pain relief in neonates. Objectives To determine the efficacy, effect of dose, method of administration and safety of sucrose for relieving procedural pain in neonates as assessed by validated composite pain scores, physiological pain indicators (heart rate, respiratory rate, saturation of peripheral oxygen in the blood, transcutaneous oxygen and carbon dioxide (gas exchange measured across the skin ‐ TcpO 2 , TcpCO 2 ), n ear i nfra r ed s pectroscopy (NIRS), e lectro e ncephalo g ram (EEG), or behavioural pain indicators (cry duration, proportion of time crying, proportion of time facial actions (e.g. grimace) are present), or a combination of these and long‐term neurodevelopmental outcomes. Search methods We used the standard methods of the Cochrane Neonatal. We performed electronic and manual literature searches in February 2016 for published randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library , Issue 1, 2016), MEDLINE (1950 to 2016), EMBASE (1980 to 2016), and CINAHL (1982 to 2016) . We did not impose language restrictions. Selection criteria RCTs in which term or preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age), or both, received sucrose for procedural pain. Control interventions included no treatment, water, glucose, breast milk, breastfeeding, local anaesthetic, pacifier, positioning/containing or acupuncture. Data collection and analysis Our main outcome measures were composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We reported a mean difference (MD) or weighted MD (WMD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. For categorical data we used risk ratio (RR) and risk difference. We assessed heterogeneity by the I 2 test. We assessed the risk of bias of included trials using the Cochrane 'Risk of bias' tool, and assessed the quality of the evidence using the GRADE system. Main results Seventy‐four studies enrolling 7049 infants were included. Results from only a few studies could be combined in meta‐analyses and for most analyses the GRADE assessments indicated low‐ or moderate‐quality evidence. There was high‐quality evidence for the beneficial effect of sucrose (24%) with non‐nutritive sucking (pacifier dipped in sucrose) or 0.5 mL of sucrose orally in preterm and term infants: Premature Infant Pain Profile (PIPP) 30 s after heel lance WMD ‐1.70 (95% CI ‐2.13 to ‐1.26; I 2 = 0% (no heterogeneity); 3 studies, n = 278); PIPP 60 s after heel lance WMD ‐2.14 (95% CI ‐3.34 to ‐0.94; I 2 = 0% (no heterogeneity; 2 studies, n = 164). There was high‐quality evidence for the use of 2 mL 24% sucrose prior to venipuncture: PIPP during venipuncture WMD ‐2.79 (95% CI ‐3.76 to ‐1.83; I 2 = 0% (no heterogeneity; 2 groups in 1 study, n = 213); and intramuscular injections: PIPP during intramuscular injection WMD ‐1.05 (95% CI ‐1.98 to ‐0.12; I 2 = 0% (2 groups in 1 study, n = 232). Evidence from studies that could not be included in RevMan‐analyses supported these findings. Reported adverse effects were minor and similar in the sucrose and control groups. Sucrose is not effective in reducing pain from circumcision. The effectiveness of sucrose for reducing pain/stress from other interventions such as arterial puncture, subcutaneous injection, insertion of nasogastric or orogastric tubes, bladder catherization, eye examinations and echocardiography examinations are inconclusive. Most trials indicated some benefit of sucrose use but that the evidence for other painful procedures is of lower quality as it is based on few studies of small sample sizes. The effects of sucrose on long‐term neurodevelopmental outcomes are unknown. Authors' conclusions Sucrose is effective for reducing procedural pain from single events such as heel lance, venipuncture and intramuscular injection in both preterm and term infants. No serious side effects or harms have been documented with this intervention. We could not identify an optimal dose due to inconsistency in effective sucrose dosage among studies. Further investigation of repeated administration of sucrose in neonates is needed. There is some moderate‐quality evidence that sucrose in combination with other non‐pharmacological interventions such as non‐nutritive sucking is more effective than sucrose alone, but more research of this and sucrose in combination with pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing painful procedures Review question Cochrane reviewers investigated how well sucrose (table sugar) works as a reliever of pain in newborn babies who are having painful procedures (e.g. an injection, or heel lance, or insertion of a needle to obtain a blood sample (venipuncture), or eye examinations). The babies' pain responses (e.g. crying, grimacing) were assessed by scoring systems for pain used by health care professionals to measure the pain that babies are experiencing. In addition, the reviewers wanted to investigate whether the level of pain relief is related to the dose of sucrose, or the method of delivery (e.g. as a solution squirted into the mouth, or on a pacifier (also called a soother or dummy), and whether there are any safety concerns about using sucrose to relieve pain. Background Although there are ways to manage the pain of surgery, medical illness and major procedures, ways of preventing or reducing pain from minor medical procedures (e.g. heel lance and venipuncture) have, until relatively recently, been lacking. Sucrose has been examined for its calming effects in crying newborns and its pain‐relieving effects for invasive procedures in full‐term and premature newborns. Study characteristics We searched the medical literature widely up to February 2016 for studies that investigated the pain‐relieving effect of sucrose for minor medical procedures in newborn full‐term and premature babies. We included randomised controlled trials only, as these provide the most reliable medical evidence. We identified 74 studies that reported on a total of more than 7000 infants in this Cochrane Review. Thirty‐eight studies included full‐term babies only, 31 included premature babies only, and five included both full‐term and premature babies. Heel lance was the painful procedure in 38 studies, and venipuncture in nine; the remaining studies investigated a wide variety of other minor painful procedures. The studies used a variety of delivery methods for the sucrose solution (oral syringe, dropper or sucrose‐dipped pacifier), as well as a range of concentrations and volumes of dose. Sucrose treatment was compared with giving the babies a similar volume of water, a pacifier, routine care, breastfeeding, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), laser acupuncture, swaddling, warmth, anaesthetic cream for the skin (EMLA), or a combination of these. The studies used a range of pain assessment scales to measure their results. Study funding sources We did not identify any studies that received funding from the industry. Key results There was high‐quality evidence that sucrose reduces different measures of newborn pain during heel lance, venipuncture and intramuscular injection. However, sucrose does not provide effective pain relief during circumcision. There is conflicting evidence for whether sucrose reduces pain for other minor painful procedures and further research is needed to investigate these more thoroughly. Twenty‐nine studies reported on adverse events (harms of the sucrose and other treatments) and found that the number of minor adverse events (e.g. choking or gagging) was very low, and was similar in the different groups (so not attributable to the sucrose treatment). No major adverse events were reported. Quality of evidence Although sucrose has been widely studied as a pain reliever for newborn babies, most studies have included few babies and have used many different measures of pain to assess its effectiveness. We identified high‐quality evidence that sucrose reduces pain for heel lance, venipuncture and intramuscular injection. The quality of evidence was low or moderate in favour for the use of sucrose for other painful procedures.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stevens, B, Yamada, J, Ohlsson, A, Haliburton, S, Shorkey, A", "articleTypes": [], "doi": "10.1002/14651858.CD001069.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.077Z" }, { "id": "9a7a8253-af88-43e6-b9e8-7b1fd5e5d5b3", "pmid": "", "title": "A Multicenter, Open-label, Randomized Study to Evaluate the Efficacy and Safety of Ropeginterferon Alfa-2b in the Treatment of Patients With Moderate COVID-19", "imported": false, "abstract": "To evaluate the efficacy of subcutaneous ropeginterferon alfa 2b ( P1101combined with standard of care (SOC) compared with standard care alone in hospitalized adults with moderate COVID 19.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.152Z" }, { "id": "9ad33ebe-085c-4b21-a148-8a957f716db7", "pmid": "", "title": "Antibiotics for the induction and maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Antibiotics have been considered to treat ulcerative colitis (UC) due to their antimicrobial properties against intestinal bacteria linked to inflammation. However, there are concerns about their efficacy and safety. Objectives To determine whether antibiotic therapy is safe and effective for the induction and maintenance of remission in people with UC. Search methods We searched five electronic databases on 10 December 2021 for randomised controlled trials (RCTs) comparing antibiotic therapy to placebo or an active comparator. Selection criteria We considered people with UC of all ages, treated with antibiotics of any type, dose, and route of administration for inclusion. Induction studies required a minimum duration of two weeks for inclusion. Maintenance studies required a minimum duration of three months to be considered for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcome for induction studies was failure to achieve remission and for maintenance studies was relapse, as defined by the primary studies. Main results We included 12 RCTs (847 participants). One maintenance of remission study used sole antibiotic therapy compared with 5‐aminosalicylic acid (5‐ASA). All other trials used concurrent medications or standard care regimens and antibiotics as an adjunct therapy or compared antibiotics with other adjunct therapies to examine the effect on induction of remission. There is high certainty evidence that antibiotics (154/304 participants) compared to placebo (175/304 participants) result in no difference in failure to achieve clinical remission (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.06). A subgroup analysis found no differences when steroids, steroids plus 5‐ASA, or steroids plus 5‐ASA plus probiotics were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (102/168 participants) compared to placebo (121/175 participants) may result in no difference in failure to achieve clinical response (RR 0.75, 95% CI 0.47 to 1.22). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (6/342 participants) compared to placebo (5/349 participants) may result in no difference in serious adverse events (RR 1.19, 95% CI 0.38 to 3.71). A subgroup analysis found no differences when steroids were additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (3/342 participants) compared to placebo (1/349 participants) may result in no difference in withdrawals due to adverse events (RR 2.06, 95% CI 0.27 to 15.72). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were additional therapies to antibiotics and placebo. It is unclear if there is any difference between antibiotics in combination with probiotics compared to no treatment or placebo for failure to achieve clinical remission (RR 0.68, 95% CI 0.39 to 1.19), serious adverse events (RR 1.00, 95% CI 0.07 to 15.08), or withdrawals due to adverse events (RR 1.00, 95% CI 0.07 to 15.08). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to achieve clinical remission (RR 2.20, 95% CI 1.17 to 4.14). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to probiotics for failure to achieve clinical remission (RR 0.47, 95% CI 0.23 to 0.94). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to maintain clinical remission (RR 0.71, 95% CI 0.47 to 1.06). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to no treatment for failure to achieve clinical remission in a mixed population of people with active and inactive disease (RR 0.56, 95% CI 0.29 to 1.07). The certainty of the evidence is very low. For all other outcomes, no effects could be estimated due to a lack of data. Authors' conclusions There is high certainty evidence that there is no difference between antibiotics and placebo in the proportion of people who achieve clinical remission at the end of the intervention period. However, there is evidence that there may be a greater proportion of people who achieve clinical remission and probably a greater proportion who achieve clinical response with antibiotics when compared with placebo at 12 months. There may be no difference in serious adverse events or withdrawals due to adverse events between antibiotics and placebo. No clear conclusions can be drawn for any other comparisons. A clear direction for future research appears to be comparisons of antibiotics and placebo (in addition to standard therapies) with longer‐term measurement of outcomes. Additionally. As there were single studies of other head‐to‐head comparisons, there may be scope for future studies in this area. Plain language summary The use of antibiotics in the treatment of ulcerative colitis What was the aim of this review? This Cochrane Review aimed to determine whether antibiotics are useful and safe for people with ulcerative colitis (UC) in achieving or maintaining remission. Key messages We found that antibiotics, when added to standard therapies, are similar to placebo in how often they fail to achieve remission or disease improvement for people with UC, measured up to three months from taking them. We found that antibiotics when compared to placebo may be useful in achieving remission or some improvement of UC symptoms, measured at 12 months from taking them. In terms of safety, the evidence is of low certainty, but antibiotics may be as safe as placebo. We have confidence in the findings up to three months, but have less confidence in the evidence at 12 months due to low numbers of study participants. What is ulcerative colitis? UC is a chronic (long term) inflammatory disease that affects the large bowel. The most common symptoms include bloody diarrhoea, abdominal pain, and a sudden almost uncontrollable urge to pass stool. Some people have other symptoms including sore joints, mouth sores, and inflammation in their eyes. When someone is experiencing symptoms of UC, they are said to have 'active' disease. When symptoms improve with treatment, the disease is said to be responding to therapy. When symptoms stop, the disease is said to be in 'remission'. People with UC in remission are often given therapy with medicines to try and prolong (maintain) their remission or response to therapy. What did the review study? This review studied the use of antibiotics in the treatment of UC. Eleven studies considered antibiotics as a therapy for achieving remission and one study as therapy for maintaining remission. Antibiotics could theoretically be helpful as they might be able to fight harmful bacteria in the gut that are thought to be a partial cause for the presence of UC symptoms. Currently, most doctors do not recommend the use of antibiotics unless the patient has an infection. What were the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing antibiotics with another treatment or dummy treatment. We found 12 RCTs including 847 participants. The trials looked at people of all ages; using different types and doses of antibiotics; and at antibiotics taken as tablets, injections, or any other way. The main results from our review are as follows. 1. Antibiotics, when added to standard therapies, are no different from placebo in failing to achieve remission or improve disease symptoms for people with UC when measured up to three months from taking them. 2. Antibiotics probably fail less than placebo in achieving remission or some improvement of UC symptoms measured at 12 months from taking them. 3. In terms of safety, antibiotics may be similar to placebo, but the evidence is of low certainty. 4. We are uncertain about how antibiotics compare to other treatments because there is not enough good evidence to make a judgement. Conclusion There is no difference between antibiotics and placebo when added to standard therapies to achieve remission or improvement of symptoms in the short term. However, they may help to lessen the number of people who do not achieve remission, and they probably lead to fewer numbers of people who have not achieved improvement of symptoms at 12 months. No conclusions can be drawn on other treatments or safety due to lack of evidence, even though there may be a possibility that antibiotics are as safe as placebo. Further research would be needed to clarify the usefulness of antibiotics in the treatment of UC; however, such studies should focus on longer‐term outcomes given the findings of this review. How up‐to‐date is this review? This review is up‐to‐date as of December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Gordon, M, Sinopoulou, V, Grafton-Clarke, C, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.768Z" }, { "id": "9ae903d8-797f-4b5c-b718-e986631b11f1", "pmid": "", "title": "Sucrose analgesia for venepuncture in neonates", "imported": false, "abstract": "Abstract - Rationale Sucrose is, in general, safe and effective for analgesia during venepuncture in hospitalised neonates. However, there is a lack of evidence on its analgesic effects. Objectives To evaluate the benefits and harms of orally administered sucrose for pain relief from venepuncture in preterm and term neonates compared to no intervention, standard care, and other types of analgesic interventions. Search methods We searched CENTRAL, MEDLINE, Ovid Embase, and trial registries in July 2025, and the China National Knowledge Infrastructure, VIP Chinese Science and Technology Periodicals, and Wanfang Data in August 2024. We checked reference lists of included studies and topic‐related systematic reviews. Eligibility criteria We included randomised controlled trials (RCTs), including cross‐over and cluster‐RCTs, that evaluated the effects of sucrose analgesia in neonates (including term and preterm infants) up to 44 weeks' postmenstrual age undergoing venepuncture. We excluded quasi‐RCTs and studies reported only as conference abstracts. We included studies administering sucrose with or without non‐nutritive sucking (NNS) before, at the time of, or after venepuncture. Sucrose could be of any concentration, volume, or dose. Sucrose was compared to: no intervention, water, or standard care; skin‐to‐skin care; breastfeeding; feeding; NNS alone (e.g. pacifier); glucose; positioning; or topical anaesthetics. Outcomes Outcomes of interest were pain intensity score, as measured by validated pain assessment scales, and adverse events. Risk of bias We used the Cochrane risk of bias tool (RoB 1). Synthesis methods We synthesised results for each outcome using meta‐analysis where possible. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous data (presence or absence of pain). We calculated the standardised mean difference (SMD) or mean difference (MD) for pain intensity scores (continuous outcome), each with its 95% CI. We used a fixed‐effect model to combine data and quantified the impact of heterogeneity using the I² statistic. Where these methods were not feasible due to the nature of the data, we synthesised the results narratively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included a total of 29 studies, accounting for 2764 term and preterm neonates. There was a large variation in sucrose dose and concentration (from 0.1 mL/kg to 0.5 mL/kg or a set volume from 0.1 mL to 2 mL) as well as mode of administration (e.g. oral syringe, pacifier, dropper, in combination with a pacifier). Most of the studies compared sucrose to no intervention, water, or standard care (n = 17). Other comparisons include non‐nutritive sucking, skin‐to‐skin care, breastfeeding, expressed breast milk, and other sweet solutions. Synthesis of results Adverse events (e.g. gagging, apnoea) were not reported for any comparison. Sucrose (with or without NNS) versus no intervention, water, or standard care Sucrose with or without NNS probably reduces pain intensity scores during and 30 seconds after venepuncture compared to no intervention (SMD −0.82, 95% CI −1.02 to −0.63; 7 studies, 477 participants; moderate‐certainty evidence). Sucrose with NNS reduces pain intensity scores one minute after venepuncture compared to no intervention (MD −9.15, 95% CI −9.91 to −8.39; 1 study, 100 participants; high‐certainty evidence). The evidence is uncertain about the effect of sucrose without NNS on pain intensity scores two minutes after venepuncture compared to no intervention (SMD −0.99, 95% CI −1.31 to −0.68; 3 studies, 186 participants; very low‐certainty evidence). Sucrose (with or without NNS) versus skin‐to‐skin care Sucrose without NNS may make little to no difference to pain scores during venepuncture when compared to skin‐to‐skin care (MD 1.49, 95% CI 0.86 to 2.12; 2 studies, 208 participants; low‐certainty evidence). Pain scores after 30 seconds, one minute, and two minutes were not reported. Sucrose (with or without NNS) versus breastfeeding Sucrose probably reduces pain during venepuncture compared to breastfeeding, as measured with the Neonatal Facial Coding System (where 0 = no pain, > 0 = pain) (RR 1.38, 95% CI 1.01 to 1.88; 1 study, 103 participants; moderate‐certainty evidence). Sucrose may result in little to no difference in pain compared to breastfeeding two minutes after venepuncture (RR 1.06, 95% CI 0.94 to 1.19; 1 study, 104 participants; low‐certainty evidence). Pain scores after 30 seconds and one minute were not reported. Sucrose (with or without NNS) versus NNS Sucrose with NNS likely reduces pain during venepuncture compared to NNS (SMD −1.52, 95% CI −1.92 to −1.12; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS may not reduce pain intensity scores during venepuncture compared to NNS (MD 1.37, 95% CI 0.57 to 2.17; 2 studies, 133 participants; low‐certainty evidence). Sucrose with NNS may reduce pain intensity scores one minute after venepuncture compared to NNS (MD −5.81, 95% CI −6.30 to −5.32; 2 studies, 200 participants; low‐certainty evidence). Sucrose with NNS probably reduces pain intensity two minutes after venepuncture compared to NNS alone (SMD −1.30, 95% CI −1.71 to −0.89; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS (MD 0.47, 95% CI −0.14 to 1.08; 1 study, 56 participants; moderate‐certainty evidence). We downgraded the certainty of the evidence in several comparisons, mostly due to unclear or high risk of selection, performance, detection, and reporting bias. High heterogeneity was also detected. Authors' conclusions Current evidence suggests sucrose probably reduces pain scores during and shortly after venepuncture compared to no intervention, water, or standard care. The evidence is very uncertain regarding the effects of sucrose compared to skin‐to‐skin care for analgesia during venepuncture. Compared to breastfeeding, sucrose probably results in a reduction of pain scores during venepuncture, but may result in little difference in pain scores two minutes after venepuncture. The evidence suggests sucrose with NNS probably reduces pain scores during and following venepuncture compared to NNS alone. Sucrose alone probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS. Funding This review had no dedicated funding. Registration Protocol available via doi/10.1002/14651858.CD015221 Plain language summary Does giving newborns sugar water during needle procedures reduce their pain? Key messages Newborn babies given sucrose (sugar water) when undergoing a needle procedure probably have less pain during and shortly after the procedure than babies given nothing, water, or standard comfort measures. Sucrose seems to reduce pain more than pacifiers. We do not have good evidence about the effect of sucrose compared to skin‐to‐skin care. No studies reported on harmful side effects, such as gagging or apnoea (a temporary pause in breathing). What is sucrose analgesia (pain relief)? Sucrose is table sugar. When mixed with water, and in very small amounts, it can be used for pain relief in newborn babies. Sucrose is dropped on a baby's tongue about two minutes before and/or immediately before venepuncture, when a needle is put into a vein to take blood or give treatment. Why is pain relief important for newborn babies who are in hospital? Hospitalised preterm babies (i.e. born early) and term babies (i.e. born at the normal time) are exposed to many painful procedures to give them medicine and to diagnose problems. Pain has many consequences for newborn babies. It can contribute to poor physical growth and affect brain development. Therefore, it is important to reduce babies' experience of pain as much as possible to ensure health as they grow. What did we want to find out? We wanted to find out how well sucrose worked to relieve pain in newborn babies during and shortly after needle punctures. We wanted to know how sucrose compared to other pain relief methods such as pacifier sucking, breastfeeding, or being held next to a mother or father's skin (skin‐to‐skin care). We also wanted to find out if sucrose caused negative effects. What did we do? We searched for studies that investigated the pain‐relief effects of sucrose compared to other methods (e.g. breastfeeding, pacifiers, holding). We summarised the results and rated our confidence in the evidence based on factors such as the number of infants treated and the quality of the methods used in the studies. What did we find? We found 29 studies that included 2764 newborn babies. The studies used different doses of sucrose and gave the sucrose to the babies in different ways. The studies were conducted worldwide. Most were carried out in Asia, with additional studies from Europe, North America, and South America. All the studies were randomised controlled trials, in which infants were assigned randomly to two or more treatment groups. This is the best way to ensure that the infant groups are similar, and that investigators and parents don’t know who is in which group. None of the studies were supported by the pharmaceutical industry. Main results Sucrose probably reduces babies' pain during and shortly after (30 seconds to 1 minute) the needle insertion compared to no pain relief (such as water). Sucrose may make little to no difference to pain during the procedure compared to skin‐to‐skin care. Sucrose probably reduces pain during the needle insertion compared to breastfeeding. Sucrose (with pacifier sucking) likely reduces pain during and shortly after (30 seconds to 2 minutes) the needle insertion compared to pacifier sucking alone. No study reported on harmful effects for any of our comparisons of interest. What are the limitations of the evidence? Sucrose versus no intervention or water We are moderately confident that sucrose probably reduces pain compared to no intervention. However, it is possible that people in the studies were aware of which treatment babies were receiving, and the studies involved small numbers of babies. Sucrose versus skin‐to‐skin care We are not confident that sucrose reduces pain more than skin‐to‐skin care because the two studies reported very different results. Further research is likely to change these results. Sucrose versus breastfeeding We are moderately confident that sucrose probably reduces pain more than breastfeeding. However, the study did not clearly report details of how it was conducted. Sucrose versus pacifier We are moderately confident that sucrose with a pacifier probably reduces pain more than pacifiers alone. The studies differed in how sucrose was given, including the amount of sucrose, how it was administered, and whether it was given with or without a pacifier. How current is this evidence? This evidence is current to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Bueno, M; Candido, L; Hu, J; Fiander, M; Cracknell, J; Xu, E; Kang, J; Yamada, J", "articleTypes": [], "doi": "10.1002/14651858.CD015221.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "9ae919cf-1245-420a-bc50-603aef771c75", "pmid": "", "title": "Fortification of maize flour with iron for controlling anaemia and iron deficiency in populations", "imported": false, "abstract": "Abstract - Background Approximately 800 million women and children have anaemia, a condition thought to cause almost 9% of the global burden of years lived with disability. Around half this burden could be amenable to interventions that involve the provision of iron. Maize (corn) is one of the world's most important cereal grains and is cultivated across most of the globe. Several programmes around the world have fortified maize flour and other maize‐derived foodstuffs with iron and other vitamins and minerals to combat anaemia and iron deficiency. Objectives To assess the effects of iron fortification of maize flour, corn meal and fortified maize flour products for anaemia and iron status in the general population. Search methods We searched the following international and regional sources in December 2017 and January 2018: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE (R) In Process; Embase; Web of Science (both the Social Science Citation Index and the Science Citation Index); CINAHL Ebsco; POPLINE; AGRICOLA ( agricola.nal.usda.gov ); BIOSIS (ISI); Bibliomap and TRoPHI; IBECS; Scielo; Global Index Medicus ‐ AFRO (includes African Index Medicus); EMRO (includes Index Medicus for the Eastern Mediterranean Region); LILACS; PAHO (Pan American Health Library); WHOLIS (WHO Library); WPRO (includes Western Pacific Region Index Medicus); IMSEAR, Index Medicus for the South‐East Asian Region; IndMED, Indian medical journals; and the Native Health Research Database. We searched clinicaltrials.gov and the International Clinical Trials Registry Platform ( ICTRP ) for any ongoing or planned studies on 17 January 2018 and contacted authors of such studies to obtain further information or eligible data if available. For assistance in identifying ongoing or unpublished studies, we also contacted relevant international organisations and agencies working in food fortification on 9 August 2016. Selection criteria We included cluster‐ or individually randomised controlled trials and observational studies. Interventions included (central/industrial) fortification of maize flour or corn meal with iron alone or with other vitamins and minerals and provided to individuals over 2 years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies and assessed the risk of bias of the included studies. Trial designs with a comparison group were included to assess the effects of interventions. Trial designs without a control or comparison group (uncontrolled before‐and‐after studies) were included for completeness but were not considered in assessments of the overall effectiveness of interventions or used to draw conclusions regarding the effects of interventions in the review. Main results Our search yielded 4529 records. After initial screening of titles and abstracts, we reviewed the full text of 75 studies (80 records). We included 5 studies and excluded 70. All the included studies assessed the effects of providing maize products fortified with iron plus other vitamins and minerals versus unfortified maize flour. No studies compared this intervention to no intervention or looked at the relative effect of flour and products fortified with iron alone (without other vitamins and minerals). Three were randomised trials involving 2610 participants, and two were uncontrolled before‐and‐after studies involving 849 participants. Only three studies contributed data for the meta‐analysis and included children aged 2 to 11.9 years and women. Compared to unfortified maize flour, it is uncertain whether fortifying maize flour or corn meal with iron and other vitamins and minerals has any effect on anaemia (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.58 to 1.40; 2 studies; 1027 participants; very low‐certainty evidence), or on the risk of iron deficiency (RR 0.75, 95% CI 0.49 to 1.15; 2 studies; 1102 participants; very low‐certainty evidence), haemoglobin concentration (mean difference (MD) 1.25 g/L, 95% CI −2.36 to 4.86 g/L; 3 studies; 1144 participants; very low‐certainty evidence) or ferritin concentrations (MD 0.48 µg/L, 95% CI −0.37 to 1.33 µg/L; 1 study; 584 participants; very low‐certainty evidence). None of the studies reported on any adverse effects. We judged the certainty of the evidence to be very low based on GRADE, so we are uncertain whether the results reflect the true effect of the intervention. We downgraded evidence due to high risk of selection bias and unclear risk of performance bias in one of two included studies, high heterogeneity and wide CIs crossing the line of no effect for anaemia prevalence and haemoglobin concentration. Authors' conclusions It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of anaemia or iron deficiency in children aged over 2 years or in adults. Moreover, the evidence is too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population, as the certainty of the evidence is very low. No studies reported on any adverse effects. Public organisations funded three of the five included studies, while the private sector gave grants to universities to perform the other two. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. The reduced number of studies, including only two age groups (children and women of reproductive age), as well as the limited number of comparisons (only one out of the four planned) constitute the main limitations of this review. Plain language summary Fortification of maize flour with iron for preventing anaemia and iron deficiency What is the aim of this review? The aim of this Cochrane Review was to determine the effects of fortifying maize flour, corn meal and fortified‐maize flour products with iron for anaemia and iron status in the general population. We searched for relevant published studies to answer this question and analysed all relevant information. Key messages It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We do not know whether fortifying maize flour with iron reduces anaemia in the general population, as the evidence was very unreliable. No studies reported on any harmful effects. What was studied in the review? Approximately 496 million non‐pregnant women, 32 million pregnant women, and 273 million children were thought to be anaemic as of 2011. Iron deficiency is considered to be the single most prevalent nutrient deficiency worldwide, but at least half this burden is considered responsive to interventions that involve providing people with iron. Fortification means adding vitamins and minerals to foods to increase their nutritional value. In public health, fortifying staple foods is considered one way of reducing micronutrient deficiencies without changing usual and culturally acceptable diets. Maize (corn) is one of the world's most important cereal grains. In sub‐Saharan Africa, some parts of Southeast Asia and Latin America, where iron deficiency is endemic, maize is a dietary staple for more than 200 million people. Fortification of maize flour with iron (and in some cases, other nutrients) is mandatory in Brazil, Costa Rica, El Salvador, Kenya, Mexico, Nigeria, Rwanda, South Africa, Tanzania, Uganda, the USA and Venezuela. What are the main results of the review? We found five relevant studies, but none looked at the effects of maize flour or maize flour products fortified with iron alone. Five studies compared the effects of maize flour or maize‐flour products fortified with iron plus other vitamins and minerals versus unfortified maize flours or maize‐flour products (not containing iron or any other vitamin and minerals). Three of these five studies randomly divided a collective total of 2302 children aged 2 to 12 years and 130 indigenous women into groups receiving fortified versus unfortified maize flour or corn flour. One study was from Kenya and the other two took place in Mexico. The remaining two studies did not provide data to assess the effects of fortification relative to a comparison group. Three of five of the included studies were funded by public organisations and two by funds granted by private sector to universities. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency in the general population. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population. How up‐to‐date is this review? We searched for studies that had been published up to 17 January 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Garcia‐Casal, MN; Peña‐Rosas, JP; De‐Regil, LM; Gwirtz, JA; Pasricha, SR", "articleTypes": [], "doi": "10.1002/14651858.CD010187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "9af9f21c-c9c9-4b58-b538-44c83081dbef", "pmid": "", "title": "Interventions for managing halitosis", "imported": false, "abstract": "Abstract - Background Halitosis or bad breath is a symptom in which a noticeably unpleasant breath odour is present due to an underlying oral or systemic disease. 50% to 60% of the world population has experienced this problem which can lead to social stigma and loss of self‐confidence. Multiple interventions have been tried to control halitosis ranging from mouthwashes and toothpastes to lasers. This new Cochrane Review incorporates Cochrane Reviews previously published on tongue scraping and mouthrinses for halitosis. Objectives The objectives of this review were to assess the effects of various interventions used to control halitosis due to oral diseases only. We excluded studies including patients with halitosis secondary to systemic disease and halitosis‐masking interventions. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 April 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3) in the Cochrane Library (searched 8 April 2019), MEDLINE Ovid (1946 to 8 April 2019), and Embase Ovid (1980 to 8 April 2019). We also searched LILACS BIREME (1982 to 19 April 2019), the National Database of Indian Medical Journals (1985 to 19 April 2019), OpenGrey (1992 to 19 April 2019), and CINAHL EBSCO (1937 to 19 April 2019). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (8 April 2019), the World Health Organization International Clinical Trials Registry Platform (8 April 2019), the ISRCTN Registry (19 April 2019), the Clinical Trials Registry ‐ India (19 April 2019), were searched for ongoing trials. We also searched the cross‐references of included studies and systematic reviews published on the topic. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs) which involved adults over the age of 16, and any intervention for managing halitosis compared to another or placebo, or no intervention. The active interventions or controls were administered over a minimum of one week and with no upper time limit. We excluded quasi‐randomised trials, trials comparing the results for less than one week follow‐up, and studies including advanced periodontitis. Data collection and analysis Two pairs of review authors independently selected trials, extracted data, and assessed risk of bias. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach. Main results We included 44 trials in the review with 1809 participants comparing an intervention with a placebo or a control. The age of participants ranged from 17 to 77 years. Most of the trials reported on short‐term follow‐up (ranging from one week to four weeks). Only one trial reported long‐term follow‐up (three months). Three studies were at low overall risk of bias, 16 at high overall risk of bias, and the remaining 25 at unclear overall risk of bias. We compared different types of interventions which were categorised as mechanical debridement, chewing gums, systemic deodorising agents, topical agents, toothpastes, mouthrinse/mouthwash, tablets, and combination methods. Mechanical debridement: for mechanical tongue cleaning versus no tongue cleaning, the evidence was very uncertain for the outcome dentist‐reported organoleptic test (OLT) scores (MD ‐0.20, 95% CI ‐0.34 to ‐0.07; 2 trials, 46 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Chewing gums: for 0.6% eucalyptus chewing gum versus placebo chewing gum, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.10, 95% CI ‐0.31 to 0.11; 1 trial, 65 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Systemic deodorising agents: for 1000 mg champignon versus placebo, the evidence was very uncertain for the outcome patient‐reported visual analogue scale (VAS) scores (MD ‐1.07, 95% CI ‐14.51 to 12.37; 1 trial, 40 participants; very low‐certainty evidence). No data were reported for dentist‐reported OLT score or adverse events. Topical agents: for hinokitiol gel versus placebo gel, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.27, 95% CI ‐1.26 to 0.72; 1 trial, 18 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Toothpastes: for 0.3% triclosan toothpaste versus control toothpaste, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐3.48, 95% CI ‐3.77 to ‐3.19; 1 trial, 81 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Mouthrinse/mouthwash: for mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.20, 95% CI ‐0.58 to 0.18; 1 trial, 44 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Tablets: no data were reported on key outcomes for this comparison. Combination methods: for brushing plus cetylpyridium mouthwash versus brushing, the evidence was uncertain for the outcome dentist‐reported OLT scores (MD ‐0.48, 95% CI ‐0.72 to ‐0.24; 1 trial, 70 participants; low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Authors' conclusions We found low‐ to very low‐certainty evidence to support the effectiveness of interventions for managing halitosis compared to placebo or control for the OLT and patient‐reported outcomes tested. We were unable to draw any conclusions regarding the superiority of any intervention or concentration. Well‐planned RCTs need to be conducted by standardising the interventions and concentrations. Plain language summary Interventions for managing bad breath Review question With this Cochrane Review we tried to find out the best way to control bad breath, also called halitosis, due to a disease within the mouth in adults. Background Bad breath or halitosis is caused by too much bacteria or small food parts left inside the mouth, most commonly at the back of the tongue. It can be a sign of a disease within the mouth or other body diseases. People with bad breath can have low self‐esteem and feel embarrassed. It can affect their personal relationships and work. In this review, we looked at treatments for bad breath due to a disease within the mouth and at treatments that aim to control not just mask bad breath. Study characteristics This review is up‐to‐date as of 8 April 2019. The review includes 44 studies involving 1809 people who were 17 to 77 years old. The review compared an intervention with another intervention, a placebo or a control. It looked at eight different ways to control bad breath: mechanical cleaning (e.g. tongue cleaners and toothbrushes), chewing gums, systemic deodorising agents (e.g. mushroom extract that you eat), topical agents (e.g. gel that you apply), toothpastes, mouthrinse/mouthwash, tablets, and combination of different treatments. Key results The evidence was very uncertain for mechanical tongue cleaning versus no tongue cleaning, 0.6% eucalyptus chewing gum versus placebo chewing gum, 1000 mg mushroom extract versus placebo, hinokitiol gel versus placebo gel, 0.3% triclosan toothpaste versus control toothpaste, mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, and brushing plus cetylpyridium mouthwash versus brushing. Harmful effects of the different interventions were not reported or were not important. Certainty of the evidence The level of certainty we have in these findings is low to very low. This was due mainly to risk of bias and the small number of people studied in the included trials. Conclusion We do not have enough evidence to say which intervention works better to control bad breath.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kumbargere Nagraj, S, Eachempati, P, Uma, E, Singh, VP, Ismail, NM, Varghese, E", "articleTypes": [], "doi": "10.1002/14651858.CD012213.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.763Z" }, { "id": "9afc9b9d-302c-4f10-8532-486fe139f46b", "pmid": "", "title": "Chinese herbal medicine for menopausal symptoms", "imported": false, "abstract": "Abstract - Background Chinese herbal medicine (CHM) usage is expected to increase as women suffering from menopausal symptoms are seeking alternative therapy due to concerns from the adverse effects (AEs) associated with hormone therapy (HT). Scientific evidence for their effectiveness and safety is needed. Objectives To evaluate the effectiveness and safety of CHM in the treatment of menopausal symptoms. Search methods We searched the Gynaecology and Fertility Group's Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), MEDLINE, Embase, CINAHL, AMED, and PsycINFO (from inception to March 2015). Others included Current Control Trials, Citation Indexes, conference abstracts in the ISI Web of Knowledge, LILACS database, PubMed, OpenSIGLE database, and China National Knowledge Infrastructure database (CNKI, 1999 to 2015). Other resources included reference lists of articles as well as direct contact with authors. Selection criteria Randomised controlled trials (RCTs) comparing the effectiveness of CHM with placebo, HT, pharmaceutical drugs, acupuncture, or another CHM formula in women over 18 years of age, and suffering from menopausal symptoms. Data collection and analysis Two review authors independently assessed 864 studies for eligibility. Data extractions were performed by them with disagreements resolved through group discussion and clarification of data or direct contact with the study authors. Data analyses were performed in accordance with Cochrane Collaboration guidelines. Main results We included 22 RCTs (2902 women). Participants were from different ethnic backgrounds with the majority of Chinese origin. When CHM was compared with placebo (eight RCTs), there was little or no evidence of a difference between the groups for the following pooled outcomes: hot flushes per day (MD 0.00, 95% CI ‐0.88 to 0.89; 2 trials, 199 women; moderate quality evidence); hot flushes per day assessed by an overall hot flush score in which a difference of one point equates to one mild hot flush per day (MD ‐0.81 points, 95% CI ‐2.08 to 0.45; 3 RCTs, 263 women; low quality evidence); and overall vasomotor symptoms per month measured by the Menopause‐Specific Quality of Life questionnaire (MENQOL, scale 0 to 6) (MD ‐0.42 points; 95% CI ‐1.52 to 0.68; 3 RCTs, 256 women; low quality evidence). In addition, results from individual studies suggested there was no evidence of a difference between the groups for daily hot flushes assessed by severity (MD ‐0.70 points, 95% CI ‐1.00, ‐0.40; 1 RCT, 108 women; moderate quality evidence); or overall monthly hot flushes scores (MD ‐2.80 points, 95% CI ‐8.93 to 3.33; 1 RCT, 84 women; very low quality evidence); or overall daily night sweats scores (MD 0.07 points, 95% CI ‐0.19 to 0.33, 1 RCT, 64 women; low quality evidence); or overall monthly night sweats scores (MD 1.30 points, 95% CI ‐1.76 to 4.36, 1 RCT, 84 women; very low quality evidence). However one study using the Kupperman Index reported that overall monthly vasomotor symptom scores were lower in the CHM group (MD ‐4.79 points, 95% CI ‐5.52 to ‐4.06; 1 RCT, 69 women; low quality evidence). When CHM was compared with hormone therapy (HT) (10 RCTs), only two RCTs reported monthly vasomotor symptoms using MENQOL. It was uncertain whether CHM reduces vasomotor symptoms (MD 0.47 points, 95% CI ‐0.50 to 1.44; 2 RCTs, 127 women; very low quality evidence). Adverse effects were not fully reported in the included studies. Adverse events reported by women taking CHM included mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects were inconclusive because of imprecise estimates of effects: CHM versus placebo (RR 1.51; 95% CI 0.69 to 3.33; 7 trials, 705 women; I² = 40%); CHM versus HT (RR 0.96; 95% CI 0.66 to 1.39; 2 RCTs, 864 women; I² = 0%); and CHM versus specific conventional medications (such as Fluoxetine and Estazolam) (RR 0.20; 95% CI 0.03 to 1.17; 2 RCTs, 139 women; I² = 61%). Authors' conclusions We found insufficient evidence that Chinese herbal medicines were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Effects on safety were inconclusive. The quality of the evidence ranged from very low to moderate; there is a need for well‐designed randomised controlled studies. Plain language summary Title: Chinese herbal medicines for menopausal symptoms Review Question: Are Chinese herbal medicines effective and safe for relieving menopausal symptoms? Background: Menopause usually takes place when a woman is around 51 years of age. Women can experience symptoms such as hot flushes, sweats, poor sleep, joint pains, anxiousness, dry skin and vagina when the organs which produce female hormones slow down. Usually hormone therapy (HT) is prescribed to reduce the symptoms. Due to concerns on long term use of HT resulting in adverse effects, women have been looking for alternative treatments to relieve their symptoms. Chinese herbal medicines (CHM) is one of the popular choices. Although CHM has been used for a very long time clinically, its effectiveness and long‐term safety remained unanswered from a scientific perspective. Study characteristics: This review examined 22 randomised clinical trials where 2902 women took part in the studies; 1499 in the CHM group and 1403 in the control group which might include a placebo (non‐active compound made to look, taste and smell the same as the study compound) or a drug or HT or another CHM formula (different from the one being tested). Most of the studies had a trial period for 12 weeks. The data are current to March 2015. Key results: We found insufficient evidence that CHM were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Adverse effects were not well reported, some women taking CHM reported mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects on safety were inconclusive. Quality of the evidence: The quality of the evidence ranged from very low to moderate. The studies did not produce good quality evidence to allow the authors to draw a conclusive statement regarding the effectiveness or safety of CHM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Zhu, X, Liew, Y, Liu, ZL", "articleTypes": [], "doi": "10.1002/14651858.CD009023.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.074Z" }, { "id": "9b06f38b-ba43-42ac-a91c-a0460e330969", "pmid": "", "title": "Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries", "imported": false, "abstract": "Abstract - Background Protein Energy Malnutrition is an important cause of child morbidity and mortality in middle‐ and low‐income countries. It has been suggested that excessive free radical activity may be responsible for the clinical manifestation of kwashiorkor. Antioxidants may be able to curb excessive free radical activity and prevent the development of kwashiorkor in susceptible children. Objectives To evaluate the benefits of supplementation of vitamin E, selenium, cysteine and riboflavin (alone or in combination) in preventing kwashiorkor. Search methods We conducted searches of CENTRAL 2009 ( The Cochrane Library 2009 Issue 2), MEDLINE 1966 to 2009, EMBASE 1980 to 2009, CINAHL 1982 to 2009, LILACS 1982 to 2009, Meta register of Controlled trials, Open Sigle, African Index Medicus. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating vitamin E, selenium, cysteine and riboflavin alone or in combination in healthy pre‐school children in middle‐ and low‐income countries. Data collection and analysis Two authors extracted and independently analysed data. Main results One cluster‐RCT including 2372 children met our inclusion criteria. Children were randomised, based on household, either to a supplement containing all four micronutrients or to placebo. No statistically significant difference in the incidence of kwashiorkor between the intervention and control groups could be demonstrated at 20 weeks (RR 1.70; 95% CI 0.98 to 2.42). Nor could any statistically significant difference in all‐cause mortality be demonstrated (RR 0.75; 95% CI 0.17 to 3.36). Authors' conclusions Based on the one available trial, we could draw no firm conclusion for the effectiveness of supplementary antioxidant micronutrients for the prevention of kwashiorkor in pre‐school children. Plain language summary Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries Undernutrition is one of the leading underlying causes of childhood morbidity and mortality in developing countries. Providing antioxidants that would help curb excess free radicals in the body may help prevent the development of kwashiorkor. We identified one cluster‐RCT that attempted to investigate this. Based on the published evidence reviewed, we could draw no firm conclusions of the benefits of supplementary antioxidants for the prevention of kwashiorkor in pre‐school children. There is a need for further research in this area to be certain if antioxidant supplementation can help prevent kwashiorkor in young children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Odigwe, CC; Smedslund, G; Ejemot‐Nwadiaro, RI; Anyanechi, CC; Krawinkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD008147.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "9b11e877-d571-43fa-a752-b4fe9b1cb658", "pmid": "", "title": "Clonidine for pain in non‐ventilated infants", "imported": false, "abstract": "Abstract - Background Critically ill newborn infants undergo a variety of painful procedures or experience a variety of painful conditions during their early life in the neonatal unit. In the critically ill paediatric and neonatal population, clonidine is prescribed as an adjunct to opioids or benzodiazepines aiming to reduce the doses of these drugs that are required for analgesia or sedation, or to facilitate weaning from mechanical ventilation. It has been shown that clonidine premedication might have a positive effect on postoperative pain in children. Objectives To assess the benefit and harms of clonidine for the prevention or treatment of procedural pain; postoperative pain; or pain associated with clinical conditions in non‐ventilated neonates. Search methods We used the standard search strategy of Cochrane Neonatal to search the CENTRAL, MEDLINE via PubMed, Embase, and CINAHL to December 2018. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials. We ran an updated search from 1 January 2018 to 11 March 2020 in CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials, and cluster trials comparing clonidine to placebo or no treatment, opioids, paracetamol, dexmedetomidine, or non‐pharmacological pain‐reducing interventions for the management of procedural pain, postoperative pain, and pain associated with clinical conditions in preterm and term newborns. Data collection and analysis Two review authors independently planned to extract data (e.g. number of participants, birth weight, gestational age, modality of administration, and dose of clonidine) and assess the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow‐up). The primary outcome considered was pain: for procedural pain, the mean values of each analgesia scale assessed during the procedure and at one to two hours after the procedure; for postoperative pain and for pain associated with clinical conditions, the mean values of each analgesia scale assessed at 30 minutes, three hours, and 12 hours after the administration of the intervention. We planned to use the GRADE approach to assess the quality of evidence. Main results Our search strategy yielded 3383 references. Two review authors independently assessed all references for inclusion. We did not find any completed studies for inclusion. We excluded three trials where clonidine was administered for spinal anaesthesia. Authors' conclusions We did not find any studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of clonidine for the prevention or treatment of procedural or postoperative pain, or pain associated with clinical conditions in neonates. Plain language summary Clonidine for painful procedures and conditions in infants Review question: does clonidine administration reduce pain in newborns exposed to painful procedures or conditions? Background: newborns admitted to the hospital are exposed to a number of painful procedures which might include blood sampling, lumbar puncture (a medical procedure where a needle is inserted into the spinal canal, usually to collect cerebrospinal fluid for testing), tubes in the stomach, different types of catheters, and minor surgical procedures such as neonatal circumcision. In addition, newborns might have pain because of clinical conditions, such as, fractured bone, pain following traumatic vaginal birth, disease of the skin (open skin lesions from an inherited skin disorder), or intestines (necrotising enterocolitis (inflammation)). All babies, and especially those born too early (preterm), are very sensitive to pain. Moreover, the experience of repeated episodes of pain might cause problems, such as an altered development of the nervous system, in early life and an increased pain sensitivity when they grow up. Most of the medicines to manage pain and stress in babies have side effects, and might also harm the immature developing brain by inducing death of cells (apoptosis) in the brain. Study characteristics: we searched for studies up to 11 March 2020. The aim of this review was to assess if clonidine could reduce pain in newborns. This medicine can be given through injections, using a tube in the stomach (nasogastric tube), through the skin, and as spinal anaesthesia. However, the latter is not in the focus of this review as it is used for babies undergoing specific surgical procedures. Clonidine works on the brain modifying responses and reducing stress and agitation. Furthermore, clonidine may reduce pain, especially if used in combination with other medicines. Key results: we found no studies for our review. Three studies were excluded because clonidine was given for spinal anaesthesia, whereas our review focuses on other indications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Romantsik, O; Calevo, MG; Norman, E; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD013104.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "9b173d3e-832c-4cd2-b9eb-59121eac97ed", "pmid": "", "title": "Effects of Lutein Supplementation on Macular Pigment Optical Density and Visual Acuity in Patients With Age-related Macular Degeneration", "imported": false, "abstract": "The macular pigment (MP) in humans consists of the yellow, blue-absorbing carotenoids lutein and zeaxanthin. The highest concentrations of lutein and zeaxanthin are found in the fovea. Since light entering the eye passes through the MP before reaching the photo receptors it absorbs a significant portion of short-wavelength light. There is evidence that this absorbing properties of the MP as well as the ability of inactivating highly reactive oxygen species are protective for the retina.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.240Z" }, { "id": "9b1b7271-b230-4910-ba47-067845871016", "pmid": "", "title": "Do Appetitive Gut Hormones Reduce Addictive and Eating Behaviours in Obesity, and Nicotine and Alcohol Dependence?", "imported": false, "abstract": "The \"Gut Hormones in Addiction\" study is a proof-of-concept experimental medicine human study to answer the following questions:", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.267Z" }, { "id": "9b43c3ca-4987-47ac-9506-5d3cce639552", "pmid": "", "title": "Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen‐ultraviolet A photochemotherapy for psoriasis", "imported": false, "abstract": "Abstract - Background The most commonly used types of phototherapy for treating psoriasis are narrow‐band ultraviolet B (NB‐UVB); broad‐band ultraviolet B (BB‐UVB), which includes selective (delivering radiation with a wavelength range of 305 to 325 nm) and conventional BB‐UVB (280 to 320 nm); and psoralen ultraviolet A photochemotherapy (oral or bath PUVA). There is substantial controversy regarding their efficacy when compared with each other. Objectives To assess the effects of narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for psoriasis. Search methods We searched the following databases up to August 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 7), MEDLINE (from 1946), and EMBASE (from 1974). We searched the following databases up to November 2012: CNKI (from 1974) and CBM (from 1978). We also searched trials registers and the OpenGrey database. Selection criteria We included all randomised controlled trials (RCTs) that compared NB‐UVB phototherapy with BB‐UVB or PUVA for treating psoriasis, which included chronic plaque psoriasis (CPP), guttate psoriasis (GP), and palmoplantar psoriasis (PPP). Data collection and analysis Two review authors independently conducted the study selection, 'Risk of bias' assessment, and data extraction. Main results We included 13 RCTs, with a total of 662 participants. We report the results of intention‐to‐treat analyses (ITT) here. Our primary outcomes of interest were as follows: Participant‐rated global improvement, Percentage of participants reaching Psoriasis Area and Severity Index (PASI) 75 (which meant equal to or more than 75% reduction in PASI score), Withdrawal due to side‐effects, and Clearance rate. In one RCT of NB‐UVB compared with oral PUVA in participants with CPP, the difference in PASI 75 was not statistically significant (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.63 to 1.32; N = 51; low quality). In three other RCTs of CPP, the clearance rates were inconsistent because in one, there was no difference between the groups (RR 1.01, 95% CI 0.91 to 1.12; N = 54), and in the other two, the clearance rates were statistically significantly in favour of oral PUVA: RR 0.66, 95% CI 0.47 to 0.93; N = 93 and RR 0.75, 95% CI 0.59 to 0.96; N = 100, respectively. Pooled data from these three studies indicated that withdrawals due to adverse events were not significantly different between either group (RR 0.71, 95% CI 0.20 to 2.54; N = 247; low quality). The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate for CPP was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the NB‐UVB and bath PUVA groups (RR 1.79, 95% CI 0.46 to 6.91; N = 92; low quality), while a parallel RCT favoured bath PUVA (RR 0.18, 95% CI 0.05 to 0.71; N = 36; low quality). In participants with PPP, one RCT found there were no significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate (RR 0.09, 95% CI 0.01 to 1.56; N = 50; low quality). Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or GP in terms of clearance rate (RR 0.93, 95% CI 0.79 to 1.10; N = 90; low quality). One RCT in people with CPP found no significant differences between NB‐UVB and selective BB‐UVB in terms of clearance rate (RR 1.40, 95% CI 0.92 to 2.13; N = 100; low quality) and withdrawals due to adverse events (RR 3.00, 95% CI 0.32 to 27.87; N = 100; low quality). No studies reported our primary outcomes for NB‐UVB compared with conventional BB‐UVB. Authors' conclusions Current evidence is very heterogeneous and needs to be interpreted with caution. The clearance rate between oral PUVA and NB‐UVB is inconsistent among the included studies. Evidence regarding NB‐UVB versus bath PUVA is also inconsistent. Re‐NB‐UVB and re‐PUVA are similarly effective for treating people with CPP or GP. In practice, NB‐UVB may be more convenient to use since exogenous photosensitiser is not required before phototherapy. NB‐UVB is considered ineffective for PPP in clinical practice, and a small RCT did not detect a statistically significant difference between NB‐UVB and topical PUVA for clearing PPP. NB‐UVB seemed to be similar to selective BB‐UVB for clearing CPP. Larger prospective studies are needed to confirm the long‐term safety of NB‐UVB. Plain language summary Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for treating psoriasis Psoriasis is a common, chronic inflammatory skin disease, with an estimated global prevalence ranging from 0.5% to 4.6%. Based on clinical features, psoriasis is generally divided into the following: chronic plaque psoriasis (CPP); psoriasis associated with psoriatic arthritis; and pustular, erythrodermic, or guttate psoriasis. We also considered psoriasis affecting the palms and soles (palmoplantar psoriasis, or PPP). Although psoriasis is rarely life‐threatening, it can affect a person's quality of life significantly. Phototherapy is an essential treatment option for people with psoriasis. The most commonly used types of phototherapy are narrow‐band ultraviolet B (NB‐UVB), broad‐band ultraviolet B (BB‐UVB), and psoralen ultraviolet A photochemotherapy (PUVA). PUVA can be further divided into oral, bath, and topical PUVA according to the administrative route of psoralen. NB‐UVB delivers almost exclusively 311 nm radiation, whereas BB‐UVB can be divided into two types: selective BB‐UVB (305 to 325 nm radiation) and conventional BB‐UVB (280 to 320 nm radiation). This review included 13 small randomised controlled trials (RCT), with a total of 662 participants. Most of these were of poor methodological quality. For treating CPP, the clearance rate between the NB‐UVB and oral PUVA groups were inconsistent in three RCTs. In one, there was no difference between the groups, and in the other two, the clearance rate was in favour of oral PUVA. The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the two groups, while another RCT favoured bath PUVA. Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or guttate psoriasis. One RCT found no significant differences between NB‐UVB and selective BB‐UVB for clearing CPP or in the number of withdrawals due to side‐effects. In participants with PPP, one RCT found there were no statistically significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate. In summary, NB‐UVB may be preferred to oral or bath PUVA because it is more convenient to use. NB‐UVB seemed to be equal to selective BB‐UVB for clearing CPP. Evidence regarding NB‐UVB and conventional BB‐UVB is limited. The long‐term safety of NB‐UVB needs to be confirmed. The efficacy of NB‐UVB for clearing PPP needs to be confirmed in future studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Chen, X; Yang, M; Cheng, Y; Liu, GJ; Zhang, M", "articleTypes": [], "doi": "10.1002/14651858.CD009481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "9b487672-fa12-44cd-be0b-a1939a9e9ec4", "pmid": "", "title": "Interventions for fatigue in peripheral neuropathy", "imported": false, "abstract": "Abstract - Background Persistent feelings of fatigue (or subjective fatigue), which may be experienced in the absence of physiological factors, affect many people with peripheral neuropathy. A variety of interventions for subjective fatigue are available, but little is known about their efficacy or the likelihood of any adverse effects for people with peripheral neuropathy. Objectives To assess the effects of drugs and physical, psychological or behavioural interventions for fatigue in adults or children with peripheral neuropathy. Search methods On 5 November 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, CINAHL Plus, LILACS and AMED. We also searched reference lists of all studies identified for inclusion and relevant reviews, and contacted the authors of included studies and known experts in the field to identify additional published or unpublished data. We also searched trials registries for ongoing studies. Selection criteria We considered for inclusion randomised controlled trials (RCTs) and quasi‐RCTs comparing any form of intervention for fatigue management in adults with peripheral neuropathy with placebo, no intervention or an alternative form of intervention for fatigue. Interventions considered included drugs, pacing and grading of physical activity, general or specific exercise, compensatory strategies such as orthotics, relaxation, counselling, cognitive and educational strategies. Data collection and analysis Two review authors independently assessed risk of bias and extracted study data. We contacted study authors for additional information. We collected information on adverse events from the included trials. Main results The review includes three trials, which were all at low risk of bias, involving 530 people with peripheral neuropathy. The effects of amantadine from one randomised, double‐blind, placebo‐controlled, cross‐over trial comparing amantadine with placebo for the treatment of fatigue in 80 people with Guillain‐Barré syndrome (GBS) were uncertain for the proportion of people achieving a favourable outcome six weeks post‐intervention (odds ratio (OR) 0.56 (95% confidence interval (CI) 0.22 to 1.35, N = 74, P = 0.16). We assessed the quality of this evidence as low. Two parallel‐group randomised double‐blind, placebo‐controlled trials comparing the effects of two doses of ascorbic acid with placebo for reducing fatigue in adults with Charcot‐Marie‐Tooth disease type 1A (CMT1A) showed that the effects of ascorbic acid at either dose are probably small (standardised mean difference (SMD) ‐0.12 (95% CI ‐0.32 to 0.08, n = 404, P = 0.25)) for change in fatigue after 12 to 24 months (moderate quality evidence). Neither ascorbic acid study measured fatigue at four to 12 weeks, which was our primary outcome measure. No serious adverse events were reported with amantadine. Serious adverse events were reported in the trials of ascorbic acid. However,risk of serious adverse events was similar with ascorbic acid and placebo. Authors' conclusions One small imprecise study in people with GBS showed uncertain effects of amantadine on fatigue. In two studies in people with CMT1A there is moderate‐quality evidence that ascorbic acid has little meaningful benefit on fatigue. Information about adverse effects was limited, although both treatments appear to be well tolerated and safe in these conditions. There was no evidence available from RCTs to evaluate the effect of other drugs or other interventions for fatigue in either GBS, CMT1A or other causes of peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future randomised clinical trials. Plain language summary Treatments for fatigue in peripheral neuropathy Review question To assess the effects of treatments for fatigue in people with peripheral neuropathy. Background Peripheral neuropathy is damage to the nerves outside the brain and spinal cord. Many people with peripheral neuropathy have feelings of severe tiredness (fatigue) that are not necessarily related to physical problems such as muscle weakness. Evidence in other long‐term illnesses where fatigue is a problem suggests that medicines and other forms of treatment may help. The aim of this review was to assess the effect of drugs and other treatments, such as general or specific exercise, orthotics (devices such as braces), relaxation, counselling and cognitive, behavioural and educational strategies on feelings of fatigue in people with peripheral neuropathy. Study characteristics From a wide search, we identified three RCTs that met our selection criteria. The trials involved a total of 530 adults with peripheral neuropathy. Treatments were ascorbic acid (vitamin C) in people with Charcot‐Marie‐Tooth disease in two trials, and amantadine in Guillain‐Barré syndrome in the third. Charcot‐Marie‐Tooth disease is an inherited nerve disease and Guillain‐Barré syndrome is a condition where there is inflammation of the peripheral nerves. We chose measures of fatigue at four to 12 weeks as our preferred measure of the effects of treatment. The amantadine trial but not the ascorbic acid trials provided data at this time point; the ascorbic acid trials provided data more than 12 months after the start of the intervention. Key results and quality of the evidence There was insufficient evidence to determine the effects of amantadine when compared with an inactive treatment (placebo) for fatigue. and there were no major unwanted effects. We found evidence that ascorbic acid probably has little meaningful benefit for fatigue. No major unwanted effects were identified, but the trials were small. We assessed the quality of this evidence as moderate because the results were imprecise, which means they do not rule out the possibility that the drugs could have an effect. We found no evidence from RCTs on other medicines or treatments for fatigue in peripheral neuropathy. There is insufficient evidence to determine the effect of amantadine for fatigue in GBS and ascorbic acid for fatigue in CMT1A. More high‐quality studies are needed to provide evidence on which to base management of feelings of fatigue in peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future RCTs. The evidence in this review is current to November 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "White, CM, van Doorn, PA, Garssen, MPJ, Stockley, RC", "articleTypes": [], "doi": "10.1002/14651858.CD008146.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.760Z" }, { "id": "9b4f48e0-59d2-4283-9e6b-8cbc43c88740", "pmid": "", "title": "Control interventions in randomised trials among people with mental health disorders", "imported": false, "abstract": "Abstract - Background Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated. Objectives To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait‐list versus no‐treatment, (ii) usual care versus wait‐list or no‐treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait‐list or no‐treatment. Wait‐list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. Search methods In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers. Selection criteria We included randomised trials assessing patients with a mental health disorder that compared wait‐list, usual care, or placebo interventions with wait‐list or no‐treatment . Data collection and analysis Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane’s risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre‐planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random‐effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed‐effect model). Main results We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep‐wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait‐list versus no‐treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait‐list or no‐treatment and found a SMD –0.33 (95% CI ‐0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait‐list or no‐treatment was SMD −0.37 (95% CI −0.49 to −0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger’s test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD ‐0.49 (95% CI −0.64 to −0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait‐list or no‐treatment on benefits was SMD ‐0.14 (95% CI −0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD −0.21 (95% CI −0.35 to −0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep‐wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed‐effect model in a sensitivity analysis on the comparison for usual care versus wait‐list and no‐treatment, the results were significant with an SMD of –0.46 (95 % CI –0.64 to –0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains. Authors' conclusions We found marked variations in effects between placebo versus no‐treatment and wait‐list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait‐list or no‐treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research. Plain language summary Control interventions in randomised trials for people with a mental health disorder This systematic review assesses the effects of different control interventions in randomised trials including patients with a mental health disorder. In randomised trials, patients are assigned by chance to one of two or more groups – usually an experimental intervention and a control intervention. There are many types of control interventions in mental health intervention research. Some of the most common are different types of placebos that lack what is assumed to be the active component in the experimental intervention, and usual care, where patients receive the standard treatment for their mental health disorder in the area where they live. Two other types of control interventions are wait‐list or no‐treatment where patients receive no trial‐related care during the study (although some patients may receive care outside the studies). Wait‐list patients are often offered the experimental intervention after the trial has been finalised if it is likely to provide more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. We searched for randomised trials with patients with mental health disorders where wait‐list, usual care, or placebo interventions were compared with either wait‐list or no‐treatment. We looked at differences between all the types of control interventions on beneficial effects and whether they caused any adverse effects. We included 96 trials with a total of 4200 participants. Only 83 trials (3614 participants) provided usable data. Fifteen different mental health disorders were included. We found that all the trials were at high risk of bias in how they had been conducted, which reduced the interpretability of our findings. However, the risk of bias was mostly due to lack of blinding in the placebo studies, which may be seen as an aspect of the review's methodological question rather than a flaw with the review itself. We found no clinically important differences for usual care or wait‐list control interventions in the main analyses, however in our secondary analyses we found a clinically important favourable difference for usual care. In general, placebo control interventions tended to be favourable over no‐treatment or wait‐list control interventions across mental health disorders. We found no clinically important differences on adverse events. This review suggests that different control interventions have a tendency to yield very different estimates for the effects of the experimental intervention and that the choice of control intervention has a large impact on how effective a mental health treatment appears to be. Control interventions in trials with patients with mental health disorders are often poorly reported upon, and guidelines are needed to inform researchers on how to properly design, report, and interpret these trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Faltinsen, E, Todorovac, A, Staxen Bruun, L, Hróbjartsson, A, Gluud, C, Kongerslev, MT, Simonsen, E, Storebø, OJ", "articleTypes": [], "doi": "10.1002/14651858.MR000050.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.795Z" }, { "id": "9b5a5d3f-9e30-40a7-b3da-226b47025a1e", "pmid": "", "title": "Probiotics for the prevention of Clostridioides difficile‐associated diarrhea in adults and children", "imported": false, "abstract": "Abstract - Rationale Antibiotics can disturb gastrointestinal microbiota, which may lead to reduced resistance to pathogens such as Clostridioides difficile . Probiotics are live microbial preparations that, when administered in adequate amounts, may confer a health benefit to the host, and are a potential C difficile infection prevention strategy. Objectives To assess the benefits and harms of probiotics for preventing C difficile ‐associated diarrhea (CDAD) in adults and children receiving an antibiotic for any reason. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, and Ovid Embase from 18 March 2017 (search date of the previous version of the review) to 3 March 2025. Eligibility criteria We included randomized controlled trials with a placebo, alternative prophylaxis, or no‐treatment control investigating probiotics (any strain or dose) for the prevention of CDAD in adults and children receiving an antibiotic for any reason. Outcomes The critical outcome was incidence of CDAD. Important outcomes included detection of C difficile in stool (i.e. colonization in absence of symptoms), adverse events, antibiotic‐associated diarrhea (AAD), and length of hospital stay. Risk of bias Two review authors independently assessed risk of bias using Cochrane's RoB 1 tool. Synthesis methods We pooled dichotomous outcomes (e.g . incidence of CDAD) using a random‐effects complete‐case model to calculate the risk ratio (RR) and absolute risk reduction (ARR) and corresponding 95% confidence interval (95% CI). We pooled continuous outcomes (e.g. length of hospital stay) using a random‐effects model to calculate the mean difference (MD) and corresponding 95% CI. We conducted sensitivity analyses to explore the impact of missing outcome data on benefits and harms outcomes. To investigate heterogeneity, we conducted a priori subgroup analyses on risk of bias, probiotic dose, probiotic species, adults versus children, inpatients versus outpatients, and the event rate in the control group for developing CDAD (low 0% to 2%; moderate 3% to 5%; high > 5%). The certainty of the evidence for each outcome was independently assessed using the GRADE approach. Included studies Eight new studies (n = 4595) met our inclusion criteria, for a total of 47 included studies (n = 15,260). Although we noted a high risk of bias in individual studies for sequence generation or allocation concealment, this did not impact our findings. Around 30% of studies lacked a published protocol or clinical trial registration, and in some cases there were inconsistencies between the reported methods and published results. We noted authors' affiliation with a probiotic company and financial support received from probiotic companies in 28 studies. Synthesis of results Evidence from 38 trials (13,179 participants) suggests that probiotics may result in a small absolute risk reduction (ARR) of 1.6% (incidence of 1.6% [110/6787] in the probiotic group versus 3.2% [203/6392] in the control group), and a relative risk reduction (RRR) of 50% (RR 0.50, 95% CI 0.38 to 0.64; P < 0.001; low‐certainty evidence) in incidence of CDAD. Twenty‐seven of 38 trials had missing CDAD data, ranging from 2% to 45%. Our complete‐case CDAD results proved robust to sensitivity analyses of plausible and worst‐plausible assumptions regarding missing outcome data. Pooled results from 16 trials (1302 participants) suggest that probiotics may result in a small absolute reduction in C difficile in stool (i.e. colonization in absence of symptoms) (ARR 2.1%; incidence of 14.9% [101/677] in the probiotic group versus 16.2% [101/625] in the control group; RR 0.87, 95% CI 0.68 to 1.11; P = 0.27; low‐certainty evidence). Thirty‐seven studies (11,911 participants) reported on adverse events. Our pooled analysis indicates that probiotics probably result in a small ARR of 1.7% (incidence of 10.9% [669/6148] in the probiotic group versus 12.2% [701/5763] in the control group), and an RRR of 14.0% (RR 0.86, 95% CI 0.72 to 1.01; P = 0.074; moderate‐certainty evidence). The most common adverse events in both the treatment and control groups were abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. Pooled results from 40 studies (13,419 participants) suggest that probiotics may result in a large ARR of 9% (incidence of 23% [1592/6901] in the probiotic group versus 27.4% [1787/6518] in the control group), and an RRR of 33% (RR 0.67, 95% CI 0.57 to 0.78; P < 0.001; low‐certainty evidence) in incidence of AAD. Only seven trials (6553 participants) investigated length of hospital stay. There is likely little to no difference in length of hospital stay between treatment and control groups (MD −0.07, 95% CI −0.35 to 0.21; P = 0.63; moderate‐certainty evidence). We downgraded the certainty of evidence for CDAD and AAD due to the low number of events or publication bias. We observed some variability in CDAD control group event rate (< 2% to > 5%) that may impact the applicability of evidence depending on clinical setting. We downgraded the certainty of evidence for adverse events due to variation between the results of the studies and for hospital stay due to selective reporting. Authors' conclusions The currently available evidence suggests that probiotics may be effective for preventing CDAD, suggesting that for every 65 people taking probiotics, one case of CDAD may be prevented (number needed to treat for an additional beneficial outcome of 65, 95% CI 48 to 97). There are probably fewer adverse events in the probiotic group. The short‐term use of probiotics may have a small absolute benefit, and is likely not associated with adverse effects when used in patient populations receiving systemic antibiotics who are not immunocompromised. Large trials comparing probiotics with placebo in people with a low baseline risk of CDAD are needed. Funding There was no source of funding for this update. Registration The original review was done in 2013 by Johnston and colleagues, for which the protocol was developed. We followed the methods specified in the 2017 review, while modifying the search strategy and risk of bias assessment for selective reporting for this update. Plain language summary What are the benefits and harms of probiotics for preventing Clostridioides difficile‐ associated diarrhea in adults and children receiving antibiotics for any reason? Key messages In people prescribed antibiotics, probiotics may be effective in preventing Clostridioides difficile ‐associated diarrhea (CDAD), and may reduce the risk of antibiotic‐associated diarrhea. Probiotics probably do not result in harm when taken with an antibiotic, with fewer mild to moderate unwanted effects in the group receiving probiotic than the group receiving placebo (dummy treatment) or no treatment. In those taking antibiotics who do not have a weakened immune system, the short‐term use of probiotics may offer a small benefit, and are likely not harmful. However, additional large studies comparing probiotics with placebo in people with a low risk of CDAD are needed. What is Clostridioides difficile ‐associated diarrhea (CDAD) ? Antibiotics are among the most prescribed medications worldwide. Antibiotic treatment may disturb the balance of organisms that normally populate the gut. This can result in a range of symptoms, most notably diarrhea. C difficile is a particularly dangerous organism that may colonize and infect the gut if the microbial balance has been disrupted. The effects of C difficile infection can vary, with some people having no symptoms, and others suffering diarrhea, severe inflammation, enlargement of the colon, or even death. The cost of treatment is expensive, and the financial burden on the medical system is substantial. What are probiotics? Probiotics are live microorganisms (bacteria or yeast) that provide health benefits when given in adequate amounts. They help to prevent potential disturbances to the gut microbial balance that are associated with antibiotic use, and to reduce the risk of growing harmful bacteria. Probiotics can be found in dietary supplements or yogurts and are widely available as capsules sold in health food stores and supermarkets. As 'functional food' or 'good bacteria,' probiotics have been suggested as a means of both preventing and treating CDAD. What did we want to find out? We wanted to know if probiotics prevent CDAD in adults and children receiving antibiotic therapy, and whether probiotics cause any unwanted effects. The researchers searched the medical literature extensively up to 3 March 2025. What did we do? We searched for studies that compared probiotics (any strain or dose) versus placebo (dummy treatment), alternative preventive treatment, or no treatment for the prevention of CDAD in adults and children receiving antibiotic therapy for any reason. We compared and summarized the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included 47 studies with a total of 15,260 adults and children who received antibiotic therapy along with probiotics, assessing CDAD or C difficile growth. Thirty‐eight studies (13,179 participants) assessed the effectiveness of probiotics for preventing CDAD. Our results suggest that probiotics may result in a small reduction in the risk of CDAD compared to placebo or no treatment. Probiotics may result in a small reduction in C difficile growth (16 studies, 1302 participants). Thirty‐seven studies (11,911 participants) looked at unwanted effects. Our results show that probiotics probably result in a small reduction in the risk of developing unwanted effects compared to placebo or no treatment. The most commonly reported unwanted effects included abdominal cramping, nausea, fever, soft stools, flatulence (gas), and taste disturbance, and were more common in the placebo or no‐treatment group. Forty studies (13,419 participants) reported on antibiotic‐associated diarrhea (AAD); probiotics may result in a large reduction in the risk of AAD compared to placebo or no treatment. Seven studies (6553 participants) reporting on length of hospital stay showed likely little to no difference between probiotics and placebo or no treatment. What are the limitations of the evidence? The studies we reviewed used different types of probiotics, but they didn't directly compare one probiotic to another. This lack of direct comparisons makes it harder to determine which probiotic works best. We have moderate to little confidence in the available evidence. Our confidence is limited because in some studies, people who dropped out of the study or were not followed up on resulted in missing information. The two largest studies in our analysis did not show a clear benefit of probiotics for preventing CDAD. How up‐to‐date is this evidence? The evidence is current to 3 March 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Esmaeilinezhad, Z; Ghosh, NR; Walsh, CM; Steen, JP; Burgman, AM; Mertz, D; Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD006095.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "9b686220-09ec-4c3a-8b85-fe1e359df84f", "pmid": "", "title": "Environmental interventions to reduce the consumption of sugar‐sweetened beverages and their effects on health", "imported": false, "abstract": "Abstract - Background Frequent consumption of excess amounts of sugar‐sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB. Objectives To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar‐sweetened beverages and sugar‐sweetened milk, diet‐related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes. Search methods We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors. Selection criteria We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet‐related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) and interrupted‐time‐series (ITS) studies, implemented in real‐world settings with a combined length of intervention and follow‐up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB‐specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review. Data collection and analysis Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta‐analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented ‘Summary of findings’ tables. Main results We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow‐up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non‐randomised designs. The studies examine a broad range of interventions, and we present results for these separately. Labelling interventions (8 studies): We found moderate‐certainty evidence that traffic‐light labelling is associated with decreasing sales of SSBs, and low‐certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu‐board calorie labelling reported effects on SSB sales varied. Nutrition standards in public institutions (16 studies): We found low‐certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low‐certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied. Economic tools (7 studies): We found moderate‐certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low‐calorie beverages reported effects on SSB sales varied. Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied. Retail and food service interventions (7 studies): We found low‐certainty evidence that healthier default beverages in children’s menus in chain restaurants are associated with decreasing SSB sales, and moderate‐certainty evidence that in‐store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low‐certainty evidence that urban planning restrictions on new fast‐food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied. Intersectoral approaches (8 studies): We found moderate‐certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate‐certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied. Home‐based interventions (7 studies): We found moderate‐certainty evidence that improved availability of low‐calorie beverages in the home environment is associated with decreased SSB intake, and high‐certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs. Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low‐calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes. We analysed interventions targeting sugar‐sweetened milk separately, and found low‐ to moderate‐certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar‐sweetened milk. We found low‐certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar‐sweetened milk consumption. Authors' conclusions The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high‐quality evaluations using appropriate study designs, with a particular focus on the long‐term effects of approaches suitable for large‐scale implementation. Plain language summary Cutting back on sugar‐sweetened beverages: What works? What are sugar‐sweetened beverages? Sugar‐sweetened beverages (SSBs) are cold and hot drinks with added sugar. Common SSBs are non‐diet soft drinks, regular soda, iced tea, sports drinks, energy drinks, fruit punches, sweetened waters, and sweetened tea and coffee. Why are SSBs an important health topic? Research shows that people who drink a lot of SSBs often gain weight. Drinking a lot of SSBs can also increase the risk of diabetes, heart disease, and dental decay. Doctors therefore recommend that children, teenagers and adults drink fewer SSBs. Governments, businesses, schools and workplaces have taken various measures to support healthier beverage choices. What is the aim of this review? We wanted to find out whether the measures taken so far have been successful in helping people to drink fewer SSBs to improve their health. We focused on measures that change the environment in which people make beverage choices. We did not look at studies on educational programmes or on SSB taxes, as these are examined in separate reviews. (We did, however, examine price increases on SSB which were not due to taxes.) We searched for all available studies meeting clearly‐defined criteria to answer this question. This review reflects the state of the evidence up until January 2018. What studies did we find? We found 58 studies, which included more than one million adults, teenagers and children. Most studies lasted about one year, and were done in schools, stores or restaurants. Some studies used methods that are not very reliable. For example, in some studies participants were simply asked how much SSB they drank, which is not very reliable, as people sometimes forget how much SSB they drank. Some of the findings of our review may therefore change when more and better studies become available. What do these studies tell us? We have found some evidence that some of the measures implemented to help people drink fewer SSBs have been successful, including the following: ▪ Labels which are easy to understand, such as traffic‐light labels, and labels which rate the healthfulness of beverages with stars or numbers. ▪ Limits to the availability of SSB in schools (e.g. replacing SSBs with water in school cafeterias). ▪ Price increases on SSBs in restaurants, stores and leisure centres. ▪ Children’s menus in chain restaurants which include healthier beverages as their standard beverage. ▪ Promotion of healthier beverages in supermarkets. ▪ Government food benefits (e.g. food stamps) which cannot be used to buy SSBs. ▪ Community campaigns focused on SSBs. ▪ Measures that improve the availability of low‐calorie beverages at home, e.g. through home deliveries of bottled water and diet beverages. We have also found some evidence that improved availability of drinking water and diet beverages at home can help people lose weight. There are also other measures which may influence how much SSB people drink, but for these the available evidence is less certain. Some, but not all studies found that such measures can have effects which were not intended and which may be negative. Some studies reported that profits of stores and restaurants decreased when the measures were implemented, but other studies showed that profits increased or stayed the same. Children who get free drinking water in schools may drink less milk. Some studies reported that people were unhappy with the measures. We also looked at studies on sugar‐sweetened milk. We found that small prizes for children who chose plain milk in their school cafeteria, as well as emoticon labels, may help children drink less sugar‐sweetened milk. However, this may also drive up the share of milk which is wasted because children choose but do not drink it. What does this mean in practice? Our review shows that measures which change the environment in which people make beverage choices can help people drink less SSB. Based on our findings we suggest that such measures may be used more widely. Government officials, business people and health professionals implementing such measures should work together with researchers to find out more about their effects in the short and long term.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "von Philipsborn, P; Stratil, JM; Burns, J; Busert, LK; Pfadenhauer, LM; Polus, S; Holzapfel, C; Hauner, H; Rehfuess, E", "articleTypes": [], "doi": "10.1002/14651858.CD012292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "9b7a61b3-4a4f-4f48-9f6a-1e104e27cb10", "pmid": "", "title": "Dietary Pistachio Intake and Nutrition-Related Outcomes in Individuals Using GLP-1 Receptor Agonists: A Randomized Controlled Trial", "imported": false, "abstract": "In this study will look at how eating pistachios every day might affect participants weight, how healthy their diet is, and how they feel when eating. Investigators want to see if adding pistachios to meals for 12 weeks helps participants feel fuller, have more energy, and improve body composition. The study will include adults who have been taking GLP-1 medicines like semaglutide or tirzepatide for at least three months. Investigators also want to see if eating pistachios improves overall diet quality and health markers like tiredness and certain levels in blood.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.151Z" }, { "id": "9b85be6b-d184-4906-8d9d-3ce8ee52d4ab", "pmid": "", "title": "Interventions to improve adherence to antiretroviral therapy in children with HIV infection", "imported": false, "abstract": "Abstract - Background Achieving and maintaining high levels of medication adherence are required to achieve the full benefits of antiretroviral therapy (ART), yet suboptimal adherence among children is common in both developed and developing countries. Objectives To conduct a systematic review of the literature of evaluations of interventions for improving paediatric ART adherence. Search methods We created a comprehensive search strategy in order to identify all studies relevant to this topic. In July 2010, we searched the following electronic databases: EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, LILACS, Web of Science, Web of Social Science, NLM Gateway (supplemented by a manual search of the most recent abstracts not included in the Gateway database). We searched abstracts from the International AIDS Conference from 2002 to 2010, the International AIDS Society Conference on Pathogenesis, Treatment and Prevention from 2003 to 2009, and from the Conference on Retroviruses and Opportunistic Infections from 1997 to 2010. We used search strategies determined by the Cochrane Review Group on HIV/AIDS. We also contacted researchers who work in this field and checked reference lists of related systematic reviews and of all included studies. Selection criteria Randomised and non‐randomised controlled trials of interventions to improve adherence to ART among children and adolescents (age ≤18 years) were included. Studies had to report adherence to ART as an outcome. Data collection and analysis After one author performed an initial screening to exclude citations that did not meet the inclusion criteria, two authors did a second screening of those citations that likely met the criteria. For all articles that passed the second screening, full articles were pulled in order to make a final determination. Two authors then extracted data and graded methodological quality independently. Differences were resolved through discussion. Main results Four studies met the inclusion criteria. No single intervention was evaluated by more than one trial. Two studies were conducted in low‐income countries. Two studies were randomised controlled trials (RCT), and two were non‐randomised trials. An RCT of a home‐based nursing programme showed a positive effect of the intervention on knowledge and medication refills (p=.002), but no effect on CD4 count and viral load. A second RCT of caregiver medication diaries showed that the intervention group had fewer participants reporting no missed doses compared to the control group (85% vs. 92%, respectively), although this difference was not statistically significant (p=.08). The intervention had no effect on CD4 percentage or viral load. A non‐randomised trial of peer support group therapy for adolescents demonstrated no change in self‐reported adherence, yet the percentage of participants with suppressed viral load increased from 30% to 80% (p=.06). The second non‐randomised trial found that the percentage of children achieving >80% adherence was no different between children on a lopinavir‐ritonavir (LPV/r) regimen compared to children on a non‐nucleoside reverse transcriptase regimen (p=.781). However, the proportion of children achieving virological suppression was significantly greater for children on the LPV/r regimen than for children on the NNRTI‐containing regimen (p=.002). Authors' conclusions A home‐based nursing intervention has the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence or disease outcomes. Two interventions, an LPV/r‐containing regimen and peer support therapy for adolescents, did not demonstrate improvements in adherence, yet demonstrated greater viral load suppression compared to control groups, suggesting a different mechanism for improved health outcomes. Well‐designed evaluations of interventions to improve paediatric adherence to ART are needed. Plain language summary Interventions to improve adherence to ART in children and adolescents Achieving and maintaining high levels of medication adherence are required to realise the full benefits of antiretroviral therapy (ART). We identified four studies that evaluated interventions designed to improve adherence to ART among children and adolescents age 18 years and younger. These studies showed that home‐based nursing, peer support for adolescents and LPV/r‐containing regimens have the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence. There is a need for well‐designed evaluations of interventions to improve paediatric adherence to ART.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Bain‐Brickley, D; Butler, LM; Kennedy, GE; Rutherford, GW", "articleTypes": [], "doi": "10.1002/14651858.CD009513", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "9ba6ee2d-8939-4e45-a76a-aad83b9a5a3f", "pmid": "", "title": "Environmental enrichment for stroke and other non‐progressive brain injury", "imported": false, "abstract": "Abstract - Background Rehabilitation is effective for recovery after stroke and other non‐progressive brain injuries but it is unclear if the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. Environmental enrichment is a relatively new concept within rehabilitation for humans. In this review, this is defined as an intervention designed to facilitate physical (motor and sensory), cognitive and social activity by the provision of equipment and organisation of a structured, stimulating environment. The environment should be designed to encourage (but not force) activities without additional specialised rehabilitation input. Objectives To assess the effects of environmental enrichment on well‐being, functional recovery, activity levels and quality of life in people who have stroke or non‐progressive brain injury. Search methods We conducted the search on 26 October 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers. Selection criteria We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services. Data collection and analysis Two review authors independently assessed eligible studies, extracted data, and assessed study quality. Any disagreements were resolved through discussion with a third review author. We determined the risk of bias for the included study and performed a 'best evidence' synthesis using the GRADE approach. Main results We identified one RCT, involving 53 participants with stroke, comparing environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. We excluded five studies, found two studies awaiting classification and one ongoing study which described environmental enrichment in their interventions. Of the excluded studies, three were non‐RCTs and two described co‐interventions with a significant component of rehabilitation. Based on the single small included RCT at high risk of bias, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the provision of environmental enrichment. Authors' conclusions The gap in current research should not, however, be interpreted as proof that environmental enrichment is ineffective. Further research is needed with robust study designs, such as cluster RCTs, and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (inpatient versus outpatient), the relative effectiveness of various components of environmental enrichment, cost‐effectiveness, and safety of the intervention in people following stroke or other non‐progressive brain injuries. It should be noted, however, that it is challenging to randomise or double‐blind trials of environmental enrichment given the nature of the intervention. Plain language summary Treatment using environmental enrichment for supporting rehabilitation following stroke and other brain injuries which do not get worse over time (non‐progressive brain injury) Background Rehabilitation helps with recovery after stroke and other non‐progressive brain injuries through therapy. However, outside of therapy hours, people may have very little to keep them stimulated. Environmental enrichment is a relatively new concept in rehabilitation where the environment itself is designed to be engaging and to include physical, thinking, and social activities like exercises and games. For example, a nursery for babies may be interesting and stimulating but a hospital environment for adults is generally not. The design of the environment alone should encourage (but not force) activities without additional specialised rehabilitation. Review question 
We wanted to find out whether treatment with environmental enrichment is better or worse than alternatives. Search date 
The evidence is current to 26 October 2020. Study characteristics 
Population: we planned to include studies in which participants were adults who had had a stroke or a non‐progressive brain injury (such as traumatic brain injury but not dementia, Alzheimer's diease, or multiple sclerosis). Intervention: environmental enrichment interventions will usually include multiple activities, such as computers plus gaming technology plus music and reading. Comparison: we planned to compare environmental interventions with usual care (regular physiotherapy, speech therapy, occupational therapy) or alternative treatment. Outcomes: we divided outcomes into primary and secondary outcomes. Primary outcomes focused on psychological well‐being (anxiety, depression, stress) and coping. Secondary outcomes focused on quality of life, physical function, communication and cognitive function, and activity levels. We also planned to report adverse events. Key results 
We found one trial that compared environmental intervention alone with usual care or alternative treatment. The trial included 53 participants who had had a stroke and was based in a hospital rehabilitation ward. The trial compared environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services. The main outcomes related to psychological well‐being and coping. We were uncertain of the results because the trial was very small and highly prone to bias. Conclusion 
The gap in current research does not mean that environmental enrichment is ineffective. Further research is needed with strong study designs and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (in hospital versus out of hospital), which components of environmental enrichment are effective, whether environmental enrichment is cost‐effective, and if it is safe for people following stroke or other non‐progressive brain injuries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Qin, H; Reid, I; Gorelik, A; Ng, L", "articleTypes": [], "doi": "10.1002/14651858.CD011879.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "9bbd610a-7c5d-4ec0-9493-86f05733e596", "pmid": "", "title": "Blood pressure lowering efficacy of beta‐blockers as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Beta‐blockers are one of the more commonly prescribed classes of anti‐hypertensive drugs, both as first‐line and second‐line. Objectives To quantify the effect on systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and withdrawals due to adverse effects of beta‐blocker therapy when given as a second‐line drug in adult patients with primary hypertension. Search methods CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1966‐Aug 2009), EMBASE (1988‐Aug 2009) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized controlled trials comparing a beta‐blocker in combination with a drug from another class of anti‐hypertensive drugs compared with that drug alone for a duration of 3 to 12 weeks in patients with primary hypertension were included. Data collection and analysis Two reviewers independently extracted the data and assessed trial quality of each included study. Main results 20 double‐blind RCTs evaluated the BP lowering efficacy of beta‐blockers as second‐line drug in 3744 hypertensive patients (baseline BP of 158/102 mmHg; mean duration of 7 weeks). The BP reduction from adding a beta‐blocker as the second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. A reduction in BP was seen with adding a beta‐blocker to thiazide diuretics or calcium channel blockers at doses as low as 0.25 times the manufacturer's recommended starting dose. The BP lowering efficacy of beta‐blockers as a second drug was 6/4 mmHg at 1 times the starting dose and 8/6 mmHg at 2 times the starting dose. Beta‐blockers reduced heart rate by 10 beats/min at 1 to 2 times the starting dose. Beta‐blockers did not statistically significantly increase withdrawals due to adverse effects but this was likely due to the lack of reporting of this outcome in 35% of the included RCTs. Authors' conclusions Addition of a beta‐blocker to diuretics or calcium‐channel blockers reduces BP by 6/4mmHg at 1 times the starting dose and by 8/6 mmHg at 2 times the starting dose. When the blood pressure lowering effect of beta‐blockers from this review was compared to that of thiazide diuretics from our previous review ( Chen 2009 ), second‐line beta‐blockers reduce systolic BP to the same extent as second‐line thiazide diuretics, but reduce diastolic BP to a greater degree. The different effect on diastolic BP means that beta‐blockers have little or no effect on pulse pressure whereas thiazides cause a significant dose‐related decrease in pulse pressure. This difference in the pattern of BP lowering with beta‐blockers as compared to thiazides might be the explanation for the fact that beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than thiazide diuretics, particularly in older individuals. Plain language summary Beta‐blockers lower blood pressure when given as a second drug Beta‐blockers are commonly used in the treatment for high blood pressure (BP). In this review, we asked how much do beta‐blockers reduce BP when used as the second drug to treat hypertension. Twenty trials lasting an average of 7 weeks were found in the world scientific literature to answer this question. The data showed that the addition of a beta‐blocker to thiazide diuretics or calcium channel blockers reduced BP by 8/6 mmHg when given at doses 2 times the recommended starting dose. When we compared these results with our previous review of the blood pressure lowering effect of thiazide diuretics as second line drug, we found that beta‐blockers have a different pattern of BP lowering. This different pattern of effect on blood pressure might explain why first‐line beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than first‐line thiazide diuretics, particularly in older individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, JMH; Heran, BS; Perez, MI; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007185.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "9bcdeb17-11fb-4a2b-a95b-af9865fa4df5", "pmid": "", "title": "Tartrazine exclusion for allergic asthma", "imported": false, "abstract": "Abstract - Background Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There has been conflicting evidence as to whether tartrazine causes exacerbations of asthma with some studies finding a positive association especially in individuals with cross‐sensitivity to aspirin. Objectives To assess the overall effect of tartrazine (exclusion or challenge) in the management of asthma. Search methods A search was carried out on the Cochrane Airways Group Specialised Register. Bibliographies of each RCT was searched for additional papers. Authors of identified RCTs were contacted for further information. Searches are updated annually and are current as of February 2006. Selection criteria RCTs of oral administration of tartrazine (as a challenge) versus placebo or dietary avoidance of tartrazine versus normal diet were considered. Studies which focused upon allergic asthma, were also included. Studies of tartrazine exclusion for other allergic conditions such as hay fever, allergic rhinitis and eczema were only considered if the results for subjects with asthma were separately identified. Trials could be in either adults or children with asthma or allergic asthma (e.g. sensitivity to aspirin or food items known to contain tartrazine). Data collection and analysis Study quality was assessed and data abstracted by two reviewers independently. Outcomes were analysed using RevMan 4.1.1. Main results Ninety four abstracts were found, of which 20 were potentially relevant. Six? met the inclusion criteria, but only three presented results in a format that permitted analysis and none could be combined in a meta‐analysis. In none of the studies did tartrazine challenge or avoidance in diet significantly alter asthma outcomes. Authors' conclusions Due to the paucity of available evidence, it is not possible to provide firm conclusions as to the effects of tartrazine on asthma control. However, the six RCTs that could be included in this review all arrived at the same conclusion. Routine tartrazine exclusion may not benefit most patients, except those very few individuals with proven sensitivity. Plain language summary Tartrazine exclusion for allergic asthma Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There is no evidence that tartrazine makes asthma worse or avoiding it makes asthma patients any better.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Ardern, K", "articleTypes": [], "doi": "10.1002/14651858.CD000460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.069Z" }, { "id": "9bd4b20d-c4f0-4310-87df-bbd529ded561", "pmid": "", "title": "Omega‐3 fatty acids supplementation for autism spectrum disorders (ASD)", "imported": false, "abstract": "Abstract - Background It has been suggested that impairments associated with autism spectrum disorders (ASD) may be partially explained by deficits of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. Objectives To review the efficacy of omega‐3 fatty acids for improving core features of ASD (for example, social interaction, communication, and stereotypies) and associated symptoms. Search methods We searched the following databases on 2 June 2010: CENTRAL (2010, Issue 2), MEDLINE (1950 to May Week 3 2010), EMBASE (1980 to 2010 Week 21), PsycINFO (1806 to current), BIOSIS (1985 to current), CINAHL (1982 to current), Science Citation Index (1970 to current), Social Science Citation Index (1970 to current), metaRegister of Controlled Trials (20 November 2008) and ClinicalTrials.gov (10 December 2010). Dissertation Abstracts International was searched on 10 December 2008, but was no longer available to the authors or editorial base in 2010. Selection criteria All randomised controlled trials of omega‐3 fatty acids supplementation compared to placebo in individuals with ASD. Data collection and analysis Three authors independently selected studies, assessed them for risk of bias and extracted relevant data. We conducted meta‐analysis of the included studies for three primary outcomes (social interaction, communication, and stereotypy) and one secondary outcome (hyperactivity). Main results We included two trials with a total of 37 children diagnosed with ASD who were randomised into groups that received either omega‐3 fatty acids supplementation or a placebo. We excluded six trials because they were either non‐randomised controlled trials, did not contain a control group, or the control group did not receive a placebo. Overall, there was no evidence that omega‐3 supplements had an effect on social interaction (mean difference (MD) 0.82, 95% confidence interval (CI) ‐2.84 to 4.48, I 2 = 0%), communication (MD 0.62, 95% CI ‐0.89 to 2.14, I 2 = 0%), stereotypy (MD 0.77, 95% CI ‐0.69 to 2.22, I 2 = 8%), or hyperactivity (MD 3.46, 95% CI ‐0.79 to 7.70, I 2 = 0%). Authors' conclusions To date there is no high quality evidence that omega‐3 fatty acids supplementation is effective for improving core and associated symptoms of ASD. Given the paucity of rigorous studies in this area, there is a need for large well‐conducted randomised controlled trials that examine both high and low functioning individuals with ASD, and that have longer follow‐up periods. Plain language summary Omega‐3 fatty acids for autism spectrum disorders (ASD) It has been suggested that difficulties associated with ASD may be explained in part by lack of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. The purpose of this review was to assess the evidence for the effectiveness of omega‐3 supplementation for core features of ASD and associated symptoms. We found only two small randomised controlled trials that evaluated omega‐3 fatty acids for ASD. There is insufficient evidence that omega‐3 fatty acids supplementation is an effective treatment for ASD. However, high quality large randomised controlled trials are needed before definite recommendations about this treatment can be made.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "James, S; Montgomery, P; Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD007992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "9bd55e22-0322-4555-a603-2e61cdbd69ab", "pmid": "", "title": "Fortification of condiments and seasonings with iron for preventing anaemia and improving health", "imported": false, "abstract": "Abstract - Background Anaemia affects approximately 1.8 billion people worldwide; over 60% of anaemia cases globally are due to iron deficiency (ID). Iron deficiency and anaemia contribute to the global burden of disease and affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortification of food with iron, alone or in combination with other nutrients, is an effective intervention to control ID. Condiments and seasonings are ideal food vehicles for iron fortification in countries where they are commonly used. Objectives To determine the effects and safety of condiment and seasoning fortification with iron alone or iron plus other micronutrients on iron deficiency, anaemia, and health‐related outcomes in the general population. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 24 January 2023. We also searched the International clinical trials registry platform (ICTRP) for any ongoing trials. Selection criteria We included randomised controlled trials (RCTs) (randomisation at individual or cluster level), non‐randomised controlled trials, interrupted time series with at least three measure points both before and after intervention, and controlled before‐after studies. Participants were populations of any age (including pregnant women), from any country, excluding those with critical illness or severe co‐morbidities. We included interventions in which condiments or seasonings have been fortified with any combination of iron and other vitamins and minerals, irrespective of the fortification technology used. Data collection and analysis Two review authors independently screened and assessed the eligibility of studies. Disagreements were resolved through discussion or input from a third review author. Two review authors extracted the data and assessed the risk of bias in all the included studies. We followed the methods laid out by Cochrane and used GRADE criteria for assessing certainty of the evidence. Main results Our search identified 15,902 records after removal of duplicates. We included 16 studies with 20,512 participants (18,410 participants after adjusting for clustering effects). They were all carried out in upper‐middle‐ and lower‐middle‐income countries. Three studies were controlled before‐after studies, one was non‐randomised trial, and 12 were RCTs (including three cluster RCTs). Six studies took place in schools; seven in communities; and one each in a nursery/kindergarten, tea estate, and factory. Three studies involved only women, one study involved both women and their children, and all other studies focused on children and/or adolescents. Nine studies used salt as a vehicle for iron fortification, three used fish sauce, two used soy sauce, one used curry powder, and one a \"seasoning powder\". The dose of iron received by participants ranged from 4.4 mg to 55 mg/day. The sample sizes in the trials ranged from 123 to 14,398, and study durations ranged from three months to two years. Twelve RCTs contributed data for meta‐analysis. Six trials compared iron‐fortified condiments versus the unfortified condiment, and six trials provided data comparing iron fortification in combination with other micronutrients versus the same condiment with other micronutrients, but no added iron. In one trial, the fortificant contained micronutrients that may have affected the absorption of iron. Overall no studies were assessed as having a low risk of bias. All included studies were assessed to have a high overall risk of bias, with the most concerns being around allocation concealment, blinding, and random sequence generation. There was very high heterogeneity amongst studies in almost all examined outcomes. Condiments/seasonings fortified with iron versus unfortified condiments/seasonings We are uncertain about whether consuming condiments/seasonings fortified with iron in comparison to the same unfortified condiment reduces anaemia at the end of intervention (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.18 to 0.65; 2328 participants; 4 studies; very low‐certainty of evidence). We are uncertain about whether consuming iron‐fortified condiments increases haemoglobin concentrations (mean difference (MD) 6.40 (g/L), 95% CI ‐0.62 to 13.41; 2808 participants; 5 studies; very low‐certainty evidence). Fortification of condiments/seasonings with iron probably slightly reduces ID (RR 0.33, 95% CI 0.11 to 1.01; 391 participants; 2 studies; moderate‐certainty evidence). We are uncertain about whether fortification with iron increases ferritin concentration (MD 14.81 (µg/L), 95% CI 5.14 to 24.48; 4459 participants; 6 studies; very low‐certainty evidence). Condiments/seasonings fortified with iron plus other micronutrients versus condiments/seasonings fortified with other micronutrients except iron Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia (RR 0.59, 95% CI 0.40 to 0.89; 1007 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification of condiments/seasonings with iron plus other micronutrients will improve haemoglobin concentration (MD 6.22 g/dL, 95% CI 1.60 to 10.83; 1270 participants; 5 studies; very low‐certainty evidence). It may reduce ID (RR 0.36, 95% CI 0.19 to 0.69; 1154 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification with iron plus other micronutrients improves ferritin concentration (MD 10.63 µg/L, 95% CI 2.40 to 18.85; 1251 participants; 5 studies; very low ‐certainty evidence). Condiments/seasonings fortified with iron versus no intervention No trial reported data on this comparison. No studies reported adverse effects. Funding sources do not appear to have distorted the results in any of the assessed trials. Authors' conclusions We are uncertain whether consuming iron‐fortified condiments/seasonings reduces anaemia, improves haemoglobin concentration, or improves ferritin concentration. It may reduce ID. Findings about ferritin should be interpreted with caution since its concentrations increase during inflammation. Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia, and we are uncertain whether this will improve haemoglobin concentration or ferritin concentration. More studies are needed to determine the true effect of iron‐fortified condiments/seasonings on preventing anaemia and improving health. The effects of this intervention on other health outcomes like malaria incidence, growth and development are unclear. Plain language summary Adding iron to condiments and seasonings for preventing anaemia and improving health Key messages ‐ Adding iron to condiments/seasonings may slightly improve iron status and reduce iron deficiency. When iron is added along with other micronutrients, it may reduce anaemia. Unwanted effects were not reported. ‐ There was a lot of variation between the studies included in this review, making it more difficult to draw definitive conclusions. The effects of fortifying condiments and seasonings with iron should continue to be examined in populations consuming them through well‐designed studies. What is anaemia? Iron deficiency is one of the most common nutritional deficiencies throughout the world and contributes significantly to the global burden of disease. Multiple factors cause anaemia, including insufficient iron intake (the most common cause of anaemia), and it affects approximately 1.8 billion people worldwide. In general, low‐income countries have more anaemia than higher‐income countries. Iron deficiency and anaemia have several lifetime consequences that can affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortifying condiments or seasonings with iron may be a useful and cost‐effective approach to help reduce iron deficiency. To date, there has been no systematic assessment of the safety and effectiveness of this intervention to inform policymaking. What did we want to find out? If fortifying condiments and seasonings with iron alone or iron plus other micronutrients improves measures of iron nutrition in the general population, in particular: ‐ anaemia; ‐ haemoglobin concentration; ‐ iron deficiency; ‐ iron status (including ferritin, transferrin saturation, and more). We also wanted to find out if consuming iron‐fortified condiments/seasonings was associated with any unwanted effects. What did we do? 
We searched for studies that provided iron‐fortified condiments/seasonings to one group, and condiments/seasonings not fortified with iron to another. We compared and summarised the results of the studies and rated our confidence in the evidence, based on study characteristics. What did we find? We identified 16 studies that involved 18,410 participants in middle‐income countries, most within schools or communities, with study durations ranging from three months to two years. The type of iron‐fortified condiments/seasonings used included salt, fish sauce, soy sauce, and seasoning powders. The dose of iron received by participants ranged from 4.4mg to 55 mg/day. Compared to unfortified condiments/seasonings, those which are iron‐fortified likely improve iron deficiency slightly. We are uncertain whether they reduce anaemia, improve haemoglobin, or other measures of iron status. Condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia; we are uncertain about whether they improve haemoglobin or ferritin concentrations. They may improve iron deficiency and total iron binding capacity. No studies reported adverse effects. More studies are needed to determine the effect of iron‐fortified condiments/seasonings on health such as malaria incidence, growth and development and any potential adverse effects. What are the limitations of the evidence? Our confidence in the evidence is very low to moderate; several factors reduced our confidence in the evidence. Firstly, we observed limitations in the way few studies were conducted with respect to the recruitment of people to assign interventions (this means that differences between the groups could be due to differences between people rather than between the treatments). Secondly, people in some studies may have been aware of which treatment they were getting. Also, not all the studies provided data about everything that were interested in, and results were inconsistent across the different studies. Finally, some studies were small. The results of future research could differ from the results of this review. How up to date is this evidence? The evidence is up‐to‐date to January 2023. What this means We judged the evidence in this review as very low to moderate certainty, which means we are not certain of the effect of condiments/seasonings with added iron on the reduction of anaemia and iron deficiency in people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jalal, CSB; De-Regil, LM; Pike, V; Mithra, P", "articleTypes": [], "doi": "10.1002/14651858.CD009604.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "9be0c28d-2ab8-48c5-8b92-487983d0db74", "pmid": "", "title": "Beclomethasone versus placebo for chronic asthma", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Adams, NP, Bestall, JC, Malouf, R, Lasserson, TJ, Jones, P", "articleTypes": [], "doi": "10.1002/14651858.CD002738.pub2 AB - Abstract - Background Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti‐inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane‐134a (HFA) propellant which is free from chlorofluorocarbon (CFC). Objectives The objectives of this review were to: 
 (1) Compare the efficacy of BDP with placebo with both CFC and HFA propellants in the treatment of chronic asthma. 
 (2) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. 
 (3) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies. Search methods Electronic searches were current as of January 2003. Selection criteria Randomised parallel group design trials for a minimum period of four weeks, in children and adults comparing CFC‐BDP or HFA‐BDP with placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality. Data collection and analysis One reviewer extracted data; authors were contacted to clarify missing information. We analysed data with RevMan Analyses 1.0.2. Main results 60 studies recruiting 6542 participants met the inclusion criteria. CFC‐BDP (57 studies): In non‐oral steroid treated patients, at doses of 400mcg/day or less CFC‐BDP produced significant improvements from baseline in a number of efficacy measures compared with placebo, including forced expiratory volume in one second (FEV1) 360 ml (95% CI 260 to 460); FEV1 (% predicted) WMD 12.41% (95% CI 8.18 to 16.64) and morning peak expiratory flow rate (am PEF) WMD 35.95 L/min (95% CI 27.85 to 44.04). BDP also led to reductions in rescue beta‐2 agonist use compared with placebo of ‐2.32 puffs/d (95% CI ‐2.55 to ‐2.09) and reduced the relative risk (RR) of trial withdrawal due to an asthma exacerbation 0.25 (95% CI 0.12 to 0.51). Subgroup analyses based on treatment duration provide support to the proposal that a treatment period of greater than four weeks is required to realise a fuller treatment effect. In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD ‐4.91 mg/d (95% CI ‐5.88 to ‐3.94 mg/d) and greater likelihood of withdrawing oral steroid treatment RR 8.02 (95% CI 3.23 to 19.92). HFA‐BDP (3 studies): In non‐oral steroid‐treated patients, HFA‐BDP was significantly more effective than placebo in improving FEV1, morning and evening PEF, FEF25 to 75%, reduced asthma symptoms and beta2‐agonists daily consumption. Significant effects for such outcomes were apparent after six weeks of treatment. In oral steroid treated patients, HFA‐BDP improved significantly FEV1 and am PEF. The summary estimates for these outcomes suggested a high level of heterogeneity, and divergent aims of the studies may contribute to the variation we observed. Limited data on adverse events were reported. Authors' conclusions This review has quantified the efficacy of CFC‐BDP and HFA‐BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose‐response in people with severe asthma. Plain language summary Inhaled beclomethasone compared with placebo for chronic asthma During an asthma attack, the airways narrow, causing breathing problems, wheezing and coughing. Inhaled corticosteroids (ICS) are used to reduce swelling of the airways. Inhaled beclomethasone dipropionate (BDP) is commonly used. There is now a new formulation of the drug which uses a new propellant (HFA‐BDP). This review of trials found that BDP delivered with the old and new propellant is effective in helping people with chronic asthma. BDP at all doses improves airflow, reduces symptoms and the need for rescue bronchodilators. The review only included studies conducted for more than 4 weeks. The drug was well tolerated and the safety profile was comparable with placebo. The findings apply to both children and adults. The effects of the new propellant suggest that it could be more effective than the older version, although a different review will address that particular question.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.132Z" }, { "id": "9bfca69c-89ff-400a-a399-f95d16e3c65c", "pmid": "", "title": "Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years", "imported": false, "abstract": "Abstract - Background Zinc deficiency is prevalent in low‐ and middle‐income countries, and is considered a significant risk factor for morbidity, mortality, and linear growth failure. The effectiveness of preventive zinc supplementation in reducing prevalence of zinc deficiency needs to be assessed. Objectives To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged 6 months to 12 years. Search methods A previous version of this review was published in 2014. In this update, we searched CENTRAL, MEDLINE, Embase, five other databases, and one trials register up to February 2022, together with reference checking and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) of preventive zinc supplementation in children aged 6 months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalized children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions. Data collection and analysis Two review authors screened studies, extracted data, and assessed the risk of bias. We contacted study authors for missing information and used GRADE to assess the certainty of evidence. The primary outcomes of this review were all‐cause mortality; and cause‐specific mortality, due to all‐cause diarrhea, lower respiratory tract infection (LRTI, including pneumonia), and malaria. We also collected information on a number of secondary outcomes, such as those related to diarrhea and LRTI morbidity, growth outcomes and serum levels of micronutrients, and adverse events. Main results We included 16 new studies in this review, resulting in a total of 96 RCTs with 219,584 eligible participants. The included studies were conducted in 34 countries; 87 of them in low‐ or middle‐income countries. Most of the children included in this review were under five years of age. The intervention was delivered most commonly in the form of syrup as zinc sulfate, and the most common dose was between 10 mg and 15 mg daily. The median duration of follow‐up was 26 weeks. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes was affected by risk of bias. High‐certainty evidence showed little to no difference in all‐cause mortality with preventive zinc supplementation compared to no zinc (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.84 to 1.03; 16 studies, 17 comparisons, 143,474 participants). Moderate‐certainty evidence showed that preventive zinc supplementation compared to no zinc likely results in little to no difference in mortality due to all‐cause diarrhea (RR 0.95, 95% CI 0.69 to 1.31; 4 studies, 132,321 participants); but probably reduces mortality due to LRTI (RR 0.86, 95% CI 0.64 to 1.15; 3 studies, 132,063 participants) and mortality due to malaria (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 42,818 participants); however, the confidence intervals around the summary estimates for these outcomes were wide, and we could not rule out a possibility of increased risk of mortality. Preventive zinc supplementation likely reduces the incidence of all‐cause diarrhea (RR 0.91, 95% CI 0.90 to 0.93; 39 studies, 19,468 participants; moderate‐certainty evidence) but results in little to no difference in morbidity due to LRTI (RR 1.01, 95% CI 0.95 to 1.08; 19 studies, 10,555 participants; high‐certainty evidence) compared to no zinc. There was moderate‐certainty evidence that preventive zinc supplementation likely leads to a slight increase in height (standardized mean difference (SMD) 0.12, 95% CI 0.09 to 0.14; 74 studies, 20,720 participants). Zinc supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46; 5 studies, 35,192 participants; high‐certainty evidence). We report a number of other outcomes, including the effect of zinc supplementation on weight and serum markers such as zinc, hemoglobin, iron, copper, etc. We also performed a number of subgroup analyses and there was a consistent finding for a number of outcomes that co‐supplementation of zinc with iron decreased the beneficial effect of zinc. Authors' conclusions Even though we included 16 new studies in this update, the overall conclusions of the review remain unchanged. Zinc supplementation might help prevent episodes of diarrhea and improve growth slightly, particularly in children aged 6 months to 12 years of age. The benefits of preventive zinc supplementation may outweigh the harms in regions where the risk of zinc deficiency is relatively high. Plain language summary Is zinc supplementation effective for preventing death and disease, and for promoting growth, in children aged 6 months to 12 years and does it cause unwanted effects? Key messages ‐ Zinc supplementation in children aged 6 months to 12 years makes little to no difference to all‐cause mortality and probably makes no difference to deaths from diarrea. Zinc supplementation probably reduces mortality due to lower respiratory tract infections and malaria but a small possibility of increased risk of mortality cannot be ruled out. ‐ Zinc supplementation in children aged 6 months to 12 years might prevent illness due to diarrhea, but might lead to vomiting after supplementation. It might lead to a small increase in height gain. Why is it important to study zinc supplementation? Zinc is an essential micronutrient. It is important to help children grow normally and to promote a healthy immune system. Lack of zinc may lead to diarrhea, pneumonia, malaria and even death. Low dietary zinc intake is often linked to poverty. As many as half of all children in low‐ and middle‐income countries may have zinc deficiency. Meat, fish, eggs and dairy products are good natural sources of zinc, but are expensive. Lack of clean water and poor sanitation increases exposure to diseases, which zinc might help to fight. The human body cannot produce or store zinc, so giving dietary supplements is important. What did we want to find out? We wanted to find out if giving children zinc supplements helps prevent child death and disease, and promotes growth. What did we do? We searched for studies that randomly assigned children aged 6 months to 12 years to receive zinc supplementation or no zinc. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 96 studies in the review, with 219,584 children. Studies took place in 34, mainly low‐ to middle‐income countries. Most of the children in the studies were under five years old. Zinc was most commonly given as a syrup (zinc sulfate), and the most common dose was between 10 mg and 15 mg daily. We found that giving children zinc supplementation might lead to a small to no reduction in the risk of death for any reason and the risk of death due to diarrhea. The risk of death due to lower respiratory tract infections or malaria may be reduced. Children given zinc experienced less disease due to diarrhea than children not given zinc; however, zinc does not seem to reduce children's risk of respiratory infection. Zinc supplementation may have a small positive effect on growth. Children who take zinc supplementation may experience vomiting as an unwanted effect. What are the limitations of the evidence? We are confident about our results on the effects of zinc supplements on reducing the risk of death due to any cause, illness due to respiratory infection, and occurrence of vomiting after supplementation. Our confidence in the results for our other outcomes was moderate because relatively few studies reported these outcomes and because studies sometimes reported different results from other studies for the same outcomes. How up to date is this evidence? This review updates a previous version published in 2014. The evidence is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Imdad, A, Rogner, J, Sherwani, RN, Sidhu, J, Regan, A, Haykal, MR, Tsistinas, O, Smith, A, Chan, XHS, Mayo-Wilson, E, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD009384.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.106Z" }, { "id": "9c20404d-d957-46f8-938b-615c8774a65e", "pmid": "", "title": "Protein and energy supplementation in elderly people at risk from malnutrition", "imported": false, "abstract": "Abstract - Background Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. Objectives This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip‐feeds'. Search methods We searched The Cochrane Library , MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip‐feed' manufacturers. Selection criteria Randomised and quasi‐randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. Data collection and analysis Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. Main results Sixty‐two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97). The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (‐0.8 days, 95% CI ‐2.8 to 1.3). Adverse effects included nausea or diarrhoea. Authors' conclusions Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large‐scale multi‐centre trials are still required. Plain language summary Protein and energy supplementation in elderly people at risk from malnutrition Much emphasis is placed on the importance of good diet, usually in relation to concern about the health risks of obesity. However it has been generally agreed that the risk of undernutrition rather than overnutrition is the main cause for concern in elderly people, particularly those who are hospitalised or institutionalised. Malnutrition has been shown to have important effects on recovery in a broad range of patients and conditions. It has been associated strongly with impaired immune response, impaired muscle and respiratory function, delayed wound healing, overall increased complications, longer rehabilitation, greater length of hospital stay and increased mortality. Oral protein and energy supplements are potentially safer and easier to administer than nasogastric enteral feeds and are therefore particularly suited to elderly people and are also widely used. However, there may be problems with the willingness and ability of older people to consume oral supplements, and supplements may not be used effectively. Even if supplements are prescribed, they may not always be given, or are given but not consumed. In addition to taste, the composition and timing of administration in relation to meals may be important. Efforts also need to be made to provide normal meals and snacks which meet the needs of elderly people and to provide assistance with feeding if required. A total of 10,187 randomised participants from the 62 trials has been included. Maximum duration of intervention was 18 months. The reviewers suggest that supplementation appears to produce a small but consistent weight gain. There was no evidence in this updated review of a beneficial effect on mortality overall, but there may be a beneficial effect on mortality in people who are undernourished. Supplementation may also reduce the number of complications. The reported acceptance of supplements was variable between trials. Some adverse effects such as nausea or diarrhoea were reported. However, there were problems of study design and quality. More studies are required to confirm the beneficial effect on the number of complications, to establish whether there is a beneficial effect on mortality for undernourished elderly people and to provide evidence about whether protein and energy supplements can improve morbidity and functional status in frail older people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Milne, AC; Potter, J; Vivanti, A; Avenell, A", "articleTypes": [], "doi": "10.1002/14651858.CD003288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "9c2faa15-9265-4958-a56d-8782b629c115", "pmid": "", "title": "Ribavirin monotherapy for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. A high proportion of patients never experience symptoms. Peginterferon plus ribavirin is the recommended treatment for chronic hepatitis C. However, ribavirin monotherapy may be considered for some patients. Objectives To assess the beneficial and harmful effects of ribavirin monotherapy for patients with chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included all randomised trials irrespective of blinding, language, or publication status comparing ribavirin versus no intervention, placebo, or interferon for chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained virological response (loss of hepatitis C virus RNA at least six months after treatment), liver‐related morbidity plus all‐cause mortality, and adverse events. Secondary outcome measures were end of treatment virological response, biochemical response (transaminase activity), and histological response. Randomisation methods, blinding, data handling, and funding were extracted as measures of bias control. Random‐effects and fixed‐effect meta‐analyses were performed for all outcomes. We only present the results of the fixed‐effect model if both models provide the same result regarding statistical significance. We present data as risk difference (RD) with 95% confidence intervals (CI). Main results We included 14 randomised trials with 657 patients. The majority of trials had unclear control of bias. Compared with placebo or no intervention, ribavirin had no significant effect on the sustained virological response (RD 0%, 95% CI ‐2% to 3%, five trials) or end of treatment virological response (RD 0% 95% CI ‐3% to 3%, ten trials). Ribavirin had no significant effect on liver‐related morbidity plus mortality (RD 0%, 95% CI ‐2% to 3%, 11 trials). Ribavirin significantly increased the risk of adverse reactions, including anaemia. Ribavirin significantly improved end of treatment biochemical and histological response but not the sustained biochemical response. Ribavirin was significantly inferior to interferon regarding virological and biochemical responses (five trials). Authors' conclusions Ribavirin seems without beneficial effects on serum virological response and liver‐related morbidity or mortality, and significantly increased the risk of adverse reactions. Ribavirin monotherapy seems significantly inferior to interferon monotherapy. The total number of included patients is small, and more trials are perhaps needed. The use of ribavirin monotherapy for chronic hepatitis C cannot be recommended outside randomised trials. Plain language summary Treatment of patients infected with hepatitis C virus Globally, about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behaviour, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die from it. Treatment with interferon clears hepatitis C virus from the blood in about 15% of the patients. Adding ribavirin to interferon (combination therapy) significantly improves the number that clears hepatitis C from the blood to about 40%. Not all patients are tolerant to interferon, and also interferon is costly. This is why ribavirin given as a single drug may be considered as an option for patients with chronic hepatitis C. This review identified 11 randomised trials comparing ribavirin with no antiviral treatment in patient with chronic hepatitis C. Combining the results from all identified trials ribavirin alone seemed without beneficial effects for patients with chronic hepatitis C. Moreover, ribavirin given alone was significantly inferior compared with interferon regarding clearing hepatitis C from the blood and regarding reducing liver enzymes activity in the blood. Furthermore, ribavirin given alone increased the risk of anaemia. Thus, ribavirin given alone cannot be recommended, but more trials may be needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brok, J; Gluud, LL; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005527.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "9c664ad3-ed5e-47d6-bd74-1bdadfe3e25a", "pmid": "", "title": "Interventions for oropharyngeal dysphagia in children with neurological impairment", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Morgan, AT, Dodrill, P, Ward, EC", "articleTypes": [], "doi": "10.1002/14651858.CD009456.pub2 AB - Abstract - Background Oropharyngeal dysphagia encompasses problems with the oral preparatory phase of swallowing (chewing and preparing the food), oral phase (moving the food or fluid posteriorly through the oral cavity with the tongue into the back of the throat) and pharyngeal phase (swallowing the food or fluid and moving it through the pharynx to the oesophagus). Populations of children with neurological impairment who commonly experience dysphagia include, but are not limited to, those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). Objectives To examine the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. Search methods We searched the following electronic databases in October 2011: CENTRAL 2011(3), MEDLINE (1948 to September Week 4 2011), EMBASE (1980 to 2011 Week 40)
, CINAHL (1937 to current)
, ERIC (1966 to current), PsycINFO (1806 to October Week 1 2011), Science Citation Index (1970 to 7 October 2011), Social Science Citation Index (1970 to 7 October 2011), Cochrane Database of Systematic Reviews, 2011(3), DARE 2011(3), Current Controlled Trials (ISRCTN Register) (15 October 2011), ClinicalTrials.gov (15 October 2011) and WHO ICTRP (15 October 2011). We searched for dissertations and theses using Networked Digital Library of Theses and Dissertations, Australasian Digital Theses Program and DART‐Europe E‐theses Portal (11 October 2011). Finally, additional references were also obtained from reference lists from articles. Selection criteria The review included randomised controlled trials and quasi‐randomised controlled trials for children with oropharyngeal dysphagia and neurological impairment. Data collection and analysis All three review authors (AM, PD and EW) independently screened titles and abstracts for inclusion and discussed results. In cases of uncertainty over whether an abstract met inclusion criterion, review authors obtained the full‐text article and independently evaluated each paper for inclusion. The data were categorised for comparisons depending on the nature of the control group (for example, oral sensorimotor treatment versus no treatment). Effectiveness of the oropharyngeal dysphagia intervention was assessed by considering primary outcomes of physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency a child is able to consume. Secondary outcomes were changes in growth, child’s level of participation in the mealtime routine and the level of parent or carer stress associated with feeding. Main results Three studies met the inclusion criteria for the review. Two studies were based on oral sensorimotor interventions for participants with cerebral palsy compared to standard care and a third study trialled lip strengthening exercises for children with myotonic dystrophy type 1 compared to no treatment ( Sjogreen 2010 ). A meta‐analysis combining results across the three studies was not possible because one of the studies had participants with a different condition, and the remaining two, although using oral sensorimotor treatments, used vastly different approaches with different intensities and durations. The decision not to combine these was in line with our protocol. In this review, we present the results from individual studies for four outcomes: physiological functions of the oropharyngeal mechanism for swallowing, the presence of chest infection and pneumonia, diet consistency, and changes in growth. However, it is not possible to reach definitive conclusions on the effectiveness of particular interventions for oropharyngeal dysphagia based on these studies. One study had a high risk of attrition bias owing to missing data, had statistically significant differences (in weight) across experimental and control groups at baseline, and did not describe other aspects of the trial sufficiently to enable assessment of other potential risks of bias. Another study was at high risk of detection bias as some outcomes were assessed by parents who knew whether their child was in the intervention or control group. The third study overall seemed to be at low risk of bias, but like the other two studies, suffered from a small sample size. Authors' conclusions The review demonstrates that there is currently insufficient high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials to provide conclusive results about the effectiveness of any particular type of oral‐motor therapy for children with neurological impairment. There is an urgent need for larger‐scale (appropriately statistically powered), randomised trials to evaluate the efficacy of interventions for oropharyngeal dysphagia. Plain language summary Interventions for swallowing difficulty in children with neurological impairment Oropharyngeal dysphagia, or swallowing difficulty, can be defined as problems with chewing and preparing food, difficulty moving food through the mouth to the back of the tongue, and difficulty with swallowing and movement of food through the 'throat' or pharynx. Many children with neurological impairment experience swallowing difficulties, including those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). This review examined the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. The three studies included in the review examined oral sensorimotor treatments and lip strengthening interventions. We were interested in three primary outcomes, which were physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency, and three secondary outcomes, which were changes in growth, child's level of participation in the mealtime routine, and the level of parent or carer stress associated with feeding. We concluded that there is currently not enough high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials for any particular type of oropharyngeal dysphagia intervention in this population of children. There is a need for larger‐scale randomised controlled trials to evaluate the effects of interventions for oropharyngeal dysphagia in children with neurological impairment.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.777Z" }, { "id": "9c7328ea-3f30-44ca-9dfd-da343d4a04e2", "pmid": "", "title": "Oral nutritional interventions in hospitalised older people at nutritional risk: a network meta‐analysis of individual participant data", "imported": false, "abstract": "Abstract - Rationale Malnutrition affects 35% to 64% of hospitalised older people, and is associated with adverse health outcomes such as disease complications and hospital readmission. Identifying effective nutritional interventions is essential to improve clinical outcomes and reduce healthcare costs in this population. Objectives To evaluate the effects of various nutritional interventions, compared with either a control group (standard care or placebo) or each other, on patient‐relevant outcomes in hospitalised older people at risk of or with established malnutrition, and to rank the effects of these different interventions using network meta‐analysis (NMA) based on individual participant data (IPD). Search methods We searched CENTRAL, MEDLINE, five other databases, and two trial registries to 2 July 2024, and checked the reference lists of included studies and relevant systematic reviews. Eligibility criteria We included older people (≥ 65 years) hospitalised for different acute conditions at risk of or with malnutrition enrolled in randomised controlled trials (RCTs) comparing oral nutritional interventions with control or each other. For RCTs that met our inclusion criteria, either fully or partially, we requested IPD from the study authors. If we did not receive a response or IPD were unavailable, we used published aggregated data. We excluded RCTs that only partially met the eligibility criteria if neither IPD nor sufficient aggregated data were obtainable. Outcomes Critical outcomes were all‐cause mortality, serious adverse events (SAEs), and functional status (e.g. activities of daily living). Important outcomes were health‐related quality of life (HRQoL), length of hospital stay (LOS), body weight, and fat‐free mass. The main outcome assessment time point was at hospital discharge or 30 days after randomisation. Risk of bias We used the Cochrane risk of bias 2 (RoB 2) tool. Synthesis methods For each outcome, we first analysed IPD within each study. Second, we pooled results in an NMA which also included the aggregated data from RCTs without available IPD. We performed random‐effects NMAs based on the frequentist approach and ranked treatments by P‐scores. We rated the certainty of evidence using the GRADE approach. Included studies We included 21 RCTs (72 reports; 12 RCTs with IPD) with 3309 older participants (mean age ranged from 75 to 85 years; 1863 participants with IPD) with different acute conditions. Interventions included the provision of additional protein (three studies), energy supplements (two studies), oral nutritional supplements (ONS; eight studies), individualised feeding support (two studies), and comprehensive individualised nutritional care (eight studies). In all but two RCTs, interventions were compared to control (standard care with or without a placebo). We judged 16.1% of outcome assessments to be at low risk of bias and 16.8% at high risk. Synthesis of results ONS may reduce all‐cause mortality (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.25 to 0.84; absolute risk difference 57 fewer deaths per 1000 people, 95% CI 79 fewer to 17 fewer; low‐certainty evidence) compared to control, while comprehensive individualised nutritional care may show little to no effect (RR 0.98, 95% CI 0.55 to 1.73; 1 fewer per 1000 people, 95% CI 26 fewer to 46 more; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 13 RCTs, 2728 participants; Q between designs: not applicable (NA)). ONS may reduce SAEs compared to control (RR 0.56, 95% CI 0.32 to 0.95; 84 fewer SAEs per 1000 people, 95% CI 131 fewer to 10 fewer; Q between designs: Q 1.95, df 2, P = 0.3772; low‐certainty evidence ). For all other treatment comparisons, the evidence is very uncertain (NMA with 14 RCTs, 2184 participants). Comprehensive individualised nutritional care may make little to no difference in activities of daily living compared to control (standardised mean difference (SMD) 0.06, 95% CI −0.08 to 0.20; low‐certainty evidence) and ONS compared to energy supplements (SMD −0.15, 95% CI −0.53 to 0.23; low‐certainty evidence). For all other treatment comparisons, the evidence is very uncertain (NMA with 5 RCTs, 1128 participants; Q between designs: NA). Energy supplements probably make little to no difference in HRQoL compared with ONS (mean difference (MD) 0.01, 95% CI −0.06 to 0.08; Q between designs: NA; moderate‐certainty evidence). All other comparisons of different nutritional interventions may make little to no difference to HRQoL (NMA with 3 RCTs, 1513 participants). The provision of additional protein, energy supplements, ONS, and comprehensive individualised nutritional care may make little to no difference in LOS compared to control (18 RCTs, 3013 participants; Q between designs: Q 2.86, df 3, P = 0.4145). Body weight (16 RCTs, 2114 participants; Q between designs: Q 2.03, df 3, P = 0.5655) may increase with ONS when compared to control (MD 0.9 kg, 95% CI 0.37 to 1.42) or comprehensive individualised nutritional care (MD 1.00 kg, 95% CI 0.12 to 1.87), but the evidence is very uncertain. Energy supplements and ONS probably have similar effects on body weight (MD 0.11 kg, 95% CI −0.85 to 0.63; moderate‐certainty evidence). For fat‐free mass, no meta‐analysis was possible. One RCT (102 participants) compared ONS with energy supplements and found little or no difference between groups (MD 0.13 kg, 95% CI −0.63 to 0.90; low‐certainty evidence), while evidence regarding the effects of additional protein compared with control was very uncertain (1 RCT, 19 participants). Rankings of treatments by P‐scores were not consistent across outcomes. Authors' conclusions In older hospitalised people at risk of or with malnutrition, oral nutritional supplements may reduce mortality and SAEs compared to control 30 days after randomisation . For other outcomes, there may be little or no differences in results. Overall, the evidence was of low to very low certainty, primarily due to a limited number of studies and participants per comparison. The comparison of treatment effects across outcomes was constrained by variations in network structure. When interpreting the results, the heterogeneity of the population in terms of acute and chronic conditions needs to be considered. To improve certainty, adequately powered studies with robust methodologies should compare interventions with controls as well as against each other. Funding The German Federal Ministry of Education and Research funded this work (grant number: 01KG2102). Registration Protocol (2022) doi.org/10.1002/14651858.CD015468 Plain language summary What are the benefits and risks of different types of nutritional support for older, hospitalised people who are malnourished or at risk of malnutrition? Key messages Compared to standard hospital care, specialised foods and drinks may reduce the chances of dying and of having a serious negative health event one month after hospital admission. In terms of people's ability to perform basic daily activities, their quality of life, length of hospital stay, and body weight, we are either very uncertain about the benefits and risks of the different types of nutritional support, or evidence shows they may make little or no difference compared to standard hospital care. Larger and well‐designed studies comparing different types of nutritional support may increase our confidence in these findings. What is malnutrition? People become malnourished when their intake of energy and protein is not enough to meet their body's needs. This condition can reduce someone's fat and muscle stores. Being malnourished threatens people's health and compromises the immune system's ability to fight infections. Older people who are malnourished are at higher risk of disease complications, losing their independence, and dying than non‐malnourished older people. They also experience a lower quality of life. Older people may become malnourished or be at risk of malnutrition for several reasons, including having a reduced appetite, chewing problems, physical limitations (e.g. unable to stand for long periods to prepare meals), and loneliness. Older people in hospital are particularly prone to malnutrition. They may not eat enough at a time when their illness increases their energy and protein needs. Malnutrition affects roughly one‐third to two‐thirds of hospitalised older people. How is malnutrition treated? There is a wide range of treatments for malnutrition, including: specialised foods and beverages that provide extra energy, protein, and other nutrients; practical help with eating and drinking; additional snacks, protein‐rich foods or supplements; nutritional counselling; or tailored combinations of these approaches. What did we want to find out? In older, hospitalised people who are malnourished or at risk of malnutrition, we wanted to know if different types of nutritional support are better than standard care at: reducing the risk of dying and serious negative health events (e.g. complications such as infections or wound healing); improving people's ability to perform basic daily activities and their quality of life; reducing time spent in hospital; and boosting people's body weight and muscle mass. We also wanted to know which type of nutritional support works best. What did we do? We searched for studies in people 65 years and older who were in hospital and malnourished or at risk of malnutrition. We included studies that compared one type of nutritional support to another type, or compared nutritional support to standard hospital care (i.e. usual hospital food service), sometimes in combination with a 'dummy treatment' that looked identical to the supplements tested. We summarised and compared all treatments, and rated our confidence in the results based on factors such as study methods and the numbers of people included. What did we find? We found 21 studies involving 3309 hospitalised older people with different acute conditions. We grouped the treatments they received into five categories: specialised foods and drinks; protein‐enriched foods or supplements; energy supplements; personalised feeding support from an assistant (who would, for example, accommodate food preferences, adjust someone's position, and help with eating); multi‐component personalised nutritional care from a dietitian or nutritionist (who would, for example, modify foods or offer counselling). Main findings Compared to standard hospital care, after a month in hospital, specialised foods and drinks may: reduce the chance of death: they may lead to 57 fewer deaths per 1000 people; reduce serious negative health events: they may lead to 84 fewer events per 1000 people. Compared to standard hospital care, we are either very uncertain about the effects of specialised foods and drinks, protein‐enriched foods or supplements, energy supplements, personalised feeding support, and multi‐component personalised nutritional care, or these treatments may make little or no difference to people's: ability to perform basic daily activities; quality of life; length of hospital stay; body weight and muscle mass. When we compared the different types of nutritional support to each other, we did not find that any one approach worked better than all others in improving the results we measured. What are the limitations of the evidence? Our confidence in the findings is low or very low for several reasons. Some studies used methods that may have led to errors in the results. Studies often involved too few people, or did not look at everything we were interested in, such as muscle mass as outcome or comparisons of different types of nutritional support. Moreover, older people in hospital have different illnesses and functional abilities, and we could not assess how the different types of nutritional support work for different people. How current is this evidence? The evidence is current to 2 July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E, Schwarzer, G, Stadelmaier, J, Lohner, S, Grummich, K, Dagnelie, PC, Beck, AM, Beelen, J, Botella-Carretero, JI, Faxén-Irving, G, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015468.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.821Z" }, { "id": "9c73e6e7-23bc-4ead-b8ad-5a5971aa4906", "pmid": "", "title": "Oral zinc for the prevention of hyperbilirubinaemia in neonates", "imported": false, "abstract": "Abstract - Background Between 6% and 15% of neonates develop hyperbilirubinaemia requiring treatment. Successful management of neonatal hyperbilirubinaemia relies on prevention and early treatment, with phototherapy being the mainstay of treatment. Oral zinc has been reported to decrease the serum total bilirubin (STB), presumably by decreasing the enterohepatic circulation. Objectives To determine the effect of oral zinc supplementation compared to placebo or no treatment on the incidence of hyperbilirubinaemia in neonates during the first week of life and to assess the safety of oral zinc in enrolled neonates. Search methods We searched CENTRAL (The Cochrane Library 2014, Issue 1), MEDLINE (1966 to November 30, 2014), and EMBASE (1990 to November 30, 2014). Selection criteria Randomised controlled trials were eligible for inclusion if they enrolled neonates (term and preterm) to whom oral zinc, in a dose of 10 to 20 mg/day, was initiated within the first 96 hours of life, for any duration until day seven, compared with no treatment or placebo. Data collection and analysis We used the standard methods of The Cochrane Collaboration and its Neonatal Review Group for data collection and analysis. Main results Only one study met the criteria of inclusion in the review. This study compared oral zinc with placebo. Oral zinc was administered in a dose of 5 mL twice daily from day 2 to day 7 postpartum. The drug was administered into the mouth of the infant by the plastic measure provided with the bottle or with a spoon. Incidence of hyperbilirubinaemia, defined as serum total bilirubin (STB) ≥ 15 mg/dL, was similar between groups (N = 286; risk ratio (RR) 0.94, 95% confidence interval (CI) 0.58 to 1.52). Mean STB levels, mg/dL, at 72 ± 12 hours were comparable in both the groups (N = 286; mean difference (MD) ‐0.20; 95% CI ‐1.03 to 0.63). Although the duration of phototherapy in the zinc group was significantly shorter compared to the placebo group (N = 286; MD ‐12.80, 95% CI ‐16.93 to ‐8.67), the incidence of need for phototherapy was comparable across both the groups (N = 286; RR 1.20; 95% CI 0.66 to 2.18). Incidences of side effects like vomiting (N = 286; RR 0.65, 95% CI 0.19 to 2.25), diarrhoea (N = 286; RR 2.92, 95% CI 0.31 to 27.71), and rash (N = 286; RR 2.92, 95% CI 0.12 to 71.03) were found to be rare and statistically comparable between groups. Authors' conclusions The limited evidence available has not shown that oral zinc supplementation given to infants up to one week old reduces the incidence of hyperbilirubinaemia or need for phototherapy. Plain language summary Oral zinc for the prevention of hyperbilirubinaemia in neonates Review question In newborn infants less than one week old, does oral zinc salt supplementation compared to placebo or no treatment decrease the incidence of hyperbilirubinaemia (jaundice)? Background Jaundice, or yellowish discolouration of the skin, can occur due to an increased amount of bilirubin pigment in the blood. It is a commonly observed and usually harmless condition in newborn infants during the first week after birth. However, in some babies, the amount of bilirubin pigment can increase to dangerous levels and necessitate treatment. Bilirubin is metabolised in the liver and is excreted via the intestine in faeces. Increased reabsorption of bilirubin from the intestine is one of the major factors inducing hyperbilirubinaemia in newborn infants. Oral zinc salt, a relatively harmless medicine, can reduce the bilirubin level in newborn infants by decreasing its reabsorption from the intestine. Study characteristics Researchers from Cochrane searched for all available literature up to 30 November 2014. One randomised controlled trial met our inclusion criteria. Results In this review, the efficacy of oral zinc salt was compared with placebo. One study enrolling 294 infants was identified. This study evaluated oral zinc salt, given in a dose of 5 mg twice daily to infants between 25 and 168 hours old. The administration of oral zinc salt did not affect the incidence of jaundice (hyperbilirubinaemia) in these infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mishra, S, Cheema, A, Agarwal, R, Deorari, A, Paul, V", "articleTypes": [], "doi": "10.1002/14651858.CD008432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.085Z" }, { "id": "9c7b5dbd-bb35-423f-b569-8408ae152177", "pmid": "", "title": "Gelsectan® in the Treatment of Patients With Diarrhoea-predominant Irritable Bowel Syndrome: a Multicentre, Randomized, Double-blind, Parallel-group, Placebo-controlled Study", "imported": false, "abstract": "Irritable Bowel Syndrome (IBS) is one of the major Disorders of Gut-Brain Interaction (DGBI) and the most frequent reasons for referral to both primary care providers and gastroenterologists.IBS is not a life-threatening disease, but imposes a significant burden on society, entailing a decrease in patients' Quality of Life (QoL), elevated rates of psychological comorbidities and loss of work productivity, which might be the greatest in subjects with IBS-D, for whom the fear of incontinence in a social situation can be especially debilitating. Moreover, IBS is associated with significant direct and indirect healthcare costs and has a considerable socioeconomic impact on society.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.269Z" }, { "id": "9c9d050b-33f2-4003-992e-ebb99f601317", "pmid": "", "title": "A Randomized, Double Blind, Placebo-controlled Study to Investigate the Safety, Pharmacodynamics and Effect on Allergic Reactivity of Repeat Intranasal Administration of the TLR7 Agonist GSK2245035 in Subjects With Respiratory Allergies", "imported": false, "abstract": "The purpose of this study is to examine the safety and effects on the immune system of treatment with GSK2245035 in subjects who suffer from nasal symptoms caused by an allergy to pollen or perennial allergen, with or without mild asthma. In addition, the effect of treatment with GSK2245035 on the body's allergic response in test situations will be explored. Approximately 28 subjects will receive GSK2245035 (up to 14 subjects each receiving 80 nanograms [ng] GSK2245035 and up to 14 subjects each receiving 20 ng GSK2245035) and 14 subjects will receive the dummy drug (placebo) during the study. Assignment of a subject to GSK2245035 or placebo will be done by chance, like flipping a coin. Neither the subjects nor the clinic staff will know whether a subject is being dosed with GSK2245035 or placebo during the course of the study. The study will include (a) Screening phase where the eligibility of subjects for enrolment will be assessed (b) Treatment phase during which subjects will receive either 8 nasal sprays of GSK2245035 80 ng or a matching placebo once weekly for 8 weeks (each dose will be split between the two nostrils). Subjects participating in this study in 2014 will receive a reduced dose of 20 ng i.n. of GSK2245035 once weekly for eight administrations (c) Follow-up period where any GSK2245035 induced changes to the immune system and the effect of treatment on the body's allergic response in test situations will be monitored. The maximum planned study duration for all subjects, including the screening, treatment and follow-up periods, is approximately 180 days.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.153Z" }, { "id": "9ca23ac3-f069-4bc3-95f0-ab45ea1fdff9", "pmid": "", "title": "Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status", "imported": false, "abstract": "Abstract - Background Iron deficiency is an important micronutrient deficiency contributing to the global burden of disease, and particularly affects children, premenopausal women, and people in low‐resource settings. Anaemia is a possible consequence of iron deficiency, although clinical and functional manifestations of anemia can occur without iron deficiency (e.g. from other nutritional deficiencies, inflammation, and parasitic infections). Direct nutritional interventions, such as large‐scale food fortification, can improve micronutrient status, especially in vulnerable populations. Given the highly successful delivery of iodine through salt iodisation, fortifying salt with iodine and iron has been proposed as a method for preventing iron deficiency anaemia. Further investigation of the effect of double‐fortified salt (i.e. with iron and iodine) on iron deficiency and related outcomes is warranted. Objectives To assess the effect of double‐fortified salt (DFS) compared to iodised salt (IS) on measures of iron and iodine status in all age groups. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases, and two trial registries up to April 2021. We also searched relevant websites, reference lists, and contacted the authors of included studies. Selection criteria All prospective randomised controlled trials (RCTs), including cluster‐randomised controlled trials (cRCTs), and controlled before‐after (CBA) studies, comparing DFS with IS on measures of iron and iodine status were eligible, irrespective of language or publication status. Study reports published as abstracts were also eligible. Data collection and analysis Three review authors applied the study selection criteria, extracted data, and assessed risk of bias. Two review authors rated the certainty of the evidence using GRADE. When necessary, we contacted study authors for additional information. We assessed RCTs, cRCTs and CBA studies using the Cochrane RoB 1 tool and Cochrane Effective Practice and Organisation of Care (EPOC) tool across the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other potential sources of bias due to similar baseline characteristics, similar baseline outcome assessments, and declarations of conflicts of interest and funding sources. We also assessed cRCTs for recruitment bias, baseline imbalance, loss of clusters, incorrect analysis, and comparability with individually randomised studies. We assigned studies an overall risk of bias judgement (low risk, high risk, or unclear). Main results We included 18 studies (7 RCTs, 7 cRCTs, 4 CBA studies), involving over 8800 individuals from five countries. One study did not contribute to analyses. All studies used IS as the comparator and measured and reported outcomes at study endpoint. With regards to risk of bias, five RCTs had unclear risk of bias, with some concerns in random sequence generation and allocation concealment, while we assessed two RCTs to have a high risk of bias overall, whereby high risk was noted in at least one or more domain(s). Of the seven cRCTs, we assessed six at high risk of bias overall, with one or more domain(s) judged as high risk and one cRCT had an unclear risk of bias with concerns around allocation and blinding. The four CBA studies had high or unclear risk of bias for most domains. The RCT evidence suggested that, compared to IS, DFS may slightly improve haemoglobin concentration (mean difference (MD) 0.43 g/dL, 95% confidence interval (CI) 0.23 to 0.63; 13 studies, 4564 participants; low‐certainty evidence), but DFS may reduce urinary iodine concentration compared to IS (MD −96.86 μg/L, 95% CI −164.99 to −28.73; 7 studies, 1594 participants; low‐certainty evidence), although both salts increased mean urinary iodine concentration above the cut‐off deficiency. For CBA studies, we found DFS made no difference in haemoglobin concentration (MD 0.26 g/dL, 95% CI −0.10 to 0.63; 4 studies, 1397 participants) or urinary iodine concentration (MD −17.27 µg/L, 95% CI −49.27 to 14.73; 3 studies, 1127 participants). No studies measured blood pressure. For secondary outcomes reported in RCTs, DFS may result in little to no difference in ferritin concentration (MD −3.94 µg/L, 95% CI −20.65 to 12.77; 5 studies, 1419 participants; low‐certainty evidence) or transferrin receptor concentration (MD −4.68 mg/L, 95% CI −11.67 to 2.31; 5 studies, 1256 participants; low‐certainty evidence) compared to IS . However, DFS may reduce zinc protoporphyrin concentration (MD −27.26 µmol/mol, 95% CI −47.49 to −7.03; 3 studies, 921 participants; low‐certainty evidence) and result in a slight increase in body iron stores (MD 1.77 mg/kg, 95% CI 0.79 to 2.74; 4 studies, 847 participants; low‐certainty evidence). In terms of prevalence of anaemia, DFS may reduce the risk of anaemia by 21% (risk ratio (RR) 0.79, 95% CI 0.66 to 0.94; P = 0.007; 8 studies, 2593 participants; moderate‐certainty evidence). Likewise, DFS may reduce the risk of iron deficiency anaemia by 65% (RR 0.35, 95% CI 0.24 to 0.52; 5 studies, 1209 participants; low‐certainty evidence). Four studies measured salt intake at endline, although only one study reported this for both groups. Two studies reported prevalence of goitre, while one CBA study measured and reported serum iron concentration. One study reported adverse effects. No studies measured hepcidin concentration. Authors' conclusions Our findings suggest DFS may have a small positive impact on haemoglobin concentration and the prevalence of anaemia compared to IS, particularly when considering efficacy studies. Future research should prioritise studies that incorporate robust study designs and outcome measures (e.g. anaemia, iron status measures) to better understand the effect of DFS provision to a free‐living population (non‐research population), where there could be an added cost to purchase double‐fortified salt. Adequately measuring salt intake, both at baseline and endline, and adjusting for inflammation will be important to understanding the true effect on measures of iron status. Plain language summary Fortification of salt with iron and iodine compared to salt fortified with iodine only for improving iron and iodine status Key messages Compared to iodised salt, double‐fortified salt (salt fortified with iron and iodine) may improve some measures of iron and iodine nutrition, such as haemoglobin (i.e. the substance that gives red blood cells their colour) concentrations and body iron stores. However, it may reduce urinary iodine concentration and may make little or no difference to ferritin (i.e. iron‐storage protein) concentrations and transferrin receptor (i.e. protein that affects the uptake of iron) concentrations. It probably also reduces the prevalence of anaemia (lack of haemoglobin), and may reduce the prevalence of iron deficiency anaemia (lack of iron), compared to iodised salt. Well‐designed studies that assess the effects of double‐fortified salt within non‐research populations (i.e. real‐life settings), and that measure salt intake, including changes in salt consumption, are needed. What is iron deficiency? Almost two billion people experience a deficiency in a vitamin or mineral (or both), with women and children in resource‐limited settings most frequently affected. Iron‐related deficiencies are among the most common deficiencies in the world and have important short‐ and long‐term health consequences. Interventions to provide iron frequently include iron supplementation, including iron tablets, powders, or syrups. However, these have known barriers, and food fortification strategies may be attractive alternatives. Salt is one of few universally consumed food vehicles. Iodised salt is fortified to provide 100% of a person's iodine requirements and is highly effective. Double‐fortified salt was developed to provide 30% of a person's daily dietary iron requirement and 100% of their iodine requirement. In some resource‐limited settings, where iron‐related deficiencies are a common problem, there has been interest in making double‐fortified salt more available to the public. This calls for further understanding of the effect of double‐fortified salt on related outcomes. What did we want to find out? If double‐fortified salt is better than salt fortified with iodine alone for improving measures of iron and iodine‐related nutrition, in particular: ‐ haemoglobin concentration; ‐ urinary iodine concentration; ‐ blood pressure; ‐ ferritin concentration; ‐ transferrin receptor concentration; ‐ prevalence of anaemia; ‐ prevalence of iron deficiency anaemia. What did we do? We looked for studies that provided double‐fortified salt to one group of participants and iodised salt to another. We compared their results, and rated our confidence in the evidence, based on factors such as study methods and sample size. What did we find? We identified 18 studies, involving over 8800 individuals from five countries; 13 studies were conducted in India. In 13 studies the intervention lasted between 6 and 12 months; in two studies it lasted 3 months, and in single studies it lasted for 18 months, 24 months, or the duration was unclear. Nine studies were conducted in children and adolescents (5 to 17 years), four in adults (18 years and older), and five included multiple age groups. All studies compared double‐fortified salt to iodised salt. Most studies were funded by non‐profit organisations, university grants or academic institutes. In four studies, double‐fortified salt was provided by a commercial organisation, and in three studies the funding source unclear. Compared to iodised salt, double‐fortified salt may improve haemoglobin concentration and body iron stores slightly, and probably reduces the prevalence of anaemia by 21%. However, double‐fortified salt may also reduce urinary iodine concentration compared to iodised salt and may make little or no difference in ferritin and transferrin receptor concentration. Double‐fortified salt may reduce the prevalence of iron deficiency anaemia by 65%, compared to iodised salt, although this conclusion is uncertain because of some problems with the way the studies were conducted. Very few studies measured zinc protoporphyrin concentration, adverse effects, prevalence of goitre and salt intake. One study measured serum iron concentration. No studies measured blood pressure or hepcidin concentration. What are the limitations of the evidence? We have relatively low confidence in the evidence for the outcomes: haemoglobin, urinary iodine, ferritin, and transferrin receptor concentration, and prevalence of iron deficiency anaemia. Not all studies provided data about all outcomes of interest; studies delivered the intervention differently; and studies were small, both in number and size. For the prevalence of anaemia, we are moderately confident in the evidence because studies used different ways of delivering the intervention. Care should be taken in interpreting our findings in relation to public health policy and programmes. Most studies were conducted in monitored research settings and double‐fortified salt was provided without an added cost. We are unsure if the effect we observed would be the same in real‐life (i.e. non‐research population), where purchasing double‐fortified salt could increase the cost. More studies looking at the effect of double‐fortified salt within real‐life settings are needed to understand the true effects of double‐fortified salt with greater certainty. Given the changing guidelines for salt intake, future studies should measure salt intake to understand if double‐fortified salt should be considered to prevent anaemia at the population level and how to integrate double‐fortified salt into the supply chain. How up to date is this evidence? The evidence is up to date to April 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Baxter, J-AB, Carducci, B, Kamali, M, Zlotkin, SH, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD013463.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.805Z" }, { "id": "9ca8bd96-cead-4cc7-ae52-644db6d362c2", "pmid": "", "title": "Zinc supplements for preventing otitis media", "imported": false, "abstract": "Abstract - Background Otitis media is inflammation of the middle ear and is usually caused by infection. It affects people of all ages but is particularly common in young children. Around 164 million people worldwide have long‐term hearing loss caused by this condition, 90% of them in low‐income countries. As zinc supplements prevent pneumonia in disadvantaged children, we wanted to investigate whether zinc supplements could also prevent otitis media. Objectives To evaluate whether zinc supplements prevent otitis media in adults and children of different ages. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (1950 to February week 4, 2014) and EMBASE (1974 to March 2014). Selection criteria Randomised, placebo‐controlled trials of zinc supplements given at least once a week for at least a month for preventing otitis media. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of the included trials and extracted and analysed data. We summarised results using risk ratios (RRs) or rate ratios for dichotomous data and mean differences (MDs) for continuous data. We combined trial results where appropriate. Main results No new trials were identified for inclusion in this update. We identified 12 trials for inclusion, 10 of which contributed outcomes data. There were a total of 6820 participants. In trials of healthy children living in low‐income communities, two trials did not demonstrate a significant difference between the zinc‐supplemented and placebo groups in the numbers of participants experiencing an episode of definite otitis media during follow‐up (3191 participants); another trial showed a significantly lower incidence rate of otitis media in the zinc group (rate ratio 0.69, 95% confidence interval (CI) 0.61 to 0.79, n = 1621). A small trial of 39 infants undergoing treatment for severe malnutrition suggested a benefit of zinc for the mean number of episodes of otitis media (mean difference (MD) ‐1.12 episodes, 95% CI ‐2.21 to ‐0.03). Zinc supplements did not seem to cause any serious adverse events but a small minority of children were reported to have vomited shortly after ingestion of the supplements. The trial evidence included is generally of good quality, with a low risk of bias. Authors' conclusions Evidence on whether zinc supplementation can reduce the incidence of otitis media in healthy children under the age of five years living in low‐ and middle‐income countries is mixed. There is some evidence of benefit in children being treated for marasmus (severe malnutrition), but this is based on one small trial and should therefore be treated with caution. Plain language summary Zinc supplements for preventing middle ear infections Background Middle ear infections are common, especially among young children, usually causing earache and some temporary (occasionally permanent) hearing loss. Zinc is an essential micronutrient, which has a role in the optimal functioning of the immune system and resistance to infection. It must be consumed regularly as it cannot be stored in the body. Some people, especially children in low‐ and middle‐income countries, may not have adequate zinc intake from food alone. Researchers have examined the potential role of zinc supplements in preventing infective illnesses. Therefore we wanted to discover whether zinc supplements have any role in preventing middle ear infections. Study characteristics The review authors searched the medical literature for studies up to March 2014. We searched for trials which compared middle ear infections in people randomly selected to receive zinc supplements or who did not receive supplements. We found 10 eligible studies, all conducted amongst young children. The total number of participants was 6820. Nine trials were conducted in low‐ and middle‐income countries. Seven trials were conducted on healthy children. Participants included both males and females. Results The results of the trials provided no convincing evidence that zinc supplements reduce the occurrence of middle ear infections in healthy children. However, in one small study of severely malnourished children, those receiving zinc supplements had fewer middle ear infections. The only adverse effect was vomiting. Quality of evidence The trial evidence included is generally of good quality, with a low risk of bias. All the included trials included otitis media only as a secondary outcome. Therefore, there was a potential to miss trials which were less publicised or less well indexed within the electronic databases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Gulani, A, Sachdev, HS", "articleTypes": [], "doi": "10.1002/14651858.CD006639.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.081Z" }, { "id": "9cab1d05-2f15-45eb-9691-b975c3df704b", "pmid": "", "title": "Antiplatelet agents for the treatment of adults with COVID‐19", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Fischer, A-L, Messer, S, Riera, R, Martimbianco, ALC, Stegemann, M, Estcourt, LJ, Weibel, S, Monsef, I, Andreas, M, Pacheco, RL, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015078 AB - Abstract - Background Severe coronavirus disease 2019 (COVID‐19) can cause thrombotic events that lead to severe complications or death. Antiplatelet agents, such as acetylsalicylic acid, have been shown to effectively reduce thrombotic events in other diseases: they could influence the course of COVID‐19 in general. Objectives To assess the efficacy and safety of antiplatelets given with standard care compared to no treatment or standard care (with/without placebo) for adults with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (which comprises MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO ICTRP, medRxiv, CENTRAL), Web of Science, WHO COVID‐19 Global literature on coronavirus disease and the Epistemonikos COVID‐19 L*OVE Platform to identify completed and ongoing studies without language restrictions to December 2022. Selection criteria We followed standard Cochrane methodology. We included randomised controlled trials (RCTs) evaluating antiplatelet agents for the treatment of COVID‐19 in adults with COVID‐19, irrespective of disease severity, gender or ethnicity. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane risk of bias tool (RoB 2) for RCTs. We rated the certainty of evidence using the GRADE approach for the outcomes. Main results Antiplatelets plus standard care versus standard care (with/without placebo) Adults with a confirmed diagnosis of moderate to severe COVID‐19 We included four studies (17,541 participants) that recruited hospitalised people with a confirmed diagnosis of moderate to severe COVID‐19. A total of 8964 participants were analysed in the antiplatelet arm (either with cyclooxygenase inhibitors or P2Y12 inhibitors) and 8577 participants in the control arm. Most people were older than 50 years and had comorbidities such as hypertension, lung disease or diabetes. The studies were conducted in high‐ to lower middle‐income countries prior to wide‐scale vaccination programmes. Antiplatelets compared to standard care: – probably result in little to no difference in 28‐day mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.85 to 1.05; 3 studies, 17,249 participants; moderate‐certainty evidence). In absolute terms, this means that for every 177 deaths per 1000 people not receiving antiplatelets, there were 168 deaths per 1000 people who did receive the intervention (95% CI 151 to 186 per 1000 people); – probably result in little to no difference in worsening (new need for invasive mechanical ventilation or death up to day 28) (RR 0.95, 95% CI 0.90 to 1.01; 2 studies, 15,266 participants; moderate‐certainty evidence); – probably result in little to no difference in improvement (participants discharged alive up to day 28) (RR 1.00, 95% CI 0.96 to 1.04; 2 studies, 15,454 participants; moderate‐certainty evidence); – probably result in a slight reduction of thrombotic events at longest follow‐up (RR 0.90, 95% CI 0.80 to 1.02; 4 studies, 17,518 participants; moderate‐certainty evidence); – may result in a slight increase in serious adverse events at longest follow‐up (Peto odds ratio (OR) 1.57, 95% CI 0.48 to 5.14; 1 study, 1815 participants; low‐certainty evidence), but non‐serious adverse events during study treatment were not reported; – probably increase the occurrence of major bleeding events at longest follow‐up (Peto OR 1.68, 95% CI 1.29 to 2.19; 4 studies, 17,527 participants; moderate‐certainty evidence). Adults with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included two RCTs allocating participants, of whom 4209 had confirmed mild COVID‐19 and were not hospitalised. A total of 2109 participants were analysed in the antiplatelet arm (treated with acetylsalicylic acid) and 2100 participants in the control arm. No study included people with asymptomatic SARS‐CoV‐2 infection. Antiplatelets compared to standard care: – may result in little to no difference in all‐cause mortality at day 45 (Peto OR 1.00, 95% CI 0.45 to 2.22; 2 studies, 4209 participants; low‐certainty evidence); – may slightly decrease the incidence of new thrombotic events up to day 45 (Peto OR 0.37, 95% CI 0.09 to 1.46; 2 studies, 4209 participants; low‐certainty evidence); – may make little or no difference to the incidence of serious adverse events up to day 45 (Peto OR 1.00, 95% CI 0.60 to 1.64; 1 study, 3881 participants; low‐certainty evidence), but non‐serious adverse events were not reported. The evidence is very uncertain about the effect of antiplatelets on the following outcomes (compared to standard care plus placebo): – admission to hospital or death up to day 45 (Peto OR 0.79, 95% CI 0.57 to 1.10; 2 studies, 4209 participants; very low‐certainty evidence); – major bleeding events up to longest follow‐up (no event occurred in 328 participants; very low‐certainty evidence). Quality of life and adverse events during study treatment were not reported. Authors' conclusions In people with confirmed or suspected COVID‐19 and moderate to severe disease, we found moderate‐certainty evidence that antiplatelets probably result in little to no difference in 28‐day mortality, clinical worsening or improvement, but probably result in a slight reduction in thrombotic events. They probably increase the occurrence of major bleeding events. Low‐certainty evidence suggests that antiplatelets may result in a slight increase in serious adverse events. In people with confirmed COVID‐19 and mild symptoms, we found low‐certainty evidence that antiplatelets may result in little to no difference in 45‐day mortality and serious adverse events, and may slightly reduce thrombotic events. The effects on the combined outcome admission to hospital or death up to day 45 and major bleeding events are very uncertain. Quality of life was not reported. Included studies were conducted in high‐ to lower middle‐income settings using antiplatelets prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, adverse events and people with asymptomatic infection. The 14 ongoing and three completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. Plain language summary Are antiplatelets an effective treatment for people with COVID‐19? Key messages Antiplatelets are a group of different medicines that can prevent potentially fatal clot formation in the blood vessels ('thrombotic events'). For hospitalised patients with COVID‐19, they probably slightly reduce thrombotic events but probably do not affect deaths, clinical worsening or improvement in COVID‐19 compared with placebo or standard care. However, antiplatelets may result in a slight increase in serious unwanted effects ('adverse events') and probably increase major bleeding. Similarly, in non‐hospitalised people, antiplatelets slightly decrease thrombotic events. They may result in little to no difference in deaths or serious unwanted effects, however the evidence on admission to hospital or death and major bleeding events is very uncertain. There are 14 further studies that have not completed yet, and the results of three other completed studies are not yet available. What are antiplatelets? Antiplatelets are a group of drugs which, in different ways, stop blood from changing to a gel‐like substance called a clot, which we mean by the term 'thrombotic events'. They are taken mainly by mouth, usually by people who are at high risk of developing a clot (people who have already experienced or who tend to build up a clot). A clot could lead to a stroke, coronary heart disease, poor blood circulation in the legs, thromboses in the legs or clot obstruction ('embolism') in the lung circulation that could lead to shortness of breath, heart failure and death. How might antiplatelets treat COVID‐19? People with COVID‐19 might be at risk from blood clots. Antiplatelets prevent clots from forming in the body, and this could in turn prevent complications that lead to death and clinical deterioration. What did we want to find out? We wanted to know whether antiplatelets in addition to usual care are effective for adults with COVID‐19, when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in: – number of deaths from any cause up to 28 days after treatment, or longer if reported;
– whether people got better or worse after treatment (including unwanted effects of the disease itself, like thrombotic events);
– unwanted effects of the treatment (especially major bleeding). What did we do? We searched for studies that reported on people with COVID‐19 who received antiplatelets together with usual care, or usual care alone (with/without placebo). We summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We identified four studies, including 17,541 people with moderate to severe COVID‐19 (hospitalised). Of these, one compared acetylsalicylic acid (aspirin) with usual care, two studies compared 'P2Y12 inhibitors' (e.g. clopidogrel, prasugrel, ticagrelor) with usual care, and a fourth one compared either acetylsalicylic acid or P2Y12 inhibitors with usual care. The studies included people with a confirmed or suspected diagnosis of SARS‐CoV‐2 infection. Two studies compared acetylsalicylic acid to placebo in 4209 non‐hospitalised people with confirmed mild COVID‐19. We also found 14 ongoing studies, two studies without published results and another that had been withdrawn after a preprint version. We found no studies that included people with COVID‐19 infection but no symptoms. Main results Antiplatelets: – probably make little or no difference to deaths by 28 or 180 days, worsening up to day 28 (new invasive mechanical ventilation or death) or improvement (discharged alive) up to day 28, and they probably slightly decrease thrombotic events; – may result in a slight increase in serious unwanted effects and probably increase major bleeding events. In people not in hospital, with mild disease, antiplatelets may result in little to no difference in death within 45 days, or in the incidence of serious adverse events, and they may slightly decrease the incidence of thrombotic events. The evidence for these participants is very uncertain about the effects on worsening (hospitalisation or death within 45 days) and on major bleeding events. Studies did not report on quality of life and general unwanted effects. What are the limitations of the evidence? The studies were conducted in populations from high‐ to middle‐income countries, many of them prior to the roll‐out of COVID‐19 vaccination programmes and before Omicron became the most prevalent variant. We have moderate confidence in the evidence for mortality, worsening/improvement up to day 28, and major bleeding events or thrombotic events in hospitalised people. We have low confidence in the evidence for the effects on serious unwanted effects, because they occurred rarely. For non‐hospitalised people, our confidence in the evidence is low for the effects on death, thrombotic events and serious adverse events, and very low for the effects on worsening and major bleeding events (those events were rare and the time period between symptom onset and treatment was long). Information about other unwanted effects and quality of life was not available. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 22 December 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.121Z" }, { "id": "9cb63dc9-6445-49cf-8975-0cd26ca96749", "pmid": "", "title": "Fatty Acid Taste Thresholds: Caproic, Lauric, Oleic, Linoleic, Linolenic", "imported": false, "abstract": "Differences in human oral sensitivity for caproic, lauric, oleic, linoleic, and linolenic acids will be explored. Prior work indicates that there may be a learning effect in measuring detection thresholds for free fatty acids. This study is designed to determine the number of visits necessary to attenuate this learning effect and also to test whether this effect continues across different types of fatty acids or is specific to each fatty acid. This will aid in understanding how many visits are required to obtain reliable data and if less expensive fatty acids can be used to attenuate learning before testing thresholds for more expensive fatty acids.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.232Z" }, { "id": "9cbd6e8c-8dba-4650-9c52-0f8b02af0124", "pmid": "", "title": "Anticholinergic therapy for chronic asthma in children over two years of age", "imported": false, "abstract": "Abstract - Background In the intrinsic system of controlling airway calibre, the cholinergic (muscarinic) sympathetic nervous system has an important role. Anticholinergic, anti muscarinic bronchodilators such as ipratropium bromide are frequently used in the management of childhood airway disease. In asthma, ipratropium is a less potent bronchodilator than beta‐2 adrenergic agents but it is known to be a useful adjunct to other therapies, particularly in status asthmaticus. What remains unclear is the role of anticholinergic drugs in the maintenance treatment of chronic asthma. Objectives To determine the effectiveness of anticholinergic drugs in chronic asthma in children over the age of 2 years. Search methods The Cochrane Airways Group Specialised Register and reference lists of articles were searched. The most recent search was carried out in Febuary 2010. Selection criteria Randomised controlled trials in which anticholinergic drugs were given for chronic asthma in children over 2 years of age were included. Studies including comparison of: anticholinergics with placebo, and anticholinergics with any other drug were included. Data collection and analysis Eligibility for inclusion and quality of trials were assessed independently by two reviewers. Main results Eight studies met the inclusion criteria. Three papers compared the effects of anticholinergic drugs with placebo, and a meta‐analysis of these results demonstrated no statistically significant benefit of the use of anticholinergic drugs over placebo in any of the outcome measures used. The results of one of these trials could not be included in the meta‐analysis but the authors did report significantly lower symptom scores with inhaled anticholinergics compared with placebo. However, there was no significant difference between ipratropium bromide and placebo in the percentage of symptom‐free nights or days. Two trials studied the effects of anticholinergics on bronchial hyper responsiveness to histamine, by measuring the provocation dose of histamine needed to cause a fall of 20 % in FEV1 (PD 20). One study (comparing anticholinergics with placebo) reported a statistically significant increase in PD 20 but this was not found in another study (comparing anticholinergics with a beta‐2 agonist). Both trials also examined the effect of anticholinergic drugs on diurnal variation in peak expiratory flow rate (PEFR) and reported no significant effect. Two studies compared the addition of an anticholinergic drug to a beta‐2 agonist with the beta‐2 agonist alone. Both trials failed to show any significant benefit from the long term use of combined anticholinergics with beta‐2 agonists compared with beta‐2 agonists alone. One trial compared the effects of oral and inhaled anticholinergic drugs with placebo. No statistically significant differences were found in any of the outcome measures except for a higher FEV1 / VC ratio and RV / TLC ratio with oral anticholinergic therapy when compared with placebo. Authors' conclusions The present review summarises the best evidence available to date. Although there were some small beneficial findings in favour of anticholinergic therapy, there is insufficient data to support the use of anticholinergic drugs in the maintenance treatment of chronic asthma in children. Plain language summary Anticholinergic drugs versus either placebo or other medications for children over two years of age with asthma Anticholinergic drugs are widely used in the management of both acute and chronic asthma in children. Their effect is achieved through relief of narrowing of the airways that occurs in asthma. Current guidelines for the management of chronic asthma advise that anticholinergic drugs may be used if children are already on high dose inhaled steroids. This study undertook a comprehensive search of the literature unrestricted by country of publication or language. Unfortunately small numbers of relevant trials were found and these were of variable quality. This review found that although anticholinergic drugs are well tolerated, in children over two years of age, there is not enough data to be sure if they are better than placebo in terms of effects on lung function or symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "McDonald, N; Bara, A; McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD003535", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "9cca038b-2fd5-4a49-b699-fea41df662ff", "pmid": "", "title": "Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010. For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established. Objectives To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications. Search methods Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012. Selection criteria Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Data collection and analysis Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information. Main results One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012. Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study. Weight loss was greater for the NG group at six weeks post‐treatment than for the PEG group (P = 0.001). At six months post‐treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post‐treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively. We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review. Authors' conclusions There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required. Plain language summary Artificial tube feeding methods for use with patients with head and neck cancer who are receiving treatment with radiotherapy, chemotherapy or both Patients with cancer of the head and neck are at risk of malnutrition during radiotherapy treatment due to the side effects of this treatment and they may need tube feeding to meet their nutritional needs. Tube feeding can either be delivered via a nasogastric feeding tube, which is a fine tube inserted through the nose into the stomach, or a gastrostomy tube which is inserted through the skin of the abdomen directly into the stomach. Both of these methods allow the delivery of nutrients directly into the stomach. Tube feeding is essential to meet the nutritional needs of head and neck cancer patients as malnutrition can lead to a poorer prognosis for this patient group. There is debate over which method of tube feeding provides the most benefit to the patient for outcomes such as nutritional benefit and quality of life, as well as avoiding delays in radiotherapy treatment. Following our analysis of the available literature, only one clinical trial was eligible to be included in this review. The authors of this review found no evidence to support the use of any one method of tube feeding over another.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Nugent, B, Lewis, S, O'Sullivan, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007904.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.079Z" }, { "id": "9ce03588-de39-48ea-80e6-b2b8522b403a", "pmid": "", "title": "Management of gag reflex for patients undergoing dental treatment", "imported": false, "abstract": "Abstract - Background The gag reflex is an involuntary defence mechanism to protect the pharynx and throat from foreign objects. Gagging is a common problem encountered during dental treatment, making therapeutic procedures distressing and often difficult or even impossible to perform. Various interventions can be used to control the gag reflex: anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behavioural therapies, acupressure, acupuncture, laser, and prosthetic devices. This is an update of the Cochrane Review first published in 2015. Objectives To assess the effects of pharmacological and non‐pharmacological interventions for the management of gagging in people undergoing dental treatment. Search methods Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register (to 18 March 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2) in the Cochrane Library (searched 18 March 2019), MEDLINE Ovid (1946 to 18 March 2019), Embase Ovid (1980 to 18 March 2019), CINAHL EBSCO (1937 to 18 March 2019), AMED Ovid (1985 to 18 March 2019), and the proceedings of the International Association for Dental Research (IADR) online (2001 to 18 March 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We also conducted forwards citation searching on the included studies via Google Scholar. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs), involving people who were given a pharmacological or non‐pharmacological intervention to manage gagging that interfered with dental treatment. We excluded quasi‐RCTs. We excluded trials with participants who had central or peripheral nervous system disorders, who had oral lesions or were on systemic medications that might affect the gag sensation, or had undergone surgery which might alter anatomy permanently. Data collection and analysis We independently selected trials, extracted data, and assessed risk of bias. We followed Cochrane's statistical guidelines. We assessed the overall certainty of the evidence using GRADE. Main results We included four trials at unclear risk of bias with 328 participants (263 adults and 65 children who were four years or older), in which one trial compared acupuncture and acupressure (with thumb, device and sea band) at P6 (point located three‐finger breadths below the wrist on the inner forearm in between the two tendons) to sham acupuncture and acupressure with and without sedation. One trial compared acupuncture at P6 point to sham acupuncture. These trials reported both completion of dental procedure and reduction in gagging (assessor and patient reported) as their outcomes. One cross‐over and one split‐mouth trial studied the effect of laser at P6 point compared to control. One trial reported reduction in gagging and another reported presence or absence of gagging during dental procedure. Acupuncture at P6 showed uncertain evidence regarding the successful completion of dental procedure (RR 1.78, 95% CI 1.05 to 3.01; two trials, 59 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 2.57, 95% CI 1.12 to 5.89; one trial, 26 participants; very low‐certainty evidence) in comparison to sham acupuncture. Acupuncture at P6 with sedation did not show any difference when compared to sham acupuncture with sedation (RR 1.08, 95% CI 0.91 to 1.28; one trial, 34 participants; very low‐certainty evidence). Acupressure using thumb pressure with or without sedation showed no clear difference in completing dental procedure (RR 0.96, 95% CI 0.84 to 1.10; one trial, 39 participants; very low‐certainty evidence; and RR 0.85, 95% CI 0.50 to 1.46; one trial, 30 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 1.06, 95% CI 0.92 to 1.23; one trial, 39 participants; very low‐certainty evidence; and RR 0.92, 95% CI 0.60 to 1.41; one trial, 30 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Acupressure at P6 with device showed uncertain evidence regarding the successful completion of dental procedure (RR 2.63, 95% CI 1.33 to 5.18; one trial, 34 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 3.94, 95% CI 1.63 to 9.53; one trial, 34 participants; very low‐certainty evidence) when compared to sham acupressure. However, device combined with sedation showed no difference for either outcome (RR 1.16, 95% CI 0.90 to 1.48; one trial, 27 participants; very low‐certainty evidence; and RR 1.26, 95% CI 0.93 to 1.69; one trial, 27 participants; very low‐certainty evidence; respectively). Acupressure using a sea band with or without sedation showed no clear difference in completing dental procedure (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 1.80, 95% CI 0.63 to 5.16; one trial, 19 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 2.70, 95% CI 0.72 to 10.14; one trial, 19 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Laser at P6 showed a difference in absence of gagging (odds ratio (OR) 86.33, 95% CI 29.41 to 253.45; one trial, 40 participants; very low‐certainty evidence) and reduction in gagging (MD 1.80, 95% CI 1.53 to 2.07; one trial, 25 participants; very low‐certainty evidence) during dental procedure when compared to dummy laser application. No noteworthy adverse effects were reported. For acupuncture at P6, the trial authors were unsure whether the reported adverse effects were due to participant anxiety or due to the intervention. None of the trials on acupressure or laser reported on this outcome. We did not find trials evaluating any other interventions used to manage gagging in people undergoing dental treatment. Authors' conclusions We found very low‐certainty evidence from four trials that was insufficient to conclude if there is any benefit of acupuncture, acupressure or laser at P6 point in reducing gagging and allowing successful completion of dental procedures. We did not find any evidence on any other interventions for managing the gag reflex during dental treatment. More well‐designed and well‐reported trials evaluating different interventions are needed. Plain language summary Management of gagging in dental patients Review question With this Cochrane Review we tried to find out the best way to manage gagging in people having dental treatment. Background The gag reflex is a normal process to protect the throat and airway from foreign objects and prevent choking. Many people have an exaggerated gag reflex that causes distress during dental treatment. This can make it difficult or even impossible to perform the treatment. The interventions used to manage gagging include anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behaviour therapy and cognitive behaviour therapy, acupressure, acupuncture, laser, and prosthetic devices. We wanted to know how effective and safe these interventions are in helping people complete their dental treatment with less gagging. We compared them to no intervention or a placebo or to other interventions. Study characteristics This review is up‐to‐date as of 18 March 2019. We included four trials with 328 people (263 adults and 65 children who were 4 years or older). These people had nausea before when having dental treatment that caused the treatment to be stopped or not carried out properly. Key results Acupuncture at P6 point (a point located in the inside of the wrist) showed uncertain evidence regarding the successful completion of dental treatment and reduction in gagging when compared to sham (fake) acupuncture. The same intervention with sedation did not show a difference. Acupressure (with thumb or sea band (bands that fit around the wrist just like a sweat band with a pressure stud sewn inside)) at P6 point with or without sedation did not show any difference when compared to sham acupressure. Acupressure at P6 point with device showed a difference in completing dental treatment and reduction in gagging. It did not show a difference when combined with sedation. Laser at P6 point showed a difference in absence of gagging and reduction in gagging during dental treatment when compared to sham laser application. The included studies did not report any important harmful effects of the treatment. Certainty of the evidence The level of belief we have in these findings is very low. This was due to unclear risk of bias and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to manage gagging in people having dental treatment. We suggest that more well‐conducted studies should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Eachempati, P; Kumbargere Nagraj, S; Kiran Kumar Krishanappa, S; George, RP; Soe, HH; Karanth, L", "articleTypes": [], "doi": "10.1002/14651858.CD011116.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "9ce81625-3334-4300-afa1-09dd838994a5", "pmid": "", "title": "Topiramate for the prophylaxis of episodic migraine in adults", "imported": false, "abstract": "Abstract - Background Some antiepileptic drugs but not others are useful in clinical practice for the prophylaxis of migraine. This might be explained by the variety of actions of these drugs in the central nervous system. The present review is part of an update of a Cochrane review first published in 2004, and previously updated (conclusions not changed) in 2007. Objectives To describe and assess the evidence from controlled trials on the efficacy and tolerability of topiramate for preventing migraine attacks in adult patients with episodic migraine. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2012, Issue 12), PubMed/MEDLINE (1966 to 15 January 2013), MEDLINE In‐Process (current week, 15 January 2013), and EMBASE (1974 to 15 January 2013) and handsearched Headache and Cephalalgia through January 2013. Selection criteria Studies were required to be prospective, controlled trials of topiramate taken regularly to prevent the occurrence of migraine attacks, to improve migraine‐related quality of life, or both. Data collection and analysis Two review authors independently selected studies and extracted data. For headache frequency data, we calculated mean differences (MDs) between topiramate and comparator (placebo, active control, or topiramate in a different dose) for individual studies and pooled these across studies. For dichotomous data on responders (patients with ≥ 50% reduction in headache frequency), we calculated odds ratios (ORs) and, in select cases, risk ratios (RRs); we also calculated numbers needed to treat (NNTs). We calculated MDs for selected quality of life instruments. Finally, we summarised data on adverse events from placebo‐controlled trials and calculated risk differences (RDs) and numbers needed to harm (NNHs). Main results Twenty papers describing 17 unique trials met the inclusion criteria. Analysis of data from nine trials (1737 participants) showed that topiramate reduced headache frequency by about 1.2 attacks per 28 days as compared to placebo (MD ‐1.20; 95% confidence interval (CI) ‐1.59 to ‐0.80). Data from nine trials (1190 participants) show that topiramate approximately doubled the proportion of responders relative to placebo (RR 2.02; 95% CI 1.57 to 2.60; NNT 4; 95% CI 3 to 6). Separate analysis of different topiramate doses produced similar MDs versus placebo at 50 mg (‐0.95; 95% CI ‐1.95 to 0.04; three studies; 520 participants), 100 mg (‐1.15; 95% CI ‐1.58 to ‐0.71; six studies; 1620 participants), and 200 mg (‐0.94; 95% CI ‐1.53 to ‐0.36; five studies; 804 participants). All three doses significantly increased the proportion of responders relative to placebo; ORs were as follows: for 50 mg, 2.35 (95% CI 1.60 to 3.44; three studies; 519 participants); for 100 mg, 3.49 (95% CI 2.23 to 5.45; five studies; 852 participants); and for 200 mg, 2.49 (95% CI 1.61 to 3.87; six studies; 1025 participants). All three doses also significantly improved three or more domains of quality of life as compared to placebo. Meta‐analysis of the three studies that included more than one dose of topiramate suggests that 200 mg is no more effective than 100 mg. With regard to mean headache frequency and/or responder rate, seven trials using active comparators found (a) no significant difference between topiramate and amitriptyline (one study, 330 participants); (b) no significant difference between topiramate and flunarizine (one study, 83 participants); (c) no significant difference between topiramate and propranolol (two studies, 342 participants); (d) no significant difference between topiramate and relaxation (one study, 61 participants); but (e) a slight significant advantage of topiramate over valproate (two studies, 120 participants). Relaxation improved migraine‐specific quality of life significantly more than topiramate. In trials of topiramate against placebo, seven adverse events (AEs) were reported by at least three studies. These were usually mild and of a non‐serious nature. Except for taste disturbance and weight loss, there were no significant differences in the frequency of AEs in general, or of the seven specific AEs, between placebo and topiramate 50 mg. AEs in general and all of the specific AEs except nausea were significantly more common on topiramate 100 mg than on placebo, with NNHs varying from 3 to 25, and the RDs versus placebo were even higher for topiramate 200 mg, with NNHs varying from 2 to 17. Authors' conclusions Meta‐analysis demonstrates that topiramate in a 100 mg/day dosage is effective in reducing headache frequency and reasonably well‐tolerated in adult patients with episodic migraine. This provides good evidence to support its use in routine clinical management. More studies designed specifically to compare the efficacy or safety of topiramate versus other interventions with proven efficacy in the prophylaxis of migraine are needed. Plain language summary Topiramate for preventing migraine attacks in adults Various medicines, collectively termed 'antiepileptics', are used to treat epilepsy. For several years, some of these drugs have also been used for preventing migraine attacks. For the present review, researchers in The Cochrane Collaboration reviewed the evidence about the effects of topiramate in adult patients (≥ 16 years of age) with 'episodic' migraine (headache on < 15 days per month). They examined research published up to 15 January 2013 and found 17 relevant studies. Compared with placebo, topiramate reduced the frequency of migraine headaches by approximately 1.2 per month (nine studies, 1737 participants). Patients were also about twice as likely to reduce the number of their migraine headaches by 50% or more with topiramate than with placebo (nine studies, 1190 participants). Side effects associated with topiramate were common but generally mild; topiramate can, however, cause birth defects and so should be used with caution in women of childbearing age. Further research is needed comparing topiramate with other active drugs used for preventing migraine attacks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Linde, M; Mulleners, WM; Chronicle, EP; McCrory, DC", "articleTypes": [], "doi": "10.1002/14651858.CD010610", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "9ce9f2f0-20e3-4f22-8846-f212aa90564a", "pmid": "", "title": "Tartrazine exclusion for allergic asthma", "imported": false, "abstract": "Abstract - Background Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There has been conflicting evidence as to whether tartrazine causes exacerbations of asthma with some studies finding a positive association especially in individuals with cross‐sensitivity to aspirin. Objectives To assess the overall effect of tartrazine (exclusion or challenge) in the management of asthma. Search methods A search was carried out on the Cochrane Airways Group Specialised Register. Bibliographies of each RCT was searched for additional papers. Authors of identified RCTs were contacted for further information. Searches are updated annually and are current as of February 2006. Selection criteria RCTs of oral administration of tartrazine (as a challenge) versus placebo or dietary avoidance of tartrazine versus normal diet were considered. Studies which focused upon allergic asthma, were also included. Studies of tartrazine exclusion for other allergic conditions such as hay fever, allergic rhinitis and eczema were only considered if the results for subjects with asthma were separately identified. Trials could be in either adults or children with asthma or allergic asthma (e.g. sensitivity to aspirin or food items known to contain tartrazine). Data collection and analysis Study quality was assessed and data abstracted by two reviewers independently. Outcomes were analysed using RevMan 4.1.1. Main results Ninety four abstracts were found, of which 20 were potentially relevant. Six? met the inclusion criteria, but only three presented results in a format that permitted analysis and none could be combined in a meta‐analysis. In none of the studies did tartrazine challenge or avoidance in diet significantly alter asthma outcomes. Authors' conclusions Due to the paucity of available evidence, it is not possible to provide firm conclusions as to the effects of tartrazine on asthma control. However, the six RCTs that could be included in this review all arrived at the same conclusion. Routine tartrazine exclusion may not benefit most patients, except those very few individuals with proven sensitivity. Plain language summary Tartrazine exclusion for allergic asthma Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There is no evidence that tartrazine makes asthma worse or avoiding it makes asthma patients any better.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Ardern, K", "articleTypes": [], "doi": "10.1002/14651858.CD000460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.733Z" }, { "id": "9cf6464b-c6e9-4034-8ef9-5fbb489964a4", "pmid": "", "title": "The Effects of Taste Receptors Regulation in Upper Airway Innate Immunity of CF Patients", "imported": false, "abstract": "The project is intended to be realised in two phases. In the first stage, a case control study will be performed. In the second phase, double-blind, placebo controlled cross-over study will be conducted. The first stage it to compare innate immunity activation and Pseudomonas aeruginosa (Pa) expression between Pa positive and negative patients. In the second phase the effects of inhaled lactizole- TAS3R inhibitor will be assessed.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.141Z" }, { "id": "9cf9a622-80f1-4a04-a49e-aebd28865b37", "pmid": "", "title": "Buspirone for Early Satiety and Symptoms of Gastroparesis: A Multicenter, Randomized, Placebo-Controlled, Double-Masked Trial (BESST)", "imported": false, "abstract": "This study evaluates whether the study medication, buspirone, an antianxiety drug, improves the symptoms of gastroparesis in patients with gastroparesis symptoms and at least moderately severe symptoms of fullness and/or inability to eat a full meal. Half the patients will receive buspirone and half the patients will receive a placebo.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.248Z" }, { "id": "9d012e7f-50fb-4c29-b5d9-357bb73155fb", "pmid": "", "title": "Acetylcholinesterase inhibitors for autistic spectrum disorders", "imported": false, "abstract": "Abstract - Background Autism spectrum disorder (autism) is a neurodevelopmental condition characterised by impairments in social communication and interaction, plus restricted, repetitive patterns of behaviour and interests. Whilst some people embrace autism as part of their identity, others struggle with their difficulties, and some seek treatment. There are no current interventions that result in complete reduction of autism features. Acetylcholine is a neurotransmitter for the cholinergic system and has a role in attention, novelty seeking, and memory. Low levels of acetylcholine have been investigated as a potential contributor to autism symptomatology. Donepezil, galantamine, and rivastigmine (commonly referred to as acetylcholinesterase inhibitors) all inhibit acetylcholinesterase, and have slightly different modes of action and biological availability, so their effectiveness and side‐effect profiles may vary. The effect of various acetylcholinesterase inhibitor on core autism features across the lifespan, and possible adverse effects, have not been thoroughly investigated. Objectives To evaluate the efficacy and harms of acetylcholinesterase inhibitors for people with the core features (social interaction, communication, and restrictive and repetitive behaviours) of autism. To assess the effects of acetylcholinesterase inhibitors on non‐core features of autism. Search methods In November 2022, we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the reference lists of included studies and relevant reviews, and contacted authors of relevant studies. Selection criteria Randomised controlled trials (RCTs), comparing acetylcholinesterase inhibitors (e.g. galantamine, donepezil, or rivastigmine) of varying doses, delivered orally or via transdermal patch, either as monotherapy or adjunct therapy, with placebo. People of any age, with a clinical diagnosis of autism were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were core features of autism and adverse effects. Secondary outcomes were language, irritability, hyperactivity, and general health and function. We used GRADE to assess certainty of evidence. Main results We included two RCTs (74 participants). One study was conducted in Iran, the second in the USA, although exact location in the USA is unclear. Galantamine plus risperidone versus placebo plus risperidone One study compared the effects of galantamine plus risperidone to placebo plus risperidone (40 participants, aged 4 years to 12 years). Primary and secondary outcomes of interest were measured postintervention, using subscales of the Aberrant Behavior Checklist (score 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed there was little to no difference between the two groups postintervention for social communication (mean difference (MD) ‐2.75, 95% confidence interval (CI) ‐5.88 to 0.38), and restricted and repetitive behaviour (MD ‐0.55, 95% CI ‐3.47 to 2.37). Overall autism features were not assessed. Adverse events may be higher in the galantamine plus risperidone group (75%) compared with the placebo plus risperidone group (35%): odds ratio 5.57, 95% CI 1.42 to 21.86, low‐certainty evidence. No serious adverse events were reported. Low‐certainty evidence showed a small difference in irritability (MD ‐3.50, 95% CI ‐6.39 to ‐0.61), with the galantamine plus risperidone group showing a greater decline on the irritability subscale than the placebo group postintervention. There was no evidence of a difference between the groups in hyperactivity postintervention (MD ‐5.20, 95% CI ‐10.51 to 0.11). General health and function were not assessed. Donepezil versus placebo One study compared donepezil to placebo (34 participants aged 8 years to 17 years). Primary outcomes of interest were measured postintervention, using subscales of the Modified Version of The Real Life Rating Scale (scored 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed no evidence of group differences immediately postintervention in overall autism features (MD 0.07, 95% CI ‐0.19 to 0.33), or in the autism symptom domains of social communication (MD ‐0.02, 95% CI ‐0.34 to 0.30), and restricted and repetitive behaviours (MD 0.04, 95% CI ‐0.27 to 0.35). Significant adverse events leading to study withdrawal in at least one participant was implied in the data analysis section, but not explicitly reported. The evidence is very uncertain about the effect of donepezil, compared to placebo, on the secondary outcomes of interest, including irritability (MD 1.08, 95% CI ‐0.41 to 2.57), hyperactivity (MD 2.60, 95% CI 0.50 to 4.70), and general health and function (MD 0.03, 95% CI ‐0.48 to 0.54) postintervention. Across all analyses within this comparison, we judged the evidence to be very low‐certainty due to high risk of bias, and very serious imprecision (results based on one small study with wide confidence intervals). The study narratively reported adverse events for the study as a whole, rather than by treatment group. Authors' conclusions Evidence about the effectiveness of acetylcholinesterase inhibitors as a medication to improve outcomes for autistic adults is lacking, and for autistic children is very uncertain. There is a need for more evidence of improvement in outcomes of relevance to clinical care, autistic people, and their families. There are a number of ongoing studies involving acetylcholinesterase inhibitors, and future updates of this review may add to the current evidence. Plain language summary Do acetylcholinesterase inhibitors reduce the core impairments associated with autism spectrum disorder Key messages At present, it is unclear whether acetylcholinesterase inhibitors are effective in treating the core features of autism. This is because very few studies have been carried out. The two we found were small, and did not report the outcomes very well. However, there are a number of ongoing studies in this area. What is autism spectrum disorder? Autism spectrum disorder (autism) is a condition that affects the way a person thinks, feels, interacts with others, and experiences their environment. The core behaviours of autism include reduced sharing of interests, difficulties with nonverbal communication (for example, little eye contact), difficulties forming and maintaining relationships and restricted, or repetitive behaviours or interests. These behaviours can vary in severity, but they still interfere with the person's daily functioning and participation in activities. Medicines, called acetylcholinesterase inhibitors (chemicals that block the normal breakdown of nerve transmitters), have been used to treat Alzheimer's disease (for example, donepezil and galantamine). Recently, it has been suggested that they may also decrease some of the difficulties seen in people with autism. What did we want to find out? Do acetylcholinesterase inhibitors, alone or with other medicines, reduce the core features of autism (social communication and interaction, restrictive and repetitive behaviours) compared with a placebo (a dummy pill). We also wanted to find out if acetylcholinesterase inhibitors were associated with any unwanted side effects. What did we do? We searched for studies that explored whether there were any differences in autistic people's behaviours after they had taken acetylcholinesterase inhibitors compared to people who had taken placebo pills. We compared and summarised the results of the studies, and rated our confidence in the evidence, based on things, such how big and well carried out the studies were. What did we find? We found two relevant studies. One study looked at whether an acetylcholinesterase inhibitor called galantamine, combined with a drug called risperidone (traditionally used to treat psychosis), was better than a placebo combined with risperidone. The study included 40 children, aged between 4 and 12 years, with a diagnosis of autism. it took place over 10 weeks in Iran. A second study compared an acetylcholinesterase inhibitor called donepezil with placebo. It included 34 children, aged between 8 and 17 years, with a diagnosis of autism. It was carried out in the USA. All studies involved children attending outpatient clinics. What are the main results of the review? It is unclear if acetylcholinesterase inhibitors make any difference to the core features of autism in children or adults. Galantamine may cause little to no difference in social interaction and communication skills and irritability levels in children with autism after 10 weeks of treatment. There is no evidence that galantamine reduces difficulties associated with restricted or repetitive behaviours or hyperactivity. Galantamine may also cause some side effects, including nervousness, drowsiness, increased appetite, and tremor. There is no evidence that donepezil reduces difficulties associated with the core features of autism or associated secondary problems. We were unable to find out whether it causes unwanted side effects in children with autism, because the study did not report the results completely. What are the limitations of the evidence? We have little confidence in the evidence for using this medicine to treat problems associated with autism, because the evidence comes from only two small studies that were not very well carried out or reported. Each study looked at a different type of acetylcholinesterase inhibitor and delivered the medicine differently. They did not provide information about all the issues we were interested in, and they measured the side effects differently. If more studies are included in future reviews, these results may change. How up‐to‐date is this review? The evidence in this review is current to November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ure, A; Cox, GR; Haslam, R; Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD013851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "9d1dcee0-7c32-4e89-a08b-70092814ecbd", "pmid": "", "title": "A Phase 1, Randomised, Single-blind, Placebo-controlled, Single-centre Study to Investigate the Safety, Tolerability and Pharmacokinetics of Single and Multiple Doses of Elarekibep Given Twice Daily as Inhaled or a Single IV Formulation in Healthy Japanese Subjects", "imported": false, "abstract": "This study will assess the safety, tolerability and pharmacokinetics (PK) of elarekibep after single and multiple doses given twice daily (BID) by inhalation or intravenous (IV) in healthy Japanese subjects compared with placebo.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "9d26511f-6fc9-45ff-beaa-fc6eb346b5ea", "pmid": "", "title": "Chinese medicinal herbs for asymptomatic carriers of hepatitis B virus infection", "imported": false, "abstract": "Abstract - Background About 350 million people are chronically infected carriers of hepatitis B virus and are at a higher risk of serious illness and death from cirrhosis of the liver and liver cancer. Chinese medicinal herbs have been used widely for more than 2000 years to treat chronic liver disease. Objectives To assess whether Chinese medicinal herbs are effective and safe for treating asymptomatic carriers of hepatitis B virus. Search methods The trials registers of The Cochrane Hepato‐Biliary Group , The Cochrane Library , and The Cochrane Complementary Medicine Field were searched in combination with MEDLINE , EMBASE , and handsearches of Chinese journals and conference proceedings (October 2000). Selection criteria Randomised or quasi‐randomised trials (minimum follow‐up three months) in asymptomatic carriers of hepatitis B virus. Chinese medicinal herbs (single herb or compound of herbs) compared with placebo, no intervention, general non‐specific treatment, or interferon treatment. Trials of Chinese medicinal herbs plus interferon versus interferon alone were also included. Data collection and analysis Data were extracted independently by two authors. Analysis was performed by intention‐to‐treat where possible. Pre‐specified subgroup analyses were: ethnic origin, age at time of infection, and single herb or compound of herbs. Main results Three randomised clinical trials (307 patients) that followed patients for three months or more after the end of treatment were included. The methodological quality was poor. The herbal compound 'Jianpi Wenshen recipe' had significant effects on viral markers compared to interferon: relative risk 2.40 (95% CI 1.01 to 5.72) for clearance of serum HBsAg, 2.03 (95% CI 0.98 to 4.20) for clearance of HBeAg, and 2.54 (95% CI 1.13 to 5.70) for seroconversion of HBeAg to anti‐HBe. Phyllanthus amarus and Astragalus membranaceus showed no significant antiviral effect compared with placebo. Analysis of pooling eight randomised clinical trials with less than three months follow‐up did not show a significant benefit of Chinese medicinal herbs on viral markers. Data on long‐term clinical outcomes and quality of life were lacking. Authors' conclusions Based on one low quality trial, the medicinal herb 'Jianpi Wenshen recipe' may have an antiviral activity in asymptomatic carriers of hepatitis B virus. However, rigorous randomised, double‐blind, placebo‐controlled trials are needed before herbs should be used for this condition. Plain language summary Firm evidence for effect of Chinese medicinal herbs for asymptomatic hepatitis B virus carriers is still awaited Chinese medicinal herbs have a long history in the treatment of liver diseases. Three randomised clinical trials were included. Due to their poor methodologic quality and the existing small number of trials, there is currently insufficient evidence for treating asymptomatic hepatitis B virus carriers with Chinese medicinal herbs like the herbal compound 'Jianpi Wenshen recipe', Phyllanthus amarus and Astragalus membranaceus. Methodologically better and larger randomised trials are needed comparing medicinal herbs versus placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Liu, JP; McIntosh, H; Lin, H", "articleTypes": [], "doi": "10.1002/14651858.CD002231", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "9d333977-d456-46c9-8927-87614d0a1ef3", "pmid": "", "title": "Antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lassi, ZS, Padhani, ZA, Das, JK, Salam, RA, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD009576.pub3 AB - Abstract - Background Worldwide, pneumonia is the leading cause of death amongst children under five years of age, and accounts for approximately two million deaths annually. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, and the severity of the disease. Treatment is then tailored according to the classification. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. The WHO recommends treating non‐severe pneumonia with oral antibiotics. Pneumonia is more commonly caused by viruses that do not require antibiotic treatment, but pneumonia caused by bacteria needs management with antibiotics to avoid complications. There is no clear way to quickly distinguish between viral and bacterial pneumonia. It is considered safe to give antibiotics, however, this may lead to the development of antibiotic resistance, and thus, limit their use in future infections. Therefore, it is essential to explore the efficacy of antibiotics for children with WHO‐defined non‐severe pneumonia and wheeze. Objectives To evaluate the efficacy of antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze. Search methods We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers (December 2020). Selection criteria We included randomised controlled trials (RCTs) evaluating the efficacy of antibiotic therapy versus no antibiotic therapy for children, aged 2 to 59 months, with non‐severe pneumonia and wheeze. We defined non‐severe pneumonia as 'a cough or difficulty in breathing, with rapid breathing (a respiratory rate of 50 breaths per minute or more for children aged 2 to 12 months, or a respiratory rate of 40 breaths per minute or more for children aged 12 to 59 months), chest indrawing and wheeze'. We excluded trials involving children with severe or very severe pneumonia, and non‐RCTs. Data collection and analysis Our primary outcomes were clinical cure and treatment failure; secondary outcomes were relapse, mortality, and treatment harms. We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Two review authors independently assessed the search results, extracted data, assessed risk of bias and the certainty of the evidence. We contacted the authors of two included trials and the author of the trial awaiting classification to obtain missing numerical outcome data. Main results We included three trials involving 3256 children aged between 2 to 59 months, who exhibited features of non‐severe pneumonia with wheeze. The included trials were multi‐centre, double‐blind, randomised, placebo‐controlled trials carried out in Malawi, Pakistan, and India. The children were treated with a three‐day course of amoxicillin or placebo, and were followed up for a total of two weeks. We assessed the included trials at overall low risk of bias for random sequence generation, allocation concealment, blinding, attrition bias, and selective reporting. Only one trial was assessed to be at high risk for blinding of outcome assessors. One trial is awaiting classification Antibiotic therapy may result in a reduction of treatment failure by 20% (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.68 to 0.94; three trials; 3222 participants; low‐certainty evidence). Antibiotic therapy probably results in little or no difference to clinical cure (RR 1.02, 95% CI 0.96 to 1.08; one trial; 456 participants; moderate‐certainty evidence), and in little or no difference to relapse (RR 1.00, 95% CI 0.74 to 1.34; three trials; 2795 participants; low‐certainty evidence), and treatment harms (RR 0.81, 95% CI 0.60 to 1.09; three trials, 3253 participants; low‐certainty evidence). Two trials (2112 participants ) reported on mortality; no deaths occurred in either group. One trial reported cases of hospitalisation, diarrhoea (with and without dehydration), rash (without itch), tremors, mild nausea and vomiting. Authors' conclusions We do not currently have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. There is a clear need for RCTs to address this question in children aged 2 to 59 months with 2014 WHO‐defined non‐severe pneumonia and wheeze. Plain language summary Comparing treatment of non‐severe pneumonia, in children aged 2 to 59 months, with and without antibiotics Review question 
We tried to identify whether there was a difference in the outcomes for children aged 2 to 59 months with non‐severe pneumonia and wheeze, treated with or without antibiotics. Background 
Pneumonia is an infection of the lungs. In children, it is one of the leading causes of deaths globally. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, severity of the disease and its treatment according to the severity. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. More commonly, pneumonia is caused by viruses that require supportive care rather than antibiotic treatment; however, pneumonia caused by bacteria should be treated with antibiotics to avoid complications. Since there is no clear way to quickly distinguish which organism actually caused the pneumonia, it is considered safe to give antibiotics. However, this may lead to the development of antibiotic resistance, and limit their use in future infections. The question is whether the use of antibiotics is justified in non‐severe pneumonia. Search date Our evidence is current to 23 December 2020. Study characteristics We included three trials (3256 children). They were conducted in four hospitals in three cities in Pakistan (Islamabad, Lahore and Rawalpindi), and in hospital outpatient departments in India and Malawi. The children were treated with a three‐day course of amoxicillin (antibiotic) or placebo, and followed up for two weeks. One trial is awaiting classification. Study funding source The included trials were supported by the USAID through INCLEN and IndiaClen; ARI Research Cell, Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and by a grant from the Bill & Melinda Gates Foundation. Key results Limited data showed a 20% reduction in treatment failure, however, no impact was observed on clinical cure, relapse, and treatment harms. No deaths were reported in either group. Our review did not have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. Certainty of the evidence The certainty of evidence for clinical cure was moderate. The certainty of evidence for treatment failure, relapse, and treatments harms was low, due to downgrading for imprecision and risk of bias.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.105Z" }, { "id": "9d378c51-c64b-4d3a-9ae2-11863960734b", "pmid": "", "title": "Exploring the Use of Genetic and Behavioural Data in Tailoring Dietary and Lifestyle Support: An n=1 Randomised Trial", "imported": false, "abstract": "Personalised nutrition approaches typically rely on static information such as health status, lifestyle and genetic data. However, adherence often remains low because daily behaviours are influenced by psychological states, motivation and real-time barriers. There is growing interest in whether integrating behavioural signals and timely prompts could strengthen engagement. The purpose of this study is to explore whether incorporating psychological adaptation and just-in-time behavioural prompts leads to better adherence to a personalised nutrition programme compared with commonly used personalised approach (combining health, lifestyle and genetics data without psycho-behavioural adaptation). Using a six-week n-of-1 randomised trial design implemented across multiple participants, the research will also assess the feasibility of delivering this adaptive support in a free-living environment, as well as participants' engagement, acceptability and perceived usefulness. Following completion of the 6-week intervention, an optional focus group will be conducted with a subset of participants (maximum 8) within four weeks of the final study day. The focus group will last approximately 60-90 minutes and will be conducted in person or via video call. Qualitative data from the focus group will be analysed using reflexive thematic analysis (Braun & Clarke, 2021). These findings will inform the development of an adaptive personalised nutrition AI agent.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.158Z" }, { "id": "9d38be6a-9022-4081-bcaf-beccf43da881", "pmid": "", "title": "Interventions for the prevention of recurrent erysipelas and cellulitis", "imported": false, "abstract": "Abstract - Background Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. Objectives To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. Search methods We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. Selection criteria Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. Data collection and analysis Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. Main results We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study. Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow‐up period of up to one and a half to two years. Four studies were single‐centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria. Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate. Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate‐certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate‐certainty evidence). The protective effects of antibiotic did not last after prophylaxis had been stopped ('post‐prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty. Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years. We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay. The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin). None of the included studies assessed the development of antimicrobial resistance or quality‐of‐life measures. With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. Authors' conclusions In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate‐certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low‐certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low‐certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high‐quality studies are warranted, including long‐term follow‐up and other prophylactic measures. Plain language summary Preventive treatments for repeated episodes of cellulitis and erysipelas Background Cellulitis and erysipelas are both bacterial infections of the skin that most commonly affect the leg. Erysipelas affects the upper layers of the skin, and cellulitis affects its deeper parts, but in practice it is often hard to tell the difference between them, so we consider them together for this review (and refer to them as 'cellulitis'). Up to 50% of people with cellulitis experience repeated episodes. Despite the burden of this condition, there is a lack of high‐certainty, evidence‐based information about the desirable treatment for the prevention of recurrent cellulitis. Review question What are the best available treatments to prevent repeated episodes of cellulitis in adults aged over 16 years compared to no treatment, placebo, another intervention, or the same intervention with a different plan of treatment, and what are their side effects? Study characteristics We searched relevant databases and registers up to June 2016. We identified six trials, with 573 participants, who had an average age between 50 and 70. Both genders were included, but there were nearly twice as many women. Five trials used antibiotic treatment (four penicillin and one erythromycin), which was compared to either no treatment or placebo, and one trial used selenium compared to physiological salt solution. Treatments lasted from six to 18 months. The most common setting was the hospital, and two studies were multicentre. The studies were conducted in the UK, Sweden, Tunisia, Israel, and Austria. There was a small number of previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes in each study. The antibiotic trials assessed prevention with antibiotics in people with cellulitis of the legs, and the selenium trial assessed people with cellulitis of the arms. Key results Our main outcome was prevention of repeated episodes of cellulitis. Our other outcomes included the number of repeated attacks of cellulitis, time to next attack, hospitalisation, quality of life, development of antibiotic resistance, adverse reactions and death. Combining the results of all five trials that used antibiotics, we found moderate‐certainty evidence that for those people under preventative treatment, antibiotic treatment in general, and penicillin in particular, is probably both effective and safe for the prevention of repeated episodes of leg cellulitis when compared with no treatment or placebo. The analyses showed that, compared with no treatment or placebo, taking antibiotics decreased the risk of future episodes by 69%, reduced their number by more than 50%, and significantly reduced the rate until the next attack (moderate‐certainty evidence). However, we found low‐certainty evidence that the protective effect of antibiotics for these three outcomes tailed off over time after treatment had been stopped. In addition, the beneficial effect of antibiotics was relevant for people with at least two past episodes of cellulitis within a time frame of up to three years. We found low‐certainty evidence that there is no difference between antibiotics and no treatment/placebo for side effects and hospitalisation. The evidence did not allow for full exploration of the treatment's effect on length of hospital stay. No serious adverse effects were reported, and common side effects included diarrhoea, nausea, rash (severe skin adverse reactions were not reported) and thrush. In three studies, adverse effects caused those taking part to stop taking the antibiotic. Three people taking erythromycin had abdominal pain and nausea, causing them to stop taking the treatment and to take penicillin instead. In one study, two people withdrew from treatment with penicillin because of diarrhoea or nausea. In another study, because of pain at the site of injection, around 10% of those taking part stopped taking intramuscular injections of benzathine penicillin. None of the included studies measured quality of life or the development of antibiotic resistance. Certainty of evidence Evidence for the effects of antibiotics compared with no treatment or placebo on the recurrence, incidence rate and time to next episode of cellulitis under preventive treatment was of moderate certainty, and was limited by the small number of participants and events. Evidence for the remaining reported outcomes was of low certainty for the same reasons, as well as imprecise results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Dalal, A; Eskin‐Schwartz, M; Mimouni, D; Ray, S; Days, W; Hodak, E; Leibovici, L; Paul, M", "articleTypes": [], "doi": "10.1002/14651858.CD009758.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "9d42d09d-063e-4e4c-9f9c-d477028b2740", "pmid": "", "title": "Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco", "imported": false, "abstract": "Abstract - Background Overeating and harmful alcohol and tobacco use have been linked to the aetiology of various non‐communicable diseases, which are among the leading global causes of morbidity and premature mortality. As people are repeatedly exposed to varying sizes and shapes of food, alcohol and tobacco products in environments such as shops, restaurants, bars and homes, this has stimulated public health policy interest in product size and shape as potential targets for intervention. Objectives 1) To assess the effects of interventions involving exposure to different sizes or sets of physical dimensions of a portion, package, individual unit or item of tableware on unregulated selection or consumption of food, alcohol or tobacco products in adults and children. 2) To assess the extent to which these effects may be modified by study, intervention and participant characteristics. Search methods We searched CENTRAL, MEDLINE, EMBASE, PsycINFO, eight other published or grey literature databases, trial registries and key websites up to November 2012, followed by citation searches and contacts with study authors. This original search identified eligible studies published up to July 2013, which are fully incorporated into the review. We conducted an updated search up to 30 January 2015 but further eligible studies are not yet fully incorporated due to their minimal potential to change the conclusions. Selection criteria Randomised controlled trials with between‐subjects (parallel‐group) or within‐subjects (cross‐over) designs, conducted in laboratory or field settings, in adults or children. Eligible studies compared at least two groups of participants, each exposed to a different size or shape of a portion of a food (including non‐alcoholic beverages), alcohol or tobacco product, its package or individual unit size, or of an item of tableware used to consume it, and included a measure of unregulated selection or consumption of food, alcohol or tobacco. Data collection and analysis We applied standard Cochrane methods to select eligible studies for inclusion and to collect data and assess risk of bias. We calculated study‐level effect sizes as standardised mean differences (SMDs) between comparison groups, measured as quantities selected or consumed. We combined these results using random‐effects meta‐analysis models to estimate summary effect sizes (SMDs with 95% confidence intervals (CIs)) for each outcome for size and shape comparisons. We rated the overall quality of evidence using the GRADE system. Finally, we used meta‐regression analysis to investigate statistical associations between summary effect sizes and variant study, intervention or participant characteristics. Main results The current version of this review includes 72 studies, published between 1978 and July 2013, assessed as being at overall unclear or high risk of bias with respect to selection and consumption outcomes. Ninety‐six per cent of included studies (69/72) manipulated food products and 4% (3/72) manipulated cigarettes. No included studies manipulated alcohol products. Forty‐nine per cent (35/72) manipulated portion size, 14% (10/72) package size and 21% (15/72) tableware size or shape. More studies investigated effects among adults (76% (55/72)) than children and all studies were conducted in high‐income countries ‐ predominantly in the USA (81% (58/72)). Sources of funding were reported for the majority of studies, with no evidence of funding by agencies with possible commercial interests in their results. A meta‐analysis of 86 independent comparisons from 58 studies (6603 participants) found a small to moderate effect of portion, package, individual unit or tableware size on consumption of food (SMD 0.38, 95% CI 0.29 to 0.46), providing moderate quality evidence that exposure to larger sizes increased quantities of food consumed among children (SMD 0.21, 95% CI 0.10 to 0.31) and adults (SMD 0.46, 95% CI 0.40 to 0.52). The size of this effect suggests that, if sustained reductions in exposure to larger‐sized food portions, packages and tableware could be achieved across the whole diet, this could reduce average daily energy consumed from food by between 144 and 228 kcal (8.5% to 13.5% from a baseline of 1689 kcal) among UK children and adults. A meta‐analysis of six independent comparisons from three studies (108 participants) found low quality evidence for no difference in the effect of cigarette length on consumption (SMD 0.25, 95% CI ‐0.14 to 0.65). One included study (50 participants) estimated a large effect on consumption of exposure to differently shaped tableware (SMD 1.17, 95% CI 0.57 to 1.78), rated as very low quality evidence that exposure to shorter, wider bottles (versus taller, narrower bottles) increased quantities of water consumed by young adult participants. A meta‐analysis of 13 independent comparisons from 10 studies (1164 participants) found a small to moderate effect of portion or tableware size on selection of food (SMD 0.42, 95% CI 0.24 to 0.59), rated as moderate quality evidence that exposure to larger sizes increased the quantities of food people selected for subsequent consumption. This effect was present among adults (SMD 0.55, 95% CI 0.35 to 0.75) but not children (SMD 0.14, 95% CI ‐0.06 to 0.34). In addition, a meta‐analysis of three independent comparisons from three studies (232 participants) found a very large effect of exposure to differently shaped tableware on selection of non‐alcoholic beverages (SMD 1.47, 95% CI 0.52 to 2.43), rated as low quality evidence that exposure to shorter, wider (versus taller, narrower) glasses or bottles increased the quantities selected for subsequent consumption among adults (SMD 2.31, 95% CI 1.79 to 2.83) and children (SMD 1.03, 95% CI 0.41 to 1.65). Authors' conclusions This review found that people consistently consume more food and drink when offered larger‐sized portions, packages or tableware than when offered smaller‐sized versions. This suggests that policies and practices that successfully reduce the size, availability and appeal of larger‐sized portions, packages, individual units and tableware can contribute to meaningful reductions in the quantities of food (including non‐alcoholic beverages) people select and consume in the immediate and short term. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. We are unable to highlight clear implications for tobacco or alcohol policy due to identified gaps in the current evidence base. Plain language summary Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco Review question We reviewed the evidence to establish by how much the amounts of food, alcohol or tobacco adults and children select or consume change in response to being presented with larger or smaller‐sized (or differently shaped) portions or packages of these products, or of items of tableware (such as plates or glasses) used to consume them. Study characteristics This review includes 72 randomised controlled trials (RCTs) published up to July 2013 that compared at least two groups of participants, each presented with a different size of a portion, package or item of tableware. Included studies measured the amounts of food, alcohol or tobacco selected and/or consumed by participants, typically over a period of one day or less. Almost all of the included studies investigated food, with only three tobacco studies and no alcohol studies found. Almost all assessed participants' responses to different sizes rather than different shapes. The average age of participants in the different studies ranged from three to 55 years, with more studies involving adults than children and most conducted in the USA. Sources of funding were reported for the majority of studies and there was no evidence of study funding by agencies with commercial interests in their results. Key findings and quality of evidence Effects of size on consumption: We found evidence that people consistently ate more food or drank more non‐alcoholic drinks when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. We estimate the size of this effect to be small to moderate among both children and adults. If an effect of this size were sustained across the whole diet it would be equivalent to around a 12% to 16% change in average daily energy intake from food among UK adults. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations arising from incomplete or unclear reporting of methods and procedures. From three tobacco studies, we found no effect of longer compared with shorter cigarettes on the amounts of tobacco consumed. We rated the overall quality of evidence for this effect as low due to concerns about study limitations and not having enough evidence. Effects of shape on consumption: One study found that adults provided with shorter, wider bottles drank larger amounts of water from them, having already poured more, compared with those provided with taller, narrower bottles. However, we rated the quality of this evidence as very low, due to very serious concerns about study limitations and not having enough evidence (only one study with outcome data from 50 participants). Effects of size on selection: We further found that adults, but not children, consistently chose (selected) more food (including non‐alcoholic drinks) when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. The estimated size of this effect was again small to moderate. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations. Effects of shape on selection: Evidence from three studies suggested that adults and children provided with shorter, wider bottles or glasses selected increased quantities of non‐alcoholic beverages for subsequent consumption, compared with those provided with taller, narrower bottles or glasses. We rated the quality of this evidence as low, again due to concerns about study limitations and unexplained variation in effects between the three studies. Conclusions Overall, this review provides the most conclusive evidence to date that acting to reduce the size, availability and appeal of larger‐sized portions, packages and tableware has potential to reduce the quantities of food that people select and consume by meaningful amounts. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. Our findings highlight the need for further research that aims to reduce uncertainties about these effects and address identified gaps in the evidence base, including not having enough evidence for longer‐term effects and the absence of evidence about alcohol products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hollands, GJ; Shemilt, I; Marteau, TM; Jebb, SA; Lewis, HB; Wei, Y; Higgins, JPT; Ogilvie, D", "articleTypes": [], "doi": "10.1002/14651858.CD011045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "9d4fa963-cdf0-41cc-9402-bf1c5f8ad5a8", "pmid": "", "title": "Antioxidants for male subfertility", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "de Ligny, W, Smits, RM, Mackenzie-Proctor, R, Jordan, V, Fleischer, K, de Bruin, JP, Showell, MG", "articleTypes": [], "doi": "10.1002/14651858.CD007411.pub5 AB - Abstract - Background The inability to have children affects 10% to 15% of couples worldwide. A male factor is estimated to account for up to half of the infertility cases with between 25% to 87% of male subfertility considered to be due to the effect of oxidative stress. Oral supplementation with antioxidants is thought to improve sperm quality by reducing oxidative damage. Antioxidants are widely available and inexpensive when compared to other fertility treatments, however most antioxidants are uncontrolled by regulation and the evidence for their effectiveness is uncertain. We compared the benefits and risks of different antioxidants used for male subfertility. Objectives To evaluate the effectiveness and safety of supplementary oral antioxidants in subfertile men. Search methods The Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, and two trial registers were searched on 15 February 2021, together with reference checking and contact with experts in the field to identify additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any type, dose or combination of oral antioxidant supplement with placebo, no treatment, or treatment with another antioxidant, among subfertile men of a couple attending a reproductive clinic. We excluded studies comparing antioxidants with fertility drugs alone and studies that included men with idiopathic infertility and normal semen parameters or fertile men attending a fertility clinic because of female partner infertility. Data collection and analysis We used standard methodological procedures recommended by Cochrane. The primary review outcome was live birth. Clinical pregnancy, adverse events and sperm parameters were secondary outcomes. Main results We included 90 studies with a total population of 10,303 subfertile men, aged between 18 and 65 years, part of a couple who had been referred to a fertility clinic and some of whom were undergoing medically assisted reproduction (MAR). Investigators compared and combined 20 different oral antioxidants. The evidence was of 'low' to 'very low' certainty: the main limitation was that out of the 67 included studies in the meta‐analysis only 20 studies reported clinical pregnancy, and of those 12 reported on live birth. The evidence is current up to February 2021. Live birth: antioxidants may lead to increased live birth rates (odds ratio (OR) 1.43, 95% confidence interval (CI) 1.07 to 1.91, P = 0.02, 12 RCTs, 1283 men, I 2 = 44%, very low‐certainty evidence). Results in the studies contributing to the analysis of live birth rate suggest that if the baseline chance of live birth following placebo or no treatment is assumed to be 16%, the chance following the use of antioxidants is estimated to be between 17% and 27%. However, this result was based on only 246 live births from 1283 couples in 12 small or medium‐sized studies. When studies at high risk of bias were removed from the analysis, there was no evidence of increased live birth (Peto OR 1.22, 95% CI 0.85 to 1.75, 827 men, 8 RCTs, P = 0.27, I 2 = 32%). Clinical pregnancy rate: antioxidants may lead to increased clinical pregnancy rates (OR 1.89, 95% CI 1.45 to 2.47, P < 0.00001, 20 RCTs, 1706 men, I 2 = 3%, low‐certainty evidence) compared with placebo or no treatment. This suggests that, in the studies contributing to the analysis of clinical pregnancy, if the baseline chance of clinical pregnancy following placebo or no treatment is assumed to be 15%, the chance following the use of antioxidants is estimated to be between 20% and 30%. This result was based on 327 clinical pregnancies from 1706 couples in 20 small studies. Adverse events
Miscarriage: only six studies reported on this outcome and the event rate was very low. No evidence of a difference in miscarriage rate was found between the antioxidant and placebo or no treatment group (OR 1.46, 95% CI 0.75 to 2.83, P = 0.27, 6 RCTs, 664 men, I 2 = 35%, very low‐certainty evidence). The findings suggest that in a population of subfertile couples, with male factor infertility, with an expected miscarriage rate of 5%, the risk of miscarriage following the use of an antioxidant would be between 4% and 13%. Gastrointestinal: antioxidants may lead to an increase in mild gastrointestinal discomfort when compared with placebo or no treatment (OR 2.70, 95% CI 1.46 to 4.99, P = 0.002, 16 RCTs, 1355 men, I 2 = 40%, low‐certainty evidence). This suggests that if the chance of gastrointestinal discomfort following placebo or no treatment is assumed to be 2%, the chance following the use of antioxidants is estimated to be between 2% and 7%. However, this result was based on a low event rate of 46 out of 1355 men in 16 small or medium‐sized studies, and the certainty of the evidence was rated low and heterogeneity was high. We were unable to draw conclusions from the antioxidant versus antioxidant comparison as insufficient studies compared the same interventions. Authors' conclusions In this review, there is very low‐certainty evidence from 12 small or medium‐sized randomised controlled trials suggesting that antioxidant supplementation in subfertile males may improve live birth rates for couples attending fertility clinics. Low‐certainty evidence suggests that clinical pregnancy rates may increase. There is no evidence of increased risk of miscarriage, however antioxidants may give more mild gastrointestinal discomfort, based on very low‐certainty evidence. Subfertile couples should be advised that overall, the current evidence is inconclusive based on serious risk of bias due to poor reporting of methods of randomisation, failure to report on the clinical outcomes live birth rate and clinical pregnancy, often unclear or even high attrition, and also imprecision due to often low event rates and small overall sample sizes. Further large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants. Plain language summary Antioxidants for male subfertility Review question 
Do supplementary oral antioxidants compared with placebo, no treatment or another antioxidant improve fertility outcomes for subfertile men? Background 
A couple may be considered to have fertility problems if they have been trying to conceive for over a year with no success. Many subfertile men undergoing fertility treatment also take dietary supplements in the hope of improving their fertility. Fertility treatment can be a very stressful time for men and their partners. It is important that these couples have access to high‐certainty evidence that will allow them to make informed decisions on whether to take a supplemental antioxidant. This is especially important as most antioxidant supplements are uncontrolled by regulation. This review aimed to assess whether supplements with oral antioxidants, taken by subfertile men, would increase the chances of a couple to achieve a (clinical) pregnancy confirmed by ultrasound and ultimately the birth of a baby (live birth). This review did not examine the use of antioxidants in men with normal sperm. Study characteristics Cochrane authors conducted a review including 90 randomised controlled trials comparing 18 different antioxidants with placebo, no treatment or another antioxidant in a total population of 10,303 subfertile men. The age range of the participants was 18 to 65 years; they were part of a couple who had been referred to a fertility clinic and some were undergoing fertility treatment. The evidence is current to February 2021. Main results 
Antioxidants may be associated with an increased live birth and clinical pregnancy rate. Based on the studied population for live birth, we would expect that out of 100 subfertile men not taking antioxidants, 16 couples would have a baby. In subfertile men taking antioxidants, between 17 and 27 per 100 couples would have a baby. If studies with high risk of bias were removed from the analysis, there was no evidence of increased live birth in the population taking antioxidants. In the people who were studied for clinical pregnancy, we would expect that out of 100 subfertile men not taking antioxidants, 15 couples would have a clinical pregnancy. In subfertile men taking antioxidants, between 20 and 30 per 100 couples would have a clinical pregnancy. Adverse events were poorly reported. Only six studies reported miscarriage. In these studies, miscarriage did not occur more often in the group using antioxidants when compared with the group with placebo or no treatment. However, there is insufficient evidence to draw conclusions about antioxidant use and the risk of miscarriage. The use of antioxidants may be associated with more mild stomach discomfort, with a frequency of 2% in subfertile men not taking antioxidants, and between 2% and 7% in men taking antioxidants. The oral supplements may cause discomforts such as nausea or stomach ache. Authors' conclusion and certainty of the evidence 
Antioxidant supplementation taken by subfertile males of a couple attending a fertility clinic may increase the chance of a live birth, however the overall certainty of evidence was very low from only 12 small to medium‐sized randomised controlled trials. Low‐certainty evidence suggests that clinical pregnancy rates may increase. Overall, there is no evidence of increased risk of miscarriage. Evidence of low certainty suggests that antioxidants may be associated with more gastrointestinal discomfort. Subfertile couples should be advised that overall the current evidence is inconclusive due to the poor reporting of methods, failure to report on live birth and clinical pregnancy rate, imprecision due to low event rates, high number of dropouts and small study group sizes. Large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.795Z" }, { "id": "9d7c748f-b414-4b64-84f9-65112f9b9134", "pmid": "", "title": "Aclidinium bromide for stable chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Bronchodilators are the mainstay for symptom relief in the management of stable chronic obstructive pulmonary disease (COPD). Aclidinium bromide is a new long‐acting muscarinic antagonist (LAMA) that differs from tiotropium by its higher selectivity for M3 muscarinic receptors with a faster onset of action. However, the duration of action of aclidinium is shorter than for tiotropium. It has been approved as maintenance therapy for stable, moderate to severe COPD, but its efficacy and safety in the management of COPD is uncertain compared to other bronchodilators. Objectives To assess the efficacy and safety of aclidinium bromide in stable COPD. Search methods We identified randomised controlled trials (RCT) from the Cochrane Airways Group Specialised Register of trials (CAGR), as well as www.clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), US Food and Drug Administration (FDA) website and Almirall Clinical Trials Registry and Results. We contacted Forest Laboratories for any unpublished trials and checked the reference lists of identified articles for additional information. The last search was performed on 7 April 2014 for CAGR and 11 April 2014 for other sources. Selection criteria Parallel‐group RCTs of aclidinium bromide compared with placebo, long‐acting beta 2 ‐agonists (LABA) or LAMA in adults with stable COPD. Data collection and analysis Two review authors independently selected studies, assessed the risk of bias, and extracted data. We sought missing data from the trial authors as well as manufacturers of aclidinium. We used odds ratios (OR) for dichotomous data and mean difference (MD) for continuous data, and reported both with their 95% confidence intervals (CI). We used standard methodological procedures expected by The Cochrane Collaboration. We applied the GRADE approach to summarise results and to assess the overall quality of evidence. Main results This review included 12 multicentre RCTs randomly assigning 9547 participants with stable COPD. All the studies were industry‐sponsored and had similar inclusion criteria with relatively good methodological quality. All but one study included in the meta‐analysis were double‐blind and scored low risk of bias. The study duration ranged from four weeks to 52 weeks. Participants were more often males, mainly Caucasians, mean age ranging from 61.7 to 65.6 years, and with a smoking history of 10 or more pack years. They had moderate to severe symptoms at randomisation; the mean post‐bronchodilator forced expiratory volume in one second (FEV1) was between 46% and 57.6% of the predicted normal value, and the mean St George's Respiratory Questionnaire score (SGRQ) ranged from 45.1 to 50.4 when reported. There was no difference between aclidinium and placebo in all‐cause mortality (low quality) and number of patients with exacerbations requiring a short course of oral steroids or antibiotics, or both (moderate quality). Aclidinium improved quality of life by lowering the SGRQ total score with a mean difference of ‐2.34 (95% CI ‐3.18 to ‐1.51; I 2 = 48%, 7 trials, 4442 participants) when compared to placebo. More patients on aclidinium achieved a clinically meaningful improvement of at least four units decrease in SGRQ total score (OR 1.49; 95% CI 1.31 to 1.70; I 2 = 34%; number needed to treat (NNT) = 10, 95% CI 8 to 15, high quality evidence) over 12 to 52 weeks than on placebo. Aclidinium also resulted in a significantly greater improvement in pre‐dose FEV1 than placebo with a mean difference of 0.09 L (95% CI 0.08 to 0.10; I 2 = 39%, 9 trials, 4963 participants). No trials assessed functional capacity. Aclidinium reduced the number of patients with exacerbations requiring hospitalisation by 4 to 20 fewer per 1000 over 4 to 52 weeks (OR 0.64; 95% CI 0.46 to 0.88; I 2 = 0%, 10 trials, 5624 people; NNT = 77, 95% CI 51 to 233, high quality evidence) compared to placebo. There was no difference in non‐fatal serious adverse events (moderate quality evidence) between aclidinium and placebo. Compared to tiotropium, aclidinium did not demonstrate significant differences for exacerbations requiring oral steroids or antibiotics, or both, exacerbation‐related hospitalisations and non‐fatal serious adverse events (very low quality evidence). Inadequate data prevented the comparison of aclidinium to formoterol or other LABAs. Authors' conclusions Aclidinium is associated with improved quality of life and reduced hospitalisations due to severe exacerbations in patients with moderate to severe stable COPD compared to placebo. Overall, aclidinium did not significantly reduce mortality, serious adverse events or exacerbations requiring oral steroids or antibiotics, or both. Currently, the available data are insufficient and of very low quality in comparisons of the efficacy of aclidinium versus tiotropium. The efficacy of aclidinium versus LABAs cannot be assessed due to inaccurate data. Thus additional trials are recommended to assess the efficacy and safety of aclidinium compared to other LAMAs or LABAs. Plain language summary Effectiveness and safety of inhalers containing the drug aclidinium bromide for managing patients with stable COPD Review question We reviewed the evidence on the effectiveness and safety of aclidinium inhalers used by people with chronic obstructive pulmonary disease (COPD). Background COPD, also known as 'smoker's lung disease', includes conditions called emphysema and chronic bronchitis where there is airway narrowing that cannot be fully corrected. It is a progressive disease. COPD patients usually have breathing problems and a cough that produces a lot of phlegm. It is diagnosed by international guidelines set by the Global Initiative for Obstructive Lung Disease (GOLD). Symptoms may worsen during flare‐ups. The main aims of treating COPD patients are to relieve symptoms, reduce flare‐ups and improve quality of life. Aclidinium is a new inhaled drug that widens the airways (a bronchodilator). It is delivered by an inhaler called Genuair or Pressair. We wanted to discover whether aclidinium was better or worse than using other inhalers or a dummy inhaler. Study characteristics The evidence was current to 7 April 2014. We included 12 studies involving 9547 COPD patients over a period of four to 52 weeks. These studies were sponsored by drug companies and were well designed. Both patients and the people doing the research did not know which treatment the patients were getting; although in one study one treatment was known to both parties. More men than women took part, and they were mostly Caucasians. They were in their 60s and had smoked a lot in their lives. These people had moderate to severe symptoms when they started treatment. Key results Aclidinium did not reduce the number of people with flare‐ups that need additional drugs. There was little or no difference in deaths or serious side effects between aclidinium and a dummy inhaler. Aclidinium inhalers improved quality of life more than the dummy inhalers. People who took aclidinium had fewer hospital admissions due to serious flare‐ups. Based on our results, among 1000 COPD patients using a dummy inhaler over four weeks to one year 37 would have severe flare‐ups needing hospital admission. Only 17 to 33 patients out of 1000 would require hospital admission if they were using aclidinium inhalers. We also set out to compare this new medication with tiotropium, which is already used to treat COPD. There were only two studies for this comparison thus we could not be sure how aclidinium compared to tiotropium. We also could not compare aclidinium with another well known inhaler that contains the drug formoterol because of unreliable data. Quality of the evidence For the comparison of aclidinium inhalers and dummy inhalers, we are confident that there are benefits in terms of the number of hospitalisations and patients' quality of life; we are less certain about the numbers of flare‐ups needing additional drugs and serious side effects. We do not have enough information to assess any effect on the number of deaths. We did not have enough information to reliably compare aclidinium with tiotropium or formoterol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ni, H; Soe, Z; Moe, S", "articleTypes": [], "doi": "10.1002/14651858.CD010509.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "9d8889d5-1cdc-4e60-a145-ea3223c01c77", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 1. Commonly‐used classes of drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres ( ˜ 8200 feet ). Acute hypoxia, acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude. In this review, the first in a series of three about preventive strategies for HAI, we assess the effectiveness of six of the most recommended classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of commonly‐used pharmacological interventions for preventing acute HAI. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), LILACS and trial registries in January 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text terms to search. Selection criteria We included randomized‐controlled and cross‐over trials conducted in any setting where commonly‐used classes of drugs were used to prevent acute HAI. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Main results We included 64 studies (78 references) and 4547 participants in this review, and classified 12 additional studies as ongoing. A further 12 studies await classification, as we were unable to obtain the full texts. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. Risks of bias were unclear for several domains, and a considerable number of studies did not report adverse events of the evaluated interventions. We found 26 comparisons, 15 of them comparing commonly‐used drugs versus placebo. We report results for the three most important comparisons: Acetazolamide versus placebo (28 parallel studies; 2345 participants) The risk of AMS was reduced with acetazolamide (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.56; I 2 = 0%; 16 studies; 2301 participants; moderate quality of evidence). No events of HAPE were reported and only one event of HACE (RR 0.32, 95% CI 0.01 to 7.48; 6 parallel studies; 1126 participants; moderate quality of evidence). Few studies reported side effects for this comparison, and they showed an increase in the risk of paraesthesia with the intake of acetazolamide (RR 5.53, 95% CI 2.81 to 10.88, I 2 = 60%; 5 studies, 789 participants; low quality of evidence). Budenoside versus placebo (2 parallel studies; 132 participants) Data on budenoside showed a reduction in the incidence of AMS compared with placebo (RR 0.37, 95% CI 0.23 to 0.61; I 2 = 0%; 2 studies, 132 participants; low quality of evidence). Studies included did not report events of HAPE or HACE, and they did not find side effects (low quality of evidence). Dexamethasone versus placebo (7 parallel studies; 205 participants) For dexamethasone, the data did not show benefits at any dosage (RR 0.60, 95% CI 0.36 to 1.00; I2 = 39%; 4 trials, 176 participants; low quality of evidence). Included studies did not report events of HAPE or HACE, and we rated the evidence about adverse events as of very low quality. Authors' conclusions Our assessment of the most commonly‐used pharmacological interventions suggests that acetazolamide is an effective pharmacological agent to prevent acute HAI in dosages of 250 to 750 mg/day. This information is based on evidence of moderate quality. Acetazolamide is associated with an increased risk of paraesthesia, although there are few reports about other adverse events from the available evidence. The clinical benefits and harms of other pharmacological interventions such as ibuprofen, budenoside and dexamethasone are unclear. Large multicentre studies are needed for most of the pharmacological agents evaluated in this review, to evaluate their effectiveness and safety. Plain language summary Drugs commonly‐used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and breathing conditions that can occur while travelling to altitudes above 2500 metres ( ˜ 8200 feet ). HAI is generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but may affect the brain or the lungs in different individuals. In this review, we assessed the most commonly‐used drugs to prevent the onset of this illness. Study characteristics The evidence is current to January 2017. We included 64 studies related to six different types of drugs recommended for HAI prevention. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. The participants' ages ranged between 16 and 65 years. Eleven studies included people at a high risk of this condition due to their history of HAI or other illnesses such as asthma. Twenty‐four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. In 23 of the included studies, the source of funding was unclear. Only 18 studies declared their possible conflicts of interests. We classed 24 more studies as still ongoing or waiting for assessment. Key results Our findings suggest that acetazolamide is an effective treatment for the prevention of acute HAI in dosages of 250 to 750 mg/day, when this drug is compared to a placebo (i.e. a pill with no active agent). Most of the available information relates to the prevention of uncomplicated HAI (headache, nausea, vomiting and tiredness) rather than to more serious brain or lung problems. We also found that acetazolamide is associated with an increased risk of paraesthesia in the fingers (i.e. a sensation of tingling, tickling, pricking, or burning of the skin), although this outcome is not well reported in the available evidence. The benefits and harms of other drugs such as ibuprofen, budenoside and dexamethasone are unclear, due to the small number of studies. Quality of the evidence We rated the quality of the evidence as moderate to very low. Several studies had quality shortcomings, including their use of small numbers of participants and a lack of reporting of important outcomes such as side effects. For most of the drugs covered by the studies, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Nieto Estrada, VH; Molano Franco, D; Medina, RD; Gonzalez Garay, AG; Martí‐Carvajal, AJ; Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD009761.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "9d8be227-ce6c-4641-865c-b3bff5f7845b", "pmid": "", "title": "Immediate‐release versus controlled‐release carbamazepine in the treatment of epilepsy", "imported": false, "abstract": "Abstract - Background Carbamazepine (CBZ) is a commonly used drug for epilepsy that is associated with troublesome adverse events including dizziness, double vision, drowsiness, poor co‐ordination and unsteadiness. These adverse events often occur during peaks in drug plasma concentration. These adverse events may limit the daily dose of CBZ that can be tolerated and reduce the chances of seizure control in patients who require high doses. A controlled‐release formulation of CBZ delivers the same dose over a longer period of time when compared to a standard immediate‐release formulation, thereby reducing post‐dose peaks in CBZ plasma concentration and potentially reducing adverse events. This is an updated version of the original Cochrane review published in Issue 12, 2014. Objectives To determine the efficacy of immediate‐release CBZ (IR CBZ) versus controlled‐release CBZ (CR CBZ) in patients diagnosed with epilepsy. The following review questions were investigated.
 (1) For newly diagnosed patients commencing CBZ, how do IR and CR formulations compare for efficacy and tolerability?
 (2) For patients on established treatment with IR CBZ but experiencing unacceptable adverse events, what is the effect on seizure control and the tolerability of a switch to a CR formulation versus remaining on the IR formulation? Search methods We searched the Cochrane Epilepsy Group Specialized Register, CENTRAL, and MEDLINE (Ovid) from inception to 30 August 2016. Selection criteria Randomised controlled trials comparing IR CBZ to CR CBZ in patients commencing monotherapy and patients presently treated with IR CBZ but experiencing unacceptable adverse events. Primary outcome measures included measures of seizure frequency, incidence of adverse events, proportion of patients with treatment failure and quality of life measures. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted the data and recorded relevant information on a standardised data extraction form. We used the Cochrane risk of bias tool to assess the methodological quality of included studies. The heterogeneity of the included trials with respect to the reporting of outcomes resulted in only a narrative, descriptive analysis being possible for both the categorical and time‐to‐event data. Main results Ten trials (296 participants) fulfilled the criteria for inclusion in this review. Only one study had a low risk of bias. Two studies had a high risk of bias and the rest of the studies were rated as unclear risk of bias. One trial included patients with newly diagnosed epilepsy and nine included patients on treatment with IR CBZ. Eight trials reported heterogeneous measures of seizure frequency with conflicting results. A statistically significant difference was observed in only one trial, with patients prescribed CR CBZ experiencing fewer seizures than patients prescribed IR CBZ. Nine trials reported measures of adverse events. There was a trend in favour of CR CBZ with four trials reporting a statistically significant reduction in adverse events compared to IR CBZ. A further two trials reported fewer adverse events with CR CBZ but the reduction was not statistically significant. One trial found no difference in adverse events, and another trial reported more adverse events in the CR CBZ group than the IR CBZ group, although the increase was not statistically significant. Authors' conclusions For this update no new eligible studies were identified and the conclusions drawn from the initial review remain unchanged. At present, data from trials do not confirm or refute an advantage for CR CBZ over IR CBZ for seizure frequency or adverse events in patients with newly diagnosed epilepsy. For trials involving epilepsy patients already prescribed IR CBZ, no conclusions can be drawn concerning the superiority of CR CBZ with respect to seizure frequency. There is a trend for CR CBZ to be associated with fewer adverse events when compared to IR CBZ. A change to CR CBZ may therefore be a worthwhile strategy in patients with acceptable seizure control on IR CBZ but experiencing unacceptable adverse events. The included trials were of small size and of poor methodological quality limiting the validity of this conclusion. Randomised controlled trials comparing CR CBZ to IR CBZ and using clinically relevant outcomes are required to inform the choice of CBZ preparation for patients with newly diagnosed epilepsy. Plain language summary Fast‐release versus slow‐release carbamazepine as medication for patients with epilepsy Background Epilepsy is a common brain disorder that is often treated with carbamazepine. With treatment, people often have fewer seizures but many people experience side effects. When carbamazepine is swallowed it is taken into the blood stream quickly and there is a sharp rise of drug levels in the blood. These 'peaks' may be associated with side effects such as dizziness, double vision, drowsiness, unsteadiness and poor co‐ordination. A type of carbamazepine that releases the medication into the body slowly may lessen these 'peaks' in the blood levels, possibly meaning fewer side effects. This review compared studies looking at the differences between a 'fast‐release' carbamazepine and a 'slow‐release' carbamazepine. Participants To be included in this review, all participants had to be diagnosed with epilepsy and be either just starting carbamazepine treatment or be already on it but with intolerable side effects. The participants could be of any age or gender. Studies Ten trials with a total of 296 people with epilepsy were included in the review. All 10 trials were randomised controlled trials (patients were compared in randomly assigned groups). All of the studies had at least two groups, one group taking fast‐release carbamazepine and one group taking slow‐release carbamazepine, and some also had a control group (a group of non‐epileptic people). The evidence is current to August 2016. Results Just one of 10 studies found a significant difference between the two carbamazepine types in the number of seizures experienced, with patients prescribed the slow‐release carbamazepine experiencing fewer seizures than patients prescribed the fast‐release drug. Patients taking slow‐release carbamazepine tended to experience fewer side effects. Quality of the evidence Out of the 10 trials in the review, only one study was judged to be of 'good' quality, and so the evidence in this review was rated as low quality. It must be stressed that there are not many studies assessing the differences between these two carbamazepine types and more studies are needed before we can make a definitive conclusion about one over the other.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, G; Saunders, M; Rigby, A; Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007124.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "9d9b1255-7f2e-4f5c-9635-32fc1713f467", "pmid": "", "title": "Ibuprofen for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non‐steroidal anti‐inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period. Objectives 1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled). Search methods We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023. Selection criteria We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules. Data collection and analysis We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence. Main results We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child‐reported pain intensity less than two hours postintervention compared to placebo (SMD −1.12, 95% CI −1.39 to −0.86; 3 studies, 259 children; moderate‐certainty evidence). Ibuprofen may reduce child‐reported pain intensity, two hours to less than 24 hours postintervention (SMD −1.01, 95% CI −1.24 to −0.78; 5 studies, 345 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low‐certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child‐reported pain intensity less than two hours postintervention compared to paracetamol (SMD −0.42, 95% CI −0.82 to −0.02; 2 studies, 100 children; moderate‐certainty evidence). Ibuprofen may slightly reduce child‐reported pain intensity two hours to 24 hours postintervention (SMD −0.21, 95% CI −0.40 to −0.02; 6 studies, 422 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low‐certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) −0.25, 95% CI −0.40 to −0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate‐certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD −0.29, 95% CI −0.53 to −0.04; NNTB 4; 1 study, 59 children; low‐certainty evidence). Authors' conclusions Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs. Plain language summary What are the benefits and harms of ibuprofen for managing pain after an operation in children? Key messages • Ibuprofen probably reduces pain intensity just after an operation up to two hours compared to a placebo (dummy) and compared to paracetamol. The evidence compared to other medicines and in the longer term is unclear or lacking. • Overall, we are uncertain about unwanted effects of ibuprofen, especially serious unwanted effects, since the studies in the review rarely measured them. • Future studies should examine ibuprofen compared to commonly used medications and measure benefits and unwanted effects for both short‐ and long‐term use. Why is pain management important? It is common for children to experience pain after an operation (postoperative pain). Pain causes suffering and agitation, and it can delay recovery. One way to manage pain in children is by using different medicines, for example, ibuprofen. Ibuprofen is a type of medicine called a 'non‐steroidal anti‐inflammatory drug' (NSAID) that can reduce inflammation and pain. What did we want to find out? We wanted to find out if ibuprofen is an effective pain treatment and whether it causes unwanted effects compared to other pain treatments. Also, the most effective way to deliver ibuprofen to children. What did we do? We searched for studies that compared ibuprofen to other treatment options for postoperative pain as well as for studies that looked at different ways to deliver ibuprofen to children. We summarised the results and rated our confidence in the evidence. What did we find? We found 43 studies with 4265 children with postoperative pain. We used data from 3935 children in this review. The largest study included 741 children and the smallest, 23 children. The studies were conducted in many countries around the world; most commonly the USA (12 studies). Children's ages ranged from 2.2 months up to 17 years. Studies used ibuprofen to manage postoperative pain in 10 different types of surgery: mostly dental procedures (21 studies); and ear, nose and throat procedures (11 studies). Main results Compared to placebo (a dummy medicine), ibuprofen probably reduces pain intensity less than two hours after the operation and may reduce pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol , ibuprofen probably reduces pain intensity less than two hours after the operation and probably reduces pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol, ibuprofen probably makes little difference to the chances of bleeding. Compared to morphine , ibuprofen probably leads to a reduction in any reported unwanted effects. Compared to ketorolac , ibuprofen may lead to a reduction in overall harms. No studies reported pain intensity or serious unwanted effects, such as lasting disability or hospitalisation for either morphine or ketorolac. We did not find any studies that compared different routes of administration of ibuprofen. What are the limitations of the evidence? We are uncertain about the overall evidence of ibuprofen use in postoperative pain in children, primarily because there were not enough large studies to be certain about any differences in ibuprofen when compared to other alternatives. In addition, only a few of the studies provided data about important benefits and unwanted effects for children experiencing pain following surgery, especially in the longer term. How up to date is this evidence? The evidence is up‐to‐date to August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Pessano, S; Gloeck, NR; Tancredi, L; Ringsten, M; Hohlfeld, A; Ebrahim, S; Albertella, M; Kredo, T; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "9db8ad84-7f21-4c37-9630-f846311f1118", "pmid": "", "title": "Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "van den Bosch, CH, van Woensel, J, van de Wetering, MD", "articleTypes": [], "doi": "10.1002/14651858.CD003295.pub4 AB - Abstract - Background This is an updated version of a Cochrane Review last published in 2013. Long‐term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating people with cancer. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infections remain a common complication. These infections are mainly caused by gram‐positive bacteria. Antimicrobial prevention strategies aimed at these micro‐organisms could potentially decrease the majority of CVC‐related infections. The aim of this review was to evaluate the efficacy of prophylactic antibiotics for the prevention of gram‐positive infections in people with cancer who have long‐term CVCs. Objectives To assess the effects of administering antibiotics prior to the insertion of long‐term CVCs or as a flush/lock solution, or both during long‐term CVC access to prevent gram‐positive CVC‐related infections in adults and children receiving treatment for cancer. Search methods The search for this updated review was conducted on 19 November 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE via Ovid and Embase via Ovid. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform portal for additional articles. Selection criteria We included randomised controlled trials (RCTs) that compared either the administration of prophylactic antibiotics prior to long‐term CVC insertion versus no administration of antibiotics, or the use of an antibiotic versus a non‐antibiotic flush/lock solution in long‐term CVCs, in adults and children receiving treatment for cancer. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two authors independently selected studies, classified them and extracted data onto a predesigned data collection form. The outcomes of interest were gram‐positive catheter‐related infection events and total number of CVCs and CVC days. We pooled the data using a random‐effects model for meta‐analyses. We used the GRADE approach to assess the certainty of the evidence. Main results For this update, we identified 310 potentially relevant studies and screened them for eligibility. We included one additional RCT with 404 participants. The original review included 11 RCTs with a total of 840 people with cancer (adults and children). In total this review included 12 RCTs with 1244 participants. Antibiotics prior to insertion of the CVC 
Six trials compared the use of antibiotics (vancomycin, teicoplanin, ceftazidime or cefazolin) versus no antibiotics given before the insertion of a long‐term CVC. One study did not observe any CVC‐related infection events in either group was not included in the quantitative analysis as it was not possible to calculate a risk ratio. Administering an antibiotic prior to insertion of the CVC may not reduce gram‐positive CVC‐related infections (pooled risk ratio 0.67, confidence interval (CI) 95% 0.32 to 1.43; control versus intervention group risk 10.4% versus 7.3% of the participants; 5 studies, 648 participants; moderate‐certainty evidence). We sought adverse event data, but these were not described by the authors. The overall risk of bias was deemed low. Antibiotics as a flushing or locking solution 
Six trials compared a combined antibiotic (vancomycin, amikacin or taurolidine) and heparin solution with a heparin‐only solution for flushing or locking the long‐term CVC after use. One study did not observe any CVC‐related sepsis events (CRS) and was not included in this study in the quantitative analysis as it was not possible to calculate a risk ratio. Flushing and locking long‐term CVCs with a combined antibiotic and heparin solution likely reduced the risk of gram‐positive CVC‐related infections compared to a heparin‐only solution (pooled rate ratio 0.47, CI 95% 0.26 to 0.85; control versus intervention group rate ratio 0.66 versus 0.27 per 1000 CVC‐days; 5 studies, 443 participants; moderate‐certainty evidence). One trial reported a higher incidence of occlusions and participants in one trial reported an unpleasant taste after flushing associated with a combined antibiotic and heparin solution. The overall risk of bias was deemed low. Authors' conclusions Since the last version of this review, we included one additional study. There was no observed benefit of administering antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing or locking long‐term CVCs with an antibiotic solution likely reduces gram‐positive CVC‐related infections experienced in people at risk of neutropenia through chemotherapy or disease. However, a limitation of this review is heterogeneity between the studies for both outcomes. Insufficient data were available to evaluate if the conclusions apply equally for different CVC types and for adults versus children. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if the baseline CVC‐related infection rates are high. Further research is needed to identify high‐risk groups most likely to benefit from these antibiotic flush/lock solutions. Plain language summary Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer The issue 
People undergoing anti‐cancer treatment (chemotherapy) often have a catheter (tube) inserted into a large vein, through which their chemotherapy is given. This is known as a central venous catheter (CVC). As chemotherapy is usually administered over several months to years, long‐term CVCs are used. Despite sterile insertion and care afterwards, these CVCs often become infected by a type of bacteria called gram‐positive bacteria. Giving antibiotics as a preventive (prophylactic antibiotics) before the catheter is inserted, or using the antibiotics as a lock or flush solution, or both, may prevent these infections. A lock/flush solution is instilled in the catheter when it is not in use. This solution often contains heparin, saline, or both, to prevent a clot forming in the catheter. The aim of the review 
The aim of this review was to determine whether giving antibiotics before catheter insertion or as a lock/flush solution can prevent gram‐positive CVC‐related infections. What are the main findings? 
We searched databases to identify randomised controlled trials (RCTs ‐ clinical studies where people are randomly put into one of two or more treatment groups). We identified 12 relevant studies, which included a total of 1244 adults and children with cancer. We included six studies (756 people) that compared giving antibiotics before the insertion of the CVC against not giving antibiotics. We found that giving an antibiotic before CVC insertion did not prevent infections. The studies authors' did not describe side‐effects. We included six studies (488 people) that compared an antibiotic solution with a heparin‐only solution to flush/lock a CVC. We found that an antibiotic lock/flush solution reduced the number of CVC‐related infections. People in one study reported an unpleasant taste after flushing, and one study found there were fewer CVC obstructions (e.g. a clot) in people who received the combined antibiotic and anticoagulant solution. Certainty of the evidence 
We have moderate confidence in the evidence for giving antibiotics prior to CVC insertion and antibiotic lock/flush solutions since the studies were done in different people, used different types of catheters and antibiotics, and measured their results in different ways. What are the conclusions? 
We did not observe any benefit of giving antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing/locking long‐term CVCs with an antibiotic appeared to reduce gram‐positive CVC‐related infections in people with cancer. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if baseline CVC‐related infection rates are high. This review updates our previous review. The evidence is up to date to 19 November 2020.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.072Z" }, { "id": "9dbb227b-723f-4489-aa07-3144487dfb3d", "pmid": "", "title": "The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement", "imported": false, "abstract": "Abstract - Background The World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework is an holistic, settings‐based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed. Objectives To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well‐being of students and their academic achievement. Search methods We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov , Current controlled trials , and WHO International Clinical Trials Registry Platform . We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles. Selection criteria We included cluster‐randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school’s ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements. Data collection and analysis At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random‐effects meta‐analyses to provide a summary of results across studies. Main results We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand‐washing (2), multiple risk behaviours (7), cycle‐helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self‐reported data and high attrition rates for some studies. In addition, there was a lack of long‐term follow‐up data for most studies. We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta‐analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school‐related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement. Authors' conclusions The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well‐designed research is required to establish the effectiveness of this approach for other health topics and academic achievement. Plain language summary The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement Background Health and education are strongly connected: healthy children achieve better results at school, which in turn are associated with improved health later in life. This relationship between health and education forms the basis of the World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework, an approach to promoting health in schools that addresses the whole school environment. Although the HPS framework is used in many schools, we currently do not know if it is effective. This review aimed to assess whether the HPS framework can improve students’ health and well‐being and their performance at school. Study characteristics We searched 20 health, education, and social science databases, as well as trials registries and relevant websites, for cluster‐randomised controlled trials of school‐based interventions aiming to improve the health of young people aged four to 18 years. We only included trials of programmes that addressed all three points in the HPS framework: including health education in the curriculum; changing the school’s social or physical environment, or both; and involving students’ families or the local community, or both. Key results We found 67 trials, comprising 1345 schools and 98 districts, that fulfilled our criteria. These focused on a wide range of health topics, including physical activity, nutrition, substance use (tobacco, alcohol, and drugs), bullying, violence, mental health, sexual health, hand‐washing, cycle‐helmet use, sun protection, eating disorders, and oral health. For each study, two review authors independently extracted relevant data and assessed the risk of the study being biased. We grouped together studies according to the health topic(s) they focused on. We found that interventions using the HPS approach were able to reduce students’ body mass index (BMI), increase physical activity and fitness levels, improve fruit and vegetable consumption, decrease cigarette use, and reduce reports of being bullied. However, we found little evidence of an effect on BMI when age and gender were taken into account (zBMI), and no evidence of effectiveness on fat intake, alcohol and drug use, mental health, violence, and bullying others. We did not have enough data to draw conclusions about the effectiveness of the HPS approach for sexual health, hand‐washing, cycle‐helmet use, eating disorders, sun protection, oral health or academic outcomes. Few studies discussed whether the health promotion activities, or the collection of data relating to these, could have caused any harm to the students involved. Quality of the evidence Overall, the quality of evidence was low to moderate. We identified some problems with the way studies were conducted, which may have introduced bias, including many studies relying on students’ accounts of their own behaviours (rather than these being measured objectively) and high numbers of students dropping out of studies. These problems, and the small number of studies included in our analysis, limit our ability to draw clear conclusions about the effectiveness of the HPS framework in general. Conclusions Overall, we found some evidence to suggest the HPS approach can produce improvements in certain areas of health, but there are not enough data to draw conclusions about its effectiveness for others. We need more studies to find out if this approach can improve other aspects of health and how students perform at school.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Langford, R; Bonell, CP; Jones, HE; Pouliou, T; Murphy, SM; Waters, E; Komro, KA; Gibbs, LF; Magnus, D; Campbell, R", "articleTypes": [], "doi": "10.1002/14651858.CD008958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "9dbd9324-c8a6-496c-9282-5fe7d774d7d9", "pmid": "", "title": "Glutamatergic drugs for schizophrenia", "imported": false, "abstract": "Abstract - Background It has been shown that central nervous system dopamine can play a major role in the pathophysiology of schizophrenia. Brain glutamate is thought to mediate symptoms in schizophrenia due to the influence of glutamate neurons on the dopaminergic transmission in the brain. It might be possible to decrease negative symptoms and the cognitive impairment of people with schizophrenia by treatment with glutamatergic drugs. Objectives To determine the efficacy of glutamatergic drugs in the treatment of schizophrenia. Search methods We searched the Cochrane Schizophrenia Group's Trials Register (May 2002 and October 2003), inspected references of all identified studies and contacted relevant authors. Selection criteria We included all randomised controlled trials in which glutamatergic medication was administered to people with schizophrenia. Data collection and analysis We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results We included eighteen short‐term trials with 358 randomised participants. The single studies were small with numbers of participants ranging between six and 51. All trials were short‐term trials with a maximum duration of 12 weeks. In all of these trials, glycine, D‐serine, D‐cycloserine, or ampakine CX516 was used to augment the effect of antipsychotic drugs. D‐cycloserine, a partial agonist of NMDA receptors' glycine site, seemed ineffective towards the symptoms of schizophrenia. NMDA receptor co‐agonists glycine and D‐serine showed some effects in reducing the negative symptoms of schizophrenia (n=132, SMD ‐0.66, CI ‐1.0 to ‐0.3, p=0.0004), but the magnitude of the effect was moderate. Furthermore, when responder rates rather than mean scores of negative symptoms were analysed the data were inconsistent: There was no difference in responder rates between glycine and the control in terms of more than 20% improvement of negative symptoms (n=62, RR 0.70, CI 0.3 to 1.71) and only a borderline significant superiority in terms of more than 50% improvement (n=62, RR 0.87, CI 0.8 to 1.00). There were also some effects in favour of glycine and/or D‐serine in terms of overall and general symptoms, but the results were again inconsistent and depended on the response definition applied. Available rating scale data on positive symptoms and cognitive functioning did not indicate a statistically significant effect of glycine or D‐serine. Authors' conclusions In general, all glutamatergic drugs appeared to be ineffective in further reducing positive symptoms of the disease when added to the existing antipsychotic treatment. Glycine and D‐serine may somewhat improve negative symptoms when added to regular antipsychotic medication, but the results were not fully consistent and data are too few to allow any firm conclusions. Many participants in the included trials were treatment‐resistant which may have reduced treatment response. Additional research on glutamatergic mechanisms of schizophrenia is needed. Plain language summary Glutamatergic drugs for schizophrenia Schizophrenia is a severe psychiatric disease characterised by positive symptoms such as hallucinations and delusions and negative symptoms such as blunted affect and emotional withdrawal. People with schizophrenia may also suffer from cognitive deficits. Current medication is effective in reducing positive symptoms, but negative and cognitive symptoms are fairly resistant to treatment. Antipsychotic drugs act mainly on the dopamine system in the brain, although other neurotransmitter systems may also play a role in schizophrenia. We sought to review all randomised trials that used glutamatergic drugs in the treatment of schizophrenia. This review shows that substances acting on the glutamate system may improve symptoms when added to regular antipsychotic medication, although the available evidence base is too limited to allow for any firm conclusions. Presently, glutamatergic drugs are not available for clinical use. Additional research is needed to determine their ultimate role in the treatment of schizophrenia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Tiihonen, J; Wahlbeck, K", "articleTypes": [], "doi": "10.1002/14651858.CD003730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "9dc4d41f-6436-40eb-882b-da1d02ba67e7", "pmid": "", "title": "Honey and lozenges for children with non‐specific cough", "imported": false, "abstract": "Abstract - Background Chronic non‐specific cough is a chronic, dry cough of in the absence of identifiable respiratory disease or known aetiology. Although it is usually not reflective of an underlying severe illness, it does cause significant morbidity, and as such relief from it is often sought. The use of honey and lozenges to soothe upper respiratory tract irritation is common, inexpensive, and potentially more effective in treating the symptoms than pharmacological interventions. Objectives To evaluate the efficacy of honey and/or lozenges in the management of children with chronic non‐specific cough. Search methods The Cochrane Airways Group searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, OLDMEDLINE, and EMBASE databases in October 2010. Selection criteria All randomised controlled trials comparing honey or lozenges with a placebo in treating children with chronic non‐specific cough. Data collection and analysis The results of the searches were assessed according to the pre‐determined criteria. None of the trials identified by the searches were eligible for inclusion, leaving no data available for analysis in this review. Main results The search did not provide any applicable randomised controlled trials that investigated the efficacy of honey and lozenges in treating children with non‐specific chronic cough. Data from acute studies suggest a potential role for honey in relieving cough, but whether this is applicable to chronic cough is unknown. Authors' conclusions Clinically, this review was unable to provide any justifiable recommendation for or against honey and/or lozenges due to the lack of evidence. The absence of applicable studies highlights the need for further research into the area of treating children with chronic non‐specific coughs with honey and/or lozenges. These treatments are not recommended when managing very young children (as lozenges are a potential choking hazard, and honey may cause infant botulism in children under one year of age). Plain language summary Honey and lozenges for children with non‐specific cough Symptomatic relief is often sought for children with chronic non‐specific cough (which is defined as a dry, non‐productive cough with no known cause lasting longer than four consecutive weeks). This review aimed to assess the efficacy of treating children with such coughs using honey or lozenges, as these options are inexpensive. No randomised controlled trials were found to be applicable to this review, primarily due to the participants in the studies not fulfilling the inclusion criteria. However, studies on the efficacy of these treatments in treating acute cough in children showed that honey has the potential to be beneficial in children over a year old. Further research evaluating the efficacy of honey and lozenges in treating chronic non‐specific coughs in children is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Mulholland, S, Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD007523.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.745Z" }, { "id": "9dd5c566-04a7-4884-a9f4-c0a7c08d4761", "pmid": "", "title": "A meta-analysis on polymorphic trait of taste perception mediated by TAS2R38 genotype.", "imported": false, "abstract": "The objective of this study is to review the association of TAS2R38 polymorphisms and taste phenotypes to bitter compounds (phenylthiocarbamide [PTC]/propylthiouracil [PROP]), and its association among persons who drink alcohol and individuals with smoking behavior. A literature search was carried out in PubMed, ScienceDirect, Cochrane, and Wiley online library databases using the keyword \"(Bitter taste receptor genes OR TAS2R38) AND (PROP OR propylthiouracil) AND (PTC OR phenylthiocarbamide),\" \"(Bitter taste receptor genes OR TAS2R38) AND (alcohol),\" \"(Bitter taste receptor genes OR TAS2R38) AND (tobacco OR smoker)\" to find articles evaluating the association of taste phenotypes and TAS2R38 polymorphisms, and its association among persons who drink alcohol and individuals with smoking behavior. The analysis show that TAS2R38 taster genotype (proline-alanine-valine [PAV] allele) was significantly (OR, 5.88; CI [3.87, 8.95], p < .001) associated with taster phenotype for bitter compounds (PTC/PROP), and TAS2R38 nontaster genotype (alanine-valine-isoleucine allele) was significantly (OR, 6.73; CI [4.57, 9.90], p < .001) associated with nontaster phenotype for bitter compounds. Further, TAS2R38 taster genotypes (PAV homozygotes and heterozygotes) were significantly associated with higher alcohol intake (OR, 5.15; 95% CI [2.66, 9.98]; p < .001) and among individuals with smoking behavior (OR, 1.73; 95% CI [1.24, 2.42]; p = .001). This suggests that TAS2R38 single nucleotide polymorphisms can be identified by clinically assessing taste phenotype status for bitter compounds and can be used as a potential therapeutic target in the prevention and treatment of harmful higher alcohol intake and smoking behavior. (PsycInfo Database Record (c) 2024 APA, all rights reserved).", "journal": "Experimental and clinical psychopharmacology", "year": "2024", "authors": "Shivam V", "articleTypes": [], "doi": "10.1037/pha0000728", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.439Z" }, { "id": "9dee7ecd-beb3-4c07-ab59-fdebdc72c001", "pmid": "", "title": "The Effect of Omega Galil Hazelnut Chocolate Spread \"O'Sweet Spread\" With 80% Reduced Sucrose on Glucose Response of People With TID - a Randomized, Double-blind, Active Control Trial", "imported": false, "abstract": "Omega Galil has developed a novel fatty sweetener that allows the use of up to 80% less sugar (particularly sucrose) and yet achieves a natural sweet flavor, using a novel technology of milling the natural sucrose crystals together with oil and thus creating a micro-suspension of sugar in oil or fat. The suspension increases the surface area of the sugar particles and thus a lower quantity of sugar is required in order to reach an enhanced perception of sweetness at the sweet taste receptors in the mouth. Omega Galil provides fatty food products that use up to 80% less sucrose, while tasting as sweet as regular sugar sweetened foods, with no aftertastes of sugar substitutes, and no chemical modifications or additives.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.265Z" }, { "id": "9df15194-4757-461a-be5b-1afa6c12826b", "pmid": "", "title": "Evaluation of the Perception of Freshness and Swallowing Safety in Stroke Patients With Dysphagia Receiving a Specially Designed Thickened Oral Nutritional Supplement: the Cooling Sensation Safe Deglution Study", "imported": false, "abstract": "Dysphagia is a common complication in patients who have suffered a cerebrovascular accident (CVA), with an incidence ranging from 29% to 81%. Rehabilitation improves dysphagia in 47% of cases within the first few weeks and in 17% within 2-4 months. However, dysphagia can lead to nutritional and respiratory complications, affecting recovery and increasing healthcare costs due to the need for prolonged hospitalizations and readmissions.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.246Z" }, { "id": "9e06d16c-5973-42c8-aea0-d58858d1c7a0", "pmid": "", "title": "Environmental interventions to reduce the consumption of sugar‐sweetened beverages and their effects on health", "imported": false, "abstract": "Abstract - Background Frequent consumption of excess amounts of sugar‐sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB. Objectives To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar‐sweetened beverages and sugar‐sweetened milk, diet‐related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes. Search methods We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors. Selection criteria We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet‐related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) and interrupted‐time‐series (ITS) studies, implemented in real‐world settings with a combined length of intervention and follow‐up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB‐specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review. Data collection and analysis Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta‐analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented ‘Summary of findings’ tables. Main results We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow‐up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non‐randomised designs. The studies examine a broad range of interventions, and we present results for these separately. Labelling interventions (8 studies): We found moderate‐certainty evidence that traffic‐light labelling is associated with decreasing sales of SSBs, and low‐certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu‐board calorie labelling reported effects on SSB sales varied. Nutrition standards in public institutions (16 studies): We found low‐certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low‐certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied. Economic tools (7 studies): We found moderate‐certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low‐calorie beverages reported effects on SSB sales varied. Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied. Retail and food service interventions (7 studies): We found low‐certainty evidence that healthier default beverages in children’s menus in chain restaurants are associated with decreasing SSB sales, and moderate‐certainty evidence that in‐store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low‐certainty evidence that urban planning restrictions on new fast‐food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied. Intersectoral approaches (8 studies): We found moderate‐certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate‐certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied. Home‐based interventions (7 studies): We found moderate‐certainty evidence that improved availability of low‐calorie beverages in the home environment is associated with decreased SSB intake, and high‐certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs. Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low‐calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes. We analysed interventions targeting sugar‐sweetened milk separately, and found low‐ to moderate‐certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar‐sweetened milk. We found low‐certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar‐sweetened milk consumption. Authors' conclusions The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high‐quality evaluations using appropriate study designs, with a particular focus on the long‐term effects of approaches suitable for large‐scale implementation. Plain language summary Cutting back on sugar‐sweetened beverages: What works? What are sugar‐sweetened beverages? Sugar‐sweetened beverages (SSBs) are cold and hot drinks with added sugar. Common SSBs are non‐diet soft drinks, regular soda, iced tea, sports drinks, energy drinks, fruit punches, sweetened waters, and sweetened tea and coffee. Why are SSBs an important health topic? Research shows that people who drink a lot of SSBs often gain weight. Drinking a lot of SSBs can also increase the risk of diabetes, heart disease, and dental decay. Doctors therefore recommend that children, teenagers and adults drink fewer SSBs. Governments, businesses, schools and workplaces have taken various measures to support healthier beverage choices. What is the aim of this review? We wanted to find out whether the measures taken so far have been successful in helping people to drink fewer SSBs to improve their health. We focused on measures that change the environment in which people make beverage choices. We did not look at studies on educational programmes or on SSB taxes, as these are examined in separate reviews. (We did, however, examine price increases on SSB which were not due to taxes.) We searched for all available studies meeting clearly‐defined criteria to answer this question. This review reflects the state of the evidence up until January 2018. What studies did we find? We found 58 studies, which included more than one million adults, teenagers and children. Most studies lasted about one year, and were done in schools, stores or restaurants. Some studies used methods that are not very reliable. For example, in some studies participants were simply asked how much SSB they drank, which is not very reliable, as people sometimes forget how much SSB they drank. Some of the findings of our review may therefore change when more and better studies become available. What do these studies tell us? We have found some evidence that some of the measures implemented to help people drink fewer SSBs have been successful, including the following: ▪ Labels which are easy to understand, such as traffic‐light labels, and labels which rate the healthfulness of beverages with stars or numbers. ▪ Limits to the availability of SSB in schools (e.g. replacing SSBs with water in school cafeterias). ▪ Price increases on SSBs in restaurants, stores and leisure centres. ▪ Children’s menus in chain restaurants which include healthier beverages as their standard beverage. ▪ Promotion of healthier beverages in supermarkets. ▪ Government food benefits (e.g. food stamps) which cannot be used to buy SSBs. ▪ Community campaigns focused on SSBs. ▪ Measures that improve the availability of low‐calorie beverages at home, e.g. through home deliveries of bottled water and diet beverages. We have also found some evidence that improved availability of drinking water and diet beverages at home can help people lose weight. There are also other measures which may influence how much SSB people drink, but for these the available evidence is less certain. Some, but not all studies found that such measures can have effects which were not intended and which may be negative. Some studies reported that profits of stores and restaurants decreased when the measures were implemented, but other studies showed that profits increased or stayed the same. Children who get free drinking water in schools may drink less milk. Some studies reported that people were unhappy with the measures. We also looked at studies on sugar‐sweetened milk. We found that small prizes for children who chose plain milk in their school cafeteria, as well as emoticon labels, may help children drink less sugar‐sweetened milk. However, this may also drive up the share of milk which is wasted because children choose but do not drink it. What does this mean in practice? Our review shows that measures which change the environment in which people make beverage choices can help people drink less SSB. Based on our findings we suggest that such measures may be used more widely. Government officials, business people and health professionals implementing such measures should work together with researchers to find out more about their effects in the short and long term.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "von Philipsborn, P, Stratil, JM, Burns, J, Busert, LK, Pfadenhauer, LM, Polus, S, Holzapfel, C, Hauner, H, Rehfuess, E", "articleTypes": [], "doi": "10.1002/14651858.CD012292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.805Z" }, { "id": "9e245020-0e35-4d3a-9507-881782bb57f0", "pmid": "", "title": "Pharmacological treatments for Friedreich ataxia", "imported": false, "abstract": "Abstract - Rationale Friedreich ataxia (FRDA) is a rare inherited autosomal recessive neurological disorder, characterised initially by unsteadiness in standing and walking, and slowly progressing to wheelchair dependency, usually in the late teens or early twenties. Scoliosis, pes cavus and cardiomyopathy are often present at diagnosis. As the disease progresses, individuals usually develop slurred speech, auditory impairment (especially in a noisy environment), urinary tract morbidity, diabetes, anxiety, depression, muscle spasticity and visual disturbances. Cardiac abnormalities cause premature death in 60% of people with FRDA. There is no easily defined clinical or biochemical marker to assess progression and no known curative treatment. This is the third update of a review published in 2009 and updated in 2012 and 2016. Objectives To assess the effects of pharmacological treatments for people with Friedreich ataxia (FRDA) after 12 months of treatment. Search methods To identify studies for inclusion in this review, we searched CENTRAL, MEDLINE, Embase, CINAHL Plus, TRIP, Orphanet, WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. We also checked reference lists of relevant studies and contacted study authors. The most recent search was on 4 February 2025. Eligibility criteria We were interested in randomised controlled trials (RCTs) and quasi‐RCTs of pharmacological treatments (including vitamins) in people with genetically‐confirmed FRDA. To be included in the review, studies had to last at least 12 months. Outcomes We assessed the following outcomes after 12 months of treatment: change in score on a validated ataxia rating scale; change in interventricular septal thickness in diastole (IVSTd) by cardiac magnetic resonance imaging or echocardiogram; change in activities of daily living (ADL) using a validated questionnaire; change in upper limb dexterity; and change in cardiopulmonary exercise testing (CPET). We also assessed treatment‐related adverse events with medication continued for the study period, and treatment‐emergent adverse events leading to cessation of medication or death during the study period. Risk of bias Using the Cochrane risk of bias tool RoB 2, we assessed the risk of bias in the seven outcomes reported in our summary of findings tables. Synthesis methods We synthesised the results of the studies for each outcome using meta‐analysis, where possible. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and the risk ratio (RR) for dichotomous outcomes, all with 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for our prespecified outcomes as high, moderate, low or very low. Included studies We included eight RCTs in this updated review. We included seven of them in meta‐analysis, and these studies enroled a total of 574 participants, with sample sizes ranging from 29 to 232 participants per study. One study was international, with centres in North America, Europe and Australia. There were four other multicentre studies (three in Europe and one in North America). Single‐centre studies were conducted in the UK, Italy and France. Participants in the studies ranged from eight to 70 years of age at enrolment, with the mean age in each study being between 18 years and 35 years (with an unweighted pooled mean age across studies of 25.9 years). All of the studies enroled both males and females, with the proportion of female participants ranging from 21% to 58%. Sixty‐eight per cent of participants had severe ataxia, while the other 32% had moderate ataxia. The studies tested epoetin alpha, CoQ10 and vitamin E, idebenone, leriglitazone, omaveloxolone, and RT001. One study tested pioglitazone but has not published any results. Four of the studies were pharmaceutical‐industry‐controlled. Synthesis of results Meta‐analysis of seven studies demonstrated that pharmacological treatment probably makes little or no difference to scores on the ataxia rating scale after 12 months of treatment (SMD 0.02, 95% CI −0.23 to 0.26; I² = 42%; 7 studies, 513 participants; moderate‐certainty evidence). The evidence was very uncertain about the effects of treatment on IVSTd (MD −0.51, 95% CI −1.10 to 0.09; I² = 80%; 2 studies, 72 participants; very low‐certainty evidence) and on ADL (MD −0.59, 95% CI −1.39 to 0.21; I² = 24%; 3 studies, 167 participants; very low‐certainty evidence). Meta‐analysis of three studies showed that treatment probably improves upper limb dexterity (SMD −0.42, 95% CI −0.73 to −0.11; I² = 0%; 3 studies, 166 participants; moderate‐certainty evidence). We are very uncertain about the effect of pharmacological treatment on CPET (SMD −0.16, 95% CI −0.46 to 0.13; I² = 0%; 3 studies, 181 participants; very low‐certainty evidence). We are very uncertain whether pharmacological treatment has any effect on treatment‐related adverse events (RR 0.88, 95% CI 0.63 to 1.22; I² = 0%; 2 studies, 104 participants; very low‐certainty evidence). There were only 104 participants in this analysis out of a total of 545 participants, so the result may have little relevance. Meta‐analysis of six studies found that there may be little to no difference between pharmacological treatment and placebo in treatment‐emergent adverse events leading to cessation of medication or death (RR 1.24, 95% CI 0.44 to 3.48; I² = 0%; 6 studies, 313 participants; low‐certainty evidence). Our certainty in the evidence ranged from very low to moderate. We downgraded all outcomes by one or two levels for imprecision, with further downgrades for inconsistency (for the outcomes of IVSTd, ADL, CPET) and suspected publication bias (for the outcomes of IVSTd, ADL, CPET and adverse events). Authors' conclusions In this updated Cochrane systematic review, meta‐analysis of results on the ataxia rating scale showed that pharmacological treatments probably make little or no difference compared with placebo after 12 months of treatment. Given this result, the probable improvement that we found in upper limb dexterity was unexpected. Treatment‐emergent adverse events leading to cessation of medication or death may be no more common in treatment groups than placebo groups as there were few adverse events detected in the treated groups. However, the studies may not have detected all rare and serious adverse events. Funding The authors in this review received no funding. Registration Protocol (2009) DOI: 10.1002/14651858.CD007791 Original review (2009) DOI: 10.1002/14651858.CD99791.pub2 Update (2012) DOI: 10.1002/14651858.CD007791.pub3 Update (2016) DOI: 10.1002/14651858.CD007791.pub4 Plain language summary Does taking medicine help people with Friedreich ataxia? Key messages For people with a progressive genetic condition called Friedreich ataxia, which affects nerves and muscles, taking medicine for a year probably has little to no effect on measures of ataxia (problems with co‐ordination and balance) or speech, although it probably improves upper limb dexterity (the ability to co‐ordinate the action of the arms, hands and fingers). We are uncertain whether taking medicine has any effect on heart health, the ability to perform daily tasks, or the body's response to exercise in people with Friedreich ataxia. From the available evidence, it is very uncertain whether the medicines cause any unwanted effects. What is Friedreich ataxia? Friedreich ataxia is a rare inherited condition affecting the nerves and muscles, which usually appears in childhood, at between 5 and 15 years of age. It causes clumsiness of movement, which progresses to unsteadiness in standing and walking, and to being dependent on a wheelchair by the late teens or early twenties. It can be associated with a curved spine (scoliosis), foot deformity (a high arch) and heart problems. As the disease progresses, slurred speech, hearing difficulties, problems going to the toilet, muscle spasticity, depression, anxiety and visual disturbances are common. Heart problems are a cause of early death in nearly two‐thirds of people with Friedreich ataxia. Clinical examination and laboratory tests are not very useful for judging the progression of the disease, which makes it difficult to understand the results of studies with Friedreich ataxia patients. What are the possible options for treating Friedreich ataxia? There is currently no cure for Friedreich ataxia. Various medicines have been tried. A new medicine, omaveloxolone, was recently approved in the USA and Europe for people over 16 years of age with Friedreich ataxia. What did we want to find out? We wanted to know if any of the medicines tested in randomised clinical trials help improve the lives of people with Friedreich ataxia. Randomised clinical trials are studies where some people take medicine and others take placebo, which is a substance that has no medical benefit but looks the same as the active medicine. No‐one involved with the study knows who is taking medicine and who is taking placebo. This is the third update of a Cochrane review that was first published in 2009. What did we do? We searched for randomised clinical trials that compared medicine to placebo in people with Friedreich ataxia and lasted at least 12 months. We combined the results of the studies and rated our confidence in this evidence, based on factors such as study methods and the number of people involved. What did we find? We found eight studies, seven of which reported results after taking medicine or placebo for 12 months. The studies included a total of 574 people, whose average ages were between 18 and 35 years. Most of the participants (68%) had severe ataxia, while 32% had moderate ataxia. The studies took place in Europe, North America and Australia. Four of them were carried out by the pharmaceutical industry (i.e. by companies who make the medicines). Two studies used a medicine called idebenone, and each of the others used a different medicine: co‐Q10 with vitamin E, epoetin alpha, omaveloxolone, leriglitazone, pioglitazone, and RT001. We found that, after one year, there was probably little to no difference in the level of ataxia that people experienced, regardless of whether they took medicine or placebo (7 studies, 513 people). We are very uncertain whether medicine has any effect on heart health (based on measuring the thickness of the heart muscle) or the ability to do daily tasks or how people score on special tests designed to measure the body's response to exercise. We found that medicine probably improves upper limb dexterity after one year (3 studies (testing leriglitazone, epoetin alpha and omaveloxolone), 166 people). With regard to safety, we are very uncertain whether the medicines cause any more unwanted effects than placebo. We found that there may be little to no difference between people taking medicine and people taking placebo in terms of the number of who either stopped taking the medicine or placebo, or the number of who died during the study years (6 studies, 313 people). What are the limitations of the evidence? Our confidence in the effect of medicine on ataxia is only moderate. This is because the results were not very precise. We are only moderately confident about the effect of medicine on upper limb dexterity because this was only reported in small studies. We had very little confidence in the other outcomes because of the small numbers of people in the studies. The studies reported varied results, and some studies did not publish the results for all the assessments that were carried out. It is difficult to measure an individual's perceptions of the positive effects of any new medicine, which may vary depending on their expectations prior to starting the medicine and whether their illness is early or advanced. How up to date is this evidence? The evidence is current to 4 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lyons, S; Kearney, M; Fahey, MC; Janjal, P; Pandolfo, M; Patton, P", "articleTypes": [], "doi": "10.1002/14651858.CD007791.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "9e41b10d-a37e-43fc-9638-0b7a0bd2ace7", "pmid": "", "title": "Horticultural therapy for schizophrenia", "imported": false, "abstract": "Abstract - Background Horticultural therapy is defined as the process of utilising fruits, vegetables, flowers and plants facilitated by a trained therapist or healthcare provider, to achieve specific treatment goals or to simply improve a person's well‐being. It can be used for therapy or rehabilitation programs for cognitive, physical, social, emotional, and recreational benefits, thus improving the person's body, mind and spirit. Between 5% to 15% of people with schizophrenia continue to experience symptoms in spite of medication, and may also develop undesirable adverse effects, horticultural therapy may be of value for these people. Objectives To evaluate the effects of horticultural therapy for people with schizophrenia or schizophrenia‐like illnesses compared with standard care or other additional psychosocial interventions. Search methods We searched the Cochrane Schizophrenia Group Trials Register (Janurary 2013) and supplemented this by contacting relevant study authors, and manually searching reference lists. Selection criteria We included one randomised controlled trial (RCT) comparing horticultural therapy plus standard care with standard care alone for people with schizophrenia. Data collection and analysis We reliably selected, quality assessed and extracted data. For continuous outcomes, we calculated a mean difference (MD) and for binary outcomes we calculated risk ratio (RR), both with 95% confidence intervals (CI). We assessed risk of bias and created a 'Summary of findings' table using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. Main results We included one single blind study (total n = 24). The overall risk of bias in the study was considered to be unclear although the randomisation was adequate. It compared a package of horticultural therapy which consisted of one hour per day of horticultural activity plus standard care with standard care alone over two weeks (10 consecutive days) with no long‐term follow‐up. Only two people were lost to follow‐up in the study, both in the horticultural therapy group (1 RCT n = 24,RR 5.00 95% CI 0.27 to 94.34, very low quality evidence ). There was no clear evidence of a difference in Personal Wellbeing Index (PWI‐C) change scores between groups, however confidence intervals were wide (1 RCT n = 22, MD ‐0.90 95% CI ‐10.35 to 8.55, very low quality evidence ). At the end of treatment, the Depression Anxiety Stress Scale (DASS21) change scores in horticultural therapy group were greater than that in the control group (1 RCT n = 22, MD ‐23.70 CI ‐35.37 to ‐ 12.03, very low quality evidence). The only included study did not report on adverse effects of interventions. Authors' conclusions Based on the current very low quality data, there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. This therapy remains unproven and more and larger randomised trials are needed to increase high quality evidence in this area. Plain language summary Gardening activity as a therapy for schizophrenia Horticultural therapy is based on the therapeutic value of participating in garden activities such as growing fruit or vegetables and/or flowers. Gardening is thought to improve people's well‐being through being a recreational and sociable activity which may lead to improvements in people's thinking, new friendships and more positive emotions. The benefits of gardening can also apply to people with serious mental illness such as schizophrenia. Gardening reduces stress, which is important because stress can often lead to mental illness. Gardening is also hard work and a physical activity, and so motivates people with mental illness who often feel tired and apathetic. Weight gain is common for people with mental illness and gardening is good physical exercise. Since 5% to 15% of people with schizophrenia experience symptoms in spite of taking antipsychotic drugs and also because these drugs have debilitating side effects, horticultural therapy may be of value to these people. This review focuses on the effects of horticultural therapy for people with schizophrenia. An electronic search for relevant randomised trials was run in January 2013. Only one trial was included, it randomised a total of 24 people with schizophrenia to received either their standard care plus horticultural therapy or standard care only. The trial only lasted 2 weeks (10 consecutive days) with no long‐term follow‐up. There are few results and the quality of evidence was rated by the review authors to be very low quality. Some of the information from this one study favoured horticultural therapy but there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. More large, better conducted and reported trials are required to determine the effectiveness and benefits of horticultural therapy. This plain language summary has been written by a consumer Ben Gray, Service User and Service User Expert, Rethink Mental Illness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Liu, Y; Li, B; Sampson, SJ; Roberts, S; Zhang, G; Wu, W", "articleTypes": [], "doi": "10.1002/14651858.CD009413.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "9e5b4764-f89a-45f2-b526-819c211db7f5", "pmid": "", "title": "Topiramate for neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background Topiramate is an antiepileptic drug with multiple possible mechanisms of action. Antiepileptic drugs are widely used to treat chronic neuropathic pain (pain due to nerve damage) and fibromyalgia, and many guidelines recommend them. Objectives To assess the analgesic efficacy and associated adverse events of topiramate for chronic neuropathic pain and fibromyalgia in adults (aged 18 years and above). Search methods On 8 May 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We reviewed the bibliographies of all randomised trials identified and review articles, and also searched two clinical trial databases, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform, to identify additional published or unpublished data. Selection criteria We included randomised controlled trials (RCTs) with double‐blind assessment of participant outcomes following two weeks of treatment or longer (though the emphasis of the review was on studies of eight weeks or longer) that used a placebo or active comparator. Data collection and analysis We extracted efficacy and adverse event data, and two study authors examined issues of study quality independently. We performed analysis using two tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First tier studies did not use last‐observation‐carried‐forward (LOCF) or other imputation methods for dropouts. The second tier used data that failed to meet this standard; second tier results were therefore subject to potential bias. Main results We included four studies with 1684 participants. Three parallel‐group placebo comparisons were in painful diabetic neuropathy (1643 participants), and one cross‐over study with diphenhydramine as an active placebo (41 participants) was in lumbar radiculopathy. Doses of topiramate were titrated up to 200 mg/day or 400 mg/day. All studies had one or more sources of potential major bias, as they either used LOCF imputation or were of small size. No study provided first tier evidence for an efficacy outcome. There was no convincing evidence for efficacy of topiramate at 200 to 400 mg/day over placebo. Eighty‐two per cent of participants taking topiramate 200 to 400 mg/day experienced at least one adverse event, as did 71% with placebo, and the number needed to treat for an additional harmful effect (NNTH) was 8.6 (95% confidence interval (CI) 4.9 to 35). There was no difference in serious adverse events recorded (6.6% versus 7.5%). Adverse event withdrawals with 400 mg daily were much more common with topiramate (27%) than with placebo (8%), with an NNTH of 5.4 (95% CI 4.3 to 7.1). Lack of efficacy withdrawal was less frequent with topiramate (12%) than placebo (18%). Weight loss was a common event in most studies. No deaths attributable to treatment were reported. Authors' conclusions Topiramate is without evidence of efficacy in diabetic neuropathic pain, the only neuropathic condition in which it has been adequately tested. The data we have includes the likelihood of major bias due to LOCF imputation, where adverse event withdrawals are much higher with active treatment than placebo control. Despite the strong potential for bias, no difference in efficacy between topiramate and placebo was apparent. Plain language summary Topiramate for treating neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (for example from a fall, a cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in treating neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our knowledge about fibromyalgia is even less advanced, but fibromyalgia can respond to the same medicines as neuropathic pain. Topiramate is a medicine used to treat epilepsy, and so it might be a useful medicine for neuropathic pain or fibromyalgia. On 8 May 2013, we performed searches to look for clinical trials on the use of topiramate to treat neuropathic pain or fibromyalgia. We found four studies of reasonable quality that tested topiramate against placebo for a number of weeks. Almost all of the 1684 people in the studies had painful limbs because of damaged nerves caused by diabetes. Topiramate did not help the pain and was no different from placebo except in causing more side‐effects, which made many more people withdraw from the studies early. About 3 people in 10 withdrew because of side‐effects with topiramate compared with 1 in 10 with placebo. Topiramate has not been shown to work as a pain medicine in diabetic neuropathy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ, Derry, S, Lunn, MPT, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008314.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.784Z" }, { "id": "9e71ff36-2a29-421d-b64d-08a6c8c542e8", "pmid": "", "title": "Immunostimulants for preventing respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are a major cause of childhood morbidity and mortality. Immunostimulants (IS) may reduce the incidence of ARTIs. Objectives To determine the efficacy and safety of IS in preventing ARTIs in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 1, which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to February week 4, 2011), EMBASE (1990 to February 2011), Google Scholar (2009 to February 2011), Scopus (2009 to February 2011), PASCAL (1990 to February 2010), SciSearch (1990 to February 2010) and IPA (1990 to February 2010). Selection criteria We included all comparative randomized controlled trials (RCTs) which enrolled participants less than 18 years of age. The intervention was IS medication, administered by any method, compared to placebo to prevent ARTIs. Data collection and analysis We analyzed the outcome on ARTIs both as the mean number of ARTIs by group and as a percent change in the rate of ARTIs. We undertook meta‐analyses using a random‐effects model and presented results as mean differences (MD) with 95% confidence intervals (CI). Two review authors independently assessed the search results and risk of bias, and extracted data. A funnel plot suggested there may be publication bias in the identified trials. Main results Thirty‐five placebo‐controlled trials (4060 participants) provided data in a form suitable for inclusion in the meta‐analyses. When compared with placebo, the use of IS was shown to reduce ARTIs measured as the total numbers of ARTIs (MD ‐1.24; 95% CI ‐1.54 to ‐0.94) and the difference in ARTI rates (MD ‐38.84%; 95% CI ‐46.37% to ‐31.31%). Trial quality was generally poor and a high level of statistical heterogeneity was evident. The subgroup analysis of bacterial IS, D53 and OM‐85 studies produced similar results, with lower heterogeneity. No difference in adverse events was evident between the placebo and IS groups. Authors' conclusions This review shows that IS reduce the incidence of ARTIs by 40% on average in susceptible children. Studies in healthy children are not available. Although the safety profile in the studies was good, some IS may be unsafe. ARTI‐susceptible children may benefit from IS treatment. Further high‐quality trials are needed and we encourage national health authorities to conduct large, multicentre, double‐blind, placebo‐controlled RCTs on the role of IS in preventing ARTIs in children. Plain language summary Immunostimulants to prevent acute respiratory tract infections in children Acute respiratory tract infections (ARTIs) are responsible for 19% of all deaths in children younger than five years of age, mainly in low‐income countries in Africa, Asia and Latin America. In high‐income countries ARTIs are among the most frequent illnesses, leading to 20% of medical consultations, 30% of days lost from work and 75% of antibiotic prescriptions. In the USA the total cost of non‐influenza‐related viral ARTIs is around $40 billion annually, while the corresponding cost for influenza is US $87.1 billion. The main signs and symptoms of ARTIs include sneezing, runny nose, sore throat, cough and malaise. Children living in rural communities, not attending daycare centres, suffer about seven ARTI episodes in the first year of life; eight ARTIs per year from the ages of one to four; six per year aged five to nine; and five per year aged 10 to 19. Children exposed to risks factors, such as attendance at daycare centres, overcrowding, contact with older siblings, smoking at home and lack of breast feeding, may suffer more ARTIs. Several treatments have been used to reduce the incidence of ARTIs (vitamin A, vitamin C, zinc, antibiotics). Among them are immunostimulants (herbal extracts, bacterial extracts, synthetic compounds), which aim to increase the immune defences of the respiratory tract. We searched for clinical trials of immunostimulants to prevent ARTIs in children compared to placebo. Our review includes 35 studies with 4060 participants. However, the quality of many of the studies was poor and the results were very diverse. By combining results, immunostimulants reduced 1.24 ARTIs in a six‐month period, equivalent to a 39% reduction in ARTIs compared to the placebo group. Only 20 studies provided adequate data on adverse events: the most frequent were rash, nausea, vomiting, abdominal pain and diarrhea. The main limitations of this review were the poor methodological quality and diverse trial results. We conclude that ARTI‐susceptible children may benefit from immunostimulants, but more high‐quality studies are needed. We suggest that national health authorities conduct high‐quality randomized controlled trials to assess the true effects of immunostimulant preparations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Del‐Rio‐Navarro, BE; Espinosa‐Rosales, FJ; Flenady, V; Sienra‐Monge, JJL", "articleTypes": [], "doi": "10.1002/14651858.CD004974.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "9e8c6b89-f022-4260-81ef-e5bda5efee81", "pmid": "", "title": "Modifying the consistency of food and fluids for swallowing difficulties in dementia", "imported": false, "abstract": "Abstract - Background People with dementia can have feeding and swallowing difficulties (dysphagia). Modification of the consistency of food or fluids, or both, is a common management strategy. However, diet modification can affect quality of life and may lead to dehydration and malnutrition. Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia. Objectives To determine the effectiveness and adverse effects associated with modifying the consistency of food and fluids in improving oral intake and eliminating aspiration in adults with dysphagia and dementia. Search methods We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE via Ovid SP, Embase via Ovid SP, PsycINFO via Ovid SP, CINAHL via EBSCOhost, LILACS via BIREME, ClinicalTrials.gov and the World Health Organization (WHO) Portal on 9 May 2018. We also checked the reference lists of relevant articles to identify any additional studies. Selection criteria We included randomised controlled trials (RCTs), quasi‐RCTs and cluster‐RCTs published in any language that measured any of the outcomes of interest. We included trials with adults with a clinical diagnosis of dementia with symptoms and signs of dysphagia confirmed on instrumental assessment. We included participants with all types, stages and severities of dementia. Control groups received either no intervention or interventions not involving diet modification or modification to sensory properties of food. Data collection and analysis Two review authors independently assessed for inclusion all potential studies identified. Data were extracted independently along with assessment of methodological quality using standard Cochrane methods. We contacted study authors for additional unpublished information. Main results No trials on modification of food met the inclusion criteria. We included two studies that examined modification to fluids. Both were part of the same large multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. Participation in the second trial was determined by results from the first trial. With unpublished data supplied by study authors, we examined data from participants with dementia only. The first study, a cross‐over trial, investigated the immediate effects on aspiration of two viscosities of liquids (nectar thick and honey thick) compared to regular liquids in 351 participants with dementia using videofluoroscopy. Regular liquids with a chin down head posture, as well as regular liquids without any intervention were also compared. The sequence of interventions during videofluoroscopy may have influenced response to intervention. The second study, a parallel designed RCT, compared the effect of nectar and honey thick liquids with a chin down head posture over a three‐month period in a subgroup of 260 participants with dementia. Outcomes were pneumonia and adverse intervention effects. Honey thick liquids, which are more consistent with descriptors for 'spoon thick' or 'extremely thick' liquids, showed a more positive impact on immediate elimination of aspiration during videofluoroscopy, but this consistency showed more adverse effects in the second follow‐up study. During the second three‐month follow‐up trial, there were a greater number of incidents of pneumonia in participants receiving honey thick liquids than those receiving nectar thick liquids or taking regular liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of fluids prescribed. Neither trial addressed quality of life. Risk of bias for both studies is high. The overall quality of evidence for outcomes in this review is low. Authors' conclusions We are uncertain about the immediate and long‐term effects of modifying the consistency of fluid for swallowing difficulties in dementia as too few studies have been completed. There may be differences in outcomes depending on the grade of thickness of fluids and the sequence of interventions trialled in videofluoroscopy for people with dementia. Clinicians should be aware that while thickening fluids may have an immediate positive effect on swallowing, the long‐term impact of thickened fluids on the health of the person with dementia should be considered. Further high‐quality clinical trials are required. Plain language summary Modifying the consistency of food and fluids for swallowing difficulties in dementia Background Individuals with dementia often present with swallowing difficulties (dysphagia). The consequences can include choking, dehydration, malnutrition, weight loss, pneumonia and death. Modification of food and liquid is a popular management strategy. It is believed that increasing the viscosity of liquids or altering the consistency of food allows individuals a better opportunity to swallow, with a reduced risk of choking or liquids entering the airway. However, there is growing evidence suggesting that this strategy can lead to dehydration, malnutrition, negative psychological/social consequences, and can affect quality of life for the person with dementia. Review question We wished to find out if changing the viscosity or consistency of food or fluids, or both, makes swallowing safer and has positive outcomes for people with dementia in terms of respiratory status, nutritional status and quality of life. We wanted to examine if modifying food or fluids, or both, also had any adverse effects for the person with dementia. Study characteristics We found two studies, which were both part of the same multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. We included data on people with dementia only. The first of the two studies looked at the immediate effects of two viscosities of liquids compared to regular thin liquids on aspiration (entry of food or fluid into the lungs) in 351 people with dementia. This study also compared drinking regular thin liquids using a chin down head posture as well as drinking regular thin liquids without any changes to head position; the main outcome was fluid entering the lungs. Using a subgroup of 260 people with dementia from the first study, the second study compared the effect of the same liquid viscosities with a chin down head posture. The effectiveness of these interventions on the incidence of pneumonia and adverse effects of these interventions was examined over a three‐month period. Study results Honey thick viscosity liquids, which clinically are similar to descriptions of 'very thick liquids', had a more positive immediate impact on preventing fluid entering the lungs when examined during videofluoroscopy (specialised swallow x‐ray) examination. However, during the three‐month follow‐up period there were a greater number of incidents of pneumonia in the group of people with dementia receiving these honey thick liquids, than those receiving nectar thick liquids and those receiving regular thin liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of liquids that the person with dementia was receiving. Conclusion There were a number of methodological flaws in both studies in this review and these were acknowledged by the authors. While thickening fluids may have an immediate positive effect on swallow function, clinicians should consider the effects of this intervention on the person with dementia in the longer‐term. People with dementia on thickened fluids require long‐term follow‐up. The overall risk of bias of included studies is high. The quality of evidence is low. Further well‐designed research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Flynn, E; Smith, CH; Walsh, CD; Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD011077.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "9eb76791-603c-4902-a6ed-db48b7ae0784", "pmid": "", "title": "Supplementation with multiple micronutrients for breastfeeding women for improving outcomes for the mother and baby", "imported": false, "abstract": "Abstract - Background Globally, more than two billion people are estimated to be deficient in key vitamins and minerals, particularly iodine, iron and zinc. The majority of these people live in low‐income settings and are typically deficient in more than one micronutrient. However, micronutrient deficiency among breastfeeding mothers and their infants also remains an issue in high‐income settings, specifically among women who avoid meat and/or milk, women who may lack sufficient supplies of vitamin B12 and vitamin D, and/or women who are iron‐deficient. Young children, pregnant and lactating women are particularly vulnerable to micronutrient deficiencies. They not only have a relatively greater need for vitamins and minerals because of their physiological state, but are also more susceptible to the harmful consequences of deficiencies. Multiple‐micronutrient supplementation might be an option to solve these problems. Objectives The objective of this review was to evaluate the effects of multiple‐micronutrient supplementation in breastfeeding mothers on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. Selection criteria Randomised controlled trials of multiple‐micronutrient supplementation of three or more micronutrients versus placebo, no supplementation or supplementation with two or fewer micronutrients, irrespective of dosage of micronutrients, in breastfeeding mothers. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We found no studies that compared multiple‐micronutrient supplementation (with three or more micronutrients) versus supplementation with two or fewer micronutrients. Two small studies (involving a total of 52 women) were included. One study compared multiple micronutrients with placebo and the other study compared multiple micronutrients with a group who received no supplementation. The studies were carried out in Brazil (36 adolescent mothers) and the USA (16 women) and included women with a low socioeconomic status. A lack of information in the study reports meant that risk of bias could not be adequately assessed (unclear risk of bias for many domains). There were no quantitative data for any of this review's outcomes so meta‐analysis was not possible. Neither of the studies reported on the primary outcomes of interest in this review: maternal morbidity (febrile illness, respiratory tract infection, diarrhoea) , adverse effects of micronutrients within three days of receiving the supplement , infant mortality (defined as a child dying before completing the first year of age) . One study reported qualitatively on maternal anaemia (a secondary outcome of this review) ‐ the study found that multiple‐micronutrient supplementation was effective for recuperating from anaemia but there were no data for inclusion in our analyses. Maternal satisfaction was not reported in the included studies. Similarly, none of this review's infant secondary outcomes were reported in the included studies: clinical micronutrient deficiency ; morbidity episodes (febrile illness, respiratory tract infection, diarrhoea, other) , adverse effects of micronutrients within three days of receiving the supplement . Authors' conclusions We found no evidence to quantitatively assess the effectiveness of multiple‐micronutrient supplementation in improving health outcomes in mother and baby. The results of this review are limited by the small numbers of studies available, small sample sizes and the studies not reporting on the outcomes of interest in this review. There is no evidence to evaluate potential adverse effects of multiple‐micronutrient supplements, particularly excess dosages. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Further research should focus on whether multiple‐micronutrient supplementation during lactation compared with none, a placebo or supplementation with fewer than two micronutrients is beneficial to maternal and infant health outcomes. Future studies should collect data on outcomes beyond micronutrient concentrations, for example: maternal and infant morbidity, adverse effects, maternal satisfaction, the risks of excess supplementation, and potential adverse interactions between the micronutrients and the other outcomes. This would help to bridge the gap between research on intermediary outcomes and health outcomes in order to develop sound policy in this field. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these affect maternal and infant health outcomes. Larger studies with longer follow‐up would improve the quality of studies and provide stronger evidence. In most of the included studies, bias could not be adequately assessed due to lack of information, therefore attention should be given to adequate methods of randomisation and allocation concealment, adequate methods of blinding of the participants, providers and the outcome assessors to improve the methodological quality of studies in this field. Plain language summary Multiple micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby The benefits and risks of multiple‐micronutrient supplementation during lactation are not clear from randomised controlled studies. Key vitamins and minerals, particularly iodine, iron and zinc, are required in small amounts to ensure normal body metabolism, physical growth and development. Nutrient deficiency affects nearly one third of the world’s population, especially in low‐ and middle‐income countries. Breastfeeding mothers need higher levels than usual in order to provide sufficient vitamins and minerals for their own health and that of their babies, particularly for normal functioning and the growth and development of the baby. Previous studies have assessed supplementation of individual micronutrients. This review looked at the use of multiple‐micronutrient supplements for breastfeeding women for improving outcomes for the mother and her baby. We searched for studies on 30 September 2015 and identified two small studies (involving 52 women) for inclusion in this review. The studies were carried out in Brazil and the USA and included women who had a low socioeconomic status. The studies were poorly reported and this lack of information made it difficult to determine whether the studies were at risk of bias. Neither of the studies provided data for any of this review's important outcomes: maternal illness (fever, respiratory infection, diarrhoea), adverse effects of micronutrients within three days of taking them, infant death (defined as a child dying before reaching one year of age). Similarly, there were no data for any of the other outcomes that we were interested in. For the mother, these outcomes were maternal anaemia, and women's satisfaction. For the baby, these outcomes were micronutrient deficiency; illness episodes (fever, respiratory infection, diarrhoea, other), adverse effects of micronutrients within three days of the woman receiving the supplement. However, one of the included studies reported that multiple‐micronutrient supplementation was effective for lactating women recuperating from anaemia. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Larger studies with longer‐term follow‐up would improve the quality of studies and provide stronger evidence. Further research should focus on whether multiple‐micronutrient supplementation during lactation (compared with no supplementation, a placebo or supplementation with fewer than two micronutrients) is beneficial to the mother and her baby and any associated adverse effects of the intervention. Futher studies should report on important outcomes such as those listed in this review and consider the risks of excess supplementation. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these effect outcomes for the mother and her baby.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Abe, SK, Balogun, OO, Ota, E, Takahashi, K, Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD010647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.783Z" }, { "id": "9ed0fa69-e9ed-4112-ac99-6e678fa63e4a", "pmid": "", "title": "Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years", "imported": false, "abstract": "Abstract - Background Extensive evidence exists showing analgesic effects of sweet solutions for newborns and infants. It is less certain if the same analgesic effects exist for children one year to 16 years of age. This is an updated version of the original Cochrane review published in Issue 10, 2011 (Harrison 2011) titled Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. Objectives To determine the efficacy of sweet tasting solutions or substances for reducing needle‐related procedural pain in children beyond one year of age. Search methods Searches were run to the end of June 2014. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, the NHS Economic Evaluation Database, MEDLINE, EMBASE, PsycINFO, and ACP Journal Club (all via OvidSP), and CINAH (via EBSCOhost). We applied no language restrictions. Selection criteria Published or unpublished randomised controlled trials (RCT) in which children aged one year to 16 years, received a sweet tasting solution or substance for needle‐related procedural pain. Control conditions included water, non‐sweet tasting substances, pacifier, distraction, positioning/containment, breastfeeding, or no treatment. Data collection and analysis Outcome measures included crying duration, composite pain scores, physiological or behavioral pain indicators, self‐report of pain or parental or healthcare professional‐report of the child's pain. We reported mean differences (MD), weighted mean difference (WMD), or standardized mean difference (SMD) with 95% confidence intervals (CI) using fixed‐effect or random‐effects models as appropriate for continuous outcome measures. We reported risk ratio (RR), risk difference (RD), and the number needed to treat to benefit (NNTB) for dichotomous outcomes. We used the I 2 statistic to assess between‐study heterogeneity. Main results We included one unpublished and seven published studies (total of 808 participants); four more studies and 478 more participants than the 2011 review. Six trials included young children aged one to four years receiving sucrose or candy lollypops for immunisation pain compared with water or no treatment. Usual care included topical anaesthetics, upright parental holding, and distraction. All studies were well designed blinded RCTs, however, five of the six studies had a high risk of bias based on small sample sizes. Two studies included school‐aged children receiving sweet or unsweetened chewing gum before, or before and during, immunisation and blood collection. Both studies, conducted by the same author, had a high risk of bias based on small sample sizes. Results for the toddlers/pre‐school children were conflicting. Duration of cry, using a random‐effects model, was not significantly reduced by sweet taste (six trials, 520 children, WMD ‐15 seconds, 95% CI ‐54 to 24, I 2 = 94%). Composite pain score at time of first needle was reported in four studies (n = 121 children). The scores were not significantly different between the sucrose and control group (SMD ‐0.26, 95% CI ‐1.27 to 0.75, I 2 = 86%). A Children's Hospital of Eastern Ontario Pain Scale score > 4 was significantly less common in the sucrose group compared to the control group in one study (n = 472, RR 0.55, 95% CI 0.45 to 0.67; RD ‐0.29, 95% CI ‐0.37 to ‐0.20; NNTB 3, 95% CI 3 to 5; tests for heterogeneity not applicable. For school‐aged children, chewing sweet gum before needle‐related painful procedures (two studies, n = 111 children) or during the procedures (two studies, n = 103 children) did not significantly reduce pain scores. A comparison of the Faces Pain Scale scores in children chewing sweet gum before the procedures compared with scores of children chewing unsweetened gum revealed a WMD of ‐0.15 (95% CI ‐0.61 to 0.30). Similar results were found when comparing the chewing of sweet gum with unsweetened gum during the procedure (WMD 0.23, 95% CI ‐0.28 to 0.74). The Colored Analogue Scale for children chewing sweet gum compared to unsweetened gum before the procedure was not significantly different (WMD 0.24 (‐0.69 to 1.18)) nor was it different when children chewed the gum during the procedure (WMD 0.86 (95% CI ‐0.12 to 1.83)). There was no heterogeneity for any of these analyses in school‐aged children (I 2 = 0%). Authors' conclusions Based on the eight studies included in this systematic review update, two of which were subgroups of small numbers of eligible toddlers from larger studies, and three of which were pilot RCTs with small numbers of participants, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children between one and four years of age. Further rigorously conducted, adequately powered RCTs are warranted in this population. Based on the two studies by the same author, there was no evidence of analgesic effects of sweet taste in school‐aged children. As there are other effective evidence‐based strategies available to use in this age group, further trials are not warranted. Despite the addition of four studies in this review, conclusions have not changed since the last version of the review. Plain language summary Sweet taste to ease injection needle pain in children aged one to 16 years This is an updated version of the original Cochrane review published in Issue 10, 2011: Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. We re‐ran the search in October 2014. Review question: Do sweet tasting solutions reduce pain during needles in children aged from one to 16 years, compared to no treatment, water, other non‐sweet solutions, or other interventions such as non‐nutritive sucking (babies) or sweet foods or chewing gum (children), topical anaesthetics, music, and distraction? Background: Small amounts of sweet tasting sugar solutions given orally to babies before and during painful needles significantly reduces distress. However it was not known if the same pain‐reducing effects of sweet solutions occurred in children older than one year of age. We therefore examined studies looking at pain‐reducing effects of sweet solutions such as sucrose or glucose for painful needle procedures in children aged one to 16 years. Search date: We searched the literature for published and unpublished studies up to October 2014. Study characteristics : We found six studies focused on young children aged one to four years; two of these studies were included in the original review and four were new studies. The two studies included in the original review used a low concentration of sucrose, just 12%, which is not considered sweet enough for the pain reducing effects. Three of the four new studies were small pilot studies, conducted to inform full trials, and only one study of sweet solutions in young children included large numbers of children. When we compared results of all six studies, only two showed that sugar water (sucrose) reduced pain during injections. However, the four studies that showed no effect all included small numbers of children, therefore they were not considered large enough to detect significant differences in pain. Further well conducted trials with large enough numbers of young children are needed to work out if sweet taste effectively reduces their pain and distress during needles. For older school‐aged children, there were two studies published by the same author, both of which were included in the original review. Neither study showed that sweet taste helped to reduce pain. As other studies show that strategies such as distraction and topical anaesthetics can effectively reduce needle pain in school‐aged children, further studies of sweet taste for pain management in school‐aged children are not warranted. Study funding sources : Of the six studies including young children, two did not acknowledge receipt of research funding. For the remaining four: a state‐wide nursing fund supported two of the pilot studies, an internal research institute provided support for the remaining pilot study and another study was supported in part by a Maternal and Child Health grant. The two studies including school‐aged children, conducted by the same author, were supported by a grant from the Canadian Institutes of Health Research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Harrison, D; Yamada, J; Adams‐Webber, T; Ohlsson, A; Beyene, J; Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD008408.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "9ed9c209-fb20-4fc7-b314-24ceefcdffb8", "pmid": "", "title": "Potentiators (specific therapies for class III and IV mutations) for cystic fibrosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Skilton, M, Krishan, A, Patel, S, Sinha, IP, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD009841.pub3 AB - Abstract - Background Cystic fibrosis (CF) is the commonest inherited life‐shortening illness in white populations, caused by a mutation in the gene that codes for the cystic fibrosis transmembrane regulator protein (CFTR), which functions as a salt transporter. This mutation mainly affects the airways where excess salt absorption dehydrates the airway lining leading to impaired mucociliary clearance. Consequently, thick, sticky mucus accumulates making the airway prone to chronic infection and progressive inflammation; respiratory failure often ensues. Other complications include malnutrition, diabetes and subfertility. Increased understanding of the condition has allowed pharmaceutical companies to design mutation‐specific therapies targeting the underlying molecular defect. CFTR potentiators target mutation classes III and IV and aim to normalise airway surface liquid and mucociliary clearance, which in turn impacts on the chronic infection and inflammation. This is an update of a previously published review. Objectives To evaluate the effects of CFTR potentiators on clinically important outcomes in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles, reviews and online clinical trial registries. Last search: 21 November 2018. Selection criteria Randomised controlled trials (RCTs) of parallel design comparing CFTR potentiators to placebo in people with CF. A separate review examines trials combining CFTR potentiators with other mutation‐specific therapies. Data collection and analysis The authors independently extracted data, assessed the risk of bias in included trials and used GRADE to assess evidence quality. Trial authors were contacted for additional data. Main results We included five RCTs (447 participants with different mutations) lasting from 28 days to 48 weeks, all assessing the CFTR potentiator ivacaftor. The quality of the evidence was moderate to low, mainly due to risk of bias (incomplete outcome data and selective reporting) and imprecision of results, particularly where few individuals experienced adverse events. Trial design was generally well‐documented. All trials were industry‐sponsored and supported by other non‐pharmaceutical funding bodies. F508del (class II) (140 participants) One 16‐week trial reported no deaths, or changes in quality of life (QoL) or lung function (either relative or absolute change in forced expiratory volume in one second (FEV1) (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in ivacaftor and placebo groups, but there was no difference between groups (low‐quality evidence); there was also no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. There was also no difference in weight. Sweat chloride concentration decreased, mean difference (MD) ‐2.90 mmol/L (95% confidence interval (CI) ‐5.60 to ‐0.20). G551D (class III) (238 participants) The 28‐day phase 2 trial (19 participants) and two 48‐week phase 3 trials (adult trial (167 adults), paediatric trial (52 children)) reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor in the adult trial at 24 weeks, MD 8.10 (95% CI 4.77 to 11.43) and 48 weeks, MD 8.60 (95% CI 5.27 to 11.93 (moderate‐quality evidence). The adult trial reported a higher relative change in FEV1 with ivacaftor at 24 weeks, MD 16.90% (95% CI 13.60 to 20.20) and 48 weeks, MD 16.80% (95% CI 13.50 to 20.10); the paediatric trial reported this at 24 weeks, MD 17.4% (P < 0.0001)) (moderate‐quality evidence). These trials demonstrated absolute improvements in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32). The phase 3 trials reported increased cough, odds ratio (OR) 0.57 (95% CI 0.33 to 1.00) and episodes of decreased pulmonary function, OR 0.29 (95% CI 0.10 to 0.82) in the placebo group; ivacaftor led to increased dizziness in adults, OR 10.55 (95% CI 1.32 to 84.47). There was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Fewer participants taking ivacaftor developed serious pulmonary exacerbations; adults taking ivacaftor developed fewer exacerbations (serious or not), OR 0.54 (95% CI 0.29 to 1.01). A higher proportion of participants were exacerbation‐free at 24 weeks with ivacaftor (moderate‐quality evidence). Ivacaftor led to a greater absolute change from baseline in FEV1 (% predicted) at 24 weeks, MD 10.80% (95% CI 8.91 to 12.69) and 48 weeks, MD 10.44% (95% CI 8.56 to 12.32); weight also increased at 24 weeks, MD 2.37 kg (95% CI 1.68 to 3.06) and 48 weeks, MD 2.75 kg (95% CI 1.74 to 3.75). Sweat chloride concentration decreased at 24 weeks, MD ‐48.98 mmol/L (95% CI ‐52.07 to ‐45.89) and 48 weeks, MD ‐49.03 mmol/L (95% CI ‐52.11 to ‐45.94). R117H (class IV) (69 participants) One 24‐week trial reported no deaths. QoL scores (respiratory domain) were higher with ivacaftor at 24 weeks, MD 8.40 (95% CI 2.17 to 14.63), but no relative changes in lung function were reported (moderate‐quality evidence). Pulmonary exacerbations and cough were the most reported adverse events in both groups, but there was no difference between groups; there was no difference between groups in participants interrupting or discontinuing treatment (low‐quality evidence). Number of days until the first exacerbation was not reported, but there was no difference between groups in how many participants developed pulmonary exacerbations. No changes in absolute change in FEV1 or weight were reported. Sweat chloride concentration decreased, MD ‐24.00 mmol/L (CI 95% ‐24.69 to ‐23.31). Authors' conclusions There is no evidence supporting the use of ivacaftor in people with the F508del mutation. Both G551D phase 3 trials demonstrated a clinically relevant impact of ivacaftor on outcomes at 24 and 48 weeks in adults and children (over six years of age) with CF. The R117H trial demonstrated an improvement in the respiratory QoL score, but no improvement in respiratory function. As new mutation‐specific therapies emerge, it is important that trials examine outcomes relevant to people with CF and their families and that adverse events are reported robustly and consistently. Post‐market surveillance is essential and ongoing health economic evaluations are required. Plain language summary Ivacaftor (marketed as Kalydeco®), a new specific therapy for cystic fibrosis Review question How does ivacaftor affect clinical outcomes (survival, quality of life and lung function) in people with cystic fibrosis (CF)? Background In people with CF, airway surfaces do not have enough water because of an abnormal protein; this makes it difficult to clear thick and sticky mucus, which leads to lung infections. Ivacaftor works on the abnormal protein in people with some mutations to allow the airways retain more water and better clear mucus, so fewer lung infections develop. Ivacaftor was aimed at people with class III and IV mutations, and has been studied in people with G551D (class III), R117H (class IV) and F508del (class II) mutations. Trial characteristics We included five trials (447 participants) comparing ivacaftor to placebo (dummy treatment with no active medication) lasting between four and 48 weeks. Three trials enrolled a total of 238 people with at least one copy of the G551D mutation, one trial enrolled 140 people with two copies of the F508del mutation and one enrolled 69 people with at least one copy of the R117H mutation. The evidence is up to date as of 21 November 2018. Key results F508del mutation The trial did not report any deaths or show improvements in lung function, quality of life scores or weight. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. Sweat chloride concentrations were reduced with ivacaftor. G551D mutation No deaths were reported. Both children and adults taking ivacaftor showed improvements in lung function, but only adults reported higher quality of life scores. People given placebo reported more coughing and experienced more episodes of decreased lung function; more adults taking ivacaftor reported episodes of dizziness. Similar numbers of people taking ivacaftor and placebo delayed the course of medication, or withdrew from the trial altogether, due to side effects (e.g. psychological issues, liver disease, severe breathing problems). There were more serious pulmonary exacerbations whilst taking placebo compared to ivacaftor. Adults taking ivacaftor were admitted to hospital less often and had fewer courses of intravenous antibiotics for exacerbations. Both children and adults and children increased their weight with ivacaftor. There was a drop in sweat chloride concentrations with ivacaftor. R117H mutation No deaths occurred in this trial. While quality of life scores improved with ivacaftor, lung function did not. Cough and pulmonary exacerbations (flare ups of lung disease) were the most reported adverse events when taking both ivacaftor and placebo; there were a similar number of flare ups for both groups. There was no difference in weight; but as for other mutations there was a reduction in sweat chloride concentration with ivacaftor.
 
 Evidence suggests that ivacaftor is an effective treatment for people (over six years of age) with cystic fibrosis and the G551D mutation, but not for those with the F508del or R117H mutations. Quality of the evidence In most trials, individuals were put into different treatment groups at random with equal chances of being given either placebo or ivacaftor; no one could work out which treatment the next person would receive, so that healthier people did not receive ivacaftor and make the results seem better. We were not sure whether anyone involved in the trial knew who was receiving which treatment and how this might affect results. No trials reported all results clearly; sometimes they did not report them in a way that we could use in the review and sometimes they did not report the data at all. This affected our certainty regarding the overall results. Information about some side effects was limited as not many people experienced them, therefore, it is difficult to judge whether there was a difference between treatment groups We judged the evidence in this review to be moderate to low quality. Trial funding sources All trials were sponsored by Vertex Pharmaceuticals Incorporated. The National Institute of Health (NIH), the Cystic Fibrosis Foundation (CFF) and other non‐pharmaceutical funding bodies also supported the trials.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.787Z" }, { "id": "9ee40fdb-2c04-4a56-a423-e79f375ca7c1", "pmid": "", "title": "Ghrelin for the management of cachexia associated with cancer", "imported": false, "abstract": "Abstract - Background Cancer sufferers are amongst the most malnourished of all the patient groups. Studies have shown that ghrelin, a gut hormone can be a potential therapeutic agent for cachexia (wasting syndrome) associated with cancer. A variety of mechanisms of action of ghrelin in people with cancer cachexia have been proposed. However, safety and efficacy of ghrelin for cancer‐associated cachexia have not been systematically reviewed. The aim of this review was to assess whether ghrelin is associated with better food intake, body composition and survival than other options for adults with cancer cachexia. Objectives To assess the efficacy and safety of ghrelin in improving food intake, body composition and survival in people with cachexia associated with cancer. Search methods We searched CENTRAL, MEDLINE and Embase without language restrictions up to July 2017. We also searched for ongoing studies in trials registers, performed handsearching, checked bibliographic references of relevant articles and contacted authors and experts in the field to seek potentially relevant research. We applied no restrictions on language, date, or publication status. Selection criteria We included randomised controlled (parallel‐group or cross‐over) trials comparing ghrelin (any formulation or route of administration) with placebo or an active comparator in adults (aged 18 years and over) who met any of the international criteria for cancer cachexia. Data collection and analysis Two review authors independently assessed studies for eligibility. Two review authors then extracted data and assessed the risk of bias for individual studies using standard Cochrane methodology. For dichotomous variables, we planned to calculate risk ratio with 95% confidence intervals (CI) and for continuous data, we planned to calculate mean differences (MD) with 95% CI. We assessed the evidence using GRADE and created 'Summary of findings' tables. Main results We screened 926 individual references and identified three studies that satisfied the inclusion criteria. Fifty‐nine participants (37 men and 22 women) aged between 54 and 78 years were randomised initially, 47 participants completed the treatment. One study had a parallel design and two had a cross‐over design. The studies included people with a variety of cancers and also differed in the dosage, route of administration, frequency and duration of treatment. One trial, which compared ghrelin with placebo, found that ghrelin improved food intake (very low‐quality evidence) and had no adverse events (very low‐quality evidence). Due to unavailability of data we were unable to report on comparisons for ghrelin versus no treatment or alternative experimental treatment modalities, or ghrelin in combination with other treatments or ghrelin analogues/ghrelin mimetics/ghrelin potentiators. Two studies compared a higher dose of ghrelin with a lower dose of ghrelin, however due to differences in study designs and great diversity in the treatment provided we did not pool the results. In both trials, food intake did not differ between participants on higher‐dose and lower‐dose ghrelin. None of the included studies assessed data on body weight. One study reported higher adverse events with a higher dose as compared to a lower dose of ghrelin. All studies were at high risk of attrition bias and bias for size of the study. Risk of bias in other domains was unclear or low. We rated the overall quality of the evidence for primary outcomes (food intake, body weight, adverse events) as very low. We downgraded the quality of the evidence due to lack of data, high or unclear risk of bias of the studies and small study size. Authors' conclusions There is insufficient evidence to be able to support or refute the use of ghrelin in people with cancer cachexia. Adequately powered randomised controlled trials focusing on evaluation of safety and efficacy of ghrelin in people with cancer cachexia is warranted. Plain language summary Ghrelin, a hunger hormone for management of cancer patients with loss of appetite and weight loss Bottom line There is no good evidence to support or reject the suggestion that ghrelin is useful in the management of cancer patients with loss of appetite and weight loss. There is insufficient evidence to recommend it for clinical practice. Background Sixty to eighty percent of cancer patients suffer from loss of appetite and weight loss, which in turn is associated with decreased life expectancy and quality of life. Ghrelin, a hunger hormone is secreted by the stomach and other organs of the body. Studies have shown that ghrelin can be used in treatment for loss of appetite and weight loss in cancer patients. However, the effectiveness and safety of ghrelin in such people have not been assessed. In this review we set out to examine all evidence on the effectiveness and safety of ghrelin in improving appetite and body weight in cancer patients with loss of appetite and weight loss. Search date The evidence is current to 20th July 2017. Study characteristics We found three studies that recruited a total of 59 cancer patients (37 men and 22 women) aged between 54 and 78 years. Forty‐seven cancer patients completed the treatment. Studies differed in study design and included people with a variety of cancers. Studies also differed in dosage, route of injection, frequency and duration of treatment. One study compared ghrelin with a placebo while two studies compared different doses of ghrelin (higher dose with lower dose). Outcomes of interest to cancer patients with loss of appetite and weight loss, such as improvement in food intake and improvement in body weight, were not adequately reported. All three included studies were funded by government agencies. One study received an additional grant from a pharmaceutical company. Key findings We found insufficient evidence that using ghrelin demonstrated differences in food intake. We found no evidence that using ghrelin alone or in combination made any difference to body weight. We could not reach any conclusions about its side effects. The limited amount of information means that we could not draw any conclusions. Quality of the evidence We rated the quality of evidence from studies using four levels: high, moderate, low, or very low. High‐quality evidence means that we are very confident in the results. Very low‐quality evidence means that we are very uncertain about the results. The evidence in this review was of very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Khatib, MN; Shankar, AH; Kirubakaran, R; Gaidhane, A; Gaidhane, S; Simkhada, P; Quazi Syed, Z", "articleTypes": [], "doi": "10.1002/14651858.CD012229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "9ee5d764-9a01-4e20-923c-afb459ee7a5c", "pmid": "", "title": "Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID‐19", "imported": false, "abstract": "Abstract - Background COVID‐19 illness is highly variable, ranging from infection with no symptoms through to pneumonia and life‐threatening consequences. Symptoms such as fever, cough, or loss of sense of smell (anosmia) or taste (ageusia), can help flag early on if the disease is present. Such information could be used either to rule out COVID‐19 disease, or to identify people who need to go for COVID‐19 diagnostic tests. This is the second update of this review, which was first published in 2020. Objectives To assess the diagnostic accuracy of signs and symptoms to determine if a person presenting in primary care or to hospital outpatient settings, such as the emergency department or dedicated COVID‐19 clinics, has COVID‐19. Search methods We undertook electronic searches up to 10 June 2021 in the University of Bern living search database. In addition, we checked repositories of COVID‐19 publications. We used artificial intelligence text analysis to conduct an initial classification of documents. We did not apply any language restrictions. Selection criteria Studies were eligible if they included people with clinically suspected COVID‐19, or recruited known cases with COVID‐19 and also controls without COVID‐19 from a single‐gate cohort. Studies were eligible when they recruited people presenting to primary care or hospital outpatient settings. Studies that included people who contracted SARS‐CoV‐2 infection while admitted to hospital were not eligible. The minimum eligible sample size of studies was 10 participants. All signs and symptoms were eligible for this review, including individual signs and symptoms or combinations. We accepted a range of reference standards. Data collection and analysis Pairs of review authors independently selected all studies, at both title and abstract, and full‐text stage. They resolved any disagreements by discussion with a third review author. Two review authors independently extracted data and assessed risk of bias using the QUADAS‐2 checklist, and resolved disagreements by discussion with a third review author. Analyses were restricted to prospective studies only. We presented sensitivity and specificity in paired forest plots, in receiver operating characteristic (ROC) space and in dumbbell plots. We estimated summary parameters using a bivariate random‐effects meta‐analysis whenever five or more primary prospective studies were available, and whenever heterogeneity across studies was deemed acceptable. Main results We identified 90 studies; for this update we focused on the results of 42 prospective studies with 52,608 participants. Prevalence of COVID‐19 disease varied from 3.7% to 60.6% with a median of 27.4%. Thirty‐five studies were set in emergency departments or outpatient test centres (46,878 participants), three in primary care settings (1230 participants), two in a mixed population of in‐ and outpatients in a paediatric hospital setting (493 participants), and two overlapping studies in nursing homes (4007 participants). The studies did not clearly distinguish mild COVID‐19 disease from COVID‐19 pneumonia, so we present the results for both conditions together. Twelve studies had a high risk of bias for selection of participants because they used a high level of preselection to decide whether reverse transcription polymerase chain reaction (RT‐PCR) testing was needed, or because they enrolled a non‐consecutive sample, or because they excluded individuals while they were part of the study base. We rated 36 of the 42 studies as high risk of bias for the index tests because there was little or no detail on how, by whom and when, the symptoms were measured. For most studies, eligibility for testing was dependent on the local case definition and testing criteria that were in effect at the time of the study, meaning most people who were included in studies had already been referred to health services based on the symptoms that we are evaluating in this review. The applicability of the results of this review iteration improved in comparison with the previous reviews. This version has more studies of people presenting to ambulatory settings, which is where the majority of assessments for COVID‐19 take place. Only three studies presented any data on children separately, and only one focused specifically on older adults. We found data on 96 symptoms or combinations of signs and symptoms. Evidence on individual signs as diagnostic tests was rarely reported, so this review reports mainly on the diagnostic value of symptoms. Results were highly variable across studies. Most had very low sensitivity and high specificity. RT‐PCR was the most often used reference standard (40/42 studies). Only cough (11 studies) had a summary sensitivity above 50% (62.4%, 95% CI 50.6% to 72.9%)); its specificity was low (45.4%, 95% CI 33.5% to 57.9%)). Presence of fever had a sensitivity of 37.6% (95% CI 23.4% to 54.3%) and a specificity of 75.2% (95% CI 56.3% to 87.8%). The summary positive likelihood ratio of cough was 1.14 (95% CI 1.04 to 1.25) and that of fever 1.52 (95% CI 1.10 to 2.10). Sore throat had a summary positive likelihood ratio of 0.814 (95% CI 0.714 to 0.929), which means that its presence increases the probability of having an infectious disease other than COVID‐19. Dyspnoea (12 studies) and fatigue (8 studies) had a sensitivity of 23.3% (95% CI 16.4% to 31.9%) and 40.2% (95% CI 19.4% to 65.1%) respectively. Their specificity was 75.7% (95% CI 65.2% to 83.9%) and 73.6% (95% CI 48.4% to 89.3%). The summary positive likelihood ratio of dyspnoea was 0.96 (95% CI 0.83 to 1.11) and that of fatigue 1.52 (95% CI 1.21 to 1.91), which means that the presence of fatigue slightly increases the probability of having COVID‐19. Anosmia alone (7 studies), ageusia alone (5 studies), and anosmia or ageusia (6 studies) had summary sensitivities below 50% but summary specificities over 90%. Anosmia had a summary sensitivity of 26.4% (95% CI 13.8% to 44.6%) and a specificity of 94.2% (95% CI 90.6% to 96.5%). Ageusia had a summary sensitivity of 23.2% (95% CI 10.6% to 43.3%) and a specificity of 92.6% (95% CI 83.1% to 97.0%). Anosmia or ageusia had a summary sensitivity of 39.2% (95% CI 26.5% to 53.6%) and a specificity of 92.1% (95% CI 84.5% to 96.2%). The summary positive likelihood ratios of anosmia alone and anosmia or ageusia were 4.55 (95% CI 3.46 to 5.97) and 4.99 (95% CI 3.22 to 7.75) respectively, which is just below our arbitrary definition of a 'red flag', that is, a positive likelihood ratio of at least 5. The summary positive likelihood ratio of ageusia alone was 3.14 (95% CI 1.79 to 5.51). Twenty‐four studies assessed combinations of different signs and symptoms, mostly combining olfactory symptoms. By combining symptoms with other information such as contact or travel history, age, gender, and a local recent case detection rate, some multivariable prediction scores reached a sensitivity as high as 90%. Authors' conclusions Most individual symptoms included in this review have poor diagnostic accuracy. Neither absence nor presence of symptoms are accurate enough to rule in or rule out the disease. The presence of anosmia or ageusia may be useful as a red flag for the presence of COVID‐19. The presence of cough also supports further testing. There is currently no evidence to support further testing with PCR in any individuals presenting only with upper respiratory symptoms such as sore throat, coryza or rhinorrhoea. Combinations of symptoms with other readily available information such as contact or travel history, or the local recent case detection rate may prove more useful and should be further investigated in an unselected population presenting to primary care or hospital outpatient settings. The diagnostic accuracy of symptoms for COVID‐19 is moderate to low and any testing strategy using symptoms as selection mechanism will result in both large numbers of missed cases and large numbers of people requiring testing. Which one of these is minimised, is determined by the goal of COVID‐19 testing strategies, that is, controlling the epidemic by isolating every possible case versus identifying those with clinically important disease so that they can be monitored or treated to optimise their prognosis. The former will require a testing strategy that uses very few symptoms as entry criterion for testing, the latter could focus on more specific symptoms such as fever and anosmia. Plain language summary How accurate are symptoms and medical examination to diagnose COVID‐19? Key messages ‐ The results suggest that a single symptom included in this review cannot accurately diagnose COVID‐19. ‐ Loss of sense of taste or smell could be a 'red flag' for the presence of COVID‐19. Cough or fever might be useful to identify people who might have COVID‐19. These symptoms might be useful to prompt further testing when they are present. ‐ We need more research to investigate combinations of symptoms and signs with other information such as recent contact or travel history, or vaccination status, and in children, and adults aged 65 years and over. What are symptoms or signs of COVID‐19? Symptoms are experienced by patients. COVID‐19 symptoms include cough, sore throat, high temperature, diarrhoea, headache, muscle or joint pain, fatigue, and loss of sense of smell and taste. Signs are measured by healthcare workers during clinical examination. They include lung sounds, blood pressure, blood oxygen level and heart rate. Symptoms and signs of COVID‐19 might be important to help people know whether they and the people they come into contact with should isolate at home, undergo testing with a rapid lateral flow test or PCR (laboratory‐based) test, or be hospitalised. What did we want to find out? Symptoms and signs of COVID‐19 are varied and may indicate other diseases, not just COVID‐19. We wanted to know how accurate diagnosis of COVID‐19 is, based on symptoms and signs from medical examination. We were interested in people with suspected COVID‐19, who go to their doctor, outpatient test centres or hospital. What did we do? We searched for studies that assessed the accuracy of symptoms and signs to diagnose COVID‐19. Studies had to be conducted in general practice, outpatient test centres or hospital outpatient settings only. We only included studies of people in hospital if signs and symptoms were recorded when they were admitted to the hospital, for example through the emergency department. What did we find? We focused on 42 studies with 52,608 participants in this review. The studies assessed 96 separate or combined symptoms and signs. Thirty‐five studies were conducted in emergency departments or outpatient COVID‐19 test centres (46,878 participants), 3 studies in general practice (1230 participants), 2 studies in children’s hospitals (493 in‐ and outpatients), and 2 studies in nursing homes (4007 participants). The studies were conducted in 18 different countries around the world. Twenty‐three studies were conducted in Europe, 8 in North‐America, 5 in Asia, and 3 in South‐America and 3 in Australia. We didn’t find any studies conducted in Africa. Three focused specifically on children, and only 1 focused on adults aged 65 years and over. Most studies did not clearly distinguish between mild and severe COVID‐19, so we present the results for mild, moderate and severe disease together. Few studies reported individual signs as diagnostic tests, so we focus mainly on the diagnostic value of symptoms. The most frequently reported symptoms were cough, fever, shortness of breath and sore throat. According to the studies in our review, in a group of 1000 people with suspected COVID‐19 of whom 270 (27%) would actually have COVID‐19, around 567 people would have a cough. Of these 567, 168 would actually have COVID‐19. Of the 433 who do not have a cough, 102 would have COVID‐19. In the same 1000 people, around 283 people would have a fever. Of these 283, 102 would actually have COVID‐19. Of the 717 people without fever, 168 would have COVID‐19. Someone who has lost their sense of smell or taste is five times more likely to have COVID‐19 than someone who hasn’t. Other symptoms, such as a sore throat or runny nose, are more likely to indicate the presence of an infectious disease other than COVID‐19. In the same 1000 people as described above, around 362 people would have a sore throat. Of these, only 84 would actually have COVID‐19. Of the 638 patients without sore throat, 186 would have COVID‐19. We found similar figures for having a runny nose. What are the limitations of the evidence? The results of this updated review are more reliable than those in previous versions as we included more high‐quality studies. However, the accuracy of individual symptoms varied across studies and the diagnostic value of symptoms such as fever, cough or other respiratory symptoms might still be overestimated, as most studies deliberately included participants because they had these symptoms. The results do not clearly differentiate between people with mild, moderate or severe COVID‐19. Only a few studies investigated the symptom‐based diagnosis of COVID‐19 in children or older adults. How up to date is this review? This review updates our previous review. The evidence is up to date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Struyf, T, Deeks, JJ, Dinnes, J, Takwoingi, Y, Davenport, C, Leeflang, MMG, Spijker, R, Hooft, L, Emperador, D, Domen, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013665.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.073Z" }, { "id": "9efdf029-448a-4204-a15e-e15a63850b48", "pmid": "", "title": "Topical benzoyl peroxide for acne", "imported": false, "abstract": "Abstract - Background Acne is a common, economically burdensome condition that can cause psychological harm and, potentially, scarring. Topical benzoyl peroxide (BPO) is a widely used acne treatment; however, its efficacy and safety have not been clearly evaluated. Objectives To assess the effects of BPO for acne. Search methods We searched the following databases up to February 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of relevant randomised controlled trials (RCTs) and systematic reviews. Selection criteria We included RCTs that compared topical BPO used alone (including different formulations and concentrations of BPO) or as part of combination treatment against placebo, no treatment, or other active topical medications for clinically diagnosed acne (used alone or in combination with other topical drugs not containing BPO) on the face or trunk. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Primary outcome measures were 'participant global self‐assessment of acne improvement' and 'withdrawal due to adverse events in the whole course of a trial'. 'Percentage of participants experiencing any adverse event in the whole course of a trial' was a key secondary outcome. Main results We included 120 trials (29,592 participants randomised in 116 trials; in four trials the number of randomised participants was unclear). Ninety‐one studies included males and females. When reported, 72 trials included participants with mild to moderate acne, 26 included participants with severe acne, and the mean age of participants ranged from 18 to 30 years. Our included trials assessed BPO as monotherapy, as add‐on treatment, or combined with other active treatments, as well as BPO of different concentrations and BPO delivered through different vehicles. Comparators included different concentrations or formulations of BPO, placebo, no treatment, or other active treatments given alone or combined. Treatment duration in 80 trials was longer than eight weeks and was only up to 12 weeks in 108 trials. Industry funded 50 trials; 63 trials did not report funding. We commonly found high or unclear risk of performance, detection, or attrition bias. Trial setting was under‐reported but included hospitals, medical centres/departments, clinics, general practices, and student health centres. We reported on outcomes assessed at the end of treatment, and we classified treatment periods as short‐term (two to four weeks), medium‐term (five to eight weeks), or long‐term (longer than eight weeks). For 'participant‐reported acne improvement', BPO may be more effective than placebo or no treatment (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.12 to 1.45; 3 RCTs; 2234 participants; treatment for 10 to 12 weeks; low‐certainty evidence). Based on low‐certainty evidence, there may be little to no difference between BPO and adapalene (RR 0.99, 95% CI 0.90 to 1.10; 5 RCTs; 1472 participants; treatment for 11 to 12 weeks) or between BPO and clindamycin (RR 0.95, 95% CI 0.68 to 1.34; 1 RCT; 240 participants; treatment for 10 weeks) (outcome not reported for BPO versus erythromycin or salicylic acid). For 'withdrawal due to adverse effects', risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment (RR 2.13, 95% CI 1.55 to 2.93; 24 RCTs; 13,744 participants; treatment for 10 to 12 weeks; low‐certainty evidence); the most common causes of withdrawal were erythema, pruritus, and skin burning. Only very low‐certainty evidence was available for the following comparisons: BPO versus adapalene (RR 1.85, 95% CI 0.94 to 3.64; 11 RCTs; 3295 participants; treatment for 11 to 24 weeks; causes of withdrawal not clear), BPO versus clindamycin (RR 1.93, 95% CI 0.90 to 4.11; 8 RCTs; 3330 participants; treatment for 10 to 12 weeks; causes of withdrawal included local hypersensitivity, pruritus, erythema, face oedema, rash, and skin burning), erythromycin (RR 1.00, 95% CI 0.07 to 15.26; 1 RCT; 60 participants; treatment for 8 weeks; withdrawal due to dermatitis), and salicylic acid (no participants had adverse event‐related withdrawal; 1 RCT; 59 participants; treatment for 12 weeks). There may be little to no difference between these groups in terms of withdrawal; however, we are unsure of the results because the evidence is of very low certainty. For 'proportion of participants experiencing any adverse event', very low‐certainty evidence leaves us uncertain about whether BPO increased adverse events when compared with placebo or no treatment (RR 1.40, 95% CI 1.15 to 1.70; 21 RCTs; 11,028 participants; treatment for 10 to 12 weeks), with adapalene (RR 0.71, 95% CI 0.50 to 1.00; 7 RCTs; 2120 participants; treatment for 11 to 24 weeks), with erythromycin (no participants reported any adverse events; 1 RCT; 89 participants; treatment for 10 weeks), or with salicylic acid (RR 4.77, 95% CI 0.24 to 93.67; 1 RCT; 41 participants; treatment for 6 weeks). Moderate‐certainty evidence shows that the risk of adverse events may be increased for BPO versus clindamycin (RR 1.24, 95% CI 0.97 to 1.58; 6 RCTs; 3018 participants; treatment for 10 to 12 weeks); however, the 95% CI indicates that BPO might make little to no difference. Most reported adverse events were mild to moderate, and local dryness, irritation, dermatitis, erythema, application site pain, and pruritus were the most common. Authors' conclusions Current evidence suggests that BPO as monotherapy or add‐on treatment may be more effective than placebo or no treatment for improving acne, and there may be little to no difference between BPO and either adapalene or clindamycin. Our key efficacy evidence is based on participant self‐assessment; trials of BPO versus erythromycin or salicylic acid did not report this outcome. For adverse effects, the evidence is very uncertain regarding BPO compared with adapalene, erythromycin, or salicylic acid. However, risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment. Withdrawal may be linked to tolerability rather than to safety. Risk of mild to moderate adverse events may be higher with BPO compared with clindamycin. Further trials should assess the comparative effects of different preparations or concentrations of BPO and combination BPO versus monotherapy. These trials should fully assess and report adverse effects and patient‐reported outcomes measured on a standardised scale. Plain language summary Topical benzoyl peroxide for acne Review question We reviewed the evidence showing effects and safety of topical benzoyl peroxide (BPO), used alone or in combination. Eligible comparisons included placebo (an identical but inactive treatment), no treatment, or other active (medical) topical medications for treating acne (used alone or in combination with other topical drugs not containing BPO) (evidence is current to February 2019). The main outcomes of interest in this review were participant‐reported acne improvement and withdrawal from the study due to any side effects. More generally, we also considered the percentage of participants experiencing any side effects over the whole course of a trial. Background As a common skin disease, acne vulgaris affects the physical, mental, and social well‐being of millions of adolescents and young adults. A wide range of treatments for acne vulgaris are available, and topical BPO has been recommended as a priority therapy to be used alone or combined with other topical or oral treatments, depending on acne severity. However, the benefits and harms of BPO have yet to be evaluated. Study characteristics We included 120 studies (which comprised 29,592 people randomised in 116 trials; in four trials the number of randomised participants was unclear). Through our search, we found studies assessing different concentrations of BPO, BPO delivered through various means, or BPO used alone or given with other treatments that may or may not be considered as the primary treatment. These studies compared treatments against different concentrations or formulations of BPO, placebo, no treatment, or other medical treatments given alone or in combination. Most of the studies included male and female participants with mild to moderate acne; only 67% of studies reported participant age, which ranged between 18 and 30 years. Participants were treated for over eight weeks in nearly two‐thirds of the trials. Industry financially supported approximately two‐fifths of the trials, and more than half of the trials did not report their funding sources. Few studies reported where they were set, but locations included hospitals, medical centres, national medical institutes, clinics, medical departments, and general practices. Key results We found low‐certainty evidence to suggest that long‐term (i.e. given for longer than eight weeks) BPO treatment may increase self‐reported treatment success compared to placebo or no BPO treatment (three studies), but there may be little to no difference when BPO treatment is compared to adapalene (five studies) or clindamycin (one study). This outcome was not reported by studies comparing BPO treatment to erythromycin or salicylic acid. Long‐term BPO may lead to an increased chance of treatment discontinuation compared to placebo or no treatment (24 studies), with the most common causes being redness, itch, and skin burning (low‐certainty evidence). When medium‐ to long‐term BPO was compared to adapalene (11 studies), clindamycin (eight studies), erythromycin (one study), or salicylic acid (one study), we found only very low‐certainty evidence, meaning that although there may be little to no difference in withdrawal between these groups, we are not sure of the results. It should be noted that participant withdrawal may be linked to issues around treatment acceptability (dermatitis, rash, facial swelling, sensitivity) rather than to safety. Very low‐certainty evidence means that we are uncertain if BPO leads to more side effects among participants receiving medium‐ to long‐term BPO than among those given no treatment/placebo (21 studies), adapalene (seven studies), erythromycin (one study), or salicylic acid (one study). Medium‐term treatment with BPO may lead to increased risk of side effects when compared against clindamycin, but the effects of this treatment vary, so the treatment chosen may make little to no difference (six studies; moderate‐certainty evidence). Side effects reported in these studies were usually mild to moderate, and the most common were local dryness, irritation, eczema, redness, pain at the site of application, and pruritus. Certainty of the evidence For our key comparisons, we rated the certainty of evidence for 'participant‐reported acne improvement' as low. For the outcomes 'withdrawal due to adverse effects' and ‘percentage of participants having any adverse events', the evidence was mainly of very low certainty. Included trials were at high or unclear risk of bias, participant numbers were small, results were not consistent across trials, and we suspected publication bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Yang, Z, Zhang, Y, Lazic Mosler, E, Hu, J, Li, H, Zhang, Y, Liu, J, Zhang, Q", "articleTypes": [], "doi": "10.1002/14651858.CD011154.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.819Z" }, { "id": "9f03ddb8-fbdf-4e37-802d-764270f0b2a6", "pmid": "", "title": "Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Herpes zoster oticus (HZO) is a viral infection of the ear and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first‐line treatment for herpes zoster infections at other body sites and are thought to reduce or minimise nerve damage, thereby improving outcomes. It has been suggested that these agents improve the chance of facial weakness improving or resolving completely in patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy). Search methods We searched the Cochrane ENT Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medline (1950 ‐ 2007), PubMed 2007 ‐ 2008, EMBASE (1974 onwards) and other relevant databases. The date of the most recent search was June 2008. Selection criteria Two authors scrutinized all possible citations to identify randomised controlled trials in which antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) were given as treatment for Ramsay Hunt syndrome. We contacted an author for further information. Data collection and analysis Two reviewers independently assessed eligibility and trial quality. Main results Only one randomised, controlled trial was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, intravenous acyclovir and corticosteroids were compared with corticosteroids alone. Our analysis found no statistically significant difference between the two groups. Authors' conclusions We found no evidence that anti‐viral agents have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. The use of these drugs in patients with herpes zoster infections in other parts of the body might suggest that they have a role in herpes zoster oticus. As usual, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically under‐powered study) does not necessarily indicate that antivirals are ineffective. However, these drugs are associated with a number of adverse effects and this must be taken into consideration when undertaking the requisite risk‐benefit analysis before instigating treatment. Plain language summary Uncertainty about usefulness of antiviral drugs in Ramsay Hunt syndrome It seems logical that antiviral drugs might help patients with a herpes virus infection of the ear producing facial weakness (a condition known as 'Ramsay Hunt syndrome'). These drugs often help similar viral infections elsewhere in the body. However, trials that might address this issue have not been done and there is therefore some uncertainty about their usefulness. Since patients can experience side‐effects when taking these drugs, the risks of these have to be balanced with the unknown prospect of benefit when considering whether to use them in Ramsay Hunt syndrome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T, Doree, C, Chamberlain, IJ, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.735Z" }, { "id": "9f06b3fa-d5d1-417d-bcc7-12b2358a0a7f", "pmid": "", "title": "The Effect of Omega Galil Hazelnut Chocolate Spread \"O'Sweet Spread\" With 80% Reduced Sucrose on Glucose Response of People With TID - a Randomized, Double-blind, Active Control Trial", "imported": false, "abstract": "Omega Galil has developed a novel fatty sweetener that allows the use of up to 80% less sugar (particularly sucrose) and yet achieves a natural sweet flavor, using a novel technology of milling the natural sucrose crystals together with oil and thus creating a micro-suspension of sugar in oil or fat. The suspension increases the surface area of the sugar particles and thus a lower quantity of sugar is required in order to reach an enhanced perception of sweetness at the sweet taste receptors in the mouth. Omega Galil provides fatty food products that use up to 80% less sucrose, while tasting as sweet as regular sugar sweetened foods, with no aftertastes of sugar substitutes, and no chemical modifications or additives.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.246Z" }, { "id": "9f49e3bc-466c-4408-bf49-3ef445d8ad1b", "pmid": "", "title": "Changes in Insulin Sensitivity in Liver and Esqueletal Muscle Due to Sucralose Consumption", "imported": false, "abstract": "Recently, it has been proposed that the consumption of non-nutritive sweeteners, including sucralose, it's not harmless and is related with metabolic effects. Some studies have reported that sucralose produces alterations in glucose homeostasis. In vitro studies indicate that sucralose is capable of interacting with sweet taste receptors (T1R2 and T1R3) in the intestine, thus increasing the expression of glucose transporters including the sodium-glucose cotransporter type 1 (SGLT1) and the glucose transporter 2 (GLUT2), increasing glucose absorption. This interaction with intestinal sweet taste receptors also generates an increase in the secretion of the incretins glucagon-like peptide type 1 (GLP-1) and the glucose-dependent insulinotropic polypeptide (GIP), which might enhance the postprandial insulin release. However, these results are preliminary and it's desirable to confirm if sucralose consumption is associated with glucose metabolism modifications using an appropriate methodological design and with gold standard methods. The aim of this triple-blind, placebo-controlled, parallel, randomized clinical trial is to confirm the changes in insulin sensitivity associated with sucralose consumption in humans, to identify whether these changes are in the liver or skeletal muscle and to investigate the pathophysiological mechanisms generating these changes. Specifically, we will investigate if sucralose generates a dysbiosis in the gut microbiota that could be related to insulin resistance by increasing concentrations of lipopolysaccharide, a toxin present in Gram-negative bacteria that triggers a low grade inflammation known as metabolic endotoxemia. In addition, the changes in postprandial concentrations of GLP-1, glucose, insulin and C-peptide due to the combination of sucralose with a mixed meal will be investigated. The results of this study will determine if sucralose consumption, frequently used as a non-nutritive sweetener, is associated to significant changes in glucose homeostasis in humans.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "9f514ca2-bb0c-45c4-80e5-01ecb7f0751f", "pmid": "", "title": "Effects of opioid, hypnotic and sedating medications on sleep‐disordered breathing in adults with obstructive sleep apnoea", "imported": false, "abstract": "Abstract - Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by partial or complete upper airway occlusion during sleep, leading to intermittent cessation (apnoea) or reduction (hypopnoea) of airflow and dips in arterial oxygen saturation during sleep. Many patients with recognised and unrecognised OSA receive hypnotics, sedatives and opiates/opioids to treat conditions including pain, anxiety and difficulty sleeping. Concerns have been expressed that administration of these drugs to people with co‐existing OSA may worsen OSA. Objectives To investigate whether administration of sedative and hypnotic drugs exacerbates the severity of OSA (as measured by the apnoea‐hypopnoea index (AHI) or the 4% oxygen desaturation index (ODI)) in people with known OSA. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR) of trials. The search was current as of March 2015. Selection criteria Randomised, placebo‐controlled trials including adult participants with confirmed OSA, where participants were randomly assigned to use opiates or opioids, sedatives, hypnotics or placebo. We included participants already using continuous positive airway pressure (CPAP) or a mandibular advancement device. Data collection and analysis We used standard methodological procedures as recommended by The Cochrane Collaboration. Main results Fourteen studies examining the effects of 10 drugs and including a total of 293 participants contributed to this review. Trials were small, with only two trials, which used sodium oxybate, recruiting more than 40 participants, and all but three trials were of only one to three nights in duration. Most participants had mild to moderate OSA with a mean AHI of 11 to 25 events/h, and only two trials recruited patients with severe OSA. Two trials investigating the effects of ramelteon, a treatment option for insomnia, recruited adults over 60 years of age with OSA and concomitant insomnia. The drugs studied in this review included remifentanil (infusion) 0.75 mcg/kg/h, eszopiclone 3 mg, zolpidem 10 and 20 mg, brotizolam 0.25 mg, flurazepam 30 mg, nitrazepam 10 mg to 15 mg, temazepam 10 mg, triazolam 0.25 mg, ramelteon 8 mg and 16 mg and sodium oxybate 4.5 g and 9 g. We were unable to pool most of the data, with the exception of data for eszopiclone and ramelteon. None of the drugs in this review produced a significant increase in AHI or ODI. Two trials have shown a beneficial effect on OSA. One study showed that a single administration of eszopiclone 3 mg significantly decreased AHI compared with placebo (24 ± 4 vs 31 ± 5; P value < 0.05), and a second study of sodium oxybate 4.5 g showed a significant decrease in AHI compared with placebo (mean difference (MD) ‐7.41, 95% confidence interval (CI) ‐14.17 to ‐0.65; N = 48). Only four trials reported outcome data on ODI. No significant increase, in comparison with placebo, was shown with eszopiclone (21 (22 to 37) vs 28.0 (15 to 36); P value = NS), zolpidem (0.81 ± 0.29 vs 1.46 ± 0.53; P value = NS), flurazepam (18.6 ± 19 vs 19.6 ± 15.9; P value = NS) and temazepam (6.53 ± 9.4 vs 6.56 ± 8.3; P value = 0.98). A significant decrease in minimum nocturnal peripheral capillary oxygen saturation (SpO 2 ) was observed with zolpidem 20 mg (76.8 vs 85.2; P value = 0.002), flurazepam 30 mg (81.7 vs 85.2; P value = 0.002), remifentanil infusion (MD ‐7.00, 95% CI ‐11.95 to ‐2.05) and triazolam 0.25 mg in both rapid eye movement (REM) and non‐REM (NREM) sleep (MD ‐14.00, 95% CI ‐21.84 to ‐6.16; MD ‐10.20, 95% CI ‐16.08 to ‐4.32, respectively. One study investigated the effect of an opiate (remifentanil) on patients with moderate OSA. Remifentanil infusion did not significantly change AHI (MD 10.00, 95% CI ‐9.83 to 29.83); however it did significantly decrease the number of obstructive apnoeas (MD ‐9.00, 95% CI ‐17.40 to ‐0.60) and significantly increased the number of central apnoeas (MD 16.00, 95% CI ‐2.21 to 34.21). Similarly, although without significant effect on obstructive apnoeas, central apnoeas were increased in the sodium oxybate 9 g treatment group (MD 7.3 (18); P value = 0.005) in a cross‐over trial. Drugs studied in this review were generally well tolerated, apart from adverse events reported in 19 study participants prescribed remifentanil (n = 1), eszopiclone (n = 6), sodium oxybate (n = 9) or ramelteon (n = 3). Authors' conclusions The findings of this review show that currently no evidence suggests that the pharmacological compounds assessed have a deleterious effect on the severity of OSA as measured by change in AHI or ODI. Significant clinical and statistical decreases in minimum overnight SpO 2 were observed with remifentanil, zolpidem 20 mg and triazolam 0.25 mg. Eszopiclone 3 mg and sodium oxybate 4.5 g showed a beneficial effect on the severity of OSA with a reduction in AHI and may merit further assessment as a potential therapeutic option for a subgroup of patients with OSA. Only one trial assessed the effect of an opioid (remifentanil); some studies included CPAP treatment, whilst in a significant number of participants, previous treatment with CPAP was not stated and thus a residual treatment effect of CPAP could not be excluded. Most studies were small and of short duration, with indiscernible methodological quality.Caution is therefore required when such agents are prescribed for patients with OSA, especially outside the severity of the OSA cohorts and the corresponding dose of compounds given in the particular studies. Larger, longer trials involving patients across a broader spectrum of OSA severity are needed to clarify these results. Plain language summary Effects of opioid, hypnotic and sedating medications on obstructive sleep apnoea (OSA) in adults with known OSA Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by intermittent apnoeas (pauses in breathing) leading to dips in oxygen levels in the blood during sleep. Many people with known or unknown (undiagnosed) OSA receive hypnotics, sedatives and opiate/opioid drugs to treat other conditions including pain, anxiety and difficulty sleeping. Opiates/opioids are commonly prescribed to treat pain after major surgery. These drugs might make sleep apnoea worse ‐ increasing the frequency and duration of apnoeas. Review question We set out to look at evidence derived from randomised placebo‐controlled trials to identify the risks of these drugs for patients with known OSA. What we did We searched and reviewed all randomised placebo‐controlled trials involving adult patients with known OSA who received these drugs. Most of the trials were short at just one or two nights' duration, involved only a small number of patients and used poorly described methodology. Therefore it was difficult to find out the exact effects of these drugs on patients with OSA. Results We found 14 studies examining the effects of 10 drugs in trials including 293 people. Opiates and opioids (treatment of acute and chronic pain) Remifentanil infusion Remifentanil infusion did not significantly change severity of OSA as measured by numbers and duration of pauses in breathing during sleep, but it significantly lowered minimum oxygen levels during the night when compared with placebo. Sedatives and hypnotics 'Z drugs' (a treatment for insomnia, inability to fall asleep or inability to maintain sleep) Eszopiclone and zolpidem Eszopiclone did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, it reduced the severity of OSA, and it might be beneficial in treating this condition, although further studies are needed to assess this effect. Zolpidem did not significantly worsen OSA as measured by the numbers and duration of pauses in breathing during sleep, but in one trial, it significantly lowered minimum oxygen levels during the night when compared with placebo. Benzodiazepines (short‐term relief of severe anxiety, behavioural disturbance or agitation and panic disorders) Brotizolam, flurazepam, nitrazepam, temazepam and triazolam None of the drugs examined had significantly worsened OSA as measured by the numbers and duration of pauses in breathing during sleep. In small, single‐night studies, zolpidem 20 mg, flurazepam 20 mg and triazolam 0.25 mg showed a tendency to increase numbers and duration of pauses during sleep, which was not statistically significant, but these drugs significantly lowered minimum oxygen levels during the night when compared with placebo. Sodium oxybate (a treatment for narcolepsy, a condition causing excessive sleepiness during the day) Sodium oxybate was compared with placebo in two trials. Results showed that sodium oxybate did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, sodium oxybate 4.5 g reduced the severity of OSA and might have proved beneficial in treating this condition, although further studies are needed to assess this effect. Melatonin and melatonin‐related drugs Ramelteon (a treatment drug for insomnia) Ramelteon was assessed in older adults, over 60 years of age, with OSA and insomnia and was found not to worsen OSA. Results of this review show that the drugs studied do not worsen the severity of OSA as measured by the numbers and duration of pauses in breathing during sleep, but significant clinical and statistical decreases in minimum oxygen levels during the night were observed with remifentanil, zolpidem and triazolam; therefore prescribing these drugs for patients with OSA still warrants caution. Sodium oxybate 4.5 g and eszopiclone reduced the severity of OSA and might be beneficial in treating this condition; nonetheless further studies are needed to support these results. Bottom line The long‐term effect and potential side effects of sedative drugs in people with OSA need to be assessed in larger, longer and methodologically robust studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mason, M, Cates, CJ, Smith, I", "articleTypes": [], "doi": "10.1002/14651858.CD011090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.111Z" }, { "id": "9f5a9d5d-86cc-407d-a7e9-d3b8c5b0cf1e", "pmid": "", "title": "Antiviral treatment for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gagyor, I, Madhok, VB, Daly, F, Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001869.pub9 AB - Abstract - Background Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. This review was first published in 2001 and most recently updated in 2015. Since a significant benefit of corticosteroids for the early management of Bell's palsy has been demonstrated, the main focus of this update, as in the previous version, was to determine the effect of adding antivirals to corticosteroid treatment. We undertook this update to integrate additional evidence and to better assess the robustness of findings, taking risk of bias fully into account. Objectives To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy. Search methods We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS in July 2019. We reviewed the bibliographies of the identified trials and contacted trial authors to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies. Selection criteria We considered randomised controlled trials (RCTs) or quasi‐RCTs of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that followed‐up participants for less than three months. Data collection and analysis We independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures. We performed sensitivity analyses excluding trials at high or unclear risk of bias in at least five domains, and reported these data as the primary analyses. Main results Fourteen trials, including 2488 participants, met the inclusion criteria. Most were small, and most were at high or unclear risk of bias in multiple domains. We included four new studies at this update. Incomplete recovery A combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in people with Bell's palsy compared to corticosteroids alone (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.38 to 1.74; 3 trials, N = 766; random‐effects; low‐certainty evidence). We excluded 10 trials that were at high or unclear risk of bias in several domains from this analysis and limited all analyses to studies at lower risk of bias. Recovery rates were better in participants receiving corticosteroids alone than antivirals alone (RR 2.69, 95% CI 0.73 to 10.01; 2 trials, N = 667; random‐effects), but the result was imprecise and allowed for the possibility of no effect. The rate of incomplete recovery was lower with antivirals plus corticosteroids than with placebo or no treatment (RR 0.56, 95% CI 0.42 to 0.76; 2 trials, N = 658; random‐effects). Antivirals alone had no clear effect on incomplete recovery rates compared with placebo, but the result was imprecise (RR 1.10, 95% CI 0.87 to 1.40; 2 trials, N = 658; fixed‐effect). For people with severe Bell's palsy (House‐Brackmann score of 5 and 6, or equivalent on other scales), we found that the combination of antivirals and corticosteroids had no clear effect on incomplete recovery at month six compared to corticosteroids alone, although the result was again imprecise (RR 0.82, 95% CI 0.57 to 1.17; 2 trials, N = 98; random‐effects). Motor synkinesis or crocodile tears Antivirals plus corticosteroids reduced the proportion of participants who experienced these long‐term sequelae from Bell's palsy compared to placebo plus corticosteroids (RR 0.56, 95% CI 0.36 to 0.87; 2 trials, N = 469; fixed‐effect; moderate‐certainty evidence). Antivirals plus corticosteroids reduced long‐term sequelae compared to placebo but there was no clear difference in this outcome with antivirals alone compared to placebo. Adverse events Adverse event data were available in four studies providing data on 1592 participants. None of the four comparisons showed clear differences in adverse events between treatment and comparison arms (very low‐certainty evidence); for the comparison of antivirals plus corticosteroids and corticosteroids alone in studies at lower risk of bias, the RR was 1.17 (95% CI 0.81 to 1.69; 2 trials, N = 656; fixed‐effect; very low‐certainty evidence). Authors' conclusions The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, or in people with severe Bell's palsy, but the results were very imprecise. Corticosteroids alone were probably more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no clear benefit from antivirals alone over placebo. The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone. Studies also showed fewer episodes of long‐term sequelae in corticosteroid‐treated participants than antiviral‐treated participants. We found no clear difference in adverse events from the use of antivirals compared with either placebo or corticosteroids, but the evidence is too uncertain for us to draw conclusions. An adequately powered RCT in people with Bell’s palsy that compares different antiviral agents may be indicated. Plain language summary Antiviral treatment for Bell's palsy Review question We reviewed the evidence about the effect of antiviral therapy (drugs used specifically to treat viral infections), alone or in combination with any other therapy, on Bell's palsy. Our focus in this updated review was combined therapy with antiviral drugs and corticosteroids (which are drugs used to reduce inflammation) as there is already good evidence that corticosteroids can reduce rates of incomplete recovery from Bell's palsy. Background Bell's palsy is a disease of the facial nerve that causes one side of the face to be paralysed. Some studies have suggested that it is caused by the same viral infections that cause cold sores or shingles and investigated the effect of antiviral therapy. Earlier versions of this review have found that antivirals alone are not helpful compared to a dummy pill, and are less effective than corticosteroids alone. However, studies of antiviral treatment in combination with corticosteroids have conflicting results. Study characteristics We identified 14 trials, which included 2488 participants with mild, moderate, or severe one‐sided Bell's palsy of unknown cause. Participants were aged from 14 to 84 years. The trials compared:
 ‐ antivirals plus corticosteroids to corticosteroids alone or in combination with placebo;
 ‐ antivirals alone or in combination with placebo to placebo or no treatment;
 ‐ antivirals alone or in combination with placebo to corticosteroid treatment alone or in combination with placebo; or
 ‐ antivirals plus corticosteroids to placebo or no treatment. For the majority of the studies, no information on funding was given. The remaining were mostly partly public funded, and one trial was funded by a pharmaceutical company. Eleven studies had high or uncertain risk of bias from various factors that can systematically affect trial results. We chose to base our conclusions only on data from three studies at a lower risk of bias. Key results and certainty of the evidence The review showed that there may be no clear difference in rates of incomplete recovery from Bell's palsy after treatment with the combination of antivirals and corticosteroids, compared to corticosteroids alone. This finding was of low certainty and was based on data from three trials involving 766 people with Bell's palsy of various degrees of severity. We excluded data from 10 trials with multiple potential sources of bias. However, we can be moderately confident that the combined therapy reduced the number of people left with long‐term effects of Bell's palsy (excessive tearing of the eyes or an abnormal facial movement) compared to corticosteroid treatment alone. Data from two studies (98 participants) showed that in people with severe Bell's palsy (complete or almost complete facial paralysis), combined antivirals and corticosteroids had no clear effect on recovery compared with corticosteroid treatment alone. Corticosteroids alone were more effective than antivirals alone on rates of incomplete recovery (667 participants, 2 trials); antivirals and corticosteroids combined were more effective than placebo or no treatment (658 participants, 2 trials); and there was no clear benefit from antivirals alone over placebo (658 participants, 2 trials). Although, based on data from two trials (656 participants), we found no clear difference in the occurrence of side effects between people receiving both antivirals and corticosteroids, compared to those receiving corticosteroids alone, this evidence is too uncertain for us to draw conclusions. Large studies in people with Bell's palsy comparing additional antiviral agents may be indicated in the future.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.781Z" }, { "id": "9f7767b5-ee23-4527-b205-a98a36732228", "pmid": "", "title": "Dornase alfa for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Dornase alfa is currently used as a mucolytic to treat pulmonary disease (the major cause of morbidity and mortality) in cystic fibrosis. It reduces mucus viscosity in the lungs, promoting improved clearance of secretions. This is an update of a previously published review. Objectives To determine whether the use of dornase alfa in cystic fibrosis is associated with improved mortality and morbidity compared to placebo or other medications that improve airway clearance, and to identify any adverse events associated with its use. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstracts from conferences. Date of the most recent search of the Group's Cystic Fibrosis Register: 12 October 2020. Clinicaltrials.gov and the International Clinical Trials Registry Platform were also searched to identify unpublished or ongoing trials. Date of most recent search: 08 February 2021. Selection criteria All randomised and quasi‐randomised controlled trials comparing dornase alfa to placebo, standard therapy or other medications that improve airway clearance. Data collection and analysis Authors independently assessed trials against the inclusion criteria; two authors carried out analysis of methodological quality and data extraction. GRADE was used to assess the level of evidence. Main results The searches identified 74 trials, of which 19 (2565 participants) met our inclusion criteria. 15 trials compared dornase alfa to placebo or no dornase alfa (2447 participants); two compared daily dornase to hypertonic saline (32 participants); one compared daily dornase alfa to hypertonic saline and alternate day dornase alfa (48 participants); one compared dornase alfa to mannitol and the combination of both drugs (38 participants). Trial duration varied from six days to three years. Dornase alfa compared to placebo or no treatment Dornase alfa probably improved forced expiratory volume at one second (FEV 1 ) at one month (four trials, 248 participants), three months (one trial, 320 participants; moderate‐quality evidence), six months (one trial, 647 participants; high‐quality evidence) and two years (one trial, 410 participants). Limited low‐quality evidence showed treatment may make little or no difference in quality of life. Dornase alfa probably reduced the number of pulmonary exacerbations in trials of up to two years (moderate‐quality evidence). One trial that examined the cost of care, including the cost of dornase alfa, found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa: daily versus alternate day One cross‐over trial (43 children) found little or no difference between treatment regimens for lung function, quality of life or pulmonary exacerbations (low‐quality evidence). Dornase alfa compared to other medications that improve airway clearance Results for these comparisons were mixed. One trial (43 children) showed dornase alfa may lead to a greater improvement in FEV 1 compared to hypertonic saline (low‐quality evidence), and one trial (23 participants) reported little or no differences in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol (low‐quality evidence). One trial (23 participants) found dornase alfa may improve quality of life compared to dornase alfa plus mannitol (low‐quality evidence); other comparisons found little or no difference in this outcome (low‐quality evidence). No trials in any comparison reported any difference between groups in the number of pulmonary exacerbations (low‐quality evidence). When all comparisons are assessed, dornase alfa did not cause significantly more adverse effects than other treatments, except voice alteration and rash. Authors' conclusions There is evidence to show that, compared with placebo, therapy with dornase alfa may improve lung function in people with cystic fibrosis in trials lasting from one month to two years. There was a decrease in pulmonary exacerbations in trials of six months or longer, probably due to treatment. Voice alteration and rash appear to be the only adverse events reported with increased frequency in randomised controlled trials. There is not enough evidence to firmly conclude if dornase alfa is superior to other hyperosmolar agents in improving lung function. Plain language summary Dornase alfa, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of using inhaled dornase alfa for treating lung disease in people with cystic fibrosis. Background Cystic fibrosis is an inherited condition which affects the movement of salt across cells in the body and affects, for example, the sweat glands, airways, pancreas and male reproductive system. Lung disease is the most common cause of death in people with cystic fibrosis and although the average life expectancy has increased over the last 30 years, it is still only 48.5 years in high‐income countries. People with cystic fibrosis develop chronic lung disease because of thick mucus that builds up in the lungs which causes infections and inflammation. Dornase alfa was developed to thin out this mucus, so it is easier for people to cough it up from their lungs; this in turn should decrease the number of infections and amount of inflammation and prevent chronic lung disease. Search date The evidence is current to: 12 October 2020. Study characteristics We included 19 trials with 2565 people with cystic fibrosis; 15 trials (2447 people) compared dornase alfa to placebo (a dummy treatment with no active medication) or no dornase alfa treatment; two trials (32 people) compared daily dornase to hypertonic saline; one trial (48 people) compared daily dornase alfa with hypertonic saline and alternate day dornase alfa; and one trial (38 people) compared dornase alfa to mannitol and the combination of both drugs. People from all age groups (infants through to adults) took part in the trials which lasted from six days to three years. Key results Dornase alfa compared to placebo or no treatment We found that dornase alfa probably improves lung function within one month when compared to a placebo or no treatment and this improvement was also seen in longer trials lasting from six months to two years (eight trials; 1708 participants). There were also fewer pulmonary exacerbations (flare up of lung inflammation) in these longer trials. One trial found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa ‐ daily versus alternate day One trial (43 children) found no differences between treatment schedules for lung function, quality of life or pulmonary exacerbations. Dornase alfa compared to other medications that improve airway clearance The results from trials comparing dornase alfa to hypertonic saline or mannitol were mixed. One trial (43 children) showed a greater improvement in lung function with dornase alfa compared to hypertonic saline and one trial (23 participants) reported no difference in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol. In one trial (23 participants) quality of life scores were better with dornase alfa alone than with dornase alfa plus mannitol; other drug comparisons found no difference between treatments for quality of life. No trials in any comparison of treatments reported any difference between groups in the number of pulmonary exacerbations. Overall, no serious side effects were reported, with only rash and a change in voice seen more frequently in those people taking dornase alfa. However, it is not definitively clear from the current evidence if dornase alfa is better than other medications such as hypertonic saline or mannitol. Quality of the evidence The quality of evidence from the trials comparing dornase alfa to placebo or no treatment was moderate to high for lung function results, but only one trial reported any changes in quality of life so the evidence for this outcome is limited. Also, there were few trials comparing different treatment schedules of dornase alfa (e.g. once a day versus twice a day) or comparing dornase alfa to other medications which help with clearing secretions, so current evidence from these trials is limited and of low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Yang, C; Montgomery, M", "articleTypes": [], "doi": "10.1002/14651858.CD001127.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "9f84f20b-bde5-4d59-a883-e297cf42e7bb", "pmid": "", "title": "Hyperbaric oxygen therapy for late radiation tissue injury", "imported": false, "abstract": "Abstract - Background This is the third update of the original Cochrane Review published in July 2005 and updated previously in 2012 and 2016. Cancer is a significant global health issue. Radiotherapy is a treatment modality for many malignancies, and about 50% of people having radiotherapy will be long‐term survivors. Some will experience late radiation tissue injury (LRTI), developing months or years following radiotherapy. Hyperbaric oxygen therapy (HBOT) has been suggested as a treatment for LRTI based on the ability to improve the blood supply to these tissues. It is postulated that HBOT may result in both healing of tissues and the prevention of complications following surgery and radiotherapy. Objectives To evaluate the benefits and harms of hyperbaric oxygen therapy (HBOT) for treating or preventing late radiation tissue injury (LRTI) compared to regimens that excluded HBOT. Search methods We used standard, extensive Cochrane search methods. The latest search date was 24 January 2022. Selection criteria We included randomised controlled trials (RCTs) comparing the effect of HBOT versus no HBOT on LRTI prevention or healing. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. survival from time of randomisation to death from any cause; 2. complete or substantial resolution of clinical problem; 3. site‐specific outcomes; and 4. adverse events. Our secondary outcomes were 5. resolution of pain; 6. improvement in quality of life, function, or both; and 7. site‐specific outcomes. We used GRADE to assess certainty of evidence. Main results Eighteen studies contributed to this review (1071 participants) with publications ranging from 1985 to 2022. We added four new studies to this updated review and evidence for the treatment of radiation proctitis, radiation cystitis, and the prevention and treatment of osteoradionecrosis (ORN). HBOT may not prevent death at one year (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.47 to 1.83; I 2 = 0%; 3 RCTs, 166 participants; low‐certainty evidence). There is some evidence that HBOT may result in complete resolution or provide significant improvement of LRTI (RR 1.39, 95% CI 1.02 to 1.89; I 2 = 64%; 5 RCTs, 468 participants; low‐certainty evidence) and HBOT may result in a large reduction in wound dehiscence following head and neck soft tissue surgery (RR 0.24, 95% CI 0.06 to 0.94; I 2 = 70%; 2 RCTs, 264 participants; low‐certainty evidence). In addition, pain scores in ORN improve slightly after HBOT at 12 months (mean difference (MD) −10.72, 95% CI −18.97 to −2.47; I 2 = 40%; 2 RCTs, 157 participants; moderate‐certainty evidence). Regarding adverse events, HBOT results in a higher risk of a reduction in visual acuity (RR 4.03, 95% CI 1.65 to 9.84; 5 RCTs, 438 participants; high‐certainty evidence). There was a risk of ear barotrauma in people receiving HBOT when no sham pressurisation was used for the control group (RR 9.08, 95% CI 2.21 to 37.26; I 2 = 0%; 4 RCTs, 357 participants; high‐certainty evidence), but no such increase when a sham pressurisation was employed (RR 1.07, 95% CI 0.52 to 2.21; I 2 = 74%; 2 RCTs, 158 participants; high‐certainty evidence). Authors' conclusions These small studies suggest that for people with LRTI affecting tissues of the head, neck, bladder and rectum, HBOT may be associated with improved outcomes (low‐ to moderate‐certainty evidence). HBOT may also result in a reduced risk of wound dehiscence and a modest reduction in pain following head and neck irradiation. However, HBOT is unlikely to influence the risk of death in the short term. HBOT also carries a risk of adverse events, including an increased risk of a reduction in visual acuity (usually temporary) and of ear barotrauma on compression. Hence, the application of HBOT to selected participants may be justified. The small number of studies and participants, and the methodological and reporting inadequacies of some of the primary studies included in this review demand a cautious interpretation. More information is required on the subset of disease severity and tissue type affected that is most likely to benefit from this therapy, the time for which we can expect any benefits to persist and the most appropriate oxygen dose. Further research is required to establish the optimum participant selection and timing of any therapy. An economic evaluation should also be undertaken. Plain language summary Hyperbaric oxygen therapy for the treatment of the late effects of radiotherapy Key message – In selected people and areas of the body hyperbaric oxygen therapy (HBOT) may help resolve symptoms associated with late radiation tissue injury (LRTI) but further research is required to establish which people may respond and the best timing of such therapy. What are the problems after radiation treatment and how can it be treated? There is a risk of serious complications developing in the months and years after radiation treatment (radiotherapy) for cancer. These problems are collectively called LRTI and are due to progressive damage to normal tissue (cells within the body) that has been exposed to radiation. These problems can be very difficult to resolve, and there is some doubt as to the best approaches to treatment. HBOT involves breathing oxygen in a specially designed pressurised chamber. It is used to improve oxygen supply to damaged tissue and support healing. What did we want to find out? We wanted to find out if HBOT results in both healing of tissues and the prevention of complications following surgery in an irradiated field and radiotherapy for cancer. What did we do? We searched medical databases for clinical studies reporting the evidence for or against the ability of HBOT to improve these complications compared to either no treatment or alternative treatments. What were the main findings? There was some evidence that HBOT may improve outcomes in LRTI affecting both bone and soft tissues of the head and neck, the bladder and the lower bowel. There was also some evidence that HBOT may reduce wound breakdown and improve pain following LRTI. HBOT did not affect the risk of dying over the short time that these studies followed their patients. HBOT is generally safe and well‐tolerated, but there is a risk of becoming temporarily short‐sighted from the oxygen exposure and of injury to the ear drum on compression. What are the limitations of the evidence? The evidence was mainly limited by small numbers of people and studies, poor reporting of methods and results, and uncertainty as to the exact degree of improvement with HBOT. A study of costs would also be useful. How up to date is this evidence? The evidence is current to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lin, ZC, Bennett, MH, Hawkins, GC, Azzopardi, CP, Feldmeier, J, Smee, R, Milross, C", "articleTypes": [], "doi": "10.1002/14651858.CD005005.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.115Z" }, { "id": "9f8900f1-5f59-4f2c-9001-cd2ade3ccbd8", "pmid": "", "title": "Universal screening for SARS‐CoV‐2 infection: a rapid review", "imported": false, "abstract": "Abstract - Background Coronavirus disease 2019 (COVID‐19) is caused by the novel betacoronavirus, severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2). Most people infected with SARS‐CoV‐2 have mild disease with unspecific symptoms, but about 5% become critically ill with respiratory failure, septic shock and multiple organ failure. An unknown proportion of infected individuals never experience COVID‐19 symptoms although they are infectious, that is, they remain asymptomatic. Those who develop the disease, go through a presymptomatic period during which they are infectious. Universal screening for SARS‐CoV‐2 infections to detect individuals who are infected before they present clinically, could therefore be an important measure to contain the spread of the disease. Objectives We conducted a rapid review to assess (1) the effectiveness of universal screening for SARS‐CoV‐2 infection compared with no screening and (2) the accuracy of universal screening in people who have not presented to clinical care for symptoms of COVID‐19. Search methods An information specialist searched Ovid MEDLINE and the Centers for Disease Control (CDC) COVID‐19 Research Articles Downloadable Database up to 26 May 2020. We searched Embase.com, the CENTRAL, and the Cochrane Covid‐19 Study Register on 14 April 2020. We searched LitCovid to 4 April 2020. The World Health Organization (WHO) provided records from daily searches in Chinese databases and in PubMed up to 15 April 2020. We also searched three model repositories (Covid‐Analytics, Models of Infectious Disease Agent Study [MIDAS], and Society for Medical Decision Making) on 8 April 2020. Selection criteria Trials, observational studies, or mathematical modelling studies assessing screening effectiveness or screening accuracy among general populations in which the prevalence of SARS‐CoV2 is unknown. Data collection and analysis After pilot testing review forms, one review author screened titles and abstracts. Two review authors independently screened the full text of studies and resolved any disagreements by discussion with a third review author. Abstracts excluded by a first review author were dually reviewed by a second review author prior to exclusion. One review author independently extracted data, which was checked by a second review author for completeness and accuracy. Two review authors independently rated the quality of included studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool for diagnostic accuracy studies and a modified form designed originally for economic evaluations for modelling studies. We resolved differences by consensus. We synthesized the evidence in narrative and tabular formats. We rated the certainty of evidence for days to outbreak, transmission, cases missed and detected, diagnostic accuracy (i.e. true positives, false positives, true negatives, false negatives) using the GRADE approach. Main results We included 22 publications. Two modelling studies reported on effectiveness of universal screening. Twenty studies (17 cohort studies and 3 modelling studies) reported on screening test accuracy. Effectiveness of screening We included two modelling studies. One study suggests that symptom screening at travel hubs, such as airports, may slightly slow but not stop the importation of infected cases (assuming 10 or 100 infected travellers per week reduced the delay in a local outbreak to 8 days or 1 day, respectively). We assessed risk of bias as minor or no concerns, and certainty of evidence was low, downgraded for very serious indirectness. The second modelling study provides very low‐certainty evidence that screening of healthcare workers in emergency departments using laboratory tests may reduce transmission to patients and other healthcare workers (assuming a transmission constant of 1.2 new infections per 10,000 people, weekly screening reduced infections by 5.1% within 30 days). The certainty of evidence was very low, downgraded for high risk of bias (major concerns) and indirectness. No modelling studies reported on harms of screening. Screening test accuracy All 17 cohort studies compared an index screening strategy to a reference reverse transcriptase polymerase chain reaction (RT‐PCR) test. All but one study reported on the accuracy of single point‐in‐time screening and varied widely in prevalence of SARS‐CoV‐2, settings, and methods of measurement. We assessed the overall risk of bias as unclear in 16 out of 17 studies, mainly due to limited information on the index test and reference standard. We rated one study as being at high risk of bias due to the inclusion of two separate populations with likely different prevalences. For several screening strategies, the estimates of sensitivity came from small samples. For single point‐in‐time strategies, for symptom assessment, the sensitivity from 12 cohorts (524 people) ranged from 0.00 to 0.60 (very low‐certainty evidence) and the specificity from 12 cohorts (16,165 people) ranged from 0.66 to 1.00 (low‐certainty evidence). For screening using direct temperature measurement (3 cohorts, 822 people), international travel history (2 cohorts, 13,080 people), or exposure to known infected people (3 cohorts, 13,205 people) or suspected infected people (2 cohorts, 954 people), sensitivity ranged from 0.00 to 0.23 (very low‐ to low‐certainty evidence) and specificity ranged from 0.90 to 1.00 (low‐ to moderate‐certainty evidence). For symptom assessment plus direct temperature measurement (2 cohorts, 779 people), sensitivity ranged from 0.12 to 0.69 (very low‐certainty evidence) and specificity from 0.90 to 1.00 (low‐certainty evidence). For rapid PCR test (1 cohort, 21 people), sensitivity was 0.80 (95% confidence interval (CI) 0.44 to 0.96; very low‐certainty evidence) and specificity was 0.73 (95% CI 0.39 to 0.94; very low‐certainty evidence). One cohort (76 people) reported on repeated screening with symptom assessment and demonstrates a sensitivity of 0.44 (95% CI 0.29 to 0.59; very low‐certainty evidence) and specificity of 0.62 (95% CI 0.42 to 0.79; low‐certainty evidence). Three modelling studies evaluated the accuracy of screening at airports. The main outcomes measured were cases missed or detected by entry or exit screening, or both, at airports. One study suggests very low sensitivity at 0.30 (95% CI 0.1 to 0.53), missing 70% of infected travellers. Another study described an unrealistic scenario to achieve a 90% detection rate, requiring 0% asymptomatic infections. The final study provides very uncertain evidence due to low methodological quality. Authors' conclusions The evidence base for the effectiveness of screening comes from two mathematical modelling studies and is limited by their assumptions. Low‐certainty evidence suggests that screening at travel hubs may slightly slow the importation of infected cases. This review highlights the uncertainty and variation in accuracy of screening strategies. A high proportion of infected individuals may be missed and go on to infect others, and some healthy individuals may be falsely identified as positive, requiring confirmatory testing and potentially leading to the unnecessary isolation of these individuals. Further studies need to evaluate the utility of rapid laboratory tests, combined screening, and repeated screening. More research is also needed on reference standards with greater accuracy than RT‐PCR. Given the poor sensitivity of existing approaches, our findings point to the need for greater emphasis on other ways that may prevent transmission such as face coverings, physical distancing, quarantine, and adequate personal protective equipment for frontline workers. Plain language summary How effective is screening for COVID‐19? Why does screening matter? Screening aims to identify a condition in people who may not be showing any symptoms. Some people may have the COVID‐19 virus but appear healthy or have only mild symptoms. It is important to identify infected people so they can stay away from others and seek appropriate care. Incorrectly identifying COVID‐19 in healthy people could lead to unnecessary self‐isolation and further tests. Incorrectly identifying no infection in infected people could spread the virus. Screening for COVID‐19 can include temperature checks, or asking about international travel or contact with COVID‐19 cases, or rapid tests. Screening can occur over the telephone, online, or in person, in homes, clinics, workplaces, airports or schools. What did the review study? We wanted to identify: · the benefits and negative effects of screening apparently healthy people for COVID‐19 infection; · whether screening can identify those with and without the virus correctly. To answer these questions rapidly, we shortened some steps of the normal Cochrane Review process. We are confident these changes do not affect our overall conclusions. What did we do? We looked for studies that screened people who had not sought care for potential COVID‐19 symptoms. This review includes evidence up to May 2020. Key results We found 22 studies; 17 assessed people (cohort studies) and five were computer‐generated models (modelling studies). Studies took place in USA, Europe, and Asia. Benefits and negative effects 
Two modelling studies reported on the benefits and negative effects of screening. One suggested that asking about symptoms at airports may slightly slow, but not stop, the importation of infected people. Another model reported that weekly or biweekly screening of healthcare workers may reduce transmission to patients and other healthcare workers in emergency departments. No studies reported on negative effects of screening. Identification of infected people 
Seventeen cohort studies and three modelling studies reported on whether screening can correctly identify those with and without the virus. Studies varied widely in the baseline level of COVID‐19, settings, and methods. All cohort studies compared screening strategies to a ‘gold standard’ test called RT‐PCR. Cohort studies
All screening strategies (17 studies, 17,574 people), incorrectly identified: · between 20 and 100 out of 100 infected people as healthy; · between 0 and 38 people out of 100 healthy people as infected Asking about symptoms (13 studies, 16,762 people ), incorrectly identified: · between 40 to 100 out of 100 infected people as healthy · between 0 to 34 out of 100 healthy people as infected Temperature measurements , asking about international travel , exposure to known infected people and exposure to known or suspected infected people (6 studies, 14,741 people), incorrectly identified : · between 77 and 100 out of 100 infected people as healthy · between 0 and 10 out of 100 healthy people as infected Asking about symptoms plus temperature measurement (2 studies, 779 people), incorrectly identified: · between 31 and 88 out of 100 infected people as healthy · between 0 to 10 people out of 100 healthy people as infected There was insufficient evidence from two small studies on rapid laboratory tests and repeated symptom assessment to tell how accurate they were in identifying healthy and infected people. Modelling studies 
Three studies modelled entry and exit screening in airports. One study missed 70% of infected travellers. Another detected 90% of infections, but used an unrealistic scenario. The third used very unreliable methods so we cannot use evidence from this study. How confident are we in the results of the studies? Our confidence in these findings is limited because most studies did not describe their screening methods clearly, some found very few cases of infections and the types of participants and settings varied greatly, making it difficult to judge whether the results apply broadly. Authors’ conclusions One‐time screening in apparently healthy people is likely to miss people who are infected. We are unsure whether combined screenings, repeated symptom assessment, or rapid laboratory tests are useful. As more people become infected, screening will identify more cases. However, because screening can miss people who are infected, public health measures such as face coverings, physical distancing, and quarantine for those who are apparently healthy, continue to be very important.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Viswanathan, M; Kahwati, L; Jahn, B; Giger, K; Dobrescu, AI; Hill, C; Klerings, I; Meixner, J; Persad, E; Teufer, B; Gartlehner, G", "articleTypes": [], "doi": "10.1002/14651858.CD013718", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "9f99624f-0c51-4bce-b28d-8322114b91b4", "pmid": "", "title": "Identifying the Mechanisms of Gut-brain Axis to Sweet Sensing in Patients With Type 2 Diabetes Using Neuroimaging Techniques", "imported": false, "abstract": "Diabetes is a global challenge and the number of people affected by diabetes is expected to rise to 5.5 million by 2030, of which 90% are type 2 diabetes (T2D). Habitual high consumption of sugars is an important risk factor in the development, and progression, of type 2 diabetes (T2D). Several studies have now shown that individuals with T2D have reduced lingual sweet taste sensation and this in turns increases their sugar intake to achieve the same hedonic reward values compared to the healthy population. This subsequently will lead to development of diabetes or worsening of the blood sugar control.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.148Z" }, { "id": "9f9bfd3c-d34b-4fd1-a915-118525fcac84", "pmid": "", "title": "Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults", "imported": false, "abstract": "Abstract - Background Acetylcholinesterase inhibitors, such as neostigmine, have traditionally been used for reversal of non‐depolarizing neuromuscular blocking agents. However, these drugs have significant limitations, such as indirect mechanisms of reversal, limited and unpredictable efficacy, and undesirable autonomic responses. Sugammadex is a selective relaxant‐binding agent specifically developed for rapid reversal of non‐depolarizing neuromuscular blockade induced by rocuronium. Its potential clinical benefits include fast and predictable reversal of any degree of block, increased patient safety, reduced incidence of residual block on recovery, and more efficient use of healthcare resources. Objectives The main objective of this review was to compare the efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade caused by non‐depolarizing neuromuscular agents in adults. Search methods We searched the following databases on 2 May 2016: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (WebSPIRS Ovid SP), Embase (WebSPIRS Ovid SP), and the clinical trials registries www.controlled‐trials.com , clinicaltrials.gov , and www.centerwatch.com . We re‐ran the search on 10 May 2017. Selection criteria We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published, or language. We included adults, classified as American Society of Anesthesiologists (ASA) I to IV, who received non‐depolarizing neuromuscular blocking agents for an elective in‐patient or day‐case surgical procedure. We included all trials comparing sugammadex versus neostigmine that reported recovery times or adverse events. We included any dose of sugammadex and neostigmine and any time point of study drug administration. Data collection and analysis Two review authors independently screened titles and abstracts to identify trials for eligibility, examined articles for eligibility, abstracted data, assessed the articles, and excluded obviously irrelevant reports. We resolved disagreements by discussion between review authors and further disagreements through consultation with the last review author. We assessed risk of bias in 10 methodological domains using the Cochrane risk of bias tool and examined risk of random error through trial sequential analysis. We used the principles of the GRADE approach to prepare an overall assessment of the quality of evidence. For our primary outcomes (recovery times to train‐of‐four ratio (TOFR) > 0.9), we presented data as mean differences (MDs) with 95 % confidence intervals (CIs), and for our secondary outcomes (risk of adverse events and risk of serious adverse events), we calculated risk ratios (RRs) with CIs. Main results We included 41 studies (4206 participants) in this updated review, 38 of which were new studies. Twelve trials were eligible for meta‐analysis of primary outcomes (n = 949), 28 trials were eligible for meta‐analysis of secondary outcomes (n = 2298), and 10 trials (n = 1647) were ineligible for meta‐analysis. We compared sugammadex 2 mg/kg and neostigmine 0.05 mg/kg for reversal of rocuronium‐induced moderate neuromuscular blockade (NMB). Sugammadex 2 mg/kg was 10.22 minutes (6.6 times) faster then neostigmine 0.05 mg/kg (1.96 vs 12.87 minutes) in reversing NMB from the second twitch (T2) to TOFR > 0.9 (MD 10.22 minutes, 95% CI 8.48 to 11.96; I 2 = 84%; 10 studies, n = 835; GRADE: moderate quality). We compared sugammadex 4 mg/kg and neostigmine 0.07 mg/kg for reversal of rocuronium‐induced deep NMB. Sugammadex 4 mg/kg was 45.78 minutes (16.8 times) faster then neostigmine 0.07 mg/kg (2.9 vs 48.8 minutes) in reversing NMB from post‐tetanic count (PTC) 1 to 5 to TOFR > 0.9 (MD 45.78 minutes, 95% CI 39.41 to 52.15; I 2 = 0%; two studies, n = 114; GRADE: low quality). For our secondary outcomes, we compared sugammadex, any dose, and neostigmine, any dose, looking at risk of adverse and serious adverse events. We found significantly fewer composite adverse events in the sugammadex group compared with the neostigmine group (RR 0.60, 95% CI 0.49 to 0.74; I 2 = 40%; 28 studies, n = 2298; GRADE: moderate quality). Risk of adverse events was 28% in the neostigmine group and 16% in the sugammadex group, resulting in a number needed to treat for an additional beneficial outcome (NNTB) of 8. When looking at specific adverse events, we noted significantly less risk of bradycardia (RR 0.16, 95% CI 0.07 to 0.34; I 2 = 0%; 11 studies, n = 1218; NNTB 14; GRADE: moderate quality), postoperative nausea and vomiting (PONV) (RR 0.52, 95% CI 0.28 to 0.97; I 2 = 0%; six studies, n = 389; NNTB 16; GRADE: low quality) and overall signs of postoperative residual paralysis (RR 0.40, 95% CI 0.28 to 0.57; I 2 = 0%; 15 studies, n = 1474; NNTB 13; GRADE: moderate quality) in the sugammadex group when compared with the neostigmine group. Finally, we found no significant differences between sugammadex and neostigmine regarding risk of serious adverse events (RR 0.54, 95% CI 0.13 to 2.25; I 2 = 0%; 10 studies, n = 959; GRADE: low quality). Application of trial sequential analysis (TSA) indicates superiority of sugammadex for outcomes such as recovery time from T2 to TOFR > 0.9, adverse events, and overall signs of postoperative residual paralysis. Authors' conclusions Review results suggest that in comparison with neostigmine, sugammadex can more rapidly reverse rocuronium‐induced neuromuscular block regardless of the depth of the block. Sugammadex 2 mg/kg is 10.22 minutes (˜ 6.6 times) faster in reversing moderate neuromuscular blockade (T2) than neostigmine 0.05 mg/kg (GRADE: moderate quality), and sugammadex 4 mg/kg is 45.78 minutes (˜ 16.8 times) faster in reversing deep neuromuscular blockade (PTC 1 to 5) than neostigmine 0.07 mg/kg (GRADE: low quality). With an NNTB of 8 to avoid an adverse event, sugammadex appears to have a better safety profile than neostigmine. Patients receiving sugammadex had 40% fewer adverse events compared with those given neostigmine. Specifically, risks of bradycardia (RR 0.16, NNTB 14; GRADE: moderate quality), PONV (RR 0.52, NNTB 16; GRADE: low quality), and overall signs of postoperative residual paralysis (RR 0.40, NNTB 13; GRADE: moderate quality) were reduced. Both sugammadex and neostigmine were associated with serious adverse events in less than 1% of patients, and data showed no differences in risk of serious adverse events between groups (RR 0.54; GRADE: low quality). Plain language summary Benefits and harms of sugammadex versus neostigmine in reversing induced paralysis Background Different levels of induced paralysis are sometimes necessary when patients are put to sleep or are prepared for operations. When the operation is finished, paralysis should be reversed in a fast, reliable, and safe way. Neostigmine is a medication that is traditionally used to reverse induced paralysis. However, its use can be associated with incomplete or slow reversal as well as changes in lung function, heart function, and vomiting and nausea. Sugammadex is a relatively new medication specifically designed to reverse rocuronium‐induced paralysis in a faster, more reliable, and safer way when compared with neostigmine. Objective This review systematically sets out to compare the benefits and harms of sugammadex and neostigmine. The evidence is current up to May 2017. Study characteristics We identified 41 randomized controlled trials comparing sugammadex with neostigmine that provided suitable data on efficacy and safety. All of these trials included adults undergoing surgery and involved a total of 4206 participants. Key results Data indicate that sugammadex was 10.22 minutes (6.6 times) faster than neostigmine (1.96 vs 12.87 minutes) in reversing moderate induced paralysis. Sugammadex was 45.78 minutes (16.8 times) faster than neostigmine (2.9 vs 48.8 minutes) in reversing deep induced paralysis. Participants receiving sugammadex appeared to have a 40% reduced risk of experiencing harmful events than those given neostigmine. Statistically, eight persons can be treated with sugammadex as opposed to neostigmine to avoid one person experiencing a single random harmful event. The occurrence of serious harmful events was nearly non‐existent and data show no differences between compared groups. Conclusion Sugammadex is more efficient and safer than neostigmine for reversing moderate and deep induced paralysis. Quality of evidence We consider our overall findings on benefits and harms to provide evidence of moderate quality in favour of sugammadex.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Hristovska, AM; Duch, P; Allingstrup, M; Afshari, A", "articleTypes": [], "doi": "10.1002/14651858.CD012763", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "9f9f8d8c-c2aa-4159-a939-d4aaff3b515c", "pmid": "", "title": "Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Ethnic minority groups in upper‐middle‐income and high‐income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population. Objectives To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Search methods A systematic literature search was performed of the following databases: The Cochrane Library , MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well. Selection criteria We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper‐middle‐income or high‐income countries. Data collection and analysis Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification. Main results A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta‐analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education. Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) ‐0.4% (95% confidence interval (CI) ‐0.5 to ‐0.2); 14 trials; 1442 participants; high‐quality evidence) and at six months (MD ‐0.5% (95% CI ‐0.7 to ‐0.4); 14 trials; 1972 participants; high‐quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD ‐0.2% (95% CI ‐0.3 to ‐0.04); 9 trials; 1936 participants) and at 24 months (MD ‐0.3% (95% CI ‐0.6 to ‐0.1); 4 trials; 2268 participants; moderate‐quality evidence) post intervention. Neutral effects on health‐related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies — the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI ‐40 to ‐8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low‐density lipoprotein (LDL) cholesterol or high‐density lipoprotein (HDL) cholesterol were reported at any follow‐up point. Other outcome measures (blood pressure, body mass index, self‐efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient. Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self‐reported via questionnaires, leading to high bias in subjective outcome assessment. Authors' conclusions Culturally appropriate health education has short‐ to medium‐term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long‐term trials, and so clinically important long‐term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long‐term, standardised, multi‐centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium‐term effects could lead to clinically important health outcomes, if sustained. Plain language summary Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus Review question Does culturally appropriate diabetes health education lead to better outcomes than 'usual care' for people in ethnic minority groups with type 2 diabetes? Background In upper‐middle‐income and high‐income countries, minority ethnic groups often have a higher prevalence of type 2 diabetes mellitus than is seen in the local population. They also tend to come from lower socioeconomic backgrounds, with attendant difficulties in accessing good‐quality health care. In some cases, cultural and communication barriers increase the problems that minority ethnic communities experience when attempting to access good‐quality diabetes health education, which is vital for those who wish to understand diabetes and use available services to gain empowerment and bring about behaviour change toward a healthier lifestyle. In this review, 'culturally appropriate' health education is taken to mean any type of health education that has been specifically tailored to the cultural needs of a target minority group with type 2 diabetes mellitus. Study characteristics This updated review found in the world literature 33 randomised controlled trials (RCTs) of culturally appropriate health education on diabetes that met the selection criteria (participants from a defined ethnic minority group living in a upper‐middle‐income or high‐income country, over 16 years of age, diagnosed with type 2 diabetes mellitus and receiving a culturally tailored health education intervention). The median duration of the intervention was six months, and a total of 7453 participants were involved in the studies. Key results Culturally appropriate health education improved blood sugar control among participants, compared with those receiving 'usual' care, at three, six, 12 and 24 months after the intervention was provided. Knowledge about diabetes improved, and participants attained healthier lifestyles. No information was available regarding complications of diabetes and death from any cause, and there was a general lack of reporting of adverse effects in most studies. Neutral effects were observed for health‐related quality of life, blood lipids like cholesterol, blood pressure and weight. The costs of educational programmes were rarely analysed. Compared with the first review, performed in 2008 (11 studies), many more published studies were identified in this review (altogether 33 studies), strengthening the original findings that blood sugar control and knowledge of diabetes are improved when culturally appropriate health education is provided to people in ethnic minority groups diagnosed with diabetes. The effects of this improvement are shown in this update as lasting longer — up to 24 months after health education was provided in some trials. However, additional high‐quality standardised RCTs of longer duration are needed, along with full evaluation of costs. Quality of the evidence Heterogeneity of the studies, in terms of populations studied, type and duration of health education provided, variety of outcomes measured and differences in timing of assessment, limits interpretation of our findings. Also, risk of bias was judged to be high for many outcomes. Currentness of evidence This evidence is up‐to‐date as of September 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Attridge, M, Creamer, J, Ramsden, M, Cannings‐John, R, Hawthorne, K", "articleTypes": [], "doi": "10.1002/14651858.CD006424.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.140Z" }, { "id": "9fa1490b-2a3a-4682-bfd9-b59f7f5fdad2", "pmid": "", "title": "Sucrose analgesia for heel‐lance procedures in neonates", "imported": false, "abstract": "Abstract - Background Sucrose has been examined for calming and pain‐relieving effects in neonates for invasive procedures such as heel lance. Objectives To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long‐term outcomes Search methods We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries. Selection criteria We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non‐nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin‐to‐skin care. Data collection and analysis We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. We assessed heterogeneity by the I 2 test. We used GRADE to assess certainty of evidence. Main results We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing. Sucrose vs control The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD ‐1.74 (95% CI ‐2.11 to ‐1.37); I 2 = 62%; moderate‐certainty evidence) and 60 seconds after lancing (MD ‐2.14, 95% CI ‐3.34 to ‐0.94; I 2 = 0%; moderate‐certainty evidence). The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD ‐1.90, 95% CI ‐8.58 to 4.78; heterogeneity not applicable (N/A); very low‐certainty evidence). The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD ‐2.00, 95% CI ‐2.42 to ‐1.58; heterogeneity N/A; moderate‐certainty evidence). Sucrose vs NNS The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI ‐0.30 to 1.50; heterogeneity not applicable; very low‐certainty evidence) and on DAN scores at 30 seconds after lancing (MD ‐1.20, 95% CI ‐7.87 to 5.47; heterogeneity N/A; very low‐certainty evidence). Sucrose + NNS vs NNS The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD ‐4.90, 95% CI ‐5.73 to ‐4.07; heterogeneity not applicable; very low‐certainty evidence) and during recovery after lancing (MD ‐3.80, 95% CI ‐4.47 to ‐3.13; heterogeneity N/A; very low‐certainty evidence). The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD ‐0.60, 95% CI ‐1.47 to 0.27; heterogeneity N/A; very low‐certainty evidence). Sucrose vs glucose The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI ‐0.70 to 1.22; heterogeneity not applicable; low‐certainty evidence) and 60 seconds after lancing (MD ‐0.02, 95% CI ‐0.79 to 0.75; heterogeneity N/A; low‐certainty evidence). Sucrose vs breastfeeding The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD ‐0.70, 95% CI ‐0.49 to 1.88; I 2 = 94%; very low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD ‐2.60, 95% CI ‐3.06 to ‐2.14; heterogeneity N/A; very low‐certainty evidence). Sucrose vs expressed breast milk The evidence suggests that sucrose may result in little to no difference in PIPP‐R scores compared to expressed breast milk during (MD 0.3, 95% CI ‐0.24 to 0.84; heterogeneity not applicable; low‐certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI ‐0.11 to 0.71; heterogeneity N/A; low‐certainty evidence). The evidence suggests that sucrose probably may result in slightly increased PIPP‐R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low‐certainty evidence). The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD ‐1.80, 95% CI ‐8.47 to 4.87; heterogeneity N/A; very low‐certainty evidence). Sucrose vs laser acupuncture There was no difference in PIPP‐R scores between sucrose and music groups; however, data were reported as medians and IQRs. The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD ‐0.86, 95% CI ‐1.43 to ‐0.29; heterogeneity N/A; very low‐certainty evidence). Sucrose vs facilitated tucking The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD ‐2.27, 95% CI ‐4.66 to 0.12; heterogeneity N/A; very low‐certainty evidence) and during recovery after lancing (MD ‐0.31, 95% CI ‐1.72 to 1.10; heterogeneity N/A; very low‐certainty evidence). Sucrose vs skin‐to‐skin + water (repeated lancing) The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 30 seconds after 1st (MD 0.13, 95% CI ‐0.70 to 0.96); 2nd (MD ‐0.56, 95% CI ‐1.57 to 0.45); or 3rd lancing (MD‐0.15, 95% CI ‐1.26 to 0.96); heterogeneity N/A, low‐certainty evidence for all comparisons. The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin‐to‐skin + water at 60 seconds after 1st (MD –0.61, 95% CI ‐1.55 to 0.33); 2nd (MD ‐0.12, 95% CI ‐0.99 to 0.75); or 3rd lancing (MD‐0.40, 95% CI ‐1.48 to 0.68); heterogeneity N/A, low‐certainty evidence for all comparisons. Minor adverse events required no intervention. Authors' conclusions Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate‐certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin‐to‐skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing heel lance Key messages ‐ Sucrose, compared to control interventions, probably reduces pain for a single painful event (heel lance). ‐ There were a few minor immediate adverse events, such as gagging, that resolved without intervention. ‐ We need studies that assess the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. ‐ We need to assess how sucrose affects neonates who are extremely preterm, unstable, or ventilated (or a combination of these factors). What is sucrose analgesia? Sucrose (table sugar) is mixed with water in various concentrations (usually 24%) and is given to babies in very small amounts (e.g. a few drops) about two minutes before a painful procedure. Sucrose is also given with other nondrug pain‐relieving interventions such as a pacifier (non‐nutritive sucking ‐ NNS) or when the baby is receiving skin‐to‐skin care. Why is this important for newborn babies who are undergoing heel lance procedures? Babies who are sick or immature, and require a stay in hospital, have several painful procedures per day and multiple painful procedures throughout the hospital stay; for most babies, the majority of painful procedures are heel lances. If untreated, pain has immediate and long‐term consequences that can impact their brain and behavioural development. It is important to minimise the number of painful procedures and the associated pain and suffering. What did we want to find out? We wanted to know how well sucrose worked to relieve pain in newborn babies who are having heel lance procedures while they were in hospital. We also wanted to know whether there were any safety concerns about using sucrose to relieve pain from single painful events such as heel lance. What did we do? We searched for studies that investigated: ‐ Sucrose compared to no treatment or standard care; ‐ Sucrose compared to water, other sweet solutions (e.g. glucose); ‐ Sucrose compared to another nondrug intervention (e.g. NNS); ‐ Whether sucrose was effective in decreasing the amount and severity of pain that babies experienced as assessed by baby’s pain responses (e.g. crying, grimacing, heart rate) and by using standardised infant pain scales. We also wanted to know if sucrose was associated with any unwanted effects in preterm or term babies. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods. What did we find out? We reviewed 55 studies that included a total of 6273 babies. Twenty‐nine studies had full‐term babies only, 22 had preterm babies only, and four had both full‐term and preterm babies. Heel lance was the painful procedure in 50 studies. Five studies investigated a variety of other minor painful procedures in addition to heel lancing. Main results ‐ Sucrose compared to the control treatment probably reduces pain from single heel lances in babies. ‐ Results are uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, and facilitated tucking, in reducing pain scores. ‐ Results are uncertain about the effect of sucrose + NNS compared to NNS, in reducing pain. ‐ Sucrose does not seem to reduce pain from single heel lances compared to glucose, expressed breast milk, and skin‐to‐skin care. ‐ Reported adverse events were minor and resolved without any intervention. What are the limitations of the evidence? We have moderate‐certainty evidence that sucrose likely reduces pain from heel lance. How up‐to‐date is this evidence? This evidence is up‐to‐date as of February 2022. Study funding sources We did not identify any studies that received funding from industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yamada, J; Bueno, M; Santos, L; Haliburton, S; Campbell-Yeo, M; Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD014806", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "9fab7c37-dd85-4841-877b-67d041914031", "pmid": "", "title": "Interventions for the management of dry mouth: non‐pharmacological interventions", "imported": false, "abstract": "Abstract - Background Xerostomia is the subjective sensation of dry mouth. Common causes of xerostomia include adverse effects of many commonly prescribed medications, disease (e.g. Sjogren's Syndrome) and radiotherapy treatment for head and neck cancers. Non‐pharmacological techniques such as acupuncture or mild electrostimulation may be used to improve symptoms. Objectives To assess the effects of non‐pharmacological interventions administered to stimulate saliva production for the relief of dry mouth. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 16th April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 3), MEDLINE via OVID (1948 to 16th April 2013), EMBASE via OVID (1980 to 16th April 2013), AMED via OVID (1985 to 16th April 2013), CINAHL via EBSCO (1981 to 16th April 2013), and CANCERLIT via PubMed (1950 to 16th April 2013). The meta Register of Controlled Clinical Trials ( www.controlled‐trials.com ) and ClinicalTrials.gov ( www.clinicaltrials.gov ) were also searched to identify ongoing and completed trials. References lists of included studies and relevant reviews were also searched. There were no restrictions on the language of publication or publication status. Selection criteria We included parallel group randomised controlled trials of non‐pharmacological interventions to treat dry mouth, where participants had dry mouth symptoms at baseline. Data collection and analysis At least two review authors assessed each of the included studies to confirm eligibility, assess risk of bias and extract data using a piloted data extraction form. We calculated mean difference (MD) and 95% confidence intervals (CI) for continuous outcomes or where different scales were used to assess an outcome, we calculated standardised mean differences (SMD) together with 95% CIs. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information. Main results There were nine studies (total 366 participants randomised) included in this review of non‐pharmacological interventions for dry mouth which were divided into three comparisons. Eight studies were assessed at high risk of bias in at least one domain and the remaining study was at unclear risk of bias. Five small studies (total 153 participants, with dry mouth following radiotherapy treatment) compared acupuncture with placebo. Four were assessed at high risk and one at unclear risk of bias. Two trials reported outcome data for dry mouth in a form suitable for meta‐analysis. The pooled estimate of these two trials (70 participants, low quality evidence) showed no difference between acupuncture and control in dry mouth symptoms (SMD ‐0.34, 95% CI ‐0.81 to 0.14, P value 0.17, I 2 = 39%) with the confidence intervals including both a possible reduction or a possible increase in dry mouth symptoms. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). There was a very small increase in unstimulated whole saliva (UWS) at the end of 4 to 6 weeks of treatment (three trials, 71 participants, low quality evidence) (MD 0.02 ml/minute, 95% CI 0 to 0.04, P value 0.04, I 2 = 57%), and this benefit persisted at the 12‐month follow‐up evaluation (two trials, 54 participants, low quality evidence) (UWS, MD 0.06 ml/minute, 95% CI 0.01 to 0.11, P value 0.03, I 2 = 10%). For the outcome of stimulated whole saliva (SWS, three trials, 71 participants, low quality evidence) there was a benefit favouring acupuncture (MD 0.19 ml/minute, 95% CI 0.07 to 0.31, P value 0.002, I 2 = 1%) an effect which also persisted at the 12‐month follow‐up evaluation (SWS MD 0.28 ml/minute, 95% CI 0.09 to 0.47, P value 0.004, I 2 = 0%) (two trials, 54 participants, low quality evidence). Two small studies, both at high risk of bias, compared the use of an electrostimulation device with a placebo device in participants with Sjögren's Syndrome (total 101 participants). A further study, also at high risk of bias, compared acupuncture‐like electrostimulation of different sets of points in participants who had previously been treated with radiotherapy. None of these studies reported the outcome of dry mouth. There was no difference between electrostimulation and placebo in the outcomes of UWS or SWS at the end of the 4‐week treatment period in the one study (very low that provided data for these outcomes. No adverse effects were reported. A single study at high risk of bias, compared the stimulatory effect of powered versus manual toothbrushing and found no difference for the outcomes of UWS or SWS. Authors' conclusions There is low quality evidence that acupuncture is no different from placebo acupuncture with regard to dry mouth symptoms, which is the most important outcome. This may be because there were insufficient participants included in the two trials to show a possible effect or it may be that there was some benefit due to 'placebo' acupuncture which could have biased the effect to the null. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms. It is well known that dry mouth symptoms may be problematic even when saliva production is increased, yet only two of the trials that evaluated acupuncture reported dry mouth symptoms, a worrying reporting bias. There is some low quality evidence that acupuncture results in a small increase in saliva production in patients with dry mouth following radiotherapy. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms or saliva production in patients with Sjögren's Syndrome. Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation. Plain language summary Non‐drug treatments for dry mouth symptoms Review question This review, carried out by authors of the Cochrane Oral Health Group, has been produced to assess the effects of non‐drug treatments used to stimulate saliva production for the relief of dry mouth (xerostomia) symptoms. Background Dry mouth is a common problem with an estimated incidence of between 10% and 26% in men and between 10% and 33% in women, which may or may not be due to reduced saliva secretion. Common causes of dry mouth include the side effects of many commonly prescribed medications, diseases (such as Sjögren's syndrome where the immune system destroys tissues in the glands which produce saliva) and radiotherapy treatments for head and neck cancers. Saliva moistens the skin in the mouth and helps to maintain oral health. The presence of saliva facilitates speech, acts to wash away food residue from around the teeth, neutralises potentially damaging food and bacterial acids, enhances a person's ability to taste the food, and generally lubricates the mouth. Saliva also acts to soften food, making it easier to chew and swallow. Enzymes in saliva start the digestion of starch and fats, and other substances in saliva, such as epidermal growth factors, promote tissue growth, differentiation and wound healing. The antibacterial, antifungal and antiviral agents in saliva balance the oral flora and help to prevent oral infections, while the minerals in saliva help to maintain tooth enamel. Non‐drug treatments such as acupuncture, mild electrical stimulation, lasers, tooth brushing and other stimulation techniques are used to improve dry mouth symptoms. Study characteristics The evidence on which this review is based was up‐to‐date as of 16 April 2013. Nine studies were included in this review. A total of 366 adult participants took part in these trials, with an average of 40 participants per trial, and an age range from 12 to 77 years. The causes of dry mouth were radiotherapy for oral cancers in four trials, Sjögren's syndrome in three trials, medication‐related in one trial, and in the remaining trial participants had a range of causes of dry mouth. The included studies were divided into three groups, according the interventions evaluated. 1. Five small studies with a total 153 participants evaluated acupuncture. 2. Three studies evaluated electrostimulation devices. 3. One study evaluated a power toothbrush. Key results The five studies evaluating the effects of acupuncture in people who had dry mouth were generally of poor quality. There was no evidence of a difference in dry mouth symptoms, but there was some evidence of a small increase in saliva production which persisted for a year after the end of the acupuncture treatment. There may not have been enough people included in the trials to show a difference in dry mouth, or it may have been that both the real acupuncture and the 'placebo' acupuncture had some beneficial effect. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). The studies evaluating the effects of electrostimulation devices were poorly conducted and reported, and provided insufficient evidence to determine the effects of these devices on either dry mouth or saliva production. The single small study of a powered versus a manual toothbrush also found no difference for either dry mouth or saliva production. None of the included studies reported the outcomes of duration of effectiveness, quality of life, patient satisfaction, or oral health assessment. Quality of the evidence These studies were generally of poor quality (low and very low).", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Furness, S; Bryan, G; McMillan, R; Birchenough, S; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD009603.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "9fb32b6a-68de-4835-8007-b0c293d7667f", "pmid": "", "title": "Interventions for pityriasis rosea", "imported": false, "abstract": "Abstract - Background Pityriasis rosea is a scaly, itchy rash that mainly affects young adults and lasts for 2 to 12 weeks. The effects of many available treatments are uncertain. This is an update of a Cochrane Review first published in 2007. Objectives To assess the effects of interventions for the management of pityriasis rosea in any individual diagnosed by a medical practitioner. Search methods We updated our searches of the following databases to October 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched five trials registers. We also checked the reference lists of included and excluded studies, contacted trial authors, scanned the abstracts from major dermatology conference proceedings, and searched the CAB Abstracts database. We searched PubMed for adverse effects to November 2018. Selection criteria Randomised controlled trials of interventions in pityriasis rosea. Treatment could be given in a single therapy or in combination. Eligible comparators were no treatment, placebo, vehicle only, another active compound, or placebo radiation treatment. Data collection and analysis We used standard methodological procedures expected by the Cochrane. Our key outcomes were good or excellent rash improvement within two weeks, rated separately by the participant and medical practitioner; serious adverse events; resolution of itch within two weeks (participant‐rated); reduction in itch score within two weeks (participant‐rated); and minor participant‐reported adverse events not requiring withdrawal of the treatment. Main results We included 14 trials (761 participants). In general, risk of selection bias was unclear or low, but risk of performance bias and reporting bias was high for 21% of the studies. Participant age ranged from 2 to 60 years, and sex ratio was similar. Disease severity was measured by various severity indices, which the included studies did not categorise. Six studies were conducted in India, three in Iran, two in the Philippines, and one each in Pakistan, the USA, and China. The included studies were conducted in dermatology departments and a paediatric clinic. Study duration ranged from 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding source. The included studies assessed macrolide antibiotics, an antiviral agent, phototherapy, steroids and antihistamine, and Chinese medicine. None of the studies measured participant‐rated good or excellent rash improvement. All reported outcomes were assessed within two weeks of treatment, except for adverse effects, which were measured throughout treatment. There is probably no difference between oral clarithromycin and placebo in itch resolution (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.47 to 1.52; 1 study, 28 participants) or rash improvement (medical practitioner‐rated) (RR 1.13, 95% CI 0.89 to 1.44; 1 study, 60 participants). For this comparison, there were no serious adverse events (1 study, 60 participants); minor adverse events and reduction in itch score were not measured; and all evidence was of moderate quality. When compared with placebo, erythromycin may lead to increased rash improvement (medical practitioner‐rated) (RR 4.02, 95% CI 0.28 to 56.61; 2 studies, 86 participants, low‐quality evidence); however, the 95% CI indicates that the result may also be compatible with a benefit of placebo, and there may be little or no difference between treatments. Itch resolution was not measured, but one study measured reduction in itch score, which is probably larger with erythromycin (MD 3.95, 95% CI 3.37 to 4.53; 34 participants, moderate‐quality evidence). In the same single, small trial, none of the participants had a serious adverse event, and there was no clear difference between groups in minor adverse events, which included gastrointestinal upset (RR 2.00, CI 0.20 to 20.04; moderate‐quality evidence). Two trials compared oral azithromycin to placebo or vitamins. There is probably no difference between groups in itch resolution (RR 0.83, 95% CI 0.28 to 2.48) or reduction in itch score (MD 0.04, 95% CI −0.35 to 0.43) (both outcomes based on one study; 70 participants, moderate‐quality evidence). Low‐quality evidence from two studies indicates there may be no difference between groups in rash improvement (medical practitioner‐rated) (RR 1.02, 95% CI 0.52 to 2.00; 119 participants). In these same two studies, no serious adverse events were reported, and there was no clear difference between groups in minor adverse events, specifically mild abdominal pain (RR 5.82, 95% CI 0.72 to 47.10; moderate‐quality evidence). Acyclovir was compared to placebo, vitamins, or no treatment in three trials (all moderate‐quality evidence). Based on one trial (21 participants), itch resolution is probably higher with placebo than with acyclovir (RR 0.34, 95% CI 0.12 to 0.94); reduction in itch score was not measured. However, there is probably a significant difference between groups in rash improvement (medical practitioner‐rated) in favour of acyclovir versus all comparators (RR 2.45, 95% CI 1.33 to 4.53; 3 studies, 141 participants). Based on the same three studies, there were no serious adverse events in either group, and there was probably no difference between groups in minor adverse events (only one participant in the placebo group experienced abdominal pain and diarrhoea). One trial compared acyclovir added to standard care (calamine lotion and oral cetirizine) versus standard care alone (24 participants). The addition of acyclovir may lead to increased itch resolution (RR 4.50, 95% CI 1.22 to 16.62) and reduction in itch score (MD 1.26, 95% CI 0.74 to 1.78) compared to standard care alone. Rash improvement (medical practitioner‐rated) was not measured. The trial reported no serious adverse events in either group, and there may be no difference between groups in minor adverse events, such as headache (RR 7.00, 95% CI 0.40 to 122.44) (all results based on low‐quality evidence). Authors' conclusions When compared with placebo or no treatment, oral acyclovir probably leads to increased good or excellent, medical practitioner‐rated rash improvement. However, evidence for the effect of acyclovir on itch was inconclusive. We found low‐ to moderate‐quality evidence that erythromycin probably reduces itch more than placebo. Small study sizes, heterogeneity, and bias in blinding and selective reporting limited our conclusions. Further research is needed to investigate different dose regimens of acyclovir and the effect of antivirals on pityriasis rosea. Plain language summary Treatments for pityriasis rosea Background Pityriasis rosea is a common scaly rash prevalent in young adults. A patch of redness and scales is followed by widespread rash. Pityriasis rosea usually resolves within 2 to 12 weeks; however, the rash can resemble a serious contagious skin condition, causing concern. Moreover, pityriasis rosea can cause moderate to severe itching, making effective treatment necessary. Review question We wanted to evaluate the effectiveness and safety of treatments for pityriasis rosea. Eligible treatments were topical, systemic (oral or injected medicines that work throughout the entire body), or light therapy, given alone or in combination with another treatment, and compared against no treatment, placebo (an identical but inactive treatment), vehicle (inactive ingredients that help deliver an active treatment) only, or another active treatment. As spontaneous recovery usually occurs between 2 and 12 weeks in cases of untreated pityriasis rosea, we considered outcomes reported at two weeks. Study characteristics The evidence is current to October 2018. We included 14 studies with a total of 761 participants aged between 2 and 60 years (similar numbers of males and females). Most studies were conducted in Asia in dermatology departments and lasted between 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding sources. Disease severity was assessed by various measures, but participants were not categorised into mild, moderate, or severe disease. Important treatments assessed by the studies included various antibiotics and acyclovir (a drug meant to treat herpes infections), which were compared to placebo, no treatment, or standard care. Additional treatments included phototherapy, corticosteroids and antihistamine, and Chinese medicine (potenline). Most studies assessed treatment used for one week. All reported outcomes were assessed within two weeks of treatment, except for side effects, which were measured throughout treatment. None of the included studies reported on the participant's rating of rash improvement. Itch was always participant‐assessed. Rash improvement was rated as good or excellent. There is probably no difference between clarithromycin and placebo in medical practitioner‐rated rash improvement or itch resolution, and no serious adverse events were reported (all moderate‐quality evidence). Reduction in itch score and minor side effects were not measured. Similarly, there may be no difference in medical practitioner‐rated rash improvement between azithromycin and placebo or vitamins, but erythromycin may lead to increased rash improvement when compared to placebo; however, the results show there may be a benefit with placebo or little or no difference between treatments (low‐quality evidence for both outcomes). There is probably no difference between azithromycin and comparators in itch resolution or reduction in itch score; there was no clear difference in minor side effects, such as mild abdominal pain (both moderate‐quality evidence). When comparing erythromycin to placebo, itch resolution was not measured, but there is probably a greater reduction in itch score with erythromycin. There was no clear difference in the likelihood of minor side effects, such as gastrointestinal upset, between groups (moderate‐quality evidence for both outcomes). A single study suggested that acyclovir is probably less effective than placebo in achieving itch resolution (but itch score reduction was not measured). However, results from three studies indicate that acyclovir is probably significantly more beneficial than placebo, no treatment, or vitamin tablets in medical practitioner‐rated rash improvement. There is probably no difference between acyclovir and placebo in the incidence of minor side effects: one participant in the placebo group experienced mild abdominal pain and diarrhoea (all outcomes based on moderate‐quality evidence). A single trial indicated that acyclovir used in combination with standard care (calamine (anti‐itch lotion) and the antihistamine cetirizine) may reduce itch score and increase itch resolution (low‐quality evidence). Medical practitioner‐rated rash improvement was not measured. There may be no difference between groups in minor side effects, such as headache, increased sleep, sickness, and impact on taste. None of the studies reported serious adverse events (low‐ to moderate‐quality evidence). Quality of the evidence The quality of the evidence for the main comparisons was low to moderate. Many of the results were based on a small number of trials, with a low number of participants. There was also some variation amongst the trial results and concerns over study design.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Contreras‐Ruiz, J, Peternel, S, Jiménez Gutiérrez, C, Culav‐Koscak, I, Reveiz, L, Silbermann‐Reynoso, MDL", "articleTypes": [], "doi": "10.1002/14651858.CD005068.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.797Z" }, { "id": "9fc050e7-21e6-458d-a388-2a1a17c40440", "pmid": "", "title": "Transitional discharge interventions for people with schizophrenia", "imported": false, "abstract": "Abstract - Background Schizophrenia is a chronic mental illness characterized by delusions, hallucinations, and important functional and social disability. Interventions labeled as 'transitional' add to care plans made during the hospital stay in preparation for discharge. They also include interventions developed after discharge to support people with serious mental illness as they make the transition from the hospital to the community. Transitional discharge interventions may anticipate the future needs of the patient after discharge by co‐ordinating the different levels of the health system that can effectively guarantee continuity of care in the community. This occurs through the provision of therapeutic relationships which give a safety net throughout the discharge and community reintegration processes to improve the general condition of users, level of functioning, use of health resources, and satisfaction with care. Objectives To assess the effects of transitional discharge interventions for people with schizophrenia. Search methods On 7 December 2022, we searched the Cochrane Schizophrenia Group's Study‐Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, PubMed, CINAHL, ClinicalTrials.gov, ISRCTN, PsycINFO, and WHO ICTRP. Selection criteria Randomized controlled trials (RCTs) evaluating the effects of transitional discharge interventions in people with schizophrenia and schizophrenia‐related disorders. Eligible interventions included three key elements: predischarge planning, co‐ordination of care and follow‐up, and postdischarge support. Data collection and analysis We used standard Cochrane methods. Outcomes of this review included global state (relapse), service use (hospitalization), general functioning, satisfaction with care, adverse effects/events, quality of life, and direct costs. For binary outcomes, we calculated risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardized mean difference (SMD) and their 95% CIs. We used GRADE to assess certainty of evidence. Main results We found 12 studies with 1748 participants comparing transitional discharge interventions to usual care. All were parallel‐group RCTs. No studies assessed global state (relapse) or reported data about adverse events/effects. All studies had a high risk of bias, mainly due to serious concerns about allocation concealment, deviations from intended interventions, measurement of the outcomes, and missing outcome data. Transitional discharge interventions may make little to no difference in service use (hospitalization) at short‐ and long‐term follow‐ups, but the evidence is very uncertain (RR 1.18, 95% CI 0.55 to 2.50; I 2 = 54%; 4 studies, 462 participants; very low‐certainty evidence). Transitional discharge intervention may increase the levels of functioning after discharge (clinically important change in general functioning) (SMD 0.95, 95% CI −0.06 to 1.97; I² = 95%; 4 studies, 437 participants; very low‐certainty evidence) and may increase the proportion of participants who are satisfied with the intervention (clinically important change in satisfaction) (RR 1.96, 95% CI 1.37 to 2.80; 1 study, 76 participants; very low‐certainty evidence), but for both outcomes the evidence is very uncertain. Transitional discharge intervention may make little to no difference in quality of life compared to treatment as usual (SMD 0.24, 95% CI −0.30 to 0.78; I² = 90%; 4 studies, 748 participants; very low‐certainty evidence), but we are very uncertain. For direct costs, one study with 124 participants did not report full details and thus the results were inconclusive. Authors' conclusions There is currently no clear evidence for or against implementing transitional discharge interventions for people with schizophrenia. Transitional discharge interventions may improve patient satisfaction and functionality, but this evidence is also very uncertain. For future research, it is important to improve the quality of the conduct and reporting of these trials, including using validated tools for measuring their outcomes. Plain language summary What are the benefits of transitional discharge care for people with schizophrenia? Key messages – Transitional discharge care (an intervention that supports a person move from a stay in hospital to the community) may make little to no difference in admissions to hospital and quality of life, and may improve how well a person functions in day‐to‐day life and how happy they are with their treatment when they return home, but we are very uncertain about the results. – The results on costs of running the transitional discharge care program are inconclusive, and the studies provided no information on relapse (a new mental health crisis) or unwanted effects. – We need more and better studies to investigate how to support people with schizophrenia or schizophrenia‐related disorders during the transition from hospital to community. What is schizophrenia? Schizophrenia is a persistent and severe mental health condition where people have hallucinations (where they hear, see, smell, taste, or feel things that appear to be real but only exist in their mind) and delusions (a strong belief in something that is untrue), among other debilitating symptoms, leading to poor quality of life. People with schizophrenia‐related disorders have symptoms that are similar to those of schizophrenia. The illness varies, with people having different symptoms at different times, often with them requiring admission to hospital for treatment. What happens when a person with schizophrenia or schizophrenia‐related disorders is discharged from hospital? People with schizophrenia or schizophrenia‐related disorders are sometimes admitted to hospital to improve their health, and afterward, they are discharged to their homes or other care facilities. This transition might be difficult and frightening for them and their carers, and they may need help to adapt. There are some interventions to support people with schizophrenia or schizophrenia‐related disorders after they leave the hospital, such as case management with an expert guide or continuous care with a nurse. What is transitional discharge care? Transitional discharge care is an intervention which provides support to people leaving hospital to cover their medical, practical, and emotional needs. This starts before hospital discharge and continues until people are confident in their homes or care facilities. This may include help with housing; communicating and co‐ordinating among healthcare staff, patients, and families; planning meetings; sessions with families; visits to the neighborhood; talking therapy sessions; telephone and face‐to‐face support; and support groups focusing on recreation, medication, shopping, cooking, and financial responsibilities. What did we want to find out? We wanted to know whether transitional discharge care helps people with schizophrenia or schizophrenia‐related disorders when leaving the hospital, especially if it reduces the rate of a new mental health crisis (relapse), repeat admissions to hospital, overall functioning in day‐to‐day life, satisfaction with the care they receive, quality of life, unwanted effects, and costs. What did we do? We searched for studies that investigated whether transitional discharge care, compared to no transitional discharge care or usual care, was effective in adults with schizophrenia or schizophrenia‐related disorders. What did we find? We found 12 studies with 1748 people that compared transitional discharge care to usual care. Transitional discharge care may make little to no difference to admissions to hospital (4 studies, 462 people). Transitional discharge care may improve functioning (4 studies, 437 people) and may increase people's satisfaction with care (1 study, 76 people), but we are very uncertain about the results. Transitional discharge care may make little to no difference to quality of life (4 studies, 748 people). The results on costs were inconclusive as the study did not fully report the methods (1 study, 124 people). ​​ None of the included studies provided data for relapse or unwanted effects of transitional discharge care. What are the limitations of the evidence? All 12 studies had problems with their methods and results were inconsistent. Some studies included people with other mental disorders, so the results might not apply directly to people with schizophrenia or schizophrenia‐related disorders. Therefore, we have very low confidence in our findings. How up to date is this evidence? The evidence is up to date to December 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Roson Rodriguez, P; Chen, X; Arancibia, M; Garegnani, L; Escobar Liquitay, CM; Mohammad, HA; Franco, JVA", "articleTypes": [], "doi": "10.1002/14651858.CD009788.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "9fc4636a-bc22-4cee-8c16-f73acd23c92b", "pmid": "", "title": "Ganoderma lucidum (Reishi mushroom) for cancer treatment", "imported": false, "abstract": "Abstract - Background Ganoderma lucidum is a natural medicine that is widely used and recommended by Asian physicians and naturopaths for its supporting effects on immune system. Laboratory research and a handful of preclinical trials have suggested that G. lucidum carries promising anticancer and immunomodulatory properties. The popularity of taking G. lucidum as an alternative medicine has been increasing in cancer patients. However, there is no systematic review that has been conducted to evaluate the actual benefits of G. lucidum in cancer treatment. Objectives To evaluate the clinical effects of G. lucidum on long‐term survival, tumour response, host immune functions and quality of life in cancer patients, as well as adverse events associated with its use. Search methods We searched an extensive set of databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, NIH, AMED, CBM, CNKI, CMCC and VIP Information/Chinese Scientific Journals Database was searched for randomised controlled trials (RCTs) in October 2011. Other strategies used were scanning the references of articles retrieved, handsearching of the International Journal of Medicinal Mushrooms and contact with herbal medicine experts and manufacturers of G. lucidum . For this update we updated the searches in February 2016. Selection criteria To be eligible for being included in this review, studies had to be RCTs comparing the efficacy of G. lucidum medications to active or placebo control in patients with cancer that had been diagnosed by pathology. All types and stages of cancer were eligible for inclusion. Trials were not restricted on the basis of language. Data collection and analysis Five RCTs met the inclusion criteria and were included in this review. Two independent review authors assessed the methodological quality of individual trials. Common primary outcomes were tumour response evaluated according to the World Health Organization (WHO) criteria, immune function parameters such as natural killer (NK)‐cell activity and T‐lymphocyte co‐receptor subsets, and quality of life measured by the Karnofsky scale score. No trial had recorded long‐term survival rates. Associated adverse events were reported in one study. A meta‐analysis was performed to pool available data from the primary trials. Results were gauged using relative risks (RR) and standard mean differences (SMD) for dichotomous and continuous data respectively, with a 95% confidence interval (CI). Main results The methodological quality of primary studies was generally unsatisfying and the results were reported inadequately in many aspects. Additional information was not available from primary trialists. The meta‐analysis results showed that patients who had been given G. lucidum alongside with chemo/radiotherapy were more likely to respond positively compared to chemo/radiotherapy alone (RR 1.50; 95% CI 0.90 to 2.51, P = 0.02). G. lucidum treatment alone did not demonstrate the same regression rate as that seen in combined therapy. The results for host immune function indicators suggested that G. lucidum simultaneously increases the percentage of CD3, CD4 and CD8 by 3.91% (95% CI 1.92% to 5.90%, P < 0.01), 3.05% (95% CI 1.00% to 5.11%, P < 0.01) and 2.02% (95% CI 0.21% to 3.84%, P = 0.03), respectively. In addition, leukocyte, NK‐cell activity and CD4/CD8 ratio were marginally elevated. Four studies showed that patients in the G. lucidum group had relatively improved quality of life in comparison to controls. One study recorded minimal side effects, including nausea and insomnia. No significant haematological or hepatological toxicity was reported. Authors' conclusions Our review did not find sufficient evidence to justify the use of G. lucidum as a first‐line treatment for cancer. It remains uncertain whether G. lucidum helps prolong long‐term cancer survival. However, G. lucidum could be administered as an alternative adjunct to conventional treatment in consideration of its potential of enhancing tumour response and stimulating host immunity. G. lucidum was generally well tolerated by most participants with only a scattered number of minor adverse events. No major toxicity was observed across the studies. Although there were few reports of harmful effect of G. lucidum , the use of its extract should be judicious, especially after thorough consideration of cost‐benefit and patient preference. Future studies should put emphasis on the improvement in methodological quality and further clinical research on the effect of G. lucidum on cancer long‐term survival are needed. An update to this review will be performed every two years. Plain language summary G. lucidum (Reishi mushroom) for cancer treatment There have been an increasing number of patients diagnosed with cancer each year. Certain malignancies have been a major cause of death in some populations. People who have been diagnosed with cancer want to do everything they can to combat the disease, manage its symptoms and cope with the side effects of radio/chemotherapy. Many turn to complementary and alternative medicine. G. lucidum extract is a medication that has been widely used by traditional Chinese medicine (TCM) practitioners for this regard. It is usually recommended as an immune system support supplement in cancer treatment. Latest laboratory research and preclinical trials of G. lucidum have shown promising results of its antitumour activity. However, clinical evidence of its efficacy is sparse and a systematic review is in need to provide collective information for health‐care consumers. Our review identified and subsequently included five relevant randomised controlled trials. A total of 373 subjects were analysed. A meta‐analysis was performed to pool available data from individual trials. Our results found that patients with G. lucidum extract in their anticancer regimen were 1.27 times more likely to respond to chemotherapy or radiotherapy than those without. However, the data failed to demonstrate significant effect on tumour shrinkage when it was used alone. In addition, G. lucidum could stimulate host immune functions by considerably increasing CD3, CD4 and CD8 lymphocyte percentages. Nevertheless, natural killer (NK)‐cell activity, which has been suggested to be an indicator of self‐defence against tumour cell, was marginally elevated. Patients in the G. lucidum group were found to have a relatively better quality of life after treatment than those in the control group. A few cases of minor side effect associated with G. lucidum treatment including nausea and insomnia were reported. There are limitations of the results from this systematic review. First, most included studies were small and there were concerns on the methodological quality of individual trials. Second, all participants in the individual trials were recruited from the Chinese population. Together, the robustness and applicability of the results were largely affected.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Jin, X, Ruiz Beguerie, J, Sze, DMY, Chan, GCF", "articleTypes": [], "doi": "10.1002/14651858.CD007731.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.785Z" }, { "id": "9fd46623-4a41-436f-858f-dde4da8f524c", "pmid": "", "title": "Drugs for preventing malaria in pregnant women in endemic areas: any drug regimen versus placebo or no treatment", "imported": false, "abstract": "Abstract - Background Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. To reduce these effects, the World Health Organization recommends that pregnant women living in malaria endemic areas sleep under insecticide‐treated bednets, are treated for malaria illness and anaemia, and receive chemoprevention with an effective antimalarial drug during the second and third trimesters. Objectives To assess the effects of malaria chemoprevention given to pregnant women living in malaria endemic areas on substantive maternal and infant health outcomes. We also summarised the effects of intermittent preventive treatment with sulfadoxine‐pyrimethamine (SP) alone, and preventive regimens for Plasmodium vivax. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and reference lists up to 1 June 2014. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs of any antimalarial drug regimen for preventing malaria in pregnant women living in malaria‐endemic areas compared to placebo or no intervention. In the mother, we sought outcomes that included mortality, severe anaemia, and severe malaria; anaemia, haemoglobin values, and malaria episodes; indicators of malaria infection, and adverse events. In the baby, we sought foetal loss, perinatal, neonatal and infant mortality; preterm birth and birthweight measures; and indicators of malaria infection. We included regimens that were known to be effective against the malaria parasite at the time but may no longer be used because of parasite drug resistance. Data collection and analysis Two review authors applied inclusion criteria, assessed risk of bias and extracted data. Dichotomous outcomes were compared using risk ratios (RR), and continuous outcomes using mean differences (MD); both are presented with 95% confidence intervals (CI). We assessed the quality of evidence using the GRADE approach. Main results Seventeen trials enrolling 14,481 pregnant women met our inclusion criteria. These trials were conducted between 1957 and 2008, in Nigeria (three trials), The Gambia (three trials), Kenya (three trials), Mozambique (two trials), Uganda (two trials), Cameroon (one trial), Burkina Faso (one trial), and Thailand (two trials). Six different antimalarials were evaluated against placebo or no intervention; chloroquine (given weekly), pyrimethamine (weekly or monthly), proguanil (daily), pyrimethamine‐dapsone (weekly or fortnightly), and mefloquine (weekly), or intermittent preventive therapy with SP (given twice, three times or monthly). Trials recruited women in their first or second pregnancy (eight trials); only multigravid women (one trial); or all women (eight trials). Only six trials had adequate allocation concealment. For women in their first or second pregnancy, malaria chemoprevention reduces the risk of moderate to severe anaemia by around 40% (RR 0.60, 95% CI 0.47 to 0.75; three trials, 2503 participants, high quality evidence ), and the risk of any anaemia by around 17% (RR 0.83, 95% CI 0.74 to 0.93; five trials,, 3662 participants, high quality evidence ). Malaria chemoprevention reduces the risk of antenatal parasitaemia by around 61% (RR 0.39, 95% CI 0.26 to 0.58; seven trials, 3663 participants, high quality evidence ), and two trials reported a reduction in febrile illness ( low quality evidence ). There were only 16 maternal deaths and these trials were underpowered to detect an effect on maternal mortality ( very low quality evidence ). For infants of women in their first and second pregnancies, malaria chemoprevention probably increases mean birthweight by around 93 g (MD 92.72 g, 95% CI 62.05 to 123.39; nine trials, 3936 participants, moderate quality evidence ), reduces low birthweight by around 27% (RR 0.73, 95% CI 0.61 to 0.87; eight trials, 3619 participants, moderate quality evidence ), and reduces placental parasitaemia by around 46% (RR 0.54, 95% CI 0.43 to 0.69; seven trials, 2830 participants, high quality evidence ). Fewer trials evaluated spontaneous abortions, still births, perinatal deaths, or neonatal deaths, and these analyses were underpowered to detect clinically important differences. In multigravid women, chemoprevention has similar effects on antenatal parasitaemia (RR 0.38, 95% CI 0.28 to 0.50; three trials, 977 participants, high quality evidence )but there are too few trials to evaluate effects on other outcomes. In trials giving chemoprevention to all pregnant women irrespective of parity, the average effects of chemoprevention measured in all women indicated it may prevent severe anaemia (defined by authors, but at least < 8 g/L: RR 0.19, 95% CI 0.05 to 0.75; two trials, 1327 participants, low quality evidence), but consistent benefits have not been shown for other outcomes. In an analysis confined only to intermittent preventive therapy with SP, the estimates of effect and the quality of the evidence were similar. A summary of a single trial in Thailand of prophylaxis against P. vivax showed chloroquine prevented vivax infection (RR 0.01, 95% CI 0.00 to 0.20; one trial, 942 participants). Authors' conclusions Routine chemoprevention to prevent malaria and its consequences has been extensively tested in RCTs, with clinically important benefits on anaemia and parasitaemia in the mother, and on birthweight in infants. 8 May 2019 No update planned Review superseded The intervention is clearly effective. The questions now are around head‐to‐head comparisons not included in this review. Plain language summary The effect of taking antimalarial drugs routinely to prevent malaria in pregnancy Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. For this reason, women are encouraged to try and prevent malaria infection during pregnancy by sleeping under mosquito bed‐nets, and by taking drugs effective against malaria throughout pregnancy as chemoprevention. This Cochrane Review looked at all drug regimens compared to placebo. The review authors sought to summarise and quantify the overall effects of chemoprevention. Seventeen trials were included, all conducted between 1957 and 2008, and all but two in countries of Africa. For women in their first or second pregnancy, malaria chemoprevention prevents moderate to severe anaemia ( high quality evidence ); and prevents malaria parasites being detected in the blood ( high quality evidence ). It may also prevent malaria illness. We don't know if it prevents maternal deaths, as this would require very large studies to detect an effect. In their infants, malaria chemoprevention improves the average birthweight ( moderate quality evidence ), and reduces the number of low birthweight infants ( moderate quality evidence ). We are not sure if chemoprevention reduces mortality of babies in the first week, month and year, as again studies would need to be very large to show these effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Radeva‐Petrova, D, Kayentao, K, ter Kuile, FO, Sinclair, D, Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD000169.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.096Z" }, { "id": "9fe90995-cb5c-4c8f-9a2b-94ae12d75c15", "pmid": "", "title": "Hyperbaric oxygen therapy for late radiation tissue injury", "imported": false, "abstract": "Abstract - Background This is the third update of the original Cochrane Review published in July 2005 and updated previously in 2012 and 2016. Cancer is a significant global health issue. Radiotherapy is a treatment modality for many malignancies, and about 50% of people having radiotherapy will be long‐term survivors. Some will experience late radiation tissue injury (LRTI), developing months or years following radiotherapy. Hyperbaric oxygen therapy (HBOT) has been suggested as a treatment for LRTI based on the ability to improve the blood supply to these tissues. It is postulated that HBOT may result in both healing of tissues and the prevention of complications following surgery and radiotherapy. Objectives To evaluate the benefits and harms of hyperbaric oxygen therapy (HBOT) for treating or preventing late radiation tissue injury (LRTI) compared to regimens that excluded HBOT. Search methods We used standard, extensive Cochrane search methods. The latest search date was 24 January 2022. Selection criteria We included randomised controlled trials (RCTs) comparing the effect of HBOT versus no HBOT on LRTI prevention or healing. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. survival from time of randomisation to death from any cause; 2. complete or substantial resolution of clinical problem; 3. site‐specific outcomes; and 4. adverse events. Our secondary outcomes were 5. resolution of pain; 6. improvement in quality of life, function, or both; and 7. site‐specific outcomes. We used GRADE to assess certainty of evidence. Main results Eighteen studies contributed to this review (1071 participants) with publications ranging from 1985 to 2022. We added four new studies to this updated review and evidence for the treatment of radiation proctitis, radiation cystitis, and the prevention and treatment of osteoradionecrosis (ORN). HBOT may not prevent death at one year (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.47 to 1.83; I 2 = 0%; 3 RCTs, 166 participants; low‐certainty evidence). There is some evidence that HBOT may result in complete resolution or provide significant improvement of LRTI (RR 1.39, 95% CI 1.02 to 1.89; I 2 = 64%; 5 RCTs, 468 participants; low‐certainty evidence) and HBOT may result in a large reduction in wound dehiscence following head and neck soft tissue surgery (RR 0.24, 95% CI 0.06 to 0.94; I 2 = 70%; 2 RCTs, 264 participants; low‐certainty evidence). In addition, pain scores in ORN improve slightly after HBOT at 12 months (mean difference (MD) −10.72, 95% CI −18.97 to −2.47; I 2 = 40%; 2 RCTs, 157 participants; moderate‐certainty evidence). Regarding adverse events, HBOT results in a higher risk of a reduction in visual acuity (RR 4.03, 95% CI 1.65 to 9.84; 5 RCTs, 438 participants; high‐certainty evidence). There was a risk of ear barotrauma in people receiving HBOT when no sham pressurisation was used for the control group (RR 9.08, 95% CI 2.21 to 37.26; I 2 = 0%; 4 RCTs, 357 participants; high‐certainty evidence), but no such increase when a sham pressurisation was employed (RR 1.07, 95% CI 0.52 to 2.21; I 2 = 74%; 2 RCTs, 158 participants; high‐certainty evidence). Authors' conclusions These small studies suggest that for people with LRTI affecting tissues of the head, neck, bladder and rectum, HBOT may be associated with improved outcomes (low‐ to moderate‐certainty evidence). HBOT may also result in a reduced risk of wound dehiscence and a modest reduction in pain following head and neck irradiation. However, HBOT is unlikely to influence the risk of death in the short term. HBOT also carries a risk of adverse events, including an increased risk of a reduction in visual acuity (usually temporary) and of ear barotrauma on compression. Hence, the application of HBOT to selected participants may be justified. The small number of studies and participants, and the methodological and reporting inadequacies of some of the primary studies included in this review demand a cautious interpretation. More information is required on the subset of disease severity and tissue type affected that is most likely to benefit from this therapy, the time for which we can expect any benefits to persist and the most appropriate oxygen dose. Further research is required to establish the optimum participant selection and timing of any therapy. An economic evaluation should also be undertaken. Plain language summary Hyperbaric oxygen therapy for the treatment of the late effects of radiotherapy Key message – In selected people and areas of the body hyperbaric oxygen therapy (HBOT) may help resolve symptoms associated with late radiation tissue injury (LRTI) but further research is required to establish which people may respond and the best timing of such therapy. What are the problems after radiation treatment and how can it be treated? There is a risk of serious complications developing in the months and years after radiation treatment (radiotherapy) for cancer. These problems are collectively called LRTI and are due to progressive damage to normal tissue (cells within the body) that has been exposed to radiation. These problems can be very difficult to resolve, and there is some doubt as to the best approaches to treatment. HBOT involves breathing oxygen in a specially designed pressurised chamber. It is used to improve oxygen supply to damaged tissue and support healing. What did we want to find out? We wanted to find out if HBOT results in both healing of tissues and the prevention of complications following surgery in an irradiated field and radiotherapy for cancer. What did we do? We searched medical databases for clinical studies reporting the evidence for or against the ability of HBOT to improve these complications compared to either no treatment or alternative treatments. What were the main findings? There was some evidence that HBOT may improve outcomes in LRTI affecting both bone and soft tissues of the head and neck, the bladder and the lower bowel. There was also some evidence that HBOT may reduce wound breakdown and improve pain following LRTI. HBOT did not affect the risk of dying over the short time that these studies followed their patients. HBOT is generally safe and well‐tolerated, but there is a risk of becoming temporarily short‐sighted from the oxygen exposure and of injury to the ear drum on compression. What are the limitations of the evidence? The evidence was mainly limited by small numbers of people and studies, poor reporting of methods and results, and uncertainty as to the exact degree of improvement with HBOT. A study of costs would also be useful. How up to date is this evidence? The evidence is current to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lin, ZC, Bennett, MH, Hawkins, GC, Azzopardi, CP, Feldmeier, J, Smee, R, Milross, C", "articleTypes": [], "doi": "10.1002/14651858.CD005005.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.797Z" }, { "id": "9fee4a61-7dfa-4988-9ccc-8e2a0be6c4e4", "pmid": "", "title": "Helminth therapy (worms) for induction of remission in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease (IBD) is a chronic, globally‐occurring gastrointestinal disorder and a major cause of illness and disability. It is conventionally classified into Crohn’s disease (CD) and ulcerative colitis (UC). Helminths are parasitic worms with complex life cycles involving tissue‐ or lumen‐dwelling stages in their hosts, and causing long‐lasting or chronic infections that are frequently asymptomatic. Helminths modulate immune responses of their hosts, and many observational and experimental studies support the hypothesis that helminths suppress immune‐mediated chronic inflammation that occurs in asthma, allergy and IBD. Objectives The objective was to evaluate the efficacy and safety of helminth treatment for induction of remission in IBD. Search methods We searched the following databases from inception to 13 July 2013: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Inflammatory Bowel Disease Group Specialized Trials Register. We also searched four online trials registries, and abstracts from major meetings. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) where the intervention was any helminth species or combination of helminth species, administered in any dose and by any route and for any duration of exposure to people with active CD or UC, confirmed through any combination of clinical, endoscopic and histological criteria were eligible for inclusion. Data collection and analysis Two authors independently extracted data and assessed eligibility using a standardized data collection form. We used the RevMan software for analyses. The primary outcome was induction of remission as defined by the included studies. Secondary outcomes included clinical, histologic, or endoscopic improvement as defined by the authors, endoscopic mucosal healing, change in disease activity index score, change in quality of life score, hospital admissions, requirement for intravenous corticosteroids, surgery, study withdrawal and the incidence of adverse events. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. We calculated the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria. Main results Two RCTs (90 participants) were included. One trial assessed the efficacy and safety of Trichuris suis ( T. suis ) ova in patients with UC (n = 54). The other RCT was a phase one that assessed the safety and tolerability of T. suis ova in patients with CD (n = 36). The risk of bias in both studies was judged to be low. In the UC study, during the 12‐week study period, participants in the active arm received 2‐weekly aliquots of 2500 T. suis eggs, added to 0.8 mL of saline; those in the placebo arm received 0.8 mL saline only. There were sparse data available for the outcomes clinical remission and clinical improvement. Ten per cent (3/30) of patients in the T. suis arm entered remission compared to 4% (1/24) of patients in the placebo arm (RR 2.40, 95% CI 0.27 to 21.63). Forty‐three per cent (13/30) of patients in the T. suis group achieved clinical improvement compared to 17% (4/24) of placebo patients (RR 2.60, 95% CI 0.97 to 6.95). The mean ulcerative colitis disease activity index (UCDAI) score was lower in the T. suis group (6.1 +/‐ 0.61) compared to the placebo group (7.5 +/‐ 0.66) after 12 weeks of treatment (MD ‐1.40, 95% CI ‐1.75 to ‐1.05). There was only limited evidence relating to the proportion of patients who experienced an adverse event. Three per cent (1/30) of patients in the T. suis group experienced at least one adverse event compared to 12% (3/24) of placebo patients (RR 0.27, 95% CI 0.03 to 2.40). None of the adverse events reported in this study were judged to be related to the study treatment. GRADE analyses rated the overall quality of the evidence for the primary and secondary outcomes (i.e. clinical remission and improvement) as low due to serious imprecision. In the CD study, participants received a single treatment of T. suis ova at a dosage of 500 (n = 9), 2500 (n = 9), or 7500 (n = 9) embryonated eggs or matching placebo (n = 9). The CD study did not assess clinical remission or improvement as outcomes. There were sparse data on adverse events at two weeks. Thirty‐seven per cent (10/27) of patients in the T. suis group experienced at least one adverse event compared to 44% (4/9) of placebo patients (RR 0.83, 95% CI 0.35 to 2.01). Only one adverse event (dysgeusia) was judged to be possibly related to treatment in this study. Dysgeusia was reported in one patient in the T. suis group and in one patient in the placebo group. Authors' conclusions Currently, there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of helminths used to treat patients with IBD. The evidence for our primary efficacy outcomes in this review comes from one small study and is of low quality due to serious imprecision. We do not have enough evidence to determine whether helminths are safe when used in patients with UC and CD. Further RCTs are required to assess the efficacy and safety of helminth therapy in IBD. Plain language summary Helminth therapy (worms) for induction of remission in inflammatory bowel disease Inflammatory bowel disease (IBD) is comprised of two disorders: ulcerative colitis and Crohn’s disease. These disorders have both distinct and overlapping symptoms, but the underlying cause remains incompletely understood. Standard therapy for IBD includes sulfasalazine, 5‐ASA drugs, steroids, immunosuppressives such as azathioprine, 6‐mercaptopurine and methotrexate and biological agents such as infliximab. Helminths are worm‐like parasites, that inhabit larger organisms. Helminths cause changes in the immune systems of their hosts including an altered immunological response to antigens and this has implications for the treatment of inflammatory bowel disease which is thought to be caused by immune dysregulation. The purpose of this systematic review was to examine the effectiveness and safety of helminth therapy for inducing remission in people with IBD. This review identified two randomised controlled trials including a total of 90 participants. One study compared twice weekly treatment with helminths (an 0.8 mL solution containing 2500 live eggs of the helminth Trichuris suis ) for 12 weeks to a matching placebo (an 0.8 ml identical looking solution with no Trichuris suis eggs) in 54 patients with active ulcerative colitis. Few remissions occurred during the trial and helminth treatment had no detectable effect on these remissions. Ten per cent (3/30) of patients in the helminth group achieved remission compared to four per cent (1/24) of placebo patients. A higher proportion of patients in the helminth group (43% or 13/30) improved clinically compared to the placebo group (17% or 4/24). However, this difference could be a chance effect. We could not determine whether the proportion of patients who had a side effect was higher in either group. No observed side effects were thought to be related to treatment were reported in this study. The other study compared one treatment with various doses of helminths (a solution of 500, 2500 or 7500 Trichuris suis eggs) to a matching placebo in 36 patients with Crohn's disease. This study was designed to assess side effects and did not measure clinical remission or improvement. There amount of information available on side‐effects at two weeks was limited and the results were uncertain due to the small number of participants in the study. The only side effect that was judged to be possibly related to the study treatment was dysgeusia (a distortion of the sense of taste). This was reported in one patient in the helminth group and in one patient in the placebo group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and safety of helminths used to treat patients with IBD. The only information available relating to clinical improvement in patients with active ulcerative colitis comes from one small study. We do not know how safe helminths are when used in patients with ulcerative colitis and Crohn's disease. Further randomised controlled trials are required to assess the efficacy and safety of helminth therapy in IBD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Garg, SK; Croft, AM; Bager, P", "articleTypes": [], "doi": "10.1002/14651858.CD009400.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "9ff2feb1-93c7-4652-b681-53fc7604f218", "pmid": "", "title": "Chloral hydrate as a sedating agent for neurodiagnostic procedures in children", "imported": false, "abstract": "Abstract - Background This is an updated version of a Cochrane Review published in 2017. Paediatric neurodiagnostic investigations, including brain neuroimaging and electroencephalography (EEG), play an important role in the assessment of neurodevelopmental disorders. The use of an appropriate sedative agent is important to ensure the successful completion of the neurodiagnostic procedures, particularly in children, who are usually unable to remain still throughout the procedure. Objectives To assess the effectiveness and adverse effects of chloral hydrate as a sedative agent for non‐invasive neurodiagnostic procedures in children. Search methods We searched the following databases on 14 May 2020, with no language restrictions: the Cochrane Register of Studies (CRS Web) and MEDLINE (Ovid, 1946 to 12 May 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including Cochrane Epilepsy. Selection criteria Randomised controlled trials that assessed chloral hydrate agent against other sedative agent(s), non‐drug agent(s), or placebo. Data collection and analysis Two review authors independently evaluated studies identified by the search for their eligibility, extracted data, and assessed risk of bias. Results were expressed in terms of risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CIs). Main results We included 16 studies with a total of 2922 children. The methodological quality of the included studies was mixed. Blinding of the participants and personnel was not achieved in most of the included studies, and three of the 16 studies were at high risk of bias for selective reporting. Evaluation of the efficacy of the sedative agents was also underpowered, with all the comparisons performed in small studies. Fewer children who received oral chloral hydrate had sedation failure compared with oral promethazine (RR 0.11, 95% CI 0.01 to 0.82; 1 study; moderate‐certainty evidence). More children who received oral chloral hydrate had sedation failure after one dose compared to intravenous pentobarbital (RR 4.33, 95% CI 1.35 to 13.89; 1 study; low‐certainty evidence), but there was no clear difference after two doses (RR 3.00, 95% CI 0.33 to 27.46; 1 study; very low‐certainty evidence). Children with oral chloral hydrate had more sedation failure compared with rectal sodium thiopental (RR 1.33, 95% CI 0.60 to 2.96; 1 study; moderate‐certainty evidence) and music therapy (RR 17.00, 95% CI 2.37 to 122.14; 1 study; very low‐certainty evidence). Sedation failure rates were similar between groups for comparisons with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam and oral clonidine. Children who received oral chloral hydrate had a shorter time to adequate sedation compared with those who received oral dexmedetomidine (MD −3.86, 95% CI −5.12 to −2.6; 1 study), oral hydroxyzine hydrochloride (MD −7.5, 95% CI −7.85 to −7.15; 1 study), oral promethazine (MD −12.11, 95% CI −18.48 to −5.74; 1 study) (moderate‐certainty evidence for three aforementioned outcomes), rectal midazolam (MD −95.70, 95% CI −114.51 to −76.89; 1 study), and oral clonidine (MD −37.48, 95% CI −55.97 to −18.99; 1 study) (low‐certainty evidence for two aforementioned outcomes). However, children with oral chloral hydrate took longer to achieve adequate sedation when compared with intravenous pentobarbital (MD 19, 95% CI 16.61 to 21.39; 1 study; low‐certainty evidence), intranasal midazolam (MD 12.83, 95% CI 7.22 to 18.44; 1 study; moderate‐certainty evidence), and intranasal dexmedetomidine (MD 2.80, 95% CI 0.77 to 4.83; 1 study, moderate‐certainty evidence). Children who received oral chloral hydrate appeared significantly less likely to complete neurodiagnostic procedure with child awakening when compared with rectal sodium thiopental (RR 0.95, 95% CI 0.83 to 1.09; 1 study; moderate‐certainty evidence). Chloral hydrate was associated with a higher risk of the following adverse events: desaturation versus rectal sodium thiopental (RR 5.00, 95% 0.24 to 102.30; 1 study), unsteadiness versus intranasal dexmedetomidine (MD 10.21, 95% CI 0.58 to 178.52; 1 study), vomiting versus intranasal dexmedetomidine (MD 10.59, 95% CI 0.61 to 185.45; 1 study) (low‐certainty evidence for aforementioned three outcomes), and crying during administration of sedation versus intranasal dexmedetomidine (MD 1.39, 95% CI 1.08 to 1.80; 1 study, moderate‐certainty evidence). Chloral hydrate was associated with a lower risk of the following: diarrhoea compared with rectal sodium thiopental (RR 0.04, 95% CI 0.00 to 0.72; 1 study), lower mean diastolic blood pressure compared with sodium thiopental (MD 7.40, 95% CI 5.11 to 9.69; 1 study), drowsiness compared with oral clonidine (RR 0.44, 95% CI 0.30 to 0.64; 1 study), vertigo compared with oral clonidine (RR 0.15, 95% CI 0.01 to 2.79; 1 study) (moderate‐certainty evidence for aforementioned four outcomes), and bradycardia compared with intranasal dexmedetomidine (MD 0.17, 95% CI 0.05 to 0.59; 1 study; high‐certainty evidence). No other adverse events were significantly associated with chloral hydrate, although there was an increased risk of combined adverse events overall (RR 7.66, 95% CI 1.78 to 32.91; 1 study; low‐certainty evidence). Authors' conclusions The certainty of evidence for the comparisons of oral chloral hydrate against several other methods of sedation was variable. Oral chloral hydrate appears to have a lower sedation failure rate when compared with oral promethazine. Sedation failure was similar between groups for other comparisons such as oral dexmedetomidine, oral hydroxyzine hydrochloride, and oral midazolam. Oral chloral hydrate had a higher sedation failure rate when compared with intravenous pentobarbital, rectal sodium thiopental, and music therapy. Chloral hydrate appeared to be associated with higher rates of adverse events than intranasal dexmedetomidine. However, the evidence for the outcomes for oral chloral hydrate versus intravenous pentobarbital, rectal sodium thiopental, intranasal dexmedetomidine, and music therapy was mostly of low certainty, therefore the findings should be interpreted with caution. Further research should determine the effects of oral chloral hydrate on major clinical outcomes such as successful completion of procedures, requirements for an additional sedative agent, and degree of sedation measured using validated scales, which were rarely assessed in the studies included in this review. The safety profile of chloral hydrate should be studied further, especially for major adverse effects such as oxygen desaturation. Plain language summary The effectiveness of chloral hydrate as a sedative agent for children undergoing neurodiagnostic procedures Review question In children undergoing non‐invasive neurodiagnostic procedures, is chloral hydrate more effective at producing adequate sedation (slowing of brain activity) and safer than other ways of achieving sedation? Background Neurodiagnostic procedures are non‐invasive neurological investigations important for children with suspected neurological disorders. These investigations include brain imaging and brain electrical activity testing. For these tests to be successfully performed, the child needs to remain still for at least 30 to 45 minutes during the investigation period. Sedative agents are required for children, who are usually unable to remain still for this period of time. Search date The evidence is current to May 2020. Study characteristics We included 16 studies involving a total of 2922 children (age up to 18 years old) in the review. All of the included studies were performed in hospitals that provided neurodiagnostic services. Most studies assessed the following three main outcomes: proportion of children who were unsuccessfully sedated for the neurodiagnostic procedure; length of time taken for adequate sedation; and side effects associated with the sedative agent. The quality of the evidence was mixed, ranging from very low to high. The main reason for lowering the quality of the evidence was that those closely involved in the trials, such as the doctors giving the sedation or the parents of the child, were not masked to the sedative agent used in the child, which could have affected their recording or interpretation of the results. Key results We summarised the evidence of effectiveness and harms of oral chloral hydrate sedation when compared with other sedative agents. Our review suggests that oral chloral hydrate is just as effective a sedative agent with similar sedation failure rate when compared with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam, and oral clonidine; and probably a more effective sedative agent with a lower sedation failure rate when compared with oral promethazine. Whilst most of the included studies showed that chloral hydrate was safe with no increase in side effects when compared to other sedative agents, one study reported an increased risk of side effects with oral chloral hydrate when compared with intranasal dexmedetomidine. Quality of the evidence The quality of most of the evidence was poor due to flaws in study methods and the small sample size of each study, therefore our confidence in the results of the studies is reduced. Conclusions Apart from intravenous pentobarbital, rectal sodium thiopental, and music therapy, oral chloral hydrate is either just as effective or more effective as a sedating agent when compared to other sedating agents for children undergoing non‐invasive neurodiagnostic procedures. Given the poor quality of the evidence, we could draw no clear conclusions on the effectiveness or safety of any of the paediatric sedative agents studied in the review. Further study is needed to look at the side effects of oral chloral hydrate when compared to other sedatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Fong, CY; Lim, WK; Li, L; Lai, NM", "articleTypes": [], "doi": "10.1002/14651858.CD011786.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "a0029add-a1db-4fb3-91ec-2851a1755536", "pmid": "", "title": "Sapropterin dihydrochloride for phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria results from a deficiency of the enzyme phenylalanine hydroxylase. Dietary restriction of phenylalanine keeps blood phenylalanine concentration low. Most natural foods are excluded from diet and supplements are used to supply other nutrients. Recent publications report a decrease in blood phenylalanine concentration in some patients treated with sapropterin dihydrochloride. We examined the evidence for the use of sapropterin dihydrochloride to treat phenylketonuria. This is an update of a previously published Cochrane Review. Objectives To assess the safety and efficacy of sapropterin dihydrochloride in lowering blood phenylalanine concentration in people with phenylketonuria. Search methods We identified relevant trials from the Group's Inborn Errors of Metabolism Trials Register. Date of last search: 11 August 2014. We also searched ClinicalTrials.gov and Current controlled trials. Last search: 4 September 2014 We contacted the manufacturers of the drug (BioMarin Pharmaceutical Inc.) for information regarding any unpublished trials. Selection criteria Randomized controlled trials comparing sapropterin with no supplementation or placebo in people with phenylketonuria due to phenylalanine hydroxylase deficiency. Data collection and analysis Two authors independently assessed trials and extracted outcome data. Main results Two placebo‐controlled trials were included. One trial administered 10 mg/kg/day sapropterin in 89 children and adults with phenylketonuria whose diets were not restricted and who had previously responded to saproterin.This trial measured change in blood phenylalanine concentration. The second trial screened 90 children (4 to 12 years) with phenylketonuria whose diet was restricted, for responsiveness to sapropterin. Forty‐six responders entered the placebo‐controlled part of the trial and received 20 mg/kg/day sapropterin. This trial measured change in both phenylalanine concentration and protein tolerance. Both trials reported adverse events. The trials showed an overall low risk of bias; but both are Biomarin‐sponsored. One trial showed a significant lowering in blood phenylalanine concentration in the sapropterin group (10 mg/kg/day), mean difference ‐238.80 μmol/L (95% confidence interval ‐343.09 to ‐134.51); a second trial (20 mg/kg/day sapropterin) showed a non‐significant difference, mean difference ‐51.90 μmol/L (95% confidence interval ‐197.27 to 93.47). The second trial also reported a significant increase in phenylalanine tolerance, mean difference18.00 mg/kg/day (95% confidence interval 12.28 to 23.72) in the 20 mg/kg/day sapropterin group. Authors' conclusions There is evidence of short‐term benefit from using sapropterin in some people with sapropterin‐responsive forms of phenylketonuria; blood phenylalanine concentration is lowered and protein tolerance increased. There are no serious adverse events associated with using sapropterin in the short term. There is no evidence on the long‐term effects of sapropterin and no clear evidence of effectiveness in severe phenylketonuria. Plain language summary The use of sapropterin to lower phenylalanine concentration in blood in people with phenylketonuria. Phenylketonuria occurs due to an inherited deficiency of the enzyme phenylalanine hydroxylase. If untreated it causes an excessive accumulation of the amino acid phenylalanine in the body which prevents normal brain development. The established treatment for phenylketonuria consists of dietary restriction of natural protein but with prescribed phenylalanine‐free amino acid, mineral and vitamin supplements. With this treatment the long‐term outcome for people with phenylketonuria is excellent but the diet is onerous. Sapropterin dihydrochloride, the cofactor for phenylalanine hydroxylase, could lower phenylalanine concentration significantly in phenylketonuria and might allow a relaxation of dietary restrictions. The review identified two trials of sapropterin dihydrochloride; one in children and adults with no restricted diet and one in just children whose diet was restricted. The trials used different doses of sapropterin dihydrochloride (10 mg/kg/day and 20 mg/kg/day). We could not combine any data due to different formats of presentation. We found evidence to show that some people with mild or moderate phenylketonuria can benefit from the use of sapropterin dihydrochloride in the short term; the concentration of blood phenylalanine was lowered after treatment in both trials. The trial with the higher dose also measured the outcome change in protein tolerance. It reported an increase in protein tolerance in response to sapropterin. There were no adverse effects associated with the use of sapropterin dihydrochloride in the short term. We found no evidence on the effects of long‐term treatment. We could not draw any conclusions on its benefits in severe phenylketonuria.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Somaraju, UR; Merrin, M", "articleTypes": [], "doi": "10.1002/14651858.CD008005.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "a00b1279-84b6-42dd-8d89-1df51e7d7b61", "pmid": "", "title": "Venepuncture versus heel lance for blood sampling in term neonates", "imported": false, "abstract": "Abstract - Rationale Reducing procedural pain is a key priority in neonatal care, as even routine procedures for blood sampling can cause significant discomfort and pain to the neonate. This systematic review aims to compare venepuncture and heel lance for blood sampling, focusing on pain response, to guide clinical practice. Objectives To evaluate the benefits (degree of pain) and harms (need for more than one skin puncture) of venepuncture compared to heel lance in term neonates. Search methods We searched CENTRAL, MEDLINE, Embase, two trial registries and conference abstracts, and checked references of included studies and related systematic reviews up to 04 July 2025. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs that compared pain response from venepuncture versus heel lance. Neonates could receive a sweet‐tasting solution (such as glucose or sucrose), which is a commonly used analgesic in neonates for pain relief. We excluded studies that reported on pain using physiological parameters in isolation, as they are reflective of overall clinical status and non‐specific arousal. Outcomes Our outcomes of interest were pain reported using validated pain scores (measured using one or more of the following scales: Neonatal Facial Coding System, Neonatal Infant Pain scores, or the Premature Infant Pain Profile) and the need for more than one skin puncture. Risk of bias We used the Risk of bias 1 (RoB) tool to assess bias in the included RCTs. Synthesis methods We conducted a meta‐analysis where possible by calculating standardized mean difference (SMD) and risk ratio (RR) with their 95% confidence intervals (CIs) for continuous and dichotomous outcomes, respectively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included eight studies with 826 neonates. The studies were performed in six high‐, upper‐middle, or low‐income countries. Synthesis of results We judged the overall risk of bias in the eight studies to be high. Most studies had concerns related to blinding and allocation concealment. Venepuncture compared to heel lance (with no sweet‐tasting solution) Pain scores 
Venepuncture probably reduces pain compared to heel lance during the procedure when no sweet‐tasting solution is administered (SMD −1.34, 95% CI −1.55 to −1.14; I² = 94%; 6 studies, 488 participants; moderate‐certainty evidence). Need for more than one skin puncture 
Venepuncture probably reduces the need for more than one skin puncture compared to heel lance when no sweet tasting solution is administered (RR 0.63, 95% CI 0.40 to 0.97; I² = 20%; 6 studies, 397 participants; moderate‐certainty evidence) Venepuncture compared to heel lance (with sweet‐tasting solution) Pain scores 
Venepuncture may reduce pain compared to heel lance during the procedure when a sweet‐tasting solution is administered (SMD −0.38, 95% CI −0.69 to −0.07; I² = 79%; 3 studies, 170 participants; low‐certainty evidence). Need for more than one skin puncture 
The evidence is very uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture when a sweet‐tasting solution is used (RR 7.00, 95% CI 0.38 to 129.93; I² not applicable; 2 studies, 110 participants; very low‐certainty evidence). This is due to the small number of participants in each group. Authors' conclusions Based on moderate‐certainty evidence, venepuncture probably reduces pain during the procedure and the need for more than one skin puncture compared to heel lance when no sweet‐tasting solution is used. When sweet‐tasting solutions are administered, venepuncture may reduce pain during the procedure compared to heel lance, based on low‐certainty evidence. The evidence is very uncertain about the effect of venepuncture compared to heel lance on the number of skin punctures required in the presence of sweet‐tasting solutions. This is due to the small sample size, and hence we could not draw any meaningful conclusions. Further high‐quality studies are needed, particularly in settings where sweet‐tasting solutions are used, to better understand the comparative effectiveness of venepuncture and heel lance for neonatal blood sampling. Funding Cochrane Neonatal editorial support for this review update, as part of a suite of reviews addressing “The infant and family experience in the neonatal intensive care unit”, has been provided by a grant from The Gerber Foundation. The Gerber Foundation is a separately endowed, private, 501(c)(3) foundation not related to Gerber Products Company in any way. Registration Original review (2001): DOI 10.1002/14651858.CD001452
Review update (2004): DOI 10.1002/14651858.CD001452.pub2
Review update (2007): DOI 10.1002/14651858.CD001452.pub3
Review update (2011): DOI 10.1002/14651858.CD001452.pub4 Plain language summary Is using a needle (venepuncture) better than using a device (heel lance) for taking a blood sample from full‐term newborn babies? Key messages Venepuncture (inserting a needle into a vein) may be less painful than heel lance (using a special device to puncture the skin) for newborn babies when having a blood sample taken, with or without sugar water for pain relief, and may reduce the need for more than one skin puncture when no sugar water is given for pain relief. We don’t know whether venepuncture reduces the need for more than one skin puncture compared with heel lance when sugar water is given for pain relief. We need better designed and larger studies that fully report their results to show which method is better for babies. Why do we take blood samples from newborn babies? In most countries, a blood sample from newborn babies is needed for routine screening tests. Blood samples may also be needed for other blood tests to diagnose and manage diseases, such as jaundice or low blood sugar (hypoglycemia). However, taking blood from babies is painful. Untreated pain in newborn babies may affect their physical growth and brain development. A sweet, sugar solution (such as sucrose) can be given to babies before the procedure, which helps to reduce the pain. It is difficult to measure pain in babies, but we rely on things like facial expressions, crying, and changes in heart rate to assess their pain. How are blood samples taken? Venepuncture Venepuncture is a method of taking a blood sample where a person uses a needle to directly puncture the vein. The person who performs this must be well‐trained to help ensure they successfully take a blood sample. This technique is often used when 1 mL or more of blood is required, and to prevent repeated punctures to the skin and associated complications (such as skin infections) from heel lance. Heel lance Heel lance is the standard way of taking a blood sample from newborn babies in hospitals worldwide. It is commonly used when the blood sample required is less than 1 mL. It does not require special training or expertise for successful use. The procedure involves making a small puncture (between 1 mm and 2 mm deep) on the heel of the foot using a lancet, which is usually an automatic device. Following the puncture, the infant's heel is squeezed to collect the required blood sample, which causes further pain. What did we want to find out? We wanted to find out: whether venepuncture is less painful than heel lance for newborn babies; and which procedure works best first time, so a second skin puncture is not needed. What did we do? We searched for studies that compared venepuncture and heel lance for taking blood samples in newborn babies. The studies needed to measure pain responses and the number of skin punctures needed for a successful sample. They also needed to record whether babies were given sugar solution as pain relief. Babies in the studies had to be healthy and born at full term. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included eight studies involving 826 full‐term newborn babies. Three studies took place in Sweden, and one each in Japan, Malaysia, Nepal, Spain, and the UK. When no sweet‐tasting solution was given: venepuncture probably causes less pain compared to heel lance (6 studies, 488 babies); and venepuncture probably reduces the need for more than one skin puncture compared to heel lance (6 studies, 397 babies). When a sweet‐tasting solution was given: venepuncture may cause less pain compared to heel lance (3 studies, 170 babies); and we are uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture (2 studies, 110 babies). What are the limitations of the evidence? Our confidence in the evidence was limited, and ranged from moderate to very low. This is because all the studies had limitations in how they were carried out. These included issues with how babies were assigned to each group, how the studies reported their results, and the number of babies included in the studies. In addition, the people doing the procedures knew which sampling method each baby received, which could have influenced how the studies assessed pain. How up to date is this evidence? This review updates our 2011 Cochrane review. The evidence is up to date to July 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Martins, G; Fiander, M; Taddio, A; Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD001452.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "a01f793f-4115-4574-b51f-4c13a5e8db89", "pmid": "", "title": "Preoperative carbohydrate treatment for enhancing recovery after elective surgery", "imported": false, "abstract": "Abstract - Background Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast‐track surgery protocols. Although fast‐track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis. Objectives To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data. Selection criteria We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time. Data collection and analysis Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis. Main results We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I‐II or I‐III. A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding. In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low‐quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference ‐0.13 days; 95% CI ‐0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high‐quality evidence). As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low‐quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation. Authors' conclusions Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases. Plain language summary Does giving patients carbohydrate supplements before planned surgery lead to improved recovery? Review question We reviewed the evidence on effects of carbohydrate supplements on the recovery of people undergoing planned surgical procedures. We found 27 studies investigating this question. Background Carbohydrate (sugar‐containing) nutritional supplements have become a routine part of the package of care for people undergoing planned surgical procedures. We wanted to discover whether carbohydrate supplements are a useful part of care packages used by doctors to improve recovery after planned surgical procedures. Study characteristics The evidence is current up to March 2014. We identified 27 studies and included the outcomes of 1976 participants. Studies investigated the outcomes of patients undergoing planned surgical procedures on the abdomen (18), the bones or joints (4), the heart (4) or the thyroid gland (1). Eighteen studies compared carbohydrate supplements versus an identical appearing placebo drink that did not contain carbohydrates; in six of these studies, an additional group of patients had nothing to eat or drink for at least six hours before surgery. In nine studies, taking carbohydrate supplements was compared with having nothing to eat or drink for six hours before surgery. The primary outcomes of length of hospital stay and complication rate were reported by 19 and 14 studies, respectively. Key results Patients given carbohydrates before planned surgical procedures went home between 0.04 and 0.56 days sooner than those receiving a placebo drink or having nothing to eat or drink before surgery. Carbohydrate supplements had little or no effect on complication rate or on how people feel in‐hospital during recovery from surgery. Quality of the evidence The overall quality of the evidence varied from very low to high. The quality of evidence in support of carbohydrate supplements resulting in a shorter hospital stay was very low because the included studies had important flaws in their design, a very wide range of results was described and evidence revealed that studies showing no differences in length of hospital stay may not have been published. When we looked only at well‐conducted studies, we found that carbohydrate supplements had little or no effect on length of hospital stay. The quality of evidence to support the effects of carbohydrate supplements on complication rate was low because issues with study design were identified and results were not similar across studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Smith, MD; McCall, J; Plank, L; Herbison, GP; Soop, M; Nygren, J", "articleTypes": [], "doi": "10.1002/14651858.CD009161.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "a02ce39e-5e9d-4b1c-9bb0-562f3925fada", "pmid": "", "title": "Interventions for the cessation of non‐nutritive sucking habits in children", "imported": false, "abstract": "Abstract - Background Comforting behaviours, such as the use of pacifiers (dummies, soothers), blankets and finger or thumb sucking, are common in babies and young children. These comforting habits, which can be referred to collectively as 'non‐nutritive sucking habits' (NNSHs), tend to stop as children get older, under their own impetus or with support from parents and carers. However, if the habit continues whilst the permanent dentition is becoming established, it can contribute to, or cause, development of a malocclusion (abnormal bite). A diverse variety of approaches has been used to help children with stopping a NNSH. These include advice, removal of the comforting object, fitting an orthodontic appliance to interfere with the habit, application of an aversive taste to the digit or behaviour modification techniques. Some of these interventions are easier to apply than others and less disturbing for the child and their parent; some are more applicable to a particular type of habit. Objectives The primary objective of the review was to evaluate the effects of different interventions for cessation of NNSHs in children. The secondary objectives were to determine which interventions work most quickly and are the most effective in terms of child and parent‐ or carer‐centred outcomes of least discomfort and psychological distress from the intervention, as well as the dental measures of malocclusion (reduction in anterior open bite, overjet and correction of posterior crossbite) and cost‐effectiveness. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 8 October 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 9), MEDLINE via OVID (1946 to 8 October 2014), EMBASE via OVID (1980 to 8 October 2014), PsycINFO via OVID (1980 to 8 October 2014) and CINAHL via EBSCO (1937 to 8 October 2014), the US National Institutes of Health Trials Register (Clinical Trials.gov) (to 8 October 2014) and the WHO International Clinical Trials Registry Platform (to 8 October 2014). There were no restrictions regarding language or date of publication in the searches of the electronic databases. We screened reference lists from relevant articles and contacted authors of eligible studies for further information where necessary. Selection criteria Randomised or quasi‐randomised controlled trials in children with a non‐nutritive sucking habit that compared one intervention with another intervention or a no‐intervention control group. The primary outcome of interest was cessation of the habit. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Three review authors were involved in screening the records identified; two undertook data extraction, two assessed risk of bias and two assessed overall quality of the evidence base. Most of the data could not be combined and only one meta‐analysis could be carried out. Main results We included six trials, which recruited 252 children (aged 2 and a half to 18 years), but presented follow‐up data on only 246 children. Digit sucking was the only NNSH assessed in the studies. Five studies compared single or multiple interventions with a no‐intervention or waiting list control group and one study made a head‐to‐head comparison. All the studies were at high risk of bias due to major limitations in methodology and reporting. There were small numbers of participants in the studies (20 to 38 participants per study) and follow‐up times ranged from 1 to 36 months. Short‐term outcomes were observed under one year post‐intervention and long‐term outcomes were observed at one year or more post‐intervention. Orthodontics appliance (with or without psychological intervention) versus no treatment Two trials that assessed this comparison evaluated our primary outcome of cessation of habit. One of the trials evaluated palatal crib and one used a mix of palatal cribs and arches. Both trials were at high risk of bias. The orthodontic appliance was more likely to stop digit sucking than no treatment, whether it was used over the short term (risk ratio (RR) 6.53, 95% confidence interval (CI) 1.67 to 25.53; 2 trials, 70 participants) or long term (RR 5.81, 95% CI 1.49 to 22.66; 1 trial, 37 participants) or used in combination with a psychological intervention (RR 6.36, 95% CI 0.97 to 41.96; 1 trial, 32 participants). Psychological intervention versus no treatment Two trials (78 participants) at high risk of bias evaluated positive reinforcement (alone or in combination with gaining the child's co‐operation) or negative reinforcement compared with no treatment. Pooling of data showed a statistically significant difference in favour of the psychological interventions in the short term (RR 6.16, 95% CI 1.18 to 32.10; I 2 = 0%). One study, with data from 57 participants, reported on the long‐term effect of positive and negative reinforcement on sucking cessation and found a statistically significant difference in favour of the psychological interventions (RR 6.25, 95% CI 1.65 to 23.65). Head‐to‐head comparisons Only one trial demonstrated a clear difference in effectiveness between different active interventions. This trial, which had only 22 participants, found a higher likelihood of cessation of habit with palatal crib than palatal arch (RR 0.13, 95% CI 0.03 to 0.59). Authors' conclusions This review found low‐quality evidence that orthodontic appliances (palatal arch and palatal crib) and psychological interventions (including positive and negative reinforcement) are effective at improving sucking cessation in children. There is very low‐quality evidence that palatal crib is more effective than palatal arch. This review has highlighted the need for high‐quality trials evaluating interventions to stop non‐nutritive sucking habits to be conducted and the need for a consolidated, standardised approach to reporting outcomes in these trials. Plain language summary Interventions for stopping dummy or finger or thumb sucking habits in children Review question This review has been produced to assess the effects of interventions to stop sucking habits in children, which are not linked to food. Important considerations are: which treatment or combination of treatments work most effectively, when should treatment be started, what is the optimum length of time for the intervention and what causes least upset to children and their parents? Background Often babies and children develop a habit of sucking objects to comfort and calm them. They frequently suck dummies (known as pacifiers in the USA), fingers, thumbs or other items like blankets. Eventually, most children grow out of the habit, or stop due to encouragement from their parents. Some children, however, continue sucking as a habit. If they continue to do so as their adult teeth start to grow through (around the age of six), there is a risk that these adult teeth will grow into the wrong position causing them to stick out too far or not meet properly when biting. As a result these children often need dental treatment to fix the problems caused by their sucking habit. Possible treatments to help children break their sucking habits examined in studies in this review include the use of two different braces in the mouth; giving advice and incentives for changing behaviour (known as psychological advice/treatment); applying a bitter, nasty tasting substance to the children’s thumbs/fingers or combinations of these treatments. None of the studies included looked at barrier methods, for example the use of gloves or plasters or withdrawal of dummies. Study characteristics Review authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 8 October 2014. The review includes six studies published from 1967 to 1997, which involved 252 children as participants (although data were supplied on only 246 of the children). Three of the studies were carried out in the USA, one in Canada, one in Sweden and one in Australia. Not all of the studies gave the ages of children involved; in four of the studies children were aged from two and a half to 18 years old, in one study they were aged four years and over and in another nine years and over. Results Use of an orthodontic brace (such as a palatal crib or arch) or a psychological intervention (such as use of positive or negative reinforcement), or both, was more likely to lead to cessation of the habit than no treatment. Most of the trials that compared two different interventions were inconclusive but one study suggested that, of two different types of braces,a palatal crib is more effective than a palatal arch design. Quality of the evidence The evidence presented is of low quality due to the small number of participants in the few available studies and problems with the way in which the studies were conducted. There was a high risk of bias across the studies. Conclusion Orthodontic braces or psychological intervention seems to be effective to help children stop sucking that does not have a feeding purpose but the evidence is low quality. Further high quality clinical trials are required to guide decision making for what is a common problem that can require lengthy and expensive dental treatment to correct.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Borrie, FRP, Bearn, DR, Innes, NPT, Iheozor-Ejiofor, Z", "articleTypes": [], "doi": "10.1002/14651858.CD008694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.729Z" }, { "id": "a05f564c-6ea8-4d55-b549-29ed4027f7c3", "pmid": "", "title": "Hyperbaric oxygen therapy for late radiation tissue injury", "imported": false, "abstract": "Abstract - Background This is the third update of the original Cochrane Review published in July 2005 and updated previously in 2012 and 2016. Cancer is a significant global health issue. Radiotherapy is a treatment modality for many malignancies, and about 50% of people having radiotherapy will be long‐term survivors. Some will experience late radiation tissue injury (LRTI), developing months or years following radiotherapy. Hyperbaric oxygen therapy (HBOT) has been suggested as a treatment for LRTI based on the ability to improve the blood supply to these tissues. It is postulated that HBOT may result in both healing of tissues and the prevention of complications following surgery and radiotherapy. Objectives To evaluate the benefits and harms of hyperbaric oxygen therapy (HBOT) for treating or preventing late radiation tissue injury (LRTI) compared to regimens that excluded HBOT. Search methods We used standard, extensive Cochrane search methods. The latest search date was 24 January 2022. Selection criteria We included randomised controlled trials (RCTs) comparing the effect of HBOT versus no HBOT on LRTI prevention or healing. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. survival from time of randomisation to death from any cause; 2. complete or substantial resolution of clinical problem; 3. site‐specific outcomes; and 4. adverse events. Our secondary outcomes were 5. resolution of pain; 6. improvement in quality of life, function, or both; and 7. site‐specific outcomes. We used GRADE to assess certainty of evidence. Main results Eighteen studies contributed to this review (1071 participants) with publications ranging from 1985 to 2022. We added four new studies to this updated review and evidence for the treatment of radiation proctitis, radiation cystitis, and the prevention and treatment of osteoradionecrosis (ORN). HBOT may not prevent death at one year (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.47 to 1.83; I 2 = 0%; 3 RCTs, 166 participants; low‐certainty evidence). There is some evidence that HBOT may result in complete resolution or provide significant improvement of LRTI (RR 1.39, 95% CI 1.02 to 1.89; I 2 = 64%; 5 RCTs, 468 participants; low‐certainty evidence) and HBOT may result in a large reduction in wound dehiscence following head and neck soft tissue surgery (RR 0.24, 95% CI 0.06 to 0.94; I 2 = 70%; 2 RCTs, 264 participants; low‐certainty evidence). In addition, pain scores in ORN improve slightly after HBOT at 12 months (mean difference (MD) −10.72, 95% CI −18.97 to −2.47; I 2 = 40%; 2 RCTs, 157 participants; moderate‐certainty evidence). Regarding adverse events, HBOT results in a higher risk of a reduction in visual acuity (RR 4.03, 95% CI 1.65 to 9.84; 5 RCTs, 438 participants; high‐certainty evidence). There was a risk of ear barotrauma in people receiving HBOT when no sham pressurisation was used for the control group (RR 9.08, 95% CI 2.21 to 37.26; I 2 = 0%; 4 RCTs, 357 participants; high‐certainty evidence), but no such increase when a sham pressurisation was employed (RR 1.07, 95% CI 0.52 to 2.21; I 2 = 74%; 2 RCTs, 158 participants; high‐certainty evidence). Authors' conclusions These small studies suggest that for people with LRTI affecting tissues of the head, neck, bladder and rectum, HBOT may be associated with improved outcomes (low‐ to moderate‐certainty evidence). HBOT may also result in a reduced risk of wound dehiscence and a modest reduction in pain following head and neck irradiation. However, HBOT is unlikely to influence the risk of death in the short term. HBOT also carries a risk of adverse events, including an increased risk of a reduction in visual acuity (usually temporary) and of ear barotrauma on compression. Hence, the application of HBOT to selected participants may be justified. The small number of studies and participants, and the methodological and reporting inadequacies of some of the primary studies included in this review demand a cautious interpretation. More information is required on the subset of disease severity and tissue type affected that is most likely to benefit from this therapy, the time for which we can expect any benefits to persist and the most appropriate oxygen dose. Further research is required to establish the optimum participant selection and timing of any therapy. An economic evaluation should also be undertaken. Plain language summary Hyperbaric oxygen therapy for the treatment of the late effects of radiotherapy Key message – In selected people and areas of the body hyperbaric oxygen therapy (HBOT) may help resolve symptoms associated with late radiation tissue injury (LRTI) but further research is required to establish which people may respond and the best timing of such therapy. What are the problems after radiation treatment and how can it be treated? There is a risk of serious complications developing in the months and years after radiation treatment (radiotherapy) for cancer. These problems are collectively called LRTI and are due to progressive damage to normal tissue (cells within the body) that has been exposed to radiation. These problems can be very difficult to resolve, and there is some doubt as to the best approaches to treatment. HBOT involves breathing oxygen in a specially designed pressurised chamber. It is used to improve oxygen supply to damaged tissue and support healing. What did we want to find out? We wanted to find out if HBOT results in both healing of tissues and the prevention of complications following surgery in an irradiated field and radiotherapy for cancer. What did we do? We searched medical databases for clinical studies reporting the evidence for or against the ability of HBOT to improve these complications compared to either no treatment or alternative treatments. What were the main findings? There was some evidence that HBOT may improve outcomes in LRTI affecting both bone and soft tissues of the head and neck, the bladder and the lower bowel. There was also some evidence that HBOT may reduce wound breakdown and improve pain following LRTI. HBOT did not affect the risk of dying over the short time that these studies followed their patients. HBOT is generally safe and well‐tolerated, but there is a risk of becoming temporarily short‐sighted from the oxygen exposure and of injury to the ear drum on compression. What are the limitations of the evidence? The evidence was mainly limited by small numbers of people and studies, poor reporting of methods and results, and uncertainty as to the exact degree of improvement with HBOT. A study of costs would also be useful. How up to date is this evidence? The evidence is current to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lin, ZC; Bennett, MH; Hawkins, GC; Azzopardi, CP; Feldmeier, J; Smee, R; Milross, C", "articleTypes": [], "doi": "10.1002/14651858.CD005005.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "a0800dd9-7cb6-4588-a5e8-76e32aaf5be6", "pmid": "", "title": "Probiotics for the prevention of pediatric antibiotic‐associated diarrhea", "imported": false, "abstract": "Abstract - Background Antibiotics alter the microbial balance commonly resulting in antibiotic‐associated diarrhea (AAD). Probiotics may prevent AAD via providing gut barrier, restoration of the gut microflora, and other potential mechanisms of action. Objectives The primary objectives were to assess the efficacy and safety of probiotics (any specified strain or dose) used for the prevention of AAD in children. Search methods MEDLINE, Embase, CENTRAL, CINAHL, and the Web of Science (inception to 28 May 2018) were searched along with registers including the ISRCTN and Clinicaltrials.gov. We also searched the NICE Evidence Services database as well as reference lists from relevant articles. Selection criteria Randomized, parallel, controlled trials in children (0 to 18 years) receiving antibiotics, that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhea secondary to antibiotic use were considered for inclusion. Data collection and analysis Study selection, data extraction, and risk of bias assessment were conducted independently by two authors. Dichotomous data (incidence of AAD, adverse events) were combined using a pooled risk ratio (RR) or risk difference (RD), and continuous data (mean duration of diarrhea) as mean difference (MD), along with corresponding 95% confidence interval (95% CI). We calculated the number needed to treat for an additional beneficial outcome (NNTB) where appropriate. For studies reporting on microbiome characteristics using heterogeneous outcomes, we describe the results narratively. The certainty of the evidence was evaluated using GRADE. Main results Thirty‐three studies (6352 participants) were included. Probiotics assessed included Bacillus spp., Bifidobacterium spp., Clostridium butyricum , Lactobacilli spp. , Lactococcus spp., Leuconostoc cremoris , Saccharomyces spp., or Streptococcus spp., alone or in combination. The risk of bias was determined to be high in 20 studies and low in 13 studies. Complete case (patients who did not complete the studies were not included in the analysis) results from 33 trials reporting on the incidence of diarrhea show a precise benefit from probiotics compared to active, placebo or no treatment control. After 5 days to 12 weeks of follow‐up, the incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group (RR 0.45, 95% CI 0.36 to 0.56; I² = 57%, 6352 participants; NNTB 9, 95% CI 7 to 13; moderate certainty evidence). Nineteen studies had loss to follow‐up ranging from 1% to 46%. After making assumptions for those lost, the observed benefit was still statistically significant using an extreme plausible intention‐to‐treat (ITT) analysis, wherein the incidence of AAD in the probiotic group was 12% (436/3551) compared to 19% (664/3468) in the control group (7019 participants; RR 0.61; 95% CI 0.49 to 0.77; P <0.00001; I² = 70%). An a priori available case subgroup analysis exploring heterogeneity indicated that high dose (≥ 5 billion CFUs per day) is more effective than low probiotic dose (< 5 billion CFUs per day), interaction P value = 0.01. For the high dose studies the incidence of AAD in the probiotic group was 8% (162/2029) compared to 23% (462/2009) in the control group (4038 participants; RR 0.37; 95% CI 0.30 to 0.46; P = 0.06; moderate certainty evidence). For the low dose studies the incidence of AAD in the probiotic group was 8% (97/1155) compared to 13% (133/1059) in the control group (2214 participants; RR 0.68; 95% CI 0.46 to 1.01; P = 0.02). Again, assumptions for loss to follow‐up using an extreme plausible ITT analysis was statistically significant. For high dose studies the incidence of AAD in the probiotic group was 13% (278/2218) compared to 23% (503/2207) in control group (4425 participants; RR 0.54; 95% CI 0.42 to 0.70; P <0.00001; I² = 68%; moderate certainty evidence). None of the 24 trials (4415 participants) that reported on adverse events reported any serious adverse events attributable to probiotics. Adverse event rates were low. After 5 days to 4 weeks follow‐up, 4% (86/2229) of probiotics participants had an adverse event compared to 6% (121/2186) of control participants (RD 0.00; 95% CI ‐0.01 to 0.01; P < 0.00001; I² = 75%; low certainty evidence). Common adverse events included rash, nausea, gas, flatulence, abdominal bloating, and constipation. After 10 days to 12 weeks of follow‐up, eight studies recorded data on our secondary outcome, the mean duration of diarrhea; with probiotics reducing diarrhea duration by almost one day (MD ‐0.91; 95% CI ‐1.38 to ‐0.44; P <0.00001; low certainty evidence). One study reported on microbiome characteristics, reporting no difference in changes with concurrent antibiotic and probiotic use. Authors' conclusions The overall evidence suggests a moderate protective effect of probiotics for preventing AAD (NNTB 9, 95% CI 7 to 13). Using five criteria to evaluate the credibility of the subgroup analysis on probiotic dose, the results indicate the subgroup effect based on high dose probiotics (≥ 5 billion CFUs per day) was credible. Based on high‐dose probiotics, the NNTB to prevent one case of diarrhea is 6 (95% CI 5 to 9). The overall certainty of the evidence for the primary endpoint, incidence of AAD, based on high dose probiotics was moderate due to the minor issues with risk of bias and inconsistency related to a diversity of probiotic agents used. Evidence also suggests that probiotics may moderately reduce the duration of diarrhea, a reduction by almost one day. The benefit of high dose probiotics (e.g. Lactobacillus rhamnosus or Saccharomyces boulardii ) needs to be confirmed by a large well‐designed multi‐centered randomized trial. It is premature to draw firm conclusions about the efficacy and safety of 'other' probiotic agents as an adjunct to antibiotics in children. Adverse event rates were low and no serious adverse events were attributable to probiotics. Although no serious adverse events were observed among inpatient and outpatient children, including small studies conducted in the intensive care unit and in the neonatal unit, observational studies not included in this review have reported serious adverse events in severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter use and disorders associated with bacterial/fungal translocation. Plain language summary Probiotics for the prevention of antibiotic‐associated diarrhea in children What is antibiotic‐associated diarrhea? Antibiotic‐associated diarrhea (AAD) occurs when antibiotics disturb the natural balance of \"good\" and \"bad\" bacteria in the intestinal tract causing harmful bacteria to multiply beyond their normal numbers. The symptoms of AAD include frequent watery bowel movements and crampy abdominal pain. What are probiotics? Probiotics are found in dietary supplements or yogurts and contain potentially beneficial bacteria or yeast. Probiotics may restore the natural balance of bacteria in the intestinal tract. What did the researchers investigate? The researchers investigated whether probiotics prevent AAD in children receiving antibiotic therapy and whether probiotics causes any harms (side effects). The researchers searched the medical literature extensively up to May 28, 2018. What did the researchers find? Thirty‐three studies were reviewed and provide the best available evidence. The studies tested 6352 children (3 days to 17 years of age) who were receiving probiotics co‐administered with antibiotics to prevent AAD. The participants received probiotics ( Lactobacilli spp., Bifidobacterium spp., Streptococcus spp. , or Saccharomyces boulardii alone or in combination), placebo (pills not including probiotics), other treatments thought to prevent AAD (i.e. diosmectite or infant formula) or no treatment. The studies were short‐term, ranging in length from 5 days to 12 weeks. Analyses showed that probiotics are effective for preventing AAD. The incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group, demonstrating a moderate reduction (11% fewer will suffer diarrhea). For every 9 children treated, probiotics will prevent one case of diarrhea. Further, evidence suggests that higher dose probiotics (≥ 5 billion CFUs per day) reduce the incidence of AAD. Eight per cent (162/2029) of the high dose probiotics group had AAD compared to 23% (462/2009) in the control group, demonstrating a moderate to large reduction (15% fewer suffer diarrhea). Probiotics were generally well tolerated, and minor side effects (e.g. rash, nausea, gas, flatulence, abdominal bloating, constipation) occurred infrequently. . Evidence suggested that probiotics are effective for a moderate reduction in duration of diarrhea (almost one day). Among the various probiotics evaluated, Lactobacillus rhamnosus or Saccharomyces boulardii at 5 to 40 billion colony forming units/day appear most appropriate for preventing AAD in children receiving antibiotics. It is premature to draw conclusions about the effectiveness and safety of 'other' probiotic agents for preventing AAD. Although no serious probiotic‐related side effects were observed among the mostly otherwise healthy children who participated in the studies, serious side effects have been reported in observational studies not included in this review, including severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter (a flexible tube used to give medicines) use and disorders associated with bacterial or fungal translocation (the passage of bacteria from the gut to other areas of the body).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Guo, Q, Goldenberg, JZ, Humphrey, C, El Dib, R, Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD004827.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.098Z" }, { "id": "a0a90093-4814-4839-a26f-3fe1e7684a84", "pmid": "", "title": "Pharmacological treatment of gastro‐oesophageal reflux in children", "imported": false, "abstract": "Abstract - Background Gastro‐oesophageal reflux (GOR) is characterised by the regurgitation of gastric contents into the oesophagus. GOR is a common presentation in infancy, both in primary and secondary care, affecting approximately 50% of infants under three months old. The natural history of GOR in infancy is generally of a self‐limiting condition that improves with age, but older children and children with co‐existing medical conditions can have more protracted symptoms. The distinction between gastro‐oesophageal reflux disease (GORD) and GOR is debated. Current National Institute of Health and Care Excellence (NICE) guidelines define GORD as GOR causing symptoms severe enough to merit treatment. This is an update of a review first published in 2014. Objectives To assess the effects of pharmacological treatments for GOR in infants and children. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, and Web of Science up to 17 September 2022. We also searched for ongoing trials in clinical trials registries, contacted experts in the field, and searched the reference lists of trials and reviews for any additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any currently‐available pharmacological treatment for GOR in children with placebo or another medication. We excluded studies assessing dietary management of GORD and studies of thickened feeds. We included studies in infants and children up to 16 years old. Data collection and analysis We used standard methodology expected by Cochrane. Main results We included 36 RCTs involving 2251 children and infants. We were able to extract summary data from 14 RCTs; the remaining trials had insufficient data for extraction. We were unable to pool results in a meta‐analysis due to methodological differences in the included studies (including heterogeneous outcomes, study populations, and study design). We present the results in two groups by age: infants up to 12 months old, and children aged 12 months to 16 years old. Infants Omeprazole versus placebo: there is no clear effect on symptoms from omeprazole. One study (30 infants; very low‐certainty evidence) showed cry/fuss time in infants aged three to 12 months had altered from 246 ± 105 minutes/day at baseline (mean +/‐ standard deviation (SD)) to 191 ± 120 minutes/day in the omeprazole group and from 287 ± 132 minutes/day to 201 ± 100 minutes/day in the placebo group (mean difference (MD) 10 minutes/day lower (95% confidence interval (CI) ‐89.1 to 69.1)). The reflux index changed in the omeprazole group from 9.9 ± 5.8% in 24 hours to 1.0 ± 1.3% and in the placebo group from 7.2 ± 6.0% to 5.3 ± 4.9% in 24 hours (MD 7% lower, 95% CI ‐4.7 to ‐9.3). Omeprazole versus ranitidine: one study (76 infants; very low‐certainty evidence) showed omeprazole may or may not provide symptomatic benefit equivalent to ranitidine. Symptom scores in the omeprazole group changed from 51.9 ± 5.4 to 2.4 ± 1.2, and in the ranitidine group from 47 ± 5.6 to 2.5 ± 0.6 after two weeks: MD ‐4.97 (95% CI ‐7.33 to ‐2.61). Esomeprazole versus placebo: esomeprazole appeared to show no additional reduction in the number of GORD symptoms compared to placebo (1 study, 52 neonates; very low‐certainty evidence): both the esomeprazole group (184.7 ± 78.5 to 156.7 ± 75.1) and placebo group (183.1 ± 77.5 to 158.3 ± 75.9) improved: MD ‐3.2 (95% CI ‐4.6 to ‐1.8). Children Proton pump inhibitors (PPIs) at different doses may provide little to no symptomatic and endoscopic benefit. Rabeprazole given at different doses (0.5 mg/kg and 1 mg/kg) may provide similar symptom improvement (127 children in total; very low‐certainty evidence). In the lower‐dose group (0.5 mg/kg), symptom scores improved in both a low‐weight group of children (< 15 kg) (mean ‐10.6 ± SD 11.13) and a high‐weight group of children (> 15 kg) (mean ‐13.6 ± 13.1). In the higher‐dose groups (1 mg/kg), scores improved in the low‐weight (‐9 ± 11.2) and higher‐weight groups (‐8.3 ± 9.2). For the higher‐weight group, symptom score mean difference between the two different dosing regimens was 2.3 (95% CI ‐2 to 6.6), and for the lower‐weight group, symptom score MD was 4.6 (95% CI ‐2.9 to 12). Pantoprazole: pantoprazole may or may not improve symptom scores at 0.3 mg/kg, 0.6 mg/kg, and 1.2 mg/kg pantoprazole in children aged one to five years by week eight, with no difference between 0.3 mg/kg and 1.2 mg/kg dosing (0.3 mg/kg mean −2.4 ± 1.7; 1.2 mg/kg −1.7 ± 1.2: MD 0.7 (95% CI ‐0.4 to 1.8)) (one study, 60 children; very low‐certainty evidence). There were insufficient summary data to assess other medications. Authors' conclusions There is very low‐certainty evidence about symptom improvements and changes in pH indices for infants. There are no summary data for endoscopic changes. Medications may or may not provide a benefit (based on very low‐certainty evidence) for infants whose symptoms remain bothersome, despite nonmedical interventions or parental reassurance. If a medication is required, there is no clear evidence based on summary data for omeprazole, esomeprazole (in neonates), H₂antagonists, and alginates for symptom improvements (very low‐certainty evidence). Further studies with longer follow‐up are needed. In older children with GORD, in studies with summary data extracted, there is very low‐certainty evidence that PPIs (rabeprazole and pantoprazole) may or may not improve GORD outcomes. No robust data exist for other medications. Further RCT evidence is required in all areas, including subgroups (preterm babies and children with neurodisabilities). Plain language summary Medicines for children with reflux Review question What is the best and safest treatment for babies and children with gastro‐oesophageal reflux? Key messages: ‐ the evidence for medications for babies with gastro‐oesophageal reflux/reflux disease is very uncertain; ‐ for children with gastro‐oesophageal reflux disease, the evidence is very uncertain regarding the effects of proton pump inhibitors. There was no adequate evidence to draw conclusions regarding other medications. What is gastro‐oesophageal reflux? Gastro‐oesophageal reflux happens when stomach contents come back up into the oesophagus (food pipe). Most babies (under 1 year) grow out of reflux symptoms, but does medicine help? Children (older than 1 year) can have reflux just like adults. Reflux can be normal ('physiological reflux'), but in babies and children, it can cause symptoms, including pain or weight loss, as the oesophagus becomes inflamed (oesophagitis). Bothersome symptoms of reflux are called 'gastro‐oesophageal reflux disease' (GORD). How is gastro‐oesophageal reflux treated? Medicines can thicken the stomach contents (alginates), neutralise stomach acid (ranitidine, omeprazole, lansoprazole), or help the stomach to empty faster (domperidone, erythromycin). What did we want to find out? We wanted to learn the best way to reduce reflux in babies and children. We wanted to see if medicines help infants and children to feel better (symptom scores), heal the oesophagus (which is checked by using endoscopy, where a tiny camera is put down the oesophagus), or lower the time the oesophagus is exposed to stomach acid. We also investigated whether the medicines were safe by considering the harmful or unwanted effects reported in the studies. What did we do? We searched for studies testing gastro‐oesophageal reflux medicines in babies and children. We included all studies comparing these medicines, or comparing them to an inactive medicine (placebo). We assessed results which are important to doctors, nurses, and parents, and performed our own analysis of the results. We rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 36 suitable studies (involving 2251 babies and children), conducted worldwide, with most in the USA. The largest study recruited 268 babies, the smallest, 16 children. Fifteen studies compared an active medicine to placebo; 8 compared one active medication to another; and 11 studies gave the same medication at different doses. We found useable outcome information in 14 of the 36 studies. The remaining studies either did not report outcomes we were interested in or did not report them in a way we could analyse. We could not combine the results of any studies because they were too different (in terms of how long they followed participants up and the outcomes they investigated) to use in a meaningful way. Key results Babies. There is no clear effect on symptoms or measured acidity (one measure is reflux index, which is the percentage of time in 24 hours the oesophagus is exposed to stomach acid) between babies given omeprazole or placebo. One study (30 babies) showed cry/fuss time went down from 287 to 201 minutes/day in the placebo group and 246 to 191 minutes/day in the omeprazole group. Reflux index changed in the omeprazole group from 9.9% to 1.0% in 24 hours, and in the placebo group from 7.2% to 5.3%. One study (76 babies) showed that omeprazole and ranitidine may have a similar benefit for symptoms after 2 weeks: symptom scores (higher scores mean worse symptoms) in the omeprazole group dropped from 51.9 to 2.4, and in the ranitidine group, from 47 to 2.5. In one study of 52 newborn babies, esomeprazole appeared to show no reduction in the number of symptoms (184.7 to 156.7) compared to placebo (183.1 to 158.3). None of the studies reported harmful events or results about changes to babies' oesophaguses. Children. In children older than 1 year of age, no studies assessed medical treatment versus placebo. Proton pump inhibitors (PPIs), which block stomach acid production, at different doses may provide little to no improvements in symptoms or oesophagus healing. In one study (127 children), both lower‐weight and higher‐weight children given rabeprazole at lower and higher doses had both minimal – probably unimportant – changes in symptom scores and endoscopic scores (which indicate whether healing of the oesophagus has occurred). Pantoprazole may or may not improve symptom scores in children aged 1 to 5 years by week 8: there was no difference between lower and higher dosing in one study (60 children). Studies investigating other medications did not report enough information for us to assess their results properly. Quality of the evidence We are not confident in the evidence, which was mainly based on single studies with few babies and children. Several studies had pharmaceutical company help with manuscript writing. The question of how best to treat children with disabilities, and whether any PPIs are better than other medicines remain. The evidence is current to 17 September 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Tighe, MP, Andrews, E, Liddicoat, I, Afzal, NA, Hayen, A, Beattie, RM", "articleTypes": [], "doi": "10.1002/14651858.CD008550.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.790Z" }, { "id": "a0acb6df-16a8-404f-ac2c-927b9866b503", "pmid": "", "title": "Intestinal Sweet Taste Receptor Function and Adaptation to Dietary Sugars and Sweeteners", "imported": false, "abstract": "The purpose of this study is to collect data that will help researchers better understand the various causes of obesity and diabetes; particularly to understand how consumption of NCASs affects the way the body uses nutrients.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "a0ae644e-0268-4185-91e9-29b01bbc7a35", "pmid": "", "title": "Effects of Morbid Obesity and Bariatric Surgery on Brain Inflammation, Insulin Resistance and Activation of Central Reward System Studied Using PET- and MRI-imaging", "imported": false, "abstract": "Background: Morbid obesity is associated with decreased brain µ-opioid receptor availability, possibly resulting in higher food intake needed to gain pleasure from eating. This decrease seems to normalize already 6 months after bariatric surgery, but the longer-term effects have not been studied. Obesity and insulin resistance result in significantly increased brain insulin-stimulated glucose uptake, whereas in every other tissue glucose uptake is lower. One possible explanation to this could be central inflammation and activation of brain glial cells, which has been shown to occur in animal models of obesity. Obesity has also been shown to associate with increased risk of Alzheimer's disease and cognitive decline in several studies.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.241Z" }, { "id": "a0b5f9e1-5ead-41f5-aee8-81f929a0fa8f", "pmid": "", "title": "Chlorhexidine treatment for the prevention of dental caries in children and adolescents", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) is a common disease that is preventable by reducing the dietary intake of free sugars and using topical sodium fluoride products. An antibacterial agent known as chlorhexidine may also help prevent caries. A number of over‐the‐counter and professionally administered chlorhexidine‐based preparations are available in a variety of formulations and in a range of strengths. Although previous reviews have concluded that some formulations of chlorhexidine may be effective in inhibiting the progression of established caries in children, there is currently a lack of evidence to either claim or refute a benefit for its use in preventing dental caries. Objectives To assess the effects of chlorhexidine‐containing oral products (toothpastes, mouthrinses, varnishes, gels, gums and sprays) on the prevention of dental caries in children and adolescents. Search methods We searched the Cochrane Oral Health Group Trials Register (25 February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 12), MEDLINE via OVID (1946 to 25 February 2015), EMBASE via OVID (1980 to 25 February 2015) and CINAHL via EBSCO (1937 to 25 February 2015). We handsearched several journals placed no language restrictions on our search. After duplicate citations were removed, the electronic searches retrieved 1075 references to studies. Selection criteria We included parallel‐group, randomised controlled trials (RCTs) that compared the caries preventive effects of chlorhexidine gels, toothpastes, varnishes, mouthrinses, chewing gums or sprays with each other, placebo or no intervention in children and adolescents. We excluded trials with combined interventions of chlorhexidine and fluoride or comparisons between chlorhexidine and fluoride interventions. Data collection and analysis Two review authors independently extracted trial data and assessed risk of bias. We resolved disagreements by consensus. We contacted trial authors for clarification or additional study details when necessary. The number of included studies that were suitable for meta‐analysis was limited due to the clinical diversity of the included studies with respect to age, composition of intervention, and variation in outcome measures and follow‐up. Where we were unable to conduct meta‐analysis, we elected to present a narrative synthesis of the results. Main results We included eight RCTs that evaluated the effects of chlorhexidine varnishes (1%, 10% or 40% concentration) and chlorhexidine gel (0.12%) on the primary or permanent teeth, or both, of children from birth to 15 years of age at the start of the study. The studies randomised a total of 2876 participants, of whom 2276 (79%) were evaluated. We assessed six studies as being at high risk of bias overall and two studies as being at unclear risk of bias overall. Follow‐up assessment ranged from 6 to 36 months. Six trials compared chlorhexidine varnish with placebo or no treatment. It was possible to pool the data from two trials in the permanent dentition (one study using 10% chlorhexidine and the other, 40%). This led to an increase in the DMFS increment in the varnish group of 0.53 (95% confidence interval (CI) ‐0.47 to 1.53; two trials, 690 participants; very low quality evidence). Only one trial (10% concentration chlorhexidine varnish) provided usable data for elevated mutans streptococci levels > 4 with RR 0.93 (95% CI 0.80 to 1.07, 496 participants; very low quality evidence). One trial measured adverse effects (for example, ulcers or tooth staining) and reported that there were none; another trial reported that no side effects of the treatment were noted. No trials reported on pain, quality of life, patient satisfaction or costs. Two trials compared chlorhexidine gel (0.12% concentration) with no treatment in the primary dentition. The presence of new caries gave rise to a 95% confidence interval that was compatible with either an increase or a decrease in caries incidence (RR 1.00, 95% CI 0.36 to 2.77; 487 participants; very low quality evidence). Similarly, data for the effects of chlorhexidine gel on the prevalence of mutans streptococci were inconclusive (RR 1.26, 95% CI 0.95 to 1.66; two trials, 490 participants; very low quality evidence). Both trials measured adverse effects and did not observe any. Neither of these trials reported on the other secondary outcomes such as measures of pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Authors' conclusions We found little evidence from the eight trials on varnishes and gels included in this review to either support or refute the assertion that chlorhexidine is more effective than placebo or no treatment in the prevention of caries or the reduction of mutans streptococci levels in children and adolescents. There were no trials on other products containing chlorhexidine such as sprays, toothpastes, chewing gums or mouthrinses. Further high quality research is required, in particular evaluating the effects on both the primary and permanent dentition and using other chlorhexidine‐containing oral products. Plain language summary Antiseptic treatment (chlorhexidine) to prevent tooth decay in children and young people Review question This review examined the effectiveness of varnishes and gels containing chlorhexidine in preventing tooth decay in children and young people. Background Tooth decay is a very common disease that over time destroys the tooth surface. It has been estimated to affect up to 80% of people in high‐income countries and, despite being preventable through oral hygiene and dietary measures and the use of agents such as fluoride that reduce risk of decay, it is likely to remain a problem, especially in low‐income countries. Tooth decay can result in pain and infection, and in young children may require treatment in hospital under a general anaesthetic. As well as causing anxiety and pain, this may mean the child or young person missing time at school and their parents or carers having to take time off work, possibly losing income and incurring extra costs. Prevention of tooth decay is simpler and possibly cheaper than waiting until it occurs and then requires extensive treatment. Tooth decay is largely preventable, and a range of things may assist this: twice‐daily toothbrushing with a fluoride toothpaste, reducing both the amount of and number of times per day sugar is eaten, and drinking water that contains fluoride (bottled or tap, depending on where you live). Tooth decay occurs when certain types of bacteria (germs) in the mouth, such as Streptococcus mutans, produce acids from the sugar we eat, which dissolve the hard enamel coating on our teeth. The chemical antiseptic treatment chlorhexidine is highly successful at destroying these bacteria and can be used safely at home in the form of a gel, spray, chewing gum, toothpaste or mouthrinse. Alternatively, chlorhexidine can be applied as a varnish to the surface of teeth by a dentist. Study characteristics The evidence in this review, carried out through the Cochrane Oral Health Group, is up‐to‐date at 25 February 2015. We found eight studies that were suitable to include in this review. The studies involved a total of 2876 children from birth to 15 years of age who were at moderate to high risk of tooth decay. Six of the studies looked at the effects of dental professionals applying different strengths of chlorhexidine varnishes to the baby teeth, permanent teeth or both types of teeth in children and adolescents. The other two studies looked at the effects of parents placing chlorhexidine gel on their children's baby teeth. There were no studies that examined other products containing chlorhexidine, such as sprays, toothpastes, chewing gums or mouthrinses. Key results The results did not provide evidence that chlorhexidine varnish or gel reduces tooth decay or reduces the bacteria that encourage tooth decay. The studies did not evaluate other outcomes such as pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Four studies measured side effects and found none were observed. Quality of the evidence Due to the lack of suitable studies and concerns about possible bias in the included studies, the evidence is very low quality. As a result, we are not able to conclude whether or not chlorhexidine is effective in preventing tooth decay in children or adolescents, when compared to placebo (an inactive substitute for chlorhexidine) or no treatment. Future research on the use of chlorhexidine to prevent tooth decay is needed and should consider both primary and permanent teeth and should assess other chlorhexidine‐containing products that can be used at home, such as toothpastes or mouthrinses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Walsh, T; Oliveira‐Neto, JM; Moore, D", "articleTypes": [], "doi": "10.1002/14651858.CD008457.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "a0d30c75-bec2-4760-a357-01c76523fb0c", "pmid": "", "title": "Hydroxyurea (hydroxycarbamide) for sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and a reduced life expectancy. Hydroxyurea (hydroxycarbamide), an oral chemotherapeutic drug, ameliorates some of the clinical problems of SCD, in particular that of pain, by raising foetal haemoglobin (HbF). This is an update of a previously published Cochrane Review. Objectives The aims of this review are to determine through a review of randomised or quasi‐randomised studies whether the use of hydroxyurea in people with SCD alters the pattern of acute events, including pain; prevents, delays or reverses organ dysfunction; alters mortality and quality of life; or is associated with adverse effects. In addition, we hoped to assess whether the response to hydroxyurea in SCD varies with the type of SCD, age of the individual, duration and dose of treatment, and healthcare setting. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Haemoglobinopathies Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. The date of the most recent search was 17 February 2022. Selection criteria Randomised and quasi‐randomised controlled trials (RCTs and quasi‐RCTs), of one month or longer, comparing hydroxyurea with placebo or standard therapy in people with SCD. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction, assessed the risk of bias and assessed the quality of the evidence using GRADE. Main results We included nine RCTs recruiting 1104 adults and children with SCD (haemoglobin SS (HbSS), haemoglobin SC (HbSC) or haemoglobin Sβºthalassaemia (HbSβºthal) genotypes). Studies lasted from six to 30 months. We judged the quality of the evidence for the first two comparisons below as moderate to low as the studies contributing to these comparisons were mostly large and well‐designed (and at low risk of bias); however, the evidence was limited and imprecise for some outcomes such as quality of life, deaths during the studies and adverse events, and the results are applicable only to individuals with HbSS and HbSβºthal genotypes. We judged the quality of the evidence for the third and fourth comparisons to be very low due to the limited number of participants, the lack of statistical power (both studies were terminated early with approximately only 20% of their target sample size recruited) and the lack of applicability to all age groups and genotypes. Hydroxyurea versus placebo Five studies (784 adults and children with HbSS or HbSβºthal) compared hydroxyurea to placebo; four recruited individuals with only severe disease and one recruited individuals with all disease severities. Hydroxyurea probably improves pain alteration (using measures such as pain crisis frequency, duration, intensity, hospital admissions and opoid use) and life‐threatening illness, but we found no difference in death rates (10 deaths occurred during the studies, but the rates did not differ by treatment group) (all moderate‐quality evidence). Hydroxyurea may improve measures of HbF (low‐quality evidence) and probably decreases neutrophil counts (moderate‐quality evidence). There were no consistent differences in terms of quality of life and adverse events (including serious or life‐threatening events) (low‐quality evidence). There were fewer occurrences of acute chest syndrome and blood transfusions in the hydroxyurea groups. Hydroxyurea and phlebotomy versus transfusion and chelation Two studies (254 children with HbSS or HbSβºthal also with risk of primary or secondary stroke) contributed to this comparison. There were no consistent differences in terms of pain alteration, death or adverse events (low‐quality evidence) or life‐threatening illness (moderate‐quality evidence). Hydroxyurea with phlebotomy probably increased HbF and decreased neutrophil counts (moderate‐quality evidence), but there were more occurrences of acute chest syndrome and infections. Quality of life was not reported. In the primary prevention study, no strokes occurred in either treatment group but in the secondary prevention study, seven strokes occurred in the hydroxyurea and phlebotomy group (none in the transfusion and chelation group) and the study was terminated early. Hydroxyurea versus observation One study (22 children with HbSS or HbSβºthal also at risk of stoke) compared hydroxyurea to observation. Pain alteration and quality of life were not reported. There were no differences in life‐threatening illness, death (no deaths reported in either group) or adverse events (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF or decreases neutrophil counts (very low‐quality evidence). Treatment regimens with and without hydroxyurea One study (44 adults and children with HbSC) compared treatment regimens with and without hydroxyurea. Pain alteration, life‐threatening illness and quality of life were not reported. There were no differences in death rates (no deaths reported in either group), adverse events or neutrophil levels (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF (very low‐quality evidence). Authors' conclusions There is evidence to suggest that hydroxyurea may be effective in decreasing the frequency of pain episodes and other acute complications in adults and children with sickle cell anaemia of HbSS or HbSβºthal genotypes and in preventing life‐threatening neurological events in those with sickle cell anaemia at risk of primary stroke by maintaining transcranial Doppler velocities. However, there is still insufficient evidence on the long‐term benefits of hydroxyurea, particularly with regard to preventing chronic complications of SCD, or recommending a standard dose or dose escalation to maximum tolerated dose. There is also insufficient evidence about the long‐term risks of hydroxyurea, including its effects on fertility and reproduction. Evidence is also limited on the effects of hydroxyurea on individuals with the HbSC genotype. Future studies should be designed to address such uncertainties. Plain language summary Hydroxyurea (also known as hydroxycarbamide) for people with sickle cell disease Review question What is the effect of hydroxyurea on clinical outcomes (changes in pain crises, life‐threatening illnesses, survival, haemoglobin levels, quality of life and side effects) in people with sickle cell disease (SCD) of any genotype? Background Sickle cell disease (SCD) is an inherited genetic disorder that creates problems with haemoglobin (the substance in red blood cells that carries oxygen around the body). The disease can be inherited in different ways; people can inherit two sickle genes (HbSS genotype) or they can inherit the sickle gene from one parent and a different haemoglobin gene such as haemoglobin C, resulting in the HbSC genotype, or a beta thalassaemia gene from the second parent, which gives rise to HbSβ+ or HbSβºthal. In people with SCD the abnormal sickle haemoglobin forms long polymers (chains) within the red blood cells when they become de‐oxygenated. This damages the red blood cells and makes them stickier, leading to blockages and reduced blood flow, causing pain and organ damage. Foetal haemoglobin (HbF) stops these polymers forming in the sickle haemoglobin within the red blood cell. The drug hydroxyurea is used to increase HbF and can reduce the effects of the disease. This is an update of a previously published Cochrane Review. Search date The evidence is current to 17 February 2022. Study characteristics We included nine randomised studies (1104 adults and children with SCD (HbSS, HbSC or HbSβºthal genotypes)). Studies lasted from six to 30 months. Key results and quality of the evidence In five studies, 784 adults and children with SCD were randomly selected to receive hydroxyurea or placebo. In two studies, 254 children with SCD, who were also at an increased risk of having a first or second stroke, were randomly selected to receive hydroxyurea and phlebotomy (collection of blood) or blood transfusion and chelation (administration of agents to remove excess iron from the body). These seven studies only recruited people with HbSS or HbSβºthal genotypes so the results do not apply to people with the HbSC genotype. There was moderate‐quality evidence from these seven studies that hydroxyurea may reduce the frequency of pain crises, may increase HbF and may decrease neutrophil (white blood cell) counts compared to the comparator treatment. We found no difference between people receiving hydroxyurea or other treatments in terms of quality of life, deaths during the studies and adverse effects (including serious and life‐threatening effects). However, there is less information about these outcomes in the studies, so the quality of this evidence is low. Two further studies were included in the review. In one study, 22 children with SCD, who were also at increased risk of having a stroke, were randomly selected to receive hydroxyurea or no treatment (observation only) and in one study 44 adults and children were randomly selected to receive treatments with or without adding hydroxyurea. In both studies we are unsure if hydroxyurea led to an increase in HbF compared to the comparator treatment. There were no deaths during the studies. There was no difference between people receiving hydroxyurea or other treatments in terms of pain crises and adverse effects (including serious or life‐threatening effects) and neither study measured quality of life. The quality of the evidence from these studies is very low, given the studies were very small and only recruited around 20% of the intended number of people, and the results do not apply to all people with SCD (different genotypes). Conclusions The evidence shows that hydroxyurea is likely to be effective in the short term at decreasing the frequency of painful episodes and raising HbF levels in the blood in people with SCD. Hydroxyurea is also likely to be effective in preventing first strokes for those at an increased risk of stroke and does not seem to be associated with an increase in any adverse effects (including serious and life‐threatening effects). There is currently little evidence from the studies that we examined on whether hydroxyurea is beneficial over a long period of time, what the best dose to take is, or whether treatment causes any long‐term or serious side effects. More studies are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Rankine-Mullings, AE; Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD002202.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "a0d8b475-cf57-4764-9efb-2d29ff8a5a84", "pmid": "", "title": "Antibiotics for community‐acquired pneumonia in adult outpatients", "imported": false, "abstract": "Abstract - Background Lower respiratory tract infection (LRTI) is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Community‐acquired pneumonia (CAP) is a common condition that causes a significant disease burden for the community, particularly in children younger than five years, the elderly and immunocompromised people. Antibiotics are the standard treatment for CAP. However, increasing antibiotic use is associated with the development of bacterial resistance and side effects for the patient. Several studies have been published regarding optimal antibiotic treatment for CAP but many of these data address treatments in hospitalised patients. This is an update of our 2009 Cochrane Review and addresses antibiotic therapies for CAP in outpatient settings. Objectives To compare the efficacy and safety of different antibiotic treatments for CAP in participants older than 12 years treated in outpatient settings with respect to clinical, radiological and bacteriological outcomes. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (January 1966 to March week 3, 2014), EMBASE (January 1974 to March 2014), CINAHL (2009 to March 2014), Web of Science (2009 to March 2014) and LILACS (2009 to March 2014). Selection criteria We looked for randomised controlled trials (RCTs), fully published in peer‐reviewed journals, of antibiotics versus placebo as well as antibiotics versus another antibiotic for the treatment of CAP in outpatient settings in participants older than 12 years of age. However, we did not find any studies of antibiotics versus placebo. Therefore, this review includes RCTs of one or more antibiotics, which report the diagnostic criteria and describe the clinical outcomes considered for inclusion in this review. Data collection and analysis Two review authors (LMB, TJMV) independently assessed study reports in the first publication. In the 2009 update, LMB performed study selection, which was checked by TJMV and MMK. In this 2014 update, two review authors (SP, SM) independently performed and checked study selection. We contacted trial authors to resolve any ambiguities in the study reports. We compiled and analysed the data. We resolved differences between review authors by discussion and consensus. Main results We included 11 RCTs in this review update (3352 participants older than 12 years with a diagnosis of CAP); 10 RCTs assessed nine antibiotic pairs (3321 participants) and one RCT assessed four antibiotics (31 participants) in people with CAP. The study quality was generally good, with some differences in the extent of the reporting. A variety of clinical, bacteriological and adverse events were reported. Overall, there was no significant difference in the efficacy of the various antibiotics. Studies evaluating clarithromycin and amoxicillin provided only descriptive data regarding the primary outcome. Though the majority of adverse events were similar between all antibiotics, nemonoxacin demonstrated higher gastrointestinal and nervous system adverse events when compared to levofloxacin, while cethromycin demonstrated significantly more nervous system side effects, especially dysgeusia, when compared to clarithromycin. Similarly, high‐dose amoxicillin (1 g three times a day) was associated with higher incidence of gastritis and diarrhoea compared to clarithromycin, azithromycin and levofloxacin. Authors' conclusions Available evidence from recent RCTs is insufficient to make new evidence‐based recommendations for the choice of antibiotic to be used for the treatment of CAP in outpatient settings. Pooling of study data was limited by the very low number of studies assessing the same antibiotic pairs. Individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups. However, two studies did find significantly more adverse events with use of cethromycin as compared to clarithromycin and nemonoxacin when compared to levofloxacin. Multi‐drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations. Further studies focusing on diagnosis, management, cost‐effectiveness and misuse of antibiotics in CAP and LRTI are warranted in high‐, middle‐ and low‐income countries. Plain language summary Antibiotics for community‐acquired pneumonia in adolescent and adult outpatients Review question This review studied the effects of antibiotics on adolescents and adults with pneumonia acquired and treated in the community (as opposed to acquiring pneumonia in hospital and/or being treated for pneumonia in hospital). The evidence is current to March 2014. Background Lower respiratory tract infection is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Pneumonia, or infection of the lungs, is a common condition representing a significant disease burden for the community. Pneumonia is especially life‐threatening in children younger than five years, in older people and in people with other illnesses that may affect their immune system (such as diabetes or HIV/AIDS, or solid organ transplant recipients). Antibiotics are the most common treatment for pneumonia and these can vary in their effectiveness and adverse effects. Study characteristics We identified 11 trials (with 3352 participants older than 12 years with a diagnosis of community‐acquired pneumonia), fully published in peer‐reviewed journals, focused on treatment of pneumonia in adolescents and adults treated in the community in outpatient settings. This included five new trials included since our last review published in 2009. None of the trials included antibiotics versus placebo; all trials included one or more antibiotics. All participants were diagnosed with pneumonia based upon clinical diagnosis by the physician and chest X‐ray. Study funding sources All included trials were well conducted; nine of the 11 trials were sponsored by bio‐pharmaceutical companies manufacturing the antibiotics used in the study, or their authors were closely linked with the company. Key results Nine of the included trials compared different antibiotics and, hence, we could not combine the results of the individual trials to present our overall conclusion. There were some notable adverse events in seven studies: 1) erythromycin demonstrated significant gastrointestinal side effects compared to clarithromycin in two studies; 2) nemonoxacin demonstrated higher gastrointestinal (nausea, diarrhoea) and nervous system (dizziness, headache) adverse events compared to levofloxacin; 3) cethromycin demonstrated more side effects, especially a distortion of the sense of taste, than clarithromycin; 4) gastritis and diarrhoea were more common in the high‐dose amoxicillin group (1 g three times a day) compared to the other three antibiotic groups (clarithromycin, azithromycin and levofloxacin). Conclusion Unfortunately, there were not enough trials to compare the effects of different antibiotics for pneumonia acquired and treated in the community.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Pakhale, S; Mulpuru, S; Verheij, TJM; Kochen, MM; Rohde, GGU; Bjerre, LM", "articleTypes": [], "doi": "10.1002/14651858.CD002109.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "a0d8da8e-ebba-430f-9552-da3e9d68fb8e", "pmid": "", "title": "Corticosteroids for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve are implicated in causing Bell's palsy. Corticosteroids have a potent anti‐inflammatory action that should minimise nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Objectives To determine the effectiveness and safety of corticosteroid therapy in people with Bell's palsy. Search methods On 4 March 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS. We reviewed the bibliographies of the randomised trials and contacted known experts in the field to identify additional published or unpublished trials. We also searched clinical trials registries for ongoing trials. Selection criteria Randomised trials and quasi‐randomised trials comparing different routes of administration and dosage schemes of corticosteroid or adrenocorticotrophic hormone therapy versus a control group receiving no therapy considered effective for this condition, unless the same therapy was given in a similar way to the experimental group. Data collection and analysis We used standard Cochrane methodology. The main outcome of interest was incomplete recovery of facial motor function (i.e. residual facial weakness). Secondary outcomes were cosmetically disabling persistent sequelae, development of motor synkinesis or autonomic dysfunction (i.e. hemifacial spasm, crocodile tears) and adverse effects of corticosteroid therapy manifested during follow‐up. Main results We identified seven trials, with 895 evaluable participants for this review. All provided data suitable for the primary outcome meta‐analysis. One of the trials was new since the last version of this Cochrane systematic review. Risk of bias in the older, smaller studies included some unclear‐ or high‐risk assessments, whereas we deemed the larger studies at low risk of bias. Overall, 79/452 (17%) participants allocated to corticosteroids had incomplete recovery of facial motor function six months or more after randomisation; significantly fewer than the 125/447 (28%) in the control group (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.50 to 0.80, seven trials, n = 895). The number of people who need to be treated with corticosteroids to avoid one incomplete recovery was 10 (95% CI 6 to 20). The reduction in the proportion of participants with cosmetically disabling sequelae six months after randomisation was very similar in the corticosteroid and placebo groups (RR 0.96, 95% CI 0.40 to 2.29, two trials, n = 75, low‐quality evidence). However, there was a significant reduction in motor synkinesis during follow‐up in participants receiving corticosteroids (RR 0.64, 95% CI 0.45 to 0.91, three trials, n = 485, moderate‐quality evidence). Three studies explicitly recorded the absence of adverse effects attributable to corticosteroids. One trial reported that three participants receiving prednisolone had temporary sleep disturbances and two trials gave a detailed account of adverse effects occurring in 93 participants, all non‐serious; the combined analysis of data from these three trials found no significant difference in adverse effect rates between people receiving corticosteroids and people receiving placebo (RR 1.04, 95% CI 0.71 to 1.51, n = 715). Authors' conclusions The available moderate‐ to high‐quality evidence from randomised controlled trials showed significant benefit from treating Bell's palsy with corticosteroids. Plain language summary Corticosteroids for Bell's palsy Review question What are the effects of corticosteroids on Bell's palsy? Background Bell's palsy is a paralysis or weakness of muscles in the face, usually on one side, with no certain cause. Symptoms usually recover, although not always. Reducing inflammation of the facial nerve using corticosteroid medicines (steroids) is thought to limit nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Study characteristics We identified seven clinical trials involving 895 people with one‐sided mild, moderate or severe Bell's palsy of unknown cause. All of these trials reported rates of incomplete recovery (the proportion of people left with facial weakness) and we were able to combine the results. People in the studies were aged from 2 to 84 years. They were treated with corticosteroids or placebo (inactive treatment), either alone or in combination with other therapies. One trial only involved children, from 24 months to 74 months old. The duration of the included studies for adults and children ranged from 157 days to 12 months. Key results and quality of the evidence Incomplete recovery According to moderate quality to high quality evidence, corticosteroids reduced the number of people left with facial weakness after Bell's palsy compared to placebo (a pretend medicine). This finding was based on data from seven studies involving 895 participants with Bell's palsy of varying degrees of severity. We calculated that to stop one person from being left with facial weakness, 10 people need to be treated. Five studies provided data on long‐term after‐effects of Bell's palsy following treatment. Two of the studies (75 participants) looked at persistent effects on facial appearance after six months or more. The effect was nearly the same for corticosteroids and placebo, showing that participants who had corticosteroids benefited slightly, although this evidence was low quality. Data from three studies (485 participants) showed clearly that people who received corticosteroids developed less motor synkinesis (unwanted facial movements) and crocodile tears (watery eyes when eating or chewing), compared with people who received placebo alone. This finding was based on moderate‐quality evidence. Side effects Three studies reported that no side effects could be attributed to corticosteroid treatment. Based on moderate‐quality evidence from three studies (715 participants), numbers experiencing side effects were similar with corticosteroids and placebo. The evidence is current to March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Madhok, VB; Gagyor, I; Daly, F; Somasundara, D; Sullivan, M; Gammie, F; Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001942.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "a0f05c55-f8d8-43ea-84f8-879a135f4d07", "pmid": "", "title": "Omega‐3 fatty acids for the treatment of dementia", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) from fish and plant sources are commonly considered as a promising non‐medical alternative to improve brain functions and slow down the progression of dementia. This assumption is mostly based on findings of preclinical studies and epidemiological research. Resulting explanatory models aim at the role omega‐3 PUFAs play in the development and integrity of the brain's neurons, their protective antioxidative effect on cell membranes and potential neurochemical mechanisms directly related to Alzheimer‐specific pathology. Epidemiological research also found evidence of malnutrition in people with dementia. Considering this and the fact that omega‐3 PUFA cannot be synthesised by humans, omega‐3 PUFAs might be a promising treatment option for dementia. Objectives To assess the efficacy and safety of omega‐3 polyunsaturated fatty acid (PUFA) supplementation for the treatment of people with dementia. Search methods We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 10 December 2015. We contacted manufacturers of omega‐3 supplements and scanned reference lists of landmark papers and included articles. Selection criteria We included randomised controlled trials (RCTs) in which omega‐3 PUFA in the form of supplements or enriched diets were administered to people with Alzheimer's disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), Parkinson's disease dementia (PDD) or frontotemporal dementia (FTD). Data collection and analysis The primary outcome measures of interest were changes in global and specific cognitive functions, functional performance, dementia severity and adverse effects. Two review authors independently selected studies, extracted data and assessed the quality of trials according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We received unpublished data from the trial authors and collected adverse effects information from the published articles. We conducted meta‐analyses for available outcome measures at six months. Main results We included three comparable randomised, placebo‐controlled trials investigating omega‐3 PUFA supplements in 632 participants with mild to moderate AD over six, 12 and 18 months. We found no studies investigating other types of dementia. All trials were of high methodological quality. The overall quality of evidence for most of the outcomes was high. There was no evidence of a benefit from omega‐3 PUFAs on cognitive function when measured at six months with the Alzheimer's Disease Assessment Scale ‐ Cognitive subscale (standardised mean difference (SMD) ‐0.02, 95% confidence interval (CI) ‐0.19 to 0.15; 566 participants; 3 studies; high quality evidence) or Mini‐Mental State Examination (mean difference (MD) 0.18, 95% CI ‐1.05 to 1.41; 202 participants; 2 studies; high quality evidence) or on activities of daily living (SMD ‐0.02, 95% CI ‐0.19 to 0.16; 544 participants; 2 studies; high quality evidence). There was also no effect at six months of treatment on severity of dementia measured with the Clinical Dementia Rating ‐ Sum of Boxes (MD ‐0.00, 95% CI ‐0.58 to 0.57; 542 participants; 2 studies; high quality evidence) or on quality of life measured with the Quality of Life Alzheimer's Disease scale (MD ‐0.10, 95% CI ‐1.28 to 1.08; 322 participants; 1 study; high quality evidence). There was no difference at six months on mental health measured with the Montgomery‐Åsberg Depression Rating Scale (MD ‐0.10, 95% CI ‐0.74 to 0.54; 178 participants: 1 study; high quality of evidence) or the Neuropsychiatric Inventory (SMD 0.10, 95% CI ‐0.07 to 0.27; 543 participants; 2 studies; high quality of evidence). One very small study showed a benefit for omega‐3 PUFAs in instrumental activities of daily living after 12 months of treatment (MD ‐3.50, 95% CI ‐4.30 to ‐2.70; 22 participants; moderate quality evidence). The included studies did not measure specific cognitive function. The studies did not report adverse events well. Two studies stated that all adverse events were mild and that they did not differ in overall frequency between omega‐3 PUFA and placebo groups. Data from one study showed no difference between groups in frequency of any adverse event (risk ratio (RR) 1.02, 95% CI 0.95 to 1.10; 402 participants; 1 study; moderate quality evidence) or any serious adverse event (RR 1.05, 95% CI 0.78 to 1.41; 402 participants; 1 study; high quality evidence) at 18 months of treatment. Authors' conclusions We found no convincing evidence for the efficacy of omega‐3 PUFA supplements in the treatment of mild to moderate AD. This result was consistent for all outcomes relevant for people with dementia. Adverse effects of omega‐3 PUFAs seemed to be low, but based on the evidence synthesised in this review, we cannot make a final statement on tolerability. The effects on other populations remain unclear. Plain language summary Omega‐3 fatty acids for the treatment of dementia Background Omega‐3 polyunsaturated fatty acids (omega‐3 PUFAs) are assumed to have a beneficial effect on the function of the brain. It has been suggested that they might improve or delay decline in memory and ability to carry out everyday tasks in people with dementia. In this review, we investigated randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) comparing omega‐3 PUFAs, given in the form of supplements or enriched diets, with placebo (a pretend treatment) in people with the most common types of dementia. Included trials We included three trials that investigated 632 people with Alzheimer's disease of mild to moderate severity. We found no trials on other types of dementia. In all trials participants took either placebo or omega‐3 PUFA supplements. The quality of the trials was good. The participants were allocated to the groups randomly. The participants and most of the investigators did not know which treatment was given. Results When we combined the results of the trials, we found that taking omega‐3 PUFA supplements for six months had no effect on cognition (learning and understanding), everyday functioning, quality of life or mental health. One very small study observed that omega‐3 PUFAs improved cognitively complex daily activities, such as shopping, when taken for a longer period of time. However, the quality of the evidence was only moderate, so this should be confirmed in further trials. Omega‐3 PUFAs also had no effect on ratings of the overall severity of the illness. The trials did not report side effects very well, but none of the studies reported significant harmful effects on health. Conclusion Altogether, the quality of the evidence was moderate or high for most of the effects that we measured, but we found no evidence for either benefit or harm from omega‐3 PUFA supplements in people with mild to moderate Alzheimer's disease. The effects on people with other types of dementia remain unclear.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Burckhardt, M; Herke, M; Wustmann, T; Watzke, S; Langer, G; Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD009002.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "a1139a59-fff2-4d50-b5a4-a6671a7f418e", "pmid": "", "title": "Omega‐3 fatty acid addition during pregnancy", "imported": false, "abstract": "Abstract - Background Higher intakes of foods containing omega‐3 long‐chain polyunsaturated fatty acids (LCPUFA), such as fish, during pregnancy have been associated with longer gestations and improved perinatal outcomes. This is an update of a review that was first published in 2006. Objectives To assess the effects of omega‐3 LCPUFA, as supplements or as dietary additions, during pregnancy on maternal, perinatal, and neonatal outcomes and longer‐term outcomes for mother and child. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (16 August 2018), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing omega‐3 fatty acids (as supplements or as foods, stand‐alone interventions, or with a co‐intervention) during pregnancy with placebo or no omega‐3, and studies or study arms directly comparing omega‐3 LCPUFA doses or types. Trials published in abstract form were eligible for inclusion. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, assessed risk of bias in trials and assessed quality of evidence for prespecified birth/infant, maternal, child/adult and health service outcomes using the GRADE approach. Main results In this update, we included 70 RCTs (involving 19,927 women at low, mixed or high risk of poor pregnancy outcomes) which compared omega‐3 LCPUFA interventions (supplements and food) compared with placebo or no omega‐3. Overall study‐level risk of bias was mixed, with selection and performance bias mostly at low risk, but there was high risk of attrition bias in some trials. Most trials were conducted in upper‐middle or high‐income countries; and nearly half the trials included women at increased/high risk for factors which might increase the risk of adverse maternal and birth outcomes. Preterm birth < 37 weeks (13.4% versus 11.9%; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.81 to 0.97; 26 RCTs, 10,304 participants; high‐quality evidence) and early preterm birth < 34 weeks (4.6% versus 2.7%; RR 0.58, 95% CI 0.44 to 0.77; 9 RCTs, 5204 participants; high‐quality evidence) were both lower in women who received omega‐3 LCPUFA compared with no omega‐3. Prolonged gestation > 42 weeks was probably increased from 1.6% to 2.6% in women who received omega‐3 LCPUFA compared with no omega‐3 (RR 1.61 95% CI 1.11 to 2.33; 5141 participants; 6 RCTs; moderate‐quality evidence ). For infants, there was a possibly reduced risk of perinatal death (RR 0.75, 95% CI 0.54 to 1.03; 10 RCTs, 7416 participants; moderate‐quality evidence: 62/3715 versus 83/3701 infants) and possibly fewer neonatal care admissions (RR 0.92, 95% CI 0.83 to 1.03; 9 RCTs, 6920 participants; moderate‐quality evidence ‐ 483/3475 infants versus 519/3445 infants). There was a reduced risk of low birthweight (LBW) babies (15.6% versus 14%; RR 0.90, 95% CI 0.82 to 0.99; 15 trials, 8449 participants; high‐quality evidence); but a possible small increase in large‐for‐gestational age (LGA) babies (RR 1.15, 95% CI 0.97 to 1.36; 6 RCTs, 3722 participants; moderate‐quality evidence, for omega‐3 LCPUFA compared with no omega‐3. Little or no difference in small‐for‐gestational age or intrauterine growth restriction (RR 1.01, 95% CI 0.90 to 1.13; 8 RCTs, 6907 participants; moderate‐quality evidence) was seen. For the maternal outcomes , there is insufficient evidence to determine the effects of omega‐3 on induction post‐term (average RR 0.82, 95% CI 0.22 to 2.98; 3 trials, 2900 participants; low‐quality evidence), maternal serious adverse events (RR 1.04, 95% CI 0.40 to 2.72; 2 trials, 2690 participants; low‐quality evidence), maternal admission to intensive care (RR 0.56, 95% CI 0.12 to 2.63; 2 trials, 2458 participants; low‐quality evidence), or postnatal depression (average RR 0.99, 95% CI 0.56 to 1.77; 2 trials, 2431 participants; low‐quality evidence). Mean gestational length was greater in women who received omega‐3 LCPUFA (mean difference (MD) 1.67 days, 95% CI 0.95 to 2.39; 41 trials, 12,517 participants; moderate‐quality evidence), and pre‐eclampsia may possibly be reduced with omega‐3 LCPUFA (RR 0.84, 95% CI 0.69 to 1.01; 20 trials, 8306 participants; low‐quality evidence). For the child/adult outcomes, very few differences between antenatal omega‐3 LCPUFA supplementation and no omega‐3 were observed in cognition, IQ, vision, other neurodevelopment and growth outcomes, language and behaviour (mostly low‐quality to very low‐quality evidence). The effect of omega‐3 LCPUFA on body mass index at 19 years (MD 0, 95% CI ‐0.83 to 0.83; 1 trial, 243 participants; very low‐quality evidence) was uncertain. No data were reported for development of diabetes in the children of study participants. Authors' conclusions In the overall analysis, preterm birth < 37 weeks and early preterm birth < 34 weeks were reduced in women receiving omega‐3 LCPUFA compared with no omega‐3. There was a possibly reduced risk of perinatal death and of neonatal care admission , a reduced risk of LBW babies; and possibly a small increased risk of LGA babies with omega‐3 LCPUFA. For our GRADE quality assessments, we assessed most of the important perinatal outcomes as high‐quality (e.g. preterm birth) or moderate‐quality evidence (e.g. perinatal death). For the other outcome domains (maternal, child/adult and health service outcomes) GRADE ratings ranged from moderate to very low, with over half rated as low. Reasons for downgrading across the domain were mostly due to design limitations and imprecision. Omega‐3 LCPUFA supplementation during pregnancy is an effective strategy for reducing the incidence of preterm birth, although it probably increases the incidence of post‐term pregnancies. More studies comparing omega‐3 LCPUFA and placebo (to establish causality in relation to preterm birth) are not needed at this stage. A further 23 ongoing trials are still to report on over 5000 women, so no more RCTs are needed that compare omega‐3 LCPUFA against placebo or no intervention. However, further follow‐up of completed trials is needed to assess longer‐term outcomes for mother and child, to improve understanding of metabolic, growth and neurodevelopment pathways in particular, and to establish if, and how, outcomes vary by different types of omega‐3 LCPUFA, timing and doses; or by characteristics of women. Plain language summary Omega‐3 fatty acid addition during pregnancy What is the issue? Do omega‐3 long chain polyunsaturated fatty acids (LCPUFA) taken during pregnancy ‐ either as supplements or as dietary additions in food (such as some types of fish) ‐ improve health outcomes for babies and their mothers? This is an update of a Cochrane Review that was first published in 2006. Why is this important? Preterm birth (babies born before 37 weeks pregnancy (gestation)) is a leading cause of disability or death in the first five years of life. Fish and fish oil contain omega‐3 LCPUFA (particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)) and have been associated with longer pregnancies. So it is suggested that additional omega‐3 LCPUFAs in pregnancy may reduce the number of babies born preterm and may improve outcomes for children and mothers. However, many pregnant women do not eat fish very often. Encouraging pregnant women to eat fatty fish (which generally have low toxin levels) or to use omega‐3 LCPUFA supplements may improve children’s and women's health. This is an update of a Cochrane Review that was first published in 2006. What evidence did we find? We searched for evidence in August 2018 and found 70 randomised controlled trials (RCTs; this type of trial provides the most reliable results) (involving 19,927 women). Most trials evaluated a group of women who received omega‐3 LCPUFA and compared them with a group of women who received something that looked like omega‐3 LCPUFA but did not contain it (placebo) or received no omega‐3. The trials were mostly undertaken in upper‐middle or high‐income countries. Some studies included women at increased risk of preterm birth. The quality of the evidence from the included studies ranged from high to very low; this affected the certainty of the findings for different outcomes. We found the incidence of preterm birth (before 37 weeks) and very preterm birth (before 34 weeks) was lower in women who received omega‐3 LCPUFA compared with no additional omega‐3. There were also fewer babies with low birthweight. However, omega‐3 LCPUFA probably increased the incidence of pregnancies continuing beyond 42 weeks, although there was no difference identified in induction of labour for post‐term pregnancies. The risk of the baby dying or being very sick and going to neonatal intensive care may be lower with omega‐3 LCPUFA compared with no omega‐3. We did not see any differences between groups for serious adverse events for mothers or in postnatal depression. Very few differences between the omega‐3 LCPUFA groups and no omega‐3 groups were observed in child development and growth. Eleven trials reported that they had received industry funding. When we omitted these trials from the main outcomes (such as preterm birth and very preterm birth) it made very little, or no difference, to the results. What does this mean? Increasing omega‐3 LCPUFA intake during pregnancy, either through supplements or in foods, may reduce the incidence of preterm birth (before 37 weeks and before 34 weeks) and there may be less chance of having a baby with a low birthweight. Women who take omega‐3 LCPUFA supplements during pregnancy may also be more likely to have longer pregnancies. More studies are underway and their results will be included in a further update of this review. Future studies could consider if and how outcomes may vary in different populations of women, and could test different ways of increasing omega‐3 LCPUFA during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Middleton, P; Gomersall, JC; Gould, JF; Shepherd, E; Olsen, SF; Makrides, M", "articleTypes": [], "doi": "10.1002/14651858.CD003402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "a1357f0a-f5c1-4faa-a403-8eb0aeb8f498", "pmid": "", "title": "Glucocorticoids for croup in children", "imported": false, "abstract": "Abstract - Background Glucocorticoids are the mainstay for the treatment of croup. The existing evidence demonstrates that glucocorticoids are effective in the treatment of croup in children. However, updating the evidence on their clinical relevance in croup is imperative. This is an update to a review first published in 1999, and updated in 2004, 2011, and 2018. Objectives To investigate the effects and safety of glucocorticoids in the treatment of croup in children aged 18 years and below. Search methods We searched the Cochrane Library, which includes the Cochrane Central Register of Controlled Trials (CENTRAL; 2022 Issue 9), Ovid MEDLINE Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations and Ovid MEDLINE (1946 to 4 March 2022), Embase (Ovid) (1974 to 4 March 2022). We also searched the WHO ICTRP and ClinicalTrials.gov on 4 March 2022. Selection criteria We included randomised controlled trials (RCTs) in children (aged 18 years and below) with croup. We assessed the effect of glucocorticoids compared to the following: placebo, any other pharmacologic agents, any other glucocorticoids, any combination of other glucocorticoids, given by different modes of administration, or given in different doses. The included studies must have assessed at least one of our primary outcomes (defined as the change in croup score or return visits, (re)admissions to the hospital or both) or secondary outcomes (defined as the length of stay in hospital or emergency departments, patient improvement, use of additional treatments, or adverse events). Data collection and analysis Review authors independently extracted data, with another review author verified. We entered the data into Review Manager 5 for meta‐analysis. Two review authors independently assessed studies for risk of bias using the Cochrane risk of bias tool. Two review authors assessed the certainty of the evidence for the primary outcomes using the GRADE approach. Main results This updated review includes 45 RCTs with a total of 5888 children, an increase of two RCTs with 1323 children since the last update. We also identified one ongoing study and one study awaiting classification. We assessed most studies (98%) as at high or unclear risk of bias. Any glucocorticoid compared to placebo Compared to placebo, glucocorticoids may result in greater reductions in croup score after two hours (standardised mean difference (SMD) −0.65, 95% confidence interval (CI) −1.13 to −0.18; 7 RCTs, 426 children; low‐certainty evidence); six hours (SMD −0.76, 95% CI −1.12 to −0.40; 11 RCTs, 959 children; low‐certainty evidence); and 12 hours (SMD −1.03, 95% CI −1.53 to ‐0.53; 8 RCTs, 571 children; low‐certainty evidence). The evidence for change in croup score after 24 hours is very uncertain (SMD −0.86, 95% CI −1.40 to −0.31; 8 RCTs, 351 children; very low‐certainty evidence). One glucocorticoid compared to another glucocorticoid There was little to no difference between prednisolone and dexamethasone for reduction in croup score at two‐hour post‐baseline score (SMD 0.06, 95% CI −0.06 to 0.18; 1 RCT, 1231 children; high‐certainty evidence). There was likely little to no difference between prednisolone and dexamethasone for reduction in croup score at six‐hour post‐baseline score (SMD 0.21, 95% CI −0.21 to 0.62; 1 RCT, 99 children; moderate‐certainty evidence). However, dexamethasone probably reduced the return visits or (re)admissions for croup by almost half (risk ratio (RR) 0.55, 95% CI 0.28 to 1.11; 4 RCTs, 1537 children; moderate‐certainty evidence), and showed a 28% reduction in the use of supplemental glucocorticoids as an additional treatment (RR 0.72, 95% CI 0.53 to 0.97; 2 RCTs, 926 children). Dexamethasone given in different doses Compared to 0.15 mg/kg, 0.60 mg/kg dexamethasone probably reduced the severity of croup as assessed by the croup scoring scale at 24‐hour postbaseline score (SMD 0.63, 95% CI 0.16 to 1.10; 1 RCT, 72 children; moderate‐certainty evidence); however, this was not the case at two hours (SMD −0.27, 95% CI −0.76 to 0.22; 2 RCTs, 861 children; high‐certainty evidence). There was probably no reduction at six hours (SMD −0.45, 95% CI −1.26 to 0.35; 3 RCTs, 178 children; moderate‐certainty evidence), and the evidence at 12 hours is very uncertain (SMD −0.60, 95% CI −4.39 to 3.19; 2 RCTs, 113 children; very low‐certainty evidence). There was little to no difference between doses of dexamethasone in return visits or (re)admissions of children or both (RR 0.91, 95% CI 0.71 to 1.17; 3 RCTs, 949 children; high‐certainty evidence) or length of stay in the hospital or emergency department (mean difference 0.12, 95% CI −0.32 to 0.56; 2 RCTs, 892 children). The need for additional treatments, such as epinephrine (RR 0.78, 95% CI 0.34 to 1.75; 2 RCTs, 885 children); intubation (risk difference 0.00, 95% CI −0.00 to 0.00; 2 RCTs, 861 children); or use of supplemental glucocorticoids (RR 0.77, 95% CI 0.51 to 1.15; 2 RCTs, 617 children), also did not differ between doses of dexamethasone. There were moderate to high levels of heterogeneity in the analyses for most comparisons. Adverse events were observed for some of the comparisons reported in the review. Authors' conclusions The evidence that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions has not changed in this update. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg. More RCTs are needed to strengthen the evidence for effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. Plain language summary Glucocorticoids for croup in children Review question What is the effectiveness and safety of glucocorticoids when treating children with croup? Background Respiratory viruses are the main cause of croup in children. Croup leads to a swelling of the throat and airway, which can make breathing difficult. Children also present with a special type of cough called a barking cough. Glucocorticoids are types of steroids that help reduce the swelling, thereby making it easier for children with croup to breathe. This is an update of a review first published in 1999 and updated in 2004, 2011, and 2018. Search date The evidence is current to 4 March 2022. Study characteristics We included 2 new studies with 1323 children, for a total of 45 studies with 5888 children aged 0 to 18 years published between 1964 and 2021. The three types of glucocorticoids used in the new studies were budesonide, dexamethasone, and prednisolone. The most recent study compared the effectiveness of budesonide and dexamethasone. The other new study compared the effectiveness of dexamethasone and prednisolone, as well as a small dose of dexamethasone (0.15 mg/kg) versus 0.60 mg/kg dexamethasone. We added the data from the new study that compared the doses of dexamethasone to previously included studies looking at the same comparison. Study funding sources Funding sources included government (11%), academic or research institute (7%), industry (18%), or foundations (9%). More than half of the studies (55%) did not report funding sources. Key results Compared to prednisolone, dexamethasone showed no improvement in croup score at two and six hours after presenting to the hospital or emergency department, and probably reduced return visits or (re)admissions for croup by almost half. The addition of supplemental glucocorticoid favoured dexamethasone versus prednisolone. Compared to 0.15 mg/kg dexamethasone, the standard dose of 0.60 mg/kg probably reduced the severity of croup as assessed by the croup scoring scale at 24 hours after presenting to the hospital or emergency department. However, we did not find any important difference between groups in croup scoring scale at 2, 6, or 12 hours, return visits or (re)admissions of children, or length of stay in the hospital or emergency department. The need for additional treatments such as the use of other drugs like epinephrine, supplemental glucocorticoid, or the use of a tube to help breathing did not differ between 0.15 mg/kg and 0.60 mg/kg dexamethasone. No serious adverse events from the use of the glucocorticoids were reported in the newly included studies. Conclusions The evidence has not changed that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions compared to placebo (dummy treatment). A small dose of dexamethasone at 0.15 mg/kg may be as effective as the standard dose of 0.60 mg/kg. More studies are needed to strengthen the evidence for the effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. We conclude that glucocorticoids are effective in the treatment of croup in children. Certainty of evidence Most studies (98%) had problems related to their methods, reporting issues, or both. For any glucocorticoid compared to placebo, we downgraded the certainty of the evidence for change in croup score after 2, 6, 12, and 24 hours and return visits or (re)admissions due to study variability, imprecision and inconsistency of study results, and risk of bias. There is little evidence that reporting bias influenced our results for return visits or (re)admissions, or both. Similar threats to the certainty of the evidence were present in the other comparisons in this review, including concerns related to risk of bias and inconsistency and imprecision of study results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aregbesola, A; Tam, CM; Kothari, A; Le, M-L; Ragheb, M; Klassen, TP", "articleTypes": [], "doi": "10.1002/14651858.CD001955.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "a143b149-7cd9-4911-a314-d63c8905eca8", "pmid": "", "title": "Interventions for pityriasis rosea", "imported": false, "abstract": "Abstract - Background Pityriasis rosea is a scaly, itchy rash that mainly affects young adults and lasts for 2 to 12 weeks. The effects of many available treatments are uncertain. This is an update of a Cochrane Review first published in 2007. Objectives To assess the effects of interventions for the management of pityriasis rosea in any individual diagnosed by a medical practitioner. Search methods We updated our searches of the following databases to October 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched five trials registers. We also checked the reference lists of included and excluded studies, contacted trial authors, scanned the abstracts from major dermatology conference proceedings, and searched the CAB Abstracts database. We searched PubMed for adverse effects to November 2018. Selection criteria Randomised controlled trials of interventions in pityriasis rosea. Treatment could be given in a single therapy or in combination. Eligible comparators were no treatment, placebo, vehicle only, another active compound, or placebo radiation treatment. Data collection and analysis We used standard methodological procedures expected by the Cochrane. Our key outcomes were good or excellent rash improvement within two weeks, rated separately by the participant and medical practitioner; serious adverse events; resolution of itch within two weeks (participant‐rated); reduction in itch score within two weeks (participant‐rated); and minor participant‐reported adverse events not requiring withdrawal of the treatment. Main results We included 14 trials (761 participants). In general, risk of selection bias was unclear or low, but risk of performance bias and reporting bias was high for 21% of the studies. Participant age ranged from 2 to 60 years, and sex ratio was similar. Disease severity was measured by various severity indices, which the included studies did not categorise. Six studies were conducted in India, three in Iran, two in the Philippines, and one each in Pakistan, the USA, and China. The included studies were conducted in dermatology departments and a paediatric clinic. Study duration ranged from 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding source. The included studies assessed macrolide antibiotics, an antiviral agent, phototherapy, steroids and antihistamine, and Chinese medicine. None of the studies measured participant‐rated good or excellent rash improvement. All reported outcomes were assessed within two weeks of treatment, except for adverse effects, which were measured throughout treatment. There is probably no difference between oral clarithromycin and placebo in itch resolution (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.47 to 1.52; 1 study, 28 participants) or rash improvement (medical practitioner‐rated) (RR 1.13, 95% CI 0.89 to 1.44; 1 study, 60 participants). For this comparison, there were no serious adverse events (1 study, 60 participants); minor adverse events and reduction in itch score were not measured; and all evidence was of moderate quality. When compared with placebo, erythromycin may lead to increased rash improvement (medical practitioner‐rated) (RR 4.02, 95% CI 0.28 to 56.61; 2 studies, 86 participants, low‐quality evidence); however, the 95% CI indicates that the result may also be compatible with a benefit of placebo, and there may be little or no difference between treatments. Itch resolution was not measured, but one study measured reduction in itch score, which is probably larger with erythromycin (MD 3.95, 95% CI 3.37 to 4.53; 34 participants, moderate‐quality evidence). In the same single, small trial, none of the participants had a serious adverse event, and there was no clear difference between groups in minor adverse events, which included gastrointestinal upset (RR 2.00, CI 0.20 to 20.04; moderate‐quality evidence). Two trials compared oral azithromycin to placebo or vitamins. There is probably no difference between groups in itch resolution (RR 0.83, 95% CI 0.28 to 2.48) or reduction in itch score (MD 0.04, 95% CI −0.35 to 0.43) (both outcomes based on one study; 70 participants, moderate‐quality evidence). Low‐quality evidence from two studies indicates there may be no difference between groups in rash improvement (medical practitioner‐rated) (RR 1.02, 95% CI 0.52 to 2.00; 119 participants). In these same two studies, no serious adverse events were reported, and there was no clear difference between groups in minor adverse events, specifically mild abdominal pain (RR 5.82, 95% CI 0.72 to 47.10; moderate‐quality evidence). Acyclovir was compared to placebo, vitamins, or no treatment in three trials (all moderate‐quality evidence). Based on one trial (21 participants), itch resolution is probably higher with placebo than with acyclovir (RR 0.34, 95% CI 0.12 to 0.94); reduction in itch score was not measured. However, there is probably a significant difference between groups in rash improvement (medical practitioner‐rated) in favour of acyclovir versus all comparators (RR 2.45, 95% CI 1.33 to 4.53; 3 studies, 141 participants). Based on the same three studies, there were no serious adverse events in either group, and there was probably no difference between groups in minor adverse events (only one participant in the placebo group experienced abdominal pain and diarrhoea). One trial compared acyclovir added to standard care (calamine lotion and oral cetirizine) versus standard care alone (24 participants). The addition of acyclovir may lead to increased itch resolution (RR 4.50, 95% CI 1.22 to 16.62) and reduction in itch score (MD 1.26, 95% CI 0.74 to 1.78) compared to standard care alone. Rash improvement (medical practitioner‐rated) was not measured. The trial reported no serious adverse events in either group, and there may be no difference between groups in minor adverse events, such as headache (RR 7.00, 95% CI 0.40 to 122.44) (all results based on low‐quality evidence). Authors' conclusions When compared with placebo or no treatment, oral acyclovir probably leads to increased good or excellent, medical practitioner‐rated rash improvement. However, evidence for the effect of acyclovir on itch was inconclusive. We found low‐ to moderate‐quality evidence that erythromycin probably reduces itch more than placebo. Small study sizes, heterogeneity, and bias in blinding and selective reporting limited our conclusions. Further research is needed to investigate different dose regimens of acyclovir and the effect of antivirals on pityriasis rosea. Plain language summary Treatments for pityriasis rosea Background Pityriasis rosea is a common scaly rash prevalent in young adults. A patch of redness and scales is followed by widespread rash. Pityriasis rosea usually resolves within 2 to 12 weeks; however, the rash can resemble a serious contagious skin condition, causing concern. Moreover, pityriasis rosea can cause moderate to severe itching, making effective treatment necessary. Review question We wanted to evaluate the effectiveness and safety of treatments for pityriasis rosea. Eligible treatments were topical, systemic (oral or injected medicines that work throughout the entire body), or light therapy, given alone or in combination with another treatment, and compared against no treatment, placebo (an identical but inactive treatment), vehicle (inactive ingredients that help deliver an active treatment) only, or another active treatment. As spontaneous recovery usually occurs between 2 and 12 weeks in cases of untreated pityriasis rosea, we considered outcomes reported at two weeks. Study characteristics The evidence is current to October 2018. We included 14 studies with a total of 761 participants aged between 2 and 60 years (similar numbers of males and females). Most studies were conducted in Asia in dermatology departments and lasted between 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding sources. Disease severity was assessed by various measures, but participants were not categorised into mild, moderate, or severe disease. Important treatments assessed by the studies included various antibiotics and acyclovir (a drug meant to treat herpes infections), which were compared to placebo, no treatment, or standard care. Additional treatments included phototherapy, corticosteroids and antihistamine, and Chinese medicine (potenline). Most studies assessed treatment used for one week. All reported outcomes were assessed within two weeks of treatment, except for side effects, which were measured throughout treatment. None of the included studies reported on the participant's rating of rash improvement. Itch was always participant‐assessed. Rash improvement was rated as good or excellent. There is probably no difference between clarithromycin and placebo in medical practitioner‐rated rash improvement or itch resolution, and no serious adverse events were reported (all moderate‐quality evidence). Reduction in itch score and minor side effects were not measured. Similarly, there may be no difference in medical practitioner‐rated rash improvement between azithromycin and placebo or vitamins, but erythromycin may lead to increased rash improvement when compared to placebo; however, the results show there may be a benefit with placebo or little or no difference between treatments (low‐quality evidence for both outcomes). There is probably no difference between azithromycin and comparators in itch resolution or reduction in itch score; there was no clear difference in minor side effects, such as mild abdominal pain (both moderate‐quality evidence). When comparing erythromycin to placebo, itch resolution was not measured, but there is probably a greater reduction in itch score with erythromycin. There was no clear difference in the likelihood of minor side effects, such as gastrointestinal upset, between groups (moderate‐quality evidence for both outcomes). A single study suggested that acyclovir is probably less effective than placebo in achieving itch resolution (but itch score reduction was not measured). However, results from three studies indicate that acyclovir is probably significantly more beneficial than placebo, no treatment, or vitamin tablets in medical practitioner‐rated rash improvement. There is probably no difference between acyclovir and placebo in the incidence of minor side effects: one participant in the placebo group experienced mild abdominal pain and diarrhoea (all outcomes based on moderate‐quality evidence). A single trial indicated that acyclovir used in combination with standard care (calamine (anti‐itch lotion) and the antihistamine cetirizine) may reduce itch score and increase itch resolution (low‐quality evidence). Medical practitioner‐rated rash improvement was not measured. There may be no difference between groups in minor side effects, such as headache, increased sleep, sickness, and impact on taste. None of the studies reported serious adverse events (low‐ to moderate‐quality evidence). Quality of the evidence The quality of the evidence for the main comparisons was low to moderate. Many of the results were based on a small number of trials, with a low number of participants. There was also some variation amongst the trial results and concerns over study design.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Contreras‐Ruiz, J, Peternel, S, Jiménez Gutiérrez, C, Culav‐Koscak, I, Reveiz, L, Silbermann‐Reynoso, MDL", "articleTypes": [], "doi": "10.1002/14651858.CD005068.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.821Z" }, { "id": "a153ba3c-2f8c-4a75-a830-ebc857cf9541", "pmid": "", "title": "Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Harmful alcohol use is defined as unhealthy alcohol use that results in adverse physical, psychological, social, or societal consequences and is among the leading risk factors for disease, disability and premature mortality globally. The burden of harmful alcohol use is increasing in low‐ and middle‐income countries (LMICs) and there remains a large unmet need for indicated prevention and treatment interventions to reduce harmful alcohol use in these settings. Evidence regarding which interventions are effective and feasible for addressing harmful and other patterns of unhealthy alcohol use in LMICs is limited, which contributes to this gap in services. Objectives To assess the efficacy and safety of psychosocial and pharmacologic treatment and indicated prevention interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs. Search methods We searched for randomized controlled trials (RCTs) indexed in the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, the Cochrane Clinical Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, and the Latin American and Caribbean Health Sciences Literature (LILACS) through 12 December 2021. We searched clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, Web of Science, and Opengrey database to identify unpublished or ongoing studies. We searched the reference lists of included studies and relevant review articles for eligible studies. Selection criteria All RCTs comparing an indicated prevention or treatment intervention (pharmacologic or psychosocial) versus a control condition for people with harmful alcohol use in LMICs were included. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 66 RCTs with 17,626 participants. Sixty‐two of these trials contributed to the meta‐analysis. Sixty‐three studies were conducted in middle‐income countries (MICs), and the remaining three studies were conducted in low‐income countries (LICs). Twenty‐five trials exclusively enrolled participants with alcohol use disorder. The remaining 51 trials enrolled participants with harmful alcohol use, some of which included both cases of alcohol use disorder and people reporting hazardous alcohol use patterns that did not meet criteria for disorder. Fifty‐two RCTs assessed the efficacy of psychosocial interventions; 27 were brief interventions primarily based on motivational interviewing and were compared to brief advice, information, or assessment only. We are uncertain whether a reduction in harmful alcohol use is attributable to brief interventions given the high levels of heterogeneity among included studies (Studies reporting continuous outcomes: Tau² = 0.15, Q =139.64, df =16, P<.001, I² = 89%, 3913 participants, 17 trials, very low certainty; Studies reporting dichotomous outcomes: Tau²=0.18, Q=58.26, df=3, P<.001, I² =95%, 1349 participants, 4 trials, very low certainty). The other types of psychosocial interventions included a range of therapeutic approaches such as behavioral risk reduction, cognitive‐behavioral therapy, contingency management, rational emotive therapy, and relapse prevention. These interventions were most commonly compared to usual care involving varying combinations of psychoeducation, counseling, and pharmacotherapy. We are uncertain whether a reduction in harmful alcohol use is attributable to psychosocial treatments due to high levels of heterogeneity among included studies (Heterogeneity: Tau² = 1.15; Q = 444.32, df = 11, P<.001; I²=98%, 2106 participants, 12 trials, very low certainty). Eight trials compared combined pharmacologic and psychosocial interventions with placebo, psychosocial intervention alone, or another pharmacologic treatment. The active pharmacologic study conditions included disulfiram, naltrexone, ondansetron, or topiramate. The psychosocial components of these interventions included counseling, encouragement to attend Alcoholics Anonymous, motivational interviewing, brief cognitive‐behavioral therapy, or other psychotherapy (not specified). Analysis of studies comparing a combined pharmacologic and psychosocial intervention to psychosocial intervention alone found that the combined approach may be associated with a greater reduction in harmful alcohol use (standardized mean difference (standardized mean difference (SMD))=‐0.43, 95% confidence interval (CI): ‐0.61 to ‐0.24; 475 participants; 4 trials; low certainty). Four trials compared pharmacologic intervention alone with placebo and three with another pharmacotherapy. Drugs assessed were: acamprosate, amitriptyline, baclofen disulfiram, gabapentin, mirtazapine, and naltrexone. None of these trials evaluated the primary clinical outcome of interest, harmful alcohol use. Thirty‐one trials reported rates of retention in the intervention. Meta‐analyses revealed that rates of retention between study conditions did not differ in any of the comparisons (pharmacologic risk ratio (RR) = 1.13, 95% CI: 0.89 to 1.44, 247 participants, 3 trials, low certainty; pharmacologic in addition to psychosocial intervention: RR = 1.15, 95% CI: 0.95 to 1.40, 363 participants, 3 trials, moderate certainty). Due to high levels of heterogeneity, we did not calculate pooled estimates comparing retention in brief (Heterogeneity: Tau² = 0.00; Q = 172.59, df = 11, P<.001; I 2 = 94%; 5380 participants; 12 trials, very low certainty) or other psychosocial interventions (Heterogeneity: Tau² = 0.01; Q = 34.07, df = 8, P<.001; I 2 = 77%; 1664 participants; 9 trials, very low certainty). Two pharmacologic trials and three combined pharmacologic and psychosocial trials reported on side effects. These studies found more side effects attributable to amitriptyline relative to mirtazapine, naltrexone and topiramate relative to placebo, yet no differences in side effects between placebo and either acamprosate or ondansetron. Across all intervention types there was substantial risk of bias. Primary threats to validity included lack of blinding and differential/high rates of attrition. Authors' conclusions In LMICs there is low‐certainty evidence supporting the efficacy of combined psychosocial and pharmacologic interventions on reducing harmful alcohol use relative to psychosocial interventions alone. There is insufficient evidence to determine the efficacy of pharmacologic or psychosocial interventions on reducing harmful alcohol use largely due to the substantial heterogeneity in outcomes, comparisons, and interventions that precluded pooling of these data in meta‐analyses. The majority of studies are brief interventions, primarily among men, and using measures that have not been validated in the target population. Confidence in these results is reduced by the risk of bias and significant heterogeneity among studies as well as the heterogeneity of results on different outcome measures within studies. More evidence on the efficacy of pharmacologic interventions, specific types of psychosocial interventions are needed to increase the certainty of these results. Plain language summary Interventions to reduce harmful alcohol use in low‐ and middle‐income countries Why is this review important? Harmful alcohol use is one of the main contributors to the global burden of disease. In low‐ and middle‐income countries, harmful alcohol use is increasing. However, services to prevent and treat harmful alcohol use are limited. One contributor to the lack of available services is the limited information about which intervention approaches are effective in reducing harmful alcohol use and whether these approaches are feasible and acceptable in low‐resource settings. In order to prevent the physical, psychological, and societal burden of harmful alcohol use, it is important that effective interventions are available to reduce alcohol‐related harm. What is the goal of this review? The goal of this review is to summarize evidence on whether psychosocial and pharmacologic interventions are able to reduce harmful alcohol use in low‐ and middle‐income countries. We also aim to evaluate the safety of treatments and how many people remain in treatment until its completion. What does the research say? We identified 66 randomized controlled trials that evaluated the effect of interventions on reducing harmful alcohol use. Most of these studies assessed psychosocial interventions (n = 52 studies), six assessed pharmacologic interventions alone, and eight assessed combined pharmacologic and psychosocial interventions. The majority of included trials were funded by government agencies (36 trials) followed by multiple public and private funders (8 trials) or private foundations (5 trials). Seventeen trials did not report the funding source. We are uncertain whether brief psychosocial interventions and other psychosocial interventions reduce harmful alcohol use. Combined pharmacologic and psychosocial interventions may reduce harmful alcohol use relative to psychosocial interventions combined with placebo, yet the certainty of the evidence has been assessed as low. No studies were found that looked at the effect of pharmacologic interventions alone on harmful alcohol use. We did not find evidence that rates of retention differed between study conditions for any of the intervention types. Certainty of evidence: The certainty of evidence on the effect of brief and other psychosocial interventions on harmful alcohol use was very low due to lack of masking, differential attrition and missing data, selective outcome reporting, high heterogeneity, and differences in patient populations. The certainty of evidence on the effect of combined pharmacologic and psychosocial interventions on harmful alcohol use was low due to lack of blinding, incomplete outcome data, and heterogeneity in the pharmacologic interventions under investigation. No studies evaluated the effect of pharmacologic interventions alone on harmful alcohol use. The evidence is current to 12 December 2021. What are the next steps? Future research on interventions to reduce harmful alcohol use is needed to address some of the limitations described in this review. Studies evaluating similar interventions across studies and contexts are needed to improve generalizability and understand the necessary characteristics of and conditions for effective intervention. Studies must utilize measurement tools that are valid in the population they are studying. Lastly, studies must be designed to reduce the risk of bias leading to the high degree of uncertainty in the results reported in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, MC, Kane, J, Alto, M, Giusto, A, Lovero, K, Stockton, M, McClendon, J, Nicholson, T, Wainberg, ML., Johnson, RM, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013350.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.774Z" }, { "id": "a166a41e-1d44-409e-b775-09e0a1d67149", "pmid": "", "title": "Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under", "imported": false, "abstract": "Abstract - Background Although complementary feeding is a universal practice, the methods and manner in which it is practiced vary between cultures, individuals and socioeconomic classes. The period of complementary feeding is a critical time of transition in the life of an infant, and inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. Educational interventions are widely acknowledged as effective in promoting public health strategy, and those aimed at improving complementary feeding practices provide information about proper complementary feeding practices to caregivers of infants/children. It is therefore important to summarise evidence on the effectiveness of educational interventions to improve the complementary feeding practices of caregivers of infants. Objectives To assess the effectiveness of educational interventions for improving the complementary feeding (weaning) practices of primary caregivers of children of complementary feeding age, and related health and growth outcomes in infants. Search methods In November 2017, we searched CENTRAL, MEDLINE, Embase, 10 other databases and two trials registers. We also searched the reference lists of relevant studies and reviews to identify any additional studies. We did not limit the searches by date, language or publication status. Selection criteria Randomised controlled trials (RCTs), comparing educational interventions to no intervention, usual practice, or educational interventions provided in conjunction with another intervention, so long as the educational intervention was only available in the experimental group and the adjunctive intervention was available to the control group. Study participants included caregivers of infants aged 4 to 24 months undergoing complementary feeding. Pregnant women who were expected to give birth and commence complementary feeding during the period of the study were also included. Data collection and analysis Two review authors independently extracted data on participants, settings, interventions, methodology and outcomes using a specifically‐developed and piloted data extraction form. We calculated risk ratios (RR) and 95% confidence intervals (CIs) for dichotomous data, and mean differences (MD) and 95% CIs for continuous data. Where data permitted, we conducted a meta‐analysis using a random‐effects model. We assessed the included studies for risk of bias and also assessed the quality of evidence using the GRADE approach. Main results We included 23 studies (from 35 reports) with a total of 11,170 caregiver‐infant pairs who were randomly assigned to receive an educational intervention delivered to the caregiver or usual care. Nineteen of the included studies were community‐based studies while four were facility‐based studies. In addition, 13 of the included studies were cluster‐randomised while the others were individually randomised. Generally, the interventions were focused on the introduction of complementary feeding at the appropriate time, the types and amount of complementary foods to be fed to infants, and hygiene. Using the GRADE criteria, we assessed the quality of the evidence as moderate, mostly due to inadequate allocation concealment and insufficient blinding. Educational interventions led to improvements in complementary feeding practices for age at introduction of complementary foods (average RR 0.88, 95% CI 0.83 to 0.94; 4 studies, 1738 children; moderate‐quality evidence) and hygiene practices (average RR 1.38, 95% CI 1.23 to 1.55; 4 studies, 2029 participants; moderate‐quality evidence). For duration of exclusive breastfeeding, pooled results were compatible with both a reduction and an increase in the outcome (average RR 1.58, 95% CI 0.77 to 3.22; 3 studies, 1544 children; very low‐quality evidence). There was limited (low to very low‐quality) evidence of an effect for all growth outcomes. Quality of evidence There is moderate to very low‐quality evidence that educational interventions can improve complementary feeding practices but insufficient evidence to conclude that it impacts growth outcomes. Authors' conclusions Overall, we found evidence that education improves complementary feeding practices. Plain language summary Educational interventions for improving complementary feeding practices Background Complementary feeding is the period when an infant moves from taking only breast milk or breast‐milk substitutes (such as infant formula) to family food. It is a critical period in the life of an infant. Inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. This is because inappropriate complementary feeding practices, such as introduction of semi‐solid foods too early (before six months of age), poor hygiene or giving foods that do not contain adequate nutrients, are all major causes of illness. Such illnesses include malnutrition, diarrhoea, poor growth, infections and poor mental development of children. Education has been proposed as an effective means of improving complementary feeding practices. Review question Does education improve complementary feeding practices of caregivers of infants as well as the health and growth of the infants? Study characteristics We searched for randomised controlled trials (a type of experiment in which people are randomly allocated to one or more treatment groups) up until November 2017. The search identified 23 studies involving a total of 11,170 caregivers and their children. The ages of the children ranged from birth to 24 months. The caregivers received educational interventions alone while the control group received no intervention, usual care or any other non‐educational intervention. The educational methods included printed materials such as leaflets, counselling, teaching sessions, peer support, videos and practical demonstrations. Generally, the education messages were focused on the introduction of semi‐solid foods at the appropriate age, the types and amount of complementary foods to be fed to infants, and hygiene. Key results Education reduced the number of caregivers that introduced semi‐solid foods to their infants before six months of age by up to 12% (moderate‐quality evidence). Hygiene practices of caregivers who received education also showed some improvement compared to those that did not (moderate‐quality evidence). In studies conducted in the community, education increased the duration of exclusive breastfeeding, but not in studies conducted in health facilities. There was no convincing evidence of an effect of education on the growth of children (low to very low‐quality evidence). We could not combine the results from different studies for diarrhoea, knowledge of caregivers and adequacy of complementary food. However, from the individual reports of the study authors, education led to a reduction in diarrhoea and an improvement in the knowledge of caregivers. It also led to improvement in the quality and quantity of complementary foods fed to infants. Overall, we found evidence that education improves complementary feeding practices.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Arikpo, D; Edet, ES; Chibuzor, MT; Odey, F; Caldwell, DM", "articleTypes": [], "doi": "10.1002/14651858.CD011768.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "a1946a0b-12fb-4bf2-8dba-2c5088aec131", "pmid": "", "title": "Quinine for muscle cramps", "imported": false, "abstract": "Abstract - Background Muscle cramps can occur anywhere and for many reasons. Quinine has been used to treat cramps of all causes. However, controversy continues about its efficacy and safety. This review was first published in 2010 and searches were updated in 2014. Objectives To assess the efficacy and safety of quinine‐based agents in treating muscle cramps. Search methods On 27 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE. We searched reference lists of articles up to 2014. We also searched for ongoing trials in November 2014. Selection criteria Randomised controlled trials of people of all ages with muscle cramps in any location and of any cause, treated with quinine or its derivatives. Data collection and analysis Three review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We contacted study authors for additional information. For comparisons including more than one trial, we assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Main results We identified 23 trials with a total of 1586 participants. Fifty‐eight per cent of these participants were from five unpublished studies. Quinine was compared to placebo (20 trials, n = 1140), vitamin E (four trials, n = 543), a quinine‐vitamin E combination (three trials, n = 510), a quinine‐theophylline combination (one trial, n = 77), and xylocaine injections into the gastrocnemius muscle (one trial, n = 24). The most commonly used quinine dosage was 300 mg/day (range 200 to 500 mg). We found no new trials for inclusion when searches were updated in 2014. The risk of bias in the trials varied considerably. All 23 trials claimed to be randomised, but only a minority described randomisation and allocation concealment adequately. Compared to placebo, quinine significantly reduced cramp number over two weeks by 28%, cramp intensity by 10%, and cramp days by 20%. Cramp duration was not significantly affected. A significantly greater number of people suffered minor adverse events on quinine than placebo (risk difference (RD) 3%, 95% confidence interval (CI) 0% to 6%), mainly gastrointestinal symptoms. Overdoses of quinine have been reported elsewhere to cause potentially fatal adverse effects, but in the included trials there was no significant difference in major adverse events compared with placebo (RD 0%, 95% CI ‐1% to 2%). One participant suffered from thrombocytopenia (0.12% risk) on quinine. A quinine‐vitamin E combination, vitamin E alone, and xylocaine injections into gastrocnemius were not significantly different to quinine across all outcomes, including adverse effects. Based on a single trial comparison, quinine alone was significantly less effective than a quinine‐theophylline combination but with no significant differences in adverse events. Authors' conclusions There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that with use up to 60 days, the incidence of serious adverse events is not significantly greater than for placebo in the identified trials, but because serious adverse events can be rarely fatal, in some countries prescription of quinine is severely restricted. Evidence from single trials suggests that theophylline combined with quinine improves cramps more than quinine alone, and the effects of xylocaine injections into gastrocnemius are not significantly different to quinine across all outcomes. Low or moderate quality evidence shows no significant difference between quinine and vitamin E or quinine and quinine‐vitamin E mixture. Further research into these alternatives, as well other pharmacological and non‐pharmacological treatments, is thus warranted. There is no evidence to judge optimal dosage or duration of quinine treatment. Further studies using different dosages and measurement of serum quinine levels will allow a therapeutic range to be defined for muscle cramp. Because serious adverse events are not common, large population studies are required to more accurately inform incidence. Longer lengths of follow‐up in future trials will help determine the duration of action following cessation of quinine as well as long‐term adverse events. The search for new therapies, pharmacological and nonpharmacological, should continue and further trials should compare vitamin E, quinine‐vitamin E combination, and quinine‐theophylline mixture with quinine. Plain language summary Quinine for muscle cramps Review question We reviewed the evidence about the effect of quinine on muscle cramps. Background Muscle cramps can occur anywhere and in anyone; however, leg cramps are especially common in older people. Quinine is a medicine which has been used to treat cramps for many years. There is conflicting evidence for its ability to reduce cramps. Quinine can cause serious, even fatal adverse events, especially in overdosage. Study characteristics This review includes 23 trials, with 1586 participants. The trials compared quinine or quinine‐based medicines against inactive treatment (placebo) or other active treatments. We found no new studies when we searched the medical literature again and updated the review in 2014. Key results and quality of the evidence The risk of bias in the included trials varied considerably. All 23 trials claimed to be randomised, but many failed to clearly describe how participants were assigned to treatments. There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that there are more minor adverse events with quinine compared to placebo but no increase in major adverse events. However, there are reliable reports from other sources that an overdose of quinine can cause serious harm including death. Low or moderate quality evidence shows there is no significant difference when comparing quinine to vitamin E or to a quinine‐vitamin E mixture. There is evidence from one trial that theophylline combined with quinine improves cramps more than quinine alone. In a single trial there was no significant difference when comparing quinine to xylocaine injections. More research is needed to clarify the best dose and duration of treatment, as well as alternatives to quinine for cramps. The evidence is current to October 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El‐Tawil, S, Al Musa, T, Valli, H, Lunn, MPT, Brassington, R, El‐Tawil, T, Weber, M", "articleTypes": [], "doi": "10.1002/14651858.CD005044.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.779Z" }, { "id": "a1a1db33-4b71-423c-aa80-f981f9eb43ae", "pmid": "", "title": "High-dose Vitamin D Supplement for the Prevention of Acute Asthma-like Symptoms in Preschool Children - a Double-blind, Randomized, Controlled Trial", "imported": false, "abstract": "To investigate whether high-dose vitamin D supplementation may have a beneficial effect on secondary prevention in preschool children (1-5 years of age), with respiratory infections being the primary cause of acute exacerbations with asthma-like symptoms.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.155Z" }, { "id": "a1cc8e5a-4875-440d-bf73-35b8398409d6", "pmid": "", "title": "Full‐mouth treatment modalities (within 24 hours) for periodontitis in adults", "imported": false, "abstract": "Abstract - Background Periodontitis is a highly prevalent, chronic inflammation that causes damage to the soft tissues and bones supporting the teeth. Conventional treatment is quadrant scaling and root planing (the second step of periodontal therapy), which comprises scaling and root planing of teeth in one quadrant of the mouth at a time, with the four different sessions separated by at least one week. Alternative protocols for anti‐infective periodontal therapy have been introduced to help enhance treatment outcomes: full‐mouth scaling (subgingival instrumentation of all quadrants within 24 hours), or full‐mouth disinfection (subgingival instrumentation of all quadrants in 24 hours plus adjunctive antiseptic). We use the older term 'scaling and root planing' (SRP) interchangeably with the newer term 'subgingival instrumentation' in this iteration of the review, which updates one originally published in 2008 and first updated in 2015. Objectives To evaluate the clinical effects of full‐mouth scaling or full‐mouth disinfection (within 24 hours) for the treatment of periodontitis compared to conventional quadrant subgingival instrumentation (over a series of visits at least one week apart) and to evaluate whether there was a difference in clinical effects between full‐mouth disinfection and full‐mouth scaling. Search methods An information specialist searched five databases up to 17 June 2021 and used additional search methods to identify published, unpublished and ongoing studies. Selection criteria We included randomised controlled trials (RCTs) lasting at least three months that evaluated full‐mouth scaling and root planing within 24 hours, with or without adjunctive use of an antiseptic, compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of (chronic) periodontitis according to the International Classification of Periodontal Diseases from 1999. A new periodontitis classification was launched in 2018; however, we used the 1999 classification for inclusion or exclusion of studies, as most studies used it. We excluded studies of people with systemic disorders, taking antibiotics or with the older diagnosis of 'aggressive periodontitis'. Data collection and analysis Several review authors independently conducted data extraction and risk of bias assessment (based on randomisation method, allocation concealment, examiner blinding and completeness of follow‐up). Our primary outcomes were tooth loss and change in probing pocket depth (PPD); secondary outcomes were change in probing attachment (i.e. clinical attachment level (CAL)), bleeding on probing (BOP), adverse events and pocket closure (the number/proportion of sites with PPD of 4 mm or less after treatment). We followed Cochrane's methodological guidelines for data extraction and analysis. Main results We included 20 RCTs, with 944 participants, in this updated review. No studies assessed the primary outcome tooth loss. Thirteen trials compared full‐mouth scaling and root planing within 24 hours without the use of antiseptic (FMS) versus control, 13 trials compared full‐mouth scaling and root planing within 24 hours with adjunctive use of an antiseptic (FMD) versus control, and six trials compared FMS with FMD. Of the 13 trials comparing FMS versus control, we assessed three at high risk of bias, six at low risk of bias and four at unclear risk of bias. We assessed our certainty about the evidence as low or very low for the outcomes in this comparison. There was no evidence for a benefit for FMS over control for change in PPD, gain in CAL or reduction in BOP at six to eight months (PPD: mean difference (MD) 0.03 mm, 95% confidence interval (CI) –0.14 to 0.20; 5 trials, 148 participants; CAL: MD 0.10 mm, 95% CI –0.05 to 0.26; 5 trials, 148 participants; BOP: MD 2.64%, 95% CI –8.81 to 14.09; 3 trials, 80 participants). There was evidence of heterogeneity for BOP (I² = 50%), but none for PPD and CAL. Of the 13 trials comparing FMD versus control, we judged four at high risk of bias, one at low risk of bias and eight at unclear risk of bias. At six to eight months, there was no evidence for a benefit for FMD over control for change in PPD or CAL (PPD: MD 0.11 mm, 95% CI –0.04 to 0.27; 6 trials, 224 participants; low‐certainty evidence; CAL: 0.07 mm, 95% CI –0.11 to 0.24; 6 trials, 224 participants; low‐certainty evidence). The analyses found no evidence of a benefit for FMD over control for BOP (very low‐certainty evidence). There was no evidence of heterogeneity for PPD or CAL, but considerable evidence of heterogeneity for BOP, attributed to one study. There were no consistent differences in these outcomes between intervention and control (low‐ to very low‐certainty evidence). Of the six trials comparing FMS and FMD, we judged two trials at high risk of bias, one at low risk of bias and three as unclear. At six to eight months, there was no evidence of a benefit of FMD over FMS for change in PPD or gain in CAL (PPD: MD –0.11 mm, 95% CI –0.30 to 0.07; P = 0.22; 4 trials, 112 participants; low‐certainty evidence; CAL: MD –0.05 mm, 95% CI –0.23 to –0.13; P = 0.58; 4 trials, 112 participants; low‐certainty evidence). There was no evidence of a difference between FMS and FMD for BOP at any time point (P = 0.98; 2 trials, 22 participants; low‐ to very low‐certainty evidence). There was evidence of heterogeneity for BOP (I² = 52%), but not for PPD or CAL. Thirteen studies predefined adverse events as an outcome; three reported an event after FMD or FMS. The most important harm identified was an increase in body temperature. We assessed the certainty of the evidence for most comparisons and outcomes as low because of design limitations leading to risk of bias, and the small number of trials and participants, leading to imprecision in the effect estimates. Authors' conclusions The inclusion of nine new RCTs in this updated review has not changed the conclusions of the previous version of the review. There is still no clear evidence that FMS or FMD approaches provide additional clinical benefit compared to conventional mechanical treatment for adult periodontitis. In practice, the decision to select one approach to non‐surgical periodontal therapy over another should include patient preference and the convenience of the treatment schedule. Plain language summary Treating all teeth (full mouth) within 24 hours for gum disease (periodontitis) in adults Background Long‐lasting gum disease (periodontitis) is a common chronic inflammatory disease that causes damage to soft tissues (gums) and bone around teeth, and can result in tooth loss. Non‐surgical treatments are used to stop and control the disease. These are based on 'subgingival instrumentation', that is, the mechanical removal of bacteria below the gums from the infected root surfaces of the teeth. Conventional treatment is carried out in two to four sessions over several weeks, scaling a different section (or 'quadrant') of the mouth each time. This has traditionally been known as 'scaling and root planing' (SRP). An alternative approach is to treat the whole mouth within 24 hours in one or two sessions (known as full‐mouth scaling (FMS)). When an antiseptic agent (like chlorhexidine) is added to FMS, the intervention is called full‐mouth disinfection (FMD). The rationale for using these full‐mouth approaches is to reduce the likelihood of re‐infection in already treated sites. Review question This review, produced within Cochrane Oral Health, is the second update of one we originally published in 2008. It evaluates the effectiveness of full‐mouth treatments within 24 hours (FMS and FMD) compared to conventional treatment over a number of weeks, and whether there is a difference between FMS and FMD. The evidence is current up to June 2021. Study characteristics The included studies were randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that evaluated a full‐mouth approach to subgingival instrumentation, with at least three months of monitoring (follow‐up). Both FMS and FMD were compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of chronic periodontitis and we excluded studies of people with aggressive periodontitis, systemic disorders (affecting other part of the body) or who were taking antibiotics. We included nine new studies in this update and we excluded one trial that had been included in the previous version of the review. In total, the review now includes 20 studies that involved 944 participants. Key results Treatment effects of FMS and FMD are modest and there are no clear implications for periodontal care. Neither treatment was superior to the usual treatment of scaling and root planing a quarter of the mouth at a time. The most important harm identified was an increased body temperature after FMS or FMD treatments, reported in three out of 13 studies. In practice, the decision to select one approach over another will be based on preference and convenience for patient and dentist. Certainty of the evidence Our confidence in the results is low for most comparisons and outcomes, due to the small number of studies and participants involved, and limitations in study designs. The addition of nine studies has not changed the findings of our previous version of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jervøe-Storm, P-M, Eberhard, J, Needleman, I, Worthington, HV, Jepsen, S", "articleTypes": [], "doi": "10.1002/14651858.CD004622.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.786Z" }, { "id": "a1d05f6c-5fc8-4968-b02c-8ae0d6521e9a", "pmid": "", "title": "Omega‐3 fatty acid addition during pregnancy", "imported": false, "abstract": "Abstract - Background Higher intakes of foods containing omega‐3 long‐chain polyunsaturated fatty acids (LCPUFA), such as fish, during pregnancy have been associated with longer gestations and improved perinatal outcomes. This is an update of a review that was first published in 2006. Objectives To assess the effects of omega‐3 LCPUFA, as supplements or as dietary additions, during pregnancy on maternal, perinatal, and neonatal outcomes and longer‐term outcomes for mother and child. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (16 August 2018), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing omega‐3 fatty acids (as supplements or as foods, stand‐alone interventions, or with a co‐intervention) during pregnancy with placebo or no omega‐3, and studies or study arms directly comparing omega‐3 LCPUFA doses or types. Trials published in abstract form were eligible for inclusion. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, assessed risk of bias in trials and assessed quality of evidence for prespecified birth/infant, maternal, child/adult and health service outcomes using the GRADE approach. Main results In this update, we included 70 RCTs (involving 19,927 women at low, mixed or high risk of poor pregnancy outcomes) which compared omega‐3 LCPUFA interventions (supplements and food) compared with placebo or no omega‐3. Overall study‐level risk of bias was mixed, with selection and performance bias mostly at low risk, but there was high risk of attrition bias in some trials. Most trials were conducted in upper‐middle or high‐income countries; and nearly half the trials included women at increased/high risk for factors which might increase the risk of adverse maternal and birth outcomes. Preterm birth < 37 weeks (13.4% versus 11.9%; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.81 to 0.97; 26 RCTs, 10,304 participants; high‐quality evidence) and early preterm birth < 34 weeks (4.6% versus 2.7%; RR 0.58, 95% CI 0.44 to 0.77; 9 RCTs, 5204 participants; high‐quality evidence) were both lower in women who received omega‐3 LCPUFA compared with no omega‐3. Prolonged gestation > 42 weeks was probably increased from 1.6% to 2.6% in women who received omega‐3 LCPUFA compared with no omega‐3 (RR 1.61 95% CI 1.11 to 2.33; 5141 participants; 6 RCTs; moderate‐quality evidence ). For infants, there was a possibly reduced risk of perinatal death (RR 0.75, 95% CI 0.54 to 1.03; 10 RCTs, 7416 participants; moderate‐quality evidence: 62/3715 versus 83/3701 infants) and possibly fewer neonatal care admissions (RR 0.92, 95% CI 0.83 to 1.03; 9 RCTs, 6920 participants; moderate‐quality evidence ‐ 483/3475 infants versus 519/3445 infants). There was a reduced risk of low birthweight (LBW) babies (15.6% versus 14%; RR 0.90, 95% CI 0.82 to 0.99; 15 trials, 8449 participants; high‐quality evidence); but a possible small increase in large‐for‐gestational age (LGA) babies (RR 1.15, 95% CI 0.97 to 1.36; 6 RCTs, 3722 participants; moderate‐quality evidence, for omega‐3 LCPUFA compared with no omega‐3. Little or no difference in small‐for‐gestational age or intrauterine growth restriction (RR 1.01, 95% CI 0.90 to 1.13; 8 RCTs, 6907 participants; moderate‐quality evidence) was seen. For the maternal outcomes , there is insufficient evidence to determine the effects of omega‐3 on induction post‐term (average RR 0.82, 95% CI 0.22 to 2.98; 3 trials, 2900 participants; low‐quality evidence), maternal serious adverse events (RR 1.04, 95% CI 0.40 to 2.72; 2 trials, 2690 participants; low‐quality evidence), maternal admission to intensive care (RR 0.56, 95% CI 0.12 to 2.63; 2 trials, 2458 participants; low‐quality evidence), or postnatal depression (average RR 0.99, 95% CI 0.56 to 1.77; 2 trials, 2431 participants; low‐quality evidence). Mean gestational length was greater in women who received omega‐3 LCPUFA (mean difference (MD) 1.67 days, 95% CI 0.95 to 2.39; 41 trials, 12,517 participants; moderate‐quality evidence), and pre‐eclampsia may possibly be reduced with omega‐3 LCPUFA (RR 0.84, 95% CI 0.69 to 1.01; 20 trials, 8306 participants; low‐quality evidence). For the child/adult outcomes, very few differences between antenatal omega‐3 LCPUFA supplementation and no omega‐3 were observed in cognition, IQ, vision, other neurodevelopment and growth outcomes, language and behaviour (mostly low‐quality to very low‐quality evidence). The effect of omega‐3 LCPUFA on body mass index at 19 years (MD 0, 95% CI ‐0.83 to 0.83; 1 trial, 243 participants; very low‐quality evidence) was uncertain. No data were reported for development of diabetes in the children of study participants. Authors' conclusions In the overall analysis, preterm birth < 37 weeks and early preterm birth < 34 weeks were reduced in women receiving omega‐3 LCPUFA compared with no omega‐3. There was a possibly reduced risk of perinatal death and of neonatal care admission , a reduced risk of LBW babies; and possibly a small increased risk of LGA babies with omega‐3 LCPUFA. For our GRADE quality assessments, we assessed most of the important perinatal outcomes as high‐quality (e.g. preterm birth) or moderate‐quality evidence (e.g. perinatal death). For the other outcome domains (maternal, child/adult and health service outcomes) GRADE ratings ranged from moderate to very low, with over half rated as low. Reasons for downgrading across the domain were mostly due to design limitations and imprecision. Omega‐3 LCPUFA supplementation during pregnancy is an effective strategy for reducing the incidence of preterm birth, although it probably increases the incidence of post‐term pregnancies. More studies comparing omega‐3 LCPUFA and placebo (to establish causality in relation to preterm birth) are not needed at this stage. A further 23 ongoing trials are still to report on over 5000 women, so no more RCTs are needed that compare omega‐3 LCPUFA against placebo or no intervention. However, further follow‐up of completed trials is needed to assess longer‐term outcomes for mother and child, to improve understanding of metabolic, growth and neurodevelopment pathways in particular, and to establish if, and how, outcomes vary by different types of omega‐3 LCPUFA, timing and doses; or by characteristics of women. Plain language summary Omega‐3 fatty acid addition during pregnancy What is the issue? Do omega‐3 long chain polyunsaturated fatty acids (LCPUFA) taken during pregnancy ‐ either as supplements or as dietary additions in food (such as some types of fish) ‐ improve health outcomes for babies and their mothers? This is an update of a Cochrane Review that was first published in 2006. Why is this important? Preterm birth (babies born before 37 weeks pregnancy (gestation)) is a leading cause of disability or death in the first five years of life. Fish and fish oil contain omega‐3 LCPUFA (particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)) and have been associated with longer pregnancies. So it is suggested that additional omega‐3 LCPUFAs in pregnancy may reduce the number of babies born preterm and may improve outcomes for children and mothers. However, many pregnant women do not eat fish very often. Encouraging pregnant women to eat fatty fish (which generally have low toxin levels) or to use omega‐3 LCPUFA supplements may improve children’s and women's health. This is an update of a Cochrane Review that was first published in 2006. What evidence did we find? We searched for evidence in August 2018 and found 70 randomised controlled trials (RCTs; this type of trial provides the most reliable results) (involving 19,927 women). Most trials evaluated a group of women who received omega‐3 LCPUFA and compared them with a group of women who received something that looked like omega‐3 LCPUFA but did not contain it (placebo) or received no omega‐3. The trials were mostly undertaken in upper‐middle or high‐income countries. Some studies included women at increased risk of preterm birth. The quality of the evidence from the included studies ranged from high to very low; this affected the certainty of the findings for different outcomes. We found the incidence of preterm birth (before 37 weeks) and very preterm birth (before 34 weeks) was lower in women who received omega‐3 LCPUFA compared with no additional omega‐3. There were also fewer babies with low birthweight. However, omega‐3 LCPUFA probably increased the incidence of pregnancies continuing beyond 42 weeks, although there was no difference identified in induction of labour for post‐term pregnancies. The risk of the baby dying or being very sick and going to neonatal intensive care may be lower with omega‐3 LCPUFA compared with no omega‐3. We did not see any differences between groups for serious adverse events for mothers or in postnatal depression. Very few differences between the omega‐3 LCPUFA groups and no omega‐3 groups were observed in child development and growth. Eleven trials reported that they had received industry funding. When we omitted these trials from the main outcomes (such as preterm birth and very preterm birth) it made very little, or no difference, to the results. What does this mean? Increasing omega‐3 LCPUFA intake during pregnancy, either through supplements or in foods, may reduce the incidence of preterm birth (before 37 weeks and before 34 weeks) and there may be less chance of having a baby with a low birthweight. Women who take omega‐3 LCPUFA supplements during pregnancy may also be more likely to have longer pregnancies. More studies are underway and their results will be included in a further update of this review. Future studies could consider if and how outcomes may vary in different populations of women, and could test different ways of increasing omega‐3 LCPUFA during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Middleton, P, Gomersall, JC, Gould, JF, Shepherd, E, Olsen, SF, Makrides, M", "articleTypes": [], "doi": "10.1002/14651858.CD003402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.807Z" }, { "id": "a1d338e3-dbe7-46de-8bf2-bbdc9f771e87", "pmid": "", "title": "Enteral nutrition for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Prevention of relapse is a major issue in the management of quiescent Crohn's disease (CD). Current therapies (e.g. methotrexate, biologics, 6‐mercaptopurine and azathioprine) may be effective for maintaining remission in CD, but these drugs may cause significant adverse events. Interventions that are effective and safe for maintenance of remission in CD are desirable. Objectives The primary objectives were to evaluate the efficacy and safety of enteral nutrition for the maintenance of remission in CD and to assess the impact of formula composition on effectiveness. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and clinicaltrials.gov from inception to 27 July 2018. We also searched references of retrieved studies and reviews. Selection criteria Randomised controlled trials (RCTs) including participants of any age with quiescent CD were considered for inclusion. Studies that compared enteral nutrition with no intervention, placebo or any other intervention were selected for review. Data collection and analysis Two authors independently screened studies for inclusion, extracted data and assessed methodological quality using the Cochrane risk of bias tool. The primary outcome was clinical or endoscopic relapse as defined by the primary studies. Secondary outcomes included anthropometric measures (i.e. height and weight), quality of life (QoL), adverse events, serious adverse events and withdrawal due to adverse events. We calculated the risk ratio and 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated the mean difference and 95% CI. A random‐effects model was used for the statistical analysis. We used the GRADE criteria to assess the overall certainty of the evidence supporting the primary outcome and selected secondary outcomes. Main results Four RCTs (262 adult participants) met the inclusion criteria. One study (N = 33) compared an elemental diet to a non‐elemental (polymeric) diet. One study (N = 51) compared a half elemental diet to a regular free diet. Another study (N = 95) compared an elemental diet to 6‐mercaptopurine (6‐MP) or a no treatment control group. One study (N= 83) compared a polymeric diet to mesalamine. Two studies were rated as high risk of bias due to lack of blinding or incomplete outcome data. The other two studies were judged to have an unclear risk of bias. The studies were not pooled due to differences in control interventions and the way outcomes were assessed. The effect of an elemental diet compared to a polymeric diet on remission rates or withdrawal due to adverse events is uncertain. Fifty‐eight per cent (11/19) of participants in the elemental diet group relapsed at 12 months compared to 57% (8/14) of participants in the polymeric diet group (RR 1.01, 95% CI 0.56 to 1.84; very low certainty evidence). Thirty‐two per cent (6/19) of participants in the elemental diet group were intolerant to the enteral nutritional formula because of taste or smell and were withdrawn from the study in the first 2 weeks compared to zero participants (0/14) in the polymeric diet group (RR 9.75, 95% CI 0.59 to 159.93; low certainty evidence). Anthropometric measures, QoL, adverse events and serious adverse events were not reported as outcomes. The effect of an elemental diet (half of total daily calorie requirements) compared to a normal free diet on relapse rates is uncertain. Thirty‐five per cent (9/26) of participants in the elemental diet group relapsed at 12 months compared to 64% (16/25) of participants in the free diet group (RR 0.54, 95% CI 0.30 to 0.99; very low certainty evidence). No adverse events were reported. This study reported no differences in weight change between the two diet groups. Height and QoL were not reported as outcomes. The effect of an elemental diet compared to 6‐MP on relapse rates or adverse events is uncertain. Thirty‐eight per cent (12/32) of participants in the elemental diet group relapsed at 12 months compared to 23% (7/30) of participants in the 6‐MP group (RR 1.61; 95% CI 0.73 to 3.53; very low certainty evidence). Three per cent (1/32) of participants in the elemental diet group had an adverse event compared to 13% (4/30) of participants in the 6‐MP group (RR 0.23, 95% CI 0.03 to 1.98; low certainty evidence). Adverse events in the elemental diet group included surgery due to worsening CD. Adverse events in the 6‐MP group included liver injury (n = 2), hair loss (n = 1) and surgery due to an abscess (n = 1). No serious adverse events or withdrawals due to adverse events were reported. Weight, height and QoL were not reported as outcomes The effect of a polymeric diet compared to mesalamine on relapse rates and weight is uncertain. Forty‐two per cent (18/43) of participants in the polymeric diet group relapsed at 6 months compared to 55% (22/40) of participants in the mesalamine group (RR 0.76; 95% CI 0.49 to 1.19; low certainty evidence). The mean difference in weight gain over the study period was 1.9 kg higher in the polymeric diet group compared to mesalamine (95% CI ‐4.62 to 8.42; low certainty evidence). Two participants in the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had an adverse event. Height, QoL, serious adverse events and withdrawal due to adverse events were not reported as outcomes. Authors' conclusions The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the efficacy and safety of enteral nutrition in quiescent CD can be drawn. More research is needed to determine the efficacy and safety of using enteral nutrition as maintenance therapy in CD. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available. Plain language summary Enteral nutrition (liquid feeds) for maintenance of remission in Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disease of the intestines that frequently occurs in the lower part of the small intestine (ileum). Symptoms include abdominal pain, diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms the disease is considered 'active'. When the symptoms stop, it is called 'remission'. When people in remission experience symptoms it is called a 'relapse'. What is enteral nutrition? Enteral nutrition is a feeding method where a person's daily caloric intake is delivered via a liquid diet using the GI tract. Enteral nutrition can be administered by mouth or by tube feeding, where a tube is inserted through the nose or abdomen into the stomach to deliver the liquid feed. Enteral nutrition is a form of nutritional therapy for Crohn's disease patients. The mechanism by which enteral nutrition may influence inflammation is unknown and is being studied. Enteral nutrition can be classified as elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets are composed of amino‐acids (organic compounds), fats, sugars, vitamins and minerals. Elemental diets are easily absorbed and digested. Non‐elemental diets are based on oligopeptide (organic compounds composed of 2 to 20 amino‐acids) or whole protein sources. Non‐elemental diets are best for people who can digest and absorb nutrients without difficulty. What is 6‐mercaptopurine? 6‐Mercaptopurine is an immunosuppressive drug that is thought to reduce inflammation in people with Crohn's disease by blocking the immune system. What is mesalamine? Mesalamine is a 5‐aminosalicylic acid drug. 5‐Aminosalicylic drugs are thought to treat Crohn's disease by reducing inflammation in the gastrointestinal tract. These drugs are usually taken by mouth. What did the researchers investigate? The researchers studied whether enteral nutrition helps to maintain remission in people with Crohn's disease. The researchers also investigated whether one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) for maintaining remission in people with Crohn's disease. What did the researchers find? Four studies including 262 adult participants with Crohn's disease in remission were included. One study (33 participants) compared an elemental diet to a non‐elemental (polymeric) diet. One study (51 participants) compared an elemental diet to a normal diet (no supplements). One study (95 participants) compared an elemental diet to 6‐mercaptopurine or a no treatment control group. One study (83 participants) compared a non‐elemental polymeric diet to mesalamine. The researchers searched the medical literature extensively up to 27 July 2018. The study comparing an elemental diet to a polymeric diet found no difference in remission rates at 12 months. Six elemental diet participants were not able to tolerate the enteral nutritional formula because of taste or smell and were withdrawn from the study. Participants who received half of their total daily calorie requirements as elemental diet and the remaining half by normal diet had a lower chance of relapse at 12 months compared to participants who received a free diet. No side effects were reported in this study. The study comparing an elemental diet to 6‐mercaptopurine did not show any difference in relapse rates at 12 months. There was no difference in side effect rates. The only side effect reported in the elemental diet group was surgery due to worsening Crohn's disease. Side effects in the 6‐mercaptopurine group included liver injury in two participants, hair loss in one participant and surgery to treat an abscess in one participant. The study comparing a polymeric diet to mesalamine found no difference in relapse rates at six months. Two participants the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had side effects. No serious side effects were reported in any of the studies. The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the effectiveness and safety of enteral nutrition for maintenance of remission in Crohn's disease can be drawn. More research is needed to determine the effectiveness and safety of using enteral nutrition as maintenance therapy in Crohn's disease. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Akobeng, AK; Zhang, D; Gordon, M; MacDonald, JK", "articleTypes": [], "doi": "10.1002/14651858.CD005984.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "a1d78f80-801c-402d-82b9-486fd2c9290d", "pmid": "", "title": "Nutritional supplementation for hip fracture aftercare in older people", "imported": false, "abstract": "Abstract - Background Older people with hip fractures are often malnourished at the time of fracture, and subsequently have poor food intake. This is an update of a Cochrane review first published in 2000, and previously updated in 2010. Objectives To review the effects (benefits and harms) of nutritional interventions in older people recovering from hip fracture. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, MEDLINE In‐Process & Other Non‐Indexed Citations, Embase, CAB Abstracts, CINAHL, trial registers and reference lists. The search was last run in November 2015. Selection criteria Randomised and quasi‐randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture where the interventions were started within the first month after hip fracture. Data collection and analysis Two review authors independently selected trials, extracted data and assessed risk of bias. Where possible, we pooled data for primary outcomes which were: all cause mortality; morbidity; postoperative complications (e.g. wound infections, pressure sores, deep venous thromboses, respiratory and urinary infections, cardiovascular events); and 'unfavourable outcome' defined as the number of trial participants who died plus the number of survivors with complications. We also pooled data for adverse events such as diarrhoea. Main results We included 41 trials involving 3881 participants. Outcome data were limited and risk of bias assessment showed that trials were often methodologically flawed, with less than half of trials at low risk of bias for allocation concealment, incomplete outcome data, or selective reporting of outcomes. The available evidence was judged of either low or very low quality indicating that we were uncertain or very uncertain about the estimates. Eighteen trials evaluated oral multinutrient feeds that provided non‐protein energy, protein, vitamins and minerals. There was low‐quality evidence that oral feeds had little effect on mortality (24/486 versus 31/481; risk ratio (RR) 0.81 favouring supplementation, 95% confidence interval (CI) 0.49 to 1.32; 15 trials). Thirteen trials evaluated the effect of oral multinutrient feeds on complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was low‐quality evidence that the number of participants with complications may be reduced with oral multinutrient feeds (123/370 versus 157/367; RR 0.71, 95% CI 0.59 to 0.86; 11 trials). Based on very low‐quality evidence from six studies (334 participants), oral supplements may result in lower numbers with 'unfavourable outcome' (death or complications): RR 0.67, 95% CI 0.51 to 0.89. There was very low‐quality evidence for six studies (442 participants) that oral supplementation did not result in an increased incidence of vomiting and diarrhoea (RR 0.99, 95% CI 0.47 to 2.05). Only very low‐quality evidence was available from the four trials examining nasogastric multinutrient feeding. Pooled data from three heterogeneous trials showed no evidence of an effect of supplementation on mortality (14/142 versus 14/138; RR 0.99, 95% CI 0.50 to 1.97). One trial (18 participants) found no difference in complications. None reported on unfavourable outcome. Nasogastric feeding was poorly tolerated. One study reported no cases of aspiration pneumonia. There is very low‐quality evidence from one trial (57 participants, mainly men) of no evidence for an effect of tube feeding followed by oral supplementation on mortality or complications. Tube feeding, however, was poorly tolerated. There is very low‐quality evidence from one trial (80 participants) that a combination of intravenous feeding and oral supplements may not affect mortality but could reduce complications. However, this expensive intervention is usually reserved for people with non‐functioning gastrointestinal tracts, which is unlikely in this trial. Four trials tested increasing protein intake in an oral feed. These provided low‐quality evidence for no clear effect of increased protein intake on mortality (30/181 versus 21/180; RR 1.42, 95% CI 0.85 to 2.37; 4 trials) or number of participants with complications but very low‐quality and contradictory evidence of a reduction in unfavourable outcomes (66/113 versus 82/110; RR 0.78, 95% CI 0.65 to 0.95; 2 trials). There was no evidence of an effect on adverse events such as diarrhoea. Trials testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. Based on low‐quality evidence, one trial evaluating the use of dietetic assistants to help with feeding indicated that this intervention may reduce mortality (19/145 versus 36/157; RR 0.57, 95% CI 0.34 to 0.95) but not the number of participants with complications (79/130 versus 84/125). Authors' conclusions There is low‐quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low‐quality evidence that oral supplements may reduce 'unfavourable outcome' (death or complications) and that they do not result in an increased incidence of vomiting and diarrhoea. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding or nasogastric feeding in very malnourished people require further evaluation. Plain language summary Nutritional supplementation for older people after hip fracture Background and aim Older people with hip fractures are often malnourished at the time of their fracture and many have poor food intake while in hospital. Malnutrition may hinder recovery after hip fracture. We reviewed the effects of nutritional interventions in older people recovering from hip fracture. Search results We searched the scientific literature up to November 2015 and include 41 studies including 3881 participants. All nutritional interventions were started within one month of hip fracture. The studies had flaws in their methods that may affect the validity of their results. Some evidence was very low quality which means we are very unsure of the results. Key results Eighteen studies examined the use of additional oral feeds that provided energy from sources other than protein, protein, some vitamins and minerals. There was low‐quality evidence that these multinutrient oral feeds may not reduce mortality but that they may reduce the number of people with complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was very low‐quality evidence that oral multinutrient feeds may reduce unfavourable outcome (death or complications) and that they did not result in increased vomiting and diarrhoea. Four studies examined nasogastric tube feeding, where liquid food is delivered via a tube inserted into the nose and passed down into the stomach, with non‐protein energy, protein, some vitamins and minerals. These studies provided very low‐quality evidence that tube feeding, which was poorly tolerated, did not seem to make a difference to mortality or complications. Unfavourable outcome was not recorded and there was insufficient evidence on adverse events. One study provided very low‐quality evidence that nasogastric tube feeding followed by oral feeds may not affect mortality or complications. It reported that tube feeding was poorly tolerated. One study provided very low‐quality evidence that giving feed into a vein initially and then by mouth may not affect mortality but may reduce complications. However, we were surprised that this intervention was being used in people who seemed to be able to take nutrition orally. Increasing protein intake in an oral feed was tested in four studies. These provided low‐quality evidence of no clear effect on mortality or complications and very low‐quality evidence for a reduction in unfavourable outcome. Studies testing intravenous vitamin B1 and other water soluble vitamins, oral 1‐alpha‐hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha‐ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low‐ or very low‐quality evidence of no clear effect on mortality or complications, where reported. One study, evaluating the use of dietetic assistants to help with feeding, provided low‐quality evidence that this may reduce mortality but not the numbers of people with complications. Conclusions Oral supplements with non‐protein energy, protein, vitamins and minerals started before or soon after surgery may prevent complications after hip fracture in older people but may not affect mortality. Adequately sized randomised studies with better design are required. We suggest that the role of dietetic assistants, and of peripheral venous feeding or nasogastric feeding in very malnourished patients, require further evaluation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Avenell, A; Smith, TO; Curtain, JP; Mak, JCS; Myint, PK", "articleTypes": [], "doi": "10.1002/14651858.CD001880.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "a20a791a-e1ee-466d-a094-7935d1126e25", "pmid": "", "title": "Fluvoxamine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Fluvoxamine, one of the oldest selective serotonin reuptake inhibitors (SSRIs), is prescribed to patients with major depression in many countries. Several studies have previously reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are now outdated. Objectives Our objective is to evaluate the effectiveness, tolerability and side effect profile of fluvoxamine for major depression in comparison with other anti‐depressive agents, including tricyclics (TCAs), heterocyclics, other SSRIs, SNRIs, other newer agents and other conventional psychotropic drugs. Search methods We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register. Trial databases and ongoing trial registers in North America, Europe, Japan and Australia, were handsearched for randomised controlled trials. We checked reference lists of the articles included in the review, previous systematic reviews and major textbooks of affective disorder for published reports and citations of unpublished research. The date of last search was 31 August 2008. Selection criteria We included all randomised controlled trials, published in any language, that compared fluvoxamine with any other active antidepressants in the acute phase treatment of major depression. Data collection and analysis Two independent review authors inspected citations and abstracts, obtained papers, extracted data and assessed the risk of bias of included studies. We analysed dichotomous data using odds ratios (ORs) and continuous data using the standardised mean difference (SMD). A random effects model was used to combine studies. Main results A total of 54 randomised controlled trials (n = 5122) were included. No strong evidence was found to indicate that fluvoxamine was either superior or inferior to other antidepressants regarding response, remission and tolerability. However, differing side effect profiles were evident, especially with regard to gastrointestinal side effects of fluvoxamine when compared to other antidepressants. For example, fluvoxamine was generally associated with a higher incidence of vomiting/nausea (versus imipramine, OR 2.23, CI 1.59 to 3.14; versus clomipramine, OR 2.13, CI 1.06 to 4.27; versus amitriptyline, OR 2.86, CI 1.31 to 2.63). Authors' conclusions We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, differing side effect profiles were evident. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations, including these differences in side effect profiles. Plain language summary Fluvoxamine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Although pharmacological and psychological interventions are both effective for major depression, antidepressant (AD) drugs remain the mainstay for treatment of moderate or severe depression. Fluvoxamine is one of the oldest selective serotonin reuptake inhibitors (SSRIs) and is prescribed to patients with major depression in many countries. This review reports trials comparing fluvoxamine with other antidepressants for treatment of major depression. We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, there is evidence of differing side‐effect profiles, especially when comparing gastrointestinal side effects between fluvoxamine and tricyclic antidepressants (TCAs). Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including these differences in side effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Omori, IM; Watanabe, N; Nakagawa, A; Cipriani, A; Barbui, C; McGuire, H; Churchill, R; Furukawa, TA", "articleTypes": [], "doi": "10.1002/14651858.CD006114.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "a20f2e6f-3733-4fa7-935c-cf2de198fa93", "pmid": "", "title": "Central Dopamine Receptors In Obesity", "imported": false, "abstract": "Central dopamine is thought to play a significant role in obesity. In support of this idea, animal studies and one human positron emission tomography (PET) study have found reduced postsynaptic D2-like receptor availability in the striatum in obesity, with lower D2 receptor availability associated with higher weight. In addition, reward sensitivity and hedonic responses, known to be related to dopamine function, have also been implicated in obesity and obesity-related eating behavior. These reports have led to the concept that dopaminergic abnormalities (e.g. reduced D2-like receptors) influence reward sensitivity, leading to altered eating behaviors and eventually obesity. However, there are several critical limitations of the human D2 receptor studies that limit the strength of their conclusions and thus the interpretations and speculations embedded in literature that relies on this work. First, estimates of D2-like receptors in humans have been confounded by potential differences in endogenous dopamine release since the PET ligand (raclopride) used is known to be displaceable from receptors by endogenous dopamine. Second, failure to rigorously screen obese individuals for diabetes confounds conclusions, since diabetes has been independently associated with dopaminergic abnormalities such as reduced D2-like receptors and muted dopamine release in diabetic rats. Finally, no human studies have addressed whether reduced D2-like receptor levels are a risk factor for obesity, a consequence of engaging in obesity-related behaviors or being obese or all of the above.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.232Z" }, { "id": "a2285a10-05aa-424c-8038-f809680957b1", "pmid": "", "title": "Neurogenic Mechanisms in Burning Mouth Syndrome With Focus on Localization and Desensibilization of Vanilloid Receptor TRPV1", "imported": false, "abstract": "Burning mouth syndrome (BMS) is characterized by a bilateral burning sensation in the anterior tongue, hard palate and lips in the absence of any clinical or laboratory findings. The term syndrome implicates the simultaneous presence of oral dryness (xerostomia) and altered taste (dysgeusia) in addition to the burning sensation in the oral mucosa. BMS is most often seen in women and is more frequent during menopause. The etiology and pathogenesis are still unclear but recent studies suggest that BMS is a neuropathic pain condition.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.238Z" }, { "id": "a22a1d97-e82a-465e-bf44-a52fc83839c0", "pmid": "", "title": "Influence of Medication Palatability on Prescribing Habits of Pediatric Prescribers", "imported": false, "abstract": "The purpose of this study is to see if a medication taste test influences the prescribing habits of pediatric prescribers at Mayo Clinic.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.144Z" }, { "id": "a2398533-304f-4bd9-b690-ea59e9b9435f", "pmid": "", "title": "Oral versus intravenous steroids for treatment of relapses in multiple sclerosis", "imported": false, "abstract": "Abstract - Background This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD006921. DOI: 10.1002/14651858.CD006921.pub2). Multiple sclerosis (MS), a chronic inflammatory and neurodegenerative disease of the central nervous system (CNS), is characterized by recurrent relapses of CNS inflammation ranging from mild to severely disabling. Relapses have long been treated with steroids to reduce inflammation and hasten recovery. However, the commonly used intravenous methylprednisolone (IVMP) requires repeated infusions with the added costs of homecare or hospitalization, and may interfere with daily responsibilities. Oral steroids have been used in place of intravenous steroids, with lower direct and indirect costs. Objectives The primary objective was to compare efficacy of oral versus intravenous steroids in promoting disability recovery in MS relapses <= six weeks. Secondary objectives included subsequent relapse rate, disability, ambulation, hospitalization, immunological markers, radiological markers, and quality of life. Search methods A literature search was performed using Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group's Trials Register (January 2012), abstracts from meetings of the American Academy of Neurology (2008‐2012), the European Federation of Neurological Sciences (2008‐2012), the European Committee for Treatment and Research in Multiple Sclerosis and American Committee for Treatment and Research in Multiple Sclerosis (2008‐2012) handsearching. No language restrictions were applied. Selection criteria Randomized or quasi‐randomized trials comparing oral versus intravenous steroids for acute relapses (<= six weeks) in patients with clinically definite MSover age 16 were eligible. Data collection and analysis Three review authors (JB, PO and MH) participated in the independent assessment of all published articles as potentially relevant to the review. Any disagreement was resolved by discussion among review authors. We contacted study authors for additional information. Methodological quality was assessed by the same three review authors. Relevant data were extracted, and effect size was reported as mean difference (MD), mean difference (MD), odds ratio (OR) and absolute risk difference (ARD). Main results With this current update, a total of five eligible studies (215 patients) were identified. Only one outcome, the proportion of patients with Expanded Disability Status Scale (EDSS) improvement at four weeks, was common to three trials, while two trials examined magnetic resonance imaging (MRI) outcomes. The results of this review shows there is no significant difference in relapse recovery at week four (MD ‐0.22, 95% confidence interval (95% CI), 0.71 to 0.26, P = 0.20) nor differences in magnetic resonance imaging (MRI) gadolinium enhancement activity based on oral versus intravenous steroid treatment. However, only two of the five studies employed more current and rigorous methodological techniques, so these results must be taken with some caution. The Oral Megadose Corticosteroid Therapy of Acute Exacerbations of Multiple Sclerosis (OMEGA) trial and the \"Efficacy and Safety of Methylprednisolone Per os Versus IV for the Treatment of Multiple Sclerosis (MS) Relapses\" (COPOUSEP) trial, designed to address such limitations, are currently underway. Authors' conclusions The analysis of the five included trials comparing intravenous versus oral steroid therapy for MS relapses do not demonstrate any significant differences in clinical (benefits and adverse events), radiological or pharmacological outcomes. Based on the evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy in the treatment of MS relapses. Plain language summary A comparison of the efficacy of oral versus intravenous steroids in relapsing‐remitting multiple sclerosis (RRMS) RRMS is characterized by periods of disability (relapse) due to inflammation in the central nervous system. All research has shown that a \"speeding up\" of recovery is obtained by use of corticosteroids, given most often in intravenous form. If oral steroids worked as well as intravenous ones for relapse events, they would be easier to take and are more affordable. 
 
 The objective of this review was to assess if oral and intravenous steroids are equally effective and safe in aiding in the recovery from relapses. Among the pertinent literature, only five studies met the inclusion criteria, comprising a total of 215 participants. Despite some limitations in the methods used to conduct the studies (i.e. incomplete reporting of the participants who dropped out the studies and appropriateness of the sample size) and in the analysis of the data, all five studies found that there were no significant differences in term of benefits and adverse events and in the pharmacological and radiological outcomes in patients taking oral or intravenous steroids. Both treatments appear to be equally effective and safe. Based on this evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy for the treatment of MS relapses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Burton, JM; O'Connor, PW; Hohol, M; Beyene, J", "articleTypes": [], "doi": "10.1002/14651858.CD006921.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "a23c8df9-4573-4f61-a204-577b8bf2b937", "pmid": "", "title": "Folic acid for fragile X syndrome", "imported": false, "abstract": "Abstract - Background It has been argued that individuals with fragile X syndrome could have low folate levels in their bodies and that supplementing their dietary intake might remediate the adverse developmental and behavioural effects of the condition. Objectives To review the efficacy and safety of folic acid in the treatment of people with fragile X syndrome. Search methods We searched four databases in November 2010: CENTRAL, PubMed, EMBASE and PsycINFO. Selection criteria Randomised controlled trials. Data collection and analysis Two review authors independently extracted data and assessed risk of bias using the Cochrane 'Risk of bias' tool. Main results We included five trials, which were published between 1986 and 1992. Overall, they included 67 patients, all male, with ages ranging from one to 54 years. Intellectual disability in participants varied from borderline to severe and some studies included patients with an additional diagnosis of autism or autistic behaviour. Four of the studies were placebo‐controlled cross‐over trials and one study was a parallel design. The duration of follow‐up ranged from two months to 12 months and the period on folic acid or placebo ranged from two to eight months. Doses of folic acid ranged from 10 mg to 250 mg per day, 10 mg per day being the most common. Most of the younger patients involved were also taking part in special education programmes (usually involving language and occupational therapy). We were not able to perform meta‐analysis to combine results but none of the individual studies found evidence of clinical benefit with the use of folic acid medication in fragile X syndrome patients on any of the areas of interest, either psychological and learning capabilities or behaviour and social performance, as measured with standardised tools. Separate analysis of evidence for patients of different age groups, i.e. prepubertal children and postpubertal young people, found some statistically significant results, but did not show clear evidence of benefit for either group. Adverse effects of folic acid treatment were rare, not serious and transient. Studies were generally poorly reported and we classified only one study as being at low risk of bias. Authors' conclusions The quality of available evidence is low and not suitable for drawing conclusions about the effect of folic acid on fragile X syndrome patients. It consists of few studies with small samples of patients, all of them male, with little statistical power to detect anything other than huge effects. Plain language summary Folic acid for fragile X syndrome People with fragile X syndrome (or FXS) have intellectual limitations that can range from mild to severe. Fragile X syndrome is considered the most common form of inherited intellectual disability and it has been estimated that it affects approximately 1 in 4000 males and 1 in 8000 females. Folate is particularly important during the early development of the brain and in later life is involved in methylation processes that are essential for the maintenance of normal brain function. It was observed that cells from patients with fragile X syndrome cultured in solutions deficient in folic acid revealed a fragile site at the X chromosome; consequently it was thought that individuals with fragile X syndrome had low folate levels in their bodies, which may be due to insufficient dietary intake, inefficient absorption or impaired metabolic utilisation. It was argued that supplementing their dietary intake might help improve the adverse developmental and behavioural effects of the condition. This review asks whether folic acid helps improve symptoms in people with fragile X syndrome and whether it has any side effects. We found five randomised controlled trials, all of which were published between 1986 and 1992. These studies included 69 people, all male. One of the studies compared a folic acid group with a control group; the other four used a cross‐over design (i.e. participants received first one treatment and then the other). The quality of reporting of the trials was generally poor, particularly the methods used, which made it difficult to assess the risk of bias in the studies. The results of the few published studies did not find significant differences in the effects of folic acid or placebo on psychological or learning capabilities, behaviour or social performance, as measured by standardised tools. There is therefore no evidence to support the recommendation of supplementing dietary intake with folic acid medication for people with fragile X syndrome. However, due to the number and quality of the studies, it is not possible to conclude with any certainty that folic acid does not help. Given that intellectual, behavioural, emotional and/or learning performance in people with fragile X syndrome are strongly influenced by different social factors, future studies should also pay attention to the evaluation of non‐pharmacological interventions, such as modifications in the home environment, tailored behavioural interventions and classroom environments, or language and occupational therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Rueda, JR; Ballesteros, J; Guillen, V; Tejada, MI; Solà, I", "articleTypes": [], "doi": "10.1002/14651858.CD008476.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "a269bee3-6034-42be-97f5-1e0beba5be07", "pmid": "", "title": "Using Bitter Taste Receptor Blockers to Improve the Palatability of Pediatric Medicines: Trained Human Sensory Panels", "imported": false, "abstract": "Many people, particularly small children, must take drugs in liquid form because they cannot swallow pills or capsules. The bad taste of some liquid drugs can keep patients from taking drugs they need for their health. Our main goal in this research study is find ingredients that might make drugs taste better.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.143Z" }, { "id": "a2831fb9-f893-40db-b2f3-b9ac540b2b26", "pmid": "", "title": "Colchicine for pericarditis", "imported": false, "abstract": "Abstract - Background Pericarditis is the inflammation of the pericardium, the membranous sac surrounding the heart. Recurrent pericarditis is the most common complication of acute pericarditis, causing severe and disabling chest pains. Recurrent pericarditis affects one in three patients with acute pericarditis within the first 18 months. Colchicine has been suggested to be beneficial in preventing recurrent pericarditis. Objectives To review all randomised controlled trials (RCTs) that assess the effects of colchicine alone or combined, compared to any other intervention to prevent further recurrences of pericarditis, in people with acute or recurrent pericarditis. Search methods We searched the following bibliographic databases on 4 August 2014: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2014 on The Cochrane Library ), MEDLINE (OVID, 1946 to July week 4, 2014), EMBASE (OVID, 1947 to 2014 week 31), and the Conference Proceedings Citation Index ‐ Science on Web of Science (Thomson Reuters) 1990 to 1 Aug 2014. We did not apply any language or time restrictions. Selection criteria RCTs of people with acute or recurrent pericarditis who are receiving colchicine compared to any other treatment, in order to prevent recurrences. Data collection and analysis Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The first primary outcome was the time to recurrence, measured by calculating the hazard ratios (HRs). The second primary outcome was the adverse effects of colchicine. Secondary outcomes were the rate of recurrences at 6, 12 and 18 months, and symptom relief. Main results We included four RCTs, involving 564 participants in this review. We compared the effects of colchicine in addition to a non‐steroidal anti‐inflammatory drug (NSAID) such as ibuprofen, aspirin or indomethacin to the effects of the NSAID alone. Two comparable trials studied the effects of colchicine in 204 participants with recurrent pericarditis and two trials studied 360 people with acute pericarditis. All trials had a moderate quality for the primary outcomes. We identified two on‐going trials; one of these trials examines acute pericarditis and the other assesses recurrent pericarditis. There was moderate quality evidence that colchicine reduces episodes of pericarditis in people with recurrent pericarditis over 18 months follow‐up (HR 0.37; 95% confidence interval (CI) 0.24 to 0.58). It is expected that at 18 months, the number needed to treat (NNT) is 4. In people with acute pericarditis, there was moderate quality evidence that colchicine reduces recurrence (HR 0.40; 95% CI 0.27 to 0.61) at 18 months follow‐up. Colchicine led to a greater chance of symptom relief at 72 hours (risk ratio (RR) 1.4; 95% CI 1.26 to 1.56; low quality evidence). Adverse effects were mainly gastrointestinal and included abdominal pain and diarrhoea. The pooled RR for adverse events was 1.26 (95% CI 0.75 to 2.12). While the number of people experiencing adverse effects was higher in the colchicine than the control groups (9% versus 7%), the quality of evidence was low owing to imprecision, and there was no statistically significant difference between the treatment groups (P = 0.42). There was moderate quality evidence that treatment with colchicine led to more people stopping treatment due to adverse events (RR 1.87; 95% CI 1.02 to 3.41). Authors' conclusions Colchicine, as adjunctive therapy to NSAIDs, is effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis. However, evidence is based on a limited number of small trials. Patients with multiple resistant recurrences were not represented in any published or on‐going trials, and it is these patients that are in the most need for treatment. Plain language summary Systematic review of randomised controlled trials about the efficacy and safety of colchicine in people with pericarditis Pericarditis is the inflammation and swelling of the tissue covering the outer layer of the heart. Pericarditis causes severe and disabling chest pain and fever, however the main issue is the repeated recurrence of pericarditis attacks. Colchicine is an ancient medication that has been used in the treatment of other inflammatory diseases such as gout. We wanted to discover whether colchicine alone or added to other medications is better or worse than alternative therapies in preventing pericarditis. We have reviewed all randomised controlled trials about the effect of colchicine in preventing recurrence of pericarditis in people with pericarditis. We found four trials involving 564 participants, who were followed up for at least 18 months. Two studies examined the use of colchicine in people with recurrent pericarditis and two examined the use of colchicine in people with a first episode of pericarditis. The evidence is current to August 2014. The trials showed that people taking colchicine have a lower risk of developing pericarditis recurrence and a higher proportion experience symptom relief. It is expected that at 18 months, one pericarditis recurrence can be avoided for every four people receiving colchicine with NSAIDs rather than NSAIDs alone. Adverse effects were reported in all trials and affected 15 people (9%) of the 162 taking colchicine. Adverse effects included abdominal pain, nausea and vomiting. Two studies were designed so that participants knew the type of intervention they were taking and people in the comparison group had no dummy pill. The results of these studies could exaggerate the effects of the drug. The evidence suggests beneficial effects of colchicine in preventing recurrence of pericarditis, however this is based on a limited number of small trials. More trials are currently being done and we await their results to see if the benefits of colchicine can be further confirmed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Alabed, S; Cabello, JB; Irving, GJ; Qintar, M; Burls, A", "articleTypes": [], "doi": "10.1002/14651858.CD010652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "a28720fb-039d-4c42-ba11-28efee29e3b8", "pmid": "", "title": "Antioxidants for male subfertility", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "de Ligny, W, Smits, RM, Mackenzie-Proctor, R, Jordan, V, Fleischer, K, de Bruin, JP, Showell, MG", "articleTypes": [], "doi": "10.1002/14651858.CD007411.pub5 AB - Abstract - Background The inability to have children affects 10% to 15% of couples worldwide. A male factor is estimated to account for up to half of the infertility cases with between 25% to 87% of male subfertility considered to be due to the effect of oxidative stress. Oral supplementation with antioxidants is thought to improve sperm quality by reducing oxidative damage. Antioxidants are widely available and inexpensive when compared to other fertility treatments, however most antioxidants are uncontrolled by regulation and the evidence for their effectiveness is uncertain. We compared the benefits and risks of different antioxidants used for male subfertility. Objectives To evaluate the effectiveness and safety of supplementary oral antioxidants in subfertile men. Search methods The Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, and two trial registers were searched on 15 February 2021, together with reference checking and contact with experts in the field to identify additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any type, dose or combination of oral antioxidant supplement with placebo, no treatment, or treatment with another antioxidant, among subfertile men of a couple attending a reproductive clinic. We excluded studies comparing antioxidants with fertility drugs alone and studies that included men with idiopathic infertility and normal semen parameters or fertile men attending a fertility clinic because of female partner infertility. Data collection and analysis We used standard methodological procedures recommended by Cochrane. The primary review outcome was live birth. Clinical pregnancy, adverse events and sperm parameters were secondary outcomes. Main results We included 90 studies with a total population of 10,303 subfertile men, aged between 18 and 65 years, part of a couple who had been referred to a fertility clinic and some of whom were undergoing medically assisted reproduction (MAR). Investigators compared and combined 20 different oral antioxidants. The evidence was of 'low' to 'very low' certainty: the main limitation was that out of the 67 included studies in the meta‐analysis only 20 studies reported clinical pregnancy, and of those 12 reported on live birth. The evidence is current up to February 2021. Live birth: antioxidants may lead to increased live birth rates (odds ratio (OR) 1.43, 95% confidence interval (CI) 1.07 to 1.91, P = 0.02, 12 RCTs, 1283 men, I 2 = 44%, very low‐certainty evidence). Results in the studies contributing to the analysis of live birth rate suggest that if the baseline chance of live birth following placebo or no treatment is assumed to be 16%, the chance following the use of antioxidants is estimated to be between 17% and 27%. However, this result was based on only 246 live births from 1283 couples in 12 small or medium‐sized studies. When studies at high risk of bias were removed from the analysis, there was no evidence of increased live birth (Peto OR 1.22, 95% CI 0.85 to 1.75, 827 men, 8 RCTs, P = 0.27, I 2 = 32%). Clinical pregnancy rate: antioxidants may lead to increased clinical pregnancy rates (OR 1.89, 95% CI 1.45 to 2.47, P < 0.00001, 20 RCTs, 1706 men, I 2 = 3%, low‐certainty evidence) compared with placebo or no treatment. This suggests that, in the studies contributing to the analysis of clinical pregnancy, if the baseline chance of clinical pregnancy following placebo or no treatment is assumed to be 15%, the chance following the use of antioxidants is estimated to be between 20% and 30%. This result was based on 327 clinical pregnancies from 1706 couples in 20 small studies. Adverse events
Miscarriage: only six studies reported on this outcome and the event rate was very low. No evidence of a difference in miscarriage rate was found between the antioxidant and placebo or no treatment group (OR 1.46, 95% CI 0.75 to 2.83, P = 0.27, 6 RCTs, 664 men, I 2 = 35%, very low‐certainty evidence). The findings suggest that in a population of subfertile couples, with male factor infertility, with an expected miscarriage rate of 5%, the risk of miscarriage following the use of an antioxidant would be between 4% and 13%. Gastrointestinal: antioxidants may lead to an increase in mild gastrointestinal discomfort when compared with placebo or no treatment (OR 2.70, 95% CI 1.46 to 4.99, P = 0.002, 16 RCTs, 1355 men, I 2 = 40%, low‐certainty evidence). This suggests that if the chance of gastrointestinal discomfort following placebo or no treatment is assumed to be 2%, the chance following the use of antioxidants is estimated to be between 2% and 7%. However, this result was based on a low event rate of 46 out of 1355 men in 16 small or medium‐sized studies, and the certainty of the evidence was rated low and heterogeneity was high. We were unable to draw conclusions from the antioxidant versus antioxidant comparison as insufficient studies compared the same interventions. Authors' conclusions In this review, there is very low‐certainty evidence from 12 small or medium‐sized randomised controlled trials suggesting that antioxidant supplementation in subfertile males may improve live birth rates for couples attending fertility clinics. Low‐certainty evidence suggests that clinical pregnancy rates may increase. There is no evidence of increased risk of miscarriage, however antioxidants may give more mild gastrointestinal discomfort, based on very low‐certainty evidence. Subfertile couples should be advised that overall, the current evidence is inconclusive based on serious risk of bias due to poor reporting of methods of randomisation, failure to report on the clinical outcomes live birth rate and clinical pregnancy, often unclear or even high attrition, and also imprecision due to often low event rates and small overall sample sizes. Further large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants. Plain language summary Antioxidants for male subfertility Review question 
Do supplementary oral antioxidants compared with placebo, no treatment or another antioxidant improve fertility outcomes for subfertile men? Background 
A couple may be considered to have fertility problems if they have been trying to conceive for over a year with no success. Many subfertile men undergoing fertility treatment also take dietary supplements in the hope of improving their fertility. Fertility treatment can be a very stressful time for men and their partners. It is important that these couples have access to high‐certainty evidence that will allow them to make informed decisions on whether to take a supplemental antioxidant. This is especially important as most antioxidant supplements are uncontrolled by regulation. This review aimed to assess whether supplements with oral antioxidants, taken by subfertile men, would increase the chances of a couple to achieve a (clinical) pregnancy confirmed by ultrasound and ultimately the birth of a baby (live birth). This review did not examine the use of antioxidants in men with normal sperm. Study characteristics Cochrane authors conducted a review including 90 randomised controlled trials comparing 18 different antioxidants with placebo, no treatment or another antioxidant in a total population of 10,303 subfertile men. The age range of the participants was 18 to 65 years; they were part of a couple who had been referred to a fertility clinic and some were undergoing fertility treatment. The evidence is current to February 2021. Main results 
Antioxidants may be associated with an increased live birth and clinical pregnancy rate. Based on the studied population for live birth, we would expect that out of 100 subfertile men not taking antioxidants, 16 couples would have a baby. In subfertile men taking antioxidants, between 17 and 27 per 100 couples would have a baby. If studies with high risk of bias were removed from the analysis, there was no evidence of increased live birth in the population taking antioxidants. In the people who were studied for clinical pregnancy, we would expect that out of 100 subfertile men not taking antioxidants, 15 couples would have a clinical pregnancy. In subfertile men taking antioxidants, between 20 and 30 per 100 couples would have a clinical pregnancy. Adverse events were poorly reported. Only six studies reported miscarriage. In these studies, miscarriage did not occur more often in the group using antioxidants when compared with the group with placebo or no treatment. However, there is insufficient evidence to draw conclusions about antioxidant use and the risk of miscarriage. The use of antioxidants may be associated with more mild stomach discomfort, with a frequency of 2% in subfertile men not taking antioxidants, and between 2% and 7% in men taking antioxidants. The oral supplements may cause discomforts such as nausea or stomach ache. Authors' conclusion and certainty of the evidence 
Antioxidant supplementation taken by subfertile males of a couple attending a fertility clinic may increase the chance of a live birth, however the overall certainty of evidence was very low from only 12 small to medium‐sized randomised controlled trials. Low‐certainty evidence suggests that clinical pregnancy rates may increase. Overall, there is no evidence of increased risk of miscarriage. Evidence of low certainty suggests that antioxidants may be associated with more gastrointestinal discomfort. Subfertile couples should be advised that overall the current evidence is inconclusive due to the poor reporting of methods, failure to report on live birth and clinical pregnancy rate, imprecision due to low event rates, high number of dropouts and small study group sizes. Large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.819Z" }, { "id": "a28918ee-28c9-4b66-bf0b-950331756202", "pmid": "", "title": "Desmopressin for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐old children and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Desmopressin has been used to treat bedwetting since the 1970s. This is an update of a Cochrane review first published in 2000 and last updated in 2006. Objectives To assess the effects of desmopressin on treating nocturnal enuresis in children. Search methods We searched Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched January 2023) and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of desmopressin or desmopressin combined with another intervention for treating nocturnal enuresis in children between five and 16 years old. Data collection and analysis Three review authors independently extracted data and assessed the risk of bias in the eligible trials. We used standard methodological procedures expected by Cochrane. Main results We identified 50 new studies for this review, which now includes 95 studies (8473) participants, of whom 5434 received desmopressin. In this review we continued the assessment of the effect of combination therapy involving desmopressin. The majority of the trials were in children between the ages of five to 16 years in an outpatient setting. The quality of the evidence was assessed as low or very low. The first comparison was desmopressin versus placebo. Desmopressin may reduce the mean number of wet nights per week compared with placebo (MD ‐1.81, 95% CI ‐2.24 to ‐1.39; participants = 1267; studies = 16; low‐certainty evidence). Desmopressin probably leads to more children achieving 14 consecutive dry nights by the end of treatment compared with placebo (RR 3.18, 95% CI 1.75 to 5.80; participants = 922: studies = 11; moderate‐certainty evidence). There may be little to no difference in children experiencing adverse effects with desmopressin compared to placebo (RR 1.11, 95% CI 0.81 to 1.52; participants = 269; studies = 3; low‐certainty evidence). Desmopressin was compared with alarm therapy. It is uncertain if there is any difference between desmopressin compared with alarm training in reducing the number of wet nights per week (MD 0.63, 95% CI ‐0.49 to 1.75; participants = 285; studies = 4; I 2 = 82%; very low‐certainty evidence). There may be little or no difference between desmopressin and alarm therapy in the number of children achieving 14 consecutive dry nights (RR 0.98, 95% CI 0.88 to 1.09; participants = 1530; studies = 15; low‐certainty evidence). There may be little to no difference in children experiencing side effects with desmopressin therapy compared with alarm therapy (RR 1.50, 95% CI 0.33 to 6.78; participants = 461, studies = 4; low‐certainty evidence). We compared desmopressin with other medications, including tricyclics and anticholinergics. It is uncertain if there is any difference between desmopressin compared to tricyclics in reducing the mean number of wet nights per week (MD 0.23, 95% CI ‐ 0.88 to 1.33; participants = 331; studies = 4; I 2 = 79%; very low‐certainty evidence) or in the number of children achieving 14 consecutive dry nights at the end of treatment (RR 0.94, 95% CI 0.63 to 1.38; participants = 371; studies = 7; I 2 = 71%; very low‐certainty evidence). It is uncertain whether children experience more side effects with desmopressin compared with tricyclics (RR 0.29, 95%CI 0.06 to 1.39; participants = 351; studies = 4, very low‐certainty evidence). This review included studies with combination therapies. It is uncertain if desmopressin combined with alarm therapy reduces the mean number of wet nights at the end of treatment compared with alarm monotherapy (MD ‐0.80, 95% CI ‐1.34 to ‐0.25; participants = 528; studies = 6; I 2 = 84%; very low‐certainty evidence); or if it increases the number of children achieving 14 consecutive dry nights (RR 1.25, 95% CI 0.96 to 1.63; participants = 822; studies = 10; very low‐certainty evidence). Desmopressin plus alarm therapy may make little to no difference in children experiencing side effects compared with alarm therapy alone (RR 1.05 95% CI 0.07 to 16.56; participants = 207; studies = 1; low‐certainty evidence). Combining desmopressin with alarm therapy probably reduces the number of wet nights at the end of treatment (MD ‐0.88; 95%CI ‐1.38 to ‐0.38; participants = 156; studies = 2; moderate‐certainty evidence), and may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin monotherapy (RR 1.26, 95% CI 1.06 to 1.51; participants = 370; studies = 5; low‐certainty evidence). It is uncertain if combined desmopressin and anticholinergic therapy versus desmopressin monotherapy reduces the mean number of wet nights at the end of therapy (MD ‐0.50; 95% CI ‐1.05 to 0.06; participants = 188; studies = 3; I 2 = 66%; very low‐certainty evidence); or if it may increase the number of children achieving 14 consecutive dry nights at the end of treatment (RR 1.53, 95% CI 1.10 to 2.11; participants = 611; studies = 8; low‐certainty evidence). There may be little to no difference in adverse events between desmopressin plus anticholinergics and desmopressin monotherapy (RR 1.51 95% CI 0.73 to 3.09, participants = 187; studies =2; low‐certainty evidence). Minor adverse effects were common for desmopressin, including dizziness, headache, mood changes, gastrointestinal discomfort, nasal discomfort, hyponatraemia and one report of a convulsion. Authors' conclusions Desmopressin compared with placebo may increase the number of dry nights per week at the end of treatment in children. Desmopressin therapy may be as effective as alarm therapy at the end of treatment. However, the quality of evidence was assessed as low or very low. Alarm therapy compared to desmopressin may improve the number of children who are dry at follow‐up (moderate‐certainty evidence). Plain language summary Desmopressin for bedwetting in children Review question Is desmopressin an effective treatment for bedwetting in children? Key messages: Desmopressin may improve bedwetting. Only one study assessed quality of life. Further studies with good patient numbers are required. What is enuresis? What does desmopressin do ? Enuresis or bedwetting is involuntary wetting during sleep at an age when a child should be dry, usually at age five. The generally quoted prevalence rates (that is the proportion of a population with bedwetting in a given time period) are 15% to 20% of five‐year‐olds, 7% of seven‐year‐olds, 5% of 10‐year‐old children, and 2% to 3% of teenagers. Various treatments have been used to treat bedwetting. Desmopressin is a man‐made form of vasopressin, a chemical released from the brain that helps control the amount of urine made by the kidneys. Desmopressin is used to control bedwetting at night and reduces the number of bedwetting episodes. Why was it important to do this review? Although bedwetting is not a harmful condition and, with time, stops spontaneously, it is stigmatising and can impact the child’s quality of life, emotional and psychological wellbeing. It is a condition that unsettles the whole family and the affected children may suffer parental discontentment, teasing and may be at risk of physical or emotional abuse. Successful therapies that reduce bedwetting improve the child's self‐esteem and, therefore, it is important to see if desmopressin is as effective as other known treatments. How is the condition treated ? • Desmopressin therapy • Alarm therapy • Anticholinergic medications • Combination therapy – such as desmopressin and alarm therapy compared to desmopressin therapy There are several other therapies, such as behavioural therapies and laser therapy, though we have concentrated on the main therapies utilised. What did we want to find out? We wanted to see if desmopressin: • was effective in reducing the episodes of wet nights children may have; • was as effective as other treatments such as alarm therapy in treating bedwetting; • worked in combination with other treatments; • was associated with any unwanted effects. What did we do? We searched for studies where people were randomly placed into different treatment groups. We searched for and included studies that compared: • desmopressin with no treatment or placebo; • desmopressin and alarm therapy; • combination treatments of desmopressin and alarm. We compared and analysed our results, then rated our confidence in the evidence based on factors such as study methods and size of the studies. What did we find? We found 98 studies with 8699 participants, of whom 5616 received desmopressin. Main results • We found the use of desmopressin compared with placebo may improve wetting by giving children one more dry night a week while receiving treatment. This suggests that more children may stop wetting while using desmopressin (28% versus 1% who are given placebo or no treatment). • More children who received desmopressin therapy compared with placebo probably achieved 14 consecutive dry nights at the end of treatment. • We found that, when desmopressin was compared with alarm therapy, there was little to no difference in the number of children achieving 14 dry nights in a row. The evidence is also uncertain if desmopressin versus alarm therapy reduces the number of dry nights per week. • We found that combining desmopressin with alarm therapy may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin alone. • We found that side effects were commonly reported for desmopressin. These included dizziness, headache, mood changes, abdominal discomfort, nasal discomfort, hyponatraemia (low sodium level) and one report of a seizure. Thirty‐two studies reported no adverse effects occurring, and 25 studies omitted to report or mention adverse effects. What are the limitations of the evidence? We, however, have little confidence in the evidence as, in several studies, participants were aware of the therapy they were receiving, and several studies were very small. How up‐to‐date is this review? The evidence is current up to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hahn, D; Stewart, F; Raman, G", "articleTypes": [], "doi": "10.1002/14651858.CD002112.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "a2915343-2946-4401-a77c-f719e2cefed2", "pmid": "", "title": "Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is the most common life‐limiting autosomal recessive genetic disorder in white populations. Distal intestinal obstruction syndrome (DIOS) is an important morbidity in cystic fibrosis. It is the result of the accumulation of viscid faecal material within the bowel which combines with thick, sticky mucus produced in the intestines of people with cystic fibrosis. The intestine may be completely blocked (complete DIOS) or only partially blocked (incomplete DIOS). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the acute complete or incomplete faecal obstruction and ultimately prevent the need for surgical intervention . Objectives This review aimed to evaluate the effectiveness and safety of different treatment regimens for the treatment of DIOS (complete and incomplete) in children and adults with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials (including cross‐over trials (to be judged on an individual basis)) comparing the use of laxative agents or surgery for treating DIOS in children, young people and adults with cystic fibrosis to each other, placebo or no intervention. Data collection and analysis Two authors independently screened papers, extracted trial details and assessed for risk of bias. The authors assessed the quality of evidence using GRADE. Main results There was one trial with 20 participants (16 females) included in the review. The mean age of participants was 13.1 years. The trial was a double‐blinded, randomised cross‐over trial which had a duration of 12 months in total and compared high‐dose and low‐dose pancreatic enzyme therapy. As only the abstract of the trial was available, the overall risk of bias was judged to be unclear. The trial did not address either of our primary outcomes (time until resolution of DIOS and treatment failure rate), but reported episodes of acute DIOS, presence of abdominal mass and abdominal pain. There were no numerical data available for these outcomes, but the authors stated that there was no difference between treatment with high‐dose or low‐dose pancreatic enzymes. The overall certainty of the evidence was found to be very low. Authors' conclusions There is a clear lack of evidence for the treatment of DIOS in people with cystic fibrosis. The included abstract did not address our primary outcome measures and did not provide numerical data for the two secondary outcomes it did address. Therefore, we cannot justify the use of high‐dose pancreatic enzymes for treating DIOS, nor can we comment on the efficacy and safety of other laxative agents. From our findings, it is clear that more randomised controlled trials need to be conducted in this area. Plain language summary Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis Review question We reviewed the evidence about the effectiveness and safety of different treatments for distal intestinal obstruction syndrome (DIOS) in children and adults with cystic fibrosis. Background Cystic fibrosis is a common, life‐limiting, inherited disease. One of the main features of cystic fibrosis is the thick, sticky mucus produced by many organs including the lungs, pancreas and intestine. DIOS occurs when mucus in the intestine combines with faeces and builds up to produce a mass. This mass can partially or completely block the intestine and cause symptoms such as vomiting, severe abdominal pain and a swollen stomach (abdominal distension). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the complete or partial blockage and ultimately prevent the need for any surgical intervention. Search date The evidence is current to: 12 October 2021. Trial characteristics The review included one trial with 20 people with cystic fibrosis who were aged between 7.1 and 23.2 years of age (average 13.1 years old). The 12‐month trial compared a high dose of pancreatic enzymes with a low dose of pancreatic enzymes for treating chronic DIOS. Key results The trial did not report on our primary outcomes (time until DIOS successfully treated and treatment failure rate), but addressed two of our secondary outcomes; episodes of acute DIOS and the harmful effects that might occur in participants (the presence of an abdominal mass and abdominal pain). There were no numerical data available for these results, but the authors reported that there was no difference between high‐dose or low‐dose pancreatic enzymes. Certainty of the evidence We found the overall certainty of the evidence to be very low. The trial itself was only published as an abstract from a conference which did not include numerical data and it was not published as a full report. This meant that we do not know many details about the trial. We thought that the overall risk of bias was unclear, as the trial authors did not describe how participants were put into the treatment groups, whether any participants dropped out or whether the planned outcomes were the same as the reported outcomes. The trial also had a very small number of participants and a limited age range, making it difficult to draw conclusions about the relevance of the treatment for all people with cystic fibrosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gilchrist, FJ, Green, J, Carroll, W", "articleTypes": [], "doi": "10.1002/14651858.CD012798.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.074Z" }, { "id": "a29545c8-3732-4f31-834a-b444b1002f78", "pmid": "", "title": "Systemic antifungal therapy for tinea capitis in children", "imported": false, "abstract": "Abstract - Background Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread. This is an update of the original Cochrane review. Objectives To assess the effects of systemic antifungal drugs for tinea capitis in children. Search methods We updated our searches of the following databases to November 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and CINAHL (from 1981). We searched five trial registers and checked the reference lists of studies for references to relevant randomised controlled trials (RCTs). We obtained unpublished, ongoing trials and grey literature via correspondence with experts in the field and from pharmaceutical companies. Selection criteria RCTs of systemic antifungal therapy in children with normal immunity under the age of 18 with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 25 studies (N = 4449); 4 studies (N = 2637) were new to this update. Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy for the primary outcome of complete (i.e. clinical and mycological) cure in three studies involving 328 participants with Trichophyton species infections (84.2% versus 79.0%; risk ratio (RR) 1.06, 95% confidence interval (CI) 0.98 to 1.15; low quality evidence). Complete cure with itraconazole (two to six weeks) and griseofulvin (six weeks) was similar in two studies (83.6% versus 91.0%; RR 0.92, 95% CI 0.81 to 1.05; N = 134; very low quality evidence). In two studies, there was no difference between itraconazole and terbinafine for two to three weeks treatment (73.8% versus 78.8%; RR 0.93, 95% CI 0.72 to 1.19; N = 160; low quality evidence). In three studies, there was a similar proportion achieving complete cured with two to four weeks of fluconazole or six weeks of griseofulvin (41.4% versus 52.7%; RR 0.92, 95% CI 0.81 to 1.05; N = 615; moderate quality evidence). Current evidence for ketoconazole versus griseofulvin was limited. One study favoured griseofulvin (12 weeks) because ketoconazole (12 weeks) appeared less effective for complete cure (RR 0.76, 95% CI 0.62 to 0.94; low quality evidence). However, their effects appeared to be similar when the treatment lasted 26 weeks (RR 0.95, 95% CI 0.83 to 1.07; low quality evidence). Another study indicated that complete cure was similar for ketoconazole (12 weeks) and griseofulvin (12 weeks) (RR 0.89, 95% CI 0.57 to 1.39; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole (for two to three weeks) and terbinafine (for two to three weeks) (82.0% versus 94.0%; RR 0.87, 95% CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, we did not find a significant difference between fluconazole (for two to three weeks) and itraconazole (for two to three weeks) (82.0% versus 82.0%; RR 1.00, 95% CI 0.83 to 1.20; low quality evidence). This update provides new data: in children with Microsporum infections, a meta‐analysis of two studies found that the complete cure was lower for terbinafine (6 weeks) than for griseofulvin (6‐12 weeks) (34.7% versus 50.9%; RR 0.68, 95% CI 0.53 to 0.86; N = 334; moderate quality evidence). In the original review, there was no significant difference in complete cure between terbinafine (four weeks) and griseofulvin (eight weeks) in children with Microsporum infections in one small study (27.2% versus 60.0%; RR 0.45, 95% CI 0.15 to 1.35; N = 21; low quality evidence). One study provides new evidence that terbinafine and griseofulvin for six weeks show similar efficacy (49.5% versus 37.8%; RR 1.18, 95% CI 0.74 to 1.88; N = 1006; low quality evidence). However, in children infected with T. tonsurans , terbinafine was better than griseofulvin (52.1% versus 35.4%; RR 1.47, 95% CI 1.22 to 1.77; moderate quality evidence). For children infected with T. violaceum, these two regimens have similar effects (41.3% versus 45.1%; RR 0.91, 95% CI 0.68 to 1.24; low quality evidence). Additionally, three weeks of fluconazole was similar to six weeks of fluconazole in one study in 491 participants infected with T. tonsurans and M. canis (30.2% versus 34.1%; RR 0.88, 95% CI 0.68 to 1.14; low quality evidence). The frequency of adverse events attributed to the study drugs was similar for terbinafine and griseofulvin (9.2% versus 8.3%; RR 1.11, 95% CI 0.79 to 1.57; moderate quality evidence), and severe adverse events were rare (0.6% versus 0.6%; RR 0.97, 95% CI 0.24 to 3.88; moderate quality evidence). Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible. All of the included studies were at either high or unclear risk of bias in at least one domain. Using GRADE to rate the overall quality of the evidence, lower quality evidence resulted in lower confidence in the estimate of effect. Authors' conclusions Newer treatments including terbinafine, itraconazole and fluconazole are at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Limited evidence suggests that terbinafine, itraconazole and fluconazole have similar effects, whereas ketoconazole may be less effective than griseofulvin in children infected with Trichophyton . With some interventions the proportion achieving complete clinical cure was in excess of 90% (e.g. one study of terbinafine or griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. New evidence from this update suggests that terbinafine is more effective than griseofulvin in children with T. tonsurans infection. However, in children with Microsporum infections, new evidence suggests that the effect of griseofulvin is better than terbinafine. We did not find any evidence to support a difference in terms of adherence between four weeks of terbinafine versus eight weeks of griseofulvin. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles. Plain language summary Antifungal medicines for treating children with ringworm Background Tinea capitis, or ringworm, is a fungal infection of the scalp caused mainly by two species of fungi called Trichophyton and Microsporum . It is common in children. Most fungal infections can be treated with antifungal creams applied directly to the skin (topical treatments). However, because the fungal infection is found at the root of the hair follicles, where topical treatments cannot reach, tinea capitis always requires medication administered by mouth so that the treatment spreads throughout the entire body (systemic treatments). There are several different types of antifungal medicines available. Review question Which antifungal medicine is best for treating ringworm on the scalp in children? Study characteristics In November 2015, we searched for studies that used the gold standard design for clinical trials (randomised controlled trials) of antifungal treatments taken by mouth. We found 25 studies in which 4449 children under 18 years (4 studies with 2637 children were new to this update) had taken part. Key results With respect to complete cure (both cure of the infection and visible cure (i.e. fungal and clinical cure) low to moderate quality evidence suggests that newer treatments such as terbinafine, itraconazole and fluconazole are at least as good as griseofulvin, the usual treatment in children with tinea capitis caused by Trichophyton infections. However, new evidence in this update suggests that terbinafine may have better effects than griseofulvin for completely curing children with T. tonsurans infection. By contrast, in children with Microsporum infections, new evidence seems to indicate that griseofulvin is more effective than terbinafine. Terbinafine, itraconazole and fluconazole appear to have similar effects in terms of the proportion of participants achieving complete cure, whereas ketoconazole appears to be less effective than griseofulvin for children with tinea capitis caused by Trichophyton species. However, the quality of this evidence is low. With some interventions, the proportion with complete clinical cure was in excess of 90% (e.g. one study of terbinafine versus griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. The included studies reported on negative side effects, which were similarly mild and reversible for terbinafine, griseofulvin, itraconazole, ketoconazole and fluconazole. They included skin‐specific effects such as itching as well as abdominal discomfort, headache and nausea. Quality of the evidence The quality of the evidence in this review was generally low to moderate, so further research is likely to have an important effect on our confidence in these results. Some evidence was even of very low quality. We still need more and better evidence to help us understand the effectiveness and adverse events of systemic antifungal drugs for tinea capitis in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chen, X, Jiang, X, Yang, M, González, U, Lin, X, Hua, X, Xue, S, Zhang, M, Bennett, C", "articleTypes": [], "doi": "10.1002/14651858.CD004685.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.755Z" }, { "id": "a2b2e09b-fbba-424f-ad93-c1dcf21ff64e", "pmid": "", "title": "Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their aetiology is unknown. The management of chronic rhinosinusitis with nasal polyps, aimed at improving these symptoms, includes both surgical and medical treatments, but there is no universally accepted management protocol. Objectives To assess the effectiveness of endonasal/endoscopic surgery versus medical treatment in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised controlled trials of any surgical intervention (e.g. polypectomy, endoscopic sinus surgery) versus any medical treatment (e.g. intranasal and/or systemic steroids), including placebo, in adult patients with chronic rhinosinusitis with nasal polyps. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Meta‐analysis was not possible due to the heterogeneity of the studies and the selective (incomplete) outcome reporting by the studies. Main results Four studies (231 participants randomised) are included in the review. No studies were at low risk of bias. The studies compared different types of surgery versus various types and doses of systemic and topical steroids and antibiotics. There were three comparison pairs: (1) endoscopic sinus surgery (ESS) versus systemic steroids (one study, n = 109), (2) polypectomy versus systemic steroids (two studies, n = 87); (3) ESS plus topical steroid versus antibiotics plus high‐dose topical steroid (one study, n = 35). All participants also received topical steroids but doses and types were the same between the treatment arms of each study, except for the study using antibiotics. In that study, the medical treatment arm had higher doses than the surgical arm. In two of the studies, the authors failed to report the outcomes of interest. Although there were important differences in the types of treatments and comparisons used in these studies, the results were similar. Primary outcomes: symptom scores and quality of life scores There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) failed to find a difference in generic health‐related quality of life scores. The quality of this evidence is low or very low . Endoscopic scores and other secondary outcomes Two studies reported endoscopic scores. One study (ESS versus systemic steroids) reported a large, significant effect size in the surgical group, with a mean difference (MD) in score of ‐1.5 (95% confidence interval (CI) ‐1.78 to ‐1.22, n = 95) on a scale of 0 to 3 (0 = no polyposis, 3 = severe polyposis). In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups (MD 2.3%, 95% CI ‐17.4% to 12.8%, n = 34). None of the included studies reported recurrence rates. No differences were found for any objective measurements or olfactory tests in those studies in which they were measured. Complications Complication rates were not reported in all studies, but rates of up to 21% for medical treatment and 14.3% for surgical treatment are described. Epistaxis was the most commonly reported complication with both medical and surgical treatments, with severe complications reported rarely. Authors' conclusions The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis with nasal polyps is of very low quality. The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. The one positive finding from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. As the overall evidence is of very low quality (serious methodological limitations, reporting bias, indirectness and imprecision) and insufficient to draw firm conclusions, further research to investigate this problem, which has significant implications for quality of life and healthcare service usage, is justified. Plain language summary Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps Background Nasal polyps are common, benign swellings of the lining of the nose. In some people they may cause no symptoms, but in others they may lead to nasal obstruction, congestion, facial pressure and anosmia (loss of sense of smell). The incidence of symptomatic nasal polyps increases with age and they are more common in men than in women. The cause of nasal polyps is not fully understood but they may be a result of chronic (long‐term) inflammation of the lining of the nose (termed 'chronic rhinosinusitis with nasal polyps'). Chronic rhinosinusitis with nasal polyps can be treated medically, for example with drugs such as topical (intranasal) steroid sprays, or with surgery (for example, nasal polypectomy with or without endoscopic sinus surgery (ESS)). However, it is unclear what is the most effective management strategy. Study characteristics Four randomised controlled trials, involving a total of 231 patients with chronic rhinosinusitis with nasal polyps, are included in this review. The number of patients in each study ranged from 34 to 109. The studies took place in ENT departments in several European countries. All patients were adults and most of the studies enrolled more men than women. In all studies the patients were randomly assigned to either surgery or medical treatment (such as antibiotics or steroid tablets or injections) in addition to topical steroids given as nasal sprays or drops. Both the type of surgery performed and the medical treatments used varied widely between the studies, and did not allow all of the studies to be looked at together. Rather, we considered the treatment groups in the four studies as three separate pairs of comparisons instead of simply 'surgical' versus 'medical' treatments. Key results The main outcome measures were patient‐reported disease‐specific symptom scores and health‐related quality of life scores, as well as generic health‐related quality of life scores. There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) did not find a difference in general health‐related quality of life scores. Two studies reported changes in polyp size (when looked at with an endoscope) using a score. One study (ESS versus systemic steroids) reported a significantly better score in the surgery group than in the steroids group at 12 months. In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups. There were no reported differences between the different medical and surgical treatment groups in any study for any other objective (clinician‐based) measurements. Complication rates were not reported in all studies, but nosebleeds (epistaxis) were the most commonly described complication with both medical and surgical treatment; severe complications were reported rarely in either group. Conclusion The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. One positive finding (polyps size scores) from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. There is not enough evidence to draw firm conclusions regarding the most appropriate treatment for this condition. Chronic rhinosinusitis with nasal polyps has significant implications for quality of life and the use of healthcare services. Further research to investigate this problem is justified. Quality of the evidence Overall, we found this evidence to be of low or very low quality. We have low confidence in the estimates of these studies; further research will very likely change these estimates. There were serious limitations in how the studies were carried out or reported (or both), and the number of participants involved was small. In addition, some of the treatment regimens used in the trials are no longer current standards of therapy for patients with chronic rhinosinusitis with nasal polyps. This evidence is up to date to 20 February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Rimmer, J; Fokkens, W; Chong, LY; Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "a2c4c6b0-c49b-4350-b8dd-067aed15bbee", "pmid": "", "title": "School feeding programs for improving the physical and psychological health of school children experiencing socioeconomic disadvantage", "imported": false, "abstract": "Abstract - Rationale School feeding aims to alleviate hunger and enhance child outcomes. Since the first Cochrane systematic review of school meals, there has been a marked increase in studies and reviews of school feeding programs. However, most systematic reviews are geographically limited and use qualitative analysis. We reviewed worldwide papers and performed several meta‐analyses, providing a more comprehensive picture of the effectiveness of school feeding. Objectives 1. To assess effectiveness of school feeding programs for improving the physical and psychological health of children experiencing socioeconomic disadvantage worldwide.
2. To assess effectiveness of school feeding programs for improving the health of children experiencing socioeconomic disadvantage compared with children who are more advantaged. Search methods We searched 17 subject‐specific and multidisciplinary databases and registries up to November 2023. In November 2024, two Information Specialists ran a top‐up search for randomized controlled trials (RCTs). We handsearched references of included studies and relevant reviews. Eligibility criteria We included individually randomized, cluster‐randomized, and cross‐over trials, as well as longitudinal non‐randomized studies of interventions (NRSIs). Studies had to compare the provision of free or reduced‐price food in schools versus no school feeding, focusing on socioeconomically disadvantaged children. The food had to contain at least 3% of the daily energy requirement and at least 10% of the daily protein requirement for the specified age group(s). Eligible participants were primary or secondary school students aged five to 19 years. Outcomes Our critical outcomes were change in: math achievement, reading achievement, attendance, enrollment, height‐for‐age z‐score (HAZ), weight‐for‐age z‐score (WAZ), and overweight/obesity. Our important outcomes were change in: overall academic achievement, fluid intelligence, working memory, behavioral/emotional outcomes, height, weight, and anemia. We planned to study changes between baseline and final outcomes. In one study with extreme contamination, we used the first follow‐up. Risk of bias We assessed the risk of bias for RCTs by outcome using the appropriate version of the Cochrane risk of bias tool (RoB 2): RoB 2 for individually randomized trials, for cluster‐RCTs, and for cross‐over trials. We evaluated the quality of NRSIs using the School‐based Measurement & Assessment of Results Tool (SMART), which is adapted from the Newcastle Ottawa Scale. Synthesis methods We used standardized mean differences (SMDs) with 95% confidence intervals (CIs) for educational and cognitive outcomes. We used mean differences (MDs), odds ratios (ORs), or incidence rate ratios (IRRs) for others. All meta‐analyses used random‐effects generic inverse variance. We conducted equity subgroup analyses by sex and socioeconomic status. We used GRADE to assess our confidence in the evidence for critical outcomes reported in RCTs. Included studies We included 40 studies with 83 reports. There were 13 RCTs (12 cluster‐randomized trials and one individually randomized trial) and 27 NRSIs. Most studies (34) were from low‐ and middle‐income countries (LMICs). In total, there were more than 91,885 students (four studies didn't report sample size). One study involved 59,613 students, while the others had between 60 and 6038 students. The studies included 48 outcomes; we meta‐analyzed or reported 14. Synthesis of results Low‐ and middle‐income countries (LMICs) School feeding compared to no school feeding improves math achievement slightly (SMD 0.14, 95% CI 0.06 to 0.23; P = 0.001; I² = 68%; 6 cluster‐RCTs, 5587 participants; high‐certainty evidence), but may have little to no effect on reading achievement (SMD 0.02, 95% CI −0.06 to 0.11; P = 0.61; I 2 = 54%; 3 cluster‐RCTs, 3417 participants; low‐certainty evidence). School feeding programs lead to a slight increase in enrollment rates (MD 3.44% increase, 95% CI 0.83 to 6.04; P = 0.01; I² = 0%; 2 cluster‐RCTs, 5200 participants, high‐certainty evidence) but may have little to no effect on attendance (MD 0.17%, 95% CI −2.64% to 2.97%; P = 0.91; I 2 = 81%; 3 cluster‐RCTs, 3566 participants; low‐certainty evidence). School feeding programs likely lead to a slight increase in HAZ (MD 0.06, 95% CI 0.03 to 0.09; P < 0.001; I 2 = 0%; 2 cluster‐RCTs, 3678 participants; moderate‐certainty evidence) and WAZ (MD 0.08, 95% CI 0.05 to 0.12; P < 0.001; I 2 = 0%; 3 cluster‐RCTs, 2132 participants; moderate‐certainty evidence). Two cluster‐RCTs assessed change in obesity/overweight. One 10‐month study found that the odds of being overweight/obese were 53% lower among adolescents receiving school meals compared to control adolescents (OR 0.47, 95% CI 0.30 to 0.72). Another study found no cases of overweight/obesity before or after the intervention. These findings are of very low certainty. Some researchers encountered implementation problems beyond their control, including conflicts, delays, and bureaucratic decisions. Heterogeneity in contexts, outcomes, child populations, and statistics was a limitation of this review. High‐income countries (HICs) One NRSI found very uncertain evidence that children assigned to a breakfast club increased their attendance by more than 1.6% on average compared to children in the control group. Equity analyses The equity (subgroup) analyses by sex and by socio‐economic status were all non‐significant. There were only two studies in each subgroup analysis; they were likely underpowered. Authors' conclusions In LMICs, school feeding programs lead to a slight improvement in math achievement, but may have little to no effect on reading achievement. School feeding programs lead to a slight increase in enrollment, but may have little to no impact on attendance. They likely lead to slight gains in HAZ and WAZ. There may be little to no association between school feeding and overweight/obesity, but the evidence is very uncertain. We recommend that researchers and policymakers view research as an integral part of the implementation process. To reduce heterogeneity in outcomes, we recommend even greater co‐ordination of research, and that researchers and interest holders work together to identify a core set of outcomes. Funding The authors would like to thank the following donors for their generous support in making this review possible: Dubai Cares, the World Food Programme's School Meals and Social Protection Service, and the Research Consortium for School Health and Nutrition. Registration Protocol (2022): https://doi.org/10.1002/14651858.CD014794 
Original review (2007): https://doi.org/10.1002/14651858.CD004676.pub2 
Original Campbell protocol (2006): doi.org/10.1002/CL2.12 Plain language summary Can school meal programs improve health and educational goals in children experiencing socioeconomic disadvantage? Key messages School meal programs in low‐ and middle‐income countries lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. Research should be a key part of planning and running school meal programs. To make it easier to compare results from different studies, researchers, parents, and policymakers should work together to agree on a list of the most important goals for children's health, development, and success in school. Why did we want to review studies on school meals? Worldwide, many children do not get enough nutritious food to keep them healthy and ready to learn in school. This affects their ability to enroll, attend school regularly, and learn there. School meals aim to reduce hunger and improve children's learning, focus, and overall health. School meals are one of the world's largest social safety nets. We sought to understand their effectiveness for children in disadvantaged circumstances across the globe. Most previous reviews of the evidence are limited in geographical scope, and many use narrative analyses. What did we want to find out? We asked the following two health equity (fairness) questions. Do school meals improve the physical health of socioeconomically disadvantaged children worldwide? Do school meals benefit children who are disadvantaged by sex and low family income more than they benefit less disadvantaged children? What did we do? We searched for studies that evaluated the effects of school meals for school students aged five to 19 years. We included randomized studies, which allocate students or schools to different study groups at random. However, because randomized studies are not always possible, we included non‐randomized studies that compared school meal groups with groups that received no school meals. These non‐randomized studies needed to measure outcomes at least twice; once at the beginning of the study and once at the end. We rated our confidence in the findings separately for each outcome. What did we find? We found 13 randomized studies and 27 non‐randomized studies, which collectively involved more than 91,995 students aged five to 19 years. One study included 59,613 students, while others had student populations ranging from 40 to 6038 students. Across all studies, there was a similar number of boys and girls, although three studies included only girls. Most studies took place in low‐ and middle‐income countries (34 studies), while six were from high‐income countries. In low‐ and middle‐income countries, school meals lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. In high‐income countries, one study presented very uncertain evidence that school meals may increase attendance slightly. What are the limitations of the evidence? Because we found very few eligible studies conducted in high‐income countries, we do not recommend applying our findings to this setting. We are confident in the results for math test scores and enrollment. We are moderately confident in the results for height and weight for age, because we had some concerns about the study methods. We have little confidence in the results for reading test scores and attendance, because we had some concerns about the study methods, and the results differed substantially among the trials. We are not confident in the results for overweight/obesity, because we have some concerns about the study methods, the two studies measured the outcome in different ways, and one of the studies was very small. Several studies faced barriers due to their context, such as conflict, droughts, bureaucratic delays, and difficulties in distributing funds to caterers, as well as eagerness to initiate school meal programs in control schools. We need more evidence on school meals and their impact on disadvantaged school students—especially those in secondary school—in countries of all income levels. We also need more studies that assess the difference between disadvantaged groups and more advantaged children in high‐income countries. We suggest that researchers, school feeding experts, teachers, and parents collaborate to develop a core set of key outcomes, and that these outcomes be put in an open‐access repository. How up‐to‐date is this evidence? This review updates and expands our 2007 review of school meal programs. The evidence is current to November 2024. Funding Dubai Cares funded this review through the World Food Program School Feeding Program. The London School of Hygiene and Tropical Medicine also funded this review. The funders had no influence on the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kristjansson, E; Dignam, M; Rizvi, A; Osman, M; Magwood, O; Olarte, D; Cohen, JFW; Krasevec, J; Grover, T; Labelle, PR; Garner, JA; Janzen, L; Rossiter, S; Dewidar, O; Shea, B; Welch, V; Wells, GA", "articleTypes": [], "doi": "10.1002/14651858.CD014794.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "a2d0a450-8068-442f-8032-fa3f94bdafe1", "pmid": "", "title": "Oral zinc for treating diarrhoea in children", "imported": false, "abstract": "Abstract - Background In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). Objectives To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, m RCT, and reference lists up to 30 September 2016. We also contacted researchers. Selection criteria Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery. Data collection and analysis Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses (using either a fixed‐effect or random‐effects model) and assessed heterogeneity. We assessed the certainty of the evidence using the GRADE approach. Main results Thirty‐three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoea There is currently not enough evidence from well‐conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized ( very low certainty evidence ). In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD −11.46 hours, 95% CI −19.72 to −3.19; 2581 children, 9 trials, low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD −26.39 hours, 95% CI −36.54 to −16.23; 419 children, 5 trials, high certainty evidence ). Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI −4.00 to 14.45; 1334 children, 2 trials, low certainty evidence ), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, low certainty evidence ). None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence ; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence ). Persistent diarrhoea In children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD −15.84 hours, 95% CI −25.43 to −6.24; 529 children, 5 trials, moderate certainty evidence ). Authors' conclusions In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency. 12 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (30 Sep, 2016) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Oral zinc supplementation for treating diarrhoea in children In low‐ and middle‐income countries, millions of children suffer from severe diarrhoea every year and many die from dehydration. Giving fluids by mouth (using an oral rehydration solution (ORS)) has been shown to save children's lives, but it has no effect on the length of time the children suffer with diarrhoea. Zinc supplementation could help reduce the duration and the severity of diarrhoea, and therefore have an additional benefit over ORS in reducing children mortality. What is oral zinc and how may it shorten the duration and severity of diarrhoea Zinc is usually given as zinc sulphate, zinc acetate, or zinc gluconate, which are all water‐soluble compounds. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend 10 mg to 20 mg of zinc per day for children with diarrhoea. There are several mechanism of action of zinc on acute diarrhoea, some of which are specific to the gastrointestinal system: zinc restores mucosal barrier integrity and enterocyte brush‐border enzyme activity, it promotes the production of antibodies and circulating lymphocytes against intestinal pathogens, and has a direct effect on ion channels, acting as a potassium channel blocker of adenosine 3‐5‐cyclic monophosphate‐mediated chlorine secretion. Cochrane researchers examined the evidence available up to 30 September 2016. What the evidence in the review suggests Thirty‐three trials that included 10,841 children met the inclusion criteria of this review. Among children with acute diarrhoea, we don't know if treating children with zinc has an effect on death or number of children hospitalized ( very low certainty evidence ). In children older than six months, zinc supplementation may shorten the average duration of diarrhoea by around half a day ( low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven ( moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day ( high certainty evidence ). Conversely, in children younger than six months, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea ( low certainty evidence ), or the number of children who still have diarrhoea on day seven ( low certainty evidence ). Zinc supplementation increased the risk of vomiting in both age groups ( moderate certainty evidence ). No other adverse effects were reported. Among children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours ( moderate certainty ) but it probably increases the risk of vomiting ( moderate certainty evidence ). In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lazzerini, M, Wanzira, H", "articleTypes": [], "doi": "10.1002/14651858.CD005436.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.740Z" }, { "id": "a2db1980-5c41-407f-b8d8-916a8e6bc65a", "pmid": "", "title": "Statins for Smith‐Lemli‐Opitz syndrome", "imported": false, "abstract": "Abstract - Background Smith‐Lemli‐Opitz syndrome (SLOS) is a multiple congenital malformations syndrome caused by defective cholesterol biosynthesis. Affected individuals show cholesterol deficiency and accumulation of various precursor molecules, mainly 7‐dehydrocholesterol and 8‐dehydrocholesterol. There is currently no cure for SLOS, with cholesterol supplementation being primarily a biochemical therapy of limited evidence. However, several anecdotal reports and preclinical studies have highlighted statins as a potential therapy for SLOS. Objectives To evaluate the effects of statins, either alone or in combination with other non‐statin therapies (e.g. cholesterol, bile acid, or vitamin co‐supplementation), compared to cholesterol supplementation alone or in combination with other non‐statin therapies (e.g. bile acid or vitamin supplementation) on several important outcomes including overall survival, neurobehavioral features, and adverse effects in individuals with SLOS. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and three trials registers on 15 February 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs with parallel or cross‐over designs, and non‐randomized studies of interventions (NRSIs) including non‐randomized trials, cohort studies, and controlled before‐and‐after studies, were eligible for inclusion in this review if they met our prespecified inclusion criteria, i.e. involved human participants with biochemically or genetically diagnosed SLOS receiving statin therapy or cholesterol supplementation, or both. Data collection and analysis Two authors screened titles and abstracts and subsequently full‐texts for all potentially‐relevant references. Both authors independently extracted relevant data from included studies and assessed the risks of bias. We analyzed the data extracted from the included NRSIs and cohort studies separately from the data extracted from the single included RCT. We used a random‐effects model to account for the inherent heterogeneity and methodological variation between these different study designs. We used GRADE to assess the certainty of evidence. Main results We included six studies (61 participants with SLOS); one RCT (N = 18), three prospective NRSIs (N = 20), and two retrospective NRSIs (N = 22). Five studies included only children, and two limited their participant inclusion by disease severity. Overall, there were nearly twice as many males as females. All six studies compared add‐on statin therapy to cholesterol supplementation alone. However, the dosages, formulations, and durations of treatment were highly variable across studies. We judged the RCT as having a high risk of bias due to missing data and selective reporting. All included NRSIs had a serious or critical overall risk of bias assessed by the Risk Of Bias In Non‐randomized Studies of Interventions tool (ROBINS‐I). None of the included studies evaluated survival or reported quality of life (QoL). Only the included RCT formally assessed changes in the neurobehavioral manifestations of SLOS, and we are uncertain whether statin therapy improves this outcome (very low‐certainty evidence). We are also uncertain whether the adverse events reported in the RCT were statin‐related (very low‐certainty evidence). In contrast, the adverse events reported in the NRSIs seem to be possibly due to statin therapy (risk ratio 13.00, 95% confidence interval 1.85 to 91.49; P = 0.01; low‐certainty evidence), with only one of the NRSIs retrospectively mentioning changes in the irritability of two of their participants. We are uncertain whether statins affect growth based on the RCT or NRSI results (very low‐certainty evidence). The RCT showed that statins may make little or no difference to plasma biomarker levels (low‐certainty evidence), while we are uncertain of their effects on such parameters in the NRSIs (very low‐certainty evidence). Authors' conclusions Currently, there is no evidence on the potential effects of statin therapy in people with SLOS regarding survival or QoL, and very limited evidence on the effects on neurobehavioral manifestations. Likewise, current evidence is insufficient and of very low certainty regarding the effects of statins on growth parameters in children with SLOS and plasma or cerebrospinal fluid (CSF) levels of various disease biomarkers. Despite these limitations, current evidence seemingly suggests that statins may increase the risk of adverse reactions in individuals with SLOS receiving statins compared to those who are not. Given the insufficient evidence on potential benefits of statins in individuals with SLOS, and their potential for causing adverse reactions, anyone considering this therapy should take these findings into consideration. Future studies should address the highlighted gaps in evidence on the use of statins in individuals with SLOS by collecting prospective data on survival and performing serial standardized assessments of neurobehavioral features, QoL, anthropometric measures, and plasma and CSF biomarker levels after statin introduction. Future studies should also attempt to use consistent dosages, formulations and durations of cholesterol and statin therapy. Plain language summary Statins for Smith‐Lemli‐Opitz syndrome Review question Is statin therapy, either alone or combined with cholesterol therapy, linked to better outcomes (e.g. survival, quality of life, severity or frequency of neurobehavioral abnormalities, changes in growth parameters or biomarker levels) compared to cholesterol therapy alone for people with Smith‐Lemli‐Opitz syndrome (SLOS), and what are the risks of harmful effects for either option? Background Smith‐Lemli‐Opitz syndrome is a genetic malformation syndrome, which occurs when cholesterol is not able to be produced by the body and there is a build up of several toxic molecules that would, under normal circumstances, go on to become cholesterol, such as 7DHC and 8DHC. This means that people with SLOS may fail to achieve normal physical growth, show various degrees of intellectual disability or developmental delay (or both), and show a range of possible behavioral abnormalities (e.g. irritability, aggressiveness, anxiety, attention‐deficit hyperactivity disorder (ADHD), impulsivity and sleep disturbances, among others). It is also notable that SLOS may cause various possible physical abnormalities and disability. There is currently no cure for SLOS, but cholesterol supplementation remains common practice among clinicians caring for people with SLOS. This is based solely on our current understanding of the underlying biochemistry of the disease itself. However, there has been evidence from studies in the laboratory and in single individuals suggesting that statins may be helpful for treating people with SLOS. Search date We conducted our latest search on 15 February 2022. Study characteristics In this review, we included six studies of different designs that included a total of 61 people with SLOS, mostly males. Five of the studies only included children (18 years old or younger). All studies compared a combination of statin and cholesterol therapy to cholesterol supplementation alone. However, the studies used different doses and formulations of statin or cholesterol therapy (or both), as well as different durations of treatment. Key results We found no evidence for the effects of combined statin and cholesterol supplementation, compared to cholesterol supplementation alone, on survival or quality of life in people with SLOS. We are also not sure if combined statin and cholesterol therapy has positive effects on neurobehavioral manifestations or growth in individuals with SLOS compared with cholesterol therapy alone, as we have low confidence in the evidence. We think people with SLOS receiving statin therapy in addition to cholesterol supplementation are more likely to experience adverse events that are usually associated with using statins, compared to those who are only receiving cholesterol supplementation. Finally, we are uncertain about the effects of statin therapy on the levels of various biomarkers usually measured in the blood of people with SLOS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ballout, RA, Livinski, A, Fu, Y-P, Steiner, RD, Remaley, AT", "articleTypes": [], "doi": "10.1002/14651858.CD013521.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.774Z" }, { "id": "a2dbeaa7-fedb-4f75-8112-cb8d29945af4", "pmid": "", "title": "Laxatives for the management of constipation in people receiving palliative care", "imported": false, "abstract": "Abstract - Background This article describes the second update of a Cochrane review on the effectiveness of laxatives for the management of constipation in people receiving palliative care. Previous versions were published in 2006 and 2010 where we also evaluated trials of methylnaltrexone; these trials have been removed as they are included in another review in press. In these earlier versions, we drew no conclusions on individual effectiveness of different laxatives because of the limited number of evaluations. This is despite constipation being common in palliative care, generating considerable suffering due to the unpleasant physical symptoms and the availability of a wide range of laxatives with known differences in effect in other populations. Objectives To determine the effectiveness and differential efficacy of laxatives used to manage constipation in people receiving palliative care. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library ), MEDLINE, EMBASE, CINAHL and Web of Science (SCI & CPCI‐S) for trials to September 2014. Selection criteria Randomised controlled trials (RCTs) evaluating laxatives for constipation in people receiving palliative care. Data collection and analysis Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity. Main results We identified five studies involving the laxatives lactulose, senna, co‐danthramer, misrakasneham, docusate and magnesium hydroxide with liquid paraffin. Overall, the study findings were at an unclear risk of bias. As all five studies compared different laxatives or combinations of laxatives, it was not possible to perform a meta‐analysis. There was no evidence on whether individual laxatives were more effective than others or caused fewer adverse effects. Authors' conclusions This second update found that laxatives were of similar effectiveness but the evidence remains limited due to insufficient data from a few small RCTs. None of the studies evaluated polyethylene glycol or any intervention given rectally. There is a need for more trials to evaluate the effectiveness of laxatives in palliative care populations. Extrapolating findings on the effectiveness of laxatives evaluated in other populations should proceed with caution. This is because of the differences inherent in people receiving palliative care that may impact, in a likely negative way, on the effect of a laxative. Plain language summary Laxatives for the management of constipation in people receiving palliative care Background People with an incurable illness may receive palliative care, which involves making the person as comfortable as possible by controlling pain and other distressing symptoms. People receiving palliative care commonly experience constipation. This is as a result of the use of medicines (e.g. morphine) for pain control, as well as disease, dietary and mobility factors. There is a wide range of laxatives available. The aim of this review was to determine what we know about the effectiveness of laxatives for the management of constipation in people receiving palliative care. Study characteristics We searched medical databases for clinical trials of the use of laxatives for constipation in people receiving palliative care. Two review authors assessed study quality and extracted data. Key results and quality of evidence We identified five studies involving 370 people. The laxatives evaluated were lactulose, senna, co‐danthramer combined with poloxamer, docusate and magnesium hydroxide combined with liquid paraffin. Misrakasneham was also evaluated; this is a traditional Indian medicine and is used as a laxative, containing castor oil, ghee, milk and 21 types of herbs. There was no evidence on which laxative provided the best treatment. However, the review was limited as the evidence was from only five small trials and patient preference and cost were under evaluated. Further rigorous, independent trials are needed to evaluate the effectiveness of laxatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Candy, B; Jones, L; Larkin, PJ; Vickerstaff, V; Tookman, A; Stone, P", "articleTypes": [], "doi": "10.1002/14651858.CD003448.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "a2e3b286-c987-4904-bb86-10edf0b7f061", "pmid": "", "title": "Nirmatrelvir combined with ritonavir for preventing and treating COVID‐19", "imported": false, "abstract": "Abstract - Background Oral nirmatrelvir/ritonavir (Paxlovid) aims to avoid severe COVID‐19 in asymptomatic people or those with mild symptoms, thereby decreasing hospitalization and death. It remains to be evaluated for which indications and patient populations the drug is suitable. Objectives To assess the efficacy and safety of nirmatrelvir/ritonavir plus standard of care (SoC) compared to SoC with or without placebo, or any other intervention for treating COVID‐19 or preventing SARS‐CoV‐2 infection. To explore equity aspects in subgroup analyses. To keep up to date with the evolving evidence base using a living systematic review (LSR) approach and make new relevant studies available to readers in‐between publication of review updates. Search methods We searched the Cochrane COVID‐19 Study Register, Scopus, and World Health Organization COVID‐19 Research Database, identifying completed and ongoing studies without language restrictions and incorporating studies up to 15 May 2023. This is a LSR. We conduct update searches every two months and make them publicly available on the open science framework (OSF) platform. Selection criteria We included randomized controlled trials (RCTs) comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo, or any other intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. We screened all studies for research integrity. Studies were ineligible if they had been retracted, or if they were not prospectively registered including appropriate ethics approval. Data collection and analysis We followed standard Cochrane methodology and used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the following outcomes: 1. to treat outpatients with mild COVID‐19; 2. to treat inpatients with moderate to severe COVID‐19: mortality, clinical worsening or improvement, quality of life, (serious) adverse events, and viral clearance; 3. to prevent SARS‐CoV‐2 infection in postexposure prophylaxis (PEP); and 4. pre‐exposure prophylaxis (PrEP) scenarios: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, mortality, admission to hospital, quality of life, and (serious) adverse events. We explored inequity by subgroup analysis for elderly people, socially‐disadvantaged people with comorbidities, populations from low‐income countries and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. Main results As of 15 May 2023, we included two RCTs with 2510 participants with mild and mild to moderate symptomatic COVID‐19 in outpatient and inpatient settings comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo. All trial participants were without previous confirmed SARS‐CoV‐2 infection and at high risk for progression to severe disease. Randomization coincided with the Delta wave for outpatients and Omicron wave for inpatients. Outpatient trial participants and 73% of inpatients were unvaccinated. Symptom onset in outpatients was no more than five days before randomisation and prior or concomitant therapies including medications highly dependent on CYP3A4 were not allowed. We excluded two studies due to concerns with research integrity. We identified 13 ongoing studies. Three studies are currently awaiting classification. Nirmatrelvir/ritonavir for treating people with asymptomatic or mild COVID‐19 in outpatient settings Nirmatrelvir/ritonavir plus SoC compared to SoC plus placebo may reduce all‐cause mortality at 28 days (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.68; 1 study, 2224 participants; low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.13, 95% CI 0.07 to 0.27; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC may reduce serious adverse events during the study period compared to SoC plus placebo (RR 0.24, 95% CI 0.15 to 0.41; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably has little or no effect on treatment‐emergent adverse events (RR 0.95, 95% CI 0.82 to 1.10; 1 study, 2224 participants; moderate‐certainty evidence), and probably increases treatment‐related adverse events such as dysgeusia and diarrhoea during the study period compared to SoC plus placebo (RR 2.06, 95% CI 1.44 to 2.95; 1 study, 2224 participants; moderate‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably decreases discontinuation of study drug due to adverse events compared to SoC plus placebo (RR 0.49, 95% CI 0.30 to 0.80; 1 study, 2224 participants; moderate‐certainty evidence). No studies reported improvement of clinical status, quality of life, or viral clearance. Nirmatrelvir/ritonavir for treating people with moderate to severe COVID‐19 in inpatient settings We are uncertain whether nirmatrelvir/ritonavir plus SoC compared to SoC reduces all‐cause mortality at 28 days (RR 0.63, 95% CI 0.21 to 1.86; 1 study, 264 participants; very low‐certainty evidence), or increases viral clearance at seven days (RR 1.06, 95% CI 0.71 to 1.58; 1 study, 264 participants; very low‐certainty evidence) and 14 days (RR 1.05, 95% CI 0.92 to 1.20; 1 study, 264 participants; very low‐certainty evidence). No studies reported improvement or worsening of clinical status and quality of life. We did not include data for safety outcomes due to insufficient and inconsistent information. Subgroup analyses for equity For outpatients, the outcome 'admission to hospital or death' was investigated for equity regarding age (less than 65 years versus 65 years or greater) and ethnicity. There were no subgroup differences for age or ethnicity. For inpatients, the outcome 'all‐cause mortality' was investigated for equity regarding age (65 years or less versus greater than 65 years). There was no difference between subgroups of age. No further equity‐related subgroups were reported, and no subgroups were reported for other outcomes. Nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection (PrEP and PEP) No studies available. Authors' conclusions Low‐certainty evidence suggests nirmatrelvir/ritonavir reduces the risk of all‐cause mortality and hospital admission or death in high‐risk, unvaccinated COVID‐19 outpatients infected with the Delta variant of SARS‐CoV‐2. There is low‐ to moderate‐certainty evidence of the safety of nirmatrelvir/ritonavir. Very low‐certainty evidence exists regarding the effects of nirmatrelvir/ritonavir on all‐cause mortality and viral clearance in mildly to moderately affected, mostly unvaccinated COVID‐19 inpatients infected with the Omicron variant of SARS‐CoV‐2. Insufficient and inconsistent information prevents the assessment of safety outcomes. No reliable differences in effect size and direction were found regarding equity aspects. There is no available evidence supporting the use of nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection. We are continually updating our search and making search results available on the OSF platform. Plain language summary Is the combination of nirmatrelvir plus ritonavir effective for treating or preventing COVID‐19? Key messages Nirmatrelvir/ritonavir (Paxlovid) is evaluated for the treatment of coronavirus disease 2019 (COVID‐19). Nirmatrelvir/ritonavir may lead to fewer deaths and improve patient condition, as assessed by need for hospitalization or death within 28 days for unvaccinated outpatients at increased risk for disease progression receiving treatment within five days of symptom onset. We are very uncertain about the effectiveness of nirmatrelvir/ritonavir in inpatients. We excluded two studies due to concerns with research integrity. We found 13 ongoing studies. What is nirmatrelvir/ritonavir? The combination of nirmatrelvir with ritonavir is a new medicine developed to treat infection with the SARS‐CoV‐2 virus and aims to avoid severe COVID‐19 in people without symptoms, or those with mild symptoms. Ritonavir increases the effectiveness of nirmatrelvir but it can interact with many other medicines, which can increase side effects. What did we want to find out? We wanted to know if nirmatrelvir/ritonavir reduces death, illness, and length of infection in people with COVID‐19, or if it is useful in prevention of the disease. We included studies comparing the medicine with placebo (dummy treatment), no treatment, usual care, or any other treatments for COVID‐19. We addressed equity and wanted to know whether there are certain groups of people for which nirmatrelvir/ritonavir works best or is less effective. We looked at elderly people, socially disadvantaged people with other illnesses (comorbidities), people from low‐income and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. We evaluated the effects of nirmatrelvir/ritonavir in people with COVID‐19 regarding: – people dying; – whether COVID‐19 symptoms got better or worse; – quality of life; – unwanted effects of the medicine; – virus elimination. For prevention, we sought the effect on preventing COVID‐19 and SARS‐CoV‐2 infection. What did we do? We searched for randomized controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that investigated nirmatrelvir/ritonavir to prevent or treat COVID‐19. People receiving nirmatrelvir/ritonavir as treatment had to have laboratory‐confirmed COVID‐19 and be treated in hospital or as outpatients. People receiving nirmatrelvir/ritonavir to prevent an infection had to have a high risk of contracting the disease or had to have had a high‐risk contact with a person with confirmed COVID‐19. We summarized the results of the studies and rated our confidence in the evidence, based on common criteria as to how reliable the evidence was. We examined differences with respect to age, level of comorbidity, country according to the World Bank country classification by income level, and ethnicity. What did we find? We found two studies with 2510 participants that investigated nirmatrelvir/ritonavir compared to placebo or standard of care for the treatment of COVID‐19 in people without previous confirmed SARS‐CoV‐2 infection and at increased risk for progression to severe disease due to a comorbidity or risk factor such as current smoking. Included outpatients were enrolled during the Delta wave, unvaccinated, and had a symptom onset of up to five days before starting treatment. Included inpatients were enrolled during the Omicron wave, mostly unvaccinated, and mildly to moderately affected. We found 13 ongoing studies that have not yet been completed, and three studies are currently awaiting classification. Main results Treating outpatients with COVID‐19 For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir may: – lead to fewer deaths; – improve patients' condition assessed by need for admission to hospital or death within 28 days; – reduce serious unwanted events. For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir probably: – has little effect on any unwanted events; – increases any treatment‐related unwanted events (mostly taste disturbance and diarrhoea); – decreases discontinuation of study medicine due to unwanted events. Equity aspects Most study participants were younger than 65 years and of white ethnicity. There was no difference in effectiveness between younger and older participants and participants from different ethnic groups. No subgroups were reported for different levels of comorbidity and World Bank country classification by income level. Treating inpatients with COVID‐19 We are uncertain whether, for the specific population of mildly to moderately affected, high‐risk patients, nirmatrelvir/ritonavir: – leads to fewer deaths; and – increases virus elimination Equity aspects Most study participants were older than 65 years. There was no difference in effectiveness between younger and older participants. No subgroups were reported for different levels of comorbidity, ethnicity, and World Bank country classification by income level. No subgroups were reported for other outcomes. What are the limitations of the evidence? Our confidence in the evidence is low to moderate for outpatients and very low for inpatients. The studies did not report everything we were interested in, such as quality of life and symptom resolution, and had a highly specific population of people at high risk of progression to severe COVID‐19. How up to date is this evidence? The evidence is up to date to 15 May 2023. According to this review's living approach, we will update our search every two months. We are making search results and new relevant studies publicly available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Reis, S; Metzendorf, M-I; Kuehn, R; Popp, M; Gagyor, I; Kranke, P; Meybohm, P; Skoetz, N; Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015395.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "a2fe25ea-5139-442a-a260-79b3eeae98f8", "pmid": "", "title": "Oral antifungal medication for toenail onychomycosis", "imported": false, "abstract": "Abstract - Background Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence‐based choice for treatment. Objectives To assess the effects of oral antifungal treatments for toenail onychomycosis. Search methods We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies. Selection criteria RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years. We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high‐risk domain was 'blinding of personnel and participants'. We found high‐quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine‐treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate‐quality evidence). There was high‐quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu‐like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate‐quality evidence). Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low‐quality evidence). There is moderate‐quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate‐quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low‐quality evidence). Common adverse events in both groups included headache, viral infection, and nausea. Moderate‐quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate‐quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin‐treated participants) along with nausea and vomiting (in azole‐treated participants). Very low‐quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants). There is low‐quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low‐quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin‐treated participants) as well as taste loss and nausea (in terbinafine‐treated participants). No studies addressed recurrence rate for this comparison. No study addressed quality of life. Authors' conclusions We found high‐quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate‐quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate‐quality evidence). Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate‐quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low‐quality evidence). Only four comparisons assessed recurrence rate: low‐quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them. Only a limited number of studies reported adverse events, and the severity of the events was not taken into account. Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding. Plain language summary What is the best medication for a fungal infection of the toenail? Review question We aimed to find out which medications, taken by mouth for at least six weeks, are the most effective at curing fungal infection of the toenail, a condition that is known as onychomycosis, in people of any age. We compared these medications to each other or placebo (an inactive drug or treatment). Background Fungal infection of the toenails is a common condition, which has a low risk of complications and associated health risks. However, for those severely affected, it might affect normal daily activities. Medication taken by mouth appears to cure the condition more quickly and effectively than topical treatment. There are three main antifungal medications: griseofulvin, different medications in the azole group (itraconazole, fluconazole, albaconazole, posaconazole, ravuconazole), and terbinafine. We wanted to assess the following two main outcomes. 1. Does the nail look normal after treatment (clinical cure)?
 2. Is the nail free from fungus at a microscopic level (mycological cure)? Study characteristics We identified 48 studies with 10,200 participants of both sexes. The average age of the participants across studies ranged from 36 to 68; most studies included participants aged 18 and over. Our included studies compared the three main groups of medication against each other or to placebo. Most studies took place in outpatient dermatology settings in the USA and Europe. The participants mainly had fungal infection under the toenails. A small number of studies included a specific group of participants, such as those with diabetes. All but one study looked at fungal infections caused by dermatophyte, which are fungi that digest keratin. Study duration ranged from 4 months to 2 years, with most lasting 12 to 15 months. Key results The evidence is current to October 2016. We found high‐quality evidence that compared with placebo, both terbinafine and azoles are more effective for achieving a normal‐looking nail and curing the toenail infection (i.e. looking at the microscopic level to see if the fungus is gone). Terbinafine or azoles may also prevent the infection reoccurring more than placebo (low‐quality evidence). There was probably no significant difference in the risk of adverse events reported when comparing either azoles or terbinafine with placebo (moderate‐quality evidence). The most common adverse events amongst terbinafine‐treated and azole‐treated participants included stomach problems and headache. We found that compared to azoles, terbinafine was probably more effective in curing the nails in terms of appearance and infection (moderate‐quality evidence). The risk of side effects was probably the same for both treatments (moderate‐quality evidence), and the most common adverse events in both groups were headache, viral infection, and rash. There may be no difference in recurrence rate (low‐quality evidence). A third type of treatment, griseofulvin, was probably as effective as the azole medications in curing the nails in terms of appearance and infection (moderate‐quality evidence), but it may be less effective than terbinafine when assessing the same outcomes (low‐quality evidence). Griseofulvin caused more side effects than the other two treatments, although the quality of the evidence was moderate (compared to azole) to low (compared to terbinafine). The most common adverse events in both groups included stomach problems and feeling sick. We are uncertain about the effect of griseofulvin compared to azoles on the rate of recurrence, and studies comparing terbinafine and griseofulvin did not assess this outcome. Quality of the evidence The evidence for the primary outcomes of cure (in terms of appearance and infection) was high to moderate quality except for the comparisons of griseofulvin versus terbinafine (low quality) and combination terbinafine plus azole versus terbinafine alone (very low quality). The evidence quality for side effects was mainly moderate, but two comparisons had low evidence for this outcome. Not all comparisons measured recurrence rate, and the available evidence was based on low‐ to very low‐quality evidence. No studies reported on participants' quality of life. Many studies had problems in the study design: it was often unclear how they decided which participants would receive which treatment or ensured that participants weren't aware of the treatment allocation. Many studies also did not use a placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kreijkamp‐Kaspers, S; Hawke, K; Guo, L; Kerin, G; Bell‐Syer, SEM; Magin, P; Bell‐Syer, SV; van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD010031.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "a3131074-2f6a-4cd1-89ab-bc3091b1dec8", "pmid": "", "title": "Macrolide antibiotics (including azithromycin) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a life‐limiting genetic condition, affecting over 90,000 people worldwide. CF affects several organs in the body, but airway damage has the most profound impact on quality of life (QoL) and survival. Causes of lower airway infection in people with CF are, most notably, Staphylococcus aureus in the early course of the disease and Pseudomonas aeruginosa at a later stage. Macrolide antibiotics, e.g. azithromycin and clarithromycin, are usually taken orally, have a broad spectrum of action against gram‐positive (e.g. S aureus ) and some gram‐negative bacteria (e.g. Haemophilus influenzae ), and may have a modifying role in diseases involving airway infection and inflammation such as CF. They are well‐tolerated and relatively inexpensive, but widespread use has resulted in the emergence of resistant bacteria. This is an updated review. Objectives To assess the potential effects of macrolide antibiotics on clinical status in terms of benefit and harm in people with CF. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals, and abstract books of conference proceedings. We last searched the Group's Cystic Fibrosis Trials Register on 2 November 2022. We last searched the trial registries WHO ICTRP and clinicaltrials.gov on 9 November 2022. We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow‐up data, where possible. Selection criteria We included randomised controlled trials of macrolide antibiotics in adults and children with CF. We compared them to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose or type of administration. Data collection and analysis Two authors independently extracted data and assessed risk of bias. We assessed the certainty of evidence using GRADE. Main results We included 14 studies (1467 participants) lasting 28 days to 36 months. All the studies assessed azithromycin: 11 compared oral azithromycin to placebo (1167 participants); one compared a high dose to a low dose (47 participants); one compared nebulised to oral azithromycin (45 participants); and one looked at weekly versus daily dose (208 participants). Oral azithromycin versus placebo There is a slight improvement in forced expiratory volume (FEV 1 % predicted) in one second in the azithromycin group at up to six months compared to placebo (mean difference (MD) 3.97, 95% confidence interval (CI) 1.74 to 6.19; high‐certainty evidence), although there is probably no difference at three months, (MD 2.70%, 95% CI ‐0.12 to 5.52), or 12 months (MD ‐0.13, 95% CI ‐4.96 to 4.70). Participants in the azithromycin group are probably at a decreased risk of pulmonary exacerbation with a longer time to exacerbation (hazard ratio (HR) 0.61, 95% CI 0.50 to 0.75; moderate‐certainty evidence). Mild side effects were common, but there was no difference between groups (moderate‐certainty evidence). There is no difference in hospital admissions at six months (odds ratio (OR) 0.61, 95% CI 0.36 to 1.04; high‐certainty evidence), or in new acquisition of P aeruginosa at 12 months (HR 1.00, 95% CI 0.64 to 1.55; moderate‐certainty evidence). High‐dose versus low‐dose azithromycin We are uncertain whether there is any difference in FEV 1 % predicted at six months between the two groups (no data available) or in the rate of exacerbations per child per month (MD ‐0.05 (95% CI ‐0.20 to 0.10)); very low‐certainty evidence for both outcomes. Only children were included in the study and the study did not report on any of our other clinically important outcomes. Nebulised azithromycin versus oral azithromycin We were unable to include any of the data into our analyses and have reported findings directly from the paper; we graded all evidence as being of very low certainty. The authors reported that there was a greater mean change in FEV 1 % predicted at one month in the nebulised azithromycin group (P < 0.001). We are uncertain whether there was a change in P aeruginosa count. Weekly azithromycin versus daily azithromycin There is probably a lower mean change in FEV 1 % predicted at six months in the weekly group compared to the daily group (MD ‐0.70, 95% CI ‐0.95 to ‐0.45) and probably also a longer period of time until first exacerbation in the weekly group (MD 17.30 days, 95% CI 4.32 days to 30.28 days). Gastrointestinal side effects are probably more common in the weekly group and there is likely no difference in admissions to hospital or QoL. We graded all evidence as moderate certainty. Authors' conclusions Azithromycin therapy is associated with a small but consistent improvement in respiratory function, a decreased risk of exacerbation and longer time to exacerbation at six months; but evidence for treatment efficacy beyond six months remains limited. Azithromycin appears to have a good safety profile (although a weekly dose was associated with more gastrointestinal side effects, which makes it less acceptable for long‐term therapy), with a relatively minimal treatment burden for people with CF, and it is inexpensive. A wider concern may be the emergence of macrolide resistance reported in the most recent study which, combined with the lack of long‐term data, means we do not feel that the current evidence is strong enough to support azithromycin therapy for all people with CF. Future research should report over longer time frames using validated tools and consistent reporting, to allow for easier synthesis of data. In particular, future trials should report important adverse events such as hearing impairment or liver disease. More data on the effects of azithromycin given in different ways and reporting on our primary outcomes would benefit decision‐making on whether and how to give macrolide antibiotics. Finally, it is important to assess azithromycin therapy for people with CF who are established on the relatively new cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies which correct the underlying molecular defect associated with CF (none of the trials included in the review are relevant to this population). Plain language summary Treatment with macrolide antibiotics (including azithromycin) for people with cystic fibrosis Review question What are the effects of macrolide antibiotics in people with cystic fibrosis (CF) and infection of their airways? Key messages ‐ People with CF are more prone to chest infections caused by bacteria that can be hard to treat. ‐ Macrolide antibiotics (such as azithromycin and clarithromycin) may lessen the effects of bacteria. ‐ One macrolide antibiotic, azithromycin, can improve lung function at six months compared to a placebo (treatment with no active ingredient) and may reduce the risk of getting a flare‐up of lung infection. We are not sure whether a higher dose of azithromycin is any better than a lower dose, or if azithromycin when inhaled is any better than azithromycin when swallowed (oral). Oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. ‐ Current evidence does not support longer‐term use of azithromycin for all people with CF. Introduction People with CF suffer from infections in their airways, often caused by the bug Pseudomonas aeruginosa , which is resistant to nearly all antibiotics that can be swallowed (oral). Macrolide antibiotics, e.g. azithromycin and clarithromycin, have no direct killing effect on Pseudomonas aeruginosa , but they may reduce the activity of these bacteria. What did we want to find out? We wanted to discover whether the use of macrolide antibiotics (usually taken orally) affected the health of people with CF and whether these drugs have any side effects. What did we do? We searched for studiesthat looked at the effects of macrolide antibiotics in children and adults with CF and summarised the evidence. What did we find? We found 14 studies, which put the total of 1467 children and adults into different treatment groups at random, which we included in this review. Eleven studies compared azithromycin to placebo, one compared two different doses of azithromycin (high versus low dose), one compared inhaled azithromycin to oral azithromycin, and one compared oral azithromycin once a week to once a day. Main results We found that there was a slight improvement in lung function in people that were given azithromycin compared to a placebo at six months and also that the risk of a flare‐up of infection was lower. The risk of side effects (such as vomiting, diarrhoea and headache) was similar in both groups, as was the chance of a new infection with Pseudomonas aeruginosa. In terms of lung function and flare‐up of infection, we were unsure whether a higher dose of azithromycin is better than a lower dose (but only one study in children examined dose), or whether inhaled azithromycin is better than oral azithromycin. Taking oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. What are the limitations of the evidence? We were unable to combine all the study results because they were measured in different ways and at different time points; future trials should address this issue. Also, now that many people with CF are being treated with the new modulator therapies (e.g. elexacaftor‐tezacaftor‐ivacaftor), it is important to assess how macrolide antibiotics affect the health of these people. In the studies we found for this review, none of the people taking part were being treated with modulator therapies. We are able to report the results of the studies that compared azithromycin to placebo with certainty as the studies were well conducted and included a larger number of participants. The evidence from the studies comparing high and low doses or nebulised and oral azithromycin was much less certain because the studies were small and there was risk of bias in the way they were carried out. We were moderately certain of the results of the study comparing weekly azithromycin to daily azithromycin. How up to date is this evidence? The studies we have reported are the most up to date we could find. We last searched for studies in November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Southern, KW, Solis-Moya, A, Kurz, D, Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD002203.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.780Z" }, { "id": "a32252d0-bfe1-43cf-a19b-6618b41c35be", "pmid": "", "title": "Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, rhinorrhoea, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. The use of topical (intranasal) corticosteroids has been widely advocated for the treatment of chronic rhinosinusitis given the belief that inflammation is a major component of this condition. Objectives To assess the effects of intranasal corticosteroids in people with chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) with a follow‐up period of at least three months comparing intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) against placebo or no treatment in patients with chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity and the commonest adverse event ‐ epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation or other systemic adverse events. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 18 RCTs with a total of 2738 participants. Fourteen studies had participants with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. Intranasal corticosteroids versus placebo or no intervention Only one study (20 adult participants without polyps) measured our primary outcome disease‐specific HRQL using the Rhinosinusitis Outcome Measures‐31 (RSOM‐31). They reported no significant difference (numerical data not available) ( very low quality evidence). Our second primary outcome, disease severity , was measured using the Chronic Sinusitis Survey in a second study (134 participants without polyps), which found no important difference (mean difference (MD) 2.84, 95% confidence interval (CI) ‐5.02 to 10.70; scale 0 to 100). Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group (RR 2.78, 95% CI 1.76 to 4.40; 109 participants). The quality of the evidence was low . Six studies provided data on at least two of the individual symptoms used in the EPOS 2012 criteria to define chronic rhinosinusitis (nasal blockage, rhinorrhoea, loss of sense of smell and facial pain/pressure). When all four symptoms in the EPOS criteria were available on a scale of 0 to 3 (higher = more severe symptoms), the average MD in change from baseline was ‐0.26 (95% CI ‐0.37 to ‐0.15; 243 participants; two studies; low quality evidence). Although there were more studies and participants when only nasal blockage and rhinorrhoea were considered (MD ‐0.31, 95% CI ‐0.38 to ‐0.24; 1702 participants; six studies), the MD was almost identical to when loss of sense of smell was also considered (1345 participants, four studies; moderate quality evidence). When considering the results for the individual symptoms, benefit was shown in the intranasal corticosteroids group. The effect size was larger for nasal blockage (MD ‐0.40, 95% CI ‐0.52 to ‐0.29; 1702 participants; six studies) than for rhinorrhoea (MD ‐0.25, 95% CI ‐0.33 to ‐0.17; 1702 participants; six studies) or loss of sense of smell (MD ‐0.19, 95% CI ‐0.28 to ‐0.11; 1345 participants; four studies). There was heterogeneity in the analysis for facial pain/pressure (MD ‐0.27, 95% CI ‐0.56 to 0.02; 243 participants; two studies). The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure. There was an increased risk of epistaxis with intranasal corticosteroids (risk ratio (RR) 2.74, 95% CI 1.88 to 4.00; 2508 participants; 13 studies; high quality evidence). Considering our secondary outcome, general HRQL, one study (134 participants without polyps) measured this using the SF‐36 and reported a statistically significant benefit only on the general health subscale. The quality of the evidence was very low . It is unclear whether there is a difference in the risk of local irritation (RR 0.94, 95% CI 0.53 to 1.64; 2124 participants; 11 studies) ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis or stunted growth (children). Other comparisons We identified no other studies that compared intranasal corticosteroids plus co‐intervention A versus placebo plus co‐intervention A. Authors' conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life ( very low quality evidence). For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of epistaxis is increased ( high quality evidence), but these data included all levels of severity; small streaks of blood may not be a major concern for patients. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) . Plain language summary Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of intranasal (in the nose) steroids given to people with chronic rhinosinusitis. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose (rhinorrhoea), pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation in order to improve patient symptoms. Study characteristics We included 18 randomised controlled trials (RCTs) with a total of 2738 participants in this review. Most studies were relatively small, with as few as 9 or 10 patients per intervention arm. The largest study had 748 patients in total. Most were conducted in tertiary referral centres in northern Europe, the US and Canada. Fourteen studies only included participants with chronic rhinosinusitis with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Key results and quality of the evidence One study (20 participants) reported no statistically significant difference in disease‐specific health‐related quality of life. Another measured general health‐related quality of life and reported a statistically significant benefit only on a subscale for general health. Both studies recruited participants with chronic rhinosinusitis without nasal polyps. The quality of the evidence was very low (we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect). Disease severity was measured in one study (chronic rhinosinusitis without nasal polyps, 134 participants), which found no important difference. Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group. The quality of the evidence was low (our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect). When each type of symptom was measured separately (nasal blockage, rhinorrhoea, loss of sense of smell, facial pain/pressure), benefit was shown in the intranasal corticosteroids group. The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure (moderate quality evidence means we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different). There was an increased risk of nosebleeds (epistaxis) with intranasal corticosteroids ( high quality evidence). However, it was unclear whether there was a difference in the risk of local (nose or throat) irritation ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis (fragile bones) or stunted growth (in children). Conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life and the quality of this evidence is very low . For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of nosebleeds is increased ( high quality evidence), but this included all levels of severity; for some patients small streaks of blood may not be a major concern. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) .", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chong, LY, Head, K, Hopkins, C, Philpott, C, Schilder, AGM, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.118Z" }, { "id": "a324a510-dfee-48db-bb28-2e12a1e6b4ee", "pmid": "", "title": "Omega‐3 fatty acid supplementation for depression in children and adolescents", "imported": false, "abstract": "Abstract - Background Mental health disorders including major depressive disorder (MDD) are well recognized as major contributors to the global burden of disease among adolescents. The prevalence of adolescent depression is estimated to have increased by at least 25% during the COVID‐19 pandemic, compounding the already challenging problem of insufficient mental health service and service accessibility that existed prepandemic. Omega‐3 polyunsaturated fatty acid (PUFA) supplementation is currently recommended as a preventive treatment for depression in high‐risk adults as well as a second‐line monotherapy for adults with mild to moderate MDD, and adjunctive to antidepressants for adults with moderate to severe MDD. The benefits of omega‐3 PUFA intake on depressive illness have been hypothesized to occur as a result of their effect on neurotransmission, maintenance of membrane fluidity, and anti‐inflammatory action. A comprehensive synthesis and quantification of the existing evidence on omega‐3 PUFA's efficacy in treating depression among children and adolescents is essential for clinicians to provide informed guidance to young people and their families, especially considering the absence of current guidelines for this age group. Objectives Primary objective To determine the impact of omega‐3 PUFA supplementation versus a comparator (e.g. placebo, wait list controls, no treatment/supplementation, or standard care) on clinician‐diagnosed depression or self‐reported depression symptoms in children and adolescents. Secondary objectives To estimate the size of the effect of omega‐3 PUFAs on depression symptoms. To estimate the effect of each type of omega‐3 PUFA (EPA or DHA), compared with placebo, on depression. To determine if the effect is modified by dosage, format (capsule or liquid), sex, or age. To determine compliance and attrition for omega‐3 PUFAs as an intervention for depression in children and adolescents. To determine the safety of omega‐3 PUFAs as an intervention for depression in children and adolescents. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases, reference lists of included studies, grey literature, and relevant reviews. The latest search date was 18 May 2023. Selection criteria We included randomized controlled trials (RCTs) involving males and females aged 19 years or younger with diagnosed depression comparing omega‐3 PUFA supplementation to placebo, wait list control, no treatment/supplementation, or standard care. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were self‐reported depression symptoms and clinically diagnosed resolution of depression. Our secondary outcomes were attrition, adverse effects, and compliance with the intervention. We used GRADE to assess the certainty of evidence for key outcomes. Main results We included five trials with 228 participants in our meta‐analysis. All trials used a placebo comparator; intervention duration ranged from 10 to 16 weeks (median: 12 weeks). Omega‐3 PUFA supplementation compared to placebo may reduce self‐reported depression symptoms, but the evidence is very uncertain (standardized mean difference [SMD] −0.34, 95% confidence interval [CI] −0.85 to 0.17; lower SMD means greater improvement in depression due to omega‐3 PUFA; 5 trials, 185 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may have little to no effect on remission of depression symptoms compared to placebo, but the evidence is very uncertain (omega‐3 PUFA versus placebo: 50% versus 48%; odds ratio [OR] 1.11, 95% CI 0.45 to 2.75; 4 trials, 127 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in attrition (dropouts) compared to placebo (omega‐3 PUFA versus placebo: 18% versus 19%; OR 0.94, 95% CI 0.46 to 1.90; 5 trials, 228 participants; low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in adverse effects, with one study reporting more muscle cramps in the fish oil group (13/27 participants) compared to the placebo group (6/29 participants); one study reported more frequent defecation in the omega‐3 group (1/29 participants) and one study identified mild skin rash and unusual/manic behavior in the placebo group (2/27 participants). None of the included studies reported serious adverse effects. Authors' conclusions Based on five small studies, omega‐3 PUFA supplementation may reduce self‐reported depression symptoms, but the evidence is very uncertain. Omega‐3 PUFA supplementation may have little to no effect on depression remission compared to placebo, but the evidence is very uncertain. Omega‐3 PUFA supplementation may result in little to no difference in attrition or adverse effects. The studies observed no serious adverse effects. This review highlights early‐stage research on omega‐3 PUFA and depression in young people. The evidence on the effects of omega‐3 PUFA supplementation in improving self‐reported depression symptoms or achieving depression remission in children and adolescents is very uncertain. While no harms are evident, more data are needed to confirm potential risks. Addressing current limitations in the evidence base through the design and conduct of methodologically rigorous studies — larger sample sizes, varied dosages, eicosapentaenoic acid/docosahexaenoic acid ratios, treatment durations, and safety profiles — is crucial to advance our understanding of the role of omega‐3 PUFA supplementation for depression in children and adolescents. Plain language summary Is omega‐3 polyunsaturated fatty acid supplementation better than a placebo for treating depression among children and adolescents? Key messages – Due to a lack of robust evidence, the benefits and unwanted effects of omega‐3 polyunsaturated fatty acids (which are important fats that you must obtain from your diet) supplementation for treating depression among children and adolescents are unclear. – Larger, well‐designed studies are needed to give better estimates of the potential benefits and harms of omega‐3 polyunsaturated fatty acid supplementation for child and adolescent depression. Why is it important to find treatments for children and adolescents with depression? People with depression have a low mood or lose pleasure or interest in usual activities. It is a long‐lasting (chronic) disorder that is both serious and recurrent (it can return after periods of feeling well). It often begins during childhood and adolescence, affecting up to eight in every 100 children. Unfortunately, response to current treatments for depression in children and adolescents is poor, and relieving symptoms (remission) can be challenging. In recent studies, supplements of omega‐3 polyunsaturated fatty acids have shown promise as a potential treatment for depression in adults. Our body cannot make these beneficial fats, but they are naturally present in oily fish, marine sources, and certain nuts and seeds. They can also be given as daily supplements in capsule or liquid forms (for example, as cod liver oil capsules). What did we want to find out? We wanted to find out: – if omega‐3 polyunsaturated fatty acids supplementation works to decrease symptoms of depression in children and adolescents; and – if omega‐3 polyunsaturated fatty acids supplementation helps children and adolescents achieve remission from depression. We also wanted to know if omega‐3 polyunsaturated fatty acids supplementation can cause any unwanted effects. What did we do? We searched for studies in which children and adolescents were assigned randomly to two or more treatment groups that compared omega‐3 polyunsaturated fatty acids supplementation with a placebo (pretend treatment with the same appearance), on a waiting list, no treatment/supplementation, or usual care. This is the best way to ensure that groups of people are similar and that investigators do not know who is in which group. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found five studies that involved 228 children and adolescents ranging from 10 to 16 years of age with depression. The largest study included 60 people, and the smallest study included 28 people. Three studies were conducted in the USA, one in Israel, and one in Slovakia. Four studies lasted for around 12 weeks and one study lasted for 16 weeks. We found that omega‐3 polyunsaturated fatty acids supplementation may reduce self‐reported depression symptoms, but the results are very uncertain. If omega‐3 PUFA supplements and placebos were given to a group of 100 children and adolescents with depression, then 50 children receiving omega‐3 polyunsaturated fatty acids would achieve remission and 48 receiving the placebo would achieve remission. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results, and the studies were very small. To date, there is insufficient evidence to determine if omega‐3 polyunsaturated fatty acids supplementation improves depression for children and adolescents. How up to date is this evidence? The evidence is up to date to 18 May 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Campisi, SC; Zasowski, C; Bradley-Ridout, G; Schumacher, A; Szatmari, P; Korczak, D", "articleTypes": [], "doi": "10.1002/14651858.CD014803.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "a33252d7-47bf-4112-b40e-de71827b20c3", "pmid": "", "title": "Probiotics for the prevention of Clostridioides difficile‐associated diarrhea in adults and children", "imported": false, "abstract": "Abstract - Rationale Antibiotics can disturb gastrointestinal microbiota, which may lead to reduced resistance to pathogens such as Clostridioides difficile . Probiotics are live microbial preparations that, when administered in adequate amounts, may confer a health benefit to the host, and are a potential C difficile infection prevention strategy. Objectives To assess the benefits and harms of probiotics for preventing C difficile ‐associated diarrhea (CDAD) in adults and children receiving an antibiotic for any reason. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, and Ovid Embase from 18 March 2017 (search date of the previous version of the review) to 3 March 2025. Eligibility criteria We included randomized controlled trials with a placebo, alternative prophylaxis, or no‐treatment control investigating probiotics (any strain or dose) for the prevention of CDAD in adults and children receiving an antibiotic for any reason. Outcomes The critical outcome was incidence of CDAD. Important outcomes included detection of C difficile in stool (i.e. colonization in absence of symptoms), adverse events, antibiotic‐associated diarrhea (AAD), and length of hospital stay. Risk of bias Two review authors independently assessed risk of bias using Cochrane's RoB 1 tool. Synthesis methods We pooled dichotomous outcomes (e.g . incidence of CDAD) using a random‐effects complete‐case model to calculate the risk ratio (RR) and absolute risk reduction (ARR) and corresponding 95% confidence interval (95% CI). We pooled continuous outcomes (e.g. length of hospital stay) using a random‐effects model to calculate the mean difference (MD) and corresponding 95% CI. We conducted sensitivity analyses to explore the impact of missing outcome data on benefits and harms outcomes. To investigate heterogeneity, we conducted a priori subgroup analyses on risk of bias, probiotic dose, probiotic species, adults versus children, inpatients versus outpatients, and the event rate in the control group for developing CDAD (low 0% to 2%; moderate 3% to 5%; high > 5%). The certainty of the evidence for each outcome was independently assessed using the GRADE approach. Included studies Eight new studies (n = 4595) met our inclusion criteria, for a total of 47 included studies (n = 15,260). Although we noted a high risk of bias in individual studies for sequence generation or allocation concealment, this did not impact our findings. Around 30% of studies lacked a published protocol or clinical trial registration, and in some cases there were inconsistencies between the reported methods and published results. We noted authors' affiliation with a probiotic company and financial support received from probiotic companies in 28 studies. Synthesis of results Evidence from 38 trials (13,179 participants) suggests that probiotics may result in a small absolute risk reduction (ARR) of 1.6% (incidence of 1.6% [110/6787] in the probiotic group versus 3.2% [203/6392] in the control group), and a relative risk reduction (RRR) of 50% (RR 0.50, 95% CI 0.38 to 0.64; P < 0.001; low‐certainty evidence) in incidence of CDAD. Twenty‐seven of 38 trials had missing CDAD data, ranging from 2% to 45%. Our complete‐case CDAD results proved robust to sensitivity analyses of plausible and worst‐plausible assumptions regarding missing outcome data. Pooled results from 16 trials (1302 participants) suggest that probiotics may result in a small absolute reduction in C difficile in stool (i.e. colonization in absence of symptoms) (ARR 2.1%; incidence of 14.9% [101/677] in the probiotic group versus 16.2% [101/625] in the control group; RR 0.87, 95% CI 0.68 to 1.11; P = 0.27; low‐certainty evidence). Thirty‐seven studies (11,911 participants) reported on adverse events. Our pooled analysis indicates that probiotics probably result in a small ARR of 1.7% (incidence of 10.9% [669/6148] in the probiotic group versus 12.2% [701/5763] in the control group), and an RRR of 14.0% (RR 0.86, 95% CI 0.72 to 1.01; P = 0.074; moderate‐certainty evidence). The most common adverse events in both the treatment and control groups were abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. Pooled results from 40 studies (13,419 participants) suggest that probiotics may result in a large ARR of 9% (incidence of 23% [1592/6901] in the probiotic group versus 27.4% [1787/6518] in the control group), and an RRR of 33% (RR 0.67, 95% CI 0.57 to 0.78; P < 0.001; low‐certainty evidence) in incidence of AAD. Only seven trials (6553 participants) investigated length of hospital stay. There is likely little to no difference in length of hospital stay between treatment and control groups (MD −0.07, 95% CI −0.35 to 0.21; P = 0.63; moderate‐certainty evidence). We downgraded the certainty of evidence for CDAD and AAD due to the low number of events or publication bias. We observed some variability in CDAD control group event rate (< 2% to > 5%) that may impact the applicability of evidence depending on clinical setting. We downgraded the certainty of evidence for adverse events due to variation between the results of the studies and for hospital stay due to selective reporting. Authors' conclusions The currently available evidence suggests that probiotics may be effective for preventing CDAD, suggesting that for every 65 people taking probiotics, one case of CDAD may be prevented (number needed to treat for an additional beneficial outcome of 65, 95% CI 48 to 97). There are probably fewer adverse events in the probiotic group. The short‐term use of probiotics may have a small absolute benefit, and is likely not associated with adverse effects when used in patient populations receiving systemic antibiotics who are not immunocompromised. Large trials comparing probiotics with placebo in people with a low baseline risk of CDAD are needed. Funding There was no source of funding for this update. Registration The original review was done in 2013 by Johnston and colleagues, for which the protocol was developed. We followed the methods specified in the 2017 review, while modifying the search strategy and risk of bias assessment for selective reporting for this update. Plain language summary What are the benefits and harms of probiotics for preventing Clostridioides difficile‐ associated diarrhea in adults and children receiving antibiotics for any reason? Key messages In people prescribed antibiotics, probiotics may be effective in preventing Clostridioides difficile ‐associated diarrhea (CDAD), and may reduce the risk of antibiotic‐associated diarrhea. Probiotics probably do not result in harm when taken with an antibiotic, with fewer mild to moderate unwanted effects in the group receiving probiotic than the group receiving placebo (dummy treatment) or no treatment. In those taking antibiotics who do not have a weakened immune system, the short‐term use of probiotics may offer a small benefit, and are likely not harmful. However, additional large studies comparing probiotics with placebo in people with a low risk of CDAD are needed. What is Clostridioides difficile ‐associated diarrhea (CDAD) ? Antibiotics are among the most prescribed medications worldwide. Antibiotic treatment may disturb the balance of organisms that normally populate the gut. This can result in a range of symptoms, most notably diarrhea. C difficile is a particularly dangerous organism that may colonize and infect the gut if the microbial balance has been disrupted. The effects of C difficile infection can vary, with some people having no symptoms, and others suffering diarrhea, severe inflammation, enlargement of the colon, or even death. The cost of treatment is expensive, and the financial burden on the medical system is substantial. What are probiotics? Probiotics are live microorganisms (bacteria or yeast) that provide health benefits when given in adequate amounts. They help to prevent potential disturbances to the gut microbial balance that are associated with antibiotic use, and to reduce the risk of growing harmful bacteria. Probiotics can be found in dietary supplements or yogurts and are widely available as capsules sold in health food stores and supermarkets. As 'functional food' or 'good bacteria,' probiotics have been suggested as a means of both preventing and treating CDAD. What did we want to find out? We wanted to know if probiotics prevent CDAD in adults and children receiving antibiotic therapy, and whether probiotics cause any unwanted effects. The researchers searched the medical literature extensively up to 3 March 2025. What did we do? We searched for studies that compared probiotics (any strain or dose) versus placebo (dummy treatment), alternative preventive treatment, or no treatment for the prevention of CDAD in adults and children receiving antibiotic therapy for any reason. We compared and summarized the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included 47 studies with a total of 15,260 adults and children who received antibiotic therapy along with probiotics, assessing CDAD or C difficile growth. Thirty‐eight studies (13,179 participants) assessed the effectiveness of probiotics for preventing CDAD. Our results suggest that probiotics may result in a small reduction in the risk of CDAD compared to placebo or no treatment. Probiotics may result in a small reduction in C difficile growth (16 studies, 1302 participants). Thirty‐seven studies (11,911 participants) looked at unwanted effects. Our results show that probiotics probably result in a small reduction in the risk of developing unwanted effects compared to placebo or no treatment. The most commonly reported unwanted effects included abdominal cramping, nausea, fever, soft stools, flatulence (gas), and taste disturbance, and were more common in the placebo or no‐treatment group. Forty studies (13,419 participants) reported on antibiotic‐associated diarrhea (AAD); probiotics may result in a large reduction in the risk of AAD compared to placebo or no treatment. Seven studies (6553 participants) reporting on length of hospital stay showed likely little to no difference between probiotics and placebo or no treatment. What are the limitations of the evidence? The studies we reviewed used different types of probiotics, but they didn't directly compare one probiotic to another. This lack of direct comparisons makes it harder to determine which probiotic works best. We have moderate to little confidence in the available evidence. Our confidence is limited because in some studies, people who dropped out of the study or were not followed up on resulted in missing information. The two largest studies in our analysis did not show a clear benefit of probiotics for preventing CDAD. How up‐to‐date is this evidence? The evidence is current to 3 March 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Esmaeilinezhad, Z; Ghosh, NR; Walsh, CM; Steen, JP; Burgman, AM; Mertz, D; Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD006095.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "a332b2ec-9e05-47f8-9496-b9dfe1e7d103", "pmid": "", "title": "Ibuprofen for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non‐steroidal anti‐inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period. Objectives 1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled). Search methods We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023. Selection criteria We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules. Data collection and analysis We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence. Main results We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child‐reported pain intensity less than two hours postintervention compared to placebo (SMD −1.12, 95% CI −1.39 to −0.86; 3 studies, 259 children; moderate‐certainty evidence). Ibuprofen may reduce child‐reported pain intensity, two hours to less than 24 hours postintervention (SMD −1.01, 95% CI −1.24 to −0.78; 5 studies, 345 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low‐certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child‐reported pain intensity less than two hours postintervention compared to paracetamol (SMD −0.42, 95% CI −0.82 to −0.02; 2 studies, 100 children; moderate‐certainty evidence). Ibuprofen may slightly reduce child‐reported pain intensity two hours to 24 hours postintervention (SMD −0.21, 95% CI −0.40 to −0.02; 6 studies, 422 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low‐certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) −0.25, 95% CI −0.40 to −0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate‐certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD −0.29, 95% CI −0.53 to −0.04; NNTB 4; 1 study, 59 children; low‐certainty evidence). Authors' conclusions Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs. Plain language summary What are the benefits and harms of ibuprofen for managing pain after an operation in children? Key messages • Ibuprofen probably reduces pain intensity just after an operation up to two hours compared to a placebo (dummy) and compared to paracetamol. The evidence compared to other medicines and in the longer term is unclear or lacking. • Overall, we are uncertain about unwanted effects of ibuprofen, especially serious unwanted effects, since the studies in the review rarely measured them. • Future studies should examine ibuprofen compared to commonly used medications and measure benefits and unwanted effects for both short‐ and long‐term use. Why is pain management important? It is common for children to experience pain after an operation (postoperative pain). Pain causes suffering and agitation, and it can delay recovery. One way to manage pain in children is by using different medicines, for example, ibuprofen. Ibuprofen is a type of medicine called a 'non‐steroidal anti‐inflammatory drug' (NSAID) that can reduce inflammation and pain. What did we want to find out? We wanted to find out if ibuprofen is an effective pain treatment and whether it causes unwanted effects compared to other pain treatments. Also, the most effective way to deliver ibuprofen to children. What did we do? We searched for studies that compared ibuprofen to other treatment options for postoperative pain as well as for studies that looked at different ways to deliver ibuprofen to children. We summarised the results and rated our confidence in the evidence. What did we find? We found 43 studies with 4265 children with postoperative pain. We used data from 3935 children in this review. The largest study included 741 children and the smallest, 23 children. The studies were conducted in many countries around the world; most commonly the USA (12 studies). Children's ages ranged from 2.2 months up to 17 years. Studies used ibuprofen to manage postoperative pain in 10 different types of surgery: mostly dental procedures (21 studies); and ear, nose and throat procedures (11 studies). Main results Compared to placebo (a dummy medicine), ibuprofen probably reduces pain intensity less than two hours after the operation and may reduce pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol , ibuprofen probably reduces pain intensity less than two hours after the operation and probably reduces pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol, ibuprofen probably makes little difference to the chances of bleeding. Compared to morphine , ibuprofen probably leads to a reduction in any reported unwanted effects. Compared to ketorolac , ibuprofen may lead to a reduction in overall harms. No studies reported pain intensity or serious unwanted effects, such as lasting disability or hospitalisation for either morphine or ketorolac. We did not find any studies that compared different routes of administration of ibuprofen. What are the limitations of the evidence? We are uncertain about the overall evidence of ibuprofen use in postoperative pain in children, primarily because there were not enough large studies to be certain about any differences in ibuprofen when compared to other alternatives. In addition, only a few of the studies provided data about important benefits and unwanted effects for children experiencing pain following surgery, especially in the longer term. How up to date is this evidence? The evidence is up‐to‐date to August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Pessano, S; Gloeck, NR; Tancredi, L; Ringsten, M; Hohlfeld, A; Ebrahim, S; Albertella, M; Kredo, T; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "a3554218-9f79-4d5f-b036-13ceff243a03", "pmid": "", "title": "Interventions for treating burning mouth syndrome", "imported": false, "abstract": "Abstract - Background Burning mouth syndrome (BMS) is a term used for oral mucosal pain (burning pain or discomfort in the tongue, lips or entire oral cavity) without identifiable cause. General population prevalence varies from 0.1% to 3.9%. Many BMS patients indicate anxiety, depression, personality disorders and impaired quality of life (QoL). This review updates the previous versions published in 2000 and 2005. Objectives To determine the effectiveness and safety of any intervention versus placebo for symptom relief and changes in QoL, taste, and feeling of dryness in people with BMS. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 31 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 11) in the Cochrane Library (searched 31 December 2015), MEDLINE Ovid (1946 to 31 December 2015), and Embase Ovid (1980 to 31 December 2015). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching the electronic databases Selection criteria Randomised controlled trials (RCTs) comparing any treatment against placebo in people with BMS. The primary outcomes were symptom relief (pain/burning) and change in QoL. Secondary outcomes included change in taste, feeling of dryness, and adverse effects. Data collection and analysis We used standard methodological procedures expected by Cochrane. Outcome data were analysed as short‐term (up to three months) or long‐term (three to six months). Main results We included 23 RCTs (1121 analysed participants; 83% female). Interventions were categorised as: antidepressants and antipsychotics, anticonvulsants, benzodiazepines, cholinergics, dietary supplements, electromagnetic radiation, physical barriers, psychological therapies, and topical treatments. Only one RCT was assessed at low risk of bias overall, four RCTs' risk of bias was unclear, and 18 studies were at high risk of bias. Overall quality of the evidence for effectiveness was very low for all interventions and all outcomes. Twenty‐one RCTs assessed short‐term symptom relief. There is very low‐quality evidence of benefit from electromagnetic radiation (one RCT, 58 participants), topical benzodiazepines (two RCTs, 111 participants), physical barriers (one RCT, 50 participants), and anticonvulsants (one RCT, 100 participants). We found insufficient/contradictory evidence regarding the effectiveness of antidepressants, cholinergics, systemic benzodiazepines, dietary supplements or topical treatments. No RCT assessing psychological therapies evaluated short‐term symptom relief. Four studies assessed long‐term symptom relief. There is very low‐quality evidence of a benefit from psychological therapies (one RCT, 30 participants), capsaicin oral rinse (topical treatment) (one RCT, 18 participants), and topical benzodiazepines (one RCT, 66 participants). We found no evidence of a difference for dietary supplements or lactoperoxidase oral rinse. No studies assessing antidepressants, anticonvulsants, cholinergics, electromagnetic radiation or physical barriers evaluated long‐term symptom relief. Short‐term change in QoL was assessed by seven studies (none long‐term).The quality of evidence was very low. A benefit was found for electromagnetic radiation (one RCT, 58 participants), however findings were inconclusive for antidepressants, benzodiazepines, dietary supplements and physical barriers. Secondary outcomes (change in taste and feeling of dryness) were only assessed short‐term, and the findings for both were also inconclusive. With regard to adverse effects, there is very low‐quality evidence that antidepressants increase dizziness and drowsiness (one RCT, 37 participants), and that alpha lipoic acid increased headache (two RCTs, 118 participants) and gastrointestinal complaints (3 RCTs, 138 participants). We found insufficient/contradictory evidence regarding adverse events for anticonvulsants or benzodiazepines. Adverse events were poorly reported or unreported for cholinergics, electromagnetic radiation, and psychological therapies. No adverse events occurred from physical barriers or topical therapy use. Authors' conclusions Given BMS' potentially disabling nature, the need to identify effective modes of treatment for sufferers is vital. Due to the limited number of clinical trials at low risk of bias, there is insufficient evidence to support or refute the use of any interventions in managing BMS. Further clinical trials, with improved methodology and standardised outcome sets are required in order to establish which treatments are effective. Future studies are encouraged to assess the role of treatments used in other neuropathic pain conditions and psychological therapies in the treatment of BMS. Plain language summary Interventions for treating burning mouth syndrome Review question Which treatments help to relieve symptoms for people with burning mouth syndrome (BMS)? Background BMS is a common painful condition. Symptoms include burning, dryness or uncomfortable sensations in the mouth and changes to taste, with no obvious underlying medical or dental cause. BMS is usually persistent and suffered long term, and can lead to a reduced quality of life (QoL). Currently, scientific research suggests that BMS is caused by underlying damage to the nerves. There are many treatments available including drugs for anxiety, other psychological conditions and increasing saliva production, protective barriers and treatments applied to the mouth surface amongst others. Study characteristics This review of studies was carried out through Cochrane Oral Health, and the evidence is current up to 31 December 2015. We found 23 studies (assessing 1121 people; 83% were women), published between 1995 and 2015 to include in this review. Twenty‐one studies assessed short‐term (up to three months) symptom relief, and four studies assessed long‐term (from three to six months) symptom relief. Seventeen studies provided information about side effect occurrence, seven studies assessed a measure of QoL, and two studies assessed changes in taste and feeling of dryness. All of the 23 treatments included in this review were compared to a placebo (fake treatment): antidepressants and antipsychotics (two studies), antiseizure drugs (one study), types of tranquillisers (four studies), saliva stimulants (one study), dietary supplements (12 studies), directed energy waves (one study), physical barriers (one study), psychological therapies (one study), and treatments applied to the mouth surface (five studies). Key results Short‐term symptom relief We found evidence of short‐term symptom relief for directed energy waves (one study, 58 participants), a type of tranquilliser used topically (that is held in the mouth before being removed, and which also acts as an antiseizure drug) called clonazepam (two studies, 111 participants), thin plastic tongue covers (one study, 50 participants), and an antiseizure drug called gabapentin (one study, 100 participants). There was no difference in short‐term symptom relief found for antidepressants, saliva stimulants, and another type of tranquilliser used systemically (one that is swallowed) also called clonazepam. We were unable to show whether dietary supplements or treatments applied to the mouth surface provide symptom relief in the short term or not. Short‐term relief was not reported for the single study that assessed a psychological therapy. Long‐term symptom relief We found evidence of long‐term symptom relief for psychological therapy (one study, 30 participants), chili pepper mouthrinse (one study, 18 participants) and the topical tranquilliser called clonazepam (one study, 66 participants). We found there was no difference in long‐term symptom relief for dietary supplements or treatments applied to the mouth surface. Studies which assessed antidepressants, directed energy waves, saliva stimulants, antiseizure drugs, or physical barriers did not evaluate long‐term symptom relief. Change in QoL There was evidence of short‐term improvement in QoL for directed energy waves (one study, 58 patients), although no difference was found for antidepressants, tranquillisers, dietary supplements and physical barriers. No study assessed long‐term QoL changes. Change in taste or feeling of dryness A few studies assessed short‐term change in taste or feeling of dryness (none evaluated these outcomes long‐term), but there was not enough evidence to judge the effects of treatment on these outcomes. Side effects Side effects were more likely to be experienced with antidepressants (dizziness and drowsiness more likely: one study, 37 people), and with a dietary supplement called alpha lipoic acid (also known as ALA) with or without other ingredients (headaches more likely: two studies, 118 people; and upset stomachs more likely: three studies, 138 people). Quality of the evidence 
 Overall, we found very low‐quality evidence for each short‐ and long‐term outcome we investigated (symptom relief; changes in QoL, taste and feeling of dryness; and side effects) in all types of assessed treatment: antidepressants and antipsychotics, antiseizure drugs, types of tranquillisers, saliva stimulants, dietary supplements, directed energy waves, physical barriers (except side effects, which was assessed as low quality), psychological therapies, and treatments applied to the mouth surface. As we found so few studies at low risk of bias, we are currently unable to prove or disprove the effectiveness of any treatments for managing BMS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McMillan, R; Forssell, H; Buchanan, JAG; Glenny, AM; Weldon, JC; Zakrzewska, JM", "articleTypes": [], "doi": "10.1002/14651858.CD002779.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "a36734f9-4ca0-4243-ac3b-1ed7df69b680", "pmid": "", "title": "Magnesium for skeletal muscle cramps", "imported": false, "abstract": "Abstract - Background Skeletal muscle cramps are common and often occur in association with pregnancy, advanced age, exercise or motor neuron disorders (such as amyotrophic lateral sclerosis). Typically, such cramps have no obvious underlying pathology, and so are termed idiopathic. Magnesium supplements are marketed for the prophylaxis of cramps but the efficacy of magnesium for this purpose remains unclear. This is an update of a Cochrane Review first published in 2012, and performed to identify and incorporate more recent studies. Objectives To assess the effects of magnesium supplementation compared to no treatment, placebo control or other cramp therapies in people with skeletal muscle cramps. Search methods On 9 September 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, CINAHL Plus, AMED, and SPORTDiscus. We also searched WHO‐ICTRP and ClinicalTrials.gov for registered trials that might be ongoing or unpublished, and ISI Web of Science for studies citing the studies included in this review. Selection criteria Randomized controlled trials (RCTs) of magnesium supplementation (in any form) to prevent skeletal muscle cramps in any patient group (i.e. all clinical presentations of cramp). We considered comparisons of magnesium with no treatment, placebo control, or other therapy. Data collection and analysis Two review authors independently selected trials for inclusion and extracted data. Two review authors assessed risk of bias. We attempted to contact all study authors when questions arose and obtained participant‐level data for four of the included trials, one of which was unpublished. We collected all data on adverse effects from the included RCTs. Main results We identified 11 trials (nine parallel‐group, two cross‐over) enrolling a total of 735 individuals, amongst whom 118 cross‐over participants additionally served as their own controls. Five trials enrolled women with pregnancy‐associated leg cramps (408 participants) and five trials enrolled people with idiopathic cramps (271 participants, with 118 additionally crossed over to control). Another study enrolled 29 people with liver cirrhosis, only some of whom suffered muscle cramps. All trials provided magnesium as an oral supplement, except for one trial which provided magnesium as a series of slow intravenous infusions. Nine trials compared magnesium to placebo, one trial compared magnesium to no treatment, calcium carbonate or vitamin B, and another trial compared magnesium to vitamin E or calcium. We judged the single trial in people with liver cirrhosis and all five trials in participants with pregnancy‐associated leg cramps to be at high risk of bias. In contrast, we rated the risk of bias high in only one of five trials in participants with idiopathic rest cramps. For idiopathic cramps, largely in older adults (mean age 61.6 to 69.3 years) presumed to have nocturnal leg cramps (the commonest presentation), differences in measures of cramp frequency when comparing magnesium to placebo were small, not statistically significant, and showed minimal heterogeneity (I² = 0% to 12%). This includes the primary endpoint, percentage change from baseline in the number of cramps per week at four weeks (mean difference (MD) −9.59%, 95% confidence interval (CI) −23.14% to 3.97%; 3 studies, 177 participants; moderate‐certainty evidence); and the difference in the number of cramps per week at four weeks (MD −0.18 cramps/week, 95% CI −0.84 to 0.49; 5 studies, 307 participants; moderate‐certainty evidence). The percentage of individuals experiencing a 25% or better reduction in cramp rate from baseline was also no different (RR 1.04, 95% CI 0.84 to 1.29; 3 studies, 177 participants; high‐certainty evidence). Similarly, no statistically significant difference was found at four weeks in measures of cramp intensity or cramp duration. This includes the number of participants rating their cramps as moderate or severe at four weeks (RR 1.33, 95% CI 0.81 to 2.21; 2 studies, 91 participants; moderate‐certainty evidence); and the percentage of participants with the majority of cramp durations of one minute or more at four weeks (RR 1.83, 95% CI 0.74 to 4.53, 1 study, 46 participants; low‐certainty evidence). We were unable to perform meta‐analysis for trials of pregnancy‐associated leg cramps. The single study comparing magnesium to no treatment failed to find statistically significant benefit on a three‐point ordinal scale of overall treatment efficacy. Of the three trials comparing magnesium to placebo, one found no benefit on frequency or intensity measures, another found benefit for both, and a third reported inconsistent results for frequency that could not be reconciled. The single study in people with liver cirrhosis was small and had limited reporting of cramps, but found no difference in terms of cramp frequency or cramp intensity. Our analysis of adverse events pooled all studies, regardless of the setting in which cramps occurred. Major adverse events (occurring in 2 out of 72 magnesium recipients and 3 out of 68 placebo recipients), and withdrawals due to adverse events, were not significantly different from placebo. However, in the four studies for which it could be determined, more participants experienced minor adverse events in the magnesium group than in the placebo group (RR 1.51, 95% CI 0.98 to 2.33; 4 studies, 254 participants; low��certainty evidence). Overall, oral magnesium was associated with mostly gastrointestinal adverse events (e.g. diarrhoea), experienced by 11% (10% in control) to 37% (14% in control) of participants. Authors' conclusions It is unlikely that magnesium supplementation provides clinically meaningful cramp prophylaxis to older adults experiencing skeletal muscle cramps. In contrast, for those experiencing pregnancy‐associated rest cramps the literature is conflicting and further research in this population is needed. We found no RCTs evaluating magnesium for exercise‐associated muscle cramps or disease‐state‐associated muscle cramps (for example amyotrophic lateral sclerosis/motor neuron disease) other than a single small (inconclusive) study in people with liver cirrhosis, only some of whom suffered cramps. Plain language summary Magnesium for muscle cramps Review question We reviewed the evidence about the effect of magnesium supplements on muscle cramps, and included the widest possible range of studies. This meant including studies on anyone suffering muscle cramps, regardless of why they suffered them. It also meant including studies where magnesium was given in any of the ways available. This includes being swallowed as a pill or liquid, being injected slowly over a number of hours directly into the blood ('intravenous infusion'), and being injected into muscle ('intramuscular injection'). We included studies comparing magnesium to placebo, comparing magnesium to no treatment, and comparing magnesium to other existing cramp treatments. We found a total of 11 studies. To assess benefit, we examined the effect of magnesium on cramp frequency, cramp pain, and cramp duration, and we examined the number of participants whose cramp rate reduced by 25% or more. To assess for potential harm, we examined how often major and minor adverse health events occurred. Background Muscle cramps are common and occur in a wide range of settings. Older adults and pregnant women commonly complain of leg cramps while they are resting, athletes can cramp when they are pushing the limits of their endurance, and some people develop muscle cramps as a symptom of other medical conditions. One potential treatment that is already being marketed to prevent muscle cramps is magnesium supplementation. Magnesium is a common mineral in our diets and extra oral supplements of this mineral are available either over the Internet or in health food stores and pharmacies (usually in the form of tablets or powders to be dissolved in water). We wanted to combine studies to get the best estimate of magnesium's effect on cramping. We also wanted to examine the effect of magnesium in different categories of cramp sufferers, in case it might work in one setting, and not another. Study characteristics We searched for all high‐quality published studies evaluating the effectiveness of magnesium to prevent muscle cramps and found five studies in older adults, five studies in pregnant women, and one study in people with liver cirrhosis. The studies in older adults included 271 participants (61.6 to 69.3 years of age) and the studies in pregnant women included 408 participants. The single study in people with liver cirrhosis enrolled only 29 people, not all of whom experienced cramping. There were no studies of people who cramp while exercising. Magnesium was compared to placebo in nine of 11 studies, and compared to calcium, vitamin E, vitamins B₁ and B₆, and no treatment, in two studies of pregnant women. The included studies ranged from 14 to 56 days of treatment. Magnesium was given orally in 10 of 11 studies, and by four‐hour intravenous infusion on five consecutive days in one study. Funding for included studies came from a manufacturer of magnesium tablets in two studies, independent sources in three studies, and was not reported in six studies. Key results and certainty of the evidence The combined results of five seemingly reliable studies suggest, with moderate‐certainty, that magnesium is unlikely to reduce the frequency or severity of muscle cramps in older adults. In contrast, the five studies in pregnant women had important limitations to their reliability (both in study design and reporting of results), did not consistently show benefit, and could not be combined. As a result we are very uncertain as to whether pregnant women experiencing muscle cramps would benefit from magnesium. The single study in people with liver cirrhosis reported no difference in cramp frequency or intensity but was too small for conclusions to be drawn. More research on magnesium in pregnant women is needed. The same is true for those who suffer cramps associated with medical conditions, or while exercising. However older adult cramp sufferers appear unlikely to benefit from this therapy. Major side effects were infrequent and participants withdrew from the study at similar rates when given magnesium or placebo. However minor side effects, mostly diarrhoea (as would be expected from magnesium salts) and nausea, were common and affected roughly 11% (10% in control) to 37% (14% in control) of participants. The review is up to date to September 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Garrison, SR; Korownyk, CS; Kolber, MR; Allan, GM; Musini, VM; Sekhon, RK; Dugré, N", "articleTypes": [], "doi": "10.1002/14651858.CD009402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "a36e99cd-495a-47c3-990f-b6626a7195c3", "pmid": "", "title": "Lactoferrin for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "Abstract - Background Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be due in part to disruption of the integrity of the gut and its altered intestinal microflora. Lactoferrin is a whey protein found in milk and is an important innate mammalian defence mechanism. Lactoferrin has been reported to have antimicrobial and anti‐inflammatory properties. It has also been reported to help establish a healthy gut microflora and aid in the intestinal immune system. Lactoferrin supplementation has been reported to decrease sepsis in preterm infants. There may be a role for lactoferrin to reduce the incidence of sepsis, thus reducing morbidity and mortality and improving enteral feeding in postoperative term neonates. Objectives The primary objective of this review was to evaluate the efficacy of administering lactoferrin on the incidence of sepsis and mortality in term neonates after gastrointestinal surgery. The secondary objective was to assess the impact of administering lactoferrin on time to full enteral feeds, the intestinal microflora, duration of hospital stay, and mortality before discharge in the same population. Search methods The Cochrane Neonatal Information Specialist searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase Ovid, CINAHL, the WHO ICTRP and ClinicalTrials.gov trials registries. The date of the last search was February 2023. There were no restrictions to language, publication year or publication type. We checked references of potentially relevant studies and systematic reviews. Selection criteria We planned to include randomised controlled trials that studied infants born at 37 or more weeks of gestation who had one or more episodes of gastrointestinal surgery within 28 days of birth, and compared administration of lactoferrin with a placebo. Data collection and analysis We used standard Cochrane methodological procedures. We planned to use the GRADE approach to assess the certainty of evidence for each outcome. Main results We identified no published randomised controlled studies that assessed the efficacy of lactoferrin for the postoperative management of term neonates following gastrointestinal surgery. Authors' conclusions There is currently no evidence available from randomised controlled trials to show whether lactoferrin is effective or ineffective for the postoperative management of term neonates after gastrointestinal surgery. There is a need for randomised controlled trials to be performed to assess the role of lactoferrin in this setting. Plain language summary What are the benefits and risks of giving lactoferrin to full‐term babies who had digestive tract surgery? Key message We found no medical studies that investigated the effects of giving lactoferrin (a protein found in milk) to babies born at full‐term (at or after 37 weeks of pregnancy) who had surgery of their digestive tract. What is lactoferrin? Lactoferrin is a protein found in milk that can protect against infection. Lactoferrin supplements are available and have been researched in premature babies. There is some evidence that lactoferrin can prevent infection in premature babies. What are some of the risks of digestive tract surgery in babies? Surgery of the digestive tract increases the risk of infection. Infections can increase the length of stay in hospital. Treatment with antibiotics (medicines that fight bacterial infections) and stress from surgery can disrupt good bacteria in the digestive tract. What did we want to find out? We wanted to find out if giving lactoferrin to full‐term babies, after digestive tract surgery, decreased rates of infection and death, and improved the presence of good bacteria in the digestive tract. What did we do? We searched for studies in which babies who had digestive tract surgery were assigned randomly to lactoferrin or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested). What did we find? We did not find any studies that compared giving lactoferrin to a placebo in full‐term babies who had digestive tract surgery. Well‐designed and large studies are needed to answer this question. How up to date is this evidence? The search is up‐to‐date as of February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Trivedi, A; Maheshwari, R; Tarnow-Mordi, WO; Saxena, N", "articleTypes": [], "doi": "10.1002/14651858.CD012218.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "a382cd8b-52d3-481f-abcf-6c66350eecb1", "pmid": "", "title": "Ghrelin for the management of cachexia associated with cancer", "imported": false, "abstract": "Abstract - Background Cancer sufferers are amongst the most malnourished of all the patient groups. Studies have shown that ghrelin, a gut hormone can be a potential therapeutic agent for cachexia (wasting syndrome) associated with cancer. A variety of mechanisms of action of ghrelin in people with cancer cachexia have been proposed. However, safety and efficacy of ghrelin for cancer‐associated cachexia have not been systematically reviewed. The aim of this review was to assess whether ghrelin is associated with better food intake, body composition and survival than other options for adults with cancer cachexia. Objectives To assess the efficacy and safety of ghrelin in improving food intake, body composition and survival in people with cachexia associated with cancer. Search methods We searched CENTRAL, MEDLINE and Embase without language restrictions up to July 2017. We also searched for ongoing studies in trials registers, performed handsearching, checked bibliographic references of relevant articles and contacted authors and experts in the field to seek potentially relevant research. We applied no restrictions on language, date, or publication status. Selection criteria We included randomised controlled (parallel‐group or cross‐over) trials comparing ghrelin (any formulation or route of administration) with placebo or an active comparator in adults (aged 18 years and over) who met any of the international criteria for cancer cachexia. Data collection and analysis Two review authors independently assessed studies for eligibility. Two review authors then extracted data and assessed the risk of bias for individual studies using standard Cochrane methodology. For dichotomous variables, we planned to calculate risk ratio with 95% confidence intervals (CI) and for continuous data, we planned to calculate mean differences (MD) with 95% CI. We assessed the evidence using GRADE and created 'Summary of findings' tables. Main results We screened 926 individual references and identified three studies that satisfied the inclusion criteria. Fifty‐nine participants (37 men and 22 women) aged between 54 and 78 years were randomised initially, 47 participants completed the treatment. One study had a parallel design and two had a cross‐over design. The studies included people with a variety of cancers and also differed in the dosage, route of administration, frequency and duration of treatment. One trial, which compared ghrelin with placebo, found that ghrelin improved food intake (very low‐quality evidence) and had no adverse events (very low‐quality evidence). Due to unavailability of data we were unable to report on comparisons for ghrelin versus no treatment or alternative experimental treatment modalities, or ghrelin in combination with other treatments or ghrelin analogues/ghrelin mimetics/ghrelin potentiators. Two studies compared a higher dose of ghrelin with a lower dose of ghrelin, however due to differences in study designs and great diversity in the treatment provided we did not pool the results. In both trials, food intake did not differ between participants on higher‐dose and lower‐dose ghrelin. None of the included studies assessed data on body weight. One study reported higher adverse events with a higher dose as compared to a lower dose of ghrelin. All studies were at high risk of attrition bias and bias for size of the study. Risk of bias in other domains was unclear or low. We rated the overall quality of the evidence for primary outcomes (food intake, body weight, adverse events) as very low. We downgraded the quality of the evidence due to lack of data, high or unclear risk of bias of the studies and small study size. Authors' conclusions There is insufficient evidence to be able to support or refute the use of ghrelin in people with cancer cachexia. Adequately powered randomised controlled trials focusing on evaluation of safety and efficacy of ghrelin in people with cancer cachexia is warranted. Plain language summary Ghrelin, a hunger hormone for management of cancer patients with loss of appetite and weight loss Bottom line There is no good evidence to support or reject the suggestion that ghrelin is useful in the management of cancer patients with loss of appetite and weight loss. There is insufficient evidence to recommend it for clinical practice. Background Sixty to eighty percent of cancer patients suffer from loss of appetite and weight loss, which in turn is associated with decreased life expectancy and quality of life. Ghrelin, a hunger hormone is secreted by the stomach and other organs of the body. Studies have shown that ghrelin can be used in treatment for loss of appetite and weight loss in cancer patients. However, the effectiveness and safety of ghrelin in such people have not been assessed. In this review we set out to examine all evidence on the effectiveness and safety of ghrelin in improving appetite and body weight in cancer patients with loss of appetite and weight loss. Search date The evidence is current to 20th July 2017. Study characteristics We found three studies that recruited a total of 59 cancer patients (37 men and 22 women) aged between 54 and 78 years. Forty‐seven cancer patients completed the treatment. Studies differed in study design and included people with a variety of cancers. Studies also differed in dosage, route of injection, frequency and duration of treatment. One study compared ghrelin with a placebo while two studies compared different doses of ghrelin (higher dose with lower dose). Outcomes of interest to cancer patients with loss of appetite and weight loss, such as improvement in food intake and improvement in body weight, were not adequately reported. All three included studies were funded by government agencies. One study received an additional grant from a pharmaceutical company. Key findings We found insufficient evidence that using ghrelin demonstrated differences in food intake. We found no evidence that using ghrelin alone or in combination made any difference to body weight. We could not reach any conclusions about its side effects. The limited amount of information means that we could not draw any conclusions. Quality of the evidence We rated the quality of evidence from studies using four levels: high, moderate, low, or very low. High‐quality evidence means that we are very confident in the results. Very low‐quality evidence means that we are very uncertain about the results. The evidence in this review was of very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Khatib, MN, Shankar, AH, Kirubakaran, R, Gaidhane, A, Gaidhane, S, Simkhada, P, Quazi Syed, Z", "articleTypes": [], "doi": "10.1002/14651858.CD012229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.116Z" }, { "id": "a38ab98e-b3ad-4ce1-8d35-a176ab72e800", "pmid": "", "title": "Interventions for reducing inflammation in familial Mediterranean fever", "imported": false, "abstract": "Abstract - Background Familial Mediterranean fever (FMF), a hereditary auto‐inflammatory disease, mainly affects ethnic groups living in the Mediterranean region. Early studies reported colchicine may potentially prevent FMF attacks. For people who are colchicine‐resistant or intolerant, drugs such as anakinra, rilonacept, canakinumab, etanercept, infliximab or adalimumab might be beneficial. This is an update of the review last published in 2018. Objectives To evaluate the efficacy and safety of interventions for reducing inflammation in people with FMF. Search methods We searched CENTRAL, MEDLINE, Embase and four Chinese databases on in August 2021. We searched clinical trials registries and references listed in relevant reports. The last search was 17 August 2021. Selection criteria We included randomized controlled trials (RCTs) of people with FMF, comparing active interventions (including colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (herbal dietary supplement)) with placebo or no treatment, or comparing active drugs to each other. Data collection and analysis We used standard Cochrane methodology. We assessed certainty of the evidence using GRADE. Main results We included 10 RCTs with 312 participants (aged three to 53 years), including five parallel and five cross‐over designed studies. Six studies used oral colchicine, one used oral ImmunoGuard, and the remaining three used rilonacept, anakinra or canakinumab as a subcutaneous injection. The duration of each study arm ranged from one to eight months. There were inadequacies in the design of the four older colchicine studies and the two studies comparing a single to a divided dose of colchicine. However, the four studies of ImmunoGuard, rilonacept, anakinra and canakinumab were generally well‐designed. We aimed to report on the number of participants experiencing an attack, the timing of attacks, the prevention of amyloid A amyloidosis, adverse drug reactions and the response of a number of biochemical markers from the acute phase of an attack; but no study reported on the prevention of amyloid A amyloidosis. Colchicine (oral) versus placebo After three months, colchicine 0.6 mg three times daily may reduce the number of people experiencing attacks (risk ratio (RR) 0.21, 95% confidence interval (CI) 0.05 to 0.95; 1 study, 10 participants; low‐certainty evidence). One study (20 participants) of colchicine 0.5 mg twice daily showed there may be no difference in the number of participants experiencing attacks at two months (RR 0.78, 95% CI 0.49 to 1.23; low‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; very low‐certainty evidence), or in the number of days between attacks: (narrative summary; very low‐certainty evidence). Regarding adverse drug reactions, one study reported loose stools and frequent bowel movements and a second reported diarrhea (narrative summary; both very low‐certainty evidence). There were no data on acute‐phase response. Rilonacept versus placebo There is probably no difference in the number of people experiencing attacks at three months (RR 0.87, 95% CI 0.59 to 1.26; moderate‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; low‐certainty evidence) or in the number of days between attacks (narrative summary; low‐certainty evidence). Regarding adverse drug reactions, the rilonacept study reported there may be no differences in gastrointestinal symptoms, hypertension, headache, respiratory tract infections, injection site reactions and herpes, compared to placebo (narrative summary; low‐certainty evidence). The study narratively reported there may be no differences in acute‐phase response indicators after three months (low‐certainty evidence). ImmunoGuard versus placebo The ImmunoGuard study observed there are probably no differences in adverse effects (moderate‐certainty evidence) or in acute‐phase response indicators after one month of treatment (moderate‐certainty evidence). No data were reported for the number of people experiencing an attack, duration of attacks or days between attacks. Anakinra versus placebo A study of anakinra given to 25 colchicine‐resistant participants found there is probably no difference in the number of participants experiencing an attack at four months (RR 0.76, 95% CI 0.54 to 1.07; moderate‐certainty evidence). There were no data for duration of attacks or days between attacks. There are probably no differences between anakinra and placebo with regards to injection site reaction, headache, presyncope, dyspnea and itching (narrative summary; moderate‐certainty evidence). For acute‐phase response, anakinra probably reduced C‐reactive protein (CRP) after four months (narrative summary; moderate‐certainty evidence). Canakinumab versus placebo Canakinumab probably reduces the number of participants experiencing an attack at 16 weeks (RR 0.41, 95% CI 0.26 to 0.65; 1 study, 63 colchicine‐resistant participants; moderate‐certainty evidence). There were no data for the duration of attacks or days between attacks. The included study reported the number of serious adverse events per 100 patient‐years was probably 42.7 with canakinumab versus 97.4 with placebo among people with colchicine‐resistant FMF (moderate‐certainty evidence). For acute‐phase response, canakinumab probably caused a higher proportion of participants to have a CRP level of 10 mg/L or less compared to placebo (68% with canakinumab versus 6% with placebo; 1 study, 63 participants; moderate‐certainty evidence). Colchicine single dose versus divided dose There is probably no difference in the duration of attacks at three months (MD −0.04 hours, 95% CI −10.91 to 10.83) or six months (MD 2.80 hours, 95% CI −5.39 to 10.99; moderate‐certainty evidence). There were no data for the number of participants experiencing an attack or days between attacks. There is probably no difference in adverse events (including anorexia, nausea, diarrhea, abdominal pain, vomiting and elevated liver enzymes) between groups (narrative summary; moderate‐certainty evidence). For acute‐phase response, there may be no evidence of a difference between groups (narrative summary; low‐ to moderate‐certainty evidence). Authors' conclusions There were limited RCTs assessing interventions for people with FMF. Based on the evidence, three times daily colchicine may reduce the number of people experiencing attacks, colchicine single dose and divided dose may not be different for children with FMF, canakinumab probably reduces the number of people experiencing attacks, and anakinra or canakinumab probably reduce CRP in colchicine‐resistant participants; however, only a few RCTs contributed data for analysis. Further RCTs examining active interventions, not only colchicine, are necessary before a comprehensive conclusion regarding the efficacy and safety of interventions for reducing inflammation in FMF can be drawn. Plain language summary Medicines for reducing inflammation in people with familial Mediterranean fever Review question Can treatments such as colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (a herbal supplement)) reduce inflammation in people with familial Mediterranean fever (FMF)? Background FMF is a hereditary inflammatory disease, with symptoms of an attack often including fever over 38 °C, pain and inflammation of the membrane surrounding the chest cavity, the joints or the lungs. We wanted to discover whether these medicines were better for reducing inflammation for people with FMF than placebo (a dummy treatment containing no active medicine) or no treatment, and also to compare these medicines with each other. Search date The evidence is current to 17 August 2021. Study characteristics The review included 10 studies with 312 people with FMF aged between three and 53 years. Eight studies compared five medicines, colchicine, rilonacept, ImmunoGuard, anakinra and canakinumab, with placebo. Participants received one medicine or placebo at random over one to four months. The remaining two studies compared colchicine 1 mg per day once daily with colchicine two or three times daily in children for six to eight months. Key results We aimed to report on the number of participants experiencing an attack, the timing of attacks, prevention of amyloid A amyloidosis (which is a reaction to a chronic inflammatory disease or infection leading to a build‐up of an abnormal protein called amyloid in organs and tissues throughout the body stopping them working properly), and any side effects of treatment and the levels of a number of markers of inflammation during an attack. Not all studies reported these outcomes. Given the differences in treatments and study design, it was not possible to combine any of the results that we did obtain from these studies. One study (15 participants) with oral colchicine 0.6 mg three times a day and another study (63 participants) with subcutaneous (under the skin) canakinumab 150 mg every four weeks for 16 weeks may help to reduce the numbers of people with attacks of FMF. However, oral colchicine 0.5 mg twice a day (20 participants), rilonacept (14 participants) or anakinra (25 participants) did not reduce the numbers of people with attacks. ImmunoGuard (24 participants) did not reduce levels of the markers of inflammation in the blood which are raised during the attack phase of FMF; these include the rate of fall of red blood cells when placed in a test tube, the white blood cell count and the presence of C‐reactive protein (a protein that is produced in the liver). Anakinra and canakinumab reduced C‐reactive protein levels. Colchicine taken once daily and two or three times daily might not result in different outcomes including the timing of attacks, sider effects of the medicine and acute‐phase response indicators. Quality of the evidence Four studies were well‐designed, while the others had some design problems that might have affected the results. Four studies did not report clearly how the people were assigned to each treatment group. Four studies did not report whether researchers, who assessed the study outcomes, knew which individuals were assigned to which treatment. Four studies did not clearly explain the reasons for people withdrawing from a study and one study had a high percentage of participants who did not complete study. We could not confirm whether each planned outcome was reported in five studies. Five studies did not report the severity of FMF in groups at the beginning of treatment. We judged the evidence for the reported outcomes to be of moderate to very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Yin, X; Tian, F; Wu, B; Xu, T", "articleTypes": [], "doi": "10.1002/14651858.CD010893.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "a39d4136-b726-4c8e-9387-d25dab1bdceb", "pmid": "", "title": "Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years", "imported": false, "abstract": "Abstract - Background Zinc deficiency is prevalent in low‐ and middle‐income countries, and is considered a significant risk factor for morbidity, mortality, and linear growth failure. The effectiveness of preventive zinc supplementation in reducing prevalence of zinc deficiency needs to be assessed. Objectives To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged 6 months to 12 years. Search methods A previous version of this review was published in 2014. In this update, we searched CENTRAL, MEDLINE, Embase, five other databases, and one trials register up to February 2022, together with reference checking and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) of preventive zinc supplementation in children aged 6 months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalized children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions. Data collection and analysis Two review authors screened studies, extracted data, and assessed the risk of bias. We contacted study authors for missing information and used GRADE to assess the certainty of evidence. The primary outcomes of this review were all‐cause mortality; and cause‐specific mortality, due to all‐cause diarrhea, lower respiratory tract infection (LRTI, including pneumonia), and malaria. We also collected information on a number of secondary outcomes, such as those related to diarrhea and LRTI morbidity, growth outcomes and serum levels of micronutrients, and adverse events. Main results We included 16 new studies in this review, resulting in a total of 96 RCTs with 219,584 eligible participants. The included studies were conducted in 34 countries; 87 of them in low‐ or middle‐income countries. Most of the children included in this review were under five years of age. The intervention was delivered most commonly in the form of syrup as zinc sulfate, and the most common dose was between 10 mg and 15 mg daily. The median duration of follow‐up was 26 weeks. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes was affected by risk of bias. High‐certainty evidence showed little to no difference in all‐cause mortality with preventive zinc supplementation compared to no zinc (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.84 to 1.03; 16 studies, 17 comparisons, 143,474 participants). Moderate‐certainty evidence showed that preventive zinc supplementation compared to no zinc likely results in little to no difference in mortality due to all‐cause diarrhea (RR 0.95, 95% CI 0.69 to 1.31; 4 studies, 132,321 participants); but probably reduces mortality due to LRTI (RR 0.86, 95% CI 0.64 to 1.15; 3 studies, 132,063 participants) and mortality due to malaria (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 42,818 participants); however, the confidence intervals around the summary estimates for these outcomes were wide, and we could not rule out a possibility of increased risk of mortality. Preventive zinc supplementation likely reduces the incidence of all‐cause diarrhea (RR 0.91, 95% CI 0.90 to 0.93; 39 studies, 19,468 participants; moderate‐certainty evidence) but results in little to no difference in morbidity due to LRTI (RR 1.01, 95% CI 0.95 to 1.08; 19 studies, 10,555 participants; high‐certainty evidence) compared to no zinc. There was moderate‐certainty evidence that preventive zinc supplementation likely leads to a slight increase in height (standardized mean difference (SMD) 0.12, 95% CI 0.09 to 0.14; 74 studies, 20,720 participants). Zinc supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46; 5 studies, 35,192 participants; high‐certainty evidence). We report a number of other outcomes, including the effect of zinc supplementation on weight and serum markers such as zinc, hemoglobin, iron, copper, etc. We also performed a number of subgroup analyses and there was a consistent finding for a number of outcomes that co‐supplementation of zinc with iron decreased the beneficial effect of zinc. Authors' conclusions Even though we included 16 new studies in this update, the overall conclusions of the review remain unchanged. Zinc supplementation might help prevent episodes of diarrhea and improve growth slightly, particularly in children aged 6 months to 12 years of age. The benefits of preventive zinc supplementation may outweigh the harms in regions where the risk of zinc deficiency is relatively high. Plain language summary Is zinc supplementation effective for preventing death and disease, and for promoting growth, in children aged 6 months to 12 years and does it cause unwanted effects? Key messages ‐ Zinc supplementation in children aged 6 months to 12 years makes little to no difference to all‐cause mortality and probably makes no difference to deaths from diarrea. Zinc supplementation probably reduces mortality due to lower respiratory tract infections and malaria but a small possibility of increased risk of mortality cannot be ruled out. ‐ Zinc supplementation in children aged 6 months to 12 years might prevent illness due to diarrhea, but might lead to vomiting after supplementation. It might lead to a small increase in height gain. Why is it important to study zinc supplementation? Zinc is an essential micronutrient. It is important to help children grow normally and to promote a healthy immune system. Lack of zinc may lead to diarrhea, pneumonia, malaria and even death. Low dietary zinc intake is often linked to poverty. As many as half of all children in low‐ and middle‐income countries may have zinc deficiency. Meat, fish, eggs and dairy products are good natural sources of zinc, but are expensive. Lack of clean water and poor sanitation increases exposure to diseases, which zinc might help to fight. The human body cannot produce or store zinc, so giving dietary supplements is important. What did we want to find out? We wanted to find out if giving children zinc supplements helps prevent child death and disease, and promotes growth. What did we do? We searched for studies that randomly assigned children aged 6 months to 12 years to receive zinc supplementation or no zinc. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 96 studies in the review, with 219,584 children. Studies took place in 34, mainly low‐ to middle‐income countries. Most of the children in the studies were under five years old. Zinc was most commonly given as a syrup (zinc sulfate), and the most common dose was between 10 mg and 15 mg daily. We found that giving children zinc supplementation might lead to a small to no reduction in the risk of death for any reason and the risk of death due to diarrhea. The risk of death due to lower respiratory tract infections or malaria may be reduced. Children given zinc experienced less disease due to diarrhea than children not given zinc; however, zinc does not seem to reduce children's risk of respiratory infection. Zinc supplementation may have a small positive effect on growth. Children who take zinc supplementation may experience vomiting as an unwanted effect. What are the limitations of the evidence? We are confident about our results on the effects of zinc supplements on reducing the risk of death due to any cause, illness due to respiratory infection, and occurrence of vomiting after supplementation. Our confidence in the results for our other outcomes was moderate because relatively few studies reported these outcomes and because studies sometimes reported different results from other studies for the same outcomes. How up to date is this evidence? This review updates a previous version published in 2014. The evidence is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Imdad, A, Rogner, J, Sherwani, RN, Sidhu, J, Regan, A, Haykal, MR, Tsistinas, O, Smith, A, Chan, XHS, Mayo-Wilson, E, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD009384.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.766Z" }, { "id": "a3bd909a-f2f7-42b8-b80e-e08fe53219c6", "pmid": "", "title": "Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia", "imported": false, "abstract": "Abstract - Background Fibromyalgia is a clinically defined chronic condition of unknown etiology characterized by chronic widespread pain that often co‐exists with sleep disturbances, cognitive dysfunction and fatigue. People with fibromyalgia often report high disability levels and poor quality of life. Drug therapy, for example, with serotonin and noradrenaline reuptake inhibitors (SNRIs), focuses on reducing key symptoms and improving quality of life. This review updates and extends the 2013 version of this systematic review. Objectives To assess the efficacy, tolerability and safety of serotonin and noradrenaline reuptake inhibitors (SNRIs) compared with placebo or other active drug(s) in the treatment of fibromyalgia in adults. Search methods For this update we searched CENTRAL, MEDLINE, Embase, the US National Institutes of Health and the World Health Organization (WHO) International Clinical Trials Registry Platform for published and ongoing trials and examined the reference lists of reviewed articles, to 8 August 2017. Selection criteria We selected randomized, controlled trials of any formulation of SNRIs against placebo or any other active treatment of fibromyalgia in adults. Data collection and analysis Three review authors independently extracted data, examined study quality, and assessed risk of bias. For efficacy, we calculated the number needed to treat for an additional beneficial outcome (NNTB) for pain relief of 50% or greater and of 30% or greater, patient's global impression to be much or very much improved, dropout rates due to lack of efficacy, and the standardized mean differences (SMD) for fatigue, sleep problems, health‐related quality of life, mean pain intensity, depression, anxiety, disability, sexual function, cognitive disturbances and tenderness. For tolerability we calculated number needed to treat for an additional harmful outcome (NNTH) for withdrawals due to adverse events and for nausea, insomnia and somnolence as specific adverse events. For safety we calculated NNTH for serious adverse events. We undertook meta‐analysis using a random‐effects model. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We added eight new studies with 1979 participants for a total of 18 included studies with 7903 participants. Seven studies investigated duloxetine and nine studies investigated milnacipran against placebo. One study compared desvenlafaxine with placebo and pregabalin. One study compared duloxetine with L‐carnitine. The majority of studies were at unclear or high risk of bias in three to five domains. The quality of evidence of all comparisons of desvenlafaxine, duloxetine and milnacipran versus placebo in studies with a parallel design was low due to concerns about publication bias and indirectness, and very low for serious adverse events due to concerns about publication bias, imprecision and indirectness. The quality of evidence of all comparisons of duloxetine and desvenlafaxine with other active drugs was very low due to concerns about publication bias, imprecision and indirectness. Duloxetine and milnacipran had no clinically relevant benefit over placebo for pain relief of 50% or greater: 1274 of 4104 (31%) on duloxetine and milnacipran reported pain relief of 50% or greater compared to 591 of 2814 (21%) participants on placebo (risk difference (RD) 0.09, 95% confidence interval (CI) 0.07 to 0.11; NNTB 11, 95% CI 9 to 14). Duloxetine and milnacipran had a clinically relevant benefit over placebo in patient's global impression to be much or very much improved: 888 of 1710 (52%) on duloxetine and milnacipran (RD 0.19, 95% CI 0.12 to 0.26; NNTB 5, 95% CI 4 to 8) reported to be much or very much improved compared to 354 of 1208 (29%) of participants on placebo. Duloxetine and milnacipran had a clinically relevant benefit compared to placebo for pain relief of 30% or greater. RD was 0.10; 95% CI 0.08 to 0.12; NNTB 10, 95% CI 8 to 12. Duloxetine and milnacipran had no clinically relevant benefit for fatigue (SMD ‐0.13, 95% CI ‐0.18 to ‐0.08; NNTB 18, 95% CI 12 to 29), compared to placebo. There were no differences between either duloxetine or milnacipran and placebo in reducing sleep problems (SMD ‐0.07; 95 % CI ‐0.15 to 0.01). Duloxetine and milnacipran had no clinically relevant benefit compared to placebo in improving health‐related quality of life (SMD ‐0.20, 95% CI ‐0.25 to ‐0.15; NNTB 11, 95% CI 8 to 14). There were 794 of 4166 (19%) participants on SNRIs who dropped out due to adverse events compared to 292 of 2863 (10%) of participants on placebo (RD 0.07, 95% CI 0.04 to 0.10; NNTH 14, 95% CI 10 to 25). There was no difference in serious adverse events between either duloxetine, milnacipran or desvenlafaxine and placebo (RD ‐0.00, 95% CI ‐0.01 to 0.00). There was no difference between desvenlafaxine and placebo in efficacy, tolerability and safety in one small trial. There was no difference between duloxetine and desvenlafaxine in efficacy, tolerability and safety in two trials with active comparators (L‐carnitine, pregabalin). Authors' conclusions The update did not change the major findings of the previous review. Based on low‐ to very low‐quality evidence, the SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in the frequency of pain relief of 50% or greater, but for patient's global impression to be much or very much improved and in the frequency of pain relief of 30% or greater there was a clinically relevant benefit. The SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in improving health‐related quality of life and in reducing fatigue. Duloxetine and milnacipran did not significantly differ from placebo in reducing sleep problems. The dropout rates due to adverse events were higher for duloxetine and milnacipran than for placebo. On average, the potential benefits of duloxetine and milnacipran in fibromyalgia were outweighed by their potential harms. However, a minority of people with fibromyalgia might experience substantial symptom relief without clinically relevant adverse events with duloxetine or milnacipran. We did not find placebo‐controlled studies with other SNRIs than desvenlafaxine, duloxetine and milnacipran. Plain language summary Serotonin and noradrenaline reuptake inhibitors for fibromyalgia Bottom line Duloxetine and milnacipran may reduce pain in people with fibromyalgia. However, some of these people may also experience side effects, such as nausea (feeling sick) and drowsiness. A minority of people with fibromyalgia experience symptom relief without side effects from duloxetine and milnacipran. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as problems with sleep, thinking and exhaustion. They often report poor health‐related quality of life. There is no cure for fibromyalgia at present, so the treatments aim to relieve the symptoms and to improve health‐related quality of life. Serotonin and noradrenaline are chemicals which are produced by the human body, involved in the regulation of pain, sleep and mood. Low concentrations of serotonin have been reported in people with fibromyalgia. Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a class of antidepressants that increase the concentration of serotonin and noradrenaline in the brain. Study characteristics In August 2017, we updated our searches for clinical trials in which SNRIs were used to treat symptoms of fibromyalgia in adults. We found eight new studies since the previous version of the review. In total, we found 18 studies with 7903 participants. The studies were four to 27 weeks long and compared the SNRIs desvenlafaxine, duloxetine and milnacipran against a fake medication (placebo). We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. Key results and quality of the evidence Duloxetine and milnacipran were better than placebo in reducing pain by 50% or more and in improving global well‐being (low‐quality evidence). Duloxetine and milnacipran were better than placebo in improving health‐related quality of life and in reducing fatigue (low‐quality evidence). Duloxetine and milnacipran were not better than placebo in reducing sleep problems (low‐quality evidence). More people dropped out of the trial due to side effects with duloxetine and milnacipran than with placebo (low‐quality evidence). More people reported nausea and drowsiness with duloxetine and milnacipran than with placebo (low‐quality evidence). Duloxetine, milnacipran and placebo did not differ in the frequency of serious side effects experienced (very low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Welsch, P, Üçeyler, N, Klose, P, Walitt, B, Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD010292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.796Z" }, { "id": "a3e0dfa8-a782-49c6-9d72-95db3f302d56", "pmid": "", "title": "Optimum duration of regimens for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background The optimal duration for Helicobacter pylori (H. pylori) eradication therapy is controversial, with recommendations ranging from 7 to 14 days. Several systematic reviews have attempted to address this issue but have given conflicting results and limited their analysis to proton pump inhibitor (PPI), two antibiotics (PPI triple) therapy. We performed a systematic review and meta‐analysis to investigate the optimal duration of multiple H. pylori eradication regimens. Objectives The primary objective was to assess the relative effectiveness of different durations (7, 10 or 14 days) of a variety of regimens for eradicating H. pylori . The primary outcome was H. pylori persistence. The secondary outcome was adverse events. Search methods The Cochrane Library , MEDLINE, EMBASE, and CINAHL were searched up to December 2011 to identify eligible randomised controlled trials (RCTs). We also searched the proceedings of six conferences from 1995 to 2011, dissertations and theses, and grey literature. There were no language restrictions applied to any search. Selection criteria Only parallel group RCTs assessing the efficacy of one to two weeks duration of first line H. pylori eradication regimens in adults were eligible. Within each regimen, the same combinations of drugs at the same dose were compared over different durations. Studies with at least two arms comparing 7, 10, or 14 days were eligible. Enrolled participants needed to be diagnosed with at least one positive test for H. pylori on the basis of a rapid urease test (RUT), histology, culture, urea breath test (UBT), or a stool antigen test (HpSA) before treatment. Eligible trials needed to confirm eradication of H. pylori as their primary outcome at least 28 days after completion of eradication treatment. Trials using only serology or a polymerase chain reaction (PCR) to determine H. pylori infection or eradication were excluded. Data collection and analysis Study eligibility and data extraction were performed by two independent review authors. Data analyses were performed within each type of intervention, for both primary and secondary outcomes. The relative risk (RR) and number needed to treat (NNT)/number needed to harm (NNTH) according to duration of therapy were calculated using the outcomes of H. pylori persistence and adverse events. A random‐effects model was used. Subgroup analyses and sensitivity analyses were planned a priori. Main results In total, 75 studies met the inclusion criteria. Eight types of regimens were reported with at least two comparative eligible durations. They included: PPI + two antibiotics triple therapy (n = 59), PPI bismuth‐based quadruple therapy (n = 6), PPI + three antibiotics quadruple therapy (n = 1), PPI dual therapy (n = 2), histamine H 2 ‐receptor antagonist (H 2 RA) bismuth quadruple therapy (n = 3), H 2 RA bismuth‐based triple therapy (n = 2), H 2 RA + two antibiotics triple therapy (n = 3), and bismuth + two antibiotics triple therapy (n = 2). Some studies provided data for more than one regimen or more than two durations. For the PPI triple therapy, 59 studies with five regimens were reported: PPI + clarithromycin + amoxicillin (PCA); PPI + clarithromycin + a nitroimidazole (PCN); PPI + amoxicillin + nitroimidazole (PAN); PPI + amoxicillin + a quinolone (PAQ); and PPI + amoxicillin + a nitrofuran (PANi). Regardless of type and dose of antibiotics, increased duration of PPI triple therapy from 7 to 14 days significantly increased the H. pylor i eradication rate (45 studies, 72.9% versus 81.9%), the RR for H. pylori persistence was 0.66 (95% CI 0.60 to 0.74), NNT was 11 (95% CI 9 to 14). Significant effects were seen in the subgroup of PCA (34 studies, RR 0.65, 95% CI 0.57 to 0.75; NNT 12, 95% CI 9 to 16); PAN (10 studies, RR 0.67, 95% CI 0.52 to 0.86; NNT = 11, 95% CI 8 to 25); and in PAQ (2 studies, RR 0.37, 95% CI 0.16 to 0.83; NNT 3, 95% CI 2 to 10); but not in PCN triple therapy (4 studies, RR 0.87, 95% CI 0.71 to 1.07). Significantly increased eradication rates were also seen for PPI triple therapy with 10 versus 7 days (24 studies, 79.9% versus 75.7%; RR 0.80, 95% CI 0.72 to 0.89; NNT 21, 95% CI 15 to 38) and 14 versus 10 days (12 studies, 84.4% versus 78.5%; RR 0.72, 95% CI 0.58 to 0.90; NNT 17, 95% CI 11 to 46); especially in the subgroup of PAC for 10 versus 7 days (17 studies, RR 0.80, 95% CI 0.70 to 0.91) and for 14 versus 10 days (10 studies, RR 0.69, 95% CI 0.52 to 0.91). A trend towards increased H. pylori eradication rates was seen with increased duration of PCN for 10 versus 7 days, and of PAN for 10 versus 7 days and 14 versus 10 days, though this was not statistical significant. The proportion of patients with adverse events, defined by authors, was marginally significantly increased only between 7 days and 14 days (15.5% versus 19.4%; RR 1.21, 95% CI 1.06 to 1.37; NNTH 31, 95% CI 18 to 104) but not for other duration comparisons. The proportion of patients discontinuing treatment due to adverse events was not significantly different between treatment durations. Only limited data were reported for different durations of regimens other than PPI triple therapy. No significant difference of the eradication rate was seen for all regimens according to different durations except for H 2 RA bismuth quadruple therapy, where a significantly higher eradication rate was seen for 14 days versus 7 days, however only one study reported outcome data. Authors' conclusions Increasing the duration of PPI‐based triple therapy increases H. pylori eradication rates. For PCA, prolonging treatment duration from 7 to 10 or from 10 to 14 days is associated with a significantly higher eradication rate. The optimal duration of therapy for PCA and PAN is at least 14 days. More data are needed to confirm if there is any benefit of increasing the duration of therapy for PCN therapy. Information is limited for regimens other than PPI triple therapy; more studies are needed to draw meaningful conclusions for optimal duration of other H. pylori eradication regimens. Plain language summary Ideal length of treatment for Helicobacter pylori ( H. pylori ) eradication The ideal duration of therapy for H. pylori eradication is controversial, with recommendations ranging from 7 to 14 days. A proton pump inhibitor (PPI) plus two antibiotics is the most commonly used first treatment to remove H. pylori infection. Current data suggest that increasing the length of treatment to 14 days of a PPI plus amoxicillin and clarithromycin or amoxicillin and a nitroimidazole significantly increases the eradication rate, while increasing the adverse events by a small amount. Based on the overall evidence, the ideal length of treatment with a PPI plus amoxicillin and clarithromycin is at least 14 days.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Yuan, Y, Ford, AC, Khan, KJ, Gisbert, JP, Forman, D, Leontiadis, GI, Tse, F, Calvet, X, Fallone, C, Fischbach, L, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD008337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.748Z" }, { "id": "a3eb9868-7013-47ff-b521-cdea5cde3357", "pmid": "", "title": "Pharmacological interventions for prevention of weight gain in people with schizophrenia", "imported": false, "abstract": "Abstract - Background Antipsychotic‐induced weight gain is an extremely common problem in people with schizophrenia and is associated with increased morbidity and mortality. Adjunctive pharmacological interventions may be necessary to help manage antipsychotic‐induced weight gain. This review splits and updates a previous Cochrane Review that focused on both pharmacological and behavioural approaches to this problem. Objectives To determine the effectiveness of pharmacological interventions for preventing antipsychotic‐induced weight gain in people with schizophrenia. Search methods The Cochrane Schizophrenia Information Specialist searched Cochrane Schizophrenia's Register of Trials on 10 February 2021. There are no language, date, document type, or publication status limitations for inclusion of records in the register. Selection criteria We included all randomised controlled trials (RCTs) that examined any adjunctive pharmacological intervention for preventing weight gain in people with schizophrenia or schizophrenia‐like illnesses who use antipsychotic medications. Data collection and analysis At least two review authors independently extracted data and assessed the quality of included studies. For continuous outcomes, we combined mean differences (MD) in endpoint and change data in the analysis. For dichotomous outcomes, we calculated risk ratios (RR). We assessed risk of bias for included studies and used GRADE to judge certainty of evidence and create summary of findings tables. The primary outcomes for this review were clinically important change in weight, clinically important change in body mass index (BMI), leaving the study early, compliance with treatment, and frequency of nausea. The included studies rarely reported these outcomes, so, post hoc, we added two new outcomes, average endpoint/change in weight and average endpoint/change in BMI. Main results Seventeen RCTs, with a total of 1388 participants, met the inclusion criteria for the review. Five studies investigated metformin, three topiramate, three H2 antagonists, three monoamine modulators, and one each investigated monoamine modulators plus betahistine, melatonin and samidorphan. The comparator in all studies was placebo or no treatment (i.e. standard care alone). We synthesised all studies in a quantitative meta‐analysis. Most studies inadequately reported their methods of allocation concealment and blinding of participants and personnel. The resulting risk of bias and often small sample sizes limited the overall certainty of the evidence. Only one reboxetine study reported the primary outcome, number of participants with clinically important change in weight. Fewer people in the treatment condition experienced weight gains of more than 5% and more than 7% of their bodyweight than those in the placebo group (> 5% weight gain RR 0.27, 95% confidence interval (CI) 0.11 to 0.65; 1 study, 43 participants; > 7% weight gain RR 0.24, 95% CI 0.07 to 0.83; 1 study, 43 participants; very low‐certainty evidence). No studies reported the primary outcomes, 'clinically important change in BMI', or 'compliance with treatment'. However, several studies reported 'average endpoint/change in body weight' or 'average endpoint/change in BMI'. Metformin may be effective in preventing weight gain (MD −4.03 kg, 95% CI −5.78 to −2.28; 4 studies, 131 participants; low‐certainty evidence); and BMI increase (MD −1.63 kg/m2, 95% CI −2.96 to −0.29; 5 studies, 227 participants; low‐certainty evidence). Other agents that may be slightly effective in preventing weight gain include H2 antagonists such as nizatidine, famotidine and ranitidine (MD −1.32 kg, 95% CI −2.09 to −0.56; 3 studies, 248 participants; low‐certainty evidence) and monoamine modulators such as reboxetine and fluoxetine (weight: MD −1.89 kg, 95% CI −3.31 to −0.47; 3 studies, 103 participants; low‐certainty evidence; BMI: MD −0.66 kg/m2, 95% CI −1.05 to −0.26; 3 studies, 103 participants; low‐certainty evidence). Topiramate did not appear effective in preventing weight gain (MD −4.82 kg, 95% CI −9.99 to 0.35; 3 studies, 168 participants; very low‐certainty evidence ) . For all agents, there was no difference between groups in terms of individuals leaving the study or reports of nausea. However, the results of these outcomes are uncertain given the very low‐certainty evidence. Authors' conclusions There is low‐certainty evidence to suggest that metformin may be effective in preventing weight gain. Interpretation of this result and those for other agents, is limited by the small number of studies, small sample size, and short study duration. In future, we need studies that are adequately powered and with longer treatment durations to further evaluate the efficacy and safety of interventions for managing weight gain. Plain language summary How effective are medications given alongside antipsychotics at preventing weight gain in people with schizophrenia? Key messages ‐ Metformin may be effective in preventing weight gain caused by antipsychotics. ‐ H2 antagonists and monoamine modulators may be slightly effective in preventing weight gain caused by antipsychotics. ‐ Future studies should include more people and evaluate them for longer. What are antipsychotics? Antipsychotics are medications used to treat symptoms of psychosis, such as hallucinations, delusions and agitation. They are often used to treat people with schizophrenia. Examples of antipsychotics are haloperidol (Haldol), chlorpromazine (Thorazine), olanzapine (Zyprexa) and risperidone (Risperdal). Schizophrenia and weight gain People with schizophrenia are twice as likely as the general population to be overweight, perhaps due to a poor diet and an inactive lifestyle. Excess weight can lead to other health conditions, such as heart disease, stroke and diabetes. Unfortunately, an unwanted effect of antipsychotics is weight gain. Sometimes, people with schizophrenia are given medications alongside antipsychotics (‘add‐on’ medications) to prevent this additional weight gain. These add‐on medications may stop people feeling hungry or help them feel full. Usually, they are medications developed for other purposes, such as metformin, which is a medicine to treat diabetes, and fluoxetine, which is an antidepressant. What did we want to find out? We wanted to find out whether add‐on medications to prevent weight gain caused by antipsychotics were effective in people with schizophrenia. What did we do? We searched for studies that examined any medicine given alongside antipsychotics to prevent weight gain in people with schizophrenia. Study participants could be any age or sex but had to have a diagnosis of schizophrenia or a schizophrenia‐like illness. They had to be chosen at random to receive either the weight‐prevention medicine, or a placebo (a dummy medicine) or no add‐on medicine (standard treatment). We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 17 studies with 1388 people that examined the effects of add‐on medications to prevent weight gain caused by antipsychotics. The add‐on medications were metformin, topiramate, H2 antagonists, monoamine modulators, monoamine modulators plus betahistine, melatonin, and samidorphan. Studies were short, lasting between 6 and 24 weeks. And they were small, with only 63 people on average ‐ the smallest included only 14 people, the largest 561 people. Studies done to date suggest that: ‐ metformin may be effective in preventing weight gain and is well‐tolerated compared to standard treatment (5 studies, 232 participants); ‐ H2 antagonists, such as nizatidine, famotidine and ranitidine, or monoamine modulators, such as reboxetine and fluoxetine may be potentially effective in preventing weight gain caused by antipsychotics; ‐ topiramate is probably not effective in preventing weight gain caused by antipsychotics. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only a small number of studies for each add‐on medication. Studies included few people, and lasted only a short time. How up to date is this evidence? The evidence is up to date to February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Agarwal, SM; Stogios, N; Ahsan, ZA; Lockwood, JT; Duncan, MJ; Takeuchi, H; Cohn, T; Taylor, VH; Remington, G; Faulkner, GE J; Hahn, M", "articleTypes": [], "doi": "10.1002/14651858.CD013337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "a3fc71dd-6642-4e3f-a2a3-1398708fddd8", "pmid": "", "title": "Chinese herbal medicine for primary dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Conventional treatment for primary dysmenorrhoea has a failure rate of 20% to 25% and may be contraindicated or not tolerated by some women. Chinese herbal medicine may be a suitable alternative. Objectives To determine the efficacy and safety of Chinese herbal medicine for primary dysmenorrhoea when compared with placebo, no treatment, and other treatment. Search methods The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007), EMBASE (1980 to January 2007), CINAHL (1982 to January 2007), AMED (1985 to January 2007), CENTRAL (The Cochrane Library issue 4, 2006), China National Knowledge Infrastructure (CNKI, 1990 to January 2007), Traditional Chinese Medicine Database System (TCMDS, 1990 to December 2006), and the Chinese BioMedicine Database (CBM, 1990 to December 2006) were searched. Citation lists of included trials were also reviewed. Selection criteria Any randomised controlled trials involving Chinese herbal medicine versus placebo, no treatment, conventional therapy, heat compression, another type of Chinese herbal medicine, acupuncture or massage. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra‐uterine contraceptive device. Data collection and analysis Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Data were combined for meta‐analysis using either Peto odds ratios or relative risk (RR) for dichotomous data or weighted mean difference for continuous data. A fixed‐effect statistical model was used, where suitable. If data were not suitable for meta‐analysis, any available data from the trial were extracted and presented as descriptive data. Main results Thirty‐nine randomised controlled trials involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for Chinese herbal medicine compared to placebo were unclear as data could not be combined (3 RCTs). Chinese herbal medicine resulted in significant improvements in pain relief (14 RCTs; RR 1.99, 95% CI 1.52 to 2.60), overall symptoms (6 RCTs; RR 2.17, 95% CI 1.73 to 2.73) and use of additional medication (2 RCTs; RR 1.58, 95% CI 1.30 to 1.93) when compared to use of pharmaceutical drugs. Self‐designed Chinese herbal formulae resulted in significant improvements in pain relief (18 RCTs; RR 2.06, 95% CI 1.80 to 2.36), overall symptoms (14 RCTs; RR 1.99, 95% CI 1.65 to 2.40) and use of additional medication (5 RCTs; RR 1.58, 95% CI 1.34 to 1.87) after up to three months of follow‐up when compared to commonly used Chinese herbal health products. Chinese herbal medicine also resulted in better pain relief than acupuncture (2 RCTs; RR 1.75, 95% CI 1.09 to 2.82) and heat compression (1 RCT; RR 2.08, 95% CI 2.06 to 499.18). Authors' conclusions The review found promising evidence supporting the use of Chinese herbal medicine for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials. Plain language summary Chinese herbal medicine may help reduce menstrual pain. Dysmenorrhoea is a very common complaint that refers to painful menstrual cramps in abdomen. Primary dysmenorrhoea refers to pain of an unknown cause (i.e. no medical condition is identified). Nonsteroidal anti‐inflammatory drugs or the contraceptive pill have been used successfully for treatment but more women are looking for non‐drug therapies. Chinese herbal medicine has been used for centuries in China and it is currently used in public hospitals in China for the treatment of primary dysmenorrhoea. The review found promising evidence for the use of Chinese herbal medicine in reducing menstrual pain in the treatment of primary dysmenorrhoea, compared to conventional medicine such as NSAIDs and the oral contraceptive pill, acupuncture and heat compression. No significant adverse effects were identified in this review. However the findings should be interpreted with caution due to the generally low methodological quality of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Zhu, X, Proctor, M, Bensoussan, A, Wu, E, Smith, CA", "articleTypes": [], "doi": "10.1002/14651858.CD005288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.776Z" }, { "id": "a406c48c-cedb-4d23-b5bd-43923506555e", "pmid": "", "title": "Dietary supplements for dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Dysmenorrhoea refers to painful menstrual cramps and is a common gynaecological complaint. Conventional treatments include non‐steroidal anti‐inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs), which both reduce myometrial activity (contractions of the uterus). A suggested alternative approach is dietary supplements. We used the term 'dietary supplement' to include herbs or other botanical, vitamins, minerals, enzymes, and amino acids. We excluded traditional Chinese medicines. Objectives To determine the efficacy and safety of dietary supplements for treating dysmenorrhoea. Search methods We searched sources including the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, PsycINFO (all from inception to 23 March 2015), trial registries, and the reference lists of relevant articles. Selection criteria We included randomised controlled trials (RCTs) of dietary supplements for moderate or severe primary or secondary dysmenorrhoea. We excluded studies of women with an intrauterine device. Eligible comparators were other dietary supplements, placebo, no treatment, or conventional analgesia. Data collection and analysis Two review authors independently performed study selection, performed data extraction and assessed the risk of bias in the included trials. The primary outcomes were pain intensity and adverse effects. We used a fixed‐effect model to calculate odds ratios (ORs) for dichotomous data, and mean differences (MDs) or standardised mean differences (SMDs) for continuous data, with 95% confidence intervals (CIs). We presented data that were unsuitable for analysis either descriptively or in additional tables. We assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods. Main results We included 27 RCTs (3101 women). Most included studies were conducted amongst cohorts of students with primary dysmenorrhoea in their late teens or early twenties. Twenty‐two studies were conducted in Iran and the rest were performed in other middle‐income countries. Only one study addressed secondary dysmenorrhoea. Interventions included 12 different herbal medicines (German chamomile ( Matricaria chamomilla, M recutita, Chamomilla recutita) , cinnamon ( Cinnamomum zeylanicum, C. verum) , Damask rose ( Rosa damascena), dill ( Anethum graveolens ), fennel ( Foeniculum vulgare ), fenugreek ( Trigonella foenum‐graecum ), ginger ( Zingiber officinale ), guava ( Psidium guajava ), rhubarb ( Rheum emodi ), uzara ( Xysmalobium undulatum ), valerian ( Valeriana officinalis ), and zataria ( Zataria multiflora )) and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Comparators included other supplements, placebo, no treatment, and NSAIDs. We judged all the evidence to be of low or very low quality. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few studies reported adverse effects. Effectiveness of supplements for primary dysmenorrhoea We have presented pain scores (all on a visual analogue scale (VAS) 0 to 10 point scale) or rates of pain relief, or both, at the first post‐treatment follow‐up. Supplements versus placebo or no treatment There was no evidence of effectiveness for vitamin E (MD 0.00 points, 95% CI −0.34 to 0.34; two RCTs, 135 women). There was no consistent evidence of effectiveness for dill (MD ‐1.15 points, 95% CI −2.22 to −0.08, one RCT, 46 women), guava (MD 0.59, 95% CI −0.13 to 1.31; one RCT, 151 women); one RCT, 73 women), or fennel (MD −0.34 points, 95% CI −0.74 to 0.06; one RCT, 43 women). There was very limited evidence of effectiveness for fenugreek (MD −1.71 points, 95% CI −2.35 to −1.07; one RCT, 101 women), fish oil (MD 1.11 points, 95% CI 0.45 to 1.77; one RCT, 120 women), fish oil plus vitamin B1 (MD −1.21 points, 95% CI −1.79 to −0.63; one RCT, 120 women), ginger (MD −1.55 points, 95% CI −2.43 to −0.68; three RCTs, 266 women; OR 5.44, 95% CI 1.80 to 16.46; one RCT, 69 women), valerian (MD −0.76 points, 95% CI −1.44 to −0.08; one RCT, 100 women), vitamin B1 alone (MD −2.70 points, 95% CI −3.32 to −2.08; one RCT, 120 women), zataria (OR 6.66, 95% CI 2.66 to 16.72; one RCT, 99 women), and zinc sulphate (MD −0.95 points, 95% CI −1.54 to −0.36; one RCT, 99 women). Data on chamomile and cinnamon versus placebo were unsuitable for analysis. Supplements versus NSAIDS There was no evidence of any difference between NSAIDs and dill (MD 0.13 points, 95% CI −1.01 to 1.27; one RCT, 47 women), fennel (MD −0.70 points, 95% CI −1.81 to 0.41; one RCT, 59 women), guava (MD 1.19, 95% CI 0.42 to 1.96; one RCT, 155 women), rhubarb (MD −0.20 points, 95% CI −0.44 to 0.04; one RCT, 45 women), or valerian (MD points 0.62 , 95% CI 0.03 to 1.21; one RCT, 99 women), There was no consistent evidence of a difference between Damask rose and NSAIDs (MD −0.15 points, 95% CI −0.55 to 0.25; one RCT, 92 women). There was very limited evidence that chamomile was more effective than NSAIDs (MD −1.42 points, 95% CI −1.69 to −1.15; one RCT, 160 women). Supplements versus other supplements There was no evidence of a difference in effectiveness between ginger and zinc sulphate (MD 0.02 points, 95% CI −0.58 to 0.62; one RCT, 101 women). Vitamin B1 may be more effective than fish oil (MD −1.59 points, 95% CI −2.25 to −0.93; one RCT, 120 women). Effectiveness of supplements for secondary dysmenorrhoea There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis (data were unsuitable for analysis). Safety of supplements Only four of the 27 included studies reported adverse effects in both treatment groups. There was no evidence of a difference between the groups but data were too scanty to reach any conclusions about safety. Authors' conclusions There is no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety is lacking. However for several supplements there was some low quality evidence of effectiveness and more research is justified. Plain language summary Dietary supplements for pain during menstruation Review question Cochrane authors reviewed the evidence of the effect of dietary supplements (e.g. vitamins, minerals, herbs) on period pain (dysmenorrhoea). Background Dietary supplements have been used in the treatment of period pain. It is important to explore their benefits and harms. We investigated the effectiveness of dietary supplements compared to other supplements, placebo, no treatment or conventional analgesics (pain relief) in women with either primary dysmenorrhoea (not related to any other diagnosis) or secondary dysmenorrhoea (related to other causes, such as endometriosis). The evidence is current to 23 March 2015. Study characteristics We included 27 randomised controlled trials (3101 women). Most participants were students in their late teens or early twenties with primary dysmenorrhoea. Most studies were conducted in Iran. Interventions included 12 different herbal medicines (chamomile, cinnamon, Damask rose, dill, fennel, fenugreek, ginger, guava, rhubarb, uzara, valerian, and zataria), and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Supplements were compared with other supplements, placebo, no treatment, and non‐steroidal anti‐inflammatory drugs (NSAIDs). Key results There was no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety was lacking. However, for several supplements there was some low quality evidence of effectiveness. Supplements for which there was some very limited evidence to suggest a potential benefit were fenugreek, ginger, valerian, zataria, zinc sulphate, fish oil, and vitamin B1. There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis. Quality of the evidence The evidence was of low or very low quality for all comparisons. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few included studies reported adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pattanittum, P, Kunyanone, N, Brown, J, Sangkomkamhang, US, Barnes, J, Seyfoddin, V, Marjoribanks, J", "articleTypes": [], "doi": "10.1002/14651858.CD002124.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.096Z" }, { "id": "a406f38a-2fba-4022-8df1-d68f963ccc80", "pmid": "", "title": "Glucocorticoids for croup in children", "imported": false, "abstract": "Abstract - Background Glucocorticoids are the mainstay for the treatment of croup. The existing evidence demonstrates that glucocorticoids are effective in the treatment of croup in children. However, updating the evidence on their clinical relevance in croup is imperative. This is an update to a review first published in 1999, and updated in 2004, 2011, and 2018. Objectives To investigate the effects and safety of glucocorticoids in the treatment of croup in children aged 18 years and below. Search methods We searched the Cochrane Library, which includes the Cochrane Central Register of Controlled Trials (CENTRAL; 2022 Issue 9), Ovid MEDLINE Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations and Ovid MEDLINE (1946 to 4 March 2022), Embase (Ovid) (1974 to 4 March 2022). We also searched the WHO ICTRP and ClinicalTrials.gov on 4 March 2022. Selection criteria We included randomised controlled trials (RCTs) in children (aged 18 years and below) with croup. We assessed the effect of glucocorticoids compared to the following: placebo, any other pharmacologic agents, any other glucocorticoids, any combination of other glucocorticoids, given by different modes of administration, or given in different doses. The included studies must have assessed at least one of our primary outcomes (defined as the change in croup score or return visits, (re)admissions to the hospital or both) or secondary outcomes (defined as the length of stay in hospital or emergency departments, patient improvement, use of additional treatments, or adverse events). Data collection and analysis Review authors independently extracted data, with another review author verified. We entered the data into Review Manager 5 for meta‐analysis. Two review authors independently assessed studies for risk of bias using the Cochrane risk of bias tool. Two review authors assessed the certainty of the evidence for the primary outcomes using the GRADE approach. Main results This updated review includes 45 RCTs with a total of 5888 children, an increase of two RCTs with 1323 children since the last update. We also identified one ongoing study and one study awaiting classification. We assessed most studies (98%) as at high or unclear risk of bias. Any glucocorticoid compared to placebo Compared to placebo, glucocorticoids may result in greater reductions in croup score after two hours (standardised mean difference (SMD) −0.65, 95% confidence interval (CI) −1.13 to −0.18; 7 RCTs, 426 children; low‐certainty evidence); six hours (SMD −0.76, 95% CI −1.12 to −0.40; 11 RCTs, 959 children; low‐certainty evidence); and 12 hours (SMD −1.03, 95% CI −1.53 to ‐0.53; 8 RCTs, 571 children; low‐certainty evidence). The evidence for change in croup score after 24 hours is very uncertain (SMD −0.86, 95% CI −1.40 to −0.31; 8 RCTs, 351 children; very low‐certainty evidence). One glucocorticoid compared to another glucocorticoid There was little to no difference between prednisolone and dexamethasone for reduction in croup score at two‐hour post‐baseline score (SMD 0.06, 95% CI −0.06 to 0.18; 1 RCT, 1231 children; high‐certainty evidence). There was likely little to no difference between prednisolone and dexamethasone for reduction in croup score at six‐hour post‐baseline score (SMD 0.21, 95% CI −0.21 to 0.62; 1 RCT, 99 children; moderate‐certainty evidence). However, dexamethasone probably reduced the return visits or (re)admissions for croup by almost half (risk ratio (RR) 0.55, 95% CI 0.28 to 1.11; 4 RCTs, 1537 children; moderate‐certainty evidence), and showed a 28% reduction in the use of supplemental glucocorticoids as an additional treatment (RR 0.72, 95% CI 0.53 to 0.97; 2 RCTs, 926 children). Dexamethasone given in different doses Compared to 0.15 mg/kg, 0.60 mg/kg dexamethasone probably reduced the severity of croup as assessed by the croup scoring scale at 24‐hour postbaseline score (SMD 0.63, 95% CI 0.16 to 1.10; 1 RCT, 72 children; moderate‐certainty evidence); however, this was not the case at two hours (SMD −0.27, 95% CI −0.76 to 0.22; 2 RCTs, 861 children; high‐certainty evidence). There was probably no reduction at six hours (SMD −0.45, 95% CI −1.26 to 0.35; 3 RCTs, 178 children; moderate‐certainty evidence), and the evidence at 12 hours is very uncertain (SMD −0.60, 95% CI −4.39 to 3.19; 2 RCTs, 113 children; very low‐certainty evidence). There was little to no difference between doses of dexamethasone in return visits or (re)admissions of children or both (RR 0.91, 95% CI 0.71 to 1.17; 3 RCTs, 949 children; high‐certainty evidence) or length of stay in the hospital or emergency department (mean difference 0.12, 95% CI −0.32 to 0.56; 2 RCTs, 892 children). The need for additional treatments, such as epinephrine (RR 0.78, 95% CI 0.34 to 1.75; 2 RCTs, 885 children); intubation (risk difference 0.00, 95% CI −0.00 to 0.00; 2 RCTs, 861 children); or use of supplemental glucocorticoids (RR 0.77, 95% CI 0.51 to 1.15; 2 RCTs, 617 children), also did not differ between doses of dexamethasone. There were moderate to high levels of heterogeneity in the analyses for most comparisons. Adverse events were observed for some of the comparisons reported in the review. Authors' conclusions The evidence that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions has not changed in this update. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg. More RCTs are needed to strengthen the evidence for effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. Plain language summary Glucocorticoids for croup in children Review question What is the effectiveness and safety of glucocorticoids when treating children with croup? Background Respiratory viruses are the main cause of croup in children. Croup leads to a swelling of the throat and airway, which can make breathing difficult. Children also present with a special type of cough called a barking cough. Glucocorticoids are types of steroids that help reduce the swelling, thereby making it easier for children with croup to breathe. This is an update of a review first published in 1999 and updated in 2004, 2011, and 2018. Search date The evidence is current to 4 March 2022. Study characteristics We included 2 new studies with 1323 children, for a total of 45 studies with 5888 children aged 0 to 18 years published between 1964 and 2021. The three types of glucocorticoids used in the new studies were budesonide, dexamethasone, and prednisolone. The most recent study compared the effectiveness of budesonide and dexamethasone. The other new study compared the effectiveness of dexamethasone and prednisolone, as well as a small dose of dexamethasone (0.15 mg/kg) versus 0.60 mg/kg dexamethasone. We added the data from the new study that compared the doses of dexamethasone to previously included studies looking at the same comparison. Study funding sources Funding sources included government (11%), academic or research institute (7%), industry (18%), or foundations (9%). More than half of the studies (55%) did not report funding sources. Key results Compared to prednisolone, dexamethasone showed no improvement in croup score at two and six hours after presenting to the hospital or emergency department, and probably reduced return visits or (re)admissions for croup by almost half. The addition of supplemental glucocorticoid favoured dexamethasone versus prednisolone. Compared to 0.15 mg/kg dexamethasone, the standard dose of 0.60 mg/kg probably reduced the severity of croup as assessed by the croup scoring scale at 24 hours after presenting to the hospital or emergency department. However, we did not find any important difference between groups in croup scoring scale at 2, 6, or 12 hours, return visits or (re)admissions of children, or length of stay in the hospital or emergency department. The need for additional treatments such as the use of other drugs like epinephrine, supplemental glucocorticoid, or the use of a tube to help breathing did not differ between 0.15 mg/kg and 0.60 mg/kg dexamethasone. No serious adverse events from the use of the glucocorticoids were reported in the newly included studies. Conclusions The evidence has not changed that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions compared to placebo (dummy treatment). A small dose of dexamethasone at 0.15 mg/kg may be as effective as the standard dose of 0.60 mg/kg. More studies are needed to strengthen the evidence for the effectiveness of low‐dose dexamethasone at 0.15 mg/kg to treat croup. We conclude that glucocorticoids are effective in the treatment of croup in children. Certainty of evidence Most studies (98%) had problems related to their methods, reporting issues, or both. For any glucocorticoid compared to placebo, we downgraded the certainty of the evidence for change in croup score after 2, 6, 12, and 24 hours and return visits or (re)admissions due to study variability, imprecision and inconsistency of study results, and risk of bias. There is little evidence that reporting bias influenced our results for return visits or (re)admissions, or both. Similar threats to the certainty of the evidence were present in the other comparisons in this review, including concerns related to risk of bias and inconsistency and imprecision of study results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Aregbesola, A, Tam, CM, Kothari, A, Le, M-L, Ragheb, M, Klassen, TP", "articleTypes": [], "doi": "10.1002/14651858.CD001955.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.745Z" }, { "id": "a409e2cd-73b4-4c41-a367-32bb8c4f1a45", "pmid": "", "title": "Lifestyle interventions for chronic gout", "imported": false, "abstract": "Abstract - Background Although lifestyle interventions are commonly recommended in the management of patients with chronic gout, the evidence from trial data for their benefits and safety has not been previously examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with chronic gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies on 5 April 2013. We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials (RCTs or CCTs) which compared lifestyle interventions to another therapy (active or placebo) in patients with chronic gout. Outcomes of interest were changes in gout attack frequency, joint pain, serum urate levels, tophus size, function, quality of life and adverse effects. Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (120 participants), at moderate risk of bias, was included in the review. Patients were randomised to one of three interventions: either skim milk powder (SMP) enriched with glycomacropeptide (GMP) and G600, non‐enriched SMP or lactose powder, over a three‐month period. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the three‐month study period. Low quality evidence indicated that there was no difference between the SMP/GMP/G600 group and combined control groups (SMP and lactose powder) at three months (mean difference (MD) ‐0.21, 95% confidence interval (CI) ‐0.76 to 0.34). There were no significant between‐group differences in terms of withdrawals due to adverse effects (risk ratio (RR) 1.27, 95% CI 0.53 to 3.03), and serious adverse events resulting in hospitalisation (2/40 SMP/GMP/G600 group versus 3/80 controls; RR 1.33, 95% CI 0.23 to 7.66). Gastrointestinal adverse effects were the most commonly reported. Pain from self reported gout flares, measured on a 10‐point Likert scale, improved more in the SMP/GMP/G600 group compared to controls (MD ‐1.03, 95% CI ‐1.96 to ‐0.10), an absolute difference of 10% (absolute risk difference ‐0.10, 95% CI ‐0.20 to ‐0.01). This is unlikely to be of clinical significance. There was no significant difference in physical function between SMP/GMP/G600 and the control groups at three‐month followup (MD ‐0.03, 95% CI ‐0.14 to 0.08). Tophus regression and serum urate normalisation were not reported in this study. Authors' conclusions While there is good evidence from observational studies of an association between various lifestyle risk factors and gout development, there is a paucity of high‐quality evidence from randomised controlled trials to either support or refute the use of lifestyle modifications for improving outcomes in people with chronic gout. Plain language summary Lifestyle interventions for chronic gout This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with chronic gout. There was one study included in this review which looked at the benefits and safety of consuming skim milk powder (SMP) enriched with two components of dairy products (glycomacropeptide (GMP) and G600 milk fat extract) compared to standard skim milk or lactose powder in reducing the frequency of gout attacks over a three‐month period. The review shows that, in people with chronic gout : Compared with standard skim milk or lactose powder, SMP enriched with GMP and G600 may not reduce the frequency of gout attacks, may not improve physical function, but may reduce pain. We do not know if consuming these dairy preparations improves tophus size (tophi are gout crystal deposits commonly found in skin, on the surface of joints or in cartilage) or blood uric acid levels, as these were not reported. We do not have precise information about side effects and complications. Possible side effects may include nausea or diarrhoea. What is gout and what are lifestyle interventions? Gout is a very common form of painful joint inflammation (arthritis) caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness and swelling of affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic makeup, being overweight, ingesting certain medications (e.g. diuretics), having impaired kidney function and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Although medications are the mainstay of gout treatment, given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as losing weight, stopping smoking, exercising more, drinking more coffee and dairy products, and consuming less sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout. Best estimate of what happens to people with gout who consume enriched skim milk powder: Gout attacks People who consumed enriched skim milk powder had 0.21 fewer gout attacks per month at 3 months (or 2.5 fewer gout attacks per year) . ‐ People who consumed enriched skim milk powder had 0.49 gout attacks per month (or 6 gout attacks per year). ‐ People who consumed standard skim milk powder or lactose had 0.70 gout attacks per month (or 8 gout attacks per year). Withdrawals due to adverse events 4 more people out of 100 who consumed enriched skim milk powder discontinued the supplement at 3 months (4% more withdrawals absolute change, from 10% fewer to 18% more). ‐ 18 out of 100 stopped consuming enriched skim milk powder. ‐ 14 out of 100 stopped consuming standard skim milk powder or lactose. Pain (lower score means less pain) People who consumed enriched skim milk powder rated their pain 1 point lower on a 0 to 10 point pain scale (10% absolute improvement; 20% to 1% improvement) at 3 months. ‐ People who consumed enriched skim milk powder rated their pain to be 0.67 points on a scale of 0 to 10. ‐ People who consumed standard skim milk powder or lactose rated their pain to be 1.7 points on a scale of 0 to 10. Physical function (lower score means better function) People who consumed enriched skim milk powder rated their function 0.03 better (0.14 better to 0.08 worse) on a 0 to 3 point scale (1% absolute improvement; 5% improvement to 3% worse) at 3 months. ‐ People who consumed enriched skim milk powder rated their function to be 0.08 points on a scale of 0 to 3. ‐ People who consumed standard skim milk powder or lactose rated their function to be 0.11 points on a scale of 0 to 3. Serious adverse events 1 more person out of 100 who consumed enriched skim milk powder reported a serious adverse event. ‐ 5 out of 100 who consumed enriched skim milk powder had a serious adverse event. ‐ 4 out of 100 who consumed standard skim milk powder or lactose had a serious adverse event.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY; Sriranganathan, MK; Edwards, CJ; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "a41171da-16fd-4397-a8f4-8574e3371514", "pmid": "", "title": "Lamotrigine for chronic neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This is an update of the original Cochrane review entitled Lamotrigine for acute and chronic pain published in Issue 2, 2007, and updated in Issue 2, 2011. Some antiepileptic medicines have a place in the treatment of neuropathic pain (pain due to nerve damage). This updated review adds no new additional studies looking at evidence for lamotrigine as an effective treatment for chronic neuropathic pain or fibromyalgia. The update uses higher standards of evidence than previously. Objectives To assess the analgesic efficacy of lamotrigine in the treatment of chronic neuropathic pain and fibromyalgia, and to evaluate adverse effects reported in the studies. Search methods We identified randomised controlled trials (RCTs) of lamotrigine for chronic neuropathic pain and fibromyalgia (including cancer pain) from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). We ran searches for the original review in 2006, in 2011 for the first update, and subsequent searches in August 2013 for this update. We sought additional studies from the reference lists of the retrieved papers. The original review and first update included acute pain, but no acute pain studies were identified. Selection criteria RCTs investigating the use of lamotrigine (any dose, by any route, and for any study duration) for the treatment of chronic neuropathic pain or fibromyalgia. Assessment of pain intensity or pain relief, or both, using validated scales. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First‐tier studies did not use last observation carried forward (LOCF) or other imputational methods for dropouts. The second tier used data that failed to meet this standard and second‐tier results were therefore subject to potential bias. Main results Twelve included studies in 11 publications (1511 participants), all with chronic neuropathic pain: central post‐stroke pain (1), chemotherapy‐induced neuropathic pain (1), diabetic neuropathy (4), HIV‐related neuropathy (2), mixed neuropathic pain (2), spinal cord injury‐related pain (1), and trigeminal neuralgia (1). We did not identify any additional studies. Participants were aged between 26 and 77 years. Study duration was two weeks in one study and at least six weeks in the remainder; eight were of eight‐week duration or longer. No study provided first‐tier evidence for an efficacy outcome. There was no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of 200 mg to 400 mg daily. Almost 10% of participants taking lamotrigine reported a skin rash. Authors' conclusions Large, high‐quality, long‐duration studies reporting clinically useful levels of pain relief for individual participants provided no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of about 200 to 400 mg daily. Given the availability of more effective treatments including antiepileptics and antidepressant medicines, lamotrigine does not have a significant place in therapy based on the available evidence. The adverse effect profile of lamotrigine is also of concern. Plain language summary Lamotrigine (an antiepileptic drug) for chronic neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our understanding of fibromyalgia (a condition of persistent, widespread pain and tenderness, sleep problems, and fatigue) is lacking, but fibromyalgia can respond to the same medicines as neuropathic pain. Lamotrigine is a medicine used to treat epilepsy, and so might be a useful medicine for neuropathic pain or fibromyalgia. On 26 November 2013 we performed searches to look for clinical trials where lamotrigine was used to treat neuropathic pain or fibromyalgia. We found 12 studies of reasonable quality that tested lamotrigine against placebo for a number of weeks. Almost half of the 1511 people in the studies had painful limbs because of damaged nerves caused by diabetes, and seven different painful neuropathic conditions were examined. No studies looked at fibromyalgia. Lamotrigine did not help the pain, and was no different from placebo except in causing more side effects. Adverse events were more frequent with lamotrigine than placebo, with rash in 1 person in 27.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD006044.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "a4167213-b02d-412a-9af9-f3718f4331d9", "pmid": "", "title": "OTIS - Optimized Complementary Feeding Study", "imported": false, "abstract": "Dietary factors during infancy, e.g. high intakes of protein, fast carbohydrates and saturated fat increase the risk of adult obesity, type 2 diabetes and hypertension. However, current dietary recommendations to infants are based on traditions and experiences whereas research is basically lacking.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "a43a4827-e03b-40b7-907d-bacb31257f63", "pmid": "", "title": "Foetal haemoglobin inducers for reducing blood transfusion in non‐transfusion‐dependent beta‐thalassaemias", "imported": false, "abstract": "Abstract - Background Non‐transfusion‐dependent β‐thalassaemia (NTDβT) is a subset of inherited haemoglobin disorders characterised by reduced production of the β‐globin chain of haemoglobin leading to anaemia of varying severity. Although blood transfusion is not a necessity for survival, it may be required to prevent complications of chronic anaemia, such as impaired growth and hypercoagulability. People with NTDβT also experience iron overload due to increased iron absorption from food sources which becomes more pronounced in those requiring blood transfusion. People with a higher foetal haemoglobin (HbF) level have been found to require fewer blood transfusions, thus leading to the emergence of treatments that could increase its level. HbF inducers stimulate HbF production without altering any gene structures. Evidence for the possible benefits and harms of these inducers is important for making an informed decision on their use. Objectives To compare the effectiveness and safety of the following for reducing blood transfusion for people with NTDβT: 1. HbF inducers versus usual care or placebo; 2. single HbF inducer with another HbF inducer, and single dose with another dose; and 3. combination of HbF inducers versus usual care or placebo, or single HbF inducer. Search methods We used standard, extensive Cochrane search methods. The latest search date was 21 August 2022. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs comparing single HbF inducer with placebo or usual care, with another single HbF inducer or with a combination of HbF inducers; or comparing different doses of the same HbF inducer. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were blood transfusion and haemoglobin levels. Our secondary outcomes were HbF levels, the long‐term sequelae of NTDβT, quality of life and adverse events. Main results We included seven RCTs involving 291 people with NTDβT, aged two to 49 years, from five countries. We reported 10 comparisons using eight different HbF inducers (four pharmacological and four natural): three RCTs compared a single HbF inducer to placebo and seven to another HbF inducer. The duration of the intervention lasted from 56 days to six months. Most studies did not adequately report the randomisation procedures or whether and how blinding was achieved. HbF inducer against placebo or usual care Three HbF inducers, HQK‐1001, Radix Astragali or a 3‐in‐1 combined natural preparation (CNP), were compared with a placebo. None of the comparisons reported the frequency of blood transfusion. We are uncertain whether Radix Astragali and CNP increase haemoglobin at three months (mean difference (MD) 1.33 g/dL, 95% confidence interval (CI) 0.54 to 2.11; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). We are uncertain whether Radix Astragali and CNP have any effect on HbF (MD 12%, 95% CI −0.74% to 24.75%; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). Only medians on haemoglobin and HbF levels were reported for HQK‐1001. Adverse effects reported for HQK‐1001 were nausea, vomiting, dizziness and suprapubic pain. There were no prespecified adverse effects for Radix Astragali and CNP. HbF inducer versus another HbF inducer Four studies compared a single inducer with another over three to six months. Comparisons included hydroxyurea versus resveratrol, hydroxyurea versus thalidomide, hydroxyurea versus decitabine and Radix Astragali versus CNP. No study reported our prespecified outcomes on blood transfusion. Haemoglobin and HbF were reported for the comparison Radix Astragali versus CNP, but we are uncertain whether there were any differences (1 study, 24 participants; low‐certainty evidence). Different doses of the same HbF inducer Two studies compared two different types of HbF inducers at different doses over two to six months. Comparisons included hydroxyurea 20 mg/kg/day versus 10 mg/kg/day and HQK‐1001 10 mg/kg/day, 20 mg/kg/day, 30 mg/kg/day and 40 mg/kg/day. Blood transfusion, as prespecified, was not reported. In one study (61 participants) we are uncertain whether the lower levels of both haemoglobin and HbF at 24 weeks were due to the higher dose of hydroxyurea (haemoglobin: MD −2.39 g/dL, 95% CI −2.80 to −1.98; very low‐certainty evidence; HbF: MD −10.20%, 95% CI −16.28% to −4.12%; very low‐certainty evidence). The study of the four different doses of HQK‐1001 did not report results for either haemoglobin or HbF. We are not certain if major adverse effects may be more common with higher hydroxyurea doses (neutropenia: risk ratio (RR) 9.93, 95% CI 1.34 to 73.97; thrombocytopenia: RR 3.68, 95% CI 1.12 to 12.07; very low‐certainty evidence). Taking HQK‐1001 20 mg/kg/day may result in the fewest adverse effects. A combination of HbF inducers versus a single HbF inducer Two studies compared three combinations of two inducers with a single inducer over six months: hydroxyurea plus resveratrol versus resveratrol or hydroxyurea alone, and hydroxyurea plus l‐carnitine versus hydroxyurea alone. Blood transfusion was not reported. Hydroxyurea plus resveratrol may reduce haemoglobin compared with either resveratrol or hydroxyurea alone (MD −0.74 g/dL, 95% CI −1.45 to −0.03; 1 study, 54 participants; low‐certainty evidence). We are not certain whether the gastrointestinal disturbances, headache and malaise more commonly reported with hydroxyurea plus resveratrol than resveratrol alone were due to the interventions. We are uncertain whether hydroxyurea plus l‐carnitine compared with hydroxyurea alone may increase mean haemoglobin, and reduce pulmonary hypertension (1 study, 60 participants; very low‐certainty evidence). Adverse events were reported but not in the intervention group. None of the comparisons reported the outcome of HbF. Authors' conclusions We are uncertain whether any of the eight HbF inducers in this review have a beneficial effect on people with NTDβT. For each of these HbF inducers, we found only one or at the most two small studies. There is no information on whether any of these HbF inducers have an effect on our primary outcome, blood transfusion. For the second primary outcome, haemoglobin, there may be small differences between intervention groups, but these may not be clinically meaningful and are of low‐ to very low‐certainty evidence. Data on adverse effects and optimal doses are limited. Five studies are awaiting classification, but none are ongoing. Plain language summary Medicines to increase foetal haemoglobin levels and reduce the need for blood transfusion in people with non‐transfusion‐dependent thalassaemia Review question Do medicines that increase foetal haemoglobin (HbF) levels in people with non‐transfusion‐dependent β‐thalassaemia (NTDβT) reduce their need for blood transfusion? What is thalassaemia? Thalassaemia is a genetic (inherited) blood disorder that causes defects in adult haemoglobin (the oxygen carrying component of red blood cells) leading to destruction of the red blood cells and anaemia with different degrees of severity. Persistent anaemia can affect general health and reduce quality of life. People with NTDβT may require periodic blood transfusion to replace the red blood cells and this could lead to excess iron being deposited in various organs in the body, affecting their function. People with NTDβT have higher levels of HbF (the main form of haemoglobin found during the development of a baby before birth) which persists after birth. The amount of HbF that persists varies and people with a higher HbF level require less frequent blood transfusions. What are HbF inducers? HbF inducers are substances which increase HbF levels without alteration to the gene. They may reduce the need for blood transfusion in people with NTDβT. However, it is not known which HbF inducers are effective and safe, and if so, what the optimal dose is and at what age treatment should be started. What did we do? We searched medical databases for studies comparing single HbF inducer with placebo (dummy treatment) or usual care, with another inducer or with a combination of inducers; or comparing different doses for a same inducer. What did we find? We found seven very small randomised controlled trials (where people taking part in the trial had equal chances of being in the treatment or the control group), involving 291 people with NTDβT, aged between two and 49 years, from five countries. These studies varied widely in the type of HbF inducers investigated and their comparison, the doses and how outcomes were reported. The duration of the trials ranged from two to six months. The inducers used include hydroxyurea, decitabine, HQK‐1001, thalidomide, Radix Astragali, resveratrol, l‐carnitine and combined natural preparation (CNP). Main results None of the studies reported our main outcome of changes to the frequency of blood transfusion. All inducers may have caused a small increase in haemoglobin and HbF when compared to placebo, but we are very uncertain about this. Four studies compared a single HbF inducer against another, for three to six months. There were changes to haemoglobin and HbF, but we cannot be certain if a single HbF inducer or a combination of HbF inducers would work better than another. Two studies, each compared a different dose of the same inducer. Lower doses of hydroxyurea appeared to increase haemoglobin and HbF levels more than the higher doses, but we are very uncertain. The other study used four different doses of HQK‐1001 but did not actually look for a difference in the effect of these four different doses on haemoglobin or HbF. Two studies compared a combination of two HbF inducers with a single HbF inducer for six months. We are very uncertain whether the combination or a single inducer improves haemoglobin. None of the studies reported whether HbF inducers have any effect on quality of life. Adverse (unwanted) drug effects were reported for each HbF inducer, but there was little information available to guide us on the safety of these substances. What are the limitations of the evidence? The main reason we are very uncertain about the effects of HbF inducers are because the studies were all very small and had weaknesses in their design. None of the studies lasted long enough to provide meaningful information for many of the outcomes we measured. How up to date is this evidence? The evidence is current to 21 August 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Foong, WC, Loh, CK, Ho, JJ, Lau, DSC", "articleTypes": [], "doi": "10.1002/14651858.CD013767.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.757Z" }, { "id": "a44ac3cd-5068-4e4d-887b-cfa095d7de4a", "pmid": "", "title": "Blood pressure lowering efficacy of diuretics as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Diuretics are widely prescribed for hypertension not only as a first‐line drug but also as a second‐line drug. Therefore, it is essential to determine the effects of diuretics on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a second‐line drug. Objectives To quantify the additional reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of diuretic therapy as a second‐line drug in patients with primary hypertension Search methods CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (1966‐July 2008), EMBASE (1988‐July 2008) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized, controlled trials evaluating the BP lowering efficacy of a diuretic in combination therapy with another class of anti‐hypertensive drugs compared with the respective monotherapy (without a diuretic) for a duration of 3 to 12 weeks in patients with primary hypertension. Data collection and analysis Two review authors independently extracted the data and assessed trial quality. Main results Fifty‐three double‐blind RCTs evaluating a thiazide in 15129 hypertensive patients (baseline BP of 156/101 mmHg) were included. Hydrochlorothiazide was the thiazide used in 49/53 (92%) of the included studies. The additional BP reduction caused by the thiazide as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. Thiazides as a second‐line drug reduced BP by 6/3 and 8/4 mmHg at doses of 1 and 2 times the manufacturer's recommended starting dose respectively. The BP lowering effect was dose related. The effect was similar to that obtained when thiazides are used as a single agent. Only 3 double‐blind RCTs evaluating loop diuretics were identified. These RCTs showed a BP lowering effect of a starting dose of about 6/3 mmHg. Authors' conclusions Thiazides when given as a second‐line drug have a dose related effect to lower blood pressure that is similar to when they are added as a first‐line drug. This means that the BP lowering effect of thiazides is additive. Loop diuretics appear to have a similar blood pressure lowering effect as thiazides at 1 times the recommended starting dose. Because of the short duration of the trials and lack of reporting of adverse events, this review does not provide a good estimate of the incidence of adverse effects of diuretics given as a second‐line drug. Plain language summary Diuretics effective in lowering blood pressure when given as a second drug Diuretics are a good first‐line treatment for high blood pressure (BP). Diuretics include loop diuretics and thiazides. We asked how much do diuretics reduce BP when used as the second drug to treat hypertension. We performed a search of the available scientific literature to find all trial evidence to assess this question. Fifty‐six trials were found. Fifty‐three trials involved thiazide diuretics (92% with the drug hydrochlorothiazide) and included a total of 15310 participants. Adding a thiazide to another anti‐hypertensive drug further reduces the BP by an additional 6/3 mmHg when given at the starting dose and reduces BP by 8/4 mmHg at 2 times the starting dose. This is approximately the same effect as when the drugs are used alone. A good estimate of the harms associated with diuretics cannot be estimated in this review because of the lack of reporting and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Chen, JMH; Heran, BS; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "a45865cc-ed31-40eb-b641-a89162fef565", "pmid": "", "title": "Olfactory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Preterm infants, often gavage‐fed due to immaturity, may benefit from interventions that hasten the move to breastfeeding. Olfactory stimulation may increase appetite and speed up the transition to full oral feeding, potentially shortening hospital stay and improving outcomes for both infants and families. Objectives To evaluate the benefits and harms of olfactory stimulation for reducing morbidity and promoting development in hospitalized preterm infants. Search methods We searched MEDLINE, Embase, CENTRAL, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 2 April 2025. We checked the reference lists of included studies and systematic reviews on olfactory or sensory stimulation. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs evaluating olfactory stimulation with different odorants (maternal breast milk, food‐associated odors, or non‐food‐associated odors) in preterm infants (born before 37 weeks' gestation). Eligible controls were no intervention, placebo, or standard care (considered together) or another odorant. We excluded studies combining olfactory stimulation with taste, as another review will focus on combined sensory stimulation. Outcomes Our critical outcomes were apnea, intermittent hypoxemia, duration of hospital stay, time to full oral feeding, and exclusive breastfeeding. Our important outcomes included blindness and sensorineural deafness requiring amplification. Risk of bias We used the Cochrane risk of bias tool (RoB 2) to assess risk of bias in the included studies. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, each with its 95% confidence interval (CI). We assessed the certainty of evidence using GRADE. Included studies We included 14 trials enrolling 1087 neonates. The types of olfactory stimulation under investigation were maternal breast milk (9 studies); food‐associated odors such as cinnamon, vanilla, or anise (5 studies); and non‐food‐associated odors such as rose or parents' scent (3 studies). Three studies evaluated two different odorants. Gestational age and bodyweight varied widely. The comparators were placebo, no intervention, and standard care. Eleven studies aimed to assess the effect of olfactory stimulation on infant feeding outcomes such as time to full oral feeding, weight gain, length of hospital stay, or a combination of these outcomes. Three studies aimed to assess the effect of olfactory stimulation on apnea prevention, oxygen saturation, or both. We identified five ongoing trials. Synthesis of results No studies reported apnea as a dichotomous outcome, intermittent hypoxemia, exclusive breastfeeding, or major neurodevelopmental disability for any of the comparisons. We downgraded the certainty of evidence for limitations in study design, imprecision, and indirectness. Olfactory stimulation with maternal breast milk versus no intervention, placebo, or standard care The evidence is very uncertain about the effect of olfactory stimulation with maternal breast milk on the mean number of daily apnea episodes (MD −0.50, 95% CI −1.27 to 0.27; 1 study, 26 participants; very low‐certainty evidence) and duration of hospital stay in days (MD −0.18, 95% CI −0.64 to 0.27; I² = 0%; 4 studies, 270 participants; very low‐certainty evidence). Olfactory stimulation with maternal breast milk may result in a slight reduction in time to full oral feeding in days (MD −1.68, 95% CI −3.25 to −0.11; I² = 30%; 3 studies, 204 participants; low‐certainty evidence). Olfactory stimulation with food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with food‐associated odors may result in a slight reduction in the mean number of daily apnea episodes (MD −1.99, 95% CI −2.69 to −1.29; I² = 58%; 2 studies, 62 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with food‐associated odors on duration of hospital stay in days (MD −2.65, 95% CI −6.18 to 0.89; I² = 20%; 3 studies, 185 participants; very low‐certainty evidence) and time to full oral feeding in days (MD −2.06, 95% CI −5.16 to 1.04; I² = 36%; 3 studies, 185 participants; very low‐certainty evidence). Olfactory stimulation with non‐food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with non‐food‐associated odors may result in a slight reduction in duration of hospital stay in days (MD −3.23, 95% CI −5.50 to −0.97; I² = 0%; 2 studies, 94 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with non‐food‐associated odor on the mean number of daily apnea episodes (MD −2.13, 95% CI −2.28 to −1.98; 1 study, 60 participants; very low‐certainty evidence) and time to full oral feeding (mean 21 (standard deviation 3.1) days in the intervention group and mean 21 (standard deviation 15.6) days in the control group; 1 study, 27 participants; very low‐certainty evidence). Authors' conclusions Olfactory stimulation with maternal breast milk compared to no intervention, placebo, or standard care may result in a slight reduction in time to full oral feeding, but the evidence is very uncertain about its effect on frequency of apnea episodes and duration of hospital stay. Olfactory stimulation with food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in frequency of apnea episodes, but the evidence is very uncertain about its effect on duration of hospital stay and time to full oral feeding. Olfactory stimulation with non‐food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in duration of hospital stay, but the evidence is very uncertain about its effect on frequency of apnea episodes and time to full oral feeding. Future studies should be more rigorous in their design, report using TIDieR (Template for Intervention Description and Replication) checklists, have larger sample sizes, and measure outcomes such as apnea (number of infants with ≥ 1 episode), intermittent hypoxemia (number of infants with ≥ 1 episode), exclusive breastfeeding, and major neurodevelopmental disabilities. Funding Dedicated funding for this review can be found in the 'Sources of support' section. Registration Protocol: https://doi.org/10.1002/14651858.CD016074 . Plain language summary Does introducing smells to preterm infants improve their physical and mental development? Key messages Introducing preterm infants to the smell of maternal breast milk may slightly reduce the time it takes for them to feed fully by mouth. Introducing them to food smells such as vanilla and cinnamon may slightly reduce how often they stop breathing. Finally, introducing preterm babies to the smell of rose or a parent's scent may reduce slightly the time they have to stay in hospital. All other results are very uncertain. Future studies should include more infants, use more rigorous designs, and measure outcomes such as breathing problems, low blood oxygen levels, exclusive breastfeeding, and long‐term neurodevelopmental outcomes. What is preterm birth? A normal pregnancy usually lasts from 37 weeks to 42 weeks. Preterm birth is when a baby is born before 37 weeks of pregnancy. Babies born preterm have not had enough time to fully develop before birth. Their organs may not yet be ready to work on their own, which means they often need intensive medical care and are at greater risk of breathing and feeding difficulties, infection, and problems that can affect their long‐term development. What is olfactory stimulation, and how does it work? Preterm infants often take time to build up the skills or physical capacity to feed by mouth, and in the meantime are fed through a tube passed into the stomach. Olfactory stimulation involves introducing smells to preterm infants while they are in hospital to see if it helps them start breastfeeding more quickly. These smells include breast milk, food smells such as vanilla or cinnamon, and other smells such as a floral scent or a parent's scent. What did we want to find out? We wanted to find out whether introducing a smell to preterm infants in hospital could be helpful and safe for their short‐term and long‐term well‐being. More specifically, we wanted to find out whether introducing a smell to preterm infants is better than placebo (dummy treatment), no treatment, or usual care for: reducing the number of infants who have apnea (brief pauses in breathing); reducing the number of infants with low oxygen levels in the blood; reducing the time spent in hospital; reducing the time needed for the infants to learn to feed fully by mouth; increasing the number of infants that are fed only with breast milk; reducing the number of infants with blindness or deafness between 18 and 24 months of age. What did we do? We searched for studies that compared olfactory stimulation with placebo, no treatment, or usual care in preterm infants. We summarized the results of the studies and rated our confidence in the evidence based on factors such as study size (number of infants) and methods. What did we find? We included 14 studies with 1087 infants. Nine studies used the smell of maternal breast milk, five used food‐associated smells (vanilla, cinnamon, or anise), and three studies used other smells (rose or parents' scent). All studies compared these smells with no treatment, placebo, or usual care. Main results Introducing the smell of maternal breast milk may reduce slightly the time it takes infants to feed fully by mouth. It is unclear whether stimulation with this smell has any effect on how often infants have apnea episodes and how long they stay in hospital. Introducing the smell of cinnamon, vanilla, or anise may slightly reduce how often infants have apnea episodes. It is unclear whether stimulation with these smells has any effect on how long infants stay in hospital or how long it takes them to feed fully by mouth. Introducing the scent of rose or a parent's scent may slightly reduce how long infants spend in hospital. It is unclear whether stimulation with these smells has any effect on how often infants have apnea episodes or how long it takes them to feed fully by mouth. What are the limitations of the evidence? We have little confidence in these results, as the studies included could have been better designed and included more babies. Several studies did not report outcomes we were interested in. How up to date is this evidence? The evidence is current to 2 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lenells, M; Prescott, MG; Wróblewska-Seniuk, K; Fiander, M; Soll, RF; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD016074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "a47a9cdd-71c6-45b7-be43-d8a5bfaa0dfe", "pmid": "", "title": "Treatment and prevention of pouchitis after ileal pouch‐anal anastomosis for chronic ulcerative colitis", "imported": false, "abstract": "Abstract - Background Pouchitis occurs in approximately 50% of patients following ileal pouch‐anal anastomosis (IPAA) for chronic ulcerative colitis (UC). Objectives The primary objective was to determine the efficacy and safety of medical therapies for prevention or treatment of acute or chronic pouchitis. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 25 July 2018. We also searched references, trials registers, and conference proceedings. Selection criteria Randomized controlled trials of prevention or treatment of acute or chronic pouchitis in adults who underwent IPAA for UC were considered for inclusion. Data collection and analysis Two authors independently screened studies for eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was evaluated using GRADE. The primary outcome was clinical improvement or remission in participants with acute or chronic pouchitis, or the proportion of participants with no episodes of pouchitis after IPAA. Adverse events (AEs) was a secondary outcome. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for each dichotomous outcome. Main results Fifteen studies (547 participants) were included. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Three studies were low risk of bias. Three studies were high risk of bias and the other studies were unclear. Acute pouchitis: All ciprofloxacin participants (7/7) achieved remission at two weeks compared to 33% (3/9) of metronidazole participants (RR 2.68, 95% CI 1.13 to 6.35, very low certainty evidence). No ciprofloxacin participants (0/7) had an AE compared to 33% (3/9) of metronidazole participants (RR 0.18, 95% CI 0.01 to 2.98; very low certainty evidence). AEs included vomiting, dysgeusia or transient peripheral neuropathy. Forty‐three per cent (6/14) of metronidazole participants achieved remission at 6 weeks compared to 50% (6/12) of budesonide enema participants (RR 0.86, 95% CI 0.37 to 1.96, very low certainty evidence). Fifty per cent (7/14) of metronidazole participants improved clinically at 6 weeks compared to 58% (7/12) of budesonide enema participants (RR 0.86, 95% CI 0.42 to 1.74, very low certainty evidence). Fifty‐seven per cent (8/14) of metronidazole participants had an AE compared to 25% (3/12) of budesonide enema participants (RR 2.29, 95% CI 0.78 to 6.73, very low certainty evidence). AEs included anorexia, nausea, headache, asthenia, metallic taste, vomiting, paraesthesia, and depression. Twenty‐five per cent (2/8) of rifaximin participants achieved remission at 4 weeks compared to 0% (0/10) of placebo participants (RR 6.11, 95% CI 0.33 to 111.71, very low certainty evidence). Thirty‐eight per cent (3/8) of rifaximin participants improved clinically at 4 weeks compared to 30% (3/10) of placebo participants (RR 1.25, 95% CI 0.34 to 4.60, very low certainty evidence). Seventy‐five per cent (6/8) of rifaximin participants had an AE compared to 50% (5/10) of placebo participants (RR 1.50, 95% CI 0.72 to 3.14, very low certainty evidence). AEs included diarrhea, flatulence, nausea, proctalgia, vomiting, thirst, candida, upper respiratory tract infection, increased hepatic enzyme, and cluster headache. Ten per cent (1/10) of Lactobacillus GG participants improved clinically at 12 weeks compared to 0% (0/10) of placebo participants (RR 3.00, 95% CI 0.14 to 65.90, very low certainty evidence). Chronic pouchitis: Eighty‐five per cent (34/40) of De Simone Formulation (a probiotic formulation) participants maintained remission at 9 to 12 months compared to 3% (1/36) of placebo participants (RR 20.24, 95% CI 4.28 to 95.81, 2 studies; low certainty evidence). Two per cent (1/40) of De Simone Formulation participants had an AE compared to 0% (0/36) of placebo participants (RR 2.43, 95% CI 0.11 to 55.89; low certainty evidence). AEs included abdominal cramps, vomiting and diarrhea. Fifty per cent (3/6) of adalimumab patients achieved clinical improvement at 4 weeks compared to 43% (3/7) of placebo participants (RR, 1.17, 95% CI 0.36 to 3.76, low certainty evidence). Sixty per cent (6/10) of glutamine participants maintained remission at 3 weeks compared to 33% (3/9) of butyrate participants (RR 1.80, 95% CI 0.63 to 5.16, very low certainty evidence). Forty‐five per cent (9/20) of patients treated with bismuth carbomer foam enema improved clinically at 3 weeks compared to 45% (9/20) of placebo participants (RR 1.00, 95% CI 0.50 to 1.98, very low certainty evidence). Twenty‐five per cent (5/20) of participants in the bismuth carbomer foam enema group had an AE compared to 35% (7/20) of placebo participants (RR 0.71, 95% CI 0.27 to 1.88, very low certainty evidence). Adverse events included diarrhea, worsening symptoms, cramping, sinusitis, and abdominal pain. Prevention: At 12 months, 90% (18/20) of De Simone Formulation participants had no episodes of acute pouchitis compared to 60% (12/20) of placebo participants (RR 1.50, 95% CI 1.02 to 2.21, low certainty evidence). Another study found 100% (16/16) of De Simone Formulation participants had no episodes of acute pouchitis at 12 months compared to 92% (11/12) of the no treatment control group (RR 1.10, 95% 0.89 to 1.36, very low certainty evidence). Eighty‐six per cent (6/7) of Bifidobacterium longum participants had no episodes of acute pouchitis at 6 months compared to 60% (3/5) of placebo participants (RR 1.43, 95% CI 0.66 to 3.11, very low certainty evidence). Eleven per cent (1/9) of Clostridium butyricum MIYAIRI participants had no episodes of acute pouchitis at 24 months compared to 50% (4/8) of placebo participants (RR 0.22, 95% CI 0.03 to 1.60, very low certainty evidence). Forty‐six per cent (43/94) of allopurinol participants had no episodes of pouchitis at 24 months compared to 43% (39/90) of placebo participants (RR 1.06, 95% CI 0.76 to 1.46; low certainty evidence). Eighty‐one per cent (21/26) of tinidazole participants had no episodes of pouchitis over 12 months compared to 58% (7/12) of placebo participants (RR 1.38, 95% CI 0.83 to 2.31, very low certainty evidence). Authors' conclusions The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. Well designed, adequately powered studies are needed to determine the optimal therapy for the treatment and prevention of pouchitis. Plain language summary Therapy for treatment and prevention of pouchitis What is pouchitis? Some people with ulcerative colitis have their colon and rectum removed with construction of a pouch (made from a loop of small intestine) in place of the rectum ‐ known as ileal pouch‐anal anastomosis (IPAA) surgery. Pouchitis is inflammation of the surgically‐constructed pouch. Symptoms of active pouchitis include diarrhea, increased stool frequency, abdominal cramping, fecal urgency, tenesmus (feeling of constantly needing to pass stools), and incontinence. Acute refers to symptoms that last less than four weeks while chronic refers to symptoms that last more than four weeks. Periods when symptoms stop are called 'remission'. What therapies are used for pouchitis? Therapies used for pouchitis include antibiotics (drugs for bacteria infections), budesonide enemas (a steroid drug), probiotics (helpful bacteria), biologic agents that target tumor necrosis factor, glutamine suppositories (an amino acid), butyrate suppositories (short chain fatty acid), bismuth enemas (diarrhea medication), allopurinol (a purine analogue drug), and tinidazole (an anti‐parasitic drug). What did the researchers investigate? The researchers investigated whether these medications produce remission in people with active pouchitis, maintain remission in people with inactive pouchitis or prevent pouchitis in people who've had IPAA surgery. Side effects were also assessed. The medical literature was searched up to 25 July 2018. What did the researchers find? We found 15 studies with a total of 547 participants. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Acute pouchitis: It is uncertain whether ciprofloxacin is more effective than metronidazole for treatment of acute pouchitis (1 study, 16 participants). Side effects included vomiting, metallic taste and temporary damage to nerves. It is unclear whether there are any differences between metronidazole and budesonide enemas in terms of clinical remission, symptom improvement or side effects (1 study, 26 participants). Side effects included anorexia, nausea, headache, lack of energy and strength, metallic taste, vomiting, pins and needles, and depression. It is uncertain whether there are any differences between rifaximin and placebo in terms of clinical remission, symptom improvement, or side effects (1 study, 18 participants). Side effects included diarrhea, flatulence, nausea, rectal pain, vomiting, thirst, yeast infection, common cold, increased liver enzymes, and cluster headache. It is uncertain whether there is any difference between Lactobacillus GG and placebo in symptom improvement (1 study, 20 participants. The results of these studies are uncertain due to low event numbers caused by the small numbers of people who participated in the studies. Chronic pouchitis: It is uncertain whether De Simone Formulation (a probiotic formulation) is more effective than placebo for maintaining remission in people with inactive disease (2 studies, 76 participants). Side effects included abdominal cramps, vomiting and diarrhea. It is unclear whether there is any difference in effectiveness between adalimumab and placebo for treating chronic pouchitis(1 study, 13 participants). It is unclear whether there is any difference between glutamine and butyrate suppositories for maintenance of remission (1 study, 19 participants). It is unclear whether there are any differences in symptom improvement or side effects between bismuth carbomer foam enemas and placebo (1 study, 40 participants). Side effects included diarrhea, worsening symptoms, cramping, sinus infection, and abdominal pain. The results of these studies are uncertain due to the small number of people who participated in the studies. Prevention of pouchitis: It is uncertain whether De Simone Formulation is more effective than placebo for prevention of pouchitis (1 study, 40 participants). However, it is unclear whether there is any difference in prevention of pouchitis between De Simone Formulation and a no treatment control group (1 study, 28 participants). It is unclear whether there are any differences in prevention of pouchitis between Clostridium butyricum MIYAIRI and placebo (1 study, 17 participants) , Bifidobacterium longum and placebo (1 study, 12 participants) , allopurinol and placebo (1 study, 184 participants) and tinidazole and placebo (1 study, 38 participants). The results of these studies are uncertain due to the small number of people who participated in the studies. The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. More research is needed to determine which of these different medications are best for treatment of pouchitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nguyen, N, Zhang, B, Holubar, SD, Pardi, DS, Singh, S", "articleTypes": [], "doi": "10.1002/14651858.CD001176.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.064Z" }, { "id": "a498250f-5f13-44d0-80e1-f0156c344511", "pmid": "", "title": "Interventions for treating oro‐antral communications and fistulae due to dental procedures", "imported": false, "abstract": "Abstract - Background An oro‐antral communication is an unnatural opening between the oral cavity and maxillary sinus. When it fails to close spontaneously, it remains patent and is epithelialized to develop into an oro‐antral fistula. Various surgical and non‐surgical techniques have been used for treating the condition. Surgical procedures include flaps, grafts and other techniques like re‐implantation of third molars. Non‐surgical techniques include allogenic materials and xenografts. This is an update of a review first published in May 2016. Objectives To assess the effectiveness and safety of various interventions for the treatment of oro‐antral communications and fistulae due to dental procedures. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 23 May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 4), MEDLINE Ovid (1946 to 23 May 2018), and Embase Ovid (1980 to 23 May 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the reference lists of included and excluded trials for any randomised controlled trials (RCTs). Selection criteria We included RCTs evaluating any intervention for treating oro‐antral communications or oro‐antral fistulae due to dental procedures. We excluded quasi‐RCTs and cross‐over trials. We excluded studies on participants who had oro‐antral communications, fistulae or both related to Caldwell‐Luc procedure or surgical excision of tumours. Data collection and analysis Two review authors independently selected trials. Two review authors assessed trial risk of bias and extracted data independently. We estimated risk ratios (RR) for dichotomous data, with 95% confidence intervals (CI). We assessed the overall quality of the evidence using the GRADE approach. Main results We included only one study in this review, which compared two surgical interventions: pedicled buccal fat pad flap and buccal flap for the treatment of oro‐antral communications. The study involved 20 participants. The risk of bias was unclear. The relevant outcome reported in this trial was successful (complete) closure of oro‐antral communication. The quality of the evidence for the primary outcome was very low. The study did not find evidence of a difference between interventions for the successful (complete) closure of an oro‐antral communication (RR 1.00, 95% Cl 0.83 to 1.20) one month after the surgery. All oro‐antral communications in both groups were successfully closed so there were no adverse effects due to treatment failure. We did not find trials evaluating any other intervention for treating oro‐antral communications or fistulae due to dental procedures. Authors' conclusions We found very low quality evidence from a single small study that compared pedicled buccal fat pad and buccal flap. The evidence was insufficient to judge whether there is a difference in the effectiveness of these interventions as all oro‐antral communications in the study were successfully closed by one month after surgery. Large, well‐conducted RCTs investigating different interventions for the treatment of oro‐antral communications and fistulae caused by dental procedures are needed to inform clinical practice. Plain language summary Treatment of communications between the oral cavity and the maxillary sinus due to dental procedures Review question What evidence is available for the safe and effective treatment of openings between the mouth and main sinus caused by dental procedures? Background The floor of the main sinus near the nose is thin and lies directly above the roots of the teeth at the back of the mouth. Sometimes following infection or dental treatment, this structure becomes damaged and openings or channels between the mouth and the sinus are formed. These are known as oro‐antral communications (OAC). If the OAC is left open (then described as an oro‐antral fistula (OAF), it may become permanent, leading to long‐lasting sinus infections. This condition can be treated surgically by using flaps, grafts and other techniques; or non‐surgically using a variety of methods and materials. There is little evidence for the most effective and safe treatments for closing OACs and OAFs and clinicians who treat these conditions have identified an urgent need for this. This is an update of a review first published in May 2016. Study characteristics We searched various databases until 23 May 2018. Only one study, which was conducted in Iran, is included in our review. The study ran for two years and involved 20 people with OAC aged between 25 and 56 years. Participants were divided into two groups and two surgical treatments were compared for treating oro‐antral communications; one group was treated with pedicled buccal fat pad flap (PBFPF) and the other with buccal flap (BF). Key results and quality of evidence The study did not find evidence of a difference between PBFPF and BF in terms of successful (complete) closure of OAC. Both interventions resulted in successful closure by one month after surgery. The study did not therefore report any adverse effects of treatment failure. It may not be possible to generalise these findings because the quality of the evidence was very low, due to unclear risk of bias and the small numbers studied in the single included trial. Conclusion The evidence currently available is insufficient to draw reliable conclusions regarding the effects of interventions used to treat OAC or fistulae due to dental procedures. More well‐designed and well‐reported trials evaluating different interventions are needed to provide reliable evidence to inform clinical decisions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Kiran Kumar Krishanappa, S, Eachempati, P, Kumbargere Nagraj, S, Shetty, NY, Moe, S, Aggarwal, H, Mathew, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD011784.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.087Z" }, { "id": "a4a0e7e3-b7cb-4978-81fe-46a5f4783e61", "pmid": "", "title": "The Effects of the Dopamine Receptor Agonist Pramipexole on Reward and Emotion Related Information Processing in Healthy Volunteers", "imported": false, "abstract": "The dopamine agonist pramipexole has recently been suggested as a potential novel antidepressant drug. While preliminary clinical data hint at its efficacy in treating depressive symptoms, our current understanding of its impact on neurocognitive processes is relatively limited. This is in part because mechanistic studies have largely focused on the effects of single-dose treatments. However, such acute administration of dopaminergic drugs likely has different cognitive effects than the more prolonged administration that is used clinically. This study therefore aims to explore and characterise the neurocognitive effects of more prolonged pramipexole treatment. Forty healthy volunteers will be randomly allocated to 12 to 15 days of treatment with either pramipexole or placebo. Study participants as well as researchers will be blinded as to which treatment is used. Before and after treatment all participants will perform a set of psychological tasks and questionnaires evaluating reward-based learning, emotional information processing, motivational vigour and subjective experience. Furthermore, functional magnetic resonance imaging (fMRI) will be used to compare neural activity during emotion and reward processing between the two treatment groups. We hypothesises that pramipexole might enhance reward sensitivity, motivational vigour, and pleasure experience and could induce positive biases in emotional information processing.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "a4b191a7-468f-408f-b1b3-ddbd61c5e1e5", "pmid": "", "title": "Sumatriptan (intranasal route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Intranasal administration may be preferable to oral for individuals experiencing nausea and/or vomiting, although it is primarily absorbed in the gut, not the nasal mucosa. Objectives To determine the efficacy and tolerability of intranasal sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using intranasal sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Twelve studies (4755 participants) compared intranasal sumatriptan with placebo or an active comparator. Most of the data were for the 10 mg and 20 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 10 mg versus placebo the NNTs were 7.3, 7.4, and 5.5 for pain‐free at two hours, and headache relief at one and two hours, respectively. For sumatriptan 20 mg versus placebo the NNTs were 4.7, 4.9, and 3.5, respectively, for the same outcomes. The 20 mg dose was significantly better than the 10 mg dose for each of these three primary efficacy outcomes. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Direct comparison of sumatriptan with active treatments was limited to two studies, one comparing sumatriptan 20 mg and dihydroergotamine (DHE) 1 mg, and one comparing sumatriptan 20 mg with rizatriptan 10 mg. Authors' conclusions Intranasal sumatriptan is effective as an abortive treatment for acute migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events compared with placebo. Plain language summary Sumatriptan (intranasal route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a nasal spray, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, although absorption of the drug occurs primarily in the gut rather than the nasal mucosa. This review found that a single intranasal dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in approximately 2 in 10 people (24%) taking sumatriptan 10 mg, compared with about 1 in 10 (10%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 5 in 10 people (50%) taking sumatriptan 10 mg, compared with approximately 3 in 10 (32%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those who took placebo. The 20 mg dose had greater efficacy, but may be associated with more adverse events, most of which were of short duration and mild or moderate in severity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009663", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.728Z" }, { "id": "a4bf5ffe-2fad-452f-bb51-94ed8bfc3c3d", "pmid": "", "title": "Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low‐ and middle‐income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid‐based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition. Objectives To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low‐ and middle‐income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective. Search methods In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. Selection criteria We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before‐and‐after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low‐ and middle‐income countries. Data collection and analysis Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses using the random‐effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods. Main results Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care ‐ the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight‐for‐height (MD 0.20 z‐score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid‐based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses ‐ there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid‐based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non‐recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight‐for‐height, and mid‐upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid‐based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses ‐ no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid‐based nutrient supplements versus specific types of blended foods ‐ a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods ‐ in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet ‐ no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. Authors' conclusions In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short‐term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent. Plain language summary Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries Moderate acute malnutrition (MAM) affects around 10% of children under five years of age in low‐ and middle‐income countries. Different food strategies have been used for the nutritional recovery of children with MAM, such as lipid‐based nutrient supplements or blended foods, which can be provided in full dose or in a low dose as a complement to the usual diet. However, there is no definitive consensus on the most effective way to treat children with MAM. We searched eight electronic databases and three trials registers (in October 2012 for all except Embase, which was searched in August 2012). We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. We found eight relevant randomised controlled trials, enrolling 10,037 children under five years of age. All but one study was conducted in Africa. The risk of bias in the studies was generally low, though two studies had a high dropout rate. The participants were aware which intervention group they were in and this may have influenced their behaviour but we thought it unlikely it would have influenced the results since the outcomes measured were objective ones. For four of the studies, we were unable to assess if the study authors reported all the outcomes they intended to measure. When any type of specially formulated food was compared to standard care (medical care and counselling without foods), the children treated with foods had a higher chance of recovering from moderate malnutrition (two studies), greater improvement in nutritional status (two studies), and a lower number of dropouts (one study). A reduction in mortality was not shown. When lipid‐based nutrient supplements (which are food with high energy density and high lipid content) at full dose were compared to blended foods at full dose (which are dry food mixtures without high lipid content), there was no difference between these two types of foods in terms of number of deaths (five studies), children progressing to severe acute malnutrition (three studies), and children dropping out (four studies). However, lipid‐based nutrient supplements increased the number recovered by 10% (five studies), decreased the number of children non‐recovering (three studies), and slightly improved the nutritional status among the recovered. One study observed more children vomiting when given lipid‐based nutrient supplements compared to blended foods, but this was not reported by the other studies. No other side effects were reported. Few studies evaluated foods at complementary dosage (i.e. foods given in low quantity, just to complement the diet and not to fully substitute it), and no conclusion could be drawn from these studies. When specific foods were compared to each other, a type of corn‐soy blended food called CSB++ compared to lipid‐based nutrient supplements resulted in similar outcomes, while results of another blended food (CSB pre‐mix) versus lipid‐based nutrient supplements were unclear. In one study, CSB++ did not show any significant benefit over locally‐made blended foods, for example, Misola. No study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with moderate acute malnutrition. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. There are no studies evaluating special recipes to improve the adequacy of the usual home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lazzerini, M, Rubert, L, Pani, P", "articleTypes": [], "doi": "10.1002/14651858.CD009584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.775Z" }, { "id": "a4c97255-0363-479a-9ab3-eaa7d6207139", "pmid": "", "title": "Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer", "imported": false, "abstract": "Abstract - Background This is an updated version of a Cochrane Review last published in 2013. Long‐term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating people with cancer. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infections remain a common complication. These infections are mainly caused by gram‐positive bacteria. Antimicrobial prevention strategies aimed at these micro‐organisms could potentially decrease the majority of CVC‐related infections. The aim of this review was to evaluate the efficacy of prophylactic antibiotics for the prevention of gram‐positive infections in people with cancer who have long‐term CVCs. Objectives To assess the effects of administering antibiotics prior to the insertion of long‐term CVCs or as a flush/lock solution, or both during long‐term CVC access to prevent gram‐positive CVC‐related infections in adults and children receiving treatment for cancer. Search methods The search for this updated review was conducted on 19 November 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE via Ovid and Embase via Ovid. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform portal for additional articles. Selection criteria We included randomised controlled trials (RCTs) that compared either the administration of prophylactic antibiotics prior to long‐term CVC insertion versus no administration of antibiotics, or the use of an antibiotic versus a non‐antibiotic flush/lock solution in long‐term CVCs, in adults and children receiving treatment for cancer. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two authors independently selected studies, classified them and extracted data onto a predesigned data collection form. The outcomes of interest were gram‐positive catheter‐related infection events and total number of CVCs and CVC days. We pooled the data using a random‐effects model for meta‐analyses. We used the GRADE approach to assess the certainty of the evidence. Main results For this update, we identified 310 potentially relevant studies and screened them for eligibility. We included one additional RCT with 404 participants. The original review included 11 RCTs with a total of 840 people with cancer (adults and children). In total this review included 12 RCTs with 1244 participants. Antibiotics prior to insertion of the CVC 
Six trials compared the use of antibiotics (vancomycin, teicoplanin, ceftazidime or cefazolin) versus no antibiotics given before the insertion of a long‐term CVC. One study did not observe any CVC‐related infection events in either group was not included in the quantitative analysis as it was not possible to calculate a risk ratio. Administering an antibiotic prior to insertion of the CVC may not reduce gram‐positive CVC‐related infections (pooled risk ratio 0.67, confidence interval (CI) 95% 0.32 to 1.43; control versus intervention group risk 10.4% versus 7.3% of the participants; 5 studies, 648 participants; moderate‐certainty evidence). We sought adverse event data, but these were not described by the authors. The overall risk of bias was deemed low. Antibiotics as a flushing or locking solution 
Six trials compared a combined antibiotic (vancomycin, amikacin or taurolidine) and heparin solution with a heparin‐only solution for flushing or locking the long‐term CVC after use. One study did not observe any CVC‐related sepsis events (CRS) and was not included in this study in the quantitative analysis as it was not possible to calculate a risk ratio. Flushing and locking long‐term CVCs with a combined antibiotic and heparin solution likely reduced the risk of gram‐positive CVC‐related infections compared to a heparin‐only solution (pooled rate ratio 0.47, CI 95% 0.26 to 0.85; control versus intervention group rate ratio 0.66 versus 0.27 per 1000 CVC‐days; 5 studies, 443 participants; moderate‐certainty evidence). One trial reported a higher incidence of occlusions and participants in one trial reported an unpleasant taste after flushing associated with a combined antibiotic and heparin solution. The overall risk of bias was deemed low. Authors' conclusions Since the last version of this review, we included one additional study. There was no observed benefit of administering antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing or locking long‐term CVCs with an antibiotic solution likely reduces gram‐positive CVC‐related infections experienced in people at risk of neutropenia through chemotherapy or disease. However, a limitation of this review is heterogeneity between the studies for both outcomes. Insufficient data were available to evaluate if the conclusions apply equally for different CVC types and for adults versus children. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if the baseline CVC‐related infection rates are high. Further research is needed to identify high‐risk groups most likely to benefit from these antibiotic flush/lock solutions. Plain language summary Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer The issue 
People undergoing anti‐cancer treatment (chemotherapy) often have a catheter (tube) inserted into a large vein, through which their chemotherapy is given. This is known as a central venous catheter (CVC). As chemotherapy is usually administered over several months to years, long‐term CVCs are used. Despite sterile insertion and care afterwards, these CVCs often become infected by a type of bacteria called gram‐positive bacteria. Giving antibiotics as a preventive (prophylactic antibiotics) before the catheter is inserted, or using the antibiotics as a lock or flush solution, or both, may prevent these infections. A lock/flush solution is instilled in the catheter when it is not in use. This solution often contains heparin, saline, or both, to prevent a clot forming in the catheter. The aim of the review 
The aim of this review was to determine whether giving antibiotics before catheter insertion or as a lock/flush solution can prevent gram‐positive CVC‐related infections. What are the main findings? 
We searched databases to identify randomised controlled trials (RCTs ‐ clinical studies where people are randomly put into one of two or more treatment groups). We identified 12 relevant studies, which included a total of 1244 adults and children with cancer. We included six studies (756 people) that compared giving antibiotics before the insertion of the CVC against not giving antibiotics. We found that giving an antibiotic before CVC insertion did not prevent infections. The studies authors' did not describe side‐effects. We included six studies (488 people) that compared an antibiotic solution with a heparin‐only solution to flush/lock a CVC. We found that an antibiotic lock/flush solution reduced the number of CVC‐related infections. People in one study reported an unpleasant taste after flushing, and one study found there were fewer CVC obstructions (e.g. a clot) in people who received the combined antibiotic and anticoagulant solution. Certainty of the evidence 
We have moderate confidence in the evidence for giving antibiotics prior to CVC insertion and antibiotic lock/flush solutions since the studies were done in different people, used different types of catheters and antibiotics, and measured their results in different ways. What are the conclusions? 
We did not observe any benefit of giving antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing/locking long‐term CVCs with an antibiotic appeared to reduce gram‐positive CVC‐related infections in people with cancer. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if baseline CVC‐related infection rates are high. This review updates our previous review. The evidence is up to date to 19 November 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "van den Bosch, CH; van Woensel, J; van de Wetering, MD", "articleTypes": [], "doi": "10.1002/14651858.CD003295.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "a4df90b2-71ad-462b-81e2-7aa851aef1da", "pmid": "", "title": "Blood pressure lowering efficacy of diuretics as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Diuretics are widely prescribed for hypertension not only as a first‐line drug but also as a second‐line drug. Therefore, it is essential to determine the effects of diuretics on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a second‐line drug. Objectives To quantify the additional reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of diuretic therapy as a second‐line drug in patients with primary hypertension Search methods CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (1966‐July 2008), EMBASE (1988‐July 2008) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized, controlled trials evaluating the BP lowering efficacy of a diuretic in combination therapy with another class of anti‐hypertensive drugs compared with the respective monotherapy (without a diuretic) for a duration of 3 to 12 weeks in patients with primary hypertension. Data collection and analysis Two review authors independently extracted the data and assessed trial quality. Main results Fifty‐three double‐blind RCTs evaluating a thiazide in 15129 hypertensive patients (baseline BP of 156/101 mmHg) were included. Hydrochlorothiazide was the thiazide used in 49/53 (92%) of the included studies. The additional BP reduction caused by the thiazide as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. Thiazides as a second‐line drug reduced BP by 6/3 and 8/4 mmHg at doses of 1 and 2 times the manufacturer's recommended starting dose respectively. The BP lowering effect was dose related. The effect was similar to that obtained when thiazides are used as a single agent. Only 3 double‐blind RCTs evaluating loop diuretics were identified. These RCTs showed a BP lowering effect of a starting dose of about 6/3 mmHg. Authors' conclusions Thiazides when given as a second‐line drug have a dose related effect to lower blood pressure that is similar to when they are added as a first‐line drug. This means that the BP lowering effect of thiazides is additive. Loop diuretics appear to have a similar blood pressure lowering effect as thiazides at 1 times the recommended starting dose. Because of the short duration of the trials and lack of reporting of adverse events, this review does not provide a good estimate of the incidence of adverse effects of diuretics given as a second‐line drug. Plain language summary Diuretics effective in lowering blood pressure when given as a second drug Diuretics are a good first‐line treatment for high blood pressure (BP). Diuretics include loop diuretics and thiazides. We asked how much do diuretics reduce BP when used as the second drug to treat hypertension. We performed a search of the available scientific literature to find all trial evidence to assess this question. Fifty‐six trials were found. Fifty‐three trials involved thiazide diuretics (92% with the drug hydrochlorothiazide) and included a total of 15310 participants. Adding a thiazide to another anti‐hypertensive drug further reduces the BP by an additional 6/3 mmHg when given at the starting dose and reduces BP by 8/4 mmHg at 2 times the starting dose. This is approximately the same effect as when the drugs are used alone. A good estimate of the harms associated with diuretics cannot be estimated in this review because of the lack of reporting and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Chen, JMH, Heran, BS, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.799Z" }, { "id": "a4dffc31-041a-4951-9f74-7f229f1ee8b3", "pmid": "", "title": "Echinacea for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Echinacea plant preparations (family Asteraceae ) are widely used in Europe and North America for common colds. Most consumers and physicians are not aware that products available under the term Echinacea differ appreciably in their composition, mainly due to the use of variable plant material, extraction methods and the addition of other components. Objectives To assess whether there is evidence that Echinacea preparations are effective and safe compared to placebo in the prevention and treatment of the common cold. Search methods We searched CENTRAL 2013, Issue 5, MEDLINE (1946 to May week 5, 2013), EMBASE (1991 to June 2013), CINAHL (1981 to June 2013), AMED (1985 to February 2012), LILACS (1981 to June 2013), Web of Science (1955 to June 2013), CAMBASE (no time limits), the Centre for Complementary Medicine Research (1988 to September 2007), WHO ICTRP and clinicaltrials.gov (last searched 5 June 2013), screened references and asked experts in the field about published and unpublished studies. Selection criteria Randomized controlled trials (RCTs) comparing mono‐preparations of Echinacea with placebo. Data collection and analysis At least two review authors independently assessed eligibility and trial quality and extracted data. The primary efficacy outcome was the number of individuals with at least one cold in prevention trials and the duration of colds in treatment trials. For all included trials the primary safety and acceptability outcome was the number of participants dropping out due to adverse events. We assessed trial quality using the Cochrane 'Risk of bias' tool. Main results Twenty‐four double‐blind trials with 4631 participants including a total of 33 comparisons of Echinacea preparations and placebo met the inclusion criteria. A variety of different Echinacea preparations based on different species and parts of plant were used. Evidence from seven trials was available for preparations based on the aerial parts of Echinacea purpurea. Ten trials were considered to have a low risk of bias, six to have an unclear risk of bias and eight to have a high risk of bias. Ten trials with 13 comparisons investigated prevention and 15 trials with 20 comparisons investigated treatment of colds (one trial addressed both prevention and treatment). Due to the strong clinical heterogeneity of the studies we refrained from pooling for the main analysis. None of the 12 prevention comparisons reporting the number of patients with at least one cold episode found a statistically significant difference. However a post hoc pooling of their results, suggests a relative risk reduction of 10% to 20%. Of the six treatment trials reporting data on the duration of colds, only two showed a significant effect of Echinacea over placebo. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. Authors' conclusions Echinacea products have not here been shown to provide benefits for treating colds, although, it is possible there is a weak benefit from some Echinacea products : the results of individual prophylaxis trials consistently show positive (if non‐significant) trends, although potential effects are of questionable clinical relevance. Plain language summary Echinacea for preventing and treating the common cold Preparations of the plant Echinacea are widely used in some European countries and in North America for common colds. Echinacea preparations available on the market differ greatly as different types (species) and parts (herb, root or both) of the plant are used, different manufacturing methods (drying, alcoholic extraction or pressing out the juice from fresh plants) are used and sometimes also other herbs are added. We reviewed 24 controlled clinical trials with 4631 participants investigating the effectiveness of several different Echinacea preparations for preventing and treating common colds or induced rhinovirus infections. Our review shows that a variety of products prepared from different Echinacea species, different plant parts and in a different form have been compared to placebo in randomized trials. Due to the significant differences in the preparations tested, it was difficult to draw strong conclusions. Five trials were rated as having a low risk of bias in all five categories of the Cochrane 'Risk of bias' tool. Five more trials were rated as low risk of bias, having an unclear risk of bias in only one category. Eight trials were rated as having a high risk of bias in at least one category and the remaining six as having an unclear risk of bias. The majority of trials investigated whether taking Echinacea preparations after the onset of cold symptoms shortens the duration, compared with placebo. Although it seems possible that some Echinacea products are more effective than a placebo for treating colds, the overall evidence for clinically relevant treatment effects is weak. In general, trials investigating Echinacea for preventing colds did not show statistically significant reductions in illness occurrence. However, nearly all prevention trials pointed in the direction of small preventive effects. The number of patients dropping out or reporting adverse effects did not differ significantly between treatment and control groups in prevention and treatment trials. However, in prevention trials there was a trend towards a larger number of patients dropping out due to adverse events in the treatment groups. The evidence is current to July 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Karsch‐Völk, M; Barrett, B; Kiefer, D; Bauer, R; Ardjomand‐Woelkart, K; Linde, K", "articleTypes": [], "doi": "10.1002/14651858.CD000530.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "a50428f6-025f-46b2-ae7c-8ab4bfc28ff8", "pmid": "", "title": "Topiramate for essential tremor", "imported": false, "abstract": "Abstract - Background Essential tremor (ET) is one of the most common movement disorders. The management is primarily based on pharmacological agents and in clinical practice propranolol and primidone are considered the first‐line therapy. However, these treatments can be ineffective in 25% to 55% of people and are frequently associated with serious adverse events (AEs). For these reasons, it is worthwhile evaluating other treatments for ET. Topiramate has been suggested as a potentially useful agent for the treatment of ET but there is uncertainty about its efficacy and safety. Objectives To assess the efficacy and safety of topiramate in the treatment of ET. Search methods We carried out a systematic search without language restrictions to identify all relevant trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to January 2017), Embase (January 1988 to January 2017), National Institute for Health and Care Excellence (1999 to January 2017), ClinicalTrials.gov (1997 to January 2017) and World Health Organization International Clinical Trials Registry Platform (ICTRP; 2004 to January 2017). We searched BIOSIS Citation Index (2000 to January 2017) for conference proceedings. We handsearched grey literature and the reference lists of identified studies and reviews. Selection criteria We included all randomised controlled trials (RCTs) of topiramate versus placebo/open control or any other treatments. We included studies in which the diagnosis of ET was made according to accepted and validated diagnostic criteria. We excluded studies conducted in people presenting with secondary forms of tremor or reporting only neurophysiological parameters to assess outcomes. Data collection and analysis Two review authors independently collected and extracted data using a data collection form. We assessed the risk of bias and the quality of evidence. We used a fixed‐effect meta‐analysis for data synthesis. Main results This review included three trials comparing topiramate to placebo (309 participants). They were all at high overall risk of bias. The quality of evidence ranged from very low to low. Compared to placebo, participants treated with topiramate showed a significant improvement in functional disability and an increased risk of withdrawal (risk ratio (RR) 1.78, 95% confidence interval (CI) 1.23 to 2.60). There were more AEs for topiramate‐treated participants, particularly paraesthesia, weight loss, appetite decrease and memory difficulty. Authors' conclusions This systematic review highlighted the presence of limited data and very low to low quality evidence to support the apparent efficacy and the occurrence of treatment‐limiting AEs in people with ET treated with topiramate. Further research to assess topiramate efficacy and safety on ET is needed. Plain language summary Use of topiramate for the treatment of essential tremor Review question The authors of this review tried to assess the effectiveness and safety of topiramate in people with essential tremor. Background Essential tremor is a type of uncontrollable shaking or trembling of parts of the body. Although it is not harmful in terms of its effect on life expectancy, it generally gets worse and may be disabling. Treatment is usually with medicines (called propranolol and primidone), which may not work in a quarter to a half of people with essential tremor. Some specialists have suggested that another medicine, topiramate, could be useful for treating the condition. Study characteristics We searched medical databases for studies of topiramate compared with placebo (a pretend tablet) or any other medicine in adults with essential tremor. We found three studies comparing topiramate versus placebo, involving 309 participants with moderate to severe essential tremor. Key results The effect of topiramate on daily activities, risk of stopping treatment and side effects was uncertain because the quality of evidence was very low to low. Quality of evidence We only found a few studies that had problems with their methods so we could not make firm conclusions about how well topiramate works and if it has side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Bruno, E; Nicoletti, A; Quattrocchi, G; Allegra, R; Filippini, G; Colosimo, C; Zappia, M", "articleTypes": [], "doi": "10.1002/14651858.CD009683.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "a51a95e4-0f43-4726-a545-02edf5c7646c", "pmid": "", "title": "Capsaicin for non‐allergic rhinitis", "imported": false, "abstract": "Abstract - Background There are many forms of rhinitis. Patients are diagnosed with non‐allergic rhinitis when anatomic, infectious and allergic aetiologies have been excluded. The symptoms, including nasal congestion, blockage or obstruction, clear rhinorrhoea, sneezing and, less frequently, nasal itching, can range from mild to debilitating. It affects between 25% and 50% of patients with rhinitis. Several medications are widely used in the treatment of non‐allergic rhinitis, including oral and topical nasal antihistamines, intranasal and (rarely) systemic corticosteroids, and anticholinergics. Capsaicin, the active component of chili peppers, delivered intranasally, is considered a treatment option for non‐allergic rhinitis. Objectives To assess the effectiveness of capsaicin in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications, or two or more of the above therapies in combination, or different capsaicin regimens. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 5); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2015. Selection criteria Randomised controlled trials in adult patients with non‐allergic rhinitis comparing intranasal capsaicin with no therapy, placebo or other topical or systemic medications, or their combinations. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We included four studies (five publications) involving 302 participants with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe, idiopathic non‐allergic rhinitis who were between the ages of 16 and 65. Studies had follow‐up periods ranging from four to 38 weeks. The overall risk of bias in the studies was either high or unclear (two studies had overall high risk of bias, while two others had low to unclear risk of bias). Using the GRADE system we assessed the evidence as being of low to moderate quality. A meta‐analysis was not possible, given lack of similarity of the reported outcomes. Two studies compared capsaicin with placebo. One study reported that capsaicin resulted in an improvement of overall nasal symptoms (a primary outcome) measured on a visual analogue scale (VAS) of 0 to 10. There was a mean difference (MD) of ‐3.34 (95% confidence interval (CI) ‐5.24 to ‐1.44), MD ‐3.73 (95% CI ‐5.45 to ‐2.01) and MD ‐3.52 (95% CI ‐5.55 to ‐1.48) at two, 12 and 36 weeks post‐treatment, respectively. Another study reported that, compared to placebo, capsaicin (at 4 µg/puff) was more likely to produce overall symptom resolution (reduction in nasal blockage, sneezing/itching/coughing and nasal secretion measured with a daily record chart) at four weeks post‐treatment (a primary outcome). The risk ratio (RR) was 3.17 (95% CI 1.38 to 7.29). One study compared capsaicin to budesonide (an intranasal corticosteroid). This study found that patients treated with capsaicin had a better overall symptom score compared to those treated with budesonide (MD 2.50, 95% CI 1.06 to 3.94, VAS of 0 to 10). However, there were no differences in the individual symptom scores for headache, postnasal drip, rhinorrhoea, nasal blockage, sneezing and sore throat assessed during the last three days of a four‐week treatment. One study compared two different regimens of capsaicin administration: five treatments in one day versus five treatments given every two to three days during two weeks. Using daily record charts, the study reported significant improvement of individual symptom scores for rhinorrhoea in patients treated five times per day, however numerical data were not presented. There were no improvements in the other outcomes: rhinorrhoea, nasal obstruction, sneezing and overall nasal symptoms, measured on a VAS. Finally, one of these studies also compared three doses of capsaicin (to placebo). Patients treated with a 1 µg versus 4 µg per puff dose of capsaicin had a worse daily record chart overall symptom score resolution (RR 0.63, 95% CI 0.34 to 1.16). Only one study attempted to measure adverse effects (a primary outcome), however due to methodological issues with the assessment we are unable to draw any conclusions. We sought to include other secondary outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Authors' conclusions Capsaicin may be an option in the treatment of idiopathic non‐allergic rhinitis. It is given in the form of brief treatments, usually during the same day. It appears to have beneficial effects on overall nasal symptoms up to 36 weeks after treatment, based on a few, small studies (low‐quality evidence). Well‐conducted randomised controlled trials are required to further advance our understanding of the effectiveness of capsaicin in non‐allergic rhinitis, especially in patients with non‐allergic rhinitis of different types and severity, and using different methods of capsaicin application. Plain language summary Capsaicin for non‐allergic rhinitis Review question Is capsaicin applied into the nose (intranasal) effective in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications? Background Rhinitis means inflammation of the nose. It affects 30% to 40% of the general population. There are many forms of rhinitis: rhinosinusitis (or simply sinusitis), allergic rhinitis and non‐allergic rhinitis. Non‐allergic rhinitis is diagnosed in patients who have negative tests for allergies and also do not have sinusitis. The symptoms include congestion of the nose, a blocked or obstructed sensation in the nose that causes difficulty breathing, clear nasal discharge (runny nose), sneezing and nasal itching. There are several subtypes of non‐allergic rhinitis: occupational (from exposure to chemicals), smoking, gustatory (related to eating food or drinking fluid), hormonal (from changes in hormone levels in the body), pregnancy, senile or elderly (mostly affecting the older population), medication‐induced (for example, from overuse of decongestant nasal sprays) and local allergic (local allergy in the nose, while skin or blood allergy tests are negative). The most common subtype of non‐allergic rhinitis is 'idiopathic' or 'vasomotor' rhinitis, which results from imbalance of the neural (nerve) system that manages the function of the nose. The mechanisms of many of these subtypes remain unknown. Non‐allergic rhinitis affects about 25% to 50% of patients with rhinitis and is therefore very common. Capsaicin is the active ingredient of chili peppers. It has medicinal properties and is used elsewhere in medicine, for example for neuralgias (nerve pain) and psoriasis (a skin disease). The side effects of using capsaicin in the nose include irritation, burning, sneezing and coughing, however there are no known long‐term side effects of capsaicin use. Capsaicin is given in the form of brief treatments, usually during the same day. It works by down‐regulating transient receptor potential vanilloid (TRPV) receptor expression on C‐sensory fibres. TRPV represents special ion channels involved in the sensations of pain, cold, hotness, tastes, pressure and vision. C fibres help to conduct some of these sensations. There is ongoing research into the effects of capsaicin on these mechanisms and its clinical uses. Study characteristics We included four studies involving 302 patients with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe idiopathic non‐allergic rhinitis, who were between the ages of 16 and 65. The studies had a follow‐up ranging from four to 38 weeks after treatment. Key results Individually, the studies reported that the overall function of the nose in patients with non‐allergic rhinitis improved when treated with capsaicin compared to placebo. Capsaicin also seems to work better than another common type of nasal medication, budesonide (a steroid). The best knowledge that we have on capsaicin treatment supports giving it five times in one day, and to use doses of at least 4 micrograms in each puff. We could not combine the results together. The included studies did not have sufficient information to allow us to draw a conclusion about side effects. We also wanted to include other outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Quality of the evidence Overall, we judged the quality of the evidence to be of low to moderate quality. The evidence is up to date to June 2015. Conclusions Given that many other options do not work well in non‐allergic rhinitis, capsaicin is a reasonable option to try under physician supervision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Gevorgyan, A, Segboer, C, Gorissen, R, van Drunen, CM, Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010591.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.134Z" }, { "id": "a5547bbd-05f3-4fc2-a5d0-13114d477d4d", "pmid": "", "title": "Chlorhexidine treatment for the prevention of dental caries in children and adolescents", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) is a common disease that is preventable by reducing the dietary intake of free sugars and using topical sodium fluoride products. An antibacterial agent known as chlorhexidine may also help prevent caries. A number of over‐the‐counter and professionally administered chlorhexidine‐based preparations are available in a variety of formulations and in a range of strengths. Although previous reviews have concluded that some formulations of chlorhexidine may be effective in inhibiting the progression of established caries in children, there is currently a lack of evidence to either claim or refute a benefit for its use in preventing dental caries. Objectives To assess the effects of chlorhexidine‐containing oral products (toothpastes, mouthrinses, varnishes, gels, gums and sprays) on the prevention of dental caries in children and adolescents. Search methods We searched the Cochrane Oral Health Group Trials Register (25 February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 12), MEDLINE via OVID (1946 to 25 February 2015), EMBASE via OVID (1980 to 25 February 2015) and CINAHL via EBSCO (1937 to 25 February 2015). We handsearched several journals placed no language restrictions on our search. After duplicate citations were removed, the electronic searches retrieved 1075 references to studies. Selection criteria We included parallel‐group, randomised controlled trials (RCTs) that compared the caries preventive effects of chlorhexidine gels, toothpastes, varnishes, mouthrinses, chewing gums or sprays with each other, placebo or no intervention in children and adolescents. We excluded trials with combined interventions of chlorhexidine and fluoride or comparisons between chlorhexidine and fluoride interventions. Data collection and analysis Two review authors independently extracted trial data and assessed risk of bias. We resolved disagreements by consensus. We contacted trial authors for clarification or additional study details when necessary. The number of included studies that were suitable for meta‐analysis was limited due to the clinical diversity of the included studies with respect to age, composition of intervention, and variation in outcome measures and follow‐up. Where we were unable to conduct meta‐analysis, we elected to present a narrative synthesis of the results. Main results We included eight RCTs that evaluated the effects of chlorhexidine varnishes (1%, 10% or 40% concentration) and chlorhexidine gel (0.12%) on the primary or permanent teeth, or both, of children from birth to 15 years of age at the start of the study. The studies randomised a total of 2876 participants, of whom 2276 (79%) were evaluated. We assessed six studies as being at high risk of bias overall and two studies as being at unclear risk of bias overall. Follow‐up assessment ranged from 6 to 36 months. Six trials compared chlorhexidine varnish with placebo or no treatment. It was possible to pool the data from two trials in the permanent dentition (one study using 10% chlorhexidine and the other, 40%). This led to an increase in the DMFS increment in the varnish group of 0.53 (95% confidence interval (CI) ‐0.47 to 1.53; two trials, 690 participants; very low quality evidence). Only one trial (10% concentration chlorhexidine varnish) provided usable data for elevated mutans streptococci levels > 4 with RR 0.93 (95% CI 0.80 to 1.07, 496 participants; very low quality evidence). One trial measured adverse effects (for example, ulcers or tooth staining) and reported that there were none; another trial reported that no side effects of the treatment were noted. No trials reported on pain, quality of life, patient satisfaction or costs. Two trials compared chlorhexidine gel (0.12% concentration) with no treatment in the primary dentition. The presence of new caries gave rise to a 95% confidence interval that was compatible with either an increase or a decrease in caries incidence (RR 1.00, 95% CI 0.36 to 2.77; 487 participants; very low quality evidence). Similarly, data for the effects of chlorhexidine gel on the prevalence of mutans streptococci were inconclusive (RR 1.26, 95% CI 0.95 to 1.66; two trials, 490 participants; very low quality evidence). Both trials measured adverse effects and did not observe any. Neither of these trials reported on the other secondary outcomes such as measures of pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Authors' conclusions We found little evidence from the eight trials on varnishes and gels included in this review to either support or refute the assertion that chlorhexidine is more effective than placebo or no treatment in the prevention of caries or the reduction of mutans streptococci levels in children and adolescents. There were no trials on other products containing chlorhexidine such as sprays, toothpastes, chewing gums or mouthrinses. Further high quality research is required, in particular evaluating the effects on both the primary and permanent dentition and using other chlorhexidine‐containing oral products. Plain language summary Antiseptic treatment (chlorhexidine) to prevent tooth decay in children and young people Review question This review examined the effectiveness of varnishes and gels containing chlorhexidine in preventing tooth decay in children and young people. Background Tooth decay is a very common disease that over time destroys the tooth surface. It has been estimated to affect up to 80% of people in high‐income countries and, despite being preventable through oral hygiene and dietary measures and the use of agents such as fluoride that reduce risk of decay, it is likely to remain a problem, especially in low‐income countries. Tooth decay can result in pain and infection, and in young children may require treatment in hospital under a general anaesthetic. As well as causing anxiety and pain, this may mean the child or young person missing time at school and their parents or carers having to take time off work, possibly losing income and incurring extra costs. Prevention of tooth decay is simpler and possibly cheaper than waiting until it occurs and then requires extensive treatment. Tooth decay is largely preventable, and a range of things may assist this: twice‐daily toothbrushing with a fluoride toothpaste, reducing both the amount of and number of times per day sugar is eaten, and drinking water that contains fluoride (bottled or tap, depending on where you live). Tooth decay occurs when certain types of bacteria (germs) in the mouth, such as Streptococcus mutans, produce acids from the sugar we eat, which dissolve the hard enamel coating on our teeth. The chemical antiseptic treatment chlorhexidine is highly successful at destroying these bacteria and can be used safely at home in the form of a gel, spray, chewing gum, toothpaste or mouthrinse. Alternatively, chlorhexidine can be applied as a varnish to the surface of teeth by a dentist. Study characteristics The evidence in this review, carried out through the Cochrane Oral Health Group, is up‐to‐date at 25 February 2015. We found eight studies that were suitable to include in this review. The studies involved a total of 2876 children from birth to 15 years of age who were at moderate to high risk of tooth decay. Six of the studies looked at the effects of dental professionals applying different strengths of chlorhexidine varnishes to the baby teeth, permanent teeth or both types of teeth in children and adolescents. The other two studies looked at the effects of parents placing chlorhexidine gel on their children's baby teeth. There were no studies that examined other products containing chlorhexidine, such as sprays, toothpastes, chewing gums or mouthrinses. Key results The results did not provide evidence that chlorhexidine varnish or gel reduces tooth decay or reduces the bacteria that encourage tooth decay. The studies did not evaluate other outcomes such as pain, quality of life, patient satisfaction or direct and indirect costs of interventions. Four studies measured side effects and found none were observed. Quality of the evidence Due to the lack of suitable studies and concerns about possible bias in the included studies, the evidence is very low quality. As a result, we are not able to conclude whether or not chlorhexidine is effective in preventing tooth decay in children or adolescents, when compared to placebo (an inactive substitute for chlorhexidine) or no treatment. Future research on the use of chlorhexidine to prevent tooth decay is needed and should consider both primary and permanent teeth and should assess other chlorhexidine‐containing products that can be used at home, such as toothpastes or mouthrinses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Walsh, T, Oliveira‐Neto, JM, Moore, D", "articleTypes": [], "doi": "10.1002/14651858.CD008457.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.084Z" }, { "id": "a55842b2-a695-4242-83b9-d6a2535f8a77", "pmid": "", "title": "Sucrose analgesia for venepuncture in neonates", "imported": false, "abstract": "Abstract - Rationale Sucrose is, in general, safe and effective for analgesia during venepuncture in hospitalised neonates. However, there is a lack of evidence on its analgesic effects. Objectives To evaluate the benefits and harms of orally administered sucrose for pain relief from venepuncture in preterm and term neonates compared to no intervention, standard care, and other types of analgesic interventions. Search methods We searched CENTRAL, MEDLINE, Ovid Embase, and trial registries in July 2025, and the China National Knowledge Infrastructure, VIP Chinese Science and Technology Periodicals, and Wanfang Data in August 2024. We checked reference lists of included studies and topic‐related systematic reviews. Eligibility criteria We included randomised controlled trials (RCTs), including cross‐over and cluster‐RCTs, that evaluated the effects of sucrose analgesia in neonates (including term and preterm infants) up to 44 weeks' postmenstrual age undergoing venepuncture. We excluded quasi‐RCTs and studies reported only as conference abstracts. We included studies administering sucrose with or without non‐nutritive sucking (NNS) before, at the time of, or after venepuncture. Sucrose could be of any concentration, volume, or dose. Sucrose was compared to: no intervention, water, or standard care; skin‐to‐skin care; breastfeeding; feeding; NNS alone (e.g. pacifier); glucose; positioning; or topical anaesthetics. Outcomes Outcomes of interest were pain intensity score, as measured by validated pain assessment scales, and adverse events. Risk of bias We used the Cochrane risk of bias tool (RoB 1). Synthesis methods We synthesised results for each outcome using meta‐analysis where possible. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous data (presence or absence of pain). We calculated the standardised mean difference (SMD) or mean difference (MD) for pain intensity scores (continuous outcome), each with its 95% CI. We used a fixed‐effect model to combine data and quantified the impact of heterogeneity using the I² statistic. Where these methods were not feasible due to the nature of the data, we synthesised the results narratively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included a total of 29 studies, accounting for 2764 term and preterm neonates. There was a large variation in sucrose dose and concentration (from 0.1 mL/kg to 0.5 mL/kg or a set volume from 0.1 mL to 2 mL) as well as mode of administration (e.g. oral syringe, pacifier, dropper, in combination with a pacifier). Most of the studies compared sucrose to no intervention, water, or standard care (n = 17). Other comparisons include non‐nutritive sucking, skin‐to‐skin care, breastfeeding, expressed breast milk, and other sweet solutions. Synthesis of results Adverse events (e.g. gagging, apnoea) were not reported for any comparison. Sucrose (with or without NNS) versus no intervention, water, or standard care Sucrose with or without NNS probably reduces pain intensity scores during and 30 seconds after venepuncture compared to no intervention (SMD −0.82, 95% CI −1.02 to −0.63; 7 studies, 477 participants; moderate‐certainty evidence). Sucrose with NNS reduces pain intensity scores one minute after venepuncture compared to no intervention (MD −9.15, 95% CI −9.91 to −8.39; 1 study, 100 participants; high‐certainty evidence). The evidence is uncertain about the effect of sucrose without NNS on pain intensity scores two minutes after venepuncture compared to no intervention (SMD −0.99, 95% CI −1.31 to −0.68; 3 studies, 186 participants; very low‐certainty evidence). Sucrose (with or without NNS) versus skin‐to‐skin care Sucrose without NNS may make little to no difference to pain scores during venepuncture when compared to skin‐to‐skin care (MD 1.49, 95% CI 0.86 to 2.12; 2 studies, 208 participants; low‐certainty evidence). Pain scores after 30 seconds, one minute, and two minutes were not reported. Sucrose (with or without NNS) versus breastfeeding Sucrose probably reduces pain during venepuncture compared to breastfeeding, as measured with the Neonatal Facial Coding System (where 0 = no pain, > 0 = pain) (RR 1.38, 95% CI 1.01 to 1.88; 1 study, 103 participants; moderate‐certainty evidence). Sucrose may result in little to no difference in pain compared to breastfeeding two minutes after venepuncture (RR 1.06, 95% CI 0.94 to 1.19; 1 study, 104 participants; low‐certainty evidence). Pain scores after 30 seconds and one minute were not reported. Sucrose (with or without NNS) versus NNS Sucrose with NNS likely reduces pain during venepuncture compared to NNS (SMD −1.52, 95% CI −1.92 to −1.12; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS may not reduce pain intensity scores during venepuncture compared to NNS (MD 1.37, 95% CI 0.57 to 2.17; 2 studies, 133 participants; low‐certainty evidence). Sucrose with NNS may reduce pain intensity scores one minute after venepuncture compared to NNS (MD −5.81, 95% CI −6.30 to −5.32; 2 studies, 200 participants; low‐certainty evidence). Sucrose with NNS probably reduces pain intensity two minutes after venepuncture compared to NNS alone (SMD −1.30, 95% CI −1.71 to −0.89; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS (MD 0.47, 95% CI −0.14 to 1.08; 1 study, 56 participants; moderate‐certainty evidence). We downgraded the certainty of the evidence in several comparisons, mostly due to unclear or high risk of selection, performance, detection, and reporting bias. High heterogeneity was also detected. Authors' conclusions Current evidence suggests sucrose probably reduces pain scores during and shortly after venepuncture compared to no intervention, water, or standard care. The evidence is very uncertain regarding the effects of sucrose compared to skin‐to‐skin care for analgesia during venepuncture. Compared to breastfeeding, sucrose probably results in a reduction of pain scores during venepuncture, but may result in little difference in pain scores two minutes after venepuncture. The evidence suggests sucrose with NNS probably reduces pain scores during and following venepuncture compared to NNS alone. Sucrose alone probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS. Funding This review had no dedicated funding. Registration Protocol available via doi/10.1002/14651858.CD015221 Plain language summary Does giving newborns sugar water during needle procedures reduce their pain? Key messages Newborn babies given sucrose (sugar water) when undergoing a needle procedure probably have less pain during and shortly after the procedure than babies given nothing, water, or standard comfort measures. Sucrose seems to reduce pain more than pacifiers. We do not have good evidence about the effect of sucrose compared to skin‐to‐skin care. No studies reported on harmful side effects, such as gagging or apnoea (a temporary pause in breathing). What is sucrose analgesia (pain relief)? Sucrose is table sugar. When mixed with water, and in very small amounts, it can be used for pain relief in newborn babies. Sucrose is dropped on a baby's tongue about two minutes before and/or immediately before venepuncture, when a needle is put into a vein to take blood or give treatment. Why is pain relief important for newborn babies who are in hospital? Hospitalised preterm babies (i.e. born early) and term babies (i.e. born at the normal time) are exposed to many painful procedures to give them medicine and to diagnose problems. Pain has many consequences for newborn babies. It can contribute to poor physical growth and affect brain development. Therefore, it is important to reduce babies' experience of pain as much as possible to ensure health as they grow. What did we want to find out? We wanted to find out how well sucrose worked to relieve pain in newborn babies during and shortly after needle punctures. We wanted to know how sucrose compared to other pain relief methods such as pacifier sucking, breastfeeding, or being held next to a mother or father's skin (skin‐to‐skin care). We also wanted to find out if sucrose caused negative effects. What did we do? We searched for studies that investigated the pain‐relief effects of sucrose compared to other methods (e.g. breastfeeding, pacifiers, holding). We summarised the results and rated our confidence in the evidence based on factors such as the number of infants treated and the quality of the methods used in the studies. What did we find? We found 29 studies that included 2764 newborn babies. The studies used different doses of sucrose and gave the sucrose to the babies in different ways. The studies were conducted worldwide. Most were carried out in Asia, with additional studies from Europe, North America, and South America. All the studies were randomised controlled trials, in which infants were assigned randomly to two or more treatment groups. This is the best way to ensure that the infant groups are similar, and that investigators and parents don’t know who is in which group. None of the studies were supported by the pharmaceutical industry. Main results Sucrose probably reduces babies' pain during and shortly after (30 seconds to 1 minute) the needle insertion compared to no pain relief (such as water). Sucrose may make little to no difference to pain during the procedure compared to skin‐to‐skin care. Sucrose probably reduces pain during the needle insertion compared to breastfeeding. Sucrose (with pacifier sucking) likely reduces pain during and shortly after (30 seconds to 2 minutes) the needle insertion compared to pacifier sucking alone. No study reported on harmful effects for any of our comparisons of interest. What are the limitations of the evidence? Sucrose versus no intervention or water We are moderately confident that sucrose probably reduces pain compared to no intervention. However, it is possible that people in the studies were aware of which treatment babies were receiving, and the studies involved small numbers of babies. Sucrose versus skin‐to‐skin care We are not confident that sucrose reduces pain more than skin‐to‐skin care because the two studies reported very different results. Further research is likely to change these results. Sucrose versus breastfeeding We are moderately confident that sucrose probably reduces pain more than breastfeeding. However, the study did not clearly report details of how it was conducted. Sucrose versus pacifier We are moderately confident that sucrose with a pacifier probably reduces pain more than pacifiers alone. The studies differed in how sucrose was given, including the amount of sucrose, how it was administered, and whether it was given with or without a pacifier. How current is this evidence? This evidence is current to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Bueno, M, Candido, L, Hu, J, Fiander, M, Cracknell, J, Xu, E, Kang, J, Yamada, J", "articleTypes": [], "doi": "10.1002/14651858.CD015221.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.753Z" }, { "id": "a5590035-9f57-4e07-b830-23ed799cc347", "pmid": "", "title": "Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Madsen, KS, Chi, Y, Metzendorf, MI, Richter, B, Hemmingsen, B", "articleTypes": [], "doi": "10.1002/14651858.CD008558.pub2 AB - Abstract - Background The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether metformin can prevent or delay T2DM and its complications in people with increased risk of developing T2DM is unknown. Objectives To assess the effects of metformin for the prevention or delay of T2DM and its associated complications in persons at increased risk for the T2DM. Search methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was March 2019. Selection criteria We included randomised controlled trials (RCTs) with a duration of one year or more comparing metformin with any pharmacological glucose‐lowering intervention, behaviour‐changing intervention, placebo or standard care in people with impaired glucose tolerance, impaired fasting glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or combinations of these. Data collection and analysis Two review authors read all abstracts and full‐text articles and records, assessed risk of bias and extracted outcome data independently. We used a random‐effects model to perform meta‐analysis and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using GRADE. Main results We included 20 RCTs randomising 6774 participants. One trial contributed 48% of all participants. The duration of intervention in the trials varied from one to five years. We judged none of the trials to be at low risk of bias in all 'Risk of bias' domains. Our main outcome measures were all‐cause mortality, incidence of T2DM, serious adverse events (SAEs), cardiovascular mortality, non‐fatal myocardial infarction or stroke, health‐related quality of life and socioeconomic effects.The following comparisons mostly reported only a fraction of our main outcome set.
 Fifteen RCTs compared metformin with diet and exercise with or without placebo: all‐cause mortality was 7/1353 versus 7/1480 (RR 1.11, 95% CI 0.41 to 3.01; P = 0.83; 2833 participants, 5 trials; very low‐quality evidence); incidence of T2DM was 324/1751 versus 529/1881 participants (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 3632 participants, 12 trials; moderate‐quality evidence); the reporting of SAEs was insufficient and diverse and meta‐analysis could not be performed (reported numbers were 4/118 versus 2/191; 309 participants; 4 trials; very low‐quality evidence); cardiovascular mortality was 1/1073 versus 4/1082 (2416 participants; 2 trials; very low‐quality evidence). One trial reported no clear difference in health‐related quality of life after 3.2 years of follow‐up (very low‐quality evidence). Two trials estimated the direct medical costs (DMC) per participant for metformin varying from $220 to $1177 versus $61 to $184 in the comparator group (2416 participants; 2 trials; low‐quality evidence). Eight RCTs compared metformin with intensive diet and exercise: all‐cause mortality was 7/1278 versus 4/1272 (RR 1.61, 95% CI 0.50 to 5.23; P = 0.43; 2550 participants, 4 trials; very low‐quality evidence); incidence of T2DM was 304/1455 versus 251/1505 (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 2960 participants, 7 trials; moderate‐quality evidence); the reporting of SAEs was sparse and meta‐analysis could not be performed (one trial reported 1/44 in the metformin group versus 0/36 in the intensive exercise and diet group with SAEs). One trial reported that 1/1073 participants in the metformin group compared with 2/1079 participants in the comparator group died from cardiovascular causes. One trial reported that no participant died due to cardiovascular causes (very low‐quality evidence). Two trials estimated the DMC per participant for metformin varying from $220 to $1177 versus $225 to $3628 in the comparator group (2400 participants; 2 trials; very low‐quality evidence). Three RCTs compared metformin with acarbose: all‐cause mortality was 1/44 versus 0/45 (89 participants; 1 trial; very low‐quality evidence); incidence of T2DM was 12/147 versus 7/148 (RR 1.72, 95% CI 0.72 to 4.14; P = 0.22; 295 participants; 3 trials; low‐quality evidence); SAEs were 1/51 versus 2/50 (101 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin with thiazolidinediones: incidence of T2DM was 9/161 versus 9/159 (RR 0.99, 95% CI 0.41 to 2.40; P = 0.98; 320 participants; 3 trials; low‐quality evidence). SAEs were 3/45 versus 0/41 (86 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin plus intensive diet and exercise with identical intensive diet and exercise: all‐cause mortality was 1/121 versus 1/120 participants (450 participants; 2 trials; very low‐quality evidence); incidence of T2DM was 48/166 versus 53/166 (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; 332 participants; 2 trials; very low‐quality evidence). One trial estimated the DMC of metformin plus intensive diet and exercise to be $270 per participant compared with $225 in the comparator group (94 participants; 1 trial; very‐low quality evidence). One trial in 45 participants compared metformin with a sulphonylurea. The trial reported no patient‐important outcomes. For all comparisons there were no data on non‐fatal myocardial infarction, non‐fatal stroke or microvascular complications. We identified 11 ongoing trials which potentially could provide data of interest for this review. These trials will add a total of 17,853 participants in future updates of this review. Authors' conclusions Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate‐quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate‐quality evidence). Likewise, the combination of metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of T2DM (very low‐quality evidence). Data on patient‐important outcomes such as mortality, macrovascular and microvascular diabetic complications and health‐related quality of life were sparse or missing. Plain language summary Metformin for prevention/delay of type 2 diabetes mellitus (T2DM) and associated complications in persons at increased risk for development of T2DM Review question Is the antidiabetic drug metformin able to prevent or delay the development of type 2 diabetes and its associated complications in people with moderately elevated blood sugar levels? Background People with moderately elevated blood sugar levels (often referred to as 'prediabetes') are said to have an increased risk for developing diabetes. Metformin is a blood sugar‐lowering medicine which has been used for a long time to treat people with type 2 diabetes. Type 2 diabetes, also known as adult‐onset diabetes, is the most common type of diabetes and prevents the body from using insulin properly (insulin resistance). Type 2 diabetes can have bad effects on health in the long term (diabetic complications), such as severe eye or kidney disease or 'diabetic feet', eventually resulting in foot ulcers. We investigated whether metformin can also be used to prevent or delay type 2 diabetes in people at increased risk. We examined the effects of metformin on patient‐important outcomes, such as complications of diabetes, death from any cause, health‐related quality of life and side effects of the drug. Study characteristics To be included, people had to have blood sugar levels higher than normal, but below the levels that are used to diagnose diabetes. We found 20 randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 6774 participants. The comparator group consisted of diet and exercise, intensive diet and exercise or another blood sugar‐lowering drug. One study dominated the evidence (48% of the total number of all participants). Twelve studies were performed in China. We only included studies with a treatment duration of one year or more. The treatment duration in the included studies varied from one to five years. This evidence is up to date as of March 2019. Key results Fifteen studies compared metformin against diet and exercise. Eight studies compared metformin against intensive diet and exercise and three studies compared metformin plus intensive diet and exercise against intensive diet and exercise only. When compared to standard diet and exercise metformin slightly reduces or delays development of diabetes. However, when compared to intensive diet and exercise, metformin does not provide an additional benefit in reducing or delaying development of diabetes. Seven studies compared metformin with another glucose‐lowering drug: three studies compared metformin with acarbose. Three studies compared metformin with a thiazolidinedione (such as pioglitazone). There was neither an advantage or disadvantage when comparing metformin with these drugs with respect to the development of diabetes. One study compared metformin with a sulphonylurea (glimepiride). The trial did not report patient‐important outcomes. In general, the reporting of serious side effects was sparse. Few participants died and we did not detect a clear difference between the intervention and comparator groups. We also did not detect an advantage or disadvantage of metformin in relation to health‐related quality of life. Our included studies did not report on non‐fatal heart attacks, strokes or complications of diabetes such as kidney or eye disease. Few studies estimated the direct medical costs. When compared to diet and exercise, metformin was more expensive. When compared to intensive diet and exercise, metformin was less expensive. We identified 11 ongoing studies which potentially could provide data for this review. These studies will add a total of 17,853 participants in future updates of our review. Future studies should investigate more patient‐important outcomes such as complications of diabetes and especially the side effects of the drugs. We do not know whether 'prediabetes' is just a condition defined by laboratory measurements, or whether it is in fact a real risk factor for diabetes. It is also unknown whether treatment of this condition translates into better patient‐important outcomes. Certainty of the evidence All included studies had problems in the way they were conduced or reported.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.744Z" }, { "id": "a56be2df-74e6-49c6-bc6c-598ada77fabd", "pmid": "", "title": "Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Nedocromil sodium and sodium cromoglycate inhaled shortly before exercise appear to reduce the severity of exercise‐induced bronchoconstriction. There is some debate over which drug may be more effective. Objectives The objective of this review was to compare the effects on post‐exercise lung function between prophylactic doses of nedocromil sodium (NSG) and sodium cromoglycate (SCG) in persons diagnosed with exercise‐induced bronchoconstriction. Search methods Randomized controlled trials were identified from the Cochrane Airways Review Group Asthma Register. Bibliographies of relevant studies and review articles were searched and primary authors, content experts and manufacturers of drugs were contacted for additional relevant studies. No language restrictions were applied. Searches were current as of December 2007. Selection criteria Randomized controlled trials comparing NCS to SCG in prophylactic treatment of exercise‐induced bronchoconstriction were eligible. Studies were included if: the participants, aged 6 or over, had a confirmed diagnosis of asthma with exercise‐induced bronchoconstriction, were subjected to an exercise challenge sufficient to trigger bronchoconstriction, and the measures of lung function were reported as either changes in forced expiratory volume in one second or peak expiratory flow rate. Data collection and analysis Data extraction and methodological quality assessments were conducted independently by two reviewers using standard forms and validated assessment criteria. In some cases results were extrapolated from graphs. Results from similar studies were pooled and reported as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CI) using the random effects model. Main results Nine studies (162 participants) are included in this review. No significant difference was noted between NCS and SCG with respect to the maximum percent decrease in FEV1 (WMD = ‐0.88; 95% CI: ‐4.50, 2.74), complete protection (i.e. maximum % fall FEV1 still =>10%); OR = 0.95; 95% CI: 0.50 to 1.8, clinical protection (i.e. < 50% improvement over placebo); OR = 0.71; 95% CI: 0.36 to 1.39; unpleasant taste (OR = 6.85; 95% CI: 0.77, 60.73), or sore throat (OR = 3.46; 95% CI: 0.32, 37.48). For these pooled comparisons, no statistically significant heterogeneity was identified. Subgroup analyses based on age, dosage of medications and timing of exercise post‐inhalation were consistent with the overall pooled analyses. Authors' conclusions No significant differences were evident between the effect of NCS and SCG during the immediate post‐exercise period in adults and children with EIB with regards to pulmonary function �� specifically maximum percent decrease in FEV1, complete protection, clinical protection, or side effects. Plain language summary Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. Two drugs, nedocromil sodium (Tilade) and sodium cromoglycate are sometimes used before exercise to prevent asthma. The review of trials found that both were similarly effective in relieving exercise‐induced asthma for both children and adults. More people have sore throats and an unpleasant after‐taste after using nedocromil sodium.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Kelly, KD, Spooner, C, Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD002731", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.738Z" }, { "id": "a56c07e8-e9a0-40da-9e3d-d82e38eef93a", "pmid": "", "title": "Antithyroid drug regimen for treating Graves' hyperthyroidism", "imported": false, "abstract": "Abstract - Background Antithyroid drugs are widely used in the therapy of hyperthyroidism. There are wide variations in the dose, regimen or duration of treatment used by health professionals. Objectives To assess the effects of dose, regimen and duration of antithyroid drug therapy for Graves' hyperthyroidism. Search methods We searched seven databases and reference lists. Selection criteria Randomised and quasi‐randomised trials of antithyroid medication for Graves' hyperthyroidism. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Pooling of data for primary outcomes, and select exploratory analyses were undertaken. Main results Twenty‐six randomised trials involving 3388 participants were included. Overall the quality of trials, as reported, was poor. None of the studies investigated incidence of hypothyroidism, changes in weight, health‐related quality of life, ophthalmopathy progression or economic outcomes. Four trials examined the effect of duration of therapy on relapse rates, and when using the titration regimen 12 months was superior to six months, but there was no benefit in extending treatment beyond 18 months. Twelve trials examined the effect of block‐replace versus titration block‐regimens. The relapse rates were similar in both groups at 51% in the block‐replace group and 54% in the titration block‐group (OR 0.86, 95% confidence interval (CI) 0.68 to1.08) though adverse effects (rashes (10% versus 6%) and withdrawing due to side effects (16% versus 9%)) were significantly higher in the block‐replace group. Three studies considered the addition of thyroxine with continued low dose antithyroid therapy after initial therapy with antithyroid drugs. There was significant heterogeneity between the studies and the difference between the two groups was not significant (OR 0.58, 95% CI 0.05 to 6.21). Four studies considered the addition of thyroxine alone after initial therapy with antithyroid drugs. There was no significant difference in the relapse rates between the groups after 12 months follow‐up (OR 1.15, 95% CI 0.79 to 1.67). Two studies considered the addition of immunosuppressive agents. The results which were in favour of the interventions would need to be validated in other populations. Authors' conclusions The evidence suggests that the optimal duration of antithyroid drug therapy for the titration regimen is 12 to 18 months. The titration (low dose) regimen had fewer adverse effects than the block‐replace (high dose) regimen and was no less effective. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Immunosuppressive therapies need further evaluation. Plain language summary Antithyroid drug regimen for treating Graves' hyperthyroidism People who have Graves' hyperthyroidism have thyroid glands which are releasing too much thyroid hormone. This can cause goitres (swelling in the neck around the thyroid gland), sweating, bowel or menstrual problems, and other, especially eye symptoms (ophthalmopathy). Treatments include anti‐thyroid drugs, surgery or radiation to reduce thyroid tissue. There are several choices to be made when considering the drug treatment of Graves' hyperthyroidism including the choice of drug, dose, duration of therapy, addition of thyroid hormone (thyroxine) and when to discontinue therapy. The antithyroid drugs which were used in the included randomised controlled trials (RCTs) comprised carbimazole, propylthiouracil and methimazole. Twenty‐six RCTs involving 3388 participants were identified. The majority of participants in all the studies were female (83% in the studies reporting sex distribution). The mean age was 40 years. The duration of follow up was between two to five years in eleven trials. In high dose ('block‐replace') versus low dose ('titration') studies the duration of therapy was six months in two studies, 18 months in four studies and 12 months in the remaining trials. The main outcome was the relapse rate of hyperthyroidism over one year after completion of drug treatment and this was the primary outcome in all the studies assessed. There were no deaths reported in any of the studies. None of the studies detailed incidence of hypothyroidism, changes in weight during the course of therapy, health‐related quality of life, ophthalmopathy progression or economic outcomes. The evidence (based on four studies) suggests that the optimal duration of antithyroid drug therapy for the low dose regimen is 12 to 18 months. The low dose regimen had fewer adverse effects than the high dose regimen and was no less effective in trials (based on 12 trials) of equal duration. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Studies using immunosuppressive agents need further validation of safety and efficacy in controlled trials among different populations. Data regarding side effects and number of participants withdrawn from therapy due to side effects were available in seven studies. The number of participants reporting rashes was significantly higher in the high versus low dose group (10% versus 6%). The number of participants withdrawing due to side effects were also significantly higher in the high versus low dose group (16% versus 9%).", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Abraham, P; Avenell, A; McGeoch, SC; Clark, LF; Bevan, JS", "articleTypes": [], "doi": "10.1002/14651858.CD003420.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "a56eaef8-9f9d-4fc6-b6be-32c42a6d5de1", "pmid": "", "title": "Protein and energy supplementation in elderly people at risk from malnutrition", "imported": false, "abstract": "Abstract - Background Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. Objectives This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip‐feeds'. Search methods We searched The Cochrane Library , MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip‐feed' manufacturers. Selection criteria Randomised and quasi‐randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. Data collection and analysis Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. Main results Sixty‐two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97). The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (‐0.8 days, 95% CI ‐2.8 to 1.3). Adverse effects included nausea or diarrhoea. Authors' conclusions Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large‐scale multi‐centre trials are still required. Plain language summary Protein and energy supplementation in elderly people at risk from malnutrition Much emphasis is placed on the importance of good diet, usually in relation to concern about the health risks of obesity. However it has been generally agreed that the risk of undernutrition rather than overnutrition is the main cause for concern in elderly people, particularly those who are hospitalised or institutionalised. Malnutrition has been shown to have important effects on recovery in a broad range of patients and conditions. It has been associated strongly with impaired immune response, impaired muscle and respiratory function, delayed wound healing, overall increased complications, longer rehabilitation, greater length of hospital stay and increased mortality. Oral protein and energy supplements are potentially safer and easier to administer than nasogastric enteral feeds and are therefore particularly suited to elderly people and are also widely used. However, there may be problems with the willingness and ability of older people to consume oral supplements, and supplements may not be used effectively. Even if supplements are prescribed, they may not always be given, or are given but not consumed. In addition to taste, the composition and timing of administration in relation to meals may be important. Efforts also need to be made to provide normal meals and snacks which meet the needs of elderly people and to provide assistance with feeding if required. A total of 10,187 randomised participants from the 62 trials has been included. Maximum duration of intervention was 18 months. The reviewers suggest that supplementation appears to produce a small but consistent weight gain. There was no evidence in this updated review of a beneficial effect on mortality overall, but there may be a beneficial effect on mortality in people who are undernourished. Supplementation may also reduce the number of complications. The reported acceptance of supplements was variable between trials. Some adverse effects such as nausea or diarrhoea were reported. However, there were problems of study design and quality. More studies are required to confirm the beneficial effect on the number of complications, to establish whether there is a beneficial effect on mortality for undernourished elderly people and to provide evidence about whether protein and energy supplements can improve morbidity and functional status in frail older people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Milne, AC, Potter, J, Vivanti, A, Avenell, A", "articleTypes": [], "doi": "10.1002/14651858.CD003288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.759Z" }, { "id": "a56f7c13-6987-4d44-8807-6dffe7134b31", "pmid": "", "title": "Interventions for chronic palmoplantar pustulosis", "imported": false, "abstract": "Abstract - Background Palmoplantar pustulosis is a chronic inflammatory disease in which sterile, relapsing pustules appear on the palms and soles, possibly in conjunction with other symptoms. The previous Cochrane Review on this topic was published in 2006, before biological treatments were extensively used. Objectives To assess the effects of interventions for chronic palmoplantar pustulosis to induce and maintain complete remission. Search methods We searched the following databases up to March 2019: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of the included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria We considered RCTs including people with palmoplantar pustulosis or chronic palmoplantar pustular psoriasis assessing topical therapy, systemic therapy, combinations of topical or systemic therapies, or non‐pharmacological therapies compared with placebo, no intervention, or each other. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our outcomes included 'Proportion of participants cleared or almost cleared', 'Proportion of participants with adverse effects serious or severe enough to cause withdrawal', 'Proportion of participants with at least 50% improvement in disease severity', and 'Proportion of participants with adverse effects'. Main results We included 37 studies (1663 participants; mean age 50 years (range 34 to 63); 24% males). These studies reported condition severity differently. Around half of the included trials stated the setting (hospitals, community clinics, or both). More than half of the studies were at high risk of bias in at least one domain. Our included studies assessed mainly systemic treatments (retinoids, ciclosporin, biologics, etretinate + PUVA (combination of psoralens and long‐wave ultraviolet radiation) therapy combined, and antibiotics), but also topical treatments (dermocorticoids, vitamin D) and phototherapy (PUVA, ultraviolet A1 (UVA1)). Other interventions were assessed by single studies. The most common comparator was placebo. All results presented in this abstract were assessed in the short term (mean treatment duration was 11 weeks (range 8 to 24 weeks)) and are based on participants with chronic palmoplantar pustulosis. All outcome time point measurements were taken from baseline and assessed at the end of treatment. Short‐term and long‐term outcomes were defined as measurement up to 24 weeks after randomisation and between 24 and 104 weeks after randomisation, respectively. One trial (188 participants) assessed the topical vitamin D derivative maxacalcitol versus placebo and found that maxacalcitol may be more effective than placebo in achieving clearance (risk ratio (RR) 7.83, 95% confidence interval (CI) 1.85 to 33.12; low‐quality evidence), and the risk of adverse effects (such as mild local irritation, pruritus, and haematological or urinary test abnormalities) is probably similar in both groups (RR 0.87, 95% CI 0.64 to 1.19; moderate‐quality evidence). Severity was not reported. Two trials (49 participants) assessed PUVA therapy versus placebo or no treatment, providing very low‐quality evidence. Adverse effects were reported with oral PUVA (including nausea, ankle swelling, and non‐purulent conjunctivitis) and with local PUVA (including blistering, erythema, and pruritus). With regard to the systemic retinoid alitretinoin, one trial (33 participants; moderate‐quality evidence) showed that alitretinoin probably makes little or no difference in reducing severity when compared to placebo (RR 0.69, 95% CI 0.36 to 1.30). A similar number of adverse events were reported in both treatment groups, including headache, cheilitis, nausea, arthralgia, and nasopharyngitis (RR 0.84, 95% CI 0.61 to 1.17). Clearance was not reported. There may be little or no difference between etanercept and placebo in achieving clearance (RR 1.64, 95% CI 0.08 to 34.28; 1 study; 15 participants; low‐quality evidence); however, the 95% CI was very wide, showing there may be a difference between groups. Severity was not measured. More patients treated with placebo may achieve reduced severity than those treated with ustekinumab, but the wide 95% CI indicates there might be little or no difference between groups and there might be greater effect with ustekinumab (RR 0.48, 95% CI 0.11 to 2.13; 1 study; 33 participants; low‐quality evidence). Clearance was not reported. It is uncertain whether guselkumab increases clearance when compared to placebo (2 studies; 154 participants) because the quality of evidence is very low, but guselkumab probably better reduces disease severity (RR 2.88, 95% CI 1.24 to 6.69; 1 study; 49 participants; moderate‐quality evidence). Secukinumab is probably superior to placebo in reducing severity (RR 1.55, 95% CI 1.02 to 2.35; 1 study; 157 participants; moderate‐quality evidence), but our clearance outcome was not reported. None of these trials reported on occurrence of adverse effects. Only two of the studies discussed above reported adverse effects serious or severe enough to cause withdrawal. Guselkumab may cause more serious adverse events when compared to placebo, but there is uncertainty due to the very wide 95% CI showing there may be little or no difference and showing more events with placebo (RR 2.88, 95% CI 0.32 to 25.80; 1 study; 49 participants; low‐quality evidence). Secukinumab probably causes more serious adverse events than placebo (RR 3.29, 95% CI 1.40 to 7.75; 1 study; 157 participants; moderate‐quality evidence). Authors' conclusions Evidence is lacking for major chronic palmoplantar pustulosis treatments such as superpotent corticosteroids, phototherapy, acitretin, methotrexate, and ciclosporin. Risk of bias and imprecision limit our confidence. Maxacalcitol may be more effective than placebo in achieving clearance in the short term (low‐quality evidence), and the risk of adverse effects is probably similar (moderate‐quality evidence). Oral alitretinoin is probably no more effective than placebo in reducing severity, with a similar risk of adverse effects (moderate‐quality evidence). Regarding biological treatments, we are uncertain of the effect of etanercept on clearance and the effect of ustekinumab on severity (low‐quality evidence). Secukinumab and guselkumab are probably superior to placebo in reducing severity (moderate‐quality evidence). Adverse events not requiring withdrawal were not reported for these treatments. Reporting of serious adverse effects was incomplete: compared to placebo, secukinumab probably caused more participant withdrawals (moderate‐quality evidence), but we are uncertain of the effect of guselkumab (low‐quality evidence). Future trials should assess commonly used treatments using validated severity and quality of life scales. Plain language summary Treating long‐term palmoplantar pustulosis (pustules on the hands and feet) Review question We wanted to assess treatments for palmoplantar pustulosis (a persistent condition characterised by small, pus‐filled blisters on the hands and feet), when compared to an inactive substance (placebo), no intervention, or each other. We included 37 studies. Background Palmoplantar pustulosis negatively affects a person's life; there is no cure or standard treatment. Over time, the skin becomes thicker and redder, and may develop cracks or flake off as scales. Symptoms are treated with topical medicines (usually corticosteroids), systemic medicines (medicines injected or taken by mouth that work throughout the entire body; usually medicines based on vitamin A or D), or phototherapy (ultraviolet light treatment). Study characteristics The studies involved 1663 adults (mostly women) 34 to 63 years of age (average age 50 years). In 19 studies, participants had had palmoplantar pustulosis from two to 16 years (average 6.4 years). Participants had palmoplantar pustular psoriasis (6 studies), palmoplantar pustulosis (29 studies), or both (2 studies). Study authors reported condition severity differently. The included studies assessed a variety of different treatments: mainly systemic treatments (including biologic medicines, vitamin A medicines, immunosuppressants, antibiotics, and light therapy combined with a vitamin A medicine), but also topical medicines (containing steroids or vitamin D) and light treatments. Single studies assessed other treatments. Treatments were most commonly compared against placebo. Treatment length varied; for our key results, this ranged from 8 to 24 weeks (average 11 weeks). When reported, studies were conducted in hospitals, community clinics, or both. Pharmaceutical companies funded 18 studies. Key results Low‐quality evidence suggests that maxacalcitol (a topical vitamin D derivative) may work better than placebo in achieving clearance; moderate‐quality evidence indicates that the number of side effects is probably similar in both groups (participants experienced itching, irritation, and blood or urine test abnormalities) (1 trial; 188 participants). Severity was not measured. We found very low‐quality evidence for PUVA therapy (i.e. psoralen, a drug to sensitise the skin, and ultraviolet light A) versus placebo or no treatment (2 studies; 49 participants), so we are unable to draw conclusions. Side effects with PUVA included skin blisters, redness, itching, swelling, and feeling sick. Oral alitretinoin probably makes little or no difference in reducing severity when compared to placebo (moderate‐quality evidence; 1 study; 33 participants). A similar result was found for side effects, with headache, sickness, joint pain, high cholesterol, and colds reported in both groups. Clearance was not reported. Five studies assessed biological treatments (etanercept, ustekinumab, guselkumab, secukinumab), which use substances made from living organisms, or synthetic versions, to target the immune system. Low‐quality evidence (1 study; 15 participants) suggests that etanercept may make little or no difference in clearance when compared to placebo, but we are very uncertain of this result. Side effects and severity were not measured. We found low‐quality evidence suggesting that ustekinumab may be worse than placebo in reducing disease severity, but we are very uncertain of this result. Side effects and clearance were not reported (1 study; 33 participants). Compared to placebo, guselkumab probably reduces severity (moderate‐quality evidence; 1 study; 49 participants), but its effects on clearance are uncertain (very low‐quality evidence; 2 studies; 154 participants). Side effects were not measured. Moderate‐quality evidence shows that secukinumab was probably superior to placebo in reducing severity, but skin clearance and side effects were not reported (1 study; 157 participants). Only two studies described above reported withdrawals from treatment due to serious side effects; these are probably more frequent with secukinumab than with placebo (157 participants), and may occur more often with guselkumab than with placebo (49 participants), but we are very uncertain of the guselkumab result. For these key results, outcomes were assessed between 8 and 24 weeks, which we deemed short term. This evidence is current to March 2019. Quality of the evidence The key comparisons reported clearance most often, but evidence quality was mainly very low. Only two key studies reported side effects causing withdrawal (low‐ and moderate‐quality evidence). The evidence underlying our severity and side effects outcomes was variable in quality (very low to moderate). Small participant numbers, results with wide margins of error, and selective reporting have limited our confidence in the evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Obeid, G, Do, G, Kirby, L, Hughes, C, Sbidian, E, Le Cleach, L", "articleTypes": [], "doi": "10.1002/14651858.CD011628.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.132Z" }, { "id": "a574b559-22c1-4e8e-910f-3f2428c54589", "pmid": "", "title": "Protein substitute for children and adults with phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria is an inherited metabolic disorder characterised by an absence or deficiency of the enzyme phenylalanine hydroxylase. The aim of treatment is to lower blood phenylalanine concentrations to the recommended therapeutic range to prevent developmental delay and support normal growth. Current treatment consists of a low‐phenylalanine diet in combination with a protein substitute which is free from or low in phenylalanine. Guidance regarding the use, dosage, and distribution of dosage of the protein substitute over a 24‐hour period is unclear, and there is variation in recommendations among treatment centres. This is an update of a Cochrane review first published in 2005, and previously updated in 2008. Objectives To assess the benefits and adverse effects of protein substitute, its dosage, and distribution of dose in children and adults with phenylketonuria who are adhering to a low‐phenylalanine diet. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which consists of references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. We also contacted manufacturers of the phenylalanine‐free and low‐phenylalanine protein substitutes for any data from published and unpublished randomised controlled trials. Date of the most recent search of the Group's Inborn Errors of Metabolism Trials Register: 03 April 2014. Selection criteria All randomised or quasi‐randomised controlled trials comparing: any dose of protein substitute with no protein substitute; an alternative dosage; or the same dose, but given as frequent small doses throughout the day compared with the same total daily dose given as larger boluses less frequently. Data collection and analysis Both authors independently extracted data and assessed trial quality. Main results Three trials (69 participants) are included in this review. One trial investigated the use of protein substitute in 16 participants, while a further two trials investigated the dosage of protein substitute in a total of 53 participants. Due to issues with data presentation in each trial, described in full in the review, formal statistical analyses of the data were impossible. Investigators will be contacted for further information. Authors' conclusions No conclusions could be drawn about the short‐ or long‐term use of protein substitute in phenylketonuria due to the lack of adequate or analysable trial data. Additional data and randomised controlled trials are needed to investigate the use of protein substitute in phenylketonuria. Until further evidence is available, current practice in the use of protein substitute should continue to be monitored with care. Plain language summary The impact of protein substitute on the nutrition status, growth, and neuropsychological performance of children and adults with phenylketonuria People with phenylketonuria (PKU) who follow a low‐phenylalanine diet are required to take protein substitute to ensure adequate consumption of protein, energy, and other nutrients. The need for protein substitute has been established through clinical experience and observational data. Randomised, controlled trials are needed to confirm this need as well as its proper dosage and frequency of use. We performed a systematic review of randomised control trials investigating the impact of the use, dosage, and distribution of protein substitute on physical and neuropsychological outcomes in the treatment of PKU. Trials of children and adults diagnosed with PKU in the newborn period who were treated early and continuously were included. We planned to pool the results of the trials to estimate treatment effect. Three trials met the inclusion criteria for the review. One trial evaluated the impact of protein substitute versus no protein substitute on neuropsychological status, plasma amino acid concentrations, and nutrient intake. The remaining two trials investigated the impact of differing dosages of protein substitute on plasma amino acid concentrations and nutrient intake. No trials investigating daily protein substitute distribution were eligible for inclusion in the review. Results are presented in text form only since adequate information for data pooling was not provided. The investigators will be contacted for further information. Currently data are insufficient to reach any conclusions regarding the use, dosage, and distribution of protein substitute in the treatment of PKU. Further randomized or controlled clinical trials are needed to provide evidence for the effectiveness, dosage, and distribution of protein substitute in the treatment of PKU.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Yi, SHL; Singh, RH", "articleTypes": [], "doi": "10.1002/14651858.CD004731.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "a5799534-25fa-4daa-8d39-21bc56d15c73", "pmid": "", "title": "Treatment and prevention of pouchitis after ileal pouch‐anal anastomosis for chronic ulcerative colitis", "imported": false, "abstract": "Abstract - Background Pouchitis occurs in approximately 50% of patients following ileal pouch‐anal anastomosis (IPAA) for chronic ulcerative colitis (UC). Objectives The primary objective was to determine the efficacy and safety of medical therapies for prevention or treatment of acute or chronic pouchitis. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 25 July 2018. We also searched references, trials registers, and conference proceedings. Selection criteria Randomized controlled trials of prevention or treatment of acute or chronic pouchitis in adults who underwent IPAA for UC were considered for inclusion. Data collection and analysis Two authors independently screened studies for eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was evaluated using GRADE. The primary outcome was clinical improvement or remission in participants with acute or chronic pouchitis, or the proportion of participants with no episodes of pouchitis after IPAA. Adverse events (AEs) was a secondary outcome. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for each dichotomous outcome. Main results Fifteen studies (547 participants) were included. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Three studies were low risk of bias. Three studies were high risk of bias and the other studies were unclear. Acute pouchitis: All ciprofloxacin participants (7/7) achieved remission at two weeks compared to 33% (3/9) of metronidazole participants (RR 2.68, 95% CI 1.13 to 6.35, very low certainty evidence). No ciprofloxacin participants (0/7) had an AE compared to 33% (3/9) of metronidazole participants (RR 0.18, 95% CI 0.01 to 2.98; very low certainty evidence). AEs included vomiting, dysgeusia or transient peripheral neuropathy. Forty‐three per cent (6/14) of metronidazole participants achieved remission at 6 weeks compared to 50% (6/12) of budesonide enema participants (RR 0.86, 95% CI 0.37 to 1.96, very low certainty evidence). Fifty per cent (7/14) of metronidazole participants improved clinically at 6 weeks compared to 58% (7/12) of budesonide enema participants (RR 0.86, 95% CI 0.42 to 1.74, very low certainty evidence). Fifty‐seven per cent (8/14) of metronidazole participants had an AE compared to 25% (3/12) of budesonide enema participants (RR 2.29, 95% CI 0.78 to 6.73, very low certainty evidence). AEs included anorexia, nausea, headache, asthenia, metallic taste, vomiting, paraesthesia, and depression. Twenty‐five per cent (2/8) of rifaximin participants achieved remission at 4 weeks compared to 0% (0/10) of placebo participants (RR 6.11, 95% CI 0.33 to 111.71, very low certainty evidence). Thirty‐eight per cent (3/8) of rifaximin participants improved clinically at 4 weeks compared to 30% (3/10) of placebo participants (RR 1.25, 95% CI 0.34 to 4.60, very low certainty evidence). Seventy‐five per cent (6/8) of rifaximin participants had an AE compared to 50% (5/10) of placebo participants (RR 1.50, 95% CI 0.72 to 3.14, very low certainty evidence). AEs included diarrhea, flatulence, nausea, proctalgia, vomiting, thirst, candida, upper respiratory tract infection, increased hepatic enzyme, and cluster headache. Ten per cent (1/10) of Lactobacillus GG participants improved clinically at 12 weeks compared to 0% (0/10) of placebo participants (RR 3.00, 95% CI 0.14 to 65.90, very low certainty evidence). Chronic pouchitis: Eighty‐five per cent (34/40) of De Simone Formulation (a probiotic formulation) participants maintained remission at 9 to 12 months compared to 3% (1/36) of placebo participants (RR 20.24, 95% CI 4.28 to 95.81, 2 studies; low certainty evidence). Two per cent (1/40) of De Simone Formulation participants had an AE compared to 0% (0/36) of placebo participants (RR 2.43, 95% CI 0.11 to 55.89; low certainty evidence). AEs included abdominal cramps, vomiting and diarrhea. Fifty per cent (3/6) of adalimumab patients achieved clinical improvement at 4 weeks compared to 43% (3/7) of placebo participants (RR, 1.17, 95% CI 0.36 to 3.76, low certainty evidence). Sixty per cent (6/10) of glutamine participants maintained remission at 3 weeks compared to 33% (3/9) of butyrate participants (RR 1.80, 95% CI 0.63 to 5.16, very low certainty evidence). Forty‐five per cent (9/20) of patients treated with bismuth carbomer foam enema improved clinically at 3 weeks compared to 45% (9/20) of placebo participants (RR 1.00, 95% CI 0.50 to 1.98, very low certainty evidence). Twenty‐five per cent (5/20) of participants in the bismuth carbomer foam enema group had an AE compared to 35% (7/20) of placebo participants (RR 0.71, 95% CI 0.27 to 1.88, very low certainty evidence). Adverse events included diarrhea, worsening symptoms, cramping, sinusitis, and abdominal pain. Prevention: At 12 months, 90% (18/20) of De Simone Formulation participants had no episodes of acute pouchitis compared to 60% (12/20) of placebo participants (RR 1.50, 95% CI 1.02 to 2.21, low certainty evidence). Another study found 100% (16/16) of De Simone Formulation participants had no episodes of acute pouchitis at 12 months compared to 92% (11/12) of the no treatment control group (RR 1.10, 95% 0.89 to 1.36, very low certainty evidence). Eighty‐six per cent (6/7) of Bifidobacterium longum participants had no episodes of acute pouchitis at 6 months compared to 60% (3/5) of placebo participants (RR 1.43, 95% CI 0.66 to 3.11, very low certainty evidence). Eleven per cent (1/9) of Clostridium butyricum MIYAIRI participants had no episodes of acute pouchitis at 24 months compared to 50% (4/8) of placebo participants (RR 0.22, 95% CI 0.03 to 1.60, very low certainty evidence). Forty‐six per cent (43/94) of allopurinol participants had no episodes of pouchitis at 24 months compared to 43% (39/90) of placebo participants (RR 1.06, 95% CI 0.76 to 1.46; low certainty evidence). Eighty‐one per cent (21/26) of tinidazole participants had no episodes of pouchitis over 12 months compared to 58% (7/12) of placebo participants (RR 1.38, 95% CI 0.83 to 2.31, very low certainty evidence). Authors' conclusions The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. Well designed, adequately powered studies are needed to determine the optimal therapy for the treatment and prevention of pouchitis. Plain language summary Therapy for treatment and prevention of pouchitis What is pouchitis? Some people with ulcerative colitis have their colon and rectum removed with construction of a pouch (made from a loop of small intestine) in place of the rectum ‐ known as ileal pouch‐anal anastomosis (IPAA) surgery. Pouchitis is inflammation of the surgically‐constructed pouch. Symptoms of active pouchitis include diarrhea, increased stool frequency, abdominal cramping, fecal urgency, tenesmus (feeling of constantly needing to pass stools), and incontinence. Acute refers to symptoms that last less than four weeks while chronic refers to symptoms that last more than four weeks. Periods when symptoms stop are called 'remission'. What therapies are used for pouchitis? Therapies used for pouchitis include antibiotics (drugs for bacteria infections), budesonide enemas (a steroid drug), probiotics (helpful bacteria), biologic agents that target tumor necrosis factor, glutamine suppositories (an amino acid), butyrate suppositories (short chain fatty acid), bismuth enemas (diarrhea medication), allopurinol (a purine analogue drug), and tinidazole (an anti‐parasitic drug). What did the researchers investigate? The researchers investigated whether these medications produce remission in people with active pouchitis, maintain remission in people with inactive pouchitis or prevent pouchitis in people who've had IPAA surgery. Side effects were also assessed. The medical literature was searched up to 25 July 2018. What did the researchers find? We found 15 studies with a total of 547 participants. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Acute pouchitis: It is uncertain whether ciprofloxacin is more effective than metronidazole for treatment of acute pouchitis (1 study, 16 participants). Side effects included vomiting, metallic taste and temporary damage to nerves. It is unclear whether there are any differences between metronidazole and budesonide enemas in terms of clinical remission, symptom improvement or side effects (1 study, 26 participants). Side effects included anorexia, nausea, headache, lack of energy and strength, metallic taste, vomiting, pins and needles, and depression. It is uncertain whether there are any differences between rifaximin and placebo in terms of clinical remission, symptom improvement, or side effects (1 study, 18 participants). Side effects included diarrhea, flatulence, nausea, rectal pain, vomiting, thirst, yeast infection, common cold, increased liver enzymes, and cluster headache. It is uncertain whether there is any difference between Lactobacillus GG and placebo in symptom improvement (1 study, 20 participants. The results of these studies are uncertain due to low event numbers caused by the small numbers of people who participated in the studies. Chronic pouchitis: It is uncertain whether De Simone Formulation (a probiotic formulation) is more effective than placebo for maintaining remission in people with inactive disease (2 studies, 76 participants). Side effects included abdominal cramps, vomiting and diarrhea. It is unclear whether there is any difference in effectiveness between adalimumab and placebo for treating chronic pouchitis(1 study, 13 participants). It is unclear whether there is any difference between glutamine and butyrate suppositories for maintenance of remission (1 study, 19 participants). It is unclear whether there are any differences in symptom improvement or side effects between bismuth carbomer foam enemas and placebo (1 study, 40 participants). Side effects included diarrhea, worsening symptoms, cramping, sinus infection, and abdominal pain. The results of these studies are uncertain due to the small number of people who participated in the studies. Prevention of pouchitis: It is uncertain whether De Simone Formulation is more effective than placebo for prevention of pouchitis (1 study, 40 participants). However, it is unclear whether there is any difference in prevention of pouchitis between De Simone Formulation and a no treatment control group (1 study, 28 participants). It is unclear whether there are any differences in prevention of pouchitis between Clostridium butyricum MIYAIRI and placebo (1 study, 17 participants) , Bifidobacterium longum and placebo (1 study, 12 participants) , allopurinol and placebo (1 study, 184 participants) and tinidazole and placebo (1 study, 38 participants). The results of these studies are uncertain due to the small number of people who participated in the studies. The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. More research is needed to determine which of these different medications are best for treatment of pouchitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nguyen, N; Zhang, B; Holubar, SD; Pardi, DS; Singh, S", "articleTypes": [], "doi": "10.1002/14651858.CD001176.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "a58f73c9-042d-4888-a0f5-904615acda56", "pmid": "", "title": "Alpha‐blockers as medical expulsive therapy for ureteral stones", "imported": false, "abstract": "Abstract - Background Ureteral colic is a common reason for patients to seek medical care. Alpha‐blockers are commonly used to improve stone passage through so‐called medical expulsive therapy (MET), but their effectiveness remains controversial. This is an update of a 2014 Cochrane review; since that time, several large randomised controlled trials (RCTs) have been reported, making this update relevant. Objectives To assess effects of alpha‐blockers compared with standard therapy for ureteral stones 1 cm or smaller confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease. Search methods On 18 November 2017, we searched CENTRAL, MEDLINE Ovid, and Embase. We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials. We checked all references of included and review articles and conference proceedings for articles relevant to this review. We sent letters to investigators to request information about unpublished or incomplete studies. Selection criteria We included RCTs of ureteral stone passage in adult patients that compared alpha‐blockers versus standard therapy. Data collection and analysis Two review authors screened studies for inclusion and extracted data using standard methodological procedures. We performed meta‐analysis using a random‐effects model. Primary outcomes were stone clearance and major adverse events; secondary outcomes were stone expulsion time, number of pain episodes, use of diclofenac, hospitalisation, and surgical intervention. We assessed the quality of evidence on a per‐outcome basis using the GRADE approach. Main results We included 67 studies with 10,509 participants overall. Of these, 15 studies with 5787 participants used a placebo. Stone clearance: Based on the overall analysis, treatment with an alpha‐blocker may result in a large increase in stone clearance (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.36 to 1.55; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that the likely effect is probably smaller (RR 1.16, 95% CI 1.07 to 1.25; moderate‐quality evidence), corresponding to 116 more (95% CI 51 more to 182 more) stone clearances per 1000 participants. Major adverse events: Based on the overall analysis, treatment with an alpha‐blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that alpha‐blockers likely increase the risk of major adverse events slightly (RR 2.09, 95% CI 1.13 to 3.86), corresponding to 29 more (95% CI 3 more to 75 more) major adverse events per 1000 participants. Patients treated with alpha‐blockers may experience shorter stone expulsion times (mean difference (MD) ‐3.40 days, 95% CI ‐4.17 to ‐2.63; low‐quality evidence), may use less diclofenac (MD ‐82.41, 95% CI ‐122.51 to ‐42.31; low‐quality evidence), and likely require fewer hospitalisations (RR 0.51, 95% CI 0.34 to 0.77; moderate‐quality evidence), corresponding to 69 fewer hospitalisations (95% CI 93 fewer to 32 fewer) per 1000 participants. Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI 0.53 to 1.02; low‐quality evidence), corresponding to 28 fewer surgical interventions (95% CI 51 fewer to 2 more) per 1000 participants. A predefined subgroup analysis (test for subgroup differences; P = 0.002) suggests that effects of alpha‐blockers may vary with stone size, with RR of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or smaller versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones larger than 5 mm. We found no evidence suggesting possible subgroup effects based on stone location or alpha‐blocker type. Authors' conclusions For patients with ureteral stones, alpha‐blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha‐blockers may be less effective for smaller (5 mm or smaller) than for larger stones (greater than 5 mm). Plain language summary Alpha‐blockers for ureteral stones in adult patients with symptoms of stone disease Review question Does medical treatment with alpha‐blockers improve the outcomes of patients with stones stuck in their ureter? Background Stones stuck in the ureter, which is the tube that transports urine from the kidney to the bladder, often cause pain and make people see a doctor. Depending on which part of the ureter the stone is stuck in and the size of the stone, it will often pass into the bladder on its own over the course of weeks. If the stone does not come out by itself, people often need to have procedures done to remove the stone. Alpha‐blockers are medications that relax muscles in the urinary tract and may make the stone pass into the bladder faster. However, they can cause unwanted effects. We updated an existing Cochrane Review from 2014 to look into the effects of alpha‐blockers. Study characteristics Based on our latest search of the literature from November 2017, we included 64 studies with 10,509 participants. Of these, 15 studies compared alpha‐blockers with placebo with 5787 participants. A placebo is a pill that looks and tastes exactly like the real medication, so participants did not know what they were getting. These were the higher‐quality studies, which we trusted more. Key results Based on the subset of higher‐quality studies that used a placebo, alpha‐blockers likely resulted in more people passing their stones. However, these patients are likely to experience slightly more serious unwanted effects of this medication. People taking alpha‐blockers may pass their stones in a shorter time, may use less diclofenac (which is a type of pain medication), and are likely to be admitted to the hospital less often. Meanwhile, the need for surgery for their stones was similar. Upon completing additional analyses, we found that effects of alpha‐blockers may be different in people with small (5 mm or smaller) versus larger (larger than 5 mm) stones. It appears that this medication works better in people with larger stones. We could find no difference in how well alpha‐blockers work, no matter where in the ureter the stone is stuck or what type of alpha‐blocker is used. Authors' conclusions For patients with stones stuck in the ureter, alpha‐blockers likely make passing the stone easier but cause slightly more unwanted effects. It appears that alpha‐blockers work better in people with larger (greater than 5 mm) rather than smaller (5 mm or smaller) stones. Quality of the evidence The quality of the evidence for most outcomes was moderate or low, meaning that we have moderate or low confidence in most of the reported results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Campschroer, T, Zhu, X, Vernooij, RWM, Lock, MTWT", "articleTypes": [], "doi": "10.1002/14651858.CD008509.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.816Z" }, { "id": "a5b9c523-4cc3-4188-a46f-0ff560e137ed", "pmid": "", "title": "Non‐invasive diagnostic tests for Helicobacter pylori infection", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) infection has been implicated in a number of malignancies and non‐malignant conditions including peptic ulcers, non‐ulcer dyspepsia, recurrent peptic ulcer bleeding, unexplained iron deficiency anaemia, idiopathic thrombocytopaenia purpura, and colorectal adenomas. The confirmatory diagnosis of H pylori is by endoscopic biopsy, followed by histopathological examination using haemotoxylin and eosin (H & E) stain or special stains such as Giemsa stain and Warthin‐Starry stain. Special stains are more accurate than H & E stain. There is significant uncertainty about the diagnostic accuracy of non‐invasive tests for diagnosis of H pylori . Objectives To compare the diagnostic accuracy of urea breath test, serology, and stool antigen test, used alone or in combination, for diagnosis of H pylori infection in symptomatic and asymptomatic people, so that eradication therapy for H pylori can be started. Search methods We searched MEDLINE, Embase, the Science Citation Index and the National Institute for Health Research Health Technology Assessment Database on 4 March 2016. We screened references in the included studies to identify additional studies. We also conducted citation searches of relevant studies, most recently on 4 December 2016. We did not restrict studies by language or publication status, or whether data were collected prospectively or retrospectively. Selection criteria We included diagnostic accuracy studies that evaluated at least one of the index tests (urea breath test using isotopes such as 13 C or 14 C, serology and stool antigen test) against the reference standard (histopathological examination using H & E stain, special stains or immunohistochemical stain) in people suspected of having H pylori infection. Data collection and analysis Two review authors independently screened the references to identify relevant studies and independently extracted data. We assessed the methodological quality of studies using the QUADAS‐2 tool. We performed meta‐analysis by using the hierarchical summary receiver operating characteristic (HSROC) model to estimate and compare SROC curves. Where appropriate, we used bivariate or univariate logistic regression models to estimate summary sensitivities and specificities. Main results We included 101 studies involving 11,003 participants, of which 5839 participants (53.1%) had H pylori infection. The prevalence of H pylori infection in the studies ranged from 15.2% to 94.7%, with a median prevalence of 53.7% (interquartile range 42.0% to 66.5%). Most of the studies (57%) included participants with dyspepsia and 53 studies excluded participants who recently had proton pump inhibitors or antibiotics.There was at least an unclear risk of bias or unclear applicability concern for each study. Of the 101 studies, 15 compared the accuracy of two index tests and two studies compared the accuracy of three index tests. Thirty‐four studies (4242 participants) evaluated serology; 29 studies (2988 participants) evaluated stool antigen test; 34 studies (3139 participants) evaluated urea breath test‐ 13 C; 21 studies (1810 participants) evaluated urea breath test‐ 14 C; and two studies (127 participants) evaluated urea breath test but did not report the isotope used. The thresholds used to define test positivity and the staining techniques used for histopathological examination (reference standard) varied between studies. Due to sparse data for each threshold reported, it was not possible to identify the best threshold for each test. Using data from 99 studies in an indirect test comparison, there was statistical evidence of a difference in diagnostic accuracy between urea breath test‐ 13 C, urea breath test‐ 14 C, serology and stool antigen test (P = 0.024). The diagnostic odds ratios for urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test were 153 (95% confidence interval (CI) 73.7 to 316), 105 (95% CI 74.0 to 150), 47.4 (95% CI 25.5 to 88.1) and 45.1 (95% CI 24.2 to 84.1). The sensitivity (95% CI) estimated at a fixed specificity of 0.90 (median from studies across the four tests), was 0.94 (95% CI 0.89 to 0.97) for urea breath test‐ 13 C, 0.92 (95% CI 0.89 to 0.94) for urea breath test‐ 14 C, 0.84 (95% CI 0.74 to 0.91) for serology, and 0.83 (95% CI 0.73 to 0.90) for stool antigen test. This implies that on average, given a specificity of 0.90 and prevalence of 53.7% (median specificity and prevalence in the studies), out of 1000 people tested for H pylori infection, there will be 46 false positives (people without H pylori infection who will be diagnosed as having H pylori i nfection). In this hypothetical cohort, urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test will give 30 (95% CI 15 to 58), 42 (95% CI 30 to 58), 86 (95% CI 50 to 140), and 89 (95% CI 52 to 146) false negatives respectively (people with H pylori infection for whom the diagnosis of H pylori will be missed). Direct comparisons were based on few head‐to‐head studies. The ratios of diagnostic odds ratios (DORs) were 0.68 (95% CI 0.12 to 3.70; P = 0.56) for urea breath test‐ 13 C versus serology (seven studies), and 0.88 (95% CI 0.14 to 5.56; P = 0.84) for urea breath test‐ 13 C versus stool antigen test (seven studies). The 95% CIs of these estimates overlap with those of the ratios of DORs from the indirect comparison. Data were limited or unavailable for meta‐analysis of other direct comparisons. Authors' conclusions In people without a history of gastrectomy and those who have not recently had antibiotics or proton ,pump inhibitors, urea breath tests had high diagnostic accuracy while serology and stool antigen tests were less accurate for diagnosis of Helicobacter pylori infection.This is based on an indirect test comparison (with potential for bias due to confounding), as evidence from direct comparisons was limited or unavailable. The thresholds used for these tests were highly variable and we were unable to identify specific thresholds that might be useful in clinical practice. We need further comparative studies of high methodological quality to obtain more reliable evidence of relative accuracy between the tests. Such studies should be conducted prospectively in a representative spectrum of participants and clearly reported to ensure low risk of bias. Most importantly, studies should prespecify and clearly report thresholds used, and should avoid inappropriate exclusions. Plain language summary Accuracy of different non‐invasive methods for identifying Helicobacter pylori Why is it important to know whether someone has Helicobacter pylori ? Helicobacter pylori (H pylori) is a type of bacteria which may be present in the stomach of some people. H pylori is believed to cause a number of cancers, including stomach cancer, pancreatic cancer, and throat cancer. H pylori is also linked with other diseases including stomach ulcers, heart burn, and a bloated feeling. If H pylori is found in an individual, appropriate treatment can be started. What is the aim of this review? To compare the accuracy of three different types of test for H pylori. These are: urea breath tests, blood tests (the specific blood test is called serology), and stool tests (in faeces). What was studied in this review? There are two types of urea breath test which use two different forms of carbon known as 13 C and 14 C, as well as multiple versions of serology and stool tests. What are the main results of the review? We found 101 studies which included 11,003 people who were tested for H pylori . Of these 11,003 participants, 5839 (53.1%) had H pylori infection. All the studies used one of the three tests listed above and compared these test results with the diagnosis given by endoscopic biopsy. Endoscopic biopsy involves obtaining tissue from the stomach using a thin flexible tube introduced through the mouth and testing for the presence of H pylori under the microscope. It is currently the most accurate available test, however it causes physical discomfort to the patient, with associated risks for harm. This is in contrast to the alternative non‐invasive tests in this review which are significantly less uncomfortable and have minimal or no risk of harm, making them desirable alternatives if they can be shown to be as accurate at diagnosing H pylori as endoscopic biopsy. Most of the studies included participants with heart burn or similar problems in the stomach and excluded participants who had previously undergone partial removal of the stomach and those having treatment for H pylori . Thirty‐four studies (4242 participants) used serology; 29 studies (2988 participants) used stool antigen test; 34 studies (3139 participants) used urea breath test‐ 13 C; 21 studies (1810 participants) used urea breath test‐ 14 C; and two studies (127 participants) used urea breath test but did not report the type of carbon used. Studies varied in the limit they used before saying a test was positive for H pylori infection and the type of stains used to examine the biopsy material. When we looked at all the data we found that urea breath tests were more accurate than blood and stool tests. The results mean that, on average, if 1000 people are tested, there will be 46 people without H pylori who will be misdiagnosed as having H pylori . Also, there will be 30, 42, 86, and 89 people with H pylori infection for whom the diagnosis of H pylori infection will be missed by urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test, respectively. When we looked at the seven studies which compared urea breath test‐ 13 C and serology, or urea breath test‐ 13 C and stool antigen tests in the same participants, the results were uncertain and we cannot tell which test is more accurate. How reliable are the results of the studies? Except for one study, all the studies were of poor methodological quality, which makes their results unreliable. Who do the results of this review apply to? These results apply to children and adults with suspected H pylori infection, but only in those who have not previously undergone stomach operations and those who have not recently had antibiotics or treatment for H pylori infection. What are the implications of this review? Urea breath tests, blood tests, and stool tests may be suitable for identifying whether someone has H pylori infection. However, the level of the result of urea breath test, blood test, or stool test which should be used to make a diagnosis of H pylori infection remains unclear. How up‐to‐date is the review? We performed a thorough literature search for studies reporting the accuracy of these different tests until 4 March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Best, LMJ; Takwoingi, Y; Siddique, S; Selladurai, A; Gandhi, A; Low, B; Yaghoobi, M; Gurusamy, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "a5ebbe65-dd2f-49fd-97de-b19a580df0a3", "pmid": "", "title": "Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Hip and knee replacement surgery is a well‐established means of improving quality of life, but is associated with a significant risk of bleeding. One‐third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care. Objectives To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta‐analysis (NMA) methodology. Search methods We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO host ), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). Selection criteria We included RCTs of people undergoing elective hip or knee surgery only. We excluded non‐elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon‐aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non‐fibrin sealants. Data collection and analysis We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all‐cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received. Main results We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra‐articularly and orally at a total dose of greater than 3 g pre‐incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate‐certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre‐incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low‐certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low‐certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low‐certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low‐certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low‐certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all‐cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low‐certainty evidence). This was followed by TXA given intravenously and intra‐articularly at a total dose of 2 g pre‐incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low‐certainty evidence) and TXA given intravenously and intra‐articularly, total dose greater than 3 g pre‐incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low‐certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low‐certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials). Authors' conclusions We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra‐articular, oral and intravenous, or intravenous and intra‐articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review. Plain language summary What is the best medication to stop bleeding in those having non‐emergency hip or knee surgery? Key messages • Tranexamic acid may be an effective medicine to help blood to clot during hip or knee replacement surgery, which reduces bleeding and the need for a blood transfusion (replacing lost blood with donated blood). • A high dose of this medicine and administering it in more than one way (for example, as a tablet and injected into the joint at the end of surgery) appears to work best. • Tranexamic acid is potentially as effective when given as a tablet as when injected into a vein. • There is little to no evidence to indicate that higher doses of tranexamic acid increase the risk of blood clots in the leg or other harms. Background Why is it important to stop bleeding during hip or knee surgery? Controlling bleeding during surgery reduces the likelihood of the person developing anaemia and requiring a blood transfusion, which carries the risk of complications. Anaemia occurs when the number of red blood cells (haemoglobin) available to carry oxygen is lower than normal. This causes symptoms such as fatigue, weakness, dizziness, shortness of breath and, in severe cases, can be life‐threatening. Preventing blood loss during surgery improves patient outcomes, decreases healthcare costs and preserves the limited supplies of donated blood. Is there a medication that helps control bleeding? Many research studies have investigated whether certain medication, such as tranexamic acid, can help minimise blood loss during surgery. Most of the studies test different doses of medications, different methods of administration and different times of use, either before, during or after an operation. What did we want to find out? We wanted to find out whether medication can reduce blood loss and the need for blood transfusions in people having hip or knee replacement surgery. We also wanted to know the most effective way of giving this medication to patients. What did we do? We searched for studies comparing different medications that could help reduce bleeding in adults undergoing planned hip or knee replacement surgery. We also searched for studies comparing medication with a placebo. A placebo is a 'dummy' medication that looks or tastes identical to the medication being tested. What did we find? We found 102 studies. Twelve studies did not report the number of included participants; in the other 90 studies, there were 8418 included participants. On average, people were between 50 and 77 years of age and 64% were women. The smallest study included 16 people and the largest involved 300. Studies took place around the globe, with the highest number in Europe and Asia. Of those studies that reported a source of funding, seven were fully funded and five partly funded by pharmaceutical (medication) companies. All studies investigated medications that helped the blood to clot. However, most studies assessed the effectiveness and safety of tranexamic acid administered intravenously (injected into a vein), orally (swallowing a tablet or liquid), injected into the joint during surgery, or with a combination of these methods. Main results Our review of the studies showed the following: • Tranexamic acid was the most effective at controlling bleeding compared to other medications. • Adults who underwent hip or knee replacement surgery required fewer blood transfusions if they were given tranexamic acid. • Tranexamic acid given in higher doses using multiple methods of administration, such as orally and injected into the joint during surgery, may be more likely to prevent bleeding. • Taking tranexamic acid orally is probably as effective at preventing a blood transfusion as injecting the medication into a vein. We were unable to decide on the optimal dose, which combination of methods are best to administer tranexamic acid and when it is most beneficial to use it (before, during and after surgery). We did not find evidence to suggest that higher doses of tranexamic acid increase the risk of developing a blood clot, or any other harms. What are the limitations of the evidence? We are not able to definitively draw conclusions based on the trials included within this review. We have little confidence in the evidence for some outcomes, and are not confident about the evidence for others. This is because it is possible that people in the studies were aware of which treatment they were getting. Also, the studies were small and did not all provide data about everything in which we were interested. Ongoing studies and future updates Thirty studies with a planned total of 3776 participants are currently ongoing. These studies should be completed and published within the next few years. Once the authors publish their data, we may update our analyses and provide stronger answers than we can at present. How up‐to‐date is this evidence? The evidence is current to 18 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gibbs, VN, Champaneria, R, Sandercock, J, Welton, NJ, Geneen, LJ, Brunskill, SJ, Dorée, C, Kimber, C, Palmer, AJR, Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD013295.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.143Z" }, { "id": "a5f59997-6d98-44f8-ac9c-dba0306dd928", "pmid": "", "title": "Postnatal phenobarbital for the prevention of intraventricular haemorrhage in preterm infants", "imported": false, "abstract": "Abstract - Background Intraventricular haemorrhage (IVH) is a major complication of preterm birth. Large haemorrhages are associated with a high risk of disability and hydrocephalus. Instability of blood pressure and cerebral blood in the newborn flow are postulated as causative factors. Another mechanism may involve reperfusion damage from oxygen free radicals. It has been suggested that phenobarbital stabilises blood pressure and may protect against free radicals. This is an update of a review first published in 2001 and updated in 2007 and 2013. Objectives To assess the benefits and harms of the postnatal administration of phenobarbital in preterm infants at risk of developing IVH compared to control (i.e. no intervention or placebo). Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL and clinical trial registries in January 2022. A new, more sensitive search strategy was developed, and searches were conducted without date limits. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs in which phenobarbital was given within the first 24 hours of life to preterm infants identified as being at risk of IVH because of gestational age below 34 weeks, birth weight below 1500 g or respiratory failure. Phenobarbital was compared to no intervention or placebo. We excluded infants with serious congenital malformations. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were all grades of IVH and severe IVH (i.e. grade III and IV); secondary outcomes were ventricular dilation or hydrocephalus, hypotension, pneumothorax, hypercapnia, acidosis, mechanical ventilation, neurodevelopmental impairment and death. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 10 RCTs (792 infants). The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH of any grade compared with control (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.84 to 1.19; risk difference (RD) 0.00, 95% CI ‐0.06 to 0.07; I² for RD = 65%; 10 RCTs, 792 participants; low certainty evidence) and in severe IVH (RR 0.88, 95% CI 0.64 to 1.21; 10 RCTs, 792 participants; low certainty evidence). The evidence is very uncertain about the effect of phenobarbital on posthaemorrhagic ventricular dilation or hydrocephalus (RR 0.62, 95% CI 0.31 to 1.26; 4 RCTs, 271 participants; very low certainty evidence), mild neurodevelopmental impairment (RR 0.57, 95% CI 0.15 to 2.17; 1RCT, 101 participants; very low certainty evidence), and severe neurodevelopmental impairment (RR 1.12, 95% CI 0.44 to 2.82; 2 RCTs, 153 participants; very low certainty evidence). Phenobarbital may result in little to no difference in death before discharge (RR 0.88, 95% CI 0.64 to 1.21; 9 RCTs, 740 participants; low certainty evidence) and mortality during study period (RR 0.98, 95% CI 0.72 to 1.33; 10 RCTs, 792 participants; low certainty evidence) compared with control. We identified no ongoing trials. Authors' conclusions The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH (any grade or severe) compared with control (i.e. no intervention or placebo). The evidence is very uncertain about the effects of phenobarbital on ventricular dilation or hydrocephalus and on neurodevelopmental impairment. The evidence suggests that phenobarbital results in little to no difference in death before discharge and all deaths during the study period compared with control. Since 1993, no randomised studies have been published on phenobarbital for the prevention of IVH in preterm infants, and no trials are ongoing. The effects of postnatal phenobarbital might be assessed in infants with both neonatal seizures and IVH, in both randomised and observational studies. The assessment of benefits and harms should include long‐term outcomes. Plain language summary What are the benefits and risks of phenobarbital for preventing bleeding to the brain in babies born too early? Key messages • Giving phenobarbital (a medicine used to control seizures) to babies born too early may have little to no effect in preventing intraventricular haemorrhage (bleeding to the brain) and death. • The evidence is very uncertain about the effect of phenobarbital on preventing ventricular dilation (enlarged spaces in the brain) and long‐term brain development. What is bleeding to the brain (intraventricular haemorrhage)? Large bleeds in the centre of the brain can cause disability or death in babies born too early. Unstable blood pressure and blood flow to the brain are believed to cause bleeding into the fluid‐filled cavities of the brain (ventricles). What did we want to find out? Phenobarbital is believed to stabilise blood pressure and therefore potentially help prevent bleeding to the brain. We wanted to find out whether phenobarbital was better than no medicine or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) to prevent bleeding to the brain. What did we do? We searched for studies that compared giving phenobarbital against no medicines. We compared and summarised the results of these studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We included 10 studies (792 babies). The evidence suggests that phenobarbital has little to no effect in preventing bleeding to the brain. The evidence is very uncertain about the effect of phenobarbital on dilation of the ventricles in the brain and long‐term development. The evidence suggests that phenobarbital has little to no effect in preventing deaths. We identified no ongoing trials. What are the limitations of the evidence? It is possible that people conducting the studies were aware of what treatment they were giving. Not all the studies provided data about everything that we were interested in. The studies were very small. How up to date is this evidence? This review updates our previous review. The evidence is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Romantsik, O; Smit, E; Odd, DE; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD001691.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "a5fdc027-3de0-44d8-9599-e9178eb48069", "pmid": "", "title": "Thoracic imaging tests for the diagnosis of COVID‐19", "imported": false, "abstract": "Abstract - Background Our March 2021 edition of this review showed thoracic imaging computed tomography (CT) to be sensitive and moderately specific in diagnosing COVID‐19 pneumonia. This new edition is an update of the review. Objectives Our objectives were to evaluate the diagnostic accuracy of thoracic imaging in people with suspected COVID‐19; assess the rate of positive imaging in people who had an initial reverse transcriptase polymerase chain reaction (RT‐PCR) negative result and a positive RT‐PCR result on follow‐up; and evaluate the accuracy of thoracic imaging for screening COVID‐19 in asymptomatic individuals. The secondary objective was to assess threshold effects of index test positivity on accuracy. Search methods We searched the COVID‐19 Living Evidence Database from the University of Bern, the Cochrane COVID‐19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID‐19 publications through to 17 February 2021. We did not apply any language restrictions. Selection criteria We included diagnostic accuracy studies of all designs, except for case‐control, that recruited participants of any age group suspected to have COVID‐19. Studies had to assess chest CT, chest X‐ray, or ultrasound of the lungs for the diagnosis of COVID‐19, use a reference standard that included RT‐PCR, and report estimates of test accuracy or provide data from which we could compute estimates. We excluded studies that used imaging as part of the reference standard and studies that excluded participants with normal index test results. Data collection and analysis The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using QUADAS‐2. We presented sensitivity and specificity per study on paired forest plots, and summarized pooled estimates in tables. We used a bivariate meta‐analysis model where appropriate. Main results We included 98 studies in this review. Of these, 94 were included for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eight studies were included for assessing the rate of positive imaging in individuals with initial RT‐PCR negative results and positive RT‐PCR results on follow‐up, and 10 studies were included for evaluating the accuracy of thoracic imaging for imagining asymptomatic individuals. For all 98 included studies, risk of bias was high or unclear in 52 (53%) studies with respect to participant selection, in 64 (65%) studies with respect to reference standard, in 46 (47%) studies with respect to index test, and in 48 (49%) studies with respect to flow and timing. Concerns about the applicability of the evidence to: participants were high or unclear in eight (8%) studies; index test were high or unclear in seven (7%) studies; and reference standard were high or unclear in seven (7%) studies. Imaging in people with suspected COVID‐19 We included 94 studies. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All studies used RT‐PCR alone or in combination with other criteria (for example, clinical signs and symptoms, positive contacts) as the reference standard for the diagnosis of COVID‐19. For chest CT (69 studies, 28285 participants, 14,342 (51%) cases), sensitivities ranged from 45% to 100%, and specificities from 10% to 99%. The pooled sensitivity of chest CT was 86.9% (95% confidence interval (CI) 83.6 to 89.6), and pooled specificity was 78.3% (95% CI 73.7 to 82.3). Definition for index test positivity was a source of heterogeneity for sensitivity, but not specificity. Reference standard was not a source of heterogeneity. For chest X‐ray (17 studies, 8529 participants, 5303 (62%) cases), the sensitivity ranged from 44% to 94% and specificity from 24 to 93%. The pooled sensitivity of chest X‐ray was 73.1% (95% CI 64.1 to 80.5), and pooled specificity was 73.3% (95% CI 61.9 to 82.2). Definition for index test positivity was not found to be a source of heterogeneity. Definition for index test positivity and reference standard were not found to be sources of heterogeneity. For ultrasound of the lungs (15 studies, 2410 participants, 1158 (48%) cases), the sensitivity ranged from 73% to 94% and the specificity ranged from 21% to 98%. The pooled sensitivity of ultrasound was 88.9% (95% CI 84.9 to 92.0), and the pooled specificity was 72.2% (95% CI 58.8 to 82.5). Definition for index test positivity and reference standard were not found to be sources of heterogeneity. Indirect comparisons of modalities evaluated across all 94 studies indicated that chest CT and ultrasound gave higher sensitivity estimates than X‐ray (P = 0.0003 and P = 0.001, respectively). Chest CT and ultrasound gave similar sensitivities (P = 0.42). All modalities had similar specificities (CT versus X‐ray P = 0.36; CT versus ultrasound P = 0.32; X‐ray versus ultrasound P = 0.89). Imaging in PCR‐negative people who subsequently became positive For rate of positive imaging in individuals with initial RT‐PCR negative results, we included 8 studies (7 CT, 1 ultrasound) with a total of 198 participants suspected of having COVID‐19, all of whom had a final diagnosis of COVID‐19. Most studies (7/8) evaluated CT. Of 177 participants with initially negative RT‐PCR who had positive RT‐PCR results on follow‐up testing, 75.8% (95% CI 45.3 to 92.2) had positive CT findings. Imaging in asymptomatic PCR‐positive people For imaging asymptomatic individuals, we included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with a total of 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. For chest CT (7 studies, 3134 participants, 315 (10%) cases), the pooled sensitivity was 55.7% (95% CI 35.4 to 74.3) and the pooled specificity was 91.1% (95% CI 82.6 to 95.7). Authors' conclusions Chest CT and ultrasound of the lungs are sensitive and moderately specific in diagnosing COVID‐19. Chest X‐ray is moderately sensitive and moderately specific in diagnosing COVID‐19. Thus, chest CT and ultrasound may have more utility for ruling out COVID‐19 than for differentiating SARS‐CoV‐2 infection from other causes of respiratory illness. The uncertainty resulting from high or unclear risk of bias and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results. Plain language summary How accurate is chest imaging for diagnosing COVID‐19? Why is this question important? People with suspected COVID‐19 need to know quickly whether they are infected, so they can receive appropriate treatment, self‐isolate, and inform close contacts. Currently, a formal diagnosis of COVID‐19 requires a laboratory test (RT‐PCR) of nose and throat samples. RT‐PCR requires specialist equipment and takes at least 24 hours to produce a result. It is not completely accurate, and may require a second RT‐PCR or a different test to confirm diagnosis. Clinicians may use chest imaging to diagnose people who have COVID‐19 symptoms, while awaiting RT‐PCR results or when RT‐PCR results are negative, and the person has COVID‐19 symptoms. This is the fourth version of this review. What did we want to find out? We wanted to know whether chest imaging is accurate enough to diagnose COVID‐19 in people with suspected infection; we included studies in people with suspected COVID‐19 only and excluded studies in people with confirmed COVID‐19. We also wanted to assess the accuracy of chest imaging for screening asymptomatic people. The evidence is up to date to 17 February 2021. What are chest imaging tests? X‐rays or scans produce an image of the organs and structures in the chest. ‐ X‐rays (radiography) use radiation to produce a 2‐D image. Usually done in hospitals, using fixed equipment by a radiographer; they can also be done on portable machines. ‐ Computed tomography (CT) scans use a computer to merge 2‐D X‐ray images and convert them to a 3‐D image. They require highly‐specialized equipment and are done in hospital by a specialist radiographer. ‐ Ultrasound scans use high‐frequency sound waves to produce an image. They can be done in hospitals or other healthcare settings, such as a doctor’s office. What did we do? We searched for studies that assessed the accuracy of chest imaging to diagnose COVID‐19 in people of any age with suspected COVID‐19. We included studies with ‘symptomatic' or 'mixed populations'. What did we find? We found 94 studies with 37,631 participants (of whom 19,768 (53%) had a final diagnosis of COVID‐19) for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All 94 studies used RT‐PCR either alone or in combination with other criteria (such as clinical signs and symptoms, or positive contacts) as the reference standard for the diagnosis of COVID‐19. Chest CT: suspected people Pooled results showed that chest CT (69 studies) correctly diagnosed COVID‐19 in 87% of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 21% of people who did not have COVID‐19. Chest X‐ray: suspected people Pooled results showed that chest X‐ray (17 studies) correctly diagnosed COVID‐19 in 73 % of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 27% of people who did not have COVID‐19. Lung ultrasound: suspected people Pooled results showed that lung ultrasound (15 studies) correctly diagnosed COVID‐19 in 87% of people with COVID‐19. However, it incorrectly diagnosed COVID‐19 in 24% of people who did not have COVID‐19. Screening asymptomatic people We included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. Pooled results of seven studies, showed that CT correctly diagnosed COVID‐19 in 56% of people who had COVID‐19, and incorrectly identified COVID‐19 in 8% of people who did not have COVID‐19. How reliable are the results? The studies differed from each other and used different methods to report their results. Very few studies directly compared one type of imaging test with another. Also, the risk of bias was high or unclear in about half of all included studies. Therefore, it is difficult to draw confident conclusions. What does this mean? The evidence suggests that chest CT and ultrasound are better at ruling out COVID‐19 infection than distinguishing it from other respiratory problems. So, their usefulness may be limited to excluding COVID‐19 infection rather than differentiating it from other causes of lung infection. In addition, chest CT imaging had poor sensitivity and high specificity for detecting asymptomatic individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ebrahimzadeh, S, Islam, N, Dawit, H, Salameh, J-P, Kazi, S, Fabiano, N, Treanor, L, Absi, M, Ahmad, F, Rooprai, P, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013639.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.123Z" }, { "id": "a6066474-ac36-4847-83bd-14c570cbc54c", "pmid": "", "title": "Alpha‐blockers as medical expulsive therapy for ureteral stones", "imported": false, "abstract": "Abstract - Background Ureteral colic is a common reason for patients to seek medical care. Alpha‐blockers are commonly used to improve stone passage through so‐called medical expulsive therapy (MET), but their effectiveness remains controversial. This is an update of a 2014 Cochrane review; since that time, several large randomised controlled trials (RCTs) have been reported, making this update relevant. Objectives To assess effects of alpha‐blockers compared with standard therapy for ureteral stones 1 cm or smaller confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease. Search methods On 18 November 2017, we searched CENTRAL, MEDLINE Ovid, and Embase. We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials. We checked all references of included and review articles and conference proceedings for articles relevant to this review. We sent letters to investigators to request information about unpublished or incomplete studies. Selection criteria We included RCTs of ureteral stone passage in adult patients that compared alpha‐blockers versus standard therapy. Data collection and analysis Two review authors screened studies for inclusion and extracted data using standard methodological procedures. We performed meta‐analysis using a random‐effects model. Primary outcomes were stone clearance and major adverse events; secondary outcomes were stone expulsion time, number of pain episodes, use of diclofenac, hospitalisation, and surgical intervention. We assessed the quality of evidence on a per‐outcome basis using the GRADE approach. Main results We included 67 studies with 10,509 participants overall. Of these, 15 studies with 5787 participants used a placebo. Stone clearance: Based on the overall analysis, treatment with an alpha‐blocker may result in a large increase in stone clearance (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.36 to 1.55; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that the likely effect is probably smaller (RR 1.16, 95% CI 1.07 to 1.25; moderate‐quality evidence), corresponding to 116 more (95% CI 51 more to 182 more) stone clearances per 1000 participants. Major adverse events: Based on the overall analysis, treatment with an alpha‐blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that alpha‐blockers likely increase the risk of major adverse events slightly (RR 2.09, 95% CI 1.13 to 3.86), corresponding to 29 more (95% CI 3 more to 75 more) major adverse events per 1000 participants. Patients treated with alpha‐blockers may experience shorter stone expulsion times (mean difference (MD) ‐3.40 days, 95% CI ‐4.17 to ‐2.63; low‐quality evidence), may use less diclofenac (MD ‐82.41, 95% CI ‐122.51 to ‐42.31; low‐quality evidence), and likely require fewer hospitalisations (RR 0.51, 95% CI 0.34 to 0.77; moderate‐quality evidence), corresponding to 69 fewer hospitalisations (95% CI 93 fewer to 32 fewer) per 1000 participants. Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI 0.53 to 1.02; low‐quality evidence), corresponding to 28 fewer surgical interventions (95% CI 51 fewer to 2 more) per 1000 participants. A predefined subgroup analysis (test for subgroup differences; P = 0.002) suggests that effects of alpha‐blockers may vary with stone size, with RR of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or smaller versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones larger than 5 mm. We found no evidence suggesting possible subgroup effects based on stone location or alpha‐blocker type. Authors' conclusions For patients with ureteral stones, alpha‐blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha‐blockers may be less effective for smaller (5 mm or smaller) than for larger stones (greater than 5 mm). Plain language summary Alpha‐blockers for ureteral stones in adult patients with symptoms of stone disease Review question Does medical treatment with alpha‐blockers improve the outcomes of patients with stones stuck in their ureter? Background Stones stuck in the ureter, which is the tube that transports urine from the kidney to the bladder, often cause pain and make people see a doctor. Depending on which part of the ureter the stone is stuck in and the size of the stone, it will often pass into the bladder on its own over the course of weeks. If the stone does not come out by itself, people often need to have procedures done to remove the stone. Alpha‐blockers are medications that relax muscles in the urinary tract and may make the stone pass into the bladder faster. However, they can cause unwanted effects. We updated an existing Cochrane Review from 2014 to look into the effects of alpha‐blockers. Study characteristics Based on our latest search of the literature from November 2017, we included 64 studies with 10,509 participants. Of these, 15 studies compared alpha‐blockers with placebo with 5787 participants. A placebo is a pill that looks and tastes exactly like the real medication, so participants did not know what they were getting. These were the higher‐quality studies, which we trusted more. Key results Based on the subset of higher‐quality studies that used a placebo, alpha‐blockers likely resulted in more people passing their stones. However, these patients are likely to experience slightly more serious unwanted effects of this medication. People taking alpha‐blockers may pass their stones in a shorter time, may use less diclofenac (which is a type of pain medication), and are likely to be admitted to the hospital less often. Meanwhile, the need for surgery for their stones was similar. Upon completing additional analyses, we found that effects of alpha‐blockers may be different in people with small (5 mm or smaller) versus larger (larger than 5 mm) stones. It appears that this medication works better in people with larger stones. We could find no difference in how well alpha‐blockers work, no matter where in the ureter the stone is stuck or what type of alpha‐blocker is used. Authors' conclusions For patients with stones stuck in the ureter, alpha‐blockers likely make passing the stone easier but cause slightly more unwanted effects. It appears that alpha‐blockers work better in people with larger (greater than 5 mm) rather than smaller (5 mm or smaller) stones. Quality of the evidence The quality of the evidence for most outcomes was moderate or low, meaning that we have moderate or low confidence in most of the reported results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Campschroer, T, Zhu, X, Vernooij, RWM, Lock, MTWT", "articleTypes": [], "doi": "10.1002/14651858.CD008509.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.133Z" }, { "id": "a61af05e-47b7-4d77-8975-4b932b82a199", "pmid": "", "title": "Obesity and Lipids: a Matter of Taste? Impact of Bariatric Surgery on Taste Receptors", "imported": false, "abstract": "The purpose of the protocol is to determine the impact of bariatric surgery on taste receptors and taste perceptions and to precise the factors implicated in taste alterations in 50 obese patients before and 6 months after bariatric surgery (25 Roux Y gastric bypass and 25 sleeve gastrectomy).", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.229Z" }, { "id": "a61ee81d-df43-40e7-9bb1-50bdb56f9acb", "pmid": "", "title": "Different strategies for diagnosing gestational diabetes to improve maternal and infant health", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycaemia with onset or first recognition during pregnancy. If untreated, perinatal morbidity and mortality may be increased. Accurate diagnosis allows appropriate treatment. Use of different tests and different criteria will influence which women are diagnosed with GDM. This is an update of a review published in 2011 and 2015. Objectives To evaluate and compare different testing strategies for diagnosis of gestational diabetes mellitus to improve maternal and infant health while assessing their impact on healthcare service costs. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (9 January 2017) and reference lists of retrieved studies. Selection criteria We included randomised trials if they evaluated tests carried out to diagnose GDM. We excluded studies that used a quasi‐random model, cluster‐randomised or cross‐over trials. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. Main results We included a total of seven small trials, with 1420 women. One trial including 726 women was identified by this update and examined the two step versus one step approach. These trials were assessed as having varying risk of bias, with few outcomes reported. We prespecified six outcomes to be assessed for quality using the GRADE approach for one comparison: 75 g oral glucose tolerance test (OGTT) versus 100 g OGTT; data for only one outcome (diagnosis of gestational diabetes) were available for assessment. One trial compared three different methods of delivering glucose: a candy bar (39 women), a 50 g glucose polymer drink (40 women) and a 50 g glucose monomer drink (43 women). We have included the results reported by this trial as separate comparisons. No trial reported on measures of costs of health services. We examined six main comparisons. 75 g OGTT versus 100 g OGTT (1 trial, 248 women): women who received 75 g OGTT had a higher relative risk of being diagnosed with GDM (risk ratio (RR) 2.55, 95% confidence interval (CI) 0.96 to 6.75; very‐low quality evidence ). No data were reported for the following additional outcomes prespecified for GRADE assessment: caesarean section, macrosomia > 4.5 kg or however defined in the trial, long‐term type 2 diabetes maternal, long‐term type 2 diabetes infant and economic costs. Candy bar versus 50 g glucose monomer drink (1 trial, 60 women): more women receiving the candy bar, rather than glucose monomer, preferred the taste of the candy bar (RR 0.60, 95% CI 0.42 to 0.86) and 1‐hour glucose was less with the candy bar. There were no differences in the other outcomes reported (maternal side effects). No infant outcomes were reported or any review primary outcomes. 50 g glucose polymer drink versus 50 g glucose monomer drink (3 trials, 239 women): mean difference (MD) in gestation at birth was ‐0.80 weeks (1 trial, 100 women; 95% CI ‐1.69 to 0.09). Total side effects were less common with the glucose polymer drink (1 trial, 63 women; RR 0.21, 95% CI 0.07 to 0.59), and no clear difference in taste acceptability was reported (1 trial, 63 women; RR 0.99, 95% CI 0.76 to 1.29). Fewer women reported nausea following the 50 g glucose polymer drink compared with the 50 g glucose monomer drink (1 trial, 66 women; RR 0.29, 95% CI 0.11 to 0.78). No other measures of maternal morbidity or outcomes for the infant were reported. 50 g glucose food versus 50 g glucose drink (1 trial, 30 women): women receiving glucose in their food, rather than as a drink, reported fewer side effects (RR 0.08, 95% CI 0.01 to 0.56). No clear difference was noted in the number of women requiring further testing (RR 0.14, 95% CI 0.01 to 2.55). No other measures of maternal morbidity or outcome were reported for the infant or review primary outcomes. 75 g OGTT World Health Organization (WHO) criteria versus 75 g OGTT American Diabetes Association (ADA) criteria (1 trial, 116 women): no clear differences in included outcomes were observed between women who received the 75 g OGTT and were diagnosed using criteria based on WHO (1999) recommendations and women who received the 75 g OGTT and were diagnosed using criteria recommended by the ADA (1979). Outcomes measured included diagnosis of gestational diabetes (RR 1.47, 95% CI 0.66 to 3.25), caesarean section (RR 1.07, 95% CI 0.85 to 1.35), macrosomia defined as > 90th percentile by ultrasound or birthweight equal to or exceeding 4000 g (RR 0.73, 95% CI 0.19 to 2.79), stillbirth (RR 0.49, 95% CI 0.02 to 11.68) and instrumental birth (RR 0.21, 95% CI 0.01 to 3.94). No other secondary outcomes were reported. Two‐step approach (50 g oral glucose challenge test followed by selective 100 g OGTT Carpenter and Coustan criteria) versus one‐step approach (universal 75 g OGTT ADA criteria) (1 trial, 726 women): women allocated the two‐step approach had a lower risk of being diagnosed with GDM at 11 to 14 weeks' gestation compared to women allocated the one‐step approach (RR 0.51, 95% CI 0.28 to 0.95). No other primary or secondary outcomes were reported. Authors' conclusions There is insufficient evidence to suggest which strategy is best for diagnosing GDM. Large randomised trials are required to establish the best strategy for correctly identifying women with GDM. Plain language summary Different strategies for diagnosing gestational diabetes mellitus (GDM) to improve maternal and infant health What is the issue? We aimed to evaluate and compare different ways of diagnosing gestational diabetes mellitus (GDM). We searched for all relevant studies in January 2017. Why is this important? Between seven and 24 pregnant women in every 100 develop GDM. GDM is when there is an inability to process carbohydrates properly, which leads to high blood sugar (hyperglycaemia). GDM can result in increased risks of problems around the time of birth for the mother and her baby. Treatment can reduce these risks, and therefore diagnosing the condition accurately means that treatment can be given to improve the health of mothers and their babies. Different testing strategies aim to diagnose GDM. We wanted to compare the different strategies, to see how they affected the health of women and their infants, and to assess the cost of the strategies to the healthcare service. What evidence did we find? We found seven trials. A total of 1420 women were included, in settings in Turkey, Mexico, Nigeria, New Zealand, Canada and the USA. Across the trials, different testing approaches and criteria were evaluated as were different diagnostic tests including different oral glucose tolerance test loads; a glucose drink; a candy bar and food high in glucose. Women were given these items to eat/drink, and this was then followed by a blood test to measure blood sugar levels and questionnaires. In some tests, women were required to fast from the night before. The main outcomes we looked for were frequency of diagnosis, incidence of caesarean section, assisted birth and vaginal birth, and incidence of macrosomia in babies (larger than normal weight at birth). Other outcomes spanned a range, including any side effects of the tests, the mothers' preferences, and the health of the babies. There were a number of weaknesses among the studies: the methodology was not clear and there were important gaps in the data. The studies in this review do not provide enough evidence to guide clinical practice and health policy regarding identifying women with GDM. What does this mean? We are uncertain about which strategies to diagnose GDM are better, as we have assessed the quality of evidence as very low. Large randomised trials are needed to establish the best way for identifying women with GDM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Farrar, D; Duley, L; Dowswell, T; Lawlor, DA", "articleTypes": [], "doi": "10.1002/14651858.CD007122.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "a6331fd8-a2f0-4bb4-b20d-e7fd477094a1", "pmid": "", "title": "Lasers for caries removal in deciduous and permanent teeth", "imported": false, "abstract": "Abstract - Background Despite considerable improvements in oral health, dental caries continue to be a public health issue. The most frequently used, and universally accepted technique, to remove caries is through mechanical ablation of decayed tissues by means of rotating drills (diamond or tungsten carbide, or both). In the past few decades, the introduction of adhesive filling materials (resin composites) has affected cavity filling procedures by reducing its retention needs, with advantages for dental tissue conservation. Consequently, new minimally invasive strategies were introduced into dental practice, such as the use of lasers to perform highly controlled tissue ablation. Laser use has also raised expectations of limiting pain and discomfort compared to using drills, as well as overcoming drill phobia. Objectives The main objective of the review was to compare the effects of laser‐based methods to conventional mechanical methods for removing dental caries in deciduous and permanent teeth. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (searched 22 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 22 June 2016), MEDLINE Ovid (1946 to 22 June 2016), Embase Ovid (1980 to 22 June 2016), ProQuest Dissertations and Theses (1980 to 22 June 2016), Zetoc (limited to conference proceedings) (1993 to 22 June 2016), and ISI Web of Knowledge (limited to conference proceedings) (1990 to 22 June 2016). We checked the reference lists of relevant articles to identify additional studies. We searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. Selection criteria We included randomised controlled trials, split‐mouth trials and cluster‐randomised trials (irrespective of their language) comparing laser therapy to drill ablation of caries. We included participants of any age (children, adolescents and adults). Data collection and analysis Two review authors independently screened titles and abstracts of citations identified by the review search strategy. Two review authors independently evaluated the full text of relevant primary studies, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. Main results We included nine randomised trials, published between 1998 and 2014, involving 662 participants. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Four studies examined only permanent teeth, and five studies evaluated both deciduous and permanent teeth. Six trials used Er:YAG (erbium‐doped yttrium aluminium garnet) lasers, two trials employed Er,Cr:YSGG (erbium, chromium: yttrium‐scandium‐gallium‐garnet) lasers, and one trial used Nd:YAG (neodymium‐doped yttrium aluminium garnet) laser. Overall, the trials had small sample sizes, and the majority were at unclear or high risk of bias. The primary outcomes were evaluated in a limited number of trials (removal of caries (four trials (but only two reported quantitative data)); episodes of pain (five studies)). There was insufficient evidence to suggest that either lasers or drill were better at caries removal (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.99 to 1.01; 2 studies; 256 treated caries; P = 0.75; I 2 = 0%; low‐quality evidence). The incidence of moderate or high pain was greater in the drill group compared to the laser group (RR 0.40, 95% CI 0.28 to 0.57; 2 studies; 143 participants; P < 0.001; I 2 = 50%). Similarly, the need for anaesthesia was significantly higher in the drill group than in the laser group (RR 0.25, 95% CI 0.10 to 0.65; 3 studies; 217 children/adolescents; P = 0.004; I 2 = 0%). In terms of marginal integrity of restoration, there was no evidence of a difference between laser and drill comparisons evaluated at 6 months (RR 1.00, 95% CI 0.21 to 4.78; 3 studies), 1 year (RR 1.59, 95% CI 0.34 to 7.38; 2 studies), or 2 years (RR 1.00, 95% CI 0.21 to 4.74; 1 study). There was no evidence of a difference for durability of restoration between laser therapy or drill at 6 months' follow‐up (RR 2.40, 95% CI 0.65 to 8.77; 4 studies), at 1 year (RR 1.40, 95% CI 0.29 to 6.78; 2 studies) or at 2 years' follow‐up (RR 0.50, 95% CI 0.02 to 14.60; 1 study). Only two trials investigated the recurrence of caries, but no events occurred during 6 months' follow‐up. There was insufficient evidence of a difference between laser or drill in terms of pulpal inflammation or necrosis at 1 week (RR 1.51, 95% CI 0.26 to 8.75; 3 studies) and at 6 months (RR 0.99, 95% CI 0.10 to 9.41; 2 studies). Authors' conclusions Given the low quality of the body of evidence, we concluded that evidence was insufficient to support the use of laser as an alternative to traditional drill therapy for caries removal. We found some evidence in favour of laser therapy for pain control, need of anaesthesia and patient discomfort, but, again, the body of evidence was of low quality. Additional well‐designed, randomised trials investigating the most relevant outcomes are needed. Plain language summary Lasers for the removal of decay in first and permanent teeth Review question This review addressed the issue of whether there is an advantage to laser therapy for the removal of decay in teeth and patient pain, compared to a traditional drill, in children, adolescents and adults. Background Dental decay is a cavity formation in teeth resulting from the destruction of dental tissue caused by bacteria under certain conditions, including poor oral hygiene and excessive sugar intake. Symptoms may include pain and difficulty with eating, and complications may include tooth loss, infection or inflammation of the gum. Rotating drills are traditionally used to remove decay. However, this mechanical tool may have unexpected side effects, such as the removal of too much or too little decay, in addition to discomfort due to pain, noise and vibration. Laser therapy is a potential alternative to a mechanical drill. Study characteristics Cochrane Oral Health provided the search strategies and carried out the search in several electronic databases. We selected nine randomised trials for inclusion in this review that were conducted between 1998 and 2014. The evidence in the review is up to date as of 22 June 2016. The trials involved a total of 662 participants, with 1498 teeth treated. Three studies were conducted in the USA, one in Taiwan, one in China, one in Bulgaria, one in Germany, one in Turkey and one in the UK. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Key results Despite the number of included studies, only a few trials adequately and completely reported information on the primary outcomes. Two trials reported on removal of decay, and there was not enough evidence to conclude that either lasers or drills were better at decay removal. Only five trials reported on episodes of pain, which was significantly reduced in people treated with lasers. There was no difference in terms of side effects, such as inflammation or death of dental pulp, between the two interventions. Quality of the evidence The overall quality of the evidence for the nine studies was low. Only one study adequately randomised participants, and none of the included studies was at low risk of bias. This review highlights the need for high‐quality studies comparing laser therapy and mechanical drills in the treatment of dental decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Montedori, A, Abraha, I, Orso, M, D'Errico, PG, Pagano, S, Lombardo, G", "articleTypes": [], "doi": "10.1002/14651858.CD010229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.737Z" }, { "id": "a6381d94-3799-49d9-a239-728fa3586ea8", "pmid": "", "title": "Citalopram versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Recent US and UK clinical practice guidelines recommend that second‐generation antidepressants should be considered amongst the best first‐line options when drug therapy is indicated for a depressive episode. Systematic reviews have already highlighted some differences in efficacy between second‐generation antidepressants. Citalopram, one of the first selective serotonin reuptake inhibitors (SSRI) introduced in the market, is one of these antidepressant drugs that clinicians use for routine depression care. Objectives To assess the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with tricyclics, heterocyclics, other SSRIs and other conventional and non‐conventional antidepressants in the acute‐phase treatment of major depression. Search methods We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to February 2012. No language restriction was applied. We contacted pharmaceutical companies and experts in this field for supplemental data. Selection criteria Randomised controlled trials allocating patients with major depression to citalopram versus any other antidepressants. Data collection and analysis Two reviewers independently extracted data. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (the number of patients who responded or remitted), patient acceptability (the number of patients who failed to complete the study) and tolerability (side‐effects). Main results Thirty‐seven trials compared citalopram with other antidepressants (such as tricyclics, heterocyclics, SSRIs and other antidepressants, either conventional ones, such as mirtazapine, venlafaxine and reboxetine, or non‐conventional, like hypericum ). Citalopram was shown to be significantly less effective than escitalopram in achieving acute response (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.08 to 2.02), but more effective than paroxetine (OR 0.65, 95% CI 0.44 to 0.96) and reboxetine (OR 0.63, 95% CI 0.43 to 0.91). Significantly fewer patients allocated to citalopram withdrew from trials due to adverse events compared with patients allocated to tricyclics (OR 0.54, 95% CI 0.38 to 0.78) and fewer patients allocated to citalopram reported at least one side effect than reboxetine or venlafaxine (OR 0.64, 95% CI 0.42 to 0.97 and OR 0.46, 95% CI 0.24 to 0.88, respectively). Authors' conclusions Some statistically significant differences between citalopram and other antidepressants for the acute phase treatment of major depression were found in terms of efficacy, tolerability and acceptability. Citalopram was more efficacious than paroxetine and reboxetine and more acceptable than tricyclics, reboxetine and venlafaxine, however, it seemed to be less efficacious than escitalopram. As with most systematic reviews in psychopharmacology, the potential for overestimation of treatment effect due to sponsorship bias and publication bias should be borne in mind when interpreting review findings. Economic analyses were not reported in the included studies, however, cost effectiveness information is needed in the field of antidepressant trials. Plain language summary Citalopram versus other antidepressants for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Antidepressant drugs remain the mainstay of treatment in moderate‐to‐severe major depression. During the last 20 years, selective serotonin reuptake inhibitors (SSRIs) have progressively become the most commonly prescribed antidepressants. Citalopram, one of the first SSRIs introduced in the market, is the racemic mixture of S‐ and R‐enantiomer. In the present review we assessed the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with all other antidepressants in the acute‐phase treatment of major depression. Thirty‐seven randomised controlled trials (more than 6000 participants) were included in the present review. In terms of efficacy, citalopram was more efficacious than other reference compounds like paroxetine or reboxetine, but worse than escitalopram. In terms of side effects, citalopram was more acceptable than older antidepressants, like tricyclics. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including differences in efficacy and side‐effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cipriani, A, Purgato, M, Furukawa, TA, Trespidi, C, Imperadore, G, Signoretti, A, Churchill, R, Watanabe, N, Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006534.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.083Z" }, { "id": "a63b068c-8647-417d-86bf-18debb1c8c0b", "pmid": "", "title": "Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Soil‐transmitted helminth (STH) infections are amongst the most common infectious diseases worldwide, with an estimated 24% of the world’s population currently infected. Mass drug administration (MDA) is the periodic medicinal treatment, without prior individual diagnosis, of at‐risk people living in endemic areas. The World Health Organization currently recommends MDA for STHs. MDA programmes are complex health interventions; achieving adherence is important to their success. Adherence is influenced by the target population's perceptions of the drug, the programme, and those delivering it. Objectives To synthesize qualitative research evidence about community experiences and perceptions of mass drug administration programmes for soil‐transmitted helminths. To assess whether our findings confirm, extend, enrich, or conflict with those of a 2022 Cochrane qualitative evidence review of mass drug administration programmes for lymphatic filariasis. Search methods We searched CENTRAL, MEDLINE, Embase, and four other databases up to 11 November 2024, together with reference checking, and citation searching. Selection criteria We synthesized qualitative and mixed‐methods studies. We included studies exploring community experiences and perceptions of MDA programmes for STHs in any country, conducted between 2001 and 2024. We included all participants of MDA programmes, regardless of disease status, individual participation, or other demographic information. We also included lay healthcare workers and formally qualified healthcare workers, if their perspectives were clearly separated from those of the general population. Data collection and analysis We collected data on study characteristics and programme delivery, including country, endemicity, drug regimen, how the drugs were delivered, use of health education and sensitization, and adherence monitoring. We conducted thematic analysis using a 'best‐fit' framework synthesis based on a framework developed in a 2022 Cochrane review exploring community views on mass drug administration for filariasis (a parasitic infection caused by filarial worms). We conducted a deductive phase, accommodating our data within the existing model, followed by an inductive phase, during which we explored data not accommodated by the framework. We used the GRADE‐CERQual approach to assess our confidence in the findings, and updated the filariasis review's conceptual model to display our findings. Main results We included 17 studies, conducted in Bangladesh, Benin, India, Kenya, Malawi, Nigeria, the Philippines, and Turkey. Four themes emerged, three of which were identified in the review of MDA for lymphatic filariasis. People weigh up the benefits and harms in their decision to participate in MDA, though some may not have a choice. Outcomes of individual participation in MDA may be positive, negative, or both. The decision to partake is a careful balance of risk, benefit, and feasibility (high confidence). Unpleasant associations become part of the narrative and spread rapidly through the community (moderate confidence). Physical and social barriers prevent some people from being able to access MDA even if they want to participate (moderate confidence). Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical legacies, rumours, and mistrust of people involved in the programme affect overall trust in drug distribution and influence whether people choose to participate. Past experiences can have a profound effect on people, and negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background and in‐depth training around the drug or the disease itself (moderate confidence). Some community members prefer distribution from people they know or trust (high confidence). However, others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors (CDDs) cannot answer their programme‐related questions (moderate confidence). Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign, which includes improved sanitation, is necessary to tackle STH burden (moderate confidence). One theme that the filariasis review identified was not substantiated by the findings in this review (Programmes expect compliance: this can result in coercion and blame). Authors' conclusions Despite the prevalence and undoubted impact of MDA programmes over the past 10 years, endemic hotspots and continued transmission are common, due in part to poor community adherence. The 2022 Cochrane review outlined several key community concerns and doubts that hinder the effective implementation of MDA for lymphatic filariasis. This review shows that most of these concerns and doubts are shared by communities targeted for MDA for STHs, indicating that there are fundamental challenges in the overall conceptualization and design of MDA programmes that need to be addressed. Funding TF, MT, RK, and the Cochrane Infectious Diseases Group editorial base were funded by UK aid from the UK Government for the benefit of low‐ and middle‐income countries (project number 300342‐104). The views expressed do not necessarily reflect the UK Government’s official policies. Registration The protocol for this review was published in January 2024 on the Cochrane Database of Systematic Reviews. Available at doi.org/10.1002/14651858.CD015794. Plain language summary Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis Key messages People consider several personal, social, and historical factors before deciding to take medicine. Within one community, different individuals will experience benefits and harms associated with treatment, which shape their decision to participate. The decision to adhere depends on the perceived benefits compared to harms, the trust built between communities and the programme, the competency of people delivering the drugs to provide reassurance to the community members, and the perceived organisation of the delivery programme. Our findings are largely consistent with those of a 2022 Cochrane review exploring people's views and experiences of mass drug administration (MDA) programmes for lymphatic filariasis. This evidence overlap suggests that there are key challenges in the design of MDA programmes in general that need to be addressed to increase adherence. What was studied in this synthesis? Mass drug administration (MDA) involves the periodic delivery of drugs to treat entire communities or groups, regardless of whether an individual has a particular disease. This method aims to prevent onward transmission of infection within the population. MDA is currently recommended for some disease‐control programmes in low‐ and middle‐income countries, including for soil‐transmitted helminth (STH) infections. STHs are a group of parasitic worms, including roundworm, hookworm, whipworm, and threadworm. These MDA programmes are usually delivered within a community or as a school‐based programme. Successfully stopping STH infections through MDA depends on community members being willing and able to participate. In this review, we looked for studies that explored how people view and experience mass drug administration programmes for STHs. We identified 17 studies relevant to this synthesis. What was the aim of this synthesis? In this synthesis of qualitative research, we searched for studies that explored people's views on MDA programmes for treating STHs in low‐ and middle‐income countries. We wanted to understand how people view and experience mass drug administration programmes for soil‐transmitted helminths. We were also interested in whether our findings would support, extend, or conflict with findings from a 2022 Cochrane review which looked at MDA programmes for lymphatic filariasis, another infectious disease caused by worms. What were the main findings? We included 17 studies in our analysis. The studies covered several countries in Africa and South‐East Asia, and one country in the Eastern Mediterranean region. The included studies explored the views and experiences of community members and those distributing the medicines in low‐income countries where STH infection is a considerable problem. From the data, four themes emerged. The 2022 Cochrane review of MDA for lymphatic filariasis identified three of these themes, highlighting the similarities between these programmes. One new theme emerged. 1. People weigh up benefits and harms in their decision to participate in MDA, though some may not have a choice. There are many outcomes to participating in the MDA programme, both positive and negative. For community members, several of these may exist at once, and the decision to partake is a careful balance of risk, benefit, and feasibility (we have high confidence in the evidence). Unpleasant experiences can quickly spread through the community (moderate confidence). Physical and social barriers (e.g. travel distance or not attending school, respectively) prevent some people from accessing treatment through the MDA programme (moderate confidence). 2. Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical experiences, rumours, and mistrust of people involved in the programme affect overall trust in the programme. Past experiences can have a strong effect on people; negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). 3. The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background, and in‐depth training around the drug or the disease itself (moderate confidence). Whilst some community members prefer distribution from people who they know or trust (high confidence), others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors cannot answer their questions related to the programme (moderate confidence). 4. (New theme) Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign which includes improved sanitation is necessary to tackle STH burden (moderate confidence). How current is this evidence? The evidence is current to November 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fox, T; Shrestha, S; Kuehn, R; Taylor, M", "articleTypes": [], "doi": "10.1002/14651858.CD015794.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "a63d4f7f-413c-4e37-bbdd-acc23609771e", "pmid": "", "title": "OTIS - Optimized Complementary Feeding Study", "imported": false, "abstract": "Dietary factors during infancy, e.g. high intakes of protein, fast carbohydrates and saturated fat increase the risk of adult obesity, type 2 diabetes and hypertension. However, current dietary recommendations to infants are based on traditions and experiences whereas research is basically lacking.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.239Z" }, { "id": "a64420df-cfdf-4774-8e4a-f884988fe118", "pmid": "", "title": "Oral nicotine pouches for cessation or reduction of use of other tobacco or nicotine products", "imported": false, "abstract": "Abstract - Rationale Oral nicotine pouches (ONP) emerged in the late 2000s, but have gained popularity since their introduction to the global market in 2016, with claims about their harm reduction potential. Objectives Primary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from combustible tobacco use (smoking). • To evaluate the impact of ONP on the prevalence of combustible tobacco use. Secondary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from other non‐combustible tobacco/commercial nicotine product use. • To evaluate the impact of ONP on the prevalence of use of other non‐combustible tobacco/commercial nicotine products. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO from 2000 to 13 January 2025. We also covered ClinicalTrials.gov and the WHO ICTRP through our search of CENTRAL. Eligibility criteria We included randomised controlled trials (RCTs) of ONP in people using tobacco or other non‐combustible tobacco/non‐pharmaceutical nicotine products. RCTs must have reported tobacco/nicotine use at 4+ weeks or biomarkers or adverse events at 1+ weeks. We also sought interrupted/multiple time‐series studies of ONP's population‐level effects on the prevalence of use of other tobacco/nicotine products. Outcomes Our critical outcomes were: smoking abstinence at 4+ weeks; number of people reporting serious adverse events (SAEs) at 1+ weeks; and change in the prevalence of smoking. Important outcomes included tobacco‐specific nitrosamines (TSNAs), carboxyhaemoglobin (COHb), metals, and inflammatory markers detected in human biosamples. Risk of bias We used the Cochrane RoB 1 tool to assess risk of bias. Synthesis methods We synthesised results using random‐effects meta‐analysis where possible. We used I 2 to quantify statistical heterogeneity. Where meta‐analysis was not possible, we graphically plotted available data in forest plots. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CI). We assessed the certainty of evidence using GRADE. Included studies We included four small studies (n < 150 for each, total n = 284; 3 independent, 1 industry‐funded; 3 at high risk of bias and 1 at unclear risk of bias). All were RCTs in people who smoked combustible cigarettes at baseline. Three were conducted in the USA, and one in New Zealand. Two compared higher‐ versus lower‐nicotine dose ONP. Two compared ONP to instructions to continue smoking as usual. One each compared ONP to electronic cigarettes (e‐cigarettes), snus, and pharmaceutical nicotine replacement therapy (NRT). Synthesis of results Smoking abstinence Smoking abstinence may be slightly higher in people randomised to ONP compared to no intervention at eight‐week follow‐up (RR 1.58, 95% CI 0.07 to 35.32; 1 study, 27 participants; very low‐certainty evidence (risk of bias and imprecision; CI incorporated possibility of no difference)), but the evidence is very uncertain. Low‐certainty evidence (serious imprecision; CI incorporated possibility of no difference) suggests there may be lower abstinence rates in those randomised to ONP compared to e‐cigarettes (RR 0.25, 95% CI 0.03 to 2.02; 1 study, 36 participants). Evidence from one study (n = 30) comparing higher‐ versus lower‐dose ONP found a higher quit rate in the higher‐dose arm, but again with wide CI encompassing the possibility of no difference and of higher quit rates in the lower‐dose arm (RR 5.00, 95% CI 0.26 to 96.13; evidence certainty not assessed). Serious adverse events No SAEs occurred in the three studies reporting this outcome. Data were available for the comparisons ONP versus minimal control (2 studies, 124 participants; very low‐certainty evidence (risk of bias and serious imprecision)) and ONP versus e‐cigarettes (1 study, 26 participants; low‐certainty evidence (serious imprecision)). TSNA One study reported on a TSNA (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol (NNAL)) comparing ONP with instructions to continue smoking. There may be lower levels with ONP (MD −265.30 ng/g creatinine, 95% CI −350.64 to −179.96; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. Data from two studies suggested no difference in NNAL levels between higher‐ and lower‐dose ONP (SMD −0.16, 95% CI −1.87 to 1.56; I 2 = 0%; 77 participants; evidence certainty not assessed). COHb Based on one study, there may be lower levels of COHb with ONP compared to instructions to continue smoking (MD −6.7%, 95% CI −8.33 to −5.07; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. When comparing higher‐ versus lower‐dose ONP, the same study found very slightly lower levels in the higher‐dose group, with the 95% CI incorporating the possibility of no difference (MD −0.40%, 95% CI −1.19 to 0.39; evidence certainty not assessed). No studies reported on prevalence, inflammatory markers, metals, or use of tobacco/nicotine products other than cigarettes. Authors' conclusions There is limited evidence on the use of ONP for cessation or reduction of cigarette use. There is no evidence on the use of ONP for cessation or reduction of other tobacco or nicotine products or on the effects of ONP on prevalence of tobacco use/nicotine vaping. Low‐certainty evidence suggests that people randomised to ONP may be slightly less likely to quit smoking than those randomised to e‐cigarettes, but data were from one small study and therefore imprecise. Limited, short‐term data did not identify any serious health harms from ONP when used to help people transition away from tobacco smoking. More research on the effects of ONP for cessation or reduction of use of other tobacco or non‐pharmaceutical nicotine products is urgently needed. Future trials should prioritise comparing ONP to other active interventions (e.g. NRT and e‐cigarettes). Funding This Cochrane review was funded by the National Cancer Institute of the National Institutes of Health (NIH) and FDA Center for Tobacco Products (CTP) under Award Number 2U54CA229974. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food & Drug Administration. Registration Registration: Cochrane, via protocol available via DOI:10.1002/14651858.CD016220. Plain language summary What are the benefits and risks of oral nicotine pouches when used to help people stop smoking, vaping nicotine, or using other forms of tobacco? Key messages Limited evidence from three small studies found no short‐term serious health harms of oral nicotine pouches in people who smoke. We are uncertain if oral nicotine pouches help people quit smoking compared to instructions to continue smoking as usual or no support to quit. Future research is needed, in particular comparing oral nicotine pouches to other active treatments (e.g. nicotine replacement therapy and e‐cigarettes). What are oral nicotine pouches? Oral nicotine pouches are preportioned pouches containing nicotine, sold in various flavours and nicotine strengths. They are similar in appearance and use to snus. Snus is a form of smokeless tobacco placed between the gum and lip that is popular in Nordic countries, but whose sale is banned in the UK and European Union countries excluding Sweden. Unlike snus, nicotine pouches do not contain tobacco leaf. Like nicotine e‐cigarettes and pharmaceutical forms of nicotine replacement therapy (such as nicotine patches and gums), oral nicotine pouches may be able to help people transition away from harmful forms of tobacco/nicotine product use by replacing them with a product that does not contain tobacco leaf and which, unlike e‐cigarettes, does not involve inhaling vapour into the lungs. Common brand names of oral nicotine pouches include Zyn, Velo, and Nordic Spirit. What did we want to find out? We wanted to find out if oral nicotine pouches can help people transition away from smoking, nicotine vaping, or other forms of tobacco use. We also wanted to know if oral nicotine pouches caused any unwanted effects when used for this purpose. What did we do? We searched for studies where people who smoked, vaped, or used other tobacco products were given oral nicotine pouches as a way to quit. We included studies if they tracked tobacco use or vaping for at least four weeks or looked at unwanted effects or chemical changes in the blood, breath, or urine for at least one week. What did we find? We found four studies including a total of 284 people who were smokers at study start. The studies were conducted between 2006 and 2023, and in those that reported race or ethnicity, were conducted in majority white populations. The average age across studies ranged from 34 to 50 years. The average number of cigarettes smoked by participants at study start was between 14 and 23 per day. The longest study ran for eight weeks. Three studies were independently funded, and one was funded by a tobacco manufacturer. Based on two small studies, it was not clear whether using nicotine pouches helped more people to quit smoking compared to instructions to continue smoking as usual or no support to quit, and there may be lower quit rates in those using nicotine pouches compared to those using a nicotine e‐cigarette (vaping). No serious health harms occurred in any group in the three studies that reported this information, so it is unclear if using nicotine pouches affects the chances of experiencing a serious health harm. We also looked at certain chemicals measured in blood, breath, or urine that can signal exposures to harmful substances. Tobacco use exposes the body to cancer‐causing chemicals. NNAL (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol), a chemical formed when these cancer‐causing chemicals enter the body, measures exposure to harmful ingredients in tobacco smoke. One small study reported lower levels of NNAL in people using oral nicotine pouches compared to those given no specific treatment to stop smoking. Combined evidence from two studies suggested no difference in NNAL levels between people receiving higher‐ versus lower‐dose nicotine pouches. Carbon monoxide is a poisonous gas present in tobacco smoke. When carbon monoxide binds with blood haemoglobin, it forms a substance called carboxyhaemoglobin. Carboxyhaemoglobin measures how much carbon monoxide a person has been exposed to in their blood. One study found lower levels of carboxyhaemoglobin in people using oral nicotine pouches compared to those who continued smoking. When comparing higher‐ versus lower‐dose nicotine pouches, the same study found very slightly lower carboxyhaemoglobin levels in the higher‐dose group. What are the limitations of the evidence? We have little to very low confidence in the evidence because the studies were relatively small, and there are not enough studies to be certain about the results. Also, some studies had issues with the way they were designed that could have affected their results. Many studies are currently underway, and we plan to update this review when their findings become available. How up‐to‐date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hartmann-Boyce, J, Tattan-Birch, H, Brown, J, Shahab, L, Goniewicz, ML, Ma, CL, Wu, AD, Travis, N, Jarman, H, Livingstone-Banks, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD016220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.738Z" }, { "id": "a653be5f-bc59-4ed9-b917-26afd47044f9", "pmid": "", "title": "Omega 3 fatty acids for preventing or slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Lawrenson, JG, Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD010015.pub3 AB - Abstract - Background Evidence from animal models and observational studies in humans has suggested that there is an inverse relationship between dietary intake of omega 3 long‐chain polyunsaturated fatty acids (LCPUFA) and risk of developing age‐related macular degeneration (AMD) or progression to advanced AMD. Objectives To review the evidence that increasing the levels of omega 3 LCPUFA in the diet (either by eating more foods rich in omega 3 or by taking nutritional supplements) prevents AMD or slows the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 1), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2015), EMBASE (January 1980 to February 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to February 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 February 2015. Selection criteria We included randomised controlled trials (RCTs) where increased dietary intake of omega 3 LCPUFA was compared to placebo or no intervention with the aim of preventing the development of AMD, or slowing its progression. Data collection and analysis Both authors independently selected studies, assessed them for risk of bias and extracted data. One author entered data into RevMan 5 and the other author checked the data entry. We conducted a meta‐analysis for one primary outcome, progression of AMD, using a fixed‐effect inverse variance model. Main results We included two RCTs in this review, in which 2343 participants with AMD were randomised to receive either omega 3 fatty acid supplements or a placebo. The trials, which had a low risk of bias, were conducted in the USA and France. Overall, there was no evidence that people who took omega 3 fatty acid supplements were at decreased (or increased risk) of progression to advanced AMD (pooled hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.84 to 1.10, high quality evidence). Similarly, people taking these supplements were no more (or less) likely to lose 15 or more letters of visual acuity (USA study HR 0.96, 95% CI 0.84 to 1.10; French study at 36 months risk ratio (RR) 1.25, 95% CI 0.69 to 2.26, participants = 230). The number of adverse events was similar in the intervention and placebo groups (USA study participants with one or more serious adverse event RR 1.00, 95% CI 0.91 to 1.09, participants = 2080; French study total adverse events RR 1.05, 95% CI 0.97 to 1.13, participants = 263). Authors' conclusions This review found that omega 3 LCPUFA supplementation in people with AMD for periods up to five years does not reduce the risk of progression to advanced AMD or the development of moderate to severe visual loss. No published randomised trials were identified on dietary omega 3 fatty acids for primary prevention of AMD. Currently available evidence does not support increasing dietary intake of omega 3 LCPUFA for the explicit purpose of preventing or slowing the progression of AMD. Plain language summary Omega 3 fatty acids for preventing and slowing the progression of age‐related macular degeneration Review question 
 We asked the question whether increased dietary intake of omega 3 fatty acids prevented or slowed the progression of age‐related macular degeneration. Background 
 Age‐related macular degeneration (AMD) is an eye condition that affects the central area of the retina (light‐sensitive tissue at the back of the eye). AMD is associated with a loss of detailed vision and adversely affects tasks such as reading, driving and face recognition. In the absence of a cure, there has been considerable interest in the role of modifiable risk factors to prevent or slow down the progression of AMD. Evidence from population studies suggests that people who have a diet with relatively high levels of omega 3 fatty acids (such as those derived from fish oils) are less likely to develop AMD. Study characteristics 
 We searched for studies up to 2 February 2015. We identified two trials with a total of 2343 participants. The trials were conducted in the USA and France and investigated the use of fish oil supplements in people with AMD who were at high risk of progressing to advanced disease. We judged the studies to be at low risk of bias. One study was funded by government grants and the other study was funded by the manufacturer of the dietary supplement. Key results 
 These studies found that omega 3 supplementation for periods up to five years did not reduce the rate of progression to advanced AMD or reduce significant visual loss compared to a placebo. The incidence of adverse effects was similar in the intervention and placebo groups. Quality of the evidence 
 We judged the quality of the evidence on rate of progression to AMD to be high, and the quality of the evidence for other outcomes to be moderate because the estimates were imprecise.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.759Z" }, { "id": "a65c5359-ec1f-4a24-ab78-7fa0e7382579", "pmid": "", "title": "Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors", "imported": false, "abstract": "Abstract - Background Poor diet and insufficient physical activity are major risk factors for non‐communicable diseases. Developing healthy diet and physical activity behaviors early in life is important as these behaviors track between childhood and adulthood. Parents and other adult caregivers have important influences on children's health behaviors, but whether their involvement in children's nutrition and physical activity interventions contributes to intervention effectiveness is not known. Objectives • To assess effects of caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors, including those intended to prevent overweight and obesity • To describe intervention content and behavior change techniques employed, drawing from a behavior change technique taxonomy developed and advanced by Abraham, Michie, and colleagues (Abraham 2008; Michie 2011; Michie 2013; Michie 2015) • To identify content and techniques related to reported outcomes when such information was reported in included studies Search methods In January 2019, we searched CENTRAL, MEDLINE, Embase, 11 other databases, and three trials registers. We also searched the references lists of relevant reports and systematic reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of interventions to improve children's dietary intake or physical activity behavior, or both, with children aged 2 to 18 years as active participants and at least one component involving caregivers versus the same interventions but without the caregiver component(s). We excluded interventions meant as treatment or targeting children with pre‐existing conditions, as well as caregiver‐child units residing in orphanages and school hostel environments. Data collection and analysis We used standard methodological procedures outlined by Cochrane. Main results We included 23 trials with approximately 12,192 children in eligible intervention arms. With the exception of two studies, all were conducted in high‐income countries, with more than half performed in North America. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The specific intervention strategies used were not always reported completely. However, based on available reports, the behavior change techniques used most commonly in the child‐only arm were \"shaping knowledge,\" \"comparison of behavior,\" \"feedback and monitoring,\" and \"repetition and substitution.\" In the child + caregiver arm, the strategies used most commonly included additional \"shaping knowledge\" or \"feedback and monitoring\" techniques, as well as \"social support\" and \"natural consequences.\" We considered all trials to be at high risk of bias for at least one design factor. Seven trials did not contribute any data to analyses. The quality of reporting of intervention content varied between studies, and there was limited scope for meta‐analysis. Both validated and non‐validated instruments were used to measure outcomes of interest. Outcomes measured and reported differed between studies, with 16 studies contributing data to the meta‐analyses. About three‐quarters of studies reported their funding sources; no studies reported industry funding. We assessed the quality of evidence to be low or very low. Dietary behavior change interventions with a caregiver component versus interventions without a caregiver component Seven studies compared dietary behavior change interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (mean difference [MD] −0.42%, 95% confidence interval [CI] −1.25 to 0.41, 1 study, n = 207; low‐quality evidence) or from sodium intake (MD −0.12 g/d, 95% CI −0.36 to 0.12, 1 study, n = 207; low‐quality evidence). No trial in this comparison reported data for children's combined fruit and vegetable intake, sugar‐sweetened beverage (SSB) intake, or physical activity levels, nor for adverse effects of interventions. Physical activity interventions with a caregiver component versus interventions without a caregiver component Six studies compared physical activity interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's total physical activity (MD 0.20 min/h, 95% CI −1.19 to 1.59, 1 study, n = 54; low‐quality evidence) or moderate to vigorous physical activity (MVPA) (standard mean difference [SMD] 0.04, 95% CI −0.41 to 0.49, 2 studies, n = 80; moderate‐quality evidence). No trial in this comparison reported data for percentage of children's total energy intake from saturated fat, sodium intake, fruit and vegetable intake, or SSB intake, nor for adverse effects of interventions. Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component Ten studies compared dietary and physical activity interventions with and without a caregiver component. At the end of the intervention, we detected a small positive impact of a caregiver component on children's SSB intake (SMD −0.28, 95% CI −0.44 to −0.12, 3 studies, n = 651; moderate‐quality evidence). We did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (MD 0.06%, 95% CI −0.67 to 0.80, 2 studies, n = 216; very low‐quality evidence), sodium intake (MD 35.94 mg/d, 95% CI −322.60 to 394.47, 2 studies, n = 315; very low‐quality evidence), fruit and vegetable intake (MD 0.38 servings/d, 95% CI −0.51 to 1.27, 1 study, n = 134; very low‐quality evidence), total physical activity (MD 1.81 min/d, 95% CI −15.18 to 18.80, 2 studies, n = 573; low‐quality evidence), or MVPA (MD −0.05 min/d, 95% CI −18.57 to 18.47, 1 study, n = 622; very low‐quality evidence). One trial indicated that no adverse events were reported by study participants but did not provide data. Authors' conclusions Current evidence is insufficient to support the inclusion of caregiver involvement in interventions to improve children's dietary intake or physical activity behavior, or both. For most outcomes, the quality of the evidence is adversely impacted by the small number of studies with available data, limited effective sample sizes, risk of bias, and imprecision. To establish the value of caregiver involvement, additional studies measuring clinically important outcomes using valid and reliable measures, employing appropriate design and power, and following established reporting guidelines are needed, as is evidence on how such interventions might contribute to health equity. Plain language summary Effects of involving parents and other adult caregivers in children's diet and physical activity interventions Review question Does it make a difference if parents or other adult caregivers are involved in interventions to encourage children to eat healthier or be more physically active? Background Diet and physical activity behaviors are important determinants of health. Parents and other adult caregivers have an essential role in shaping children's health habits by controlling availability of and access to healthy foods and opportunities to be active; supporting, encouraging, and role‐modeling healthy behaviors; and adopting supportive feeding styles and practices. For these reasons, it often is argued that parent and caregiver involvement in children's diet and physical activity interventions is important; however, it remains unclear if involvement of parents and caregivers actually provides benefit. Objectives We assessed the effects of involving parents or other adult caregivers in children's healthy eating and physical activity interventions compared to the effects of the same child interventions without a parent or caregiver component. We were particularly interested in understanding effects on children's dietary intake, children's physical activity levels, and adverse effects of interventions. Study characteristics We found 23 studies, published between 1982 and 2019, that implemented diet interventions, physical activity interventions, or combined diet and physical activity interventions with children or adolescents, and evaluated the effects of adding an intervention component involving parents or other adult caregivers. Approximately 12,192 children aged 2 to 18 years were examined. More than half of studies took place in North America, and all but two were conducted in high‐income countries. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The breadth of information provided about intervention content varied between studies. The most commonly used intervention techniques were those aimed at shaping participants' knowledge, such as providing instruction about how to perform a behavior (e.g. dance, cooking lessons). About three‐quarters of studies reported their funding source; no studies reported industry funding. Key results The findings of this review suggest that adding a parent or caregiver component to dietary behavior change interventions or physical activity interventions may make little or no difference to children's dietary intake or physical activity levels. For interventions that target both diet and physical activity behaviors, involving a parent or caregiver probably slightly reduces children's sugar‐sweetened beverage intake by the end of the intervention. We do not know whether any of these types of interventions result in adverse effects because these data are not available. Quality of evidence Overall, the evidence from studies is of low or very low quality, which means that we are uncertain about study results. Currentness of evidence The evidence is current to January 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Morgan, EH; Schoonees, A; Sriram, U; Faure, M; Seguin‐Fowler, RA", "articleTypes": [], "doi": "10.1002/14651858.CD012547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "a6862f21-e6fc-48f1-a822-8818b6257de3", "pmid": "", "title": "Medical interventions for treating anthracycline‐induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer", "imported": false, "abstract": "Abstract - Background Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline‐induced cardiotoxicity. This review is an update of a previously published Cochrane review. Objectives To compare the effect of medical interventions on anthracycline‐induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions, or no treatment. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 8), MEDLINE/PubMed (1949 to September 2015), and EMBASE/Ovid (1980 to September 2015) for potentially relevant articles. In addition, we searched reference lists of relevant articles, conference proceedings of the International Society for Paediatric Oncology (SIOP), the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), the International Conference on Long‐Term Complications of Treatment of Children & Adolescents for Cancer, and the European Symposium on Late Complications from Childhood Cancer (from 2005 to 2015), and ongoing trial databases (the ISRCTN Register, the National Institutes of Health (NIH) Register, and the trials register of the World Health Organization (WHO); all searched in September 2015). Selection criteria Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline‐induced cardiotoxicity with either placebo, other medical interventions, or no treatment. Data collection and analysis Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments, which another review author checked. We performed analyses according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results In the original version of the review we identified two RCTs; in this update we identified no additional studies. One trial (135 participants) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline‐induced cardiac dysfunction. The other trial (68 participants) compared a two‐week treatment of phosphocreatine with a control treatment (vitamin C, adenosine triphosphate, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline‐induced cardiotoxicity. Both studies had methodological limitations. The RCT on enalapril showed no statistically significant differences in overall survival, mortality due to heart failure, development of clinical heart failure, and quality of life between treatment and control groups. A post‐hoc analysis showed a decrease (that is improvement) in one measure of cardiac function (left ventricular end‐systolic wall stress (LVESWS): ‐8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Participants treated with enalapril had a higher risk of dizziness or hypotension (risk ratio 7.17, 95% confidence interval 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013). The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function, and adverse events between treatment and control groups. Authors' conclusions Only one trial evaluated the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side effects of enalapril in childhood cancer survivors with asymptomatic anthracycline‐induced cardiotoxicity. Only one trial evaluated the effect of phosphocreatine in childhood cancer patients with anthracycline‐induced cardiotoxicity. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatments on echocardiographic function and clinical outcomes. We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors. High‐quality studies should be performed. Plain language summary Treatment for cardiac problems caused by anthracycline chemotherapy for childhood cancer Anthracyclines are anticancer drugs used in the treatment of different types of childhood cancer. An important adverse effect of anthracyclines is damage to the heart, which can lead to asymptomatic (without complaints) or symptomatic (with complaints) cardiac problems during and after cancer treatment. While there are several drugs available to treat other types of cardiac problems in adults, it is not known if these drugs are beneficial in treating cardiac problems caused by anthracyclines in childhood cancer patients and survivors. A physician confronted with a childhood cancer patient or survivor with anthracycline‐induced cardiac problems should be able to make an informed decision on how to treat this patient based on high‐quality evidence about the beneficial and adverse effects of the treatment options. We searched for and summarised studies that evaluated drugs for treating anthracycline‐induced cardiac problems in childhood cancer patients and survivors. We identified two randomised studies evaluating two different drugs in two different types of patients. One of these drugs, an angiotensin‐converting enzyme (ACE) inhibitor (enalapril), had a short‐term beneficial effect on heart function in survivors of childhood cancer with asymptomatic cardiac problems caused by anthracyclines compared with placebo. However, the drug had no significant beneficial effect on other important outcomes and was associated with side effects such as dizziness and fatigue. This study was of reasonable/good quality. The other study was of low quality and found no effect of a short treatment with phosphocreatine in childhood leukaemia patients with symptomatic or asymptomatic cardiac problems compared with a control treatment with vitamin C, adenosine triphosphate, vitamin E, and oral coenzyme Q10. We could make no definitive conclusions about treatment options for anthracycline‐induced cardiac problems in childhood cancer patients and survivors. High‐quality studies are needed to determine if there are drugs that improve heart function in these patients.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cheuk, DKL; Sieswerda, E; van Dalen, EC; Postma, A; Kremer, LCM", "articleTypes": [], "doi": "10.1002/14651858.CD008011.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "a69f675f-84c4-4cc8-a31b-c102ef004746", "pmid": "", "title": "Interventions for hyperthyroidism pre‐pregnancy and during pregnancy", "imported": false, "abstract": "Abstract - Background Women with hyperthyroidism in pregnancy have increased risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction; and they can develop severe pre‐eclampsia or placental abruption. Objectives To identify interventions used in the management of hyperthyroidism pre‐pregnancy or during pregnancy and to ascertain the impact of these interventions on important maternal, fetal, neonatal and childhood outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 September 2013). Selection criteria We planned to include randomised controlled trials, quasi‐randomised controlled trials, and cluster‐randomised trials comparing antithyroid interventions for hyperthyroidism pre‐pregnancy or during pregnancy with another intervention or no intervention (placebo or no treatment). Data collection and analysis Two review authors assessed trial eligibility and planned to assess trial quality and extract the data independently. Main results No trials were included in the review. Authors' conclusions As we did not identify any eligible trials, we are unable to comment on implications for practice, although early identification of hyperthyroidism before pregnancy may allow a woman to choose radioactive iodine therapy or surgery before planning to have a child. Designing and conducting a trial of antithyroid interventions for pregnant women with hyperthyroidism presents formidable challenges. Not only is hyperthyroidism a relatively rare condition, both of the two main drugs used have potential for harm, one for the mother and the other for the child. More observational research is required about the potential harms of methimazole in early pregnancy and about the potential liver damage from propylthiouracil. Plain language summary No evidence found from randomised trials for drugs to treat pregnant women with hyperthyroidism Hyperthyroidism in pregnancy is a rare, serious condition which can increase the risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction. Pregnant women who are hyperthyroid may also develop severe pre‐eclampsia or placental abruption. Most of these women have Graves' disease, an autoimmune disease most common in women aged 20 to 40 years. Most pregnant women with hyperthyroidism are diagnosed with thyroid disease prior to conception and will have previously received treatment for the condition. Generally only drug therapy is considered for treating pregnant women with hyperthyroidism. Radioiodine treatment is not used in pregnancy because it destroys the fetal thyroid gland, resulting in permanent hypothyroidism in the newborn. The main antithyroid drugs used are the thionamides, propylthiouracil (PTU), methimazole and carbimazole. PTU is currently the favoured drug for use in pregnancy, as it is associated with fewer teratogenic effects (scalp lesions) than methimazole. However, since there have been reports of liver damage in people taking PTU, it may be reasonable for pregnant hyperthyroid women to be treated with PTU in the first trimester (to reduce any teratogenic effects of methimazole) and then to change to methimazole. We did not identify any randomised trials to help inform women and their doctors about which antithyroid drugs are most effective, with the lowest potential for harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Earl, R; Crowther, CA; Middleton, P", "articleTypes": [], "doi": "10.1002/14651858.CD008633.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "a6c00e22-a42c-4985-baa8-177d4722f6c7", "pmid": "", "title": "The Role of the Endocannabinoid System in Sweet Taste Intensity and Liking", "imported": false, "abstract": "The endocannabinoid (eCB) system, a neurochemical signalling system consisting of CB-receptors and their endogenous ligands, has been found to be involved in food intake of sweet and palatable foods. Activation of the eCB system increases food intake and vice versa. The mechanism behind this effect is still unknown and the current study aims at clarifying why sweet food intake increases. It is hypothesized that sweet taste intensity increases and that sweet taste is experienced as more pleasant.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.145Z" }, { "id": "a6d4105a-1528-4625-812f-e3f103aa4808", "pmid": "", "title": "The Effects of Lactobacillus Rhamnosus (JB-1) on Stress and Cognition in Healthy Volunteers", "imported": false, "abstract": "Emerging evidence suggests that microorganisms acting via the Brain-Gut axis may have potential benefits for the management of stress-related conditions. The majority of studies have focused on animal models. Preclinical studies have identified the Lactobacillus Rhamnosus JB-1 strain as a putative psychobiotic with an impact on stress-related behaviours, physiology and cognitive performance. Whether such preclinical effects could be translated to healthy human volunteers remains unknown.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.261Z" }, { "id": "a6d485c8-9673-42fb-b738-f47fa8f9c251", "pmid": "", "title": "Topical silver diamine fluoride (SDF) for preventing and managing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is the world's most prevalent disease. Untreated caries can cause pain and negatively impact psychosocial health, functioning, and nutrition. It is important to identify cost‐effective, easy‐to‐use agents, which can prevent or arrest caries. This review evaluates silver diamine fluoride (SDF). Objectives To assess the effects of silver diamine fluoride for preventing and managing caries in primary and permanent teeth (coronal and root caries) compared to any other intervention including placebo or no treatment. Search methods We searched CENTRAL, MEDLINE, Embase, Cochrane Oral Health's Trial Register and two clinical trials registers in June 2023. Selection criteria We included randomised controlled trials (RCTs), with parallel‐group or split‐mouth design, in children and adults (with or without carious lesions) that compared SDF with placebo or no treatment; different frequencies, concentrations or duration of SDF; or any other intervention. Data collection and analysis We used standard methodological procedures expected by Cochrane, and GRADE to assess the certainty of the evidence. We collected data for primary caries prevention (change in caries increment), arrest of carious lesions, secondary prevention of caries (lesions do not progress from initial classification), adverse effects, dental pain or sensitivity, and aesthetics at the end of study follow‐up. Main results We included 29 RCTs (13,036 participants; 12,020 children, 1016 older adults). We summarise outcome data for the five most clinically relevant comparisons. All studies included high risks of bias, and some findings were imprecise (e.g. because of small sample sizes). SDF versus placebo or no treatment (14 studies; 2695 children, 905 older adults) Compared to placebo or no treatment, SDF may help prevent new caries in the primary dentition (1 study, 373 participants), or on the coronal surfaces of permanent dentition (1 study, 373 participants) but the evidence is very uncertain. SDF likely prevents new root caries (mean difference (MD) −0.79 surfaces, 95% confidence interval (CI) −1.40 to −0.17; 3 studies, 439 participants; moderate‐certainty evidence). SDF may help arrest caries in the primary dentition (MD 0.86 surfaces, 95% CI 0.39 to 1.33; 2 studies, 841 participants; low‐certainty evidence) and the permanent dentition (coronal: 1 study, 373 participants; root: 1 study, 158 participants) but the evidence is very uncertain. The evidence is very uncertain for secondary prevention of caries (primary dentition: 1 study, 128 participants; permanent dentition (coronal): 1 study, 663 participants), for adverse effects (5 studies, 1299 participants), and aesthetics (1 study, 43 participants). Different approaches to SDF application (5 studies, 1808 children) Studies compared different frequencies or intervals of application, different concentrations of SDF, and different durations of treatment. Some studies included multiple comparisons of different approaches. Because of the different approaches, we could not combine findings from these studies. Due to very low‐certainty evidence, we were unsure whether any approach to SDF application was better than another for caries arrest (4 studies, including 8 comparisons of different approaches, 1360 participants); secondary prevention of caries (1 study, 203 participants), or led to differences in adverse effects (3 studies, 1121 children) or aesthetics (1 study, 119 children). SDF versus fluoride varnish (8 studies, 2868 children, 223 older adults) Compared to flouride varnish, SDF may result in little or no difference to the prevention of new caries in the primary dentition (MD 0.00, 95% CI ‐0.26 to 0.26; 1 study, 434 participants; low‐certainty evidence). The evidence is very uncertain for this outcome measure in the permanent dentition (coronal: 1 study, 237 participants; root: 1 study, 100 participants; very low‐certainty evidence). Due to very low‐certainty evidence, we were unsure whether or not there were any differences between flouride varnish (applied weekly for three applications) and SDF for caries arrest and secondary prevention of caries in the primary dentition (1 study, 309 participants). Similarly, we were unsure of adverse effects (3 studies, 980 children), dental pain or sensitivity (1 study, 62 children), or aesthetics (1 study, 263 children). SDF versus sealants and resin infiltration (2 studies, 343 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other for primary prevention of caries in permanent dentition (coronal: 1 study, 242 participants), or adverse effects (2 studies, 336 participants). SDF versus atraumatic restorative treatment (ART) with glass ionomer cement (GIC) or GI material (4 studies, 610 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other at arresting caries in the primary dentition (1 study, 143 participants). We were also unsure whether there were any differences between treatments in adverse effects (3 studies, 482 participants), dental pain or sensitivity (1 study, 234 participants), or aesthetics (2 studies, 248 participants). Authors' conclusions In the primary dentition, evidence remains uncertain whether SDF prevents new caries or progression of existing caries compared to placebo or no treatment, but it may offer benefit over placebo or no treatment in caries arrest. Compared to placebo or no treatment, SDF probably also helps prevent new root caries. However, the evidence is uncertain for other caries outcome measures in this dentition and in all caries outcomes for coronal surfaces of permanent dentition. Compared to flouride varnish, SDF may offer little or no benefit in preventing new caries in the primary dentition, but the evidence is very uncertain for other caries outcome measures in the primary dentition and for preventing new caries in the permanent dentition. We were unable to establish whether one SDF treatment approach was better than another, or how SDF compared to other treatments, because of very low‐certainty evidence. The impact of SDF staining of teeth was poorly reported and the evidence for adverse effects is very uncertain. Additional well‐conducted studies are needed. These should measure the impact of staining and be analysed to take account of clustering issues within participants. Plain language summary Is silver diamine fluoride varnish an effective treatment for preventing and managing tooth decay in children and adults? Key messages ‐ We can't tell if silver diamine fluoride (SDF) is better than no treatment at preventing or treating tooth decay. ‐ We can't tell if SDF is better or worse than other treatments at preventing or treating tooth decay. ‐ New studies could help to find out about the unwanted effects of SDF, whether people are bothered by the staining on the teeth caused by SDF, and the best treatment approach. What is tooth decay? Tooth decay happens when bacteria in your mouth break down sugars from food, producing acids that damage tooth enamel (hard surfaces). This can lead to holes, or cavities, in the teeth. Tooth decay affects the crown of the tooth (the part above the gum) of baby teeth, and the crown and root of permanent teeth. If it is not prevented or treated it can cause toothache, infections and tooth loss. How is tooth decay treated? Treatments for tooth decay include liquids, gels (varnishes) and sealants. These treatments are painted onto the tooth to protect against bacteria. Treatment may also include fillings in larger cavities. Silver diamine fluoride (SDF) is a low‐cost liquid that can be painted on a tooth by a dentist or another trained person. It is suitable for people of all ages, including people with special health needs. However, SDF can permanently stain the treated tooth surface black or dark brown. What did we want to find out? We wanted to find out: ‐ if SDF was better than no treatment or other treatments at preventing new tooth decay, stopping existing tooth decay or preventing tooth decay from progressing; ‐ if there were benefits to applying SDF for different numbers of times, strengths of solution, or durations; ‐ if SDF caused unwanted effects, toothache, or if people were bothered by staining. What did we do? We searched for studies that compared SDF with no treatment or placebo (a dummy treatment), other treatments, or different application approaches. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 29 studies, with 12,020 children and 1016 older adults. Main results Compared with no treatment or placebo, we can't tell if SDF prevents new tooth decay in baby teeth or crown surfaces of permanent teeth. SDF is likely to prevent new tooth decay on root surfaces of permanent teeth. It may also completely stop existing tooth decay in baby teeth. However, we are unsure if it completely stops existing tooth decay on crown and root surfaces of permanent teeth, prevents existing tooth decay from progressing in any types of teeth, increases the risk of unwanted effects, or if people are bothered by the appearance of staining. Studies used different combinations of treatment approaches (number of times SDF is applied and how often, the strength of solution, and duration of treatment). We can't tell if one approach is better than another at stopping or preventing further decay, unwanted effects, or bother with appearance of staining. When SDF is compared with fluoride varnish, neither treatment may be better than the other at preventing new tooth decay in baby teeth. We are unsure about the effect on crown and root surfaces of permanent teeth. We also can't tell if either treatment is better than the other at stopping existing tooth decay or preventing further decay in baby teeth, or if there are any differences in unwanted effects, toothache, or bother with appearance of staining. When SDF is compared with sealants, we can't tell if there are any differences between treatments in preventing new tooth decay on the crown surfaces of permanent teeth, or whether there are any differences between these treatments in unwanted effects. When SDF is compared with fillings (with tooth decay first removed using only hand tools), we can't tell if there were any differences between treatments in stopping existing decay in baby teeth, unwanted effects, toothache, or bother with appearance of staining. What are the limitations of the evidence? Often we were very unsure of the evidence for the following reasons. ‐ SDF stains the teeth. Everyone in the studies would have known what treatment they were given. This might affect their usual teeth‐brushing routine. In most studies, the person checking teeth for new or existing decay would also have known this information. ‐ When we compared different approaches to SDF, the studies were too different from one another to allow us to compare them. ‐ Although we found 29 studies, most evidence was from individual (or few) studies, which were very small. How current is this evidence? The evidence is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Worthington, HV; Lewis, SR; Glenny, A-M; Huang, SS; Innes, NPT; O'Malley, L; Riley, P; Walsh, T; Wong, MC; Clarkson, JE; Veitz-Keenan, A", "articleTypes": [], "doi": "10.1002/14651858.CD012718.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "a6d62673-4b36-49c4-87bd-d311abe540f3", "pmid": "", "title": "The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement", "imported": false, "abstract": "Abstract - Background The World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework is an holistic, settings‐based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed. Objectives To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well‐being of students and their academic achievement. Search methods We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov , Current controlled trials , and WHO International Clinical Trials Registry Platform . We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles. Selection criteria We included cluster‐randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school’s ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements. Data collection and analysis At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random‐effects meta‐analyses to provide a summary of results across studies. Main results We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand‐washing (2), multiple risk behaviours (7), cycle‐helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self‐reported data and high attrition rates for some studies. In addition, there was a lack of long‐term follow‐up data for most studies. We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta‐analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school‐related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement. Authors' conclusions The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well‐designed research is required to establish the effectiveness of this approach for other health topics and academic achievement. Plain language summary The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement Background Health and education are strongly connected: healthy children achieve better results at school, which in turn are associated with improved health later in life. This relationship between health and education forms the basis of the World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework, an approach to promoting health in schools that addresses the whole school environment. Although the HPS framework is used in many schools, we currently do not know if it is effective. This review aimed to assess whether the HPS framework can improve students’ health and well‐being and their performance at school. Study characteristics We searched 20 health, education, and social science databases, as well as trials registries and relevant websites, for cluster‐randomised controlled trials of school‐based interventions aiming to improve the health of young people aged four to 18 years. We only included trials of programmes that addressed all three points in the HPS framework: including health education in the curriculum; changing the school’s social or physical environment, or both; and involving students’ families or the local community, or both. Key results We found 67 trials, comprising 1345 schools and 98 districts, that fulfilled our criteria. These focused on a wide range of health topics, including physical activity, nutrition, substance use (tobacco, alcohol, and drugs), bullying, violence, mental health, sexual health, hand‐washing, cycle‐helmet use, sun protection, eating disorders, and oral health. For each study, two review authors independently extracted relevant data and assessed the risk of the study being biased. We grouped together studies according to the health topic(s) they focused on. We found that interventions using the HPS approach were able to reduce students’ body mass index (BMI), increase physical activity and fitness levels, improve fruit and vegetable consumption, decrease cigarette use, and reduce reports of being bullied. However, we found little evidence of an effect on BMI when age and gender were taken into account (zBMI), and no evidence of effectiveness on fat intake, alcohol and drug use, mental health, violence, and bullying others. We did not have enough data to draw conclusions about the effectiveness of the HPS approach for sexual health, hand‐washing, cycle‐helmet use, eating disorders, sun protection, oral health or academic outcomes. Few studies discussed whether the health promotion activities, or the collection of data relating to these, could have caused any harm to the students involved. Quality of the evidence Overall, the quality of evidence was low to moderate. We identified some problems with the way studies were conducted, which may have introduced bias, including many studies relying on students’ accounts of their own behaviours (rather than these being measured objectively) and high numbers of students dropping out of studies. These problems, and the small number of studies included in our analysis, limit our ability to draw clear conclusions about the effectiveness of the HPS framework in general. Conclusions Overall, we found some evidence to suggest the HPS approach can produce improvements in certain areas of health, but there are not enough data to draw conclusions about its effectiveness for others. We need more studies to find out if this approach can improve other aspects of health and how students perform at school.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Langford, R, Bonell, CP, Jones, HE, Pouliou, T, Murphy, SM, Waters, E, Komro, KA, Gibbs, LF, Magnus, D, Campbell, R", "articleTypes": [], "doi": "10.1002/14651858.CD008958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.799Z" }, { "id": "a6e9a60a-63f5-4934-b18d-c589de7eb6a7", "pmid": "", "title": "Anticoagulation for people receiving long‐term haemodialysis", "imported": false, "abstract": "Abstract - Background Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding. Objectives To assess the efficacy and safety of anticoagulation strategies (including both heparin and non‐heparin drugs) for long‐term HD in people with kidney failure. Any intervention preventing clotting within the extracorporeal circuit without establishing anticoagulation within the patient, such as regional citrate, citrate enriched dialysate, heparin‐coated dialysers, pre‐dilution haemodiafiltration (HDF), and saline flushes were also included. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to November 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐randomised controlled studies (quasi‐RCTs) evaluating anticoagulant agents administered during HD treatment in adults and children with kidney failure. Data collection and analysis Two authors independently assessed the risk of bias using the Cochrane tool and extracted data. Treatment effects were estimated using random effects meta‐analysis and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE). Main results We included 113 studies randomising 4535 participants. The risk of bias in each study was adjudicated as high or unclear for most risk domains. Compared to UFH, LMWH had uncertain effects on extracorporeal circuit thrombosis (3 studies, 91 participants: RR 1.58, 95% CI 0.46 to 5.42; I 2 = 8%; low certainty evidence), while major bleeding and minor bleeding were not adequately reported. Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH (2 studies, 82 participants: RR 0.34, 95% CI 0.14 to 0.85; I 2 = 0%; low certainty evidence). No studies reported data comparing regional citrate to UFH on risks of extracorporeal circuit thrombosis and major bleeding. The effects of very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors or heparin‐grafted membranes were uncertain due to insufficient data. The effects of different LMWH, different doses of LMWH, and the administration of LMWH anticoagulants using inlet versus outlet bloodline or bolus versus infusion were uncertain. Evidence to compare citrate to another citrate or control was scant. The effects of UFH compared to no anticoagulant therapy or different doses of UFH were uncertain. Death, dialysis vascular access outcomes, blood transfusions, measures of anticoagulation effect, and costs of interventions were rarely reported. No studies evaluated the effects of treatment on non‐fatal myocardial infarction, non‐fatal stroke and hospital admissions. Adverse events were inconsistently and rarely reported. Authors' conclusions Anticoagulant strategies, including UFH and LMWH, have uncertain comparative risks on extracorporeal circuit thrombosis, while major bleeding and minor bleeding were not adequately reported. Regional citrate may decrease minor bleeding, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported. Evidence supporting clinical decision‐making for different forms of anticoagulant strategies for HD is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes. Plain language summary Treatments to thin the blood during haemodialysis: which treatments reduce clotting problems without causing bleeding? What is the issue? When people have dialysis using a machine to clean their blood (called haemodialysis (HD)), blood‐thinning treatment helps prevent blood clots in the dialysis tubing. However, thinning the blood too much with treatment can lead to bleeding problems. There are several different medications to thin the blood, but it is not clear which is the best or the safest choice. What did we do? We searched for all the research trials that assessed the blood thinning treatments during HD for adults and children up until November 2023. We measured the certainty we could have about the results of this research using \"GRADE\". What did we find? We found 113 studies involving 4535 patients treated with HD. Patients were given different forms of blood thinning therapy. The treatment they got was decided by random chance (like the toss of a coin). Most of the studies looked at a treatment called \"low molecular weight heparin\" and compared this with standard blood thinning care (called \"standard heparin\"). Unfortunately, the studies included only a small number of patients and only looked for risks of clotting or bleeding during one or two months of therapy. Because of this short time frame, and other limitations of the research studies, we were very uncertain about the results. The current research doesn't tell us whether one blood thinning treatment is better or safer than another for patients during dialysis treatment. Conclusions We still can't be certain about the best way to thin the blood for HD treatment based on existing research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Natale, P, Palmer, SC, Ruospo, M, Longmuir, H, Dodds, B, Prasad, R, Batt, TJ, Jose, MD, Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD011858.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.790Z" }, { "id": "a700805e-caae-4db7-b548-d0173e5d781f", "pmid": "", "title": "Modafinil for people with schizophrenia or related disorders", "imported": false, "abstract": "Abstract - Background People with schizophrenia have a range of different symptoms, including positive symptoms (hallucinations and delusions), negative symptoms (such as social withdrawal and lack of affect), and cognitive impairment. The standard medication for people with schizophrenia is antipsychotics. However, these medications may not be effective for all symptoms of schizophrenia, as cognitive and negative symptoms are usually hard to treat. Additional therapies or medications are available for the management of these symptoms. Modafinil, a wakefulness‐promoting agent most frequently used in narcolepsy or shift work sleep disorder, is one intervention that is theorised to have an effect of these symptoms. Objectives The primary objective of this review was to assess the effects of modafinil for people with schizophrenia or related disorders. Search methods On 27 April 2015, 24 May 2017, and 31 October 2019, we searched the Cochrane Schizophrenia Group's register of trials, which is based on regular searches of CENTRAL, MEDLINE, Embase, AMED, BIOSIS, CINAHL, PsycINFO, PubMed, and registries of clinical trials. There are no language, time, document type, or publication status limitations for the inclusion of records in the register. Selection criteria We selected all randomised controlled trials comparing modafinil with placebo or other treatments for people with schizophrenia or schizophrenia‐spectrum disorders. Data collection and analysis We independently extracted data from the included studies. We analysed dichotomous data using risk ratios (RR) and 95% confidence intervals (CI). We analysed continuous data using mean difference (MD) with a 95% CI. We used a random‐effects model for the meta‐analysis. We used GRADE to complete a 'Summary of findings' table and assessed risk of bias for the included studies. Main results Eleven studies including a total of 422 participants contributed to data analyses. Most studies had a small population size (average 38 people per study) and were of short duration. We also detected a high risk of bias for selective outcome reporting in just under 50% of the trials. We therefore rated the overall methodological quality of the included studies as low. We considered seven main outcomes of interest: clinically important change in overall mental state, clinically important change in cognitive functioning, incidence of a clinically important adverse effect/event, clinically important change in global state, leaving the study early for any reason, clinically important change in quality of life, and hospital admission. All studies assessed the effects of adding modafinil to participants' usual antipsychotic treatment compared to adding placebo to usual antipsychotic treatment. Six studies found that adding modafinil to antipsychotic treatment may have little or no effect on overall mental state of people with schizophrenia, specifically the risk of worsening psychosis (RR 0.91, 95% CI 0.28 to 2.98; participants = 209; studies = 6, low‐quality evidence ). Regarding the effect of modafinil on cognitive function, the trials did not report clinically important change data, but one study reported endpoint scores on the MATRICS Consensus Cognitive Battery (MCCB): in this study we found no clear difference in scores between modafinil and placebo treatment groups (MD −3.10, 95% CI −10.9 to 4.7; participants = 48; studies = 1, very low‐quality evidence ). Only one study (N = 35) reported adverse effect/event data. In this study one serious adverse event occurred in each group (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). One study measured change in global state using the Clinical Global Impression ‐ Improvement Scale. This study found that adding modafinil to antipsychotic treatment may have little or no effect on global state (RR 6.36, 95% CI 0.94 to 43.07, participants = 21; studies = 1, very low‐quality evidence ). Nine studies found that modafinil has no effect on numbers of participants leaving the study early (RR 1.26, 95% CI 0.63 to 2.52 participants = 357; studies = 9, moderate‐quality evidence ). None of the trials reported clinically important change in quality of life, but one study did report quality of life using endpoint scores on the Quality of Life Inventory, finding no clear difference between treatment groups (MD −0.2, 95% CI −1.18 to 0.78; participants = 20; studies = 1, very low‐quality evidence ). Finally, one study reported data for number of participants needing hospitalisation: one participant in each group was hospitalised (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). Authors' conclusions Due to methodological issues, low sample size, and short duration of the clinical trials as well as high risk of bias for outcome reporting, most of the evidence available for this review is of very low or low quality. For results where quality is low or very low, we are uncertain or very uncertain if the effect estimates are true effects, limiting our conclusions. Specifically, we found that modafinil is no better or worse than placebo at preventing worsening of psychosis; however, we are uncertain about this result. We have more confidence that participants receiving modafinil are no more likely to leave a trial early than participants receiving placebo. However, we are very uncertain about the remaining equivocal results between modafinil and placebo for outcomes such as improvement in global state or cognitive function, incidence of adverse events, and changes in quality of life. More high‐quality data are needed before firm conclusions regarding the effects of modafinil for people with schizophrenia or related disorders can be made. Plain language summary Modafinil for schizophrenia Review question: Is adding modafinil to antipsychotic treatment effective and safe for people with schizophrenia? Background Schizophrenia is a complicated and chronic mental disorder that usually presents with a wide range of symptoms. The standard treatment (antipsychotics) is considered to be effective for the positive symptoms (such as delusions and hallucinations or bizarre thoughts). However, there are negative and cognitive symptoms (such as social withdrawal, lack of affect, problems with memory) that are not adequately treated with these medications. These symptoms tend to be chronic and can therefore have a long‐term impact on an individual's quality of life. Additional treatments are often added to antipsychotic treatment, of which one is modafinil, a wakefulness‐promoting medication usually used for sleep disorders. Searching for evidence We ran an electronic search of Cochrane Schizophrenia's register of trials in April 2015, May 2017, and October 2019 for trials that randomised (allocated participants to treatment groups using a random method) people with schizophrenia to receive add‐on modafinil (modafinil added to their standard care) or to receive add‐on placebo. We identified 67 records that referred to 25 studies. Evidence found Eleven studies met the review requirements and reported data that could be used in analyses. However, the trials included small numbers of participants and were of short duration; schizophrenia is a long‐term health problem that ideally requires studies of longer duration. Our analysis of the data showed there is no clear difference between add‐on modafinil and add‐on placebo for improving mental state or global state, changing cognitive functioning, causing participants to leave a study early, producing adverse effects, or affecting rates of hospitalisation. However, most of these results were based on very low‐ or low‐quality data, therefore it is uncertain if these statistical effect sizes found by our data analyses are true effects. Conclusions The results of this review indicate no clear difference in effectiveness and safety between add‐on modafinil and add‐on placebo, however these results are not conclusive as they are based low‐ or very low‐quality evidence. Based on the current evidence we were unable to provide an answer to our review question as to whether modafinil is better than placebo for improving the symptoms of schizophrenia, or if it is safe to use for people with schizophrenia. More high‐quality research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ortiz-Orendain, J, Covarrubias-Castillo, SA, Vazquez-Alvarez, AO, Castiello-de Obeso, S, Arias Quiñones, GE, Seegers, M, Colunga-Lozano, LE", "articleTypes": [], "doi": "10.1002/14651858.CD008661.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.807Z" }, { "id": "a716b124-a7ca-46d3-998b-bda2968578f1", "pmid": "", "title": "Interventions for deliberately altering blood pressure in acute stroke", "imported": false, "abstract": "Abstract - Background It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001 and 2008. Objectives To assess the clinical effectiveness of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke. Search methods We searched the Cochrane Stroke Group Trials Register (last searched in February 2014), the Cochrane Database of Systematic reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 2), MEDLINE (Ovid) (1966 to May 2014), EMBASE (Ovid) (1974 to May 2014), Science Citation Index (ISI, Web of Science, 1981 to May 2014) and the Stroke Trials Registry (searched May 2014). Selection criteria Randomised controlled trials of interventions that aimed to alter blood pressure compared with control in participants within one week of acute ischaemic or haemorrhagic stroke. Data collection and analysis Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data. The review authors cross‐checked data and resolved discrepancies by discussion to reach consensus. We obtained published and unpublished data where available. Main results We included 26 trials involving 17,011 participants (8497 participants were assigned active therapy and 8514 participants received placebo/control). Not all trials contributed to each outcome. Most data came from trials that had a wide time window for recruitment; four trials gave treatment within six hours and one trial within eight hours. The trials tested alpha‐2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide‐like diuretics, and target‐driven blood pressure lowering. One trial tested phenylephrine. At 24 hours after randomisation oral ACEIs reduced systolic blood pressure (SBP, mean difference (MD) ‐8 mmHg, 95% confidence interval (CI) ‐17 to 1) and diastolic blood pressure (DBP, MD ‐3 mmHg, 95% CI ‐9 to 2), sublingual ACEIs reduced SBP (MD ‐12.00 mm Hg, 95% CI ‐26 to 2) and DBP (MD ‐2, 95%CI ‐10 to 6), oral ARA reduced SBP (MD ‐1 mm Hg, 95% CI ‐3 to 2) and DBP (MD ‐1 mm Hg, 95% CI ‐3 to 1), oral beta blockers reduced SBP (MD ‐14 mm Hg; 95% CI ‐27 to ‐1) and DBP (MD ‐1 mm Hg, 95% CI ‐9 to 7), intravenous (iv) beta blockers reduced SBP (MD ‐5 mm Hg, 95% CI ‐18 to 8) and DBP (‐5 mm Hg, 95% CI ‐13 to 3), oral CCBs reduced SBP (MD ‐13 mmHg, 95% CI ‐43 to 17) and DBP (MD ‐6 mmHg, 95% CI ‐14 to 2), iv CCBs reduced SBP (MD ‐32 mmHg, 95% CI ‐65 to 1) and DBP (MD ‐13, 95% CI ‐31 to 6), NO donors reduced SBP (MD ‐12 mmHg, 95% CI ‐19 to ‐5) and DBP (MD ‐3, 95% CI ‐4 to ‐2) while phenylephrine, non‐significantly increased SBP (MD 21 mmHg, 95% CI ‐13 to 55) and DBP (MD 1 mmHg, 95% CI ‐15 to 16). Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05), stroke type (OR 0.98, 95% CI 0.92 to 1.05) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05). Treatment within six hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99) but not death (OR 0.70, 95% CI 0.38 to 1.26) at the end of the trial. Although death or dependency did not differ between people who continued pre‐stroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24), disability scores at the end of the trial were worse in participants randomised to continue treatment (Barthel Index, MD ‐3.2, 95% CI ‐5.8, ‐0.6). Authors' conclusions There is insufficient evidence that lowering blood pressure during the acute phase of stroke improves functional outcome. It is reasonable to withhold blood pressure‐lowering drugs until patients are medically and neurologically stable, and have suitable oral or enteral access, after which drugs can than be reintroduced. In people with acute stroke, CCBs, ACEI, ARA, beta blockers and NO donors each lower blood pressure while phenylephrine probably increases blood pressure. Further trials are needed to identify which people are most likely to benefit from early treatment, in particular whether treatment started very early is beneficial. Plain language summary Drug interventions for deliberately altering blood pressure in acute stroke Background: In people who have just had a stroke (a sudden brain attack due to either blockage or rupture of an artery in the brain), very high and very low blood pressures may be harmful. Therefore, drugs that raise low blood pressure or lower high blood pressure might be beneficial. Up to 50% of people admitted with acute stroke are taking blood pressure tablets on hospital admission and it is not clear whether these medications should be continued or discontinued in the acute situation. This review looked at those trials that deliberately altered blood pressure or compared continuing or stopping blood pressure‐lowering tablets taken before stroke. Study characteristics: This review is up‐to‐date to May 2014. We included 26 trials involving 17,011 participants: 24 trials assessed lowering blood pressure, one trial tested raising blood pressure, and two trials assessed what to do with drugs taken before stroke. All studies took place in hospitals that were used to treating people with stroke. Not all trials contributed information to all outcomes, and we have used data that were available in publications. Key results: There is insufficient evidence to say that lowering blood pressure saves lives or reduces disability in people with acute stroke. Immediately restarting blood pressure‐lowering drugs taken before the stroke may increase disability. Conclusion: More research is needed to identify those people who are most likely to benefit from altering blood pressure in acute stroke, the time window in which the treatment is likely to be of benefit, what types of stroke are likely to respond favourably, and the environment in which such treatment may be best given in routine practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bath, PMW; Krishnan, K", "articleTypes": [], "doi": "10.1002/14651858.CD000039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "a71837a0-e973-4afa-ad69-8dbaeb957b17", "pmid": "", "title": "Prophylactic TCM for Mitigation of EGFR-TKI Related Dermatological Adverse Effect", "imported": false, "abstract": "Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have become standard practice for advanced non-small cell lung cancer (NSCLC) with EGFR gene mutation. EGFR-TKIs involving Afatinib, Erlotinib, and Gefitinib were Food and Drug Administration (FDA) approved since 2006 and given payment continuously for lung adenocarcinoma with EGFR mutation in Taiwan.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.160Z" }, { "id": "a718d064-8521-41b6-b52d-61b7eb1a3611", "pmid": "", "title": "Ginkgo biloba extract for age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Ginkgo is used in the treatment of peripheral vascular disease and 'cerebral insufficiency'. It is thought to have several potential mechanisms of action including increased blood flow, platelet activating factor antagonism, and prevention of membrane damage caused by free radicals. Vascular factors and oxidative damage are thought to be two potential mechanisms in the pathology of age‐related macular degeneration (AMD). Objectives The objective of this review was to determine the effect of Ginkgo biloba extract on the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2012), EMBASE (January 1980 to October 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to October 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 5 October 2012. We searched the reference lists of identified reports and the Science Citation Index. We also contacted investigators of included studies for additional information. Selection criteria All randomised trials in people with AMD where Ginkgo biloba extract had been compared to control were included. Data collection and analysis The review author extracted data using a standardised form. The data were verified with the trial investigators. Trial quality was assessed. Main results Two published trials were identified that randomised a total of 119 people. In one study conducted in France, 20 people were randomly allocated to Gingko biloba extract EGb 761 80 mg twice daily or placebo. In the other study conducted in Germany, 99 people were randomly allocated to two different doses of Ginkgo biloba extract EGb 761 (240 mg per day and 60 mg per day). Treatment duration in both studies was six months. Both trials reported some positive effects of Ginkgo biloba on vision however their results could not be pooled. Adverse effects and quality of life for people with AMD were not reported. Authors' conclusions The question as to whether people with AMD should take Ginkgo biloba extract to prevent progression of the disease has not been answered by research to date. Two small trials have suggested possible benefit of Gingko biloba on vision and further trials are warranted. Ginkgo biloba is widely used in China, Germany, and France. Future trials should be larger, and last longer, in order to provide a more robust measure of the effect of Gingko biloba extract on AMD. Plain language summary Use of Gingko biloba, an extract from the leaves of the maidenhair tree, for slowing the progression of age‐related macular degeneration Age‐related macular degeneration (AMD) is a condition affecting the central area of the retina (the back of the eye). The retina can deteriorate with age and some people get lesions that lead to loss of central vision. Gingko biloba, extracted from the leaves of the maidenhair tree, is used in Chinese herbal medicine to treat a variety of medical conditions, in particular circulatory problems. Ginkgo biloba extract contains two constituents (flavonoids and terpenoids) which have antioxidant properties. It is believed these may help to slow down the progression of AMD. The author identified two small randomised controlled studies (with a total of 119 participants); one in France and one in Germany. One trial compared Gingko biloba to placebo and the other compared two different doses of the extract. Although both trials reported some positive effects of Ginkgo biloba on vision, the trials were small and of short duration. Adverse effects and quality of life were not assessed. The overall conclusion of this review is that current research has not answered the question as to whether Ginkgo biloba is of benefit to people with AMD. Future trials need to include a larger number of participants and be conducted over a longer time.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD001775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.750Z" }, { "id": "a721e07d-098e-42bb-9929-e52b5b999227", "pmid": "", "title": "Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010. For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established. Objectives To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications. Search methods Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012. Selection criteria Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Data collection and analysis Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information. Main results One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012. Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study. Weight loss was greater for the NG group at six weeks post‐treatment than for the PEG group (P = 0.001). At six months post‐treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post‐treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively. We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review. Authors' conclusions There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required. Plain language summary Artificial tube feeding methods for use with patients with head and neck cancer who are receiving treatment with radiotherapy, chemotherapy or both Patients with cancer of the head and neck are at risk of malnutrition during radiotherapy treatment due to the side effects of this treatment and they may need tube feeding to meet their nutritional needs. Tube feeding can either be delivered via a nasogastric feeding tube, which is a fine tube inserted through the nose into the stomach, or a gastrostomy tube which is inserted through the skin of the abdomen directly into the stomach. Both of these methods allow the delivery of nutrients directly into the stomach. Tube feeding is essential to meet the nutritional needs of head and neck cancer patients as malnutrition can lead to a poorer prognosis for this patient group. There is debate over which method of tube feeding provides the most benefit to the patient for outcomes such as nutritional benefit and quality of life, as well as avoiding delays in radiotherapy treatment. Following our analysis of the available literature, only one clinical trial was eligible to be included in this review. The authors of this review found no evidence to support the use of any one method of tube feeding over another.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Nugent, B; Lewis, S; O'Sullivan, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007904.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "a73f2ef5-f216-4066-8e8e-30903998ec73", "pmid": "", "title": "Oral protein‐based supplements versus placebo or no treatment for people with chronic kidney disease requiring dialysis", "imported": false, "abstract": "Abstract - Background Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein‐based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein‐based nutritional supplements in this population is limited. Objectives The aims of this review were to determine the benefits and harms of using oral protein‐based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein‐based nutritional supplements to no oral protein‐based nutritional supplements or placebo. Data collection and analysis Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes. Main results Twenty‐two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow‐up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self‐reported outcomes. Oral protein‐based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I 2 = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein‐based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I 2 = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein‐based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid‐arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein‐based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI ‐0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD ‐0.04 kg/m 2 , 95% CI ‐0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI ‐1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein‐based nutritional supplements affect triceps skinfold thickness, mid‐arm circumference, C‐reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein‐based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies. Authors' conclusions Overall, it is likely that oral protein‐based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid‐arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well‐designed RCTs in this population are required. Plain language summary Oral protein‐based nutritional supplement in people with chronic kidney disease requiring dialysis What is the issue? People with chronic kidney disease requiring dialysis are at risk of developing malnutrition for many reasons and often do not eat enough because their appetite is poor. Oral nutritional supplements are commonly provided to people who do not eat enough to meet their needs. Provision of nutritional supplements to dialysis patients requires careful consideration of potassium, phosphate and fluid limits. What did we do? We aimed to determine if giving oral protein‐based nutritional supplements improved serum albumin levels and other measures of nutrition. What did we find? A total of 1278 people took part in 22 studies that were included in this review to investigate the effects of oral protein‐based nutritional supplements. All participants were adults on maintenance dialysis (79% haemodialysis and 21% peritoneal dialysis). The studies lasted from one to 12 months. The findings suggest that giving oral protein‐based nutritional supplementation probably results in a slightly greater increase in albumin level and may improve prealbumin level and mid‐arm muscle circumference. The increase in albumin level was more evident in participants who were on haemodialysis and in those who were malnourished. It is uncertain whether oral protein‐based nutritional supplementation affects potassium and phosphate levels. Oral protein‐based nutritional supplements may result in little or no difference in the risk of developing abdominal symptoms.There were some differences between the quality of the studies and their designs. Conclusions The authors conclude that oral protein‐based nutritional supplements appear to be effective in improving some nutritional markers in people who need dialysis; however, it remains uncertain whether these results translate to meaningful outcomes for this population. More research is required to determine the cost‐effectiveness of this treatment, and if it can bring benefit to patients such as feeling better and living longer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Mah, JY, Choy, SW, Roberts, MA, Desai, AM, Corken, M, Gwini, SM, McMahon, LP", "articleTypes": [], "doi": "10.1002/14651858.CD012616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.760Z" }, { "id": "a7561b46-34d7-4b26-8313-e36b4067afeb", "pmid": "", "title": "Interventions for the management of dry mouth: non‐pharmacological interventions", "imported": false, "abstract": "Abstract - Background Xerostomia is the subjective sensation of dry mouth. Common causes of xerostomia include adverse effects of many commonly prescribed medications, disease (e.g. Sjogren's Syndrome) and radiotherapy treatment for head and neck cancers. Non‐pharmacological techniques such as acupuncture or mild electrostimulation may be used to improve symptoms. Objectives To assess the effects of non‐pharmacological interventions administered to stimulate saliva production for the relief of dry mouth. Search methods We searched the Cochrane Oral Health Group's Trials Register (to 16th April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 3), MEDLINE via OVID (1948 to 16th April 2013), EMBASE via OVID (1980 to 16th April 2013), AMED via OVID (1985 to 16th April 2013), CINAHL via EBSCO (1981 to 16th April 2013), and CANCERLIT via PubMed (1950 to 16th April 2013). The meta Register of Controlled Clinical Trials ( www.controlled‐trials.com ) and ClinicalTrials.gov ( www.clinicaltrials.gov ) were also searched to identify ongoing and completed trials. References lists of included studies and relevant reviews were also searched. There were no restrictions on the language of publication or publication status. Selection criteria We included parallel group randomised controlled trials of non‐pharmacological interventions to treat dry mouth, where participants had dry mouth symptoms at baseline. Data collection and analysis At least two review authors assessed each of the included studies to confirm eligibility, assess risk of bias and extract data using a piloted data extraction form. We calculated mean difference (MD) and 95% confidence intervals (CI) for continuous outcomes or where different scales were used to assess an outcome, we calculated standardised mean differences (SMD) together with 95% CIs. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information. Main results There were nine studies (total 366 participants randomised) included in this review of non‐pharmacological interventions for dry mouth which were divided into three comparisons. Eight studies were assessed at high risk of bias in at least one domain and the remaining study was at unclear risk of bias. Five small studies (total 153 participants, with dry mouth following radiotherapy treatment) compared acupuncture with placebo. Four were assessed at high risk and one at unclear risk of bias. Two trials reported outcome data for dry mouth in a form suitable for meta‐analysis. The pooled estimate of these two trials (70 participants, low quality evidence) showed no difference between acupuncture and control in dry mouth symptoms (SMD ‐0.34, 95% CI ‐0.81 to 0.14, P value 0.17, I 2 = 39%) with the confidence intervals including both a possible reduction or a possible increase in dry mouth symptoms. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). There was a very small increase in unstimulated whole saliva (UWS) at the end of 4 to 6 weeks of treatment (three trials, 71 participants, low quality evidence) (MD 0.02 ml/minute, 95% CI 0 to 0.04, P value 0.04, I 2 = 57%), and this benefit persisted at the 12‐month follow‐up evaluation (two trials, 54 participants, low quality evidence) (UWS, MD 0.06 ml/minute, 95% CI 0.01 to 0.11, P value 0.03, I 2 = 10%). For the outcome of stimulated whole saliva (SWS, three trials, 71 participants, low quality evidence) there was a benefit favouring acupuncture (MD 0.19 ml/minute, 95% CI 0.07 to 0.31, P value 0.002, I 2 = 1%) an effect which also persisted at the 12‐month follow‐up evaluation (SWS MD 0.28 ml/minute, 95% CI 0.09 to 0.47, P value 0.004, I 2 = 0%) (two trials, 54 participants, low quality evidence). Two small studies, both at high risk of bias, compared the use of an electrostimulation device with a placebo device in participants with Sjögren's Syndrome (total 101 participants). A further study, also at high risk of bias, compared acupuncture‐like electrostimulation of different sets of points in participants who had previously been treated with radiotherapy. None of these studies reported the outcome of dry mouth. There was no difference between electrostimulation and placebo in the outcomes of UWS or SWS at the end of the 4‐week treatment period in the one study (very low that provided data for these outcomes. No adverse effects were reported. A single study at high risk of bias, compared the stimulatory effect of powered versus manual toothbrushing and found no difference for the outcomes of UWS or SWS. Authors' conclusions There is low quality evidence that acupuncture is no different from placebo acupuncture with regard to dry mouth symptoms, which is the most important outcome. This may be because there were insufficient participants included in the two trials to show a possible effect or it may be that there was some benefit due to 'placebo' acupuncture which could have biased the effect to the null. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms. It is well known that dry mouth symptoms may be problematic even when saliva production is increased, yet only two of the trials that evaluated acupuncture reported dry mouth symptoms, a worrying reporting bias. There is some low quality evidence that acupuncture results in a small increase in saliva production in patients with dry mouth following radiotherapy. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms or saliva production in patients with Sjögren's Syndrome. Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation. Plain language summary Non‐drug treatments for dry mouth symptoms Review question This review, carried out by authors of the Cochrane Oral Health Group, has been produced to assess the effects of non‐drug treatments used to stimulate saliva production for the relief of dry mouth (xerostomia) symptoms. Background Dry mouth is a common problem with an estimated incidence of between 10% and 26% in men and between 10% and 33% in women, which may or may not be due to reduced saliva secretion. Common causes of dry mouth include the side effects of many commonly prescribed medications, diseases (such as Sjögren's syndrome where the immune system destroys tissues in the glands which produce saliva) and radiotherapy treatments for head and neck cancers. Saliva moistens the skin in the mouth and helps to maintain oral health. The presence of saliva facilitates speech, acts to wash away food residue from around the teeth, neutralises potentially damaging food and bacterial acids, enhances a person's ability to taste the food, and generally lubricates the mouth. Saliva also acts to soften food, making it easier to chew and swallow. Enzymes in saliva start the digestion of starch and fats, and other substances in saliva, such as epidermal growth factors, promote tissue growth, differentiation and wound healing. The antibacterial, antifungal and antiviral agents in saliva balance the oral flora and help to prevent oral infections, while the minerals in saliva help to maintain tooth enamel. Non‐drug treatments such as acupuncture, mild electrical stimulation, lasers, tooth brushing and other stimulation techniques are used to improve dry mouth symptoms. Study characteristics The evidence on which this review is based was up‐to‐date as of 16 April 2013. Nine studies were included in this review. A total of 366 adult participants took part in these trials, with an average of 40 participants per trial, and an age range from 12 to 77 years. The causes of dry mouth were radiotherapy for oral cancers in four trials, Sjögren's syndrome in three trials, medication‐related in one trial, and in the remaining trial participants had a range of causes of dry mouth. The included studies were divided into three groups, according the interventions evaluated. 1. Five small studies with a total 153 participants evaluated acupuncture. 2. Three studies evaluated electrostimulation devices. 3. One study evaluated a power toothbrush. Key results The five studies evaluating the effects of acupuncture in people who had dry mouth were generally of poor quality. There was no evidence of a difference in dry mouth symptoms, but there was some evidence of a small increase in saliva production which persisted for a year after the end of the acupuncture treatment. There may not have been enough people included in the trials to show a difference in dry mouth, or it may have been that both the real acupuncture and the 'placebo' acupuncture had some beneficial effect. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). The studies evaluating the effects of electrostimulation devices were poorly conducted and reported, and provided insufficient evidence to determine the effects of these devices on either dry mouth or saliva production. The single small study of a powered versus a manual toothbrush also found no difference for either dry mouth or saliva production. None of the included studies reported the outcomes of duration of effectiveness, quality of life, patient satisfaction, or oral health assessment. Quality of the evidence These studies were generally of poor quality (low and very low).", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Furness, S; Bryan, G; McMillan, R; Birchenough, S; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD009603.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "a78c7c02-29de-4926-9de0-36776ade4f32", "pmid": "", "title": "Interventions for treating people with symptoms of bladder pain syndrome: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide‐ranging treatment options, used alone or in combination, with limited evidence. A network meta‐analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS. Objectives To conduct a network meta‐analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS). Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible. Data collection and analysis We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random‐effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta‐analysis of head‐to‐head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories. Main results We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low‐certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD ‐1.27, 95% CrI ‐3.25 to 0.71; low‐certainty evidence), daytime frequency (MD ‐2.41, 95% CrI ‐6.85 to 2.05; very low‐certainty evidence) or nocturia (MD 0.01, 95% CrI ‐2.53 to 2.50; very low‐certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low‐certainty evidence) or reduced pain (MD 0.42, 95% CrI ‐1.04 to 1.91; low‐certainty evidence), frequency (MD ‐0.37, 95% CrI ‐5.00 to 3.44; very low‐certainty evidence) or nocturia (MD ‐1.20, 95% CrI ‐3.62 to 1.28; very low‐certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD ‐0.33, 95% CrI ‐1.71 to 1.03), frequency (MD ‐0.91, 95% CrI ‐3.24, 1.29) or nocturia (MD ‐0.04, 95% CrI ‐1.35 to 1.27). The certainty of this evidence was always very low. Authors' conclusions We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base. Plain language summary Treatments for people with bladder pain syndrome What is bladder pain syndrome? Bladder pain syndrome (BPS; also called painful bladder syndrome or interstitial cystitis) is a long‐term painful condition that affects the bladder. ‘Syndrome’ refers to a collection of symptoms. In BPS, these symptoms include: intense pain in the pelvis (felt below the bellybutton); sudden strong urges to urinate; needing to urinate more often than usual; and waking up several times during the night to urinate. BPS is more common in women. We do not know what causes it or how to cure it. Symptoms sometimes come and go in phases. BPS can significantly affect lifestyle, work, emotional health and relationships. Treatments for BPS Lifestyle changes are usually tried first, then medicines and supportive therapies. Surgery may be needed as a last resort. Medicines used include pentosan polysulfate sodium – which may help to restore the inner surface of the bladder – anti‐inflammatories, antidepressants and antihistamines. Medicines that block the connection between nerves and muscles can be injected into the bladder muscle to try to relax it (‘neuromuscular blockade’). Supportive therapies and treatments include behavioural therapy, physiotherapy, bladder re‐training, psychological therapy and transcutaneous electrical nerve stimulation (TENS). Review question In this Cochrane Review, we wanted to find out which treatments work best to treat BPS. What did we do? We searched for studies that looked at any type of treatment for BPS. We looked for randomised controlled studies, in which the treatment people receive is randomly decided, because these studies usually give the most reliable evidence about treatments. Search date We included evidence published up to 11 May 2018. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. What we found We found 81 studies involving 4674 people with BPS. The biggest study included 369 people, and the smallest study included 10 people. Most studies lasted around three months; only six studies lasted 12 months or longer. Twenty‐four studies were funded by pharmaceutical companies. We found 65 treatments for BPS, which we grouped into 31 categories based on how the treatments worked. In most studies, a treatment for BPS was compared with a placebo (or dummy) treatment. We compared all treatments with each other using a mathematical method called network meta‐analysis. What are the results of our review? After 12 months, antidepressants or neuromuscular blockade (and some other treatments) may improve symptoms of BPS more than placebo, but we are not certain about this result. We did not find enough evidence to know if pentosan polysulfate sodium improves symptoms. We are uncertain whether 12 months of treatment with antidepressants, neuromuscular blockade or pentosan polysulfate sodium reduced pain (as measured on a scale); the number of times people had to urinate during the day; or the number of times people had to get up to urinate during the night. Our confidence in the results We are uncertain about our results because we did not find enough reliable evidence. Although we obtained results from 81 studies, most of these studies were small and did not include enough people for us to be certain of their results. Some of the studies (30%) were conducted by pharmaceutical companies, and this may have affected how the studies were designed, conducted and reported. Our results may change when results from more, and larger, studies become available. Conclusions We did not find enough reliable evidence about how well medicines, behavioural therapy, physiotherapy and neuromuscular blockade worked to treat all, or any, of the symptoms of BPS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Imamura, M, Scott, NW, Wallace, SA, Ogah, JA, Ford, AA, Dubos, YA, Brazzelli, M", "articleTypes": [], "doi": "10.1002/14651858.CD013325.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.804Z" }, { "id": "a78d7b47-3564-4510-ab1b-1f88b5e04c5e", "pmid": "", "title": "Nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy", "imported": false, "abstract": "Abstract - Background Across the developed world, an estimated 150,000 to 300,000 people are treated annually with pelvic radiotherapy and 80% will develop gastrointestinal (GI) symptoms during treatment. Acute GI symptoms are associated with a greater risk of chronic, often debilitating, GI symptoms. Up to one‐third of patients are malnourished before pelvic radiotherapy and up to four‐fifths of patients lose weight during treatment. Malnutrition is linked to a higher risk of GI toxicity, which can lead to breaks in radiotherapy and early cessation of chemotherapy, thus compromising the efficacy of the primary cancer treatment. Objectives To assess the effects of nutritional interventions for reducing GI toxicity in adults undergoing radical pelvic radiotherapy. Search methods We searched the Cochrane Gynaecological Cancer Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 4, 2012, MEDLINE and EMBASE to May 2012. We handsearched the citation lists of included studies and previous systematic reviews identified to identify further relevant trials. Selection criteria We included studies if they were randomised controlled trials (RCTs) or non‐randomised studies with concurrent comparison groups including quasi‐randomised trials, cluster RCTs, non‐randomised trials, prospective and retrospective cohort studies, and case series of 30 or more patients. We only included studies if they assessed the effect of a nutritional intervention in adults aged 18 years or over undergoing radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic malignancy. We excluded patients with stomas and a previous history of inflammatory bowel disease. Nutritional support interventions could be provided at any stage before or during pelvic radiotherapy and included dietary counselling; dietary modification of fibre, lactose or fat; supplementary foods or drinks or fortified foods; standard oral nutrition supplements including polymeric‐, peptide‐ or amino acid‐based supplements and those where novel substrates have been added; enteral tube feeds; or parenteral nutrition (partial or total). We excluded probiotics, prebiotics and synbiotics. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors to obtain missing data. We assessed bias for each of the included studies using the bias assessment tables in the Cochrane software Review Manager5. We performed meta‐analysis, when indicated, using the Mantel‐Haenszel fixed‐effect method or inverse variance fixed‐effect method displayed with heterogeneity. We undertook meta‐analyses on trials evaluating dietary modification against standard treatment for diarrhoea at the end of radiotherapy and for change in weight from baseline to end of radiotherapy. Main results The searches identified 7558 titles, and we excluded 7513 during title and abstract searches. We reviewed 45 papers in full, and excluded 39. We identified four studies on handsearching of the references, which, along with the six eligible papers from the database search, led to 10 studies being included. Four studies, three of which were RCTs and one prospective study, investigated the effect of elemental diet on GI symptoms; one RCT investigated the effect of dietary modification and elemental diet; and five RCTs investigated dietary modification. Studies were varied in terms of risk of bias. Data were dichotomised for presence and absence of diarrhoea at the end of radiotherapy for four trials evaluating dietary modification comprising modified fat, lactose, fibre or combinations of these dietary changes. A reduction in diarrhoea was demonstrated with nutritional intervention (risk ratio (RR) 0.66; 95% confidence interval (CI) 0.51 to 0.87, four studies, 413 participants, moderate quality of evidence) with low heterogeneity (Chi 2 = 3.50, I 2 = 14%). Two trials evaluating dietary modification on weight change (comparing baseline and end of radiotherapy) showed no difference between intervention or control (mean difference (MD) ‐0.57 kg; 95% CI ‐1.22 to 0.09) with low heterogeneity (Chi 2 = 1.41, I 2 = 29%). Generally adverse effects were poorly reported in included studies. Elemental diet in particular was poorly tolerated. GI symptoms or toxicity > 6 months after radiotherapy was not reported in included studies Authors' conclusions There have been benefits demonstrated with dietary modification during pelvic radiotherapy to reduce diarrhoea. Those diets included single interventions or combinations of modified fat, lactose‐restriction, fat‐restriction and fibre supplementation. We were unable to meta‐analyse elemental diet, as data were not available. We considered some of the studies to be at high risk of bias. There have been recent advances in novel, more targeted radiotherapy techniques, such that the findings of older studies need to be interpreted with caution. In addition, there were problems with compliance and palatability with some of the interventions, particularly elemental diet, which limits its usefulness in clinical practice. Plain language summary Do nutritional interventions reduce gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy? Background Research has shown that nutrition and radiotherapy have effects on each other. People with malnutrition tend to get more bowel side effects during radiotherapy. It has also been shown that many people lose weight during radiotherapy due to the treatment side effects. These side effects can lead to some people needing gaps in their radiotherapy and sometimes they even need to stop it entirely. This can reduce the chance of cancer cure. This review looked at the literature for providing extra nourishment or changes in diet to patients before or during radiotherapy, to determine whether this is of benefit in terms of reducing bowel symptoms, improving nutritional status and quality of life. Study characteristics Searches of all relevant sources of medical information identified 7558 articles, and, after initial screening of all these articles, we selected 45 as being suitable for this review. On reading the summaries of these 45 trials, 10 were suitable to be included in this review. We included trials that looked at the effects of a nutritional intervention in adults aged 18 years or over having radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic cancer. We excluded patients with stomas and a previous history of inflammatory bowel disease. Key results Results showed that studies evaluating dietary changes, including changes in dietary fat, fibre and lactose, during radiotherapy reduced diarrhoea at the end of treatment. However, these dietary changes did not seem to improve patients' weights. Quality of the evidence While some changes to diet during radiotherapy may benefit patients by reducing diarrhoea, it is important to recognise that some of the studies reviewed were dated and there have been changes in radiotherapy technique since then that may give patients less diarrhoea anyway. In addition, many studies were of poor quality and, therefore, only a small number were able to be included in this review. Some interventions described, for example, having to take a liquid diet, were not acceptable as many patients found them difficult to tolerate and were unable to take them completely.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Henson, CC, Burden, S, Davidson, SE, Lal, S", "articleTypes": [], "doi": "10.1002/14651858.CD009896.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.772Z" }, { "id": "a7ad73d6-3cd8-4149-a145-a4378adf5a1e", "pmid": "", "title": "Multisensory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Multisensory stimulation is a structured, developmentally appropriate intervention that provides simultaneous or sequential stimulation of two or more senses (e.g. tactile, auditory, visual, or vestibular) in a controlled and non‐stressful manner, with the aim of supporting early neurodevelopment in preterm infants. It has the potential to enhance physiological regulation in preterm infants by stabilizing key functions, such as respiratory patterns, heart rate, and oxygen saturation; reducing the need for respiratory support; and improving feeding performance and sleep regulation. Targeted multisensory interventions have also been associated with improved neurodevelopmental outcomes, including enhanced psychomotor development and visual function. Objectives To assess the benefits and harms of multisensory stimulation compared to any single sensory intervention or standard care on major neurodevelopmental disability, mortality, and growth in preterm infants. Search methods We searched CENTRAL, MEDLINE, Embase, Emcare, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 28 November 2025. We checked reference lists of included trials, and systematic reviews on sensory interventions. Eligibility criteria We included 18 randomized controlled trials (RCTs) comparing multisensory stimulation in preterm infants with no intervention (placebo or standard care), and one RCT comparing multisensory stimulation with single‐sense stimulation (tactile stimulation). Outcomes Our critical outcomes were major neurodevelopmental disability at 18 to 24 months: cerebral palsy (CP), developmental delay, intellectual impairment, blindness, sensorineural deafness; death during initial hospitalization; and total weight gain (grams), assessed at discharge. When comparing multisensory stimulation with single‐sense intervention, we also included weight gain during the intervention, an outcome added during the post‐hoc analysis. Important outcomes were duration of hospital stay, of NICU stay, and of respiratory support; and time until full oral feeding. Risk of bias We used the Cochrane tool, RoB 2. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RR) for dichotomous data, and mean differences (MDs) for continuous data, each with its 95% confidence intervals (CIs). We assessed statistical heterogeneity by calculating the I 2 statistic when we included more than two trials in a meta‐analysis. We evaluated the certainty of evidence using GRADE. Included studies We included 19 trials (1554 newborn infants): 18 studies compared multisensory stimulation with standard care; one compared multisensory stimulation with single‐sensory stimulation (tactile). In 10 studies, the primary aim was to assess the neurobehavioral outcomes of multisensory stimulation on preterm neo­nates. The other nine studies aimed to assess the impact of multisensory stimulation on weight gain during the intervention, weight gain until hospital discharge, length of neonatal intensive care unit (NICU) stay, length of hospital stay, time until full oral feeding, length of respiratory support, or a combination. In the abstract we report results for the critical outcomes only. We identified 13 ongoing studies. Four studies are awaiting assessment. Synthesis of results Multisensory stimulation compared to standard care No studies reported on these major neurodevelopmental disabilities, assessed at 18 to 24 months' corrected age (CA): developmental delay, intellectual impairment, blindness, or sensorineural deafness. One study reported on rates of CP at 12 months of age. The evidence is very uncertain about the effect of multisensory stimulation on CP (RR 0.67, 95% CI 0.28 to 1.58; I² not applicable; 1 study, 18 participants; very low‐certainty evidence). The evidence suggests that multisensory stimulation may result in little to no difference in death during initial hospitalization (RR 0.97, 95% CI 0.54 to 1.73; I² not applicable; 1 study, 395 participants; low‐certainty evidence). Multisensory stimulation may increase total weight gain prior to discharge (MD 72.67, 95% CI 68.23 to 77.12; I² = 0%; 3 studies, 474 participants; low‐certainty evidence). Multisensory stimulation compared to single‐sense (tactile) stimulation No studies reported on major neurodevelopmental disability, assessed at 18 to 24 months' CA, or death during initial hospitalization. The evidence is very uncertain about the effect of multisensory stimulation compared to tactile stimulation on weight gain during the intervention (MD −175.00, 95% CI −376.60 to 26.60; I² not applicable; 1 study, 20 participants; very low‐certainty evidence). The certainty of the evidence was low to very low across outcomes, primarily due to risk of bias, imprecision from small sample sizes and wide CIs, and in some cases, inconsistency. The evidence base was also limited by the lack of reporting of relevant outcomes and reliance on surrogate outcomes or shorter follow‐up periods. Authors' conclusions The available evidence on multisensory stimulation in preterm infants is limited and of low to very low certainty. No included studies reported on major neurodevelopmental disabilities at 18 to 24 months’ CA, which represented a critical outcome for this review. Evidence regarding the effect of multisensory stimulation on CP is very uncertain, as it is based on a single small study reporting a surrogate outcome at 12 months. Multisensory stimulation may result in little to no difference in mortality during the initial hospitalization. It may increase total weight gain prior to discharge. However, the clinical significance of this finding is uncertain, particularly given the low certainty of the evidence and the multifactorial nature of growth in preterm infants. The evidence is very uncertain about the effect of multisensory stimulation compared to single‐sense (tactile) stimulation on weight gain during the intervention. The only included study did not report major neurodevelopmental disabilities at 18 to 24 months’ CA, mortality during the initial hospitalization, or total weight gain prior to discharge, which represented the critical outcomes for this review. Overall, the current evidence does not allow firm conclusions about the effectiveness of multisensory stimulation in promoting development or preventing morbidity in preterm infants. Future studies on multisensory stimulation should use more rigorous designs, larger samples, and report interventions using the template for intervention description and replication (TIDieR) checklist to ensure transparency. They should also report essential outcomes, such as neonatal death, major neurodevelopmental disabilities, length of hospital and NICU stay, time to full oral feeding, duration of respiratory support, and weight gain, to better assess the long‑term effects of multisensory stimulation in preterm infants. Funding This Cochrane review had no dedicated funding . Registration Protocol available via DOI: 10.1002/14651858.CD016073 Plain language summary Does stimulating multiple senses (such as hearing, touch, taste, smell) of premature babies improve growth and healthy development or reduce the risk of death? Key messages Multisensory stimulation (the stimulation of more than one sense at a time) may support growth in preterm infants by increasing weight gain before discharge from the hospital. However, it is unclear whether it improves longer‐term developmental outcomes or reduces the risk of death, as the available evidence is limited and uncertain. When compared with stimulation of a single sense (touch alone), it is uncertain whether multisensory stimulation is better than touch alone at increasing weight gain during the intervention. What is multisensory stimulation, and how does it work? Multisensory stimulation means giving premature babies experiences that activate two or more of their senses. The senses involved and the types of stimulation used include the sense of: hearing — a parent’s voice, singing, or calming music; touch — massage or passive movements; smell and taste — a mother’s scent or breast milk; balance — gentle rocking or changing the baby's position; sight — soft, cycled lighting and simple shapes, colors, or moving patterns. During the newborn period, the brain grows very quickly. Providing positive sensory experiences at this time may help premature babies in several ways, such as supporting their memory, helping them regulate emotions, and improving early learning and development. What did we want to find out? We wanted to find out whether multisensory stimulation compared with single‑sense stimulation or standard care helps premature babies survive, grow, stay healthy, and develop well. Specifically, we wanted to find out whether multisensory stimulation might: reduce the number of babies with severe developmental problems at 18 to 24 months' age, such as cerebral palsy, delay in development, limitations in mental abilities, blindness, or deafness; reduce the number of babies who die during the newborn period or before hospital discharge; increase the amount of weight the infants gained by the time they left the hospital. We also looked at other important measures of the babies’ health, including: how long they stayed in the hospital or in the neonatal intensive care unit (NICU); how long it took before they could feed fully by mouth; how many days they needed breathing support. What did we do? We searched for studies in which multisensory stimulation began before the baby was discharged from the hospital after birth, and which compared multisensory stimulation with: no intervention or standard care; single‐sense stimulation. We summarized the results of the studies and rated our confidence in the evidence, based on factors, such as the size of the study (number of babies enrolled) and the methods used. What did we find? We included 19 studies (1544 premature babies). Eighteen of these studies compared multisensory stimulation with standard care, and one study compared multisensory stimulation with a single‑sense intervention (touch only). In 10 studies, the main goal was to examine how multisensory stimulation affects babies’ brain and behavioral development. The remaining nine studies focused on weight gain during the intervention, weight gain prior to hospital discharge, length of stay in the NICU, total length of hospital stay, time until the baby could feed fully by mouth, number of days the baby needed breathing support, or a combination of these measures. We also found 13 ongoing studies and 4 studies that have not yet been fully assessed. They may give us more useful information in the future. Main results None of the studies that compared multisensory stimulation with no intervention reported on the critical outcome major developmental disability at 18 to 24 months' corrected age. Only one study assessed a related outcome, cerebral palsy at 12 months. Because this study was very small, the evidence is very uncertain about whether multisensory stimulation modifies the risk of cerebral palsy. Multisensory stimulation may result in little or no difference in death before hospital discharge, although it was reported in only one large study. It may increase total weight gain prior to discharge, but the observed effect is small, and its clinical significance remains uncertain. Compared with single‐sense stimulation (touch), we could not tell whether multisensory stimulation helped babies gain more weight during the intervention. The only study we found comparing a multi‐ to single‐sensory intervention did not report the critical outcomes, such as major developmental problems at 18 to 24 months' corrected age, death during the first hospital stay, or total weight gain prior to discharge. What are the limitations of the evidence? We have limited confidence in these findings because many of the studies were small or not well‐designed. Several studies did not report the outcomes we were most interested in or did not provide enough data for us to analyze. Because of these limitations, the true effects of multisensory stimulation may be different from what we found. How up‐to‐date is this evidence? The evidence is up‐to‐date to 28 November 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Wróblewska-Seniuk, K; Lenells, M; Prescott, MG; Fiander, M; Soll, RF; Bruschettini, M; supported by Cochrane Sweden and Cochrane Neonatal,", "articleTypes": [], "doi": "10.1002/14651858.CD016073.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "a7b42fe2-81f8-4c28-a5f0-caba5377763b", "pmid": "", "title": "Evaluation of the Efficacy of Serotoninergic Antidepressants in Bulimia Nervosa, According to Brain Serotonin Profile Determined by Positron Emission Tomography With [18F] MPPF - a Multicenter Study", "imported": false, "abstract": "Bulimia nervosa (BN) is a serious mental illness characterized by massive food crises followed by anxiety and compensatory behaviours (vomiting more often). Recent data show an increasing prevalence and a serious prognosis, due to excess mortality by suicide but also somatic complications.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.266Z" }, { "id": "a7cccafb-463b-4f6c-8eb9-0513ccf904b3", "pmid": "", "title": "Supplementation with multiple micronutrients for breastfeeding women for improving outcomes for the mother and baby", "imported": false, "abstract": "Abstract - Background Globally, more than two billion people are estimated to be deficient in key vitamins and minerals, particularly iodine, iron and zinc. The majority of these people live in low‐income settings and are typically deficient in more than one micronutrient. However, micronutrient deficiency among breastfeeding mothers and their infants also remains an issue in high‐income settings, specifically among women who avoid meat and/or milk, women who may lack sufficient supplies of vitamin B12 and vitamin D, and/or women who are iron‐deficient. Young children, pregnant and lactating women are particularly vulnerable to micronutrient deficiencies. They not only have a relatively greater need for vitamins and minerals because of their physiological state, but are also more susceptible to the harmful consequences of deficiencies. Multiple‐micronutrient supplementation might be an option to solve these problems. Objectives The objective of this review was to evaluate the effects of multiple‐micronutrient supplementation in breastfeeding mothers on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. Selection criteria Randomised controlled trials of multiple‐micronutrient supplementation of three or more micronutrients versus placebo, no supplementation or supplementation with two or fewer micronutrients, irrespective of dosage of micronutrients, in breastfeeding mothers. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We found no studies that compared multiple‐micronutrient supplementation (with three or more micronutrients) versus supplementation with two or fewer micronutrients. Two small studies (involving a total of 52 women) were included. One study compared multiple micronutrients with placebo and the other study compared multiple micronutrients with a group who received no supplementation. The studies were carried out in Brazil (36 adolescent mothers) and the USA (16 women) and included women with a low socioeconomic status. A lack of information in the study reports meant that risk of bias could not be adequately assessed (unclear risk of bias for many domains). There were no quantitative data for any of this review's outcomes so meta‐analysis was not possible. Neither of the studies reported on the primary outcomes of interest in this review: maternal morbidity (febrile illness, respiratory tract infection, diarrhoea) , adverse effects of micronutrients within three days of receiving the supplement , infant mortality (defined as a child dying before completing the first year of age) . One study reported qualitatively on maternal anaemia (a secondary outcome of this review) ‐ the study found that multiple‐micronutrient supplementation was effective for recuperating from anaemia but there were no data for inclusion in our analyses. Maternal satisfaction was not reported in the included studies. Similarly, none of this review's infant secondary outcomes were reported in the included studies: clinical micronutrient deficiency ; morbidity episodes (febrile illness, respiratory tract infection, diarrhoea, other) , adverse effects of micronutrients within three days of receiving the supplement . Authors' conclusions We found no evidence to quantitatively assess the effectiveness of multiple‐micronutrient supplementation in improving health outcomes in mother and baby. The results of this review are limited by the small numbers of studies available, small sample sizes and the studies not reporting on the outcomes of interest in this review. There is no evidence to evaluate potential adverse effects of multiple‐micronutrient supplements, particularly excess dosages. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Further research should focus on whether multiple‐micronutrient supplementation during lactation compared with none, a placebo or supplementation with fewer than two micronutrients is beneficial to maternal and infant health outcomes. Future studies should collect data on outcomes beyond micronutrient concentrations, for example: maternal and infant morbidity, adverse effects, maternal satisfaction, the risks of excess supplementation, and potential adverse interactions between the micronutrients and the other outcomes. This would help to bridge the gap between research on intermediary outcomes and health outcomes in order to develop sound policy in this field. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these affect maternal and infant health outcomes. Larger studies with longer follow‐up would improve the quality of studies and provide stronger evidence. In most of the included studies, bias could not be adequately assessed due to lack of information, therefore attention should be given to adequate methods of randomisation and allocation concealment, adequate methods of blinding of the participants, providers and the outcome assessors to improve the methodological quality of studies in this field. Plain language summary Multiple micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby The benefits and risks of multiple‐micronutrient supplementation during lactation are not clear from randomised controlled studies. Key vitamins and minerals, particularly iodine, iron and zinc, are required in small amounts to ensure normal body metabolism, physical growth and development. Nutrient deficiency affects nearly one third of the world’s population, especially in low‐ and middle‐income countries. Breastfeeding mothers need higher levels than usual in order to provide sufficient vitamins and minerals for their own health and that of their babies, particularly for normal functioning and the growth and development of the baby. Previous studies have assessed supplementation of individual micronutrients. This review looked at the use of multiple‐micronutrient supplements for breastfeeding women for improving outcomes for the mother and her baby. We searched for studies on 30 September 2015 and identified two small studies (involving 52 women) for inclusion in this review. The studies were carried out in Brazil and the USA and included women who had a low socioeconomic status. The studies were poorly reported and this lack of information made it difficult to determine whether the studies were at risk of bias. Neither of the studies provided data for any of this review's important outcomes: maternal illness (fever, respiratory infection, diarrhoea), adverse effects of micronutrients within three days of taking them, infant death (defined as a child dying before reaching one year of age). Similarly, there were no data for any of the other outcomes that we were interested in. For the mother, these outcomes were maternal anaemia, and women's satisfaction. For the baby, these outcomes were micronutrient deficiency; illness episodes (fever, respiratory infection, diarrhoea, other), adverse effects of micronutrients within three days of the woman receiving the supplement. However, one of the included studies reported that multiple‐micronutrient supplementation was effective for lactating women recuperating from anaemia. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Larger studies with longer‐term follow‐up would improve the quality of studies and provide stronger evidence. Further research should focus on whether multiple‐micronutrient supplementation during lactation (compared with no supplementation, a placebo or supplementation with fewer than two micronutrients) is beneficial to the mother and her baby and any associated adverse effects of the intervention. Futher studies should report on important outcomes such as those listed in this review and consider the risks of excess supplementation. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these effect outcomes for the mother and her baby.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Abe, SK, Balogun, OO, Ota, E, Takahashi, K, Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD010647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.762Z" }, { "id": "a7e8df70-3e0d-4abc-9b7f-ac6093068582", "pmid": "", "title": "Nirmatrelvir combined with ritonavir for preventing and treating COVID‐19", "imported": false, "abstract": "Abstract - Background Oral nirmatrelvir/ritonavir (Paxlovid) aims to avoid severe COVID‐19 in asymptomatic people or those with mild symptoms, thereby decreasing hospitalization and death. It remains to be evaluated for which indications and patient populations the drug is suitable. Objectives To assess the efficacy and safety of nirmatrelvir/ritonavir plus standard of care (SoC) compared to SoC with or without placebo, or any other intervention for treating COVID‐19 or preventing SARS‐CoV‐2 infection. To explore equity aspects in subgroup analyses. To keep up to date with the evolving evidence base using a living systematic review (LSR) approach and make new relevant studies available to readers in‐between publication of review updates. Search methods We searched the Cochrane COVID‐19 Study Register, Scopus, and World Health Organization COVID‐19 Research Database, identifying completed and ongoing studies without language restrictions and incorporating studies up to 15 May 2023. This is a LSR. We conduct update searches every two months and make them publicly available on the open science framework (OSF) platform. Selection criteria We included randomized controlled trials (RCTs) comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo, or any other intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. We screened all studies for research integrity. Studies were ineligible if they had been retracted, or if they were not prospectively registered including appropriate ethics approval. Data collection and analysis We followed standard Cochrane methodology and used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the following outcomes: 1. to treat outpatients with mild COVID‐19; 2. to treat inpatients with moderate to severe COVID‐19: mortality, clinical worsening or improvement, quality of life, (serious) adverse events, and viral clearance; 3. to prevent SARS‐CoV‐2 infection in postexposure prophylaxis (PEP); and 4. pre‐exposure prophylaxis (PrEP) scenarios: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, mortality, admission to hospital, quality of life, and (serious) adverse events. We explored inequity by subgroup analysis for elderly people, socially‐disadvantaged people with comorbidities, populations from low‐income countries and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. Main results As of 15 May 2023, we included two RCTs with 2510 participants with mild and mild to moderate symptomatic COVID‐19 in outpatient and inpatient settings comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo. All trial participants were without previous confirmed SARS‐CoV‐2 infection and at high risk for progression to severe disease. Randomization coincided with the Delta wave for outpatients and Omicron wave for inpatients. Outpatient trial participants and 73% of inpatients were unvaccinated. Symptom onset in outpatients was no more than five days before randomisation and prior or concomitant therapies including medications highly dependent on CYP3A4 were not allowed. We excluded two studies due to concerns with research integrity. We identified 13 ongoing studies. Three studies are currently awaiting classification. Nirmatrelvir/ritonavir for treating people with asymptomatic or mild COVID‐19 in outpatient settings Nirmatrelvir/ritonavir plus SoC compared to SoC plus placebo may reduce all‐cause mortality at 28 days (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.68; 1 study, 2224 participants; low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.13, 95% CI 0.07 to 0.27; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC may reduce serious adverse events during the study period compared to SoC plus placebo (RR 0.24, 95% CI 0.15 to 0.41; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably has little or no effect on treatment‐emergent adverse events (RR 0.95, 95% CI 0.82 to 1.10; 1 study, 2224 participants; moderate‐certainty evidence), and probably increases treatment‐related adverse events such as dysgeusia and diarrhoea during the study period compared to SoC plus placebo (RR 2.06, 95% CI 1.44 to 2.95; 1 study, 2224 participants; moderate‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably decreases discontinuation of study drug due to adverse events compared to SoC plus placebo (RR 0.49, 95% CI 0.30 to 0.80; 1 study, 2224 participants; moderate‐certainty evidence). No studies reported improvement of clinical status, quality of life, or viral clearance. Nirmatrelvir/ritonavir for treating people with moderate to severe COVID‐19 in inpatient settings We are uncertain whether nirmatrelvir/ritonavir plus SoC compared to SoC reduces all‐cause mortality at 28 days (RR 0.63, 95% CI 0.21 to 1.86; 1 study, 264 participants; very low‐certainty evidence), or increases viral clearance at seven days (RR 1.06, 95% CI 0.71 to 1.58; 1 study, 264 participants; very low‐certainty evidence) and 14 days (RR 1.05, 95% CI 0.92 to 1.20; 1 study, 264 participants; very low‐certainty evidence). No studies reported improvement or worsening of clinical status and quality of life. We did not include data for safety outcomes due to insufficient and inconsistent information. Subgroup analyses for equity For outpatients, the outcome 'admission to hospital or death' was investigated for equity regarding age (less than 65 years versus 65 years or greater) and ethnicity. There were no subgroup differences for age or ethnicity. For inpatients, the outcome 'all‐cause mortality' was investigated for equity regarding age (65 years or less versus greater than 65 years). There was no difference between subgroups of age. No further equity‐related subgroups were reported, and no subgroups were reported for other outcomes. Nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection (PrEP and PEP) No studies available. Authors' conclusions Low‐certainty evidence suggests nirmatrelvir/ritonavir reduces the risk of all‐cause mortality and hospital admission or death in high‐risk, unvaccinated COVID‐19 outpatients infected with the Delta variant of SARS‐CoV‐2. There is low‐ to moderate‐certainty evidence of the safety of nirmatrelvir/ritonavir. Very low‐certainty evidence exists regarding the effects of nirmatrelvir/ritonavir on all‐cause mortality and viral clearance in mildly to moderately affected, mostly unvaccinated COVID‐19 inpatients infected with the Omicron variant of SARS‐CoV‐2. Insufficient and inconsistent information prevents the assessment of safety outcomes. No reliable differences in effect size and direction were found regarding equity aspects. There is no available evidence supporting the use of nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection. We are continually updating our search and making search results available on the OSF platform. Plain language summary Is the combination of nirmatrelvir plus ritonavir effective for treating or preventing COVID‐19? Key messages Nirmatrelvir/ritonavir (Paxlovid) is evaluated for the treatment of coronavirus disease 2019 (COVID‐19). Nirmatrelvir/ritonavir may lead to fewer deaths and improve patient condition, as assessed by need for hospitalization or death within 28 days for unvaccinated outpatients at increased risk for disease progression receiving treatment within five days of symptom onset. We are very uncertain about the effectiveness of nirmatrelvir/ritonavir in inpatients. We excluded two studies due to concerns with research integrity. We found 13 ongoing studies. What is nirmatrelvir/ritonavir? The combination of nirmatrelvir with ritonavir is a new medicine developed to treat infection with the SARS‐CoV‐2 virus and aims to avoid severe COVID‐19 in people without symptoms, or those with mild symptoms. Ritonavir increases the effectiveness of nirmatrelvir but it can interact with many other medicines, which can increase side effects. What did we want to find out? We wanted to know if nirmatrelvir/ritonavir reduces death, illness, and length of infection in people with COVID‐19, or if it is useful in prevention of the disease. We included studies comparing the medicine with placebo (dummy treatment), no treatment, usual care, or any other treatments for COVID‐19. We addressed equity and wanted to know whether there are certain groups of people for which nirmatrelvir/ritonavir works best or is less effective. We looked at elderly people, socially disadvantaged people with other illnesses (comorbidities), people from low‐income and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. We evaluated the effects of nirmatrelvir/ritonavir in people with COVID‐19 regarding: – people dying; – whether COVID‐19 symptoms got better or worse; – quality of life; – unwanted effects of the medicine; – virus elimination. For prevention, we sought the effect on preventing COVID‐19 and SARS‐CoV‐2 infection. What did we do? We searched for randomized controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that investigated nirmatrelvir/ritonavir to prevent or treat COVID‐19. People receiving nirmatrelvir/ritonavir as treatment had to have laboratory‐confirmed COVID‐19 and be treated in hospital or as outpatients. People receiving nirmatrelvir/ritonavir to prevent an infection had to have a high risk of contracting the disease or had to have had a high‐risk contact with a person with confirmed COVID‐19. We summarized the results of the studies and rated our confidence in the evidence, based on common criteria as to how reliable the evidence was. We examined differences with respect to age, level of comorbidity, country according to the World Bank country classification by income level, and ethnicity. What did we find? We found two studies with 2510 participants that investigated nirmatrelvir/ritonavir compared to placebo or standard of care for the treatment of COVID‐19 in people without previous confirmed SARS‐CoV‐2 infection and at increased risk for progression to severe disease due to a comorbidity or risk factor such as current smoking. Included outpatients were enrolled during the Delta wave, unvaccinated, and had a symptom onset of up to five days before starting treatment. Included inpatients were enrolled during the Omicron wave, mostly unvaccinated, and mildly to moderately affected. We found 13 ongoing studies that have not yet been completed, and three studies are currently awaiting classification. Main results Treating outpatients with COVID‐19 For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir may: – lead to fewer deaths; – improve patients' condition assessed by need for admission to hospital or death within 28 days; – reduce serious unwanted events. For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir probably: – has little effect on any unwanted events; – increases any treatment‐related unwanted events (mostly taste disturbance and diarrhoea); – decreases discontinuation of study medicine due to unwanted events. Equity aspects Most study participants were younger than 65 years and of white ethnicity. There was no difference in effectiveness between younger and older participants and participants from different ethnic groups. No subgroups were reported for different levels of comorbidity and World Bank country classification by income level. Treating inpatients with COVID‐19 We are uncertain whether, for the specific population of mildly to moderately affected, high‐risk patients, nirmatrelvir/ritonavir: – leads to fewer deaths; and – increases virus elimination Equity aspects Most study participants were older than 65 years. There was no difference in effectiveness between younger and older participants. No subgroups were reported for different levels of comorbidity, ethnicity, and World Bank country classification by income level. No subgroups were reported for other outcomes. What are the limitations of the evidence? Our confidence in the evidence is low to moderate for outpatients and very low for inpatients. The studies did not report everything we were interested in, such as quality of life and symptom resolution, and had a highly specific population of people at high risk of progression to severe COVID‐19. How up to date is this evidence? The evidence is up to date to 15 May 2023. According to this review's living approach, we will update our search every two months. We are making search results and new relevant studies publicly available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Reis, S, Metzendorf, M-I, Kuehn, R, Popp, M, Gagyor, I, Kranke, P, Meybohm, P, Skoetz, N, Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015395.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.820Z" }, { "id": "a7f34148-f3c1-4514-bb10-4299b6a1297a", "pmid": "", "title": "Sucrose for analgesia in newborn infants undergoing painful procedures", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose with and without non‐nutritive sucking is the most frequently studied non‐pharmacological intervention for procedural pain relief in neonates. Objectives To determine the efficacy, effect of dose, method of administration and safety of sucrose for relieving procedural pain in neonates as assessed by validated composite pain scores, physiological pain indicators (heart rate, respiratory rate, saturation of peripheral oxygen in the blood, transcutaneous oxygen and carbon dioxide (gas exchange measured across the skin ‐ TcpO 2 , TcpCO 2 ), n ear i nfra r ed s pectroscopy (NIRS), e lectro e ncephalo g ram (EEG), or behavioural pain indicators (cry duration, proportion of time crying, proportion of time facial actions (e.g. grimace) are present), or a combination of these and long‐term neurodevelopmental outcomes. Search methods We used the standard methods of the Cochrane Neonatal. We performed electronic and manual literature searches in February 2016 for published randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library , Issue 1, 2016), MEDLINE (1950 to 2016), EMBASE (1980 to 2016), and CINAHL (1982 to 2016) . We did not impose language restrictions. Selection criteria RCTs in which term or preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age), or both, received sucrose for procedural pain. Control interventions included no treatment, water, glucose, breast milk, breastfeeding, local anaesthetic, pacifier, positioning/containing or acupuncture. Data collection and analysis Our main outcome measures were composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We reported a mean difference (MD) or weighted MD (WMD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. For categorical data we used risk ratio (RR) and risk difference. We assessed heterogeneity by the I 2 test. We assessed the risk of bias of included trials using the Cochrane 'Risk of bias' tool, and assessed the quality of the evidence using the GRADE system. Main results Seventy‐four studies enrolling 7049 infants were included. Results from only a few studies could be combined in meta‐analyses and for most analyses the GRADE assessments indicated low‐ or moderate‐quality evidence. There was high‐quality evidence for the beneficial effect of sucrose (24%) with non‐nutritive sucking (pacifier dipped in sucrose) or 0.5 mL of sucrose orally in preterm and term infants: Premature Infant Pain Profile (PIPP) 30 s after heel lance WMD ‐1.70 (95% CI ‐2.13 to ‐1.26; I 2 = 0% (no heterogeneity); 3 studies, n = 278); PIPP 60 s after heel lance WMD ‐2.14 (95% CI ‐3.34 to ‐0.94; I 2 = 0% (no heterogeneity; 2 studies, n = 164). There was high‐quality evidence for the use of 2 mL 24% sucrose prior to venipuncture: PIPP during venipuncture WMD ‐2.79 (95% CI ‐3.76 to ‐1.83; I 2 = 0% (no heterogeneity; 2 groups in 1 study, n = 213); and intramuscular injections: PIPP during intramuscular injection WMD ‐1.05 (95% CI ‐1.98 to ‐0.12; I 2 = 0% (2 groups in 1 study, n = 232). Evidence from studies that could not be included in RevMan‐analyses supported these findings. Reported adverse effects were minor and similar in the sucrose and control groups. Sucrose is not effective in reducing pain from circumcision. The effectiveness of sucrose for reducing pain/stress from other interventions such as arterial puncture, subcutaneous injection, insertion of nasogastric or orogastric tubes, bladder catherization, eye examinations and echocardiography examinations are inconclusive. Most trials indicated some benefit of sucrose use but that the evidence for other painful procedures is of lower quality as it is based on few studies of small sample sizes. The effects of sucrose on long‐term neurodevelopmental outcomes are unknown. Authors' conclusions Sucrose is effective for reducing procedural pain from single events such as heel lance, venipuncture and intramuscular injection in both preterm and term infants. No serious side effects or harms have been documented with this intervention. We could not identify an optimal dose due to inconsistency in effective sucrose dosage among studies. Further investigation of repeated administration of sucrose in neonates is needed. There is some moderate‐quality evidence that sucrose in combination with other non‐pharmacological interventions such as non‐nutritive sucking is more effective than sucrose alone, but more research of this and sucrose in combination with pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing painful procedures Review question Cochrane reviewers investigated how well sucrose (table sugar) works as a reliever of pain in newborn babies who are having painful procedures (e.g. an injection, or heel lance, or insertion of a needle to obtain a blood sample (venipuncture), or eye examinations). The babies' pain responses (e.g. crying, grimacing) were assessed by scoring systems for pain used by health care professionals to measure the pain that babies are experiencing. In addition, the reviewers wanted to investigate whether the level of pain relief is related to the dose of sucrose, or the method of delivery (e.g. as a solution squirted into the mouth, or on a pacifier (also called a soother or dummy), and whether there are any safety concerns about using sucrose to relieve pain. Background Although there are ways to manage the pain of surgery, medical illness and major procedures, ways of preventing or reducing pain from minor medical procedures (e.g. heel lance and venipuncture) have, until relatively recently, been lacking. Sucrose has been examined for its calming effects in crying newborns and its pain‐relieving effects for invasive procedures in full‐term and premature newborns. Study characteristics We searched the medical literature widely up to February 2016 for studies that investigated the pain‐relieving effect of sucrose for minor medical procedures in newborn full‐term and premature babies. We included randomised controlled trials only, as these provide the most reliable medical evidence. We identified 74 studies that reported on a total of more than 7000 infants in this Cochrane Review. Thirty‐eight studies included full‐term babies only, 31 included premature babies only, and five included both full‐term and premature babies. Heel lance was the painful procedure in 38 studies, and venipuncture in nine; the remaining studies investigated a wide variety of other minor painful procedures. The studies used a variety of delivery methods for the sucrose solution (oral syringe, dropper or sucrose‐dipped pacifier), as well as a range of concentrations and volumes of dose. Sucrose treatment was compared with giving the babies a similar volume of water, a pacifier, routine care, breastfeeding, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), laser acupuncture, swaddling, warmth, anaesthetic cream for the skin (EMLA), or a combination of these. The studies used a range of pain assessment scales to measure their results. Study funding sources We did not identify any studies that received funding from the industry. Key results There was high‐quality evidence that sucrose reduces different measures of newborn pain during heel lance, venipuncture and intramuscular injection. However, sucrose does not provide effective pain relief during circumcision. There is conflicting evidence for whether sucrose reduces pain for other minor painful procedures and further research is needed to investigate these more thoroughly. Twenty‐nine studies reported on adverse events (harms of the sucrose and other treatments) and found that the number of minor adverse events (e.g. choking or gagging) was very low, and was similar in the different groups (so not attributable to the sucrose treatment). No major adverse events were reported. Quality of evidence Although sucrose has been widely studied as a pain reliever for newborn babies, most studies have included few babies and have used many different measures of pain to assess its effectiveness. We identified high‐quality evidence that sucrose reduces pain for heel lance, venipuncture and intramuscular injection. The quality of evidence was low or moderate in favour for the use of sucrose for other painful procedures.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stevens, B; Yamada, J; Ohlsson, A; Haliburton, S; Shorkey, A", "articleTypes": [], "doi": "10.1002/14651858.CD001069.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "a803f39a-e8f2-4375-87ad-27259ca67eb8", "pmid": "", "title": "Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants", "imported": false, "abstract": "Abstract - Background It is important to institute an effective supportive therapy to maintain or recover soft tissue health around dental implants. Different maintenance regimens have been suggested, however it is unclear which are the most effective. Objectives To assess the effects of different interventions for 1) maintaining and 2) recovering soft tissue health around osseointegrated dental implants. Search methods We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and to an Internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 2 June 2010. Selection criteria All randomised controlled trials comparing agents or interventions for maintaining or recovering healthy tissues around dental implants. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random‐effects models using standardised mean differences for continuous data and risk ratios for dichotomous data with 95% confidence intervals. Main results Five trials compared interventions for maintaining soft tissue health around implants and a further six trials compared interventions to recover soft tissue health where there was evidence of peri‐implant mucositis. No statistically significant differences were found between the effectiveness of powered versus manual toothbrushes for either maintaining or recovering soft tissue health. There was no statistically significant difference found between different types of self administered antimicrobials for maintaining soft tissue health (hyaluronic acid gel compared to chlorhexidine gel, amine fluoride/stannous fluoride mouthwash compared to chlorhexidine mouthwash) and triclosan dentifrice compared to sodium fluoride dentifrice showed no statistically significant difference in recovering soft tissue health. However chlorhexidine irrigation was more effective in reducing plaque and marginal bleeding scores compared to chlorhexidine mouthwash and Listerine mouthwash was found to be statistically significantly better than placebo with regard to reducing mean plaque scores and marginal bleeding scores. When interventions administered by dental professional were compared there was no statistically significant difference found between chlorhexidine and physiologic solutions as irrigants at second stage surgery to maintain health of soft tissues. In patients with peri‐implant mucositis two trials evaluated interventions performed by dental professionals. There was no statistically significant difference between mechanical debridement followed by either minocycline or chlorhexidine gel, or between debridement with a titanium curette compared to an ultrasonic debridement tool. Authors' conclusions There was only low quality evidence for which are the most effective interventions for maintaining or recovering health of peri‐implant soft tissues. The included RCTs had short follow‐up periods and few subjects and although overall the risk of bias of the studies was either low or unclear, only single trials were available for each outcome. There was no reliable evidence as to which regimens are most effective for long term maintenance. This should not be interpreted as meaning that current maintenance regimens are ineffective. There was weak evidence that antibacterial mouthrinses are effective in reducing plaque and marginal bleeding around implants. More RCTs should be conducted in this area. In particular, there is a definite need for trials powered to find possible differences, using primary outcome measures and with much longer follow up. Such trials should be reported according to the CONSORT guidelines ( www.consort‐statement.org/ ). Plain language summary Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants Missing teeth can be replaced by dental implants. However, keeping the gums around the implants healthy is important, as they can be negatively affected by dental plaque and its induced inflammation. Prevention of this may include daily implant cleaning techniques by patients and regular cleaning by dental professionals. Antibacterial mouthrinses may help reduce plaque and bleeding around dental implants, but there is no evidence that powered toothbrushes are better than manual toothbrushes or that brushing with a certain gel or dentifrice is better than another. Among the professionally administered treatments there is no evidence that phosphoric acid is more effective than scaling and polishing, that chlorhexidine enclosed in the inner part of implants is superior to physiologic solution or that a topical antibiotic inserted submucosally is better than a chlorhexidine gel.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Grusovin, MG; Coulthard, P; Worthington, HV; George, P; Esposito, M", "articleTypes": [], "doi": "10.1002/14651858.CD003069.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "a8064d5b-159c-473f-9242-48c412a39af7", "pmid": "", "title": "Chinese medicinal herbs for mumps", "imported": false, "abstract": "Abstract - Background Mumps is an infectious disease caused by the mumps virus. Chinese physicians generally believe that Chinese medicinal herbs are effective in alleviating symptoms and reducing the duration of mumps. Herbalists tend to develop a treatment plan according to the individual's symptoms. Objectives To evaluate the effectiveness and safety of Chinese medicinal herbs combined with routine treatments for mumps. Search methods We searched CENTRAL (2015, Issue 1), MEDLINE (1948 to January week 4, 2015), EMBASE (1974 to February 2015), CINAHL (1981 to February 2015), AMED (1985 to April 2014), the Chinese Biomedical Database (CBM) (1980 to February 2015), China National Knowledge Infrastructure (CNKI) (1979 to February 2015), VIP Information (1989 to February 2015), and relevant databases of ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs for mumps (with or without complications). Data collection and analysis Two review authors independently evaluated trial quality and conducted data extraction. We contacted the trial authors for missing data regarding participant allocation. Some trials allocated participants according to the participants' admission sequence, making it a pseudo‐random allocation. None of the trials concealed participants' allocation or used blinding. Main results We did not identify any eligible trials for inclusion. We identified 108 studies that claimed to use random allocation. We excluded 104 studies because the allocation methods the authors had used were not actually randomised. We were unable to contact the trial authors of the remaining four studies. These trials require further evaluation and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions We did not find any RCTs for or against Chinese herbal medicine used in the treatment of mumps. We hope more high‐quality RCTs will be conducted in the future. Plain language summary Chinese medicinal herbs for mumps Review question 
 We reviewed the evidence about the effect and safety of Chinese medicinal herbs for mumps. Background 
 Mumps (epidemic parotitis) is an infectious illness caused by the multiplication of the mumps virus in the upper respiratory tract. It can range from a mild upper respiratory disease to serious complications. Herbal medicines have been used in traditional Chinese medicine (TCM) as the main therapy to prevent and treat mumps for thousands of years. Many Chinese physicians believe that Chinese medicinal herbs are effective in treating mumps. Study characteristics 
 The evidence is current to February 2015. The review authors did not find any randomised controlled trials (RCTs) to provide reliable evidence for the effectiveness and safety of Chinese medicinal herbs for mumps. Although no trials were included, we reviewed the studies and found no reports of adverse events with Chinese medicinal herbs as a treatment for mumps. Key results 
 High‐quality trials are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Shu, M; Zhang, YQ; Li, Z; Liu, GJ; Wan, C; Wen, Y", "articleTypes": [], "doi": "10.1002/14651858.CD008578.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "a811993a-aa2c-4015-b30e-b84fd42a41bb", "pmid": "", "title": "Pine bark (Pinus spp.) extract for treating chronic disorders", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Robertson, NU, Schoonees, A, Brand, A, Visser, J", "articleTypes": [], "doi": "10.1002/14651858.CD008294.pub5 AB - Abstract - Background Pine bark ( Pinus spp.) extract is rich in bioflavonoids, predominantly proanthocyanidins, which are antioxidants. Commercially‐available extract supplements are marketed for preventing or treating various chronic conditions associated with oxidative stress. This is an update of a previously published review. Objectives To assess the efficacy and safety of pine bark extract supplements for treating chronic disorders. Search methods We searched three databases and three trial registries; latest search: 30 September 2019. We contacted the manufacturers of pine bark extracts to identify additional studies and hand‐searched bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) evaluating pine bark extract supplements in adults or children with any chronic disorder. Data collection and analysis Two authors independently assessed trial eligibility, extracted data and assessed risk of bias. Where possible, we pooled data in meta‐analyses. We used GRADE to evaluate the certainty of evidence. Primary outcomes were participant‐ and investigator‐reported clinical outcomes directly related to each disorder and all‐cause mortality. We also assessed adverse events and biomarkers of oxidative stress. Main results This review included 27 RCTs (22 parallel and five cross‐over designs; 1641 participants) evaluating pine bark extract supplements across 10 chronic disorders: asthma (two studies; 86 participants); attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), cardiovascular disease (CVD) and risk factors (seven studies; 338 participants), chronic venous insufficiency (CVI) (two studies; 60 participants), diabetes mellitus (DM) (six studies; 339 participants), erectile dysfunction (three studies; 277 participants), female sexual dysfunction (one study; 83 participants), osteoarthritis (three studies; 293 participants), osteopenia (one study; 44 participants) and traumatic brain injury (one study; 60 participants). Two studies exclusively recruited children; the remainder recruited adults. Trials lasted between four weeks and six months. Placebo was the control in 24 studies. Overall risk of bias was low for four, high for one and unclear for 22 studies. In adults with asthma, we do not know whether pine bark extract increases change in forced expiratory volume in one second (FEV 1 ) % predicted/forced vital capacity (FVC) (mean difference (MD) 7.70, 95% confidence interval (CI) 3.19 to 12.21; one study; 44 participants; very low‐certainty evidence), increases change in FEV 1 % predicted (MD 7.00, 95% CI 0.10 to 13.90; one study; 44 participants; very low‐certainty evidence), improves asthma symptoms (risk ratio (RR) 1.85, 95% CI 1.32 to 2.58; one study; 60 participants; very low‐certainty evidence) or increases the number of people able to stop using albuterol inhalers (RR 6.00, 95% CI 1.97 to 18.25; one study; 60 participants; very low‐certainty evidence). In children with ADHD, we do not know whether pine bark extract decreases inattention and hyperactivity assessed by parent‐ and teacher‐rating scales (narrative synthesis; one study; 57 participants; very low‐certainty evidence) or increases the change in visual‐motoric coordination and concentration (MD 3.37, 95% CI 2.41 to 4.33; one study; 57 participants; very low‐certainty evidence). In participants with CVD, we do not know whether pine bark extract decreases diastolic blood pressure (MD ‐3.00 mm Hg, 95% CI ‐4.51 to ‐1.49; one study; 61 participants; very low‐certainty evidence); increases HDL cholesterol (MD 0.05 mmol/L, 95% CI ‐0.01 to 0.11; one study; 61 participants; very low‐certainty evidence) or decreases LDL cholesterol (MD ‐0.03 mmol/L, 95% CI ‐0.05 to 0.00; one study; 61 participants; very low‐certainty evidence). In participants with CVI, we do not know whether pine bark extract decreases pain scores (MD ‐0.59, 95% CI ‐1.02 to ‐0.16; one study; 40 participants; very low‐certainty evidence), increases the disappearance of pain (RR 25.0, 95% CI 1.58 to 395.48; one study; 40 participants; very low‐certainty evidence) or increases physician‐judged treatment efficacy (RR 4.75, 95% CI 1.97 to 11.48; 1 study; 40 participants; very low‐certainty evidence). In type 2 DM, we do not know whether pine bark extract leads to a greater reduction in fasting blood glucose (MD 1.0 mmol/L, 95% CI 0.91 to 1.09; one study; 48 participants;very low‐certainty evidence) or decreases HbA1c (MD ‐0.90 %, 95% CI ‐1.78 to ‐0.02; 1 study; 48 participants; very low‐certainty evidence). In a mixed group of participants with type 1 and type 2 DM we do not know whether pine bark extract decreases HbA1c (MD ‐0.20 %, 95% CI ‐1.83 to 1.43; one study; 67 participants; very low‐certainty evidence). In men with erectile dysfunction, we do not know whether pine bark extract supplements increase International Index of Erectile Function‐5 scores (not pooled; two studies; 147 participants; very low‐certainty evidence). In women with sexual dysfunction, we do not know whether pine bark extract increases satisfaction as measured by the Female Sexual Function Index (MD 5.10, 95% CI 3.49 to 6.71; one study; 75 participants; very low‐certainty evidence) or leads to a greater reduction of pain scores (MD 4.30, 95% CI 2.69 to 5.91; one study; 75 participants; very low‐certainty evidence). In adults with osteoarthritis of the knee, we do not know whether pine bark extract decreases composite Western Ontario and McMaster Universities Osteoarthritis Index scores (MD ‐730.00, 95% CI ‐1011.95 to ‐448.05; one study; 37 participants; very low‐certainty evidence) or the use of non‐steroidal anti‐inflammatory medication (MD ‐18.30, 95% CI ‐25.14 to ‐11.46; one study; 35 participants; very low‐certainty evidence). We do not know whether pine bark extract increases bone alkaline phosphatase in post‐menopausal women with osteopenia (MD 1.16 ug/L, 95% CI ‐2.37 to 4.69; one study; 40 participants; very low‐certainty evidence). In individuals with traumatic brain injury, we do not know whether pine bark extract decreases cognitive failure scores (MD ‐2.24, 95% CI ‐11.17 to 6.69; one study; 56 participants; very low‐certainty evidence) or post‐concussion symptoms (MD ‐0.76, 95% CI ‐5.39 to 3.87; one study; 56 participants; very low‐certainty evidence). For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. Authors' conclusions Small sample sizes, limited numbers of RCTs per condition, variation in outcome measures, and poor reporting of the included RCTs mean no definitive conclusions regarding the efficacy or safety of pine bark extract supplements are possible. Plain language summary Using pine bark supplements to help treat a variety of chronic diseases Review question Can pine bark antioxidant supplements help to treat chronic diseases? Background The main ingredients in pine bark extract supplements are proanthocyanidins, which are antioxidants. These supplements are marketed to prevent or treat a wide range of chronic diseases. This is an update of a previously published review, where we assessed how well these supplements work for treating chronic diseases, as well as their safety. Search date The evidence is current to 30 September 2019. Study characteristics We included 27 studies (1641 participants) across 10 chronic diseases. These included: asthma (two studies; 86 participants), attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), heart disease and risk factors (seven studies; 332 participants), chronic venous insufficiency (leg veins not working effectively; two studies; 60 participants), diabetes (six studies; 336 participants), erectile dysfunction (three studies; 227 participants), female sexual dysfunction (one study; 75 participants), osteoarthritis (cartilage damage in joints; three studies; 293 participants), osteopenia (beginning of bone mass loss; one study; 44 participants) and traumatic brain injury (one study; 56 participants). Two of the studies were conducted exclusively in children; the others were in adults. Studies compared pine bark supplements with placebo (i.e. a dummy supplement) or non‐antioxidant interventions and participants were randomly selected for one treatment or the other. The duration of treatment ranged from four weeks to six months. Key results For most outcomes across the different chronic diseases we only included one study with a small number of participants. In adults with asthma, we do not know whether pine bark extract increases lung function, improves asthma symptoms or increases the number of people able to stop using albuterol inhalers (a specific type of asthma pump).
In children with ADHD, we do not know whether pine bark supplements decrease inattention and hyperactivity (assessed by parents and teachers) or whether it increases co‐ordination and concentration.
In people with heart disease we do not know if pine bark supplements decrease blood pressure and LDL cholesterol (the bad type) or whether it increases HDL cholesterol (the good type).
In adults with chronic venous insufficiency we do not know whether pine bark supplements decrease pain, increase the number of people free of pain, or how well doctors think the treatment works. In people with type 2 diabetes, we do not know whether pine bark supplements improve blood sugar levels or HbA1c levels (the long‐term marker for measuring blood sugar control); we also do not know if pine bark supplements decrease HbA1c in people with type 1 or type 2 diabetes.
In men with erectile dysfunction, we do not know if pine bark supplements increase erectile function. Similarly, in women with sexual dysfunction, we do not know if pine bark supplements increase sexual satisfaction or reduce pain.
In adults with osteoarthritis, it is not clear if pine bark supplements improve pain, swelling or stiffness in the knee, or whether it decreases the use of anti‐inflammatory drugs. We also do not know if pine bark supplements increase bone formation in postmenopausal women with weakened bones. Lastly, in people with a traumatic brain injury, it is not clear if pine bark supplements improve memory and post‐concussion symptoms . For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. With the available studies, we cannot clearly say how well (or not) pine bark supplements work and whether they are safe. Quality of the evidence The overall risk of bias was low for four studies, high for one and unclear for 22 studies. By this we mean the extent to which the methods used in a study enable it to determine the truth. The certainty of evidence was very low for all outcomes across all chronic diseases in the included studies.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.140Z" }, { "id": "a815cb5f-1a66-4bbe-b8b6-10dfd38b1c8c", "pmid": "", "title": "Pain in Endometriosis And the Relation to Lifestyle: Effectiveness of a Dietary Intervention and Cognitive Behavioral Therapy in Endometriosis-associated Pain", "imported": false, "abstract": "The goal of this clinical trial is to investigate the effect of an anti-inflammatory diet and cognitive behavioral therapy (CBT) on pain symptoms, health related quality of life and the effect on inflammatory characteristics in serum and menstruum samples as well as the effect on the gut and vaginal microbiome in women with endometriosis. In addition, we want to investigate the differences in stress (measured by hair cortisol levels), inflammatory markers in peripheral blood, menstrual effluent, and the vaginal and intestinal microbiome between persons without and with endometriosis. Participants will be randomized between standard care (control group), standard care and an anti-inflammatory diet intervention, or standard care, an anti-inflammatory diet intervention and CBT or CBT alone. Participants will follow an anti-inflammatory diet based on the Dutch Dietary Guidelines or CBT or a combination of both interventions for 12 weeks. They will receive personalized dietary advice from a dietician and recipes will be available. cognitive behavioral therapy will be administered in a total of seven individual sessions led by a psychotherapist. The content of these sessions will be psycho-education regarding pain mechanisms (and diet).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.160Z" }, { "id": "a81cb984-7b4e-4ae0-8608-85536d11dcb0", "pmid": "", "title": "Lamotrigine for chronic neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This is an update of the original Cochrane review entitled Lamotrigine for acute and chronic pain published in Issue 2, 2007, and updated in Issue 2, 2011. Some antiepileptic medicines have a place in the treatment of neuropathic pain (pain due to nerve damage). This updated review adds no new additional studies looking at evidence for lamotrigine as an effective treatment for chronic neuropathic pain or fibromyalgia. The update uses higher standards of evidence than previously. Objectives To assess the analgesic efficacy of lamotrigine in the treatment of chronic neuropathic pain and fibromyalgia, and to evaluate adverse effects reported in the studies. Search methods We identified randomised controlled trials (RCTs) of lamotrigine for chronic neuropathic pain and fibromyalgia (including cancer pain) from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). We ran searches for the original review in 2006, in 2011 for the first update, and subsequent searches in August 2013 for this update. We sought additional studies from the reference lists of the retrieved papers. The original review and first update included acute pain, but no acute pain studies were identified. Selection criteria RCTs investigating the use of lamotrigine (any dose, by any route, and for any study duration) for the treatment of chronic neuropathic pain or fibromyalgia. Assessment of pain intensity or pain relief, or both, using validated scales. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First‐tier studies did not use last observation carried forward (LOCF) or other imputational methods for dropouts. The second tier used data that failed to meet this standard and second‐tier results were therefore subject to potential bias. Main results Twelve included studies in 11 publications (1511 participants), all with chronic neuropathic pain: central post‐stroke pain (1), chemotherapy‐induced neuropathic pain (1), diabetic neuropathy (4), HIV‐related neuropathy (2), mixed neuropathic pain (2), spinal cord injury‐related pain (1), and trigeminal neuralgia (1). We did not identify any additional studies. Participants were aged between 26 and 77 years. Study duration was two weeks in one study and at least six weeks in the remainder; eight were of eight‐week duration or longer. No study provided first‐tier evidence for an efficacy outcome. There was no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of 200 mg to 400 mg daily. Almost 10% of participants taking lamotrigine reported a skin rash. Authors' conclusions Large, high‐quality, long‐duration studies reporting clinically useful levels of pain relief for individual participants provided no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of about 200 to 400 mg daily. Given the availability of more effective treatments including antiepileptics and antidepressant medicines, lamotrigine does not have a significant place in therapy based on the available evidence. The adverse effect profile of lamotrigine is also of concern. Plain language summary Lamotrigine (an antiepileptic drug) for chronic neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our understanding of fibromyalgia (a condition of persistent, widespread pain and tenderness, sleep problems, and fatigue) is lacking, but fibromyalgia can respond to the same medicines as neuropathic pain. Lamotrigine is a medicine used to treat epilepsy, and so might be a useful medicine for neuropathic pain or fibromyalgia. On 26 November 2013 we performed searches to look for clinical trials where lamotrigine was used to treat neuropathic pain or fibromyalgia. We found 12 studies of reasonable quality that tested lamotrigine against placebo for a number of weeks. Almost half of the 1511 people in the studies had painful limbs because of damaged nerves caused by diabetes, and seven different painful neuropathic conditions were examined. No studies looked at fibromyalgia. Lamotrigine did not help the pain, and was no different from placebo except in causing more side effects. Adverse events were more frequent with lamotrigine than placebo, with rash in 1 person in 27.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD006044.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.752Z" }, { "id": "a828b472-5d4f-4d58-8f53-0b3cb19dd092", "pmid": "", "title": "Pharmacological interventions for preventing dry mouth and salivary gland dysfunction following radiotherapy", "imported": false, "abstract": "Abstract - Background Salivary gland dysfunction is an 'umbrella' term for the presence of either xerostomia (subjective sensation of dryness), or salivary gland hypofunction (reduction in saliva production). It is a predictable side effect of radiotherapy to the head and neck region, and is associated with a significant impairment of quality of life. A wide range of pharmacological interventions, with varying mechanisms of action, have been used for the prevention of radiation‐induced salivary gland dysfunction. Objectives To assess the effects of pharmacological interventions for the prevention of radiation‐induced salivary gland dysfunction. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 14 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 14 September 2016); MEDLINE Ovid (1946 to 14 September 2016); Embase Ovid (1980 to 14 September 2016); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 14 September 2016); LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 14 September 2016); Zetoc Conference Proceedings (1993 to 14 September 2016); and OpenGrey (1997 to 14 September 2016). We searched the US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials, irrespective of their language of publication or publication status. Trials included participants of all ages, ethnic origin and gender, scheduled to receive radiotherapy on its own or in addition to chemotherapy to the head and neck region. Participants could be outpatients or inpatients. We included trials comparing any pharmacological agent regimen, prescribed prophylactically for salivary gland dysfunction prior to or during radiotherapy, with placebo, no intervention or an alternative pharmacological intervention. Comparisons of radiation techniques were excluded. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 39 studies that randomised 3520 participants; the number of participants analysed varied by outcome and time point. The studies were ordered into 14 separate comparisons with meta‐analysis only being possible in three of those. We found low‐quality evidence to show that amifostine, when compared to a placebo or no treatment control, might reduce the risk of moderate to severe xerostomia (grade 2 or higher on a 0 to 4 scale) at the end of radiotherapy (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.19 to 0.67; P = 0.001, 3 studies, 119 participants), and up to three months after radiotherapy (RR 0.66, 95% CI 0.48 to 0.92; P = 0.01, 5 studies, 687 participants), but there is insufficient evidence that the effect is sustained up to 12 months after radiotherapy (RR 0.70, 95% CI 0.40 to 1.23; P = 0.21, 7 studies, 682 participants). We found very low‐quality evidence that amifostine increased unstimulated salivary flow rate up to 12 months after radiotherapy, both in terms of mg of saliva per 5 minutes (mean difference (MD) 0.32, 95% CI 0.09 to 0.55; P = 0.006, 1 study, 27 participants), and incidence of producing greater than 0.1 g of saliva over 5 minutes (RR 1.45, 95% CI 1.13 to 1.86; P = 0.004, 1 study, 175 participants). However, there was insufficient evidence to show a difference when looking at stimulated salivary flow rates. There was insufficient (very low‐quality) evidence to show that amifostine compromised the effects of cancer treatment when looking at survival measures. There was some very low‐quality evidence of a small benefit for amifostine in terms of quality of life (10‐point scale) at 12 months after radiotherapy (MD 0.70, 95% CI 0.20 to 1.20; P = 0.006, 1 study, 180 participants), but insufficient evidence at the end of and up to three months postradiotherapy. A further study showed no evidence of a difference at 6, 12, 18 and 24 months postradiotherapy. There was low‐quality evidence that amifostine is associated with increases in: vomiting (RR 4.90, 95% CI 2.87 to 8.38; P < 0.00001, 5 studies, 601 participants); hypotension (RR 9.20, 95% CI 2.84 to 29.83; P = 0.0002, 3 studies, 376 participants); nausea (RR 2.60, 95% CI 1.81 to 3.74; P < 0.00001, 4 studies, 556 participants); and allergic response (RR 7.51, 95% CI 1.40 to 40.39; P = 0.02, 3 studies, 524 participants). We found insufficient evidence (that was of very low quality) to determine whether or not pilocarpine performed better or worse than a placebo or no treatment control for the outcomes: xerostomia, salivary flow rate, survival, and quality of life. There was some low‐quality evidence that pilocarpine was associated with an increase in sweating (RR 2.98, 95% CI 1.43 to 6.22; P = 0.004, 5 studies, 389 participants). We found insufficient evidence to determine whether or not palifermin performed better or worse than placebo for: xerostomia (low quality); survival (moderate quality); and any adverse effects. There was also insufficient evidence to determine the effects of the following interventions: biperiden plus pilocarpine, Chinese medicines, bethanechol, artificial saliva, selenium, antiseptic mouthrinse, antimicrobial lozenge, polaprezinc, azulene rinse, and Venalot Depot (coumarin plus troxerutin). Authors' conclusions There is some low‐quality evidence to suggest that amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months postradiotherapy). However, it is less clear whether or not this effect is sustained to 12 months postradiotherapy. The benefits of amifostine should be weighed against its high cost and side effects. There was insufficient evidence to show that any other intervention is beneficial. Plain language summary Drugs for preventing dry mouth and problems with saliva after radiotherapy Review question To assess the effects of treatment with drugs in order to prevent damage to salivary glands following radiotherapy to the head and neck Background Problems with saliva production and salivary glands are a significant and mostly permanent side effect for people after radiotherapy treatment to the head and neck. When this occurs the condition is known as dry mouth or xerostomia. Dry mouth is not measurable and is a subjective or personal expression of how the mouth feels. It can have other causes and is a consequence of the production of less saliva or by the consistency of saliva. The rate of flow of saliva in an individual's mouth however can be measured. People who have dry mouth have a reduced quality of life. They can experience issues with taste and general discomfort, difficulties chewing, swallowing and speaking as well as tooth decay, thrush and other infections of the mouth. A wide range of drugs that work in different ways have been used to try and prevent problems with salivary glands caused by radiotherapy. Unfortunately there is currently not enough evidence to show which drugs or which type of drugs are most effective. Study characteristics The evidence in this review is current up to 14 September 2016. 39 studies were included with a total of 3520 participants. Participants were male and female, all ages and ethnic origins, out patients or in patients, who were scheduled to have radiation therapy with or without chemotherapy to the head and neck. Drugs included were any prescribed to prevent salivary gland problems and given before or during radiotherapy. Information was collected from the end of radiotherapy except for that about adverse effects. Different techniques for giving radiation treatment that might reduce damage were not included. The main outcomes measured were participant's own assessment of dry mouth and the measurement of salivary flow. Secondary outcomes measured included adverse or unwanted effects such as sweating, crying, watery discharge from the nose, diarrhoea and nausea. Key results There is some low‐quality evidence to suggest that the drug amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short‐ (end of radiotherapy) to medium‐term (three months after radiotherapy). However it is less clear whether or not this effect is sustained to 12 months after radiotherapy. The benefits of amifostine should be weighed against its high costs and side effects. Adverse effects of vomiting, low blood pressure, feeling of sickness and allergic response were all more frequent in those receiving amifostine. There was insufficient evidence to show that any other treatment is beneficial. Quality of the evidence The quality of evidence for amifostine was found to be low because of risk of bias, inconsistency and imprecision caused by the small number of studies in the comparison or sample size. A standardized scale for measuring participant's experience of dry mouth would in future allow comparison and pooling together of results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P, Glenny, AM, Hua, F, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD012744", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.735Z" }, { "id": "a837cb1f-1623-4a47-aace-ae91458aea2e", "pmid": "", "title": "Nebulised hypertonic saline for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Hypertonic saline enhances mucociliary clearance and may lessen the destructive inflammatory process in the airways. This is an update of a previously published review. Objectives To investigate efficacy and tolerability of nebulised hypertonic saline treatment in people with cystic fibrosis (CF) compared to placebo or other treatments that enhance mucociliary clearance. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also searched ongoing trials databases. Most recent search: 25 April 2022. Selection criteria We included randomised and quasi‐randomised controlled trials assessing hypertonic saline compared to placebo or other mucolytic therapy, for any duration or dose regimen in people with CF (any age or disease severity). Data collection and analysis Two authors independently reviewed all identified trials and data, and assessed trial quality. We assessed the certainty of the evidence using GRADE. For cross‐over trials we stipulated a one‐week washout period. We planned to use results from a paired analysis in the review, but this was only possible in one trial. For other cross‐over trials, we chose to treat the trials as if they were parallel. Main results We included 24 trials (1318 participants, aged one month to 56 years); we excluded 29 trials, two trials are ongoing and six are awaiting classification. We judged 15 of the 24 included trials to have a high risk of bias due to participants' ability to discern the taste of the solutions. Hypertonic saline 3% to 7% versus placebo (stable disease) We are uncertain whether the regular use of nebulised hypertonic saline in stable lung disease leads to an improvement in forced expiratory volume in one second (FEV 1 ) % predicted at four weeks, (mean difference (MD) 3.30%, 95% confidence interval (CI) 0.71 to 5.89; 4 trials, 246 participants; very low‐certainty evidence). In preschool children we found no difference in lung clearance index (LCI) at four weeks, but a small improvement after 48 weeks of treatment with hypertonic saline compared to isotonic saline (MD ‐0.60, 95% CI ‐1.00 to ‐0.19; 2 trials, 192 participants). We are also uncertain whether hypertonic saline made a difference to mucociliary clearance, pulmonary exacerbations or adverse events compared to placebo. Hypertonic saline versus control (acute exacerbation) Two trials compared hypertonic saline to control, but only one provided data. There may be little or no difference in lung function measured by FEV 1 % predicted after hypertonic saline compared to isotonic saline (MD 5.10%, 95% CI ‐14.67 to 24.87; 1 trial, 130 participants). Neither trial reported any deaths or measures of sputum clearance. There were no serious adverse events. Hypertonic saline versus rhDNase Three trials compared a similar dose of hypertonic saline to recombinant deoxyribonuclease (rhDNase); two trials (61 participants) provided data for inclusion in the review. We are uncertain whether there was an effect of hypertonic saline on FEV 1 % predicted after three weeks (MD 1.60%, 95% CI ‐7.96 to 11.16; 1 trial, 14 participants; very low‐certainty evidence). At three months, rhDNase may lead to a greater increase in FEV 1 % predicted than hypertonic saline (5 mL twice daily) at 12 weeks in participants with moderate to severe lung disease (MD 8.00%, 95% CI 2.00 to 14.00; low‐certainty evidence). We are uncertain whether adverse events differed between the two treatments. No deaths were reported. Hypertonic saline versus amiloride One trial (12 participants) compared hypertonic saline to amiloride but did not report on most of our outcomes. The trial found that there was no difference between treatments in measures of sputum clearance (very low‐certainty evidence). Hypertonic saline compared with sodium‐2‐mercaptoethane sulphonate (Mistabron®) One trial (29 participants) compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate. The trial did not measure our primary outcomes. There was no difference between treatments in any measures of sputum clearance, courses of antibiotics or adverse events (very low‐certainty evidence). Hypertonic saline versus mannitol One trial (12 participants) compared hypertonic saline to mannitol, but did not report lung function at relevant time points for this review; there were no differences in sputum clearance, but mannitol was reported to be more 'irritating' (very low‐certainty evidence). Hypertonic saline versus xylitol Two trials compared hypertonic saline to xylitol, but we are uncertain whether there is any difference in FEV 1 % predicted or median time to exacerbation between groups (very low‐certainty evidence). No other outcomes were reported in the review. Hypertonic saline 7% versus hypertonic saline 3% We are uncertain whether there was an improvement in FEV 1 % predicted after treatment with 7% hypertonic saline compared with 3% (very low‐certainty evidence). Authors' conclusions We are very uncertain if regular use of nebulised hypertonic saline by adults and children over the age of 12 years with CF results in an improvement in lung function after four weeks (three trials; very low‐certainty evidence); there was no difference seen at 48 weeks (one trial; low‐certainty evidence). Hypertonic saline improved LCI modestly in children under the age of six years. Evidence from one small cross‐over trial in children indicates that rhDNase may lead to better lung function than hypertonic saline at three months; qualifying this, we highlight that while the study did demonstrate that the improvement in FEV 1 was greater with daily rhDNase, there were no differences seen in any of the secondary outcomes. Hypertonic saline does appear to be an effective adjunct to physiotherapy during acute exacerbations of lung disease in adults. However, for the outcomes assessed, the certainty of the evidence ranged from very low to low at best, according to the GRADE criteria. The role of hypertonic saline in conjunction with cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy now needs to be considered, and future research needs to focus on this aspect. Plain language summary Hypertonic saline (salt water with at least 3% salt) nebulised as a fine mist through a mask or mouthpiece for cystic fibrosis Review question Is inhaling hypertonic saline (salt water with at least 3% salt) as a mist through a mask or mouthpiece better for improving mucus clearance in the lungs of people with cystic fibrosis (CF) than a placebo (a mist with no or very little salt) or other agents? Background People with CF produce large amounts of thick mucus which is difficult to clear and blocks up their airways. Chest physiotherapy or medication, e.g. hypertonic saline, or both combined, are used to try and clear this mucus from the airways. Hypertonic saline is water with a concentration of 3% to 7% salt and is inhaled as a fine mist. This is an update of an earlier review. Key messages • We are uncertain whether inhaling nebulised hypertonic saline regularly improves lung function compared to placebo. • Nebulised hypertonic saline does seem to work well as an add‐on to physiotherapy. What did we do? We searched for studies that looked at the use of nebulised hypertonic saline compared to either a placebo or a different type of treatment for clearing mucus from the lungs. We compared the size and methods of the studies and stated how confident we were in the results. What did we find? We included 24 trials with 1318 people with CF aged between one month and 56 years. Two thirds of the trials compared hypertonic saline to a placebo (a dummy treatment); the remaining trials compared hypertonic saline to another type of mucus clearing treatment (including mannitol; rhDNase (Pulmozyme®); amiloride; Mistabron®; xylitol); and one trial compared 7% hypertonic saline with 3% hypertonic saline. Trials assessed different concentrations of hypertonic saline with different nebulisers and different treatment schedules; the most common treatment was twice‐daily 7% hypertonic saline and the most common nebuliser was ultrasonic. Most trials treated people with a bronchodilator to widen the airways before giving the hypertonic saline. Main results Hypertonic saline 3% to 7% versus placebo We are not sure whether hypertonic saline leads to an improvement in lung function in stable disease after four weeks. Two trials showed that there may be a small improvement in lung function (measured using the lung clearance index) with hypertonic saline compared to placebo in preschool children. We are also unsure whether hypertonic saline makes a difference to clearing mucus from the lungs, exacerbations or side effects compared to placebo. During exacerbations, we found that there may be little or no difference in lung function after hypertonic saline compared to placebo. The trials did not report any serious side effects and there were no deaths. One study compared 7% hypertonic saline with a lower concentration of hypertonic saline (3%); we are uncertain whether the higher concentration improved lung function. Hypertonic saline versus mucus mobilising treatments Three trials compared hypertonic saline with rhDNase and found that rhDNase may lead to an improvement in lung function compared to hypertonic saline after three months. We are unsure whether there is any difference in side effects. One trial compared hypertonic saline to amiloride and a further trial compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate (Mistabron®), but neither of the trials gave information about the effect of the treatments on lung function. Similarly, a trial comparing hypertonic saline with mannitol did not give information about the effects on lung function, but they did report that there was no difference between treatments in clearing mucus from the lungs. People taking mannitol said it was more irritating than hypertonic saline. Two trials compared hypertonic saline with xylitol, but we are unsure if there is any difference in lung function and none of our other outcomes were measured. What are the limitations of this evidence? We are not confident in the evidence from these trials. There is a high risk that people knew which treatment they were receiving in half the trials as they could taste the difference between the solutions. Other factors that made us unsure of the results were the small numbers of people taking part in the trials combined with a wide variation in results; also, some trials limited participants to those who could tolerate hypertonic saline or to certain age groups. How up to date is this evidence? The evidence is current to 25 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wark, P, McDonald, VM, Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD001506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.751Z" }, { "id": "a83a3f82-e738-42ff-b668-2280d07e7309", "pmid": "", "title": "Antioxidant supplementation for lung disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Airway infection leads to progressive damage of the lungs in cystic fibrosis (CF) and oxidative stress has been implicated in the etiology. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, beta‐carotene and selenium) or N‐acetylcysteine (NAC) as a source of glutathione, may therefore potentially help maintain an oxidant‐antioxidant balance. Glutathione or NAC can also be inhaled and if administered in this way can also have a mucolytic effect besides the antioxidant effect. Current literature suggests a relationship between oxidative status and lung function. This is an update of a previously published review. Objectives To synthesise existing knowledge on the effect of antioxidants such as vitamin C, vitamin E, beta‐carotene, selenium and glutathione (or NAC as precursor of glutathione) on lung function through inflammatory and oxidative stress markers in people with CF. Search methods The Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and PubMed were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies. We also searched online trials registries. Last search of Cystic Fibrosis Trials Register: 08 January 2019. Selection criteria Randomised and quasi‐randomised controlled studies comparing antioxidants as listed above (individually or in combination) in more than a single administration to placebo or standard care in people with CF. Data collection and analysis Two authors independently selected studies, extracted data and assessed the risk of bias in the included studies. We contacted study investigators to obtain missing information. If meta‐analysed, studies were subgrouped according to supplement, method of administration and the duration of supplementation. We assessed the quality of the evidence using GRADE. Main results One quasi‐randomised and 19 randomised controlled studies (924 children and adults) were included; 16 studies (n = 639) analysed oral antioxidant supplementation and four analysed inhaled supplements (n = 285). Only one of the 20 included studies was judged to be free of bias. Oral supplements versus control The change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted at three months and six months was only reported for the comparison of NAC to control. Four studies (125 participants) reported at three months; we are uncertain whether NAC improved FEV 1 % predicted as the quality of the evidence was very low, mean difference (MD) 2.83% (95% confidence interval (CI) ‐2.16 to 7.83). However, at six months two studies (109 participants) showed that NAC probably increased FEV 1 % predicted from baseline (moderate‐quality evidence), MD 4.38% (95% CI 0.89 to 7.87). A study of a combined vitamin and selenium supplement (46 participants) reported a greater change from baseline in FEV 1 % predicted in the control group at two months, MD ‐4.30% (95% CI ‐5.64 to ‐2.96). One study (61 participants) found that NAC probably makes little or no difference in the change from baseline in quality of life (QoL) at six months (moderate‐quality evidence), standardised mean difference (SMD) ‐0.03 (95% CI ‐0.53 to 0.47), but the two‐month combined vitamin and selenium study reported a small difference in QoL in favour of the control group, SMD ‐0.66 (95% CI ‐1.26 to ‐0.07). The NAC study reported on the change from baseline in body mass index (BMI) (62 participants) and similarly found that NAC probably made no difference between groups (moderate‐quality evidence). One study (69 participants) found that a mixed vitamin and mineral supplement may lead to a slightly lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) provided information on adverse events, but did not find any clear and consistent evidence of differences between treatment or control groups with the quality of the evidence ranging from low to moderate. Studies of β‐carotene and vitamin E consistently reported greater plasma levels of the respective antioxidants. Inhaled supplements versus control Two studies (258 participants) showed inhaled glutathione probably improves FEV 1 % predicted at three months, MD 3.50% (95% CI 1.38 to 5.62), but not at six months compared to placebo, MD 2.30% (95% CI ‐0.12 to 4.71) (moderate‐quality evidence). The same studies additionally reported an improvement in FEV 1 L in the treated group compared to placebo at both three and six months. One study (153 participants) reported inhaled glutathione probably made little or no difference to the change in QoL from baseline, MD 0.80 (95% CI ‐1.63 to 3.23) (moderate‐quality evidence). No study reported on the change from baseline in BMI at six months, but one study (16 participants) reported at two months and a further study (105 participants) at 12 months; neither study found any difference at either time point. One study (153 participants) reported no difference in the time to the first pulmonary exacerbation at six months. Two studies (223 participants) reported treatment may make little or no difference in adverse events (low‐quality evidence), a further study (153 participants) reported that the number of serious adverse events were similar across groups. Authors' conclusions With regards to micronutrients, there does not appear to be a positive treatment effect of antioxidant micronutrients on clinical end‐points; however, oral supplementation with glutathione showed some benefit to lung function and nutritional status. Based on the available evidence, inhaled and oral glutathione appear to improve lung function, while oral administration decreases oxidative stress; however, due to the very intensive antibiotic treatment and other concurrent treatments that people with CF take, the beneficial effect of antioxidants remains difficult to assess in those with chronic infection without a very large population sample and a long‐term study period. Further studies, especially in very young children, using outcome measures such as lung clearance index and the bronchiectasis scores derived from chest scans, with improved focus on study design variables (such as dose levels and timing), and elucidating clear biological pathways by which oxidative stress is involved in CF, are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn. The benefit of antioxidants in people with CF who receive CFTR modulators therapies should also be assessed in the future. Plain language summary How do vitamins E and C, beta‐carotene, selenium and glutathione affect lung disease in people with cystic fibrosis? Background Frequent chest infections cause long‐term lung inflammation; inflammation‐causing cells produce an oxygen molecule (reactive oxygen species (ROS)), which may harm body tissue (oxidative damage); the body uses antioxidants to protect itself. People with cystic fibrosis (CF) have high levels of ROS compared to low levels of antioxidants. Antioxidant supplements might reduce oxidative damage and build up levels of antioxidants. Given difficulties in absorbing fat, people with CF have low levels of fat‐soluble antioxidants (vitamin E and beta‐carotene). Water‐soluble vitamin C decreases with age in people with CF. Glutathione, one of the most abundant antioxidants in cells, is not released properly into the lungs of people with CF. Some enzymes that help antioxidants work depend on the mineral selenium, so selenium supplements aim to stimulate antioxidant action. Most supplements are swallowed, but glutathione and N‐acetylcysteine (NAC) (which the body uses to make glutathione) can also be inhaled; these may affect lung function as antioxidants, but also due to thinning mucus when inhaled (allowing easier mucus clearance). Search date Last search for this updated review: 08 January 2019. Study characteristics We included 20 studies (924 people with CF, almost equal gender split, aged six months to 59 years); 16 studies compared oral supplements to placebo ('dummy' treatment) and four compared inhaled supplements to placebo. Key results Oral supplements We are uncertain whether NAC changes lung function (forced expiratory volume in one second (FEV 1 ) % predicted) at three months (four studies, 125 participants, very low‐quality evidence), but at six months two studies (109 participants) reported NAC probably improved FEV 1 % predicted (moderate‐quality evidence). One study (46 participants) reported a greater change in FEV 1 % predicted with placebo than with a combined vitamin and selenium supplement after two months. One study (61 participants) reported little or no difference in quality of life (QoL) scores between NAC and control after six months (moderate‐quality evidence), but the two‐month combined vitamin and selenium study reported slightly better QoL scores in the control group. NAC probably made no difference to body mass index (BMI) (one study, 62 participants, moderate‐quality evidence). One study (69 participants) reported that a mixed vitamin and mineral supplement may lead to a lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) did not find any clear and consistent differences in side effects between groups (evidence ranged from low to moderate quality). Vitamin E and β‐carotene studies consistently reported greater levels of these antioxidants in blood samples. Inhaled supplements In two studies (258 participants), inhaled glutathione probably improved FEV 1 % predicted compared to placebo at three months but not at six months (moderate‐quality evidence); these studies also reported a greater improvement in FEV 1 litres with glutathione compared to placebo at both time points. Two studies (258 participants) found little or no difference in the change in QoL scores (moderate‐quality evidence). One two‐month study (16 participants) and a 12‐month study (105 participants) reported no difference between groups in the change in BMI. There was no difference in the time to the first pulmonary exacerbation in one six‐month study. Two studies (223 participants) reported no difference between groups in side effects (low‐quality evidence) and another study (153 participants) reported that the number of serious side effects were similar across groups. Conclusions Vitamin and mineral supplements do not seem to improve clinical outcomes. Inhaled glutathione appears to improve lung function, while oral administration lowers oxidative stress, with benefits to lung function and nutritional measures. Intensive antibiotic and other concurrent treatments for people with CF and chronic infection mean it is difficult to assess the effect of antioxidants without a very large and long study. Future research should look at how antioxidants affect people with CF taking CFTR modulator therapies. Quality of the evidence Evidence ranged from very low to moderate quality. All but one study had some bias; mostly because data were not fully reported (likely to affect our results). We were also largely unsure if participants knew which treatment they received, both in advance and once the studies started (unsure how this might affect our results).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ciofu, O; Smith, S; Lykkesfeldt, J", "articleTypes": [], "doi": "10.1002/14651858.CD007020.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "a853b8ee-01ff-458c-95a7-9c2890d84437", "pmid": "", "title": "Antibody tests for identification of current and past infection with SARS‐CoV‐2", "imported": false, "abstract": "Abstract - Background The diagnostic challenges associated with the COVID‐19 pandemic resulted in rapid development of diagnostic test methods for detecting SARS‐CoV‐2 infection. Serology tests to detect the presence of antibodies to SARS‐CoV‐2 enable detection of past infection and may detect cases of SARS‐CoV‐2 infection that were missed by earlier diagnostic tests. Understanding the diagnostic accuracy of serology tests for SARS‐CoV‐2 infection may enable development of effective diagnostic and management pathways, inform public health management decisions and understanding of SARS‐CoV‐2 epidemiology. Objectives To assess the accuracy of antibody tests, firstly, to determine if a person presenting in the community, or in primary or secondary care has current SARS‐CoV‐2 infection according to time after onset of infection and, secondly, to determine if a person has previously been infected with SARS‐CoV‐2. Sources of heterogeneity investigated included: timing of test, test method, SARS‐CoV‐2 antigen used, test brand, and reference standard for non‐SARS‐CoV‐2 cases. Search methods The COVID‐19 Open Access Project living evidence database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) was searched on 30 September 2020. We included additional publications from the Evidence for Policy and Practice Information and Co‐ordinating Centre (EPPI‐Centre) ‘COVID‐19: Living map of the evidence’ and the Norwegian Institute of Public Health ’NIPH systematic and living map on COVID‐19 evidence’. We did not apply language restrictions. Selection criteria We included test accuracy studies of any design that evaluated commercially produced serology tests, targeting IgG, IgM, IgA alone, or in combination. Studies must have provided data for sensitivity, that could be allocated to a predefined time period after onset of symptoms, or after a positive RT‐PCR test. Small studies with fewer than 25 SARS‐CoV‐2 infection cases were excluded. We included any reference standard to define the presence or absence of SARS‐CoV‐2 (including reverse transcription polymerase chain reaction tests (RT‐PCR), clinical diagnostic criteria, and pre‐pandemic samples). Data collection and analysis We use standard screening procedures with three reviewers. Quality assessment (using the QUADAS‐2 tool) and numeric study results were extracted independently by two people. Other study characteristics were extracted by one reviewer and checked by a second. We present sensitivity and specificity with 95% confidence intervals (CIs) for each test and, for meta‐analysis, we fitted univariate random‐effects logistic regression models for sensitivity by eligible time period and for specificity by reference standard group. Heterogeneity was investigated by including indicator variables in the random‐effects logistic regression models. We tabulated results by test manufacturer and summarised results for tests that were evaluated in 200 or more samples and that met a modification of UK Medicines and Healthcare products Regulatory Agency (MHRA) target performance criteria. Main results We included 178 separate studies (described in 177 study reports, with 45 as pre‐prints) providing 527 test evaluations. The studies included 64,688 samples including 25,724 from people with confirmed SARS‐CoV‐2; most compared the accuracy of two or more assays (102/178, 57%). Participants with confirmed SARS‐CoV‐2 infection were most commonly hospital inpatients (78/178, 44%), and pre‐pandemic samples were used by 45% (81/178) to estimate specificity. Over two‐thirds of studies recruited participants based on known SARS‐CoV‐2 infection status (123/178, 69%). All studies were conducted prior to the introduction of SARS‐CoV‐2 vaccines and present data for naturally acquired antibody responses. Seventy‐nine percent (141/178) of studies reported sensitivity by week after symptom onset and 66% (117/178) for convalescent phase infection. Studies evaluated enzyme‐linked immunosorbent assays (ELISA) (165/527; 31%), chemiluminescent assays (CLIA) (167/527; 32%) or lateral flow assays (LFA) (188/527; 36%). Risk of bias was high because of participant selection (172, 97%); application and interpretation of the index test (35, 20%); weaknesses in the reference standard (38, 21%); and issues related to participant flow and timing (148, 82%). We judged that there were high concerns about the applicability of the evidence related to participants in 170 (96%) studies, and about the applicability of the reference standard in 162 (91%) studies. Average sensitivities for current SARS‐CoV‐2 infection increased by week after onset for all target antibodies. Average sensitivity for the combination of either IgG or IgM was 41.1% in week one (95% CI 38.1 to 44.2; 103 evaluations; 3881 samples, 1593 cases), 74.9% in week two (95% CI 72.4 to 77.3; 96 evaluations, 3948 samples, 2904 cases) and 88.0% by week three after onset of symptoms (95% CI 86.3 to 89.5; 103 evaluations, 2929 samples, 2571 cases). Average sensitivity during the convalescent phase of infection (up to a maximum of 100 days since onset of symptoms, where reported) was 89.8% for IgG (95% CI 88.5 to 90.9; 253 evaluations, 16,846 samples, 14,183 cases), 92.9% for IgG or IgM combined (95% CI 91.0 to 94.4; 108 evaluations, 3571 samples, 3206 cases) and 94.3% for total antibodies (95% CI 92.8 to 95.5; 58 evaluations, 7063 samples, 6652 cases). Average sensitivities for IgM alone followed a similar pattern but were of a lower test accuracy in every time slot. Average specificities were consistently high and precise, particularly for pre‐pandemic samples which provide the least biased estimates of specificity (ranging from 98.6% for IgM to 99.8% for total antibodies). Subgroup analyses suggested small differences in sensitivity and specificity by test technology however heterogeneity in study results, timing of sample collection, and smaller sample numbers in some groups made comparisons difficult. For IgG, CLIAs were the most sensitive (convalescent‐phase infection) and specific (pre‐pandemic samples) compared to both ELISAs and LFAs (P < 0.001 for differences across test methods). The antigen(s) used (whether from the Spike‐protein or nucleocapsid) appeared to have some effect on average sensitivity in the first weeks after onset but there was no clear evidence of an effect during convalescent‐phase infection. Investigations of test performance by brand showed considerable variation in sensitivity between tests, and in results between studies evaluating the same test. For tests that were evaluated in 200 or more samples, the lower bound of the 95% CI for sensitivity was 90% or more for only a small number of tests (IgG, n = 5; IgG or IgM, n = 1; total antibodies, n = 4). More test brands met the MHRA minimum criteria for specificity of 98% or above (IgG, n = 16; IgG or IgM, n = 5; total antibodies, n = 7). Seven assays met the specified criteria for both sensitivity and specificity. In a low‐prevalence (2%) setting, where antibody testing is used to diagnose COVID‐19 in people with symptoms but who have had a negative PCR test, we would anticipate that 1 (1 to 2) case would be missed and 8 (5 to 15) would be falsely positive in 1000 people undergoing IgG or IgM testing in week three after onset of SARS‐CoV‐2 infection. In a seroprevalence survey, where prevalence of prior infection is 50%, we would anticipate that 51 (46 to 58) cases would be missed and 6 (5 to 7) would be falsely positive in 1000 people having IgG tests during the convalescent phase (21 to 100 days post‐symptom onset or post‐positive PCR) of SARS‐CoV‐2 infection. Authors' conclusions Some antibody tests could be a useful diagnostic tool for those in whom molecular‐ or antigen‐based tests have failed to detect the SARS‐CoV‐2 virus, including in those with ongoing symptoms of acute infection (from week three onwards) or those presenting with post‐acute sequelae of COVID‐19. However, antibody tests have an increasing likelihood of detecting an immune response to infection as time since onset of infection progresses and have demonstrated adequate performance for detection of prior infection for sero‐epidemiological purposes. The applicability of results for detection of vaccination‐induced antibodies is uncertain. Plain language summary What is the diagnostic accuracy of antibody tests for the detection of infection with the COVID‐19 virus? Background COVID‐19 is an infectious disease caused by the SARS‐CoV‐2 virus that spreads easily between people in a similar way to the common cold or ‘flu’. Most people with COVID‐19 have a mild‐to‐moderate respiratory illness, and some may have no symptoms (asymptomatic infection). Others experience severe symptoms and need specialist treatment and intensive care. In response to COVID‐19 infection, the immune system develops proteins called antibodies that can attack the virus as it circulates in their blood. People who have been vaccinated against COVID‐19 also produce these antibodies against the virus. Tests are available to detect antibodies in peoples' blood, which may indicate that they currently have COVID‐19 or have had it previously, or it may indicate that they have been vaccinated (although this group was not the focus of this review). Why are accurate tests important? Accurate testing allows identification of people who need to isolate themselves to prevent the spread of infection, or who might need treatment for their infection. Failure of diagnostic tests to detect infection with COVID‐19 when it is present (a false negative result) may delay treatment and risk further spread of infection to others. Incorrect diagnosis of COVID‐19 when it is not present (a false positive result) may lead to unnecessary further testing, treatment, and isolation of the person and close contacts. Accurate identification of people who have previously had COVID‐19 is important in measuring disease spread and assessing the success of public health interventions. To determine the accuracy of an antibody test in identifying COVID‐19, test results are compared in people known to have (or have had) COVID‐19 and in people known not to have (or have had) COVID‐19. The criteria used to determine whether people are known or not known to have COVID‐19 is called the ‘reference standard’. Many studies use a test called reverse transcriptase polymerase chain reaction (RT‐PCR) as the reference standard, with samples taken from the nose and throat. Additional tests that can be used include measuring symptoms, like coughing or high temperature, or ‘imaging’ tests like chest X‐rays. People known not to have COVID‐19 are sometimes identified from stored blood samples taken before COVID‐19 existed, or from patients with symptoms confirmed to be caused by other diseases. What did the review study? We wanted to find out whether antibody tests: ‐ are able to diagnose infection in people with or without symptoms of COVID‐19, and ‐ can be used to find out if someone has already had COVID‐19. The studies we included in our review looked at three types of antibodies. Most commonly, antibody tests measure two types known as IgG and IgM, but some tests only measure a single type of antibody or different combinations of the three types of antibodies (IgA, IgG, IgM). What did we do? We looked for studies that measured the diagnostic accuracy of antibody tests to detect current or past COVID‐19 infection and compared them with reference standard criteria. Since there are many antibody tests available, we included studies assessing any antibody test compared with any reference standard. People could be tested in hospital or in the community. The people tested may have been confirmed to have, or not to have, COVID‐19 infection, or they may be suspected of having COVID‐19. Study characteristics We found 178 relevant studies. Studies took place in Europe (94), Asia (45), North America (35), Australia (2), and South America (2). Seventy‐eight studies included people who were in hospital with suspected or confirmed COVID‐19 infection and 14 studies included people in community settings. Several studies included people from multiple settings (35) or did not report where the participants were recruited from (39). One hundred and forty‐one studies included recent infection cases (mainly week 1 to week 3 after onset of symptoms), and many also included people tested later (from day 21 onwards after infection) (117). Main results In participants that had COVID‐19 and were tested one week after symptoms developed, antibody tests detected only 27% to 41% of infections. In week 2 after first symptoms, 64% to 79% of infections were detected, rising to 78% to 88% in week 3. Tests that specifically detected IgG or IgM antibodies were the most accurate and, when testing people from 21 days after first symptoms, they detected 93% of people with COVID‐19. Tests gave false positive results for 1% of those without COVID‐19. Below we illustrate results for two different scenarios. If 1000 people were tested for IgG or IgM antibodies during the third week after onset of symptoms and only 20 (2%) of them actually had COVID‐19: ‐ 26 people would test positive. Of these, 8 people (31%) would not have COVID‐19 (false positive result). ‐ 974 people would test negative. Of these, 2 people (0.2%) would actually have COVID‐19 (false negative result). If 1000 people with no symptoms for COVID‐19 were tested for IgG antibodies and 500 (50%) of them had previously had COVID‐19 infection more than 21 days previously: ‐ 455 people would test positive. Of these, 6 people (1%) would not have been infected (false positive result). ‐ 545 people would test negative. Of these, 51 (9%) would actually have had a prior COVID‐19 infection (false negative result). How reliable were the results of the studies of this review? We have limited confidence in the evidence for several reasons. The number of samples contributed by studies for each week post‐symptom onset was often small, and there were sometimes problems with how studies were conducted. Participants included in the studies were often hospital patients who were more likely to have experienced severe symptoms of COVID‐19. The accuracy of antibody tests for detecting COVID‐19 in these patients may be different from the accuracy of the tests in people with mild or moderate symptoms. It is not possible to identify by how much the test results would differ in other populations. Who do the results of this review apply to? A high percentage of participants were in hospital with COVID‐19, so were likely to have more severe disease than people with COVID‐19 who were not hospitalised. Only a small number of studies assessed these tests in people with no symptoms. The results of the review may therefore be more applicable to those with severe disease than people with mild symptoms. Studies frequently did not report whether participants had symptoms at the time samples were taken for testing making it difficult to fully separate test results for early‐phase infection as opposed to later‐phase infections. The studies in our review assessed several test methods across a global population, therefore it is likely that test results would be similar in most areas of the world. What are the implications of this review? The review shows that antibody tests could have a useful role in detecting if someone has had COVID‐19, but the timing of test use is important. Some antibody tests may help to confirm COVID‐19 infection in people who have had symptoms for more than two weeks but who have been unable to confirm their infection using other methods. This is particularly useful if they are experiencing potentially serious symptoms that may be due to COVID‐19 as they may require specific treatment. Antibody tests may also be useful to determine how many people have had a previous COVID‐19 infection. We could not be certain about how well the tests work for people who have milder disease or no symptoms, or for detecting antibodies resulting from vaccination. How up‐to‐date is this review? This review updates our previous review. The evidence is up‐to‐date to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Fox, T, Geppert, J, Dinnes, J, Scandrett, K, Bigio, J, Sulis, G, Hettiarachchi, D, Mathangasinghe, Y, Weeratunga, P, Wickramasinghe, D, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.801Z" }, { "id": "a85cb77a-cf72-4daf-ab30-76364ea54e61", "pmid": "", "title": "Ghrelin for the management of cachexia associated with cancer", "imported": false, "abstract": "Abstract - Background Cancer sufferers are amongst the most malnourished of all the patient groups. Studies have shown that ghrelin, a gut hormone can be a potential therapeutic agent for cachexia (wasting syndrome) associated with cancer. A variety of mechanisms of action of ghrelin in people with cancer cachexia have been proposed. However, safety and efficacy of ghrelin for cancer‐associated cachexia have not been systematically reviewed. The aim of this review was to assess whether ghrelin is associated with better food intake, body composition and survival than other options for adults with cancer cachexia. Objectives To assess the efficacy and safety of ghrelin in improving food intake, body composition and survival in people with cachexia associated with cancer. Search methods We searched CENTRAL, MEDLINE and Embase without language restrictions up to July 2017. We also searched for ongoing studies in trials registers, performed handsearching, checked bibliographic references of relevant articles and contacted authors and experts in the field to seek potentially relevant research. We applied no restrictions on language, date, or publication status. Selection criteria We included randomised controlled (parallel‐group or cross‐over) trials comparing ghrelin (any formulation or route of administration) with placebo or an active comparator in adults (aged 18 years and over) who met any of the international criteria for cancer cachexia. Data collection and analysis Two review authors independently assessed studies for eligibility. Two review authors then extracted data and assessed the risk of bias for individual studies using standard Cochrane methodology. For dichotomous variables, we planned to calculate risk ratio with 95% confidence intervals (CI) and for continuous data, we planned to calculate mean differences (MD) with 95% CI. We assessed the evidence using GRADE and created 'Summary of findings' tables. Main results We screened 926 individual references and identified three studies that satisfied the inclusion criteria. Fifty‐nine participants (37 men and 22 women) aged between 54 and 78 years were randomised initially, 47 participants completed the treatment. One study had a parallel design and two had a cross‐over design. The studies included people with a variety of cancers and also differed in the dosage, route of administration, frequency and duration of treatment. One trial, which compared ghrelin with placebo, found that ghrelin improved food intake (very low‐quality evidence) and had no adverse events (very low‐quality evidence). Due to unavailability of data we were unable to report on comparisons for ghrelin versus no treatment or alternative experimental treatment modalities, or ghrelin in combination with other treatments or ghrelin analogues/ghrelin mimetics/ghrelin potentiators. Two studies compared a higher dose of ghrelin with a lower dose of ghrelin, however due to differences in study designs and great diversity in the treatment provided we did not pool the results. In both trials, food intake did not differ between participants on higher‐dose and lower‐dose ghrelin. None of the included studies assessed data on body weight. One study reported higher adverse events with a higher dose as compared to a lower dose of ghrelin. All studies were at high risk of attrition bias and bias for size of the study. Risk of bias in other domains was unclear or low. We rated the overall quality of the evidence for primary outcomes (food intake, body weight, adverse events) as very low. We downgraded the quality of the evidence due to lack of data, high or unclear risk of bias of the studies and small study size. Authors' conclusions There is insufficient evidence to be able to support or refute the use of ghrelin in people with cancer cachexia. Adequately powered randomised controlled trials focusing on evaluation of safety and efficacy of ghrelin in people with cancer cachexia is warranted. Plain language summary Ghrelin, a hunger hormone for management of cancer patients with loss of appetite and weight loss Bottom line There is no good evidence to support or reject the suggestion that ghrelin is useful in the management of cancer patients with loss of appetite and weight loss. There is insufficient evidence to recommend it for clinical practice. Background Sixty to eighty percent of cancer patients suffer from loss of appetite and weight loss, which in turn is associated with decreased life expectancy and quality of life. Ghrelin, a hunger hormone is secreted by the stomach and other organs of the body. Studies have shown that ghrelin can be used in treatment for loss of appetite and weight loss in cancer patients. However, the effectiveness and safety of ghrelin in such people have not been assessed. In this review we set out to examine all evidence on the effectiveness and safety of ghrelin in improving appetite and body weight in cancer patients with loss of appetite and weight loss. Search date The evidence is current to 20th July 2017. Study characteristics We found three studies that recruited a total of 59 cancer patients (37 men and 22 women) aged between 54 and 78 years. Forty‐seven cancer patients completed the treatment. Studies differed in study design and included people with a variety of cancers. Studies also differed in dosage, route of injection, frequency and duration of treatment. One study compared ghrelin with a placebo while two studies compared different doses of ghrelin (higher dose with lower dose). Outcomes of interest to cancer patients with loss of appetite and weight loss, such as improvement in food intake and improvement in body weight, were not adequately reported. All three included studies were funded by government agencies. One study received an additional grant from a pharmaceutical company. Key findings We found insufficient evidence that using ghrelin demonstrated differences in food intake. We found no evidence that using ghrelin alone or in combination made any difference to body weight. We could not reach any conclusions about its side effects. The limited amount of information means that we could not draw any conclusions. Quality of the evidence We rated the quality of evidence from studies using four levels: high, moderate, low, or very low. High‐quality evidence means that we are very confident in the results. Very low‐quality evidence means that we are very uncertain about the results. The evidence in this review was of very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Khatib, MN; Shankar, AH; Kirubakaran, R; Gaidhane, A; Gaidhane, S; Simkhada, P; Quazi Syed, Z", "articleTypes": [], "doi": "10.1002/14651858.CD012229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "a862de2b-f587-42aa-ad38-7a7b278f97c8", "pmid": "", "title": "Pharmacological intervention for irritability, aggression, and self‐injury in autism spectrum disorder (ASD)", "imported": false, "abstract": "Abstract - Background Pharmacological interventions are frequently used for people with autism spectrum disorder (ASD) to manage behaviours of concern, including irritability, aggression, and self‐injury. Some pharmacological interventions might help treat some behaviours of concern, but can also have adverse effects (AEs). Objectives To assess the effectiveness and AEs of pharmacological interventions for managing the behaviours of irritability, aggression, and self‐injury in ASD. Search methods We searched CENTRAL, MEDLINE, Embase, 11 other databases and two trials registers up to June 2022. We also searched reference lists of relevant studies, and contacted study authors, experts and pharmaceutical companies. Selection criteria We included randomised controlled trials of participants of any age with a clinical diagnosis of ASD, that compared any pharmacological intervention to an alternative drug, standard care, placebo, or wait‐list control. Data collection and analysis We used standard Cochrane methods. Primary outcomes were behaviours of concern in ASD, (irritability, aggression and self‐injury); and AEs. Secondary outcomes were quality of life, and tolerability and acceptability. Two review authors independently assessed each study for risk of bias, and used GRADE to judge the certainty of the evidence for each outcome. Main results We included 131 studies involving 7014 participants in this review. We identified 26 studies as awaiting classification and 25 as ongoing. Most studies involved children (53 studies involved only children under 13 years), children and adolescents (37 studies), adolescents only (2 studies) children and adults (16 studies), or adults only (23 studies). All included studies compared a pharmacological intervention to a placebo or to another pharmacological intervention. Atypical antipsychotics versus placebo At short‐term follow−up (up to 6 months), atypical antipsychotics probably reduce irritability compared to placebo (standardised mean difference (SMD) −0.90, 95% confidence interval (CI) −1.25 to −0.55, 12 studies, 973 participants; moderate‐certainty evidence), which may indicate a large effect. However, there was no clear evidence of a difference in aggression between groups (SMD −0.44, 95% CI −0.89 to 0.01; 1 study, 77 participants; very low‐certainty evidence). Atypical antipsychotics may also reduce self‐injury (SMD −1.43, 95% CI −2.24 to −0.61; 1 study, 30 participants; low‐certainty evidence), possibly indicating a large effect. There may be higher rates of neurological AEs (dizziness, fatigue, sedation, somnolence, and tremor) in the intervention group (low‐certainty evidence), but there was no clear evidence of an effect on other neurological AEs. Increased appetite may be higher in the intervention group (low‐certainty evidence), but we found no clear evidence of an effect on other metabolic AEs. There was no clear evidence of differences between groups in musculoskeletal or psychological AEs. Neurohormones versus placebo At short‐term follow‐up, neurohormones may have minimal to no clear effect on irritability when compared to placebo (SMD −0.18, 95% CI −0.37 to −0.00; 8 studies; 466 participants; very low‐certainty evidence), although the evidence is very uncertain. No data were reported for aggression or self ‐injury. Neurohormones may reduce the risk of headaches slightly in the intervention group, although the evidence is very uncertain. There was no clear evidence of an effect of neurohormones on any other neurological AEs, nor on any psychological, metabolic, or musculoskeletal AEs (low‐ and very low‐certainty evidence). Attention‐deficit hyperactivity disorder (ADHD)‐related medications versus placebo At short‐term follow‐up, ADHD‐related medications may reduce irritability slightly (SMD −0.20, 95% CI −0.40 to −0.01; 10 studies, 400 participants; low‐certainty evidence), which may indicate a small effect. However, there was no clear evidence that ADHD‐related medications have an effect on self‐injury (SMD −0.62, 95% CI −1.63 to 0.39; 1 study, 16 participants; very low‐certainty evidence). No data were reported for aggression. Rates of neurological AEs (drowsiness, emotional AEs, fatigue, headache, insomnia, and irritability), metabolic AEs (decreased appetite) and psychological AEs (depression) may be higher in the intervention group, although the evidence is very uncertain (very low‐certainty evidence). There was no evidence of a difference between groups for any other metabolic, neurological, or psychological AEs (very low‐certainty evidence). No data were reported for musculoskeletal AEs. Antidepressants versus placebo At short‐term follow‐up, there was no clear evidence that antidepressants have an effect on irritability (SMD −0.06, 95% CI −0.30 to 0.18; 3 studies, 267 participants; low‐certainty evidence). No data for aggression or self‐injury were reported or could be included in the analysis. Rates of metabolic AEs (decreased energy) may be higher in participants receiving antidepressants (very low‐certainty evidence), although no other metabolic AEs showed clear evidence of a difference. Rates of neurological AEs (decreased attention) and psychological AEs (impulsive behaviour and stereotypy) may also be higher in the intervention group (very low‐certainty evidence) although the evidence is very uncertain. There was no clear evidence of any difference in the other metabolic, neurological, or psychological AEs (very low‐certainty evidence), nor between groups in musculoskeletal AEs (very low‐certainty evidence). Risk of bias We rated most of the studies across the four comparisons at unclear overall risk of bias due to having multiple domains rated as unclear, very few rated as low across all domains, and most having at least one domain rated as high risk of bias. Authors' conclusions Evidence suggests that atypical antipsychotics probably reduce irritability, ADHD‐related medications may reduce irritability slightly, and neurohormones may have little to no effect on irritability in the short term in people with ASD. There was some evidence that atypical antipsychotics may reduce self‐injury in the short term, although the evidence is uncertain. There was no clear evidence that antidepressants had an effect on irritability. There was also little to no difference in aggression between atypical antipsychotics and placebo, or self‐injury between ADHD‐related medications and placebo. However, there was some evidence that atypical antipsychotics may result in a large reduction in self‐injury, although the evidence is uncertain. No data were reported (or could be used) for self‐injury or aggression for neurohormones versus placebo. Studies reported a wide range of potential AEs. Atypical antipsychotics and ADHD‐related medications in particular were associated with an increased risk of metabolic and neurological AEs, although the evidence is uncertain for atypical antipsychotics and very uncertain for ADHD‐related medications. The other drug classes had minimal or no associated AEs. Plain language summary Which medications reduce irritability, aggression or self‐harm in people with autism spectrum disorder (ASD)? Key messages • Only 3 classes of medications showed any reduction in irritability, aggression or self‐harm when compared to placebo (a dummy medication). Atypical (second‐generation) antipsychotic medications probably reduce irritability and aggression, but appear to have little to no effect on self‐injury. Attention deficit hyperactivity disorder (ADHD)‐related medications may reduce irritability, although the evidence is uncertain. Neurohormones (oxytocin and secretin) may also reduce irritability, but we are very uncertain about the evidence. • Antidepressants appear to have no effect on irritability. Studies did not report on the effects of antidepressants, ADHD‐related medications and neurohormones on aggression or self‐injury. • Studies reported a wide range of unwanted effects, but only atypical antipsychotics, ADHD‐related medications, and neurohormones showed evidence of a higher risk of any unwanted effects compared to placebo. What is autism spectrum disorder (ASD)? Autism is a disorder that affects a child's physical, mental and behavioural development. It is a lifelong disability that starts in childhood but continues throughout adulthood. People with autism may find it difficult to communicate and interact with the world. However, autism affects each person differently and may be more or less severe in different people, so it is described as a 'spectrum' disorder. Some people with autism spectrum disorder (ASD) may be irritable, angry or aggressive, or hurt themselves physically (self‐injury), which are 'behaviours of concern' that can be difficult to manage and distressing for the person. How are behaviours of concern managed? Behaviours of concern are frequently managed with various types of medications that have been developed to treat other conditions. This means that their effectiveness for behaviours of concern is largely unknown, and they may cause serious and varied unwanted effects that affect all parts of the body. For example: • the heart and lungs; • the stomach and digestive system; • the immune system; • movement, joints and bones; and • mood and emotion. What did we want to find out? We wanted to know which types of medication were effective in reducing behaviours of concern in people with ASD and whether they caused unwanted effects. What did we do? We searched for studies that investigated any medication used to manage behaviours of concern. Studies compared the medication with placebo (a dummy medication) or another medication. People in the studies could be adults or children, but all had ASD with behaviours of concern. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 131 studies with 7014 people. Most studies involved children, although some studies involved both children and adults, or adults only. Studies looked at a wide range of medications, including those usually used to treat schizophrenia or bipolar disorder, depression, attention deficit hyperactivity disorder (ADHD), convulsions, emotional problems, heart and lungs, dementia, Parkinson's, and anxiety. Atypical (second‐generation) antipsychotics are usually used to treat schizophrenia or bipolar disorder. They probably reduce irritability, but they may have little to no effect on aggression and self‐injury. People receiving antipsychotics might be more likely to experience unwanted effects such as increased appetite, dizziness, sedation (slowed thought and movement), sleepiness, tiredness and tremor compared to those receiving no treatment or other medications. People receiving antipsychotics may be no more or less likely than those receiving placebo to experience other unwanted effects. Neurohormones (such as oxytocin and secretin) may have a minimal to small effect on irritability but no studies reported data for the effects of neurohormones on self‐harm or aggression. People receiving neurohormones may be no more or less likely than those receiving placebo to experience unwanted effects. ADHD‐related medications may reduce irritability but may have no effect on self‐injury. No studies reported data for aggression. People receiving ADHD‐related medications might be more likely to experience unwanted effects such as drowsiness, tiredness, headache, difficulties sleeping, and decreased appetite. But they may be no more or less likely than those receiving placebo to experience other unwanted effects. Antidepressants may have little to no effect on irritability. No studies reported useful data for aggression and self‐injury. People receiving antidepressants might be more likely to experience unwanted effects such as impulsive behaviour and making repetitive movements or sounds (stereotypy) compared to placebo. But they may be no more or less likely than those receiving placebo to experience other types of unwanted effects. What are the limitations of the evidence? Most of the studies lasted less than 3 months, and very few studies involved adults. Therefore, we are uncertain if the same effects would be seen over a longer period of time or in adults. How up‐to‐date is the evidence? The review authors searched for studies that had been published up to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Iffland, M; Livingstone, N; Jorgensen, M; Hazell, P; Gillies, D", "articleTypes": [], "doi": "10.1002/14651858.CD011769.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "a87fa52b-15c5-4bc4-b38b-c0717bd6e2b0", "pmid": "", "title": "A Multiple Ascending Dose Study of Tadalafil to Assess the Pharmacokinetics and Safety in a Pediatric Population With Pulmonary Arterial Hypertension", "imported": false, "abstract": "The purpose of this study is to see how much study drug is in the blood of children with pulmonary arterial hypertension (PAH) after dosing to establish the correct dose for further clinical research.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.154Z" }, { "id": "a8811c23-815c-4786-9745-fdc390c75563", "pmid": "", "title": "Endometrial preparation for women undergoing embryo transfer with frozen embryos or embryos derived from donor oocytes", "imported": false, "abstract": "Abstract - Background A frozen embryo transfer (FET) cycle is when one or more embryos (frozen during a previous treatment cycle) are thawed and transferred to the uterus. Some women undergo fresh embryo transfer (ET) cycles with embryos derived from donated oocytes. In both situations, the endometrium is primed with oestrogen and progestogen in different doses and routes of administration. Objectives To evaluate the most effective endometrial preparation for women undergoing transfer with frozen embryos or embryos from donor oocytes with regard to the subsequent live birth rate (LBR). Search methods The Cochrane Gynaecology and Fertility Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, LILACS, trials registers and abstracts of reproductive societies' meetings were searched in June 2020 together with reference checking and contact with study authors and experts in the field to identify additional studies. Selection criteria Randomised controlled trials (RCTs) evaluating endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. Data collection and analysis We used standard methodological procedures recommended by Cochrane. We analysed all available interventions versus placebo, no treatment, or between each other. The primary review outcome was live birth rate. Secondary outcomes were clinical and multiple pregnancy, miscarriage, cycle cancellation, endometrial thickness and adverse effects. Main results Thirty‐one RCTs (5426 women) were included. Evidence was moderate to very low‐quality: the main limitations were serious risk of bias due to poor reporting of methods, and serious imprecision. Stimulated versus programmed cycle We are uncertain whether a letrozole‐stimulated cycle compared to a programmed cycle, for endometrial preparation, improves LBR (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.49 to 3.26; 100 participants; one study; very low‐quality evidence). Stimulating with follicle stimulating hormone (FSH), letrozole or clomiphene citrate may improve clinical pregnancy rate (CPR) (OR 1.63, 95% CI 1.12 to 2.38; 656 participants; five studies; I 2 = 11%; low‐quality evidence). We are uncertain if they reduce miscarriage rate (MR) (OR 0.79, 95% CI 0.36 to 1.71; 355 participants; three studies; I 2 = 0%; very low‐quality evidence). Endometrial thickness (ET) may be reduced with clomiphene citrate (mean difference(MD) ‐1.04, 95% CI ‐1.59 to ‐0.49; 92 participants; one study; low‐quality evidence). Other outcomes were not reported. Natural versus programmed cycle We are uncertain of the effect from a natural versus programmed cycle for LBR (OR 0.97, 95% CI 0.74 to 1.28; 1285 participants; four studies; I 2 = 0%; very low‐quality evidence) and CPR (OR 0.79, 95% CI 0.62 to 1.01; 1249 participants; five studies; I 2 = 60%; very low‐quality evidence), while a natural cycle probably reduces the cycle cancellation rate (CCR) (OR 0.60, 95% CI 0.44 to 0.82; 734 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and ET. No study reported other outcomes. Transdermal versus oral oestrogens From low‐quality evidence we are uncertain of the effect transdermal compared to oral oestrogens has on CPR (OR 0.86, 95% CI 0.59 to 1.25; 504 participants; three studies; I 2 = 58%) or MR (OR 0.55, 95% CI 0.27 to 1.09; 414 participants; two studies; I 2 = 0%). Other outcomes were not reported. Day of starting administration of progestogen When doing a fresh ET using donated oocytes in a synchronised cycle starting progestogen on the day of oocyte pick‐up (OPU) or the day after OPU, in comparison with recipients that start progestogen the day prior to OPU, probably increases the CPR (OR 1.87, 95% CI 1.13 to 3.08; 282 participants; one study, moderate‐quality evidence). We are uncertain of the effect on multiple pregnancy rate (MPR) or MR. It probably reduces the CCR (OR 0.28, 95% CI 0.11 to 0.74; 282 participants; one study; moderate‐quality evidence). No study reported other outcomes. Gonadotropin‐releasing hormone (GnRH) agonist versus control A cycle with GnRH agonist compared to without may improve LBR (OR 2.62, 95% CI 1.19 to 5.78; 234 participants; one study; low‐quality evidence). From low‐quality evidence we are uncertain of the effect on CPR (OR 1.08, 95% CI 0.82 to 1.43; 1289 participants; eight studies; I 2 = 20%), MR (OR 0.85, 95% CI 0.36 to 2.00; 828 participants; four studies; I 2 = 0%), CCR (OR 0.49, 95% CI 0.21 to 1.17; 530 participants; two studies; I 2 = 0%) and ET (MD ‐0.08, 95% CI ‐0.33 to 0.16; 697 participants; four studies; I 2 = 4%). No study reported other outcomes. Among different GnRH agonists From very low‐quality evidence we are uncertain if cycles among different GnRH agonists improves CPR or MR. No study reported other outcomes. GnRH agonists versus GnRH antagonists GnRH antagonists compared to agonists probably improves CPR (OR 0.62, 95% CI 0.42 to 0.90; 473 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and MPR. No study reported other outcomes. Aspirin versus control From very low‐quality evidence we are uncertain whether a cycle with aspirin versus without improves LBR, CPR, or ET. Steroids versus control From very low‐quality evidence we are uncertain whether a cycle with steroids compared to without improves LBR, CPR or MR. No study reported other outcomes. Authors' conclusions There is insufficient evidence on the use of any particular intervention for endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. In frozen embryo transfers, low‐quality evidence showed that clinical pregnancy rates may be improved in a stimulated cycle compared to a programmed one, and we are uncertain of the effect when comparing a programmed cycle to a natural cycle. Cycle cancellation rates are probably reduced in a natural cycle. Although administering a GnRH agonist, compared to without, may improve live birth rates, clinical pregnancy rates will probably be improved in a GnRH antagonist cycle over an agonist cycle. In fresh synchronised oocyte donor cycles, the clinical pregnancy rate is probably improved and cycle cancellation rates are probably reduced when starting progestogen the day of or day after donor oocyte retrieval. Adequately powered studies are needed to evaluate each treatment more accurately. Plain language summary Endometrial preparation for egg donor recipients or for frozen embryo transfers Review question What is the most effective method for endometrial preparation in women undergoing embryo transfers with frozen embryos or embryos derived from donor oocytes? Background Couples undergo infertility treatments due to male factor, female factors or unexplained infertility. After an unsuccessful fresh embryo transfer cycle, a frozen‐thawed embryo transfer can be performed when frozen embryos are available. Adequate hormonal preparation of the endometrium is of utmost importance for both egg donor and frozen embryo replacement cycles to provide the optimal chances of pregnancy. Many drugs and various modes of administration have been tried by several investigators in order to optimise implantation rates and consequently improve the success rates of the embryo transfer procedures: stimulated cycles (to generate endogenous oestradiol), programmed cycles (administering exogenous oestradiol) or natural cycles (allowing the ovaries to produce oestradiol without stimulation) are some of the options; avoiding spontaneous ovulation with gonadotropin‐releasing hormone (GnRH) agonists and antagonists could have some impact; or using some other drugs such as aspirin or steroids that could potentially enhance the endometrial receptivity were also evaluated. Study characteristics We found 31 randomised controlled trials comparing different interventions such as the dose and route of administration of oestrogens and progestogen, the use of drugs that stop the patient from ovulating prematurely (GnRH agonists), and the use of other medications to improve the endometrium in a total of 5426 women. The evidence is current to June 2020. Key results We are uncertain whether a stimulated cycle (with letrozole) compared to a programmed cycle, for endometrial preparation, improves live birth. The evidence suggests that if the chance of live birth following a programmed cycle is assumed to be 24%, the chance following a stimulated cycle would be between 13% and 51%. We are also uncertain of the impact on miscarriage rate and endometrial thickness. A stimulated cycle may improve clinical pregnancy rate. Data were lacking on multiple pregnancy, cycle cancellation and other adverse effects. We are uncertain whether a natural cycle improves the live birth rate, pregnancy rate, miscarriage rate and endometrial thickness in comparison with a programmed cycle. Data were lacking for all other outcomes. We are uncertain if transdermal (delivered via the skin) oestrogens compared with oral (by mouth) oestrogens improve clinical pregnancy rate and miscarriage rate. Data were lacking for all other outcomes in this comparison. Starting progestogen on the day of the donor oocyte retrieval or the day after probably increases the clinical pregnancy rate and probably reduces the cycle cancellation rate. We are uncertain if it reduces the miscarriage rate. Data were lacking for all other outcomes. A cycle with GnRH agonist compared to without may improve live birth rate. We are uncertain of the effect of a GnRH cycle compared to no GnRH for the outcomes of clinical pregnancy rate, miscarriage rate, and endometrial thickness. No study reported on the other outcomes for this comparison. We are uncertain if any GnRH agonist is better than other: a cycle with daily leuprolide or with deposit tryptorelin improves clinical pregnancy rate, or if daily acetate leuprolide or daily nafarelin reduces the miscarriage rate. Other outcomes were not reported. GnRH antagonists compared to agonists probably improve clinical pregnancy rate. We are uncertain of the effect on miscarriage rate and multiple pregnancy rate. No study reported the other outcomes. We are uncertain whether a cycle with aspirin compared to a cycle without improves live birth, clinical pregnancy rate or endometrial thickness. Data were lacking for all other outcomes. We are also uncertain whether a cycle with steroids compared to a cycle without steroids improves live birth rate, clinical pregnancy rate or miscarriage rate. No study reported on the other outcomes. Quality of the evidence The evidence was of moderate to very low‐quality. The main limitations in the evidence were poor reporting of study methods, and lack of precision in the findings for live birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Glujovsky, D, Pesce, R, Sueldo, C, Quinteiro Retamar, AM, Hart, RJ, Ciapponi, A", "articleTypes": [], "doi": "10.1002/14651858.CD006359.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.802Z" }, { "id": "a88cf34a-9669-4ffd-b3bb-f099307edd09", "pmid": "", "title": "Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment", "imported": false, "abstract": "Abstract - Background Early dental decay or demineralised lesions (DLs, also known as white spot lesions) can appear on teeth during fixed orthodontic (brace) treatment. Fluoride reduces decay in susceptible individuals, including orthodontic patients. This review compared various forms of topical fluoride to prevent the development of DLs during orthodontic treatment. This is the second update of the Cochrane Review first published in 2004 and previously updated in 2013. Objectives The primary objective was to evaluate whether topical fluoride reduces the proportion of orthodontic patients with new DLs after fixed appliances. The secondary objectives were to examine the effectiveness of different modes of topical fluoride delivery in reducing the proportions of orthodontic patients with new DLs, as well as the severity of lesions, in terms of number, size and colour. Participant‐assessed outcomes, such as perception of DLs, and oral health‐related quality of life data were to be included, as would reports of adverse effects. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 1 February 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library (searched 1 February 2019), MEDLINE Ovid (1946 to 1 February 2019), and Embase Ovid (1980 to 1 February 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Parallel‐group, randomised controlled trials comparing the use of a fluoride‐containing product versus a placebo, no treatment or a different type of fluoride treatment, in which the outcome of enamel demineralisation was assessed at the start and at the end of orthodontic treatment. Data collection and analysis At least two review authors independently, in duplicate, conducted risk of bias assessments and extracted data. Authors of trials were contacted to obtain missing data or to ask for clarification of aspects of trial methodology. Cochrane's statistical guidelines were followed. Main results This update includes 10 studies and contains data from nine studies, comparing eight interventions, involving 1798 randomised participants (1580 analysed). One report contained insufficient information and the authors have been contacted. We assessed two studies as at low risk of bias, six at unclear risk of bias, and two at high risk of bias. Two placebo (non‐fluoride) controlled studies, at low risk of bias, investigated the professional application of varnish (7700 or 10,000 parts per million (ppm) fluoride (F)), every six weeks and found insufficient evidence of a difference regarding its effectiveness in preventing new DLs (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.14 to 1.93; 405 participants; low‐certainty evidence). One placebo (non‐fluoride) controlled study, at unclear risk of bias, provides a low level of certainty that fluoride foam (12,300 ppm F), professionally applied every two months, may reduce the incidence of new DLs (12% versus 49%) after fixed orthodontic treatment (RR 0.26, 95% CI 0.11 to 0.57; 95 participants). One study, at unclear risk of bias, also provides a low level of certainty that use of a high‐concentration fluoride toothpaste (5000 ppm F) by patients may reduce the incidence of new DLs (18% versus 27%) compared with a conventional fluoride toothpaste (1450 ppm F) (RR 0.68, 95% CI 0.46 to 1.00; 380 participants). There was no evidence for a difference in the proportions of orthodontic patients with new DLs on the teeth after treatment with fixed orthodontic appliances for the following comparisons:
 ‐ an amine fluoride and stannous fluoride toothpaste/mouthrinse combination versus a sodium fluoride toothpaste/mouthrinse,
 ‐ an amine fluoride gel versus a non‐fluoride placebo applied by participants at home once a week and by professional application every three months,
 ‐ resin‐modified glass ionomer cement versus light‐cured composite resin for bonding orthodontic brackets,
 ‐ a 250 ppm F mouthrinse versus 0 ppm F placebo mouthrinse,
 ‐ the use of an intraoral fluoride‐releasing glass bead device attached to the brace versus a daily fluoride mouthrinse. The last two comparisons involved studies that were assessed at high risk of bias, because a substantial number of participants were lost to follow‐up. Unfortunately, although the internal validity and hence the quality of the studies has improved since the first version of the review, they have compared different interventions; therefore, the findings are only considered to provide low level of certainty, because none has been replicated by follow‐up studies, in different settings, to confirm external validity. A patient‐reported outcome, such as concern about the aesthetics of any DLs, was still not included as an outcome in any study. Reports of adverse effects from topical fluoride applications were rare and unlikely to be significant. One study involving fluoride‐containing glass beads reported numerous breakages. Authors' conclusions This review found a low level of certainty that 12,300 ppm F foam applied by a professional every 6 to 8 weeks throughout fixed orthodontic treatment, might be effective in reducing the proportion of orthodontic patients with new DLs. In addition, there is a low level of certainty that the patient use of a high fluoride toothpaste (5000 ppm F) throughout orthodontic treatment, might be more effective than a conventional fluoride toothpaste. These two comparisons were based on single studies. There was insufficient evidence of a difference regarding the professional application of fluoride varnish (7700 or 10,000 ppm F). Further adequately powered, randomised controlled trials are required to increase the certainty of these findings and to determine the best means of preventing DLs in patients undergoing fixed orthodontic treatment. The most accurate means of assessing adherence with the use of fluoride products by patients and any possible adverse effects also need to be considered. Future studies should follow up participants beyond the end of orthodontic treatment to determine the effect of DLs on patient satisfaction with treatment. Plain language summary Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment Review question 
 Ugly white or brown marks sometimes appear on the teeth during treatment with braces to straighten teeth. These are due to early tooth decay and usually occur with fixed, glued‐on 'train track', braces, which make it more difficult to clean the teeth. We know that fluoride in toothpaste helps to prevent tooth decay and think that if extra fluoride is given to people wearing fixed braces, it will protect them from getting these marks. The aim of this Cochrane Oral Health's review was to look at how well fluorides help to prevent early tooth decay during fixed brace treatment and to find out the best way to get fluoride to the teeth. Background 
 Wearing a fixed brace makes it harder for people to keep their teeth clean and may also cause pain. Pain can make it more difficult for people to brush their teeth. This can lead to a build‐up of dental plaque around the brackets that attach the fixed brace to the teeth, and if the plaque stays on the tooth for long enough, it will cause early tooth decay, which looks like white or brown marks (demineralised lesions, also known as white spot lesions). People often wear braces for 18 months or longer and if the decay is left to progress, it can cause holes, which are sometimes bad enough to need fillings to be done in the teeth. Fluoride helps the tooth to heal, reducing tooth decay in people who are at risk of developing it. People receiving fixed brace treatment may be given different forms of fluoride treatment. It is important to think about how the fluoride gets to the teeth. Does the fluoride need to be placed by a dentist or dental nurse, or can people having treatment with braces apply the fluoride to their own teeth? Study characteristics 
 This review is up‐to‐date as of 1 February 2019. The review includes 10 studies but we could only use the information from nine studies involving 1798 randomised people. We have asked for more information about one study. The review looks at eight different ways of applying fluoride to the teeth. People taking part in the studies were all having treatment with fixed braces. The number of people with new decay on the teeth at end of fixed brace treatment, as well as the amount of decay in each person, were measured and counted. We compared the following treatments:
 ‐ dentist or nurse‐applied fluoride e.g. varnish, gel or foam,
 ‐ patient‐applied/used fluoride e.g. toothpaste, mouthwash, gel or foam, and
 ‐ materials that release fluoride over time e.g. glues, elastic bands. Key results 
 One study showed that when the dentist applies a foam with a high level of fluoride in it onto the teeth every time the patient is seen, this might reduce the risk of new decay. Another study found that if patients use a toothpaste with a higher level of fluoride than normal, then this might also reduce the risk of new marks on their teeth. No studies have shown that other ways of giving the teeth extra fluoride reduced the number and/or size of new decay on teeth in people wearing fixed braces. Harmful effects of the different ways of giving the teeth more fluoride were not reported in any of the included studies. Certainty of the evidence 
 The level of belief we have in these findings is low, due to the lack of studies testing the same fluorides and showing the same results. We suggest that more, well‐conducted studies should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Benson, PE; Parkin, N; Dyer, F; Millett, DT; Germain, P", "articleTypes": [], "doi": "10.1002/14651858.CD003809.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "a891077c-846a-44a6-a543-1127a0026295", "pmid": "", "title": "Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection", "imported": false, "abstract": "Abstract - Background Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted infections. The majority of women with genital herpes will have a recurrence during pregnancy. Transmission of the virus from mother to fetus typically occurs by direct contact with virus in the genital tract during birth. Objectives To assess the effectiveness of antenatal antiviral prophylaxis for recurrent genital herpes on neonatal herpes and maternal recurrences at delivery. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2006, Issue 4), MEDLINE (January 1966 to February 2007) and EMBASE (January 1974 to February 2007; handsearched conference proceedings; reviewed bibliographies of all relevant articles for further references; and contacted experts in the field. Selection criteria Randomized controlled trials which assessed the effectiveness of antivirals compared to placebo or no therapy, on neonatal herpes and maternal disease endpoints among pregnant women with genital herpes. Data collection and analysis Two authors independently applied study selection criteria and extracted data. Main results Seven randomized controlled trials (1249 participants) which met our inclusion criteria compared acyclovir to placebo or no treatment (five trials) and valacyclovir to placebo (two trials). The effect of antepartum antiviral prophylaxis on neonatal herpes could not be estimated. There were no cases of symptomatic neonatal herpes in the included studies in either the treatment or placebo groups. Women who received antiviral prophylaxis were significantly less likely to have a recurrence of genital herpes at delivery (relative risk (RR) 0.28, 95% confidence interval (CI) 0.18 to 0.43, I 2 = 0%). Women who received antiviral prophylaxis were also significantly less likely to have a cesarean delivery for genital herpes (RR 0.30, 95% CI 0.20 to 0.45, I 2 = 27.3%). Women who received antiviral prophylaxis were significantly less likely to have HSV detected at delivery (RR 0.14, 95% CI 0.05 to 0.39, I 2 = 0%). Authors' conclusions Women with recurrent genital herpes simplex virus should be informed that the risk of neonatal herpes is low. There is insufficient evidence to determine if antiviral prophylaxis reduces the incidence of neonatal herpes. Antenatal antiviral prophylaxis reduces viral shedding and recurrences at delivery and reduces the need for cesarean delivery for genital herpes. Limited information exists regarding the neonatal safety of prophylaxis. The risks, benefits, and alternatives to antenatal prophylaxis should be discussed with women who have a history and prophylaxis initiated for women who desire intervention. Plain language summary Use of antiviral drugs in late pregnancy for reducing the recurrence of genital herpes at labor and birth and reducing the risk of newborn HSV infection The incidence of herpes, a sexually transmitted disease, varies across the world. Among pregnant women with herpes, nearly 75% can expect at least one flare‐up during their pregnancy. Transmission of the virus from mother to baby typically occurs by direct contact with the virus during birth. It is often recommended that a cesarean should be offered to women with active lesions to reduce the risk of transmission to the baby. In addition, several antiviral agents are available for use both for therapy and for preventing a flare‐up. These antiviral drugs include acyclovir, penciclovir, valacyclovir, and famciclovir. The review assessed whether antiviral drugs given to pregnant women with herpes before a recurrence might be effective in reducing transmission to the baby. Seven studies were identified involving 1249 women. Giving antiviral drugs reduces viral shedding and recurrences at labor and birth. They also reduced the use of cesarean, but there is no evidence of reduction in neonatal herpes. Women should also be informed that the risk of the baby getting herpes during birth is low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Hollier, LM; Wendel, GD", "articleTypes": [], "doi": "10.1002/14651858.CD004946.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "a893d54e-9878-4281-acaa-07c1f27012dd", "pmid": "", "title": "Interventions for chronic palmoplantar pustulosis", "imported": false, "abstract": "Abstract - Background Palmoplantar pustulosis is a chronic inflammatory disease in which sterile, relapsing pustules appear on the palms and soles, possibly in conjunction with other symptoms. The previous Cochrane Review on this topic was published in 2006, before biological treatments were extensively used. Objectives To assess the effects of interventions for chronic palmoplantar pustulosis to induce and maintain complete remission. Search methods We searched the following databases up to March 2019: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of the included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria We considered RCTs including people with palmoplantar pustulosis or chronic palmoplantar pustular psoriasis assessing topical therapy, systemic therapy, combinations of topical or systemic therapies, or non‐pharmacological therapies compared with placebo, no intervention, or each other. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our outcomes included 'Proportion of participants cleared or almost cleared', 'Proportion of participants with adverse effects serious or severe enough to cause withdrawal', 'Proportion of participants with at least 50% improvement in disease severity', and 'Proportion of participants with adverse effects'. Main results We included 37 studies (1663 participants; mean age 50 years (range 34 to 63); 24% males). These studies reported condition severity differently. Around half of the included trials stated the setting (hospitals, community clinics, or both). More than half of the studies were at high risk of bias in at least one domain. Our included studies assessed mainly systemic treatments (retinoids, ciclosporin, biologics, etretinate + PUVA (combination of psoralens and long‐wave ultraviolet radiation) therapy combined, and antibiotics), but also topical treatments (dermocorticoids, vitamin D) and phototherapy (PUVA, ultraviolet A1 (UVA1)). Other interventions were assessed by single studies. The most common comparator was placebo. All results presented in this abstract were assessed in the short term (mean treatment duration was 11 weeks (range 8 to 24 weeks)) and are based on participants with chronic palmoplantar pustulosis. All outcome time point measurements were taken from baseline and assessed at the end of treatment. Short‐term and long‐term outcomes were defined as measurement up to 24 weeks after randomisation and between 24 and 104 weeks after randomisation, respectively. One trial (188 participants) assessed the topical vitamin D derivative maxacalcitol versus placebo and found that maxacalcitol may be more effective than placebo in achieving clearance (risk ratio (RR) 7.83, 95% confidence interval (CI) 1.85 to 33.12; low‐quality evidence), and the risk of adverse effects (such as mild local irritation, pruritus, and haematological or urinary test abnormalities) is probably similar in both groups (RR 0.87, 95% CI 0.64 to 1.19; moderate‐quality evidence). Severity was not reported. Two trials (49 participants) assessed PUVA therapy versus placebo or no treatment, providing very low‐quality evidence. Adverse effects were reported with oral PUVA (including nausea, ankle swelling, and non‐purulent conjunctivitis) and with local PUVA (including blistering, erythema, and pruritus). With regard to the systemic retinoid alitretinoin, one trial (33 participants; moderate‐quality evidence) showed that alitretinoin probably makes little or no difference in reducing severity when compared to placebo (RR 0.69, 95% CI 0.36 to 1.30). A similar number of adverse events were reported in both treatment groups, including headache, cheilitis, nausea, arthralgia, and nasopharyngitis (RR 0.84, 95% CI 0.61 to 1.17). Clearance was not reported. There may be little or no difference between etanercept and placebo in achieving clearance (RR 1.64, 95% CI 0.08 to 34.28; 1 study; 15 participants; low‐quality evidence); however, the 95% CI was very wide, showing there may be a difference between groups. Severity was not measured. More patients treated with placebo may achieve reduced severity than those treated with ustekinumab, but the wide 95% CI indicates there might be little or no difference between groups and there might be greater effect with ustekinumab (RR 0.48, 95% CI 0.11 to 2.13; 1 study; 33 participants; low‐quality evidence). Clearance was not reported. It is uncertain whether guselkumab increases clearance when compared to placebo (2 studies; 154 participants) because the quality of evidence is very low, but guselkumab probably better reduces disease severity (RR 2.88, 95% CI 1.24 to 6.69; 1 study; 49 participants; moderate‐quality evidence). Secukinumab is probably superior to placebo in reducing severity (RR 1.55, 95% CI 1.02 to 2.35; 1 study; 157 participants; moderate‐quality evidence), but our clearance outcome was not reported. None of these trials reported on occurrence of adverse effects. Only two of the studies discussed above reported adverse effects serious or severe enough to cause withdrawal. Guselkumab may cause more serious adverse events when compared to placebo, but there is uncertainty due to the very wide 95% CI showing there may be little or no difference and showing more events with placebo (RR 2.88, 95% CI 0.32 to 25.80; 1 study; 49 participants; low‐quality evidence). Secukinumab probably causes more serious adverse events than placebo (RR 3.29, 95% CI 1.40 to 7.75; 1 study; 157 participants; moderate‐quality evidence). Authors' conclusions Evidence is lacking for major chronic palmoplantar pustulosis treatments such as superpotent corticosteroids, phototherapy, acitretin, methotrexate, and ciclosporin. Risk of bias and imprecision limit our confidence. Maxacalcitol may be more effective than placebo in achieving clearance in the short term (low‐quality evidence), and the risk of adverse effects is probably similar (moderate‐quality evidence). Oral alitretinoin is probably no more effective than placebo in reducing severity, with a similar risk of adverse effects (moderate‐quality evidence). Regarding biological treatments, we are uncertain of the effect of etanercept on clearance and the effect of ustekinumab on severity (low‐quality evidence). Secukinumab and guselkumab are probably superior to placebo in reducing severity (moderate‐quality evidence). Adverse events not requiring withdrawal were not reported for these treatments. Reporting of serious adverse effects was incomplete: compared to placebo, secukinumab probably caused more participant withdrawals (moderate‐quality evidence), but we are uncertain of the effect of guselkumab (low‐quality evidence). Future trials should assess commonly used treatments using validated severity and quality of life scales. Plain language summary Treating long‐term palmoplantar pustulosis (pustules on the hands and feet) Review question We wanted to assess treatments for palmoplantar pustulosis (a persistent condition characterised by small, pus‐filled blisters on the hands and feet), when compared to an inactive substance (placebo), no intervention, or each other. We included 37 studies. Background Palmoplantar pustulosis negatively affects a person's life; there is no cure or standard treatment. Over time, the skin becomes thicker and redder, and may develop cracks or flake off as scales. Symptoms are treated with topical medicines (usually corticosteroids), systemic medicines (medicines injected or taken by mouth that work throughout the entire body; usually medicines based on vitamin A or D), or phototherapy (ultraviolet light treatment). Study characteristics The studies involved 1663 adults (mostly women) 34 to 63 years of age (average age 50 years). In 19 studies, participants had had palmoplantar pustulosis from two to 16 years (average 6.4 years). Participants had palmoplantar pustular psoriasis (6 studies), palmoplantar pustulosis (29 studies), or both (2 studies). Study authors reported condition severity differently. The included studies assessed a variety of different treatments: mainly systemic treatments (including biologic medicines, vitamin A medicines, immunosuppressants, antibiotics, and light therapy combined with a vitamin A medicine), but also topical medicines (containing steroids or vitamin D) and light treatments. Single studies assessed other treatments. Treatments were most commonly compared against placebo. Treatment length varied; for our key results, this ranged from 8 to 24 weeks (average 11 weeks). When reported, studies were conducted in hospitals, community clinics, or both. Pharmaceutical companies funded 18 studies. Key results Low‐quality evidence suggests that maxacalcitol (a topical vitamin D derivative) may work better than placebo in achieving clearance; moderate‐quality evidence indicates that the number of side effects is probably similar in both groups (participants experienced itching, irritation, and blood or urine test abnormalities) (1 trial; 188 participants). Severity was not measured. We found very low‐quality evidence for PUVA therapy (i.e. psoralen, a drug to sensitise the skin, and ultraviolet light A) versus placebo or no treatment (2 studies; 49 participants), so we are unable to draw conclusions. Side effects with PUVA included skin blisters, redness, itching, swelling, and feeling sick. Oral alitretinoin probably makes little or no difference in reducing severity when compared to placebo (moderate‐quality evidence; 1 study; 33 participants). A similar result was found for side effects, with headache, sickness, joint pain, high cholesterol, and colds reported in both groups. Clearance was not reported. Five studies assessed biological treatments (etanercept, ustekinumab, guselkumab, secukinumab), which use substances made from living organisms, or synthetic versions, to target the immune system. Low‐quality evidence (1 study; 15 participants) suggests that etanercept may make little or no difference in clearance when compared to placebo, but we are very uncertain of this result. Side effects and severity were not measured. We found low‐quality evidence suggesting that ustekinumab may be worse than placebo in reducing disease severity, but we are very uncertain of this result. Side effects and clearance were not reported (1 study; 33 participants). Compared to placebo, guselkumab probably reduces severity (moderate‐quality evidence; 1 study; 49 participants), but its effects on clearance are uncertain (very low‐quality evidence; 2 studies; 154 participants). Side effects were not measured. Moderate‐quality evidence shows that secukinumab was probably superior to placebo in reducing severity, but skin clearance and side effects were not reported (1 study; 157 participants). Only two studies described above reported withdrawals from treatment due to serious side effects; these are probably more frequent with secukinumab than with placebo (157 participants), and may occur more often with guselkumab than with placebo (49 participants), but we are very uncertain of the guselkumab result. For these key results, outcomes were assessed between 8 and 24 weeks, which we deemed short term. This evidence is current to March 2019. Quality of the evidence The key comparisons reported clearance most often, but evidence quality was mainly very low. Only two key studies reported side effects causing withdrawal (low‐ and moderate‐quality evidence). The evidence underlying our severity and side effects outcomes was variable in quality (very low to moderate). Small participant numbers, results with wide margins of error, and selective reporting have limited our confidence in the evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Obeid, G; Do, G; Kirby, L; Hughes, C; Sbidian, E; Le Cleach, L", "articleTypes": [], "doi": "10.1002/14651858.CD011628.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "a89fd481-86e3-453f-8cf6-de83347ca9c7", "pmid": "", "title": "Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults", "imported": false, "abstract": "Abstract - Background The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non‐opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. Objectives To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. Selection criteria We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. Data collection and analysis We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. Main results We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after). The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies. IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) −0.50, 95% confidence interval (CI) −0.72 to −0.28; 29 studies, 1656 participants; very low‐quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD −0.14, 95% CI −0.25 to −0.04; 33 studies, 1847 participants; moderate‐quality evidence), and at late time points (48 hours) (SMD −0.11, 95% CI −0.25 to 0.04; 24 studies, 1404 participants; moderate‐quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures. We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) −7.92 hours, 95% CI −12.71 to −3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD −4.52 mg morphine equivalents , 95% CI −6.25 to −2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes. The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low‐quality evidence). IV Lidocaine compared to TEA The effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI −0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI −1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD −1.66, 95% CI −10.88 to 7.56; 2 studies, 102 participants); all very low‐quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low‐quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low‐quality evidence). Authors' conclusions We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review. Plain language summary Intravenous infusion of lidocaine starting at the time of surgery for reduction of pain and improvement of recovery after surgery Background The most common problems immediately following surgery under general anaesthesia are pain, nausea and vomiting, delirium and slow or no movement of food through the digestive system. Opioid medications given to reduce postoperative pain may also be associated with nausea and constipation, also preventing a smooth recovery. It is of interest for patients and clinicians to reduce or prevent these complications leading to an early recovery so that patients can leave hospital earlier. One option for pain relief after surgery is epidural analgesia, where an opioid or local anaesthetic such as lidocaine is injected into the space surrounding the spinal cord. Not all patients may be suited to epidural analgesia, and so additional options such as intravenous non‐opioid analgesic medications that enable a rapid recovery are required. The aim of this review was to assess the benefits and risks of intravenous infusion of lidocaine in patients undergoing various surgical procedures. Lidocaine is a medication used to numb tissue in a specific area. Study characteristics This review was published in 2015, and updated in 2017. We found 68 randomized controlled studies (RCTs), (clinical studies where people are randomly put into one of two or more treatment groups), with results from a total of 4525 participants. RCTs are used because they provide the most reliable evidence. Intravenous lidocaine was compared with placebo or standard care in 66 of the studies, and with thoracic (chest area of spine) epidural analgesia in two studies. (A placebo is an inactive substance or procedure given to a participant in a medical trial to compare its effects with those of a real drug or other intervention). Lidocaine infusion was started during the surgery, before the first cut, and continued to at least the end of surgery. The included studies were moderately well conducted. Key results We are uncertain whether lidocaine infusion reduces pain, one to four hours after surgery when compared to placebo or usual care (29 studies, over 1600 participants). There was probably no difference in pain at 24 hours (33 studies, 1847 participants) and at 48 hours (24 studies, 1404 participants) between participants in the lidocaine and the placebo group. We are uncertain whether lidocaine infusion improves recovery of bowel function, with a reduction in the time to first defaecation or bowel movements (12 studies, 684 participants), and reduced risk of stopping the passage of food in the gut (4 studies, 273 participants). We are also uncertain whether lidocaine reduces postoperative nausea (35 studies, 1903 participants), and the requirement for opioids for pain relief (40 studies, 2201 participants). Only a limited number of studies systematically analysed adverse effects of intravenous lidocaine infusion. The side effects of intravenous lidocaine were unclear. In the two studies that investigated intravenous lidocaine compared to epidural analgesia (102 participants), the effect on pain at 24 and 48 hours, and on the time to first bowel movement, remains unclear. The effect of lidocaine on the risk of stopping the passage of food in the gut and for postoperative nausea is also unclear, as only one small trial assessed these outcomes. Neither study investigated the effect on pain immediately after surgery, or on opioid consumption. Both studies looked at adverse effects associated with lidocaine, but the effect is uncertain. Quality of the evidence We rated the quality of evidence for most outcomes as very low. This was because of inconsistent findings across studies and the fact that the evidence came from small studies that were of moderate design quality or a limited number of studies. The quality of the evidence for minimal or no effect on pain at 24 and 48 hours was moderate quality. The studies involved a variety of surgical procedures. The dose of lidocaine used, and how long it was delivered for after the end of surgery, also varied between studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Weibel, S; Jelting, Y; Pace, NL; Helf, A; Eberhart, LHJ; Hahnenkamp, K; Hollmann, MW; Poepping, DM; Schnabel, A; Kranke, P", "articleTypes": [], "doi": "10.1002/14651858.CD009642.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "a8caa19d-b1fa-4ada-98f3-b46cdf1f4ad1", "pmid": "", "title": "Short‐course oral steroids as an adjunct therapy for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of a short course of oral corticosteroids as an adjunct ('add‐on') therapy in people with chronic rhinosinusitis who are already on standard treatments. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids to placebo or no treatment, where all patients were also receiving pharmacological treatment for chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score, and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results Two trials with a total of 78 participants met the inclusion criteria. Both the populations and the 'standard' treatments differed in the two studies. Oral steroids as an adjunct to intranasal corticosteroids One trial in adults with nasal polyps included 30 participants. All participants used intranasal corticosteroids and were randomised to either short‐course oral steroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 21‐day treatment course) or no additional treatment. None of the primary outcome measures of interest in this review were reported by the study. There may have been an important reduction in the size of the polyps (measured by the nasal polyps score, a secondary outcome measure) in patients receiving oral steroids and intranasal corticosteroids, compared to intranasal corticosteroids alone (mean difference (MD) ‐0.46, 95% confidence interval (CI) ‐0.87 to ‐0.05; 30 participants; scale 1 to 4) at the end of treatment (21 days). This corresponds to a large effect size, but we are very uncertain about this estimate as we judged the study to be at high risk of bias. Moreover, longer‐term data were not available and the other outcomes of interest were not reported. Oral steroids as an adjunct to antibiotics One trial in children (mean age of eight years) without nasal polyps included 48 participants. The trial compared oral corticosteroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 15‐day treatment course) with placebo in participants who also received a 30‐day course of antibiotics. This study addressed one of the primary outcome measures (disease severity) and one secondary outcome (CT score). For disease severity the four key symptoms used to define chronic rhinosinusitis in children (nasal blockage, nasal discharge, facial pressure, cough) were combined into one score. There was a greater improvement in symptom severity 30 days after the start of treatment in patients who received oral steroids and antibiotics compared with placebo and antibiotics (MD ‐7.10, 95% CI ‐9.59 to ‐4.61; 45 participants; scale 0 to 40). The observed mean difference corresponds to a large effect size. At the same time point there was a difference in CT scan score (MD ‐2.90, 95% CI ‐4.91 to ‐0.89; 45 participants; scale 0 to 24). We assessed the quality of the evidence to be low . There were no data available for the longer term (three months). Authors' conclusions There might be an improvement in symptom severity, polyps size and condition of the sinuses when assessed using CT scans in patients taking oral corticosteroids when these are used as an adjunct therapy to antibiotics or intranasal corticosteroids, but the quality of the evidence supporting this is low or very low (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). It is unclear whether the benefits of oral corticosteroids as an adjunct therapy are sustained beyond the short follow‐up period reported (up to 30 days), as no longer‐term data were available. There were no data in this review about the adverse effects associated with short courses of oral corticosteroids as an adjunct therapy. More research in this area, particularly research evaluating longer‐term outcomes and adverse effects, is required. Plain language summary Short‐term oral corticosteroids in addition to other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of adding a short course (typically up to 14 days) of corticosteroid given by mouth to people with chronic rhinosinusitis who were also receiving another type of treatment (such as corticosteroids delivered through the nose). Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling inflammation and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included two randomised controlled trials with a total of 78 participants. One trial involved 30 adults with nasal polyps. Participants received either intranasal corticosteroids and oral corticosteroids or only intranasal corticosteroids. The only result reported of interest to this review was whether the size of the nasal polyps was reduced, when these treatments were completed (three weeks). One trial involved 48 children (mean age of eight years) with chronic rhinosinusitis but no nasal polyps. Participants received either antibiotics and oral corticosteroids or only antibiotics and a placebo (sugar pill). The oral corticosteroids and placebo were given for 15 days and the antibiotics were given for 30 days. The trial reported findings when the antibiotic treatment was completed (at one month). Key results At the end of a three‐week treatment course, people who took both intranasal corticosteroids and oral steroids may have had smaller nasal polyps than people who just received intranasal corticosteroids. The trial did not follow up people to determine whether the polyp size increased after the end of the trial. The trial did not provide information on adverse events or other outcomes important to patients, such as symptom severity or quality of life. Children who received both antibiotics and oral corticosteroids seemed to have a lower total symptom score and better computerised tomography (CT) scan score after treatment compared with children who received antibiotics and control treatment. The reporting of adverse effects in this trial was not very clear and so is difficult to tell if any participant experienced gastrointestinal disturbances, mood changes or difficulty in sleeping. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be very low (we are very uncertain about the estimate) as the evidence comes from one trial that has a low number of participants. The trial had a high risk of bias due to the way it was conducted. The trial did not report adverse events and did not report results after the end of treatment. We judged the quality of the evidence for oral steroids plus antibiotics for children to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate) as the evidence comes from one small trial. The trial did not have a high risk of bias, but it only included children without nasal polyps, who might not have the same results as adults with nasal polyps. The trial did not report results after the end of treatment and the adverse effects of treatment were not well reported.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K, Chong, LY, Hopkins, C, Philpott, C, Schilder, AGM, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.768Z" }, { "id": "a8d01e2c-18dc-4c02-94dc-7cfc96991bd7", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 2. Less commonly‐used drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of mainly cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres (˜ 8200 feet). Acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude ascent. In this second review, in a series of three about preventive strategies for HAI, we assessed the effectiveness of five of the less commonly used classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of five of the less commonly used pharmacological interventions for preventing acute HAI in participants who are at risk of developing high altitude illness in any setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in May 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text search terms. We scanned the reference lists and citations of included trials and any relevant systematic reviews that we identified for further references to additional trials. Selection criteria We included randomized controlled trials conducted in any setting where one of five classes of drugs was employed to prevent acute HAI: selective 5‐hydroxytryptamine(1) receptor agonists; N‐methyl‐D‐aspartate (NMDA) antagonist; endothelin‐1 antagonist; anticonvulsant drugs; and spironolactone. We included trials involving participants who are at risk of developing high altitude illness (AMS or HACE, or HAPE, or both). We included participants with and without a history of high altitude illness. We applied no age or gender restrictions. We included trials where the relevant medication was administered before the beginning of ascent. We excluded trials using these drugs during ascent or after ascent. Data collection and analysis We used the standard methodological procedures employed by Cochrane. Main results We included eight studies (334 participants, 9 references) in this review. Twelve studies are ongoing and will be considered in future versions of this review as appropriate. We have been unable to obtain full‐text versions of a further 12 studies and have designated them as 'awaiting classification'. Four studies were at a low risk of bias for randomization; two at a low risk of bias for allocation concealment. Four studies were at a low risk of bias for blinding of participants and personnel. We considered three studies at a low risk of bias for blinding of outcome assessors. We considered most studies at a high risk of selective reporting bias. We report results for the following four main comparisons. Sumatriptan versus placebo (1 parallel study; 102 participants) Data on sumatriptan showed a reduction of the risk of AMS when compared with a placebo (risk ratio (RR) = 0.43, CI 95% 0.21 to 0.84; 1 study, 102 participants; low quality of evidence). The one included study did not report events of HAPE, HACE or adverse events related to administrations of sumatriptan. Magnesium citrate versus placebo (1 parallel study; 70 participants) The estimated RR for AMS, comparing magnesium citrate tablets versus placebo, was 1.09 (95% CI 0.55 to 2.13; 1 study; 70 participants; low quality of evidence). In addition, the estimated RR for loose stools was 3.25 (95% CI 1.17 to 8.99; 1 study; 70 participants; low quality of evidence). The one included study did not report events of HAPE or HACE. Spironolactone versus placebo (2 parallel studies; 205 participants) Pooled estimation of RR for AMS was not performed due to considerable heterogeneity between the included studies (I² = 72%). RR from individual studies was 0.40 (95% CI 0.12 to 1.31) and 1.44 (95% CI 0.79 to 2.01; very low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Acetazolamide versus spironolactone (1 parallel study; 232 participants) Data on acetazolamide compared with spironolactone showed a reduction of the risk of AMS with the administration of acetazolamide (RR = 0.36, 95% CI 0.18 to 0.70; 232 participants; low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Authors' conclusions This Cochrane Review is the second in a series of three providing relevant information to clinicians and other interested parties on how to prevent high altitude illness. The assessment of five of the less commonly used classes of drugs suggests that there is a scarcity of evidence related to these interventions. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Overall, the evidence is limited due to the low number of studies identified (for most of the comparison only one study was identified); limitations in the quality of the evidence (moderate to low); and the number of studies pending classification (24 studies awaiting classification or ongoing). We lack the large and methodologically sound studies required to establish or refute the efficacy and safety of most of the pharmacological agents evaluated in this review. Plain language summary Medicines less commonly used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and lung conditions that can occur during travel to altitudes above 2500 metres (˜ 8200 feet). HAI‐related conditions are generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but primarily affect the brain (drowsiness, confusion or unconsciousness) or the lungs (cough, breathlessness) in different individuals. We assessed five classes of medicines less commonly used to prevent the onset of this illness in this review. Study characteristics The evidence is current to May 2017. We included eight studies and 334 participants related to five different classes of medicines sometimes recommended for HAI prevention. These medicines included those that mimic the action of serotonin at selected sites (selective 5‐hydroxytryptamine(1) receptor agonists), medicines that regulate the action of calcium (N‐methyl‐D‐aspartate (NMDA) antagonist), medicines that promote dilation of the blood vessels (endothelin‐1 antagonist), medicines that prevent a neuron (nerve cell) from 'firing' (initiating an action) and convulsions from developing (anticonvulsant medicines), as well as medicines that regulate the body´s sodium and water levels (spironolactone). All studies were undertaken in high altitude mountain areas. The participants ranged between 16 and 65 years of age. Only one study included people at a high risk of this condition due to their history of HAI. Four trials provided the intervention between one to three days prior to the ascent (50%), and three trials less than 24 hours prior (37.5%). The participants in all these studies reached a final altitude of between 3500 and 5895 metres above sea level. Only one of the eight included studies did not provide clear information about the source of funding (12.5%). Twenty‐four additional studies were classified as ongoing (12), or awaiting classification (12; unable to obtain full texts). Key results The assessment of the less commonly used pharmacological interventions suggest that there is a scarcity of evidence related to these interventions. For most of the assessed comparisons, we only found evidence from a single study. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Quality of the evidence The quality of the evidence was rated from low to very low. Several studies had quality shortcomings such as only having small sample sizes and therefore generating uncertain results. For most of the medicines evaluated, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Gonzalez Garay, AG, Molano Franco, D, Nieto Estrada, VH, Martí‐Carvajal, AJ, Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD012983", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.743Z" }, { "id": "a8d71a41-b5e7-4b69-8377-9ecedb7917e8", "pmid": "", "title": "A Multicenter, RandoMized, Double-blind, Parallel-grOup, Afluxin® Stick Pack vs. Inactive contRol Clinical Investigation to Evaluate the Performance and Safety in Patients With Gastroesophageal Reflux Disease (GERD)", "imported": false, "abstract": "Gastroesophageal Reflux Disease (GERD) is a chronic condition in which stomach acid flows back into the esophagus, causing irritation and inflammation. GERD is categorized into Nonerosive Reflux Disease (NERD), Erosive Esophagitis (EE), and Barrett's esophagus (BE). Common symptoms include heartburn and acid regurgitation. Lifestyle factors such as smoking, obesity, and Helicobacter pylori infection can increase the risk of developing GERD. The clinical management of GERD typically involves Proton Pump Inhibitors (PPIs) therapy, which, although effective, may not benefit all patients and can be associated with long-term risks. The American College of Gastroenterology (ACG) suggests PPIs discontinuation or on-demand therapy for uncomplicated GERD after an 8-week trial. However, evidence indicates that PPIs are used more frequently, often long-term and in high doses, and not necessarily according to recommendations. Moreover, the availability of Over-The-Counter (OTC) PPIs has led to prolonged use by patients without medical guidance. Concerns have been raised due to potential side effects of long-term PPIs use, including enteric, respiratory, and urinary tract infections, as well as an increased risk of vitamin and mineral deficiencies and osteoporosis.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.159Z" }, { "id": "a8d90438-d43e-4fd3-8865-80533d2ceb94", "pmid": "", "title": "Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer", "imported": false, "abstract": "Abstract - Background Radioactive iodine treatment for differentiated thyroid cancer possibly results in xerostomia. Amifostine has been used to prevent the effects of irradiation to salivary glands. To date, the effects of amifostine on salivary glands in radioactive iodine treated differentiated thyroid cancer remain uncertain. Objectives To assess the effects of amifostine on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer. Search methods Studies were obtained from computerized searches of MEDLINE, EMBASE, The Cochrane Library and paper collections of conferences held in Chinese. Selection criteria Randomised controlled clinical trials and quasi‐randomised controlled clinical trials comparing the effects of amifostine on salivary glands after radioactive iodine treatment for differentiated thyroid cancer with placebo and a duration of follow up of at least three months. Data collection and analysis Two authors independently assessed risk of bias and extracted data. Main results Two trials with 130 patients (67 and 63 patients randomised to intervention versus control) were included. Both studies had a low risk of bias. Amifostine versus placebo showed no statistically significant differences in the incidence of xerostomia (130 patients, two studies), the decrease of scintigraphically measured uptake of technetium‐99m by salivary or submandibular glands at twelve months (80 patients, one study), and the reduction of blood pressure (130 patients, two studies). Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Meta‐analysis was not performed on the function of salivary glands measured by technetium‐99m scintigraphy at three months after high dose radioactive iodine treatment due to the highly inconsistent findings across studies (I 2 statistic 99%). None of the included trials investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions Results from two randomised controlled clinical trials suggest that the amifostine has no significant radioprotective effects on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer patients. Moreover, no health‐related quality of life and other patient‐oriented outcomes were evaluated in the two included trials. Randomised controlled clinical trials with low risk of bias investigating patient‐oriented outcomes are needed to guide treatment choice. Plain language summary Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer Thyroid cancer is the most common malignancy of the endocrine system consisting of several subtypes like papillary carcinoma (accounting for 80% of cases) and follicular carcinoma (accounting for 11% of cases). These are collectively referred to as 'differentiated thyroid cancer'. Treatment with radioactive iodine after surgery (ablation of the thyroid gland or 'thyroidectomy') is important for the detection of metastatic disease and for the destruction of the remaining thyroid tissue with microscopic cancer. After radioactive iodine treatment, adverse effects may happen in the salivary glands and cause salivary gland swelling and pain, usually involving the parotid. The symptoms may develop immediately after a therapeutic dose of radioactive iodine or months later and progress in intensity with time. Secondary complications reported include dry mouth ('xerostomia') and taste alterations. Amifostine is thought to be a radioprotector of salivary glands used in conjunction with radioiodine therapy. This medication is administered intravenously and was reported to ameliorate the damage of salivary glands caused by radioactive iodine therapy. We found only two randomised controlled trials in which the effects of amifostine were compared with placebo. The two randomised clinical trials investigated 130 patients treated with high dose radioactive iodine for thyroid cancer. Altogether data from the two trials suggest that amifostine has no obvious protective effects on the salivary glands in these patients. Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Until better data become available, the use of sour candy or lemon juice to increase salivation might be more appropriate during radioactive iodine treatment for patients with differentiated thyroid cancer. Patients should be well informed of the importance of hydration, acid stimulation and glandular massage after radioactive iodine treatment. In addition, early recognition and treatment of xerostomia may improve outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Ma, C, Xie, J, Chen, Q, Wang, G, Zuo, S", "articleTypes": [], "doi": "10.1002/14651858.CD007956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.755Z" }, { "id": "a8e9b41e-599d-4c3c-bd58-ef677ba76b0e", "pmid": "", "title": "Oral xanthines as maintenance treatment for asthma in children", "imported": false, "abstract": "Abstract - Background Xanthines have been used in the treatment of asthma as a bronchodilator, though they may also have anti‐inflammatory effects. The current role of xanthines in the long‐term treatment of childhood asthma needs to be reassessed. Objectives To determine the efficacy of xanthines (e.g. theophylline) in the maintenance treatment of paediatric asthma. Search methods A search of the Cochrane Airways Group Specialised Register was undertaken with predefined search terms. Searches are current to May 2008. Selection criteria Randomised controlled trials, lasting at least four weeks comparing a xanthine with placebo, regular short‐acting beta‐agonist (SABA), inhaled corticosteroids (ICS), cromoglycate (SCG), ketotifen (KET) or leukotriene antagonist, in children with diagnosed with chronic asthma between 18 months and 18 years old. Data collection and analysis Two reviewers independently selected each study for inclusion in the review and extracted data. Primary outcome was percentage of symptom‐free days. Main results Thirty‐six studies (2838 participants) were included. Xanthine versus placebo (18 studies): The proportion of symptom free days was larger with xanthine compared with placebo (7.97% [95% CI 3.41, 12.53]). Rescue medication usage was lower with xanthine, with no significant difference in symptom scores or hospitalisations. FEV 1 , and PEF were better with xanthine. Xanthine was associated with non ‐ specific side‐effects. Data from behavioural scores were inconclusive. Xanthine versus ICS (four studies) : Exacerbations were less frequent with ICS, but no significant difference on lung function was observed. Individual studies reported significant improvements in symptom measures in favour of steroids, and one study reported a difference in growth rate in favour of xanthine. No difference was observed for study withdrawal or tremor. Xanthine was associated with more frequent headache and nausea. Xanthine versus regular SABA (10 studies): No significant difference in symptoms, rescue medication usage and spirometry. Individual studies reported improvement in PEF with beta‐agonist. Beta‐agonist treatment led to fewer hospitalisations and headaches. Xanthine was associated with less tremor. Xanthine versus SCG (six studies ): No significant difference in symptoms, exacerbations and rescue medication. Sodium cromoglycate was associated with fewer gastro‐intestinal side‐effects than xanthine. Xanthine versus KET (one study): No statistical tests of significance between xanthine and ketotifen were reported. : Xanthine + ICS versus placebo + same dose ICS (three studies) : Results were conflicting due to clinical/methodological differences, and could not be aggregated. Xanthine + ICS versus ICS + leukotriene (one study): Results from one trial One small parallel study did not measure the primary outcome of symptoms; differences between treatments in end of treatment values were not statistically significant. Authors' conclusions Xanthines as first‐line preventer alleviate symptoms and reduce requirement for rescue medication in children with mild to moderate asthma. When compared with ICS they were less effective in preventing exacerbations. Xanthines had similar efficacy as single preventative agent compared with regular SABA and SCG. Evidence on AEs (adverse effects) was equivocal: there was evidence for increased AEs overall, but no evidence that any specific AE (including effects on behaviour and attention) occurred more frequently than with placebo. There is insufficient evidence from available studies to make firm conclusions about the effectiveness of xanthines as add‐on preventative treatment to ICS, and there are no published paediatric studies comparing xanthines with alternatives in this role. Our data suggest that xanthines are only suitable as first‐line preventative asthma therapy in children when ICS are not available. Pre‐trial exposure to the agents assessed may have pre‐disposed the trial populations to tolerate the drug, and may have threatened blinding. They may have a role as add‐on therapy in more severe asthma not controlled by ICS, but further studies are needed to examine this, and to define the risk‐benefit ratio compared with other agents. Plain language summary The effects of oral xanthines (e.g. theophylline) for chronic asthma in children Xanthines (e.g. theophylline) are a group of drugs thought to have helpful preventative and reliever properties in the treatment of asthma in children. This review of studies has established that there is evidence for useful effects of these drugs in terms of symptom relief and lung function, but also some evidence of side‐effects. As a primary preventative therapy , whilst there is evidence that xanthines are effective, this review suggests that more effective alternative treatment options (inhaled steroids) are available. In children with more severe asthma, the role of xanthines as an add‐on therapy has only been assessed in a small number of trials, which report mixed effects. More studies in this area would help to generate a more reliable overview of the effects of treatment in these children. Xanthines are an effective preventative treatment in childhood asthma, but less effective than inhaled steroids, and with a less favourable side‐effect profile. There is insufficient evidence at present to assess their role as \"add‐on\" preventer treatment versus newer alternatives. Some of the trials exposed the children they recruited to a pre‐trial phase of xanthine in order to maintain effective dosing during the trial. This could have made the trial participants less representative of the general population by making them more inclined to tolerate the study drug. This exposure also may have meant that they could recognise what drug they were taking during the blinded phase of the study.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Seddon, P, Bara, A, Lasserson, TJ, Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.767Z" }, { "id": "a8ef9871-5300-45ed-a6a0-efe0c70384bb", "pmid": "", "title": "Oral stimulation for promoting oral feeding in preterm infants", "imported": false, "abstract": "Abstract - Background Preterm infants (< 37 weeks' post‐menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co‐ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review. Objectives To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA. Search methods Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi‐randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis. Selection criteria Randomised and quasi‐randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non‐oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes. Data collection and analysis Following the updated search, two review authors screened the titles and abstracts of studies and full‐text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non‐oral or sham intervention. We performed meta‐analysis using a fixed‐effect model. Main results We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) ‐4.07 days, 95% confidence interval (CI) ‐4.81 to ‐3.32 days, 6 studies, 292 infants; I 2 =85%, very low‐certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD ‐4.33, 95% CI ‐5.97 to ‐2.68 days, 5 studies, 249 infants; i 2 =68%, very low‐certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non‐oral intervention Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non‐oral intervention (MD ‐7.17, 95% CI ‐8.04 to ‐6.29 days, 10 studies, 574 infants; I 2 =80%, very low‐certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD ‐6.15, 95% CI ‐8.63 to ‐3.66 days, 10 studies, 591 infants; I 2 =0%, low‐certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD ‐2.85, 95% CI ‐6.13 to 0.42, 3 studies, 268 infants; very low‐certainty evidence due to serious risk of bias, inconsistency and imprecision). Authors' conclusions There remains uncertainty about the effects of oral stimulation (versus either standard care or a non‐oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta‐analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well‐designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions. Plain language summary Effects of oral stimulation for oral feeding in preterm infants Review questions Do oral stimulation interventions that involve finger stimulation protocols in preterm infants born before 37 weeks' gestation: Reduce time (days) taken to achieve exclusive oral feeding? Reduce time (days) spent in Neonatal Intensive Care (NICU)? Reduce length of time (days) spent in hospital? Reduce length of time (days) that an infant spends on tube feeding (parenteral nutrition)? Background This is an update of the 2016 review. Many preterm infants have delayed establishment of oral (suck) feeding and are fed at first with feeding tubes or with intravenous (parenteral) nutrition. Development of oral feeding skills needs careful co‐ordination of sucking, swallowing and breathing. In preterm infants, the development of oral feeding can be challenging because of long hospitalisations, breathing difficulties and other medical conditions associated with preterm birth. Unpleasant and invasive procedures such as ventilation or frequent suctioning of secretions from the mouth or nose can negatively impact feeding skills. International guidelines for the transition from tube feeding to oral feeding vary widely. Healthcare providers use a range of interventions to improve sucking and feeding skills in preterm infants, and studies report faster transition time from tube feeds to oral feeds, reduced length of stay in hospital and improvement in infants' sucking skills. The first review in 2016 showed that while oral stimulation interventions appear to reduce length of hospital stay, reduce need for tube feeding and accelerate time to oral feeding, the studies were of poor methodological quality leaving some uncertainty about overall effects. This update assessed whether current research supports these findings and if the quality of studies has improved, leading to increased certainty of results. Study characteristics This review included randomised controlled trials (RCTs) that explored oral stimulation by finger stimulation only in preterm infants. Review authors identified studies to be included by searching electronic databases, clinical trials registers, peer‐reviewed journals and published conference proceedings. Search is up‐to‐date as of March 2022. Key results For this update, we added 12 new studies of variable quality with small numbers of participants, making a total of 28 included studies. As the certainty of evidence was considered 'low' to 'very low', it remains uncertain whether oral stimulation interventions can shorten the transition to oral feeding, reduce length of hospital stay and decrease time spent on parenteral nutrition, although there may be some potential benefit. No studies reported length of stay in NICU. No studies looked at longer‐term outcomes of the interventions (i.e. beyond six months). Certainty of evidence The numbers of infants in these studies were small, the methods employed by researchers varied in quality and the certainty of evidence is estimated to be 'low' to 'very low'.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, Z; O'Donnell, CPF; Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD009720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "a8f4e994-7035-451d-91b7-d6b36fe136ae", "pmid": "", "title": "Topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antiseptics, a possible treatment for CSOM, inhibit the micro‐organisms that may be responsible for the infection. Antiseptics can be used alone or in addition to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). However, the effects of topical antiseptics for CSOM remain unclear. This is an update of a review last published in 2020, with one new study added. It is one of a suite of seven Cochrane reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To assess the effects of topical antiseptics for people with CSOM. Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The date of the latest search was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antiseptic agent of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antiseptics (a) compared to placebo or no intervention, and (b) compared to another topical antiseptic (e.g. topical antiseptic A versus topical antiseptic B). Within each comparison, we separated studies into (a) those in which both groups of participants had received aural toileting in addition to the topical antiseptics, and those where neither group had received aural toileting, and (b) those in which both groups had received some other concomitant treatment (such as antibiotics) and those with no such concomitant treatment. Data collection and analysis We used standard Cochrane methodological procedures. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results We found one new study (32 participants) in this update, for a total of six included studies with 435 participants (over four studies), plus 222 ears that could not be accounted for in participant numbers (in two studies). Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics (boric acid versus acetic acid, and boric acid versus hydrogen peroxide). The two core comparisons of interest are reported below; other comparisons are described in the Results section of the review. No study measured health‐related quality of life or ear pain. 1. Topical antiseptic versus placebo or no treatment Three studies (297 participants plus 174 ears) compared topical antiseptics with no treatment. Evidence from one study (unclear number of participants, 174 ears) is very uncertain about the effect of a single application of povidone iodine in hydroxypropyl methyl‐cellulose (HPMC) on resolution of ear discharge at one week compared to HPMC alone; however, these results were only provided by ear (rather than by participant) and therefore could not be used quantitatively (very low‐certainty evidence). One study (254 children; cluster‐RCT) found that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge after four weeks compared with dry mopping alone, but the evidence is very uncertain (risk ratio (RR) 1.73, 95% confidence interval (CI) 1.21 to 2.47; 180 participants; very low‐certainty evidence). We made adjustments to the data to account for the intracluster correlation. This study narratively described no clear differences in suspected ototoxicity or hearing outcomes between study arms, but the evidence is very uncertain (very low‐certainty evidence). Evidence from one study (43 children; 58 ears) is very uncertain about the effect of antiseptics on serious complications. The study reported one case of mastoiditis and one of meningitis with focal encephalitis; however, it was unclear whether these were detected pre‐randomisation or during/after treatment. 2. Topical antiseptics versus no treatment/placebo, where both study arms received systemic antibiotics One study (32 participants) compared topical povidone iodine with placebo (saline) in conjunction with oral amoxicillin and dry mopping. Topical povidone iodine with oral amoxicillin and dry mopping may increase resolution of ear discharge at one to two weeks (RR 3.25, 95% CI 1.35 to 7.84; 32 participants; low‐certainty evidence). The study narratively reported no ototoxicity in the topical antiseptic arm; however, this was unclear for the placebo group, so we do not know if povidone iodine increases suspected ototoxicity (low‐certainty evidence). The study did not assess resolution of ear discharge after four weeks, hearing, or serious complications. Authors' conclusions We are very uncertain about the effect of topical antiseptics on improving resolution of ear discharge in people with CSOM given the low and very low certainty of the evidence, which was mostly due to risk of bias and imprecision. However, there is some evidence suggesting that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge compared with dry mopping alone, and that topical povidone iodine may be more effective than placebo (where both arms used systemic beta‐lactam antibiotics and dry mopping). There is insufficient evidence to draw any conclusions about harmful effects. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and risks of topical antiseptics for treating long‐term middle ear infection (chronic suppurative otitis media)? Key messages • Due to a lack of studies, we are very uncertain of the benefits and risks of topical antiseptics in the treatment of chronic suppurative otitis media (long‐term middle ear infection). • We need more information about possible harmful effects of topical antiseptics, as these were not well reported in the studies. What was studied in the review? Chronic suppurative otitis media (CSOM) is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (eardrum). The main symptoms are ear discharge and hearing loss. Topical antiseptics (antiseptics put directly into the ear as ear drops or as a powder) are sometimes used to treat CSOM. Topical antiseptics kill or stop the growth of the micro‐organisms that may be responsible for the infection. Topical antiseptics can be used on their own or added to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). Applying topical antiseptics can cause irritation of the skin within the outer ear, which may result in discomfort, pain, or itching. Some antiseptics (such as alcohol) can be toxic to the inner ear (ototoxicity), which means they may cause irreparable hearing loss (sensorineural), dizziness, or ringing in the ear (tinnitus). What is the aim of this review? The aim of this Cochrane review was to find out the benefits and risks of topical antiseptics compared to placebo (dummy medicine) or no treatment for CSOM. We also wanted to know whether one topical antiseptic was more effective than another. We collected and analysed all relevant studies to answer this question. This is an update of a review last published in 2020, with one new study added. What are the main results of the review? We included a total of six studies in the review. The total number of people in the studies was unclear, as two studies only reported how many ears were treated. However, there were 435 participants plus 222 ears (between 111 and 222 participants) that could not be accounted for in participant numbers. Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics. Different types of antiseptics were used, some in the form of ear drops and others as powders. No study measured health‐related quality of life or ear pain. Topical antiseptic versus placebo or no treatment (with a background treatment of ear cleaning) Three studies (297 participants plus 174 ears) compared topical antiseptics with placebo/no treatment. Based on evidence from one study (unclear number of participants, 174 ears), we do not know if a single application of antiseptic (povidone iodine plus hydroxypropyl methyl‐cellulose) resolves ear discharge at one to two weeks compared with no treatment. Another study (180 children) compared topical antiseptics (boric acid in alcohol ear drops) with no topical antiseptics. All children also had their ears cleaned daily using cotton wool sticks (dry mopping). It is unclear if antiseptics (boric acid) led to an increase in resolution of ear discharge at four weeks or at three to four months compared with no antiseptics. The same study (254 participants) also reported no clear difference between groups in hearing or suspected ototoxicity (hearing or balance problems that develop as a result of taking a medicine), but the evidence is very uncertain. A third study (43 children; 58 ears) found no clear evidence that antiseptics have any effect on serious complications, but it is not known if this was assessed before, during, or after treatment. Topical antiseptic (povidone iodine) versus no treatment/placebo, where both study groups received systemic antibiotics One study (32 participants) compared one antiseptic (povidone iodine) with placebo (saline). All participants also received oral antibiotics (amoxicillin) and ear cleaning. This study found that topical povidone iodine, when given in addition to antibiotics and ear cleaning, may increase the number of people with resolution of ear discharge at between one and two weeks, compared with placebo plus antibiotics and ear cleaning. We do not know if povidone iodine increases suspected ototoxicity. In their report, the study authors stated there was no ototoxicity in participants in the topical antiseptic group, but this was unclear for the placebo group. There was no information on resolution of ear discharge after four weeks, hearing, or serious complications. What are the limitations of the evidence? There is limited information on certain population groups or treatments. Also, the evidence in the review comes from studies that were not conducted recently. How up‐to‐date is the review? The evidence is current to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K, Chong, LY, Bhutta, MF, Daw, J, Veselinović, T, Morris, PS, Vijayasekaran, S, Schilder, AGM, Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013055.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.096Z" }, { "id": "a90f8d15-04ac-4e72-877c-ed7779f322b1", "pmid": "", "title": "Omega‐3 fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids from oily fish (long‐chain omega‐3 (LCn3)), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha‐linolenic acid (ALA)) may benefit cardiovascular health. Guidelines recommend increasing omega‐3‐rich foods, and sometimes supplementation, but recent trials have not confirmed this. Objectives To assess the effects of increased intake of fish‐ and plant‐based omega‐3 fats for all‐cause mortality, cardiovascular events, adiposity and lipids. Search methods We searched CENTRAL, MEDLINE and Embase to February 2019, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to August 2019, with no language restrictions. We handsearched systematic review references and bibliographies and contacted trial authors. Selection criteria We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation or advice to increase LCn3 or ALA intake, or both, versus usual or lower intake. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed validity. We performed separate random‐effects meta‐analysis for ALA and LCn3 interventions, and assessed dose‐response relationships through meta‐regression. Main results We included 86 RCTs (162,796 participants) in this review update and found that 28 were at low summary risk of bias. Trials were of 12 to 88 months' duration and included adults at varying cardiovascular risk, mainly in high‐income countries. Most trials assessed LCn3 supplementation with capsules, but some used LCn3‐ or ALA‐rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5 g a day to more than 5 g a day (19 RCTs gave at least 3 g LCn3 daily). Meta‐analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all‐cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.93 to 1.01; 143,693 participants; 11,297 deaths in 45 RCTs; high‐certainty evidence), cardiovascular mortality (RR 0.92, 95% CI 0.86 to 0.99; 117,837 participants; 5658 deaths in 29 RCTs; moderate‐certainty evidence), cardiovascular events (RR 0.96, 95% CI 0.92 to 1.01; 140,482 participants; 17,619 people experienced events in 43 RCTs; high‐certainty evidence), stroke (RR 1.02, 95% CI 0.94 to 1.12; 138,888 participants; 2850 strokes in 31 RCTs; moderate‐certainty evidence) or arrhythmia (RR 0.99, 95% CI 0.92 to 1.06; 77,990 participants; 4586 people experienced arrhythmia in 30 RCTs; low‐certainty evidence). Increasing LCn3 may slightly reduce coronary heart disease mortality (number needed to treat for an additional beneficial outcome (NNTB) 334 , RR 0.90, 95% CI 0.81 to 1.00; 127,378 participants; 3598 coronary heart disease deaths in 24 RCTs, low‐certainty evidence) and coronary heart disease events ( NNTB 167 , RR 0.91, 95% CI 0.85 to 0.97; 134,116 participants; 8791 people experienced coronary heart disease events in 32 RCTs, low‐certainty evidence). Overall, effects did not differ by trial duration or LCn3 dose in pre‐planned subgrouping or meta‐regression. There is little evidence of effects of eating fish. Increasing ALA intake probably makes little or no difference to all‐cause mortality (RR 1.01, 95% CI 0.84 to 1.20; 19,327 participants; 459 deaths in 5 RCTs, moderate‐certainty evidence), cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25; 18,619 participants; 219 cardiovascular deaths in 4 RCTs; moderate‐certainty evidence), coronary heart disease mortality (RR 0.95, 95% CI 0.72 to 1.26; 18,353 participants; 193 coronary heart disease deaths in 3 RCTs; moderate‐certainty evidence) and coronary heart disease events (RR 1.00, 95% CI 0.82 to 1.22; 19,061 participants; 397 coronary heart disease events in 4 RCTs; low‐certainty evidence). However, increased ALA may slightly reduce risk of cardiovascular disease events ( NNTB 500 , RR 0.95, 95% CI 0.83 to 1.07; but RR 0.91, 95% CI 0.79 to 1.04 in RCTs at low summary risk of bias; 19,327 participants; 884 cardiovascular disease events in 5 RCTs; low‐certainty evidence), and probably slightly reduces risk of arrhythmia ( NNTB 91 , RR 0.73, 95% CI 0.55 to 0.97; 4912 participants; 173 events in 2 RCTs; moderate‐certainty evidence). Effects on stroke are unclear . Increasing LCn3 and ALA had little or no effect on serious adverse events, adiposity, lipids and blood pressure, except increasing LCn3 reduced triglycerides by ˜15% in a dose‐dependent way (high‐certainty evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐3 fats on cardiovascular health to date. Moderate‐ and low‐certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials). Increasing ALA slightly reduces risk of cardiovascular events and arrhythmia. Plain language summary Omega‐3 intake for cardiovascular disease Review question We reviewed randomised trials (where participants have an equal chance of being assigned to either treatment) examining effects of increasing fish‐ and plant‐based omega‐3 fats on heart and circulatory disease (called cardiovascular diseases, which include heart attacks and stroke), fatness and blood fats (lipids, including cholesterol, triglycerides, high‐density lipoprotein (HDL – 'good' cholesterol) and low‐density lipoprotein (LDL – 'bad' cholesterol)). Background The main types of omega‐3 fats are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), both found in fish, and alpha‐linolenic acid (ALA) found in plant foods. Many people believe that taking omega‐3 supplements reduces risk of heart disease, stroke and death. Trial characteristics The evidence is current to February 2019. The review included 86 trials involving 162,796 people. These trials assessed effects of greater omega‐3 intake versus lower omega‐3 intake for at least a year on heart and circulatory disease. Twenty‐eight trials were very trustworthy (well‐designed so as not to give biased results). Participants were adults, some with existing illness and some healthy, living in North America, Europe, Australia and Asia. Most EPA and DHA trials provided capsules, few gave oily fish. Key results Increasing EPA and DHA has little or no effect on deaths and cardiovascular events (high‐certainty evidence) and probably makes little or no difference to cardiovascular death, stroke, or heart irregularities (moderate‐certainty evidence). However, increasing EPA and DHA may slightly reduce risk of coronary death and coronary events (low‐certainty evidence, coronary events are illnesses of arteries supplying the heart). To prevent one person having a coronary event, 167 people would need to increase their EPA and DHA, and 334 people would need to increase their EPA and DHA to prevent one person dying from coronary disease. EPA and DHA reduce triglycerides by about 15% but do not affect fatness or other lipids (high‐certainty evidence). Eating more ALA (for example, by increasing walnuts or enriched margarine) probably makes little or no difference to all‐cause, cardiovascular or coronary deaths or coronary events but probably slightly reduces cardiovascular events and heart irregularities (moderate‐ or low‐certainty evidence). To prevent one person having a coronary event, 500 people would need to increase their ALA, 91 people to prevent one person having arrhythmia. There is little evidence of effects of eating fish. EPA and DHA reduce triglycerides. EPA, DHA and ALA may be slightly protective of some heart and circulatory diseases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Abdelhamid, AS, Brown, TJ, Brainard, JS, Biswas, P, Thorpe, GC, Moore, HJ, Deane, KHO, Summerbell, CD, Worthington, HV, Song, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD003177.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.802Z" }, { "id": "a911b54b-ec3e-453a-8de2-c2d630d3bbb3", "pmid": "", "title": "Dietary marine fatty acids (fish oil) for asthma in adults and children", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Thien, FCK, De Luca, S, Woods, RK, Abramson, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD001283 AB - Abstract - Background Epidemiological studies suggest that a diet high in marine fatty acids (fish oil) may have beneficial effects on inflammatory conditions such as rheumatoid arthritis and possibly asthma. Objectives (1) To determine the effect of marine n‐3 fatty acid (fish oil) supplementation in asthma.
 (2) To determine the effect of a diet high in fish oil in asthma. Search methods We searched the Cochrane Airways Group Specialised Register. We also searched bibliographies of retrieved trials and contacted fish oil manufacturers. Searches were current as of May 2010. Selection criteria We included randomised controlled trials in patients with asthma more than two years of age. The study duration had to be in excess of four weeks. Double blind trials were preferred, but we also reviewed single‐blind and open trials for possible inclusion. All four reviewers read each paper, blind to its identity. Decisions concerning inclusion were made by simple majority. We all performed quality assessment independently. Data collection and analysis The only comparison possible was between marine n‐3 fatty acid supplementation and placebo. There were insufficient trials to examine dietary manipulation alone. Main results Nine randomised controlled trials conducted between 1986 and 2001 satisfied the inclusion criteria. Seven were of parallel design and two were cross‐over studies. Eight compared fish oil with placebo whilst one compared high dose versus low dose marine n‐3 fatty acid supplementation. Two studies were conducted in children, whilst the remaining seven studies were conducted in adults. None of the included studies reported asthma exacerbations, health status or hospital admissions. There was no consistent effect on any of the analysable outcomes: FEV1, peak flow rate, asthma symptoms, asthma medication use or bronchial hyper reactivity. One of the studies performed in children which combined dietary manipulation with fish oil supplementation showed improved peak flow and reduced asthma medication use. There were no adverse events associated with fish oil supplements. Authors' conclusions There is little evidence to recommend that people with asthma supplement or modify their dietary intake of marine n‐3 fatty acids (fish oil) in order to improve their asthma control. Equally, there is no evidence that they are at risk if they do so. Plain language summary Dietary marine fatty acids (fish oil) for asthma in adults and children Eating more fish has been recommended as one way of possibly reducing asthma. Populations (such as Eskimo communities) with diets high in fish also have low rates of asthma. As diets in other communities have become higher in saturated fats, asthma has also increased. The theory has been that an ingredient in fish oil may reduce inflammation. Inflammation causes the swelling in the airways of the lungs that leads to asthma attacks. However, this review of trials found that people with asthma changing their diets to include more fish oil did not improve their asthma.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.737Z" }, { "id": "a93881f7-8b5a-424a-a9dc-ddd71bd657d2", "pmid": "", "title": "Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption", "imported": false, "abstract": "Abstract - Background Overconsumption of food, alcohol, and tobacco products increases the risk of non‐communicable diseases. Interventions to change characteristics of physical micro‐environments where people may select or consume these products ‐ including shops, restaurants, workplaces, and schools – are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers. Objectives 1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non‐alcoholic beverages), (b) alcohol, and (c) tobacco products. 2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii. participants. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches. Selection criteria We included randomised controlled trials with between‐participants (parallel group) or within‐participants (cross‐over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product. Data collection and analysis We used a novel semi‐automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random‐effects meta‐analysis and meta‐regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE. Main results We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between‐participants designs (19/24). All studies were conducted in high‐income countries, predominantly in the USA (14/24). Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less‐healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta‐analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD −1.13 (95% confidence interval (CI) −1.90 to −0.37) (low certainty evidence). For consumption outcomes, meta‐analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD −0.55 (95% CI −1.27 to 0.18) (low certainty evidence). Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD −0.65 (95% CI −1.29 to −0.01) (very low certainty evidence). For consumption outcomes, meta‐analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD −0.60 (95% CI −0.84 to −0.36) (low certainty evidence). Meta‐regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias. Authors' conclusions The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real‐world settings, intervening across a wider range of foods ‐ as well as alcohol and tobacco products ‐ and over sustained time periods. Plain language summary Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption Unhealthy patterns of consumption of food, alcohol, and tobacco products are important causes of ill health. Changing the availability (the range or amount of options, or both) of these products or their proximity (the distance at which they are positioned) to potential consumers could help people make healthier choices. What is the aim of this review? This review investigated whether altering the availability or proximity of food (including non‐alcoholic beverages), alcohol, and tobacco products changed people's selection (such as purchasing) or consumption of those products. We searched for all available evidence from randomised controlled trials (a type of study in which participants are assigned to one of two or more treatment groups using a random method) to answer this question, and found 24 studies, all of which were conducted in high‐income countries. What are the main results of the review? Six studies involved availability interventions, of which four changed the relative proportion of less‐healthy to healthier options, and two changed the absolute number of different options available. In statistical analyses that combined results from multiple studies, it was found that reducing the number of available options for a particular range or category of food(s) reduced selection of those food products (from analysing 154 participants) and possibly reduced consumption of those products (from 150 participants). However, the certainty of the evidence for these effects was low. Eighteen studies involved proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. One study found that this reduced selection of food (from analysing 41 participants), whilst in a statistical analysis combining results from multiple studies, it was found that placing food farther away reduced consumption of those food products (from analysing 1098 participants). However, the certainty of the evidence for these effects was very low and low, respectively. Key messages Mindful of its limitations, the current evidence suggests that changing the number of available food options or changing where foods are positioned could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes to food environments. However, more high‐quality studies in real‐world settings are needed to make this finding more certain. How up‐to‐date is this review? The evidence is current to 23 July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hollands, GJ; Carter, P; Anwer, S; King, SE; Jebb, SA; Ogilvie, D; Shemilt, I; Higgins, JPT; Marteau, TM", "articleTypes": [], "doi": "10.1002/14651858.CD012573.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "a93d486d-ea21-4424-84fb-8b97efa7b6b9", "pmid": "", "title": "Non‐invasive diagnostic tests for Helicobacter pylori infection", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) infection has been implicated in a number of malignancies and non‐malignant conditions including peptic ulcers, non‐ulcer dyspepsia, recurrent peptic ulcer bleeding, unexplained iron deficiency anaemia, idiopathic thrombocytopaenia purpura, and colorectal adenomas. The confirmatory diagnosis of H pylori is by endoscopic biopsy, followed by histopathological examination using haemotoxylin and eosin (H & E) stain or special stains such as Giemsa stain and Warthin‐Starry stain. Special stains are more accurate than H & E stain. There is significant uncertainty about the diagnostic accuracy of non‐invasive tests for diagnosis of H pylori . Objectives To compare the diagnostic accuracy of urea breath test, serology, and stool antigen test, used alone or in combination, for diagnosis of H pylori infection in symptomatic and asymptomatic people, so that eradication therapy for H pylori can be started. Search methods We searched MEDLINE, Embase, the Science Citation Index and the National Institute for Health Research Health Technology Assessment Database on 4 March 2016. We screened references in the included studies to identify additional studies. We also conducted citation searches of relevant studies, most recently on 4 December 2016. We did not restrict studies by language or publication status, or whether data were collected prospectively or retrospectively. Selection criteria We included diagnostic accuracy studies that evaluated at least one of the index tests (urea breath test using isotopes such as 13 C or 14 C, serology and stool antigen test) against the reference standard (histopathological examination using H & E stain, special stains or immunohistochemical stain) in people suspected of having H pylori infection. Data collection and analysis Two review authors independently screened the references to identify relevant studies and independently extracted data. We assessed the methodological quality of studies using the QUADAS‐2 tool. We performed meta‐analysis by using the hierarchical summary receiver operating characteristic (HSROC) model to estimate and compare SROC curves. Where appropriate, we used bivariate or univariate logistic regression models to estimate summary sensitivities and specificities. Main results We included 101 studies involving 11,003 participants, of which 5839 participants (53.1%) had H pylori infection. The prevalence of H pylori infection in the studies ranged from 15.2% to 94.7%, with a median prevalence of 53.7% (interquartile range 42.0% to 66.5%). Most of the studies (57%) included participants with dyspepsia and 53 studies excluded participants who recently had proton pump inhibitors or antibiotics.There was at least an unclear risk of bias or unclear applicability concern for each study. Of the 101 studies, 15 compared the accuracy of two index tests and two studies compared the accuracy of three index tests. Thirty‐four studies (4242 participants) evaluated serology; 29 studies (2988 participants) evaluated stool antigen test; 34 studies (3139 participants) evaluated urea breath test‐ 13 C; 21 studies (1810 participants) evaluated urea breath test‐ 14 C; and two studies (127 participants) evaluated urea breath test but did not report the isotope used. The thresholds used to define test positivity and the staining techniques used for histopathological examination (reference standard) varied between studies. Due to sparse data for each threshold reported, it was not possible to identify the best threshold for each test. Using data from 99 studies in an indirect test comparison, there was statistical evidence of a difference in diagnostic accuracy between urea breath test‐ 13 C, urea breath test‐ 14 C, serology and stool antigen test (P = 0.024). The diagnostic odds ratios for urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test were 153 (95% confidence interval (CI) 73.7 to 316), 105 (95% CI 74.0 to 150), 47.4 (95% CI 25.5 to 88.1) and 45.1 (95% CI 24.2 to 84.1). The sensitivity (95% CI) estimated at a fixed specificity of 0.90 (median from studies across the four tests), was 0.94 (95% CI 0.89 to 0.97) for urea breath test‐ 13 C, 0.92 (95% CI 0.89 to 0.94) for urea breath test‐ 14 C, 0.84 (95% CI 0.74 to 0.91) for serology, and 0.83 (95% CI 0.73 to 0.90) for stool antigen test. This implies that on average, given a specificity of 0.90 and prevalence of 53.7% (median specificity and prevalence in the studies), out of 1000 people tested for H pylori infection, there will be 46 false positives (people without H pylori infection who will be diagnosed as having H pylori i nfection). In this hypothetical cohort, urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test will give 30 (95% CI 15 to 58), 42 (95% CI 30 to 58), 86 (95% CI 50 to 140), and 89 (95% CI 52 to 146) false negatives respectively (people with H pylori infection for whom the diagnosis of H pylori will be missed). Direct comparisons were based on few head‐to‐head studies. The ratios of diagnostic odds ratios (DORs) were 0.68 (95% CI 0.12 to 3.70; P = 0.56) for urea breath test‐ 13 C versus serology (seven studies), and 0.88 (95% CI 0.14 to 5.56; P = 0.84) for urea breath test‐ 13 C versus stool antigen test (seven studies). The 95% CIs of these estimates overlap with those of the ratios of DORs from the indirect comparison. Data were limited or unavailable for meta‐analysis of other direct comparisons. Authors' conclusions In people without a history of gastrectomy and those who have not recently had antibiotics or proton ,pump inhibitors, urea breath tests had high diagnostic accuracy while serology and stool antigen tests were less accurate for diagnosis of Helicobacter pylori infection.This is based on an indirect test comparison (with potential for bias due to confounding), as evidence from direct comparisons was limited or unavailable. The thresholds used for these tests were highly variable and we were unable to identify specific thresholds that might be useful in clinical practice. We need further comparative studies of high methodological quality to obtain more reliable evidence of relative accuracy between the tests. Such studies should be conducted prospectively in a representative spectrum of participants and clearly reported to ensure low risk of bias. Most importantly, studies should prespecify and clearly report thresholds used, and should avoid inappropriate exclusions. Plain language summary Accuracy of different non‐invasive methods for identifying Helicobacter pylori Why is it important to know whether someone has Helicobacter pylori ? Helicobacter pylori (H pylori) is a type of bacteria which may be present in the stomach of some people. H pylori is believed to cause a number of cancers, including stomach cancer, pancreatic cancer, and throat cancer. H pylori is also linked with other diseases including stomach ulcers, heart burn, and a bloated feeling. If H pylori is found in an individual, appropriate treatment can be started. What is the aim of this review? To compare the accuracy of three different types of test for H pylori. These are: urea breath tests, blood tests (the specific blood test is called serology), and stool tests (in faeces). What was studied in this review? There are two types of urea breath test which use two different forms of carbon known as 13 C and 14 C, as well as multiple versions of serology and stool tests. What are the main results of the review? We found 101 studies which included 11,003 people who were tested for H pylori . Of these 11,003 participants, 5839 (53.1%) had H pylori infection. All the studies used one of the three tests listed above and compared these test results with the diagnosis given by endoscopic biopsy. Endoscopic biopsy involves obtaining tissue from the stomach using a thin flexible tube introduced through the mouth and testing for the presence of H pylori under the microscope. It is currently the most accurate available test, however it causes physical discomfort to the patient, with associated risks for harm. This is in contrast to the alternative non‐invasive tests in this review which are significantly less uncomfortable and have minimal or no risk of harm, making them desirable alternatives if they can be shown to be as accurate at diagnosing H pylori as endoscopic biopsy. Most of the studies included participants with heart burn or similar problems in the stomach and excluded participants who had previously undergone partial removal of the stomach and those having treatment for H pylori . Thirty‐four studies (4242 participants) used serology; 29 studies (2988 participants) used stool antigen test; 34 studies (3139 participants) used urea breath test‐ 13 C; 21 studies (1810 participants) used urea breath test‐ 14 C; and two studies (127 participants) used urea breath test but did not report the type of carbon used. Studies varied in the limit they used before saying a test was positive for H pylori infection and the type of stains used to examine the biopsy material. When we looked at all the data we found that urea breath tests were more accurate than blood and stool tests. The results mean that, on average, if 1000 people are tested, there will be 46 people without H pylori who will be misdiagnosed as having H pylori . Also, there will be 30, 42, 86, and 89 people with H pylori infection for whom the diagnosis of H pylori infection will be missed by urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test, respectively. When we looked at the seven studies which compared urea breath test‐ 13 C and serology, or urea breath test‐ 13 C and stool antigen tests in the same participants, the results were uncertain and we cannot tell which test is more accurate. How reliable are the results of the studies? Except for one study, all the studies were of poor methodological quality, which makes their results unreliable. Who do the results of this review apply to? These results apply to children and adults with suspected H pylori infection, but only in those who have not previously undergone stomach operations and those who have not recently had antibiotics or treatment for H pylori infection. What are the implications of this review? Urea breath tests, blood tests, and stool tests may be suitable for identifying whether someone has H pylori infection. However, the level of the result of urea breath test, blood test, or stool test which should be used to make a diagnosis of H pylori infection remains unclear. How up‐to‐date is the review? We performed a thorough literature search for studies reporting the accuracy of these different tests until 4 March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Best, LMJ, Takwoingi, Y, Siddique, S, Selladurai, A, Gandhi, A, Low, B, Yaghoobi, M, Gurusamy, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.105Z" }, { "id": "a96531b8-c1ff-43fd-a187-9036c8738148", "pmid": "", "title": "Zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance", "imported": false, "abstract": "Abstract - Background Diabetes is associated with long‐term damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity. Insulin resistance is a fundamental aspect of the aetiology of type 2 diabetes. Insulin resistance has been shown to be associated with atherosclerosis, dyslipidaemia, glucose intolerance, hyperuricaemia, hypertension and polycystic ovary syndrome. The mineral zinc plays a key role in the synthesis and action of insulin, both physiologically and in diabetes mellitus. Zinc seems to stimulate insulin action and insulin receptor tyrosine kinase activity. Objectives To assess the effects of zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance. Search methods This review is an update of a previous Cochrane systematic review published in 2007. We searched the Cochrane Library (2015, Issue 3), MEDLINE, EMBASE, LILACS and the ICTRP trial register (from inception to March 2015). There were no language restrictions. We conducted citation searches and screened reference lists of included studies. Selection criteria We included studies if they had a randomised or quasi‐randomised design and if they investigated zinc supplementation compared with placebo or no intervention in adults with insulin resistance living in the community. Data collection and analysis Two review authors selected relevant trials, assessed risk of bias and extracted data. Main results We included three trials with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Risk of bias was unclear for most studies regarding selection bias (random sequence generation, allocation concealment) and detection bias (blinding of outcome assessment). No study reported on our key outcome measures (incidence of type 2 diabetes mellitus, adverse events, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). Evaluation of insulin resistance as measured by the Homeostasis Model Assessment of Insulin Resistance (HOMA‐IR) showed neutral effects when comparing zinc supplementation with control (two trials; 114 participants). There were neutral effects for trials comparing zinc supplementation with placebo for total cholesterol, high‐density lipoprotein (HDL) cholesterol, low‐density lipoprotein (LDL) cholesterol and triglycerides (2 studies, 70 participants). The one trial comparing zinc supplementation with exercise also showed neutral effects for total cholesterol, HDL and LDL cholesterol, and a mean difference in triglycerides of ‐30 mg/dL (95% confidence interval (CI) ‐49 to ‐10) in favour of zinc supplementation (53 participants). Various surrogate laboratory parameters were also analysed in the included trials. Authors' conclusions There is currently no evidence on which to base the use of zinc supplementation for the prevention of type 2 diabetes mellitus. Future trials should investigate patient‐important outcome measures such as incidence of type 2 diabetes mellitus, health‐related quality of life, diabetic complications, all‐cause mortality and socioeconomic effects. Plain language summary Zinc supplementation for the prevention of type 2 diabetes mellitus Review question What are the effects of zinc supplementation compared with placebo or no treatment for the prevention of type 2 diabetes in adults with insulin resistance? Background Some studies have shown that zinc improves glucose levels (glycaemic control) in people with diabetes. As a consequence of diabetes long‐term complications may develop, such as kidney, nerve and eye disease. Also, the risk of cardiovascular complications like heart attacks and strokes is raised. Type 1 diabetes is a form of diabetes where the body cannot produce insulin any more. The risk of developing type 2 diabetes increases with age, obesity and lack of physical activity and is characterised by an increasing inability of the body to make good use of insulin (insulin resistance). The mineral zinc plays a key role in the action of insulin and theoretically zinc supplementation used by people with insulin resistance could prevent the onset of diabetes. Study characteristics We included three randomised controlled studies with a total of 128 participants in this review. The duration of zinc supplementation ranged between four and 12 weeks. Key results No study reported on our patient‐important key outcomes (new onset of type 2 diabetes mellitus, side effects, health‐related quality of life, all‐cause mortality, diabetic complications, socioeconomic effects). The effects of zinc supplementation are uncertain regarding insulin resistance and lipid levels in the blood (mainly cholesterol and triglycerides). Quality of evidence The overall quality of the included studies was unclear because study authors did not provide important information for us to judge how the studies were performed (unclear risk of bias in most cases). In addition, the number of studies and participants is low and the study authors did not investigate important outcomes such as new onset of type 2 diabetes mellitus or side effects of zinc supplementation. Currentness of evidence This evidence is up to date as of March 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El Dib, R, Gameiro, OLF, Ogata, MSP, Módolo, NSP, Braz, LG, Jorge, EC, do Nascimento Junior, P, Beletate, V", "articleTypes": [], "doi": "10.1002/14651858.CD005525.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.752Z" }, { "id": "a970743c-4f27-4584-9c80-944ef3449334", "pmid": "", "title": "Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Tan, ML, Ho, JJ, Teh, KH", "articleTypes": [], "doi": "10.1002/14651858.CD009398.pub3 AB - Abstract - Background About 5% of school children have a specific learning disorder, defined as unexpected failure to acquire adequate abilities in reading, writing or mathematics that is not a result of reduced intellectual ability, inadequate teaching or social deprivation. Of these events, 80% are reading disorders. Polyunsaturated fatty acids (PUFAs), in particular, omega‐3 and omega‐6 fatty acids, which normally are abundant in the brain and in the retina, are important for learning. Some children with specific learning disorders have been found to be deficient in these PUFAs, and it is argued that supplementation of PUFAs may help these children improve their learning abilities. Objectives 1. To assess effects on learning outcomes of supplementation of polyunsaturated fatty acids (PUFAs) for children with specific learning disorders.
 2. To determine whether adverse effects of supplementation of PUFAs are reported in these children. Search methods In November 2015, we searched CENTRAL, Ovid MEDLINE, Embase, PsycINFO, 10 other databases and two trials registers. We also searched the reference lists of relevant articles. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing PUFAs with placebo or no treatment in children younger than 18 years with specific learning disabilities, as diagnosed in accordance with the fifth (or earlier) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5), or the 10th (or earlier) revision of the International Classification of Diseases (ICD‐10) or equivalent criteria. We included children with coexisting developmental disorders such as attention deficit hyperactivity disorder (ADHD) or autism. Data collection and analysis Two review authors (MLT and KHT) independently screened the titles and abstracts of articles identified by the search and eliminated all studies that did not meet the inclusion criteria. We contacted study authors to ask for missing information and clarification, when needed. We used the GRADE approach to assess the quality of evidence. Main results Two small studies involving 116 children, mainly boys between 10 and 18 years of age, met the inclusion criteria. One study was conducted in a school setting, the other at a specialised clinic. Both studies used three months of a combination of omega‐3 and omega‐6 supplements as the intervention compared with placebo. Although both studies had generally low risk of bias, we judged the risk of reporting bias as unclear in one study, and as high in the other study. In addition, one of the studies was funded by industry and reported active company involvement in the study. None of the studies reported data on the primary outcomes of reading, writing, spelling and mathematics scores, as assessed by standardised tests. Evidence of low quality indicates that supplementation of PUFAs did not increase the risk of gastrointestinal disturbances (risk ratio 1.43, 95% confidence interval 0.25 to 8.15; two studies, 116 children). Investigators reported no other adverse effects. Both studies reported attention deficit hyperactivity disorder (ADHD)‐related behaviour outcomes. We were unable to combine the results in a meta‐analysis because one study reported findings as a continuous outcome, and the other as a dichotomous outcome. No other secondary outcomes were reported. We excluded one study because it used a cointervention (carnosine), and five other studies because they did not provide a robust diagnosis of a specific learning disorder. We identified one ongoing study and found three studies awaiting classification. Authors' conclusions Evidence is insufficient to permit any conclusions about the effect of PUFAs on the learning abilities of children with specific learning disorders. Well‐designed RCTs with clearly defined populations of children with specific learning disorders who have been diagnosed by standardised diagnostic criteria are needed. Plain language summary Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders Review question We reviewed the evidence on the effects of polyunsaturated fatty acids (PUFAs), compared with placebo or no treatment, on reading, writing or mathematical abilities of children up to 18 years of age who have specific learning disorders. Background Children with specific learning disorders are those whose abilities in reading, spelling, writing and mathematics are considerably below what is expected for their age, and whose problems are not a result of lower intelligence, inadequate teaching or social deprivation. A child may have a single disorder, such as a reading disorder, or a combined disorder, such as a reading and mathematics disorder. Children may have other problems too, such as attention deficit hyperactivity disorder (ADHD), along with a specific learning disorder. Polyunsaturated fatty acids are known to be necessary for normal brain development and function. The best known PUFAs are the omega‐3 fatty acids, which include docosahexaenoic acid (commonly known as DHA), but the omega‐6 fatty acids are also well known. Polyunsaturated fatty acids must be obtained from foods or supplements, as the human body cannot make them from other types of fat. Because they are needed for normal brain growth and development, PUFAs might help children with specific learning disorders. Study characteristics The evidence is current to November 2015. We found two small studies involving 116 children that met our inclusion criteria. Both studies gave children a combination of omega‐3 and omega‐6 capsules as the intervention for three months. Most of these studies involved boys between 10 and 18 years of age ‐ one was conducted in a school setting, and the other at a specialised clinic. One of the studies was funded by the company that supplied the omega‐3 and omega‐6 supplements. Another study could not be included in this review because investigators added carnosine (an amino acid that is highly concentrated in the brain) to the PUFAs. Carnosine and PUFAs might have similar effects, so it would not be possible to separate the effects of the two ingredients. Review authors excluded five studies because it was not confirmed that a specific learning disorder was diagnosed in these children. Key results None of the included studies reported effects of PUFAs on reading, writing, spelling or mathematical abilities of children. Evidence of low quality (because studies included few participants and showed evidence of bias) suggests that using PUFAs did not increase the risk of minor disturbances to the digestive system. Included studies reported no other types of adverse effects. Both studies reported on ADHD‐related behaviour. However, the format of available data did not allow us to readily combine them or to reach any conclusions. Included studies reported no other secondary outcomes. Conclusion Evidence is not sufficient to support or refute the use of PUFAs in children with specific learning disorders.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.069Z" }, { "id": "a971ce08-904f-4f68-9a19-70ecd7b92563", "pmid": "", "title": "Antipsychotics for fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue. It affects approximately 2% of the general population. Up to 70% of patients with fibromyalgia meet the criteria for a depressive or anxiety disorder. People often report high disability levels and poor health‐related quality of life. Drug therapy focuses on reducing key symptoms and disability, and improving health‐related quality of life. Antipsychotics might reduce fibromyalgia and associated mental health symptoms. Objectives To assess the efficacy, tolerability and safety of antipsychotics in fibromyalgia in adults. Search methods We searched CENTRAL (2016, Issue 4), MEDLINE and EMBASE to 20 May 2016, together with reference lists of retrieved papers and reviews and two clinical trial registries. We also contacted trial authors. Selection criteria We selected controlled trials of at least four weeks duration of any formulation of antipsychotics used for the treatment of fibromyalgia in adults. Data collection and analysis We extracted the data from all included studies and two review authors independently assessed study risks of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. We derived first tier evidence from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs, at least 200 participants in the comparison, eight to 12 weeks duration, parallel design), second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison, and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. We rated the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main results We included a total of four studies with 296 participants. Three studies with 206 participants compared quetiapine, an atypical (second‐generation) antipsychotic, with placebo. One study used a cross‐over design and two studies a parallel‐group design. Study duration was eight or 12 weeks. Quetiapine was used in all studies with a bedtime dosage between 50 and 300 mg/day. All studies had one or more sources of potential major bias and we judged them to be at moderate risk of bias overall. The primary outcomes in this review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Second tier evidence indicated that quetiapine was not statistically superior to placebo in the number of participants with a 50% or more pain reduction (very low quality evidence). No study reported data on PGIC. A greater proportion of participants on quetiapine reported a 30% or more pain reduction (risk difference (RD) 0.12, 95% confidence interval (CI) 0.00 to 0.23; number needed to treat for an additional benefit (NNTB) 8, 95% CI 5 to 100) (very low quality evidence). A greater proportion of participants on quetiapine reported a clinically relevant improvement of health‐related quality of life compared to placebo ( RD 0.18, 95% CI 0.05 to 0.31; NNTB 5, 95% CI 3 to 20) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing sleep problems (standardised mean difference (SMD) ‐0.67, 95% CI ‐1.10 to ‐0.23), depression (SMD ‐0.39, 95% CI ‐0.74 to ‐0.04) and anxiety (SMD ‐0.40, 95% CI ‐0.69 to ‐0.11) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing the risk of withdrawing from the study due to a lack of efficacy (RD ‐0.14, 95% CI ‐0.23 to ‐0.05) (very low quality evidence). There was no statistically significant difference between quetiapine and placebo in the proportion of participants withdrawing due to adverse events (tolerability) (very low quality evidence), in the frequency of serious adverse events (safety) (very low quality evidence) and in the proportion of participants reporting dizziness and somnolence as an adverse event (very low quality evidence). In more participants in the quetiapine group a substantial weight gain was noted (RD 0.08, 95% CI 0.02 to 0.15; number needed to treat for an additional harm (NNTH) 12, 95% CI 6 to 50) (very low quality evidence). We downgraded the quality of evidence by three levels to a very low quality rating because of limitations of study design, indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). One parallel design study with 90 participants compared quetiapine (50 to 300 mg/day flexible at bedtime) to amitriptyline (10 to 75 mg/day flexible at bedtime). The study had three major risks of bias and we judged it to be at moderate risk of bias overall. We downgraded the quality of evidence by two levels to a low quality rating because of indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). Third tier evidence indicated no statistically significant differences between the two drugs. Both drugs did not statistically significantly differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life and in the proportion of participants reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared to amitriptyline, more participants left the study due to adverse events (low quality evidence). No serious adverse events were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia. Authors' conclusions Very low quality evidence suggests that quetiapine may be considered for a time‐limited trial (4 to 12 weeks) to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits in shared decision making with the patient. Plain language summary Antipsychotics for fibromyalgia symptoms in adults Bottom line Quetiapine may be considered for 4 to 12 weeks to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as sleep problems, problems with thinking and exhaustion. They often report severe limitations of daily functioning and poor quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. In addition, many patients with fibromyalgia suffer from depression. Medicines used to treat depression can reduce the main symptoms in some people with fibromyalgia. Quetiapine is a drug for the treatment of psychosis (an abnormal condition of the mind described as involving a loss of contact with reality), which is also licensed for the treatment of major depression in some countries. Study characteristics In May 2016, we searched for clinical trials in which antipsychotics were used to treat symptoms of fibromyalgia in adults. We found a total of four studies with 298 participants. We found three studies with 208 participants, which were eight and 12 weeks long and compared quetiapine, an antipsychotic, against a fake medication (placebo). One hundred and sixty‐six participants were diagnosed with major depression. We also found one study comprising 90 patients that compared quetiapine to an antidepressant named amitriptyline, which is frequently used in the treatment of fibromyalgia. Five people in this study were diagnosed with major depression. Key results and quality of the evidence Quetiapine was not better than a fake medication in achieving a pain reduction of 50% or more (very low quality evidence). Quetiapine was better than the fake medication in achieving a pain reduction of 30% or more, reducing sleep problems, and improving depressed mood and anxiety (very low quality evidence). Quetiapine was better than the fake medication in improving health‐related quality of life. Fewer participants dropped out of the trial due to lack of efficacy with quetiapine than with fake medication (very low quality evidence). There was no difference in tolerability and safety between quetiapine and a fake medication (very low quality evidence). For some people, quetiapine led to substantial weight gain and somnolence (sleepiness). Quetiapine and amitriptyline (an antidepressant which is frequently used to improve sleep and reduce pain in people with fibromyalgia) did not differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life. Both drugs did not differ in the proportion of patients reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared with amitriptyline, more people experienced side effects and left the study due to side effects with quetiapine (low quality evidence). No serious side effects with either drug were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B, Klose, P, Üçeyler, N, Phillips, T, Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011804.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.793Z" }, { "id": "a98421c8-3965-444c-91a4-154fc64ac11b", "pmid": "", "title": "Environmental enrichment for stroke and other non‐progressive brain injury", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Qin, H, Reid, I, Gorelik, A, Ng, L", "articleTypes": [], "doi": "10.1002/14651858.CD011879.pub2 AB - Abstract - Background Rehabilitation is effective for recovery after stroke and other non‐progressive brain injuries but it is unclear if the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. Environmental enrichment is a relatively new concept within rehabilitation for humans. In this review, this is defined as an intervention designed to facilitate physical (motor and sensory), cognitive and social activity by the provision of equipment and organisation of a structured, stimulating environment. The environment should be designed to encourage (but not force) activities without additional specialised rehabilitation input. Objectives To assess the effects of environmental enrichment on well‐being, functional recovery, activity levels and quality of life in people who have stroke or non‐progressive brain injury. Search methods We conducted the search on 26 October 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers. Selection criteria We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services. Data collection and analysis Two review authors independently assessed eligible studies, extracted data, and assessed study quality. Any disagreements were resolved through discussion with a third review author. We determined the risk of bias for the included study and performed a 'best evidence' synthesis using the GRADE approach. Main results We identified one RCT, involving 53 participants with stroke, comparing environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. We excluded five studies, found two studies awaiting classification and one ongoing study which described environmental enrichment in their interventions. Of the excluded studies, three were non‐RCTs and two described co‐interventions with a significant component of rehabilitation. Based on the single small included RCT at high risk of bias, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the provision of environmental enrichment. Authors' conclusions The gap in current research should not, however, be interpreted as proof that environmental enrichment is ineffective. Further research is needed with robust study designs, such as cluster RCTs, and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (inpatient versus outpatient), the relative effectiveness of various components of environmental enrichment, cost‐effectiveness, and safety of the intervention in people following stroke or other non‐progressive brain injuries. It should be noted, however, that it is challenging to randomise or double‐blind trials of environmental enrichment given the nature of the intervention. Plain language summary Treatment using environmental enrichment for supporting rehabilitation following stroke and other brain injuries which do not get worse over time (non‐progressive brain injury) Background Rehabilitation helps with recovery after stroke and other non‐progressive brain injuries through therapy. However, outside of therapy hours, people may have very little to keep them stimulated. Environmental enrichment is a relatively new concept in rehabilitation where the environment itself is designed to be engaging and to include physical, thinking, and social activities like exercises and games. For example, a nursery for babies may be interesting and stimulating but a hospital environment for adults is generally not. The design of the environment alone should encourage (but not force) activities without additional specialised rehabilitation. Review question 
We wanted to find out whether treatment with environmental enrichment is better or worse than alternatives. Search date 
The evidence is current to 26 October 2020. Study characteristics 
Population: we planned to include studies in which participants were adults who had had a stroke or a non‐progressive brain injury (such as traumatic brain injury but not dementia, Alzheimer's diease, or multiple sclerosis). Intervention: environmental enrichment interventions will usually include multiple activities, such as computers plus gaming technology plus music and reading. Comparison: we planned to compare environmental interventions with usual care (regular physiotherapy, speech therapy, occupational therapy) or alternative treatment. Outcomes: we divided outcomes into primary and secondary outcomes. Primary outcomes focused on psychological well‐being (anxiety, depression, stress) and coping. Secondary outcomes focused on quality of life, physical function, communication and cognitive function, and activity levels. We also planned to report adverse events. Key results 
We found one trial that compared environmental intervention alone with usual care or alternative treatment. The trial included 53 participants who had had a stroke and was based in a hospital rehabilitation ward. The trial compared environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services. The main outcomes related to psychological well‐being and coping. We were uncertain of the results because the trial was very small and highly prone to bias. Conclusion 
The gap in current research does not mean that environmental enrichment is ineffective. Further research is needed with strong study designs and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (in hospital versus out of hospital), which components of environmental enrichment are effective, whether environmental enrichment is cost‐effective, and if it is safe for people following stroke or other non‐progressive brain injuries.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.798Z" }, { "id": "a98f442c-4625-4753-87d6-b2192d0cb473", "pmid": "", "title": "Interventions for cleaning dentures in adults", "imported": false, "abstract": "Abstract - Background Removing denture plaque may be essential for maintaining the oral health of edentulous people. Brushing and soaking in chemical products are two of the most commonly used methods of cleaning dentures. Objectives To evaluate the effectiveness and safety of different methods for cleansing removable dentures. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to May 2009); CENTRAL ( The Cochrane Library 2009, Issue 2); MEDLINE (1965 to May 2009); EMBASE (1980 to May 2009); LILACS (1980 to May 2009); and CINAHL (1997 to May 2009). There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing any mechanical method (e.g. brushing or ultrasound) or chemical (e.g. enzymes, sodium hypochlorite, oral rinses or peroxide solutions) in adults over the age of 18 wearing removable partial dentures or complete dentures. The primary outcomes considered were the health of denture bearing areas (soft tissues, periodontal tissues and teeth) and participants' satisfaction and preference. Secondary outcomes included denture plaque coverage area, indicators of halitosis and microbial counts on abutment teeth, soft tissues or denture base or saliva. Data collection and analysis Two independent review authors screened and extracted information from, and independently assessed the risk of bias in the included trials. Main results Although six RCTs were included in this review, the wide range of different interventions and outcome variables did not permit pooling of data in a meta‐analysis. Isolated reports indicated that chemicals and brushing appear to be more effective than placebo in the reduction of plaque coverage and microbial counts of anaerobes and aerobes on complete denture bases. Authors' conclusions There is a lack of evidence about the comparative effectiveness of the different denture cleaning methods considered in this review. Few well designed RCTs were found. Future research should focus on comparisons between mechanical and chemical methods; the assessment of the association of methods, primary variables and costs should also receive future attention. Plain language summary Interventions for cleaning dentures in adults Plaque formed on the surfaces of removable dentures can have a significant impact on oral health, as long as it can lead to infection of denture‐supporting mucosa (stomatitis), gum inflammation (gingivitis) and tooth decay. Denture plaque can be removed by several different methods which include: brushing with paste, soaking in chemicals (e.g. effervescent tablets or bleach) and using special devices (a microwave oven or ultrasonic device). This review found weak evidence in support of soaking of dentures in effervescent tablets or enzymatic solutions and that brushing with paste can remove plaque and kill microbes better than inactive treatments. It is, however, unclear which is the most effective and there is a paucity of data on the use of alternative methods. Futures studies should aim to provide reliable information about which method is more effective in maintaining oral health of removable denture wearers. The scarce data found was restricted to the cleansing of complete dentures made from an acrylic resin base. Further research should also investigate how removable partial dentures can be cleaned, and in particular on the corrosive effects of cleaners on their metallic components.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "de Souza, RF; de Freitas Oliveira Paranhos, H; Lovato da Silva, CH; Abu‐Naba'a, L; Fedorowicz, Z; Gurgan, CA", "articleTypes": [], "doi": "10.1002/14651858.CD007395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "a99037fc-07e2-443f-8ab2-f686b2cc80d8", "pmid": "", "title": "D‐penicillamine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is used for patients with primary biliary cirrhosis due to its hepatic copper decreasing and immunomodulatory potentials. The results from randomised clinical trials have been inconsistent. Objectives To systematically review the beneficial and harmful effects of D‐penicillamine for patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register (September 2003), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2003) , MEDLINE (January 1966 to September 2003) , EMBASE (January 1980 to September 2003) , The Chinese Biomedical CD Database (January 1979 to August 2003) , and LILACS (1982 to 2003); through manual searches of bibliographies; and by contacting authors of the trials and pharmaceutical companies. Selection criteria We included randomised clinical trials comparing D‐penicillamine with placebo/no intervention or other control intervention irrespective of language, year of publication, and publication status. Data collection and analysis Two reviewers independently assessed the methodological quality of the trials and extracted data, validated by a third reviewer. The primary outcomes were 1) mortality and 2) a combination of those who died or underwent liver transplantation. We analysed dichotomous outcomes as relative risk (RR) with 95% confidence interval (CI) by a fixed effect model and a random effects model. We investigated sources of heterogeneity by subgroup analyses and tested the robustness of our findings by sensitivity analyses. Main results We included seven trials randomising 706 patients with primary biliary cirrhosis. D‐penicillamine compared with placebo/no intervention tended to increase mortality (RR 1.34, 95% CI 1.09 to 1.64, fixed; RR 1.46, 95% CI 0.85 to 2.50, random). However, there was substantial heterogeneity. No significant differences were detected regarding the risks of mortality or liver transplantation, pruritus, liver complications, progression of liver histological stage, or the levels of liver biochemical variables (except alanine aminotransferase). D‐penicillamine versus placebo/no intervention significantly increased the risk of adverse events (RR 3.11, 95% CI 2.33 to 4.16, fixed; RR 4.18, 95% CI 1.38 to 12.69, random). Authors' conclusions D‐penicillamine did not appear to reduce the risk of mortality, but significantly increased the occurrences of adverse events in patients with primary biliary cirrhosis. We do not support the use of D‐penicillamine for patients with primary biliary cirrhosis. Plain language summary D‐penicillamine did not reduce the risk of mortality of patients with primary biliary cirrhosis but increased the occurrences of adverse events Primary biliary cirrhosis is an uncommon, chronic liver disease of unknown etiology. D‐penicillamine, a cupruretic drug, has been tested in randomised clinical trials and is used to treat patients with primary biliary cirrhosis. After combining results from seven trials, D‐penicillamine did not appear to improve survival of patients. D‐penicillamine was associated with a four‐time increase of adverse events. There were no significant differences between D‐penicillamine and placebo/no intervention with respect to clinical changes, liver histology, and liver biochemistry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y, Klingenberg, SL, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004789.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.067Z" }, { "id": "a99f633a-1893-4001-a4a4-798990b9163a", "pmid": "", "title": "Prognostic models for radiation‐induced complications after radiotherapy in head and neck cancer patients", "imported": false, "abstract": "Abstract - Background Radiotherapy is the mainstay of treatment for head and neck cancer (HNC) but may induce various side effects on surrounding normal tissues. To reach an optimal balance, normal tissue complication probability (NTCP) models have been reported to predict the risk of radiation‐induced side effects in patients with HNC. However, the quality of study design, conduct, and analysis (i.e. risk of bias (ROB)), as well as the predictive performance of these models, remains to be evaluated. Objectives To identify, describe and appraise NTCP models to predict the risk of radiation‐induced side effects in patients with HNC. Search methods We searched Ovid MEDLINE, Embase and the World Health Organization International Clinical Trials Registry Platform from conception to January 2024. In addition, we screened references cited in the retrieved articles. Selection criteria Two review authors independently included articles reporting on the development and external validation of NTCP models to predict any type of radiation‐induced side effects in patients with HNC. Data collection and analysis One reviewer extracted data from each article and assessed their applicability and ROB, while another reviewer carefully verified the results. For models externally validated at least twice for the same outcome as their original developmental study, we performed qualitative analyses of the model performance. The GRADE system was not applied, since it has not been established for reviews of prognostic model studies. Main results Amongst 617 models developed from 152 articles, including 162,527 HNC patients, only 58 (9%) models from seven articles were judged to have low ROB and low concerns for applicability. No external validation was performed for 481 models (78%). For the remaining 136 models and six additional models which were not eligible for the present review, 193 external validations were performed in 48,852 patients with HNC in 39 articles. Models for salivary‐related outcomes Amongst 285 models, two models were externally validated at least twice. The Beetz 2012b model for xerostomia six months after radiotherapy was validated in two studies. C‐statistics ranged from 0.70 to 0.74. Calibration performance was reported in one study. One validation study was rated as having low ROB in all domains, while the other was rated as having high ROB in the analysis domain. The Cavallo 2021 model for acute xerostomia during radiotherapy for patients with nasopharyngeal cancer was externally validated in the same study, using two different types of cohorts. C‐statistics ranged from 0.68 to 0.73 and calibration plots were reported in both cohorts. Both validations were rated as having unclear ROB in the participants' domain because no detailed information about recruiting was provided. Models for swallowing‐related outcomes Amongst 85 models, two models were externally validated at least twice. The Christianen 2012 model for dysphagia six months after radiotherapy was validated in five studies. C‐statistics ranged from 0.66 to 0.75. Calibration performance was assessed in all of them, while four of them were rated as having high ROB in the analysis domain due to the small sample size. The Wopken 2014b model for tube feeding dependence six months after radiotherapy was validated in three external validation studies. C‐statistics ranged from 0.79 to 0.95, while calibration was evaluated in all studies. Due to the small size of the validation datasets, they were judged as having high ROB in the analysis domain. Models for hypothyroidism Of 72 models for hypothyroidism, two models were externally validated at least twice. In addition, there was another model which was not originally developed for patients with HNC, but validated in this domain. The Boomsma 2012 for hypothyroidism within two years after radiotherapy was externally validated in two studies. C‐statistics ranged from 0.64 to 0.74, while only one study reported its calibration performance. Both validation studies were rated as having high ROB in the analysis domain. The Ronjom 2013 model for radiation‐induced hypothyroidism was validated in three studies. C‐statistics ranged from 0.65 to 0.69 and calibration plots were reported in only one study. Two validation studies were judged as having high and the other was rated as having unclear ROB in the analysis domain. The Cella 2012 model was originally developed to predict radiation‐induced hypothyroidism in patients with Hodgkin’s lymphoma. In two validation studies in patients with HNC, c‐statistics ranged from 0.65 to 0.68, but calibration performance was not reported. One validation study was rated as having a high ROB and the other was rated as being unclear in the analysis domain. Models for brain and nerve‐related outcomes Amongst 40 models, three were externally validated at least twice for temporal lobe injury. The OuYang 2023 model, using deep learning in patients with nasopharyngeal cancer, was validated in the same paper using two different cohorts. C‐statistics ranged from 0.80 to 0.82, while calibration performance was assessed in both cohorts. Both validations were judged as having low ROB in all domains. The Wen 2021 model was developed to predict temporal lobe injury in newly diagnosed nasopharyngeal cancer patients. The model was validated by OuYang 2023 using two cohorts and by Yang 2023a using four cohorts. C‐statistics ranged from 0.75 to 0.79, while calibration performance was not reported. The two validations by OuYang 2023 were judged as having unclear ROB in the analysis domain, and the four validations by Yang 2023a were judged as having high ROB in the analysis domain. The Yang 2023a model was validated in the same paper using two cohorts. C‐statistics ranged from 0.79 to 0.81, while calibration performance was assessed in both cohorts. Both validations were judged as having high ROB in the analysis domain. Models for outcomes related to hoarseness, fatigue, nausea‐vomiting, throat pain, aspiration No models were externally validated at least twice. Authors' conclusions Amongst 617 developed models, only one‐fifth were externally validated, of which, ten models at least twice. These ten models showed acceptable discriminative performance at external validation. However, their calibration was not always reported. Furthermore, most validation studies were judged as having high ROB. In conclusion, this review shows the need for more external validation studies and improvement of the quality of conducting and reporting of prediction model studies. Plain language summary Which normal tissue complication probability (NTCP) models are available to predict the risk of radiation‐induced side effects after radiotherapy in patients with head and neck cancer, what is their quality, and what is their predictive performance? Key messages ° Many NTCP models have been developed to predict unwanted effects following radiotherapy in head and neck cancer patients but most of them have not been sufficiently externally validated, that is, tested with patients who were not involved in the original model developmental study, to know how well they really predict the unwanted effects. ° For models tested in two or more studies in addition to their original model development studies, the quality of testing and reporting of their results was generally poor, so it is difficult to know how useful they might be. ° More and better designed studies are required to investigate this issue in the area of head and neck cancer. How can we decide on the likelihood of having unwanted effects as a result of treatment? The likelihood of having unwanted effects as a result of radiotherapy can be calculated by using so‐called NTCP models. NTCP models calculate the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. What did we want to find out? Radiotherapy is the mainstay of treatment of patients with head and neck cancer. However, radiotherapy exposes healthy, sometimes crucial, parts of the head and neck region to radiation. This may result in damage to these normal organs, e.g. disturbed saliva production, which may have important consequences for the quality of life of head and neck cancer patients treated with radiotherapy. To reach an optimal balance between tumour control and preventing radiation‐induced side effects, normal tissue complication probability (NTCP) models can be helpful. These models predict the risk of radiation‐induced side effects based on information from the patient, their disease, and their treatment. There have been a substantial number of NTCP models for patients with head and neck cancer. We wanted to find out what the quality of study design, conduct, and analysis (i.e. risk of bias) is, and how well these models can predict the risk of radiation‐induced side effects. What did we do? We searched for studies that developed and/or validated NTCP models in patients with head and neck cancer. What did we find? In most of the 617 models developed from 162,527 patients in 152 identified articles, the quality of the models was not sufficient; and it has not been investigated how well they perform in new patients for 78% of these models. For the remaining 22% of the models, 193 external validations were found in 48,852 patients from 39 articles. There were only ten models with two or more external validations. The models were able to distinguish patients with and without the outcome well, but it was often unclear whether their predictions were in line with what was observed, because the latter was not always assessed and/or reported. Overall, the quality of most of these studies was low. How up to date is the review? The evidence is current to 8th January 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Takada, T, Tambas, M, Clementel, E, Leeuwenberg, A, Sharabiani, M, Damen, JAAG, Dunias, ZS, Nauta, JF, Idema, DL, Choi, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014745.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.770Z" }, { "id": "a9b84f0b-97fa-48c1-8783-09f7424893a0", "pmid": "", "title": "Homeopathic medicinal products for preventing and treating acute respiratory tract infections in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common and may lead to complications. Most children experience between three and six ARTIs annually. Although most infections are self‐limiting, symptoms can be distressing. Many treatments are used to control symptoms and shorten illness duration. Most treatments have minimal benefit and may lead to adverse events. Oral homeopathic medicinal products could play a role in childhood ARTI management if evidence for their effectiveness is established. This is an update of a review first published in 2018. Objectives To assess the effectiveness and safety of oral homeopathic medicinal products compared with placebo or conventional therapy to prevent and treat ARTIs in children. Search methods We searched CENTRAL (2022, Issue 3), including the Cochrane Acute Respiratory Infections Specialised Register, MEDLINE (1946 to 16 March 2022), Embase (2010 to 16 March 2022), CINAHL (1981 to 16 March 2022), AMED (1985 to 16 March 2022), CAMbase (searched 16 March 2022), and British Homeopathic Library (searched 26 June 2013 ‐ no longer operating). We also searched the WHO ICTRP and ClinicalTrials.gov (16 March 2022), checked references, and contacted study authors to identify additional studies. Selection criteria We included double‐blind randomised controlled trials (RCTs) or double‐blind cluster‐RCTs comparing oral homeopathy medicinal products with identical placebo or self‐selected conventional treatments to prevent or treat ARTIs in children aged 0 to 16 years. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results In this 2022 update, we identified three new RCTs involving 251 children, for a total of 11 included RCTs with 1813 children receiving oral homeopathic medicinal products or a control treatment (placebo or conventional treatment) for ARTIs. All studies focused on upper respiratory tract infections (URTIs), with only one study including some lower respiratory tract infections (LRTIs). Six treatment studies examined the effect on URTI recovery, and five studies investigated the effect on preventing URTIs after one to four months of treatment. Two treatment and three prevention studies involved homeopaths individualising treatment. The other studies used predetermined, non‐individualised treatments. All studies involved highly diluted homeopathic medicinal products, with dilutions ranging from 1 x 10 ‐4 to 1 x 10 ‐200 . We identified several limitations to the included studies, in particular methodological inconsistencies and high attrition rates, failure to conduct intention‐to‐treat analysis, selective reporting, and apparent protocol deviations. We assessed three studies as at high risk of bias in at least one domain, and many studies had additional domains with unclear risk of bias. Four studies received funding from homeopathy manufacturers; one study support from a non‐government organisation; two studies government support; one study was co‐sponsored by a university; and three studies did not report funding support. Methodological inconsistencies and significant clinical and statistical heterogeneity precluded robust quantitative meta‐analysis. Only four outcomes were common to more than one study and could be combined for analysis. Odds ratios (OR) were generally small with wide confidence intervals (CI), and the contributing studies found conflicting effects, so there was little certainty that the efficacy of the intervention could be ascertained. All studies assessed as at low risk of bias showed no benefit from oral homeopathic medicinal products, whilst trials at unclear or high risk of bias reported beneficial effects. For the comparison of individualised homeopathy versus placebo or usual care for the prevention of ARTIs, two trials reported on disease severity; due to heterogeneity the data were not combined, but neither study demonstrated a clinically significant difference. We combined data from two trials for the outcome need for antibiotics (OR 0.79, 95% CI 0.35 to 1.76; low‐certainty evidence). For the comparison of non‐individualised homeopathy versus placebo or usual care for the prevention of ARTIs, only the outcome recurrence of ARTI was reported by more than one trial; data from three studies were combined for this outcome (OR 0.60, 95% CI 0.21 to 1.72; low‐certainty evidence). For the comparison of both individualised and non‐individualised homeopathy versus placebo or usual care for the treatment of ARTIs, two studies provided data on short‐term cure (OR 1.31, 95% CI 0.09 to 19.54) and long‐term cure (OR 1.01, 95% CI 0.10 to 9.96; very low‐certainty evidence). The studies demonstrated an opposite direction of effect for both outcomes. Six studies reported on disease severity but were not combined as they used different scoring systems and scales. Three studies reported adverse events (OR 0.79, 95% CI 0.16 to 4.03; low‐certainty evidence). Authors' conclusions Pooling of five prevention and six treatment studies did not show any consistent benefit of homeopathic medicinal products compared to placebo on ARTI recurrence or cure rates in children. We assessed the certainty of the evidence as low to very low for the majority of outcomes. We found no evidence to support the efficacy of homeopathic medicinal products for ARTIs in children. Adverse events were poorly reported, and we could not draw conclusions regarding safety. Plain language summary What are the benefits and risks of oral homeopathic medicines in preventing and treating acute respiratory tract infections in children? Key messages Homeopathy is a type of complementary and alternative medicine. It is based on two main ideas: that substances that may cause illness or symptoms in a healthy person can, in very small doses, treat those symptoms in a person who is unwell; and that molecules in highly diluted substances retain a memory of the original substance. Due to a lack of solid evidence, the benefits and risks of oral homeopathic medicines for preventing and treating acute respiratory tract infections (ARTIs) in children are unclear. Studies of lower quality in design and reporting often suggest a possible benefit for oral homeopathic medicines, but studies of higher quality do not find benefit. What are respiratory tract infections? Respiratory infections are commonly caused by viruses, especially colds and influenza, though some lung and ear infections are caused by bacteria. It may be difficult to tell these infections apart, and sometimes they occur together. Most such infections improve without treatment, but sometimes symptoms persist after the initial infection has gone. Treatment is therefore aimed at relieving symptoms. Why is this important in children? Children have on average three to six respiratory tract infections each year. Although most are mild and treatable, they are sometimes acute (serious, swift, or sudden onset) respiratory tract infections that may require hospital treatment, but very rarely result in death. How are ARTIs treated? Antibiotic medicines taken orally (by mouth/swallowed, usually in the form of a tablet, pill, lozenge, or liquid) are often prescribed for ARTIs, even though they are ineffective against viruses. Homeopathic medicines may treat ARTIs with few side effects, but their effectiveness and safety has not been well researched. What did we want to find out? We wanted to know whether homeopathic medicines help children with ARTIs. We were interested in the effect of homeopathic medicines compared to placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) or to usual care therapies for ARTIs. We were also interested in the effect of homeopathic medicines on improvement in the severity or symptoms of infection, the need for antibiotics, duration of illness (that would affect days off school or days off work for parents), symptom reappearance, and any medicine adverse effects. What did we do? We searched for randomised controlled trials (studies where people are randomly assigned to one of two or more treatment groups) that investigated whether oral homeopathic medicines, compared to placebo or usual care ARTI therapies, were effective in the prevention or treatment of ARTIs in children aged up to 16 years. We compared and summarised the results of the studies, and rated our confidence in the evidence based on factors such as study methods and number of participants. What did we find? We found 11 studies involving 1813 children (5 studies for prevention and 6 studies for treatment of ARTIs). All studies investigated upper respiratory tract (from the nose to the windpipe (trachea)) infections, but one study combined reporting of upper and lower respiratory tract (from the windpipe to the lungs and pleura (membranes covering the lungs)) infections, so the numbers of children with upper or lower ARTIs is unknown. Main results In the treatment or prevention of ARTIs in children, homeopathic medicines showed little or no beneficial effects, whether individualised by a trained homeopath or a standard commercially available homeopathic therapy (11 studies, 1813 children). Where results could be combined, there was little or no difference between groups for short‐term cure (2 studies, 155 participants) or long‐term cure (2 studies, 155 participants), but the evidence is very uncertain. There may be little or no difference between groups for prevention of ARTI (3 studies, 735 participants). There was no important difference between homeopathy and placebo groups for parents' time off work, antibiotic use, or adverse events. We are unsure about the safety of homeopathic medicines because data on adverse events were poorly reported. Overall, the findings of this review do not support the use of homeopathic medicinal products for ARTIs in children. What are the limitations of the evidence? We have little confidence in the evidence because the studies involved only small numbers of children, used different types of homeopathic medicines for various ARTIs, contained numerous biases, and failed to report information about important outcomes. Further research could provide results that differ from the results of this review. How up‐to‐date is this evidence? The evidence is current to 16 March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hawke, K; King, D; van Driel, ML; McGuire, TM", "articleTypes": [], "doi": "10.1002/14651858.CD005974.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "a9d3bd53-4098-4722-bed6-44a0e60483d0", "pmid": "", "title": "Antibiotics prior to amniotomy for reducing infectious morbidity in mother and infant", "imported": false, "abstract": "Abstract - Background Amniotomy (the deliberate rupture of membranes) was described almost two centuries ago and since then has been used both for induction and augmentation of labour ‐ which are common obstetric practices. Trends have shown a rise in the induction rates over the last decade and data suggest that the rate of labour inductions is increasing faster than the rate of pregnancy complications. Recent years have seen the emergence of a variety of other methods of induction of labour but amniotomy combined with oxytocin infusion remains the most commonly used method of augmentation of labour. The newer agents for induction are expensive and in resource‐poor settings amniotomy is still the chosen method for both induction and augmentation. As with any invasive procedure amniotomy can lead to infection, ascending from the vagina into the uterine cavity and can contribute significantly to both maternal and neonatal infectious morbidity. Objectives The objective of this review was to evaluate the prophylactic use of antibiotics versus placebo or no treatment prior to amniotomy on maternal and neonatal infectious morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014), the International Clinical Trials Registry Platform ( ICTRP ) and ClinicalTrials.gov (12 September 2014). Selection criteria Randomised controlled trials or cluster‐randomised trials comparing antibiotics prior to amniotomy versus placebo (or no treatment) were eligible for inclusion in this review but none were identified. Quasi‐randomised trials or cross‐over trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed one trial report for inclusion. In future updates of this review, two review authors will independently assess risk of bias and carry out data extraction. Data will be checked for accuracy. Main results We identified one trial report but this was excluded. No studies met the inclusion criteria for this review. Authors' conclusions High‐quality trials are needed to justify or refute the routine use of antibiotics at amniotomy for prevention of infection in the mother and infant. Future studies should be conducted, especially in resource‐constrained settings where amniotomy is still used as a means of induction of labour, in order to evaluate the routine use of antibiotics at amniotomy in these settings. Future research in this area should include important maternal and infant outcomes listed in this review and also consider cost effectiveness and side effects of antibiotic use, including the emergence of antibiotic‐resistant strains. Plain language summary Antibiotic use before amniotomy (artificially rupturing the membranes) for reducing infections in mother and infant The artificial rupture of the membranes (amniotomy) is a common obstetrical procedure. It may be done to either initiate or to augment labour, with or without oxytocin. This invasive procedure allows vaginal micro‐organisms access into the uterine cavity, which can in turn lead to infections in both the mother and the infant. A greater time interval between rupture of membranes and delivery, as with induction of labour, increases the chances of an infection. The purpose of this review was to evaluate the routine use of antibiotics immediately prior to amniotomy for both initiation and augmentation of labour using randomised controlled trials. However, our search only identified one trial which did not meet the inclusion criteria for this review. Consequently, there is no evidence to support or refute the routine use of antibiotics prior to amniotomy. Randomised controlled trials on this topic are needed, especially in resource‐constrained settings where amniotomy is still used as a means of inducing labour, to evaluate the routine use of antibiotics at amniotomy in such settings. Future research in this area should also consider cost effectiveness and side effects of antibiotic use including the emergence of antibiotic‐resistant strains.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ray, A, Ray, S", "articleTypes": [], "doi": "10.1002/14651858.CD010626.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.754Z" }, { "id": "a9e5c0f5-d1db-401d-942e-1303e84f5cdd", "pmid": "", "title": "Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults", "imported": false, "abstract": "Abstract - Background Acetylcholinesterase inhibitors, such as neostigmine, have traditionally been used for reversal of non‐depolarizing neuromuscular blocking agents. However, these drugs have significant limitations, such as indirect mechanisms of reversal, limited and unpredictable efficacy, and undesirable autonomic responses. Sugammadex is a selective relaxant‐binding agent specifically developed for rapid reversal of non‐depolarizing neuromuscular blockade induced by rocuronium. Its potential clinical benefits include fast and predictable reversal of any degree of block, increased patient safety, reduced incidence of residual block on recovery, and more efficient use of healthcare resources. Objectives The main objective of this review was to compare the efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade caused by non‐depolarizing neuromuscular agents in adults. Search methods We searched the following databases on 2 May 2016: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (WebSPIRS Ovid SP), Embase (WebSPIRS Ovid SP), and the clinical trials registries www.controlled‐trials.com , clinicaltrials.gov , and www.centerwatch.com . We re‐ran the search on 10 May 2017. Selection criteria We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published, or language. We included adults, classified as American Society of Anesthesiologists (ASA) I to IV, who received non‐depolarizing neuromuscular blocking agents for an elective in‐patient or day‐case surgical procedure. We included all trials comparing sugammadex versus neostigmine that reported recovery times or adverse events. We included any dose of sugammadex and neostigmine and any time point of study drug administration. Data collection and analysis Two review authors independently screened titles and abstracts to identify trials for eligibility, examined articles for eligibility, abstracted data, assessed the articles, and excluded obviously irrelevant reports. We resolved disagreements by discussion between review authors and further disagreements through consultation with the last review author. We assessed risk of bias in 10 methodological domains using the Cochrane risk of bias tool and examined risk of random error through trial sequential analysis. We used the principles of the GRADE approach to prepare an overall assessment of the quality of evidence. For our primary outcomes (recovery times to train‐of‐four ratio (TOFR) > 0.9), we presented data as mean differences (MDs) with 95 % confidence intervals (CIs), and for our secondary outcomes (risk of adverse events and risk of serious adverse events), we calculated risk ratios (RRs) with CIs. Main results We included 41 studies (4206 participants) in this updated review, 38 of which were new studies. Twelve trials were eligible for meta‐analysis of primary outcomes (n = 949), 28 trials were eligible for meta‐analysis of secondary outcomes (n = 2298), and 10 trials (n = 1647) were ineligible for meta‐analysis. We compared sugammadex 2 mg/kg and neostigmine 0.05 mg/kg for reversal of rocuronium‐induced moderate neuromuscular blockade (NMB). Sugammadex 2 mg/kg was 10.22 minutes (6.6 times) faster then neostigmine 0.05 mg/kg (1.96 vs 12.87 minutes) in reversing NMB from the second twitch (T2) to TOFR > 0.9 (MD 10.22 minutes, 95% CI 8.48 to 11.96; I 2 = 84%; 10 studies, n = 835; GRADE: moderate quality). We compared sugammadex 4 mg/kg and neostigmine 0.07 mg/kg for reversal of rocuronium‐induced deep NMB. Sugammadex 4 mg/kg was 45.78 minutes (16.8 times) faster then neostigmine 0.07 mg/kg (2.9 vs 48.8 minutes) in reversing NMB from post‐tetanic count (PTC) 1 to 5 to TOFR > 0.9 (MD 45.78 minutes, 95% CI 39.41 to 52.15; I 2 = 0%; two studies, n = 114; GRADE: low quality). For our secondary outcomes, we compared sugammadex, any dose, and neostigmine, any dose, looking at risk of adverse and serious adverse events. We found significantly fewer composite adverse events in the sugammadex group compared with the neostigmine group (RR 0.60, 95% CI 0.49 to 0.74; I 2 = 40%; 28 studies, n = 2298; GRADE: moderate quality). Risk of adverse events was 28% in the neostigmine group and 16% in the sugammadex group, resulting in a number needed to treat for an additional beneficial outcome (NNTB) of 8. When looking at specific adverse events, we noted significantly less risk of bradycardia (RR 0.16, 95% CI 0.07 to 0.34; I 2 = 0%; 11 studies, n = 1218; NNTB 14; GRADE: moderate quality), postoperative nausea and vomiting (PONV) (RR 0.52, 95% CI 0.28 to 0.97; I 2 = 0%; six studies, n = 389; NNTB 16; GRADE: low quality) and overall signs of postoperative residual paralysis (RR 0.40, 95% CI 0.28 to 0.57; I 2 = 0%; 15 studies, n = 1474; NNTB 13; GRADE: moderate quality) in the sugammadex group when compared with the neostigmine group. Finally, we found no significant differences between sugammadex and neostigmine regarding risk of serious adverse events (RR 0.54, 95% CI 0.13 to 2.25; I 2 = 0%; 10 studies, n = 959; GRADE: low quality). Application of trial sequential analysis (TSA) indicates superiority of sugammadex for outcomes such as recovery time from T2 to TOFR > 0.9, adverse events, and overall signs of postoperative residual paralysis. Authors' conclusions Review results suggest that in comparison with neostigmine, sugammadex can more rapidly reverse rocuronium‐induced neuromuscular block regardless of the depth of the block. Sugammadex 2 mg/kg is 10.22 minutes (˜ 6.6 times) faster in reversing moderate neuromuscular blockade (T2) than neostigmine 0.05 mg/kg (GRADE: moderate quality), and sugammadex 4 mg/kg is 45.78 minutes (˜ 16.8 times) faster in reversing deep neuromuscular blockade (PTC 1 to 5) than neostigmine 0.07 mg/kg (GRADE: low quality). With an NNTB of 8 to avoid an adverse event, sugammadex appears to have a better safety profile than neostigmine. Patients receiving sugammadex had 40% fewer adverse events compared with those given neostigmine. Specifically, risks of bradycardia (RR 0.16, NNTB 14; GRADE: moderate quality), PONV (RR 0.52, NNTB 16; GRADE: low quality), and overall signs of postoperative residual paralysis (RR 0.40, NNTB 13; GRADE: moderate quality) were reduced. Both sugammadex and neostigmine were associated with serious adverse events in less than 1% of patients, and data showed no differences in risk of serious adverse events between groups (RR 0.54; GRADE: low quality). Plain language summary Benefits and harms of sugammadex versus neostigmine in reversing induced paralysis Background Different levels of induced paralysis are sometimes necessary when patients are put to sleep or are prepared for operations. When the operation is finished, paralysis should be reversed in a fast, reliable, and safe way. Neostigmine is a medication that is traditionally used to reverse induced paralysis. However, its use can be associated with incomplete or slow reversal as well as changes in lung function, heart function, and vomiting and nausea. Sugammadex is a relatively new medication specifically designed to reverse rocuronium‐induced paralysis in a faster, more reliable, and safer way when compared with neostigmine. Objective This review systematically sets out to compare the benefits and harms of sugammadex and neostigmine. The evidence is current up to May 2017. Study characteristics We identified 41 randomized controlled trials comparing sugammadex with neostigmine that provided suitable data on efficacy and safety. All of these trials included adults undergoing surgery and involved a total of 4206 participants. Key results Data indicate that sugammadex was 10.22 minutes (6.6 times) faster than neostigmine (1.96 vs 12.87 minutes) in reversing moderate induced paralysis. Sugammadex was 45.78 minutes (16.8 times) faster than neostigmine (2.9 vs 48.8 minutes) in reversing deep induced paralysis. Participants receiving sugammadex appeared to have a 40% reduced risk of experiencing harmful events than those given neostigmine. Statistically, eight persons can be treated with sugammadex as opposed to neostigmine to avoid one person experiencing a single random harmful event. The occurrence of serious harmful events was nearly non‐existent and data show no differences between compared groups. Conclusion Sugammadex is more efficient and safer than neostigmine for reversing moderate and deep induced paralysis. Quality of evidence We consider our overall findings on benefits and harms to provide evidence of moderate quality in favour of sugammadex.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Hristovska, AM, Duch, P, Allingstrup, M, Afshari, A", "articleTypes": [], "doi": "10.1002/14651858.CD012763", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.116Z" }, { "id": "aa0250a1-41cd-433e-853a-c2b99f9e4e39", "pmid": "", "title": "Environmental and behavioural modifications for improving food and fluid intake in people with dementia", "imported": false, "abstract": "Abstract - Background Weight loss, malnutrition and dehydration are common problems for people with dementia. Environmental modifications such as, change of routine, context or ambience at mealtimes, or behavioural modifications, such as education or training of people with dementia or caregivers, may be considered to try to improve food and fluid intake and nutritional status of people with dementia. Objectives Primary: To assess the effects of environmental or behavioural modifications on food and fluid intake and nutritional status in people with dementia. Secondary: To assess the effects of environmental or behavioural modifications in connection with nutrition on mealtime behaviour, cognitive and functional outcomes and quality of life, in specific settings (i.e. home care, residential care and nursing home care) for different stages of dementia. To assess the adverse consequences or effects of the included interventions. Search methods We searched the Specialized Register of Cochrane Dementia and Cognitive Improvement (ALOIS), MEDLINE, Eembase, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 17 January 2018. We scanned reference lists of other reviews and of included articles. Selection criteria We included randomised controlled trials (RCTs) investigating interventions designed to modify the mealtime environment of people with dementia, to modify the mealtime behaviour of people with dementia or their caregivers, or both, with the intention of improving food and fluid intake. We included people with any common dementia subtype. Data collection and analysis Two review authors independently selected studies, extracted data and assessed the risk of bias of included trials. We assessed the quality of evidence for each outcome using the GRADE approach. Main results We included nine studies, investigating 1502 people. Three studies explicitly investigated participants with Alzheimer's disease; six did not specify the type of dementia. Five studies provided clear measures to identify the severity of dementia at baseline, and overall very mild to severe stages were covered. The interventions and outcome measures were diverse. The overall quality of evidence was mainly low to very low. One study implemented environmental as well as behavioural modifications by providing additional food items between meals and personal encouragement to consume them. The control group received no intervention. Differences between groups were very small and the quality of the evidence from this study was very low, so we are very uncertain of any effect of this intervention. The remaining eight studies implemented behavioural modifications. Three studies provided nutritional education and nutrition promotion programmes. Control groups did not receive these programmes. After 12 months, the intervention group showed slightly higher protein intake per day (mean difference (MD) 0.11 g/kg, 95% confidence interval (CI) ‐0.01 to 0.23; n = 78, 1 study; low‐quality evidence), but there was no clear evidence of a difference in nutritional status assessed with body mass index (BMI) (MD ‐0.26 kg/m² favouring control, 95% CI ‐0.70 to 0.19; n = 734, 2 studies; moderate‐quality evidence), body weight (MD ‐1.60 kg favouring control, 95% CI ‐3.47 to 0.27; n = 656, 1 study; moderate‐quality evidence), or score on Mini Nutritional Assessment (MNA) (MD ‐0.10 favouring control, 95% CI ‐0.67 to 0.47; n = 656, 1 study; low‐quality evidence). After six months, the intervention group in one study had slightly lower BMI (MD ‐1.79 kg/m² favouring control, 95% CI ‐1.28 to ‐2.30; n = 52, 1 study; moderate‐quality evidence) and body weight (MD ‐8.11 kg favouring control, 95% CI ‐2.06 to ‐12.56; n = 52, 1 study; moderate‐quality evidence). This type of intervention may have a small positive effect on food intake, but little or no effect, or a negative effect, on nutritional status. Two studies compared self‐feeding skills training programmes. In one study, the control group received no training and in the other study the control group received a different self‐feeding skills training programme. For both comparisons the quality of the evidence was very low and we are very uncertain whether these interventions have any effect. One study investigated general training of nurses to impart knowledge on how to feed people with dementia and improve attitudes towards people with dementia. Again, the quality of the evidence was very low so that we cannot be certain of any effect. Two studies investigated vocal or tactile positive feedback provided by caregivers while feeding participants. After three weeks, the intervention group showed an increase in calories consumed per meal (MD 200 kcal, 95% CI 119.81 to 280.19; n = 42, 1 study; low‐quality evidence) and protein consumed per meal (MD 15g, 95% CI 7.74 to 22.26; n = 42, 1 study; low‐quality evidence). This intervention may increase the intake of food and liquids slightly; nutritional status was not assessed. Authors' conclusions Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia. Plain language summary Environmental and behavioural modifications for improving food and fluid intake in people with dementia What we wanted to know Weight loss, malnutrition and dehydration are common problems for people with dementia and can occur at any stage of the illness. People with dementia often develop psychological symptoms or behaviours which cause them to eat or drink less. In the later stages of the illness, they become dependent on others to help them eat or drink. We wanted to investigate how to keep people with dementia eating and drinking as well as possible. We looked for studies which changed the way food and drink are presented to people with dementia, and for studies which attempted to change the behaviour of people with dementia or of those helping them to eat. We called these environmental and behavioural modifications respectively, though some interventions include aspects of both. We were mainly interested in the effect on how much people with dementia ate and drank and on measures of how well‐nourished they were (e.g. body weight or body mass index (BMI)), but we also looked for effects on eating behaviour, symptoms of dementia and quality of life. How we tried to answer the question We searched for all the randomised controlled trials (RCTs) which were relevant to our question. In these trials, some people with dementia got an environmental or behavioural modification intended to improve their eating and drinking and were then compared with other people who had not had the intervention (the control group). Whether someone got the intervention or not was decided at random. We found nine RCTs to include in our review. In total, there were 1502 people in these trials. They had varying degrees of dementia, probably mostly due to Alzheimer's disease. Seven of the trials took place in care homes. In one trial, people were given extra snacks between meals and encouraged to eat them. In three trials, people with dementia were given education about diet and eating. In two trials, people with dementia were taught skills to help them to eat independently. In three trials, training was given to the carers responsible for helping people with dementia to eat. What we found out All the trials we found tested different interventions and measured their effects in different ways. Generally, the trials were small and there were problems with the way they were done, which reduced our confidence in the results. For some interventions, the quality of the evidence was so low that we could not draw any conclusions. For others, there was a mixture of positive and negative effects. What we concluded Because of the amount and quality of the evidence we found, we cannot at the moment, identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Herke, M, Fink, A, Langer, G, Wustmann, T, Watzke, S, Hanff, AM, Burckhardt, M", "articleTypes": [], "doi": "10.1002/14651858.CD011542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.113Z" }, { "id": "aa1b4e76-99d2-4d30-a4d3-4cc4593b4c1f", "pmid": "", "title": "Anticholinergic agents for chronic asthma in adults", "imported": false, "abstract": "Abstract - Background Anticholinergic agents such as ipratropium bromide are sometimes used in the treatment of chronic asthma. They effect bronchodilation and have also been used in combination with ß2 ‐agonists in the management of chronic asthma. Objectives To examine the effectiveness of anticholinergic agents versus placebo and in comparison with ß2 ‐agonists or as adjunctive therapy to ß2 ‐agonists. Search methods The Cochrane Airways Group asthma and wheeze database was searched with a pre‐defined search strategy. Searches were current as of August 2008. Reference lists of articles were also examined. Selection criteria Randomised trials or quasi‐randomised trials were considered for inclusion. Studies assessing an anticholinergic agent versus placebo or in combination/comparison with ß2 ‐agonists were included. In practice, all ß2 ‐agonists were short acting. Short‐term (less than 24 hours duration) were not considered for this review. Data collection and analysis Two reviewers independently assessed abstracts for retrieval of full text articles. Papers were then assessed for suitability for inclusion in the review. Data from included studies were extracted by two reviewers and entered into the software package (RevMan 4.2). We contacted authors for missing data and some responded. Adverse effect data were analysed if reported in the included studies. Main results The studies analysed were in two groups: those comparing anticholinergics with placebo and those comparing the combination of anticholinergics with short acting ß2 ‐agonists versus short acting ß2 ‐agonists alone. The former group had 13 studies involving 205 participants included in this review, and the latter 9 studies involving 440 patients. Generally methodological quality was poorly reported, and there were some reservations with respect to the quality of the studies. Despite the limited number of studies that could be combined, anticholinergic agents in comparison with placebo resulted in more favourable symptom scores particularly in respect of daytime dyspnoea (WMD ‐0.09 (95%CI ‐0.14, ‐0.04, 3 studies, 59 patients). Daily peak flow measurements also showed a statistically significant improvement for the anticholinergic (e.g. morning PEF: WMD =14.38 litres/min (95%CI 7.69, 21.08; 3 studies, 59 patients). However the clinical significance is small and in terms of peak flow measurements equates to approximately a 7% increase over placebo. The more clinically relevant comparison of a combination of anticholinergic plus short acting ß2 ‐agonist versus short acting ß2 ‐agonist alone gave no evidence in respect of symptom scores or peak flow rates of any significant differences between the two regimes. Again there are reservations with respect to the quality of the information from which these conclusions are drawn. An update search in August 2004 did not identify any new studies. Authors' conclusions Overall this review provides no justification for routinely introducing anticholinergics as part of add‐on treatment for patients whose asthma is not well controlled on standard therapies. This does not exclude the possibility that there may be a sub‐group of patients who derive some benefit and a trial of treatment in individual patients may still be justified. The role of long term anticholinergics such as tiotropium bromide has yet to be established in patients with asthma and any future trials might draw on the messages derived from this review. Plain language summary Anticholinergic agents for chronic asthma in adults Anticholinergic agents such as Atrovent are sometimes used to treat people with asthma as a bronchodilator that opens up the airways in the lungs. This review found that although this treatment was better than placebo, the size of the effect was rather small. When the drug was used in combination with more widely used bronchodilators (beta‐agonists such as fenoterol), it did not appear to add much benefit. However, there are concerns about the quality of the studies that have been analysed. It could be that there are some adults with chronic asthma who respond to treatment with anticholinergic drugs, but the review has not been able to identify their common characteristics.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Westby, MJ; Benson, MK; Gibson, PG", "articleTypes": [], "doi": "10.1002/14651858.CD003269.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "aa1ccd66-b757-4b37-8e7b-24756fc53732", "pmid": "", "title": "Macrolide antibiotics (including azithromycin) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a life‐limiting genetic condition, affecting over 90,000 people worldwide. CF affects several organs in the body, but airway damage has the most profound impact on quality of life (QoL) and survival. Causes of lower airway infection in people with CF are, most notably, Staphylococcus aureus in the early course of the disease and Pseudomonas aeruginosa at a later stage. Macrolide antibiotics, e.g. azithromycin and clarithromycin, are usually taken orally, have a broad spectrum of action against gram‐positive (e.g. S aureus ) and some gram‐negative bacteria (e.g. Haemophilus influenzae ), and may have a modifying role in diseases involving airway infection and inflammation such as CF. They are well‐tolerated and relatively inexpensive, but widespread use has resulted in the emergence of resistant bacteria. This is an updated review. Objectives To assess the potential effects of macrolide antibiotics on clinical status in terms of benefit and harm in people with CF. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals, and abstract books of conference proceedings. We last searched the Group's Cystic Fibrosis Trials Register on 2 November 2022. We last searched the trial registries WHO ICTRP and clinicaltrials.gov on 9 November 2022. We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow‐up data, where possible. Selection criteria We included randomised controlled trials of macrolide antibiotics in adults and children with CF. We compared them to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose or type of administration. Data collection and analysis Two authors independently extracted data and assessed risk of bias. We assessed the certainty of evidence using GRADE. Main results We included 14 studies (1467 participants) lasting 28 days to 36 months. All the studies assessed azithromycin: 11 compared oral azithromycin to placebo (1167 participants); one compared a high dose to a low dose (47 participants); one compared nebulised to oral azithromycin (45 participants); and one looked at weekly versus daily dose (208 participants). Oral azithromycin versus placebo There is a slight improvement in forced expiratory volume (FEV 1 % predicted) in one second in the azithromycin group at up to six months compared to placebo (mean difference (MD) 3.97, 95% confidence interval (CI) 1.74 to 6.19; high‐certainty evidence), although there is probably no difference at three months, (MD 2.70%, 95% CI ‐0.12 to 5.52), or 12 months (MD ‐0.13, 95% CI ‐4.96 to 4.70). Participants in the azithromycin group are probably at a decreased risk of pulmonary exacerbation with a longer time to exacerbation (hazard ratio (HR) 0.61, 95% CI 0.50 to 0.75; moderate‐certainty evidence). Mild side effects were common, but there was no difference between groups (moderate‐certainty evidence). There is no difference in hospital admissions at six months (odds ratio (OR) 0.61, 95% CI 0.36 to 1.04; high‐certainty evidence), or in new acquisition of P aeruginosa at 12 months (HR 1.00, 95% CI 0.64 to 1.55; moderate‐certainty evidence). High‐dose versus low‐dose azithromycin We are uncertain whether there is any difference in FEV 1 % predicted at six months between the two groups (no data available) or in the rate of exacerbations per child per month (MD ‐0.05 (95% CI ‐0.20 to 0.10)); very low‐certainty evidence for both outcomes. Only children were included in the study and the study did not report on any of our other clinically important outcomes. Nebulised azithromycin versus oral azithromycin We were unable to include any of the data into our analyses and have reported findings directly from the paper; we graded all evidence as being of very low certainty. The authors reported that there was a greater mean change in FEV 1 % predicted at one month in the nebulised azithromycin group (P < 0.001). We are uncertain whether there was a change in P aeruginosa count. Weekly azithromycin versus daily azithromycin There is probably a lower mean change in FEV 1 % predicted at six months in the weekly group compared to the daily group (MD ‐0.70, 95% CI ‐0.95 to ‐0.45) and probably also a longer period of time until first exacerbation in the weekly group (MD 17.30 days, 95% CI 4.32 days to 30.28 days). Gastrointestinal side effects are probably more common in the weekly group and there is likely no difference in admissions to hospital or QoL. We graded all evidence as moderate certainty. Authors' conclusions Azithromycin therapy is associated with a small but consistent improvement in respiratory function, a decreased risk of exacerbation and longer time to exacerbation at six months; but evidence for treatment efficacy beyond six months remains limited. Azithromycin appears to have a good safety profile (although a weekly dose was associated with more gastrointestinal side effects, which makes it less acceptable for long‐term therapy), with a relatively minimal treatment burden for people with CF, and it is inexpensive. A wider concern may be the emergence of macrolide resistance reported in the most recent study which, combined with the lack of long‐term data, means we do not feel that the current evidence is strong enough to support azithromycin therapy for all people with CF. Future research should report over longer time frames using validated tools and consistent reporting, to allow for easier synthesis of data. In particular, future trials should report important adverse events such as hearing impairment or liver disease. More data on the effects of azithromycin given in different ways and reporting on our primary outcomes would benefit decision‐making on whether and how to give macrolide antibiotics. Finally, it is important to assess azithromycin therapy for people with CF who are established on the relatively new cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies which correct the underlying molecular defect associated with CF (none of the trials included in the review are relevant to this population). Plain language summary Treatment with macrolide antibiotics (including azithromycin) for people with cystic fibrosis Review question What are the effects of macrolide antibiotics in people with cystic fibrosis (CF) and infection of their airways? Key messages ‐ People with CF are more prone to chest infections caused by bacteria that can be hard to treat. ‐ Macrolide antibiotics (such as azithromycin and clarithromycin) may lessen the effects of bacteria. ‐ One macrolide antibiotic, azithromycin, can improve lung function at six months compared to a placebo (treatment with no active ingredient) and may reduce the risk of getting a flare‐up of lung infection. We are not sure whether a higher dose of azithromycin is any better than a lower dose, or if azithromycin when inhaled is any better than azithromycin when swallowed (oral). Oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. ‐ Current evidence does not support longer‐term use of azithromycin for all people with CF. Introduction People with CF suffer from infections in their airways, often caused by the bug Pseudomonas aeruginosa , which is resistant to nearly all antibiotics that can be swallowed (oral). Macrolide antibiotics, e.g. azithromycin and clarithromycin, have no direct killing effect on Pseudomonas aeruginosa , but they may reduce the activity of these bacteria. What did we want to find out? We wanted to discover whether the use of macrolide antibiotics (usually taken orally) affected the health of people with CF and whether these drugs have any side effects. What did we do? We searched for studiesthat looked at the effects of macrolide antibiotics in children and adults with CF and summarised the evidence. What did we find? We found 14 studies, which put the total of 1467 children and adults into different treatment groups at random, which we included in this review. Eleven studies compared azithromycin to placebo, one compared two different doses of azithromycin (high versus low dose), one compared inhaled azithromycin to oral azithromycin, and one compared oral azithromycin once a week to once a day. Main results We found that there was a slight improvement in lung function in people that were given azithromycin compared to a placebo at six months and also that the risk of a flare‐up of infection was lower. The risk of side effects (such as vomiting, diarrhoea and headache) was similar in both groups, as was the chance of a new infection with Pseudomonas aeruginosa. In terms of lung function and flare‐up of infection, we were unsure whether a higher dose of azithromycin is better than a lower dose (but only one study in children examined dose), or whether inhaled azithromycin is better than oral azithromycin. Taking oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. What are the limitations of the evidence? We were unable to combine all the study results because they were measured in different ways and at different time points; future trials should address this issue. Also, now that many people with CF are being treated with the new modulator therapies (e.g. elexacaftor‐tezacaftor‐ivacaftor), it is important to assess how macrolide antibiotics affect the health of these people. In the studies we found for this review, none of the people taking part were being treated with modulator therapies. We are able to report the results of the studies that compared azithromycin to placebo with certainty as the studies were well conducted and included a larger number of participants. The evidence from the studies comparing high and low doses or nebulised and oral azithromycin was much less certain because the studies were small and there was risk of bias in the way they were carried out. We were moderately certain of the results of the study comparing weekly azithromycin to daily azithromycin. How up to date is this evidence? The studies we have reported are the most up to date we could find. We last searched for studies in November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Southern, KW; Solis-Moya, A; Kurz, D; Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD002203.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "aa22449b-4d8d-4ae4-a23d-861c13fe1cc7", "pmid": "", "title": "Interventions for the treatment of Frey's syndrome", "imported": false, "abstract": "Abstract - Background Frey's syndrome is a rare disorder, the symptoms of which include sweating, flushing and warming over the preauricular and temporal areas following a gustatory stimulus. It often occurs in patients who have undergone parotidectomy, submandibular gland surgery, radical neck dissection, infection and traumatic injury in the parotid region, and is caused by the aberrant regrowth of facial autonomic nerve fibres. Currently there are several options used to treat patients with Frey's syndrome; for example, the topical application of anticholinergics and antiperspirants, and the intradermal injection of botulinum toxin. It is uncertain which treatment is most effective and safe. Objectives To assess the efficacy and safety of different interventions for the treatment of Frey's syndrome. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; ICTRP and additional sources for published and unpublished trials. The date of the search was 28 April 2014. Selection criteria We included randomised or quasi‐randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome using a clinical standard such as Minor's starch‐iodine test. We planned to include trials in which participants received any intervention versus no treatment (observation) or an alternative intervention, with or without a second active treatment. Our primary outcome measures were success rate (as assessed clinically by Minor's starch‐iodine test, the iodine‐sublimated paper histogram method, blotting paper technique or another method) and adverse events. Our secondary outcome measure was success rate as assessed by patients (disappearance or improvement of symptoms). Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no RCTs or quasi‐RCTs that fulfilled the inclusion criteria. Our searches retrieved eight potentially relevant studies, but after assessment of the full‐text reports we excluded all of them due to the absence of randomisation or because the patients did not have Frey's syndrome. We excluded one randomised controlled trial that compared two different doses of botulinum toxin in patients with Frey's syndrome because the comparator was not an alternative treatment. Authors' conclusions We are unable to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome. RCTs are urgently needed to assess the effectiveness of interventions for the treatment of Frey's syndrome. Future RCTs should include patients with Frey's syndrome of different ranges of severity and report these patients separately. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective assessment of Frey's syndrome should be considered as one of the outcome measures. Plain language summary Interventions for the treatment of Frey's syndrome Background Frey's syndrome is a rare disorder, the symptoms of which include sweating and flushing of the facial skin when eating, smelling, thinking or even dreaming about food. It usually happens in patients who have undergone surgery to the parotid (salivary) gland. This problem may have an impact on quality of life (for example, restricting normal activity such as eating in public). Many methods are currently used to treat Frey's syndrome, including topical application of anticholinergics and antiperspirants, and intradermal (into the skin) injections of botulinum toxin. This systematic review aimed to assess the efficacy and safety of these different methods for the treatment of Frey's syndrome. Study characteristics We carried out a comprehensive search for randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome. We planned to include trials in which participants received any intervention compared to no treatment (observation) or an alternative intervention, with or without a second active treatment. Despite extensive searching, we were unable to identify any studies that met our inclusion criteria. Key results There is no high‐quality evidence to establish which type of treatment is most effective for the treatment of Frey's syndrome. High‐quality clinical trials in this area should be urgently conducted. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective (patient) assessment of Frey's syndrome should be one of the outcome measures used. Quality of the evidence This review is up to date to 28 April 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Li, C; Wu, F; Zhang, Q; Gao, Q; Shi, Z; Li, L", "articleTypes": [], "doi": "10.1002/14651858.CD009959.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "aa312f85-2507-41ba-84a9-a93d1443f36c", "pmid": "", "title": "Pharmacological interventions for smoking cessation: an overview and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Smoking is the leading preventable cause of illness and premature death worldwide. Some medications have been proven to help people to quit, with three licensed for this purpose in Europe and the USA: nicotine replacement therapy (NRT), bupropion, and varenicline. Cytisine (a treatment pharmacologically similar to varenicline) is also licensed for use in Russia and some of the former socialist economy countries. Other therapies, including nortriptyline, have also been tested for effectiveness. Objectives How do NRT, bupropion and varenicline compare with placebo and with each other in achieving long‐term abstinence (six months or longer)?
 How do the remaining treatments compare with placebo in achieving long‐term abstinence?
 How do the risks of adverse and serious adverse events (SAEs) compare between the treatments, and are there instances where the harms may outweigh the benefits? Methods The overview is restricted to Cochrane reviews, all of which include randomised trials. Participants are usually adult smokers, but we exclude reviews of smoking cessation for pregnant women and in particular disease groups or specific settings. We cover nicotine replacement therapy (NRT), antidepressants (bupropion and nortriptyline), nicotine receptor partial agonists (varenicline and cytisine), anxiolytics, selective type 1 cannabinoid receptor antagonists (rimonabant), clonidine, lobeline, dianicline, mecamylamine, Nicobrevin, opioid antagonists, nicotine vaccines, and silver acetate. Our outcome for benefit is continuous or prolonged abstinence at least six months from the start of treatment. Our outcome for harms is the incidence of serious adverse events associated with each of the treatments.
 We searched the Cochrane Database of Systematic Reviews (CDSR) in The Cochrane Library , for any reviews with 'smoking' in the title, abstract or keyword fields. The last search was conducted in November 2012. We assessed methodological quality using a revised version of the AMSTAR scale. For NRT, bupropion and varenicline we conducted network meta‐analyses, comparing each with the others and with placebo for benefit, and varenicline and bupropion for risks of serious adverse events. Main results We identified 12 treatment‐specific reviews. The analyses covered 267 studies, involving 101,804 participants. Both NRT and bupropion were superior to placebo (odds ratios (OR) 1.84; 95% credible interval (CredI) 1.71 to 1.99, and 1.82; 95% CredI 1.60 to 2.06 respectively). Varenicline increased the odds of quitting compared with placebo (OR 2.88; 95% CredI 2.40 to 3.47). Head‐to‐head comparisons between bupropion and NRT showed equal efficacy (OR 0.99; 95% CredI 0.86 to 1.13). Varenicline was superior to single forms of NRT (OR 1.57; 95% CredI 1.29 to 1.91), and to bupropion (OR 1.59; 95% CredI 1.29 to 1.96).
 Varenicline was more effective than nicotine patch (OR 1.51; 95% CredI 1.22 to 1.87), than nicotine gum (OR 1.72; 95% CredI 1.38 to 2.13), and than 'other' NRT (inhaler, spray, tablets, lozenges; OR 1.42; 95% CredI 1.12 to 1.79), but was not more effective than combination NRT (OR 1.06; 95% CredI 0.75 to 1.48). Combination NRT also outperformed single formulations. The four categories of NRT performed similarly against each other, apart from 'other' NRT, which was marginally more effective than NRT gum (OR 1.21; 95% CredI 1.01 to 1.46).
 Cytisine (a nicotine receptor partial agonist) returned positive findings (risk ratio (RR) 3.98; 95% CI 2.01 to 7.87), without significant adverse events or SAEs.
 Across the 82 included and excluded bupropion trials, our estimate of six seizures in the bupropion arms versus none in the placebo arms was lower than the expected rate (1:1000), at about 1:1500. SAE meta‐analysis of the bupropion studies demonstrated no excess of neuropsychiatric (RR 0.88; 95% CI 0.31 to 2.50) or cardiovascular events (RR 0.77; 95% CI 0.37 to 1.59). SAE meta‐analysis of 14 varenicline trials found no difference between the varenicline and placebo arms (RR 1.06; 95% CI 0.72 to 1.55), and subgroup analyses detected no significant excess of neuropsychiatric events (RR 0.53; 95% CI 0.17 to 1.67), or of cardiac events (RR 1.26; 95% CI 0.62 to 2.56).
 Nortriptyline increased the chances of quitting (RR 2.03; 95% CI 1.48 to 2.78). Neither nortriptyline nor bupropion were shown to enhance the effect of NRT compared with NRT alone. Clonidine increased the chances of quitting (RR 1.63; 95% CI 1.22 to 2.18), but this was offset by a dose‐dependent rise in adverse events. Mecamylamine in combination with NRT may increase the chances of quitting, but the current evidence is inconclusive. Other treatments failed to demonstrate a benefit compared with placebo. Nicotine vaccines are not yet licensed for use as an aid to smoking cessation or relapse prevention. Nicobrevin's UK license is now revoked, and the manufacturers of rimonabant, taranabant and dianicline are no longer supporting the development or testing of these treatments. Authors' conclusions NRT, bupropion, varenicline and cytisine have been shown to improve the chances of quitting. Combination NRT and varenicline are equally effective as quitting aids. Nortriptyline also improves the chances of quitting. On current evidence, none of the treatments appear to have an incidence of adverse events that would mitigate their use.
 Further research is warranted into the safety of varenicline and into cytisine's potential as an effective and affordable treatment, but not into the efficacy and safety of NRT. Plain language summary Medications to help people to stop smoking: an overview of reviews Background 
 Smoking is a main cause of early death throughout the world. There are a number of medications which can help people to quit smoking. Three of these, nicotine replacement therapy (NRT), bupropion and varenicline, are licensed for this purpose in the USA and Europe. Cytisine (similar to varenicline) is licensed for use in Russia and Eastern Europe. We reviewed studies of these and other treatments, including nortriptyline, to compare their benefits and risks.
 Methods 
 We found 12 Cochrane reviews of different treatments. The treatments include nicotine replacement therapy (NRT); antidepressants (bupropion and nortriptyline); nicotine receptor partial agonists (varenicline and cytisine); anxiolytics; selective type 1 cannabinoid receptor antagonists (rimonabant); clonidine; lobeline; dianicline; mecamylamine; Nicobrevin; opioid antagonists; nicotine vaccines; and silver acetate. The reviews were conducted between 2008 and 2012, and analysed 267 trials, covering more than 101,000 smokers. All the reviews used randomised controlled trials, and compared the active treatment with a placebo, and sometimes with other treatments. The outcomes were measured at least six months from the start of treatment, and the results were usually checked by testing breath, blood or urine. We also assessed the risk of harms from each treatment. We then compared NRT, bupropion and varenicline with each other, using a network meta‐analysis.
 Results 
 NRT and bupropion helped about 80% more people to quit than placebo; this means that for every 10 people who quit with placebo about 18 could be expected to quit with NRT or with bupropion. Varenicline more than doubled the chances of quitting compared with placebo, so that for every 10 who quit with placebo about 28 could be expected to quit with varenicline.
 Varenicline helped about 50% more people to quit than nicotine patch and 'other' NRT (tablets, sprays, lozenges and inhalers), and about 70% more people than nicotine gum. So for every 10 people who quit with NRT patch or with 'other' NRT, about 15 could be expected to quit with varenicline, and for every 10 who quit with NRT gum about 17 could be expected to quit with varenicline. Combining two type of NRT was as effective as using varenicline, and helped more people to quit than single types of NRT. There was little to choose between different types of NRT, apart from 'other' NRT, which helped slightly more people than nicotine gum; for every 10 people who quit with NRT gum, about 12 could be expected to quit with 'other' NRT.
 NRT combined with nortriptyline or with bupropion was not more effective than NRT alone.
 Both cytisine and nortriptyline compared with placebo improved the chances of quitting, with minimal risk of harms.
 
 Bupropion carries a known risk of seizures (about 1 per 1000 users), but we found fewer than expected in the included and excluded trials, at about 1 in 1500. Although there may be a marginal increase in the likelihood of any serious adverse event while taking bupropion, we did not find increased risks of neuropsychiatric or heart and circulatory problems in the bupropion studies. The evidence for the safety of varenicline is still under investigation; we found no evidence from the trials that it is linked to an increase in neuropsychiatric problems, or with increased heart and circulatory problems.
 
 Clonidine helped people to quit, but caused side effects. It is not clear whether or not mecamylamine used with NRT helps people to quit. Other treatments did not seem to help. So far, nicotine vaccines are not licensed for use anywhere in the world. Nicobrevin is no longer available in the UK, and rimonabant, taranabant and dianicline have all been withdrawn from the market.
 Conclusions 
 NRT, bupropion and varenicline all improve the chances of quitting, with a low risk of harms.
 Combination use of NRT is as effective as varenicline, and more effective than single types of NRT.
 Cytisine has potential as a safe, effective and affordable treatment.
 Nortriptyline improves the chances of quitting, with little evidence of harmful events.
 We need continued monitoring of the safety of varenicline.
 More research into NRT versus placebo is unlikely to change our understanding of the treatment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Cahill, K; Stevens, S; Perera, R; Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD009329.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "aa350912-bc0b-4dd8-a865-767cb0fe0cbb", "pmid": "", "title": "D‐penicillamine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is used for patients with primary biliary cirrhosis due to its hepatic copper decreasing and immunomodulatory potentials. The results from randomised clinical trials have been inconsistent. Objectives To systematically review the beneficial and harmful effects of D‐penicillamine for patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register (September 2003), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2003) , MEDLINE (January 1966 to September 2003) , EMBASE (January 1980 to September 2003) , The Chinese Biomedical CD Database (January 1979 to August 2003) , and LILACS (1982 to 2003); through manual searches of bibliographies; and by contacting authors of the trials and pharmaceutical companies. Selection criteria We included randomised clinical trials comparing D‐penicillamine with placebo/no intervention or other control intervention irrespective of language, year of publication, and publication status. Data collection and analysis Two reviewers independently assessed the methodological quality of the trials and extracted data, validated by a third reviewer. The primary outcomes were 1) mortality and 2) a combination of those who died or underwent liver transplantation. We analysed dichotomous outcomes as relative risk (RR) with 95% confidence interval (CI) by a fixed effect model and a random effects model. We investigated sources of heterogeneity by subgroup analyses and tested the robustness of our findings by sensitivity analyses. Main results We included seven trials randomising 706 patients with primary biliary cirrhosis. D‐penicillamine compared with placebo/no intervention tended to increase mortality (RR 1.34, 95% CI 1.09 to 1.64, fixed; RR 1.46, 95% CI 0.85 to 2.50, random). However, there was substantial heterogeneity. No significant differences were detected regarding the risks of mortality or liver transplantation, pruritus, liver complications, progression of liver histological stage, or the levels of liver biochemical variables (except alanine aminotransferase). D‐penicillamine versus placebo/no intervention significantly increased the risk of adverse events (RR 3.11, 95% CI 2.33 to 4.16, fixed; RR 4.18, 95% CI 1.38 to 12.69, random). Authors' conclusions D‐penicillamine did not appear to reduce the risk of mortality, but significantly increased the occurrences of adverse events in patients with primary biliary cirrhosis. We do not support the use of D‐penicillamine for patients with primary biliary cirrhosis. Plain language summary D‐penicillamine did not reduce the risk of mortality of patients with primary biliary cirrhosis but increased the occurrences of adverse events Primary biliary cirrhosis is an uncommon, chronic liver disease of unknown etiology. D‐penicillamine, a cupruretic drug, has been tested in randomised clinical trials and is used to treat patients with primary biliary cirrhosis. After combining results from seven trials, D‐penicillamine did not appear to improve survival of patients. D‐penicillamine was associated with a four‐time increase of adverse events. There were no significant differences between D‐penicillamine and placebo/no intervention with respect to clinical changes, liver histology, and liver biochemistry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y; Klingenberg, SL; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004789.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "aa3d7e95-bdb5-4c01-9086-d19bafd18a23", "pmid": "", "title": "Corticosteroids for hospitalised children with acute asthma", "imported": false, "abstract": "Abstract - Background Systemic corticosteroids are used routinely in the management of children with severe acute asthma. There is a lack of consensus regarding the agent, dose and route of corticosteroid administration. Objectives To determine the benefit of systemic corticosteroids (oral, intravenous, or intramuscular) compared to placebo and inhaled steroids in acute paediatric asthma. Search methods All controlled trials were identified from the Cochrane Airways Review Group Register, hand searching of respiratory journals, reference lists and contacts with experts and pharmaceutical companies. Selection criteria Studies were included if they described a randomised controlled trial (RCT) involving children aged 1‐18 years with severe acute asthma who received oral, inhaled, intravenous or intramuscular corticosteroids. Only studies in which patients required hospital admission were included. Data collection and analysis Two reviewers using a standard form extracted all data. All data, numeric calculations and graphic extrapolations were independently confirmed. Main results Seven trials were included with a total of 426 children studied (274 with oral prednisone vs. placebo, 106 with intravenous steroids vs placebo and 46 with nebulised budesonide vs prednisolone). A significant number of steroid treated children were discharged early after admission (>4 hours) with an OR of 7.00 (95% CI: 2.98 to 16.45) and NNT of 3 (95%CI: 2 to 8). The length of stay was shorter in the steroid groups with a WMD of ‐8.75 hours (95% CI: ‐19.23 to 1.74). There were no significant differences between groups in pulmonary function or oxygen saturation measurements. Children treated with steroids in hospital were less likely to relapse within one to three months with OR 0.19 (95%CI: 0.07 to 0.55) and NNT of 3 (95%CI: 2 to 7). The single small study that compared nebulised budesonide to oral prednisone failed to demonstrate equivalence or a difference between each therapy. Authors' conclusions Systemic corticosteroids produce some improvements for children admitted to hospital with acute asthma. The benefits may include earlier discharge and fewer relapses. Inhaled or nebulised corticosteroids cannot be recommended as equivalent to systemic steroids at this time. Further studies examining differing doses and routes of administration for corticosteroids will clarify the optimal therapy. Plain language summary Corticosteroids for hospitalised children with acute asthma An acute asthma attack in a child often results in a trip to the hospital. In the emergency department steroid drugs are given which may improve the child's condition and allow them to be sent home after a few hours observation. However, some children require continued treatment in hospital. This review asked the question \"do steroid drugs help children admitted to hospital with asthma?\" We found that steroids given by mouth or through an intravenous tube help children recover from acute asthma. The benefits may include earlier discharge or a shorter stay in hospital. Children were less likely to come back to hospital in the one to three months following the admission. However, the evidence was not overwhelming due to the limited number of studies available and different medicines used. Further research needs to concentrate on the best medications to use and the best route of administration.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Smith, M, Iqbal, SMSI, Rowe, BH, N'Diaye, T", "articleTypes": [], "doi": "10.1002/14651858.CD002886", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.100Z" }, { "id": "aa46a3fb-4d9b-427d-b901-d72cc28f4ca3", "pmid": "", "title": "Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether metformin can prevent or delay T2DM and its complications in people with increased risk of developing T2DM is unknown. Objectives To assess the effects of metformin for the prevention or delay of T2DM and its associated complications in persons at increased risk for the T2DM. Search methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was March 2019. Selection criteria We included randomised controlled trials (RCTs) with a duration of one year or more comparing metformin with any pharmacological glucose‐lowering intervention, behaviour‐changing intervention, placebo or standard care in people with impaired glucose tolerance, impaired fasting glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or combinations of these. Data collection and analysis Two review authors read all abstracts and full‐text articles and records, assessed risk of bias and extracted outcome data independently. We used a random‐effects model to perform meta‐analysis and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using GRADE. Main results We included 20 RCTs randomising 6774 participants. One trial contributed 48% of all participants. The duration of intervention in the trials varied from one to five years. We judged none of the trials to be at low risk of bias in all 'Risk of bias' domains. Our main outcome measures were all‐cause mortality, incidence of T2DM, serious adverse events (SAEs), cardiovascular mortality, non‐fatal myocardial infarction or stroke, health‐related quality of life and socioeconomic effects.The following comparisons mostly reported only a fraction of our main outcome set.
 Fifteen RCTs compared metformin with diet and exercise with or without placebo: all‐cause mortality was 7/1353 versus 7/1480 (RR 1.11, 95% CI 0.41 to 3.01; P = 0.83; 2833 participants, 5 trials; very low‐quality evidence); incidence of T2DM was 324/1751 versus 529/1881 participants (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 3632 participants, 12 trials; moderate‐quality evidence); the reporting of SAEs was insufficient and diverse and meta‐analysis could not be performed (reported numbers were 4/118 versus 2/191; 309 participants; 4 trials; very low‐quality evidence); cardiovascular mortality was 1/1073 versus 4/1082 (2416 participants; 2 trials; very low‐quality evidence). One trial reported no clear difference in health‐related quality of life after 3.2 years of follow‐up (very low‐quality evidence). Two trials estimated the direct medical costs (DMC) per participant for metformin varying from $220 to $1177 versus $61 to $184 in the comparator group (2416 participants; 2 trials; low‐quality evidence). Eight RCTs compared metformin with intensive diet and exercise: all‐cause mortality was 7/1278 versus 4/1272 (RR 1.61, 95% CI 0.50 to 5.23; P = 0.43; 2550 participants, 4 trials; very low‐quality evidence); incidence of T2DM was 304/1455 versus 251/1505 (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 2960 participants, 7 trials; moderate‐quality evidence); the reporting of SAEs was sparse and meta‐analysis could not be performed (one trial reported 1/44 in the metformin group versus 0/36 in the intensive exercise and diet group with SAEs). One trial reported that 1/1073 participants in the metformin group compared with 2/1079 participants in the comparator group died from cardiovascular causes. One trial reported that no participant died due to cardiovascular causes (very low‐quality evidence). Two trials estimated the DMC per participant for metformin varying from $220 to $1177 versus $225 to $3628 in the comparator group (2400 participants; 2 trials; very low‐quality evidence). Three RCTs compared metformin with acarbose: all‐cause mortality was 1/44 versus 0/45 (89 participants; 1 trial; very low‐quality evidence); incidence of T2DM was 12/147 versus 7/148 (RR 1.72, 95% CI 0.72 to 4.14; P = 0.22; 295 participants; 3 trials; low‐quality evidence); SAEs were 1/51 versus 2/50 (101 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin with thiazolidinediones: incidence of T2DM was 9/161 versus 9/159 (RR 0.99, 95% CI 0.41 to 2.40; P = 0.98; 320 participants; 3 trials; low‐quality evidence). SAEs were 3/45 versus 0/41 (86 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin plus intensive diet and exercise with identical intensive diet and exercise: all‐cause mortality was 1/121 versus 1/120 participants (450 participants; 2 trials; very low‐quality evidence); incidence of T2DM was 48/166 versus 53/166 (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; 332 participants; 2 trials; very low‐quality evidence). One trial estimated the DMC of metformin plus intensive diet and exercise to be $270 per participant compared with $225 in the comparator group (94 participants; 1 trial; very‐low quality evidence). One trial in 45 participants compared metformin with a sulphonylurea. The trial reported no patient‐important outcomes. For all comparisons there were no data on non‐fatal myocardial infarction, non‐fatal stroke or microvascular complications. We identified 11 ongoing trials which potentially could provide data of interest for this review. These trials will add a total of 17,853 participants in future updates of this review. Authors' conclusions Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate‐quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate‐quality evidence). Likewise, the combination of metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of T2DM (very low‐quality evidence). Data on patient‐important outcomes such as mortality, macrovascular and microvascular diabetic complications and health‐related quality of life were sparse or missing. Plain language summary Metformin for prevention/delay of type 2 diabetes mellitus (T2DM) and associated complications in persons at increased risk for development of T2DM Review question Is the antidiabetic drug metformin able to prevent or delay the development of type 2 diabetes and its associated complications in people with moderately elevated blood sugar levels? Background People with moderately elevated blood sugar levels (often referred to as 'prediabetes') are said to have an increased risk for developing diabetes. Metformin is a blood sugar‐lowering medicine which has been used for a long time to treat people with type 2 diabetes. Type 2 diabetes, also known as adult‐onset diabetes, is the most common type of diabetes and prevents the body from using insulin properly (insulin resistance). Type 2 diabetes can have bad effects on health in the long term (diabetic complications), such as severe eye or kidney disease or 'diabetic feet', eventually resulting in foot ulcers. We investigated whether metformin can also be used to prevent or delay type 2 diabetes in people at increased risk. We examined the effects of metformin on patient‐important outcomes, such as complications of diabetes, death from any cause, health‐related quality of life and side effects of the drug. Study characteristics To be included, people had to have blood sugar levels higher than normal, but below the levels that are used to diagnose diabetes. We found 20 randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 6774 participants. The comparator group consisted of diet and exercise, intensive diet and exercise or another blood sugar‐lowering drug. One study dominated the evidence (48% of the total number of all participants). Twelve studies were performed in China. We only included studies with a treatment duration of one year or more. The treatment duration in the included studies varied from one to five years. This evidence is up to date as of March 2019. Key results Fifteen studies compared metformin against diet and exercise. Eight studies compared metformin against intensive diet and exercise and three studies compared metformin plus intensive diet and exercise against intensive diet and exercise only. When compared to standard diet and exercise metformin slightly reduces or delays development of diabetes. However, when compared to intensive diet and exercise, metformin does not provide an additional benefit in reducing or delaying development of diabetes. Seven studies compared metformin with another glucose‐lowering drug: three studies compared metformin with acarbose. Three studies compared metformin with a thiazolidinedione (such as pioglitazone). There was neither an advantage or disadvantage when comparing metformin with these drugs with respect to the development of diabetes. One study compared metformin with a sulphonylurea (glimepiride). The trial did not report patient‐important outcomes. In general, the reporting of serious side effects was sparse. Few participants died and we did not detect a clear difference between the intervention and comparator groups. We also did not detect an advantage or disadvantage of metformin in relation to health‐related quality of life. Our included studies did not report on non‐fatal heart attacks, strokes or complications of diabetes such as kidney or eye disease. Few studies estimated the direct medical costs. When compared to diet and exercise, metformin was more expensive. When compared to intensive diet and exercise, metformin was less expensive. We identified 11 ongoing studies which potentially could provide data for this review. These studies will add a total of 17,853 participants in future updates of our review. Future studies should investigate more patient‐important outcomes such as complications of diabetes and especially the side effects of the drugs. We do not know whether 'prediabetes' is just a condition defined by laboratory measurements, or whether it is in fact a real risk factor for diabetes. It is also unknown whether treatment of this condition translates into better patient‐important outcomes. Certainty of the evidence All included studies had problems in the way they were conduced or reported.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Madsen, KS; Chi, Y; Metzendorf, MI; Richter, B; Hemmingsen, B", "articleTypes": [], "doi": "10.1002/14651858.CD008558.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "aa49b717-1667-4c3b-b85f-58fd0fe03cbb", "pmid": "", "title": "The effects of antimicrobial therapy on bacterial vaginosis in non‐pregnant women", "imported": false, "abstract": "Abstract - Background Bacterial vaginosis (BV) is a very common cause of vaginitis that has been associated with a high incidence of obstetric and gynaecologic complications and increased risk of HIV‐1 transmission. This has led to renewed research interest in its treatment. Objectives To assess the effects of antimicrobial agents on BV in non‐pregnant women. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE, LILACS, and African Healthline (December 2007); and proceedings of relevant international conferences (from 1981 to date). Selection criteria Randomised controlled trials comparing any two or more antimicrobial agents, or antimicrobial agents with placebo or no treatment, in women with clinical or Gram‐stain criteria of BV. Data collection and analysis Two authors independently assessed trial quality and extracted data from the original publications while the third author cross checked the data. Main results Twenty‐four trials involving 4422 participants were reviewed. Most examined symptomatic women only. Only seven trials analysed results by intention to treat; we re‐analysed the remainder. Compared with placebo, clindamycin showed a lower rate of treatment failure (relative risk (RR) 0.25, 95% confidence interval (CI) 0.16 to 0.37). Clindamycin and metronidazole showed identical rates of treatment failure, irrespective of regimen type, at two and four‐week follow up (RR 1.01, 95% CI 0.69 to 1.46; RR 0.91, 95% CI 0.70 to 1.18, respectively). Clindamycin tended to cause a lower rate of adverse events (RR 0.75, 95% CI 0.56 to 1.02); metallic taste, and nausea and vomiting were more common in the metronidazole group (RR 0.08, 95% CI 0.1 to 0.59; RR 0.23, 95% CI 0.10 to 0.51, respectively). Given intravaginally as gelatin tablets, lactobacillus was more effective than oral metronidazole (RR 0.20, 95% CI 0.05 to 0.08). Similarly, oral lactobacillus combined with metronidazole was more effective than metronidazole alone (RR 0.33, 95% CI 0.14 to 0.77). Clindamycin showed a lower rate of clinical failure than triple sulfonamide cream (RR 0.46, 95% CI 0.29 to 0.72). Hydrogen peroxide douche showed a higher rate of clinical failure (RR 1.75, 95% CI 1.02 to 3.00) and adverse events (RR 2.33, 95% CI 1.21 to 4.52) than a single 2 g dose of metronidazole. Authors' conclusions Clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus were effective for bacterial vaginosis. Hydrogen peroxide douche and triple sulphonamide cream were ineffective. Metronidazole caused metallic taste, nausea and vomiting. We need better‐designed trials with larger sample sizes to test the effectiveness of promising drugs. Plain language summary The effects of antimicrobial treatment on bacterial vaginosis in non‐pregnant women Bacterial vaginosis (BV) is a very common cause of symptomatic and asymptomatic vaginal infection. It has been associated with a high incidence of obstetric and gynaecologic complications and an increased risk of transmission of HIV (human immunodeficiency virus). This review evaluated the effectiveness and adverse effects of antimicrobial agents used to treat BV in non‐pregnant women. Twenty‐four trials involving 4422 women were reviewed. With regard to less treatment failure, clindamycin was superior to placebo but comparable to metronidazole, irrespective of the dose regimen. Metronidazole tended to cause a higher rate of adverse events, such as metallic taste and nausea and vomiting, than did clindamycin. Oral lactobacillus combined with metronidazole was more effective than metronidazole alone. Administered in an intravaginal gelatin tablet, lactobacillus was also more effective than oral metronidazole. Triple sulfonamide cream was less effective compared with clindamycin. Hydrogen peroxide douche was not as effective as a single 2 g dose of metronidazole yet caused more harms. Only one trial involved asymptomatic women and the result was not conclusive. There was insufficient evidence to reach a conclusion on the effectiveness of other promising drugs. Drugs effective for bacterial vaginosis include clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus. Adverse effects of metronidazole include metallic taste, and nausea and vomiting. Information on possible side effects of lactobacillus preparations is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Oduyebo, OO; Anorlu, RI; Ogunsola, FT", "articleTypes": [], "doi": "10.1002/14651858.CD006055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "aa4b7fd0-f305-415b-b6e9-754842bc7bf0", "pmid": "", "title": "Fluoride toothpastes of different concentrations for preventing dental caries", "imported": false, "abstract": "Abstract - Background Caries (dental decay) is a disease of the hard tissues of the teeth caused by an imbalance, over time, in the interactions between cariogenic bacteria in dental plaque and fermentable carbohydrates (mainly sugars). Regular toothbrushing with fluoride toothpaste is the principal non‐professional intervention to prevent caries, but the caries‐preventive effect varies according to different concentrations of fluoride in toothpaste, with higher concentrations associated with increased caries control. Toothpastes with higher fluoride concentration increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Objectives To determine and compare the effects of toothpastes of different fluoride concentrations (parts per million (ppm)) in preventing dental caries in children, adolescents, and adults. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 August 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7) in the Cochrane Library (searched 15 August 2018); MEDLINE Ovid (1946 to 15 August 2018); and Embase Ovid (1980 to 15 August 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 August 2018). No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials that compared toothbrushing with fluoride toothpaste with toothbrushing with a non‐fluoride toothpaste or toothpaste of a different fluoride concentration, with a follow‐up period of at least 1 year. The primary outcome was caries increment measured by the change from baseline in the decayed, (missing), and filled surfaces or teeth index in all permanent or primary teeth (D(M)FS/T or d(m)fs/t). Data collection and analysis Two members of the review team, independently and in duplicate, undertook the selection of studies, data extraction, and risk of bias assessment. We graded the certainty of the evidence through discussion and consensus. The primary effect measure was the mean difference (MD) or standardised mean difference (SMD) caries increment. Where it was appropriate to pool data, we used random‐effects pairwise or network meta‐analysis. Main results We included 96 studies published between 1955 and 2014 in this updated review. Seven studies with 11,356 randomised participants (7047 evaluated) reported the effects of fluoride toothpaste up to 1500 ppm on the primary dentition; one study with 2500 randomised participants (2008 evaluated) reported the effects of 1450 ppm fluoride toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants (40,066 evaluated) reported the effects of toothpaste up to 2400 ppm on the immature permanent dentition; and three studies with 2675 randomised participants (2162 evaluated) reported the effects of up to 1100 ppm fluoride toothpaste on the mature permanent dentition. Follow‐up in most studies was 36 months. In the primary dentition of young children, 1500 ppm fluoride toothpaste reduces caries increment when compared with non‐fluoride toothpaste (MD ‐1.86 dfs, 95% confidence interval (CI) ‐2.51 to ‐1.21; 998 participants, one study, moderate‐certainty evidence); the caries‐preventive effects for the head‐to‐head comparison of 1055 ppm versus 550 ppm fluoride toothpaste are similar (MD ‐0.05, dmfs, 95% CI ‐0.38 to 0.28; 1958 participants, two studies, moderate‐certainty evidence), but toothbrushing with 1450 ppm fluoride toothpaste slightly reduces decayed, missing, filled teeth (dmft) increment when compared with 440 ppm fluoride toothpaste (MD ‐0.34, dmft, 95%CI ‐0.59 to ‐0.09; 2362 participants, one study, moderate‐certainty evidence). The certainty of the remaining evidence for this comparison was judged to be low. We included 81 studies in the network meta‐analysis of D(M)FS increment in the permanent dentition of children and adolescents. The network included 21 different comparisons of seven fluoride concentrations. The certainty of the evidence was judged to be low with the following exceptions: there was high‐ and moderate‐certainty evidence that 1000 to 1250 ppm or 1450 to 1500 ppm fluoride toothpaste reduces caries increments when compared with non‐fluoride toothpaste (SMD ‐0.28, 95% CI ‐0.32 to ‐0.25, 55 studies; and SMD ‐0.36, 95% CI ‐0.43 to ‐0.29, four studies); there was moderate‐certainty evidence that 1450 to 1500 ppm fluoride toothpaste slightly reduces caries increments when compared to 1000 to 1250 ppm (SMD ‐0.08, 95% CI ‐0.14 to ‐0.01, 10 studies); and moderate‐certainty evidence that the caries increments are similar for 1700 to 2200 ppm and 2400 to 2800 ppm fluoride toothpaste when compared to 1450 to 1500 ppm (SMD 0.04, 95% CI ‐0.07 to 0.15, indirect evidence only; SMD ‐0.05, 95% CI ‐0.14 to 0.05, two studies). In the adult permanent dentition, 1000 or 1100 ppm fluoride toothpaste reduces DMFS increment when compared with non‐fluoride toothpaste in adults of all ages (MD ‐0.53, 95% CI ‐1.02 to ‐0.04; 2162 participants, three studies, moderate‐certainty evidence). The evidence for DMFT was low certainty. Only a minority of studies assessed adverse effects of toothpaste. When reported, effects such as soft tissue damage and tooth staining were minimal. Authors' conclusions This Cochrane Review supports the benefits of using fluoride toothpaste in preventing caries when compared to non‐fluoride toothpaste. Evidence for the effects of different fluoride concentrations is more limited, but a dose‐response effect was observed for D(M)FS in children and adolescents. For many comparisons of different concentrations the caries‐preventive effects and our confidence in these effect estimates are uncertain and could be challenged by further research. The choice of fluoride toothpaste concentration for young children should be balanced against the risk of fluorosis. Plain language summary Fluoride toothpastes of different strengths for preventing tooth decay Review question 
 This review has been produced to assess the effects of toothpastes of different fluoride strengths on preventing tooth decay in children, adolescents and adults. Background 
 Tooth decay (caries) is a widespread disease, affecting billions of people worldwide. Fluoride has long been used to prevent decay, through a variety of different methods including toothpaste, water, milk, mouthrinses, tooth gels and varnish. Regular toothbrushing is recommended to prevent decay and other oral diseases, and toothbrushing for 2 minutes twice daily with a fluoride toothpaste is generally recommended. The typical strength of regular or family toothpaste is around 1000 to 1500 parts per million (ppm) fluoride, but many other strengths are available worldwide. There is no minimum fluoride concentration, but the maximum permissible fluoride concentration for a toothpaste varies according to age and country. Higher concentrations are rarely available over the counter, and are classed as a prescription‐only medicine. Stronger fluoride toothpaste may offer greater protection against decay but also increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Study characteristics 
 Authors from Cochrane Oral Health carried out this review and the evidence is current up to 15 August 2018. It includes 96 studies published between 1955 and 2014: seven studies with 11,356 randomised participants reported the effects of fluoride toothpaste up to 1500 ppm on the primary teeth; one study with 2500 randomised participants reported the effects of 1450 ppm toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants reported the effects of toothpaste up to 2400 ppm on the permanent teeth of children up to 18 years of age; and three studies with 2675 randomised participants reported the effects of up to 1100 ppm toothpaste on the permanent teeth of adults. Most studies assessed decay after participants had been using the toothpastes for 36 months. Main results 
 We present below findings for which there is moderate‐ or high‐certainty evidence. In primary teeth of young children, brushing teeth with a toothpaste containing 1500 ppm fluoride reduced the amount of new decay when compared with non‐fluoride toothpaste; the amount of new decay was similar with 1055 ppm compared with 550 ppm fluoride toothpaste; and there was a slight reduction in the amount of new decay with 1450 ppm toothpaste compared with 440 ppm fluoride toothpaste. Eighty‐one studies assessed the effects of different strengths of fluoride toothpaste compared against each other (seven different strengths in 21 combinations) in permanent teeth of children and adolescents. We found that there was less new decay when toothbrushing with toothpaste containing 1000 to 1250 ppm or 1450 to 1500 ppm fluoride compared with non‐fluoride toothpaste, and that toothbrushing with 1450 to 1500 ppm fluoride toothpaste reduced the amount of new decay more than 1000 to 1250 ppm toothpaste. We found that there was a similar amount of new decay when children and adolescents used a toothpaste of 1700 to 2200 ppm or 2400 to 2800 ppm fluoride compared to 1450 to 1500 ppm toothpaste. The evidence for the effects of other strengths of toothpaste was less certain. In permanent teeth of adults of all ages, 1000 or 1100 ppm toothpaste reduced decay compared with non‐fluoride toothpaste. Most studies did not measure harmful effects of toothpaste use, but when reported, effects such as soft tissue damage and tooth staining were minimal. Certainty of the evidence 
 There is high‐certainty evidence that toothpaste containing 1000 to 1250 ppm fluoride is more effective than non‐fluoride toothpaste. There is moderate‐certainty evidence for the other findings reported in 'Main results' above. For other toothpaste strengths compared against each other or against non‐fluoride toothpaste, there are too few studies with too few participants to have any clarity about the effects. Authors conclusions 
 There are benefits of using fluoride toothpaste at certain strengths to prevent tooth decay when compared with non‐fluoride toothpaste. The stronger the fluoride concentration, the more decay is prevented. For many of the comparisons of different strengths of toothpaste, the findings are uncertain and could be challenged by further research. The choice of fluoride toothpaste for young children should be balanced against the risk of fluorosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Walsh, T; Worthington, HV; Glenny, AM; Marinho, VCC; Jeroncic, A", "articleTypes": [], "doi": "10.1002/14651858.CD007868.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "aa7a41f0-6c2a-41bd-a48f-b49b7212040f", "pmid": "", "title": "Adverse events in people taking macrolide antibiotics versus placebo for any indication", "imported": false, "abstract": "Abstract - Background Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment‐specific, rather than disease‐specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases. Objectives To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides. Selection criteria We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups. Data collection and analysis Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide‐resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta‐analysis when three or more included studies reported a specific adverse event. Main results We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events or at least stated that no adverse events were observed. Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low‐quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low‐quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate‐quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate‐quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate‐quality evidence) were also reported more often in participants taking macrolides compared to placebo. The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000. The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting. There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration. Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low‐quality evidence). Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low‐quality evidence). We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low‐quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low‐quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low‐quality evidence) compared to placebo. We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo. Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate‐quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate‐quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate‐quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non‐significant. There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low‐quality evidence). Only 24 studies (13%) provided useful data on macrolide‐resistant bacteria. Macrolide‐resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent. Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials. Authors' conclusions The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as \"none were observed\". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance. Plain language summary Adverse events in people taking macrolide antibiotics Review question We wanted to find out if people treated with a macrolide antibiotic experienced more adverse events than those treated with placebo. Background Macrolide antibiotics are a group of antibiotics that are commonly used to treat both acute and chronic infections. The four most frequently used macrolides are: azithromycin, clarithromycin, erythromycin, and roxithromycin. People taking macrolide antibiotics are at risk of experiencing adverse events such as nausea, diarrhoea, or rash. Search date We searched the literature up to May 2018. Study characteristics We included 183 studies with a total of 252,886 participants. Most studies were conducted in the hospital setting. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events, or at least stated that no adverse events were observed. Study funding sources Drug companies supplied trial medications or funding, or both, in 91 studies. Funding sources were unclear in 59 studies. Key results People treated with a macrolide antibiotic experienced gastrointestinal adverse events such as nausea, vomiting, abdominal pain, and diarrhoea more often than those treated with placebo. Taste disturbances were reported more often by people taking macrolides than those taking a placebo. However, as very few studies reported on these adverse events, these results should be interpreted with caution. Hearing loss was reported more often by people taking macrolide antibiotics, however only four studies reported this outcome. Macrolides caused less cough and fewer respiratory tract infections than placebo. We did not find any evidence that macrolides caused more cardiac disorders, liver disorders, blood infections, skin and soft tissue infections, changes in liver enzymes, appetite loss, dizziness, headache, respiratory symptoms, itching, or rashes than placebo. We did not find more deaths in people treated with macrolides than in those treated with placebo. Very limited information was available to assess if people treated with a macrolide antibiotic were at greater risk of developing resistant bacteria than those treated with placebo. However, bacteria that did not respond to macrolide antibiotics were more commonly identified immediately after treatment in people taking a macrolide than in those taking a placebo, but differences in resistance thereafter were inconsistent. Quality of the evidence The quality of the evidence ranged from very low (cardiac disorders, change in liver enzymes, liver disorders) to low (abdominal pain, death, diarrhoea, dizziness, hearing loss, skin and soft tissue infections, taste disturbance, wheeze) to moderate (appetite loss, blood infection, cough, fever, headache, itching, nausea, rash, respiratory symptoms, respiratory tract infections, vomiting).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hansen, MP, Scott, AM, McCullough, A, Thorning, S, Aronson, JK, Beller, EM, Glasziou, PP, Hoffmann, TC, Clark, J, Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD011825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.066Z" }, { "id": "aa7ed4b6-7da2-4bd0-af30-813aa46f769a", "pmid": "", "title": "Aspirin with or without an antiemetic for acute migraine headaches in adults", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010). Migraine is a common, disabling condition and a burden for the individual, health services and society. Many sufferers choose not to, or are unable to, seek professional help and rely on over‐the‐counter analgesics. Co‐therapy with an antiemetic should help to reduce nausea and vomiting commonly associated with migraine headaches. Objectives To determine the efficacy and tolerability of aspirin, alone or in combination with an antiemetic, compared to placebo and other active interventions in the treatment of acute migraine headaches in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, ClinicalTrials.gov, and reference lists for studies through 10 March 2010 for the original review and to 31 January 2013 for the update. Selection criteria We included randomised, double‐blind, placebo‐controlled or active‐controlled studies, or both, using aspirin to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and numbers needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment. Main results No new studies were found for this update. Thirteen studies (4222 participants) compared aspirin 900 mg or 1000 mg, alone or in combination with metoclopramide 10 mg, with placebo or other active comparators, mainly sumatriptan 50 mg or 100 mg. For all efficacy outcomes, all active treatments were superior to placebo, with NNTs of 8.1, 4.9 and 6.6 for 2‐hour pain‐free, 2‐hour headache relief, and 24‐hour headache relief with aspirin alone versus placebo, and 8.8, 3.3 and 6.2 with aspirin plus metoclopramide versus placebo. Sumatriptan 50 mg did not differ from aspirin alone for 2‐hour pain‐free and headache relief, while sumatriptan 100 mg was better than the combination of aspirin plus metoclopramide for 2‐hour pain‐free, but not headache relief; there were no data for 24‐hour headache relief. Adverse events were mostly mild and transient, occurring slightly more often with aspirin than placebo. Additional metoclopramide significantly reduced nausea (P < 0.00006) and vomiting (P = 0.002) compared with aspirin alone. Authors' conclusions We found no new studies since the last version of this review. Aspirin 1000 mg is an effective treatment for acute migraine headaches, similar to sumatriptan 50 mg or 100 mg. Addition of metoclopramide 10 mg improves relief of nausea and vomiting. Adverse events were mainly mild and transient, and were slightly more common with aspirin than placebo, but less common than with sumatriptan 100 mg. Plain language summary Aspirin with or without an antiemetic for acute migraine headaches in adults This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010); no new studies were found. A single oral dose of 1000 mg of aspirin reduced pain from moderate or severe to none by two hours in approximately 1 in 4 people (24%) taking aspirin, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (52%) taking aspirin compared with approximately 1 in 3 (32%) taking placebo. Of those who experienced effective headache relief at two hours, more had that relief sustained over 24 hours with aspirin than with placebo. Addition of 10 mg of the antiemetic metoclopramide substantially increased relief of nausea and vomiting compared with aspirin alone, but made little difference to pain. Oral sumatriptan 100 mg was better than aspirin plus metoclopramide for pain‐free response at two hours, but otherwise there were no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short‐term use were mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Kirthi, V; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008041.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "aa80171e-fd7f-4b40-ae49-2e1eb87fc26f", "pmid": "", "title": "Using Bitter Taste Receptor Blockers to Improve the Palatability of Pediatric Medicines: Trained Human Sensory Panels", "imported": false, "abstract": "Many people, particularly small children, must take drugs in liquid form because they cannot swallow pills or capsules. The bad taste of some liquid drugs can keep patients from taking drugs they need for their health. Our main goal in this research study is find ingredients that might make drugs taste better.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.232Z" }, { "id": "aa9df430-aad4-434f-9346-8482c2421339", "pmid": "", "title": "Pharmacological interventions for people with borderline personality disorder", "imported": false, "abstract": "Abstract - Background Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off‐label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods. Objectives To assess the effects of pharmacological treatment for people with BPD. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. Selection criteria Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events. Data collection and analysis At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. Main results We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty‐nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD ‐0.18, 95% confidence interval (CI) ‐0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD −0.27, 95% CI −0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD −0.07, 95% CI −0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self‐harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale‐Modified‐Self‐Injury item (0‐5 points), 95% CI −10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide‐related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI −0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD −0.26, 95% CI −1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD −0.36, 95% CI −1.96 to 1.25; 2 trials, 44 participants). Very low‐certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD −0.16, 95% CI −0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD −0.25, 95% CI ‐0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD −0.01, 95% CI ‐0.28 to 0.26; 2 trials, 214 participants). Low‐certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD −0.21, 95% CI −0.34 to ‐0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD −0.58, 95% CI ‐1.14 to ‐0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD −0.07, 95% CI ‐0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low‐certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non‐standardised. The available evidence on non‐serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified. Authors' conclusions This review included 18 more trials than the 2010 version, so larger meta‐analyses with more statistical power were feasible. We found mostly very low‐certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma‐related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples. Plain language summary What are the benefits and risks of medication for people with borderline personality disorder? Key messages This review is an update of a previous review on the same topic published in 2010. Although this review includes an additional 18 studies, the conclusions remain the same: there are probably no benefits and risks of medications for borderline personality disorder (BDP), but the evidence is unclear. Better and larger studies comparing the effects of medication with placebo are needed. Such studies should focus on men, adolescents and those with additional psychiatric diagnoses. What is BPD? BPD affects how a person interacts with others and understands one's self. Although its exact causes are unclear, it is thought to result from a combination of genetic and environmental factors (e.g. stressful or traumatic life events when growing up). Approximately 2% of adults and 3% of adolescents are affected. The symptoms of BPD can be grouped into four categories. Instability in mood: People with BPD may experience intense feelings that change rapidly and are difficult to control. They may also feel empty and abandoned much of the time. Cognitive distortions (disturbed patterns of thinking): People with BPD often have upsetting thoughts (e.g. they may think that they are a terrible person). They can have brief episodes of strange experiences (e.g. paranoid ideations or stress‐induced dissociative experiences (i.e. feeling detached from the world around them). Impulsive behaviour: People with BPD may act impulsively and do things that could harm themselves (e.g. when sad and depressed, they may self‐harm or have suicidal feelings). They might also engage in reckless behaviour (e.g. drug misuse). Intense but unstable relationships: People with BPD may find it difficult to keep stable relationships (e.g. they may feel very worried about being abandoned and might constantly text or call, or make threats to harm or kill themselves if the person leaves them). A person only needs to experience five out of nine criteria across these categories to be given a diagnosis of BPD. How is BPD treated? No medication has been approved for the treatment of BPD. Nonetheless, a large proportion of people with BPD are given medications for sustained periods of time to alleviate their symptoms. The type of medication given is chosen based on its known effects on other disorders with similar symptoms. Review question We wanted to find out whether medications to treat BPD work better or worse than placebo; whether one medication works better than another; or whether one combination of medications work better than another combination of medications. We wanted to look at how well medications worked on BPD severity, self‐harm, suicide‐related outcomes, and functioning (how well a person performs in everyday life). We also wanted to find out if medications are associated with any unwanted side effects. What did we do? We searched for studies that compared the effects of different medications with placebo, another medication, or a combination of medications, in people diagnosed with BPD. We compared and summarised the results and rated our confidence in the evidence based on factors such as sample size and methods used. Below, we present the findings from our key comparison: medication versus placebo. What did we find? We found 46 studies that involved 2769 people with BPD. The smallest study had 13 participants and the largest 451 participants. There were four studies with more than 100 participants. Except for one study that included men only, all studies included women. The average age of the participants ranged from 16 years to 39 years. Most studies were conducted in outpatient settings (31 studies) in Europe (20 studies) and lasted between four and 52 weeks. Pharmaceutical companies fully or partially funded 16 studies. The studies looked at the effects of 27 different medications, mostly classified as: 1) antipsychotics (drugs to treat psychosis where a person’s thoughts and mood are so impaired that the person has lost contact with reality); 2) antidepressants (drugs to treat depression); or 3) mood stabilisers (drugs to control and even out mood swings, reducing both high moods (mania) and low moods (depression)). Compared with placebo, medications seem to make little to no difference to BPD severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. They may make little to no difference as to whether a person continues in a study or drops out. Compared to placebo, antipsychotics and mood stabilisers may make little to no difference to the occurrence of unwanted or harmful effects. No study reported on the side effects of antidepressants. What are the limitations of the evidence? Our confidence in the evidence varied between very low and low. The results of future research could differ from the results of this review. Four main factors reduced our confidence in the evidence. First, not all of the studies provided data about everything that we were interested in. Second, the results were very inconsistent across the different studies. Third, there were not enough studies to be certain about the results of our outcomes. Fourth, many studies did not clearly report how they were conducted. How up‐to‐date is this evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Stoffers-Winterling, JM, Storebø, OJ, Pereira Ribeiro, J, Kongerslev, MT, Völlm, BA, Mattivi, JT, Faltinsen, E, Todorovac, A, Jørgensen, MS, Callesen, HE, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.141Z" }, { "id": "aab7043e-82fe-4f40-b0b0-3f03292dc087", "pmid": "", "title": "Interventions for the prevention of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "Abstract - Background Loss of olfactory function is well recognised as a symptom of COVID‐19 infection, and the pandemic has resulted in a large number of individuals with abnormalities in their sense of smell. For many, the condition is temporary and resolves within two to four weeks. However, in a significant minority the symptoms persist. At present, it is not known whether early intervention with any form of treatment (such as medication or olfactory training) can promote recovery and prevent persisting olfactory disturbance. This is an update of the 2021 review with four studies added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with acute olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance, which had been present for less than four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the presence of normal olfactory function, serious adverse effects and change in sense of smell. Secondary outcomes were the prevalence of parosmia, change in sense of taste, disease‐related quality of life and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included five studies with 691 participants. The studies evaluated the following interventions: intranasal corticosteroid sprays, intranasal corticosteroid drops, intranasal hypertonic saline and zinc sulphate. Intranasal corticosteroid spray compared to no intervention/placebo We included three studies with 288 participants who had olfactory dysfunction for less than four weeks following COVID‐19. Presence of normal olfactory function The evidence is very uncertain about the effect of intranasal corticosteroid spray on both self‐rated recovery of olfactory function and recovery of olfactory function using psychophysical tests at up to four weeks follow‐up ( self‐rated : risk ratio (RR) 1.19, 95% confidence interval (CI) 0.85 to 1.68; 1 study; 100 participants; psychophysical testing : RR 2.3, 95% CI 1.16 to 4.63; 1 study; 77 participants; very low‐certainty evidence). Change in sense of smell The evidence is also very uncertain about the effect of intranasal corticosteroid spray on self‐rated change in the sense of smell ( at less than 4 weeks : mean difference (MD) 0.5 points lower, 95% CI 1.38 lower to 0.38 higher; 1 study; 77 participants; at > 4 weeks to 3 months : MD 2.4 points higher, 95% CI 1.32 higher to 3.48 higher; 1 study; 100 participants; very low‐certainty evidence, rated on a scale of 1 to 10, higher scores mean better olfactory function). Intranasal corticosteroids may make little or no difference to the change in sense of smell when assessed with psychophysical testing (MD 0.2 points, 95% CI 2.06 points lower to 2.06 points higher; 1 study; 77 participants; low‐certainty evidence, 0‐ to 24‐point scale, higher scores mean better olfactory function). Serious adverse effects The authors of one study reported no adverse effects, but their intention to collect these data was not pre‐specified so we are uncertain if these were systematically sought and identified. The remaining two studies did not report on adverse effects. Intranasal corticosteroid drops compared to no intervention/placebo We included one study with 248 participants who had olfactory dysfunction for ≤ 15 days following COVID‐19. Presence of normal olfactory function Intranasal corticosteroid drops may make little or no difference to self‐rated recovery at > 4 weeks to 3 months (RR 1.00, 95% CI 0.89 to 1.11; 1 study; 248 participants; low‐certainty evidence). No other outcomes were assessed by this study. Data on the use of hypertonic saline nasal irrigation and the use of zinc sulphate to prevent persistent olfactory dysfunction are included in the full text of the review. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for preventing persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the prevention of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important COVID‐19 has been found to cause problems with the sense of smell. Sometimes this is a reduction in the ability to smell things, and sometimes it is a complete loss of the sense of smell. For many people this recovers in a short time, but for others it may last for weeks or months. This review considers whether there are treatments that people might take as soon as they have lost their sense of smell (within four weeks of the symptoms starting), to try and stop this becoming a long‐standing problem. How we identified and assessed the evidence We searched for all relevant studies in the medical literature to summarise the results. We also looked at how certain the evidence was, considering things like the size of the studies and how they were carried out. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found five studies that had been completed. Intranasal corticosteroids compared to no treatment Three studies looked at this treatment. Nasal corticosteroid spray might make little or no difference to the sense of smell when measured with specific tests (rather than when asking people about their sense of smell). The rest of the evidence was of very low certainty, so we do not know whether a nasal corticosteroid spray is better or worse than no treatment at: ‐ helping the sense of smell get back to normal (either people feeling that their sense of smell is back to normal, or having a normal sense of smell according to specific tests); ‐ making people feel that their sense of smell has improved; ‐ causing any unwanted side effects. Intranasal corticosteroid drops compared to placebo (dummy treatment) One study looked at this treatment. Intranasal corticosteroid drops might not make any difference to the number of people who think their sense of smell has recovered at 30 days. We did find a number of other studies that are being carried out, but no results from these studies were available yet to be included in this review. What this means We do not know whether using a nasal corticosteroid spray or nasal drops has any benefit in preventing longer‐term loss of the sense of smell that is related to COVID‐19, or whether they may cause any harm. This review is a 'living systematic review' ‐ meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Webster, KE; O'Byrne, L; MacKeith, S; Philpott, C; Hopkins, C; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013877.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "aac283a8-17cd-43f2-b9b3-eec1ec1fda19", "pmid": "", "title": "Oral stimulation for promoting oral feeding in preterm infants", "imported": false, "abstract": "Abstract - Background Preterm infants (< 37 weeks' post‐menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co‐ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review. Objectives To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA. Search methods Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi‐randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis. Selection criteria Randomised and quasi‐randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non‐oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes. Data collection and analysis Following the updated search, two review authors screened the titles and abstracts of studies and full‐text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non‐oral or sham intervention. We performed meta‐analysis using a fixed‐effect model. Main results We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) ‐4.07 days, 95% confidence interval (CI) ‐4.81 to ‐3.32 days, 6 studies, 292 infants; I 2 =85%, very low‐certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD ‐4.33, 95% CI ‐5.97 to ‐2.68 days, 5 studies, 249 infants; i 2 =68%, very low‐certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non‐oral intervention Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non‐oral intervention (MD ‐7.17, 95% CI ‐8.04 to ‐6.29 days, 10 studies, 574 infants; I 2 =80%, very low‐certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD ‐6.15, 95% CI ‐8.63 to ‐3.66 days, 10 studies, 591 infants; I 2 =0%, low‐certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD ‐2.85, 95% CI ‐6.13 to 0.42, 3 studies, 268 infants; very low‐certainty evidence due to serious risk of bias, inconsistency and imprecision). Authors' conclusions There remains uncertainty about the effects of oral stimulation (versus either standard care or a non‐oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta‐analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well‐designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions. Plain language summary Effects of oral stimulation for oral feeding in preterm infants Review questions Do oral stimulation interventions that involve finger stimulation protocols in preterm infants born before 37 weeks' gestation: Reduce time (days) taken to achieve exclusive oral feeding? Reduce time (days) spent in Neonatal Intensive Care (NICU)? Reduce length of time (days) spent in hospital? Reduce length of time (days) that an infant spends on tube feeding (parenteral nutrition)? Background This is an update of the 2016 review. Many preterm infants have delayed establishment of oral (suck) feeding and are fed at first with feeding tubes or with intravenous (parenteral) nutrition. Development of oral feeding skills needs careful co‐ordination of sucking, swallowing and breathing. In preterm infants, the development of oral feeding can be challenging because of long hospitalisations, breathing difficulties and other medical conditions associated with preterm birth. Unpleasant and invasive procedures such as ventilation or frequent suctioning of secretions from the mouth or nose can negatively impact feeding skills. International guidelines for the transition from tube feeding to oral feeding vary widely. Healthcare providers use a range of interventions to improve sucking and feeding skills in preterm infants, and studies report faster transition time from tube feeds to oral feeds, reduced length of stay in hospital and improvement in infants' sucking skills. The first review in 2016 showed that while oral stimulation interventions appear to reduce length of hospital stay, reduce need for tube feeding and accelerate time to oral feeding, the studies were of poor methodological quality leaving some uncertainty about overall effects. This update assessed whether current research supports these findings and if the quality of studies has improved, leading to increased certainty of results. Study characteristics This review included randomised controlled trials (RCTs) that explored oral stimulation by finger stimulation only in preterm infants. Review authors identified studies to be included by searching electronic databases, clinical trials registers, peer‐reviewed journals and published conference proceedings. Search is up‐to‐date as of March 2022. Key results For this update, we added 12 new studies of variable quality with small numbers of participants, making a total of 28 included studies. As the certainty of evidence was considered 'low' to 'very low', it remains uncertain whether oral stimulation interventions can shorten the transition to oral feeding, reduce length of hospital stay and decrease time spent on parenteral nutrition, although there may be some potential benefit. No studies reported length of stay in NICU. No studies looked at longer‐term outcomes of the interventions (i.e. beyond six months). Certainty of evidence The numbers of infants in these studies were small, the methods employed by researchers varied in quality and the certainty of evidence is estimated to be 'low' to 'very low'.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, Z, O'Donnell, CPF, Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD009720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.817Z" }, { "id": "aad6844e-daef-4373-ab30-db673d629099", "pmid": "", "title": "Foetal haemoglobin inducers for reducing blood transfusion in non‐transfusion‐dependent beta‐thalassaemias", "imported": false, "abstract": "Abstract - Background Non‐transfusion‐dependent β‐thalassaemia (NTDβT) is a subset of inherited haemoglobin disorders characterised by reduced production of the β‐globin chain of haemoglobin leading to anaemia of varying severity. Although blood transfusion is not a necessity for survival, it may be required to prevent complications of chronic anaemia, such as impaired growth and hypercoagulability. People with NTDβT also experience iron overload due to increased iron absorption from food sources which becomes more pronounced in those requiring blood transfusion. People with a higher foetal haemoglobin (HbF) level have been found to require fewer blood transfusions, thus leading to the emergence of treatments that could increase its level. HbF inducers stimulate HbF production without altering any gene structures. Evidence for the possible benefits and harms of these inducers is important for making an informed decision on their use. Objectives To compare the effectiveness and safety of the following for reducing blood transfusion for people with NTDβT: 1. HbF inducers versus usual care or placebo; 2. single HbF inducer with another HbF inducer, and single dose with another dose; and 3. combination of HbF inducers versus usual care or placebo, or single HbF inducer. Search methods We used standard, extensive Cochrane search methods. The latest search date was 21 August 2022. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs comparing single HbF inducer with placebo or usual care, with another single HbF inducer or with a combination of HbF inducers; or comparing different doses of the same HbF inducer. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were blood transfusion and haemoglobin levels. Our secondary outcomes were HbF levels, the long‐term sequelae of NTDβT, quality of life and adverse events. Main results We included seven RCTs involving 291 people with NTDβT, aged two to 49 years, from five countries. We reported 10 comparisons using eight different HbF inducers (four pharmacological and four natural): three RCTs compared a single HbF inducer to placebo and seven to another HbF inducer. The duration of the intervention lasted from 56 days to six months. Most studies did not adequately report the randomisation procedures or whether and how blinding was achieved. HbF inducer against placebo or usual care Three HbF inducers, HQK‐1001, Radix Astragali or a 3‐in‐1 combined natural preparation (CNP), were compared with a placebo. None of the comparisons reported the frequency of blood transfusion. We are uncertain whether Radix Astragali and CNP increase haemoglobin at three months (mean difference (MD) 1.33 g/dL, 95% confidence interval (CI) 0.54 to 2.11; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). We are uncertain whether Radix Astragali and CNP have any effect on HbF (MD 12%, 95% CI −0.74% to 24.75%; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). Only medians on haemoglobin and HbF levels were reported for HQK‐1001. Adverse effects reported for HQK‐1001 were nausea, vomiting, dizziness and suprapubic pain. There were no prespecified adverse effects for Radix Astragali and CNP. HbF inducer versus another HbF inducer Four studies compared a single inducer with another over three to six months. Comparisons included hydroxyurea versus resveratrol, hydroxyurea versus thalidomide, hydroxyurea versus decitabine and Radix Astragali versus CNP. No study reported our prespecified outcomes on blood transfusion. Haemoglobin and HbF were reported for the comparison Radix Astragali versus CNP, but we are uncertain whether there were any differences (1 study, 24 participants; low‐certainty evidence). Different doses of the same HbF inducer Two studies compared two different types of HbF inducers at different doses over two to six months. Comparisons included hydroxyurea 20 mg/kg/day versus 10 mg/kg/day and HQK‐1001 10 mg/kg/day, 20 mg/kg/day, 30 mg/kg/day and 40 mg/kg/day. Blood transfusion, as prespecified, was not reported. In one study (61 participants) we are uncertain whether the lower levels of both haemoglobin and HbF at 24 weeks were due to the higher dose of hydroxyurea (haemoglobin: MD −2.39 g/dL, 95% CI −2.80 to −1.98; very low‐certainty evidence; HbF: MD −10.20%, 95% CI −16.28% to −4.12%; very low‐certainty evidence). The study of the four different doses of HQK‐1001 did not report results for either haemoglobin or HbF. We are not certain if major adverse effects may be more common with higher hydroxyurea doses (neutropenia: risk ratio (RR) 9.93, 95% CI 1.34 to 73.97; thrombocytopenia: RR 3.68, 95% CI 1.12 to 12.07; very low‐certainty evidence). Taking HQK‐1001 20 mg/kg/day may result in the fewest adverse effects. A combination of HbF inducers versus a single HbF inducer Two studies compared three combinations of two inducers with a single inducer over six months: hydroxyurea plus resveratrol versus resveratrol or hydroxyurea alone, and hydroxyurea plus l‐carnitine versus hydroxyurea alone. Blood transfusion was not reported. Hydroxyurea plus resveratrol may reduce haemoglobin compared with either resveratrol or hydroxyurea alone (MD −0.74 g/dL, 95% CI −1.45 to −0.03; 1 study, 54 participants; low‐certainty evidence). We are not certain whether the gastrointestinal disturbances, headache and malaise more commonly reported with hydroxyurea plus resveratrol than resveratrol alone were due to the interventions. We are uncertain whether hydroxyurea plus l‐carnitine compared with hydroxyurea alone may increase mean haemoglobin, and reduce pulmonary hypertension (1 study, 60 participants; very low‐certainty evidence). Adverse events were reported but not in the intervention group. None of the comparisons reported the outcome of HbF. Authors' conclusions We are uncertain whether any of the eight HbF inducers in this review have a beneficial effect on people with NTDβT. For each of these HbF inducers, we found only one or at the most two small studies. There is no information on whether any of these HbF inducers have an effect on our primary outcome, blood transfusion. For the second primary outcome, haemoglobin, there may be small differences between intervention groups, but these may not be clinically meaningful and are of low‐ to very low‐certainty evidence. Data on adverse effects and optimal doses are limited. Five studies are awaiting classification, but none are ongoing. Plain language summary Medicines to increase foetal haemoglobin levels and reduce the need for blood transfusion in people with non‐transfusion‐dependent thalassaemia Review question Do medicines that increase foetal haemoglobin (HbF) levels in people with non‐transfusion‐dependent β‐thalassaemia (NTDβT) reduce their need for blood transfusion? What is thalassaemia? Thalassaemia is a genetic (inherited) blood disorder that causes defects in adult haemoglobin (the oxygen carrying component of red blood cells) leading to destruction of the red blood cells and anaemia with different degrees of severity. Persistent anaemia can affect general health and reduce quality of life. People with NTDβT may require periodic blood transfusion to replace the red blood cells and this could lead to excess iron being deposited in various organs in the body, affecting their function. People with NTDβT have higher levels of HbF (the main form of haemoglobin found during the development of a baby before birth) which persists after birth. The amount of HbF that persists varies and people with a higher HbF level require less frequent blood transfusions. What are HbF inducers? HbF inducers are substances which increase HbF levels without alteration to the gene. They may reduce the need for blood transfusion in people with NTDβT. However, it is not known which HbF inducers are effective and safe, and if so, what the optimal dose is and at what age treatment should be started. What did we do? We searched medical databases for studies comparing single HbF inducer with placebo (dummy treatment) or usual care, with another inducer or with a combination of inducers; or comparing different doses for a same inducer. What did we find? We found seven very small randomised controlled trials (where people taking part in the trial had equal chances of being in the treatment or the control group), involving 291 people with NTDβT, aged between two and 49 years, from five countries. These studies varied widely in the type of HbF inducers investigated and their comparison, the doses and how outcomes were reported. The duration of the trials ranged from two to six months. The inducers used include hydroxyurea, decitabine, HQK‐1001, thalidomide, Radix Astragali, resveratrol, l‐carnitine and combined natural preparation (CNP). Main results None of the studies reported our main outcome of changes to the frequency of blood transfusion. All inducers may have caused a small increase in haemoglobin and HbF when compared to placebo, but we are very uncertain about this. Four studies compared a single HbF inducer against another, for three to six months. There were changes to haemoglobin and HbF, but we cannot be certain if a single HbF inducer or a combination of HbF inducers would work better than another. Two studies, each compared a different dose of the same inducer. Lower doses of hydroxyurea appeared to increase haemoglobin and HbF levels more than the higher doses, but we are very uncertain. The other study used four different doses of HQK‐1001 but did not actually look for a difference in the effect of these four different doses on haemoglobin or HbF. Two studies compared a combination of two HbF inducers with a single HbF inducer for six months. We are very uncertain whether the combination or a single inducer improves haemoglobin. None of the studies reported whether HbF inducers have any effect on quality of life. Adverse (unwanted) drug effects were reported for each HbF inducer, but there was little information available to guide us on the safety of these substances. What are the limitations of the evidence? The main reason we are very uncertain about the effects of HbF inducers are because the studies were all very small and had weaknesses in their design. None of the studies lasted long enough to provide meaningful information for many of the outcomes we measured. How up to date is this evidence? The evidence is current to 21 August 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Foong, WC, Loh, CK, Ho, JJ, Lau, DSC", "articleTypes": [], "doi": "10.1002/14651858.CD013767.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.778Z" }, { "id": "aaf017a5-0169-4c59-9b1c-6d0a3f0226fd", "pmid": "", "title": "Surgical techniques for the removal of mandibular wisdom teeth", "imported": false, "abstract": "Abstract - Background Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short‐term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity. Objectives To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication. Selection criteria Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth. Data collection and analysis Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel‐group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross‐over or split‐mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split‐mouth studies in our analyses, and combined parallel‐group and split‐mouth studies using the generic inverse‐variance method. We used the fixed‐effect model for three studies or fewer, and random‐effects model for more than three studies. Main results We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low‐certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low‐certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low‐certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low‐certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand‐piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low‐certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low‐certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low‐certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low‐certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low‐certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported. Authors' conclusions In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future. Plain language summary Comparing different surgical techniques used to remove wisdom teeth from the lower jaw Background The removal of wisdom teeth is a common operation, but it can cause short‐ and long‐term side effects. People may have their wisdom teeth removed if they are causing pain or infection, or if they are damaging other teeth or not breaking through the gum properly. Surgery has a risk of complications. One of the most common is dry socket (also known as alveolar osteitis). This is when a blood clot fails to form in the socket that the tooth has come out of, or the clot is disturbed before the socket has properly healed. Because the bones and nerves underlying the socket are exposed, it can be a very painful condition. Review question We aimed to find out the benefits and harms of different surgical techniques used to remove wisdom teeth from the lower jaw, specifically how surgeons can reduce the risk of complications following surgery. We considered the most important outcomes to be: dry socket, wound infection, long‐term damage to the nerves supplying sensation to the tongue and skin of the lower lip and chin, and problems such as excessive bleeding or a broken jaw. Study characteristics We searched for relevant studies up to 8 July 2019. We included 62 studies with 4643 participants. Many studies excluded people who were not in excellent health so the participants in the trials may not be truly representative. Key results The available evidence is inconclusive. It is unclear if the position of the cut into the gum makes any difference to the outcomes. It is unclear whether it is possible to avoid damaging a nerve to the tongue by using a surgical instrument called a lingual retractor. It is unclear as to whether the type of surgical tool (a chisel or a rotating drill) used to remove bone from the jaw makes a difference to the likelihood of the wound becoming infected. It is unclear if the amount and method of delivering saltwater to clean the tooth socket after the extraction makes any difference to the outcomes. It is unclear whether different methods to stitch the gum after the tooth is removed makes any difference to the outcomes. Placing products that are derived from the patient’s own blood into the tooth socket may help to reduce the occurrence of dry socket (a condition that causes intense pain a few days after extraction). Another three surgical approaches were tested in the studies, but they did not measure the important outcomes. Certainty of the evidence None of the included studies were at low risk of bias. All of the studies were quite small. The quality of the studies varied, with most having flaws that could have biased their results. In addition, some of the results were very imprecise, with variation between them that could not be explained. For these reasons, we consider the available evidence to be uncertain. Future research may be able to provide dental surgeons and patients with clearer conclusions than those listed above.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bailey, E, Kashbour, W, Shah, N, Worthington, HV, Renton, TF, Coulthard, P", "articleTypes": [], "doi": "10.1002/14651858.CD004345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.814Z" }, { "id": "aaf5cd74-453f-4485-94f3-cb926122fce6", "pmid": "", "title": "Probiotics for the prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wei, D, Heus, P, van de Wetering, FT, van Tienhoven, G, Verleye, L, Scholten, RJPM", "articleTypes": [], "doi": "10.1002/14651858.CD008831.pub3 AB - Abstract - Background Treament‐related diarrhoea is one of the most common and troublesome adverse effects related to chemotherapy or radiotherapy in people with cancer. Its reported incidence has been as high as 50% to 80%. Severe treatment‐related diarrhoea can lead to fluid and electrolyte losses and nutritional deficiencies and could adversely affect quality of life (QoL). It is also associated with increased risk of infection in people with neutropenia due to anticancer therapy and often leads to treatment delays, dose reductions, or treatment discontinuation. Probiotics may be effective in preventing or treating chemotherapy‐ or radiotherapy‐induced diarrhoea. Objectives To evaluate the clinical effectiveness and side effects of probiotics used alone or combined with other agents for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 7), MEDLINE (1946 to July week 2, 2017), and Embase (1980 to 2017, week 30). We also searched prospective clinical trial registers and the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) investigating the effects of probiotics for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Data collection and analysis Two review authors independently selected studies, extracted data, and assessed risk of bias. We used random‐effects models for all meta‐analyses. If meta‐analysis was not possible, we summarised the results narratively. Main results We included 12 studies involving 1554 participants. Eleven studies were prevention studies, of which seven compared probiotics with placebo (887 participants), one compared two doses of probiotics with each other and with placebo (246 participants), and three compared probiotics with another active agent (216 participants).The remaining study assessed the effectiveness of probiotics compared with placebo for treatment of radiotherapy‐related diarrhoea (205 participants). For prevention of radiotherapy (with or without chemotherapy)‐induced diarrhoea, review authors identified five heterogeneous placebo‐controlled studies (with 926 participants analysed). Owing to heterogeneity, we could not carry out a meta‐analysis, except for two outcomes. For occurrence of any diarrhoea, risk ratios (RRs) ranged from 0.35 (95% confidence interval (CI) 0.26 to 0.47) to 1.0 (95% CI 0.94 to 1.06) (three studies; low‐certainty evidence). A beneficial effect of probiotics on quality of life could neither be demonstrated nor refuted (two studies; low‐certainty evidence). For occurrence of grade 2 or higher diarrhoea, the pooled RR was 0.75 (95% CI 0.55 to 1.03; four studies; 420 participants; low‐certainty evidence), and for grade 3 or higher diarrhoea, RRs ranged from 0.11 (95% CI 0.06 to 0.23) to 1.24 (95% CI 0.74 to 2.08) (three studies; low‐certainty evidence). For probiotic users, time to rescue medication was 36 hours longer in one study (95% CI 34.7 to 37.3), but another study reported no difference (moderate‐certainty evidence). For the need for rescue medication, the pooled RR was 0.50 (95% CI 0.15 to 1.66; three studies; 194 participants; very low‐certainty evidence). No study reported major differences between groups with respect to adverse effects. Although not mentioned explicitly, no studies reported deaths, except one in which one participant in the probiotics group died of myocardial infarction after three sessions of radiotherapy. Three placebo‐controlled studies, with 128 analysed participants, addressed prevention of chemotherapy‐induced diarrhoea. For occurrence of any diarrhoea, the pooled RR was 0.59 (95% CI 0.36 to 0.96; two studies; 106 participants; low‐certainty evidence). For all other outcomes, a beneficial effect of probiotics could be neither demonstrated nor refuted (one to two studies; 46 to 106 participants; all low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. Three studies compared probiotics with another intervention in 213 participants treated with radiotherapy (with or without chemotherapy). One very small study (21 participants) reported less diarrhoea six weeks after treatment when dietary counselling was provided (RR 0.30, 95% CI 0.11 to 0.81; very low‐certainty evidence). In another study (148 participants), grade 3 or 4 diarrhoea occurred less often in the probiotics group than in the control group (guar gum containing nutritional supplement) (odds ratio (OR) 0.38, 95% CI 0.16 to 0.89; low‐certainty evidence), and two studies (63 participants) found less need for rescue medication of probiotics versus another active treatment (RR 0.44, 95% CI 0.22 to 0.86; very low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. One placebo‐controlled study with 205 participants addressed treatment for radiotherapy‐induced diarrhoea and could not demonstrate or refute a beneficial effect of probiotics on average diarrhoea grade, time to rescue medication for diarrhoea (13 hours longer in the probiotics group; 95% CI ‐0.9 to 26.9 hours), or need for rescue medication (RR 0.74, 95% CI 0.53 to 1.03; moderate‐certainty evidence). This study did not address quality of life. No studies reported serious adverse events or diarrhoea‐related deaths. Authors' conclusions This review presents limited low‐ or very low‐certainty evidence supporting the effects of probiotics for prevention and treatment of diarrhoea related to radiotherapy (with or without chemotherapy) or chemotherapy alone, need for rescue medication, or occurrence of adverse events. All studies were underpowered and heterogeneous. Severe side effects were absent from all studies. Robust evidence on this topic must be provided by future methodologically well‐designed trials. Plain language summary Live micro‐organisms for prevention or treatment of diarrhoea in people with cancer who are treated with chemotherapy or radiotherapy Background 
 Up to 80% of people treated with chemotherapy or radiotherapy for cancer suffer from diarrhoea ‐ one of the most common and troublesome side effects. Severe diarrhoea can lead to dehydration (fluid and salts loss) and malnutrition from changes to digestion and bowel habits and could adversely affect quality of life. It is also associated with increased risk of infection in people with low white cell blood count related to cancer treatment. Diarrhoea often leads to delays in cancer treatment or the need to lower the dose or even discontinue cancer treatment. Foods containing live bacteria or yeast (probiotics) might have a beneficial effect on the occurrence and severity of diarrhoea. Aim of the review 
 To evaluate the effects of live micro‐organisms (probiotics) in preventing the occurrence or reducing the severity of diarrhoea in people with cancer who are receiving chemotherapy or radiotherapy. Main findings 
 Overall, the studies we found do not give a clear answer on whether probiotics reduce the occurrence or severity of diarrhoea, improve quality of life, or reduce the need for other medication. However, an analysis of only well‐performed studies demonstrated a beneficial effect for some outcomes. With regard to prevention of diarrhoea compared with placebo in participants treated with radiotherapy with or without chemotherapy, we are not able to conclude whether use of probiotics would be beneficial based on the five relevant studies. For prevention of diarrhoea due to chemotherapy alone, three studies suggested that use of probiotics may not reduce diarrhoea, and one study reported use of less rescue medication for diarrhoea. Three studies that compared probiotics with another agent for preventing diarrhoea in patients treated with radiotherapy with or without chemotherapy found beneficial effects of probiotics for the occurrence and severity of diarrhoea and the need for rescue medication. With respect to treatment of diarrhoea due to radiotherapy, we found only one study that did not demonstrate a clear effect of probiotics compared with placebo. No study reported serious adverse events nor deaths related to diarrhoea. Certainty of the evidence 
 The quality (certainty) of the evidence in prevention studies was low to very low. For the only study that assessed the effects of probiotics on treatment for diarrhoea, the certainty of the evidence was moderate. What are the conclusions? 
 Evidence supporting the effects of probiotics in preventing or treating diarrhoea related to cancer treatment is insufficient. However, probiotics appear to be safe, as no studies have found severe side effects.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.779Z" }, { "id": "aaf88028-7525-4cbf-8983-3f02b3d12703", "pmid": "", "title": "Interventions for hand eczema", "imported": false, "abstract": "Abstract - Background Hand eczema is an inflammation of the skin of the hands that tends to run a chronic, relapsing course. This common condition is often associated with itch, social stigma, and impairment in employment. Many different interventions of unknown effectiveness are used to treat hand eczema. Objectives To assess the effects of topical and systemic interventions for hand eczema in adults and children. Search methods We searched the following up to April 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, AMED, LILACS, GREAT, and four trials registries. We checked the reference lists of included studies for further references to relevant trials. Selection criteria We included randomised controlled trials (RCTs) that compared interventions for hand eczema, regardless of hand eczema type and other affected sites, versus no treatment, placebo, vehicle, or active treatments. Data collection and analysis We used standard methodological procedures expected by Cochrane. Primary outcomes were participant‐ and investigator‐rated good/excellent control of symptoms, and adverse events. Main results We included 60 RCTs, conducted in secondary care (5469 participants with mild to severe chronic hand eczema). Most participants were over 18 years old. The duration of treatment was short, generally up to four months. Only 24 studies included a follow‐up period. Clinical heterogeneity in treatments and outcome measures was evident. Few studies performed head‐to‐head comparisons of different interventions. Risk of bias varied considerably, with only five studies at low risk in all domains. Twenty‐two studies were industry‐funded. Eighteen trials studied topical corticosteroids or calcineurin inhibitors; 10 studies, phototherapy; three studies, systemic immunosuppressives; and five studies, oral retinoids. Most studies compared an active intervention against no treatment, variants of the same medication, or placebo (or vehicle). Below, we present results from the main comparisons. Corticosteroid creams/ointments: when assessed 15 days after the start of treatment, clobetasol propionate 0.05% foam probably improves participant‐rated control of symptoms compared to vehicle (risk ratio (RR) 2.32, 95% confidence interval (CI) 1.38 to 3.91; number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 8; 1 study, 125 participants); the effect of clobetasol compared to vehicle for investigator‐rated improvement is less clear (RR 1.43, 95% CI 0.86 to 2.40). More participants had at least one adverse event with clobetasol (11/62 versus 5/63; RR 2.24, 95% CI 0.82 to 6.06), including application site burning/pruritus. This evidence was rated as moderate certainty. When assessed 36 weeks after the start of treatment, mometasone furoate cream used thrice weekly may slightly improve investigator‐rated symptom control compared to twice weekly (RR 1.23, 95% CI 0.94 to 1.61; 1 study, 72 participants) after remission is reached. Participant‐rated symptoms were not measured. Some mild atrophy was reported in both groups (RR 1.76, 95% CI 0.45 to 6.83; 5/35 versus 3/37). This evidence was rated as low certainty. Irradiation with ultraviolet (UV) light: local combination ultraviolet light therapy (PUVA) may lead to improvement in investigator‐rated symptom control when compared to local narrow‐band UVB after 12 weeks of treatment (RR 0.50, 95% CI 0.22 to 1.16; 1 study, 60 participants). However, the 95% CI indicates that PUVA might make little or no difference. Participant‐rated symptoms were not measured. Adverse events (mainly erythema) were reported by 9/30 participants in the narrow‐band UVB group versus none in the PUVA group. This evidence was rated as moderate certainty. Topical calcineurin inhibitors: tacrolimus 0.1% over two weeks probably improves investigator‐rated symptom control measured after three weeks compared to vehicle (14/14 tacrolimus versus 0/14 vehicle; 1 study). Participant‐rated symptoms were not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. A within‐participant study in 16 participants compared 0.1% tacrolimus to 0.1% mometasone furoate but did not measure investigator‐ or participant‐rated symptoms. Both treatments were well tolerated when assessed at two weeks during four weeks of treatment. Evidence from these studies was rated as moderate certainty. Oral interventions: oral cyclosporin 3 mg/kg/d probably slightly improves investigator‐rated (RR 1.88, 95% CI 0.88 to 3.99; 1 study, 34 participants) or participant‐rated (RR 1.25, 95% CI 0.69 to 2.27) control of symptoms compared to topical betamethasone dipropionate 0.05% after six weeks of treatment. The risk of adverse events such as dizziness was similar between groups (up to 36 weeks; RR 1.22, 95% CI 0.80 to 1.86, n = 55; 15/27 betamethasone versus 19/28 cyclosporin). The evidence was rated as moderate certainty. Alitretinoin 10 mg improves investigator‐rated symptom control compared with placebo (RR 1.58, 95% CI 1.20 to 2.07; NNTB 11, 95% CI 6.3 to 26.5; 2 studies, n = 781) and alitretinoin 30 mg also improves this outcome compared with placebo (RR 2.75, 95% CI 2.20 to 3.43; NNTB 4, 95% CI 3 to 5; 2 studies, n = 1210). Similar results were found for participant‐rated symptom control: alitretinoin 10 mg RR 1.73 (95% CI 1.25 to 2.40) and 30 mg RR 2.75 (95% CI 2.18 to 3.48). Evidence was rated as high certainty. The number of adverse events (including headache) probably did not differ between alitretinoin 10 mg and placebo (RR 1.01, 95% CI 0.66 to 1.55; 1 study, n = 158; moderate‐certainty evidence), but the risk of headache increased with alitretinoin 30 mg (RR 3.43, 95% CI 2.45 to 4.81; 2 studies, n = 1210; high‐certainty evidence). Outcomes were assessed between 48 and 72 weeks. Authors' conclusions Most findings were from single studies with low precision, so they should be interpreted with caution. Topical corticosteroids and UV phototherapy were two of the major standard treatments, but evidence is insufficient to support one specific treatment over another. The effect of topical calcineurin inhibitors is not certain. Alitretinoin is more effective than placebo in controlling symptoms, but advantages over other treatments need evaluating. Well‐designed and well‐reported, long‐term (more than three months), head‐to‐head studies comparing different treatments are needed. Consensus is required regarding the definition of hand eczema and its subtypes, and a standard severity scale should be established. The main limitation was heterogeneity between studies. Small sample size impacted our ability to detect differences between treatments. Plain language summary Treatments for hand eczema Review question We reviewed evidence on the effects of topical and systemic (oral or injected medicines that work throughout the entire body) treatments for hand eczema when compared against placebo (an identical but inactive treatment), no treatment, vehicle (inactive ingredients that help deliver an active treatment), or another treatment. We included 60 randomised trials (5469 participants) published up to April 2018. Background Hand eczema is an inflammation of the skin of the hands that can be caused by contact allergens (i.e. substances that cause an allergic reaction) such as rubber chemicals, but other external factors (e.g. irritants such as water or detergents) and atopic predisposition are often important triggers. Hand eczema can cause a reduction in quality of life leading to many work‐related problems. Various types of hand eczema exist, and different topical (creams, ointments, or lotions) and systemic treatments with unknown effectiveness can be used. Study characteristics Most participants were hospital outpatients over 18 years of age with mild to severe chronic hand eczema. Treatment was usually given for up to four months, and outcomes were mainly assessed after treatment. A large variety of treatments were studied and compared to no treatment, variants of the same medication, placebo, or vehicle. Twenty‐two studies were funded by pharmaceutical companies. Key results Limited data are available to support the best way of managing hand eczema due to varying study quality and inability to pool data from studies with similar interventions. Corticosteroid creams/ointments and phototherapy (irradiation with UV light) are the major treatment options, although comparisons between these options are lacking. Below, we present results for the main comparisons of interest. Corticosteroid creams/ointments: clobetasol propionate foam probably increases participant‐rated good/excellent control of hand eczema when compared to vehicle (516 versus 222 per 1000), but the difference between groups was less clear for investigator‐rated control, and more adverse events were reported with clobetasol propionate (178 versus 79 per 1000) (all based on moderate‐certainty evidence). Mometasone furoate cream used thrice weekly may slightly improve investigator‐rated good/excellent control compared to twice weekly treatment, and participant‐rated control was not measured. Mild skin thinning occurred in both groups, but cases were few (all based on low‐certainty evidence). Irradiation with UV light: various types of irradiation (i.e. exposure to radiation) were compared. Local PUVA may improve investigator‐rated good/excellent control compared to narrow‐band UVB (400 versus 200 per 1000); however, we are uncertain of this finding because results also show that local PUVA may make little or no difference. Participant‐rated symptoms were not measured. Nine out of 30 participants in the narrow‐band UVB group reported adverse events (mainly redness) compared to none in the PUVA group (all based on moderate‐certainty evidence). Topical calcineurin inhibitors: people receiving tacrolimus are probably more likely to achieve improved investigator‐rated good/excellent symptom control compared to those given vehicle (14/14 participants with tacrolimus compared to none with vehicle), but participant‐rated control of symptoms was not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. One small study compared tacrolimus to mometasone furoate, which were both well tolerated, but did not measure investigator‐ or participant‐rated control (all based on moderate‐certainty evidence). Oral interventions: oral immunosuppressant (a drug that hinders the immune response) cyclosporin probably slightly improves investigator‐ or participant‐rated control of good/excellent symptoms compared to topical betamethasone cream (a corticosteroid). The risk of adverse events such as dizziness was similar between groups (all based on moderate‐certainty evidence). The oral vitamin A derivative (retinoid) alitretinoin (10 mg) achieved investigator‐rated good/excellent symptom control in 307 compared to 194 participants per 1000 with placebo, and alitretinoin 30 mg achieved investigator‐rated control in 432 compared to 157 participants per 1000 with placebo. Similar results were shown for participant‐rated control (high‐certainty evidence). When the dosage of alitretinoin was increased to 30 mg, risk of headache was higher compared to placebo (74 versus 251 per 1000; high‐certainty evidence), but this probably does not differ between alitretinoin 10 mg and placebo (based on moderate‐certainty evidence). Quality of the evidence The quality of evidence was mainly moderate, with most analyses based on single studies that had small sample sizes; therefore, some results should be interpreted with care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Christoffers, WA, Coenraads, PJ, Svensson, Å, Diepgen, TL, Dickinson‐Blok, JL, Xia, J, Williams, HC", "articleTypes": [], "doi": "10.1002/14651858.CD004055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.792Z" }, { "id": "aafec0c0-d9e8-4e11-862c-ce4d0263d285", "pmid": "", "title": "Effect of alcohol on blood pressure", "imported": false, "abstract": "Abstract - Background Alcohol is consumed by over 2 billion people worldwide. It is a common substance of abuse and its use can lead to more than 200 disorders including hypertension. Alcohol has both acute and chronic effects on blood pressure. This review aimed to quantify the acute effects of different doses of alcohol over time on blood pressure and heart rate in an adult population. Objectives Primary objective To determine short‐term dose‐related effects of alcohol versus placebo on systolic blood pressure and diastolic blood pressure in healthy and hypertensive adults over 18 years of age. Secondary objective To determine short‐term dose‐related effects of alcohol versus placebo on heart rate in healthy and hypertensive adults over 18 years of age. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to March 2019: the Cochrane Hypertension Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2), in the Cochrane Library; MEDLINE (from 1946); Embase (from 1974); the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. We also contacted authors of relevant articles regarding further published and unpublished work. These searches had no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing effects of a single dose of alcohol versus placebo on blood pressure (BP) or heart rate (HR) in adults (≥ 18 years of age). Data collection and analysis Two review authors (ST and CT) independently extracted data and assessed the quality of included studies. We also contacted trial authors for missing or unclear information. Mean difference (MD) from placebo with 95% confidence interval (CI) was the outcome measure, and a fixed‐effect model was used to combine effect sizes across studies. Main results We included 32 RCTs involving 767 participants. Most of the study participants were male (N = 642) and were healthy. The mean age of participants was 33 years, and mean body weight was 78 kilograms. Low‐dose alcohol (< 14 g) within six hours (2 RCTs, N = 28) did not affect BP but did increase HR by 5.1 bpm (95% CI 1.9 to 8.2) (moderate‐certainty evidence). Medium‐dose alcohol (14 to 28 g) within six hours (10 RCTs, N = 149) decreased systolic blood pressure (SBP) by 5.6 mmHg (95% CI ‐8.3 to ‐3.0) and diastolic blood pressure (DBP) by 4.0 mmHg (95% CI ‐6.0 to ‐2.0) and increased HR by 4.6 bpm (95% CI 3.1 to 6.1) (moderate‐certainty evidence for all). Medium‐dose alcohol within 7 to 12 hours (4 RCTs, N = 54) did not affect BP or HR. Medium‐dose alcohol > 13 hours after consumption (4 RCTs, N = 66) did not affect BP or HR. High‐dose alcohol (> 30 g) within six hours (16 RCTs, N = 418) decreased SBP by 3.5 mmHg (95% CI ‐6.0 to ‐1.0), decreased DBP by 1.9 mmHg (95% CI‐3.9 to 0.04), and increased HR by 5.8 bpm (95% CI 4.0 to 7.5). The certainty of evidence was moderate for SBP and HR, and was low for DBP. High‐dose alcohol within 7 to 12 hours of consumption (3 RCTs, N = 54) decreased SBP by 3.7 mmHg (95% CI ‐7.0 to ‐0.5) and DBP by 1.7 mmHg (95% CI –4.6 to 1.8) and increased HR by 6.2 bpm (95% CI 3.0 to 9.3). The certainty of evidence was moderate for SBP and HR, and low for DBP. High‐dose alcohol ≥ 13 hours after consumption (4 RCTs, N = 154) increased SBP by 3.7 mmHg (95% CI 2.3 to 5.1), DBP by 2.4 mmHg (95% CI 0.2 to 4.5), and HR by 2.7 bpm (95% CI 0.8 to 4.6) (moderate‐certainty evidence for all). Authors' conclusions High‐dose alcohol has a biphasic effect on BP; it decreases BP up to 12 hours after consumption and increases BP > 13 hours after consumption. High‐dose alcohol increases HR at all times up to 24 hours. Findings of this review are relevant mainly to healthy males, as only small numbers of women were included in the included trials. Plain language summary Alcohol has a biphasic effect on blood pressure and increases heart rate Review question We reviewed available evidence about the short‐term effects of different doses of alcoholic drinks compared to non‐alcoholic drinks on blood pressure and heart rate in adults (≥ 18 years) with both normal and raised blood pressure. Background Drinking excessive alcohol is considered one of the most common causes of raised blood pressure. We wanted to quantify the effects of a single dose of alcohol on blood pressure and heart rate within 24 hours of consumption. Study characteristics We included 32 randomised controlled trials involving 767 participants published up to March 2019. Although these trials included adults from 18 to 96 years of age with various health conditions, most study participants were young healthy males. The source of funding was not reported for a majority of the studies. Key results For low doses of alcohol, we found that one glass of alcohol had little to no effect on blood pressure and increased heart rate within six hours of drinking. We are moderately certain that medium‐dose alcohol decreased blood pressure and increased heart rate within six hours of consumption. We did not see any significant change in blood pressure or heart rate after that, but the evidence was limited. We are also moderately certain that high‐dose alcohol decreased blood pressure within six hours, and the effect lasted up to 12 hours. After that, blood pressure was found to be increased. Heart rate increased significantly after alcohol consumption and remained increased at all times measured. Thus alcohol decreases blood pressure initially (up to 12 hours after ingestion) and increases blood pressure after that. Alcohol consistently increases heart rate at all times within 24 hours of consumption.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Tasnim, S; Tang, C; Musini, VM; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD012787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "ab3340e8-9875-4b71-9932-61b768d106f4", "pmid": "", "title": "Breastfeeding for procedural pain in infants beyond the neonatal period", "imported": false, "abstract": "Abstract - Background Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin‐to‐skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk. Objectives To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin‐to‐skin contact, expressed breast milk, formula milk, bottle feeding, sweet‐tasting solutions (e.g. sucrose or glucose), distraction, or other interventions. Search methods We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In‐Process & Other Non‐Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials. Selection criteria We included RCTs and quasi‐RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet‐tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin‐to‐skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random‐effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information. Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38‐second reduction in cry time (MD ‐38, 95% CI ‐50 to ‐26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12‐month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7‐point reduction in standardised pain scores (SMD ‐1.7, 95% CI ‐2.2 to ‐1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD ‐3.6, ‐23 to 16). Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage. No included studies reported adverse events. Authors' conclusions We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin‐breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted. Plain language summary Does breastfeeding reduce vaccination pain in babies aged 1 to 12 months? Bottom line We found that breastfeeding before and during vaccination injections helped to reduce pain in most babies up to the age of one year. Background Needles are used for babies' early childhood vaccinations and medical care during childhood illnesses. These are essential, but painful. They cause distress for the babies and often their parents/caregivers, and can result in future anxiety and fear about needles. Breastfeeding during blood tests in newborn babies reduces pain. Breastfeeding when possible and feasible may also help to comfort babies and reduce their pain beyond the newborn period and throughout infancy. Study characteristics In February 2016 we searched the medical literature for studies examining the effectiveness of breastfeeding babies 1 to 12 months old during the use of needles. We compared effectiveness of breastfeeding in reducing pain (as scored by crying time and pain scores), to holding, babies lying flat, or the giving of water or sweet solutions. We found 10 studies with a total of 1066 infants. All studies examined if breastfeeding reduced pain during vaccinations. Key results Breastfeeding reduced crying in young babies having vaccinations. On average, breastfed babies cried for 38 seconds less than babies who were not breastfed (6 studies; 547 infants; moderate‐quality evidence), and pain scores were significantly lower (5 studies; 310 infants; moderate‐quality evidence). No studies reported on any harm (very low‐quality evidence). We could draw no conclusions on risk of harm while breastfeeding healthy babies during vaccination. Going forward: if mothers are breastfeeding, it could be considered when possible for babies during vaccinations. More evidence is needed to learn if breastfeeding helps older babies and babies in hospital during blood work or procedures such as insertion of drips. Quality of the evidence The quality of the evidence was moderate for crying time and pain scores. Most studies included younger infants aged 1 to 6 months. Further research including older infants up to 12 months of age may change our conclusions. In addition, the studies evaluated the effects of breastfeeding during vaccination. We do not know whether breastfeeding helps sick babies aged 1 to 12 months in hospital during blood sampling or drip insertion.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Harrison, D; Reszel, J; Bueno, M; Sampson, M; Shah, VS; Taddio, A; Larocque, C; Turner, L", "articleTypes": [], "doi": "10.1002/14651858.CD011248.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "ab3dc7c8-2399-4dc2-af9e-cf9c00e1dfdb", "pmid": "", "title": "Long‐acting muscarinic antagonists (LAMA) added to combination long‐acting beta₂‐agonists and inhaled corticosteroids (LABA/ICS) versus LABA/ICS for adults with asthma", "imported": false, "abstract": "Abstract - Background Maintenance treatment with long‐acting beta 2 ‐agonists and inhaled corticosteroids (LABA/ICS) can relieve asthma symptoms and reduce the frequency of exacerbations, but there are limited treatment options for people who do not gain control on combination LABA/ICS. Long‐acting muscarinic antagonists (LAMA) are a class of inhaled drug which have been effective for people with chronic obstructive pulmonary disease and are now becoming available for people with asthma to take alongside their LABA/ICS inhaler. Objectives To assess the effects of adding a long‐acting muscarinic antagonist (LAMA) to combination long‐acting beta 2 ‐agonists (LABA) and inhaled corticosteroids (ICS) in adults whose asthma is not well controlled by LABA/ICS. Search methods We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to January 2016. We also searched ClinicalTrials.gov, the WHO trials portal, and reference lists of other reviews, and we contacted trial authors for additional information. Selection criteria We included parallel randomised controlled trials (RCTs) of at least 12 weeks' duration. Studies met the inclusion criteria if they compared LAMA as an add‐on to LABA/ICS versus LABA/ICS alone for adults with asthma. We included studies reported as full text, those published as abstract only, and unpublished data. Primary outcomes were exacerbations requiring oral corticosteroids (OCS), validated measures of asthma control, and serious adverse events (including mortality). Data collection and analysis Two review authors screened searches and independently extracted details on risk of bias and numerical data. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MD) using a random‐effects model. We rated all outcomes using GRADE. Main results We found four double‐blind, double‐dummy trials comparing LAMA to placebo, including 1197 people with asthma taking combination LABA/ICS. One of the trials was designed to study glycopyrronium bromide but was withdrawn prior to enrolment, and the other three all studied tiotropium bromide (mostly 5 µg once daily via Respimat) over 48 to 52 weeks. People in the trials had a mean forced expiratory volume in one second (FEV 1 ) of 55% of their predicted value, indicating severe asthma. People randomised to take tiotropium add‐on had fewer exacerbations requiring oral corticosteroids than those continuing to take LABA/ICS alone, but the confidence intervals did not rule out no difference (OR 0.76, 95% CI 0.57 to 1.02; moderate quality evidence). Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS would have to take oral corticosteroids for an exacerbation compared with 271 if they took tiotropium as well (95% CI 218 to 333 per 1000). Analyses comparing the number of exacerbations per patient in each group (rate ratio) and the time until first exacerbation (hazard ratio) were in keeping with the main result. Quality of life, as measured by the Asthma Quality of Life Questionnaire (AQLQ) was no better for those taking tiotropium add‐on than for those taking LABA/ICS alone when considered in light of the 0.5 minimal clinically important difference on the scale (MD 0.09, 95% CI − 0.03 to 0.20), and evidence for whether tiotropium increased or decreased serious adverse events in this population was inconsistent (OR 0.60, 95% CI 0.24 to 1.47; I 2 = 76%). Within the secondary outcomes, exacerbations requiring hospital admission were too rare to tell whether tiotropium was beneficial over LABA/ICS alone. There was high quality evidence showing benefits to lung function (trough FEV 1 and forced vital capacity (FVC)) and potentially small benefits to asthma control. People taking tiotropium add‐on were less likely to experience non‐serious adverse events. Authors' conclusions Tiotropium add‐on may have additional benefits over LABA/ICS alone in reducing the need for rescue oral steroids in people with severe asthma. The effect was imprecise, and there was no evidence for other LAMA preparations. Possible benefits on quality of life were negligible, and evidence for the effect on serious adverse events was inconsistent. There are likely to be small added benefits for tiotropium Respimat 5 µg daily on lung function and asthma control over LABA/ICS alone and fewer non‐serious adverse events. The benefit of tiotropium add‐on on the frequency of hospital admission is still unknown, despite year‐long trials. Ongoing and future trials should clearly describe participants' background medications to help clinicians judge how the findings relate to stepwise care. If studies test LAMAs other than tiotropium Respimat for asthma, they should be at least six months long and use accepted and validated outcomes to allow comparisons of the safety and effectiveness between different preparations. Plain language summary Does adding tiotropium, a long‐acting muscarinic antagonist (LAMA), to combination therapy (LABA/ICS) help to control asthma? Adding the LAMA tiotropium Respimat inhaler to combination LABA/ICS inhaler may reduce the need for rescue oral steroids. A noticeable benefit on quality of life is unlikely, and we couldn't tell if it reduced hospital admissions, but adding tiotropium has some benefit on lung function, asthma control, and non‐serious side effects. More detail about the studies and results: Taking a daily inhaler containing a long‐acting beta 2 ‐agonist and an inhaled corticosteroid (LABA/ICS) can improve symptoms and reduce the likelihood of asthma attacks. If this doesn't help, another type of inhaled drug called a long‐acting muscarinic antagonist (LAMA), which has been effective for people with other breathing conditions, is now available for people with asthma to take as well as their LABA/ICS inhaler. We wanted to find out whether adding a LAMA to LABA/ICS is better than continuing LABA/ICS alone for adults with asthma. We found four relevant studies, but one was withdrawn before anyone was signed up. The other three compared a LAMA called tiotropium Respimat to placebo for around a year, with participants in both groups continuing to take their usual LABA/ICS inhaler. People generally had quite poor lung function when they entered the studies, suggesting their asthma was not well controlled ‐ in respiratory medicine, this is known as 'severe asthma'. Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS had to take a course of oral steroids compared with 271 if they took tiotropium as well. However, uncertainty in the results meant that rather than there being 271 people taking oral steroids, there could be anywhere from 218 to 333 people per 1000 who would have to take oral steroids, so we couldn't be sure of the benefit. Quality of life scores were not that different between those who took tiotropium and those who didn't. The studies showed different results for whether people taking tiotropium were more likely to suffer a serious side effect, but fewer people had non‐serious side effects if they took tiotropium. We couldn't tell whether taking tiotropium on top of LABA/ICS reduced the number of people who had to go to hospital for an asthma attack because it didn't happen often enough for us to have confidence in the result. There was high quality evidence that showed benefits to lung function and probably small benefits on measures of asthma control.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Kew, KM, Dahri, K", "articleTypes": [], "doi": "10.1002/14651858.CD011721.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.791Z" }, { "id": "ab767ce4-0d89-456f-847f-ddf0bfd6f3e4", "pmid": "", "title": "Over the counter (OTC) artificial tear drops for dry eye syndrome", "imported": false, "abstract": "Abstract - Background Over the counter (OTC) artificial tears historically have been the first line of treatment for dry eye syndrome and dry eye‐related conditions like contact lens discomfort, yet currently we know little regarding the overall efficacy of individual, commercially available artificial tears. This review provides a much needed meta‐analytical look at all randomized and quasi‐randomized clinical trials that have analyzed head‐to‐head comparisons of OTC artificial tears. Objectives To evaluate the effectiveness and toxicity of OTC artificial tear applications in the treatment of dry eye syndrome compared with another class of OTC artificial tears, no treatment, or placebo. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 12), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2015), EMBASE (January 1980 to December 2015), Latin American and Caribbean Health Sciences (LILACS) (January 1982 to December 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) and the US Food and Drugs Administration (FDA) website ( www.fda.gov ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 December 2015. We searched reference lists of included trials for any additional trials not identified by the electronic searches. Selection criteria This review includes randomized controlled trials with adult participants who were diagnosed with dry eye, regardless of race and gender. We included trials in which the age of participants was not reported, and clinical trials comparing OTC artificial tears with another class of OTC artificial tears, placebo, or no treatment. This review did not consider head‐to‐head comparisons of artificial tears with another type of dry‐eye therapy. Data collection and analysis We followed the standard methodological procedures expected by Cochrane. Two authors independently screened the search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. We performed meta‐analysis for trials that compared similar interventions and reported comparable outcomes with sufficient data. We summarized all other included trial results in the text. Main results We included 43 randomized controlled trials (3497 participants with dry eye). Due to the heterogeneity of study characteristics among the included trials with respect to types of diagnostic criteria, interventions, comparisons, and measurements taken, our ability to perform meta‐analyses was limited. The review found that, in general, there was uncertainty whether different OTC artificial tears provide similar relief of signs and symptoms when compared with each other or placebo. Nevertheless, we found that 0.2% polyacrylic acid‐based artificial tears were consistently more effective at treating dry eye symptoms than 1.4% polyvinyl alcohol‐based artificial tears in two trials assessing this comparison (175 participants). All other included artificial tears produced contradictory between‐group results or found no between‐group differences. Our review also found that OTC artificial tears may be generally safe, but not without adverse events. Overall, we assessed the quality of evidence as low due to high risks of bias among included trials and poor reporting of outcome measures which were insufficient for quantitative analysis. Furthermore, we identified an additional 18 potentially eligible trials that were reported only in clinical trial registers with no associated results or publications. These trials reportedly enrolled 2079 total participants for whom no data are available. Such lack of reporting of trial results represents a high risk of publication bias. Authors' conclusions OTC artificial tears may be safe and effective means for treating dry eye syndrome; the literature indicates that the majority of OTC artificial tears may have similar efficacies. This conclusion could be greatly skewed by the inconsistencies in study designs and inconsistencies in reporting trial results. Additional research is therefore needed before we can draw robust conclusions about the effectiveness of individual OTC artificial tear formulations. Plain language summary Efficacy of over the counter (OTC) artificial tears for dry eye syndrome Research question What is the effect of over the counter (OTC) artificial tears on dry eye syndrome? Background 
 Dry eye syndrome is a long‐term condition that is known to cause eye discomfort and visual disturbances like blurred vision. This condition affects millions of people around the world, and the first‐line treatment for dry eye is typically over the counter (OTC) artificial tears. OTC artificial tears are meant to replace or supplement the tears (fluid) that naturally cover the eye’s front surface (cornea and conjunctiva). There are a great number of commercially available artificial tears, yet there is currently no agreement about whether one formulation works better than another at treating dry eye. Our review attempts to bridge this knowledge gap. Study characteristics 
 This review included 43 randomized controlled trials (3497 people with dry eye) that compared OTC artificial tears with other OTC artificial tears, with no treatment, or with placebo. We considered participant symptoms to be the primary outcome for this review. We recorded other commonly performed dry eye tests as secondary outcomes (e.g. vision, tear stability). We measured primary and secondary outcomes at two and four weeks, although we also considered other time points in this review. We searched for trials up to December 2015. Key results 
 This review analyzed many OTC artificial tear formulations, and most of the literature indicates uncertainty as to which OTC artificial tear works best. The literature also shows that OTC artificial tears may be effective at treating dry eye symptoms and that OTC artificial tears are generally safe, although not without side effects. We also identified an additional 18 potentially eligible trials that were registered, but did not provide any results or publications. These trials may have enrolled 2079 total participants for whom no data are available. Without the results of these trials, the effects of the OTC artificial tears that they evaluated are unknown. Quality of the evidence The overall quality of the evidence was low for the various OTC artificial tear formulations compared in this review. This finding indicates that future published research may have an important impact on the conclusions currently provided in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pucker, AD; Ng, SM; Nichols, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD009729.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "ab92ef91-1fef-4ea7-bd30-bd15f441d3ea", "pmid": "", "title": "Iodine fortification of foods and condiments, other than salt, for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency disorders (IDD) affect close to 1.9 billion people worldwide, and are a major public health concern in many countries. Among children, iodine deficiency is the main cause of potentially preventable deficits of central nervous system development and impairment of cognitive function, as well as goitre and hypothyroidism in people of all ages. Salt iodisation is the preferred strategy for IDD prevention and control, however, in some instances where salt is not the major condiment, alternate vehicles for iodine fortification have been considered. Objectives To assess the effects of fortifying foods, beverages, condiments, or seasonings other than salt with iodine alone or in conjunction with other micronutrients, on iodine status and health‐related outcomes in all populations. Search methods Studies were identified through systematic searches of the following databases from their start date to January 2018: Cochrane Public Health Group Specialised Register; CENTRAL; MEDLINE; MEDLINE in Process; Embase; Web of Science; CINAHL; POPLINE; AGRICOLA; BIOSIS; Food Science and Technology Abstracts; OpenGrey; Bibliomap and TRoPHI; AGRIS; IBECS; Scielo; Global Index Medicus‐AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched reference list of relevant articles, conference proceedings, and databases of ongoing trials, and contacted experts and relevant organisations to identify any unpublished work. We applied no language or date restrictions. Selection criteria Studies were eligible if they were randomised or quasi‐randomised controlled trials (RCT) with randomisation at either the individual or cluster level (including cross‐over trials), non‐randomised RCTs, or prospective observational studies with a control group, such as cohort studies, controlled before‐and‐after studies, and interrupted time series. We included studies that examined the effects of fortification of food, beverage, condiment, or seasoning with iodine alone, or in combination with other micronutrients versus the same unfortified food, or no intervention. We considered the following measures: death (all‐cause), goitre, physical development, mental development, cognitive function and motor skill development, cretinism, hypothyroidism, adverse effects (any reported by trialists), urinary iodine concentration, thyroid‐stimulating hormone (TSH) concentration, and serum thyroglobulin concentration. We included all populations, including pregnant women, from any country. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias of included studies. We used random‐effects meta‐analyses to combine data and generate an overall estimate of treatment effect, when more than one study examined the same outcome measure. The overall effect estimate was calculated as the mean difference (MD) or standardised mean difference (SMD) between the intervention group and the comparison group for continuous outcomes, and as odds ratio (OR) for dichotomous outcomes. We assessed the level of heterogeneity through the I² statistic. We conducted post‐hoc subgroup analyses to explore possible sources of heterogeneity, and sensitivity analyses to check the robustness of the findings from the primary analyses. We assessed the quality of the evidence for each outcome using the GRADE framework. Where it was not possible to pool the results in a meta‐analysis, we provided a narrative summary of the outcomes. Main results Eleven studies met the criteria, providing 14 comparisons, and capturing data on 4317 participants. Seven studies were RCTs, three were cluster non‐RCTs, and one was a randomised cross‐over design. Seven studies were carried out among school children (N = 3636), three among women of reproductive age (N = 648), and one among infants (N = 33). The studies used diverse types of food as vehicle for iodine delivery: biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. Daily amounts of iodine provided ranged from 35 µg/day to 220 µg/day; trial duration ranged from 11 days to 48 weeks. Five studies examined the effect of iodine fortification alone, two against the same unfortified food, and three against no intervention. Six studies evaluated the effect of cofortification of iodine with other micronutrients versus the same food without iodine but with different levels of other micronutrients. We assessed one study to be at low risk of bias for all bias domains, three at low risk of bias for all domains apart from selective reporting, and seven at an overall rating of high risk of bias. No study assessed the primary outcomes of death, mental development, cognitive function, cretinism, or hypothyroidism, or secondary outcomes of TSH or serum thyroglobulin concentration. Two studies reported the effects on goitre, one on physical development measures, and one on adverse effects. All studies assessed urinary iodine concentration. The effects of iodine fortification compared to control on goitre prevalence (OR 1.60, 95% CI 0.60 to 4.31; 1 non‐RCT, 83 participants; very low‐quality evidence), and five physical development measures were uncertain (1 non‐RCT, 83 participants; very low‐quality evidence): weight (MD 0.23 kg, 95% CI ‐6.30 to 6.77); height (MD ‐0.66 cm, 95% CI ‐4.64 to 3.33); weight‐for‐age (MD 0.05, 95% CI ‐0.59 to 0.69); height‐for‐age (MD ‐0.30, 95% CI ‐0.75 to 0.15); and weight‐for‐height (MD ‐0.21, 95% CI ‐0.51 to 0.10). One study reported that there were no adverse events observed during the cross‐over trial (low‐quality evidence). Pooled results from RCTs showed that urinary iodine concentration significantly increased following iodine fortification (SMD 0.59, 95% CI 0.37 to 0.81; 6 RCTs, 2032 participants; moderate‐quality evidence). This is equivalent to an increase of 38.32 µg/L (95% CI 24.03 to 52.61 µg/L). This effect was not observed in the meta‐analysis of non‐RCTs (SMD 0.25, 95% CI ‐0.16 to 0.66; 3 non‐RCTs, 262 participants; very low‐quality evidence). Sensitivity analyses did not change the effect observed in the primary analyses. Authors' conclusions The evidence on the effect of iodine fortification of foods, beverages, condiments, or seasonings other than salt on reducing goitre, improving physical development measures, and any adverse effects is uncertain. However, our findings suggest that the intervention likely increases urinary iodine concentration. Additional, adequately powered, high‐quality studies on the effects of iodine fortification of foods on these, and other important outcomes, as well as its efficacy and safety, are required. Plain language summary Adding iodine to foods, other than salt, to prevent diseases caused by inadequate iodine intake Background and review question Many people around the world do not consume enough iodine. This is a problem because iodine is important for normal childhood growth and brain development, and for ensuring a healthy adult population. Inadequate intake of iodine can lead to health problems, such as intellectual disability and goitre (enlargement of the thyroid gland). Currently, the main strategy to increase the amount of iodine consumed in populations recommended by the World Health Organization is adding iodine to salt. However, in some areas where salt is not the major condiment, adding iodine to other foods has also been explored. The aim of our study was to examine the effect of adding iodine to foods, beverages, condiments, or seasonings, other than salt, on iodine nutrition status and health‐related outcomes in all populations. Study characteristics We searched for articles from different sources including published research papers, unpublished reports, and through direct communication with experts and organisations working to address iodine and micronutrient deficiency. We last searched the databases in January 2018. Eleven studies, which captured data on 4317 participants (3636 children, 648 women of reproductive age, and 33 infants), met our inclusion criteria. The type of foods used as vehicle to deliver iodine differed between the studies, and included biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. The amount of iodine provided to participants ranged from 35 µg/day to 220 µg/day, and study duration ranged from 11 days to 48 weeks. Of the 11 studies included, five examined the effect of adding iodine alone to foods compared to either no intervention or the same foods without iodine; while six evaluated the effect of adding iodine plus other micronutrients to foods compared to the same foods without iodine, but with different levels of other micronutrients. Key results No study evaluated the effect of adding iodine to foods on death, mental development, cognitive function, cretinism (a condition characterized by impaired control of physical movement and intellectual disability), hypothyroidism (underactive thyroid), thyroid‐stimulating hormone concentration, or serum thyroglobulin concentration (these are biological markers that indicate the presence of iodine deficiency when concentration in the blood is high). Two studies reported on the effect of the intervention on goitre, one study assessed five physical development measures (weight, height, weight‐for‐age, height‐for‐age, and weight‐for‐height scores), and one examined adverse effects. All studies assessed urinary iodine concentration (the concentration of iodine secreted in the urine, which indicates the presence of iodine deficiency when concentration is low in a population group, rather than in an individual). We combined the data that met our requirements in these studies in a meta‐analysis. We are uncertain of the effects of iodine fortification on the proportion of participants with goitre, or on any of the five physical development measures. One study reported narratively that no adverse effects were observed during the trial. We found a significant increase of 38.32 µg/L in urinary iodine concentration after adding iodine to foods, compared to the groups that did not have iodine added, from studies of higher quality. Quality of the evidence Using GRADE, we rated the quality of the evidence as very low for goitre and physical development measures, due to study limitations (risk of bias) and imprecise results, and low for adverse events due to indirectness and imprecise results. We rated the quality of the evidence for urinary iodine concentration, from studies in which participants were allocated to treatment groups at random (gold standard design for clinical research), as moderate. On the other hand, quality of the evidence for urinary iodine concentration from studies without this random element was rated as very low, due to study limitations and imprecise results. Conclusion Overall, there is no clear evidence on the effect of the intervention on reducing the proportion of people with goitre, improving physical growth, or adverse events. However, our results show that adding iodine to foods likely increases urinary iodine concentration. Additional studies to better quantify the effect of the intervention on these outcomes, as well as other outcomes, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Santos, JAR; Christoforou, A; Trieu, K; McKenzie, BL; Downs, S; Billot, L; Webster, J; Li, M", "articleTypes": [], "doi": "10.1002/14651858.CD010734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "aba7b511-3533-4525-b54f-e2545063f26a", "pmid": "", "title": "Individualized Computational Assessment of the Effects of GABA Receptor Modulation in Posttraumatic Stress Disorder", "imported": false, "abstract": "A substantial majority of Veterans with posttraumatic stress disorder (PTSD) continue to suffer even with the best current medications. Progress in developing more effective medications is hampered by the substantial variability within Veterans with PTSD, meaning the most effective medication likely varies from individual to individual. New scientific tools to help identify distinct subgroups of Veterans with PTSD who are likely to respond to specific medications could help improve treatment in this population. Research has indicated that a specific subgroup of Veterans with PTSD with a high level of anxious arousal may benefit from medications which boost signaling of the neurotransmitter gamma-aminobutyric acid (GABA). This project aims to validate a clinical test to identify these individuals using new computational and neuroimaging methods combined with the medication lorazepam, a positive GABA modulator. The ultimate goal is to use these methods in future clinical trials of new medications to target the best treatments to individual Veterans with PTSD.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "abaaee12-e2f8-45f6-8e77-8f0f6a1fc3af", "pmid": "", "title": "Ribavirin plus interferon versus interferon for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. Standard therapy is ribavirin plus pegylated interferon to achieve undetectable level of virus in the blood, but the effect on clinical outcomes is controversial. Objectives To assess the beneficial and harmful effects of ribavirin and interferon combination therapy versus interferon monotherapy for chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, approaching authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included randomised trials, irrespective of blinding, language, or publication status, comparing ribavirin plus interferon versus interferon for treatment of chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained loss of hepatitis C virus, liver‐related morbidity plus all‐cause mortality, and adverse events. We performed subgroup analyses of patients who were naive, relapsers, or non‐responders to previous antiviral treatment. All outcomes were analysed with the random‐effects model. We used Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of morbidity plus mortality. The remaining outcomes were presented as relative risks (RR). We used trial sequential analyses to examine the robustness of our findings. Main results We included 83 randomised trials with 12,707 patients. Most trials had unclear or high risk of bias. We did not find any significant influence of bias on our results but cannot exclude outcome measure reporting bias as many trials did not report on the primary outcomes of this review. Compared with interferon, ribavirin plus interferon had a significant beneficial effect on sustained virological response in subgroups of naive patients (RR 0.72, 95% confidence interval (CI) 0.68 to 0.75), relapsers (RR 0.62, 95% CI 0.54 to 0.70), non‐responders (RR 0.89, 95% CI 0.84 to 0.93), and in all patients (RR 0.75, 95% CI 0.71 to 0.79). Combination therapy significantly reduced morbidity plus mortality in all patients (Peto OR, 0.43, 95% CI 0.23 to 0.79), but not in naive, relapsers, or non‐responders individually. Combination therapy significantly increased the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous (cough, dyspnoea, fatigue) adverse reactions. Accordingly, combination therapy significantly increased the risk of treatment discontinuation and dose reductions. Trial sequential analyses confirmed our findings regarding virological effects, but not regarding liver‐related morbidity and all‐cause mortality. Authors' conclusions Compared with interferon alone, ribavirin plus interferon is more effective in clearing hepatitis C virus from the blood. Combination therapy may reduce liver‐related morbidity and all‐cause mortality, but we need more evidence. The number needed to treat to obtain a beneficial effect is considerable considering the increased risk of several severe adverse reactions and costs. Plain language summary Adding ribavirin to interferon increases the number of patients who clear hepatitis C virus but also leads to several adverse reactions Globally about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behavior, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die. It is known that treatment with the drug interferon clears hepatitis C virus from the blood in about 15% of patients. This review identified studies comparing ribavirin plus interferon with interferon alone in patients with chronic hepatitis C. This review shows, by combining the results from all trials, that adding ribavirin to interferon increases the number of patients who clear the hepatitis C virus to about 40% as well as the number of patients who demonstrate improved liver histology. Ribavirin and interferon may also reduce the risk of liver‐related morbidity or all‐cause mortality. However, the number needed to treat to prevent one patient developing morbidity or dying seems very large. Furthermore, combination therapy was associated with increased risk of anaemia and several other adverse reactions. The results gives rise to a dilemma ‐ should we, by adding ribavirin to interferon, increase the risk of haematological, dermatological, gastrointestinal, infectious, and miscellaneous adverse reactions in a situation where it has not yet been clearly demonstrated that the antiviral effect of the intervention is directly linked to the reduction of all‐cause mortality? We, therefore, suggest that the combination intervention is applied only with stringent emphasis on the individual patients' well‐being. Furthermore, we suggest that all future trials within the area should focus more on adverse reactions and long‐term clinical outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Brok, J, Gluud, LL, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.776Z" }, { "id": "abb0c467-a2d9-4fa1-9545-d3944c25682e", "pmid": "", "title": "Over the counter (OTC) artificial tear drops for dry eye syndrome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pucker, AD, Ng, SM, Nichols, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD009729.pub2 AB - Abstract - Background Over the counter (OTC) artificial tears historically have been the first line of treatment for dry eye syndrome and dry eye‐related conditions like contact lens discomfort, yet currently we know little regarding the overall efficacy of individual, commercially available artificial tears. This review provides a much needed meta‐analytical look at all randomized and quasi‐randomized clinical trials that have analyzed head‐to‐head comparisons of OTC artificial tears. Objectives To evaluate the effectiveness and toxicity of OTC artificial tear applications in the treatment of dry eye syndrome compared with another class of OTC artificial tears, no treatment, or placebo. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 12), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2015), EMBASE (January 1980 to December 2015), Latin American and Caribbean Health Sciences (LILACS) (January 1982 to December 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) and the US Food and Drugs Administration (FDA) website ( www.fda.gov ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 December 2015. We searched reference lists of included trials for any additional trials not identified by the electronic searches. Selection criteria This review includes randomized controlled trials with adult participants who were diagnosed with dry eye, regardless of race and gender. We included trials in which the age of participants was not reported, and clinical trials comparing OTC artificial tears with another class of OTC artificial tears, placebo, or no treatment. This review did not consider head‐to‐head comparisons of artificial tears with another type of dry‐eye therapy. Data collection and analysis We followed the standard methodological procedures expected by Cochrane. Two authors independently screened the search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. We performed meta‐analysis for trials that compared similar interventions and reported comparable outcomes with sufficient data. We summarized all other included trial results in the text. Main results We included 43 randomized controlled trials (3497 participants with dry eye). Due to the heterogeneity of study characteristics among the included trials with respect to types of diagnostic criteria, interventions, comparisons, and measurements taken, our ability to perform meta‐analyses was limited. The review found that, in general, there was uncertainty whether different OTC artificial tears provide similar relief of signs and symptoms when compared with each other or placebo. Nevertheless, we found that 0.2% polyacrylic acid‐based artificial tears were consistently more effective at treating dry eye symptoms than 1.4% polyvinyl alcohol‐based artificial tears in two trials assessing this comparison (175 participants). All other included artificial tears produced contradictory between‐group results or found no between‐group differences. Our review also found that OTC artificial tears may be generally safe, but not without adverse events. Overall, we assessed the quality of evidence as low due to high risks of bias among included trials and poor reporting of outcome measures which were insufficient for quantitative analysis. Furthermore, we identified an additional 18 potentially eligible trials that were reported only in clinical trial registers with no associated results or publications. These trials reportedly enrolled 2079 total participants for whom no data are available. Such lack of reporting of trial results represents a high risk of publication bias. Authors' conclusions OTC artificial tears may be safe and effective means for treating dry eye syndrome; the literature indicates that the majority of OTC artificial tears may have similar efficacies. This conclusion could be greatly skewed by the inconsistencies in study designs and inconsistencies in reporting trial results. Additional research is therefore needed before we can draw robust conclusions about the effectiveness of individual OTC artificial tear formulations. Plain language summary Efficacy of over the counter (OTC) artificial tears for dry eye syndrome Research question What is the effect of over the counter (OTC) artificial tears on dry eye syndrome? Background 
 Dry eye syndrome is a long‐term condition that is known to cause eye discomfort and visual disturbances like blurred vision. This condition affects millions of people around the world, and the first‐line treatment for dry eye is typically over the counter (OTC) artificial tears. OTC artificial tears are meant to replace or supplement the tears (fluid) that naturally cover the eye’s front surface (cornea and conjunctiva). There are a great number of commercially available artificial tears, yet there is currently no agreement about whether one formulation works better than another at treating dry eye. Our review attempts to bridge this knowledge gap. Study characteristics 
 This review included 43 randomized controlled trials (3497 people with dry eye) that compared OTC artificial tears with other OTC artificial tears, with no treatment, or with placebo. We considered participant symptoms to be the primary outcome for this review. We recorded other commonly performed dry eye tests as secondary outcomes (e.g. vision, tear stability). We measured primary and secondary outcomes at two and four weeks, although we also considered other time points in this review. We searched for trials up to December 2015. Key results 
 This review analyzed many OTC artificial tear formulations, and most of the literature indicates uncertainty as to which OTC artificial tear works best. The literature also shows that OTC artificial tears may be effective at treating dry eye symptoms and that OTC artificial tears are generally safe, although not without side effects. We also identified an additional 18 potentially eligible trials that were registered, but did not provide any results or publications. These trials may have enrolled 2079 total participants for whom no data are available. Without the results of these trials, the effects of the OTC artificial tears that they evaluated are unknown. Quality of the evidence The overall quality of the evidence was low for the various OTC artificial tear formulations compared in this review. This finding indicates that future published research may have an important impact on the conclusions currently provided in this review.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.110Z" }, { "id": "abb6bc53-6115-45b1-bb1d-6605ebbddb42", "pmid": "", "title": "Cannabis and cannabinoids for symptomatic treatment for people with multiple sclerosis", "imported": false, "abstract": "Abstract - Background Spasticity and chronic neuropathic pain are common and serious symptoms in people with multiple sclerosis (MS). These symptoms increase with disease progression and lead to worsening disability, impaired activities of daily living and quality of life. Anti‐spasticity medications and analgesics are of limited benefit or poorly tolerated. Cannabinoids may reduce spasticity and pain in people with MS. Demand for symptomatic treatment with cannabinoids is high. A thorough understanding of the current body of evidence regarding benefits and harms of these drugs is required. Objectives To assess benefit and harms of cannabinoids, including synthetic, or herbal and plant‐derived cannabinoids, for reducing symptoms for adults with MS. Search methods We searched the following databases from inception to December 2021: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), CINAHL (EBSCO host), LILACS, the Physiotherapy Evidence Database (PEDro), the World Health Organisation International Clinical Trials Registry Platform, the US National Institutes of Health clinical trial register, the European Union Clinical Trials Register, the International Association for Cannabinoid Medicines databank. We hand searched citation lists of included studies and relevant reviews. Selection criteria We included randomised parallel or cross‐over trials (RCTs) evaluating any cannabinoid (including herbal C annabis, C annabis flowers, plant‐based cannabinoids, or synthetic cannabinoids) irrespective of dose, route, frequency, or duration of use for adults with MS. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane Risk of bias 2 tool for parallel RCTs and crossover trials. We rated the certainty of evidence using the GRADE approach for the following outcomes: reduction of 30% in the spasticity Numeric Rating Scale, pain relief of 50% or greater in the Numeric Rating Scale‐Pain Intensity, much or very much improvement in the Patient Global Impression of Change (PGIC), Health‐Related Quality of Life (HRQoL), withdrawals due to adverse events (AEs) (tolerability), serious adverse events (SAEs), nervous system disorders, psychiatric disorders, physical dependence. Main results We included 25 RCTs with 3763 participants of whom 2290 received cannabinoids. Age ranged from 18 to 60 years, and between 50% and 88% participants across the studies were female. The included studies were 3 to 48 weeks long and compared nabiximols, an oromucosal spray with a plant derived equal (1:1) combination of tetrahydrocannabinol (THC) and cannabidiol (CBD) (13 studies), synthetic cannabinoids mimicking THC (7 studies), an oral THC extract of C annabis sativa (2 studies), inhaled herbal C annabis (1 study) against placebo. One study compared dronabinol, THC extract of C annabis sativa and placebo, one compared inhaled herbal C annabis , dronabinol and placebo. We identified eight ongoing studies. Critical outcomes • Spasticity: nabiximols probably increases the number of people who report an important reduction of perceived severity of spasticity compared with placebo (odds ratio (OR) 2.51, 95% confidence interval (CI) 1.56 to 4.04; 5 RCTs, 1143 participants; I 2 = 67%; moderate‐certainty evidence). The absolute effect was 216 more people (95% CI 99 more to 332 more) per 1000 reporting benefit with cannabinoids than with placebo. • Chronic neuropathic pain: we found only one small trial that measured the number of participants reporting substantial pain relief with a synthetic cannabinoid compared with placebo (OR 4.23, 95% CI 1.11 to 16.17; 1 study, 48 participants; very low‐certainty evidence). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity. • Treatment discontinuation due to AEs: cannabinoids may increase slightly the number of participants who discontinue treatment compared with placebo (OR 2.41, 95% CI 1.51 to 3.84; 21 studies, 3110 participants; I² = 17%; low‐certainty evidence); the absolute effect is 39 more people (95% CI 15 more to 76 more) per 1000 people. Important outcomes • PGIC: cannabinoids probably increase the number of people who report 'very much' or 'much' improvement in health status compared with placebo (OR 1.80, 95% CI 1.37 to 2.36; 8 studies, 1215 participants; I² = 0%; moderate‐certainty evidence). The absolute effect is 113 more people (95% CI 57 more to 175 more) per 1000 people reporting improvement. • HRQoL: cannabinoids may have little to no effect on HRQoL (SMD ‐0.08, 95% CI ‐0.17 to 0.02; 8 studies, 1942 participants; I 2 = 0%; low‐certainty evidence); • SAEs: cannabinoids may result in little to no difference in the number of participants who have SAEs compared with placebo (OR 1.38, 95% CI 0.96 to 1.99; 20 studies, 3124 participants; I² = 0%; low‐certainty evidence); • AEs of the nervous system: cannabinoids may increase nervous system disorders compared with placebo (OR 2.61, 95% CI 1.53 to 4.44; 7 studies, 1154 participants; I² = 63%; low‐certainty evidence); • Psychiatric disorders: cannabinoids may increase psychiatric disorders compared with placebo (OR 1.94, 95% CI 1.31 to 2.88; 6 studies, 1122 participants; I² = 0%; low‐certainty evidence); • Drug tolerance: the evidence is very uncertain about the effect of cannabinoids on drug tolerance (OR 3.07, 95% CI 0.12 to 75.95; 2 studies, 458 participants; very low‐certainty evidence). Authors' conclusions Compared with placebo, nabiximols probably reduces the severity of spasticity in the short‐term in people with MS. We are uncertain about the effect on chronic neurological pain and health‐related quality of life. Cannabinoids may increase slightly treatment discontinuation due to AEs, nervous system and psychiatric disorders compared with placebo. We are uncertain about the effect on drug tolerance. The overall certainty of evidence is limited by short‐term duration of the included studies. Plain language summary Cannabis and cannabinoids for people with multiple sclerosis Key messages 
• Treatment with nabiximols likely results in improvement of spasticity and may not increase serious harmful effects compared with placebo • Compared with placebo, cannabinoids (nabiximols, C annabis extract, synthetic cannabinoids) likely improve well‐being when measured with patient‐reported outcomes • Due to a lack of robust evidence, the benefit of these medicines for treating chronic neuropathic pain is unclear. What is the issue? Many people with multiple sclerosis (MS) experience spasticity that causes also pain and impacts on the ability to carry out daily activities. Spasticity is a form of increased muscle tone. Cannabis ‐based medicines refer to the use of Cannabis , or its ingredients called cannabinoids, as medical therapies to alleviate spasticity, chronic pain and other symptoms in MS. An international survey found that MS was one of the five medical conditions for which C annabis was most often used. Another survey conducted in the UK found that more than one in five people with MS reported they had used C annabis to try to manage their symptoms. What did we want to find out? We wanted to find out if cannabinoids were better than placebo in adults with MS to improve: • spasticity; • chronic neuropathic pain; • well‐being, We also wanted to find out if cannabinoids were associated with: • treatment discontinuation due to unwanted effects; • serious harmful effects; • nervous system disorders or psychiatric disorders; • drug tolerance defined as a condition that occurs when the body gets used to a medicine so that more medicine is needed. What did we do? 
We searched for studies that compared cannabinoids against placebo in adult people with MS. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and certainty of evidence. What did we find? We found 25 studies that involved 3763 people with MS, 2290 of whom received cannabinoids. Fifteen studies were very short term or short‐term studies (two to 12 weeks), seven were intermediate term (12 to 26 weeks), and two were long term (50 and 156 weeks). One study reported results at three days only. The biggest study was conducted in 657 people and the smallest study involved 14 people. Most studies were done in European countries. Thirteen studies evaluated an oral spray (nabiximols) containing two compounds derived from the C annabis plant. The other studies compared different cannabinoids with placebo. Pharmaceutical companies funded 15 of the studies. Main results Compared with placebo, cannabinoids: • probably increase the number of people who report an important reduction of perceived severity of spasticity for up to 14 weeks (evidence from five studies in 1143 people); • may increase the number of people who report an important reduction of perceived severity of chronic neuropathic pain, but the evidence is very uncertain (evidence from one study in 48 people). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity: • probably increase the number of people who perceive their well‐being as 'very much' or 'much' improved (evidence from eight studies in 1215 people); • may increase slightly the number of people who discontinue treatment due to unwanted effects (evidence from 21 studies in 3110 people); • may result in little to no difference in the number of people who have serious harmful effects (evidence from 20 studies in 3124 people); • may increase nervous system disorders (evidence from seven studies in 1154 people) or psychiatric disorders (evidence from six studies in 1122 people); • may have little to no effect on the number of people who have drug tolerance, but the evidence is very uncertain (two studies in 458 people). What are the limitations of the evidence? There is no high‐quality evidence. We are moderately confident that cannabinoids work better versus no cannabinoids to improve severity of spasticity and well‐being in adults with MS. We have little confidence in our results for the effect on chronic neuropathic pain because the available evidence is limited. There is limited evidence to determine the effects of cannabinoids on serious harmful effects, nervous system or psychiatric disorders, and drug tolerance. How up to date is the evidence? 
The evidence is up‐to‐date to December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Filippini, G; Minozzi, S; Borrelli, F; Cinquini, M; Dwan, K", "articleTypes": [], "doi": "10.1002/14651858.CD013444.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "abba651a-311a-4e6e-9510-3da803726c57", "pmid": "", "title": "Factors influencing the uptake and use of nicotine replacement therapy and e‐cigarettes in pregnant women who smoke: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) delivers nicotine without the toxic chemicals present in tobacco smoke. It is an effective smoking cessation aid in non‐pregnant smokers, but there is less evidence of effectiveness in pregnancy. Systematic review evidence suggests that pregnant women do not adhere to NRT as prescribed, which might undermine effectiveness. Electronic cigarettes (e‐cigarettes) have grown in popularity, but effectiveness and safety in pregnancy are not yet established. The determinants of uptake and use of NRT and e‐cigarettes in pregnancy are unknown. Objectives To explore factors affecting uptake and use of NRT and e‐cigarettes in pregnancy. Search methods We searched MEDLINE(R), CINAHL and PsycINFO on 1 February 2019. We manually searched OpenGrey database and screened references of included studies and relevant reviews. We also conducted forward citation searches of included studies. Selection criteria We selected studies that used qualitative methods of data collection and analysis, included women who had smoked in pregnancy, and elicited participants' views about using NRT/e‐cigarettes for smoking cessation or harm reduction (i.e. to smoke fewer cigarettes) during pregnancy. Data collection and analysis We identified determinants of uptake and use of NRT/e‐cigarettes in pregnancy using a thematic synthesis approach. Two review authors assessed the quality of included studies with the Wallace tool. Two review authors used the CERQual approach to assess confidence in review findings. The contexts of studies from this review and the relevant Cochrane effectiveness review were not similar enough to fully integrate findings; however, we created a matrix to juxtapose findings from this review with the descriptions of behavioural support from trials in the effectiveness review. Main results We included 21 studies: 15 focused on NRT, 3 on e‐cigarettes, and 3 on both. Studies took place in five high‐income countries. Most studies contributed few relevant data; substantially fewer data were available on determinants of e‐cigarettes. Many studies focused predominantly on issues relating to smoking cessation, and determinants of NRT/e‐cigarette use was often presented as one of the themes. We identified six descriptive themes and 18 findings within those themes; from these we developed three overarching analytical themes representing key determinants of uptake and adherence to NRT and/or e‐cigarettes in pregnancy. The analytical themes show that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. Furthermore, women consider advice from health professionals when deciding whether to use NRT or e‐cigarettes; when health professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay for them to use these in pregnancy, women report feeling more confident about using them. Conversely, women who are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them during pregnancy feel less confident about using them. Women's past experiences with NRT can also affect their willingness to use NRT in pregnancy; women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. No trials on e‐cigarette use in pregnancy were included in the Cochrane effectiveness review, so we considered only NRT findings when integrating results from this review and the effectiveness review. No qualitative studies were conducted alongside trials, making full integration of the findings challenging. Women enrolled in trials would have agreed to being allocated to NRT or control group and would have received standardised information on NRT at the start of the trial. Overall, the findings of this synthesis are less relevant to women's decisions about starting NRT in trials and more likely to help explain trial participants' adherence to NRT after starting it. We considered most findings to be of moderate certainty; we assessed findings on NRT use as being of higher certainty than those on e‐cigarette use. This was mainly due to the limited data from fewer studies (only in the UK and USA) that contributed to e‐cigarette findings. Overall, we judged studies to be of acceptable quality with only minor methodological issues. Authors' conclusions Consistent messages from health professionals, based on high‐quality evidence and clearly explaining the safety of NRT and e‐cigarettes compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and subsequently encourage them to stay smoke‐free. Plain language summary Factors affecting use of nicotine replacement therapy and e‐cigarettes in pregnancy What was studied in this review? Nicotine replacement therapy (NRT) delivers nicotine without the harmful chemicals found in tobacco smoke. NRT helps some non‐pregnant adults to stop smoking, but it does not seem to work so well in pregnancy. This may be because pregnant women generally do not use NRT as prescribed. Studies show that some pregnant women use e‐cigarettes to help them cut down or quit, although their safety and effectiveness in pregnancy is not known. Little is known about the issues that influence pregnant women's use of NRT/e‐cigarettes. What is the aim of this review? To explore factors that affect whether women take up and use NRT or e‐cigarettes to reduce or quit smoking in pregnancy. What are the key messages of this review? Three main factors influence whether women take up and use NRT and e‐cigarettes in pregnancy: advice women receive from health professionals on using NRT or e‐cigarette in pregnancy, women's desire to protect their unborn baby from harm, and past personal experience with NRT. Each of these factors can either encourage or discourage women from using these products. What are the key findings? We included 21 studies; 15 of these focused on NRT, 3 on e‐cigarettes and 3 on both. Our findings suggest that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. They also consider the advice from their health professionals; when professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay to use them in pregnancy, their confidence about using them increases. When women are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them when they are pregnant, they feel less confident about using them. Women's past experiences with NRT will also affect how willing they are to use NRT in pregnancy. For example, women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. We conclude that consistent messages that are based on high‐quality research and clearly explain how safe NRT and e‐cigarettes are compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and encourage them to stay smoke‐free. How up‐to‐date is this review? We searched for studies that had been published before 1 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Campbell, K; Coleman-Haynes, T; Bowker, K; Cooper, SE; Connelly, S; Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD013629", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "abc20737-666c-4d7b-b31d-8b6bad272432", "pmid": "", "title": "Study of the Genetic Factors That Influence the Susceptibility to and Severity of COVID-19", "imported": false, "abstract": "COVID-19 is a viral disease induced by infection with the novel SARS-CoV-2 coronavirus. Infection arises from the inhalation of viral particles spread by an infected individual. The main virus entry pathways are the nose and mouth mucous membranes, particularly rich in ACE2 receptors, that are used by the virus to enter cells and begin its replication.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.157Z" }, { "id": "abc886e5-a9e0-4d5d-a15c-5c310d03d472", "pmid": "", "title": "Antibiotics for acute rhinosinusitis in adults", "imported": false, "abstract": "Abstract - Background Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear. We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging. Objectives To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings. Search methods We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines. Selection criteria Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis‐like signs or symptoms or sinusitis confirmed by imaging. Data collection and analysis Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required. Main results We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I² = 0%; 8 trials; high‐quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I² = 0%; 3 trials; moderate‐quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate‐quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I² = 0%; 3 trials; high‐quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I² = 16%; 10 trials; high‐quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I² = 21%; 12 trials; high‐quality evidence). A disease‐related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group). Authors' conclusions The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high‐quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate‐quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials. Plain language summary Antibiotics for sinus infection of short duration in adults Review question Do antibiotics cure sinus infection faster than no antibiotics in adults? Background A sinus is a cavity situated in the head. Adults with short‐duration sinus infection experience stuffy nose and thick, yellow discharge from the nose. People with sinus infection can feel slime in the back of the throat, facial pain, pain when bending forward, and pain in the upper teeth or when chewing. A short‐duration sinus infection may be suspected following physical examination and questions about symptoms. Blood examination or images of the sinuses can support diagnosis, but are not routinely recommended in most countries. Short‐duration sinus infections are mostly caused by viruses. Nevertheless, physicians tend to prescribe antibiotics, which should only be used to treat bacterial infections. Taking antibiotics unnecessarily results in antibiotic resistance against bacterial infections. We investigated whether antibiotics cure adults with short‐duration sinus infection faster than a dummy drug (placebo) or no treatment. Search date 18 January 2018. Study characteristics We included 15 studies in which adults with short‐duration sinus infection, whether or not confirmed by imaging, randomly received antibiotics, or a dummy drug or no treatment, in ambulatory care settings. The studies included a total of 3057 adults whose average age was 36 years; about 60% were female. Participants were followed until they were cured. Trial duration ranged from 8 to 28 days. Study funding sources Seven studies received financial support from government or academic institutions; six received grants from the pharmaceutical industry; and five did not state sources of support. Key results Without antibiotics, almost half of all participants were cured after one week, and two out of three were cured after 14 days. Five (diagnosis based on symptoms described to a doctor) to 11 (diagnosis confirmed by x‐ray) more people per 100 were cured faster with antibiotics. A computed tomography (CT) scan could better predict who would benefit from antibiotics, but routine use would cause health problems related to radiation exposure. Ten more people per 100 were relieved faster of thick, yellow discharge from the nose with antibiotics compared to a dummy drug or no treatment. Thirteen more people per 100 experienced side effects (mostly concerning stomach or intestines) with antibiotics compared to a dummy drug or no treatment. Compared with people who initially started antibiotics, five more people per 100 in the dummy drug or no treatment group had to start antibiotics because their condition worsened. Serious complications (e.g. brain abscess) were rare. We found that antibiotics are not a first‐choice treatment for adults with short‐duration sinus infection. We found no evidence relating to adults with severe sinusitis or with reduced immunity, or to children. Quality of evidence We found high‐quality evidence when the diagnosis was based on symptoms described to a doctor. We downgraded evidence quality to moderate when diagnosis was confirmed by x‐ray or CT scan because the number of participants was small, which makes the estimates less reliable.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Lemiengre, MB, van Driel, ML, Merenstein, D, Liira, H, Mäkelä, M, De Sutter, AIM", "articleTypes": [], "doi": "10.1002/14651858.CD006089.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.758Z" }, { "id": "abd4103a-5397-4fbd-b7ce-148379ac7046", "pmid": "", "title": "Nutritional interventions for survivors of childhood cancer", "imported": false, "abstract": "Abstract - Background Childhood cancer survivors are at a higher risk of developing health conditions such as osteoporosis, and cardiovascular disease than their peers. Health‐promoting behaviour, such as consuming a healthy diet, could lessen the impact of these chronic issues, yet the prevalence rate of health‐protecting behaviour amongst survivors of childhood cancer is similar to that of the general population. Targeted nutritional interventions may prevent or reduce the incidence of these chronic diseases. Objectives The primary aim of this review was to assess the efficacy of a range of nutritional interventions designed to improve the nutritional intake of childhood cancer survivors, as compared to a control group of childhood cancer survivors who did not receive the intervention. Secondary objectives were to assess metabolic and cardiovascular risk factors, measures of weight and body fat distribution, behavioural change, changes in knowledge regarding disease risk and nutritional intake, participants' views of the intervention, measures of health status and quality of life, measures of harm associated with the process or outcomes of the intervention, and cost‐effectiveness of the intervention Search methods We searched the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 3), MEDLINE/PubMed (from 1945 to April 2013), and Embase/Ovid (from 1980 to April 2013). We ran the search again in August 2015; we have not yet fully assessed these results, but we have identified one ongoing trial. We conducted additional searching of ongoing trial registers ‐ the International Standard Randomised Controlled Trial Number register and the National Institutes of Health register (both screened in the first half of 2013) ‐ reference lists of relevant articles and reviews, and conference proceedings of the International Society for Paediatric Oncology and the International Conference on Long‐Term Complications of Treatment of Children and Adolescents for Cancer (both 2008 to 2012). Selection criteria We included all randomised controlled trials (RCTs) that compared the effects of a nutritional intervention with a control group which did not receive the intervention in this review. Participants were childhood cancer survivors of any age, diagnosed with any type of cancer when less than 18 years of age. Participating childhood cancer survivors had completed their treatment with curative intent prior to the intervention. Data collection and analysis Two review authors independently selected and extracted data from each identified study, using a standardised form. We assessed the validity of each identified study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Intervention s. We used the GRADE criteria to assess the quality of each trial. Main results Three RCTs were eligible for review. A total of 616 participants were included in the analysis. One study included participants who had been treated for acute lymphoblastic leukaemia (ALL) (275 participants). Two studies included participants who had all forms of paediatric malignancies (266 and 75 participants). All participants were less than 21 years of age at study entry. The follow‐up ranged from one month to 36 months from the initial assessment. All intended outcomes were not evaluated by each included study. All studies looked at different interventions, and so we were unable to pool results. We could not rule out the presence of bias in any of the studies. There was no clear evidence of a difference in calcium intake at one month between those who received the single, half‐day, group‐based education that focused on bone health, and those who received standard care (mean difference (MD) 111.60, 95% confidence interval (CI) ‐258.97 to 482.17; P = 0.56, low quality evidence). A regression analysis, adjusting for baseline calcium intake and changes in knowledge and self‐efficacy, showed a significantly greater calcium intake for the intervention as compared with the control group at the one‐month follow‐up (beta coefficient 4.92, 95% CI 0.33 to 9.52; P = 0.04). There was statistically significant higher, self‐reported milk consumption (MD 0.43, 95% CI 0.07 to 0.79; P = 0.02, low quality evidence), number of days on calcium supplementation (MD 11.42, 95% CI 7.11 to 15.73; P < 0.00001, low quality evidence), and use of any calcium supplementation (risk ratio (RR) 3.35, 95% CI 1.86 to 6.04; P < 0.0001, low quality evidence), with those who received this single, face‐to‐face, group‐based, health behaviour session. There was no clear evidence of a difference in bone density Z‐scores measured with a dual‐energy X‐ray absorptiometry (DEXA) scan at 36 months follow‐up (MD ‐0.05, 95% CI ‐0.26 to 0.16; P = 0.64, moderate quality evidence) between those who received calcium and vitamin D supplementation combined with nutrition education and those who received nutrition education alone. There was also no clear evidence of a difference in bone mineral density between the intervention and the control group at the 12‐month (median difference ‐0.17, P = 0.99) and 24‐month follow‐up (median difference ‐0.04, P = 0.54). A single multi‐component health behaviour change intervention, focusing on general healthy eating principles, with two telephone follow‐ups brought about a 0.17 lower score on the four‐point Likert scale of self‐reported junk food intake compared with the control group (MD ‐0.17, 95% CI ‐0.33 to ‐0.01; P = 0.04, low quality evidence); this result was statistically significant. There was no clear evidence of a difference between the groups in the self‐reported use of nutrition as a health protective behaviour (MD ‐0.05, 95% CI ‐0.24 to 0.14; P = 0.60, low quality evidence). Authors' conclusions Due to a paucity of studies, and the heterogeneity of the studies included in this review, we are unable to draw conclusions regarding the effectiveness of nutritional interventions for use with childhood cancer survivors. Although there is low quality evidence for the improvement in health behaviours using health behaviour change interventions, there remains no evidence as to whether this translates into an improvement in dietary intake. There was also no evidence that the studies reduced the risk of cardiovascular and metabolic disorders in childhood cancer survivors, although no evidence of effect is not the same as evidence of no effect. This review highlights the need for further well designed trials to be implemented in this population. Plain language summary Nutritional interventions for survivors of childhood cancer Background Survivors of childhood cancer are at a higher risk of chronic health conditions such as, osteoporosis, metabolic syndrome (including obesity and type II diabetes), and cardiovascular disease. These diseases have the potential to be reduced or prevented with targeted nutritional interventions. Objective This review looks at three randomised controlled trials that studied the effects of interventions designed to improve the dietary intake of children who have completed treatment for cancer. Study Characteristics The three studies included 616 participants who had completed their therapy for childhood cancer. All of the participants were less than 21 years of age at study entry. The interventions ranged from the promotion of health behaviours to vitamin and mineral supplementation. The follow‐up ranged from one month to 36 months from the initial assessment. Key results There was low quality evidence that those who received a health behaviour intervention decreased their self‐reported intake of “junk food”. They also increased their intake of dairy foods, as well as increasing their calcium supplementation. The interventions did not appear to translate to an improvement in their dietary intake, body composition, or bone mineral density. Quality of the evidence The results from this review do not provide enough evidence regarding the effectiveness of nutritional interventions for childhood cancer survivors. There was low quality evidence overall. Further well designed research is needed in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cohen, JE; Wakefield, CE; Cohn, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD009678.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "abd74921-12a0-450e-92f3-a3f1138a7709", "pmid": "", "title": "Ondansetron Pharmacotherapy for Hazardous Drinking in HIV+, African-American Women", "imported": false, "abstract": "The proposed randomized clinical trial will investigate a novel pharmacotherapy for hazardous drinking, HIV-infected men and women, using the serotonin receptor (5-HT3) antagonist ondansetron. The investigators predict that participants who are treated with active doses of ondansetron will reduce their drinking more and show better HIV treatment participation and progress compared to participants who are treated with placebo. This study will provide important new safety and efficacy results on drinking and HIV outcomes following alcohol pharmacotherapy in HIV-infected persons.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.151Z" }, { "id": "abf0d1c8-1b2f-4b11-80d8-37aa6244411d", "pmid": "", "title": "Antioxidant vitamin supplementation for preventing and slowing the progression of age‐related cataract", "imported": false, "abstract": "Abstract - Background Age‐related cataract is a major cause of visual impairment in the elderly. Oxidative stress has been implicated in its formation and progression. Antioxidant vitamin supplementation has been investigated in this context. Objectives To assess the effectiveness of antioxidant vitamin supplementation in preventing and slowing the progression of age‐related cataract. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 2), MEDLINE (January 1950 to March 2012), EMBASE (January 1980 to March 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to March 2012), Open Grey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 2 March 2012. We also checked the reference lists of included studies and ongoing trials and contacted investigators to identify eligible randomized trials. Selection criteria We included only randomized controlled trials in which supplementation with one or more antioxidant vitamins (beta‐carotene, vitamin C and vitamin E) in any form, dosage or combination for at least one year was compared to another antioxidant vitamin or to placebo. Data collection and analysis Two authors extracted data and assessed trial quality independently. We pooled results for the primary outcomes, i.e., incidence of cataract and incidence of cataract extraction. We did not pool results of the secondary outcomes ‐ progression of cataract and loss of visual acuity, because of differences in definitions of outcomes and data presentation. We pooled results by type of cataract when data were available. We did not perform a sensitivity analysis. Main results Nine trials involving 117,272 individuals of age 35 years or older are included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States, with duration of follow‐up ranging from 2.1 to 12 years. The doses of antioxidant vitamins were higher than the recommended daily allowance. There was no evidence of effect of antioxidant vitamin supplementation in reducing the risk of cataract, cataract extraction, progression of cataract or in slowing the loss of visual acuity. In the pooled analyses, there was no evidence of effect of beta‐carotene supplementation in reducing the risk of cataract (two trials) (relative risk (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.08; n = 57,703) or in reducing the risk of cataract extraction (three trials) (RR 1.00, 95% CI 0.91 to 1.10; n = 86,836) or of vitamin E supplementation in reducing the risk of cataract (three trials) (RR 0.97, 95% CI 0.91 to 1.04; n = 50,059) or of cataract extraction (five trials) (RR 0.98, 95% CI 0.91 to 1.05; n = 83,956). The proportion of participants developing hypercarotenodermia (yellowing of skin) while on beta‐carotene ranged from 7.4% to 15.8%. Authors' conclusions There is no evidence from RCTs that supplementation with antioxidant vitamins (beta‐carotene, vitamin C or vitamin E) prevents or slows the progression of age‐related cataract. We do not recommend any further studies to examine the role of antioxidant vitamins beta‐carotene, vitamin C and vitamin E in preventing or slowing the progression of age‐related cataract. Costs and adverse effects should be weighed carefully with unproven benefits before recommending their intake above recommended daily allowances. Plain language summary Antioxidant vitamins for preventing and slowing the progression of age‐related cataract A cataract occurs when the normally clear lens in the eye becomes cloudy. Cataracts are the leading cause of correctable reduced vision worldwide. Most cataracts develop slowly with normal aging. However, cataracts also may be related to genetic diseases and medical conditions such as diabetes. Other factors such as poor nutrition, sun damage, radiation, corticosteroids, smoking, alcohol, eye trauma or other eye surgery may influence cataract formation. Mild or early cataracts may not impair vision. In some cataracts, new eye‐glass prescriptions, brighter lighting or magnifying lenses may overcome the vision losses. When these interventions fail to improve poor vision due to cataracts, surgical removal (extraction) is the generally accepted effective treatment. However, cataract surgery is associated with some risks. The estimated annual costs for outpatient, inpatient and prescription drug services related to the treatment of cataract is USD 6.8 billion. Antioxidant vitamin supplementation has been studied as a means to prevent the formation or to slow the progression of cataract. Results from observational studies have been inconsistent. The review authors searched for randomized controlled trials in which supplementation with the antioxidant vitamins beta‐carotene (provitamin A), vitamin C and vitamin E was compared to inactive placebo or no supplement. Nine trials involving 117,272 adults of age 35 years or older were included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States and were of high methodological quality. The doses of antioxidants given in each trial were higher than the recommended daily allowances. The trials provided no evidence of effect of the antioxidant vitamins beta‐carotene, vitamin E and vitamin C given alone or in combination on the incidence of cataract, its extraction or progression and on the loss of visual acuity. Some participants (7% to 16%) on beta‐carotene developed yellowing of the skin (hypercarotenodermia).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mathew, MC, Ervin, AM, Tao, J, Davis, RM", "articleTypes": [], "doi": "10.1002/14651858.CD004567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.760Z" }, { "id": "ac0a8d78-69bc-426d-8b5f-a0a424a0777f", "pmid": "", "title": "Helicobacter pylori eradication for the prevention of gastric neoplasia", "imported": false, "abstract": "Abstract - Background Gastric cancer is the third most common cause of cancer death worldwide. Individuals infected with Helicobacter pylori have a higher likelihood of developing gastric cancer than individuals who are not infected. Eradication of H. pylori in healthy asymptomatic individuals in the general population may reduce the incidence of gastric cancer, but the magnitude of this effect is unclear. Objectives To assess the effectiveness of eradication of H. pylori in healthy asymptomatic individuals in the general population in reducing the incidence of gastric cancer. Search methods We identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 1), MEDLINE (1946 to February 2020), and EMBASE (1974 to February 2020). We handsearched reference lists from trials selected by electronic searching to identify further relevant trials. We handsearched published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ) between 2001 and 2019. We contacted members of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials comparing at least one week of H. pylori therapy with placebo or no treatment in preventing subsequent development of gastric cancer in otherwise healthy and asymptomatic H. pylori ‐positive adults. Trials had to follow up participants for at least two years and needed to have at least two participants with gastric cancer as an outcome. We defined gastric cancer as any gastric adenocarcinoma, including intestinal (differentiated) or diffuse (undifferentiated) type, with or without specified histology. Data collection and analysis We collected data on incidence of gastric cancer, incidence of oesophageal cancer, deaths from gastric cancer, deaths from any cause, and adverse effects arising due to therapy. Main results Six trials met all our eligibility criteria and provided extractable data in the previous version. Following our updated search, one new RCT was identified, meaning that seven trials were included in this updated review. In addition, one previously included trial provided fully published data out to 10 years, and another previously included trial provided fully published data out to 22 years of follow‐up. Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. Six trials were conducted in Asian populations. In preventing development of subsequent gastric cancer, H. pylori eradication therapy was superior to placebo or no treatment (RR 0.54, 95% confidence interval (CI) 0.40 to 0.72, 7 trials, 8323 participants, moderate certainty evidence). Only two trials reported the effect of eradication of H. pylori on the development of subsequent oesophageal cancer. Sixteen (0.8%) of 1947 participants assigned to eradication therapy subsequently developed oesophageal cancer compared with 13 (0.7%) of 1941 participants allocated to placebo (RR 1.22, 95% CI 0.59 to 2.54, moderate certainty evidence). H. pylori eradication reduced mortality from gastric cancer compared with placebo or no treatment (RR 0.61, 95% CI 0.40 to 0.92, 4 trials, 6301 participants, moderate certainty evidence). There was little or no evidence in all‐cause mortality (RR 0.97, 95% CI 0.85 to 1.12, 5 trials, 7079 participants, moderate certainty evidence). Adverse events data were poorly reported. Authors' conclusions We found moderate certainty evidence that searching for and eradicating H. pylori reduces the incidence of gastric cancer and death from gastric cancer in healthy asymptomatic infected Asian individuals, but we cannot necessarily extrapolate this data to other populations. Plain language summary Helicobacter pylori treatment for the prevention of stomach cancer Review question Whether testing healthy people for Helicobacter pylori and treating those infected with a course of antibiotics decreases the number of new cases of gastric cancer. Background Helicobacter pylori ( H. pylori ) is a bacteria that lives in the lining of the stomach with people usually not aware they are carrying the infection. People with H. pylori infection are more likely to develop gastric cancer than people who are not infected with the bacterium. For this reason, H. pylori is classed as carcinogenic (causing cancer) to humans. Many people worldwide die of gastric cancer every year, because by the time those affected seek the opinion of a doctor, the condition is often advanced. However, H. pylori infection is easily treatable with a one‐week course of antibiotics. Study characteristics A literature search up to 02 Feburary 2020 found seven trials (containing 8323 participants, four trials at low risk of bias). Six of the studies were based in Asia. Key results We found that antibiotics for H. pylori have a small benefit in preventing gastric cancer (68 (1.6%) of 4206 participants given treatment developed gastric cancer subsequently, compared with 125 (3.0%) of 4117 given no treatment or a placebo), and in decreasing the number of deaths from gastric cancer (36 (1.1%) of 3154, compared with 59 (1.9%) of 3147); but it is unclear whether or not they increase or decrease the number of deaths due to any cause, or increase or decrease the number of cases of oesophageal cancer. Data about side effects of treatment were poorly reported. Quality of the evidence Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. One study was at high risk of bias because no placebo was used for the active eradication therapy regimen, and so this part of the trial was unblinded, and the other study was at high risk of bias due to inconsistencies in data reporting at the two points of follow‐up. We were unable to resolve this discrepancy despite contacting the original authors. As a result, we downgraded the quality of evidence from high to moderate due to serious risk of bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ford, AC, Yuan, Y, Forman, D, Hunt, R, Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD005583.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.759Z" }, { "id": "ac0afe1f-d2cf-44f7-b29a-fa330fc392d0", "pmid": "", "title": "Rinse‐free hand wash for reducing absenteeism among preschool and school children", "imported": false, "abstract": "Abstract - Background Illness‐related absenteeism is an important problem among preschool and school children for low‐, middle‐ and high‐ income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse‐free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness‐related absenteeism in preschool and school children. Objectives 1. To assess the effectiveness of rinse‐free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse‐free hand washing products are the most effective (if head‐to‐head comparisons exist), and what effect additional strategies in combination with rinse‐free hand washing have on the outcomes of interest. Search methods In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied. Selection criteria Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse‐free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions. Data collection and analysis Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings. Main results This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most‐notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse‐free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low‐certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse‐free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse‐free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low‐certainty evidence), which indicates rinse‐free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse‐free' group (eight days absent per 1000). There may be little to no difference between rinse‐free hand washing and 'no rinse‐free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low‐certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very‐low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse‐free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very‐low certainty evidence). Authors' conclusions The findings of this review may have identified a small yet potentially beneficial effect of rinse‐free hand washing regimes on illness‐related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse‐free hand washing regimens in order to provide more conclusive, higher‐certainty evidence regarding its impact. When considering the use of a rinse‐free hand washing program in a local setting, there needs to be consideration of the current rates of illness‐related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings. Plain language summary Rinse‐free hand wash for reducing absenteeism among preschool and school children Background Absenteeism from schooling is costly to parents, schools and governments and sustained absence is detrimental to student learning. Illness‐related absenteeism is a significant contributor to absenteeism from school, but can also result in parents missing work due to catching the illness themselves or having to stay home to care for their children. There are several strategies currently used to reduce illness‐related absenteeism, a common method is the implementation of appropriate hand hygiene practices. However, hand hygiene using soap and water is not always practical, and alternatives may prove to be more effective in reducing the overall rate of illness‐related absenteeism. One such alternative is the use of rinse‐free hand wash. Review question This review was designed to investigate if the use of rinse‐free hand wash can reduce the number of days spent absent from school in preschool and school children compared to no rinse‐free hand wash usage. Study characteristics The searches returned 19 relevant studies with a total of 30,747 participants. Eight studies were conducted in the USA, two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to14 years). These studies were quite varied in the composition and application of the rinse‐free hand washing program. Only two studies included information on the primary outcome (absenteeism due to any reason), whilst for absenteeism for any illness there were six studies that provided information. The evidence presented is up to date to February 2020. Key results The application of, and adherence to a rinse‐free hand wash, hand hygiene program may be associated with small, but potentially beneficial effects in reducing the number of days students were absent from school due to illness compared to no rinse‐free hand wash, hygiene program. However rinse‐free hand washing may be no different to controls at reducing absenteeism for any reason. There may also be no difference in the number of skin irritations between students who received the rinse‐free hand wash compared to those who used soap and water. Most students and teachers responded favorably to using rinse‐free hand wash and complied relatively well with its use. Certainty of the evidence The certainty of the evidence included in this review was low or very low, mainly due to the included studies using poor methods, providing imprecise data, and being very inconsistent from one another. This means that we have low and very‐low certainty, or confidence, in these results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Munn, Z; Tufanaru, C; Lockwood, C; Stern, C; McAneney, H; Barker, TH", "articleTypes": [], "doi": "10.1002/14651858.CD012566.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "ac2deef5-b824-4ab6-9fad-bf4c5ee9a52e", "pmid": "", "title": "Exposure to the smell and taste of milk to accelerate feeding in preterm infants", "imported": false, "abstract": "Abstract - Background Preterm infants (born before 37 weeks' gestation) are often unable to co‐ordinate sucking, swallowing, and breathing for oral feeding because of their immaturity. In such cases, initial nutrition is provided by orogastric or nasogastric tube feeding. Feeding intolerance is common and can delay attainment of full enteral and sucking feeds, prolonging the need for nutritional support and the hospital stay. Smell and taste play an important role in the activation of physiological pre‐absorptive processes that contribute to food digestion and absorption. However, during tube feeding, milk bypasses the nasal and oral cavities, limiting exposure to the smell and taste of milk. Provision of the smell and taste of milk with tube feeds offers a non‐invasive and low‐cost intervention that, if effective in accelerating the transition to enteral feeds and subsequently to sucking feeds, would bring considerable advantages to infants, their families, and healthcare systems. Objectives To assess whether exposure to the smell or taste (or both) of breastmilk or formula administered with tube feeds can accelerate the transition to full sucking feeds without adverse effects in preterm infants. Search methods We conducted searches in CENTRAL, MEDLINE, Embase, CINAHL, and Epistemonikos to 26 April 2023. We also searched clinical trial databases and conference proceedings. Selection criteria We included randomised and quasi‐randomised studies that evaluated exposure versus no exposure to the smell or taste of milk (or both) immediately before or at the time of tube feeds. Data collection and analysis Two review authors independently selected studies, assessed risk of bias, and extracted data according to Cochrane Neonatal methodology. We performed meta‐analyses using risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence. Main results We included eight studies (1277 preterm infants). Seven studies (1244 infants) contributed data for meta‐analysis. The evidence suggests that exposure to the smell and taste of milk with tube feeds has little to no effect on time taken to reach full sucking feeds (MD −1.07 days, 95% CI −2.63 to 0.50; 3 studies, 662 infants; very low‐certainty evidence). Two studies reported no adverse effects related to the intervention. The intervention may have little to no effect on duration of parenteral nutrition (MD 0.23 days, 95% CI −0.24 to 0.71; 3 studies, 977 infants; low‐certainty evidence), time to reach full enteral feeds (MD −0.16 days, 95% CI −0.45 to 0.12; 1 study, 736 infants; very low‐certainty evidence) or risk of necrotising enterocolitis (RR 0.93, 95% CI 0.47 to 1.84; 2 studies, 435 infants; low‐certainty evidence), although the evidence for time to reach full enteral feeds is very uncertain. Exposure to the smell and taste of milk with tube feeds probably has little to no effect on risk of late infection (RR 1.14, 95% CI 0.74 to 1.75; 2 studies, 436 infants; moderate‐certainty evidence). There were no data available to assess feeding intolerance. The included studies had small sample sizes and methodological limitations, including unclear or lack of randomisation (four studies), lack of blinding of participants and personnel (five studies), unclear or lack of blinding of the outcome assessor (all eight studies), and different inclusion criteria and methods of administering the interventions. Authors' conclusions The results of our meta‐analyses suggest that exposure to the smell and taste of milk with tube feeds may have little to no effect on time to reach full sucking feeds and time to reach full enteral feeds. We found no clear difference between exposure and no exposure to the smell or taste of milk on safety outcomes (adverse effects, necrotising enterocolitis, and late infection). Results from one ongoing study and two studies awaiting classification may alter the conclusions of this review. Future research should examine the effect of exposing preterm infants to the smell and taste of milk with tube feeds on health outcomes during hospitalisation, such as attainment of feeding skills, safety, feed tolerance, infection, and growth. Future studies should be powered to detect the effect of the intervention in infants of different gestational ages and on each sex separately. It is also important to determine the optimal method, frequency, and duration of exposure. Plain language summary Does exposure to the smell and taste of milk accelerate feeding in tube‐fed preterm infants? Key messages • Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time it takes preterm infants to reach full sucking feeds.
• We found no evidence of any unwanted effects of exposure to the smell and taste of milk with tube feeds in newborn infants. What is tube feeding? Infants born preterm (before 37 weeks of pregnancy) often need to be fed via a thin tube inserted through the mouth (orogastric tube) or nose (nasogastric tube) into the stomach until they are able to suck all of their feeds. Why is the smell and taste of milk important for tube‐fed babies? Initially, only small volumes of milk are given, and this is gradually increased depending on how well the babies tolerate the milk. Smell and taste have a significant role in helping with digestion and absorption of food, and since infants being fed by a tube may not experience the smell or taste of milk, they might be taking longer to tolerate larger volumes of milk. What did we want to find out? We wanted to find out if exposing infants to the smell and taste of milk before or while they were being fed through a tube could help them tolerate greater volumes of milk more quickly and improve their overall growth and development. We also wanted to know if this method had any unwanted effects. What did we do? We searched for studies that investigated exposing preterm infants to the smell or taste (or both) of milk with tube feeds, compared to no such exposure. We compared and summarised the results of the studies and rated the certainty of the evidence, based on factors such as study methods and number of infants included. What did we find? We identified eight completed studies involving 1277 preterm infants admitted to a neonatal intensive care unit. Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time to reach full sucking feeds, but the results are very uncertain. Two studies reported that no infants had any unwanted effects related to exposure to the smell and taste of milk with tube feeds. Exposure to the smell and taste of milk may have little to no effect on duration of intravenous nutrition (feeding through a vein), time to reach full enteral feeds (feeds though a tube into the stomach), or on the risk of necrotising enterocolitis (a serious intestinal disease), although the results for time to full enteral feeds are very uncertain. Exposure to the smell and taste of milk probably has little or no effect on the risk of developing an infection more than two days after birth. What are the limitations of the evidence? We have little confidence in the evidence because: • we identified few studies;
• most studies were small and provided different types of exposure to smell and taste;
• in many studies, clinicians and parents were aware of which treatment the infant was receiving; and
• the studies did not investigate all the outcomes we were interested in. How up‐to‐date is this evidence? This review is current to April 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Delgado Paramo, L; Bronnert, A; Lin, L; Bloomfield, FH; Muelbert, M; Harding, JE", "articleTypes": [], "doi": "10.1002/14651858.CD013038.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "ac4caff4-db41-4f5d-9673-cc251d7fa74d", "pmid": "", "title": "Interactions of Human Gut Microbiota With Intestinal Sweet Taste Receptors", "imported": false, "abstract": "The purpose of this study is to collect data to examine whether short-term consumption of non-caloric artificial sweeteners (NCASs), such as saccharin, can lead to changes in blood sugar levels and in the composition of the bacteria in the large intestine.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.142Z" }, { "id": "ac4f2ad1-6aae-44dc-a83e-2b3e3d3c13ea", "pmid": "", "title": "Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long‐term central venous catheters in infants and children", "imported": false, "abstract": "Abstract - Background Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015. Objectives To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long‐term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC). Data collection and analysis Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random‐effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review. Main results We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin. Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC‐associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC‐associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low‐certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate‐certainty evidence), and not reported in the remaining studies. Authors' conclusions The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC‐associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains. Plain language summary Replacing heparin flushing with saline flushing to prevent complications in long‐term central venous catheters in children Background A central venous catheter (CVC) is a long, thin, flexible tube which is inserted into a large central vein. This enables access to the blood stream for people with serious medical conditions to receive medications and fluids, as well as the collection of blood specimens. Long‐term CVCs are used to access the blood system in children with complex medical conditions like cancer. To stop the catheter from becoming blocked it is usual to use heparin, a drug that prevents clots forming, to flush the catheter. However, some studies have shown that heparin is not necessary, and that normal saline (a sterile salt water solution) can be safely used instead. Heparin may be associated with complications, such as bleeding and infection, along with higher costs for healthcare providers. While the complications such as infections and occlusions are uncommon, practices vary around the world and there are many inconsistencies regarding the best flush solution to use to prevent complications in long‐term catheters. Study characteristics and key results This review included randomised controlled trials (clinical studies where people were randomly assigned into one of two or more treatment groups) that compared the use of saline and heparin to prevent blockage, and other complications related to long‐term catheters. The evidence is current to 9 April 2019. Two review authors independently reviewed the studies. We included four studies with a total of 255 participants in the review. The four trials were all undertaken in large teaching (tertiary) hospitals, and directly compared the use of saline and heparin. The studies were, however, very different in the way they compared saline and heparin, with different concentrations of heparin and different frequencies of flushes reported. We were able to combine the results of two studies: the analysis showed imprecise results for the blocking of catheters and blood stream infections for normal saline versus heparin. One study reported the duration of catheter placement to be similar between the two study arms. Certainty of the evidence The overall certainty of the evidence ranged from moderate to very low. There was high risk of bias for blinding, there were differences between the studies methods and interventions, inconsistent results between the studies, and not all studies reported all outcomes of interest. We found there was not enough evidence to determine which solution, saline or heparin, is more effective for reducing complications. Further research is required and is likely to have an important impact in this area. This review is an update of a review first published in 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bradford, NK; Edwards, RM; Chan, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD010996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "ac530614-9cb1-4822-ace4-f8b089800cfa", "pmid": "", "title": "Anabolic‐androgenic steroids for alcoholic liver disease", "imported": false, "abstract": "Abstract - Background Alcohol is one of the most common causes of liver disease in the Western World. Randomised clinical trials have examined the effects of anabolic‐androgenic steroids for alcoholic liver disease. Objectives To assess the beneficial and harmful effects of anabolic‐androgenic steroids for patients with alcoholic liver disease based on the results of randomised clinical trials. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Controlled Trials Register in The Cochrane Library , MEDLINE , EMBASE, LILACS, and Science Citation Index Expanded until June 2006. Electronic searches were combined with full text searches. Manufacturers and researchers in the field were also contacted. Selection criteria Randomised clinical trials studying patients with alcoholic steatosis, alcoholic fibrosis, alcoholic hepatitis, and/or alcoholic cirrhosis were included. Interventions encompassed anabolic‐androgenic steroids at any dose or duration versus placebo or no intervention. The trials could be double blind, single blind, or unblinded. The trials could be unpublished or published, and no language limitations were applied. Data collection and analysis Outcomes are assessed at maximal follow‐up. All analyses were performed according to the intention‐to‐treat method. The statistical package RevMan Analyses was used. The methodological quality of the randomised clinical trials was assessed. Main results Combining the results of five randomised clinical trials randomising 499 patients with alcoholic hepatitis and/or cirrhosis demonstrated no significant effects of anabolic‐androgenic steroids on mortality (relative risk (RR) 1.01, 95% confidence interval (CI) 0.79 to 1.29), liver‐related mortality (RR 0.83, 95% CI 0.60 to 1.15), complications of liver disease (RR 1.25, 95% CI 0.74 to 2.10), and liver histology. Anabolic‐androgenic steroids did not significantly affect a number of other outcome measures, including sexual function and liver biochemistry. Anabolic‐androgenic steroids were not associated with a significantly increased risk of non‐serious adverse events (RR 1.14, 95% CI 0.50 to 2.59) or with serious adverse events (RR 4.54, 95% CI 0.57 to 36.30). Authors' conclusions This systematic review could not demonstrate any significant beneficial effects of anabolic‐androgenic steroids on any clinically important outcomes (mortality, liver‐related mortality, liver complications, and histology) of patients with alcoholic liver disease. Plain language summary No evidence to support anabolic‐androgenic steroids for alcoholic liver disease Alcohol causes a major part of the liver diseases in the Western World. Several trials have addressed the effects of anabolic‐androgenic steroids for alcoholic liver disease. This systematic review could not demonstrate any significant effects of anabolic‐androgenic steroids on mortality, liver‐related mortality, liver complications, and histology of patients with alcoholic liver disease. Anabolic‐androgenic steroid intervention is not associated with a significant increase in non‐serious adverse events, but with the seldom occurrence of serious adverse events. Accordingly, there is no evidence supporting the use of anabolic‐androgenic steroids for alcoholic liver disease, but further randomised clinical trials may be needed to settle the question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Rambaldi, A; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD003045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "ac5e9b39-eb34-4df8-af23-cf55a66e70c4", "pmid": "", "title": "Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega‐3 PUFA and plant oils in omega‐6 PUFA. Evidence suggests that increasing PUFA‐rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear. Objectives To assess effects of increasing total PUFA intake on cardiovascular disease and all‐cause mortality, lipids and adiposity in adults. Search methods We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all‐cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions. Data collection and analysis Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta‐analyses used random‐effects analysis, sensitivity analyses included fixed‐effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence. Main results We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA. Increasing PUFA intake probably has little or no effect on all‐cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate‐quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) and stroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low‐quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality. Increasing PUFA intake probably slightly decreases triglycerides (by 15%, MD ‐0.12 mmol/L, 95% CI ‐0.20 to ‐0.04, 20 trials, 3905 participants), but has little or no effect on total cholesterol (mean difference (MD) ‐0.12 mmol/L, 95% CI ‐0.23 to ‐0.02, 26 trials, 8072 participants), high‐density lipoprotein (HDL) (MD ‐0.01 mmol/L, 95% CI ‐0.02 to 0.01, 18 trials, 4674 participants) or low‐density lipoprotein (LDL) (MD ‐0.01 mmol/L, 95% CI ‐0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably has little or no effect on adiposity (body weight MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants). Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality. Authors' conclusions This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all‐cause or cardiovascular disease mortality. The mechanism may be via TG reduction. Plain language summary Polyunsaturated fatty acids for prevention and treatment of diseases of the heart and circulation Review question We reviewed randomised trials (participants have an equal chance to be assigned to either treatment) examining effects of increasing intake of polyunsaturated fatty acids (PUFA) on deaths and diseases of the heart and circulation (cardiovascular diseases), including heart attacks and stroke. Background We eat PUFA in our usual food, but quantities of PUFA eaten vary. There is some evidence that increasing the amount of PUFA we eat can reduce our blood cholesterol and make us less likely to develop cardiovascular disease, particularly if PUFAs are eaten instead of saturated fats (fats from animal sources such as meat and cheese). But eating more PUFA may increase our body weight, and omega‐6 fats (one component of PUFA) may worsen cardiovascular risk by increasing inflammation. Evidence on the benefits or harms of increasing PUFA intake on diseases of the heart and circulation, or on other health outcomes, is inconclusive. Trial characteristics Evidence in this Cochrane Review is current to 27 April 2017. We included 49 trials randomising 24,272 participants, for one to eight years. These trials assessed effects of eating more, compared to less PUFA, on diseases of the heart and circulation, and deaths. Twelve trials were very trustworthy (had low risk of bias overall). Participants were men and women, some with existing illnesses and some not. Trials took place in North America, Asia, Europe and Australia, and sixteen were funded only by national or charitable agencies. Key results Increasing PUFA probably makes little or no difference (neither benefit nor harm) to our risk of death (moderate‐quality evidence), and may make little or no difference to our risk of dying from cardiovascular disease (low‐quality evidence). However, increasing PUFA probably slightly reduces our risk of heart disease events and of combined heart and stroke events (moderate‐quality evidence). Fifty three people would need to eat more PUFA to prevent one person experiencing a heart disease event, and 63 people to prevent one person experiencing a heart or stroke event. Increasing PUFA may very slightly reduce risk of death due to heart disease, as well as stroke, but harm is possible (low‐quality evidence). PUFA probably slightly reduces fats circulating in the blood (triglycerides, moderate‐quality evidence but without effects on other lipids or adiposity). The evidence mainly comes from dietary‐advice trials of men living in high‐income countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abdelhamid, AS, Martin, N, Bridges, C, Brainard, JS, Wang, X, Brown, TJ, Hanson, S, Jimoh, OF, Ajabnoor, SM, Deane, KHO, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.801Z" }, { "id": "ac619436-57e1-4069-8ac9-13d6bbcaa46e", "pmid": "", "title": "Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults", "imported": false, "abstract": "Abstract - Background Acetylcholinesterase inhibitors, such as neostigmine, have traditionally been used for reversal of non‐depolarizing neuromuscular blocking agents. However, these drugs have significant limitations, such as indirect mechanisms of reversal, limited and unpredictable efficacy, and undesirable autonomic responses. Sugammadex is a selective relaxant‐binding agent specifically developed for rapid reversal of non‐depolarizing neuromuscular blockade induced by rocuronium. Its potential clinical benefits include fast and predictable reversal of any degree of block, increased patient safety, reduced incidence of residual block on recovery, and more efficient use of healthcare resources. Objectives The main objective of this review was to compare the efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade caused by non‐depolarizing neuromuscular agents in adults. Search methods We searched the following databases on 2 May 2016: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (WebSPIRS Ovid SP), Embase (WebSPIRS Ovid SP), and the clinical trials registries www.controlled‐trials.com , clinicaltrials.gov , and www.centerwatch.com . We re‐ran the search on 10 May 2017. Selection criteria We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published, or language. We included adults, classified as American Society of Anesthesiologists (ASA) I to IV, who received non‐depolarizing neuromuscular blocking agents for an elective in‐patient or day‐case surgical procedure. We included all trials comparing sugammadex versus neostigmine that reported recovery times or adverse events. We included any dose of sugammadex and neostigmine and any time point of study drug administration. Data collection and analysis Two review authors independently screened titles and abstracts to identify trials for eligibility, examined articles for eligibility, abstracted data, assessed the articles, and excluded obviously irrelevant reports. We resolved disagreements by discussion between review authors and further disagreements through consultation with the last review author. We assessed risk of bias in 10 methodological domains using the Cochrane risk of bias tool and examined risk of random error through trial sequential analysis. We used the principles of the GRADE approach to prepare an overall assessment of the quality of evidence. For our primary outcomes (recovery times to train‐of‐four ratio (TOFR) > 0.9), we presented data as mean differences (MDs) with 95 % confidence intervals (CIs), and for our secondary outcomes (risk of adverse events and risk of serious adverse events), we calculated risk ratios (RRs) with CIs. Main results We included 41 studies (4206 participants) in this updated review, 38 of which were new studies. Twelve trials were eligible for meta‐analysis of primary outcomes (n = 949), 28 trials were eligible for meta‐analysis of secondary outcomes (n = 2298), and 10 trials (n = 1647) were ineligible for meta‐analysis. We compared sugammadex 2 mg/kg and neostigmine 0.05 mg/kg for reversal of rocuronium‐induced moderate neuromuscular blockade (NMB). Sugammadex 2 mg/kg was 10.22 minutes (6.6 times) faster then neostigmine 0.05 mg/kg (1.96 vs 12.87 minutes) in reversing NMB from the second twitch (T2) to TOFR > 0.9 (MD 10.22 minutes, 95% CI 8.48 to 11.96; I 2 = 84%; 10 studies, n = 835; GRADE: moderate quality). We compared sugammadex 4 mg/kg and neostigmine 0.07 mg/kg for reversal of rocuronium‐induced deep NMB. Sugammadex 4 mg/kg was 45.78 minutes (16.8 times) faster then neostigmine 0.07 mg/kg (2.9 vs 48.8 minutes) in reversing NMB from post‐tetanic count (PTC) 1 to 5 to TOFR > 0.9 (MD 45.78 minutes, 95% CI 39.41 to 52.15; I 2 = 0%; two studies, n = 114; GRADE: low quality). For our secondary outcomes, we compared sugammadex, any dose, and neostigmine, any dose, looking at risk of adverse and serious adverse events. We found significantly fewer composite adverse events in the sugammadex group compared with the neostigmine group (RR 0.60, 95% CI 0.49 to 0.74; I 2 = 40%; 28 studies, n = 2298; GRADE: moderate quality). Risk of adverse events was 28% in the neostigmine group and 16% in the sugammadex group, resulting in a number needed to treat for an additional beneficial outcome (NNTB) of 8. When looking at specific adverse events, we noted significantly less risk of bradycardia (RR 0.16, 95% CI 0.07 to 0.34; I 2 = 0%; 11 studies, n = 1218; NNTB 14; GRADE: moderate quality), postoperative nausea and vomiting (PONV) (RR 0.52, 95% CI 0.28 to 0.97; I 2 = 0%; six studies, n = 389; NNTB 16; GRADE: low quality) and overall signs of postoperative residual paralysis (RR 0.40, 95% CI 0.28 to 0.57; I 2 = 0%; 15 studies, n = 1474; NNTB 13; GRADE: moderate quality) in the sugammadex group when compared with the neostigmine group. Finally, we found no significant differences between sugammadex and neostigmine regarding risk of serious adverse events (RR 0.54, 95% CI 0.13 to 2.25; I 2 = 0%; 10 studies, n = 959; GRADE: low quality). Application of trial sequential analysis (TSA) indicates superiority of sugammadex for outcomes such as recovery time from T2 to TOFR > 0.9, adverse events, and overall signs of postoperative residual paralysis. Authors' conclusions Review results suggest that in comparison with neostigmine, sugammadex can more rapidly reverse rocuronium‐induced neuromuscular block regardless of the depth of the block. Sugammadex 2 mg/kg is 10.22 minutes (˜ 6.6 times) faster in reversing moderate neuromuscular blockade (T2) than neostigmine 0.05 mg/kg (GRADE: moderate quality), and sugammadex 4 mg/kg is 45.78 minutes (˜ 16.8 times) faster in reversing deep neuromuscular blockade (PTC 1 to 5) than neostigmine 0.07 mg/kg (GRADE: low quality). With an NNTB of 8 to avoid an adverse event, sugammadex appears to have a better safety profile than neostigmine. Patients receiving sugammadex had 40% fewer adverse events compared with those given neostigmine. Specifically, risks of bradycardia (RR 0.16, NNTB 14; GRADE: moderate quality), PONV (RR 0.52, NNTB 16; GRADE: low quality), and overall signs of postoperative residual paralysis (RR 0.40, NNTB 13; GRADE: moderate quality) were reduced. Both sugammadex and neostigmine were associated with serious adverse events in less than 1% of patients, and data showed no differences in risk of serious adverse events between groups (RR 0.54; GRADE: low quality). Plain language summary Benefits and harms of sugammadex versus neostigmine in reversing induced paralysis Background Different levels of induced paralysis are sometimes necessary when patients are put to sleep or are prepared for operations. When the operation is finished, paralysis should be reversed in a fast, reliable, and safe way. Neostigmine is a medication that is traditionally used to reverse induced paralysis. However, its use can be associated with incomplete or slow reversal as well as changes in lung function, heart function, and vomiting and nausea. Sugammadex is a relatively new medication specifically designed to reverse rocuronium‐induced paralysis in a faster, more reliable, and safer way when compared with neostigmine. Objective This review systematically sets out to compare the benefits and harms of sugammadex and neostigmine. The evidence is current up to May 2017. Study characteristics We identified 41 randomized controlled trials comparing sugammadex with neostigmine that provided suitable data on efficacy and safety. All of these trials included adults undergoing surgery and involved a total of 4206 participants. Key results Data indicate that sugammadex was 10.22 minutes (6.6 times) faster than neostigmine (1.96 vs 12.87 minutes) in reversing moderate induced paralysis. Sugammadex was 45.78 minutes (16.8 times) faster than neostigmine (2.9 vs 48.8 minutes) in reversing deep induced paralysis. Participants receiving sugammadex appeared to have a 40% reduced risk of experiencing harmful events than those given neostigmine. Statistically, eight persons can be treated with sugammadex as opposed to neostigmine to avoid one person experiencing a single random harmful event. The occurrence of serious harmful events was nearly non‐existent and data show no differences between compared groups. Conclusion Sugammadex is more efficient and safer than neostigmine for reversing moderate and deep induced paralysis. Quality of evidence We consider our overall findings on benefits and harms to provide evidence of moderate quality in favour of sugammadex.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Hristovska, AM; Duch, P; Allingstrup, M; Afshari, A", "articleTypes": [], "doi": "10.1002/14651858.CD012763", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "ac65ab4d-54b3-4998-a35f-21b06c5181d4", "pmid": "", "title": "Alpha‐blockers as medical expulsive therapy for ureteral stones", "imported": false, "abstract": "Abstract - Background Ureteral colic is a common reason for patients to seek medical care. Alpha‐blockers are commonly used to improve stone passage through so‐called medical expulsive therapy (MET), but their effectiveness remains controversial. This is an update of a 2014 Cochrane review; since that time, several large randomised controlled trials (RCTs) have been reported, making this update relevant. Objectives To assess effects of alpha‐blockers compared with standard therapy for ureteral stones 1 cm or smaller confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease. Search methods On 18 November 2017, we searched CENTRAL, MEDLINE Ovid, and Embase. We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials. We checked all references of included and review articles and conference proceedings for articles relevant to this review. We sent letters to investigators to request information about unpublished or incomplete studies. Selection criteria We included RCTs of ureteral stone passage in adult patients that compared alpha‐blockers versus standard therapy. Data collection and analysis Two review authors screened studies for inclusion and extracted data using standard methodological procedures. We performed meta‐analysis using a random‐effects model. Primary outcomes were stone clearance and major adverse events; secondary outcomes were stone expulsion time, number of pain episodes, use of diclofenac, hospitalisation, and surgical intervention. We assessed the quality of evidence on a per‐outcome basis using the GRADE approach. Main results We included 67 studies with 10,509 participants overall. Of these, 15 studies with 5787 participants used a placebo. Stone clearance: Based on the overall analysis, treatment with an alpha‐blocker may result in a large increase in stone clearance (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.36 to 1.55; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that the likely effect is probably smaller (RR 1.16, 95% CI 1.07 to 1.25; moderate‐quality evidence), corresponding to 116 more (95% CI 51 more to 182 more) stone clearances per 1000 participants. Major adverse events: Based on the overall analysis, treatment with an alpha‐blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low‐quality evidence). A subset of higher‐quality, placebo‐controlled trials suggest that alpha‐blockers likely increase the risk of major adverse events slightly (RR 2.09, 95% CI 1.13 to 3.86), corresponding to 29 more (95% CI 3 more to 75 more) major adverse events per 1000 participants. Patients treated with alpha‐blockers may experience shorter stone expulsion times (mean difference (MD) ‐3.40 days, 95% CI ‐4.17 to ‐2.63; low‐quality evidence), may use less diclofenac (MD ‐82.41, 95% CI ‐122.51 to ‐42.31; low‐quality evidence), and likely require fewer hospitalisations (RR 0.51, 95% CI 0.34 to 0.77; moderate‐quality evidence), corresponding to 69 fewer hospitalisations (95% CI 93 fewer to 32 fewer) per 1000 participants. Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI 0.53 to 1.02; low‐quality evidence), corresponding to 28 fewer surgical interventions (95% CI 51 fewer to 2 more) per 1000 participants. A predefined subgroup analysis (test for subgroup differences; P = 0.002) suggests that effects of alpha‐blockers may vary with stone size, with RR of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or smaller versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones larger than 5 mm. We found no evidence suggesting possible subgroup effects based on stone location or alpha‐blocker type. Authors' conclusions For patients with ureteral stones, alpha‐blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha‐blockers may be less effective for smaller (5 mm or smaller) than for larger stones (greater than 5 mm). Plain language summary Alpha‐blockers for ureteral stones in adult patients with symptoms of stone disease Review question Does medical treatment with alpha‐blockers improve the outcomes of patients with stones stuck in their ureter? Background Stones stuck in the ureter, which is the tube that transports urine from the kidney to the bladder, often cause pain and make people see a doctor. Depending on which part of the ureter the stone is stuck in and the size of the stone, it will often pass into the bladder on its own over the course of weeks. If the stone does not come out by itself, people often need to have procedures done to remove the stone. Alpha‐blockers are medications that relax muscles in the urinary tract and may make the stone pass into the bladder faster. However, they can cause unwanted effects. We updated an existing Cochrane Review from 2014 to look into the effects of alpha‐blockers. Study characteristics Based on our latest search of the literature from November 2017, we included 64 studies with 10,509 participants. Of these, 15 studies compared alpha‐blockers with placebo with 5787 participants. A placebo is a pill that looks and tastes exactly like the real medication, so participants did not know what they were getting. These were the higher‐quality studies, which we trusted more. Key results Based on the subset of higher‐quality studies that used a placebo, alpha‐blockers likely resulted in more people passing their stones. However, these patients are likely to experience slightly more serious unwanted effects of this medication. People taking alpha‐blockers may pass their stones in a shorter time, may use less diclofenac (which is a type of pain medication), and are likely to be admitted to the hospital less often. Meanwhile, the need for surgery for their stones was similar. Upon completing additional analyses, we found that effects of alpha‐blockers may be different in people with small (5 mm or smaller) versus larger (larger than 5 mm) stones. It appears that this medication works better in people with larger stones. We could find no difference in how well alpha‐blockers work, no matter where in the ureter the stone is stuck or what type of alpha‐blocker is used. Authors' conclusions For patients with stones stuck in the ureter, alpha‐blockers likely make passing the stone easier but cause slightly more unwanted effects. It appears that alpha‐blockers work better in people with larger (greater than 5 mm) rather than smaller (5 mm or smaller) stones. Quality of the evidence The quality of the evidence for most outcomes was moderate or low, meaning that we have moderate or low confidence in most of the reported results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Campschroer, T; Zhu, X; Vernooij, RWM; Lock, MTWT", "articleTypes": [], "doi": "10.1002/14651858.CD008509.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "ac694aec-8cb1-40cf-946f-2c9350636ade", "pmid": "", "title": "Metabolic and bariatric surgery in adults with obesity and diabetes mellitus: a network meta‐analysis", "imported": false, "abstract": "Abstract - Rationale Obesity and its associated comorbidities, particularly type 2 diabetes (T2D), have reached epidemic dimensions globally. Both conditions are related to an increased risk of serious health outcomes and impose a substantial burden on those affected. Metabolic and bariatric surgery (MBS) may offer a therapeutic option for achieving sustained weight loss, improving comorbidities and thereby enhancing long‐term quality of life. Objectives To investigate the medium‐ and long‐term benefits and harms of different MBS procedures compared with each other and to non‐surgical treatment on outcomes relevant to adults with obesity and T2D, and to obtain a clinically meaningful ranking of these interventions by considering both randomised controlled trials (RCTs) and cohort studies. Search methods We searched MEDLINE, Cochrane CENTRAL, CINAHL, LILACS, BASE as well as the WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 25 June 2024. We did not apply any language restrictions. Eligibility criteria We included RCTs and both prospective and retrospective cohort studies with a minimum follow‐up of three years in adults (≥ 18 years) with obesity (body mass index ≥ 30 kg/m² or ethnic‐specific cut‐off values) and T2D. Eligible interventions include MBS procedures (i.e. laparoscopic adjustable gastric banding [LAGB], sleeve gastrectomy [SG], Roux‐en‐Y gastric bypass [RYGB], one‐anastomosis gastric bypass [OAGB], gastric plication [GCP], biliopancreatic diversion with duodenal switch, and their variations) or non‐surgical treatment (i.e. lifestyle intervention, medical treatment [LI/MT]). Outcomes Critical outcomes were medium‐ (≥ 3 to < 5 years) and long‐term (≥ 5 years) weight loss (%), waist circumference (cm), T2D remission (complete, partial), and serious adverse events (SAE). Important outcomes included all‐cause mortality, T2D complications, glycaemic control (glycated haemoglobin (HbA1c) in %) and health‐related quality of life (HRQoL). Risk of bias We used the Risk of Bias 2 (RoB 2) tool for RCTs and Risk Of Bias In Non‐randomized Studies – of Interventions (ROBINS‐I) for cohort studies. Synthesis methods We performed random‐effects network meta‐analyses based on the frequentist approach and ranked treatments by P scores. We rated the certainty of evidence according to the GRADE approach for long‐term outcomes (≥ 5 years). Included studies We included 18 studies (with 70 reports) with 15,282 participants in this review. Of these, 13 studies were RCTs (n = 911) and five were cohort studies (n = 14,371). Two RCTs compared MBS with LI/MT, ten compared two or three different MBS procedures and one with a 3‐arm design investigated two different MBS procedures as well as LI/MT. All cohort studies compared different MBS procedures. The networks were based on the following MBS procedures: RYGB, SG, OAGB, LAGB, GCP, and LI/MT. Synthesis of results NMA results (8 RCTs; n = 491) suggest greater long‐term weight loss after RYGB compared to LI/MT (MD ‐16.95%; 95% CI ‐24.19 to ‐9.71). OAGB (MD ‐12.10%; 95% CI ‐22.85 to ‐1.34) and SG (MD ‐9.40 %; 95% CI ‐17.45 to ‐1.34) may also result in greater weight loss compared to LI/MT, but the evidence is very uncertain. A reduction in waist circumference at long‐term follow‐up (6 RCTs; n = 348) is likely higher after RYGB compared to LI/MT (MD ‐12.34 cm; 95% CI ‐17.88 to ‐6.81). OAGB (MD: ‐13.28 cm; 95% CI ‐22.04 to ‐4.53) and SG (MD‐9.08 cm; 95% CI ‐15.74 to ‐2.43) may also lead to a higher reduction in waist circumference compared to LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effects of MBS procedures compared to LI/MT on long‐term complete T2D remission (9 RCTs; n = 536). All MBS procedures (8 RCTs; n = 588) may result more often in partial T2D remissions than LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effect of all MBS procedures compared to LI/MT on SAE (9 RCTs; n = 598) and all‐cause mortality in the long term (7 RCTs; n = 520). RYGB may reduce total long‐term T2D complications compared to LI/MT (Rate ratio (RaR) 0.17; 95% CI 0.03 to 0.89; 5 RCTs; n = 356), but the evidence is very uncertain. Based on NMA results (10 RCTs; n = 612), RYGB may reduce HbA1c compared to LI/MT (MD ‐1.44%; 95% CI ‐2.26 to ‐0.63). OAGB (MD ‐2.01%; 95%CI ‐3.42 to ‐0.60) and SG (MD ‐1.01%; 95%CI ‐1.94 to ‐0.08) may also reduce HbA1c compared to LI/MT, but the evidence is every uncertain. Both RYGB and SG may increase mental and physical components of HRQoL compared to LI/MT (both 2 RCTs; n = 118), but evidence is very uncertain. The inclusion of cohort studies in the analyses of percentage weight loss, partial type 2 diabetes remission, SAE, and all‐cause mortality confirmed the main findings. For most outcomes, the main reasons for downgrading certainty of evidence were related to risk of bias and imprecision. Authors' conclusions In people with obesity and T2D, RYGB, OAGB and, to a lesser extent, SG may lead to long‐term improvements in body weight, waist circumference, partial T2D remission, and HbA1c compared with LI/MT. However, due to imprecise results, the magnitude of the effects often remains uncertain or very uncertain. For other outcomes, especially complete T2D remission, SAE, all‐cause mortality and T2D complications, the evidence is mainly very uncertain, due to a low numbers of participants and events. When interpreting these findings, it should be noted that cohort studies were not, as originally planned, included in the certainty of evidence assessment, as these studies were judged to have a high or critical risk of bias. Larger and well‐designed studies may contribute to diminishing the existing uncertainties and enhancing our confidence in the findings. Funding This Cochrane review was funded by the German Federal Ministry of Education and Research (BMBF) (grant number: 01KG2201). Registration Protocol (2024) DOI: https://doi.org/10.1002/14651858.CD015622 PROSPERO ID: CRD42023457363 Plain language summary Review question What are the long‐term benefits and risks of different types of weight loss surgery (also called metabolic and bariatric surgery) to treat obesity and type 2 diabetes in adults? Key messages In people with obesity and type 2 diabetes, gastric (stomach) bypass (i.e. Roux‐en‐Y gastric bypass and one‐anastomosis gastric bypass) may be most beneficial for improving body weight, waist circumference, type 2 diabetes status and long‐term blood sugar levels at least five years after surgery, but for one‐anastomosis gastric bypass, we are very uncertain about the results. It is unclear whether the different surgical procedures have an effect on risks such as serious unwanted health effects and death from any cause at least five years after surgery. Larger and well‐designed studies may help reduce the existing uncertainties and increase our confidence in the findings. What are obesity and type 2 diabetes? 
Obesity is a condition with too many fat deposits that can damage health. In type 2 diabetes, the body has difficulty controlling blood sugar levels because the hormone insulin does not work properly. Type 2 diabetes often occurs in people with obesity, and both conditions increase the risk of premature death and other health problems, such as cardiovascular disease. How are obesity and type 2 diabetes treated? Lifestyle interventions such as nutrition, exercise, and behavioural programmes, along with medicines, are often used first for weight loss and improvement of diabetes status. When these do not work well, metabolic and bariatric surgery may be considered as an additional treatment option. There are a number of different types of bariatric surgery: gastric (stomach) banding; gastric sleeve (removal of a part of the stomach); Roux‐en‐Y gastric bypass (RYGB); one‐anastomosis gastric bypass, or mini‐gastric bypass; gastric plication (folding to make the stomach smaller); biliopancreatic diversion with duodenal switch. What did we want to find out? Which of the different types of surgery are the safest and most beneficial ones by comparing them with each other and with lifestyle and medication therapy regarding their long‐term (at least 5 years follow‐up) benefits and risks. Whether these surgical procedures improve body weight, waist circumference, type 2 diabetes status, long‐term blood sugar levels, and quality of life at least five years after surgery. Whether surgery affects serious unwanted health effects, death from any cause, and type 2 diabetes complications over this period. What did we do? 
We searched for studies involving people with obesity and type 2 diabetes. We included studies that compared at least two different surgical procedures, or surgery with lifestyle and medication treatment. We summarised and compared all treatments using a method called network meta‐analysis, and we rated our confidence in the results based on factors such as study methods and sample size. What did we find? 
We found 18 studies, including 15,282 people with obesity and type 2 diabetes. In 13 of these studies (including 911 people), participants were assigned randomly to two or more treatment groups. This is the best way to ensure that groups of people are similar. Five studies (with 14,371 people) used ‘real‐life’ observational data. The studies investigated surgical procedures such as gastric band, gastric sleeve, Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, and gastric plication. We found that: Roux‐en‐Y gastric bypass, may improve body weight and likely reduce waist circumference compared with lifestyle and medication treatment in the long term. One‐anastomosis gastric bypass and, to a lesser extent, gastric sleeve, may also improve body weight and waist circumference, but we are very uncertain about the results. Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, gastric sleeve, and gastric band may improve type 2 diabetes status, but we are very uncertain about the results. It is unclear whether the types of surgery have an effect on serious unwanted health effects or death from any cause. Roux‐en‐Y gastric bypass may reduce type 2 diabetes complications in the long term compared to non‐surgical treatments, but we are very uncertain about the results. Roux‐en‐Y gastric bypass may improve blood sugar levels compared to non‐surgical treatments. One‐anastomosis gastric bypass and gastric sleeve may also improve blood sugar levels, but we are very uncertain about the results. RYGB and SG may lead to a greater increase in health‐related quality of life than non‐surgical treatments, but again, we are very uncertain about the results. What are the limitations of the evidence? 
Our confidence in the evidence is often low to very low because the studies included only small numbers of people, and the results for some outcomes, especially serious unwanted health effects, death from any cause, and type 2 diabetes complications, were based on very few events. Moreover, for several surgical procedures, there were not enough studies to be certain about the outcomes. It is important to note that rating our confidence in findings was based only on studies in which participants were randomly assigned to groups and did not include observational studies. How up to date is this evidence? 
This evidence is up to date as of June 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E; Gorenflo, L; Schwarzer, G; Stadelmaier, J; Wallerer, S; Marjanovic, G; Fink, JM; Lehane, C; Metzendorf, MI; Meerpohl, J; Schwingshackl, L", "articleTypes": [], "doi": "10.1002/14651858.CD015622.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "ac84d0d1-47c2-48a5-a250-75ba8463647a", "pmid": "", "title": "Treatment of periodontitis for glycaemic control in people with diabetes mellitus", "imported": false, "abstract": "Abstract - Background Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontitis. Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus, and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement, or non‐surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe. This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care. Objectives To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis. Search methods An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. Selection criteria We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment or adjunctive antimicrobial therapy or both) to no active intervention or 'usual care' (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least 3 months and have measured HbA1c (glycated haemoglobin). Data collection and analysis At least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials, and assessed included trials for risk of bias. Where necessary and possible, we attempted to contact study authors. Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol). Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index, and probing pocket depth), quality of life, cost implications, and diabetic complications. Main results We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel‐RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 diabetes, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair, or poor. Most studies were carried out in secondary care. We assessed two studies as being at low risk of bias, 14 studies at high risk of bias, and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings. Moderate‐certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) ‐0.59% to ‐0.28%; ‐6.4 mmol/mol to ‐3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI ‐0.52% to ‐0.08%; ‐5.7 mmol/mol to ‐0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI ‐0.55% to ‐0.45%; ‐6.0 mmol/mol to ‐4.9 mmol/mol; 1 study, 264 participants). Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, adverse effects of periodontal treatments were not evaluated in most studies. Authors' conclusions Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate‐certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in this review. Plain language summary Does treatment for gum disease help people with diabetes control blood sugar levels? Review question The main question addressed by this review is: how effective is gum disease (periodontitis) treatment for controlling blood sugar levels (known as glycaemic control) in people with diabetes, compared to no active treatment or usual care? Background The aim of treating periodontitis is to reduce swelling and infection and stabilise the condition of the gums and supporting bone. The level of sugar in the blood is too high in people with diabetes, so keeping blood sugar levels under control is a key issue. Some clinical research suggests a relationship exists between gum disease treatment and glycaemic control. Glycaemic control can be measured in different ways. For this review, we focused on HbA1c, which shows average blood glucose levels over the preceding 3 months. It can be reported as a percentage (of total haemoglobin) or as mmol/mol (millimoles per mole). Excellent glycaemic control in a diabetic person might be around 6.5% or 48 mmol/mol. This review was carried out by authors working with the Cochrane Oral Health and is part one of an update of a review previously published in 2010 and 2015. This review evaluates gum disease treatment versus no active treatment or usual care. Part two of the review will compare different types of periodontal treatment. We carried out this review as it is important to discover if gum disease treatment does improve glycaemic control in order to ensure best use of clinical resources. Study characteristics We searched six research databases and found 35 relevant trials where people with diabetes and periodontitis were randomly allocated to an experimental group or a control group. The experimental groups received gum disease treatment called 'subgingival instrumentation', also known as scaling and root planing or deep cleaning. In some experimental groups, the deep cleaning was supplemented with instructions for cleaning teeth properly ('oral hygiene instruction'), or other gum treatments, for example, antimicrobials, which are used to treat infections. Control groups received no active treatment or 'usual care', which was oral hygiene instruction, support with oral hygiene, and/or removal of plaque above the gumline. The trials randomised 3249 participants in total. Almost all participants had type 2 diabetes, with a mix of good, fair, and poor diabetic control. Most of the studies were carried out in hospitals. The studies followed up participants for between 3 and 12 months. Key results Evidence from 30 trials (results from 2443 participants) showed that periodontitis treatment reduces blood sugar levels (measured by HbA1c) in diabetic patients on average by 0.43 percentage points (e.g. from 7.43% to 7%; 4.7 mmol/mol) 3 to 4 months after receiving the treatment compared with no active treatment or usual care. A difference of 0.30% (3.3 mmol/mol) was seen after 6 months (12 studies), and 0.50% (5.4 mmol/mol) at 12 months (one study). There were not enough studies measuring side effects to be able to evaluate the risk of harm from gum disease treatments. Certainty of the evidence Most of the studies were conducted in a way that meant they were at a high risk of bias or did not provide enough information for us to make a judgement on this. However, the consistency of our findings suggests they are reliable and future research is not likely to change them. In summary, currently there is moderate‐certainty evidence to support gum disease treatment (known as subgingival instrumentation) for controlling blood sugar levels in people with periodontitis (gum disease) and diabetes up to 12 months after the start of the periodontal treatment. Date of the search The evidence is current up to 7 September 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Simpson, TC; Clarkson, JE; Worthington, HV; MacDonald, L; Weldon, JC; Needleman, I; Iheozor-Ejiofor, Z; Wild, SH; Qureshi, A; Walker, A; Patel, VA; Boyers, D; Twigg, J", "articleTypes": [], "doi": "10.1002/14651858.CD004714.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "ac8b97c2-8706-4de3-b136-c88cfc5ceb65", "pmid": "", "title": "Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status", "imported": false, "abstract": "Abstract - Background Iron deficiency is an important micronutrient deficiency contributing to the global burden of disease, and particularly affects children, premenopausal women, and people in low‐resource settings. Anaemia is a possible consequence of iron deficiency, although clinical and functional manifestations of anemia can occur without iron deficiency (e.g. from other nutritional deficiencies, inflammation, and parasitic infections). Direct nutritional interventions, such as large‐scale food fortification, can improve micronutrient status, especially in vulnerable populations. Given the highly successful delivery of iodine through salt iodisation, fortifying salt with iodine and iron has been proposed as a method for preventing iron deficiency anaemia. Further investigation of the effect of double‐fortified salt (i.e. with iron and iodine) on iron deficiency and related outcomes is warranted. Objectives To assess the effect of double‐fortified salt (DFS) compared to iodised salt (IS) on measures of iron and iodine status in all age groups. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases, and two trial registries up to April 2021. We also searched relevant websites, reference lists, and contacted the authors of included studies. Selection criteria All prospective randomised controlled trials (RCTs), including cluster‐randomised controlled trials (cRCTs), and controlled before‐after (CBA) studies, comparing DFS with IS on measures of iron and iodine status were eligible, irrespective of language or publication status. Study reports published as abstracts were also eligible. Data collection and analysis Three review authors applied the study selection criteria, extracted data, and assessed risk of bias. Two review authors rated the certainty of the evidence using GRADE. When necessary, we contacted study authors for additional information. We assessed RCTs, cRCTs and CBA studies using the Cochrane RoB 1 tool and Cochrane Effective Practice and Organisation of Care (EPOC) tool across the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other potential sources of bias due to similar baseline characteristics, similar baseline outcome assessments, and declarations of conflicts of interest and funding sources. We also assessed cRCTs for recruitment bias, baseline imbalance, loss of clusters, incorrect analysis, and comparability with individually randomised studies. We assigned studies an overall risk of bias judgement (low risk, high risk, or unclear). Main results We included 18 studies (7 RCTs, 7 cRCTs, 4 CBA studies), involving over 8800 individuals from five countries. One study did not contribute to analyses. All studies used IS as the comparator and measured and reported outcomes at study endpoint. With regards to risk of bias, five RCTs had unclear risk of bias, with some concerns in random sequence generation and allocation concealment, while we assessed two RCTs to have a high risk of bias overall, whereby high risk was noted in at least one or more domain(s). Of the seven cRCTs, we assessed six at high risk of bias overall, with one or more domain(s) judged as high risk and one cRCT had an unclear risk of bias with concerns around allocation and blinding. The four CBA studies had high or unclear risk of bias for most domains. The RCT evidence suggested that, compared to IS, DFS may slightly improve haemoglobin concentration (mean difference (MD) 0.43 g/dL, 95% confidence interval (CI) 0.23 to 0.63; 13 studies, 4564 participants; low‐certainty evidence), but DFS may reduce urinary iodine concentration compared to IS (MD −96.86 μg/L, 95% CI −164.99 to −28.73; 7 studies, 1594 participants; low‐certainty evidence), although both salts increased mean urinary iodine concentration above the cut‐off deficiency. For CBA studies, we found DFS made no difference in haemoglobin concentration (MD 0.26 g/dL, 95% CI −0.10 to 0.63; 4 studies, 1397 participants) or urinary iodine concentration (MD −17.27 µg/L, 95% CI −49.27 to 14.73; 3 studies, 1127 participants). No studies measured blood pressure. For secondary outcomes reported in RCTs, DFS may result in little to no difference in ferritin concentration (MD −3.94 µg/L, 95% CI −20.65 to 12.77; 5 studies, 1419 participants; low‐certainty evidence) or transferrin receptor concentration (MD −4.68 mg/L, 95% CI −11.67 to 2.31; 5 studies, 1256 participants; low‐certainty evidence) compared to IS . However, DFS may reduce zinc protoporphyrin concentration (MD −27.26 µmol/mol, 95% CI −47.49 to −7.03; 3 studies, 921 participants; low‐certainty evidence) and result in a slight increase in body iron stores (MD 1.77 mg/kg, 95% CI 0.79 to 2.74; 4 studies, 847 participants; low‐certainty evidence). In terms of prevalence of anaemia, DFS may reduce the risk of anaemia by 21% (risk ratio (RR) 0.79, 95% CI 0.66 to 0.94; P = 0.007; 8 studies, 2593 participants; moderate‐certainty evidence). Likewise, DFS may reduce the risk of iron deficiency anaemia by 65% (RR 0.35, 95% CI 0.24 to 0.52; 5 studies, 1209 participants; low‐certainty evidence). Four studies measured salt intake at endline, although only one study reported this for both groups. Two studies reported prevalence of goitre, while one CBA study measured and reported serum iron concentration. One study reported adverse effects. No studies measured hepcidin concentration. Authors' conclusions Our findings suggest DFS may have a small positive impact on haemoglobin concentration and the prevalence of anaemia compared to IS, particularly when considering efficacy studies. Future research should prioritise studies that incorporate robust study designs and outcome measures (e.g. anaemia, iron status measures) to better understand the effect of DFS provision to a free‐living population (non‐research population), where there could be an added cost to purchase double‐fortified salt. Adequately measuring salt intake, both at baseline and endline, and adjusting for inflammation will be important to understanding the true effect on measures of iron status. Plain language summary Fortification of salt with iron and iodine compared to salt fortified with iodine only for improving iron and iodine status Key messages Compared to iodised salt, double‐fortified salt (salt fortified with iron and iodine) may improve some measures of iron and iodine nutrition, such as haemoglobin (i.e. the substance that gives red blood cells their colour) concentrations and body iron stores. However, it may reduce urinary iodine concentration and may make little or no difference to ferritin (i.e. iron‐storage protein) concentrations and transferrin receptor (i.e. protein that affects the uptake of iron) concentrations. It probably also reduces the prevalence of anaemia (lack of haemoglobin), and may reduce the prevalence of iron deficiency anaemia (lack of iron), compared to iodised salt. Well‐designed studies that assess the effects of double‐fortified salt within non‐research populations (i.e. real‐life settings), and that measure salt intake, including changes in salt consumption, are needed. What is iron deficiency? Almost two billion people experience a deficiency in a vitamin or mineral (or both), with women and children in resource‐limited settings most frequently affected. Iron‐related deficiencies are among the most common deficiencies in the world and have important short‐ and long‐term health consequences. Interventions to provide iron frequently include iron supplementation, including iron tablets, powders, or syrups. However, these have known barriers, and food fortification strategies may be attractive alternatives. Salt is one of few universally consumed food vehicles. Iodised salt is fortified to provide 100% of a person's iodine requirements and is highly effective. Double‐fortified salt was developed to provide 30% of a person's daily dietary iron requirement and 100% of their iodine requirement. In some resource‐limited settings, where iron‐related deficiencies are a common problem, there has been interest in making double‐fortified salt more available to the public. This calls for further understanding of the effect of double‐fortified salt on related outcomes. What did we want to find out? If double‐fortified salt is better than salt fortified with iodine alone for improving measures of iron and iodine‐related nutrition, in particular: ‐ haemoglobin concentration; ‐ urinary iodine concentration; ‐ blood pressure; ‐ ferritin concentration; ‐ transferrin receptor concentration; ‐ prevalence of anaemia; ‐ prevalence of iron deficiency anaemia. What did we do? We looked for studies that provided double‐fortified salt to one group of participants and iodised salt to another. We compared their results, and rated our confidence in the evidence, based on factors such as study methods and sample size. What did we find? We identified 18 studies, involving over 8800 individuals from five countries; 13 studies were conducted in India. In 13 studies the intervention lasted between 6 and 12 months; in two studies it lasted 3 months, and in single studies it lasted for 18 months, 24 months, or the duration was unclear. Nine studies were conducted in children and adolescents (5 to 17 years), four in adults (18 years and older), and five included multiple age groups. All studies compared double‐fortified salt to iodised salt. Most studies were funded by non‐profit organisations, university grants or academic institutes. In four studies, double‐fortified salt was provided by a commercial organisation, and in three studies the funding source unclear. Compared to iodised salt, double‐fortified salt may improve haemoglobin concentration and body iron stores slightly, and probably reduces the prevalence of anaemia by 21%. However, double‐fortified salt may also reduce urinary iodine concentration compared to iodised salt and may make little or no difference in ferritin and transferrin receptor concentration. Double‐fortified salt may reduce the prevalence of iron deficiency anaemia by 65%, compared to iodised salt, although this conclusion is uncertain because of some problems with the way the studies were conducted. Very few studies measured zinc protoporphyrin concentration, adverse effects, prevalence of goitre and salt intake. One study measured serum iron concentration. No studies measured blood pressure or hepcidin concentration. What are the limitations of the evidence? We have relatively low confidence in the evidence for the outcomes: haemoglobin, urinary iodine, ferritin, and transferrin receptor concentration, and prevalence of iron deficiency anaemia. Not all studies provided data about all outcomes of interest; studies delivered the intervention differently; and studies were small, both in number and size. For the prevalence of anaemia, we are moderately confident in the evidence because studies used different ways of delivering the intervention. Care should be taken in interpreting our findings in relation to public health policy and programmes. Most studies were conducted in monitored research settings and double‐fortified salt was provided without an added cost. We are unsure if the effect we observed would be the same in real‐life (i.e. non‐research population), where purchasing double‐fortified salt could increase the cost. More studies looking at the effect of double‐fortified salt within real‐life settings are needed to understand the true effects of double‐fortified salt with greater certainty. Given the changing guidelines for salt intake, future studies should measure salt intake to understand if double‐fortified salt should be considered to prevent anaemia at the population level and how to integrate double‐fortified salt into the supply chain. How up to date is this evidence? The evidence is up to date to April 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Baxter, J-AB; Carducci, B; Kamali, M; Zlotkin, SH; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD013463.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "acb991ff-de1b-4c1f-95f2-e09ef525584c", "pmid": "", "title": "Nedocromil sodium for chronic asthma in children", "imported": false, "abstract": "Abstract - Background Currently inhaled corticosteroids are the main stay in the maintenance treatment of chronic asthma in children. Although inhaled corticosteroids play a crucial role in the management of childhood asthma, the long‐term side effects of inhaled corticosteroids used in the management of chronic asthma in children are not clearly known. Objectives The objective of this review is to compare the safety and efficacy of inhaled nedocromil sodium with placebo in the treatment of chronic asthma in children. Search methods We searched the Cochrane Airway Group trials register, review articles, and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. We also searched abstracts of major respiratory society meetings. The last search was carried out in November 2009. Selection criteria Randomised placebo controlled trials comparing nedocromil sodium to placebo in the treatment of chronic asthma in children (0 to 18 years). Data collection and analysis Both authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Fifteen trials (twelve parallel group studies; three crossover trials recruiting 1422 children (837 males and 585 females)) were included. The studies were generally of good methodological quality. Two large long term studies used nedocromil for six months and four to six years and showed conflicting results in symptom free days. Short term studies (duration between 4 weeks to 12 weeks) showed that nedocromil sodium produced some improvement in a number of efficacy measures compared to placebo including FEV 1 , FVC, FEV 1 % predicted, PC20 FEV 1 , evening PEF and symptom scores. The parent's assessment of efficacy was in favour of nedocromil (odds ratio (OR) 0.5 (95% CI 0.3 to 0.8). Nedocromil sodium has a good safety profile. The only significant side effect observed was unpleasant taste. There was little evidence for a clinically dose response effect and only a few studies recruited participants with severe asthma. Authors' conclusions A limited number of small studies have shown that nedocromil is of benefit in improving lung function and some measures of symptoms, but the evidence with regard to the primary outcome of the review was conflicting. Two long‐term trials did not show consistent effects on lung function outcomes, whereas several small short‐term trials have shown benefit in these outcomes. Differing severities at baseline may explain this difference with milder participants experiencing less benefit, although the discrepancy between study findings may also reflect publication bias. Nedocromil sodium is associated with a very good safety profile with no significant short term or long‐ term adverse side effects. Although nedocromil may have advantages over inhaled corticosteroids in terms of side effects, there is a need for head to head trials of nedocromil and inhaled corticosteroids to establish whether asthma control is similar, especially in mild asthma. It is not yet clear where nedocromil should sit in relation to other therapies in the treatment of asthma in children. Plain language summary Nedocromil sodium for chronic asthma in children Nedocromil (or Tilade) is a 'preventer' therapy used to treat chronic asthma in children. It is thought to be safer than inhaled steroids and can be used for the management of mild to moderate asthma. The review of studies including 15 trials and 1422 children found that there were some encouraging results in short term studies when nedocromil was compared on its own with placebo, particularly with regard to lung function tests. However, these results were not confirmed in one large, longer term study of four to six years duration, which did not show significant difference in the primary outcome of symptom free days. This study was conducted in children who had mild asthma. There may be a role for nedocromil in the management of moderate asthma, but it should be assessed in relation to inhaled steroids, whose efficacy is well‐established. This particularly important in symptomatic asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Sridhar, AV, McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD004108.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.728Z" }, { "id": "acbc009d-3e7c-4ca1-bb7f-f60b0eb183ff", "pmid": "", "title": "Nutritional support in children and young people with cancer undergoing chemotherapy", "imported": false, "abstract": "Abstract - Background It is well documented that malnutrition is a common complication of paediatric malignancy and its treatment. Malnutrition can often be a consequence of cancer itself or a result of chemotherapy. Nutritional support aims to reverse malnutrition seen at diagnosis, prevent malnutrition associated with treatment and promote weight gain and growth. The most effective and safe forms of nutritional support in children and young people with cancer are not known. Objectives To determine the effects of any form of parenteral (PN) or enteral (EN) nutritional support, excluding vitamin supplementation and micronutrient supplementation, in children and young people with cancer undergoing chemotherapy and to determine the effect of the nutritional content of PN and EN. This is an update of a previous Cochrane review. Search methods We searched the following databases for the initial review: CENTRAL ( The Cochrane Library , Issue 2, 2009), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), CINAHL (1982 to 2006), the National Research Register (2007) and Dissertations & Theses (2007). Experts in the field were also contacted for information on relevant trials. For this update, we searched the same electronic databases from 2006 to September 2013. We also scrutinised the reference lists of included articles to identify additional trials. Selection criteria Randomised or quasi‐randomised controlled trials comparing any form of nutritional support with another, or control, in children or young people with cancer undergoing chemotherapy. Data collection and analysis Two authors independently selected trials. At least two authors independently assessed quality and extracted data. We contacted trialists for missing information. Main results The current review included the eight trials from the initial review and six new trials which randomised 595 participants (< 21 years of age) with leukaemias or solid tumours undergoing chemotherapy. The trials were all of low quality with the exception of two of the trials looking at glutamine supplementation. One small trial found that compared to EN, PN significantly increased weight (mean difference (MD) 4.12, 95% CI 1.91 to 6.33), serum albumin levels (MD 0.70, 95% CI 0.14 to 1.26), calorie intake (MD 22.00, 95% CI 5.12 to 38.88) and protein intake (MD 0.80, 95% CI 0.45 to 1.15). One trial comparing peripheral PN and EN with central PN found that mean daily weight gain (MD ‐27.00, 95% CI ‐43.32 to ‐10.68) and energy intake (MD ‐15.00, 95% CI ‐26.81 to ‐3.19) were significantly less for the peripheral PN and EN group, whereas mean change in serum albumin was significantly greater for that group (MD 0.47, 95% CI 0.13 to 0.81, P = 0.008). Another trial with few participants found an increase in mean energy intake (% recommended daily amount) in children fed an energy dense feed compared to a standard calorie feed (MD +28%, 95% CI 17% to 39%). Three studies looked at glutamine supplementation. The evidence suggesting that glutamine reduces severity of mucositis was not statistically significant in two studies (RR 0.64, 95% CI 0.19 to 2.2 and RR 0.85, 95% CI 0.66 to 1.1) and differences in reduction of infection rates were also not significant in two studies (RR 1.0, 95% CI 0.72 to 1.4 and RR 0.98, 95% CI 0.63 to 1.51). Only one study compared olive oil based PN to standard lipid containing PN. Despite similar calorie contents in both feeds, the standard lipid formula lead to greater weight gain (MD ‐0.34 z‐scores, 95% CI ‐0.68 to 0.00). A single study compared standard EN with fructooligosaccharide containing EN. There was no difference in weight gain between groups (mean difference ‐0.12, 95% CI ‐0.57 to 0.33), with adverse effects (nausea) occurring equally between the groups (RR 0.92, 95% CI 0.48 to 1.74). Authors' conclusions There is limited evidence from individual trials to suggest that PN is more effective than EN in well‐nourished children and young people with cancer undergoing chemotherapy. The evidence for other methods of nutritional support remains unclear. Limited evidence suggests an energy dense feed increases mean daily energy intake and has a positive effect on weight gain. Evidence suggesting glutamine supplementation reduces incidence and severity of mucositis, infection rates and length of hospital stay is not statistically significant. Further research, incorporating larger sample sizes and rigorous methodology utilising valid and reliable outcome measures, is essential. Plain language summary Nutritional support in children and young people with cancer undergoing chemotherapy The provision of safe, appropriate and effective nutritional support for children and young people undergoing treatment for cancer is now well recognised as an important part of their care. It may help to reverse malnutrition seen at diagnosis, prevent malnutrition associated with the cancer, promote weight gain and growth and improve quality of life. Nutritional support may be provided by one of two methods: intravenous nutritional liquids delivered through a central or peripheral vein which bypass the gut (parenteral nutrition); or nutritional liquids or solids that pass through any part of the gut, regardless of method of delivery (e.g. orally or via a tube; enteral nutrition). We found evidence from one small trial to suggest that parenteral nutrition may result in an increase in weight, serum albumin levels and calorie and protein intake when compared to enteral nutrition (usual food intake). However, the effect of other methods of delivery of nutritional support remains unclear. Results from another small study suggested that the use of energy dense enteral feeds resulted in greater average daily energy intake and subsequently improved weight gain. Three studies looked at glutamine supplementation and did not show a benefit from its use. One study looked at the effect of using olive oil based parenteral feeds rather than those containing standard fats and found that it lead to less weight gain. One study considered the effect of adding fructooligosaccharide to enteral feeds and found that it did not effect the amount of weight gained or how often participants felt nauseated. No studies were identified that compared the nutritional content in either the PN or EN groups of studies. The trials were all of low quality and very different in terms of outcome measures used. In the future, much larger, rigorously conducted trials are needed in order to address this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Ward, EJ; Henry, LM; Friend, AJ; Wilkins, S; Phillips, RS", "articleTypes": [], "doi": "10.1002/14651858.CD003298.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "acd631ad-47a0-4b9a-8908-13c22e8a3f0a", "pmid": "", "title": "Glutamatergic drugs for schizophrenia", "imported": false, "abstract": "Abstract - Background It has been shown that central nervous system dopamine can play a major role in the pathophysiology of schizophrenia. Brain glutamate is thought to mediate symptoms in schizophrenia due to the influence of glutamate neurons on the dopaminergic transmission in the brain. It might be possible to decrease negative symptoms and the cognitive impairment of people with schizophrenia by treatment with glutamatergic drugs. Objectives To determine the efficacy of glutamatergic drugs in the treatment of schizophrenia. Search methods We searched the Cochrane Schizophrenia Group's Trials Register (May 2002 and October 2003), inspected references of all identified studies and contacted relevant authors. Selection criteria We included all randomised controlled trials in which glutamatergic medication was administered to people with schizophrenia. Data collection and analysis We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results We included eighteen short‐term trials with 358 randomised participants. The single studies were small with numbers of participants ranging between six and 51. All trials were short‐term trials with a maximum duration of 12 weeks. In all of these trials, glycine, D‐serine, D‐cycloserine, or ampakine CX516 was used to augment the effect of antipsychotic drugs. D‐cycloserine, a partial agonist of NMDA receptors' glycine site, seemed ineffective towards the symptoms of schizophrenia. NMDA receptor co‐agonists glycine and D‐serine showed some effects in reducing the negative symptoms of schizophrenia (n=132, SMD ‐0.66, CI ‐1.0 to ‐0.3, p=0.0004), but the magnitude of the effect was moderate. Furthermore, when responder rates rather than mean scores of negative symptoms were analysed the data were inconsistent: There was no difference in responder rates between glycine and the control in terms of more than 20% improvement of negative symptoms (n=62, RR 0.70, CI 0.3 to 1.71) and only a borderline significant superiority in terms of more than 50% improvement (n=62, RR 0.87, CI 0.8 to 1.00). There were also some effects in favour of glycine and/or D‐serine in terms of overall and general symptoms, but the results were again inconsistent and depended on the response definition applied. Available rating scale data on positive symptoms and cognitive functioning did not indicate a statistically significant effect of glycine or D‐serine. Authors' conclusions In general, all glutamatergic drugs appeared to be ineffective in further reducing positive symptoms of the disease when added to the existing antipsychotic treatment. Glycine and D‐serine may somewhat improve negative symptoms when added to regular antipsychotic medication, but the results were not fully consistent and data are too few to allow any firm conclusions. Many participants in the included trials were treatment‐resistant which may have reduced treatment response. Additional research on glutamatergic mechanisms of schizophrenia is needed. Plain language summary Glutamatergic drugs for schizophrenia Schizophrenia is a severe psychiatric disease characterised by positive symptoms such as hallucinations and delusions and negative symptoms such as blunted affect and emotional withdrawal. People with schizophrenia may also suffer from cognitive deficits. Current medication is effective in reducing positive symptoms, but negative and cognitive symptoms are fairly resistant to treatment. Antipsychotic drugs act mainly on the dopamine system in the brain, although other neurotransmitter systems may also play a role in schizophrenia. We sought to review all randomised trials that used glutamatergic drugs in the treatment of schizophrenia. This review shows that substances acting on the glutamate system may improve symptoms when added to regular antipsychotic medication, although the available evidence base is too limited to allow for any firm conclusions. Presently, glutamatergic drugs are not available for clinical use. Additional research is needed to determine their ultimate role in the treatment of schizophrenia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Tiihonen, J, Wahlbeck, K", "articleTypes": [], "doi": "10.1002/14651858.CD003730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.784Z" }, { "id": "ace4d756-20d8-4a3a-b383-203071fed177", "pmid": "", "title": "Influence of Medication Palatability on Prescribing Habits of Pediatric Prescribers", "imported": false, "abstract": "The purpose of this study is to see if a medication taste test influences the prescribing habits of pediatric prescribers at Mayo Clinic.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.233Z" }, { "id": "acfffbe7-ab25-4782-8cf5-4b797f42021a", "pmid": "", "title": "Acute Effects of the Two Alternative Sweeteners D-allulose and Erythritol on Gastrointestinal Hormone Secretion and Glycemic Control", "imported": false, "abstract": "The aim of this project is to investigate the effect of intragastric (ig) D-allulose on metabolic parameters in general and to investigate the effect of sweet taste receptor blockade on GI hormone responses, glycemic control, gastric emptying (GE) rates and appetite-related sensations to ig administration of erythritol and D-allulose.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "ad429471-494d-45ed-9084-8da1c2456179", "pmid": "", "title": "Antibiotics for the induction and maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Antibiotics have been considered to treat ulcerative colitis (UC) due to their antimicrobial properties against intestinal bacteria linked to inflammation. However, there are concerns about their efficacy and safety. Objectives To determine whether antibiotic therapy is safe and effective for the induction and maintenance of remission in people with UC. Search methods We searched five electronic databases on 10 December 2021 for randomised controlled trials (RCTs) comparing antibiotic therapy to placebo or an active comparator. Selection criteria We considered people with UC of all ages, treated with antibiotics of any type, dose, and route of administration for inclusion. Induction studies required a minimum duration of two weeks for inclusion. Maintenance studies required a minimum duration of three months to be considered for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcome for induction studies was failure to achieve remission and for maintenance studies was relapse, as defined by the primary studies. Main results We included 12 RCTs (847 participants). One maintenance of remission study used sole antibiotic therapy compared with 5‐aminosalicylic acid (5‐ASA). All other trials used concurrent medications or standard care regimens and antibiotics as an adjunct therapy or compared antibiotics with other adjunct therapies to examine the effect on induction of remission. There is high certainty evidence that antibiotics (154/304 participants) compared to placebo (175/304 participants) result in no difference in failure to achieve clinical remission (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.06). A subgroup analysis found no differences when steroids, steroids plus 5‐ASA, or steroids plus 5‐ASA plus probiotics were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (102/168 participants) compared to placebo (121/175 participants) may result in no difference in failure to achieve clinical response (RR 0.75, 95% CI 0.47 to 1.22). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (6/342 participants) compared to placebo (5/349 participants) may result in no difference in serious adverse events (RR 1.19, 95% CI 0.38 to 3.71). A subgroup analysis found no differences when steroids were additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (3/342 participants) compared to placebo (1/349 participants) may result in no difference in withdrawals due to adverse events (RR 2.06, 95% CI 0.27 to 15.72). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were additional therapies to antibiotics and placebo. It is unclear if there is any difference between antibiotics in combination with probiotics compared to no treatment or placebo for failure to achieve clinical remission (RR 0.68, 95% CI 0.39 to 1.19), serious adverse events (RR 1.00, 95% CI 0.07 to 15.08), or withdrawals due to adverse events (RR 1.00, 95% CI 0.07 to 15.08). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to achieve clinical remission (RR 2.20, 95% CI 1.17 to 4.14). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to probiotics for failure to achieve clinical remission (RR 0.47, 95% CI 0.23 to 0.94). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to maintain clinical remission (RR 0.71, 95% CI 0.47 to 1.06). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to no treatment for failure to achieve clinical remission in a mixed population of people with active and inactive disease (RR 0.56, 95% CI 0.29 to 1.07). The certainty of the evidence is very low. For all other outcomes, no effects could be estimated due to a lack of data. Authors' conclusions There is high certainty evidence that there is no difference between antibiotics and placebo in the proportion of people who achieve clinical remission at the end of the intervention period. However, there is evidence that there may be a greater proportion of people who achieve clinical remission and probably a greater proportion who achieve clinical response with antibiotics when compared with placebo at 12 months. There may be no difference in serious adverse events or withdrawals due to adverse events between antibiotics and placebo. No clear conclusions can be drawn for any other comparisons. A clear direction for future research appears to be comparisons of antibiotics and placebo (in addition to standard therapies) with longer‐term measurement of outcomes. Additionally. As there were single studies of other head‐to‐head comparisons, there may be scope for future studies in this area. Plain language summary The use of antibiotics in the treatment of ulcerative colitis What was the aim of this review? This Cochrane Review aimed to determine whether antibiotics are useful and safe for people with ulcerative colitis (UC) in achieving or maintaining remission. Key messages We found that antibiotics, when added to standard therapies, are similar to placebo in how often they fail to achieve remission or disease improvement for people with UC, measured up to three months from taking them. We found that antibiotics when compared to placebo may be useful in achieving remission or some improvement of UC symptoms, measured at 12 months from taking them. In terms of safety, the evidence is of low certainty, but antibiotics may be as safe as placebo. We have confidence in the findings up to three months, but have less confidence in the evidence at 12 months due to low numbers of study participants. What is ulcerative colitis? UC is a chronic (long term) inflammatory disease that affects the large bowel. The most common symptoms include bloody diarrhoea, abdominal pain, and a sudden almost uncontrollable urge to pass stool. Some people have other symptoms including sore joints, mouth sores, and inflammation in their eyes. When someone is experiencing symptoms of UC, they are said to have 'active' disease. When symptoms improve with treatment, the disease is said to be responding to therapy. When symptoms stop, the disease is said to be in 'remission'. People with UC in remission are often given therapy with medicines to try and prolong (maintain) their remission or response to therapy. What did the review study? This review studied the use of antibiotics in the treatment of UC. Eleven studies considered antibiotics as a therapy for achieving remission and one study as therapy for maintaining remission. Antibiotics could theoretically be helpful as they might be able to fight harmful bacteria in the gut that are thought to be a partial cause for the presence of UC symptoms. Currently, most doctors do not recommend the use of antibiotics unless the patient has an infection. What were the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing antibiotics with another treatment or dummy treatment. We found 12 RCTs including 847 participants. The trials looked at people of all ages; using different types and doses of antibiotics; and at antibiotics taken as tablets, injections, or any other way. The main results from our review are as follows. 1. Antibiotics, when added to standard therapies, are no different from placebo in failing to achieve remission or improve disease symptoms for people with UC when measured up to three months from taking them. 2. Antibiotics probably fail less than placebo in achieving remission or some improvement of UC symptoms measured at 12 months from taking them. 3. In terms of safety, antibiotics may be similar to placebo, but the evidence is of low certainty. 4. We are uncertain about how antibiotics compare to other treatments because there is not enough good evidence to make a judgement. Conclusion There is no difference between antibiotics and placebo when added to standard therapies to achieve remission or improvement of symptoms in the short term. However, they may help to lessen the number of people who do not achieve remission, and they probably lead to fewer numbers of people who have not achieved improvement of symptoms at 12 months. No conclusions can be drawn on other treatments or safety due to lack of evidence, even though there may be a possibility that antibiotics are as safe as placebo. Further research would be needed to clarify the usefulness of antibiotics in the treatment of UC; however, such studies should focus on longer‐term outcomes given the findings of this review. How up‐to‐date is this review? This review is up‐to‐date as of December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Gordon, M, Sinopoulou, V, Grafton-Clarke, C, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.084Z" }, { "id": "ad69cf6c-bd38-4247-b54e-a2e7a0834da9", "pmid": "", "title": "Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve due to viral infection by the herpes zoster virus are implicated in the aetiology and clinical manifestation of Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Corticosteroids, with their powerful anti‐inflammatory effect, have a potential role to play in the reduction or minimisation of nerve damage when administered together with antiviral therapy, and therefore may improve the outcome for patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of corticosteroids as an adjuvant to antiviral therapy in adult patients with Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Search methods We searched the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 4, 2007), MEDLINE (1950 to December 2007) and EMBASE (1974 to December 2007), CINAHL (1982 to December 2007), LILACS, KoreaMed, IndMed, PakMediNet, ZETOC, Cambridge Scientific Abstracts (Conference Proceedings Database), ISI Proceedings (Web of Science), the National Research Register (NRR), the UK Clinical Research Network Portfolio Database (UKCRN), the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Research Findings Register (ReFeR) and the metaRegister of Controlled Trials (mRCT). Selection criteria All randomised controlled trials in which corticosteroids (by any route of administration at any dosage) were given as an adjuvant to antiviral agents in the treatment of Ramsay Hunt syndrome. Data collection and analysis Two reviewers independently assessed eligibility and trial quality of the available studies, whether they were published or unpublished. No trials were found and therefore no data were analysed. Main results This is an empty review as no trials were found that fulfilled the inclusion criteria. Authors' conclusions Since no randomised controlled trials investigating the use of corticosteroids as an adjuvant to antiviral treatment in Ramsay Hunt syndrome were identified, such studies are needed to assess the effects of such therapy. Plain language summary Corticosteroids used in addition to antiviral drugs in patients with Ramsay Hunt syndrome Ramsay Hunt syndrome (also known as herpes zoster oticus) consists of weakness of the face due to infection with the varicella zoster virus. Five cases arise per 100,000 of the population per year in the US. It is more common among those over 60 and rare in children. Other symptoms may include severe ear pain and small blisters on the outer ear or in the mouth. Prompt diagnosis and treatment (ideally within 72 hours of the onset of symptoms) are crucial to secure the best outcomes. In cases where treatment has been started within this time period, facial weakness recovers in up to 75% of patients. Standard treatment is with antiviral therapy (most commonly acyclovir). Corticosteroids are known for their anti‐inflammatory properties and are commonly used together with antivirals to reduce the inflammation in the facial nerve. This is thought to be the cause of the facial weakness. The aim of the review was to see if corticosteroids, used at the same time as antiviral drugs, improved outcomes in patients with Ramsay Hunt syndrome. However the review found no trials matching the inclusion criteria, and no conclusions can be drawn about the effectiveness of using corticosteroids in this way. It is recommended that high‐quality randomised controlled trials be undertaken to address this issue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T, Doree, C, Chamberlain, IJ, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006852.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.759Z" }, { "id": "ad6dadd4-9b00-4b35-abbb-a14fb4cc2772", "pmid": "", "title": "Fortification of staple foods with vitamin A for vitamin A deficiency", "imported": false, "abstract": "Abstract - Background Vitamin A deficiency is a significant public health problem in many low‐ and middle‐income countries, especially affecting young children, women of reproductive age, and pregnant women. Fortification of staple foods with vitamin A has been used to increase vitamin A consumption among these groups. Objectives To assess the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving health‐related outcomes in the general population older than two years of age. Search methods We searched the following international databases with no language or date restrictions: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library; MEDLINE and MEDLINE In Process OVID; Embase OVID; CINAHL Ebsco; Web of Science (ISI) SCI, SSCI, CPCI‐exp and CPCI‐SSH; BIOSIS (ISI); POPLINE; Bibliomap; TRoPHI; ASSIA (Proquest); IBECS; SCIELO; Global Index Medicus ‐ AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched clinicaltrials.gov and the International Clinical Trials Registry Platform to identify ongoing and unpublished studies. The date of the last search was 19 July 2018. Selection criteria We included individually or cluster‐randomised controlled trials (RCTs) in this review. The intervention included fortification of staple foods (sugar, edible oils, edible fats, maize flour or corn meal, wheat flour, milk and dairy products, and condiments and seasonings) with vitamin A alone or in combination with other vitamins and minerals. We included the general population older than two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two authors independently screened and assessed eligibility of studies for inclusion, extracted data from included studies and assessed their risk of bias. We used standard Cochrane methodology to carry out the review. Main results We included 10 randomised controlled trials involving 4455 participants. All the studies were conducted in low‐ and upper‐middle income countries where vitamin A deficiency was a public health issue. One of the included trials did not contribute data to the outcomes of interest. Three trials compared provision of staple foods fortified with vitamin A versus unfortified staple food, five trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus unfortified staple foods, and two trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus no intervention. No studies compared staple foods fortified with vitamin A alone versus no intervention. The duration of interventions ranged from three to nine months. We assessed six studies at high risk of bias overall. Government organisations, non‐governmental organisations, the private sector, and academic institutions funded the included studies; funding source does not appear to have distorted the results. Staple food fortified with vitamin A versus unfortified staple food We are uncertain whether fortifying staple foods with vitamin A alone makes little or no difference for serum retinol concentration (mean difference (MD) 0.03 μmol/L, 95% CI −0.06 to 0.12; 3 studies, 1829 participants; I² = 90%, very low‐certainty evidence ). It is uncertain whether vitamin A alone reduces the risk of subclinical vitamin A deficiency (risk ratio (RR) 0.45, 95% CI 0.19 to 1.05; 2 studies; 993 participants; I² = 33%, very low‐certainty evidence ). The certainty of the evidence was mainly affected by risk of bias, imprecision and inconsistency. It is uncertain whether vitamin A fortification reduces clinical vitamin A deficiency, defined as night blindness (RR 0.11, 95% CI 0.01 to 1.98; 1 study, 581 participants, very low‐certainty evidence ). The certainty of the evidence was mainly affected by imprecision, inconsistency, and risk of bias. Staple foods fortified with vitamin A versus no intervention No studies provided data for this comparison. Staple foods fortified with vitamin A plus other micronutrients versus same unfortified staple foods Fortifying staple foods with vitamin A plus other micronutrients may not increase the serum retinol concentration (MD 0.08 μmol/L, 95% CI ‐0.06 to 0.22; 4 studies; 1009 participants; I² = 95%, low‐certainty evidence ). The certainty of the evidence was mainly affected by serious inconsistency and risk of bias. In comparison to unfortified staple foods, fortification with vitamin A plus other micronutrients probably reduces the risk of subclinical vitamin A deficiency (RR 0.27, 95% CI 0.16 to 0.49; 3 studies; 923 participants; I² = 0%; moderate‐certainty evidence ). The certainty of the evidence was mainly affected by serious risk of bias. Staple foods fortified with vitamin A plus other micronutrients versus no intervention Fortification of staple foods with vitamin A plus other micronutrients may increase serum retinol concentration (MD 0.22 μmol/L, 95% CI 0.15 to 0.30; 2 studies; 318 participants; I² = 0%; low‐certainty evidence ). When compared to no intervention, it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency (RR 0.71, 95% CI 0.52 to 0.98; 2 studies; 318 participants; I² = 0%; very low‐certainty evidence ) . The certainty of the evidence was affected mainly by serious imprecision and risk of bias. No trials reported on the outcomes of all‐cause morbidity, all‐cause mortality, adverse effects, food intake, congenital anomalies (for pregnant women), or breast milk concentration (for lactating women). Authors' conclusions Fortifying staple foods with vitamin A alone may make little or no difference to serum retinol concentrations or the risk of subclinical vitamin A deficiency. In comparison with provision of unfortified foods, provision of staple foods fortified with vitamin A plus other micronutrients may not increase serum retinol concentration but probably reduces the risk of subclinical vitamin A deficiency. Compared to no intervention, staple foods fortified with vitamin A plus other micronutrients may increase serum retinol concentration, although it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency as the certainty of the evidence has been assessed as very low. It was not possible to estimate the effect of staple food fortification on outcomes such as mortality, morbidity, adverse effects, congenital anomalies, or breast milk vitamin A, as no trials included these outcomes. The type of funding source for the studies did not appear to distort the results from the analysis. Plain language summary Fortification of staple foods with vitamin A for vitamin A deficiency What is the aim of the review? We wanted to investigate the effects of fortifying common staple foods with vitamin A, with or without other micronutrients, in populations two years of age and older. Staple foods used in public health fortification programmes have included refined sugar, edible vegetable oils and fats, rice, wheat flour, maize flours and corn meals, condiments and seasonings, and powdered or liquid milk. We searched for all the possible information on this question and found 10 eligible studies. Key messages Fortifiying staple foods with vitamin A plus other micronutrients may increase the serum retinol concentrations (an indicator of vitamin A stores in the body) and reduce the risk of subclinical vitamin A deficiency (those without clinical eye signs for risk of blinding undernutrition, detected through a serum/plasma retinol 70 μmol/L or less). However, adding vitamin A alone to the staple foods may have little or no effect on vitamin A status or deficiency. What was studied in this review? Vitamin A is an essential nutrient vital for good vision, cell growth, and immunity. Many people in low‐ and middle‐income countries have vitamin A deficiency, especially young children, pregnant women, and women of reproductive age, who may not get enough to eat to cover their increased nutritional demands. Long‐term deprivation of vitamin A could lead to visual impairment, blindness, common infections of the upper respiratory tract, diarrhoea, and measles. There are several strategies to combat the vitamin A deficiency, such as supplementing the diet with vitamin A capsules, adding vitamins and minerals in powder form to energy‐containing foods, eating more vitamin A‐rich foods, and fortifying staple foods with vitamin A during processing. This review focused on the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving the health of the general population older than two years of age. What are the main results of the review? We found 10 relevant studies (involving 4455 participants) from China, India, the Philippines, Bangladesh, Thailand, and Mexico. Three studies provided one study group with staple foods fortified with vitamin A alone, and another group with the same unfortified staple foods. Five studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus the same unfortified staple food, and two studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus no intervention. No studies compared staple foods fortified with vitamin A versus no intervention. Government agencies, private agencies, non‐governmental organisations, the private sector, and academic institutions funded the studies. The source of funding does not appear to have distorted the results. The effect of fortification of staple foods with vitamin A alone on vitamin A stores and on subclinical vitamin A deficiency is uncertain. It is uncertain whether this intervention might reduce clinical vitamin A deficiency (night blindness). We are moderately confident that fortifying staple foods with vitamin A and other micronutrients may not improve vitamin A status. However, children and adolescents in low‐ and middle‐income populations who eat foods fortified with vitamin A and other micronutrients may have a lower risk of subclinical vitamin A deficiency compared to those receiving unfortified staple foods. We do not know how vitamin A fortification affects other health indicators, such as the rate of disease in the population, mortality, adverse effects, food intake, birth defects (for pregnant women), or breast milk concentration for lactating women. We considered six of the included studies to be of poor methodological quality. The review authors searched for published studies up to July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hombali, AS, Solon, JA, Venkatesh, BT, Nair, NS, Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010068.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.809Z" }, { "id": "ad7917a9-001d-4f4e-b003-0741f066b0e4", "pmid": "", "title": "Short- and Long-term Effects of Once Weekly Semaglutide 2.4 mg on Appetite, Eating Behavior, and Psychosocial Status", "imported": false, "abstract": "This study will evaluate the effect of semaglutide on eating behavior, appetite (hunger/fullness), and food liking in the long-term, as compared to placebo. All participants will receive lifestyle modification (diet and exercise) counseling, and will be prescribed the FDA-approved weight loss medication, semaglutide, or placebo (an inactive saline solution) for 72 weeks.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.251Z" }, { "id": "adbd7a84-5046-455d-9a8c-9d3174531fb2", "pmid": "", "title": "Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries", "imported": false, "abstract": "Abstract - Background Protein Energy Malnutrition is an important cause of child morbidity and mortality in middle‐ and low‐income countries. It has been suggested that excessive free radical activity may be responsible for the clinical manifestation of kwashiorkor. Antioxidants may be able to curb excessive free radical activity and prevent the development of kwashiorkor in susceptible children. Objectives To evaluate the benefits of supplementation of vitamin E, selenium, cysteine and riboflavin (alone or in combination) in preventing kwashiorkor. Search methods We conducted searches of CENTRAL 2009 ( The Cochrane Library 2009 Issue 2), MEDLINE 1966 to 2009, EMBASE 1980 to 2009, CINAHL 1982 to 2009, LILACS 1982 to 2009, Meta register of Controlled trials, Open Sigle, African Index Medicus. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating vitamin E, selenium, cysteine and riboflavin alone or in combination in healthy pre‐school children in middle‐ and low‐income countries. Data collection and analysis Two authors extracted and independently analysed data. Main results One cluster‐RCT including 2372 children met our inclusion criteria. Children were randomised, based on household, either to a supplement containing all four micronutrients or to placebo. No statistically significant difference in the incidence of kwashiorkor between the intervention and control groups could be demonstrated at 20 weeks (RR 1.70; 95% CI 0.98 to 2.42). Nor could any statistically significant difference in all‐cause mortality be demonstrated (RR 0.75; 95% CI 0.17 to 3.36). Authors' conclusions Based on the one available trial, we could draw no firm conclusion for the effectiveness of supplementary antioxidant micronutrients for the prevention of kwashiorkor in pre‐school children. Plain language summary Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries Undernutrition is one of the leading underlying causes of childhood morbidity and mortality in developing countries. Providing antioxidants that would help curb excess free radicals in the body may help prevent the development of kwashiorkor. We identified one cluster‐RCT that attempted to investigate this. Based on the published evidence reviewed, we could draw no firm conclusions of the benefits of supplementary antioxidants for the prevention of kwashiorkor in pre‐school children. There is a need for further research in this area to be certain if antioxidant supplementation can help prevent kwashiorkor in young children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Odigwe, CC, Smedslund, G, Ejemot‐Nwadiaro, RI, Anyanechi, CC, Krawinkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD008147.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.816Z" }, { "id": "add9d417-312e-418f-a408-85a8a886cd6e", "pmid": "", "title": "Chinese herbal medicine for menopausal symptoms", "imported": false, "abstract": "Abstract - Background Chinese herbal medicine (CHM) usage is expected to increase as women suffering from menopausal symptoms are seeking alternative therapy due to concerns from the adverse effects (AEs) associated with hormone therapy (HT). Scientific evidence for their effectiveness and safety is needed. Objectives To evaluate the effectiveness and safety of CHM in the treatment of menopausal symptoms. Search methods We searched the Gynaecology and Fertility Group's Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), MEDLINE, Embase, CINAHL, AMED, and PsycINFO (from inception to March 2015). Others included Current Control Trials, Citation Indexes, conference abstracts in the ISI Web of Knowledge, LILACS database, PubMed, OpenSIGLE database, and China National Knowledge Infrastructure database (CNKI, 1999 to 2015). Other resources included reference lists of articles as well as direct contact with authors. Selection criteria Randomised controlled trials (RCTs) comparing the effectiveness of CHM with placebo, HT, pharmaceutical drugs, acupuncture, or another CHM formula in women over 18 years of age, and suffering from menopausal symptoms. Data collection and analysis Two review authors independently assessed 864 studies for eligibility. Data extractions were performed by them with disagreements resolved through group discussion and clarification of data or direct contact with the study authors. Data analyses were performed in accordance with Cochrane Collaboration guidelines. Main results We included 22 RCTs (2902 women). Participants were from different ethnic backgrounds with the majority of Chinese origin. When CHM was compared with placebo (eight RCTs), there was little or no evidence of a difference between the groups for the following pooled outcomes: hot flushes per day (MD 0.00, 95% CI ‐0.88 to 0.89; 2 trials, 199 women; moderate quality evidence); hot flushes per day assessed by an overall hot flush score in which a difference of one point equates to one mild hot flush per day (MD ‐0.81 points, 95% CI ‐2.08 to 0.45; 3 RCTs, 263 women; low quality evidence); and overall vasomotor symptoms per month measured by the Menopause‐Specific Quality of Life questionnaire (MENQOL, scale 0 to 6) (MD ‐0.42 points; 95% CI ‐1.52 to 0.68; 3 RCTs, 256 women; low quality evidence). In addition, results from individual studies suggested there was no evidence of a difference between the groups for daily hot flushes assessed by severity (MD ‐0.70 points, 95% CI ‐1.00, ‐0.40; 1 RCT, 108 women; moderate quality evidence); or overall monthly hot flushes scores (MD ‐2.80 points, 95% CI ‐8.93 to 3.33; 1 RCT, 84 women; very low quality evidence); or overall daily night sweats scores (MD 0.07 points, 95% CI ‐0.19 to 0.33, 1 RCT, 64 women; low quality evidence); or overall monthly night sweats scores (MD 1.30 points, 95% CI ‐1.76 to 4.36, 1 RCT, 84 women; very low quality evidence). However one study using the Kupperman Index reported that overall monthly vasomotor symptom scores were lower in the CHM group (MD ‐4.79 points, 95% CI ‐5.52 to ‐4.06; 1 RCT, 69 women; low quality evidence). When CHM was compared with hormone therapy (HT) (10 RCTs), only two RCTs reported monthly vasomotor symptoms using MENQOL. It was uncertain whether CHM reduces vasomotor symptoms (MD 0.47 points, 95% CI ‐0.50 to 1.44; 2 RCTs, 127 women; very low quality evidence). Adverse effects were not fully reported in the included studies. Adverse events reported by women taking CHM included mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects were inconclusive because of imprecise estimates of effects: CHM versus placebo (RR 1.51; 95% CI 0.69 to 3.33; 7 trials, 705 women; I² = 40%); CHM versus HT (RR 0.96; 95% CI 0.66 to 1.39; 2 RCTs, 864 women; I² = 0%); and CHM versus specific conventional medications (such as Fluoxetine and Estazolam) (RR 0.20; 95% CI 0.03 to 1.17; 2 RCTs, 139 women; I² = 61%). Authors' conclusions We found insufficient evidence that Chinese herbal medicines were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Effects on safety were inconclusive. The quality of the evidence ranged from very low to moderate; there is a need for well‐designed randomised controlled studies. Plain language summary Title: Chinese herbal medicines for menopausal symptoms Review Question: Are Chinese herbal medicines effective and safe for relieving menopausal symptoms? Background: Menopause usually takes place when a woman is around 51 years of age. Women can experience symptoms such as hot flushes, sweats, poor sleep, joint pains, anxiousness, dry skin and vagina when the organs which produce female hormones slow down. Usually hormone therapy (HT) is prescribed to reduce the symptoms. Due to concerns on long term use of HT resulting in adverse effects, women have been looking for alternative treatments to relieve their symptoms. Chinese herbal medicines (CHM) is one of the popular choices. Although CHM has been used for a very long time clinically, its effectiveness and long‐term safety remained unanswered from a scientific perspective. Study characteristics: This review examined 22 randomised clinical trials where 2902 women took part in the studies; 1499 in the CHM group and 1403 in the control group which might include a placebo (non‐active compound made to look, taste and smell the same as the study compound) or a drug or HT or another CHM formula (different from the one being tested). Most of the studies had a trial period for 12 weeks. The data are current to March 2015. Key results: We found insufficient evidence that CHM were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Adverse effects were not well reported, some women taking CHM reported mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects on safety were inconclusive. Quality of the evidence: The quality of the evidence ranged from very low to moderate. The studies did not produce good quality evidence to allow the authors to draw a conclusive statement regarding the effectiveness or safety of CHM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Zhu, X, Liew, Y, Liu, ZL", "articleTypes": [], "doi": "10.1002/14651858.CD009023.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.737Z" }, { "id": "adf7c050-cd87-42e0-854b-dce4b8ad82bf", "pmid": "", "title": "Fortification of staple foods with zinc for improving zinc status and other health outcomes in the general population", "imported": false, "abstract": "Abstract - Background Zinc deficiency is a global nutritional problem, particularly in children and women residing in settings where diets are cereal based and monotonous. It has several negative health consequences. Fortification of staple foods with zinc may be an effective strategy for preventing zinc deficiency and improving zinc‐related health outcomes. Objectives To evaluate the beneficial and adverse effects of fortification of staple foods with zinc on health‐related outcomes and biomarkers of zinc status in the general population. Search methods We searched the following databases in April 2015: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3 of 12, 2015, the Cochrane Library), MEDLINE & MEDLINE In Process (OVID) (1950 to 8 April 2015), EMBASE (OVID) (1974 to 8 April 2015), CINAHL (1982 to April 2015), Web of Science (1900 to 9 April 2015), BIOSIS (1969 to 9 April 2015), POPLINE (1970 to April 2015), AGRICOLA, OpenGrey, BiblioMap, and Trials Register of Promoting Health Interventions (TRoPHI), besides regional databases (April 2015) and theses. We also searched clinical trial registries (17 March 2015) and contacted relevant organisations (May 2014) in order to identify ongoing and unpublished studies. Selection criteria We included randomised controlled trials, randomised either at the level of the individual or cluster. We also included non‐randomised trials at the level of the individual if there was a concurrent comparison group. We included non‐randomised cluster trials and controlled before‐after studies only if there were at least two intervention sites and two control sites. Interventions included fortification (central/industrial) of staple foods (cereal flours, edible fats, sugar, condiments, seasonings, milk and beverages) with zinc for a minimum period of two weeks. Participants were members of the general population who were over two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies, and assessed the risk of bias of the included studies. Main results We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Four trials compared the effect of zinc‐fortified staple foods with unfortified foods (comparison 1), and four compared zinc‐fortified staple foods in combination with other nutrients/factors with the same foods containing other nutrients or factors without zinc (comparison 2). The interventions lasted between one and nine months. We categorised most trials as having unclear or high risk of bias for randomisation, but low risk of bias for blinding and attrition. None of the studies in comparison 1 reported data on zinc deficiency. Foods fortified with zinc increased the serum or plasma zinc levels in comparison to foods without added zinc (mean difference (MD) 2.12 µmol/L, 95% confidence interval (CI) 1.25 to 3.00 µmol/L; 3 studies; 158 participants; low‐quality evidence). Participants consuming foods fortified with zinc versus participants consuming the same food without zinc had similar risk of underweight (average risk ratio 3.10, 95% CI 0.52 to 18.38; 2 studies; 397 participants; low‐quality evidence) and stunting (risk ratio (RR) 0.88, 95% CI 0.36 to 2.13; 2 studies; 397 participants; low‐quality evidence). A single trial of addition of zinc to iron in wheat flour did not find a reduction in proportion of zinc deficiency (RR 0.17, 95% CI 0.01 to 3.94; very low‐quality evidence). We did not find a difference in serum or plasma zinc levels in participants consuming foods fortified with zinc plus other micronutrients when compared with participants consuming the same foods with micronutrients but no added zinc (MD 0.03 µmol/L, 95% CI ‐0.67 to 0.72 µmol/L; 4 studies; 250 participants; low‐quality evidence). No trial in comparison 2 provided information about underweight or stunting. There was no reported adverse effect of fortification of foods with zinc on indicators of iron or copper status. Authors' conclusions Fortification of foods with zinc may improve the serum zinc status of populations if zinc is the only micronutrient used for fortification. If zinc is added to food in combination with other micronutrients, it may make little or no difference to the serum zinc status. Effects of fortification of foods with zinc on other outcomes including zinc deficiency, children’s growth, cognition, work capacity of adults, or on haematological indicators are unknown. Given the small number of trials and participants in each trial, further investigation of these outcomes is required. Plain language summary The effects of fortification of common foods with zinc on health outcomes Background It is believed that zinc deficiency is widespread globally, particularly in children and women living in low‐ and middle‐income countries. Cereal‐based foods are rich in dietary fibre and phytates, which reduce absorption of zinc from the intestine. As people in low‐income households eat a lot of cereal‐based foods, they are more likely to develop zinc deficiency. Fortification of common staple foods with zinc alone or in combination with other vitamins and minerals has been proposed as an intervention to increase intake of zinc in populations who consume these foods. Review question We evaluated the effects of fortification of staple foods with zinc on blood zinc levels and health‐related outcomes in the general population above two years of age. Study characteristics We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Key results and quality of the evidence The effect of fortification of foods with zinc on incidence of zinc deficiency is uncertain. Fortification of foods with zinc may slightly improve the blood zinc levels of populations if zinc is the only micronutrient used for fortification. Zinc added to food in combination with other micronutrients may make little or no difference to blood zinc levels. The fortification of foods with zinc may make little or no difference on incidence of underweight or stunting. The effects of fortification of foods with zinc on other outcomes, including wasting and weight/height, are unknown. Fortification of foods with zinc does not seem to have any adverse effect on indicators of iron or copper status. Most studies included in this review involved a small number of participants and were judged to be at low or unclear risk of bias. There were also some inconsistencies in the results across different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Shah, D; Sachdev, HS; Gera, T; De‐Regil, LM; Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010697.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "adfb5d8b-4a96-4bcc-bffb-7316d5d738d2", "pmid": "", "title": "Topical silver diamine fluoride (SDF) for preventing and managing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is the world's most prevalent disease. Untreated caries can cause pain and negatively impact psychosocial health, functioning, and nutrition. It is important to identify cost‐effective, easy‐to‐use agents, which can prevent or arrest caries. This review evaluates silver diamine fluoride (SDF). Objectives To assess the effects of silver diamine fluoride for preventing and managing caries in primary and permanent teeth (coronal and root caries) compared to any other intervention including placebo or no treatment. Search methods We searched CENTRAL, MEDLINE, Embase, Cochrane Oral Health's Trial Register and two clinical trials registers in June 2023. Selection criteria We included randomised controlled trials (RCTs), with parallel‐group or split‐mouth design, in children and adults (with or without carious lesions) that compared SDF with placebo or no treatment; different frequencies, concentrations or duration of SDF; or any other intervention. Data collection and analysis We used standard methodological procedures expected by Cochrane, and GRADE to assess the certainty of the evidence. We collected data for primary caries prevention (change in caries increment), arrest of carious lesions, secondary prevention of caries (lesions do not progress from initial classification), adverse effects, dental pain or sensitivity, and aesthetics at the end of study follow‐up. Main results We included 29 RCTs (13,036 participants; 12,020 children, 1016 older adults). We summarise outcome data for the five most clinically relevant comparisons. All studies included high risks of bias, and some findings were imprecise (e.g. because of small sample sizes). SDF versus placebo or no treatment (14 studies; 2695 children, 905 older adults) Compared to placebo or no treatment, SDF may help prevent new caries in the primary dentition (1 study, 373 participants), or on the coronal surfaces of permanent dentition (1 study, 373 participants) but the evidence is very uncertain. SDF likely prevents new root caries (mean difference (MD) −0.79 surfaces, 95% confidence interval (CI) −1.40 to −0.17; 3 studies, 439 participants; moderate‐certainty evidence). SDF may help arrest caries in the primary dentition (MD 0.86 surfaces, 95% CI 0.39 to 1.33; 2 studies, 841 participants; low‐certainty evidence) and the permanent dentition (coronal: 1 study, 373 participants; root: 1 study, 158 participants) but the evidence is very uncertain. The evidence is very uncertain for secondary prevention of caries (primary dentition: 1 study, 128 participants; permanent dentition (coronal): 1 study, 663 participants), for adverse effects (5 studies, 1299 participants), and aesthetics (1 study, 43 participants). Different approaches to SDF application (5 studies, 1808 children) Studies compared different frequencies or intervals of application, different concentrations of SDF, and different durations of treatment. Some studies included multiple comparisons of different approaches. Because of the different approaches, we could not combine findings from these studies. Due to very low‐certainty evidence, we were unsure whether any approach to SDF application was better than another for caries arrest (4 studies, including 8 comparisons of different approaches, 1360 participants); secondary prevention of caries (1 study, 203 participants), or led to differences in adverse effects (3 studies, 1121 children) or aesthetics (1 study, 119 children). SDF versus fluoride varnish (8 studies, 2868 children, 223 older adults) Compared to flouride varnish, SDF may result in little or no difference to the prevention of new caries in the primary dentition (MD 0.00, 95% CI ‐0.26 to 0.26; 1 study, 434 participants; low‐certainty evidence). The evidence is very uncertain for this outcome measure in the permanent dentition (coronal: 1 study, 237 participants; root: 1 study, 100 participants; very low‐certainty evidence). Due to very low‐certainty evidence, we were unsure whether or not there were any differences between flouride varnish (applied weekly for three applications) and SDF for caries arrest and secondary prevention of caries in the primary dentition (1 study, 309 participants). Similarly, we were unsure of adverse effects (3 studies, 980 children), dental pain or sensitivity (1 study, 62 children), or aesthetics (1 study, 263 children). SDF versus sealants and resin infiltration (2 studies, 343 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other for primary prevention of caries in permanent dentition (coronal: 1 study, 242 participants), or adverse effects (2 studies, 336 participants). SDF versus atraumatic restorative treatment (ART) with glass ionomer cement (GIC) or GI material (4 studies, 610 children) Very low‐certainty evidence in this comparison meant we were unsure if either treatment was better than the other at arresting caries in the primary dentition (1 study, 143 participants). We were also unsure whether there were any differences between treatments in adverse effects (3 studies, 482 participants), dental pain or sensitivity (1 study, 234 participants), or aesthetics (2 studies, 248 participants). Authors' conclusions In the primary dentition, evidence remains uncertain whether SDF prevents new caries or progression of existing caries compared to placebo or no treatment, but it may offer benefit over placebo or no treatment in caries arrest. Compared to placebo or no treatment, SDF probably also helps prevent new root caries. However, the evidence is uncertain for other caries outcome measures in this dentition and in all caries outcomes for coronal surfaces of permanent dentition. Compared to flouride varnish, SDF may offer little or no benefit in preventing new caries in the primary dentition, but the evidence is very uncertain for other caries outcome measures in the primary dentition and for preventing new caries in the permanent dentition. We were unable to establish whether one SDF treatment approach was better than another, or how SDF compared to other treatments, because of very low‐certainty evidence. The impact of SDF staining of teeth was poorly reported and the evidence for adverse effects is very uncertain. Additional well‐conducted studies are needed. These should measure the impact of staining and be analysed to take account of clustering issues within participants. Plain language summary Is silver diamine fluoride varnish an effective treatment for preventing and managing tooth decay in children and adults? Key messages ‐ We can't tell if silver diamine fluoride (SDF) is better than no treatment at preventing or treating tooth decay. ‐ We can't tell if SDF is better or worse than other treatments at preventing or treating tooth decay. ‐ New studies could help to find out about the unwanted effects of SDF, whether people are bothered by the staining on the teeth caused by SDF, and the best treatment approach. What is tooth decay? Tooth decay happens when bacteria in your mouth break down sugars from food, producing acids that damage tooth enamel (hard surfaces). This can lead to holes, or cavities, in the teeth. Tooth decay affects the crown of the tooth (the part above the gum) of baby teeth, and the crown and root of permanent teeth. If it is not prevented or treated it can cause toothache, infections and tooth loss. How is tooth decay treated? Treatments for tooth decay include liquids, gels (varnishes) and sealants. These treatments are painted onto the tooth to protect against bacteria. Treatment may also include fillings in larger cavities. Silver diamine fluoride (SDF) is a low‐cost liquid that can be painted on a tooth by a dentist or another trained person. It is suitable for people of all ages, including people with special health needs. However, SDF can permanently stain the treated tooth surface black or dark brown. What did we want to find out? We wanted to find out: ‐ if SDF was better than no treatment or other treatments at preventing new tooth decay, stopping existing tooth decay or preventing tooth decay from progressing; ‐ if there were benefits to applying SDF for different numbers of times, strengths of solution, or durations; ‐ if SDF caused unwanted effects, toothache, or if people were bothered by staining. What did we do? We searched for studies that compared SDF with no treatment or placebo (a dummy treatment), other treatments, or different application approaches. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 29 studies, with 12,020 children and 1016 older adults. Main results Compared with no treatment or placebo, we can't tell if SDF prevents new tooth decay in baby teeth or crown surfaces of permanent teeth. SDF is likely to prevent new tooth decay on root surfaces of permanent teeth. It may also completely stop existing tooth decay in baby teeth. However, we are unsure if it completely stops existing tooth decay on crown and root surfaces of permanent teeth, prevents existing tooth decay from progressing in any types of teeth, increases the risk of unwanted effects, or if people are bothered by the appearance of staining. Studies used different combinations of treatment approaches (number of times SDF is applied and how often, the strength of solution, and duration of treatment). We can't tell if one approach is better than another at stopping or preventing further decay, unwanted effects, or bother with appearance of staining. When SDF is compared with fluoride varnish, neither treatment may be better than the other at preventing new tooth decay in baby teeth. We are unsure about the effect on crown and root surfaces of permanent teeth. We also can't tell if either treatment is better than the other at stopping existing tooth decay or preventing further decay in baby teeth, or if there are any differences in unwanted effects, toothache, or bother with appearance of staining. When SDF is compared with sealants, we can't tell if there are any differences between treatments in preventing new tooth decay on the crown surfaces of permanent teeth, or whether there are any differences between these treatments in unwanted effects. When SDF is compared with fillings (with tooth decay first removed using only hand tools), we can't tell if there were any differences between treatments in stopping existing decay in baby teeth, unwanted effects, toothache, or bother with appearance of staining. What are the limitations of the evidence? Often we were very unsure of the evidence for the following reasons. ‐ SDF stains the teeth. Everyone in the studies would have known what treatment they were given. This might affect their usual teeth‐brushing routine. In most studies, the person checking teeth for new or existing decay would also have known this information. ‐ When we compared different approaches to SDF, the studies were too different from one another to allow us to compare them. ‐ Although we found 29 studies, most evidence was from individual (or few) studies, which were very small. How current is this evidence? The evidence is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Worthington, HV; Lewis, SR; Glenny, A-M; Huang, SS; Innes, NPT; O'Malley, L; Riley, P; Walsh, T; Wong, MC; Clarkson, JE; Veitz-Keenan, A", "articleTypes": [], "doi": "10.1002/14651858.CD012718.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "ae0c9a8c-92d1-4f19-8e1e-7e5c543fa500", "pmid": "", "title": "Relief of pain due to uterine cramping/involution after birth", "imported": false, "abstract": "Abstract - Background Women may experience differing types of pain and discomfort following birth, including cramping pain (often called after‐birth pain) associated with uterine involution, where the uterus contracts to reduce blood loss and return the uterus to its non‐pregnant size. This is an update of a review first published in 2011. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological pain relief/analgesia for the relief of after‐birth pains following vaginal birth. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (31 October 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials comparing two different types of analgesia or analgesia versus placebo or analgesia versus no treatment, for the relief of after‐birth pains following vaginal birth. Types of analgesia included pharmacological and non‐pharmacological. Quasi‐randomised trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed trials for inclusion, conducted 'Risk of bias' assessment, extracted data and assessed the certainty of the evidence using the GRADE approach. Main results In this update, we include 28 studies (involving 2749 women). The evidence identified in this review comes from middle‐ to high‐income countries. Generally the trials were at low risk of selection bias, performance bias and attrition bias, but some trials were at high risk of bias due to selective reporting and lack of blinding. Our GRADE certainty of evidence assessments ranged from moderate to very low certainty, with downgrading decisions based on study limitations, imprecision, and (for one comparison) indirectness. Most studies reported our primary outcome of adequate pain relief as reported by the women. No studies reported data relating to neonatal adverse events, duration of hospital stay, or breastfeeding rates. Almost half of the included studies (11/28) excluded breastfeeding women from participating, making the evidence less generalisable to a broader group of women. Non‐steroidal anti‐inflammatory drugs (NSAIDs) compared to placebo NSAIDs are probably better than placebo for adequate pain relief as reported by the women (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.45 to 1.91; 11 studies, 946 women; moderate‐certainty evidence). NSAIDs may reduce the need for additional pain relief compared to placebo (RR 0.15, 95% CI 0.07 to 0.33; 4 studies, 375 women; low‐certainty evidence). There may be a similar risk of maternal adverse events (RR 1.05, 95% CI 0.78 to 1.41; 9 studies, 598 women; low‐certainty evidence). NSAIDs compared to opioids NSAIDs are probably better than opioids for adequate pain relief as reported by the women (RR 1.33, 95% CI 1.13 to 1.57; 5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of maternal adverse events (RR 0.62, 95% CI 0.43 to 0.89; 3 studies, 255 women; low‐certainty evidence). NSAIDs may be better than opioids for the need for additional pain relief, but the wide CIs include the possibility that the two classes of drugs are similarly effective or that opioids are better (RR 0.37, 95% CI 0.12 to 1.12; 2 studies, 232 women; low‐certainty evidence). Opioids compared to placebo Opioids may be better than placebo for adequate pain relief as reported by the women (RR 1.26, 95% CI 0.99 to 1.61; 5 studies, 299 women; low‐certainty evidence). Opioids may reduce the need for additional pain relief compared to placebo (RR 0.48, 95% CI 0.28 to 0.82; 3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of maternal adverse events compared with placebo, although the certainty of evidence is low (RR 1.59, 95% CI 0.99 to 2.55; 3 studies, 188 women; low‐certainty evidence). Paracetamol compared to placebo Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events (2 studies, 123 women). Paracetamol compared to NSAIDs Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events. No data were reported about the need for additional pain relief comparing paracetamol and NSAIDs (2 studies, 112 women). NSAIDs compared to herbal analgesia We are uncertain if there are any differences between NSAIDs and herbal analgesia for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events, because the certainty of evidence is very low (4 studies, 394 women). Transcutaneous nerve stimulation (TENS) compared to no TENS Very low‐certainty evidence means we are uncertain if TENS is better than no TENS for adequate pain relief as reported by the women. No other data were reported comparing TENS with no TENS (1 study, 32 women). Authors' conclusions NSAIDs may be better than placebo and are probably better than opioids at relieving pain from uterine cramping/involution following vaginal birth. NSAIDs and paracetamol may be as effective as each other, whereas opioids may be more effective than placebo. Due to low‐certainty evidence, we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater generalisability by including breastfeeding women. In addition, further research is required, including a survey of postpartum women to describe appropriately their experience of uterine cramping and involution. We identified nine ongoing studies, which may help to increase the level of certainty of the evidence around pain relief due to uterine cramping in future updates of this review. Plain language summary Relief of pain caused by uterine cramping or involution after giving birth This updated review investigates the effectiveness and safety of drug and non‐drug pain relief in women experiencing after‐birth pains following vaginal birth. Giving an agent for pain relief was compared to an inactive placebo, to no treatment, or to a different type of agent in randomised controlled trials. What is the issue? Women may experience cramping pain and discomfort following the birth of their baby, as the uterus contracts and returns to its normal pre‐pregnancy size. These pains usually last for two to three days after the birth. Women who have previously had a baby are more likely to experience after‐birth pains. Breastfeeding stimulates the uterus to contract and increases the severity of the pains. Types of pain relief used to treat the pain include paracetamol, non‐steroidal anti‐inflammatory drugs (NSAIDs) ibuprofen and naproxen, opioids including codeine, and non‐medicine methods such as herbal preparations and transcutaneous electrical nerve stimulation (TENS). Why is this important? Management of pain after birth is important, as the pain can affect a mother carrying out her normal activities as well as bonding with and caring for her baby. After‐pains can interfere with establishing breastfeeding. What evidence did we find? We searched for evidence from randomised controlled trials (October 2019) and identified 28 studies (2749 mothers) who were in hospital after uncomplicated single births. Most of the evidence is low‐certainty because the studies did not include sufficient numbers of women. Many of the studies excluded breastfeeding women.This makes the evidence less relevant to a broader group of women. No studies reported evidence on adverse events in the newborn infants. NSAIDs are probably better than placebo (a dummy treatment) in giving adequate pain relief as reported by the women (11 studies, 946 women; moderate‐certainty evidence), and they may reduce the need for additional pain relief (4 studies, 375 women; low‐certainty evidence). There may be little difference between NSAIDs and placebo in the risk of adverse events in the mother (9 studies, 598 women; low‐certainty evidence). NSAIDs are probably better than opioids in providing adequate pain relief as reported by the women (5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of adverse events in the mother (3 studies, 255 women; low‐certainty evidence). NSAIDs may slightly reduce the need for additional pain relief compared with opioids (2 studies, 232 women; low‐certainty evidence). Opioids may be better than placebo for adequate pain relief as reported by the women (5 studies, 299 women; low‐certainty evidence) and for the need for additional pain relief (3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of adverse events in the mother compared with placebo (3 studies, 188 women; low‐certainty evidence). Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional analgesia, or risk of maternal adverse events (2 studies, 123 women). Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events (2 studies, 112 women). Very low‐certainty evidence means we are uncertain if NSAIDs are better than herbal pain relief for adequate pain relief as reported by the women (4 studies, 394 women), the need for additional pain relief (1 study, 90 women) or risk of maternal adverse events (1 study, 108 women). Very low‐certainty evidence means we are uncertain if there is any difference between TENS and no TENS for adequate pain relief as reported by the women (1 study, 32 women). What does this mean? NSAIDs may be better than placebo and are probably better than opioids at relieving after‐birth pains following vaginal birth. The quality of the evidence was poor and we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater relevance by including breastfeeding women. Further research could also include a survey of women after delivery to capture their experience of after‐birth pains following vaginal birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Deussen, AR, Ashwood, P, Martis, R, Stewart, F, Grzeskowiak, LE", "articleTypes": [], "doi": "10.1002/14651858.CD004908.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.121Z" }, { "id": "ae23d706-5fbf-4fed-a69e-68494ad2628c", "pmid": "", "title": "Translational Health Research Into Vascular and Neurocognitive Effects of Weight Loss", "imported": false, "abstract": "The goal of this clinical trial is to learn about the nature of brain abnormalities associated with excess body fat in healthy adults aged 35-55. The main questions it aims to answer are:", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.156Z" }, { "id": "ae3987e3-7443-4e76-81ff-2e105ad29939", "pmid": "", "title": "Melatonin for the prevention and treatment of jet lag", "imported": false, "abstract": "Abstract - Background Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Objectives To assess the effectiveness of oral melatonin taken in different dosage regimens for alleviating jet lag after air travel across several time zones. Search methods We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsychLit and Science Citation Index electronically, and the journals 'Aviation, Space and Environmental Medicine' and 'Sleep' by hand. We searched citation lists of relevant studies for other relevant trials. We asked principal authors of relevant studies to tell us about unpublished trials. Reports of adverse events linked to melatonin use outside randomised trials were searched for systematically in 'Side Effects of Drugs' (SED) and SED Annuals, 'Reactions Weekly', MEDLINE, and the adverse drug reactions databases of the WHO Uppsala Monitoring Centre (UMC) and the US Food & Drug Administration. An updating search was carried out on 12/2/2008 but no new studies were identified. Selection criteria Randomised trials in airline passengers, airline staff or military personnel given oral melatonin, compared with placebo or other medication. Outcome measures should consist of subjective rating of jet lag or related components, such as subjective well being, daytime tiredness, onset and quality of sleep, psychological functioning, duration of return to normal, or indicators of circadian rhythms. Data collection and analysis Ten trials met the inclusion criteria. All compared melatonin with placebo; one in addition compared it with a hypnotic, zolpidem. Nine of the trials were of adequate quality to contribute to the assessment, one had a design fault and could not be used in the assessment. 
 Reports of adverse events outside trials were found through MEDLINE, 'Reactions Weekly', and in the WHO UMC database. Main results Eight of the ten trials found that melatonin, taken close to the target bedtime at the destination (10pm to midnight), decreased jet‐lag from flights crossing five or more time zones. Daily doses of melatonin between 0.5 and 5mg are similarly effective, except that people fall asleep faster and sleep better after 5mg than 0.5mg. Doses above 5mg appear to be no more effective. The relative ineffectiveness of 2mg slow‐release melatonin suggests that a short‐lived higher peak concentration of melatonin works better. The estimated number needed to treat (NNT) is 2, based on the only two trials that gave the necessary data. The benefit is likely to be greater the more time zones are crossed, and less for westward flights. The timing of the melatonin dose is important: if it is taken at the wrong time, early in the day, it is liable to cause sleepiness and delay adaptation to local time. The incidence of other side effects is low. Case reports suggest that people with epilepsy, and patients taking warfarin may come to harm from melatonin. Authors' conclusions Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be. The pharmacology and toxicology of melatonin needs systematic study, and routine pharmaceutical quality control of melatonin products must be established. The effects of melatonin in people with epilepsy, and a possible interaction with warfarin, need investigation. Plain language summary Melatonin for the prevention and treatment of jet lag Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Herxheimer, A; Petrie, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD001520", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "ae400ff5-e09f-453a-ae07-ab99fb4a9875", "pmid": "", "title": "Honey and lozenges for children with non‐specific cough", "imported": false, "abstract": "Abstract - Background Chronic non‐specific cough is a chronic, dry cough of in the absence of identifiable respiratory disease or known aetiology. Although it is usually not reflective of an underlying severe illness, it does cause significant morbidity, and as such relief from it is often sought. The use of honey and lozenges to soothe upper respiratory tract irritation is common, inexpensive, and potentially more effective in treating the symptoms than pharmacological interventions. Objectives To evaluate the efficacy of honey and/or lozenges in the management of children with chronic non‐specific cough. Search methods The Cochrane Airways Group searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, OLDMEDLINE, and EMBASE databases in October 2010. Selection criteria All randomised controlled trials comparing honey or lozenges with a placebo in treating children with chronic non‐specific cough. Data collection and analysis The results of the searches were assessed according to the pre‐determined criteria. None of the trials identified by the searches were eligible for inclusion, leaving no data available for analysis in this review. Main results The search did not provide any applicable randomised controlled trials that investigated the efficacy of honey and lozenges in treating children with non‐specific chronic cough. Data from acute studies suggest a potential role for honey in relieving cough, but whether this is applicable to chronic cough is unknown. Authors' conclusions Clinically, this review was unable to provide any justifiable recommendation for or against honey and/or lozenges due to the lack of evidence. The absence of applicable studies highlights the need for further research into the area of treating children with chronic non‐specific coughs with honey and/or lozenges. These treatments are not recommended when managing very young children (as lozenges are a potential choking hazard, and honey may cause infant botulism in children under one year of age). Plain language summary Honey and lozenges for children with non‐specific cough Symptomatic relief is often sought for children with chronic non‐specific cough (which is defined as a dry, non‐productive cough with no known cause lasting longer than four consecutive weeks). This review aimed to assess the efficacy of treating children with such coughs using honey or lozenges, as these options are inexpensive. No randomised controlled trials were found to be applicable to this review, primarily due to the participants in the studies not fulfilling the inclusion criteria. However, studies on the efficacy of these treatments in treating acute cough in children showed that honey has the potential to be beneficial in children over a year old. Further research evaluating the efficacy of honey and lozenges in treating chronic non‐specific coughs in children is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Mulholland, S; Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD007523.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "ae40d46d-0fa4-41b0-a00a-9d82a8d1f7a0", "pmid": "", "title": "Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Herpes zoster oticus (HZO) is a viral infection of the ear and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first‐line treatment for herpes zoster infections at other body sites and are thought to reduce or minimise nerve damage, thereby improving outcomes. It has been suggested that these agents improve the chance of facial weakness improving or resolving completely in patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy). Search methods We searched the Cochrane ENT Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medline (1950 ‐ 2007), PubMed 2007 ‐ 2008, EMBASE (1974 onwards) and other relevant databases. The date of the most recent search was June 2008. Selection criteria Two authors scrutinized all possible citations to identify randomised controlled trials in which antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) were given as treatment for Ramsay Hunt syndrome. We contacted an author for further information. Data collection and analysis Two reviewers independently assessed eligibility and trial quality. Main results Only one randomised, controlled trial was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, intravenous acyclovir and corticosteroids were compared with corticosteroids alone. Our analysis found no statistically significant difference between the two groups. Authors' conclusions We found no evidence that anti‐viral agents have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. The use of these drugs in patients with herpes zoster infections in other parts of the body might suggest that they have a role in herpes zoster oticus. As usual, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically under‐powered study) does not necessarily indicate that antivirals are ineffective. However, these drugs are associated with a number of adverse effects and this must be taken into consideration when undertaking the requisite risk‐benefit analysis before instigating treatment. Plain language summary Uncertainty about usefulness of antiviral drugs in Ramsay Hunt syndrome It seems logical that antiviral drugs might help patients with a herpes virus infection of the ear producing facial weakness (a condition known as 'Ramsay Hunt syndrome'). These drugs often help similar viral infections elsewhere in the body. However, trials that might address this issue have not been done and there is therefore some uncertainty about their usefulness. Since patients can experience side‐effects when taking these drugs, the risks of these have to be balanced with the unknown prospect of benefit when considering whether to use them in Ramsay Hunt syndrome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T; Doree, C; Chamberlain, IJ; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "ae6c94b3-f667-4914-b639-c38200e60a81", "pmid": "", "title": "Drug interventions for the treatment of obesity in children and adolescents", "imported": false, "abstract": "Abstract - Background Child and adolescent obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. Objectives To assess the efficacy of drug interventions for the treatment of obesity in children and adolescents. Search methods We searched CENTRAL , MEDLINE, Embase, PubMed (subsets not available on Ovid), LILACS as well as the trial registers ICTRP (WHO) and ClinicalTrials.gov. Searches were undertaken from inception to March 2016. We checked references and applied no language restrictions. Selection criteria We selected randomised controlled trials (RCTs) of pharmacological interventions for treating obesity (licensed and unlicensed for this indication) in children and adolescents (mean age under 18 years) with or without support of family members, with a minimum of three months' pharmacological intervention and six months' follow‐up from baseline. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. In addition, we excluded trials which included growth hormone therapies and pregnant participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data following standard Cochrane methodology. Where necessary we contacted authors for additional information. Main results We included 21 trials and identified eight ongoing trials. The included trials evaluated metformin (11 trials), sibutramine (six trials), orlistat (four trials), and one trial arm investigated the combination of metformin and fluoxetine. The ongoing trials evaluated metformin (four trials), topiramate (two trials) and exenatide (two trials). A total of 2484 people participated in the included trials, 1478 participants were randomised to drug intervention and 904 to comparator groups (91 participants took part in two cross‐over trials; 11 participants not specified). Eighteen trials used a placebo in the comparator group. Two trials had a cross‐over design while the remaining 19 trials were parallel RCTs. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up from baseline ranged from six months to 100 weeks. Trials generally had a low risk of bias for random sequence generation, allocation concealment and blinding (participants, personnel and assessors) for subjective and objective outcomes. We judged approximately half of the trials as having a high risk of bias in one or more domain such as selective reporting. The primary outcomes of this review were change in body mass index (BMI), change in weight and adverse events. All 21 trials measured these outcomes. The secondary outcomes were health‐related quality of life (only one trial reported results showing no marked differences; very low certainty evidence), body fat distribution (measured in 18 trials), behaviour change (measured in six trials), participants' views of the intervention (not reported), morbidity associated with the intervention (measured in one orlistat trial only reporting more new gallstones following the intervention; very low certainty evidence), all‐cause mortality (one suicide in the orlistat intervention group; low certainty evidence) and socioeconomic effects (not reported). Intervention versus comparator for mean difference (MD) in BMI change was ‐1.3 kg/m 2 (95% confidence interval (CI) ‐1.9 to ‐0.8; P < 0.00001; 16 trials; 1884 participants; low certainty evidence). When split by drug type, sibutramine, metformin and orlistat all showed reductions in BMI in favour of the intervention. Intervention versus comparator for change in weight showed a MD of ‐3.9 kg (95% CI ‐5.9 to ‐1.9; P < 0.00001; 11 trials; 1180 participants; low certainty evidence). As with BMI, when the trials were split by drug type, sibutramine, metformin and orlistat all showed reductions in weight in favour of the intervention. Five trials reported serious adverse events: 24/878 (2.7%) participants in the intervention groups versus 8/469 (1.7%) participants in the comparator groups (risk ratio (RR) 1.43, 95% CI 0.63 to 3.25; 1347 participants; low certainty evidence). A total 52/1043 (5.0%) participants in the intervention groups versus 17/621 (2.7%) in the comparator groups discontinued the trial because of adverse events (RR 1.45, 95% CI 0.83 to 2.52; 10 trials; 1664 participants; low certainty evidence). The most common adverse events in orlistat and metformin trials were gastrointestinal (such as diarrhoea, mild abdominal pain or discomfort, fatty stools). The most frequent adverse events in sibutramine trials included tachycardia, constipation and hypertension. The single fluoxetine trial reported dry mouth and loose stools. No trial investigated drug treatment for overweight children. Authors' conclusions This systematic review is part of a series of associated Cochrane reviews on interventions for obese children and adolescents and has shown that pharmacological interventions (metformin, sibutramine, orlistat and fluoxetine) may have small effects in reduction in BMI and bodyweight in obese children and adolescents. However, many of these drugs are not licensed for the treatment of obesity in children and adolescents, or have been withdrawn. Trials were generally of low quality with many having a short or no post‐intervention follow‐up period and high dropout rates (overall dropout of 25%). Future research should focus on conducting trials with sufficient power and long‐term follow‐up, to ensure the long‐term effects of any pharmacological intervention are comprehensively assessed. Adverse events should be reported in a more standardised manner specifying amongst other things the number of participants experiencing at least one adverse event. The requirement of regulatory authorities (US Food and Drug Administration and European Medicines Agency) for trials of all new medications to be used in children and adolescents should drive an increase in the number of high quality trials. Plain language summary Drug interventions for the treatment of obesity in children and adolescents Review question Do drug (medicine) interventions reduce weight in obese children and adolescents and are they safe? Background Across the world more children and adolescents are becoming overweight and obese. These children and adolescents are more likely to have health problems, both while as children or adolescents and in later life. More information is needed about what works best for treating this problem recognising that so‐called lifestyle changes (diet, exercise and counselling) have limited efficacy. Study characteristics We found 21 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) comparing various drugs plus a behaviour changing intervention such as diet, exercise or both (= intervention groups) usually with placebo (a pretend drug) plus a behaviour changing intervention (= control groups). We also identified eight ongoing studies (studies which are currently running but not completed yet). A total of 2484 children and adolescents took part in the included studies. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up ranged from six months to 100 weeks. Key results The included studies investigated metformin (10 studies), sibutramine (six studies), orlistat (four studies) and one study group evaluated the combination of metformin and fluoxetine. The ongoing studies are investigating metformin (four studies), topiramate (two studies) and exenatide (two studies). Most studies reported on body mass index (BMI) and bodyweight: BMI is a measure of body fat and is calculated from weight and height measurements (kg/m 2 ). In children, BMI is often measured in a way that takes into account sex, weight and height as children grow older (BMI z score). The average change in BMI across control groups was between a 1.8 kg/m 2 reduction to a 0.9 kg/m 2 increase, while across all intervention groups the average reduction was more pronounced (1.3 kg/m 2 reduction). The same effect was observed for weight change: on average, children and adolescents in the intervention groups lost 3.9 kg more weight than the children and adolescents in the control groups. Study authors reported an average of serious side effects in 24 per 1000 participants in the intervention groups compared with an average of 17 per 1000 participants in the control groups. The numbers of participants dropping out of the study because of side effects were 40 per 1000 in the intervention groups and 27 per 1000 in the control groups. The most common side effects in the orlistat and metformin studies were gut (such as diarrhoea and mild tummy pain). Common side effects in the sibutramine trials included increased heart rate (tachycardia), constipation and high blood pressure. The fluoxetine study reported dry mouth and loose stools. One study reported health‐related quality of life (a measure of physical, mental, emotional and social functioning) and found no marked differences between intervention and control. No study reported the participants' views of the intervention or socioeconomic effects. Only one study reported on morbidity (how often a disease occurs in a specific area) associated with the intervention, where there were more gallstones after the orlistat treatment. Study authors reported one suicide in the orlistat intervention group. However, studies were not long enough to reliably investigate death from any cause. No study investigated drug treatment for children who were only overweight (obese children have a much higher weight, BMI or BMI z score than children being overweight). This evidence is up to date to March 2016. Quality of the evidence The overall certainty of the evidence was low or very low, mainly because there were only a few studies per outcome measurement, the number of included children or adolescents was small, and due to variation in the results of the studies. In addition, many children or adolescents left the studies before the study had finished.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Axon, E, Atkinson, G, Richter, B, Metzendorf, MI, Baur, L, Finer, N, Corpeleijn, E, O'Malley, C, Ells, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012436", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.758Z" }, { "id": "ae77a9c8-8b64-48bd-ad66-94770b8e8e73", "pmid": "", "title": "Aclidinium bromide for stable chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Bronchodilators are the mainstay for symptom relief in the management of stable chronic obstructive pulmonary disease (COPD). Aclidinium bromide is a new long‐acting muscarinic antagonist (LAMA) that differs from tiotropium by its higher selectivity for M3 muscarinic receptors with a faster onset of action. However, the duration of action of aclidinium is shorter than for tiotropium. It has been approved as maintenance therapy for stable, moderate to severe COPD, but its efficacy and safety in the management of COPD is uncertain compared to other bronchodilators. Objectives To assess the efficacy and safety of aclidinium bromide in stable COPD. Search methods We identified randomised controlled trials (RCT) from the Cochrane Airways Group Specialised Register of trials (CAGR), as well as www.clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), US Food and Drug Administration (FDA) website and Almirall Clinical Trials Registry and Results. We contacted Forest Laboratories for any unpublished trials and checked the reference lists of identified articles for additional information. The last search was performed on 7 April 2014 for CAGR and 11 April 2014 for other sources. Selection criteria Parallel‐group RCTs of aclidinium bromide compared with placebo, long‐acting beta 2 ‐agonists (LABA) or LAMA in adults with stable COPD. Data collection and analysis Two review authors independently selected studies, assessed the risk of bias, and extracted data. We sought missing data from the trial authors as well as manufacturers of aclidinium. We used odds ratios (OR) for dichotomous data and mean difference (MD) for continuous data, and reported both with their 95% confidence intervals (CI). We used standard methodological procedures expected by The Cochrane Collaboration. We applied the GRADE approach to summarise results and to assess the overall quality of evidence. Main results This review included 12 multicentre RCTs randomly assigning 9547 participants with stable COPD. All the studies were industry‐sponsored and had similar inclusion criteria with relatively good methodological quality. All but one study included in the meta‐analysis were double‐blind and scored low risk of bias. The study duration ranged from four weeks to 52 weeks. Participants were more often males, mainly Caucasians, mean age ranging from 61.7 to 65.6 years, and with a smoking history of 10 or more pack years. They had moderate to severe symptoms at randomisation; the mean post‐bronchodilator forced expiratory volume in one second (FEV1) was between 46% and 57.6% of the predicted normal value, and the mean St George's Respiratory Questionnaire score (SGRQ) ranged from 45.1 to 50.4 when reported. There was no difference between aclidinium and placebo in all‐cause mortality (low quality) and number of patients with exacerbations requiring a short course of oral steroids or antibiotics, or both (moderate quality). Aclidinium improved quality of life by lowering the SGRQ total score with a mean difference of ‐2.34 (95% CI ‐3.18 to ‐1.51; I 2 = 48%, 7 trials, 4442 participants) when compared to placebo. More patients on aclidinium achieved a clinically meaningful improvement of at least four units decrease in SGRQ total score (OR 1.49; 95% CI 1.31 to 1.70; I 2 = 34%; number needed to treat (NNT) = 10, 95% CI 8 to 15, high quality evidence) over 12 to 52 weeks than on placebo. Aclidinium also resulted in a significantly greater improvement in pre‐dose FEV1 than placebo with a mean difference of 0.09 L (95% CI 0.08 to 0.10; I 2 = 39%, 9 trials, 4963 participants). No trials assessed functional capacity. Aclidinium reduced the number of patients with exacerbations requiring hospitalisation by 4 to 20 fewer per 1000 over 4 to 52 weeks (OR 0.64; 95% CI 0.46 to 0.88; I 2 = 0%, 10 trials, 5624 people; NNT = 77, 95% CI 51 to 233, high quality evidence) compared to placebo. There was no difference in non‐fatal serious adverse events (moderate quality evidence) between aclidinium and placebo. Compared to tiotropium, aclidinium did not demonstrate significant differences for exacerbations requiring oral steroids or antibiotics, or both, exacerbation‐related hospitalisations and non‐fatal serious adverse events (very low quality evidence). Inadequate data prevented the comparison of aclidinium to formoterol or other LABAs. Authors' conclusions Aclidinium is associated with improved quality of life and reduced hospitalisations due to severe exacerbations in patients with moderate to severe stable COPD compared to placebo. Overall, aclidinium did not significantly reduce mortality, serious adverse events or exacerbations requiring oral steroids or antibiotics, or both. Currently, the available data are insufficient and of very low quality in comparisons of the efficacy of aclidinium versus tiotropium. The efficacy of aclidinium versus LABAs cannot be assessed due to inaccurate data. Thus additional trials are recommended to assess the efficacy and safety of aclidinium compared to other LAMAs or LABAs. Plain language summary Effectiveness and safety of inhalers containing the drug aclidinium bromide for managing patients with stable COPD Review question We reviewed the evidence on the effectiveness and safety of aclidinium inhalers used by people with chronic obstructive pulmonary disease (COPD). Background COPD, also known as 'smoker's lung disease', includes conditions called emphysema and chronic bronchitis where there is airway narrowing that cannot be fully corrected. It is a progressive disease. COPD patients usually have breathing problems and a cough that produces a lot of phlegm. It is diagnosed by international guidelines set by the Global Initiative for Obstructive Lung Disease (GOLD). Symptoms may worsen during flare‐ups. The main aims of treating COPD patients are to relieve symptoms, reduce flare‐ups and improve quality of life. Aclidinium is a new inhaled drug that widens the airways (a bronchodilator). It is delivered by an inhaler called Genuair or Pressair. We wanted to discover whether aclidinium was better or worse than using other inhalers or a dummy inhaler. Study characteristics The evidence was current to 7 April 2014. We included 12 studies involving 9547 COPD patients over a period of four to 52 weeks. These studies were sponsored by drug companies and were well designed. Both patients and the people doing the research did not know which treatment the patients were getting; although in one study one treatment was known to both parties. More men than women took part, and they were mostly Caucasians. They were in their 60s and had smoked a lot in their lives. These people had moderate to severe symptoms when they started treatment. Key results Aclidinium did not reduce the number of people with flare‐ups that need additional drugs. There was little or no difference in deaths or serious side effects between aclidinium and a dummy inhaler. Aclidinium inhalers improved quality of life more than the dummy inhalers. People who took aclidinium had fewer hospital admissions due to serious flare‐ups. Based on our results, among 1000 COPD patients using a dummy inhaler over four weeks to one year 37 would have severe flare‐ups needing hospital admission. Only 17 to 33 patients out of 1000 would require hospital admission if they were using aclidinium inhalers. We also set out to compare this new medication with tiotropium, which is already used to treat COPD. There were only two studies for this comparison thus we could not be sure how aclidinium compared to tiotropium. We also could not compare aclidinium with another well known inhaler that contains the drug formoterol because of unreliable data. Quality of the evidence For the comparison of aclidinium inhalers and dummy inhalers, we are confident that there are benefits in terms of the number of hospitalisations and patients' quality of life; we are less certain about the numbers of flare‐ups needing additional drugs and serious side effects. We do not have enough information to assess any effect on the number of deaths. We did not have enough information to reliably compare aclidinium with tiotropium or formoterol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ni, H, Soe, Z, Moe, S", "articleTypes": [], "doi": "10.1002/14651858.CD010509.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.125Z" }, { "id": "ae8eeb06-6266-4cf8-999c-84b70c9f90ae", "pmid": "", "title": "The effect of sample site and collection procedure on identification of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Sample collection is a key driver of accuracy in the diagnosis of SARS‐CoV‐2 infection. Viral load may vary at different anatomical sampling sites and accuracy may be compromised by difficulties obtaining specimens and the expertise of the person taking the sample. It is important to optimise sampling accuracy within cost, safety and accessibility constraints. Objectives To compare the sensitivity of different sampling collection sites and methods for the detection of current SARS‐CoV‐2 infection with any molecular or antigen‐based test. Search methods Electronic searches of the Cochrane COVID‐19 Study Register and the COVID‐19 Living Evidence Database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) were undertaken on 22 February 2022. We included independent evaluations from national reference laboratories, FIND and the Diagnostics Global Health website. We did not apply language restrictions. Selection criteria We included studies of symptomatic or asymptomatic people with suspected SARS‐CoV‐2 infection undergoing testing. We included studies of any design that compared results from different sample types (anatomical location, operator, collection device) collected from the same participant within a 24‐hour period. Data collection and analysis Within a sample pair, we defined a reference sample and an index sample collected from the same participant within the same clinical encounter (within 24 hours). Where the sample comparison was different anatomical sites, the reference standard was defined as a nasopharyngeal or combined naso/oropharyngeal sample collected into the same sample container and the index sample as the alternative anatomical site. Where the sample comparison was concerned with differences in the sample collection method from the same site, we defined the reference sample as that closest to standard practice for that sample type. Where the sample pair comparison was concerned with differences in personnel collecting the sample, the more skilled or experienced operator was considered the reference sample. Two review authors independently assessed the risk of bias and applicability concerns using the QUADAS‐2 and QUADAS‐C checklists, tailored to this review. We present estimates of the difference in the sensitivity (reference sample (%) minus index sample sensitivity (%)) in a pair and as an average across studies for each index sampling method using forest plots and tables. We examined heterogeneity between studies according to population (age, symptom status) and index sample (time post‐symptom onset, operator expertise, use of transport medium) characteristics. Main results This review includes 106 studies reporting 154 evaluations and 60,523 sample pair comparisons, of which 11,045 had SARS‐CoV‐2 infection. Ninety evaluations were of saliva samples, 37 nasal, seven oropharyngeal, six gargle, six oral and four combined nasal/oropharyngeal samples. Four evaluations were of the effect of operator expertise on the accuracy of three different sample types. The majority of included evaluations (146) used molecular tests, of which 140 used RT‐PCR (reverse transcription polymerase chain reaction). Eight evaluations were of nasal samples used with Ag‐RDTs (rapid antigen tests). The majority of studies were conducted in Europe (35/106, 33%) or the USA (27%) and conducted in dedicated COVID‐19 testing clinics or in ambulatory hospital settings (53%). Targeted screening or contact tracing accounted for only 4% of evaluations. Where reported, the majority of evaluations were of adults (91/154, 59%), 28 (18%) were in mixed populations with only seven (4%) in children. The median prevalence of confirmed SARS‐CoV‐2 was 23% (interquartile (IQR) 13%‐40%). Risk of bias and applicability assessment were hampered by poor reporting in 77% and 65% of included studies, respectively. Risk of bias was low across all domains in only 3% of evaluations due to inappropriate inclusion or exclusion criteria, unclear recruitment, lack of blinding, nonrandomised sampling order or differences in testing kit within a sample pair. Sixty‐eight percent of evaluation cohorts were judged as being at high or unclear applicability concern either due to inflation of the prevalence of SARS‐CoV‐2 infection in study populations by selectively including individuals with confirmed PCR‐positive samples or because there was insufficient detail to allow replication of sample collection. When used with RT‐PCR • There was no evidence of a difference in sensitivity between gargle and nasopharyngeal samples (on average ‐1 percentage points, 95% CI ‐5 to +2, based on 6 evaluations, 2138 sample pairs, of which 389 had SARS‐CoV‐2). • There was no evidence of a difference in sensitivity between saliva collection from the deep throat and nasopharyngeal samples (on average +10 percentage points, 95% CI ‐1 to +21, based on 2192 sample pairs, of which 730 had SARS‐CoV‐2). • There was evidence that saliva collection using spitting, drooling or salivating was on average ‐12 percentage points less sensitive (95% CI ‐16 to ‐8, based on 27,253 sample pairs, of which 4636 had SARS‐CoV‐2) compared to nasopharyngeal samples. We did not find any evidence of a difference in the sensitivity of saliva collected using spitting, drooling or salivating (sensitivity difference: range from ‐13 percentage points (spit) to –21 percentage points (salivate)). • Nasal samples (anterior and mid‐turbinate collection combined) were, on average, 12 percentage points less sensitive compared to nasopharyngeal samples (95% CI ‐17 to ‐7), based on 9291 sample pairs, of which 1485 had SARS‐CoV‐2. We did not find any evidence of a difference in sensitivity between nasal samples collected from the mid‐turbinates (3942 sample pairs) or from the anterior nares (8272 sample pairs). • There was evidence that oropharyngeal samples were, on average, 17 percentage points less sensitive than nasopharyngeal samples (95% CI ‐29 to ‐5), based on seven evaluations, 2522 sample pairs, of which 511 had SARS‐CoV‐2. A much smaller volume of evidence was available for combined nasal/oropharyngeal samples and oral samples. Age, symptom status and use of transport media do not appear to affect the sensitivity of saliva samples and nasal samples. When used with Ag‐RDTs • There was no evidence of a difference in sensitivity between nasal samples compared to nasopharyngeal samples (sensitivity, on average, 0 percentage points ‐0.2 to +0.2, based on 3688 sample pairs, of which 535 had SARS‐CoV‐2). Authors' conclusions When used with RT‐PCR, there is no evidence for a difference in sensitivity of self‐collected gargle or deep‐throat saliva samples compared to nasopharyngeal samples collected by healthcare workers when used with RT‐PCR. Use of these alternative, self‐collected sample types has the potential to reduce cost and discomfort and improve the safety of sampling by reducing risk of transmission from aerosol spread which occurs as a result of coughing and gagging during the nasopharyngeal or oropharyngeal sample collection procedure. This may, in turn, improve access to and uptake of testing. Other types of saliva, nasal, oral and oropharyngeal samples are, on average, less sensitive compared to healthcare worker‐collected nasopharyngeal samples, and it is unlikely that sensitivities of this magnitude would be acceptable for confirmation of SARS‐CoV‐2 infection with RT‐PCR. When used with Ag‐RDTs, there is no evidence of a difference in sensitivity between nasal samples and healthcare worker‐collected nasopharyngeal samples for detecting SARS‐CoV‐2. The implications of this for self‐testing are unclear as evaluations did not report whether nasal samples were self‐collected or collected by healthcare workers. Further research is needed in asymptomatic individuals, children and in Ag‐RDTs, and to investigate the effect of operator expertise on accuracy. Quality assessment of the evidence base underpinning these conclusions was restricted by poor reporting. There is a need for further high‐quality studies, adhering to reporting standards for test accuracy studies. Plain language summary How accurate are different types of sample collection for diagnosing COVID‐19 infection? Key messages • When used with RT‐PCR tests (a molecular test that detects genetic material in COVID‐19 using a technique called reverse transcription polymerase chain reaction), self‐collected gargle and deep throat saliva samples have a similar sensitivity compared to trained healthcare worker‐collected nasopharyngeal samples (taken from the back of the throat through the nose) in detecting COVID‐19. • When used with RT‐PCR, samples collected from the nose, oropharynx (throat via the mouth), oral cavity, and other saliva collection methods are less sensitive for detecting COVID‐19 compared to healthcare worker‐collected nasopharyngeal samples. • When used with rapid antigen tests (Ag‐RDTs; at‐home/self‐tests), samples collected from the nose have a similar sensitivity to healthcare worker‐collected nasopharyngeal samples in detecting COVID‐19. Why is improving the diagnosis of COVID‐19 important? Coronavirus disease (COVID‐19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). People with suspected COVID‐19 may decide to take a test to know whether they are infected, so that they can receive treatment, and follow recommended guidance to self‐isolate and inform close contacts. Not detecting COVID‐19 when it is present (a false negative result) risks spreading infection and results in missed opportunities for treatment. Types of sample collection methods for diagnosing COVID‐19? The type and quality of sample taken for confirmation of COVID‐19 affects the reliability of diagnosis. The most accurate type of sample to diagnose COVID‐19 is that taken by a trained healthcare worker from the back of the throat through the nose (a nasopharyngeal sample). This type of test detects genetic material in the virus using a technique called reverse transcription polymerase chain reaction (RT‐PCR). However, this sample is difficult to obtain correctly, causes discomfort and risks spreading infection if individuals cough or sneeze when the sample is taken. Alternative sample types, particularly those that can be self‐collected using rapid antigen tests (Ag‐RDTs; i.e. self‐tests), may reduce cost and discomfort and improve the safety of sampling. This may, in turn, improve access to and uptake of testing. What did we want to find out? We wanted to compare the sensitivity of different sample sites and collection methods in detecting COVID‐19 with molecular tests (RT‐PCR tests) or self‐based tests (Ag‐RDT tests). What did we do? We searched for studies that had compared the accuracy of nasopharyngeal samples to any alternative that could be used in patients outside of hospital, including nose (nasal) samples, throat samples taken through the mouth (oropharyngeal), gargle samples and saliva samples. We looked at the use of samples with either RT‐PCR or Ag‐RDTs. We also searched for studies that had compared different methods for taking samples, such as samples collected by a healthcare worker compared to those collected by individuals with no or minimal instructions. What did we find? The review included 106 studies with a total of 60,523 participants, of whom 11,045 had COVID‐19 infection. Fifty‐nine per cent of studies were conducted on adults and 79% on symptomatic or mixed symptomatic and asymptomatic participants. Sixty per cent of studies took place in Europe or the USA; just over half (55%) took place in dedicated COVID‐19 testing centres or in outpatient settings. Main results With RT‐PCR, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also test positive on self‐collected gargle samples or saliva samples (collected by coughing and then spitting (deep throat saliva)); ‐ 88% of positive nasopharyngeal samples collected by healthcare workers would also test positive with self‐ or healthcare worker‐collected nose samples; ‐ 87% of positive nasopharyngeal samples collected by healthcare workers would also be detected by saliva self‐collected using spitting, 84% by saliva self‐collected using drooling and 79% by saliva self‐collected by sucking on a swab; and ‐ 83% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐ or healthcare worker‐collected oropharyngeal samples. With Ag‐RDTs, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐collected or healthcare worker‐collected nose samples. Summary results The results of these studies indicate that in a group of 1000 people, of whom 230 (23%) have COVID‐19, then: when used with PCR, compared to healthcare worker‐collected nasopharyngeal samples: ‐ no cases of COVID‐19 would be missed using self‐collected gargle samples (12 less to 5 more) or deep throat saliva samples (2 less to 48 more); ‐ 28 (16 to 39) fewer cases of COVID‐19 infection would be detected using healthcare worker‐ or self‐collected nose sample; ‐ 30 (18 to 41) fewer cases of COVID‐19 infection would be detected by saliva self‐collected using spitting, 37 (12 to 62) fewer by saliva collected by drooling and 48 (12 to 85) fewer by saliva collected by sucking on a swab; ‐ 39 (12 to 67) fewer cases of COVID‐19 infection would be detected by healthcare worker‐ or self‐collected oropharyngeal samples; and when used with Ag‐RDTs, compared to healthcare worker‐collected nasopharyngeal samples: no cases of COVID‐19 infection would be missed using healthcare worker‐ or self‐collected nose samples. What are the limitations of the evidence? It was often not clear whether included studies deliberately excluded inadequate samples or whether the results of the more accurate nasopharyngeal sample were known when alternative samples were interpreted. This may have resulted in alternative sample types appearing more accurate than they are in practice, decreasing the number of missed cases of COVID‐19 infection. More than half of studies did not give information about how long participants had had symptoms at the time of sampling. This reduces our confidence in the comparison of different sample types. Most studies evaluated self‐collected samples by adults with symptoms for use with RT‐PCR; therefore, the findings of this review may not be applicable to asymptomatic individuals or children. For studies conducted with Ag‐RDTs, it is unclear whether sensitivity estimates of nose samples are applicable to home use (self‐collected and self‐interpreted). How up to date is this review? The evidence is current to 22 February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Davenport, C; Arevalo-Rodriguez, I; Mateos-Haro, M; Berhane, S; Dinnes, J; Spijker, R; Buitrago-Garcia, D; Ciapponi, A; Takwoingi, Y; Deeks, JJ; Emperador, D; Leeflang, MM. G.; Van den Bruel, A", "articleTypes": [], "doi": "10.1002/14651858.CD014780", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "aebdfeed-a275-419b-9a00-2e3abce3282a", "pmid": "", "title": "Reduced dietary salt for the prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review that was first published in 2011 of the effects of reducing dietary salt intake, through advice to reduce salt intake or low‐sodium salt substitution, on mortality and cardiovascular events. Objectives 1. To assess the long‐term effects of advice and salt substitution, aimed at reducing dietary salt, on mortality and cardiovascular morbidity. 2. To investigate whether a reduction in blood pressure is an explanatory factor in the effect of such dietary interventions on mortality and cardiovascular outcomes. Search methods We updated the searches of CENTRAL (2013, Issue 4), MEDLINE (OVID, 1946 to April week 3 2013), EMBASE (OVID, 1947 to 30 April 2013) and CINAHL (EBSCO, inception to 1 April 2013) and last ran these on 1 May 2013. We also checked the references of included studies and reviews. We applied no language restrictions. Selection criteria Trials fulfilled the following criteria: (1) randomised, with follow‐up of at least six months, (2) the intervention was reduced dietary salt (through advice to reduce salt intake or low‐sodium salt substitution), (3) participants were adults and (4) mortality or cardiovascular morbidity data were available. Two review authors independently assessed whether studies met these criteria. Data collection and analysis A single author extracted data and assessed study validity, and a second author checked this. We contacted trial authors where possible to obtain missing information. We extracted events and calculated risk ratios (RRs) and 95% confidence intervals (CIs). Main results Eight studies met the inclusion criteria: three in normotensives (n = 3518) and five in hypertensives or mixed populations of normo‐ and hypertensives (n = 3766). End of trial follow‐up ranged from six to 36 months and the longest observational follow‐up (after trial end) was 12.7 years. The risk ratios (RR) for all‐cause mortality in normotensives were imprecise and showed no evidence of reduction (end of trial RR 0.67, 95% confidence interval (CI) 0.40 to 1.12, 60 deaths; longest follow‐up RR 0.90, 95% CI 0.58 to 1.40, 79 deaths n=3518) or in hypertensives (end of trial RR 1.00, 95% CI 0.86 to 1.15, 565 deaths; longest follow‐up RR 0.99, 95% CI 0.87 to 1.14, 674 deaths n=3085). There was weak evidence of benefit for cardiovascular mortality (hypertensives: end of trial RR 0.67, 95% CI 0.45 to 1.01, 106 events n=2656) and for cardiovascular events (hypertensives: end of trial RR 0.76, 95% CI 0.57 to 1.01, 194 events, four studies, n = 3397; normotensives: at longest follow‐up RR 0.84, 95% CI 0.64 to 1.10, 200 events; hypertensives: RR 0.77, 95% CI 0.58 to 1.02, 192 events; pooled analysis of six trials (RR 0.81, 95% CI 0.66 to 0.98; n = 5762). These findings were driven by one trial among retirement home residents that reduced salt intake in the kitchens of the homes, thereby not requiring individual behaviour change. Advice to reduce salt showed small reductions in systolic blood pressure (mean difference (MD) ‐1.15 mmHg, 95% CI ‐2.32 to 0.02 n=2079) and diastolic blood pressure (MD ‐0.80 mmHg, 95% CI ‐1.37 to ‐0.23 n=2079) in normotensives and greater reductions in systolic blood pressure in hypertensives (MD ‐4.14 mmHg, 95% CI ‐5.84 to ‐2.43 n=675), but no difference in diastolic blood pressure (MD ‐3.74 mmHg, 95% CI ‐8.41 to 0.93 n=675). Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Health‐related quality of life was assessed in one trial in normotensives, which reported significant improvements in well‐being but no data were presented. Authors' conclusions Despite collating more event data than previous systematic reviews of randomised controlled trials, there is insufficient power to confirm clinically important effects of dietary advice and salt substitution on cardiovascular mortality in normotensive or hypertensive populations. Our estimates of the clinical benefits from advice to reduce dietary salt are imprecise, but are larger than would be predicted from the small blood pressure reductions achieved. Further well‐powered studies would be needed to obtain more precise estimates. Our findings do not support individual dietary advice as a means of restricting salt intake. It is possible that alternative strategies that do not require individual behaviour change may be effective and merit further trials. Plain language summary Reduced dietary salt for the prevention of cardiovascular disease Cardiovascular disease includes heart attacks and strokes and is a major cause of premature death and disability. This is an update of a review first published in 2011. This review sets out to assess whether intensive support and encouragement to cut down on salt in foods, and substituting low‐sodium salt, reduces the risk of death or cardiovascular disease. This update includes two new studies and eliminates one problematic study, giving a total of eight trials with 7284 participants. Dietary advice and salt substitution did reduce the amount of salt eaten, which led to a small reduction in blood pressure by six months. There was weak evidence of benefit for cardiovascular events, but these findings were inconclusive and were driven by a single trial among retirement home residents, which reduced salt intake in the kitchens of the homes. The findings of our review do not mean that advising people to reduce salt should be stopped. However, additional measures ‐ reducing the amount of hidden salt in processed foods, for example – will make it much easier for people to achieve a lower salt diet. Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Further evidence of the effects of different ways of reducing dietary salt on clinical events is needed from experimental and observational studies to underpin public health policies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Adler, AJ, Taylor, F, Martin, N, Gottlieb, S, Taylor, RS, Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD009217.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.134Z" }, { "id": "aecea14d-521c-4376-8b49-4aafdd3a3f2f", "pmid": "", "title": "Immediate‐release versus controlled‐release carbamazepine in the treatment of epilepsy", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, G, Saunders, M, Rigby, A, Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007124.pub5 AB - Abstract - Background Carbamazepine (CBZ) is a commonly used drug for epilepsy that is associated with troublesome adverse events including dizziness, double vision, drowsiness, poor co‐ordination and unsteadiness. These adverse events often occur during peaks in drug plasma concentration. These adverse events may limit the daily dose of CBZ that can be tolerated and reduce the chances of seizure control in patients who require high doses. A controlled‐release formulation of CBZ delivers the same dose over a longer period of time when compared to a standard immediate‐release formulation, thereby reducing post‐dose peaks in CBZ plasma concentration and potentially reducing adverse events. This is an updated version of the original Cochrane review published in Issue 12, 2014. Objectives To determine the efficacy of immediate‐release CBZ (IR CBZ) versus controlled‐release CBZ (CR CBZ) in patients diagnosed with epilepsy. The following review questions were investigated.
 (1) For newly diagnosed patients commencing CBZ, how do IR and CR formulations compare for efficacy and tolerability?
 (2) For patients on established treatment with IR CBZ but experiencing unacceptable adverse events, what is the effect on seizure control and the tolerability of a switch to a CR formulation versus remaining on the IR formulation? Search methods We searched the Cochrane Epilepsy Group Specialized Register, CENTRAL, and MEDLINE (Ovid) from inception to 30 August 2016. Selection criteria Randomised controlled trials comparing IR CBZ to CR CBZ in patients commencing monotherapy and patients presently treated with IR CBZ but experiencing unacceptable adverse events. Primary outcome measures included measures of seizure frequency, incidence of adverse events, proportion of patients with treatment failure and quality of life measures. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted the data and recorded relevant information on a standardised data extraction form. We used the Cochrane risk of bias tool to assess the methodological quality of included studies. The heterogeneity of the included trials with respect to the reporting of outcomes resulted in only a narrative, descriptive analysis being possible for both the categorical and time‐to‐event data. Main results Ten trials (296 participants) fulfilled the criteria for inclusion in this review. Only one study had a low risk of bias. Two studies had a high risk of bias and the rest of the studies were rated as unclear risk of bias. One trial included patients with newly diagnosed epilepsy and nine included patients on treatment with IR CBZ. Eight trials reported heterogeneous measures of seizure frequency with conflicting results. A statistically significant difference was observed in only one trial, with patients prescribed CR CBZ experiencing fewer seizures than patients prescribed IR CBZ. Nine trials reported measures of adverse events. There was a trend in favour of CR CBZ with four trials reporting a statistically significant reduction in adverse events compared to IR CBZ. A further two trials reported fewer adverse events with CR CBZ but the reduction was not statistically significant. One trial found no difference in adverse events, and another trial reported more adverse events in the CR CBZ group than the IR CBZ group, although the increase was not statistically significant. Authors' conclusions For this update no new eligible studies were identified and the conclusions drawn from the initial review remain unchanged. At present, data from trials do not confirm or refute an advantage for CR CBZ over IR CBZ for seizure frequency or adverse events in patients with newly diagnosed epilepsy. For trials involving epilepsy patients already prescribed IR CBZ, no conclusions can be drawn concerning the superiority of CR CBZ with respect to seizure frequency. There is a trend for CR CBZ to be associated with fewer adverse events when compared to IR CBZ. A change to CR CBZ may therefore be a worthwhile strategy in patients with acceptable seizure control on IR CBZ but experiencing unacceptable adverse events. The included trials were of small size and of poor methodological quality limiting the validity of this conclusion. Randomised controlled trials comparing CR CBZ to IR CBZ and using clinically relevant outcomes are required to inform the choice of CBZ preparation for patients with newly diagnosed epilepsy. Plain language summary Fast‐release versus slow‐release carbamazepine as medication for patients with epilepsy Background Epilepsy is a common brain disorder that is often treated with carbamazepine. With treatment, people often have fewer seizures but many people experience side effects. When carbamazepine is swallowed it is taken into the blood stream quickly and there is a sharp rise of drug levels in the blood. These 'peaks' may be associated with side effects such as dizziness, double vision, drowsiness, unsteadiness and poor co‐ordination. A type of carbamazepine that releases the medication into the body slowly may lessen these 'peaks' in the blood levels, possibly meaning fewer side effects. This review compared studies looking at the differences between a 'fast‐release' carbamazepine and a 'slow‐release' carbamazepine. Participants To be included in this review, all participants had to be diagnosed with epilepsy and be either just starting carbamazepine treatment or be already on it but with intolerable side effects. The participants could be of any age or gender. Studies Ten trials with a total of 296 people with epilepsy were included in the review. All 10 trials were randomised controlled trials (patients were compared in randomly assigned groups). All of the studies had at least two groups, one group taking fast‐release carbamazepine and one group taking slow‐release carbamazepine, and some also had a control group (a group of non‐epileptic people). The evidence is current to August 2016. Results Just one of 10 studies found a significant difference between the two carbamazepine types in the number of seizures experienced, with patients prescribed the slow‐release carbamazepine experiencing fewer seizures than patients prescribed the fast‐release drug. Patients taking slow‐release carbamazepine tended to experience fewer side effects. Quality of the evidence Out of the 10 trials in the review, only one study was judged to be of 'good' quality, and so the evidence in this review was rated as low quality. It must be stressed that there are not many studies assessing the differences between these two carbamazepine types and more studies are needed before we can make a definitive conclusion about one over the other.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.109Z" }, { "id": "aefc0807-7205-42a9-a256-569ec36abe3d", "pmid": "", "title": "Pine bark (Pinus spp.) extract for treating chronic disorders", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Robertson, NU, Schoonees, A, Brand, A, Visser, J", "articleTypes": [], "doi": "10.1002/14651858.CD008294.pub5 AB - Abstract - Background Pine bark ( Pinus spp.) extract is rich in bioflavonoids, predominantly proanthocyanidins, which are antioxidants. Commercially‐available extract supplements are marketed for preventing or treating various chronic conditions associated with oxidative stress. This is an update of a previously published review. Objectives To assess the efficacy and safety of pine bark extract supplements for treating chronic disorders. Search methods We searched three databases and three trial registries; latest search: 30 September 2019. We contacted the manufacturers of pine bark extracts to identify additional studies and hand‐searched bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) evaluating pine bark extract supplements in adults or children with any chronic disorder. Data collection and analysis Two authors independently assessed trial eligibility, extracted data and assessed risk of bias. Where possible, we pooled data in meta‐analyses. We used GRADE to evaluate the certainty of evidence. Primary outcomes were participant‐ and investigator‐reported clinical outcomes directly related to each disorder and all‐cause mortality. We also assessed adverse events and biomarkers of oxidative stress. Main results This review included 27 RCTs (22 parallel and five cross‐over designs; 1641 participants) evaluating pine bark extract supplements across 10 chronic disorders: asthma (two studies; 86 participants); attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), cardiovascular disease (CVD) and risk factors (seven studies; 338 participants), chronic venous insufficiency (CVI) (two studies; 60 participants), diabetes mellitus (DM) (six studies; 339 participants), erectile dysfunction (three studies; 277 participants), female sexual dysfunction (one study; 83 participants), osteoarthritis (three studies; 293 participants), osteopenia (one study; 44 participants) and traumatic brain injury (one study; 60 participants). Two studies exclusively recruited children; the remainder recruited adults. Trials lasted between four weeks and six months. Placebo was the control in 24 studies. Overall risk of bias was low for four, high for one and unclear for 22 studies. In adults with asthma, we do not know whether pine bark extract increases change in forced expiratory volume in one second (FEV 1 ) % predicted/forced vital capacity (FVC) (mean difference (MD) 7.70, 95% confidence interval (CI) 3.19 to 12.21; one study; 44 participants; very low‐certainty evidence), increases change in FEV 1 % predicted (MD 7.00, 95% CI 0.10 to 13.90; one study; 44 participants; very low‐certainty evidence), improves asthma symptoms (risk ratio (RR) 1.85, 95% CI 1.32 to 2.58; one study; 60 participants; very low‐certainty evidence) or increases the number of people able to stop using albuterol inhalers (RR 6.00, 95% CI 1.97 to 18.25; one study; 60 participants; very low‐certainty evidence). In children with ADHD, we do not know whether pine bark extract decreases inattention and hyperactivity assessed by parent‐ and teacher‐rating scales (narrative synthesis; one study; 57 participants; very low‐certainty evidence) or increases the change in visual‐motoric coordination and concentration (MD 3.37, 95% CI 2.41 to 4.33; one study; 57 participants; very low‐certainty evidence). In participants with CVD, we do not know whether pine bark extract decreases diastolic blood pressure (MD ‐3.00 mm Hg, 95% CI ‐4.51 to ‐1.49; one study; 61 participants; very low‐certainty evidence); increases HDL cholesterol (MD 0.05 mmol/L, 95% CI ‐0.01 to 0.11; one study; 61 participants; very low‐certainty evidence) or decreases LDL cholesterol (MD ‐0.03 mmol/L, 95% CI ‐0.05 to 0.00; one study; 61 participants; very low‐certainty evidence). In participants with CVI, we do not know whether pine bark extract decreases pain scores (MD ‐0.59, 95% CI ‐1.02 to ‐0.16; one study; 40 participants; very low‐certainty evidence), increases the disappearance of pain (RR 25.0, 95% CI 1.58 to 395.48; one study; 40 participants; very low‐certainty evidence) or increases physician‐judged treatment efficacy (RR 4.75, 95% CI 1.97 to 11.48; 1 study; 40 participants; very low‐certainty evidence). In type 2 DM, we do not know whether pine bark extract leads to a greater reduction in fasting blood glucose (MD 1.0 mmol/L, 95% CI 0.91 to 1.09; one study; 48 participants;very low‐certainty evidence) or decreases HbA1c (MD ‐0.90 %, 95% CI ‐1.78 to ‐0.02; 1 study; 48 participants; very low‐certainty evidence). In a mixed group of participants with type 1 and type 2 DM we do not know whether pine bark extract decreases HbA1c (MD ‐0.20 %, 95% CI ‐1.83 to 1.43; one study; 67 participants; very low‐certainty evidence). In men with erectile dysfunction, we do not know whether pine bark extract supplements increase International Index of Erectile Function‐5 scores (not pooled; two studies; 147 participants; very low‐certainty evidence). In women with sexual dysfunction, we do not know whether pine bark extract increases satisfaction as measured by the Female Sexual Function Index (MD 5.10, 95% CI 3.49 to 6.71; one study; 75 participants; very low‐certainty evidence) or leads to a greater reduction of pain scores (MD 4.30, 95% CI 2.69 to 5.91; one study; 75 participants; very low‐certainty evidence). In adults with osteoarthritis of the knee, we do not know whether pine bark extract decreases composite Western Ontario and McMaster Universities Osteoarthritis Index scores (MD ‐730.00, 95% CI ‐1011.95 to ‐448.05; one study; 37 participants; very low‐certainty evidence) or the use of non‐steroidal anti‐inflammatory medication (MD ‐18.30, 95% CI ‐25.14 to ‐11.46; one study; 35 participants; very low‐certainty evidence). We do not know whether pine bark extract increases bone alkaline phosphatase in post‐menopausal women with osteopenia (MD 1.16 ug/L, 95% CI ‐2.37 to 4.69; one study; 40 participants; very low‐certainty evidence). In individuals with traumatic brain injury, we do not know whether pine bark extract decreases cognitive failure scores (MD ‐2.24, 95% CI ‐11.17 to 6.69; one study; 56 participants; very low‐certainty evidence) or post‐concussion symptoms (MD ‐0.76, 95% CI ‐5.39 to 3.87; one study; 56 participants; very low‐certainty evidence). For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. Authors' conclusions Small sample sizes, limited numbers of RCTs per condition, variation in outcome measures, and poor reporting of the included RCTs mean no definitive conclusions regarding the efficacy or safety of pine bark extract supplements are possible. Plain language summary Using pine bark supplements to help treat a variety of chronic diseases Review question Can pine bark antioxidant supplements help to treat chronic diseases? Background The main ingredients in pine bark extract supplements are proanthocyanidins, which are antioxidants. These supplements are marketed to prevent or treat a wide range of chronic diseases. This is an update of a previously published review, where we assessed how well these supplements work for treating chronic diseases, as well as their safety. Search date The evidence is current to 30 September 2019. Study characteristics We included 27 studies (1641 participants) across 10 chronic diseases. These included: asthma (two studies; 86 participants), attention deficit hyperactivity disorder (ADHD) (one study; 61 participants), heart disease and risk factors (seven studies; 332 participants), chronic venous insufficiency (leg veins not working effectively; two studies; 60 participants), diabetes (six studies; 336 participants), erectile dysfunction (three studies; 227 participants), female sexual dysfunction (one study; 75 participants), osteoarthritis (cartilage damage in joints; three studies; 293 participants), osteopenia (beginning of bone mass loss; one study; 44 participants) and traumatic brain injury (one study; 56 participants). Two of the studies were conducted exclusively in children; the others were in adults. Studies compared pine bark supplements with placebo (i.e. a dummy supplement) or non‐antioxidant interventions and participants were randomly selected for one treatment or the other. The duration of treatment ranged from four weeks to six months. Key results For most outcomes across the different chronic diseases we only included one study with a small number of participants. In adults with asthma, we do not know whether pine bark extract increases lung function, improves asthma symptoms or increases the number of people able to stop using albuterol inhalers (a specific type of asthma pump).
In children with ADHD, we do not know whether pine bark supplements decrease inattention and hyperactivity (assessed by parents and teachers) or whether it increases co‐ordination and concentration.
In people with heart disease we do not know if pine bark supplements decrease blood pressure and LDL cholesterol (the bad type) or whether it increases HDL cholesterol (the good type).
In adults with chronic venous insufficiency we do not know whether pine bark supplements decrease pain, increase the number of people free of pain, or how well doctors think the treatment works. In people with type 2 diabetes, we do not know whether pine bark supplements improve blood sugar levels or HbA1c levels (the long‐term marker for measuring blood sugar control); we also do not know if pine bark supplements decrease HbA1c in people with type 1 or type 2 diabetes.
In men with erectile dysfunction, we do not know if pine bark supplements increase erectile function. Similarly, in women with sexual dysfunction, we do not know if pine bark supplements increase sexual satisfaction or reduce pain.
In adults with osteoarthritis, it is not clear if pine bark supplements improve pain, swelling or stiffness in the knee, or whether it decreases the use of anti‐inflammatory drugs. We also do not know if pine bark supplements increase bone formation in postmenopausal women with weakened bones. Lastly, in people with a traumatic brain injury, it is not clear if pine bark supplements improve memory and post‐concussion symptoms . For most comparisons, studies did not report outcomes of hospital admissions or serious adverse events. With the available studies, we cannot clearly say how well (or not) pine bark supplements work and whether they are safe. Quality of the evidence The overall risk of bias was low for four studies, high for one and unclear for 22 studies. By this we mean the extent to which the methods used in a study enable it to determine the truth. The certainty of evidence was very low for all outcomes across all chronic diseases in the included studies.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.799Z" }, { "id": "aeff8c28-74bf-4cc4-9887-a08483ddab64", "pmid": "", "title": "Prophylactic Treatment of Episodic Cluster Headache With an Angiotensin II Receptor Blocker (Candesartan Cilexetil); a Randomized, Placebo Controlled Parallel Study", "imported": false, "abstract": "The purpose of this study is to determine whether candesartan cilexetil are effective prophylactic treatment of episodic Cluster headache", "journal": "", "year": "2005", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "af11ee38-523a-4ec8-ac18-a45340ea25c1", "pmid": "", "title": "Eszopiclone for insomnia", "imported": false, "abstract": "Abstract - Background Insomnia is a major public health issue affecting between 6% to 10% of the adult population in Western countries. Eszopiclone is a hypnotic drug belonging to a newer group of hypnotic agents, known as new generation hypnotics, which was marketed as being just as effective as benzodiazepines for this condition, while being safer and having a lower risk for abuse and dependence. It is the aim of the review to integrate evidence from randomised controlled trials and to draw conclusions on eszopiclone's efficacy and safety profile, while taking methodological features and bias risks into consideration. Objectives To assess the efficacy and safety of eszopiclone for the treatment of insomnia compared to placebo or active control. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, Embase, PsycINFO, PSYNDEX and registry databases (WHO trials portal, ClinicalTrials.gov) with results incorporated from searches to 10 February 2016. To identify trials not registered in electronic databases, we contacted key informants and searched reference lists of identified studies. We ran an update search (21 February 2018) and have placed studies of interest in awaiting classification/ongoing studies. These will be incorporated into the next version of the review, as appropriate. Selection criteria Parallel group randomised controlled trials (RCTs) comparing eszopiclone with either placebo or active control were included in the review. Participants were adults with insomnia, as diagnosed with a standardised diagnostic system, including primary insomnia and comorbid insomnia. Data collection and analysis Two authors independently extracted outcome data; one reviewer assessed trial quality and the second author cross‐checked it. Main results A total of 14 RCTs, with 4732 participants, were included in this review covering short‐term (≤ 4 weeks; 6 studies), medium‐term (> 4 weeks ≤ 6 months; 6 studies) and long‐term treatment (> 6 months; 2 studies) with eszopiclone. Most RCTs included in the review included participants aged between 18 and 64 years, three RCTs only included elderly participants (64 to 85 years) and one RCT included participants with a broader age range (35 to 85 years). Seven studies considered primary insomnia; the remaining studies considered secondary insomnia comorbid with depression (2), generalised anxiety (1), back pain (1), Parkinson's disease (1), rheumatoid arthritis (1) and menopausal transition (1). Meta‐analytic integrations of participant‐reported data on sleep efficacy outcomes demonstrated better results for eszopiclone compared to placebo: a 12‐minute decrease of sleep onset latency (mean difference (MD) ‐11.94 min, 95% confidence interval (CI) ‐16.03 to ‐7.86; 9 studies, 2890 participants, moderate quality evidence), a 17‐minute decrease of wake time after sleep onset (MD ‐17.02 min, 95% CI ‐24.89 to ‐9.15; 8 studies, 2295 participants, moderate quality evidence) and a 28‐minute increase of total sleep time (MD 27.70 min, 95% CI 20.30 to 35.09; 10 studies, 2965 participants, moderate quality evidence). There were no significant changes from baseline to the first three nights after drug discontinuation for sleep onset latency (MD 17.00 min, 95% CI ‐4.29 to 38.29; 1 study, 291 participants, low quality evidence) and wake time after sleep onset (MD ‐6.71 min, 95% CI ‐21.25 to 7.83; 1 study, 291 participants, low quality evidence). Adverse events during treatment that were documented more frequently under eszopiclone compared to placebo included unpleasant taste (risk difference (RD) 0.18, 95% CI 0.14 to 0.21; 9 studies, 3787 participants), dry mouth (RD 0.04, 95% CI 0.02 to 0.06; 6 studies, 2802 participants), somnolence (RD 0.04, 95% CI 0.02 to 0.06; 8 studies, 3532 participants) and dizziness (RD 0.03, 95% CI 0.01 to 0.05; 7 studies, 2933 participants). According to the GRADE criteria, evidence was rated as being of moderate quality for sleep efficacy outcomes and adverse events and of low quality for rebound effects and next‐day functioning. Authors' conclusions Eszopiclone appears to be an efficient drug with moderate effects on sleep onset and maintenance. There was no or little evidence of harm if taken as recommended. However, as certain patient subgroups were underrepresented in RCTs included in the review, findings might not have displayed the entire spectrum of possible adverse events. Further, increased caution is required in elderly individuals with cognitive and motor impairments and individuals who are at increased risk of using eszopiclone in a non‐recommended way. Plain language summary Eszopiclone (Lunesta) for sleep difficulty Why is this review important? Insomnia is the medical term for sleep difficulty covering trouble falling asleep, difficulties staying asleep, waking up too early or experiencing sleep as non‐restorative. Insomnia can be treated with different methods including behaviour modification, relaxation techniques, or sleeping medication. Eszopiclone (Lunesta) is a sleeping medication that belongs to a class of sleeping tablets known as non‐benzodiazepine hypnotics. Who will be interested in this review? People who are affected by insomnia, general practitioners, professionals working in health services, and addiction treatment and health policy makers. What questions does this review aim to answer? The review aimed to find out more about the wanted effects and unwanted effects of eszopiclone. Wanted effects included the immediate effects eszopiclone has on sleep; unwanted effects included side effects, effects on next‐day functioning, but also addictive properties of the drug. Which studies were included in the review? The review summarised findings from 14 clinical studies with 4732 people, either receiving eszopiclone or an identically‐appearing, but inert substance (placebo). What does the evidence from the review tell us? On average, people taking eszopiclone fell asleep 12 minutes faster than those taking placebo, were 17 minutes less awake during the night and had, in total, about half an hour more sleep than people in the placebo group. As side effects, eszopiclone can cause unpleasant taste, dizziness, dry mouth, and tiredness during the day. Clinical studies did not find evidence that eszopiclone was causing serious harm or withdrawal symptoms or whether it was addictive if it was stopped and not taken after several weeks or months of treatment. Nevertheless, as clinical studies included in the review did not cover certain groups (e.g. elderly people with cognitive or motor problems or certain conditions of medication intake), it is important for patients to consult their doctor who knows their medical history and condition. What should happen next? Future research needs to compare eszopiclone with other sleep medications to help physicians and patients decide which of the available treatment options to prefer. In addition, sleep medications that are also well tolerated by elderly individuals and individuals with alcohol or drug problems need to be identified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rösner, S, Englbrecht, C, Wehrle, R, Hajak, G, Soyka, M", "articleTypes": [], "doi": "10.1002/14651858.CD010703.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.748Z" }, { "id": "af2e3c14-9dbd-42c5-9648-4fdba0d8ad8c", "pmid": "", "title": "Interventions for the management of dry mouth: topical therapies", "imported": false, "abstract": "Abstract - Background Xerostomia (the feeling of dry mouth) is a common symptom especially in older adults. Causes of dry mouth include medications, autoimmune disease (Sjögren's Syndrome), radiotherapy or chemotherapy for cancer, hormone disorders and infections. Objectives To determine which topical treatments for dry mouth are effective in reducing this symptom. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (28 October 2011), The Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 4 2011), MEDLINE via OVID (1950 to 28 October 2011), EMBASE via OVID (1980 to 28 October 2011), CINAHL via EBSCO (1980 to 28 October 2011), AMED via OVID (1985 to 28 October 2011), CANCERLIT via PubMed (1950 to 28 October 2011). Selection criteria We included randomised controlled trials of topical interventions such as lozenges, sprays, mouthrinses, gels, oils, chewing gum or toothpastes for the treatment of dry mouth symptom. We classified interventions into two broad categories, saliva stimulants and saliva substitutes, and these were compared with either placebo or another intervention. We included both parallel group and crossover trials. Data collection and analysis Two or more review authors independently carried out data extraction and assessed risk of bias. Trial authors were contacted for additional information as required. Main results Thirty‐six randomised controlled trials involving 1597 participants met the inclusion criteria. Two trials compared saliva stimulants to placebo, nine trials compared saliva substitutes to placebo, five trials compared saliva stimulants directly with saliva substitutes, 18 trials directly compared two or more saliva substitutes, and two trials directly compared two or more saliva stimulants. Only one trial was at low risk of bias and 17 were at high risk of bias. Due to the range of interventions, comparisons and outcome measures in the trials, meta‐analysis was possible for only a few comparisons. Oxygenated glycerol triester (OGT) saliva substitute spray shows evidence of effectiveness compared to an electrolyte spray (standardised mean difference (SMD) 0.77, 95% confidence interval (CI) 0.38 to 1.15) which corresponds to approximately a mean difference of 2 points on a 10‐point visual analogue scale (VAS) for mouth dryness. Both integrated mouthcare systems (toothpaste + gel + mouthwash) and oral reservoir devices show promising results but there is insufficient evidence at present to recommend their use. Although chewing gum is associated with increased saliva production in the majority of those with residual capacity, there is no evidence that gum is more or less effective than saliva substitutes. Authors' conclusions There is no strong evidence from this review that any topical therapy is effective for relieving the symptom of dry mouth. OGT spray is more effective than an aqueous electrolyte spray (SMD 0.77, 95% CI 0.38 to 1.15) which is approximately equivalent to a mean difference of 2 points on a 10‐point VAS scale for mouth dryness. Chewing gums appear to increase saliva production in those with residual secretory capacity and may be preferred by patients, but there is no evidence that gum is better or worse than saliva substitutes. Integrated mouthcare systems and oral reservoir devices may be helpful but further research is required to confirm this. Well designed, adequately powered randomised controlled trials of topical interventions for dry mouth, which are designed and reported according to CONSORT guidelines, are required to provide evidence to guide clinical care. For many people the symptom of dry mouth is a chronic problem and trials should evaluate whether treatments are palatable, effective in reducing xerostomia, as well as the long‐term effects of treatments on quality of life of those with chronic dry mouth symptoms. Plain language summary Interventions for the management of dry mouth: topical therapies Dry mouth is a common problem with a range of causes. The symptom may be due to a reduction in the quantity of saliva produced, or a change in the composition of saliva, but a feeling of dry mouth may also be present in people with normal saliva production. Radiotherapy or chemotherapy for head and neck cancers, and diseases such as Sjögren's Syndrome, may result in reduced saliva production. Many commonly prescribed medications are associated with a feeling of dry mouth, despite normal saliva production. As well as difficulty in speaking, chewing and swallowing, prolonged dry mouth may result in increased risk of tooth decay and reduced quality of life. In many sufferers dry mouth cannot be cured, but effective ways for people to manage dry mouth symptoms are available. Many topical treatments (applied directly to the inside of the mouth) such as sprays, lozenges, mouthrinses, gels, oils, chewing gum or toothpastes have been evaluated in this review, but there is no strong evidence that any topical treatment is effective for relieving the sensation of dry mouth. Oxygenated glycerol triester (OGT) saliva substitute spray is more effective than a water based electrolyte spray. A gel‐releasing device worn in the mouth, or a mouthcare system might be effective but more research is needed. Chewing gum increases saliva production but there is no evidence that gum is better or worse than saliva substitutes. Acidic products and those containing sugar should be avoided.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Furness, S; Worthington, HV; Bryan, G; Birchenough, S; McMillan, R", "articleTypes": [], "doi": "10.1002/14651858.CD008934.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "af35815d-04f2-4622-ba46-f1c3f00669f2", "pmid": "", "title": "Effects of Synbiotic Supplement on Anthropometric Parameters, Cardiovascular Disease Risk Factors, and Bone Metabolism Markers in Transplanted Kidney Patients on Chronic Post-kidney Transplant Phase Diet", "imported": false, "abstract": "The aim of this double-blind randomized clinical trial is to determine the effects of synbiotic supplement on cardiovascular disease risk factors and bone metabolism markers and depression, in transplanted kidney patients on chronic post-kidney transplant phase diet.This study is a double-blind, randomized controlled clinical trial with two parallel groups. 44 patients will be randomly assigned into synbiotic and control group. Transplanted kidney patients referring to the hospital clinics will be invited to participate. After assessing the entrance criteria, 7 cc blood samples are taken. The food recall is completed. Supplements are given to patients for 10-12 weeks. Serum concentrations of malondialdehyde; high sensitivity c-reactive protein; Soluble intercellular adhesion molecule-1; glucose; pentosidine; carboxy-methyl lysine; osteoprotegerin; Receptor activator of nuclear factor kappa-Β ligand; N-telopeptide; Intact parathyroid hormone; triglyceride; total cholesterol; High-density lipoprotein cholesterol; low-density lipoprotein cholesterol; lipoprotein-a; albumin; calcium; phosphorous; blood nitrogen urea; creatinine; and also systolic blood pressure; diastolic blood pressure; Weight; Body mass index; Waist circumference; Hip circumference; and questionnaires including quality of depression.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.244Z" }, { "id": "af616fe9-7434-41b3-9d5c-86bfebadc7d2", "pmid": "", "title": "Acupuncture for Bell's palsy", "imported": false, "abstract": "Abstract - Background Bell's palsy or idiopathic facial palsy is an acute facial paralysis due to inflammation of the facial nerve. A number of studies published in China have suggested acupuncture is beneficial for facial palsy. Objectives The objective of this review was to examine the efficacy of acupuncture in hastening recovery and reducing long‐term morbidity from Bell's palsy. Search methods We updated the searches of the Cochrane Neuromuscular Disease Group Trials Specialized Register (24 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2010), MEDLINE (January 1966 to May 2010), EMBASE (January 1980 to May 2010), AMED (January 1985 to May 2010), LILACS (from January 1982 to May 2010) and the Chinese Biomedical Retrieval System (January 1978 to May 2010) for randomised controlled trials using 'Bell's palsy' and its synonyms, 'idiopathic facial paralysis' or 'facial palsy' as well as search terms including 'acupuncture'. Chinese journals in which we thought we might find randomised controlled trials relevant to our study were handsearched. We reviewed the bibliographies of the randomised trials and contacted the authors and known experts in the field to identify additional published or unpublished data. Selection criteria We included all randomised controlled trials involving acupuncture by needle insertion in the treatment of Bell's palsy irrespective of any language restrictions. Data collection and analysis Two review authors identified potential articles from the literature search, extracted data and assessed quality of each trial independently. All disagreements were resolved by discussion between the review authors. Main results The literature search and handsearching identified 49 potentially relevant articles. Of these, six RCTs were included involving 537 participants with Bell's palsy. Two more possible trials were identified in the update than the previous version of this systematic review, but both were excluded because they were not real RCTs. Of the six included trials, five used acupuncture while the other one used acupuncture combined with drugs. No trial reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. Authors' conclusions The quality of the included trials was inadequate to allow any conclusion about the efficacy of acupuncture. More research with high quality trials is needed. Plain language summary Acupuncture for Bell's palsy Bell's palsy or idiopathic facial palsy is the most common disorder affecting the facial nerves and results in weakness or paralysis on one side of the face. The paralysis causes distortion of the face and interferes with normal functions, such as closing the eye and eating. It is thought to be caused by inflammation of the facial nerve. According to Traditional Chinese Medicine, facial paralysis is known as 'deviated mouth'. It was attributed to 'wind' by past dynasties. 'Qi' refers to the vital substances comprising the human body and the physiological functions of viscera and bowels, channels and collaterals. It maintains life activities and reflects the resistance of the human body. Deficiency of 'qi' allows the invasion of exogenous pathogenic wind. Acupuncture is part of Traditional Chinese Medicine and dates back thousands of years. It involves inserting fine needles into specific points on the skin or applying various other techniques to the acupuncture points to bring about healing. In Bell's palsy, acupuncture treatment might have numerous beneficial effects. This review aimed to review systematically all randomised controlled trials and controlled clinical trials, which examined the effectiveness of acupuncture by needle insertion for Bell's palsy. Six studies including a total of 537 participants met the inclusion criteria. Five studies used acupuncture while the other used acupuncture combined with drugs. No trials reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. More research with high quality trials is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, N, Zhou, M, He, L, Zhou, D, Li, N", "articleTypes": [], "doi": "10.1002/14651858.CD002914.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.078Z" }, { "id": "af73c4d6-0e75-4b49-a706-bb51c59e73b7", "pmid": "", "title": "A Placebo-Controlled, Randomized, Double-Blind Study to Assess the Safety, Tolerability and Efficacy of Folinic Acid Administered to Pediatric Subjects With Autism Spectrum Disorder (ASD)", "imported": false, "abstract": "Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by difficulties in social communication and the presence of restricted or repetitive behaviors. Although behavioral and educational interventions can be helpful, there is currently no established medication for the core symptoms of ASD. Medications approved for associated irritability may be effective in some children but are often associated with significant adverse effects.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.157Z" }, { "id": "af8a995f-4cbd-473e-8f9b-efe2559f6504", "pmid": "", "title": "Gelsectan® in the Treatment of Patients With Diarrhoea-predominant Irritable Bowel Syndrome: a Multicentre, Randomized, Double-blind, Parallel-group, Placebo-controlled Study", "imported": false, "abstract": "Irritable Bowel Syndrome (IBS) is one of the major Disorders of Gut-Brain Interaction (DGBI) and the most frequent reasons for referral to both primary care providers and gastroenterologists.IBS is not a life-threatening disease, but imposes a significant burden on society, entailing a decrease in patients' Quality of Life (QoL), elevated rates of psychological comorbidities and loss of work productivity, which might be the greatest in subjects with IBS-D, for whom the fear of incontinence in a social situation can be especially debilitating. Moreover, IBS is associated with significant direct and indirect healthcare costs and has a considerable socioeconomic impact on society.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.250Z" }, { "id": "af912e25-dee4-44a1-b79d-b36270284591", "pmid": "", "title": "Smectite for acute infectious diarrhoea in children", "imported": false, "abstract": "Abstract - Background As mortality secondary to acute infectious diarrhoea has decreased worldwide, the focus shifts to adjuvant therapies to lessen the burden of disease. Smectite, a medicinal clay, could offer a complementary intervention to reduce the duration of diarrhoea. Objectives To assess the effects of smectite for treating acute infectious diarrhoea in children. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Pubmed), Embase (Ovid), LILACS, reference lists from studies and previous reviews, and conference abstracts, up to 27 June 2017. Selection criteria Randomized and quasi‐randomized trials comparing smectite to a control group in children aged one month to 18 years old with acute infectious diarrhoea. Data collection and analysis Two review authors independently screened abstracts and the full texts for inclusion, extracted data, and assessed risk of bias. Our primary outcomes were duration of diarrhoea and clinical resolution at day 3. We summarized continuous outcomes using mean differences (MD) and dichotomous outcomes using risk ratios (RR), with 95% confidence intervals (CI). Where appropriate, we pooled data in meta‐analyses and assessed heterogeneity. We explored publication bias using a funnel plot. Main results Eighteen trials with 2616 children met our inclusion criteria. Studies were conducted in both ambulatory and in‐hospital settings, and in both high‐income and low‐ or middle‐income countries. Most studies included children with rotavirus infections, and half included breastfed children. Smectite may reduce the duration of diarrhoea by approximately a day (MD ‐24.38 hours, 95% CI ‐30.91 to ‐17.85; 14 studies; 2209 children; low‐certainty evidence); may increase clinical resolution at day 3 (risk ratio (RR) 2.10, 95% CI 1.30 to 3.39; 5 trials; 312 children; low‐certainty evidence); and may reduce stool output (MD ‐11.37, 95% CI ‐21.94 to ‐0.79; 3 studies; 634 children; low‐certainty evidence). We are uncertain whether smectite reduces stool frequency, measured as depositions per day (MD ‐1.33, 95% CI ‐2.28 to ‐0.38; 3 studies; 954 children; very low‐certainty evidence). There was no evidence of an effect on need for hospitalization (RR 0.93, 95% CI 0.75 to 1.15; 2 studies; 885 children; low‐certainty evidence) and need for intravenous rehydration (RR 0.77, 95% CI 0.54 to 1.11; 1 study; 81 children; moderate‐certainty evidence). The most frequently reported side effect was constipation, which did not differ between groups (RR 4.71, 95% CI 0.56 to 39.19; 2 studies; 128 children; low‐certainty evidence). No deaths or serious adverse effects were reported. Authors' conclusions Based on low‐certainty evidence, smectite used as an adjuvant to rehydration therapy may reduce the duration of diarrhoea in children with acute infectious diarrhoea by a day; may increase cure rate by day 3; and may reduce stool output, but has no effect on hospitalization rates or need for intravenous therapy. 2 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (27 Jun, 2017) were included Plain language summary Smectite for treating children with acute diarrhoea What is the aim of this review? The aim of this Cochrane Review was to find out if smectite (or diosmectite), a medicinal clay commonly prescribed to people who have diarrhoea in order to reduce their stool output, helps children with acute diarrhoea. We collected and analysed all relevant studies to answer this question and found 18 relevant studies. Key messages Giving smectite to children with acute diarrhoea may reduce its duration. However, more high‐quality studies are still needed, including studies that assess different causes of diarrhoea and the economic effects of this treatment. What was studied in the review? Acute diarrhoea is one of the most common diseases in children. It is usually caused by a viral infection. The main aim of treatment is to maintain a good level of hydration. This is achieved with oral rehydration solutions, and few children need to be hospitalized or require intravenous rehydration. Still, even with proper hydration, having loose stools is a burden for both parents and patients. Smectite may help by reducing inflammation in the gut; by acting as a barrier to reduce the penetration of toxins; or by increasing water absorption. What are the main results? We found 18 relevant studies with 2616 children that were conducted in both high‐income and low‐ or middle‐income countries. These studies compared children receiving smectite with children receiving routine care or a placebo (a pill or liquid that contains no medicine). Eight studies were funded by the manufacturer. Smectite may reduce the duration of diarrhoea by one day (low‐certainty evidence); may increase the number of children cured by day 3 (low‐certainty evidence); and may slightly reduce the quantity of loose stools (low‐certainty evidence). We are uncertain whether smectite has an effect on how many stools children have (very low‐certainty evidence). It may not have an effect on how many children need to be hospitalized (low‐certainty evidence), and probably does not have an effect on how many children need intravenous rehydration (moderate‐certainty evidence). We found no reports of serious adverse effects. Minor adverse effects included constipation, vomiting, and bad taste, but these did not differ between groups. How up‐to‐date is this review? We searched for studies published up to 27 June 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pérez‐Gaxiola, G; Cuello‐García, CA; Florez, ID; Pérez‐Pico, VM", "articleTypes": [], "doi": "10.1002/14651858.CD011526.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "afa7b58b-fb85-489c-b531-00f4790530aa", "pmid": "", "title": "Fish oil for induction of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Fish oil supplements, which are rich in n‐3 fatty acids, may reduce inflammation, decrease the need for anti‐inflammatory drugs, and promote normal weight gain in people with ulcerative colitis. Objectives This review evaluates the efficacy of fish oil for induction of remission in ulcerative colitis using all available randomised controlled trials. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, EMBASE, CINAHL, the database of ongoing trials and the reference lists of all publications of included or excluded trials were searched. Selection criteria Randomised controlled trials and quasi‐randomised controlled trials with active ulcerative colitis patients who were treated with fish oil. Data collection and analysis The reviewers performed study selection, assessment of methodological quality by using different approaches: including Cochrane assessment of allocation concealment and Jadad quality assessment score. Data extraction forms were used by the two reviewers to extract the data independently. Authors were contacted for additional information. Main results Six studies were included. Three were of cross‐over design and three were of parallel design. No data were pooled for analysis due to differences in outcomes and methodology among the included studies. One small study shows a positive benefit for induction of remission (RR 19.00; 95% CI 1.27 to 284.24). Some of the other included studies show some positive benefits for secondary outcomes. However, these results need to be interpreted with caution due to small study size and poor study quality. Authors' conclusions The current data does not allow for a definitive conclusion regarding the efficacy of fish oil. There is no adequate information to make recommendations for clinical practice. More research is required. Plain language summary Fish oil for the treatment of active ulcerative colitis Ulcerative colitis is an inflammation of the large intestine that causes diarrhea, abdominal pain, rectal bleeding and fever. Since there is no cure for the disease the aim of treatment is to cause a reduction of the unpleasant and painful signs and symptoms. Current, proven, treatment options for active ulcerative colitis include corticosteroids, aminosalicylates, immunosuppressive and biological agents. However, these drugs can cause side effects. New treatments which cause fewer side effects are being sought. Fish oil, which is rich in omega‐3 fatty acids may reduce inflammation and decrease the need for anti‐inflammatory drugs in patients with ulcerative colitis. Six studies looking at the effects of fish oil in active ulcerative colitis were included in the review. Study quality was mostly poor. One small study showed a positive benefit for the treatment of active ulcerative colitis. However, this result should be interpreted with caution due to small study size and poor study quality. Due to limited data there is not enough information available to determine whether fish oil treatment is effective for induction of remission in ulcerative colitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "De Ley, M; de Vos, R; Hommes, DW; Stokkers, PC", "articleTypes": [], "doi": "10.1002/14651858.CD005986.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "afd61fe1-7929-4b2d-8d1c-b00c36234692", "pmid": "", "title": "Tranexamic acid for patients with nasal haemorrhage (epistaxis)", "imported": false, "abstract": "Abstract - Background Epistaxis (nosebleed) most commonly affects children and the elderly. The majority of episodes are managed at home with simple measures. In more severe cases medical intervention is required to either cauterise the bleeding vessel, or to pack the nose with various materials. Tranexamic acid is used in a number of clinical settings to stop bleeding by preventing clot breakdown (fibrinolysis). It may have a role in the management of epistaxis as an adjunct to standard treatments, reducing the need for further intervention. Objectives To determine the effects of tranexamic acid (oral, intravenous or topical) compared with placebo, no additional intervention or any other haemostatic agent in the management of patients with epistaxis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register (via CRS Web); Central Register of Controlled Trials (CENTRAL) (via CRS Web); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 October 2018. Selection criteria Randomised controlled trials (RCTs) of tranexamic acid (in addition to usual care) compared with usual care plus placebo, usual care alone or usual care plus any other haemostatic agent, to control epistaxis in adults or children. Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were control of epistaxis: re‐bleeding (as measured by the proportion of patients re‐bleeding within a period of up to 10 days) and significant adverse effects (seizures, thromboembolic events). Secondary outcomes were control of epistaxis as measured by the time to stop initial bleeding (the proportion of patients whose bleeding is controlled within a period of up to 30 minutes); severity of re‐bleeding (as measured by (a) the proportion of patients requiring any further intervention and (b) the proportion of patients requiring blood transfusion); length of hospital stay and other adverse effects. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included six RCTs (692 participants). The overall risk of bias in the studies was low. Two studies assessed oral administration of tranexamic acid, given regularly over several days, and compared it to placebo. In the other four studies, a single application of topical tranexamic acid was compared with placebo (one study) and a combination of epinephrine and lidocaine or phenylephrine (three studies). All participants were adults. Tranexamic acid versus placebo For our primary outcome, control of epistaxis: re‐bleeding (proportion re‐bleeding within 10 days), we were able to pool data from three studies. The pooled result demonstrated a benefit of tranexamic acid compared to placebo, the risk of re‐bleeding reducing from 67% to 47% (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; three studies; 225 participants; moderate‐quality evidence ). When we compared the effects of oral and topical tranexamic acid separately the risk of re‐bleeding with oral tranexamic acid reduced from 69% to 49%, RR 0.73 (95% CI 0.55 to 0.96; two studies, 157 participants; moderate‐quality evidence ) and with topical tranexamic acid it reduced from 66% to 43%, RR 0.66 (95% CI 0.41 to 1.05; single study, 68 participants). We rated the quality of evidence provided by the single study as low , therefore it is uncertain whether topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. No study specifically sought to identify and report our primary outcome: significant adverse effects (i.e. seizures, thromboembolic events). The secondary outcome time to stop initial bleeding (proportion with bleeding controlled within 30 minutes) was measured in one study using topical tranexamic acid and there was no evidence of a difference at 30 minutes (RR 0.79, 95% CI 0.56 to 1.11; 68 participants; low‐quality evidence ). No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery, embolisation). One study of oral tranexamic acid reported the proportion of patients requiring blood transfusion and found no difference between groups: 5/45 (11%) versus 6/44 (14%) (RR 0.81, 95% CI 0.27 to 2.48; 89 participants; low‐quality evidence ). Two studies reported hospital length of stay. One study reported a significantly shorter stay in the oral tranexamic acid group (mean difference (MD) ‐1.60 days, 95% CI ‐2.49 to ‐0.71; 68 participants). The other study found no evidence of a difference between the groups. Tranexamic acid versus other haemostatic agents When we pooled the data from three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the topical tranexamic acid group compared to the group receiving another haemostatic agent (70% versus 30%: RR 2.35, 95% CI 1.90 to 2.92; 460 participants) ( moderate‐quality evidence ). Adverse effects across all studies Five studies recorded 'adverse effects' in a general way. None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient developed a superficial thrombophlebitis of both legs following discharge, however it is not reported in which group this occurred. No \"other serious adverse effect\" was reported in any study. Authors' conclusions We found moderate‐quality evidence that there is probably a reduction in the risk of re‐bleeding with the use of either oral or topical tranexamic acid in addition to usual care in adult patients with epistaxis, compared to placebo with usual care. However, the quality of evidence relating solely to topical tranexamic acid was low (one study only), so we are uncertain whether or not topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. We found moderate‐quality evidence that topical tranexamic acid is probably better than other topical agents in stopping bleeding in the first 10 minutes. There have been only three RCTs on this subject since 1995. Since then there have been significant changes in nasal cauterisation and packing techniques (for example, techniques including nasal endoscopy and more invasive approaches such as endoscopic sphenopalatine artery ligation). New trials would inform us about the effectiveness of tranexamic acid in light of these developments. Plain language summary Tranexamic acid to help treat nosebleeds (epistaxis) Background Nosebleeds are a very common condition, with the majority of those affected either children or those over the age of 60. They usually stop on their own or by simply compressing the nose with fingers, although a small number require medical attention. This will involve either cauterising (sealing) the bleeding vessel, if it can be seen, or packing the inside of the nose with a material to cause pressure to build up and stop the bleeding ('usual care'). Occasionally bleeding continues despite these measures, or it restarts having initially been controlled. This can lead to a prolonged hospital stay and the possibility of further procedures such as repacking with a different type of nasal pack or an operation. Tranexamic acid is a drug that is known to help promote blood clotting by preventing a natural process called fibrinolysis (dissolution of a clot). It is already used in a number of situations where bleeding is a significant worry, such as after heart surgery or major trauma. It can be given by mouth (orally), directly to the bleeding site (topically) or by injection into a vein (intravenously). Study characteristics We searched for randomised controlled trials in patients of any age with nosebleed requiring intervention. Patients were treated with tranexamic acid (in addition to usual care) compared to placebo, no treatment or any other agent used to stop bleeding. We found six studies that met our inclusion criteria, with a total of 692 participants. Two studies used oral administration of tranexamic acid and four used topical administration. All participants in the studies were adults. Three of the six studies were conducted over 20 years ago. Key results Three studies measured re‐bleeding within 10 days. When we combined the results we found that fewer patients who were given either oral or topical tranexamic acid had further episodes of re‐bleeding following an initial nosebleed compared to those treated with usual care. The time to stop initial bleeding (control of bleeding within 30 minutes) was measured in four studies. In three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the group receiving topical tranexamic acid compared to the group receiving a different drug (topical epinephrine and lidocaine or phenylephrine). In the other study there was no significant difference at 30 minutes when topical tranexamic acid was compared with placebo. No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery). Only one study of oral tranexamic acid reported the proportion of patients requiring a blood transfusion and there was no evidence of a difference between the groups. Length of hospital stay was reported in two studies. One study reported a significantly shorter stay in the oral tranexamic acid group, while the other found no evidence of a difference. Five studies mention recording \"adverse effects\". None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient did develop a superficial thrombophlebitis (inflammation and a blood clot in a vein near the surface of the skin) of both legs following discharge, but the study did not report in which treatment group this happened. No serious adverse event was seen in any of the studies. Quality of the evidence and conclusions Overall, the risk of bias in the six studies was low. We graded the quality of the evidence for the main outcome (control of epistaxis: re‐bleeding within 10 days) as moderate, which means that further research is likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate. In light of this and the fact that 'usual care' has changed, with the development of more modern nasal cauterisation and packing techniques, since three of the included studies were carried out, there remains uncertainty about the role of tranexamic acid in the treatment of patients with epistaxis. Newer research into the effect of tranexamic acid as a treatment for nosebleeds would inform future management decisions for this condition. The evidence in this review is up to date to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Joseph, J, Martinez‐Devesa, P, Bellorini, J, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.751Z" }, { "id": "afeb1519-a060-4017-89ac-35080b30b220", "pmid": "", "title": "Nebulized and oral thiol derivatives for pulmonary disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is an inherited condition resulting in thickened, sticky respiratory secretions. Respiratory failure, due to recurrent pulmonary infection and inflammation, is the most common cause of mortality. Muco‐active therapies (e.g. dornase alfa and nebulized hypertonic saline) may decrease sputum viscosity, increase airway clearance of sputum, reduce infection and inflammation and improve lung function. Thiol derivatives, either oral or nebulized, have shown benefit in other respiratory diseases. Their mode of action is likely to differ according to the route of administration. There are several thiol derivatives, and it is unclear which of these may be beneficial in cystic fibrosis. Objectives To evaluate the efficacy and safety of nebulized and oral thiol derivatives in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches, hand searches of relevant journals, abstract books and conference proceedings. Most recent search: 13 June 2013. We also conducted a PubMed search on 26 February 2013 for relevant published articles. Selection criteria Randomized and quasi‐randomized controlled trials comparing nebulized or oral thiol derivatives to placebo or another thiol derivative in people with cystic fibrosis. Data collection and analysis The authors independently assessed trials for inclusion, analysed risk of bias and extracted data. Main results Searches identified 23 trials; nine trials (255 participants) are included, of these seven trials are more than 10 years old. Three trials of nebulized thiol derivatives were identified (one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and another compared glutathione to 4% hypertonic saline). Although generally well‐tolerated with no significant adverse effects, there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Six trials of oral thiol derivatives were identified. Three trials compared N‐acetylcysteine to placebo; one compared N‐acetylcysteine, ambroxol and placebo; one compared carbocysteine to ambroxol; and one compared low and high‐dose N‐acetylcysteine. Oral thiol derivatives were generally well‐tolerated with no significant adverse effects, however there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Authors' conclusions We found no evidence to recommend the use of either nebulized or oral thiol derivatives in people with cystic fibrosis. There are very few good quality trials investigating the effect of these medications in cystic fibrosis, and further research is required to investigate the potential role of these medications in improving the outcomes of people with cystic fibrosis. Plain language summary Compounds which can break down the structure of mucus for lung disease in cystic fibrosis Cystic fibrosis is a genetic disorder which mainly affects the lungs. Chest infections recur in people with cystic fibrosis due to a build up of thick sputum (phlegm) in the air passages. Several treatments, including thiol derivatives, aim to loosen this sputum and so improve lung function and reduce the frequency of chest infections. Thiol derivatives may be either nebulized (breathed in) or oral (by mouth). They have been shown to help in other lung conditions, such as chronic obstructive pulmonary disease. This review aims to find out if there is enough evidence to recommend the use of nebulized or oral thiol derivatives for people with cystic fibrosis. We included nine trials; three assessed the effect of nebulized thiol derivatives. Of the nebulized trials, one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and the other compared glutathione to 4% hypertonic saline. Nebulized thiol derivatives were generally well‐tolerated with no major adverse effects. However they showed no significant improvements in any of our outcome measures. Six included trials assessed the effects of oral thiol derivatives.Three of these trials compared oral N‐acetylcysteine to placebo; one compared oral N‐acetylcysteine, oral ambroxol and placebo; and one compared oral carbocysteine and oral ambroxol (no placebo). None of the trials showed an overall significant benefit in any of the outcome measures of this review. Oral thiol derivatives were generally well‐tolerated with no major adverse effects. In summary, the trials included in the review did not provide any evidence that nebulized or oral thiol derivatives were either beneficial or harmful to people with cystic fibrosis. Further research investigating the effects of thiol derivatives in people with cystic fibrosis is required before their use can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Tam, J; Nash, EF; Ratjen, F; Tullis, E; Stephenson, A", "articleTypes": [], "doi": "10.1002/14651858.CD007168.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "aff1e888-3e2a-4f8a-8c0a-44161f277567", "pmid": "", "title": "Blood pressure lowering efficacy of potassium‐sparing diuretics (that block the epithelial sodium channel) for primary hypertension", "imported": false, "abstract": "Abstract - Background Potassium‐sparing diuretics, which block the epithelial sodium channel (ENaC), are widely prescribed for hypertension as a second‐line drug in patients taking other diuretics (e.g. thiazide diuretics) and much less commonly prescribed as monotherapy. Therefore, it is essential to determine the effects of ENaC blockers on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a first‐line or second‐line therapy. Objectives To quantify the dose‐related reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of ENaC blocker therapy as a first‐line or second‐line drug in patients with primary hypertension. Search methods We searched CENTRAL (The Cochrane Library 2012), MEDLINE (1950 to August 2012), EMBASE (1980 to August 2012) and reference lists of articles. Selection criteria Double‐blind, randomized, controlled trials in patients with primary hypertension that evaluate, for a duration of 3 to 12 weeks, the BP lowering efficacy of: 1) fixed‐dose monotherapy with an ENaC blocker compared with placebo; or 2) an ENaC blocker in combination with another class of anti‐hypertensive drugs compared with the respective monotherapy (without an ENaC blocker). Data collection and analysis Two authors independently assessed the risk of bias and extracted data. Study authors were contacted for additional information. WDAE information was also collected from the trials. Main results No trials evaluating the BP lowering efficacy of ENaC blockers as monotherapy in patients with primary hypertension were identified. Only 6 trials evaluated the BP lowering efficacy of low doses of amiloride and triamterene as a second drug in 496 participants with a baseline BP of 151/102 mm Hg. The additional BP reduction caused by the ENaC blocker as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. The addition of low doses of amiloride and triamterene in these trials did not reduce BP. An estimate of the dose‐related BP lowering efficacy for ENaC blockers was not possible because of a lack of trial data at higher doses. Authors' conclusions ENaC blockers do not have a statistically or clinically significant BP lowering effect at low doses but trials at higher doses are not available. The review did not provide a good estimate of the incidence of harms associated with ENaC blockers. Plain language summary The blood pressure lowering effect of ENaC blockers is not known Potassium‐sparing diuretics, which block the epithelial sodium channel (also called ENaC blockers), are a class of drugs commonly prescribed to prevent loss of potassium but also might help to lower elevated blood pressure. This class includes drugs such as amiloride (Midamor, Amilzide) and triamterene (Dyrenium, Dyazide). We asked how much this class of drugs lowers blood pressure, when used alone or when used as the second drug to treat hypertension. The available scientific literature was searched to find all the trials that had assessed this question. No trials were found studying the blood pressure lowering ability of ENaC blockers when used alone. We found 6 trials studying the blood pressure lowering ability of amiloride and triamterene, when added as a second drug, in 496 participants. All 6 trials studied the ENaC blockers at low doses and there was no blood pressure lowering effect. Trials studying these drugs at higher doses are needed in order to determine if they lower blood pressure. The harms associated with ENaC blockers could not be estimated in this review because of the low doses studied and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Heran, BS, Chen, JMH, Wang, JJ, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD008167.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.102Z" }, { "id": "aff3cb1e-6691-44b5-906c-f368aa9152e4", "pmid": "", "title": "Treatment and prevention of pouchitis after ileal pouch‐anal anastomosis for chronic ulcerative colitis", "imported": false, "abstract": "Abstract - Background Pouchitis occurs in approximately 50% of patients following ileal pouch‐anal anastomosis (IPAA) for chronic ulcerative colitis (UC). Objectives The primary objective was to determine the efficacy and safety of medical therapies for prevention or treatment of acute or chronic pouchitis. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 25 July 2018. We also searched references, trials registers, and conference proceedings. Selection criteria Randomized controlled trials of prevention or treatment of acute or chronic pouchitis in adults who underwent IPAA for UC were considered for inclusion. Data collection and analysis Two authors independently screened studies for eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was evaluated using GRADE. The primary outcome was clinical improvement or remission in participants with acute or chronic pouchitis, or the proportion of participants with no episodes of pouchitis after IPAA. Adverse events (AEs) was a secondary outcome. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for each dichotomous outcome. Main results Fifteen studies (547 participants) were included. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Three studies were low risk of bias. Three studies were high risk of bias and the other studies were unclear. Acute pouchitis: All ciprofloxacin participants (7/7) achieved remission at two weeks compared to 33% (3/9) of metronidazole participants (RR 2.68, 95% CI 1.13 to 6.35, very low certainty evidence). No ciprofloxacin participants (0/7) had an AE compared to 33% (3/9) of metronidazole participants (RR 0.18, 95% CI 0.01 to 2.98; very low certainty evidence). AEs included vomiting, dysgeusia or transient peripheral neuropathy. Forty‐three per cent (6/14) of metronidazole participants achieved remission at 6 weeks compared to 50% (6/12) of budesonide enema participants (RR 0.86, 95% CI 0.37 to 1.96, very low certainty evidence). Fifty per cent (7/14) of metronidazole participants improved clinically at 6 weeks compared to 58% (7/12) of budesonide enema participants (RR 0.86, 95% CI 0.42 to 1.74, very low certainty evidence). Fifty‐seven per cent (8/14) of metronidazole participants had an AE compared to 25% (3/12) of budesonide enema participants (RR 2.29, 95% CI 0.78 to 6.73, very low certainty evidence). AEs included anorexia, nausea, headache, asthenia, metallic taste, vomiting, paraesthesia, and depression. Twenty‐five per cent (2/8) of rifaximin participants achieved remission at 4 weeks compared to 0% (0/10) of placebo participants (RR 6.11, 95% CI 0.33 to 111.71, very low certainty evidence). Thirty‐eight per cent (3/8) of rifaximin participants improved clinically at 4 weeks compared to 30% (3/10) of placebo participants (RR 1.25, 95% CI 0.34 to 4.60, very low certainty evidence). Seventy‐five per cent (6/8) of rifaximin participants had an AE compared to 50% (5/10) of placebo participants (RR 1.50, 95% CI 0.72 to 3.14, very low certainty evidence). AEs included diarrhea, flatulence, nausea, proctalgia, vomiting, thirst, candida, upper respiratory tract infection, increased hepatic enzyme, and cluster headache. Ten per cent (1/10) of Lactobacillus GG participants improved clinically at 12 weeks compared to 0% (0/10) of placebo participants (RR 3.00, 95% CI 0.14 to 65.90, very low certainty evidence). Chronic pouchitis: Eighty‐five per cent (34/40) of De Simone Formulation (a probiotic formulation) participants maintained remission at 9 to 12 months compared to 3% (1/36) of placebo participants (RR 20.24, 95% CI 4.28 to 95.81, 2 studies; low certainty evidence). Two per cent (1/40) of De Simone Formulation participants had an AE compared to 0% (0/36) of placebo participants (RR 2.43, 95% CI 0.11 to 55.89; low certainty evidence). AEs included abdominal cramps, vomiting and diarrhea. Fifty per cent (3/6) of adalimumab patients achieved clinical improvement at 4 weeks compared to 43% (3/7) of placebo participants (RR, 1.17, 95% CI 0.36 to 3.76, low certainty evidence). Sixty per cent (6/10) of glutamine participants maintained remission at 3 weeks compared to 33% (3/9) of butyrate participants (RR 1.80, 95% CI 0.63 to 5.16, very low certainty evidence). Forty‐five per cent (9/20) of patients treated with bismuth carbomer foam enema improved clinically at 3 weeks compared to 45% (9/20) of placebo participants (RR 1.00, 95% CI 0.50 to 1.98, very low certainty evidence). Twenty‐five per cent (5/20) of participants in the bismuth carbomer foam enema group had an AE compared to 35% (7/20) of placebo participants (RR 0.71, 95% CI 0.27 to 1.88, very low certainty evidence). Adverse events included diarrhea, worsening symptoms, cramping, sinusitis, and abdominal pain. Prevention: At 12 months, 90% (18/20) of De Simone Formulation participants had no episodes of acute pouchitis compared to 60% (12/20) of placebo participants (RR 1.50, 95% CI 1.02 to 2.21, low certainty evidence). Another study found 100% (16/16) of De Simone Formulation participants had no episodes of acute pouchitis at 12 months compared to 92% (11/12) of the no treatment control group (RR 1.10, 95% 0.89 to 1.36, very low certainty evidence). Eighty‐six per cent (6/7) of Bifidobacterium longum participants had no episodes of acute pouchitis at 6 months compared to 60% (3/5) of placebo participants (RR 1.43, 95% CI 0.66 to 3.11, very low certainty evidence). Eleven per cent (1/9) of Clostridium butyricum MIYAIRI participants had no episodes of acute pouchitis at 24 months compared to 50% (4/8) of placebo participants (RR 0.22, 95% CI 0.03 to 1.60, very low certainty evidence). Forty‐six per cent (43/94) of allopurinol participants had no episodes of pouchitis at 24 months compared to 43% (39/90) of placebo participants (RR 1.06, 95% CI 0.76 to 1.46; low certainty evidence). Eighty‐one per cent (21/26) of tinidazole participants had no episodes of pouchitis over 12 months compared to 58% (7/12) of placebo participants (RR 1.38, 95% CI 0.83 to 2.31, very low certainty evidence). Authors' conclusions The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. Well designed, adequately powered studies are needed to determine the optimal therapy for the treatment and prevention of pouchitis. Plain language summary Therapy for treatment and prevention of pouchitis What is pouchitis? Some people with ulcerative colitis have their colon and rectum removed with construction of a pouch (made from a loop of small intestine) in place of the rectum ‐ known as ileal pouch‐anal anastomosis (IPAA) surgery. Pouchitis is inflammation of the surgically‐constructed pouch. Symptoms of active pouchitis include diarrhea, increased stool frequency, abdominal cramping, fecal urgency, tenesmus (feeling of constantly needing to pass stools), and incontinence. Acute refers to symptoms that last less than four weeks while chronic refers to symptoms that last more than four weeks. Periods when symptoms stop are called 'remission'. What therapies are used for pouchitis? Therapies used for pouchitis include antibiotics (drugs for bacteria infections), budesonide enemas (a steroid drug), probiotics (helpful bacteria), biologic agents that target tumor necrosis factor, glutamine suppositories (an amino acid), butyrate suppositories (short chain fatty acid), bismuth enemas (diarrhea medication), allopurinol (a purine analogue drug), and tinidazole (an anti‐parasitic drug). What did the researchers investigate? The researchers investigated whether these medications produce remission in people with active pouchitis, maintain remission in people with inactive pouchitis or prevent pouchitis in people who've had IPAA surgery. Side effects were also assessed. The medical literature was searched up to 25 July 2018. What did the researchers find? We found 15 studies with a total of 547 participants. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Acute pouchitis: It is uncertain whether ciprofloxacin is more effective than metronidazole for treatment of acute pouchitis (1 study, 16 participants). Side effects included vomiting, metallic taste and temporary damage to nerves. It is unclear whether there are any differences between metronidazole and budesonide enemas in terms of clinical remission, symptom improvement or side effects (1 study, 26 participants). Side effects included anorexia, nausea, headache, lack of energy and strength, metallic taste, vomiting, pins and needles, and depression. It is uncertain whether there are any differences between rifaximin and placebo in terms of clinical remission, symptom improvement, or side effects (1 study, 18 participants). Side effects included diarrhea, flatulence, nausea, rectal pain, vomiting, thirst, yeast infection, common cold, increased liver enzymes, and cluster headache. It is uncertain whether there is any difference between Lactobacillus GG and placebo in symptom improvement (1 study, 20 participants. The results of these studies are uncertain due to low event numbers caused by the small numbers of people who participated in the studies. Chronic pouchitis: It is uncertain whether De Simone Formulation (a probiotic formulation) is more effective than placebo for maintaining remission in people with inactive disease (2 studies, 76 participants). Side effects included abdominal cramps, vomiting and diarrhea. It is unclear whether there is any difference in effectiveness between adalimumab and placebo for treating chronic pouchitis(1 study, 13 participants). It is unclear whether there is any difference between glutamine and butyrate suppositories for maintenance of remission (1 study, 19 participants). It is unclear whether there are any differences in symptom improvement or side effects between bismuth carbomer foam enemas and placebo (1 study, 40 participants). Side effects included diarrhea, worsening symptoms, cramping, sinus infection, and abdominal pain. The results of these studies are uncertain due to the small number of people who participated in the studies. Prevention of pouchitis: It is uncertain whether De Simone Formulation is more effective than placebo for prevention of pouchitis (1 study, 40 participants). However, it is unclear whether there is any difference in prevention of pouchitis between De Simone Formulation and a no treatment control group (1 study, 28 participants). It is unclear whether there are any differences in prevention of pouchitis between Clostridium butyricum MIYAIRI and placebo (1 study, 17 participants) , Bifidobacterium longum and placebo (1 study, 12 participants) , allopurinol and placebo (1 study, 184 participants) and tinidazole and placebo (1 study, 38 participants). The results of these studies are uncertain due to the small number of people who participated in the studies. The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. More research is needed to determine which of these different medications are best for treatment of pouchitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nguyen, N; Zhang, B; Holubar, SD; Pardi, DS; Singh, S", "articleTypes": [], "doi": "10.1002/14651858.CD001176.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "aff6fc3e-57ee-4c9c-ad87-e84cc5e452a2", "pmid": "", "title": "Statins for Smith‐Lemli‐Opitz syndrome", "imported": false, "abstract": "Abstract - Background Smith‐Lemli‐Opitz syndrome (SLOS) is a multiple congenital malformations syndrome caused by defective cholesterol biosynthesis. Affected individuals show cholesterol deficiency and accumulation of various precursor molecules, mainly 7‐dehydrocholesterol and 8‐dehydrocholesterol. There is currently no cure for SLOS, with cholesterol supplementation being primarily a biochemical therapy of limited evidence. However, several anecdotal reports and preclinical studies have highlighted statins as a potential therapy for SLOS. Objectives To evaluate the effects of statins, either alone or in combination with other non‐statin therapies (e.g. cholesterol, bile acid, or vitamin co‐supplementation), compared to cholesterol supplementation alone or in combination with other non‐statin therapies (e.g. bile acid or vitamin supplementation) on several important outcomes including overall survival, neurobehavioral features, and adverse effects in individuals with SLOS. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and three trials registers on 15 February 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs with parallel or cross‐over designs, and non‐randomized studies of interventions (NRSIs) including non‐randomized trials, cohort studies, and controlled before‐and‐after studies, were eligible for inclusion in this review if they met our prespecified inclusion criteria, i.e. involved human participants with biochemically or genetically diagnosed SLOS receiving statin therapy or cholesterol supplementation, or both. Data collection and analysis Two authors screened titles and abstracts and subsequently full‐texts for all potentially‐relevant references. Both authors independently extracted relevant data from included studies and assessed the risks of bias. We analyzed the data extracted from the included NRSIs and cohort studies separately from the data extracted from the single included RCT. We used a random‐effects model to account for the inherent heterogeneity and methodological variation between these different study designs. We used GRADE to assess the certainty of evidence. Main results We included six studies (61 participants with SLOS); one RCT (N = 18), three prospective NRSIs (N = 20), and two retrospective NRSIs (N = 22). Five studies included only children, and two limited their participant inclusion by disease severity. Overall, there were nearly twice as many males as females. All six studies compared add‐on statin therapy to cholesterol supplementation alone. However, the dosages, formulations, and durations of treatment were highly variable across studies. We judged the RCT as having a high risk of bias due to missing data and selective reporting. All included NRSIs had a serious or critical overall risk of bias assessed by the Risk Of Bias In Non‐randomized Studies of Interventions tool (ROBINS‐I). None of the included studies evaluated survival or reported quality of life (QoL). Only the included RCT formally assessed changes in the neurobehavioral manifestations of SLOS, and we are uncertain whether statin therapy improves this outcome (very low‐certainty evidence). We are also uncertain whether the adverse events reported in the RCT were statin‐related (very low‐certainty evidence). In contrast, the adverse events reported in the NRSIs seem to be possibly due to statin therapy (risk ratio 13.00, 95% confidence interval 1.85 to 91.49; P = 0.01; low‐certainty evidence), with only one of the NRSIs retrospectively mentioning changes in the irritability of two of their participants. We are uncertain whether statins affect growth based on the RCT or NRSI results (very low‐certainty evidence). The RCT showed that statins may make little or no difference to plasma biomarker levels (low‐certainty evidence), while we are uncertain of their effects on such parameters in the NRSIs (very low‐certainty evidence). Authors' conclusions Currently, there is no evidence on the potential effects of statin therapy in people with SLOS regarding survival or QoL, and very limited evidence on the effects on neurobehavioral manifestations. Likewise, current evidence is insufficient and of very low certainty regarding the effects of statins on growth parameters in children with SLOS and plasma or cerebrospinal fluid (CSF) levels of various disease biomarkers. Despite these limitations, current evidence seemingly suggests that statins may increase the risk of adverse reactions in individuals with SLOS receiving statins compared to those who are not. Given the insufficient evidence on potential benefits of statins in individuals with SLOS, and their potential for causing adverse reactions, anyone considering this therapy should take these findings into consideration. Future studies should address the highlighted gaps in evidence on the use of statins in individuals with SLOS by collecting prospective data on survival and performing serial standardized assessments of neurobehavioral features, QoL, anthropometric measures, and plasma and CSF biomarker levels after statin introduction. Future studies should also attempt to use consistent dosages, formulations and durations of cholesterol and statin therapy. Plain language summary Statins for Smith‐Lemli‐Opitz syndrome Review question Is statin therapy, either alone or combined with cholesterol therapy, linked to better outcomes (e.g. survival, quality of life, severity or frequency of neurobehavioral abnormalities, changes in growth parameters or biomarker levels) compared to cholesterol therapy alone for people with Smith‐Lemli‐Opitz syndrome (SLOS), and what are the risks of harmful effects for either option? Background Smith‐Lemli‐Opitz syndrome is a genetic malformation syndrome, which occurs when cholesterol is not able to be produced by the body and there is a build up of several toxic molecules that would, under normal circumstances, go on to become cholesterol, such as 7DHC and 8DHC. This means that people with SLOS may fail to achieve normal physical growth, show various degrees of intellectual disability or developmental delay (or both), and show a range of possible behavioral abnormalities (e.g. irritability, aggressiveness, anxiety, attention‐deficit hyperactivity disorder (ADHD), impulsivity and sleep disturbances, among others). It is also notable that SLOS may cause various possible physical abnormalities and disability. There is currently no cure for SLOS, but cholesterol supplementation remains common practice among clinicians caring for people with SLOS. This is based solely on our current understanding of the underlying biochemistry of the disease itself. However, there has been evidence from studies in the laboratory and in single individuals suggesting that statins may be helpful for treating people with SLOS. Search date We conducted our latest search on 15 February 2022. Study characteristics In this review, we included six studies of different designs that included a total of 61 people with SLOS, mostly males. Five of the studies only included children (18 years old or younger). All studies compared a combination of statin and cholesterol therapy to cholesterol supplementation alone. However, the studies used different doses and formulations of statin or cholesterol therapy (or both), as well as different durations of treatment. Key results We found no evidence for the effects of combined statin and cholesterol supplementation, compared to cholesterol supplementation alone, on survival or quality of life in people with SLOS. We are also not sure if combined statin and cholesterol therapy has positive effects on neurobehavioral manifestations or growth in individuals with SLOS compared with cholesterol therapy alone, as we have low confidence in the evidence. We think people with SLOS receiving statin therapy in addition to cholesterol supplementation are more likely to experience adverse events that are usually associated with using statins, compared to those who are only receiving cholesterol supplementation. Finally, we are uncertain about the effects of statin therapy on the levels of various biomarkers usually measured in the blood of people with SLOS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ballout, RA; Livinski, A; Fu, Y-P; Steiner, RD; Remaley, AT", "articleTypes": [], "doi": "10.1002/14651858.CD013521.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "aff81ef2-3bfe-473e-8f11-b13d4101cd21", "pmid": "", "title": "Oral Astragalus (Huang qi) for preventing frequent episodes of acute respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common in children and can involve both upper and lower airways. Many children experience frequent ARTI episodes or recurrent respiratory tract infections (RRTIs) in early life, which creates challenges for paediatricians, primary care physicians, parents and carers of children. In China, Astragalus (Huang qi), alone or in combination with other herbs, is used by Traditional Chinese Medicine (TCM) practitioners in the form of a water extract, to reduce the risk of ARTIs; it is believed to stimulate the immune system. Better understanding of the therapeutic mechanisms of Astragalus may provide insights into ARTI prevention, and consequently reduced antibiotic use. Objectives To assess the effectiveness and safety of oral Astragalus for preventing frequent episodes of acute respiratory tract infections (ARTIs) in children in community settings. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2015), MEDLINE (Ovid) (1946 to 31 December 2015), Embase (Elsevier) (1974 to 31 December 2015), AMED (Ovid) (1985 to 31 December 2015), Chinese National Knowledge Infrastructure (CNKI) (1979 to 31 December 2015) and Chinese Scientific Journals full text database (CQVIP) (1989 to 31 December 2015), China Biology Medicine disc (CBM 1976 to 31 December 2015) and Wanfang Data Knowledge Service Platform (WanFang) (1998 to 31 December 2015). Selection criteria We included randomised controlled trials (RCTs) comparing oral Astragalus as a sole Chinese herbal preparation with placebo to prevent frequent episodes of ARTIs in children. Data collection and analysis We used standard Cochrane methodological procedures for this review. We assessed search results to identify relevant studies. We planned to extract data using standardised forms. Disagreements were to be resolved through discussion. Risk of bias was to be assessed using the Cochrane 'Risk of bias' tool. We planned to use mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) or odds ratio (OR) to analyse dichotomous data, both with 95% confidence intervals (CIs). Main results We identified 6080 records: 3352 from English language databases, 2724 from Chinese databases, and four from other sources. Following initial screening and deduplication, we obtained 120 full‐text papers for assessment. Of these, 21 were not RCTs; 55 did not meet the inclusion criteria because: participants were aged over 14 years; definition was not included for recurrent or frequent episodes; Astragalus preparation was not an intervention; Astragalus preparation was in the formula but was not the sole agent; the Astragalus preparation was not administered orally; or Astragalus was used for treatment rather than prevention of ARTI. A further 44 studies were excluded because they were not placebo‐controlled, although other inclusion criteria were fulfilled. No RCTs met our inclusion criteria. Authors' conclusions We found insufficient evidence to enable assessment of the effectiveness and safety of oral Astragalus as a sole intervention to prevent frequent ARTIs in children aged up to 14 years. Plain language summary Can oral Astragalus (Huang qi) prevent frequent acute respiratory tract infections in children? Review question We assessed evidence for the benefits and harms of oral Astragalus used alone to prevent frequent episodes of acute respiratory infections (ARTIs) in children aged up to 14 years, compared to a dummy treatment. ARTIs include colds, sore throats, laryngitis, influenza, bronchitis and pneumonia. Background Many therapies are used to prevent ARTIs, especially in children. Astragalus, is a widely used and available herbal therapy that has been used for thousands of years in China to help prevent ARTIs. It is thought to boost immunity. Almost one in five children experience frequent ARTIs and treatment accounts for up to 75% of all prescribed antibiotics for children. Because most ARTIs are caused by viruses, antibiotics are not effective in treating these illnesses. Search date We searched the literature up to 31 December 2015. Study characteristics We identified 6080 potentially relevant records. After removing duplicate records, and those that did not meet our inclusion criteria, we obtained 120 full‐text studies. We carefully assessed these studies for possible inclusion. We excluded most studies because: they presented unclear diagnosis criteria; Astragalus preparation was used with other agents; or Astragalus was not compared with a dummy treatment. No studies met our inclusion criteria and so we were unable to analyse any results. Study funding sources We could not assess study funding sources. Key results We did not find any studies that compared use of oral Astragalus alone with a dummy treatment to prevent frequent episodes of ARTI in children aged up to 14 years. Well‐designed, conducted and reported studies investigating this issue are needed to enable assessment in the future. Quality of the evidence We could not assess evidence quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Su, G; Chen, X; Liu, Z; Yang, L; Zhang, L; Stålsby Lundborg, C; Wen, Z; Guo, X; Qin, X; Liang, J; Liu, X", "articleTypes": [], "doi": "10.1002/14651858.CD011958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "b023104e-5a4f-4efb-9633-8fefdec7585d", "pmid": "", "title": "Corticosteroids for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve are implicated in causing Bell's palsy. Corticosteroids have a potent anti‐inflammatory action that should minimise nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Objectives To determine the effectiveness and safety of corticosteroid therapy in people with Bell's palsy. Search methods On 4 March 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS. We reviewed the bibliographies of the randomised trials and contacted known experts in the field to identify additional published or unpublished trials. We also searched clinical trials registries for ongoing trials. Selection criteria Randomised trials and quasi‐randomised trials comparing different routes of administration and dosage schemes of corticosteroid or adrenocorticotrophic hormone therapy versus a control group receiving no therapy considered effective for this condition, unless the same therapy was given in a similar way to the experimental group. Data collection and analysis We used standard Cochrane methodology. The main outcome of interest was incomplete recovery of facial motor function (i.e. residual facial weakness). Secondary outcomes were cosmetically disabling persistent sequelae, development of motor synkinesis or autonomic dysfunction (i.e. hemifacial spasm, crocodile tears) and adverse effects of corticosteroid therapy manifested during follow‐up. Main results We identified seven trials, with 895 evaluable participants for this review. All provided data suitable for the primary outcome meta‐analysis. One of the trials was new since the last version of this Cochrane systematic review. Risk of bias in the older, smaller studies included some unclear‐ or high‐risk assessments, whereas we deemed the larger studies at low risk of bias. Overall, 79/452 (17%) participants allocated to corticosteroids had incomplete recovery of facial motor function six months or more after randomisation; significantly fewer than the 125/447 (28%) in the control group (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.50 to 0.80, seven trials, n = 895). The number of people who need to be treated with corticosteroids to avoid one incomplete recovery was 10 (95% CI 6 to 20). The reduction in the proportion of participants with cosmetically disabling sequelae six months after randomisation was very similar in the corticosteroid and placebo groups (RR 0.96, 95% CI 0.40 to 2.29, two trials, n = 75, low‐quality evidence). However, there was a significant reduction in motor synkinesis during follow‐up in participants receiving corticosteroids (RR 0.64, 95% CI 0.45 to 0.91, three trials, n = 485, moderate‐quality evidence). Three studies explicitly recorded the absence of adverse effects attributable to corticosteroids. One trial reported that three participants receiving prednisolone had temporary sleep disturbances and two trials gave a detailed account of adverse effects occurring in 93 participants, all non‐serious; the combined analysis of data from these three trials found no significant difference in adverse effect rates between people receiving corticosteroids and people receiving placebo (RR 1.04, 95% CI 0.71 to 1.51, n = 715). Authors' conclusions The available moderate‐ to high‐quality evidence from randomised controlled trials showed significant benefit from treating Bell's palsy with corticosteroids. Plain language summary Corticosteroids for Bell's palsy Review question What are the effects of corticosteroids on Bell's palsy? Background Bell's palsy is a paralysis or weakness of muscles in the face, usually on one side, with no certain cause. Symptoms usually recover, although not always. Reducing inflammation of the facial nerve using corticosteroid medicines (steroids) is thought to limit nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Study characteristics We identified seven clinical trials involving 895 people with one‐sided mild, moderate or severe Bell's palsy of unknown cause. All of these trials reported rates of incomplete recovery (the proportion of people left with facial weakness) and we were able to combine the results. People in the studies were aged from 2 to 84 years. They were treated with corticosteroids or placebo (inactive treatment), either alone or in combination with other therapies. One trial only involved children, from 24 months to 74 months old. The duration of the included studies for adults and children ranged from 157 days to 12 months. Key results and quality of the evidence Incomplete recovery According to moderate quality to high quality evidence, corticosteroids reduced the number of people left with facial weakness after Bell's palsy compared to placebo (a pretend medicine). This finding was based on data from seven studies involving 895 participants with Bell's palsy of varying degrees of severity. We calculated that to stop one person from being left with facial weakness, 10 people need to be treated. Five studies provided data on long‐term after‐effects of Bell's palsy following treatment. Two of the studies (75 participants) looked at persistent effects on facial appearance after six months or more. The effect was nearly the same for corticosteroids and placebo, showing that participants who had corticosteroids benefited slightly, although this evidence was low quality. Data from three studies (485 participants) showed clearly that people who received corticosteroids developed less motor synkinesis (unwanted facial movements) and crocodile tears (watery eyes when eating or chewing), compared with people who received placebo alone. This finding was based on moderate‐quality evidence. Side effects Three studies reported that no side effects could be attributed to corticosteroid treatment. Based on moderate‐quality evidence from three studies (715 participants), numbers experiencing side effects were similar with corticosteroids and placebo. The evidence is current to March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Madhok, VB, Gagyor, I, Daly, F, Somasundara, D, Sullivan, M, Gammie, F, Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001942.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.773Z" }, { "id": "b0288177-e67c-4fda-86e2-715ded6a7bff", "pmid": "", "title": "Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection", "imported": false, "abstract": "Abstract - Background Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted infections. The majority of women with genital herpes will have a recurrence during pregnancy. Transmission of the virus from mother to fetus typically occurs by direct contact with virus in the genital tract during birth. Objectives To assess the effectiveness of antenatal antiviral prophylaxis for recurrent genital herpes on neonatal herpes and maternal recurrences at delivery. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2006, Issue 4), MEDLINE (January 1966 to February 2007) and EMBASE (January 1974 to February 2007; handsearched conference proceedings; reviewed bibliographies of all relevant articles for further references; and contacted experts in the field. Selection criteria Randomized controlled trials which assessed the effectiveness of antivirals compared to placebo or no therapy, on neonatal herpes and maternal disease endpoints among pregnant women with genital herpes. Data collection and analysis Two authors independently applied study selection criteria and extracted data. Main results Seven randomized controlled trials (1249 participants) which met our inclusion criteria compared acyclovir to placebo or no treatment (five trials) and valacyclovir to placebo (two trials). The effect of antepartum antiviral prophylaxis on neonatal herpes could not be estimated. There were no cases of symptomatic neonatal herpes in the included studies in either the treatment or placebo groups. Women who received antiviral prophylaxis were significantly less likely to have a recurrence of genital herpes at delivery (relative risk (RR) 0.28, 95% confidence interval (CI) 0.18 to 0.43, I 2 = 0%). Women who received antiviral prophylaxis were also significantly less likely to have a cesarean delivery for genital herpes (RR 0.30, 95% CI 0.20 to 0.45, I 2 = 27.3%). Women who received antiviral prophylaxis were significantly less likely to have HSV detected at delivery (RR 0.14, 95% CI 0.05 to 0.39, I 2 = 0%). Authors' conclusions Women with recurrent genital herpes simplex virus should be informed that the risk of neonatal herpes is low. There is insufficient evidence to determine if antiviral prophylaxis reduces the incidence of neonatal herpes. Antenatal antiviral prophylaxis reduces viral shedding and recurrences at delivery and reduces the need for cesarean delivery for genital herpes. Limited information exists regarding the neonatal safety of prophylaxis. The risks, benefits, and alternatives to antenatal prophylaxis should be discussed with women who have a history and prophylaxis initiated for women who desire intervention. Plain language summary Use of antiviral drugs in late pregnancy for reducing the recurrence of genital herpes at labor and birth and reducing the risk of newborn HSV infection The incidence of herpes, a sexually transmitted disease, varies across the world. Among pregnant women with herpes, nearly 75% can expect at least one flare‐up during their pregnancy. Transmission of the virus from mother to baby typically occurs by direct contact with the virus during birth. It is often recommended that a cesarean should be offered to women with active lesions to reduce the risk of transmission to the baby. In addition, several antiviral agents are available for use both for therapy and for preventing a flare‐up. These antiviral drugs include acyclovir, penciclovir, valacyclovir, and famciclovir. The review assessed whether antiviral drugs given to pregnant women with herpes before a recurrence might be effective in reducing transmission to the baby. Seven studies were identified involving 1249 women. Giving antiviral drugs reduces viral shedding and recurrences at labor and birth. They also reduced the use of cesarean, but there is no evidence of reduction in neonatal herpes. Women should also be informed that the risk of the baby getting herpes during birth is low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Hollier, LM, Wendel, GD", "articleTypes": [], "doi": "10.1002/14651858.CD004946.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.125Z" }, { "id": "b02ed720-e79a-4641-93c2-6f88391f1697", "pmid": "", "title": "Hydroxyurea (hydroxycarbamide) for sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and a reduced life expectancy. Hydroxyurea (hydroxycarbamide), an oral chemotherapeutic drug, ameliorates some of the clinical problems of SCD, in particular that of pain, by raising foetal haemoglobin (HbF). This is an update of a previously published Cochrane Review. Objectives The aims of this review are to determine through a review of randomised or quasi‐randomised studies whether the use of hydroxyurea in people with SCD alters the pattern of acute events, including pain; prevents, delays or reverses organ dysfunction; alters mortality and quality of life; or is associated with adverse effects. In addition, we hoped to assess whether the response to hydroxyurea in SCD varies with the type of SCD, age of the individual, duration and dose of treatment, and healthcare setting. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Haemoglobinopathies Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. The date of the most recent search was 17 February 2022. Selection criteria Randomised and quasi‐randomised controlled trials (RCTs and quasi‐RCTs), of one month or longer, comparing hydroxyurea with placebo or standard therapy in people with SCD. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction, assessed the risk of bias and assessed the quality of the evidence using GRADE. Main results We included nine RCTs recruiting 1104 adults and children with SCD (haemoglobin SS (HbSS), haemoglobin SC (HbSC) or haemoglobin Sβºthalassaemia (HbSβºthal) genotypes). Studies lasted from six to 30 months. We judged the quality of the evidence for the first two comparisons below as moderate to low as the studies contributing to these comparisons were mostly large and well‐designed (and at low risk of bias); however, the evidence was limited and imprecise for some outcomes such as quality of life, deaths during the studies and adverse events, and the results are applicable only to individuals with HbSS and HbSβºthal genotypes. We judged the quality of the evidence for the third and fourth comparisons to be very low due to the limited number of participants, the lack of statistical power (both studies were terminated early with approximately only 20% of their target sample size recruited) and the lack of applicability to all age groups and genotypes. Hydroxyurea versus placebo Five studies (784 adults and children with HbSS or HbSβºthal) compared hydroxyurea to placebo; four recruited individuals with only severe disease and one recruited individuals with all disease severities. Hydroxyurea probably improves pain alteration (using measures such as pain crisis frequency, duration, intensity, hospital admissions and opoid use) and life‐threatening illness, but we found no difference in death rates (10 deaths occurred during the studies, but the rates did not differ by treatment group) (all moderate‐quality evidence). Hydroxyurea may improve measures of HbF (low‐quality evidence) and probably decreases neutrophil counts (moderate‐quality evidence). There were no consistent differences in terms of quality of life and adverse events (including serious or life‐threatening events) (low‐quality evidence). There were fewer occurrences of acute chest syndrome and blood transfusions in the hydroxyurea groups. Hydroxyurea and phlebotomy versus transfusion and chelation Two studies (254 children with HbSS or HbSβºthal also with risk of primary or secondary stroke) contributed to this comparison. There were no consistent differences in terms of pain alteration, death or adverse events (low‐quality evidence) or life‐threatening illness (moderate‐quality evidence). Hydroxyurea with phlebotomy probably increased HbF and decreased neutrophil counts (moderate‐quality evidence), but there were more occurrences of acute chest syndrome and infections. Quality of life was not reported. In the primary prevention study, no strokes occurred in either treatment group but in the secondary prevention study, seven strokes occurred in the hydroxyurea and phlebotomy group (none in the transfusion and chelation group) and the study was terminated early. Hydroxyurea versus observation One study (22 children with HbSS or HbSβºthal also at risk of stoke) compared hydroxyurea to observation. Pain alteration and quality of life were not reported. There were no differences in life‐threatening illness, death (no deaths reported in either group) or adverse events (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF or decreases neutrophil counts (very low‐quality evidence). Treatment regimens with and without hydroxyurea One study (44 adults and children with HbSC) compared treatment regimens with and without hydroxyurea. Pain alteration, life‐threatening illness and quality of life were not reported. There were no differences in death rates (no deaths reported in either group), adverse events or neutrophil levels (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF (very low‐quality evidence). Authors' conclusions There is evidence to suggest that hydroxyurea may be effective in decreasing the frequency of pain episodes and other acute complications in adults and children with sickle cell anaemia of HbSS or HbSβºthal genotypes and in preventing life‐threatening neurological events in those with sickle cell anaemia at risk of primary stroke by maintaining transcranial Doppler velocities. However, there is still insufficient evidence on the long‐term benefits of hydroxyurea, particularly with regard to preventing chronic complications of SCD, or recommending a standard dose or dose escalation to maximum tolerated dose. There is also insufficient evidence about the long‐term risks of hydroxyurea, including its effects on fertility and reproduction. Evidence is also limited on the effects of hydroxyurea on individuals with the HbSC genotype. Future studies should be designed to address such uncertainties. Plain language summary Hydroxyurea (also known as hydroxycarbamide) for people with sickle cell disease Review question What is the effect of hydroxyurea on clinical outcomes (changes in pain crises, life‐threatening illnesses, survival, haemoglobin levels, quality of life and side effects) in people with sickle cell disease (SCD) of any genotype? Background Sickle cell disease (SCD) is an inherited genetic disorder that creates problems with haemoglobin (the substance in red blood cells that carries oxygen around the body). The disease can be inherited in different ways; people can inherit two sickle genes (HbSS genotype) or they can inherit the sickle gene from one parent and a different haemoglobin gene such as haemoglobin C, resulting in the HbSC genotype, or a beta thalassaemia gene from the second parent, which gives rise to HbSβ+ or HbSβºthal. In people with SCD the abnormal sickle haemoglobin forms long polymers (chains) within the red blood cells when they become de‐oxygenated. This damages the red blood cells and makes them stickier, leading to blockages and reduced blood flow, causing pain and organ damage. Foetal haemoglobin (HbF) stops these polymers forming in the sickle haemoglobin within the red blood cell. The drug hydroxyurea is used to increase HbF and can reduce the effects of the disease. This is an update of a previously published Cochrane Review. Search date The evidence is current to 17 February 2022. Study characteristics We included nine randomised studies (1104 adults and children with SCD (HbSS, HbSC or HbSβºthal genotypes)). Studies lasted from six to 30 months. Key results and quality of the evidence In five studies, 784 adults and children with SCD were randomly selected to receive hydroxyurea or placebo. In two studies, 254 children with SCD, who were also at an increased risk of having a first or second stroke, were randomly selected to receive hydroxyurea and phlebotomy (collection of blood) or blood transfusion and chelation (administration of agents to remove excess iron from the body). These seven studies only recruited people with HbSS or HbSβºthal genotypes so the results do not apply to people with the HbSC genotype. There was moderate‐quality evidence from these seven studies that hydroxyurea may reduce the frequency of pain crises, may increase HbF and may decrease neutrophil (white blood cell) counts compared to the comparator treatment. We found no difference between people receiving hydroxyurea or other treatments in terms of quality of life, deaths during the studies and adverse effects (including serious and life‐threatening effects). However, there is less information about these outcomes in the studies, so the quality of this evidence is low. Two further studies were included in the review. In one study, 22 children with SCD, who were also at increased risk of having a stroke, were randomly selected to receive hydroxyurea or no treatment (observation only) and in one study 44 adults and children were randomly selected to receive treatments with or without adding hydroxyurea. In both studies we are unsure if hydroxyurea led to an increase in HbF compared to the comparator treatment. There were no deaths during the studies. There was no difference between people receiving hydroxyurea or other treatments in terms of pain crises and adverse effects (including serious or life‐threatening effects) and neither study measured quality of life. The quality of the evidence from these studies is very low, given the studies were very small and only recruited around 20% of the intended number of people, and the results do not apply to all people with SCD (different genotypes). Conclusions The evidence shows that hydroxyurea is likely to be effective in the short term at decreasing the frequency of painful episodes and raising HbF levels in the blood in people with SCD. Hydroxyurea is also likely to be effective in preventing first strokes for those at an increased risk of stroke and does not seem to be associated with an increase in any adverse effects (including serious and life‐threatening effects). There is currently little evidence from the studies that we examined on whether hydroxyurea is beneficial over a long period of time, what the best dose to take is, or whether treatment causes any long‐term or serious side effects. More studies are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Rankine-Mullings, AE, Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD002202.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.123Z" }, { "id": "b03f1499-2903-4227-8f84-a007b1421aed", "pmid": "", "title": "Preoperative carbohydrate treatment for enhancing recovery after elective surgery", "imported": false, "abstract": "Abstract - Background Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast‐track surgery protocols. Although fast‐track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis. Objectives To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data. Selection criteria We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time. Data collection and analysis Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis. Main results We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I‐II or I‐III. A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding. In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low‐quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference ‐0.13 days; 95% CI ‐0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high‐quality evidence). As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low‐quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation. Authors' conclusions Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases. Plain language summary Does giving patients carbohydrate supplements before planned surgery lead to improved recovery? Review question We reviewed the evidence on effects of carbohydrate supplements on the recovery of people undergoing planned surgical procedures. We found 27 studies investigating this question. Background Carbohydrate (sugar‐containing) nutritional supplements have become a routine part of the package of care for people undergoing planned surgical procedures. We wanted to discover whether carbohydrate supplements are a useful part of care packages used by doctors to improve recovery after planned surgical procedures. Study characteristics The evidence is current up to March 2014. We identified 27 studies and included the outcomes of 1976 participants. Studies investigated the outcomes of patients undergoing planned surgical procedures on the abdomen (18), the bones or joints (4), the heart (4) or the thyroid gland (1). Eighteen studies compared carbohydrate supplements versus an identical appearing placebo drink that did not contain carbohydrates; in six of these studies, an additional group of patients had nothing to eat or drink for at least six hours before surgery. In nine studies, taking carbohydrate supplements was compared with having nothing to eat or drink for six hours before surgery. The primary outcomes of length of hospital stay and complication rate were reported by 19 and 14 studies, respectively. Key results Patients given carbohydrates before planned surgical procedures went home between 0.04 and 0.56 days sooner than those receiving a placebo drink or having nothing to eat or drink before surgery. Carbohydrate supplements had little or no effect on complication rate or on how people feel in‐hospital during recovery from surgery. Quality of the evidence The overall quality of the evidence varied from very low to high. The quality of evidence in support of carbohydrate supplements resulting in a shorter hospital stay was very low because the included studies had important flaws in their design, a very wide range of results was described and evidence revealed that studies showing no differences in length of hospital stay may not have been published. When we looked only at well‐conducted studies, we found that carbohydrate supplements had little or no effect on length of hospital stay. The quality of evidence to support the effects of carbohydrate supplements on complication rate was low because issues with study design were identified and results were not similar across studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Smith, MD, McCall, J, Plank, L, Herbison, GP, Soop, M, Nygren, J", "articleTypes": [], "doi": "10.1002/14651858.CD009161.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.114Z" }, { "id": "b06bc71d-75c7-463c-9abe-dd098059f4ad", "pmid": "", "title": "Supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults", "imported": false, "abstract": "Abstract - Background Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy. Objectives To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults. Search methods We identified publications from comprehensive searches of the Cochrane Library , MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016. Selection criteria Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care. Data collection and analysis Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta‐analyses for the outcome measures, 'all‐cause mortality', 'hospitalisation' and 'nutritional status (weight change)'. Main results Forty‐one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow‐up ranged from ‘duration of hospital stay’ to 12 months. The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all‐cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate‐quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low‐quality evidence). Only five trials (4451 participants) investigated health‐related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of ‐0.5 days (95% CI ‐2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low‐quality evidence. Only three of 41 included trials (4108 participants; very low‐quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta‐analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate‐quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low‐quality evidence). Authors' conclusions There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all‐cause mortality for supportive interventions comes from hospital‐based trials and more research is needed to confirm this effect. There is very low‐quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient‐important outcomes in future research. Plain language summary Supportive interventions for improving dietary intake in nutritionally vulnerable groups Review question Are supportive interventions for improving dietary intake in nutritionally vulnerable groups (malnourished or nutritionally at‐risk individuals) effective? Background Serving meals in a dining room, or the use of assistance to help feed people in need and other similar methods are often recommended to help especially sick and elderly people who have lost or are likely to lose weight (nutritionally vulnerable groups). Such supportive interventions are implemented in the health care in many countries but their effects are not well investigated. Study characteristics We included 41 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 10,681 people in our review. There were five different interventions which we call 'supportive interventions': changes to the organisation of nutritional care (13 studies, 3456 people), changes to the feeding environment (5 studies, 351 people), modification of the meal profile or pattern (12 studies, 649 people), additional supplementation of meals (10 studies, 6022 people) and home meal delivery systems (1 study, 203 people). Monitoring participants over time (follow‐up) ranged from ‘duration of hospital stay’ to 12 months. The comparator groups received 'usual' care. More than half of all participants took part in studies investigating the additional supplementation of meals (for example a protein‐energy oral nutritional supplement in addition to the usual diet). Key results It is possible that supportive interventions for enhancing dietary intake in nutritionally vulnerable groups reduce death from any cause (approximately 23 fewer cases of death per 1000 participants in favour of supportive interventions). However, this has to be confirmed by more evidence from high‐quality randomised controlled studies. The number of participants experiencing any medical complication did not differ substantially between the supportive interventions and the comparator groups. The same was found for health‐related quality of life (which is physical, mental, emotional and social health attributed to health), patient satisfaction, nutritional or energy intake and days spent in hospital. Economic costs were not well investigated. Only three studies reported on side effects, describing intolerance to the nutritional supplement (such as diarrhoea or vomiting in 5 of 34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567 of 2017 participants). After analysing 15 studies in 1945 participants we found a beneficial effect of supportive interventions compared with comparators on weight: on average people in the supportive interventions groups increased their weight 0.6 kg more than people in the comparator groups. This evidence is up to date as of September 2016. Quality of evidence The overall quality of evidence ranged between moderate to very low, mainly because for most of our outcomes there was only a small number of studies and participants to achieve reliable information, or because risk of bias made results uncertain. However, if some randomised controlled studies with low risk of bias for our patient‐important outcomes and a good number of participants were performed, this review could quickly provide good guidance for better health care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Baldwin, C, Kimber, KL, Gibbs, M, Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD009840.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.068Z" }, { "id": "b090fe92-510c-449b-82cb-9342639a1485", "pmid": "", "title": "Relief of pain due to uterine cramping/involution after birth", "imported": false, "abstract": "Abstract - Background Women may experience differing types of pain and discomfort following birth, including cramping pain (often called after‐birth pain) associated with uterine involution, where the uterus contracts to reduce blood loss and return the uterus to its non‐pregnant size. This is an update of a review first published in 2011. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological pain relief/analgesia for the relief of after‐birth pains following vaginal birth. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (31 October 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials comparing two different types of analgesia or analgesia versus placebo or analgesia versus no treatment, for the relief of after‐birth pains following vaginal birth. Types of analgesia included pharmacological and non‐pharmacological. Quasi‐randomised trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed trials for inclusion, conducted 'Risk of bias' assessment, extracted data and assessed the certainty of the evidence using the GRADE approach. Main results In this update, we include 28 studies (involving 2749 women). The evidence identified in this review comes from middle‐ to high‐income countries. Generally the trials were at low risk of selection bias, performance bias and attrition bias, but some trials were at high risk of bias due to selective reporting and lack of blinding. Our GRADE certainty of evidence assessments ranged from moderate to very low certainty, with downgrading decisions based on study limitations, imprecision, and (for one comparison) indirectness. Most studies reported our primary outcome of adequate pain relief as reported by the women. No studies reported data relating to neonatal adverse events, duration of hospital stay, or breastfeeding rates. Almost half of the included studies (11/28) excluded breastfeeding women from participating, making the evidence less generalisable to a broader group of women. Non‐steroidal anti‐inflammatory drugs (NSAIDs) compared to placebo NSAIDs are probably better than placebo for adequate pain relief as reported by the women (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.45 to 1.91; 11 studies, 946 women; moderate‐certainty evidence). NSAIDs may reduce the need for additional pain relief compared to placebo (RR 0.15, 95% CI 0.07 to 0.33; 4 studies, 375 women; low‐certainty evidence). There may be a similar risk of maternal adverse events (RR 1.05, 95% CI 0.78 to 1.41; 9 studies, 598 women; low‐certainty evidence). NSAIDs compared to opioids NSAIDs are probably better than opioids for adequate pain relief as reported by the women (RR 1.33, 95% CI 1.13 to 1.57; 5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of maternal adverse events (RR 0.62, 95% CI 0.43 to 0.89; 3 studies, 255 women; low‐certainty evidence). NSAIDs may be better than opioids for the need for additional pain relief, but the wide CIs include the possibility that the two classes of drugs are similarly effective or that opioids are better (RR 0.37, 95% CI 0.12 to 1.12; 2 studies, 232 women; low‐certainty evidence). Opioids compared to placebo Opioids may be better than placebo for adequate pain relief as reported by the women (RR 1.26, 95% CI 0.99 to 1.61; 5 studies, 299 women; low‐certainty evidence). Opioids may reduce the need for additional pain relief compared to placebo (RR 0.48, 95% CI 0.28 to 0.82; 3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of maternal adverse events compared with placebo, although the certainty of evidence is low (RR 1.59, 95% CI 0.99 to 2.55; 3 studies, 188 women; low‐certainty evidence). Paracetamol compared to placebo Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events (2 studies, 123 women). Paracetamol compared to NSAIDs Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events. No data were reported about the need for additional pain relief comparing paracetamol and NSAIDs (2 studies, 112 women). NSAIDs compared to herbal analgesia We are uncertain if there are any differences between NSAIDs and herbal analgesia for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events, because the certainty of evidence is very low (4 studies, 394 women). Transcutaneous nerve stimulation (TENS) compared to no TENS Very low‐certainty evidence means we are uncertain if TENS is better than no TENS for adequate pain relief as reported by the women. No other data were reported comparing TENS with no TENS (1 study, 32 women). Authors' conclusions NSAIDs may be better than placebo and are probably better than opioids at relieving pain from uterine cramping/involution following vaginal birth. NSAIDs and paracetamol may be as effective as each other, whereas opioids may be more effective than placebo. Due to low‐certainty evidence, we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater generalisability by including breastfeeding women. In addition, further research is required, including a survey of postpartum women to describe appropriately their experience of uterine cramping and involution. We identified nine ongoing studies, which may help to increase the level of certainty of the evidence around pain relief due to uterine cramping in future updates of this review. Plain language summary Relief of pain caused by uterine cramping or involution after giving birth This updated review investigates the effectiveness and safety of drug and non‐drug pain relief in women experiencing after‐birth pains following vaginal birth. Giving an agent for pain relief was compared to an inactive placebo, to no treatment, or to a different type of agent in randomised controlled trials. What is the issue? Women may experience cramping pain and discomfort following the birth of their baby, as the uterus contracts and returns to its normal pre‐pregnancy size. These pains usually last for two to three days after the birth. Women who have previously had a baby are more likely to experience after‐birth pains. Breastfeeding stimulates the uterus to contract and increases the severity of the pains. Types of pain relief used to treat the pain include paracetamol, non‐steroidal anti‐inflammatory drugs (NSAIDs) ibuprofen and naproxen, opioids including codeine, and non‐medicine methods such as herbal preparations and transcutaneous electrical nerve stimulation (TENS). Why is this important? Management of pain after birth is important, as the pain can affect a mother carrying out her normal activities as well as bonding with and caring for her baby. After‐pains can interfere with establishing breastfeeding. What evidence did we find? We searched for evidence from randomised controlled trials (October 2019) and identified 28 studies (2749 mothers) who were in hospital after uncomplicated single births. Most of the evidence is low‐certainty because the studies did not include sufficient numbers of women. Many of the studies excluded breastfeeding women.This makes the evidence less relevant to a broader group of women. No studies reported evidence on adverse events in the newborn infants. NSAIDs are probably better than placebo (a dummy treatment) in giving adequate pain relief as reported by the women (11 studies, 946 women; moderate‐certainty evidence), and they may reduce the need for additional pain relief (4 studies, 375 women; low‐certainty evidence). There may be little difference between NSAIDs and placebo in the risk of adverse events in the mother (9 studies, 598 women; low‐certainty evidence). NSAIDs are probably better than opioids in providing adequate pain relief as reported by the women (5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of adverse events in the mother (3 studies, 255 women; low‐certainty evidence). NSAIDs may slightly reduce the need for additional pain relief compared with opioids (2 studies, 232 women; low‐certainty evidence). Opioids may be better than placebo for adequate pain relief as reported by the women (5 studies, 299 women; low‐certainty evidence) and for the need for additional pain relief (3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of adverse events in the mother compared with placebo (3 studies, 188 women; low‐certainty evidence). Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional analgesia, or risk of maternal adverse events (2 studies, 123 women). Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events (2 studies, 112 women). Very low‐certainty evidence means we are uncertain if NSAIDs are better than herbal pain relief for adequate pain relief as reported by the women (4 studies, 394 women), the need for additional pain relief (1 study, 90 women) or risk of maternal adverse events (1 study, 108 women). Very low‐certainty evidence means we are uncertain if there is any difference between TENS and no TENS for adequate pain relief as reported by the women (1 study, 32 women). What does this mean? NSAIDs may be better than placebo and are probably better than opioids at relieving after‐birth pains following vaginal birth. The quality of the evidence was poor and we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater relevance by including breastfeeding women. Further research could also include a survey of women after delivery to capture their experience of after‐birth pains following vaginal birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Deussen, AR; Ashwood, P; Martis, R; Stewart, F; Grzeskowiak, LE", "articleTypes": [], "doi": "10.1002/14651858.CD004908.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "b0cc21f4-55cb-4bd4-8395-306d4492addd", "pmid": "", "title": "Misoprostol for intrauterine device placement", "imported": false, "abstract": "Abstract - Rationale Identifying effective approaches to reduce pain and improve providers' ease of intrauterine device (IUD) placement may reduce barriers to IUD access and use. The cervical softening and dilation effects of misoprostol might make IUD placement less painful for women and technically easier for providers. However, evidence suggests that misoprostol does not improve many outcomes and may only be helpful for some patients (e.g. those with a recent failed IUD placement). Objectives To examine the effect of misoprostol for routine IUD placement on patient and provider outcomes compared to placebo or no treatment. Search methods In November 2021 we searched CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ClinicalTrials.gov. We conducted update searches in July 2022 and September 2024. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in July 2025. Eligibility criteria We included randomized controlled trials (RCTs) of women undergoing interval IUD placement (i.e. placement outside the postabortion or postpartum period) that compared misoprostol to placebo or no treatment. We included trials that examined the placement of currently available levonorgestrel (LNG)‐releasing IUDs, or any copper T IUD, for women of any age, of any parity, and for any indication. Outcomes Our core critical and important outcomes were pain (during tenaculum placement, during IUD placement, and after IUD placement before clinic discharge); providers' ease of placement; need for cervical dilation; placement success; patient satisfaction; misoprostol side effects (preplacement abdominal pain or cramping, and diarrhea); and adverse events (vasovagal reaction). Risk of bias We used the Risk of Bias 2 tool (RoB 2) to assess the risk of bias for outcomes. Synthesis methods We synthesized results for each outcome using meta‐analysis. We calculated mean differences (MD) for continuous outcomes using inverse variance estimation and random‐effects models. We calculated risk ratios (RR) for dichotomous outcomes using Mantel‐Haenszel estimation and random‐effects models. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included 14 RCTs with a total of 1972 women. The trials were conducted in North America, South America, Europe and Africa, and were published between 2007 and 2022. Synthesis of results The results below summarize the effect of misoprostol on outcomes compared to placebo or no treatment. Pain: misoprostol results in little to no difference in pain during tenaculum placement (MD −0.73, 95% confidence interval [CI] −1.19 to −0.28; 3 RCTs, 261 women; high‐certainty evidence) and after IUD placement before clinic discharge (MD −0.01, 95% CI −0.45 to 0.43; 5 RCTs, 448 women; high‐certainty evidence). Misoprostol may result in little to no difference in pain during IUD placement (MD −0.47, 95% CI −1.23 to 0.29; 7 RCTs, 766 women; low‐certainty evidence). Providers' ease of placement: misoprostol may result in little to no difference in a clinically meaningful effect on ease of IUD placement for providers (MD −0.89, 95% CI −1.55 to −0.22; 8 RCTs, 848 women; low‐certainty evidence). Need for cervical dilation: misoprostol may result in little to no difference in need for cervical dilation for women without a recent failed placement attempt (RR 0.84, 95% CI 0.38 to 1.85; 6 RCTs, 562 women; low‐certainty evidence). Misoprostol probably results in little to no difference in need for cervical dilation for women with a recent failed placement attempt (RR 0.88, 95% CI 0.56 to 1.36; 1 RCT, 90 women; moderate‐certainty evidence). Placement success: misoprostol probably results in little to no difference in placement success for women without a recent failed placement attempt (RR 1.01, 95% CI 0.98 to 1.04; 12 RCTs, 1579 women; moderate‐certainty evidence) but probably results in a slight increase in placement success for women with a recent failed placement attempt (RR 1.41, 95% CI 1.09 to 1.83; 1 RCT, 90 women; moderate‐certainty evidence). Patient satisfaction: misoprostol may increase women's satisfaction with the IUD placement procedure, but the evidence is very uncertain (MD 2.00, 95% CI −0.05 to 4.06; 2 RCTs, 226 women; very low‐certainty evidence) Misoprostol side effects before clinic discharge: misoprostol probably results in an increase in preplacement abdominal pain or cramping (RR 2.14, 95% CI 1.42 to 3.23; 7 RCTs, 781 women; moderate‐certainty evidence)and probably results in a slight increase in diarrhea (RR 1.76, 95% CI 1.01 to 3.06; 9 RCTs, 940 women; moderate‐certainty evidence). Adverse events before clinic discharge: misoprostol may result in little to no difference in vasovagal reaction (RR 0.94, 95% CI 0.37 to 2.37; 6 RCTs [3 RCTs had 0 events], 780 women; low‐certainty evidence). We downgraded the evidence due to serious concerns about inconsistency and serious or very serious concerns about imprecision. Authors' conclusions Evidence from RCTs of women seeking routine IUD placement suggests that receiving misoprostol compared to placebo or no treatment makes little to no difference to pain during tenaculum placement or after IUD placement; and may make little to no difference to pain during IUD placement. Misoprostol may make little to no difference to reduced vasovagal reaction, improved providers' ease of placement, or reduced need for cervical dilation; and probably makes little to no difference to placement success, except for women with a recent failed IUD placement attempt, where misoprostol probably leads to a clinically meaningful increase in placement success. Misoprostol use probably leads to clinically important increases in harms, specifically preplacement abdominal pain or cramping and diarrhea. Misoprostol may increase patient satisfaction with the IUD placement procedure, but the evidence is very uncertain. The number of available RCTs did not support examining effect modifiers such as prior vaginal delivery status, misoprostol dose, or IUD type. Funding This review was supported in part by an appointment to the Research Participation Program at the Centers for Disease Control and Prevention (CDC) administered by the Oak Ridge Institute for Science and Education. Registration Protocol (2022): doi.org/10.1002/14651858.CD015584 Plain language summary Is misoprostol an effective treatment for routine intrauterine device (IUD) placement and does it cause unwanted effects? Key messages Using misoprostol (a medication that softens and widens the cervix ‐ the neck of the womb) before placing an intrauterine device (IUD ‐ a contraceptive device placed inside the womb) makes little to no difference to pain when a tool (a tenaculum) is used to hold the cervix in place during IUD placement or pain after IUD placement. It may make little to no difference to pain during placement, ease of placement for providers, or need for cervical widening; and probably makes little to no difference to placement success, except for women who recently tried unsuccessfully to have an IUD placed. Misoprostol‐related unwanted effects like stomach cramps and diarrhea probably increase, but it may make little to no difference to other unwanted events. We don't know whether misoprostol use affects women's satisfaction with the procedure. What is an intrauterine device? An intrauterine device (IUD) is a small t‐shaped device inserted through the cervix (the neck of the womb) into the womb to prevent pregnancy. IUDs need to be placed by a trained doctor, nurse, or healthcare provider. IUD placement may be a painful procedure, and it may be more difficult for women who have not had a baby or who have already tried unsuccessfully to have an IUD placed. Serious unwanted events are rare with IUD placement but women may experience non‐serious unwanted effects similar to period pain (cramps) or light bleeding. What is misoprostol? Misoprostol is a medication that is commonly used to start labor and to treat bleeding following birth. It causes the cervix to soften and widen, and so might make IUD placement less painful for women and easier for providers. Misoprostol may cause some unwanted effects like cramps, sickness or diarrhea. Sometimes women may feel dizzy, sweaty or light‐headed. An IUD is an effective and reversible contraceptive method, so identifying ways to reduce pain and improve ease of placement for providers may reduce barriers to IUD access and use. What did we want to find out? We wanted to find out if misoprostol reduces pain, makes IUD placement easier for providers, reduces the need for other methods to widen the cervix, improves placement success and women's satisfaction with the procedure, and whether it causes unwanted effects. What did we do? We searched for studies that examined misoprostol for routine IUD placement compared to placebo (a sham medication) or no treatment. We combined and analyzed the studies' results and rated our confidence in the evidence, based on factors such as study methods. What did we find? We found 14 RCTs with 1972 women. The studies took place in North America, South America, Europe, and Africa. All the studies compared misoprostol with placebo or no treatment. Main results Pain. Misoprostol: results in little to no difference in pain during tenaculum placement (a tenaculum is a tool that holds the cervix in place during IUD placement) (3 studies, 261 women); may result in little to no difference in pain during IUD placement (7 studies, 766 women); results in little to no difference in pain after IUD placement before leaving the clinic (5 studies, 448 women). Providers' ease of placing the IUD Misoprostol may result in little to no difference in ease of IUD placement for providers (8 studies, 848 women). Need for cervical dilation. Misoprostol: may result in little to no difference in the need for cervical widening for women without a recent failed placement attempt (6 studies, 562 women); probably results in little to no difference in the need for cervical widening for women with a recent failed placement attempt (1 study, 90 women). Placement success. Misoprostol: probably results in little to no difference in placement success for women without a recent failed placement attempt (12 studies, 1579 women); probably results in a slight increase in placement success for women with a recent failed placement attempt (1 study, 90 women). Patient satisfaction We are not sure whether misoprostol increases patient satisfaction with the IUD placement procedure (2 studies, 226 women). Unwanted effects. Misoprostol: probably results in an increase in stomach cramps (7 studies, 781 women); probably results in a slight increase in diarrhea (9 studies, 940 women); may result in little to no difference in dizziness or light‐headedness (6 studies, 780 women). What are the limitations of the evidence? Some studies did not report key information about what we wanted to know, and some studies were different from each other, so we couldn't include them in our analyses. We had planned to examine whether certain factors affected the results, such as whether women had previously given birth vaginally, the dose of misoprostol used, or the type of IUD placed, but there were not enough studies to do this in a meaningful way. How up to date is this evidence? The evidence is up to date to 23 September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Zapata, LB, Snyder, E, Nguyen, AT, Kapp, N, Ti, A, Whiteman, MK, Curtis, KM", "articleTypes": [], "doi": "10.1002/14651858.CD015584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.769Z" }, { "id": "b0d88473-d80a-43ac-b4d8-dae4296a4959", "pmid": "", "title": "Paediatric formulations of artemisinin‐based combination therapies for treating uncomplicated malaria in children", "imported": false, "abstract": "Abstract - Background In endemic malarial areas, young children have high levels of malaria morbidity and mortality. The World Health Organization recommends oral artemisinin‐based combination therapy (ACT) for treating uncomplicated malaria. Paediatric formulations of ACT have been developed to make it easier to treat children. Objectives To evaluate evidence from trials on the efficacy, safety, tolerability, and acceptability of paediatric ACT formulations compared to tablet ACT formulations for uncomplicated P falciparum malaria in children up to 14 years old. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; the Latin American and Caribbean Health Science Information database (LILACS); ISI Web of Science; Google Scholar; Scopus; and the metaRegister of Controlled Trials (mRCT) to 11 December 2019. Selection criteria We included randomised controlled clinical trials (RCTs) of paediatric versus non‐paediatric formulated ACT in children aged 14 years or younger with acute uncomplicated malaria. Data collection and analysis Two authors independently assessed eligibility and risk of bias, and carried out data extraction. We analyzed the primary outcomes of efficacy, safety and tolerability of paediatric versus non‐paediatric ACT using risk ratios (RR) and 95% confidence intervals (CI). Secondary outcomes were: treatment failure on the last day of observation (day 42), fever clearance time, parasite clearance time, pharmacokinetics, and acceptability. Main results Three trials met the inclusion criteria. Two compared a paediatric dispersible tablet formulation against crushed tablets of artemether‐lumefantrine (AL) and dihydroartemisinin‐piperaquine (DHA‐PQ), and one trial assessed artemether‐lumefantrine formulated as powder for suspension compared with crushed tablets. The trials were carried out between 2006 and 2015 in sub‐Saharan Africa (Benin, Mali, Mozambique, Tanzania, Kenya, Democratic Republic of the Congo, Burkina Faso, and The Gambia). In all three trials, the paediatric and control ACT achieved polymerase chain reaction (PCR)‐adjusted treatment failure rates of < 10% on day 28 in the per‐protocol (PP) population. For the comparison of dispersible versus crushed tablets, the two trials did not detect a difference for treatment failure by day 28 (PCR‐adjusted PP population: RR 1.35, 95% CI 0.49 to 3.72; 1061 participants, 2 studies, low‐certainty evidence). Similarly, for the comparison of suspension versus crushed tablet ACT, we did not detect any difference in treatment failure at day 28 (PCR‐adjusted PP population: RR 1.64, 95% CI 0.55 to 4.87; 245 participants, 1 study). We did not detect any difference in serious adverse events for the comparison of dispersible versus crushed tablets (RR 1.05, 95% CI 0.38 to 2.88; 1197 participants, 2 studies, low‐certainty evidence), or for the comparison of suspension versus crushed tablet ACT (RR 0.74, 95% CI 0.17 to 3.26; 267 participants, 1 study). In the dispersible ACT arms, drug‐related adverse events occurred in 9% of children in the AL study and 34% of children in the DHA‐PQ study. In the control arms, drug‐related adverse events occurred in 12% of children in the AL study and in 42% of children in the DHA‐PQ study. Drug‐related adverse events were lower in the dispersible ACT arms (RR 0.78, 95% CI 0.62 to 0.99; 1197 participants, 2 studies, moderate‐certainty evidence). There was no detected difference in the rate of drug‐related adverse events for suspension ACT versus crushed tablet ACT (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study). Drug‐related vomiting appeared to be less common in the dispersible ACT arms (RR 0.75, 95% CI 0.56 to 1.01; 1197 participants, 2 studies, low‐certainty evidence) and in the suspension ACT arm (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study), but both analyses were underpowered. No study assessed acceptability. Authors' conclusions Trials did not demonstrate a difference in efficacy between paediatric dispersible or suspension ACT when compared with the respective crushed tablet ACT for treating uncomplicated P falciparum malaria in children. However, the evidence is of low to moderate certainty due to limited power. There appeared to be fewer drug‐related adverse events with dispersible ACT compared to crushed tablet ACT. None of the included studies assessed acceptability of paediatric ACT formulation. Plain language summary Treating uncomplicated malaria in children: do child‐friendly formulations of medicines work better than usual tablet formulations? What is the aim of this review? We wanted to find out about the potential benefits and harms of child‐friendly formulations of artemisinin‐based combination therapy (ACT) to treat uncomplicated malaria in children. We searched for studies that investigated the use of child‐friendly formulations of ACTs, compared with the usual ACT tablet formulations, to treat uncomplicated malaria in children aged under 14 years. We looked for randomized controlled studies, in which the treatments the children received were decided at random. This type of study usually gives the most reliable evidence about the effects of a treatment. We found three relevant studies of two child‐friendly formulations. Key messages Child‐friendly formulations of ACT probably work as well as crushed tablets to treat uncomplicated malaria in children, and probably cause fewer unwanted effects. What was studied in this review? Malaria is a tropical disease spread by mosquitoes infected with Plasmodium parasites. The most common, and most serious, type of malaria is caused by Plasmodium falciparum . This parasite causes high levels of illness and death, particularly in young children in regions where malaria is widespread. Malaria can be a mild illness, but is sometimes severe and life‐threatening if not treated soon enough or with the right medicines. Medicines based on artemisinin, a compound derived from a plant ( Artemisia annua ), are commonly taken by mouth (orally) to treat malaria in combination with other drugs. The World Health Organization recommends treating uncomplicated malaria with oral artemisinin‐based combination therapy (called ACT). Oral ACT tablets are often crushed to help make them easier for children to swallow. New formulations of oral ACTs have been developed especially for children, such as syrups, and granules, powders or tablets that can be dissolved in water, and which may be flavoured. What are the main results of this review? We found three relevant studies in 1306 children (aged 6 months to 11 years) with uncomplicated malaria. The studies were conducted in sub‐Saharan Africa between 2006 and 2015. All studies were funded by pharmaceutical companies that made child‐friendly formulations of the ACTs. The studies compared crushed ACT tablets to child‐friendly formulations of ACTs: these were dissolvable tablets of artemether‐lumefantrine or dihydroartemisinin‐piperaquine, or artemether‐lumefantrine syrup. We were interested in: · whether children remained cured of malaria after 28 days (measured by absence of Plasmodium parasites in the blood); and · whether the medicines caused any unwanted effects. None of the studies looked at how any of the medicine formulations were accepted by children. There may be little or no difference between the child‐friendly formulations of ACTs (dissolvable tablets or syrup) and the usual crushed tablets for how many children: · were successfully treated after 28 days; or · experienced serious unwanted effects. The crushed ACT tablets and the child‐friendly formulations successfully treated most cases of uncomplicated malaria. After 28 days the rates of treatment failure were similar in both groups. On average, 59 of every 1000 children taking crushed ACT tablets and 62 of every 1000 children taking dissolvable tablets would still have Plasmodium infection (2 studies; 1139 children). Similar numbers of serious unwanted effects were reported for the usual crushed tablets and the dissolvable tablets (2 studies; 1197 children) or syrup (1 study; 267 children), therefore differences as a result of the formulation are unlikely. A dissolvable tablet probably reduces unwanted effects of the medicine, including vomiting (throwing up), compared with the usual crushed tablets. Children taking dissolvable tablets had fewer unwanted effects associated with the medicine (139 of every 1000 children) than those taking crushed tablets (178 of every 1000 children). There was no difference in the number of unwanted effects found in the study with the syrup formulation compared with the usual crushed tablets. Our confidence in our results is low to moderate. The results come from a small number of studies. All studies were supported by manufacturers of the child‐friendly formulations, which could have affected how the studies were designed, conducted, and reported. How up‐to‐date is this review? We searched for studies that had been published up to 11 December 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bélard, S; Ramharter, M; Kurth, F", "articleTypes": [], "doi": "10.1002/14651858.CD009568.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "b100cc06-4230-4ffd-af5d-a37d6c83d5f0", "pmid": "", "title": "Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions", "imported": false, "abstract": "Abstract - Background Individuals on continuous treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) are at increased risk of bleeding complications during and after oral or dental procedures. Anticoagulant treatment is preferably continued at the same dose, since dose reduction or discontinuation of treatment is associated with an increased risk of thromboembolism. The use of haemostatic measures during or after the procedure (or both) could enable continuation of the oral anticoagulant treatment. Objectives We aimed to assess the efficacy of antifibrinolytic agents for preventing bleeding complications in people on oral anticoagulants undergoing minor oral surgery or dental extractions. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and the Cochrane Library. Additional searches were performed using ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), the CINAHL database of nursing and allied health services, the open access ProQuest dissertation database, papers and reports from the American College of Clinical Pharmacy (ACCP) and abstract books from annual scientific conferences. Date of last search: 04 January 2018. Selection criteria Randomised and quasi‐randomised controlled trials in people on continuous treatment with VKAs or DOACs undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid (TXA) or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. Data collection and analysis Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained from potentially relevant abstracts and two authors independently assessed these for inclusion based of the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. The quality of the evidence was assessed using GRADE. Main results No eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures were identified. Three randomised trials and one quasi‐randomised trial (follow‐up in all was seven days) in people on continuous treatment with VKAs were included with a total of 253 participants (mean age 60 years). Two trials published in 1989 and 1993 compared the antifibrinolytic agent TXA with placebo in people using VKAs. Two other trials were published in 1999 and 2015 and compared TXA with gelatin sponge and sutures, and dry gauze compression, respectively. In all included trials, those who were treated with VKAs had international normalised ratio (INR) values within the therapeutic range and TXA was applied locally, not systemically. The two trials from 1989 and 1993 comparing TXA with placebo showed a statistically significant beneficial effect regarding the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) of ‐0.25 (95% confidence interval (CI) ‐0.36 to ‐0.14) (128 participants) (moderate‐quality evidence). For the two trials that compared TXA with either gelatin sponge and sutures or with dry gauze compression, there was no difference between the TXA and the standard care group, RD 0.02 (95% CI ‐0.07 to 0.11) (125 participants) (moderate‐quality evidence). The combined RD of all included trials was ‐0.13 (95% CI ‐0.30 to 0.05) (moderate‐quality evidence). There were no side effects of antifibrinolytic therapy that required treatment withdrawal (128 participants) (moderate‐quality evidence). Despite heterogeneity between trials with respect to the different haemostatic measures used in the control groups, the trials were comparable regarding design and baseline participant characteristics. Overall, we considered the risk of bias to be low in the trials comparing TXA with placebo and moderate in the trials comparing TXA with alternative haemostatic measures. Authors' conclusions Based on the results of this Cochrane Review, there seems to be a beneficial effect of locally applied TXA in preventing oral bleeding in people on continuous treatment with VKAs undergoing minor oral surgery or dental extractions. However, the small number of identified randomised controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population. We were unable to identify any eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures. Therefore, a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs. Plain language summary Drugs that prevent oral bleeding in people using oral anticoagulants undergoing minor oral surgery or dental extractions Review question We reviewed the evidence about whether antifibrinolytic medicine (drugs that prevent breakdown of a blood clot), such as tranexamic acid or epsilon aminocaproic acid, can prevent oral bleeding after minor oral surgery or dental extractions in people using oral anticoagulants (blood thinners that are taken by mouth) without interruption during the procedure. Background People on continuous oral anticoagulant treatment are at an increased risk of bleeding complications during and after oral surgery or dental extractions. There are two types of oral anticoagulant treatment: vitamin K antagonists (VKAs) (e.g. warfarin and coumarin) and direct oral anticoagulants (DOACs) (e.g. dabigatran, rivaroxaban, apixaban, edoxaban). DOACs are becoming an increasingly popular alternative for VKAs, traditionally used for preventing blood clotting in people at risk of thrombosis. The number of bleeds and the severity of each bleed depend on medication‐related factors (such as the degree of anticoagulation, measured by the international normalised ratio (INR)), surgery‐related factors (such as the size of the wound or the number of roots extracted), as well as patient‐related factors (such as inflammation of the gums or blood vessel diseases). The INR level is important to determine how well the anticoagulant treatment is preventing blood clots. Within the desired range of the INR level, a person has both the least risk of blood clotting complications and the least risk of excessive bleeding. In routine practice antifibrinolytic medicine is often used before, during and after minor oral surgery or dental extractions for people using oral anticoagulants. The question is whether there is reliable scientific evidence for this practice. Search date The evidence is current to: 04 January 2018. Study characteristics We did not find any trials of antifibrinolytic medicine for preventing bleeding after minor oral surgery or dental extractions in people using DOACs. This review includes four trials (253 participants) in people continuously treated with VKAs during minor oral surgery or dental extractions. The earliest included trial was published in 1989 and the most recent one in 2015. The mean age of all participants was 60 years. The follow‐up time in all trials was seven days. Key results Overall, the included trials showed a reduction in the number of bleeds after dental extraction when using tranexamic acid solution in the mouth. Combining the results of the separate trials it appeared that antifibrinolytic medication reduces the bleeding rate after dental extractions by 25% when compared to placebo ('dummy' treatment). However, there was no difference in bleeding rate between people treated with tranexamic acid and those treated with standard care (e.g. gauze compression or stitches). Side effects of the antifibrinolytic medication rarely occurred and did not lead to individuals discontinuing tranexamic acid treatment. No evidence was found for people being treated with DOACs. It could, however, be argued that, if antifibrinolytic medicine is effective in people on continuous treatment with VKAs, it might also work for people receiving other comparable anticoagulant drugs. Quality of evidence In relation to the review's two primary outcomes of number of postoperative bleeds and side effects of therapy, we judged there to be moderate‐quality evidence. In the two trials comparing tranexamic acid with placebo, the risk of bias, in relation to trial design, was considered to be low, in the two trials comparing tranexamic acid to standard care (gelatin sponge and sutures; or dry gauze compression) the risk of bias was considered to be moderate. This was mainly due to the lack of blinding (a way of making sure that the people involved in the trial do not know which trial arm they are assigned to) and inadequate allocation concealment (using the play of chance to assign participants to comparison groups to prevent selection bias) in two of these trials. There were differences between the trials with regards to different standard care treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Engelen, ET, Schutgens, REG, Mauser‐Bunschoten, EP, van Es, RJJ, van Galen, KPM", "articleTypes": [], "doi": "10.1002/14651858.CD012293.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.772Z" }, { "id": "b106825b-d3d2-4f1b-bd90-779a290492d1", "pmid": "", "title": "Evaluation of the Perception of Freshness and Swallowing Safety in Stroke Patients With Dysphagia Receiving a Specially Designed Thickened Oral Nutritional Supplement: the Cooling Sensation Safe Deglution Study", "imported": false, "abstract": "Dysphagia is a common complication in patients who have suffered a cerebrovascular accident (CVA), with an incidence ranging from 29% to 81%. Rehabilitation improves dysphagia in 47% of cases within the first few weeks and in 17% within 2-4 months. However, dysphagia can lead to nutritional and respiratory complications, affecting recovery and increasing healthcare costs due to the need for prolonged hospitalizations and readmissions.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.156Z" }, { "id": "b11db86e-a7f4-4993-8454-10541d0db704", "pmid": "", "title": "Adjunctive systemic antimicrobials for the non‐surgical treatment of periodontitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Khattri, S, Kumbargere Nagraj, S, Arora, A, Eachempati, P, Kusum, CK, Bhat, KG, Johnson, TM, Lodi, G", "articleTypes": [], "doi": "10.1002/14651858.CD012568.pub2 AB - Abstract - Background Systemic antimicrobials can be used as an adjunct to mechanical debridement (scaling and root planing (SRP)) as a non‐surgical treatment approach to manage periodontitis. A range of antibiotics with different dosage and combinations are documented in the literature. The review follows the previous classification of periodontitis as all included studies used this classification. Objectives To assess the effects of systemic antimicrobials as an adjunct to SRP for the non‐surgical treatment of patients with periodontitis. Search methods Cochrane Oral Health's Information Specialist searched the following databases to 9 March 2020: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, and Embase. The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included randomized controlled trials (RCTs) which involved individuals with clinically diagnosed untreated periodontitis. Trials compared SRP with systemic antibiotics versus SRP alone/placebo, or with other systemic antibiotics. Data collection and analysis We selected trials, extracted data, and assessed risk of bias in duplicate. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE. Main results We included 45 trials conducted worldwide involving 2664 adult participants. 14 studies were at low, 8 at high, and the remaining 23 at unclear overall risk of bias. Seven trials did not contribute data to the analysis. We assessed the certainty of the evidence for the 10 comparisons which reported long‐term follow‐up (≥ 1 year). None of the studies reported data on antimicrobial resistance and patient‐reported quality of life changes. Amoxicillin + metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐16.20%, 95% CI ‐25.87 to ‐6.53; 1 study, 44 participants); clinical attachment level (CAL) (MD ‐0.47 mm, 95% CI ‐0.90 to ‐0.05; 2 studies, 389 participants); probing pocket depth (PD) (MD ‐0.30 mm, 95% CI ‐0.42 to ‐0.18; 2 studies, 389 participants); and percentage of bleeding on probing (BOP) (MD ‐8.06%, 95% CI ‐14.26 to ‐1.85; 2 studies, 389 participants) was of very low certainty. Only the results for closed pockets and BOP showed a minimally important clinical difference (MICD) favouring amoxicillin + metronidazole + SRP. Metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐12.20%, 95% CI ‐29.23 to 4.83; 1 study, 22 participants); CAL (MD ‐1.12 mm, 95% CI ‐2.24 to 0; 3 studies, 71 participants); PD (MD ‐1.11 mm, 95% CI ‐2.84 to 0.61; 2 studies, 47 participants); and percentage of BOP (MD ‐6.90%, 95% CI ‐22.10 to 8.30; 1 study, 22 participants) was of very low certainty. Only the results for CAL and PD showed an MICD favouring the MTZ + SRP group. Azithromycin + SRP versus SRP for chronic/aggressive periodontitis: we found no evidence of a difference in percentage of closed pockets (MD 2.50%, 95% CI ‐10.19 to 15.19; 1 study, 40 participants); CAL (MD ‐0.59 mm, 95% CI ‐1.27 to 0.08; 2 studies, 110 participants); PD (MD ‐0.77 mm, 95% CI ‐2.33 to 0.79; 2 studies, 110 participants); and percentage of BOP (MD ‐1.28%, 95% CI ‐4.32 to 1.76; 2 studies, 110 participants) (very low‐certainty evidence for all outcomes). Amoxicillin + clavulanate + SRP versus SRP for chronic periodontitis: the evidence from 1 study, 21 participants for CAL (MD 0.10 mm, 95% CI ‐0.51 to 0.71); PD (MD 0.10 mm, 95% CI ‐0.17 to 0.37); and BOP (MD 0%, 95% CI ‐0.09 to 0.09) was of very low certainty and did not show a difference between the groups. Doxycycline + SRP versus SRP in aggressive periodontitis: the evidence from 1 study, 22 participants for CAL (MD ‐0.80 mm, 95% CI ‐1.49 to ‐0.11); and PD (MD ‐1.00 mm, 95% CI ‐1.78 to ‐0.22) was of very low certainty, with the doxycycline + SRP group showing an MICD in PD only. Tetracycline + SRP versus SRP for aggressive periodontitis: we found very low‐certainty evidence of a difference in long‐term improvement in CAL for the tetracycline group (MD ‐2.30 mm, 95% CI ‐2.50 to ‐2.10; 1 study, 26 participants). Clindamycin + SRP versus SRP in aggressive periodontitis: we found very low‐certainty evidence from 1 study, 21 participants of a difference in long‐term improvement in CAL (MD ‐1.70 mm, 95% CI ‐2.40 to ‐1.00); and PD (MD ‐1.80 mm, 95% CI ‐2.47 to ‐1.13) favouring clindamycin + SRP. Doxycycline + SRP versus metronidazole + SRP for aggressive periodontitis: there was very low‐certainty evidence from 1 study, 27 participants of a difference in long‐term CAL (MD 1.10 mm, 95% CI 0.36 to 1.84); and PD (MD 1.00 mm, 95% CI 0.30 to 1.70) favouring metronidazole + SRP. Clindamycin + SRP versus metronidazole + SRP for aggressive periodontitis: the evidence from 1 study, 26 participants for CAL (MD 0.20 mm, 95% CI ‐0.55 to 0.95); and PD (MD 0.20 mm, 95% CI ‐0.38 to 0.78) was of very low certainty and did not show a difference between the groups. Clindamycin + SRP versus doxycycline + SRP for aggressive periodontitis: the evidence from 1 study, 23 participants for CAL (MD ‐0.90 mm, 95% CI ‐1.62 to ‐0.18); and PD (MD ‐0.80 mm, 95% CI ‐1.58 to ‐0.02) was of very low certainty and did not show a difference between the groups. Most trials testing amoxicillin, metronidazole, and azithromycin reported adverse events such as nausea, vomiting, diarrhoea, mild gastrointestinal disturbances, and metallic taste. No serious adverse events were reported. Authors' conclusions There is very low‐certainty evidence (for long‐term follow‐up) to inform clinicians and patients if adjunctive systemic antimicrobials are of any help for the non‐surgical treatment of periodontitis. There is insufficient evidence to decide whether some antibiotics are better than others when used alongside SRP. None of the trials reported serious adverse events but patients should be made aware of the common adverse events related to these drugs. Well‐planned RCTs need to be conducted clearly defining the minimally important clinical difference for the outcomes closed pockets, CAL, PD, and BOP. Plain language summary What are the benefits and risks of using antibiotics as well as cleaning by a dental care professional to treat gum disease? Why is this question important? Gum disease is a common condition in which the gums become swollen, sore or infected. It is caused by bacteria that accumulate on gums and teeth. Diseased gums may bleed when people brush their teeth, and may cause bad breath. If gum disease is not treated, teeth can become loose and eventually fall out. This can affect a person’s ability to chew and speak. It can also make people feel self‐conscious about their appearance. Dental‐care professionals can clean teeth and gums to remove excess bacteria from the mouth. They use special instruments – typically, an ultrasound scraper followed by specialised hand‐held instruments – to scrape bacteria from the teeth, and stop these from affecting the gums. Antibiotics (medicines that kill bacteria) taken by mouth (orally) can be used alongside professional cleaning, to remove bacteria from the area between the teeth and gums. However, there are potential risks associated with antibiotics, such as allergic reactions and antibiotic resistance (changes in bacteria after exposure to antibiotics, that allow the bacteria to survive future antibiotic treatment). We conducted a review of the evidence from research studies to find out about the benefits and risks of using antibiotics alongside professional dental cleaning to treat gum disease. We also wanted to know if some antibiotics work better than others in this situation. How did we identify and evaluate the evidence? First, we searched for randomized controlled studies (clinical studies where people are randomly put into one of two or more treatment groups), because these studies provide the most robust evidence about the effects of a treatment. We then compared the results, and summarized the evidence from all the studies. Finally, we rated our confidence in the evidence, based on factors such as study methods and sizes, and the consistency of findings across studies. What did we find? We found 45 studies that involved a total of 2664 people over the age of 18 who had gum disease. The studies compared professional cleaning plus antibiotics against professional cleaning alone, or compared different antibiotics used alongside professional cleaning against one another. We cannot tell whether antibiotics reduce gum disease in the long term (one year or more after treatment), or whether some antibiotics are better than others. This is because we have very little confidence in the evidence we found. We cannot tell whether antibiotics are associated with unwanted effects, because we have too little confidence in the evidence. The most commonly reported unwanted effects were temporary, mild gastrointestinal disturbances, such as nausea, vomiting, diarrhoea, or a metallic taste in the mouth. No serious unwanted effects were reported. No studies reported on antimicrobial resistance or changes in people’s quality of life. What does this mean? We do not know whether: ‐ using antibiotics alongside professional cleaning is beneficial for treating gum disease in the long term (more than one year after treatment);
‐ using antibiotics alongside professional cleaning is associated with unwanted effects; or
‐ some antibiotics are better than others for treating gum disease alongside professional cleaning. Our confidence in the available evidence is very low. The results of our review are likely to change if more evidence becomes available. Future studies should clearly define what qualifies as a minimally important improvement in gum disease. How‐up‐to date is this review? The evidence in this Cochrane Review is current to March 2020.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.736Z" }, { "id": "b131b805-328f-41d1-84b8-132111afec81", "pmid": "", "title": "Statins for asthma", "imported": false, "abstract": "Abstract - Background Asthma is a common chronic respiratory disease. People with asthma have inflammation of their airways that causes recurrent episodes of wheezing, breathlessness and chest tightness, with or without a cough. Statins possess multiple therapeutic effects, including lowering lipid levels in the blood. Statins are reported to have a potential role as an adjunct treatment in asthma. However, comprehensive evidence of the benefits and harms of using statins is required to facilitate decision making. Objectives To assess the benefits and harms of statins as an adjunct therapy for asthma in adults and children. Search methods We searched for studies in the Cochrane Airways Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid SP and Embase Ovid SP, from their inception dates We handsearched the proceedings of major respiratory conferences. We also searched clinical trials registries for completed, ongoing and unpublished studies, and scanned the reference lists of included studies and relevant reviews to identify additional studies. The search is current to 7 February 2020. Selection criteria We included randomised controlled trials (RCTs) with a parallel‐group design that assessed statins for at least 12 weeks' duration. We considered all participants with a clinical diagnosis of asthma to be eligible, regardless of age, sex, disease severity and previous or current treatment. We planned to include studies reported as full text, those published as abstract only, and unpublished data. Data collection and analysis Two review authors independently screened and selected the studies, extracted outcome data and intervention characteristics from included studies, and assessed risk of bias according to standard Cochrane methodological procedures. We resolved any disagreement through discussion. Main results We found only one trial involving a total of 60 people living with asthma. The trial compared the effect of atorvastatin with a placebo (dummy treatment containing lactose) in treating people with chronic asthma. The trial did not report data for the primary outcomes or adverse events. There was uncertainty about the relative effect on forced expiratory volume in one second (FEV 1 ) and peak expiratory flow (PEF) in the atorvastatin group compared with the placebo group. The study did not report serious adverse effects for the interventions. The included study had internal discrepancies in its reported data. Authors' conclusions The evidence was of very low certainty, so we are unable to draw conclusions about the effectiveness and safety of statins to treat asthma. High‐quality RCTs are needed to assess the effect of statins on people with asthma. Well‐designed multicentre trials with larger samples and longer duration of treatment are required, which assess outcomes such as adverse events, hospital utilisation and costs, to provide better quality evidence. Future studies that include subgroups of obese people with asthma are also required. Plain language summary Statins for asthma Review question We reviewed the evidence about the effect of statins in people with asthma. Background Asthma is a common chronic (persistent) airway disease. Asthma is caused by inflammation in the lungs and bronchoconstriction (tightening of the small tubes in the lungs in response to a trigger such as pollen or cold air). Inflammation and bronchoconstriction cause airflow obstruction (narrowing and blockage). People with asthma experience recurrent attacks of wheezing, difficultly in breathing, and chest tightness, with or without a cough. Statins are anti‐inflammatory medicines. We wanted to review the evidence for statins because the theory is that their anti‐inflammatory properties will help people with asthma. We wanted to discover whether using statin therapy was better or worse than other alternatives, such as usual care alone or different types of statins (atorvastatin, simvastatin). Study characteristics We found only one trial that assessed atorvastatin (a type of statin drug) and placebo (dummy treatment) in 60 adults with asthma over a period of 12 weeks. These people had chronic asthma (persistent airway disease) when they started treatment. Key results We found that the statin (atorvastatin) did not result in any clear improvement in lung function in people with asthma, but may be better in asthma control than the dummy drug. However, because there is only one trial, we cannot draw firm conclusions. The trial did not report on adverse effects or severe adverse effects (harms). We are uncertain whether statins may have beneficial effects on relieving asthma or whether they may increase the risk of adverse events or non‐serious adverse events. Quality of the evidence The evidence was of very low certainty, so we cannot draw firm conclusions about whether statins are helpful and safe to be used by people with asthma. The evidence is current to 7 February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Naing, C, Ni, H", "articleTypes": [], "doi": "10.1002/14651858.CD013268.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.777Z" }, { "id": "b165c70d-5914-4c26-b10b-c59e0cdedde0", "pmid": "", "title": "Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve due to viral infection by the herpes zoster virus are implicated in the aetiology and clinical manifestation of Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Corticosteroids, with their powerful anti‐inflammatory effect, have a potential role to play in the reduction or minimisation of nerve damage when administered together with antiviral therapy, and therefore may improve the outcome for patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of corticosteroids as an adjuvant to antiviral therapy in adult patients with Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Search methods We searched the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 4, 2007), MEDLINE (1950 to December 2007) and EMBASE (1974 to December 2007), CINAHL (1982 to December 2007), LILACS, KoreaMed, IndMed, PakMediNet, ZETOC, Cambridge Scientific Abstracts (Conference Proceedings Database), ISI Proceedings (Web of Science), the National Research Register (NRR), the UK Clinical Research Network Portfolio Database (UKCRN), the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Research Findings Register (ReFeR) and the metaRegister of Controlled Trials (mRCT). Selection criteria All randomised controlled trials in which corticosteroids (by any route of administration at any dosage) were given as an adjuvant to antiviral agents in the treatment of Ramsay Hunt syndrome. Data collection and analysis Two reviewers independently assessed eligibility and trial quality of the available studies, whether they were published or unpublished. No trials were found and therefore no data were analysed. Main results This is an empty review as no trials were found that fulfilled the inclusion criteria. Authors' conclusions Since no randomised controlled trials investigating the use of corticosteroids as an adjuvant to antiviral treatment in Ramsay Hunt syndrome were identified, such studies are needed to assess the effects of such therapy. Plain language summary Corticosteroids used in addition to antiviral drugs in patients with Ramsay Hunt syndrome Ramsay Hunt syndrome (also known as herpes zoster oticus) consists of weakness of the face due to infection with the varicella zoster virus. Five cases arise per 100,000 of the population per year in the US. It is more common among those over 60 and rare in children. Other symptoms may include severe ear pain and small blisters on the outer ear or in the mouth. Prompt diagnosis and treatment (ideally within 72 hours of the onset of symptoms) are crucial to secure the best outcomes. In cases where treatment has been started within this time period, facial weakness recovers in up to 75% of patients. Standard treatment is with antiviral therapy (most commonly acyclovir). Corticosteroids are known for their anti‐inflammatory properties and are commonly used together with antivirals to reduce the inflammation in the facial nerve. This is thought to be the cause of the facial weakness. The aim of the review was to see if corticosteroids, used at the same time as antiviral drugs, improved outcomes in patients with Ramsay Hunt syndrome. However the review found no trials matching the inclusion criteria, and no conclusions can be drawn about the effectiveness of using corticosteroids in this way. It is recommended that high‐quality randomised controlled trials be undertaken to address this issue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T, Doree, C, Chamberlain, IJ, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006852.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.738Z" }, { "id": "b16d2051-abb6-49d3-9841-ea11b2ec7ee4", "pmid": "", "title": "Interventions for bullous pemphigoid", "imported": false, "abstract": "Abstract - Background Bullous pemphigoid (BP) is the most common autoimmune blistering disease. Oral steroids are the standard treatment. We have updated this review, which was first published in 2002, because several new treatments have since been tried. Objectives To assess the effects of treatments for bullous pemphigoid. Search methods We updated searches of the following databases to November 2021: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched five trial databases to January 2022, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria RCTs of treatments for immunofluorescence‐confirmed bullous pemphigoid. Data collection and analysis At least two review authors, working independently, evaluated the studies against the review's inclusion criteria and extracted data from included studies. Using GRADE methodology, we assessed the certainty of the evidence for each outcome in each comparison. Our primary outcomes were healing of skin lesions and mortality. Main results We identified 14 RCTs (1442 participants). The main treatment modalities assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Most studies reported mortality but adverse events and quality of life were not well reported. We decided to look at the primary outcomes 'disease control' and 'mortality'. Almost all studies investigated different comparisons; two studies were placebo‐controlled. The results are therefore based on a single study for each comparison except azathioprine. Most studies involved only small numbers of participants. We assessed the risk of bias for all key outcomes as having 'some concerns' or high risk, due to missing data, inappropriate analysis, or insufficient information. Clobetasol propionate cream versus oral prednisone Compared to oral prednisone, clobetasol propionate cream applied over the whole body probably increases skin healing at day 21 (risk ratio (RR 1.08, 95% confidence interval (CI) 1.03 to 1.13; 1 study, 341 participants; moderate‐certainty evidence). Skin healing at 21 days was seen in 99.8% of participants assigned to clobetasol and 92.4% of participants assigned to prednisone. Clobetasol propionate cream applied over the whole body compared to oral prednisone may reduce mortality at one year (RR 0.73, 95% CI 0.53 to 1.01; 1 study, 341 participants; low‐certainty evidence). Death occurred in 26.5% (45/170) of participants assigned to clobetasol and 36.3% (62/171) of participants assigned to oral prednisone. This study did not measure quality of life. Clobetasol propionate cream may reduce risk of severe complications by day 21 compared with oral prednisone (RR 0.65, 95% CI 0.50 to 0.86; 1 study, 341 participants; low‐certainty evidence). Mild clobetasol propionate cream regimen (10 to 30 g/day) versus standard clobetasol propionate cream regimen (40 g/day) A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen probably does not change skin healing at day 21 (RR 1.00, 95% CI 0.97 to 1.03; 1 study, 312 participants; moderate‐certainty evidence). Both groups showed complete healing of lesions at day 21 in 98% participants. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change mortality at one year (RR 1.00, 95% CI 0.75 to 1.32; 1 study, 312 participants; low‐certainty evidence), which occurred in 118/312 (37.9%) participants. This study did not measure quality of life. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change adverse events at one year (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 309 participants; low‐certainty evidence). Doxycycline versus prednisolone Compared to prednisolone (0.5 mg/kg/day), doxycycline (200 mg/day) induces less skin healing at six weeks (RR 0.81, 95% CI 0.72 to 0.92; 1 study, 213 participants; high‐certainty evidence). Complete skin healing was reported in 73.8% of participants assigned to doxycycline and 91.1% assigned to prednisolone. Doxycycline compared to prednisolone probably decreases mortality at one year (RR 0.25, 95% CI 0.07 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 14; 1 study, 234 participants; moderate‐certainty evidence). Mortality occurred in 2.3% (3/132) of participants with doxycycline and 9.1% (11/121) with prednisolone. Compared to prednisolone, doxycycline improved quality of life at one year (mean difference 1.8 points lower, which is more favourable on the Dermatology Life Quality Index, 95% CI 1.02 to 2.58 lower; 1 study, 234 participants; high‐certainty evidence). Doxycycline compared to prednisolone probably reduces severe or life‐threatening treatment‐related adverse events at one year (RR 0.59, 95% CI 0.35 to 0.99; 1 study, 234 participants; moderate‐certainty evidence). Prednisone plus azathioprine versus prednisone It is unclear whether azathioprine plus prednisone compared to prednisone alone affects skin healing or mortality because there was only very low‐certainty evidence from two trials (98 participants). These studies did not measure quality of life. Adverse events were reported in a total of 20/48 (42%) participants assigned to azathioprine plus prednisone and 15/44 (34%) participants assigned to prednisone. Nicotinamide plus tetracycline versus prednisone It is unclear whether nicotinamide plus tetracycline compared to prednisone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (18 participants). This study did not measure quality of life. Fewer adverse events were reported in the nicotinamide group. Methylprednisolone plus azathioprine versus methylprednisolone plus dapsone It is unclear whether azathioprine plus methylprednisolone compared to dapsone plus methylprednisolone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (54 participants). This study did not measure quality of life. A total of 18 adverse events were reported in the azathioprine group and 13 in the dapsone group. Authors' conclusions Clobetasol propionate cream applied over the whole body is probably similarly effective as, and may cause less mortality than, oral prednisone for treating bullous pemphigoid. Lower‐dose clobetasol propionate cream applied over the whole body is probably similarly effective as standard‐dose clobetasol propionate cream and has similar mortality. Doxycycline is less effective but causes less mortality than prednisolone for treating bullous pemphigoid. Other treatments need further investigation. Plain language summary Treatments for bullous pemphigoid Which treatments work best for bullous pemphigoid (a rare, itchy skin disease that causes blisters)? Key messages • A cream, containing topical steroid clobetasol propionate, applied on the entire skin surface is as effective as oral steroids (prednisone), causes less severe unwanted or harmful effects, and may decrease deaths. • Initiating treatment with doxycycline (200 mg/day), an antibiotic with anti‐inflammatory effect, leads to an acceptable short‐term blister control compared to the oral steroid prednisolone (0.5 mg/kg/day), and is superior in long‐term safety aspects, including deaths. What is bullous pemphigoid? Bullous pemphigoid is the most common autoimmune blistering disease. In autoimmune diseases, the body's immune system mistakes its own tissues as foreign and attacks them. In bullous pemphigoid, this causes blisters on the skin. Bullous pemphigoid usually occurs in the elderly, but may also affect younger people. How is bullous pemphigoid treated? Until recently, the leading treatment for bullous pemphigoid was oral steroids which suppress inflammation and the body's own immune system. However, given over a long period of time, oral steroids will cause severe adverse (i.e. harmful) effects. This review assessed studies which investigated the effectiveness of other treatment options for bullous pemphigoid; for example, a steroid cream applied on the skin and the anti‐inflammatory antibiotic medicine, doxycycline. What did we want to find out? We wanted to find out which treatments work best for bullous pemphigoid with respect to the healing of blisters (efficacy) and reduction in adverse effects, such as death. What did we do? We searched for studies that looked at treatments for bullous pemphigoid. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 14 studies including 1442 people with bullous pemphigoid. The main treatments assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Other treatments tested were oral (i.e. taken by mouth) immunosuppressives (medicines that keep your immune system in check) and immunoglobulins (also called antibodies. Antibodies are proteins that your immune system makes to fight germs, for example). ‐ Topical steroid cream, clobetasol propionate, applied over the whole body (40 grams of cream applied per day, with the amount decreased over 12 months) is an effective and safe treatment for bullous pemphigoid. ‐ Treatment with a lower amount of clobetasol propionate cream (10 to 30 grams per day, decreased over 4 months) is equally effective and safe. ‐ Prednisolone, an oral corticosteroid, in the dose of 0.5 mg/kg/day, may be adequate to control disease in most people and reduces adverse effects compared to higher doses of oral corticosteroid. ‐ Initiating treatment with 200 mg/day of doxycycline leads to acceptable blister control compared to oral prednisolone (0.5 mg/kg/day) and is safer. ‐ A study with 20 participants suggests that nicotinamide (a form of vitamin B 3 )and tetracycline (an antibiotic used to treat a wide variety of infections) may be an effective alternative to prednisone and may decrease treatment‐associated death. ‐ Adding azathioprine, a drug which suppresses the immune system, to an oral corticosteroid does not improve disease control; it may lead to a reduced need for oral corticosteroid. ‐ Further research is needed to fully understand the effectiveness of alternatives to oral steroids (such as dapsone or immunoglobulins), as well as the effectiveness of giving other medicines alongside an oral steroid. What are the limitations of the evidence? Except for the studies on topical clobetasol cream and doxycycline, the studies included relatively few participants. The methodological quality of these studies was further limited because of unclear methods of allocating people to different treatment groups; lack of masking (participants and researchers knew which treatments were given to which people, which are not good conditions for fair assessment); and the exclusion of people who dropped out of the studies from treatment analysis. We are confident about the efficacy of initiating treatment with doxycycline and moderately confident about the efficacy of topical clobetasol cream for the treatment of bullous pemphigoid. How up to date is this evidence? The evidence is current to 11 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Singh, S, Kirtschig, G, Anchan, VN, Chi, C-C, Taghipour, K, Boyle, RJ, Murrell, DF", "articleTypes": [], "doi": "10.1002/14651858.CD002292.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.107Z" }, { "id": "b16fa307-bbc2-4889-8712-bca6b6ff63d3", "pmid": "", "title": "Antiplatelet agents for the treatment of adults with COVID‐19", "imported": false, "abstract": "Abstract - Background Severe coronavirus disease 2019 (COVID‐19) can cause thrombotic events that lead to severe complications or death. Antiplatelet agents, such as acetylsalicylic acid, have been shown to effectively reduce thrombotic events in other diseases: they could influence the course of COVID‐19 in general. Objectives To assess the efficacy and safety of antiplatelets given with standard care compared to no treatment or standard care (with/without placebo) for adults with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (which comprises MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO ICTRP, medRxiv, CENTRAL), Web of Science, WHO COVID‐19 Global literature on coronavirus disease and the Epistemonikos COVID‐19 L*OVE Platform to identify completed and ongoing studies without language restrictions to December 2022. Selection criteria We followed standard Cochrane methodology. We included randomised controlled trials (RCTs) evaluating antiplatelet agents for the treatment of COVID‐19 in adults with COVID‐19, irrespective of disease severity, gender or ethnicity. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane risk of bias tool (RoB 2) for RCTs. We rated the certainty of evidence using the GRADE approach for the outcomes. Main results Antiplatelets plus standard care versus standard care (with/without placebo) Adults with a confirmed diagnosis of moderate to severe COVID‐19 We included four studies (17,541 participants) that recruited hospitalised people with a confirmed diagnosis of moderate to severe COVID‐19. A total of 8964 participants were analysed in the antiplatelet arm (either with cyclooxygenase inhibitors or P2Y12 inhibitors) and 8577 participants in the control arm. Most people were older than 50 years and had comorbidities such as hypertension, lung disease or diabetes. The studies were conducted in high‐ to lower middle‐income countries prior to wide‐scale vaccination programmes. Antiplatelets compared to standard care: – probably result in little to no difference in 28‐day mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.85 to 1.05; 3 studies, 17,249 participants; moderate‐certainty evidence). In absolute terms, this means that for every 177 deaths per 1000 people not receiving antiplatelets, there were 168 deaths per 1000 people who did receive the intervention (95% CI 151 to 186 per 1000 people); – probably result in little to no difference in worsening (new need for invasive mechanical ventilation or death up to day 28) (RR 0.95, 95% CI 0.90 to 1.01; 2 studies, 15,266 participants; moderate‐certainty evidence); – probably result in little to no difference in improvement (participants discharged alive up to day 28) (RR 1.00, 95% CI 0.96 to 1.04; 2 studies, 15,454 participants; moderate‐certainty evidence); – probably result in a slight reduction of thrombotic events at longest follow‐up (RR 0.90, 95% CI 0.80 to 1.02; 4 studies, 17,518 participants; moderate‐certainty evidence); – may result in a slight increase in serious adverse events at longest follow‐up (Peto odds ratio (OR) 1.57, 95% CI 0.48 to 5.14; 1 study, 1815 participants; low‐certainty evidence), but non‐serious adverse events during study treatment were not reported; – probably increase the occurrence of major bleeding events at longest follow‐up (Peto OR 1.68, 95% CI 1.29 to 2.19; 4 studies, 17,527 participants; moderate‐certainty evidence). Adults with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included two RCTs allocating participants, of whom 4209 had confirmed mild COVID‐19 and were not hospitalised. A total of 2109 participants were analysed in the antiplatelet arm (treated with acetylsalicylic acid) and 2100 participants in the control arm. No study included people with asymptomatic SARS‐CoV‐2 infection. Antiplatelets compared to standard care: – may result in little to no difference in all‐cause mortality at day 45 (Peto OR 1.00, 95% CI 0.45 to 2.22; 2 studies, 4209 participants; low‐certainty evidence); – may slightly decrease the incidence of new thrombotic events up to day 45 (Peto OR 0.37, 95% CI 0.09 to 1.46; 2 studies, 4209 participants; low‐certainty evidence); – may make little or no difference to the incidence of serious adverse events up to day 45 (Peto OR 1.00, 95% CI 0.60 to 1.64; 1 study, 3881 participants; low‐certainty evidence), but non‐serious adverse events were not reported. The evidence is very uncertain about the effect of antiplatelets on the following outcomes (compared to standard care plus placebo): – admission to hospital or death up to day 45 (Peto OR 0.79, 95% CI 0.57 to 1.10; 2 studies, 4209 participants; very low‐certainty evidence); – major bleeding events up to longest follow‐up (no event occurred in 328 participants; very low‐certainty evidence). Quality of life and adverse events during study treatment were not reported. Authors' conclusions In people with confirmed or suspected COVID‐19 and moderate to severe disease, we found moderate‐certainty evidence that antiplatelets probably result in little to no difference in 28‐day mortality, clinical worsening or improvement, but probably result in a slight reduction in thrombotic events. They probably increase the occurrence of major bleeding events. Low‐certainty evidence suggests that antiplatelets may result in a slight increase in serious adverse events. In people with confirmed COVID‐19 and mild symptoms, we found low‐certainty evidence that antiplatelets may result in little to no difference in 45‐day mortality and serious adverse events, and may slightly reduce thrombotic events. The effects on the combined outcome admission to hospital or death up to day 45 and major bleeding events are very uncertain. Quality of life was not reported. Included studies were conducted in high‐ to lower middle‐income settings using antiplatelets prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, adverse events and people with asymptomatic infection. The 14 ongoing and three completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. Plain language summary Are antiplatelets an effective treatment for people with COVID‐19? Key messages Antiplatelets are a group of different medicines that can prevent potentially fatal clot formation in the blood vessels ('thrombotic events'). For hospitalised patients with COVID‐19, they probably slightly reduce thrombotic events but probably do not affect deaths, clinical worsening or improvement in COVID‐19 compared with placebo or standard care. However, antiplatelets may result in a slight increase in serious unwanted effects ('adverse events') and probably increase major bleeding. Similarly, in non‐hospitalised people, antiplatelets slightly decrease thrombotic events. They may result in little to no difference in deaths or serious unwanted effects, however the evidence on admission to hospital or death and major bleeding events is very uncertain. There are 14 further studies that have not completed yet, and the results of three other completed studies are not yet available. What are antiplatelets? Antiplatelets are a group of drugs which, in different ways, stop blood from changing to a gel‐like substance called a clot, which we mean by the term 'thrombotic events'. They are taken mainly by mouth, usually by people who are at high risk of developing a clot (people who have already experienced or who tend to build up a clot). A clot could lead to a stroke, coronary heart disease, poor blood circulation in the legs, thromboses in the legs or clot obstruction ('embolism') in the lung circulation that could lead to shortness of breath, heart failure and death. How might antiplatelets treat COVID‐19? People with COVID‐19 might be at risk from blood clots. Antiplatelets prevent clots from forming in the body, and this could in turn prevent complications that lead to death and clinical deterioration. What did we want to find out? We wanted to know whether antiplatelets in addition to usual care are effective for adults with COVID‐19, when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in: – number of deaths from any cause up to 28 days after treatment, or longer if reported;
– whether people got better or worse after treatment (including unwanted effects of the disease itself, like thrombotic events);
– unwanted effects of the treatment (especially major bleeding). What did we do? We searched for studies that reported on people with COVID‐19 who received antiplatelets together with usual care, or usual care alone (with/without placebo). We summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We identified four studies, including 17,541 people with moderate to severe COVID‐19 (hospitalised). Of these, one compared acetylsalicylic acid (aspirin) with usual care, two studies compared 'P2Y12 inhibitors' (e.g. clopidogrel, prasugrel, ticagrelor) with usual care, and a fourth one compared either acetylsalicylic acid or P2Y12 inhibitors with usual care. The studies included people with a confirmed or suspected diagnosis of SARS‐CoV‐2 infection. Two studies compared acetylsalicylic acid to placebo in 4209 non‐hospitalised people with confirmed mild COVID‐19. We also found 14 ongoing studies, two studies without published results and another that had been withdrawn after a preprint version. We found no studies that included people with COVID‐19 infection but no symptoms. Main results Antiplatelets: – probably make little or no difference to deaths by 28 or 180 days, worsening up to day 28 (new invasive mechanical ventilation or death) or improvement (discharged alive) up to day 28, and they probably slightly decrease thrombotic events; – may result in a slight increase in serious unwanted effects and probably increase major bleeding events. In people not in hospital, with mild disease, antiplatelets may result in little to no difference in death within 45 days, or in the incidence of serious adverse events, and they may slightly decrease the incidence of thrombotic events. The evidence for these participants is very uncertain about the effects on worsening (hospitalisation or death within 45 days) and on major bleeding events. Studies did not report on quality of life and general unwanted effects. What are the limitations of the evidence? The studies were conducted in populations from high‐ to middle‐income countries, many of them prior to the roll‐out of COVID‐19 vaccination programmes and before Omicron became the most prevalent variant. We have moderate confidence in the evidence for mortality, worsening/improvement up to day 28, and major bleeding events or thrombotic events in hospitalised people. We have low confidence in the evidence for the effects on serious unwanted effects, because they occurred rarely. For non‐hospitalised people, our confidence in the evidence is low for the effects on death, thrombotic events and serious adverse events, and very low for the effects on worsening and major bleeding events (those events were rare and the time period between symptom onset and treatment was long). Information about other unwanted effects and quality of life was not available. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 22 December 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Fischer, A-L; Messer, S; Riera, R; Martimbianco, ALC; Stegemann, M; Estcourt, LJ; Weibel, S; Monsef, I; Andreas, M; Pacheco, RL; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015078", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "b17ec83f-417c-486e-99cb-4e7c00cba763", "pmid": "", "title": "Ganoderma lucidum (Reishi mushroom) for cancer treatment", "imported": false, "abstract": "Abstract - Background Ganoderma lucidum is a natural medicine that is widely used and recommended by Asian physicians and naturopaths for its supporting effects on immune system. Laboratory research and a handful of preclinical trials have suggested that G. lucidum carries promising anticancer and immunomodulatory properties. The popularity of taking G. lucidum as an alternative medicine has been increasing in cancer patients. However, there is no systematic review that has been conducted to evaluate the actual benefits of G. lucidum in cancer treatment. Objectives To evaluate the clinical effects of G. lucidum on long‐term survival, tumour response, host immune functions and quality of life in cancer patients, as well as adverse events associated with its use. Search methods We searched an extensive set of databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, NIH, AMED, CBM, CNKI, CMCC and VIP Information/Chinese Scientific Journals Database was searched for randomised controlled trials (RCTs) in October 2011. Other strategies used were scanning the references of articles retrieved, handsearching of the International Journal of Medicinal Mushrooms and contact with herbal medicine experts and manufacturers of G. lucidum . For this update we updated the searches in February 2016. Selection criteria To be eligible for being included in this review, studies had to be RCTs comparing the efficacy of G. lucidum medications to active or placebo control in patients with cancer that had been diagnosed by pathology. All types and stages of cancer were eligible for inclusion. Trials were not restricted on the basis of language. Data collection and analysis Five RCTs met the inclusion criteria and were included in this review. Two independent review authors assessed the methodological quality of individual trials. Common primary outcomes were tumour response evaluated according to the World Health Organization (WHO) criteria, immune function parameters such as natural killer (NK)‐cell activity and T‐lymphocyte co‐receptor subsets, and quality of life measured by the Karnofsky scale score. No trial had recorded long‐term survival rates. Associated adverse events were reported in one study. A meta‐analysis was performed to pool available data from the primary trials. Results were gauged using relative risks (RR) and standard mean differences (SMD) for dichotomous and continuous data respectively, with a 95% confidence interval (CI). Main results The methodological quality of primary studies was generally unsatisfying and the results were reported inadequately in many aspects. Additional information was not available from primary trialists. The meta‐analysis results showed that patients who had been given G. lucidum alongside with chemo/radiotherapy were more likely to respond positively compared to chemo/radiotherapy alone (RR 1.50; 95% CI 0.90 to 2.51, P = 0.02). G. lucidum treatment alone did not demonstrate the same regression rate as that seen in combined therapy. The results for host immune function indicators suggested that G. lucidum simultaneously increases the percentage of CD3, CD4 and CD8 by 3.91% (95% CI 1.92% to 5.90%, P < 0.01), 3.05% (95% CI 1.00% to 5.11%, P < 0.01) and 2.02% (95% CI 0.21% to 3.84%, P = 0.03), respectively. In addition, leukocyte, NK‐cell activity and CD4/CD8 ratio were marginally elevated. Four studies showed that patients in the G. lucidum group had relatively improved quality of life in comparison to controls. One study recorded minimal side effects, including nausea and insomnia. No significant haematological or hepatological toxicity was reported. Authors' conclusions Our review did not find sufficient evidence to justify the use of G. lucidum as a first‐line treatment for cancer. It remains uncertain whether G. lucidum helps prolong long‐term cancer survival. However, G. lucidum could be administered as an alternative adjunct to conventional treatment in consideration of its potential of enhancing tumour response and stimulating host immunity. G. lucidum was generally well tolerated by most participants with only a scattered number of minor adverse events. No major toxicity was observed across the studies. Although there were few reports of harmful effect of G. lucidum , the use of its extract should be judicious, especially after thorough consideration of cost‐benefit and patient preference. Future studies should put emphasis on the improvement in methodological quality and further clinical research on the effect of G. lucidum on cancer long‐term survival are needed. An update to this review will be performed every two years. Plain language summary G. lucidum (Reishi mushroom) for cancer treatment There have been an increasing number of patients diagnosed with cancer each year. Certain malignancies have been a major cause of death in some populations. People who have been diagnosed with cancer want to do everything they can to combat the disease, manage its symptoms and cope with the side effects of radio/chemotherapy. Many turn to complementary and alternative medicine. G. lucidum extract is a medication that has been widely used by traditional Chinese medicine (TCM) practitioners for this regard. It is usually recommended as an immune system support supplement in cancer treatment. Latest laboratory research and preclinical trials of G. lucidum have shown promising results of its antitumour activity. However, clinical evidence of its efficacy is sparse and a systematic review is in need to provide collective information for health‐care consumers. Our review identified and subsequently included five relevant randomised controlled trials. A total of 373 subjects were analysed. A meta‐analysis was performed to pool available data from individual trials. Our results found that patients with G. lucidum extract in their anticancer regimen were 1.27 times more likely to respond to chemotherapy or radiotherapy than those without. However, the data failed to demonstrate significant effect on tumour shrinkage when it was used alone. In addition, G. lucidum could stimulate host immune functions by considerably increasing CD3, CD4 and CD8 lymphocyte percentages. Nevertheless, natural killer (NK)‐cell activity, which has been suggested to be an indicator of self‐defence against tumour cell, was marginally elevated. Patients in the G. lucidum group were found to have a relatively better quality of life after treatment than those in the control group. A few cases of minor side effect associated with G. lucidum treatment including nausea and insomnia were reported. There are limitations of the results from this systematic review. First, most included studies were small and there were concerns on the methodological quality of individual trials. Second, all participants in the individual trials were recruited from the Chinese population. Together, the robustness and applicability of the results were largely affected.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Jin, X; Ruiz Beguerie, J; Sze, DMY; Chan, GCF", "articleTypes": [], "doi": "10.1002/14651858.CD007731.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "b1b06716-710a-4e13-ac23-7dc03c83d560", "pmid": "", "title": "Adjunctive systemic antimicrobials for the non‐surgical treatment of periodontitis", "imported": false, "abstract": "Abstract - Background Systemic antimicrobials can be used as an adjunct to mechanical debridement (scaling and root planing (SRP)) as a non‐surgical treatment approach to manage periodontitis. A range of antibiotics with different dosage and combinations are documented in the literature. The review follows the previous classification of periodontitis as all included studies used this classification. Objectives To assess the effects of systemic antimicrobials as an adjunct to SRP for the non‐surgical treatment of patients with periodontitis. Search methods Cochrane Oral Health's Information Specialist searched the following databases to 9 March 2020: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, and Embase. The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included randomized controlled trials (RCTs) which involved individuals with clinically diagnosed untreated periodontitis. Trials compared SRP with systemic antibiotics versus SRP alone/placebo, or with other systemic antibiotics. Data collection and analysis We selected trials, extracted data, and assessed risk of bias in duplicate. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE. Main results We included 45 trials conducted worldwide involving 2664 adult participants. 14 studies were at low, 8 at high, and the remaining 23 at unclear overall risk of bias. Seven trials did not contribute data to the analysis. We assessed the certainty of the evidence for the 10 comparisons which reported long‐term follow‐up (≥ 1 year). None of the studies reported data on antimicrobial resistance and patient‐reported quality of life changes. Amoxicillin + metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐16.20%, 95% CI ‐25.87 to ‐6.53; 1 study, 44 participants); clinical attachment level (CAL) (MD ‐0.47 mm, 95% CI ‐0.90 to ‐0.05; 2 studies, 389 participants); probing pocket depth (PD) (MD ‐0.30 mm, 95% CI ‐0.42 to ‐0.18; 2 studies, 389 participants); and percentage of bleeding on probing (BOP) (MD ‐8.06%, 95% CI ‐14.26 to ‐1.85; 2 studies, 389 participants) was of very low certainty. Only the results for closed pockets and BOP showed a minimally important clinical difference (MICD) favouring amoxicillin + metronidazole + SRP. Metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD ‐12.20%, 95% CI ‐29.23 to 4.83; 1 study, 22 participants); CAL (MD ‐1.12 mm, 95% CI ‐2.24 to 0; 3 studies, 71 participants); PD (MD ‐1.11 mm, 95% CI ‐2.84 to 0.61; 2 studies, 47 participants); and percentage of BOP (MD ‐6.90%, 95% CI ‐22.10 to 8.30; 1 study, 22 participants) was of very low certainty. Only the results for CAL and PD showed an MICD favouring the MTZ + SRP group. Azithromycin + SRP versus SRP for chronic/aggressive periodontitis: we found no evidence of a difference in percentage of closed pockets (MD 2.50%, 95% CI ‐10.19 to 15.19; 1 study, 40 participants); CAL (MD ‐0.59 mm, 95% CI ‐1.27 to 0.08; 2 studies, 110 participants); PD (MD ‐0.77 mm, 95% CI ‐2.33 to 0.79; 2 studies, 110 participants); and percentage of BOP (MD ‐1.28%, 95% CI ‐4.32 to 1.76; 2 studies, 110 participants) (very low‐certainty evidence for all outcomes). Amoxicillin + clavulanate + SRP versus SRP for chronic periodontitis: the evidence from 1 study, 21 participants for CAL (MD 0.10 mm, 95% CI ‐0.51 to 0.71); PD (MD 0.10 mm, 95% CI ‐0.17 to 0.37); and BOP (MD 0%, 95% CI ‐0.09 to 0.09) was of very low certainty and did not show a difference between the groups. Doxycycline + SRP versus SRP in aggressive periodontitis: the evidence from 1 study, 22 participants for CAL (MD ‐0.80 mm, 95% CI ‐1.49 to ‐0.11); and PD (MD ‐1.00 mm, 95% CI ‐1.78 to ‐0.22) was of very low certainty, with the doxycycline + SRP group showing an MICD in PD only. Tetracycline + SRP versus SRP for aggressive periodontitis: we found very low‐certainty evidence of a difference in long‐term improvement in CAL for the tetracycline group (MD ‐2.30 mm, 95% CI ‐2.50 to ‐2.10; 1 study, 26 participants). Clindamycin + SRP versus SRP in aggressive periodontitis: we found very low‐certainty evidence from 1 study, 21 participants of a difference in long‐term improvement in CAL (MD ‐1.70 mm, 95% CI ‐2.40 to ‐1.00); and PD (MD ‐1.80 mm, 95% CI ‐2.47 to ‐1.13) favouring clindamycin + SRP. Doxycycline + SRP versus metronidazole + SRP for aggressive periodontitis: there was very low‐certainty evidence from 1 study, 27 participants of a difference in long‐term CAL (MD 1.10 mm, 95% CI 0.36 to 1.84); and PD (MD 1.00 mm, 95% CI 0.30 to 1.70) favouring metronidazole + SRP. Clindamycin + SRP versus metronidazole + SRP for aggressive periodontitis: the evidence from 1 study, 26 participants for CAL (MD 0.20 mm, 95% CI ‐0.55 to 0.95); and PD (MD 0.20 mm, 95% CI ‐0.38 to 0.78) was of very low certainty and did not show a difference between the groups. Clindamycin + SRP versus doxycycline + SRP for aggressive periodontitis: the evidence from 1 study, 23 participants for CAL (MD ‐0.90 mm, 95% CI ‐1.62 to ‐0.18); and PD (MD ‐0.80 mm, 95% CI ‐1.58 to ‐0.02) was of very low certainty and did not show a difference between the groups. Most trials testing amoxicillin, metronidazole, and azithromycin reported adverse events such as nausea, vomiting, diarrhoea, mild gastrointestinal disturbances, and metallic taste. No serious adverse events were reported. Authors' conclusions There is very low‐certainty evidence (for long‐term follow‐up) to inform clinicians and patients if adjunctive systemic antimicrobials are of any help for the non‐surgical treatment of periodontitis. There is insufficient evidence to decide whether some antibiotics are better than others when used alongside SRP. None of the trials reported serious adverse events but patients should be made aware of the common adverse events related to these drugs. Well‐planned RCTs need to be conducted clearly defining the minimally important clinical difference for the outcomes closed pockets, CAL, PD, and BOP. Plain language summary What are the benefits and risks of using antibiotics as well as cleaning by a dental care professional to treat gum disease? Why is this question important? Gum disease is a common condition in which the gums become swollen, sore or infected. It is caused by bacteria that accumulate on gums and teeth. Diseased gums may bleed when people brush their teeth, and may cause bad breath. If gum disease is not treated, teeth can become loose and eventually fall out. This can affect a person’s ability to chew and speak. It can also make people feel self‐conscious about their appearance. Dental‐care professionals can clean teeth and gums to remove excess bacteria from the mouth. They use special instruments – typically, an ultrasound scraper followed by specialised hand‐held instruments – to scrape bacteria from the teeth, and stop these from affecting the gums. Antibiotics (medicines that kill bacteria) taken by mouth (orally) can be used alongside professional cleaning, to remove bacteria from the area between the teeth and gums. However, there are potential risks associated with antibiotics, such as allergic reactions and antibiotic resistance (changes in bacteria after exposure to antibiotics, that allow the bacteria to survive future antibiotic treatment). We conducted a review of the evidence from research studies to find out about the benefits and risks of using antibiotics alongside professional dental cleaning to treat gum disease. We also wanted to know if some antibiotics work better than others in this situation. How did we identify and evaluate the evidence? First, we searched for randomized controlled studies (clinical studies where people are randomly put into one of two or more treatment groups), because these studies provide the most robust evidence about the effects of a treatment. We then compared the results, and summarized the evidence from all the studies. Finally, we rated our confidence in the evidence, based on factors such as study methods and sizes, and the consistency of findings across studies. What did we find? We found 45 studies that involved a total of 2664 people over the age of 18 who had gum disease. The studies compared professional cleaning plus antibiotics against professional cleaning alone, or compared different antibiotics used alongside professional cleaning against one another. We cannot tell whether antibiotics reduce gum disease in the long term (one year or more after treatment), or whether some antibiotics are better than others. This is because we have very little confidence in the evidence we found. We cannot tell whether antibiotics are associated with unwanted effects, because we have too little confidence in the evidence. The most commonly reported unwanted effects were temporary, mild gastrointestinal disturbances, such as nausea, vomiting, diarrhoea, or a metallic taste in the mouth. No serious unwanted effects were reported. No studies reported on antimicrobial resistance or changes in people’s quality of life. What does this mean? We do not know whether: ‐ using antibiotics alongside professional cleaning is beneficial for treating gum disease in the long term (more than one year after treatment);
‐ using antibiotics alongside professional cleaning is associated with unwanted effects; or
‐ some antibiotics are better than others for treating gum disease alongside professional cleaning. Our confidence in the available evidence is very low. The results of our review are likely to change if more evidence becomes available. Future studies should clearly define what qualifies as a minimally important improvement in gum disease. How‐up‐to date is this review? The evidence in this Cochrane Review is current to March 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Khattri, S; Kumbargere Nagraj, S; Arora, A; Eachempati, P; Kusum, CK; Bhat, KG; Johnson, TM; Lodi, G", "articleTypes": [], "doi": "10.1002/14651858.CD012568.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "b1b12720-a824-4193-ac43-d916f6653dba", "pmid": "", "title": "Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants", "imported": false, "abstract": "Abstract - Background It is important to institute an effective supportive therapy to maintain or recover soft tissue health around dental implants. Different maintenance regimens have been suggested, however it is unclear which are the most effective. Objectives To assess the effects of different interventions for 1) maintaining and 2) recovering soft tissue health around osseointegrated dental implants. Search methods We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and to an Internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 2 June 2010. Selection criteria All randomised controlled trials comparing agents or interventions for maintaining or recovering healthy tissues around dental implants. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random‐effects models using standardised mean differences for continuous data and risk ratios for dichotomous data with 95% confidence intervals. Main results Five trials compared interventions for maintaining soft tissue health around implants and a further six trials compared interventions to recover soft tissue health where there was evidence of peri‐implant mucositis. No statistically significant differences were found between the effectiveness of powered versus manual toothbrushes for either maintaining or recovering soft tissue health. There was no statistically significant difference found between different types of self administered antimicrobials for maintaining soft tissue health (hyaluronic acid gel compared to chlorhexidine gel, amine fluoride/stannous fluoride mouthwash compared to chlorhexidine mouthwash) and triclosan dentifrice compared to sodium fluoride dentifrice showed no statistically significant difference in recovering soft tissue health. However chlorhexidine irrigation was more effective in reducing plaque and marginal bleeding scores compared to chlorhexidine mouthwash and Listerine mouthwash was found to be statistically significantly better than placebo with regard to reducing mean plaque scores and marginal bleeding scores. When interventions administered by dental professional were compared there was no statistically significant difference found between chlorhexidine and physiologic solutions as irrigants at second stage surgery to maintain health of soft tissues. In patients with peri‐implant mucositis two trials evaluated interventions performed by dental professionals. There was no statistically significant difference between mechanical debridement followed by either minocycline or chlorhexidine gel, or between debridement with a titanium curette compared to an ultrasonic debridement tool. Authors' conclusions There was only low quality evidence for which are the most effective interventions for maintaining or recovering health of peri‐implant soft tissues. The included RCTs had short follow‐up periods and few subjects and although overall the risk of bias of the studies was either low or unclear, only single trials were available for each outcome. There was no reliable evidence as to which regimens are most effective for long term maintenance. This should not be interpreted as meaning that current maintenance regimens are ineffective. There was weak evidence that antibacterial mouthrinses are effective in reducing plaque and marginal bleeding around implants. More RCTs should be conducted in this area. In particular, there is a definite need for trials powered to find possible differences, using primary outcome measures and with much longer follow up. Such trials should be reported according to the CONSORT guidelines ( www.consort‐statement.org/ ). Plain language summary Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants Missing teeth can be replaced by dental implants. However, keeping the gums around the implants healthy is important, as they can be negatively affected by dental plaque and its induced inflammation. Prevention of this may include daily implant cleaning techniques by patients and regular cleaning by dental professionals. Antibacterial mouthrinses may help reduce plaque and bleeding around dental implants, but there is no evidence that powered toothbrushes are better than manual toothbrushes or that brushing with a certain gel or dentifrice is better than another. Among the professionally administered treatments there is no evidence that phosphoric acid is more effective than scaling and polishing, that chlorhexidine enclosed in the inner part of implants is superior to physiologic solution or that a topical antibiotic inserted submucosally is better than a chlorhexidine gel.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Grusovin, MG, Coulthard, P, Worthington, HV, George, P, Esposito, M", "articleTypes": [], "doi": "10.1002/14651858.CD003069.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.752Z" }, { "id": "b1b55a50-e13e-4a44-b7ec-4947caaea424", "pmid": "", "title": "Hydroxyurea (hydroxycarbamide) for sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and a reduced life expectancy. Hydroxyurea (hydroxycarbamide), an oral chemotherapeutic drug, ameliorates some of the clinical problems of SCD, in particular that of pain, by raising foetal haemoglobin (HbF). This is an update of a previously published Cochrane Review. Objectives The aims of this review are to determine through a review of randomised or quasi‐randomised studies whether the use of hydroxyurea in people with SCD alters the pattern of acute events, including pain; prevents, delays or reverses organ dysfunction; alters mortality and quality of life; or is associated with adverse effects. In addition, we hoped to assess whether the response to hydroxyurea in SCD varies with the type of SCD, age of the individual, duration and dose of treatment, and healthcare setting. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Haemoglobinopathies Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. The date of the most recent search was 17 February 2022. Selection criteria Randomised and quasi‐randomised controlled trials (RCTs and quasi‐RCTs), of one month or longer, comparing hydroxyurea with placebo or standard therapy in people with SCD. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction, assessed the risk of bias and assessed the quality of the evidence using GRADE. Main results We included nine RCTs recruiting 1104 adults and children with SCD (haemoglobin SS (HbSS), haemoglobin SC (HbSC) or haemoglobin Sβºthalassaemia (HbSβºthal) genotypes). Studies lasted from six to 30 months. We judged the quality of the evidence for the first two comparisons below as moderate to low as the studies contributing to these comparisons were mostly large and well‐designed (and at low risk of bias); however, the evidence was limited and imprecise for some outcomes such as quality of life, deaths during the studies and adverse events, and the results are applicable only to individuals with HbSS and HbSβºthal genotypes. We judged the quality of the evidence for the third and fourth comparisons to be very low due to the limited number of participants, the lack of statistical power (both studies were terminated early with approximately only 20% of their target sample size recruited) and the lack of applicability to all age groups and genotypes. Hydroxyurea versus placebo Five studies (784 adults and children with HbSS or HbSβºthal) compared hydroxyurea to placebo; four recruited individuals with only severe disease and one recruited individuals with all disease severities. Hydroxyurea probably improves pain alteration (using measures such as pain crisis frequency, duration, intensity, hospital admissions and opoid use) and life‐threatening illness, but we found no difference in death rates (10 deaths occurred during the studies, but the rates did not differ by treatment group) (all moderate‐quality evidence). Hydroxyurea may improve measures of HbF (low‐quality evidence) and probably decreases neutrophil counts (moderate‐quality evidence). There were no consistent differences in terms of quality of life and adverse events (including serious or life‐threatening events) (low‐quality evidence). There were fewer occurrences of acute chest syndrome and blood transfusions in the hydroxyurea groups. Hydroxyurea and phlebotomy versus transfusion and chelation Two studies (254 children with HbSS or HbSβºthal also with risk of primary or secondary stroke) contributed to this comparison. There were no consistent differences in terms of pain alteration, death or adverse events (low‐quality evidence) or life‐threatening illness (moderate‐quality evidence). Hydroxyurea with phlebotomy probably increased HbF and decreased neutrophil counts (moderate‐quality evidence), but there were more occurrences of acute chest syndrome and infections. Quality of life was not reported. In the primary prevention study, no strokes occurred in either treatment group but in the secondary prevention study, seven strokes occurred in the hydroxyurea and phlebotomy group (none in the transfusion and chelation group) and the study was terminated early. Hydroxyurea versus observation One study (22 children with HbSS or HbSβºthal also at risk of stoke) compared hydroxyurea to observation. Pain alteration and quality of life were not reported. There were no differences in life‐threatening illness, death (no deaths reported in either group) or adverse events (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF or decreases neutrophil counts (very low‐quality evidence). Treatment regimens with and without hydroxyurea One study (44 adults and children with HbSC) compared treatment regimens with and without hydroxyurea. Pain alteration, life‐threatening illness and quality of life were not reported. There were no differences in death rates (no deaths reported in either group), adverse events or neutrophil levels (very low‐quality evidence). We are uncertain if hydroxyurea improves HbF (very low‐quality evidence). Authors' conclusions There is evidence to suggest that hydroxyurea may be effective in decreasing the frequency of pain episodes and other acute complications in adults and children with sickle cell anaemia of HbSS or HbSβºthal genotypes and in preventing life‐threatening neurological events in those with sickle cell anaemia at risk of primary stroke by maintaining transcranial Doppler velocities. However, there is still insufficient evidence on the long‐term benefits of hydroxyurea, particularly with regard to preventing chronic complications of SCD, or recommending a standard dose or dose escalation to maximum tolerated dose. There is also insufficient evidence about the long‐term risks of hydroxyurea, including its effects on fertility and reproduction. Evidence is also limited on the effects of hydroxyurea on individuals with the HbSC genotype. Future studies should be designed to address such uncertainties. Plain language summary Hydroxyurea (also known as hydroxycarbamide) for people with sickle cell disease Review question What is the effect of hydroxyurea on clinical outcomes (changes in pain crises, life‐threatening illnesses, survival, haemoglobin levels, quality of life and side effects) in people with sickle cell disease (SCD) of any genotype? Background Sickle cell disease (SCD) is an inherited genetic disorder that creates problems with haemoglobin (the substance in red blood cells that carries oxygen around the body). The disease can be inherited in different ways; people can inherit two sickle genes (HbSS genotype) or they can inherit the sickle gene from one parent and a different haemoglobin gene such as haemoglobin C, resulting in the HbSC genotype, or a beta thalassaemia gene from the second parent, which gives rise to HbSβ+ or HbSβºthal. In people with SCD the abnormal sickle haemoglobin forms long polymers (chains) within the red blood cells when they become de‐oxygenated. This damages the red blood cells and makes them stickier, leading to blockages and reduced blood flow, causing pain and organ damage. Foetal haemoglobin (HbF) stops these polymers forming in the sickle haemoglobin within the red blood cell. The drug hydroxyurea is used to increase HbF and can reduce the effects of the disease. This is an update of a previously published Cochrane Review. Search date The evidence is current to 17 February 2022. Study characteristics We included nine randomised studies (1104 adults and children with SCD (HbSS, HbSC or HbSβºthal genotypes)). Studies lasted from six to 30 months. Key results and quality of the evidence In five studies, 784 adults and children with SCD were randomly selected to receive hydroxyurea or placebo. In two studies, 254 children with SCD, who were also at an increased risk of having a first or second stroke, were randomly selected to receive hydroxyurea and phlebotomy (collection of blood) or blood transfusion and chelation (administration of agents to remove excess iron from the body). These seven studies only recruited people with HbSS or HbSβºthal genotypes so the results do not apply to people with the HbSC genotype. There was moderate‐quality evidence from these seven studies that hydroxyurea may reduce the frequency of pain crises, may increase HbF and may decrease neutrophil (white blood cell) counts compared to the comparator treatment. We found no difference between people receiving hydroxyurea or other treatments in terms of quality of life, deaths during the studies and adverse effects (including serious and life‐threatening effects). However, there is less information about these outcomes in the studies, so the quality of this evidence is low. Two further studies were included in the review. In one study, 22 children with SCD, who were also at increased risk of having a stroke, were randomly selected to receive hydroxyurea or no treatment (observation only) and in one study 44 adults and children were randomly selected to receive treatments with or without adding hydroxyurea. In both studies we are unsure if hydroxyurea led to an increase in HbF compared to the comparator treatment. There were no deaths during the studies. There was no difference between people receiving hydroxyurea or other treatments in terms of pain crises and adverse effects (including serious or life‐threatening effects) and neither study measured quality of life. The quality of the evidence from these studies is very low, given the studies were very small and only recruited around 20% of the intended number of people, and the results do not apply to all people with SCD (different genotypes). Conclusions The evidence shows that hydroxyurea is likely to be effective in the short term at decreasing the frequency of painful episodes and raising HbF levels in the blood in people with SCD. Hydroxyurea is also likely to be effective in preventing first strokes for those at an increased risk of stroke and does not seem to be associated with an increase in any adverse effects (including serious and life‐threatening effects). There is currently little evidence from the studies that we examined on whether hydroxyurea is beneficial over a long period of time, what the best dose to take is, or whether treatment causes any long‐term or serious side effects. More studies are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Rankine-Mullings, AE, Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD002202.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.784Z" }, { "id": "b1fea351-a975-4d56-8030-c024bf688e96", "pmid": "", "title": "Interventions for iatrogenic inferior alveolar and lingual nerve injury", "imported": false, "abstract": "Abstract - Background Iatrogenic injury of the inferior alveolar or lingual nerve or both is a known complication of oral and maxillofacial surgery procedures. Injury to these two branches of the mandibular division of the trigeminal nerve may result in altered sensation associated with the ipsilateral lower lip or tongue or both and may include anaesthesia, paraesthesia, dysaesthesia, hyperalgesia, allodynia, hypoaesthesia and hyperaesthesia. Injury to the lingual nerve may also affect taste perception on the affected side of the tongue. The vast majority (approximately 90%) of these injuries are temporary in nature and resolve within eight weeks. However, if the injury persists beyond six months it is deemed to be permanent. Surgical, medical and psychological techniques have been used as a treatment for such injuries, though at present there is no consensus on the preferred intervention, or the timing of the intervention. Objectives To evaluate the effects of different interventions and timings of interventions to treat iatrogenic injury of the inferior alveolar or lingual nerves. Search methods We searched the following electronic databases: the Cochrane Oral Health Group's Trial Register (to 9 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 9 October 2013) and EMBASE via OVID (1980 to 9 October 2013). No language restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials (RCTs) involving interventions to treat patients with neurosensory defect of the inferior alveolar or lingual nerve or both as a sequela of iatrogenic injury. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. We performed data extraction and assessment of the risk of bias independently and in duplicate. We contacted authors to clarify the inclusion criteria of the studies. Main results Two studies assessed as at high risk of bias, reporting data from 26 analysed participants were included in this review. The age range of participants was from 17 to 55 years. Both trials investigated the effectiveness of low‐level laser treatment compared to placebo laser therapy on inferior alveolar sensory deficit as a result of iatrogenic injury. Patient‐reported altered sensation was partially reported in one study and fully reported in another. Following treatment with laser therapy, there was some evidence of an improvement in the subjective assessment of neurosensory deficit in the lip and chin areas compared to placebo, though the estimates were imprecise: a difference in mean change in neurosensory deficit of the chin of 8.40 cm (95% confidence interval (CI) 3.67 to 13.13) and a difference in mean change in neurosensory deficit of the lip of 21.79 cm (95% CI 5.29 to 38.29). The overall quality of the evidence for this outcome was very low; the outcome data were fully reported in one small study of 13 patients, with differential drop‐out in the control group, and patients suffered only partial loss of sensation. No studies reported on the effects of the intervention on the remaining primary outcomes of pain, difficulty eating or speaking or taste. No studies reported on quality of life or adverse events. The overall quality of the evidence was very low as a result of limitations in the conduct and reporting of the studies, indirectness of the evidence and the imprecision of the results. Authors' conclusions There is clearly a need for randomised controlled clinical trials to investigate the effectiveness of surgical, medical and psychological interventions for iatrogenic inferior alveolar and lingual nerve injuries. Primary outcomes of this research should include: patient‐focused morbidity measures including altered sensation and pain, pain, quantitative sensory testing and the effects of delayed treatment. Plain language summary Treatments for accidental damage during surgery to the nerves supplying sensation to the tongue, lower lip and chin Review question The main question addressed by this review is how effective are different treatments and what are the best timings for these treatments following accidental damage during surgery to the nerves that supply sensation to the tongue, lower lip and chin. Background The nerves (alveolar and lingual) supplying sensation to the tongue, lower lip and chin, may be injured as a result of surgical treatments to the mouth and face, including surgery to remove lower wisdom teeth. The vast majority (90%) of these injuries are temporary and get better within eight weeks. However if they last for longer than six months they are considered to be permanent. Damage to these nerves can lead to altered sensation in the region of the lower lip and chin, or tongue or both. Furthermore, damage to the nerve supplying the tongue may lead to altered taste perception. These injuries can affect people's quality of life leading to emotional problems, problems with socialising and disabilities. Accidental injury after surgery can also give rise to legal action. There are many interventions or treatments available, surgical and non‐surgical, that may enhance recovery, including improving sensation. They can be grouped as. 1. Surgical – a variety of procedures.
 2. Laser treatment – low‐level laser treatment has been used to treat partial loss of sensation.
 3. Medical – treatment with drugs including antiepileptics, antidepressants and painkillers.
 4. Counselling – including cognitive behavioural and relaxation therapy, changing behaviour and hypnosis. Study characteristics The Cochrane Oral Health Group carried out this review, and the evidence is current as of 9 October 2013. There are two studies included, both published in 1996, which compared low‐level laser treatment to placebo or fake treatment for partial loss of sensation following surgery to the lower jaw. There were 15 participants in one study and 16 in the other, their ages ranging from 17 to 55 years. All had suffered accidental damage to nerves of the lower jaw and tongue causing some loss of sensation following surgery. Key results Low‐level laser therapy was the only treatment to be evaluated in the included studies and this was compared to fake or placebo laser therapy. No studies were found that evaluated other surgical, medical or counselling treatments. There was some evidence of an improvement when participants reported whether or not sensation was better in the lip and chin areas with low‐level laser therapy. This is based on the results of a single, small study, so the results should be interpreted with caution. No studies reported on the effects of the treatment on other outcomes such as pain, difficulty eating or speaking or taste. No studies reported on quality of life or harm. Quality of the evidence The overall quality of the evidence is very low as a result of limitations in the conduct and reporting of the two included studies and the low number of participants, and evidence from participants with only partial sensory loss.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Coulthard, P; Kushnerev, E; Yates, JM; Walsh, T; Patel, N; Bailey, E; Renton, TF", "articleTypes": [], "doi": "10.1002/14651858.CD005293.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "b227a54d-ef72-4ebb-9989-e0f0d9166def", "pmid": "", "title": "Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults", "imported": false, "abstract": "Abstract - Background The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non‐opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. Objectives To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. Selection criteria We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. Data collection and analysis We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. Main results We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after). The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies. IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) −0.50, 95% confidence interval (CI) −0.72 to −0.28; 29 studies, 1656 participants; very low‐quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD −0.14, 95% CI −0.25 to −0.04; 33 studies, 1847 participants; moderate‐quality evidence), and at late time points (48 hours) (SMD −0.11, 95% CI −0.25 to 0.04; 24 studies, 1404 participants; moderate‐quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures. We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) −7.92 hours, 95% CI −12.71 to −3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD −4.52 mg morphine equivalents , 95% CI −6.25 to −2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes. The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low‐quality evidence). IV Lidocaine compared to TEA The effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI −0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI −1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD −1.66, 95% CI −10.88 to 7.56; 2 studies, 102 participants); all very low‐quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low‐quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low‐quality evidence). Authors' conclusions We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review. Plain language summary Intravenous infusion of lidocaine starting at the time of surgery for reduction of pain and improvement of recovery after surgery Background The most common problems immediately following surgery under general anaesthesia are pain, nausea and vomiting, delirium and slow or no movement of food through the digestive system. Opioid medications given to reduce postoperative pain may also be associated with nausea and constipation, also preventing a smooth recovery. It is of interest for patients and clinicians to reduce or prevent these complications leading to an early recovery so that patients can leave hospital earlier. One option for pain relief after surgery is epidural analgesia, where an opioid or local anaesthetic such as lidocaine is injected into the space surrounding the spinal cord. Not all patients may be suited to epidural analgesia, and so additional options such as intravenous non‐opioid analgesic medications that enable a rapid recovery are required. The aim of this review was to assess the benefits and risks of intravenous infusion of lidocaine in patients undergoing various surgical procedures. Lidocaine is a medication used to numb tissue in a specific area. Study characteristics This review was published in 2015, and updated in 2017. We found 68 randomized controlled studies (RCTs), (clinical studies where people are randomly put into one of two or more treatment groups), with results from a total of 4525 participants. RCTs are used because they provide the most reliable evidence. Intravenous lidocaine was compared with placebo or standard care in 66 of the studies, and with thoracic (chest area of spine) epidural analgesia in two studies. (A placebo is an inactive substance or procedure given to a participant in a medical trial to compare its effects with those of a real drug or other intervention). Lidocaine infusion was started during the surgery, before the first cut, and continued to at least the end of surgery. The included studies were moderately well conducted. Key results We are uncertain whether lidocaine infusion reduces pain, one to four hours after surgery when compared to placebo or usual care (29 studies, over 1600 participants). There was probably no difference in pain at 24 hours (33 studies, 1847 participants) and at 48 hours (24 studies, 1404 participants) between participants in the lidocaine and the placebo group. We are uncertain whether lidocaine infusion improves recovery of bowel function, with a reduction in the time to first defaecation or bowel movements (12 studies, 684 participants), and reduced risk of stopping the passage of food in the gut (4 studies, 273 participants). We are also uncertain whether lidocaine reduces postoperative nausea (35 studies, 1903 participants), and the requirement for opioids for pain relief (40 studies, 2201 participants). Only a limited number of studies systematically analysed adverse effects of intravenous lidocaine infusion. The side effects of intravenous lidocaine were unclear. In the two studies that investigated intravenous lidocaine compared to epidural analgesia (102 participants), the effect on pain at 24 and 48 hours, and on the time to first bowel movement, remains unclear. The effect of lidocaine on the risk of stopping the passage of food in the gut and for postoperative nausea is also unclear, as only one small trial assessed these outcomes. Neither study investigated the effect on pain immediately after surgery, or on opioid consumption. Both studies looked at adverse effects associated with lidocaine, but the effect is uncertain. Quality of the evidence We rated the quality of evidence for most outcomes as very low. This was because of inconsistent findings across studies and the fact that the evidence came from small studies that were of moderate design quality or a limited number of studies. The quality of the evidence for minimal or no effect on pain at 24 and 48 hours was moderate quality. The studies involved a variety of surgical procedures. The dose of lidocaine used, and how long it was delivered for after the end of surgery, also varied between studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Weibel, S; Jelting, Y; Pace, NL; Helf, A; Eberhart, LHJ; Hahnenkamp, K; Hollmann, MW; Poepping, DM; Schnabel, A; Kranke, P", "articleTypes": [], "doi": "10.1002/14651858.CD009642.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "b2319435-2f22-4ce8-acdd-3fd9a8edc401", "pmid": "", "title": "Osmotic therapies added to antibiotics for acute bacterial meningitis", "imported": false, "abstract": "Abstract - Background Every day children and adults die from acute community‐acquired bacterial meningitis, particularly in low‐income countries, and survivors risk deafness, epilepsy and neurological disabilities. Osmotic therapies may attract extra‐vascular fluid and reduce cerebral oedema, and thus reduce death and improve neurological outcomes. This is an update of a Cochrane Review first published in 2013. Objectives To evaluate the effects of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults on mortality, deafness and neurological disability. Search methods We searched CENTRAL (2017, Issue 1), MEDLINE (1950 to 17 February 2017), Embase (1974 to 17 February 2017), CINAHL (1981 to 17 February 2017), LILACS (1982 to 17 February 2017) and registers of ongoing clinical trials (ClinicalTrials.com, WHO ICTRP) (21 February 2017). We also searched conference abstracts and contacted researchers in the field (up to 12 December 2015). Selection criteria Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis. Data collection and analysis Two review authors independently screened the search results and selected trials for inclusion. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not. We used the GRADE approach to assess the certainty of the evidence. Main results We included five trials with 1451 participants. Four trials evaluated glycerol against placebo, and one evaluated glycerol against 50% dextrose; in addition three trials evaluated dexamethasone and one trial evaluated acetaminophen (paracetamol) in a factorial design. Stratified analysis shows no effect modification with steroids; we present aggregate effect estimates. Compared to placebo, glycerol probably has little or no effect on death in people with bacterial meningitis (RR 1.08, 95% CI 0.90 to 1.30; 5 studies, 1272 participants; moderate‐certainty evidence ), but may reduce neurological disability (RR 0.73, 95% CI 0.53 to 1.00; 5 studies, 1270 participants; low‐certainty evidence ). Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30; 4 studies, 1090 participants; low‐certainty evidence ). Glycerol may reduce the risk of subsequent deafness (RR 0.64, 95% CI 0.44 to 0.93; 5 studies, 922 participants; low to moderate‐certainty evidence ). Glycerol probably has little or no effect on gastrointestinal bleeding (RR 0.93, 95% CI 0.39 to 2.19; 3 studies, 607 participants; moderate‐certainty evidence ). The evidence on nausea, vomiting and diarrhoea is uncertain (RR 1.09, 95% CI 0.81 to 1.47; 2 studies, 851 participants; very low‐certainty evidence ). Authors' conclusions Glycerol was the only osmotic therapy evaluated, and data from trials to date have not demonstrated an effect on death. Glycerol may reduce neurological deficiency and deafness. Plain language summary Osmotic therapies added to antibiotics for acute bacterial meningitis What is the aim of this review? The aim of this Cochrane Review is to collect and analyse trials evaluating osmotic therapies given orally or intravenously to people with acute bacterial meningitis. Cochrane authors collected and analysed all relevant studies to answer this question; they found five relevant studies. Key messages Giving glycerol, an osmotic diuretic, probably has little or no effect on death ( moderate‐certainty evidence ), but may reduce subsequent deafness ( moderate‐certainty evidence) or neurological disability ( low‐certainty evidence ). The evidence is current to 17 February 2017. What was studied in the review? In meningitis, the cerebrospinal fluid that surrounds the brain and spinal cord is infected, usually as a result of spread from the blood. Any form of meningitis can result in death or severe disability, but acute bacterial meningitis is rapidly fatal without treatment. Even with antibiotics, 10% to 15% of children with bacterial meningitis die in high‐income countries with much higher rates in low‐income settings. The infection causes the brain to swell, and this is thought to contribute to death and to long‐term brain damage in survivors. Osmotic therapies increase the concentration of the blood by exerting an osmotic pressure across a semi‐permeable membrane (such as a cell wall or blood vessel lining in the brain). This draws water from the brain into the blood, thereby reducing pressure in the brain. Potentially osmotic therapies could increase the rate of survival, or they could do harm. What are the main results of the review? We included five trials that compared glycerol with placebo in a total of 1451 patients with bacterial meningitis. In the studies steroids were often given as well, but this did not appear to modify any of the effects seen with glycerol. This review detected no benefit from glycerol relating to death. There appeared to be marginal protection against deafness and against neurological disability. No effect on epileptic seizures at follow‐up was noted. Glycerol was not associated with any severe adverse effects. The number of trials included was small and only two tested a large number of participants. All trials were from different healthcare settings and examined either adults or children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wall, ECB; Ajdukiewicz, KMB; Bergman, H; Heyderman, RS; Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD008806.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "b23ed606-6109-4add-a7a5-b58f4bce7c44", "pmid": "", "title": "Vigabatrin add‐on therapy for drug‐resistant focal epilepsy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane Review published in 2008 and updated in 2013. Epilepsy is a common neurological condition which affects up to 1% of the population. Approximately 30% of people with epilepsy do not respond to treatment with currently available drugs. The majority of these people have focal epilepsy. Vigabatrin is an antiepileptic drug licensed for use in drug‐resistant epilepsy. Objectives To assess the efficacy and tolerability of vigabatrin as an add‐on therapy for people with drug‐resistant focal epilepsy. Search methods For the latest update of this review, we searched the following databases on 1 November 2018: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid 1946 to 31 October 2018), ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL) are both included in the Cochrane Register of Studies (CRS Web). We checked reference lists of retrieved studies for additional reports of relevant studies and contacted Hoechst Marion Roussel (manufacturers of vigabatrin) in 2000. Selection criteria We included randomised, double‐blind, placebo‐controlled, fully published trials of vigabatrin in people of any age with drug‐resistant focal epilepsy. Data collection and analysis Two review authors assessed trials for inclusion and extracted data using the standard methodological procedures expected by Cochrane. Primary analysis was by intention‐to‐treat (ITT). We evaluated: 50% or greater reduction in seizure frequency, treatment withdrawal, adverse effects, dose‐response analysis, cognitive outcomes and quality of life. We presented results as risk ratios (RR) with 95% or 99% confidence intervals (CI). Main results We identified 11 trials that included 756 participants (age range: 10 to 64 years). The trials tested vigabatrin doses between 1 g/day and 6 g/day. All 11 trials displayed a risk of bias across at least three risk of bias domains. Predominantly, the risk of bias was associated with: allocation concealment (selection bias), blinding of outcome assessment (detection bias) and incomplete outcome data (attrition bias). Participants treated with vigabatrin may be two to three times more likely to obtain a 50% or greater reduction in seizure frequency compared with those treated with placebo (RR 2.60, 95% CI 1.87 to 3.63; 4 studies; low‐certainty evidence). Those treated with vigabatrin may also be three times more likely to have treatment withdrawn although we are uncertain (RR 2.86, 95% CI 1.25 to 6.55; 4 studies; very low‐certainty evidence). Compared to placebo, participants given vigabatrin were more likely to experience adverse effects: dizziness/light‐headedness (RR 1.74, 95% CI 1.05 to 2.87; 9 studies; low‐certainty evidence), fatigue (RR 1.65, 95% CI 1.08 to 2.51; 9 studies; low‐certainty evidence), drowsiness (RR 1.70, 95% CI 1.18 to 2.44; 8 studies) and depression (RR 3.28, 95% CI 1.30 to 8.27; 6 studies). Although the incidence rates were higher among participants receiving vigabatrin compared to those receiving placebo, the effect was not significant for the following adverse effects: ataxia (RR 2.76, 95% CI 0.96 to 7.94; 7 studies; very low‐certainty evidence), nausea (RR 3.57, 95% CI 0.63 to 20.30; 4 studies), abnormal vision (RR 1.64, 95% CI 0.67 to 4.02; 5 studies; very low‐certainty evidence), headache (RR 1.23, 95% CI 0.79 to 1.92; 9 studies), diplopia (RR 1.76, 99% CI 0.94 to 3.30) and nystagmus (RR 1.53, 99% CI 0.62 to 3.76; 2 studies; low‐certainty evidence). Vigabatrin had little to no effect on cognitive outcomes or quality of life. Authors' conclusions Vigabatrin may significantly reduce seizure frequency in people with drug‐resistant focal epilepsy. The results largely apply to adults and should not be extrapolated to children under 10 years old. Short‐term follow‐up of participants showed that some adverse effects were associated with its use. Analysis of longer‐term observational studies elsewhere, however, has demonstrated that vigabatrin use can lead to the development of visual field defects. Plain language summary Vigabatrin add‐on for drug‐resistant focal epilepsy Background Epilepsy is a common neurological disorder affecting approximately 1 in 100 people. Around 30% of these people cannot control their epilepsy with currently available antiepileptic medication and are said to have drug‐resistant epilepsy. Most often, drug‐resistant epilepsy is focal in nature, meaning that the seizures start in one specific area of the brain. Vigabatrin is an antiepileptic medication that can be used as an add‐on treatment for drug‐resistant focal epilepsy, meaning that it is taken in addition to other antiepileptic medications. Main results We found 11 clinical trials, involving 756 people, which investigated vigabatrin as an add‐on for people with drug‐resistant focal epilepsy. The people in the trials were aged between 10 to 64 years and were given doses of 1 g/day to 6 g/day vigabatrin. We found that people given vigabatrin may be two to three times more likely to experience a 50% or greater reduction in seizure frequency than people given placebo (a non‐active treatment). We also suggest that people given vigabatrin may be up to three times more likely to stop treatment than people given placebo. People given vigabatrin were more likely to experience side effects: dizziness/light‐headedness, fatigue, drowsiness and depression, than people given placebo. However, the evidence suggested that they should not be more likely to experience: ataxia (disorders that affect co‐ordination, balance and speech), feeling sick (nausea), abnormal vision, headache, seeing double (diplopia), or involuntary movement of the eyes (nystagmus) than people given placebo. Reliability of the evidence We judged that all studies had significant risk of bias. The studies did not explain how people were allocated to treatment groups and did not say whether investigators knew which treatment people were receiving. Alongside other reasons, this reduced our confidence (certainty) in the results. Overall, we are uncertain to very uncertain whether the results we have reported are reliable. The true effect of vigabatrin could be significantly different to that reported here. Conclusions Vigabatrin may significantly reduce seizure frequency for people with drug‐resistant focal epilepsy but we are uncertain. Most of the evidence was gathered from adults, therefore, the effects of vigabatrin could be different in children. All of the included trials were of short duration; therefore, we cannot report any long‐term effects of vigabatrin. Importantly, reviews of long‐term studies have reported that long‐term vigabatrin use can lead to the development of visual problems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bresnahan, R; Gianatsi, M; Maguire, MJ; Tudur Smith, C; Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "b24c4463-7f18-4bcd-9e6f-7570aae9365a", "pmid": "", "title": "A Randomized, Multicenter, Open-label, Phase III Study of Lapatinib (GW572016) in Combination With Weekly Paclitaxel Versus Weekly Paclitaxel Alone in the Second Line Treatment of ErbB2 Amplified Advanced Gastric Cancer", "imported": false, "abstract": "EGF104578 is two-part study (Pilot part/Randomized part).Pilot part is designed to find the optimal (best) doses of lapatinib and paclitaxel when given together,Randomized part is designed to evaluate the overall survival in patients receiving lapatinib and paclitaxel compared to patients receiving only paclitaxel.", "journal": "", "year": "2007", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.252Z" }, { "id": "b24e23b4-8b92-4e61-89bf-00028921679b", "pmid": "", "title": "Outpatient Administration of Teclistamab or Talquetamab for Multiple Myeloma", "imported": false, "abstract": "This is a phase II study to evaluate the outpatient administration of Teclistamab or Talquetamab in Multiple Myeloma patients", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.266Z" }, { "id": "b2539b7f-9feb-4abc-8749-61f206973490", "pmid": "", "title": "Herbal interventions for chronic asthma in adults and children", "imported": false, "abstract": "Abstract - Background Herb and plant based preparations are a popular treatment for asthma, although there remain concerns as to their efficacy and safety. In Western societies, motivations for using such treatments may be both positive and negative, with their perceived safety and dissatisfaction with conventional medicine among them. In China such treatments are more commonly used and many compounds considered 'conventional' are derived from herbs or plants. Objectives To assess the efficacy and safety of herb and plant extracts in the management of chronic asthma. Search methods The Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, EMBASE and AMED were searched with pre‐defined terms. Searches are current as of February 2007. Selection criteria Randomised placebo controlled trials of any herb or plant extract were eligible. Study participants had to have a primary diagnosis of asthma. Studies in both adults and children were eligible for the review. Data collection and analysis Two reviewers assessed studies for suitability. Data were extracted and double‐checked. Main results Twenty‐seven studies (29 experimental groups) met the review entry criteria, randomising a total of 1925 participants. The studies identified assessed the effects of 21 different herbal preparations. Study quality varied considerably, and the sample sizes were often small. For primary outcomes (exacerbations, steroids use and lung function measurements): Two out of six studies reporting change in FEV1 were positive, with very few data available on the frequency of exacerbations. One study which did report these data was negative. Health‐related quality of life was only measured in one trial. Authors' conclusions The evidence base for the effects of herbal treatments is hampered by the variety of treatments assessed, poor reporting quality of the studies and lack of available data. The data that are available from the studies provide only a small insight into the long‐term efficacy and harm profiles of these treatments. The absence of common endpoint measurements limits the validity of our findings further. Positive findings in this review warrant additional well‐designed trials in this area. Plain language summary Herbal interventions for chronic asthma in adults and children Chronic asthma is a inflammatory disease of the airways characterised by wheeze and breathlessness. Drug therapy is usually used to control symptoms but complementary medicine is often used, including herbal treatments, and the efficacy and safety of such treatments is not clear. We reviewed evidence from 27 trials covering 21 different herbal treatments in both adults and children from both in‐patient and out‐patient settings. In general, the reporting of trials was poor. The outcomes measured by the trials varied considerably which made it difficult to compare the results of studies that did look at the same treatment. On the basis of the available evidence it is not possible to show whether any of these herbal treatments can improve asthma symptoms. Further trials of high quality are needed to assess the use of herbal treatments in asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Arnold, E; Clark, CE; Lasserson, TJ; Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD005989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "b2593b3a-89d7-4999-adfd-a737c62151de", "pmid": "", "title": "Honey and lozenges for children with non‐specific cough", "imported": false, "abstract": "Abstract - Background Chronic non‐specific cough is a chronic, dry cough of in the absence of identifiable respiratory disease or known aetiology. Although it is usually not reflective of an underlying severe illness, it does cause significant morbidity, and as such relief from it is often sought. The use of honey and lozenges to soothe upper respiratory tract irritation is common, inexpensive, and potentially more effective in treating the symptoms than pharmacological interventions. Objectives To evaluate the efficacy of honey and/or lozenges in the management of children with chronic non‐specific cough. Search methods The Cochrane Airways Group searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, OLDMEDLINE, and EMBASE databases in October 2010. Selection criteria All randomised controlled trials comparing honey or lozenges with a placebo in treating children with chronic non‐specific cough. Data collection and analysis The results of the searches were assessed according to the pre‐determined criteria. None of the trials identified by the searches were eligible for inclusion, leaving no data available for analysis in this review. Main results The search did not provide any applicable randomised controlled trials that investigated the efficacy of honey and lozenges in treating children with non‐specific chronic cough. Data from acute studies suggest a potential role for honey in relieving cough, but whether this is applicable to chronic cough is unknown. Authors' conclusions Clinically, this review was unable to provide any justifiable recommendation for or against honey and/or lozenges due to the lack of evidence. The absence of applicable studies highlights the need for further research into the area of treating children with chronic non‐specific coughs with honey and/or lozenges. These treatments are not recommended when managing very young children (as lozenges are a potential choking hazard, and honey may cause infant botulism in children under one year of age). Plain language summary Honey and lozenges for children with non‐specific cough Symptomatic relief is often sought for children with chronic non‐specific cough (which is defined as a dry, non‐productive cough with no known cause lasting longer than four consecutive weeks). This review aimed to assess the efficacy of treating children with such coughs using honey or lozenges, as these options are inexpensive. No randomised controlled trials were found to be applicable to this review, primarily due to the participants in the studies not fulfilling the inclusion criteria. However, studies on the efficacy of these treatments in treating acute cough in children showed that honey has the potential to be beneficial in children over a year old. Further research evaluating the efficacy of honey and lozenges in treating chronic non‐specific coughs in children is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Mulholland, S; Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD007523.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "b25e20ef-be3b-4bfc-a20a-95069fb37415", "pmid": "", "title": "Nutritional support in children and young people with cancer undergoing chemotherapy", "imported": false, "abstract": "Abstract - Background It is well documented that malnutrition is a common complication of paediatric malignancy and its treatment. Malnutrition can often be a consequence of cancer itself or a result of chemotherapy. Nutritional support aims to reverse malnutrition seen at diagnosis, prevent malnutrition associated with treatment and promote weight gain and growth. The most effective and safe forms of nutritional support in children and young people with cancer are not known. Objectives To determine the effects of any form of parenteral (PN) or enteral (EN) nutritional support, excluding vitamin supplementation and micronutrient supplementation, in children and young people with cancer undergoing chemotherapy and to determine the effect of the nutritional content of PN and EN. This is an update of a previous Cochrane review. Search methods We searched the following databases for the initial review: CENTRAL ( The Cochrane Library , Issue 2, 2009), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), CINAHL (1982 to 2006), the National Research Register (2007) and Dissertations & Theses (2007). Experts in the field were also contacted for information on relevant trials. For this update, we searched the same electronic databases from 2006 to September 2013. We also scrutinised the reference lists of included articles to identify additional trials. Selection criteria Randomised or quasi‐randomised controlled trials comparing any form of nutritional support with another, or control, in children or young people with cancer undergoing chemotherapy. Data collection and analysis Two authors independently selected trials. At least two authors independently assessed quality and extracted data. We contacted trialists for missing information. Main results The current review included the eight trials from the initial review and six new trials which randomised 595 participants (< 21 years of age) with leukaemias or solid tumours undergoing chemotherapy. The trials were all of low quality with the exception of two of the trials looking at glutamine supplementation. One small trial found that compared to EN, PN significantly increased weight (mean difference (MD) 4.12, 95% CI 1.91 to 6.33), serum albumin levels (MD 0.70, 95% CI 0.14 to 1.26), calorie intake (MD 22.00, 95% CI 5.12 to 38.88) and protein intake (MD 0.80, 95% CI 0.45 to 1.15). One trial comparing peripheral PN and EN with central PN found that mean daily weight gain (MD ‐27.00, 95% CI ‐43.32 to ‐10.68) and energy intake (MD ‐15.00, 95% CI ‐26.81 to ‐3.19) were significantly less for the peripheral PN and EN group, whereas mean change in serum albumin was significantly greater for that group (MD 0.47, 95% CI 0.13 to 0.81, P = 0.008). Another trial with few participants found an increase in mean energy intake (% recommended daily amount) in children fed an energy dense feed compared to a standard calorie feed (MD +28%, 95% CI 17% to 39%). Three studies looked at glutamine supplementation. The evidence suggesting that glutamine reduces severity of mucositis was not statistically significant in two studies (RR 0.64, 95% CI 0.19 to 2.2 and RR 0.85, 95% CI 0.66 to 1.1) and differences in reduction of infection rates were also not significant in two studies (RR 1.0, 95% CI 0.72 to 1.4 and RR 0.98, 95% CI 0.63 to 1.51). Only one study compared olive oil based PN to standard lipid containing PN. Despite similar calorie contents in both feeds, the standard lipid formula lead to greater weight gain (MD ‐0.34 z‐scores, 95% CI ‐0.68 to 0.00). A single study compared standard EN with fructooligosaccharide containing EN. There was no difference in weight gain between groups (mean difference ‐0.12, 95% CI ‐0.57 to 0.33), with adverse effects (nausea) occurring equally between the groups (RR 0.92, 95% CI 0.48 to 1.74). Authors' conclusions There is limited evidence from individual trials to suggest that PN is more effective than EN in well‐nourished children and young people with cancer undergoing chemotherapy. The evidence for other methods of nutritional support remains unclear. Limited evidence suggests an energy dense feed increases mean daily energy intake and has a positive effect on weight gain. Evidence suggesting glutamine supplementation reduces incidence and severity of mucositis, infection rates and length of hospital stay is not statistically significant. Further research, incorporating larger sample sizes and rigorous methodology utilising valid and reliable outcome measures, is essential. Plain language summary Nutritional support in children and young people with cancer undergoing chemotherapy The provision of safe, appropriate and effective nutritional support for children and young people undergoing treatment for cancer is now well recognised as an important part of their care. It may help to reverse malnutrition seen at diagnosis, prevent malnutrition associated with the cancer, promote weight gain and growth and improve quality of life. Nutritional support may be provided by one of two methods: intravenous nutritional liquids delivered through a central or peripheral vein which bypass the gut (parenteral nutrition); or nutritional liquids or solids that pass through any part of the gut, regardless of method of delivery (e.g. orally or via a tube; enteral nutrition). We found evidence from one small trial to suggest that parenteral nutrition may result in an increase in weight, serum albumin levels and calorie and protein intake when compared to enteral nutrition (usual food intake). However, the effect of other methods of delivery of nutritional support remains unclear. Results from another small study suggested that the use of energy dense enteral feeds resulted in greater average daily energy intake and subsequently improved weight gain. Three studies looked at glutamine supplementation and did not show a benefit from its use. One study looked at the effect of using olive oil based parenteral feeds rather than those containing standard fats and found that it lead to less weight gain. One study considered the effect of adding fructooligosaccharide to enteral feeds and found that it did not effect the amount of weight gained or how often participants felt nauseated. No studies were identified that compared the nutritional content in either the PN or EN groups of studies. The trials were all of low quality and very different in terms of outcome measures used. In the future, much larger, rigorously conducted trials are needed in order to address this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Ward, EJ; Henry, LM; Friend, AJ; Wilkins, S; Phillips, RS", "articleTypes": [], "doi": "10.1002/14651858.CD003298.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "b271c59a-f152-4bce-9492-3419c3769433", "pmid": "", "title": "Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions", "imported": false, "abstract": "Abstract - Background Individuals on continuous treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) are at increased risk of bleeding complications during and after oral or dental procedures. Anticoagulant treatment is preferably continued at the same dose, since dose reduction or discontinuation of treatment is associated with an increased risk of thromboembolism. The use of haemostatic measures during or after the procedure (or both) could enable continuation of the oral anticoagulant treatment. Objectives We aimed to assess the efficacy of antifibrinolytic agents for preventing bleeding complications in people on oral anticoagulants undergoing minor oral surgery or dental extractions. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and the Cochrane Library. Additional searches were performed using ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), the CINAHL database of nursing and allied health services, the open access ProQuest dissertation database, papers and reports from the American College of Clinical Pharmacy (ACCP) and abstract books from annual scientific conferences. Date of last search: 04 January 2018. Selection criteria Randomised and quasi‐randomised controlled trials in people on continuous treatment with VKAs or DOACs undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid (TXA) or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. Data collection and analysis Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained from potentially relevant abstracts and two authors independently assessed these for inclusion based of the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. The quality of the evidence was assessed using GRADE. Main results No eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures were identified. Three randomised trials and one quasi‐randomised trial (follow‐up in all was seven days) in people on continuous treatment with VKAs were included with a total of 253 participants (mean age 60 years). Two trials published in 1989 and 1993 compared the antifibrinolytic agent TXA with placebo in people using VKAs. Two other trials were published in 1999 and 2015 and compared TXA with gelatin sponge and sutures, and dry gauze compression, respectively. In all included trials, those who were treated with VKAs had international normalised ratio (INR) values within the therapeutic range and TXA was applied locally, not systemically. The two trials from 1989 and 1993 comparing TXA with placebo showed a statistically significant beneficial effect regarding the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) of ‐0.25 (95% confidence interval (CI) ‐0.36 to ‐0.14) (128 participants) (moderate‐quality evidence). For the two trials that compared TXA with either gelatin sponge and sutures or with dry gauze compression, there was no difference between the TXA and the standard care group, RD 0.02 (95% CI ‐0.07 to 0.11) (125 participants) (moderate‐quality evidence). The combined RD of all included trials was ‐0.13 (95% CI ‐0.30 to 0.05) (moderate‐quality evidence). There were no side effects of antifibrinolytic therapy that required treatment withdrawal (128 participants) (moderate‐quality evidence). Despite heterogeneity between trials with respect to the different haemostatic measures used in the control groups, the trials were comparable regarding design and baseline participant characteristics. Overall, we considered the risk of bias to be low in the trials comparing TXA with placebo and moderate in the trials comparing TXA with alternative haemostatic measures. Authors' conclusions Based on the results of this Cochrane Review, there seems to be a beneficial effect of locally applied TXA in preventing oral bleeding in people on continuous treatment with VKAs undergoing minor oral surgery or dental extractions. However, the small number of identified randomised controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population. We were unable to identify any eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures. Therefore, a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs. Plain language summary Drugs that prevent oral bleeding in people using oral anticoagulants undergoing minor oral surgery or dental extractions Review question We reviewed the evidence about whether antifibrinolytic medicine (drugs that prevent breakdown of a blood clot), such as tranexamic acid or epsilon aminocaproic acid, can prevent oral bleeding after minor oral surgery or dental extractions in people using oral anticoagulants (blood thinners that are taken by mouth) without interruption during the procedure. Background People on continuous oral anticoagulant treatment are at an increased risk of bleeding complications during and after oral surgery or dental extractions. There are two types of oral anticoagulant treatment: vitamin K antagonists (VKAs) (e.g. warfarin and coumarin) and direct oral anticoagulants (DOACs) (e.g. dabigatran, rivaroxaban, apixaban, edoxaban). DOACs are becoming an increasingly popular alternative for VKAs, traditionally used for preventing blood clotting in people at risk of thrombosis. The number of bleeds and the severity of each bleed depend on medication‐related factors (such as the degree of anticoagulation, measured by the international normalised ratio (INR)), surgery‐related factors (such as the size of the wound or the number of roots extracted), as well as patient‐related factors (such as inflammation of the gums or blood vessel diseases). The INR level is important to determine how well the anticoagulant treatment is preventing blood clots. Within the desired range of the INR level, a person has both the least risk of blood clotting complications and the least risk of excessive bleeding. In routine practice antifibrinolytic medicine is often used before, during and after minor oral surgery or dental extractions for people using oral anticoagulants. The question is whether there is reliable scientific evidence for this practice. Search date The evidence is current to: 04 January 2018. Study characteristics We did not find any trials of antifibrinolytic medicine for preventing bleeding after minor oral surgery or dental extractions in people using DOACs. This review includes four trials (253 participants) in people continuously treated with VKAs during minor oral surgery or dental extractions. The earliest included trial was published in 1989 and the most recent one in 2015. The mean age of all participants was 60 years. The follow‐up time in all trials was seven days. Key results Overall, the included trials showed a reduction in the number of bleeds after dental extraction when using tranexamic acid solution in the mouth. Combining the results of the separate trials it appeared that antifibrinolytic medication reduces the bleeding rate after dental extractions by 25% when compared to placebo ('dummy' treatment). However, there was no difference in bleeding rate between people treated with tranexamic acid and those treated with standard care (e.g. gauze compression or stitches). Side effects of the antifibrinolytic medication rarely occurred and did not lead to individuals discontinuing tranexamic acid treatment. No evidence was found for people being treated with DOACs. It could, however, be argued that, if antifibrinolytic medicine is effective in people on continuous treatment with VKAs, it might also work for people receiving other comparable anticoagulant drugs. Quality of evidence In relation to the review's two primary outcomes of number of postoperative bleeds and side effects of therapy, we judged there to be moderate‐quality evidence. In the two trials comparing tranexamic acid with placebo, the risk of bias, in relation to trial design, was considered to be low, in the two trials comparing tranexamic acid to standard care (gelatin sponge and sutures; or dry gauze compression) the risk of bias was considered to be moderate. This was mainly due to the lack of blinding (a way of making sure that the people involved in the trial do not know which trial arm they are assigned to) and inadequate allocation concealment (using the play of chance to assign participants to comparison groups to prevent selection bias) in two of these trials. There were differences between the trials with regards to different standard care treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Engelen, ET; Schutgens, REG; Mauser‐Bunschoten, EP; van Es, RJJ; van Galen, KPM", "articleTypes": [], "doi": "10.1002/14651858.CD012293.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "b2be485a-81ba-4609-a5d1-65312baf97ae", "pmid": "", "title": "Interventions for the management of dry mouth: topical therapies", "imported": false, "abstract": "Abstract - Background Xerostomia (the feeling of dry mouth) is a common symptom especially in older adults. Causes of dry mouth include medications, autoimmune disease (Sjögren's Syndrome), radiotherapy or chemotherapy for cancer, hormone disorders and infections. Objectives To determine which topical treatments for dry mouth are effective in reducing this symptom. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (28 October 2011), The Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 4 2011), MEDLINE via OVID (1950 to 28 October 2011), EMBASE via OVID (1980 to 28 October 2011), CINAHL via EBSCO (1980 to 28 October 2011), AMED via OVID (1985 to 28 October 2011), CANCERLIT via PubMed (1950 to 28 October 2011). Selection criteria We included randomised controlled trials of topical interventions such as lozenges, sprays, mouthrinses, gels, oils, chewing gum or toothpastes for the treatment of dry mouth symptom. We classified interventions into two broad categories, saliva stimulants and saliva substitutes, and these were compared with either placebo or another intervention. We included both parallel group and crossover trials. Data collection and analysis Two or more review authors independently carried out data extraction and assessed risk of bias. Trial authors were contacted for additional information as required. Main results Thirty‐six randomised controlled trials involving 1597 participants met the inclusion criteria. Two trials compared saliva stimulants to placebo, nine trials compared saliva substitutes to placebo, five trials compared saliva stimulants directly with saliva substitutes, 18 trials directly compared two or more saliva substitutes, and two trials directly compared two or more saliva stimulants. Only one trial was at low risk of bias and 17 were at high risk of bias. Due to the range of interventions, comparisons and outcome measures in the trials, meta‐analysis was possible for only a few comparisons. Oxygenated glycerol triester (OGT) saliva substitute spray shows evidence of effectiveness compared to an electrolyte spray (standardised mean difference (SMD) 0.77, 95% confidence interval (CI) 0.38 to 1.15) which corresponds to approximately a mean difference of 2 points on a 10‐point visual analogue scale (VAS) for mouth dryness. Both integrated mouthcare systems (toothpaste + gel + mouthwash) and oral reservoir devices show promising results but there is insufficient evidence at present to recommend their use. Although chewing gum is associated with increased saliva production in the majority of those with residual capacity, there is no evidence that gum is more or less effective than saliva substitutes. Authors' conclusions There is no strong evidence from this review that any topical therapy is effective for relieving the symptom of dry mouth. OGT spray is more effective than an aqueous electrolyte spray (SMD 0.77, 95% CI 0.38 to 1.15) which is approximately equivalent to a mean difference of 2 points on a 10‐point VAS scale for mouth dryness. Chewing gums appear to increase saliva production in those with residual secretory capacity and may be preferred by patients, but there is no evidence that gum is better or worse than saliva substitutes. Integrated mouthcare systems and oral reservoir devices may be helpful but further research is required to confirm this. Well designed, adequately powered randomised controlled trials of topical interventions for dry mouth, which are designed and reported according to CONSORT guidelines, are required to provide evidence to guide clinical care. For many people the symptom of dry mouth is a chronic problem and trials should evaluate whether treatments are palatable, effective in reducing xerostomia, as well as the long‐term effects of treatments on quality of life of those with chronic dry mouth symptoms. Plain language summary Interventions for the management of dry mouth: topical therapies Dry mouth is a common problem with a range of causes. The symptom may be due to a reduction in the quantity of saliva produced, or a change in the composition of saliva, but a feeling of dry mouth may also be present in people with normal saliva production. Radiotherapy or chemotherapy for head and neck cancers, and diseases such as Sjögren's Syndrome, may result in reduced saliva production. Many commonly prescribed medications are associated with a feeling of dry mouth, despite normal saliva production. As well as difficulty in speaking, chewing and swallowing, prolonged dry mouth may result in increased risk of tooth decay and reduced quality of life. In many sufferers dry mouth cannot be cured, but effective ways for people to manage dry mouth symptoms are available. Many topical treatments (applied directly to the inside of the mouth) such as sprays, lozenges, mouthrinses, gels, oils, chewing gum or toothpastes have been evaluated in this review, but there is no strong evidence that any topical treatment is effective for relieving the sensation of dry mouth. Oxygenated glycerol triester (OGT) saliva substitute spray is more effective than a water based electrolyte spray. A gel‐releasing device worn in the mouth, or a mouthcare system might be effective but more research is needed. Chewing gum increases saliva production but there is no evidence that gum is better or worse than saliva substitutes. Acidic products and those containing sugar should be avoided.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Furness, S, Worthington, HV, Bryan, G, Birchenough, S, McMillan, R", "articleTypes": [], "doi": "10.1002/14651858.CD008934.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.729Z" }, { "id": "b2c272bb-691c-467c-95be-c29311d88f00", "pmid": "", "title": "Paediatric formulations of artemisinin‐based combination therapies for treating uncomplicated malaria in children", "imported": false, "abstract": "Abstract - Background In endemic malarial areas, young children have high levels of malaria morbidity and mortality. The World Health Organization recommends oral artemisinin‐based combination therapy (ACT) for treating uncomplicated malaria. Paediatric formulations of ACT have been developed to make it easier to treat children. Objectives To evaluate evidence from trials on the efficacy, safety, tolerability, and acceptability of paediatric ACT formulations compared to tablet ACT formulations for uncomplicated P falciparum malaria in children up to 14 years old. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; the Latin American and Caribbean Health Science Information database (LILACS); ISI Web of Science; Google Scholar; Scopus; and the metaRegister of Controlled Trials (mRCT) to 11 December 2019. Selection criteria We included randomised controlled clinical trials (RCTs) of paediatric versus non‐paediatric formulated ACT in children aged 14 years or younger with acute uncomplicated malaria. Data collection and analysis Two authors independently assessed eligibility and risk of bias, and carried out data extraction. We analyzed the primary outcomes of efficacy, safety and tolerability of paediatric versus non‐paediatric ACT using risk ratios (RR) and 95% confidence intervals (CI). Secondary outcomes were: treatment failure on the last day of observation (day 42), fever clearance time, parasite clearance time, pharmacokinetics, and acceptability. Main results Three trials met the inclusion criteria. Two compared a paediatric dispersible tablet formulation against crushed tablets of artemether‐lumefantrine (AL) and dihydroartemisinin‐piperaquine (DHA‐PQ), and one trial assessed artemether‐lumefantrine formulated as powder for suspension compared with crushed tablets. The trials were carried out between 2006 and 2015 in sub‐Saharan Africa (Benin, Mali, Mozambique, Tanzania, Kenya, Democratic Republic of the Congo, Burkina Faso, and The Gambia). In all three trials, the paediatric and control ACT achieved polymerase chain reaction (PCR)‐adjusted treatment failure rates of < 10% on day 28 in the per‐protocol (PP) population. For the comparison of dispersible versus crushed tablets, the two trials did not detect a difference for treatment failure by day 28 (PCR‐adjusted PP population: RR 1.35, 95% CI 0.49 to 3.72; 1061 participants, 2 studies, low‐certainty evidence). Similarly, for the comparison of suspension versus crushed tablet ACT, we did not detect any difference in treatment failure at day 28 (PCR‐adjusted PP population: RR 1.64, 95% CI 0.55 to 4.87; 245 participants, 1 study). We did not detect any difference in serious adverse events for the comparison of dispersible versus crushed tablets (RR 1.05, 95% CI 0.38 to 2.88; 1197 participants, 2 studies, low‐certainty evidence), or for the comparison of suspension versus crushed tablet ACT (RR 0.74, 95% CI 0.17 to 3.26; 267 participants, 1 study). In the dispersible ACT arms, drug‐related adverse events occurred in 9% of children in the AL study and 34% of children in the DHA‐PQ study. In the control arms, drug‐related adverse events occurred in 12% of children in the AL study and in 42% of children in the DHA‐PQ study. Drug‐related adverse events were lower in the dispersible ACT arms (RR 0.78, 95% CI 0.62 to 0.99; 1197 participants, 2 studies, moderate‐certainty evidence). There was no detected difference in the rate of drug‐related adverse events for suspension ACT versus crushed tablet ACT (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study). Drug‐related vomiting appeared to be less common in the dispersible ACT arms (RR 0.75, 95% CI 0.56 to 1.01; 1197 participants, 2 studies, low‐certainty evidence) and in the suspension ACT arm (RR 0.66, 95% CI 0.33 to 1.32; 267 participants, 1 study), but both analyses were underpowered. No study assessed acceptability. Authors' conclusions Trials did not demonstrate a difference in efficacy between paediatric dispersible or suspension ACT when compared with the respective crushed tablet ACT for treating uncomplicated P falciparum malaria in children. However, the evidence is of low to moderate certainty due to limited power. There appeared to be fewer drug‐related adverse events with dispersible ACT compared to crushed tablet ACT. None of the included studies assessed acceptability of paediatric ACT formulation. Plain language summary Treating uncomplicated malaria in children: do child‐friendly formulations of medicines work better than usual tablet formulations? What is the aim of this review? We wanted to find out about the potential benefits and harms of child‐friendly formulations of artemisinin‐based combination therapy (ACT) to treat uncomplicated malaria in children. We searched for studies that investigated the use of child‐friendly formulations of ACTs, compared with the usual ACT tablet formulations, to treat uncomplicated malaria in children aged under 14 years. We looked for randomized controlled studies, in which the treatments the children received were decided at random. This type of study usually gives the most reliable evidence about the effects of a treatment. We found three relevant studies of two child‐friendly formulations. Key messages Child‐friendly formulations of ACT probably work as well as crushed tablets to treat uncomplicated malaria in children, and probably cause fewer unwanted effects. What was studied in this review? Malaria is a tropical disease spread by mosquitoes infected with Plasmodium parasites. The most common, and most serious, type of malaria is caused by Plasmodium falciparum . This parasite causes high levels of illness and death, particularly in young children in regions where malaria is widespread. Malaria can be a mild illness, but is sometimes severe and life‐threatening if not treated soon enough or with the right medicines. Medicines based on artemisinin, a compound derived from a plant ( Artemisia annua ), are commonly taken by mouth (orally) to treat malaria in combination with other drugs. The World Health Organization recommends treating uncomplicated malaria with oral artemisinin‐based combination therapy (called ACT). Oral ACT tablets are often crushed to help make them easier for children to swallow. New formulations of oral ACTs have been developed especially for children, such as syrups, and granules, powders or tablets that can be dissolved in water, and which may be flavoured. What are the main results of this review? We found three relevant studies in 1306 children (aged 6 months to 11 years) with uncomplicated malaria. The studies were conducted in sub‐Saharan Africa between 2006 and 2015. All studies were funded by pharmaceutical companies that made child‐friendly formulations of the ACTs. The studies compared crushed ACT tablets to child‐friendly formulations of ACTs: these were dissolvable tablets of artemether‐lumefantrine or dihydroartemisinin‐piperaquine, or artemether‐lumefantrine syrup. We were interested in: · whether children remained cured of malaria after 28 days (measured by absence of Plasmodium parasites in the blood); and · whether the medicines caused any unwanted effects. None of the studies looked at how any of the medicine formulations were accepted by children. There may be little or no difference between the child‐friendly formulations of ACTs (dissolvable tablets or syrup) and the usual crushed tablets for how many children: · were successfully treated after 28 days; or · experienced serious unwanted effects. The crushed ACT tablets and the child‐friendly formulations successfully treated most cases of uncomplicated malaria. After 28 days the rates of treatment failure were similar in both groups. On average, 59 of every 1000 children taking crushed ACT tablets and 62 of every 1000 children taking dissolvable tablets would still have Plasmodium infection (2 studies; 1139 children). Similar numbers of serious unwanted effects were reported for the usual crushed tablets and the dissolvable tablets (2 studies; 1197 children) or syrup (1 study; 267 children), therefore differences as a result of the formulation are unlikely. A dissolvable tablet probably reduces unwanted effects of the medicine, including vomiting (throwing up), compared with the usual crushed tablets. Children taking dissolvable tablets had fewer unwanted effects associated with the medicine (139 of every 1000 children) than those taking crushed tablets (178 of every 1000 children). There was no difference in the number of unwanted effects found in the study with the syrup formulation compared with the usual crushed tablets. Our confidence in our results is low to moderate. The results come from a small number of studies. All studies were supported by manufacturers of the child‐friendly formulations, which could have affected how the studies were designed, conducted, and reported. How up‐to‐date is this review? We searched for studies that had been published up to 11 December 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bélard, S; Ramharter, M; Kurth, F", "articleTypes": [], "doi": "10.1002/14651858.CD009568.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "b2d90baf-e00c-47fe-bde6-c5e9572faf5c", "pmid": "", "title": "Surgical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Surgical treatment of chronic rhinosinusitis with nasal polyps is an established treatment for medically resistant nasal polyp disease. Whether a nasal polypectomy with additional sinus dissection offers any advantage over an isolated nasal polypectomy has not been systematically reviewed. Objectives To assess the effectiveness of simple polyp surgery versus more extensive surgical clearance in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 1); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised and quasi‐randomised controlled trials in patients over 16 with chronic rhinosinusitis with nasal polyps, who have failed a course of medical management and who have not previously undergone any previous surgical intervention for their nasal disease. Studies compared nasal polypectomy with more extensive sinus clearance in this patient cohort. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no trials which met our inclusion criteria. Six controlled trials (five randomised) met some but not all of the inclusion criteria and were therefore excluded from the review. Authors' conclusions We are unable to reach any conclusions as to whether isolated nasal polypectomy or more extensive sinus surgery is a superior surgical treatment modality for chronic rhinosinusitis with nasal polyps. There is a need for high‐quality randomised controlled trials to assess whether additional sinus surgery confers any benefit when compared to nasal polypectomy performed in isolation. Plain language summary Surgical interventions for chronic rhinosinusitis with nasal polyps Background Benign nasal polyps are abnormal tissue growths inside the nasal passages and sinuses, often on both sides of the nose. They can cause a wide array of symptoms including blocked nose, poor sense of smell that can lead to a loss of taste, runny nose and nasal congestion. Sinuses are air‐filled cavities in the bones of the face, which are in continuity with the nasal passages. The first‐line treatment for nasal polyps is usually medical therapy in the form of steroids ‐ as sprays (topically) or by mouth (orally). In patients where this treatment has failed to relieve the symptoms, the polyps can be removed surgically. These surgical procedures are often not curative and patients may need to continue medical therapy or undergo further surgeries. A number of well‐established surgical techniques can be used to remove polyps. What has not been established is whether removing the nasal polyps and clearing out the sinuses offers any advantage in the control of the disease when compared to simply removing the polyps and leaving the sinuses unchanged. We sought evidence in the literature to establish whether there was any difference in patients who underwent nasal polyp removal alone versus those who had nasal polyps removed as well as opening up of the sinuses. Study characteristics No trials met our inclusion criteria. We did identify six controlled trials (five of which were randomised) in which some but not all of our inclusion criteria were met, but we had to exclude these studies from the review. Key results No trials met our inclusion criteria. Quality of evidence At present, we cannot comment on whether taking nasal polyps out alone or also opening up the sinuses at the same time is a better treatment for patients with this disease. There is a need for high‐quality randomised controlled trials to answer this question. This evidence is current to February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Sharma, R; Lakhani, R; Rimmer, J; Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "b2e1f87b-4bcd-4095-8bad-ec7fa4a5e03d", "pmid": "", "title": "Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their aetiology is unknown. The management of chronic rhinosinusitis with nasal polyps, aimed at improving these symptoms, includes both surgical and medical treatments, but there is no universally accepted management protocol. Objectives To assess the effectiveness of endonasal/endoscopic surgery versus medical treatment in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised controlled trials of any surgical intervention (e.g. polypectomy, endoscopic sinus surgery) versus any medical treatment (e.g. intranasal and/or systemic steroids), including placebo, in adult patients with chronic rhinosinusitis with nasal polyps. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Meta‐analysis was not possible due to the heterogeneity of the studies and the selective (incomplete) outcome reporting by the studies. Main results Four studies (231 participants randomised) are included in the review. No studies were at low risk of bias. The studies compared different types of surgery versus various types and doses of systemic and topical steroids and antibiotics. There were three comparison pairs: (1) endoscopic sinus surgery (ESS) versus systemic steroids (one study, n = 109), (2) polypectomy versus systemic steroids (two studies, n = 87); (3) ESS plus topical steroid versus antibiotics plus high‐dose topical steroid (one study, n = 35). All participants also received topical steroids but doses and types were the same between the treatment arms of each study, except for the study using antibiotics. In that study, the medical treatment arm had higher doses than the surgical arm. In two of the studies, the authors failed to report the outcomes of interest. Although there were important differences in the types of treatments and comparisons used in these studies, the results were similar. Primary outcomes: symptom scores and quality of life scores There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) failed to find a difference in generic health‐related quality of life scores. The quality of this evidence is low or very low . Endoscopic scores and other secondary outcomes Two studies reported endoscopic scores. One study (ESS versus systemic steroids) reported a large, significant effect size in the surgical group, with a mean difference (MD) in score of ‐1.5 (95% confidence interval (CI) ‐1.78 to ‐1.22, n = 95) on a scale of 0 to 3 (0 = no polyposis, 3 = severe polyposis). In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups (MD 2.3%, 95% CI ‐17.4% to 12.8%, n = 34). None of the included studies reported recurrence rates. No differences were found for any objective measurements or olfactory tests in those studies in which they were measured. Complications Complication rates were not reported in all studies, but rates of up to 21% for medical treatment and 14.3% for surgical treatment are described. Epistaxis was the most commonly reported complication with both medical and surgical treatments, with severe complications reported rarely. Authors' conclusions The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis with nasal polyps is of very low quality. The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. The one positive finding from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. As the overall evidence is of very low quality (serious methodological limitations, reporting bias, indirectness and imprecision) and insufficient to draw firm conclusions, further research to investigate this problem, which has significant implications for quality of life and healthcare service usage, is justified. Plain language summary Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps Background Nasal polyps are common, benign swellings of the lining of the nose. In some people they may cause no symptoms, but in others they may lead to nasal obstruction, congestion, facial pressure and anosmia (loss of sense of smell). The incidence of symptomatic nasal polyps increases with age and they are more common in men than in women. The cause of nasal polyps is not fully understood but they may be a result of chronic (long‐term) inflammation of the lining of the nose (termed 'chronic rhinosinusitis with nasal polyps'). Chronic rhinosinusitis with nasal polyps can be treated medically, for example with drugs such as topical (intranasal) steroid sprays, or with surgery (for example, nasal polypectomy with or without endoscopic sinus surgery (ESS)). However, it is unclear what is the most effective management strategy. Study characteristics Four randomised controlled trials, involving a total of 231 patients with chronic rhinosinusitis with nasal polyps, are included in this review. The number of patients in each study ranged from 34 to 109. The studies took place in ENT departments in several European countries. All patients were adults and most of the studies enrolled more men than women. In all studies the patients were randomly assigned to either surgery or medical treatment (such as antibiotics or steroid tablets or injections) in addition to topical steroids given as nasal sprays or drops. Both the type of surgery performed and the medical treatments used varied widely between the studies, and did not allow all of the studies to be looked at together. Rather, we considered the treatment groups in the four studies as three separate pairs of comparisons instead of simply 'surgical' versus 'medical' treatments. Key results The main outcome measures were patient‐reported disease‐specific symptom scores and health‐related quality of life scores, as well as generic health‐related quality of life scores. There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) did not find a difference in general health‐related quality of life scores. Two studies reported changes in polyp size (when looked at with an endoscope) using a score. One study (ESS versus systemic steroids) reported a significantly better score in the surgery group than in the steroids group at 12 months. In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups. There were no reported differences between the different medical and surgical treatment groups in any study for any other objective (clinician‐based) measurements. Complication rates were not reported in all studies, but nosebleeds (epistaxis) were the most commonly described complication with both medical and surgical treatment; severe complications were reported rarely in either group. Conclusion The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. One positive finding (polyps size scores) from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. There is not enough evidence to draw firm conclusions regarding the most appropriate treatment for this condition. Chronic rhinosinusitis with nasal polyps has significant implications for quality of life and the use of healthcare services. Further research to investigate this problem is justified. Quality of the evidence Overall, we found this evidence to be of low or very low quality. We have low confidence in the estimates of these studies; further research will very likely change these estimates. There were serious limitations in how the studies were carried out or reported (or both), and the number of participants involved was small. In addition, some of the treatment regimens used in the trials are no longer current standards of therapy for patients with chronic rhinosinusitis with nasal polyps. This evidence is up to date to 20 February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Rimmer, J, Fokkens, W, Chong, LY, Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.801Z" }, { "id": "b2ec6194-d5da-4302-957a-20578d9be16e", "pmid": "", "title": "Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega‐3 PUFA and plant oils in omega‐6 PUFA. Evidence suggests that increasing PUFA‐rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear. Objectives To assess effects of increasing total PUFA intake on cardiovascular disease and all‐cause mortality, lipids and adiposity in adults. Search methods We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all‐cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions. Data collection and analysis Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta‐analyses used random‐effects analysis, sensitivity analyses included fixed‐effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence. Main results We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA. Increasing PUFA intake probably has little or no effect on all‐cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate‐quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) and stroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low‐quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality. Increasing PUFA intake probably slightly decreases triglycerides (by 15%, MD ‐0.12 mmol/L, 95% CI ‐0.20 to ‐0.04, 20 trials, 3905 participants), but has little or no effect on total cholesterol (mean difference (MD) ‐0.12 mmol/L, 95% CI ‐0.23 to ‐0.02, 26 trials, 8072 participants), high‐density lipoprotein (HDL) (MD ‐0.01 mmol/L, 95% CI ‐0.02 to 0.01, 18 trials, 4674 participants) or low‐density lipoprotein (LDL) (MD ‐0.01 mmol/L, 95% CI ‐0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably has little or no effect on adiposity (body weight MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants). Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality. Authors' conclusions This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all‐cause or cardiovascular disease mortality. The mechanism may be via TG reduction. Plain language summary Polyunsaturated fatty acids for prevention and treatment of diseases of the heart and circulation Review question We reviewed randomised trials (participants have an equal chance to be assigned to either treatment) examining effects of increasing intake of polyunsaturated fatty acids (PUFA) on deaths and diseases of the heart and circulation (cardiovascular diseases), including heart attacks and stroke. Background We eat PUFA in our usual food, but quantities of PUFA eaten vary. There is some evidence that increasing the amount of PUFA we eat can reduce our blood cholesterol and make us less likely to develop cardiovascular disease, particularly if PUFAs are eaten instead of saturated fats (fats from animal sources such as meat and cheese). But eating more PUFA may increase our body weight, and omega‐6 fats (one component of PUFA) may worsen cardiovascular risk by increasing inflammation. Evidence on the benefits or harms of increasing PUFA intake on diseases of the heart and circulation, or on other health outcomes, is inconclusive. Trial characteristics Evidence in this Cochrane Review is current to 27 April 2017. We included 49 trials randomising 24,272 participants, for one to eight years. These trials assessed effects of eating more, compared to less PUFA, on diseases of the heart and circulation, and deaths. Twelve trials were very trustworthy (had low risk of bias overall). Participants were men and women, some with existing illnesses and some not. Trials took place in North America, Asia, Europe and Australia, and sixteen were funded only by national or charitable agencies. Key results Increasing PUFA probably makes little or no difference (neither benefit nor harm) to our risk of death (moderate‐quality evidence), and may make little or no difference to our risk of dying from cardiovascular disease (low‐quality evidence). However, increasing PUFA probably slightly reduces our risk of heart disease events and of combined heart and stroke events (moderate‐quality evidence). Fifty three people would need to eat more PUFA to prevent one person experiencing a heart disease event, and 63 people to prevent one person experiencing a heart or stroke event. Increasing PUFA may very slightly reduce risk of death due to heart disease, as well as stroke, but harm is possible (low‐quality evidence). PUFA probably slightly reduces fats circulating in the blood (triglycerides, moderate‐quality evidence but without effects on other lipids or adiposity). The evidence mainly comes from dietary‐advice trials of men living in high‐income countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abdelhamid, AS, Martin, N, Bridges, C, Brainard, JS, Wang, X, Brown, TJ, Hanson, S, Jimoh, OF, Ajabnoor, SM, Deane, KHO, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.825Z" }, { "id": "b317f06b-aa64-49f7-a906-8fa470785216", "pmid": "", "title": "Folic acid supplementation and malaria susceptibility and severity among people taking antifolate antimalarial drugs in endemic areas", "imported": false, "abstract": "Abstract - Background Malaria is an infectious disease transmitted by female Anopheles mosquitoes, with ongoing transmission in over 80 countries. The malaria parasite requires folate for survival and growth; antifolate antimalarial medications used for prevention and treatment target enzymes in folate metabolism as their mechanism of action. Periconceptional folic acid (synthetic form of folate) supplementation (400 μg/day) is the standard of care for neural tube defect prevention. Concerns have been raised about the potential effects of folic acid (including above the tolerable upper intake level (UL) > 1.0 mg/day) in the context of malaria prevention and treatment, including the efficacy of antimalarial medications. Examining the potential impact of folic acid on malaria risk and severity amongst people taking antifolate antimalarial medications may inform public health programmes in malaria‐endemic areas. Objectives To examine the effects of folic acid supplementation on the risk and severity of malaria infection amongst people taking antifolate antimalarials and living in areas with malaria endemicity. Prevention: Amongst uninfected people taking antifolate antimalarial medications for malaria prevention, does folic acid supplementation increase susceptibility or severity of malaria infection? Treatment: Amongst people with malaria infection who are being treated with antifolate antimalarial drugs, does folic acid supplementation reduce parasite clearance or increase the risk of treatment failure? Search methods We searched databases including CENTRAL, MEDLINE, Embase, CINAHL, Scopus, and trial registries (September 13, 2024), grey literature, and reference searches to identify additional studies. Selection criteria Randomised trials evaluating the effects of folic acid supplementation (alone or in combination with iron or other vitamins and minerals) amongst individuals taking antifolate antimalarial medications in malaria‐endemic areas. Data collection and analysis Primary outcomes included uncomplicated malaria or severe malaria, parasite clearance, and treatment failure. Cochrane RoB 2 was used to evaluate the risk of bias. Certainty of evidence was assessed using GRADE for primary outcomes. We performed meta‐analyses using random‐effects models for all outcomes. Main results Eight trials with 3486 participants were included: three malaria prevention trials and five malaria treatment trials. Most treatment trials included folic acid doses above the UL ( > 1.0 mg/d); one trial included 400 μg per day. Antifolate antimalarials included sulfadoxine‐pyrimethamine (SP; five trials), sulfisoxazole plus pyrimethamine (one trial), atovaquone‐proguanil (one trial), and proguanil (one trial). Some studies had unclear or high risk of bias due to missing outcome data. Malaria prevention Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medications. Data for primary outcomes, uncomplicated and severe malaria, were not reported. One trial reported laboratory parasitaemia; there was little to no difference in malaria parasitaemia amongst pregnant women receiving folic acid (with iron) and antifolate antimalarials compared to iron and antifolate antimalarials (Risk Ratio (RR) 1.21; 95% CI 0.56 to 2.62; P = 0.63; 1 trial, 643 individuals). Comparisons 2–4: No studies reported data for Comparisons 2–4. Malaria treatment 
 Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarial medications versus placebo/no folic acid with antifolate antimalarials. People receiving folic acid (alone or with iron) and antifolate antimalarials were less likely to clear malaria parasites (day 3) compared to individuals who did not receive folic acid (RR 0.89; 95% CI 0.84 to 0.95, 4 trials, 929 individuals, moderate‐certainty evidence); and had increased risk of treatment failure on day 7 (RR 2.12; 95% CI 1.41 to 3.19, 4 trials, 1062 individuals, moderate‐certainty evidence), day 14 (RR 1.97; 95% CI 1.44 to 2.70, 3 trials; 891 individuals; moderate‐certainty evidence), and day 28 (RR 1.35; 95% CI 1.21 to 1.51; 4 trials; 1012 individuals, moderate‐certainty evidence). Comparison 2: Folic acid alone + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medication. Folic acid supplementation with antifolate antimalarials likely had lower parasite clearance (day 3) (RR 0.87; 95% CI 0.79 to 0.96, 2 trials, 229 individuals, moderate certainty of the evidence), and increased treatment failure (day 7: RR 2.58; 95% CI 0.89 to 7.45; P = 0.08; 2 trials; 344 individuals, moderate‐certainty evidence; day 14: RR 4.15; 95% CI 0.92 to 18.65; P = 0.06; 1 trial; 173 individuals, moderate‐certainty evidence; and day 28: RR 1.47; 95% CI 0.86 to 2.49; P = 0.16; 2 trials; 294 individuals, moderate‐certainty evidence), compared to no folic acid and antifolate antimalarials. Comparison 3: Folic acid with iron + antifolate antimalarial medication versus placebo/no folic acid with iron + antifolate antimalarial medication. People receiving folic acid with iron and antifolate antimalarials were less likely to clear malaria parasites (day 3: RR 0.90; 95% CI 0.83 to 0.98; P = 0.02; 2 trials; 700 individuals, moderate‐certainty evidence), and had increased treatment failure (day 7: RR 1.96; 95% CI 1.05 to 3.65; P = 0.03; 2 trials; 718 individuals; day 14: RR 1.90; 95% CI 1.35 to 2.67; 2 trials; 718 individuals; day 28: RR 1.17; 95% CI 0.79 to 1.74; 2 trials; 578 individuals; all moderate‐certainty evidence), compared to iron and antifolate antimalarials. Comparison 4: No studies reported data. Authors' conclusions Malaria prevention: None of the included trials reported primary outcomes. Malaria treatment: People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to clear malaria parasitaemia (day 3), and had increased treatment failure (days 7, 14, 28). Most of the included trials provided folic acid with doses above the tolerable UL ( > 1.0 mg). One trial included folic acid at a dose of 400 μg/d (recommended dose for preventing neural tube defects) and showed little to no difference in parasite clearance or treatment failure. Plain language summary Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common? Review question 
Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common?

 Key messages 
° People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to eliminate malaria parasites and had increased treatment failure. 
° There were not enough studies to examine whether taking folic acid supplementation at a lower dose, like 400 μg, might affect the risk of malaria infection or health outcomes if infected. This low dose is currently recommended before and during early pregnancy for the prevention of neural tube defects. Malaria and the importance of folate 
Malaria is a disease spread by the bite of certain types of female mosquitoes and is found in over 80 countries. The malaria parasite needs folate to grow and survive, and some medicines used to prevent and treat malaria target folate. Folic acid (the synthetic form of folate) is recommended at a dose of 400 μg daily to prevent neural tube defects. There are some concerns that folic acid (particularly higher doses) may affect malaria and how well some medicines work to prevent and treat malaria. What did we want to find out? 
This review was done to see how folic acid affects malaria risk and severity amongst people taking antifolate antimalarial medications and living in areas where malaria is common. Specifically, we aimed to answer the following questions: Prevention: For people who do not have malaria and are taking antimalarial drugs to prevent malaria, do folic acid supplements increase their risk of getting malaria or having worse outcomes? Treatment: For people who have malaria and are being treated with antifolate antimalarial medications, does taking folic acid supplements affect how well the drugs work to treat malaria? What did we do? 
We searched for trials that looked at folic acid supplementation in people taking antifolate antimalarial medications to prevent or treat malaria. We compared and summarised the results of the trials and rated our confidence in the information based on how the study was done. What did we find? 
We included eight trials (3486 people); three were prevention trials and five were treatment trials. Most trials used higher folic acid doses ( > 1.0 mg) and included the medication sulfadoxine‐pyrimethamine (SP). The prevention studies did not include the main outcomes we were trying to assess. In the treatment studies, people who took folic acid and antifolate antimalarial drugs were less likely to clear malaria parasites from their bodies (day 3) and were more likely to have treatment failure (up to 28 days after treatment) compared to the same treatment but without folic acid. Most of the included trials provided the antimalarial SP and folic acid with doses above the tolerable upper intake level (upper limit; > 1.0 mg). Only one trial included folic acid at a dose of 400 μg per day (the recommended daily dose of folic acid for prevention of neural tube defects); there were no differences in parasite clearance or treatment failure between the arm with 400 μg per day of folic acid and the arm with no folic acid. What are the limitations of the evidence? 
The small number of trials and the size of the studies were limitations of this review, and no prevention studies reported main outcomes. How up to date is this evidence? 
The evidence is up‐to‐date as of September 13, 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Qi, YP; Crider, KS; Gutman, J; Centeno-Tablante, E; Fothergill, A; Daniels, K; Yeung, LF; Mai, CT; Mehta, S; Williams, JL; Finkelstein, JL", "articleTypes": [], "doi": "10.1002/14651858.CD014217.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "b31e2a53-ef22-4e82-b479-e15ec0d6d1da", "pmid": "", "title": "Zinc supplementation for tinnitus", "imported": false, "abstract": "Abstract - Background Tinnitus is the perception of sound without external acoustic stimuli. Patients with severe tinnitus may have physical and psychological complaints and their tinnitus can cause deterioration in their quality of life. At present no specific therapy for tinnitus has been found to be satisfactory in all patients. In recent decades, a number of reports have suggested that oral zinc supplementation may be effective in the management of tinnitus. Since zinc has a role in cochlear physiology and in the synapses of the auditory system, there is a plausible mechanism of action for this treatment. Objectives To evaluate the effectiveness and safety of oral zinc supplementation in the management of patients with tinnitus. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 6); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 July 2016. Selection criteria Randomised controlled trials comparing zinc supplementation versus placebo in adults (18 years and over) with tinnitus. Data collection and analysis We used the standard methodological procedures recommended by Cochrane. Our primary outcome measures were improvement in tinnitus severity and disability, measured by a validated tinnitus‐specific questionnaire, and adverse effects. Secondary outcomes were quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters, change in tinnitus loudness, change in overall severity of tinnitus and change in thresholds on pure tone audiometry. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included three trials involving a total of 209 participants. The studies were at moderate to high risk of bias. All included studies had differences in participant selection criteria, length of follow‐up and outcome measurement, precluding a meta‐analysis. The participants were all adults over 18 years with subjective tinnitus, but one study conducted in 2013 (n = 109) included only elderly patients. Improvement in tinnitus severity and disability Only the study in elderly patients used a validated instrument (Tinnitus Handicap Questionnaire) for this primary outcome. The authors of this cross‐over study did not report the results of the two phases separately and found no significant differences in the proportion of patients reporting tinnitus improvement at four months of follow‐up: 5% (5/93) versus 2% (2/94) in the zinc and placebo groups, respectively (risk ratio (RR) 2.53, 95% confidence interval (CI) 0.50 to 12.70; very low‐quality evidence ). None of the included studies reported any significant adverse effects. Secondary outcomes For the secondary outcome change in tinnitus loudness, one study reported no significant difference between the zinc and placebo groups after eight weeks: mean difference in tinnitus loudness ‐9.71 dB (95% CI ‐25.53 to 6.11; very low‐quality evidence ). Another study also measured tinnitus loudness but used a 0‐ to 100‐point scale. The authors of this second study reported no significant difference between the zinc and placebo groups after four months: mean difference in tinnitus loudness rating scores 0.50 (95% CI ‐5.08 to 6.08; very low‐quality evidence ). Two studies used unvalidated instruments to assess tinnitus severity. One (with 50 participants) reported the severity of tinnitus using a non‐validated scale (0 to 7 points) and found no significant difference in subjective tinnitus scores between the zinc and placebo groups at the end of eight weeks of follow‐up (mean difference (MD) ‐1.41, 95% CI ‐2.97 to 0.15; very low‐quality evidence ). A third trial (n = 50) also evaluated the improvement of tinnitus using a non‐validated instrument (a 0 to 10 scale: 10 = severe and unbearable tinnitus). In this study, after eight weeks there was no difference in the proportion of patients with improvement in their tinnitus, 8.7% (2/23) treated with zinc versus 8% (2/25) of those who received a placebo (RR 1.09, 95% CI 0.17 to 7.10, very low‐quality evidence ). None of the included studies reported any of our other secondary outcomes (quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters or change in thresholds on pure tone audiometry). Authors' conclusions We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. Plain language summary Zinc supplements for tinnitus Background Tinnitus is the perceived sensation of sound in the ear or head. Severe tinnitus affects 1% to 2% of the population. People with severe tinnitus frequently have psychological changes and a decrease in their quality of life. Tinnitus is difficult to control and many doctors are testing new treatments to improve the quality of life of people who suffer from this problem. This review looked for high‐quality studies in the literature that involved zinc supplements as a possible treatment for tinnitus in adults. The aim was to evaluate whether oral zinc is effective in the treatment of tinnitus. Study characteristics We included a total of three trials involving 209 participants who were treated with oral zinc pills or placebo. All patients were adults over 18 years who had subjective tinnitus. All three studies investigated improvement in tinnitus as their primary outcome. One study assessed adverse effects and our secondary outcome 'change in overall severity of tinnitus'. Two studies assessed tinnitus loudness. Only one study, which enrolled only elderly patients, used a validated instrument (the Tinnitus Handicap Questionnaire (THQ)) to measure the primary outcome. The other two studies measured tinnitus using scales (from 0 to 7 and from 0 to 10), but these scales were not validated instruments for studying tinnitus. Key results All three included studies had differences in their participant selection, length of follow‐up and outcome measurement, which prevented a meta‐analysis (combining of results). Only one trial (conducted in 2013) used a validated instrument (the THQ) to measure improvement in tinnitus, our primary outcome. The authors reported no significant difference between the groups. Another study (2003) reported the severity of tinnitus using a non‐validated scale (0 to 7) and found a significant difference in the subjective tinnitus scores, which favoured the zinc group. However, this result may be biased because the losses were unbalanced and higher in the placebo group. A third study (1991) also evaluated improvement of tinnitus using a non‐validated instrument (a scale of 0 to 10) and found no significant difference between groups. There were no severe adverse effects associated with zinc. Three cases of mild adverse effects were reported in different participants (e.g. mild gastric symptoms). Two studies (2003 and 2013) assessed change in tinnitus loudness (one of our secondary outcomes), but did not find a difference between patients treated with zinc compared to those who took a placebo. Two studies assessed change in the overall severity of tinnitus. One study, published in 1991, did not find any difference for this outcome between the groups. The second study, published in 2003, reported a significant reduction in subjective tinnitus score in the zinc group and no difference in the placebo group. However, both studies used a non‐validated scale. Quality of the evidence The quality of the evidence is very low. We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. This evidence is up to date to 14 July 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Person, OC; Puga, MES; da Silva, EMK; Torloni, MR", "articleTypes": [], "doi": "10.1002/14651858.CD009832.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "b329cced-705d-4582-8518-15d33b8052f4", "pmid": "", "title": "Drugs for treating giardiasis", "imported": false, "abstract": "Abstract - Background Giardiasis infection may be asymptomatic, or can cause diarrhoea (sometimes severe), weight loss, malabsorption, and, in children, failure to thrive. It is usually treated with metronidazole given three times daily for five to 10 days. Objectives To evaluate the relative effectiveness of alternative antibiotic regimens for treating adults or children with symptomatic giardiasis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6 2012); MEDLINE, EMBASE, LILACS and the International Clinical Trials Registry Platform Search Portal (3 July 2012). Selection criteria We included randomized controlled trials (RCT) comparing metronidazole administered for five to 10 days with any of the following drugs: metronidazole (single dose), tinidazole, albendazole, mebendazole, and nitazoxanide. The primary outcomes were parasitological and clinical cure. Data collection and analysis Two authors independently assessed studies for inclusion, performed the risk of bias assessment, and extracted data. We summarized data using risk ratios and mean differences and we presented the results in forest plots and performed meta‐analyses where possible. We assessed heterogeneity using the Chi 2 test, I 2 statistic and visual inspection; and we explored this by using subgroup analyses.We assessed the quality of evidence by using the GRADE approach. Main results We included 19 trials, involving 1817 participants, of which 1441 were children. Studies were generally small, with poor methods reporting. . Most reported parasitological outcomes rather than clinical improvement. Ten trials, from India, Mexico, Peru, Iran, Cuba, and Turkey, compared albendazole (400 mg once daily for five to 10 days) with metronidazole (250 mg to 500 mg three times daily for five to 10 days). This once‐daily regimen of albendazole is probably equivalent to metronidazole at achieving parasitological cure (RR 0.99, 95% CI 0.95 to 1.03; 932 participants, 10 trials; moderate quality evidence ), and improving symptoms (RR 0.98, 95% confidence interval (CI) 0.93 to 1.04; 483 participants, five trials; moderate quality evidence ), but the duration of follow‐up was short (two to three weeks). Albendazole probably has fewer side effects than metronidazole (gastrointestinal side effects: RR 0.29, 95% CI 0.13 to 0.63; 717 participants, eight trials; moderate quality evidence ; neurological side effects: RR 0.34, 95% CI 0.18 to 0.64; 453 participants, five trials; low quality evidence ). Five trials from Turkey, Spain and the UK compared mebendazole (200 mg three times daily for five to 10 days) with metronidazole (5 mg/kg (or 250 mg) three times daily for five to 10 days). These trials were small in size, and at high risk of bias. Consequently, reliable conclusions on the relative effectiveness cannot be made ( very low quality evidence) . Five further trials, from Iran, Spain and Peru, have evaluated shortened regimens of tinidazole (single dose; 179 participants, three trials), metronidazole (single dose; 55 participants, one trial), and nitazoxanide (three days; 55 participants, one trial). Again, these trials were at high risk of bias and too small to reliably detect or exclude important differences ( very low quality evidence) . Authors' conclusions Albendazole may be of similar effectiveness to metronidazole, may have fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes (such as diarrhoea) will help assess further alternatives. 15 April 2019 Update pending Studies awaiting assessment The CIDG is currently examining a new search conducted in April 2019 for potentially relevant studies. These studies have not yet been incorporated into this Cochrane Review. Plain language summary Drugs for treating giardiasis Giardiasis is an infection of the small intestine caused by a microscopic organism called Giardia lamblia . The infection is passed from person to person by ingesting faecally contaminated water or food. Symptoms frequently include diarrhoea, abdominal pain, flatulence, bloating, vomiting, and weight loss. In this review, we assess alternatives to the most commonly used treatment for giardiasis; metronidazole given orally for five or more days. We identified 19 trials involving 1817 participants, of which 1441 were children. Most trials had a small number of participants and were at high risk of bias. Albendazole is probably of similar effectiveness to metronidazole, probably has fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes are required to assess further alternatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Granados, CE, Reveiz, L, Uribe, LG, Criollo, CP", "articleTypes": [], "doi": "10.1002/14651858.CD007787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.745Z" }, { "id": "b32d51a0-f082-4f3d-89d3-ef2e26c4c6a0", "pmid": "", "title": "Interventions for the treatment of Frey's syndrome", "imported": false, "abstract": "Abstract - Background Frey's syndrome is a rare disorder, the symptoms of which include sweating, flushing and warming over the preauricular and temporal areas following a gustatory stimulus. It often occurs in patients who have undergone parotidectomy, submandibular gland surgery, radical neck dissection, infection and traumatic injury in the parotid region, and is caused by the aberrant regrowth of facial autonomic nerve fibres. Currently there are several options used to treat patients with Frey's syndrome; for example, the topical application of anticholinergics and antiperspirants, and the intradermal injection of botulinum toxin. It is uncertain which treatment is most effective and safe. Objectives To assess the efficacy and safety of different interventions for the treatment of Frey's syndrome. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; ICTRP and additional sources for published and unpublished trials. The date of the search was 28 April 2014. Selection criteria We included randomised or quasi‐randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome using a clinical standard such as Minor's starch‐iodine test. We planned to include trials in which participants received any intervention versus no treatment (observation) or an alternative intervention, with or without a second active treatment. Our primary outcome measures were success rate (as assessed clinically by Minor's starch‐iodine test, the iodine‐sublimated paper histogram method, blotting paper technique or another method) and adverse events. Our secondary outcome measure was success rate as assessed by patients (disappearance or improvement of symptoms). Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no RCTs or quasi‐RCTs that fulfilled the inclusion criteria. Our searches retrieved eight potentially relevant studies, but after assessment of the full‐text reports we excluded all of them due to the absence of randomisation or because the patients did not have Frey's syndrome. We excluded one randomised controlled trial that compared two different doses of botulinum toxin in patients with Frey's syndrome because the comparator was not an alternative treatment. Authors' conclusions We are unable to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome. RCTs are urgently needed to assess the effectiveness of interventions for the treatment of Frey's syndrome. Future RCTs should include patients with Frey's syndrome of different ranges of severity and report these patients separately. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective assessment of Frey's syndrome should be considered as one of the outcome measures. Plain language summary Interventions for the treatment of Frey's syndrome Background Frey's syndrome is a rare disorder, the symptoms of which include sweating and flushing of the facial skin when eating, smelling, thinking or even dreaming about food. It usually happens in patients who have undergone surgery to the parotid (salivary) gland. This problem may have an impact on quality of life (for example, restricting normal activity such as eating in public). Many methods are currently used to treat Frey's syndrome, including topical application of anticholinergics and antiperspirants, and intradermal (into the skin) injections of botulinum toxin. This systematic review aimed to assess the efficacy and safety of these different methods for the treatment of Frey's syndrome. Study characteristics We carried out a comprehensive search for randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome. We planned to include trials in which participants received any intervention compared to no treatment (observation) or an alternative intervention, with or without a second active treatment. Despite extensive searching, we were unable to identify any studies that met our inclusion criteria. Key results There is no high‐quality evidence to establish which type of treatment is most effective for the treatment of Frey's syndrome. High‐quality clinical trials in this area should be urgently conducted. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective (patient) assessment of Frey's syndrome should be one of the outcome measures used. Quality of the evidence This review is up to date to 28 April 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Li, C, Wu, F, Zhang, Q, Gao, Q, Shi, Z, Li, L", "articleTypes": [], "doi": "10.1002/14651858.CD009959.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.747Z" }, { "id": "b3435bee-2a92-4648-bfb1-95c692607542", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 2. Less commonly‐used drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of mainly cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres (˜ 8200 feet). Acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude ascent. In this second review, in a series of three about preventive strategies for HAI, we assessed the effectiveness of five of the less commonly used classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of five of the less commonly used pharmacological interventions for preventing acute HAI in participants who are at risk of developing high altitude illness in any setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in May 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text search terms. We scanned the reference lists and citations of included trials and any relevant systematic reviews that we identified for further references to additional trials. Selection criteria We included randomized controlled trials conducted in any setting where one of five classes of drugs was employed to prevent acute HAI: selective 5‐hydroxytryptamine(1) receptor agonists; N‐methyl‐D‐aspartate (NMDA) antagonist; endothelin‐1 antagonist; anticonvulsant drugs; and spironolactone. We included trials involving participants who are at risk of developing high altitude illness (AMS or HACE, or HAPE, or both). We included participants with and without a history of high altitude illness. We applied no age or gender restrictions. We included trials where the relevant medication was administered before the beginning of ascent. We excluded trials using these drugs during ascent or after ascent. Data collection and analysis We used the standard methodological procedures employed by Cochrane. Main results We included eight studies (334 participants, 9 references) in this review. Twelve studies are ongoing and will be considered in future versions of this review as appropriate. We have been unable to obtain full‐text versions of a further 12 studies and have designated them as 'awaiting classification'. Four studies were at a low risk of bias for randomization; two at a low risk of bias for allocation concealment. Four studies were at a low risk of bias for blinding of participants and personnel. We considered three studies at a low risk of bias for blinding of outcome assessors. We considered most studies at a high risk of selective reporting bias. We report results for the following four main comparisons. Sumatriptan versus placebo (1 parallel study; 102 participants) Data on sumatriptan showed a reduction of the risk of AMS when compared with a placebo (risk ratio (RR) = 0.43, CI 95% 0.21 to 0.84; 1 study, 102 participants; low quality of evidence). The one included study did not report events of HAPE, HACE or adverse events related to administrations of sumatriptan. Magnesium citrate versus placebo (1 parallel study; 70 participants) The estimated RR for AMS, comparing magnesium citrate tablets versus placebo, was 1.09 (95% CI 0.55 to 2.13; 1 study; 70 participants; low quality of evidence). In addition, the estimated RR for loose stools was 3.25 (95% CI 1.17 to 8.99; 1 study; 70 participants; low quality of evidence). The one included study did not report events of HAPE or HACE. Spironolactone versus placebo (2 parallel studies; 205 participants) Pooled estimation of RR for AMS was not performed due to considerable heterogeneity between the included studies (I² = 72%). RR from individual studies was 0.40 (95% CI 0.12 to 1.31) and 1.44 (95% CI 0.79 to 2.01; very low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Acetazolamide versus spironolactone (1 parallel study; 232 participants) Data on acetazolamide compared with spironolactone showed a reduction of the risk of AMS with the administration of acetazolamide (RR = 0.36, 95% CI 0.18 to 0.70; 232 participants; low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Authors' conclusions This Cochrane Review is the second in a series of three providing relevant information to clinicians and other interested parties on how to prevent high altitude illness. The assessment of five of the less commonly used classes of drugs suggests that there is a scarcity of evidence related to these interventions. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Overall, the evidence is limited due to the low number of studies identified (for most of the comparison only one study was identified); limitations in the quality of the evidence (moderate to low); and the number of studies pending classification (24 studies awaiting classification or ongoing). We lack the large and methodologically sound studies required to establish or refute the efficacy and safety of most of the pharmacological agents evaluated in this review. Plain language summary Medicines less commonly used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and lung conditions that can occur during travel to altitudes above 2500 metres (˜ 8200 feet). HAI‐related conditions are generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but primarily affect the brain (drowsiness, confusion or unconsciousness) or the lungs (cough, breathlessness) in different individuals. We assessed five classes of medicines less commonly used to prevent the onset of this illness in this review. Study characteristics The evidence is current to May 2017. We included eight studies and 334 participants related to five different classes of medicines sometimes recommended for HAI prevention. These medicines included those that mimic the action of serotonin at selected sites (selective 5‐hydroxytryptamine(1) receptor agonists), medicines that regulate the action of calcium (N‐methyl‐D‐aspartate (NMDA) antagonist), medicines that promote dilation of the blood vessels (endothelin‐1 antagonist), medicines that prevent a neuron (nerve cell) from 'firing' (initiating an action) and convulsions from developing (anticonvulsant medicines), as well as medicines that regulate the body´s sodium and water levels (spironolactone). All studies were undertaken in high altitude mountain areas. The participants ranged between 16 and 65 years of age. Only one study included people at a high risk of this condition due to their history of HAI. Four trials provided the intervention between one to three days prior to the ascent (50%), and three trials less than 24 hours prior (37.5%). The participants in all these studies reached a final altitude of between 3500 and 5895 metres above sea level. Only one of the eight included studies did not provide clear information about the source of funding (12.5%). Twenty‐four additional studies were classified as ongoing (12), or awaiting classification (12; unable to obtain full texts). Key results The assessment of the less commonly used pharmacological interventions suggest that there is a scarcity of evidence related to these interventions. For most of the assessed comparisons, we only found evidence from a single study. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Quality of the evidence The quality of the evidence was rated from low to very low. Several studies had quality shortcomings such as only having small sample sizes and therefore generating uncertain results. For most of the medicines evaluated, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Gonzalez Garay, AG, Molano Franco, D, Nieto Estrada, VH, Martí‐Carvajal, AJ, Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD012983", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.080Z" }, { "id": "b373318b-2474-4d2c-af59-ccfb733a57fa", "pmid": "", "title": "Blood pressure lowering efficacy of diuretics as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Diuretics are widely prescribed for hypertension not only as a first‐line drug but also as a second‐line drug. Therefore, it is essential to determine the effects of diuretics on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a second‐line drug. Objectives To quantify the additional reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of diuretic therapy as a second‐line drug in patients with primary hypertension Search methods CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (1966‐July 2008), EMBASE (1988‐July 2008) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized, controlled trials evaluating the BP lowering efficacy of a diuretic in combination therapy with another class of anti‐hypertensive drugs compared with the respective monotherapy (without a diuretic) for a duration of 3 to 12 weeks in patients with primary hypertension. Data collection and analysis Two review authors independently extracted the data and assessed trial quality. Main results Fifty‐three double‐blind RCTs evaluating a thiazide in 15129 hypertensive patients (baseline BP of 156/101 mmHg) were included. Hydrochlorothiazide was the thiazide used in 49/53 (92%) of the included studies. The additional BP reduction caused by the thiazide as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. Thiazides as a second‐line drug reduced BP by 6/3 and 8/4 mmHg at doses of 1 and 2 times the manufacturer's recommended starting dose respectively. The BP lowering effect was dose related. The effect was similar to that obtained when thiazides are used as a single agent. Only 3 double‐blind RCTs evaluating loop diuretics were identified. These RCTs showed a BP lowering effect of a starting dose of about 6/3 mmHg. Authors' conclusions Thiazides when given as a second‐line drug have a dose related effect to lower blood pressure that is similar to when they are added as a first‐line drug. This means that the BP lowering effect of thiazides is additive. Loop diuretics appear to have a similar blood pressure lowering effect as thiazides at 1 times the recommended starting dose. Because of the short duration of the trials and lack of reporting of adverse events, this review does not provide a good estimate of the incidence of adverse effects of diuretics given as a second‐line drug. Plain language summary Diuretics effective in lowering blood pressure when given as a second drug Diuretics are a good first‐line treatment for high blood pressure (BP). Diuretics include loop diuretics and thiazides. We asked how much do diuretics reduce BP when used as the second drug to treat hypertension. We performed a search of the available scientific literature to find all trial evidence to assess this question. Fifty‐six trials were found. Fifty‐three trials involved thiazide diuretics (92% with the drug hydrochlorothiazide) and included a total of 15310 participants. Adding a thiazide to another anti‐hypertensive drug further reduces the BP by an additional 6/3 mmHg when given at the starting dose and reduces BP by 8/4 mmHg at 2 times the starting dose. This is approximately the same effect as when the drugs are used alone. A good estimate of the harms associated with diuretics cannot be estimated in this review because of the lack of reporting and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Chen, JMH, Heran, BS, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.117Z" }, { "id": "b37629bf-bfea-46bb-9f35-c4babf6cabc3", "pmid": "", "title": "Adverse events in people taking macrolide antibiotics versus placebo for any indication", "imported": false, "abstract": "Abstract - Background Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment‐specific, rather than disease‐specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases. Objectives To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides. Selection criteria We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups. Data collection and analysis Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide‐resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta‐analysis when three or more included studies reported a specific adverse event. Main results We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events or at least stated that no adverse events were observed. Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low‐quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low‐quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate‐quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate‐quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate‐quality evidence) were also reported more often in participants taking macrolides compared to placebo. The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000. The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting. There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration. Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low‐quality evidence). Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low‐quality evidence). We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low‐quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low‐quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low‐quality evidence) compared to placebo. We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo. Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate‐quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate‐quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate‐quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non‐significant. There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low‐quality evidence). Only 24 studies (13%) provided useful data on macrolide‐resistant bacteria. Macrolide‐resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent. Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials. Authors' conclusions The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as \"none were observed\". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance. Plain language summary Adverse events in people taking macrolide antibiotics Review question We wanted to find out if people treated with a macrolide antibiotic experienced more adverse events than those treated with placebo. Background Macrolide antibiotics are a group of antibiotics that are commonly used to treat both acute and chronic infections. The four most frequently used macrolides are: azithromycin, clarithromycin, erythromycin, and roxithromycin. People taking macrolide antibiotics are at risk of experiencing adverse events such as nausea, diarrhoea, or rash. Search date We searched the literature up to May 2018. Study characteristics We included 183 studies with a total of 252,886 participants. Most studies were conducted in the hospital setting. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events, or at least stated that no adverse events were observed. Study funding sources Drug companies supplied trial medications or funding, or both, in 91 studies. Funding sources were unclear in 59 studies. Key results People treated with a macrolide antibiotic experienced gastrointestinal adverse events such as nausea, vomiting, abdominal pain, and diarrhoea more often than those treated with placebo. Taste disturbances were reported more often by people taking macrolides than those taking a placebo. However, as very few studies reported on these adverse events, these results should be interpreted with caution. Hearing loss was reported more often by people taking macrolide antibiotics, however only four studies reported this outcome. Macrolides caused less cough and fewer respiratory tract infections than placebo. We did not find any evidence that macrolides caused more cardiac disorders, liver disorders, blood infections, skin and soft tissue infections, changes in liver enzymes, appetite loss, dizziness, headache, respiratory symptoms, itching, or rashes than placebo. We did not find more deaths in people treated with macrolides than in those treated with placebo. Very limited information was available to assess if people treated with a macrolide antibiotic were at greater risk of developing resistant bacteria than those treated with placebo. However, bacteria that did not respond to macrolide antibiotics were more commonly identified immediately after treatment in people taking a macrolide than in those taking a placebo, but differences in resistance thereafter were inconsistent. Quality of the evidence The quality of the evidence ranged from very low (cardiac disorders, change in liver enzymes, liver disorders) to low (abdominal pain, death, diarrhoea, dizziness, hearing loss, skin and soft tissue infections, taste disturbance, wheeze) to moderate (appetite loss, blood infection, cough, fever, headache, itching, nausea, rash, respiratory symptoms, respiratory tract infections, vomiting).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hansen, MP, Scott, AM, McCullough, A, Thorning, S, Aronson, JK, Beller, EM, Glasziou, PP, Hoffmann, TC, Clark, J, Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD011825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.751Z" }, { "id": "b379b01f-9ee9-4995-a40f-2f1530e75c68", "pmid": "", "title": "Calcitonin for metastatic bone pain", "imported": false, "abstract": "Abstract - Background Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastases. The hormone calcitonin has the potential to relieve pain and also retain bone density, thus reducing the risk of fractures. This review is an update of a previously published review in the Cochrane Library (2003, Issue 3) which was also updated in 2006 (Issue 3) and in 2011 (Issue 9). Objectives The main objective of the review is to determine the effectiveness of calcitonin to reduce metastatic bone pain in patients with painful bone metastases. Secondary objectives are to assess the benefits of calcitonin in reducing the incidence of bone complications (hypercalcemia, fractures and nervous compression) and improving patient survival, and to report any adverse effects of the treatment. Search methods We updated the electronic searches in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2015. We also searched registers of clinical trials in progress up to February 2015. Selection criteria We included studies if they were randomised, double‐blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. Data collection and analysis Two independent review authors performed study selection and data extraction. Only two studies (90 participants) were eligible for inclusion in the review and therefore meta‐analysis of the data was not possible. We performed intention‐to‐treat (ITT) analysis by imputing all missing values as adverse effects. Main results The overall quality of the evidence was very low. In this update no new studies were identified for inclusion; one additional study was excluded. Of the two small included studies, one study showed a non‐significant effect of calcitonin on the number of patients with complete pain relief (risk ratio (RR) 2.50; 95% confidence interval (CI) 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; 95% CI 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases, for improving quality of life or for patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.50; 95% CI 0.77 to 15.88). Authors' conclusions Current available research evidence is of very low quality and there is a lack of evidence to support the use of calcitonin for managing bone pain from bone metastases. Since the last version of this review, we did not identify any additional studies. Plain language summary Calcitonin used to treat metastatic bone pain People who have cancer which has spread to their bones and the nerves adjacent to the bones often suffer severe pain. There are several treatments to help relieve this pain: radiotherapy, analgesic drugs (pain killers) such as opioids, and bone‐modulating drugs such as bisphosphonates and calcitonin. Calcitonin has the potential to relieve pain and maintain bone strength, thus reducing the risk of broken bones. This review looked at the effectiveness of calcitonin for controlling pain from bone metastases. However, only two studies were found with very low quality evidence to support the use of calcitonin for patients suffering from bone pain. We updated the review in 2015 and did not find any more studies. There were slightly more side effects for the patients given calcitonin. Unless new studies provide additional relevant information about this treatment, other therapeutic approaches should be considered.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Martinez-Zapata, MJ; Roqué i Figuls, M; Català, E; Roman, Y; Alonso Coello, P", "articleTypes": [], "doi": "10.1002/14651858.CD003223.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "b37d70de-1dc8-44e5-a4a1-d34f07e11a61", "pmid": "", "title": "Listening to music for insomnia in adults", "imported": false, "abstract": "Abstract - Background Insomnia is a common problem in modern society. It is associated with reduced quality of life and impairments in physical and mental health. Listening to music is widely used as a sleep aid, but it remains unclear if it can actually improve insomnia in adults. This Cochrane Review is an update of a review published in 2015. Objectives To assess the effects of listening to music on sleep in adults with insomnia and to assess the influence of specific variables that may moderate the effect . Search methods For this update, we searched CENTRAL, MEDLINE, Embase, nine other databases and two trials registers up to December 2021. In addition, we handsearched reference lists of included studies, and contacted authors of published studies to identify additional studies eligible for inclusion, including any unpublished or ongoing trials. Selection criteria Randomised controlled trials comparing the effects of listening to music with no treatment or treatment as usual (TAU) in adults complaining of sleep difficulties. Data collection and analysis Two review authors independently screened records for eligibility, selected studies for inclusion, extracted data and assessed risk of bias of the included studies. We assessed the certainty of the evidence using GRADE. The primary outcomes were sleep quality, insomnia severity, sleep‐onset latency, total sleep time, sleep interruption, sleep efficiency and adverse events. Data on the predefined outcome measures were included in meta‐analyses when consistently reported by at least two studies that were homogeneous in terms of participants, interventions and outcomes. We undertook meta‐analyses using random‐effects models. Main results We included 13 studies (eight studies new to this update) comprising 1007 participants. The studies examined the effect of listening to prerecorded music daily, for 25 to 60 minutes, for a period of three days to three months. The risk of bias within the studies varied, with all studies being at high risk of performance bias, because of limited possibilities to blind participants to the music intervention. Some studies were at high risk of detection bias or other bias. Four studies reported funding from national research councils, three studies reported financial support from university sources and one study reported a grant from a private foundation. Five studies did not report any financial support. At the end of the intervention, we found moderate‐certainty evidence for improved sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI) in themusic groups compared to no intervention or TAU (mean difference (MD) −2.79, 95% confidence interval (CI) −3.86 to −1.72; 10 studies, 708 participants). The PSQI scale ranges from 0 to 21 with higher scores indicating poorer sleep. The size of the effect indicates an increase in sleep quality of the size of about one standard deviation in favour of the intervention. We found no clear evidence of a difference in the effects of listening to music compared to no treatment or TAU on insomnia severity (MD −6.96, 95% CI −15.21 to 1.28; 2 studies, 63 participants; very low‐certainty evidence). We found low‐certainty evidence that, compared to no treatment or TAU, listening to music may reduce problems with sleep‐onset latency (MD −0.60, 95% CI −0.83 to −0.37; 3 studies, 197 participants), total sleep time (MD −0.69, 95% CI −1.16 to −0.23; 3 studies, 197 participants) and sleep efficiency (MD −0.96, 95% CI −1.38 to −0.54; 3 studies, 197 participants), but may have no effect on perceived sleep interruption (MD −0.53, 95% CI −1.47 to 0.40; 3 studies, 197 participants). In addition, three studies (136 participants) included objective measures of sleep‐onset latency, total sleep time, sleep efficiency and sleep interruption and showed that listening to music may not improve these outcomes compared to no treatment or TAU. None of the included studies reported any adverse events. Authors' conclusions The findings of this review provide evidence that music may be effective for improving subjective sleep quality in adults with symptoms of insomnia. More research is needed to establish the effect of listening to music on other aspects of sleep as well as the daytime consequences of insomnia. Plain language summary Music for insomnia in adults Review question This review assessed the effects of listening to music on insomnia (sleep problems) in adults and the impact of factors that may influence the effect. Key messages We found a beneficial effect of music on sleep quality. For all the other outcomes, we did not find enough good‐quality evidence as there were too few participants and the people doing the scoring of the data were aware of the treatment. What is insomnia? Worldwide, millions of people experience insomnia. People can have difficulties getting to sleep, staying asleep or may experience poor sleep quality. Poor sleep affects people's physical and mental health. The consequences of poor sleep are costly, for both individuals and society. Many people listen to music to improve their sleep, but the effect of listening to music is unclear. What did we do? We searched electronic databases to identify relevant studies. We included 13 studies with 1007 participants. The studies compared the effect of listening to music to treatment as usual or no treatment. Treatment as usual could be sleep hygiene education (learning a set of rituals to help with sleep) or standard care for participants with insomnia related to chronic medical conditions. The studies examined the effect of listening to prerecorded music daily, for 25 to 50 minutes, for three days to three months. Seven of the included studies reported funding from national research councils or university sources, and one study reported funding from a private foundation. Five studies did not report any funding sources. What did we find? Ten studies measured sleep quality, and the results showed that music probably facilitates a large improvement in the quality of sleep compared to no treatment or treatment as usual. We do not know if listening to music has an effect on the severity of insomnia (difficulty in falling or staying asleep) or the number of times a person wakes up (broken sleep) compared to no treatment or treatment as usual. Listening to music may improve slightly sleep‐onset latency (how quickly a person falls asleep), sleep duration (length of time a person is asleep) and sleep efficiency (amount of a time a person is asleep compared to the total time spent in bed), compared to no treatment or treatment as usual. None of the studies reported any negative effects caused by listening to music. What are the limitations of the evidence? The quality of evidence from the 10 studies that examined sleep quality was moderate. Our confidence in the evidence for the quality of sleep is only moderate because the people in the studies were aware of which treatment they were getting and the people scoring the data were also sometimes aware of which treatment the participants were getting, which could introduce bias. We have little confidence in the evidence for the severity of insomnia because the studies were very small and were done in different types of people who knew which treatment they were getting. Our confidence in the evidence on sleep‐onset latency, sleep duration and sleep efficiency is low because the studies used very different methods to measure these outcomes, and the people in the studies were aware of the nature of the treatment. We have little confidence in the evidence on sleep interruption because the studies used different methods and showed different results. Furthermore, the participants in the studies knew which treatment they were getting. Future studies should assess other aspects of sleep as well as measures of daytime functioning, such as mood, fatigue, concentration, and quality of life. How up to date is this evidence? The evidence is current to 31 December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jespersen, KV, Pando-Naude, V, Koenig, J, Jennum, P, Vuust, P", "articleTypes": [], "doi": "10.1002/14651858.CD010459.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.122Z" }, { "id": "b38333c2-b056-491a-be08-4deb8ad20976", "pmid": "", "title": "Honey for acute cough in children", "imported": false, "abstract": "Abstract - Background Cough causes concern for parents and is a major cause of outpatient visits. Cough can impact quality of life, cause anxiety, and affect sleep in children and their parents. Honey has been used to alleviate cough symptoms. This is an update of reviews previously published in 2014, 2012, and 2010. Objectives To evaluate the effectiveness of honey for acute cough in children in ambulatory settings. Search methods We searched CENTRAL (2018, Issue 2), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (2014 to 8 February 2018), Embase (2014 to 8 February 2018), CINAHL (2014 to 8 February 2018), EBSCO (2014 to 8 February 2018), Web of Science (2014 to 8 February 2018), and LILACS (2014 to 8 February 2018). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trial Registry Platform (WHO ICTRP) on 12 February 2018. The 2014 review included searches of AMED and CAB Abstracts, but these were not searched for this update due to lack of institutional access. Selection criteria Randomised controlled trials comparing honey alone, or in combination with antibiotics, versus no treatment, placebo, honey‐based cough syrup, or other over‐the‐counter cough medications for children aged 12 months to 18 years for acute cough in ambulatory settings. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included six randomised controlled trials involving 899 children; we added three studies (331 children) in this update. We assessed two studies as at high risk of performance and detection bias; three studies as at unclear risk of attrition bias; and three studies as at unclear risk of other bias. Studies compared honey with dextromethorphan, diphenhydramine, salbutamol, bromelin (an enzyme from the Bromeliaceae (pineapple) family), no treatment, and placebo. Five studies used 7‐point Likert scales to measure symptomatic relief of cough; one used an unclear 5‐point scale. In all studies, low score indicated better cough symptom relief. Using a 7‐point Likert scale, honey probably reduces cough frequency better than no treatment or placebo (no treatment: mean difference (MD) ‐1.05, 95% confidence interval (CI) ‐1.48 to ‐0.62; I² = 0%; 2 studies; 154 children; moderate‐certainty evidence; placebo: MD ‐1.62, 95% CI ‐3.02 to ‐0.22; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Honey may have a similar effect as dextromethorphan in reducing cough frequency (MD ‐0.07, 95% CI ‐1.07 to 0.94; I² = 87%; 2 studies; 149 children; low‐certainty evidence). Honey may be better than diphenhydramine in reducing cough frequency (MD ‐0.57, 95% CI ‐0.90 to ‐0.24; 1 study; 80 children; low‐certainty evidence). Giving honey for up to three days is probably more effective in relieving cough symptoms compared with placebo or salbutamol. Beyond three days honey probably had no advantage over salbutamol or placebo in reducing cough severity, bothersome cough, and impact of cough on sleep for parents and children (moderate‐certainty evidence). With a 5‐point cough scale, there was probably little or no difference between the effects of honey and bromelin mixed with honey in reducing cough frequency and severity. Adverse events included nervousness, insomnia, and hyperactivity, experienced by seven children (9.3%) treated with honey and two children (2.7%) treated with dextromethorphan (risk ratio (RR) 2.94, 95% Cl 0.74 to 11.71; I² = 0%; 2 studies; 149 children; low‐certainty evidence). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14, 95% Cl 0.01 to 2.68; 1 study; 80 children; low‐certainty evidence). When honey was compared with placebo, 34 children (12%) in the honey group and 13 (11%) in the placebo group complained of gastrointestinal symptoms (RR 1.91, 95% CI 1.12 to 3.24; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Four children who received salbutamol had rashes compared to one child in the honey group (RR 0.19, 95% CI 0.02 to 1.63; 1 study; 100 children; moderate‐certainty evidence). No adverse events were reported in the no‐treatment group. Authors' conclusions Honey probably relieves cough symptoms to a greater extent than no treatment, diphenhydramine, and placebo, but may make little or no difference compared to dextromethorphan. Honey probably reduces cough duration better than placebo and salbutamol. There was no strong evidence for or against using honey. Most of the children received treatment for one night, which is a limitation to the results of this review. There was no difference in occurrence of adverse events between the honey and control arms. Plain language summary Honey for acute cough in children Review question Can honey reduce cough symptoms caused by bacteria and viruses in children? Background Cough causes concern for parents and is a major reason for outpatient visits. Honey is believed to prevent growth of germs and reduce inflammation. Search date We searched databases to 8 February 2018 and trial registers to 12 February 2018. Study characteristics We included six small trials involving 899 children aged 12 months to 18 years conducted in Iran, Israel, the USA, Brazil, and Kenya. This update included three new trials conducted between 2007 and 2016 that involved 331 children. Study funding sources Two studies were supported by pharmaceutical manufacturers; one by a university research centre; one by the Honey Board of Israel and non‐government agencies; and one by USA National Honey Board. One study did not report funding sources. Key results We compared honey to over‐the‐counter cough preparations, bromelin (a pineapple enzyme) mixed with honey, fake treatment (placebo), and no treatment. Honey probably reduces cough symptoms more than placebo and salbutamol (a drug that opens lung airways) when given for up to three days. Honey is probably more effective at providing cough relief and reducing the impact of cough on children's sleep at night than no treatment. There may be little or no difference between the effects of honey and dextromethorphan (an ingredient in over‐the‐counter cough remedies) or honey and bromelin with honey on all cough symptoms. Honey may be better than diphenhydramine (an antihistamine) at relieving and reducing children's cough. The parents of seven children given honey and two given dextromethorphan reported side effects in their children, such as not falling asleep easily, restlessness, and becoming overexcited. The parents of three children in the diphenhydramine group reported that their children were often sleepy. The parents of nine children given salbutamol, seven given honey, and six given placebo reported diarrhoea. The parents of four children who received salbutamol and one child given honey reported rash. We found no evidence for or against the use of honey to relieve cough in children. Using honey for infants aged up to 12 months is not advised because of poor immunity against bacteria that may be present, which can cause paralysis. Most of the children received honey for just one night, which is a limitation to the results of this review. Quality of the evidence Overall, evidence quality was low to moderate. Some studies did not blind participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Oduwole, O, Udoh, EE, Oyo‐Ita, A, Meremikwu, MM", "articleTypes": [], "doi": "10.1002/14651858.CD007094.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.759Z" }, { "id": "b3ba7ec7-6425-4040-83f4-830ee08db77d", "pmid": "", "title": "Melatonin and agomelatine for preventing seasonal affective disorder", "imported": false, "abstract": "Abstract - Background Seasonal affective disorder (SAD) is a seasonal pattern of recurrent major depressive episodes that most commonly starts in autumn or winter and remits in spring. The prevalence of SAD depends on latitude and ranges from 1.5% to 9%. The predictable seasonal aspect of SAD provides a promising opportunity for prevention in people who have a history of SAD. This is one of four reviews on the efficacy and safety of interventions to prevent SAD; we focus on agomelatine and melatonin as preventive interventions. Objectives To assess the efficacy and safety of agomelatine and melatonin (in comparison with each other, placebo, second‐generation antidepressants, light therapy, psychological therapy or lifestyle interventions) in preventing SAD and improving person‐centred outcomes among adults with a history of SAD. Search methods We searched Ovid MEDLINE (1950‐ ), Embase (1974‐ ), PsycINFO (1967‐ ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 19 June 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD‐CTR) (all years to 11 August 2015). Furthermore, we searched the Cumulative Index to Nursing and Allied Health Literature, Web of Science, the Cochrane Library , the Allied and Complementary Medicine Database and international trial registers (to 19 June 2018). We also conducted a grey literature search and handsearched the reference lists of included studies and pertinent review articles. Selection criteria To examine efficacy, we included randomised controlled trials (RCTs) on adults with a history of winter‐type SAD who were free of symptoms at the beginning of the study. For adverse events, we intended also to include non‐randomised studies. We planned to include studies that compared agomelatine versus melatonin, or agomelatine or melatonin versus placebo, any second‐generation antidepressant, light therapy, psychological therapies or lifestyle changes. We also intended to compare melatonin or agomelatine in combination with any of the comparator interventions mentioned above versus the same comparator intervention as monotherapy. Data collection and analysis Two review authors screened abstracts and full‐text publications, abstracted data and assessed risk of bias of included studies independently. We intended to pool data in a meta‐analysis using a random‐effects model, but included only one study. Main results We identified 3745 citations through electronic searches and reviews of reference lists after deduplication of search results. We excluded 3619 records during title and abstract review and assessed 126 full‐text papers for inclusion in the review. Only one study, providing data of 225 participants, met our eligibility criteria and compared agomelatine (25 mg/day) with placebo. We rated it as having high risk of attrition bias because nearly half of the participants left the study before completion. We rated the certainty of the evidence as very low for all outcomes, because of high risk of bias, indirectness, and imprecision. The main analysis based on data of 199 participants rendered an indeterminate result with wide confidence intervals (CIs) that may encompass both a relevant reduction as well as a relevant increase of SAD incidence by agomelatine (risk ratio (RR) 0.83, 95% CI 0.51 to 1.34; 199 participants; very low‐certainty evidence). Also the severity of SAD may be similar in both groups at the end of the study with a mean SIGH‐SAD (Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders) score of 8.3 (standard deviation (SD) 9.4) in the agomelatine group and 10.1 (SD 10.6) in the placebo group (mean difference (MD) ‐1.80, 95% CI ‐4.58 to 0.98; 199 participants; very low‐certainty evidence). The incidence of adverse events and serious adverse events may be similar in both groups. In the agomelatine group, 64 out of 112 participants experienced at least one adverse event, while 61 out of 113 did in the placebo group (RR 1.06, 95% CI 0.84 to 1.34; 225 participants; very low‐certainty evidence). Three out of 112 patients experienced serious adverse events in the agomelatine group, compared to 4 out of 113 in the placebo group (RR 0.76, 95% CI 0.17 to 3.30; 225 participants; very low‐certainty evidence). No data on quality of life or interpersonal functioning were reported. We did not identify any studies on melatonin. Authors' conclusions Given the uncertain evidence on agomelatine and the absence of studies on melatonin, no conclusion about efficacy and safety of agomelatine and melatonin for prevention of SAD can currently be drawn. The decision for or against initiating preventive treatment of SAD and the treatment selected should consider patient preferences and reflect on the evidence base of all available treatment options. Plain language summary Melatonin and agomelatine for prevention of winter depression Why is this review important? Many people in northern latitudes suffer from seasonal affective disorder (SAD), which occurs as a reaction to reduced sunlight. Three‐quarters of those affected are women. Lethargy, overeating, craving for carbohydrates and depressed mood are common symptoms. In some people, SAD becomes depression that seriously affects their daily lives. Up to two‐thirds experience depressive symptoms every winter. Who might be interested in this review? General practitioners, psychiatrists, pharmacists, other health professionals working in adult mental health services, and researchers could be interested in the results of this review. Anyone who has experienced winter depression, or who has friends or relatives who have experienced winter depression might also be interested. What questions does this review aim to answer? Because of the seasonal pattern and high recurrence of SAD, melatonin or agomelatine could be used to prevent the onset of depressed mood. The goal of this report is to examine whether benefits outweigh harms of melatonin or agomelatine when used to prevent onset of a new depressive episode in people with a history of SAD who were free of symptoms when the preventive intervention started. To date, this question has not been examined in a systematic way. This is one of four reviews on the efficacy and potential harms of interventions to prevent SAD. Which studies were included in the review? We searched databases up to June 2018 for studies on melatonin or agomelatine for prevention of winter depression. Among 3745 records, we found one randomised controlled study comparing agomelatine with placebo for one year. All 225 participants had a history of winter depression but were not depressed when the prevention study started. What does evidence from the review reveal? The included study showed neither a clear effect in favour nor against agomelatine as a preventive treatment. In addition, the certainty of evidence for all outcomes was very low, making it impossible to draw any conclusions about the efficacy and safety of agomelatine for the prevention of winter depression. No evidence on melatonin for prevention of SAD was identified. Doctors need to discuss with persons with a history of SAD that currently evidence on agomelatine or melatonin for preventive treatment options for SAD is inconclusive, therefore treatment selection should be strongly based on peoples' preferences and reflect on the evidence base of all available treatment options. What should happen next? Review authors recommend that future studies should evaluate the efficacy of agomelatine or melatonin in preventing SAD and should directly compare these interventions against other treatment options, such as light therapy, antidepressants, or psychological therapies to determine the best treatment option for prevention of SAD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nussbaumer‐Streit, B; Greenblatt, A; Kaminski‐Hartenthaler, A; Van Noord, MG; Forneris, CA; Morgan, LC; Gaynes, BN; Wipplinger, J; Lux, LJ; Winkler, D; Gartlehner, G", "articleTypes": [], "doi": "10.1002/14651858.CD011271.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "b3c73b82-4011-4186-950a-a384929302cb", "pmid": "", "title": "Eradication therapy for peptic ulcer disease in Helicobacter pylori‐positive people", "imported": false, "abstract": "Abstract - Background Peptic ulcer disease is the cause of dyspepsia in about 10% of people. Ninety‐five percent of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori . Eradication of H. pylori reduces the relapse rate of ulcers but the magnitude of this effect is uncertain. This is an update of Ford AC, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori ‐positive patients. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003840. DOI: 10.1002/14651858.CD003840.pub4. Objectives To assess the proportion of peptic ulcers healed and the proportion of participants who remained free from relapse with eradication therapy against placebo or other pharmacological therapies in H. pylori ‐positive people. To assess the proportion of participants that achieved complete relief of symptoms and improvement in quality of life scores. To compare the incidence of adverse effects/drop‐outs (total number for each drug) associated with the different treatments. To assess the proportion of participants in whom successful eradication was achieved. Search methods In this update, we identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1950 to March 2016) and Ovid EMBASE (1980 to March 2016). To identify further relevant trials, we handsearched reference lists from trials selected by electronic searching, and published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ). The search was last updated in March 2016. We contacted members of Cochrane Upper GI and Pancreatic Diseases, and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials of short‐ and long‐term treatment of peptic ulcer disease in H. pylori ‐positive adults. Participants received at least one week of H. pylori eradication compared with ulcer healing drug, placebo or no treatment. Trials were included if they reported assessment from two weeks onwards. Data collection and analysis We collected data on ulcer healing, recurrence, relief of symptoms and adverse effects. We calculated the risk ratio (RR) with 95% confidence intervals (CI) using both fixed‐effect and random‐effects models with Review Manager software (RevMan 5.3) based on intention‐to‐treat analysis as far as possible. Main results A total of 55 trials were included for one or more outcomes for this review. In duodenal ulcer healing, eradication therapy was superior to ulcer healing drug (UHD) (34 trials, 3910 participants, RR of ulcer persisting = 0.66, 95% confidence interval (CI) 0.58 to 0.76; 381/2286 (adjusted proportion: 12.4%) in eradication therapy plus UHD versus 304/1624 (18.7%) in UHD; low quality evidence) and no treatment (two trials, 207 participants, RR 0.37, 95% CI 0.26 to 0.53; 30/125 (adjusted proportion: 21.7%) in eradication therapy versus 48/82 (58.5%) in no treatment; low quality evidence). In gastric ulcer healing, the differences were imprecise between eradication therapy and UHD (15 trials, 1974 participants, RR 1.23, 95% CI 0.90 to 1.68; 220/1192 (adjusted proportion: 16.0%) in eradication therapy plus UHD versus 102/782 (13.0%) in UHD; very low quality evidence). In preventing duodenal ulcer recurrence the differences were imprecise between maintenance therapy with H.pylori eradication therapy and maintenance therapy with UHD (four trials, 319 participants, RR of ulcer recurring 0.73; 95% CI 0.42 to 1.25; 19/159 (adjusted proportion: 11.9%) in eradication therapy versus 26/160 (16.3%) in UHD; very low quality evidence), but eradication therapy was superior to no treatment (27 trials 2509 participants, RR 0.20, 95% CI 0.15 to 0.26; 215/1501 (adjusted proportion: 12.9%) in eradication therapy versus 649/1008 (64.4%) in no treatment; very low quality evidence). In preventing gastric ulcer recurrence, eradication therapy was superior to no treatment (12 trials, 1476 participants, RR 0.31, 95% CI 0.22 to 0.45; 116/697 (adjusted proportion: 16.3%) in eradication therapy versus 356/679 (52.4%) in no treatment; very low quality evidence). None of the trials reported proportion of people with gastric ulcer not healed after initial therapy between H.pylori eradication therapy and no active treatment or the proportion of people with recurrent gastric ulcer or peptic ulcers during maintenance therapy between H.pylori eradication therapy and ulcer healing drug therapy. Authors' conclusions Adding a one to two‐week course of H. pylori eradication therapy is an effective treatment for people with H. pylori‐ positive duodenal ulcer when compared to ulcer healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer healing drug. However, confidence intervals were wide and significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment, and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Plain language summary Antibiotics for people with peptic ulcers caused by Helicobacter pylori infection Review question Are antibiotics useful for the treatment of peptic ulcer (ulcers in the stomach or upper small intestine) in people with Helicobacter pylori ( H. pylori ) infection? Background Peptic ulcers are caused by acidic stomach juices damaging the lining of the stomach (gastric ulcer) or upper small intestine (duodenal ulcer). This causes pain, indigestion and sometimes, bleeding. Ulcers can return after being healed, especially if the person is infected with Helicobacter pylori (a lifelong infection unless treated). H. pylori causes most peptic ulcers. It is not clear whether eradicating H.pylori by treating with antibiotics as part of a combination of drugs ( H.pylori eradication therapy) is helpful in the treatment of people with peptic ulcers compared to no treatment or other medical treatments. This is an update of a previous Cochrane review published in 2006. Study characteristics Fifty‐five studies provided information for the review. Thirty‐four studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of duodenal ulcer. Two studies compared H. pylori eradication therapy against no treatment in the healing of duodenal ulcer. Fifteen studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of gastric ulcer. Three studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of peptic ulcer (gastric or duodenal ulcer). One study compared H. pylori eradication therapy against no treatment in the healing of peptic ulcer (gastric or duodenal ulcer). Four studies compared H. pylori eradication therapy against ulcer‐healing drug in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twenty‐seven studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twelve studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of gastric ulcer after initial ulcer had been healed, while one study compared H. pylori eradication therapy against no treatment in preventing the recurrence of peptic ulcer (gastric or duodenal ulcer) after initial ulcer had been healed. Four studies compared H. pylori eradication therapy plus ulcer‐healing drug versus comparison regimen in the relief of symptoms from peptic ulcer (gastric or duodenal ulcer). There were no studies comparing H. pylori eradication therapy against no treatment in the healing of gastric ulcer, H. pylori eradication therapy against ulcer‐healing drug as maintenance therapy in preventing the recurrence of gastric ulcer after initial ulcer had been healed, or H. pylori eradication therapy plus ulcer‐healing drug against no treatment or ulcer‐healing drug in the relief of symptoms in people with peptic ulcer. Some trials provided information for more than one comparison. The evidence is current until March 2016. Key results Adding a one to two‐week course of H. pylori eradication therapy speeds up ulcer healing for people with H. pylori‐ positive duodenal ulcer when compared to ulcer‐healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer (ulcer returning after initial healing) compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer‐healing drugs. However, because of the small number of studies included for the last two comparisons, significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Quality of the evidence The quality of evidence was low or very low because most of the studies had errors in study design. As a result, there is a lot of uncertainty regarding the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Ford, AC, Gurusamy, KS, Delaney, B, Forman, D, Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD003840.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.751Z" }, { "id": "b3cf94b4-0afa-4866-8119-932ea075531e", "pmid": "", "title": "Melatonin for the prevention and treatment of jet lag", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Herxheimer, A, Petrie, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD001520 AB - Abstract - Background Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Objectives To assess the effectiveness of oral melatonin taken in different dosage regimens for alleviating jet lag after air travel across several time zones. Search methods We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsychLit and Science Citation Index electronically, and the journals 'Aviation, Space and Environmental Medicine' and 'Sleep' by hand. We searched citation lists of relevant studies for other relevant trials. We asked principal authors of relevant studies to tell us about unpublished trials. Reports of adverse events linked to melatonin use outside randomised trials were searched for systematically in 'Side Effects of Drugs' (SED) and SED Annuals, 'Reactions Weekly', MEDLINE, and the adverse drug reactions databases of the WHO Uppsala Monitoring Centre (UMC) and the US Food & Drug Administration. An updating search was carried out on 12/2/2008 but no new studies were identified. Selection criteria Randomised trials in airline passengers, airline staff or military personnel given oral melatonin, compared with placebo or other medication. Outcome measures should consist of subjective rating of jet lag or related components, such as subjective well being, daytime tiredness, onset and quality of sleep, psychological functioning, duration of return to normal, or indicators of circadian rhythms. Data collection and analysis Ten trials met the inclusion criteria. All compared melatonin with placebo; one in addition compared it with a hypnotic, zolpidem. Nine of the trials were of adequate quality to contribute to the assessment, one had a design fault and could not be used in the assessment. 
 Reports of adverse events outside trials were found through MEDLINE, 'Reactions Weekly', and in the WHO UMC database. Main results Eight of the ten trials found that melatonin, taken close to the target bedtime at the destination (10pm to midnight), decreased jet‐lag from flights crossing five or more time zones. Daily doses of melatonin between 0.5 and 5mg are similarly effective, except that people fall asleep faster and sleep better after 5mg than 0.5mg. Doses above 5mg appear to be no more effective. The relative ineffectiveness of 2mg slow‐release melatonin suggests that a short‐lived higher peak concentration of melatonin works better. The estimated number needed to treat (NNT) is 2, based on the only two trials that gave the necessary data. The benefit is likely to be greater the more time zones are crossed, and less for westward flights. The timing of the melatonin dose is important: if it is taken at the wrong time, early in the day, it is liable to cause sleepiness and delay adaptation to local time. The incidence of other side effects is low. Case reports suggest that people with epilepsy, and patients taking warfarin may come to harm from melatonin. Authors' conclusions Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be. The pharmacology and toxicology of melatonin needs systematic study, and routine pharmaceutical quality control of melatonin products must be established. The effects of melatonin in people with epilepsy, and a possible interaction with warfarin, need investigation. Plain language summary Melatonin for the prevention and treatment of jet lag Jet lag commonly affects air travellers who cross several time zones. It results from the body's internal rhythms being out of step with the day‐night cycle at the destination. Melatonin is a pineal hormone that plays a central part in regulating bodily rhythms and has been used as a drug to re‐align them with the outside world. Melatonin is remarkably effective in preventing or reducing jet lag, and occasional short‐term use appears to be safe. It should be recommended to adult travellers flying across five or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. Travellers crossing 2‐4 time zones can also use it if need be.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.758Z" }, { "id": "b3dcec89-76e5-48b6-a218-62a4e585c0c9", "pmid": "", "title": "Quinine for muscle cramps", "imported": false, "abstract": "Abstract - Background Muscle cramps can occur anywhere and for many reasons. Quinine has been used to treat cramps of all causes. However, controversy continues about its efficacy and safety. This review was first published in 2010 and searches were updated in 2014. Objectives To assess the efficacy and safety of quinine‐based agents in treating muscle cramps. Search methods On 27 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE. We searched reference lists of articles up to 2014. We also searched for ongoing trials in November 2014. Selection criteria Randomised controlled trials of people of all ages with muscle cramps in any location and of any cause, treated with quinine or its derivatives. Data collection and analysis Three review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We contacted study authors for additional information. For comparisons including more than one trial, we assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Main results We identified 23 trials with a total of 1586 participants. Fifty‐eight per cent of these participants were from five unpublished studies. Quinine was compared to placebo (20 trials, n = 1140), vitamin E (four trials, n = 543), a quinine‐vitamin E combination (three trials, n = 510), a quinine‐theophylline combination (one trial, n = 77), and xylocaine injections into the gastrocnemius muscle (one trial, n = 24). The most commonly used quinine dosage was 300 mg/day (range 200 to 500 mg). We found no new trials for inclusion when searches were updated in 2014. The risk of bias in the trials varied considerably. All 23 trials claimed to be randomised, but only a minority described randomisation and allocation concealment adequately. Compared to placebo, quinine significantly reduced cramp number over two weeks by 28%, cramp intensity by 10%, and cramp days by 20%. Cramp duration was not significantly affected. A significantly greater number of people suffered minor adverse events on quinine than placebo (risk difference (RD) 3%, 95% confidence interval (CI) 0% to 6%), mainly gastrointestinal symptoms. Overdoses of quinine have been reported elsewhere to cause potentially fatal adverse effects, but in the included trials there was no significant difference in major adverse events compared with placebo (RD 0%, 95% CI ‐1% to 2%). One participant suffered from thrombocytopenia (0.12% risk) on quinine. A quinine‐vitamin E combination, vitamin E alone, and xylocaine injections into gastrocnemius were not significantly different to quinine across all outcomes, including adverse effects. Based on a single trial comparison, quinine alone was significantly less effective than a quinine‐theophylline combination but with no significant differences in adverse events. Authors' conclusions There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that with use up to 60 days, the incidence of serious adverse events is not significantly greater than for placebo in the identified trials, but because serious adverse events can be rarely fatal, in some countries prescription of quinine is severely restricted. Evidence from single trials suggests that theophylline combined with quinine improves cramps more than quinine alone, and the effects of xylocaine injections into gastrocnemius are not significantly different to quinine across all outcomes. Low or moderate quality evidence shows no significant difference between quinine and vitamin E or quinine and quinine‐vitamin E mixture. Further research into these alternatives, as well other pharmacological and non‐pharmacological treatments, is thus warranted. There is no evidence to judge optimal dosage or duration of quinine treatment. Further studies using different dosages and measurement of serum quinine levels will allow a therapeutic range to be defined for muscle cramp. Because serious adverse events are not common, large population studies are required to more accurately inform incidence. Longer lengths of follow‐up in future trials will help determine the duration of action following cessation of quinine as well as long‐term adverse events. The search for new therapies, pharmacological and nonpharmacological, should continue and further trials should compare vitamin E, quinine‐vitamin E combination, and quinine‐theophylline mixture with quinine. Plain language summary Quinine for muscle cramps Review question We reviewed the evidence about the effect of quinine on muscle cramps. Background Muscle cramps can occur anywhere and in anyone; however, leg cramps are especially common in older people. Quinine is a medicine which has been used to treat cramps for many years. There is conflicting evidence for its ability to reduce cramps. Quinine can cause serious, even fatal adverse events, especially in overdosage. Study characteristics This review includes 23 trials, with 1586 participants. The trials compared quinine or quinine‐based medicines against inactive treatment (placebo) or other active treatments. We found no new studies when we searched the medical literature again and updated the review in 2014. Key results and quality of the evidence The risk of bias in the included trials varied considerably. All 23 trials claimed to be randomised, but many failed to clearly describe how participants were assigned to treatments. There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that there are more minor adverse events with quinine compared to placebo but no increase in major adverse events. However, there are reliable reports from other sources that an overdose of quinine can cause serious harm including death. Low or moderate quality evidence shows there is no significant difference when comparing quinine to vitamin E or to a quinine‐vitamin E mixture. There is evidence from one trial that theophylline combined with quinine improves cramps more than quinine alone. In a single trial there was no significant difference when comparing quinine to xylocaine injections. More research is needed to clarify the best dose and duration of treatment, as well as alternatives to quinine for cramps. The evidence is current to October 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El‐Tawil, S; Al Musa, T; Valli, H; Lunn, MPT; Brassington, R; El‐Tawil, T; Weber, M", "articleTypes": [], "doi": "10.1002/14651858.CD005044.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "b3ff2896-00f0-4284-ae1e-3f3d70ebb80f", "pmid": "", "title": "Topical anaesthetics for pain control during repair of dermal laceration", "imported": false, "abstract": "Abstract - Background Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine‐free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017. Objectives To assess whether benefits of non‐invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single‐component or multi‐component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine. Search methods For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta‐registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010. Selection criteria We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence. Main results The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self‐reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine‐phenylephrine (PP) was higher than the mean self‐reported VAS (0 to 100 mm) score for topical tetracaine‐epinephrine‐cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine‐free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self‐limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine‐based or cocaine‐free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Authors' conclusions We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously. Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non‐invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine‐based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Plain language summary Local anaesthesia (numbing medicine) that is directly applied to the skin can provide pain control for repair of skin lacerations Background : Pain control during suturing of torn skin is generally achieved by injecting medication into the skin (infiltration) to numb the area. This injection itself may cause pain, but topical anaesthetics are applied directly to the skin and are painless to administer. Cocaine was one of the first anaesthetics to be successfully applied topically. Concerns over adverse effects of cocaine, its potential misuse and the administrative burden of dispensing a controlled substance led to the development of cocaine‐free topical anaesthetics. Multiple cocaine‐free topical anaesthetics have been found to provide effective anaesthesia for repair of dermal lacerations. Study characteristics : The evidence is current to December 2016. We included in this review 25 randomized controlled trials involving 3278 participants. Studies included both adults and children. Fifteen of the included trials used self‐reporting of pain intensity by trial participants to determine the effectiveness of local anaesthetics. Key results : Study results suggest that directly applying local anaesthetics to the skin is an effective, non‐invasive way of providing pain control during suturing or stapling of skin lacerations. Study findings on the efficacy of individual topical anaesthetics were limited by study design, and data on the efficacy of each topical agent were obtained mostly from single trials. Researchers reported no serious side effects following the use of cocaine‐containing or cocaine‐free topical anaesthetics. The overall broadly comparable effectiveness of cocaine‐free topical anaesthetics for skin laceration repair brings into question the necessity to include cocaine as a component of local anaesthetic solutions. The small number of trials in each comparison group and the range of outcome measures assessed prevented pooling and quantitative analysis of data for all but the single outcome of pain intensity. Additional studies are necessary to directly compare the effectiveness of different formulations of topical anaesthetics. Our review was limited to pain control for repair of superficial lacerations, and our results might not be generalizable to deeper lacerations or more complex procedures performed on intact skin. Further research is needed to strengthen the evidence and to overcome the weakness of the included studies. Quality of the evidence : The overall quality of the evidence was low owing to limitations in study design, ways that studies were carried out (implementation), imprecision of results and high probability of selective data reporting. Most of the trials that compared infiltrated and topical anaesthetics were at high risk of bias, and this was likely to influence measured effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tayeb, BO, Eidelman, A, Eidelman, CL, McNicol, ED, Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD005364.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.756Z" }, { "id": "b412f376-d5ac-4738-8d52-2df1e12b4b2e", "pmid": "", "title": "Complementary therapies for acne vulgaris", "imported": false, "abstract": "Abstract - Background Acne is a chronic skin disease characterised by inflamed spots and blackheads on the face, neck, back, and chest. Cysts and scarring can also occur, especially in more severe disease. People with acne often turn to complementary and alternative medicine (CAM), such as herbal medicine, acupuncture, and dietary modifications, because of their concerns about the adverse effects of conventional medicines. However, evidence for CAM therapies has not been systematically assessed. Objectives To assess the effects and safety of any complementary therapies in people with acne vulgaris. Search methods We searched the following databases from inception up to 22 January 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 , Issue 1 ), MEDLINE (from 1946), Embase (from 1974), PsycINFO (from 1806), AMED (from 1985), CINAHL (from 1981), Scopus (from 1966), and a number of other databases listed in the Methods section of the review. The Cochrane CAM Field Specialised Register was searched up to May 2014. We also searched five trials registers and checked the reference lists of articles for further references to relevant trials. Selection criteria We included parallel‐group randomised controlled trials (or the first phase data of randomised cross‐over trials) of any kind of CAM, compared with no treatment, placebo, or other active therapies, in people with a diagnosis of acne vulgaris. Data collection and analysis Three authors collected data from each included trial and evaluated the methodological quality independently. They resolved disagreements by discussion and, as needed, arbitration by another author. Main results We included 35 studies, with a total of 3227 participants. We evaluated the majority as having unclear risk of selection, attrition, reporting, detection, and other biases. Because of the clinical heterogeneity between trials and the incomplete data reporting, we could only include four trials in two meta‐analyses, with two trials in each meta‐analysis. The categories of CAM included herbal medicine, acupuncture, cupping therapy, diet, purified bee venom (PBV), and tea tree oil. A pharmaceutical company funded one trial; the other trials did not report their funding sources. Our main primary outcome was 'Improvement of clinical signs assessed through skin lesion counts', which we have reported as 'Change in inflammatory and non‐inflammatory lesion counts', 'Change of total skin lesion counts', 'Skin lesion scores', and 'Change of acne severity score'. For 'Change in inflammatory and non‐inflammatory lesion counts', we combined 2 studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD) at 12 weeks and found no clear evidence of a difference between the groups in change in non‐inflammatory lesion counts (mean difference (MD) ‐3.89, 95% confidence interval (CI) ‐10.07 to 2.29, P = 0.10, 75 participants, 2 trials, low quality of evidence). However, although data from 1 of these 2 trials showed benefit of LGLD for reducing inflammatory lesions (MD ‐7.60, 95% CI ‐13.52 to ‐1.68, 43 participants, 1 trial) and total skin lesion counts (MD ‐8.10, 95% CI ‐14.89 to ‐1.31, 43 participants, 1 trial) for people with acne vulgaris, data regarding inflammatory and total lesion counts from the other study were incomplete and unusable in synthesis. Data from a single trial showed potential benefit of tea tree oil compared with placebo in improving total skin lesion counts (MD ‐7.53, 95% CI ‐10.40 to ‐4.66, 60 participants, 1 trial, low quality of evidence) and acne severity scores (MD ‐5.75, 95% CI ‐9.51 to ‐1.99, 60 participants, 1 trial). Another trial showed pollen bee venom to be better than control in reducing numbers of skin lesions (MD ‐1.17, 95% CI ‐2.06 to ‐0.28, 12 participants, 1 trial). Results from the other 31 trials showed inconsistent effects in terms of whether acupuncture, herbal medicine, or wet‐cupping therapy were superior to controls in increasing remission or reducing skin lesions. Twenty‐six of the 35 included studies reported adverse effects; they did not report any severe adverse events, but specific included trials reported mild adverse effects from herbal medicines, wet‐cupping therapy, and tea tree oil gel. Thirty trials measured two of our secondary outcomes, which we combined and expressed as 'Number of participants with remission'. We were able to combine 2 studies (low quality of evidence), which compared Ziyin Qinggan Xiaocuo Granule and the antibiotic, minocycline (100 mg daily) (worst case = risk ratio (RR) 0.49, 95% CI 0.09 to 2.53, 2 trials, 206 participants at 4 weeks; best case = RR 2.82, 95% CI 0.82 to 9.06, 2 trials, 206 participants at 4 weeks), but there was no clear evidence of a difference between the groups. None of the included studies assessed 'Psychosocial function'. Two studies assessed 'Quality of life', and significant differences in favour of the complementary therapy were found in both of them on 'feelings of self‐worth' (MD 1.51, 95% CI 0.88 to 2.14, P < 0.00001, 1 trial, 70 participants; MD 1.26, 95% CI 0.20 to 2.32, 1 trial, 46 participants) and emotional functionality (MD 2.20, 95% CI 1.75 to 2.65, P < 0.00001, 1 trial, 70 participants; MD 0.93, 95% CI 0.17 to 1.69, 1 trial, 46 participants). Because of limitations and concerns about the quality of the included studies, we could not draw a robust conclusion for consistency, size, and direction of outcome effects in this review. Authors' conclusions There is some low‐quality evidence from single trials that LGLD, tea tree oil, and bee venom may reduce total skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs, such as herbal medicine, acupuncture, or wet‐cupping therapy, for the treatment of this condition. There is a potential for adverse effects from herbal medicines; however, future studies need to assess the safety of all of these CAM therapies. Methodological and reporting quality limitations in the included studies weakened any evidence. Future studies should be designed to ensure low risk of bias and meet current reporting standards for clinical trials. Plain language summary Complementary therapies for acne vulgaris Background Acne is a chronic skin disease, which causes spots to occur simultaneously on several areas of the body, including the face, neck, back, and chest. Besides the current commonly used treatments, complementary and alternative medicines (CAM) are of increasing interest to people who often use them in addition to conventional treatments as additive or single therapies to treat acne. The review question Can any complementary therapies improve the clinical symptoms of acne vulgaris? Study characteristics We searched relevant databases and trials registers up to 22 January 2014. We identified 35 randomised controlled trials, with 3227 participants, which used 6 kinds of CAM (herbal medicine, acupuncture, wet cupping, diet, purified bee venom, and tea tree oil). A pharmaceutical company funded one trial; the other trials did not report their funding sources. Key results For our primary outcome, we combined two studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD), but found no clear evidence of a difference between the 2 groups at 12 weeks for a change in non‐inflammatory lesion counts. Only one of these two trials provided usable data to show potential benefit of LGLD for reducing inflammatory and total skin lesion counts. Tea tree oil and pollen bee venom were found to reduce total skin lesion counts in single trials, respectively. The remaining 31 included trials gave mixed results about whether complementary therapies might reduce the total number of skin lesion counts. Twenty‐six trials reported adverse events. The herbal medicine group found some mild side‐effects, such as nausea, diarrhoea, and stomach upset. The acupuncture group found some itch or redness and pain following needle insertion. Participants who used tea tree oil reported itchiness, dryness, and flaking of the skin. None of the trials reported severe adverse effects. For our secondary outcome, there was no clear evidence of a difference in the number of participants with remission between Ziyin Qinggan Xiaocuo Granule and minocycline according to a meta‐analysis of two studies. Quality of the evidence There is some low‐quality evidence from single trials that a low‐glycaemic‐load diet, tea tree oil, and bee venom may reduce skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs. Methodological and reporting quality limitations in the included studies weakened any evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Cao, H; Yang, G; Wang, Y; Liu, JP; Smith, CA; Luo, H; Liu, Y", "articleTypes": [], "doi": "10.1002/14651858.CD009436.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "b4371b0f-1087-40f4-9bd3-54492e26a4e4", "pmid": "", "title": "Fish oil for kidney transplant recipients", "imported": false, "abstract": "Abstract - Background Calcineurin inhibitors used in kidney transplantation for immunosuppression have adverse effects that may contribute to nephrotoxicity and increased cardiovascular risk profile. Fish oils are rich in very long chain omega‐3 fatty acids, which may reduce nephrotoxicity by improving endothelial function and reduce rejection rates through their immuno‐modulatory effects. They may also modify the cardiovascular risk profile. Hence, fish oils may potentially prolong graft survival and reduce cardiovascular mortality. Objectives This review aimed to look at the benefits and harms of fish oil treatment in ameliorating the kidney and cardiovascular adverse effects of CNI‐based immunosuppressive therapy in kidney transplant recipients. Search methods We searched the Cochrane Kidney and Transplant Specialised Register (up to 17 March 2016) through contact with the Information Specialist using search terms relevant to this review. Selection criteria All randomised controlled trials (RCTs) and quasi‐RCTs of fish oils in kidney transplant recipients on a calcineurin inhibitor‐based immunosuppressive regimen. RCTs of fish oil versus statins were included. Data collection and analysis Data was extracted and the quality of studies assessed by two authors, with differences resolved by discussion with a third independent author. Dichotomous outcomes were reported as risk ratio (RR) and continuous outcome measures were reported as the mean difference (MD) with 95% confidence intervals using the random effects model. Heterogeneity was assessed using a Chi 2 test on n‐1 degrees of freedom and the I 2 statistic. Data not suitable for pooling were tabulated and described. Main results Fifteen studies (733 patients) were suitable for analysis. All studies were small and had variable methodology. Fish oil did not significantly affect patient or graft survival, acute rejection rates, or calcineurin inhibitor toxicity when compared to placebo. Overall SCr was significantly lower in the fish oil group compared to placebo (5 studies, 237 participants: MD ‐30.63 µmol/L, 95% CI ‐59.74 to ‐1.53; I 2 = 88%). In the subgroup analysis, this was only significant in the long‐course (six months or more) group (4 studies, 157 participants: MD ‐37.41 µmol/L, 95% CI ‐69.89 to ‐4.94; I 2 = 82%). Fish oil treatment was associated with a lower diastolic blood pressure (4 studies, 200 participants: MD ‐4.53 mm Hg, 95% CI ‐7.60 to ‐1.45) compared to placebo. Patients receiving fish oil for more than six months had a modest increase in HDL (5 studies, 178 participants: MD 0.12 mmol/L, 95% CI 0.03 to 0.21; I 2 = 47%) compared to placebo. Fish oil effects on lipids were not significantly different from low‐dose statins. There was insufficient data to analyse cardiovascular outcomes. Fishy aftertaste and gastrointestinal upset were common but did not result in significant patient drop‐out. Authors' conclusions There is insufficient evidence from currently available RCTs to recommend fish oil therapy to improve kidney function, rejection rates, patient survival or graft survival. The improvements in HDL cholesterol and diastolic blood pressure were too modest to recommend routine use. To determine a benefit in clinical outcomes, future RCTs will need to be adequately powered with these outcomes in mind. Plain language summary Fish oil for kidney transplant recipients This review set out to assess any benefit or harm in using fish oil to reduce the risk of kidney damage and heart disease in people who have had a kidney transplant and are receiving standard drugs to prevent rejection. Information from 15 studies was used and showed that fish oils provide a slight improvement in HDL cholesterol and diastolic blood pressure. These studies did not provide enough information on the differences in the risk of death, heart disease, kidney transplant rejection or kidney function between patients receiving fish oils and those receiving placebo. There appeared to be no harmful effects of taking fish oil. The benefits of taking fish oil after a kidney transplant are a mild improvement in some heart disease risk factors. There was not enough information to show any benefit in preventing heart disease or reduction in kidney function. Larger, better studies are needed before regular use of fish oil can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lim, AKH; Manley, KJ; Roberts, MA; Fraenkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD005282.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "b45fa4a3-7eff-40dc-9506-e19af0c50cb4", "pmid": "", "title": "Interventions for fatigue management after traumatic brain injury", "imported": false, "abstract": "Abstract - Rationale Despite the high prevalence and medico‐social significance of fatigue in post‐traumatic brain injury (post‐TBI) populations, there are no validated management strategies to control this condition. It is timely to provide clinicians and patients with the best available evidence of the efficacy of current pharmacological and non‐pharmacological fatigue management practices. Objectives To assess the effectiveness of pharmacological and non‐pharmacological interventions for fatigue in people who have experienced a TBI. Search methods For this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO. We also searched relevant conference proceedings, and we searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for ongoing trials. The most recent searches were conducted on 12 February 2025. Eligibility criteria Eligible study designs were randomised controlled trials (RCTs) and randomised cross‐over trials (for pharmacological interventions only). Studies with participants of all ages (children and adults) with a TBI (of any severity) were included, where at least 75% of participants had a TBI. Any type of treatment for fatigue was considered. Four categories of interventions were prioritised: pharmacological, cognitive, stimulation/biofeedback, and psychoeducational. These interventions were compared to placebo groups, no treatment, or groups receiving other interventions. Outcomes The critical outcome was fatigue. Important outcomes include fatigue‐related outcomes of psychological functioning (depression and anxiety), cognitive functioning (processing speed), general quality of life, and daytime sleepiness. Risk of bias We assessed risk of bias using the original Cochrane risk of bias tool for RCTs (RoB 1). Synthesis methods We synthesised the results for each outcome by meta‐analysis where possible using mean differences (MDs) and standardised mean differences (SMDs) and a fixed‐effect model. Where meta‐analysis was not possible due to the nature of the data , we narratively reported the results. We used GRADE to assess the certainty of evidence for each outcome . We performed all statistical analyses using RevMan and presented results with 95% confidence intervals (CI). Included studies We included a total of 3518 trial participants (at baseline) across 40 studies, described in 49 publications. The 40 included studies are grouped by type of intervention. There were seven categories of interventions: pharmacological, cognitive, physical activity, stimulation/biofeedback, health visits, psychoeducational, and a final category for trials with multiple interventions (multi‐interventions). Four published studies identified in the most recent search are awaiting classification. Synthesis of results Pharmacological interventions (melatonin; recombinant human growth hormones (rhGH); psychostimulants; atorvastatin; monoaminergic stabiliser (‐)‐OSU6162) likely reduce fatigue slightly (SMD ‐0.25, 95% CI ‐0.44 to ‐0.06; 8 studies, 395 participants; moderate‐certainty evidence). Cognitive interventions (cognitive rehabilitation; technology‐enhanced training; functional skills training) may reduce fatigue slightly (MD ‐0.32, 95% CI ‐0.59 to ‐0.06; 6 studies, 222 participants; low‐certainty evidence). Stimulation/biofeedback interventions (light therapy; electrical/magnetic stimulation; acupressure) may reduce fatigue slightly, but the evidence is very uncertain (SMD ‐0.23, 95% CI ‐0.47 to 0.01; 8 studies, 295 participants; very low‐certainty evidence). Psychoeducation interventions (cognitive behavioural therapy; acceptance and commitment therapy; individualised occupational therapy; novel therapies) may reduce fatigue, but the evidence is very uncertain (SMD ‐0.55, 95% CI ‐0.74 to ‐0.35; 8 studies, 474 participants; very low‐certainty evidence). There may be little to no difference in psychological functioning (depression), psychological functioning (anxiety), cognitive functioning (processing speed), or daytime sleepiness. However, these results are very uncertain. Authors' conclusions There is very limited and moderate to very low‐certainty evidence from RCTs about treatments to reduce fatigue after TBI. Despite the prevalence of fatigue post‐TBI, we lack high‐quality studies that evaluate interventions to improve this disabling, but potentially treatable, symptom. There is a need for considerable further work to identify an effective treatment for fatigue in people with TBI. Funding This Cochrane review had no dedicated funding. Registration Protocol available via DOI: 10.1002/14651858.CD006448 Plain language summary Which treatments are effective for fatigue after traumatic brain injury? Key messages Medications (such as melatonin, growth hormones, brain stimulants, atorvastatin, or dopamine and serotonin regulators) likely reduce fatigue after a traumatic brain injury. Other treatments, such as talking therapies, sensory stimulation, and counselling, may reduce fatigue after a traumatic brain injury. Future studies should involve more people, including children and young people. They should investigate different kinds of treatments in different settings, and the severity and causes of traumatic brain injury. What is traumatic brain injury? Traumatic brain injury is damage to the brain following a bump or blow to the head. The injury might result from a traffic accident, fall, assault, sports injury, or an explosion. People with traumatic brain injury might experience headaches, become forgetful, and have difficulties sleeping and moving. They may also experience fatigue, which is defined as an overwhelming sense of tiredness unrelated to previous effort, which does not usually improve with rest. Fatigue makes it hard for people to concentrate and perform everyday activities, which affects their quality of life. How is fatigue after traumatic brain injury treated? Treatments for fatigue vary because the causes and symptoms of fatigue may be very different. Treatments include medication to stimulate or protect the brain, and hormones and antidepressants to help people sleep and improve their mood. Treatments that don’t involve medication include counselling, education, behavioural therapy and exercise. What did we want to find out? We mainly wanted to find out if different treatments reduce fatigue in people with traumatic brain injury. We were also interested in the effect of the treatments on people’s mood, memory or attention, quality of life, and sleepiness. What did we do? We searched for studies that randomly assigned people to receive treatment for fatigue, usual care (that is, no specific treatment for fatigue), or a placebo (dummy) treatment. We also looked at studies that compared different treatments. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 40 studies with 3518 adults and children living with traumatic brain injury. The studies took place in 12, mainly high‐income, countries in Europe, North America, and Oceania. They were conducted in different settings, including medical centres, rehabilitation clinics, military bases, clinical research facilities, and hospitals. Main results Fatigue Medications likely reduce fatigue after a traumatic brain injury (8 studies, 395 people). Medications included melatonin, growth hormones, psychostimulants, statins, and dopamine regulators. Other treatments (without medication) may reduce fatigue after a traumatic brain injury (31 studies, 2203 people). Treatments included cognitive behavioural therapy, technical‐enhanced training, functional skills training, sensory stimulation, electrical/magnetic stimulation, acupressure, counselling, acceptance and commitment therapy, individualised occupational therapy, cognitive symptom management rehabilitation therapy, aerobic exercise, prescribed light exercise, location of exercise, vestibular rehabilitation, health visits, and multi‐interventional therapies. For treatments with medication, there were some reported adverse (unwanted or harmful) events that are specific to particular studies. For other treatments (without medication), adverse events were often not reported. Fatigue‐related symptoms Medications may make little or no difference to depression, anxiety, processing speed, quality of life, and daytime sleepiness (21 studies, 1016 people). Of the treatments without medication, only cognitive therapy showed any noticeable effect; it may reduce anxiety (2 studies, 57 people). What are the limitations of the evidence? We have limited confidence in the evidence due to the small numbers of people in the different studies, and the variation in settings, treatments, ages of participants, and the severity and causes of traumatic brain injury. How up to date is this evidence? We searched for studies up to 12 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Senior, HE; Leung, JH; Meehan, B; Leao, S; Jordan, V; Barker-Collo, S; Crummey, S; Purdy, SC", "articleTypes": [], "doi": "10.1002/14651858.CD006448.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "b467e828-ccbc-419b-b594-cfa78f2470df", "pmid": "", "title": "Maternal Characteristics Associated With Child Growth and Adiposity. Search for Nutrigenomic Biomarkers in Peripheral Blood", "imported": false, "abstract": "The goal of this observational study is to investigate the concentrations of leptin, insulin, liver expressed antimicrobial peptide 2 (LEAP2), and cortisol in plasma and breast milk and their relationship with eating behavior, growth, adiposity and with the levels of these hormones in infants, comparing mothers with normal weight and with pre-pregnancy overweight/obesity. The main question[s] it aims to answer are:", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "b477b5f0-fef3-4c3a-bbe3-1faea7113ea1", "pmid": "", "title": "Taste Physiology in Healthy, Normal-weight Volunteers", "imported": false, "abstract": "Taste physiology describes five main taste qualities in humans: sweet, sour, salty, umami and bitter. The receptors found on the tongue are also found in the entire gut. The correlation of stimulation of these gut receptors and brain activity has not yet been examined. The objectives are to investigate the effect of different taste substances on i) regional brain activity and ii) satiation peptide release.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "b4a272c3-4e77-422f-b1d1-70f83e86c587", "pmid": "", "title": "Sucrose analgesia for venepuncture in neonates", "imported": false, "abstract": "Abstract - Rationale Sucrose is, in general, safe and effective for analgesia during venepuncture in hospitalised neonates. However, there is a lack of evidence on its analgesic effects. Objectives To evaluate the benefits and harms of orally administered sucrose for pain relief from venepuncture in preterm and term neonates compared to no intervention, standard care, and other types of analgesic interventions. Search methods We searched CENTRAL, MEDLINE, Ovid Embase, and trial registries in July 2025, and the China National Knowledge Infrastructure, VIP Chinese Science and Technology Periodicals, and Wanfang Data in August 2024. We checked reference lists of included studies and topic‐related systematic reviews. Eligibility criteria We included randomised controlled trials (RCTs), including cross‐over and cluster‐RCTs, that evaluated the effects of sucrose analgesia in neonates (including term and preterm infants) up to 44 weeks' postmenstrual age undergoing venepuncture. We excluded quasi‐RCTs and studies reported only as conference abstracts. We included studies administering sucrose with or without non‐nutritive sucking (NNS) before, at the time of, or after venepuncture. Sucrose could be of any concentration, volume, or dose. Sucrose was compared to: no intervention, water, or standard care; skin‐to‐skin care; breastfeeding; feeding; NNS alone (e.g. pacifier); glucose; positioning; or topical anaesthetics. Outcomes Outcomes of interest were pain intensity score, as measured by validated pain assessment scales, and adverse events. Risk of bias We used the Cochrane risk of bias tool (RoB 1). Synthesis methods We synthesised results for each outcome using meta‐analysis where possible. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous data (presence or absence of pain). We calculated the standardised mean difference (SMD) or mean difference (MD) for pain intensity scores (continuous outcome), each with its 95% CI. We used a fixed‐effect model to combine data and quantified the impact of heterogeneity using the I² statistic. Where these methods were not feasible due to the nature of the data, we synthesised the results narratively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included a total of 29 studies, accounting for 2764 term and preterm neonates. There was a large variation in sucrose dose and concentration (from 0.1 mL/kg to 0.5 mL/kg or a set volume from 0.1 mL to 2 mL) as well as mode of administration (e.g. oral syringe, pacifier, dropper, in combination with a pacifier). Most of the studies compared sucrose to no intervention, water, or standard care (n = 17). Other comparisons include non‐nutritive sucking, skin‐to‐skin care, breastfeeding, expressed breast milk, and other sweet solutions. Synthesis of results Adverse events (e.g. gagging, apnoea) were not reported for any comparison. Sucrose (with or without NNS) versus no intervention, water, or standard care Sucrose with or without NNS probably reduces pain intensity scores during and 30 seconds after venepuncture compared to no intervention (SMD −0.82, 95% CI −1.02 to −0.63; 7 studies, 477 participants; moderate‐certainty evidence). Sucrose with NNS reduces pain intensity scores one minute after venepuncture compared to no intervention (MD −9.15, 95% CI −9.91 to −8.39; 1 study, 100 participants; high‐certainty evidence). The evidence is uncertain about the effect of sucrose without NNS on pain intensity scores two minutes after venepuncture compared to no intervention (SMD −0.99, 95% CI −1.31 to −0.68; 3 studies, 186 participants; very low‐certainty evidence). Sucrose (with or without NNS) versus skin‐to‐skin care Sucrose without NNS may make little to no difference to pain scores during venepuncture when compared to skin‐to‐skin care (MD 1.49, 95% CI 0.86 to 2.12; 2 studies, 208 participants; low‐certainty evidence). Pain scores after 30 seconds, one minute, and two minutes were not reported. Sucrose (with or without NNS) versus breastfeeding Sucrose probably reduces pain during venepuncture compared to breastfeeding, as measured with the Neonatal Facial Coding System (where 0 = no pain, > 0 = pain) (RR 1.38, 95% CI 1.01 to 1.88; 1 study, 103 participants; moderate‐certainty evidence). Sucrose may result in little to no difference in pain compared to breastfeeding two minutes after venepuncture (RR 1.06, 95% CI 0.94 to 1.19; 1 study, 104 participants; low‐certainty evidence). Pain scores after 30 seconds and one minute were not reported. Sucrose (with or without NNS) versus NNS Sucrose with NNS likely reduces pain during venepuncture compared to NNS (SMD −1.52, 95% CI −1.92 to −1.12; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS may not reduce pain intensity scores during venepuncture compared to NNS (MD 1.37, 95% CI 0.57 to 2.17; 2 studies, 133 participants; low‐certainty evidence). Sucrose with NNS may reduce pain intensity scores one minute after venepuncture compared to NNS (MD −5.81, 95% CI −6.30 to −5.32; 2 studies, 200 participants; low‐certainty evidence). Sucrose with NNS probably reduces pain intensity two minutes after venepuncture compared to NNS alone (SMD −1.30, 95% CI −1.71 to −0.89; 2 studies, 136 participants; moderate‐certainty evidence). Sucrose without NNS probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS (MD 0.47, 95% CI −0.14 to 1.08; 1 study, 56 participants; moderate‐certainty evidence). We downgraded the certainty of the evidence in several comparisons, mostly due to unclear or high risk of selection, performance, detection, and reporting bias. High heterogeneity was also detected. Authors' conclusions Current evidence suggests sucrose probably reduces pain scores during and shortly after venepuncture compared to no intervention, water, or standard care. The evidence is very uncertain regarding the effects of sucrose compared to skin‐to‐skin care for analgesia during venepuncture. Compared to breastfeeding, sucrose probably results in a reduction of pain scores during venepuncture, but may result in little difference in pain scores two minutes after venepuncture. The evidence suggests sucrose with NNS probably reduces pain scores during and following venepuncture compared to NNS alone. Sucrose alone probably results in little to no difference in pain intensity scores two minutes after venepuncture compared to NNS. Funding This review had no dedicated funding. Registration Protocol available via doi/10.1002/14651858.CD015221 Plain language summary Does giving newborns sugar water during needle procedures reduce their pain? Key messages Newborn babies given sucrose (sugar water) when undergoing a needle procedure probably have less pain during and shortly after the procedure than babies given nothing, water, or standard comfort measures. Sucrose seems to reduce pain more than pacifiers. We do not have good evidence about the effect of sucrose compared to skin‐to‐skin care. No studies reported on harmful side effects, such as gagging or apnoea (a temporary pause in breathing). What is sucrose analgesia (pain relief)? Sucrose is table sugar. When mixed with water, and in very small amounts, it can be used for pain relief in newborn babies. Sucrose is dropped on a baby's tongue about two minutes before and/or immediately before venepuncture, when a needle is put into a vein to take blood or give treatment. Why is pain relief important for newborn babies who are in hospital? Hospitalised preterm babies (i.e. born early) and term babies (i.e. born at the normal time) are exposed to many painful procedures to give them medicine and to diagnose problems. Pain has many consequences for newborn babies. It can contribute to poor physical growth and affect brain development. Therefore, it is important to reduce babies' experience of pain as much as possible to ensure health as they grow. What did we want to find out? We wanted to find out how well sucrose worked to relieve pain in newborn babies during and shortly after needle punctures. We wanted to know how sucrose compared to other pain relief methods such as pacifier sucking, breastfeeding, or being held next to a mother or father's skin (skin‐to‐skin care). We also wanted to find out if sucrose caused negative effects. What did we do? We searched for studies that investigated the pain‐relief effects of sucrose compared to other methods (e.g. breastfeeding, pacifiers, holding). We summarised the results and rated our confidence in the evidence based on factors such as the number of infants treated and the quality of the methods used in the studies. What did we find? We found 29 studies that included 2764 newborn babies. The studies used different doses of sucrose and gave the sucrose to the babies in different ways. The studies were conducted worldwide. Most were carried out in Asia, with additional studies from Europe, North America, and South America. All the studies were randomised controlled trials, in which infants were assigned randomly to two or more treatment groups. This is the best way to ensure that the infant groups are similar, and that investigators and parents don’t know who is in which group. None of the studies were supported by the pharmaceutical industry. Main results Sucrose probably reduces babies' pain during and shortly after (30 seconds to 1 minute) the needle insertion compared to no pain relief (such as water). Sucrose may make little to no difference to pain during the procedure compared to skin‐to‐skin care. Sucrose probably reduces pain during the needle insertion compared to breastfeeding. Sucrose (with pacifier sucking) likely reduces pain during and shortly after (30 seconds to 2 minutes) the needle insertion compared to pacifier sucking alone. No study reported on harmful effects for any of our comparisons of interest. What are the limitations of the evidence? Sucrose versus no intervention or water We are moderately confident that sucrose probably reduces pain compared to no intervention. However, it is possible that people in the studies were aware of which treatment babies were receiving, and the studies involved small numbers of babies. Sucrose versus skin‐to‐skin care We are not confident that sucrose reduces pain more than skin‐to‐skin care because the two studies reported very different results. Further research is likely to change these results. Sucrose versus breastfeeding We are moderately confident that sucrose probably reduces pain more than breastfeeding. However, the study did not clearly report details of how it was conducted. Sucrose versus pacifier We are moderately confident that sucrose with a pacifier probably reduces pain more than pacifiers alone. The studies differed in how sucrose was given, including the amount of sucrose, how it was administered, and whether it was given with or without a pacifier. How current is this evidence? This evidence is current to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Bueno, M, Candido, L, Hu, J, Fiander, M, Cracknell, J, Xu, E, Kang, J, Yamada, J", "articleTypes": [], "doi": "10.1002/14651858.CD015221.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.732Z" }, { "id": "b4aac5e8-9b42-439a-96b6-27f460a21e48", "pmid": "", "title": "Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non‐hospitalised term infants", "imported": false, "abstract": "Abstract - Background Many women express concern about their ability to produce enough milk, and insufficient milk is frequently cited as the reason for supplementation and early termination of breastfeeding. When addressing this concern, it is important first to consider the influence of maternal and neonatal health, infant suck, proper latch, and feeding frequency on milk production, and that steps be taken to correct or compensate for any contributing issues. Oral galactagogues are substances that stimulate milk production. They may be pharmacological or non‐pharmacological (natural). Natural galactagogues are usually botanical or other food agents. The choice between pharmacological or natural galactagogues is often influenced by familiarity and local customs. Evidence for the possible benefits and harms of galactagogues is important for making an informed decision on their use. Objectives To assess the effect of oral galactagogues for increasing milk production in non‐hospitalised breastfeeding mother‐term infant pairs. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov , the World Health Organization (WHO) International Clinical Trials Registry Platform ( ICTRP ), Health Research and Development Network ‐ Phillippines ( HERDIN ), Natural Products Alert ( Napralert ), the personal reference collection of author LM, and reference lists of retrieved studies (4 November 2019). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs (including published abstracts) comparing oral galactagogues with placebo, no treatment, or another oral galactagogue in mothers breastfeeding healthy term infants. We also included cluster‐randomised trials but excluded cross‐over trials. Data collection and analysis We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two to four review authors independently selected the studies, assessed the risk of bias, extracted data for analysis and checked accuracy. Where necessary, we contacted the study authors for clarification. Main results Forty‐one RCTs involving 3005 mothers and 3006 infants from at least 17 countries met the inclusion criteria. Studies were conducted either in hospitals immediately postpartum or in the community. There was considerable variation in mothers, particularly in parity and whether or not they had lactation insufficiency. Infants' ages at commencement of the studies ranged from newborn to 6 months. The overall certainty of evidence was low to very low because of high risk of biases (mainly due to lack of blinding), substantial clinical and statistical heterogeneity, and imprecision of measurements. Pharmacological galactagogues Nine studies compared a pharmacological galactagogue (domperidone, metoclopramide, sulpiride, thyrotropin‐releasing hormone) with placebo or no treatment. The primary outcome of proportion of mothers who continued breastfeeding at 3, 4 and 6 months was not reported. Only one study (metoclopramide) reported on the outcome of infant weight, finding little or no difference (mean difference (MD) 23.0 grams, 95% confidence interval (CI) ‐47.71 to 93.71; 1 study, 20 participants; low‐certainty evidence). Three studies (metoclopramide, domperidone, sulpiride) reported on milk volume, finding pharmacological galactagogues may increase milk volume (MD 63.82 mL, 95% CI 25.91 to 101.72; I² = 34%; 3 studies, 151 participants; low‐certainty evidence). Subgroup analysis indicates there may be increased milk volume with each drug, but with varying CIs. There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints, such as tiredness, nausea, headache and dry mouth (very low‐certainty evidence). No adverse effects were reported for infants. Natural galactagogues Twenty‐seven studies compared natural oral galactagogues (banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves or other natural mixtures) with placebo or no treatment. One study (Mother's Milk Tea) reported breastfeeding rates at six months with a concluding statement of \"no significant difference\" (no data and no measure of significance provided, 60 participants, very low‐certainty evidence). Three studies (fennel, fenugreek, moringa, mixed botanical tea) reported infant weight but could not be meta‐analysed due to substantial clinical and statistical heterogeneity (I 2 = 60%, 275 participants, very low‐certainty evidence). Subgroup analysis shows we are very uncertain whether fennel or fenugreek improves infant weight, whereas moringa and mixed botanical tea may increase infant weight compared to placebo. Thirteen studies (Bu Xue Sheng Ru, Chanbao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants) reported on milk volume, but meta‐analysis was not possible due to substantial heterogeneity (I 2 = 99%). The subgroup analysis for each intervention suggested either benefit or little or no difference (very low‐certainty evidence). There was limited reporting of adverse effects, none of which could be meta‐analysed. Where reported, they were limited to minor complaints such as mothers with urine that smelled like maple syrup and urticaria in infants (very low‐certainty evidence). Galactagogue versus galactagogue Eight studies (Chanbao; Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one oral galactagogue with another. We were unable to perform meta‐analysis because there was only one small study for each match‐up, so we do not know if one galactagogue is better than another for any outcome. Authors' conclusions Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low‐certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High‐quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used. Plain language summary Milk boosters (galactagogues) for mothers breastfeeding their healthy infants born at term What is the issue? We set out to determine the ability of milk boosters taken by mouth (medicine, herb or food) to increase milk production in breastfeeding mothers of healthy infants born at term. Poor milk supply is often given as the reason for early supplementation and weaning sooner than desired. A range of factors, including mother's and baby's health, baby's sucking skills, proper latch and frequency of feeds, can affect milk production. Every attempt should first be made to identify and correct the causes for low milk production before trying a milk booster. Why is this important? Inadequate milk production can be distressing for mothers and threatening to babies' health. The choice of milk booster is often influenced by familiarity or local customs. Some mothers may prefer medications, while others prefer natural remedies. Evidence for the possible benefits and harms of milk boosters is important to assist mothers in making informed decisions. What evidence did we find? We searched for evidence from randomised controlled studies up to 4 November 2019 and identified 41 eligible studies involving 3005 mothers and 3006 infants from at least 17 countries. The studies varied widely in babies ages, type of milk boosters investigated, how long they were taken, and how outcomes were reported. Medications included sulpiride, metoclopramide, domperidone and thyrotropin‐releasing hormone. Natural interventions included banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves, and a variety of natural mixtures as teas or soups. Milk‐boosting medication Nine studies compared a milk‐boosting medication with placebo or no treatment. None reported exclusive breastfeeding rates at 3. 4 or 6 months and only one (metoclopramide, 20 participants) reported on weight gain in infants receiving only their mothers' own milk, with better results in the milk booster group. Three studies that tracked milk volume (domperidone, metoclopramide, sulpiride; 151 participants) reported more milk in the booster groups, though the certainty of the evidence was low. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as tiredness, nausea, decreased appetite, headache and dry mouth. Natural milk boosters Twenty‐seven studies compared natural milk boosters with placebo or no treatment. Only one (Mother’s Milk Tea; 60 participants) examined the impact on breastfeeding rates, reporting \"no significant difference at 6 months\" without providing any data (very low‐certainty evidence). Three studies (275 participants) reported infant weight, two of which (moringa, mixed botanical tea) reported higher gains in the milk booster group, while the other study (fennel and fenugreek) was inconclusive on whether infant weight gain improved with the milk boosters. In the 13 studies tracking changes in milk volume (Bu Xue Sheng Ru, Chan Bao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants), some showed benefits and others little or no difference, so we are very uncertain about the results for milk volume. Adverse effects were poorly reported. Where mentioned, they were limited to minor complaints, such as mothers with urine that smells like maple syrup and rash in infants (very low‐certainty evidence). One milk booster compared with another Eight studies (Chanbao, Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one milk booster with another. There was only one small study for each particular match‐up, hence we cannot be certain if any one milk booster truly worked better than another. What does this mean? There is limited evidence that milk‐boosting medications may increase milk volume and that natural milk boosters may improve milk volume and infants' weight, but we are very uncertain about the supporting evidence. Due to limited information, we are also uncertain if there are any risks to the mother or baby in taking any particular milk booster. More high‐quality studies are needed to increase our certainty about the effects of milk boosters.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Foong, SC, Tan, ML, Foong, WC, Marasco, LA, Ho, JJ, Ong, JH", "articleTypes": [], "doi": "10.1002/14651858.CD011505.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.095Z" }, { "id": "b4ae1702-f347-4646-ad5d-447098ce2f0f", "pmid": "", "title": "Progestin‐only pills for contraception", "imported": false, "abstract": "Abstract - Background The introduction of a new progestin‐only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. Objectives This review examined randomized controlled trials of progestin‐only pills for differences in efficacy, acceptability, and continuation rates. Search methods Through October 2013, we searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, and LILACS for studies of progestin‐only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. Selection criteria We included all randomized controlled trials in any language that included progestin‐only pills for contraception. We incorporated any comparison with a progestin‐only pill; this could include different doses, other progestin‐only pills, combined oral contraceptives, or other contraceptives. Data collection and analysis The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry. We attempted to extract life‐table rates (actuarial or continuous) and used the rate difference as the effect measure. Where life‐table rates were not published, we used the incidence rate ratio (ratio of Pearl rates). Where only the crude number of events was published, we calculated the Peto odds ratio with 95% confidence interval (CI) using a fixed‐effect model. For continuous variables, the mean difference (MD) was computed with 95% CI. Because of disparate exposures, we were not able to combine studies in meta‐analysis. Main results Six trials met the inclusion criteria. We have not found any new studies since the initial review. In the trial comparing the desogestrel versus levonorgestrel progestin‐only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin‐only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low‐dose mifepristone versus a levonorgestrel progestin‐only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin‐only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin‐only and two combined oral contraceptives, the progestin‐only pill containing levonorgestrel 30 μg had higher efficacy than did the pill containing norethisterone 350 μg. An early trial found megestrol acetate inferior to other progestin‐only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. Authors' conclusions Evidence is insufficient to compare progestin‐only pills to each other or to combined oral contraceptives. Plain language summary Progestin‐only pills for contraception Progestin‐only pills, as their name implies, contain just one hormone. The more common birth control pills combine two hormones. How these one‐hormone pills compare to each other or to two‐hormone pills is not clear. Hence, we did this review to compare progestin‐only pills to other similar pills or to combined (two‐hormone) pills. Through October 2013, we did a computer search and literature search to find randomized trials of progestin‐only pills. We found six trials for the initial review. We have not found any more studies since then. Some studies are several decades old and not very relevant to pills available today. A newer pill containing the progestin desogestrel may work better to prevent pregnancy than an older pill with levonorgestrel. The newer pill caused more bleeding problems. Pills with levonorgestrel may be more effective than pills with other progestins that are no longer used. These studies are not adequate to tell how progestin‐only pills compare to each other or to combined (two‐hormone) pills. Larger studies with currently used pills are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grimes, DA; Lopez, LM; O'Brien, PA; Raymond, EG", "articleTypes": [], "doi": "10.1002/14651858.CD007541.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "b4d252cd-ce81-4763-b11d-809ac7934ee8", "pmid": "", "title": "Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta‐analyses", "imported": false, "abstract": "Abstract - Background Tobacco smoking is the leading preventable cause of death and disease worldwide. Stopping smoking can reduce this harm and many people would like to stop. There are a number of medicines licenced to help people quit globally, and e‐cigarettes are used for this purpose in many countries. Typically treatments work by reducing cravings to smoke, thus aiding initial abstinence and preventing relapse. More information on comparative effects of these treatments is needed to inform treatment decisions and policies. Objectives To investigate the comparative benefits, harms and tolerability of different smoking cessation pharmacotherapies and e‐cigarettes, when used to help people stop smoking tobacco. Search methods We identified studies from recent updates of Cochrane Reviews investigating our interventions of interest. We updated the searches for each review using the Cochrane Tobacco Addiction Group (TAG) specialised register to 29 April 2022. Selection criteria We included randomised controlled trials (RCTs), cluster‐RCTs and factorial RCTs, which measured smoking cessation at six months or longer, recruited adults who smoked combustible cigarettes at enrolment (excluding pregnant people) and randomised them to approved pharmacotherapies and technologies used for smoking cessation worldwide (varenicline, cytisine, nortriptyline, bupropion, nicotine replacement therapy (NRT) and e‐cigarettes) versus no pharmacological intervention, placebo (control) or another approved pharmacotherapy. Studies providing co‐interventions (e.g. behavioural support) were eligible if the co‐intervention was provided equally to study arms. Data collection and analysis We followed standard Cochrane methods for screening, data extraction and risk of bias (RoB) assessment (using the RoB 1 tool). Primary outcome measures were smoking cessation at six months or longer, and the number of people reporting serious adverse events (SAEs). We also measured withdrawals due to treatment. We used Bayesian component network meta‐analyses (cNMA) to examine intervention type, delivery mode, dose, duration, timing in relation to quit day and tapering of nicotine dose, using odds ratios (OR) and 95% credibility intervals (CrIs). We calculated an effect estimate for combination NRT using an additive model. We evaluated the influence of population and study characteristics, provision of behavioural support and control arm rates using meta‐regression. We evaluated certainty using GRADE. Main results Of our 332 eligible RCTs, 319 (835 study arms, 157,179 participants) provided sufficient data to be included in our cNMA. Of these, we judged 51 to be at low risk of bias overall, 104 at high risk and 164 at unclear risk, and 118 reported pharmaceutical or e‐cigarette/tobacco industry funding. Removing studies at high risk of bias did not change our interpretation of the results. Benefits We found high‐certainty evidence that nicotine e‐cigarettes (OR 2.37, 95% CrI 1.73 to 3.24; 16 RCTs, 3828 participants), varenicline (OR 2.33, 95% CrI 2.02 to 2.68; 67 RCTs, 16,430 participants) and cytisine (OR 2.21, 95% CrI 1.66 to 2.97; 7 RCTs, 3848 participants) were associated with higher quit rates than control. In absolute terms, this might lead to an additional eight (95% CrI 4 to 13), eight (95% CrI 6 to 10) and seven additional quitters per 100 (95% CrI 4 to 12), respectively. These interventions appeared to be more effective than the other interventions apart from combination NRT (patch and a fast‐acting form of NRT), which had a lower point estimate (calculated additive effect) but overlapping 95% CrIs (OR 1.93, 95% CrI 1.61 to 2.34). There was also high‐certainty evidence that nicotine patch alone (OR 1.37, 95% CrI 1.20 to 1.56; 105 RCTs, 37,319 participants), fast‐acting NRT alone (OR 1.41, 95% CrI 1.29 to 1.55; 120 RCTs, 31,756 participants) and bupropion (OR 1.43, 95% CrI 1.26 to 1.62; 71 RCTs, 14,759 participants) were more effective than control, resulting in two (95% CrI 1 to 3), three (95% CrI 2 to 3) and three (95% CrI 2 to 4) additional quitters per 100 respectively. Nortriptyline is probably associated with higher quit rates than control (OR 1.35, 95% CrI 1.02 to 1.81; 10 RCTs, 1290 participants; moderate‐certainty evidence), resulting in two (CrI 0 to 5) additional quitters per 100. Non‐nicotine/placebo e‐cigarettes (OR 1.16, 95% CrI 0.74 to 1.80; 8 RCTs, 1094 participants; low‐certainty evidence), equating to one additional quitter (95% CrI ‐2 to 5), had point estimates favouring the intervention over control, but CrIs encompassed the potential for no difference and harm. There was low‐certainty evidence that tapering the dose of NRT prior to stopping treatment may improve effectiveness; however, 95% CrIs also incorporated the null (OR 1.14, 95% CrI 1.00 to 1.29; 111 RCTs, 33,156 participants). This might lead to an additional one quitter per 100 (95% CrI 0 to 2). Harms There were insufficient data to include nortriptyline and non‐nicotine EC in the final SAE model. Overall rates of SAEs for the remaining treatments were low (average 3%). Low‐certainty evidence did not show a clear difference in the number of people reporting SAEs for nicotine e‐cigarettes, varenicline, cytisine or NRT when compared to no pharmacotherapy/e‐cigarettes or placebo. Bupropion may slightly increase rates of SAEs, although the CrI also incorporated no difference (moderate certainty). In absolute terms bupropion may cause one more person in 100 to experience an SAE (95% CrI 0 to 2). Authors' conclusions The most effective interventions were nicotine e‐cigarettes, varenicline and cytisine (all high certainty), as well as combination NRT (additive effect, certainty not rated). There was also high‐certainty evidence for the effectiveness of nicotine patch, fast‐acting NRT and bupropion. Less certain evidence of benefit was present for nortriptyline (moderate certainty), non‐nicotine e‐cigarettes and tapering of nicotine dose (both low certainty). There was moderate‐certainty evidence that bupropion may slightly increase the frequency of SAEs, although there was also the possibility of no increased risk. There was no clear evidence that any other tested interventions increased SAEs. Overall, SAE data were sparse with very low numbers of SAEs, and so further evidence may change our interpretation and certainty. Future studies should report SAEs to strengthen certainty in this outcome. More head‐to‐head comparisons of the most effective interventions are needed, as are tests of combinations of these. Future work should unify data from behavioural and pharmacological interventions to inform approaches to combined support for smoking cessation. Plain language summary How effective are medications and e‐cigarettes for quitting smoking, and what works best? Key messages Some medicines and e‐cigarettes (handheld devices that work by heating liquid that usually contains nicotine and flavourings) can help people to quit smoking for six months or longer. E‐cigarettes, and the medicines cytisine (otherwise known as Tabex) and varenicline (otherwise known as Chantix and Champix), appear to help the most people to quit smoking, followed by using two types of nicotine replacement therapy at once (nicotine patch and another type, such as gum or lozenge). We need more evidence on possible long‐term harms of e‐cigarettes and medicines to help people quit smoking, but there were very low numbers of serious harms found. Stopping smoking Tobacco smoking is bad for people's health and stopping can lead to significant improvements. Most people would like to quit smoking and there are medicines and e‐cigarettes available to help people to do that. These medicines are called nicotine replacement therapy, cytisine, varenicline, bupropion (sometimes known as Zyban or Wellbutrin) and nortriptyline (sometimes known as Norpress). Nortriptyline is only available for quitting smoking in New Zealand, and cytisine is not available in many countries. At time of writing, there are shortages of varenicline due to a manufacturing issue. These medicines and e‐cigarettes can be provided alongside behavioural support, such as counselling. Stop smoking medications and e‐cigarettes are designed to reduce people's craving to smoke. By finding out more information on how these treatments compare to each other, we hope this review will be used to decide the best treatments to help people stop smoking. Why we did this Cochrane Review We wanted to find out: ‐ which treatments (medicines and e‐cigarettes) help people to stop smoking; ‐ how these treatments compare to each other; ‐ whether there are ways of providing these treatments that mean they are more likely to help people stop smoking (e.g. different doses or treatment lengths); ‐ whether these treatments are likely to cause serious harms; and ‐ whether certain treatments are better tolerated, as indicated by fewer people leaving a study due to treatment. What did we do? We searched for studies that looked at these treatments to help adults quit smoking. We looked for randomised controlled trials, where the treatments people received were decided at random. This type of study usually gives the most reliable evidence about the effects of treatments. We compared all treatments with each other using a method called network meta‐analysis. Search date: 29 April 2022 What we found We found 332 studies that met our criteria and 319 of these provided information that we could use in our analyses. These included 157,179 adults who smoked tobacco cigarettes. Most of the studies took place in the USA or Europe. The studies compared the effects of the stop smoking treatments listed above with: ‐ no medicine/e‐cigarettes for stopping smoking; ‐ e‐cigarettes that did not contain nicotine; ‐ placebo (a dummy medication); and ‐ other types of stop smoking medicine or e‐cigarettes. What are the main results of our review? E‐cigarettes, varenicline and cytisine were most likely to help people quit smoking. For every 100 people, 10 to 19 are likely to quit using an e‐cigarette; 12 to 16 using varenicline; and 10 to 18 using cytisine. This is compared to the 6 in 100 people likely to quit when using no medicine/e‐cigarette or placebo. People using two forms of nicotine replacement therapy at the same time, for example, a combination of nicotine patch and nicotine gum, seemed to have similar rates of quitting to people using e‐cigarettes, varenicline and cytisine. Nicotine patches alone, another form of nicotine replacement therapy alone (such as gum, lozenge) and bupropion appeared to help fewer people quit but still work better than no medicine/e‐cigarette or placebo (8, 9 and 9 people per 100, respectively). Nortriptyline appeared to result in the lowest number of people quitting smoking; for every 100 people using nortriptyline 6 to 11 are likely to quit. We are moderately confident that bupropion could rarely cause some serious health effects. The information we have for other treatments does not provide clear evidence of serious harms. For all treatments, findings suggest very few people experience serious harms when using them. How confident are we in our results? We are confident that e‐cigarettes, cytisine, varenicline, nicotine replacement therapy and bupropion help people stop smoking. We do not expect more evidence will change these results. However, more evidence on how these treatments compare to one another, particularly in relation to harms, would be useful. Due to the nature of our analyses we were not able to judge our confidence in the evidence for combination nicotine replacement therapy (two types used together). We are moderately confident that nortriptyline also helps people to stop smoking, but are less confident in our results for non‐nicotine e‐cigarettes and for potential harms of most of the treatments. We still need more evidence on potential harms and hope more studies will report on these in future; however, nicotine replacement therapy has been used since the 1980s with no evidence of serious harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lindson, N; Theodoulou, A; Ordóñez-Mena, JM; Fanshawe, TR; Sutton, AJ; Livingstone-Banks, J; Hajizadeh, A; Zhu, S; Aveyard, P; Freeman, SC; Agrawal, S; Hartmann-Boyce, J", "articleTypes": [], "doi": "10.1002/14651858.CD015226.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "b4d96f3b-a58d-4c7b-af70-e97f63b493eb", "pmid": "", "title": "Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia", "imported": false, "abstract": "Abstract - Background Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases children's risk of developing pneumonia. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited. This is an update of a Cochrane Review first published in 2018. Objectives To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia. Search methods We searched CENTRAL, MEDLINE, Embase, and two trial registries on 28 December 2021. We applied no language restrictions. Selection criteria We included randomised controlled trials (RCTs) that compared vitamin D supplementation with placebo in children (aged one month to five years) hospitalised with acute community‐acquired pneumonia, as defined by the World Health Organization (WHO) acute respiratory infection guidelines. For this update, we reappraised eligible trials according to research integrity criteria, excluding RCTs published from April 2018 that were not prospectively registered in a trials registry according to WHO or Clinical Trials Registry – India (CTRI) guidelines (it was not mandatory to register clinical trials in India before April 2018). Data collection and analysis Two review authors independently assessed trials for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with number of participants in each group. We used standard methodological procedures expected by Cochrane. Main results In this update, we included three new trials involving 468 children, bringing the total number of trials to seven, with 1601 children (631 with pneumonia and 970 with severe or very severe pneumonia). We categorised three previously included studies and three new studies as 'awaiting classification' based on the research integrity screen.
Five trials used a single bolus dose of vitamin D (300,000 IU in one trial and 100,000 IU in four trials) at the onset of illness or within 24 hours of hospital admission; one used a daily dose of oral vitamin D (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used variable doses (on day 1, 20,000 IU in children younger than six months, 50,000 IU in children aged six to 12 months, and 100,000 IU in children aged 13 to 59 months; followed by 10,000 IU/day for four days or until discharge). Three trials performed microbiological diagnosis of pneumonia, radiological diagnosis of pneumonia, or both. Vitamin D probably has little or no effect on the time to resolution of acute illness (mean difference (MD) −1.28 hours, 95% confidence interval (CI) −5.47 to 2.91; 5 trials, 1188 children; moderate‐certainty evidence). We do not know if vitamin D has an effect on the duration of hospitalisation (MD 4.96 hours, 95% CI −8.28 to 18.21; 5 trials, 1023 children; very low‐certainty evidence). We do not know if vitamin D has an effect on mortality rate (risk ratio (RR) 0.69, 95% CI 0.44 to 1.07; 3 trials, 584 children; low‐certainty evidence). The trials reported no major adverse events. According to GRADE criteria, the evidence was of very low‐to‐moderate certainty for all outcomes, owing to serious trial limitations, inconsistency, indirectness, and imprecision. Three trials received funding: one from the New Zealand Aid Corporation, one from an institutional grant, and one from multigovernment organisations (Bangladesh, Sweden, and UK). The remaining four trials were unfunded. Authors' conclusions Based on the available evidence, we are uncertain whether vitamin D supplementation has important effects on outcomes of acute pneumonia when used as an adjunct to antibiotics. The trials reported no major adverse events. Uncertainty in the evidence is due to imprecision, risk of bias, inconsistency, and indirectness. Plain language summary Is vitamin D an effective and safe addition to antibiotics for treating children with acute pneumonia? What is pneumonia, and how can it be treated? Pneumonia is inflammation (swelling) of the lungs caused by an infection. Treatment for pneumonia includes antibiotics, providing oxygen through a mask, and other supportive therapies. Vitamin D boosts immune defences and reduces excessive inflammation: these effects may help children recover from an episode of pneumonia. What did we want to find out? We wanted to find out if vitamin D, taken together with antibiotics, can help children to recover from an episode of pneumonia. What did we do? We searched for trials that looked at vitamin D compared with placebo (dummy treatment) in children aged between one month and five years who had pneumonia. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. Study characteristics We included seven trials involving 1601 children from low‐ and middle‐income countries. In five trials, children received a single large dose of vitamin D when they joined the trial or within 24 hours of admission to hospital. In two trials, children received vitamin D for five days. One trial excluded children with normal vitamin D levels. Two trials reported the cause of children's pneumonia. Key results Vitamin D probably has little or no effect on the time it takes children to get better from pneumonia. We do not know if vitamin D has an effect on the time children spend in hospital or the number of children who die. The studies reported no major harmful events. What are the limitations of the evidence? We have only moderate confidence in the evidence on the time it took children to recover from pneumonia, because all children in this comparison were from low‐income regions, so the results may not apply to higher‐income populations. We have little confidence in the evidence on death rate, because of the same applicability problem outlined above, and because the result was compatible with both appreciable benefit and harm. We have very little confidence in the evidence on time spent in hospital, because of the same applicability problem outlined above, because the children and health providers in one study knew what the allocated treatment was, and because the results were very inconsistent across the studies included in the comparison. How up to date is the evidence? The evidence is current to 28 December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Das, RR; Singh, M; Naik, SS", "articleTypes": [], "doi": "10.1002/14651858.CD011597.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "b4daef4c-4ac9-4bef-b56b-27c06b0c430c", "pmid": "", "title": "Zinc supplementation for the treatment of measles in children", "imported": false, "abstract": "Abstract - Background Measles is an important cause of childhood morbidity and mortality globally, despite increasing vaccine coverage. Zinc plays a significant role in the maintenance of normal immunological functions, therefore supplements given to zinc‐deficient children will increase the availability of zinc and could reduce measles‐related morbidity and mortality. This is an update of a review first published in 2015. Objectives To assess the effects of zinc supplementation in reducing morbidity and mortality in children with measles. Search methods We searched CENTRAL (03 February 2017, Issue 2), MEDLINE (1946 to 03 February 2017), Embase (1974 to 03 February 2017), CINAHL (1981 to 03 February 2017), LILACS (1982 to 03 February 2017), Web of Science (1985 to 03 February 2017), and BIOSIS Previews (1985 to 27 June 2014). We also searched ClinicalTrials.gov, the Australian New Zealand Clinical Trials Registry and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 03 February 2017 to identify unpublished and ongoing studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of zinc in reducing morbidity and mortality in children with measles. Data collection and analysis Two review authors independently assessed the studies for inclusion and extracted data on outcomes, details of the interventions, and other study characteristics using a standardised data extraction form. We used risk ratio (RR) and hazard ratio (HR) as measures of effect with 95% confidence intervals (CI). We included only one study, and did not conduct meta‐analysis. Main results We did not identify any new studies for inclusion in this update. One RCT met our inclusion criteria. The study was conducted in India and included 85 children diagnosed with measles and pneumonia. The trial showed no significant difference in mortality between children with measles and pneumonia who received zinc supplements and those who received placebo (RR 0.34, 95% CI 0.01 to 8.14). There was no significant difference in time to absence of fever between children who received zinc supplements and those who did not (HR 1.08, 95% CI 0.67 to 1.74). No treatment‐related side effects were reported in either group. We assessed the overall quality of the evidence as very low. Authors' conclusions We could not draw any definitive conclusions from this review about the effects of zinc supplementation on clinical outcomes of children with measles due to the very low quality of the evidence available. There is insufficient evidence to confirm or refute the effect of zinc supplementation in children with measles. Plain language summary Zinc supplementation for the treatment of measles in children Review question What is the effect of zinc supplementation in the treatment of children with measles? Background Measles infection has reduced globally over the last decade, but large outbreaks still occur, especially in low‐income countries. Zinc is one of the essential micronutrients necessary for the optimal functioning of the immune system. Zinc deficiency is particularly common in children in low‐ and middle‐income countries. It was therefore important to examine the potential role of zinc supplementation in controlling the symptoms of measles infection in children. We aimed to critically assess the current evidence from published studies on the effect of zinc supplementation for the treatment of measles in children. Search date We searched for evidence up to 03 February 2017. This is an update of a review first published in 2015. We did not include any new studies for this update. Study characteristics We found one small randomised trial (involving 85 children) that compared zinc supplements versus placebo administered to children with measles and pneumonia. All 85 children received supportive care and vitamin A. The study was conducted in India and funded by the Child Health Foundation USA and the Nestlé Foundation. Key results The included study was small and did not provide enough data to determine whether zinc had an effect on mortality when compared with placebo. Although no adverse effects were reported, there was insufficient evidence to draw any conclusions about the use of zinc supplements to improve measles symptoms in children. More research is needed to clarify any benefits or harms. Quality of the evidence We assessed the quality of the evidence as very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Awotiwon, AA; Oduwole, O; Sinha, A; Okwundu, CI", "articleTypes": [], "doi": "10.1002/14651858.CD011177.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "b4daf196-d9b5-427d-bfab-d25bf3dce2f6", "pmid": "", "title": "Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen‐ultraviolet A photochemotherapy for psoriasis", "imported": false, "abstract": "Abstract - Background The most commonly used types of phototherapy for treating psoriasis are narrow‐band ultraviolet B (NB‐UVB); broad‐band ultraviolet B (BB‐UVB), which includes selective (delivering radiation with a wavelength range of 305 to 325 nm) and conventional BB‐UVB (280 to 320 nm); and psoralen ultraviolet A photochemotherapy (oral or bath PUVA). There is substantial controversy regarding their efficacy when compared with each other. Objectives To assess the effects of narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for psoriasis. Search methods We searched the following databases up to August 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 7), MEDLINE (from 1946), and EMBASE (from 1974). We searched the following databases up to November 2012: CNKI (from 1974) and CBM (from 1978). We also searched trials registers and the OpenGrey database. Selection criteria We included all randomised controlled trials (RCTs) that compared NB‐UVB phototherapy with BB‐UVB or PUVA for treating psoriasis, which included chronic plaque psoriasis (CPP), guttate psoriasis (GP), and palmoplantar psoriasis (PPP). Data collection and analysis Two review authors independently conducted the study selection, 'Risk of bias' assessment, and data extraction. Main results We included 13 RCTs, with a total of 662 participants. We report the results of intention‐to‐treat analyses (ITT) here. Our primary outcomes of interest were as follows: Participant‐rated global improvement, Percentage of participants reaching Psoriasis Area and Severity Index (PASI) 75 (which meant equal to or more than 75% reduction in PASI score), Withdrawal due to side‐effects, and Clearance rate. In one RCT of NB‐UVB compared with oral PUVA in participants with CPP, the difference in PASI 75 was not statistically significant (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.63 to 1.32; N = 51; low quality). In three other RCTs of CPP, the clearance rates were inconsistent because in one, there was no difference between the groups (RR 1.01, 95% CI 0.91 to 1.12; N = 54), and in the other two, the clearance rates were statistically significantly in favour of oral PUVA: RR 0.66, 95% CI 0.47 to 0.93; N = 93 and RR 0.75, 95% CI 0.59 to 0.96; N = 100, respectively. Pooled data from these three studies indicated that withdrawals due to adverse events were not significantly different between either group (RR 0.71, 95% CI 0.20 to 2.54; N = 247; low quality). The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate for CPP was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the NB‐UVB and bath PUVA groups (RR 1.79, 95% CI 0.46 to 6.91; N = 92; low quality), while a parallel RCT favoured bath PUVA (RR 0.18, 95% CI 0.05 to 0.71; N = 36; low quality). In participants with PPP, one RCT found there were no significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate (RR 0.09, 95% CI 0.01 to 1.56; N = 50; low quality). Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or GP in terms of clearance rate (RR 0.93, 95% CI 0.79 to 1.10; N = 90; low quality). One RCT in people with CPP found no significant differences between NB‐UVB and selective BB‐UVB in terms of clearance rate (RR 1.40, 95% CI 0.92 to 2.13; N = 100; low quality) and withdrawals due to adverse events (RR 3.00, 95% CI 0.32 to 27.87; N = 100; low quality). No studies reported our primary outcomes for NB‐UVB compared with conventional BB‐UVB. Authors' conclusions Current evidence is very heterogeneous and needs to be interpreted with caution. The clearance rate between oral PUVA and NB‐UVB is inconsistent among the included studies. Evidence regarding NB‐UVB versus bath PUVA is also inconsistent. Re‐NB‐UVB and re‐PUVA are similarly effective for treating people with CPP or GP. In practice, NB‐UVB may be more convenient to use since exogenous photosensitiser is not required before phototherapy. NB‐UVB is considered ineffective for PPP in clinical practice, and a small RCT did not detect a statistically significant difference between NB‐UVB and topical PUVA for clearing PPP. NB‐UVB seemed to be similar to selective BB‐UVB for clearing CPP. Larger prospective studies are needed to confirm the long‐term safety of NB‐UVB. Plain language summary Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for treating psoriasis Psoriasis is a common, chronic inflammatory skin disease, with an estimated global prevalence ranging from 0.5% to 4.6%. Based on clinical features, psoriasis is generally divided into the following: chronic plaque psoriasis (CPP); psoriasis associated with psoriatic arthritis; and pustular, erythrodermic, or guttate psoriasis. We also considered psoriasis affecting the palms and soles (palmoplantar psoriasis, or PPP). Although psoriasis is rarely life‐threatening, it can affect a person's quality of life significantly. Phototherapy is an essential treatment option for people with psoriasis. The most commonly used types of phototherapy are narrow‐band ultraviolet B (NB‐UVB), broad‐band ultraviolet B (BB‐UVB), and psoralen ultraviolet A photochemotherapy (PUVA). PUVA can be further divided into oral, bath, and topical PUVA according to the administrative route of psoralen. NB‐UVB delivers almost exclusively 311 nm radiation, whereas BB‐UVB can be divided into two types: selective BB‐UVB (305 to 325 nm radiation) and conventional BB‐UVB (280 to 320 nm radiation). This review included 13 small randomised controlled trials (RCT), with a total of 662 participants. Most of these were of poor methodological quality. For treating CPP, the clearance rate between the NB‐UVB and oral PUVA groups were inconsistent in three RCTs. In one, there was no difference between the groups, and in the other two, the clearance rate was in favour of oral PUVA. The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the two groups, while another RCT favoured bath PUVA. Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or guttate psoriasis. One RCT found no significant differences between NB‐UVB and selective BB‐UVB for clearing CPP or in the number of withdrawals due to side‐effects. In participants with PPP, one RCT found there were no statistically significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate. In summary, NB‐UVB may be preferred to oral or bath PUVA because it is more convenient to use. NB‐UVB seemed to be equal to selective BB‐UVB for clearing CPP. Evidence regarding NB‐UVB and conventional BB‐UVB is limited. The long‐term safety of NB‐UVB needs to be confirmed. The efficacy of NB‐UVB for clearing PPP needs to be confirmed in future studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Chen, X, Yang, M, Cheng, Y, Liu, GJ, Zhang, M", "articleTypes": [], "doi": "10.1002/14651858.CD009481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.801Z" }, { "id": "b4f9e29b-6bcf-47d9-9b55-60ec4092156a", "pmid": "", "title": "Pharmaceutical interventions for emotionalism after stroke", "imported": false, "abstract": "Abstract - Background Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2019. Objectives To evaluate the benefits and harms of pharmaceutical treatment in people with emotionalism after stroke. Search methods We searched the Cochrane Stroke Group Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registers (May 2022). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). Data collection and analysis Two review authors independently selected trials, assessed risk of bias, extracted data from all included trials, and used GRADE to assess the certainty of the body of evidence. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I 2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on the Center for Neurologic Study ‐ Lability Scale (CNS‐LS) or Clinician Interview‐Based Impression of Change (CIBIC), or diminished tearfulness. Main results We did not identify any new trials for this update. We included seven trials with a total of 239 participants. Two trials had a cross‐over design, but outcome data were not available from the first phase (precross‐over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with a total of 213 participants. It is uncertain whether fluoxetine increases the number of people who have a 50% reduction in emotionalism when compared to placebo (risk ratio (RR) 0.26, 95% CI 0.09 to 0.77; P = 0.02; 1 trial, 19 participants) because the certainty of evidence is very low. Sertraline may lead to little to no difference in Center for Neurologic Study ‐ Lability Scale (CNS‐LS) scores and Clinician Interview‐Based Impression of Change (CIBIC) scores when compared to placebo (RR 0.20, 95% CI 0.03 to 1.50; P = 0.12; 1 trial, 28 participants; low‐certainty evidence). Antidepressants probably increase the number of people who experience a reduction in tearfulness (RR 0.32, 95% CI 0.12 to 0.86; P = 0.02; 3 trials, 164 participants; moderate‐certainty evidence). No trials were found that evaluated the impact of other pharmaceutical interventions. Only two trial authors systematically recorded and reported adverse events, resulting in limited data on the potential harms of treatment. Six trials reported death as an adverse event and found no difference between the groups (antidepressants versus placebo) in the number of deaths reported (RR 0.59, 95% CI 0.08 to 4.50; P = 0.61; 172 participants; moderate‐certainty evidence). This review provides very low‐ to moderate‐certainty evidence that antidepressants may reduce the frequency and severity of emotionalism. The included trials were small and had some degree of bias. Authors' conclusions Antidepressants may reduce the frequency and severity of crying or laughing episodes when compared to placebo, based on very low‐certainty evidence. Our conclusions must be qualified by several methodological deficiencies in the trials and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post‐stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity, and assess change over time; provide treatment for a sufficient duration and follow‐up to better assess rates of relapse or maintenance; and include careful assessment and complete reporting of adverse events. Plain language summary Medicines for emotionalism after stroke Review question To evaluate the benefits and harms of medicine in people with emotionalism after stroke. Background Emotionalism often occurs after stroke. Emotionalism means that the person has difficulty controlling their emotional behaviour. After stroke, people may suddenly start crying or, less commonly, laughing for no apparent reason. This is distressing for that particular person and their carers. Antidepressants, known to be helpful in people with depression, may be an effective treatment for emotionalism after stroke, but there have been very few randomised controlled trials (RCTs) in this area. (RCTs are studies in which participants are assigned randomly to 2 or more treatment groups. This is the best way to ensure that groups of participants are similar, and that investigators and participants do not know who is in which group.) Search date We identified studies through searches conducted on 26 May 2022. Study characteristics We included 7 randomised controlled trials, involving 239 people with emotionalism, in the review, which reported on the use of antidepressants for treating emotionalism. The numbers of people included in the studies ranged from 10 to 92. The mean/median ages ranged from 57.8 years to 73 years. Studies were from Europe (UK: 1; Denmark: 1; Scotland: 1; and Sweden: 1); Asia (South Korea: 1 and Japan: 1); and the USA (1). Key results We did not identify any new studies in our search update. We included 7 studies involving 239 people. However, 2 studies were not available in the appropriate format to include in the analysis. Therefore, we included only 5 studies, with 213 people, in our analyses. It is uncertain whether antidepressants affect the number of people with at least a 50% reduction in emotional displays, tearfulness, and scores on the questionnaires that measure uncontrollable laughing or crying, but they had no effect on lability (frequency of mood changes) scores and whether a clinician thought there had been an improvement when compared to placebo. No studies of other types of medicine were found. Six studies reported death and found no differences between those who were on antidepressants and those who were not. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low, and the results of further research could differ from the results of this review. Our confidence is limited because the included studies were small, and there was no consistency in how emotionalism was measured across the studies. Conclusion It is uncertain whether antidepressant medicines reduce outbursts of crying or laughing. More studies with systematic assessment and reporting of unwanted or harmful effects of a treatment are needed to ensure that any benefits outweigh the risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Allida, S, House, A, Hackett, ML", "articleTypes": [], "doi": "10.1002/14651858.CD003690.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.791Z" }, { "id": "b4fd88f8-4d6c-4989-acc9-feacf39a0677", "pmid": "", "title": "Effects of Morbid Obesity and Bariatric Surgery on Brain Inflammation, Insulin Resistance and Activation of Central Reward System Studied Using PET- and MRI-imaging", "imported": false, "abstract": "Background: Morbid obesity is associated with decreased brain µ-opioid receptor availability, possibly resulting in higher food intake needed to gain pleasure from eating. This decrease seems to normalize already 6 months after bariatric surgery, but the longer-term effects have not been studied. Obesity and insulin resistance result in significantly increased brain insulin-stimulated glucose uptake, whereas in every other tissue glucose uptake is lower. One possible explanation to this could be central inflammation and activation of brain glial cells, which has been shown to occur in animal models of obesity. Obesity has also been shown to associate with increased risk of Alzheimer's disease and cognitive decline in several studies.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.261Z" }, { "id": "b505c5af-36c8-402b-b2df-26bfc579c7a6", "pmid": "", "title": "Phytoestrogens for menopausal vasomotor symptoms", "imported": false, "abstract": "Abstract - Background Vasomotor symptoms, such as hot flushes and night sweats, are very common during the menopausal transition. Hormone therapy has traditionally been used as a highly effective treatment, but concerns about increased risk of some chronic diseases have markedly increased the interest of women in alternative treatments. Some of the most popular of these treatments are foods or supplements enriched with phytoestrogens—plant‐derived chemicals that have estrogenic action. Objectives To assess the efficacy, safety and acceptability of food products, extracts and dietary supplements containing high levels of phytoestrogens when compared with no treatment, placebo or hormone therapy for the amelioration of vasomotor menopausal symptoms (such as hot flushes and night sweats) in perimenopausal and postmenopausal women. Search methods Searches targeted the following electronic databases: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of randomised trials (29 July 2013), the Cochrane Register of Controlled Trials (CENTRAL; 29 July 2013), MEDLINE (inception to 29 July 2013), EMBASE (inception to 29 July 2013), AMED (1985 to 29 July 2013), PsycINFO (inception to 29 July 2013) and CINAHL (inception to 29 July 2013). Attempts were made to access grey literature by sending letters to pharmaceutical companies and performing searches of ongoing trial registers. Reference lists of included trials were also searched. Selection criteria Studies were included if they were randomised, included perimenopausal or postmenopausal participants with vasomotor symptoms (hot flushes or night sweats), lasted at least 12 weeks and provided interventions such as foods or supplements with high levels of phytoestrogens (not combined with other herbal treatments). Trials that included women who had breast cancer or a history of breast cancer were excluded. Data collection and analysis Selection of trials, extraction of data and assessment of quality were undertaken by at least two review authors. Most trials were too dissimilar for their results to be combined in a meta‐analysis, so these findings are provided in narrative 'Summary of results' tables. Studies were grouped into broad categories: dietary soy, soy extracts, red clover extracts, genistein extracts and other types of phytoestrogens. Five trials used Promensil, a red clover extract; results of these trials were combined in a meta‐analysis, and summary effect measures were calculated. Main results A total of 43 randomised controlled trials (4,364 participants) were included in this review. Very few trials provided data suitable for inclusion in a meta‐analysis. Among the five trials that yielded data assessing the daily frequency of hot flushes suitable for pooling, no significant difference overall was noted in the incidence of hot flushes between participants taking Promensil (a red clover extract) and those given placebo (mean difference (MD) ‐0.93, 95% confidence interval (CI) ‐1.95 to 0.10, I 2 = 31%). No evidence indicated a difference in percentage reduction in hot flushes in two trials between Promensil and placebo (MD 20.15, 95% CI ‐12.08 to 52.38, I 2 = 82%). Four trials that were not combined in meta‐analyses suggested that extracts with high (> 30 mg/d) levels of genistein consistently reduced the frequency of hot flushes. Individual results from the remaining trials were compared in broad subgroups such as dietary soy, soy extracts and other types of phytoestrogens that could not be combined. Some of these trials found that phytoestrogen treatments alleviated the frequency and severity of hot flushes and night sweats when compared with placebo, but many trials were small and were determined to be at high risk of bias. A strong placebo effect was noted in most trials, with a reduction in frequency ranging from 1% to 59% with placebo. No indication suggested that discrepant results were due to the amount of isoflavone in the active treatment arm, the severity of vasomotor symptoms or trial quality factors. Also, no evidence indicated that these treatments caused oestrogenic stimulation of the endometrium or the vagina or other adverse effects when used for up to two years. Authors' conclusions No conclusive evidence shows that phytoestrogen supplements effectively reduce the frequency or severity of hot flushes and night sweats in perimenopausal or postmenopausal women, although benefits derived from concentrates of genistein should be further investigated. Plain language summary Phytoestrogens for vasomotor menopausal symptoms Review question: This Cochrane review has evaluated whether phytoestrogen treatments reduce the number and severity of hot flushes and whether they are safe and acceptable. Background: Hormone therapy is an effective treatment for controlling the most common menopausal symptoms—hot flushes and night sweats. However, it is now recommended only in low doses given for the shortest possible time because of concerns about increased risk of some chronic diseases. Many women have started to use therapies that they perceive as 'natural' and safe, but they often do not have good information about the potential benefits and risks. Some of these therapies contain phytoestrogens—a group of plant‐derived chemicals that are thought to prevent or treat disease. Phytoestrogens are found in a wide variety of plants, some of which are foods, particularly soy, alfalfa and red clover. Study characteristics: This review found 43 RCTs conducted up to July 2013 that included 4,084 participants with hot flushes who were close to the menopause or were menopausal. Evidence obtained is current to July 2013. Key results: Some trials reported a slight reduction in hot flushes and night sweats with phytoestrogen‐based treatment. Extracts containing high levels of genistein (a substance derived from soy) appeared to reduce the number of daily hot flushes and need to be investigated further. Overall no indication suggested that other types of phytoestrogens work any better than no treatment. No evidence was found of harmful effects on the lining of the womb, stimulation of the vagina or other adverse effects with short‐term use. Quality of the evidence: Many of the trials in this review were small, of short duration and of poor quality, and the types of phytoestrogens used varied substantially.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lethaby, A, Marjoribanks, J, Kronenberg, F, Roberts, H, Eden, J, Brown, J", "articleTypes": [], "doi": "10.1002/14651858.CD001395.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.077Z" }, { "id": "b50a419b-7968-4d8b-9f48-7678fcbe9005", "pmid": "", "title": "Universal screening for SARS‐CoV‐2 infection: a rapid review", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Viswanathan, M, Kahwati, L, Jahn, B, Giger, K, Dobrescu, AI, Hill, C, Klerings, I, Meixner, J, Persad, E, Teufer, B, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013718 AB - Abstract - Background Coronavirus disease 2019 (COVID‐19) is caused by the novel betacoronavirus, severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2). Most people infected with SARS‐CoV‐2 have mild disease with unspecific symptoms, but about 5% become critically ill with respiratory failure, septic shock and multiple organ failure. An unknown proportion of infected individuals never experience COVID‐19 symptoms although they are infectious, that is, they remain asymptomatic. Those who develop the disease, go through a presymptomatic period during which they are infectious. Universal screening for SARS‐CoV‐2 infections to detect individuals who are infected before they present clinically, could therefore be an important measure to contain the spread of the disease. Objectives We conducted a rapid review to assess (1) the effectiveness of universal screening for SARS‐CoV‐2 infection compared with no screening and (2) the accuracy of universal screening in people who have not presented to clinical care for symptoms of COVID‐19. Search methods An information specialist searched Ovid MEDLINE and the Centers for Disease Control (CDC) COVID‐19 Research Articles Downloadable Database up to 26 May 2020. We searched Embase.com, the CENTRAL, and the Cochrane Covid‐19 Study Register on 14 April 2020. We searched LitCovid to 4 April 2020. The World Health Organization (WHO) provided records from daily searches in Chinese databases and in PubMed up to 15 April 2020. We also searched three model repositories (Covid‐Analytics, Models of Infectious Disease Agent Study [MIDAS], and Society for Medical Decision Making) on 8 April 2020. Selection criteria Trials, observational studies, or mathematical modelling studies assessing screening effectiveness or screening accuracy among general populations in which the prevalence of SARS‐CoV2 is unknown. Data collection and analysis After pilot testing review forms, one review author screened titles and abstracts. Two review authors independently screened the full text of studies and resolved any disagreements by discussion with a third review author. Abstracts excluded by a first review author were dually reviewed by a second review author prior to exclusion. One review author independently extracted data, which was checked by a second review author for completeness and accuracy. Two review authors independently rated the quality of included studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool for diagnostic accuracy studies and a modified form designed originally for economic evaluations for modelling studies. We resolved differences by consensus. We synthesized the evidence in narrative and tabular formats. We rated the certainty of evidence for days to outbreak, transmission, cases missed and detected, diagnostic accuracy (i.e. true positives, false positives, true negatives, false negatives) using the GRADE approach. Main results We included 22 publications. Two modelling studies reported on effectiveness of universal screening. Twenty studies (17 cohort studies and 3 modelling studies) reported on screening test accuracy. Effectiveness of screening We included two modelling studies. One study suggests that symptom screening at travel hubs, such as airports, may slightly slow but not stop the importation of infected cases (assuming 10 or 100 infected travellers per week reduced the delay in a local outbreak to 8 days or 1 day, respectively). We assessed risk of bias as minor or no concerns, and certainty of evidence was low, downgraded for very serious indirectness. The second modelling study provides very low‐certainty evidence that screening of healthcare workers in emergency departments using laboratory tests may reduce transmission to patients and other healthcare workers (assuming a transmission constant of 1.2 new infections per 10,000 people, weekly screening reduced infections by 5.1% within 30 days). The certainty of evidence was very low, downgraded for high risk of bias (major concerns) and indirectness. No modelling studies reported on harms of screening. Screening test accuracy All 17 cohort studies compared an index screening strategy to a reference reverse transcriptase polymerase chain reaction (RT‐PCR) test. All but one study reported on the accuracy of single point‐in‐time screening and varied widely in prevalence of SARS‐CoV‐2, settings, and methods of measurement. We assessed the overall risk of bias as unclear in 16 out of 17 studies, mainly due to limited information on the index test and reference standard. We rated one study as being at high risk of bias due to the inclusion of two separate populations with likely different prevalences. For several screening strategies, the estimates of sensitivity came from small samples. For single point‐in‐time strategies, for symptom assessment, the sensitivity from 12 cohorts (524 people) ranged from 0.00 to 0.60 (very low‐certainty evidence) and the specificity from 12 cohorts (16,165 people) ranged from 0.66 to 1.00 (low‐certainty evidence). For screening using direct temperature measurement (3 cohorts, 822 people), international travel history (2 cohorts, 13,080 people), or exposure to known infected people (3 cohorts, 13,205 people) or suspected infected people (2 cohorts, 954 people), sensitivity ranged from 0.00 to 0.23 (very low‐ to low‐certainty evidence) and specificity ranged from 0.90 to 1.00 (low‐ to moderate‐certainty evidence). For symptom assessment plus direct temperature measurement (2 cohorts, 779 people), sensitivity ranged from 0.12 to 0.69 (very low‐certainty evidence) and specificity from 0.90 to 1.00 (low‐certainty evidence). For rapid PCR test (1 cohort, 21 people), sensitivity was 0.80 (95% confidence interval (CI) 0.44 to 0.96; very low‐certainty evidence) and specificity was 0.73 (95% CI 0.39 to 0.94; very low‐certainty evidence). One cohort (76 people) reported on repeated screening with symptom assessment and demonstrates a sensitivity of 0.44 (95% CI 0.29 to 0.59; very low‐certainty evidence) and specificity of 0.62 (95% CI 0.42 to 0.79; low‐certainty evidence). Three modelling studies evaluated the accuracy of screening at airports. The main outcomes measured were cases missed or detected by entry or exit screening, or both, at airports. One study suggests very low sensitivity at 0.30 (95% CI 0.1 to 0.53), missing 70% of infected travellers. Another study described an unrealistic scenario to achieve a 90% detection rate, requiring 0% asymptomatic infections. The final study provides very uncertain evidence due to low methodological quality. Authors' conclusions The evidence base for the effectiveness of screening comes from two mathematical modelling studies and is limited by their assumptions. Low‐certainty evidence suggests that screening at travel hubs may slightly slow the importation of infected cases. This review highlights the uncertainty and variation in accuracy of screening strategies. A high proportion of infected individuals may be missed and go on to infect others, and some healthy individuals may be falsely identified as positive, requiring confirmatory testing and potentially leading to the unnecessary isolation of these individuals. Further studies need to evaluate the utility of rapid laboratory tests, combined screening, and repeated screening. More research is also needed on reference standards with greater accuracy than RT‐PCR. Given the poor sensitivity of existing approaches, our findings point to the need for greater emphasis on other ways that may prevent transmission such as face coverings, physical distancing, quarantine, and adequate personal protective equipment for frontline workers. Plain language summary How effective is screening for COVID‐19? Why does screening matter? Screening aims to identify a condition in people who may not be showing any symptoms. Some people may have the COVID‐19 virus but appear healthy or have only mild symptoms. It is important to identify infected people so they can stay away from others and seek appropriate care. Incorrectly identifying COVID‐19 in healthy people could lead to unnecessary self‐isolation and further tests. Incorrectly identifying no infection in infected people could spread the virus. Screening for COVID‐19 can include temperature checks, or asking about international travel or contact with COVID‐19 cases, or rapid tests. Screening can occur over the telephone, online, or in person, in homes, clinics, workplaces, airports or schools. What did the review study? We wanted to identify: · the benefits and negative effects of screening apparently healthy people for COVID‐19 infection; · whether screening can identify those with and without the virus correctly. To answer these questions rapidly, we shortened some steps of the normal Cochrane Review process. We are confident these changes do not affect our overall conclusions. What did we do? We looked for studies that screened people who had not sought care for potential COVID‐19 symptoms. This review includes evidence up to May 2020. Key results We found 22 studies; 17 assessed people (cohort studies) and five were computer‐generated models (modelling studies). Studies took place in USA, Europe, and Asia. Benefits and negative effects 
Two modelling studies reported on the benefits and negative effects of screening. One suggested that asking about symptoms at airports may slightly slow, but not stop, the importation of infected people. Another model reported that weekly or biweekly screening of healthcare workers may reduce transmission to patients and other healthcare workers in emergency departments. No studies reported on negative effects of screening. Identification of infected people 
Seventeen cohort studies and three modelling studies reported on whether screening can correctly identify those with and without the virus. Studies varied widely in the baseline level of COVID‐19, settings, and methods. All cohort studies compared screening strategies to a ‘gold standard’ test called RT‐PCR. Cohort studies
All screening strategies (17 studies, 17,574 people), incorrectly identified: · between 20 and 100 out of 100 infected people as healthy; · between 0 and 38 people out of 100 healthy people as infected Asking about symptoms (13 studies, 16,762 people ), incorrectly identified: · between 40 to 100 out of 100 infected people as healthy · between 0 to 34 out of 100 healthy people as infected Temperature measurements , asking about international travel , exposure to known infected people and exposure to known or suspected infected people (6 studies, 14,741 people), incorrectly identified : · between 77 and 100 out of 100 infected people as healthy · between 0 and 10 out of 100 healthy people as infected Asking about symptoms plus temperature measurement (2 studies, 779 people), incorrectly identified: · between 31 and 88 out of 100 infected people as healthy · between 0 to 10 people out of 100 healthy people as infected There was insufficient evidence from two small studies on rapid laboratory tests and repeated symptom assessment to tell how accurate they were in identifying healthy and infected people. Modelling studies 
Three studies modelled entry and exit screening in airports. One study missed 70% of infected travellers. Another detected 90% of infections, but used an unrealistic scenario. The third used very unreliable methods so we cannot use evidence from this study. How confident are we in the results of the studies? Our confidence in these findings is limited because most studies did not describe their screening methods clearly, some found very few cases of infections and the types of participants and settings varied greatly, making it difficult to judge whether the results apply broadly. Authors’ conclusions One‐time screening in apparently healthy people is likely to miss people who are infected. We are unsure whether combined screenings, repeated symptom assessment, or rapid laboratory tests are useful. As more people become infected, screening will identify more cases. However, because screening can miss people who are infected, public health measures such as face coverings, physical distancing, and quarantine for those who are apparently healthy, continue to be very important.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.755Z" }, { "id": "b51dc978-6fd4-4ecb-a55f-8a40c288aa3f", "pmid": "", "title": "Vitamin D supplementation for chronic liver diseases in adults", "imported": false, "abstract": "Abstract - Background Vitamin D deficiency is often reported in people with chronic liver diseases. Improving vitamin D status could therefore be beneficial for people with chronic liver diseases. Objectives To assess the beneficial and harmful effects of vitamin D supplementation in adults with chronic liver diseases. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index‐Science. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We scanned bibliographies of relevant publications and enquired experts and pharmaceutical companies as to additional trials. All searches were up to November 2020. Selection criteria Randomised clinical trials that compared vitamin D at any dose, duration, and route of administration versus placebo or no intervention in adults with chronic liver diseases. Vitamin D could have been administered as supplemental vitamin D (vitamin D 3 (cholecalciferol) or vitamin D 2 (ergocalciferol)), or an active form of vitamin D (1α‐hydroxyvitamin D (alfacalcidol), 25‐hydroxyvitamin D (calcidiol), or 1,25‐dihydroxyvitamin D (calcitriol)). Data collection and analysis We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of evidence. Main results We included 27 randomised clinical trials with 1979 adult participants. This review update added 12 trials with 945 participants. We assessed all trials at high risk of bias. All trials had a parallel‐group design. Eleven trials were conducted in high‐income countries and 16 trials in middle‐income countries. Ten trials included participants with chronic hepatitis C, five trials participants with liver cirrhosis, 11 trials participants with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. All of the included trials reported the baseline vitamin D status of participants. Participants in nine trials had baseline serum 25‐hydroxyvitamin D levels at or above vitamin D adequacy (20 ng/mL), whilst participants in the remaining 18 trials were vitamin D insufficient (less than 20 ng/mL). Twenty‐four trials administered vitamin D orally, two trials intramuscularly, and one trial intramuscularly and orally. In all 27 trials, the mean duration of vitamin D supplementation was 6 months, and the mean follow‐up of participants from randomisation was 7 months. Twenty trials (1592 participants; 44% women; mean age 48 years) tested vitamin D 3 (cholecalciferol); three trials (156 participants; 28% women; mean age 54 years) tested vitamin D 2 ; four trials (291 participants; 60% women; mean age 52 years) tested 1,25‐dihydroxyvitamin D; and one trial (18 participants; 0% women; mean age 52 years) tested 25‐hydroxyvitamin D. One trial did not report the form of vitamin D. Twelve trials used a placebo, whilst the other 15 trials used no intervention in the control group. Fourteen trials appeared to be free of vested interest. Eleven trials did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on all‐cause mortality (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.51 to 1.45; 27 trials; 1979 participants). The mean follow‐up was 7 months (range 1 to 18 months). We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on liver‐related mortality (RR 1.62, 95% CI 0.08 to 34.66; 1 trial; 18 participants) (follow‐up: 12 months); serious adverse events such as hypercalcaemia (RR 5.00, 95% CI 0.25 to 100.8; 1 trial; 76 participants); myocardial infarction (RR 0.75, 95% CI 0.08 to 6.81; 2 trials; 86 participants); thyroiditis (RR 0.33, 95% CI 0.01 to 7.91; 1 trial; 68 participants); circular haemorrhoidal prolapse (RR 3.00, 95% CI 0.14 to 65.9; 1 trial; 20 participants); bronchopneumonia (RR 0.33, 95% CI 0.02 to 7.32; 1 trial 20 participants); and non‐serious adverse events. The certainty of evidence for all outcomes is very low. We found no data on liver‐related morbidity such as gastrointestinal bleeding, hepatic encephalopathy, hepatorenal syndrome, ascites, or liver cancer. There were also no data on health‐related quality of life. The evidence is also very uncertain regarding the effect of vitamin D versus placebo or no intervention on rapid, early, and sustained virological response in people with chronic hepatitis C. Authors' conclusions Given the high risk of bias and insufficient power of the included trials and the very low certainty of the available evidence, vitamin D supplementation versus placebo or no intervention may increase or reduce all‐cause mortality, liver‐related mortality, serious adverse events, or non‐serious adverse events in adults with chronic liver diseases. There is a lack of data on liver‐related morbidity and health‐related quality of life. Further evidence on clinically important outcomes analysed in this review is needed. Plain language summary Vitamin D supplementation for chronic liver diseases Review question Is vitamin D supplementation beneficial or harmful for adults with chronic liver diseases? Background The available evidence on vitamin D and chronic liver diseases in adults is inconclusive. The aim of this systematic review (a summary of results of available healthcare trials) was to analyse the benefits and harms of the different forms of vitamin D in people with chronic liver diseases. Study characteristics Twenty‐seven trials with 1979 adult participants provided data for this review. This review update added 12 trials with 945 participants. The 1979 trial participants were randomly assigned to vitamin D compared with placebo (dummy pill) or no treatment. Eleven trials were conducted in high‐income countries, and 16 trials in middle‐income countries. The age range of the participants was 28 years to 61 years, and on average 44% were women. Ten trials included people with chronic hepatitis C, five trials people with liver cirrhosis, 11 trials people with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. There were no trials including people with chronic hepatitis B or inherited liver diseases. All of the included trials reported the baseline vitamin D status of participants. Vitamin D administration lasted on average six months, and most trials used the cholecalciferol (vitamin D 3 ) form. Funding Fourteen trials appeared to be free of vested interest that could bias the trial results. Eleven trials may not have been free of vested interest, as they did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We found no difference between trials without industry support compared to trials at risk of industry support in our analysis. Key results There is not enough evidence to determine whether vitamin D has beneficial or harmful effects, or has little to no effect on chronic liver diseases in adults. There were too few participants in the individual trials as well as in our evidence synthesis. The trials were at high risk of bias so we lack fair assessments of the benefits and harms of vitamin D in this population. Neither benefits nor harms of vitamin D supplementation in people with chronic liver diseases can be excluded. There were no trials including people with chronic hepatitis B and inherited liver diseases. Quality of the evidence We judged all trials to be at high risk of bias (that is an underestimation or overestimation of the true intervention effect). The certainty of evidence is very low. Currentness of evidence The evidence is current to November 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Bjelakovic, M, Nikolova, D, Bjelakovic, G, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD011564.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.767Z" }, { "id": "b53d68dc-5d53-471b-b398-dfe7be5a3a19", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: cytokines and growth factors", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulceration can lead to severe pain and difficulty with eating and drinking, which may necessitate opioid analgesics, hospitalisation and supplemental nutrition. These complications may disrupt cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining of the mouth, thus preventing or reducing oral mucositis and its negative effects. Objectives To assess the effects of cytokines and growth factors for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (searched 10 May 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4) in the Cochrane Library (searched 10 May 2017); MEDLINE Ovid (1946 to 10 May 2017); Embase Ovid (7 December 2015 to 10 May 2017); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 10 May 2017); and CANCERLIT PubMed (1950 to 10 May 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of cytokines and growth factors in patients with cancer receiving treatment. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 35 RCTs analysing 3102 participants. Thirteen studies were at low risk of bias, 12 studies were at unclear risk of bias, and 10 studies were at high risk of bias. Our main findings were regarding keratinocyte growth factor (KGF) and are summarised as follows. There might be a reduction in the risk of moderate to severe oral mucositis in adults receiving bone marrow/stem cell transplantation after conditioning therapy for haematological cancers (RR 0.89, 95% CI 0.80 to 0.99; 6 studies; 852 participants; low‐quality evidence). We would need to treat 11 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 6 to 112). There might be a reduction in the risk of severe oral mucositis in this population, but there is also some possibility of an increase in risk (RR 0.85, 95% CI 0.65 to 1.11; 6 studies; 852 participants; low‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to prevent the outcome to 14 to cause the outcome). There is probably a reduction in the risk of moderate to severe oral mucositis in adults receiving radiotherapy to the head and neck with cisplatin or fluorouracil (RR 0.91, 95% CI 0.83 to 1.00; 3 studies; 471 participants; moderate‐quality evidence). We would need to treat 12 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 7 to infinity). It is very likely that there is a reduction in the risk of severe oral mucositis in this population (RR 0.79, 95% CI 0.69 to 0.90; 3 studies; 471 participants; high‐quality evidence). We would need to treat 7 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to 15). It is likely that there is a reduction in the risk of moderate to severe oral mucositis in adults receiving chemotherapy alone for mixed solid and haematological cancers (RR 0.56, 95% CI 0.45 to 0.70; 4 studies; 344 participants; moderate‐quality evidence). We would need to treat 4 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 3 to 6). There might be a reduction in the risk of severe oral mucositis in this population (RR 0.30, 95% CI 0.14 to 0.65; 3 studies; 263 participants; low ‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 8 to 19). Due to the low volume of evidence, single‐study comparisons and insufficient sample sizes, we found no compelling evidence of a benefit for any other cytokines or growth factors and there was no evidence on children. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Authors' conclusions We are confident that KGF is beneficial in the prevention of oral mucositis in adults who are receiving: a) radiotherapy to the head and neck with cisplatin or fluorouracil; or b) chemotherapy alone for mixed solid and haematological cancers. We are less confident about a benefit for KGF in adults receiving bone marrow/stem cell transplant after conditioning therapy for haematological cancers because of multiple factors involved in that population, such as whether or not they received total body irradiation (TBI) and whether the transplant was autologous (the patients' own cells) or allogeneic (cells from a donor). KGF appears to be a relatively safe intervention. Due to limited research, we are not confident that there are any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Plain language summary Can cytokines and growth factors help prevent mouth soreness and ulcers (oral mucositis) in patients being treated for cancer? Review question This review has been produced to assess whether or not the use of cytokines and growth factors during cancer treatment, can help prevent mouth soreness and ulcers. Background Sore mouth and ulcers (oral mucositis) is a side effect of treatment for cancer including chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulcers can lead to severe pain and difficulty with eating and drinking. Sufferers may need strong painkillers, possibly have to go into hospital and even be fed through a tube into their stomach or their veins. These complications may disrupt their cancer therapy, meaning they are not receiving the best treatment, which may reduce survival. Cancer patients have weakened immune systems due to their treatment and are less able to fight infections. An ulcer is an open wound and there is a risk that bacteria can enter the body leading to infection or sepsis (a dangerous inflammatory reaction of the body to infection). Mouth soreness and ulcers can be costly to healthcare systems, yet there are few preventive interventions or treatments proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining the mouth, thus preventing or reducing oral mucositis and its negative effects. Study characteristics Authors from Cochrane Oral Health carried out this review of existing studies and the evidence is current up to 10 May 2017. It includes 35 studies (published between 1993 and 2017) with 3102 participants, all patients being treated for cancer, aged from 1 to 87 years old. Review authors included studies comparing cytokines and growth factors for the prevention of oral mucositis. The studies were carried out all over the world and often featured multiple sites, although most took place in high‐income countries. Main results The main findings were regarding keratinocyte growth factor (KGF). KGF is likely to reduce the risk of oral mucositis in adults who are receiving either radiotherapy to the head and neck with chemotherapy (cisplatin or fluorouracil), or chemotherapy alone for mixed solid and blood cancers. KGF may also reduce the risk of oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, but these results are less clear because of multiple complicating factors. KGF appears to be a relatively safe intervention. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Due to limited research, review authors are uncertain of any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Quality of the evidence For reducing oral mucositis in adults receiving radiotherapy to the head and neck with chemotherapy, review authors rated the evidence for KGF as moderate to high quality. For reducing oral mucositis in adults receiving chemotherapy alone for mixed solid and blood cancers, they rated the evidence for KGF as low to moderate quality. This evidence was downgraded due to there not being enough data and because some results have not yet been published. For reducing oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, they rated the evidence for KGF as low quality because results were not similar across the studies and some results have not yet been published. Evidence on side effects of KGF was poorly reported and inconsistent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P; Glenny, AM; Worthington, HV; Littlewood, A; Fernandez Mauleffinch, LM; Clarkson, JE; McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "b55b4983-a706-41cc-a315-77e1364dd14a", "pmid": "", "title": "Pharmacologic Augmentation of TMS for Depression With D-serine", "imported": false, "abstract": "The goal of this study is to test whether combining D-serine with 30 treatments of a) iTBS and b) 18-Hz protocols will enhance clinical outcomes compared to rTMS with placebo (i.e., sugar pill). The investigators hypothesize that NMDA receptor activation via D-serine combined with repeated sessions of rTMS will produce greater clinical outcomes than iTBS with placebo and 18-Hz with placebo.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "b55f30c2-6d3c-44c8-b0de-e3d99ec94b50", "pmid": "", "title": "Changes in Taste Perception, Eating Habits, and Other Behavioral Aspects Associated With the Use of GLP-1 Receptor Agonists in Patients Undergoing Weight Loss Treatment: A Retrospective Observational Study.", "imported": false, "abstract": "This observational retrospective study aims to evaluate changes in taste perception, eating habits, and behavioral aspects in adults treated with GLP-1 receptor agonists for weight loss. Participants include adults aged 18-60 receiving treatment at specialized nutrition centers in Italy. Data are collected from clinical records, dietary questionnaires, and metabolic assessments before and after at least 12 weeks of GLP-1 agonist treatment. The study's primary goal is to understand how these treatments affect food preferences and taste perception. Secondary outcomes include changes in body weight, body composition, gastrointestinal side effects, and treatment adherence. All data are anonymized and collected according to ethical guidelines.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.142Z" }, { "id": "b5662d22-282a-47cc-965f-fe295dda6fd9", "pmid": "", "title": "Helicobacter pylori eradication for the prevention of gastric neoplasia", "imported": false, "abstract": "Abstract - Background Gastric cancer is the third most common cause of cancer death worldwide. Individuals infected with Helicobacter pylori have a higher likelihood of developing gastric cancer than individuals who are not infected. Eradication of H. pylori in healthy asymptomatic individuals in the general population may reduce the incidence of gastric cancer, but the magnitude of this effect is unclear. Objectives To assess the effectiveness of eradication of H. pylori in healthy asymptomatic individuals in the general population in reducing the incidence of gastric cancer. Search methods We identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 1), MEDLINE (1946 to February 2020), and EMBASE (1974 to February 2020). We handsearched reference lists from trials selected by electronic searching to identify further relevant trials. We handsearched published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ) between 2001 and 2019. We contacted members of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials comparing at least one week of H. pylori therapy with placebo or no treatment in preventing subsequent development of gastric cancer in otherwise healthy and asymptomatic H. pylori ‐positive adults. Trials had to follow up participants for at least two years and needed to have at least two participants with gastric cancer as an outcome. We defined gastric cancer as any gastric adenocarcinoma, including intestinal (differentiated) or diffuse (undifferentiated) type, with or without specified histology. Data collection and analysis We collected data on incidence of gastric cancer, incidence of oesophageal cancer, deaths from gastric cancer, deaths from any cause, and adverse effects arising due to therapy. Main results Six trials met all our eligibility criteria and provided extractable data in the previous version. Following our updated search, one new RCT was identified, meaning that seven trials were included in this updated review. In addition, one previously included trial provided fully published data out to 10 years, and another previously included trial provided fully published data out to 22 years of follow‐up. Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. Six trials were conducted in Asian populations. In preventing development of subsequent gastric cancer, H. pylori eradication therapy was superior to placebo or no treatment (RR 0.54, 95% confidence interval (CI) 0.40 to 0.72, 7 trials, 8323 participants, moderate certainty evidence). Only two trials reported the effect of eradication of H. pylori on the development of subsequent oesophageal cancer. Sixteen (0.8%) of 1947 participants assigned to eradication therapy subsequently developed oesophageal cancer compared with 13 (0.7%) of 1941 participants allocated to placebo (RR 1.22, 95% CI 0.59 to 2.54, moderate certainty evidence). H. pylori eradication reduced mortality from gastric cancer compared with placebo or no treatment (RR 0.61, 95% CI 0.40 to 0.92, 4 trials, 6301 participants, moderate certainty evidence). There was little or no evidence in all‐cause mortality (RR 0.97, 95% CI 0.85 to 1.12, 5 trials, 7079 participants, moderate certainty evidence). Adverse events data were poorly reported. Authors' conclusions We found moderate certainty evidence that searching for and eradicating H. pylori reduces the incidence of gastric cancer and death from gastric cancer in healthy asymptomatic infected Asian individuals, but we cannot necessarily extrapolate this data to other populations. Plain language summary Helicobacter pylori treatment for the prevention of stomach cancer Review question Whether testing healthy people for Helicobacter pylori and treating those infected with a course of antibiotics decreases the number of new cases of gastric cancer. Background Helicobacter pylori ( H. pylori ) is a bacteria that lives in the lining of the stomach with people usually not aware they are carrying the infection. People with H. pylori infection are more likely to develop gastric cancer than people who are not infected with the bacterium. For this reason, H. pylori is classed as carcinogenic (causing cancer) to humans. Many people worldwide die of gastric cancer every year, because by the time those affected seek the opinion of a doctor, the condition is often advanced. However, H. pylori infection is easily treatable with a one‐week course of antibiotics. Study characteristics A literature search up to 02 Feburary 2020 found seven trials (containing 8323 participants, four trials at low risk of bias). Six of the studies were based in Asia. Key results We found that antibiotics for H. pylori have a small benefit in preventing gastric cancer (68 (1.6%) of 4206 participants given treatment developed gastric cancer subsequently, compared with 125 (3.0%) of 4117 given no treatment or a placebo), and in decreasing the number of deaths from gastric cancer (36 (1.1%) of 3154, compared with 59 (1.9%) of 3147); but it is unclear whether or not they increase or decrease the number of deaths due to any cause, or increase or decrease the number of cases of oesophageal cancer. Data about side effects of treatment were poorly reported. Quality of the evidence Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. One study was at high risk of bias because no placebo was used for the active eradication therapy regimen, and so this part of the trial was unblinded, and the other study was at high risk of bias due to inconsistencies in data reporting at the two points of follow‐up. We were unable to resolve this discrepancy despite contacting the original authors. As a result, we downgraded the quality of evidence from high to moderate due to serious risk of bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ford, AC; Yuan, Y; Forman, D; Hunt, R; Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD005583.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "b56de021-2d9a-475b-a0e6-15d6f4e91192", "pmid": "", "title": "Fortification of condiments and seasonings with iron for preventing anaemia and improving health", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jalal, CSB, De-Regil, LM, Pike, V, Mithra, P", "articleTypes": [], "doi": "10.1002/14651858.CD009604.pub2 AB - Abstract - Background Anaemia affects approximately 1.8 billion people worldwide; over 60% of anaemia cases globally are due to iron deficiency (ID). Iron deficiency and anaemia contribute to the global burden of disease and affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortification of food with iron, alone or in combination with other nutrients, is an effective intervention to control ID. Condiments and seasonings are ideal food vehicles for iron fortification in countries where they are commonly used. Objectives To determine the effects and safety of condiment and seasoning fortification with iron alone or iron plus other micronutrients on iron deficiency, anaemia, and health‐related outcomes in the general population. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 24 January 2023. We also searched the International clinical trials registry platform (ICTRP) for any ongoing trials. Selection criteria We included randomised controlled trials (RCTs) (randomisation at individual or cluster level), non‐randomised controlled trials, interrupted time series with at least three measure points both before and after intervention, and controlled before‐after studies. Participants were populations of any age (including pregnant women), from any country, excluding those with critical illness or severe co‐morbidities. We included interventions in which condiments or seasonings have been fortified with any combination of iron and other vitamins and minerals, irrespective of the fortification technology used. Data collection and analysis Two review authors independently screened and assessed the eligibility of studies. Disagreements were resolved through discussion or input from a third review author. Two review authors extracted the data and assessed the risk of bias in all the included studies. We followed the methods laid out by Cochrane and used GRADE criteria for assessing certainty of the evidence. Main results Our search identified 15,902 records after removal of duplicates. We included 16 studies with 20,512 participants (18,410 participants after adjusting for clustering effects). They were all carried out in upper‐middle‐ and lower‐middle‐income countries. Three studies were controlled before‐after studies, one was non‐randomised trial, and 12 were RCTs (including three cluster RCTs). Six studies took place in schools; seven in communities; and one each in a nursery/kindergarten, tea estate, and factory. Three studies involved only women, one study involved both women and their children, and all other studies focused on children and/or adolescents. Nine studies used salt as a vehicle for iron fortification, three used fish sauce, two used soy sauce, one used curry powder, and one a \"seasoning powder\". The dose of iron received by participants ranged from 4.4 mg to 55 mg/day. The sample sizes in the trials ranged from 123 to 14,398, and study durations ranged from three months to two years. Twelve RCTs contributed data for meta‐analysis. Six trials compared iron‐fortified condiments versus the unfortified condiment, and six trials provided data comparing iron fortification in combination with other micronutrients versus the same condiment with other micronutrients, but no added iron. In one trial, the fortificant contained micronutrients that may have affected the absorption of iron. Overall no studies were assessed as having a low risk of bias. All included studies were assessed to have a high overall risk of bias, with the most concerns being around allocation concealment, blinding, and random sequence generation. There was very high heterogeneity amongst studies in almost all examined outcomes. Condiments/seasonings fortified with iron versus unfortified condiments/seasonings We are uncertain about whether consuming condiments/seasonings fortified with iron in comparison to the same unfortified condiment reduces anaemia at the end of intervention (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.18 to 0.65; 2328 participants; 4 studies; very low‐certainty of evidence). We are uncertain about whether consuming iron‐fortified condiments increases haemoglobin concentrations (mean difference (MD) 6.40 (g/L), 95% CI ‐0.62 to 13.41; 2808 participants; 5 studies; very low‐certainty evidence). Fortification of condiments/seasonings with iron probably slightly reduces ID (RR 0.33, 95% CI 0.11 to 1.01; 391 participants; 2 studies; moderate‐certainty evidence). We are uncertain about whether fortification with iron increases ferritin concentration (MD 14.81 (µg/L), 95% CI 5.14 to 24.48; 4459 participants; 6 studies; very low‐certainty evidence). Condiments/seasonings fortified with iron plus other micronutrients versus condiments/seasonings fortified with other micronutrients except iron Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia (RR 0.59, 95% CI 0.40 to 0.89; 1007 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification of condiments/seasonings with iron plus other micronutrients will improve haemoglobin concentration (MD 6.22 g/dL, 95% CI 1.60 to 10.83; 1270 participants; 5 studies; very low‐certainty evidence). It may reduce ID (RR 0.36, 95% CI 0.19 to 0.69; 1154 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification with iron plus other micronutrients improves ferritin concentration (MD 10.63 µg/L, 95% CI 2.40 to 18.85; 1251 participants; 5 studies; very low ‐certainty evidence). Condiments/seasonings fortified with iron versus no intervention No trial reported data on this comparison. No studies reported adverse effects. Funding sources do not appear to have distorted the results in any of the assessed trials. Authors' conclusions We are uncertain whether consuming iron‐fortified condiments/seasonings reduces anaemia, improves haemoglobin concentration, or improves ferritin concentration. It may reduce ID. Findings about ferritin should be interpreted with caution since its concentrations increase during inflammation. Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia, and we are uncertain whether this will improve haemoglobin concentration or ferritin concentration. More studies are needed to determine the true effect of iron‐fortified condiments/seasonings on preventing anaemia and improving health. The effects of this intervention on other health outcomes like malaria incidence, growth and development are unclear. Plain language summary Adding iron to condiments and seasonings for preventing anaemia and improving health Key messages ‐ Adding iron to condiments/seasonings may slightly improve iron status and reduce iron deficiency. When iron is added along with other micronutrients, it may reduce anaemia. Unwanted effects were not reported. ‐ There was a lot of variation between the studies included in this review, making it more difficult to draw definitive conclusions. The effects of fortifying condiments and seasonings with iron should continue to be examined in populations consuming them through well‐designed studies. What is anaemia? Iron deficiency is one of the most common nutritional deficiencies throughout the world and contributes significantly to the global burden of disease. Multiple factors cause anaemia, including insufficient iron intake (the most common cause of anaemia), and it affects approximately 1.8 billion people worldwide. In general, low‐income countries have more anaemia than higher‐income countries. Iron deficiency and anaemia have several lifetime consequences that can affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortifying condiments or seasonings with iron may be a useful and cost‐effective approach to help reduce iron deficiency. To date, there has been no systematic assessment of the safety and effectiveness of this intervention to inform policymaking. What did we want to find out? If fortifying condiments and seasonings with iron alone or iron plus other micronutrients improves measures of iron nutrition in the general population, in particular: ‐ anaemia; ‐ haemoglobin concentration; ‐ iron deficiency; ‐ iron status (including ferritin, transferrin saturation, and more). We also wanted to find out if consuming iron‐fortified condiments/seasonings was associated with any unwanted effects. What did we do? 
We searched for studies that provided iron‐fortified condiments/seasonings to one group, and condiments/seasonings not fortified with iron to another. We compared and summarised the results of the studies and rated our confidence in the evidence, based on study characteristics. What did we find? We identified 16 studies that involved 18,410 participants in middle‐income countries, most within schools or communities, with study durations ranging from three months to two years. The type of iron‐fortified condiments/seasonings used included salt, fish sauce, soy sauce, and seasoning powders. The dose of iron received by participants ranged from 4.4mg to 55 mg/day. Compared to unfortified condiments/seasonings, those which are iron‐fortified likely improve iron deficiency slightly. We are uncertain whether they reduce anaemia, improve haemoglobin, or other measures of iron status. Condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia; we are uncertain about whether they improve haemoglobin or ferritin concentrations. They may improve iron deficiency and total iron binding capacity. No studies reported adverse effects. More studies are needed to determine the effect of iron‐fortified condiments/seasonings on health such as malaria incidence, growth and development and any potential adverse effects. What are the limitations of the evidence? Our confidence in the evidence is very low to moderate; several factors reduced our confidence in the evidence. Firstly, we observed limitations in the way few studies were conducted with respect to the recruitment of people to assign interventions (this means that differences between the groups could be due to differences between people rather than between the treatments). Secondly, people in some studies may have been aware of which treatment they were getting. Also, not all the studies provided data about everything that were interested in, and results were inconsistent across the different studies. Finally, some studies were small. The results of future research could differ from the results of this review. How up to date is this evidence? The evidence is up‐to‐date to January 2023. What this means We judged the evidence in this review as very low to moderate certainty, which means we are not certain of the effect of condiments/seasonings with added iron on the reduction of anaemia and iron deficiency in people.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.106Z" }, { "id": "b58ab53b-99b5-46ff-9704-6201f6e60246", "pmid": "", "title": "Perioperative nutrition interventions for women with ovarian cancer", "imported": false, "abstract": "Abstract - Background Women with ovarian cancer have been shown to be at significant risk of malnutrition with incidence rates described as being between 28% to 67%. Nutrition interventions may improve clinical outcomes positively, nutritional status or quality of life measures in this patient group. Objectives This review was conducted to assess the effects of nutrition interventions during the perioperative period for women with ovarian cancer. Search methods Electronic searches were conducted of the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 7), Medline (1946 to July week 4 2012), Embase (1980 to 2012 week 31), DARE (to 7th August 2012) AMED (1985 to April 2012), BNI (1992 to April 2012), CINAHL (to April 2012). We also searched trials databases, conference proceedings and related citation lists. Reference listings were handsearched. No restrictions were applied on language or date. Selection criteria Randomised controlled trials (RCTs) in which women 18 years and over with any stage of ovarian cancer, including recurrent cancer, were in the perioperative phase of treatment and received any type of nutrition intervention. Data collection and analysis Titles and abstracts were screened by two review authors with study selection discussed by a team. Pairs of review authors worked independently on data collection and compared findings. Main results A total of 4092 titles were screened and 14 full text reports reviewed; a single small study met the inclusion criteria. In the included RCT, 40 women (35 with ovarian cancer) had extensive elective surgery including bowel resection for treatment of gynaecological malignancy. Randomisation was made to either early oral feeding (oral fluids in the first 24 hours, solid foods on the following day) or to a 'traditional' feeding regimen where oral fluids and foods were delayed until there was evidence of bowel function. Most women in the early feeding group (14/18) were able to resume eating solid food one day after surgery. This resulted in a significantly shorter hospital stay with no increase in postoperative complications or change in quality of life measures in comparison with the women on the 'traditional' feeding regimen. The incidence of nausea and vomiting during the postoperative stay was similar in both groups and was noted in slightly more than half of the women. Overall survival was evaluated until 30 days following discharge from hospital; in this period, there was one death of a woman who had been in the 'traditional oral feeding' group, cause of death was not noted. We assessed risk of bias and found no high risk of bias was identified in the methodology and reporting of the included study, although there was an increased risk of bias due to the small size of the study in which not all of the women had ovarian cancer. Authors' conclusions Although women with ovarian cancer have been shown to be at risk of malnutrition, there is a lack of evidence derived from RCTs evaluating the identification, assessment and treatment of malnutrition during the perioperative phase of treatment. There is evidence from one small study that some women with ovarian cancer undergoing surgery with associated bowel resection may safely commence oral fluids within 24 hours of surgery and solid foods on the following day. Further research is required, including a RCT, to generate guidance concerning the treatment of malnutrition in this patient group. Plain language summary Nutrition for women who are having surgery for ovarian cancer Women who have ovarian cancer, (a cancer which develops in the two organs (ovaries) that produce eggs in women) are more likely to have difficulties with food and with eating a nourishing diet in comparison to women with other types of gynaecological cancers. One reason may be because the symptoms of ovarian cancer can be difficult to recognise. Women may have a lack of interest in food, feel full, feel sick or have a painful or swollen abdomen. Some women become thinner in parts of their bodies while becoming bigger around their abdomen due to an abnormal build up of fluid or large tumours. There may be no change in body weight or weight may increase, this can make it difficult to know which women are developing problems due to a poor food intake. Women who are unable to eat and drink well are at risk of becoming malnourished and may then have more complications from the treatments for ovarian cancer than women who are not malnourished. It is recommended that people who are having difficulties with eating and drinking should be identified and helped when they receive hospital care. Currently, there is no agreed method for finding and treating nutritional problems for women with ovarian cancer. In this review, the authors looked for studies (randomised controlled trials (RCTs)) from around the world to find out how women with ovarian cancer were assessed to see if they were eating and drinking well and what help they may be given with nutrition before or after surgery. A lack of information was found on this topic. One RCT was found where a small group of women (40 including 35 with ovarian cancer) requiring extensive elective surgery for gynaecological cancer including surgery to the gut, were able to restart eating normal foods on the day after surgery. They were able to leave hospital earlier and did not have more complications in the month after surgery than women who were not allowed to resume eating normal foods until at least three days after the operation. More studies are needed to confirm whether restarting normal eating one day after surgery can be recommended for women having surgery for ovarian cancer. More research is needed to provide information about how to identify and treat problems of malnutrition in women with ovarian cancer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Billson, HA, Holland, C, Curwell, J, Davey, VL, Kinsey, L, Lawton, LJ, Whitworth, AJ, Burden, S", "articleTypes": [], "doi": "10.1002/14651858.CD009884.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.783Z" }, { "id": "b5924622-dd48-4b2a-b64f-7e50daf035d2", "pmid": "", "title": "Chinese medicinal herbs for asymptomatic carriers of hepatitis B virus infection", "imported": false, "abstract": "Abstract - Background About 350 million people are chronically infected carriers of hepatitis B virus and are at a higher risk of serious illness and death from cirrhosis of the liver and liver cancer. Chinese medicinal herbs have been used widely for more than 2000 years to treat chronic liver disease. Objectives To assess whether Chinese medicinal herbs are effective and safe for treating asymptomatic carriers of hepatitis B virus. Search methods The trials registers of The Cochrane Hepato‐Biliary Group , The Cochrane Library , and The Cochrane Complementary Medicine Field were searched in combination with MEDLINE , EMBASE , and handsearches of Chinese journals and conference proceedings (October 2000). Selection criteria Randomised or quasi‐randomised trials (minimum follow‐up three months) in asymptomatic carriers of hepatitis B virus. Chinese medicinal herbs (single herb or compound of herbs) compared with placebo, no intervention, general non‐specific treatment, or interferon treatment. Trials of Chinese medicinal herbs plus interferon versus interferon alone were also included. Data collection and analysis Data were extracted independently by two authors. Analysis was performed by intention‐to‐treat where possible. Pre‐specified subgroup analyses were: ethnic origin, age at time of infection, and single herb or compound of herbs. Main results Three randomised clinical trials (307 patients) that followed patients for three months or more after the end of treatment were included. The methodological quality was poor. The herbal compound 'Jianpi Wenshen recipe' had significant effects on viral markers compared to interferon: relative risk 2.40 (95% CI 1.01 to 5.72) for clearance of serum HBsAg, 2.03 (95% CI 0.98 to 4.20) for clearance of HBeAg, and 2.54 (95% CI 1.13 to 5.70) for seroconversion of HBeAg to anti‐HBe. Phyllanthus amarus and Astragalus membranaceus showed no significant antiviral effect compared with placebo. Analysis of pooling eight randomised clinical trials with less than three months follow‐up did not show a significant benefit of Chinese medicinal herbs on viral markers. Data on long‐term clinical outcomes and quality of life were lacking. Authors' conclusions Based on one low quality trial, the medicinal herb 'Jianpi Wenshen recipe' may have an antiviral activity in asymptomatic carriers of hepatitis B virus. However, rigorous randomised, double‐blind, placebo‐controlled trials are needed before herbs should be used for this condition. Plain language summary Firm evidence for effect of Chinese medicinal herbs for asymptomatic hepatitis B virus carriers is still awaited Chinese medicinal herbs have a long history in the treatment of liver diseases. Three randomised clinical trials were included. Due to their poor methodologic quality and the existing small number of trials, there is currently insufficient evidence for treating asymptomatic hepatitis B virus carriers with Chinese medicinal herbs like the herbal compound 'Jianpi Wenshen recipe', Phyllanthus amarus and Astragalus membranaceus. Methodologically better and larger randomised trials are needed comparing medicinal herbs versus placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Liu, JP, McIntosh, H, Lin, H", "articleTypes": [], "doi": "10.1002/14651858.CD002231", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.092Z" }, { "id": "b59adf76-c361-4acf-b30c-a725e2fdc9de", "pmid": "", "title": "Chlorhexidine mouthrinse as an adjunctive treatment for gingival health", "imported": false, "abstract": "Abstract - Background Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build‐up of plaque thereby reducing gingivitis. Objectives To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day). To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs. Data collection and analysis Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random‐effects models for all meta‐analyses. Main results We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high‐quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high‐quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate‐quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies). Authors' conclusions There is high‐quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high‐quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies. Plain language summary Chlorhexidine mouthrinse to reduce gingivitis and plaque build‐up Review question Does the use of chlorhexidine mouthrinse (a broad spectrum antiseptic) in addition to other conventional tooth cleaning help to control and improve gingivitis (inflammation of the gums)? Does the frequency of rinsing or the concentration of the solution affect the result and are there any undesirable side effects? Background Gingivitis is a reversible condition when gums become red, swollen and can bleed easily. Gingivitis is also very common ‐ studies suggest that as many as 50% to 90% of adults in the UK and USA suffer from it. In susceptible people gingivitis may lead to periodontitis, which is not reversible. In periodontitis inflammation is accompanied by loss of ligaments and bone supporting the teeth. If untreated it may eventually lead to tooth loss. Severe periodontitis is the sixth most widespread disease globally. It is recognised that maintaining a high standard of oral hygiene is important for the prevention and treatment of gingivitis. Toothbrushing is the main method for maintaining good oral hygiene. Other cleaning methods commonly used include dental floss, interdental brushes and scaling and polishing carried out by a dental professional. Some people have difficulty controlling plaque build‐up and preventing gingivitis using only conventional tooth cleaning. Therefore people sometimes use mouthrinses containing chlorhexidine in addition to conventional tooth cleaning. These mouthrinses are readily available over the counter; prescriptions generally not being required outside the USA. Study characteristics We included 51 studies that analysed a total of 5345 participants. The evidence in this review is up to date as of 28 September 2016. Generally study participants were children and adults who had gingivitis or periodontitis, were able to use usual tooth cleaning methods and were healthy. We did not exclude studies where some or all participants had medical conditions or special care needs as we considered the use of mouthrinses with chlorhexidine to be particularly relevant to them. The included studies assessed the effects of chlorhexidine mouthrinse used for at least 4 weeks in addition to conventional tooth cleaning on gingivitis in children and adults. Key results There is high‐quality evidence that the use of mouthrinses containing chlorhexidine in addition to usual toothbrushing and cleaning for 4 to 6 weeks or 6 months leads to a large reduction in the build‐up of plaque. There is also high‐quality evidence of a moderate reduction in gingivitis in people with a mild level of it, although because the level of disease was already low this is not considered clinically important. The nature of the available evidence does not allow us to determine the level of reduction of gingivitis in people with moderate to severe levels of it. There was no evidence that one concentration or strength of chlorhexidine rinse was more effective than another. Rinsing for 4 weeks or longer causes tooth staining, which requires scaling and polishing carried out by a dental professional. Other side effects have been reported, including build‐up of calculus (tartar), temporary taste disturbance and temporary shedding of/damage to the lining of the mouth. Quality of the evidence One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "James, P, Worthington, HV, Parnell, C, Harding, M, Lamont, T, Cheung, A, Whelton, H, Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD008676.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.732Z" }, { "id": "b5b376c8-cc2a-4991-9f9f-fb463543a16f", "pmid": "", "title": "Omega‐3 fatty acid supplementation for depression in children and adolescents", "imported": false, "abstract": "Abstract - Background Mental health disorders including major depressive disorder (MDD) are well recognized as major contributors to the global burden of disease among adolescents. The prevalence of adolescent depression is estimated to have increased by at least 25% during the COVID‐19 pandemic, compounding the already challenging problem of insufficient mental health service and service accessibility that existed prepandemic. Omega‐3 polyunsaturated fatty acid (PUFA) supplementation is currently recommended as a preventive treatment for depression in high‐risk adults as well as a second‐line monotherapy for adults with mild to moderate MDD, and adjunctive to antidepressants for adults with moderate to severe MDD. The benefits of omega‐3 PUFA intake on depressive illness have been hypothesized to occur as a result of their effect on neurotransmission, maintenance of membrane fluidity, and anti‐inflammatory action. A comprehensive synthesis and quantification of the existing evidence on omega‐3 PUFA's efficacy in treating depression among children and adolescents is essential for clinicians to provide informed guidance to young people and their families, especially considering the absence of current guidelines for this age group. Objectives Primary objective To determine the impact of omega‐3 PUFA supplementation versus a comparator (e.g. placebo, wait list controls, no treatment/supplementation, or standard care) on clinician‐diagnosed depression or self‐reported depression symptoms in children and adolescents. Secondary objectives To estimate the size of the effect of omega‐3 PUFAs on depression symptoms. To estimate the effect of each type of omega‐3 PUFA (EPA or DHA), compared with placebo, on depression. To determine if the effect is modified by dosage, format (capsule or liquid), sex, or age. To determine compliance and attrition for omega‐3 PUFAs as an intervention for depression in children and adolescents. To determine the safety of omega‐3 PUFAs as an intervention for depression in children and adolescents. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases, reference lists of included studies, grey literature, and relevant reviews. The latest search date was 18 May 2023. Selection criteria We included randomized controlled trials (RCTs) involving males and females aged 19 years or younger with diagnosed depression comparing omega‐3 PUFA supplementation to placebo, wait list control, no treatment/supplementation, or standard care. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were self‐reported depression symptoms and clinically diagnosed resolution of depression. Our secondary outcomes were attrition, adverse effects, and compliance with the intervention. We used GRADE to assess the certainty of evidence for key outcomes. Main results We included five trials with 228 participants in our meta‐analysis. All trials used a placebo comparator; intervention duration ranged from 10 to 16 weeks (median: 12 weeks). Omega‐3 PUFA supplementation compared to placebo may reduce self‐reported depression symptoms, but the evidence is very uncertain (standardized mean difference [SMD] −0.34, 95% confidence interval [CI] −0.85 to 0.17; lower SMD means greater improvement in depression due to omega‐3 PUFA; 5 trials, 185 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may have little to no effect on remission of depression symptoms compared to placebo, but the evidence is very uncertain (omega‐3 PUFA versus placebo: 50% versus 48%; odds ratio [OR] 1.11, 95% CI 0.45 to 2.75; 4 trials, 127 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in attrition (dropouts) compared to placebo (omega‐3 PUFA versus placebo: 18% versus 19%; OR 0.94, 95% CI 0.46 to 1.90; 5 trials, 228 participants; low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in adverse effects, with one study reporting more muscle cramps in the fish oil group (13/27 participants) compared to the placebo group (6/29 participants); one study reported more frequent defecation in the omega‐3 group (1/29 participants) and one study identified mild skin rash and unusual/manic behavior in the placebo group (2/27 participants). None of the included studies reported serious adverse effects. Authors' conclusions Based on five small studies, omega‐3 PUFA supplementation may reduce self‐reported depression symptoms, but the evidence is very uncertain. Omega‐3 PUFA supplementation may have little to no effect on depression remission compared to placebo, but the evidence is very uncertain. Omega‐3 PUFA supplementation may result in little to no difference in attrition or adverse effects. The studies observed no serious adverse effects. This review highlights early‐stage research on omega‐3 PUFA and depression in young people. The evidence on the effects of omega‐3 PUFA supplementation in improving self‐reported depression symptoms or achieving depression remission in children and adolescents is very uncertain. While no harms are evident, more data are needed to confirm potential risks. Addressing current limitations in the evidence base through the design and conduct of methodologically rigorous studies — larger sample sizes, varied dosages, eicosapentaenoic acid/docosahexaenoic acid ratios, treatment durations, and safety profiles — is crucial to advance our understanding of the role of omega‐3 PUFA supplementation for depression in children and adolescents. Plain language summary Is omega‐3 polyunsaturated fatty acid supplementation better than a placebo for treating depression among children and adolescents? Key messages – Due to a lack of robust evidence, the benefits and unwanted effects of omega‐3 polyunsaturated fatty acids (which are important fats that you must obtain from your diet) supplementation for treating depression among children and adolescents are unclear. – Larger, well‐designed studies are needed to give better estimates of the potential benefits and harms of omega‐3 polyunsaturated fatty acid supplementation for child and adolescent depression. Why is it important to find treatments for children and adolescents with depression? People with depression have a low mood or lose pleasure or interest in usual activities. It is a long‐lasting (chronic) disorder that is both serious and recurrent (it can return after periods of feeling well). It often begins during childhood and adolescence, affecting up to eight in every 100 children. Unfortunately, response to current treatments for depression in children and adolescents is poor, and relieving symptoms (remission) can be challenging. In recent studies, supplements of omega‐3 polyunsaturated fatty acids have shown promise as a potential treatment for depression in adults. Our body cannot make these beneficial fats, but they are naturally present in oily fish, marine sources, and certain nuts and seeds. They can also be given as daily supplements in capsule or liquid forms (for example, as cod liver oil capsules). What did we want to find out? We wanted to find out: – if omega‐3 polyunsaturated fatty acids supplementation works to decrease symptoms of depression in children and adolescents; and – if omega‐3 polyunsaturated fatty acids supplementation helps children and adolescents achieve remission from depression. We also wanted to know if omega‐3 polyunsaturated fatty acids supplementation can cause any unwanted effects. What did we do? We searched for studies in which children and adolescents were assigned randomly to two or more treatment groups that compared omega‐3 polyunsaturated fatty acids supplementation with a placebo (pretend treatment with the same appearance), on a waiting list, no treatment/supplementation, or usual care. This is the best way to ensure that groups of people are similar and that investigators do not know who is in which group. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found five studies that involved 228 children and adolescents ranging from 10 to 16 years of age with depression. The largest study included 60 people, and the smallest study included 28 people. Three studies were conducted in the USA, one in Israel, and one in Slovakia. Four studies lasted for around 12 weeks and one study lasted for 16 weeks. We found that omega‐3 polyunsaturated fatty acids supplementation may reduce self‐reported depression symptoms, but the results are very uncertain. If omega‐3 PUFA supplements and placebos were given to a group of 100 children and adolescents with depression, then 50 children receiving omega‐3 polyunsaturated fatty acids would achieve remission and 48 receiving the placebo would achieve remission. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results, and the studies were very small. To date, there is insufficient evidence to determine if omega‐3 polyunsaturated fatty acids supplementation improves depression for children and adolescents. How up to date is this evidence? The evidence is up to date to 18 May 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Campisi, SC, Zasowski, C, Bradley-Ridout, G, Schumacher, A, Szatmari, P, Korczak, D", "articleTypes": [], "doi": "10.1002/14651858.CD014803.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.796Z" }, { "id": "b5b440bd-f64b-4710-be46-b06f872c3149", "pmid": "", "title": "Probiotic treatment for women with gestational diabetes to improve maternal and infant health and well‐being", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance first recognised during pregnancy and associated with complications for mothers and babies. Probiotics are naturally occurring micro‐organisms, which when ingested in adequate amounts, may confer health benefits. Evidence of the role of probiotics as treatment for GDM is limited. Objectives To evaluate the safety and effectiveness of probiotics in treating women with GDM on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth’s Trials Register ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (24 July 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing the use of probiotics versus placebo/standard care for the treatment of GDM. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, checked data accuracy, and assessed risk of bias of included trials. The certainty of evidence for selected maternal and infant/child outcomes was assessed using GRADE. Main results Nine RCTs (695 pregnant women with GDM) comparing probiotics versus placebo were identified. The overall risk of bias in the nine RCTs was low to unclear and the evidence was downgraded for imprecision due to the small numbers of women participating in the trials. The trials were carried out in hospitals and universities in Iran (seven trials), Thailand (one trial) and Ireland (one trial). All trials compared probiotics with placebo. Maternal outcomes We are uncertain if probiotics have any effect compared with placebo on hypertensive disorders of pregnancy, (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.64 to 3.53; participants = 256; studies = 3; low‐certainty evidence) and mode of birth as caesareans (average RR 0.64, 95% CI 0.30 to 1.35; participants = 267; studies = 3; low‐certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm . No trials reported primary outcomes of: mode of birth as vaginal/assisted and subsequent development of type 2 diabetes. We are uncertain if probiotics have any effect compared with placebo on induction of labour (RR 1.33, 95% CI 0.74 to 2.37; participants = 127; studies = 1; very low‐certainty evidence). For other secondary maternal outcomes, we are uncertain if there are differences between probiotics and placebo for: postpartum haemorrhage; weight gain during pregnancy intervention and total gestational weight gain; fasting plasma glucose and need for extra pharmacotherapy (insulin). Probiotics may be associated with a slight reduction in triglycerides and total cholesterol. In probiotics compared with placebo, there was evidence of reduction in markers for insulin resistance (HOMA‐IR) and HOMA‐B; and insulin secretion. There was also an increase in quantitative insulin sensitivity check index (QUICKI). Probiotics were associated with minor benefits in relevant bio‐markers with evidence of a reduction in inflammatory markers high‐sensitivity C‐reactive protein (hs‐CRP), interleukin 6 (IL‐6), and marker of oxidative stress malondialdehyde; and an increase in antioxidant total glutathione, but we are uncertain if there is any difference in total antioxidant capacity. No trials reported secondary outcomes: perineal trauma, postnatal weight retention or return to pre‐pregnancy weight and postnatal depression. Infant/child/adult outcomes We are uncertain if probiotics have any effect, compared with placebo, on the risk of large‐for‐gestational‐age babies (RR 0.73, 95% CI 0.35 to 1.52; participants = 174; studies = 2; low‐certainty evidence) or infant hypoglycaemia (RR 0.85, 95% CI 0.39 to 1.84; participants = 177; studies = 3; low ‐ certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm. No trials reported primary outcomes of: perinatal (fetal/neonatal) mortality; or neurosensory disability. For other secondary outcomes, we are uncertain if there is any difference between probiotics and placebo in gestational age at birth, preterm birth, macrosomia, birthweight, head circumference, length, infant hypoglycaemia, and neonatal intensive care unit (NICU) admissions. There was evidence of a reduction in infant hyperbilirubinaemia with probiotics compared with placebo. No trials reported secondary outcomes: infant adiposity, and later childhood adiposity. There were no adverse events reported by any of the trials. Authors' conclusions Low‐certainty evidence means we are not certain if there is any difference between probiotic and placebo groups in maternal hypertensive disorders of pregnancy, caesareans; and large‐for‐gestational‐age babies . There were no adverse events reported by the trials. Due to the variability of probiotics used and small sample sizes of trials, evidence from this review has limited ability to inform practice. Well‐designed adequately‐powered trials are needed to identify whether probiotics may improve maternal blood glucose levels and/or infant/child/adult outcomes; and whether they can be used to treat GDM. Plain language summary Probiotics as an added treatment for gestational diabetes to improve mother and baby outcomes What is the issue? Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in high blood glucose levels, first recognised during pregnancy. Pregnant women with GDM are at risk of high blood pressure, labour induction, and caesareans. Their babies are at risk of being born large, birth difficulties, respiratory distress, low blood glucose at birth and jaundice that can cause brain injury. There is increased risks of having long‐term diabetes in the mother, and the baby being overweight. Probiotics are micro‐organisms naturally in food and are in fermented milk, yogurt, or capsules. There are many different probiotics; the two most used are Lactobacillus and Bifidobacterium, and if consumed in adequate amounts may confer health benefits. Why is this important? Probiotics need to be safe and maternal blood glucose levels carefully managed during pregnancy. Women with GDM may receive dietary and physical activity education with monitoring blood glucose levels as initial management. When blood glucose levels are above a certain threshold, women with GDM are prescribed glucose‐lowering medications including metformin and/or insulin. This review aimed to determine the safety and effectiveness of probiotics in treating women with GDM. What evidence did we find? We searched for evidence for randomised controlled trials (latest July 2019). We identified nine studies, involving 695 women with GDM. All trials compared probiotics with placebo. The certainty of the evidence was assessed as very low or low. The overall risk of bias was low to unclear. Seven trials were conducted in Iran; one in Thailand, and one in Ireland. Trials took place in hospitals and universities. We are uncertain if there is any difference between probiotic and placebo in rates of: high blood‐pressure disorders (three studies, 256 participants, low‐certainty evidence); caesarean section (three studies, 267 women, low‐certainty evidence ); and large‐for‐gestational‐age babies (two studies, 174 participants, low‐certainty evidence). We are uncertain if there is any difference between probiotic and placebo for induction of labour (one study, 127 participants, very low‐certainty evidence) and low blood glucose levels in the newborn (three studies, 177 participants, low‐certainty evidence). We are also uncertain if there is any difference between probiotics and placebo for heavy bleeding immediately after birth, weight gain during pregnancy or total gestational weight gain. We are uncertain if there is any difference in fasting blood glucose between probiotics and placebo (seven studies, 554 participants). Probiotics may be assoicated with a slight reduction in triglycerides and total cholesterol (four studies, 320 participants). There was reduction in insulin secretion with probiotics (seven studies, 505 participants). One trial (60 participants) showed no difference between groups in need for insulin. Biomarkers, did show a reduction in insulin resistance (HOMA‐IR), (seven studies, 505 participants) and insulin resistance and β cell function (HOMA‐B) (two studies,130 participants) with probiotics. Quantitative insulin sensitivity check index (QUICKI) increased (four studies, 276 participants) with probiotics. Inflammatory markers, hs‐CRP (four studies, 248 participants) and interleukin 6 (two studies, 128 participants) were reduced with probiotics. Antioxidant total glutathione was increased (two studies, 120 participants) and the oxidative stress biomarker malondialdehyde was reduced with probiotics (three studies, 176 participants). We are uncertain if there is any difference in total antioxidant capacity (four studies 266 participants). For the newborn baby, we are uncertain if there is any difference between groups for: birthweight, gestational age at birth, preterm births, large babies, head circumference and length scores, or need for admission to the neonatal intensive care unit. The number of babies with high levels of bilirubin was reduced with probiotics. No adverse events were reported by the trials. What does this mean? Based on the clinical trials available, the evidence is limited to support the use of probiotics as treatment for women with GDM to improve pregnancy outcomes for mothers and their babies. Larger well‐designed randomised controlled trials are needed to assess the effects of probiotics on management of glucose levels and when available, they can be included in the update of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Okesene-Gafa, KAM, Moore, AE, Jordan, V, McCowan, L, Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD012970.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.768Z" }, { "id": "b5bbfb43-b0b5-496a-81cb-854a8fbfe233", "pmid": "", "title": "Multimodal interventions for cachexia management", "imported": false, "abstract": "Abstract - Background Cachexia (disease‐related wasting) is a complex metabolic syndrome which occurs in people with chronic illnesses, including cancer, HIV/AIDS, kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People with cachexia experience unintentional weight loss, muscle loss, fatigue, loss of appetite, and reduced quality of life. Multimodal interventions which work synergistically to treat the syndrome could lead to benefits. Objectives To assess the benefits and harms of multimodal interventions aimed at alleviating or stabilising cachexia in people with a chronic illness. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers in July 2024, together with reference checking, citation searching, and contact with study authors to identify studies. Selection criteria We included randomised controlled trials (RCTs) in adults with or at risk of cachexia, comparing multimodal interventions combining two or more modalities (of pharmacology, nutrition, exercise) to treatment as usual, variation of the intervention, or unimodal intervention. Data collection and analysis Two review authors independently screened potentially eligible studies, extracted data, and assessed risk of bias (RoB 1). Primary outcomes were physical function, strength, and adverse events. Secondary outcomes were body composition and weight, quality of life (QoL), appetite, fatigue, and biochemical markers. We assessed the certainty of evidence with GRADE. Main results We included nine studies with 926 adults (mean age: 63 years). Study sample sizes ranged from 20 to 332 participants. Six studies were conducted in Europe, and one each in Turkey, New Zealand, and the USA. There were six studies in people with cancer, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. We judged four studies to be at an overall high risk of bias, and five at an overall unclear risk. All outcomes in all comparisons had very low‐certainty evidence, downgraded once for risk of bias and/or indirectness and twice for imprecision. Multimodal intervention (pharmacological, nutritional, and/or exercise) compared to treatment as usual One cancer study randomised 46 participants, with 41 included in all analyses except adverse events. The study assessed outcomes immediately after treatment, lasting six weeks. Compared to treatment as usual, there is no clear evidence for an effect of a multimodal intervention on: physical function (mean difference (MD) −16.10 m, 95% confidence interval (CI) −79.06 to 46.86; 41 participants); strength (MD 3.80 kg, 95% CI −3.21 to 10.81; 41 participants); adverse events (risk ratio (RR) 1.36, 95% CI 0.70 to 2.65; 46 participants); body composition (MD 7.89 cm 2 , 95% CI −10.43 to 26.21; 41 participants); weight (MD 5.89 kg, 95% CI −1.45 to 13.23; 41 participants); appetite (MD 0.68 points, 95% CI −0.60 to 1.96; 41 participants); fatigue (MD 0.12, 95% CI −1.05 to 1.29; 41 participants); and biochemical markers (MD 2%, 95% CI 0.99 to 3.01; 41 participants), but the evidence was very uncertain; QoL was not reported. Multimodal intervention compared to variation of the intervention Three cancer studies and one HIV/AIDS study randomised 192 participants. We could not use the available data, nor obtain additional data, from two studies (one in cancer, one in HIV/AIDS). The studies assessed outcomes immediately after treatment, ranging from three to seven months. Compared to a variation of the intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (MD 10.0 m, 95% CI −36.27 to 56.27; 1 study, 56 participants); strength (MD 0.7 kg, 95% CI −3.75 to 5.15; 1 study, 56 participants); adverse events (RR 0.87, 95% CI 0.38 to 2.02; P = 0.75, I 2 = 0%; 2 studies, 95 participants); body composition (MD −2.67 kg, 95% CI −5.89 to 0.54; P = 0.10, I 2 = 0%; 2 studies, 95 participants); weight (MD −2.47 kg, 95% CI −7.11 to 2.16; P = 0.30, I 2 = 0%; 2 studies, 95 participants); QoL (standardised mean difference (SMD) −0.15, 95% CI −0.55 to 0.26; P = 0.47, I 2 = 0%; 2 studies, 95 participants); appetite (SMD −0.34, 95% CI −1.27 to 0.59; P = 0.48, I 2 = 79%; 2 studies, 95 participants); fatigue (MD 6.40 points, 95% CI −1.10 to 13.90; 1 study, 56 participants); or biochemical markers (MD 9.80 pg/mL, 95% CI −6.25 to 25.85; P = 0.23, I 2 = 73%; 2 studies, 95 participants), but the evidence is very uncertain. Multimodal intervention compared to unimodal intervention We included six studies (802 participants) in this comparison: three cancer studies, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. The studies assessed outcomes immediately after treatment, ranging from three to seven months. We could not use the available data, nor obtain additional data, from the HIV/AIDS study. Compared to a unimodal intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (SMD 0.02, 95% CI −0.22 to 0.26; P = 0.86, I 2 = 0%; 2 studies, 348 participants); strength (SMD 0.23, 95% CI −0.81 to 1.27; P = 0.66, I 2 = 0%; 2 studies, 348 participants); adverse events (RR 0.87, 95% CI −0.43 to 1.73; P = 0.68, I 2 = 45%; 2 studies, 395 participants); body composition (SMD 0.11, 95% CI −0.28 to 0.50; P = 0.58, I 2 = 74%; 5 studies, 742 participants); body weight (SMD −0.02, 95% CI −0.38 to 0.33; P = 0.90, I 2 = 49%; 4 studies, 431 participants); QoL (SMD 0.22, 95% CI −0.29 to 0.73; P = 0.39, I 2 = 61%; 3 studies, 411 participants); appetite (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.72, I 2 = 58%; 2 studies, 395 participants); fatigue (MD −6.80 points, 95% CI −12.44 to −1.17; 1 study, 244 participants); and biochemical markers (SMD 0.11, 95% CI −0.59 to 0.80; P = 0.76, I 2 = 79%; 3 studies, 411 participants), but the evidence is very uncertain. Authors' conclusions The review found insufficient evidence to support or refute the use of multimodal interventions in managing cachexia. The certainty of the evidence was very low. Methodologically rigorous, well‐powered RCTs with adequate interaction times are needed to assess the effectiveness of multimodal interventions in managing cachexia across chronic illnesses. Plain language summary What are the benefits and risks of using a combination of treatments to manage cachexia (disease‐related wasting)? Key messages: • We do not know if combinations of two or more treatments (of medication, diet, and exercise) benefit people who have or are at risk of developing cachexia (disease‐related wasting). This is because there are currently not enough robust studies in this area. • We need future research to increase our confidence in the evidence by conducting better designed and larger studies. What is cachexia? Cachexia is a complex metabolic syndrome that occurs in people with long‐term illnesses (known as chronic illnesses), such as cancer, HIV/AIDS, chronic kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People who have cachexia may: • lose weight unintentionally;
• lose muscle;
• feel tired, weak, or both; 
• lose their appetite. Cachexia affects well‐being and can be life‐threatening. How is cachexia treated? Studies are investigating how to best manage cachexia with different treatments. These treatments can include medications, diet, and exercise, provided in a single (unimodal) or combined (multimodal) treatment. It is thought that due to the complex biology of cachexia, a combination of treatments may work in a complementary way (synergistically) to help improve the symptoms associated with cachexia and people's well‐being, extend life, or both. What did we want to find out? We wanted to find out if combining at least two treatments (out of diet, exercise, and medication) helped to improve: physical function and strength; muscle loss; weight; well‐being; appetite; fatigue; and biological indicators within the blood (biochemical markers). We also wanted to find out if these interventions were associated with any unwanted or harmful (adverse) effects. What did we do? We searched for studies that compared treatment combinations of diet, exercise and/or medication (where at least two treatments were used together) to: different combinations of treatments; a single treatment; or treatment as usual (standard care) in adults with cachexia or at risk of developing cachexia. We compared and summarised the results of the included studies. We rated our confidence in the evidence based on factors such as study methods and the number of people included. What did we find? We found nine studies that included a total of 926 adults, with an average age of 63 years. Just over half of participants (57%) were men. Studies took place around the world, including Europe (six studies), Turkey (one study), New Zealand (one study), and the USA (one study). One study included people with HIV/AIDS (average age 43 years; 35 of 50 people in the study were men); one study included people with COPD (average age 72 years; 20 of 28 people in the study were men); and one study included people with chronic kidney disease (average age 70 years; 11 of 21 in the study were men). Six studies included people with cancer (average age 64 years; 461 of 893 people in the studies were men). The studies lasted six weeks to two years. The studies used combinations of treatments which could have included diet, exercise, and/or medication, where at least two treatments were used together, and compared these to: • treatment as usual (1 study, 46 people);
• different combinations of treatments (4 studies, 192 people);
• a single treatment (6 studies, 802 people). The studies did not provide enough robust evidence to determine if multimodal interventions are associated with benefits or harms in people with or at risk of cachexia. What are the limitations of the evidence? We are not confident in the evidence because not all the studies provided information about everything that we were interested in. Additionally, the studies used different ways of measuring results, and most of the studies included only small numbers of people. Importantly, future studies may change the conclusions of this review. How current is this review? The evidence is current to June 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Reid, J; Blair, C; Dempster, M; McKeaveney, C; Slee, A; Fitzsimons, D", "articleTypes": [], "doi": "10.1002/14651858.CD015749.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "b5c1e3d7-39dd-4350-acfd-6cab94cb1dd1", "pmid": "", "title": "Antioxidants for male subfertility", "imported": false, "abstract": "Abstract - Background The inability to have children affects 10% to 15% of couples worldwide. A male factor is estimated to account for up to half of the infertility cases with between 25% to 87% of male subfertility considered to be due to the effect of oxidative stress. Oral supplementation with antioxidants is thought to improve sperm quality by reducing oxidative damage. Antioxidants are widely available and inexpensive when compared to other fertility treatments, however most antioxidants are uncontrolled by regulation and the evidence for their effectiveness is uncertain. We compared the benefits and risks of different antioxidants used for male subfertility. Objectives To evaluate the effectiveness and safety of supplementary oral antioxidants in subfertile men. Search methods The Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, and two trial registers were searched on 15 February 2021, together with reference checking and contact with experts in the field to identify additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any type, dose or combination of oral antioxidant supplement with placebo, no treatment, or treatment with another antioxidant, among subfertile men of a couple attending a reproductive clinic. We excluded studies comparing antioxidants with fertility drugs alone and studies that included men with idiopathic infertility and normal semen parameters or fertile men attending a fertility clinic because of female partner infertility. Data collection and analysis We used standard methodological procedures recommended by Cochrane. The primary review outcome was live birth. Clinical pregnancy, adverse events and sperm parameters were secondary outcomes. Main results We included 90 studies with a total population of 10,303 subfertile men, aged between 18 and 65 years, part of a couple who had been referred to a fertility clinic and some of whom were undergoing medically assisted reproduction (MAR). Investigators compared and combined 20 different oral antioxidants. The evidence was of 'low' to 'very low' certainty: the main limitation was that out of the 67 included studies in the meta‐analysis only 20 studies reported clinical pregnancy, and of those 12 reported on live birth. The evidence is current up to February 2021. Live birth: antioxidants may lead to increased live birth rates (odds ratio (OR) 1.43, 95% confidence interval (CI) 1.07 to 1.91, P = 0.02, 12 RCTs, 1283 men, I 2 = 44%, very low‐certainty evidence). Results in the studies contributing to the analysis of live birth rate suggest that if the baseline chance of live birth following placebo or no treatment is assumed to be 16%, the chance following the use of antioxidants is estimated to be between 17% and 27%. However, this result was based on only 246 live births from 1283 couples in 12 small or medium‐sized studies. When studies at high risk of bias were removed from the analysis, there was no evidence of increased live birth (Peto OR 1.22, 95% CI 0.85 to 1.75, 827 men, 8 RCTs, P = 0.27, I 2 = 32%). Clinical pregnancy rate: antioxidants may lead to increased clinical pregnancy rates (OR 1.89, 95% CI 1.45 to 2.47, P < 0.00001, 20 RCTs, 1706 men, I 2 = 3%, low‐certainty evidence) compared with placebo or no treatment. This suggests that, in the studies contributing to the analysis of clinical pregnancy, if the baseline chance of clinical pregnancy following placebo or no treatment is assumed to be 15%, the chance following the use of antioxidants is estimated to be between 20% and 30%. This result was based on 327 clinical pregnancies from 1706 couples in 20 small studies. Adverse events
Miscarriage: only six studies reported on this outcome and the event rate was very low. No evidence of a difference in miscarriage rate was found between the antioxidant and placebo or no treatment group (OR 1.46, 95% CI 0.75 to 2.83, P = 0.27, 6 RCTs, 664 men, I 2 = 35%, very low‐certainty evidence). The findings suggest that in a population of subfertile couples, with male factor infertility, with an expected miscarriage rate of 5%, the risk of miscarriage following the use of an antioxidant would be between 4% and 13%. Gastrointestinal: antioxidants may lead to an increase in mild gastrointestinal discomfort when compared with placebo or no treatment (OR 2.70, 95% CI 1.46 to 4.99, P = 0.002, 16 RCTs, 1355 men, I 2 = 40%, low‐certainty evidence). This suggests that if the chance of gastrointestinal discomfort following placebo or no treatment is assumed to be 2%, the chance following the use of antioxidants is estimated to be between 2% and 7%. However, this result was based on a low event rate of 46 out of 1355 men in 16 small or medium‐sized studies, and the certainty of the evidence was rated low and heterogeneity was high. We were unable to draw conclusions from the antioxidant versus antioxidant comparison as insufficient studies compared the same interventions. Authors' conclusions In this review, there is very low‐certainty evidence from 12 small or medium‐sized randomised controlled trials suggesting that antioxidant supplementation in subfertile males may improve live birth rates for couples attending fertility clinics. Low‐certainty evidence suggests that clinical pregnancy rates may increase. There is no evidence of increased risk of miscarriage, however antioxidants may give more mild gastrointestinal discomfort, based on very low‐certainty evidence. Subfertile couples should be advised that overall, the current evidence is inconclusive based on serious risk of bias due to poor reporting of methods of randomisation, failure to report on the clinical outcomes live birth rate and clinical pregnancy, often unclear or even high attrition, and also imprecision due to often low event rates and small overall sample sizes. Further large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants. Plain language summary Antioxidants for male subfertility Review question 
Do supplementary oral antioxidants compared with placebo, no treatment or another antioxidant improve fertility outcomes for subfertile men? Background 
A couple may be considered to have fertility problems if they have been trying to conceive for over a year with no success. Many subfertile men undergoing fertility treatment also take dietary supplements in the hope of improving their fertility. Fertility treatment can be a very stressful time for men and their partners. It is important that these couples have access to high‐certainty evidence that will allow them to make informed decisions on whether to take a supplemental antioxidant. This is especially important as most antioxidant supplements are uncontrolled by regulation. This review aimed to assess whether supplements with oral antioxidants, taken by subfertile men, would increase the chances of a couple to achieve a (clinical) pregnancy confirmed by ultrasound and ultimately the birth of a baby (live birth). This review did not examine the use of antioxidants in men with normal sperm. Study characteristics Cochrane authors conducted a review including 90 randomised controlled trials comparing 18 different antioxidants with placebo, no treatment or another antioxidant in a total population of 10,303 subfertile men. The age range of the participants was 18 to 65 years; they were part of a couple who had been referred to a fertility clinic and some were undergoing fertility treatment. The evidence is current to February 2021. Main results 
Antioxidants may be associated with an increased live birth and clinical pregnancy rate. Based on the studied population for live birth, we would expect that out of 100 subfertile men not taking antioxidants, 16 couples would have a baby. In subfertile men taking antioxidants, between 17 and 27 per 100 couples would have a baby. If studies with high risk of bias were removed from the analysis, there was no evidence of increased live birth in the population taking antioxidants. In the people who were studied for clinical pregnancy, we would expect that out of 100 subfertile men not taking antioxidants, 15 couples would have a clinical pregnancy. In subfertile men taking antioxidants, between 20 and 30 per 100 couples would have a clinical pregnancy. Adverse events were poorly reported. Only six studies reported miscarriage. In these studies, miscarriage did not occur more often in the group using antioxidants when compared with the group with placebo or no treatment. However, there is insufficient evidence to draw conclusions about antioxidant use and the risk of miscarriage. The use of antioxidants may be associated with more mild stomach discomfort, with a frequency of 2% in subfertile men not taking antioxidants, and between 2% and 7% in men taking antioxidants. The oral supplements may cause discomforts such as nausea or stomach ache. Authors' conclusion and certainty of the evidence 
Antioxidant supplementation taken by subfertile males of a couple attending a fertility clinic may increase the chance of a live birth, however the overall certainty of evidence was very low from only 12 small to medium‐sized randomised controlled trials. Low‐certainty evidence suggests that clinical pregnancy rates may increase. Overall, there is no evidence of increased risk of miscarriage. Evidence of low certainty suggests that antioxidants may be associated with more gastrointestinal discomfort. Subfertile couples should be advised that overall the current evidence is inconclusive due to the poor reporting of methods, failure to report on live birth and clinical pregnancy rate, imprecision due to low event rates, high number of dropouts and small study group sizes. Large well‐designed randomised placebo‐controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "de Ligny, W; Smits, RM; Mackenzie-Proctor, R; Jordan, V; Fleischer, K; de Bruin, JP; Showell, MG", "articleTypes": [], "doi": "10.1002/14651858.CD007411.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "b5e8286b-7b74-4d07-982d-6ed6d58070ce", "pmid": "", "title": "Fixed‐dose combinations of drugs versus single‐drug formulations for treating pulmonary tuberculosis", "imported": false, "abstract": "Abstract - Background People who are newly diagnosed with pulmonary tuberculosis (TB) typically receive a standard first‐line treatment regimen that consists of two months of isoniazid, rifampicin, pyrazinamide, and ethambutol followed by four months of isoniazid and rifampicin. Fixed‐dose combinations (FDCs) of these drugs are widely recommended. Objectives To compare the efficacy, safety, and acceptability of anti‐tuberculosis regimens given as fixed‐dose combinations compared to single‐drug formulations for treating people with newly diagnosed pulmonary tuberculosis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL, published in the Cochrane Library, Issue 11 2015); MEDLINE (1966 to 20 November 2015); EMBASE (1980 to 20 November 2015); LILACS (1982 to 20 November 2015); the metaRegister of Controlled Trials; and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), without language restrictions, up to 20 November 2015. Selection criteria Randomized controlled trials that compared the use of FDCs with single‐drug formulations in adults (aged 15 years or more) newly diagnosed with pulmonary TB. Data collection and analysis Two review authors independently assessed studies for inclusion, and assessed the risk of bias and extracted data from the included trials. We used risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data with 95% confidence intervals (CIs). We attempted to assess the effect of treatment for time‐to‐event measures with hazard ratios and their 95% CIs. We used the Cochrane 'Risk of bias' assessment tool to determine the risk of bias in included trials. We used the fixed‐effect model when there was little heterogeneity and the random‐effects model with moderate heterogeneity. We used an I² statistic value of 75% or greater to denote significant heterogeneity, in which case we did not perform a meta‐analysis. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We included 13 randomized controlled trials (RCTs) in the review, which enrolled 5824 participants. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. Overall there is little or no difference detected between FDCs and single‐drug formulations for most outcomes reported. We did not detect a difference in treatment failure between FDCs compared with single‐drug formulations (RR 1.28, 95% CI 0.82 to 2.00; 3606 participants, seven trials, moderate quality evidence ). Relapse may be more frequent in people treated with FDCs compared to single‐drug formulations, although the confidence interval (CI) includes no difference (RR 1.28, 95% CI 1.00 to 1.64; 3621 participants, 10 trials, low quality evidence ). We did not detect any difference in death between fixed‐dose and single‐drug formulation groups (RR 0.96, 95% CI 0.67 to 1.39; 4800 participants, 11 trials, moderate quality evidence ). When we compared FDCs with single‐drug formulations we found little or no difference for sputum smear or culture conversion at the end of treatment (RR 0.99, 95% CI 0.96 to 1.02; 2319 participants, seven trials, high quality evidence ), for serious adverse events (RR 1.45, 95% CI 0.90 to 2.33; 3388 participants, six trials, moderate quality evidence ), and for adverse events that led to discontinuation of therapy (RR 0.96, 95% CI 0.56 to 1.66; 5530 participants, 13 trials, low quality evidence ). We conducted a sensitivity analysis excluding studies at high risk of bias and this did not alter the review findings. Authors' conclusions Fixed‐dose combinations and single‐drug formulations probably have similar effects for treating people with newly diagnosed pulmonary TB. 23 April 2019 No update planned Other This is not a current research question. Plain language summary Fixed‐dose combinations for treating pulmonary tuberculosis What are fixed‐dose combinations and how might they improve care of people with tuberculosis Tuberculosis (TB) is an important health problem, especially in developing countries. The treatment for pulmonary TB in new patients includes four oral medicines taken for six months, sometimes as fixed‐dose combinations (FDCs) that are combined in one tablet, or taken separately as single‐drug formulations. The World Health Organization recommends prescribers use fixed‐dose combinations to reduce the number of tablets that people take. On the supply side, this might reduce prescribing errors and improve drug supply efficiency; on the patient's side, FDCS simplify treatment and improve adherence. We conducted a review to assess the efficacy, safety, and acceptability of FDCs compared with single‐drug formulations for treating people with newly diagnosed pulmonary TB. What the research says We searched for relevant trials up to 20 November 2015, and included 13 randomized controlled trials that enrolled 5824 people. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. There is probably little or no difference in FDCs compared to single‐drug formulations for treatment failure ( moderate quality evidence ); relapse may be more frequent ( low quality evidence ); and the number of deaths were similar ( moderate quality evidence ). There is little or no difference in sputum smear or culture conversion ( high quality evidence ), and no difference was shown for serious adverse events ( moderate quality evidence ) or adverse events that led to discontinuation of therapy ( low quality evidence ). Authors’ conclusions We concluded that fixed‐dose combinations have similar efficacy to single‐drug formulations for treating people with newly diagnosed pulmonary TB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Gallardo, CR; Rigau Comas, D; Valderrama Rodríguez, A; Roqué i Figuls, M; Parker, LA; Caylà, J; Bonfill Cosp, X", "articleTypes": [], "doi": "10.1002/14651858.CD009913.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "b5f89325-b9df-4954-a19c-6b4b09241d23", "pmid": "", "title": "Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries", "imported": false, "abstract": "Abstract - Background Protein Energy Malnutrition is an important cause of child morbidity and mortality in middle‐ and low‐income countries. It has been suggested that excessive free radical activity may be responsible for the clinical manifestation of kwashiorkor. Antioxidants may be able to curb excessive free radical activity and prevent the development of kwashiorkor in susceptible children. Objectives To evaluate the benefits of supplementation of vitamin E, selenium, cysteine and riboflavin (alone or in combination) in preventing kwashiorkor. Search methods We conducted searches of CENTRAL 2009 ( The Cochrane Library 2009 Issue 2), MEDLINE 1966 to 2009, EMBASE 1980 to 2009, CINAHL 1982 to 2009, LILACS 1982 to 2009, Meta register of Controlled trials, Open Sigle, African Index Medicus. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating vitamin E, selenium, cysteine and riboflavin alone or in combination in healthy pre‐school children in middle‐ and low‐income countries. Data collection and analysis Two authors extracted and independently analysed data. Main results One cluster‐RCT including 2372 children met our inclusion criteria. Children were randomised, based on household, either to a supplement containing all four micronutrients or to placebo. No statistically significant difference in the incidence of kwashiorkor between the intervention and control groups could be demonstrated at 20 weeks (RR 1.70; 95% CI 0.98 to 2.42). Nor could any statistically significant difference in all‐cause mortality be demonstrated (RR 0.75; 95% CI 0.17 to 3.36). Authors' conclusions Based on the one available trial, we could draw no firm conclusion for the effectiveness of supplementary antioxidant micronutrients for the prevention of kwashiorkor in pre‐school children. Plain language summary Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries Undernutrition is one of the leading underlying causes of childhood morbidity and mortality in developing countries. Providing antioxidants that would help curb excess free radicals in the body may help prevent the development of kwashiorkor. We identified one cluster‐RCT that attempted to investigate this. Based on the published evidence reviewed, we could draw no firm conclusions of the benefits of supplementary antioxidants for the prevention of kwashiorkor in pre‐school children. There is a need for further research in this area to be certain if antioxidant supplementation can help prevent kwashiorkor in young children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Odigwe, CC, Smedslund, G, Ejemot‐Nwadiaro, RI, Anyanechi, CC, Krawinkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD008147.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.792Z" }, { "id": "b5fe0741-14fb-41c6-b9a8-1176928fc9da", "pmid": "", "title": "Non‐immunosuppressive treatment for IgA nephropathy", "imported": false, "abstract": "Abstract - Background IgA nephropathy (IgAN) is the most common primary glomerular disease, with approximately 20% to 40% of patients progressing to kidney failure within 25 years. Non‐immunosuppressive treatment has become a mainstay in the management of IgAN by improving blood pressure (BP) management, decreasing proteinuria, and avoiding the risks of long‐term immunosuppressive management. Due to the slowly progressive nature of the disease, clinical trials are often underpowered, and conflicting information about management with non‐immunosuppressive treatment is common. This is an update of a Cochrane review, first published in 2011. Objectives To assess the benefits and harms of non‐immunosuppressive treatment for treating IgAN in adults and children. We aimed to examine all non‐immunosuppressive therapies (e.g. anticoagulants, antihypertensives, dietary restriction and supplementation, tonsillectomy, and herbal medicines) in the management of IgAN. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to December 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs of non‐immunosuppressive agents in adults and children with biopsy‐proven IgAN were included. Data collection and analysis Two authors independently reviewed search results, extracted data and assessed study quality. Results were expressed as mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI) using random‐effects meta‐analysis. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results This review includes 80 studies (4856 participants), of which 24 new studies (2018 participants) were included in this review update. The risk of bias within the included studies was mostly high or unclear for many of the assessed methodological domains, with poor reporting of important key clinical trial methods in most studies. Antihypertensive therapies were the most examined non‐immunosuppressive therapy (37 studies, 1799 participants). Compared to placebo or no treatment, renin‐angiotensin system (RAS) inhibition probably decreases proteinuria (3 studies, 199 participants: MD ‐ 0.71 g/24 h, 95% CI ‐1.04 to ‐0.39; moderate certainty evidence) but may result in little or no difference to kidney failure or doubling of serum creatinine (SCr), or complete remission of proteinuria (low certainty evidence). Death, remission of haematuria, relapse of proteinuria or > 50% increase in SCr were not reported. Compared to symptomatic treatment, RAS inhibition (3 studies, 168 participants) probably decreases proteinuria (MD ‐1.16 g/24 h, 95% CI ‐1.52 to ‐0.81) and SCr (MD ‐9.37 µmol/L, 95% CI ‐71.95 to ‐6.80) and probably increases creatinine clearance (2 studies, 127 participants: MD 23.26 mL/min, 95% CI 10.40 to 36.12) (all moderate certainty evidence); however, the risk of kidney failure is uncertain (1 study, 34 participants: RR 0.20, 95% CI 0.01 to 3.88; very low certainty evidence). Death, remission of proteinuria or haematuria, or relapse of proteinuria were not reported. The risk of adverse events may be no different with RAS inhibition compared to either placebo or symptomatic treatment (low certainty evidence). In low certainty evidence, tonsillectomy in people with IgAN in addition to standard care may increase remission of proteinuria compared to standard care alone (2 studies, 143 participants: RR 1.90, 95% CI 1.45 to 2.47) and remission of microscopic haematuria (2 studies, 143 participants: RR 1.93, 95% CI 1.47 to 2.53) and may decrease relapse of proteinuria (1 study, 73 participants: RR 0.70, 95% CI 0.57 to 0.85) and relapse of haematuria (1 study, 72 participants: RR 0.70, 95% CI 0.51 to 0.98). Death, kidney failure and a > 50% increase in SCr were not reported. These trials have only been conducted in Japanese people with IgAN, and the findings' generalisability is unclear. Anticoagulant therapy, fish oil, and traditional Chinese medicines exhibited small benefits to kidney function in patients with IgAN when compared to placebo or no treatment. However, compared to standard care, the kidney function benefits are no longer evident. Antimalarial therapy compared to placebo in one study reported an increase in a > 50% reduction of proteinuria (53 participants: RR 3.13 g/24 h, 95% CI 1.17 to 8.36; low certainty evidence). Although, there was uncertainty regarding adverse events from this study due to very few events. Authors' conclusions Available RCTs focused on a diverse range of interventions. They were few, small, and of insufficient duration to determine potential long‐term benefits on important kidney and cardiovascular outcomes and harms of treatment. Antihypertensive agents appear to be the most beneficial non‐immunosuppressive intervention for IgAN. The antihypertensives examined were predominantly angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers. The benefits of RAS inhibition appear to outweigh the harms in patients with IgAN. The certainty of the evidence of RCTs demonstrating a benefit of tonsillectomy to patients with Japanese patients with IgAN was low. In addition, these findings are inconsistent across observational studies in people with IgAN of other ethnicities; hence, tonsillectomy is not widely recommended, given the potential harm of therapy. The RCT evidence is insufficiently robust to demonstrate efficacy for the other non‐immunosuppressive treatments evaluated here. Plain language summary Non‐immunosuppressive treatment for IgA nephropathy Key messages Treatment with renin‐angiotensin system (RAS) inhibition, namely angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, is the most common first‐line, non‐immunosuppressive therapy used for managing patients with IgA nephropathy (IgAN). The role of other non‐immunosuppressive treatments in managing IgAN is unclear and warrants further clinical studies. Why treat IgA nephropathy with non‐immunosuppressive therapies? IgAN is one of the most common kidney diseases, leading to reduced kidney function and kidney failure for about 20% to 40% of patients within 20 to 25 years. The cause of IgAN is not widely understood, but most people have an abnormality in their immune system that leads to damage to the kidney. However, other non‐immune functions play a role in the disease's impact on the kidney. What did we want to find out? We wanted to find out if non‐immunosuppressive treatments (e.g. antihypertensive agents, anticoagulants, fish oil, tonsillectomy, herbal medicine) improved kidney function in adults and children with IgAN. What did we do? We searched for all trials that assessed the benefits and harms of randomly allocated non‐immunosuppressive treatment in people with IgAN. We compared and summarised the results of the trials and rated our confidence in the information based on factors such as trial methods and sizes. What did we find? We included 80 studies involving 4856 people with IgAN treated with a diverse collection of non‐immunosuppressive treatments. Patients in studies were given various therapies, including blood pressure lowering agents (antihypertensives), removal of participant's tonsils (tonsillectomy), antimalarials, traditional Chinese medicine, dietary supplements (e.g. fish oil), and vitamin D receptor agonists. Antihypertensive medication aimed at inhibiting the RAS appears to slow damage to the kidney with minimal side effects. However, its impact in preventing people from progressing to kidney failure is unclear. Other interventions, such as tonsillectomy, antimalarial medication, and low‐calorie restricted diets role in treating patients are still unclear. What are the limitations of the evidence? The small number of studies per comparison and the small size of the studies were limitations in this review. Not all the studies provided data about the outcomes we were interested in. We are unsure about the results. How up to date is the evidence? The evidence is up to date as of December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Tunnicliffe, DJ, Reid, S, Craig, JC, Samuels, JA, Molony, DA, Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD003962.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.784Z" }, { "id": "b602cb19-928b-421e-a249-09135c4c0636", "pmid": "", "title": "SOMESThesia in Patients With Head and Neck Cancer: Variability and Influence on the ALIMentation Experience", "imported": false, "abstract": "Cancer patients are at high risk for undernutrition. A study with head and neck cancer patients showed that 50% suffered from undernutrition (Prevost et al., 2014). Sensory alterations may also involve sensory changes from the physiological structures of the mouth or neural pathways and hedonic changes, i.e., although food may taste the same as usual, that taste is no longer judged as pleasant. These changes lead to an aversion to food and a decrease in the pleasure of eating (Bernhardson et al., 2009).", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "b60819d8-8e68-4a1f-bd57-c754c9bb8513", "pmid": "", "title": "Intravenous iron versus oral iron versus no iron with or without erythropoiesis‐ stimulating agents (ESA) for cancer patients with anaemia: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Anaemia is common among cancer patients and they may require red blood cell transfusions. Erythropoiesis‐stimulating agents (ESAs) and iron might help in reducing the need for red blood cell transfusions. However, it remains unclear whether the combination of both drugs is preferable compared to using one drug. Objectives To systematically review the effect of intravenous iron, oral iron or no iron in combination with or without ESAs to prevent or alleviate anaemia in cancer patients and to generate treatment rankings using network meta‐analyses (NMAs). Search methods We identified studies by searching bibliographic databases (CENTRAL, MEDLINE, Embase; until June 2021). We also searched various registries, conference proceedings and reference lists of identified trials. Selection criteria We included randomised controlled trials comparing intravenous, oral or no iron, with or without ESAs for the prevention or alleviation of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in cancer patients. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Outcomes were on‐study mortality, number of patients receiving red blood cell transfusions, number of red blood cell units, haematological response, overall mortality and adverse events. We conducted NMAs and generated treatment rankings. We assessed the certainty of the evidence using GRADE. Main results Ninety‐six trials (25,157 participants) fulfilled our inclusion criteria; 62 trials (24,603 participants) could be considered in the NMA (12 different treatment options). Here we present the comparisons of ESA with or without iron and iron alone versus no treatment. Further results and subgroup analyses are described in the full text. On‐study mortality We estimated that 92 of 1000 participants without treatment for anaemia died up to 30 days after the active study period. Evidence from NMA (55 trials; 15,074 participants) suggests that treatment with ESA and intravenous iron (12 of 1000; risk ratio (RR) 0.13, 95% confidence interval (CI) 0.01 to 2.29; low certainty) or oral iron (34 of 1000; RR 0.37, 95% CI 0.01 to 27.38; low certainty) may decrease or increase and ESA alone (103 of 1000; RR 1.12, 95% CI 0.92 to 1.35; moderate certainty) probably slightly increases on‐study mortality. Additionally, treatment with intravenous iron alone (271 of 1000; RR 2.95, 95% CI 0.71 to 12.34; low certainty) may increase and oral iron alone (24 of 1000; RR 0.26, 95% CI 0.00 to 19.73; low certainty) may increase or decrease on‐study mortality. Haematological response We estimated that 90 of 1000 participants without treatment for anaemia had a haematological response. Evidence from NMA (31 trials; 6985 participants) suggests that treatment with ESA and intravenous iron (604 of 1000; RR 6.71, 95% CI 4.93 to 9.14; moderate certainty), ESA and oral iron (527 of 1000; RR 5.85, 95% CI 4.06 to 8.42; moderate certainty), and ESA alone (467 of 1000; RR 5.19, 95% CI 4.02 to 6.71; moderate certainty) probably increases haematological response. Additionally, treatment with oral iron alone may increase haematological response (153 of 1000; RR 1.70, 95% CI 0.69 to 4.20; low certainty). Red blood cell transfusions We estimated that 360 of 1000 participants without treatment for anaemia needed at least one transfusion. Evidence from NMA (69 trials; 18,684 participants) suggests that treatment with ESA and intravenous iron (158 of 1000; RR 0.44, 95% CI 0.31 to 0.63; moderate certainty), ESA and oral iron (144 of 1000; RR 0.40, 95% CI 0.24 to 0.66; moderate certainty) and ESA alone (212 of 1000; RR 0.59, 95% CI 0.51 to 0.69; moderate certainty) probably decreases the need for transfusions. Additionally, treatment with intravenous iron alone (268 of 1000; RR 0.74, 95% CI 0.43 to 1.28; low certainty) and with oral iron alone (333 of 1000; RR 0.92, 95% CI 0.54 to 1.57; low certainty) may decrease or increase the need for transfusions. Overall mortality We estimated that 347 of 1000 participants without treatment for anaemia died overall. Low‐certainty evidence from NMA (71 trials; 21,576 participants) suggests that treatment with ESA and intravenous iron (507 of 1000; RR 1.46, 95% CI 0.87 to 2.43) or oral iron (482 of 1000; RR 1.39, 95% CI 0.60 to 3.22) and intravenous iron alone (521 of 1000; RR 1.50, 95% CI 0.63 to 3.56) or oral iron alone (534 of 1000; RR 1.54, 95% CI 0.66 to 3.56) may decrease or increase overall mortality. Treatment with ESA alone may lead to little or no difference in overall mortality (357 of 1000; RR 1.03, 95% CI 0.97 to 1.10; low certainty). Thromboembolic events We estimated that 36 of 1000 participants without treatment for anaemia developed thromboembolic events. Evidence from NMA (50 trials; 15,408 participants) suggests that treatment with ESA and intravenous iron (66 of 1000; RR 1.82, 95% CI 0.98 to 3.41; moderate certainty) probably slightly increases and with ESA alone (66 of 1000; RR 1.82, 95% CI 1.34 to 2.47; high certainty) slightly increases the number of thromboembolic events. None of the trials reported results on the other comparisons. Thrombocytopenia or haemorrhage We estimated that 76 of 1000 participants without treatment for anaemia developed thrombocytopenia/haemorrhage. Evidence from NMA (13 trials, 2744 participants) suggests that treatment with ESA alone probably leads to little or no difference in thrombocytopenia/haemorrhage (76 of 1000; RR 1.00, 95% CI 0.67 to 1.48; moderate certainty). None of the trials reported results on other comparisons. Hypertension We estimated that 10 of 1000 participants without treatment for anaemia developed hypertension. Evidence from NMA (24 trials; 8383 participants) suggests that treatment with ESA alone probably increases the number of hypertensions (29 of 1000; RR 2.93, 95% CI 1.19 to 7.25; moderate certainty). None of the trials reported results on the other comparisons. Authors' conclusions When considering ESAs with iron as prevention for anaemia, one has to balance between efficacy and safety. Results suggest that treatment with ESA and iron probably decreases number of blood transfusions, but may increase mortality and the number of thromboembolic events. For most outcomes the different comparisons within the network were not fully connected, so ranking of all treatments together was not possible. More head‐to‐head comparisons including all evaluated treatment combinations are needed to fill the gaps and prove results of this review. Plain language summary Which combinations of medicines are best for the prevention and treatment of anaemia in people with cancer? Key messages • Giving medicines that stimulate the bone marrow to produce red blood cells (ESAs) with iron supplements probably decreases the number of blood transfusions, but may also cause more deaths and increase the number of unwanted effects, such as blood clots. • Because of missing data from the studies we could not compare the different treatment options to each other and rank them. • We need more studies that compare these medicines directly against each other. What is anaemia and why do people with cancer develop it? Anaemia develops when levels of red blood cells are too low. Red blood cells contain a protein called haemoglobin. Iron molecules in the haemoglobin bind to oxygen and carry it around the body. A lack of oxygen to the organs and tissues in the body makes people feel tired and lack energy, and they may be at greater risk of infections. People with cancer are particularly likely to suffer from anaemia. This might be because the cancers cause inflammation and prevent red blood cell production. Or it might be because treatments like chemotherapy slow down production of red blood cells in bone marrow. People suffering from anaemia may need blood transfusions. However, treatment with medicines that stimulate the production of red blood cells in bone marrow (called erythropoiesis‐stimulating agents or ESAs) and iron supplements may reduce the need for transfusions. What did we want to find out? We wanted to identify the most effective treatments for anaemia in people with cancer and whether they cause any unwanted effects. We were interested in whether iron supplements or ESAs given alone or together affect: • deaths; • haemoglobin levels; • blood transfusions; and • unwanted effects. We also wanted to know the best way to give the medicines: by injection (intravenous), or swallowed (oral). What did we do? We searched for studies that compared intravenous, oral or no iron with or without ESAs for the prevention or treatment of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in people with cancer. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and numbers of participants. We used statistical methods to compare multiple treatments against each other and rank them in order of effectiveness and unwanted effects. What did we find? We found 96 relevant studies with 25,157 people. People in the studies were different ages and were receiving a mix of anti‐cancer treatments or no treatment. They had different types of cancer. Ninety‐two studies reported data for our review. They included 24,603 people and compared 12 different treatment options for anaemia. The treatments included combinations of ESAs with intravenous or oral iron and placebo (something that looks, tastes and smells the same as the iron supplement or ESA but with no active ingredient). Not every study reported everything we were interested in, so we did not have enough information to compare each treatment with each of the other treatments. Treatment with ESAs when used on their own or with iron probably increases levels of red blood cells and reduces the need for red blood cell transfusions when compared with no treatment. We cannot rule out an increase in the risk of mortality with ESA in combination with iron, which also appeared to cause more deaths and lead to increased risk of harm caused by the formation of clots in the blood vessels. Our confidence in the findings Overall, we are moderately confident in the evidence that one treatment is better or worse than another. Our confidence is limited because we sometimes found very different results for the same treatments, meaning they could have been both good and bad for patients ‐ we did not have enough evidence to reach firm conclusions. Also, due to a lack of evidence we could not rank the treatments. How up to date is the evidence? The evidence is up‐to‐date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Adams, A, Scheckel, B, Habsaoui, A, Haque, M, Kuhr, K, Monsef, I, Bohlius, J, Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012633.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.823Z" }, { "id": "b6156296-d120-4cb7-86e5-d9c00ec3cd49", "pmid": "", "title": "Corticosteroids for treating sepsis in children and adults", "imported": false, "abstract": "Abstract - Background Sepsis occurs when an infection is complicated by organ failure. Sepsis may be complicated by impaired corticosteroid metabolism. Thus, providing corticosteroids may benefit patients. This is an update of a review originally published in 2004 and previously updated in 2010, 2015 and 2019. Objectives To examine the benefits and harms of corticosteroids in children and adults with sepsis. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, ISRCTN and the WHO Clinical Trials Search Portal on 31 December 2023. In addition, we conducted reference checking and citation research, and contacted study authors, to identify additional studies as needed. We updated this search in December 2024, but these results have not yet been incorporated. Selection criteria We included randomised controlled trials (RCTs) of corticosteroids versus placebo or usual care (antimicrobials, fluid replacement and vasopressor therapy as needed) in children and adults with sepsis. We also included RCTs of continuous infusion versus intermittent bolus of corticosteroids. Data collection and analysis We used the same methods in comparisons of corticosteroids versus placebo or usual care, and of continuous infusion versus intermittent bolus administration of corticosteroids. The primary outcome was all‐cause mortality at 28 days. The most critical secondary outcomes were (i) all‐cause mortality in the long term (last follow‐up from 90 days to one year) and in the hospital; (ii) length of stay in the intensive care unit and in hospital; (iii) adverse effects, i.e. superinfection and muscle weakness (within 28 days). All review authors screened and selected studies for inclusion. One review author extracted data, which was checked by the others, and by the lead author of the primary study when possible. For this update, we used Covidence software for screening and selection of studies and abstraction of data by paired review authors, with discrepancies resolved by a third review author. We obtained unpublished data from the authors of some trials. We assessed the risk of bias in trials using the Cochrane risk of bias tool (RoB 1) and applied GRADE to assess the certainty of evidence. The review authors did not contribute to the assessment of eligibility or risk of bias, nor to data extraction, for the trials they had participated in. Main results We included 87 trials (24,336 participants), of which six included only children, two included children and adults, and the remaining trials included only adults. Seventeen additional trials are ongoing and will be considered in future versions of this review. We judged 25 trials as being at low risk of bias. Corticosteroids versus placebo or usual care Compared to placebo or usual care, corticosteroids probably reduce 28‐day mortality (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.84 to 0.95; 72 trials, 22,915 participants; moderate‐certainty evidence). We downgraded the certainty of evidence for this outcome from high to moderate for inconsistency (significant heterogeneity across trial results). Corticosteroids may result in little to no difference in long‐term mortality (RR 0.97, 95% CI 0.91 to 1.03; 12 trials, 8468 participants; low‐certainty evidence) and probably reduce in‐hospital mortality (RR 0.90, 95% CI 0.84 to 0.97; 40 trials, 17,459 participants; moderate‐certainty evidence). Corticosteroids may reduce length of intensive care unit (ICU) stay for all participants (mean difference (MD) ‐0.86 days, 95% CI ‐1.67 to ‐0.05; 25 trials, 8069 participants; low‐certainty evidence) and may reduce length of hospital stay for all participants (MD ‐1.09 days, 95% CI ‐1.85 to ‐0.34; 31 trials, 16,954 participants; low‐certainty evidence). The evidence is uncertain about the effect of corticosteroids on the risk of muscle weakness (RR 1.09, 95% CI 0.78 to 1.53; 7 trials, 6729 participants; very low‐certainty evidence). Corticosteroids may result in little to no difference in the risk of superinfection (RR 0.96, 95% CI 0.86 to 1.07; 36 trials, 7961 participants; low‐certainty evidence). Continuous infusion of corticosteroids versus intermittent bolus Four trials reported data for this comparison, and the certainty of evidence for all outcomes was very low. We are uncertain about the effects of continuous infusion of corticosteroids compared with intermittent bolus administration on 28‐day mortality (RR 1.03, 95% CI 0.81 to 1.32; 3 trials, 310 participants). We downgraded the certainty of evidence to very low due to high risk of bias in all except one trial and due to imprecision. Compared to bolus administration, we are uncertain of the effects of continuous infusion of corticosteroids on long‐term mortality (RR 1.36, 95% CI 1.02 to 1.81; 1 trial, 70 participants; very low‐certainty evidence), in‐hospital mortality (RR 0.92, 95% CI 0.71 to 1.19; 3 trials, 352 participants; very low‐certainty evidence), ICU length of stay amongst all participants (MD ‐0.56 days, 95% CI ‐3.44 to 2.32; 4 trials, 422 participants; very low‐certainty evidence), hospital length of stay amongst all participants (MD ‐0.21 days, 95% CI ‐4.72 to 4.30; 4 trials, 422 participants; very low‐certainty evidence), risk of muscle weakness (RR 0.89, 95% CI 0.13 to 5.98; 1 trial, 70 participants; very low‐certainty evidence) and risk of superinfection (RR 1.12, 95% CI 0.37 to 3.33; 2 trials, 193 participants; very low‐certainty evidence). Authors' conclusions Moderate‐certainty evidence indicates that corticosteroids probably reduce 28‐day, 90‐day and hospital mortality amongst patients with sepsis. Corticosteroids may shorten ICU and hospital length of stay (low‐certainty evidence). There may be little or no difference in the risk of superinfection. The risk of muscle weakness is uncertain. The effects of continuous versus intermittent bolus administration of corticosteroids are uncertain. Plain language summary What are the benefits and harms of corticosteroids in the treatment of children and adults with sepsis? Key messages • Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days and of in‐hospital death, and may have little or no effect on the risk of dying beyond three months. • We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. • Future studies should measure the benefits and harms of corticosteroids for the treatment of specific populations, including children, patients with sepsis without shock or with a mild form of septic shock, patients with acute respiratory distress syndrome (ARDS) and patients with different types of infections. Defining the optimal methods for corticosteroid administration, including the types of molecule ‐ with or without producing sodium and fluid retention and potassium excretion (mineralocorticoid activity), timing of initiation, dose and duration, continuous infusion or intermittent intravenous boluses, and ending of treatment ‐ with or without gradually decreasing the dose to zero, also requires additional studies. Future studies should measure the longer‐term effects, i.e. longer than one year, on survival and complications of sepsis. What is sepsis? Sepsis is present when an infection is complicated by organ failure. People develop rapid breathing, hypotension (low blood pressure) and mental confusion. Sepsis can interfere with the effectiveness of the body’s corticosteroids, which control how your body recognises and defends itself against bacteria, viruses and substances that appear foreign and harmful. What are corticosteroids (medicine)? Corticosteroids are medicines used to stop excessive inflammation. However, these medicines may cause unwanted harms, such as increased blood sugar or salt levels, infections, bleeding in the stomach, agitation or delirium, and weakness of the limbs. Corticosteroids have been given for decades to people with infection resulting from various causes. What did we want to find out? We wanted to find out: • the benefits of using corticosteroids in children and adults with sepsis; and • the best ways to administer this treatment (including the best people to give it to). We also wanted to know if corticosteroids can cause any unwanted effects. What did we do? We searched for studies that compared: • corticosteroids administered intravenously against a 'dummy' treatment, or sham treatment, which does not contain any medicine but looks or tastes identical to corticosteroids, or usual care; or • continuous infusion against intermittent rapid intravenous injections (boluses) of corticosteroids administration. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? This review includes 87 trials (24,336 participants). The biggest study was of 3800 people and the smallest study was of 21 people. Eighty‐three trials compared corticosteroids to no corticosteroids (placebo or usual care in 59 and 24 trials, respectively). Four trials also compared continuous administration versus rapid intravenous injection (i.e. bolus) of corticosteroids given at fixed intervals of six or eight hours. Thirty‐three trials were conducted in Europe, 15 in North America, 22 in Asia, six in the Middle East, six in Africa and three in Latin America; four were multinational trials. Three trials were funded by a drug company, 27 by public organisations or through charitable funding and six by both a drug company and public organisations or charitable funding; 25 did not declare the source of funding. Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days by 10% (72 trials; 22,915 participants), with consistent treatment effects between children and adults. There may be little or no effect of corticosteroids on the risk of dying over the long term (longer than three months), but these results are less certain. Corticosteroids probably reduce the risk of dying in hospital. Corticosteroids may result in a reduction in the length of stay in the intensive care unit (ICU) and in hospital. They may not increase the risk of superinfection (second infection). The evidence is very uncertain about the effect of corticosteroids on the risk of muscle weakness. We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. Four studies reported data for this comparison, and the certainty of evidence for all outcomes was very low. What are the limitations of the evidence? • Corticosteroids versus placebo or usual care We have moderate confidence in our findings that corticosteroids reduced 28‐day mortality. We found some differences amongst the study populations, the types of corticosteroids and how they were given, and the use of additional medicines. • Continuous infusion versus bolus administration of corticosteroids We have very little confidence in our findings about the absence of a difference in 28‐day mortality between the administration of corticosteroids continuously and repeated rapid intravenous injections. We found only four studies that enrolled very few patients. How up‐to‐date is this evidence? The evidence provided in this review is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Annane, D, Briegel, J, Granton, D, Bellissant, E, Bollaert, PE, Keh, D, Kupfer, Y, Pirracchio, R, Rochwerg, B", "articleTypes": [], "doi": "10.1002/14651858.CD002243.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.800Z" }, { "id": "b6211030-5d6a-46c3-8dd7-affc90aa8a73", "pmid": "", "title": "Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions", "imported": false, "abstract": "Abstract - Background Individuals on continuous treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) are at increased risk of bleeding complications during and after oral or dental procedures. Anticoagulant treatment is preferably continued at the same dose, since dose reduction or discontinuation of treatment is associated with an increased risk of thromboembolism. The use of haemostatic measures during or after the procedure (or both) could enable continuation of the oral anticoagulant treatment. Objectives We aimed to assess the efficacy of antifibrinolytic agents for preventing bleeding complications in people on oral anticoagulants undergoing minor oral surgery or dental extractions. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and the Cochrane Library. Additional searches were performed using ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), the CINAHL database of nursing and allied health services, the open access ProQuest dissertation database, papers and reports from the American College of Clinical Pharmacy (ACCP) and abstract books from annual scientific conferences. Date of last search: 04 January 2018. Selection criteria Randomised and quasi‐randomised controlled trials in people on continuous treatment with VKAs or DOACs undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid (TXA) or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. Data collection and analysis Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained from potentially relevant abstracts and two authors independently assessed these for inclusion based of the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. The quality of the evidence was assessed using GRADE. Main results No eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures were identified. Three randomised trials and one quasi‐randomised trial (follow‐up in all was seven days) in people on continuous treatment with VKAs were included with a total of 253 participants (mean age 60 years). Two trials published in 1989 and 1993 compared the antifibrinolytic agent TXA with placebo in people using VKAs. Two other trials were published in 1999 and 2015 and compared TXA with gelatin sponge and sutures, and dry gauze compression, respectively. In all included trials, those who were treated with VKAs had international normalised ratio (INR) values within the therapeutic range and TXA was applied locally, not systemically. The two trials from 1989 and 1993 comparing TXA with placebo showed a statistically significant beneficial effect regarding the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) of ‐0.25 (95% confidence interval (CI) ‐0.36 to ‐0.14) (128 participants) (moderate‐quality evidence). For the two trials that compared TXA with either gelatin sponge and sutures or with dry gauze compression, there was no difference between the TXA and the standard care group, RD 0.02 (95% CI ‐0.07 to 0.11) (125 participants) (moderate‐quality evidence). The combined RD of all included trials was ‐0.13 (95% CI ‐0.30 to 0.05) (moderate‐quality evidence). There were no side effects of antifibrinolytic therapy that required treatment withdrawal (128 participants) (moderate‐quality evidence). Despite heterogeneity between trials with respect to the different haemostatic measures used in the control groups, the trials were comparable regarding design and baseline participant characteristics. Overall, we considered the risk of bias to be low in the trials comparing TXA with placebo and moderate in the trials comparing TXA with alternative haemostatic measures. Authors' conclusions Based on the results of this Cochrane Review, there seems to be a beneficial effect of locally applied TXA in preventing oral bleeding in people on continuous treatment with VKAs undergoing minor oral surgery or dental extractions. However, the small number of identified randomised controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population. We were unable to identify any eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures. Therefore, a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs. Plain language summary Drugs that prevent oral bleeding in people using oral anticoagulants undergoing minor oral surgery or dental extractions Review question We reviewed the evidence about whether antifibrinolytic medicine (drugs that prevent breakdown of a blood clot), such as tranexamic acid or epsilon aminocaproic acid, can prevent oral bleeding after minor oral surgery or dental extractions in people using oral anticoagulants (blood thinners that are taken by mouth) without interruption during the procedure. Background People on continuous oral anticoagulant treatment are at an increased risk of bleeding complications during and after oral surgery or dental extractions. There are two types of oral anticoagulant treatment: vitamin K antagonists (VKAs) (e.g. warfarin and coumarin) and direct oral anticoagulants (DOACs) (e.g. dabigatran, rivaroxaban, apixaban, edoxaban). DOACs are becoming an increasingly popular alternative for VKAs, traditionally used for preventing blood clotting in people at risk of thrombosis. The number of bleeds and the severity of each bleed depend on medication‐related factors (such as the degree of anticoagulation, measured by the international normalised ratio (INR)), surgery‐related factors (such as the size of the wound or the number of roots extracted), as well as patient‐related factors (such as inflammation of the gums or blood vessel diseases). The INR level is important to determine how well the anticoagulant treatment is preventing blood clots. Within the desired range of the INR level, a person has both the least risk of blood clotting complications and the least risk of excessive bleeding. In routine practice antifibrinolytic medicine is often used before, during and after minor oral surgery or dental extractions for people using oral anticoagulants. The question is whether there is reliable scientific evidence for this practice. Search date The evidence is current to: 04 January 2018. Study characteristics We did not find any trials of antifibrinolytic medicine for preventing bleeding after minor oral surgery or dental extractions in people using DOACs. This review includes four trials (253 participants) in people continuously treated with VKAs during minor oral surgery or dental extractions. The earliest included trial was published in 1989 and the most recent one in 2015. The mean age of all participants was 60 years. The follow‐up time in all trials was seven days. Key results Overall, the included trials showed a reduction in the number of bleeds after dental extraction when using tranexamic acid solution in the mouth. Combining the results of the separate trials it appeared that antifibrinolytic medication reduces the bleeding rate after dental extractions by 25% when compared to placebo ('dummy' treatment). However, there was no difference in bleeding rate between people treated with tranexamic acid and those treated with standard care (e.g. gauze compression or stitches). Side effects of the antifibrinolytic medication rarely occurred and did not lead to individuals discontinuing tranexamic acid treatment. No evidence was found for people being treated with DOACs. It could, however, be argued that, if antifibrinolytic medicine is effective in people on continuous treatment with VKAs, it might also work for people receiving other comparable anticoagulant drugs. Quality of evidence In relation to the review's two primary outcomes of number of postoperative bleeds and side effects of therapy, we judged there to be moderate‐quality evidence. In the two trials comparing tranexamic acid with placebo, the risk of bias, in relation to trial design, was considered to be low, in the two trials comparing tranexamic acid to standard care (gelatin sponge and sutures; or dry gauze compression) the risk of bias was considered to be moderate. This was mainly due to the lack of blinding (a way of making sure that the people involved in the trial do not know which trial arm they are assigned to) and inadequate allocation concealment (using the play of chance to assign participants to comparison groups to prevent selection bias) in two of these trials. There were differences between the trials with regards to different standard care treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Engelen, ET, Schutgens, REG, Mauser‐Bunschoten, EP, van Es, RJJ, van Galen, KPM", "articleTypes": [], "doi": "10.1002/14651858.CD012293.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.751Z" }, { "id": "b6402f97-94b8-423d-8a63-554372ba5e6a", "pmid": "", "title": "Interventions for paracetamol (acetaminophen) overdose", "imported": false, "abstract": "Abstract - Background Paracetamol (acetaminophen) is the most widely used non‐prescription analgesic in the world. Paracetamol is commonly taken in overdose either deliberately or unintentionally. In high‐income countries, paracetamol toxicity is a common cause of acute liver injury. There are various interventions to treat paracetamol poisoning, depending on the clinical status of the person. These interventions include inhibiting the absorption of paracetamol from the gastrointestinal tract (decontamination), removal of paracetamol from the vascular system, and antidotes to prevent the formation of, or to detoxify, metabolites. Objectives To assess the benefits and harms of interventions for paracetamol overdosage irrespective of the cause of the overdose. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register (January 2017), CENTRAL (2016, Issue 11), MEDLINE (1946 to January 2017), Embase (1974 to January 2017), and Science Citation Index Expanded (1900 to January 2017). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov database (US National Institute of Health) for any ongoing or completed trials (January 2017). We examined the reference lists of relevant papers identified by the search and other published reviews. Selection criteria Randomised clinical trials assessing benefits and harms of interventions in people who have ingested a paracetamol overdose. The interventions could have been gastric lavage, ipecacuanha, or activated charcoal, or various extracorporeal treatments, or antidotes. The interventions could have been compared with placebo, no intervention, or to each other in differing regimens. Data collection and analysis Two review authors independently extracted data from the included trials. We used fixed‐effect and random‐effects Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of the review outcomes. We used the Cochrane 'Risk of bias' tool to assess the risks of bias (i.e. systematic errors leading to overestimation of benefits and underestimation of harms). We used Trial Sequential Analysis to control risks of random errors (i.e. play of chance) and GRADE to assess the quality of the evidence and constructed 'Summary of findings' tables using GRADE software. Main results We identified 11 randomised clinical trials (of which one acetylcysteine trial was abandoned due to low numbers recruited), assessing several different interventions in 700 participants. The variety of interventions studied included decontamination, extracorporeal measures, and antidotes to detoxify paracetamol's toxic metabolite; which included methionine, cysteamine, dimercaprol, or acetylcysteine. There were no randomised clinical trials of agents that inhibit cytochrome P‐450 to decrease the activation of the toxic metabolite N ‐acetyl‐ p ‐benzoquinone imine. Of the 11 trials, only two had two common outcomes, and hence, we could only meta‐analyse two comparisons. Each of the remaining comparisons included outcome data from one trial only and hence their results are presented as described in the trials. All trial analyses lack power to access efficacy. Furthermore, all the trials were at high risk of bias. Accordingly, the quality of evidence was low or very low for all comparisons. Interventions that prevent absorption, such as gastric lavage, ipecacuanha, or activated charcoal were compared with placebo or no intervention and with each other in one four‐armed randomised clinical trial involving 60 participants with an uncertain randomisation procedure and hence very low quality. The trial presented results on lowering plasma paracetamol levels. Activated charcoal seemed to reduce the absorption of paracetamol, but the clinical benefits were unclear. Activated charcoal seemed to have the best risk:benefit ratio among gastric lavage, ipecacuanha, or supportive treatment if given within four hours of ingestion. There seemed to be no difference between gastric lavage and ipecacuanha, but gastric lavage and ipecacuanha seemed more effective than no treatment (very low quality of evidence). Extracorporeal interventions included charcoal haemoperfusion compared with conventional treatment (supportive care including gastric lavage, intravenous fluids, and fresh frozen plasma) in one trial with 16 participants. The mean cumulative amount of paracetamol removed was 1.4 g. One participant from the haemoperfusion group who had ingested 135 g of paracetamol, died. There were no deaths in the conventional treatment group. Accordingly, we found no benefit of charcoal haemoperfusion (very low quality of evidence). Acetylcysteine appeared superior to placebo and had fewer adverse effects when compared with dimercaprol or cysteamine. Acetylcysteine superiority to methionine was unproven. One small trial (low quality evidence) found that acetylcysteine may reduce mortality in people with fulminant hepatic failure (Peto OR 0.29, 95% CI 0.09 to 0.94). The most recent randomised clinical trials studied different acetylcysteine regimens, with the primary outcome being adverse events. It was unclear which acetylcysteine treatment protocol offered the best efficacy, as most trials were underpowered to look at this outcome. One trial showed that a modified 12‐hour acetylcysteine regimen with a two‐hour acetylcysteine 100 mg/kg bodyweight loading dose was associated with significantly fewer adverse reactions compared with the traditional three‐bag 20.25‐hour regimen (low quality of evidence). All Trial Sequential Analyses showed lack of sufficient power. Children were not included in the majority of trials. Hence, the evidence pertains only to adults. Authors' conclusions These results highlight the paucity of randomised clinical trials comparing different interventions for paracetamol overdose and their routes of administration and the low or very low level quality of the evidence that is available. Evidence from a single trial found activated charcoal seemed the best choice to reduce absorption of paracetamol. Acetylcysteine should be given to people at risk of toxicity including people presenting with liver failure. Further randomised clinical trials with low risk of bias and adequate number of participants are required to determine which regimen results in the fewest adverse effects with the best efficacy. Current management of paracetamol poisoning worldwide involves the administration of intravenous or oral acetylcysteine which is based mainly on observational studies. Results from these observational studies indicate that treatment with acetylcysteine seems to result in a decrease in morbidity and mortality, However, further evidence from randomised clinical trials comparing different treatments are needed. Plain language summary Interventions for paracetamol (acetaminophen) overdose Review question: in this review, we looked at the evidence for the interventions (treatments) used to treat people with paracetamol (acetaminophen) poisoning. Mainly, we tried to assess what effects the interventions had on the number of deaths and the need for a liver transplant. Background: paracetamol is one of the most common drugs taken in overdose. Intentional or accidental poisoning with paracetamol is a common cause of liver injury. Search date: the evidence is current to January 2017. Study characteristics: randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) where participants had come to medical attention because they had taken a paracetamol overdose, intentionally or by accident, regardless of the amount of paracetamol taken or the age, sex, or other medical conditions of the person involved. There are many different interventions that can be used to try to treat people with paracetamol poisoning. These interventions include decreasing the absorption of the paracetamol ingested and hence decreasing the amount absorbed into the bloodstream. The agents include activated charcoal (that binds paracetamol together in the stomach), gastric lavage (stomach washout to remove as much paracetamol as possible), or ipecacuanha (a syrup that is swallowed and causes vomiting (being sick)). Paracetamol once absorbed into the bloodstream goes to the liver where the majority is broken down to harmless products. However, a small amount of the medicine is converted into a toxic product that the liver can normally handle but, when large amounts of paracetamol are taken, the liver is overwhelmed. As a consequence, the toxic product can damage the liver leading to liver failure, kidney failure, and in some cases death. Other interventions to treat paracetamol poisoning include medicines (antidotes) that may decrease the amount of the toxic products (such as a medicine called cimetidine) or breakdown the toxic products (including medicines called methionine, cysteamine, dimercaprol, or acetylcysteine). Finally, attempts can be made to remove paracetamol and its toxic products from the bloodstream using special blood cleansing equipment. All these treatments were examined. We found 11 randomised clinical trials with 700 participants. Most of these trials looked at different treatments. Key results: activated charcoal, gastric lavage, and ipecacuanha may reduce absorption of paracetamol if started within one to two hours of paracetamol ingestion, but the clinical benefit was unclear. Activated charcoal seems to be the best choice if the person is able to take it. People may not be able to take charcoal if they are drowsy and some may dislike its taste or texture (or both). Of the treatments that remove the toxic products of paracetamol, acetylcysteine seems to reduce the rate of liver injury from paracetamol poisoning. Furthermore, it has fewer side effects than some other antidotes such as dimercaprol and cysteamine; its superiority to methionine was unclear. Acetylcysteine should be given to people with paracetamol poisoning at risk of liver damage, risk is determined by the dose ingested, time of ingestion, and investigations. More recent clinical trials have looked at ways to decrease side effects of intravenous (into a vein) acetylcysteine treatment, by altering the way it is given. These trials have shown that by using a slower infusion and lower initial dose of acetylcysteine, the proportion of side effects such as nausea (feeling sick) and vomiting, and allergy (the body's bad reaction to the medicine such as a rash) may be lowered. Quality of the evidence: this review of interventions for paracetamol poisoning found surprisingly few published randomised clinical trials for this very common condition. Furthermore, the majority of trials had few participants and all were at high risk of bias. Accordingly, the quality of the evidence should be considered as low or very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Chiew, AL, Gluud, C, Brok, J, Buckley, NA", "articleTypes": [], "doi": "10.1002/14651858.CD003328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.819Z" }, { "id": "b675dc76-16da-4821-8c45-37fe270b2612", "pmid": "", "title": "Models for delivery and co‐ordination of primary or secondary health care (or both) to older adults living in aged care facilities", "imported": false, "abstract": "Abstract - Background The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co‐ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost‐effectiveness of alternative models of providing health care to ACF residents. Objectives Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost‐effectiveness of the alternative models. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included individual and cluster‐randomised trials, and cost/cost‐effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co‐ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co‐ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline‐recommended care, health‐related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work‐related satisfaction and work‐related stress of ACF staff. Data collection and analysis Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. Main results We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co‐ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low‐certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I 2 = 53%; 8 trials, 1263 participants; low‐certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low‐certainty evidence) and adherence to guideline‐recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health‐related quality of life of ACF residents (MD ‐0.016, 95% CI ‐0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low‐certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate‐certainty evidence). We did not pool the cost‐effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co‐ordination of care), we are uncertain of the cost‐effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. Authors' conclusions Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health‐related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost‐effectiveness of alternative models of care due to the limited, disparate data available. Plain language summary Alternative ways to organise delivery of health care to older adults living in aged care facilities What is the aim of this review? This Cochrane review set out to determine if providing residents of aged care facilities (ACF) with the same care as usual care, just delivered in a different way (alternative models of care), is better in terms of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs. For example, are multidisciplinary teams (alternative model) a better way of delivering care to residents of ACFs compared to providing care through individual practitioners (usual care)? Key messages Compared to usual care, alternative models of care may reduce unplanned hospital admissions, but may make little or no difference to the number of emergency department visits and the health‐related quality of life of ACF residents, and probably make little or no difference to mortality. We are uncertain of the effect of alternative models of care on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guideline‐recommended care. Importantly, we are uncertain whether alternative models of care are cost‐effective due to the limited, conflicting data available. Studies differed widely in terms of intervention characteristics, health care settings and descriptions of usual care and this hindered many analyses in this review. Future studies should provide a detailed description of what intervention and usual care constitutes in their setting. What was studied in this review? The world's population is ageing and the number of persons living in residential ACFs is growing worldwide. ACF residents are often frail, elderly people with multiple health conditions that require intensive medical care. When an ACF is not able to deliver appropriate health care, residents are often transferred to a hospital for treatment. Such transfers are often burdensome and traumatic for ACF residents and their families and may lead to increased costs. Alternative models of care, designed to provide care that is better co‐ordinated and more timely, aim to reduce unnecessary hospital transfers and improve residents' well‐being. Alternative models of care may be more expensive to implement (e.g. employ more healthcare personnel) but may lead to cost savings down the line (e.g. more residents receive care in ACF, avoiding costly hospital transfers). The synthesised evidence in this review compares the effect of alternative models of care with usual care on the number of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs (i.e. does the model deliver better value for money compared to usual care). What are the main results of this review? We identified 40 studies (with in total 21,787 participants; three studies did not provide number of participants) conducted in 15 countries. The study participants differed with respect to their health needs. In 11 studies, the alternative model of care was aimed at all ACF residents (with mixed health needs/conditions). Other studies included residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers; 13 studies) or residents requiring a specific type of care (e.g. residents after discharge from a hospital; four studies). In most (31) of the studies, the alternative model of care focused on 'co‐ordination of care'. In three studies, the alternative models of care focused on 'who provides care' (e.g. nurse practitioner‐led care using best practice guide instead of GP‐led care) and in two studies, alternative models of care focused on 'where care is provided' (i.e. investigating alternative locations for the provision of care, for example within ACF versus outside of ACF). In four studies, the alternative models of care focused on the use of information and communications technology for the provision of care to ACF residents. In all studies, the alternative model of care was compared with usual care. We found that, compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits; however, the number of unplanned hospital admissions may be reduced. We are uncertain of the effect of alternative models of care on adverse events and adherence to clinical guideline‐recommended care compared with usual care. Alternative models of care may have little or no effect on ACF residents' health‐related quality of life and probably make little or no difference to mortality. Based on the findings of five studies that provided full economic evaluations (all alternative models of care focused on 'co‐ordination of care'), we are uncertain whether alternative models of care are more cost‐effective than usual care. What are the limitations of the evidence? Our confidence in the evidence is limited because participants in the studies were aware of which treatment they were getting. Usual care was poorly described by most of the studies. Usual care differs across countries and regions, so this lack of information limits our interpretation, contextualisation and generalisation of the comparisons. Not all of the studies provided data about outcomes we were looking to assess. How up‐to‐date is this review? The review authors searched for studies published up to October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Putrik, P; Grobler, L; Lalor, A; Ramsay, H; Gorelik, A; Karnon, J; Parker, D; Morgan, M; Buchbinder, R; O'Connor, D", "articleTypes": [], "doi": "10.1002/14651858.CD013880.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "b6772641-f56e-4479-aa2b-12e77ad626d7", "pmid": "", "title": "Enteral nutrition for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Prevention of relapse is a major issue in the management of quiescent Crohn's disease (CD). Current therapies (e.g. methotrexate, biologics, 6‐mercaptopurine and azathioprine) may be effective for maintaining remission in CD, but these drugs may cause significant adverse events. Interventions that are effective and safe for maintenance of remission in CD are desirable. Objectives The primary objectives were to evaluate the efficacy and safety of enteral nutrition for the maintenance of remission in CD and to assess the impact of formula composition on effectiveness. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and clinicaltrials.gov from inception to 27 July 2018. We also searched references of retrieved studies and reviews. Selection criteria Randomised controlled trials (RCTs) including participants of any age with quiescent CD were considered for inclusion. Studies that compared enteral nutrition with no intervention, placebo or any other intervention were selected for review. Data collection and analysis Two authors independently screened studies for inclusion, extracted data and assessed methodological quality using the Cochrane risk of bias tool. The primary outcome was clinical or endoscopic relapse as defined by the primary studies. Secondary outcomes included anthropometric measures (i.e. height and weight), quality of life (QoL), adverse events, serious adverse events and withdrawal due to adverse events. We calculated the risk ratio and 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated the mean difference and 95% CI. A random‐effects model was used for the statistical analysis. We used the GRADE criteria to assess the overall certainty of the evidence supporting the primary outcome and selected secondary outcomes. Main results Four RCTs (262 adult participants) met the inclusion criteria. One study (N = 33) compared an elemental diet to a non‐elemental (polymeric) diet. One study (N = 51) compared a half elemental diet to a regular free diet. Another study (N = 95) compared an elemental diet to 6‐mercaptopurine (6‐MP) or a no treatment control group. One study (N= 83) compared a polymeric diet to mesalamine. Two studies were rated as high risk of bias due to lack of blinding or incomplete outcome data. The other two studies were judged to have an unclear risk of bias. The studies were not pooled due to differences in control interventions and the way outcomes were assessed. The effect of an elemental diet compared to a polymeric diet on remission rates or withdrawal due to adverse events is uncertain. Fifty‐eight per cent (11/19) of participants in the elemental diet group relapsed at 12 months compared to 57% (8/14) of participants in the polymeric diet group (RR 1.01, 95% CI 0.56 to 1.84; very low certainty evidence). Thirty‐two per cent (6/19) of participants in the elemental diet group were intolerant to the enteral nutritional formula because of taste or smell and were withdrawn from the study in the first 2 weeks compared to zero participants (0/14) in the polymeric diet group (RR 9.75, 95% CI 0.59 to 159.93; low certainty evidence). Anthropometric measures, QoL, adverse events and serious adverse events were not reported as outcomes. The effect of an elemental diet (half of total daily calorie requirements) compared to a normal free diet on relapse rates is uncertain. Thirty‐five per cent (9/26) of participants in the elemental diet group relapsed at 12 months compared to 64% (16/25) of participants in the free diet group (RR 0.54, 95% CI 0.30 to 0.99; very low certainty evidence). No adverse events were reported. This study reported no differences in weight change between the two diet groups. Height and QoL were not reported as outcomes. The effect of an elemental diet compared to 6‐MP on relapse rates or adverse events is uncertain. Thirty‐eight per cent (12/32) of participants in the elemental diet group relapsed at 12 months compared to 23% (7/30) of participants in the 6‐MP group (RR 1.61; 95% CI 0.73 to 3.53; very low certainty evidence). Three per cent (1/32) of participants in the elemental diet group had an adverse event compared to 13% (4/30) of participants in the 6‐MP group (RR 0.23, 95% CI 0.03 to 1.98; low certainty evidence). Adverse events in the elemental diet group included surgery due to worsening CD. Adverse events in the 6‐MP group included liver injury (n = 2), hair loss (n = 1) and surgery due to an abscess (n = 1). No serious adverse events or withdrawals due to adverse events were reported. Weight, height and QoL were not reported as outcomes The effect of a polymeric diet compared to mesalamine on relapse rates and weight is uncertain. Forty‐two per cent (18/43) of participants in the polymeric diet group relapsed at 6 months compared to 55% (22/40) of participants in the mesalamine group (RR 0.76; 95% CI 0.49 to 1.19; low certainty evidence). The mean difference in weight gain over the study period was 1.9 kg higher in the polymeric diet group compared to mesalamine (95% CI ‐4.62 to 8.42; low certainty evidence). Two participants in the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had an adverse event. Height, QoL, serious adverse events and withdrawal due to adverse events were not reported as outcomes. Authors' conclusions The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the efficacy and safety of enteral nutrition in quiescent CD can be drawn. More research is needed to determine the efficacy and safety of using enteral nutrition as maintenance therapy in CD. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available. Plain language summary Enteral nutrition (liquid feeds) for maintenance of remission in Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disease of the intestines that frequently occurs in the lower part of the small intestine (ileum). Symptoms include abdominal pain, diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms the disease is considered 'active'. When the symptoms stop, it is called 'remission'. When people in remission experience symptoms it is called a 'relapse'. What is enteral nutrition? Enteral nutrition is a feeding method where a person's daily caloric intake is delivered via a liquid diet using the GI tract. Enteral nutrition can be administered by mouth or by tube feeding, where a tube is inserted through the nose or abdomen into the stomach to deliver the liquid feed. Enteral nutrition is a form of nutritional therapy for Crohn's disease patients. The mechanism by which enteral nutrition may influence inflammation is unknown and is being studied. Enteral nutrition can be classified as elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets are composed of amino‐acids (organic compounds), fats, sugars, vitamins and minerals. Elemental diets are easily absorbed and digested. Non‐elemental diets are based on oligopeptide (organic compounds composed of 2 to 20 amino‐acids) or whole protein sources. Non‐elemental diets are best for people who can digest and absorb nutrients without difficulty. What is 6‐mercaptopurine? 6‐Mercaptopurine is an immunosuppressive drug that is thought to reduce inflammation in people with Crohn's disease by blocking the immune system. What is mesalamine? Mesalamine is a 5‐aminosalicylic acid drug. 5‐Aminosalicylic drugs are thought to treat Crohn's disease by reducing inflammation in the gastrointestinal tract. These drugs are usually taken by mouth. What did the researchers investigate? The researchers studied whether enteral nutrition helps to maintain remission in people with Crohn's disease. The researchers also investigated whether one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) for maintaining remission in people with Crohn's disease. What did the researchers find? Four studies including 262 adult participants with Crohn's disease in remission were included. One study (33 participants) compared an elemental diet to a non‐elemental (polymeric) diet. One study (51 participants) compared an elemental diet to a normal diet (no supplements). One study (95 participants) compared an elemental diet to 6‐mercaptopurine or a no treatment control group. One study (83 participants) compared a non‐elemental polymeric diet to mesalamine. The researchers searched the medical literature extensively up to 27 July 2018. The study comparing an elemental diet to a polymeric diet found no difference in remission rates at 12 months. Six elemental diet participants were not able to tolerate the enteral nutritional formula because of taste or smell and were withdrawn from the study. Participants who received half of their total daily calorie requirements as elemental diet and the remaining half by normal diet had a lower chance of relapse at 12 months compared to participants who received a free diet. No side effects were reported in this study. The study comparing an elemental diet to 6‐mercaptopurine did not show any difference in relapse rates at 12 months. There was no difference in side effect rates. The only side effect reported in the elemental diet group was surgery due to worsening Crohn's disease. Side effects in the 6‐mercaptopurine group included liver injury in two participants, hair loss in one participant and surgery to treat an abscess in one participant. The study comparing a polymeric diet to mesalamine found no difference in relapse rates at six months. Two participants the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had side effects. No serious side effects were reported in any of the studies. The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the effectiveness and safety of enteral nutrition for maintenance of remission in Crohn's disease can be drawn. More research is needed to determine the effectiveness and safety of using enteral nutrition as maintenance therapy in Crohn's disease. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Akobeng, AK, Zhang, D, Gordon, M, MacDonald, JK", "articleTypes": [], "doi": "10.1002/14651858.CD005984.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.728Z" }, { "id": "b6907808-3385-4e2e-8508-7c17c72c014a", "pmid": "", "title": "Enteral nutritional therapy for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta‐analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review. Objectives To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts. Selection criteria Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review. Data collection and analysis Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random‐effects model was used to pool data. We performed intention‐to‐treat and per‐protocol analyses for the primary outcome. Heterogeneity was explored using the Chi 2 and I 2 statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes. Main results Twenty‐seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non‐elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non‐elemental diets differing in glutamine enrichment. Meta‐analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty‐four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non‐elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per‐protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non‐elemental diets (elemental, semi‐elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non‐elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating. Ten trials compared EN to steroid therapy. Meta‐analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per‐protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per‐protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet. Authors' conclusions Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy Plain language summary Enteral nutritional therapy for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a long‐term inflammation of the gastrointestinal (GI) tract, occurring anywhere from mouth to anus. Common symptoms of this condition include abdominal pain, diarrhea and weight loss. When Crohn's disease patients are experiencing symptoms, it is characterized to be 'active' disease. When the symptoms stop, it is called 'remission'. What is enteral nutrition? Enteral nutrition is a feeding method where all of a person's daily caloric intake is delivered using the GI tract. An example of this is nasogastric tube feeding, where a tube is inserted through a person's nose to deliver their daily nutritional requirements in liquid form. Enteral nutrition can be a form of nutritional therapy for Crohn's disease patients. Enteral nutrition is categorized into elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets come from amino‐acid sources, whereas non‐elemental diets come from oligopeptide or whole protein sources. What are corticosteroids? Corticosteroids are an effective treatment option for active Crohn's disease. These drugs that are taken by mouth and work as immunosuppressants. What did the researchers investigate? The researchers studied whether enteral nutrition is better than steroid therapy at producing remission in Crohn's disease patients. In addition, the investigators looked to see if one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) at producing remission in Crohn's disease. What did the researchers find? The researchers found twenty‐seven studies (1,011 participants) that fulfilled the search criteria. Eleven of these studies, which included 378 patients, compared elemental to non‐elemental diets at producing remission in Crohn's disease. Eight studies, which included 352 patients, investigated enteral nutrition compared to steroid therapy at inducing remission in Crohn's disease. The researchers searched the medical literature extensively up to July 5, 2017. Very low quality evidence suggests that steroids may be more effective than enteral nutrition for induction of remission in adults with active Crohn's disease. Very low quality evidence also suggests that enteral nutrition may be more effective than steroids for induction of remission in children with active Crohn's disease. There was no difference in remission rates between elemental and non‐elemental diets. An increase in side effects was not seen with elemental diets compared to non‐elemental diets, nor with enteral nutrition compared to steroids. Common side effects experienced with enteral nutrition included vomiting, diarrhea, heartburn and flatulence . Common side effects associated with steroid use included acne, moon facies, muscle weakness, hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) . Patients on enteral nutrition were more likely to withdraw from the study due to side effects than those on steroids. The most common reason for study withdrawal was inability to tolerate the taste of the enteral nutrition diet. Enteral nutrition should be considered in pediatric Crohn's patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient compliance with this therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Narula, N, Dhillon, A, Zhang, D, Sherlock, ME, Tondeur, M, Zachos, M", "articleTypes": [], "doi": "10.1002/14651858.CD000542.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.811Z" }, { "id": "b6a2f42a-c99d-4bdc-b56f-022825099640", "pmid": "", "title": "Parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review on parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy (published in Issue 3, 2007). Salivary gland dysfunction is a predictable side effect of radiotherapy to the head and neck region. Pilocarpine hydrochloride (a choline ester) is licensed in many countries for the treatment of radiation‐induced salivary gland dysfunction. Other parasympathomimetics have also been used 'off licence' in the treatment of this condition. Objectives To determine the efficacy and tolerability of parasympathomimetic drugs in the treatment of radiation‐induced salivary gland dysfunction (specifically radiation‐induced xerostomia). Search methods For this update, we ran searches of the Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 6), MEDLINE, EMBASE, and CINAHL in July 2015. We checked the reference lists of retrieved articles for additional studies, contacted experts in the field for unpublished and ongoing trials, and contacted relevant pharmaceutical companies for unpublished and ongoing trials. Selection criteria The selection criteria for the review were: 1) randomised controlled trials; 2) people suffering from radiation‐induced salivary gland dysfunction; 3) people treated with parasympathomimetic drugs; and 4) assessable data available on primary outcome measure. Data collection and analysis The two review authors independently collected data from the full‐text version of relevant papers including: 1) citation details; 2) participants; 3) interventions; 4) assessments; 5) outcomes (that is efficacy, tolerability); and 6) quality issues. Due to a lack of appropriate data, we were unable to perform a meta‐analysis. Main results In the original review, three studies, including a total of 298 participants, fulfilled the inclusion criteria. All three studies involved the use of pilocarpine hydrochloride. We have included no additional studies in the update of the review; we have excluded eight additional studies. The data suggest that pilocarpine hydrochloride is more effective than placebo and at least as effective as artificial saliva. The response rate was 42% to 51%. The time to response was up to 12 weeks. The overall side effect rate was high, and side effects were the main reason for withdrawal (6% to 15% of participants taking 5 mg three times a day had to withdraw). The side effects were usually the result of generalised parasympathomimetic stimulation (for example sweating, headaches, urinary frequency, vasodilatation). Response rates were not dose dependent, but side effect rates were dose dependent. Authors' conclusions There is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced xerostomia. Currently, there is little evidence to support the use of other parasympathomimetic drugs in the treatment of radiation‐induced xerostomia. Available studies suggest that approximately half of patients will respond, but side effects can be problematic. The conclusions of the update are the same as the conclusions of the original review, since no new relevant studies have been published in the interim. Plain language summary Parasympathomimetic drugs for the treatment of 'dry mouth' due to radiotherapy This updated review found there is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced salivary gland dysfunction ('dry mouth'). Salivary gland damage is a frequent and important complication of radiotherapy to the head and neck area; it causes dryness of the mouth with resultant problems with eating, talking, and local infection. The parasympathomimetic group of drugs have been used to treat radiotherapy‐induced salivary gland damage. We identified three studies that involved a total of 289 participants, and they all used the drug pilocarpine. The review found that 42% to 51% of participants (4 to 5 in 10) responded to pilocarpine, although in some participants the response did not occur for up to 12 weeks. Pilocarpine was more effective than a placebo treatment, and at least as effective as an artificial saliva. Side effects were common with pilocarpine (for example sweating, headache, passing urine frequently, flushing), but were usually reported to be mild; 6% to 15% (0.6 to 1.5 in 10) participants had to stop taking pilocarpine due to side effects. The findings of this review are limited by the small number of good‐quality trials that have been performed in this area. The update of this review did not find any new information on this topic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Davies, AN, Thompson, J", "articleTypes": [], "doi": "10.1002/14651858.CD003782.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.091Z" }, { "id": "b6a64c0b-d562-4b18-b95f-34f568cb6803", "pmid": "", "title": "Herbal interventions for chronic asthma in adults and children", "imported": false, "abstract": "Abstract - Background Herb and plant based preparations are a popular treatment for asthma, although there remain concerns as to their efficacy and safety. In Western societies, motivations for using such treatments may be both positive and negative, with their perceived safety and dissatisfaction with conventional medicine among them. In China such treatments are more commonly used and many compounds considered 'conventional' are derived from herbs or plants. Objectives To assess the efficacy and safety of herb and plant extracts in the management of chronic asthma. Search methods The Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, EMBASE and AMED were searched with pre‐defined terms. Searches are current as of February 2007. Selection criteria Randomised placebo controlled trials of any herb or plant extract were eligible. Study participants had to have a primary diagnosis of asthma. Studies in both adults and children were eligible for the review. Data collection and analysis Two reviewers assessed studies for suitability. Data were extracted and double‐checked. Main results Twenty‐seven studies (29 experimental groups) met the review entry criteria, randomising a total of 1925 participants. The studies identified assessed the effects of 21 different herbal preparations. Study quality varied considerably, and the sample sizes were often small. For primary outcomes (exacerbations, steroids use and lung function measurements): Two out of six studies reporting change in FEV1 were positive, with very few data available on the frequency of exacerbations. One study which did report these data was negative. Health‐related quality of life was only measured in one trial. Authors' conclusions The evidence base for the effects of herbal treatments is hampered by the variety of treatments assessed, poor reporting quality of the studies and lack of available data. The data that are available from the studies provide only a small insight into the long‐term efficacy and harm profiles of these treatments. The absence of common endpoint measurements limits the validity of our findings further. Positive findings in this review warrant additional well‐designed trials in this area. Plain language summary Herbal interventions for chronic asthma in adults and children Chronic asthma is a inflammatory disease of the airways characterised by wheeze and breathlessness. Drug therapy is usually used to control symptoms but complementary medicine is often used, including herbal treatments, and the efficacy and safety of such treatments is not clear. We reviewed evidence from 27 trials covering 21 different herbal treatments in both adults and children from both in‐patient and out‐patient settings. In general, the reporting of trials was poor. The outcomes measured by the trials varied considerably which made it difficult to compare the results of studies that did look at the same treatment. On the basis of the available evidence it is not possible to show whether any of these herbal treatments can improve asthma symptoms. Further trials of high quality are needed to assess the use of herbal treatments in asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Arnold, E, Clark, CE, Lasserson, TJ, Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD005989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.083Z" }, { "id": "b6c2f632-37a5-4499-ad67-325de169350d", "pmid": "", "title": "Evaluation of the Efficacy of Serotoninergic Antidepressants in Bulimia Nervosa, According to Brain Serotonin Profile Determined by Positron Emission Tomography With [18F] MPPF - a Multicenter Study", "imported": false, "abstract": "Bulimia nervosa (BN) is a serious mental illness characterized by massive food crises followed by anxiety and compensatory behaviours (vomiting more often). Recent data show an increasing prevalence and a serious prognosis, due to excess mortality by suicide but also somatic complications.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.157Z" }, { "id": "b6d368a3-3f2e-460d-b5f0-98daef120a19", "pmid": "", "title": "Topical anaesthetics for pain control during repair of dermal laceration", "imported": false, "abstract": "Abstract - Background Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine‐free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017. Objectives To assess whether benefits of non‐invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single‐component or multi‐component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine. Search methods For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta‐registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010. Selection criteria We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence. Main results The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self‐reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine‐phenylephrine (PP) was higher than the mean self‐reported VAS (0 to 100 mm) score for topical tetracaine‐epinephrine‐cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine‐free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self‐limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine‐based or cocaine‐free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Authors' conclusions We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously. Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non‐invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine‐based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Plain language summary Local anaesthesia (numbing medicine) that is directly applied to the skin can provide pain control for repair of skin lacerations Background : Pain control during suturing of torn skin is generally achieved by injecting medication into the skin (infiltration) to numb the area. This injection itself may cause pain, but topical anaesthetics are applied directly to the skin and are painless to administer. Cocaine was one of the first anaesthetics to be successfully applied topically. Concerns over adverse effects of cocaine, its potential misuse and the administrative burden of dispensing a controlled substance led to the development of cocaine‐free topical anaesthetics. Multiple cocaine‐free topical anaesthetics have been found to provide effective anaesthesia for repair of dermal lacerations. Study characteristics : The evidence is current to December 2016. We included in this review 25 randomized controlled trials involving 3278 participants. Studies included both adults and children. Fifteen of the included trials used self‐reporting of pain intensity by trial participants to determine the effectiveness of local anaesthetics. Key results : Study results suggest that directly applying local anaesthetics to the skin is an effective, non‐invasive way of providing pain control during suturing or stapling of skin lacerations. Study findings on the efficacy of individual topical anaesthetics were limited by study design, and data on the efficacy of each topical agent were obtained mostly from single trials. Researchers reported no serious side effects following the use of cocaine‐containing or cocaine‐free topical anaesthetics. The overall broadly comparable effectiveness of cocaine‐free topical anaesthetics for skin laceration repair brings into question the necessity to include cocaine as a component of local anaesthetic solutions. The small number of trials in each comparison group and the range of outcome measures assessed prevented pooling and quantitative analysis of data for all but the single outcome of pain intensity. Additional studies are necessary to directly compare the effectiveness of different formulations of topical anaesthetics. Our review was limited to pain control for repair of superficial lacerations, and our results might not be generalizable to deeper lacerations or more complex procedures performed on intact skin. Further research is needed to strengthen the evidence and to overcome the weakness of the included studies. Quality of the evidence : The overall quality of the evidence was low owing to limitations in study design, ways that studies were carried out (implementation), imprecision of results and high probability of selective data reporting. Most of the trials that compared infiltrated and topical anaesthetics were at high risk of bias, and this was likely to influence measured effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tayeb, BO; Eidelman, A; Eidelman, CL; McNicol, ED; Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD005364.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "b6e6f606-5727-4a3d-9280-6bf32edc597d", "pmid": "", "title": "Lactoferrin for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "Abstract - Background Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be due in part to disruption of the integrity of the gut and its altered intestinal microflora. Lactoferrin is a whey protein found in milk and is an important innate mammalian defence mechanism. Lactoferrin has been reported to have antimicrobial and anti‐inflammatory properties. It has also been reported to help establish a healthy gut microflora and aid in the intestinal immune system. Lactoferrin supplementation has been reported to decrease sepsis in preterm infants. There may be a role for lactoferrin to reduce the incidence of sepsis, thus reducing morbidity and mortality and improving enteral feeding in postoperative term neonates. Objectives The primary objective of this review was to evaluate the efficacy of administering lactoferrin on the incidence of sepsis and mortality in term neonates after gastrointestinal surgery. The secondary objective was to assess the impact of administering lactoferrin on time to full enteral feeds, the intestinal microflora, duration of hospital stay, and mortality before discharge in the same population. Search methods The Cochrane Neonatal Information Specialist searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase Ovid, CINAHL, the WHO ICTRP and ClinicalTrials.gov trials registries. The date of the last search was February 2023. There were no restrictions to language, publication year or publication type. We checked references of potentially relevant studies and systematic reviews. Selection criteria We planned to include randomised controlled trials that studied infants born at 37 or more weeks of gestation who had one or more episodes of gastrointestinal surgery within 28 days of birth, and compared administration of lactoferrin with a placebo. Data collection and analysis We used standard Cochrane methodological procedures. We planned to use the GRADE approach to assess the certainty of evidence for each outcome. Main results We identified no published randomised controlled studies that assessed the efficacy of lactoferrin for the postoperative management of term neonates following gastrointestinal surgery. Authors' conclusions There is currently no evidence available from randomised controlled trials to show whether lactoferrin is effective or ineffective for the postoperative management of term neonates after gastrointestinal surgery. There is a need for randomised controlled trials to be performed to assess the role of lactoferrin in this setting. Plain language summary What are the benefits and risks of giving lactoferrin to full‐term babies who had digestive tract surgery? Key message We found no medical studies that investigated the effects of giving lactoferrin (a protein found in milk) to babies born at full‐term (at or after 37 weeks of pregnancy) who had surgery of their digestive tract. What is lactoferrin? Lactoferrin is a protein found in milk that can protect against infection. Lactoferrin supplements are available and have been researched in premature babies. There is some evidence that lactoferrin can prevent infection in premature babies. What are some of the risks of digestive tract surgery in babies? Surgery of the digestive tract increases the risk of infection. Infections can increase the length of stay in hospital. Treatment with antibiotics (medicines that fight bacterial infections) and stress from surgery can disrupt good bacteria in the digestive tract. What did we want to find out? We wanted to find out if giving lactoferrin to full‐term babies, after digestive tract surgery, decreased rates of infection and death, and improved the presence of good bacteria in the digestive tract. What did we do? We searched for studies in which babies who had digestive tract surgery were assigned randomly to lactoferrin or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested). What did we find? We did not find any studies that compared giving lactoferrin to a placebo in full‐term babies who had digestive tract surgery. Well‐designed and large studies are needed to answer this question. How up to date is this evidence? The search is up‐to‐date as of February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Trivedi, A, Maheshwari, R, Tarnow-Mordi, WO, Saxena, N", "articleTypes": [], "doi": "10.1002/14651858.CD012218.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.115Z" }, { "id": "b6e79b77-470e-4de2-bc7c-056a57e3025b", "pmid": "", "title": "Osmotic therapies added to antibiotics for acute bacterial meningitis", "imported": false, "abstract": "Abstract - Background Every day children and adults die from acute community‐acquired bacterial meningitis, particularly in low‐income countries, and survivors risk deafness, epilepsy and neurological disabilities. Osmotic therapies may attract extra‐vascular fluid and reduce cerebral oedema, and thus reduce death and improve neurological outcomes. This is an update of a Cochrane Review first published in 2013. Objectives To evaluate the effects of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults on mortality, deafness and neurological disability. Search methods We searched CENTRAL (2017, Issue 1), MEDLINE (1950 to 17 February 2017), Embase (1974 to 17 February 2017), CINAHL (1981 to 17 February 2017), LILACS (1982 to 17 February 2017) and registers of ongoing clinical trials (ClinicalTrials.com, WHO ICTRP) (21 February 2017). We also searched conference abstracts and contacted researchers in the field (up to 12 December 2015). Selection criteria Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis. Data collection and analysis Two review authors independently screened the search results and selected trials for inclusion. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not. We used the GRADE approach to assess the certainty of the evidence. Main results We included five trials with 1451 participants. Four trials evaluated glycerol against placebo, and one evaluated glycerol against 50% dextrose; in addition three trials evaluated dexamethasone and one trial evaluated acetaminophen (paracetamol) in a factorial design. Stratified analysis shows no effect modification with steroids; we present aggregate effect estimates. Compared to placebo, glycerol probably has little or no effect on death in people with bacterial meningitis (RR 1.08, 95% CI 0.90 to 1.30; 5 studies, 1272 participants; moderate‐certainty evidence ), but may reduce neurological disability (RR 0.73, 95% CI 0.53 to 1.00; 5 studies, 1270 participants; low‐certainty evidence ). Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30; 4 studies, 1090 participants; low‐certainty evidence ). Glycerol may reduce the risk of subsequent deafness (RR 0.64, 95% CI 0.44 to 0.93; 5 studies, 922 participants; low to moderate‐certainty evidence ). Glycerol probably has little or no effect on gastrointestinal bleeding (RR 0.93, 95% CI 0.39 to 2.19; 3 studies, 607 participants; moderate‐certainty evidence ). The evidence on nausea, vomiting and diarrhoea is uncertain (RR 1.09, 95% CI 0.81 to 1.47; 2 studies, 851 participants; very low‐certainty evidence ). Authors' conclusions Glycerol was the only osmotic therapy evaluated, and data from trials to date have not demonstrated an effect on death. Glycerol may reduce neurological deficiency and deafness. Plain language summary Osmotic therapies added to antibiotics for acute bacterial meningitis What is the aim of this review? The aim of this Cochrane Review is to collect and analyse trials evaluating osmotic therapies given orally or intravenously to people with acute bacterial meningitis. Cochrane authors collected and analysed all relevant studies to answer this question; they found five relevant studies. Key messages Giving glycerol, an osmotic diuretic, probably has little or no effect on death ( moderate‐certainty evidence ), but may reduce subsequent deafness ( moderate‐certainty evidence) or neurological disability ( low‐certainty evidence ). The evidence is current to 17 February 2017. What was studied in the review? In meningitis, the cerebrospinal fluid that surrounds the brain and spinal cord is infected, usually as a result of spread from the blood. Any form of meningitis can result in death or severe disability, but acute bacterial meningitis is rapidly fatal without treatment. Even with antibiotics, 10% to 15% of children with bacterial meningitis die in high‐income countries with much higher rates in low‐income settings. The infection causes the brain to swell, and this is thought to contribute to death and to long‐term brain damage in survivors. Osmotic therapies increase the concentration of the blood by exerting an osmotic pressure across a semi‐permeable membrane (such as a cell wall or blood vessel lining in the brain). This draws water from the brain into the blood, thereby reducing pressure in the brain. Potentially osmotic therapies could increase the rate of survival, or they could do harm. What are the main results of the review? We included five trials that compared glycerol with placebo in a total of 1451 patients with bacterial meningitis. In the studies steroids were often given as well, but this did not appear to modify any of the effects seen with glycerol. This review detected no benefit from glycerol relating to death. There appeared to be marginal protection against deafness and against neurological disability. No effect on epileptic seizures at follow‐up was noted. Glycerol was not associated with any severe adverse effects. The number of trials included was small and only two tested a large number of participants. All trials were from different healthcare settings and examined either adults or children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wall, ECB, Ajdukiewicz, KMB, Bergman, H, Heyderman, RS, Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD008806.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.774Z" }, { "id": "b6e7e515-d96d-41bb-88f8-e048f79563c4", "pmid": "", "title": "Omega 3 fatty acids for preventing or slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Lawrenson, JG, Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD010015.pub3 AB - Abstract - Background Evidence from animal models and observational studies in humans has suggested that there is an inverse relationship between dietary intake of omega 3 long‐chain polyunsaturated fatty acids (LCPUFA) and risk of developing age‐related macular degeneration (AMD) or progression to advanced AMD. Objectives To review the evidence that increasing the levels of omega 3 LCPUFA in the diet (either by eating more foods rich in omega 3 or by taking nutritional supplements) prevents AMD or slows the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 1), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2015), EMBASE (January 1980 to February 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to February 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 February 2015. Selection criteria We included randomised controlled trials (RCTs) where increased dietary intake of omega 3 LCPUFA was compared to placebo or no intervention with the aim of preventing the development of AMD, or slowing its progression. Data collection and analysis Both authors independently selected studies, assessed them for risk of bias and extracted data. One author entered data into RevMan 5 and the other author checked the data entry. We conducted a meta‐analysis for one primary outcome, progression of AMD, using a fixed‐effect inverse variance model. Main results We included two RCTs in this review, in which 2343 participants with AMD were randomised to receive either omega 3 fatty acid supplements or a placebo. The trials, which had a low risk of bias, were conducted in the USA and France. Overall, there was no evidence that people who took omega 3 fatty acid supplements were at decreased (or increased risk) of progression to advanced AMD (pooled hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.84 to 1.10, high quality evidence). Similarly, people taking these supplements were no more (or less) likely to lose 15 or more letters of visual acuity (USA study HR 0.96, 95% CI 0.84 to 1.10; French study at 36 months risk ratio (RR) 1.25, 95% CI 0.69 to 2.26, participants = 230). The number of adverse events was similar in the intervention and placebo groups (USA study participants with one or more serious adverse event RR 1.00, 95% CI 0.91 to 1.09, participants = 2080; French study total adverse events RR 1.05, 95% CI 0.97 to 1.13, participants = 263). Authors' conclusions This review found that omega 3 LCPUFA supplementation in people with AMD for periods up to five years does not reduce the risk of progression to advanced AMD or the development of moderate to severe visual loss. No published randomised trials were identified on dietary omega 3 fatty acids for primary prevention of AMD. Currently available evidence does not support increasing dietary intake of omega 3 LCPUFA for the explicit purpose of preventing or slowing the progression of AMD. Plain language summary Omega 3 fatty acids for preventing and slowing the progression of age‐related macular degeneration Review question 
 We asked the question whether increased dietary intake of omega 3 fatty acids prevented or slowed the progression of age‐related macular degeneration. Background 
 Age‐related macular degeneration (AMD) is an eye condition that affects the central area of the retina (light‐sensitive tissue at the back of the eye). AMD is associated with a loss of detailed vision and adversely affects tasks such as reading, driving and face recognition. In the absence of a cure, there has been considerable interest in the role of modifiable risk factors to prevent or slow down the progression of AMD. Evidence from population studies suggests that people who have a diet with relatively high levels of omega 3 fatty acids (such as those derived from fish oils) are less likely to develop AMD. Study characteristics 
 We searched for studies up to 2 February 2015. We identified two trials with a total of 2343 participants. The trials were conducted in the USA and France and investigated the use of fish oil supplements in people with AMD who were at high risk of progressing to advanced disease. We judged the studies to be at low risk of bias. One study was funded by government grants and the other study was funded by the manufacturer of the dietary supplement. Key results 
 These studies found that omega 3 supplementation for periods up to five years did not reduce the rate of progression to advanced AMD or reduce significant visual loss compared to a placebo. The incidence of adverse effects was similar in the intervention and placebo groups. Quality of the evidence 
 We judged the quality of the evidence on rate of progression to AMD to be high, and the quality of the evidence for other outcomes to be moderate because the estimates were imprecise.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.074Z" }, { "id": "b706ee1f-450f-4b71-8c7c-7008d1edffcb", "pmid": "", "title": "Interventions for deliberately altering blood pressure in acute stroke", "imported": false, "abstract": "Abstract - Background It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001 and 2008. Objectives To assess the clinical effectiveness of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke. Search methods We searched the Cochrane Stroke Group Trials Register (last searched in February 2014), the Cochrane Database of Systematic reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 2), MEDLINE (Ovid) (1966 to May 2014), EMBASE (Ovid) (1974 to May 2014), Science Citation Index (ISI, Web of Science, 1981 to May 2014) and the Stroke Trials Registry (searched May 2014). Selection criteria Randomised controlled trials of interventions that aimed to alter blood pressure compared with control in participants within one week of acute ischaemic or haemorrhagic stroke. Data collection and analysis Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data. The review authors cross‐checked data and resolved discrepancies by discussion to reach consensus. We obtained published and unpublished data where available. Main results We included 26 trials involving 17,011 participants (8497 participants were assigned active therapy and 8514 participants received placebo/control). Not all trials contributed to each outcome. Most data came from trials that had a wide time window for recruitment; four trials gave treatment within six hours and one trial within eight hours. The trials tested alpha‐2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide‐like diuretics, and target‐driven blood pressure lowering. One trial tested phenylephrine. At 24 hours after randomisation oral ACEIs reduced systolic blood pressure (SBP, mean difference (MD) ‐8 mmHg, 95% confidence interval (CI) ‐17 to 1) and diastolic blood pressure (DBP, MD ‐3 mmHg, 95% CI ‐9 to 2), sublingual ACEIs reduced SBP (MD ‐12.00 mm Hg, 95% CI ‐26 to 2) and DBP (MD ‐2, 95%CI ‐10 to 6), oral ARA reduced SBP (MD ‐1 mm Hg, 95% CI ‐3 to 2) and DBP (MD ‐1 mm Hg, 95% CI ‐3 to 1), oral beta blockers reduced SBP (MD ‐14 mm Hg; 95% CI ‐27 to ‐1) and DBP (MD ‐1 mm Hg, 95% CI ‐9 to 7), intravenous (iv) beta blockers reduced SBP (MD ‐5 mm Hg, 95% CI ‐18 to 8) and DBP (‐5 mm Hg, 95% CI ‐13 to 3), oral CCBs reduced SBP (MD ‐13 mmHg, 95% CI ‐43 to 17) and DBP (MD ‐6 mmHg, 95% CI ‐14 to 2), iv CCBs reduced SBP (MD ‐32 mmHg, 95% CI ‐65 to 1) and DBP (MD ‐13, 95% CI ‐31 to 6), NO donors reduced SBP (MD ‐12 mmHg, 95% CI ‐19 to ‐5) and DBP (MD ‐3, 95% CI ‐4 to ‐2) while phenylephrine, non‐significantly increased SBP (MD 21 mmHg, 95% CI ‐13 to 55) and DBP (MD 1 mmHg, 95% CI ‐15 to 16). Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05), stroke type (OR 0.98, 95% CI 0.92 to 1.05) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05). Treatment within six hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99) but not death (OR 0.70, 95% CI 0.38 to 1.26) at the end of the trial. Although death or dependency did not differ between people who continued pre‐stroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24), disability scores at the end of the trial were worse in participants randomised to continue treatment (Barthel Index, MD ‐3.2, 95% CI ‐5.8, ‐0.6). Authors' conclusions There is insufficient evidence that lowering blood pressure during the acute phase of stroke improves functional outcome. It is reasonable to withhold blood pressure‐lowering drugs until patients are medically and neurologically stable, and have suitable oral or enteral access, after which drugs can than be reintroduced. In people with acute stroke, CCBs, ACEI, ARA, beta blockers and NO donors each lower blood pressure while phenylephrine probably increases blood pressure. Further trials are needed to identify which people are most likely to benefit from early treatment, in particular whether treatment started very early is beneficial. Plain language summary Drug interventions for deliberately altering blood pressure in acute stroke Background: In people who have just had a stroke (a sudden brain attack due to either blockage or rupture of an artery in the brain), very high and very low blood pressures may be harmful. Therefore, drugs that raise low blood pressure or lower high blood pressure might be beneficial. Up to 50% of people admitted with acute stroke are taking blood pressure tablets on hospital admission and it is not clear whether these medications should be continued or discontinued in the acute situation. This review looked at those trials that deliberately altered blood pressure or compared continuing or stopping blood pressure‐lowering tablets taken before stroke. Study characteristics: This review is up‐to‐date to May 2014. We included 26 trials involving 17,011 participants: 24 trials assessed lowering blood pressure, one trial tested raising blood pressure, and two trials assessed what to do with drugs taken before stroke. All studies took place in hospitals that were used to treating people with stroke. Not all trials contributed information to all outcomes, and we have used data that were available in publications. Key results: There is insufficient evidence to say that lowering blood pressure saves lives or reduces disability in people with acute stroke. Immediately restarting blood pressure‐lowering drugs taken before the stroke may increase disability. Conclusion: More research is needed to identify those people who are most likely to benefit from altering blood pressure in acute stroke, the time window in which the treatment is likely to be of benefit, what types of stroke are likely to respond favourably, and the environment in which such treatment may be best given in routine practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bath, PMW; Krishnan, K", "articleTypes": [], "doi": "10.1002/14651858.CD000039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "b7098db2-f827-424a-9eaf-be0ae3468d42", "pmid": "", "title": "Preprocedural mouth rinses for preventing transmission of infectious diseases through aerosols in dental healthcare providers", "imported": false, "abstract": "Abstract - Background Aerosols and spatter are generated in a dental clinic during aerosol‐generating procedures (AGPs) that use high‐speed hand pieces. Dental healthcare providers can be at increased risk of transmission of diseases such as tuberculosis, measles and severe acute respiratory syndrome (SARS) through droplets on mucosae, inhalation of aerosols or through fomites on mucosae, which harbour micro‐organisms. There are ways to mitigate and contain spatter and aerosols that may, in turn, reduce any risk of disease transmission. In addition to personal protective equipment (PPE) and aerosol‐reducing devices such as high‐volume suction, it has been hypothesised that the use of mouth rinse by patients before dental procedures could reduce the microbial load of aerosols that are generated during dental AGPs. Objectives To assess the effects of preprocedural mouth rinses used in dental clinics to minimise incidence of infection in dental healthcare providers and reduce or neutralise contamination in aerosols. Search methods We used standard, extensive Cochrane search methods. The latest search date was 4 February 2022. Selection criteria We included randomised controlled trials and excluded laboratory‐based studies. Study participants were dental patients undergoing AGPs. Studies compared any preprocedural mouth rinse used to reduce contaminated aerosols versus placebo, no mouth rinse or another mouth rinse. Our primary outcome was incidence of infection of dental healthcare providers and secondary outcomes were reduction in the level of contamination of the dental operatory environment, cost, change in mouth microbiota, adverse events, and acceptability and feasibility of the intervention. Data collection and analysis Two review authors screened search results, extracted data from included studies, assessed the risk of bias in the studies and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random‐effects meta‐analysis to combine data Main results We included 17 studies with 830 participants aged 18 to 70 years. We judged three trials at high risk of bias, two at low risk and 12 at unclear risk of bias. None of the studies measured our primary outcome of the incidence of infection in dental healthcare providers. The primary outcome in the studies was reduction in the level of bacterial contamination measured in colony‐forming units (CFUs) at distances of less than 2 m (intended to capture larger droplets) and 2 m or more (to capture droplet nuclei from aerosols arising from the participant's oral cavity). It is unclear what size of CFU reduction represents a clinically significant amount. There is low‐ to very low‐certainty evidence that chlorhexidine (CHX) may reduce bacterial contamination, as measured by CFUs, compared with no rinsing or rinsing with water. There were similar results when comparing cetylpyridinium chloride (CPC) with no rinsing and when comparing CPC, essential oils/herbal mouthwashes or boric acid with water. There is very low‐certainty evidence that tempered mouth rinses may provide a greater reduction in CFUs than cold mouth rinses. There is low‐certainty evidence that CHX may reduce CFUs more than essential oils/herbal mouthwashes. The evidence for other head‐to‐head comparisons was limited and inconsistent. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or adverse events such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess acceptability of the intervention to patients or feasibility of implementation for dentists. Authors' conclusions None of the included studies measured the incidence of infection among dental healthcare providers. The studies measured only reduction in level of bacterial contamination in aerosols. None of the studies evaluated viral or fungal contamination. We have only low to very low certainty for all findings. We are unable to draw conclusions regarding whether there is a role for preprocedural mouth rinses in reducing infection risk or the possible superiority of one preprocedural rinse over another. Studies are needed that measure the effect of rinses on infectious disease risk among dental healthcare providers and on contaminated aerosols at larger distances with standardised outcome measurement. Plain language summary Does use of mouth rinse before a dental procedure reduce the risk of infection transmission from patient to health professional? Why is this question important? Many dental procedures generate droplets that settle on a surface quickly. If high‐speed instruments, such as a drill, are used, aerosols are generated, which consist of tiny particles that remain suspended in the air and that can be inhaled or that settle farther away on surfaces. These aerosols contain a variety of micro‐organisms and may transmit infections either through direct contact or indirectly through the contaminated surfaces. To prevent the spread of infection, it may help to reduce the number of micro‐organisms that are present in these aerosols. The use of mouth rinses before a dental procedure ('preprocedural mouth rinse') has been suggested as a possible way to reduce the amount of contamination of these aerosols. Chlorhexidine, povidone iodine and cetylpyridinium chloride (CPC) are some of the commonly used mouth rinses. They act by killing or inactivating the micro‐organisms in the mouth and thereby reducing the level of contamination in the aerosol that is generated. We wanted to find out whether rinsing the mouth before a dental procedure reduces the contamination of aerosols produced during dental procedures in practice and helps prevent the transmission of infectious diseases. How did we identify and evaluate the evidence? We searched for all relevant studies that compared mouth rinses used before dental procedures against placebo (fake treatment), no intervention or another mouth rinse considered to be inactive. We then compared the results, and summarised the evidence from all the studies. Finally, we assessed our confidence in the evidence. To do this, we considered factors such as the way studies were conducted, study sizes and consistency of findings across studies. What did we find? We found 17 studies that met our inclusion criteria. These studies used chlorhexidine, CPC, essential oil/herbal mouth rinses, povidone iodine and boric acid in comparison to no rinsing, or rinsing with water, saline (salt water) or another mouth rinse. None of the studies measured the how often dental healthcare providers became infected with micro‐organisms. All the included studies measured the level of bacterial contamination in droplets or aerosols in the dental clinic. They did not examine contamination with viruses or fungi. Most rinses decreased bacterial contamination in aerosols to some extent, but there was considerable variation in the effects and we do not know what size of reduction is necessary to reduce infection risk. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or side effects such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess whether patients were happy to use a mouth rinse or whether it was easy for dentists to implement. Overall, the results suggest that using a preprocedural mouth rinse may reduce the level of bacterial contamination in aerosols compared with no rinsing or rinsing with water, but we have only low or very low certainty that the evidence is reliable and we do not know how this reduction in contamination relates to the risk of infection. What does this mean? We have very little confidence in the evidence, and further studies may change the findings of our review. No studies measured infection risk or investigated viral or fungal contamination. How up‐to‐date is this review? The evidence in this Cochrane Review is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kumbargere Nagraj, S; Eachempati, P; Paisi, M; Nasser, M; Sivaramakrishnan, G; Francis, T; Verbeek, JH", "articleTypes": [], "doi": "10.1002/14651858.CD013826.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "b7124a55-a7fc-41f8-9399-6441755d2765", "pmid": "", "title": "Interventions for recurrent idiopathic epistaxis (nosebleeds) in children", "imported": false, "abstract": "Abstract - Background Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified. Although nosebleeds are very common in children, and most cases are self limiting or settle with simple measures (such as pinching the nose), more severe recurrent cases can require treatment from a healthcare professional. However, there is no consensus on the effectiveness of the different clinical interventions currently used in managing this condition. Objectives To assess the effects of different interventions for the management of recurrent idiopathic epistaxis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 5 March 2012. Selection criteria We identified all randomised controlled trials (RCTs) (with or without blinding) in which any surgical or medical intervention for the treatment of recurrent idiopathic epistaxis in children was evaluated in comparison with either no treatment, a placebo or another intervention, and in which the frequency and severity of episodes of nasal bleeding following treatment was stated or calculable. The two authors reviewed the full‐text articles of all retrieved trials of possible relevance and applied the inclusion criteria independently. Data collection and analysis We graded trials for risk of bias using the Cochrane approach. One author performed data extraction in a standardised manner and this was rechecked by the other author. Where necessary we contacted investigators to obtain missing information. We did not undertake a meta‐analysis because of the heterogeneity of the treatments, procedures and quality of the included trials. A narrative overview of the results is therefore presented. Main results Five studies (four RCTs and one quasi‐randomised controlled trial) involving 468 participants satisfied the inclusion criteria. The identified RCTs compared 0.5% neomycin + 0.1% chlorhexidine (Naseptin®) cream with no treatment, Vaseline® petroleum jelly with no treatment, 75% with 95% silver nitrate nasal cautery, and silver nitrate cautery combined with Naseptin® against Naseptin® alone; the quasi‐randomised controlled trial compared Naseptin® antiseptic cream with silver nitrate cautery. Overall results were inconclusive, with no statistically significant difference found between the compared treatments upon completion of the trials, however 75% silver nitrate was more effective than 95% silver nitrate at two weeks following application. The group treated with 75% silver nitrate had 88% complete resolution of epistaxis compared to 65% in the group treated with 95% silver nitrate (P = 0.01). No serious adverse effects were reported from any of the interventions, although children receiving silver nitrate cautery reported that it was a painful experience (despite the use of local anaesthetic). The pain scores were significantly less in those treated with 75% silver nitrate, the mean score being 1 compared to a mean score of 5 in those treated with 95% silver nitrate; this was statistically significant (P = 0.001). We carried out a 'Risk of bias' assessment of each study according to the Cochrane methodology and judged that two randomised controlled trials had a low risk of bias, two had an unclear risk of bias and the quasi‐randomised controlled trial had a high risk of bias. Authors' conclusions The optimal management of children with recurrent idiopathic epistaxis is unknown, however if silver nitrate nasal cautery is undertaken 75% is preferable to 95% as it is more effective in the short term and causes less pain. High‐quality randomised controlled trials comparing interventions either with placebo or no treatment, and with a follow‐up period of at least a year, are needed to assess the relative merits of the various treatments currently in use. Plain language summary Interventions for recurrent nosebleeds of unknown cause in children Nosebleeds in children usually just stop by themselves or after pinching the nose. However, some children get repeated nosebleeds with no specific cause (recurrent idiopathic epistaxis). The most common treatments are cautery or antiseptic cream, or both. Cautery (a method of sealing) can be painful even with local anaesthetic, and usually involves using a silver nitrate stick to seal off a visible blood vessel inside the nose that may be rupturing. Other options include ointments and nasal sprays. The review of trials found that there is not enough evidence to compare the effectiveness of different treatment options, however using a lower concentration of silver nitrate cautery is more effective in the short term and less painful. More research is needed to show the best options for reducing recurrent nosebleeds of unknown cause in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Qureishi, A; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004461.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "b7196c74-f2af-480d-b514-caaaad7a3de2", "pmid": "", "title": "Alarm interventions for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs. Objectives To assess the effects of enuresis alarms for treating enuresis in children. Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old. Data collection and analysis Two review authors independently assessed risk of bias and extracted data. Main results We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) −2.68, 95% confidence interval (CI) −4.59 to −0.78; 4 trials, 127 children; low‐quality evidence). Low‐quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post‐treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low‐quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD −0.96, 95% CI −2.32 to 0.41; 1 trial, 47 children; very low‐quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low‐quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post‐treatment. Compared with control alarms, code‐word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate‐quality evidence) but there is probably little to no difference in the number of children remaining dry post‐treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate‐quality evidence). Very low‐quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry‐bed training, and star chart plus rewards) (MD ‐0.81, 95% CI ‐2.01 to 0.38; low‐quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low‐quality evidence) and may slightly increase the number of children remaining dry post‐treatment (RR 1.39, 95% CI 0.81 to 2.41; low‐quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD −0.64, 95% CI −1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low‐quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post‐treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate‐quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post‐treatment, because the quality of evidence is very low. Due to very low‐quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD −0.88, 95% CI −0.38 to −1.38; 2 trials, 156 children; low‐quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low‐quality evidence) and the number of children remaining dry post‐treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low‐quality evidence) compared with desmopressin alone. Alarm plus dry‐bed training may increase the number of children achieving a complete response compared to dry‐bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low‐quality evidence). It is unclear if there is any difference in the number of children remaining dry post‐treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low‐quality evidence). Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code‐word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate‐quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate‐quality evidence). Very low‐quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments. Authors' conclusions Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately‐powered trials with robust randomisation are still needed to determine the full effect of alarm therapy. Plain language summary Alarm interventions for nocturnal enuresis (bedwetting) in children Review question Is alarm training an effective treatment for bedwetting in children? Background Bedwetting is common in childhood and affects up to 20% of five‐year‐olds. Although children may spontaneously recover from this, bedwetting can have significant social, emotional and psychological effects on the child and their family. Treatments for bedwetting include alarms (activated by urination), behavioural interventions and drugs. How up‐to‐date is this review? The evidence is current up to 25 June 2018. Study characteristics This review includes 74 trials involving 5983 children. Study funding sources Three of the studies included in the review were funded or supported by a pharmaceutical company. Key results Alarms may be better than no treatment in terms of reducing the number of wet nights a week and increasing the number of children achieving 14 consecutive dry nights. Alarms may increase the number of children remaining dry after stopping treatment, compared to no treatment. We are uncertain if there is any difference between alarms and behavioural interventions (such as bladder training), or between alarms and desmopressin medication in terms of reducing the number of wet nights a week, increasing the number of children achieving 14 consecutive dry nights and increasing the number of children remaining dry after stopping treatment. We are uncertain whether alarms reduce the number of wet nights more than placebo drugs, other types of alarms, tricyclics medication, or various treatments such as hypnotherapy or restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin alone. It may increase the number of children achieving 14 consecutive dry nights and increase the number of children remaining dry after stopping treatment. Alarm plus dry‐bed training may increase the number of children achieving 14 consecutive dry nights compared to dry‐bed training alone, but we are uncertain if the response is maintained after stopping treatment. Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Alarm therapy probably reduces the number of children experiencing adverse events compared with desmopressin. We think there is probably a slight increase in adverse events between code‐word alarms and standard alarms but until we have more evidence from more children we cannot be certain about this. We are uncertain about the safety of alarm therapy compared to other treatments, because the quality of evidence is very low. Quality of the evidence The quality of the evidence means that, in general, the level of certainty in our conclusions is low. Authors' conclusions Alarm therapy may be more effective than no treatment, but due to the low‐quality evidence we do not know how much alarm therapy is more effective than none at all. Adding alarm therapy to desmopressin may be more effective than desmopressin alone. Despite the large number of trials we identified, the low certainty of the evidence means that we cannot tell from these studies whether or not alarm therapy is better than most other therapies for reducing bedwetting in children. We cannot be sure about its effects until there are better‐designed trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Caldwell, PHY, Codarini, M, Stewart, F, Hahn, D, Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002911.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.131Z" }, { "id": "b71ef62b-b7ab-4564-995b-17931fd94b66", "pmid": "", "title": "Pharmacological interventions for the treatment of depression in chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Studies report that up to 80% of individuals with chronic obstructive pulmonary disease (COPD) may struggle with symptoms of depression. However, this major comorbidity in COPD is rarely managed effectively. A number of recent studies indicate that left untreated, COPD‐related depression is associated with worse quality of life, worse compliance with COPD treatment plan, increased exacerbations, hospital admissions, and healthcare costs when compared to individuals with COPD without depression. Regrettably, COPD practice guidelines do not provide conclusive treatment recommendations for the use of antidepressants in patients with COPD, and base their guidelines on findings from trials in the general population. This may be problematic, as there is an elevated risk of respiratory issues associated with antidepressant treatment and COPD. Evaluating effectiveness and safety of pharmacological interventions specifically for patients with COPD and depression was therefore paramount. Objectives To assess the effectiveness and safety of pharmacological interventions for the treatment of depression in patients with COPD. Search methods The last search was performed on 26 November 2018. We initially searched the following databases via the Specialised Trials Registers of the Cochrane Airways and Common Mental Disorders Groups (to June 2016): MEDLINE, Embase, PsycINFO, CINAHL, AMED, and the Cochrane Library trials register (CENTRAL). Searches from June 2016 to November 2018 were performed directly on Ovid MEDLINE, Embase, PsycINFO and the Cochrane Library (Issue 11, 2018). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform to 26 November 2018. We searched the grey literature databases to identify studies not indexed in major databases and the reference lists of studies initially identified for full‐text screening. Selection criteria All published and unpublished randomised controlled trials (RCTs) comparing the efficacy of pharmacological interventions with no intervention, placebo or co‐intervention in adults with diagnosed COPD and depression were eligible for inclusion. Data collection and analysis Two review authors independently assessed articles identified by the search for eligibility. Our primary outcomes were change in depressive symptoms and adverse events. The secondary outcomes were: change in quality of life, change in dyspnoea, change in forced expiratory volume in one second (FEV 1 ), change in exercise tolerance, change in hospital utilisation (length of stay and readmission rates), and cost‐effectiveness. For continuous outcomes, we calculated the pooled mean difference (MD) or standardised mean difference (SMD) with 95% confidence interval (CI) as appropriate. For dichotomous outcomes, we calculated the pooled odds ratio (OR) and corresponding 95% CI using a random‐effects model. We assessed the quality of evidence using the GRADE framework. Main results Of the 1125 records screened for eligibility, four RCTs (N = 201 participants), and one on‐going study, met the inclusion criteria. Two classes of antidepressants were investigated in two separate comparisons with placebo: a tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitors (SSRIs). TCA versus placebo Only one RCT (N = 30 participants) provided results for this comparison. Primary outcomes The TCA (nortriptyline) reduced depressive symptoms post‐treatment compared to placebo (MD ‐10.20, 95% CI ‐16.75 to ‐3.65; P = 0.007; very low‐quality evidence), as measured by the Hamilton Depression Rating Scale (HAM‐D). Three participants withdrew from the trial due to adverse events related to the tested antidepressant (dry mouth, sedation, orthostatic hypotension). Secondary outcomes The overall results post‐treatment indicated that nortriptyline was not effective in improving the quality of life of individuals with COPD, as measured by the Sickness Impact Profile (MD ‐2.80, 95% CI ‐11.02 to 5.42; P = 0.50; very low‐quality evidence). The results for the change in dyspnoea for the domains examined (e.g. dyspnoea scores for 'most day‐to‐day activities') post‐treatment showed no improvement in the intervention group (MD 9.80, 95% CI ‐6.20 to 25.80; P = 0.23; very low‐quality evidence). No data were reported for change in FEV 1 , change in exercise tolerance, change in hospital utilisation, or cost‐effectiveness. The TCA study provided short‐term results, with the last follow‐up data collection at 12 weeks. The quality of the evidence for all the outcomes evaluated was very low due to a small sample size, imprecision, attrition, and selection and reporting bias. SSRIs versus placebo Three RCTs (N = 171 participants) provided results for this comparison. Primary outcomes The pooled results for two studies showed no difference for the change in depressive symptoms post‐intervention (SMD 0.75, 95% CI ‐1.14 to 2.64; 148 participants; 2 studies; P = 0.44; very low‐quality evidence). High heterogeneity was observed (I² = 95%), limiting the reliability of these findings. While it was not possible to meta‐analyse the total adverse events rates across the studies, it was possible to combine the results for two medication‐specific adverse effects: nausea and dizziness. There were no significant post‐treatment group differences for nausea (OR 2.32, 95% CI 0.66 to 8.12; 171 participants; 3 studies; P = 0.19; very low‐quality evidence) or dizziness (OR 0.61, 95% CI 0.09 to 4.06; 143 participants; 2 studies; P = 0.61; very low‐quality evidence). Secondary outcomes The pooled analysis of two trials reporting data for the change in quality of life did not show improvement post‐treatment in the intervention group compared to placebo (SMD 1.17, 95% CI ‐0.80 to 3.15; 148 participants; 2 studies; P = 0.25; very low‐quality evidence). There was no difference between groups in change in FEV 1 post‐treatment (MD 0.01, 95% CI ‐0.03 to 0.05; 148 participants; 2 studies; P = 0.60; low‐quality evidence). However, two trials reported improvement in exercise tolerance in the SSRI group versus the placebo group (MD 13.88, 95% CI 11.73 to 16.03; 148 participants; 2 studies; P < 0.001; very low‐quality evidence). The trials included in this comparison did not report data related to the change in dyspnoea, hospital utilisation rates, or cost‐effectiveness. Authors' conclusions There is insufficient evidence to make definitive statements about the efficacy or safety of antidepressants for treating COPD‐related depression. New RCTs are needed; with better methodological quality and more accurate reporting of the methods used. Moreover, longer‐term follow‐up data collection is needed, including outcomes such as adverse events, hospital utilisation and cost‐effectiveness. Plain language summary Medication for the treatment of depression in chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a term that mainly describes two lung conditions: chronic bronchitis and emphysema. The main symptoms of COPD include shortness of breath, persistent cough, wheezing, and/or frequent chest infections. There is no cure for COPD, but treatment can help slow the disease progress and relieve symptoms. Depression is very common in patients with COPD, but is often untreated. Studies show that untreated depression in patients with COPD can worsen quality of life, increase COPD exacerbations and hospital admissions, and make following a COPD treatment plan difficult. Treatment for depression can include antidepressant medication, psychological therapy, or both. However, evidence‐based recommendations regarding antidepressant medication use specifically for patients with COPD are not currently available. Why is this review important? There is currently no clear overview of existing evidence showing whether antidepressants can effectively and safely reduce depressive symptoms in patients with COPD, therefore it was important to assess the existing experimental studies. Who will be interested in this review? Healthcare professionals, people with COPD and depression, researchers, and policymakers will be interested in the findings of this review. What questions does this review aim to answer? Our main aim was to assess whether pharmacological treatment (e.g. antidepressants) could effectively and safely treat COPD‐related depression. Which studies were included in the review? This review included experimental studies called randomised controlled trials (studies in which participants are assigned to a treatment group based on a random method) that compared the effectiveness of pharmacological interventions (antidepressants) to placebo (inactive treatment in the same form as the active treatment, e.g. a pill). Study participants were adults diagnosed with COPD and depression. What does the evidence from the review tell us? We have identified only four studies worldwide that were eligible for inclusion in our review. This means limited evidence to support the use of antidepressants for the treatment of depression in patients with COPD. Only one study evaluated a tricyclic antidepressant, nortriptyline, finding that it reduced depressive symptoms when compared to a placebo. Three studies evaluated a newer generation class of antidepressants called selective serotonin reuptake inhibitors (SSRIs), finding no evidence for their effectiveness in improving depressive symptoms. Due to the limited evidence, we are unable to make definitive statements about the effectiveness but also safety of antidepressants when used for COPD‐related depression. However, SSRIs may increase exercise capacity in patients with COPD. Given that the current findings were based on only four small studies with evidence rated as of very low quality, it is important to interpret our results with caution. What should happen next? Insufficient evidence prevented us from making clear recommendations for doctors, other healthcare professionals, researchers, or policymakers. More studies with better methodological quality and a larger number of participants are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pollok, J; van Agteren, JEM; Carson‐Chahhoud, KV", "articleTypes": [], "doi": "10.1002/14651858.CD012346.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "b741726b-513e-4e8f-b60f-4ef63e130716", "pmid": "", "title": "Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Wells, GA, Hsieh, S-C, Peterson, J, Zheng, C, Kelly, SE, Shea, B, Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD003376.pub4 AB - Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Etidronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts – bone cells that break down bone tissue. This is an update of a Cochrane review first published in 2008. For clinical relevance, we investigated etidronate's effects on postmenopausal women stratified by fracture risk (low versus high). Objectives To assess the benefits and harms of intermittent/cyclic etidronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE, Embase, two clinical trial registers, the websites of drug approval agencies, and the bibliographies of relevant systematic reviews. We identified eligible trials published between 1966 and February 2023. Selection criteria We included randomized controlled trials that assessed the benefits and harms of etidronate in the prevention of fractures for postmenopausal women. Women in the experimental arms must have received at least one year of etidronate, with or without other anti‐osteoporotic drugs and concurrent calcium/vitamin D. Eligible comparators were placebo (i.e. no treatment; or calcium, vitamin D, or both) or another anti‐osteoporotic drug. Major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. We classified a study as secondary prevention if its population fulfilled one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (≤ ‐2.5), or aged 75 years or older. If none of these criteria were met, we considered the study to be primary prevention. Data collection and analysis We used standard methodological procedures expected by Cochrane. The review has three main comparisons: (1) etidronate 400 mg/day versus placebo; (2) etidronate 200 mg/day versus placebo; (3) etidronate at any dosage versus another anti‐osteoporotic agent. We stratified the analyses for each comparison into primary and secondary prevention studies. For major outcomes in the placebo‐controlled studies of etidronate 400 mg/day, we followed our original review by defining a greater than 15% relative change as clinically important. For all outcomes of interest, we extracted outcome measurements at the longest time point in the study. Main results Thirty studies met the review's eligibility criteria. Of these, 26 studies, with a total of 2770 women, reported data that we could extract and quantitatively synthesize. There were nine primary and 17 secondary prevention studies. We had concerns about at least one risk of bias domain in each study. None of the studies described appropriate methods for allocation concealment, although 27% described adequate methods of random sequence generation. We judged that only 8% of the studies avoided performance bias, and provided adequate descriptions of appropriate blinding methods. One‐quarter of studies that reported efficacy outcomes were at high risk of attrition bias, whilst 23% of studies reporting safety outcomes were at high risk in this domain. The 30 included studies compared (1) etidronate 400 mg/day to placebo (13 studies: nine primary and four secondary prevention); (2) etidronate 200 mg/day to placebo (three studies, all secondary prevention); or (3) etidronate (both dosing regimens) to another anti‐osteoporotic agent (14 studies: one primary and 13 secondary prevention). We discuss only the etidronate 400 mg/day versus placebo comparison here. For primary prevention, we collected moderate‐ to very low‐certainty evidence from nine studies (one to four years in length) including 740 postmenopausal women at lower risk of fractures. Compared to placebo, etidronate 400 mg/day probably results in little to no difference in non‐vertebral fractures (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.20 to 1.61); absolute risk reduction (ARR) 4.8% fewer, 95% CI 8.9% fewer to 6.1% more) and serious adverse events (RR 0.90, 95% CI 0.52 to 1.54; ARR 1.1% fewer, 95% CI 4.9% fewer to 5.3% more), based on moderate‐certainty evidence. Etidronate 400 mg/day may result in little to no difference in clinical vertebral fractures (RR 3.03, 95% CI 0.32 to 28.44; ARR 0.02% more, 95% CI 0% fewer to 0% more) and withdrawals due to adverse events (RR 1.41, 95% CI 0.81 to 2.47; ARR 2.3% more, 95% CI 1.1% fewer to 8.4% more), based on low‐certainty evidence. We do not know the effect of etidronate on hip fractures because the evidence is very uncertain (RR not estimable based on very low‐certainty evidence). Wrist fractures were not reported in the included studies. For secondary prevention, four studies (two to four years in length) including 667 postmenopausal women at higher risk of fractures provided the evidence. Compared to placebo, etidronate 400 mg/day may make little or no difference to non‐vertebral fractures (RR 1.07, 95% CI 0.72 to 1.58; ARR 0.9% more, 95% CI 3.8% fewer to 8.1% more), based on low‐certainty evidence. The evidence is very uncertain about etidronate's effects on hip fractures (RR 0.93, 95% CI 0.17 to 5.19; ARR 0.0% fewer, 95% CI 1.2% fewer to 6.3% more), wrist fractures (RR 0.90, 95% CI 0.13 to 6.04; ARR 0.0% fewer, 95% CI 2.5% fewer to 15.9% more), withdrawals due to adverse events (RR 1.09, 95% CI 0.54 to 2.18; ARR 0.4% more, 95% CI 1.9% fewer to 4.9% more), and serious adverse events (RR not estimable), compared to placebo. Clinical vertebral fractures were not reported in the included studies. Authors' conclusions This update echoes the key findings of our previous review that etidronate probably makes or may make little to no difference to vertebral and non‐vertebral fractures for both primary and secondary prevention. Plain language summary Does etidronate prevent fractures caused by osteoporosis in postmenopausal women? Key messages • For women with close to normal bone density (bone strength) and no previous broken spinal bones, etidronate probably makes little or no difference to the likelihood of having a hip or wrist fracture or a serious adverse (unwanted/harmful) event.
 • For women who have low bone density and are at risk for or have had a previous broken spinal bone, etidronate may make little or no difference in preventing fractures in bones other than the spine. What is osteoporosis? Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow, and old bone cells break down to make room for new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break, even after a minor injury, such as a slight bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. What is etidronate? Etidronate belongs to the class of medicines called bisphosphonates, which slow down the cells that break down the old bone. It is given by mouth in an intermittent or cyclical schedule; for example, a 400 mg tablet daily for two weeks every 90 days, followed by calcium or no treatment for the remainder of each 90‐day treatment cycle. What did we want to find out? We wanted to find out if etidronate was better than placebo (inactive or 'dummy' medicine) or another medicine for osteoporosis in preventing broken bones in postmenopausal women. For clinical relevance, we looked at etidronate's effects on women, as grouped by their risk of fracture (lower versus higher risk). We also wanted to find out if etidronate was associated with any unwanted effects. What did we do? We searched for studies comparing etidronate to placebo or another medicine for preventing osteoporosis. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Overall, we found 30 studies, but 4 studies provided insufficient information about their results. Thus, we were able to analyse the results of 26 studies involving 2770 women. Nine studies were interested in 'primary prevention' of osteoporosis‐based fractures, meaning they focused on women at lower fracture risk, who had bones with near‐to‐normal density/strength and no previous broken spinal bones. Seventeen studies were interested in 'secondary prevention' with etidronate, meaning they focused on women at higher fracture risk, who already had weak bones (low bone density), had a broken spinal bone, or both. Most studies mainly included white women. The studies lasted between 1 and 4 years. Some studies gave the women 400 mg/day of etidronate, whilst other studies gave 200 mg/day. Main results for primary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate: • probably makes little or no difference to non‐vertebral (non‐spinal) fractures and serious adverse events; • may make little or no difference to clinical vertebral fractures (that is, spinal fractures suggested by clinical signs and symptoms) and the number of women who left the studies due to adverse events. The evidence is very uncertain about the effect of etidronate on hip fractures. None of the studies reported on the effect on wrist fractures. Main results for secondary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate may make little or no difference in preventing fractures in bones other than the spine. The evidence is very uncertain about the effect of etidronate on hip and wrist fractures, the number of women who left the studies due to adverse events, and serious adverse events. None of the studies reported on etidronate's effect on clinical vertebral fractures. What are the limitations of the evidence? Our confidence in the evidence ranged from very low to moderate. In general, we have little confidence in the evidence because it is possible that the women in the studies were aware of which treatment they were getting, which could influence the results, and because many of the studies were very small. How up to date is this evidence? The evidence is current to February 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.789Z" }, { "id": "b7477dfa-1388-4181-8595-ef3296fe083b", "pmid": "", "title": "Pharmacological intervention for irritability, aggression, and self‐injury in autism spectrum disorder (ASD)", "imported": false, "abstract": "Abstract - Background Pharmacological interventions are frequently used for people with autism spectrum disorder (ASD) to manage behaviours of concern, including irritability, aggression, and self‐injury. Some pharmacological interventions might help treat some behaviours of concern, but can also have adverse effects (AEs). Objectives To assess the effectiveness and AEs of pharmacological interventions for managing the behaviours of irritability, aggression, and self‐injury in ASD. Search methods We searched CENTRAL, MEDLINE, Embase, 11 other databases and two trials registers up to June 2022. We also searched reference lists of relevant studies, and contacted study authors, experts and pharmaceutical companies. Selection criteria We included randomised controlled trials of participants of any age with a clinical diagnosis of ASD, that compared any pharmacological intervention to an alternative drug, standard care, placebo, or wait‐list control. Data collection and analysis We used standard Cochrane methods. Primary outcomes were behaviours of concern in ASD, (irritability, aggression and self‐injury); and AEs. Secondary outcomes were quality of life, and tolerability and acceptability. Two review authors independently assessed each study for risk of bias, and used GRADE to judge the certainty of the evidence for each outcome. Main results We included 131 studies involving 7014 participants in this review. We identified 26 studies as awaiting classification and 25 as ongoing. Most studies involved children (53 studies involved only children under 13 years), children and adolescents (37 studies), adolescents only (2 studies) children and adults (16 studies), or adults only (23 studies). All included studies compared a pharmacological intervention to a placebo or to another pharmacological intervention. Atypical antipsychotics versus placebo At short‐term follow−up (up to 6 months), atypical antipsychotics probably reduce irritability compared to placebo (standardised mean difference (SMD) −0.90, 95% confidence interval (CI) −1.25 to −0.55, 12 studies, 973 participants; moderate‐certainty evidence), which may indicate a large effect. However, there was no clear evidence of a difference in aggression between groups (SMD −0.44, 95% CI −0.89 to 0.01; 1 study, 77 participants; very low‐certainty evidence). Atypical antipsychotics may also reduce self‐injury (SMD −1.43, 95% CI −2.24 to −0.61; 1 study, 30 participants; low‐certainty evidence), possibly indicating a large effect. There may be higher rates of neurological AEs (dizziness, fatigue, sedation, somnolence, and tremor) in the intervention group (low‐certainty evidence), but there was no clear evidence of an effect on other neurological AEs. Increased appetite may be higher in the intervention group (low‐certainty evidence), but we found no clear evidence of an effect on other metabolic AEs. There was no clear evidence of differences between groups in musculoskeletal or psychological AEs. Neurohormones versus placebo At short‐term follow‐up, neurohormones may have minimal to no clear effect on irritability when compared to placebo (SMD −0.18, 95% CI −0.37 to −0.00; 8 studies; 466 participants; very low‐certainty evidence), although the evidence is very uncertain. No data were reported for aggression or self ‐injury. Neurohormones may reduce the risk of headaches slightly in the intervention group, although the evidence is very uncertain. There was no clear evidence of an effect of neurohormones on any other neurological AEs, nor on any psychological, metabolic, or musculoskeletal AEs (low‐ and very low‐certainty evidence). Attention‐deficit hyperactivity disorder (ADHD)‐related medications versus placebo At short‐term follow‐up, ADHD‐related medications may reduce irritability slightly (SMD −0.20, 95% CI −0.40 to −0.01; 10 studies, 400 participants; low‐certainty evidence), which may indicate a small effect. However, there was no clear evidence that ADHD‐related medications have an effect on self‐injury (SMD −0.62, 95% CI −1.63 to 0.39; 1 study, 16 participants; very low‐certainty evidence). No data were reported for aggression. Rates of neurological AEs (drowsiness, emotional AEs, fatigue, headache, insomnia, and irritability), metabolic AEs (decreased appetite) and psychological AEs (depression) may be higher in the intervention group, although the evidence is very uncertain (very low‐certainty evidence). There was no evidence of a difference between groups for any other metabolic, neurological, or psychological AEs (very low‐certainty evidence). No data were reported for musculoskeletal AEs. Antidepressants versus placebo At short‐term follow‐up, there was no clear evidence that antidepressants have an effect on irritability (SMD −0.06, 95% CI −0.30 to 0.18; 3 studies, 267 participants; low‐certainty evidence). No data for aggression or self‐injury were reported or could be included in the analysis. Rates of metabolic AEs (decreased energy) may be higher in participants receiving antidepressants (very low‐certainty evidence), although no other metabolic AEs showed clear evidence of a difference. Rates of neurological AEs (decreased attention) and psychological AEs (impulsive behaviour and stereotypy) may also be higher in the intervention group (very low‐certainty evidence) although the evidence is very uncertain. There was no clear evidence of any difference in the other metabolic, neurological, or psychological AEs (very low‐certainty evidence), nor between groups in musculoskeletal AEs (very low‐certainty evidence). Risk of bias We rated most of the studies across the four comparisons at unclear overall risk of bias due to having multiple domains rated as unclear, very few rated as low across all domains, and most having at least one domain rated as high risk of bias. Authors' conclusions Evidence suggests that atypical antipsychotics probably reduce irritability, ADHD‐related medications may reduce irritability slightly, and neurohormones may have little to no effect on irritability in the short term in people with ASD. There was some evidence that atypical antipsychotics may reduce self‐injury in the short term, although the evidence is uncertain. There was no clear evidence that antidepressants had an effect on irritability. There was also little to no difference in aggression between atypical antipsychotics and placebo, or self‐injury between ADHD‐related medications and placebo. However, there was some evidence that atypical antipsychotics may result in a large reduction in self‐injury, although the evidence is uncertain. No data were reported (or could be used) for self‐injury or aggression for neurohormones versus placebo. Studies reported a wide range of potential AEs. Atypical antipsychotics and ADHD‐related medications in particular were associated with an increased risk of metabolic and neurological AEs, although the evidence is uncertain for atypical antipsychotics and very uncertain for ADHD‐related medications. The other drug classes had minimal or no associated AEs. Plain language summary Which medications reduce irritability, aggression or self‐harm in people with autism spectrum disorder (ASD)? Key messages • Only 3 classes of medications showed any reduction in irritability, aggression or self‐harm when compared to placebo (a dummy medication). Atypical (second‐generation) antipsychotic medications probably reduce irritability and aggression, but appear to have little to no effect on self‐injury. Attention deficit hyperactivity disorder (ADHD)‐related medications may reduce irritability, although the evidence is uncertain. Neurohormones (oxytocin and secretin) may also reduce irritability, but we are very uncertain about the evidence. • Antidepressants appear to have no effect on irritability. Studies did not report on the effects of antidepressants, ADHD‐related medications and neurohormones on aggression or self‐injury. • Studies reported a wide range of unwanted effects, but only atypical antipsychotics, ADHD‐related medications, and neurohormones showed evidence of a higher risk of any unwanted effects compared to placebo. What is autism spectrum disorder (ASD)? Autism is a disorder that affects a child's physical, mental and behavioural development. It is a lifelong disability that starts in childhood but continues throughout adulthood. People with autism may find it difficult to communicate and interact with the world. However, autism affects each person differently and may be more or less severe in different people, so it is described as a 'spectrum' disorder. Some people with autism spectrum disorder (ASD) may be irritable, angry or aggressive, or hurt themselves physically (self‐injury), which are 'behaviours of concern' that can be difficult to manage and distressing for the person. How are behaviours of concern managed? Behaviours of concern are frequently managed with various types of medications that have been developed to treat other conditions. This means that their effectiveness for behaviours of concern is largely unknown, and they may cause serious and varied unwanted effects that affect all parts of the body. For example: • the heart and lungs; • the stomach and digestive system; • the immune system; • movement, joints and bones; and • mood and emotion. What did we want to find out? We wanted to know which types of medication were effective in reducing behaviours of concern in people with ASD and whether they caused unwanted effects. What did we do? We searched for studies that investigated any medication used to manage behaviours of concern. Studies compared the medication with placebo (a dummy medication) or another medication. People in the studies could be adults or children, but all had ASD with behaviours of concern. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 131 studies with 7014 people. Most studies involved children, although some studies involved both children and adults, or adults only. Studies looked at a wide range of medications, including those usually used to treat schizophrenia or bipolar disorder, depression, attention deficit hyperactivity disorder (ADHD), convulsions, emotional problems, heart and lungs, dementia, Parkinson's, and anxiety. Atypical (second‐generation) antipsychotics are usually used to treat schizophrenia or bipolar disorder. They probably reduce irritability, but they may have little to no effect on aggression and self‐injury. People receiving antipsychotics might be more likely to experience unwanted effects such as increased appetite, dizziness, sedation (slowed thought and movement), sleepiness, tiredness and tremor compared to those receiving no treatment or other medications. People receiving antipsychotics may be no more or less likely than those receiving placebo to experience other unwanted effects. Neurohormones (such as oxytocin and secretin) may have a minimal to small effect on irritability but no studies reported data for the effects of neurohormones on self‐harm or aggression. People receiving neurohormones may be no more or less likely than those receiving placebo to experience unwanted effects. ADHD‐related medications may reduce irritability but may have no effect on self‐injury. No studies reported data for aggression. People receiving ADHD‐related medications might be more likely to experience unwanted effects such as drowsiness, tiredness, headache, difficulties sleeping, and decreased appetite. But they may be no more or less likely than those receiving placebo to experience other unwanted effects. Antidepressants may have little to no effect on irritability. No studies reported useful data for aggression and self‐injury. People receiving antidepressants might be more likely to experience unwanted effects such as impulsive behaviour and making repetitive movements or sounds (stereotypy) compared to placebo. But they may be no more or less likely than those receiving placebo to experience other types of unwanted effects. What are the limitations of the evidence? Most of the studies lasted less than 3 months, and very few studies involved adults. Therefore, we are uncertain if the same effects would be seen over a longer period of time or in adults. How up‐to‐date is the evidence? The review authors searched for studies that had been published up to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Iffland, M, Livingstone, N, Jorgensen, M, Hazell, P, Gillies, D", "articleTypes": [], "doi": "10.1002/14651858.CD011769.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.137Z" }, { "id": "b779bdc9-d4e9-48a0-a1b2-e7eaec5a011b", "pmid": "", "title": "Olfactory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Preterm infants, often gavage‐fed due to immaturity, may benefit from interventions that hasten the move to breastfeeding. Olfactory stimulation may increase appetite and speed up the transition to full oral feeding, potentially shortening hospital stay and improving outcomes for both infants and families. Objectives To evaluate the benefits and harms of olfactory stimulation for reducing morbidity and promoting development in hospitalized preterm infants. Search methods We searched MEDLINE, Embase, CENTRAL, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 2 April 2025. We checked the reference lists of included studies and systematic reviews on olfactory or sensory stimulation. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs evaluating olfactory stimulation with different odorants (maternal breast milk, food‐associated odors, or non‐food‐associated odors) in preterm infants (born before 37 weeks' gestation). Eligible controls were no intervention, placebo, or standard care (considered together) or another odorant. We excluded studies combining olfactory stimulation with taste, as another review will focus on combined sensory stimulation. Outcomes Our critical outcomes were apnea, intermittent hypoxemia, duration of hospital stay, time to full oral feeding, and exclusive breastfeeding. Our important outcomes included blindness and sensorineural deafness requiring amplification. Risk of bias We used the Cochrane risk of bias tool (RoB 2) to assess risk of bias in the included studies. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, each with its 95% confidence interval (CI). We assessed the certainty of evidence using GRADE. Included studies We included 14 trials enrolling 1087 neonates. The types of olfactory stimulation under investigation were maternal breast milk (9 studies); food‐associated odors such as cinnamon, vanilla, or anise (5 studies); and non‐food‐associated odors such as rose or parents' scent (3 studies). Three studies evaluated two different odorants. Gestational age and bodyweight varied widely. The comparators were placebo, no intervention, and standard care. Eleven studies aimed to assess the effect of olfactory stimulation on infant feeding outcomes such as time to full oral feeding, weight gain, length of hospital stay, or a combination of these outcomes. Three studies aimed to assess the effect of olfactory stimulation on apnea prevention, oxygen saturation, or both. We identified five ongoing trials. Synthesis of results No studies reported apnea as a dichotomous outcome, intermittent hypoxemia, exclusive breastfeeding, or major neurodevelopmental disability for any of the comparisons. We downgraded the certainty of evidence for limitations in study design, imprecision, and indirectness. Olfactory stimulation with maternal breast milk versus no intervention, placebo, or standard care The evidence is very uncertain about the effect of olfactory stimulation with maternal breast milk on the mean number of daily apnea episodes (MD −0.50, 95% CI −1.27 to 0.27; 1 study, 26 participants; very low‐certainty evidence) and duration of hospital stay in days (MD −0.18, 95% CI −0.64 to 0.27; I² = 0%; 4 studies, 270 participants; very low‐certainty evidence). Olfactory stimulation with maternal breast milk may result in a slight reduction in time to full oral feeding in days (MD −1.68, 95% CI −3.25 to −0.11; I² = 30%; 3 studies, 204 participants; low‐certainty evidence). Olfactory stimulation with food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with food‐associated odors may result in a slight reduction in the mean number of daily apnea episodes (MD −1.99, 95% CI −2.69 to −1.29; I² = 58%; 2 studies, 62 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with food‐associated odors on duration of hospital stay in days (MD −2.65, 95% CI −6.18 to 0.89; I² = 20%; 3 studies, 185 participants; very low‐certainty evidence) and time to full oral feeding in days (MD −2.06, 95% CI −5.16 to 1.04; I² = 36%; 3 studies, 185 participants; very low‐certainty evidence). Olfactory stimulation with non‐food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with non‐food‐associated odors may result in a slight reduction in duration of hospital stay in days (MD −3.23, 95% CI −5.50 to −0.97; I² = 0%; 2 studies, 94 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with non‐food‐associated odor on the mean number of daily apnea episodes (MD −2.13, 95% CI −2.28 to −1.98; 1 study, 60 participants; very low‐certainty evidence) and time to full oral feeding (mean 21 (standard deviation 3.1) days in the intervention group and mean 21 (standard deviation 15.6) days in the control group; 1 study, 27 participants; very low‐certainty evidence). Authors' conclusions Olfactory stimulation with maternal breast milk compared to no intervention, placebo, or standard care may result in a slight reduction in time to full oral feeding, but the evidence is very uncertain about its effect on frequency of apnea episodes and duration of hospital stay. Olfactory stimulation with food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in frequency of apnea episodes, but the evidence is very uncertain about its effect on duration of hospital stay and time to full oral feeding. Olfactory stimulation with non‐food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in duration of hospital stay, but the evidence is very uncertain about its effect on frequency of apnea episodes and time to full oral feeding. Future studies should be more rigorous in their design, report using TIDieR (Template for Intervention Description and Replication) checklists, have larger sample sizes, and measure outcomes such as apnea (number of infants with ≥ 1 episode), intermittent hypoxemia (number of infants with ≥ 1 episode), exclusive breastfeeding, and major neurodevelopmental disabilities. Funding Dedicated funding for this review can be found in the 'Sources of support' section. Registration Protocol: https://doi.org/10.1002/14651858.CD016074 . Plain language summary Does introducing smells to preterm infants improve their physical and mental development? Key messages Introducing preterm infants to the smell of maternal breast milk may slightly reduce the time it takes for them to feed fully by mouth. Introducing them to food smells such as vanilla and cinnamon may slightly reduce how often they stop breathing. Finally, introducing preterm babies to the smell of rose or a parent's scent may reduce slightly the time they have to stay in hospital. All other results are very uncertain. Future studies should include more infants, use more rigorous designs, and measure outcomes such as breathing problems, low blood oxygen levels, exclusive breastfeeding, and long‐term neurodevelopmental outcomes. What is preterm birth? A normal pregnancy usually lasts from 37 weeks to 42 weeks. Preterm birth is when a baby is born before 37 weeks of pregnancy. Babies born preterm have not had enough time to fully develop before birth. Their organs may not yet be ready to work on their own, which means they often need intensive medical care and are at greater risk of breathing and feeding difficulties, infection, and problems that can affect their long‐term development. What is olfactory stimulation, and how does it work? Preterm infants often take time to build up the skills or physical capacity to feed by mouth, and in the meantime are fed through a tube passed into the stomach. Olfactory stimulation involves introducing smells to preterm infants while they are in hospital to see if it helps them start breastfeeding more quickly. These smells include breast milk, food smells such as vanilla or cinnamon, and other smells such as a floral scent or a parent's scent. What did we want to find out? We wanted to find out whether introducing a smell to preterm infants in hospital could be helpful and safe for their short‐term and long‐term well‐being. More specifically, we wanted to find out whether introducing a smell to preterm infants is better than placebo (dummy treatment), no treatment, or usual care for: reducing the number of infants who have apnea (brief pauses in breathing); reducing the number of infants with low oxygen levels in the blood; reducing the time spent in hospital; reducing the time needed for the infants to learn to feed fully by mouth; increasing the number of infants that are fed only with breast milk; reducing the number of infants with blindness or deafness between 18 and 24 months of age. What did we do? We searched for studies that compared olfactory stimulation with placebo, no treatment, or usual care in preterm infants. We summarized the results of the studies and rated our confidence in the evidence based on factors such as study size (number of infants) and methods. What did we find? We included 14 studies with 1087 infants. Nine studies used the smell of maternal breast milk, five used food‐associated smells (vanilla, cinnamon, or anise), and three studies used other smells (rose or parents' scent). All studies compared these smells with no treatment, placebo, or usual care. Main results Introducing the smell of maternal breast milk may reduce slightly the time it takes infants to feed fully by mouth. It is unclear whether stimulation with this smell has any effect on how often infants have apnea episodes and how long they stay in hospital. Introducing the smell of cinnamon, vanilla, or anise may slightly reduce how often infants have apnea episodes. It is unclear whether stimulation with these smells has any effect on how long infants stay in hospital or how long it takes them to feed fully by mouth. Introducing the scent of rose or a parent's scent may slightly reduce how long infants spend in hospital. It is unclear whether stimulation with these smells has any effect on how often infants have apnea episodes or how long it takes them to feed fully by mouth. What are the limitations of the evidence? We have little confidence in these results, as the studies included could have been better designed and included more babies. Several studies did not report outcomes we were interested in. How up to date is this evidence? The evidence is current to 2 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lenells, M; Prescott, MG; Wróblewska-Seniuk, K; Fiander, M; Soll, RF; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD016074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "b79261b6-9336-4d9a-975f-bd5430c6ebdf", "pmid": "", "title": "The Impact of Multivitamin Supplementation on Micronutrient Levels in GLP-1 Users: A Randomized, Double-Blind, Placebo-Controlled Trial", "imported": false, "abstract": "Rationale: Glucagon-Like Peptide-1 (GLP-1) receptor agonists have emerged as effective treatments for obesity and associated medical conditions. However, patients may be at risk of micronutrient deficiencies during therapy due to reduced appetite, altered gastrointestinal physiology, and weight loss. Multivitamin supplementation is commonly prescribed to mitigate these risks, but the necessity and efficacy of multivitamin use in GLP-1 users remain debatable, as some clinicians advocate for routine supplementation while others do not.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.261Z" }, { "id": "b799725d-29e7-43c2-bf3b-a1171a8d015b", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high risk patients. Ulceration can lead to severe pain and difficulty eating and drinking, which may necessitate opioid analgesics, hospitalisation and nasogastric or intravenous nutrition. These complications may lead to interruptions or alterations to cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Oral cryotherapy is a low‐cost, simple intervention which is unlikely to cause side‐effects. It has shown promise in clinical trials and warrants an up‐to‐date Cochrane review to assess and summarise the international evidence. Objectives To assess the effects of oral cryotherapy for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to 17 June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) ( Cochrane Library 2015, Issue 5), MEDLINE via Ovid (1946 to 17 June 2015), EMBASE via Ovid (1980 to 17 June 2015), CANCERLIT via PubMed (1950 to 17 June 2015) and CINAHL via EBSCO (1937 to 17 June 2015). We searched the US National Institutes of Health Trials Registry, and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching databases. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of oral cryotherapy in patients with cancer receiving treatment. We used outcomes from a published core outcome set registered on the COMET website. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. We contacted study authors for information where feasible. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 14 RCTs analysing 1280 participants. The vast majority of participants did not receive radiotherapy to the head and neck, so this review primarily assesses prevention of chemotherapy‐induced oral mucositis. All studies were at high risk of bias. The following results are for the main comparison: oral cryotherapy versus control (standard care or no treatment). Adults receiving fluorouracil‐based (5FU) chemotherapy for solid cancers Oral cryotherapy probably reduces oral mucositis of any severity (RR 0.61, 95% CI 0.52 to 0.72, 5 studies, 444 analysed, moderate quality evidence). In a population where 728 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 444 (95% CI 379 to 524). The number needed to treat to benefit one additional person (NNTB), i.e. to prevent them from developing oral mucositis, is 4 people (95% CI 3 to 5). The results were similar for moderate to severe oral mucositis (RR 0.52, 95% CI 0.41 to 0.65, 5 studies, 444 analysed, moderate quality evidence). NNTB 4 (95% CI 4 to 6). Severe oral mucositis is probably reduced (RR 0.40, 95% CI 0.27 to 0.61, 5 studies, 444 analysed, moderate quality evidence). Where 300 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 120 (95% CI 81 to 183), NNTB 6 (95% CI 5 to 9). Adults receiving high‐dose melphalan‐based chemotherapy before haematopoietic stem cell transplantation (HSCT) Oral cryotherapy may reduce oral mucositis of any severity (RR 0.59, 95% CI 0.35 to 1.01, 5 studies, 270 analysed, low quality evidence). Where 824 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 486 (95% CI reduced to 289 to increased to 833). The NNTB is 3, although the uncertainty surrounding the effect estimate means that the 95% CI ranges from 2 NNTB, to 111 NNTH (number needed to treat in order to harm one additional person, i.e. for one additional person to develop oral mucositis). The results were similar for moderate to severe oral mucositis (RR 0.43, 95% CI 0.17 to 1.09, 5 studies, 270 analysed, low quality evidence). NNTB 3 (95% CI 2 NNTB to 17 NNTH). Severe oral mucositis is probably reduced (RR 0.38, 95% CI 0.20 to 0.72, 5 studies, 270 analysed, moderate quality evidence). Where 427 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 162 (95% CI 85 to 308), NNTB 4 (95% CI 3 to 9). Oral cryotherapy was shown to be safe, with very low rates of minor adverse effects, such as headaches, chills, numbness/taste disturbance, and tooth pain. This appears to contribute to the high rates of compliance seen in the included studies. There was limited or no evidence on the secondary outcomes of this review, or on patients undergoing other chemotherapies, radiotherapy, targeted therapy, or on comparisons of oral cryotherapy with other interventions or different oral cryotherapy regimens. Therefore no further robust conclusions can be made. There was also no evidence on the effects of oral cryotherapy in children undergoing cancer treatment. Authors' conclusions We are confident that oral cryotherapy leads to large reductions in oral mucositis of all severities in adults receiving 5FU for solid cancers. We are less confident in the ability of oral cryotherapy to reduce oral mucositis in adults receiving high‐dose melphalan before HSCT. Evidence suggests that it does reduce oral mucositis in these adults, but we are less certain about the size of the reduction, which could be large or small. However, we are confident that there is an appreciable reduction in severe oral mucositis in these adults. This Cochrane review includes some very recent and currently unpublished data, and strengthens international guideline statements for adults receiving the above cancer treatments. Plain language summary Can keeping the mouth cold during cancer treatment help to prevent mouth soreness and ulcers in children and adults? Review question This review has been produced to assess whether or not keeping the mouth cold during cancer treatment, by using ice, ice‐cold water, ice cream or ice lollies/popsicles, can help prevent mouth soreness and ulcers in children and adults. Background People receiving treatment for cancer are at risk of developing a sore mouth and ulcers as a side effect. This side effect is called oral mucositis and affects over 75% of high‐risk patients (those receiving radiotherapy to the head and neck or high‐dose chemotherapy). The pain caused by this condition can be severe and can stop the person's ability to eat and drink, which may mean they need to take strong pain killers, stay in hospital and be fed through a tube into their stomach, or even into their veins. This in turn can lead to disruption to their cancer treatment, meaning they are not receiving the best possible treatment. The results may be a reduction in the patient's chances of survival, and increased costs to the healthcare system. Cancer patients have weakened immune systems due to their treatment, meaning that their bodies are less able to fight infections. This can be a problem if bacteria enter the body through the ulcer, which is an open wound. This can lead to sepsis (a dangerous inflammatory reaction of the body to infection), which requires antibiotics and hospitalisation, and can cause death. Oral cryotherapy is the cooling of the mouth using ice, ice‐cold water, ice cream or ice lollies/popsicles. It is thought to help prevent oral mucositis in people receiving certain types of chemotherapy because the coldness makes the blood vessels in the mouth more narrow, and this reduces the amount of blood containing chemotherapy drugs from reaching the mouth and causing oral mucositis. It is a low‐cost, natural treatment without serious side effects. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 17 June 2015. It includes 14 studies published from 1991 to 2015 in which 1316 participants were randomised (1280 of whom were included in the analyses) to receive oral cryotherapy versus standard care (usually saline mouthrinses) or no treatment or a different treatment or a different method of oral cryotherapy, and the number of people developing oral mucositis of different severities was compared. Nearly all the evidence was on adults receiving oral cryotherapy versus standard care or no treatment. This evidence fell into two main groups: 1) adults receiving fluorouracil‐based (5FU) treatment for solid cancers; or 2) adults receiving high‐dose melphalan‐based cancer treatment before haematopoietic stem cell transplantation (HSCT). HSCT is given to help the body to produce all types of blood cells, which are destroyed during cancer treatment. Key results There is evidence showing that oral cryotherapy can lead to large reductions in the numbers of adults who get oral mucositis of all severities after receiving 5FU‐based treatment for solid cancers. There is less certain evidence to suggest that oral cryotherapy may reduce the numbers of adults who get oral mucositis after receiving high‐dose melphalan‐based cancer treatment prior to HSCT. The evidence suggests that it does reduce oral mucositis in these adults, but the size of the reduction is much less certain. However, there is more certain evidence that there is a large reduction in severe oral mucositis in these adults. Oral cryotherapy did not cause any serious side effects in any of the participants of these studies, and most people seemed able to carry it out properly and complete it. Quality of the evidence The evidence presented, on the main outcome of whether or not people developed oral mucositis of all severities, is of moderate (because the nature of the oral cryotherapy treatment meant that the studies could not be 'blinded' which is a desirable characteristic of these studies) to low quality (because in addition to the above problem, the results of the individual studies were too different to give a precise result when they were combined).", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P; Glenny, AM; Worthington, HV; Littlewood, A; Clarkson, JE; McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011552.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "b7b69f5d-6364-4353-a8f1-5e0c3581ef4a", "pmid": "", "title": "Nitrous oxide‐based techniques versus nitrous oxide‐free techniques for general anaesthesia", "imported": false, "abstract": "Abstract - Background Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise. Objectives To determine if nitrous oxide‐based anaesthesia results in similar outcomes to nitrous oxide‐free anaesthesia in adults undergoing surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites ( http://clinicaltrials.gov/ , http://controlled‐trials.com/ , and http://www.centerwatch.com ). Selection criteria We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol‐based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay. Data collection and analysis Two review authors independently assessed trial quality and extracted the outcome data. We used meta‐analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed‐effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random‐effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Main results We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta‐analyses showed that nitrous oxide‐based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta‐analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide‐based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low. Authors' conclusions Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review. Plain language summary Nitrous oxide (laughing gas)‐based techniques versus nitrous oxide‐free techniques for general anaesthesia Review question We reviewed the evidence about the harmful effects of nitrous oxide on people undergoing general anaesthesia. Background Nitrous oxide is an anaesthetic gas which has been used for more than 160 years for inducing anaesthesia and keeping patients anaesthetized throughout an operation. It is also known as 'laughing gas'. It is a colourless non‐flammable gas with a pleasant, faint sweet odour and taste. Its low cost and low toxicity have made nitrous oxide by far the most commonly used general anaesthetic. However, some studies have reported that adding nitrous oxide may lead to harmful effects. This has led many anaesthetists to question its continued routine use in a variety of operating room settings. We wanted to discover whether using nitrous oxide in general anaesthesia was better or worse than not using nitrous oxide. Study characteristics We examined the evidence available up to 17 October 2014. We included 35 trials involving 13,872 adult participants, all of whom were randomized to either receive nitrous oxide or no nitrous oxide. The trials covered a variety of situations during general anaesthesia. Key results We found that general anaesthesia with nitrous oxide increased the risk of pulmonary atelectasis (i.e. failure of the lungs to expand fully). When we restricted the results to the highest quality studies only, we found evidence that nitrous oxide may potentially increase the risk of pneumonia and severe nausea and vomiting. However, nitrous oxide had no effect on the patients' survival, the incidence of heart attack, stroke, wound infection, the occurrence of blood clots within veins, the length of hospital stay, or the length of intensive care unit stay. Quality of the evidence The evidence related to survival of participants was of moderate quality because we did not have enough data. The evidence related to some harmful effects, such as failure of the lungs to expand fully and heart attack, was of high quality, while for other harmful effects, such as stroke and the occurrence of blood clots within veins, the evidence was of moderate quality. For others, such as pneumonia, severe nausea and vomiting, and wound infection, the evidence was of low quality. The evidence related to the length of time spend in hospital was of moderate quality. Authors conclusions The avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Sun, R, Jia, WQ, Zhang, P, Yang, K, Tian, JH, Ma, B, Liu, Y, Jia, RH, Luo, XF, Kuriyama, A", "articleTypes": [], "doi": "10.1002/14651858.CD008984.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.101Z" }, { "id": "b7befa85-5010-4484-a20e-f6f716bb3753", "pmid": "", "title": "Vitamin B12 supplementation during pregnancy for maternal and child health outcomes", "imported": false, "abstract": "Abstract - Background Vitamin B 12 deficiency is a major public health problem worldwide, with the highest burden in elderly people, pregnant women, and young children. Due to its role in DNA synthesis and methylation, folate metabolism, and erythropoiesis, vitamin B 12 supplementation during pregnancy may confer longer‐term benefits to maternal and child health outcomes. Objectives To evaluate the benefits and harms of oral vitamin B 12 supplementation during pregnancy on maternal and child health outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov , the World Health Organization International Clinical Trials Registry Platform ( ICTRP ) on 2 June 2023, and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs), quasi‐RCTs, or cluster‐RCTs evaluating the effects of oral vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation during pregnancy. Data collection and analysis We used standard Cochrane methods. Four review authors independently assessed trial eligibility. Two review authors independently extracted data from included studies and conducted checks for accuracy. Three review authors independently assessed the risk of bias of the included studies using the Cochrane RoB 1 tool. We used GRADE to evaluate the certainty of evidence for primary outcomes. Main results The review included five trials with 984 pregnant women. All trials were conducted in low‐ and middle‐income countries, including India, Bangladesh, South Africa, and Croatia. At enrolment, 26% to 51% of pregnant women had vitamin B 12 deficiency (less than 150 pmol/L), and the prevalence of anaemia (haemoglobin less than 11.0 g/dL) ranged from 30% to 46%. The dosage of vitamin B 12 supplementation varied from 5 μg/day to 250 μg/day, with administration beginning at 8 to 28 weeks' gestation through to delivery or three months' postpartum, and the duration of supplementation ranged from 8 to 16 weeks to 32 to 38 weeks. Three trials, involving 609 pregnant women, contributed data for meta‐analyses of the effects of vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation. Maternal anaemia: there may be little to no difference for maternal anaemia by intervention group, but the evidence is very uncertain (70.9% versus 65.0%; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.93 to 1.26; 2 trials, 284 women; very low‐certainty evidence). Maternal vitamin B 12 status: vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain (25.9% versus 67.9%; RR 0.38, 95% CI 0.28 to 0.51; 2 trials, 272 women; very low‐certainty evidence). Women who received vitamin B 12 supplements during pregnancy may have higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (mean difference (MD) 60.89 pmol/L, 95% CI 40.86 to 80.92; 3 trials, 412 women). However, there was substantial heterogeneity (I 2 = 85%). Adverse pregnancy outcomes: the evidence is uncertain about the effect on adverse pregnancy outcomes, including preterm birth (RR 0.97, 95% CI 0.55 to 1.74; 2 trials, 340 women; low‐certainty evidence), and low birthweight (RR 1.50, 95% CI 0.93 to 2.43; 2 trials, 344 women; low‐certainty evidence). Two trials reported data on spontaneous abortion (or miscarriage); however, the trials did not report quantitative data for meta‐analysis and there was no clear definition of spontaneous abortion in the study reports. No trials evaluated the effects of vitamin B 12 supplementation during pregnancy on neural tube defects. Infant vitamin B 12 status: children born to women who received vitamin B 12 supplementation had higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (MD 71.89 pmol/L, 95% CI 20.23 to 123.54; 2 trials, 144 children). Child cognitive outcomes : three ancillary analyses of one trial reported child cognitive outcomes; however, data were not reported in a format that could be included in quantitative meta‐analyses. In one study, maternal vitamin B 12 supplementation did not improve neurodevelopment status (e.g. cognitive, language (receptive and expressive), motor (fine and gross), social‐emotional, or adaptive (conceptual, social, practical) domains) in children compared to placebo (9 months, Bayley Scales of Infant and Toddler Development Third Edition (BSID‐III); 1 trial; low‐certainty evidence) or neurophysiological outcomes (72 months, event‐related potential measures; 1 trial; low‐certainty evidence), though children born to women who received vitamin B 12 supplementation had improved expressive language domain compared to placebo (30 months, BSID‐III; 1 trial; low‐certainty evidence). Authors' conclusions Oral vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency and may improve maternal vitamin B 12 concentrations during pregnancy or postpartum compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain. The effects of vitamin B 12 supplementation on other primary outcomes assessed in this review were not reported, or were not reported in a format for inclusion in quantitative analyses. Vitamin B 12 supplementation during pregnancy may improve maternal and infant vitamin B 12 status, but the potential impact on longer‐term clinical and functional maternal and child health outcomes has not yet been established. Plain language summary Vitamin B 12 supplementation for women during pregnancy Key messages – Women who took vitamin B 12 supplements during pregnancy may have improved vitamin B 12 status during pregnancy or postpartum, including less vitamin B 12 deficiency and higher vitamin B 12 levels, compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. – The effects of taking vitamin B 12 supplements during pregnancy on other health outcomes in pregnant women or their children are not known. Public health implications Vitamin B 12 is an important nutrient that helps keep your body's blood and nerve cells healthy. Vitamin B 12 deficiency is an important public health problem, particularly in low‐ and middle‐income countries, with a high burden amongst pregnant women and children. Lower vitamin B 12 levels in pregnancy have been linked to greater risk of some adverse pregnancy outcomes such as miscarriage, poor growth of the baby in the womb, problems with the baby's brain or spinal cord (called neural tube defects), and lower vitamin B 12 status in infants. Vitamin B 12 supplementation during pregnancy may help improve the health and nutrition of women and their babies. However, this has not been examined in well‐conducted reviews, and vitamin B 12 is not part of supplements recommended by the World Health Organization (WHO; a specialised agency of the United Nations responsible for international public health) for women during pregnancy. What did we want to find out? We wanted to find out if taking vitamin B 12 supplements during pregnancy would improve the health and nutrition of women and their babies. What did we do? We searched for clinical trials that looked at vitamin B 12 supplementation during pregnancy. We compared and summarised the results of the trials and rated our confidence in the information, based on factors such as trial methods and sizes. What did we find? We included five trials with 984 pregnant women. Three trials, including 609 pregnant women, had data included in analyses. Women who took vitamin B 12 supplements during pregnancy had less vitamin B 12 deficiency and higher vitamin B 12 levels compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. There were no differences between groups for maternal anaemia. We could not assess the effects of vitamin B 12 supplementation on other outcomes such as miscarriage, neural tube defects, and child cognition (a child's ability to gain knowledge through thought, understanding, and the senses) due to limited or no availability of results for analysis. What are the limitations of the evidence? The small number of trials and small size of trials were limitations in this review. Not all the trials provided data about the outcomes we were interested in. We are very unsure about the results. How up to date is this evidence? The evidence is up to date as of June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Finkelstein, JL, Fothergill, A, Venkatramanan, S, Layden, AJ, Williams, JL, Crider, KS, Qi, YP", "articleTypes": [], "doi": "10.1002/14651858.CD013823.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.750Z" }, { "id": "b7e20355-172e-4798-97b6-2b37bea762b6", "pmid": "", "title": "Eszopiclone for insomnia", "imported": false, "abstract": "Abstract - Background Insomnia is a major public health issue affecting between 6% to 10% of the adult population in Western countries. Eszopiclone is a hypnotic drug belonging to a newer group of hypnotic agents, known as new generation hypnotics, which was marketed as being just as effective as benzodiazepines for this condition, while being safer and having a lower risk for abuse and dependence. It is the aim of the review to integrate evidence from randomised controlled trials and to draw conclusions on eszopiclone's efficacy and safety profile, while taking methodological features and bias risks into consideration. Objectives To assess the efficacy and safety of eszopiclone for the treatment of insomnia compared to placebo or active control. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, Embase, PsycINFO, PSYNDEX and registry databases (WHO trials portal, ClinicalTrials.gov) with results incorporated from searches to 10 February 2016. To identify trials not registered in electronic databases, we contacted key informants and searched reference lists of identified studies. We ran an update search (21 February 2018) and have placed studies of interest in awaiting classification/ongoing studies. These will be incorporated into the next version of the review, as appropriate. Selection criteria Parallel group randomised controlled trials (RCTs) comparing eszopiclone with either placebo or active control were included in the review. Participants were adults with insomnia, as diagnosed with a standardised diagnostic system, including primary insomnia and comorbid insomnia. Data collection and analysis Two authors independently extracted outcome data; one reviewer assessed trial quality and the second author cross‐checked it. Main results A total of 14 RCTs, with 4732 participants, were included in this review covering short‐term (≤ 4 weeks; 6 studies), medium‐term (> 4 weeks ≤ 6 months; 6 studies) and long‐term treatment (> 6 months; 2 studies) with eszopiclone. Most RCTs included in the review included participants aged between 18 and 64 years, three RCTs only included elderly participants (64 to 85 years) and one RCT included participants with a broader age range (35 to 85 years). Seven studies considered primary insomnia; the remaining studies considered secondary insomnia comorbid with depression (2), generalised anxiety (1), back pain (1), Parkinson's disease (1), rheumatoid arthritis (1) and menopausal transition (1). Meta‐analytic integrations of participant‐reported data on sleep efficacy outcomes demonstrated better results for eszopiclone compared to placebo: a 12‐minute decrease of sleep onset latency (mean difference (MD) ‐11.94 min, 95% confidence interval (CI) ‐16.03 to ‐7.86; 9 studies, 2890 participants, moderate quality evidence), a 17‐minute decrease of wake time after sleep onset (MD ‐17.02 min, 95% CI ‐24.89 to ‐9.15; 8 studies, 2295 participants, moderate quality evidence) and a 28‐minute increase of total sleep time (MD 27.70 min, 95% CI 20.30 to 35.09; 10 studies, 2965 participants, moderate quality evidence). There were no significant changes from baseline to the first three nights after drug discontinuation for sleep onset latency (MD 17.00 min, 95% CI ‐4.29 to 38.29; 1 study, 291 participants, low quality evidence) and wake time after sleep onset (MD ‐6.71 min, 95% CI ‐21.25 to 7.83; 1 study, 291 participants, low quality evidence). Adverse events during treatment that were documented more frequently under eszopiclone compared to placebo included unpleasant taste (risk difference (RD) 0.18, 95% CI 0.14 to 0.21; 9 studies, 3787 participants), dry mouth (RD 0.04, 95% CI 0.02 to 0.06; 6 studies, 2802 participants), somnolence (RD 0.04, 95% CI 0.02 to 0.06; 8 studies, 3532 participants) and dizziness (RD 0.03, 95% CI 0.01 to 0.05; 7 studies, 2933 participants). According to the GRADE criteria, evidence was rated as being of moderate quality for sleep efficacy outcomes and adverse events and of low quality for rebound effects and next‐day functioning. Authors' conclusions Eszopiclone appears to be an efficient drug with moderate effects on sleep onset and maintenance. There was no or little evidence of harm if taken as recommended. However, as certain patient subgroups were underrepresented in RCTs included in the review, findings might not have displayed the entire spectrum of possible adverse events. Further, increased caution is required in elderly individuals with cognitive and motor impairments and individuals who are at increased risk of using eszopiclone in a non‐recommended way. Plain language summary Eszopiclone (Lunesta) for sleep difficulty Why is this review important? Insomnia is the medical term for sleep difficulty covering trouble falling asleep, difficulties staying asleep, waking up too early or experiencing sleep as non‐restorative. Insomnia can be treated with different methods including behaviour modification, relaxation techniques, or sleeping medication. Eszopiclone (Lunesta) is a sleeping medication that belongs to a class of sleeping tablets known as non‐benzodiazepine hypnotics. Who will be interested in this review? People who are affected by insomnia, general practitioners, professionals working in health services, and addiction treatment and health policy makers. What questions does this review aim to answer? The review aimed to find out more about the wanted effects and unwanted effects of eszopiclone. Wanted effects included the immediate effects eszopiclone has on sleep; unwanted effects included side effects, effects on next‐day functioning, but also addictive properties of the drug. Which studies were included in the review? The review summarised findings from 14 clinical studies with 4732 people, either receiving eszopiclone or an identically‐appearing, but inert substance (placebo). What does the evidence from the review tell us? On average, people taking eszopiclone fell asleep 12 minutes faster than those taking placebo, were 17 minutes less awake during the night and had, in total, about half an hour more sleep than people in the placebo group. As side effects, eszopiclone can cause unpleasant taste, dizziness, dry mouth, and tiredness during the day. Clinical studies did not find evidence that eszopiclone was causing serious harm or withdrawal symptoms or whether it was addictive if it was stopped and not taken after several weeks or months of treatment. Nevertheless, as clinical studies included in the review did not cover certain groups (e.g. elderly people with cognitive or motor problems or certain conditions of medication intake), it is important for patients to consult their doctor who knows their medical history and condition. What should happen next? Future research needs to compare eszopiclone with other sleep medications to help physicians and patients decide which of the available treatment options to prefer. In addition, sleep medications that are also well tolerated by elderly individuals and individuals with alcohol or drug problems need to be identified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rösner, S, Englbrecht, C, Wehrle, R, Hajak, G, Soyka, M", "articleTypes": [], "doi": "10.1002/14651858.CD010703.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.727Z" }, { "id": "b7e26280-2b8e-49ca-87e8-75db748046c7", "pmid": "", "title": "Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, rhinorrhoea, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. The use of topical (intranasal) corticosteroids has been widely advocated for the treatment of chronic rhinosinusitis given the belief that inflammation is a major component of this condition. Objectives To assess the effects of intranasal corticosteroids in people with chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) with a follow‐up period of at least three months comparing intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) against placebo or no treatment in patients with chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity and the commonest adverse event ‐ epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation or other systemic adverse events. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 18 RCTs with a total of 2738 participants. Fourteen studies had participants with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. Intranasal corticosteroids versus placebo or no intervention Only one study (20 adult participants without polyps) measured our primary outcome disease‐specific HRQL using the Rhinosinusitis Outcome Measures‐31 (RSOM‐31). They reported no significant difference (numerical data not available) ( very low quality evidence). Our second primary outcome, disease severity , was measured using the Chronic Sinusitis Survey in a second study (134 participants without polyps), which found no important difference (mean difference (MD) 2.84, 95% confidence interval (CI) ‐5.02 to 10.70; scale 0 to 100). Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group (RR 2.78, 95% CI 1.76 to 4.40; 109 participants). The quality of the evidence was low . Six studies provided data on at least two of the individual symptoms used in the EPOS 2012 criteria to define chronic rhinosinusitis (nasal blockage, rhinorrhoea, loss of sense of smell and facial pain/pressure). When all four symptoms in the EPOS criteria were available on a scale of 0 to 3 (higher = more severe symptoms), the average MD in change from baseline was ‐0.26 (95% CI ‐0.37 to ‐0.15; 243 participants; two studies; low quality evidence). Although there were more studies and participants when only nasal blockage and rhinorrhoea were considered (MD ‐0.31, 95% CI ‐0.38 to ‐0.24; 1702 participants; six studies), the MD was almost identical to when loss of sense of smell was also considered (1345 participants, four studies; moderate quality evidence). When considering the results for the individual symptoms, benefit was shown in the intranasal corticosteroids group. The effect size was larger for nasal blockage (MD ‐0.40, 95% CI ‐0.52 to ‐0.29; 1702 participants; six studies) than for rhinorrhoea (MD ‐0.25, 95% CI ‐0.33 to ‐0.17; 1702 participants; six studies) or loss of sense of smell (MD ‐0.19, 95% CI ‐0.28 to ‐0.11; 1345 participants; four studies). There was heterogeneity in the analysis for facial pain/pressure (MD ‐0.27, 95% CI ‐0.56 to 0.02; 243 participants; two studies). The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure. There was an increased risk of epistaxis with intranasal corticosteroids (risk ratio (RR) 2.74, 95% CI 1.88 to 4.00; 2508 participants; 13 studies; high quality evidence). Considering our secondary outcome, general HRQL, one study (134 participants without polyps) measured this using the SF‐36 and reported a statistically significant benefit only on the general health subscale. The quality of the evidence was very low . It is unclear whether there is a difference in the risk of local irritation (RR 0.94, 95% CI 0.53 to 1.64; 2124 participants; 11 studies) ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis or stunted growth (children). Other comparisons We identified no other studies that compared intranasal corticosteroids plus co‐intervention A versus placebo plus co‐intervention A. Authors' conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life ( very low quality evidence). For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of epistaxis is increased ( high quality evidence), but these data included all levels of severity; small streaks of blood may not be a major concern for patients. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) . Plain language summary Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of intranasal (in the nose) steroids given to people with chronic rhinosinusitis. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose (rhinorrhoea), pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation in order to improve patient symptoms. Study characteristics We included 18 randomised controlled trials (RCTs) with a total of 2738 participants in this review. Most studies were relatively small, with as few as 9 or 10 patients per intervention arm. The largest study had 748 patients in total. Most were conducted in tertiary referral centres in northern Europe, the US and Canada. Fourteen studies only included participants with chronic rhinosinusitis with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Key results and quality of the evidence One study (20 participants) reported no statistically significant difference in disease‐specific health‐related quality of life. Another measured general health‐related quality of life and reported a statistically significant benefit only on a subscale for general health. Both studies recruited participants with chronic rhinosinusitis without nasal polyps. The quality of the evidence was very low (we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect). Disease severity was measured in one study (chronic rhinosinusitis without nasal polyps, 134 participants), which found no important difference. Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group. The quality of the evidence was low (our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect). When each type of symptom was measured separately (nasal blockage, rhinorrhoea, loss of sense of smell, facial pain/pressure), benefit was shown in the intranasal corticosteroids group. The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure (moderate quality evidence means we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different). There was an increased risk of nosebleeds (epistaxis) with intranasal corticosteroids ( high quality evidence). However, it was unclear whether there was a difference in the risk of local (nose or throat) irritation ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis (fragile bones) or stunted growth (in children). Conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life and the quality of this evidence is very low . For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of nosebleeds is increased ( high quality evidence), but this included all levels of severity; for some patients small streaks of blood may not be a major concern. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) .", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chong, LY, Head, K, Hopkins, C, Philpott, C, Schilder, AGM, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.778Z" }, { "id": "b7e4e8dc-48c1-4c51-9852-02a7065b074a", "pmid": "", "title": "Evaluation of the Efficacy and Safety of a Drinkable Nutraceutical in Improving Hair Loss in Patients Treated With GLP-1/GIP Receptor Agonists: a Double-blind, 1:1 Randomized, Placebo-controlled Study.", "imported": false, "abstract": "The purpose of this clinical trial is to evaluate the efficacy of Olistic© Next Women, a nutraceutical supplement, compared with placebo in improving hair loss in patients undergoing treatment with GLP-1/GIP agonists. This 6-month, randomized, placebo-controlled clinical study investigates whether daily supplementation with Olistic© Next Women leads to significant improvements in hair loss in this patient population. In addition, the study assesses the safety and tolerability of the product throughout the treatment period.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.238Z" }, { "id": "b81ba90e-6079-4846-8ce7-9cdd4e45b272", "pmid": "", "title": "Antibiotics prior to amniotomy for reducing infectious morbidity in mother and infant", "imported": false, "abstract": "Abstract - Background Amniotomy (the deliberate rupture of membranes) was described almost two centuries ago and since then has been used both for induction and augmentation of labour ‐ which are common obstetric practices. Trends have shown a rise in the induction rates over the last decade and data suggest that the rate of labour inductions is increasing faster than the rate of pregnancy complications. Recent years have seen the emergence of a variety of other methods of induction of labour but amniotomy combined with oxytocin infusion remains the most commonly used method of augmentation of labour. The newer agents for induction are expensive and in resource‐poor settings amniotomy is still the chosen method for both induction and augmentation. As with any invasive procedure amniotomy can lead to infection, ascending from the vagina into the uterine cavity and can contribute significantly to both maternal and neonatal infectious morbidity. Objectives The objective of this review was to evaluate the prophylactic use of antibiotics versus placebo or no treatment prior to amniotomy on maternal and neonatal infectious morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014), the International Clinical Trials Registry Platform ( ICTRP ) and ClinicalTrials.gov (12 September 2014). Selection criteria Randomised controlled trials or cluster‐randomised trials comparing antibiotics prior to amniotomy versus placebo (or no treatment) were eligible for inclusion in this review but none were identified. Quasi‐randomised trials or cross‐over trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed one trial report for inclusion. In future updates of this review, two review authors will independently assess risk of bias and carry out data extraction. Data will be checked for accuracy. Main results We identified one trial report but this was excluded. No studies met the inclusion criteria for this review. Authors' conclusions High‐quality trials are needed to justify or refute the routine use of antibiotics at amniotomy for prevention of infection in the mother and infant. Future studies should be conducted, especially in resource‐constrained settings where amniotomy is still used as a means of induction of labour, in order to evaluate the routine use of antibiotics at amniotomy in these settings. Future research in this area should include important maternal and infant outcomes listed in this review and also consider cost effectiveness and side effects of antibiotic use, including the emergence of antibiotic‐resistant strains. Plain language summary Antibiotic use before amniotomy (artificially rupturing the membranes) for reducing infections in mother and infant The artificial rupture of the membranes (amniotomy) is a common obstetrical procedure. It may be done to either initiate or to augment labour, with or without oxytocin. This invasive procedure allows vaginal micro‐organisms access into the uterine cavity, which can in turn lead to infections in both the mother and the infant. A greater time interval between rupture of membranes and delivery, as with induction of labour, increases the chances of an infection. The purpose of this review was to evaluate the routine use of antibiotics immediately prior to amniotomy for both initiation and augmentation of labour using randomised controlled trials. However, our search only identified one trial which did not meet the inclusion criteria for this review. Consequently, there is no evidence to support or refute the routine use of antibiotics prior to amniotomy. Randomised controlled trials on this topic are needed, especially in resource‐constrained settings where amniotomy is still used as a means of inducing labour, to evaluate the routine use of antibiotics at amniotomy in such settings. Future research in this area should also consider cost effectiveness and side effects of antibiotic use including the emergence of antibiotic‐resistant strains.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ray, A; Ray, S", "articleTypes": [], "doi": "10.1002/14651858.CD010626.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "b8309641-761c-45a5-a3c3-2388c32d4e6f", "pmid": "", "title": "Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants", "imported": false, "abstract": "Abstract - Background It is important to institute an effective supportive therapy to maintain or recover soft tissue health around dental implants. Different maintenance regimens have been suggested, however it is unclear which are the most effective. Objectives To assess the effects of different interventions for 1) maintaining and 2) recovering soft tissue health around osseointegrated dental implants. Search methods We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and to an Internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 2 June 2010. Selection criteria All randomised controlled trials comparing agents or interventions for maintaining or recovering healthy tissues around dental implants. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random‐effects models using standardised mean differences for continuous data and risk ratios for dichotomous data with 95% confidence intervals. Main results Five trials compared interventions for maintaining soft tissue health around implants and a further six trials compared interventions to recover soft tissue health where there was evidence of peri‐implant mucositis. No statistically significant differences were found between the effectiveness of powered versus manual toothbrushes for either maintaining or recovering soft tissue health. There was no statistically significant difference found between different types of self administered antimicrobials for maintaining soft tissue health (hyaluronic acid gel compared to chlorhexidine gel, amine fluoride/stannous fluoride mouthwash compared to chlorhexidine mouthwash) and triclosan dentifrice compared to sodium fluoride dentifrice showed no statistically significant difference in recovering soft tissue health. However chlorhexidine irrigation was more effective in reducing plaque and marginal bleeding scores compared to chlorhexidine mouthwash and Listerine mouthwash was found to be statistically significantly better than placebo with regard to reducing mean plaque scores and marginal bleeding scores. When interventions administered by dental professional were compared there was no statistically significant difference found between chlorhexidine and physiologic solutions as irrigants at second stage surgery to maintain health of soft tissues. In patients with peri‐implant mucositis two trials evaluated interventions performed by dental professionals. There was no statistically significant difference between mechanical debridement followed by either minocycline or chlorhexidine gel, or between debridement with a titanium curette compared to an ultrasonic debridement tool. Authors' conclusions There was only low quality evidence for which are the most effective interventions for maintaining or recovering health of peri‐implant soft tissues. The included RCTs had short follow‐up periods and few subjects and although overall the risk of bias of the studies was either low or unclear, only single trials were available for each outcome. There was no reliable evidence as to which regimens are most effective for long term maintenance. This should not be interpreted as meaning that current maintenance regimens are ineffective. There was weak evidence that antibacterial mouthrinses are effective in reducing plaque and marginal bleeding around implants. More RCTs should be conducted in this area. In particular, there is a definite need for trials powered to find possible differences, using primary outcome measures and with much longer follow up. Such trials should be reported according to the CONSORT guidelines ( www.consort‐statement.org/ ). Plain language summary Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants Missing teeth can be replaced by dental implants. However, keeping the gums around the implants healthy is important, as they can be negatively affected by dental plaque and its induced inflammation. Prevention of this may include daily implant cleaning techniques by patients and regular cleaning by dental professionals. Antibacterial mouthrinses may help reduce plaque and bleeding around dental implants, but there is no evidence that powered toothbrushes are better than manual toothbrushes or that brushing with a certain gel or dentifrice is better than another. Among the professionally administered treatments there is no evidence that phosphoric acid is more effective than scaling and polishing, that chlorhexidine enclosed in the inner part of implants is superior to physiologic solution or that a topical antibiotic inserted submucosally is better than a chlorhexidine gel.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Grusovin, MG, Coulthard, P, Worthington, HV, George, P, Esposito, M", "articleTypes": [], "doi": "10.1002/14651858.CD003069.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.067Z" }, { "id": "b84b0f83-8004-4528-a755-2f0254d54f64", "pmid": "", "title": "Xylitol‐containing products for preventing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is a highly prevalent chronic disease which affects the majority of people. It has been postulated that the consumption of xylitol could help to prevent caries. The evidence on the effects of xylitol products is not clear and therefore it is important to summarise the available evidence to determine its effectiveness and safety. Objectives To assess the effects of different xylitol‐containing products for the prevention of dental caries in children and adults. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 14 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , 2014, Issue 7), MEDLINE via OVID (1946 to 14 August 2014), EMBASE via OVID (1980 to 14 August 2014), CINAHL via EBSCO (1980 to 14 August 2014), Web of Science Conference Proceedings (1990 to 14 August 2014), Proquest Dissertations and Theses (1861 to 14 August 2014). We searched the US National Institutes of Health Trials Register ( http://clinicaltrials.gov ) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference and 95% confidence interval (CI). We used the continuous data to calculate prevented fractions (PF) and 95% CIs to summarise the percentage reduction in caries. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. As there were less than four studies included in the meta‐analysis, we used a fixed‐effect model. We planned to use a random‐effects model in the event that there were four or more studies in a meta‐analysis. Main results We included 10 studies that analysed a total of 5903 participants. One study was assessed as being at low risk of bias, two were assessed as being at unclear risk of bias, with the remaining seven being at high risk of bias. The main finding of the review was that, over 2.5 to 3 years of use, a fluoride toothpaste containing 10% xylitol may reduce caries by 13% when compared to a fluoride‐only toothpaste (PF ‐0.13, 95% CI ‐0.18 to ‐0.08, 4216 children analysed, low‐quality evidence). The remaining evidence on children, from small single studies with risk of bias issues and great uncertainty associated with the effect estimates, was insufficient to determine a benefit from xylitol products. One study reported that xylitol syrup (8 g per day) reduced caries by 58% (95% CI 33% to 83%, 94 infants analysed, low quality evidence) when compared to a low‐dose xylitol syrup (2.67 g per day) consumed for 1 year. The following results had 95% CIs that were compatible with both a reduction and an increase in caries associated with xylitol: xylitol lozenges versus no treatment in children (very low quality body of evidence); xylitol sucking tablets versus no treatment in infants (very low quality body of evidence); xylitol tablets versus control (sorbitol) tablets in infants (very low quality body of evidence); xylitol wipes versus control wipes in infants (low quality body of evidence). There was only one study investigating the effects of xylitol lozenges, when compared to control lozenges, in adults (low quality body of evidence). The effect estimate had a 95% CI that was compatible with both a reduction and an increase in caries associated with xylitol. Four studies reported that there were no adverse effects from any of the interventions. Two studies reported similar rates of adverse effects between study arms. The remaining studies either mentioned adverse effects but did not report any usable data, or did not mention them at all. Adverse effects include sores in the mouth, cramps, bloating, constipation, flatulence, and loose stool or diarrhoea. Authors' conclusions We found some low quality evidence to suggest that fluoride toothpaste containing xylitol may be more effective than fluoride‐only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse‐effects from such toothpastes. The effect estimate should be interpreted with caution due to high risk of bias and the fact that it results from two studies that were carried out by the same authors in the same population. The remaining evidence we found is of low to very low quality and is insufficient to determine whether any other xylitol‐containing products can prevent caries in infants, older children, or adults. Plain language summary Can xylitol used in products like sweets, candy, chewing gum and toothpaste help prevent tooth decay in children and adults? Review question This review has been produced to assess whether or not xylitol, a natural sweetener used in products such as sweets, candy, chewing gum and toothpaste, can help prevent tooth decay in children and adults. Background Tooth decay is a common disease affecting up to 90% of children and most adults worldwide. It impacts on quality of life and can be the reason for thousands of children needing dental treatment under general anaesthetic in hospital. However, it can easily be prevented and treated by good oral health habits such as brushing teeth regularly with toothpaste that contains fluoride and cutting down on sugary food and drinks. If left undisturbed, the unhelpful bacteria in the mouth ‐ which cause decay ‐ multiply and stick to the surfaces of teeth producing a sticky film. Then, when sugar is eaten or drank, the bad bacteria in the film are able to make acid resulting in tooth decay. Xylitol is a natural sweetener, which is equally as sweet as normal sugar (sucrose). As well as providing an alternative to sugar, it has other properties that are thought to help prevent tooth decay, such as increasing the production of saliva and reducing the growth of bad bacteria in the mouth so that less acid is produced. In humans, xylitol is known to cause possible side effects such as bloating, wind and diarrhoea. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 14 August 2014. It includes 10 studies published from 1991 to 2014 in which 7969 participants were randomised (5903 of whom were included in the analyses) to receive xylitol products or a placebo (a substitute without xylitol) or no treatment, and the amount of tooth decay was compared. One study included adults, the others included children aged from 1 month to 13 years. The products tested were the kind that are held in the mouth and sucked (lozenges, sucking tablets and sweets) or slowly released through a dummy/pacifier, as well as toothpastes, syrups, and wipes. Key results There is some evidence to suggest that using a fluoride toothpaste containing xylitol may reduce tooth decay in the permanent teeth of children by 13% over a 3 year period when compared to a fluoride‐only toothpaste. Over this period, there were no side effects reported by the children. The remaining evidence we found did not allow us to conclude whether or not any other xylitol‐containing products can prevent tooth decay in infants, older children, or adults. Quality of the evidence The evidence presented is of low to very low quality due to the small amount of available studies, uncertain results, and issues with the way in which they were conducted.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P, Moore, D, Ahmed, F, Sharif, MO, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD010743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.139Z" }, { "id": "b857fc7a-9a12-4190-9733-9275b3b7b636", "pmid": "", "title": "Adhesives for bonded molar tubes during fixed brace treatment", "imported": false, "abstract": "Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. The success of a fixed appliance depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a fixed appliance. It can also be costly in terms of clinical time, materials and time lost from education/work for the patient. This is an update of the Cochrane review first published in 2011. A new full search was conducted on 15 February 2017 but no new studies were identified. We have only updated the search methods section in this new version. The conclusions of this Cochrane review remain the same. Objectives To evaluate the effectiveness of the adhesives used to attach bonded molar tubes, and the relative effectiveness of the adhesives used to attach bonded molar tubes versus adhesives used to attach bands, during fixed appliance treatment, in terms of: (1) how often the tubes (or bands) come off during treatment; and (2) whether they protect the bonded (or banded) teeth against decay. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (to 15 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library (searched 15 February 2017), MEDLINE Ovid (1946 to 15 February 2017), and Embase Ovid (1980 to 15 February 2017). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials of participants with full arch fixed orthodontic appliance(s) with molar tubes, bonded to first or second permanent molars. Trials which compared any type of adhesive used to bond molar tubes (stainless steel or titanium) with any other adhesive, were included. Trials were also included where: (1) a tube was bonded to a molar tooth on one side of an arch and a band cemented to the same tooth type on the opposite side of the same arch;
 (2) molar tubes had been allocated to one tooth type in one patient group and molar bands to the same tooth type in another patient group. Data collection and analysis The selection of papers, decision about eligibility and data extraction were carried out independently and in duplicate without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Two trials (n = 190), at low risk of bias, were included in the review and both presented data on first time failure at the tooth level. Pooling of the data showed a statistically significant difference in favour of molar bands, with a hazard ratio of 2.92 (95% confidence intervals (CI) 1.80 to 4.72). No statistically significant heterogeneity was shown between the two studies. Data on first time failure at the patient level were also available and showed statistically different difference in favour of molar bands (risk ratio 2.30; 95% CI 1.56 to 3.41) (risk of event for molar tubes = 57%; risk of event for molar bands 25%). One trial presented data on decalcification again showing a statistically significant difference in favour of molar bands. No other adverse events identified. Authors' conclusions From the two well‐designed and low risk of bias trials included in this review it was shown that the failure of molar tubes bonded with either a chemically‐cured or light‐cured adhesive was considerably higher than that of molar bands cemented with glass ionomer cement. One trial indicated that there was less decalcification with molar bands cemented with glass ionomer cement than with bonded molar tubes cemented with a light‐cured adhesive. However, given there are limited data for this outcome, further evidence is required to draw more robust conclusions. Plain language summary Adhesives for bonded molar tubes during fixed brace treatment Background Orthodontic treatment involves using fixed or removable dental braces to correct the positions of teeth. The success of dental braces depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a dental brace. Study characteristics The evidence in this review, which was carried out together with Cochrane Oral Health, is up‐to‐date as of 15 February 2017. We included two studies that evaluated 190 participants. Both trials were conducted in the UK and both compared bonded molar tubes with molar bands. Key results From the limited data of two studies at low risk of bias, it would appear that bonded molar tubes are associated with a higher failure rate than with molar bands.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Millett, DT; Mandall, NA; Mattick, RCR; Hickman, J; Glenny, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008236.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "b861b058-424d-4522-921a-a794e33aa702", "pmid": "", "title": "Foetal haemoglobin inducers for reducing blood transfusion in non‐transfusion‐dependent beta‐thalassaemias", "imported": false, "abstract": "Abstract - Background Non‐transfusion‐dependent β‐thalassaemia (NTDβT) is a subset of inherited haemoglobin disorders characterised by reduced production of the β‐globin chain of haemoglobin leading to anaemia of varying severity. Although blood transfusion is not a necessity for survival, it may be required to prevent complications of chronic anaemia, such as impaired growth and hypercoagulability. People with NTDβT also experience iron overload due to increased iron absorption from food sources which becomes more pronounced in those requiring blood transfusion. People with a higher foetal haemoglobin (HbF) level have been found to require fewer blood transfusions, thus leading to the emergence of treatments that could increase its level. HbF inducers stimulate HbF production without altering any gene structures. Evidence for the possible benefits and harms of these inducers is important for making an informed decision on their use. Objectives To compare the effectiveness and safety of the following for reducing blood transfusion for people with NTDβT: 1. HbF inducers versus usual care or placebo; 2. single HbF inducer with another HbF inducer, and single dose with another dose; and 3. combination of HbF inducers versus usual care or placebo, or single HbF inducer. Search methods We used standard, extensive Cochrane search methods. The latest search date was 21 August 2022. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs comparing single HbF inducer with placebo or usual care, with another single HbF inducer or with a combination of HbF inducers; or comparing different doses of the same HbF inducer. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were blood transfusion and haemoglobin levels. Our secondary outcomes were HbF levels, the long‐term sequelae of NTDβT, quality of life and adverse events. Main results We included seven RCTs involving 291 people with NTDβT, aged two to 49 years, from five countries. We reported 10 comparisons using eight different HbF inducers (four pharmacological and four natural): three RCTs compared a single HbF inducer to placebo and seven to another HbF inducer. The duration of the intervention lasted from 56 days to six months. Most studies did not adequately report the randomisation procedures or whether and how blinding was achieved. HbF inducer against placebo or usual care Three HbF inducers, HQK‐1001, Radix Astragali or a 3‐in‐1 combined natural preparation (CNP), were compared with a placebo. None of the comparisons reported the frequency of blood transfusion. We are uncertain whether Radix Astragali and CNP increase haemoglobin at three months (mean difference (MD) 1.33 g/dL, 95% confidence interval (CI) 0.54 to 2.11; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). We are uncertain whether Radix Astragali and CNP have any effect on HbF (MD 12%, 95% CI −0.74% to 24.75%; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). Only medians on haemoglobin and HbF levels were reported for HQK‐1001. Adverse effects reported for HQK‐1001 were nausea, vomiting, dizziness and suprapubic pain. There were no prespecified adverse effects for Radix Astragali and CNP. HbF inducer versus another HbF inducer Four studies compared a single inducer with another over three to six months. Comparisons included hydroxyurea versus resveratrol, hydroxyurea versus thalidomide, hydroxyurea versus decitabine and Radix Astragali versus CNP. No study reported our prespecified outcomes on blood transfusion. Haemoglobin and HbF were reported for the comparison Radix Astragali versus CNP, but we are uncertain whether there were any differences (1 study, 24 participants; low‐certainty evidence). Different doses of the same HbF inducer Two studies compared two different types of HbF inducers at different doses over two to six months. Comparisons included hydroxyurea 20 mg/kg/day versus 10 mg/kg/day and HQK‐1001 10 mg/kg/day, 20 mg/kg/day, 30 mg/kg/day and 40 mg/kg/day. Blood transfusion, as prespecified, was not reported. In one study (61 participants) we are uncertain whether the lower levels of both haemoglobin and HbF at 24 weeks were due to the higher dose of hydroxyurea (haemoglobin: MD −2.39 g/dL, 95% CI −2.80 to −1.98; very low‐certainty evidence; HbF: MD −10.20%, 95% CI −16.28% to −4.12%; very low‐certainty evidence). The study of the four different doses of HQK‐1001 did not report results for either haemoglobin or HbF. We are not certain if major adverse effects may be more common with higher hydroxyurea doses (neutropenia: risk ratio (RR) 9.93, 95% CI 1.34 to 73.97; thrombocytopenia: RR 3.68, 95% CI 1.12 to 12.07; very low‐certainty evidence). Taking HQK‐1001 20 mg/kg/day may result in the fewest adverse effects. A combination of HbF inducers versus a single HbF inducer Two studies compared three combinations of two inducers with a single inducer over six months: hydroxyurea plus resveratrol versus resveratrol or hydroxyurea alone, and hydroxyurea plus l‐carnitine versus hydroxyurea alone. Blood transfusion was not reported. Hydroxyurea plus resveratrol may reduce haemoglobin compared with either resveratrol or hydroxyurea alone (MD −0.74 g/dL, 95% CI −1.45 to −0.03; 1 study, 54 participants; low‐certainty evidence). We are not certain whether the gastrointestinal disturbances, headache and malaise more commonly reported with hydroxyurea plus resveratrol than resveratrol alone were due to the interventions. We are uncertain whether hydroxyurea plus l‐carnitine compared with hydroxyurea alone may increase mean haemoglobin, and reduce pulmonary hypertension (1 study, 60 participants; very low‐certainty evidence). Adverse events were reported but not in the intervention group. None of the comparisons reported the outcome of HbF. Authors' conclusions We are uncertain whether any of the eight HbF inducers in this review have a beneficial effect on people with NTDβT. For each of these HbF inducers, we found only one or at the most two small studies. There is no information on whether any of these HbF inducers have an effect on our primary outcome, blood transfusion. For the second primary outcome, haemoglobin, there may be small differences between intervention groups, but these may not be clinically meaningful and are of low‐ to very low‐certainty evidence. Data on adverse effects and optimal doses are limited. Five studies are awaiting classification, but none are ongoing. Plain language summary Medicines to increase foetal haemoglobin levels and reduce the need for blood transfusion in people with non‐transfusion‐dependent thalassaemia Review question Do medicines that increase foetal haemoglobin (HbF) levels in people with non‐transfusion‐dependent β‐thalassaemia (NTDβT) reduce their need for blood transfusion? What is thalassaemia? Thalassaemia is a genetic (inherited) blood disorder that causes defects in adult haemoglobin (the oxygen carrying component of red blood cells) leading to destruction of the red blood cells and anaemia with different degrees of severity. Persistent anaemia can affect general health and reduce quality of life. People with NTDβT may require periodic blood transfusion to replace the red blood cells and this could lead to excess iron being deposited in various organs in the body, affecting their function. People with NTDβT have higher levels of HbF (the main form of haemoglobin found during the development of a baby before birth) which persists after birth. The amount of HbF that persists varies and people with a higher HbF level require less frequent blood transfusions. What are HbF inducers? HbF inducers are substances which increase HbF levels without alteration to the gene. They may reduce the need for blood transfusion in people with NTDβT. However, it is not known which HbF inducers are effective and safe, and if so, what the optimal dose is and at what age treatment should be started. What did we do? We searched medical databases for studies comparing single HbF inducer with placebo (dummy treatment) or usual care, with another inducer or with a combination of inducers; or comparing different doses for a same inducer. What did we find? We found seven very small randomised controlled trials (where people taking part in the trial had equal chances of being in the treatment or the control group), involving 291 people with NTDβT, aged between two and 49 years, from five countries. These studies varied widely in the type of HbF inducers investigated and their comparison, the doses and how outcomes were reported. The duration of the trials ranged from two to six months. The inducers used include hydroxyurea, decitabine, HQK‐1001, thalidomide, Radix Astragali, resveratrol, l‐carnitine and combined natural preparation (CNP). Main results None of the studies reported our main outcome of changes to the frequency of blood transfusion. All inducers may have caused a small increase in haemoglobin and HbF when compared to placebo, but we are very uncertain about this. Four studies compared a single HbF inducer against another, for three to six months. There were changes to haemoglobin and HbF, but we cannot be certain if a single HbF inducer or a combination of HbF inducers would work better than another. Two studies, each compared a different dose of the same inducer. Lower doses of hydroxyurea appeared to increase haemoglobin and HbF levels more than the higher doses, but we are very uncertain. The other study used four different doses of HQK‐1001 but did not actually look for a difference in the effect of these four different doses on haemoglobin or HbF. Two studies compared a combination of two HbF inducers with a single HbF inducer for six months. We are very uncertain whether the combination or a single inducer improves haemoglobin. None of the studies reported whether HbF inducers have any effect on quality of life. Adverse (unwanted) drug effects were reported for each HbF inducer, but there was little information available to guide us on the safety of these substances. What are the limitations of the evidence? The main reason we are very uncertain about the effects of HbF inducers are because the studies were all very small and had weaknesses in their design. None of the studies lasted long enough to provide meaningful information for many of the outcomes we measured. How up to date is this evidence? The evidence is current to 21 August 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Foong, WC; Loh, CK; Ho, JJ; Lau, DSC", "articleTypes": [], "doi": "10.1002/14651858.CD013767.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "b86eee07-b616-4d05-b1dc-002042533e61", "pmid": "", "title": "Corticosteroids for treating sepsis in children and adults", "imported": false, "abstract": "Abstract - Background Sepsis occurs when an infection is complicated by organ failure. Sepsis may be complicated by impaired corticosteroid metabolism. Thus, providing corticosteroids may benefit patients. This is an update of a review originally published in 2004 and previously updated in 2010, 2015 and 2019. Objectives To examine the benefits and harms of corticosteroids in children and adults with sepsis. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, ISRCTN and the WHO Clinical Trials Search Portal on 31 December 2023. In addition, we conducted reference checking and citation research, and contacted study authors, to identify additional studies as needed. We updated this search in December 2024, but these results have not yet been incorporated. Selection criteria We included randomised controlled trials (RCTs) of corticosteroids versus placebo or usual care (antimicrobials, fluid replacement and vasopressor therapy as needed) in children and adults with sepsis. We also included RCTs of continuous infusion versus intermittent bolus of corticosteroids. Data collection and analysis We used the same methods in comparisons of corticosteroids versus placebo or usual care, and of continuous infusion versus intermittent bolus administration of corticosteroids. The primary outcome was all‐cause mortality at 28 days. The most critical secondary outcomes were (i) all‐cause mortality in the long term (last follow‐up from 90 days to one year) and in the hospital; (ii) length of stay in the intensive care unit and in hospital; (iii) adverse effects, i.e. superinfection and muscle weakness (within 28 days). All review authors screened and selected studies for inclusion. One review author extracted data, which was checked by the others, and by the lead author of the primary study when possible. For this update, we used Covidence software for screening and selection of studies and abstraction of data by paired review authors, with discrepancies resolved by a third review author. We obtained unpublished data from the authors of some trials. We assessed the risk of bias in trials using the Cochrane risk of bias tool (RoB 1) and applied GRADE to assess the certainty of evidence. The review authors did not contribute to the assessment of eligibility or risk of bias, nor to data extraction, for the trials they had participated in. Main results We included 87 trials (24,336 participants), of which six included only children, two included children and adults, and the remaining trials included only adults. Seventeen additional trials are ongoing and will be considered in future versions of this review. We judged 25 trials as being at low risk of bias. Corticosteroids versus placebo or usual care Compared to placebo or usual care, corticosteroids probably reduce 28‐day mortality (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.84 to 0.95; 72 trials, 22,915 participants; moderate‐certainty evidence). We downgraded the certainty of evidence for this outcome from high to moderate for inconsistency (significant heterogeneity across trial results). Corticosteroids may result in little to no difference in long‐term mortality (RR 0.97, 95% CI 0.91 to 1.03; 12 trials, 8468 participants; low‐certainty evidence) and probably reduce in‐hospital mortality (RR 0.90, 95% CI 0.84 to 0.97; 40 trials, 17,459 participants; moderate‐certainty evidence). Corticosteroids may reduce length of intensive care unit (ICU) stay for all participants (mean difference (MD) ‐0.86 days, 95% CI ‐1.67 to ‐0.05; 25 trials, 8069 participants; low‐certainty evidence) and may reduce length of hospital stay for all participants (MD ‐1.09 days, 95% CI ‐1.85 to ‐0.34; 31 trials, 16,954 participants; low‐certainty evidence). The evidence is uncertain about the effect of corticosteroids on the risk of muscle weakness (RR 1.09, 95% CI 0.78 to 1.53; 7 trials, 6729 participants; very low‐certainty evidence). Corticosteroids may result in little to no difference in the risk of superinfection (RR 0.96, 95% CI 0.86 to 1.07; 36 trials, 7961 participants; low‐certainty evidence). Continuous infusion of corticosteroids versus intermittent bolus Four trials reported data for this comparison, and the certainty of evidence for all outcomes was very low. We are uncertain about the effects of continuous infusion of corticosteroids compared with intermittent bolus administration on 28‐day mortality (RR 1.03, 95% CI 0.81 to 1.32; 3 trials, 310 participants). We downgraded the certainty of evidence to very low due to high risk of bias in all except one trial and due to imprecision. Compared to bolus administration, we are uncertain of the effects of continuous infusion of corticosteroids on long‐term mortality (RR 1.36, 95% CI 1.02 to 1.81; 1 trial, 70 participants; very low‐certainty evidence), in‐hospital mortality (RR 0.92, 95% CI 0.71 to 1.19; 3 trials, 352 participants; very low‐certainty evidence), ICU length of stay amongst all participants (MD ‐0.56 days, 95% CI ‐3.44 to 2.32; 4 trials, 422 participants; very low‐certainty evidence), hospital length of stay amongst all participants (MD ‐0.21 days, 95% CI ‐4.72 to 4.30; 4 trials, 422 participants; very low‐certainty evidence), risk of muscle weakness (RR 0.89, 95% CI 0.13 to 5.98; 1 trial, 70 participants; very low‐certainty evidence) and risk of superinfection (RR 1.12, 95% CI 0.37 to 3.33; 2 trials, 193 participants; very low‐certainty evidence). Authors' conclusions Moderate‐certainty evidence indicates that corticosteroids probably reduce 28‐day, 90‐day and hospital mortality amongst patients with sepsis. Corticosteroids may shorten ICU and hospital length of stay (low‐certainty evidence). There may be little or no difference in the risk of superinfection. The risk of muscle weakness is uncertain. The effects of continuous versus intermittent bolus administration of corticosteroids are uncertain. Plain language summary What are the benefits and harms of corticosteroids in the treatment of children and adults with sepsis? Key messages • Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days and of in‐hospital death, and may have little or no effect on the risk of dying beyond three months. • We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. • Future studies should measure the benefits and harms of corticosteroids for the treatment of specific populations, including children, patients with sepsis without shock or with a mild form of septic shock, patients with acute respiratory distress syndrome (ARDS) and patients with different types of infections. Defining the optimal methods for corticosteroid administration, including the types of molecule ‐ with or without producing sodium and fluid retention and potassium excretion (mineralocorticoid activity), timing of initiation, dose and duration, continuous infusion or intermittent intravenous boluses, and ending of treatment ‐ with or without gradually decreasing the dose to zero, also requires additional studies. Future studies should measure the longer‐term effects, i.e. longer than one year, on survival and complications of sepsis. What is sepsis? Sepsis is present when an infection is complicated by organ failure. People develop rapid breathing, hypotension (low blood pressure) and mental confusion. Sepsis can interfere with the effectiveness of the body’s corticosteroids, which control how your body recognises and defends itself against bacteria, viruses and substances that appear foreign and harmful. What are corticosteroids (medicine)? Corticosteroids are medicines used to stop excessive inflammation. However, these medicines may cause unwanted harms, such as increased blood sugar or salt levels, infections, bleeding in the stomach, agitation or delirium, and weakness of the limbs. Corticosteroids have been given for decades to people with infection resulting from various causes. What did we want to find out? We wanted to find out: • the benefits of using corticosteroids in children and adults with sepsis; and • the best ways to administer this treatment (including the best people to give it to). We also wanted to know if corticosteroids can cause any unwanted effects. What did we do? We searched for studies that compared: • corticosteroids administered intravenously against a 'dummy' treatment, or sham treatment, which does not contain any medicine but looks or tastes identical to corticosteroids, or usual care; or • continuous infusion against intermittent rapid intravenous injections (boluses) of corticosteroids administration. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? This review includes 87 trials (24,336 participants). The biggest study was of 3800 people and the smallest study was of 21 people. Eighty‐three trials compared corticosteroids to no corticosteroids (placebo or usual care in 59 and 24 trials, respectively). Four trials also compared continuous administration versus rapid intravenous injection (i.e. bolus) of corticosteroids given at fixed intervals of six or eight hours. Thirty‐three trials were conducted in Europe, 15 in North America, 22 in Asia, six in the Middle East, six in Africa and three in Latin America; four were multinational trials. Three trials were funded by a drug company, 27 by public organisations or through charitable funding and six by both a drug company and public organisations or charitable funding; 25 did not declare the source of funding. Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days by 10% (72 trials; 22,915 participants), with consistent treatment effects between children and adults. There may be little or no effect of corticosteroids on the risk of dying over the long term (longer than three months), but these results are less certain. Corticosteroids probably reduce the risk of dying in hospital. Corticosteroids may result in a reduction in the length of stay in the intensive care unit (ICU) and in hospital. They may not increase the risk of superinfection (second infection). The evidence is very uncertain about the effect of corticosteroids on the risk of muscle weakness. We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. Four studies reported data for this comparison, and the certainty of evidence for all outcomes was very low. What are the limitations of the evidence? • Corticosteroids versus placebo or usual care We have moderate confidence in our findings that corticosteroids reduced 28‐day mortality. We found some differences amongst the study populations, the types of corticosteroids and how they were given, and the use of additional medicines. • Continuous infusion versus bolus administration of corticosteroids We have very little confidence in our findings about the absence of a difference in 28‐day mortality between the administration of corticosteroids continuously and repeated rapid intravenous injections. We found only four studies that enrolled very few patients. How up‐to‐date is this evidence? The evidence provided in this review is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Annane, D, Briegel, J, Granton, D, Bellissant, E, Bollaert, PE, Keh, D, Kupfer, Y, Pirracchio, R, Rochwerg, B", "articleTypes": [], "doi": "10.1002/14651858.CD002243.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.141Z" }, { "id": "b8701efe-04d0-4484-abff-57a739fe7f0f", "pmid": "", "title": "Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Ethnic minority groups in upper‐middle‐income and high‐income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population. Objectives To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Search methods A systematic literature search was performed of the following databases: The Cochrane Library , MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well. Selection criteria We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper‐middle‐income or high‐income countries. Data collection and analysis Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification. Main results A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta‐analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education. Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) ‐0.4% (95% confidence interval (CI) ‐0.5 to ‐0.2); 14 trials; 1442 participants; high‐quality evidence) and at six months (MD ‐0.5% (95% CI ‐0.7 to ‐0.4); 14 trials; 1972 participants; high‐quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD ‐0.2% (95% CI ‐0.3 to ‐0.04); 9 trials; 1936 participants) and at 24 months (MD ‐0.3% (95% CI ‐0.6 to ‐0.1); 4 trials; 2268 participants; moderate‐quality evidence) post intervention. Neutral effects on health‐related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies — the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI ‐40 to ‐8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low‐density lipoprotein (LDL) cholesterol or high‐density lipoprotein (HDL) cholesterol were reported at any follow‐up point. Other outcome measures (blood pressure, body mass index, self‐efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient. Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self‐reported via questionnaires, leading to high bias in subjective outcome assessment. Authors' conclusions Culturally appropriate health education has short‐ to medium‐term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long‐term trials, and so clinically important long‐term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long‐term, standardised, multi‐centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium‐term effects could lead to clinically important health outcomes, if sustained. Plain language summary Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus Review question Does culturally appropriate diabetes health education lead to better outcomes than 'usual care' for people in ethnic minority groups with type 2 diabetes? Background In upper‐middle‐income and high‐income countries, minority ethnic groups often have a higher prevalence of type 2 diabetes mellitus than is seen in the local population. They also tend to come from lower socioeconomic backgrounds, with attendant difficulties in accessing good‐quality health care. In some cases, cultural and communication barriers increase the problems that minority ethnic communities experience when attempting to access good‐quality diabetes health education, which is vital for those who wish to understand diabetes and use available services to gain empowerment and bring about behaviour change toward a healthier lifestyle. In this review, 'culturally appropriate' health education is taken to mean any type of health education that has been specifically tailored to the cultural needs of a target minority group with type 2 diabetes mellitus. Study characteristics This updated review found in the world literature 33 randomised controlled trials (RCTs) of culturally appropriate health education on diabetes that met the selection criteria (participants from a defined ethnic minority group living in a upper‐middle‐income or high‐income country, over 16 years of age, diagnosed with type 2 diabetes mellitus and receiving a culturally tailored health education intervention). The median duration of the intervention was six months, and a total of 7453 participants were involved in the studies. Key results Culturally appropriate health education improved blood sugar control among participants, compared with those receiving 'usual' care, at three, six, 12 and 24 months after the intervention was provided. Knowledge about diabetes improved, and participants attained healthier lifestyles. No information was available regarding complications of diabetes and death from any cause, and there was a general lack of reporting of adverse effects in most studies. Neutral effects were observed for health‐related quality of life, blood lipids like cholesterol, blood pressure and weight. The costs of educational programmes were rarely analysed. Compared with the first review, performed in 2008 (11 studies), many more published studies were identified in this review (altogether 33 studies), strengthening the original findings that blood sugar control and knowledge of diabetes are improved when culturally appropriate health education is provided to people in ethnic minority groups diagnosed with diabetes. The effects of this improvement are shown in this update as lasting longer — up to 24 months after health education was provided in some trials. However, additional high‐quality standardised RCTs of longer duration are needed, along with full evaluation of costs. Quality of the evidence Heterogeneity of the studies, in terms of populations studied, type and duration of health education provided, variety of outcomes measured and differences in timing of assessment, limits interpretation of our findings. Also, risk of bias was judged to be high for many outcomes. Currentness of evidence This evidence is up‐to‐date as of September 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Attridge, M; Creamer, J; Ramsden, M; Cannings‐John, R; Hawthorne, K", "articleTypes": [], "doi": "10.1002/14651858.CD006424.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "b872f40f-3666-42bc-9129-083e91e0ea5e", "pmid": "", "title": "Drugs for preventing malaria in pregnant women in endemic areas: any drug regimen versus placebo or no treatment", "imported": false, "abstract": "Abstract - Background Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. To reduce these effects, the World Health Organization recommends that pregnant women living in malaria endemic areas sleep under insecticide‐treated bednets, are treated for malaria illness and anaemia, and receive chemoprevention with an effective antimalarial drug during the second and third trimesters. Objectives To assess the effects of malaria chemoprevention given to pregnant women living in malaria endemic areas on substantive maternal and infant health outcomes. We also summarised the effects of intermittent preventive treatment with sulfadoxine‐pyrimethamine (SP) alone, and preventive regimens for Plasmodium vivax. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and reference lists up to 1 June 2014. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs of any antimalarial drug regimen for preventing malaria in pregnant women living in malaria‐endemic areas compared to placebo or no intervention. In the mother, we sought outcomes that included mortality, severe anaemia, and severe malaria; anaemia, haemoglobin values, and malaria episodes; indicators of malaria infection, and adverse events. In the baby, we sought foetal loss, perinatal, neonatal and infant mortality; preterm birth and birthweight measures; and indicators of malaria infection. We included regimens that were known to be effective against the malaria parasite at the time but may no longer be used because of parasite drug resistance. Data collection and analysis Two review authors applied inclusion criteria, assessed risk of bias and extracted data. Dichotomous outcomes were compared using risk ratios (RR), and continuous outcomes using mean differences (MD); both are presented with 95% confidence intervals (CI). We assessed the quality of evidence using the GRADE approach. Main results Seventeen trials enrolling 14,481 pregnant women met our inclusion criteria. These trials were conducted between 1957 and 2008, in Nigeria (three trials), The Gambia (three trials), Kenya (three trials), Mozambique (two trials), Uganda (two trials), Cameroon (one trial), Burkina Faso (one trial), and Thailand (two trials). Six different antimalarials were evaluated against placebo or no intervention; chloroquine (given weekly), pyrimethamine (weekly or monthly), proguanil (daily), pyrimethamine‐dapsone (weekly or fortnightly), and mefloquine (weekly), or intermittent preventive therapy with SP (given twice, three times or monthly). Trials recruited women in their first or second pregnancy (eight trials); only multigravid women (one trial); or all women (eight trials). Only six trials had adequate allocation concealment. For women in their first or second pregnancy, malaria chemoprevention reduces the risk of moderate to severe anaemia by around 40% (RR 0.60, 95% CI 0.47 to 0.75; three trials, 2503 participants, high quality evidence ), and the risk of any anaemia by around 17% (RR 0.83, 95% CI 0.74 to 0.93; five trials,, 3662 participants, high quality evidence ). Malaria chemoprevention reduces the risk of antenatal parasitaemia by around 61% (RR 0.39, 95% CI 0.26 to 0.58; seven trials, 3663 participants, high quality evidence ), and two trials reported a reduction in febrile illness ( low quality evidence ). There were only 16 maternal deaths and these trials were underpowered to detect an effect on maternal mortality ( very low quality evidence ). For infants of women in their first and second pregnancies, malaria chemoprevention probably increases mean birthweight by around 93 g (MD 92.72 g, 95% CI 62.05 to 123.39; nine trials, 3936 participants, moderate quality evidence ), reduces low birthweight by around 27% (RR 0.73, 95% CI 0.61 to 0.87; eight trials, 3619 participants, moderate quality evidence ), and reduces placental parasitaemia by around 46% (RR 0.54, 95% CI 0.43 to 0.69; seven trials, 2830 participants, high quality evidence ). Fewer trials evaluated spontaneous abortions, still births, perinatal deaths, or neonatal deaths, and these analyses were underpowered to detect clinically important differences. In multigravid women, chemoprevention has similar effects on antenatal parasitaemia (RR 0.38, 95% CI 0.28 to 0.50; three trials, 977 participants, high quality evidence )but there are too few trials to evaluate effects on other outcomes. In trials giving chemoprevention to all pregnant women irrespective of parity, the average effects of chemoprevention measured in all women indicated it may prevent severe anaemia (defined by authors, but at least < 8 g/L: RR 0.19, 95% CI 0.05 to 0.75; two trials, 1327 participants, low quality evidence), but consistent benefits have not been shown for other outcomes. In an analysis confined only to intermittent preventive therapy with SP, the estimates of effect and the quality of the evidence were similar. A summary of a single trial in Thailand of prophylaxis against P. vivax showed chloroquine prevented vivax infection (RR 0.01, 95% CI 0.00 to 0.20; one trial, 942 participants). Authors' conclusions Routine chemoprevention to prevent malaria and its consequences has been extensively tested in RCTs, with clinically important benefits on anaemia and parasitaemia in the mother, and on birthweight in infants. 8 May 2019 No update planned Review superseded The intervention is clearly effective. The questions now are around head‐to‐head comparisons not included in this review. Plain language summary The effect of taking antimalarial drugs routinely to prevent malaria in pregnancy Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. For this reason, women are encouraged to try and prevent malaria infection during pregnancy by sleeping under mosquito bed‐nets, and by taking drugs effective against malaria throughout pregnancy as chemoprevention. This Cochrane Review looked at all drug regimens compared to placebo. The review authors sought to summarise and quantify the overall effects of chemoprevention. Seventeen trials were included, all conducted between 1957 and 2008, and all but two in countries of Africa. For women in their first or second pregnancy, malaria chemoprevention prevents moderate to severe anaemia ( high quality evidence ); and prevents malaria parasites being detected in the blood ( high quality evidence ). It may also prevent malaria illness. We don't know if it prevents maternal deaths, as this would require very large studies to detect an effect. In their infants, malaria chemoprevention improves the average birthweight ( moderate quality evidence ), and reduces the number of low birthweight infants ( moderate quality evidence ). We are not sure if chemoprevention reduces mortality of babies in the first week, month and year, as again studies would need to be very large to show these effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Radeva‐Petrova, D; Kayentao, K; ter Kuile, FO; Sinclair, D; Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD000169.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "b88ce006-35fe-47dc-8dad-3019851348c5", "pmid": "", "title": "Interventions for recurrent idiopathic epistaxis (nosebleeds) in children", "imported": false, "abstract": "Abstract - Background Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified. Although nosebleeds are very common in children, and most cases are self limiting or settle with simple measures (such as pinching the nose), more severe recurrent cases can require treatment from a healthcare professional. However, there is no consensus on the effectiveness of the different clinical interventions currently used in managing this condition. Objectives To assess the effects of different interventions for the management of recurrent idiopathic epistaxis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 5 March 2012. Selection criteria We identified all randomised controlled trials (RCTs) (with or without blinding) in which any surgical or medical intervention for the treatment of recurrent idiopathic epistaxis in children was evaluated in comparison with either no treatment, a placebo or another intervention, and in which the frequency and severity of episodes of nasal bleeding following treatment was stated or calculable. The two authors reviewed the full‐text articles of all retrieved trials of possible relevance and applied the inclusion criteria independently. Data collection and analysis We graded trials for risk of bias using the Cochrane approach. One author performed data extraction in a standardised manner and this was rechecked by the other author. Where necessary we contacted investigators to obtain missing information. We did not undertake a meta‐analysis because of the heterogeneity of the treatments, procedures and quality of the included trials. A narrative overview of the results is therefore presented. Main results Five studies (four RCTs and one quasi‐randomised controlled trial) involving 468 participants satisfied the inclusion criteria. The identified RCTs compared 0.5% neomycin + 0.1% chlorhexidine (Naseptin®) cream with no treatment, Vaseline® petroleum jelly with no treatment, 75% with 95% silver nitrate nasal cautery, and silver nitrate cautery combined with Naseptin® against Naseptin® alone; the quasi‐randomised controlled trial compared Naseptin® antiseptic cream with silver nitrate cautery. Overall results were inconclusive, with no statistically significant difference found between the compared treatments upon completion of the trials, however 75% silver nitrate was more effective than 95% silver nitrate at two weeks following application. The group treated with 75% silver nitrate had 88% complete resolution of epistaxis compared to 65% in the group treated with 95% silver nitrate (P = 0.01). No serious adverse effects were reported from any of the interventions, although children receiving silver nitrate cautery reported that it was a painful experience (despite the use of local anaesthetic). The pain scores were significantly less in those treated with 75% silver nitrate, the mean score being 1 compared to a mean score of 5 in those treated with 95% silver nitrate; this was statistically significant (P = 0.001). We carried out a 'Risk of bias' assessment of each study according to the Cochrane methodology and judged that two randomised controlled trials had a low risk of bias, two had an unclear risk of bias and the quasi‐randomised controlled trial had a high risk of bias. Authors' conclusions The optimal management of children with recurrent idiopathic epistaxis is unknown, however if silver nitrate nasal cautery is undertaken 75% is preferable to 95% as it is more effective in the short term and causes less pain. High‐quality randomised controlled trials comparing interventions either with placebo or no treatment, and with a follow‐up period of at least a year, are needed to assess the relative merits of the various treatments currently in use. Plain language summary Interventions for recurrent nosebleeds of unknown cause in children Nosebleeds in children usually just stop by themselves or after pinching the nose. However, some children get repeated nosebleeds with no specific cause (recurrent idiopathic epistaxis). The most common treatments are cautery or antiseptic cream, or both. Cautery (a method of sealing) can be painful even with local anaesthetic, and usually involves using a silver nitrate stick to seal off a visible blood vessel inside the nose that may be rupturing. Other options include ointments and nasal sprays. The review of trials found that there is not enough evidence to compare the effectiveness of different treatment options, however using a lower concentration of silver nitrate cautery is more effective in the short term and less painful. More research is needed to show the best options for reducing recurrent nosebleeds of unknown cause in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Qureishi, A, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004461.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.087Z" }, { "id": "b8a02d49-8991-49cc-b991-071e29608b92", "pmid": "", "title": "Fluoride toothpastes of different concentrations for preventing dental caries", "imported": false, "abstract": "Abstract - Background Caries (dental decay) is a disease of the hard tissues of the teeth caused by an imbalance, over time, in the interactions between cariogenic bacteria in dental plaque and fermentable carbohydrates (mainly sugars). Regular toothbrushing with fluoride toothpaste is the principal non‐professional intervention to prevent caries, but the caries‐preventive effect varies according to different concentrations of fluoride in toothpaste, with higher concentrations associated with increased caries control. Toothpastes with higher fluoride concentration increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Objectives To determine and compare the effects of toothpastes of different fluoride concentrations (parts per million (ppm)) in preventing dental caries in children, adolescents, and adults. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 August 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7) in the Cochrane Library (searched 15 August 2018); MEDLINE Ovid (1946 to 15 August 2018); and Embase Ovid (1980 to 15 August 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 August 2018). No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials that compared toothbrushing with fluoride toothpaste with toothbrushing with a non‐fluoride toothpaste or toothpaste of a different fluoride concentration, with a follow‐up period of at least 1 year. The primary outcome was caries increment measured by the change from baseline in the decayed, (missing), and filled surfaces or teeth index in all permanent or primary teeth (D(M)FS/T or d(m)fs/t). Data collection and analysis Two members of the review team, independently and in duplicate, undertook the selection of studies, data extraction, and risk of bias assessment. We graded the certainty of the evidence through discussion and consensus. The primary effect measure was the mean difference (MD) or standardised mean difference (SMD) caries increment. Where it was appropriate to pool data, we used random‐effects pairwise or network meta‐analysis. Main results We included 96 studies published between 1955 and 2014 in this updated review. Seven studies with 11,356 randomised participants (7047 evaluated) reported the effects of fluoride toothpaste up to 1500 ppm on the primary dentition; one study with 2500 randomised participants (2008 evaluated) reported the effects of 1450 ppm fluoride toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants (40,066 evaluated) reported the effects of toothpaste up to 2400 ppm on the immature permanent dentition; and three studies with 2675 randomised participants (2162 evaluated) reported the effects of up to 1100 ppm fluoride toothpaste on the mature permanent dentition. Follow‐up in most studies was 36 months. In the primary dentition of young children, 1500 ppm fluoride toothpaste reduces caries increment when compared with non‐fluoride toothpaste (MD ‐1.86 dfs, 95% confidence interval (CI) ‐2.51 to ‐1.21; 998 participants, one study, moderate‐certainty evidence); the caries‐preventive effects for the head‐to‐head comparison of 1055 ppm versus 550 ppm fluoride toothpaste are similar (MD ‐0.05, dmfs, 95% CI ‐0.38 to 0.28; 1958 participants, two studies, moderate‐certainty evidence), but toothbrushing with 1450 ppm fluoride toothpaste slightly reduces decayed, missing, filled teeth (dmft) increment when compared with 440 ppm fluoride toothpaste (MD ‐0.34, dmft, 95%CI ‐0.59 to ‐0.09; 2362 participants, one study, moderate‐certainty evidence). The certainty of the remaining evidence for this comparison was judged to be low. We included 81 studies in the network meta‐analysis of D(M)FS increment in the permanent dentition of children and adolescents. The network included 21 different comparisons of seven fluoride concentrations. The certainty of the evidence was judged to be low with the following exceptions: there was high‐ and moderate‐certainty evidence that 1000 to 1250 ppm or 1450 to 1500 ppm fluoride toothpaste reduces caries increments when compared with non‐fluoride toothpaste (SMD ‐0.28, 95% CI ‐0.32 to ‐0.25, 55 studies; and SMD ‐0.36, 95% CI ‐0.43 to ‐0.29, four studies); there was moderate‐certainty evidence that 1450 to 1500 ppm fluoride toothpaste slightly reduces caries increments when compared to 1000 to 1250 ppm (SMD ‐0.08, 95% CI ‐0.14 to ‐0.01, 10 studies); and moderate‐certainty evidence that the caries increments are similar for 1700 to 2200 ppm and 2400 to 2800 ppm fluoride toothpaste when compared to 1450 to 1500 ppm (SMD 0.04, 95% CI ‐0.07 to 0.15, indirect evidence only; SMD ‐0.05, 95% CI ‐0.14 to 0.05, two studies). In the adult permanent dentition, 1000 or 1100 ppm fluoride toothpaste reduces DMFS increment when compared with non‐fluoride toothpaste in adults of all ages (MD ‐0.53, 95% CI ‐1.02 to ‐0.04; 2162 participants, three studies, moderate‐certainty evidence). The evidence for DMFT was low certainty. Only a minority of studies assessed adverse effects of toothpaste. When reported, effects such as soft tissue damage and tooth staining were minimal. Authors' conclusions This Cochrane Review supports the benefits of using fluoride toothpaste in preventing caries when compared to non‐fluoride toothpaste. Evidence for the effects of different fluoride concentrations is more limited, but a dose‐response effect was observed for D(M)FS in children and adolescents. For many comparisons of different concentrations the caries‐preventive effects and our confidence in these effect estimates are uncertain and could be challenged by further research. The choice of fluoride toothpaste concentration for young children should be balanced against the risk of fluorosis. Plain language summary Fluoride toothpastes of different strengths for preventing tooth decay Review question 
 This review has been produced to assess the effects of toothpastes of different fluoride strengths on preventing tooth decay in children, adolescents and adults. Background 
 Tooth decay (caries) is a widespread disease, affecting billions of people worldwide. Fluoride has long been used to prevent decay, through a variety of different methods including toothpaste, water, milk, mouthrinses, tooth gels and varnish. Regular toothbrushing is recommended to prevent decay and other oral diseases, and toothbrushing for 2 minutes twice daily with a fluoride toothpaste is generally recommended. The typical strength of regular or family toothpaste is around 1000 to 1500 parts per million (ppm) fluoride, but many other strengths are available worldwide. There is no minimum fluoride concentration, but the maximum permissible fluoride concentration for a toothpaste varies according to age and country. Higher concentrations are rarely available over the counter, and are classed as a prescription‐only medicine. Stronger fluoride toothpaste may offer greater protection against decay but also increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Study characteristics 
 Authors from Cochrane Oral Health carried out this review and the evidence is current up to 15 August 2018. It includes 96 studies published between 1955 and 2014: seven studies with 11,356 randomised participants reported the effects of fluoride toothpaste up to 1500 ppm on the primary teeth; one study with 2500 randomised participants reported the effects of 1450 ppm toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants reported the effects of toothpaste up to 2400 ppm on the permanent teeth of children up to 18 years of age; and three studies with 2675 randomised participants reported the effects of up to 1100 ppm toothpaste on the permanent teeth of adults. Most studies assessed decay after participants had been using the toothpastes for 36 months. Main results 
 We present below findings for which there is moderate‐ or high‐certainty evidence. In primary teeth of young children, brushing teeth with a toothpaste containing 1500 ppm fluoride reduced the amount of new decay when compared with non‐fluoride toothpaste; the amount of new decay was similar with 1055 ppm compared with 550 ppm fluoride toothpaste; and there was a slight reduction in the amount of new decay with 1450 ppm toothpaste compared with 440 ppm fluoride toothpaste. Eighty‐one studies assessed the effects of different strengths of fluoride toothpaste compared against each other (seven different strengths in 21 combinations) in permanent teeth of children and adolescents. We found that there was less new decay when toothbrushing with toothpaste containing 1000 to 1250 ppm or 1450 to 1500 ppm fluoride compared with non‐fluoride toothpaste, and that toothbrushing with 1450 to 1500 ppm fluoride toothpaste reduced the amount of new decay more than 1000 to 1250 ppm toothpaste. We found that there was a similar amount of new decay when children and adolescents used a toothpaste of 1700 to 2200 ppm or 2400 to 2800 ppm fluoride compared to 1450 to 1500 ppm toothpaste. The evidence for the effects of other strengths of toothpaste was less certain. In permanent teeth of adults of all ages, 1000 or 1100 ppm toothpaste reduced decay compared with non‐fluoride toothpaste. Most studies did not measure harmful effects of toothpaste use, but when reported, effects such as soft tissue damage and tooth staining were minimal. Certainty of the evidence 
 There is high‐certainty evidence that toothpaste containing 1000 to 1250 ppm fluoride is more effective than non‐fluoride toothpaste. There is moderate‐certainty evidence for the other findings reported in 'Main results' above. For other toothpaste strengths compared against each other or against non‐fluoride toothpaste, there are too few studies with too few participants to have any clarity about the effects. Authors conclusions 
 There are benefits of using fluoride toothpaste at certain strengths to prevent tooth decay when compared with non‐fluoride toothpaste. The stronger the fluoride concentration, the more decay is prevented. For many of the comparisons of different strengths of toothpaste, the findings are uncertain and could be challenged by further research. The choice of fluoride toothpaste for young children should be balanced against the risk of fluorosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Walsh, T; Worthington, HV; Glenny, AM; Marinho, VCC; Jeroncic, A", "articleTypes": [], "doi": "10.1002/14651858.CD007868.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "b8b650ad-0c5d-4915-9cb5-53cf7cd3c359", "pmid": "", "title": "Nirmatrelvir combined with ritonavir for preventing and treating COVID‐19", "imported": false, "abstract": "Abstract - Background Oral nirmatrelvir/ritonavir (Paxlovid) aims to avoid severe COVID‐19 in asymptomatic people or those with mild symptoms, thereby decreasing hospitalization and death. It remains to be evaluated for which indications and patient populations the drug is suitable. Objectives To assess the efficacy and safety of nirmatrelvir/ritonavir plus standard of care (SoC) compared to SoC with or without placebo, or any other intervention for treating COVID‐19 or preventing SARS‐CoV‐2 infection. To explore equity aspects in subgroup analyses. To keep up to date with the evolving evidence base using a living systematic review (LSR) approach and make new relevant studies available to readers in‐between publication of review updates. Search methods We searched the Cochrane COVID‐19 Study Register, Scopus, and World Health Organization COVID‐19 Research Database, identifying completed and ongoing studies without language restrictions and incorporating studies up to 15 May 2023. This is a LSR. We conduct update searches every two months and make them publicly available on the open science framework (OSF) platform. Selection criteria We included randomized controlled trials (RCTs) comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo, or any other intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. We screened all studies for research integrity. Studies were ineligible if they had been retracted, or if they were not prospectively registered including appropriate ethics approval. Data collection and analysis We followed standard Cochrane methodology and used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the following outcomes: 1. to treat outpatients with mild COVID‐19; 2. to treat inpatients with moderate to severe COVID‐19: mortality, clinical worsening or improvement, quality of life, (serious) adverse events, and viral clearance; 3. to prevent SARS‐CoV‐2 infection in postexposure prophylaxis (PEP); and 4. pre‐exposure prophylaxis (PrEP) scenarios: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, mortality, admission to hospital, quality of life, and (serious) adverse events. We explored inequity by subgroup analysis for elderly people, socially‐disadvantaged people with comorbidities, populations from low‐income countries and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. Main results As of 15 May 2023, we included two RCTs with 2510 participants with mild and mild to moderate symptomatic COVID‐19 in outpatient and inpatient settings comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo. All trial participants were without previous confirmed SARS‐CoV‐2 infection and at high risk for progression to severe disease. Randomization coincided with the Delta wave for outpatients and Omicron wave for inpatients. Outpatient trial participants and 73% of inpatients were unvaccinated. Symptom onset in outpatients was no more than five days before randomisation and prior or concomitant therapies including medications highly dependent on CYP3A4 were not allowed. We excluded two studies due to concerns with research integrity. We identified 13 ongoing studies. Three studies are currently awaiting classification. Nirmatrelvir/ritonavir for treating people with asymptomatic or mild COVID‐19 in outpatient settings Nirmatrelvir/ritonavir plus SoC compared to SoC plus placebo may reduce all‐cause mortality at 28 days (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.68; 1 study, 2224 participants; low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.13, 95% CI 0.07 to 0.27; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC may reduce serious adverse events during the study period compared to SoC plus placebo (RR 0.24, 95% CI 0.15 to 0.41; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably has little or no effect on treatment‐emergent adverse events (RR 0.95, 95% CI 0.82 to 1.10; 1 study, 2224 participants; moderate‐certainty evidence), and probably increases treatment‐related adverse events such as dysgeusia and diarrhoea during the study period compared to SoC plus placebo (RR 2.06, 95% CI 1.44 to 2.95; 1 study, 2224 participants; moderate‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably decreases discontinuation of study drug due to adverse events compared to SoC plus placebo (RR 0.49, 95% CI 0.30 to 0.80; 1 study, 2224 participants; moderate‐certainty evidence). No studies reported improvement of clinical status, quality of life, or viral clearance. Nirmatrelvir/ritonavir for treating people with moderate to severe COVID‐19 in inpatient settings We are uncertain whether nirmatrelvir/ritonavir plus SoC compared to SoC reduces all‐cause mortality at 28 days (RR 0.63, 95% CI 0.21 to 1.86; 1 study, 264 participants; very low‐certainty evidence), or increases viral clearance at seven days (RR 1.06, 95% CI 0.71 to 1.58; 1 study, 264 participants; very low‐certainty evidence) and 14 days (RR 1.05, 95% CI 0.92 to 1.20; 1 study, 264 participants; very low‐certainty evidence). No studies reported improvement or worsening of clinical status and quality of life. We did not include data for safety outcomes due to insufficient and inconsistent information. Subgroup analyses for equity For outpatients, the outcome 'admission to hospital or death' was investigated for equity regarding age (less than 65 years versus 65 years or greater) and ethnicity. There were no subgroup differences for age or ethnicity. For inpatients, the outcome 'all‐cause mortality' was investigated for equity regarding age (65 years or less versus greater than 65 years). There was no difference between subgroups of age. No further equity‐related subgroups were reported, and no subgroups were reported for other outcomes. Nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection (PrEP and PEP) No studies available. Authors' conclusions Low‐certainty evidence suggests nirmatrelvir/ritonavir reduces the risk of all‐cause mortality and hospital admission or death in high‐risk, unvaccinated COVID‐19 outpatients infected with the Delta variant of SARS‐CoV‐2. There is low‐ to moderate‐certainty evidence of the safety of nirmatrelvir/ritonavir. Very low‐certainty evidence exists regarding the effects of nirmatrelvir/ritonavir on all‐cause mortality and viral clearance in mildly to moderately affected, mostly unvaccinated COVID‐19 inpatients infected with the Omicron variant of SARS‐CoV‐2. Insufficient and inconsistent information prevents the assessment of safety outcomes. No reliable differences in effect size and direction were found regarding equity aspects. There is no available evidence supporting the use of nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection. We are continually updating our search and making search results available on the OSF platform. Plain language summary Is the combination of nirmatrelvir plus ritonavir effective for treating or preventing COVID‐19? Key messages Nirmatrelvir/ritonavir (Paxlovid) is evaluated for the treatment of coronavirus disease 2019 (COVID‐19). Nirmatrelvir/ritonavir may lead to fewer deaths and improve patient condition, as assessed by need for hospitalization or death within 28 days for unvaccinated outpatients at increased risk for disease progression receiving treatment within five days of symptom onset. We are very uncertain about the effectiveness of nirmatrelvir/ritonavir in inpatients. We excluded two studies due to concerns with research integrity. We found 13 ongoing studies. What is nirmatrelvir/ritonavir? The combination of nirmatrelvir with ritonavir is a new medicine developed to treat infection with the SARS‐CoV‐2 virus and aims to avoid severe COVID‐19 in people without symptoms, or those with mild symptoms. Ritonavir increases the effectiveness of nirmatrelvir but it can interact with many other medicines, which can increase side effects. What did we want to find out? We wanted to know if nirmatrelvir/ritonavir reduces death, illness, and length of infection in people with COVID‐19, or if it is useful in prevention of the disease. We included studies comparing the medicine with placebo (dummy treatment), no treatment, usual care, or any other treatments for COVID‐19. We addressed equity and wanted to know whether there are certain groups of people for which nirmatrelvir/ritonavir works best or is less effective. We looked at elderly people, socially disadvantaged people with other illnesses (comorbidities), people from low‐income and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. We evaluated the effects of nirmatrelvir/ritonavir in people with COVID‐19 regarding: – people dying; – whether COVID‐19 symptoms got better or worse; – quality of life; – unwanted effects of the medicine; – virus elimination. For prevention, we sought the effect on preventing COVID‐19 and SARS‐CoV‐2 infection. What did we do? We searched for randomized controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that investigated nirmatrelvir/ritonavir to prevent or treat COVID‐19. People receiving nirmatrelvir/ritonavir as treatment had to have laboratory‐confirmed COVID‐19 and be treated in hospital or as outpatients. People receiving nirmatrelvir/ritonavir to prevent an infection had to have a high risk of contracting the disease or had to have had a high‐risk contact with a person with confirmed COVID‐19. We summarized the results of the studies and rated our confidence in the evidence, based on common criteria as to how reliable the evidence was. We examined differences with respect to age, level of comorbidity, country according to the World Bank country classification by income level, and ethnicity. What did we find? We found two studies with 2510 participants that investigated nirmatrelvir/ritonavir compared to placebo or standard of care for the treatment of COVID‐19 in people without previous confirmed SARS‐CoV‐2 infection and at increased risk for progression to severe disease due to a comorbidity or risk factor such as current smoking. Included outpatients were enrolled during the Delta wave, unvaccinated, and had a symptom onset of up to five days before starting treatment. Included inpatients were enrolled during the Omicron wave, mostly unvaccinated, and mildly to moderately affected. We found 13 ongoing studies that have not yet been completed, and three studies are currently awaiting classification. Main results Treating outpatients with COVID‐19 For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir may: – lead to fewer deaths; – improve patients' condition assessed by need for admission to hospital or death within 28 days; – reduce serious unwanted events. For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir probably: – has little effect on any unwanted events; – increases any treatment‐related unwanted events (mostly taste disturbance and diarrhoea); – decreases discontinuation of study medicine due to unwanted events. Equity aspects Most study participants were younger than 65 years and of white ethnicity. There was no difference in effectiveness between younger and older participants and participants from different ethnic groups. No subgroups were reported for different levels of comorbidity and World Bank country classification by income level. Treating inpatients with COVID‐19 We are uncertain whether, for the specific population of mildly to moderately affected, high‐risk patients, nirmatrelvir/ritonavir: – leads to fewer deaths; and – increases virus elimination Equity aspects Most study participants were older than 65 years. There was no difference in effectiveness between younger and older participants. No subgroups were reported for different levels of comorbidity, ethnicity, and World Bank country classification by income level. No subgroups were reported for other outcomes. What are the limitations of the evidence? Our confidence in the evidence is low to moderate for outpatients and very low for inpatients. The studies did not report everything we were interested in, such as quality of life and symptom resolution, and had a highly specific population of people at high risk of progression to severe COVID‐19. How up to date is this evidence? The evidence is up to date to 15 May 2023. According to this review's living approach, we will update our search every two months. We are making search results and new relevant studies publicly available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Reis, S, Metzendorf, M-I, Kuehn, R, Popp, M, Gagyor, I, Kranke, P, Meybohm, P, Skoetz, N, Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015395.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.137Z" }, { "id": "b8c0fc90-391f-4dc2-b16b-c293b6e6395f", "pmid": "", "title": "Vasodilators for primary Raynaud's phenomenon", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Su, KYC, Sharma, M, Kim, HJ, Kaganov, E, Hughes, I, Abdeen, MH, Ng, JH", "articleTypes": [], "doi": "10.1002/14651858.CD006687.pub4 AB - Abstract - Background Numerous agents have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered to be the drugs of choice, evidence of the effects of alternative pharmacological treatments is limited. This is an update of a review first published in 2008. Objectives To assess the effects of drugs with vasodilator effects on primary Raynaud's phenomenon as determined by frequency, severity, and duration of vasospastic attacks; quality of life; adverse events; and Raynauds Condition Score. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trial register to November 16, 2020. Selection criteria We included randomized controlled trials evaluating effects of oral, intravenous, and topical formulations of any drug with vasodilator effects on subjective symptoms, severity scores, and radiological outcomes in primary Raynaud's phenomenon. Treatment with calcium channel blockers was not assessed in this review, nor were these agents compared. Data collection and analysis Two review authors independently selected studies for inclusion, assessed studies using the Cochrane \"Risk of bias\" tool, and extracted study data. Outcomes of interest included frequency, severity, and duration of attacks; quality of life (QoL); adverse events (AEs); and the Raynaud Condition Score (RCS). We assessed the certainty of the evidence using GRADE. Main results We identified seven new studies for this update. In total, we included 15 studies involving 635 participants. These studies compared different vasodilators to placebo. Individual studies used different methods and measures to report different outcomes. Angiotensin‐converting enzyme (ACE) inhibitors Combining data from three studies revealed a possible small increase in the frequency of attacks per week after treatment (captopril or enalapril) compared to placebo (mean difference [MD] 0.79, 95% confidence interval [CI] 0.43 to 1.17; low‐certainty evidence). There was no evidence of a difference between groups in severity of attacks (MD ‐0.17, 95% CI ‐4.66 to 4.31; 34 participants, 2 studies; low‐certainty evidence); duration of attacks (MD 0.54, 95% CI ‐2.42 to 1.34; 14 participants, 1 study; low‐certainty evidence); or AEs (risk ratio [RR] 1.35, 95% CI 0.67 to 2.73; 46 participants, 3 studies; low‐certainty evidence). QoL and RCS were not reported. Alpha blockers Two studies used alpha blockers (buflomedil or moxisylyte). We were unable to combine data due to the way results were presented. Buflomedil probably reduced the frequency of attacks compared to placebo (MD ‐8.82, 95% CI ‐11.04 to ‐6.60; 31 participants, 1 study; moderate‐certainty evidence) and may improve severity scores (MD ‐0.41, 95% CI ‐0.62 to ‐0.30; moderate‐certainty evidence). With moxisylyte, investigators reported fewer attacks (P < 0.02), less severe symptoms (P < 0.01), and shorter duration of attacks, but the clinical relevance of these results is unclear. No evidence of a difference in AEs between buflomedil and placebo groups was noted (RR 1.41, 95% CI 0.27 to 7.28; 31 participants, 1 study; moderate‐certainty evidence). More AEs were observed in participants in the moxisylyte group than in the placebo group. Prostaglandin/prostacyclin analogues One study compared beraprost versus placebo. There was no evidence of benefit for frequency (MD 2.00, 95% CI ‐0.35 to 4.35; 118 participants, low‐certainty evidence) or severity (MD ‐0.06, 95% CI ‐0.34 to 0.22; 118 participants, low‐certainty evidence) of attacks. Overall, more AEs were noted in the beraprost group (RR 1.59, 95% CI 1.05 to 2.42; 125 participants; low‐certainty evidence). This study did not report on duration of attacks, QoL, or RCS. Thromboxane synthase inhibitors One study compared a thromboxane synthase inhibitor (dazoxiben) versus placebo. There was no evidence of benefit for frequency of attacks (MD 0.8, 95% CI ‐1.81 to 3.41; 6 participants; very low‐certainty evidence). Adverse events were not reported in subgroup analyses of participants with primary Raynaud's phenomenon, and the study did not report on duration of attacks, severity of symptoms, QoL, or RCS. Selective serotonin reuptake inhibitors One study compared ketanserin with placebo. There may be a slight reduction in the number of attacks per week with ketanserin compared to placebo (MD ‐14.0, 95% CI ‐27.72 to ‐0.28; 41 participants; very low‐certainty evidence) and reduced severity score (MD ‐133.00, 95% CI ‐162.40 to ‐103.60; 41 participants; very low‐certainty evidence). There was no evidence that ketanserin reduced the duration of attacks (MD ‐4.00, 95% CI ‐14.82 to 6.82; 41 participants; very low‐certainty evidence), or that AEs were increased in either group (RR 1.54, 95% CI 0.89 to 2.65; 41 participants; very low‐certainty evidence). This study did not report on QoL or RCS. Nitrate/nitrate derivatives Four studies compared topical treatments of nitroglycerin or glyceryl trinitrate versus placebo, each reporting on limited outcomes. Meta‐analysis demonstrated no evidence of effect on frequency of attacks per week (MD ‐1.57, 95% CI ‐4.31 to 1.17; 86 participants, 2 studies; very low‐certainty evidence). We were unable to pool any data for the remaining outcomes. Phosphodiesterase inhibitors Three studies compared phosphodiesterase inhibitors (vardenafil, cilostazol or PF‐00489791) to an equivalent placebo. Results showed no evidence of a difference in frequency of attacks (standardized MD [SMD] ‐0.05, 95% CI ‐6.71 to 6.61; 111 participants, 2 studies; low‐certainty evidence), severity of attacks (MD ‐0.03, 95% CI ‐1.04 to 0.97; 111 participants, 2 studies; very low‐certainty evidence), duration of attacks (MD ‐1.60, 95% CI ‐7.51 to 4.31; 73 participants, 1 study; low‐certainty evidence), or RCS (SMD ‐0.8, 95% CI ‐1.74 to 0.13; 79 participants, 2 studies; low‐certainty evidence). Study authors reported that 35% of participants on cilostazol complained of headaches, which were not reported in the placebo group. PF‐00489791 caused 34 of 54 participants to experience AEs versus 43 of 102 participants receiving placebo (RR 1.49). Headache was most common, affecting 14 participants (PF‐00489791) versus nine participants (placebo). Authors' conclusions The included studies investigated several different vasodilators (topical and oral) for treatment of primary Raynaud's phenomenon. Small sample sizes, limited data, and variability in outcome reporting yielded evidence of very low to moderate certainty. Evidence is insufficient to support the use of vasodilators and suggests that vasodilator use may even worsen disease. Plain language summary Vasodilator drugs to reduce the symptoms of primary Raynaud's phenomenon Background Raynaud's phenomenon (RP) is a condition affecting the small blood vessels in the extremities, usually in the fingers but also in the toes and other body parts. It is caused by temporary narrowing of the blood vessels, which leads to color changes with associated numbness, tingling, and pain. Various triggers for this condition are known, such as stress, cold, and use of vibrational hand tools. Conservative measures to control this condition include stopping smoking and maintaining both peripheral and ambient warmth. Medications that dilate the blood vessels such as calcium channel blockers (CCBs) may be used but can have side effects. This review aims to investigate the effectiveness and safety of drugs that dilate the blood vessels other than CCBs. Study characteristics and key results We found seven new studies for this update, bringing the total to 15 (search was good to November 16, 2020). This update now includes other routes of administration such as through the veins (intravenous) and the skin (topical), in contrast to previous reviews, which focused on oral forms of treatment. The studies were published between 1989 and 2013 and involved a total of 635 participants randomly assigned to receive treatment or placebo control. Many studies did not describe various aspects of study methods such as randomization, allocation concealment, and blinding. Treatment duration varied between two weeks and six months.
Angiotensin‐converting enzyme (ACE) inhibitors as a drug class, specifically enalapril and captopril in this review, in general increased the frequency of Raynaud's attacks per week but did not affect the severity of the attacks. Enalapril worsened subjective assessment of improvement, and captopril did not improve subjective outcomes or digital blood flow. Buflomedil showed a small reduction in the frequency and severity of attacks with increased side effects. Beraprost and dazoxiben did not demonstrate any change in frequency or severity of attacks nor in disability score and were associated with increased side effects. Ketanserin did not demonstrate improvement in frequency or duration of attacks nor in digital blood flow but did demonstrate improvement in severity scoring of RP. In a small study, moxisylyte was shown to reduce the frequency and severity of attacks to a small degree but with increased side effects. Topical glyceryl trinitrate did not show any effect on reducing the frequency of attacks per week. One study reported subjective improvement in Raynaud Condition Score (RCS). One small study reported improvements in frequency and severity of attacks as subjective changes. Headaches were the most significant and common side effect of treatment. Phosphodiesterase inhibitors did not cause a reduction in frequency, severity, or duration of attacks and did not improve RCS. One study reported in favor of vardenafil alone to reduce RCS but found that the effect is likely small. One study reported that cilostazol increased the frequency and severity of attacks; more research is needed to confirm this finding. Risk of headache as a side effect of treatment was increased with cilostazol use. PF‐00489791 at a dose of 20 mg was found to slightly improve all subjective outcome measures and RCS. Reliability of the evidence We have very low to moderate confidence in these results, so we cannot make any firm conclusions about the benefit of these drugs for improving symptoms of primary RP. We cannot be confident because of the small numbers of participants involved in studies, issues with how studies were designed, and differences in how they measured whether or not treatments were effective. Therefore, the clinical importance of these results is difficult to assess, especially when placebo response is high. It is also pertinent that the results for each drug class and for individual drugs within each drug class must be interpreted in the context that they may have varying pharmacologic effects in addition to vasodilation. This must be taken into consideration when any conclusions are made about the overall effects of each drug class and/or individual drug.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.126Z" }, { "id": "b8c124cb-bc86-4a03-b50b-7568d3ff89bd", "pmid": "", "title": "Interventions for acute otitis externa", "imported": false, "abstract": "Abstract - Background Acute otitis externa is an inflammatory condition of the ear canal, with or without infection. Symptoms include ear discomfort, itchiness, discharge and impaired hearing. It is also known as 'swimmer's ear' and can usually be treated successfully with a course of ear drops. Objectives To assess the effectiveness of interventions for acute otitis externa. Search methods Our search for published and unpublished trials included the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources. The date of the most recent search was 6 January 2009. Selection criteria Randomised controlled trials evaluating ear cleaning, topical medication or systemic therapy in the treatment of acute otitis externa were eligible. We excluded complicated acute otitis externa; otitis externa secondary to otitis media or chronic suppurative otitis media; chronic otitis externa; fungal otitis externa (otomycosis); eczematous otitis externa; viral otitis externa and furunculosis. Data collection and analysis Two authors assessed eligibility and quality. Main results Nineteen randomised controlled trials with a total of 3382 participants were included. Three meta‐analyses were possible. The overall quality of studies was low. Topical antimicrobials containing steroids were significantly more effective than placebo drops: OR 11 (95% CI 2.00 to 60.57; one trial). In general, no clinically meaningful differences were noted in clinical cure rates between the various topical interventions reviewed. One notable exception involved a trial of high quality which showed that acetic acid was significantly less effective when compared with antibiotic/steroid drops in terms of cure rate at two and three weeks (OR 0.29 (95% CI 0.13 to 0.62) and OR 0.25 (95% CI 0.11 to 0.58) respectively). One trial of low quality comparing quinolone with non‐quinolone antibiotics did not find any difference in clinical cure rate. No trials evaluated the effectiveness of ear cleaning. Only two trials evaluated steroid‐only drops. One trial of low quality suggested no significant difference between steroid and antibiotic/steroid but did not report the magnitude or precision of the result. Another trial of moderate quality comparing an oral antihistamine with topical steroid against topical steroid alone found that cure rates in both groups were high and comparable (100% (15/15) and 94% (14/15) respectively at three weeks). Authors' conclusions There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available: Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow‐up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid. The evidence for steroid‐only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed. Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision. Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated. Plain language summary Interventions to treat acute otitis externa, a specific form of ear canal inflammation also known as swimmer's ear Acute otitis externa causes inflammation of the ear canal. It is a common clinical problem encountered in general practice. This review assesses the various forms of medication used to treat the condition. Nineteen randomised controlled trials were included (3382 participants). Most were of low quality. The findings of the review may not be wholly relevant to primary care as most of the trials were conducted in a hospital setting and over half involved ear cleaning as part of the treatment (this is generally not available in primary care). However, the review does demonstrate that topical treatments alone are effective at treating acute otitis externa. There was little to choose between them in terms of effectiveness. However, when treatment needs to be extended beyond one week acetic acid drops appear to be less effective than antibiotic/steroid drops. In addition, symptoms persist for two days longer in those treated with acetic acid. More research is needed to determine the effectiveness of steroid‐only drops. Patients treated with antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Kaushik, V, Malik, T, Saeed, SR", "articleTypes": [], "doi": "10.1002/14651858.CD004740.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.814Z" }, { "id": "b8d779b6-9bae-425e-ae4e-dd4531d81268", "pmid": "", "title": "Interventions to prevent obesity in children aged 5 to 11 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well‐being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review. Objectives To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta‐analyses. One hundred forty‐six studies were based in high‐income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0, 95% confidence interval (CI) ‐0.10 to 0.10; 5 studies, 2107 participants; low‐certainty evidence) and at medium‐term follow‐up (MD ‐0.01, 95% CI ‐0.15 to 0.12; 9 studies, 6815 participants; low‐certainty evidence) or zBMI at long‐term follow‐up (MD ‐0.05, 95% CI ‐0.10 to 0.01; 7 studies, 5285 participants; low‐certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long‐term follow‐up (MD ‐0.17, 95% CI ‐0.48 to 0.13; 2 studies, 945 participants; moderate‐certainty evidence) and zBMI at short‐ or medium‐term follow‐up (MD ‐0.06, 95% CI ‐0.13 to 0.01; 8 studies, 3695 participants; MD ‐0.04, 95% CI ‐0.10 to 0.02; 9 studies, 7048 participants; moderate‐certainty evidence). Five studies (1913 participants; very low‐certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short‐term or long‐term follow‐up (BMI short‐term: MD ‐0.02, 95% CI ‐0.17 to 0.13; 14 studies, 4069 participants; zBMI short‐term: MD ‐0.02, 95% CI ‐0.07 to 0.02; 6 studies, 3580 participants; low‐certainty evidence; BMI long‐term: MD ‐0.07, 95% CI ‐0.24 to 0.10; 8 studies, 8302 participants; zBMI long‐term: MD ‐0.02, 95% CI ‐0.09 to 0.04; 6 studies, 6940 participants; low‐certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.18 to ‐0.05; 16 studies, 21,286 participants; zBMI: MD ‐0.05, 95% CI ‐0.09 to ‐0.02; 13 studies, 20,600 participants; moderate‐certainty evidence). Eleven studies (21,278 participants; low‐certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to ‐0.01; 27 studies, 16,066 participants; zBMI: MD ‐0.03, 95% CI ‐0.06 to 0.00; 26 studies, 12,784 participants; low‐certainty evidence) and likely result in a reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD ‐0.05, 95% CI ‐0.07 to ‐0.02; 24 studies, 20,998 participants; moderate‐certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long‐term follow‐up (BMI: MD 0.03, 95% CI ‐0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD ‐0.02, 95% CI ‐0.06 to 0.01; 22 studies, 23,594 participants; low‐certainty evidence). Nineteen studies (27,882 participants; low‐certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow‐up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high‐income versus non‐high‐income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability. Authors' conclusions The body of evidence in this review demonstrates that a range of school‐based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short‐ and medium‐term, but not at long‐term follow‐up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community‐based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities. Plain language summary Do dietary and activity strategies help prevent obesity in children aged 5 to 11 years? Key messages ‐ Strategies for changing activity levels, or both activity levels and diet, of children to help prevent them developing overweight or obesity might be effective in making small reductions in body mass index (BMI) in children aged 5 to 11 years. ‐ There is very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but from what we found there appears to be little or no effect. ‐ This change in BMI, when provided to many children across a whole population, is useful for parents concerned about their children becoming overweight as they move into adulthood and for governments in trying to tackle the problems of obesity through the life course. Why is preventing obesity in children important? More children are developing overweight and obesity worldwide. Being overweight as a child can cause health problems, and people may be affected psychologically and in their social life. Children that are overweight are likely to be overweight as adults and continue to experience poor physical and mental health. Indeed, childhood obesity is associated with type 2 diabetes and heart disease in adulthood and middle‐age mortality. What did we want to find out? We wanted to find out if strategies to help people modify their diet or activity (or both) are effective at preventing obesity in children aged 5 to 11 years. We also wanted to find out if these strategies were associated with any serious adverse events. What did we do? We searched many scientific databases to find studies that looked at ways of preventing obesity in children. We included studies aimed at children aged 5 to 11 years. We did not include studies only aimed at children who were already overweight or were already living with obesity. However, we included studies in which children who were overweight or living with obesity were included in the analysis. We only included studies if the methods they used were aimed at changing children's diet, or their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed people into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 172 studies that involved 189,707 children. One hundred forty‐six studies were based in high‐income countries (e.g. the USA and in Europe). In 111 studies, the strategies were tried in schools, though 15 were based in the community, eight in the home and seven in clinical settings; one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six strategies were implemented for less than nine months, with the shortest being conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry (e.g. food suppliers, pharmaceutical industry and private healthcare services). Our statistical analyses included results from 149 studies of 160,267 children. We found that children who were helped with a strategy to change their activity levels alone or in combination with a strategy to change their diet may have their BMI reduced, compared with children who were not given any strategy. This means that these children may have been able to minimise their excess weight gain by a small amount which, for public health, is important. In contrast, children who were helped with a strategy to change their diet only did not have their BMI reduced. Only a few studies reported any possible harms of the strategies, and no serious harms were identified in these. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low. However, it is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. A lot of the studies had limitations in how they were done. 3. There were not enough studies reporting particular types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons, and also certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way such that we could include them in our analyses (e.g. without any detail of the difference between the strategies examined) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for children with disabilities, or whether those implemented in community settings are effective. How up‐to‐date is this evidence? This review updates our previous review. The evidence is up‐to‐date to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F; Davies, AL; Tomlinson, E; Moore, THM; Dawson, S; Breheny, K; Savović, J; Gao, Y; Phillips, SM; Hillier-Brown, F; Hodder, RK; Wolfenden, L; Higgins, JPT; Summerbell, CD", "articleTypes": [], "doi": "10.1002/14651858.CD015328.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "b8fcd9ab-7bf9-4843-91e0-831baf463b41", "pmid": "", "title": "Hyperimmune immunoglobulin for people with COVID‐19", "imported": false, "abstract": "Abstract - Background Hyperimmune immunoglobulin (hIVIG) contains polyclonal antibodies, which can be prepared from large amounts of pooled convalescent plasma or prepared from animal sources through immunisation. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). This review was previously part of a parent review addressing convalescent plasma and hIVIG for people with COVID‐19 and was split to address hIVIG and convalescent plasma separately. Objectives To assess the benefits and harms of hIVIG therapy for the treatment of people with COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods To identify completed and ongoing studies, we searched the World Health Organization (WHO) COVID‐19 Research Database, the Cochrane COVID‐19 Study Register, the Epistemonikos COVID‐19 L*OVE Platform and Medline and Embase from 1 January 2019 onwards. We carried out searches on 31 March 2022. Selection criteria We included randomised controlled trials (RCTs) that evaluated hIVIG for COVID‐19, irrespective of disease severity, age, gender or ethnicity. We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)), as well as studies that evaluated standard immunoglobulin. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used RoB 2. We rated the certainty of evidence, using the GRADE approach, for the following outcomes: all‐cause mortality, improvement and worsening of clinical status (for individuals with moderate to severe disease), quality of life, adverse events, and serious adverse events. Main results We included five RCTs with 947 participants, of whom 688 received hIVIG prepared from humans, 18 received heterologous swine glyco‐humanised polyclonal antibody, and 241 received equine‐derived processed and purified F(ab’) 2 fragments. All participants were hospitalised with moderate‐to‐severe disease, most participants were not vaccinated (only 12 participants were vaccinated). The studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with mild COVID‐19. We identified a further 10 ongoing studies evaluating hIVIG. Benefits of hIVIG prepared from humans We included data on one RCT (579 participants) that assessed the benefits and harms of hIVIG 0.4 g/kg compared to saline placebo. hIVIG may have little to no impact on all‐cause mortality at 28 days (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.43 to 1.44; absolute effect 77 per 1000 with placebo versus 61 per 1000 (33 to 111) with hIVIG; low‐certainty evidence). The evidence is very uncertain about the effect on worsening of clinical status at day 7 (RR 0.85, 95% CI 0.58 to 1.23; very low‐certainty evidence). It probably has little to no impact on improvement of clinical status on day 28 (RR 1.02, 95% CI 0.97 to 1.08; moderate‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if hIVIG has any impact on quality of life. Harms of hIVIG prepared from humans hIVIG may have little to no impact on adverse events at any grade on day 1 (RR 0.98, 95% CI 0.81 to 1.18; 431 per 1000; 1 study 579 participants; low‐certainty evidence). Patients receiving hIVIG probably experience more adverse events at grade 3‐4 severity than patients who receive placebo (RR 4.09, 95% CI 1.39 to 12.01; moderate‐certainty evidence). hIVIG may have little to no impact on the composite outcome of serious adverse events or death up to day 28 (RR 0.72, 95% CI 0.45 to 1.14; moderate‐certainty evidence). We also identified additional results on the benefits and harms of other dose ranges of hIVIG, not included in the summary of findings table, but summarised in additional tables. Benefits of animal‐derived polyclonal antibodies We included data on one RCT (241 participants) to assess the benefits and harms of receptor‐binding domain‐specific polyclonal F(ab´) 2 fragments of equine antibodies (EpAbs) compared to saline placebo. EpAbs may reduce all‐cause mortality at 28 days (RR 0.60, 95% CI 0.26 to 1.37; absolute effect 114 per 1000 with placebo versus 68 per 1000 (30 to 156) ; low‐certainty evidence). EpAbs may reduce worsening of clinical status up to day 28 (RR 0.67, 95% CI 0.38 to 1.18; absolute effect 203 per 1000 with placebo versus 136 per 1000 (77 to 240); low‐certainty evidence). It may have some effect on improvement of clinical status on day 28 (RR 1.06, 95% CI 0.96 to 1.17; low‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if EpAbs have any impact on quality of life. Harms of animal‐derived polyclonal antibodies EpAbs may have little to no impact on the number of adverse events at any grade up to 28 days (RR 0.99, 95% CI 0.74 to 1.31; low‐certainty evidence). Adverse events at grade 3‐4 severity were not reported. Individuals receiving EpAbs may experience fewer serious adverse events than patients receiving placebo (RR 0.67, 95% CI 0.38 to 1.19; low‐certainty evidence). We also identified additional results on the benefits and harms of other animal‐derived polyclonal antibody doses, not included in the summary of findings table, but summarised in additional tables. Authors' conclusions We included data from five RCTs that evaluated hIVIG compared to standard therapy, with participants with moderate‐to‐severe disease. As the studies evaluated different preparations (from humans or from various animals) and doses, we could not pool them. hIVIG prepared from humans may have little to no impact on mortality, and clinical improvement and worsening. hIVIG may increase grade 3‐4 adverse events. Studies did not evaluate quality of life. RBD‐specific polyclonal F(ab´) 2 fragments of equine antibodies may reduce mortality and serious adverse events, and may reduce clinical worsening. However, the studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern and prior to widespread vaccine rollout. As no studies evaluated hIVIG for participants with asymptomatic infection or mild disease, benefits for these individuals remains uncertain. This is a living systematic review. We search monthly for new evidence and update the review when we identify relevant new evidence. Plain language summary Are concentrated antibodies from people who have recovered from COVID‐19 or animals an effective treatment for people with COVID‐19? Key messages • We do not know whether hyperimmune immunoglobulin (a preparation made with antibodies from people who have recovered from COVID‐19) reduces deaths or serious unwanted effects in people with moderate to severe COVID‐19. But a similar preparation made by injecting animals with certain antibodies may reduce deaths, and serious unwanted effects and may stop people’s condition getting worse. • We found no studies that investigated people with COVID‐19 but without symptoms or people with mild COVID‐19, so we do not know how effective human or animal hyperimmune immunoglobulin is for them. • We found 10 ongoing studies. We will update this review when their results become available. What is hyperimmune immunoglobulin? The body produces antibodies as one of its defences against infection. Antibodies, or 'immunoglobulins', are found in blood plasma. They act as a critical part of the immune response. Plasma from people who have recovered from COVID‐19 contains COVID‐19 antibodies, and can be used to make two preparations. Firstly, it can be used to make convalescent plasma, which is plasma that contains these antibodies. Secondly, it can be used to make hyperimmune immunoglobulin, which is more concentrated, and therefore contains more antibodies. The manufacturing process of hyperimmune immunoglobulin is complex and requires large pools of human plasma. Similar antibodies can be made from animal sources and used in humans. Why is hyperimmune immunoglobulin a possible treatment for COVID‐19? Hyperimmune immunoglobulin products contain high levels of antibodies that target SARS‐CoV‐2, the virus that causes COVID‐19. The products are thought to inactivate the virus particles. What did we want to find out? We wanted to know if hyperimmune immunoglobulin is an effective and helpful treatment for people with suspected or confirmed COVID‐19 in any setting (for example, home or hospital). We were interested in: • death from any cause up 30 days after treatment, 60 days, or longer if reported; • improvement or worsening of symptoms; • quality of life; • unwanted effects. What did we do? We searched for studies that investigated hyperimmune immunoglobulin and usual care compared to usual care only, or in addition to a dummy medicine that did not contain any active ingredients (placebo). To make a fair comparison, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the hyperimmune immunoglobulin or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies. We used a standardised method to rate our confidence in the evidence. The confidence is based on study features such as how it was designed and the number of people in them. What did we find? We found five studies with 957 people. Studies took place in Pakistan, India, France, and Argentina, and one study was conducted in multiple countries, including Denmark, Greece, Japan, Nigeria, Spain, the UK and the USA. The studies took place before or during the emergence of several new COVID‐19 variants and prior to widespread vaccine rollout. All the participants in four studies were unvaccinated. In one study, 12 from 579 participants were vaccinated. We also found 10 ongoing studies. Main results All studies compared hyperimmune immunoglobulin from human or animal sources with usual care or placebo. The studies included only hospitalised people with moderate to severe disease. No studies looked at people without COVID‐19 symptoms or mild COVID‐19. No studies reported on quality of life. We are uncertain whether or not hyperimmune immunoglobulin prepared from humans affects risk of death from any cause up to 28 days after treatment. It may have little to no impact on improvement or worsening of symptoms up to 28 days after treatment. We are uncertain about a possible difference in unwanted or serious unwanted effects. The individual studies decided which events to classify as serious unwanted effects, but this usually means something that may cause hospitalisation or permanent harm. Hyperimmune immunoglobulin from animals may reduce deaths up to 28 days after treatment, may reduce worsening of symptoms, may improve patients' condition and may reduce serious unwanted events. What are the limitations of the evidence? We are uncertain whether hyperimmune immunoglobulin is an effective treatment for people hospitalised with COVID‐19, and whether it affects the number of unwanted or serious unwanted effects because the studies were small and did not all provide evidence on all our points of interest. The studies were conducted predominantly in people from wealthy countries, before the widespread rollout of COVID‐19 vaccines and the emergence of the omicron variant, so the results may not apply to people with omicron variant infection, or people who were vaccinated before falling ill. There was no evidence for people without symptoms or with mild COVID‐19. How up to date is this evidence? Our evidence is up‐to‐date to 31st March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kimber, C; Valk, SJ; Chai, KL; Piechotta, V; Iannizzi, C; Monsef, I; Wood, EM; Lamikanra, AA; Roberts, DJ; McQuilten, Z; So-Osman, C; Estcourt, LJ; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015167.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "b91a342b-6dcb-406f-9927-48169c5473d5", "pmid": "", "title": "Interventions for fatigue in people with kidney failure requiring dialysis", "imported": false, "abstract": "Abstract - Background Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD). Objectives We aimed to evaluate the effects of pharmacological and non‐pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Studies evaluating pharmacological and non‐pharmacological interventions affecting levels of fatigue or fatigue‐related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue‐related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered. Data collection and analysis Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta‐analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Ninety‐four studies involving 8191 randomised participants were eligible. Pharmacological and non‐pharmacological interventions were compared either to placebo or control, or to another pharmacological or non‐pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis‐Related Fatigue scale score): SMD ‐1.18, 95% CI ‐2.04 to ‐0.31; I 2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD ‐1.23, 95% CI ‐1.96 to ‐0.50; I 2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD ‐1.06, 95% CI ‐1.47, ‐0.65; I 2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I 2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD ‐0.64, 95% CI ‐1.03 to ‐0.25; I 2 = 75%) in HD. A wide range of heterogenous interventions and fatigue‐related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non‐pharmacological interventions on fatigue or fatigue‐related outcomes, including non‐physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive‐behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta‐blockers, anabolic steroids, glucose‐enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non‐pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported. Authors' conclusions Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non‐pharmacological interventions had uncertain effects on fatigue or fatigue‐related outcomes in people receiving dialysis. Future adequately powered, high‐quality studies are likely to change the estimated effects of interventions for fatigue and fatigue‐related outcomes in people receiving dialysis. Plain language summary Are interventions for fatigue effective among people with kidney failure requiring dialysis? What is the issue? Fatigue is a frequent and debilitating symptom that can limit life participation in people receiving dialysis. Fatigue is linked to impaired quality of life, cardiovascular disease, death and depression in people on dialysis. Several potential interventions, including drugs or other non‐pharmacological treatments (e.g. exercise, diet, massage, aromatherapy, acupressure), have been evaluated for their effect on fatigue in people on dialysis. What did we do? We evaluated whether drugs or other non‐pharmacological interventions are beneficial for adults and children receiving haemodialysis or peritoneal dialysis to manage fatigue. We evaluated all clinical studies available and summarised the results. We evaluated how certain we could be about the evidence related to interventions for fatigue using a system called \"GRADE\". What did we find? Ninety‐four studies involving 8191 randomised participants were available. Patients in the studies were given a drug, non‐pharmacological intervention, standard care or a sugar pill (placebo). The treatment they received was decided by random chance. The studies were generally short‐term (over a few months). There were no studies in children. Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. Drugs or other non‐pharmacological interventions have uncertain effects on fatigue in people on dialysis. Conclusions Exercise, aromatherapy, massage and acupressure improve fatigue compared to placebo or standard care. It remains uncertain whether drugs or other non‐pharmacological interventions have any impact on fatigue in people on dialysis when compared to a sugar pill, standard care or other treatments for fatigue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Natale, P; Ju, A; Strippoli, GFM; Craig, JC; Saglimbene, VM; Unruh, ML; Stallone, G; Jaure, A", "articleTypes": [], "doi": "10.1002/14651858.CD013074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "b922e2a2-cff5-4867-a951-34a93110028c", "pmid": "", "title": "The effect of sample site and collection procedure on identification of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Sample collection is a key driver of accuracy in the diagnosis of SARS‐CoV‐2 infection. Viral load may vary at different anatomical sampling sites and accuracy may be compromised by difficulties obtaining specimens and the expertise of the person taking the sample. It is important to optimise sampling accuracy within cost, safety and accessibility constraints. Objectives To compare the sensitivity of different sampling collection sites and methods for the detection of current SARS‐CoV‐2 infection with any molecular or antigen‐based test. Search methods Electronic searches of the Cochrane COVID‐19 Study Register and the COVID‐19 Living Evidence Database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) were undertaken on 22 February 2022. We included independent evaluations from national reference laboratories, FIND and the Diagnostics Global Health website. We did not apply language restrictions. Selection criteria We included studies of symptomatic or asymptomatic people with suspected SARS‐CoV‐2 infection undergoing testing. We included studies of any design that compared results from different sample types (anatomical location, operator, collection device) collected from the same participant within a 24‐hour period. Data collection and analysis Within a sample pair, we defined a reference sample and an index sample collected from the same participant within the same clinical encounter (within 24 hours). Where the sample comparison was different anatomical sites, the reference standard was defined as a nasopharyngeal or combined naso/oropharyngeal sample collected into the same sample container and the index sample as the alternative anatomical site. Where the sample comparison was concerned with differences in the sample collection method from the same site, we defined the reference sample as that closest to standard practice for that sample type. Where the sample pair comparison was concerned with differences in personnel collecting the sample, the more skilled or experienced operator was considered the reference sample. Two review authors independently assessed the risk of bias and applicability concerns using the QUADAS‐2 and QUADAS‐C checklists, tailored to this review. We present estimates of the difference in the sensitivity (reference sample (%) minus index sample sensitivity (%)) in a pair and as an average across studies for each index sampling method using forest plots and tables. We examined heterogeneity between studies according to population (age, symptom status) and index sample (time post‐symptom onset, operator expertise, use of transport medium) characteristics. Main results This review includes 106 studies reporting 154 evaluations and 60,523 sample pair comparisons, of which 11,045 had SARS‐CoV‐2 infection. Ninety evaluations were of saliva samples, 37 nasal, seven oropharyngeal, six gargle, six oral and four combined nasal/oropharyngeal samples. Four evaluations were of the effect of operator expertise on the accuracy of three different sample types. The majority of included evaluations (146) used molecular tests, of which 140 used RT‐PCR (reverse transcription polymerase chain reaction). Eight evaluations were of nasal samples used with Ag‐RDTs (rapid antigen tests). The majority of studies were conducted in Europe (35/106, 33%) or the USA (27%) and conducted in dedicated COVID‐19 testing clinics or in ambulatory hospital settings (53%). Targeted screening or contact tracing accounted for only 4% of evaluations. Where reported, the majority of evaluations were of adults (91/154, 59%), 28 (18%) were in mixed populations with only seven (4%) in children. The median prevalence of confirmed SARS‐CoV‐2 was 23% (interquartile (IQR) 13%‐40%). Risk of bias and applicability assessment were hampered by poor reporting in 77% and 65% of included studies, respectively. Risk of bias was low across all domains in only 3% of evaluations due to inappropriate inclusion or exclusion criteria, unclear recruitment, lack of blinding, nonrandomised sampling order or differences in testing kit within a sample pair. Sixty‐eight percent of evaluation cohorts were judged as being at high or unclear applicability concern either due to inflation of the prevalence of SARS‐CoV‐2 infection in study populations by selectively including individuals with confirmed PCR‐positive samples or because there was insufficient detail to allow replication of sample collection. When used with RT‐PCR • There was no evidence of a difference in sensitivity between gargle and nasopharyngeal samples (on average ‐1 percentage points, 95% CI ‐5 to +2, based on 6 evaluations, 2138 sample pairs, of which 389 had SARS‐CoV‐2). • There was no evidence of a difference in sensitivity between saliva collection from the deep throat and nasopharyngeal samples (on average +10 percentage points, 95% CI ‐1 to +21, based on 2192 sample pairs, of which 730 had SARS‐CoV‐2). • There was evidence that saliva collection using spitting, drooling or salivating was on average ‐12 percentage points less sensitive (95% CI ‐16 to ‐8, based on 27,253 sample pairs, of which 4636 had SARS‐CoV‐2) compared to nasopharyngeal samples. We did not find any evidence of a difference in the sensitivity of saliva collected using spitting, drooling or salivating (sensitivity difference: range from ‐13 percentage points (spit) to –21 percentage points (salivate)). • Nasal samples (anterior and mid‐turbinate collection combined) were, on average, 12 percentage points less sensitive compared to nasopharyngeal samples (95% CI ‐17 to ‐7), based on 9291 sample pairs, of which 1485 had SARS‐CoV‐2. We did not find any evidence of a difference in sensitivity between nasal samples collected from the mid‐turbinates (3942 sample pairs) or from the anterior nares (8272 sample pairs). • There was evidence that oropharyngeal samples were, on average, 17 percentage points less sensitive than nasopharyngeal samples (95% CI ‐29 to ‐5), based on seven evaluations, 2522 sample pairs, of which 511 had SARS‐CoV‐2. A much smaller volume of evidence was available for combined nasal/oropharyngeal samples and oral samples. Age, symptom status and use of transport media do not appear to affect the sensitivity of saliva samples and nasal samples. When used with Ag‐RDTs • There was no evidence of a difference in sensitivity between nasal samples compared to nasopharyngeal samples (sensitivity, on average, 0 percentage points ‐0.2 to +0.2, based on 3688 sample pairs, of which 535 had SARS‐CoV‐2). Authors' conclusions When used with RT‐PCR, there is no evidence for a difference in sensitivity of self‐collected gargle or deep‐throat saliva samples compared to nasopharyngeal samples collected by healthcare workers when used with RT‐PCR. Use of these alternative, self‐collected sample types has the potential to reduce cost and discomfort and improve the safety of sampling by reducing risk of transmission from aerosol spread which occurs as a result of coughing and gagging during the nasopharyngeal or oropharyngeal sample collection procedure. This may, in turn, improve access to and uptake of testing. Other types of saliva, nasal, oral and oropharyngeal samples are, on average, less sensitive compared to healthcare worker‐collected nasopharyngeal samples, and it is unlikely that sensitivities of this magnitude would be acceptable for confirmation of SARS‐CoV‐2 infection with RT‐PCR. When used with Ag‐RDTs, there is no evidence of a difference in sensitivity between nasal samples and healthcare worker‐collected nasopharyngeal samples for detecting SARS‐CoV‐2. The implications of this for self‐testing are unclear as evaluations did not report whether nasal samples were self‐collected or collected by healthcare workers. Further research is needed in asymptomatic individuals, children and in Ag‐RDTs, and to investigate the effect of operator expertise on accuracy. Quality assessment of the evidence base underpinning these conclusions was restricted by poor reporting. There is a need for further high‐quality studies, adhering to reporting standards for test accuracy studies. Plain language summary How accurate are different types of sample collection for diagnosing COVID‐19 infection? Key messages • When used with RT‐PCR tests (a molecular test that detects genetic material in COVID‐19 using a technique called reverse transcription polymerase chain reaction), self‐collected gargle and deep throat saliva samples have a similar sensitivity compared to trained healthcare worker‐collected nasopharyngeal samples (taken from the back of the throat through the nose) in detecting COVID‐19. • When used with RT‐PCR, samples collected from the nose, oropharynx (throat via the mouth), oral cavity, and other saliva collection methods are less sensitive for detecting COVID‐19 compared to healthcare worker‐collected nasopharyngeal samples. • When used with rapid antigen tests (Ag‐RDTs; at‐home/self‐tests), samples collected from the nose have a similar sensitivity to healthcare worker‐collected nasopharyngeal samples in detecting COVID‐19. Why is improving the diagnosis of COVID‐19 important? Coronavirus disease (COVID‐19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). People with suspected COVID‐19 may decide to take a test to know whether they are infected, so that they can receive treatment, and follow recommended guidance to self‐isolate and inform close contacts. Not detecting COVID‐19 when it is present (a false negative result) risks spreading infection and results in missed opportunities for treatment. Types of sample collection methods for diagnosing COVID‐19? The type and quality of sample taken for confirmation of COVID‐19 affects the reliability of diagnosis. The most accurate type of sample to diagnose COVID‐19 is that taken by a trained healthcare worker from the back of the throat through the nose (a nasopharyngeal sample). This type of test detects genetic material in the virus using a technique called reverse transcription polymerase chain reaction (RT‐PCR). However, this sample is difficult to obtain correctly, causes discomfort and risks spreading infection if individuals cough or sneeze when the sample is taken. Alternative sample types, particularly those that can be self‐collected using rapid antigen tests (Ag‐RDTs; i.e. self‐tests), may reduce cost and discomfort and improve the safety of sampling. This may, in turn, improve access to and uptake of testing. What did we want to find out? We wanted to compare the sensitivity of different sample sites and collection methods in detecting COVID‐19 with molecular tests (RT‐PCR tests) or self‐based tests (Ag‐RDT tests). What did we do? We searched for studies that had compared the accuracy of nasopharyngeal samples to any alternative that could be used in patients outside of hospital, including nose (nasal) samples, throat samples taken through the mouth (oropharyngeal), gargle samples and saliva samples. We looked at the use of samples with either RT‐PCR or Ag‐RDTs. We also searched for studies that had compared different methods for taking samples, such as samples collected by a healthcare worker compared to those collected by individuals with no or minimal instructions. What did we find? The review included 106 studies with a total of 60,523 participants, of whom 11,045 had COVID‐19 infection. Fifty‐nine per cent of studies were conducted on adults and 79% on symptomatic or mixed symptomatic and asymptomatic participants. Sixty per cent of studies took place in Europe or the USA; just over half (55%) took place in dedicated COVID‐19 testing centres or in outpatient settings. Main results With RT‐PCR, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also test positive on self‐collected gargle samples or saliva samples (collected by coughing and then spitting (deep throat saliva)); ‐ 88% of positive nasopharyngeal samples collected by healthcare workers would also test positive with self‐ or healthcare worker‐collected nose samples; ‐ 87% of positive nasopharyngeal samples collected by healthcare workers would also be detected by saliva self‐collected using spitting, 84% by saliva self‐collected using drooling and 79% by saliva self‐collected by sucking on a swab; and ‐ 83% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐ or healthcare worker‐collected oropharyngeal samples. With Ag‐RDTs, on average: ‐ 100% of positive nasopharyngeal samples collected by healthcare workers would also be detected by self‐collected or healthcare worker‐collected nose samples. Summary results The results of these studies indicate that in a group of 1000 people, of whom 230 (23%) have COVID‐19, then: when used with PCR, compared to healthcare worker‐collected nasopharyngeal samples: ‐ no cases of COVID‐19 would be missed using self‐collected gargle samples (12 less to 5 more) or deep throat saliva samples (2 less to 48 more); ‐ 28 (16 to 39) fewer cases of COVID‐19 infection would be detected using healthcare worker‐ or self‐collected nose sample; ‐ 30 (18 to 41) fewer cases of COVID‐19 infection would be detected by saliva self‐collected using spitting, 37 (12 to 62) fewer by saliva collected by drooling and 48 (12 to 85) fewer by saliva collected by sucking on a swab; ‐ 39 (12 to 67) fewer cases of COVID‐19 infection would be detected by healthcare worker‐ or self‐collected oropharyngeal samples; and when used with Ag‐RDTs, compared to healthcare worker‐collected nasopharyngeal samples: no cases of COVID‐19 infection would be missed using healthcare worker‐ or self‐collected nose samples. What are the limitations of the evidence? It was often not clear whether included studies deliberately excluded inadequate samples or whether the results of the more accurate nasopharyngeal sample were known when alternative samples were interpreted. This may have resulted in alternative sample types appearing more accurate than they are in practice, decreasing the number of missed cases of COVID‐19 infection. More than half of studies did not give information about how long participants had had symptoms at the time of sampling. This reduces our confidence in the comparison of different sample types. Most studies evaluated self‐collected samples by adults with symptoms for use with RT‐PCR; therefore, the findings of this review may not be applicable to asymptomatic individuals or children. For studies conducted with Ag‐RDTs, it is unclear whether sensitivity estimates of nose samples are applicable to home use (self‐collected and self‐interpreted). How up to date is this review? The evidence is current to 22 February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Davenport, C; Arevalo-Rodriguez, I; Mateos-Haro, M; Berhane, S; Dinnes, J; Spijker, R; Buitrago-Garcia, D; Ciapponi, A; Takwoingi, Y; Deeks, JJ; Emperador, D; Leeflang, MM. G.; Van den Bruel, A", "articleTypes": [], "doi": "10.1002/14651858.CD014780", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "b9298548-852f-44ae-ad3a-7e034ab51476", "pmid": "", "title": "Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Etidronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts – bone cells that break down bone tissue. This is an update of a Cochrane review first published in 2008. For clinical relevance, we investigated etidronate's effects on postmenopausal women stratified by fracture risk (low versus high). Objectives To assess the benefits and harms of intermittent/cyclic etidronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE, Embase, two clinical trial registers, the websites of drug approval agencies, and the bibliographies of relevant systematic reviews. We identified eligible trials published between 1966 and February 2023. Selection criteria We included randomized controlled trials that assessed the benefits and harms of etidronate in the prevention of fractures for postmenopausal women. Women in the experimental arms must have received at least one year of etidronate, with or without other anti‐osteoporotic drugs and concurrent calcium/vitamin D. Eligible comparators were placebo (i.e. no treatment; or calcium, vitamin D, or both) or another anti‐osteoporotic drug. Major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. We classified a study as secondary prevention if its population fulfilled one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (≤ ‐2.5), or aged 75 years or older. If none of these criteria were met, we considered the study to be primary prevention. Data collection and analysis We used standard methodological procedures expected by Cochrane. The review has three main comparisons: (1) etidronate 400 mg/day versus placebo; (2) etidronate 200 mg/day versus placebo; (3) etidronate at any dosage versus another anti‐osteoporotic agent. We stratified the analyses for each comparison into primary and secondary prevention studies. For major outcomes in the placebo‐controlled studies of etidronate 400 mg/day, we followed our original review by defining a greater than 15% relative change as clinically important. For all outcomes of interest, we extracted outcome measurements at the longest time point in the study. Main results Thirty studies met the review's eligibility criteria. Of these, 26 studies, with a total of 2770 women, reported data that we could extract and quantitatively synthesize. There were nine primary and 17 secondary prevention studies. We had concerns about at least one risk of bias domain in each study. None of the studies described appropriate methods for allocation concealment, although 27% described adequate methods of random sequence generation. We judged that only 8% of the studies avoided performance bias, and provided adequate descriptions of appropriate blinding methods. One‐quarter of studies that reported efficacy outcomes were at high risk of attrition bias, whilst 23% of studies reporting safety outcomes were at high risk in this domain. The 30 included studies compared (1) etidronate 400 mg/day to placebo (13 studies: nine primary and four secondary prevention); (2) etidronate 200 mg/day to placebo (three studies, all secondary prevention); or (3) etidronate (both dosing regimens) to another anti‐osteoporotic agent (14 studies: one primary and 13 secondary prevention). We discuss only the etidronate 400 mg/day versus placebo comparison here. For primary prevention, we collected moderate‐ to very low‐certainty evidence from nine studies (one to four years in length) including 740 postmenopausal women at lower risk of fractures. Compared to placebo, etidronate 400 mg/day probably results in little to no difference in non‐vertebral fractures (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.20 to 1.61); absolute risk reduction (ARR) 4.8% fewer, 95% CI 8.9% fewer to 6.1% more) and serious adverse events (RR 0.90, 95% CI 0.52 to 1.54; ARR 1.1% fewer, 95% CI 4.9% fewer to 5.3% more), based on moderate‐certainty evidence. Etidronate 400 mg/day may result in little to no difference in clinical vertebral fractures (RR 3.03, 95% CI 0.32 to 28.44; ARR 0.02% more, 95% CI 0% fewer to 0% more) and withdrawals due to adverse events (RR 1.41, 95% CI 0.81 to 2.47; ARR 2.3% more, 95% CI 1.1% fewer to 8.4% more), based on low‐certainty evidence. We do not know the effect of etidronate on hip fractures because the evidence is very uncertain (RR not estimable based on very low‐certainty evidence). Wrist fractures were not reported in the included studies. For secondary prevention, four studies (two to four years in length) including 667 postmenopausal women at higher risk of fractures provided the evidence. Compared to placebo, etidronate 400 mg/day may make little or no difference to non‐vertebral fractures (RR 1.07, 95% CI 0.72 to 1.58; ARR 0.9% more, 95% CI 3.8% fewer to 8.1% more), based on low‐certainty evidence. The evidence is very uncertain about etidronate's effects on hip fractures (RR 0.93, 95% CI 0.17 to 5.19; ARR 0.0% fewer, 95% CI 1.2% fewer to 6.3% more), wrist fractures (RR 0.90, 95% CI 0.13 to 6.04; ARR 0.0% fewer, 95% CI 2.5% fewer to 15.9% more), withdrawals due to adverse events (RR 1.09, 95% CI 0.54 to 2.18; ARR 0.4% more, 95% CI 1.9% fewer to 4.9% more), and serious adverse events (RR not estimable), compared to placebo. Clinical vertebral fractures were not reported in the included studies. Authors' conclusions This update echoes the key findings of our previous review that etidronate probably makes or may make little to no difference to vertebral and non‐vertebral fractures for both primary and secondary prevention. Plain language summary Does etidronate prevent fractures caused by osteoporosis in postmenopausal women? Key messages • For women with close to normal bone density (bone strength) and no previous broken spinal bones, etidronate probably makes little or no difference to the likelihood of having a hip or wrist fracture or a serious adverse (unwanted/harmful) event.
 • For women who have low bone density and are at risk for or have had a previous broken spinal bone, etidronate may make little or no difference in preventing fractures in bones other than the spine. What is osteoporosis? Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow, and old bone cells break down to make room for new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break, even after a minor injury, such as a slight bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. What is etidronate? Etidronate belongs to the class of medicines called bisphosphonates, which slow down the cells that break down the old bone. It is given by mouth in an intermittent or cyclical schedule; for example, a 400 mg tablet daily for two weeks every 90 days, followed by calcium or no treatment for the remainder of each 90‐day treatment cycle. What did we want to find out? We wanted to find out if etidronate was better than placebo (inactive or 'dummy' medicine) or another medicine for osteoporosis in preventing broken bones in postmenopausal women. For clinical relevance, we looked at etidronate's effects on women, as grouped by their risk of fracture (lower versus higher risk). We also wanted to find out if etidronate was associated with any unwanted effects. What did we do? We searched for studies comparing etidronate to placebo or another medicine for preventing osteoporosis. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Overall, we found 30 studies, but 4 studies provided insufficient information about their results. Thus, we were able to analyse the results of 26 studies involving 2770 women. Nine studies were interested in 'primary prevention' of osteoporosis‐based fractures, meaning they focused on women at lower fracture risk, who had bones with near‐to‐normal density/strength and no previous broken spinal bones. Seventeen studies were interested in 'secondary prevention' with etidronate, meaning they focused on women at higher fracture risk, who already had weak bones (low bone density), had a broken spinal bone, or both. Most studies mainly included white women. The studies lasted between 1 and 4 years. Some studies gave the women 400 mg/day of etidronate, whilst other studies gave 200 mg/day. Main results for primary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate: • probably makes little or no difference to non‐vertebral (non‐spinal) fractures and serious adverse events; • may make little or no difference to clinical vertebral fractures (that is, spinal fractures suggested by clinical signs and symptoms) and the number of women who left the studies due to adverse events. The evidence is very uncertain about the effect of etidronate on hip fractures. None of the studies reported on the effect on wrist fractures. Main results for secondary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate may make little or no difference in preventing fractures in bones other than the spine. The evidence is very uncertain about the effect of etidronate on hip and wrist fractures, the number of women who left the studies due to adverse events, and serious adverse events. None of the studies reported on etidronate's effect on clinical vertebral fractures. What are the limitations of the evidence? Our confidence in the evidence ranged from very low to moderate. In general, we have little confidence in the evidence because it is possible that the women in the studies were aware of which treatment they were getting, which could influence the results, and because many of the studies were very small. How up to date is this evidence? The evidence is current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Wells, GA; Hsieh, S-C; Peterson, J; Zheng, C; Kelly, SE; Shea, B; Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD003376.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "b99470f3-1c7f-41b2-a69a-1c36b2e94468", "pmid": "", "title": "Multisensory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Multisensory stimulation is a structured, developmentally appropriate intervention that provides simultaneous or sequential stimulation of two or more senses (e.g. tactile, auditory, visual, or vestibular) in a controlled and non‐stressful manner, with the aim of supporting early neurodevelopment in preterm infants. It has the potential to enhance physiological regulation in preterm infants by stabilizing key functions, such as respiratory patterns, heart rate, and oxygen saturation; reducing the need for respiratory support; and improving feeding performance and sleep regulation. Targeted multisensory interventions have also been associated with improved neurodevelopmental outcomes, including enhanced psychomotor development and visual function. Objectives To assess the benefits and harms of multisensory stimulation compared to any single sensory intervention or standard care on major neurodevelopmental disability, mortality, and growth in preterm infants. Search methods We searched CENTRAL, MEDLINE, Embase, Emcare, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 28 November 2025. We checked reference lists of included trials, and systematic reviews on sensory interventions. Eligibility criteria We included 18 randomized controlled trials (RCTs) comparing multisensory stimulation in preterm infants with no intervention (placebo or standard care), and one RCT comparing multisensory stimulation with single‐sense stimulation (tactile stimulation). Outcomes Our critical outcomes were major neurodevelopmental disability at 18 to 24 months: cerebral palsy (CP), developmental delay, intellectual impairment, blindness, sensorineural deafness; death during initial hospitalization; and total weight gain (grams), assessed at discharge. When comparing multisensory stimulation with single‐sense intervention, we also included weight gain during the intervention, an outcome added during the post‐hoc analysis. Important outcomes were duration of hospital stay, of NICU stay, and of respiratory support; and time until full oral feeding. Risk of bias We used the Cochrane tool, RoB 2. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RR) for dichotomous data, and mean differences (MDs) for continuous data, each with its 95% confidence intervals (CIs). We assessed statistical heterogeneity by calculating the I 2 statistic when we included more than two trials in a meta‐analysis. We evaluated the certainty of evidence using GRADE. Included studies We included 19 trials (1554 newborn infants): 18 studies compared multisensory stimulation with standard care; one compared multisensory stimulation with single‐sensory stimulation (tactile). In 10 studies, the primary aim was to assess the neurobehavioral outcomes of multisensory stimulation on preterm neo­nates. The other nine studies aimed to assess the impact of multisensory stimulation on weight gain during the intervention, weight gain until hospital discharge, length of neonatal intensive care unit (NICU) stay, length of hospital stay, time until full oral feeding, length of respiratory support, or a combination. In the abstract we report results for the critical outcomes only. We identified 13 ongoing studies. Four studies are awaiting assessment. Synthesis of results Multisensory stimulation compared to standard care No studies reported on these major neurodevelopmental disabilities, assessed at 18 to 24 months' corrected age (CA): developmental delay, intellectual impairment, blindness, or sensorineural deafness. One study reported on rates of CP at 12 months of age. The evidence is very uncertain about the effect of multisensory stimulation on CP (RR 0.67, 95% CI 0.28 to 1.58; I² not applicable; 1 study, 18 participants; very low‐certainty evidence). The evidence suggests that multisensory stimulation may result in little to no difference in death during initial hospitalization (RR 0.97, 95% CI 0.54 to 1.73; I² not applicable; 1 study, 395 participants; low‐certainty evidence). Multisensory stimulation may increase total weight gain prior to discharge (MD 72.67, 95% CI 68.23 to 77.12; I² = 0%; 3 studies, 474 participants; low‐certainty evidence). Multisensory stimulation compared to single‐sense (tactile) stimulation No studies reported on major neurodevelopmental disability, assessed at 18 to 24 months' CA, or death during initial hospitalization. The evidence is very uncertain about the effect of multisensory stimulation compared to tactile stimulation on weight gain during the intervention (MD −175.00, 95% CI −376.60 to 26.60; I² not applicable; 1 study, 20 participants; very low‐certainty evidence). The certainty of the evidence was low to very low across outcomes, primarily due to risk of bias, imprecision from small sample sizes and wide CIs, and in some cases, inconsistency. The evidence base was also limited by the lack of reporting of relevant outcomes and reliance on surrogate outcomes or shorter follow‐up periods. Authors' conclusions The available evidence on multisensory stimulation in preterm infants is limited and of low to very low certainty. No included studies reported on major neurodevelopmental disabilities at 18 to 24 months’ CA, which represented a critical outcome for this review. Evidence regarding the effect of multisensory stimulation on CP is very uncertain, as it is based on a single small study reporting a surrogate outcome at 12 months. Multisensory stimulation may result in little to no difference in mortality during the initial hospitalization. It may increase total weight gain prior to discharge. However, the clinical significance of this finding is uncertain, particularly given the low certainty of the evidence and the multifactorial nature of growth in preterm infants. The evidence is very uncertain about the effect of multisensory stimulation compared to single‐sense (tactile) stimulation on weight gain during the intervention. The only included study did not report major neurodevelopmental disabilities at 18 to 24 months’ CA, mortality during the initial hospitalization, or total weight gain prior to discharge, which represented the critical outcomes for this review. Overall, the current evidence does not allow firm conclusions about the effectiveness of multisensory stimulation in promoting development or preventing morbidity in preterm infants. Future studies on multisensory stimulation should use more rigorous designs, larger samples, and report interventions using the template for intervention description and replication (TIDieR) checklist to ensure transparency. They should also report essential outcomes, such as neonatal death, major neurodevelopmental disabilities, length of hospital and NICU stay, time to full oral feeding, duration of respiratory support, and weight gain, to better assess the long‑term effects of multisensory stimulation in preterm infants. Funding This Cochrane review had no dedicated funding . Registration Protocol available via DOI: 10.1002/14651858.CD016073 Plain language summary Does stimulating multiple senses (such as hearing, touch, taste, smell) of premature babies improve growth and healthy development or reduce the risk of death? Key messages Multisensory stimulation (the stimulation of more than one sense at a time) may support growth in preterm infants by increasing weight gain before discharge from the hospital. However, it is unclear whether it improves longer‐term developmental outcomes or reduces the risk of death, as the available evidence is limited and uncertain. When compared with stimulation of a single sense (touch alone), it is uncertain whether multisensory stimulation is better than touch alone at increasing weight gain during the intervention. What is multisensory stimulation, and how does it work? Multisensory stimulation means giving premature babies experiences that activate two or more of their senses. The senses involved and the types of stimulation used include the sense of: hearing — a parent’s voice, singing, or calming music; touch — massage or passive movements; smell and taste — a mother’s scent or breast milk; balance — gentle rocking or changing the baby's position; sight — soft, cycled lighting and simple shapes, colors, or moving patterns. During the newborn period, the brain grows very quickly. Providing positive sensory experiences at this time may help premature babies in several ways, such as supporting their memory, helping them regulate emotions, and improving early learning and development. What did we want to find out? We wanted to find out whether multisensory stimulation compared with single‑sense stimulation or standard care helps premature babies survive, grow, stay healthy, and develop well. Specifically, we wanted to find out whether multisensory stimulation might: reduce the number of babies with severe developmental problems at 18 to 24 months' age, such as cerebral palsy, delay in development, limitations in mental abilities, blindness, or deafness; reduce the number of babies who die during the newborn period or before hospital discharge; increase the amount of weight the infants gained by the time they left the hospital. We also looked at other important measures of the babies’ health, including: how long they stayed in the hospital or in the neonatal intensive care unit (NICU); how long it took before they could feed fully by mouth; how many days they needed breathing support. What did we do? We searched for studies in which multisensory stimulation began before the baby was discharged from the hospital after birth, and which compared multisensory stimulation with: no intervention or standard care; single‐sense stimulation. We summarized the results of the studies and rated our confidence in the evidence, based on factors, such as the size of the study (number of babies enrolled) and the methods used. What did we find? We included 19 studies (1544 premature babies). Eighteen of these studies compared multisensory stimulation with standard care, and one study compared multisensory stimulation with a single‑sense intervention (touch only). In 10 studies, the main goal was to examine how multisensory stimulation affects babies’ brain and behavioral development. The remaining nine studies focused on weight gain during the intervention, weight gain prior to hospital discharge, length of stay in the NICU, total length of hospital stay, time until the baby could feed fully by mouth, number of days the baby needed breathing support, or a combination of these measures. We also found 13 ongoing studies and 4 studies that have not yet been fully assessed. They may give us more useful information in the future. Main results None of the studies that compared multisensory stimulation with no intervention reported on the critical outcome major developmental disability at 18 to 24 months' corrected age. Only one study assessed a related outcome, cerebral palsy at 12 months. Because this study was very small, the evidence is very uncertain about whether multisensory stimulation modifies the risk of cerebral palsy. Multisensory stimulation may result in little or no difference in death before hospital discharge, although it was reported in only one large study. It may increase total weight gain prior to discharge, but the observed effect is small, and its clinical significance remains uncertain. Compared with single‐sense stimulation (touch), we could not tell whether multisensory stimulation helped babies gain more weight during the intervention. The only study we found comparing a multi‐ to single‐sensory intervention did not report the critical outcomes, such as major developmental problems at 18 to 24 months' corrected age, death during the first hospital stay, or total weight gain prior to discharge. What are the limitations of the evidence? We have limited confidence in these findings because many of the studies were small or not well‐designed. Several studies did not report the outcomes we were most interested in or did not provide enough data for us to analyze. Because of these limitations, the true effects of multisensory stimulation may be different from what we found. How up‐to‐date is this evidence? The evidence is up‐to‐date to 28 November 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Wróblewska-Seniuk, K, Lenells, M, Prescott, MG, Fiander, M, Soll, RF, Bruschettini, M, supported by Cochrane Sweden and Cochrane Neonatal,", "articleTypes": [], "doi": "10.1002/14651858.CD016073.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.750Z" }, { "id": "b9b02602-6d27-4f34-a2a6-122af633d184", "pmid": "", "title": "A Phase 3, Global, Multi-center, Double-blind, Randomized Study of ASP2138 Plus Chemotherapy (CAPOX or mFOLFOX6) With Pembrolizumab vs Placebo Plus Chemotherapy With or Without Pembrolizumab in First-line Treatment of Locally Advanced Unresectable or Metastatic Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma in Participants Whose Tumors Are HER2-negative and Claudin (CLDN) 18.2-positive", "imported": false, "abstract": "Claudin 18.2 or CLDN18.2 is a protein found on cells in the digestive system. It is also found in some tumors. Researchers are looking at ways to attack CLDN18.2 to help control tumors. ASP2138 is thought to bind to CLDN18.2 and a type of immune cell called a T cell. This \"tells\" the immune system to attack the tumor. ASP2138 is a potential treatment for people with gastric cancer (also known as stomach cancer) or gastroesophageal junction cancer (GEJ cancer). GEJ is where the tube that carries food (esophagus) joins the stomach.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.162Z" }, { "id": "b9ed4670-d0e2-48f8-b079-e0cf3edd9775", "pmid": "", "title": "Interventions for the treatment of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "Abstract - Background Olfactory dysfunction is a common consequence of COVID‐19 infection and persistent symptoms can have a profound impact on quality of life. At present there is little guidance on how best to treat this condition. A variety of interventions have been suggested to promote recovery, including medication and olfactory training. However, it is uncertain whether any intervention is of benefit. This is an update of the 2021 review with one additional study added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with persisting olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance that had persisted for at least four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the recovery of sense of smell, disease‐related quality of life and serious adverse effects. Secondary outcomes were the change in sense of smell, general quality of life, prevalence of parosmia and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included two studies with 30 participants. The studies evaluated the following interventions: systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant and palmitoylethanolamide plus luteolin. Systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant compared to no intervention We included a single RCT with 18 participants who had anosmia for at least 30 days following COVID‐19 infection. Participants received a 15‐day course of oral corticosteroids combined with nasal irrigation (consisting of an intranasal corticosteroid/mucolytic/decongestant solution) or no intervention. Psychophysical testing was used to assess olfactory function at 40 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Palmitoylethanolamide plus luteolin compared to no intervention We included a single RCT with 12 participants who had anosmia or hyposmia for at least 90 days following COVID‐19 infection. Participants received a 30‐day course of palmitoylethanolamide and luteolin or no intervention. Psychophysical testing was used to assess olfactory function at 30 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the treatment of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important The sense of smell is critical to one's enjoyment of odours and tastes, and is important for safety. During the COVID‐19 pandemic there has been an increasing focus on change in sense of smell as one of the early symptoms associated with infection. This can be a reduction, change or complete loss of the sense of smell. For most people this is temporary, however for some this lasts weeks or even months. If a person has lost their sense of smell for a long time (over four weeks after having COVID‐19), we do not know if there are any treatments that might help it to recover. How we identified and assessed the evidence We searched the medical literature, identifying relevant studies and summarising the results. We assessed the quality of the studies as well as the certainty of the evidence. Factors influencing this included the size of the studies, the methods used to perform them and how results were reported by researchers. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found two small studies to include in the review, including a total of 30 people. All participants had problems with their sense of smell that had lasted for at least four weeks, and started after a COVID‐19 infection. Problems with the sense of smell were identified using special smell identification tests carried out by the research team. The patients were randomly divided into two groups: those who would receive treatment and those who would not. The treatment in one study was a course of corticosteroid tablets ('systemic') and nasal irrigation (with a wash consisting of a mix of corticosteroids, decongestant and an agent that breaks down mucus). The second study used a course of a supplement known as palmitoylethanolamide and luteolin. Systemic corticosteroids and nasal irrigation (intranasal corticosteroids/decongestant/mucolytic) compared to no treatment We do not know whether corticosteroid tablets with nasal irrigation is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 40 days;
 ‐ changing the sense of smell after 40 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. Palmitoylethanolamide and luteolin compared to no treatment We do not know whether palmitoylethanolamide and luteolin is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 30 days;
 ‐ changing the sense of smell after 30 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. We did find a number of other studies that are being carried out, but no results from these studies are yet available to be included in this review. What this means It is unclear whether using corticosteroids with nasal irrigation, or using a palmitoylethanolamide and luteolin supplement, might treat problems with the sense of smell after COVID‐19, or whether these treatments can potentially cause harm. Other treatments are under investigation. This review is a 'living systematic review', meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "O'Byrne, L; Webster, KE; MacKeith, S; Philpott, C; Hopkins, C; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013876.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "b9edab2c-47db-4cc3-b91d-17b2d149402d", "pmid": "", "title": "Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background It is unclear whether patients with type 2 diabetes who have poor glycaemic control despite maximal oral hypoglycaemic agents (OHAs) should be commenced on insulin as monotherapy, or insulin combined with oral hypoglycaemic agents (insulin‐OHA combination therapy). Objectives To assess the effects of insulin monotherapy versus insulin‐OHA combinations therapy. Search methods Eligible studies were identified by searching MEDLINE, EMBASE, and The Cochrane Library . Selection criteria Randomised controlled trials (RCTs) with 2 months minimum follow‐up duration comparing insulin monotherapy (all schemes) with insulin‐OHA combination therapy. Data collection and analysis Data extraction and assessment of study quality were undertaken by three reviewers in pairs. Main results Twenty RCTs (mean trial duration 10 months) including 1,811 participants, with mean age 59.8 years and mean known duration of diabetes 9.6 years. Overall, study methodological quality was low. Twenty‐eight comparisons in 20 RCTs were ordered according to clinical considerations. No studies assessed diabetes‐related morbidity, mortality or total mortality. From 13 studies (21 comparisons), sufficient data were extracted to calculate pooled effects on glycaemic control. Insulin‐OHA combination therapy had statistically significant benefits on glycaemic control over insulin monotherapy only when the latter was applied as a once‐daily injection of NPH insulin. Conversely, twice‐daily insulin monotherapy (NPH or mixed insulin) provided superior glycaemic control to insulin‐OHA combination therapy regimens where insulin was administered as a single morning injection. In more conventional comparisons, regimens utilising OHAs with bedtime NPH insulin provided comparable glycaemic control to insulin monotherapy (administered as twice daily, or multiple daily injections). Overall, insulin‐OHA combination therapy was associated with a 43% relative reduction in total daily insulin requirement compared to insulin monotherapy. Of the 14 studies (22 comparisons) reporting hypoglycaemia, 13 demonstrated no significant difference in the frequency of symptomatic or biochemical hypoglycaemia between insulin and combination therapy regimens. No significant differences in quality of life related issues were detected. Combination therapy with bedtime NPH insulin resulted in statistically significantly less weight gain compared to insulin monotherapy, provided metformin was used ± sulphonylurea. In all other comparisons no significant differences with respect to weight gain were detected. Authors' conclusions Bedtime NPH insulin combined with oral hypoglycaemic agents provides comparable glycaemic control to insulin monotherapy and is associated with less weight gain if metformin is used. Plain language summary Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus Simple application of a single daily insulin injection in addition to oral hypoglycaemic agents may facilitate the initiation of insulin therapy in type 2 diabetes mellitus.This review examined 20 trials including 1,811 participants which compared insulin monotherapy with insulin in combination with oral hypoglycaemic agents (OHA) in insulin‐requiring patients with type 2 diabetes. The results suggest that a bedtime NPH insulin‐oral hypoglycaemic agent combination therapy regimen provides comparable glycaemic control to insulin monotherapy. Due to lack of studies it remains unclear whether insulin‐OHA combination regimens with metformin alone are superior to those with metformin plus a sulphonylurea. In most cases no significant differences in hypoglycaemic events were observed between insulin mono‐ and OHA combination therapy. No study assessed diabetes‐related morbidity or mortality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Goudswaard, AN, Furlong, NJ, Valk, GD, Stolk, RP, Rutten, GEHM", "articleTypes": [], "doi": "10.1002/14651858.CD003418.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.775Z" }, { "id": "b9f5941a-bbd7-4e93-8c68-3e72ce9183fb", "pmid": "", "title": "Sensory and Gastrointestinal Impact of Taste Receptor Variants on Human Metabolism and Nutrition", "imported": false, "abstract": "We investigate the impact of taste receptors (sweet, bitter and umami) on human metabolism. There ist growing evidence, that components of the taste signalling system, including the taste receptor proteins , have important functions in the regulation of metabolic parameters in non-gustatory tissues.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.141Z" }, { "id": "ba072440-24e0-4ca8-88f3-9a72e2aab9af", "pmid": "", "title": "A Pilot Study of Facial Recognition Software to Assess Palatability in Pediatric Patients", "imported": false, "abstract": "The study is designed to see if, after tasting specific things, whether a child's facial pattern and voice pattern can determine the difference in something that has a sweet taste, no taste, and a bitter taste. The investigators will do this by comparing video recordings of a child's facial expression and voice to the child's response to follow-up questions after tasting three (3) different substances.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.236Z" }, { "id": "ba09c7e7-df27-4225-abe3-064df0f2bc87", "pmid": "", "title": "Olfactory stimulation for promoting development and preventing morbidity in preterm infants", "imported": false, "abstract": "Abstract - Rationale Preterm infants, often gavage‐fed due to immaturity, may benefit from interventions that hasten the move to breastfeeding. Olfactory stimulation may increase appetite and speed up the transition to full oral feeding, potentially shortening hospital stay and improving outcomes for both infants and families. Objectives To evaluate the benefits and harms of olfactory stimulation for reducing morbidity and promoting development in hospitalized preterm infants. Search methods We searched MEDLINE, Embase, CENTRAL, CINAHL, Epistemonikos, two trial registries, and conference abstracts up to 2 April 2025. We checked the reference lists of included studies and systematic reviews on olfactory or sensory stimulation. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs evaluating olfactory stimulation with different odorants (maternal breast milk, food‐associated odors, or non‐food‐associated odors) in preterm infants (born before 37 weeks' gestation). Eligible controls were no intervention, placebo, or standard care (considered together) or another odorant. We excluded studies combining olfactory stimulation with taste, as another review will focus on combined sensory stimulation. Outcomes Our critical outcomes were apnea, intermittent hypoxemia, duration of hospital stay, time to full oral feeding, and exclusive breastfeeding. Our important outcomes included blindness and sensorineural deafness requiring amplification. Risk of bias We used the Cochrane risk of bias tool (RoB 2) to assess risk of bias in the included studies. Synthesis methods We conducted meta‐analyses using fixed‐effect models to calculate risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, each with its 95% confidence interval (CI). We assessed the certainty of evidence using GRADE. Included studies We included 14 trials enrolling 1087 neonates. The types of olfactory stimulation under investigation were maternal breast milk (9 studies); food‐associated odors such as cinnamon, vanilla, or anise (5 studies); and non‐food‐associated odors such as rose or parents' scent (3 studies). Three studies evaluated two different odorants. Gestational age and bodyweight varied widely. The comparators were placebo, no intervention, and standard care. Eleven studies aimed to assess the effect of olfactory stimulation on infant feeding outcomes such as time to full oral feeding, weight gain, length of hospital stay, or a combination of these outcomes. Three studies aimed to assess the effect of olfactory stimulation on apnea prevention, oxygen saturation, or both. We identified five ongoing trials. Synthesis of results No studies reported apnea as a dichotomous outcome, intermittent hypoxemia, exclusive breastfeeding, or major neurodevelopmental disability for any of the comparisons. We downgraded the certainty of evidence for limitations in study design, imprecision, and indirectness. Olfactory stimulation with maternal breast milk versus no intervention, placebo, or standard care The evidence is very uncertain about the effect of olfactory stimulation with maternal breast milk on the mean number of daily apnea episodes (MD −0.50, 95% CI −1.27 to 0.27; 1 study, 26 participants; very low‐certainty evidence) and duration of hospital stay in days (MD −0.18, 95% CI −0.64 to 0.27; I² = 0%; 4 studies, 270 participants; very low‐certainty evidence). Olfactory stimulation with maternal breast milk may result in a slight reduction in time to full oral feeding in days (MD −1.68, 95% CI −3.25 to −0.11; I² = 30%; 3 studies, 204 participants; low‐certainty evidence). Olfactory stimulation with food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with food‐associated odors may result in a slight reduction in the mean number of daily apnea episodes (MD −1.99, 95% CI −2.69 to −1.29; I² = 58%; 2 studies, 62 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with food‐associated odors on duration of hospital stay in days (MD −2.65, 95% CI −6.18 to 0.89; I² = 20%; 3 studies, 185 participants; very low‐certainty evidence) and time to full oral feeding in days (MD −2.06, 95% CI −5.16 to 1.04; I² = 36%; 3 studies, 185 participants; very low‐certainty evidence). Olfactory stimulation with non‐food‐associated odors versus no intervention, placebo, or standard care Olfactory stimulation with non‐food‐associated odors may result in a slight reduction in duration of hospital stay in days (MD −3.23, 95% CI −5.50 to −0.97; I² = 0%; 2 studies, 94 participants; low‐certainty evidence). The evidence is very uncertain about the effect of olfactory stimulation with non‐food‐associated odor on the mean number of daily apnea episodes (MD −2.13, 95% CI −2.28 to −1.98; 1 study, 60 participants; very low‐certainty evidence) and time to full oral feeding (mean 21 (standard deviation 3.1) days in the intervention group and mean 21 (standard deviation 15.6) days in the control group; 1 study, 27 participants; very low‐certainty evidence). Authors' conclusions Olfactory stimulation with maternal breast milk compared to no intervention, placebo, or standard care may result in a slight reduction in time to full oral feeding, but the evidence is very uncertain about its effect on frequency of apnea episodes and duration of hospital stay. Olfactory stimulation with food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in frequency of apnea episodes, but the evidence is very uncertain about its effect on duration of hospital stay and time to full oral feeding. Olfactory stimulation with non‐food‐associated odors compared to no intervention, placebo, or standard care may result in a slight reduction in duration of hospital stay, but the evidence is very uncertain about its effect on frequency of apnea episodes and time to full oral feeding. Future studies should be more rigorous in their design, report using TIDieR (Template for Intervention Description and Replication) checklists, have larger sample sizes, and measure outcomes such as apnea (number of infants with ≥ 1 episode), intermittent hypoxemia (number of infants with ≥ 1 episode), exclusive breastfeeding, and major neurodevelopmental disabilities. Funding Dedicated funding for this review can be found in the 'Sources of support' section. Registration Protocol: https://doi.org/10.1002/14651858.CD016074 . Plain language summary Does introducing smells to preterm infants improve their physical and mental development? Key messages Introducing preterm infants to the smell of maternal breast milk may slightly reduce the time it takes for them to feed fully by mouth. Introducing them to food smells such as vanilla and cinnamon may slightly reduce how often they stop breathing. Finally, introducing preterm babies to the smell of rose or a parent's scent may reduce slightly the time they have to stay in hospital. All other results are very uncertain. Future studies should include more infants, use more rigorous designs, and measure outcomes such as breathing problems, low blood oxygen levels, exclusive breastfeeding, and long‐term neurodevelopmental outcomes. What is preterm birth? A normal pregnancy usually lasts from 37 weeks to 42 weeks. Preterm birth is when a baby is born before 37 weeks of pregnancy. Babies born preterm have not had enough time to fully develop before birth. Their organs may not yet be ready to work on their own, which means they often need intensive medical care and are at greater risk of breathing and feeding difficulties, infection, and problems that can affect their long‐term development. What is olfactory stimulation, and how does it work? Preterm infants often take time to build up the skills or physical capacity to feed by mouth, and in the meantime are fed through a tube passed into the stomach. Olfactory stimulation involves introducing smells to preterm infants while they are in hospital to see if it helps them start breastfeeding more quickly. These smells include breast milk, food smells such as vanilla or cinnamon, and other smells such as a floral scent or a parent's scent. What did we want to find out? We wanted to find out whether introducing a smell to preterm infants in hospital could be helpful and safe for their short‐term and long‐term well‐being. More specifically, we wanted to find out whether introducing a smell to preterm infants is better than placebo (dummy treatment), no treatment, or usual care for: reducing the number of infants who have apnea (brief pauses in breathing); reducing the number of infants with low oxygen levels in the blood; reducing the time spent in hospital; reducing the time needed for the infants to learn to feed fully by mouth; increasing the number of infants that are fed only with breast milk; reducing the number of infants with blindness or deafness between 18 and 24 months of age. What did we do? We searched for studies that compared olfactory stimulation with placebo, no treatment, or usual care in preterm infants. We summarized the results of the studies and rated our confidence in the evidence based on factors such as study size (number of infants) and methods. What did we find? We included 14 studies with 1087 infants. Nine studies used the smell of maternal breast milk, five used food‐associated smells (vanilla, cinnamon, or anise), and three studies used other smells (rose or parents' scent). All studies compared these smells with no treatment, placebo, or usual care. Main results Introducing the smell of maternal breast milk may reduce slightly the time it takes infants to feed fully by mouth. It is unclear whether stimulation with this smell has any effect on how often infants have apnea episodes and how long they stay in hospital. Introducing the smell of cinnamon, vanilla, or anise may slightly reduce how often infants have apnea episodes. It is unclear whether stimulation with these smells has any effect on how long infants stay in hospital or how long it takes them to feed fully by mouth. Introducing the scent of rose or a parent's scent may slightly reduce how long infants spend in hospital. It is unclear whether stimulation with these smells has any effect on how often infants have apnea episodes or how long it takes them to feed fully by mouth. What are the limitations of the evidence? We have little confidence in these results, as the studies included could have been better designed and included more babies. Several studies did not report outcomes we were interested in. How up to date is this evidence? The evidence is current to 2 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lenells, M, Prescott, MG, Wróblewska-Seniuk, K, Fiander, M, Soll, RF, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD016074.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.731Z" }, { "id": "ba2c62b5-90d2-40af-995a-db26845ead66", "pmid": "", "title": "Colchicine for pericarditis", "imported": false, "abstract": "Abstract - Background Pericarditis is the inflammation of the pericardium, the membranous sac surrounding the heart. Recurrent pericarditis is the most common complication of acute pericarditis, causing severe and disabling chest pains. Recurrent pericarditis affects one in three patients with acute pericarditis within the first 18 months. Colchicine has been suggested to be beneficial in preventing recurrent pericarditis. Objectives To review all randomised controlled trials (RCTs) that assess the effects of colchicine alone or combined, compared to any other intervention to prevent further recurrences of pericarditis, in people with acute or recurrent pericarditis. Search methods We searched the following bibliographic databases on 4 August 2014: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2014 on The Cochrane Library ), MEDLINE (OVID, 1946 to July week 4, 2014), EMBASE (OVID, 1947 to 2014 week 31), and the Conference Proceedings Citation Index ‐ Science on Web of Science (Thomson Reuters) 1990 to 1 Aug 2014. We did not apply any language or time restrictions. Selection criteria RCTs of people with acute or recurrent pericarditis who are receiving colchicine compared to any other treatment, in order to prevent recurrences. Data collection and analysis Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The first primary outcome was the time to recurrence, measured by calculating the hazard ratios (HRs). The second primary outcome was the adverse effects of colchicine. Secondary outcomes were the rate of recurrences at 6, 12 and 18 months, and symptom relief. Main results We included four RCTs, involving 564 participants in this review. We compared the effects of colchicine in addition to a non‐steroidal anti‐inflammatory drug (NSAID) such as ibuprofen, aspirin or indomethacin to the effects of the NSAID alone. Two comparable trials studied the effects of colchicine in 204 participants with recurrent pericarditis and two trials studied 360 people with acute pericarditis. All trials had a moderate quality for the primary outcomes. We identified two on‐going trials; one of these trials examines acute pericarditis and the other assesses recurrent pericarditis. There was moderate quality evidence that colchicine reduces episodes of pericarditis in people with recurrent pericarditis over 18 months follow‐up (HR 0.37; 95% confidence interval (CI) 0.24 to 0.58). It is expected that at 18 months, the number needed to treat (NNT) is 4. In people with acute pericarditis, there was moderate quality evidence that colchicine reduces recurrence (HR 0.40; 95% CI 0.27 to 0.61) at 18 months follow‐up. Colchicine led to a greater chance of symptom relief at 72 hours (risk ratio (RR) 1.4; 95% CI 1.26 to 1.56; low quality evidence). Adverse effects were mainly gastrointestinal and included abdominal pain and diarrhoea. The pooled RR for adverse events was 1.26 (95% CI 0.75 to 2.12). While the number of people experiencing adverse effects was higher in the colchicine than the control groups (9% versus 7%), the quality of evidence was low owing to imprecision, and there was no statistically significant difference between the treatment groups (P = 0.42). There was moderate quality evidence that treatment with colchicine led to more people stopping treatment due to adverse events (RR 1.87; 95% CI 1.02 to 3.41). Authors' conclusions Colchicine, as adjunctive therapy to NSAIDs, is effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis. However, evidence is based on a limited number of small trials. Patients with multiple resistant recurrences were not represented in any published or on‐going trials, and it is these patients that are in the most need for treatment. Plain language summary Systematic review of randomised controlled trials about the efficacy and safety of colchicine in people with pericarditis Pericarditis is the inflammation and swelling of the tissue covering the outer layer of the heart. Pericarditis causes severe and disabling chest pain and fever, however the main issue is the repeated recurrence of pericarditis attacks. Colchicine is an ancient medication that has been used in the treatment of other inflammatory diseases such as gout. We wanted to discover whether colchicine alone or added to other medications is better or worse than alternative therapies in preventing pericarditis. We have reviewed all randomised controlled trials about the effect of colchicine in preventing recurrence of pericarditis in people with pericarditis. We found four trials involving 564 participants, who were followed up for at least 18 months. Two studies examined the use of colchicine in people with recurrent pericarditis and two examined the use of colchicine in people with a first episode of pericarditis. The evidence is current to August 2014. The trials showed that people taking colchicine have a lower risk of developing pericarditis recurrence and a higher proportion experience symptom relief. It is expected that at 18 months, one pericarditis recurrence can be avoided for every four people receiving colchicine with NSAIDs rather than NSAIDs alone. Adverse effects were reported in all trials and affected 15 people (9%) of the 162 taking colchicine. Adverse effects included abdominal pain, nausea and vomiting. Two studies were designed so that participants knew the type of intervention they were taking and people in the comparison group had no dummy pill. The results of these studies could exaggerate the effects of the drug. The evidence suggests beneficial effects of colchicine in preventing recurrence of pericarditis, however this is based on a limited number of small trials. More trials are currently being done and we await their results to see if the benefits of colchicine can be further confirmed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Alabed, S; Cabello, JB; Irving, GJ; Qintar, M; Burls, A", "articleTypes": [], "doi": "10.1002/14651858.CD010652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "ba2f6449-8e6f-490d-9bdf-48704cf666a4", "pmid": "", "title": "Drug interventions for the treatment of obesity in children and adolescents", "imported": false, "abstract": "Abstract - Background Child and adolescent obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. Objectives To assess the efficacy of drug interventions for the treatment of obesity in children and adolescents. Search methods We searched CENTRAL , MEDLINE, Embase, PubMed (subsets not available on Ovid), LILACS as well as the trial registers ICTRP (WHO) and ClinicalTrials.gov. Searches were undertaken from inception to March 2016. We checked references and applied no language restrictions. Selection criteria We selected randomised controlled trials (RCTs) of pharmacological interventions for treating obesity (licensed and unlicensed for this indication) in children and adolescents (mean age under 18 years) with or without support of family members, with a minimum of three months' pharmacological intervention and six months' follow‐up from baseline. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. In addition, we excluded trials which included growth hormone therapies and pregnant participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data following standard Cochrane methodology. Where necessary we contacted authors for additional information. Main results We included 21 trials and identified eight ongoing trials. The included trials evaluated metformin (11 trials), sibutramine (six trials), orlistat (four trials), and one trial arm investigated the combination of metformin and fluoxetine. The ongoing trials evaluated metformin (four trials), topiramate (two trials) and exenatide (two trials). A total of 2484 people participated in the included trials, 1478 participants were randomised to drug intervention and 904 to comparator groups (91 participants took part in two cross‐over trials; 11 participants not specified). Eighteen trials used a placebo in the comparator group. Two trials had a cross‐over design while the remaining 19 trials were parallel RCTs. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up from baseline ranged from six months to 100 weeks. Trials generally had a low risk of bias for random sequence generation, allocation concealment and blinding (participants, personnel and assessors) for subjective and objective outcomes. We judged approximately half of the trials as having a high risk of bias in one or more domain such as selective reporting. The primary outcomes of this review were change in body mass index (BMI), change in weight and adverse events. All 21 trials measured these outcomes. The secondary outcomes were health‐related quality of life (only one trial reported results showing no marked differences; very low certainty evidence), body fat distribution (measured in 18 trials), behaviour change (measured in six trials), participants' views of the intervention (not reported), morbidity associated with the intervention (measured in one orlistat trial only reporting more new gallstones following the intervention; very low certainty evidence), all‐cause mortality (one suicide in the orlistat intervention group; low certainty evidence) and socioeconomic effects (not reported). Intervention versus comparator for mean difference (MD) in BMI change was ‐1.3 kg/m 2 (95% confidence interval (CI) ‐1.9 to ‐0.8; P < 0.00001; 16 trials; 1884 participants; low certainty evidence). When split by drug type, sibutramine, metformin and orlistat all showed reductions in BMI in favour of the intervention. Intervention versus comparator for change in weight showed a MD of ‐3.9 kg (95% CI ‐5.9 to ‐1.9; P < 0.00001; 11 trials; 1180 participants; low certainty evidence). As with BMI, when the trials were split by drug type, sibutramine, metformin and orlistat all showed reductions in weight in favour of the intervention. Five trials reported serious adverse events: 24/878 (2.7%) participants in the intervention groups versus 8/469 (1.7%) participants in the comparator groups (risk ratio (RR) 1.43, 95% CI 0.63 to 3.25; 1347 participants; low certainty evidence). A total 52/1043 (5.0%) participants in the intervention groups versus 17/621 (2.7%) in the comparator groups discontinued the trial because of adverse events (RR 1.45, 95% CI 0.83 to 2.52; 10 trials; 1664 participants; low certainty evidence). The most common adverse events in orlistat and metformin trials were gastrointestinal (such as diarrhoea, mild abdominal pain or discomfort, fatty stools). The most frequent adverse events in sibutramine trials included tachycardia, constipation and hypertension. The single fluoxetine trial reported dry mouth and loose stools. No trial investigated drug treatment for overweight children. Authors' conclusions This systematic review is part of a series of associated Cochrane reviews on interventions for obese children and adolescents and has shown that pharmacological interventions (metformin, sibutramine, orlistat and fluoxetine) may have small effects in reduction in BMI and bodyweight in obese children and adolescents. However, many of these drugs are not licensed for the treatment of obesity in children and adolescents, or have been withdrawn. Trials were generally of low quality with many having a short or no post‐intervention follow‐up period and high dropout rates (overall dropout of 25%). Future research should focus on conducting trials with sufficient power and long‐term follow‐up, to ensure the long‐term effects of any pharmacological intervention are comprehensively assessed. Adverse events should be reported in a more standardised manner specifying amongst other things the number of participants experiencing at least one adverse event. The requirement of regulatory authorities (US Food and Drug Administration and European Medicines Agency) for trials of all new medications to be used in children and adolescents should drive an increase in the number of high quality trials. Plain language summary Drug interventions for the treatment of obesity in children and adolescents Review question Do drug (medicine) interventions reduce weight in obese children and adolescents and are they safe? Background Across the world more children and adolescents are becoming overweight and obese. These children and adolescents are more likely to have health problems, both while as children or adolescents and in later life. More information is needed about what works best for treating this problem recognising that so‐called lifestyle changes (diet, exercise and counselling) have limited efficacy. Study characteristics We found 21 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) comparing various drugs plus a behaviour changing intervention such as diet, exercise or both (= intervention groups) usually with placebo (a pretend drug) plus a behaviour changing intervention (= control groups). We also identified eight ongoing studies (studies which are currently running but not completed yet). A total of 2484 children and adolescents took part in the included studies. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow‐up ranged from six months to 100 weeks. Key results The included studies investigated metformin (10 studies), sibutramine (six studies), orlistat (four studies) and one study group evaluated the combination of metformin and fluoxetine. The ongoing studies are investigating metformin (four studies), topiramate (two studies) and exenatide (two studies). Most studies reported on body mass index (BMI) and bodyweight: BMI is a measure of body fat and is calculated from weight and height measurements (kg/m 2 ). In children, BMI is often measured in a way that takes into account sex, weight and height as children grow older (BMI z score). The average change in BMI across control groups was between a 1.8 kg/m 2 reduction to a 0.9 kg/m 2 increase, while across all intervention groups the average reduction was more pronounced (1.3 kg/m 2 reduction). The same effect was observed for weight change: on average, children and adolescents in the intervention groups lost 3.9 kg more weight than the children and adolescents in the control groups. Study authors reported an average of serious side effects in 24 per 1000 participants in the intervention groups compared with an average of 17 per 1000 participants in the control groups. The numbers of participants dropping out of the study because of side effects were 40 per 1000 in the intervention groups and 27 per 1000 in the control groups. The most common side effects in the orlistat and metformin studies were gut (such as diarrhoea and mild tummy pain). Common side effects in the sibutramine trials included increased heart rate (tachycardia), constipation and high blood pressure. The fluoxetine study reported dry mouth and loose stools. One study reported health‐related quality of life (a measure of physical, mental, emotional and social functioning) and found no marked differences between intervention and control. No study reported the participants' views of the intervention or socioeconomic effects. Only one study reported on morbidity (how often a disease occurs in a specific area) associated with the intervention, where there were more gallstones after the orlistat treatment. Study authors reported one suicide in the orlistat intervention group. However, studies were not long enough to reliably investigate death from any cause. No study investigated drug treatment for children who were only overweight (obese children have a much higher weight, BMI or BMI z score than children being overweight). This evidence is up to date to March 2016. Quality of the evidence The overall certainty of the evidence was low or very low, mainly because there were only a few studies per outcome measurement, the number of included children or adolescents was small, and due to variation in the results of the studies. In addition, many children or adolescents left the studies before the study had finished.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Axon, E; Atkinson, G; Richter, B; Metzendorf, MI; Baur, L; Finer, N; Corpeleijn, E; O'Malley, C; Ells, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012436", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "ba3468d6-a7d5-435c-bf0a-6a06af4c011c", "pmid": "", "title": "Corticosteroids for the long‐term treatment in multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Ciccone, A, Beretta, S, Brusaferri, F, Galea, I, Protti, A, Spreafico, C", "articleTypes": [], "doi": "10.1002/14651858.CD006264.pub2 AB - Abstract - Background Short term high dose corticosteroid treatment improves symptoms and short term disability after an acute exacerbation of multiple sclerosis (MS) but it is unknown whether its long‐term use can reduce the accumulation of disability. Objectives To determine the efficacy and safety of long‐term corticosteroid use in MS. Search methods We searched The Cochrane MS Group Trials Register (February 2007),the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to February 2007) and EMBASE (1980 to February 2007). In an effort to identify further published, unpublished and ongoing trials we searched reference lists and contacted trial authors and one pharmaceutical company. Selection criteria We considered controlled, randomised trials (RCTs), with or without blinding, of long term treatment (i.e. longer than 6 months) of any type of corticosteroid in MS, irrespective of disease course. Data collection and analysis Reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Three trials, all classified at high risk of bias, contributed to this review (Miller 1961; BPSM 1995; Zivadinov 2001) resulting in a total of 183 participants (91 treated). Corticosteroid therapy did not reduce the risk of being worse at the end of follow‐up (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.26 to 1.02) but there was a substantial heterogeneity between studies (I 2 : 78.4%). I. v. periodic high dose methylprednisolone (MP) was associated with a significant reduction in the risk of disability progression at 5 years in relapsing‐remitting (RR) MS (OR 0.26, 95% CI 0.10 to 0.66), while oral continuous low dose prednisolone was not associated with any risk reduction in disability progression at 18 months (OR 1.23, 95% CI 0.43 to 3.56). Risk of experiencing at least one exacerbation at end of follow‐up was not significantly reduced with corticosteroid treatment (OR 0.36; 95% CI 0.10 to 1.25). 
 Only one study recorded adverse events: in one patient i. v. MP was discontinued after the fourth pulse when he developed acute glomerulonephritis; a second patient was removed from the study after the fifth i. v. MP pulse because of severe osteoporosis. Authors' conclusions There is no enough evidence that long‐term corticosteroid treatment delays progression of long term disability in patients with MS. Since one study at high risk of bias showed that the administration of pulsed high dose i. v. MP is associated with a significant reduction in the risk of long term disability progression in patients with RR MS, an adequately powered, high quality RCT is needed to investigate this finding. Plain language summary The long‐term use of anti‐inflammatory corticosteroids for treating multiple sclerosis Multiple sclerosis is an inflammatory disease affecting the brain and spinal cord. It results in episodes of neurological deficit which recover (relapses) as well as accumulation of sustained disability with the passage of time. Corticosteroids are potent anti‐inflammatory drugs. It is postulated that long‐term use of steroids may reduce the accumulation of disability. The reviewers found three studies addressing this issue. A meta‐analysis showed a trend towards a beneficial effect of long‐term corticosteroids on accumulation of disability; however only two small studies contributed to this result. It was not possible to reliably comment on the effect of long‐term corticosteroids on the frequency of relapses. Side effects were poorly documented. Therefore rigorous randomised controlled trials of this treatment are warranted.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.077Z" }, { "id": "ba39de73-e78b-4cb1-9b59-93469094d1bb", "pmid": "", "title": "Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Nedocromil sodium and sodium cromoglycate inhaled shortly before exercise appear to reduce the severity of exercise‐induced bronchoconstriction. There is some debate over which drug may be more effective. Objectives The objective of this review was to compare the effects on post‐exercise lung function between prophylactic doses of nedocromil sodium (NSG) and sodium cromoglycate (SCG) in persons diagnosed with exercise‐induced bronchoconstriction. Search methods Randomized controlled trials were identified from the Cochrane Airways Review Group Asthma Register. Bibliographies of relevant studies and review articles were searched and primary authors, content experts and manufacturers of drugs were contacted for additional relevant studies. No language restrictions were applied. Searches were current as of December 2007. Selection criteria Randomized controlled trials comparing NCS to SCG in prophylactic treatment of exercise‐induced bronchoconstriction were eligible. Studies were included if: the participants, aged 6 or over, had a confirmed diagnosis of asthma with exercise‐induced bronchoconstriction, were subjected to an exercise challenge sufficient to trigger bronchoconstriction, and the measures of lung function were reported as either changes in forced expiratory volume in one second or peak expiratory flow rate. Data collection and analysis Data extraction and methodological quality assessments were conducted independently by two reviewers using standard forms and validated assessment criteria. In some cases results were extrapolated from graphs. Results from similar studies were pooled and reported as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CI) using the random effects model. Main results Nine studies (162 participants) are included in this review. No significant difference was noted between NCS and SCG with respect to the maximum percent decrease in FEV1 (WMD = ‐0.88; 95% CI: ‐4.50, 2.74), complete protection (i.e. maximum % fall FEV1 still =>10%); OR = 0.95; 95% CI: 0.50 to 1.8, clinical protection (i.e. < 50% improvement over placebo); OR = 0.71; 95% CI: 0.36 to 1.39; unpleasant taste (OR = 6.85; 95% CI: 0.77, 60.73), or sore throat (OR = 3.46; 95% CI: 0.32, 37.48). For these pooled comparisons, no statistically significant heterogeneity was identified. Subgroup analyses based on age, dosage of medications and timing of exercise post‐inhalation were consistent with the overall pooled analyses. Authors' conclusions No significant differences were evident between the effect of NCS and SCG during the immediate post‐exercise period in adults and children with EIB with regards to pulmonary function ‐ specifically maximum percent decrease in FEV1, complete protection, clinical protection, or side effects. Plain language summary Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. Two drugs, nedocromil sodium (Tilade) and sodium cromoglycate are sometimes used before exercise to prevent asthma. The review of trials found that both were similarly effective in relieving exercise‐induced asthma for both children and adults. More people have sore throats and an unpleasant after‐taste after using nedocromil sodium.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Kelly, KD; Spooner, C; Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD002731", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "ba517c89-db97-443d-a3e1-8a912a697688", "pmid": "", "title": "Aminoglycosides, vancomycin, and metronidazole for people with cirrhosis and hepatic encephalopathy", "imported": false, "abstract": "Abstract - Rationale Hepatic encephalopathy is a common complication of cirrhosis. Its development is associated with increased morbidity and mortality. Its exact pathogenesis is unknown, but ammonia, produced by bacterial action in the intestine, plays a key role. Antibiotics modulate the gut flora and may reduce intestinal ammonia production. Aminoglycosides such as neomycin, paromomycin, and ribostamycin have been used to treat hepatic encephalopathy, as have other antibiotics such as vancomycin and metronidazole. Objectives To assess the beneficial and harmful effects of aminoglycosides, vancomycin, and metronidazole versus placebo, no intervention, other antibiotics, or other active pharmacological interventions, for the prevention and treatment of hepatic encephalopathy in people with cirrhosis. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, and three other databases to 15 April 2025. We also searched online trials registries for ongoing and unpublished trials, undertook manual searches of meeting and conference proceedings, checked bibliographies of relevant articles, and corresponded with investigators and pharmaceutical companies. Eligibility criteria We included randomised clinical trials (RCTs) involving participants with cirrhosis and hepatic encephalopathy, or who were at risk of developing hepatic encephalopathy, comparing aminoglycosides, vancomycin, or metronidazole to (1) placebo or no intervention; or (2) other pharmacological agents, including non‐absorbable disaccharides, other antibiotics, or other potentially beneficial agents (e.g. branched‐chain amino acids, L‐ornithine L‐aspartate, nitazoxanide (a broad‐spectrum antiparasitic/antiviral agent), and nicotinohydroxamic acid (a potent urease inhibitor). We included trials irrespective of publication status, outcomes reported, language, or blinding. We excluded trials involving people with hepatic encephalopathy associated with acute liver failure or with non‐cirrhotic portal hypertension. Outcomes The critical outcomes were all‐cause mortality, hepatic encephalopathy, and serious adverse events. The important outcomes were non‐serious adverse events and health‐related quality of life (HRQoL). Our primary time point was the maximum length of follow‐up. Risk of bias We used Cochrane's original risk of bias tool (RoB 1) to assess the risk of bias. Synthesis methods We used standard Cochrane methods. We undertook random‐effects meta‐analyses to calculate risk ratios (RRs) or standardised mean differences (SMDs), with 95% confidence intervals (CIs). We assessed heterogeneity with the I 2 statistic, and the certainty of evidence with the GRADE framework. Included studies We included 24 RCTs, involving 1405 participants experiencing 1418 hepatic encephalopathy events. Twenty‐three trials evaluated the treatment of hepatic encephalopathy and one, the secondary prevention of hepatic encephalopathy; we analysed these trials jointly. The trials assessed three aminoglycosides: neomycin (15 trials), paromomycin (three trials), and ribostamycin (one trial), as well as vancomycin (two trials), and metronidazole (three trials). Overall, 670 participants received these pharmacotherapies while 735 participants received a placebo or other potentially beneficial agents. We classified 22 of the 24 trials to be at an overall high risk of bias based on domain‐level assessments. Synthesis of results The certainty of evidence for all comparisons was low to very low, mainly due to risk of bias, imprecision, and heterogeneity. Twenty‐three of the 24 trials, involving 1383 participants, reported all‐cause mortality data. Aminoglycosides may increase mortality slightly compared to other potentially active agents (RR 1.64, 95% CI 1.03 to 2.62; I² = 0%; 3 studies, 166 participants). The evidence was very uncertain about whether aminoglycosides versus a placebo (RR 1.02, 95% CI 0.62 to 1.69; I² = 0%; 3 studies, 137 participants), non‐absorbable disaccharides (RR 1.21, 95% CI 0.57 to 2.59; I² not applicable; 4 studies, 266 participants), or other antibiotics (RR 1.00, 95% CI 0.24 to 4.23; I² = 83%; 8 studies, 496 participants) result in a difference in mortality risk. The evidence was also very uncertain when comparing vancomycin to non‐absorbable disaccharides (RR 0.94, 95% CI 0.26 to 3.40; I² not applicable; 2 studies, 72 participants), and metronidazole to other active agents (RR 0.97, 95% CI 0.14 to 6.66; I² = 0%; 3 studies, 242 participants). Nineteen trials involving 1281 participants reported data on hepatic encephalopathy. There may be little to no difference in the effects of aminoglycosides versus non‐absorbable disaccharides (RR 0.84, 95% CI 0.67 to 1.05; I² = 0%; 3 studies, 251 participants), aminoglycosides versus other potentially active agents (RR 1.21, 95% CI 0.79 to 1.85; I² = 0%; 3 studies, 166 participants), and metronidazole versus other active agents (RR 1.50, 95% CI 0.89 to 2.54; I² = 48%; 2 studies, 208 participants). The evidence is very uncertain about the effect of aminoglycosides versus placebo, other antibiotics, and vancomycin versus non‐absorbable disaccharides. Twenty trials, involving 1186 participants, reported a total of 328 serious adverse events. Aminoglycosides may slightly increase the risk of serious adverse events compared with other potentially active agents (RR 1.60, 95% CI 1.03 to 2.47; I² = 0%; 3 studies, 166 participants). The evidence is very uncertain when comparing aminoglycosides to placebo and other antibiotics, or when comparing vancomycin to non‐absorbable disaccharides. Eighteen trials, involving 922 participants, reported a total of 96 non‐serious adverse events. There may be a slight increase in the risk of adverse events when comparing aminoglycosides to placebo (RR 2.80, 95% CI 1.11 to 7.04; I² not applicable; 2 studies, 98 participants), and to other antibiotics (RR 3.24, 95% CI 1.08 to 9.70; I² = 0%; 8 studies, 251 participants). The evidence is very uncertain about the effects of aminoglycosides versus non‐absorbable disaccharides or other active agents, and metronidazole versus other active agents. Only one trial assessed HRQoL, but reported the data in a form that precluded meta‐analysis. Eight trials received support from pharmaceutical companies while six did not. Ten trials did not provide this information. Authors' conclusions Due to low‐ or very low‐certainty evidence, we do not know if aminoglycosides benefit hepatic encephalopathy compared to placebo or other potentially active agents. There may be a slight increase in the risks of mortality and serious adverse events with aminoglycosides compared to other agents, and of non‐serious adverse events when compared to placebo and other antibiotics. We do not know if vancomycin or metronidazole improve clinically relevant outcomes. Only one trial assessed health‐related quality of life. Funding This Cochrane review received no specific funding. Registration https://doi.org/10.1002/14651858.CD012734 Plain language summary Do the antibiotics aminoglycosides, vancomycin, and metronidazole help people with cirrhosis and hepatic encephalopathy, a brain disorder associated with chronic liver disease? Key messages Antibiotics previously thought to help people with cirrhosis manage the risk of hepatic encephalopathy do not appear to benefit the condition. These antibiotics possibly cause more side effects than other treatments for this condition. Research is needed to establish whether combining these antibiotics with other treatments may be beneficial. What are cirrhosis and hepatic encephalopathy? Cirrhosis is a long‐term condition in which the liver becomes badly scarred. The liver normally helps clean the blood, process nutrients, and fight infections. When it is repeatedly damaged over time, the scar tissue which develops makes it harder for the liver to work properly. People with cirrhosis may develop hepatic encephalopathy, a condition that results in poor brain functioning. The reason why people develop hepatic encephalopathy is complex, but the build‐up in the blood of toxins from the gut, particularly of a compound called ammonia, plays a key role. Ammonia is produced in the gut mainly as a result of the activities of gut bacteria. How do antibiotics work in hepatic encephalopathy? Antibiotics are medicines used to treat infections caused by bacteria. They work by killing bacteria or stopping them from growing. Certain antibiotics may reduce the levels of ammonia in the blood by interfering with ammonia production in the gut. These antibiotics have been used to treat hepatic encephalopathy for many years, but the evidence that they help is unclear. The antibiotics considered in this review are: aminoglycosides (neomycin, paromomycin, and ribostamycin); vancomycin; metronidazole. What did we want to find out? We wanted to know if these antibiotics help to prevent or treat hepatic encephalopathy in people with cirrhosis. We analysed their effects on the number of people who died, whose symptoms of hepatic encephalopathy improved or failed to improve, and the number who experienced serious or non‐serious complications. What did we do? We searched for studies that compared aminoglycosides, vancomycin, or metronidazole to: placebo – an inactive or 'dummy' medicine; non‐absorbable disaccharides – sugars that mainly act in the gut, and are commonly used to treat some digestive and liver conditions; other antibiotics; other active agents that may help the condition. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 24 studies which involved 1405 participants. Of these, 23 studies evaluated the treatment of hepatic encephalopathy, and one study explored the prevention of hepatic encephalopathy in people at risk. We found evidence for the following comparisons: aminoglycosides versus placebo, non‐absorbable disaccharides, other antibiotics, and other active agents – 19 studies in total; vancomycin versus non‐absorbable disaccharides – 2 studies; metronidazole versus other active agents – 3 studies. Main results Death Aminoglycosides may slightly increase the risk of death compared to other active agents. We do not know if aminoglycosides make any difference to the risk of death compared to placebo, non‐absorbable disaccharides, and other antibiotics. We also do not know if there is any difference in the risk of death between: vancomycin and non‐absorbable disaccharides; metronidazole and other active agents. Hepatic encephalopathy: number of people in whom hepatic encephalopathy failed to improve Aminoglycosides may make little to no difference to the number of people whose condition improves compared to non‐absorbable disaccharides and other active agents. Metronidazole may make little to no difference to the number of people whose condition improves compared to other active agents. We do not know if there is any difference in the number of people whose condition improves when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Serious complications Aminoglycosides may slightly increase the risk of serious complications compared to other active agents. We do not know if there is any difference in serious complications when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Non‐serious complications Aminoglycosides may slightly increase the risk of non‐serious complications compared to placebo or other antibiotics. We do not know if there is any difference in the risk of non‐serious complications when comparing: aminoglycosides to non‐absorbable disaccharides or other active agents; metronidazole to other active agents; vancomycin to non‐absorbable disaccharides. Only one study, using metronidazole, reported on health‐related quality of life, so we were unable to draw any conclusions for this outcome. What are the limitations of the evidence? We had little to no confidence in the results of the review because the participants and researchers in some studies were aware of which treatment the participants received, which may have influenced the results, while some studies did not report on the outcomes we were interested in. The studies were generally small, and differed in how they were conducted. There were also too few studies to be certain about the outcomes. How current is this evidence? The evidence is current to 15 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Jeyaraj, R; Zacharias, HD; Vadera, S; Low, ZY; Gluud, LL; Morgan, MY", "articleTypes": [], "doi": "10.1002/14651858.CD012734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "ba574ed1-ec7d-4638-9f12-18a83893896c", "pmid": "", "title": "Homeopathic Oscillococcinum® for preventing and treating influenza and influenza‐like illness", "imported": false, "abstract": "Abstract - Background Influenza is a highly infectious viral disease that is particularly common in the winter months. Oscillococcinum ® is a patented homeopathic medicine that is made from a 1% solution of wild duck heart and liver extract, which is then serially diluted 200 times with water and alcohol. Objectives To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Search methods We searched CENTRAL (2014, Issue 8), MEDLINE (1966 to August week 4, 2014), MEDLINE In‐Process & Other Non‐Indexed Citations (4 September 2014), AMED (2006 to September 2014), Web of Science (1985 to September 2014), LILACS (1985 to September 2014) and EMBASE (1980 to September 2014). We contacted the manufacturers of Oscillococcinum ® for information on further trials. Selection criteria Randomised, placebo‐controlled trials of Oscillococcinum ® in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Data collection and analysis Three review authors independently extracted data and assessed risk of bias in the eligible trials. Main results No new trials were included in this 2014 update. We included six studies: two prophylaxis trials (327 young to middle‐aged adults in Russia) and four treatment trials (1196 teenagers and adults in France and Germany). The overall standard of trial reporting was poor and hence many important methodological aspects of the trials had unclear risk of bias. There was no statistically significant difference between the effects of Oscillococcinum ® and placebo in the prevention of influenza‐like illness: risk ratio (RR) 0.48, 95% confidence interval (CI) 0.17 to 1.34, P value = 0.16. Two treatment trials (judged as 'low quality') reported sufficient information to allow full data extraction: 48 hours after commencing treatment, there was an absolute risk reduction of 7.7% in the frequency of symptom relief with Oscillococcinum ® compared with that of placebo (risk difference (RD) 0.077, 95% CI 0.03 to 0.12); the RR was 1.86 (95% CI 1.27 to 2.73; P value = 0.001). A significant but lesser effect was observed at three days (RR 1.27, 95% CI 1.03 to 1.56; P value = 0.03), and no significant difference between the groups was noted at four days (RR 1.11, 95% CI 0.98 to 1.27; P value = 0.10) or at five days (RR 1.06, 95% CI 0.96 to 1.16; P value = 0.25). One of the six studies reported one patient who suffered an adverse effect (headache) from taking Oscillococcinum ® . Authors' conclusions There is insufficient good evidence to enable robust conclusions to be made about Oscillococcinum ® in the prevention or treatment of influenza and influenza‐like illness. Our findings do not rule out the possibility that Oscillococcinum ® could have a clinically useful treatment effect but, given the low quality of the eligible studies, the evidence is not compelling. There was no evidence of clinically important harms due to Oscillococcinum ® . Plain language summary Homeopathic Oscillococcinum ® for preventing and treating influenza and influenza‐like illness Review question 
 To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Background 
 Influenza ('the flu') is a highly infectious viral respiratory disease. Other than treatments for complications (such as pneumonia), the conventional medical strategies for the prevention or treatment of flu are not entirely effective or satisfactory. Oscillococcinum ® is a highly diluted homeopathic preparation manufactured from wild duck heart and liver, which may be reservoirs of flu viruses. Some people take Oscillococcinum ® regularly over the winter months either to prevent flu or as a treatment for flu symptoms. Study characteristics 
 We included six studies, which comprised two prevention trials (a total of 327 young to middle‐aged adults in Russia) and four treatment trials (a total of 1196 teenagers and adults in France and Germany). Key results 
 The findings from the two prevention trials did not show that Oscillococcinum ® can prevent the onset of flu. Although the results from the four other clinical trials suggested that Oscillococcinum ® relieved flu symptoms at 48 hours, this might be due to bias in the trial methods. One patient reported headache after taking Oscillococcinum ® . The evidence is current to September 2014. Quality of the evidence 
 The overall standard of research reporting was poor, and thus many aspects of the trials' methods and results were at unclear risk of bias. We therefore judged the evidence overall as low quality, preventing clear conclusions from being made about Oscillococcinum ® in the prevention or treatment of flu and flu‐like illness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mathie, RT; Frye, J; Fisher, P", "articleTypes": [], "doi": "10.1002/14651858.CD001957.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "ba6204f2-dec0-4eda-94c4-b017664aa1bf", "pmid": "", "title": "Relief of pain due to uterine cramping/involution after birth", "imported": false, "abstract": "Abstract - Background Women may experience differing types of pain and discomfort following birth, including cramping pain (often called after‐birth pain) associated with uterine involution, where the uterus contracts to reduce blood loss and return the uterus to its non‐pregnant size. This is an update of a review first published in 2011. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological pain relief/analgesia for the relief of after‐birth pains following vaginal birth. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (31 October 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials comparing two different types of analgesia or analgesia versus placebo or analgesia versus no treatment, for the relief of after‐birth pains following vaginal birth. Types of analgesia included pharmacological and non‐pharmacological. Quasi‐randomised trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed trials for inclusion, conducted 'Risk of bias' assessment, extracted data and assessed the certainty of the evidence using the GRADE approach. Main results In this update, we include 28 studies (involving 2749 women). The evidence identified in this review comes from middle‐ to high‐income countries. Generally the trials were at low risk of selection bias, performance bias and attrition bias, but some trials were at high risk of bias due to selective reporting and lack of blinding. Our GRADE certainty of evidence assessments ranged from moderate to very low certainty, with downgrading decisions based on study limitations, imprecision, and (for one comparison) indirectness. Most studies reported our primary outcome of adequate pain relief as reported by the women. No studies reported data relating to neonatal adverse events, duration of hospital stay, or breastfeeding rates. Almost half of the included studies (11/28) excluded breastfeeding women from participating, making the evidence less generalisable to a broader group of women. Non‐steroidal anti‐inflammatory drugs (NSAIDs) compared to placebo NSAIDs are probably better than placebo for adequate pain relief as reported by the women (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.45 to 1.91; 11 studies, 946 women; moderate‐certainty evidence). NSAIDs may reduce the need for additional pain relief compared to placebo (RR 0.15, 95% CI 0.07 to 0.33; 4 studies, 375 women; low‐certainty evidence). There may be a similar risk of maternal adverse events (RR 1.05, 95% CI 0.78 to 1.41; 9 studies, 598 women; low‐certainty evidence). NSAIDs compared to opioids NSAIDs are probably better than opioids for adequate pain relief as reported by the women (RR 1.33, 95% CI 1.13 to 1.57; 5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of maternal adverse events (RR 0.62, 95% CI 0.43 to 0.89; 3 studies, 255 women; low‐certainty evidence). NSAIDs may be better than opioids for the need for additional pain relief, but the wide CIs include the possibility that the two classes of drugs are similarly effective or that opioids are better (RR 0.37, 95% CI 0.12 to 1.12; 2 studies, 232 women; low‐certainty evidence). Opioids compared to placebo Opioids may be better than placebo for adequate pain relief as reported by the women (RR 1.26, 95% CI 0.99 to 1.61; 5 studies, 299 women; low‐certainty evidence). Opioids may reduce the need for additional pain relief compared to placebo (RR 0.48, 95% CI 0.28 to 0.82; 3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of maternal adverse events compared with placebo, although the certainty of evidence is low (RR 1.59, 95% CI 0.99 to 2.55; 3 studies, 188 women; low‐certainty evidence). Paracetamol compared to placebo Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events (2 studies, 123 women). Paracetamol compared to NSAIDs Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events. No data were reported about the need for additional pain relief comparing paracetamol and NSAIDs (2 studies, 112 women). NSAIDs compared to herbal analgesia We are uncertain if there are any differences between NSAIDs and herbal analgesia for adequate pain relief as reported by the women, the need for additional pain relief, or risk of maternal adverse events, because the certainty of evidence is very low (4 studies, 394 women). Transcutaneous nerve stimulation (TENS) compared to no TENS Very low‐certainty evidence means we are uncertain if TENS is better than no TENS for adequate pain relief as reported by the women. No other data were reported comparing TENS with no TENS (1 study, 32 women). Authors' conclusions NSAIDs may be better than placebo and are probably better than opioids at relieving pain from uterine cramping/involution following vaginal birth. NSAIDs and paracetamol may be as effective as each other, whereas opioids may be more effective than placebo. Due to low‐certainty evidence, we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater generalisability by including breastfeeding women. In addition, further research is required, including a survey of postpartum women to describe appropriately their experience of uterine cramping and involution. We identified nine ongoing studies, which may help to increase the level of certainty of the evidence around pain relief due to uterine cramping in future updates of this review. Plain language summary Relief of pain caused by uterine cramping or involution after giving birth This updated review investigates the effectiveness and safety of drug and non‐drug pain relief in women experiencing after‐birth pains following vaginal birth. Giving an agent for pain relief was compared to an inactive placebo, to no treatment, or to a different type of agent in randomised controlled trials. What is the issue? Women may experience cramping pain and discomfort following the birth of their baby, as the uterus contracts and returns to its normal pre‐pregnancy size. These pains usually last for two to three days after the birth. Women who have previously had a baby are more likely to experience after‐birth pains. Breastfeeding stimulates the uterus to contract and increases the severity of the pains. Types of pain relief used to treat the pain include paracetamol, non‐steroidal anti‐inflammatory drugs (NSAIDs) ibuprofen and naproxen, opioids including codeine, and non‐medicine methods such as herbal preparations and transcutaneous electrical nerve stimulation (TENS). Why is this important? Management of pain after birth is important, as the pain can affect a mother carrying out her normal activities as well as bonding with and caring for her baby. After‐pains can interfere with establishing breastfeeding. What evidence did we find? We searched for evidence from randomised controlled trials (October 2019) and identified 28 studies (2749 mothers) who were in hospital after uncomplicated single births. Most of the evidence is low‐certainty because the studies did not include sufficient numbers of women. Many of the studies excluded breastfeeding women.This makes the evidence less relevant to a broader group of women. No studies reported evidence on adverse events in the newborn infants. NSAIDs are probably better than placebo (a dummy treatment) in giving adequate pain relief as reported by the women (11 studies, 946 women; moderate‐certainty evidence), and they may reduce the need for additional pain relief (4 studies, 375 women; low‐certainty evidence). There may be little difference between NSAIDs and placebo in the risk of adverse events in the mother (9 studies, 598 women; low‐certainty evidence). NSAIDs are probably better than opioids in providing adequate pain relief as reported by the women (5 studies, 560 women; moderate‐certainty evidence) and may reduce the risk of adverse events in the mother (3 studies, 255 women; low‐certainty evidence). NSAIDs may slightly reduce the need for additional pain relief compared with opioids (2 studies, 232 women; low‐certainty evidence). Opioids may be better than placebo for adequate pain relief as reported by the women (5 studies, 299 women; low‐certainty evidence) and for the need for additional pain relief (3 studies, 273 women; low‐certainty evidence). Opioids may increase the risk of adverse events in the mother compared with placebo (3 studies, 188 women; low‐certainty evidence). Very low‐certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional analgesia, or risk of maternal adverse events (2 studies, 123 women). Very low‐certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events (2 studies, 112 women). Very low‐certainty evidence means we are uncertain if NSAIDs are better than herbal pain relief for adequate pain relief as reported by the women (4 studies, 394 women), the need for additional pain relief (1 study, 90 women) or risk of maternal adverse events (1 study, 108 women). Very low‐certainty evidence means we are uncertain if there is any difference between TENS and no TENS for adequate pain relief as reported by the women (1 study, 32 women). What does this mean? NSAIDs may be better than placebo and are probably better than opioids at relieving after‐birth pains following vaginal birth. The quality of the evidence was poor and we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater relevance by including breastfeeding women. Further research could also include a survey of women after delivery to capture their experience of after‐birth pains following vaginal birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Deussen, AR; Ashwood, P; Martis, R; Stewart, F; Grzeskowiak, LE", "articleTypes": [], "doi": "10.1002/14651858.CD004908.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "ba8a5f4a-9fd3-4186-a28d-b6e3babb2626", "pmid": "", "title": "Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Harmful alcohol use is defined as unhealthy alcohol use that results in adverse physical, psychological, social, or societal consequences and is among the leading risk factors for disease, disability and premature mortality globally. The burden of harmful alcohol use is increasing in low‐ and middle‐income countries (LMICs) and there remains a large unmet need for indicated prevention and treatment interventions to reduce harmful alcohol use in these settings. Evidence regarding which interventions are effective and feasible for addressing harmful and other patterns of unhealthy alcohol use in LMICs is limited, which contributes to this gap in services. Objectives To assess the efficacy and safety of psychosocial and pharmacologic treatment and indicated prevention interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs. Search methods We searched for randomized controlled trials (RCTs) indexed in the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, the Cochrane Clinical Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, and the Latin American and Caribbean Health Sciences Literature (LILACS) through 12 December 2021. We searched clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, Web of Science, and Opengrey database to identify unpublished or ongoing studies. We searched the reference lists of included studies and relevant review articles for eligible studies. Selection criteria All RCTs comparing an indicated prevention or treatment intervention (pharmacologic or psychosocial) versus a control condition for people with harmful alcohol use in LMICs were included. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 66 RCTs with 17,626 participants. Sixty‐two of these trials contributed to the meta‐analysis. Sixty‐three studies were conducted in middle‐income countries (MICs), and the remaining three studies were conducted in low‐income countries (LICs). Twenty‐five trials exclusively enrolled participants with alcohol use disorder. The remaining 51 trials enrolled participants with harmful alcohol use, some of which included both cases of alcohol use disorder and people reporting hazardous alcohol use patterns that did not meet criteria for disorder. Fifty‐two RCTs assessed the efficacy of psychosocial interventions; 27 were brief interventions primarily based on motivational interviewing and were compared to brief advice, information, or assessment only. We are uncertain whether a reduction in harmful alcohol use is attributable to brief interventions given the high levels of heterogeneity among included studies (Studies reporting continuous outcomes: Tau² = 0.15, Q =139.64, df =16, P<.001, I² = 89%, 3913 participants, 17 trials, very low certainty; Studies reporting dichotomous outcomes: Tau²=0.18, Q=58.26, df=3, P<.001, I² =95%, 1349 participants, 4 trials, very low certainty). The other types of psychosocial interventions included a range of therapeutic approaches such as behavioral risk reduction, cognitive‐behavioral therapy, contingency management, rational emotive therapy, and relapse prevention. These interventions were most commonly compared to usual care involving varying combinations of psychoeducation, counseling, and pharmacotherapy. We are uncertain whether a reduction in harmful alcohol use is attributable to psychosocial treatments due to high levels of heterogeneity among included studies (Heterogeneity: Tau² = 1.15; Q = 444.32, df = 11, P<.001; I²=98%, 2106 participants, 12 trials, very low certainty). Eight trials compared combined pharmacologic and psychosocial interventions with placebo, psychosocial intervention alone, or another pharmacologic treatment. The active pharmacologic study conditions included disulfiram, naltrexone, ondansetron, or topiramate. The psychosocial components of these interventions included counseling, encouragement to attend Alcoholics Anonymous, motivational interviewing, brief cognitive‐behavioral therapy, or other psychotherapy (not specified). Analysis of studies comparing a combined pharmacologic and psychosocial intervention to psychosocial intervention alone found that the combined approach may be associated with a greater reduction in harmful alcohol use (standardized mean difference (standardized mean difference (SMD))=‐0.43, 95% confidence interval (CI): ‐0.61 to ‐0.24; 475 participants; 4 trials; low certainty). Four trials compared pharmacologic intervention alone with placebo and three with another pharmacotherapy. Drugs assessed were: acamprosate, amitriptyline, baclofen disulfiram, gabapentin, mirtazapine, and naltrexone. None of these trials evaluated the primary clinical outcome of interest, harmful alcohol use. Thirty‐one trials reported rates of retention in the intervention. Meta‐analyses revealed that rates of retention between study conditions did not differ in any of the comparisons (pharmacologic risk ratio (RR) = 1.13, 95% CI: 0.89 to 1.44, 247 participants, 3 trials, low certainty; pharmacologic in addition to psychosocial intervention: RR = 1.15, 95% CI: 0.95 to 1.40, 363 participants, 3 trials, moderate certainty). Due to high levels of heterogeneity, we did not calculate pooled estimates comparing retention in brief (Heterogeneity: Tau² = 0.00; Q = 172.59, df = 11, P<.001; I 2 = 94%; 5380 participants; 12 trials, very low certainty) or other psychosocial interventions (Heterogeneity: Tau² = 0.01; Q = 34.07, df = 8, P<.001; I 2 = 77%; 1664 participants; 9 trials, very low certainty). Two pharmacologic trials and three combined pharmacologic and psychosocial trials reported on side effects. These studies found more side effects attributable to amitriptyline relative to mirtazapine, naltrexone and topiramate relative to placebo, yet no differences in side effects between placebo and either acamprosate or ondansetron. Across all intervention types there was substantial risk of bias. Primary threats to validity included lack of blinding and differential/high rates of attrition. Authors' conclusions In LMICs there is low‐certainty evidence supporting the efficacy of combined psychosocial and pharmacologic interventions on reducing harmful alcohol use relative to psychosocial interventions alone. There is insufficient evidence to determine the efficacy of pharmacologic or psychosocial interventions on reducing harmful alcohol use largely due to the substantial heterogeneity in outcomes, comparisons, and interventions that precluded pooling of these data in meta‐analyses. The majority of studies are brief interventions, primarily among men, and using measures that have not been validated in the target population. Confidence in these results is reduced by the risk of bias and significant heterogeneity among studies as well as the heterogeneity of results on different outcome measures within studies. More evidence on the efficacy of pharmacologic interventions, specific types of psychosocial interventions are needed to increase the certainty of these results. Plain language summary Interventions to reduce harmful alcohol use in low‐ and middle‐income countries Why is this review important? Harmful alcohol use is one of the main contributors to the global burden of disease. In low‐ and middle‐income countries, harmful alcohol use is increasing. However, services to prevent and treat harmful alcohol use are limited. One contributor to the lack of available services is the limited information about which intervention approaches are effective in reducing harmful alcohol use and whether these approaches are feasible and acceptable in low‐resource settings. In order to prevent the physical, psychological, and societal burden of harmful alcohol use, it is important that effective interventions are available to reduce alcohol‐related harm. What is the goal of this review? The goal of this review is to summarize evidence on whether psychosocial and pharmacologic interventions are able to reduce harmful alcohol use in low‐ and middle‐income countries. We also aim to evaluate the safety of treatments and how many people remain in treatment until its completion. What does the research say? We identified 66 randomized controlled trials that evaluated the effect of interventions on reducing harmful alcohol use. Most of these studies assessed psychosocial interventions (n = 52 studies), six assessed pharmacologic interventions alone, and eight assessed combined pharmacologic and psychosocial interventions. The majority of included trials were funded by government agencies (36 trials) followed by multiple public and private funders (8 trials) or private foundations (5 trials). Seventeen trials did not report the funding source. We are uncertain whether brief psychosocial interventions and other psychosocial interventions reduce harmful alcohol use. Combined pharmacologic and psychosocial interventions may reduce harmful alcohol use relative to psychosocial interventions combined with placebo, yet the certainty of the evidence has been assessed as low. No studies were found that looked at the effect of pharmacologic interventions alone on harmful alcohol use. We did not find evidence that rates of retention differed between study conditions for any of the intervention types. Certainty of evidence: The certainty of evidence on the effect of brief and other psychosocial interventions on harmful alcohol use was very low due to lack of masking, differential attrition and missing data, selective outcome reporting, high heterogeneity, and differences in patient populations. The certainty of evidence on the effect of combined pharmacologic and psychosocial interventions on harmful alcohol use was low due to lack of blinding, incomplete outcome data, and heterogeneity in the pharmacologic interventions under investigation. No studies evaluated the effect of pharmacologic interventions alone on harmful alcohol use. The evidence is current to 12 December 2021. What are the next steps? Future research on interventions to reduce harmful alcohol use is needed to address some of the limitations described in this review. Studies evaluating similar interventions across studies and contexts are needed to improve generalizability and understand the necessary characteristics of and conditions for effective intervention. Studies must utilize measurement tools that are valid in the population they are studying. Lastly, studies must be designed to reduce the risk of bias leading to the high degree of uncertainty in the results reported in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, MC; Kane, J; Alto, M; Giusto, A; Lovero, K; Stockton, M; McClendon, J; Nicholson, T; Wainberg, ML.; Johnson, RM; Tol, WAnton", "articleTypes": [], "doi": "10.1002/14651858.CD013350.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "ba8aaac8-3ff0-4ed9-bc07-4753d10bf145", "pmid": "", "title": "Fish oil for kidney transplant recipients", "imported": false, "abstract": "Abstract - Background Calcineurin inhibitors used in kidney transplantation for immunosuppression have adverse effects that may contribute to nephrotoxicity and increased cardiovascular risk profile. Fish oils are rich in very long chain omega‐3 fatty acids, which may reduce nephrotoxicity by improving endothelial function and reduce rejection rates through their immuno‐modulatory effects. They may also modify the cardiovascular risk profile. Hence, fish oils may potentially prolong graft survival and reduce cardiovascular mortality. Objectives This review aimed to look at the benefits and harms of fish oil treatment in ameliorating the kidney and cardiovascular adverse effects of CNI‐based immunosuppressive therapy in kidney transplant recipients. Search methods We searched the Cochrane Kidney and Transplant Specialised Register (up to 17 March 2016) through contact with the Information Specialist using search terms relevant to this review. Selection criteria All randomised controlled trials (RCTs) and quasi‐RCTs of fish oils in kidney transplant recipients on a calcineurin inhibitor‐based immunosuppressive regimen. RCTs of fish oil versus statins were included. Data collection and analysis Data was extracted and the quality of studies assessed by two authors, with differences resolved by discussion with a third independent author. Dichotomous outcomes were reported as risk ratio (RR) and continuous outcome measures were reported as the mean difference (MD) with 95% confidence intervals using the random effects model. Heterogeneity was assessed using a Chi 2 test on n‐1 degrees of freedom and the I 2 statistic. Data not suitable for pooling were tabulated and described. Main results Fifteen studies (733 patients) were suitable for analysis. All studies were small and had variable methodology. Fish oil did not significantly affect patient or graft survival, acute rejection rates, or calcineurin inhibitor toxicity when compared to placebo. Overall SCr was significantly lower in the fish oil group compared to placebo (5 studies, 237 participants: MD ‐30.63 µmol/L, 95% CI ‐59.74 to ‐1.53; I 2 = 88%). In the subgroup analysis, this was only significant in the long‐course (six months or more) group (4 studies, 157 participants: MD ‐37.41 µmol/L, 95% CI ‐69.89 to ‐4.94; I 2 = 82%). Fish oil treatment was associated with a lower diastolic blood pressure (4 studies, 200 participants: MD ‐4.53 mm Hg, 95% CI ‐7.60 to ‐1.45) compared to placebo. Patients receiving fish oil for more than six months had a modest increase in HDL (5 studies, 178 participants: MD 0.12 mmol/L, 95% CI 0.03 to 0.21; I 2 = 47%) compared to placebo. Fish oil effects on lipids were not significantly different from low‐dose statins. There was insufficient data to analyse cardiovascular outcomes. Fishy aftertaste and gastrointestinal upset were common but did not result in significant patient drop‐out. Authors' conclusions There is insufficient evidence from currently available RCTs to recommend fish oil therapy to improve kidney function, rejection rates, patient survival or graft survival. The improvements in HDL cholesterol and diastolic blood pressure were too modest to recommend routine use. To determine a benefit in clinical outcomes, future RCTs will need to be adequately powered with these outcomes in mind. Plain language summary Fish oil for kidney transplant recipients This review set out to assess any benefit or harm in using fish oil to reduce the risk of kidney damage and heart disease in people who have had a kidney transplant and are receiving standard drugs to prevent rejection. Information from 15 studies was used and showed that fish oils provide a slight improvement in HDL cholesterol and diastolic blood pressure. These studies did not provide enough information on the differences in the risk of death, heart disease, kidney transplant rejection or kidney function between patients receiving fish oils and those receiving placebo. There appeared to be no harmful effects of taking fish oil. The benefits of taking fish oil after a kidney transplant are a mild improvement in some heart disease risk factors. There was not enough information to show any benefit in preventing heart disease or reduction in kidney function. Larger, better studies are needed before regular use of fish oil can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lim, AKH; Manley, KJ; Roberts, MA; Fraenkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD005282.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "ba9a149c-dd50-43ee-8e54-00baada67a41", "pmid": "", "title": "Interventions for latent autoimmune diabetes (LADA) in adults", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Brophy, S, Davies, H, Mannan, S, Brunt, H, Williams, R", "articleTypes": [], "doi": "10.1002/14651858.CD006165.pub3 AB - Abstract - Background Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes. Objectives To compare interventions used for LADA. Search methods Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta‐analysis or descriptive methods. Main results Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow‐up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: ‐1.3% (95% confidence interval (CI) ‐2.4 to ‐0.1; P = 0.03, 160 participants, four studies, follow‐up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C‐peptide, but insulin maintained stimulated C‐peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow‐up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C‐peptide levels (20 μg group) were maintained after five years. Short term (three months) follow‐up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C‐peptide levels compared to insulin alone (0.07 µg/L (95% CI ‐0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C‐peptide levels in the vitamin D group but declining fasting C‐peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow‐up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health‐related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes). Authors' conclusions Two studies show SU leading to earlier insulin dependence and a meta‐analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 μg) have been suggested to maintain fasting and stimulated C‐peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA. Plain language summary Interventions for latent autoimmune diabetes (LADA) in adults LADA is a condition that at diagnosis looks like type 2 diabetes (non‐insulin requiring diabetes mellitus) but actually is a type 1 diabetes, where the patient will become insulin requiring. In the UK approximately 3.6% of people who look like they have type 2 diabetes actually have type 1 diabetes, while other studies suggest the prevalence is higher and treatment for these patients may need to be different from that used in type 2 diabetes. 
 We identified 15 publications (10 studies) looking at 1019 patients who were followed between three months to 10 years. We found many of the publications had poor quality of reporting and had small numbers of participants. However, there does seem to be evidence from this review that the drug sulphonylurea (like glibenclamide or glyburide, gliclazide) could make patients insulin dependent sooner and it does not control blood sugar as well as insulin. Therefore, this suggests that this drug should not be a first line treatment for patients with LADA. In addition, insulin combined with vitamin D, or Chinese herbs may maintain natural insulin production better than insulin alone. Similarly, glutamic acid decarboxylase (GAD65) may maintain natural insulin production. However, there was no conclusive evidence that any of the other remaining treatment methods were better than each other. Studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic attacks. This review represents very early days of our understanding of the best way to treat LADA. It is limited by the poor reporting quality of the studies, small sample sizes, no clear single definition of LADA and many of the studies being carried out in different ethnic groups (China, Japan, Cuba, UK, Sweden) with different clinical care systems. 
 None of the publications reported on complications of diabetes, health‐related quality of life, costs or health service utilisation. All but one of the publications reported there were no deaths. 
 In summary, this review demonstrates that insulin treatment may be preferable compared to sulphonylurea treatment but there is little evidence regarding other forms of treatment. Future studies are needed, should have a clear definition of LADA, investigate patient‐important outcomes and use a common method of measuring stimulated C‐peptide (a marker of natural insulin production reflecting improved beta‐cell function of the pancreas).", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.125Z" }, { "id": "baa2f3a0-5d93-4c72-b3d2-fb048be3c3a6", "pmid": "", "title": "Omega‐3 fatty acid supplementation for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Studies suggest that a diet rich in omega‐3 essential fatty acids may have beneficial anti‐inflammatory effects for chronic conditions such as cystic fibrosis. This is an updated version of a previously published review. Objectives To determine whether there is evidence that omega‐3 polyunsaturated fatty acid supplementation reduces morbidity and mortality and to identify any adverse events associated with supplementation. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of last search: 01 April 2020. We also searched online study registries and contacted authors. Date of last search: 12 February 2020. Selection criteria Randomised controlled trials in people with cystic fibrosis comparing omega‐3 fatty acid supplements with placebo. Data collection and analysis Two authors independently selected studies for inclusion, extracted data and assessed the risk of bias of the studies. The quality of the evidence was assessed using GRADE. Main results The searches identified 23 studies; five studies with 106 participants (children and adults) were included; duration of studies and interventions differed. Two studies compared omega‐3 fatty acids to olive oil for six weeks; one study compared omega‐3 fatty acids and omega‐6 fatty acids to control capsules (customised fatty acid blends) for three months; one study compared a liquid dietary supplement containing omega‐3 fatty acids to one without for six months; and one study compared omega‐3 fatty acids to a placebo for 12 months. Three studies had a low risk of bias for randomisation, but the risk was unclear in the remaining two studies; all studies had an unclear risk of bias for allocation concealment. Three of the studies adequately blinded participants; the risk of bias for selective reporting was high in one study and unclear for four studies. Two studies reported the number of respiratory exacerbations. At three months, one study (43 participants) reported no change in antibiotic usage. At 12 months the second study (15 participants) reported a reduction in the number of pulmonary exacerbations and cumulative antibiotic days in the supplement group compared to the previous year (no data for the control group); very low‐quality evidence means we are unsure whether supplementation has any effect on this outcome. With regards to adverse events, one six‐week study (12 participants) reported no difference in diarrhoea between omega‐3 or placebo capsules; the very low‐quality evidence means we are unsure if supplementation has any effect on this outcome. Additionally, one study reported an increase in steatorrhoea requiring participants to increase their daily dose of pancreatic enzymes, but three studies had already increased pancreatic enzyme dose at study begin so as to reduce the incidence of steatorrhoea. One study (43 participants) reported stomach pains at three months (treatment or control group not specified). One six‐week study (19 participants) reported three asthma exacerbations leading to exclusion of participants since corticosteroid treatment could affect affect essential fatty acid metabolism. Four studies reported lung function. One six‐week study (19 participants) reported an increase in forced expiratory volume in one second (FEV 1 ) (L) and forced vital capacity (FVC) (L), but the very low‐quality evidence means we are unsure if supplementation has any effect on lung function. The remaining studies did not report any difference in lung function at three months (unit of measurement not specified) or at six months and one year (FEV 1 % predicted and FVC % predicted). No deaths were reported in any of the five studies. Four studies reported clinical variables. One study reported an increase in Schwachman score and weight alongside a reduction in sputum volume with supplementation compared to placebo at three months (data not analysable). However, three studies reported no differences in either weight at six weeks, in body mass index (BMI) standard deviation (SD) score at six months (very low‐quality evidence) or BMI Z score at 12 months. Three studies reported biochemical markers of fatty acid status. One study showed an increase from baseline in both EPA and DHA content of serum phospholipids in the omega‐3 group compared to placebo at three months and also a significant decrease in n‐6/n‐3 ratio in the supplement group compared to placebo; since the quality of the evidence is very low we are not certain that these changes are due to supplementation. One six‐month cross‐over study showed a higher EPA content of the neutrophil membrane in the supplement group compared to the placebo group, but, no difference in DHA membrane concentration. Furthermore, the leukotriene B 4 to leukotriene B 5 ratio was lower at six months in the omega‐3 group compared to placebo. A one‐year study reported a greater increase in the essential fatty acid profile and a decrease in AA levels in the treatment arm compared to placebo. Authors' conclusions This review found that regular omega‐3 supplements may provide some limited benefits for people with cystic fibrosis with relatively few adverse effects: however, the quality of the evidence across all outcomes was very low. The current evidence is insufficient to draw firm conclusions or recommend routine use of these supplements in people with cystic fibrosis. A large, long‐term, multicentre, randomised controlled study is needed to determine any significant therapeutic effect and to assess the influence of disease severity, dosage and duration of treatment. Future researchers should note the need for additional pancreatic enzymes when providing omega‐3 supplementation or olive oil placebo capsules. More research is required to determine the exact dose of pancreatic enzyme required. Plain language summary The use of omega‐3 supplements in people with cystic fibrosis Review question We reviewed the evidence about the effect of giving omega‐3 supplements to people with cystic fibrosis. Background In people with cystic fibrosis recurring cycles of infection and inflammation are thought to worsen lung function. Studies suggest that omega‐3 fatty acids, such as those derived from fish oils, may work to counter the inflammation and may be of benefit in chronic inflammatory diseases including cystic fibrosis. This is an updated version of the review. Search date The evidence is current to: 01 April 2020. Study characteristics This review includes five small studies which compare omega‐3 supplements to a different supplement without omega‐3. In total there were 106 participants, including both children and adults. The studies lasted between six weeks and 12 months. Key results Due to the very low‐quality evidence, we are uncertain whether the following effects are due to supplementation or not. One 12‐month study reported a reduction in pulmonary exacerbations and antibiotic use when taking omega‐3 supplementation compared to placebo and one three‐month study reported no change in antibiotic use during the study period. Few side effects were reported in any of the studies. One six‐week study reported that lung function and clinical status improved when taking omega‐3 supplements. Sputum levels were also noted to be reduced in this six‐week study. Three studies reported no difference in lung function when taking omega‐3 supplementation compared to placebo. Two longer studies found that people taking omega‐3 supplements showed definite increases in levels of essential fatty acids in their white blood cell membranes and also in levels of phospholipids (molecules that provide structure and protection to cells) measured in blood samples. We are uncertain whether regular omega‐3 supplements benefit people with cystic fibrosis and whether they cause side effects, or not. We are not able to draw firm conclusions or recommend the routine use of these supplements in people with cystic fibrosis. Larger and longer studies are needed to assess the clinical benefit of omega‐3 supplementation and to determine the appropriate dosage. Quality of the evidence We judged the quality of the evidence to be very low due to very low participant numbers, low event rates, limited reporting and poor study design. There was no consistency with regards to the time points when results were reported or the measurements used for the same outcome in different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Watson, H; Stackhouse, C", "articleTypes": [], "doi": "10.1002/14651858.CD002201.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "bab6acdb-066a-46e3-a504-6916add81557", "pmid": "", "title": "Souvenaid for Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Souvenaid is a dietary supplement with a patented composition (Fortasyn Connect™)which is intended to be used by people with Alzheimer's disease (AD). It has been designed to support the formation and function of synapses in the brain, which are thought to be strongly correlated with cognitive function. If effective, it might improve symptoms of Alzheimer's disease and also prevent the progression from prodromal Alzheimer's disease to dementia. We sought in this review to examine the evidence for this proposition. Objectives To assess the effects of Souvenaid on incidence of dementia, cognition, functional performance, and safety in people with Alzheimer's disease. Search methods We searched ALOIS, i.e. the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science (ISI Web of Science), Cinahl (EBSCOhost), Lilacs (BIREME), and clinical trials registries up to 24 June 2020. We also reviewed citations of reference lists of landmark papers, reviews, and included studies for additional studies and assessed their suitability for inclusion in the review. Selection criteria We included randomised, placebo‐controlled trials which evaluated Souvenaid in people diagnosed with mild cognitive impairment (MCI) due to AD (also termed prodromal AD) or with dementia due to AD, and with a treatment duration of at least 16 weeks. Data collection and analysis Our primary outcome measures were incidence of dementia, global and specific cognitive function, functional performance, combined cognitive‐functional outcomes and adverse events. We selected studies, extracted data, assessed the quality of trials and intended to conduct meta‐analyses according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We present all outcomes grouped by stage of AD. Main results We included three randomised, placebo‐controlled trials investigating Souvenaid in 1097 community‐dwelling participants with Alzheimer's disease. One study each included participants with prodromal AD, mild AD dementia and mild‐to‐moderate AD dementia. We rated the risks of bias of all trials as low. One study (in prodromal AD) was funded by European grants. The other two studies were funded by the manufacturer of Souvenaid. One trial investigated the incidence of dementia in people with prodromal AD at baseline, and found little to no difference between the Souvenaid group and the placebo group after 24 months (RR 1.09, 95% CI 0.82 to 1.43; 1 trial, 311 participants; moderate quality of evidence). In prodromal AD, and in mild and mild‐to‐moderate Alzheimer's disease dementia, Souvenaid probably results in little or no difference in global or specific cognitive functions (moderate quality of evidence). Everyday function, or the ability to perform activities of daily living, were measured in mild and mild‐to‐moderate AD dementia. Neither study found evidence of a difference between the groups after 24 weeks of treatment (moderate quality of evidence). Two studies investigated combined cognitive‐functional outcomes with the Clinical Dementia Rating Sum of Boxes and observed conflicting results. Souvenaid probably results in slight improvement, which is below estimates of meaningful change, in participants with prodromal Alzheimer's disease after 24 months (moderate quality of evidence), but probably has little to no effect in mild‐to‐moderate Alzheimer's disease dementia after 24 weeks (moderate quality of evidence). Adverse effects observed were low in all trials, and the available data were insufficient to determine any connection with Souvenaid. Authors' conclusions Two years of treatment with Souvenaid probably does not reduce the risk of progression to dementia in people with prodromal AD. There is no convincing evidence that Souvenaid affects other outcomes important to people with AD in the prodromal stage or mild‐to‐moderate stages of dementia. Conflicting evidence on combined cognitive‐functional outcomes in prodromal AD and mild AD dementia warrants further investigation. Adverse effects of Souvenaid seem to be uncommon, but the evidence synthesised in this review does not permit us to make a definitive statement on the long‐term tolerability of Souvenaid. The effects of Souvenaid in more severe AD dementia or in people with AD at risk of nutritional deficiencies remain unclear. Plain language summary The dietary supplement Souvenaid for preventing dementia or delaying cognitive decline in people with Alzheimer's disease Review question We investigated whether people with mild cognitive impairment (MCI) due to Alzheimer's disease (AD) can reduce their risk of developing dementia with a patented dietary supplement called Souvenaid. We also investigated the effect of Souvenaid on memory or other thinking skills, ability to carry out daily activities, and side effects in people with MCI or any stage of dementia due to AD. Background Alzheimer's disease is a brain disease. It is the commonest cause of dementia among older people. A person is said to have dementia when there has been a decline in their memory and thinking skills which is severe enough to stop them being fully independent in all their daily activities. Because AD develops slowly, it is also possible to pick up symptoms before dementia is fully developed. This pre‐dementia stage, when people with AD have a detectable decline in memory and thinking skills but are still able to manage their usual activities independently, is known as mild cognitive impairment due to AD, or 'prodromal' AD. Souvenaid is a patented mix of vitamins and minerals (Fortasyn Connect™) which was designed to improve brain function in AD. It is a drink which is to be taken once a day. It is intended to be consumed under medical supervision, in addition to the usual diet. Search for evidence We systematically searched for randomised controlled trials (RCTs) which were published up to June 2020 and which compared treatment with Souvenaid for at least 16 weeks with treatment with a dummy supplement (a placebo). For the comparison to be fair, it had to be decided randomly whether each participant was given Souvenaid or the placebo. Key results We found three RCTs with a total of 1097 participants to include in the review. Two of the trials investigated Souvenaid in people with dementia over a treatment period of 24 weeks. One of these included 527 participants with mild‐to‐moderate dementia due to AD and the other included 259 participants with mild dementia due to AD. The third trial investigated the use of Souvenaid for two years in 311 people with prodromal AD. We considered all of the trials to be well‐designed, but because of differences between them in the severity of the participants' symptoms and in the way the researchers measured their results, we were not able to combine the data numerically from the single trials. All the results we report are therefore based on single trials, which leads us to have only moderate confidence in the findings of this review. This means that results could be changed by further research. We found that people with prodromal AD who took Souvenaid daily for two years were probably no more or less likely than those taking placebo to develop dementia. Souvenaid probably had little or no effect on measures of memory or other thinking skills in people with prodromal AD (after two years of treatment) or with mild or mild‐to‐moderate dementia due to AD (after 24 weeks of treatment). It also probably had little or no effect on the ability of people with mild or mild‐to‐moderate dementia due to AD to manage everyday activities (again after 24 weeks). Two studies used an outcome scale which combined memory and thinking skills with practical skills (described as a combined cognitive‐functional outcome). There was probably a small benefit of Souvenaid on this outcome among people with prodromal AD who took Souvenaid for two years. However, there was probably little or no effect of Souvenaid on this outcome among people with mild‐to‐moderate AD dementia who took it for 24 weeks. There were only a few adverse events reported in the trials, and it was not possible to know whether any of them were side effects of Souvenaid. Study funding sources Two studies were funded by the manufacturer of Souvenaid. The third study (in prodromal AD) was funded by European grants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Burckhardt, M, Watzke, S, Wienke, A, Langer, G, Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD011679.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.095Z" }, { "id": "bac9c97c-92b4-4d62-ac62-4aff66aab645", "pmid": "", "title": "Systemic corticosteroids for acute otitis media in children", "imported": false, "abstract": "Abstract - Background Acute otitis media (AOM) is a common acute infection in children. Pain is its most prominent and distressing symptom. Antibiotics are commonly prescribed for AOM, although they have only a modest effect in reducing pain at two to three days. There is insufficient evidence for benefits of other treatment options, including systemic corticosteroids. However, systemic corticosteroids are potent anti‐inflammatory drugs, and so theoretically could be effective, either alone or as an addition to antibiotics. Objectives To assess the effects of systemic corticosteroids (oral or parenteral), with or without antibiotics, for AOM in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) which contains the Cochrane ARI Group's Specialised Register, MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), Web of Science (Thomson Reuters), and LILACS (BIREME) for published studies, and ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for completed and ongoing studies, to 20 February 2018. We checked the reference lists of all primary studies and review articles for additional references and contacted experts in the field to identify additional unpublished materials. Selection criteria We included randomised controlled trials of children with AOM that compared any systemic corticosteroid (oral or parenteral) with placebo, either with antibiotics (corticosteroid plus antibiotic versus placebo plus antibiotic) or without antibiotics (corticosteroid versus placebo). Data collection and analysis Three review authors (EDS, RR, YP) independently screened the titles and abstracts and retrieved the full texts of potentially relevant studies. We independently extracted study characteristics and outcome data from the included studies, and assessed the risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed study quality using the GRADE method. Main results We included two studies involving 252 children with AOM aged from three months to six years receiving hospital ambulatory care who were treated with intramuscular ceftriaxone, and who were then randomised to the corticosteroid group (corticosteroid and corticosteroid plus antihistamine) or the placebo group (antihistamine and double placebo). In one study, children also had a needle aspiration of middle ear fluid. Both studies were at unclear risk of bias for allocation concealment, and unclear to high risk of bias for selective reporting. One study (N = 179) included pain as an outcome, but we were unable to derive the proportion of children with persistent pain at Day 5 and Day 14. Reduction of overall or specific symptoms was presented as improvement in clinical symptoms and resolution of inflamed tympanic membranes without the need for additional antibiotic treatment: at Day 5 (94% of children in the treatment group (N = 89) versus 89% in the placebo group (N = 90); risk ratio (RR) 1.06, 95% confidence interval (CI) 0.97 to 1.16) and Day 14 (91% versus 87%; RR 1.05, 95% CI 0.95 to 1.17). Low‐quality evidence meant that we are uncertain of the effectiveness of corticosteroids for this outcome. The second study (N = 73) reported a reduction of overall or specific symptoms without additional antibiotic treatment during the first two weeks as a favourable outcome. Children in the treatment group had more favourable outcomes (adjusted odds ratio 65.9, 95% CI 1.28 to 1000; P = 0.037), although the numbers were small. We were unable to pool the results with the other study because it did not report the proportion of children with this outcome by treatment group. Only one study reported adverse effects of corticosteroids (e.g. drowsiness, nappy rash), but did not quantify incidence, so we were unable to draw conclusions about adverse effects. Neither study reported a reduction in overall or specific symptom duration. Authors' conclusions The evidence for the effect of systemic corticosteroids on AOM is of low to very low quality, meaning the effect of systemic corticosteroids on important clinical outcomes in AOM remains uncertain. Large, high‐quality studies are required to resolve the question . Plain language summary Systemic corticosteroids for improving symptoms in children with acute middle ear infection Review question We reviewed the evidence on the effects of corticosteroids given by mouth or injection for acute middle ear infection (acute otitis media (AOM)) in children, particularly in improving symptoms such as ear pain, fever, irritability, lack of sleep, and lack of appetite. We also looked at the side effects of corticosteroids. Background Acute otitis media is common in children and causes ear pain and non‐specific symptoms such as fever, irritability, and deafness. It is often treated with antibiotics, although ear pain generally resolves within two days, and antibiotics help symptoms only slightly. Other treatments (such as over‐the‐counter antihistamines and decongestants) do not help very much. Corticosteroids are often prescribed to reduce inflammation in children for other illnesses, and so may also help symptoms of AOM, which is an inflammatory process. We investigated whether using corticosteroids was better or worse than nothing in improving AOM‐related symptoms. Search date Our evidence is current to 20 February 2018. Study characteristics We included two studies involving 252 children with AOM, aged from three months to six years, receiving hospital ambulatory care. Children were treated with an antibiotic injection and either oral corticosteroid or a placebo (treatment with no effect). In one study, fluid from the middle ear was collected by inserting a needle through the eardrum to measure the level of inflammation. Study funding sources The National Institutes of Health (NIH) and the National Center for Research Resources, NIH, US Public Health Service funded both studies. Pharmaceutical companies provided the drug but did not contribute any other scientific or financial support. Key results and quality of evidence Corticosteroids did not make a significant difference in improving the symptoms and inflammation of the eardrum(s) at Day 5 and Day 14, but we are unsure of this effect due to the small numbers of children in the studies. There were no significant differences between the corticosteroid and placebo groups in terms of resolving fluid in children's middle ears (at 1, 2, and 3 months) and experiencing new episodes of AOM (at 1, 2, 3 months, and 4 and 6 months). Neither study reported a reduction in the duration of overall or specific symptoms, rupture of eardrum(s), the occurrence of middle ear inflammation in the other ear following the current ear infection, or serious complications. Only one study reported the overall side effects identified during the trial (e.g. drowsiness, dry mouth, diaper rash, nervousness). We could not draw any conclusions regarding the effects of corticosteroids for AOM in children. The quality of evidence included in this review was low to very low due to few children included in two small studies. We are uncertain about whether or not corticosteroids are useful in relieving pain from AOM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ranakusuma, RW; Pitoyo, Y; Safitri, ED; Thorning, S; Beller, EM; Sastroasmoro, S; Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD012289.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "bafc9efb-3404-4419-9cd2-43f5915bd3f3", "pmid": "", "title": "Sumatriptan (intranasal route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Intranasal administration may be preferable to oral for individuals experiencing nausea and/or vomiting, although it is primarily absorbed in the gut, not the nasal mucosa. Objectives To determine the efficacy and tolerability of intranasal sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using intranasal sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Twelve studies (4755 participants) compared intranasal sumatriptan with placebo or an active comparator. Most of the data were for the 10 mg and 20 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 10 mg versus placebo the NNTs were 7.3, 7.4, and 5.5 for pain‐free at two hours, and headache relief at one and two hours, respectively. For sumatriptan 20 mg versus placebo the NNTs were 4.7, 4.9, and 3.5, respectively, for the same outcomes. The 20 mg dose was significantly better than the 10 mg dose for each of these three primary efficacy outcomes. Relief of headache‐associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo. Direct comparison of sumatriptan with active treatments was limited to two studies, one comparing sumatriptan 20 mg and dihydroergotamine (DHE) 1 mg, and one comparing sumatriptan 20 mg with rizatriptan 10 mg. Authors' conclusions Intranasal sumatriptan is effective as an abortive treatment for acute migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events compared with placebo. Plain language summary Sumatriptan (intranasal route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a nasal spray, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, although absorption of the drug occurs primarily in the gut rather than the nasal mucosa. This review found that a single intranasal dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in approximately 2 in 10 people (24%) taking sumatriptan 10 mg, compared with about 1 in 10 (10%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 5 in 10 people (50%) taking sumatriptan 10 mg, compared with approximately 3 in 10 (32%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those who took placebo. The 20 mg dose had greater efficacy, but may be associated with more adverse events, most of which were of short duration and mild or moderate in severity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD009663", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.749Z" }, { "id": "bb05bfd6-6e09-4c50-bbd6-029b513fd45d", "pmid": "", "title": "Gelsectan® in the Treatment of Patients With Diarrhoea-predominant Irritable Bowel Syndrome: a Multicentre, Randomized, Double-blind, Parallel-group, Placebo-controlled Study", "imported": false, "abstract": "Irritable Bowel Syndrome (IBS) is one of the major Disorders of Gut-Brain Interaction (DGBI) and the most frequent reasons for referral to both primary care providers and gastroenterologists.IBS is not a life-threatening disease, but imposes a significant burden on society, entailing a decrease in patients' Quality of Life (QoL), elevated rates of psychological comorbidities and loss of work productivity, which might be the greatest in subjects with IBS-D, for whom the fear of incontinence in a social situation can be especially debilitating. Moreover, IBS is associated with significant direct and indirect healthcare costs and has a considerable socioeconomic impact on society.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.161Z" }, { "id": "bb12702f-7a06-42f5-b104-8772c0f78a55", "pmid": "", "title": "Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2010 and previously updated in 2011. Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period. Objectives To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 4 July 2013. Selection criteria We included randomised controlled trials in which oral rinses, mouthwashes and sprays, used pre‐ and postoperatively, have been compared with placebo in adults or children undergoing tonsillectomy, with or without adenoidectomy. Data collection and analysis Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently. Main results We included seven trials (593 participants; 397 children and 196 adults). The period of follow‐up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre‐specified primary outcomes and none for the secondary outcomes. The risk of bias was high in most of the included trials. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage. Authors' conclusions Poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well‐constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data. Plain language summary Oral rinses, mouthwashes and sprays for improving outcomes following tonsillectomy Tonsillectomy is one of the most common operations performed in adults and children. Pain and bleeding following the operation are common. Postoperative tonsillectomy medication should aim to minimise some of these symptoms. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the period just after surgery. This review included seven studies involving 593 participants (397 children and 196 adults) and is up to date as of July 2013. The risk of bias was high in most of the included trials. We found that lidocaine spray appeared to be more effective than a placebo saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation when they used another spray containing benzydamine but this was not sufficient to discontinue its usage. Further research should aim to provide reliable evidence for people to make informed decisions as to whether these treatments can be effective in reducing the most common symptoms and complications following tonsillectomy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fedorowicz, Z, van Zuuren, EJ, Nasser, M, Carter, B, Al Langawi, JH", "articleTypes": [], "doi": "10.1002/14651858.CD007806.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.744Z" }, { "id": "bb190ecb-b5b7-4bf2-8fcb-bc1ce723c9b2", "pmid": "", "title": "Maternal Characteristics Associated With Child Growth and Adiposity. Search for Nutrigenomic Biomarkers in Peripheral Blood", "imported": false, "abstract": "The goal of this observational study is to investigate the concentrations of leptin, insulin, liver expressed antimicrobial peptide 2 (LEAP2), and cortisol in plasma and breast milk and their relationship with eating behavior, growth, adiposity and with the levels of these hormones in infants, comparing mothers with normal weight and with pre-pregnancy overweight/obesity. The main question[s] it aims to answer are:", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.149Z" }, { "id": "bb20272a-c7cd-40cd-88df-a09d62f9622b", "pmid": "", "title": "Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years", "imported": false, "abstract": "Abstract - Background Child and adolescent overweight and obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages. Objectives To assess the effects of diet, physical activity and behavioural interventions (behaviour‐changing interventions) for the treatment of overweight or obese children aged 6 to 11 years. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases. Selection criteria We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour‐changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow‐up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. Data collection and analysis Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta‐analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty‐five trials compared a behaviour‐changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour‐changing intervention. Sixty‐four trials were parallel RCTs, and four were cluster RCTs. Sixty‐four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2. Primary analyses demonstrated that behaviour‐changing interventions compared to no treatment/usual care control at longest follow‐up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was ‐0.53 kg/m 2 (95% confidence interval (CI) ‐0.82 to ‐0.24); P < 0.00001; 24 trials; 2785 participants; low‐quality evidence. MD in BMI z score was ‐0.06 units (95% CI ‐0.10 to ‐0.02); P = 0.001; 37 trials; 4019 participants; low‐quality evidence and MD in weight was ‐1.45 kg (95% CI ‐1.88 to ‐1.02); P < 0.00001; 17 trials; 1774 participants; low‐quality evidence. Thirty‐one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health‐related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI ‐12.88 to ‐0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all‐cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta‐analysed. As the meta‐analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post‐intervention follow‐up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post‐intervention was no longer evident at follow‐up at less than six months, which has to be investigated in further trials. Authors' conclusions Multi‐component behaviour‐changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short‐term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour‐changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour‐changing interventions on health‐related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer‐term follow‐up and further research on the most appropriate forms of post‐intervention maintenance in order to ensure intervention benefits are sustained over the longer term. Plain language summary Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years Review question How effective are diet, physical activity and behavioural interventions in reducing the weight of overweight or obese children aged 6 to 11 years? Background Across the world more children are becoming overweight and obese. These children are more likely to suffer from health problems, both while as children and in later life. More information is needed about what works best for treating this problem. Study characteristics We found 70 randomised controlled trials (clinical trials where people are randomly put into one of two or more treatment groups) comparing diet, physical activity, and behavioural (where habits are changed or improved) treatments to a variety of control groups delivered to 8461 overweight or obese children aged 6 to 11 years. We reported on the effects of 64 multicomponent interventions (different combinations of diet and physical activity and behaviour change), four physical activity interventions and two dietary interventions compared with no intervention, 'usual care’ or some other therapy if it was also delivered in the intervention arm. The children in the included studies were followed up between six months and three years. Key results The average age of the children was 10 years. Most studies reported the body mass index (BMI) z score: BMI is a measure of body fat and is calculated by dividing weight (in kilograms) by the square of the body height measured in metres (kg/m²). In children, BMI is often measured in a way that takes into account sex and age, weight, and height changes as children grow older (BMI z score). We summarised the results of 37 trials in 4019 children reporting the BMI z score, which on average was 0.06 units lower in the intervention groups compared with the control groups. We summarised the results of 24 trials in 2785 children reporting BMI, which on average was 0.53 kg/m 2 lower in the intervention groups compared with the control groups. We summarised the results of 17 trials in 1774 children reporting weight, which on average was 1.45 kg lower in the intervention groups compared with the control groups. Other effects of the interventions, such as improvements in health‐related quality of life were less clear. No study investigated death from any cause, morbidity or socioeconomic effects. Serious adverse events were rare: only two of 31 trials with data reported any serious adverse events (4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). This evidence is up to date as of July 2016. Quality of the evidence The overall quality of the evidence was low or very low, mainly because of limited confidence in how studies were performed, and the results were inconsistent between the studies. Also there were just a few studies for some outcomes, with small numbers of included children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Mead, E; Brown, T; Rees, K; Azevedo, LB; Whittaker, V; Jones, D; Olajide, J; Mainardi, GM; Corpeleijn, E; O'Malley, C; Beardsmore, E; Al‐Khudairy, L; Baur, L; Metzendorf, MI; Demaio, A; Ells, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012651", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "bb330ed3-744e-4074-9e87-e231c1557f39", "pmid": "", "title": "Interventions for leg cramps in pregnancy", "imported": false, "abstract": "Abstract - Background Many women experience leg cramps in pregnancy. They become more common as pregnancy progresses and are especially troublesome at night. Objectives The objective of this review was to assess methods of preventing and treating leg cramps in pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2001). We updated this search on 4 July 2011 and added the results to the awaiting classification section. Selection criteria Randomised trials of treatments for leg cramps in pregnancy. Data collection and analysis Trial quality was assessed and data were extracted independently by two reviewers. Main results Five trials involving 352 women were included. The trials were of moderate quality. The only placebo‐controlled trial of calcium treatment showed no evidence of benefit. Trials comparing sodium chloride with placebo (odds ratio 0.54, 95% confidence interval 0.23 to 1.29) and calcium with sodium chloride (odds ratio 1.23, 95% confidence intervals 0.47 to 3.27 ) showed no evidence of benefit. Placebo controlled trials of multivitamin with mineral supplements (odds ratio 0.23, 95% confidence intervals 0.05 to 1.01) and magnesium (odds ratio 0.18, 95% confidence intervals 0.05 to 0.60) provided some suggestion of benefit. Authors' conclusions The evidence that calcium reduces cramp is weak and seems to depend on placebo effect. The evidence for sodium chloride is stronger but the results of the sodium chloride trial may no longer be relevant because of dietary changes which include an increased sodium intake in the general population. It is not possible to recommend multivitamins with mineral supplementation, as it is not clear which ingredient, if any, is helping. If a woman finds cramp troublesome in pregnancy, the best evidence is for magnesium lactate or citrate taken as 5mmol in the morning and 10mmol in the evening. [Note: The five citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Interventions for leg cramps in pregnancy Sodium supplements may decrease the number of cramp attacks experienced by women in pregnancy but the effect is slight. Calcium is of no benefit. The evidence of benefit for magnesium is stronger. Multivitamin and mineral supplements also seem to help but the relevance of this is unclear as the preparation used contained twelve separate constituents and it is not possible to discover which of these was effective, or indeed if there was synergy between constituents. There is a theoretical risk that sodium supplementation could raise blood pressure. It is unlikely that magnesium supplementation would be harmful at the suggested doses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Young, G; Jewell, D", "articleTypes": [], "doi": "10.1002/14651858.CD000121", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "bb433658-aa17-4778-af51-3a15c99c5333", "pmid": "", "title": "Changes in Taste Perception, Eating Habits, and Other Behavioral Aspects Associated With the Use of GLP-1 Receptor Agonists in Patients Undergoing Weight Loss Treatment: A Retrospective Observational Study.", "imported": false, "abstract": "This observational retrospective study aims to evaluate changes in taste perception, eating habits, and behavioral aspects in adults treated with GLP-1 receptor agonists for weight loss. Participants include adults aged 18-60 receiving treatment at specialized nutrition centers in Italy. Data are collected from clinical records, dietary questionnaires, and metabolic assessments before and after at least 12 weeks of GLP-1 agonist treatment. The study's primary goal is to understand how these treatments affect food preferences and taste perception. Secondary outcomes include changes in body weight, body composition, gastrointestinal side effects, and treatment adherence. All data are anonymized and collected according to ethical guidelines.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.231Z" }, { "id": "bb6fa399-265d-428a-86c0-3a3170e2989a", "pmid": "", "title": "N‐acetylcysteine as an adjuvant therapy for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) is one of the most common pathogens to establish and cause infection in human beings, affecting about 50% of the world's population. Prevalence may be as high as 83% in Latin American countries and as low as 17% in North America. Approximately 20% of infected people will manifest disease; people at high risk include those who live in low‐ and middle‐income countries with poor sanitary conditions, since the mechanism of transmission seems to be oral‐oral or faecal‐oral (mostly during infancy). There are several antibiotic regimens to treat the infection, but antibiotic resistance is growing around the world. New adjuvant drugs — such as probiotics, statins, curcumin, and N‐acetylcysteine (NAC) — are being tested to enhance eradication rates. N‐acetylcysteine can destabilise the biofilm structure; it also has synergic action with antibiotics, and bactericidal effects. In addition, NAC has antioxidant properties, and has a primary mucolytic effect by reducing the thickness of the gastric mucus layer, both of which may exert beneficial adjuvant effects on H pylori eradication. Objectives To assess the efficacy and safety of N‐acetylcysteine as an adjuvant therapy to antibiotics for Helicobacter pylori eradication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to April 2018), Embase (1988 to April 2018), CINAHL (1982 to April 2018), LILACS (1982 to April 2018), grey literature databases and trials registries. We handsearched the reference lists of relevant studies. We screened 726 articles and assessed 18 for eligibility. Selection criteria We included randomised controlled trials (RCTs) of any antibiotic regimen plus NAC, in adults infected with H pylori . To be included, trials had to use a control consisting of the same antibiotic regimen with or without placebo. Outcomes of interest were eradication rates, and gastrointestinal, toxic, and allergic adverse events. Reporting of the primary outcomes listed here was not an inclusion criterion for the review. Data collection and analysis Two review authors independently reviewed and extracted data and completed the 'Risk of bias' assessments. A third review author independently confirmed the 'Risk of bias' assessments. We used Review Manager 5 software for data analysis. We contacted study authors if there was missing information. Main results We included eight RCTs (with a total of 559 participants) in this review. The studies recruited outpatients aged between 17 and 76 years who were referred to endoscopy centres in several different countries. The certainty of evidence was reduced for most outcomes due to the poor methodological quality of included studies; issues mainly related to the generation of allocation sequence, allocation concealment, and blinding (this last domain related specifically to adverse outcomes). We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates, compared with the addition of placebo or no NAC (38.8% versus 49.1%, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.51 to 1.08; participants = 559; studies = eight; very low‐certainty evidence). A post‐hoc sensitivity analysis, in which we removed studies that tested antibiotic regimens no longer recommended in clinical practice, showed that the addition of NAC may improve eradication rates compared to control (27.2% versus 37.6%, RR 0.71, 95% CI 0.53 to 0.94; participants = 397; published studies = five). We are uncertain whether NAC is associated with a higher risk of gastrointestinal adverse events compared to control (23.9% versus 18.9%, RR 1.25, 95% CI 0.85 to 1.85; participants = 336; studies = five; very low‐certaintyevidence), or allergic adverse events (2% versus 0%, RR 2.98, 95% CI 0.32 to 27.74; participants = 336; studies = five; very low‐certainty evidence). There were no reports of toxic adverse events amongst included studies. Authors' conclusions We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates compared with the addition of placebo or no NAC. Due to the clinical, statistical and methodological heterogeneity found in included studies, and the uncertainty observed when analysing therapy subgroups, any possible beneficial effect of NAC should be regarded cautiously. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed, randomised clinical studies should be conducted, with good reporting standards and appropriate collection of efficacy and safety outcomes, especially for current recommended antibiotic regimens. Plain language summary N‐acetylcysteine taken with antibiotics for treatment of Helicobacter pylori infection Review question Is the addition of N‐acetylcysteine to antibiotics safe and does it improve cure rates for Helicobacter pylori infection? Background Helicobacter pylori ( H pylori ) is a bacteria that lives in the stomach and might cause several diseases such as gastric cancer, ulcer disease, and others. Colonisation occurs in about one‐half of the world's population and is more common in countries with poor sanitary conditions. People become infected by consuming contaminated water. The infection is treated using antibiotics and a drug which reduces acid production in the stomach. However, rates of antibiotic resistance are rising around the world, which is reducing the cure rates even with treatment. New medications are being tested to improve cure rates. One of these medications is N‐acetylcysteine (NAC). NAC is a drug that helps to dissolve mucus in respiratory diseases. It can be taken by mouth (orally) or injected into a vein (intravenous). NAC can destroy some mechanisms of survival of H pylori and could improve cure rates. Study characteristics We included eight studies (specifically, randomised controlled trials (RCTs)) with a total of 559 people aged between 17 and 76 years old. The evidence is current to April 2018. All studies recruited outpatients from endoscopy centres (centres that specialise in an examination done with a flexible tube with a camera that is inserted into stomach) in several countries. The antibiotic combinations tested were very different in the included studies, as were the doses of NAC (600 mg to 1800 mg per day). NAC was compared with placebo (dummy pill) or nothing. Key results We are uncertain whether the addition of NAC to antibiotics improves H pylori cure rates compared with the addition of placebo or no NAC. Any possible beneficial effect of NAC should be regarded cautiously because the included studies were very different and of low certainty, with some flaws that could have compromised their results and consequently, the results of this review. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed randomised clinical studies, with good reporting standards and appropriate collection of effectiveness and safety outcomes should be done, especially for current recommended antibiotic combinations. Quality of the evidence The overall certainty of the evidence for eradication rates ranged from very low to low. Five studies provided information on adverse events (side effects), and the certainy of evidence was very low. The included studies were poorly conducted and this reduced our confidence in the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fontes, LES; Martimbianco, ALC; Zanin, C; Riera, R", "articleTypes": [], "doi": "10.1002/14651858.CD012357.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "bbaac59c-d567-41df-abe9-1124251a5b39", "pmid": "", "title": "The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents", "imported": false, "abstract": "Abstract - Background Erythropoiesis‐stimulating agents (ESAs) are commonly used to treat chemotherapy‐induced anemia (CIA). However, about half of patients do not benefit. Objectives To evaluate the benefits and harms related to the use of iron as a supplement to ESA and iron alone compared with ESA alone in the management of CIA. Search methods We searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1 January 2016), MEDLINE (1950 to February 2016), and www.clinicaltrials.gov without using any language limits. Selection criteria All randomized controlled trials (RCTs) comparing 'iron plus ESA' or 'iron alone' versus 'ESA alone' in people with CIA were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included eight RCTs (12 comparisons) comparing ESA plus iron versus ESA alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone in people with CIA. None of the included RCTs reported overall survival. There was a beneficial effect of iron supplementation to ESAs compared with ESAs alone on hematopoietic response (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.09 to 1.26; P < 0.0001; 1712 participants; 11 comparisons; high‐quality evidence). Assuming a baseline risk of 35% to 80% for hematopoietic response without iron supplementation, between seven and 16 patients should be treated to achieve hematopoietic response in one patient. In subgroup analyses, RCTs that used intravenous (IV) iron favored ESAs and iron (RR 1.20 (95% CI 1.10 to 1.31); P < 0.00001; 1321 participants; eight comparisons), whereas we found no evidence for a difference in hematopoietic response in RCTs using oral iron (RR 1.04 (95% CI 0.87 to 1.24); P = 0.68; 391 participants; three comparisons). There was no evidence for a difference between the subgroups of IV and oral iron (P = 0.16). There was no evidence for a difference between the subgroups of types of iron (P = 0.31) and types of ESAs (P = 0.16) for hematopoietic response. The iron supplementation to ESAs might be beneficial as fewer participants treated with iron supplementation required red blood cell (RBC) transfusions compared to the number of participants treated with ESAs alone (RR 0.74 (95% CI 0.60 to 0.92); P = 0.007; 1719 participants; 11 comparisons; moderate‐quality evidence). Assuming a baseline risk of 7% to 40% for RBC transfusion without iron supplementation, between 10 and 57 patients should be treated to avoid RBC transfusion in one patient. We found no evidence for a difference in the median time to hematopoietic response with addition of iron to ESAs (hazard ratio (HR) 0.93 (95% CI 0.67 to 1.28); P = 0.65; 1042 participants; seven comparisons; low‐quality evidence). In subgroup analyses, RCTs in which dextran (HR 0.95 (95% CI 0.36 to 2.52); P = 0.92; 340 participants; three comparisons), sucrose iron (HR 1.15 (95% CI 0.60 to 2.21); P = 0.67; 102 participants; one comparison) and sulfate iron (HR 1.24 (95% CI 0.99 to 1.56); P = 0.06; 55 participants; one comparison) were used showed no evidence for difference between iron supplementation versus ESAs alone compared with RCTs in which gluconate (HR 0.78 (95% CI 0.65 to 0.94); P = 0.01; 464 participants; two comparisons) was used for median time to hematopoietic response (P = 0.02). There was no evidence for a difference between the subgroups of route of iron administration (P = 0.13) and types of ESAs (P = 0.46) for median time to hematopoietic response. Our results indicated that there could be improvement in the hemoglobin (Hb) levels with addition of iron to ESAs (mean difference (MD) 0.48 (95% CI 0.10 to 0.86); P = 0.01; 827 participants; seven comparisons; low‐quality evidence). In RCTs in which IV iron was used there was evidence for a difference (MD 0.84 (95% CI 0.21 to 1.46); P = 0.009; 436 participants; four comparisons) compared with oral iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) for mean change in Hb level (P = 0.03). RCTs in which dextran (MD 1.55 (95% CI 0.62 to 2.47); P = 0.001; 102 participants; two comparisons) was used showed evidence for a difference with iron supplementation versus ESAs alone compared with RCTs in which gluconate (MD 0.54 (95% CI ‐0.15 to 1.22); P = 0.12; 334 participants; two comparisons) and sulfate iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) were used for mean change in Hb level (P = 0.007). RCTs in which epoetin was used showed evidence for a difference with iron supplementation versus ESAs alone (MD 0.77 (95% CI 0.25 to 1.29); P = 0.004; 337 participants; five comparisons) compared with darbepoetin use (MD 0.10 (95% CI ‐0.13 to 0.33); P = 0.38; 490 participants; two comparisons) for mean change in Hb level (P = 0.02). We found no evidence for a difference in quality of life with addition of iron to ESAs (standardized mean difference 0.01 (95% CI ‐0.10 to 0.12); P = 0.88; 1124 participants; three RCTs; high‐quality evidence). We found no evidence for a difference in risk of grade III‐IV thromboembolic events (RR 0.95 (95% CI 0.54 to 1.65); P = 0.85; 783 participants; three RCTs; moderate‐quality evidence). The incidence of treatment‐related mortality (TRM) was 0% (997 participants; four comparisons; high‐quality evidence). Other common adverse events included vomiting, asthenia, and leukopenia, and were similar in both arms. Overall the risk of bias across outcomes was high to low. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown. Our main reasons for downgrading the quality of evidence were inconsistency across the included studies and imprecision of results. Authors' conclusions Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation. Plain language summary The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents Review question: Is iron alone or iron as a supplement to erythropoiesis‐stimulating agents (ESAs) superior to ESAs alone in the management of people diagnosed with chemotherapy‐induced anemia (CIA)? Background: The current treatment of CIA is ESAs, which increase the production of red blood cells (erythropoiesis), and in some cases ESAs and iron. In some cases, strategies such as no therapy or wait and watch with clinical oversight and red blood cell transfusion may be safe and suitable options. We conducted a systematic review to evaluate the benefits and harms of iron in the management of CIA. Search date: The evidence is current to February 2016. Study characteristics: We included eight industry‐funded randomized controlled trials (RCTs) comparing ESAs plus iron versus ESAs alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone. Study funding source: All the included trials were industry funded. Key results: Adding iron to ESAs improves the hematopoietic response in people with CIA. Use of iron with ESAs might reduce the risk of blood transfusions and improve hemoglobin. We found no improvement in quality of life with addition of iron. We found no evidence for a difference in time to hematopoietic response and risk of development of blood clot in veins of people with CIA treated with iron and ESAs compared with ESAs alone. There were zero treatment‐related deaths among 997 participants in the four trials that reported this outcome. Other harms included constipation, vomiting, and diarrhea, and were similar with ESAs and iron compared with ESAs alone. None of the trials reported data on survival. Quality of evidence: The quality of evidence for hematopoietic response was high. The quality of evidence for red blood cell transfusion was moderate, as the pooled estimate had large variation. The quality of evidence for change in hemoglobin and time to hematopoietic response was low, as the pooled estimates had large variation and results were not similar across studies. The quality of evidence for quality of life was high. The quality of evidence for risk of blood clots in veins was moderate due to variation in pooled estimate. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Mhaskar, R; Wao, H; Miladinovic, B; Kumar, A; Djulbegovic, B", "articleTypes": [], "doi": "10.1002/14651858.CD009624.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "bbb2cd2d-11e2-4081-b38b-480f4085c50b", "pmid": "", "title": "Antiplatelet agents for the treatment of adults with COVID‐19", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Fischer, A-L, Messer, S, Riera, R, Martimbianco, ALC, Stegemann, M, Estcourt, LJ, Weibel, S, Monsef, I, Andreas, M, Pacheco, RL, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015078 AB - Abstract - Background Severe coronavirus disease 2019 (COVID‐19) can cause thrombotic events that lead to severe complications or death. Antiplatelet agents, such as acetylsalicylic acid, have been shown to effectively reduce thrombotic events in other diseases: they could influence the course of COVID‐19 in general. Objectives To assess the efficacy and safety of antiplatelets given with standard care compared to no treatment or standard care (with/without placebo) for adults with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (which comprises MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO ICTRP, medRxiv, CENTRAL), Web of Science, WHO COVID‐19 Global literature on coronavirus disease and the Epistemonikos COVID‐19 L*OVE Platform to identify completed and ongoing studies without language restrictions to December 2022. Selection criteria We followed standard Cochrane methodology. We included randomised controlled trials (RCTs) evaluating antiplatelet agents for the treatment of COVID‐19 in adults with COVID‐19, irrespective of disease severity, gender or ethnicity. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane risk of bias tool (RoB 2) for RCTs. We rated the certainty of evidence using the GRADE approach for the outcomes. Main results Antiplatelets plus standard care versus standard care (with/without placebo) Adults with a confirmed diagnosis of moderate to severe COVID‐19 We included four studies (17,541 participants) that recruited hospitalised people with a confirmed diagnosis of moderate to severe COVID‐19. A total of 8964 participants were analysed in the antiplatelet arm (either with cyclooxygenase inhibitors or P2Y12 inhibitors) and 8577 participants in the control arm. Most people were older than 50 years and had comorbidities such as hypertension, lung disease or diabetes. The studies were conducted in high‐ to lower middle‐income countries prior to wide‐scale vaccination programmes. Antiplatelets compared to standard care: – probably result in little to no difference in 28‐day mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.85 to 1.05; 3 studies, 17,249 participants; moderate‐certainty evidence). In absolute terms, this means that for every 177 deaths per 1000 people not receiving antiplatelets, there were 168 deaths per 1000 people who did receive the intervention (95% CI 151 to 186 per 1000 people); – probably result in little to no difference in worsening (new need for invasive mechanical ventilation or death up to day 28) (RR 0.95, 95% CI 0.90 to 1.01; 2 studies, 15,266 participants; moderate‐certainty evidence); – probably result in little to no difference in improvement (participants discharged alive up to day 28) (RR 1.00, 95% CI 0.96 to 1.04; 2 studies, 15,454 participants; moderate‐certainty evidence); – probably result in a slight reduction of thrombotic events at longest follow‐up (RR 0.90, 95% CI 0.80 to 1.02; 4 studies, 17,518 participants; moderate‐certainty evidence); – may result in a slight increase in serious adverse events at longest follow‐up (Peto odds ratio (OR) 1.57, 95% CI 0.48 to 5.14; 1 study, 1815 participants; low‐certainty evidence), but non‐serious adverse events during study treatment were not reported; – probably increase the occurrence of major bleeding events at longest follow‐up (Peto OR 1.68, 95% CI 1.29 to 2.19; 4 studies, 17,527 participants; moderate‐certainty evidence). Adults with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included two RCTs allocating participants, of whom 4209 had confirmed mild COVID‐19 and were not hospitalised. A total of 2109 participants were analysed in the antiplatelet arm (treated with acetylsalicylic acid) and 2100 participants in the control arm. No study included people with asymptomatic SARS‐CoV‐2 infection. Antiplatelets compared to standard care: – may result in little to no difference in all‐cause mortality at day 45 (Peto OR 1.00, 95% CI 0.45 to 2.22; 2 studies, 4209 participants; low‐certainty evidence); – may slightly decrease the incidence of new thrombotic events up to day 45 (Peto OR 0.37, 95% CI 0.09 to 1.46; 2 studies, 4209 participants; low‐certainty evidence); – may make little or no difference to the incidence of serious adverse events up to day 45 (Peto OR 1.00, 95% CI 0.60 to 1.64; 1 study, 3881 participants; low‐certainty evidence), but non‐serious adverse events were not reported. The evidence is very uncertain about the effect of antiplatelets on the following outcomes (compared to standard care plus placebo): – admission to hospital or death up to day 45 (Peto OR 0.79, 95% CI 0.57 to 1.10; 2 studies, 4209 participants; very low‐certainty evidence); – major bleeding events up to longest follow‐up (no event occurred in 328 participants; very low‐certainty evidence). Quality of life and adverse events during study treatment were not reported. Authors' conclusions In people with confirmed or suspected COVID‐19 and moderate to severe disease, we found moderate‐certainty evidence that antiplatelets probably result in little to no difference in 28‐day mortality, clinical worsening or improvement, but probably result in a slight reduction in thrombotic events. They probably increase the occurrence of major bleeding events. Low‐certainty evidence suggests that antiplatelets may result in a slight increase in serious adverse events. In people with confirmed COVID‐19 and mild symptoms, we found low‐certainty evidence that antiplatelets may result in little to no difference in 45‐day mortality and serious adverse events, and may slightly reduce thrombotic events. The effects on the combined outcome admission to hospital or death up to day 45 and major bleeding events are very uncertain. Quality of life was not reported. Included studies were conducted in high‐ to lower middle‐income settings using antiplatelets prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, adverse events and people with asymptomatic infection. The 14 ongoing and three completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. Plain language summary Are antiplatelets an effective treatment for people with COVID‐19? Key messages Antiplatelets are a group of different medicines that can prevent potentially fatal clot formation in the blood vessels ('thrombotic events'). For hospitalised patients with COVID‐19, they probably slightly reduce thrombotic events but probably do not affect deaths, clinical worsening or improvement in COVID‐19 compared with placebo or standard care. However, antiplatelets may result in a slight increase in serious unwanted effects ('adverse events') and probably increase major bleeding. Similarly, in non‐hospitalised people, antiplatelets slightly decrease thrombotic events. They may result in little to no difference in deaths or serious unwanted effects, however the evidence on admission to hospital or death and major bleeding events is very uncertain. There are 14 further studies that have not completed yet, and the results of three other completed studies are not yet available. What are antiplatelets? Antiplatelets are a group of drugs which, in different ways, stop blood from changing to a gel‐like substance called a clot, which we mean by the term 'thrombotic events'. They are taken mainly by mouth, usually by people who are at high risk of developing a clot (people who have already experienced or who tend to build up a clot). A clot could lead to a stroke, coronary heart disease, poor blood circulation in the legs, thromboses in the legs or clot obstruction ('embolism') in the lung circulation that could lead to shortness of breath, heart failure and death. How might antiplatelets treat COVID‐19? People with COVID‐19 might be at risk from blood clots. Antiplatelets prevent clots from forming in the body, and this could in turn prevent complications that lead to death and clinical deterioration. What did we want to find out? We wanted to know whether antiplatelets in addition to usual care are effective for adults with COVID‐19, when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in: – number of deaths from any cause up to 28 days after treatment, or longer if reported;
– whether people got better or worse after treatment (including unwanted effects of the disease itself, like thrombotic events);
– unwanted effects of the treatment (especially major bleeding). What did we do? We searched for studies that reported on people with COVID‐19 who received antiplatelets together with usual care, or usual care alone (with/without placebo). We summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We identified four studies, including 17,541 people with moderate to severe COVID‐19 (hospitalised). Of these, one compared acetylsalicylic acid (aspirin) with usual care, two studies compared 'P2Y12 inhibitors' (e.g. clopidogrel, prasugrel, ticagrelor) with usual care, and a fourth one compared either acetylsalicylic acid or P2Y12 inhibitors with usual care. The studies included people with a confirmed or suspected diagnosis of SARS‐CoV‐2 infection. Two studies compared acetylsalicylic acid to placebo in 4209 non‐hospitalised people with confirmed mild COVID‐19. We also found 14 ongoing studies, two studies without published results and another that had been withdrawn after a preprint version. We found no studies that included people with COVID‐19 infection but no symptoms. Main results Antiplatelets: – probably make little or no difference to deaths by 28 or 180 days, worsening up to day 28 (new invasive mechanical ventilation or death) or improvement (discharged alive) up to day 28, and they probably slightly decrease thrombotic events; – may result in a slight increase in serious unwanted effects and probably increase major bleeding events. In people not in hospital, with mild disease, antiplatelets may result in little to no difference in death within 45 days, or in the incidence of serious adverse events, and they may slightly decrease the incidence of thrombotic events. The evidence for these participants is very uncertain about the effects on worsening (hospitalisation or death within 45 days) and on major bleeding events. Studies did not report on quality of life and general unwanted effects. What are the limitations of the evidence? The studies were conducted in populations from high‐ to middle‐income countries, many of them prior to the roll‐out of COVID‐19 vaccination programmes and before Omicron became the most prevalent variant. We have moderate confidence in the evidence for mortality, worsening/improvement up to day 28, and major bleeding events or thrombotic events in hospitalised people. We have low confidence in the evidence for the effects on serious unwanted effects, because they occurred rarely. For non‐hospitalised people, our confidence in the evidence is low for the effects on death, thrombotic events and serious adverse events, and very low for the effects on worsening and major bleeding events (those events were rare and the time period between symptom onset and treatment was long). Information about other unwanted effects and quality of life was not available. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 22 December 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.804Z" }, { "id": "bbb7b7d3-b3ed-459c-8626-a14892820386", "pmid": "", "title": "Pharmacological interventions for prevention of weight gain in people with schizophrenia", "imported": false, "abstract": "Abstract - Background Antipsychotic‐induced weight gain is an extremely common problem in people with schizophrenia and is associated with increased morbidity and mortality. Adjunctive pharmacological interventions may be necessary to help manage antipsychotic‐induced weight gain. This review splits and updates a previous Cochrane Review that focused on both pharmacological and behavioural approaches to this problem. Objectives To determine the effectiveness of pharmacological interventions for preventing antipsychotic‐induced weight gain in people with schizophrenia. Search methods The Cochrane Schizophrenia Information Specialist searched Cochrane Schizophrenia's Register of Trials on 10 February 2021. There are no language, date, document type, or publication status limitations for inclusion of records in the register. Selection criteria We included all randomised controlled trials (RCTs) that examined any adjunctive pharmacological intervention for preventing weight gain in people with schizophrenia or schizophrenia‐like illnesses who use antipsychotic medications. Data collection and analysis At least two review authors independently extracted data and assessed the quality of included studies. For continuous outcomes, we combined mean differences (MD) in endpoint and change data in the analysis. For dichotomous outcomes, we calculated risk ratios (RR). We assessed risk of bias for included studies and used GRADE to judge certainty of evidence and create summary of findings tables. The primary outcomes for this review were clinically important change in weight, clinically important change in body mass index (BMI), leaving the study early, compliance with treatment, and frequency of nausea. The included studies rarely reported these outcomes, so, post hoc, we added two new outcomes, average endpoint/change in weight and average endpoint/change in BMI. Main results Seventeen RCTs, with a total of 1388 participants, met the inclusion criteria for the review. Five studies investigated metformin, three topiramate, three H2 antagonists, three monoamine modulators, and one each investigated monoamine modulators plus betahistine, melatonin and samidorphan. The comparator in all studies was placebo or no treatment (i.e. standard care alone). We synthesised all studies in a quantitative meta‐analysis. Most studies inadequately reported their methods of allocation concealment and blinding of participants and personnel. The resulting risk of bias and often small sample sizes limited the overall certainty of the evidence. Only one reboxetine study reported the primary outcome, number of participants with clinically important change in weight. Fewer people in the treatment condition experienced weight gains of more than 5% and more than 7% of their bodyweight than those in the placebo group (> 5% weight gain RR 0.27, 95% confidence interval (CI) 0.11 to 0.65; 1 study, 43 participants; > 7% weight gain RR 0.24, 95% CI 0.07 to 0.83; 1 study, 43 participants; very low‐certainty evidence). No studies reported the primary outcomes, 'clinically important change in BMI', or 'compliance with treatment'. However, several studies reported 'average endpoint/change in body weight' or 'average endpoint/change in BMI'. Metformin may be effective in preventing weight gain (MD −4.03 kg, 95% CI −5.78 to −2.28; 4 studies, 131 participants; low‐certainty evidence); and BMI increase (MD −1.63 kg/m2, 95% CI −2.96 to −0.29; 5 studies, 227 participants; low‐certainty evidence). Other agents that may be slightly effective in preventing weight gain include H2 antagonists such as nizatidine, famotidine and ranitidine (MD −1.32 kg, 95% CI −2.09 to −0.56; 3 studies, 248 participants; low‐certainty evidence) and monoamine modulators such as reboxetine and fluoxetine (weight: MD −1.89 kg, 95% CI −3.31 to −0.47; 3 studies, 103 participants; low‐certainty evidence; BMI: MD −0.66 kg/m2, 95% CI −1.05 to −0.26; 3 studies, 103 participants; low‐certainty evidence). Topiramate did not appear effective in preventing weight gain (MD −4.82 kg, 95% CI −9.99 to 0.35; 3 studies, 168 participants; very low‐certainty evidence ) . For all agents, there was no difference between groups in terms of individuals leaving the study or reports of nausea. However, the results of these outcomes are uncertain given the very low‐certainty evidence. Authors' conclusions There is low‐certainty evidence to suggest that metformin may be effective in preventing weight gain. Interpretation of this result and those for other agents, is limited by the small number of studies, small sample size, and short study duration. In future, we need studies that are adequately powered and with longer treatment durations to further evaluate the efficacy and safety of interventions for managing weight gain. Plain language summary How effective are medications given alongside antipsychotics at preventing weight gain in people with schizophrenia? Key messages ‐ Metformin may be effective in preventing weight gain caused by antipsychotics. ‐ H2 antagonists and monoamine modulators may be slightly effective in preventing weight gain caused by antipsychotics. ‐ Future studies should include more people and evaluate them for longer. What are antipsychotics? Antipsychotics are medications used to treat symptoms of psychosis, such as hallucinations, delusions and agitation. They are often used to treat people with schizophrenia. Examples of antipsychotics are haloperidol (Haldol), chlorpromazine (Thorazine), olanzapine (Zyprexa) and risperidone (Risperdal). Schizophrenia and weight gain People with schizophrenia are twice as likely as the general population to be overweight, perhaps due to a poor diet and an inactive lifestyle. Excess weight can lead to other health conditions, such as heart disease, stroke and diabetes. Unfortunately, an unwanted effect of antipsychotics is weight gain. Sometimes, people with schizophrenia are given medications alongside antipsychotics (‘add‐on’ medications) to prevent this additional weight gain. These add‐on medications may stop people feeling hungry or help them feel full. Usually, they are medications developed for other purposes, such as metformin, which is a medicine to treat diabetes, and fluoxetine, which is an antidepressant. What did we want to find out? We wanted to find out whether add‐on medications to prevent weight gain caused by antipsychotics were effective in people with schizophrenia. What did we do? We searched for studies that examined any medicine given alongside antipsychotics to prevent weight gain in people with schizophrenia. Study participants could be any age or sex but had to have a diagnosis of schizophrenia or a schizophrenia‐like illness. They had to be chosen at random to receive either the weight‐prevention medicine, or a placebo (a dummy medicine) or no add‐on medicine (standard treatment). We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 17 studies with 1388 people that examined the effects of add‐on medications to prevent weight gain caused by antipsychotics. The add‐on medications were metformin, topiramate, H2 antagonists, monoamine modulators, monoamine modulators plus betahistine, melatonin, and samidorphan. Studies were short, lasting between 6 and 24 weeks. And they were small, with only 63 people on average ‐ the smallest included only 14 people, the largest 561 people. Studies done to date suggest that: ‐ metformin may be effective in preventing weight gain and is well‐tolerated compared to standard treatment (5 studies, 232 participants); ‐ H2 antagonists, such as nizatidine, famotidine and ranitidine, or monoamine modulators, such as reboxetine and fluoxetine may be potentially effective in preventing weight gain caused by antipsychotics; ‐ topiramate is probably not effective in preventing weight gain caused by antipsychotics. What are the limitations of the evidence? Our confidence in the evidence is limited because we found only a small number of studies for each add‐on medication. Studies included few people, and lasted only a short time. How up to date is this evidence? The evidence is up to date to February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Agarwal, SM, Stogios, N, Ahsan, ZA, Lockwood, JT, Duncan, MJ, Takeuchi, H, Cohn, T, Taylor, VH, Remington, G, Faulkner, GE J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.783Z" }, { "id": "bbbe4dab-1a00-40ba-90a9-73e6d5aabf6c", "pmid": "", "title": "Topical antibiotics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection (involving more than one micro‐organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms are ear discharge and hearing loss. Topical antibiotics, the most common treatment for CSOM, aim to kill or inhibit the growth of micro‐organisms that may be responsible for the infection. Antibiotics can be used alone or with other treatments for CSOM, such as antiseptics or ear cleaning (aural toileting). This is an update of a Cochrane review first published in 2020 and one of a suite of seven reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To evaluate the benefits and harms of topical antibiotics (without steroids) for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials with at least a one week of follow‐up involving adults and children with chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antibiotic(s) of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic compared to placebo or no intervention, and compared to another topical antibiotic (e.g. topical antibiotic A versus topical antibiotic B). Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks and up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This update found one new study (100 participants). Overall, we included 18 studies with 1783 participants (in 16 studies), plus 108 ears that could not be accounted for in participant numbers (in two studies). 1. Topical antibiotics versus placebo or no treatment (with aural toilet in both arms and no other background treatment) One study (50 participants, data unavailable for 15 participants) compared a topical antibiotic (ciprofloxacin) with placebo (saline). All participants received aural toilet. Topical ciprofloxacin may increase resolution of discharge at one to up to two weeks compared with placebo (84% with antibiotic versus 12% with placebo; risk ratio (RR) 6.74, 95% confidence interval (CI) 1.82 to 24.99; 35 participants; very low‐certainty evidence). The study authors reported \"no medical side‐effects and worsening of audiological measurements related to this topical medication were detected.\" 2. Topical antibiotics versus placebo or no treatment (with use of oral antibiotics in both arms) Four studies (438 participants) compared topical antibiotics versus no treatment, with oral antibiotics in both arms. These compared topical ciprofloxacin to no treatment (3 studies, 190 participants) or topical ceftizoxime to no treatment (1 study, 248 participants). In each study, all participants received the same antibiotic systemically (oral ciprofloxacin or injected ceftizoxime). In at least one study, all participants received aural toilet. There were no useable data comparing topical ceftizoxime to no treatment. Topical antibiotics in addition to systemic antibiotics may increase resolution of ear discharge at one to up to two weeks compared with systemic antibiotics alone (resolution of discharge occurring in 88% with topical antibiotics versus 60% without topical antibiotics; RR 1.47, 95% CI 1.14 to 1.88; 1 study, 100 participants; low‐certainty evidence). One study (40 participants) stated \"no side effect was recorded in any patient\" (low‐certainty evidence). 3. Comparisons of different topical antibiotics Eight studies (794 participants, plus 40 ears) compared aminoglycosides (gentamicin, neomycin, or tobramycin) with quinolones (ciprofloxacin or ofloxacin). Resolution of discharge at one to up to two weeks may be higher in the quinolones group, but the evidence is very uncertain (RR 1.92, 95% CI 1.00 to 3.67; 7 studies, 794 participants; very low‐certainty evidence). There was considerable heterogeneity (I 2 = 97%). One study (308 participants) stated there were no differences between the different groups for resolution of ear discharge after four weeks (low‐certainty evidence). The evidence is very uncertain about the effects of topical antibiotics on ear pain (1 study reported no differences between groups). The evidence is very uncertain about the effects of topical antibiotics on hearing loss (2 studies reported no differences between groups). 4. Other comparisons We assessed five studies (501 participants, plus 68 ears) over the following three additional comparisons: quinolones versus aminoglycosides/polymyxin B with/without gramicidin, aminoglycosides versus trimethoprim‐sulphacetamide‐polymixin B, and rifampicin versus chloramphenicol. However, these results have not been included in the abstract. Authors' conclusions We are very uncertain about the effectiveness of topical antibiotics in improving resolution of ear discharge in people with CSOM because of the limited amount of low‐ or very low‐certainty evidence available. This was mostly due to risk of bias and imprecision. However, amongst this uncertainty, there is some evidence to suggest that the use of topical antibiotics may be effective when compared to placebo, or when used in addition to a systemic antibiotic. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine whether quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, harmful effects were poorly reported. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and harms of using topical antibiotics to treat chronic suppurative otitis media? Key messages – We are uncertain whether topical antibiotics reduce ear discharge of people with swelling and infection of the middle ear (called chronic suppurative otitis media). – Topical antibiotics may reduce ear discharge compared to placebo (a salt solution), but we are very uncertain. Topical antibiotics used in addition to an antibiotic given by mouth may reduce ear discharge. – Overall, we are very uncertain which type of topical antibiotic is the most effective. What is chronic suppurative otitis media? Chronic suppurative otitis media, also known as chronic otitis media, is a swelling and infection of the middle ear that lasts for two weeks or more. People with chronic suppurative otitis media usually have ear discharge that is difficult to get rid of or keeps coming back (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Topical antibiotics (administered into the ear canal as ear drops, ointments, sprays, or creams) are the most commonly used treatment for chronic suppurative otitis media. Topical antibiotics kill or stop the growth of the bacteria (germs) that may be responsible for the infection. Topical antibiotics can be used on their own or be added to other treatments for chronic suppurative otitis media, such as antiseptics (which also kill germs) or ear cleaning (aural toileting) or systemic antibiotics (antibiotics taken either by mouth or by an injection into a muscle or vein). What was the aim of this review? We wanted to find out how effective topical antibiotics are for people with chronic suppurative otitis media, and whether they cause unwanted effects. We also wanted to know whether one type of topical antibiotic was more beneficial or harmful than any other. In particular, we wanted to know whether topical antibiotics stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found one new study (100 participants). Overall, we found 18 studies examining at least 1783 people, but it was difficult to determine precisely how many people were included as some studies did not clearly report the number. Two studies included \"mainly children,\" three included only adults, whilst the remainder appeared to include both children and adults. None of the studies reported the inclusion of people considered at high risk of having chronic suppurative otitis media (for example, people with cleft palate (where the roof of the mouth of a baby does not join together during pregnancy) or Down's syndrome; or people whose immune system does not work well enough to fight germs). The studies used different types of antibiotics and combinations of antibiotics. Comparison of topical antibiotics to placebo or no treatment One study (50 people) compared topical antibiotics to a saline (salt water) ear wash. Topical antibiotics may reduce ear discharge more than the saline ear wash when assessed one to up to two weeks after treatment, but we are very uncertain. The evidence is very uncertain about unwanted effects and worsening of hearing measurements. The study did not measure quality of life and reported that there were no serious complications. Comparison of topical antibiotics in addition to systemic (oral or injected) antibiotics Four studies (438 people) compared treatment with topical antibiotic (ciprofloxacin) drops in addition to a systemic (oral or injected) antibiotic, but one study did not contribute data. Topical plus oral antibiotics may reduce ear discharge more than oral antibiotics alone at one to up to two weeks and two to up to four weeks. One study stated there were no unwanted effects. The studies did not measure quality of life and did not report any serious complications. Comparisons of different topical antibiotics Eight studies (794 participants plus 40 ears) compared an aminoglycoside antibiotic (gentamicin, neomycin, or tobramycin) with a quinolone antibiotic (ciprofloxacin or ofloxacin). Quinolones may reduce ear discharge better than aminoglycosides, but the evidence is very uncertain. One study (100 people) measured ear pain and reported no difference between the groups, but the evidence is very uncertain. Two studies measured hearing loss, but the evidence is very uncertain. What are the limitations of the evidence? There were several limitations with the studies. For example, the results varied widely between studies, there were small numbers of people included, there was a lack of recent data, and limited information on groups of people who are more likely to have chronic suppurative otitis media. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Brennan-Jones, CG; Head, K; Chong, LY; Daw, J; Veselinović, T; Schilder, AGM; Bhutta, MF", "articleTypes": [], "doi": "10.1002/14651858.CD013051.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "bbc2c48a-a8d7-4c7e-94a5-2ccd3966bcae", "pmid": "", "title": "Nebulised hypertonic saline for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Hypertonic saline enhances mucociliary clearance and may lessen the destructive inflammatory process in the airways. This is an update of a previously published review. Objectives To investigate efficacy and tolerability of nebulised hypertonic saline treatment in people with cystic fibrosis (CF) compared to placebo or other treatments that enhance mucociliary clearance. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also searched ongoing trials databases. Most recent search: 25 April 2022. Selection criteria We included randomised and quasi‐randomised controlled trials assessing hypertonic saline compared to placebo or other mucolytic therapy, for any duration or dose regimen in people with CF (any age or disease severity). Data collection and analysis Two authors independently reviewed all identified trials and data, and assessed trial quality. We assessed the certainty of the evidence using GRADE. For cross‐over trials we stipulated a one‐week washout period. We planned to use results from a paired analysis in the review, but this was only possible in one trial. For other cross‐over trials, we chose to treat the trials as if they were parallel. Main results We included 24 trials (1318 participants, aged one month to 56 years); we excluded 29 trials, two trials are ongoing and six are awaiting classification. We judged 15 of the 24 included trials to have a high risk of bias due to participants' ability to discern the taste of the solutions. Hypertonic saline 3% to 7% versus placebo (stable disease) We are uncertain whether the regular use of nebulised hypertonic saline in stable lung disease leads to an improvement in forced expiratory volume in one second (FEV 1 ) % predicted at four weeks, (mean difference (MD) 3.30%, 95% confidence interval (CI) 0.71 to 5.89; 4 trials, 246 participants; very low‐certainty evidence). In preschool children we found no difference in lung clearance index (LCI) at four weeks, but a small improvement after 48 weeks of treatment with hypertonic saline compared to isotonic saline (MD ‐0.60, 95% CI ‐1.00 to ‐0.19; 2 trials, 192 participants). We are also uncertain whether hypertonic saline made a difference to mucociliary clearance, pulmonary exacerbations or adverse events compared to placebo. Hypertonic saline versus control (acute exacerbation) Two trials compared hypertonic saline to control, but only one provided data. There may be little or no difference in lung function measured by FEV 1 % predicted after hypertonic saline compared to isotonic saline (MD 5.10%, 95% CI ‐14.67 to 24.87; 1 trial, 130 participants). Neither trial reported any deaths or measures of sputum clearance. There were no serious adverse events. Hypertonic saline versus rhDNase Three trials compared a similar dose of hypertonic saline to recombinant deoxyribonuclease (rhDNase); two trials (61 participants) provided data for inclusion in the review. We are uncertain whether there was an effect of hypertonic saline on FEV 1 % predicted after three weeks (MD 1.60%, 95% CI ‐7.96 to 11.16; 1 trial, 14 participants; very low‐certainty evidence). At three months, rhDNase may lead to a greater increase in FEV 1 % predicted than hypertonic saline (5 mL twice daily) at 12 weeks in participants with moderate to severe lung disease (MD 8.00%, 95% CI 2.00 to 14.00; low‐certainty evidence). We are uncertain whether adverse events differed between the two treatments. No deaths were reported. Hypertonic saline versus amiloride One trial (12 participants) compared hypertonic saline to amiloride but did not report on most of our outcomes. The trial found that there was no difference between treatments in measures of sputum clearance (very low‐certainty evidence). Hypertonic saline compared with sodium‐2‐mercaptoethane sulphonate (Mistabron®) One trial (29 participants) compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate. The trial did not measure our primary outcomes. There was no difference between treatments in any measures of sputum clearance, courses of antibiotics or adverse events (very low‐certainty evidence). Hypertonic saline versus mannitol One trial (12 participants) compared hypertonic saline to mannitol, but did not report lung function at relevant time points for this review; there were no differences in sputum clearance, but mannitol was reported to be more 'irritating' (very low‐certainty evidence). Hypertonic saline versus xylitol Two trials compared hypertonic saline to xylitol, but we are uncertain whether there is any difference in FEV 1 % predicted or median time to exacerbation between groups (very low‐certainty evidence). No other outcomes were reported in the review. Hypertonic saline 7% versus hypertonic saline 3% We are uncertain whether there was an improvement in FEV 1 % predicted after treatment with 7% hypertonic saline compared with 3% (very low‐certainty evidence). Authors' conclusions We are very uncertain if regular use of nebulised hypertonic saline by adults and children over the age of 12 years with CF results in an improvement in lung function after four weeks (three trials; very low‐certainty evidence); there was no difference seen at 48 weeks (one trial; low‐certainty evidence). Hypertonic saline improved LCI modestly in children under the age of six years. Evidence from one small cross‐over trial in children indicates that rhDNase may lead to better lung function than hypertonic saline at three months; qualifying this, we highlight that while the study did demonstrate that the improvement in FEV 1 was greater with daily rhDNase, there were no differences seen in any of the secondary outcomes. Hypertonic saline does appear to be an effective adjunct to physiotherapy during acute exacerbations of lung disease in adults. However, for the outcomes assessed, the certainty of the evidence ranged from very low to low at best, according to the GRADE criteria. The role of hypertonic saline in conjunction with cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy now needs to be considered, and future research needs to focus on this aspect. Plain language summary Hypertonic saline (salt water with at least 3% salt) nebulised as a fine mist through a mask or mouthpiece for cystic fibrosis Review question Is inhaling hypertonic saline (salt water with at least 3% salt) as a mist through a mask or mouthpiece better for improving mucus clearance in the lungs of people with cystic fibrosis (CF) than a placebo (a mist with no or very little salt) or other agents? Background People with CF produce large amounts of thick mucus which is difficult to clear and blocks up their airways. Chest physiotherapy or medication, e.g. hypertonic saline, or both combined, are used to try and clear this mucus from the airways. Hypertonic saline is water with a concentration of 3% to 7% salt and is inhaled as a fine mist. This is an update of an earlier review. Key messages • We are uncertain whether inhaling nebulised hypertonic saline regularly improves lung function compared to placebo. • Nebulised hypertonic saline does seem to work well as an add‐on to physiotherapy. What did we do? We searched for studies that looked at the use of nebulised hypertonic saline compared to either a placebo or a different type of treatment for clearing mucus from the lungs. We compared the size and methods of the studies and stated how confident we were in the results. What did we find? We included 24 trials with 1318 people with CF aged between one month and 56 years. Two thirds of the trials compared hypertonic saline to a placebo (a dummy treatment); the remaining trials compared hypertonic saline to another type of mucus clearing treatment (including mannitol; rhDNase (Pulmozyme®); amiloride; Mistabron®; xylitol); and one trial compared 7% hypertonic saline with 3% hypertonic saline. Trials assessed different concentrations of hypertonic saline with different nebulisers and different treatment schedules; the most common treatment was twice‐daily 7% hypertonic saline and the most common nebuliser was ultrasonic. Most trials treated people with a bronchodilator to widen the airways before giving the hypertonic saline. Main results Hypertonic saline 3% to 7% versus placebo We are not sure whether hypertonic saline leads to an improvement in lung function in stable disease after four weeks. Two trials showed that there may be a small improvement in lung function (measured using the lung clearance index) with hypertonic saline compared to placebo in preschool children. We are also unsure whether hypertonic saline makes a difference to clearing mucus from the lungs, exacerbations or side effects compared to placebo. During exacerbations, we found that there may be little or no difference in lung function after hypertonic saline compared to placebo. The trials did not report any serious side effects and there were no deaths. One study compared 7% hypertonic saline with a lower concentration of hypertonic saline (3%); we are uncertain whether the higher concentration improved lung function. Hypertonic saline versus mucus mobilising treatments Three trials compared hypertonic saline with rhDNase and found that rhDNase may lead to an improvement in lung function compared to hypertonic saline after three months. We are unsure whether there is any difference in side effects. One trial compared hypertonic saline to amiloride and a further trial compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate (Mistabron®), but neither of the trials gave information about the effect of the treatments on lung function. Similarly, a trial comparing hypertonic saline with mannitol did not give information about the effects on lung function, but they did report that there was no difference between treatments in clearing mucus from the lungs. People taking mannitol said it was more irritating than hypertonic saline. Two trials compared hypertonic saline with xylitol, but we are unsure if there is any difference in lung function and none of our other outcomes were measured. What are the limitations of this evidence? We are not confident in the evidence from these trials. There is a high risk that people knew which treatment they were receiving in half the trials as they could taste the difference between the solutions. Other factors that made us unsure of the results were the small numbers of people taking part in the trials combined with a wide variation in results; also, some trials limited participants to those who could tolerate hypertonic saline or to certain age groups. How up to date is this evidence? The evidence is current to 25 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wark, P; McDonald, VM; Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD001506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "bbcdeaec-16fc-457f-94e5-7d8e1446ff54", "pmid": "", "title": "The Effect of Lactobacillus Reuteri ATCC PTA 6475 on Volumetric Bone Mineral Density in Patients With Osteopenia", "imported": false, "abstract": "Lactobacillus reuteri (L. reuteri) has been widely studied in clinical trials and has probiotic, health-promoting effects in both adults and children, and is safe for human consumption. Animal models indicate that treatment with L. reuteri has positive effects on bone metabolism and bone density. In other animal models of diabetes and the metabolic syndrome, positive effects on blood glucose and weight have been reported. The present double-blind, placebo-controlled, randomized study is designed to investigate if dietary supplementation with L. reuteri twice daily for 12 months has any effect on bone density, body composition, inflammation, or metabolic and endocrine markers in elderly women with osteopenia.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.242Z" }, { "id": "bbde130f-ff97-4a1d-8325-b598d9ad846d", "pmid": "", "title": "Ganoderma lucidum (Reishi mushroom) for cancer treatment", "imported": false, "abstract": "Abstract - Background Ganoderma lucidum is a natural medicine that is widely used and recommended by Asian physicians and naturopaths for its supporting effects on immune system. Laboratory research and a handful of preclinical trials have suggested that G. lucidum carries promising anticancer and immunomodulatory properties. The popularity of taking G. lucidum as an alternative medicine has been increasing in cancer patients. However, there is no systematic review that has been conducted to evaluate the actual benefits of G. lucidum in cancer treatment. Objectives To evaluate the clinical effects of G. lucidum on long‐term survival, tumour response, host immune functions and quality of life in cancer patients, as well as adverse events associated with its use. Search methods We searched an extensive set of databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, NIH, AMED, CBM, CNKI, CMCC and VIP Information/Chinese Scientific Journals Database was searched for randomised controlled trials (RCTs) in October 2011. Other strategies used were scanning the references of articles retrieved, handsearching of the International Journal of Medicinal Mushrooms and contact with herbal medicine experts and manufacturers of G. lucidum . For this update we updated the searches in February 2016. Selection criteria To be eligible for being included in this review, studies had to be RCTs comparing the efficacy of G. lucidum medications to active or placebo control in patients with cancer that had been diagnosed by pathology. All types and stages of cancer were eligible for inclusion. Trials were not restricted on the basis of language. Data collection and analysis Five RCTs met the inclusion criteria and were included in this review. Two independent review authors assessed the methodological quality of individual trials. Common primary outcomes were tumour response evaluated according to the World Health Organization (WHO) criteria, immune function parameters such as natural killer (NK)‐cell activity and T‐lymphocyte co‐receptor subsets, and quality of life measured by the Karnofsky scale score. No trial had recorded long‐term survival rates. Associated adverse events were reported in one study. A meta‐analysis was performed to pool available data from the primary trials. Results were gauged using relative risks (RR) and standard mean differences (SMD) for dichotomous and continuous data respectively, with a 95% confidence interval (CI). Main results The methodological quality of primary studies was generally unsatisfying and the results were reported inadequately in many aspects. Additional information was not available from primary trialists. The meta‐analysis results showed that patients who had been given G. lucidum alongside with chemo/radiotherapy were more likely to respond positively compared to chemo/radiotherapy alone (RR 1.50; 95% CI 0.90 to 2.51, P = 0.02). G. lucidum treatment alone did not demonstrate the same regression rate as that seen in combined therapy. The results for host immune function indicators suggested that G. lucidum simultaneously increases the percentage of CD3, CD4 and CD8 by 3.91% (95% CI 1.92% to 5.90%, P < 0.01), 3.05% (95% CI 1.00% to 5.11%, P < 0.01) and 2.02% (95% CI 0.21% to 3.84%, P = 0.03), respectively. In addition, leukocyte, NK‐cell activity and CD4/CD8 ratio were marginally elevated. Four studies showed that patients in the G. lucidum group had relatively improved quality of life in comparison to controls. One study recorded minimal side effects, including nausea and insomnia. No significant haematological or hepatological toxicity was reported. Authors' conclusions Our review did not find sufficient evidence to justify the use of G. lucidum as a first‐line treatment for cancer. It remains uncertain whether G. lucidum helps prolong long‐term cancer survival. However, G. lucidum could be administered as an alternative adjunct to conventional treatment in consideration of its potential of enhancing tumour response and stimulating host immunity. G. lucidum was generally well tolerated by most participants with only a scattered number of minor adverse events. No major toxicity was observed across the studies. Although there were few reports of harmful effect of G. lucidum , the use of its extract should be judicious, especially after thorough consideration of cost‐benefit and patient preference. Future studies should put emphasis on the improvement in methodological quality and further clinical research on the effect of G. lucidum on cancer long‐term survival are needed. An update to this review will be performed every two years. Plain language summary G. lucidum (Reishi mushroom) for cancer treatment There have been an increasing number of patients diagnosed with cancer each year. Certain malignancies have been a major cause of death in some populations. People who have been diagnosed with cancer want to do everything they can to combat the disease, manage its symptoms and cope with the side effects of radio/chemotherapy. Many turn to complementary and alternative medicine. G. lucidum extract is a medication that has been widely used by traditional Chinese medicine (TCM) practitioners for this regard. It is usually recommended as an immune system support supplement in cancer treatment. Latest laboratory research and preclinical trials of G. lucidum have shown promising results of its antitumour activity. However, clinical evidence of its efficacy is sparse and a systematic review is in need to provide collective information for health‐care consumers. Our review identified and subsequently included five relevant randomised controlled trials. A total of 373 subjects were analysed. A meta‐analysis was performed to pool available data from individual trials. Our results found that patients with G. lucidum extract in their anticancer regimen were 1.27 times more likely to respond to chemotherapy or radiotherapy than those without. However, the data failed to demonstrate significant effect on tumour shrinkage when it was used alone. In addition, G. lucidum could stimulate host immune functions by considerably increasing CD3, CD4 and CD8 lymphocyte percentages. Nevertheless, natural killer (NK)‐cell activity, which has been suggested to be an indicator of self‐defence against tumour cell, was marginally elevated. Patients in the G. lucidum group were found to have a relatively better quality of life after treatment than those in the control group. A few cases of minor side effect associated with G. lucidum treatment including nausea and insomnia were reported. There are limitations of the results from this systematic review. First, most included studies were small and there were concerns on the methodological quality of individual trials. Second, all participants in the individual trials were recruited from the Chinese population. Together, the robustness and applicability of the results were largely affected.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Jin, X, Ruiz Beguerie, J, Sze, DMY, Chan, GCF", "articleTypes": [], "doi": "10.1002/14651858.CD007731.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.102Z" }, { "id": "bbe304ad-4441-4088-bc1d-b228c850b9df", "pmid": "", "title": "Aminoglycosides, vancomycin, and metronidazole for people with cirrhosis and hepatic encephalopathy", "imported": false, "abstract": "Abstract - Rationale Hepatic encephalopathy is a common complication of cirrhosis. Its development is associated with increased morbidity and mortality. Its exact pathogenesis is unknown, but ammonia, produced by bacterial action in the intestine, plays a key role. Antibiotics modulate the gut flora and may reduce intestinal ammonia production. Aminoglycosides such as neomycin, paromomycin, and ribostamycin have been used to treat hepatic encephalopathy, as have other antibiotics such as vancomycin and metronidazole. Objectives To assess the beneficial and harmful effects of aminoglycosides, vancomycin, and metronidazole versus placebo, no intervention, other antibiotics, or other active pharmacological interventions, for the prevention and treatment of hepatic encephalopathy in people with cirrhosis. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, and three other databases to 15 April 2025. We also searched online trials registries for ongoing and unpublished trials, undertook manual searches of meeting and conference proceedings, checked bibliographies of relevant articles, and corresponded with investigators and pharmaceutical companies. Eligibility criteria We included randomised clinical trials (RCTs) involving participants with cirrhosis and hepatic encephalopathy, or who were at risk of developing hepatic encephalopathy, comparing aminoglycosides, vancomycin, or metronidazole to (1) placebo or no intervention; or (2) other pharmacological agents, including non‐absorbable disaccharides, other antibiotics, or other potentially beneficial agents (e.g. branched‐chain amino acids, L‐ornithine L‐aspartate, nitazoxanide (a broad‐spectrum antiparasitic/antiviral agent), and nicotinohydroxamic acid (a potent urease inhibitor). We included trials irrespective of publication status, outcomes reported, language, or blinding. We excluded trials involving people with hepatic encephalopathy associated with acute liver failure or with non‐cirrhotic portal hypertension. Outcomes The critical outcomes were all‐cause mortality, hepatic encephalopathy, and serious adverse events. The important outcomes were non‐serious adverse events and health‐related quality of life (HRQoL). Our primary time point was the maximum length of follow‐up. Risk of bias We used Cochrane's original risk of bias tool (RoB 1) to assess the risk of bias. Synthesis methods We used standard Cochrane methods. We undertook random‐effects meta‐analyses to calculate risk ratios (RRs) or standardised mean differences (SMDs), with 95% confidence intervals (CIs). We assessed heterogeneity with the I 2 statistic, and the certainty of evidence with the GRADE framework. Included studies We included 24 RCTs, involving 1405 participants experiencing 1418 hepatic encephalopathy events. Twenty‐three trials evaluated the treatment of hepatic encephalopathy and one, the secondary prevention of hepatic encephalopathy; we analysed these trials jointly. The trials assessed three aminoglycosides: neomycin (15 trials), paromomycin (three trials), and ribostamycin (one trial), as well as vancomycin (two trials), and metronidazole (three trials). Overall, 670 participants received these pharmacotherapies while 735 participants received a placebo or other potentially beneficial agents. We classified 22 of the 24 trials to be at an overall high risk of bias based on domain‐level assessments. Synthesis of results The certainty of evidence for all comparisons was low to very low, mainly due to risk of bias, imprecision, and heterogeneity. Twenty‐three of the 24 trials, involving 1383 participants, reported all‐cause mortality data. Aminoglycosides may increase mortality slightly compared to other potentially active agents (RR 1.64, 95% CI 1.03 to 2.62; I² = 0%; 3 studies, 166 participants). The evidence was very uncertain about whether aminoglycosides versus a placebo (RR 1.02, 95% CI 0.62 to 1.69; I² = 0%; 3 studies, 137 participants), non‐absorbable disaccharides (RR 1.21, 95% CI 0.57 to 2.59; I² not applicable; 4 studies, 266 participants), or other antibiotics (RR 1.00, 95% CI 0.24 to 4.23; I² = 83%; 8 studies, 496 participants) result in a difference in mortality risk. The evidence was also very uncertain when comparing vancomycin to non‐absorbable disaccharides (RR 0.94, 95% CI 0.26 to 3.40; I² not applicable; 2 studies, 72 participants), and metronidazole to other active agents (RR 0.97, 95% CI 0.14 to 6.66; I² = 0%; 3 studies, 242 participants). Nineteen trials involving 1281 participants reported data on hepatic encephalopathy. There may be little to no difference in the effects of aminoglycosides versus non‐absorbable disaccharides (RR 0.84, 95% CI 0.67 to 1.05; I² = 0%; 3 studies, 251 participants), aminoglycosides versus other potentially active agents (RR 1.21, 95% CI 0.79 to 1.85; I² = 0%; 3 studies, 166 participants), and metronidazole versus other active agents (RR 1.50, 95% CI 0.89 to 2.54; I² = 48%; 2 studies, 208 participants). The evidence is very uncertain about the effect of aminoglycosides versus placebo, other antibiotics, and vancomycin versus non‐absorbable disaccharides. Twenty trials, involving 1186 participants, reported a total of 328 serious adverse events. Aminoglycosides may slightly increase the risk of serious adverse events compared with other potentially active agents (RR 1.60, 95% CI 1.03 to 2.47; I² = 0%; 3 studies, 166 participants). The evidence is very uncertain when comparing aminoglycosides to placebo and other antibiotics, or when comparing vancomycin to non‐absorbable disaccharides. Eighteen trials, involving 922 participants, reported a total of 96 non‐serious adverse events. There may be a slight increase in the risk of adverse events when comparing aminoglycosides to placebo (RR 2.80, 95% CI 1.11 to 7.04; I² not applicable; 2 studies, 98 participants), and to other antibiotics (RR 3.24, 95% CI 1.08 to 9.70; I² = 0%; 8 studies, 251 participants). The evidence is very uncertain about the effects of aminoglycosides versus non‐absorbable disaccharides or other active agents, and metronidazole versus other active agents. Only one trial assessed HRQoL, but reported the data in a form that precluded meta‐analysis. Eight trials received support from pharmaceutical companies while six did not. Ten trials did not provide this information. Authors' conclusions Due to low‐ or very low‐certainty evidence, we do not know if aminoglycosides benefit hepatic encephalopathy compared to placebo or other potentially active agents. There may be a slight increase in the risks of mortality and serious adverse events with aminoglycosides compared to other agents, and of non‐serious adverse events when compared to placebo and other antibiotics. We do not know if vancomycin or metronidazole improve clinically relevant outcomes. Only one trial assessed health‐related quality of life. Funding This Cochrane review received no specific funding. Registration https://doi.org/10.1002/14651858.CD012734 Plain language summary Do the antibiotics aminoglycosides, vancomycin, and metronidazole help people with cirrhosis and hepatic encephalopathy, a brain disorder associated with chronic liver disease? Key messages Antibiotics previously thought to help people with cirrhosis manage the risk of hepatic encephalopathy do not appear to benefit the condition. These antibiotics possibly cause more side effects than other treatments for this condition. Research is needed to establish whether combining these antibiotics with other treatments may be beneficial. What are cirrhosis and hepatic encephalopathy? Cirrhosis is a long‐term condition in which the liver becomes badly scarred. The liver normally helps clean the blood, process nutrients, and fight infections. When it is repeatedly damaged over time, the scar tissue which develops makes it harder for the liver to work properly. People with cirrhosis may develop hepatic encephalopathy, a condition that results in poor brain functioning. The reason why people develop hepatic encephalopathy is complex, but the build‐up in the blood of toxins from the gut, particularly of a compound called ammonia, plays a key role. Ammonia is produced in the gut mainly as a result of the activities of gut bacteria. How do antibiotics work in hepatic encephalopathy? Antibiotics are medicines used to treat infections caused by bacteria. They work by killing bacteria or stopping them from growing. Certain antibiotics may reduce the levels of ammonia in the blood by interfering with ammonia production in the gut. These antibiotics have been used to treat hepatic encephalopathy for many years, but the evidence that they help is unclear. The antibiotics considered in this review are: aminoglycosides (neomycin, paromomycin, and ribostamycin); vancomycin; metronidazole. What did we want to find out? We wanted to know if these antibiotics help to prevent or treat hepatic encephalopathy in people with cirrhosis. We analysed their effects on the number of people who died, whose symptoms of hepatic encephalopathy improved or failed to improve, and the number who experienced serious or non‐serious complications. What did we do? We searched for studies that compared aminoglycosides, vancomycin, or metronidazole to: placebo – an inactive or 'dummy' medicine; non‐absorbable disaccharides – sugars that mainly act in the gut, and are commonly used to treat some digestive and liver conditions; other antibiotics; other active agents that may help the condition. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 24 studies which involved 1405 participants. Of these, 23 studies evaluated the treatment of hepatic encephalopathy, and one study explored the prevention of hepatic encephalopathy in people at risk. We found evidence for the following comparisons: aminoglycosides versus placebo, non‐absorbable disaccharides, other antibiotics, and other active agents – 19 studies in total; vancomycin versus non‐absorbable disaccharides – 2 studies; metronidazole versus other active agents – 3 studies. Main results Death Aminoglycosides may slightly increase the risk of death compared to other active agents. We do not know if aminoglycosides make any difference to the risk of death compared to placebo, non‐absorbable disaccharides, and other antibiotics. We also do not know if there is any difference in the risk of death between: vancomycin and non‐absorbable disaccharides; metronidazole and other active agents. Hepatic encephalopathy: number of people in whom hepatic encephalopathy failed to improve Aminoglycosides may make little to no difference to the number of people whose condition improves compared to non‐absorbable disaccharides and other active agents. Metronidazole may make little to no difference to the number of people whose condition improves compared to other active agents. We do not know if there is any difference in the number of people whose condition improves when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Serious complications Aminoglycosides may slightly increase the risk of serious complications compared to other active agents. We do not know if there is any difference in serious complications when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Non‐serious complications Aminoglycosides may slightly increase the risk of non‐serious complications compared to placebo or other antibiotics. We do not know if there is any difference in the risk of non‐serious complications when comparing: aminoglycosides to non‐absorbable disaccharides or other active agents; metronidazole to other active agents; vancomycin to non‐absorbable disaccharides. Only one study, using metronidazole, reported on health‐related quality of life, so we were unable to draw any conclusions for this outcome. What are the limitations of the evidence? We had little to no confidence in the results of the review because the participants and researchers in some studies were aware of which treatment the participants received, which may have influenced the results, while some studies did not report on the outcomes we were interested in. The studies were generally small, and differed in how they were conducted. There were also too few studies to be certain about the outcomes. How current is this evidence? The evidence is current to 15 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Jeyaraj, R, Zacharias, HD, Vadera, S, Low, ZY, Gluud, LL, Morgan, MY", "articleTypes": [], "doi": "10.1002/14651858.CD012734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.135Z" }, { "id": "bbe87dcb-2fd0-4109-99f7-a23b4cd700f3", "pmid": "", "title": "Aclidinium bromide for stable chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Bronchodilators are the mainstay for symptom relief in the management of stable chronic obstructive pulmonary disease (COPD). Aclidinium bromide is a new long‐acting muscarinic antagonist (LAMA) that differs from tiotropium by its higher selectivity for M3 muscarinic receptors with a faster onset of action. However, the duration of action of aclidinium is shorter than for tiotropium. It has been approved as maintenance therapy for stable, moderate to severe COPD, but its efficacy and safety in the management of COPD is uncertain compared to other bronchodilators. Objectives To assess the efficacy and safety of aclidinium bromide in stable COPD. Search methods We identified randomised controlled trials (RCT) from the Cochrane Airways Group Specialised Register of trials (CAGR), as well as www.clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), US Food and Drug Administration (FDA) website and Almirall Clinical Trials Registry and Results. We contacted Forest Laboratories for any unpublished trials and checked the reference lists of identified articles for additional information. The last search was performed on 7 April 2014 for CAGR and 11 April 2014 for other sources. Selection criteria Parallel‐group RCTs of aclidinium bromide compared with placebo, long‐acting beta 2 ‐agonists (LABA) or LAMA in adults with stable COPD. Data collection and analysis Two review authors independently selected studies, assessed the risk of bias, and extracted data. We sought missing data from the trial authors as well as manufacturers of aclidinium. We used odds ratios (OR) for dichotomous data and mean difference (MD) for continuous data, and reported both with their 95% confidence intervals (CI). We used standard methodological procedures expected by The Cochrane Collaboration. We applied the GRADE approach to summarise results and to assess the overall quality of evidence. Main results This review included 12 multicentre RCTs randomly assigning 9547 participants with stable COPD. All the studies were industry‐sponsored and had similar inclusion criteria with relatively good methodological quality. All but one study included in the meta‐analysis were double‐blind and scored low risk of bias. The study duration ranged from four weeks to 52 weeks. Participants were more often males, mainly Caucasians, mean age ranging from 61.7 to 65.6 years, and with a smoking history of 10 or more pack years. They had moderate to severe symptoms at randomisation; the mean post‐bronchodilator forced expiratory volume in one second (FEV1) was between 46% and 57.6% of the predicted normal value, and the mean St George's Respiratory Questionnaire score (SGRQ) ranged from 45.1 to 50.4 when reported. There was no difference between aclidinium and placebo in all‐cause mortality (low quality) and number of patients with exacerbations requiring a short course of oral steroids or antibiotics, or both (moderate quality). Aclidinium improved quality of life by lowering the SGRQ total score with a mean difference of ‐2.34 (95% CI ‐3.18 to ‐1.51; I 2 = 48%, 7 trials, 4442 participants) when compared to placebo. More patients on aclidinium achieved a clinically meaningful improvement of at least four units decrease in SGRQ total score (OR 1.49; 95% CI 1.31 to 1.70; I 2 = 34%; number needed to treat (NNT) = 10, 95% CI 8 to 15, high quality evidence) over 12 to 52 weeks than on placebo. Aclidinium also resulted in a significantly greater improvement in pre‐dose FEV1 than placebo with a mean difference of 0.09 L (95% CI 0.08 to 0.10; I 2 = 39%, 9 trials, 4963 participants). No trials assessed functional capacity. Aclidinium reduced the number of patients with exacerbations requiring hospitalisation by 4 to 20 fewer per 1000 over 4 to 52 weeks (OR 0.64; 95% CI 0.46 to 0.88; I 2 = 0%, 10 trials, 5624 people; NNT = 77, 95% CI 51 to 233, high quality evidence) compared to placebo. There was no difference in non‐fatal serious adverse events (moderate quality evidence) between aclidinium and placebo. Compared to tiotropium, aclidinium did not demonstrate significant differences for exacerbations requiring oral steroids or antibiotics, or both, exacerbation‐related hospitalisations and non‐fatal serious adverse events (very low quality evidence). Inadequate data prevented the comparison of aclidinium to formoterol or other LABAs. Authors' conclusions Aclidinium is associated with improved quality of life and reduced hospitalisations due to severe exacerbations in patients with moderate to severe stable COPD compared to placebo. Overall, aclidinium did not significantly reduce mortality, serious adverse events or exacerbations requiring oral steroids or antibiotics, or both. Currently, the available data are insufficient and of very low quality in comparisons of the efficacy of aclidinium versus tiotropium. The efficacy of aclidinium versus LABAs cannot be assessed due to inaccurate data. Thus additional trials are recommended to assess the efficacy and safety of aclidinium compared to other LAMAs or LABAs. Plain language summary Effectiveness and safety of inhalers containing the drug aclidinium bromide for managing patients with stable COPD Review question We reviewed the evidence on the effectiveness and safety of aclidinium inhalers used by people with chronic obstructive pulmonary disease (COPD). Background COPD, also known as 'smoker's lung disease', includes conditions called emphysema and chronic bronchitis where there is airway narrowing that cannot be fully corrected. It is a progressive disease. COPD patients usually have breathing problems and a cough that produces a lot of phlegm. It is diagnosed by international guidelines set by the Global Initiative for Obstructive Lung Disease (GOLD). Symptoms may worsen during flare‐ups. The main aims of treating COPD patients are to relieve symptoms, reduce flare‐ups and improve quality of life. Aclidinium is a new inhaled drug that widens the airways (a bronchodilator). It is delivered by an inhaler called Genuair or Pressair. We wanted to discover whether aclidinium was better or worse than using other inhalers or a dummy inhaler. Study characteristics The evidence was current to 7 April 2014. We included 12 studies involving 9547 COPD patients over a period of four to 52 weeks. These studies were sponsored by drug companies and were well designed. Both patients and the people doing the research did not know which treatment the patients were getting; although in one study one treatment was known to both parties. More men than women took part, and they were mostly Caucasians. They were in their 60s and had smoked a lot in their lives. These people had moderate to severe symptoms when they started treatment. Key results Aclidinium did not reduce the number of people with flare‐ups that need additional drugs. There was little or no difference in deaths or serious side effects between aclidinium and a dummy inhaler. Aclidinium inhalers improved quality of life more than the dummy inhalers. People who took aclidinium had fewer hospital admissions due to serious flare‐ups. Based on our results, among 1000 COPD patients using a dummy inhaler over four weeks to one year 37 would have severe flare‐ups needing hospital admission. Only 17 to 33 patients out of 1000 would require hospital admission if they were using aclidinium inhalers. We also set out to compare this new medication with tiotropium, which is already used to treat COPD. There were only two studies for this comparison thus we could not be sure how aclidinium compared to tiotropium. We also could not compare aclidinium with another well known inhaler that contains the drug formoterol because of unreliable data. Quality of the evidence For the comparison of aclidinium inhalers and dummy inhalers, we are confident that there are benefits in terms of the number of hospitalisations and patients' quality of life; we are less certain about the numbers of flare‐ups needing additional drugs and serious side effects. We do not have enough information to assess any effect on the number of deaths. We did not have enough information to reliably compare aclidinium with tiotropium or formoterol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ni, H; Soe, Z; Moe, S", "articleTypes": [], "doi": "10.1002/14651858.CD010509.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "bbeb5fea-6391-4c6b-90a6-9cc049dc4332", "pmid": "", "title": "Interventions for the treatment of Frey's syndrome", "imported": false, "abstract": "Abstract - Background Frey's syndrome is a rare disorder, the symptoms of which include sweating, flushing and warming over the preauricular and temporal areas following a gustatory stimulus. It often occurs in patients who have undergone parotidectomy, submandibular gland surgery, radical neck dissection, infection and traumatic injury in the parotid region, and is caused by the aberrant regrowth of facial autonomic nerve fibres. Currently there are several options used to treat patients with Frey's syndrome; for example, the topical application of anticholinergics and antiperspirants, and the intradermal injection of botulinum toxin. It is uncertain which treatment is most effective and safe. Objectives To assess the efficacy and safety of different interventions for the treatment of Frey's syndrome. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; ICTRP and additional sources for published and unpublished trials. The date of the search was 28 April 2014. Selection criteria We included randomised or quasi‐randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome using a clinical standard such as Minor's starch‐iodine test. We planned to include trials in which participants received any intervention versus no treatment (observation) or an alternative intervention, with or without a second active treatment. Our primary outcome measures were success rate (as assessed clinically by Minor's starch‐iodine test, the iodine‐sublimated paper histogram method, blotting paper technique or another method) and adverse events. Our secondary outcome measure was success rate as assessed by patients (disappearance or improvement of symptoms). Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no RCTs or quasi‐RCTs that fulfilled the inclusion criteria. Our searches retrieved eight potentially relevant studies, but after assessment of the full‐text reports we excluded all of them due to the absence of randomisation or because the patients did not have Frey's syndrome. We excluded one randomised controlled trial that compared two different doses of botulinum toxin in patients with Frey's syndrome because the comparator was not an alternative treatment. Authors' conclusions We are unable to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome. RCTs are urgently needed to assess the effectiveness of interventions for the treatment of Frey's syndrome. Future RCTs should include patients with Frey's syndrome of different ranges of severity and report these patients separately. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective assessment of Frey's syndrome should be considered as one of the outcome measures. Plain language summary Interventions for the treatment of Frey's syndrome Background Frey's syndrome is a rare disorder, the symptoms of which include sweating and flushing of the facial skin when eating, smelling, thinking or even dreaming about food. It usually happens in patients who have undergone surgery to the parotid (salivary) gland. This problem may have an impact on quality of life (for example, restricting normal activity such as eating in public). Many methods are currently used to treat Frey's syndrome, including topical application of anticholinergics and antiperspirants, and intradermal (into the skin) injections of botulinum toxin. This systematic review aimed to assess the efficacy and safety of these different methods for the treatment of Frey's syndrome. Study characteristics We carried out a comprehensive search for randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome. We planned to include trials in which participants received any intervention compared to no treatment (observation) or an alternative intervention, with or without a second active treatment. Despite extensive searching, we were unable to identify any studies that met our inclusion criteria. Key results There is no high‐quality evidence to establish which type of treatment is most effective for the treatment of Frey's syndrome. High‐quality clinical trials in this area should be urgently conducted. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective (patient) assessment of Frey's syndrome should be one of the outcome measures used. Quality of the evidence This review is up to date to 28 April 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Li, C, Wu, F, Zhang, Q, Gao, Q, Shi, Z, Li, L", "articleTypes": [], "doi": "10.1002/14651858.CD009959.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.727Z" }, { "id": "bbed21aa-6e75-480b-9e59-271ba54c02a5", "pmid": "", "title": "Micronutrient supplementation in pregnant women with HIV infection", "imported": false, "abstract": "Abstract - Background Micronutrient deficiencies are widespread and compound the effects of HIV disease; micronutrient supplements may be effective and safe in reducing this burden. Objectives To assess whether micronutrient supplements are effective and safe in reducing mortality and morbidity in pregnant and lactating women with HIV infection and their infants. Search methods The review has been updated three times since publication in 2005. In reviews prior to this update (2011), we searched the CENTRAL, EMBASE, PubMed, and GATEWAY databases to identify randomised controlled trials of micronutrient supplements using the search methods of the Cochrane HIV/AIDS Group. In the 2011 review the PubMed, EMBASE, and CENTRAL databases were searched in July 2011. As the GATEWAY database does not include conference abstracts after 2006, we also searched the AIDS‐specific conference database, www.aegis.org , and contacted researchers and organisations active in the field of research to identify additional unpublished trials. Selection criteria Randomised controlled trials were selected that compared the effects of micronutrient supplements (vitamins, trace elements, and combinations of these) with other supplements, placebo or no treatment on mortality, morbidity, pregnancy outcomes, immunologic indicators, and anthropometric measures in HIV‐positive pregnant and lactating women. Any adverse effects of supplementation were recorded. Data collection and analysis Two reviewer authors independently selected trials, appraised trial quality for risk of bias using standardised criteria, and extracted data using standardised forms. Where disagreements arose, a third author, acted as arbiter. Main results One additional trial is included in this update in addition to the three trials included in the 2010 update of the initial Cochrane review. Four relatively large, well‐conducted randomised controlled trials of the benefits of micronutrient supplementation have been conducted in pregnant and lactating women infected with HIV. Each of the trials evaluated a different micronutrient supplement and no direct comparisons or analyses can be made across the four trials. The four trials were conducted between 1995 and 2006. The trials have all been conducted by the same research team in Dar es Salaam in Tanzania, in an urban setting in hospital‐based antenatal clinics. Pregnant women were recruited with gestational age ranging from 12 to 27 weeks in each of the trials. Sample sizes range from 400 to 1129 with a median of 1000 participants. Three of the trials were placebo‐controlled. Different interventions have been evaluated in each trial, viz.:Vitamin A versus Vitamin A and multivitamins versus Multivitamins versus placebo; Selenium versus placebo; Zinc versus placebo; and Multiple RDA multivitamins versus Single RDA multivitamins. None of the women were receiving antiretrovrial therapy (ART). Multiple micronutrient supplements conferred multiple clinical benefits to pregnant women and their offspring. No significant adverse effects were reported. No significant clinical benefits were found from zinc supplementation of pregnant Tanzanian women. Selenium supplements given during and after pregnancy did not delay maternal HIV disease progression or improve pregnancy outcomes, but may improve child survival and decrease maternal diarrhoeal morbidity. There were no differences in maternal and infant outcomes when women received single RDA multivitamins or multiple RDA multivitamin supplementation. The evidence is lacking for the effects of micronutrient supplementation given concomitantly to pregnant women already initiated on antiretroviral therapy for treatment purposes. GRADE assessments were conducted on outcomes for each trial and included reviewing the data and the potential biases in each trial before grading the level of evidence. None of the trials were graded as providing high quality evidence primarily because there was no replication of results in other trials in other settings. Authors' conclusions In keeping with previous World Health Organization (WHO) recommendations everything possible should be done to promote and support adequate dietary intake of micronutrients, while recognising that this may not be sufficient to correct specific micronutrient deficiencies in all HIV‐infected individuals. Specific recommendations for pregnant and lactating women infected with HIV would be to include the provision of multivitamin supplements in single RDA formulations during the antenatal period and at least for 6 weeks post‐partum, especially for women who are breast‐feeding. There is no conclusive evidence to provide stand‐alone zinc or selenium supplementation to HIV‐infected pregnant and lactating women. Micronutrient supplementation should not be used as a substitute for provision of recommended antiretroviral medication for preventing mother‐to‐child transmission of HIV and treating maternal HIV infection when this is recommended. Further trials of single supplements are required to build the evidence base. The long‐term clinical benefits, adverse effects, and optimal formulation of multiple micronutrient supplements require further investigation in pregnant women at different stages of HIV infection. Plain language summary Micronutrient supplementation interventions to reduce harm in pregnant and lactating women living with HIV Micronutrients are vital components of a person’s daily food intake. Though only a small portion is necessary, a lack of micronutrients has been linked to tiredness, anaemia (low iron in blood), reduced learning ability, weaker immune system, and night blindness. In pregnant women, inadequate micronutrients have been shown to affect the development of the foetus and also the well‐being of the mother. In regions with high HIV prevalence, food availability may be scarce, which could lead to a double burden of disease in vulnerable/at‐risk populations. Specifically, pregnant and lactating women living with HIV may encounter the challenge of adequate food (including micronutrients) consumption, a weakened immune system, and the nutritional demands of a growing foetus or child. In this review, four randomised controlled trials, conducted between 1995 and 2006, assessed the benefits of micronutrient supplementation. The trials took place in an urban setting in hospital‐based antenatal clinics, with participants being pregnant women who ranged between 12‐27 weeks of their pregnancy, and sample sizes ranging from 400 to 1129 participants. Multiple micronutrient supplements improved the health of pregnant women and their offspring. No significant adverse effects were reported. Zinc supplementation did not show any significant beneficcial effects. Although it did not have any effect on the mother's pregnancy or her HIV disease, supplementation with selenium may increase the likelihood of a child surviving, and may reduce the likelihood of the mothers having diarrhoea. However, there is not enough evidence to determine the effect of micronutrient supplementation to pregnant women living with HIV who are being treated with antiretroviral medications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Siegfried, N, Irlam, JH, Visser, ME, Rollins, NN", "articleTypes": [], "doi": "10.1002/14651858.CD009755", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.126Z" }, { "id": "bbf2f7b8-f4f5-4ed4-ad15-5f0895d0d7a2", "pmid": "", "title": "Interventions for palliative symptom control in COVID‐19 patients", "imported": false, "abstract": "Abstract - Background Individuals dying of coronavirus disease 2019 (COVID‐19) may experience distressing symptoms such as breathlessness or delirium. Palliative symptom management can alleviate symptoms and improve the quality of life of patients. Various treatment options such as opioids or breathing techniques have been discussed for use in COVID‐19 patients. However, guidance on symptom management of COVID‐19 patients in palliative care has often been derived from clinical experiences and guidelines for the treatment of patients with other illnesses. An understanding of the effectiveness of pharmacological and non‐pharmacological palliative interventions to manage specific symptoms of COVID‐19 patients is required. Objectives To assess the efficacy and safety of pharmacological and non‐pharmacological interventions for palliative symptom control in individuals with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), Embase, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), medRxiv); Web of Science Core Collection (Science Citation Index Expanded, Emerging Sources); CINAHL; WHO COVID‐19 Global literature on coronavirus disease; and COAP Living Evidence on COVID‐19 to identify completed and ongoing studies without language restrictions until 23 March 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. Selection criteria We followed standard Cochrane methodology as outlined in the Cochrane Handbook for Systematic Reviews of Interventions . We included studies evaluating palliative symptom management for individuals with a confirmed diagnosis of COVID‐19 receiving interventions for palliative symptom control, with no restrictions regarding comorbidities, age, gender, or ethnicity. Interventions comprised pharmacological as well as non‐pharmacological treatment (e.g. acupressure, physical therapy, relaxation, or breathing techniques). We searched for the following types of studies: randomized controlled trials (RCT), quasi‐RCTs, controlled clinical trials, controlled before‐after studies, interrupted time series (with comparison group), prospective cohort studies, retrospective cohort studies, (nested) case‐control studies, and cross‐sectional studies. We searched for studies comparing pharmacological and non‐pharmacological interventions for palliative symptom control with standard care. We excluded studies evaluating palliative interventions for symptoms caused by other terminal illnesses. If studies enrolled populations with or exposed to multiple diseases, we would only include these if the authors provided subgroup data for individuals with COVID‐19. We excluded studies investigating interventions for symptom control in a curative setting, for example patients receiving life‐prolonging therapies such as invasive ventilation. Data collection and analysis We used a modified version of the Newcastle Ottawa Scale for non‐randomized studies of interventions (NRSIs) to assess bias in the included studies. We included the following outcomes: symptom relief (primary outcome); quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We rated the certainty of evidence using the GRADE approach. As meta‐analysis was not possible, we used tabulation to synthesize the studies and histograms to display the outcomes. Main results Overall, we identified four uncontrolled retrospective cohort studies investigating pharmacological interventions for palliative symptom control in hospitalized patients and patients in nursing homes. None of the studies included a comparator. We rated the risk of bias high across all studies. We rated the certainty of the evidence as very low for the primary outcome symptom relief, downgrading mainly for high risk of bias due to confounding and unblinded outcome assessors. Pharmacological interventions for palliative symptom control We identified four uncontrolled retrospective cohort studies (five references) investigating pharmacological interventions for palliative symptom control. Two references used the same register to form their cohorts, and study investigators confirmed a partial overlap of participants. We therefore do not know the exact number of participants, but individual reports included 61 to 2105 participants. Participants received multimodal pharmacological interventions: opioids, neuroleptics, anticholinergics, and benzodiazepines for relieving dyspnea (breathlessness), delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms. Primary outcome: symptom relief All identified studies reported this outcome. For all symptoms (dyspnea, delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms), a majority of interventions were rated as completely or partially effective by outcome assessors (treating clinicians or nursing staff). Interventions used in the studies were opioids, neuroleptics, anticholinergics, and benzodiazepines. We are very uncertain about the effect of pharmacological interventions on symptom relief (very low‐certainty evidence). The initial rating of the certainty of evidence was low since we only identified uncontrolled NRSIs. Our main reason for downgrading the certainty of evidence was high risk of bias due to confounding and unblinded outcome assessors. We therefore did not find evidence to confidently support or refute whether pharmacological interventions may be effective for palliative symptom relief in COVID‐19 patients. Secondary outcomes We planned to include the following outcomes: quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We did not find any data for these outcomes, or any other information on the efficacy and safety of used interventions. Non‐pharmacological interventions for palliative symptom control None of the identified studies used non‐pharmacological interventions for palliative symptom control. Authors' conclusions We found very low certainty evidence for the efficacy of pharmacological interventions for palliative symptom relief in COVID‐19 patients. We found no evidence on the safety of pharmacological interventions or efficacy and safety of non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. The evidence presented here has no specific implications for palliative symptom control in COVID‐19 patients because we cannot draw any conclusions about the effectiveness or safety based on the identified evidence. More evidence is needed to guide clinicians, nursing staff, and caregivers when treating symptoms of COVID‐19 patients at the end of life. Specifically, future studies ought to investigate palliative symptom control in prospectively registered studies, using an active‐controlled setting, assess patient‐reported outcomes, and clearly define interventions. The publication of the results of ongoing studies will necessitate an update of this review. The conclusions of an updated review could differ from those of the present review and may allow for a better judgement regarding pharmacological and non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. Plain language summary Which treatments are best for symptoms in COVID‐19 patients at the end of life? The burden of symptoms at the end of life of COVID‐19 patients and helpful treatments COVID‐19 patients may show symptoms such as breathlessness or delirium at the end of life. The goal of palliative medicine is to relieve such symptoms with specific treatments. Treatments can be drugs, for example opioids, or non‐drugs, such as breathing techniques or relaxation. What was the aim of our review? To explore how well different interventions (drugs and non‐drugs) work for the treatment of palliative symptoms in COVID‐19 patients at the end of life. We included patients of all ages and with all comorbidities (additional medical conditions). What type of studies did we search for? We searched selected medical databases and trial registries until 23 March 2021. We included studies looking at how well different palliative treatments work to relieve COVID‐19‐associated symptoms at the end of life. We wanted to compare studies investigating different medicines or therapies, but we only found studies without a comparison group. Only one study reported the specific drugs used for individual symptoms. Key results We found four studies that were published in five papers. Individual papers included between 61 and 2105 participants, and two papers partially reported on the same participants. All of the included studies investigated different drug treatments for palliative symptom management in people with COVID‐19. Drugs for symptom control at the end of life All of the included studies reported on the effectiveness of palliative care for symptom relief. In all studies, clinicians or nursing staff rated symptom relief rather than the patients themselves. Since the quality of the evidence was very low, we do not know the true effect of drug treatments on symptom relief and have very low confidence in the results of the studies. We did not find any data on quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; or safety of the drug treatments. Non‐drug therapies for symptom control at the end of life We did not find any data on the benefits and harms of non‐drug therapies for symptom control of COVID‐19 patients at the end of life. Conclusions Based on our findings, we could not draw any conclusions on palliative symptom control of people with COVID‐19. Future studies need to be designed better so that we can determine which treatments work for symptom control in people with COVID‐19.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Andreas, M; Piechotta, V; Skoetz, N; Grummich, K; Becker, M; Joos, L; Becker, G; Meissner, W; Boehlke, C", "articleTypes": [], "doi": "10.1002/14651858.CD015061", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "bc00ac35-3099-4948-a788-0b153ace3c6b", "pmid": "", "title": "Interventions for erosive lichen planus affecting mucosal sites", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cheng, S, Kirtschig, G, Cooper, S, Thornhill, M, Leonardi‐Bee, J, Murphy, R", "articleTypes": [], "doi": "10.1002/14651858.CD008092.pub2 AB - Abstract - Background Erosive lichen planus (ELP) affecting mucosal surfaces is a chronic autoimmune disease of unknown aetiology. It is often more painful and debilitating than the non‐erosive types of lichen planus. Treatment of erosive lichen planus is difficult and aimed at palliation rather than cure. Several topical and systemic agents have been used with varying results. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth. Objectives To assess the effects of interventions in the treatment of erosive lichen planus affecting the oral, anogenital, and oesophageal regions. Search methods We searched the following databases up to September 2009: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched reference lists of articles and online trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) that evaluated the effectiveness of any topical or systemic interventions for ELP affecting either the mouth, genital region, or both areas, in participants of any age, gender, or race. Data collection and analysis The primary outcome measures were as follows: (a) Pain reduction using a visual analogue scale rated by participants; 
 (b) Physician Global Assessment; and
 (c) Participant global self‐assessment. Changes in scores at the end of therapy compared with baseline were analysed. Main results Fifteen RCTs were included, giving a total of 473 participants with ELP (study sizes ranged between 8‐94). All studies involved oral sites only. Six studies included participants with non‐erosive lichen planus but only the erosive subgroup was included for intended subgroup analysis. We were unable to pool data from any of the nine studies with only ELP participants or any of the six studies with the ELP subgroup, due to small numbers and the heterogeneity of the interventions, design methods, and outcome variables between studies. One study involving 50 participants found that 0.025% clobetasol propionate administered as liquid microspheres significantly reduced pain compared to ointment (Mean difference (MD) ‐18.30, 95% confidence interval (CI) ‐28.57 to ‐8.03), but outcome data was only available in 45 participants (high risk of performance bias for blinding of participants, low/unclear risk of bias overall). However, in another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (high risk of performance and detection bias due to likely lack of blinding, low/unclear risk of bias overall). Aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo in a study involving 45 ELP participants (Risk ratio (RR) 6.16, 95% CI 2.35 to 16.13) (low risk of bias overall). No significant difference was seen in Physician Global Assessment in these three studies. In a small single study involving 20 ELP participants, 1% pimecrolimus cream was 7 times more likely to result in a strong improvement as rated by the Physician Global Assessment when compared to vehicle cream (RR 7.00, 95% CI 1.04 to 46.95) (low risk of bias overall). In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease as rated by the Physician Global Assessment, in favour of the ciclosporin group when compared to the vehicle (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (unclear risk of selection bias for allocation concealment, overall risk of bias low). No statistically significant benefits were shown for topical tacrolimus or fluticasone spray in two separate studies of 29 and 44 participants respectively. There is no overwhelming evidence for the efficacy of a single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candidiasis and dyspepsia. Authors' conclusions This review suggests that there is only weak evidence for the effectiveness of any of the treatments for oral ELP, whilst no evidence was found for genital ELP. More RCTs on a larger scale are needed in the oral and genital ELP populations. We suggest that future studies should have standardised outcome variables that are clinically important to affected individuals. We recommend the measurement of a clinical severity score and a participant‐rated symptom score using agreed and validated severity scoring tools. We also recommend the development of a validated combined severity scoring tool for both oral and genital populations. Plain language summary Treatments for erosive lichen planus affecting mucosal sites Erosive lichen planus (ELP) is a condition that affects the mouth, oesophagus (food pipe or gullet), and anogenital region. It is caused by an over‐active immune system. It is often more painful and debilitating than the non‐erosive types of lichen planus. Depending on the site involved, affected individuals may experience pain, and difficulty eating; passing urine; or having sexual intercourse. Treatment is difficult and aimed at controlling symptoms, rather than cure. Several creams and tablets have been used with varying results. This review looked at the effectiveness of treatments for ELP and included 15 studies, with 473 participants with ELP. All involved oral, but not genital, disease. Many studies were excluded either because they were not randomised controlled trials (where participants are divided into two groups at random) or because they recruited participants with all types of lichen planus, rather than just the erosive subtypes. All of these studies recruited small numbers of participants (12 to 94) and used a variety of different assessment methods and timings; hence, it was not possible to combine or compare results between studies directly. We found only weak evidence for the effectiveness of any of the treatments for oral ELP. None of the studies involved genital or oesophageal disease; hence, no evidence was found for the treatment of these conditions. One small study found that 0.025% clobetasol propionate (a very potent topical steroid) administered as a spray significantly reduced pain when compared to ointment. In another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (a potent topical steroid). In a study involving 45 ELP participants, aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo. In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease in favour of the ciclosporin group when compared to the vehicle. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candida (yeast) infection and pain or discomfort in the upper abdomen. Temporary burning was a common side‐effect reported with tacrolimus 0.1% ointment and pimecrolimus 0.1% cream. Overall, there was no overwhelming evidence for the effectiveness of any single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. This was mainly due to the lack of good‐quality, well‐conducted trials and small participant numbers. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.090Z" }, { "id": "bc47d4e8-9fc9-475b-9d03-1e7210095f6b", "pmid": "", "title": "Fortification of condiments and seasonings with iron for preventing anaemia and improving health", "imported": false, "abstract": "Abstract - Background Anaemia affects approximately 1.8 billion people worldwide; over 60% of anaemia cases globally are due to iron deficiency (ID). Iron deficiency and anaemia contribute to the global burden of disease and affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortification of food with iron, alone or in combination with other nutrients, is an effective intervention to control ID. Condiments and seasonings are ideal food vehicles for iron fortification in countries where they are commonly used. Objectives To determine the effects and safety of condiment and seasoning fortification with iron alone or iron plus other micronutrients on iron deficiency, anaemia, and health‐related outcomes in the general population. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 24 January 2023. We also searched the International clinical trials registry platform (ICTRP) for any ongoing trials. Selection criteria We included randomised controlled trials (RCTs) (randomisation at individual or cluster level), non‐randomised controlled trials, interrupted time series with at least three measure points both before and after intervention, and controlled before‐after studies. Participants were populations of any age (including pregnant women), from any country, excluding those with critical illness or severe co‐morbidities. We included interventions in which condiments or seasonings have been fortified with any combination of iron and other vitamins and minerals, irrespective of the fortification technology used. Data collection and analysis Two review authors independently screened and assessed the eligibility of studies. Disagreements were resolved through discussion or input from a third review author. Two review authors extracted the data and assessed the risk of bias in all the included studies. We followed the methods laid out by Cochrane and used GRADE criteria for assessing certainty of the evidence. Main results Our search identified 15,902 records after removal of duplicates. We included 16 studies with 20,512 participants (18,410 participants after adjusting for clustering effects). They were all carried out in upper‐middle‐ and lower‐middle‐income countries. Three studies were controlled before‐after studies, one was non‐randomised trial, and 12 were RCTs (including three cluster RCTs). Six studies took place in schools; seven in communities; and one each in a nursery/kindergarten, tea estate, and factory. Three studies involved only women, one study involved both women and their children, and all other studies focused on children and/or adolescents. Nine studies used salt as a vehicle for iron fortification, three used fish sauce, two used soy sauce, one used curry powder, and one a \"seasoning powder\". The dose of iron received by participants ranged from 4.4 mg to 55 mg/day. The sample sizes in the trials ranged from 123 to 14,398, and study durations ranged from three months to two years. Twelve RCTs contributed data for meta‐analysis. Six trials compared iron‐fortified condiments versus the unfortified condiment, and six trials provided data comparing iron fortification in combination with other micronutrients versus the same condiment with other micronutrients, but no added iron. In one trial, the fortificant contained micronutrients that may have affected the absorption of iron. Overall no studies were assessed as having a low risk of bias. All included studies were assessed to have a high overall risk of bias, with the most concerns being around allocation concealment, blinding, and random sequence generation. There was very high heterogeneity amongst studies in almost all examined outcomes. Condiments/seasonings fortified with iron versus unfortified condiments/seasonings We are uncertain about whether consuming condiments/seasonings fortified with iron in comparison to the same unfortified condiment reduces anaemia at the end of intervention (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.18 to 0.65; 2328 participants; 4 studies; very low‐certainty of evidence). We are uncertain about whether consuming iron‐fortified condiments increases haemoglobin concentrations (mean difference (MD) 6.40 (g/L), 95% CI ‐0.62 to 13.41; 2808 participants; 5 studies; very low‐certainty evidence). Fortification of condiments/seasonings with iron probably slightly reduces ID (RR 0.33, 95% CI 0.11 to 1.01; 391 participants; 2 studies; moderate‐certainty evidence). We are uncertain about whether fortification with iron increases ferritin concentration (MD 14.81 (µg/L), 95% CI 5.14 to 24.48; 4459 participants; 6 studies; very low‐certainty evidence). Condiments/seasonings fortified with iron plus other micronutrients versus condiments/seasonings fortified with other micronutrients except iron Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia (RR 0.59, 95% CI 0.40 to 0.89; 1007 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification of condiments/seasonings with iron plus other micronutrients will improve haemoglobin concentration (MD 6.22 g/dL, 95% CI 1.60 to 10.83; 1270 participants; 5 studies; very low‐certainty evidence). It may reduce ID (RR 0.36, 95% CI 0.19 to 0.69; 1154 participants; 4 studies; low‐certainty evidence). We are uncertain about whether fortification with iron plus other micronutrients improves ferritin concentration (MD 10.63 µg/L, 95% CI 2.40 to 18.85; 1251 participants; 5 studies; very low ‐certainty evidence). Condiments/seasonings fortified with iron versus no intervention No trial reported data on this comparison. No studies reported adverse effects. Funding sources do not appear to have distorted the results in any of the assessed trials. Authors' conclusions We are uncertain whether consuming iron‐fortified condiments/seasonings reduces anaemia, improves haemoglobin concentration, or improves ferritin concentration. It may reduce ID. Findings about ferritin should be interpreted with caution since its concentrations increase during inflammation. Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia, and we are uncertain whether this will improve haemoglobin concentration or ferritin concentration. More studies are needed to determine the true effect of iron‐fortified condiments/seasonings on preventing anaemia and improving health. The effects of this intervention on other health outcomes like malaria incidence, growth and development are unclear. Plain language summary Adding iron to condiments and seasonings for preventing anaemia and improving health Key messages ‐ Adding iron to condiments/seasonings may slightly improve iron status and reduce iron deficiency. When iron is added along with other micronutrients, it may reduce anaemia. Unwanted effects were not reported. ‐ There was a lot of variation between the studies included in this review, making it more difficult to draw definitive conclusions. The effects of fortifying condiments and seasonings with iron should continue to be examined in populations consuming them through well‐designed studies. What is anaemia? Iron deficiency is one of the most common nutritional deficiencies throughout the world and contributes significantly to the global burden of disease. Multiple factors cause anaemia, including insufficient iron intake (the most common cause of anaemia), and it affects approximately 1.8 billion people worldwide. In general, low‐income countries have more anaemia than higher‐income countries. Iron deficiency and anaemia have several lifetime consequences that can affect physical and cognitive development in children, and work productivity and economic well‐being in adults. Fortifying condiments or seasonings with iron may be a useful and cost‐effective approach to help reduce iron deficiency. To date, there has been no systematic assessment of the safety and effectiveness of this intervention to inform policymaking. What did we want to find out? If fortifying condiments and seasonings with iron alone or iron plus other micronutrients improves measures of iron nutrition in the general population, in particular: ‐ anaemia; ‐ haemoglobin concentration; ‐ iron deficiency; ‐ iron status (including ferritin, transferrin saturation, and more). We also wanted to find out if consuming iron‐fortified condiments/seasonings was associated with any unwanted effects. What did we do? 
We searched for studies that provided iron‐fortified condiments/seasonings to one group, and condiments/seasonings not fortified with iron to another. We compared and summarised the results of the studies and rated our confidence in the evidence, based on study characteristics. What did we find? We identified 16 studies that involved 18,410 participants in middle‐income countries, most within schools or communities, with study durations ranging from three months to two years. The type of iron‐fortified condiments/seasonings used included salt, fish sauce, soy sauce, and seasoning powders. The dose of iron received by participants ranged from 4.4mg to 55 mg/day. Compared to unfortified condiments/seasonings, those which are iron‐fortified likely improve iron deficiency slightly. We are uncertain whether they reduce anaemia, improve haemoglobin, or other measures of iron status. Condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia; we are uncertain about whether they improve haemoglobin or ferritin concentrations. They may improve iron deficiency and total iron binding capacity. No studies reported adverse effects. More studies are needed to determine the effect of iron‐fortified condiments/seasonings on health such as malaria incidence, growth and development and any potential adverse effects. What are the limitations of the evidence? Our confidence in the evidence is very low to moderate; several factors reduced our confidence in the evidence. Firstly, we observed limitations in the way few studies were conducted with respect to the recruitment of people to assign interventions (this means that differences between the groups could be due to differences between people rather than between the treatments). Secondly, people in some studies may have been aware of which treatment they were getting. Also, not all the studies provided data about everything that were interested in, and results were inconsistent across the different studies. Finally, some studies were small. The results of future research could differ from the results of this review. How up to date is this evidence? The evidence is up‐to‐date to January 2023. What this means We judged the evidence in this review as very low to moderate certainty, which means we are not certain of the effect of condiments/seasonings with added iron on the reduction of anaemia and iron deficiency in people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Jalal, CSB; De-Regil, LM; Pike, V; Mithra, P", "articleTypes": [], "doi": "10.1002/14651858.CD009604.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "bc84b0f6-dee7-42ab-823f-1965d678c149", "pmid": "", "title": "Parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review on parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy (published in Issue 3, 2007). Salivary gland dysfunction is a predictable side effect of radiotherapy to the head and neck region. Pilocarpine hydrochloride (a choline ester) is licensed in many countries for the treatment of radiation‐induced salivary gland dysfunction. Other parasympathomimetics have also been used 'off licence' in the treatment of this condition. Objectives To determine the efficacy and tolerability of parasympathomimetic drugs in the treatment of radiation‐induced salivary gland dysfunction (specifically radiation‐induced xerostomia). Search methods For this update, we ran searches of the Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 6), MEDLINE, EMBASE, and CINAHL in July 2015. We checked the reference lists of retrieved articles for additional studies, contacted experts in the field for unpublished and ongoing trials, and contacted relevant pharmaceutical companies for unpublished and ongoing trials. Selection criteria The selection criteria for the review were: 1) randomised controlled trials; 2) people suffering from radiation‐induced salivary gland dysfunction; 3) people treated with parasympathomimetic drugs; and 4) assessable data available on primary outcome measure. Data collection and analysis The two review authors independently collected data from the full‐text version of relevant papers including: 1) citation details; 2) participants; 3) interventions; 4) assessments; 5) outcomes (that is efficacy, tolerability); and 6) quality issues. Due to a lack of appropriate data, we were unable to perform a meta‐analysis. Main results In the original review, three studies, including a total of 298 participants, fulfilled the inclusion criteria. All three studies involved the use of pilocarpine hydrochloride. We have included no additional studies in the update of the review; we have excluded eight additional studies. The data suggest that pilocarpine hydrochloride is more effective than placebo and at least as effective as artificial saliva. The response rate was 42% to 51%. The time to response was up to 12 weeks. The overall side effect rate was high, and side effects were the main reason for withdrawal (6% to 15% of participants taking 5 mg three times a day had to withdraw). The side effects were usually the result of generalised parasympathomimetic stimulation (for example sweating, headaches, urinary frequency, vasodilatation). Response rates were not dose dependent, but side effect rates were dose dependent. Authors' conclusions There is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced xerostomia. Currently, there is little evidence to support the use of other parasympathomimetic drugs in the treatment of radiation‐induced xerostomia. Available studies suggest that approximately half of patients will respond, but side effects can be problematic. The conclusions of the update are the same as the conclusions of the original review, since no new relevant studies have been published in the interim. Plain language summary Parasympathomimetic drugs for the treatment of 'dry mouth' due to radiotherapy This updated review found there is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced salivary gland dysfunction ('dry mouth'). Salivary gland damage is a frequent and important complication of radiotherapy to the head and neck area; it causes dryness of the mouth with resultant problems with eating, talking, and local infection. The parasympathomimetic group of drugs have been used to treat radiotherapy‐induced salivary gland damage. We identified three studies that involved a total of 289 participants, and they all used the drug pilocarpine. The review found that 42% to 51% of participants (4 to 5 in 10) responded to pilocarpine, although in some participants the response did not occur for up to 12 weeks. Pilocarpine was more effective than a placebo treatment, and at least as effective as an artificial saliva. Side effects were common with pilocarpine (for example sweating, headache, passing urine frequently, flushing), but were usually reported to be mild; 6% to 15% (0.6 to 1.5 in 10) participants had to stop taking pilocarpine due to side effects. The findings of this review are limited by the small number of good‐quality trials that have been performed in this area. The update of this review did not find any new information on this topic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Davies, AN; Thompson, J", "articleTypes": [], "doi": "10.1002/14651858.CD003782.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "bc8baf86-b41a-4894-9ac3-6b27910a8ac0", "pmid": "", "title": "Polyunsaturated fatty acid supplementation for schizophrenia", "imported": false, "abstract": "Abstract - Background Limited evidence supports a hypothesis suggesting that the symptoms of schizophrenia may be the result of altered neuronal membrane structure and metabolism. The structure and metabolism is dependent on blood plasma levels of certain essential fatty acids and their metabolites. Objectives To assess the effects of polyunsaturated fatty acids for people with schizophrenia. Search methods We have updated the initial searches of 1998, 2002 and 2005 with a search of the Cochrane Schizophrenia Group's Register, November 2008, which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. Where necessary, we contacted authors and relevant pharmaceutical companies for additional information. Selection criteria We included all randomised controlled trials of polyunsaturated fatty acid treatment for schizophrenia. Data collection and analysis Working independently, we selected studies for quality assessment and extracted relevant data. We analysed on an intention‐to‐treat basis. Where possible and appropriate we calculated the Relative Risk (RR) and their 95% confidence intervals (CI) and estimated the number needed to treat (NNT). For continuous data we calculated weighted mean differences (WMD) and their 95% confidence intervals. We also inspected the data for heterogeneity. Main results Eight studies are now included in this review. When any dose omega‐3 (E‐EPA or EPA) is compared with placebo, small short trials suggest that the need for neuroleptics appears to be reduced for people allocated omega‐3 supplementation (n=30, 1 RCT, RR 0.73 CI 0.54 to 1.00) and mental state may improve (n=30, 1 RCT, RR not gaining 25% change in PANSS scores 0.54 CI 0.30 to 0.96, NNT 3 CI 2 to 29). There are no differences in the number of people leaving the study early (n=595, 6 RCTs, RR 0.86 CI 0.50 to 1.48). There are few data on the comparison of any dose omega‐6 (GLA) with placebo. For movement disorder outcomes, the one small study we found does not show any difference for average short‐term endpoint AIMS score (n=16, 1 RCT, WMD 1.30 CI ‐1.96 to 4.56). When any dose omega‐3 (E‐EPA or EPA) is compared with any dose omega‐3 (DHA) there is no significant difference for mental state outcome of not gaining 25% change in PANSS scores (n=31, 1 RCT, RR 0.66 CI 0.39 to 1.11). When different doses of omega‐3 (E‐EPA) are compared with placebo there are no differences in measures of global and mental state between the studies. For the outcome of 'experiencing at least one adverse effect' no differences between groups are found for any dose (1 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.97 CI 0.60 to 1.56; 2 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.67 CI 0.37 to 1.20; 4 g/day E‐EPA vs placebo n=58, 1 RCT, RR 1.15 CI 0.72 to 1.82). Authors' conclusions Three updates of this review have resulted in more included studies and more people randomised but still relatively little useful additional data. The results remain inconclusive. The new trials all compare the omega‐3 polyunsaturated fatty acids, in particular eicosapentaenoic acid and its ester, ethyl‐eicosapentaenoic acid. The use of omega‐3 polyunsaturated fatty acids for schizophrenia still remains experimental and this review highlights the need for large, well designed, conducted and reported studies. Plain language summary Polyunsaturated fatty acid supplementation for schizophrenia Schizophrenia is a serious mental health problem that affects about one percent of any population. For some people it can become an illness that they have to live with for their entire life. Early research has suggested that supplementing the diet with omega 3 or omega 6 fatty acids may have a positive effect on the symptoms of schizophrenia. This review looks at randomised control trials where omega 3 or omega 6 were used in combination with antipsychotic medication, or as a treatment in their own right for schizophrenia. Eight studies were found which included a total of 517 people who had a diagnosis of schizophrenia or schizoaffective disorder (combined symptoms of schizophrenia and a mood disorder). They ranged from six to 16 weeks in length and were in both hospital and community settings. The majority of the trials compared two different types of omega 3 fatty acids, EPA (usually as E‐EPA) and DHA with placebo, in people with schizophrenia who are stable on antipsychotic medication. Some of these trials show some improvement in general functioning and in mental state but not to a statistically significant degree. In the longest trial there was no difference between the two groups at the end of the study. One trial compared E‐EPA with DHA and found a suggestion that E‐EPA works better than DHA, but again it was not statistically significant. Where EPA was compared to placebo as a first line treatment for schizophrenia (30 people), those taking EPA had a better overall outcome and improvement in mental state. However, this was a short trial with few people. Finally, one trial compared a type of omega 6 with placebo in men who had the movement disorder tardive dykinesia (16 people). There was no improvement in the symptoms of movement adverse effects in either group at the end of six weeks. These trials were both small and short. In addition most of the data they reported were not able to be used, and half of the trials were funded by the group supplying the trial medication. Therefore it is still not clear whether taking manufactured omega 3 or 6 improves overall functioning or mental state in people with schizophrenia. (Plain language summary prepared for this review by Janey Antoniou of RETHINK, UK www.rethink.org )", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Irving, CB, Mumby‐Croft, R, Joy, LA", "articleTypes": [], "doi": "10.1002/14651858.CD001257.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.109Z" }, { "id": "bc90917e-cb10-4301-be62-3ebbfbc4cbad", "pmid": "", "title": "Intravenous iron versus oral iron versus no iron with or without erythropoiesis‐ stimulating agents (ESA) for cancer patients with anaemia: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Anaemia is common among cancer patients and they may require red blood cell transfusions. Erythropoiesis‐stimulating agents (ESAs) and iron might help in reducing the need for red blood cell transfusions. However, it remains unclear whether the combination of both drugs is preferable compared to using one drug. Objectives To systematically review the effect of intravenous iron, oral iron or no iron in combination with or without ESAs to prevent or alleviate anaemia in cancer patients and to generate treatment rankings using network meta‐analyses (NMAs). Search methods We identified studies by searching bibliographic databases (CENTRAL, MEDLINE, Embase; until June 2021). We also searched various registries, conference proceedings and reference lists of identified trials. Selection criteria We included randomised controlled trials comparing intravenous, oral or no iron, with or without ESAs for the prevention or alleviation of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in cancer patients. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Outcomes were on‐study mortality, number of patients receiving red blood cell transfusions, number of red blood cell units, haematological response, overall mortality and adverse events. We conducted NMAs and generated treatment rankings. We assessed the certainty of the evidence using GRADE. Main results Ninety‐six trials (25,157 participants) fulfilled our inclusion criteria; 62 trials (24,603 participants) could be considered in the NMA (12 different treatment options). Here we present the comparisons of ESA with or without iron and iron alone versus no treatment. Further results and subgroup analyses are described in the full text. On‐study mortality We estimated that 92 of 1000 participants without treatment for anaemia died up to 30 days after the active study period. Evidence from NMA (55 trials; 15,074 participants) suggests that treatment with ESA and intravenous iron (12 of 1000; risk ratio (RR) 0.13, 95% confidence interval (CI) 0.01 to 2.29; low certainty) or oral iron (34 of 1000; RR 0.37, 95% CI 0.01 to 27.38; low certainty) may decrease or increase and ESA alone (103 of 1000; RR 1.12, 95% CI 0.92 to 1.35; moderate certainty) probably slightly increases on‐study mortality. Additionally, treatment with intravenous iron alone (271 of 1000; RR 2.95, 95% CI 0.71 to 12.34; low certainty) may increase and oral iron alone (24 of 1000; RR 0.26, 95% CI 0.00 to 19.73; low certainty) may increase or decrease on‐study mortality. Haematological response We estimated that 90 of 1000 participants without treatment for anaemia had a haematological response. Evidence from NMA (31 trials; 6985 participants) suggests that treatment with ESA and intravenous iron (604 of 1000; RR 6.71, 95% CI 4.93 to 9.14; moderate certainty), ESA and oral iron (527 of 1000; RR 5.85, 95% CI 4.06 to 8.42; moderate certainty), and ESA alone (467 of 1000; RR 5.19, 95% CI 4.02 to 6.71; moderate certainty) probably increases haematological response. Additionally, treatment with oral iron alone may increase haematological response (153 of 1000; RR 1.70, 95% CI 0.69 to 4.20; low certainty). Red blood cell transfusions We estimated that 360 of 1000 participants without treatment for anaemia needed at least one transfusion. Evidence from NMA (69 trials; 18,684 participants) suggests that treatment with ESA and intravenous iron (158 of 1000; RR 0.44, 95% CI 0.31 to 0.63; moderate certainty), ESA and oral iron (144 of 1000; RR 0.40, 95% CI 0.24 to 0.66; moderate certainty) and ESA alone (212 of 1000; RR 0.59, 95% CI 0.51 to 0.69; moderate certainty) probably decreases the need for transfusions. Additionally, treatment with intravenous iron alone (268 of 1000; RR 0.74, 95% CI 0.43 to 1.28; low certainty) and with oral iron alone (333 of 1000; RR 0.92, 95% CI 0.54 to 1.57; low certainty) may decrease or increase the need for transfusions. Overall mortality We estimated that 347 of 1000 participants without treatment for anaemia died overall. Low‐certainty evidence from NMA (71 trials; 21,576 participants) suggests that treatment with ESA and intravenous iron (507 of 1000; RR 1.46, 95% CI 0.87 to 2.43) or oral iron (482 of 1000; RR 1.39, 95% CI 0.60 to 3.22) and intravenous iron alone (521 of 1000; RR 1.50, 95% CI 0.63 to 3.56) or oral iron alone (534 of 1000; RR 1.54, 95% CI 0.66 to 3.56) may decrease or increase overall mortality. Treatment with ESA alone may lead to little or no difference in overall mortality (357 of 1000; RR 1.03, 95% CI 0.97 to 1.10; low certainty). Thromboembolic events We estimated that 36 of 1000 participants without treatment for anaemia developed thromboembolic events. Evidence from NMA (50 trials; 15,408 participants) suggests that treatment with ESA and intravenous iron (66 of 1000; RR 1.82, 95% CI 0.98 to 3.41; moderate certainty) probably slightly increases and with ESA alone (66 of 1000; RR 1.82, 95% CI 1.34 to 2.47; high certainty) slightly increases the number of thromboembolic events. None of the trials reported results on the other comparisons. Thrombocytopenia or haemorrhage We estimated that 76 of 1000 participants without treatment for anaemia developed thrombocytopenia/haemorrhage. Evidence from NMA (13 trials, 2744 participants) suggests that treatment with ESA alone probably leads to little or no difference in thrombocytopenia/haemorrhage (76 of 1000; RR 1.00, 95% CI 0.67 to 1.48; moderate certainty). None of the trials reported results on other comparisons. Hypertension We estimated that 10 of 1000 participants without treatment for anaemia developed hypertension. Evidence from NMA (24 trials; 8383 participants) suggests that treatment with ESA alone probably increases the number of hypertensions (29 of 1000; RR 2.93, 95% CI 1.19 to 7.25; moderate certainty). None of the trials reported results on the other comparisons. Authors' conclusions When considering ESAs with iron as prevention for anaemia, one has to balance between efficacy and safety. Results suggest that treatment with ESA and iron probably decreases number of blood transfusions, but may increase mortality and the number of thromboembolic events. For most outcomes the different comparisons within the network were not fully connected, so ranking of all treatments together was not possible. More head‐to‐head comparisons including all evaluated treatment combinations are needed to fill the gaps and prove results of this review. Plain language summary Which combinations of medicines are best for the prevention and treatment of anaemia in people with cancer? Key messages • Giving medicines that stimulate the bone marrow to produce red blood cells (ESAs) with iron supplements probably decreases the number of blood transfusions, but may also cause more deaths and increase the number of unwanted effects, such as blood clots. • Because of missing data from the studies we could not compare the different treatment options to each other and rank them. • We need more studies that compare these medicines directly against each other. What is anaemia and why do people with cancer develop it? Anaemia develops when levels of red blood cells are too low. Red blood cells contain a protein called haemoglobin. Iron molecules in the haemoglobin bind to oxygen and carry it around the body. A lack of oxygen to the organs and tissues in the body makes people feel tired and lack energy, and they may be at greater risk of infections. People with cancer are particularly likely to suffer from anaemia. This might be because the cancers cause inflammation and prevent red blood cell production. Or it might be because treatments like chemotherapy slow down production of red blood cells in bone marrow. People suffering from anaemia may need blood transfusions. However, treatment with medicines that stimulate the production of red blood cells in bone marrow (called erythropoiesis‐stimulating agents or ESAs) and iron supplements may reduce the need for transfusions. What did we want to find out? We wanted to identify the most effective treatments for anaemia in people with cancer and whether they cause any unwanted effects. We were interested in whether iron supplements or ESAs given alone or together affect: • deaths; • haemoglobin levels; • blood transfusions; and • unwanted effects. We also wanted to know the best way to give the medicines: by injection (intravenous), or swallowed (oral). What did we do? We searched for studies that compared intravenous, oral or no iron with or without ESAs for the prevention or treatment of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in people with cancer. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and numbers of participants. We used statistical methods to compare multiple treatments against each other and rank them in order of effectiveness and unwanted effects. What did we find? We found 96 relevant studies with 25,157 people. People in the studies were different ages and were receiving a mix of anti‐cancer treatments or no treatment. They had different types of cancer. Ninety‐two studies reported data for our review. They included 24,603 people and compared 12 different treatment options for anaemia. The treatments included combinations of ESAs with intravenous or oral iron and placebo (something that looks, tastes and smells the same as the iron supplement or ESA but with no active ingredient). Not every study reported everything we were interested in, so we did not have enough information to compare each treatment with each of the other treatments. Treatment with ESAs when used on their own or with iron probably increases levels of red blood cells and reduces the need for red blood cell transfusions when compared with no treatment. We cannot rule out an increase in the risk of mortality with ESA in combination with iron, which also appeared to cause more deaths and lead to increased risk of harm caused by the formation of clots in the blood vessels. Our confidence in the findings Overall, we are moderately confident in the evidence that one treatment is better or worse than another. Our confidence is limited because we sometimes found very different results for the same treatments, meaning they could have been both good and bad for patients ‐ we did not have enough evidence to reach firm conclusions. Also, due to a lack of evidence we could not rank the treatments. How up to date is the evidence? The evidence is up‐to‐date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Adams, A; Scheckel, B; Habsaoui, A; Haque, M; Kuhr, K; Monsef, I; Bohlius, J; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012633.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "bc958096-9b82-4a0c-9ae9-66ea1332b6bb", "pmid": "", "title": "Fixed‐dose combinations of drugs versus single‐drug formulations for treating pulmonary tuberculosis", "imported": false, "abstract": "Abstract - Background People who are newly diagnosed with pulmonary tuberculosis (TB) typically receive a standard first‐line treatment regimen that consists of two months of isoniazid, rifampicin, pyrazinamide, and ethambutol followed by four months of isoniazid and rifampicin. Fixed‐dose combinations (FDCs) of these drugs are widely recommended. Objectives To compare the efficacy, safety, and acceptability of anti‐tuberculosis regimens given as fixed‐dose combinations compared to single‐drug formulations for treating people with newly diagnosed pulmonary tuberculosis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL, published in the Cochrane Library, Issue 11 2015); MEDLINE (1966 to 20 November 2015); EMBASE (1980 to 20 November 2015); LILACS (1982 to 20 November 2015); the metaRegister of Controlled Trials; and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), without language restrictions, up to 20 November 2015. Selection criteria Randomized controlled trials that compared the use of FDCs with single‐drug formulations in adults (aged 15 years or more) newly diagnosed with pulmonary TB. Data collection and analysis Two review authors independently assessed studies for inclusion, and assessed the risk of bias and extracted data from the included trials. We used risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data with 95% confidence intervals (CIs). We attempted to assess the effect of treatment for time‐to‐event measures with hazard ratios and their 95% CIs. We used the Cochrane 'Risk of bias' assessment tool to determine the risk of bias in included trials. We used the fixed‐effect model when there was little heterogeneity and the random‐effects model with moderate heterogeneity. We used an I² statistic value of 75% or greater to denote significant heterogeneity, in which case we did not perform a meta‐analysis. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We included 13 randomized controlled trials (RCTs) in the review, which enrolled 5824 participants. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. Overall there is little or no difference detected between FDCs and single‐drug formulations for most outcomes reported. We did not detect a difference in treatment failure between FDCs compared with single‐drug formulations (RR 1.28, 95% CI 0.82 to 2.00; 3606 participants, seven trials, moderate quality evidence ). Relapse may be more frequent in people treated with FDCs compared to single‐drug formulations, although the confidence interval (CI) includes no difference (RR 1.28, 95% CI 1.00 to 1.64; 3621 participants, 10 trials, low quality evidence ). We did not detect any difference in death between fixed‐dose and single‐drug formulation groups (RR 0.96, 95% CI 0.67 to 1.39; 4800 participants, 11 trials, moderate quality evidence ). When we compared FDCs with single‐drug formulations we found little or no difference for sputum smear or culture conversion at the end of treatment (RR 0.99, 95% CI 0.96 to 1.02; 2319 participants, seven trials, high quality evidence ), for serious adverse events (RR 1.45, 95% CI 0.90 to 2.33; 3388 participants, six trials, moderate quality evidence ), and for adverse events that led to discontinuation of therapy (RR 0.96, 95% CI 0.56 to 1.66; 5530 participants, 13 trials, low quality evidence ). We conducted a sensitivity analysis excluding studies at high risk of bias and this did not alter the review findings. Authors' conclusions Fixed‐dose combinations and single‐drug formulations probably have similar effects for treating people with newly diagnosed pulmonary TB. 23 April 2019 No update planned Other This is not a current research question. Plain language summary Fixed‐dose combinations for treating pulmonary tuberculosis What are fixed‐dose combinations and how might they improve care of people with tuberculosis Tuberculosis (TB) is an important health problem, especially in developing countries. The treatment for pulmonary TB in new patients includes four oral medicines taken for six months, sometimes as fixed‐dose combinations (FDCs) that are combined in one tablet, or taken separately as single‐drug formulations. The World Health Organization recommends prescribers use fixed‐dose combinations to reduce the number of tablets that people take. On the supply side, this might reduce prescribing errors and improve drug supply efficiency; on the patient's side, FDCS simplify treatment and improve adherence. We conducted a review to assess the efficacy, safety, and acceptability of FDCs compared with single‐drug formulations for treating people with newly diagnosed pulmonary TB. What the research says We searched for relevant trials up to 20 November 2015, and included 13 randomized controlled trials that enrolled 5824 people. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. There is probably little or no difference in FDCs compared to single‐drug formulations for treatment failure ( moderate quality evidence ); relapse may be more frequent ( low quality evidence ); and the number of deaths were similar ( moderate quality evidence ). There is little or no difference in sputum smear or culture conversion ( high quality evidence ), and no difference was shown for serious adverse events ( moderate quality evidence ) or adverse events that led to discontinuation of therapy ( low quality evidence ). Authors’ conclusions We concluded that fixed‐dose combinations have similar efficacy to single‐drug formulations for treating people with newly diagnosed pulmonary TB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Gallardo, CR, Rigau Comas, D, Valderrama Rodríguez, A, Roqué i Figuls, M, Parker, LA, Caylà, J, Bonfill Cosp, X", "articleTypes": [], "doi": "10.1002/14651858.CD009913.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.734Z" }, { "id": "bc9850de-2222-435d-ba1e-4718f3fee1a1", "pmid": "", "title": "Pharmacological and non‐pharmacological strategies for obese women with subfertility", "imported": false, "abstract": "Abstract - Background Clinicians primarily recommend weight loss for obese women seeking pregnancy. The effectiveness of interventions aimed at weight loss in obese women with subfertility is unclear. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for achieving weight loss in obese women with subfertility. Search methods We searched the CGF Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and AMED from inception to 18 August 2020. We also checked reference lists and contacted experts in the field for additional relevant papers. Selection criteria We included published and unpublished randomised controlled trials in which weight loss was the main goal of the intervention. Our primary effectiveness outcomes were live birth or ongoing pregnancy and primary safety outcomes were miscarriage and adverse events. Secondary outcomes included clinical pregnancy, weight change, quality of life, and mental health outcome. Data collection and analysis Review authors followed standard Cochrane methodology. Main results This review includes 10 trials. Evidence was of very low to low quality: the main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision. Non‐pharmacological intervention versus no intervention or placebo Evidence is insufficient to determine whether a diet or lifestyle intervention compared to no intervention affects live birth (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.65 to 1.11; 918 women, 3 studies; I² = 78%; low‐quality evidence). This suggests that if the chance of live birth following no intervention is assumed to be 43%, the chance following diet or lifestyle changes would be 33% to 46%. We are uncertain if lifestyle change compared with no intervention affects miscarriage rate (OR 1.54, 95% CI 0.99 to 2.39; 917 women, 3 studies; I² = 0%; very low‐quality evidence). Evidence is insufficient to determine whether lifestyle change compared with no intervention affects clinical pregnancy (OR 1.06, 95% CI 0.81 to 1.40; 917 women, 3 studies; I² = 73%; low‐quality evidence). Lifestyle intervention resulted in a decrease in body mass index (BMI), but data were not pooled due to heterogeneity in effect (mean difference (MD) ‐3.70, 95% CI ‐4.10 to ‐3.30; 305 women, 1 study; low‐quality evidence; and MD ‐1.80, 95% CI ‐2.67 to ‐0.93; 43 women, 1 study; very low‐quality evidence). Non‐pharmacological versus non‐pharmacological intervention We are uncertain whether intensive weight loss interventions compared to standard care nutrition counselling affects live birth (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), BMI (MD ‐3.00, 95% CI ‐5.37 to ‐0.63; 11 women, 1 study; very low‐quality evidence), weight change (MD ‐9.00, 95% CI ‐15.50 to ‐2.50; 11 women, 1 study; very low‐quality evidence), quality of life (MD 0.06, 95% CI ‐0.03 to 0.15; 11 women, 1 study; very low‐quality evidence), or mental health (MD ‐7.00, 95% CI ‐13.92 to ‐0.08; 11 women, 1 study; very low‐quality evidence). No study reported on adverse events . Pharmacological versus pharmacological intervention For metformin plus liraglutide compared to metformin we are uncertain of an effect on the adverse events nausea (OR 7.22, 95% CI 0.72 to 72.7; 28 women, 1 study; very low‐quality evidence), diarrhoea (OR 0.31, 95% CI 0.01 to 8.3; 28 women, 1 study; very low‐quality evidence), and headache (OR 5.80, 95% CI 0.25 to 133; 28 women, 1 study; very low‐quality evidence). We are uncertain if a combination of metformin plus liraglutide vs metformin affects BMI (MD 2.1, 95% CI ‐0.42 to 2.62; 28 women, 1 study; very low‐quality evidence) and total body fat (MD ‐0.50, 95% CI ‐4.65 to 3.65; 28 women, 1 study; very low‐quality evidence). For metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo, we are uncertain of an effect on miscarriage (OR 3.58, 95% CI 0.73 to 17.55; 274 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 5.56, 95% CI 2.57 to 12.02; 274 women, 1 study; very low‐quality evidence) or BMI (MD ‐0.3, 95% CI 1.17 to 0.57, 274 women, 1 study, very low‐quality evidence). We are uncertain if dexfenfluramine versus placebo affects weight loss in kilograms (MD ‐0.10, 95% CI ‐2.77 to 2.57; 21 women, 1 study; very low‐quality evidence). No study reported on live birth, quality of life, or mental health outcomes. Pharmacological intervention versus no intervention or placebo We are uncertain if metformin compared with placebo affects live birth (OR 1.57, 95% CI 0.44 to 5.57; 65 women, 1 study; very low‐quality evidence). This suggests that if the chance of live birth following placebo is assumed to be 15%, the chance following metformin would be 7% to 50%. We are uncertain if metformin compared with placebo affects gastrointestinal adverse events (OR 0.91, 95% CI 0.32 to 2.57; 65 women, 1 study; very low‐quality evidence) or miscarriage (OR 0.50, 95% CI 0.04 to 5.80; 65 women, 1 study; very low‐quality evidence) or clinical pregnancy (OR 2.67, 95% CI 0.90 to 7.93; 96 women, 2 studies; I² = 48%; very low‐quality evidence). We are also uncertain if diet combined with metformin versus diet and placebo affects BMI (MD ‐0.30, 95% CI ‐2.16 to 1.56; 143 women, 1 study; very low‐quality evidence) or waist‐to‐hip ratio (WHR) (MD 2.00, 95% CI ‐2.21 to 6.21; 143 women, 1 study; very low‐quality evidence). Pharmacological versus non‐pharmacological intervention No study undertook this comparison. Authors' conclusions Evidence is insufficient to support the use of pharmacological and non‐pharmacological strategies for obese women with subfertility. No data are available for the comparison of pharmacological versus non‐pharmacological strategies. We are uncertain whether pharmacological or non‐pharmacological strategies effect live birth, ongoing pregnancy, adverse events, clinical pregnancy, quality of life, or mental health outcomes. However, for obese women with subfertility, a lifestyle intervention may reduce BMI. Future studies should compare a combination of pharmacological and lifestyle interventions for obese women with subfertility. Plain language summary Do pharmacological and non‐pharmacological strategies reduce weight in obese women with subfertility? To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for weight reduction in obese women with subfertility. Background To prevent the adverse effects of obesity, weight loss is recommended as the first line of treatment for obese women seeking pregnancy. The effectiveness of pharmacological and non‐pharmacological interventions for obese women with subfertility is unclear. Study characteristics We found 10 randomised trials comparing pharmacological and non‐pharmacological strategies in 1490 obese women with subfertility. Key results Lack of data is a major concern in interpretation of these data. Only 10 studies were included in the analysis. Three studies compared non‐pharmacological intervention versus no intervention or placebo. We are uncertain whether diet versus no intervention improves live birth, ongoing pregnancy, clinical pregnancy, or adverse events. A diet or lifestyle intervention may result in body mass index (BMI) weight change. Evidence was insufficient to show a difference in waist‐to‐hip ratio (WHR) with diet or lifestyle change compared to no intervention. No study reported on quality of life, or mental health outcomes for this comparison. One study compared non‐pharmacological interventions ‐ intensive weight loss intervention versus standard of care nutrition counselling; however due to the very low quality of evidence, we are uncertain whether intensive weight loss interventions improve live birth, clinical pregnancy, quality of life, or mental health outcomes. No study reported on adverse events, or weight changes, for this comparison. Three studies reported on pharmacological versus pharmacological interventions. Evidence was insufficient to show a difference in adverse events between metformin compared to metformin plus liraglutide. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for miscarriage. Evidence was insufficient to reveal a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo or metformin plus liraglutide versus metformin in clinical pregnancy. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for weight change using BMI. Moreover, evidence was insufficient to reveal a difference between dexfenfluramine versus placebo or metformin plus liraglutide versus metformin for weight loss in kilograms, or per cent of total body fat. No study reported on live birth and change in quality of life or mental health outcomes for this comparison. In the comparison of pharmacological intervention versus no intervention or placebo, three studies were included. Evidence was insufficient to show a difference between metformin and control groups related to live birth. Evidence was insufficient to reveal a difference between metformin compared to placebo in live birth, clinical pregnancy, or adverse events. Evidence was insufficient to demonstrate a difference between diet combined with metformin versus diet combined with placebo for weight change using BMI or WHR. No study reported on quality of life or mental health outcomes for this comparison. We found no study comparing non‐pharmacological with pharmacological interventions. Quality of the evidence The evidence was of very low to low quality. The main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading of evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Taghavi, SA; van Wely, M; Jahanfar, S; Bazarganipour, F", "articleTypes": [], "doi": "10.1002/14651858.CD012650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "bca1d734-faf7-47fb-9b00-4d689abeea9a", "pmid": "", "title": "Interventions for the prevention of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "Abstract - Background Loss of olfactory function is well recognised as a symptom of COVID‐19 infection, and the pandemic has resulted in a large number of individuals with abnormalities in their sense of smell. For many, the condition is temporary and resolves within two to four weeks. However, in a significant minority the symptoms persist. At present, it is not known whether early intervention with any form of treatment (such as medication or olfactory training) can promote recovery and prevent persisting olfactory disturbance. This is an update of the 2021 review with four studies added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with acute olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance, which had been present for less than four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the presence of normal olfactory function, serious adverse effects and change in sense of smell. Secondary outcomes were the prevalence of parosmia, change in sense of taste, disease‐related quality of life and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included five studies with 691 participants. The studies evaluated the following interventions: intranasal corticosteroid sprays, intranasal corticosteroid drops, intranasal hypertonic saline and zinc sulphate. Intranasal corticosteroid spray compared to no intervention/placebo We included three studies with 288 participants who had olfactory dysfunction for less than four weeks following COVID‐19. Presence of normal olfactory function The evidence is very uncertain about the effect of intranasal corticosteroid spray on both self‐rated recovery of olfactory function and recovery of olfactory function using psychophysical tests at up to four weeks follow‐up ( self‐rated : risk ratio (RR) 1.19, 95% confidence interval (CI) 0.85 to 1.68; 1 study; 100 participants; psychophysical testing : RR 2.3, 95% CI 1.16 to 4.63; 1 study; 77 participants; very low‐certainty evidence). Change in sense of smell The evidence is also very uncertain about the effect of intranasal corticosteroid spray on self‐rated change in the sense of smell ( at less than 4 weeks : mean difference (MD) 0.5 points lower, 95% CI 1.38 lower to 0.38 higher; 1 study; 77 participants; at > 4 weeks to 3 months : MD 2.4 points higher, 95% CI 1.32 higher to 3.48 higher; 1 study; 100 participants; very low‐certainty evidence, rated on a scale of 1 to 10, higher scores mean better olfactory function). Intranasal corticosteroids may make little or no difference to the change in sense of smell when assessed with psychophysical testing (MD 0.2 points, 95% CI 2.06 points lower to 2.06 points higher; 1 study; 77 participants; low‐certainty evidence, 0‐ to 24‐point scale, higher scores mean better olfactory function). Serious adverse effects The authors of one study reported no adverse effects, but their intention to collect these data was not pre‐specified so we are uncertain if these were systematically sought and identified. The remaining two studies did not report on adverse effects. Intranasal corticosteroid drops compared to no intervention/placebo We included one study with 248 participants who had olfactory dysfunction for ≤ 15 days following COVID‐19. Presence of normal olfactory function Intranasal corticosteroid drops may make little or no difference to self‐rated recovery at > 4 weeks to 3 months (RR 1.00, 95% CI 0.89 to 1.11; 1 study; 248 participants; low‐certainty evidence). No other outcomes were assessed by this study. Data on the use of hypertonic saline nasal irrigation and the use of zinc sulphate to prevent persistent olfactory dysfunction are included in the full text of the review. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for preventing persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the prevention of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important COVID‐19 has been found to cause problems with the sense of smell. Sometimes this is a reduction in the ability to smell things, and sometimes it is a complete loss of the sense of smell. For many people this recovers in a short time, but for others it may last for weeks or months. This review considers whether there are treatments that people might take as soon as they have lost their sense of smell (within four weeks of the symptoms starting), to try and stop this becoming a long‐standing problem. How we identified and assessed the evidence We searched for all relevant studies in the medical literature to summarise the results. We also looked at how certain the evidence was, considering things like the size of the studies and how they were carried out. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found five studies that had been completed. Intranasal corticosteroids compared to no treatment Three studies looked at this treatment. Nasal corticosteroid spray might make little or no difference to the sense of smell when measured with specific tests (rather than when asking people about their sense of smell). The rest of the evidence was of very low certainty, so we do not know whether a nasal corticosteroid spray is better or worse than no treatment at: ‐ helping the sense of smell get back to normal (either people feeling that their sense of smell is back to normal, or having a normal sense of smell according to specific tests); ‐ making people feel that their sense of smell has improved; ‐ causing any unwanted side effects. Intranasal corticosteroid drops compared to placebo (dummy treatment) One study looked at this treatment. Intranasal corticosteroid drops might not make any difference to the number of people who think their sense of smell has recovered at 30 days. We did find a number of other studies that are being carried out, but no results from these studies were available yet to be included in this review. What this means We do not know whether using a nasal corticosteroid spray or nasal drops has any benefit in preventing longer‐term loss of the sense of smell that is related to COVID‐19, or whether they may cause any harm. This review is a 'living systematic review' ‐ meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Webster, KE, O'Byrne, L, MacKeith, S, Philpott, C, Hopkins, C, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013877.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.063Z" }, { "id": "bca5cfab-6660-4e69-a1d5-7a32ac7cf1ce", "pmid": "", "title": "Interventions for treating people with symptoms of bladder pain syndrome: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide‐ranging treatment options, used alone or in combination, with limited evidence. A network meta‐analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS. Objectives To conduct a network meta‐analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS). Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible. Data collection and analysis We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random‐effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta‐analysis of head‐to‐head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories. Main results We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low‐certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD ‐1.27, 95% CrI ‐3.25 to 0.71; low‐certainty evidence), daytime frequency (MD ‐2.41, 95% CrI ‐6.85 to 2.05; very low‐certainty evidence) or nocturia (MD 0.01, 95% CrI ‐2.53 to 2.50; very low‐certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low‐certainty evidence) or reduced pain (MD 0.42, 95% CrI ‐1.04 to 1.91; low‐certainty evidence), frequency (MD ‐0.37, 95% CrI ‐5.00 to 3.44; very low‐certainty evidence) or nocturia (MD ‐1.20, 95% CrI ‐3.62 to 1.28; very low‐certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD ‐0.33, 95% CrI ‐1.71 to 1.03), frequency (MD ‐0.91, 95% CrI ‐3.24, 1.29) or nocturia (MD ‐0.04, 95% CrI ‐1.35 to 1.27). The certainty of this evidence was always very low. Authors' conclusions We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base. Plain language summary Treatments for people with bladder pain syndrome What is bladder pain syndrome? Bladder pain syndrome (BPS; also called painful bladder syndrome or interstitial cystitis) is a long‐term painful condition that affects the bladder. ‘Syndrome’ refers to a collection of symptoms. In BPS, these symptoms include: intense pain in the pelvis (felt below the bellybutton); sudden strong urges to urinate; needing to urinate more often than usual; and waking up several times during the night to urinate. BPS is more common in women. We do not know what causes it or how to cure it. Symptoms sometimes come and go in phases. BPS can significantly affect lifestyle, work, emotional health and relationships. Treatments for BPS Lifestyle changes are usually tried first, then medicines and supportive therapies. Surgery may be needed as a last resort. Medicines used include pentosan polysulfate sodium – which may help to restore the inner surface of the bladder – anti‐inflammatories, antidepressants and antihistamines. Medicines that block the connection between nerves and muscles can be injected into the bladder muscle to try to relax it (‘neuromuscular blockade’). Supportive therapies and treatments include behavioural therapy, physiotherapy, bladder re‐training, psychological therapy and transcutaneous electrical nerve stimulation (TENS). Review question In this Cochrane Review, we wanted to find out which treatments work best to treat BPS. What did we do? We searched for studies that looked at any type of treatment for BPS. We looked for randomised controlled studies, in which the treatment people receive is randomly decided, because these studies usually give the most reliable evidence about treatments. Search date We included evidence published up to 11 May 2018. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. What we found We found 81 studies involving 4674 people with BPS. The biggest study included 369 people, and the smallest study included 10 people. Most studies lasted around three months; only six studies lasted 12 months or longer. Twenty‐four studies were funded by pharmaceutical companies. We found 65 treatments for BPS, which we grouped into 31 categories based on how the treatments worked. In most studies, a treatment for BPS was compared with a placebo (or dummy) treatment. We compared all treatments with each other using a mathematical method called network meta‐analysis. What are the results of our review? After 12 months, antidepressants or neuromuscular blockade (and some other treatments) may improve symptoms of BPS more than placebo, but we are not certain about this result. We did not find enough evidence to know if pentosan polysulfate sodium improves symptoms. We are uncertain whether 12 months of treatment with antidepressants, neuromuscular blockade or pentosan polysulfate sodium reduced pain (as measured on a scale); the number of times people had to urinate during the day; or the number of times people had to get up to urinate during the night. Our confidence in the results We are uncertain about our results because we did not find enough reliable evidence. Although we obtained results from 81 studies, most of these studies were small and did not include enough people for us to be certain of their results. Some of the studies (30%) were conducted by pharmaceutical companies, and this may have affected how the studies were designed, conducted and reported. Our results may change when results from more, and larger, studies become available. Conclusions We did not find enough reliable evidence about how well medicines, behavioural therapy, physiotherapy and neuromuscular blockade worked to treat all, or any, of the symptoms of BPS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Imamura, M; Scott, NW; Wallace, SA; Ogah, JA; Ford, AA; Dubos, YA; Brazzelli, M", "articleTypes": [], "doi": "10.1002/14651858.CD013325.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "bcb9f4bc-85e2-4b6e-a67f-d93e7fc43fe4", "pmid": "", "title": "Interventions for treating burning mouth syndrome", "imported": false, "abstract": "Abstract - Background Burning mouth syndrome (BMS) is a term used for oral mucosal pain (burning pain or discomfort in the tongue, lips or entire oral cavity) without identifiable cause. General population prevalence varies from 0.1% to 3.9%. Many BMS patients indicate anxiety, depression, personality disorders and impaired quality of life (QoL). This review updates the previous versions published in 2000 and 2005. Objectives To determine the effectiveness and safety of any intervention versus placebo for symptom relief and changes in QoL, taste, and feeling of dryness in people with BMS. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 31 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 11) in the Cochrane Library (searched 31 December 2015), MEDLINE Ovid (1946 to 31 December 2015), and Embase Ovid (1980 to 31 December 2015). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching the electronic databases Selection criteria Randomised controlled trials (RCTs) comparing any treatment against placebo in people with BMS. The primary outcomes were symptom relief (pain/burning) and change in QoL. Secondary outcomes included change in taste, feeling of dryness, and adverse effects. Data collection and analysis We used standard methodological procedures expected by Cochrane. Outcome data were analysed as short‐term (up to three months) or long‐term (three to six months). Main results We included 23 RCTs (1121 analysed participants; 83% female). Interventions were categorised as: antidepressants and antipsychotics, anticonvulsants, benzodiazepines, cholinergics, dietary supplements, electromagnetic radiation, physical barriers, psychological therapies, and topical treatments. Only one RCT was assessed at low risk of bias overall, four RCTs' risk of bias was unclear, and 18 studies were at high risk of bias. Overall quality of the evidence for effectiveness was very low for all interventions and all outcomes. Twenty‐one RCTs assessed short‐term symptom relief. There is very low‐quality evidence of benefit from electromagnetic radiation (one RCT, 58 participants), topical benzodiazepines (two RCTs, 111 participants), physical barriers (one RCT, 50 participants), and anticonvulsants (one RCT, 100 participants). We found insufficient/contradictory evidence regarding the effectiveness of antidepressants, cholinergics, systemic benzodiazepines, dietary supplements or topical treatments. No RCT assessing psychological therapies evaluated short‐term symptom relief. Four studies assessed long‐term symptom relief. There is very low‐quality evidence of a benefit from psychological therapies (one RCT, 30 participants), capsaicin oral rinse (topical treatment) (one RCT, 18 participants), and topical benzodiazepines (one RCT, 66 participants). We found no evidence of a difference for dietary supplements or lactoperoxidase oral rinse. No studies assessing antidepressants, anticonvulsants, cholinergics, electromagnetic radiation or physical barriers evaluated long‐term symptom relief. Short‐term change in QoL was assessed by seven studies (none long‐term).The quality of evidence was very low. A benefit was found for electromagnetic radiation (one RCT, 58 participants), however findings were inconclusive for antidepressants, benzodiazepines, dietary supplements and physical barriers. Secondary outcomes (change in taste and feeling of dryness) were only assessed short‐term, and the findings for both were also inconclusive. With regard to adverse effects, there is very low‐quality evidence that antidepressants increase dizziness and drowsiness (one RCT, 37 participants), and that alpha lipoic acid increased headache (two RCTs, 118 participants) and gastrointestinal complaints (3 RCTs, 138 participants). We found insufficient/contradictory evidence regarding adverse events for anticonvulsants or benzodiazepines. Adverse events were poorly reported or unreported for cholinergics, electromagnetic radiation, and psychological therapies. No adverse events occurred from physical barriers or topical therapy use. Authors' conclusions Given BMS' potentially disabling nature, the need to identify effective modes of treatment for sufferers is vital. Due to the limited number of clinical trials at low risk of bias, there is insufficient evidence to support or refute the use of any interventions in managing BMS. Further clinical trials, with improved methodology and standardised outcome sets are required in order to establish which treatments are effective. Future studies are encouraged to assess the role of treatments used in other neuropathic pain conditions and psychological therapies in the treatment of BMS. Plain language summary Interventions for treating burning mouth syndrome Review question Which treatments help to relieve symptoms for people with burning mouth syndrome (BMS)? Background BMS is a common painful condition. Symptoms include burning, dryness or uncomfortable sensations in the mouth and changes to taste, with no obvious underlying medical or dental cause. BMS is usually persistent and suffered long term, and can lead to a reduced quality of life (QoL). Currently, scientific research suggests that BMS is caused by underlying damage to the nerves. There are many treatments available including drugs for anxiety, other psychological conditions and increasing saliva production, protective barriers and treatments applied to the mouth surface amongst others. Study characteristics This review of studies was carried out through Cochrane Oral Health, and the evidence is current up to 31 December 2015. We found 23 studies (assessing 1121 people; 83% were women), published between 1995 and 2015 to include in this review. Twenty‐one studies assessed short‐term (up to three months) symptom relief, and four studies assessed long‐term (from three to six months) symptom relief. Seventeen studies provided information about side effect occurrence, seven studies assessed a measure of QoL, and two studies assessed changes in taste and feeling of dryness. All of the 23 treatments included in this review were compared to a placebo (fake treatment): antidepressants and antipsychotics (two studies), antiseizure drugs (one study), types of tranquillisers (four studies), saliva stimulants (one study), dietary supplements (12 studies), directed energy waves (one study), physical barriers (one study), psychological therapies (one study), and treatments applied to the mouth surface (five studies). Key results Short‐term symptom relief We found evidence of short‐term symptom relief for directed energy waves (one study, 58 participants), a type of tranquilliser used topically (that is held in the mouth before being removed, and which also acts as an antiseizure drug) called clonazepam (two studies, 111 participants), thin plastic tongue covers (one study, 50 participants), and an antiseizure drug called gabapentin (one study, 100 participants). There was no difference in short‐term symptom relief found for antidepressants, saliva stimulants, and another type of tranquilliser used systemically (one that is swallowed) also called clonazepam. We were unable to show whether dietary supplements or treatments applied to the mouth surface provide symptom relief in the short term or not. Short‐term relief was not reported for the single study that assessed a psychological therapy. Long‐term symptom relief We found evidence of long‐term symptom relief for psychological therapy (one study, 30 participants), chili pepper mouthrinse (one study, 18 participants) and the topical tranquilliser called clonazepam (one study, 66 participants). We found there was no difference in long‐term symptom relief for dietary supplements or treatments applied to the mouth surface. Studies which assessed antidepressants, directed energy waves, saliva stimulants, antiseizure drugs, or physical barriers did not evaluate long‐term symptom relief. Change in QoL There was evidence of short‐term improvement in QoL for directed energy waves (one study, 58 patients), although no difference was found for antidepressants, tranquillisers, dietary supplements and physical barriers. No study assessed long‐term QoL changes. Change in taste or feeling of dryness A few studies assessed short‐term change in taste or feeling of dryness (none evaluated these outcomes long‐term), but there was not enough evidence to judge the effects of treatment on these outcomes. Side effects Side effects were more likely to be experienced with antidepressants (dizziness and drowsiness more likely: one study, 37 people), and with a dietary supplement called alpha lipoic acid (also known as ALA) with or without other ingredients (headaches more likely: two studies, 118 people; and upset stomachs more likely: three studies, 138 people). Quality of the evidence 
 Overall, we found very low‐quality evidence for each short‐ and long‐term outcome we investigated (symptom relief; changes in QoL, taste and feeling of dryness; and side effects) in all types of assessed treatment: antidepressants and antipsychotics, antiseizure drugs, types of tranquillisers, saliva stimulants, dietary supplements, directed energy waves, physical barriers (except side effects, which was assessed as low quality), psychological therapies, and treatments applied to the mouth surface. As we found so few studies at low risk of bias, we are currently unable to prove or disprove the effectiveness of any treatments for managing BMS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McMillan, R; Forssell, H; Buchanan, JAG; Glenny, AM; Weldon, JC; Zakrzewska, JM", "articleTypes": [], "doi": "10.1002/14651858.CD002779.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "bcd23342-8355-47e6-bcb9-207c1d5f5062", "pmid": "", "title": "Oral deferiprone for iron chelation in people with thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. A commonly used iron chelator, deferiprone, has been found to be pharmacologically efficacious. However, important questions exist about the efficacy and safety of deferiprone compared to another iron chelator, desferrioxamine. Objectives To summarise data from trials on the clinical efficacy and safety of deferiprone and to compare the clinical efficacy and safety of deferiprone with desferrioxamine for thalassaemia. Search methods We searched the Cochrane Cystic fibrosis and Genetic Disorders Group's Haemoglobinopathies trials Register and MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus registers of ongoing trials and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). We also contacted the manufacturers of deferiprone and desferrioxamine. All searches were updated to 05 March 2013. Selection criteria Randomised controlled trials comparing deferiprone with another iron chelator; or comparing two schedules or doses of deferiprone, in people with transfusion‐dependent thalassaemia. Data collection and analysis Two authors independently assessed trials for risk of bias and extracted data. Missing data were requested from the original investigators. Main results A total of 17 trials involving 1061 participants (range 13 to 213 participants per trial) were included. Of these, 16 trials compared either deferiprone alone with desferrioxamine alone, or a combined therapy of deferiprone and desferrioxamine with either deferiprone alone or desferrioxamine alone; one compared different schedules of deferiprone. There was little consistency between outcomes and limited information to fully assess the risk of bias of most of the included trials. Four trials reported mortality; each reported the death of one individual receiving deferiprone with or without desferrioxamine. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage. Earlier trials measuring the cardiac iron load indirectly by magnetic resonance imaging (MRI) T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, a meta‐analysis of two trials suggested that left ventricular ejection fraction was significantly reduced in patients who received desferrioxamine alone compared with combination therapy. One trial, which planned five years of follow up, was stopped early due to the beneficial effects of combined treatment compared with deferiprone alone in terms of serum ferritin levels reduction. The results of this and three other trials suggest an advantage of combined therapy over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no conclusive or consistent evidence for the improved efficacy of combined deferiprone and desferrioxamine therapy over monotherapy from direct or indirect measures of liver iron. Both deferiprone and desferrioxamine produce a significant reduction in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised controlled trials to suggest that either has a greater reduction of clinically significant end organ damage. Evidence of adverse events were observed in all treatment groups. Occurrence of any adverse event was significantly more likely with deferiprone than desferrioxamine in one trial, RR 2.24 (95% CI 1.19 to 4.23). Meta‐analysis of a further two trials showed a significant increased risk of adverse events associated with combined deferiprone and desferrioxamine compared with desferrioxamine alone, RR 3.04 (95% CI 1.18 to 7.83). The most commonly reported adverse event was joint pain, which occurred significantly more frequently in patients receiving deferiprone than desferrioxamine, RR 2.64 (95% CI 1.21 to 5.77). Other common adverse events included gastrointestinal disturbances as well as neutropenia or leucopenia, or both. Authors' conclusions In the absence of data from randomised controlled trials, there is no evidence to suggest the need for a change in current treatment recommendations; namely that deferiprone is indicated for treating iron overload in people with thalassaemia major when desferrioxamine is contraindicated or inadequate. Intensified desferrioxamine treatment (by either subcutaneous or intravenous route) or use of other oral iron chelators, or both, remains the established treatment to reverse cardiac dysfunction due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently only gave support for deferiprone to be used as a last resort for treating iron overload in thalassaemia, myelodysplasia and sickle cell disease. However, there is evidence that adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcome of deferiprone with desferrioxamine. Plain language summary The use of the iron chelator deferiprone in people with thalassaemia who are dependent on blood transfusions In thalassaemia sometimes the body cannot produce enough haemoglobin. Regular blood transfusions can manage this, but may lead to excess iron in the body, which, if not removed, may damage major organs. Iron chelation therapy removes excess iron; one common chelator is deferiprone. Questions exist about whether deferiprone is as good and safe as the most widely‐used iron chelator, desferrioxamine. Desferrioxamine is administered by a needle under the skin or into a vein, and was the standard monotherapy for 20 years. Seventeen randomised controlled trials compared deferiprone with desferrioxamine. They report little data on death or end organ damage, so we report the effects of therapy using mainly other markers. Removing excess iron was assessed by iron concentration in the blood and liver; heart function; and the amount of iron passed in urine. However, the amount of iron removed with either deferiprone or desferrioxamine was not consistent; one reason being that outcomes were measured differently. This makes it difficult to compare results between trials. Adverse events included joint pain, nausea, stomach upsets and low white blood cell count with deferiprone and pain or skin reactions at the injection site and joint pain with desferrioxamine. In one trial, the risk of an adverse event with deferiprone was twice that of the risk with desferrioxamine. Two further trials showed a three‐fold increased risk of an adverse event with combined deferiprone and desferrioxamine therapy compared with desferrioxamine alone. We found no evidence to change current recommendations to treat iron overload in thalassaemia with deferiprone when desferrioxamine cannot be used or is inadequate. Intensified desferrioxamine treatment or use of other oral iron chelators (or both of these) remains the established treatment to reverse heart problems due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently gave support for deferiprone only to be used as a last resort treatment in patients with thalassaemia, myelodysplasia and sickle cell disease. The danger of raised liver enzymes or a very low white blood cell count with deferiprone means that this treatment should not be used unless close monitoring of full blood counts and liver function is possible. Large trials of chelation therapy with standardised measures of iron stores and end organ damage are needed so valuable trial data can be compared and analysed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA, Brunskill, SJ, Doree, C, Chowdhury, O, Gooding, S, Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004839.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.820Z" }, { "id": "bcd315a0-52a0-4a08-bff2-ae1181f31765", "pmid": "", "title": "Effects of Low-dose B-vitamins Supplementation on Plasma Homocysteine and Framingham Risk Score: Double Blind Randomized Controlled Trial in Healthy Chinese Elderly", "imported": false, "abstract": "The purpose of this study is to evaluate whether low dose complex B-vitamins (folic acid,vitamin B6 and vitamin B12) can lower the risk of developing hyperhomocysteinemia in an apparently healthy population with low folate/B12 and high Hcy status.", "journal": "", "year": "2008", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.159Z" }, { "id": "bcf05e6f-3ab1-4037-b241-e2180757c3e0", "pmid": "", "title": "CFTR modulator monotherapy for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a common, life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR gene variant, F508del, is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF) in some populations). The F508del variant lacks meaningful CFTR function: the faulty protein is degraded before reaching the cell membrane, where it would normally transport salt across the epithelial membrane. Corrective therapy with CFTR modulators could benefit many pwCF. This review evaluates treatment with single modulators (monotherapy). Objectives To evaluate the clinically important benefits and harms of CFTR modulator monotherapy in people of any age with cystic fibrosis with class II CFTR gene variants (most commonly F508del). Search methods We last searched the Cochrane CF Trials Register and online trials registries on 27 June 2025. We also checked the reference lists of relevant articles for additional studies. Eligibility criteria We included parallel‐group randomised controlled trials (RCTs) comparing any single CFTR modulator to placebo or any other single CFTR modulator in pwCF of any age or disease severity with class II variants. Outcomes Our critical outcomes were survival, quality of life (total score and respiratory domain), and forced expiratory volume in one second (FEV 1 % predicted; relative and absolute change from baseline). Our important outcomes included adverse effects and time to first pulmonary exacerbation. We planned to assess outcomes in the immediate term, short term, and longer term. Risk of bias We assessed risk of bias using the original Cochrane tool (RoB 1). Synthesis methods We analysed available data with RevMan using a fixed‐effect model. We reported odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. For adverse events, we reported 99% confidence intervals (CIs); for all other outcomes, we reported 95% CIs. Where we were unable to analyse data, we reported the results narratively. We used GRADE to assess the certainty of the evidence. Included studies We included 10 early‐phase placebo‐controlled RCTs (424 participants) assessing eight different drugs (4PBA, CPX, N6022, cavosonstat, lumacaftor, FDL169, GLPG2222, and riociguat) in adults; one 4PBA study additionally included adolescents (age ≥ 14 years). All participants were homozygous for F508del. The longest study lasted just 29 days, so we could only assess immediate‐term outcomes. Only two studies received no funding from pharmaceutical companies. Our main results are for lumacaftor and cavosonstat, which were the only drugs selected for further investigation in subsequent studies. Synthesis of results Investigators reported no deaths, but also no clinically relevant improvements in quality of life. There was insufficient evidence to determine effects on any measure of lung function. No studies demonstrated differences in the risk of mild, moderate, or severe adverse effects, including pulmonary exacerbations, between CFTR modulator monotherapy and placebo. The clinical relevance of adverse effects is difficult to assess, because each occurred in only a few participants per trial. We assessed the certainty of the evidence for two comparisons (lumacaftor versus placebo and cavosonstat versus placebo), rating the certainty of the evidence to be very low. Authors' conclusions There is a lack of evidence to support monotherapy with a CFTR modulator for pwCF who have two F508del variants (F508del/F508del). Funding This review was completed under a programme of work that is part of the CF Foundation grant funding for Cochrane CF. Registration The protocol was registered on PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/view/CRD420251090914 ). Plain language summary Can single‐medicine treatment with CFTR modulators (medicines that correct the faulty protein in cystic fibrosis) help people who have specific genetic variants of cystic fibrosis (most commonly F508del)? Key messages All the studies only included people with two copies of the most common cystic fibrosis‐causing gene variant (F508del). Most studies were entirely or partly funded by medicine companies. No studies reported any deaths. None of the single medicines we looked at were clearly better than placebo (dummy treatment) for improving quality of life or lung function, and there was no evidence of the medicines causing more harm than placebo. However, we are unsure about these results. The evidence for using a single CFTR modulator is weak, and future research is likely to focus on combination therapies. What is cystic fibrosis and how can it be treated? Cystic fibrosis is a serious inherited illness that shortens life. It damages many organs in the body, particularly the lungs, pancreas, and liver. In the lungs, it causes a build‐up of thick, sticky mucus that leads to repeated infections and progressive damage. Most people with cystic fibrosis experience breathing difficulties, poor nutrition, and a reduced quality of life. Cystic fibrosis is caused by a fault in a gene that makes a protein called CFTR. CFTR regulates the movement of salt and water across cell surfaces, keeping the mucus thin and slippery. The most common CFTR gene variant (found in over 80% of people with cystic fibrosis) is F508del, which is a class II variant. People with two copies of F508del usually have more severe disease than people with one copy. In people with class II variants, the CFTR protein is degraded and cannot move properly through the cell. Laboratory experiments suggest that if the protein reaches the cell wall, it may be able to function, restore salt movement, and correct the chronic problems people with cystic fibrosis experience. CFTR modulators are medicines that help the faulty CFTR protein reach the cell wall. What did we want to find out? We wanted to know if CFTR modulator monotherapy (single‐medicine treatment) can help people of any age with cystic fibrosis who have a class II variant. Specifically, we wanted to know if these medicines can improve survival, quality of life, lung function, and time to the first worsening of lung symptoms. We also wanted to know if this treatment is associated with any unwanted effects. What did we do? We searched for studies that investigated the effects of any single CFTR modulator compared with placebo (dummy treatment) or any other single CFTR modulator in people with cystic fibrosis who had at least one copy of a class II variant. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 10 studies (with 424 participants, all of whom had two copies of F508del) assessing eight different medicines given as monotherapy. Nine studies included only adults, and one study included people from age 14 years. All the studies were small (including between 18 and 89 participants) and lasted between one day and 29 days. They took place in North America (mainly the USA), Europe, and Australia. Our main findings are for two of the eight medicines, lumacaftor and cavosonstat, which have gone on to be evaluated in larger populations. Main findings No studies reported any deaths or meaningful improvements in quality of life. We did not find enough evidence to show any effect of CFTR modulators on lung function. The studies reported a wide range of unwanted effects, but each occurred in only a few participants per study. We did not find enough evidence to support using CFTR modulator monotherapy in people with cystic fibrosis who have two copies of F508del. What are the limitations of the evidence? We are not confident in the evidence, for the following reasons. The studies were small. Most results are based on evidence from a single study. The evidence is not applicable to children. Not all studies provided enough data for us to analyse the results. The evidence related to unwanted effects of treatment was based on very few events. How up‐to‐date is this evidence? This review updates our earlier review of single‐ and multiple‐medicine therapy. The evidence is current to 27 June 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Heneghan, M, Smith, S, Jahnke, N, Nevitt, S, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD016290", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.784Z" }, { "id": "bcf30b85-8ad9-470b-b0c8-5ad76c27867f", "pmid": "", "title": "Anticholinergic therapy for chronic asthma in children over two years of age", "imported": false, "abstract": "Abstract - Background In the intrinsic system of controlling airway calibre, the cholinergic (muscarinic) sympathetic nervous system has an important role. Anticholinergic, anti muscarinic bronchodilators such as ipratropium bromide are frequently used in the management of childhood airway disease. In asthma, ipratropium is a less potent bronchodilator than beta‐2 adrenergic agents but it is known to be a useful adjunct to other therapies, particularly in status asthmaticus. What remains unclear is the role of anticholinergic drugs in the maintenance treatment of chronic asthma. Objectives To determine the effectiveness of anticholinergic drugs in chronic asthma in children over the age of 2 years. Search methods The Cochrane Airways Group Specialised Register and reference lists of articles were searched. The most recent search was carried out in Febuary 2010. Selection criteria Randomised controlled trials in which anticholinergic drugs were given for chronic asthma in children over 2 years of age were included. Studies including comparison of: anticholinergics with placebo, and anticholinergics with any other drug were included. Data collection and analysis Eligibility for inclusion and quality of trials were assessed independently by two reviewers. Main results Eight studies met the inclusion criteria. Three papers compared the effects of anticholinergic drugs with placebo, and a meta‐analysis of these results demonstrated no statistically significant benefit of the use of anticholinergic drugs over placebo in any of the outcome measures used. The results of one of these trials could not be included in the meta‐analysis but the authors did report significantly lower symptom scores with inhaled anticholinergics compared with placebo. However, there was no significant difference between ipratropium bromide and placebo in the percentage of symptom‐free nights or days. Two trials studied the effects of anticholinergics on bronchial hyper responsiveness to histamine, by measuring the provocation dose of histamine needed to cause a fall of 20 % in FEV1 (PD 20). One study (comparing anticholinergics with placebo) reported a statistically significant increase in PD 20 but this was not found in another study (comparing anticholinergics with a beta‐2 agonist). Both trials also examined the effect of anticholinergic drugs on diurnal variation in peak expiratory flow rate (PEFR) and reported no significant effect. Two studies compared the addition of an anticholinergic drug to a beta‐2 agonist with the beta‐2 agonist alone. Both trials failed to show any significant benefit from the long term use of combined anticholinergics with beta‐2 agonists compared with beta‐2 agonists alone. One trial compared the effects of oral and inhaled anticholinergic drugs with placebo. No statistically significant differences were found in any of the outcome measures except for a higher FEV1 / VC ratio and RV / TLC ratio with oral anticholinergic therapy when compared with placebo. Authors' conclusions The present review summarises the best evidence available to date. Although there were some small beneficial findings in favour of anticholinergic therapy, there is insufficient data to support the use of anticholinergic drugs in the maintenance treatment of chronic asthma in children. Plain language summary Anticholinergic drugs versus either placebo or other medications for children over two years of age with asthma Anticholinergic drugs are widely used in the management of both acute and chronic asthma in children. Their effect is achieved through relief of narrowing of the airways that occurs in asthma. Current guidelines for the management of chronic asthma advise that anticholinergic drugs may be used if children are already on high dose inhaled steroids. This study undertook a comprehensive search of the literature unrestricted by country of publication or language. Unfortunately small numbers of relevant trials were found and these were of variable quality. This review found that although anticholinergic drugs are well tolerated, in children over two years of age, there is not enough data to be sure if they are better than placebo in terms of effects on lung function or symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "McDonald, N, Bara, A, McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD003535", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.782Z" }, { "id": "bd2e6f84-5433-4604-8bef-b907398de242", "pmid": "", "title": "The Effect of Artificial Sweeteners on Blood Glucose Response", "imported": false, "abstract": "The purpose of this study is to determine whether the presece of the artificial sweeteners aspartame, saccharin and asceulfame-k affect the blood glucose responses to an orally incested glucose solution.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.235Z" }, { "id": "bd31c153-71f2-47f4-8756-e9afb4afc9ba", "pmid": "", "title": "Preprocedural mouth rinses for preventing transmission of infectious diseases through aerosols in dental healthcare providers", "imported": false, "abstract": "Abstract - Background Aerosols and spatter are generated in a dental clinic during aerosol‐generating procedures (AGPs) that use high‐speed hand pieces. Dental healthcare providers can be at increased risk of transmission of diseases such as tuberculosis, measles and severe acute respiratory syndrome (SARS) through droplets on mucosae, inhalation of aerosols or through fomites on mucosae, which harbour micro‐organisms. There are ways to mitigate and contain spatter and aerosols that may, in turn, reduce any risk of disease transmission. In addition to personal protective equipment (PPE) and aerosol‐reducing devices such as high‐volume suction, it has been hypothesised that the use of mouth rinse by patients before dental procedures could reduce the microbial load of aerosols that are generated during dental AGPs. Objectives To assess the effects of preprocedural mouth rinses used in dental clinics to minimise incidence of infection in dental healthcare providers and reduce or neutralise contamination in aerosols. Search methods We used standard, extensive Cochrane search methods. The latest search date was 4 February 2022. Selection criteria We included randomised controlled trials and excluded laboratory‐based studies. Study participants were dental patients undergoing AGPs. Studies compared any preprocedural mouth rinse used to reduce contaminated aerosols versus placebo, no mouth rinse or another mouth rinse. Our primary outcome was incidence of infection of dental healthcare providers and secondary outcomes were reduction in the level of contamination of the dental operatory environment, cost, change in mouth microbiota, adverse events, and acceptability and feasibility of the intervention. Data collection and analysis Two review authors screened search results, extracted data from included studies, assessed the risk of bias in the studies and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random‐effects meta‐analysis to combine data Main results We included 17 studies with 830 participants aged 18 to 70 years. We judged three trials at high risk of bias, two at low risk and 12 at unclear risk of bias. None of the studies measured our primary outcome of the incidence of infection in dental healthcare providers. The primary outcome in the studies was reduction in the level of bacterial contamination measured in colony‐forming units (CFUs) at distances of less than 2 m (intended to capture larger droplets) and 2 m or more (to capture droplet nuclei from aerosols arising from the participant's oral cavity). It is unclear what size of CFU reduction represents a clinically significant amount. There is low‐ to very low‐certainty evidence that chlorhexidine (CHX) may reduce bacterial contamination, as measured by CFUs, compared with no rinsing or rinsing with water. There were similar results when comparing cetylpyridinium chloride (CPC) with no rinsing and when comparing CPC, essential oils/herbal mouthwashes or boric acid with water. There is very low‐certainty evidence that tempered mouth rinses may provide a greater reduction in CFUs than cold mouth rinses. There is low‐certainty evidence that CHX may reduce CFUs more than essential oils/herbal mouthwashes. The evidence for other head‐to‐head comparisons was limited and inconsistent. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or adverse events such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess acceptability of the intervention to patients or feasibility of implementation for dentists. Authors' conclusions None of the included studies measured the incidence of infection among dental healthcare providers. The studies measured only reduction in level of bacterial contamination in aerosols. None of the studies evaluated viral or fungal contamination. We have only low to very low certainty for all findings. We are unable to draw conclusions regarding whether there is a role for preprocedural mouth rinses in reducing infection risk or the possible superiority of one preprocedural rinse over another. Studies are needed that measure the effect of rinses on infectious disease risk among dental healthcare providers and on contaminated aerosols at larger distances with standardised outcome measurement. Plain language summary Does use of mouth rinse before a dental procedure reduce the risk of infection transmission from patient to health professional? Why is this question important? Many dental procedures generate droplets that settle on a surface quickly. If high‐speed instruments, such as a drill, are used, aerosols are generated, which consist of tiny particles that remain suspended in the air and that can be inhaled or that settle farther away on surfaces. These aerosols contain a variety of micro‐organisms and may transmit infections either through direct contact or indirectly through the contaminated surfaces. To prevent the spread of infection, it may help to reduce the number of micro‐organisms that are present in these aerosols. The use of mouth rinses before a dental procedure ('preprocedural mouth rinse') has been suggested as a possible way to reduce the amount of contamination of these aerosols. Chlorhexidine, povidone iodine and cetylpyridinium chloride (CPC) are some of the commonly used mouth rinses. They act by killing or inactivating the micro‐organisms in the mouth and thereby reducing the level of contamination in the aerosol that is generated. We wanted to find out whether rinsing the mouth before a dental procedure reduces the contamination of aerosols produced during dental procedures in practice and helps prevent the transmission of infectious diseases. How did we identify and evaluate the evidence? We searched for all relevant studies that compared mouth rinses used before dental procedures against placebo (fake treatment), no intervention or another mouth rinse considered to be inactive. We then compared the results, and summarised the evidence from all the studies. Finally, we assessed our confidence in the evidence. To do this, we considered factors such as the way studies were conducted, study sizes and consistency of findings across studies. What did we find? We found 17 studies that met our inclusion criteria. These studies used chlorhexidine, CPC, essential oil/herbal mouth rinses, povidone iodine and boric acid in comparison to no rinsing, or rinsing with water, saline (salt water) or another mouth rinse. None of the studies measured the how often dental healthcare providers became infected with micro‐organisms. All the included studies measured the level of bacterial contamination in droplets or aerosols in the dental clinic. They did not examine contamination with viruses or fungi. Most rinses decreased bacterial contamination in aerosols to some extent, but there was considerable variation in the effects and we do not know what size of reduction is necessary to reduce infection risk. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or side effects such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess whether patients were happy to use a mouth rinse or whether it was easy for dentists to implement. Overall, the results suggest that using a preprocedural mouth rinse may reduce the level of bacterial contamination in aerosols compared with no rinsing or rinsing with water, but we have only low or very low certainty that the evidence is reliable and we do not know how this reduction in contamination relates to the risk of infection. What does this mean? We have very little confidence in the evidence, and further studies may change the findings of our review. No studies measured infection risk or investigated viral or fungal contamination. How up‐to‐date is this review? The evidence in this Cochrane Review is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kumbargere Nagraj, S, Eachempati, P, Paisi, M, Nasser, M, Sivaramakrishnan, G, Francis, T, Verbeek, JH", "articleTypes": [], "doi": "10.1002/14651858.CD013826.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.730Z" }, { "id": "bd36ddbe-5ec6-4c45-aea5-24a027287346", "pmid": "", "title": "Treatment of U.S. Veterans With Mild Traumatic Brain Injury With Hyperbaric Oxygen Therapy", "imported": false, "abstract": "Mild traumatic brain (mTBI) injury affects 400,000 U.S. Veterans resulting in physical, cognitive and mental health symptoms. The Department of Defense (DoD) reported 26 suicides a day from mTBI despite ongoing care for the Veterans. The purpose of this pilot research study is to evaluate the effect of treating Veterans suffering from mTBI or persistent post-concussion syndrome with hyperbaric oxygen therapy (HBOT).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.162Z" }, { "id": "bd62c57e-6173-4a65-a355-cf8c782eeb89", "pmid": "", "title": "Drugs for preventing malaria in pregnant women in endemic areas: any drug regimen versus placebo or no treatment", "imported": false, "abstract": "Abstract - Background Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. To reduce these effects, the World Health Organization recommends that pregnant women living in malaria endemic areas sleep under insecticide‐treated bednets, are treated for malaria illness and anaemia, and receive chemoprevention with an effective antimalarial drug during the second and third trimesters. Objectives To assess the effects of malaria chemoprevention given to pregnant women living in malaria endemic areas on substantive maternal and infant health outcomes. We also summarised the effects of intermittent preventive treatment with sulfadoxine‐pyrimethamine (SP) alone, and preventive regimens for Plasmodium vivax. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and reference lists up to 1 June 2014. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs of any antimalarial drug regimen for preventing malaria in pregnant women living in malaria‐endemic areas compared to placebo or no intervention. In the mother, we sought outcomes that included mortality, severe anaemia, and severe malaria; anaemia, haemoglobin values, and malaria episodes; indicators of malaria infection, and adverse events. In the baby, we sought foetal loss, perinatal, neonatal and infant mortality; preterm birth and birthweight measures; and indicators of malaria infection. We included regimens that were known to be effective against the malaria parasite at the time but may no longer be used because of parasite drug resistance. Data collection and analysis Two review authors applied inclusion criteria, assessed risk of bias and extracted data. Dichotomous outcomes were compared using risk ratios (RR), and continuous outcomes using mean differences (MD); both are presented with 95% confidence intervals (CI). We assessed the quality of evidence using the GRADE approach. Main results Seventeen trials enrolling 14,481 pregnant women met our inclusion criteria. These trials were conducted between 1957 and 2008, in Nigeria (three trials), The Gambia (three trials), Kenya (three trials), Mozambique (two trials), Uganda (two trials), Cameroon (one trial), Burkina Faso (one trial), and Thailand (two trials). Six different antimalarials were evaluated against placebo or no intervention; chloroquine (given weekly), pyrimethamine (weekly or monthly), proguanil (daily), pyrimethamine‐dapsone (weekly or fortnightly), and mefloquine (weekly), or intermittent preventive therapy with SP (given twice, three times or monthly). Trials recruited women in their first or second pregnancy (eight trials); only multigravid women (one trial); or all women (eight trials). Only six trials had adequate allocation concealment. For women in their first or second pregnancy, malaria chemoprevention reduces the risk of moderate to severe anaemia by around 40% (RR 0.60, 95% CI 0.47 to 0.75; three trials, 2503 participants, high quality evidence ), and the risk of any anaemia by around 17% (RR 0.83, 95% CI 0.74 to 0.93; five trials,, 3662 participants, high quality evidence ). Malaria chemoprevention reduces the risk of antenatal parasitaemia by around 61% (RR 0.39, 95% CI 0.26 to 0.58; seven trials, 3663 participants, high quality evidence ), and two trials reported a reduction in febrile illness ( low quality evidence ). There were only 16 maternal deaths and these trials were underpowered to detect an effect on maternal mortality ( very low quality evidence ). For infants of women in their first and second pregnancies, malaria chemoprevention probably increases mean birthweight by around 93 g (MD 92.72 g, 95% CI 62.05 to 123.39; nine trials, 3936 participants, moderate quality evidence ), reduces low birthweight by around 27% (RR 0.73, 95% CI 0.61 to 0.87; eight trials, 3619 participants, moderate quality evidence ), and reduces placental parasitaemia by around 46% (RR 0.54, 95% CI 0.43 to 0.69; seven trials, 2830 participants, high quality evidence ). Fewer trials evaluated spontaneous abortions, still births, perinatal deaths, or neonatal deaths, and these analyses were underpowered to detect clinically important differences. In multigravid women, chemoprevention has similar effects on antenatal parasitaemia (RR 0.38, 95% CI 0.28 to 0.50; three trials, 977 participants, high quality evidence )but there are too few trials to evaluate effects on other outcomes. In trials giving chemoprevention to all pregnant women irrespective of parity, the average effects of chemoprevention measured in all women indicated it may prevent severe anaemia (defined by authors, but at least < 8 g/L: RR 0.19, 95% CI 0.05 to 0.75; two trials, 1327 participants, low quality evidence), but consistent benefits have not been shown for other outcomes. In an analysis confined only to intermittent preventive therapy with SP, the estimates of effect and the quality of the evidence were similar. A summary of a single trial in Thailand of prophylaxis against P. vivax showed chloroquine prevented vivax infection (RR 0.01, 95% CI 0.00 to 0.20; one trial, 942 participants). Authors' conclusions Routine chemoprevention to prevent malaria and its consequences has been extensively tested in RCTs, with clinically important benefits on anaemia and parasitaemia in the mother, and on birthweight in infants. 8 May 2019 No update planned Review superseded The intervention is clearly effective. The questions now are around head‐to‐head comparisons not included in this review. Plain language summary The effect of taking antimalarial drugs routinely to prevent malaria in pregnancy Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. For this reason, women are encouraged to try and prevent malaria infection during pregnancy by sleeping under mosquito bed‐nets, and by taking drugs effective against malaria throughout pregnancy as chemoprevention. This Cochrane Review looked at all drug regimens compared to placebo. The review authors sought to summarise and quantify the overall effects of chemoprevention. Seventeen trials were included, all conducted between 1957 and 2008, and all but two in countries of Africa. For women in their first or second pregnancy, malaria chemoprevention prevents moderate to severe anaemia ( high quality evidence ); and prevents malaria parasites being detected in the blood ( high quality evidence ). It may also prevent malaria illness. We don't know if it prevents maternal deaths, as this would require very large studies to detect an effect. In their infants, malaria chemoprevention improves the average birthweight ( moderate quality evidence ), and reduces the number of low birthweight infants ( moderate quality evidence ). We are not sure if chemoprevention reduces mortality of babies in the first week, month and year, as again studies would need to be very large to show these effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Radeva‐Petrova, D, Kayentao, K, ter Kuile, FO, Sinclair, D, Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD000169.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.779Z" }, { "id": "bd8e8272-e8ae-4c8b-9f0b-a3ebf3e8f38a", "pmid": "", "title": "Vitamin B12 supplementation for growth, development, and cognition in children", "imported": false, "abstract": "Abstract - Rationale Vitamin B 12 deficiency is an important public health problem in children, and has been associated with anaemia and impaired growth, cognition, and development. Vitamin B 12 deficiency may develop in children due to lower content in breast milk, low dietary intake, and as requirements increase with age. Vitamin B 12 supplementation may confer benefits to child growth and development, due to its role in DNA synthesis and methylation, red blood cell formation, and folate metabolism. However, no systematic reviews have been conducted to examine the effects of vitamin B 12 supplementation in children. Objectives To determine the effects of vitamin B 12 supplementation on growth, development, and cognition in children less than 12 years of age. Search methods We searched CENTRAL, MEDLINE, Embase, 12 other databases, and two trial registries on 23 September 2025. We screened reference lists of studies. Eligibility criteria We included randomised controlled trials evaluating the effects of oral vitamin B 12 supplementation, alone or in combination with other micronutrients, in children < 12 years of age. We excluded cross‐over trials, trials targeting pregnant or breastfeeding women, or participants with critical illnesses, and interventions delivered by intravenous/intramuscular injections. Outcomes Critical outcomes were vitamin B 12 status, anaemia, haemoglobin, growth, cognitive function, developmental outcomes, and any adverse effects. Important outcomes included megaloblastic anaemia, body composition, health‐related quality of life, morbidity, and all‐cause mortality. Risk of bias We used Cochrane RoB 2 to evaluate bias. Synthesis methods We conducted meta‐analyses using fixed‐effect models. If there was substantial heterogeneity, we used random‐effect models. When meta‐analyses were not conducted, we described findings from individual trials, and considered synthesis and presentation of findings using other methods. We used GRADE to evaluate the certainty of evidence for critical outcomes. Included studies We included 16 trials (4083 children; 2 days to 11 years) in 10 countries, including India, Japan, Thailand, Nepal, United Kingdom, Italy, Spain, the United States, El Salvador, and Guatemala. Follow‐up periods for outcomes in most studies ranged from five weeks to 31 months, with one study extending follow‐up to nine years. Duration of vitamin B 12 supplementation varied, ranging from 28 days to 31 months, with doses from 0.9 µg/day to 150 µg/day. Nine trials, including 2391 children, contributed data to meta‐analyses. Synthesis of results Supplementation with vitamin B 12 alone versus placebo There may be little to no difference between groups in height/length (mean difference (MD) ‐0.19 cm, 95% confidence interval (CI) ‐2.44 to 2.06; 2 trials, 143 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (standardised mean difference (SMD) 0.09, 95% CI ‐0.10 to 0.28; 2 trials, 438 children, low‐certainty evidence). There may be little to no difference between groups in motor skill development (6 to 9 years, NEuroPSYchological assessment, Second Edition (NEPSY‐II); 1 trial, 403 children, low‐certainty evidence). Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency (absolute risk difference (ARD) 56 fewer per 1000, 95% CI 68 fewer to 24 fewer; 1.8% versus 7.6%; risk ratio (RR) 0.27, 95% CI 0.11 to 0.69; 3 trials, 642 children; high‐certainty evidence), and probably increases total vitamin B 12 concentrations (MD 68.53 pmol/L, 95% CI 41.83 to 95.23; 7 trials, 705 children; moderate‐certainty evidence), compared to placebo, with an average increase of 68.5 pmol/L. There may be little to no difference between groups in anaemia (ARD 21 more per 1000, 95% CI 26 fewer to 191 more; 9.1% versus 4.5%; RR 1.48, 95% CI 0.41 to 5.27; 2 trials, 144 children; low‐certainty evidence). No trials reported the occurrence of any adverse effects. Supplementation with vitamin B 12 alone versus no intervention The evidence is very uncertain about the effects of vitamin B 12 on height/length (2 trials, 70 children; very low‐certainty evidence), compared to no intervention. No trials reported data for the other critical outcomes. Supplementation with vitamin B 12 and other micronutrients, compared to the same formulation without vitamin B 12 There may be little to no difference between groups in height/length (MD ‐0.22 cm, 95% CI ‐0.65 to 0.20; 2 trials, 608 children; low‐certainty evidence). There may be little to no difference between groups in cognitive function (e.g. attention) (SMD 0.00, 95% CI ‐0.13 to 0.13; 3 trials, 956 children; low‐certainty evidence). There may be little to no difference between groups in development outcomes (e.g. motor skill development) (SMD ‐0.05, 95% CI ‐0.18 to 0.08; 2 trials, 960 children; low‐certainty evidence). Children who received vitamin B 12 supplementation and other micronutrients may have little to no difference in vitamin B 12 deficiency (ARD 2 fewer per 1000, 95% CI 7 fewer to 32 more; 0.7% versus 0.8%; RR 0.77, 95% CI 0.12 to 5.16; 2 trials, 534 children; low‐certainty evidence), or total vitamin B 12 concentrations (MD 34.32 pmol/L, 95% CI ‐31.13 to 99.77; 3 trials, 731 children; low‐certainty evidence), compared to supplements without vitamin B 12 . There may be little to no difference between groups in anaemia (21.7% versus 25.0%; 1 trial, 35 children; low‐certainty evidence). There may be little to no difference between groups in any adverse effects (9.2% versus 5.9%; 1 trial, 574 children; low‐certainty evidence). The certainty of evidence for critical outcomes ranged from high to very low; we downgraded for imprecision due to small sample sizes or few events, risk of bias in outcome measurement, randomisation methods, selective reporting bias, or inconsistency due to substantial statistical heterogeneity. Few studies reported growth, cognition, development, anaemia, or any adverse effects. Authors' conclusions Vitamin B 12 supplementation (alone or when supplemented with other micronutrients) in children may have little to no effect on growth (i.e. height/length), cognitive function (e.g. attention), development outcomes (e.g. motor skill development), or anaemia, compared to placebo, no intervention, or the same supplements without vitamin B 12 . Vitamin B 12 supplementation in children reduces vitamin B 12 deficiency and probably improves total vitamin B 12 concentrations, compared to placebo. However, vitamin B 12 supplementation with other micronutrients may result in little to no difference in vitamin B 12 deficiency and total vitamin B 12 concentrations, compared to the same formulation without vitamin B 12 . Funding This review had no dedicated funding. Registration Protocol available via DOI 10.1002/14651858.CD015264. Plain language summary What are the effects of vitamin B 12 supplementation for children less than 12 years of age? Key messages Vitamin B 12 supplementation reduces the risk of vitamin B 12 deficiency, and probably improves vitamin B 12 levels in children less than 12 years of age, compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient) (that is, children who did not take vitamin B 12 supplements). Vitamin B 12 supplements, with other micronutrients (important vitamins and minerals the body needs in small amounts to function), may result in little to no difference in vitamin B 12 deficiency or total vitamin B 12 levels, compared to children who received the same supplements without vitamin B 12 . The impact of vitamin B 12 supplements on other health outcomes in children is less clear. What is vitamin B 12 ? Vitamin B 12 is an important nutrient that helps make red blood cells and keep the body's cells and nerves healthy. Vitamin B 12 deficiency is an important public health problem, including in children and in resource‐poor settings. Lower vitamin B 12 levels in children have been linked to anaemia (lower haemoglobin levels), and poorer growth, development, and cognition (a child's ability to gain knowledge through thought, understanding, and the senses). What did we want to find out? We wanted to find out if taking vitamin B 12 supplements would improve the nutrition and health of children less than 12 years of age. What did we do? We searched for studies that looked at the effects of vitamin B 12 compared to placebo (a substance that looks the same as the intervention/treatment but does not contain any active ingredient), no intervention, or the same supplements without vitamin B 12 . We summarised the results of the studies and our confidence in the evidence, based on information such as how the study was done. What did we find? We included 16 studies involving 4083 children less than 12 years of age (2 days to 11 years). Nine studies, including 2391 children, had data that we could analyse. The studies were conducted in 10 countries around the world. In most studies, the outcomes were assessed immediately after the intervention from five weeks to 31 months, with one study assessing outcomes after nine years. Vitamin B 12 supplements were provided from 28 days to 31 months in amounts from 0.9 to 150 micrograms a day. Supplementation with vitamin B 12 alone versus placebo There may be little to no difference in height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplements had less vitamin B 12 deficiency, and probably had higher vitamin B 12 levels, compared to placebo. There may be little to no difference between groups in anaemia. No studies provided data on any unwanted (adverse) effects. Vitamin B 12 alone versus no intervention The evidence is very uncertain for height/length. No studies reported data we could analyse for other outcomes. Vitamin B 12 and other micronutrients, compared to supplements with the same supplement without vitamin B 12 There may be little to no difference between groups for height/length, cognition (for example, attention), or development (for example, motor skill development). Children who received vitamin B 12 supplementation (with other nutrients) may have little to no difference in vitamin B 12 deficiency, vitamin B 12 levels, anaemia, or any unwanted effects. What are the limitations of the evidence? The small number and the size of studies were limitations of this review. Few studies reported on health outcomes, including growth, cognition, development, anaemia, or any adverse effects. The different ages of children, and differences in the amount of vitamin B 12 and when the outcomes were measured, are also limitations of this review. How up to date is this evidence? The evidence is up to date as of 23 September 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Larvie, DY; Güitrón Leal, CE; Venkatramanan, S; Palma Molina, XE; Steel, LB; Kuriyan, R; Finkelstein, JL", "articleTypes": [], "doi": "10.1002/14651858.CD015264.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "bd95ed48-deae-424f-a08a-c4a0b4274dd4", "pmid": "", "title": "Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Soil‐transmitted helminth (STH) infections are amongst the most common infectious diseases worldwide, with an estimated 24% of the world’s population currently infected. Mass drug administration (MDA) is the periodic medicinal treatment, without prior individual diagnosis, of at‐risk people living in endemic areas. The World Health Organization currently recommends MDA for STHs. MDA programmes are complex health interventions; achieving adherence is important to their success. Adherence is influenced by the target population's perceptions of the drug, the programme, and those delivering it. Objectives To synthesize qualitative research evidence about community experiences and perceptions of mass drug administration programmes for soil‐transmitted helminths. To assess whether our findings confirm, extend, enrich, or conflict with those of a 2022 Cochrane qualitative evidence review of mass drug administration programmes for lymphatic filariasis. Search methods We searched CENTRAL, MEDLINE, Embase, and four other databases up to 11 November 2024, together with reference checking, and citation searching. Selection criteria We synthesized qualitative and mixed‐methods studies. We included studies exploring community experiences and perceptions of MDA programmes for STHs in any country, conducted between 2001 and 2024. We included all participants of MDA programmes, regardless of disease status, individual participation, or other demographic information. We also included lay healthcare workers and formally qualified healthcare workers, if their perspectives were clearly separated from those of the general population. Data collection and analysis We collected data on study characteristics and programme delivery, including country, endemicity, drug regimen, how the drugs were delivered, use of health education and sensitization, and adherence monitoring. We conducted thematic analysis using a 'best‐fit' framework synthesis based on a framework developed in a 2022 Cochrane review exploring community views on mass drug administration for filariasis (a parasitic infection caused by filarial worms). We conducted a deductive phase, accommodating our data within the existing model, followed by an inductive phase, during which we explored data not accommodated by the framework. We used the GRADE‐CERQual approach to assess our confidence in the findings, and updated the filariasis review's conceptual model to display our findings. Main results We included 17 studies, conducted in Bangladesh, Benin, India, Kenya, Malawi, Nigeria, the Philippines, and Turkey. Four themes emerged, three of which were identified in the review of MDA for lymphatic filariasis. People weigh up the benefits and harms in their decision to participate in MDA, though some may not have a choice. Outcomes of individual participation in MDA may be positive, negative, or both. The decision to partake is a careful balance of risk, benefit, and feasibility (high confidence). Unpleasant associations become part of the narrative and spread rapidly through the community (moderate confidence). Physical and social barriers prevent some people from being able to access MDA even if they want to participate (moderate confidence). Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical legacies, rumours, and mistrust of people involved in the programme affect overall trust in drug distribution and influence whether people choose to participate. Past experiences can have a profound effect on people, and negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background and in‐depth training around the drug or the disease itself (moderate confidence). Some community members prefer distribution from people they know or trust (high confidence). However, others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors (CDDs) cannot answer their programme‐related questions (moderate confidence). Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign, which includes improved sanitation, is necessary to tackle STH burden (moderate confidence). One theme that the filariasis review identified was not substantiated by the findings in this review (Programmes expect compliance: this can result in coercion and blame). Authors' conclusions Despite the prevalence and undoubted impact of MDA programmes over the past 10 years, endemic hotspots and continued transmission are common, due in part to poor community adherence. The 2022 Cochrane review outlined several key community concerns and doubts that hinder the effective implementation of MDA for lymphatic filariasis. This review shows that most of these concerns and doubts are shared by communities targeted for MDA for STHs, indicating that there are fundamental challenges in the overall conceptualization and design of MDA programmes that need to be addressed. Funding TF, MT, RK, and the Cochrane Infectious Diseases Group editorial base were funded by UK aid from the UK Government for the benefit of low‐ and middle‐income countries (project number 300342‐104). The views expressed do not necessarily reflect the UK Government’s official policies. Registration The protocol for this review was published in January 2024 on the Cochrane Database of Systematic Reviews. Available at doi.org/10.1002/14651858.CD015794. Plain language summary Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis Key messages People consider several personal, social, and historical factors before deciding to take medicine. Within one community, different individuals will experience benefits and harms associated with treatment, which shape their decision to participate. The decision to adhere depends on the perceived benefits compared to harms, the trust built between communities and the programme, the competency of people delivering the drugs to provide reassurance to the community members, and the perceived organisation of the delivery programme. Our findings are largely consistent with those of a 2022 Cochrane review exploring people's views and experiences of mass drug administration (MDA) programmes for lymphatic filariasis. This evidence overlap suggests that there are key challenges in the design of MDA programmes in general that need to be addressed to increase adherence. What was studied in this synthesis? Mass drug administration (MDA) involves the periodic delivery of drugs to treat entire communities or groups, regardless of whether an individual has a particular disease. This method aims to prevent onward transmission of infection within the population. MDA is currently recommended for some disease‐control programmes in low‐ and middle‐income countries, including for soil‐transmitted helminth (STH) infections. STHs are a group of parasitic worms, including roundworm, hookworm, whipworm, and threadworm. These MDA programmes are usually delivered within a community or as a school‐based programme. Successfully stopping STH infections through MDA depends on community members being willing and able to participate. In this review, we looked for studies that explored how people view and experience mass drug administration programmes for STHs. We identified 17 studies relevant to this synthesis. What was the aim of this synthesis? In this synthesis of qualitative research, we searched for studies that explored people's views on MDA programmes for treating STHs in low‐ and middle‐income countries. We wanted to understand how people view and experience mass drug administration programmes for soil‐transmitted helminths. We were also interested in whether our findings would support, extend, or conflict with findings from a 2022 Cochrane review which looked at MDA programmes for lymphatic filariasis, another infectious disease caused by worms. What were the main findings? We included 17 studies in our analysis. The studies covered several countries in Africa and South‐East Asia, and one country in the Eastern Mediterranean region. The included studies explored the views and experiences of community members and those distributing the medicines in low‐income countries where STH infection is a considerable problem. From the data, four themes emerged. The 2022 Cochrane review of MDA for lymphatic filariasis identified three of these themes, highlighting the similarities between these programmes. One new theme emerged. 1. People weigh up benefits and harms in their decision to participate in MDA, though some may not have a choice. There are many outcomes to participating in the MDA programme, both positive and negative. For community members, several of these may exist at once, and the decision to partake is a careful balance of risk, benefit, and feasibility (we have high confidence in the evidence). Unpleasant experiences can quickly spread through the community (moderate confidence). Physical and social barriers (e.g. travel distance or not attending school, respectively) prevent some people from accessing treatment through the MDA programme (moderate confidence). 2. Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical experiences, rumours, and mistrust of people involved in the programme affect overall trust in the programme. Past experiences can have a strong effect on people; negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). 3. The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background, and in‐depth training around the drug or the disease itself (moderate confidence). Whilst some community members prefer distribution from people who they know or trust (high confidence), others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors cannot answer their questions related to the programme (moderate confidence). 4. (New theme) Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign which includes improved sanitation is necessary to tackle STH burden (moderate confidence). How current is this evidence? The evidence is current to November 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fox, T, Shrestha, S, Kuehn, R, Taylor, M", "articleTypes": [], "doi": "10.1002/14651858.CD015794.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.779Z" }, { "id": "bd994111-9fd1-4df6-aa2c-45ebcba5ee21", "pmid": "", "title": "Hyperimmune immunoglobulin for people with COVID‐19", "imported": false, "abstract": "Abstract - Background Hyperimmune immunoglobulin (hIVIG) contains polyclonal antibodies, which can be prepared from large amounts of pooled convalescent plasma or prepared from animal sources through immunisation. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). This review was previously part of a parent review addressing convalescent plasma and hIVIG for people with COVID‐19 and was split to address hIVIG and convalescent plasma separately. Objectives To assess the benefits and harms of hIVIG therapy for the treatment of people with COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods To identify completed and ongoing studies, we searched the World Health Organization (WHO) COVID‐19 Research Database, the Cochrane COVID‐19 Study Register, the Epistemonikos COVID‐19 L*OVE Platform and Medline and Embase from 1 January 2019 onwards. We carried out searches on 31 March 2022. Selection criteria We included randomised controlled trials (RCTs) that evaluated hIVIG for COVID‐19, irrespective of disease severity, age, gender or ethnicity. We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)), as well as studies that evaluated standard immunoglobulin. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used RoB 2. We rated the certainty of evidence, using the GRADE approach, for the following outcomes: all‐cause mortality, improvement and worsening of clinical status (for individuals with moderate to severe disease), quality of life, adverse events, and serious adverse events. Main results We included five RCTs with 947 participants, of whom 688 received hIVIG prepared from humans, 18 received heterologous swine glyco‐humanised polyclonal antibody, and 241 received equine‐derived processed and purified F(ab’) 2 fragments. All participants were hospitalised with moderate‐to‐severe disease, most participants were not vaccinated (only 12 participants were vaccinated). The studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with mild COVID‐19. We identified a further 10 ongoing studies evaluating hIVIG. Benefits of hIVIG prepared from humans We included data on one RCT (579 participants) that assessed the benefits and harms of hIVIG 0.4 g/kg compared to saline placebo. hIVIG may have little to no impact on all‐cause mortality at 28 days (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.43 to 1.44; absolute effect 77 per 1000 with placebo versus 61 per 1000 (33 to 111) with hIVIG; low‐certainty evidence). The evidence is very uncertain about the effect on worsening of clinical status at day 7 (RR 0.85, 95% CI 0.58 to 1.23; very low‐certainty evidence). It probably has little to no impact on improvement of clinical status on day 28 (RR 1.02, 95% CI 0.97 to 1.08; moderate‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if hIVIG has any impact on quality of life. Harms of hIVIG prepared from humans hIVIG may have little to no impact on adverse events at any grade on day 1 (RR 0.98, 95% CI 0.81 to 1.18; 431 per 1000; 1 study 579 participants; low‐certainty evidence). Patients receiving hIVIG probably experience more adverse events at grade 3‐4 severity than patients who receive placebo (RR 4.09, 95% CI 1.39 to 12.01; moderate‐certainty evidence). hIVIG may have little to no impact on the composite outcome of serious adverse events or death up to day 28 (RR 0.72, 95% CI 0.45 to 1.14; moderate‐certainty evidence). We also identified additional results on the benefits and harms of other dose ranges of hIVIG, not included in the summary of findings table, but summarised in additional tables. Benefits of animal‐derived polyclonal antibodies We included data on one RCT (241 participants) to assess the benefits and harms of receptor‐binding domain‐specific polyclonal F(ab´) 2 fragments of equine antibodies (EpAbs) compared to saline placebo. EpAbs may reduce all‐cause mortality at 28 days (RR 0.60, 95% CI 0.26 to 1.37; absolute effect 114 per 1000 with placebo versus 68 per 1000 (30 to 156) ; low‐certainty evidence). EpAbs may reduce worsening of clinical status up to day 28 (RR 0.67, 95% CI 0.38 to 1.18; absolute effect 203 per 1000 with placebo versus 136 per 1000 (77 to 240); low‐certainty evidence). It may have some effect on improvement of clinical status on day 28 (RR 1.06, 95% CI 0.96 to 1.17; low‐certainty evidence). We did not identify any studies that reported quality‐of‐life outcomes, so we do not know if EpAbs have any impact on quality of life. Harms of animal‐derived polyclonal antibodies EpAbs may have little to no impact on the number of adverse events at any grade up to 28 days (RR 0.99, 95% CI 0.74 to 1.31; low‐certainty evidence). Adverse events at grade 3‐4 severity were not reported. Individuals receiving EpAbs may experience fewer serious adverse events than patients receiving placebo (RR 0.67, 95% CI 0.38 to 1.19; low‐certainty evidence). We also identified additional results on the benefits and harms of other animal‐derived polyclonal antibody doses, not included in the summary of findings table, but summarised in additional tables. Authors' conclusions We included data from five RCTs that evaluated hIVIG compared to standard therapy, with participants with moderate‐to‐severe disease. As the studies evaluated different preparations (from humans or from various animals) and doses, we could not pool them. hIVIG prepared from humans may have little to no impact on mortality, and clinical improvement and worsening. hIVIG may increase grade 3‐4 adverse events. Studies did not evaluate quality of life. RBD‐specific polyclonal F(ab´) 2 fragments of equine antibodies may reduce mortality and serious adverse events, and may reduce clinical worsening. However, the studies were conducted before or during the emergence of several SARS‐CoV‐2 variants of concern and prior to widespread vaccine rollout. As no studies evaluated hIVIG for participants with asymptomatic infection or mild disease, benefits for these individuals remains uncertain. This is a living systematic review. We search monthly for new evidence and update the review when we identify relevant new evidence. Plain language summary Are concentrated antibodies from people who have recovered from COVID‐19 or animals an effective treatment for people with COVID‐19? Key messages • We do not know whether hyperimmune immunoglobulin (a preparation made with antibodies from people who have recovered from COVID‐19) reduces deaths or serious unwanted effects in people with moderate to severe COVID‐19. But a similar preparation made by injecting animals with certain antibodies may reduce deaths, and serious unwanted effects and may stop people’s condition getting worse. • We found no studies that investigated people with COVID‐19 but without symptoms or people with mild COVID‐19, so we do not know how effective human or animal hyperimmune immunoglobulin is for them. • We found 10 ongoing studies. We will update this review when their results become available. What is hyperimmune immunoglobulin? The body produces antibodies as one of its defences against infection. Antibodies, or 'immunoglobulins', are found in blood plasma. They act as a critical part of the immune response. Plasma from people who have recovered from COVID‐19 contains COVID‐19 antibodies, and can be used to make two preparations. Firstly, it can be used to make convalescent plasma, which is plasma that contains these antibodies. Secondly, it can be used to make hyperimmune immunoglobulin, which is more concentrated, and therefore contains more antibodies. The manufacturing process of hyperimmune immunoglobulin is complex and requires large pools of human plasma. Similar antibodies can be made from animal sources and used in humans. Why is hyperimmune immunoglobulin a possible treatment for COVID‐19? Hyperimmune immunoglobulin products contain high levels of antibodies that target SARS‐CoV‐2, the virus that causes COVID‐19. The products are thought to inactivate the virus particles. What did we want to find out? We wanted to know if hyperimmune immunoglobulin is an effective and helpful treatment for people with suspected or confirmed COVID‐19 in any setting (for example, home or hospital). We were interested in: • death from any cause up 30 days after treatment, 60 days, or longer if reported; • improvement or worsening of symptoms; • quality of life; • unwanted effects. What did we do? We searched for studies that investigated hyperimmune immunoglobulin and usual care compared to usual care only, or in addition to a dummy medicine that did not contain any active ingredients (placebo). To make a fair comparison, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the hyperimmune immunoglobulin or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies. We used a standardised method to rate our confidence in the evidence. The confidence is based on study features such as how it was designed and the number of people in them. What did we find? We found five studies with 957 people. Studies took place in Pakistan, India, France, and Argentina, and one study was conducted in multiple countries, including Denmark, Greece, Japan, Nigeria, Spain, the UK and the USA. The studies took place before or during the emergence of several new COVID‐19 variants and prior to widespread vaccine rollout. All the participants in four studies were unvaccinated. In one study, 12 from 579 participants were vaccinated. We also found 10 ongoing studies. Main results All studies compared hyperimmune immunoglobulin from human or animal sources with usual care or placebo. The studies included only hospitalised people with moderate to severe disease. No studies looked at people without COVID‐19 symptoms or mild COVID‐19. No studies reported on quality of life. We are uncertain whether or not hyperimmune immunoglobulin prepared from humans affects risk of death from any cause up to 28 days after treatment. It may have little to no impact on improvement or worsening of symptoms up to 28 days after treatment. We are uncertain about a possible difference in unwanted or serious unwanted effects. The individual studies decided which events to classify as serious unwanted effects, but this usually means something that may cause hospitalisation or permanent harm. Hyperimmune immunoglobulin from animals may reduce deaths up to 28 days after treatment, may reduce worsening of symptoms, may improve patients' condition and may reduce serious unwanted events. What are the limitations of the evidence? We are uncertain whether hyperimmune immunoglobulin is an effective treatment for people hospitalised with COVID‐19, and whether it affects the number of unwanted or serious unwanted effects because the studies were small and did not all provide evidence on all our points of interest. The studies were conducted predominantly in people from wealthy countries, before the widespread rollout of COVID‐19 vaccines and the emergence of the omicron variant, so the results may not apply to people with omicron variant infection, or people who were vaccinated before falling ill. There was no evidence for people without symptoms or with mild COVID‐19. How up to date is this evidence? Our evidence is up‐to‐date to 31st March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kimber, C, Valk, SJ, Chai, KL, Piechotta, V, Iannizzi, C, Monsef, I, Wood, EM, Lamikanra, AA, Roberts, DJ, McQuilten, Z, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015167.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.811Z" }, { "id": "bdb33b41-d0a7-48e0-85a6-f375e72f07e2", "pmid": "", "title": "Roselle for hypertension in adults", "imported": false, "abstract": "Abstract - Background Hypertension is considered to be a serious health problem worldwide. Controlling and lowering blood pressure are of significant benefit to people with hypertension because hypertension is a risk factor for stroke, heart disease, and cardiovascular disease. Roselle, the tropical plant Hibiscus sabdariffa , also commonly called sour tea or red tea, has been used as both a thirst‐quenching drink and for medicinal purposes. Objectives To assess the effect of Roselle on blood pressure in people with primary hypertension. Search methods For this update, the Cochrane Hypertension Information Specialist searched the following databases and trials registers for randomised controlled trials (RCTs): the Cochrane Hypertension Specialised Register (to 6 August 2021), Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), MEDLINE Ovid (1946 to 5 August 2021), Embase Ovid (1974 to 5 August 2021), ProQuest Dissertations & Theses (to 6 August 2021), Web of Science Clarivate (to 7 August 2021), Food Science and Technology Abstracts Clarivate (to 7 August 2021), the WHO International Clinical Trials Registry Platform (to 6 August 2021), and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (to 6 August 2021). We searched Google Scholar and OpenSIGLE. We also handsearched local and regional Chinese databases: CBM, CMCC, TCMLARS, CNKI, CMAC, and the Index to Chinese Periodical Literature (to 14 September 2020), as well as Thai databases (ThaiJO, CUIR, TDC, CMU e‐Theses, TCTR) (to 3 October 2020). There were no language or publication date restrictions. Selection criteria We sought RCTs evaluating the use of any forms of Roselle with placebo or no treatment in adults with hypertension. Our primary outcome was change in trough and/or peak systolic and diastolic blood pressure (SBP, DBP). Secondary outcomes were withdrawals due to adverse effects, change in pulse pressure, and change in heart rate. Data collection and analysis All search results were managed using Covidence and re‐checked for the number of records, inclusion and exclusion of studies with Mendeley reference management software. We used standard methodological procedures expected by Cochrane. Two review authors worked independently in parallel for screening (titles and abstracts, and full reports), data extraction, risk of bias assessment, and assessment of the certainty of the evidence using the GRADE approach. Any disagreements were resolved by discussion or by consultation with the third review author if necessary. We presented mean difference (MD) of change in SBP and DBP with their corresponding 95% confidence interval (CI). Main results For this update, only one RCT with a parallel‐group design involving 60 participants with type 2 diabetes mellitus fulfilled the inclusion criteria. This study investigated the effect of Roselle extract capsules (total dose of 5600 mg) compared with placebo (lactose) at eight weeks. The study was at low risk of selection bias, performance bias, and detection bias. Conversely, it was at high risk of attrition bias, reporting bias, and other bias (baseline imbalance). We have very little confidence in the effect estimate of Roselle on change‐from‐baseline in both SBP and DBP between the two groups. The MD of change in SBP was 1.65, 95% CI −7.89 to 11.19 mmHg, 52 participants, very low‐certainty evidence. The MD of change in DBP was 4.60, 95% CI −1.38 to 10.58 mmHg, 52 participants, very low‐certainty evidence. Our secondary outcomes of withdrawals due to adverse effects, change in pulse pressure, and change in heart rate were not reported. Due to the limited available data, no secondary analyses were performed (subgroup and sensitivity analysis). Authors' conclusions The evidence is currently insufficient to determine the effectiveness of Roselle compared to placebo for controlling or lowering blood pressure in people with hypertension. The certainty of evidence was very low due to methodological limitations, imprecision, and indirectness. There is a need for rigorous RCTs that address the review question. Plain language summary Red tea (Roselle) for lowering blood pressure in adults Key messages: We don't know if taking Roselle lowers blood pressure in people with hypertension (high blood pressure). We don’t know if Roselle is safe for people with hypertension to consume or if it affects heart rate or pulse pressure. What did we want to find out? We wanted to know if red tea (Roselle) is a safe and effective treatment for lowering blood pressure in adults with high blood pressure when compared to placebo (dummy treatment) or no treatment. Roselle contains substances known as anthocyanins which have been shown to have lowered blood pressure in studies carried out in animals and humans. What did we do? We searched for studies that compared Roselle to placebo or no treatment in people with hypertension. What did we find? We included one study with 60 participants with type 2 diabetes and hypertension. Participants consumed either a capsule of pure Roselle extract or a placebo containing lactose for eight weeks. We are not sure if Roselle has an effect on blood pressure and the study did not report on the safety of Roselle or on changes to heart rate. What are the main limitations of the evidence? We found only one trial which included a small number of participants, all of whom had diabetes. More studies with various types of participants and different ways of taking Roselle (forms, amounts, and time of day, length of use) are needed. How up to date is the evidence? The review updates our previous review. We searched for randomised controlled trials (studies in which participants are randomly assigned to one of two or more treatment groups) in core databases up to August 2021, and searched local and regional Chinese and Thai databases by hand up to October 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Pattanittum, P, Ngamjarus, C, Buttramee, F, Somboonporn, C", "articleTypes": [], "doi": "10.1002/14651858.CD007894.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.785Z" }, { "id": "bdb4d734-616a-4e46-95cd-e1a65c76e3ca", "pmid": "", "title": "Interventions for hand eczema", "imported": false, "abstract": "Abstract - Background Hand eczema is an inflammation of the skin of the hands that tends to run a chronic, relapsing course. This common condition is often associated with itch, social stigma, and impairment in employment. Many different interventions of unknown effectiveness are used to treat hand eczema. Objectives To assess the effects of topical and systemic interventions for hand eczema in adults and children. Search methods We searched the following up to April 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, AMED, LILACS, GREAT, and four trials registries. We checked the reference lists of included studies for further references to relevant trials. Selection criteria We included randomised controlled trials (RCTs) that compared interventions for hand eczema, regardless of hand eczema type and other affected sites, versus no treatment, placebo, vehicle, or active treatments. Data collection and analysis We used standard methodological procedures expected by Cochrane. Primary outcomes were participant‐ and investigator‐rated good/excellent control of symptoms, and adverse events. Main results We included 60 RCTs, conducted in secondary care (5469 participants with mild to severe chronic hand eczema). Most participants were over 18 years old. The duration of treatment was short, generally up to four months. Only 24 studies included a follow‐up period. Clinical heterogeneity in treatments and outcome measures was evident. Few studies performed head‐to‐head comparisons of different interventions. Risk of bias varied considerably, with only five studies at low risk in all domains. Twenty‐two studies were industry‐funded. Eighteen trials studied topical corticosteroids or calcineurin inhibitors; 10 studies, phototherapy; three studies, systemic immunosuppressives; and five studies, oral retinoids. Most studies compared an active intervention against no treatment, variants of the same medication, or placebo (or vehicle). Below, we present results from the main comparisons. Corticosteroid creams/ointments: when assessed 15 days after the start of treatment, clobetasol propionate 0.05% foam probably improves participant‐rated control of symptoms compared to vehicle (risk ratio (RR) 2.32, 95% confidence interval (CI) 1.38 to 3.91; number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 8; 1 study, 125 participants); the effect of clobetasol compared to vehicle for investigator‐rated improvement is less clear (RR 1.43, 95% CI 0.86 to 2.40). More participants had at least one adverse event with clobetasol (11/62 versus 5/63; RR 2.24, 95% CI 0.82 to 6.06), including application site burning/pruritus. This evidence was rated as moderate certainty. When assessed 36 weeks after the start of treatment, mometasone furoate cream used thrice weekly may slightly improve investigator‐rated symptom control compared to twice weekly (RR 1.23, 95% CI 0.94 to 1.61; 1 study, 72 participants) after remission is reached. Participant‐rated symptoms were not measured. Some mild atrophy was reported in both groups (RR 1.76, 95% CI 0.45 to 6.83; 5/35 versus 3/37). This evidence was rated as low certainty. Irradiation with ultraviolet (UV) light: local combination ultraviolet light therapy (PUVA) may lead to improvement in investigator‐rated symptom control when compared to local narrow‐band UVB after 12 weeks of treatment (RR 0.50, 95% CI 0.22 to 1.16; 1 study, 60 participants). However, the 95% CI indicates that PUVA might make little or no difference. Participant‐rated symptoms were not measured. Adverse events (mainly erythema) were reported by 9/30 participants in the narrow‐band UVB group versus none in the PUVA group. This evidence was rated as moderate certainty. Topical calcineurin inhibitors: tacrolimus 0.1% over two weeks probably improves investigator‐rated symptom control measured after three weeks compared to vehicle (14/14 tacrolimus versus 0/14 vehicle; 1 study). Participant‐rated symptoms were not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. A within‐participant study in 16 participants compared 0.1% tacrolimus to 0.1% mometasone furoate but did not measure investigator‐ or participant‐rated symptoms. Both treatments were well tolerated when assessed at two weeks during four weeks of treatment. Evidence from these studies was rated as moderate certainty. Oral interventions: oral cyclosporin 3 mg/kg/d probably slightly improves investigator‐rated (RR 1.88, 95% CI 0.88 to 3.99; 1 study, 34 participants) or participant‐rated (RR 1.25, 95% CI 0.69 to 2.27) control of symptoms compared to topical betamethasone dipropionate 0.05% after six weeks of treatment. The risk of adverse events such as dizziness was similar between groups (up to 36 weeks; RR 1.22, 95% CI 0.80 to 1.86, n = 55; 15/27 betamethasone versus 19/28 cyclosporin). The evidence was rated as moderate certainty. Alitretinoin 10 mg improves investigator‐rated symptom control compared with placebo (RR 1.58, 95% CI 1.20 to 2.07; NNTB 11, 95% CI 6.3 to 26.5; 2 studies, n = 781) and alitretinoin 30 mg also improves this outcome compared with placebo (RR 2.75, 95% CI 2.20 to 3.43; NNTB 4, 95% CI 3 to 5; 2 studies, n = 1210). Similar results were found for participant‐rated symptom control: alitretinoin 10 mg RR 1.73 (95% CI 1.25 to 2.40) and 30 mg RR 2.75 (95% CI 2.18 to 3.48). Evidence was rated as high certainty. The number of adverse events (including headache) probably did not differ between alitretinoin 10 mg and placebo (RR 1.01, 95% CI 0.66 to 1.55; 1 study, n = 158; moderate‐certainty evidence), but the risk of headache increased with alitretinoin 30 mg (RR 3.43, 95% CI 2.45 to 4.81; 2 studies, n = 1210; high‐certainty evidence). Outcomes were assessed between 48 and 72 weeks. Authors' conclusions Most findings were from single studies with low precision, so they should be interpreted with caution. Topical corticosteroids and UV phototherapy were two of the major standard treatments, but evidence is insufficient to support one specific treatment over another. The effect of topical calcineurin inhibitors is not certain. Alitretinoin is more effective than placebo in controlling symptoms, but advantages over other treatments need evaluating. Well‐designed and well‐reported, long‐term (more than three months), head‐to‐head studies comparing different treatments are needed. Consensus is required regarding the definition of hand eczema and its subtypes, and a standard severity scale should be established. The main limitation was heterogeneity between studies. Small sample size impacted our ability to detect differences between treatments. Plain language summary Treatments for hand eczema Review question We reviewed evidence on the effects of topical and systemic (oral or injected medicines that work throughout the entire body) treatments for hand eczema when compared against placebo (an identical but inactive treatment), no treatment, vehicle (inactive ingredients that help deliver an active treatment), or another treatment. We included 60 randomised trials (5469 participants) published up to April 2018. Background Hand eczema is an inflammation of the skin of the hands that can be caused by contact allergens (i.e. substances that cause an allergic reaction) such as rubber chemicals, but other external factors (e.g. irritants such as water or detergents) and atopic predisposition are often important triggers. Hand eczema can cause a reduction in quality of life leading to many work‐related problems. Various types of hand eczema exist, and different topical (creams, ointments, or lotions) and systemic treatments with unknown effectiveness can be used. Study characteristics Most participants were hospital outpatients over 18 years of age with mild to severe chronic hand eczema. Treatment was usually given for up to four months, and outcomes were mainly assessed after treatment. A large variety of treatments were studied and compared to no treatment, variants of the same medication, placebo, or vehicle. Twenty‐two studies were funded by pharmaceutical companies. Key results Limited data are available to support the best way of managing hand eczema due to varying study quality and inability to pool data from studies with similar interventions. Corticosteroid creams/ointments and phototherapy (irradiation with UV light) are the major treatment options, although comparisons between these options are lacking. Below, we present results for the main comparisons of interest. Corticosteroid creams/ointments: clobetasol propionate foam probably increases participant‐rated good/excellent control of hand eczema when compared to vehicle (516 versus 222 per 1000), but the difference between groups was less clear for investigator‐rated control, and more adverse events were reported with clobetasol propionate (178 versus 79 per 1000) (all based on moderate‐certainty evidence). Mometasone furoate cream used thrice weekly may slightly improve investigator‐rated good/excellent control compared to twice weekly treatment, and participant‐rated control was not measured. Mild skin thinning occurred in both groups, but cases were few (all based on low‐certainty evidence). Irradiation with UV light: various types of irradiation (i.e. exposure to radiation) were compared. Local PUVA may improve investigator‐rated good/excellent control compared to narrow‐band UVB (400 versus 200 per 1000); however, we are uncertain of this finding because results also show that local PUVA may make little or no difference. Participant‐rated symptoms were not measured. Nine out of 30 participants in the narrow‐band UVB group reported adverse events (mainly redness) compared to none in the PUVA group (all based on moderate‐certainty evidence). Topical calcineurin inhibitors: people receiving tacrolimus are probably more likely to achieve improved investigator‐rated good/excellent symptom control compared to those given vehicle (14/14 participants with tacrolimus compared to none with vehicle), but participant‐rated control of symptoms was not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. One small study compared tacrolimus to mometasone furoate, which were both well tolerated, but did not measure investigator‐ or participant‐rated control (all based on moderate‐certainty evidence). Oral interventions: oral immunosuppressant (a drug that hinders the immune response) cyclosporin probably slightly improves investigator‐ or participant‐rated control of good/excellent symptoms compared to topical betamethasone cream (a corticosteroid). The risk of adverse events such as dizziness was similar between groups (all based on moderate‐certainty evidence). The oral vitamin A derivative (retinoid) alitretinoin (10 mg) achieved investigator‐rated good/excellent symptom control in 307 compared to 194 participants per 1000 with placebo, and alitretinoin 30 mg achieved investigator‐rated control in 432 compared to 157 participants per 1000 with placebo. Similar results were shown for participant‐rated control (high‐certainty evidence). When the dosage of alitretinoin was increased to 30 mg, risk of headache was higher compared to placebo (74 versus 251 per 1000; high‐certainty evidence), but this probably does not differ between alitretinoin 10 mg and placebo (based on moderate‐certainty evidence). Quality of the evidence The quality of evidence was mainly moderate, with most analyses based on single studies that had small sample sizes; therefore, some results should be interpreted with care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Christoffers, WA, Coenraads, PJ, Svensson, Å, Diepgen, TL, Dickinson‐Blok, JL, Xia, J, Williams, HC", "articleTypes": [], "doi": "10.1002/14651858.CD004055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.132Z" }, { "id": "bdb6a24e-b543-4684-b563-73c68eab4207", "pmid": "", "title": "Nebulized and oral thiol derivatives for pulmonary disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is an inherited condition resulting in thickened, sticky respiratory secretions. Respiratory failure, due to recurrent pulmonary infection and inflammation, is the most common cause of mortality. Muco‐active therapies (e.g. dornase alfa and nebulized hypertonic saline) may decrease sputum viscosity, increase airway clearance of sputum, reduce infection and inflammation and improve lung function. Thiol derivatives, either oral or nebulized, have shown benefit in other respiratory diseases. Their mode of action is likely to differ according to the route of administration. There are several thiol derivatives, and it is unclear which of these may be beneficial in cystic fibrosis. Objectives To evaluate the efficacy and safety of nebulized and oral thiol derivatives in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches, hand searches of relevant journals, abstract books and conference proceedings. Most recent search: 13 June 2013. We also conducted a PubMed search on 26 February 2013 for relevant published articles. Selection criteria Randomized and quasi‐randomized controlled trials comparing nebulized or oral thiol derivatives to placebo or another thiol derivative in people with cystic fibrosis. Data collection and analysis The authors independently assessed trials for inclusion, analysed risk of bias and extracted data. Main results Searches identified 23 trials; nine trials (255 participants) are included, of these seven trials are more than 10 years old. Three trials of nebulized thiol derivatives were identified (one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and another compared glutathione to 4% hypertonic saline). Although generally well‐tolerated with no significant adverse effects, there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Six trials of oral thiol derivatives were identified. Three trials compared N‐acetylcysteine to placebo; one compared N‐acetylcysteine, ambroxol and placebo; one compared carbocysteine to ambroxol; and one compared low and high‐dose N‐acetylcysteine. Oral thiol derivatives were generally well‐tolerated with no significant adverse effects, however there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Authors' conclusions We found no evidence to recommend the use of either nebulized or oral thiol derivatives in people with cystic fibrosis. There are very few good quality trials investigating the effect of these medications in cystic fibrosis, and further research is required to investigate the potential role of these medications in improving the outcomes of people with cystic fibrosis. Plain language summary Compounds which can break down the structure of mucus for lung disease in cystic fibrosis Cystic fibrosis is a genetic disorder which mainly affects the lungs. Chest infections recur in people with cystic fibrosis due to a build up of thick sputum (phlegm) in the air passages. Several treatments, including thiol derivatives, aim to loosen this sputum and so improve lung function and reduce the frequency of chest infections. Thiol derivatives may be either nebulized (breathed in) or oral (by mouth). They have been shown to help in other lung conditions, such as chronic obstructive pulmonary disease. This review aims to find out if there is enough evidence to recommend the use of nebulized or oral thiol derivatives for people with cystic fibrosis. We included nine trials; three assessed the effect of nebulized thiol derivatives. Of the nebulized trials, one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and the other compared glutathione to 4% hypertonic saline. Nebulized thiol derivatives were generally well‐tolerated with no major adverse effects. However they showed no significant improvements in any of our outcome measures. Six included trials assessed the effects of oral thiol derivatives.Three of these trials compared oral N‐acetylcysteine to placebo; one compared oral N‐acetylcysteine, oral ambroxol and placebo; and one compared oral carbocysteine and oral ambroxol (no placebo). None of the trials showed an overall significant benefit in any of the outcome measures of this review. Oral thiol derivatives were generally well‐tolerated with no major adverse effects. In summary, the trials included in the review did not provide any evidence that nebulized or oral thiol derivatives were either beneficial or harmful to people with cystic fibrosis. Further research investigating the effects of thiol derivatives in people with cystic fibrosis is required before their use can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Tam, J; Nash, EF; Ratjen, F; Tullis, E; Stephenson, A", "articleTypes": [], "doi": "10.1002/14651858.CD007168.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "bdc99be8-4d42-4298-85e1-f9bfd38421cf", "pmid": "", "title": "Topical cystic fibrosis transmembrane conductance regulator gene replacement for cystic fibrosis‐related lung disease", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is caused by a defective gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR), and is characterised by chronic lung infection resulting in inflammation and progressive lung damage that results in a reduced life expectancy. Objectives To determine whether topical CFTR gene replacement therapy to the lungs in people with cystic fibrosis is associated with improvements in clinical outcomes, and to assess any adverse effects. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Date of most recent search: 05 May 2016. An additional search of the National Institutes for Health (NIH) Genetic Modification Clinical Research Information System (GeMCRIS) was also performed for the years 1992 to 2015. Date of most recent search: 20 April 2016. Selection criteria Randomised controlled studies comparing topical CFTR gene delivery to the lung, using either viral or non‐viral delivery systems, with placebo or an alternative delivery system in people with confirmed cystic fibrosis. Data collection and analysis The authors independently extracted data and assessed study quality. Authors of included studies were contacted and asked for any available additional data. Meta‐analysis was limited due to differing study designs. Main results Four randomised controlled studies met the inclusion criteria for this review, involving a total of 302 participants lasting from 29 days to 13 months; 14 studies were excluded. The included studies differed in terms of CFTR gene replacement agent and study design, which limited the meta‐analysis. One study only enrolled adult males, the remaining studies included both males and females aged 12 years and over. Risk of bias in the studies was moderate. Random sequence generation and allocation concealment was only described in the more recent study; the remaining three studies were judged to have an unclear risk of bias. All four studies documented double‐blinding to the intervention, but there is some uncertainty with regards to participant blinding in one study. Some outcome data were missing from all four studies. There were no differences in either the number of respiratory exacerbations or the number of participants with an exacerbation between replacement therapy or placebo groups at any time point. Meta‐analysis of most respiratory function tests showed no difference between treatment and placebo groups, but the smallest study (n = 16) reported forced vital capacity (litres) increased more in the placebo group at up to 24 hours. A further study reported a significant improvement in forced expiratory volume at one second (litres) at 30 days after participants had received their first dose of favouring the gene therapy agent, but this finding was not confirmed when combined with at second study in the meta‐analysis. The more recent study (n = 140) demonstrated a small improvement in forced vital capacity (per cent predicted) at two and three months and again at 11 and 12 months for participants receiving CFTR gene replacement therapy compared to those receiving placebo. The same study reported a significant difference in the relative change in forced expiratory volume at one second (per cent predicted) at two months, three months and 12 months. One small study reported significant concerns with \"influenza‐like\" symptoms in participants treated with CFTR gene replacement therapy; this was not reported on repeated use of the same agent in a larger recent study. There was no other evidence of positive impact on outcomes, in particular improved quality of life or reduced treatment burden. Two studies measured ion transport in the lower airways; one (n = 16) demonstrated significant changes toward normal values in the participants who received gene transfer agents (P < 0.0001), mean difference 6.86 (95% confidence interval 3.77 to 9.95). The second study (n = 140) also reported significant changes toward normal values (P = 0.032); however, aggregate data were not available for analysis. In the most recent study, there was also evidence of increased salt transport in cells obtained by brushing the lower airway. These outcomes, whilst important, are not of direct clinical relevance. Authors' conclusions One study of liposome‐based CFTR gene transfer therapy demonstrated some improvements in respiratory function in people with CF, but this limited evidence of efficacy does not support this treatment as a routine therapy at present. There was no evidence of efficacy for viral‐mediated gene delivery. Future studies need to investigate clinically important outcome measures. Plain language summary Replacing the defective gene is a potential treatment for progressive lung disease in people with cystic fibrosis Review question We reviewed the evidence about the effect of delivering the correct copy of the cystic fibrosis transmembrane conductance regulator (CFTR) gene directly to the lungs of people with cystic fibrosis in order to treat progressive lung disease. Background In cystic fibrosis the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. People with cystic fibrosis suffer from progressive lung infection and damage which reduces life expectancy. Agents which can deliver a correct copy of the faulty CFTR gene to cells in the lungs may be an effective treatment. Search date The evidence is current to: 20 April 2016. Study characteristics We found four studies with 302 people to include in this review. The studies lasted from 29 days to 13 months. Three of these studies included both men and women aged 12 years and over and one study only included adult men. The studies compare gene therapy to a dummy treatment (placebo) both of which are inhaled as a mist into the lungs. The studies were of different designs and used different agents. This meant we could not combine their results. Key results Three of the studies, including the largest and most recent study, showed an improvement in some measures of lung function in people with CF given gene therapy. We did not find that any more clinically relevant outcomes such as quality of life, treatment burden or flare‐up of lung disease had improved with treatment. In one study \"influenza‐like\" symptoms were more common in people who received CFTR gene transfer agents but this was not reported when the agent was used repeatedly in a larger study. In those people who took the gene transfer agents, molecules and salt in their lower airways moved more like they do in healthy people. The limited evidence of benefit does not support this as a routine therapy at present. We recommend that future studies are designed and reported clearly so that their results can be incorporated into a systematic review. Quality of the evidence The most recent study provided detailed information on how the people were put into different treatment groups completely at random, and so we are satisfied that those taking part in the study had an equal chance of being in either group (CFTR gene transfer agent or placebo) and that no one could work out which group the next person would be put into. The other studies reported that people were put into groups at random but did not specify how, so we cannot be sure that there was an equal chance of them being in either group. We believe that the clinicians running all the studies did not know which treatment the people taking part were receiving and that in three of the studies those taking part did not know either, but we could not be sure whether the people taking part in the latest study knew which treatment they were receiving and what effect this knowledge might have on results. Unfortunately, the studies did not report all their results clearly; sometimes results were not reported in a way that we could use for the review and sometimes they were not reported at all. This reduced the certainty with which we judged the overall results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Perry, LA, Penny‐Dimri, JC, Aslam, AA, Lee, TWR, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD005599.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.794Z" }, { "id": "bdcc34a5-93ca-4beb-8eee-83cd539f0256", "pmid": "", "title": "Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy", "imported": false, "abstract": "Abstract - Background In the past women have been advised that lowering their salt intake might reduce their risk of pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of advice to alter dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of dietary advice to alter salt intake compared to continuing a normal diet, on the risk of pre‐eclampsia and its consequences. Search methods We searched the register of trials maintained and updated by the Cochrane Pregnancy and Childbirth Group, and the Cochrane Controlled Trials Register Disc Issue 4, 1998. Selection criteria Studies were included if they were randomised trials of advice to either reduce or to increase dietary salt during pregnancy. Data collection and analysis All data were extracted independently by both reviewers. Main results Two trials were included, with 603 women. They compared advice about a low salt diet with no dietary advice. The confidence intervals for all of the outcomes reported were wide, and cross the no effect line. This includes pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). Even when taken together, these trials are insufficient to provide reliable information about the effects of advice on salt restriction during normal pregnancy. None of the trials included women with pre‐eclampsia, so this review provides no reliable information about changes in salt intake for treatment of pre‐eclampsia. Authors' conclusions Salt consumption during pregnancy should remain a matter of personal preference. Plain language summary Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy To be prepared.", "journal": "Cochrane Database of Systematic Reviews", "year": "1999", "authors": "Duley, L; Henderson‐Smart, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD001687", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "bdd6153e-fff0-42e3-8127-6061e3bbc8ba", "pmid": "", "title": "Effect of Maternal Vitamin D3 Supplementation on Iron Status During Pregnancy and Early Infancy", "imported": false, "abstract": "This is a secondary-use study based on previously-collected data and blood samples from a previously completed double-blind, dose-ranging trial of maternal prenatal and postpartum vitamin D supplementation in Dhaka, Bangladesh (NCT01924013). The aim of this sub-study is to examine the effect of vitamin D supplementation on iron status during pregnancy and early infancy.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.243Z" }, { "id": "bde419de-4136-43ab-b4e9-8cbb5e952d14", "pmid": "", "title": "Topical lidocaine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Lidocaine is a local anaesthetic that is sometimes used on the skin to treat neuropathic pain. Objectives To assess the analgesic efficacy of topical lidocaine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 1 July 2014, together with the reference lists of retrieved papers and other reviews. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal to identify additional published or unpublished data. Selection criteria We included randomised, double‐blind studies of at least two weeks' duration comparing any formulation of topical lidocaine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts; at least 200 participants in the comparison, 8 to 12 weeks' duration, parallel design); second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison; and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. Main results We included 12 studies (508 participants) in comparisons with placebo or an active control. Six studies enrolled participants with moderate or severe postherpetic neuralgia, and the remaining studies enrolled different, or mixed, neuropathic pain conditions, including trigeminal neuralgia and postsurgical or post‐traumatic neuralgia. Four different formulations were used: 5% medicated patch, 5% cream, 5% gel, and 8% spray. Most studies used a cross‐over design, and two used a parallel‐group design. Two studies used enriched enrolment with randomised withdrawal. Seven studies used multiple doses, with one to four‐week treatment periods, and five used single applications. We judged all of the studies at high risk of bias because of small size or incomplete outcome assessment, or both. There was no first or second tier evidence, and no pooling of data was possible for efficacy outcomes. Only one multiple‐dose study reported our primary outcome of participants with ≥ 50% or ≥ 30% pain intensity reduction. Three single‐dose studies reported participants who were pain‐free at a particular time point, or had a 2‐point (of 10) reduction in pain intensity. The two enriched enrolment, randomised withdrawal studies reported time to loss of efficacy. In all but one study, third tier (very low quality) evidence indicated that lidocaine was better than placebo for some measure of pain relief. Pooling multiple‐dose studies across conditions demonstrated no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals, but there were few events and the withdrawal phase of enriched enrolment designs is not suitable to assess the true impact of adverse events (very low quality evidence). Authors' conclusions This review found no evidence from good quality randomised controlled studies to support the use of topical lidocaine to treat neuropathic pain, although individual studies indicated that it was effective for relief of pain. Clinical experience also supports efficacy in some patients. Several large ongoing studies, of adequate duration, with clinically useful outcomes should provide more robust conclusions about both efficacy and harm. Plain language summary Topical lidocaine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It differs from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are usually not effective in neuropathic pain, while medicines that are sometimes used to treat epilepsy or depression can be very effective in some people with neuropathic pain. Other possible treatments include the use of local anaesthetic applied to the skin. Lidocaine is a local anaesthetic. It is available in plasters (or patches), sprays, and creams, as topical lidocaine. These contain high concentrations of lidocaine because it crosses the skin poorly. Treatment with plasters usually involves applying one, two, or three plasters for up to 12 hours a day. In July 2014 we performed searches to look for clinical trials where topical lidocaine was used to treat neuropathic pain. We found 12 small studies of modest quality that tested topical lidocaine against topical placebo for a number of weeks. One study also tested a cream containing amitriptyline, which is an antidepressant. The 508 people in the studies had different types of neuropathic pain, with pain after herpes zoster infection the most common. There was some indication that topical lidocaine was beneficial in these studies (very low quality evidence). There was no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals (very low quality evidence). A number of studies of topical lidocaine in neuropathic pain are ongoing. Several are large and of long duration. They will be of great help in working out the benefits of topical lidocaine when they are completed and results can be incorporated in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Derry, S; Wiffen, PJ; Moore, RA; Quinlan, J", "articleTypes": [], "doi": "10.1002/14651858.CD010958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "bdf27a2f-96df-4938-b161-2ffa59d12b01", "pmid": "", "title": "Interventions for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is the most common, life‐limiting, genetically inherited disease. It affects multiple organs, particularly the respiratory system. However, gastrointestinal problems such as constipation and distal intestinal obstruction syndrome (DIOS) are also important and well‐recognised complications in CF. They share similar symptoms e.g. bloating, abdominal pain, but are distinct conditions. Constipation occurs when there is gradual faecal impaction of the colon, but DIOS occurs when there is an accumulation of faeces and sticky mucus, forming a mass in the distal part of the small intestine. The mass may partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). Symptoms of DIOS can affect quality of life and other aspects of CF health, such as airway clearance, exercise, sleep and nutritional status. Treatment of constipation and prevention of complete bowel obstruction are required for gastrointestinal management in CF. However, many different strategies are used in clinical practice and there is a lack of consensus. The importance of this topic was highlighted in a recent research priority setting exercise by the James Lind Alliance. Objectives To evaluate the effectiveness and safety of laxative agents of differing types for preventing DIOS (complete and incomplete) in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised and quasi‐randomised controlled parallel trials comparing laxative therapy for preventing DIOS (including osmotic agents, stimulants, mucolytics and substances with more than one action) at any dose to placebo, no treatment or an alternative laxative therapy, in people of any age with pancreatic sufficient or insufficient CF and any stage of lung disease. Randomised cross‐over trials were judged on an individual basis. Data collection and analysis Two authors independently assessed trials for inclusion, extracted outcome data and performed a risk of bias assessment for the included data. We judged the certainty of the evidence using GRADE criteria. Main results We included one cross‐over trial (17 participants) with a duration of 12 months, in which participants were randomly allocated to either cisapride (a gastro‐prokinetic agent) or placebo for six months each. The trial had an unclear risk of bias for most domains but had a high risk of reporting bias. Radiograph scores revealed no difference in occurrence of DIOS between cisapride and placebo (narrative report, no data provided). There were no adverse effects. Symptom scores were the only secondary outcome within the review that were reported. Total gastrointestinal symptom scores favoured cisapride with a statistically significant mean difference (MD) of ‐7.60 (95% confidence interval (CI) ‐14.73 to ‐0.47). There was no significant difference at six months between cisapride and placebo for abdominal distension, MD ‐0.90 (95% CI ‐2.39 to 0.59) or abdominal pain, MD ‐0.4 (95% CI ‐2.05 to 1.25). The global symptom scores (whether individuals felt better or worse) were reported in the paper to favour cisapride and be statistically significant (P < 0.05). We assessed the available data to be very low certainty. There was a great deal of missing data from the included trial and the investigators failed to report numerical data for many outcomes. The overall risk of bias of the trial was unclear and it had a high risk for reporting bias. There was also indirectness; the trial drug (cisapride) has since been removed from the market in several countries due to adverse effects, thus it has no current applicability for preventing DIOS. The included trial also had very few participants, which downgraded the certainty a further level for precision. Authors' conclusions There is an absence of evidence for interventions for the prevention of DIOS. As there was only one included trial, we could not perform a meta‐analysis of the data. Furthermore, the included trial compared a prokinetic agent (cisapride) that is no longer licensed for use in a number of countries due to the risk of serious cardiac events, a finding that came to light after the trial was conducted. Therefore, the limited findings from the trial are not applicable in current clinical practice. Overall, a great deal more research needs to be undertaken on gastrointestinal complications in CF, as this is a very poorly studied area compared to respiratory complications in CF. Plain language summary Which interventions are effective and safe for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis? Background Cystic fibrosis (CF) is an inherited, life‐long condition that causes organ systems in the body to produce large amounts of thick and sticky mucus. The most commonly affected area is the lungs, in which thick mucus leads to recurrent chest infections and breathing difficulties. Another commonly affected area is the digestive system. Many people with CF suffer from bloating and abdominal pain which may be caused by constipation or distal intestinal obstruction syndrome (DIOS). In DIOS, overproduction of thick mucus combines with stool and sticks to the intestinal wall. This mass can partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). The latter causes severe pain, vomiting and is treated as a medical emergency. As part of effective care for people with CF, constipation should therefore be treated and complete bowel obstruction be prevented. It is also important to recognise that constipation and DIOS impact on other aspects of CF health. Bloating, abdominal pain and nausea may affect airway clearance, exercise and sleep. Nutritional status may also be affected due to decreased appetite and malabsorption. DIOS may affect the absorption of other medications taken by people with CF. Overall, DIOS can significantly impair quality of life. Different laxatives are currently used in clinics, but prescribing practices differ and there is no consensus on optimal treatment strategies. Hence, this review aimed to analyse the evidence for the preventing DIOS. Search date We last searched for evidence: 12 October 2021. Trial characteristics We included one trial in the review, which included 17 people aged between 13 to 35 years. These people were randomly put into groups to take either a placebo drug (with no active medication) or cisapride for six months each and then to cross over and take the alternative treatment for a further six months. Key results The trial used radiography to diagnose DIOS, but did not provide any data and only stated that there was no difference between cisapride and placebo. The trial also stated that there were no adverse effects from the cisapride. The trial assessed participant‐reported total and individual gastrointestinal symptom scores. People in the cisapride group reported an improvement in total gastrointestinal symptom scores compared to those in the placebo group. However, there were no differences reported between groups for the individual symptom scores of abdominal pain and abdominal distension (swelling). Participants also reported global symptom scores, which showed that most people felt better taking cisapride compared to placebo. Certainty of the evidence The overall certainty of the evidence was very low. With one trial in this review, we could not combine data from different trials. The trial did not provide enough information about the methods used for allocating participants or about missing data and did not fully report certain results. The small number of participants also lowered the precision of the results. Since this trial was conducted, cisapride has been removed from the market in a number of countries due to rare but serious heart complications, therefore it has no applicability to current clinical practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carroll, W; Green, J; Gilchrist, FJ", "articleTypes": [], "doi": "10.1002/14651858.CD012619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "bdfce42f-c050-4351-9c26-ca16ca684977", "pmid": "", "title": "Preoperative statin therapy for adults undergoing cardiac surgery", "imported": false, "abstract": "Abstract - Background Despite significant advances in surgical techniques and perioperative care, people undertaking cardiac surgery due to cardiovascular disease are more prone to the development of postoperative adverse events. Statins (5‐hydroxy‐3‐methylglutaryl‐co‐enzyme A (HMG‐CoA) reductase inhibitors) are well‐known for their anti‐inflammatory and antioxidant effects and are established for primary and secondary prevention of coronary artery disease. In addition, statins are thought to have clinical benefits in perioperative outcomes in people undergoing cardiac surgery. This review is an update of a review that was first published in 2012 and updated in 2015. Objectives To evaluate the benefits and harms of preoperative statin therapy in adults undergoing cardiac surgery compared to standard of care or placebo. Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2023), Ovid MEDLINE (1980 to 14 September 2023), and Ovid Embase (1980 to 2023 (week 36)). We applied no language restrictions. Selection criteria We included all randomised controlled trials (RCTs) comparing any statin treatment before cardiac surgery, for any given duration and dose, versus no preoperative statin therapy (standard of care) or placebo. We excluded trials without a registered trial protocol and trials without approval by an institutional ethics committee. Data collection and analysis We used standard Cochrane methodology. Primary outcomes were short‐term mortality and major adverse cardiovascular events. Secondary outcomes were myocardial infarction, atrial fibrillation, stroke, renal failure, length of intensive care unit (ICU) stay, length of hospital stay and adverse effects related to statin therapy. We reported effect measures as risk ratios (RRs) or mean differences (MDs) with corresponding 95% confidence intervals (CIs). We used the RoB 1 tool to assess the risk of bias in included trials, and GRADE to assess the certainty of the evidence. Main results We identified eight RCTs (five new to this review) including 5592 participants. Pooled analysis showed that statin treatment before surgery may result in little to no difference in the risk of postoperative short‐term mortality (RR 1.36, 95% CI 0.72 to 2.59; I 2 = 0%; 6 RCTs, 5260 participants; low‐certainty evidence; note 2 RCTs reported 0 events in both groups so RR calculated from 4 RCTs with 5143 participants). We are very uncertain about the effect of statins on major adverse cardiovascular events (RR 0.93, 95% CI 0.77 to 1.13; 1 RCT, 2406 participants; very low‐certainty evidence). Statins probably result in little to no difference in myocardial infarction (RR 0.88, 95% CI 0.73 to 1.06; I 2 = 0%; 5 RCTs, 4645 participants; moderate‐certainty evidence), may result in little to no difference in atrial fibrillation (RR 0.87, 95% CI 0.72 to 1.05; I 2 = 60%; 8 RCTs, 5592 participants; low‐certainty evidence), and may result in little to no difference in stroke (RR 1.47, 95% CI 0.90 to 2.40; I 2 = 0%; 4 RCTs, 5143 participants; low‐certainty evidence). We are very uncertain about the effect of statins on renal failure (RR 1.04, 95% CI 0.80 to 1.34; I 2 = 57%; 4 RCTs, 4728 participants; very low‐certainty evidence). Additionally, statins probably result in little to no difference in length of ICU stay (MD 1.40 hours, 95% CI −1.62 to 4.41; I 2 = 43%; 3 RCTs, 4528 participants; moderate‐certainty evidence) and overall hospital stay (MD −0.31 days, 95% CI −0.64 to 0.03; I 2 = 84%; 5 RCTs, 4788 participants; moderate‐certainty evidence). No study had any individual risk of bias domain classified as high. However, two studies were at high risk of bias overall given the classification of unclear risk of bias in three domains. Authors' conclusions In this updated Cochrane review, we found no evidence that statin use in the perioperative period of elective cardiac surgery was associated with any clinical benefit or worsening, when compared with placebo or standard of care. Compared with placebo or standard of care, statin use probably results in little to no difference in MIs, length of ICU stay and overall hospital stay; and may make little to no difference to mortality, atrial fibrillation and stroke. We are very uncertain about the effects of statins on major harmful cardiac events and renal failure. The certainty of the evidence validating this finding varied from moderate to very low, depending on the outcome. Future trials should focus on assessing the impact of statin therapy on mortality and major adverse cardiovascular events. Plain language summary Is it better to take statins before undergoing heart‐related surgery? Key messages – Taking statins may make little to no difference to death within 30 days of surgery, irregular heart rhythms and stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off); and probably results in little to no difference in heart attacks, length of intensive care unit stay and overall hospital stay. We are very uncertain about the effects of statins on kidney failure and harmful effects from statin treatment. – Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. What are the dangers of cardiac surgery and how may statins help? Cardiac surgeries can effectively treat people with heart and circulation problems. However, undergoing cardiac surgery also increases the risk of death, heart attack, stroke (a serious life‐threatening condition that happens when the blood supply to part of the brain is cut off), irregular heart rhythms and kidney failure. This is partly because more than half of people undergoing cardiac surgery are over 70 years of age. To reduce these risks, we should try to improve recovery rates by preventing these problems from occurring before, during and after surgery. Statins are medications used throughout the world to lower blood cholesterol (a fatty substance found in the blood that may block blood vessels) levels and reduce the chances of cardiovascular issues becoming worse. Studies have shown that fewer people who had built up dangerous amounts of cholesterol in their blood vessels (arteries) died while taking statins. However, the potential benefits of taking statins in people undergoing cardiac surgery are unclear. What did we want to find out? We wanted to find out whether taking statins before undergoing cardiac surgery could help reduce the risk of: – death occurring shortly after surgery; or
– developing other heart or kidney problems. We also wanted to find out if there were any changes in the quality of care associated with cardiac surgeries for people who had been taking statins, such as reducing the length of hospital stay or intensive care unit stay, or if there were any harmful effects from statin treatment. What did we do? We searched for studies published up to September 2023 that compared treatment with statins to treatment with a placebo (a pretend medicine that looks or tastes identical to the medicine being tested) or usual care in people undergoing cardiac surgeries. Contrary to previous versions of this review, we only included trials that we were sure were approved by an ethical review board. What did we find? We found eight studies involving 5592 people with an average age of 63 years and 79% were men. Of these, 2798 people were treated with statins and 2794 people were not treated with statins before cardiac surgery. The smallest study included 57 people and the largest involved 2406 people. All studies were conducted in hospitals affiliated with universities in Asia, Europe and North America. Each study used different statin types (atorvastatin, fluvastatin, simvastatin, pravastatin or rosuvastatin) and doses (between 20 mg and 80 mg). Main results In people undergoing cardiac surgery, compared to no statin treatment, statin treatment: – probably results in little to no difference in heart attacks (5 studies, 4645 people), length of intensive care unit stay (3 studies, 4528 people) and overall hospital stay (5 studies, 4788 people); – may make little to no difference to death within 30 days of surgery (6 studies, 5260 people), irregular heart rhythm (8 studies, 5592 people) and stroke (4 studies, 5143 people). We are very uncertain about the effects of statins on major harmful cardiac events (1 study, 2406 people) and kidney failure (4 studies, 4728 people). What are the limitations of the evidence? We are moderately confident in our findings that there were probably little to no differences in the risk of heart attack, length of hospital and intensive care unit stay. However, we have little to very little confidence about our other findings, namely the most important finding we were looking for, which was a reduction in death. This is because most of the studies had many differences between them, there were fewer comparative cases than expected, and the studies did not always provide information about the statin intervention or treatment outcomes we were interested in. In addition, all studies used a different approach to statin treatment, which made them difficult to compare. Overall, this lowered our confidence in the evidence. Further studies are required to investigate whether statin treatment can help reduce the likelihood of death and other heart‐related (cardiovascular) issues in this context. How up to date is this evidence? This is an update of a Cochrane review. The evidence is up to date to September 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Marques Antunes, M; Nunes-Ferreira, A; Duarte, GS; Gouveia e Melo, R; Sucena Rodrigues, B; Guerra, NC; Nobre, A; Pinto, FJ; Costa, J; Caldeira, D", "articleTypes": [], "doi": "10.1002/14651858.CD008493.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "be0160bf-6f6f-46a4-aea0-9d64f562a589", "pmid": "", "title": "Oral zinc for the prevention of hyperbilirubinaemia in neonates", "imported": false, "abstract": "Abstract - Background Between 6% and 15% of neonates develop hyperbilirubinaemia requiring treatment. Successful management of neonatal hyperbilirubinaemia relies on prevention and early treatment, with phototherapy being the mainstay of treatment. Oral zinc has been reported to decrease the serum total bilirubin (STB), presumably by decreasing the enterohepatic circulation. Objectives To determine the effect of oral zinc supplementation compared to placebo or no treatment on the incidence of hyperbilirubinaemia in neonates during the first week of life and to assess the safety of oral zinc in enrolled neonates. Search methods We searched CENTRAL (The Cochrane Library 2014, Issue 1), MEDLINE (1966 to November 30, 2014), and EMBASE (1990 to November 30, 2014). Selection criteria Randomised controlled trials were eligible for inclusion if they enrolled neonates (term and preterm) to whom oral zinc, in a dose of 10 to 20 mg/day, was initiated within the first 96 hours of life, for any duration until day seven, compared with no treatment or placebo. Data collection and analysis We used the standard methods of The Cochrane Collaboration and its Neonatal Review Group for data collection and analysis. Main results Only one study met the criteria of inclusion in the review. This study compared oral zinc with placebo. Oral zinc was administered in a dose of 5 mL twice daily from day 2 to day 7 postpartum. The drug was administered into the mouth of the infant by the plastic measure provided with the bottle or with a spoon. Incidence of hyperbilirubinaemia, defined as serum total bilirubin (STB) ≥ 15 mg/dL, was similar between groups (N = 286; risk ratio (RR) 0.94, 95% confidence interval (CI) 0.58 to 1.52). Mean STB levels, mg/dL, at 72 ± 12 hours were comparable in both the groups (N = 286; mean difference (MD) ‐0.20; 95% CI ‐1.03 to 0.63). Although the duration of phototherapy in the zinc group was significantly shorter compared to the placebo group (N = 286; MD ‐12.80, 95% CI ‐16.93 to ‐8.67), the incidence of need for phototherapy was comparable across both the groups (N = 286; RR 1.20; 95% CI 0.66 to 2.18). Incidences of side effects like vomiting (N = 286; RR 0.65, 95% CI 0.19 to 2.25), diarrhoea (N = 286; RR 2.92, 95% CI 0.31 to 27.71), and rash (N = 286; RR 2.92, 95% CI 0.12 to 71.03) were found to be rare and statistically comparable between groups. Authors' conclusions The limited evidence available has not shown that oral zinc supplementation given to infants up to one week old reduces the incidence of hyperbilirubinaemia or need for phototherapy. Plain language summary Oral zinc for the prevention of hyperbilirubinaemia in neonates Review question In newborn infants less than one week old, does oral zinc salt supplementation compared to placebo or no treatment decrease the incidence of hyperbilirubinaemia (jaundice)? Background Jaundice, or yellowish discolouration of the skin, can occur due to an increased amount of bilirubin pigment in the blood. It is a commonly observed and usually harmless condition in newborn infants during the first week after birth. However, in some babies, the amount of bilirubin pigment can increase to dangerous levels and necessitate treatment. Bilirubin is metabolised in the liver and is excreted via the intestine in faeces. Increased reabsorption of bilirubin from the intestine is one of the major factors inducing hyperbilirubinaemia in newborn infants. Oral zinc salt, a relatively harmless medicine, can reduce the bilirubin level in newborn infants by decreasing its reabsorption from the intestine. Study characteristics Researchers from Cochrane searched for all available literature up to 30 November 2014. One randomised controlled trial met our inclusion criteria. Results In this review, the efficacy of oral zinc salt was compared with placebo. One study enrolling 294 infants was identified. This study evaluated oral zinc salt, given in a dose of 5 mg twice daily to infants between 25 and 168 hours old. The administration of oral zinc salt did not affect the incidence of jaundice (hyperbilirubinaemia) in these infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mishra, S, Cheema, A, Agarwal, R, Deorari, A, Paul, V", "articleTypes": [], "doi": "10.1002/14651858.CD008432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.769Z" }, { "id": "be065cc6-10c0-4159-9b32-a523b9093c6c", "pmid": "", "title": "Osmotic therapies added to antibiotics for acute bacterial meningitis", "imported": false, "abstract": "Abstract - Background Every day children and adults die from acute community‐acquired bacterial meningitis, particularly in low‐income countries, and survivors risk deafness, epilepsy and neurological disabilities. Osmotic therapies may attract extra‐vascular fluid and reduce cerebral oedema, and thus reduce death and improve neurological outcomes. This is an update of a Cochrane Review first published in 2013. Objectives To evaluate the effects of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults on mortality, deafness and neurological disability. Search methods We searched CENTRAL (2017, Issue 1), MEDLINE (1950 to 17 February 2017), Embase (1974 to 17 February 2017), CINAHL (1981 to 17 February 2017), LILACS (1982 to 17 February 2017) and registers of ongoing clinical trials (ClinicalTrials.com, WHO ICTRP) (21 February 2017). We also searched conference abstracts and contacted researchers in the field (up to 12 December 2015). Selection criteria Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis. Data collection and analysis Two review authors independently screened the search results and selected trials for inclusion. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not. We used the GRADE approach to assess the certainty of the evidence. Main results We included five trials with 1451 participants. Four trials evaluated glycerol against placebo, and one evaluated glycerol against 50% dextrose; in addition three trials evaluated dexamethasone and one trial evaluated acetaminophen (paracetamol) in a factorial design. Stratified analysis shows no effect modification with steroids; we present aggregate effect estimates. Compared to placebo, glycerol probably has little or no effect on death in people with bacterial meningitis (RR 1.08, 95% CI 0.90 to 1.30; 5 studies, 1272 participants; moderate‐certainty evidence ), but may reduce neurological disability (RR 0.73, 95% CI 0.53 to 1.00; 5 studies, 1270 participants; low‐certainty evidence ). Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30; 4 studies, 1090 participants; low‐certainty evidence ). Glycerol may reduce the risk of subsequent deafness (RR 0.64, 95% CI 0.44 to 0.93; 5 studies, 922 participants; low to moderate‐certainty evidence ). Glycerol probably has little or no effect on gastrointestinal bleeding (RR 0.93, 95% CI 0.39 to 2.19; 3 studies, 607 participants; moderate‐certainty evidence ). The evidence on nausea, vomiting and diarrhoea is uncertain (RR 1.09, 95% CI 0.81 to 1.47; 2 studies, 851 participants; very low‐certainty evidence ). Authors' conclusions Glycerol was the only osmotic therapy evaluated, and data from trials to date have not demonstrated an effect on death. Glycerol may reduce neurological deficiency and deafness. Plain language summary Osmotic therapies added to antibiotics for acute bacterial meningitis What is the aim of this review? The aim of this Cochrane Review is to collect and analyse trials evaluating osmotic therapies given orally or intravenously to people with acute bacterial meningitis. Cochrane authors collected and analysed all relevant studies to answer this question; they found five relevant studies. Key messages Giving glycerol, an osmotic diuretic, probably has little or no effect on death ( moderate‐certainty evidence ), but may reduce subsequent deafness ( moderate‐certainty evidence) or neurological disability ( low‐certainty evidence ). The evidence is current to 17 February 2017. What was studied in the review? In meningitis, the cerebrospinal fluid that surrounds the brain and spinal cord is infected, usually as a result of spread from the blood. Any form of meningitis can result in death or severe disability, but acute bacterial meningitis is rapidly fatal without treatment. Even with antibiotics, 10% to 15% of children with bacterial meningitis die in high‐income countries with much higher rates in low‐income settings. The infection causes the brain to swell, and this is thought to contribute to death and to long‐term brain damage in survivors. Osmotic therapies increase the concentration of the blood by exerting an osmotic pressure across a semi‐permeable membrane (such as a cell wall or blood vessel lining in the brain). This draws water from the brain into the blood, thereby reducing pressure in the brain. Potentially osmotic therapies could increase the rate of survival, or they could do harm. What are the main results of the review? We included five trials that compared glycerol with placebo in a total of 1451 patients with bacterial meningitis. In the studies steroids were often given as well, but this did not appear to modify any of the effects seen with glycerol. This review detected no benefit from glycerol relating to death. There appeared to be marginal protection against deafness and against neurological disability. No effect on epileptic seizures at follow‐up was noted. Glycerol was not associated with any severe adverse effects. The number of trials included was small and only two tested a large number of participants. All trials were from different healthcare settings and examined either adults or children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wall, ECB; Ajdukiewicz, KMB; Bergman, H; Heyderman, RS; Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD008806.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "be0c2b60-46d7-45d0-beb7-7e6e0eeffd94", "pmid": "", "title": "Protein and energy supplementation in elderly people at risk from malnutrition", "imported": false, "abstract": "Abstract - Background Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. Objectives This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip‐feeds'. Search methods We searched The Cochrane Library , MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip‐feed' manufacturers. Selection criteria Randomised and quasi‐randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. Data collection and analysis Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. Main results Sixty‐two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97). The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (‐0.8 days, 95% CI ‐2.8 to 1.3). Adverse effects included nausea or diarrhoea. Authors' conclusions Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large‐scale multi‐centre trials are still required. Plain language summary Protein and energy supplementation in elderly people at risk from malnutrition Much emphasis is placed on the importance of good diet, usually in relation to concern about the health risks of obesity. However it has been generally agreed that the risk of undernutrition rather than overnutrition is the main cause for concern in elderly people, particularly those who are hospitalised or institutionalised. Malnutrition has been shown to have important effects on recovery in a broad range of patients and conditions. It has been associated strongly with impaired immune response, impaired muscle and respiratory function, delayed wound healing, overall increased complications, longer rehabilitation, greater length of hospital stay and increased mortality. Oral protein and energy supplements are potentially safer and easier to administer than nasogastric enteral feeds and are therefore particularly suited to elderly people and are also widely used. However, there may be problems with the willingness and ability of older people to consume oral supplements, and supplements may not be used effectively. Even if supplements are prescribed, they may not always be given, or are given but not consumed. In addition to taste, the composition and timing of administration in relation to meals may be important. Efforts also need to be made to provide normal meals and snacks which meet the needs of elderly people and to provide assistance with feeding if required. A total of 10,187 randomised participants from the 62 trials has been included. Maximum duration of intervention was 18 months. The reviewers suggest that supplementation appears to produce a small but consistent weight gain. There was no evidence in this updated review of a beneficial effect on mortality overall, but there may be a beneficial effect on mortality in people who are undernourished. Supplementation may also reduce the number of complications. The reported acceptance of supplements was variable between trials. Some adverse effects such as nausea or diarrhoea were reported. However, there were problems of study design and quality. More studies are required to confirm the beneficial effect on the number of complications, to establish whether there is a beneficial effect on mortality for undernourished elderly people and to provide evidence about whether protein and energy supplements can improve morbidity and functional status in frail older people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Milne, AC, Potter, J, Vivanti, A, Avenell, A", "articleTypes": [], "doi": "10.1002/14651858.CD003288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.738Z" }, { "id": "be19d6c0-71da-4ef5-87e1-bc6856304063", "pmid": "", "title": "Acetylcholinesterase inhibitors for autistic spectrum disorders", "imported": false, "abstract": "Abstract - Background Autism spectrum disorder (autism) is a neurodevelopmental condition characterised by impairments in social communication and interaction, plus restricted, repetitive patterns of behaviour and interests. Whilst some people embrace autism as part of their identity, others struggle with their difficulties, and some seek treatment. There are no current interventions that result in complete reduction of autism features. Acetylcholine is a neurotransmitter for the cholinergic system and has a role in attention, novelty seeking, and memory. Low levels of acetylcholine have been investigated as a potential contributor to autism symptomatology. Donepezil, galantamine, and rivastigmine (commonly referred to as acetylcholinesterase inhibitors) all inhibit acetylcholinesterase, and have slightly different modes of action and biological availability, so their effectiveness and side‐effect profiles may vary. The effect of various acetylcholinesterase inhibitor on core autism features across the lifespan, and possible adverse effects, have not been thoroughly investigated. Objectives To evaluate the efficacy and harms of acetylcholinesterase inhibitors for people with the core features (social interaction, communication, and restrictive and repetitive behaviours) of autism. To assess the effects of acetylcholinesterase inhibitors on non‐core features of autism. Search methods In November 2022, we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the reference lists of included studies and relevant reviews, and contacted authors of relevant studies. Selection criteria Randomised controlled trials (RCTs), comparing acetylcholinesterase inhibitors (e.g. galantamine, donepezil, or rivastigmine) of varying doses, delivered orally or via transdermal patch, either as monotherapy or adjunct therapy, with placebo. People of any age, with a clinical diagnosis of autism were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were core features of autism and adverse effects. Secondary outcomes were language, irritability, hyperactivity, and general health and function. We used GRADE to assess certainty of evidence. Main results We included two RCTs (74 participants). One study was conducted in Iran, the second in the USA, although exact location in the USA is unclear. Galantamine plus risperidone versus placebo plus risperidone One study compared the effects of galantamine plus risperidone to placebo plus risperidone (40 participants, aged 4 years to 12 years). Primary and secondary outcomes of interest were measured postintervention, using subscales of the Aberrant Behavior Checklist (score 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed there was little to no difference between the two groups postintervention for social communication (mean difference (MD) ‐2.75, 95% confidence interval (CI) ‐5.88 to 0.38), and restricted and repetitive behaviour (MD ‐0.55, 95% CI ‐3.47 to 2.37). Overall autism features were not assessed. Adverse events may be higher in the galantamine plus risperidone group (75%) compared with the placebo plus risperidone group (35%): odds ratio 5.57, 95% CI 1.42 to 21.86, low‐certainty evidence. No serious adverse events were reported. Low‐certainty evidence showed a small difference in irritability (MD ‐3.50, 95% CI ‐6.39 to ‐0.61), with the galantamine plus risperidone group showing a greater decline on the irritability subscale than the placebo group postintervention. There was no evidence of a difference between the groups in hyperactivity postintervention (MD ‐5.20, 95% CI ‐10.51 to 0.11). General health and function were not assessed. Donepezil versus placebo One study compared donepezil to placebo (34 participants aged 8 years to 17 years). Primary outcomes of interest were measured postintervention, using subscales of the Modified Version of The Real Life Rating Scale (scored 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed no evidence of group differences immediately postintervention in overall autism features (MD 0.07, 95% CI ‐0.19 to 0.33), or in the autism symptom domains of social communication (MD ‐0.02, 95% CI ‐0.34 to 0.30), and restricted and repetitive behaviours (MD 0.04, 95% CI ‐0.27 to 0.35). Significant adverse events leading to study withdrawal in at least one participant was implied in the data analysis section, but not explicitly reported. The evidence is very uncertain about the effect of donepezil, compared to placebo, on the secondary outcomes of interest, including irritability (MD 1.08, 95% CI ‐0.41 to 2.57), hyperactivity (MD 2.60, 95% CI 0.50 to 4.70), and general health and function (MD 0.03, 95% CI ‐0.48 to 0.54) postintervention. Across all analyses within this comparison, we judged the evidence to be very low‐certainty due to high risk of bias, and very serious imprecision (results based on one small study with wide confidence intervals). The study narratively reported adverse events for the study as a whole, rather than by treatment group. Authors' conclusions Evidence about the effectiveness of acetylcholinesterase inhibitors as a medication to improve outcomes for autistic adults is lacking, and for autistic children is very uncertain. There is a need for more evidence of improvement in outcomes of relevance to clinical care, autistic people, and their families. There are a number of ongoing studies involving acetylcholinesterase inhibitors, and future updates of this review may add to the current evidence. Plain language summary Do acetylcholinesterase inhibitors reduce the core impairments associated with autism spectrum disorder Key messages At present, it is unclear whether acetylcholinesterase inhibitors are effective in treating the core features of autism. This is because very few studies have been carried out. The two we found were small, and did not report the outcomes very well. However, there are a number of ongoing studies in this area. What is autism spectrum disorder? Autism spectrum disorder (autism) is a condition that affects the way a person thinks, feels, interacts with others, and experiences their environment. The core behaviours of autism include reduced sharing of interests, difficulties with nonverbal communication (for example, little eye contact), difficulties forming and maintaining relationships and restricted, or repetitive behaviours or interests. These behaviours can vary in severity, but they still interfere with the person's daily functioning and participation in activities. Medicines, called acetylcholinesterase inhibitors (chemicals that block the normal breakdown of nerve transmitters), have been used to treat Alzheimer's disease (for example, donepezil and galantamine). Recently, it has been suggested that they may also decrease some of the difficulties seen in people with autism. What did we want to find out? Do acetylcholinesterase inhibitors, alone or with other medicines, reduce the core features of autism (social communication and interaction, restrictive and repetitive behaviours) compared with a placebo (a dummy pill). We also wanted to find out if acetylcholinesterase inhibitors were associated with any unwanted side effects. What did we do? We searched for studies that explored whether there were any differences in autistic people's behaviours after they had taken acetylcholinesterase inhibitors compared to people who had taken placebo pills. We compared and summarised the results of the studies, and rated our confidence in the evidence, based on things, such how big and well carried out the studies were. What did we find? We found two relevant studies. One study looked at whether an acetylcholinesterase inhibitor called galantamine, combined with a drug called risperidone (traditionally used to treat psychosis), was better than a placebo combined with risperidone. The study included 40 children, aged between 4 and 12 years, with a diagnosis of autism. it took place over 10 weeks in Iran. A second study compared an acetylcholinesterase inhibitor called donepezil with placebo. It included 34 children, aged between 8 and 17 years, with a diagnosis of autism. It was carried out in the USA. All studies involved children attending outpatient clinics. What are the main results of the review? It is unclear if acetylcholinesterase inhibitors make any difference to the core features of autism in children or adults. Galantamine may cause little to no difference in social interaction and communication skills and irritability levels in children with autism after 10 weeks of treatment. There is no evidence that galantamine reduces difficulties associated with restricted or repetitive behaviours or hyperactivity. Galantamine may also cause some side effects, including nervousness, drowsiness, increased appetite, and tremor. There is no evidence that donepezil reduces difficulties associated with the core features of autism or associated secondary problems. We were unable to find out whether it causes unwanted side effects in children with autism, because the study did not report the results completely. What are the limitations of the evidence? We have little confidence in the evidence for using this medicine to treat problems associated with autism, because the evidence comes from only two small studies that were not very well carried out or reported. Each study looked at a different type of acetylcholinesterase inhibitor and delivered the medicine differently. They did not provide information about all the issues we were interested in, and they measured the side effects differently. If more studies are included in future reviews, these results may change. How up‐to‐date is this review? The evidence in this review is current to November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ure, A, Cox, GR, Haslam, R, Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD013851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.790Z" }, { "id": "be25f919-0e4e-4ddc-a9a8-e0bd1a9de6d2", "pmid": "", "title": "Synbiotics, prebiotics and probiotics for people with chronic kidney disease", "imported": false, "abstract": "Abstract - Background Chronic kidney disease (CKD) is a major public health problem affecting 13% of the global population. Prior research has indicated that CKD is associated with gut dysbiosis. Gut dysbiosis may lead to the development and/or progression of CKD, which in turn may in turn lead to gut dysbiosis as a result of uraemic toxins, intestinal wall oedema, metabolic acidosis, prolonged intestinal transit times, polypharmacy (frequent antibiotic exposures) and dietary restrictions used to treat CKD. Interventions such as synbiotics, prebiotics, and probiotics may improve the balance of the gut flora by altering intestinal pH, improving gut microbiota balance and enhancing gut barrier function (i.e. reducing gut permeability). Objectives This review aimed to evaluate the benefits and harms of synbiotics, prebiotics, and probiotics for people with CKD. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria We included randomised controlled trials (RCTs) measuring and reporting the effects of synbiotics, prebiotics, or probiotics in any combination and any formulation given to people with CKD (CKD stages 1 to 5, including dialysis and kidney transplant). Two authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. Data collection and analysis Data extraction was independently carried out by two authors using a standard data extraction form. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross‐checked by another. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Forty‐five studies (2266 randomised participants) were included in this review. Study participants were adults (two studies in children) with CKD ranging from stages 1 to 5, with patients receiving and not receiving dialysis, of whom half also had diabetes and hypertension. No studies investigated the same synbiotic, prebiotic or probiotic of similar strains, doses, or frequencies. Most studies were judged to be low risk for selection bias, performance bias and reporting bias, unclear risk for detection bias and for control of confounding factors, and high risk for attrition and other biases. Compared to prebiotics, it is uncertain whether synbiotics improve estimated glomerular filtration rate (eGFR) at four weeks (1 study, 34 participants: MD ‐3.80 mL/min/1.73 m², 95% CI ‐17.98 to 10.38), indoxyl sulfate at four weeks (1 study, 42 participants: MD 128.30 ng/mL, 95% CI ‐242.77 to 499.37), change in gastrointestinal (GI) upset (borborymgi) at four weeks (1 study, 34 participants: RR 15.26, 95% CI 0.99 to 236.23), or change in GI upset (Gastrointestinal Symptom Rating Scale) at 12 months (1 study, 56 participants: MD 0.00, 95% CI ‐0.27 to 0.27), because the certainty of the evidence was very low. Compared to certain strains of prebiotics, it is uncertain whether a different strain of prebiotics improves eGFR at 12 weeks (1 study, 50 participants: MD 0.00 mL/min, 95% CI ‐1.73 to 1.73), indoxyl sulfate at six weeks (2 studies, 64 participants: MD ‐0.20 μg/mL, 95% CI ‐1.01 to 0.61; I² = 0%) or change in any GI upset, intolerance or microbiota composition, because the certainty of the evidence was very low. Compared to certain strains of probiotics, it is uncertain whether a different strain of probiotic improves eGFR at eight weeks (1 study, 30 participants: MD ‐0.64 mL/min, 95% CI ‐9.51 to 8.23; very low certainty evidence). Compared to placebo or no treatment, it is uncertain whether synbiotics improve eGFR at six or 12 weeks (2 studies, 98 participants: MD 1.42 mL/min, 95% CI 0.65 to 2.2) or change in any GI upset or intolerance at 12 weeks because the certainty of the evidence was very low. Compared to placebo or no treatment, it is uncertain whether prebiotics improves indoxyl sulfate at eight weeks (2 studies, 75 participants: SMD ‐0.14 mg/L, 95% CI ‐0.60 to 0.31; very low certainty evidence) or microbiota composition because the certainty of the evidence is very low. Compared to placebo or no treatment, it is uncertain whether probiotics improve eGFR at eight, 12 or 15 weeks (3 studies, 128 participants: MD 2.73 mL/min, 95% CI ‐2.28 to 7.75; I² = 78%), proteinuria at 12 or 24 weeks (1 study, 60 participants: MD ‐15.60 mg/dL, 95% CI ‐34.30 to 3.10), indoxyl sulfate at 12 or 24 weeks (2 studies, 83 participants: MD ‐4.42 mg/dL, 95% CI ‐9.83 to 1.35; I² = 0%), or any change in GI upset or intolerance because the certainty of the evidence was very low. Probiotics may have little or no effect on albuminuria at 12 or 24 weeks compared to placebo or no treatment (4 studies, 193 participants: MD 0.02 g/dL, 95% CI ‐0.08 to 0.13; I² = 0%; low certainty evidence). For all comparisons, adverse events were poorly reported and were minimal (flatulence, nausea, diarrhoea, abdominal pain) and non‐serious, and withdrawals were not related to the study treatment. Authors' conclusions We found very few studies that adequately test biotic supplementation as alternative treatments for improving kidney function, GI symptoms, dialysis outcomes, allograft function, patient‐reported outcomes, CVD, cancer, reducing uraemic toxins, and adverse effects. We are not certain whether synbiotics, prebiotics, or probiotics are more or less effective compared to one another, antibiotics, or standard care for improving patient outcomes in people with CKD. Adverse events were uncommon and mild. Plain language summary Prebiotics (dietary fibre), probiotics (good bacteria) or synbiotics (prebiotics plus probiotics) for people with chronic kidney disease Key messages Chronic kidney disease (CKD) is a serious health problem that affects over 850 million people worldwide. People with kidney disease have an unhealthy balance of good and bad bacteria in their guts, called 'gut dysbiosis'. This imbalance arises because of the effects of reduced kidney function (retained toxic waste products, fluid retention causing the gut wall to swell), drugs frequently used in people with CKD (especially antibiotics), and dietary restrictions placed on people with CKD. Gut dysbiosis can, in turn, cause or worsen CKD because bacteria can produce toxins that cross the bowel wall and damage the kidneys. Gut dysbiosis can also cause stomach problems (like bloating, cramping, constipation and diarrhoea) and reduce quality of life. To improve the balance of the gut flora, good bacteria can be taken in tablets of high doses of prebiotics and probiotics. Prebiotics, or indigestible plant fibre, can encourage the growth of good bacteria. Synbiotics are a combination of prebiotics and probiotics. Some research suggests that taking high doses of the good bacteria can re‐balance the good bacteria in people's gut, thereby improving bowel symptoms and the conditions that lead to worsening of CKD. What did we do? We reviewed all of the evidence on synbiotics, prebiotics and probiotics to see whether they can improve outcomes in people who have CKD (all stages 1 to 5). What did we find? We found 45 studies randomising 2266 participants. Half of these looked at participants receiving dialysis (mostly haemodialysis), and the other half not receiving dialysis. Half also had diabetes and hypertension. We are uncertain whether synbiotics, prebiotics, or probiotics improve bowel outcomes, quality of life, kidney toxin levels or kidney function. The quality of the evidence that we found is low quality and very low certainty. All studies were conducted using moderate to poor‐quality methods with too few patients. Summary Currently, we do not have enough information from trials to know whether synbiotics, prebiotics or probiotics work to improve bowel symptoms, quality of life, kidney toxin levels, or kidney function in people with CKD. Ten studies are currently ongoing; therefore, it is possible that findings may change with the inclusion of these studies in future updates. The evidence is up to date to 9 October 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Cooper, TE, Khalid, R, Chan, S, Craig, JC, Hawley, CM, Howell, M, Johnson, DW, Jaure, A, Teixeira-Pinto, A, Wong, G", "articleTypes": [], "doi": "10.1002/14651858.CD013631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.780Z" }, { "id": "be2c92a0-4f74-40f1-892e-f0350d479379", "pmid": "", "title": "Antibiotics for induction and maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Several antibiotics have been evaluated in Crohn's disease (CD), however randomised controlled trials (RCTs) have produced conflicting results. Objectives To assess the efficacy and safety of antibiotics for induction and maintenance of remission in CD. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and Clinicaltrials.gov database from inception to 28 February 2018. We also searched reference lists and conference proceedings. Selection criteria RCTs comparing antibiotics to placebo or an active comparator in adult (> 15 years) CD patients were considered for inclusion. Data collection and analysis Two authors screened search results and extracted data. Bias was evaluated using the Cochrane risk of bias tool. The primary outcomes were failure to achieve clinical remission and relapse. Secondary outcomes included clinical response, endoscopic response, endoscopic remission, endoscopic relapse, histologic response, histologic remission, adverse events (AEs), serious AEs, withdrawal due to AEs and quality of life. Remission is commonly defined as a Crohn's disease activity index (CDAI) of < 150. Clinical response is commonly defined as a decrease in CDAI from baseline of 70 or 100 points. Relapse is defined as a CDAI > 150. For studies that enrolled participants with fistulizing CD, response was defined as a 50% reduction in draining fistulas. Remission was defined as complete closure of fistulas. We calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for dichotomous outcomes. We calculated the mean difference (MD) and corresponding 95% CI for continuous outcomes. GRADE was used to assess the certainty of the evidence. Main results Thirteen RCTs (N = 1303 participants) were eligible. Two trials were rated as high risk of bias (no blinding). Seven trials were rated as unclear risk of bias and four trials were rated as low risk of bias. Comparisons included ciprofloxacin (500 mg twice daily) versus placebo, rifaximin (800 to 2400 mg daily) versus placebo, metronidazole (400 mg to 500 mg twice daily) versus placebo, clarithromycin (1 g/day) versus placebo, cotrimoxazole (960 mg twice daily) versus placebo, ciprofloxacin (500 mg twice daily) and metronidazole (250 mg four time daily) versus methylprednisolone (0.7 to 1 mg/kg daily), ciprofloxacin (500 mg daily), metronidazole (500 mg daily) and budesonide (9 mg daily) versus placebo with budesonide (9 mg daily), ciprofloxacin (500 mg twice daily) versus mesalazine (2 g twice daily), ciprofloxacin (500 mg twice daily) with adalimumab versus placebo with adalimumab, ciprofloxacin (500 mg twice daily) with infliximab versus placebo with infliximab, clarithromycin (750 mg daily) and antimycobacterial versus placebo, and metronidazole (400 mg twice daily) and cotrimoxazole (960 mg twice daily) versus placebo. We pooled all antibiotics as a class versus placebo and antibiotics with anti‐tumour necrosis factor (anti‐TNF) versus placebo with anti‐TNF. The effect of individual antibiotics on CD was generally uncertain due to imprecision. When we pooled antibiotics as a class, 55% (289/524) of antibiotic participants failed to achieve remission at 6 to 10 weeks compared with 64% (149/231) of placebo participants (RR 0.86, 95% CI 0.76 to 0.98; 7 studies; high certainty evidence). At 10 to 14 weeks, 41% (174/428) of antibiotic participants failed to achieve a clinical response compared to 49% (93/189) of placebo participants (RR 0.77, 95% CI 0.64 to 0.93; 5 studies; moderate certainty evidence). The effect of antibiotics on relapse in uncertain. Forty‐five per cent (37/83) of antibiotic participants relapsed at 52 weeks compared to 57% (41/72) of placebo participants (RR 0.87, 95% CI 0.52 to 1.47; 2 studies; low certainty evidence). Relapse of endoscopic remission was not reported in the included studies. Antibiotics do not appear to increase the risk of AEs. Thirty‐eight per cent (214/568) of antibiotic participants had at least one adverse event compared to 45% (128/284) of placebo participants (RR 0.87, 95% CI 0.75 to 1.02; 9 studies; high certainty evidence). The effect of antibiotics on serious AEs and withdrawal due to AEs was uncertain. Two per cent (6/377) of antibiotic participants had at least one adverse event compared to 0.7% (1/143) of placebo participants (RR 1.70, 95% CI 0.29 to 10.01; 3 studies; low certainty evidence). Nine per cent (53/569) of antibiotic participants withdrew due to AEs compared to 12% (36/289) of placebo participants (RR 0.86, 95% CI 0.57 to 1.29; 9 studies; low certainty evidence) is uncertain. Common adverse events in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation and headache, change in taste and paraesthesia When we pooled antibiotics used with anti‐TNF, 21% (10/48) of patients on combination therapy failed to achieve a clinical response(50% closure of fistulas) or remission (closure of fistulas) at week 12 compared with 36% (19/52) of placebo and anti‐TNF participants (RR 0.57, 95% CI 0.29 to 1.10; 2 studies; low certainty evidence). These studies did not assess the effect of antibiotics and anti‐TNF on clinical or endoscopic relapse. Seventy‐seven per cent (37/48) of antibiotics and anti‐TNF participants had an AE compared to 83% (43/52) of anti‐TNF and placebo participants (RR 0.93, 95% CI 0.76 to 1.12; 2 studies, moderate certainty evidence). The effect of antibiotics and anti‐TNF on withdrawal due to AEs is uncertain. Six per cent (3/48) of antibiotics and anti‐TNF participants withdrew due to an AE compared to 8% (4/52) of anti‐TNF and placebo participants (RR 0.82, 95% CI 0.19 to 3.45; 2 studies, low certainty evidence). Common adverse events included nausea, vomiting, upper respiratory tract infections, change in taste, fatigue and headache Authors' conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be modest and may not be clinically meaningful. High quality evidence suggests that there is no increased risk of adverse events with antibiotics compared to placebo. The effect of antibiotics on the risk of serious adverse events is uncertain. The effect of antibiotics on maintenance of remission in CD is uncertain. Thus, no firm conclusions regarding the efficacy and safety of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the efficacy and safety of antibiotics as therapy in CD Plain language summary Antibiotics for the treatment of Crohn's disease What is Crohn's disease? Crohn's disease (CD) is an inflammatory disorder that can affect any segment of the gastrointestinal tract from the mouth to the anus. Common symptoms of CD include fever, diarrhea, abdominal pain and weight loss. CD is characterized by periods of relapse when people experience symptoms and periods of remission when the symptoms stop. What are antibiotics? Antibiotics are medications used to treat bacterial infections. Antibiotics are designed to target specific bacterial populations and have different mechanisms of action to stop a bacterial population from growing or eradicate the bacteria. What is the purpose this study? Antibiotics are commonly used for managing patients with CD because the inflammatory process in the bowel was believed to be triggered by a specific bacterial pathogen. Elimination of this bacterial target would allow the inflammatory process to resolve. However, current clinical guidelines do not recommend use of antibiotic agents to induce or maintain clinical remission in patients with CD because there is no definitive evidence to suggest a benefit to using antibiotics in this way. How was this study performed? A systematic review of current literature was performed to determine whether antibiotic therapy is effective to induce or maintain remission in CD. An electronic search of several databases was performed and studies that met our inclusion criteria were selected for further evaluation. Statistical analyses were performed to determine which specific antibiotics had an overall benefit. What were the results? Several antibiotics, including ciprofloxacin, metronidazole, clarithromycin, rifaximin and cotrimoxazole, have been studied in CD. Most of the included studies were small in size. When we pooled antibiotics as a class, these drugs provided a modest benefit over placebo (i.e. a fake drug such as a sugar pill) for induction of remission and improvement of CD symptoms. For example, remission rates were 45% (253/542) in participants who received antibiotics compared to 36% (82/231) in participants who received placebo. We rated the quality of evidence supporting this outcome as high. Few studies assessed the use of antibiotics for maintenance of remission in CD. The impact of antibiotics on preventing relapse in CD is uncertain. Antibiotics do not appear to increase the risk of side effects when compared to placebo. Common side effects reported in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation, headache, change in taste and paraesthesia (pins and needles in the extremities). Serious side effects were not well reported in the studies and the impact of antibiotics on the risk of serious side effects is uncertain. Conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be very modest. High quality evidence suggests that there is no increased risk of side effects with antibiotics compared to placebo. The effect of antibiotics on the risk of serious side effects is uncertain. The effect of antibiotics on preventing relapse in CD is uncertain. Thus, no firm conclusions regarding the benefits and harms of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the harms and benefits of antibiotic therapy in CD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Townsend, CM, Parker, CE, MacDonald, JK, Nguyen, TM, Jairath, V, Feagan, BG, Khanna, R", "articleTypes": [], "doi": "10.1002/14651858.CD012730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.067Z" }, { "id": "be458a68-502e-4cda-9d23-04445bda16ad", "pmid": "", "title": "Xylitol‐containing products for preventing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is a highly prevalent chronic disease which affects the majority of people. It has been postulated that the consumption of xylitol could help to prevent caries. The evidence on the effects of xylitol products is not clear and therefore it is important to summarise the available evidence to determine its effectiveness and safety. Objectives To assess the effects of different xylitol‐containing products for the prevention of dental caries in children and adults. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 14 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , 2014, Issue 7), MEDLINE via OVID (1946 to 14 August 2014), EMBASE via OVID (1980 to 14 August 2014), CINAHL via EBSCO (1980 to 14 August 2014), Web of Science Conference Proceedings (1990 to 14 August 2014), Proquest Dissertations and Theses (1861 to 14 August 2014). We searched the US National Institutes of Health Trials Register ( http://clinicaltrials.gov ) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference and 95% confidence interval (CI). We used the continuous data to calculate prevented fractions (PF) and 95% CIs to summarise the percentage reduction in caries. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. As there were less than four studies included in the meta‐analysis, we used a fixed‐effect model. We planned to use a random‐effects model in the event that there were four or more studies in a meta‐analysis. Main results We included 10 studies that analysed a total of 5903 participants. One study was assessed as being at low risk of bias, two were assessed as being at unclear risk of bias, with the remaining seven being at high risk of bias. The main finding of the review was that, over 2.5 to 3 years of use, a fluoride toothpaste containing 10% xylitol may reduce caries by 13% when compared to a fluoride‐only toothpaste (PF ‐0.13, 95% CI ‐0.18 to ‐0.08, 4216 children analysed, low‐quality evidence). The remaining evidence on children, from small single studies with risk of bias issues and great uncertainty associated with the effect estimates, was insufficient to determine a benefit from xylitol products. One study reported that xylitol syrup (8 g per day) reduced caries by 58% (95% CI 33% to 83%, 94 infants analysed, low quality evidence) when compared to a low‐dose xylitol syrup (2.67 g per day) consumed for 1 year. The following results had 95% CIs that were compatible with both a reduction and an increase in caries associated with xylitol: xylitol lozenges versus no treatment in children (very low quality body of evidence); xylitol sucking tablets versus no treatment in infants (very low quality body of evidence); xylitol tablets versus control (sorbitol) tablets in infants (very low quality body of evidence); xylitol wipes versus control wipes in infants (low quality body of evidence). There was only one study investigating the effects of xylitol lozenges, when compared to control lozenges, in adults (low quality body of evidence). The effect estimate had a 95% CI that was compatible with both a reduction and an increase in caries associated with xylitol. Four studies reported that there were no adverse effects from any of the interventions. Two studies reported similar rates of adverse effects between study arms. The remaining studies either mentioned adverse effects but did not report any usable data, or did not mention them at all. Adverse effects include sores in the mouth, cramps, bloating, constipation, flatulence, and loose stool or diarrhoea. Authors' conclusions We found some low quality evidence to suggest that fluoride toothpaste containing xylitol may be more effective than fluoride‐only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse‐effects from such toothpastes. The effect estimate should be interpreted with caution due to high risk of bias and the fact that it results from two studies that were carried out by the same authors in the same population. The remaining evidence we found is of low to very low quality and is insufficient to determine whether any other xylitol‐containing products can prevent caries in infants, older children, or adults. Plain language summary Can xylitol used in products like sweets, candy, chewing gum and toothpaste help prevent tooth decay in children and adults? Review question This review has been produced to assess whether or not xylitol, a natural sweetener used in products such as sweets, candy, chewing gum and toothpaste, can help prevent tooth decay in children and adults. Background Tooth decay is a common disease affecting up to 90% of children and most adults worldwide. It impacts on quality of life and can be the reason for thousands of children needing dental treatment under general anaesthetic in hospital. However, it can easily be prevented and treated by good oral health habits such as brushing teeth regularly with toothpaste that contains fluoride and cutting down on sugary food and drinks. If left undisturbed, the unhelpful bacteria in the mouth ‐ which cause decay ‐ multiply and stick to the surfaces of teeth producing a sticky film. Then, when sugar is eaten or drank, the bad bacteria in the film are able to make acid resulting in tooth decay. Xylitol is a natural sweetener, which is equally as sweet as normal sugar (sucrose). As well as providing an alternative to sugar, it has other properties that are thought to help prevent tooth decay, such as increasing the production of saliva and reducing the growth of bad bacteria in the mouth so that less acid is produced. In humans, xylitol is known to cause possible side effects such as bloating, wind and diarrhoea. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 14 August 2014. It includes 10 studies published from 1991 to 2014 in which 7969 participants were randomised (5903 of whom were included in the analyses) to receive xylitol products or a placebo (a substitute without xylitol) or no treatment, and the amount of tooth decay was compared. One study included adults, the others included children aged from 1 month to 13 years. The products tested were the kind that are held in the mouth and sucked (lozenges, sucking tablets and sweets) or slowly released through a dummy/pacifier, as well as toothpastes, syrups, and wipes. Key results There is some evidence to suggest that using a fluoride toothpaste containing xylitol may reduce tooth decay in the permanent teeth of children by 13% over a 3 year period when compared to a fluoride‐only toothpaste. Over this period, there were no side effects reported by the children. The remaining evidence we found did not allow us to conclude whether or not any other xylitol‐containing products can prevent tooth decay in infants, older children, or adults. Quality of the evidence The evidence presented is of low to very low quality due to the small amount of available studies, uncertain results, and issues with the way in which they were conducted.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P; Moore, D; Ahmed, F; Sharif, MO; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD010743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "be4d0a2a-f178-4ef7-bd0e-7b8acca97e30", "pmid": "", "title": "Phytoestrogens for menopausal vasomotor symptoms", "imported": false, "abstract": "Abstract - Background Vasomotor symptoms, such as hot flushes and night sweats, are very common during the menopausal transition. Hormone therapy has traditionally been used as a highly effective treatment, but concerns about increased risk of some chronic diseases have markedly increased the interest of women in alternative treatments. Some of the most popular of these treatments are foods or supplements enriched with phytoestrogens—plant‐derived chemicals that have estrogenic action. Objectives To assess the efficacy, safety and acceptability of food products, extracts and dietary supplements containing high levels of phytoestrogens when compared with no treatment, placebo or hormone therapy for the amelioration of vasomotor menopausal symptoms (such as hot flushes and night sweats) in perimenopausal and postmenopausal women. Search methods Searches targeted the following electronic databases: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of randomised trials (29 July 2013), the Cochrane Register of Controlled Trials (CENTRAL; 29 July 2013), MEDLINE (inception to 29 July 2013), EMBASE (inception to 29 July 2013), AMED (1985 to 29 July 2013), PsycINFO (inception to 29 July 2013) and CINAHL (inception to 29 July 2013). Attempts were made to access grey literature by sending letters to pharmaceutical companies and performing searches of ongoing trial registers. Reference lists of included trials were also searched. Selection criteria Studies were included if they were randomised, included perimenopausal or postmenopausal participants with vasomotor symptoms (hot flushes or night sweats), lasted at least 12 weeks and provided interventions such as foods or supplements with high levels of phytoestrogens (not combined with other herbal treatments). Trials that included women who had breast cancer or a history of breast cancer were excluded. Data collection and analysis Selection of trials, extraction of data and assessment of quality were undertaken by at least two review authors. Most trials were too dissimilar for their results to be combined in a meta‐analysis, so these findings are provided in narrative 'Summary of results' tables. Studies were grouped into broad categories: dietary soy, soy extracts, red clover extracts, genistein extracts and other types of phytoestrogens. Five trials used Promensil, a red clover extract; results of these trials were combined in a meta‐analysis, and summary effect measures were calculated. Main results A total of 43 randomised controlled trials (4,364 participants) were included in this review. Very few trials provided data suitable for inclusion in a meta‐analysis. Among the five trials that yielded data assessing the daily frequency of hot flushes suitable for pooling, no significant difference overall was noted in the incidence of hot flushes between participants taking Promensil (a red clover extract) and those given placebo (mean difference (MD) ‐0.93, 95% confidence interval (CI) ‐1.95 to 0.10, I 2 = 31%). No evidence indicated a difference in percentage reduction in hot flushes in two trials between Promensil and placebo (MD 20.15, 95% CI ‐12.08 to 52.38, I 2 = 82%). Four trials that were not combined in meta‐analyses suggested that extracts with high (> 30 mg/d) levels of genistein consistently reduced the frequency of hot flushes. Individual results from the remaining trials were compared in broad subgroups such as dietary soy, soy extracts and other types of phytoestrogens that could not be combined. Some of these trials found that phytoestrogen treatments alleviated the frequency and severity of hot flushes and night sweats when compared with placebo, but many trials were small and were determined to be at high risk of bias. A strong placebo effect was noted in most trials, with a reduction in frequency ranging from 1% to 59% with placebo. No indication suggested that discrepant results were due to the amount of isoflavone in the active treatment arm, the severity of vasomotor symptoms or trial quality factors. Also, no evidence indicated that these treatments caused oestrogenic stimulation of the endometrium or the vagina or other adverse effects when used for up to two years. Authors' conclusions No conclusive evidence shows that phytoestrogen supplements effectively reduce the frequency or severity of hot flushes and night sweats in perimenopausal or postmenopausal women, although benefits derived from concentrates of genistein should be further investigated. Plain language summary Phytoestrogens for vasomotor menopausal symptoms Review question: This Cochrane review has evaluated whether phytoestrogen treatments reduce the number and severity of hot flushes and whether they are safe and acceptable. Background: Hormone therapy is an effective treatment for controlling the most common menopausal symptoms—hot flushes and night sweats. However, it is now recommended only in low doses given for the shortest possible time because of concerns about increased risk of some chronic diseases. Many women have started to use therapies that they perceive as 'natural' and safe, but they often do not have good information about the potential benefits and risks. Some of these therapies contain phytoestrogens—a group of plant‐derived chemicals that are thought to prevent or treat disease. Phytoestrogens are found in a wide variety of plants, some of which are foods, particularly soy, alfalfa and red clover. Study characteristics: This review found 43 RCTs conducted up to July 2013 that included 4,084 participants with hot flushes who were close to the menopause or were menopausal. Evidence obtained is current to July 2013. Key results: Some trials reported a slight reduction in hot flushes and night sweats with phytoestrogen‐based treatment. Extracts containing high levels of genistein (a substance derived from soy) appeared to reduce the number of daily hot flushes and need to be investigated further. Overall no indication suggested that other types of phytoestrogens work any better than no treatment. No evidence was found of harmful effects on the lining of the womb, stimulation of the vagina or other adverse effects with short‐term use. Quality of the evidence: Many of the trials in this review were small, of short duration and of poor quality, and the types of phytoestrogens used varied substantially.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lethaby, A; Marjoribanks, J; Kronenberg, F; Roberts, H; Eden, J; Brown, J", "articleTypes": [], "doi": "10.1002/14651858.CD001395.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "be5daca3-f918-4a64-9789-0f4a3417b620", "pmid": "", "title": "Toward Understanding Dopamine Receptor Contributions to Prediction Error and Reversal Learning in Anorexia Nervosa", "imported": false, "abstract": "Anorexia nervosa (AN) is an eating disorder associated with intense fear of weight gain, food refusal, and severe weight loss. AN has the highest mortality rate among the psychiatric disorders; however, little is known about biomarkers, and no medication has been approved for AN. Many individuals only partially recover, and treatment options, especially for the psychological components of the illness, are not very effective, highlighting the need for more effective treatments.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.256Z" }, { "id": "be6ab662-1fe9-41b3-bd7c-87123f897761", "pmid": "", "title": "Anticholinergic therapy for chronic asthma in children over two years of age", "imported": false, "abstract": "Abstract - Background In the intrinsic system of controlling airway calibre, the cholinergic (muscarinic) sympathetic nervous system has an important role. Anticholinergic, anti muscarinic bronchodilators such as ipratropium bromide are frequently used in the management of childhood airway disease. In asthma, ipratropium is a less potent bronchodilator than beta‐2 adrenergic agents but it is known to be a useful adjunct to other therapies, particularly in status asthmaticus. What remains unclear is the role of anticholinergic drugs in the maintenance treatment of chronic asthma. Objectives To determine the effectiveness of anticholinergic drugs in chronic asthma in children over the age of 2 years. Search methods The Cochrane Airways Group Specialised Register and reference lists of articles were searched. The most recent search was carried out in Febuary 2010. Selection criteria Randomised controlled trials in which anticholinergic drugs were given for chronic asthma in children over 2 years of age were included. Studies including comparison of: anticholinergics with placebo, and anticholinergics with any other drug were included. Data collection and analysis Eligibility for inclusion and quality of trials were assessed independently by two reviewers. Main results Eight studies met the inclusion criteria. Three papers compared the effects of anticholinergic drugs with placebo, and a meta‐analysis of these results demonstrated no statistically significant benefit of the use of anticholinergic drugs over placebo in any of the outcome measures used. The results of one of these trials could not be included in the meta‐analysis but the authors did report significantly lower symptom scores with inhaled anticholinergics compared with placebo. However, there was no significant difference between ipratropium bromide and placebo in the percentage of symptom‐free nights or days. Two trials studied the effects of anticholinergics on bronchial hyper responsiveness to histamine, by measuring the provocation dose of histamine needed to cause a fall of 20 % in FEV1 (PD 20). One study (comparing anticholinergics with placebo) reported a statistically significant increase in PD 20 but this was not found in another study (comparing anticholinergics with a beta‐2 agonist). Both trials also examined the effect of anticholinergic drugs on diurnal variation in peak expiratory flow rate (PEFR) and reported no significant effect. Two studies compared the addition of an anticholinergic drug to a beta‐2 agonist with the beta‐2 agonist alone. Both trials failed to show any significant benefit from the long term use of combined anticholinergics with beta‐2 agonists compared with beta‐2 agonists alone. One trial compared the effects of oral and inhaled anticholinergic drugs with placebo. No statistically significant differences were found in any of the outcome measures except for a higher FEV1 / VC ratio and RV / TLC ratio with oral anticholinergic therapy when compared with placebo. Authors' conclusions The present review summarises the best evidence available to date. Although there were some small beneficial findings in favour of anticholinergic therapy, there is insufficient data to support the use of anticholinergic drugs in the maintenance treatment of chronic asthma in children. Plain language summary Anticholinergic drugs versus either placebo or other medications for children over two years of age with asthma Anticholinergic drugs are widely used in the management of both acute and chronic asthma in children. Their effect is achieved through relief of narrowing of the airways that occurs in asthma. Current guidelines for the management of chronic asthma advise that anticholinergic drugs may be used if children are already on high dose inhaled steroids. This study undertook a comprehensive search of the literature unrestricted by country of publication or language. Unfortunately small numbers of relevant trials were found and these were of variable quality. This review found that although anticholinergic drugs are well tolerated, in children over two years of age, there is not enough data to be sure if they are better than placebo in terms of effects on lung function or symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "McDonald, N, Bara, A, McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD003535", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.100Z" }, { "id": "be755216-e880-4b7c-a634-7e3b64733677", "pmid": "", "title": "Models for delivery and co‐ordination of primary or secondary health care (or both) to older adults living in aged care facilities", "imported": false, "abstract": "Abstract - Background The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co‐ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost‐effectiveness of alternative models of providing health care to ACF residents. Objectives Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost‐effectiveness of the alternative models. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included individual and cluster‐randomised trials, and cost/cost‐effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co‐ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co‐ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline‐recommended care, health‐related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work‐related satisfaction and work‐related stress of ACF staff. Data collection and analysis Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. Main results We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co‐ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low‐certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I 2 = 53%; 8 trials, 1263 participants; low‐certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low‐certainty evidence) and adherence to guideline‐recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health‐related quality of life of ACF residents (MD ‐0.016, 95% CI ‐0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low‐certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate‐certainty evidence). We did not pool the cost‐effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co‐ordination of care), we are uncertain of the cost‐effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. Authors' conclusions Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health‐related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost‐effectiveness of alternative models of care due to the limited, disparate data available. Plain language summary Alternative ways to organise delivery of health care to older adults living in aged care facilities What is the aim of this review? This Cochrane review set out to determine if providing residents of aged care facilities (ACF) with the same care as usual care, just delivered in a different way (alternative models of care), is better in terms of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs. For example, are multidisciplinary teams (alternative model) a better way of delivering care to residents of ACFs compared to providing care through individual practitioners (usual care)? Key messages Compared to usual care, alternative models of care may reduce unplanned hospital admissions, but may make little or no difference to the number of emergency department visits and the health‐related quality of life of ACF residents, and probably make little or no difference to mortality. We are uncertain of the effect of alternative models of care on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guideline‐recommended care. Importantly, we are uncertain whether alternative models of care are cost‐effective due to the limited, conflicting data available. Studies differed widely in terms of intervention characteristics, health care settings and descriptions of usual care and this hindered many analyses in this review. Future studies should provide a detailed description of what intervention and usual care constitutes in their setting. What was studied in this review? The world's population is ageing and the number of persons living in residential ACFs is growing worldwide. ACF residents are often frail, elderly people with multiple health conditions that require intensive medical care. When an ACF is not able to deliver appropriate health care, residents are often transferred to a hospital for treatment. Such transfers are often burdensome and traumatic for ACF residents and their families and may lead to increased costs. Alternative models of care, designed to provide care that is better co‐ordinated and more timely, aim to reduce unnecessary hospital transfers and improve residents' well‐being. Alternative models of care may be more expensive to implement (e.g. employ more healthcare personnel) but may lead to cost savings down the line (e.g. more residents receive care in ACF, avoiding costly hospital transfers). The synthesised evidence in this review compares the effect of alternative models of care with usual care on the number of emergency department transfers, unplanned hospital admissions, adverse events, adherence to clinical guideline‐recommended care, health‐related quality of life, mortality and costs (i.e. does the model deliver better value for money compared to usual care). What are the main results of this review? We identified 40 studies (with in total 21,787 participants; three studies did not provide number of participants) conducted in 15 countries. The study participants differed with respect to their health needs. In 11 studies, the alternative model of care was aimed at all ACF residents (with mixed health needs/conditions). Other studies included residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers; 13 studies) or residents requiring a specific type of care (e.g. residents after discharge from a hospital; four studies). In most (31) of the studies, the alternative model of care focused on 'co‐ordination of care'. In three studies, the alternative models of care focused on 'who provides care' (e.g. nurse practitioner‐led care using best practice guide instead of GP‐led care) and in two studies, alternative models of care focused on 'where care is provided' (i.e. investigating alternative locations for the provision of care, for example within ACF versus outside of ACF). In four studies, the alternative models of care focused on the use of information and communications technology for the provision of care to ACF residents. In all studies, the alternative model of care was compared with usual care. We found that, compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits; however, the number of unplanned hospital admissions may be reduced. We are uncertain of the effect of alternative models of care on adverse events and adherence to clinical guideline‐recommended care compared with usual care. Alternative models of care may have little or no effect on ACF residents' health‐related quality of life and probably make little or no difference to mortality. Based on the findings of five studies that provided full economic evaluations (all alternative models of care focused on 'co‐ordination of care'), we are uncertain whether alternative models of care are more cost‐effective than usual care. What are the limitations of the evidence? Our confidence in the evidence is limited because participants in the studies were aware of which treatment they were getting. Usual care was poorly described by most of the studies. Usual care differs across countries and regions, so this lack of information limits our interpretation, contextualisation and generalisation of the comparisons. Not all of the studies provided data about outcomes we were looking to assess. How up‐to‐date is this review? The review authors searched for studies published up to October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Putrik, P, Grobler, L, Lalor, A, Ramsay, H, Gorelik, A, Karnon, J, Parker, D, Morgan, M, Buchbinder, R, O'Connor, D", "articleTypes": [], "doi": "10.1002/14651858.CD013880.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.800Z" }, { "id": "be8157d8-2c0a-4fe0-85db-8046ceffa470", "pmid": "", "title": "Obesity and Lipids: a Matter of Taste? Impact of Bariatric Surgery on Taste Receptors", "imported": false, "abstract": "The purpose of the protocol is to determine the impact of bariatric surgery on taste receptors and taste perceptions and to precise the factors implicated in taste alterations in 50 obese patients before and 6 months after bariatric surgery (25 Roux Y gastric bypass and 25 sleeve gastrectomy).", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.252Z" }, { "id": "be82de22-85b6-4d6a-a399-61aef427274c", "pmid": "", "title": "Omega‐3 fatty acids for depression in adults", "imported": false, "abstract": "Abstract - Background Major depressive disorder (MDD) is highly debilitating, difficult to treat, has a high rate of recurrence, and negatively impacts the individual and society as a whole. One potential treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, some other seafood, and some nuts and seeds. Various lines of evidence suggest a role for n‐3PUFAs in MDD, but the evidence is far from conclusive. Reviews and meta‐analyses clearly demonstrate heterogeneity between studies. Investigations of heterogeneity suggest different effects of n‐3PUFAs, depending on the severity of depressive symptoms, where no effects of n‐3PUFAs are found in studies of individuals with mild depressive symptomology, but possible benefit may be suggested in studies of individuals with more severe depressive symptomology. Hence it is important to establish their effectiveness in treating MDD. This review updates and incorporates an earlier review with the same research objective (Appleton 2015). Objectives To assess the effects of n‐3 polyunsaturated fatty acids (also known as omega‐3 fatty acids) versus a comparator (e.g. placebo, antidepressant treatment, standard care, no treatment, wait‐list control) for major depressive disorder (MDD) in adults. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO together with trial registries and grey literature sources (to 9 January 2021). We checked reference lists and contacted authors of included studies for additional information when necessary. Selection criteria We included studies in the review if they: used a randomised controlled trial design; provided n‐3PUFAs as an intervention; used a comparator; measured depressive symptomology as an outcome; and were conducted in adults with MDD. Primary outcomes were depressive symptomology (continuous data collected using a validated rating scale) and adverse events. Secondary outcomes were depressive symptomology (dichotomous data on remission and response), quality of life, and non‐completion of studies. Data collection and analysis We used standard methodological procedures as expected by Cochrane. We assessed the certainty of the evidence using GRADE criteria. Main results The review includes 35 relevant studies: 34 studies involving a total of 1924 participants investigated the impact of n‐3PUFA supplementation compared to placebo, and one study involving 40 participants investigated the impact of n‐3PUFA supplementation compared to antidepressant treatment. For the placebo comparison, n‐3PUFA supplementation resulted in a small to modest benefit for depressive symptomology, compared to placebo: standardised mean difference (SMD) (random‐effects model) −0.40 (95% confidence interval (CI) −0.64 to −0.16; 33 studies, 1848 participants; very low‐certainty evidence), but this effect is unlikely to be clinically meaningful. An SMD of 0.40 represents a difference between groups in scores on the HDRS (17‐item) of approximately 2.5 points (95% CI 1.0 to 4.0), where the minimal clinically important change score on this scale is 3.0 points. The confidence intervals include both a possible clinically important effect and a possible negligible effect, and there is considerable heterogeneity between studies. Sensitivity analyses, funnel plot inspection and comparison of our results with those of large well‐conducted trials also suggest that this effect estimate may be biased towards a positive finding for n‐3PUFAs. Although the numbers of individuals experiencing adverse events were similar in intervention and placebo groups (odds ratio (OR) 1.27, 95% CI 0.99 to 1.64; 24 studies, 1503 participants; very low‐certainty evidence), the confidence intervals include a small decrease to a modest increase in adverse events with n‐3PUFAs. There was no evidence for a difference between n‐3PUFA and placebo groups in remission rates (OR 1.13, 95% CI 0.74 to 1.72; 8 studies, 609 participants, low‐certainty evidence), response rates (OR 1.20, 95% CI 0.80 to 1.79; 17 studies, 794 participants; low‐certainty evidence), quality of life (SMD −0.38 (95% CI −0.82 to 0.06), 12 studies, 476 participants, very low‐certainty evidence), or trial non‐completion (OR 0.92, 95% CI 0.70 to 1.22; 29 studies, 1777 participants, very low‐certainty evidence). The evidence on which these results are based was also very limited, highly heterogeneous, and potentially biased. Only one study, involving 40 participants, was available for the antidepressant comparison. This study found no differences between treatment with n‐3PUFAs and treatment with antidepressants in depressive symptomology (mean difference (MD) −0.70, 95% CI −5.88 to 4.48), rates of response to treatment (OR 1.23, 95% CI 0.35 to 4.31), or trial non‐completion (OR 1.00, 95% CI 0.21 to 4.71). Confidence intervals are however very wide in all analyses, and do not rule out important beneficial or detrimental effects of n‐3PUFAs compared to antidepressants. Adverse events were not reported in a manner suitable for analysis, and rates of depression remission and quality of life were not reported. Authors' conclusions At present, we do not have sufficient high‐certainty evidence to determine the effects of n‐3PUFAs as a treatment for MDD. Our primary analyses may suggest a small‐to‐modest, non‐clinically beneficial effect of n‐3PUFAs on depressive symptomology compared to placebo; however the estimate is imprecise, and we judged the certainty of the evidence on which this result is based to be low to very low. Our data may also suggest similar rates of adverse events and trial non‐completion in n‐3PUFA and placebo groups, but again our estimates are very imprecise. Effects of n‐3PUFAs compared to antidepressants are very imprecise and uncertain. More complete evidence is required for both the potential positive and negative effects of n‐3PUFAs for MDD. Plain language summary Omega‐3 fatty acids for depression in adults Why is this review important? Major depressive disorder (MDD) is characterised by depressed mood or a markedly decreased pleasure or interest in all activities, or both. It has negative impacts on the individual and on society, often over the long term. One possible treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, in some other seafood and in some nuts and seeds. Various lines of evidence suggest that n‐3PUFAs may impact on depressive symptoms, but a lot of studies have different findings, making it difficult to draw conclusions. Who will be interested in this review? Health professionals, including general practitioners, mental health and psychiatric specialists; individuals with MDD; and the people around them. What questions does this review aim to answer? Do n‐3PUFAs, compared to an alternative, have an effect on depressive symptoms, negative side effects, rates of recovery, quality of life, and rates of study non‐completion, in individuals with MDD? Which studies were included in the review? This review is an update of earlier work (Appleton 2015), using the same methods. We searched scientific databases for all randomised controlled trials in adults with MDD, where individuals received either n‐3PUFAs or an alternative, that were completed up to January 2021. We have included 35 relevant studies: 34 of them involving 1924 people compared the effects of n‐3PUFAs with those of placebo, and one study involving 40 people compared the effects of n‐3PUFAs with those of antidepressants. All studies were of direct relevance to our review, but we considered the certainty of the evidence to be low to very low. What does the evidence from the review tell us? At present, we do not have enough high quality evidence to determine the effects of n‐3PUFAs as a treatment for MDD. We found a small‐to‐modest positive effect of n‐3PUFAs compared to placebo, but the size of this effect is unlikely to be meaningful to people with MDD, and we considered the evidence to be of low or very low certainty, with many differences between studies. There was also insufficient high quality evidence to determine the effects of n‐3PUFAs on negative side effects or numbers not completing studies. What should happen next? We need more evidence, particularly to explain the differences between study findings, e.g. by looking at individuals who may or may not benefit from n‐3PUFAs. Future studies should also compare n‐3PUFAs with usual antidepressant treatment, and investigate the way these treatments may work.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Appleton, KM, Voyias, PD, Sallis, HM, Dawson, S, Ness, AR, Churchill, R, Perry, R", "articleTypes": [], "doi": "10.1002/14651858.CD004692.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.766Z" }, { "id": "be955146-3734-4a92-bb81-556992402bb4", "pmid": "", "title": "Alarm interventions for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs. Objectives To assess the effects of enuresis alarms for treating enuresis in children. Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old. Data collection and analysis Two review authors independently assessed risk of bias and extracted data. Main results We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) −2.68, 95% confidence interval (CI) −4.59 to −0.78; 4 trials, 127 children; low‐quality evidence). Low‐quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post‐treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low‐quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD −0.96, 95% CI −2.32 to 0.41; 1 trial, 47 children; very low‐quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low‐quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post‐treatment. Compared with control alarms, code‐word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate‐quality evidence) but there is probably little to no difference in the number of children remaining dry post‐treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate‐quality evidence). Very low‐quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry‐bed training, and star chart plus rewards) (MD ‐0.81, 95% CI ‐2.01 to 0.38; low‐quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low‐quality evidence) and may slightly increase the number of children remaining dry post‐treatment (RR 1.39, 95% CI 0.81 to 2.41; low‐quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD −0.64, 95% CI −1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low‐quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post‐treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate‐quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post‐treatment, because the quality of evidence is very low. Due to very low‐quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD −0.88, 95% CI −0.38 to −1.38; 2 trials, 156 children; low‐quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low‐quality evidence) and the number of children remaining dry post‐treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low‐quality evidence) compared with desmopressin alone. Alarm plus dry‐bed training may increase the number of children achieving a complete response compared to dry‐bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low‐quality evidence). It is unclear if there is any difference in the number of children remaining dry post‐treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low‐quality evidence). Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code‐word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate‐quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate‐quality evidence). Very low‐quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments. Authors' conclusions Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately‐powered trials with robust randomisation are still needed to determine the full effect of alarm therapy. Plain language summary Alarm interventions for nocturnal enuresis (bedwetting) in children Review question Is alarm training an effective treatment for bedwetting in children? Background Bedwetting is common in childhood and affects up to 20% of five‐year‐olds. Although children may spontaneously recover from this, bedwetting can have significant social, emotional and psychological effects on the child and their family. Treatments for bedwetting include alarms (activated by urination), behavioural interventions and drugs. How up‐to‐date is this review? The evidence is current up to 25 June 2018. Study characteristics This review includes 74 trials involving 5983 children. Study funding sources Three of the studies included in the review were funded or supported by a pharmaceutical company. Key results Alarms may be better than no treatment in terms of reducing the number of wet nights a week and increasing the number of children achieving 14 consecutive dry nights. Alarms may increase the number of children remaining dry after stopping treatment, compared to no treatment. We are uncertain if there is any difference between alarms and behavioural interventions (such as bladder training), or between alarms and desmopressin medication in terms of reducing the number of wet nights a week, increasing the number of children achieving 14 consecutive dry nights and increasing the number of children remaining dry after stopping treatment. We are uncertain whether alarms reduce the number of wet nights more than placebo drugs, other types of alarms, tricyclics medication, or various treatments such as hypnotherapy or restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin alone. It may increase the number of children achieving 14 consecutive dry nights and increase the number of children remaining dry after stopping treatment. Alarm plus dry‐bed training may increase the number of children achieving 14 consecutive dry nights compared to dry‐bed training alone, but we are uncertain if the response is maintained after stopping treatment. Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Alarm therapy probably reduces the number of children experiencing adverse events compared with desmopressin. We think there is probably a slight increase in adverse events between code‐word alarms and standard alarms but until we have more evidence from more children we cannot be certain about this. We are uncertain about the safety of alarm therapy compared to other treatments, because the quality of evidence is very low. Quality of the evidence The quality of the evidence means that, in general, the level of certainty in our conclusions is low. Authors' conclusions Alarm therapy may be more effective than no treatment, but due to the low‐quality evidence we do not know how much alarm therapy is more effective than none at all. Adding alarm therapy to desmopressin may be more effective than desmopressin alone. Despite the large number of trials we identified, the low certainty of the evidence means that we cannot tell from these studies whether or not alarm therapy is better than most other therapies for reducing bedwetting in children. We cannot be sure about its effects until there are better‐designed trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Caldwell, PHY, Codarini, M, Stewart, F, Hahn, D, Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002911.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.791Z" }, { "id": "be9d84d6-2c4e-478b-8d86-2ee452376187", "pmid": "", "title": "Topical cystic fibrosis transmembrane conductance regulator gene replacement for cystic fibrosis‐related lung disease", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is caused by a defective gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR), and is characterised by chronic lung infection resulting in inflammation and progressive lung damage that results in a reduced life expectancy. Objectives To determine whether topical CFTR gene replacement therapy to the lungs in people with cystic fibrosis is associated with improvements in clinical outcomes, and to assess any adverse effects. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Date of most recent search: 05 May 2016. An additional search of the National Institutes for Health (NIH) Genetic Modification Clinical Research Information System (GeMCRIS) was also performed for the years 1992 to 2015. Date of most recent search: 20 April 2016. Selection criteria Randomised controlled studies comparing topical CFTR gene delivery to the lung, using either viral or non‐viral delivery systems, with placebo or an alternative delivery system in people with confirmed cystic fibrosis. Data collection and analysis The authors independently extracted data and assessed study quality. Authors of included studies were contacted and asked for any available additional data. Meta‐analysis was limited due to differing study designs. Main results Four randomised controlled studies met the inclusion criteria for this review, involving a total of 302 participants lasting from 29 days to 13 months; 14 studies were excluded. The included studies differed in terms of CFTR gene replacement agent and study design, which limited the meta‐analysis. One study only enrolled adult males, the remaining studies included both males and females aged 12 years and over. Risk of bias in the studies was moderate. Random sequence generation and allocation concealment was only described in the more recent study; the remaining three studies were judged to have an unclear risk of bias. All four studies documented double‐blinding to the intervention, but there is some uncertainty with regards to participant blinding in one study. Some outcome data were missing from all four studies. There were no differences in either the number of respiratory exacerbations or the number of participants with an exacerbation between replacement therapy or placebo groups at any time point. Meta‐analysis of most respiratory function tests showed no difference between treatment and placebo groups, but the smallest study (n = 16) reported forced vital capacity (litres) increased more in the placebo group at up to 24 hours. A further study reported a significant improvement in forced expiratory volume at one second (litres) at 30 days after participants had received their first dose of favouring the gene therapy agent, but this finding was not confirmed when combined with at second study in the meta‐analysis. The more recent study (n = 140) demonstrated a small improvement in forced vital capacity (per cent predicted) at two and three months and again at 11 and 12 months for participants receiving CFTR gene replacement therapy compared to those receiving placebo. The same study reported a significant difference in the relative change in forced expiratory volume at one second (per cent predicted) at two months, three months and 12 months. One small study reported significant concerns with \"influenza‐like\" symptoms in participants treated with CFTR gene replacement therapy; this was not reported on repeated use of the same agent in a larger recent study. There was no other evidence of positive impact on outcomes, in particular improved quality of life or reduced treatment burden. Two studies measured ion transport in the lower airways; one (n = 16) demonstrated significant changes toward normal values in the participants who received gene transfer agents (P < 0.0001), mean difference 6.86 (95% confidence interval 3.77 to 9.95). The second study (n = 140) also reported significant changes toward normal values (P = 0.032); however, aggregate data were not available for analysis. In the most recent study, there was also evidence of increased salt transport in cells obtained by brushing the lower airway. These outcomes, whilst important, are not of direct clinical relevance. Authors' conclusions One study of liposome‐based CFTR gene transfer therapy demonstrated some improvements in respiratory function in people with CF, but this limited evidence of efficacy does not support this treatment as a routine therapy at present. There was no evidence of efficacy for viral‐mediated gene delivery. Future studies need to investigate clinically important outcome measures. Plain language summary Replacing the defective gene is a potential treatment for progressive lung disease in people with cystic fibrosis Review question We reviewed the evidence about the effect of delivering the correct copy of the cystic fibrosis transmembrane conductance regulator (CFTR) gene directly to the lungs of people with cystic fibrosis in order to treat progressive lung disease. Background In cystic fibrosis the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. People with cystic fibrosis suffer from progressive lung infection and damage which reduces life expectancy. Agents which can deliver a correct copy of the faulty CFTR gene to cells in the lungs may be an effective treatment. Search date The evidence is current to: 20 April 2016. Study characteristics We found four studies with 302 people to include in this review. The studies lasted from 29 days to 13 months. Three of these studies included both men and women aged 12 years and over and one study only included adult men. The studies compare gene therapy to a dummy treatment (placebo) both of which are inhaled as a mist into the lungs. The studies were of different designs and used different agents. This meant we could not combine their results. Key results Three of the studies, including the largest and most recent study, showed an improvement in some measures of lung function in people with CF given gene therapy. We did not find that any more clinically relevant outcomes such as quality of life, treatment burden or flare‐up of lung disease had improved with treatment. In one study \"influenza‐like\" symptoms were more common in people who received CFTR gene transfer agents but this was not reported when the agent was used repeatedly in a larger study. In those people who took the gene transfer agents, molecules and salt in their lower airways moved more like they do in healthy people. The limited evidence of benefit does not support this as a routine therapy at present. We recommend that future studies are designed and reported clearly so that their results can be incorporated into a systematic review. Quality of the evidence The most recent study provided detailed information on how the people were put into different treatment groups completely at random, and so we are satisfied that those taking part in the study had an equal chance of being in either group (CFTR gene transfer agent or placebo) and that no one could work out which group the next person would be put into. The other studies reported that people were put into groups at random but did not specify how, so we cannot be sure that there was an equal chance of them being in either group. We believe that the clinicians running all the studies did not know which treatment the people taking part were receiving and that in three of the studies those taking part did not know either, but we could not be sure whether the people taking part in the latest study knew which treatment they were receiving and what effect this knowledge might have on results. Unfortunately, the studies did not report all their results clearly; sometimes results were not reported in a way that we could use for the review and sometimes they were not reported at all. This reduced the certainty with which we judged the overall results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Perry, LA; Penny‐Dimri, JC; Aslam, AA; Lee, TWR; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD005599.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "bea19666-5b61-4e86-a231-9d09ae9f1815", "pmid": "", "title": "Needle size for vaccination procedures in children and adolescents", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane Review first published in 2015. The conclusions have not changed. Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller the diameter of the needle (e.g. a 23 G needle is 0.6 mm in diameter, whereas a 25 G needle is 0.5 mm in diameter). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. Guidelines conflict regarding the sizes of needles that should be used for vaccinating children and adolescents. Objectives To assess the effects of using needles of different sizes for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration). Search methods We updated our searches of CENTRAL, MEDLINE, Embase, and CINAHL to October 2017. We also searched proceedings of vaccine conferences and two trials registers. Selection criteria Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years. Data collection and analysis Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system. Main results We included five trials involving 1350 participants in the original review. The updated review identified no new trials. The evidence from two small trials (one trial including infants and one including adolescents) was insufficient to allow any definitive statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity. The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials included infants predominantly aged from two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole‐cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP‐Hib) and hepatitis B (DTwP‐Hib‐Hep B) antigen components. Primary outcomes Incidence of vaccine‐preventable diseases: No trials reported this outcome. Procedural pain and crying: Using a wider gauge 23 G 25 mm needle may slightly reduce procedural pain (low‐quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate‐quality evidence) compared with a narrower gauge 25 G 25 mm needle (one trial, 320 participants). The effects are probably not large enough to be clinically relevant. Secondary outcomes Immune response: There is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between use of 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP‐Hib vaccine at ages two, three, and four months (moderate‐quality evidence, one trial, numbers of participants in analyses range from 309 to 402. The immune response to the pertussis antigen was not measured). Severe and non‐severe local reactions: 25 mm needles (either 25 G or 23 G) probably lead to fewer severe and non‐severe local reactions after DTwP‐Hib vaccination compared with 25 G 16 mm needles (moderate‐quality evidence, one trial, 447 to 458 participants in analyses). We estimate that one fewer infant will experience a severe local reaction (extensive redness and swelling) after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat for an additional beneficial outcome (NNTB) with a 25 G 25 mm needle: 25 (95% confidence interval (CI) 15 to 100); NNTB with a 23 G 25 mm needle: 25 (95% CI 17 to 100)). We estimate that one fewer infant will experience a non‐severe local reaction (any redness, swelling, tenderness, or hardness (composite outcome)) at 24 hours after the first vaccine dose for every 5 or 6 infants vaccinated with a 25 mm rather than a 16 mm needle (NNTB with a 25 G 25 mm needle: 5 (95% CI 4 to 10); NNTB with a 23 G 25 mm needle: 6 (95% CI 4 to 13)). The results are similar after the second and third vaccine doses. Using a narrow gauge 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with a wider gauge 23 G 25 mm needle, but the effect estimates are imprecise (low‐quality evidence, two trials, 100 to 459 participants in analyses). Systemic reactions: The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of postvaccination fever and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence. Authors' conclusions Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole‐cell pertussis antigen component. These vaccines are predominantly used in low‐ and middle‐income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain. Plain language summary Needle size for vaccination procedures in children and adolescents Background Vaccines contain antigens that make the body's immune system produce antibodies that can protect against disease, which is known as an immune response. Antigens are modified or partial forms of the virus, bacteria, or toxin that cause the disease that the vaccine protects against. Because the antigen is altered from its original form, it cannot cause disease, but it can produce an immune response. Vaccines can be injected using needles of different lengths and gauges. The needle gauge (G) refers to the width (diameter) of the needle. The higher the gauge number, the narrower the needle. For example, a 25 G needle is approximately 0.5 mm in diameter and is narrower than a 23 G needle, which has a diameter of 0.6 mm. Guidelines conflict regarding the lengths and gauges of needles that should be used for vaccinating children and adolescents. Review question We wanted to find out if the length and gauge of needles used to vaccinate children and adolescents has an influence on the: 1) immune response to the injected vaccine; 2) pain experienced during the vaccination procedure; 3) occurrence of reactions such as swelling, tenderness, and redness at the site where the vaccine is given; fever (high temperature); and other side effects that can occur after vaccination. Quality of the evidence We included five studies involving 1350 people. We rated the quality of the evidence from studies as very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. There were problems with the design of some studies, and data were insufficient to answer some parts of our review question. The quality of the evidence from two studies was too low to allow us to draw any conclusions about the effects of the needles compared in the studies. However, there was sufficient evidence from the remaining three studies to allow us to reach conclusions. Study characteristics The three studies that allowed us to reach conclusions involved 1135 healthy infants aged mostly between two and six months. The infants were vaccinated in the thigh with either 25 G 25 mm (narrow, long needles), 23 G 25 mm (wide, long needles), or 25 G 16 mm needles (narrow, short needles). The needles were inserted at right angles (90° angle) into the skin and pushed down into the muscle of the thigh. The vaccines injected were combination vaccines designed to protect against several diseases including diphtheria (D), tetanus (T), whooping cough (pertussis), and Haemophilus influenzae type b disease (Hib). The vaccines all contained whole‐cell pertussis (wP) vaccine antigens. These vaccines are commonly used in low‐ and middle‐income countries but not in high‐income countries. Our review findings are therefore most relevant to low‐ and middle‐income countries. Key findings We found moderate‐quality evidence that infants vaccinated in the thigh with 25 mm needles probably have fewer severe reactions (extensive redness and swelling in the thigh) after DTwP‐Hib vaccination than infants vaccinated with 16 mm needles. We also found that the longer needles probably lead to fewer non‐severe reactions such as mild swelling, tenderness, and redness after vaccination. The immune response to the vaccine is probably similar with the long and the short needles. We found low‐quality evidence that the wide, long needle may slightly reduce the pain of the vaccination procedure compared with the narrow, long needle. We found moderate‐quality evidence that the wide, long needle probably slightly reduces the duration of crying immediately following vaccination compared with the narrow, long needle. The differences in pain and crying between use of the wide and narrow needles are probably too small to be of any practical importance. We found low‐quality evidence that infants vaccinated with the narrow, long needle may have slightly fewer non‐severe reactions than infants vaccinated with the wide, long needle. We do not know if needle size has an effect on fever or other reactions that sometimes occur after vaccination including drowsiness, loss of appetite, and vomiting due to the very low quality of the evidence. The evidence in our review is current to October 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Beirne, PV; Hennessy, S; Cadogan, SL; Shiely, F; Fitzgerald, T; MacLeod, F", "articleTypes": [], "doi": "10.1002/14651858.CD010720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "bea9304f-2877-4253-8217-caf41d2e5ee3", "pmid": "", "title": "Herbal interventions for chronic asthma in adults and children", "imported": false, "abstract": "Abstract - Background Herb and plant based preparations are a popular treatment for asthma, although there remain concerns as to their efficacy and safety. In Western societies, motivations for using such treatments may be both positive and negative, with their perceived safety and dissatisfaction with conventional medicine among them. In China such treatments are more commonly used and many compounds considered 'conventional' are derived from herbs or plants. Objectives To assess the efficacy and safety of herb and plant extracts in the management of chronic asthma. Search methods The Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, EMBASE and AMED were searched with pre‐defined terms. Searches are current as of February 2007. Selection criteria Randomised placebo controlled trials of any herb or plant extract were eligible. Study participants had to have a primary diagnosis of asthma. Studies in both adults and children were eligible for the review. Data collection and analysis Two reviewers assessed studies for suitability. Data were extracted and double‐checked. Main results Twenty‐seven studies (29 experimental groups) met the review entry criteria, randomising a total of 1925 participants. The studies identified assessed the effects of 21 different herbal preparations. Study quality varied considerably, and the sample sizes were often small. For primary outcomes (exacerbations, steroids use and lung function measurements): Two out of six studies reporting change in FEV1 were positive, with very few data available on the frequency of exacerbations. One study which did report these data was negative. Health‐related quality of life was only measured in one trial. Authors' conclusions The evidence base for the effects of herbal treatments is hampered by the variety of treatments assessed, poor reporting quality of the studies and lack of available data. The data that are available from the studies provide only a small insight into the long‐term efficacy and harm profiles of these treatments. The absence of common endpoint measurements limits the validity of our findings further. Positive findings in this review warrant additional well‐designed trials in this area. Plain language summary Herbal interventions for chronic asthma in adults and children Chronic asthma is a inflammatory disease of the airways characterised by wheeze and breathlessness. Drug therapy is usually used to control symptoms but complementary medicine is often used, including herbal treatments, and the efficacy and safety of such treatments is not clear. We reviewed evidence from 27 trials covering 21 different herbal treatments in both adults and children from both in‐patient and out‐patient settings. In general, the reporting of trials was poor. The outcomes measured by the trials varied considerably which made it difficult to compare the results of studies that did look at the same treatment. On the basis of the available evidence it is not possible to show whether any of these herbal treatments can improve asthma symptoms. Further trials of high quality are needed to assess the use of herbal treatments in asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Arnold, E; Clark, CE; Lasserson, TJ; Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD005989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "beb1605a-c55b-4cd9-a7d7-5382a9e83110", "pmid": "", "title": "Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age‐inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long‐term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega‐3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents. Objectives To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents. Search methods We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references. Selection criteria We included randomised and quasi‐randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD. Data collection and analysis We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow‐up; and cost. We used GRADE to assess the certainty of evidence for each outcome. Main results We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross‐over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega‐3 PUFA, six used a combined omega‐3/omega‐6 supplement, and two used an omega‐6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co‐intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega‐3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega‐3 PUFA plus atomoxetine to atomoxetine; omega‐3 PUFA plus physical training to physical training; and an omega‐3 or omega‐6 supplement plus methylphenidate to methylphenidate; and two trials compared omega‐3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months. Although we found low‐certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high‐certainty evidence that PUFA had no effect on parent‐rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) −0.08, 95% CI −0.24 to 0.07; 16 studies, 1166 participants). There was also high‐certainty evidence that parent‐rated inattention (medium‐term: SMD −0.01, 95% CI −0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium‐term: SMD 0.09, 95% CI −0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo. There was moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate‐certainty evidence that medium‐term loss to follow‐up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants). Authors' conclusions Although we found low‐certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high‐certainty evidence that PUFA had no effect on total parent‐rated ADHD symptoms. There was also high‐certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups. We found moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate‐certainty evidence that follow‐up was similar between groups. It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times. Plain language summary Polyunsaturated fatty acids (PUFA) supplements for attention deficit hyperactivity disorder (ADHD) in children and adolescents What is ADHD? Attention deficit hyperactivity disorder (ADHD) is a common problem in children and adolescents. Those affected may struggle to concentrate, feel restless, or act on impulse. As a result of these difficulties, ADHD can cause long‐term social, academic, and mental health problems. Medicines are the most frequently used treatments for ADHD, but they are not always effective and can cause unwanted side effects. What are polyunsaturated fatty acids (PUFA)? Polyunsaturated fatty acids (PUFA) are a type of fat. They are necessary for normal brain development and are found in foods such as fish (omega‐3 PUFA) and vegetable oils (omega‐6 PUFA). How could PUFA be useful in ADHD? There is some evidence that ADHD could be related to low levels of PUFA, in particular omega‐3 PUFA. PUFA supplements may therefore improve ADHD symptoms, behavioural problems, and related mental health symptoms such as anxiety and depression. What did we want to find out? We wanted to know whether PUFA supplements improve ADHD symptoms in children and adolescents with ADHD. Although there were some limited data in the original review that suggested PUFA improved symptoms of ADHD, there is currently little evidence that PUFA supplementation is beneficial. It was important to update the evidence to incorporate new studies that have been published since the original review. What did we do? We searched for all trials that compared PUFA to placebo (dummy pill), medicines, or psychological or medical therapies in children or adolescents with ADHD. We searched 13 databases and two trials registers up to October 2021. What did we find? We found 24 new studies in this update, bringing the total number of studies included in the review to 37, which involved more than 2374 children and adolescents with ADHD. Seven studies were conducted in Iran; four each in the USA and Israel; two each in Australia, Canada, New Zealand, Sweden, and the UK; and one each in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Thirty‐six studies compared PUFA to placebo. Treatment with PUFA lasted between two weeks and six months. Although there was some evidence that PUFA could improve ADHD symptoms in children and adolescents, most of the evidence indicated that PUFA did not improve ADHD symptoms such as inattention or hyperactivity‐impulsivity. PUFA probably makes little to no difference to overall side effects or whether a person drops out of a study (i.e. does not complete it). How confident are we about what we found? We are confident that PUFA has no effect on ADHD symptoms when compared to placebo. Although there was some evidence that ADHD symptoms may be more likely to improve in children and adolescents receiving PUFA compared to those receiving placebo, we have little confidence in this finding. We are fairly confident that there are no differences between PUFA and placebo groups in overall side effects or dropout. Limitations of the analyses included small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Gillies, D, Leach, MJ, Perez Algorta, G", "articleTypes": [], "doi": "10.1002/14651858.CD007986.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.779Z" }, { "id": "bec5d76b-db6e-4d8b-9f97-b4159a7898ee", "pmid": "", "title": "Interventions for erosive lichen planus affecting mucosal sites", "imported": false, "abstract": "Abstract - Background Erosive lichen planus (ELP) affecting mucosal surfaces is a chronic autoimmune disease of unknown aetiology. It is often more painful and debilitating than the non‐erosive types of lichen planus. Treatment of erosive lichen planus is difficult and aimed at palliation rather than cure. Several topical and systemic agents have been used with varying results. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth. Objectives To assess the effects of interventions in the treatment of erosive lichen planus affecting the oral, anogenital, and oesophageal regions. Search methods We searched the following databases up to September 2009: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched reference lists of articles and online trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) that evaluated the effectiveness of any topical or systemic interventions for ELP affecting either the mouth, genital region, or both areas, in participants of any age, gender, or race. Data collection and analysis The primary outcome measures were as follows: (a) Pain reduction using a visual analogue scale rated by participants; 
 (b) Physician Global Assessment; and
 (c) Participant global self‐assessment. Changes in scores at the end of therapy compared with baseline were analysed. Main results Fifteen RCTs were included, giving a total of 473 participants with ELP (study sizes ranged between 8‐94). All studies involved oral sites only. Six studies included participants with non‐erosive lichen planus but only the erosive subgroup was included for intended subgroup analysis. We were unable to pool data from any of the nine studies with only ELP participants or any of the six studies with the ELP subgroup, due to small numbers and the heterogeneity of the interventions, design methods, and outcome variables between studies. One study involving 50 participants found that 0.025% clobetasol propionate administered as liquid microspheres significantly reduced pain compared to ointment (Mean difference (MD) ‐18.30, 95% confidence interval (CI) ‐28.57 to ‐8.03), but outcome data was only available in 45 participants (high risk of performance bias for blinding of participants, low/unclear risk of bias overall). However, in another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (high risk of performance and detection bias due to likely lack of blinding, low/unclear risk of bias overall). Aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo in a study involving 45 ELP participants (Risk ratio (RR) 6.16, 95% CI 2.35 to 16.13) (low risk of bias overall). No significant difference was seen in Physician Global Assessment in these three studies. In a small single study involving 20 ELP participants, 1% pimecrolimus cream was 7 times more likely to result in a strong improvement as rated by the Physician Global Assessment when compared to vehicle cream (RR 7.00, 95% CI 1.04 to 46.95) (low risk of bias overall). In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease as rated by the Physician Global Assessment, in favour of the ciclosporin group when compared to the vehicle (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (unclear risk of selection bias for allocation concealment, overall risk of bias low). No statistically significant benefits were shown for topical tacrolimus or fluticasone spray in two separate studies of 29 and 44 participants respectively. There is no overwhelming evidence for the efficacy of a single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candidiasis and dyspepsia. Authors' conclusions This review suggests that there is only weak evidence for the effectiveness of any of the treatments for oral ELP, whilst no evidence was found for genital ELP. More RCTs on a larger scale are needed in the oral and genital ELP populations. We suggest that future studies should have standardised outcome variables that are clinically important to affected individuals. We recommend the measurement of a clinical severity score and a participant‐rated symptom score using agreed and validated severity scoring tools. We also recommend the development of a validated combined severity scoring tool for both oral and genital populations. Plain language summary Treatments for erosive lichen planus affecting mucosal sites Erosive lichen planus (ELP) is a condition that affects the mouth, oesophagus (food pipe or gullet), and anogenital region. It is caused by an over‐active immune system. It is often more painful and debilitating than the non‐erosive types of lichen planus. Depending on the site involved, affected individuals may experience pain, and difficulty eating; passing urine; or having sexual intercourse. Treatment is difficult and aimed at controlling symptoms, rather than cure. Several creams and tablets have been used with varying results. This review looked at the effectiveness of treatments for ELP and included 15 studies, with 473 participants with ELP. All involved oral, but not genital, disease. Many studies were excluded either because they were not randomised controlled trials (where participants are divided into two groups at random) or because they recruited participants with all types of lichen planus, rather than just the erosive subtypes. All of these studies recruited small numbers of participants (12 to 94) and used a variety of different assessment methods and timings; hence, it was not possible to combine or compare results between studies directly. We found only weak evidence for the effectiveness of any of the treatments for oral ELP. None of the studies involved genital or oesophageal disease; hence, no evidence was found for the treatment of these conditions. One small study found that 0.025% clobetasol propionate (a very potent topical steroid) administered as a spray significantly reduced pain when compared to ointment. In another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (a potent topical steroid). In a study involving 45 ELP participants, aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo. In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease in favour of the ciclosporin group when compared to the vehicle. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candida (yeast) infection and pain or discomfort in the upper abdomen. Temporary burning was a common side‐effect reported with tacrolimus 0.1% ointment and pimecrolimus 0.1% cream. Overall, there was no overwhelming evidence for the effectiveness of any single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. This was mainly due to the lack of good‐quality, well‐conducted trials and small participant numbers. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cheng, S; Kirtschig, G; Cooper, S; Thornhill, M; Leonardi‐Bee, J; Murphy, R", "articleTypes": [], "doi": "10.1002/14651858.CD008092.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "beceada6-7664-448c-bf8f-86cef287d423", "pmid": "", "title": "Discrepancy in Combined Genotype Distribution Data Between Two Related Studies of 5-HTTLPR and Posttraumatic Stress Disorder Risk.", "imported": false, "abstract": "No abstract available.", "journal": "American journal of medical genetics. Part B, Neuropsychiatric genetics : the official publication of the International Society of Psychiatric Genetics", "year": "2026", "authors": "Shivam V", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.439Z" }, { "id": "bee5fc45-4852-4eac-8b61-c1864e722a1f", "pmid": "", "title": "Antibody tests for identification of current and past infection with SARS‐CoV‐2", "imported": false, "abstract": "Abstract - Background The diagnostic challenges associated with the COVID‐19 pandemic resulted in rapid development of diagnostic test methods for detecting SARS‐CoV‐2 infection. Serology tests to detect the presence of antibodies to SARS‐CoV‐2 enable detection of past infection and may detect cases of SARS‐CoV‐2 infection that were missed by earlier diagnostic tests. Understanding the diagnostic accuracy of serology tests for SARS‐CoV‐2 infection may enable development of effective diagnostic and management pathways, inform public health management decisions and understanding of SARS‐CoV‐2 epidemiology. Objectives To assess the accuracy of antibody tests, firstly, to determine if a person presenting in the community, or in primary or secondary care has current SARS‐CoV‐2 infection according to time after onset of infection and, secondly, to determine if a person has previously been infected with SARS‐CoV‐2. Sources of heterogeneity investigated included: timing of test, test method, SARS‐CoV‐2 antigen used, test brand, and reference standard for non‐SARS‐CoV‐2 cases. Search methods The COVID‐19 Open Access Project living evidence database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) was searched on 30 September 2020. We included additional publications from the Evidence for Policy and Practice Information and Co‐ordinating Centre (EPPI‐Centre) ‘COVID‐19: Living map of the evidence’ and the Norwegian Institute of Public Health ’NIPH systematic and living map on COVID‐19 evidence’. We did not apply language restrictions. Selection criteria We included test accuracy studies of any design that evaluated commercially produced serology tests, targeting IgG, IgM, IgA alone, or in combination. Studies must have provided data for sensitivity, that could be allocated to a predefined time period after onset of symptoms, or after a positive RT‐PCR test. Small studies with fewer than 25 SARS‐CoV‐2 infection cases were excluded. We included any reference standard to define the presence or absence of SARS‐CoV‐2 (including reverse transcription polymerase chain reaction tests (RT‐PCR), clinical diagnostic criteria, and pre‐pandemic samples). Data collection and analysis We use standard screening procedures with three reviewers. Quality assessment (using the QUADAS‐2 tool) and numeric study results were extracted independently by two people. Other study characteristics were extracted by one reviewer and checked by a second. We present sensitivity and specificity with 95% confidence intervals (CIs) for each test and, for meta‐analysis, we fitted univariate random‐effects logistic regression models for sensitivity by eligible time period and for specificity by reference standard group. Heterogeneity was investigated by including indicator variables in the random‐effects logistic regression models. We tabulated results by test manufacturer and summarised results for tests that were evaluated in 200 or more samples and that met a modification of UK Medicines and Healthcare products Regulatory Agency (MHRA) target performance criteria. Main results We included 178 separate studies (described in 177 study reports, with 45 as pre‐prints) providing 527 test evaluations. The studies included 64,688 samples including 25,724 from people with confirmed SARS‐CoV‐2; most compared the accuracy of two or more assays (102/178, 57%). Participants with confirmed SARS‐CoV‐2 infection were most commonly hospital inpatients (78/178, 44%), and pre‐pandemic samples were used by 45% (81/178) to estimate specificity. Over two‐thirds of studies recruited participants based on known SARS‐CoV‐2 infection status (123/178, 69%). All studies were conducted prior to the introduction of SARS‐CoV‐2 vaccines and present data for naturally acquired antibody responses. Seventy‐nine percent (141/178) of studies reported sensitivity by week after symptom onset and 66% (117/178) for convalescent phase infection. Studies evaluated enzyme‐linked immunosorbent assays (ELISA) (165/527; 31%), chemiluminescent assays (CLIA) (167/527; 32%) or lateral flow assays (LFA) (188/527; 36%). Risk of bias was high because of participant selection (172, 97%); application and interpretation of the index test (35, 20%); weaknesses in the reference standard (38, 21%); and issues related to participant flow and timing (148, 82%). We judged that there were high concerns about the applicability of the evidence related to participants in 170 (96%) studies, and about the applicability of the reference standard in 162 (91%) studies. Average sensitivities for current SARS‐CoV‐2 infection increased by week after onset for all target antibodies. Average sensitivity for the combination of either IgG or IgM was 41.1% in week one (95% CI 38.1 to 44.2; 103 evaluations; 3881 samples, 1593 cases), 74.9% in week two (95% CI 72.4 to 77.3; 96 evaluations, 3948 samples, 2904 cases) and 88.0% by week three after onset of symptoms (95% CI 86.3 to 89.5; 103 evaluations, 2929 samples, 2571 cases). Average sensitivity during the convalescent phase of infection (up to a maximum of 100 days since onset of symptoms, where reported) was 89.8% for IgG (95% CI 88.5 to 90.9; 253 evaluations, 16,846 samples, 14,183 cases), 92.9% for IgG or IgM combined (95% CI 91.0 to 94.4; 108 evaluations, 3571 samples, 3206 cases) and 94.3% for total antibodies (95% CI 92.8 to 95.5; 58 evaluations, 7063 samples, 6652 cases). Average sensitivities for IgM alone followed a similar pattern but were of a lower test accuracy in every time slot. Average specificities were consistently high and precise, particularly for pre‐pandemic samples which provide the least biased estimates of specificity (ranging from 98.6% for IgM to 99.8% for total antibodies). Subgroup analyses suggested small differences in sensitivity and specificity by test technology however heterogeneity in study results, timing of sample collection, and smaller sample numbers in some groups made comparisons difficult. For IgG, CLIAs were the most sensitive (convalescent‐phase infection) and specific (pre‐pandemic samples) compared to both ELISAs and LFAs (P < 0.001 for differences across test methods). The antigen(s) used (whether from the Spike‐protein or nucleocapsid) appeared to have some effect on average sensitivity in the first weeks after onset but there was no clear evidence of an effect during convalescent‐phase infection. Investigations of test performance by brand showed considerable variation in sensitivity between tests, and in results between studies evaluating the same test. For tests that were evaluated in 200 or more samples, the lower bound of the 95% CI for sensitivity was 90% or more for only a small number of tests (IgG, n = 5; IgG or IgM, n = 1; total antibodies, n = 4). More test brands met the MHRA minimum criteria for specificity of 98% or above (IgG, n = 16; IgG or IgM, n = 5; total antibodies, n = 7). Seven assays met the specified criteria for both sensitivity and specificity. In a low‐prevalence (2%) setting, where antibody testing is used to diagnose COVID‐19 in people with symptoms but who have had a negative PCR test, we would anticipate that 1 (1 to 2) case would be missed and 8 (5 to 15) would be falsely positive in 1000 people undergoing IgG or IgM testing in week three after onset of SARS‐CoV‐2 infection. In a seroprevalence survey, where prevalence of prior infection is 50%, we would anticipate that 51 (46 to 58) cases would be missed and 6 (5 to 7) would be falsely positive in 1000 people having IgG tests during the convalescent phase (21 to 100 days post‐symptom onset or post‐positive PCR) of SARS‐CoV‐2 infection. Authors' conclusions Some antibody tests could be a useful diagnostic tool for those in whom molecular‐ or antigen‐based tests have failed to detect the SARS‐CoV‐2 virus, including in those with ongoing symptoms of acute infection (from week three onwards) or those presenting with post‐acute sequelae of COVID‐19. However, antibody tests have an increasing likelihood of detecting an immune response to infection as time since onset of infection progresses and have demonstrated adequate performance for detection of prior infection for sero‐epidemiological purposes. The applicability of results for detection of vaccination‐induced antibodies is uncertain. Plain language summary What is the diagnostic accuracy of antibody tests for the detection of infection with the COVID‐19 virus? Background COVID‐19 is an infectious disease caused by the SARS‐CoV‐2 virus that spreads easily between people in a similar way to the common cold or ‘flu’. Most people with COVID‐19 have a mild‐to‐moderate respiratory illness, and some may have no symptoms (asymptomatic infection). Others experience severe symptoms and need specialist treatment and intensive care. In response to COVID‐19 infection, the immune system develops proteins called antibodies that can attack the virus as it circulates in their blood. People who have been vaccinated against COVID‐19 also produce these antibodies against the virus. Tests are available to detect antibodies in peoples' blood, which may indicate that they currently have COVID‐19 or have had it previously, or it may indicate that they have been vaccinated (although this group was not the focus of this review). Why are accurate tests important? Accurate testing allows identification of people who need to isolate themselves to prevent the spread of infection, or who might need treatment for their infection. Failure of diagnostic tests to detect infection with COVID‐19 when it is present (a false negative result) may delay treatment and risk further spread of infection to others. Incorrect diagnosis of COVID‐19 when it is not present (a false positive result) may lead to unnecessary further testing, treatment, and isolation of the person and close contacts. Accurate identification of people who have previously had COVID‐19 is important in measuring disease spread and assessing the success of public health interventions. To determine the accuracy of an antibody test in identifying COVID‐19, test results are compared in people known to have (or have had) COVID‐19 and in people known not to have (or have had) COVID‐19. The criteria used to determine whether people are known or not known to have COVID‐19 is called the ‘reference standard’. Many studies use a test called reverse transcriptase polymerase chain reaction (RT‐PCR) as the reference standard, with samples taken from the nose and throat. Additional tests that can be used include measuring symptoms, like coughing or high temperature, or ‘imaging’ tests like chest X‐rays. People known not to have COVID‐19 are sometimes identified from stored blood samples taken before COVID‐19 existed, or from patients with symptoms confirmed to be caused by other diseases. What did the review study? We wanted to find out whether antibody tests: ‐ are able to diagnose infection in people with or without symptoms of COVID‐19, and ‐ can be used to find out if someone has already had COVID‐19. The studies we included in our review looked at three types of antibodies. Most commonly, antibody tests measure two types known as IgG and IgM, but some tests only measure a single type of antibody or different combinations of the three types of antibodies (IgA, IgG, IgM). What did we do? We looked for studies that measured the diagnostic accuracy of antibody tests to detect current or past COVID‐19 infection and compared them with reference standard criteria. Since there are many antibody tests available, we included studies assessing any antibody test compared with any reference standard. People could be tested in hospital or in the community. The people tested may have been confirmed to have, or not to have, COVID‐19 infection, or they may be suspected of having COVID‐19. Study characteristics We found 178 relevant studies. Studies took place in Europe (94), Asia (45), North America (35), Australia (2), and South America (2). Seventy‐eight studies included people who were in hospital with suspected or confirmed COVID‐19 infection and 14 studies included people in community settings. Several studies included people from multiple settings (35) or did not report where the participants were recruited from (39). One hundred and forty‐one studies included recent infection cases (mainly week 1 to week 3 after onset of symptoms), and many also included people tested later (from day 21 onwards after infection) (117). Main results In participants that had COVID‐19 and were tested one week after symptoms developed, antibody tests detected only 27% to 41% of infections. In week 2 after first symptoms, 64% to 79% of infections were detected, rising to 78% to 88% in week 3. Tests that specifically detected IgG or IgM antibodies were the most accurate and, when testing people from 21 days after first symptoms, they detected 93% of people with COVID‐19. Tests gave false positive results for 1% of those without COVID‐19. Below we illustrate results for two different scenarios. If 1000 people were tested for IgG or IgM antibodies during the third week after onset of symptoms and only 20 (2%) of them actually had COVID‐19: ‐ 26 people would test positive. Of these, 8 people (31%) would not have COVID‐19 (false positive result). ‐ 974 people would test negative. Of these, 2 people (0.2%) would actually have COVID‐19 (false negative result). If 1000 people with no symptoms for COVID‐19 were tested for IgG antibodies and 500 (50%) of them had previously had COVID‐19 infection more than 21 days previously: ‐ 455 people would test positive. Of these, 6 people (1%) would not have been infected (false positive result). ‐ 545 people would test negative. Of these, 51 (9%) would actually have had a prior COVID‐19 infection (false negative result). How reliable were the results of the studies of this review? We have limited confidence in the evidence for several reasons. The number of samples contributed by studies for each week post‐symptom onset was often small, and there were sometimes problems with how studies were conducted. Participants included in the studies were often hospital patients who were more likely to have experienced severe symptoms of COVID‐19. The accuracy of antibody tests for detecting COVID‐19 in these patients may be different from the accuracy of the tests in people with mild or moderate symptoms. It is not possible to identify by how much the test results would differ in other populations. Who do the results of this review apply to? A high percentage of participants were in hospital with COVID‐19, so were likely to have more severe disease than people with COVID‐19 who were not hospitalised. Only a small number of studies assessed these tests in people with no symptoms. The results of the review may therefore be more applicable to those with severe disease than people with mild symptoms. Studies frequently did not report whether participants had symptoms at the time samples were taken for testing making it difficult to fully separate test results for early‐phase infection as opposed to later‐phase infections. The studies in our review assessed several test methods across a global population, therefore it is likely that test results would be similar in most areas of the world. What are the implications of this review? The review shows that antibody tests could have a useful role in detecting if someone has had COVID‐19, but the timing of test use is important. Some antibody tests may help to confirm COVID‐19 infection in people who have had symptoms for more than two weeks but who have been unable to confirm their infection using other methods. This is particularly useful if they are experiencing potentially serious symptoms that may be due to COVID‐19 as they may require specific treatment. Antibody tests may also be useful to determine how many people have had a previous COVID‐19 infection. We could not be certain about how well the tests work for people who have milder disease or no symptoms, or for detecting antibodies resulting from vaccination. How up‐to‐date is this review? This review updates our previous review. The evidence is up‐to‐date to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Fox, T; Geppert, J; Dinnes, J; Scandrett, K; Bigio, J; Sulis, G; Hettiarachchi, D; Mathangasinghe, Y; Weeratunga, P; Wickramasinghe, D; Bergman, H; Buckley, BS; Probyn, K; Sguassero, Y; Davenport, C; Cunningham, J; Dittrich, S; Emperador, D; Hooft, L; Leeflang, MMG; McInnes, MDF; Spijker, R; Struyf, T; Van den Bruel, A; Verbakel, JY; Takwoingi, Y; Taylor-Phillips, S; Deeks, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD013652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "bee91f14-b545-4b31-bd7c-37be1e930df6", "pmid": "", "title": "Running Performance in Response to Different Forms of Carbohydrate", "imported": false, "abstract": "Carbohydrates serve as the body's primary energy source during intense exercise, and consuming carbohydrates during exercise has been shown to improve exercise performance. Previous research has shown that the presence of carbohydrates in the mouth activates sweet taste receptors on the tongue, which signal the brain to increase neural activation in areas associated with motor functioning, sensory perception, and reward centers during exercise through this CPR. The primary objective of this intervention is to establish how carbohydrates delivered in different forms (MR versus dissolvable strip (DS)) affect running performance during a 12.8km running TT.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "bf03b704-9655-42ac-b4df-fa6dd614e723", "pmid": "", "title": "Non‐invasive diagnostic tests for Helicobacter pylori infection", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) infection has been implicated in a number of malignancies and non‐malignant conditions including peptic ulcers, non‐ulcer dyspepsia, recurrent peptic ulcer bleeding, unexplained iron deficiency anaemia, idiopathic thrombocytopaenia purpura, and colorectal adenomas. The confirmatory diagnosis of H pylori is by endoscopic biopsy, followed by histopathological examination using haemotoxylin and eosin (H & E) stain or special stains such as Giemsa stain and Warthin‐Starry stain. Special stains are more accurate than H & E stain. There is significant uncertainty about the diagnostic accuracy of non‐invasive tests for diagnosis of H pylori . Objectives To compare the diagnostic accuracy of urea breath test, serology, and stool antigen test, used alone or in combination, for diagnosis of H pylori infection in symptomatic and asymptomatic people, so that eradication therapy for H pylori can be started. Search methods We searched MEDLINE, Embase, the Science Citation Index and the National Institute for Health Research Health Technology Assessment Database on 4 March 2016. We screened references in the included studies to identify additional studies. We also conducted citation searches of relevant studies, most recently on 4 December 2016. We did not restrict studies by language or publication status, or whether data were collected prospectively or retrospectively. Selection criteria We included diagnostic accuracy studies that evaluated at least one of the index tests (urea breath test using isotopes such as 13 C or 14 C, serology and stool antigen test) against the reference standard (histopathological examination using H & E stain, special stains or immunohistochemical stain) in people suspected of having H pylori infection. Data collection and analysis Two review authors independently screened the references to identify relevant studies and independently extracted data. We assessed the methodological quality of studies using the QUADAS‐2 tool. We performed meta‐analysis by using the hierarchical summary receiver operating characteristic (HSROC) model to estimate and compare SROC curves. Where appropriate, we used bivariate or univariate logistic regression models to estimate summary sensitivities and specificities. Main results We included 101 studies involving 11,003 participants, of which 5839 participants (53.1%) had H pylori infection. The prevalence of H pylori infection in the studies ranged from 15.2% to 94.7%, with a median prevalence of 53.7% (interquartile range 42.0% to 66.5%). Most of the studies (57%) included participants with dyspepsia and 53 studies excluded participants who recently had proton pump inhibitors or antibiotics.There was at least an unclear risk of bias or unclear applicability concern for each study. Of the 101 studies, 15 compared the accuracy of two index tests and two studies compared the accuracy of three index tests. Thirty‐four studies (4242 participants) evaluated serology; 29 studies (2988 participants) evaluated stool antigen test; 34 studies (3139 participants) evaluated urea breath test‐ 13 C; 21 studies (1810 participants) evaluated urea breath test‐ 14 C; and two studies (127 participants) evaluated urea breath test but did not report the isotope used. The thresholds used to define test positivity and the staining techniques used for histopathological examination (reference standard) varied between studies. Due to sparse data for each threshold reported, it was not possible to identify the best threshold for each test. Using data from 99 studies in an indirect test comparison, there was statistical evidence of a difference in diagnostic accuracy between urea breath test‐ 13 C, urea breath test‐ 14 C, serology and stool antigen test (P = 0.024). The diagnostic odds ratios for urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test were 153 (95% confidence interval (CI) 73.7 to 316), 105 (95% CI 74.0 to 150), 47.4 (95% CI 25.5 to 88.1) and 45.1 (95% CI 24.2 to 84.1). The sensitivity (95% CI) estimated at a fixed specificity of 0.90 (median from studies across the four tests), was 0.94 (95% CI 0.89 to 0.97) for urea breath test‐ 13 C, 0.92 (95% CI 0.89 to 0.94) for urea breath test‐ 14 C, 0.84 (95% CI 0.74 to 0.91) for serology, and 0.83 (95% CI 0.73 to 0.90) for stool antigen test. This implies that on average, given a specificity of 0.90 and prevalence of 53.7% (median specificity and prevalence in the studies), out of 1000 people tested for H pylori infection, there will be 46 false positives (people without H pylori infection who will be diagnosed as having H pylori i nfection). In this hypothetical cohort, urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test will give 30 (95% CI 15 to 58), 42 (95% CI 30 to 58), 86 (95% CI 50 to 140), and 89 (95% CI 52 to 146) false negatives respectively (people with H pylori infection for whom the diagnosis of H pylori will be missed). Direct comparisons were based on few head‐to‐head studies. The ratios of diagnostic odds ratios (DORs) were 0.68 (95% CI 0.12 to 3.70; P = 0.56) for urea breath test‐ 13 C versus serology (seven studies), and 0.88 (95% CI 0.14 to 5.56; P = 0.84) for urea breath test‐ 13 C versus stool antigen test (seven studies). The 95% CIs of these estimates overlap with those of the ratios of DORs from the indirect comparison. Data were limited or unavailable for meta‐analysis of other direct comparisons. Authors' conclusions In people without a history of gastrectomy and those who have not recently had antibiotics or proton ,pump inhibitors, urea breath tests had high diagnostic accuracy while serology and stool antigen tests were less accurate for diagnosis of Helicobacter pylori infection.This is based on an indirect test comparison (with potential for bias due to confounding), as evidence from direct comparisons was limited or unavailable. The thresholds used for these tests were highly variable and we were unable to identify specific thresholds that might be useful in clinical practice. We need further comparative studies of high methodological quality to obtain more reliable evidence of relative accuracy between the tests. Such studies should be conducted prospectively in a representative spectrum of participants and clearly reported to ensure low risk of bias. Most importantly, studies should prespecify and clearly report thresholds used, and should avoid inappropriate exclusions. Plain language summary Accuracy of different non‐invasive methods for identifying Helicobacter pylori Why is it important to know whether someone has Helicobacter pylori ? Helicobacter pylori (H pylori) is a type of bacteria which may be present in the stomach of some people. H pylori is believed to cause a number of cancers, including stomach cancer, pancreatic cancer, and throat cancer. H pylori is also linked with other diseases including stomach ulcers, heart burn, and a bloated feeling. If H pylori is found in an individual, appropriate treatment can be started. What is the aim of this review? To compare the accuracy of three different types of test for H pylori. These are: urea breath tests, blood tests (the specific blood test is called serology), and stool tests (in faeces). What was studied in this review? There are two types of urea breath test which use two different forms of carbon known as 13 C and 14 C, as well as multiple versions of serology and stool tests. What are the main results of the review? We found 101 studies which included 11,003 people who were tested for H pylori . Of these 11,003 participants, 5839 (53.1%) had H pylori infection. All the studies used one of the three tests listed above and compared these test results with the diagnosis given by endoscopic biopsy. Endoscopic biopsy involves obtaining tissue from the stomach using a thin flexible tube introduced through the mouth and testing for the presence of H pylori under the microscope. It is currently the most accurate available test, however it causes physical discomfort to the patient, with associated risks for harm. This is in contrast to the alternative non‐invasive tests in this review which are significantly less uncomfortable and have minimal or no risk of harm, making them desirable alternatives if they can be shown to be as accurate at diagnosing H pylori as endoscopic biopsy. Most of the studies included participants with heart burn or similar problems in the stomach and excluded participants who had previously undergone partial removal of the stomach and those having treatment for H pylori . Thirty‐four studies (4242 participants) used serology; 29 studies (2988 participants) used stool antigen test; 34 studies (3139 participants) used urea breath test‐ 13 C; 21 studies (1810 participants) used urea breath test‐ 14 C; and two studies (127 participants) used urea breath test but did not report the type of carbon used. Studies varied in the limit they used before saying a test was positive for H pylori infection and the type of stains used to examine the biopsy material. When we looked at all the data we found that urea breath tests were more accurate than blood and stool tests. The results mean that, on average, if 1000 people are tested, there will be 46 people without H pylori who will be misdiagnosed as having H pylori . Also, there will be 30, 42, 86, and 89 people with H pylori infection for whom the diagnosis of H pylori infection will be missed by urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test, respectively. When we looked at the seven studies which compared urea breath test‐ 13 C and serology, or urea breath test‐ 13 C and stool antigen tests in the same participants, the results were uncertain and we cannot tell which test is more accurate. How reliable are the results of the studies? Except for one study, all the studies were of poor methodological quality, which makes their results unreliable. Who do the results of this review apply to? These results apply to children and adults with suspected H pylori infection, but only in those who have not previously undergone stomach operations and those who have not recently had antibiotics or treatment for H pylori infection. What are the implications of this review? Urea breath tests, blood tests, and stool tests may be suitable for identifying whether someone has H pylori infection. However, the level of the result of urea breath test, blood test, or stool test which should be used to make a diagnosis of H pylori infection remains unclear. How up‐to‐date is the review? We performed a thorough literature search for studies reporting the accuracy of these different tests until 4 March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Best, LMJ, Takwoingi, Y, Siddique, S, Selladurai, A, Gandhi, A, Low, B, Yaghoobi, M, Gurusamy, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.787Z" }, { "id": "bf223afe-a5e7-4601-9218-67fbf13292cb", "pmid": "", "title": "Oral zinc for the prevention of hyperbilirubinaemia in neonates", "imported": false, "abstract": "Abstract - Background Between 6% and 15% of neonates develop hyperbilirubinaemia requiring treatment. Successful management of neonatal hyperbilirubinaemia relies on prevention and early treatment, with phototherapy being the mainstay of treatment. Oral zinc has been reported to decrease the serum total bilirubin (STB), presumably by decreasing the enterohepatic circulation. Objectives To determine the effect of oral zinc supplementation compared to placebo or no treatment on the incidence of hyperbilirubinaemia in neonates during the first week of life and to assess the safety of oral zinc in enrolled neonates. Search methods We searched CENTRAL (The Cochrane Library 2014, Issue 1), MEDLINE (1966 to November 30, 2014), and EMBASE (1990 to November 30, 2014). Selection criteria Randomised controlled trials were eligible for inclusion if they enrolled neonates (term and preterm) to whom oral zinc, in a dose of 10 to 20 mg/day, was initiated within the first 96 hours of life, for any duration until day seven, compared with no treatment or placebo. Data collection and analysis We used the standard methods of The Cochrane Collaboration and its Neonatal Review Group for data collection and analysis. Main results Only one study met the criteria of inclusion in the review. This study compared oral zinc with placebo. Oral zinc was administered in a dose of 5 mL twice daily from day 2 to day 7 postpartum. The drug was administered into the mouth of the infant by the plastic measure provided with the bottle or with a spoon. Incidence of hyperbilirubinaemia, defined as serum total bilirubin (STB) ≥ 15 mg/dL, was similar between groups (N = 286; risk ratio (RR) 0.94, 95% confidence interval (CI) 0.58 to 1.52). Mean STB levels, mg/dL, at 72 ± 12 hours were comparable in both the groups (N = 286; mean difference (MD) ‐0.20; 95% CI ‐1.03 to 0.63). Although the duration of phototherapy in the zinc group was significantly shorter compared to the placebo group (N = 286; MD ‐12.80, 95% CI ‐16.93 to ‐8.67), the incidence of need for phototherapy was comparable across both the groups (N = 286; RR 1.20; 95% CI 0.66 to 2.18). Incidences of side effects like vomiting (N = 286; RR 0.65, 95% CI 0.19 to 2.25), diarrhoea (N = 286; RR 2.92, 95% CI 0.31 to 27.71), and rash (N = 286; RR 2.92, 95% CI 0.12 to 71.03) were found to be rare and statistically comparable between groups. Authors' conclusions The limited evidence available has not shown that oral zinc supplementation given to infants up to one week old reduces the incidence of hyperbilirubinaemia or need for phototherapy. Plain language summary Oral zinc for the prevention of hyperbilirubinaemia in neonates Review question In newborn infants less than one week old, does oral zinc salt supplementation compared to placebo or no treatment decrease the incidence of hyperbilirubinaemia (jaundice)? Background Jaundice, or yellowish discolouration of the skin, can occur due to an increased amount of bilirubin pigment in the blood. It is a commonly observed and usually harmless condition in newborn infants during the first week after birth. However, in some babies, the amount of bilirubin pigment can increase to dangerous levels and necessitate treatment. Bilirubin is metabolised in the liver and is excreted via the intestine in faeces. Increased reabsorption of bilirubin from the intestine is one of the major factors inducing hyperbilirubinaemia in newborn infants. Oral zinc salt, a relatively harmless medicine, can reduce the bilirubin level in newborn infants by decreasing its reabsorption from the intestine. Study characteristics Researchers from Cochrane searched for all available literature up to 30 November 2014. One randomised controlled trial met our inclusion criteria. Results In this review, the efficacy of oral zinc salt was compared with placebo. One study enrolling 294 infants was identified. This study evaluated oral zinc salt, given in a dose of 5 mg twice daily to infants between 25 and 168 hours old. The administration of oral zinc salt did not affect the incidence of jaundice (hyperbilirubinaemia) in these infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mishra, S; Cheema, A; Agarwal, R; Deorari, A; Paul, V", "articleTypes": [], "doi": "10.1002/14651858.CD008432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "bf26ec28-97e4-4924-b98e-b1edbd6f8cfa", "pmid": "", "title": "Effect of Maternal Vitamin D3 Supplementation on Iron Status During Pregnancy and Early Infancy", "imported": false, "abstract": "This is a secondary-use study based on previously-collected data and blood samples from a previously completed double-blind, dose-ranging trial of maternal prenatal and postpartum vitamin D supplementation in Dhaka, Bangladesh (NCT01924013). The aim of this sub-study is to examine the effect of vitamin D supplementation on iron status during pregnancy and early infancy.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "bf2da2c4-155d-406e-a392-2e2bbb7f2080", "pmid": "", "title": "Short‐course oral steroids as an adjunct therapy for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of a short course of oral corticosteroids as an adjunct ('add‐on') therapy in people with chronic rhinosinusitis who are already on standard treatments. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids to placebo or no treatment, where all patients were also receiving pharmacological treatment for chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score, and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results Two trials with a total of 78 participants met the inclusion criteria. Both the populations and the 'standard' treatments differed in the two studies. Oral steroids as an adjunct to intranasal corticosteroids One trial in adults with nasal polyps included 30 participants. All participants used intranasal corticosteroids and were randomised to either short‐course oral steroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 21‐day treatment course) or no additional treatment. None of the primary outcome measures of interest in this review were reported by the study. There may have been an important reduction in the size of the polyps (measured by the nasal polyps score, a secondary outcome measure) in patients receiving oral steroids and intranasal corticosteroids, compared to intranasal corticosteroids alone (mean difference (MD) ‐0.46, 95% confidence interval (CI) ‐0.87 to ‐0.05; 30 participants; scale 1 to 4) at the end of treatment (21 days). This corresponds to a large effect size, but we are very uncertain about this estimate as we judged the study to be at high risk of bias. Moreover, longer‐term data were not available and the other outcomes of interest were not reported. Oral steroids as an adjunct to antibiotics One trial in children (mean age of eight years) without nasal polyps included 48 participants. The trial compared oral corticosteroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 15‐day treatment course) with placebo in participants who also received a 30‐day course of antibiotics. This study addressed one of the primary outcome measures (disease severity) and one secondary outcome (CT score). For disease severity the four key symptoms used to define chronic rhinosinusitis in children (nasal blockage, nasal discharge, facial pressure, cough) were combined into one score. There was a greater improvement in symptom severity 30 days after the start of treatment in patients who received oral steroids and antibiotics compared with placebo and antibiotics (MD ‐7.10, 95% CI ‐9.59 to ‐4.61; 45 participants; scale 0 to 40). The observed mean difference corresponds to a large effect size. At the same time point there was a difference in CT scan score (MD ‐2.90, 95% CI ‐4.91 to ‐0.89; 45 participants; scale 0 to 24). We assessed the quality of the evidence to be low . There were no data available for the longer term (three months). Authors' conclusions There might be an improvement in symptom severity, polyps size and condition of the sinuses when assessed using CT scans in patients taking oral corticosteroids when these are used as an adjunct therapy to antibiotics or intranasal corticosteroids, but the quality of the evidence supporting this is low or very low (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). It is unclear whether the benefits of oral corticosteroids as an adjunct therapy are sustained beyond the short follow‐up period reported (up to 30 days), as no longer‐term data were available. There were no data in this review about the adverse effects associated with short courses of oral corticosteroids as an adjunct therapy. More research in this area, particularly research evaluating longer‐term outcomes and adverse effects, is required. Plain language summary Short‐term oral corticosteroids in addition to other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of adding a short course (typically up to 14 days) of corticosteroid given by mouth to people with chronic rhinosinusitis who were also receiving another type of treatment (such as corticosteroids delivered through the nose). Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling inflammation and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included two randomised controlled trials with a total of 78 participants. One trial involved 30 adults with nasal polyps. Participants received either intranasal corticosteroids and oral corticosteroids or only intranasal corticosteroids. The only result reported of interest to this review was whether the size of the nasal polyps was reduced, when these treatments were completed (three weeks). One trial involved 48 children (mean age of eight years) with chronic rhinosinusitis but no nasal polyps. Participants received either antibiotics and oral corticosteroids or only antibiotics and a placebo (sugar pill). The oral corticosteroids and placebo were given for 15 days and the antibiotics were given for 30 days. The trial reported findings when the antibiotic treatment was completed (at one month). Key results At the end of a three‐week treatment course, people who took both intranasal corticosteroids and oral steroids may have had smaller nasal polyps than people who just received intranasal corticosteroids. The trial did not follow up people to determine whether the polyp size increased after the end of the trial. The trial did not provide information on adverse events or other outcomes important to patients, such as symptom severity or quality of life. Children who received both antibiotics and oral corticosteroids seemed to have a lower total symptom score and better computerised tomography (CT) scan score after treatment compared with children who received antibiotics and control treatment. The reporting of adverse effects in this trial was not very clear and so is difficult to tell if any participant experienced gastrointestinal disturbances, mood changes or difficulty in sleeping. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be very low (we are very uncertain about the estimate) as the evidence comes from one trial that has a low number of participants. The trial had a high risk of bias due to the way it was conducted. The trial did not report adverse events and did not report results after the end of treatment. We judged the quality of the evidence for oral steroids plus antibiotics for children to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate) as the evidence comes from one small trial. The trial did not have a high risk of bias, but it only included children without nasal polyps, who might not have the same results as adults with nasal polyps. The trial did not report results after the end of treatment and the adverse effects of treatment were not well reported.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K, Chong, LY, Hopkins, C, Philpott, C, Schilder, AGM, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.084Z" }, { "id": "bf34b541-e944-4ade-8f44-1a3925b0aa13", "pmid": "", "title": "Serotonin-receptor Agonism in Reward Processing", "imported": false, "abstract": "There is growing animal and human evidence for role of 5HT1A receptor agonism in treating depression and reward deficits. The next step is to translate this evidence directly into humans by characterising the effects of buspirone, as a 5HT1A agonist, on cognitive models of reward and emotional processing.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.256Z" }, { "id": "bf38f37b-e8fa-4da0-8513-2841c2e62e28", "pmid": "", "title": "Dornase alfa for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Dornase alfa is currently used as a mucolytic to treat pulmonary disease (the major cause of morbidity and mortality) in cystic fibrosis. It reduces mucus viscosity in the lungs, promoting improved clearance of secretions. This is an update of a previously published review. Objectives To determine whether the use of dornase alfa in cystic fibrosis is associated with improved mortality and morbidity compared to placebo or other medications that improve airway clearance, and to identify any adverse events associated with its use. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstracts from conferences. Date of the most recent search of the Group's Cystic Fibrosis Register: 12 October 2020. Clinicaltrials.gov and the International Clinical Trials Registry Platform were also searched to identify unpublished or ongoing trials. Date of most recent search: 08 February 2021. Selection criteria All randomised and quasi‐randomised controlled trials comparing dornase alfa to placebo, standard therapy or other medications that improve airway clearance. Data collection and analysis Authors independently assessed trials against the inclusion criteria; two authors carried out analysis of methodological quality and data extraction. GRADE was used to assess the level of evidence. Main results The searches identified 74 trials, of which 19 (2565 participants) met our inclusion criteria. 15 trials compared dornase alfa to placebo or no dornase alfa (2447 participants); two compared daily dornase to hypertonic saline (32 participants); one compared daily dornase alfa to hypertonic saline and alternate day dornase alfa (48 participants); one compared dornase alfa to mannitol and the combination of both drugs (38 participants). Trial duration varied from six days to three years. Dornase alfa compared to placebo or no treatment Dornase alfa probably improved forced expiratory volume at one second (FEV 1 ) at one month (four trials, 248 participants), three months (one trial, 320 participants; moderate‐quality evidence), six months (one trial, 647 participants; high‐quality evidence) and two years (one trial, 410 participants). Limited low‐quality evidence showed treatment may make little or no difference in quality of life. Dornase alfa probably reduced the number of pulmonary exacerbations in trials of up to two years (moderate‐quality evidence). One trial that examined the cost of care, including the cost of dornase alfa, found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa: daily versus alternate day One cross‐over trial (43 children) found little or no difference between treatment regimens for lung function, quality of life or pulmonary exacerbations (low‐quality evidence). Dornase alfa compared to other medications that improve airway clearance Results for these comparisons were mixed. One trial (43 children) showed dornase alfa may lead to a greater improvement in FEV 1 compared to hypertonic saline (low‐quality evidence), and one trial (23 participants) reported little or no differences in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol (low‐quality evidence). One trial (23 participants) found dornase alfa may improve quality of life compared to dornase alfa plus mannitol (low‐quality evidence); other comparisons found little or no difference in this outcome (low‐quality evidence). No trials in any comparison reported any difference between groups in the number of pulmonary exacerbations (low‐quality evidence). When all comparisons are assessed, dornase alfa did not cause significantly more adverse effects than other treatments, except voice alteration and rash. Authors' conclusions There is evidence to show that, compared with placebo, therapy with dornase alfa may improve lung function in people with cystic fibrosis in trials lasting from one month to two years. There was a decrease in pulmonary exacerbations in trials of six months or longer, probably due to treatment. Voice alteration and rash appear to be the only adverse events reported with increased frequency in randomised controlled trials. There is not enough evidence to firmly conclude if dornase alfa is superior to other hyperosmolar agents in improving lung function. Plain language summary Dornase alfa, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of using inhaled dornase alfa for treating lung disease in people with cystic fibrosis. Background Cystic fibrosis is an inherited condition which affects the movement of salt across cells in the body and affects, for example, the sweat glands, airways, pancreas and male reproductive system. Lung disease is the most common cause of death in people with cystic fibrosis and although the average life expectancy has increased over the last 30 years, it is still only 48.5 years in high‐income countries. People with cystic fibrosis develop chronic lung disease because of thick mucus that builds up in the lungs which causes infections and inflammation. Dornase alfa was developed to thin out this mucus, so it is easier for people to cough it up from their lungs; this in turn should decrease the number of infections and amount of inflammation and prevent chronic lung disease. Search date The evidence is current to: 12 October 2020. Study characteristics We included 19 trials with 2565 people with cystic fibrosis; 15 trials (2447 people) compared dornase alfa to placebo (a dummy treatment with no active medication) or no dornase alfa treatment; two trials (32 people) compared daily dornase to hypertonic saline; one trial (48 people) compared daily dornase alfa with hypertonic saline and alternate day dornase alfa; and one trial (38 people) compared dornase alfa to mannitol and the combination of both drugs. People from all age groups (infants through to adults) took part in the trials which lasted from six days to three years. Key results Dornase alfa compared to placebo or no treatment We found that dornase alfa probably improves lung function within one month when compared to a placebo or no treatment and this improvement was also seen in longer trials lasting from six months to two years (eight trials; 1708 participants). There were also fewer pulmonary exacerbations (flare up of lung inflammation) in these longer trials. One trial found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa ‐ daily versus alternate day One trial (43 children) found no differences between treatment schedules for lung function, quality of life or pulmonary exacerbations. Dornase alfa compared to other medications that improve airway clearance The results from trials comparing dornase alfa to hypertonic saline or mannitol were mixed. One trial (43 children) showed a greater improvement in lung function with dornase alfa compared to hypertonic saline and one trial (23 participants) reported no difference in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol. In one trial (23 participants) quality of life scores were better with dornase alfa alone than with dornase alfa plus mannitol; other drug comparisons found no difference between treatments for quality of life. No trials in any comparison of treatments reported any difference between groups in the number of pulmonary exacerbations. Overall, no serious side effects were reported, with only rash and a change in voice seen more frequently in those people taking dornase alfa. However, it is not definitively clear from the current evidence if dornase alfa is better than other medications such as hypertonic saline or mannitol. Quality of the evidence The quality of evidence from the trials comparing dornase alfa to placebo or no treatment was moderate to high for lung function results, but only one trial reported any changes in quality of life so the evidence for this outcome is limited. Also, there were few trials comparing different treatment schedules of dornase alfa (e.g. once a day versus twice a day) or comparing dornase alfa to other medications which help with clearing secretions, so current evidence from these trials is limited and of low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Yang, C, Montgomery, M", "articleTypes": [], "doi": "10.1002/14651858.CD001127.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.759Z" }, { "id": "bf649a35-6a38-46e6-888f-60854ef76b36", "pmid": "", "title": "Interventions for treating burning mouth syndrome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "McMillan, R, Forssell, H, Buchanan, JAG, Glenny, AM, Weldon, JC, Zakrzewska, JM", "articleTypes": [], "doi": "10.1002/14651858.CD002779.pub3 AB - Abstract - Background Burning mouth syndrome (BMS) is a term used for oral mucosal pain (burning pain or discomfort in the tongue, lips or entire oral cavity) without identifiable cause. General population prevalence varies from 0.1% to 3.9%. Many BMS patients indicate anxiety, depression, personality disorders and impaired quality of life (QoL). This review updates the previous versions published in 2000 and 2005. Objectives To determine the effectiveness and safety of any intervention versus placebo for symptom relief and changes in QoL, taste, and feeling of dryness in people with BMS. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 31 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 11) in the Cochrane Library (searched 31 December 2015), MEDLINE Ovid (1946 to 31 December 2015), and Embase Ovid (1980 to 31 December 2015). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching the electronic databases Selection criteria Randomised controlled trials (RCTs) comparing any treatment against placebo in people with BMS. The primary outcomes were symptom relief (pain/burning) and change in QoL. Secondary outcomes included change in taste, feeling of dryness, and adverse effects. Data collection and analysis We used standard methodological procedures expected by Cochrane. Outcome data were analysed as short‐term (up to three months) or long‐term (three to six months). Main results We included 23 RCTs (1121 analysed participants; 83% female). Interventions were categorised as: antidepressants and antipsychotics, anticonvulsants, benzodiazepines, cholinergics, dietary supplements, electromagnetic radiation, physical barriers, psychological therapies, and topical treatments. Only one RCT was assessed at low risk of bias overall, four RCTs' risk of bias was unclear, and 18 studies were at high risk of bias. Overall quality of the evidence for effectiveness was very low for all interventions and all outcomes. Twenty‐one RCTs assessed short‐term symptom relief. There is very low‐quality evidence of benefit from electromagnetic radiation (one RCT, 58 participants), topical benzodiazepines (two RCTs, 111 participants), physical barriers (one RCT, 50 participants), and anticonvulsants (one RCT, 100 participants). We found insufficient/contradictory evidence regarding the effectiveness of antidepressants, cholinergics, systemic benzodiazepines, dietary supplements or topical treatments. No RCT assessing psychological therapies evaluated short‐term symptom relief. Four studies assessed long‐term symptom relief. There is very low‐quality evidence of a benefit from psychological therapies (one RCT, 30 participants), capsaicin oral rinse (topical treatment) (one RCT, 18 participants), and topical benzodiazepines (one RCT, 66 participants). We found no evidence of a difference for dietary supplements or lactoperoxidase oral rinse. No studies assessing antidepressants, anticonvulsants, cholinergics, electromagnetic radiation or physical barriers evaluated long‐term symptom relief. Short‐term change in QoL was assessed by seven studies (none long‐term).The quality of evidence was very low. A benefit was found for electromagnetic radiation (one RCT, 58 participants), however findings were inconclusive for antidepressants, benzodiazepines, dietary supplements and physical barriers. Secondary outcomes (change in taste and feeling of dryness) were only assessed short‐term, and the findings for both were also inconclusive. With regard to adverse effects, there is very low‐quality evidence that antidepressants increase dizziness and drowsiness (one RCT, 37 participants), and that alpha lipoic acid increased headache (two RCTs, 118 participants) and gastrointestinal complaints (3 RCTs, 138 participants). We found insufficient/contradictory evidence regarding adverse events for anticonvulsants or benzodiazepines. Adverse events were poorly reported or unreported for cholinergics, electromagnetic radiation, and psychological therapies. No adverse events occurred from physical barriers or topical therapy use. Authors' conclusions Given BMS' potentially disabling nature, the need to identify effective modes of treatment for sufferers is vital. Due to the limited number of clinical trials at low risk of bias, there is insufficient evidence to support or refute the use of any interventions in managing BMS. Further clinical trials, with improved methodology and standardised outcome sets are required in order to establish which treatments are effective. Future studies are encouraged to assess the role of treatments used in other neuropathic pain conditions and psychological therapies in the treatment of BMS. Plain language summary Interventions for treating burning mouth syndrome Review question Which treatments help to relieve symptoms for people with burning mouth syndrome (BMS)? Background BMS is a common painful condition. Symptoms include burning, dryness or uncomfortable sensations in the mouth and changes to taste, with no obvious underlying medical or dental cause. BMS is usually persistent and suffered long term, and can lead to a reduced quality of life (QoL). Currently, scientific research suggests that BMS is caused by underlying damage to the nerves. There are many treatments available including drugs for anxiety, other psychological conditions and increasing saliva production, protective barriers and treatments applied to the mouth surface amongst others. Study characteristics This review of studies was carried out through Cochrane Oral Health, and the evidence is current up to 31 December 2015. We found 23 studies (assessing 1121 people; 83% were women), published between 1995 and 2015 to include in this review. Twenty‐one studies assessed short‐term (up to three months) symptom relief, and four studies assessed long‐term (from three to six months) symptom relief. Seventeen studies provided information about side effect occurrence, seven studies assessed a measure of QoL, and two studies assessed changes in taste and feeling of dryness. All of the 23 treatments included in this review were compared to a placebo (fake treatment): antidepressants and antipsychotics (two studies), antiseizure drugs (one study), types of tranquillisers (four studies), saliva stimulants (one study), dietary supplements (12 studies), directed energy waves (one study), physical barriers (one study), psychological therapies (one study), and treatments applied to the mouth surface (five studies). Key results Short‐term symptom relief We found evidence of short‐term symptom relief for directed energy waves (one study, 58 participants), a type of tranquilliser used topically (that is held in the mouth before being removed, and which also acts as an antiseizure drug) called clonazepam (two studies, 111 participants), thin plastic tongue covers (one study, 50 participants), and an antiseizure drug called gabapentin (one study, 100 participants). There was no difference in short‐term symptom relief found for antidepressants, saliva stimulants, and another type of tranquilliser used systemically (one that is swallowed) also called clonazepam. We were unable to show whether dietary supplements or treatments applied to the mouth surface provide symptom relief in the short term or not. Short‐term relief was not reported for the single study that assessed a psychological therapy. Long‐term symptom relief We found evidence of long‐term symptom relief for psychological therapy (one study, 30 participants), chili pepper mouthrinse (one study, 18 participants) and the topical tranquilliser called clonazepam (one study, 66 participants). We found there was no difference in long‐term symptom relief for dietary supplements or treatments applied to the mouth surface. Studies which assessed antidepressants, directed energy waves, saliva stimulants, antiseizure drugs, or physical barriers did not evaluate long‐term symptom relief. Change in QoL There was evidence of short‐term improvement in QoL for directed energy waves (one study, 58 patients), although no difference was found for antidepressants, tranquillisers, dietary supplements and physical barriers. No study assessed long‐term QoL changes. Change in taste or feeling of dryness A few studies assessed short‐term change in taste or feeling of dryness (none evaluated these outcomes long‐term), but there was not enough evidence to judge the effects of treatment on these outcomes. Side effects Side effects were more likely to be experienced with antidepressants (dizziness and drowsiness more likely: one study, 37 people), and with a dietary supplement called alpha lipoic acid (also known as ALA) with or without other ingredients (headaches more likely: two studies, 118 people; and upset stomachs more likely: three studies, 138 people). Quality of the evidence 
 Overall, we found very low‐quality evidence for each short‐ and long‐term outcome we investigated (symptom relief; changes in QoL, taste and feeling of dryness; and side effects) in all types of assessed treatment: antidepressants and antipsychotics, antiseizure drugs, types of tranquillisers, saliva stimulants, dietary supplements, directed energy waves, physical barriers (except side effects, which was assessed as low quality), psychological therapies, and treatments applied to the mouth surface. As we found so few studies at low risk of bias, we are currently unable to prove or disprove the effectiveness of any treatments for managing BMS.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.747Z" }, { "id": "bf6c74b8-af33-4e4d-b4b0-bdb9c7aff5e0", "pmid": "", "title": "Effects of Nutritional Supplementation With Amino Acids on Liver Lipid Content, Whole-body Protein Turnover, and Body Composition in Obese Pre-pubertal Children", "imported": false, "abstract": "The purpose of this study is to assess the effect of an eight-week dietary supplementation with essential amino acids plus arginine on liver and plasma lipid content, whole-body fat oxidation, whole-body insulin sensitivity, whole body protein metabolism, and body composition in obese pre-pubertal children.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.247Z" }, { "id": "bf747daf-a390-4f77-b419-3faa68e3159c", "pmid": "", "title": "Aminoglycosides, vancomycin, and metronidazole for people with cirrhosis and hepatic encephalopathy", "imported": false, "abstract": "Abstract - Rationale Hepatic encephalopathy is a common complication of cirrhosis. Its development is associated with increased morbidity and mortality. Its exact pathogenesis is unknown, but ammonia, produced by bacterial action in the intestine, plays a key role. Antibiotics modulate the gut flora and may reduce intestinal ammonia production. Aminoglycosides such as neomycin, paromomycin, and ribostamycin have been used to treat hepatic encephalopathy, as have other antibiotics such as vancomycin and metronidazole. Objectives To assess the beneficial and harmful effects of aminoglycosides, vancomycin, and metronidazole versus placebo, no intervention, other antibiotics, or other active pharmacological interventions, for the prevention and treatment of hepatic encephalopathy in people with cirrhosis. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, and three other databases to 15 April 2025. We also searched online trials registries for ongoing and unpublished trials, undertook manual searches of meeting and conference proceedings, checked bibliographies of relevant articles, and corresponded with investigators and pharmaceutical companies. Eligibility criteria We included randomised clinical trials (RCTs) involving participants with cirrhosis and hepatic encephalopathy, or who were at risk of developing hepatic encephalopathy, comparing aminoglycosides, vancomycin, or metronidazole to (1) placebo or no intervention; or (2) other pharmacological agents, including non‐absorbable disaccharides, other antibiotics, or other potentially beneficial agents (e.g. branched‐chain amino acids, L‐ornithine L‐aspartate, nitazoxanide (a broad‐spectrum antiparasitic/antiviral agent), and nicotinohydroxamic acid (a potent urease inhibitor). We included trials irrespective of publication status, outcomes reported, language, or blinding. We excluded trials involving people with hepatic encephalopathy associated with acute liver failure or with non‐cirrhotic portal hypertension. Outcomes The critical outcomes were all‐cause mortality, hepatic encephalopathy, and serious adverse events. The important outcomes were non‐serious adverse events and health‐related quality of life (HRQoL). Our primary time point was the maximum length of follow‐up. Risk of bias We used Cochrane's original risk of bias tool (RoB 1) to assess the risk of bias. Synthesis methods We used standard Cochrane methods. We undertook random‐effects meta‐analyses to calculate risk ratios (RRs) or standardised mean differences (SMDs), with 95% confidence intervals (CIs). We assessed heterogeneity with the I 2 statistic, and the certainty of evidence with the GRADE framework. Included studies We included 24 RCTs, involving 1405 participants experiencing 1418 hepatic encephalopathy events. Twenty‐three trials evaluated the treatment of hepatic encephalopathy and one, the secondary prevention of hepatic encephalopathy; we analysed these trials jointly. The trials assessed three aminoglycosides: neomycin (15 trials), paromomycin (three trials), and ribostamycin (one trial), as well as vancomycin (two trials), and metronidazole (three trials). Overall, 670 participants received these pharmacotherapies while 735 participants received a placebo or other potentially beneficial agents. We classified 22 of the 24 trials to be at an overall high risk of bias based on domain‐level assessments. Synthesis of results The certainty of evidence for all comparisons was low to very low, mainly due to risk of bias, imprecision, and heterogeneity. Twenty‐three of the 24 trials, involving 1383 participants, reported all‐cause mortality data. Aminoglycosides may increase mortality slightly compared to other potentially active agents (RR 1.64, 95% CI 1.03 to 2.62; I² = 0%; 3 studies, 166 participants). The evidence was very uncertain about whether aminoglycosides versus a placebo (RR 1.02, 95% CI 0.62 to 1.69; I² = 0%; 3 studies, 137 participants), non‐absorbable disaccharides (RR 1.21, 95% CI 0.57 to 2.59; I² not applicable; 4 studies, 266 participants), or other antibiotics (RR 1.00, 95% CI 0.24 to 4.23; I² = 83%; 8 studies, 496 participants) result in a difference in mortality risk. The evidence was also very uncertain when comparing vancomycin to non‐absorbable disaccharides (RR 0.94, 95% CI 0.26 to 3.40; I² not applicable; 2 studies, 72 participants), and metronidazole to other active agents (RR 0.97, 95% CI 0.14 to 6.66; I² = 0%; 3 studies, 242 participants). Nineteen trials involving 1281 participants reported data on hepatic encephalopathy. There may be little to no difference in the effects of aminoglycosides versus non‐absorbable disaccharides (RR 0.84, 95% CI 0.67 to 1.05; I² = 0%; 3 studies, 251 participants), aminoglycosides versus other potentially active agents (RR 1.21, 95% CI 0.79 to 1.85; I² = 0%; 3 studies, 166 participants), and metronidazole versus other active agents (RR 1.50, 95% CI 0.89 to 2.54; I² = 48%; 2 studies, 208 participants). The evidence is very uncertain about the effect of aminoglycosides versus placebo, other antibiotics, and vancomycin versus non‐absorbable disaccharides. Twenty trials, involving 1186 participants, reported a total of 328 serious adverse events. Aminoglycosides may slightly increase the risk of serious adverse events compared with other potentially active agents (RR 1.60, 95% CI 1.03 to 2.47; I² = 0%; 3 studies, 166 participants). The evidence is very uncertain when comparing aminoglycosides to placebo and other antibiotics, or when comparing vancomycin to non‐absorbable disaccharides. Eighteen trials, involving 922 participants, reported a total of 96 non‐serious adverse events. There may be a slight increase in the risk of adverse events when comparing aminoglycosides to placebo (RR 2.80, 95% CI 1.11 to 7.04; I² not applicable; 2 studies, 98 participants), and to other antibiotics (RR 3.24, 95% CI 1.08 to 9.70; I² = 0%; 8 studies, 251 participants). The evidence is very uncertain about the effects of aminoglycosides versus non‐absorbable disaccharides or other active agents, and metronidazole versus other active agents. Only one trial assessed HRQoL, but reported the data in a form that precluded meta‐analysis. Eight trials received support from pharmaceutical companies while six did not. Ten trials did not provide this information. Authors' conclusions Due to low‐ or very low‐certainty evidence, we do not know if aminoglycosides benefit hepatic encephalopathy compared to placebo or other potentially active agents. There may be a slight increase in the risks of mortality and serious adverse events with aminoglycosides compared to other agents, and of non‐serious adverse events when compared to placebo and other antibiotics. We do not know if vancomycin or metronidazole improve clinically relevant outcomes. Only one trial assessed health‐related quality of life. Funding This Cochrane review received no specific funding. Registration https://doi.org/10.1002/14651858.CD012734 Plain language summary Do the antibiotics aminoglycosides, vancomycin, and metronidazole help people with cirrhosis and hepatic encephalopathy, a brain disorder associated with chronic liver disease? Key messages Antibiotics previously thought to help people with cirrhosis manage the risk of hepatic encephalopathy do not appear to benefit the condition. These antibiotics possibly cause more side effects than other treatments for this condition. Research is needed to establish whether combining these antibiotics with other treatments may be beneficial. What are cirrhosis and hepatic encephalopathy? Cirrhosis is a long‐term condition in which the liver becomes badly scarred. The liver normally helps clean the blood, process nutrients, and fight infections. When it is repeatedly damaged over time, the scar tissue which develops makes it harder for the liver to work properly. People with cirrhosis may develop hepatic encephalopathy, a condition that results in poor brain functioning. The reason why people develop hepatic encephalopathy is complex, but the build‐up in the blood of toxins from the gut, particularly of a compound called ammonia, plays a key role. Ammonia is produced in the gut mainly as a result of the activities of gut bacteria. How do antibiotics work in hepatic encephalopathy? Antibiotics are medicines used to treat infections caused by bacteria. They work by killing bacteria or stopping them from growing. Certain antibiotics may reduce the levels of ammonia in the blood by interfering with ammonia production in the gut. These antibiotics have been used to treat hepatic encephalopathy for many years, but the evidence that they help is unclear. The antibiotics considered in this review are: aminoglycosides (neomycin, paromomycin, and ribostamycin); vancomycin; metronidazole. What did we want to find out? We wanted to know if these antibiotics help to prevent or treat hepatic encephalopathy in people with cirrhosis. We analysed their effects on the number of people who died, whose symptoms of hepatic encephalopathy improved or failed to improve, and the number who experienced serious or non‐serious complications. What did we do? We searched for studies that compared aminoglycosides, vancomycin, or metronidazole to: placebo – an inactive or 'dummy' medicine; non‐absorbable disaccharides – sugars that mainly act in the gut, and are commonly used to treat some digestive and liver conditions; other antibiotics; other active agents that may help the condition. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 24 studies which involved 1405 participants. Of these, 23 studies evaluated the treatment of hepatic encephalopathy, and one study explored the prevention of hepatic encephalopathy in people at risk. We found evidence for the following comparisons: aminoglycosides versus placebo, non‐absorbable disaccharides, other antibiotics, and other active agents – 19 studies in total; vancomycin versus non‐absorbable disaccharides – 2 studies; metronidazole versus other active agents – 3 studies. Main results Death Aminoglycosides may slightly increase the risk of death compared to other active agents. We do not know if aminoglycosides make any difference to the risk of death compared to placebo, non‐absorbable disaccharides, and other antibiotics. We also do not know if there is any difference in the risk of death between: vancomycin and non‐absorbable disaccharides; metronidazole and other active agents. Hepatic encephalopathy: number of people in whom hepatic encephalopathy failed to improve Aminoglycosides may make little to no difference to the number of people whose condition improves compared to non‐absorbable disaccharides and other active agents. Metronidazole may make little to no difference to the number of people whose condition improves compared to other active agents. We do not know if there is any difference in the number of people whose condition improves when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Serious complications Aminoglycosides may slightly increase the risk of serious complications compared to other active agents. We do not know if there is any difference in serious complications when comparing: aminoglycosides to placebo or other antibiotics; vancomycin to non‐absorbable disaccharides. Non‐serious complications Aminoglycosides may slightly increase the risk of non‐serious complications compared to placebo or other antibiotics. We do not know if there is any difference in the risk of non‐serious complications when comparing: aminoglycosides to non‐absorbable disaccharides or other active agents; metronidazole to other active agents; vancomycin to non‐absorbable disaccharides. Only one study, using metronidazole, reported on health‐related quality of life, so we were unable to draw any conclusions for this outcome. What are the limitations of the evidence? We had little to no confidence in the results of the review because the participants and researchers in some studies were aware of which treatment the participants received, which may have influenced the results, while some studies did not report on the outcomes we were interested in. The studies were generally small, and differed in how they were conducted. There were also too few studies to be certain about the outcomes. How current is this evidence? The evidence is current to 15 April 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Jeyaraj, R, Zacharias, HD, Vadera, S, Low, ZY, Gluud, LL, Morgan, MY", "articleTypes": [], "doi": "10.1002/14651858.CD012734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.794Z" }, { "id": "bf79cd6c-9ab4-4e5b-bdf4-243464725abe", "pmid": "", "title": "Oral protein‐based supplements versus placebo or no treatment for people with chronic kidney disease requiring dialysis", "imported": false, "abstract": "Abstract - Background Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein‐based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein‐based nutritional supplements in this population is limited. Objectives The aims of this review were to determine the benefits and harms of using oral protein‐based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein‐based nutritional supplements to no oral protein‐based nutritional supplements or placebo. Data collection and analysis Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes. Main results Twenty‐two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow‐up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self‐reported outcomes. Oral protein‐based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I 2 = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein‐based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I 2 = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein‐based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid‐arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein‐based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI ‐0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD ‐0.04 kg/m 2 , 95% CI ‐0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI ‐1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein‐based nutritional supplements affect triceps skinfold thickness, mid‐arm circumference, C‐reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein‐based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies. Authors' conclusions Overall, it is likely that oral protein‐based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid‐arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well‐designed RCTs in this population are required. Plain language summary Oral protein‐based nutritional supplement in people with chronic kidney disease requiring dialysis What is the issue? People with chronic kidney disease requiring dialysis are at risk of developing malnutrition for many reasons and often do not eat enough because their appetite is poor. Oral nutritional supplements are commonly provided to people who do not eat enough to meet their needs. Provision of nutritional supplements to dialysis patients requires careful consideration of potassium, phosphate and fluid limits. What did we do? We aimed to determine if giving oral protein‐based nutritional supplements improved serum albumin levels and other measures of nutrition. What did we find? A total of 1278 people took part in 22 studies that were included in this review to investigate the effects of oral protein‐based nutritional supplements. All participants were adults on maintenance dialysis (79% haemodialysis and 21% peritoneal dialysis). The studies lasted from one to 12 months. The findings suggest that giving oral protein‐based nutritional supplementation probably results in a slightly greater increase in albumin level and may improve prealbumin level and mid‐arm muscle circumference. The increase in albumin level was more evident in participants who were on haemodialysis and in those who were malnourished. It is uncertain whether oral protein‐based nutritional supplementation affects potassium and phosphate levels. Oral protein‐based nutritional supplements may result in little or no difference in the risk of developing abdominal symptoms.There were some differences between the quality of the studies and their designs. Conclusions The authors conclude that oral protein‐based nutritional supplements appear to be effective in improving some nutritional markers in people who need dialysis; however, it remains uncertain whether these results translate to meaningful outcomes for this population. More research is required to determine the cost‐effectiveness of this treatment, and if it can bring benefit to patients such as feeling better and living longer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Mah, JY; Choy, SW; Roberts, MA; Desai, AM; Corken, M; Gwini, SM; McMahon, LP", "articleTypes": [], "doi": "10.1002/14651858.CD012616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "bf7eb006-6da7-4746-bfa2-5908c1a8fc86", "pmid": "", "title": "Magnesium for skeletal muscle cramps", "imported": false, "abstract": "Abstract - Background Skeletal muscle cramps are common and often occur in association with pregnancy, advanced age, exercise or motor neuron disorders (such as amyotrophic lateral sclerosis). Typically, such cramps have no obvious underlying pathology, and so are termed idiopathic. Magnesium supplements are marketed for the prophylaxis of cramps but the efficacy of magnesium for this purpose remains unclear. This is an update of a Cochrane Review first published in 2012, and performed to identify and incorporate more recent studies. Objectives To assess the effects of magnesium supplementation compared to no treatment, placebo control or other cramp therapies in people with skeletal muscle cramps. Search methods On 9 September 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, CINAHL Plus, AMED, and SPORTDiscus. We also searched WHO‐ICTRP and ClinicalTrials.gov for registered trials that might be ongoing or unpublished, and ISI Web of Science for studies citing the studies included in this review. Selection criteria Randomized controlled trials (RCTs) of magnesium supplementation (in any form) to prevent skeletal muscle cramps in any patient group (i.e. all clinical presentations of cramp). We considered comparisons of magnesium with no treatment, placebo control, or other therapy. Data collection and analysis Two review authors independently selected trials for inclusion and extracted data. Two review authors assessed risk of bias. We attempted to contact all study authors when questions arose and obtained participant‐level data for four of the included trials, one of which was unpublished. We collected all data on adverse effects from the included RCTs. Main results We identified 11 trials (nine parallel‐group, two cross‐over) enrolling a total of 735 individuals, amongst whom 118 cross‐over participants additionally served as their own controls. Five trials enrolled women with pregnancy‐associated leg cramps (408 participants) and five trials enrolled people with idiopathic cramps (271 participants, with 118 additionally crossed over to control). Another study enrolled 29 people with liver cirrhosis, only some of whom suffered muscle cramps. All trials provided magnesium as an oral supplement, except for one trial which provided magnesium as a series of slow intravenous infusions. Nine trials compared magnesium to placebo, one trial compared magnesium to no treatment, calcium carbonate or vitamin B, and another trial compared magnesium to vitamin E or calcium. We judged the single trial in people with liver cirrhosis and all five trials in participants with pregnancy‐associated leg cramps to be at high risk of bias. In contrast, we rated the risk of bias high in only one of five trials in participants with idiopathic rest cramps. For idiopathic cramps, largely in older adults (mean age 61.6 to 69.3 years) presumed to have nocturnal leg cramps (the commonest presentation), differences in measures of cramp frequency when comparing magnesium to placebo were small, not statistically significant, and showed minimal heterogeneity (I² = 0% to 12%). This includes the primary endpoint, percentage change from baseline in the number of cramps per week at four weeks (mean difference (MD) −9.59%, 95% confidence interval (CI) −23.14% to 3.97%; 3 studies, 177 participants; moderate‐certainty evidence); and the difference in the number of cramps per week at four weeks (MD −0.18 cramps/week, 95% CI −0.84 to 0.49; 5 studies, 307 participants; moderate‐certainty evidence). The percentage of individuals experiencing a 25% or better reduction in cramp rate from baseline was also no different (RR 1.04, 95% CI 0.84 to 1.29; 3 studies, 177 participants; high‐certainty evidence). Similarly, no statistically significant difference was found at four weeks in measures of cramp intensity or cramp duration. This includes the number of participants rating their cramps as moderate or severe at four weeks (RR 1.33, 95% CI 0.81 to 2.21; 2 studies, 91 participants; moderate‐certainty evidence); and the percentage of participants with the majority of cramp durations of one minute or more at four weeks (RR 1.83, 95% CI 0.74 to 4.53, 1 study, 46 participants; low‐certainty evidence). We were unable to perform meta‐analysis for trials of pregnancy‐associated leg cramps. The single study comparing magnesium to no treatment failed to find statistically significant benefit on a three‐point ordinal scale of overall treatment efficacy. Of the three trials comparing magnesium to placebo, one found no benefit on frequency or intensity measures, another found benefit for both, and a third reported inconsistent results for frequency that could not be reconciled. The single study in people with liver cirrhosis was small and had limited reporting of cramps, but found no difference in terms of cramp frequency or cramp intensity. Our analysis of adverse events pooled all studies, regardless of the setting in which cramps occurred. Major adverse events (occurring in 2 out of 72 magnesium recipients and 3 out of 68 placebo recipients), and withdrawals due to adverse events, were not significantly different from placebo. However, in the four studies for which it could be determined, more participants experienced minor adverse events in the magnesium group than in the placebo group (RR 1.51, 95% CI 0.98 to 2.33; 4 studies, 254 participants; low‐certainty evidence). Overall, oral magnesium was associated with mostly gastrointestinal adverse events (e.g. diarrhoea), experienced by 11% (10% in control) to 37% (14% in control) of participants. Authors' conclusions It is unlikely that magnesium supplementation provides clinically meaningful cramp prophylaxis to older adults experiencing skeletal muscle cramps. In contrast, for those experiencing pregnancy‐associated rest cramps the literature is conflicting and further research in this population is needed. We found no RCTs evaluating magnesium for exercise‐associated muscle cramps or disease‐state‐associated muscle cramps (for example amyotrophic lateral sclerosis/motor neuron disease) other than a single small (inconclusive) study in people with liver cirrhosis, only some of whom suffered cramps. Plain language summary Magnesium for muscle cramps Review question We reviewed the evidence about the effect of magnesium supplements on muscle cramps, and included the widest possible range of studies. This meant including studies on anyone suffering muscle cramps, regardless of why they suffered them. It also meant including studies where magnesium was given in any of the ways available. This includes being swallowed as a pill or liquid, being injected slowly over a number of hours directly into the blood ('intravenous infusion'), and being injected into muscle ('intramuscular injection'). We included studies comparing magnesium to placebo, comparing magnesium to no treatment, and comparing magnesium to other existing cramp treatments. We found a total of 11 studies. To assess benefit, we examined the effect of magnesium on cramp frequency, cramp pain, and cramp duration, and we examined the number of participants whose cramp rate reduced by 25% or more. To assess for potential harm, we examined how often major and minor adverse health events occurred. Background Muscle cramps are common and occur in a wide range of settings. Older adults and pregnant women commonly complain of leg cramps while they are resting, athletes can cramp when they are pushing the limits of their endurance, and some people develop muscle cramps as a symptom of other medical conditions. One potential treatment that is already being marketed to prevent muscle cramps is magnesium supplementation. Magnesium is a common mineral in our diets and extra oral supplements of this mineral are available either over the Internet or in health food stores and pharmacies (usually in the form of tablets or powders to be dissolved in water). We wanted to combine studies to get the best estimate of magnesium's effect on cramping. We also wanted to examine the effect of magnesium in different categories of cramp sufferers, in case it might work in one setting, and not another. Study characteristics We searched for all high‐quality published studies evaluating the effectiveness of magnesium to prevent muscle cramps and found five studies in older adults, five studies in pregnant women, and one study in people with liver cirrhosis. The studies in older adults included 271 participants (61.6 to 69.3 years of age) and the studies in pregnant women included 408 participants. The single study in people with liver cirrhosis enrolled only 29 people, not all of whom experienced cramping. There were no studies of people who cramp while exercising. Magnesium was compared to placebo in nine of 11 studies, and compared to calcium, vitamin E, vitamins B₁ and B₆, and no treatment, in two studies of pregnant women. The included studies ranged from 14 to 56 days of treatment. Magnesium was given orally in 10 of 11 studies, and by four‐hour intravenous infusion on five consecutive days in one study. Funding for included studies came from a manufacturer of magnesium tablets in two studies, independent sources in three studies, and was not reported in six studies. Key results and certainty of the evidence The combined results of five seemingly reliable studies suggest, with moderate‐certainty, that magnesium is unlikely to reduce the frequency or severity of muscle cramps in older adults. In contrast, the five studies in pregnant women had important limitations to their reliability (both in study design and reporting of results), did not consistently show benefit, and could not be combined. As a result we are very uncertain as to whether pregnant women experiencing muscle cramps would benefit from magnesium. The single study in people with liver cirrhosis reported no difference in cramp frequency or intensity but was too small for conclusions to be drawn. More research on magnesium in pregnant women is needed. The same is true for those who suffer cramps associated with medical conditions, or while exercising. However older adult cramp sufferers appear unlikely to benefit from this therapy. Major side effects were infrequent and participants withdrew from the study at similar rates when given magnesium or placebo. However minor side effects, mostly diarrhoea (as would be expected from magnesium salts) and nausea, were common and affected roughly 11% (10% in control) to 37% (14% in control) of participants. The review is up to date to September 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Garrison, SR, Korownyk, CS, Kolber, MR, Allan, GM, Musini, VM, Sekhon, RK, Dugré, N", "articleTypes": [], "doi": "10.1002/14651858.CD009402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.120Z" }, { "id": "bf82566a-a3f1-4767-9190-bcf56ec45fb5", "pmid": "", "title": "A Phase III Randomized, Double-blind, Placebo-controlled Multicenter Study in Adults, to Determine the Safety, Efficacy, and Immunogenicity of AZD1222, a Non-replicating ChAdOx1 Vector Vaccine, for the Prevention of COVID-19", "imported": false, "abstract": "The aim of the study is to assess the safety, efficacy, and immunogenicity of AZD1222 for the prevention of COVID-19.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "bfa3a342-210c-4169-84a4-3246b538c0d3", "pmid": "", "title": "Magnesium for skeletal muscle cramps", "imported": false, "abstract": "Abstract - Background Skeletal muscle cramps are common and often occur in association with pregnancy, advanced age, exercise or motor neuron disorders (such as amyotrophic lateral sclerosis). Typically, such cramps have no obvious underlying pathology, and so are termed idiopathic. Magnesium supplements are marketed for the prophylaxis of cramps but the efficacy of magnesium for this purpose remains unclear. This is an update of a Cochrane Review first published in 2012, and performed to identify and incorporate more recent studies. Objectives To assess the effects of magnesium supplementation compared to no treatment, placebo control or other cramp therapies in people with skeletal muscle cramps. Search methods On 9 September 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, CINAHL Plus, AMED, and SPORTDiscus. We also searched WHO‐ICTRP and ClinicalTrials.gov for registered trials that might be ongoing or unpublished, and ISI Web of Science for studies citing the studies included in this review. Selection criteria Randomized controlled trials (RCTs) of magnesium supplementation (in any form) to prevent skeletal muscle cramps in any patient group (i.e. all clinical presentations of cramp). We considered comparisons of magnesium with no treatment, placebo control, or other therapy. Data collection and analysis Two review authors independently selected trials for inclusion and extracted data. Two review authors assessed risk of bias. We attempted to contact all study authors when questions arose and obtained participant‐level data for four of the included trials, one of which was unpublished. We collected all data on adverse effects from the included RCTs. Main results We identified 11 trials (nine parallel‐group, two cross‐over) enrolling a total of 735 individuals, amongst whom 118 cross‐over participants additionally served as their own controls. Five trials enrolled women with pregnancy‐associated leg cramps (408 participants) and five trials enrolled people with idiopathic cramps (271 participants, with 118 additionally crossed over to control). Another study enrolled 29 people with liver cirrhosis, only some of whom suffered muscle cramps. All trials provided magnesium as an oral supplement, except for one trial which provided magnesium as a series of slow intravenous infusions. Nine trials compared magnesium to placebo, one trial compared magnesium to no treatment, calcium carbonate or vitamin B, and another trial compared magnesium to vitamin E or calcium. We judged the single trial in people with liver cirrhosis and all five trials in participants with pregnancy‐associated leg cramps to be at high risk of bias. In contrast, we rated the risk of bias high in only one of five trials in participants with idiopathic rest cramps. For idiopathic cramps, largely in older adults (mean age 61.6 to 69.3 years) presumed to have nocturnal leg cramps (the commonest presentation), differences in measures of cramp frequency when comparing magnesium to placebo were small, not statistically significant, and showed minimal heterogeneity (I² = 0% to 12%). This includes the primary endpoint, percentage change from baseline in the number of cramps per week at four weeks (mean difference (MD) −9.59%, 95% confidence interval (CI) −23.14% to 3.97%; 3 studies, 177 participants; moderate‐certainty evidence); and the difference in the number of cramps per week at four weeks (MD −0.18 cramps/week, 95% CI −0.84 to 0.49; 5 studies, 307 participants; moderate‐certainty evidence). The percentage of individuals experiencing a 25% or better reduction in cramp rate from baseline was also no different (RR 1.04, 95% CI 0.84 to 1.29; 3 studies, 177 participants; high‐certainty evidence). Similarly, no statistically significant difference was found at four weeks in measures of cramp intensity or cramp duration. This includes the number of participants rating their cramps as moderate or severe at four weeks (RR 1.33, 95% CI 0.81 to 2.21; 2 studies, 91 participants; moderate‐certainty evidence); and the percentage of participants with the majority of cramp durations of one minute or more at four weeks (RR 1.83, 95% CI 0.74 to 4.53, 1 study, 46 participants; low‐certainty evidence). We were unable to perform meta‐analysis for trials of pregnancy‐associated leg cramps. The single study comparing magnesium to no treatment failed to find statistically significant benefit on a three‐point ordinal scale of overall treatment efficacy. Of the three trials comparing magnesium to placebo, one found no benefit on frequency or intensity measures, another found benefit for both, and a third reported inconsistent results for frequency that could not be reconciled. The single study in people with liver cirrhosis was small and had limited reporting of cramps, but found no difference in terms of cramp frequency or cramp intensity. Our analysis of adverse events pooled all studies, regardless of the setting in which cramps occurred. Major adverse events (occurring in 2 out of 72 magnesium recipients and 3 out of 68 placebo recipients), and withdrawals due to adverse events, were not significantly different from placebo. However, in the four studies for which it could be determined, more participants experienced minor adverse events in the magnesium group than in the placebo group (RR 1.51, 95% CI 0.98 to 2.33; 4 studies, 254 participants; low‐certainty evidence). Overall, oral magnesium was associated with mostly gastrointestinal adverse events (e.g. diarrhoea), experienced by 11% (10% in control) to 37% (14% in control) of participants. Authors' conclusions It is unlikely that magnesium supplementation provides clinically meaningful cramp prophylaxis to older adults experiencing skeletal muscle cramps. In contrast, for those experiencing pregnancy‐associated rest cramps the literature is conflicting and further research in this population is needed. We found no RCTs evaluating magnesium for exercise‐associated muscle cramps or disease‐state‐associated muscle cramps (for example amyotrophic lateral sclerosis/motor neuron disease) other than a single small (inconclusive) study in people with liver cirrhosis, only some of whom suffered cramps. Plain language summary Magnesium for muscle cramps Review question We reviewed the evidence about the effect of magnesium supplements on muscle cramps, and included the widest possible range of studies. This meant including studies on anyone suffering muscle cramps, regardless of why they suffered them. It also meant including studies where magnesium was given in any of the ways available. This includes being swallowed as a pill or liquid, being injected slowly over a number of hours directly into the blood ('intravenous infusion'), and being injected into muscle ('intramuscular injection'). We included studies comparing magnesium to placebo, comparing magnesium to no treatment, and comparing magnesium to other existing cramp treatments. We found a total of 11 studies. To assess benefit, we examined the effect of magnesium on cramp frequency, cramp pain, and cramp duration, and we examined the number of participants whose cramp rate reduced by 25% or more. To assess for potential harm, we examined how often major and minor adverse health events occurred. Background Muscle cramps are common and occur in a wide range of settings. Older adults and pregnant women commonly complain of leg cramps while they are resting, athletes can cramp when they are pushing the limits of their endurance, and some people develop muscle cramps as a symptom of other medical conditions. One potential treatment that is already being marketed to prevent muscle cramps is magnesium supplementation. Magnesium is a common mineral in our diets and extra oral supplements of this mineral are available either over the Internet or in health food stores and pharmacies (usually in the form of tablets or powders to be dissolved in water). We wanted to combine studies to get the best estimate of magnesium's effect on cramping. We also wanted to examine the effect of magnesium in different categories of cramp sufferers, in case it might work in one setting, and not another. Study characteristics We searched for all high‐quality published studies evaluating the effectiveness of magnesium to prevent muscle cramps and found five studies in older adults, five studies in pregnant women, and one study in people with liver cirrhosis. The studies in older adults included 271 participants (61.6 to 69.3 years of age) and the studies in pregnant women included 408 participants. The single study in people with liver cirrhosis enrolled only 29 people, not all of whom experienced cramping. There were no studies of people who cramp while exercising. Magnesium was compared to placebo in nine of 11 studies, and compared to calcium, vitamin E, vitamins B₁ and B₆, and no treatment, in two studies of pregnant women. The included studies ranged from 14 to 56 days of treatment. Magnesium was given orally in 10 of 11 studies, and by four‐hour intravenous infusion on five consecutive days in one study. Funding for included studies came from a manufacturer of magnesium tablets in two studies, independent sources in three studies, and was not reported in six studies. Key results and certainty of the evidence The combined results of five seemingly reliable studies suggest, with moderate‐certainty, that magnesium is unlikely to reduce the frequency or severity of muscle cramps in older adults. In contrast, the five studies in pregnant women had important limitations to their reliability (both in study design and reporting of results), did not consistently show benefit, and could not be combined. As a result we are very uncertain as to whether pregnant women experiencing muscle cramps would benefit from magnesium. The single study in people with liver cirrhosis reported no difference in cramp frequency or intensity but was too small for conclusions to be drawn. More research on magnesium in pregnant women is needed. The same is true for those who suffer cramps associated with medical conditions, or while exercising. However older adult cramp sufferers appear unlikely to benefit from this therapy. Major side effects were infrequent and participants withdrew from the study at similar rates when given magnesium or placebo. However minor side effects, mostly diarrhoea (as would be expected from magnesium salts) and nausea, were common and affected roughly 11% (10% in control) to 37% (14% in control) of participants. The review is up to date to September 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Garrison, SR, Korownyk, CS, Kolber, MR, Allan, GM, Musini, VM, Sekhon, RK, Dugré, N", "articleTypes": [], "doi": "10.1002/14651858.CD009402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.780Z" }, { "id": "bfb9966e-d02b-4328-8ee7-9efd9e2b0809", "pmid": "", "title": "Interventions for the eradication of meticillin‐resistant Staphylococcus aureus (MRSA) in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a genetic disorder characterised by recurrent and persistent pulmonary infections from resistant organisms, resulting in deterioration of lung function and early mortality. Meticillin‐resistant Staphylococcus aureus (MRSA) is an important infection in hospital patients and harmful to people with CF (pwCF). Chronic pulmonary MRSA infection may confer a worse clinical outcome on pwCF and result in a faster decline in lung function. Robust evidence clearly guiding MRSA eradication in CF is urgently needed. This is an updated review. Objectives To evaluate the effectiveness of antibiotic treatment designed to eradicate MRSA, to determine whether eradication confers better clinical and microbiological outcomes for pwCF, and to ascertain whether attempts at eradicating MRSA lead to increased acquisition of other resistant organisms (including Pseudomonas aeruginosa ), increased adverse effects from drugs, or both. Search methods We searched the Cochrane CF's Trials Register, PubMed, MEDLINE and three trials registries; handsearched article reference lists; and contacted experts in the field. We last searched Cochrane CF's Trials Register and the trials registries on 28 April 2026. Eligibility criteria Randomised controlled trials (RCTs) or quasi‐RCTs of any combination of topical, inhaled, oral or intravenous antibiotics for treating MRSA compared with placebo, standard treatment or no treatment in pwCF, regardless of age or disease severity. Outcomes We planned to assess these outcomes at up to 12 months following therapy: eradication of MRSA from respiratory cultures, time until next positive MRSA isolate, quality of life (QoL), change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted, change in weight (kg), frequency of pulmonary exacerbations and adverse effects of treatment. Risk of bias Using the original Cochrane risk of bias tool, we assessed individual domains and produced an overall risk of bias for each trial. Synthesis methods We followed Cochrane's standard methodology, conducting fixed‐effect meta‐analyses or reporting narratively. We assessed evidence certainty using GRADE. Included studies We included five RCTs (410 participants). Synthesis of results Oral antibiotics versus no treatment Two trials (106 participants) compared observation to oral trimethoprim plus sulfamethoxazole combined with rifampicin; in one trial for two weeks alongside topical decontamination and a three‐week environmental decontamination, and in a second for 21 days alongside intranasal mupirocin (five days); 29 participants withdrew from the second trial by the end of follow‐up. Oral antibiotics have little or no effect on any outcome reported below, in contrast to one study (45 participants) which was terminated early due to results clearly favouring treatment. In one trial defining eradication as negative MRSA respiratory cultures at day 28 and remaining so at day 168 (45 participants), treatment may result in more negative cultures than observation (odds ratio (OR) 12.6 (95% confidence interval (CI) 2.84 to 55.84; low‐certainty). There may be little to no difference between groups by day 168 of follow‐up (OR 1.17, 95% CI 0.31 to 4.42), and also in one trial defining successful eradication as no MRSA in at least three cultures over six months follow‐up (OR 2.74, 95% CI 0.64 to 11.75; low‐certainty). Treatment may result in an increase in FEV 1 % predicted from baseline (MD 5.67%, 95% CI 1.43 to 9.90; 2 trials, 58 participants; low‐certainty evidence). There may be little to no differences between groups in QoL, frequency of pulmonary exacerbations (although one study reported a lower hospitalisation rate through day 168 with treatment (P = 0.01)), adverse effects, or weight (all low‐certainty evidence). Nebulised antibiotics versus placebo Two trials (275 participants randomised, 251 analysed) compared a standard dose of vancomycin (one trial additionally compared a high dose) to placebo. The multi‐arm trial reported a decrease in MRSA colony forming units (CFUs) at each time point, up to one month. There were no differences in most lung function results in either trial, but treatment probably increased FEV 1 % predicted at 20 weeks (MD 3.55%, 95% CI 0.33 to 6.77; P = 0.03; 1 trial, 133 participants; moderate‐certainty evidence). This trial also reported no difference in pulmonary exacerbation frequency, while the multi‐arm trial reported a longer time to the next exacerbation with the lower vancomycin dose (no placebo data available). Evidence from both trials suggests that nebulised antibiotics may make little or no difference in QoL (high to low‐certainty), or frequency of adverse outcomes or of exacerbations (low‐to‐moderate‐certainty evidence). Oral antibiotics plus nebulised antibiotics (vancomycin) versus oral antibiotics plus placebo One trial (29 participants randomised, 25 participants analysed) compared combination antibiotic treatment (inhaled plus oral) to oral antibiotics plus inhaled placebo, defining eradication as a negative MRSA respiratory sample at one month following treatment. Combination antibiotic treatment may result in little or no difference in MRSA eradication at three months (OR 1.63, 95% CI 0.19 to 13.93; low‐certainty evidence), lung function (no data available for analysis) or adverse effects (low‐certainty evidence), in QoL (very low‐certainty evidence) or nasal colonisation with MRSA. Authors' conclusions Early eradication of MRSA is possible in pwCF; evidence from one trial suggested active MRSA treatment may result in a higher proportion of MRSA‐negative respiratory cultures after one month compared with observation. However, longer follow‐up showed treatment may make little or no difference in the proportion of participants remaining MRSA‐negative. One trial of nebulised antibiotics alone compared to placebo reported a decrease in MRSA CFUs with a higher antibiotic dose. The longer‐term clinical consequences of any treatment option – in terms of lung function, mortality and cost of care – remain unclear. We judged the evidence to range from high to very low‐certainty, due to potential biases from trial design, high attrition rates and small sample sizes. While early eradication of respiratory MRSA in pwCF may be possible, the currently available evidence does not demonstrate that routine treatment of respiratory MRSA in pwCF is effective. Research is needed to assess MRSA infection and treatment in the age of modulator therapies. Funding The 2025 update was undertaken as part of Cochrane CF funding from the UK CF Trust and the CF Foundation. Registration Protocol (2012) DOI: 10.1002/14651858.CD009650. Original review (2013) DOI: 10.1002/14651858.CD009650.pub2. Review updates: (2015) DOI: 10.1002/14651858.CD009650.pub3; (2018) DOI: 10.1002/14651858.CD123456.pub4; (2022) DOI: 10.1002/14651858.CD009650.pub5. Plain language summary Can treatment with antibiotics clear the 'superbug' MRSA from the lungs of people with cystic fibrosis? Key messages Early treatment of meticillin‐resistant Staphylococcus aureus (MRSA) (a type of bacteria which are resistant to some antibiotics) infection in people with cystic fibrosis (CF) seems possible, but we are unsure about the effectiveness of current routine treatment. Longer‐term implications of treatment are not clear. Research is needed to assess MRSA infection and treatment in the age of cystic fibrosis transmembrane conductance regulator (CFTR) modulators (drugs that fix the broken protein made by the CF gene so salt and water can move correctly across cells and help move mucus from the lungs). What is cystic fibrosis (CF)? CF is an inherited condition which causes thick mucus to build up in the lungs and other organs. It is very difficult for people with CF to cough up this thick mucus, making it an ideal breeding ground for germs (including MRSA), and making them more prone to chest infections. CF worsens over time. Although there is currently no cure, many people with CF can lead active and full lives. What is MRSA and how is it treated? MRSA (meticillin‐resistant Staphyloccocus aureus) are bacteria which cause infection that is treated with antibiotics. However, MRSA are resistant to some types of antibiotics, making the infection hard to treat. They are sometimes called 'superbugs' and infection with MRSA is particularly worrying for people with CF, as it is thought that MRSA can cause more damage than other bacteria which are not resistant to antibiotics. MRSA is usually treated with a combination of antibiotics, taken orally (by mouth) or inhaled, alongside decontamination treatment (antibiotic creams applied to the skin and nasal cavities). What did we want to find out? We wanted to know whether treatment with antibiotics: can get rid of MRSA infection in the lungs of children or adults with CF; does not cause infection with other resistant bacteria; does not cause unwanted effects. What did we do? We looked for studies that investigated antibiotics (oral or inhaled) to treat MRSA infections in people with CF. Studies had to compare antibiotic treatment with either no treatment, placebo (sham treatment) or other type of antibiotics. People had to have CF and current infection with MRSA. What did we find? We found five studies which recruited 410 people with CF and a diagnosed MRSA infection. Studies took place in Italy or North America and lasted from eight weeks to six months. People in the studies (equal numbers of males and females) were young (average age ranged from 11 to 25 years). Oral antibiotics compared to no treatment (2 studies, 106 people) One group of people with CF were treated with oral antibiotics (trimethoprim, sulfamethoxazole and rifampicin or co‐trimoxazole and rifampicin), plus decontamination treatment; the other group received no treatment. Oral antibiotics may clear MRSA. One trial stopped early due to clear benefits of antibiotics, but some people cleared the infection with no treatment. In six months, there was no difference between groups in the number of people who still had MRSA. Antibiotics may increase lung function. There may be little to no difference between groups in quality of life, frequency of flare‐ups of the disease (although one study reported fewer people taking antibiotics were admitted to hospital in the first six months), unwanted effects of treatment, or changes in weight. Inhaled antibiotics compared to placebo (2 studies, 251 people) Both studies compared a standard dose of vancomycin (an inhaled antibiotic) to placebo (a dummy drug) and one study also compared a standard dose of vancomycin to a high dose. Inhaled antibiotics probably make no difference to lung function compared to placebo (2 studies), but results from one study indicated that inhaled antibiotics probably lead to a small increase after 20 weeks. A standard dose of vancomycin probably makes no difference to the frequency of flare‐ups compared to placebo (2 studies); One study reported a longer time to the next flare‐up with the lower dose of vancomycin; One study reported a decrease in MRSA bacteria levels with a higher dose of vancomycin for up to one month; Neither study reported any differences in quality of life or unwanted effects. Oral plus inhaled antibiotics compared to oral antibiotics plus placebo (1 study, 25 people) One study compared a combination of oral plus inhaled antibiotics to inhaled antibiotics plus placebo. We are uncertain if either treatment made any difference to MRSA clearance; There may be few or no differences between groups in lung function, quality of life or unwanted effects; The study did not report changes in weight or frequency of flare‐ups. What are the limitations of the evidence? Our confidence in the results ranged from high to very low. This was due to potential issues with the trial designs (people knew which treatment they were receiving), or because there were small numbers of people in each trial and many of them dropped out. How up to date is this evidence? This review updates our previous review published in 2022. The evidence is current to 28 April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lo, DKH, Jahnke, N, Smith, S, Muhlebach, MS, Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD009650.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.778Z" }, { "id": "bfd4bad5-73bf-47ff-8518-b615d8c5aeeb", "pmid": "", "title": "Anticholinergic agents for chronic asthma in adults", "imported": false, "abstract": "Abstract - Background Anticholinergic agents such as ipratropium bromide are sometimes used in the treatment of chronic asthma. They effect bronchodilation and have also been used in combination with ß2 ‐agonists in the management of chronic asthma. Objectives To examine the effectiveness of anticholinergic agents versus placebo and in comparison with ß2 ‐agonists or as adjunctive therapy to ß2 ‐agonists. Search methods The Cochrane Airways Group asthma and wheeze database was searched with a pre‐defined search strategy. Searches were current as of August 2008. Reference lists of articles were also examined. Selection criteria Randomised trials or quasi‐randomised trials were considered for inclusion. Studies assessing an anticholinergic agent versus placebo or in combination/comparison with ß2 ‐agonists were included. In practice, all ß2 ‐agonists were short acting. Short‐term (less than 24 hours duration) were not considered for this review. Data collection and analysis Two reviewers independently assessed abstracts for retrieval of full text articles. Papers were then assessed for suitability for inclusion in the review. Data from included studies were extracted by two reviewers and entered into the software package (RevMan 4.2). We contacted authors for missing data and some responded. Adverse effect data were analysed if reported in the included studies. Main results The studies analysed were in two groups: those comparing anticholinergics with placebo and those comparing the combination of anticholinergics with short acting ß2 ‐agonists versus short acting ß2 ‐agonists alone. The former group had 13 studies involving 205 participants included in this review, and the latter 9 studies involving 440 patients. Generally methodological quality was poorly reported, and there were some reservations with respect to the quality of the studies. Despite the limited number of studies that could be combined, anticholinergic agents in comparison with placebo resulted in more favourable symptom scores particularly in respect of daytime dyspnoea (WMD ‐0.09 (95%CI ‐0.14, ‐0.04, 3 studies, 59 patients). Daily peak flow measurements also showed a statistically significant improvement for the anticholinergic (e.g. morning PEF: WMD =14.38 litres/min (95%CI 7.69, 21.08; 3 studies, 59 patients). However the clinical significance is small and in terms of peak flow measurements equates to approximately a 7% increase over placebo. The more clinically relevant comparison of a combination of anticholinergic plus short acting ß2 ‐agonist versus short acting ß2 ‐agonist alone gave no evidence in respect of symptom scores or peak flow rates of any significant differences between the two regimes. Again there are reservations with respect to the quality of the information from which these conclusions are drawn. An update search in August 2004 did not identify any new studies. Authors' conclusions Overall this review provides no justification for routinely introducing anticholinergics as part of add‐on treatment for patients whose asthma is not well controlled on standard therapies. This does not exclude the possibility that there may be a sub‐group of patients who derive some benefit and a trial of treatment in individual patients may still be justified. The role of long term anticholinergics such as tiotropium bromide has yet to be established in patients with asthma and any future trials might draw on the messages derived from this review. Plain language summary Anticholinergic agents for chronic asthma in adults Anticholinergic agents such as Atrovent are sometimes used to treat people with asthma as a bronchodilator that opens up the airways in the lungs. This review found that although this treatment was better than placebo, the size of the effect was rather small. When the drug was used in combination with more widely used bronchodilators (beta‐agonists such as fenoterol), it did not appear to add much benefit. However, there are concerns about the quality of the studies that have been analysed. It could be that there are some adults with chronic asthma who respond to treatment with anticholinergic drugs, but the review has not been able to identify their common characteristics.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Westby, MJ; Benson, MK; Gibson, PG", "articleTypes": [], "doi": "10.1002/14651858.CD003269.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "bfdef5ed-7f50-453a-82b5-65a6222ae741", "pmid": "", "title": "Role of Sweet Taste Signaling in Glucose Regulation", "imported": false, "abstract": "Data from several studies show that consuming a diet high in low-calorie sweeteners (LCS), mainly in diet sodas, is linked to the same metabolic disorders as consuming a diet high in added sugars, including an increased risk of developing type 2 diabetes. Sweet taste receptors, once thought to be unique to the mouth, have now been discovered in other parts of the body, including the intestine and the pancreas, where they play a role in blood sugar control. These newly identified receptors provide new avenues to explore how LCS may affect metabolism and health. This project is designed to examine the role of sweet taste signaling, both in the mouth and in the gut, on blood sugar control and how habitual consumption of LCS may affect sweet taste signaling and metabolism in people with obesity.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "bff44462-3346-4d03-bbb8-6c0ce0dc4482", "pmid": "", "title": "Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection", "imported": false, "abstract": "Abstract - Background Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted infections. The majority of women with genital herpes will have a recurrence during pregnancy. Transmission of the virus from mother to fetus typically occurs by direct contact with virus in the genital tract during birth. Objectives To assess the effectiveness of antenatal antiviral prophylaxis for recurrent genital herpes on neonatal herpes and maternal recurrences at delivery. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2006, Issue 4), MEDLINE (January 1966 to February 2007) and EMBASE (January 1974 to February 2007; handsearched conference proceedings; reviewed bibliographies of all relevant articles for further references; and contacted experts in the field. Selection criteria Randomized controlled trials which assessed the effectiveness of antivirals compared to placebo or no therapy, on neonatal herpes and maternal disease endpoints among pregnant women with genital herpes. Data collection and analysis Two authors independently applied study selection criteria and extracted data. Main results Seven randomized controlled trials (1249 participants) which met our inclusion criteria compared acyclovir to placebo or no treatment (five trials) and valacyclovir to placebo (two trials). The effect of antepartum antiviral prophylaxis on neonatal herpes could not be estimated. There were no cases of symptomatic neonatal herpes in the included studies in either the treatment or placebo groups. Women who received antiviral prophylaxis were significantly less likely to have a recurrence of genital herpes at delivery (relative risk (RR) 0.28, 95% confidence interval (CI) 0.18 to 0.43, I 2 = 0%). Women who received antiviral prophylaxis were also significantly less likely to have a cesarean delivery for genital herpes (RR 0.30, 95% CI 0.20 to 0.45, I 2 = 27.3%). Women who received antiviral prophylaxis were significantly less likely to have HSV detected at delivery (RR 0.14, 95% CI 0.05 to 0.39, I 2 = 0%). Authors' conclusions Women with recurrent genital herpes simplex virus should be informed that the risk of neonatal herpes is low. There is insufficient evidence to determine if antiviral prophylaxis reduces the incidence of neonatal herpes. Antenatal antiviral prophylaxis reduces viral shedding and recurrences at delivery and reduces the need for cesarean delivery for genital herpes. Limited information exists regarding the neonatal safety of prophylaxis. The risks, benefits, and alternatives to antenatal prophylaxis should be discussed with women who have a history and prophylaxis initiated for women who desire intervention. Plain language summary Use of antiviral drugs in late pregnancy for reducing the recurrence of genital herpes at labor and birth and reducing the risk of newborn HSV infection The incidence of herpes, a sexually transmitted disease, varies across the world. Among pregnant women with herpes, nearly 75% can expect at least one flare‐up during their pregnancy. Transmission of the virus from mother to baby typically occurs by direct contact with the virus during birth. It is often recommended that a cesarean should be offered to women with active lesions to reduce the risk of transmission to the baby. In addition, several antiviral agents are available for use both for therapy and for preventing a flare‐up. These antiviral drugs include acyclovir, penciclovir, valacyclovir, and famciclovir. The review assessed whether antiviral drugs given to pregnant women with herpes before a recurrence might be effective in reducing transmission to the baby. Seven studies were identified involving 1249 women. Giving antiviral drugs reduces viral shedding and recurrences at labor and birth. They also reduced the use of cesarean, but there is no evidence of reduction in neonatal herpes. Women should also be informed that the risk of the baby getting herpes during birth is low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Hollier, LM, Wendel, GD", "articleTypes": [], "doi": "10.1002/14651858.CD004946.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.785Z" }, { "id": "c0012cab-8342-4e9f-b701-99b06b055bd0", "pmid": "", "title": "Anticoagulation for people receiving long‐term haemodialysis", "imported": false, "abstract": "Abstract - Background Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding. Objectives To assess the efficacy and safety of anticoagulation strategies (including both heparin and non‐heparin drugs) for long‐term HD in people with kidney failure. Any intervention preventing clotting within the extracorporeal circuit without establishing anticoagulation within the patient, such as regional citrate, citrate enriched dialysate, heparin‐coated dialysers, pre‐dilution haemodiafiltration (HDF), and saline flushes were also included. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to November 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐randomised controlled studies (quasi‐RCTs) evaluating anticoagulant agents administered during HD treatment in adults and children with kidney failure. Data collection and analysis Two authors independently assessed the risk of bias using the Cochrane tool and extracted data. Treatment effects were estimated using random effects meta‐analysis and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE). Main results We included 113 studies randomising 4535 participants. The risk of bias in each study was adjudicated as high or unclear for most risk domains. Compared to UFH, LMWH had uncertain effects on extracorporeal circuit thrombosis (3 studies, 91 participants: RR 1.58, 95% CI 0.46 to 5.42; I 2 = 8%; low certainty evidence), while major bleeding and minor bleeding were not adequately reported. Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH (2 studies, 82 participants: RR 0.34, 95% CI 0.14 to 0.85; I 2 = 0%; low certainty evidence). No studies reported data comparing regional citrate to UFH on risks of extracorporeal circuit thrombosis and major bleeding. The effects of very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors or heparin‐grafted membranes were uncertain due to insufficient data. The effects of different LMWH, different doses of LMWH, and the administration of LMWH anticoagulants using inlet versus outlet bloodline or bolus versus infusion were uncertain. Evidence to compare citrate to another citrate or control was scant. The effects of UFH compared to no anticoagulant therapy or different doses of UFH were uncertain. Death, dialysis vascular access outcomes, blood transfusions, measures of anticoagulation effect, and costs of interventions were rarely reported. No studies evaluated the effects of treatment on non‐fatal myocardial infarction, non‐fatal stroke and hospital admissions. Adverse events were inconsistently and rarely reported. Authors' conclusions Anticoagulant strategies, including UFH and LMWH, have uncertain comparative risks on extracorporeal circuit thrombosis, while major bleeding and minor bleeding were not adequately reported. Regional citrate may decrease minor bleeding, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported. Evidence supporting clinical decision‐making for different forms of anticoagulant strategies for HD is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes. Plain language summary Treatments to thin the blood during haemodialysis: which treatments reduce clotting problems without causing bleeding? What is the issue? When people have dialysis using a machine to clean their blood (called haemodialysis (HD)), blood‐thinning treatment helps prevent blood clots in the dialysis tubing. However, thinning the blood too much with treatment can lead to bleeding problems. There are several different medications to thin the blood, but it is not clear which is the best or the safest choice. What did we do? We searched for all the research trials that assessed the blood thinning treatments during HD for adults and children up until November 2023. We measured the certainty we could have about the results of this research using \"GRADE\". What did we find? We found 113 studies involving 4535 patients treated with HD. Patients were given different forms of blood thinning therapy. The treatment they got was decided by random chance (like the toss of a coin). Most of the studies looked at a treatment called \"low molecular weight heparin\" and compared this with standard blood thinning care (called \"standard heparin\"). Unfortunately, the studies included only a small number of patients and only looked for risks of clotting or bleeding during one or two months of therapy. Because of this short time frame, and other limitations of the research studies, we were very uncertain about the results. The current research doesn't tell us whether one blood thinning treatment is better or safer than another for patients during dialysis treatment. Conclusions We still can't be certain about the best way to thin the blood for HD treatment based on existing research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Natale, P; Palmer, SC; Ruospo, M; Longmuir, H; Dodds, B; Prasad, R; Batt, TJ; Jose, MD; Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD011858.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "c00a9a38-b56a-4d21-ad29-ceb69d14f4aa", "pmid": "", "title": "Expression of Bitter Taste Receptors in Oropharynx Carcinoma", "imported": false, "abstract": "The aim of this work is to investigate the expression of the bitter taste receptors in p16-positive and negative oropharyngeal carcinomas (in comparison to healthy, local tissue).", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.141Z" }, { "id": "c03e5584-7f06-4042-b570-b83e2dcd4aa3", "pmid": "", "title": "Breastfeeding for procedural pain in infants beyond the neonatal period", "imported": false, "abstract": "Abstract - Background Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin‐to‐skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk. Objectives To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin‐to‐skin contact, expressed breast milk, formula milk, bottle feeding, sweet‐tasting solutions (e.g. sucrose or glucose), distraction, or other interventions. Search methods We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In‐Process & Other Non‐Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials. Selection criteria We included RCTs and quasi‐RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet‐tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin‐to‐skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random‐effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information. Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38‐second reduction in cry time (MD ‐38, 95% CI ‐50 to ‐26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12‐month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7‐point reduction in standardised pain scores (SMD ‐1.7, 95% CI ‐2.2 to ‐1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD ‐3.6, ‐23 to 16). Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage. No included studies reported adverse events. Authors' conclusions We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin‐breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted. Plain language summary Does breastfeeding reduce vaccination pain in babies aged 1 to 12 months? Bottom line We found that breastfeeding before and during vaccination injections helped to reduce pain in most babies up to the age of one year. Background Needles are used for babies' early childhood vaccinations and medical care during childhood illnesses. These are essential, but painful. They cause distress for the babies and often their parents/caregivers, and can result in future anxiety and fear about needles. Breastfeeding during blood tests in newborn babies reduces pain. Breastfeeding when possible and feasible may also help to comfort babies and reduce their pain beyond the newborn period and throughout infancy. Study characteristics In February 2016 we searched the medical literature for studies examining the effectiveness of breastfeeding babies 1 to 12 months old during the use of needles. We compared effectiveness of breastfeeding in reducing pain (as scored by crying time and pain scores), to holding, babies lying flat, or the giving of water or sweet solutions. We found 10 studies with a total of 1066 infants. All studies examined if breastfeeding reduced pain during vaccinations. Key results Breastfeeding reduced crying in young babies having vaccinations. On average, breastfed babies cried for 38 seconds less than babies who were not breastfed (6 studies; 547 infants; moderate‐quality evidence), and pain scores were significantly lower (5 studies; 310 infants; moderate‐quality evidence). No studies reported on any harm (very low‐quality evidence). We could draw no conclusions on risk of harm while breastfeeding healthy babies during vaccination. Going forward: if mothers are breastfeeding, it could be considered when possible for babies during vaccinations. More evidence is needed to learn if breastfeeding helps older babies and babies in hospital during blood work or procedures such as insertion of drips. Quality of the evidence The quality of the evidence was moderate for crying time and pain scores. Most studies included younger infants aged 1 to 6 months. Further research including older infants up to 12 months of age may change our conclusions. In addition, the studies evaluated the effects of breastfeeding during vaccination. We do not know whether breastfeeding helps sick babies aged 1 to 12 months in hospital during blood sampling or drip insertion.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Harrison, D; Reszel, J; Bueno, M; Sampson, M; Shah, VS; Taddio, A; Larocque, C; Turner, L", "articleTypes": [], "doi": "10.1002/14651858.CD011248.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "c04ccb63-ae23-43ec-967f-cc49fd30f0c2", "pmid": "", "title": "Preprocedural mouth rinses for preventing transmission of infectious diseases through aerosols in dental healthcare providers", "imported": false, "abstract": "Abstract - Background Aerosols and spatter are generated in a dental clinic during aerosol‐generating procedures (AGPs) that use high‐speed hand pieces. Dental healthcare providers can be at increased risk of transmission of diseases such as tuberculosis, measles and severe acute respiratory syndrome (SARS) through droplets on mucosae, inhalation of aerosols or through fomites on mucosae, which harbour micro‐organisms. There are ways to mitigate and contain spatter and aerosols that may, in turn, reduce any risk of disease transmission. In addition to personal protective equipment (PPE) and aerosol‐reducing devices such as high‐volume suction, it has been hypothesised that the use of mouth rinse by patients before dental procedures could reduce the microbial load of aerosols that are generated during dental AGPs. Objectives To assess the effects of preprocedural mouth rinses used in dental clinics to minimise incidence of infection in dental healthcare providers and reduce or neutralise contamination in aerosols. Search methods We used standard, extensive Cochrane search methods. The latest search date was 4 February 2022. Selection criteria We included randomised controlled trials and excluded laboratory‐based studies. Study participants were dental patients undergoing AGPs. Studies compared any preprocedural mouth rinse used to reduce contaminated aerosols versus placebo, no mouth rinse or another mouth rinse. Our primary outcome was incidence of infection of dental healthcare providers and secondary outcomes were reduction in the level of contamination of the dental operatory environment, cost, change in mouth microbiota, adverse events, and acceptability and feasibility of the intervention. Data collection and analysis Two review authors screened search results, extracted data from included studies, assessed the risk of bias in the studies and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random‐effects meta‐analysis to combine data Main results We included 17 studies with 830 participants aged 18 to 70 years. We judged three trials at high risk of bias, two at low risk and 12 at unclear risk of bias. None of the studies measured our primary outcome of the incidence of infection in dental healthcare providers. The primary outcome in the studies was reduction in the level of bacterial contamination measured in colony‐forming units (CFUs) at distances of less than 2 m (intended to capture larger droplets) and 2 m or more (to capture droplet nuclei from aerosols arising from the participant's oral cavity). It is unclear what size of CFU reduction represents a clinically significant amount. There is low‐ to very low‐certainty evidence that chlorhexidine (CHX) may reduce bacterial contamination, as measured by CFUs, compared with no rinsing or rinsing with water. There were similar results when comparing cetylpyridinium chloride (CPC) with no rinsing and when comparing CPC, essential oils/herbal mouthwashes or boric acid with water. There is very low‐certainty evidence that tempered mouth rinses may provide a greater reduction in CFUs than cold mouth rinses. There is low‐certainty evidence that CHX may reduce CFUs more than essential oils/herbal mouthwashes. The evidence for other head‐to‐head comparisons was limited and inconsistent. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or adverse events such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess acceptability of the intervention to patients or feasibility of implementation for dentists. Authors' conclusions None of the included studies measured the incidence of infection among dental healthcare providers. The studies measured only reduction in level of bacterial contamination in aerosols. None of the studies evaluated viral or fungal contamination. We have only low to very low certainty for all findings. We are unable to draw conclusions regarding whether there is a role for preprocedural mouth rinses in reducing infection risk or the possible superiority of one preprocedural rinse over another. Studies are needed that measure the effect of rinses on infectious disease risk among dental healthcare providers and on contaminated aerosols at larger distances with standardised outcome measurement. Plain language summary Does use of mouth rinse before a dental procedure reduce the risk of infection transmission from patient to health professional? Why is this question important? Many dental procedures generate droplets that settle on a surface quickly. If high‐speed instruments, such as a drill, are used, aerosols are generated, which consist of tiny particles that remain suspended in the air and that can be inhaled or that settle farther away on surfaces. These aerosols contain a variety of micro‐organisms and may transmit infections either through direct contact or indirectly through the contaminated surfaces. To prevent the spread of infection, it may help to reduce the number of micro‐organisms that are present in these aerosols. The use of mouth rinses before a dental procedure ('preprocedural mouth rinse') has been suggested as a possible way to reduce the amount of contamination of these aerosols. Chlorhexidine, povidone iodine and cetylpyridinium chloride (CPC) are some of the commonly used mouth rinses. They act by killing or inactivating the micro‐organisms in the mouth and thereby reducing the level of contamination in the aerosol that is generated. We wanted to find out whether rinsing the mouth before a dental procedure reduces the contamination of aerosols produced during dental procedures in practice and helps prevent the transmission of infectious diseases. How did we identify and evaluate the evidence? We searched for all relevant studies that compared mouth rinses used before dental procedures against placebo (fake treatment), no intervention or another mouth rinse considered to be inactive. We then compared the results, and summarised the evidence from all the studies. Finally, we assessed our confidence in the evidence. To do this, we considered factors such as the way studies were conducted, study sizes and consistency of findings across studies. What did we find? We found 17 studies that met our inclusion criteria. These studies used chlorhexidine, CPC, essential oil/herbal mouth rinses, povidone iodine and boric acid in comparison to no rinsing, or rinsing with water, saline (salt water) or another mouth rinse. None of the studies measured the how often dental healthcare providers became infected with micro‐organisms. All the included studies measured the level of bacterial contamination in droplets or aerosols in the dental clinic. They did not examine contamination with viruses or fungi. Most rinses decreased bacterial contamination in aerosols to some extent, but there was considerable variation in the effects and we do not know what size of reduction is necessary to reduce infection risk. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or side effects such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess whether patients were happy to use a mouth rinse or whether it was easy for dentists to implement. Overall, the results suggest that using a preprocedural mouth rinse may reduce the level of bacterial contamination in aerosols compared with no rinsing or rinsing with water, but we have only low or very low certainty that the evidence is reliable and we do not know how this reduction in contamination relates to the risk of infection. What does this mean? We have very little confidence in the evidence, and further studies may change the findings of our review. No studies measured infection risk or investigated viral or fungal contamination. How up‐to‐date is this review? The evidence in this Cochrane Review is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kumbargere Nagraj, S, Eachempati, P, Paisi, M, Nasser, M, Sivaramakrishnan, G, Francis, T, Verbeek, JH", "articleTypes": [], "doi": "10.1002/14651858.CD013826.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.066Z" }, { "id": "c0549fb8-34a4-4d5c-a4cb-cc4e3d2f2893", "pmid": "", "title": "The Effects of Semaglutide on Modulation of Taste Sensitivity, Tongue Tissue Transcriptome, Gastric Emptying and Central Neural Responses in Women With PCOS and Obesity: a Randomized, Single-blind, Placebo-controlled Clinical Trial", "imported": false, "abstract": "The purpose of the study is to explore the effects of GLP-1 receptor agonist (GLP-1 RA) semaglutide on modulation of taste sensitivity, tongue tissue transcriptome, modulation of neural response in central reward processing regions and gastric emptying rate. In addition, we aim to investigate the associations between semaglutide induced modulation of taste sensitivity, neural responses and gastric emptying with changes in body mass, eating- behavioural pattern, food perception and food intake.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.146Z" }, { "id": "c05d3b91-a2a2-49ba-b366-ffca72909534", "pmid": "", "title": "Colchicine for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The development of severe coronavirus disease 2019 (COVID‐19) and poor clinical outcomes are associated with hyperinflammation and a complex dysregulation of the immune response. Colchicine is an anti‐inflammatory medicine and is thought to improve disease outcomes in COVID‐19 through a wide range of anti‐inflammatory mechanisms. Patients and healthcare systems need more and better treatment options for COVID‐19 and a thorough understanding of the current body of evidence. Objectives To assess the effectiveness and safety of Colchicine as a treatment option for COVID‐19 in comparison to an active comparator, placebo, or standard care alone in any setting, and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising CENTRAL, MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv), Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index), and WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions to 21 May 2021. Selection criteria We included randomised controlled trials evaluating colchicine for the treatment of people with COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We excluded studies investigating the prophylactic effects of colchicine for people without severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection but at high risk of SARS‐CoV‐2 exposure. Data collection and analysis We followed standard Cochrane methodology. We used the Cochrane risk of bias tool (ROB 2) to assess bias in included studies and GRADE to rate the certainty of evidence for the following prioritised outcome categories considering people with moderate or severe COVID‐19: all‐cause mortality, worsening and improvement of clinical status, quality of life, adverse events, and serious adverse events and for people with asymptomatic infection or mild disease: all‐cause mortality, admission to hospital or death, symptom resolution, duration to symptom resolution, quality of life, adverse events, serious adverse events. Main results We included three RCTs with 11,525 hospitalised participants (8002 male) and one RCT with 4488 (2067 male) non‐hospitalised participants. Mean age of people treated in hospital was about 64 years, and was 55 years in the study with non‐hospitalised participants. Further, we identified 17 ongoing studies and 11 studies completed or terminated, but without published results. Colchicine plus standard care versus standard care (plus/minus placebo) Treatment of hospitalised people with moderate to severe COVID‐19 All‐cause mortality : colchicine plus standard care probably results in little to no difference in all‐cause mortality up to 28 days compared to standard care alone (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.93 to 1.08; 2 RCTs, 11,445 participants; moderate‐certainty evidence). Worsening of clinical status : colchicine plus standard care probably results in little to no difference in worsening of clinical status assessed as new need for invasive mechanical ventilation or death compared to standard care alone (RR 1.02, 95% CI 0.96 to 1.09; 2 RCTs, 10,916 participants; moderate‐certainty evidence). Improvement of clinical status : colchicine plus standard care probably results in little to no difference in improvement of clinical status, assessed as number of participants discharged alive up to day 28 without clinical deterioration or death compared to standard care alone (RR 0.99, 95% CI 0.96 to 1.01; 1 RCT, 11,340 participants; moderate‐certainty evidence). Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is very uncertain about the effect of colchicine on adverse events compared to placebo (RR 1.00, 95% CI 0.56 to 1.78; 1 RCT, 72 participants; very low‐certainty evidence). Serious adverse events : the evidence is very uncertain about the effect of colchicine plus standard care on serious adverse events compared to standard care alone (0 events observed in 1 RCT of 105 participants; very low‐certainty evidence). Treatment of non‐hospitalised people with asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 All‐cause mortality : the evidence is uncertain about the effect of colchicine on all‐cause mortality at 28 days (Peto odds ratio (OR) 0.57, 95% CI 0.20 to 1.62; 1 RCT, 4488 participants; low‐certainty evidence). Admission to hospital or death within 28 days : colchicine probably slightly reduces the need for hospitalisation or death within 28 days compared to placebo (RR 0.80, 95% CI 0.62 to 1.03; 1 RCT, 4488 participants; moderate‐certainty evidence). Symptom resolution : we identified no studies reporting this outcome. Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is uncertain about the effect of colchicine on adverse events compared to placebo . Results are from one RCT reporting treatment‐related events only in 4412 participants (low‐certainty evidence). Serious adverse events : colchicine probably slightly reduces serious adverse events (RR 0.78, 95% CI 0.61 to 1.00; 1 RCT, 4412 participants; moderate‐certainty evidence). Colchicine versus another active treatment (e.g. corticosteroids, anti‐viral drugs, monoclonal antibodies) No studies evaluated this comparison. Different formulations, doses, or schedules of colchicine No studies assessed this. Authors' conclusions Based on the current evidence, in people hospitalised with moderate to severe COVID‐19 the use of colchicine probably has little to no influence on mortality or clinical progression in comparison to placebo or standard care alone. We do not know whether colchicine increases the risk of (serious) adverse events. We are uncertain about the evidence of the effect of colchicine on all‐cause mortality for people with asymptomatic infection or mild disease. However, colchicine probably results in a slight reduction of hospital admissions or deaths within 28 days, and the rate of serious adverse events compared with placebo. None of the studies reported data on quality of life or compared the benefits and harms of colchicine versus other drugs, or different dosages of colchicine. We identified 17 ongoing and 11 completed but not published RCTs, which we expect to incorporate in future versions of this review as their results become available. Editorial note: due to the living approach of this work, we monitor newly published results of RCTs on colchicine on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Is colchicine an effective treatment for people with COVID‐19? Key messages ○ In hospitalised people with moderate to severe COVID‐19, colchicine probably has little to no benefit; we are uncertain about its side effects. ○In non‐hospitalised people with no symptoms or mild COVID‐19, we are uncertain whether colchicine prevents deaths or side effects, however it probably reduces the need for hospitalisation or death and serious side effects slightly. ○ Future studies should assess quality of life in people with no symptoms or mild COVID‐19 and non‐serious side effects and compare colchicine to other medicines for COVID‐19, such as corticosteroids. What is colchicine? Colchicine is a medicine used to reduce swelling and inflammation and may consequently relieve pain. It is often used to treat gout, a condition where people’s joints become swollen and painful. On the other hand, colchicine can be harmful to people with some health conditions, such as kidney or liver problems, or if you take too much of it. How might colchicine treat COVID‐19? Since colchicine is an anti‐inflammatory drug; researchers are interested in whether it might help with reducing inflammation caused by COVID‐19. What did we want to find out? We wanted to know whether colchicine is an effective treatment for people with COVID‐19 compared to placebo (a treatment that looks and tastes the same as colchicine but with no active ingredient) or usual care alone. We looked at people with moderate or severe disease being treated in hospital or with mild disease being treated in the community. We were particularly interested in the effects of colchicine on: ○ number of deaths; ○ whether people’s condition worsened or improved; ○ quality of life; ○ serious and non‐serious side effects What did we do? We searched for studies that compared colchicine together with usual care to usual care (plus/minus placebo). Studies could take place anywhere in the world and include people with mild or no symptoms, moderate or severe COVID‐19, of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our certainty in the evidence, based on factors such as study methods and sizes. What did we find? We identified four eligible randomised trials. Three included 11,525 hospitalised people and one included 4488 non‐hospitalised people. For hospitalised people, the average age was 64 years, and for non‐hospitalised people, the average age was 55 years. Two studies compared colchicine and usual care with usual care alone and 2 studies compared colchicine with usual care and placebo. None of the studies reported quality of life. We also found 17 ongoing studies and 11 completed but unpublished studies. Main results Hospitalised people with moderate to severe COVID‐19 (3 studies, 11,525 people) ○Colchicine probably does not reduce deaths in the 28 days after treatment (2 studies, 11,445 people). ○Colchicine probably does not prevent the worsening of patients’ condition (2 studies, 10,916 people) and probably does not improve it (1 study, 11,340 people). ○We are very uncertain about the effect of colchicine on side effects and serious side effects (2 studies, 177 people). Non‐hospitalised people with no symptoms or mild COVID‐19 (1 study, 4488 people) ○We are uncertain whether colchicine prevents deaths up to 28 days after treatment. ○Colchicine probably slightly reduces the risk of hospitalisation or death. ○We are uncertain about the effect of colchicine on side effects, but it probably slightly reduces serious side effects. What are the limitations of the evidence? Our certainty in the evidence is limited. Two studies did not use a placebo, so everybody knew who was treated with colchicine, which could influence the results. There were too few events for non‐hospitalised people, such as admissions to hospital and deaths, to be certain about the evidence. Studies used different ways to assess and report unwanted effects, so we could not combine studies into a single result to make a judgement. How up to date is this evidence? The evidence is up to date to 21 May 2021. Editorial note: this is a living systematic review. We search for new evidence every week and update the review when we identify relevant new evidence. Refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Mikolajewska, A; Fischer, A-L; Piechotta, V; Mueller, A; Metzendorf, M-I; Becker, M; Dorando, E; Pacheco, RL; Martimbianco, ALC; Riera, R; Skoetz, N; Stegemann, M", "articleTypes": [], "doi": "10.1002/14651858.CD015045", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "c06767b1-12ce-44ca-80c5-e1d935fdc6eb", "pmid": "", "title": "Paroxetine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Paroxetine is the most potent inhibitor of the reuptake of serotonin of all selective serotonin reuptake inhibitors (SSRIs) and has been studied in many randomised controlled trials (RCTs). However, these comparative studies provided contrasting findings and systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to paroxetine alone. The present systematic review assessed the efficacy and tolerability profile of paroxetine in comparison with tricyclics (TCAs), SSRIs and newer or non‐conventional agents. Objectives 1. To determine the efficacy of paroxetine in comparison with other anti‐depressive agents in alleviating the acute symptoms of Major Depressive Disorder. 2. To review acceptability of treatment with paroxetine in comparison with other anti‐depressive agents. 3. To investigate the adverse effects of paroxetine in comparison with other anti‐depressive agents. Search methods We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR, to 30 September 2012), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Reference lists of relevant papers and previous systematic reviews were handsearched. Pharmaceutical companies marketing paroxetine and experts in this field were contacted for supplemental data. Selection criteria All randomised controlled trials allocating participants with major depression to paroxetine versus any other antidepressants (ADs), both conventional (such as TCAs, SSRIs) and newer or non‐conventional (such as hypericum). For trials which had a cross‐over design, only results from the first randomisation period were considered. Data collection and analysis Two review authors independently checked eligibility and extracted data using a standard form. Data were then entered in RevMan 5.2 with a double‐entry procedure. Information extracted included study and participant characteristics, intervention details, settings and efficacy, acceptability and tolerability measures. Main results A total of 115 randomised controlled trials (26,134 participants) were included. In 54 studies paroxetine was compared with older ADs, in 21 studies with another SSRI, and in 40 studies with a newer or non‐conventional antidepressant other than SSRIs. For the primary outcome (patients who responded to treatment), paroxetine was more effective than reboxetine at increasing patients who responded early to treatment (Odds Ratio (OR): 0.66, 95% Confidence Interval (CI) 0.50 to 0.87, number needed to treat to provide benefit (NNTb) = 16, 95% CI 10 to 50, at one to four weeks, 3 RCTs, 1375 participants, moderate quality of evidence), and less effective than mirtazapine (OR: 2.39, 95% CI 1.42 to 4.02, NNTb = 8, 95% CI 5 to 14, at one to four weeks, 3 RCTs, 726 participants, moderate quality of evidence). Paroxetine was less effective than citalopram in improving response to treatment (OR: 1.54, 95% CI 1.04 to 2.28, NNTb = 9, 95% CI 5 to 102, at six to 12 weeks, 1 RCT, 406 participants, moderate quality of evidence). We found no clear evidence that paroxetine was more or less effective compared with other antidepressants at increasing response to treatment at acute (six to 12 weeks), early (one to four weeks), or longer term follow‐up (four to six months). Paroxetine was associated with a lower rate of adverse events than amitriptyline, imipramine and older ADs as a class, but was less well tolerated than agomelatine and hypericum. Included studies were generally at unclear or high risk of bias due to poor reporting of allocation concealment and blinding of outcome assessment, and incomplete reporting of outcomes. Authors' conclusions Some possibly clinically meaningful differences between paroxetine and other ADs exist, but no definitive conclusions can be drawn from these findings. In terms of response, there was a moderate quality of evidence that citalopram was better than paroxetine in the acute phase (six to 12 weeks), although only one study contributed data. In terms of early response to treatment (one to four weeks) there was moderate quality of evidence that mirtazapine was better than paroxetine and that paroxetine was better than reboxetine. However there was no clear evidence that paroxetine was better or worse compared with other antidepressants at increasing response to treatment at any time point. Even if some differences were identified, the findings from this review are better thought as hypothesis forming rather than hypothesis testing and it would be reassuring to see the conclusions replicated in future trials. Finally, most of included studies were at unclear or high risk of bias, and were sponsored by the drug industry. The potential for overestimation of treatment effect due to sponsorship bias should be borne in mind. Plain language summary Paroxetine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms such as appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, inappropriate guilt and morbid thoughts of death. Although medication and psychological treatments are both effective for major depression, antidepressant drugs remain the mainstay of treatment in moderate to severe major depression. However, head‐to‐head comparisons of such drugs provide contrasting findings as to whether they are effective. This review of the research on the effect of an antidepressant drug called paroxetine was conducted to shed light on the field of drug treatment for depression. In September 2012 we searched, in a wide ranging way, for all the useful studies (randomised controlled trials) which had been completed which compared paroxetine with any other antidepressant in treating people with depression. One hundred and fifteen studies were included in this review, with a total of 26,134 people. We grouped the studies according to the types of drug they compared paroxetine against; we then analysed the combined findings of these groups of studies. For the primary outcome (number of people who responded to treatment) paroxetine was more effective than reboxetine, but less effective than mirtazapine (in the early phase: one to four weeks follow‐up) and probably citalopram (at endpoint: six weeks follow‐up). There was some evidence that paroxetine is less well tolerated than agomelatine and St John's Wort, as more patients allocated to paroxetine experienced at least some side effects (though this finding for St John's Wort was only based on one study). In conclusion, some possibly meaningful differences between paroxetine and other antidepressants exist, but no definitive concluions can be drawn due to the limited number of studies per comparison. In addition, most of included studies were sponsored by the drug industry, which means they might potentially have overestimated the effect of paroxetine. Therefore, the results of this review should be interpreted with caution.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Purgato, M; Papola, D; Gastaldon, C; Trespidi, C; Magni, LR; Rizzo, C; Furukawa, TA; Watanabe, N; Cipriani, A; Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006531.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "c07bec5d-a602-4440-9676-b1687d9922f2", "pmid": "", "title": "Topical medication instillation techniques for glaucoma", "imported": false, "abstract": "Abstract - Background Glaucoma is a leading cause of irreversible blindness worldwide and the second most common cause of blindness after cataracts. The primary treatment for glaucoma aims to lower intraocular pressure (IOP) with the use of topical medicines. Topical medication instillation techniques, such as eyelid closure and nasolacrimal occlusion when instilling drops, have been proposed as potential methods to increase ocular absorption and decrease systemic absorption of the drops. Objectives To investigate the effectiveness of topical medication instillation techniques compared with usual care or another method of instillation of topical medication in the management of glaucoma or ocular hypertension. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 8 December 2016), Embase Ovid (1947 to 8 December 2016), PubMed (1948 to 8 December 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 8 December 2016), International Pharmaceutical Abstracts Database (1970 to 8 December 2016), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ) (last searched 13 May 2013), ClinicalTrials.gov ( www.clinicaltrials.gov ) (searched 8 December 2016) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) (searched 8 December 2016). We did not use any date or language restrictions in the electronic searches for trials. Selection criteria We included randomized controlled trials which had compared any topical medication instillation technique with usual care or a different method of instillation of topical medication. Data collection and analysis Two review authors independently screened records from the searches for eligibility, assessed the risk of bias, and extracted data. We followed methods recommended by Cochrane. Main results We identified two trials (122 eyes of 61 participants) that had evaluated a topical medication instillation technique. We also identified two ongoing trials. Both included trials used a within‐person design and administered prostaglandin monotherapy for glaucoma or ocular hypertension. Because the trials evaluated different instillation techniques and assessed different outcomes, we performed no meta‐analysis. One trial, conducted in the US, evaluated the effect of eyelid closure (one and three minutes) versus no eyelid closure on lowering IOP. At one to two weeks' follow‐up, reduction in IOP was similar in the eyelid closure group and the no eyelid closure group (mean difference (MD) ‐0.33 mmHg, 95% confidence interval (CI) ‐0.8 to 1.5; 51 participants; moderate‐certainty evidence). The second trial, conducted in Italy, evaluated the effect of using an absorbent cloth to wipe excess fluid after instillation (fluid removal) versus not using an absorbent cloth (no removal) on reducing dermatologic adverse events. At four months' follow‐up, eyelashes were shorter among eyes in the fluid removal group compared with the no fluid removal group (MD ‐1.70 mm, 95% CI ‐3.46 to 0.06; 10 participants; low‐certainty evidence). Fewer eyes showed skin hyperpigmentation in the eyelid region towards the nose in the fluid removal group compared with the no removal group (RR 0.07, 95% CI 0.01 to 0.84; 10 participants; low‐certainty evidence); however, the difference was uncertain in the eyelid region towards the temples (RR 0.44, 95% CI 0.07 to 2.66; 10 participants; low‐certainty evidence). The effect hypertrichosis (excessive hair growth) was uncertain between groups (RR 1.00, 95% CI 0.17 to 5.98; 10 participants; low‐certainty evidence). Neither trial reported other outcomes specified for this review, including the proportion of participants with IOP less than 21 mmHg; participant‐reported outcomes related to the ease, convenience, and comfort of instillation techniques; physiologic measurements of systemic absorption; escalation of therapy; mean change in visual fields; optic nerve progression; mean change in best‐corrected visual acuity; proportion in whom glaucoma developed; quality of life outcomes; or cost‐effectiveness outcomes. Neither trial reported data at follow‐up times of more than four months. Authors' conclusions Evidence to evaluate the effectiveness of topical medication instillation techniques for treatment of glaucoma is lacking. It is unclear what, if any, effects instillation techniques have on topical medical therapy for glaucoma. Plain language summary Topical medicine instillation techniques for glaucoma What is the aim of this review? 
 The aim of this Cochrane Review was to find out if the way that people with glaucoma put eye drops in makes a difference in how well the eye drops work. Cochrane researchers collected and analyzed all relevant studies to answer this question and found two studies. Key messages 
 It is unclear if the way that people with glaucoma put their eye drops in makes a difference in how well the drops work. What did this review study? 
 Glaucoma is a leading cause of blindness worldwide. In eyes with glaucoma, the ability to see may be lost because of damage to the optic nerve. The optic nerve is the part of the eye that sends visual information from the eye to the brain. Sometimes such damage occurs when there is too much pressure in the eye (called intraocular pressure or IOP). Sometimes eyes may have too much pressure without damage to the optic nerve (called ocular hypertension). The main goal of glaucoma and ocular hypertension treatment is to lower IOP. Topical medicines, such as eye drops, are most often used as the first treatment. Encouraging specific ways of applying the drops, such as closing your eyes or nasolacrimal occlusion (closing the eye and pressing a finger on the inside corner, by the nose) aims to increase how much medicine is absorbed into the eye and reduce how much medicine is absorbed into the body. What are the main results of the review? 
 We found two studies that compared different ways of putting in eye drops. Both studies used prostaglandin alone for glaucoma or ocular hypertension. One study, in the US, evaluated the effect of closing the eyes for one and three minutes after putting in eye drops on lowering IOP. The second study, in Italy, looked at whether wiping off the excess fluid, after putting in the eye drops, led to fewer changes in the skin surrounding the eye. After one to two weeks in the US study, closing the eyelid for one to three minutes after putting in the eye drops found no difference on IOP compared with not closing the eyelid for a specified amount of time. After four months in the Italian study, eyelashes were shorter when participants had wiped their eyes to remove excess fluid when compared with participants who did not wipe their eyes. We found two ongoing studies that do not have results yet. Based on only two studies and uncertain results, it is unclear if different ways of putting in eye drops have any effect on people with glaucoma. How up‐to‐date is this review? 
 Cochrane researchers searched for studies that had been published up to 8 December 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Xu, L; Wang, X; Wu, M", "articleTypes": [], "doi": "10.1002/14651858.CD010520.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "c07d0a26-ef98-41fd-b63b-f55e0871be18", "pmid": "", "title": "Dietary Peanut Intake and Nutrition-Related Outcomes in Individuals Using GLP-1 Receptor Agonists: A Randomized Controlled Trial", "imported": false, "abstract": "This study will look at how eating peanuts every day might affect participants weight, how healthy their diet is, and how they feel when eating. Investigators want to see if adding peanuts to meals for 12 weeks helps participants feel fuller, have more energy, and improve body composition. The study will include adults who have been taking GLP-1 medicines like semaglutide or tirzepatide for at least three months. Investigators also want to see if eating peanuts improves overall diet quality and health markers like tiredness and certain levels in blood.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.260Z" }, { "id": "c0897c05-dad3-43c4-9b56-f4c2999a5846", "pmid": "", "title": "Systemic opioids versus other analgesics and sedatives for postoperative pain in neonates", "imported": false, "abstract": "Abstract - Background Neonates may undergo surgery because of malformations such as diaphragmatic hernia, gastroschisis, congenital heart disease, and hypertrophic pyloric stenosis, or complications of prematurity, such as necrotizing enterocolitis, spontaneous intestinal perforation, and retinopathy of prematurity that require surgical treatment. Options for treatment of postoperative pain include opioids, non‐pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported. The assessment of the effects of opioids is of utmost importance, especially for neonates in substantial pain during the postoperative period. Objectives To evaluate the benefits and harms of systemic opioid analgesics in neonates who underwent surgery on all‐cause mortality, pain, and significant neurodevelopmental disability compared to no intervention, placebo, non‐pharmacological interventions, different types of opioids, or other drugs. Search methods We searched Cochrane CENTRAL, MEDLINE via PubMed and CINAHL in May 2021. We searched the WHO ICTRP, clinicaltrials.gov, and ICTRP trial registries. We searched conference proceedings, and the reference lists of retrieved articles for RCTs and quasi‐RCTs. Selection criteria We included randomized controlled trials (RCTs) conducted in preterm and term infants of a postmenstrual age up to 46 weeks and 0 days with postoperative pain where systemic opioids were compared to 1) placebo or no intervention; 2) non‐pharmacological interventions; 3) different types of opioids; or 4) other drugs. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods, all‐cause mortality during initial hospitalization, major neurodevelopmental disability, and cognitive and educational outcomes in children more than five years old. We used the fixed‐effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) for continuous data. We used GRADE to assess the certainty of evidence for each outcome. Main results We included four RCTs enrolling 331 infants in four countries across different continents. Most studies considered patients undergoing large or medium surgical procedures (including major thoracic or abdominal surgery), who potentially required pain control through opioid administration after surgery. The randomized trials did not consider patients undergoing minor surgery (including inguinal hernia repair) and those individuals exposed to opioids before the beginning of the trial. Two RCTs compared opioids with placebo; one fentanyl with tramadol; and one morphine with paracetamol. No meta‐analyses could be performed because the included RCTs reported no more than three outcomes within the prespecified comparisons. Certainty of the evidence was very low for all outcomes due to imprecision of the estimates (downgrade by two levels) and study limitations (downgrade by one level). Comparison 1: opioids versus no treatment or placebo Two trials were included in this comparison, comparing either tramadol or tapentadol with placebo. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of tramadol compared with placebo on all‐cause mortality during initial hospitalization (RR 0.32, 95% Confidence Interval (CI) 0.01 to 7.70; RD ‐0.03, 95% CI ‐0.10 to 0.05, 71 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 2: opioids versus non‐pharmacological interventions No trials were included in this comparison. Comparison 3: head‐to‐head comparisons of different opioids One trial comparing fentanyl with tramadol was included in this comparison. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of fentanyl compared with tramadol on all‐cause mortality during initial hospitalization (RR 0.99, 95% CI 0.59 to 1.64; RD 0.00, 95% CI ‐0.13 to 0.13, 171 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 4: opioids versus other analgesics and sedatives One trial comparing morphine with paracetamol was included in this comparison. The evidence is very uncertain about the effect of morphine compared with paracetamol on COMFORT pain scores (MD 0.10, 95% CI ‐0.85 to 1.05; 71 participants, 1 study; I² = not applicable). No data were reported on the other critical outcomes, i.e. major neurodevelopmental disability; cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization; retinopathy of prematurity; or intraventricular hemorrhage. Authors' conclusions Limited evidence is available on opioid administration for postoperative pain in newborn infants compared to either placebo, other opioids, or paracetamol. We are uncertain whether tramadol reduces mortality compared to placebo; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether fentanyl reduces mortality compared to tramadol; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether morphine reduces pain compared to paracetamol; none of the studies reported major neurodevelopmental disability, cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization, retinopathy of prematurity, or intraventricular hemorrhage. We identified no studies comparing opioids versus non‐pharmacological interventions. Plain language summary Are opioids the best choice for managing pain in babies after surgery? Key messages • We did not find enough good‐quality evidence about the benefits and risks of opioids (a group of pain‐relieving medicines) to manage pain after surgery in babies. We found only four studies and they had not enrolled enough babies to give reliable results. • Larger, well‐designed studies are needed to give better estimates of the benefits and potential harms of opioids, other medicines and non‐medicine‐based treatments. Why are opioids given to manage pain after surgery in babies? Babies (particularly in the first four weeks after birth) often have to have surgeries. Similar to adults, they need constant pain management after these operations and opioids are commonly used for post‐surgery pain relief in babies. What did we want to find out? We wanted to find out the impact of giving opioids to babies having surgery, compared to: 1) no treatment or placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested); 2) non‐medicine‐based treatments (such as sweet solutions); 3) other medicines; or 4) different types of opioids. What did we do? We searched for studies that compared opioids with the four treatments described above. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included four studies that involved 331 babies. The biggest study was in 171 babies and the smallest study was in 15 babies. • Two studies compared opioids with placebo: it is unclear if opioids have an effect on mortality; no studies reported pain, long‐term development, vision problems (retinopathy of prematurity) or bleeding to the brain (intraventricular hemorrhage). • One study compared one type of opioid to another type of opioid: it is unclear if fentanyl has an effect on mortality compared to tramadol; no studies reported pain, long‐term development, vision problems or bleeding to the brain. • One study compared an opioid to a different type of pain‐relieving medicine: it is unclear if the opioid morphine has an effect on pain compared with paracetamol; no studies reported long‐term development, mortality, vision problems or bleeding to the brain. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results of our outcomes. Also, it is possible that people in the studies were aware of what treatment they were given. Not all the studies provided data about everything that we were interested in. How up‐to‐date is this review? 
We searched for studies that were available up to May 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kinoshita, M; Stempel, KS; Borges do Nascimento, IJ; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD014876.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "c0abeea9-56cc-4f35-8b29-65a7ef2d16e5", "pmid": "", "title": "Thoracic imaging tests for the diagnosis of COVID‐19", "imported": false, "abstract": "Abstract - Background Our March 2021 edition of this review showed thoracic imaging computed tomography (CT) to be sensitive and moderately specific in diagnosing COVID‐19 pneumonia. This new edition is an update of the review. Objectives Our objectives were to evaluate the diagnostic accuracy of thoracic imaging in people with suspected COVID‐19; assess the rate of positive imaging in people who had an initial reverse transcriptase polymerase chain reaction (RT‐PCR) negative result and a positive RT‐PCR result on follow‐up; and evaluate the accuracy of thoracic imaging for screening COVID‐19 in asymptomatic individuals. The secondary objective was to assess threshold effects of index test positivity on accuracy. Search methods We searched the COVID‐19 Living Evidence Database from the University of Bern, the Cochrane COVID‐19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID‐19 publications through to 17 February 2021. We did not apply any language restrictions. Selection criteria We included diagnostic accuracy studies of all designs, except for case‐control, that recruited participants of any age group suspected to have COVID‐19. Studies had to assess chest CT, chest X‐ray, or ultrasound of the lungs for the diagnosis of COVID‐19, use a reference standard that included RT‐PCR, and report estimates of test accuracy or provide data from which we could compute estimates. We excluded studies that used imaging as part of the reference standard and studies that excluded participants with normal index test results. Data collection and analysis The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using QUADAS‐2. We presented sensitivity and specificity per study on paired forest plots, and summarized pooled estimates in tables. We used a bivariate meta‐analysis model where appropriate. Main results We included 98 studies in this review. Of these, 94 were included for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eight studies were included for assessing the rate of positive imaging in individuals with initial RT‐PCR negative results and positive RT‐PCR results on follow‐up, and 10 studies were included for evaluating the accuracy of thoracic imaging for imagining asymptomatic individuals. For all 98 included studies, risk of bias was high or unclear in 52 (53%) studies with respect to participant selection, in 64 (65%) studies with respect to reference standard, in 46 (47%) studies with respect to index test, and in 48 (49%) studies with respect to flow and timing. Concerns about the applicability of the evidence to: participants were high or unclear in eight (8%) studies; index test were high or unclear in seven (7%) studies; and reference standard were high or unclear in seven (7%) studies. Imaging in people with suspected COVID‐19 We included 94 studies. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All studies used RT‐PCR alone or in combination with other criteria (for example, clinical signs and symptoms, positive contacts) as the reference standard for the diagnosis of COVID‐19. For chest CT (69 studies, 28285 participants, 14,342 (51%) cases), sensitivities ranged from 45% to 100%, and specificities from 10% to 99%. The pooled sensitivity of chest CT was 86.9% (95% confidence interval (CI) 83.6 to 89.6), and pooled specificity was 78.3% (95% CI 73.7 to 82.3). Definition for index test positivity was a source of heterogeneity for sensitivity, but not specificity. Reference standard was not a source of heterogeneity. For chest X‐ray (17 studies, 8529 participants, 5303 (62%) cases), the sensitivity ranged from 44% to 94% and specificity from 24 to 93%. The pooled sensitivity of chest X‐ray was 73.1% (95% CI 64.1 to 80.5), and pooled specificity was 73.3% (95% CI 61.9 to 82.2). Definition for index test positivity was not found to be a source of heterogeneity. Definition for index test positivity and reference standard were not found to be sources of heterogeneity. For ultrasound of the lungs (15 studies, 2410 participants, 1158 (48%) cases), the sensitivity ranged from 73% to 94% and the specificity ranged from 21% to 98%. The pooled sensitivity of ultrasound was 88.9% (95% CI 84.9 to 92.0), and the pooled specificity was 72.2% (95% CI 58.8 to 82.5). Definition for index test positivity and reference standard were not found to be sources of heterogeneity. Indirect comparisons of modalities evaluated across all 94 studies indicated that chest CT and ultrasound gave higher sensitivity estimates than X‐ray (P = 0.0003 and P = 0.001, respectively). Chest CT and ultrasound gave similar sensitivities (P = 0.42). All modalities had similar specificities (CT versus X‐ray P = 0.36; CT versus ultrasound P = 0.32; X‐ray versus ultrasound P = 0.89). Imaging in PCR‐negative people who subsequently became positive For rate of positive imaging in individuals with initial RT‐PCR negative results, we included 8 studies (7 CT, 1 ultrasound) with a total of 198 participants suspected of having COVID‐19, all of whom had a final diagnosis of COVID‐19. Most studies (7/8) evaluated CT. Of 177 participants with initially negative RT‐PCR who had positive RT‐PCR results on follow‐up testing, 75.8% (95% CI 45.3 to 92.2) had positive CT findings. Imaging in asymptomatic PCR‐positive people For imaging asymptomatic individuals, we included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with a total of 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. For chest CT (7 studies, 3134 participants, 315 (10%) cases), the pooled sensitivity was 55.7% (95% CI 35.4 to 74.3) and the pooled specificity was 91.1% (95% CI 82.6 to 95.7). Authors' conclusions Chest CT and ultrasound of the lungs are sensitive and moderately specific in diagnosing COVID‐19. Chest X‐ray is moderately sensitive and moderately specific in diagnosing COVID‐19. Thus, chest CT and ultrasound may have more utility for ruling out COVID‐19 than for differentiating SARS‐CoV‐2 infection from other causes of respiratory illness. The uncertainty resulting from high or unclear risk of bias and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results. Plain language summary How accurate is chest imaging for diagnosing COVID‐19? Why is this question important? People with suspected COVID‐19 need to know quickly whether they are infected, so they can receive appropriate treatment, self‐isolate, and inform close contacts. Currently, a formal diagnosis of COVID‐19 requires a laboratory test (RT‐PCR) of nose and throat samples. RT‐PCR requires specialist equipment and takes at least 24 hours to produce a result. It is not completely accurate, and may require a second RT‐PCR or a different test to confirm diagnosis. Clinicians may use chest imaging to diagnose people who have COVID‐19 symptoms, while awaiting RT‐PCR results or when RT‐PCR results are negative, and the person has COVID‐19 symptoms. This is the fourth version of this review. What did we want to find out? We wanted to know whether chest imaging is accurate enough to diagnose COVID‐19 in people with suspected infection; we included studies in people with suspected COVID‐19 only and excluded studies in people with confirmed COVID‐19. We also wanted to assess the accuracy of chest imaging for screening asymptomatic people. The evidence is up to date to 17 February 2021. What are chest imaging tests? X‐rays or scans produce an image of the organs and structures in the chest. ‐ X‐rays (radiography) use radiation to produce a 2‐D image. Usually done in hospitals, using fixed equipment by a radiographer; they can also be done on portable machines. ‐ Computed tomography (CT) scans use a computer to merge 2‐D X‐ray images and convert them to a 3‐D image. They require highly‐specialized equipment and are done in hospital by a specialist radiographer. ‐ Ultrasound scans use high‐frequency sound waves to produce an image. They can be done in hospitals or other healthcare settings, such as a doctor’s office. What did we do? We searched for studies that assessed the accuracy of chest imaging to diagnose COVID‐19 in people of any age with suspected COVID‐19. We included studies with ‘symptomatic' or 'mixed populations'. What did we find? We found 94 studies with 37,631 participants (of whom 19,768 (53%) had a final diagnosis of COVID‐19) for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All 94 studies used RT‐PCR either alone or in combination with other criteria (such as clinical signs and symptoms, or positive contacts) as the reference standard for the diagnosis of COVID‐19. Chest CT: suspected people Pooled results showed that chest CT (69 studies) correctly diagnosed COVID‐19 in 87% of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 21% of people who did not have COVID‐19. Chest X‐ray: suspected people Pooled results showed that chest X‐ray (17 studies) correctly diagnosed COVID‐19 in 73 % of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 27% of people who did not have COVID‐19. Lung ultrasound: suspected people Pooled results showed that lung ultrasound (15 studies) correctly diagnosed COVID‐19 in 87% of people with COVID‐19. However, it incorrectly diagnosed COVID‐19 in 24% of people who did not have COVID‐19. Screening asymptomatic people We included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. Pooled results of seven studies, showed that CT correctly diagnosed COVID‐19 in 56% of people who had COVID‐19, and incorrectly identified COVID‐19 in 8% of people who did not have COVID‐19. How reliable are the results? The studies differed from each other and used different methods to report their results. Very few studies directly compared one type of imaging test with another. Also, the risk of bias was high or unclear in about half of all included studies. Therefore, it is difficult to draw confident conclusions. What does this mean? The evidence suggests that chest CT and ultrasound are better at ruling out COVID‐19 infection than distinguishing it from other respiratory problems. So, their usefulness may be limited to excluding COVID‐19 infection rather than differentiating it from other causes of lung infection. In addition, chest CT imaging had poor sensitivity and high specificity for detecting asymptomatic individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ebrahimzadeh, S; Islam, N; Dawit, H; Salameh, J-P; Kazi, S; Fabiano, N; Treanor, L; Absi, M; Ahmad, F; Rooprai, P; Al Khalil, A; Harper, K; Kamra, N; Leeflang, MMG; Hooft, L; van der Pol, CB; Prager, R; Hare, SS; Dennie, C; Spijker, R; Deeks, JJ; Dinnes, J; Jenniskens, K; Korevaar, DA; Cohen, JF; Van den Bruel, A; Takwoingi, Y; van de Wijgert, J; Wang, J; Pena, E; Sabongui, S; McInnes, MDF", "articleTypes": [], "doi": "10.1002/14651858.CD013639.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "c0b0ebef-5c60-405b-aafe-fa48202bdf26", "pmid": "", "title": "A Multimodel Examination of Bromocriptine on Homeostatic and Hedonic Mechanisms of Food Intake in Individuals at High Risk for Type 2 Diabetes", "imported": false, "abstract": "The current project applies an integrative three-prong approach to investigate the potential of the dopamine D2 receptor (DRD2) agonist bromocriptine to: 1) increase homeostatic satiation signaling, 2) alter neural circuitry to reduce hedonically motivated food intake, and 3) examines a genetic predisposition that may markedly impact the effectiveness of this medication in those at high risk for T2DM.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.241Z" }, { "id": "c0bc1902-494d-4046-a6bf-161b76e67a04", "pmid": "", "title": "Role of Sweet Taste Signaling in Glucose Regulation", "imported": false, "abstract": "Data from several studies show that consuming a diet high in low-calorie sweeteners (LCS), mainly in diet sodas, is linked to the same metabolic disorders as consuming a diet high in added sugars, including an increased risk of developing type 2 diabetes. Sweet taste receptors, once thought to be unique to the mouth, have now been discovered in other parts of the body, including the intestine and the pancreas, where they play a role in blood sugar control. These newly identified receptors provide new avenues to explore how LCS may affect metabolism and health. This project is designed to examine the role of sweet taste signaling, both in the mouth and in the gut, on blood sugar control and how habitual consumption of LCS may affect sweet taste signaling and metabolism in people with obesity.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.232Z" }, { "id": "c0e3ddc5-aa7c-4aae-a752-c756f0c55d09", "pmid": "", "title": "Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia", "imported": false, "abstract": "Abstract - Background In a review and meta‐analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion‐focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect. Objectives To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic. Search methods We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the `awaiting classification' section of this review. Selection criteria We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion‐focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post‐surgery. Data collection and analysis One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion. Where possible we used random‐effects meta‐analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges' g) to combine data from different outcome measures. If data were not available in a form suitable for meta‐analysis we performed a narrative review. Main results Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty‐one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta‐analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD ‐0.20, 95% confidence interval (CI) ‐0.35 to ‐0.06), length of stay (mean difference ‐0.52 days, 95% CI ‐0.82 to ‐0.22) and negative affect (SMD ‐0.35, 95% CI ‐0.54 to ‐0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached. Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall,we rated the quality of evidence for each outcome as ‘low’ because of the high level of heterogeneity in meta‐analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta‐analysis, so we rated the quality of evidence as `very low'. Authors' conclusions The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well‐conducted and clearly reported research. Plain language summary The effect of psychological preparation on pain, behavioural recovery, negative emotion and length of stay after surgery Background The way people think and feel before surgery can affect how they feel and what they do after surgery. For example, research shows that people who feel more anxious before their surgery experience more pain after it. A review conducted in 1993 looked at the impact of psychological preparation on outcomes after surgery. The term `psychological preparation' includes a range of techniques that aim to change what people think, how they feel or what they do. This 1993 review found that psychological preparation techniques reduced pain after surgery, improved behavioural recovery (how quickly people return to activities), decreased length of stay in hospital and reduced negative emotion (e.g. feelings of anxiety or depression). We aimed to carry out an up‐to‐date review using Cochrane methodology to learn whether there are helpful (or harmful) effects of psychological preparation for people undergoing surgery, and which outcomes (pain after surgery, behavioural recovery, negative emotion or length of stay) are improved. Study characteristics We included studies of adults who received planned surgery with general anaesthesia. We looked at seven psychological preparation techniques: procedural information (information about what, when and how processes will happen); sensory information (what the experience will feel like and what other sensations they may have, e.g. taste, smell); behavioural instruction (telling patients what they need to do); cognitive intervention (techniques that aim to change how people think); relaxation techniques; hypnosis; and emotion‐focused interventions (techniques that aim to help people to manage their feelings). The psychological preparation had to be delivered before surgery for the study to be included in the review. We included studies that looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion after surgery (within one month). Studies were included in the review up to the search date of 4 May 2014. We updated the search on 7 July 2015 and will incorporate the 38 studies found in this later search when the review is updated. We included 105 studies from 115 papers, with 10,302 participants taking part. Sixty‐one studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative emotion. In accordance with the review protocol, we did not record details about funding sources. Key results In this review we included 105 studies, which were reported in 115 papers. A total of 10,302 participants were randomized in these studies. For pain, length of stay and negative emotion we combined numerical findings from the studies. We found that psychological preparation before surgery seemed to reduce pain and negative emotion after the operation and may reduce the time spent in hospital by around half a day but the quality of the evidence was low. Also, the studies used many different psychological preparation techniques (often in different combinations) so it was not possible to discover which techniques were better. We could not statistically combine numerical findings for behavioural recovery because few studies provided sufficient details and studies used different ways of measuring how quickly people returned to usual activities. In reviewing the studies, we found that psychological preparation, in particular behavioural instruction, may have the potential to improve behavioural recovery. However, the quality of this evidence was very low. We looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion in this review and did not find evidence to suggest that psychological preparation might lead to harm in these outcomes. However, as we did not look at other outcomes it is possible that we did not identify potential harm. Quality of the evidence Many studies were poorly reported, so we could not be confident that findings were reliable. For this reason and because of the large variation in psychological techniques, types of surgery and measures used, we graded the quality of the evidence as `low' for the outcomes pain, negative emotion and length of stay; we cannot be confident that these techniques help patients to recover from surgery. For behavioural recovery, we further downgraded the quality of the evidence to `very low' because of problems with measurement and reporting of the outcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, R; Scott, NW; Manyande, A; Bruce, J; Vögele, C; Byrne‐Davis, LMT; Unsworth, M; Osmer, C; Johnston, M", "articleTypes": [], "doi": "10.1002/14651858.CD008646.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "c0f0a55c-ff25-4c34-be4d-6859b9ee4c45", "pmid": "", "title": "Vitamin C for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Vitamin C (ascorbic acid) for preventing and treating the common cold has been a subject of controversy for 70 years. Objectives To find out whether vitamin C reduces the incidence, the duration or severity of the common cold when used either as a continuous regular supplementation every day or as a therapy at the onset of cold symptoms. Search methods We searched CENTRAL 2012, Issue 11, MEDLINE (1966 to November week 3, 2012), EMBASE (1990 to November 2012), CINAHL (January 2010 to November 2012), LILACS (January 2010 to November 2012) and Web of Science (January 2010 to November 2012). We also searched the U.S. National Institutes of Health trials register and WHO ICTRP on 29 November 2012. Selection criteria We excluded trials which used less than 0.2 g per day of vitamin C and trials without a placebo comparison. We restricted our review to placebo‐controlled trials. Data collection and analysis Two review authors independently extracted data. We assessed 'incidence' of colds during regular supplementation as the proportion of participants experiencing one or more colds during the study period. 'Duration' was the mean number of days of illness of cold episodes. Main results Twenty‐nine trial comparisons involving 11,306 participants contributed to the meta‐analysis on the risk ratio (RR) of developing a cold whilst taking vitamin C regularly over the study period. In the general community trials involving 10,708 participants, the pooled RR was 0.97 (95% confidence interval (CI) 0.94 to 1.00). Five trials involving a total of 598 marathon runners, skiers and soldiers on subarctic exercises yielded a pooled RR of 0.48 (95% CI 0.35 to 0.64). Thirty‐one comparisons examined the effect of regular vitamin C on common cold duration (9745 episodes). In adults the duration of colds was reduced by 8% (3% to 12%) and in children by 14% (7% to 21%). In children, 1 to 2 g/day vitamin C shortened colds by 18%. The severity of colds was also reduced by regular vitamin C administration. Seven comparisons examined the effect of therapeutic vitamin C (3249 episodes). No consistent effect of vitamin C was seen on the duration or severity of colds in the therapeutic trials. The majority of included trials were randomised, double‐blind trials. The exclusion of trials that were either not randomised or not double‐blind had no effect on the conclusions. Authors' conclusions The failure of vitamin C supplementation to reduce the incidence of colds in the general population indicates that routine vitamin C supplementation is not justified, yet vitamin C may be useful for people exposed to brief periods of severe physical exercise. Regular supplementation trials have shown that vitamin C reduces the duration of colds, but this was not replicated in the few therapeutic trials that have been carried out. Nevertheless, given the consistent effect of vitamin C on the duration and severity of colds in the regular supplementation studies, and the low cost and safety, it may be worthwhile for common cold patients to test on an individual basis whether therapeutic vitamin C is beneficial for them. Further therapeutic RCTs are warranted. Plain language summary Vitamin C for preventing and treating the common cold The common cold is a major cause of visits to a doctor in high‐income countries and of absenteeism from work and school. There are over 200 viruses which can cause the common cold symptoms including runny nose, congestion, sneezing, sore throat, cough, and sometimes headache, fever and red eyes. Symptoms vary from person to person and cold to cold. Since the common cold is usually caused by one of the respiratory viruses, antibiotics are useless and therefore other potential treatment options are of substantial public health interest. Vitamin C has been proposed for treating respiratory infections since it was isolated in the 1930s. It became particularly popular in the 1970s when Nobel laureate Linus Pauling concluded from earlier placebo‐controlled trials that vitamin C would prevent and alleviate the common cold. Over two dozen new trials were undertaken thereafter. Vitamin C has been widely sold and used as a preventive and therapeutic agent. This review is restricted to placebo‐controlled trials testing 0.2 g/day or more of vitamin C. Regular ingestion of vitamin C had no effect on common cold incidence in the ordinary population, based on 29 trial comparisons involving 11,306 participants. However, regular supplementation had a modest but consistent effect in reducing the duration of common cold symptoms, which is based on 31 study comparisons with 9745 common cold episodes. In five trials with 598 participants exposed to short periods of extreme physical stress (including marathon runners and skiers) vitamin C halved the common cold risk. The published trials have not reported adverse effects of vitamin C. Trials of high doses of vitamin C administered therapeutically, starting after the onset of symptoms, showed no consistent effect on the duration or severity of common cold symptoms. However, only a few therapeutic trials have been carried out and none have examined children, although the effect of prophylactic vitamin C has been greater in children. One large trial with adults reported benefit from an 8 g therapeutic dose at the onset of symptoms, and two therapeutic trials using five‐day supplementation reported benefit. More trials are necessary to settle the possible role of therapeutic vitamin C, meaning administration immediately after the onset of symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H, Chalker, E", "articleTypes": [], "doi": "10.1002/14651858.CD000980.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.756Z" }, { "id": "c1012240-1f80-4b7e-996c-896ad827b335", "pmid": "", "title": "Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health services. Decay and gum disease can cause pain, eating and speaking difficulties, low self‐esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self‐administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area. Objectives To evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other. Search methods Cochrane Oral Health’s Information Specialist searched: Cochrane Oral Health’s Trials Register (to 16 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 12), MEDLINE Ovid (1946 to 16 January 2019), Embase Ovid (1980 to 16 January 2019) and CINAHL EBSCO (1937 to 16 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication. Selection criteria Randomised controlled trials (RCTs) that compared toothbrushing and a home‐use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks). Data collection and analysis At least two review authors independently screened searches, selected studies, extracted data, assessed studies' risk of bias, and assessed evidence certainty as high, moderate, low or very low, according to GRADE. We extracted indices measured on interproximal surfaces, where possible. We conducted random‐effects meta‐analyses, using mean differences (MDs) or standardised mean differences (SMDs). Main results We included 35 RCTs (3929 randomised adult participants). Studies were at high risk of performance bias as blinding of participants was not possible. Only two studies were otherwise at low risk of bias. Many participants had a low level of baseline gingival inflammation. Studies evaluated the following devices plus toothbrushing versus toothbrushing: floss (15 trials), interdental brushes (2 trials), wooden cleaning sticks (2 trials), rubber/elastomeric cleaning sticks (2 trials), oral irrigators (5 trials). Four devices were compared with floss: interdental brushes (9 trials), wooden cleaning sticks (3 trials), rubber/elastomeric cleaning sticks (9 trials) and oral irrigators (2 trials). Another comparison was rubber/elastomeric cleaning sticks versus interdental brushes (3 trials). No trials assessed interproximal caries, and most did not assess periodontitis. Gingivitis was measured by indices (most commonly, Löe‐Silness, 0 to 3 scale) and by proportion of bleeding sites. Plaque was measured by indices, most often Quigley‐Hein (0 to 5). Primary objective: comparisons against toothbrushing alone Low‐certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index (GI)) at one month (SMD ‐0.58, 95% confidence interval (CI) ‐1.12 to ‐0.04; 8 trials, 585 participants), three months or six months. The results for proportion of bleeding sites and plaque were inconsistent (very low‐certainty evidence). Very low‐certainty evidence suggested that using an interdental brush, plus toothbrushing, may reduce gingivitis (measured by GI) at one month (MD ‐0.53, 95% CI ‐0.83 to ‐0.23; 1 trial, 62 participants), though there was no clear difference in bleeding sites (MD ‐0.05, 95% CI ‐0.13 to 0.03; 1 trial, 31 participants). Low‐certainty evidence suggested interdental brushes may reduce plaque more than toothbrushing alone (SMD ‐1.07, 95% CI ‐1.51 to ‐0.63; 2 trials, 93 participants). Very low‐certainty evidence suggested that using wooden cleaning sticks, plus toothbrushing, may reduce bleeding sites at three months (MD ‐0.25, 95% CI ‐0.37 to ‐0.13; 1 trial, 24 participants), but not plaque (MD ‐0.03, 95% CI ‐0.13 to 0.07). Very low‐certainty evidence suggested that using rubber/elastomeric interdental cleaning sticks, plus toothbrushing, may reduce plaque at one month (MD ‐0.22, 95% CI ‐0.41 to ‐0.03), but this was not found for gingivitis (GI MD ‐0.01, 95% CI ‐0.19 to 0.21; 1 trial, 12 participants; bleeding MD 0.07, 95% CI ‐0.15 to 0.01; 1 trial, 30 participants). Very‐low certainty evidence suggested oral irrigators may reduce gingivitis measured by GI at one month (SMD ‐0.48, 95% CI ‐0.89 to ‐0.06; 4 trials, 380 participants), but not at three or six months. Low‐certainty evidence suggested that oral irrigators did not reduce bleeding sites at one month (MD ‐0.00, 95% CI ‐0.07 to 0.06; 2 trials, 126 participants) or three months, or plaque at one month (SMD ‐0.16, 95% CI ‐0.41 to 0.10; 3 trials, 235 participants), three months or six months, more than toothbrushing alone. Secondary objective: comparisons between devices Low‐certainty evidence suggested interdental brushes may reduce gingivitis more than floss at one and three months, but did not show a difference for periodontitis measured by probing pocket depth. Evidence for plaque was inconsistent. Low‐ to very low‐certainty evidence suggested oral irrigation may reduce gingivitis at one month compared to flossing, but very low‐certainty evidence did not suggest a difference between devices for plaque. Very low‐certainty evidence for interdental brushes or flossing versus interdental cleaning sticks did not demonstrate superiority of either intervention. Adverse events Studies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation. Authors' conclusions Using floss or interdental brushes in addition to toothbrushing may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low‐certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis. Plain language summary Home use of devices for cleaning between the teeth (in addition to toothbrushing) to prevent and control gum diseases and tooth decay Review question How effective are home‐use interdental cleaning devices, plus toothbrushing, compared with toothbrushing only or use of another device, for preventing and controlling periodontal (gum) diseases (gingivitis and periodontitis), tooth decay (dental caries) and plaque? Background Tooth decay and gum diseases affect most people. They can cause pain, difficulties with eating and speaking, low self‐esteem, and, in extreme cases, may lead to tooth loss and the need for surgery. The cost to health services of treating these diseases is very high. As dental plaque (a layer of bacteria in an organic matrix that forms on the teeth) is the root cause, it is important to remove plaque from teeth on a regular basis. While many people routinely brush their teeth to remove plaque up to the gum line, it is difficult for toothbrushes to reach into areas between teeth ('interdental'), so interdental cleaning is often recommended as an extra step in personal oral hygiene routines. Different tools can be used to clean interdentally, such as dental floss, interdental brushes, tooth cleaning sticks, and water pressure devices known as oral irrigators. Study characteristics Review authors working with Cochrane Oral Health searched for studies up to 16 January 2019. We identified 35 studies (3929 adult participants). Participants knew that they were in an experiment, which might have affected their teeth cleaning or eating behaviour. Some studies had other problems that might make their findings less reliable, such as people dropping out of the study or not using the assigned device. Studies evaluated the following devices plus toothbrushing compared to toothbrushing only: floss (15 studies), interdental brushes (2 studies), wooden cleaning sticks (2 studies), rubber/elastomeric cleaning sticks (2 studies) and oral irrigators (5 studies). Four devices were compared with floss: interdental brushes (9 studies), wooden cleaning sticks (3 studies), rubber/elastomeric cleaning sticks (9 studies), oral irrigators (2 studies). Three studies compared rubber/elastomeric cleaning sticks with interdental brushes. No studies evaluated decay, and few evaluated severe gum disease. Outcomes were measured at short (one month to six weeks) and medium term (three and six months). Key results We found that using floss, in addition to toothbrushing, may reduce gingivitis in the short and medium term. It is unclear if it reduces plaque. Using an interdental brush, in addition to a toothbrush, may reduce gingivitis and plaque in the short term. Using wooden tooth cleaning sticks may be better than toothbrushing only for reducing gingivitis (measured by bleeding sites) but not plaque in the medium term (only 24 participants). Using a tooth cleaning stick made of rubber or an elastomer may be better than toothbrushing only for reducing plaque but not gingivitis in the short term (only 30 participants). Toothbrushing plus oral irrigation (water pressure) may reduce gingivitis in the short term, but there was no evidence for this in the medium term. There was no evidence of a difference in plaque. Interdental brushes may be better than flossing for gingivitis at one and three months. The evidence for plaque is inconsistent. There was no evidence of a difference between the devices for periodontitis measured by probing pocket depth. There is some evidence that oral irrigation may be better than flossing for reducing gingivitis (but not plaque) in the short term. The available evidence for interdental cleaning sticks did not show them to be better or worse than floss or interdental brushes for controlling gingivitis or plaque. The studies that measured 'adverse events' found no serious effects and no evidence of differences between study groups in minor effects such as gum irritation. Certainty of the evidence The evidence is low to very low‐certainty. The effects observed may not be clinically important. Studies measured outcomes mostly in the short term and many participants had a low level of gum disease at the beginning of the studies. Future research Future studies should use the new periodontal diseases classification to describe the gum health of participants, and they should last long enough to measure periodontitis and tooth decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Worthington, HV; MacDonald, L; Poklepovic Pericic, T; Sambunjak, D; Johnson, TM; Imai, P; Clarkson, JE", "articleTypes": [], "doi": "10.1002/14651858.CD012018.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "c1165be2-c9ad-4301-b7f6-545c5abc3ff3", "pmid": "", "title": "A Randomized Cross-Over Study to Investigate the Effect of the Non-Nutritive Sweetener Sucralose on Glucose Metabolism in Patients with Type 1 Diabetes", "imported": false, "abstract": "The goal of this randomized crossover study is to test the prediction that consuming carbohydrates will affect insulin release differently depending on whether Non-Nutritive Sweeteners (NNSs) are consumed simultaneously. We aim to determine whether the predicted effects are associated with oral or post-oral sweet taste receptor signaling,. Our study will focus on patients diagnosed with type 1 diabetes (T1D) who are using an artificial pancreas (AP) system, as it allows us to monitor glucose and insulin levels over time.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.144Z" }, { "id": "c11bfc20-d6f6-4a6e-86a8-fe2a28d2c8f7", "pmid": "", "title": "Pharmacological interventions for promoting smoking cessation during pregnancy", "imported": false, "abstract": "Abstract - Background Tobacco smoking in pregnancy causes serious health problems for the developing fetus and mother. When used by non‐pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion, and varenicline) are effective for increasing smoking cessation, however their efficacy and safety in pregnancy remains unknown. Electronic cigarettes (ECs) are becoming widely used, but their efficacy and safety when used for smoking cessation in pregnancy are also unknown. Objectives To determine the efficacy and safety of smoking cessation pharmacotherapies and ECs used during pregnancy for smoking cessation in later pregnancy and after childbirth, and to determine adherence to smoking cessation pharmacotherapies and ECs for smoking cessation during pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2019), trial registers, and grey literature, and checked references of retrieved studies. Selection criteria Randomised controlled trials (RCTs) conducted in pregnant women, comparing smoking cessation pharmacotherapy or EC use with either placebo or no pharmacotherapy/EC control. We excluded quasi‐randomised, cross‐over, and within‐participant designs, and RCTs with additional intervention components not matched between trial arms. Data collection and analysis We followed standard Cochrane methods. The primary efficacy outcome was smoking cessation in later pregnancy; safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well‐being. We also collated data on adherence to trial treatments. We calculated the risk ratio (RR) or mean difference (MD) and the 95% confidence intervals (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta‐analyses where appropriate. Main results We included 11 trials that enrolled a total of 2412 pregnant women who smoked at enrolment, nine trials of NRT and two trials of bupropion as adjuncts to behavioural support, with comparable behavioural support provided in the control arms. No trials investigated varenicline or ECs. We assessed four trials as at low risk of bias overall. The overall certainty of the evidence was low across outcomes and comparisons as assessed using GRADE, with reductions in confidence due to risk of bias, imprecision, and inconsistency. Compared to placebo and non‐placebo (behavioural support only) controls, there was low‐certainty evidence that NRT increased the likelihood of smoking abstinence in later pregnancy (RR 1.37, 95% CI 1.08 to 1.74; I² = 34%, 9 studies, 2336 women). However, in subgroup analysis by comparator type, there was a subgroup difference between placebo‐controlled and non‐placebo controlled RCTs (test for subgroup differences P = 0.008). There was unclear evidence of an effect in placebo‐controlled RCTs (RR 1.21, 95% CI 0.95 to 1.55; I² = 0%, 6 studies, 2063 women), whereas non‐placebo‐controlled trials showed clearer evidence of a benefit (RR 8.55, 95% CI 2.05 to 35.71; I² = 0%, 3 studies, 273 women). An additional subgroup analysis in which studies were grouped by the type of NRT used found no difference in the effectiveness of NRT in those using patches or fast‐acting NRT (test for subgroup differences P = 0.08). There was no evidence of a difference between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities, or neonatal death. In one study infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' at two years of age compared to the placebo group. Non‐serious adverse effects observed with NRT included headache, nausea, and local reactions (e.g. skin irritation from patches or foul taste from gum), but data could not be pooled. Adherence to NRT treatment regimens was generally low. We identified low‐certainty evidence that there was no difference in smoking abstinence rates observed in later pregnancy in women using bupropion when compared to placebo control (RR 0.74, 95% CI 0.21 to 2.64; I² = 0%, 2 studies, 76 women). Evidence investigating the safety outcomes of bupropion use was sparse, but the existing evidence showed no difference between the bupropion and control group. Authors' conclusions NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy. However, this evidence is of low certainty, as the effect was not evident when potentially biased, non‐placebo‐controlled RCTs were excluded from the analysis. Future studies may therefore change this conclusion. We found no evidence that NRT has either positive or negative impacts on birth outcomes; however, the evidence for some of these outcomes was also judged to be of low certainty due to imprecision and inconsistency. We found no evidence that bupropion may be an effective aid for smoking cessation during pregnancy, and there was little evidence evaluating its safety in this population. Further research evidence on the efficacy and safety of pharmacotherapy and EC use for smoking cessation in pregnancy is needed, ideally from placebo‐controlled RCTs that achieve higher adherence rates and that monitor infants' outcomes into childhood. Future RCTs of NRT should investigate higher doses than those tested in the studies included in this review. Plain language summary Drug treatments and electronic cigarettes for stopping smoking in pregnancy What is the issue? Smoking during pregnancy harms women and infants. However, many women who smoke struggle to stop whilst pregnant. Medication for smoking cessation reduces the intensity of cravings, meaning that people trying to stop smoking are more likely to succeed in the long term. Providing pregnant women who smoke with these treatments could help them to stop smoking and have a positive impact on both their own health and the health of their infants. Why is this important? Medications commonly used to help people to stop smoking include nicotine replacement therapy (NRT), bupropion, and varenicline. Electronic cigarettes containing nicotine are also used by some who smoke to help avoid smoking. However, the safety and effectiveness of smoking cessation drugs and electronic cigarettes in pregnant women is unknown. We searched for studies looking at how good these aids were at helping pregnant women stop smoking and how safe they were when used during pregnancy. What evidence did we find? We searched for evidence on 20 May 2019 and identified 11 randomised studies (studies in which participants are assigned to one of two or more treatment groups using a random method) that enrolled a total of 2412 women. Nine studies tested NRT used alongside counselling to stop smoking, whilst the other two studies tested bupropion. Low‐quality evidence suggests that NRT combined with behavioural support might help women to stop smoking in later pregnancy more than behavioural support alone. Medication trials often use placebos, that is tablets or patches that look like the drug but do not actually include it, so that each comparison group has equal expectation of success and there is a fairer test of the benefits of the medicine itself. When just the higher‐quality, placebo‐controlled trials were analysed, the evidence suggested that NRT was more effective than placebo NRT. There was no evidence that either nicotine patches or fast‐acting NRT (such as gum or lozenge) was more effective than the other. Low‐quality evidence suggests that bupropion may be no more effective than placebo in helping women quit smoking later in pregnancy. We found no trials investigating other smoking cessation pharmacotherapies or electronic cigarettes. There was insufficient evidence to conclude whether NRT had either positive or negative impacts on rates of miscarriage, stillbirth, preterm birth (less than 37 weeks), mean birthweight, low birthweight (less than 2500 g), admissions of babies to neonatal intensive care, or newborn deaths. However, in one trial where infants were followed until two years of age, those infants born to women who had been randomised to NRT were more likely to have healthy development. Similarly, it is unclear whether bupropion had a positive or negative impact on birth outcomes. Studies that looked at whether women used their stop smoking medications as instructed found that use was generally low, and the majority of women used little of the NRT they were given. What does this mean? More research evidence is needed, in particular placebo‐controlled trials that test higher doses of NRT, encourage women to use sufficient medication, and follow infants into childhood. Furthermore, more studies are required investigating the effect and safety of bupropion, electronic cigarettes, and varenicline for giving up smoking during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Claire, R, Chamberlain, C, Davey, MA, Cooper, SE, Berlin, I, Leonardi‐Bee, J, Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD010078.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.080Z" }, { "id": "c144675b-3ff3-4ddc-9f34-ecb836d88539", "pmid": "", "title": "Inhaled sodium cromoglycate for asthma in children", "imported": false, "abstract": "Abstract - Background Sodium cromoglycate has been recommended as maintenance treatment for childhood asthma for many years. Its use has decreased since 1990, when inhaled corticosteroids became popular, but it is still used in many countries. Objectives To determine the efficacy of sodium cromoglycate compared to placebo in the prophylactic treatment of children with asthma. Search methods We searched the Cochrane Airways Group Trials Register (October 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library Issue 3, 2009), MEDLINE (January 1966 to October 2009), EMBASE (January 1985 to October 2009) and reference lists of articles. We also contacted the pharmaceutical company manufacturing sodium cromoglycate. Selection criteria All double‐blind, placebo‐controlled randomised trials, which addressed the effectiveness of inhaled sodium cromoglycate as maintenance therapy, studying children aged 0 up to 18 years with asthma. Data collection and analysis Two authors independently assessed trial quality and extracted data. We pooled study results. Main results Of 3500 titles retrieved from the literature, 24 papers reporting on 23 studies could be included in the review. The studies were published between 1970 and 1997 and together included 1026 participants. Most were cross‐over studies. Few studies provided sufficient information to judge the concealment of allocation. Four studies provided results for the percentage of symptom‐free days. Pooling the results did not reveal a statistically significant difference between sodium cromoglycate and placebo. For the other pooled outcomes, most of the symptom‐related outcomes and bronchodilator use showed statistically significant results, but treatment effects were small. Considering the confidence intervals of the outcome measures, a clinically relevant effect of sodium cromoglycate cannot be excluded. The funnel plot showed an under‐representation of small studies with negative results, suggesting publication bias. Authors' conclusions There is insufficient evidence to be sure about the efficacy of sodium cromoglycate over placebo. Publication bias is likely to have overestimated the beneficial effects of sodium cromoglycate as maintenance therapy in childhood asthma. Plain language summary The effects of sodium cromoglycate compared with placebo for chronic asthma in children In this review we aimed to determine whether there is evidence for the effectiveness of inhaled sodium cromoglycate as maintenance treatment in children with chronic asthma. Most of the studies were carried out in small groups of patients. Furthermore, we suspect that not all studies undertaken have been published. The results show that there is insufficient evidence to be sure about the beneficial effect of sodium cromoglycate compared to placebo. However, for several outcome measures the results favoured sodium cromoglycate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "van der Wouden, JC; Uijen, JHJM; Bernsen, RMD; Tasche, MJA; de Jongste, JC; Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002173.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "c1679145-4663-44e2-80d6-0eeba05eb65d", "pmid": "", "title": "Probiotic treatment for women with gestational diabetes to improve maternal and infant health and well‐being", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance first recognised during pregnancy and associated with complications for mothers and babies. Probiotics are naturally occurring micro‐organisms, which when ingested in adequate amounts, may confer health benefits. Evidence of the role of probiotics as treatment for GDM is limited. Objectives To evaluate the safety and effectiveness of probiotics in treating women with GDM on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth’s Trials Register ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (24 July 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing the use of probiotics versus placebo/standard care for the treatment of GDM. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, checked data accuracy, and assessed risk of bias of included trials. The certainty of evidence for selected maternal and infant/child outcomes was assessed using GRADE. Main results Nine RCTs (695 pregnant women with GDM) comparing probiotics versus placebo were identified. The overall risk of bias in the nine RCTs was low to unclear and the evidence was downgraded for imprecision due to the small numbers of women participating in the trials. The trials were carried out in hospitals and universities in Iran (seven trials), Thailand (one trial) and Ireland (one trial). All trials compared probiotics with placebo. Maternal outcomes We are uncertain if probiotics have any effect compared with placebo on hypertensive disorders of pregnancy, (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.64 to 3.53; participants = 256; studies = 3; low‐certainty evidence) and mode of birth as caesareans (average RR 0.64, 95% CI 0.30 to 1.35; participants = 267; studies = 3; low‐certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm . No trials reported primary outcomes of: mode of birth as vaginal/assisted and subsequent development of type 2 diabetes. We are uncertain if probiotics have any effect compared with placebo on induction of labour (RR 1.33, 95% CI 0.74 to 2.37; participants = 127; studies = 1; very low‐certainty evidence). For other secondary maternal outcomes, we are uncertain if there are differences between probiotics and placebo for: postpartum haemorrhage; weight gain during pregnancy intervention and total gestational weight gain; fasting plasma glucose and need for extra pharmacotherapy (insulin). Probiotics may be associated with a slight reduction in triglycerides and total cholesterol. In probiotics compared with placebo, there was evidence of reduction in markers for insulin resistance (HOMA‐IR) and HOMA‐B; and insulin secretion. There was also an increase in quantitative insulin sensitivity check index (QUICKI). Probiotics were associated with minor benefits in relevant bio‐markers with evidence of a reduction in inflammatory markers high‐sensitivity C‐reactive protein (hs‐CRP), interleukin 6 (IL‐6), and marker of oxidative stress malondialdehyde; and an increase in antioxidant total glutathione, but we are uncertain if there is any difference in total antioxidant capacity. No trials reported secondary outcomes: perineal trauma, postnatal weight retention or return to pre‐pregnancy weight and postnatal depression. Infant/child/adult outcomes We are uncertain if probiotics have any effect, compared with placebo, on the risk of large‐for‐gestational‐age babies (RR 0.73, 95% CI 0.35 to 1.52; participants = 174; studies = 2; low‐certainty evidence) or infant hypoglycaemia (RR 0.85, 95% CI 0.39 to 1.84; participants = 177; studies = 3; low ‐ certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm. No trials reported primary outcomes of: perinatal (fetal/neonatal) mortality; or neurosensory disability. For other secondary outcomes, we are uncertain if there is any difference between probiotics and placebo in gestational age at birth, preterm birth, macrosomia, birthweight, head circumference, length, infant hypoglycaemia, and neonatal intensive care unit (NICU) admissions. There was evidence of a reduction in infant hyperbilirubinaemia with probiotics compared with placebo. No trials reported secondary outcomes: infant adiposity, and later childhood adiposity. There were no adverse events reported by any of the trials. Authors' conclusions Low‐certainty evidence means we are not certain if there is any difference between probiotic and placebo groups in maternal hypertensive disorders of pregnancy, caesareans; and large‐for‐gestational‐age babies . There were no adverse events reported by the trials. Due to the variability of probiotics used and small sample sizes of trials, evidence from this review has limited ability to inform practice. Well‐designed adequately‐powered trials are needed to identify whether probiotics may improve maternal blood glucose levels and/or infant/child/adult outcomes; and whether they can be used to treat GDM. Plain language summary Probiotics as an added treatment for gestational diabetes to improve mother and baby outcomes What is the issue? Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in high blood glucose levels, first recognised during pregnancy. Pregnant women with GDM are at risk of high blood pressure, labour induction, and caesareans. Their babies are at risk of being born large, birth difficulties, respiratory distress, low blood glucose at birth and jaundice that can cause brain injury. There is increased risks of having long‐term diabetes in the mother, and the baby being overweight. Probiotics are micro‐organisms naturally in food and are in fermented milk, yogurt, or capsules. There are many different probiotics; the two most used are Lactobacillus and Bifidobacterium, and if consumed in adequate amounts may confer health benefits. Why is this important? Probiotics need to be safe and maternal blood glucose levels carefully managed during pregnancy. Women with GDM may receive dietary and physical activity education with monitoring blood glucose levels as initial management. When blood glucose levels are above a certain threshold, women with GDM are prescribed glucose‐lowering medications including metformin and/or insulin. This review aimed to determine the safety and effectiveness of probiotics in treating women with GDM. What evidence did we find? We searched for evidence for randomised controlled trials (latest July 2019). We identified nine studies, involving 695 women with GDM. All trials compared probiotics with placebo. The certainty of the evidence was assessed as very low or low. The overall risk of bias was low to unclear. Seven trials were conducted in Iran; one in Thailand, and one in Ireland. Trials took place in hospitals and universities. We are uncertain if there is any difference between probiotic and placebo in rates of: high blood‐pressure disorders (three studies, 256 participants, low‐certainty evidence); caesarean section (three studies, 267 women, low‐certainty evidence ); and large‐for‐gestational‐age babies (two studies, 174 participants, low‐certainty evidence). We are uncertain if there is any difference between probiotic and placebo for induction of labour (one study, 127 participants, very low‐certainty evidence) and low blood glucose levels in the newborn (three studies, 177 participants, low‐certainty evidence). We are also uncertain if there is any difference between probiotics and placebo for heavy bleeding immediately after birth, weight gain during pregnancy or total gestational weight gain. We are uncertain if there is any difference in fasting blood glucose between probiotics and placebo (seven studies, 554 participants). Probiotics may be assoicated with a slight reduction in triglycerides and total cholesterol (four studies, 320 participants). There was reduction in insulin secretion with probiotics (seven studies, 505 participants). One trial (60 participants) showed no difference between groups in need for insulin. Biomarkers, did show a reduction in insulin resistance (HOMA‐IR), (seven studies, 505 participants) and insulin resistance and β cell function (HOMA‐B) (two studies,130 participants) with probiotics. Quantitative insulin sensitivity check index (QUICKI) increased (four studies, 276 participants) with probiotics. Inflammatory markers, hs‐CRP (four studies, 248 participants) and interleukin 6 (two studies, 128 participants) were reduced with probiotics. Antioxidant total glutathione was increased (two studies, 120 participants) and the oxidative stress biomarker malondialdehyde was reduced with probiotics (three studies, 176 participants). We are uncertain if there is any difference in total antioxidant capacity (four studies 266 participants). For the newborn baby, we are uncertain if there is any difference between groups for: birthweight, gestational age at birth, preterm births, large babies, head circumference and length scores, or need for admission to the neonatal intensive care unit. The number of babies with high levels of bilirubin was reduced with probiotics. No adverse events were reported by the trials. What does this mean? Based on the clinical trials available, the evidence is limited to support the use of probiotics as treatment for women with GDM to improve pregnancy outcomes for mothers and their babies. Larger well‐designed randomised controlled trials are needed to assess the effects of probiotics on management of glucose levels and when available, they can be included in the update of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Okesene-Gafa, KAM; Moore, AE; Jordan, V; McCowan, L; Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD012970.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "c1d15070-7dc4-448a-a73b-3981539756d7", "pmid": "", "title": "Interventions to prevent obesity in children aged 12 to 18 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or ‘activity’ levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review. Objectives To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta‐analyses. Sixty studies were based in high‐income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty‐one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short‐term follow‐up (mean difference (MD) ‐0.18, 95% confidence interval (CI) ‐0.41 to 0.06; 3 studies, 605 participants), medium‐term follow‐up (MD ‐0.65, 95% CI ‐1.18 to ‐0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long‐term follow‐up (MD ‐0.14, 95% CI ‐0.38 to 0.10; 2 studies, 1089 participants); all very low‐certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long‐term follow‐up (MD ‐0.30, 95% CI ‐1.67 to 1.07; 1 study, 44 participants); zBMI at short‐term (MD ‐0.06, 95% CI ‐0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium‐term (MD 0.02, 95% CI ‐0.17 to 0.21; 1 study, 112 participants) follow‐up; all low‐certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low‐certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short‐term follow‐up (MD ‐0.64, 95% CI ‐1.86 to 0.58; 6 studies, 1780 participants; low‐certainty evidence) and probably do not reduce zBMI at medium‐ (MD 0, 95% CI ‐0.04 to 0.05; 6 studies, 5335 participants) or long‐term (MD ‐0.05, 95% CI ‐0.12 to 0.02; 1 study, 985 participants) follow‐up; both moderate‐certainty evidence. Activity interventions do not reduce zBMI at short‐term follow‐up (MD 0.02, 95% CI ‐0.01 to 0.05; 7 studies, 4718 participants; high‐certainty evidence), but may reduce BMI slightly at medium‐term (MD ‐0.32, 95% CI ‐0.53 to ‐0.11; 3 studies, 2143 participants) and long‐term (MD ‐0.28, 95% CI ‐0.51 to ‐0.05; 1 study, 985 participants) follow‐up; both low‐certainty evidence. Seven studies (5428 participants; low‐certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short‐term follow‐up (MD 0.03, 95% CI ‐0.07 to 0.13; 11 studies, 3429 participants; high‐certainty evidence), and probably do not reduce BMI at medium‐term (MD 0.01, 95% CI ‐0.09 to 0.11; 8 studies, 5612 participants; moderate‐certainty evidence) or long‐term (MD 0.06, 95% CI ‐0.04 to 0.16; 6 studies, 8736 participants; moderate‐certainty evidence) follow‐up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD ‐0.09, 95% CI ‐0.2 to 0.02; 3 studies, 515 participants; very low‐certainty evidence), and they may not reduce zBMI at medium‐term (MD ‐0.05, 95% CI ‐0.1 to 0.01; 6 studies, 3511 participants; low‐certainty evidence) or long‐term (MD ‐0.02, 95% CI ‐0.05 to 0.01; 7 studies, 8430 participants; low‐certainty evidence) follow‐up. Four studies (2394 participants) reported data on serious adverse events (very low‐certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect. Authors' conclusions The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low‐certainty evidence that activity interventions may have a small beneficial effect on BMI at medium‐ and long‐term follow‐up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples. Plain language summary Do dietary and activity strategies help prevent obesity in children and young people aged 12 to 18 years? Key messages ‐ Strategies to encourage adolescents to change their diet or activity levels (or both), to prevent them becoming overweight or developing obesity make no or very little difference to their body mass index (BMI; an estimate of the amount of body fat according to height and weight). ‐ Based on the very little information available about serious adverse events, there appears to be little or no effect of dietary or activity strategies, or both, to results in serious harms (e.g. injuries). ‐ Due to a lack of evidence, future research should focus on community settings (e.g. in youth clubs) and research involving adolescents with disabilities. Why is preventing obesity in children and young people important? More adolescents are developing overweight and obesity worldwide. Being overweight as an adolescent can cause health problems, and people may be affected psychologically and in their social life. Puberty and moving into adulthood is a challenging time, and many struggle with their mental health. Overweight adolescents are likely to be overweight or obese as adults and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help adolescents modify their diet or activity (or both) were effective at preventing obesity. We also wanted to know if these strategies were associated with any serious harms. What did we do? We searched scientific databases for studies that looked at ways of preventing obesity in children aged 12 to 18 years. We excluded studies aimed at adolescents who were already overweight or living with obesity. However, we included studies where the sample was a whole group (e.g. a school), which may have included those living with overweight or obesity. We only included studies if the methods they used aimed to change the children's diet, their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed children into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 74 studies involving 83,407 children and young people. Sixty studies were based in high‐income countries (e.g. USA and in Europe). In 57 studies, the strategies were tried in schools, although 12 were based at home or other places like community settings (five studies) such as youth groups. Fifty‐one strategies were implemented for fewer than nine months; the shortest intervention lasted one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five studies were partly funded by industry (food suppliers, a PlayStation manufacturer, a gym equipment supplier, a healthcare device manufacturer and a private healthcare facility). Our analyses included results from 54 studies of 46,358 adolescents (20 studies did not report their results in a way that could be included in our analyses). We found that adolescents who were helped with a strategy to change their diet or activity levels (or both) either did not reduce their BMI, or any reduction was meagre, compared to adolescents who were not given a strategy. Only a few studies reported any possible harms of the interventions, and none identified serious harms. What are the limitations of the evidence? Overall, we have limited confidence in the beneficial effects of these interventions in preventing obesity in children and adolescents. It is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. Many studies had limitations in how they were done (e.g. in some studies, the methods used to randomly place people into groups were not adequate or the results of some of the studies were not analysed correctly). 3. There were not enough studies reporting particular types of outcomes, such as BMI (an estimate of the amount of body fat according to height and weight) or zBMI (comparison of a child’s BMI with other children of the same age and sex) for a particular duration of follow‐up to be certain about the results for some comparisons. Also, certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way that we could include them in our analyses (e.g. without any detail of the difference in change between the intervention and control groups) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for adolescents with disabilities, or whether those implemented in community settings are effective. How up to date is this evidence? This review supersedes our previous review. The evidence is up‐to‐date until February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F, Tomlinson, E, Davies, AL, Moore, THM, Dawson, S, Breheny, K, Savović, J, Hodder, RK, Wolfenden, L, Higgins, JPT, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015330.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.808Z" }, { "id": "c1e82bdd-16f1-4edf-9ac9-6b5305f47427", "pmid": "", "title": "Preoperative fasting for preventing perioperative complications in children", "imported": false, "abstract": "Abstract - Background Children, like adults, are required to fast before general anaesthesia with the aim of reducing the volume and acidity of their stomach contents. It is thought that fasting reduces the risk of regurgitation and aspiration of gastric contents during surgery. Recent developments have encouraged a shift from the standard 'nil‐by‐mouth‐from‐midnight' fasting policy to more relaxed regimens. Practice has been slow to change due to questions relating to the duration of a total fast, the type and amount of intake permitted. Objectives To systematically assess the effects of different fasting regimens (duration, type and volume of permitted intake) and the impact on perioperative complications and patient well being (aspiration, regurgitation, related morbidity, thirst, hunger, pain, comfort, behaviour, nausea and vomiting) in children. Search methods We searched Cochrane Wounds Group Specialised Register (searched 25/6/09), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 2 2009), Ovid MEDLINE (1950 to June Week 2 2009), Ovid EMBASE (1980 to 2009 Week 25), EBSCO CINAHL (1982 to June Week 3 2009), the National Research Register, relevant conference proceedings and article reference lists and contacted experts. Selection criteria Randomised and quasi randomised controlled trials of preoperative fasting regimens for children were identified. Data collection and analysis Data extraction and trial quality assessment was conducted independently by three authors. Trial authors were contacted for additional information including adverse events. Main results This first update of the review identified two additional eligible studies, bringing the total number of included studies to 25 (forty seven randomised controlled comparisons involving 2543 children considered to be at normal risk of regurgitation or aspiration during anaesthesia). Only one incidence of aspiration and regurgitation was reported. Children permitted fluids up to 120 minutes preoperatively were not found to experience higher gastric volumes or lower gastric pH values than those who fasted. The children permitted fluids were less thirsty and hungry, better behaved and more comfortable than those who fasted. Clear fluids preoperatively did not result in a clinically important difference in children's gastric volume or pH. Evidence relating to the preoperative intake of milk was sparse. The volume of fluid permitted during the preoperative period did not appear to impact on children's intraoperative gastric volume or pH contents. Authors' conclusions There is no evidence that children who are denied oral fluids for more than six hours preoperatively benefit in terms of intraoperative gastric volume and pH compared with children permitted unlimited fluids up to two hours preoperatively. Children permitted fluids have a more comfortable preoperative experience in terms of thirst and hunger. This evidence applies only to children who are considered to be at normal risk of aspiration/regurgitation during anaesthesia. Plain language summary Preoperative fasting for children to prevent complications during surgery General anaesthetics inhibit the protective reflexes that stop the stomach contents reaching the lungs. In order to prevent the inadvertent inhalation of stomach contents, children are often advised to have nothing to eat or drink from the midnight before surgery. However, the review of trials found that drinking clear fluids up to a few hours before surgery did not increase the risk of regurgitation during or after surgery. Indeed there is an added benefit of a more comfortable preoperative experience in terms of thirst and hunger. Some children are considered more likely to regurgitate under anaesthetic, including those who are obese or have stomach disorders. More research is needed to determine whether these children can also safely drink up to a few hours before surgery.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brady, MC, Kinn, S, Ness, V, O'Rourke, K, Randhawa, N, Stuart, P", "articleTypes": [], "doi": "10.1002/14651858.CD005285.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.814Z" }, { "id": "c1ec24ac-dd6d-44cd-9a27-92fc12a2df7e", "pmid": "", "title": "Probiotics for the prevention of pediatric antibiotic‐associated diarrhea", "imported": false, "abstract": "Abstract - Background Antibiotics alter the microbial balance commonly resulting in antibiotic‐associated diarrhea (AAD). Probiotics may prevent AAD via providing gut barrier, restoration of the gut microflora, and other potential mechanisms of action. Objectives The primary objectives were to assess the efficacy and safety of probiotics (any specified strain or dose) used for the prevention of AAD in children. Search methods MEDLINE, Embase, CENTRAL, CINAHL, and the Web of Science (inception to 28 May 2018) were searched along with registers including the ISRCTN and Clinicaltrials.gov. We also searched the NICE Evidence Services database as well as reference lists from relevant articles. Selection criteria Randomized, parallel, controlled trials in children (0 to 18 years) receiving antibiotics, that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhea secondary to antibiotic use were considered for inclusion. Data collection and analysis Study selection, data extraction, and risk of bias assessment were conducted independently by two authors. Dichotomous data (incidence of AAD, adverse events) were combined using a pooled risk ratio (RR) or risk difference (RD), and continuous data (mean duration of diarrhea) as mean difference (MD), along with corresponding 95% confidence interval (95% CI). We calculated the number needed to treat for an additional beneficial outcome (NNTB) where appropriate. For studies reporting on microbiome characteristics using heterogeneous outcomes, we describe the results narratively. The certainty of the evidence was evaluated using GRADE. Main results Thirty‐three studies (6352 participants) were included. Probiotics assessed included Bacillus spp., Bifidobacterium spp., Clostridium butyricum , Lactobacilli spp. , Lactococcus spp., Leuconostoc cremoris , Saccharomyces spp., or Streptococcus spp., alone or in combination. The risk of bias was determined to be high in 20 studies and low in 13 studies. Complete case (patients who did not complete the studies were not included in the analysis) results from 33 trials reporting on the incidence of diarrhea show a precise benefit from probiotics compared to active, placebo or no treatment control. After 5 days to 12 weeks of follow‐up, the incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group (RR 0.45, 95% CI 0.36 to 0.56; I² = 57%, 6352 participants; NNTB 9, 95% CI 7 to 13; moderate certainty evidence). Nineteen studies had loss to follow‐up ranging from 1% to 46%. After making assumptions for those lost, the observed benefit was still statistically significant using an extreme plausible intention‐to‐treat (ITT) analysis, wherein the incidence of AAD in the probiotic group was 12% (436/3551) compared to 19% (664/3468) in the control group (7019 participants; RR 0.61; 95% CI 0.49 to 0.77; P <0.00001; I² = 70%). An a priori available case subgroup analysis exploring heterogeneity indicated that high dose (≥ 5 billion CFUs per day) is more effective than low probiotic dose (< 5 billion CFUs per day), interaction P value = 0.01. For the high dose studies the incidence of AAD in the probiotic group was 8% (162/2029) compared to 23% (462/2009) in the control group (4038 participants; RR 0.37; 95% CI 0.30 to 0.46; P = 0.06; moderate certainty evidence). For the low dose studies the incidence of AAD in the probiotic group was 8% (97/1155) compared to 13% (133/1059) in the control group (2214 participants; RR 0.68; 95% CI 0.46 to 1.01; P = 0.02). Again, assumptions for loss to follow‐up using an extreme plausible ITT analysis was statistically significant. For high dose studies the incidence of AAD in the probiotic group was 13% (278/2218) compared to 23% (503/2207) in control group (4425 participants; RR 0.54; 95% CI 0.42 to 0.70; P <0.00001; I² = 68%; moderate certainty evidence). None of the 24 trials (4415 participants) that reported on adverse events reported any serious adverse events attributable to probiotics. Adverse event rates were low. After 5 days to 4 weeks follow‐up, 4% (86/2229) of probiotics participants had an adverse event compared to 6% (121/2186) of control participants (RD 0.00; 95% CI ‐0.01 to 0.01; P < 0.00001; I² = 75%; low certainty evidence). Common adverse events included rash, nausea, gas, flatulence, abdominal bloating, and constipation. After 10 days to 12 weeks of follow‐up, eight studies recorded data on our secondary outcome, the mean duration of diarrhea; with probiotics reducing diarrhea duration by almost one day (MD ‐0.91; 95% CI ‐1.38 to ‐0.44; P <0.00001; low certainty evidence). One study reported on microbiome characteristics, reporting no difference in changes with concurrent antibiotic and probiotic use. Authors' conclusions The overall evidence suggests a moderate protective effect of probiotics for preventing AAD (NNTB 9, 95% CI 7 to 13). Using five criteria to evaluate the credibility of the subgroup analysis on probiotic dose, the results indicate the subgroup effect based on high dose probiotics (≥ 5 billion CFUs per day) was credible. Based on high‐dose probiotics, the NNTB to prevent one case of diarrhea is 6 (95% CI 5 to 9). The overall certainty of the evidence for the primary endpoint, incidence of AAD, based on high dose probiotics was moderate due to the minor issues with risk of bias and inconsistency related to a diversity of probiotic agents used. Evidence also suggests that probiotics may moderately reduce the duration of diarrhea, a reduction by almost one day. The benefit of high dose probiotics (e.g. Lactobacillus rhamnosus or Saccharomyces boulardii ) needs to be confirmed by a large well‐designed multi‐centered randomized trial. It is premature to draw firm conclusions about the efficacy and safety of 'other' probiotic agents as an adjunct to antibiotics in children. Adverse event rates were low and no serious adverse events were attributable to probiotics. Although no serious adverse events were observed among inpatient and outpatient children, including small studies conducted in the intensive care unit and in the neonatal unit, observational studies not included in this review have reported serious adverse events in severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter use and disorders associated with bacterial/fungal translocation. Plain language summary Probiotics for the prevention of antibiotic‐associated diarrhea in children What is antibiotic‐associated diarrhea? Antibiotic‐associated diarrhea (AAD) occurs when antibiotics disturb the natural balance of \"good\" and \"bad\" bacteria in the intestinal tract causing harmful bacteria to multiply beyond their normal numbers. The symptoms of AAD include frequent watery bowel movements and crampy abdominal pain. What are probiotics? Probiotics are found in dietary supplements or yogurts and contain potentially beneficial bacteria or yeast. Probiotics may restore the natural balance of bacteria in the intestinal tract. What did the researchers investigate? The researchers investigated whether probiotics prevent AAD in children receiving antibiotic therapy and whether probiotics causes any harms (side effects). The researchers searched the medical literature extensively up to May 28, 2018. What did the researchers find? Thirty‐three studies were reviewed and provide the best available evidence. The studies tested 6352 children (3 days to 17 years of age) who were receiving probiotics co‐administered with antibiotics to prevent AAD. The participants received probiotics ( Lactobacilli spp., Bifidobacterium spp., Streptococcus spp. , or Saccharomyces boulardii alone or in combination), placebo (pills not including probiotics), other treatments thought to prevent AAD (i.e. diosmectite or infant formula) or no treatment. The studies were short‐term, ranging in length from 5 days to 12 weeks. Analyses showed that probiotics are effective for preventing AAD. The incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group, demonstrating a moderate reduction (11% fewer will suffer diarrhea). For every 9 children treated, probiotics will prevent one case of diarrhea. Further, evidence suggests that higher dose probiotics (≥ 5 billion CFUs per day) reduce the incidence of AAD. Eight per cent (162/2029) of the high dose probiotics group had AAD compared to 23% (462/2009) in the control group, demonstrating a moderate to large reduction (15% fewer suffer diarrhea). Probiotics were generally well tolerated, and minor side effects (e.g. rash, nausea, gas, flatulence, abdominal bloating, constipation) occurred infrequently. . Evidence suggested that probiotics are effective for a moderate reduction in duration of diarrhea (almost one day). Among the various probiotics evaluated, Lactobacillus rhamnosus or Saccharomyces boulardii at 5 to 40 billion colony forming units/day appear most appropriate for preventing AAD in children receiving antibiotics. It is premature to draw conclusions about the effectiveness and safety of 'other' probiotic agents for preventing AAD. Although no serious probiotic‐related side effects were observed among the mostly otherwise healthy children who participated in the studies, serious side effects have been reported in observational studies not included in this review, including severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter (a flexible tube used to give medicines) use and disorders associated with bacterial or fungal translocation (the passage of bacteria from the gut to other areas of the body).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Guo, Q, Goldenberg, JZ, Humphrey, C, El Dib, R, Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD004827.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.780Z" }, { "id": "c213daa2-2168-4185-a504-9d89a2ef5948", "pmid": "", "title": "Carbetocin for preventing postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Postpartum haemorrhage (PPH) is one of the major contributors to maternal mortality and morbidity worldwide. Active management of the third stage of labour has been proven to be effective in the prevention of PPH. Syntometrine is more effective than oxytocin but is associated with more side effects. Carbetocin, a long‐acting oxytocin agonist, appears to be a promising agent for the prevention of PPH. Objectives To determine if the use of oxytocin agonist is as effective as conventional uterotonic agents for the prevention of PPH, and assess the best routes of administration and optimal doses of oxytocin agonist. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2011, Issue 1 of 4), MEDLINE (1966 to 1 March 2011) and EMBASE (1974 to 1 March 2011). We checked references of articles and communicated with authors and pharmaceutical industry contacts. Selection criteria Randomised controlled trials which compared oxytocin agonist (carbetocin) with other uterotonic agents or with placebo or no treatment for the prevention of PPH. Data collection and analysis Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Main results We included 11 studies (2635 women) in the review. Six trials compared carbetocin with oxytocin; four of these were conducted for women undergoing caesarean deliveries, one was for women following vaginal deliveries and one did not state the mode of delivery clearly. The carbetocin was administered as 100 µg intravenous dosage across the trials, while oxytocin was administered intravenously but at varied dosages. Four trials compared intramuscular carbetocin and intramuscular syntometrine for women undergoing vaginal deliveries. Three of the trials were on women with no risk factor for PPH, while one trial was on women with risk factors for PPH. One trial compared the use of intravenous carbetocin with placebo. Use of carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics (risk ratio (RR) 0.62; 95% confidence interval (CI) 0.44 to 0.88; four trials, 1173 women) compared to oxytocin for those who underwent caesarean section, but not for vaginal delivery. Compared to oxytocin, carbetocin was associated with a reduced need for uterine massage following both caesarean delivery (RR 0.54; 95% CI 0.37 to 0.79; two trials, 739 women) and vaginal delivery (RR 0.70; 95% CI 0.51 to 0.94; one trial, 160 women). There were no statistically significant differences between carbetocin and oxytocin in terms of risk of any PPH (blood loss greater than 500 ml) or in risk of severe PPH (blood loss greater than 1000 ml). Comparison between carbetocin and syntometrine showed a lower mean blood loss in women who received carbetocin compared to syntometrine (mean difference (MD) ‐48.84 ml; 95% CI ‐94.82 to ‐2.85; four trials, 1030 women). There was no statistically significant difference in terms of the need for therapeutic uterotonic agents, but the risk of adverse effects such as nausea and vomiting were significantly lower in the carbetocin group: nausea (RR 0.24; 95% CI 0.15 to 0.40; four trials, 1030 women); vomiting (RR 0.21; 95% CI 0.11 to 0.39; four trials, 1030 women). The incidence of postpartum hypertension was also significantly lower in women who received carbetocin compared to those who received syntometrine. Cost‐effectiveness of carbetocin was investigated by one study published as an abstract, with limited data. Authors' conclusions For women who undergo caesarean section, carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics compared to oxytocin, but there is no difference in the incidence of postpartum haemorrhage. Carbetocin is associated with less blood loss compared to syntometrine in the prevention of PPH for women who have vaginal deliveries and is associated with significantly fewer adverse effects. Further research is needed to analyse the cost‐effectiveness of carbetocin as a uterotonic agent. Plain language summary Carbetocin for preventing postpartum haemorrhage In low‐ and middle‐income countries, postpartum haemorrhage is a major cause of maternal deaths and ill health. In high‐income countries, the problems are much less but there is still a small risk of major bleeding problems for women after giving birth. Active management of the third stage of labour, which is generally used to reduce blood loss at birth, consists of giving the mother a drug that helps the uterus to contract, early cord clamping and controlled cord traction to deliver the placenta. Different drugs have been tried and generally either intramuscular oxytocin or intramuscular syntometrine is given. Carbetocin is an oxytocin agonist. Oxytocin agonists are a group of drugs that mimic the oxytocin action, oxytocin being the natural hormone that helps to reduce blood loss at birth. This review includes 11 randomised controlled trials involving 2635 women. The trials compared carbetocin against either oxytocin or syntometrine given after delivery, vaginally or by caesarean section. The comparison between intramuscular carbetocin and oxytocin showed that there was no difference in the risk of heavy bleeding, but that women who received carbetocin were less likely to require other medications to produce uterine contractions following caesarean sections. Comparisons between carbetocin and syntometrine showed that women who received carbetocin had less blood loss compared to women who received syntometrine after vaginal delivery, and were much less likely to experience side effects such as nausea and vomiting. The incidence of hypertension at 30 and 60 minutes post delivery was also significantly lower in women who received carbetocin compared to those who received syntometrine. Five of the 11 studies were known to be supported by a pharmaceutical company.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Su, LL, Chong, YS, Samuel, M", "articleTypes": [], "doi": "10.1002/14651858.CD005457.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.776Z" }, { "id": "c2212cab-0157-4227-911a-c849501c116a", "pmid": "", "title": "Inhaled sodium cromoglycate for asthma in children", "imported": false, "abstract": "Abstract - Background Sodium cromoglycate has been recommended as maintenance treatment for childhood asthma for many years. Its use has decreased since 1990, when inhaled corticosteroids became popular, but it is still used in many countries. Objectives To determine the efficacy of sodium cromoglycate compared to placebo in the prophylactic treatment of children with asthma. Search methods We searched the Cochrane Airways Group Trials Register (October 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library Issue 3, 2009), MEDLINE (January 1966 to October 2009), EMBASE (January 1985 to October 2009) and reference lists of articles. We also contacted the pharmaceutical company manufacturing sodium cromoglycate. Selection criteria All double‐blind, placebo‐controlled randomised trials, which addressed the effectiveness of inhaled sodium cromoglycate as maintenance therapy, studying children aged 0 up to 18 years with asthma. Data collection and analysis Two authors independently assessed trial quality and extracted data. We pooled study results. Main results Of 3500 titles retrieved from the literature, 24 papers reporting on 23 studies could be included in the review. The studies were published between 1970 and 1997 and together included 1026 participants. Most were cross‐over studies. Few studies provided sufficient information to judge the concealment of allocation. Four studies provided results for the percentage of symptom‐free days. Pooling the results did not reveal a statistically significant difference between sodium cromoglycate and placebo. For the other pooled outcomes, most of the symptom‐related outcomes and bronchodilator use showed statistically significant results, but treatment effects were small. Considering the confidence intervals of the outcome measures, a clinically relevant effect of sodium cromoglycate cannot be excluded. The funnel plot showed an under‐representation of small studies with negative results, suggesting publication bias. Authors' conclusions There is insufficient evidence to be sure about the efficacy of sodium cromoglycate over placebo. Publication bias is likely to have overestimated the beneficial effects of sodium cromoglycate as maintenance therapy in childhood asthma. Plain language summary The effects of sodium cromoglycate compared with placebo for chronic asthma in children In this review we aimed to determine whether there is evidence for the effectiveness of inhaled sodium cromoglycate as maintenance treatment in children with chronic asthma. Most of the studies were carried out in small groups of patients. Furthermore, we suspect that not all studies undertaken have been published. The results show that there is insufficient evidence to be sure about the beneficial effect of sodium cromoglycate compared to placebo. However, for several outcome measures the results favoured sodium cromoglycate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "van der Wouden, JC; Uijen, JHJM; Bernsen, RMD; Tasche, MJA; de Jongste, JC; Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002173.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "c23db2cd-031a-4dd2-b7ce-d746ffd029bb", "pmid": "", "title": "Antibiotics for acute rhinosinusitis in adults", "imported": false, "abstract": "Abstract - Background Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear. We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging. Objectives To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings. Search methods We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines. Selection criteria Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis‐like signs or symptoms or sinusitis confirmed by imaging. Data collection and analysis Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required. Main results We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I² = 0%; 8 trials; high‐quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I² = 0%; 3 trials; moderate‐quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate‐quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I² = 0%; 3 trials; high‐quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I² = 16%; 10 trials; high‐quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I² = 21%; 12 trials; high‐quality evidence). A disease‐related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group). Authors' conclusions The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high‐quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate‐quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials. Plain language summary Antibiotics for sinus infection of short duration in adults Review question Do antibiotics cure sinus infection faster than no antibiotics in adults? Background A sinus is a cavity situated in the head. Adults with short‐duration sinus infection experience stuffy nose and thick, yellow discharge from the nose. People with sinus infection can feel slime in the back of the throat, facial pain, pain when bending forward, and pain in the upper teeth or when chewing. A short‐duration sinus infection may be suspected following physical examination and questions about symptoms. Blood examination or images of the sinuses can support diagnosis, but are not routinely recommended in most countries. Short‐duration sinus infections are mostly caused by viruses. Nevertheless, physicians tend to prescribe antibiotics, which should only be used to treat bacterial infections. Taking antibiotics unnecessarily results in antibiotic resistance against bacterial infections. We investigated whether antibiotics cure adults with short‐duration sinus infection faster than a dummy drug (placebo) or no treatment. Search date 18 January 2018. Study characteristics We included 15 studies in which adults with short‐duration sinus infection, whether or not confirmed by imaging, randomly received antibiotics, or a dummy drug or no treatment, in ambulatory care settings. The studies included a total of 3057 adults whose average age was 36 years; about 60% were female. Participants were followed until they were cured. Trial duration ranged from 8 to 28 days. Study funding sources Seven studies received financial support from government or academic institutions; six received grants from the pharmaceutical industry; and five did not state sources of support. Key results Without antibiotics, almost half of all participants were cured after one week, and two out of three were cured after 14 days. Five (diagnosis based on symptoms described to a doctor) to 11 (diagnosis confirmed by x‐ray) more people per 100 were cured faster with antibiotics. A computed tomography (CT) scan could better predict who would benefit from antibiotics, but routine use would cause health problems related to radiation exposure. Ten more people per 100 were relieved faster of thick, yellow discharge from the nose with antibiotics compared to a dummy drug or no treatment. Thirteen more people per 100 experienced side effects (mostly concerning stomach or intestines) with antibiotics compared to a dummy drug or no treatment. Compared with people who initially started antibiotics, five more people per 100 in the dummy drug or no treatment group had to start antibiotics because their condition worsened. Serious complications (e.g. brain abscess) were rare. We found that antibiotics are not a first‐choice treatment for adults with short‐duration sinus infection. We found no evidence relating to adults with severe sinusitis or with reduced immunity, or to children. Quality of evidence We found high‐quality evidence when the diagnosis was based on symptoms described to a doctor. We downgraded evidence quality to moderate when diagnosis was confirmed by x‐ray or CT scan because the number of participants was small, which makes the estimates less reliable.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Lemiengre, MB; van Driel, ML; Merenstein, D; Liira, H; Mäkelä, M; De Sutter, AIM", "articleTypes": [], "doi": "10.1002/14651858.CD006089.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "c247cd74-b993-4e72-80a5-65272a3559f4", "pmid": "", "title": "A Randomized, Multicenter, Open-label, Phase III Study of Lapatinib (GW572016) in Combination With Weekly Paclitaxel Versus Weekly Paclitaxel Alone in the Second Line Treatment of ErbB2 Amplified Advanced Gastric Cancer", "imported": false, "abstract": "EGF104578 is two-part study (Pilot part/Randomized part).Pilot part is designed to find the optimal (best) doses of lapatinib and paclitaxel when given together,Randomized part is designed to evaluate the overall survival in patients receiving lapatinib and paclitaxel compared to patients receiving only paclitaxel.", "journal": "", "year": "2007", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "c24e7f08-cc3a-4f1c-a4c7-c938dacefd9a", "pmid": "", "title": "Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low‐ and middle‐income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid‐based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition. Objectives To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low‐ and middle‐income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective. Search methods In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. Selection criteria We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before‐and‐after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low‐ and middle‐income countries. Data collection and analysis Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses using the random‐effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods. Main results Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care ‐ the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight‐for‐height (MD 0.20 z‐score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid‐based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses ‐ there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid‐based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non‐recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight‐for‐height, and mid‐upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid‐based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses ‐ no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid‐based nutrient supplements versus specific types of blended foods ‐ a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods ‐ in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet ‐ no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. Authors' conclusions In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short‐term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent. Plain language summary Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries Moderate acute malnutrition (MAM) affects around 10% of children under five years of age in low‐ and middle‐income countries. Different food strategies have been used for the nutritional recovery of children with MAM, such as lipid‐based nutrient supplements or blended foods, which can be provided in full dose or in a low dose as a complement to the usual diet. However, there is no definitive consensus on the most effective way to treat children with MAM. We searched eight electronic databases and three trials registers (in October 2012 for all except Embase, which was searched in August 2012). We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. We found eight relevant randomised controlled trials, enrolling 10,037 children under five years of age. All but one study was conducted in Africa. The risk of bias in the studies was generally low, though two studies had a high dropout rate. The participants were aware which intervention group they were in and this may have influenced their behaviour but we thought it unlikely it would have influenced the results since the outcomes measured were objective ones. For four of the studies, we were unable to assess if the study authors reported all the outcomes they intended to measure. When any type of specially formulated food was compared to standard care (medical care and counselling without foods), the children treated with foods had a higher chance of recovering from moderate malnutrition (two studies), greater improvement in nutritional status (two studies), and a lower number of dropouts (one study). A reduction in mortality was not shown. When lipid‐based nutrient supplements (which are food with high energy density and high lipid content) at full dose were compared to blended foods at full dose (which are dry food mixtures without high lipid content), there was no difference between these two types of foods in terms of number of deaths (five studies), children progressing to severe acute malnutrition (three studies), and children dropping out (four studies). However, lipid‐based nutrient supplements increased the number recovered by 10% (five studies), decreased the number of children non‐recovering (three studies), and slightly improved the nutritional status among the recovered. One study observed more children vomiting when given lipid‐based nutrient supplements compared to blended foods, but this was not reported by the other studies. No other side effects were reported. Few studies evaluated foods at complementary dosage (i.e. foods given in low quantity, just to complement the diet and not to fully substitute it), and no conclusion could be drawn from these studies. When specific foods were compared to each other, a type of corn‐soy blended food called CSB++ compared to lipid‐based nutrient supplements resulted in similar outcomes, while results of another blended food (CSB pre‐mix) versus lipid‐based nutrient supplements were unclear. In one study, CSB++ did not show any significant benefit over locally‐made blended foods, for example, Misola. No study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with moderate acute malnutrition. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. There are no studies evaluating special recipes to improve the adequacy of the usual home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lazzerini, M, Rubert, L, Pani, P", "articleTypes": [], "doi": "10.1002/14651858.CD009584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.797Z" }, { "id": "c24f51dc-f88e-4981-9630-0139e662ec87", "pmid": "", "title": "Homeopathic medicinal products for preventing and treating acute respiratory tract infections in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common and may lead to complications. Most children experience between three and six ARTIs annually. Although most infections are self‐limiting, symptoms can be distressing. Many treatments are used to control symptoms and shorten illness duration. Most treatments have minimal benefit and may lead to adverse events. Oral homeopathic medicinal products could play a role in childhood ARTI management if evidence for their effectiveness is established. This is an update of a review first published in 2018. Objectives To assess the effectiveness and safety of oral homeopathic medicinal products compared with placebo or conventional therapy to prevent and treat ARTIs in children. Search methods We searched CENTRAL (2022, Issue 3), including the Cochrane Acute Respiratory Infections Specialised Register, MEDLINE (1946 to 16 March 2022), Embase (2010 to 16 March 2022), CINAHL (1981 to 16 March 2022), AMED (1985 to 16 March 2022), CAMbase (searched 16 March 2022), and British Homeopathic Library (searched 26 June 2013 ‐ no longer operating). We also searched the WHO ICTRP and ClinicalTrials.gov (16 March 2022), checked references, and contacted study authors to identify additional studies. Selection criteria We included double‐blind randomised controlled trials (RCTs) or double‐blind cluster‐RCTs comparing oral homeopathy medicinal products with identical placebo or self‐selected conventional treatments to prevent or treat ARTIs in children aged 0 to 16 years. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results In this 2022 update, we identified three new RCTs involving 251 children, for a total of 11 included RCTs with 1813 children receiving oral homeopathic medicinal products or a control treatment (placebo or conventional treatment) for ARTIs. All studies focused on upper respiratory tract infections (URTIs), with only one study including some lower respiratory tract infections (LRTIs). Six treatment studies examined the effect on URTI recovery, and five studies investigated the effect on preventing URTIs after one to four months of treatment. Two treatment and three prevention studies involved homeopaths individualising treatment. The other studies used predetermined, non‐individualised treatments. All studies involved highly diluted homeopathic medicinal products, with dilutions ranging from 1 x 10 ‐4 to 1 x 10 ‐200 . We identified several limitations to the included studies, in particular methodological inconsistencies and high attrition rates, failure to conduct intention‐to‐treat analysis, selective reporting, and apparent protocol deviations. We assessed three studies as at high risk of bias in at least one domain, and many studies had additional domains with unclear risk of bias. Four studies received funding from homeopathy manufacturers; one study support from a non‐government organisation; two studies government support; one study was co‐sponsored by a university; and three studies did not report funding support. Methodological inconsistencies and significant clinical and statistical heterogeneity precluded robust quantitative meta‐analysis. Only four outcomes were common to more than one study and could be combined for analysis. Odds ratios (OR) were generally small with wide confidence intervals (CI), and the contributing studies found conflicting effects, so there was little certainty that the efficacy of the intervention could be ascertained. All studies assessed as at low risk of bias showed no benefit from oral homeopathic medicinal products, whilst trials at unclear or high risk of bias reported beneficial effects. For the comparison of individualised homeopathy versus placebo or usual care for the prevention of ARTIs, two trials reported on disease severity; due to heterogeneity the data were not combined, but neither study demonstrated a clinically significant difference. We combined data from two trials for the outcome need for antibiotics (OR 0.79, 95% CI 0.35 to 1.76; low‐certainty evidence). For the comparison of non‐individualised homeopathy versus placebo or usual care for the prevention of ARTIs, only the outcome recurrence of ARTI was reported by more than one trial; data from three studies were combined for this outcome (OR 0.60, 95% CI 0.21 to 1.72; low‐certainty evidence). For the comparison of both individualised and non‐individualised homeopathy versus placebo or usual care for the treatment of ARTIs, two studies provided data on short‐term cure (OR 1.31, 95% CI 0.09 to 19.54) and long‐term cure (OR 1.01, 95% CI 0.10 to 9.96; very low‐certainty evidence). The studies demonstrated an opposite direction of effect for both outcomes. Six studies reported on disease severity but were not combined as they used different scoring systems and scales. Three studies reported adverse events (OR 0.79, 95% CI 0.16 to 4.03; low‐certainty evidence). Authors' conclusions Pooling of five prevention and six treatment studies did not show any consistent benefit of homeopathic medicinal products compared to placebo on ARTI recurrence or cure rates in children. We assessed the certainty of the evidence as low to very low for the majority of outcomes. We found no evidence to support the efficacy of homeopathic medicinal products for ARTIs in children. Adverse events were poorly reported, and we could not draw conclusions regarding safety. Plain language summary What are the benefits and risks of oral homeopathic medicines in preventing and treating acute respiratory tract infections in children? Key messages Homeopathy is a type of complementary and alternative medicine. It is based on two main ideas: that substances that may cause illness or symptoms in a healthy person can, in very small doses, treat those symptoms in a person who is unwell; and that molecules in highly diluted substances retain a memory of the original substance. Due to a lack of solid evidence, the benefits and risks of oral homeopathic medicines for preventing and treating acute respiratory tract infections (ARTIs) in children are unclear. Studies of lower quality in design and reporting often suggest a possible benefit for oral homeopathic medicines, but studies of higher quality do not find benefit. What are respiratory tract infections? Respiratory infections are commonly caused by viruses, especially colds and influenza, though some lung and ear infections are caused by bacteria. It may be difficult to tell these infections apart, and sometimes they occur together. Most such infections improve without treatment, but sometimes symptoms persist after the initial infection has gone. Treatment is therefore aimed at relieving symptoms. Why is this important in children? Children have on average three to six respiratory tract infections each year. Although most are mild and treatable, they are sometimes acute (serious, swift, or sudden onset) respiratory tract infections that may require hospital treatment, but very rarely result in death. How are ARTIs treated? Antibiotic medicines taken orally (by mouth/swallowed, usually in the form of a tablet, pill, lozenge, or liquid) are often prescribed for ARTIs, even though they are ineffective against viruses. Homeopathic medicines may treat ARTIs with few side effects, but their effectiveness and safety has not been well researched. What did we want to find out? We wanted to know whether homeopathic medicines help children with ARTIs. We were interested in the effect of homeopathic medicines compared to placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) or to usual care therapies for ARTIs. We were also interested in the effect of homeopathic medicines on improvement in the severity or symptoms of infection, the need for antibiotics, duration of illness (that would affect days off school or days off work for parents), symptom reappearance, and any medicine adverse effects. What did we do? We searched for randomised controlled trials (studies where people are randomly assigned to one of two or more treatment groups) that investigated whether oral homeopathic medicines, compared to placebo or usual care ARTI therapies, were effective in the prevention or treatment of ARTIs in children aged up to 16 years. We compared and summarised the results of the studies, and rated our confidence in the evidence based on factors such as study methods and number of participants. What did we find? We found 11 studies involving 1813 children (5 studies for prevention and 6 studies for treatment of ARTIs). All studies investigated upper respiratory tract (from the nose to the windpipe (trachea)) infections, but one study combined reporting of upper and lower respiratory tract (from the windpipe to the lungs and pleura (membranes covering the lungs)) infections, so the numbers of children with upper or lower ARTIs is unknown. Main results In the treatment or prevention of ARTIs in children, homeopathic medicines showed little or no beneficial effects, whether individualised by a trained homeopath or a standard commercially available homeopathic therapy (11 studies, 1813 children). Where results could be combined, there was little or no difference between groups for short‐term cure (2 studies, 155 participants) or long‐term cure (2 studies, 155 participants), but the evidence is very uncertain. There may be little or no difference between groups for prevention of ARTI (3 studies, 735 participants). There was no important difference between homeopathy and placebo groups for parents' time off work, antibiotic use, or adverse events. We are unsure about the safety of homeopathic medicines because data on adverse events were poorly reported. Overall, the findings of this review do not support the use of homeopathic medicinal products for ARTIs in children. What are the limitations of the evidence? We have little confidence in the evidence because the studies involved only small numbers of children, used different types of homeopathic medicines for various ARTIs, contained numerous biases, and failed to report information about important outcomes. Further research could provide results that differ from the results of this review. How up‐to‐date is this evidence? The evidence is current to 16 March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hawke, K, King, D, van Driel, ML, McGuire, TM", "articleTypes": [], "doi": "10.1002/14651858.CD005974.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.084Z" }, { "id": "c257ecc3-321a-47b7-813c-59e265d53301", "pmid": "", "title": "Hyperbaric oxygen therapy for late radiation tissue injury", "imported": false, "abstract": "Abstract - Background This is the third update of the original Cochrane Review published in July 2005 and updated previously in 2012 and 2016. Cancer is a significant global health issue. Radiotherapy is a treatment modality for many malignancies, and about 50% of people having radiotherapy will be long‐term survivors. Some will experience late radiation tissue injury (LRTI), developing months or years following radiotherapy. Hyperbaric oxygen therapy (HBOT) has been suggested as a treatment for LRTI based on the ability to improve the blood supply to these tissues. It is postulated that HBOT may result in both healing of tissues and the prevention of complications following surgery and radiotherapy. Objectives To evaluate the benefits and harms of hyperbaric oxygen therapy (HBOT) for treating or preventing late radiation tissue injury (LRTI) compared to regimens that excluded HBOT. Search methods We used standard, extensive Cochrane search methods. The latest search date was 24 January 2022. Selection criteria We included randomised controlled trials (RCTs) comparing the effect of HBOT versus no HBOT on LRTI prevention or healing. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. survival from time of randomisation to death from any cause; 2. complete or substantial resolution of clinical problem; 3. site‐specific outcomes; and 4. adverse events. Our secondary outcomes were 5. resolution of pain; 6. improvement in quality of life, function, or both; and 7. site‐specific outcomes. We used GRADE to assess certainty of evidence. Main results Eighteen studies contributed to this review (1071 participants) with publications ranging from 1985 to 2022. We added four new studies to this updated review and evidence for the treatment of radiation proctitis, radiation cystitis, and the prevention and treatment of osteoradionecrosis (ORN). HBOT may not prevent death at one year (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.47 to 1.83; I 2 = 0%; 3 RCTs, 166 participants; low‐certainty evidence). There is some evidence that HBOT may result in complete resolution or provide significant improvement of LRTI (RR 1.39, 95% CI 1.02 to 1.89; I 2 = 64%; 5 RCTs, 468 participants; low‐certainty evidence) and HBOT may result in a large reduction in wound dehiscence following head and neck soft tissue surgery (RR 0.24, 95% CI 0.06 to 0.94; I 2 = 70%; 2 RCTs, 264 participants; low‐certainty evidence). In addition, pain scores in ORN improve slightly after HBOT at 12 months (mean difference (MD) −10.72, 95% CI −18.97 to −2.47; I 2 = 40%; 2 RCTs, 157 participants; moderate‐certainty evidence). Regarding adverse events, HBOT results in a higher risk of a reduction in visual acuity (RR 4.03, 95% CI 1.65 to 9.84; 5 RCTs, 438 participants; high‐certainty evidence). There was a risk of ear barotrauma in people receiving HBOT when no sham pressurisation was used for the control group (RR 9.08, 95% CI 2.21 to 37.26; I 2 = 0%; 4 RCTs, 357 participants; high‐certainty evidence), but no such increase when a sham pressurisation was employed (RR 1.07, 95% CI 0.52 to 2.21; I 2 = 74%; 2 RCTs, 158 participants; high‐certainty evidence). Authors' conclusions These small studies suggest that for people with LRTI affecting tissues of the head, neck, bladder and rectum, HBOT may be associated with improved outcomes (low‐ to moderate‐certainty evidence). HBOT may also result in a reduced risk of wound dehiscence and a modest reduction in pain following head and neck irradiation. However, HBOT is unlikely to influence the risk of death in the short term. HBOT also carries a risk of adverse events, including an increased risk of a reduction in visual acuity (usually temporary) and of ear barotrauma on compression. Hence, the application of HBOT to selected participants may be justified. The small number of studies and participants, and the methodological and reporting inadequacies of some of the primary studies included in this review demand a cautious interpretation. More information is required on the subset of disease severity and tissue type affected that is most likely to benefit from this therapy, the time for which we can expect any benefits to persist and the most appropriate oxygen dose. Further research is required to establish the optimum participant selection and timing of any therapy. An economic evaluation should also be undertaken. Plain language summary Hyperbaric oxygen therapy for the treatment of the late effects of radiotherapy Key message – In selected people and areas of the body hyperbaric oxygen therapy (HBOT) may help resolve symptoms associated with late radiation tissue injury (LRTI) but further research is required to establish which people may respond and the best timing of such therapy. What are the problems after radiation treatment and how can it be treated? There is a risk of serious complications developing in the months and years after radiation treatment (radiotherapy) for cancer. These problems are collectively called LRTI and are due to progressive damage to normal tissue (cells within the body) that has been exposed to radiation. These problems can be very difficult to resolve, and there is some doubt as to the best approaches to treatment. HBOT involves breathing oxygen in a specially designed pressurised chamber. It is used to improve oxygen supply to damaged tissue and support healing. What did we want to find out? We wanted to find out if HBOT results in both healing of tissues and the prevention of complications following surgery in an irradiated field and radiotherapy for cancer. What did we do? We searched medical databases for clinical studies reporting the evidence for or against the ability of HBOT to improve these complications compared to either no treatment or alternative treatments. What were the main findings? There was some evidence that HBOT may improve outcomes in LRTI affecting both bone and soft tissues of the head and neck, the bladder and the lower bowel. There was also some evidence that HBOT may reduce wound breakdown and improve pain following LRTI. HBOT did not affect the risk of dying over the short time that these studies followed their patients. HBOT is generally safe and well‐tolerated, but there is a risk of becoming temporarily short‐sighted from the oxygen exposure and of injury to the ear drum on compression. What are the limitations of the evidence? The evidence was mainly limited by small numbers of people and studies, poor reporting of methods and results, and uncertainty as to the exact degree of improvement with HBOT. A study of costs would also be useful. How up to date is this evidence? The evidence is current to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lin, ZC, Bennett, MH, Hawkins, GC, Azzopardi, CP, Feldmeier, J, Smee, R, Milross, C", "articleTypes": [], "doi": "10.1002/14651858.CD005005.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.775Z" }, { "id": "c270449b-7112-4aa1-ad11-3ecabf8293ea", "pmid": "", "title": "School feeding programs for improving the physical and psychological health of school children experiencing socioeconomic disadvantage", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kristjansson, E, Dignam, M, Rizvi, A, Osman, M, Magwood, O, Olarte, D, Cohen, JFW, Krasevec, J, Grover, T, Labelle, PR, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014794.pub2 AB - Abstract - Rationale School feeding aims to alleviate hunger and enhance child outcomes. Since the first Cochrane systematic review of school meals, there has been a marked increase in studies and reviews of school feeding programs. However, most systematic reviews are geographically limited and use qualitative analysis. We reviewed worldwide papers and performed several meta‐analyses, providing a more comprehensive picture of the effectiveness of school feeding. Objectives 1. To assess effectiveness of school feeding programs for improving the physical and psychological health of children experiencing socioeconomic disadvantage worldwide.
2. To assess effectiveness of school feeding programs for improving the health of children experiencing socioeconomic disadvantage compared with children who are more advantaged. Search methods We searched 17 subject‐specific and multidisciplinary databases and registries up to November 2023. In November 2024, two Information Specialists ran a top‐up search for randomized controlled trials (RCTs). We handsearched references of included studies and relevant reviews. Eligibility criteria We included individually randomized, cluster‐randomized, and cross‐over trials, as well as longitudinal non‐randomized studies of interventions (NRSIs). Studies had to compare the provision of free or reduced‐price food in schools versus no school feeding, focusing on socioeconomically disadvantaged children. The food had to contain at least 3% of the daily energy requirement and at least 10% of the daily protein requirement for the specified age group(s). Eligible participants were primary or secondary school students aged five to 19 years. Outcomes Our critical outcomes were change in: math achievement, reading achievement, attendance, enrollment, height‐for‐age z‐score (HAZ), weight‐for‐age z‐score (WAZ), and overweight/obesity. Our important outcomes were change in: overall academic achievement, fluid intelligence, working memory, behavioral/emotional outcomes, height, weight, and anemia. We planned to study changes between baseline and final outcomes. In one study with extreme contamination, we used the first follow‐up. Risk of bias We assessed the risk of bias for RCTs by outcome using the appropriate version of the Cochrane risk of bias tool (RoB 2): RoB 2 for individually randomized trials, for cluster‐RCTs, and for cross‐over trials. We evaluated the quality of NRSIs using the School‐based Measurement & Assessment of Results Tool (SMART), which is adapted from the Newcastle Ottawa Scale. Synthesis methods We used standardized mean differences (SMDs) with 95% confidence intervals (CIs) for educational and cognitive outcomes. We used mean differences (MDs), odds ratios (ORs), or incidence rate ratios (IRRs) for others. All meta‐analyses used random‐effects generic inverse variance. We conducted equity subgroup analyses by sex and socioeconomic status. We used GRADE to assess our confidence in the evidence for critical outcomes reported in RCTs. Included studies We included 40 studies with 83 reports. There were 13 RCTs (12 cluster‐randomized trials and one individually randomized trial) and 27 NRSIs. Most studies (34) were from low‐ and middle‐income countries (LMICs). In total, there were more than 91,885 students (four studies didn't report sample size). One study involved 59,613 students, while the others had between 60 and 6038 students. The studies included 48 outcomes; we meta‐analyzed or reported 14. Synthesis of results Low‐ and middle‐income countries (LMICs) School feeding compared to no school feeding improves math achievement slightly (SMD 0.14, 95% CI 0.06 to 0.23; P = 0.001; I² = 68%; 6 cluster‐RCTs, 5587 participants; high‐certainty evidence), but may have little to no effect on reading achievement (SMD 0.02, 95% CI −0.06 to 0.11; P = 0.61; I 2 = 54%; 3 cluster‐RCTs, 3417 participants; low‐certainty evidence). School feeding programs lead to a slight increase in enrollment rates (MD 3.44% increase, 95% CI 0.83 to 6.04; P = 0.01; I² = 0%; 2 cluster‐RCTs, 5200 participants, high‐certainty evidence) but may have little to no effect on attendance (MD 0.17%, 95% CI −2.64% to 2.97%; P = 0.91; I 2 = 81%; 3 cluster‐RCTs, 3566 participants; low‐certainty evidence). School feeding programs likely lead to a slight increase in HAZ (MD 0.06, 95% CI 0.03 to 0.09; P < 0.001; I 2 = 0%; 2 cluster‐RCTs, 3678 participants; moderate‐certainty evidence) and WAZ (MD 0.08, 95% CI 0.05 to 0.12; P < 0.001; I 2 = 0%; 3 cluster‐RCTs, 2132 participants; moderate‐certainty evidence). Two cluster‐RCTs assessed change in obesity/overweight. One 10‐month study found that the odds of being overweight/obese were 53% lower among adolescents receiving school meals compared to control adolescents (OR 0.47, 95% CI 0.30 to 0.72). Another study found no cases of overweight/obesity before or after the intervention. These findings are of very low certainty. Some researchers encountered implementation problems beyond their control, including conflicts, delays, and bureaucratic decisions. Heterogeneity in contexts, outcomes, child populations, and statistics was a limitation of this review. High‐income countries (HICs) One NRSI found very uncertain evidence that children assigned to a breakfast club increased their attendance by more than 1.6% on average compared to children in the control group. Equity analyses The equity (subgroup) analyses by sex and by socio‐economic status were all non‐significant. There were only two studies in each subgroup analysis; they were likely underpowered. Authors' conclusions In LMICs, school feeding programs lead to a slight improvement in math achievement, but may have little to no effect on reading achievement. School feeding programs lead to a slight increase in enrollment, but may have little to no impact on attendance. They likely lead to slight gains in HAZ and WAZ. There may be little to no association between school feeding and overweight/obesity, but the evidence is very uncertain. We recommend that researchers and policymakers view research as an integral part of the implementation process. To reduce heterogeneity in outcomes, we recommend even greater co‐ordination of research, and that researchers and interest holders work together to identify a core set of outcomes. Funding The authors would like to thank the following donors for their generous support in making this review possible: Dubai Cares, the World Food Programme's School Meals and Social Protection Service, and the Research Consortium for School Health and Nutrition. Registration Protocol (2022): https://doi.org/10.1002/14651858.CD014794 
Original review (2007): https://doi.org/10.1002/14651858.CD004676.pub2 
Original Campbell protocol (2006): doi.org/10.1002/CL2.12 Plain language summary Can school meal programs improve health and educational goals in children experiencing socioeconomic disadvantage? Key messages School meal programs in low‐ and middle‐income countries lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. Research should be a key part of planning and running school meal programs. To make it easier to compare results from different studies, researchers, parents, and policymakers should work together to agree on a list of the most important goals for children's health, development, and success in school. Why did we want to review studies on school meals? Worldwide, many children do not get enough nutritious food to keep them healthy and ready to learn in school. This affects their ability to enroll, attend school regularly, and learn there. School meals aim to reduce hunger and improve children's learning, focus, and overall health. School meals are one of the world's largest social safety nets. We sought to understand their effectiveness for children in disadvantaged circumstances across the globe. Most previous reviews of the evidence are limited in geographical scope, and many use narrative analyses. What did we want to find out? We asked the following two health equity (fairness) questions. Do school meals improve the physical health of socioeconomically disadvantaged children worldwide? Do school meals benefit children who are disadvantaged by sex and low family income more than they benefit less disadvantaged children? What did we do? We searched for studies that evaluated the effects of school meals for school students aged five to 19 years. We included randomized studies, which allocate students or schools to different study groups at random. However, because randomized studies are not always possible, we included non‐randomized studies that compared school meal groups with groups that received no school meals. These non‐randomized studies needed to measure outcomes at least twice; once at the beginning of the study and once at the end. We rated our confidence in the findings separately for each outcome. What did we find? We found 13 randomized studies and 27 non‐randomized studies, which collectively involved more than 91,995 students aged five to 19 years. One study included 59,613 students, while others had student populations ranging from 40 to 6038 students. Across all studies, there was a similar number of boys and girls, although three studies included only girls. Most studies took place in low‐ and middle‐income countries (34 studies), while six were from high‐income countries. In low‐ and middle‐income countries, school meals lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. In high‐income countries, one study presented very uncertain evidence that school meals may increase attendance slightly. What are the limitations of the evidence? Because we found very few eligible studies conducted in high‐income countries, we do not recommend applying our findings to this setting. We are confident in the results for math test scores and enrollment. We are moderately confident in the results for height and weight for age, because we had some concerns about the study methods. We have little confidence in the results for reading test scores and attendance, because we had some concerns about the study methods, and the results differed substantially among the trials. We are not confident in the results for overweight/obesity, because we have some concerns about the study methods, the two studies measured the outcome in different ways, and one of the studies was very small. Several studies faced barriers due to their context, such as conflict, droughts, bureaucratic delays, and difficulties in distributing funds to caterers, as well as eagerness to initiate school meal programs in control schools. We need more evidence on school meals and their impact on disadvantaged school students—especially those in secondary school—in countries of all income levels. We also need more studies that assess the difference between disadvantaged groups and more advantaged children in high‐income countries. We suggest that researchers, school feeding experts, teachers, and parents collaborate to develop a core set of key outcomes, and that these outcomes be put in an open‐access repository. How up‐to‐date is this evidence? This review updates and expands our 2007 review of school meal programs. The evidence is current to November 2024. Funding Dubai Cares funded this review through the World Food Program School Feeding Program. The London School of Hygiene and Tropical Medicine also funded this review. The funders had no influence on the review.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.772Z" }, { "id": "c294745b-30e6-4922-bb68-24d930205e6d", "pmid": "", "title": "Topical benzoyl peroxide for acne", "imported": false, "abstract": "Abstract - Background Acne is a common, economically burdensome condition that can cause psychological harm and, potentially, scarring. Topical benzoyl peroxide (BPO) is a widely used acne treatment; however, its efficacy and safety have not been clearly evaluated. Objectives To assess the effects of BPO for acne. Search methods We searched the following databases up to February 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of relevant randomised controlled trials (RCTs) and systematic reviews. Selection criteria We included RCTs that compared topical BPO used alone (including different formulations and concentrations of BPO) or as part of combination treatment against placebo, no treatment, or other active topical medications for clinically diagnosed acne (used alone or in combination with other topical drugs not containing BPO) on the face or trunk. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Primary outcome measures were 'participant global self‐assessment of acne improvement' and 'withdrawal due to adverse events in the whole course of a trial'. 'Percentage of participants experiencing any adverse event in the whole course of a trial' was a key secondary outcome. Main results We included 120 trials (29,592 participants randomised in 116 trials; in four trials the number of randomised participants was unclear). Ninety‐one studies included males and females. When reported, 72 trials included participants with mild to moderate acne, 26 included participants with severe acne, and the mean age of participants ranged from 18 to 30 years. Our included trials assessed BPO as monotherapy, as add‐on treatment, or combined with other active treatments, as well as BPO of different concentrations and BPO delivered through different vehicles. Comparators included different concentrations or formulations of BPO, placebo, no treatment, or other active treatments given alone or combined. Treatment duration in 80 trials was longer than eight weeks and was only up to 12 weeks in 108 trials. Industry funded 50 trials; 63 trials did not report funding. We commonly found high or unclear risk of performance, detection, or attrition bias. Trial setting was under‐reported but included hospitals, medical centres/departments, clinics, general practices, and student health centres. We reported on outcomes assessed at the end of treatment, and we classified treatment periods as short‐term (two to four weeks), medium‐term (five to eight weeks), or long‐term (longer than eight weeks). For 'participant‐reported acne improvement', BPO may be more effective than placebo or no treatment (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.12 to 1.45; 3 RCTs; 2234 participants; treatment for 10 to 12 weeks; low‐certainty evidence). Based on low‐certainty evidence, there may be little to no difference between BPO and adapalene (RR 0.99, 95% CI 0.90 to 1.10; 5 RCTs; 1472 participants; treatment for 11 to 12 weeks) or between BPO and clindamycin (RR 0.95, 95% CI 0.68 to 1.34; 1 RCT; 240 participants; treatment for 10 weeks) (outcome not reported for BPO versus erythromycin or salicylic acid). For 'withdrawal due to adverse effects', risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment (RR 2.13, 95% CI 1.55 to 2.93; 24 RCTs; 13,744 participants; treatment for 10 to 12 weeks; low‐certainty evidence); the most common causes of withdrawal were erythema, pruritus, and skin burning. Only very low‐certainty evidence was available for the following comparisons: BPO versus adapalene (RR 1.85, 95% CI 0.94 to 3.64; 11 RCTs; 3295 participants; treatment for 11 to 24 weeks; causes of withdrawal not clear), BPO versus clindamycin (RR 1.93, 95% CI 0.90 to 4.11; 8 RCTs; 3330 participants; treatment for 10 to 12 weeks; causes of withdrawal included local hypersensitivity, pruritus, erythema, face oedema, rash, and skin burning), erythromycin (RR 1.00, 95% CI 0.07 to 15.26; 1 RCT; 60 participants; treatment for 8 weeks; withdrawal due to dermatitis), and salicylic acid (no participants had adverse event‐related withdrawal; 1 RCT; 59 participants; treatment for 12 weeks). There may be little to no difference between these groups in terms of withdrawal; however, we are unsure of the results because the evidence is of very low certainty. For 'proportion of participants experiencing any adverse event', very low‐certainty evidence leaves us uncertain about whether BPO increased adverse events when compared with placebo or no treatment (RR 1.40, 95% CI 1.15 to 1.70; 21 RCTs; 11,028 participants; treatment for 10 to 12 weeks), with adapalene (RR 0.71, 95% CI 0.50 to 1.00; 7 RCTs; 2120 participants; treatment for 11 to 24 weeks), with erythromycin (no participants reported any adverse events; 1 RCT; 89 participants; treatment for 10 weeks), or with salicylic acid (RR 4.77, 95% CI 0.24 to 93.67; 1 RCT; 41 participants; treatment for 6 weeks). Moderate‐certainty evidence shows that the risk of adverse events may be increased for BPO versus clindamycin (RR 1.24, 95% CI 0.97 to 1.58; 6 RCTs; 3018 participants; treatment for 10 to 12 weeks); however, the 95% CI indicates that BPO might make little to no difference. Most reported adverse events were mild to moderate, and local dryness, irritation, dermatitis, erythema, application site pain, and pruritus were the most common. Authors' conclusions Current evidence suggests that BPO as monotherapy or add‐on treatment may be more effective than placebo or no treatment for improving acne, and there may be little to no difference between BPO and either adapalene or clindamycin. Our key efficacy evidence is based on participant self‐assessment; trials of BPO versus erythromycin or salicylic acid did not report this outcome. For adverse effects, the evidence is very uncertain regarding BPO compared with adapalene, erythromycin, or salicylic acid. However, risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment. Withdrawal may be linked to tolerability rather than to safety. Risk of mild to moderate adverse events may be higher with BPO compared with clindamycin. Further trials should assess the comparative effects of different preparations or concentrations of BPO and combination BPO versus monotherapy. These trials should fully assess and report adverse effects and patient‐reported outcomes measured on a standardised scale. Plain language summary Topical benzoyl peroxide for acne Review question We reviewed the evidence showing effects and safety of topical benzoyl peroxide (BPO), used alone or in combination. Eligible comparisons included placebo (an identical but inactive treatment), no treatment, or other active (medical) topical medications for treating acne (used alone or in combination with other topical drugs not containing BPO) (evidence is current to February 2019). The main outcomes of interest in this review were participant‐reported acne improvement and withdrawal from the study due to any side effects. More generally, we also considered the percentage of participants experiencing any side effects over the whole course of a trial. Background As a common skin disease, acne vulgaris affects the physical, mental, and social well‐being of millions of adolescents and young adults. A wide range of treatments for acne vulgaris are available, and topical BPO has been recommended as a priority therapy to be used alone or combined with other topical or oral treatments, depending on acne severity. However, the benefits and harms of BPO have yet to be evaluated. Study characteristics We included 120 studies (which comprised 29,592 people randomised in 116 trials; in four trials the number of randomised participants was unclear). Through our search, we found studies assessing different concentrations of BPO, BPO delivered through various means, or BPO used alone or given with other treatments that may or may not be considered as the primary treatment. These studies compared treatments against different concentrations or formulations of BPO, placebo, no treatment, or other medical treatments given alone or in combination. Most of the studies included male and female participants with mild to moderate acne; only 67% of studies reported participant age, which ranged between 18 and 30 years. Participants were treated for over eight weeks in nearly two‐thirds of the trials. Industry financially supported approximately two‐fifths of the trials, and more than half of the trials did not report their funding sources. Few studies reported where they were set, but locations included hospitals, medical centres, national medical institutes, clinics, medical departments, and general practices. Key results We found low‐certainty evidence to suggest that long‐term (i.e. given for longer than eight weeks) BPO treatment may increase self‐reported treatment success compared to placebo or no BPO treatment (three studies), but there may be little to no difference when BPO treatment is compared to adapalene (five studies) or clindamycin (one study). This outcome was not reported by studies comparing BPO treatment to erythromycin or salicylic acid. Long‐term BPO may lead to an increased chance of treatment discontinuation compared to placebo or no treatment (24 studies), with the most common causes being redness, itch, and skin burning (low‐certainty evidence). When medium‐ to long‐term BPO was compared to adapalene (11 studies), clindamycin (eight studies), erythromycin (one study), or salicylic acid (one study), we found only very low‐certainty evidence, meaning that although there may be little to no difference in withdrawal between these groups, we are not sure of the results. It should be noted that participant withdrawal may be linked to issues around treatment acceptability (dermatitis, rash, facial swelling, sensitivity) rather than to safety. Very low‐certainty evidence means that we are uncertain if BPO leads to more side effects among participants receiving medium‐ to long‐term BPO than among those given no treatment/placebo (21 studies), adapalene (seven studies), erythromycin (one study), or salicylic acid (one study). Medium‐term treatment with BPO may lead to increased risk of side effects when compared against clindamycin, but the effects of this treatment vary, so the treatment chosen may make little to no difference (six studies; moderate‐certainty evidence). Side effects reported in these studies were usually mild to moderate, and the most common were local dryness, irritation, eczema, redness, pain at the site of application, and pruritus. Certainty of the evidence For our key comparisons, we rated the certainty of evidence for 'participant‐reported acne improvement' as low. For the outcomes 'withdrawal due to adverse effects' and ‘percentage of participants having any adverse events', the evidence was mainly of very low certainty. Included trials were at high or unclear risk of bias, participant numbers were small, results were not consistent across trials, and we suspected publication bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Yang, Z; Zhang, Y; Lazic Mosler, E; Hu, J; Li, H; Zhang, Y; Liu, J; Zhang, Q", "articleTypes": [], "doi": "10.1002/14651858.CD011154.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "c2aaa440-4a2a-45f6-9765-a9d39639ec3f", "pmid": "", "title": "Pharmacological interventions for smoking cessation: an overview and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Smoking is the leading preventable cause of illness and premature death worldwide. Some medications have been proven to help people to quit, with three licensed for this purpose in Europe and the USA: nicotine replacement therapy (NRT), bupropion, and varenicline. Cytisine (a treatment pharmacologically similar to varenicline) is also licensed for use in Russia and some of the former socialist economy countries. Other therapies, including nortriptyline, have also been tested for effectiveness. Objectives How do NRT, bupropion and varenicline compare with placebo and with each other in achieving long‐term abstinence (six months or longer)?
 How do the remaining treatments compare with placebo in achieving long‐term abstinence?
 How do the risks of adverse and serious adverse events (SAEs) compare between the treatments, and are there instances where the harms may outweigh the benefits? Methods The overview is restricted to Cochrane reviews, all of which include randomised trials. Participants are usually adult smokers, but we exclude reviews of smoking cessation for pregnant women and in particular disease groups or specific settings. We cover nicotine replacement therapy (NRT), antidepressants (bupropion and nortriptyline), nicotine receptor partial agonists (varenicline and cytisine), anxiolytics, selective type 1 cannabinoid receptor antagonists (rimonabant), clonidine, lobeline, dianicline, mecamylamine, Nicobrevin, opioid antagonists, nicotine vaccines, and silver acetate. Our outcome for benefit is continuous or prolonged abstinence at least six months from the start of treatment. Our outcome for harms is the incidence of serious adverse events associated with each of the treatments.
 We searched the Cochrane Database of Systematic Reviews (CDSR) in The Cochrane Library , for any reviews with 'smoking' in the title, abstract or keyword fields. The last search was conducted in November 2012. We assessed methodological quality using a revised version of the AMSTAR scale. For NRT, bupropion and varenicline we conducted network meta‐analyses, comparing each with the others and with placebo for benefit, and varenicline and bupropion for risks of serious adverse events. Main results We identified 12 treatment‐specific reviews. The analyses covered 267 studies, involving 101,804 participants. Both NRT and bupropion were superior to placebo (odds ratios (OR) 1.84; 95% credible interval (CredI) 1.71 to 1.99, and 1.82; 95% CredI 1.60 to 2.06 respectively). Varenicline increased the odds of quitting compared with placebo (OR 2.88; 95% CredI 2.40 to 3.47). Head‐to‐head comparisons between bupropion and NRT showed equal efficacy (OR 0.99; 95% CredI 0.86 to 1.13). Varenicline was superior to single forms of NRT (OR 1.57; 95% CredI 1.29 to 1.91), and to bupropion (OR 1.59; 95% CredI 1.29 to 1.96).
 Varenicline was more effective than nicotine patch (OR 1.51; 95% CredI 1.22 to 1.87), than nicotine gum (OR 1.72; 95% CredI 1.38 to 2.13), and than 'other' NRT (inhaler, spray, tablets, lozenges; OR 1.42; 95% CredI 1.12 to 1.79), but was not more effective than combination NRT (OR 1.06; 95% CredI 0.75 to 1.48). Combination NRT also outperformed single formulations. The four categories of NRT performed similarly against each other, apart from 'other' NRT, which was marginally more effective than NRT gum (OR 1.21; 95% CredI 1.01 to 1.46).
 Cytisine (a nicotine receptor partial agonist) returned positive findings (risk ratio (RR) 3.98; 95% CI 2.01 to 7.87), without significant adverse events or SAEs.
 Across the 82 included and excluded bupropion trials, our estimate of six seizures in the bupropion arms versus none in the placebo arms was lower than the expected rate (1:1000), at about 1:1500. SAE meta‐analysis of the bupropion studies demonstrated no excess of neuropsychiatric (RR 0.88; 95% CI 0.31 to 2.50) or cardiovascular events (RR 0.77; 95% CI 0.37 to 1.59). SAE meta‐analysis of 14 varenicline trials found no difference between the varenicline and placebo arms (RR 1.06; 95% CI 0.72 to 1.55), and subgroup analyses detected no significant excess of neuropsychiatric events (RR 0.53; 95% CI 0.17 to 1.67), or of cardiac events (RR 1.26; 95% CI 0.62 to 2.56).
 Nortriptyline increased the chances of quitting (RR 2.03; 95% CI 1.48 to 2.78). Neither nortriptyline nor bupropion were shown to enhance the effect of NRT compared with NRT alone. Clonidine increased the chances of quitting (RR 1.63; 95% CI 1.22 to 2.18), but this was offset by a dose‐dependent rise in adverse events. Mecamylamine in combination with NRT may increase the chances of quitting, but the current evidence is inconclusive. Other treatments failed to demonstrate a benefit compared with placebo. Nicotine vaccines are not yet licensed for use as an aid to smoking cessation or relapse prevention. Nicobrevin's UK license is now revoked, and the manufacturers of rimonabant, taranabant and dianicline are no longer supporting the development or testing of these treatments. Authors' conclusions NRT, bupropion, varenicline and cytisine have been shown to improve the chances of quitting. Combination NRT and varenicline are equally effective as quitting aids. Nortriptyline also improves the chances of quitting. On current evidence, none of the treatments appear to have an incidence of adverse events that would mitigate their use.
 Further research is warranted into the safety of varenicline and into cytisine's potential as an effective and affordable treatment, but not into the efficacy and safety of NRT. Plain language summary Medications to help people to stop smoking: an overview of reviews Background 
 Smoking is a main cause of early death throughout the world. There are a number of medications which can help people to quit smoking. Three of these, nicotine replacement therapy (NRT), bupropion and varenicline, are licensed for this purpose in the USA and Europe. Cytisine (similar to varenicline) is licensed for use in Russia and Eastern Europe. We reviewed studies of these and other treatments, including nortriptyline, to compare their benefits and risks.
 Methods 
 We found 12 Cochrane reviews of different treatments. The treatments include nicotine replacement therapy (NRT); antidepressants (bupropion and nortriptyline); nicotine receptor partial agonists (varenicline and cytisine); anxiolytics; selective type 1 cannabinoid receptor antagonists (rimonabant); clonidine; lobeline; dianicline; mecamylamine; Nicobrevin; opioid antagonists; nicotine vaccines; and silver acetate. The reviews were conducted between 2008 and 2012, and analysed 267 trials, covering more than 101,000 smokers. All the reviews used randomised controlled trials, and compared the active treatment with a placebo, and sometimes with other treatments. The outcomes were measured at least six months from the start of treatment, and the results were usually checked by testing breath, blood or urine. We also assessed the risk of harms from each treatment. We then compared NRT, bupropion and varenicline with each other, using a network meta‐analysis.
 Results 
 NRT and bupropion helped about 80% more people to quit than placebo; this means that for every 10 people who quit with placebo about 18 could be expected to quit with NRT or with bupropion. Varenicline more than doubled the chances of quitting compared with placebo, so that for every 10 who quit with placebo about 28 could be expected to quit with varenicline.
 Varenicline helped about 50% more people to quit than nicotine patch and 'other' NRT (tablets, sprays, lozenges and inhalers), and about 70% more people than nicotine gum. So for every 10 people who quit with NRT patch or with 'other' NRT, about 15 could be expected to quit with varenicline, and for every 10 who quit with NRT gum about 17 could be expected to quit with varenicline. Combining two type of NRT was as effective as using varenicline, and helped more people to quit than single types of NRT. There was little to choose between different types of NRT, apart from 'other' NRT, which helped slightly more people than nicotine gum; for every 10 people who quit with NRT gum, about 12 could be expected to quit with 'other' NRT.
 NRT combined with nortriptyline or with bupropion was not more effective than NRT alone.
 Both cytisine and nortriptyline compared with placebo improved the chances of quitting, with minimal risk of harms.
 
 Bupropion carries a known risk of seizures (about 1 per 1000 users), but we found fewer than expected in the included and excluded trials, at about 1 in 1500. Although there may be a marginal increase in the likelihood of any serious adverse event while taking bupropion, we did not find increased risks of neuropsychiatric or heart and circulatory problems in the bupropion studies. The evidence for the safety of varenicline is still under investigation; we found no evidence from the trials that it is linked to an increase in neuropsychiatric problems, or with increased heart and circulatory problems.
 
 Clonidine helped people to quit, but caused side effects. It is not clear whether or not mecamylamine used with NRT helps people to quit. Other treatments did not seem to help. So far, nicotine vaccines are not licensed for use anywhere in the world. Nicobrevin is no longer available in the UK, and rimonabant, taranabant and dianicline have all been withdrawn from the market.
 Conclusions 
 NRT, bupropion and varenicline all improve the chances of quitting, with a low risk of harms.
 Combination use of NRT is as effective as varenicline, and more effective than single types of NRT.
 Cytisine has potential as a safe, effective and affordable treatment.
 Nortriptyline improves the chances of quitting, with little evidence of harmful events.
 We need continued monitoring of the safety of varenicline.
 More research into NRT versus placebo is unlikely to change our understanding of the treatment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Cahill, K; Stevens, S; Perera, R; Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD009329.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "c2af82e3-189f-42f5-b20d-3b9d41d66eea", "pmid": "", "title": "Colchicine for acute gout", "imported": false, "abstract": "Abstract - Background This is an updated Cochrane Review, first published in 2006 and updated in 2014. Gout is one of the most common rheumatic diseases worldwide. Despite the use of colchicine as one of the first‐line therapies for the treatment of acute gout, evidence for its benefits and harms is relatively limited. Objectives To update the available evidence of the benefits and harms of colchicine for the treatment of acute gout. Search methods We updated the search of CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICTRP registries to 28 August 2020. We did not impose any date or language restrictions in the search. Selection criteria We considered published randomised controlled trials (RCTs) and quasi‐randomised controlled trials (quasi‐RCTs) evaluating colchicine therapy compared with another therapy (placebo or active) in acute gout; low‐dose colchicine at clinically relevant doses compared with placebo was the primary comparison. The major outcomes were pain, participant global assessment of treatment success (proportion with 50% or greater decrease in pain from baseline up to 32 to 36 hours), reduction of inflammation, function of target joint, serious adverse events, total adverse events and withdrawals due to adverse events. Data collection and analysis We used standard methodological procedures as expected by Cochrane in this review update. Main results We included four trials (803 randomised participants), including two new trials, in this updated review. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We did not identify any trials comparing colchicine to glucocorticoids (by any route). The mean age of participants ranged from 51.2 to 70 years, and trial duration from 48 hours to 12 weeks. Two trials were at low risk of bias, one was possibly susceptible to selection bias (random sequence generation), reporting bias and other bias, and one open‐label trial was at high risk of performance and detection bias. For the primary comparison, low‐quality evidence from one trial (103 participants, downgraded for imprecision and bias) suggests low‐dose colchicine may improve treatment outcome compared to placebo with little or no increased risk of adverse events. The number of people who reported treatment success (50% or greater pain reduction) at 32 to 36 hours was slightly larger with low‐dose colchicine (418 per 1000) compared with placebo (172 per 1000; risk ratio (RR) 2.43, 95% confidence interval (CI) 1.05 to 5.64; absolute improvement 25% more reported success (7% more to 42% more, the 95% CIs include both a clinically important and unimportant benefit); relative change of 143% more people reported treatment success (5% more to 464% more). The incidence of total adverse events was 364 per 1000 with low‐dose colchicine compared with 276 per 1000 with placebo: RR 1.32, 95% CI 0.68 to 2.56; absolute difference 9% more events with low‐dose colchicine (9% fewer to 43% more, the 95% CIs include both a clinically important effect and no effect); relative change of 32% more events (32% fewer to 156% more). No participants withdrew due to adverse events or reported any serious adverse events. Pain, inflammation and function were not reported. Low‐quality evidence (downgraded for imprecision and bias) from two trials (124 participants) suggests that high‐dose colchicine compared to placebo may improve symptoms, but with increased risk of harms. More participants reported treatment success at 32 to 36 hours with high‐dose colchicine (518 per 1000) compared with placebo (240 per 1000): RR 2.16, 95% CI 1.28 to 3.65, absolute improvement 28% (8% more to 46% more); more also had reduced inflammation at this time point with high‐dose colchicine (504 per 1000) compared with placebo (48 per 1000): RR 10.50, 95% CI 1.48 to 74.38; absolute improvement 45% greater (22% greater to 68% greater); but more adverse events were reported with high‐dose colchicine (829 per 1000 compared with 260 per 1000): RR 3.21, 95% CI 2.01 to 5.11, absolute difference 57% (26% more to 74% more). Pain and function were not reported. Low‐quality evidence from a single trial comparing high‐dose to low‐dose colchicine indicates there may be little or no difference in benefit in terms of treatment success at 32 to 36 hours but more adverse events associated with the higher dose. Similarly, low‐quality evidence from a single trial indicates there may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction at seven days, with a similar number of adverse events reported at four weeks follow‐up. Reduction of inflammation, function of target joint and withdrawals due to adverse events were not reported in either of these trials, and pain was not reported in the high‐dose versus low‐dose colchicine trial. We were unable to estimate the risk of serious adverse events for most comparisons as there were few events reported in the trials. One trial (399 participants) reported three serious adverse (one in a participant receiving low‐dose colchicine and two in participants receiving NSAIDs), due to reasons unrelated to the trial (low‐quality evidence downgraded for bias and imprecision). Authors' conclusions We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve pain when compared to placebo, low‐quality evidence suggests that high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo, while low‐quality evidence indicates that the number of adverse events may be similar with low‐dose colchicine and NSAIDs. Further trials comparing colchicine to placebo or other treatment will likely have an important impact on our confidence in the effect estimates and may change the conclusions of this review. There are no trials reporting the effect of colchicine in populations with comorbidities or in comparison with other commonly used treatments, such as glucocorticoids. Plain language summary Colchicine for treating acute gout flares Background Gout is a very common cause of inflammatory arthritis (pain, redness, warmth and swelling of affected joints) and is caused by urate crystals forming either within or around joints. Uric acid is a normal waste product that is usually excreted with urine. However, in the case of gout, there is either excessive production of uric acid, or the body is not able to excrete it quickly enough, or a combination of both. An attack of gout usually occurs rapidly and usually resolves within 7 to 10 days. Colchicine is a drug that is used mainly in gout to treat an acute attack or to prevent an attack while starting uric acid‐lowering therapy. Study characteristics This Cochrane Review is current to August 2020. We included four trials (803 randomised participants) in this updated review, including two new trials. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (fake medicine) (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We selected low‐dose colchicine compared with placebo as the primary comparison; the low dose is consistent with doses used in practice. Trials were performed in hospital and multicentre settings in four countries, the majority of participants were male, and mean age ranged between 51.2 and 70 years. One trial received funding from a pharmaceutical company that was involved in the study design, data collection, data analysis, and manuscript writing. Key results Compared with placebo medication, low‐dose colchicine for people with acute gout may slightly improve treatment outcomes with little or no increased risk of adverse events at 32 to 36 hours. Proportion of participants reporting treatment success (defined as 50% or more reduction in pain) 25% more people (7% more to 42% more) reported success, or 25 more out of 100 ‐ 42 people out of 100 reported treatment success with colchicine ‐ 17 people out of 100 reported treatment success with placebo Total adverse events (diarrhoea, vomiting or nausea) 6% more people reported adverse events (13% more to 23% more), or 6 more out of 100 ‐ 26 people out of 100 reported side effects with colchicine ‐ 20 people out of 100 reported side effects with placebo Pain, reduction of inflammation, function of target joint, serious adverse events or withdrawals due to adverse events were not reported for this comparison. Other comparisons are briefly summarised here: High‐dose colchicine may improve symptoms compared with placebo, but with more adverse events. High‐dose may have little or no benefit over low‐dose colchicine but more adverse events. There may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction, with a similar number of adverse events. There were no trials that compared colchicine to glucocorticoids. Quality of the evidence We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve treatment success when compared to placebo, high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo while the number of adverse events may be similar with low‐dose colchicine compared with NSAIDs. Further research is very likely to have an important impact on our confidence in the estimate of effect and may change the estimate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "McKenzie, BJ, Wechalekar, MD, Johnston, RV, Schlesinger, N, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD006190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.114Z" }, { "id": "c2c17e27-74ca-498d-b9bd-a0bde28f59e2", "pmid": "", "title": "Laxatives for the management of constipation in people receiving palliative care", "imported": false, "abstract": "Abstract - Background This article describes the second update of a Cochrane review on the effectiveness of laxatives for the management of constipation in people receiving palliative care. Previous versions were published in 2006 and 2010 where we also evaluated trials of methylnaltrexone; these trials have been removed as they are included in another review in press. In these earlier versions, we drew no conclusions on individual effectiveness of different laxatives because of the limited number of evaluations. This is despite constipation being common in palliative care, generating considerable suffering due to the unpleasant physical symptoms and the availability of a wide range of laxatives with known differences in effect in other populations. Objectives To determine the effectiveness and differential efficacy of laxatives used to manage constipation in people receiving palliative care. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library ), MEDLINE, EMBASE, CINAHL and Web of Science (SCI & CPCI‐S) for trials to September 2014. Selection criteria Randomised controlled trials (RCTs) evaluating laxatives for constipation in people receiving palliative care. Data collection and analysis Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity. Main results We identified five studies involving the laxatives lactulose, senna, co‐danthramer, misrakasneham, docusate and magnesium hydroxide with liquid paraffin. Overall, the study findings were at an unclear risk of bias. As all five studies compared different laxatives or combinations of laxatives, it was not possible to perform a meta‐analysis. There was no evidence on whether individual laxatives were more effective than others or caused fewer adverse effects. Authors' conclusions This second update found that laxatives were of similar effectiveness but the evidence remains limited due to insufficient data from a few small RCTs. None of the studies evaluated polyethylene glycol or any intervention given rectally. There is a need for more trials to evaluate the effectiveness of laxatives in palliative care populations. Extrapolating findings on the effectiveness of laxatives evaluated in other populations should proceed with caution. This is because of the differences inherent in people receiving palliative care that may impact, in a likely negative way, on the effect of a laxative. Plain language summary Laxatives for the management of constipation in people receiving palliative care Background People with an incurable illness may receive palliative care, which involves making the person as comfortable as possible by controlling pain and other distressing symptoms. People receiving palliative care commonly experience constipation. This is as a result of the use of medicines (e.g. morphine) for pain control, as well as disease, dietary and mobility factors. There is a wide range of laxatives available. The aim of this review was to determine what we know about the effectiveness of laxatives for the management of constipation in people receiving palliative care. Study characteristics We searched medical databases for clinical trials of the use of laxatives for constipation in people receiving palliative care. Two review authors assessed study quality and extracted data. Key results and quality of evidence We identified five studies involving 370 people. The laxatives evaluated were lactulose, senna, co‐danthramer combined with poloxamer, docusate and magnesium hydroxide combined with liquid paraffin. Misrakasneham was also evaluated; this is a traditional Indian medicine and is used as a laxative, containing castor oil, ghee, milk and 21 types of herbs. There was no evidence on which laxative provided the best treatment. However, the review was limited as the evidence was from only five small trials and patient preference and cost were under evaluated. Further rigorous, independent trials are needed to evaluate the effectiveness of laxatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Candy, B; Jones, L; Larkin, PJ; Vickerstaff, V; Tookman, A; Stone, P", "articleTypes": [], "doi": "10.1002/14651858.CD003448.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "c2c2f97b-1b99-4c4a-9123-06fb5b5eede4", "pmid": "", "title": "Bile acids for liver‐transplanted patients", "imported": false, "abstract": "Abstract - Background Liver transplantation has become a widely accepted form of treatment for numerous end‐stage liver diseases. Bile acids may decrease allograft rejection after liver transplantation by changing the expression of major histocompatibility complex class molecules in bile duct epithelium and central vein endothelium. Objectives To assess the beneficial and harmful effects of bile acids for liver‐transplanted patients. Search methods We performed searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials in The Cochrane Library , MEDLINE , EMBASE , and Science Citation Expanded to September, 2009. Selection criteria Randomised clinical trials comparing any dose of bile acids or duration of treatment in liver‐transplanted patients versus placebo, no intervention, or another intervention. We included randomised clinical trials irrespective of blinding, language, and publication status. Data collection and analysis Two review authors extracted and checked data independently. We evaluated the risk of bias of the trials from the method of allocation sequence generation, allocation concealment, blinding, outcome data analysis, outcome data reporting, and other potential sources of bias. We used the intention‐to‐treat principle to perform meta‐analyses and presented the outcomes as relative risks (RR) or mean differences (MD), both with 95% confidence intervals (CI). Main results The updated search resulted in no new trials meeting the inclusion criteria of this review, thus leaving it to the seven already included randomised trials (six evaluating ursodeoxycholic acid versus placebo or no intervention, and one evaluating tauro‐ursodeoxycholic acid versus no intervention) enrolling a total of 335 participants. The administration of bile acids began one day or more after liver transplantation. All patients received the standard triple‐drug immunosuppressive regimen (steroids, azathioprine, and cyclosporine or tacrolimus) to suppress the allograft rejection response after liver transplantation. Bile acids compared with placebo or no intervention did not significantly change all‐cause mortality (RR 0.85, 95% CI 0.53 to 1.36), mortality related to allograft rejection (RR 0.30, 95% CI 0.01 to 7.12), retransplantation (RR 0.76, 95% CI 0.20 to 2.86), acute cellular rejection, or number of patients with steroid‐resistant rejection. Bile acids significantly reduced the number of patients who had chronic rejection in a fixed‐effect model but not in a random‐effects model meta‐analysis. Bile acids were safe and well tolerated by liver‐transplanted patients. However, this observation is based on data analysis from three trials with only 187 patients. Authors' conclusions We did not find evidence to support or refute bile acids for liver‐transplanted patients. Further randomised trials are necessary before bile acids can be recommended to liver‐transplanted patients. Plain language summary Bile acids for liver‐transplanted patients Liver transplantation is a major surgical procedure that has been practiced for more than forty years and has nowadays become a generally accepted treatment option in patients with end‐stage liver disease. The most common cause for liver transplantation in adults is cirrhosis caused by various types of liver injuries such as infections (hepatitis B and C), alcohol, autoimmune liver diseases, early‐stage liver cancer, metabolic and hereditary disorders, but also diseases of unknown aetiology. All transplant recipients need lifetime immunosuppressive therapy to prevent transplant rejection. Bile acids are being used for a variety of chronic liver diseases, mainly primary biliary cirrhosis and primary sclerosing cholangitis. However, their mechanisms of action and beneficial and harmful effects are poorly understood. This has led to the idea of the potential use of bile acids to prevent rejection in liver‐transplanted patients. Results of the seven randomised clinical trials included in the review in which patients received standard immunosuppressive treatment (steroids, azathioprine, and cyclosporine or tacrolimus) with or without bile acids after liver transplantation, did not show any significant effects of bile acids on all‐cause mortality, mortality related to rejection, acute cellular rejection, steroid resistant rejection, or need for retransplantation. One analysis suggested that bile acids might beneficially influence number of patients with chronic rejection, but was contradicted by the analyses. The evidence that the use of ursodeoxycholic acid might have beneficial effects on chronic rejection and length of hospitalisation is weak as it is produced from trials with high risk of bias and insufficient number of included patients. That bile acids seemed well tolerated, with no reports of serious adverse events, is good knowledge, but much more research is needed before their use is acquitted. None of the randomised clinical trials assessed the effects of bile acids on quality of life or cost‐effectiveness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Poropat, G; Giljaca, V; Stimac, D; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005442.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "c2e24401-673b-4b57-a3eb-bb95a69fd9a4", "pmid": "", "title": "Intranasal corticosteroids for non‐allergic rhinitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Segboer, C, Gevorgyan, A, Avdeeva, K, Chusakul, S, Kanjanaumporn, J, Aeumjaturapat, S, Reeskamp, LF, Snidvongs, K, Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010592.pub2 AB - Abstract - Background Non‐allergic rhinitis is defined as dysfunction and non‐infectious inflammation of the nasal mucosa that is caused by provoking agents other than allergens or microbes. It is common, with an estimated prevalence of around 10% to 20%. Patients experience symptoms of nasal obstruction, anterior rhinorrhoea/post‐nasal drip and sneezing. Several subgroups of non‐allergic rhinitis can be distinguished, depending on the trigger responsible for symptoms; these include occupation, cigarette smoke, hormones, medication, food and age. On a cellular molecular level different disease mechanisms can also be identified. People with non‐allergic rhinitis often lack an effective treatment as a result of poor understanding and lack of recognition of the underlying disease mechanism. Intranasal corticosteroids are one of the most common types of medication prescribed in patients with rhinitis or rhinosinusitis symptoms, including those with non‐allergic rhinitis. However, it is unclear whether intranasal corticosteroids are truly effective in these patients. Objectives To assess the effects of intranasal corticosteroids in the management of non‐allergic rhinitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 7); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 July 2019. Selection criteria Randomised controlled trials (RCTs) comparing intranasal corticosteroids, delivered by any means and in any volume, with (a) placebo/no intervention or (b) other active treatments in adults and children (aged ≥ 12 years). Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were patient‐reported disease severity and a
 significant adverse effect ‐ epistaxis. Secondary outcomes were (disease‐specific) health‐related quality of life, objective measurements of airflow and other adverse events. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 34 studies (4452 participants); however, only 13 studies provided data for our main comparison, intranasal corticosteroids versus placebo. The participants were mainly defined as patients with perennial rhinitis symptoms and negative allergy tests. No distinction between different pheno‐ and endotypes could be made, although a few studies only included a specific phenotype such as pregnancy rhinitis, vasomotor rhinitis, rhinitis medicamentosa or senile rhinitis. Most studies were conducted in a secondary or tertiary healthcare setting. No studies reported outcomes beyond three months follow‐up. Intranasal corticosteroid dosage in the review ranged from 50 µg to 2000 µg daily. Intranasal corticosteroids versus placebo Thirteen studies (2045 participants) provided data for this comparison. These studies used different scoring systems for patient‐reported disease severity, so we pooled the data in each analysis using the standardised mean difference (SMD). Intranasal corticosteroid treatment may improve patient‐reported disease severity as measured by total nasal symptom score compared with placebo at up to four weeks (SMD ‐0.74, 95% confidence interval (CI) ‐1.15 to ‐0.33; 4 studies; 131 participants; I 2 = 22%) (low‐certainty evidence). However, between four weeks and three months the evidence is very uncertain (SMD ‐0.24, 95% CI ‐0.67 to 0.20; 3 studies; 85 participants; I 2 = 0%) (very low‐certainty evidence). Intranasal corticosteroid treatment may slightly improve patient‐reported disease severity as measured by total nasal symptom score change from baseline when compared with placebo at up to four weeks (SMD ‐0.15, 95% CI ‐0.25 to ‐0.05; 4 studies; 1465 participants; I 2 = 35%) (low‐certainty evidence) . All four studies evaluating the risk of epistaxis showed that there is probably a higher risk in the intranasal corticosteroids group (65 per 1000) compared to placebo (31 per 1000) (risk ratio (RR) 2.10, 95% CI 1.24 to 3.57; 4 studies; 1174 participants; I 2 = 0%) (moderate‐certainty evidence). The absolute risk difference (RD) was 0.04 with a number needed to treat for an additional harmful outcome (NNTH) of 25 (95% CI 16.7 to 100). Only one study reported numerical data for quality of life. It did report a higher quality of life score in the intranasal corticosteroids group (152.3 versus 145.6; SF‐12v2 range 0 to 800); however, this disappeared at longer‐term follow‐up (148.4 versus 145.6) (low‐certainty evidence). Only two studies provided data for the outcome objective measurements of airflow. These data could not be pooled because they used different methods of outcome measurement. Neither found a significant difference between the intranasal corticosteroids and placebo group (rhinomanometry SMD ‐0.46, 95% CI ‐1.06 to 0.14; 44 participants; peak expiratory flow rate SMD 0.78, 95% CI ‐0.47 to 2.03; 11 participants) (very low‐certainty evidence). Intranasal corticosteroids probably resulted in little or no difference in the risk of other adverse events compared to placebo (RR 0.99, 95% CI 0.87 to 1.12; 3 studies; 1130 participants; I 2 = 0%) (moderate‐certainty evidence) . Intranasal corticosteroids versus other treatments Only one or a few studies assessed each of the other comparisons (intranasal corticosteroids versus saline irrigation, intranasal antihistamine, capsaicin, cromoglycate sodium, ipratropium bromide, intranasal corticosteroids combined with intranasal antihistamine, intranasal corticosteroids combined with intranasal antihistamine and intranasal corticosteroids with saline compared to saline alone). It is therefore uncertain whether there are differences between intranasal corticosteroids and other active treatments for any of the outcomes reported. Authors' conclusions Overall, the certainty of the evidence for most outcomes in this review was low or very low. It is unclear whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. However, intranasal corticosteroids probably have a higher risk of the adverse effect epistaxis. There are very few studies comparing intranasal corticosteroids to other treatment modalities making it difficult to draw conclusions. Plain language summary Intranasal corticosteroids for non‐allergic rhinitis Review question We wanted to find out whether intranasal corticosteroids (steroids applied into the nose) are effective for the treatment of rhinitis that is not caused by allergy. Background Non‐allergic rhinitis is a chronic disease of the nose, which is not caused by infection or allergies. People with non‐allergic rhinitis experience symptoms that affect their quality of life, such as nasal obstruction, runny nose and sneezing. Non‐allergic rhinitis patients can be divided into different subgroups who have different underlying causes for their disease. The underlying causes of non‐allergic rhinitis are not fully understood, therefore treatment is often unsuccessful in these patients. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation. They are the most commonly prescribed drug in other chronic diseases of the nose and sinuses, such as allergic rhinitis and chronic rhinosinusitis. Intranasal corticosteroid treatment can be delivered with sprays or drops and for different time periods. Study characteristics We included 34 randomised controlled trials (RCTs) with a total of 4452 participants in this review. Most of the studies were relatively small, although the largest study had 983 patients in total. All of the patients were either adults or adolescents (aged between 12 and 18 years old) with non‐allergic rhinitis. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Nine studies were sponsored by the pharmaceutical industry or had commercial sponsors. One study was funded by the government. In several studies, the pharmaceutical industry or commercial sponsor may have provided medications, but the funding role was unclear. Funding was not reported in eight studies. Key results Intranasal corticosteroids compared with placebo It is uncertain whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. They may improve patient‐reported disease severity compared with placebo at up to four weeks, however this evidence is of low certainty. Treatment with intranasal corticosteroids probably increases the risk of epistaxis (nosebleed) but there is no difference in the risk of other adverse effects. It is not possible to tell from this review whether there is a difference between the different concentrations, delivery methods or treatment plans of intranasal corticosteroids. There are no good‐quality studies assessing changes in quality of life with intranasal corticosteroids. Intranasal corticosteroids compared with other treatments There is not enough evidence to know whether intranasal corticosteroid treatment is better, worse or the same as using other treatment strategies such as saline irrigation, intranasal antihistamines, capsaicin or ipratropium bromide for non‐allergic rhinitis. Certainty of the evidence Overall, the evidence for intranasal corticosteroids compared with placebo for most outcomes was either low‐certainty (our confidence in the effect estimate is low) or very low‐certainty (our confidence in the effect estimate is very low). This was because most studies were very small and used different methods to measure the same outcome. This evidence is up to date to July 2019.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.775Z" }, { "id": "c2fb5500-7dea-4266-b45d-e35cd7827ecc", "pmid": "", "title": "Aclidinium bromide for stable chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Bronchodilators are the mainstay for symptom relief in the management of stable chronic obstructive pulmonary disease (COPD). Aclidinium bromide is a new long‐acting muscarinic antagonist (LAMA) that differs from tiotropium by its higher selectivity for M3 muscarinic receptors with a faster onset of action. However, the duration of action of aclidinium is shorter than for tiotropium. It has been approved as maintenance therapy for stable, moderate to severe COPD, but its efficacy and safety in the management of COPD is uncertain compared to other bronchodilators. Objectives To assess the efficacy and safety of aclidinium bromide in stable COPD. Search methods We identified randomised controlled trials (RCT) from the Cochrane Airways Group Specialised Register of trials (CAGR), as well as www.clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), US Food and Drug Administration (FDA) website and Almirall Clinical Trials Registry and Results. We contacted Forest Laboratories for any unpublished trials and checked the reference lists of identified articles for additional information. The last search was performed on 7 April 2014 for CAGR and 11 April 2014 for other sources. Selection criteria Parallel‐group RCTs of aclidinium bromide compared with placebo, long‐acting beta 2 ‐agonists (LABA) or LAMA in adults with stable COPD. Data collection and analysis Two review authors independently selected studies, assessed the risk of bias, and extracted data. We sought missing data from the trial authors as well as manufacturers of aclidinium. We used odds ratios (OR) for dichotomous data and mean difference (MD) for continuous data, and reported both with their 95% confidence intervals (CI). We used standard methodological procedures expected by The Cochrane Collaboration. We applied the GRADE approach to summarise results and to assess the overall quality of evidence. Main results This review included 12 multicentre RCTs randomly assigning 9547 participants with stable COPD. All the studies were industry‐sponsored and had similar inclusion criteria with relatively good methodological quality. All but one study included in the meta‐analysis were double‐blind and scored low risk of bias. The study duration ranged from four weeks to 52 weeks. Participants were more often males, mainly Caucasians, mean age ranging from 61.7 to 65.6 years, and with a smoking history of 10 or more pack years. They had moderate to severe symptoms at randomisation; the mean post‐bronchodilator forced expiratory volume in one second (FEV1) was between 46% and 57.6% of the predicted normal value, and the mean St George's Respiratory Questionnaire score (SGRQ) ranged from 45.1 to 50.4 when reported. There was no difference between aclidinium and placebo in all‐cause mortality (low quality) and number of patients with exacerbations requiring a short course of oral steroids or antibiotics, or both (moderate quality). Aclidinium improved quality of life by lowering the SGRQ total score with a mean difference of ‐2.34 (95% CI ‐3.18 to ‐1.51; I 2 = 48%, 7 trials, 4442 participants) when compared to placebo. More patients on aclidinium achieved a clinically meaningful improvement of at least four units decrease in SGRQ total score (OR 1.49; 95% CI 1.31 to 1.70; I 2 = 34%; number needed to treat (NNT) = 10, 95% CI 8 to 15, high quality evidence) over 12 to 52 weeks than on placebo. Aclidinium also resulted in a significantly greater improvement in pre‐dose FEV1 than placebo with a mean difference of 0.09 L (95% CI 0.08 to 0.10; I 2 = 39%, 9 trials, 4963 participants). No trials assessed functional capacity. Aclidinium reduced the number of patients with exacerbations requiring hospitalisation by 4 to 20 fewer per 1000 over 4 to 52 weeks (OR 0.64; 95% CI 0.46 to 0.88; I 2 = 0%, 10 trials, 5624 people; NNT = 77, 95% CI 51 to 233, high quality evidence) compared to placebo. There was no difference in non‐fatal serious adverse events (moderate quality evidence) between aclidinium and placebo. Compared to tiotropium, aclidinium did not demonstrate significant differences for exacerbations requiring oral steroids or antibiotics, or both, exacerbation‐related hospitalisations and non‐fatal serious adverse events (very low quality evidence). Inadequate data prevented the comparison of aclidinium to formoterol or other LABAs. Authors' conclusions Aclidinium is associated with improved quality of life and reduced hospitalisations due to severe exacerbations in patients with moderate to severe stable COPD compared to placebo. Overall, aclidinium did not significantly reduce mortality, serious adverse events or exacerbations requiring oral steroids or antibiotics, or both. Currently, the available data are insufficient and of very low quality in comparisons of the efficacy of aclidinium versus tiotropium. The efficacy of aclidinium versus LABAs cannot be assessed due to inaccurate data. Thus additional trials are recommended to assess the efficacy and safety of aclidinium compared to other LAMAs or LABAs. Plain language summary Effectiveness and safety of inhalers containing the drug aclidinium bromide for managing patients with stable COPD Review question We reviewed the evidence on the effectiveness and safety of aclidinium inhalers used by people with chronic obstructive pulmonary disease (COPD). Background COPD, also known as 'smoker's lung disease', includes conditions called emphysema and chronic bronchitis where there is airway narrowing that cannot be fully corrected. It is a progressive disease. COPD patients usually have breathing problems and a cough that produces a lot of phlegm. It is diagnosed by international guidelines set by the Global Initiative for Obstructive Lung Disease (GOLD). Symptoms may worsen during flare‐ups. The main aims of treating COPD patients are to relieve symptoms, reduce flare‐ups and improve quality of life. Aclidinium is a new inhaled drug that widens the airways (a bronchodilator). It is delivered by an inhaler called Genuair or Pressair. We wanted to discover whether aclidinium was better or worse than using other inhalers or a dummy inhaler. Study characteristics The evidence was current to 7 April 2014. We included 12 studies involving 9547 COPD patients over a period of four to 52 weeks. These studies were sponsored by drug companies and were well designed. Both patients and the people doing the research did not know which treatment the patients were getting; although in one study one treatment was known to both parties. More men than women took part, and they were mostly Caucasians. They were in their 60s and had smoked a lot in their lives. These people had moderate to severe symptoms when they started treatment. Key results Aclidinium did not reduce the number of people with flare‐ups that need additional drugs. There was little or no difference in deaths or serious side effects between aclidinium and a dummy inhaler. Aclidinium inhalers improved quality of life more than the dummy inhalers. People who took aclidinium had fewer hospital admissions due to serious flare‐ups. Based on our results, among 1000 COPD patients using a dummy inhaler over four weeks to one year 37 would have severe flare‐ups needing hospital admission. Only 17 to 33 patients out of 1000 would require hospital admission if they were using aclidinium inhalers. We also set out to compare this new medication with tiotropium, which is already used to treat COPD. There were only two studies for this comparison thus we could not be sure how aclidinium compared to tiotropium. We also could not compare aclidinium with another well known inhaler that contains the drug formoterol because of unreliable data. Quality of the evidence For the comparison of aclidinium inhalers and dummy inhalers, we are confident that there are benefits in terms of the number of hospitalisations and patients' quality of life; we are less certain about the numbers of flare‐ups needing additional drugs and serious side effects. We do not have enough information to assess any effect on the number of deaths. We did not have enough information to reliably compare aclidinium with tiotropium or formoterol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ni, H, Soe, Z, Moe, S", "articleTypes": [], "doi": "10.1002/14651858.CD010509.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.808Z" }, { "id": "c2fbdb21-fbf3-4f1d-b359-954ff7e55501", "pmid": "", "title": "SOMESThesia in Patients With Head and Neck Cancer: Variability and Influence on the ALIMentation Experience", "imported": false, "abstract": "Cancer patients are at high risk for undernutrition. A study with head and neck cancer patients showed that 50% suffered from undernutrition (Prevost et al., 2014). Sensory alterations may also involve sensory changes from the physiological structures of the mouth or neural pathways and hedonic changes, i.e., although food may taste the same as usual, that taste is no longer judged as pleasant. These changes lead to an aversion to food and a decrease in the pleasure of eating (Bernhardson et al., 2009).", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.239Z" }, { "id": "c34bd2bb-6e82-43b9-b00f-7930e4d5326f", "pmid": "", "title": "Supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults", "imported": false, "abstract": "Abstract - Background Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy. Objectives To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at‐risk adults. Search methods We identified publications from comprehensive searches of the Cochrane Library , MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016. Selection criteria Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care. Data collection and analysis Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta‐analyses for the outcome measures, 'all‐cause mortality', 'hospitalisation' and 'nutritional status (weight change)'. Main results Forty‐one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow‐up ranged from ‘duration of hospital stay’ to 12 months. The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all‐cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate‐quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low‐quality evidence). Only five trials (4451 participants) investigated health‐related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of ‐0.5 days (95% CI ‐2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low‐quality evidence. Only three of 41 included trials (4108 participants; very low‐quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta‐analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate‐quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low‐quality evidence). Authors' conclusions There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all‐cause mortality for supportive interventions comes from hospital‐based trials and more research is needed to confirm this effect. There is very low‐quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient‐important outcomes in future research. Plain language summary Supportive interventions for improving dietary intake in nutritionally vulnerable groups Review question Are supportive interventions for improving dietary intake in nutritionally vulnerable groups (malnourished or nutritionally at‐risk individuals) effective? Background Serving meals in a dining room, or the use of assistance to help feed people in need and other similar methods are often recommended to help especially sick and elderly people who have lost or are likely to lose weight (nutritionally vulnerable groups). Such supportive interventions are implemented in the health care in many countries but their effects are not well investigated. Study characteristics We included 41 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 10,681 people in our review. There were five different interventions which we call 'supportive interventions': changes to the organisation of nutritional care (13 studies, 3456 people), changes to the feeding environment (5 studies, 351 people), modification of the meal profile or pattern (12 studies, 649 people), additional supplementation of meals (10 studies, 6022 people) and home meal delivery systems (1 study, 203 people). Monitoring participants over time (follow‐up) ranged from ‘duration of hospital stay’ to 12 months. The comparator groups received 'usual' care. More than half of all participants took part in studies investigating the additional supplementation of meals (for example a protein‐energy oral nutritional supplement in addition to the usual diet). Key results It is possible that supportive interventions for enhancing dietary intake in nutritionally vulnerable groups reduce death from any cause (approximately 23 fewer cases of death per 1000 participants in favour of supportive interventions). However, this has to be confirmed by more evidence from high‐quality randomised controlled studies. The number of participants experiencing any medical complication did not differ substantially between the supportive interventions and the comparator groups. The same was found for health‐related quality of life (which is physical, mental, emotional and social health attributed to health), patient satisfaction, nutritional or energy intake and days spent in hospital. Economic costs were not well investigated. Only three studies reported on side effects, describing intolerance to the nutritional supplement (such as diarrhoea or vomiting in 5 of 34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567 of 2017 participants). After analysing 15 studies in 1945 participants we found a beneficial effect of supportive interventions compared with comparators on weight: on average people in the supportive interventions groups increased their weight 0.6 kg more than people in the comparator groups. This evidence is up to date as of September 2016. Quality of evidence The overall quality of evidence ranged between moderate to very low, mainly because for most of our outcomes there was only a small number of studies and participants to achieve reliable information, or because risk of bias made results uncertain. However, if some randomised controlled studies with low risk of bias for our patient‐important outcomes and a good number of participants were performed, this review could quickly provide good guidance for better health care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Baldwin, C, Kimber, KL, Gibbs, M, Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD009840.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.753Z" }, { "id": "c379a5e0-2ecf-4180-85d6-d547616dfba6", "pmid": "", "title": "Glutamatergic drugs for schizophrenia", "imported": false, "abstract": "Abstract - Background It has been shown that central nervous system dopamine can play a major role in the pathophysiology of schizophrenia. Brain glutamate is thought to mediate symptoms in schizophrenia due to the influence of glutamate neurons on the dopaminergic transmission in the brain. It might be possible to decrease negative symptoms and the cognitive impairment of people with schizophrenia by treatment with glutamatergic drugs. Objectives To determine the efficacy of glutamatergic drugs in the treatment of schizophrenia. Search methods We searched the Cochrane Schizophrenia Group's Trials Register (May 2002 and October 2003), inspected references of all identified studies and contacted relevant authors. Selection criteria We included all randomised controlled trials in which glutamatergic medication was administered to people with schizophrenia. Data collection and analysis We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results We included eighteen short‐term trials with 358 randomised participants. The single studies were small with numbers of participants ranging between six and 51. All trials were short‐term trials with a maximum duration of 12 weeks. In all of these trials, glycine, D‐serine, D‐cycloserine, or ampakine CX516 was used to augment the effect of antipsychotic drugs. D‐cycloserine, a partial agonist of NMDA receptors' glycine site, seemed ineffective towards the symptoms of schizophrenia. NMDA receptor co‐agonists glycine and D‐serine showed some effects in reducing the negative symptoms of schizophrenia (n=132, SMD ‐0.66, CI ‐1.0 to ‐0.3, p=0.0004), but the magnitude of the effect was moderate. Furthermore, when responder rates rather than mean scores of negative symptoms were analysed the data were inconsistent: There was no difference in responder rates between glycine and the control in terms of more than 20% improvement of negative symptoms (n=62, RR 0.70, CI 0.3 to 1.71) and only a borderline significant superiority in terms of more than 50% improvement (n=62, RR 0.87, CI 0.8 to 1.00). There were also some effects in favour of glycine and/or D‐serine in terms of overall and general symptoms, but the results were again inconsistent and depended on the response definition applied. Available rating scale data on positive symptoms and cognitive functioning did not indicate a statistically significant effect of glycine or D‐serine. Authors' conclusions In general, all glutamatergic drugs appeared to be ineffective in further reducing positive symptoms of the disease when added to the existing antipsychotic treatment. Glycine and D‐serine may somewhat improve negative symptoms when added to regular antipsychotic medication, but the results were not fully consistent and data are too few to allow any firm conclusions. Many participants in the included trials were treatment‐resistant which may have reduced treatment response. Additional research on glutamatergic mechanisms of schizophrenia is needed. Plain language summary Glutamatergic drugs for schizophrenia Schizophrenia is a severe psychiatric disease characterised by positive symptoms such as hallucinations and delusions and negative symptoms such as blunted affect and emotional withdrawal. People with schizophrenia may also suffer from cognitive deficits. Current medication is effective in reducing positive symptoms, but negative and cognitive symptoms are fairly resistant to treatment. Antipsychotic drugs act mainly on the dopamine system in the brain, although other neurotransmitter systems may also play a role in schizophrenia. We sought to review all randomised trials that used glutamatergic drugs in the treatment of schizophrenia. This review shows that substances acting on the glutamate system may improve symptoms when added to regular antipsychotic medication, although the available evidence base is too limited to allow for any firm conclusions. Presently, glutamatergic drugs are not available for clinical use. Additional research is needed to determine their ultimate role in the treatment of schizophrenia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Tiihonen, J, Wahlbeck, K", "articleTypes": [], "doi": "10.1002/14651858.CD003730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.762Z" }, { "id": "c389d9c3-3f07-4697-969a-94abfc98e734", "pmid": "", "title": "Systemic antifungal therapy for tinea capitis in children", "imported": false, "abstract": "Abstract - Background Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread. This is an update of the original Cochrane review. Objectives To assess the effects of systemic antifungal drugs for tinea capitis in children. Search methods We updated our searches of the following databases to November 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and CINAHL (from 1981). We searched five trial registers and checked the reference lists of studies for references to relevant randomised controlled trials (RCTs). We obtained unpublished, ongoing trials and grey literature via correspondence with experts in the field and from pharmaceutical companies. Selection criteria RCTs of systemic antifungal therapy in children with normal immunity under the age of 18 with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 25 studies (N = 4449); 4 studies (N = 2637) were new to this update. Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy for the primary outcome of complete (i.e. clinical and mycological) cure in three studies involving 328 participants with Trichophyton species infections (84.2% versus 79.0%; risk ratio (RR) 1.06, 95% confidence interval (CI) 0.98 to 1.15; low quality evidence). Complete cure with itraconazole (two to six weeks) and griseofulvin (six weeks) was similar in two studies (83.6% versus 91.0%; RR 0.92, 95% CI 0.81 to 1.05; N = 134; very low quality evidence). In two studies, there was no difference between itraconazole and terbinafine for two to three weeks treatment (73.8% versus 78.8%; RR 0.93, 95% CI 0.72 to 1.19; N = 160; low quality evidence). In three studies, there was a similar proportion achieving complete cured with two to four weeks of fluconazole or six weeks of griseofulvin (41.4% versus 52.7%; RR 0.92, 95% CI 0.81 to 1.05; N = 615; moderate quality evidence). Current evidence for ketoconazole versus griseofulvin was limited. One study favoured griseofulvin (12 weeks) because ketoconazole (12 weeks) appeared less effective for complete cure (RR 0.76, 95% CI 0.62 to 0.94; low quality evidence). However, their effects appeared to be similar when the treatment lasted 26 weeks (RR 0.95, 95% CI 0.83 to 1.07; low quality evidence). Another study indicated that complete cure was similar for ketoconazole (12 weeks) and griseofulvin (12 weeks) (RR 0.89, 95% CI 0.57 to 1.39; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole (for two to three weeks) and terbinafine (for two to three weeks) (82.0% versus 94.0%; RR 0.87, 95% CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, we did not find a significant difference between fluconazole (for two to three weeks) and itraconazole (for two to three weeks) (82.0% versus 82.0%; RR 1.00, 95% CI 0.83 to 1.20; low quality evidence). This update provides new data: in children with Microsporum infections, a meta‐analysis of two studies found that the complete cure was lower for terbinafine (6 weeks) than for griseofulvin (6‐12 weeks) (34.7% versus 50.9%; RR 0.68, 95% CI 0.53 to 0.86; N = 334; moderate quality evidence). In the original review, there was no significant difference in complete cure between terbinafine (four weeks) and griseofulvin (eight weeks) in children with Microsporum infections in one small study (27.2% versus 60.0%; RR 0.45, 95% CI 0.15 to 1.35; N = 21; low quality evidence). One study provides new evidence that terbinafine and griseofulvin for six weeks show similar efficacy (49.5% versus 37.8%; RR 1.18, 95% CI 0.74 to 1.88; N = 1006; low quality evidence). However, in children infected with T. tonsurans , terbinafine was better than griseofulvin (52.1% versus 35.4%; RR 1.47, 95% CI 1.22 to 1.77; moderate quality evidence). For children infected with T. violaceum, these two regimens have similar effects (41.3% versus 45.1%; RR 0.91, 95% CI 0.68 to 1.24; low quality evidence). Additionally, three weeks of fluconazole was similar to six weeks of fluconazole in one study in 491 participants infected with T. tonsurans and M. canis (30.2% versus 34.1%; RR 0.88, 95% CI 0.68 to 1.14; low quality evidence). The frequency of adverse events attributed to the study drugs was similar for terbinafine and griseofulvin (9.2% versus 8.3%; RR 1.11, 95% CI 0.79 to 1.57; moderate quality evidence), and severe adverse events were rare (0.6% versus 0.6%; RR 0.97, 95% CI 0.24 to 3.88; moderate quality evidence). Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible. All of the included studies were at either high or unclear risk of bias in at least one domain. Using GRADE to rate the overall quality of the evidence, lower quality evidence resulted in lower confidence in the estimate of effect. Authors' conclusions Newer treatments including terbinafine, itraconazole and fluconazole are at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Limited evidence suggests that terbinafine, itraconazole and fluconazole have similar effects, whereas ketoconazole may be less effective than griseofulvin in children infected with Trichophyton . With some interventions the proportion achieving complete clinical cure was in excess of 90% (e.g. one study of terbinafine or griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. New evidence from this update suggests that terbinafine is more effective than griseofulvin in children with T. tonsurans infection. However, in children with Microsporum infections, new evidence suggests that the effect of griseofulvin is better than terbinafine. We did not find any evidence to support a difference in terms of adherence between four weeks of terbinafine versus eight weeks of griseofulvin. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles. Plain language summary Antifungal medicines for treating children with ringworm Background Tinea capitis, or ringworm, is a fungal infection of the scalp caused mainly by two species of fungi called Trichophyton and Microsporum . It is common in children. Most fungal infections can be treated with antifungal creams applied directly to the skin (topical treatments). However, because the fungal infection is found at the root of the hair follicles, where topical treatments cannot reach, tinea capitis always requires medication administered by mouth so that the treatment spreads throughout the entire body (systemic treatments). There are several different types of antifungal medicines available. Review question Which antifungal medicine is best for treating ringworm on the scalp in children? Study characteristics In November 2015, we searched for studies that used the gold standard design for clinical trials (randomised controlled trials) of antifungal treatments taken by mouth. We found 25 studies in which 4449 children under 18 years (4 studies with 2637 children were new to this update) had taken part. Key results With respect to complete cure (both cure of the infection and visible cure (i.e. fungal and clinical cure) low to moderate quality evidence suggests that newer treatments such as terbinafine, itraconazole and fluconazole are at least as good as griseofulvin, the usual treatment in children with tinea capitis caused by Trichophyton infections. However, new evidence in this update suggests that terbinafine may have better effects than griseofulvin for completely curing children with T. tonsurans infection. By contrast, in children with Microsporum infections, new evidence seems to indicate that griseofulvin is more effective than terbinafine. Terbinafine, itraconazole and fluconazole appear to have similar effects in terms of the proportion of participants achieving complete cure, whereas ketoconazole appears to be less effective than griseofulvin for children with tinea capitis caused by Trichophyton species. However, the quality of this evidence is low. With some interventions, the proportion with complete clinical cure was in excess of 90% (e.g. one study of terbinafine versus griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. The included studies reported on negative side effects, which were similarly mild and reversible for terbinafine, griseofulvin, itraconazole, ketoconazole and fluconazole. They included skin‐specific effects such as itching as well as abdominal discomfort, headache and nausea. Quality of the evidence The quality of the evidence in this review was generally low to moderate, so further research is likely to have an important effect on our confidence in these results. Some evidence was even of very low quality. We still need more and better evidence to help us understand the effectiveness and adverse events of systemic antifungal drugs for tinea capitis in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chen, X; Jiang, X; Yang, M; González, U; Lin, X; Hua, X; Xue, S; Zhang, M; Bennett, C", "articleTypes": [], "doi": "10.1002/14651858.CD004685.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "c39ed8d4-3b16-4331-b1b8-e499d1d646fb", "pmid": "", "title": "Investigating Salt Taste Threshold in Patients Being Investigated for Primary Hyperaldosteronism Before and After Treatment.", "imported": false, "abstract": "This study looks at how hypertensive patients, with high levels of aldosterone (hyperaldosteronism) differ from hypertensive patients without hyperaldosteronism with regards to markers of salt appetite. It also looks at how salt appetite changes after treatment of hyperaldosteronism. Salt makes food taste good and when our bodies need salt our brains make us like salty food even more. A high salt diet contributes to hypertension and a low salt diet is an important aspect of the treatment of hypertension. Unfortunately patients find it difficult to adhere to a low salt diet. Aldosterone is produced by the adrenal glands, its release is stimulated by a salt need and it has been shown, in rodent models, to activate pathways in the brain which drive a salt appetite. Mice with enhanced activity of the aldosterone pathway in the brain become hypertensive due to increased salt intake. Hyperaldosteronism, in humans, results in hypertension. The contribution of salt appetite, as opposed to the effect of aldosterone on the kidney's retention of salt and other systems, is unknown. Human studies have shown that when a human has a salt appetite, the concentration at which they can detect the taste of salt reduces, they increase their preference for salty food, and they consume more salt.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.146Z" }, { "id": "c3ba3eab-8470-4bd2-8fd1-22db9d22b239", "pmid": "", "title": "Altered dietary salt for preventing pre‐eclampsia, and its complications", "imported": false, "abstract": "Abstract - Background In the past, women have been advised that lowering their salt intake might reduce their risk of developing pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of altered dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of altered dietary salt during pregnancy on the risk of developing pre‐eclampsia and its complications. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (8 April 2005), the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2005), and EMBASE (2002 to May 2005). We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 1 October 2009 and added the results to the awaiting classification section. Selection criteria Randomised trials evaluating either reduced or increased dietary salt intake during pregnancy. Data collection and analysis Two review authors selected trials for inclusion and extracted data independently. Data were entered on Review Manager software for analysis, and double‐checked for accuracy. Main results Two trials were included, with 603 women. Both compared advice to reduce dietary salt intake with advice to continue a normal diet. The confidence intervals were wide and crossed the no‐effect line for all the reported outcomes, including pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). In other words, there was insufficient evidence for reliable conclusions about the effects of advice to reduce dietary salt. Authors' conclusions In the absence of evidence that advice to alter salt intake during pregnancy has any beneficial effect for prevention of pre‐eclampsia or any other outcome, salt consumption during pregnancy should remain a matter of personal preference. [Note: The citation in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Altered dietary salt for preventing pre‐eclampsia, and its complications Low salt intake in pregnancy is unlikely to prevent pre‐eclampsia. Pre‐eclampsia is a serious complication of pregnancy associated with poor health, or even death, for the mother and baby. Pre‐eclampsia is identified by raised blood pressure and protein in the urine during the second half of pregnancy. In the past, a low‐salt diet was often recommended, in the belief that it would help to prevent pre‐eclampsia. However, the review found just two trials that did not show any evidence of benefit for the mother or baby. Salt intake in pregnancy should be a matter of personal preference.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Duley, L, Henderson‐Smart, DJ, Meher, S", "articleTypes": [], "doi": "10.1002/14651858.CD005548", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.746Z" }, { "id": "c3c24974-da56-488b-b8cd-3fb7a6b604bb", "pmid": "", "title": "Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection", "imported": false, "abstract": "Abstract - Background Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted infections. The majority of women with genital herpes will have a recurrence during pregnancy. Transmission of the virus from mother to fetus typically occurs by direct contact with virus in the genital tract during birth. Objectives To assess the effectiveness of antenatal antiviral prophylaxis for recurrent genital herpes on neonatal herpes and maternal recurrences at delivery. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2006, Issue 4), MEDLINE (January 1966 to February 2007) and EMBASE (January 1974 to February 2007; handsearched conference proceedings; reviewed bibliographies of all relevant articles for further references; and contacted experts in the field. Selection criteria Randomized controlled trials which assessed the effectiveness of antivirals compared to placebo or no therapy, on neonatal herpes and maternal disease endpoints among pregnant women with genital herpes. Data collection and analysis Two authors independently applied study selection criteria and extracted data. Main results Seven randomized controlled trials (1249 participants) which met our inclusion criteria compared acyclovir to placebo or no treatment (five trials) and valacyclovir to placebo (two trials). The effect of antepartum antiviral prophylaxis on neonatal herpes could not be estimated. There were no cases of symptomatic neonatal herpes in the included studies in either the treatment or placebo groups. Women who received antiviral prophylaxis were significantly less likely to have a recurrence of genital herpes at delivery (relative risk (RR) 0.28, 95% confidence interval (CI) 0.18 to 0.43, I 2 = 0%). Women who received antiviral prophylaxis were also significantly less likely to have a cesarean delivery for genital herpes (RR 0.30, 95% CI 0.20 to 0.45, I 2 = 27.3%). Women who received antiviral prophylaxis were significantly less likely to have HSV detected at delivery (RR 0.14, 95% CI 0.05 to 0.39, I 2 = 0%). Authors' conclusions Women with recurrent genital herpes simplex virus should be informed that the risk of neonatal herpes is low. There is insufficient evidence to determine if antiviral prophylaxis reduces the incidence of neonatal herpes. Antenatal antiviral prophylaxis reduces viral shedding and recurrences at delivery and reduces the need for cesarean delivery for genital herpes. Limited information exists regarding the neonatal safety of prophylaxis. The risks, benefits, and alternatives to antenatal prophylaxis should be discussed with women who have a history and prophylaxis initiated for women who desire intervention. Plain language summary Use of antiviral drugs in late pregnancy for reducing the recurrence of genital herpes at labor and birth and reducing the risk of newborn HSV infection The incidence of herpes, a sexually transmitted disease, varies across the world. Among pregnant women with herpes, nearly 75% can expect at least one flare‐up during their pregnancy. Transmission of the virus from mother to baby typically occurs by direct contact with the virus during birth. It is often recommended that a cesarean should be offered to women with active lesions to reduce the risk of transmission to the baby. In addition, several antiviral agents are available for use both for therapy and for preventing a flare‐up. These antiviral drugs include acyclovir, penciclovir, valacyclovir, and famciclovir. The review assessed whether antiviral drugs given to pregnant women with herpes before a recurrence might be effective in reducing transmission to the baby. Seven studies were identified involving 1249 women. Giving antiviral drugs reduces viral shedding and recurrences at labor and birth. They also reduced the use of cesarean, but there is no evidence of reduction in neonatal herpes. Women should also be informed that the risk of the baby getting herpes during birth is low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Hollier, LM; Wendel, GD", "articleTypes": [], "doi": "10.1002/14651858.CD004946.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "c3cc70cc-7440-4771-80d0-0da381e92bbf", "pmid": "", "title": "Skin‐to‐skin care for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Skin‐to‐skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal‐infant contact, is one non‐pharmacological intervention for pain control in infants. Objectives The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonates The secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants. Search methods For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi‐randomized trials. Selection criteria Studies with randomisation or quasi‐randomisation, double‐ or single‐blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals. Data collection and analysis The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed‐effect model was reported for continuous outcome measures. We included variations on type of tissue‐damaging procedure, provider of care, and duration of SSC. Main results Twenty‐five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes. Seventeen studies (n = 810) compared SSC to a no‐treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of −10.78 beats per minute (95% CI −13.63 to −7.93) favouring SSC. Meta‐analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI −4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta‐analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta‐analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = −34.16, 95% CI −42.86 to −25.45), and two (n = 100) following IM injection (MD = −8.83, 95% CI −14.63 to −3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD −3.21, 95% CI −3.94 to −2.47), at 60 seconds (3 studies; n = 156) (MD −1.64, 95% CI −2.86 to −0.43), and at 90 seconds (n = 156) (MD −1.28, 95% CI −2.53 to −0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI −1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta‐analysis findings. Eight studies compared SSC to another intervention with or without a no‐treatment control. Two cross‐over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no‐treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies. Authors' conclusions SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother‐providers to others, with non‐significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long‐term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions. Plain language summary Skin‐to‐skin care with newborns cuts down procedural pain Review question: Is skin‐to‐skin care effective in cutting down pain from procedures in newborns? Are there any safety issues? Background: Newborns wearing only a diaper being held next to their mother's bare chest is referred to as skin‐to‐skin contact and is also sometimes called 'kangaroo care' because of its similarity to the way kangaroo mothers care for their young. Newborns, especially those who must spend time in a Neonatal Intensive Care Unit, must have various tests and procedures as part of their care, for example heel stick, venous puncture, and injections. Giving analgesic drugs for these procedures can often pose problems so that alternatives to drugs must be found. Study characteristics: Twenty‐eight studies in which newborn babies who were by chance in the kangaroo care group or condition were included from an extensive search of the literature. Skin‐to‐skin care was clearly defined and could have been compared to no pain‐reducing strategies or other pain‐reducing strategies such as sweet taste. Studies were examined which examined well‐established signs of pain, both physiological and behavioural, as well as a combination of physiological and behavioural signs. Different providers of skin‐to‐skin care other than the mother were included. Key results: Kangaroo care appears to reduce the pain response to, and recovery from, these frequent procedures, although few studies could be combined to provide strong evidence. As far as it has been reported, skin‐to‐skin care is safe. Although it appears that skin‐to‐skin care is effective, the size of the benefit remains uncertain. Quality of evidence: The quality of evidence in these studies was generally low for the response to the actual procedure but was moderate for recovery from the procedure.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Johnston, C, Campbell‐Yeo, M, Disher, T, Benoit, B, Fernandes, A, Streiner, D, Inglis, D, Zee, R", "articleTypes": [], "doi": "10.1002/14651858.CD008435.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.068Z" }, { "id": "c3d6cbd9-349a-41e8-b521-d10b061864d4", "pmid": "", "title": "Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age‐inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long‐term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega‐3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents. Objectives To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents. Search methods We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references. Selection criteria We included randomised and quasi‐randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD. Data collection and analysis We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow‐up; and cost. We used GRADE to assess the certainty of evidence for each outcome. Main results We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross‐over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega‐3 PUFA, six used a combined omega‐3/omega‐6 supplement, and two used an omega‐6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co‐intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega‐3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega‐3 PUFA plus atomoxetine to atomoxetine; omega‐3 PUFA plus physical training to physical training; and an omega‐3 or omega‐6 supplement plus methylphenidate to methylphenidate; and two trials compared omega‐3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months. Although we found low‐certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high‐certainty evidence that PUFA had no effect on parent‐rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) −0.08, 95% CI −0.24 to 0.07; 16 studies, 1166 participants). There was also high‐certainty evidence that parent‐rated inattention (medium‐term: SMD −0.01, 95% CI −0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium‐term: SMD 0.09, 95% CI −0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo. There was moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate‐certainty evidence that medium‐term loss to follow‐up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants). Authors' conclusions Although we found low‐certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high‐certainty evidence that PUFA had no effect on total parent‐rated ADHD symptoms. There was also high‐certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups. We found moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate‐certainty evidence that follow‐up was similar between groups. It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times. Plain language summary Polyunsaturated fatty acids (PUFA) supplements for attention deficit hyperactivity disorder (ADHD) in children and adolescents What is ADHD? Attention deficit hyperactivity disorder (ADHD) is a common problem in children and adolescents. Those affected may struggle to concentrate, feel restless, or act on impulse. As a result of these difficulties, ADHD can cause long‐term social, academic, and mental health problems. Medicines are the most frequently used treatments for ADHD, but they are not always effective and can cause unwanted side effects. What are polyunsaturated fatty acids (PUFA)? Polyunsaturated fatty acids (PUFA) are a type of fat. They are necessary for normal brain development and are found in foods such as fish (omega‐3 PUFA) and vegetable oils (omega‐6 PUFA). How could PUFA be useful in ADHD? There is some evidence that ADHD could be related to low levels of PUFA, in particular omega‐3 PUFA. PUFA supplements may therefore improve ADHD symptoms, behavioural problems, and related mental health symptoms such as anxiety and depression. What did we want to find out? We wanted to know whether PUFA supplements improve ADHD symptoms in children and adolescents with ADHD. Although there were some limited data in the original review that suggested PUFA improved symptoms of ADHD, there is currently little evidence that PUFA supplementation is beneficial. It was important to update the evidence to incorporate new studies that have been published since the original review. What did we do? We searched for all trials that compared PUFA to placebo (dummy pill), medicines, or psychological or medical therapies in children or adolescents with ADHD. We searched 13 databases and two trials registers up to October 2021. What did we find? We found 24 new studies in this update, bringing the total number of studies included in the review to 37, which involved more than 2374 children and adolescents with ADHD. Seven studies were conducted in Iran; four each in the USA and Israel; two each in Australia, Canada, New Zealand, Sweden, and the UK; and one each in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Thirty‐six studies compared PUFA to placebo. Treatment with PUFA lasted between two weeks and six months. Although there was some evidence that PUFA could improve ADHD symptoms in children and adolescents, most of the evidence indicated that PUFA did not improve ADHD symptoms such as inattention or hyperactivity‐impulsivity. PUFA probably makes little to no difference to overall side effects or whether a person drops out of a study (i.e. does not complete it). How confident are we about what we found? We are confident that PUFA has no effect on ADHD symptoms when compared to placebo. Although there was some evidence that ADHD symptoms may be more likely to improve in children and adolescents receiving PUFA compared to those receiving placebo, we have little confidence in this finding. We are fairly confident that there are no differences between PUFA and placebo groups in overall side effects or dropout. Limitations of the analyses included small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Gillies, D; Leach, MJ; Perez Algorta, G", "articleTypes": [], "doi": "10.1002/14651858.CD007986.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "c3ee3c43-c810-431a-ad2c-1918ddae506d", "pmid": "", "title": "Cannabinoids for Tourette's Syndrome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Curtis, A, Clarke, CE, Rickards, HE", "articleTypes": [], "doi": "10.1002/14651858.CD006565.pub2 AB - Abstract - Background Gilles de la Tourette Syndrome (GTS) is a developmental neuropsychiatric disorder characterised by the presence of chronic motor and phonic tics. Drugs currently used in the treatment of GTS either lack efficacy or are associated with intolerable side effects. There is some anecdotal and experimental evidence that cannabinoids may be effective in treating tics and compulsive behaviour in patients with GTS. There are currently no systematic Cochrane reviews of treatments used in GTS. There is one other Cochrane review being undertaken at present, on the use of fluoxetine for tics in GTS. Objectives To evaluate the efficacy and safety of cannabinoids as compared to placebo or other drugs in treating tics, premonitory urges and obsessive compulsive symptoms (OCS), in patients with GTS. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (in The Cochrane Library Issue 4 2008) , MEDLINE (January 1996 to date), EMBASE (January 1974 to date), PsycINFO (January 1887 to date), CINAHL (January 1982 to date), AMED (January 1985 to date), British Nursing Index (January 1994 to date) and DH DATA (January 1994 to date). 
 
 We also searched the reference lists of located trials and review articles for further information. Selection criteria We included randomised controlled trials (RCTs) comparing any cannabinoid preparation with placebo or other drugs used in the treatment of tics and OCS in patients with GTS. Data collection and analysis Two authors abstracted data independently and settled any differences by discussion. Main results Only two trials were found that met the inclusion criteria. Both compared a cannabinoid, delta‐9‐Tetrahydrocannabinol (Δ 9 THC), either as monotherapy or as adjuvant therapy, with placebo. One was a double blind, single dose crossover trial and the other was a double blind, parallel group study. A total of 28 different patients were studied. Although both trials reported a positive effect from Δ 9 THC, the improvements in tic frequency and severity were small and were only detected by some of the outcome measures. Authors' conclusions Not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome. Plain language summary Cannabinoids for Tourette syndrome Cannabinoid medication might be useful in the treatment of the symptoms in patients with Tourette's syndrome. At the present time only two relevant studies have been conducted. Both studies used tetrahydrocannabinol (Δ 9 THC). In both studies Δ 9 THC was associated with tic reduction. However the sample size was small and a large number of multiple comparisons were made . There were only 28 participants in total, since eight participants took part in both studies. Possibly the patients who derived the greatest benefit and experienced the least adverse effects would be the most inclined to participate in further studies. There were a high number of drop outs/exclusions in the six week study and it is unclear whether intention to treat analysis (ITT) was performed. The results that are reported are analyses done on the patients who remained in the study on the study medication at the correct dose. In reality, patients do opt not to continue treatment if there is limited efficacy or unpalatable side effects. This introduces attrition bias. Whilst there were some significant results, the authors themselves accept that very few of these results are significant if a Bonferroni correction is performed. It is possible that cannabinoid medication has a beneficial effect which is too weak to be detected using ITT and such a small sample size. There is some weak evidence that cannabinoid medication may have an effect on obsessive compulsive behaviour but the measure used was an addition to the TSSL which has not been validated.There were no data on the effect of Δ 9 THC on quality of life.There is not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.072Z" }, { "id": "c3f21f3f-874d-4104-a2d7-9c6c3c9c04b6", "pmid": "", "title": "Xylitol‐containing products for preventing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is a highly prevalent chronic disease which affects the majority of people. It has been postulated that the consumption of xylitol could help to prevent caries. The evidence on the effects of xylitol products is not clear and therefore it is important to summarise the available evidence to determine its effectiveness and safety. Objectives To assess the effects of different xylitol‐containing products for the prevention of dental caries in children and adults. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 14 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , 2014, Issue 7), MEDLINE via OVID (1946 to 14 August 2014), EMBASE via OVID (1980 to 14 August 2014), CINAHL via EBSCO (1980 to 14 August 2014), Web of Science Conference Proceedings (1990 to 14 August 2014), Proquest Dissertations and Theses (1861 to 14 August 2014). We searched the US National Institutes of Health Trials Register ( http://clinicaltrials.gov ) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference and 95% confidence interval (CI). We used the continuous data to calculate prevented fractions (PF) and 95% CIs to summarise the percentage reduction in caries. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. As there were less than four studies included in the meta‐analysis, we used a fixed‐effect model. We planned to use a random‐effects model in the event that there were four or more studies in a meta‐analysis. Main results We included 10 studies that analysed a total of 5903 participants. One study was assessed as being at low risk of bias, two were assessed as being at unclear risk of bias, with the remaining seven being at high risk of bias. The main finding of the review was that, over 2.5 to 3 years of use, a fluoride toothpaste containing 10% xylitol may reduce caries by 13% when compared to a fluoride‐only toothpaste (PF ‐0.13, 95% CI ‐0.18 to ‐0.08, 4216 children analysed, low‐quality evidence). The remaining evidence on children, from small single studies with risk of bias issues and great uncertainty associated with the effect estimates, was insufficient to determine a benefit from xylitol products. One study reported that xylitol syrup (8 g per day) reduced caries by 58% (95% CI 33% to 83%, 94 infants analysed, low quality evidence) when compared to a low‐dose xylitol syrup (2.67 g per day) consumed for 1 year. The following results had 95% CIs that were compatible with both a reduction and an increase in caries associated with xylitol: xylitol lozenges versus no treatment in children (very low quality body of evidence); xylitol sucking tablets versus no treatment in infants (very low quality body of evidence); xylitol tablets versus control (sorbitol) tablets in infants (very low quality body of evidence); xylitol wipes versus control wipes in infants (low quality body of evidence). There was only one study investigating the effects of xylitol lozenges, when compared to control lozenges, in adults (low quality body of evidence). The effect estimate had a 95% CI that was compatible with both a reduction and an increase in caries associated with xylitol. Four studies reported that there were no adverse effects from any of the interventions. Two studies reported similar rates of adverse effects between study arms. The remaining studies either mentioned adverse effects but did not report any usable data, or did not mention them at all. Adverse effects include sores in the mouth, cramps, bloating, constipation, flatulence, and loose stool or diarrhoea. Authors' conclusions We found some low quality evidence to suggest that fluoride toothpaste containing xylitol may be more effective than fluoride‐only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse‐effects from such toothpastes. The effect estimate should be interpreted with caution due to high risk of bias and the fact that it results from two studies that were carried out by the same authors in the same population. The remaining evidence we found is of low to very low quality and is insufficient to determine whether any other xylitol‐containing products can prevent caries in infants, older children, or adults. Plain language summary Can xylitol used in products like sweets, candy, chewing gum and toothpaste help prevent tooth decay in children and adults? Review question This review has been produced to assess whether or not xylitol, a natural sweetener used in products such as sweets, candy, chewing gum and toothpaste, can help prevent tooth decay in children and adults. Background Tooth decay is a common disease affecting up to 90% of children and most adults worldwide. It impacts on quality of life and can be the reason for thousands of children needing dental treatment under general anaesthetic in hospital. However, it can easily be prevented and treated by good oral health habits such as brushing teeth regularly with toothpaste that contains fluoride and cutting down on sugary food and drinks. If left undisturbed, the unhelpful bacteria in the mouth ‐ which cause decay ‐ multiply and stick to the surfaces of teeth producing a sticky film. Then, when sugar is eaten or drank, the bad bacteria in the film are able to make acid resulting in tooth decay. Xylitol is a natural sweetener, which is equally as sweet as normal sugar (sucrose). As well as providing an alternative to sugar, it has other properties that are thought to help prevent tooth decay, such as increasing the production of saliva and reducing the growth of bad bacteria in the mouth so that less acid is produced. In humans, xylitol is known to cause possible side effects such as bloating, wind and diarrhoea. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 14 August 2014. It includes 10 studies published from 1991 to 2014 in which 7969 participants were randomised (5903 of whom were included in the analyses) to receive xylitol products or a placebo (a substitute without xylitol) or no treatment, and the amount of tooth decay was compared. One study included adults, the others included children aged from 1 month to 13 years. The products tested were the kind that are held in the mouth and sucked (lozenges, sucking tablets and sweets) or slowly released through a dummy/pacifier, as well as toothpastes, syrups, and wipes. Key results There is some evidence to suggest that using a fluoride toothpaste containing xylitol may reduce tooth decay in the permanent teeth of children by 13% over a 3 year period when compared to a fluoride‐only toothpaste. Over this period, there were no side effects reported by the children. The remaining evidence we found did not allow us to conclude whether or not any other xylitol‐containing products can prevent tooth decay in infants, older children, or adults. Quality of the evidence The evidence presented is of low to very low quality due to the small amount of available studies, uncertain results, and issues with the way in which they were conducted.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P; Moore, D; Ahmed, F; Sharif, MO; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD010743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "c3f28697-4818-4aef-941d-63a52b37e3ec", "pmid": "", "title": "Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, rhinorrhoea, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. The use of topical (intranasal) corticosteroids has been widely advocated for the treatment of chronic rhinosinusitis given the belief that inflammation is a major component of this condition. Objectives To assess the effects of intranasal corticosteroids in people with chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) with a follow‐up period of at least three months comparing intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) against placebo or no treatment in patients with chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity and the commonest adverse event ‐ epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation or other systemic adverse events. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 18 RCTs with a total of 2738 participants. Fourteen studies had participants with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. Intranasal corticosteroids versus placebo or no intervention Only one study (20 adult participants without polyps) measured our primary outcome disease‐specific HRQL using the Rhinosinusitis Outcome Measures‐31 (RSOM‐31). They reported no significant difference (numerical data not available) ( very low quality evidence). Our second primary outcome, disease severity , was measured using the Chronic Sinusitis Survey in a second study (134 participants without polyps), which found no important difference (mean difference (MD) 2.84, 95% confidence interval (CI) ‐5.02 to 10.70; scale 0 to 100). Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group (RR 2.78, 95% CI 1.76 to 4.40; 109 participants). The quality of the evidence was low . Six studies provided data on at least two of the individual symptoms used in the EPOS 2012 criteria to define chronic rhinosinusitis (nasal blockage, rhinorrhoea, loss of sense of smell and facial pain/pressure). When all four symptoms in the EPOS criteria were available on a scale of 0 to 3 (higher = more severe symptoms), the average MD in change from baseline was ‐0.26 (95% CI ‐0.37 to ‐0.15; 243 participants; two studies; low quality evidence). Although there were more studies and participants when only nasal blockage and rhinorrhoea were considered (MD ‐0.31, 95% CI ‐0.38 to ‐0.24; 1702 participants; six studies), the MD was almost identical to when loss of sense of smell was also considered (1345 participants, four studies; moderate quality evidence). When considering the results for the individual symptoms, benefit was shown in the intranasal corticosteroids group. The effect size was larger for nasal blockage (MD ‐0.40, 95% CI ‐0.52 to ‐0.29; 1702 participants; six studies) than for rhinorrhoea (MD ‐0.25, 95% CI ‐0.33 to ‐0.17; 1702 participants; six studies) or loss of sense of smell (MD ‐0.19, 95% CI ‐0.28 to ‐0.11; 1345 participants; four studies). There was heterogeneity in the analysis for facial pain/pressure (MD ‐0.27, 95% CI ‐0.56 to 0.02; 243 participants; two studies). The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure. There was an increased risk of epistaxis with intranasal corticosteroids (risk ratio (RR) 2.74, 95% CI 1.88 to 4.00; 2508 participants; 13 studies; high quality evidence). Considering our secondary outcome, general HRQL, one study (134 participants without polyps) measured this using the SF‐36 and reported a statistically significant benefit only on the general health subscale. The quality of the evidence was very low . It is unclear whether there is a difference in the risk of local irritation (RR 0.94, 95% CI 0.53 to 1.64; 2124 participants; 11 studies) ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis or stunted growth (children). Other comparisons We identified no other studies that compared intranasal corticosteroids plus co‐intervention A versus placebo plus co‐intervention A. Authors' conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life ( very low quality evidence). For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of epistaxis is increased ( high quality evidence), but these data included all levels of severity; small streaks of blood may not be a major concern for patients. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) . Plain language summary Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of intranasal (in the nose) steroids given to people with chronic rhinosinusitis. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose (rhinorrhoea), pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation in order to improve patient symptoms. Study characteristics We included 18 randomised controlled trials (RCTs) with a total of 2738 participants in this review. Most studies were relatively small, with as few as 9 or 10 patients per intervention arm. The largest study had 748 patients in total. Most were conducted in tertiary referral centres in northern Europe, the US and Canada. Fourteen studies only included participants with chronic rhinosinusitis with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Key results and quality of the evidence One study (20 participants) reported no statistically significant difference in disease‐specific health‐related quality of life. Another measured general health‐related quality of life and reported a statistically significant benefit only on a subscale for general health. Both studies recruited participants with chronic rhinosinusitis without nasal polyps. The quality of the evidence was very low (we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect). Disease severity was measured in one study (chronic rhinosinusitis without nasal polyps, 134 participants), which found no important difference. Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group. The quality of the evidence was low (our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect). When each type of symptom was measured separately (nasal blockage, rhinorrhoea, loss of sense of smell, facial pain/pressure), benefit was shown in the intranasal corticosteroids group. The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure (moderate quality evidence means we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different). There was an increased risk of nosebleeds (epistaxis) with intranasal corticosteroids ( high quality evidence). However, it was unclear whether there was a difference in the risk of local (nose or throat) irritation ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis (fragile bones) or stunted growth (in children). Conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life and the quality of this evidence is very low . For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of nosebleeds is increased ( high quality evidence), but this included all levels of severity; for some patients small streaks of blood may not be a major concern. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) .", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chong, LY; Head, K; Hopkins, C; Philpott, C; Schilder, AGM; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "c4033bba-e249-444a-9ab5-43a3543e09c3", "pmid": "", "title": "Benperidol for schizophrenia", "imported": false, "abstract": "Abstract - Background Benperidol is a relatively old antipsychotic drug that has been marketed since 1966. It has been used in Germany for 30 years but is also available in Belgium, Greece, Italy, the Netherlands and the UK. Benperidol is a butyrophenone antipsychotic, with the highest neuroleptic potency in terms of D2 receptor blockade. Those taking it are therefore reputed to be at high risk of extrapyramidal side‐effects, but benperidol's unusual profile may render it valuable to certain subgroups of people with schizophrenia. Objectives To examine the clinical effects and safety of benperidol for those with schizophrenia and schizophrenia‐like psychoses. Search methods We searched the Cochrane Schizophrenia Group's register (March 2009) for this update. Selection criteria We included all randomised controlled trials that compared benperidol with other treatments for people with schizophrenia, or schizophrenia‐like psychoses. Data collection and analysis We reliably selected studies, quality rated them and extracted data. We independently extracted data but excluded data if loss to follow up was greater than 50%. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results The update yielded no further studies for inclusion in the review. We identified only one unpublished poorly randomised controlled trial (N=40, duration 30 days, comparison perphenazine). Although benperidol was inferior to perphenazine (1 RCT, N=40, global state no better or worse RR 8.0 CI 2.1 to 30, NNH 1.4 CI 1 to 2) poor reporting suggests that an overestimate of effect is likely. It was not possible to report other outcomes. Authors' conclusions Currently, there are insufficient data from randomised trials to assess the clinical effects of benperidol. This compound merits further research interest. Plain language summary Benperidol for schizophrenia Benperidol is a relatively old drug that is used for the treatment of schizophrenia in several European countries. We identified only one small, poorly reported, unpublished, randomised trial comparing benperidol with another antipsychotic. Unfortunately the quality of reporting is so poor that the results cannot be considered reliable. Although benperidol was first marketed in 1966, more trials on this drug are justified as with the advent of new compounds there is a danger that inexpensive drugs such as benperidol remain under‐researched and overlooked.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Schwarz, C; Hartung, B; Leucht, S", "articleTypes": [], "doi": "10.1002/14651858.CD003083.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "c41bdcd9-8119-4c95-be7a-691024aadb1e", "pmid": "", "title": "Venepuncture versus heel lance for blood sampling in term neonates", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Martins, G, Fiander, M, Taddio, A, Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD001452.pub5 AB - Abstract - Rationale Reducing procedural pain is a key priority in neonatal care, as even routine procedures for blood sampling can cause significant discomfort and pain to the neonate. This systematic review aims to compare venepuncture and heel lance for blood sampling, focusing on pain response, to guide clinical practice. Objectives To evaluate the benefits (degree of pain) and harms (need for more than one skin puncture) of venepuncture compared to heel lance in term neonates. Search methods We searched CENTRAL, MEDLINE, Embase, two trial registries and conference abstracts, and checked references of included studies and related systematic reviews up to 04 July 2025. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs that compared pain response from venepuncture versus heel lance. Neonates could receive a sweet‐tasting solution (such as glucose or sucrose), which is a commonly used analgesic in neonates for pain relief. We excluded studies that reported on pain using physiological parameters in isolation, as they are reflective of overall clinical status and non‐specific arousal. Outcomes Our outcomes of interest were pain reported using validated pain scores (measured using one or more of the following scales: Neonatal Facial Coding System, Neonatal Infant Pain scores, or the Premature Infant Pain Profile) and the need for more than one skin puncture. Risk of bias We used the Risk of bias 1 (RoB) tool to assess bias in the included RCTs. Synthesis methods We conducted a meta‐analysis where possible by calculating standardized mean difference (SMD) and risk ratio (RR) with their 95% confidence intervals (CIs) for continuous and dichotomous outcomes, respectively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included eight studies with 826 neonates. The studies were performed in six high‐, upper‐middle, or low‐income countries. Synthesis of results We judged the overall risk of bias in the eight studies to be high. Most studies had concerns related to blinding and allocation concealment. Venepuncture compared to heel lance (with no sweet‐tasting solution) Pain scores 
Venepuncture probably reduces pain compared to heel lance during the procedure when no sweet‐tasting solution is administered (SMD −1.34, 95% CI −1.55 to −1.14; I² = 94%; 6 studies, 488 participants; moderate‐certainty evidence). Need for more than one skin puncture 
Venepuncture probably reduces the need for more than one skin puncture compared to heel lance when no sweet tasting solution is administered (RR 0.63, 95% CI 0.40 to 0.97; I² = 20%; 6 studies, 397 participants; moderate‐certainty evidence) Venepuncture compared to heel lance (with sweet‐tasting solution) Pain scores 
Venepuncture may reduce pain compared to heel lance during the procedure when a sweet‐tasting solution is administered (SMD −0.38, 95% CI −0.69 to −0.07; I² = 79%; 3 studies, 170 participants; low‐certainty evidence). Need for more than one skin puncture 
The evidence is very uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture when a sweet‐tasting solution is used (RR 7.00, 95% CI 0.38 to 129.93; I² not applicable; 2 studies, 110 participants; very low‐certainty evidence). This is due to the small number of participants in each group. Authors' conclusions Based on moderate‐certainty evidence, venepuncture probably reduces pain during the procedure and the need for more than one skin puncture compared to heel lance when no sweet‐tasting solution is used. When sweet‐tasting solutions are administered, venepuncture may reduce pain during the procedure compared to heel lance, based on low‐certainty evidence. The evidence is very uncertain about the effect of venepuncture compared to heel lance on the number of skin punctures required in the presence of sweet‐tasting solutions. This is due to the small sample size, and hence we could not draw any meaningful conclusions. Further high‐quality studies are needed, particularly in settings where sweet‐tasting solutions are used, to better understand the comparative effectiveness of venepuncture and heel lance for neonatal blood sampling. Funding Cochrane Neonatal editorial support for this review update, as part of a suite of reviews addressing “The infant and family experience in the neonatal intensive care unit”, has been provided by a grant from The Gerber Foundation. The Gerber Foundation is a separately endowed, private, 501(c)(3) foundation not related to Gerber Products Company in any way. Registration Original review (2001): DOI 10.1002/14651858.CD001452
Review update (2004): DOI 10.1002/14651858.CD001452.pub2
Review update (2007): DOI 10.1002/14651858.CD001452.pub3
Review update (2011): DOI 10.1002/14651858.CD001452.pub4 Plain language summary Is using a needle (venepuncture) better than using a device (heel lance) for taking a blood sample from full‐term newborn babies? Key messages Venepuncture (inserting a needle into a vein) may be less painful than heel lance (using a special device to puncture the skin) for newborn babies when having a blood sample taken, with or without sugar water for pain relief, and may reduce the need for more than one skin puncture when no sugar water is given for pain relief. We don’t know whether venepuncture reduces the need for more than one skin puncture compared with heel lance when sugar water is given for pain relief. We need better designed and larger studies that fully report their results to show which method is better for babies. Why do we take blood samples from newborn babies? In most countries, a blood sample from newborn babies is needed for routine screening tests. Blood samples may also be needed for other blood tests to diagnose and manage diseases, such as jaundice or low blood sugar (hypoglycemia). However, taking blood from babies is painful. Untreated pain in newborn babies may affect their physical growth and brain development. A sweet, sugar solution (such as sucrose) can be given to babies before the procedure, which helps to reduce the pain. It is difficult to measure pain in babies, but we rely on things like facial expressions, crying, and changes in heart rate to assess their pain. How are blood samples taken? Venepuncture Venepuncture is a method of taking a blood sample where a person uses a needle to directly puncture the vein. The person who performs this must be well‐trained to help ensure they successfully take a blood sample. This technique is often used when 1 mL or more of blood is required, and to prevent repeated punctures to the skin and associated complications (such as skin infections) from heel lance. Heel lance Heel lance is the standard way of taking a blood sample from newborn babies in hospitals worldwide. It is commonly used when the blood sample required is less than 1 mL. It does not require special training or expertise for successful use. The procedure involves making a small puncture (between 1 mm and 2 mm deep) on the heel of the foot using a lancet, which is usually an automatic device. Following the puncture, the infant's heel is squeezed to collect the required blood sample, which causes further pain. What did we want to find out? We wanted to find out: whether venepuncture is less painful than heel lance for newborn babies; and which procedure works best first time, so a second skin puncture is not needed. What did we do? We searched for studies that compared venepuncture and heel lance for taking blood samples in newborn babies. The studies needed to measure pain responses and the number of skin punctures needed for a successful sample. They also needed to record whether babies were given sugar solution as pain relief. Babies in the studies had to be healthy and born at full term. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included eight studies involving 826 full‐term newborn babies. Three studies took place in Sweden, and one each in Japan, Malaysia, Nepal, Spain, and the UK. When no sweet‐tasting solution was given: venepuncture probably causes less pain compared to heel lance (6 studies, 488 babies); and venepuncture probably reduces the need for more than one skin puncture compared to heel lance (6 studies, 397 babies). When a sweet‐tasting solution was given: venepuncture may cause less pain compared to heel lance (3 studies, 170 babies); and we are uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture (2 studies, 110 babies). What are the limitations of the evidence? Our confidence in the evidence was limited, and ranged from moderate to very low. This is because all the studies had limitations in how they were carried out. These included issues with how babies were assigned to each group, how the studies reported their results, and the number of babies included in the studies. In addition, the people doing the procedures knew which sampling method each baby received, which could have influenced how the studies assessed pain. How up to date is this evidence? This review updates our 2011 Cochrane review. The evidence is up to date to July 2025.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.729Z" }, { "id": "c41bfe63-7926-4a0b-afba-507ba2acf55d", "pmid": "", "title": "Interventions for pityriasis rosea", "imported": false, "abstract": "Abstract - Background Pityriasis rosea is a scaly, itchy rash that mainly affects young adults and lasts for 2 to 12 weeks. The effects of many available treatments are uncertain. This is an update of a Cochrane Review first published in 2007. Objectives To assess the effects of interventions for the management of pityriasis rosea in any individual diagnosed by a medical practitioner. Search methods We updated our searches of the following databases to October 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched five trials registers. We also checked the reference lists of included and excluded studies, contacted trial authors, scanned the abstracts from major dermatology conference proceedings, and searched the CAB Abstracts database. We searched PubMed for adverse effects to November 2018. Selection criteria Randomised controlled trials of interventions in pityriasis rosea. Treatment could be given in a single therapy or in combination. Eligible comparators were no treatment, placebo, vehicle only, another active compound, or placebo radiation treatment. Data collection and analysis We used standard methodological procedures expected by the Cochrane. Our key outcomes were good or excellent rash improvement within two weeks, rated separately by the participant and medical practitioner; serious adverse events; resolution of itch within two weeks (participant‐rated); reduction in itch score within two weeks (participant‐rated); and minor participant‐reported adverse events not requiring withdrawal of the treatment. Main results We included 14 trials (761 participants). In general, risk of selection bias was unclear or low, but risk of performance bias and reporting bias was high for 21% of the studies. Participant age ranged from 2 to 60 years, and sex ratio was similar. Disease severity was measured by various severity indices, which the included studies did not categorise. Six studies were conducted in India, three in Iran, two in the Philippines, and one each in Pakistan, the USA, and China. The included studies were conducted in dermatology departments and a paediatric clinic. Study duration ranged from 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding source. The included studies assessed macrolide antibiotics, an antiviral agent, phototherapy, steroids and antihistamine, and Chinese medicine. None of the studies measured participant‐rated good or excellent rash improvement. All reported outcomes were assessed within two weeks of treatment, except for adverse effects, which were measured throughout treatment. There is probably no difference between oral clarithromycin and placebo in itch resolution (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.47 to 1.52; 1 study, 28 participants) or rash improvement (medical practitioner‐rated) (RR 1.13, 95% CI 0.89 to 1.44; 1 study, 60 participants). For this comparison, there were no serious adverse events (1 study, 60 participants); minor adverse events and reduction in itch score were not measured; and all evidence was of moderate quality. When compared with placebo, erythromycin may lead to increased rash improvement (medical practitioner‐rated) (RR 4.02, 95% CI 0.28 to 56.61; 2 studies, 86 participants, low‐quality evidence); however, the 95% CI indicates that the result may also be compatible with a benefit of placebo, and there may be little or no difference between treatments. Itch resolution was not measured, but one study measured reduction in itch score, which is probably larger with erythromycin (MD 3.95, 95% CI 3.37 to 4.53; 34 participants, moderate‐quality evidence). In the same single, small trial, none of the participants had a serious adverse event, and there was no clear difference between groups in minor adverse events, which included gastrointestinal upset (RR 2.00, CI 0.20 to 20.04; moderate‐quality evidence). Two trials compared oral azithromycin to placebo or vitamins. There is probably no difference between groups in itch resolution (RR 0.83, 95% CI 0.28 to 2.48) or reduction in itch score (MD 0.04, 95% CI −0.35 to 0.43) (both outcomes based on one study; 70 participants, moderate‐quality evidence). Low‐quality evidence from two studies indicates there may be no difference between groups in rash improvement (medical practitioner‐rated) (RR 1.02, 95% CI 0.52 to 2.00; 119 participants). In these same two studies, no serious adverse events were reported, and there was no clear difference between groups in minor adverse events, specifically mild abdominal pain (RR 5.82, 95% CI 0.72 to 47.10; moderate‐quality evidence). Acyclovir was compared to placebo, vitamins, or no treatment in three trials (all moderate‐quality evidence). Based on one trial (21 participants), itch resolution is probably higher with placebo than with acyclovir (RR 0.34, 95% CI 0.12 to 0.94); reduction in itch score was not measured. However, there is probably a significant difference between groups in rash improvement (medical practitioner‐rated) in favour of acyclovir versus all comparators (RR 2.45, 95% CI 1.33 to 4.53; 3 studies, 141 participants). Based on the same three studies, there were no serious adverse events in either group, and there was probably no difference between groups in minor adverse events (only one participant in the placebo group experienced abdominal pain and diarrhoea). One trial compared acyclovir added to standard care (calamine lotion and oral cetirizine) versus standard care alone (24 participants). The addition of acyclovir may lead to increased itch resolution (RR 4.50, 95% CI 1.22 to 16.62) and reduction in itch score (MD 1.26, 95% CI 0.74 to 1.78) compared to standard care alone. Rash improvement (medical practitioner‐rated) was not measured. The trial reported no serious adverse events in either group, and there may be no difference between groups in minor adverse events, such as headache (RR 7.00, 95% CI 0.40 to 122.44) (all results based on low‐quality evidence). Authors' conclusions When compared with placebo or no treatment, oral acyclovir probably leads to increased good or excellent, medical practitioner‐rated rash improvement. However, evidence for the effect of acyclovir on itch was inconclusive. We found low‐ to moderate‐quality evidence that erythromycin probably reduces itch more than placebo. Small study sizes, heterogeneity, and bias in blinding and selective reporting limited our conclusions. Further research is needed to investigate different dose regimens of acyclovir and the effect of antivirals on pityriasis rosea. Plain language summary Treatments for pityriasis rosea Background Pityriasis rosea is a common scaly rash prevalent in young adults. A patch of redness and scales is followed by widespread rash. Pityriasis rosea usually resolves within 2 to 12 weeks; however, the rash can resemble a serious contagious skin condition, causing concern. Moreover, pityriasis rosea can cause moderate to severe itching, making effective treatment necessary. Review question We wanted to evaluate the effectiveness and safety of treatments for pityriasis rosea. Eligible treatments were topical, systemic (oral or injected medicines that work throughout the entire body), or light therapy, given alone or in combination with another treatment, and compared against no treatment, placebo (an identical but inactive treatment), vehicle (inactive ingredients that help deliver an active treatment) only, or another active treatment. As spontaneous recovery usually occurs between 2 and 12 weeks in cases of untreated pityriasis rosea, we considered outcomes reported at two weeks. Study characteristics The evidence is current to October 2018. We included 14 studies with a total of 761 participants aged between 2 and 60 years (similar numbers of males and females). Most studies were conducted in Asia in dermatology departments and lasted between 5 to 26 months. Three studies were funded by drug manufacturers; most studies did not report their funding sources. Disease severity was assessed by various measures, but participants were not categorised into mild, moderate, or severe disease. Important treatments assessed by the studies included various antibiotics and acyclovir (a drug meant to treat herpes infections), which were compared to placebo, no treatment, or standard care. Additional treatments included phototherapy, corticosteroids and antihistamine, and Chinese medicine (potenline). Most studies assessed treatment used for one week. All reported outcomes were assessed within two weeks of treatment, except for side effects, which were measured throughout treatment. None of the included studies reported on the participant's rating of rash improvement. Itch was always participant‐assessed. Rash improvement was rated as good or excellent. There is probably no difference between clarithromycin and placebo in medical practitioner‐rated rash improvement or itch resolution, and no serious adverse events were reported (all moderate‐quality evidence). Reduction in itch score and minor side effects were not measured. Similarly, there may be no difference in medical practitioner‐rated rash improvement between azithromycin and placebo or vitamins, but erythromycin may lead to increased rash improvement when compared to placebo; however, the results show there may be a benefit with placebo or little or no difference between treatments (low‐quality evidence for both outcomes). There is probably no difference between azithromycin and comparators in itch resolution or reduction in itch score; there was no clear difference in minor side effects, such as mild abdominal pain (both moderate‐quality evidence). When comparing erythromycin to placebo, itch resolution was not measured, but there is probably a greater reduction in itch score with erythromycin. There was no clear difference in the likelihood of minor side effects, such as gastrointestinal upset, between groups (moderate‐quality evidence for both outcomes). A single study suggested that acyclovir is probably less effective than placebo in achieving itch resolution (but itch score reduction was not measured). However, results from three studies indicate that acyclovir is probably significantly more beneficial than placebo, no treatment, or vitamin tablets in medical practitioner‐rated rash improvement. There is probably no difference between acyclovir and placebo in the incidence of minor side effects: one participant in the placebo group experienced mild abdominal pain and diarrhoea (all outcomes based on moderate‐quality evidence). A single trial indicated that acyclovir used in combination with standard care (calamine (anti‐itch lotion) and the antihistamine cetirizine) may reduce itch score and increase itch resolution (low‐quality evidence). Medical practitioner‐rated rash improvement was not measured. There may be no difference between groups in minor side effects, such as headache, increased sleep, sickness, and impact on taste. None of the studies reported serious adverse events (low‐ to moderate‐quality evidence). Quality of the evidence The quality of the evidence for the main comparisons was low to moderate. Many of the results were based on a small number of trials, with a low number of participants. There was also some variation amongst the trial results and concerns over study design.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Contreras‐Ruiz, J; Peternel, S; Jiménez Gutiérrez, C; Culav‐Koscak, I; Reveiz, L; Silbermann‐Reynoso, MDL", "articleTypes": [], "doi": "10.1002/14651858.CD005068.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "c424e286-9b1b-4209-8177-4aca6ca07ed7", "pmid": "", "title": "Ginkgo biloba extract for age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Ginkgo is used in the treatment of peripheral vascular disease and 'cerebral insufficiency'. It is thought to have several potential mechanisms of action including increased blood flow, platelet activating factor antagonism, and prevention of membrane damage caused by free radicals. Vascular factors and oxidative damage are thought to be two potential mechanisms in the pathology of age‐related macular degeneration (AMD). Objectives The objective of this review was to determine the effect of Ginkgo biloba extract on the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2012), EMBASE (January 1980 to October 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to October 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 5 October 2012. We searched the reference lists of identified reports and the Science Citation Index. We also contacted investigators of included studies for additional information. Selection criteria All randomised trials in people with AMD where Ginkgo biloba extract had been compared to control were included. Data collection and analysis The review author extracted data using a standardised form. The data were verified with the trial investigators. Trial quality was assessed. Main results Two published trials were identified that randomised a total of 119 people. In one study conducted in France, 20 people were randomly allocated to Gingko biloba extract EGb 761 80 mg twice daily or placebo. In the other study conducted in Germany, 99 people were randomly allocated to two different doses of Ginkgo biloba extract EGb 761 (240 mg per day and 60 mg per day). Treatment duration in both studies was six months. Both trials reported some positive effects of Ginkgo biloba on vision however their results could not be pooled. Adverse effects and quality of life for people with AMD were not reported. Authors' conclusions The question as to whether people with AMD should take Ginkgo biloba extract to prevent progression of the disease has not been answered by research to date. Two small trials have suggested possible benefit of Gingko biloba on vision and further trials are warranted. Ginkgo biloba is widely used in China, Germany, and France. Future trials should be larger, and last longer, in order to provide a more robust measure of the effect of Gingko biloba extract on AMD. Plain language summary Use of Gingko biloba, an extract from the leaves of the maidenhair tree, for slowing the progression of age‐related macular degeneration Age‐related macular degeneration (AMD) is a condition affecting the central area of the retina (the back of the eye). The retina can deteriorate with age and some people get lesions that lead to loss of central vision. Gingko biloba, extracted from the leaves of the maidenhair tree, is used in Chinese herbal medicine to treat a variety of medical conditions, in particular circulatory problems. Ginkgo biloba extract contains two constituents (flavonoids and terpenoids) which have antioxidant properties. It is believed these may help to slow down the progression of AMD. The author identified two small randomised controlled studies (with a total of 119 participants); one in France and one in Germany. One trial compared Gingko biloba to placebo and the other compared two different doses of the extract. Although both trials reported some positive effects of Ginkgo biloba on vision, the trials were small and of short duration. Adverse effects and quality of life were not assessed. The overall conclusion of this review is that current research has not answered the question as to whether Ginkgo biloba is of benefit to people with AMD. Future trials need to include a larger number of participants and be conducted over a longer time.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD001775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.729Z" }, { "id": "c431e8eb-345e-4e03-9f9b-d2bafc2eb339", "pmid": "", "title": "Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Madsen, KS, Chi, Y, Metzendorf, MI, Richter, B, Hemmingsen, B", "articleTypes": [], "doi": "10.1002/14651858.CD008558.pub2 AB - Abstract - Background The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether metformin can prevent or delay T2DM and its complications in people with increased risk of developing T2DM is unknown. Objectives To assess the effects of metformin for the prevention or delay of T2DM and its associated complications in persons at increased risk for the T2DM. Search methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was March 2019. Selection criteria We included randomised controlled trials (RCTs) with a duration of one year or more comparing metformin with any pharmacological glucose‐lowering intervention, behaviour‐changing intervention, placebo or standard care in people with impaired glucose tolerance, impaired fasting glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or combinations of these. Data collection and analysis Two review authors read all abstracts and full‐text articles and records, assessed risk of bias and extracted outcome data independently. We used a random‐effects model to perform meta‐analysis and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using GRADE. Main results We included 20 RCTs randomising 6774 participants. One trial contributed 48% of all participants. The duration of intervention in the trials varied from one to five years. We judged none of the trials to be at low risk of bias in all 'Risk of bias' domains. Our main outcome measures were all‐cause mortality, incidence of T2DM, serious adverse events (SAEs), cardiovascular mortality, non‐fatal myocardial infarction or stroke, health‐related quality of life and socioeconomic effects.The following comparisons mostly reported only a fraction of our main outcome set.
 Fifteen RCTs compared metformin with diet and exercise with or without placebo: all‐cause mortality was 7/1353 versus 7/1480 (RR 1.11, 95% CI 0.41 to 3.01; P = 0.83; 2833 participants, 5 trials; very low‐quality evidence); incidence of T2DM was 324/1751 versus 529/1881 participants (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 3632 participants, 12 trials; moderate‐quality evidence); the reporting of SAEs was insufficient and diverse and meta‐analysis could not be performed (reported numbers were 4/118 versus 2/191; 309 participants; 4 trials; very low‐quality evidence); cardiovascular mortality was 1/1073 versus 4/1082 (2416 participants; 2 trials; very low‐quality evidence). One trial reported no clear difference in health‐related quality of life after 3.2 years of follow‐up (very low‐quality evidence). Two trials estimated the direct medical costs (DMC) per participant for metformin varying from $220 to $1177 versus $61 to $184 in the comparator group (2416 participants; 2 trials; low‐quality evidence). Eight RCTs compared metformin with intensive diet and exercise: all‐cause mortality was 7/1278 versus 4/1272 (RR 1.61, 95% CI 0.50 to 5.23; P = 0.43; 2550 participants, 4 trials; very low‐quality evidence); incidence of T2DM was 304/1455 versus 251/1505 (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 2960 participants, 7 trials; moderate‐quality evidence); the reporting of SAEs was sparse and meta‐analysis could not be performed (one trial reported 1/44 in the metformin group versus 0/36 in the intensive exercise and diet group with SAEs). One trial reported that 1/1073 participants in the metformin group compared with 2/1079 participants in the comparator group died from cardiovascular causes. One trial reported that no participant died due to cardiovascular causes (very low‐quality evidence). Two trials estimated the DMC per participant for metformin varying from $220 to $1177 versus $225 to $3628 in the comparator group (2400 participants; 2 trials; very low‐quality evidence). Three RCTs compared metformin with acarbose: all‐cause mortality was 1/44 versus 0/45 (89 participants; 1 trial; very low‐quality evidence); incidence of T2DM was 12/147 versus 7/148 (RR 1.72, 95% CI 0.72 to 4.14; P = 0.22; 295 participants; 3 trials; low‐quality evidence); SAEs were 1/51 versus 2/50 (101 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin with thiazolidinediones: incidence of T2DM was 9/161 versus 9/159 (RR 0.99, 95% CI 0.41 to 2.40; P = 0.98; 320 participants; 3 trials; low‐quality evidence). SAEs were 3/45 versus 0/41 (86 participants; 1 trial; very low‐quality evidence). Three RCTs compared metformin plus intensive diet and exercise with identical intensive diet and exercise: all‐cause mortality was 1/121 versus 1/120 participants (450 participants; 2 trials; very low‐quality evidence); incidence of T2DM was 48/166 versus 53/166 (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; 332 participants; 2 trials; very low‐quality evidence). One trial estimated the DMC of metformin plus intensive diet and exercise to be $270 per participant compared with $225 in the comparator group (94 participants; 1 trial; very‐low quality evidence). One trial in 45 participants compared metformin with a sulphonylurea. The trial reported no patient‐important outcomes. For all comparisons there were no data on non‐fatal myocardial infarction, non‐fatal stroke or microvascular complications. We identified 11 ongoing trials which potentially could provide data of interest for this review. These trials will add a total of 17,853 participants in future updates of this review. Authors' conclusions Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate‐quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate‐quality evidence). Likewise, the combination of metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of T2DM (very low‐quality evidence). Data on patient‐important outcomes such as mortality, macrovascular and microvascular diabetic complications and health‐related quality of life were sparse or missing. Plain language summary Metformin for prevention/delay of type 2 diabetes mellitus (T2DM) and associated complications in persons at increased risk for development of T2DM Review question Is the antidiabetic drug metformin able to prevent or delay the development of type 2 diabetes and its associated complications in people with moderately elevated blood sugar levels? Background People with moderately elevated blood sugar levels (often referred to as 'prediabetes') are said to have an increased risk for developing diabetes. Metformin is a blood sugar‐lowering medicine which has been used for a long time to treat people with type 2 diabetes. Type 2 diabetes, also known as adult‐onset diabetes, is the most common type of diabetes and prevents the body from using insulin properly (insulin resistance). Type 2 diabetes can have bad effects on health in the long term (diabetic complications), such as severe eye or kidney disease or 'diabetic feet', eventually resulting in foot ulcers. We investigated whether metformin can also be used to prevent or delay type 2 diabetes in people at increased risk. We examined the effects of metformin on patient‐important outcomes, such as complications of diabetes, death from any cause, health‐related quality of life and side effects of the drug. Study characteristics To be included, people had to have blood sugar levels higher than normal, but below the levels that are used to diagnose diabetes. We found 20 randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) with a total of 6774 participants. The comparator group consisted of diet and exercise, intensive diet and exercise or another blood sugar‐lowering drug. One study dominated the evidence (48% of the total number of all participants). Twelve studies were performed in China. We only included studies with a treatment duration of one year or more. The treatment duration in the included studies varied from one to five years. This evidence is up to date as of March 2019. Key results Fifteen studies compared metformin against diet and exercise. Eight studies compared metformin against intensive diet and exercise and three studies compared metformin plus intensive diet and exercise against intensive diet and exercise only. When compared to standard diet and exercise metformin slightly reduces or delays development of diabetes. However, when compared to intensive diet and exercise, metformin does not provide an additional benefit in reducing or delaying development of diabetes. Seven studies compared metformin with another glucose‐lowering drug: three studies compared metformin with acarbose. Three studies compared metformin with a thiazolidinedione (such as pioglitazone). There was neither an advantage or disadvantage when comparing metformin with these drugs with respect to the development of diabetes. One study compared metformin with a sulphonylurea (glimepiride). The trial did not report patient‐important outcomes. In general, the reporting of serious side effects was sparse. Few participants died and we did not detect a clear difference between the intervention and comparator groups. We also did not detect an advantage or disadvantage of metformin in relation to health‐related quality of life. Our included studies did not report on non‐fatal heart attacks, strokes or complications of diabetes such as kidney or eye disease. Few studies estimated the direct medical costs. When compared to diet and exercise, metformin was more expensive. When compared to intensive diet and exercise, metformin was less expensive. We identified 11 ongoing studies which potentially could provide data for this review. These studies will add a total of 17,853 participants in future updates of our review. Future studies should investigate more patient‐important outcomes such as complications of diabetes and especially the side effects of the drugs. We do not know whether 'prediabetes' is just a condition defined by laboratory measurements, or whether it is in fact a real risk factor for diabetes. It is also unknown whether treatment of this condition translates into better patient‐important outcomes. Certainty of the evidence All included studies had problems in the way they were conduced or reported.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.765Z" }, { "id": "c4499ae1-60f6-4440-9497-dbe2337fcd91", "pmid": "", "title": "Topical cystic fibrosis transmembrane conductance regulator gene replacement for cystic fibrosis‐related lung disease", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is caused by a defective gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR), and is characterised by chronic lung infection resulting in inflammation and progressive lung damage that results in a reduced life expectancy. Objectives To determine whether topical CFTR gene replacement therapy to the lungs in people with cystic fibrosis is associated with improvements in clinical outcomes, and to assess any adverse effects. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Date of most recent search: 05 May 2016. An additional search of the National Institutes for Health (NIH) Genetic Modification Clinical Research Information System (GeMCRIS) was also performed for the years 1992 to 2015. Date of most recent search: 20 April 2016. Selection criteria Randomised controlled studies comparing topical CFTR gene delivery to the lung, using either viral or non‐viral delivery systems, with placebo or an alternative delivery system in people with confirmed cystic fibrosis. Data collection and analysis The authors independently extracted data and assessed study quality. Authors of included studies were contacted and asked for any available additional data. Meta‐analysis was limited due to differing study designs. Main results Four randomised controlled studies met the inclusion criteria for this review, involving a total of 302 participants lasting from 29 days to 13 months; 14 studies were excluded. The included studies differed in terms of CFTR gene replacement agent and study design, which limited the meta‐analysis. One study only enrolled adult males, the remaining studies included both males and females aged 12 years and over. Risk of bias in the studies was moderate. Random sequence generation and allocation concealment was only described in the more recent study; the remaining three studies were judged to have an unclear risk of bias. All four studies documented double‐blinding to the intervention, but there is some uncertainty with regards to participant blinding in one study. Some outcome data were missing from all four studies. There were no differences in either the number of respiratory exacerbations or the number of participants with an exacerbation between replacement therapy or placebo groups at any time point. Meta‐analysis of most respiratory function tests showed no difference between treatment and placebo groups, but the smallest study (n = 16) reported forced vital capacity (litres) increased more in the placebo group at up to 24 hours. A further study reported a significant improvement in forced expiratory volume at one second (litres) at 30 days after participants had received their first dose of favouring the gene therapy agent, but this finding was not confirmed when combined with at second study in the meta‐analysis. The more recent study (n = 140) demonstrated a small improvement in forced vital capacity (per cent predicted) at two and three months and again at 11 and 12 months for participants receiving CFTR gene replacement therapy compared to those receiving placebo. The same study reported a significant difference in the relative change in forced expiratory volume at one second (per cent predicted) at two months, three months and 12 months. One small study reported significant concerns with \"influenza‐like\" symptoms in participants treated with CFTR gene replacement therapy; this was not reported on repeated use of the same agent in a larger recent study. There was no other evidence of positive impact on outcomes, in particular improved quality of life or reduced treatment burden. Two studies measured ion transport in the lower airways; one (n = 16) demonstrated significant changes toward normal values in the participants who received gene transfer agents (P < 0.0001), mean difference 6.86 (95% confidence interval 3.77 to 9.95). The second study (n = 140) also reported significant changes toward normal values (P = 0.032); however, aggregate data were not available for analysis. In the most recent study, there was also evidence of increased salt transport in cells obtained by brushing the lower airway. These outcomes, whilst important, are not of direct clinical relevance. Authors' conclusions One study of liposome‐based CFTR gene transfer therapy demonstrated some improvements in respiratory function in people with CF, but this limited evidence of efficacy does not support this treatment as a routine therapy at present. There was no evidence of efficacy for viral‐mediated gene delivery. Future studies need to investigate clinically important outcome measures. Plain language summary Replacing the defective gene is a potential treatment for progressive lung disease in people with cystic fibrosis Review question We reviewed the evidence about the effect of delivering the correct copy of the cystic fibrosis transmembrane conductance regulator (CFTR) gene directly to the lungs of people with cystic fibrosis in order to treat progressive lung disease. Background In cystic fibrosis the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. People with cystic fibrosis suffer from progressive lung infection and damage which reduces life expectancy. Agents which can deliver a correct copy of the faulty CFTR gene to cells in the lungs may be an effective treatment. Search date The evidence is current to: 20 April 2016. Study characteristics We found four studies with 302 people to include in this review. The studies lasted from 29 days to 13 months. Three of these studies included both men and women aged 12 years and over and one study only included adult men. The studies compare gene therapy to a dummy treatment (placebo) both of which are inhaled as a mist into the lungs. The studies were of different designs and used different agents. This meant we could not combine their results. Key results Three of the studies, including the largest and most recent study, showed an improvement in some measures of lung function in people with CF given gene therapy. We did not find that any more clinically relevant outcomes such as quality of life, treatment burden or flare‐up of lung disease had improved with treatment. In one study \"influenza‐like\" symptoms were more common in people who received CFTR gene transfer agents but this was not reported when the agent was used repeatedly in a larger study. In those people who took the gene transfer agents, molecules and salt in their lower airways moved more like they do in healthy people. The limited evidence of benefit does not support this as a routine therapy at present. We recommend that future studies are designed and reported clearly so that their results can be incorporated into a systematic review. Quality of the evidence The most recent study provided detailed information on how the people were put into different treatment groups completely at random, and so we are satisfied that those taking part in the study had an equal chance of being in either group (CFTR gene transfer agent or placebo) and that no one could work out which group the next person would be put into. The other studies reported that people were put into groups at random but did not specify how, so we cannot be sure that there was an equal chance of them being in either group. We believe that the clinicians running all the studies did not know which treatment the people taking part were receiving and that in three of the studies those taking part did not know either, but we could not be sure whether the people taking part in the latest study knew which treatment they were receiving and what effect this knowledge might have on results. Unfortunately, the studies did not report all their results clearly; sometimes results were not reported in a way that we could use for the review and sometimes they were not reported at all. This reduced the certainty with which we judged the overall results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Perry, LA; Penny‐Dimri, JC; Aslam, AA; Lee, TWR; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD005599.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "c465c845-ba7b-4c38-a34d-768f4e123e68", "pmid": "", "title": "A Phase II, Single Arm, Open Label, Study on the Safety, Efficacy, Pharmacokinetics & Pharmacodynamics of Quizartinib + Chemotherapy and as Single-agent After High Dose Therapy in Newly Diagnosed Pediatric FLT3-ITD+ and NPM1wt AML Patients", "imported": false, "abstract": "The CHIP-AML22 Master protocol has the overall aim of increasing the cure rate in newly diagnosed pediatric de novo AML patients, while avoiding unnecessary toxicity. The linked Quizartinib trial (CHIP-AML22/Quizartinib) is a phase II, single arm, open label, study on the safety, efficacy, pharmacokinetics and pharmacodynamics of quizartinib in combination with chemotherapy and as single-agent after high dose therapy in newly diagnosed pediatric AML patients with a FLT3-ITD mutation and NPM1 wild-type.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.161Z" }, { "id": "c468a344-5664-45c8-9759-b41eb86e53ec", "pmid": "", "title": "Pharmaceutical interventions for emotionalism after stroke", "imported": false, "abstract": "Abstract - Background Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2019. Objectives To evaluate the benefits and harms of pharmaceutical treatment in people with emotionalism after stroke. Search methods We searched the Cochrane Stroke Group Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registers (May 2022). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). Data collection and analysis Two review authors independently selected trials, assessed risk of bias, extracted data from all included trials, and used GRADE to assess the certainty of the body of evidence. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I 2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on the Center for Neurologic Study ‐ Lability Scale (CNS‐LS) or Clinician Interview‐Based Impression of Change (CIBIC), or diminished tearfulness. Main results We did not identify any new trials for this update. We included seven trials with a total of 239 participants. Two trials had a cross‐over design, but outcome data were not available from the first phase (precross‐over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with a total of 213 participants. It is uncertain whether fluoxetine increases the number of people who have a 50% reduction in emotionalism when compared to placebo (risk ratio (RR) 0.26, 95% CI 0.09 to 0.77; P = 0.02; 1 trial, 19 participants) because the certainty of evidence is very low. Sertraline may lead to little to no difference in Center for Neurologic Study ‐ Lability Scale (CNS‐LS) scores and Clinician Interview‐Based Impression of Change (CIBIC) scores when compared to placebo (RR 0.20, 95% CI 0.03 to 1.50; P = 0.12; 1 trial, 28 participants; low‐certainty evidence). Antidepressants probably increase the number of people who experience a reduction in tearfulness (RR 0.32, 95% CI 0.12 to 0.86; P = 0.02; 3 trials, 164 participants; moderate‐certainty evidence). No trials were found that evaluated the impact of other pharmaceutical interventions. Only two trial authors systematically recorded and reported adverse events, resulting in limited data on the potential harms of treatment. Six trials reported death as an adverse event and found no difference between the groups (antidepressants versus placebo) in the number of deaths reported (RR 0.59, 95% CI 0.08 to 4.50; P = 0.61; 172 participants; moderate‐certainty evidence). This review provides very low‐ to moderate‐certainty evidence that antidepressants may reduce the frequency and severity of emotionalism. The included trials were small and had some degree of bias. Authors' conclusions Antidepressants may reduce the frequency and severity of crying or laughing episodes when compared to placebo, based on very low‐certainty evidence. Our conclusions must be qualified by several methodological deficiencies in the trials and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post‐stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity, and assess change over time; provide treatment for a sufficient duration and follow‐up to better assess rates of relapse or maintenance; and include careful assessment and complete reporting of adverse events. Plain language summary Medicines for emotionalism after stroke Review question To evaluate the benefits and harms of medicine in people with emotionalism after stroke. Background Emotionalism often occurs after stroke. Emotionalism means that the person has difficulty controlling their emotional behaviour. After stroke, people may suddenly start crying or, less commonly, laughing for no apparent reason. This is distressing for that particular person and their carers. Antidepressants, known to be helpful in people with depression, may be an effective treatment for emotionalism after stroke, but there have been very few randomised controlled trials (RCTs) in this area. (RCTs are studies in which participants are assigned randomly to 2 or more treatment groups. This is the best way to ensure that groups of participants are similar, and that investigators and participants do not know who is in which group.) Search date We identified studies through searches conducted on 26 May 2022. Study characteristics We included 7 randomised controlled trials, involving 239 people with emotionalism, in the review, which reported on the use of antidepressants for treating emotionalism. The numbers of people included in the studies ranged from 10 to 92. The mean/median ages ranged from 57.8 years to 73 years. Studies were from Europe (UK: 1; Denmark: 1; Scotland: 1; and Sweden: 1); Asia (South Korea: 1 and Japan: 1); and the USA (1). Key results We did not identify any new studies in our search update. We included 7 studies involving 239 people. However, 2 studies were not available in the appropriate format to include in the analysis. Therefore, we included only 5 studies, with 213 people, in our analyses. It is uncertain whether antidepressants affect the number of people with at least a 50% reduction in emotional displays, tearfulness, and scores on the questionnaires that measure uncontrollable laughing or crying, but they had no effect on lability (frequency of mood changes) scores and whether a clinician thought there had been an improvement when compared to placebo. No studies of other types of medicine were found. Six studies reported death and found no differences between those who were on antidepressants and those who were not. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low, and the results of further research could differ from the results of this review. Our confidence is limited because the included studies were small, and there was no consistency in how emotionalism was measured across the studies. Conclusion It is uncertain whether antidepressant medicines reduce outbursts of crying or laughing. More studies with systematic assessment and reporting of unwanted or harmful effects of a treatment are needed to ensure that any benefits outweigh the risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Allida, S; House, A; Hackett, ML", "articleTypes": [], "doi": "10.1002/14651858.CD003690.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "c46f96d4-728a-4889-b5f2-288449f4a945", "pmid": "", "title": "Interventions for chronic blepharitis", "imported": false, "abstract": "Abstract - Background Blepharitis, an inflammatory condition associated with itchiness, redness, flaking, and crusting of the eyelids, is a common eye condition that affects both children and adults. It is common in all ethnic groups and across all ages. Although infrequent, blepharitis can lead to permanent alterations to the eyelid margin or vision loss from superficial keratopathy (abnormality of the cornea), corneal neovascularization, and ulceration. Most importantly, blepharitis frequently causes significant ocular symptoms such as burning sensation, irritation, tearing, and red eyes as well as visual problems such as photophobia and blurred vision. The exact etiopathogenesis is unknown, but suspected to be multifactorial, including chronic low‐grade infections of the ocular surface with bacteria, infestations with certain parasites such as demodex, and inflammatory skin conditions such as atopy and seborrhea. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. Objectives To examine the effectiveness of interventions in the treatment of chronic blepharitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 1), MEDLINE (January 1950 to February 2012), EMBASE (January 1980 to February 2012), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 9 February 2012. Selection criteria We included randomized controlled trials (RCTs) and quasi‐randomized controlled trials (CCTs) in which participants were adults aged 16 years or older and clinically diagnosed with chronic blepharitis. We also included trials where participants with chronic blepharitis were a subset of the participants included in the study and data were reported separately for these participants. Interventions within the scope of this review included medical treatment and lid hygiene measures. Data collection and analysis Two authors independently assessed search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. Data were meta‐analyzed for studies comparing similar interventions and reporting comparable outcomes with the same timing. Otherwise, results for included studies were summarized in the text. Main results There were 34 studies (2169 participants with blepharitis) included in this review: 20 studies (14 RCTs and 6 CCTs) included 1661 participants with anterior or mixed blepharitis and 14 studies (12 RCTs and 2 CCTs) included 508 participants with posterior blepharitis (MGD). Due to the heterogeneity of study characteristics among the included studies, with respect to follow‐up periods and types of interventions, comparisons, and condition of participants, our ability to perform meta‐analyses was limited. Topical antibiotics were shown to provide some symptomatic relief and were effective in eradicating bacteria from the eyelid margin for anterior blepharitis. Lid hygiene may provide symptomatic relief for anterior and posterior blepharitis. The effectiveness of other treatments for blepharitis, such as topical steroids and oral antibiotics, were inconclusive. Authors' conclusions Despite identifying 34 trials related to treatments for blepharitis, there is no strong evidence for any of the treatments in terms of curing chronic blepharitis. Commercial products are marketed to consumers and prescribed to patients without substantial evidence of effectiveness. Further research is needed to evaluate the effectiveness of such treatments. Any RCT designed for this purpose should separate participants by type of condition (e.g. staphylococcal blepharitis or MGD) in order to minimize imbalances between groups (type I errors) and to achieve statistical power for analyses (prevent type II errors). Medical interventions and commercial products should be compared with conventional lid hygiene measures, such as warm compresses and eyelid margin washing, to determine effectiveness, as well as head‐to‐head to show comparative effectiveness between treatments. Outcomes of interest should be patient‐centered and measured using validated questionnaires or scales. It is important that participants be followed long‐term, at least one year, to assess chronic outcomes properly. Plain language summary Interventions for blepharitis Blepharitis, defined as inflammation of the eyelids, is a common eye condition and affects both children and adults. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. There were 34 studies (2169 participants with blepharitis) included in the review, 20 of which included participants with anterior blepharitis and 14 of which included participants with posterior blepharitis. For anterior blepharitis, topical antibiotics provided some symptomatic relief and were effective in clearing bacteria from the eyelid margins. There was no difference between the types of topical antibiotics used. Topical steroids also provided some symptomatic relief; however, they were ineffective in eliminating bacteria. Lid hygiene, including warm compresses and lid scrubs, showed some symptomatic relief in both anterior and posterior blepharitis. Overall, there was no strong evidence for any of the treatments in terms of curing chronic blepharitis. Further research should be done to evaluate the effectiveness of treatments for blepharitis, with particular attention paid to adequate diagnosis and classification of the disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lindsley, K, Matsumura, S, Hatef, E, Akpek, EK", "articleTypes": [], "doi": "10.1002/14651858.CD005556.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.088Z" }, { "id": "c4801b17-c39f-4114-be95-de96497c954e", "pmid": "", "title": "Misoprostol for intrauterine device placement", "imported": false, "abstract": "Abstract - Rationale Identifying effective approaches to reduce pain and improve providers' ease of intrauterine device (IUD) placement may reduce barriers to IUD access and use. The cervical softening and dilation effects of misoprostol might make IUD placement less painful for women and technically easier for providers. However, evidence suggests that misoprostol does not improve many outcomes and may only be helpful for some patients (e.g. those with a recent failed IUD placement). Objectives To examine the effect of misoprostol for routine IUD placement on patient and provider outcomes compared to placebo or no treatment. Search methods In November 2021 we searched CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ClinicalTrials.gov. We conducted update searches in July 2022 and September 2024. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in July 2025. Eligibility criteria We included randomized controlled trials (RCTs) of women undergoing interval IUD placement (i.e. placement outside the postabortion or postpartum period) that compared misoprostol to placebo or no treatment. We included trials that examined the placement of currently available levonorgestrel (LNG)‐releasing IUDs, or any copper T IUD, for women of any age, of any parity, and for any indication. Outcomes Our core critical and important outcomes were pain (during tenaculum placement, during IUD placement, and after IUD placement before clinic discharge); providers' ease of placement; need for cervical dilation; placement success; patient satisfaction; misoprostol side effects (preplacement abdominal pain or cramping, and diarrhea); and adverse events (vasovagal reaction). Risk of bias We used the Risk of Bias 2 tool (RoB 2) to assess the risk of bias for outcomes. Synthesis methods We synthesized results for each outcome using meta‐analysis. We calculated mean differences (MD) for continuous outcomes using inverse variance estimation and random‐effects models. We calculated risk ratios (RR) for dichotomous outcomes using Mantel‐Haenszel estimation and random‐effects models. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included 14 RCTs with a total of 1972 women. The trials were conducted in North America, South America, Europe and Africa, and were published between 2007 and 2022. Synthesis of results The results below summarize the effect of misoprostol on outcomes compared to placebo or no treatment. Pain: misoprostol results in little to no difference in pain during tenaculum placement (MD −0.73, 95% confidence interval [CI] −1.19 to −0.28; 3 RCTs, 261 women; high‐certainty evidence) and after IUD placement before clinic discharge (MD −0.01, 95% CI −0.45 to 0.43; 5 RCTs, 448 women; high‐certainty evidence). Misoprostol may result in little to no difference in pain during IUD placement (MD −0.47, 95% CI −1.23 to 0.29; 7 RCTs, 766 women; low‐certainty evidence). Providers' ease of placement: misoprostol may result in little to no difference in a clinically meaningful effect on ease of IUD placement for providers (MD −0.89, 95% CI −1.55 to −0.22; 8 RCTs, 848 women; low‐certainty evidence). Need for cervical dilation: misoprostol may result in little to no difference in need for cervical dilation for women without a recent failed placement attempt (RR 0.84, 95% CI 0.38 to 1.85; 6 RCTs, 562 women; low‐certainty evidence). Misoprostol probably results in little to no difference in need for cervical dilation for women with a recent failed placement attempt (RR 0.88, 95% CI 0.56 to 1.36; 1 RCT, 90 women; moderate‐certainty evidence). Placement success: misoprostol probably results in little to no difference in placement success for women without a recent failed placement attempt (RR 1.01, 95% CI 0.98 to 1.04; 12 RCTs, 1579 women; moderate‐certainty evidence) but probably results in a slight increase in placement success for women with a recent failed placement attempt (RR 1.41, 95% CI 1.09 to 1.83; 1 RCT, 90 women; moderate‐certainty evidence). Patient satisfaction: misoprostol may increase women's satisfaction with the IUD placement procedure, but the evidence is very uncertain (MD 2.00, 95% CI −0.05 to 4.06; 2 RCTs, 226 women; very low‐certainty evidence) Misoprostol side effects before clinic discharge: misoprostol probably results in an increase in preplacement abdominal pain or cramping (RR 2.14, 95% CI 1.42 to 3.23; 7 RCTs, 781 women; moderate‐certainty evidence)and probably results in a slight increase in diarrhea (RR 1.76, 95% CI 1.01 to 3.06; 9 RCTs, 940 women; moderate‐certainty evidence). Adverse events before clinic discharge: misoprostol may result in little to no difference in vasovagal reaction (RR 0.94, 95% CI 0.37 to 2.37; 6 RCTs [3 RCTs had 0 events], 780 women; low‐certainty evidence). We downgraded the evidence due to serious concerns about inconsistency and serious or very serious concerns about imprecision. Authors' conclusions Evidence from RCTs of women seeking routine IUD placement suggests that receiving misoprostol compared to placebo or no treatment makes little to no difference to pain during tenaculum placement or after IUD placement; and may make little to no difference to pain during IUD placement. Misoprostol may make little to no difference to reduced vasovagal reaction, improved providers' ease of placement, or reduced need for cervical dilation; and probably makes little to no difference to placement success, except for women with a recent failed IUD placement attempt, where misoprostol probably leads to a clinically meaningful increase in placement success. Misoprostol use probably leads to clinically important increases in harms, specifically preplacement abdominal pain or cramping and diarrhea. Misoprostol may increase patient satisfaction with the IUD placement procedure, but the evidence is very uncertain. The number of available RCTs did not support examining effect modifiers such as prior vaginal delivery status, misoprostol dose, or IUD type. Funding This review was supported in part by an appointment to the Research Participation Program at the Centers for Disease Control and Prevention (CDC) administered by the Oak Ridge Institute for Science and Education. Registration Protocol (2022): doi.org/10.1002/14651858.CD015584 Plain language summary Is misoprostol an effective treatment for routine intrauterine device (IUD) placement and does it cause unwanted effects? Key messages Using misoprostol (a medication that softens and widens the cervix ‐ the neck of the womb) before placing an intrauterine device (IUD ‐ a contraceptive device placed inside the womb) makes little to no difference to pain when a tool (a tenaculum) is used to hold the cervix in place during IUD placement or pain after IUD placement. It may make little to no difference to pain during placement, ease of placement for providers, or need for cervical widening; and probably makes little to no difference to placement success, except for women who recently tried unsuccessfully to have an IUD placed. Misoprostol‐related unwanted effects like stomach cramps and diarrhea probably increase, but it may make little to no difference to other unwanted events. We don't know whether misoprostol use affects women's satisfaction with the procedure. What is an intrauterine device? An intrauterine device (IUD) is a small t‐shaped device inserted through the cervix (the neck of the womb) into the womb to prevent pregnancy. IUDs need to be placed by a trained doctor, nurse, or healthcare provider. IUD placement may be a painful procedure, and it may be more difficult for women who have not had a baby or who have already tried unsuccessfully to have an IUD placed. Serious unwanted events are rare with IUD placement but women may experience non‐serious unwanted effects similar to period pain (cramps) or light bleeding. What is misoprostol? Misoprostol is a medication that is commonly used to start labor and to treat bleeding following birth. It causes the cervix to soften and widen, and so might make IUD placement less painful for women and easier for providers. Misoprostol may cause some unwanted effects like cramps, sickness or diarrhea. Sometimes women may feel dizzy, sweaty or light‐headed. An IUD is an effective and reversible contraceptive method, so identifying ways to reduce pain and improve ease of placement for providers may reduce barriers to IUD access and use. What did we want to find out? We wanted to find out if misoprostol reduces pain, makes IUD placement easier for providers, reduces the need for other methods to widen the cervix, improves placement success and women's satisfaction with the procedure, and whether it causes unwanted effects. What did we do? We searched for studies that examined misoprostol for routine IUD placement compared to placebo (a sham medication) or no treatment. We combined and analyzed the studies' results and rated our confidence in the evidence, based on factors such as study methods. What did we find? We found 14 RCTs with 1972 women. The studies took place in North America, South America, Europe, and Africa. All the studies compared misoprostol with placebo or no treatment. Main results Pain. Misoprostol: results in little to no difference in pain during tenaculum placement (a tenaculum is a tool that holds the cervix in place during IUD placement) (3 studies, 261 women); may result in little to no difference in pain during IUD placement (7 studies, 766 women); results in little to no difference in pain after IUD placement before leaving the clinic (5 studies, 448 women). Providers' ease of placing the IUD Misoprostol may result in little to no difference in ease of IUD placement for providers (8 studies, 848 women). Need for cervical dilation. Misoprostol: may result in little to no difference in the need for cervical widening for women without a recent failed placement attempt (6 studies, 562 women); probably results in little to no difference in the need for cervical widening for women with a recent failed placement attempt (1 study, 90 women). Placement success. Misoprostol: probably results in little to no difference in placement success for women without a recent failed placement attempt (12 studies, 1579 women); probably results in a slight increase in placement success for women with a recent failed placement attempt (1 study, 90 women). Patient satisfaction We are not sure whether misoprostol increases patient satisfaction with the IUD placement procedure (2 studies, 226 women). Unwanted effects. Misoprostol: probably results in an increase in stomach cramps (7 studies, 781 women); probably results in a slight increase in diarrhea (9 studies, 940 women); may result in little to no difference in dizziness or light‐headedness (6 studies, 780 women). What are the limitations of the evidence? Some studies did not report key information about what we wanted to know, and some studies were different from each other, so we couldn't include them in our analyses. We had planned to examine whether certain factors affected the results, such as whether women had previously given birth vaginally, the dose of misoprostol used, or the type of IUD placed, but there were not enough studies to do this in a meaningful way. How up to date is this evidence? The evidence is up to date to 23 September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Zapata, LB, Snyder, E, Nguyen, AT, Kapp, N, Ti, A, Whiteman, MK, Curtis, KM", "articleTypes": [], "doi": "10.1002/14651858.CD015584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.085Z" }, { "id": "c49bf9bf-14f9-474f-8ab2-14931276dc54", "pmid": "", "title": "Surgical techniques for the removal of mandibular wisdom teeth", "imported": false, "abstract": "Abstract - Background Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short‐term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity. Objectives To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication. Selection criteria Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth. Data collection and analysis Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel‐group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross‐over or split‐mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split‐mouth studies in our analyses, and combined parallel‐group and split‐mouth studies using the generic inverse‐variance method. We used the fixed‐effect model for three studies or fewer, and random‐effects model for more than three studies. Main results We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low‐certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low‐certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low‐certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low‐certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand‐piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low‐certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low‐certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low‐certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low‐certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low‐certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported. Authors' conclusions In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future. Plain language summary Comparing different surgical techniques used to remove wisdom teeth from the lower jaw Background The removal of wisdom teeth is a common operation, but it can cause short‐ and long‐term side effects. People may have their wisdom teeth removed if they are causing pain or infection, or if they are damaging other teeth or not breaking through the gum properly. Surgery has a risk of complications. One of the most common is dry socket (also known as alveolar osteitis). This is when a blood clot fails to form in the socket that the tooth has come out of, or the clot is disturbed before the socket has properly healed. Because the bones and nerves underlying the socket are exposed, it can be a very painful condition. Review question We aimed to find out the benefits and harms of different surgical techniques used to remove wisdom teeth from the lower jaw, specifically how surgeons can reduce the risk of complications following surgery. We considered the most important outcomes to be: dry socket, wound infection, long‐term damage to the nerves supplying sensation to the tongue and skin of the lower lip and chin, and problems such as excessive bleeding or a broken jaw. Study characteristics We searched for relevant studies up to 8 July 2019. We included 62 studies with 4643 participants. Many studies excluded people who were not in excellent health so the participants in the trials may not be truly representative. Key results The available evidence is inconclusive. It is unclear if the position of the cut into the gum makes any difference to the outcomes. It is unclear whether it is possible to avoid damaging a nerve to the tongue by using a surgical instrument called a lingual retractor. It is unclear as to whether the type of surgical tool (a chisel or a rotating drill) used to remove bone from the jaw makes a difference to the likelihood of the wound becoming infected. It is unclear if the amount and method of delivering saltwater to clean the tooth socket after the extraction makes any difference to the outcomes. It is unclear whether different methods to stitch the gum after the tooth is removed makes any difference to the outcomes. Placing products that are derived from the patient’s own blood into the tooth socket may help to reduce the occurrence of dry socket (a condition that causes intense pain a few days after extraction). Another three surgical approaches were tested in the studies, but they did not measure the important outcomes. Certainty of the evidence None of the included studies were at low risk of bias. All of the studies were quite small. The quality of the studies varied, with most having flaws that could have biased their results. In addition, some of the results were very imprecise, with variation between them that could not be explained. For these reasons, we consider the available evidence to be uncertain. Future research may be able to provide dental surgeons and patients with clearer conclusions than those listed above.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bailey, E, Kashbour, W, Shah, N, Worthington, HV, Renton, TF, Coulthard, P", "articleTypes": [], "doi": "10.1002/14651858.CD004345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.132Z" }, { "id": "c4b9b767-242b-452c-80c8-b2c7c1a6c50b", "pmid": "", "title": "Guided imagery for treating hypertension in pregnancy", "imported": false, "abstract": "Abstract - Background Hypertension (high blood pressure) in pregnancy carries a high risk of maternal morbidity and mortality. Although antihypertensive drugs are commonly used, they have adverse effects on mothers and fetuses. Guided imagery is a non‐pharmacological technique that has the potential to lower blood pressure among pregnant women with hypertension. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. Objectives To determine the effect of guided imagery as a non‐pharmacological treatment of hypertension in pregnancy and its influence on perinatal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, and two trials registers (October 2018). We also searched relevant conference proceedings and journals, and scanned the reference lists of retrieved studies. Selection criteria We included randomised controlled trials (RCTs). We would have included RCTs using a cluster‐randomised design, but none were identified. We excluded quasi‐RCTs and cross‐over trials. We sought intervention studies of various guided imagery techniques performed during pregnancy in comparison with no intervention or other non‐pharmacological treatments for hypertension (e.g. quiet rest, music therapy, aromatherapy, relaxation therapy, acupuncture, acupressure, massage, device‐guided slow breathing, hypnosis, physical exercise, and yoga). Data collection and analysis Three review authors independently assessed the trials for inclusion, extracted data, and assessed risk of bias for the included studies. We checked extracted data for accuracy, and resolved differences in assessments by discussion. We assessed the certainty of the evidence using the GRADE approach. Main results We included two small trials (involving a total of 99 pregnant women) that compared guided imagery with quiet rest. The trials were conducted in Canada and the USA. We assessed both trials as at high risk of performance bias, and low risk of attrition bias; one trial was at low risk for selection, detection, and reporting bias, while the other was at unclear risk for the same domains. We could not perform a meta‐analysis because the two included studies reported different outcomes, and the frequency of the intervention was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks, or until the baby was born (whichever came first). In the other study, the intervention included guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for four total hours; the participants were instructed to practice the procedures twice daily and complete at least three relief relaxation breaks each day. The control groups were similar ‐ one was quiet rest, and the other was quiet rest as bed rest. None of our primary outcomes were reported in the included trials: severe hypertension (either systolic blood pressure of 160 mmHg or higher, or diastolic blood pressure of 110 mmHg or higher); severe pre‐eclampsia, or perinatal death (stillbirths plus deaths in the first week of life). Only one of the secondary outcomes was measured. Low‐certainty evidence from one trial (69 women) suggests that guided imagery may make little or no difference in the use of antihypertensive drugs (risk ratio 1.27, 95% confidence interval 0.72 to 2.22). Authors' conclusions There is insufficient evidence to inform practice about the use of guided imagery for hypertension in pregnancy. The available evidence for this review topic is sparse, and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. There was low‐certainty evidence that guided imagery made little or no difference to the use of antihypertensive drugs, downgraded because of imprecision. The two included trials did not report on any of the primary outcomes of this review. We did not identify any trials comparing guided imagery with no intervention, or with another non‐pharmacological method for hypertension. Large and well‐designed RCTs are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with short‐term and long‐term maternal and neonatal health. Trials could also consider utilisation and costs of health service. Plain language summary Guided imagery for treating hypertension in pregnancy What is the issue? Some women have long‐term high blood pressure, or hypertension, whereas approximately 10% of pregnant women develop high blood pressure as a complication of pregnancy. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. It can be performed by oneself, one‐to‐one, or in groups with an instructor using audio or scripts. Why is this important? High blood pressure during pregnancy is associated with an increased risk of the mother developing pre‐eclampsia with proteinuria, eclampsia with seizures and liver and blood disorders, and kidney failure. The baby of a pregnant woman with high blood pressure is more likely to be born too soon, be too small, and may need neonatal intensive care. High blood pressure drugs are recommended for women with severe high blood pressure and pre‐eclampsia because of the risk of life‐threatening complications, but such drugs can have adverse effects for the mother (including headache, decreased mental alertness, and exercise intolerance). Such drugs can also cross the placenta and may affect the unborn baby, and are not generally recommended for pregnant women with mild to moderate high blood pressure, which is when other ways of managing blood pressure are sought. Guided imagery is a non‐pharmacological technique that could potentially lower blood pressure among pregnant women with hypertension and improve pregnancy outcomes for the mother and her baby. What evidence did we find? We searched for evidence (October 2018) and found two trials (involving 99 women) conducted in Canada and the USA. Both trials compared guided imagery with quiet rest. There were no trials comparing guided imagery with no intervention, or other with another non‐pharmacological method for hypertension. The two included studies reported different outcomes and the Intervention frequency was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks or until the baby was born (whichever came first). The other study involved guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for a total of four hours; the women were instructed to practice the procedures twice daily and complete at least three relaxation breaks each day. The control groups between the two studies were similar ‐ one used quiet rest and the other used quiet rest as bed rest. Neither trial reported data for our main outcomes of interest: severe hypertension, severe pre‐eclampsia, or death of the baby during birth or within the first week of life. The trials provided data for only one of our secondary outcomes of interest. Low‐certainty evidence from the one trial (69 women) suggests that, compared with quiet rest, guided imagery may make little or no difference in the use of antihypertensive drugs. What does this mean? We included two small trials comparing guided imagery with quiet rest. We did not identify any trials comparing guided imagery with no intervention, or another non‐pharmacological treatment for hypertension. The available evidence for this review is sparse and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. The included trials did not report on any of the main outcomes in this review and only provided low‐certainty evidence on the uncertain effect on the use of antihypertensive drugs. There is insufficient evidence to inform practice about using guided imagery for hypertension in pregnancy. Large and well‐designed studies are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with the short‐term and long‐term health of mothers and their babies. The trials should also consider the use and costs of health services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Haruna, M, Matsuzaki, M, Ota, E, Shiraishi, M, Hanada, N, Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD011337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.093Z" }, { "id": "c4d629cf-e754-42f4-808d-d7e3b33d364f", "pmid": "", "title": "Chlorambucil for patients with primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. But it is unknown whether it benefits or harms these patients. Objectives To evaluate the beneficial and any harmful effects of chlorambucil for primary biliary cirrhosis patients. Search methods Eligible trials were identified by searching the Cochrane Hepato‐Biliary Group Controlled Trials Register (March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2012, Issue 2), MEDLINE (1946 to March 2012), EMBASE (1974 to March 2012), Science Citation Index EXPANDED (1900 to March 2012), The Chinese Biomedical Database (1976 to March 2012), The Chinese Medical Current Contents (1994 to March 2012), The China Hospital Knowledge Database (1994 to March 2012), and a database of ongoing trials (http://www.controlled‐trials.com/mrct/) (accessed 6 March 2012). The reference lists of the retrieved publications and review articles were also read through, and pharmaceutical companies known to produce chlorambucil were contacted. Selection criteria Randomised clinical trials, irrespective of language, year of publication, and publication status, comparing chlorambucil at any dose versus placebo, no intervention, another active drug, or one dose of chlorambucil with another dose. Data collection and analysis We planned to assess continuous data with mean differences (MD), and dichotomous outcomes with relative risk (RR), both with 95% confidence intervals (CI). As we only identified one trial, Fisher's exact tests were employed. Main results Only one randomised trial was identified and included in the review. The bias risk in the trial was high. The trial compared chlorambucil versus no intervention in 24 patients with primary biliary cirrhosis. Fisher's exact test did not show a significant reduction of mortality when comparing chlorambucil with no treatment (0/13 (0%) versus (2/11 (18.2%); P = 0.20). There was no significant difference regarding adverse events for chlorambucil compared with no treatment, but all patients receiving chlorambucil experienced adverse events (13/13 (100%) versus (3/11 (27%); P = 0.1). According to the authors of the trial, chlorambucil led to a significant improvement in mean serum levels of bilirubin (P < 0.05), albumin (P < 0.05), immunoglobulin M (P < 0.01), serum aspartate aminotransferase activity (P < 0.01), and hepatic inflammatory infiltrates (P < 0.01). Authors' conclusions There is not sufficient evidence to support or reject the use of chlorambucil for patients with primary biliary cirrhosis. Chlorambucil may show benefit in some unvalidated surrogate outcome measures (for example, serum bilirubin and immunoglobulin M levels). Chlorambucil is, however, connected with a number of adverse events. Bone marrow suppression should be noted in particular. Further randomised clinical trials are necessary to assess the benefits and harms of chlorambucil in this indication. Plain language summary Chlorambucil for patients with primary biliary cirrhosis Primary biliary cirrhosis is an autoimmune disease of the liver. Chlorambucil has been used for patients with primary biliary cirrhosis as it possesses immunosuppressive properties. This review aimed to assess the beneficial or harmful effects of chlorambucil for primary biliary cirrhosis. The authors identified only one randomised trial, with 24 participants included. This trial compared chlorambucil with no intervention. The trial is small and at a high risk of bias, which suggests that the results may not be reliable. Meta‐analyses were not possible because of the inclusion of one trial only. Fisher's exact test and t‐test were used instead. Chlorambucil was not associated with significantly lower mortality when compared with no intervention. All patients on chlorambucil experienced adverse events, especially bone marrow suppression. Chlorambucil led to a significant improvement in mean serum levels of bilirubin, albumin, immunoglobulin M, serum aspartate aminotransferase activity, and hepatic inflammatory infiltrates. However, these outcomes are unvalidated surrogate outcomes for patient‐relevant outcomes. This means that improvement of these biochemistry measures cannot be taken as proof of improvement of patient‐relevant outcomes. It remains unclear whether chlorambucil can be supported or rejected for use in patients with primary biliary cirrhosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Li, WX; Yan, X; Shi, CR; Zhang, AP", "articleTypes": [], "doi": "10.1002/14651858.CD008714.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "c4d8bbf3-0481-4e01-87a0-3798af096050", "pmid": "", "title": "Wheat flour fortification with iron and other micronutrients for reducing anaemia and improving iron status in populations", "imported": false, "abstract": "Abstract - Background Anaemia is a condition where the number of red blood cells (and consequently their oxygen‐carrying capacity) is insufficient to meet the body's physiological needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations. Objectives To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health‐related outcomes in populations over two years of age. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, 21 other databases and two trials registers up to 21 July 2020, together with contacting key organisations to identify additional studies. Selection criteria We included cluster‐ or individually‐randomised controlled trials (RCTs) carried out among the general population from any country, aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. We included trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat Data collection and analysis Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risks of bias. We followed Cochrane methods in this review. Main results Our search identified 3538 records, after removing duplicates. We included 10 trials, involving 3319 participants, carried out in Bangladesh, Brazil, India, Kuwait, Philippines, South Africa and Sri Lanka. We identified two ongoing studies and one study is awaiting classification. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, three trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial used various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta‐analyses. Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added Iron‐fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added may reduce by 27% the risk of anaemia in populations (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.55 to 0.97; 5 studies, 2315 participants; low‐certainty evidence). It is uncertain whether iron‐fortified wheat flour with or without other micronutrients reduces iron deficiency (RR 0.46, 95% CI 0.20 to 1.04; 3 studies, 748 participants; very low‐certainty evidence) or increases haemoglobin concentrations (in g/L) (mean difference MD 2.75, 95% CI 0.71 to 4.80; 8 studies, 2831 participants; very low‐certainty evidence). No trials reported data on adverse effects in children (including constipation, nausea, vomiting, heartburn or diarrhoea), except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to the risk of Infection or inflammation at individual level as measured by C‐reactive protein (CRP) (mean difference (MD) 0.04, 95% CI −0.02 to 0.11; 2 studies, 558 participants; moderate‐certainty evidence). Iron‐fortified wheat flour with other micronutrients added versus unfortified wheat flour (nil micronutrients added) It is unclear whether wheat flour fortified with iron, in combination with other micronutrients decreases anaemia (RR 0.77, 95% CI 0.41 to 1.46; 2 studies, 317 participants; very low‐certainty evidence). The intervention probably reduces the risk of iron deficiency (RR 0.73, 95% CI 0.54 to 0.99; 3 studies, 382 participants; moderate‐certainty evidence) and it is unclear whether it increases average haemoglobin concentrations (MD 2.53, 95% CI −0.39 to 5.45; 4 studies, 532 participants; very low‐certainty evidence). No trials reported data on adverse effects in children. Nine out of 10 trials reported sources of funding, with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials. Authors' conclusions Fortification of wheat flour with iron (in comparison to unfortified flour, or where both groups received the same other micronutrients) may reduce anaemia in the general population above two years of age, but its effects on other outcomes are uncertain. Iron‐fortified wheat flour in combination with other micronutrients, in comparison with unfortified flour, probably reduces iron deficiency, but its effects on other outcomes are uncertain. None of the included trials reported data on adverse side effects except for risk of infection or inflammation at the individual level. The effects of this intervention on other health outcomes are unclear. Future studies at low risk of bias should aim to measure all important outcomes, and to further investigate which variants of fortification, including the role of other micronutrients as well as types of iron fortification, are more effective, and for whom. Plain language summary Does adding iron to wheat flour reduce anaemia and increase iron levels in the general population? Why do we need iron in our diet? Iron is an essential mineral found in every cell of the body. It is needed to make haemoglobin, the oxygen‐carrying protein in the blood. Iron molecules in haemoglobin bind to oxygen and carry it from the lungs to all the cells and tissues in the body. Low levels of haemoglobin means the body does not get enough oxygen. Anaemia develops when haemoglobin levels in the blood fall too low. Symptoms of anaemia include: tiredness and lack of energy, getting out of breath quickly, pale skin and a greater susceptibility to infections. Low haemoglobin levels can be caused by blood loss, pregnancy or not eating enough foods containing iron (iron‐deficiency anaemia). Iron‐deficiency anaemia may be treated by taking iron tablets or eating foods rich in iron. Fortified foods Adding micronutrients (vitamins and minerals) to foods, whether those micronutrients were originally present or not, is called fortification. Fortifying foods is one way to improve nutrition in a population. People living in low‐income countries may not have enough iron in their diet, and may be at risk of anaemia. Adding iron and other nutrients to foods routinely eaten in large quantities, such as flour, is thought to help prevent iron‐deficiency anaemia. Why we did this Cochrane Review We wanted to find out how adding iron, and other minerals and vitamins, to wheat flour affected the blood iron levels of the general population, and whether fewer people developed anaemia or other health conditions. We also wanted to know if adding iron to wheat flour caused any unwanted effects. What did we do? We searched for studies that investigated eating any types of food made with wheat flour containing added iron, or foods made with wheat flour without added iron. We then compared the studies with each other, to find out the effects of adding iron to wheat flour on people's health and the levels of iron and haemoglobin in their blood. Search date: we included evidence published up to 21 July 2020. What we found We found 10 studies in 3319 people (aged 2 years and older). The studies lasted from 3 months to 24 months, and took place in Bangladesh, Brazil, India, Kuwait, the Philippines, Sri Lanka and South Africa. The studies looked at the effects of: · wheat flour containing added iron (with or without other minerals and vitamins) compared with wheat flour without added iron (but with the same other minerals and vitamins); · wheat flour containing added iron and other minerals and vitamins compared with wheat flour without any added minerals or vitamins. The wheat flours used in the studies contained different amounts of iron: from under 40 mg/kg to over 60 mg/kg. We were interested in: · how many people had anaemia (defined by low haemoglobin levels); · how many people had low levels of iron in their blood (iron deficiency; tested using a biomarker); · haemoglobin concentrations in people's blood; · how many children had diarrhoea or respiratory infections; · how many children died (of any cause); · signs of infection or inflammation (the body's response to injury) in children (by testing a biomarker in the blood); and · any unwanted effects. Most studies had multiple sources of funding; some were partly funded by companies involved in the food, chemical or pharmaceutical industries. What are the results of our review? Compared with flour without added iron (but with other minerals and vitamins) Flour containing added iron (with or without other minerals and vitamins): · may reduce anaemia, by 27% (evidence from 5 studies, 2315 people); and · probably makes no difference to children's risk of infection or inflammation (2 studies, 558 children). It was unclear how flour with added iron affected iron deficiency (3 studies, 748 people), or haemoglobin levels (8 studies, 2831 people ). Compared with flour without any added minerals or vitamins Flour containing added iron (with other minerals and vitamins) probably reduced iron deficiency (3 studies, 382 people). It was unclear from the studies how flour containing added iron affected anaemia (2 studies, 317 people) or haemoglobin levels (4 studies, 532 people). No studies reported information about unwanted effects, or how many children died, or had diarrhoea or respiratory infections. Our confidence in our results Our confidence is moderate to low that adding iron to flour probably reduces iron deficiency and anaemia. The studies appeared to show fewer people with iron deficiency and slightly higher haemoglobin levels associated with flour with added iron, but the results varied widely, so we are uncertain about the effect. These results might change if further evidence becomes available. We found limitations in the ways some of the studies were designed and conducted, and this could have affected their results. Key messages Adding iron to wheat flour may lead to fewer people with anaemia or low blood‐iron levels in the general population. We do not know if adding iron to wheat flour causes any unwanted effects, because no studies looked at these.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Field, MS; Mithra, P; Peña-Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD011302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "c4dd30fc-5854-4465-be35-a814c4e6372f", "pmid": "", "title": "Zinc supplementation for tinnitus", "imported": false, "abstract": "Abstract - Background Tinnitus is the perception of sound without external acoustic stimuli. Patients with severe tinnitus may have physical and psychological complaints and their tinnitus can cause deterioration in their quality of life. At present no specific therapy for tinnitus has been found to be satisfactory in all patients. In recent decades, a number of reports have suggested that oral zinc supplementation may be effective in the management of tinnitus. Since zinc has a role in cochlear physiology and in the synapses of the auditory system, there is a plausible mechanism of action for this treatment. Objectives To evaluate the effectiveness and safety of oral zinc supplementation in the management of patients with tinnitus. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 6); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 July 2016. Selection criteria Randomised controlled trials comparing zinc supplementation versus placebo in adults (18 years and over) with tinnitus. Data collection and analysis We used the standard methodological procedures recommended by Cochrane. Our primary outcome measures were improvement in tinnitus severity and disability, measured by a validated tinnitus‐specific questionnaire, and adverse effects. Secondary outcomes were quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters, change in tinnitus loudness, change in overall severity of tinnitus and change in thresholds on pure tone audiometry. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included three trials involving a total of 209 participants. The studies were at moderate to high risk of bias. All included studies had differences in participant selection criteria, length of follow‐up and outcome measurement, precluding a meta‐analysis. The participants were all adults over 18 years with subjective tinnitus, but one study conducted in 2013 (n = 109) included only elderly patients. Improvement in tinnitus severity and disability Only the study in elderly patients used a validated instrument (Tinnitus Handicap Questionnaire) for this primary outcome. The authors of this cross‐over study did not report the results of the two phases separately and found no significant differences in the proportion of patients reporting tinnitus improvement at four months of follow‐up: 5% (5/93) versus 2% (2/94) in the zinc and placebo groups, respectively (risk ratio (RR) 2.53, 95% confidence interval (CI) 0.50 to 12.70; very low‐quality evidence ). None of the included studies reported any significant adverse effects. Secondary outcomes For the secondary outcome change in tinnitus loudness, one study reported no significant difference between the zinc and placebo groups after eight weeks: mean difference in tinnitus loudness ‐9.71 dB (95% CI ‐25.53 to 6.11; very low‐quality evidence ). Another study also measured tinnitus loudness but used a 0‐ to 100‐point scale. The authors of this second study reported no significant difference between the zinc and placebo groups after four months: mean difference in tinnitus loudness rating scores 0.50 (95% CI ‐5.08 to 6.08; very low‐quality evidence ). Two studies used unvalidated instruments to assess tinnitus severity. One (with 50 participants) reported the severity of tinnitus using a non‐validated scale (0 to 7 points) and found no significant difference in subjective tinnitus scores between the zinc and placebo groups at the end of eight weeks of follow‐up (mean difference (MD) ‐1.41, 95% CI ‐2.97 to 0.15; very low‐quality evidence ). A third trial (n = 50) also evaluated the improvement of tinnitus using a non‐validated instrument (a 0 to 10 scale: 10 = severe and unbearable tinnitus). In this study, after eight weeks there was no difference in the proportion of patients with improvement in their tinnitus, 8.7% (2/23) treated with zinc versus 8% (2/25) of those who received a placebo (RR 1.09, 95% CI 0.17 to 7.10, very low‐quality evidence ). None of the included studies reported any of our other secondary outcomes (quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters or change in thresholds on pure tone audiometry). Authors' conclusions We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. Plain language summary Zinc supplements for tinnitus Background Tinnitus is the perceived sensation of sound in the ear or head. Severe tinnitus affects 1% to 2% of the population. People with severe tinnitus frequently have psychological changes and a decrease in their quality of life. Tinnitus is difficult to control and many doctors are testing new treatments to improve the quality of life of people who suffer from this problem. This review looked for high‐quality studies in the literature that involved zinc supplements as a possible treatment for tinnitus in adults. The aim was to evaluate whether oral zinc is effective in the treatment of tinnitus. Study characteristics We included a total of three trials involving 209 participants who were treated with oral zinc pills or placebo. All patients were adults over 18 years who had subjective tinnitus. All three studies investigated improvement in tinnitus as their primary outcome. One study assessed adverse effects and our secondary outcome 'change in overall severity of tinnitus'. Two studies assessed tinnitus loudness. Only one study, which enrolled only elderly patients, used a validated instrument (the Tinnitus Handicap Questionnaire (THQ)) to measure the primary outcome. The other two studies measured tinnitus using scales (from 0 to 7 and from 0 to 10), but these scales were not validated instruments for studying tinnitus. Key results All three included studies had differences in their participant selection, length of follow‐up and outcome measurement, which prevented a meta‐analysis (combining of results). Only one trial (conducted in 2013) used a validated instrument (the THQ) to measure improvement in tinnitus, our primary outcome. The authors reported no significant difference between the groups. Another study (2003) reported the severity of tinnitus using a non‐validated scale (0 to 7) and found a significant difference in the subjective tinnitus scores, which favoured the zinc group. However, this result may be biased because the losses were unbalanced and higher in the placebo group. A third study (1991) also evaluated improvement of tinnitus using a non‐validated instrument (a scale of 0 to 10) and found no significant difference between groups. There were no severe adverse effects associated with zinc. Three cases of mild adverse effects were reported in different participants (e.g. mild gastric symptoms). Two studies (2003 and 2013) assessed change in tinnitus loudness (one of our secondary outcomes), but did not find a difference between patients treated with zinc compared to those who took a placebo. Two studies assessed change in the overall severity of tinnitus. One study, published in 1991, did not find any difference for this outcome between the groups. The second study, published in 2003, reported a significant reduction in subjective tinnitus score in the zinc group and no difference in the placebo group. However, both studies used a non‐validated scale. Quality of the evidence The quality of the evidence is very low. We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. This evidence is up to date to 14 July 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Person, OC, Puga, MES, da Silva, EMK, Torloni, MR", "articleTypes": [], "doi": "10.1002/14651858.CD009832.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.777Z" }, { "id": "c4eb0c1f-b996-47ab-ac12-21e6dc6a1515", "pmid": "", "title": "The Effectiveness of Cerebrolycin, a Multi-modal Neurotrophic Factor, for Treatment of Post-covid-19 Persistent Olfactory, Gustatory and Trigeminal Chemosensory Dysfunctions: A Pilot Study", "imported": false, "abstract": "The loss of smell and taste is a prominent symptom of COVID-19. Studies found that patterns of smell loss due to Covid-19 infection differ from that of other respiratory viruses being much more profound in the Covid-19 patents and did not associate with runny, congested, or blocked-up nose. The researchers suggest that smell and taste testing can be used for fast COVID-19 screening. Studies found that the Covid-19 virus has similarities with severe acute respiratory syndrome coronavirus (SARS-CoV), which has been reported to enter the brain, via smell receptors in the nose. The sudden onset and relatively fast recovery in some patients suggest that COVID-19 anosmia is not caused by damage to the central nervous system but rather by the loss of smell information before it gets to the brain (smell receptors). They also found that it has different behavior from other respiratory viruses as it causes over-reaction of the immune system (or a cytokine storm). Trials to treat post-COVID anosmia using local steroid applications, sniffing of strong odors or scents or use of different vitamins (for several weeks to months) did not provide rapid, satisfactory or even significant recovery of olfactory dysfunction. Fortunately, the olfactory neurons can regenerate, however, studies reported variable prognoses, some patients recovered within weeks which others may have persistent deficits for months or even a year. In this study, the researchers hypothesize that cerebrolysin, a drug of neurotrophic and neuroprotective properties, can be used to treat patients with persistent post-COVID anosmia or ageusia or promote functional recovery of smell and taste deficits.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.148Z" }, { "id": "c4f7bd9b-cc67-4007-b56d-7c49d123b8ba", "pmid": "", "title": "Corticosteroids for idiopathic pulmonary fibrosis", "imported": false, "abstract": "Abstract - Background Idiopathic pulmonary fibrosis (IPF) is a disease with significant morbidity and mortality. Patients short survival time, high mortality and generally rapid decline raise the importance of early treatment. Current guidelines suggest a combination of corticosteroids and immunosuppressants as \"gold standard\" for IPF treatment, although the evidence for this recommendation is weak. Based on animal models, it has been hypothesized a central role for aberrant wound healing following repeated epithelial lung injury, weakening the rationale for using corticosteroids in IPF, previously thought to be a chronic inflammatory disease. Objectives The aim of the review is to determine the efficacy of corticosteroids in the treatment of adults with familial and sporadic IPF. Search methods We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2008), MEDLINE (January 1966 to June 2008) and EMBASE (January 1985 to June 2008) and reference lists of articles. We searched reference lists of published articles to identify clinical trials. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) using corticosteroids alone for the treatment of adults with IPF. Data collection and analysis Abstracts of identified articles were retrieved and articles possibly fulfilling inclusion criteria were retrieved in full. Two reviewers would have independently assessed trial quality if there had been any included study. Main results Seventeen articles were selected as potentially eligible for meta‐analysis. After further analysis of full text papers, no RCTs or CCTs were identified as suitable and therefore no data was available for inclusion in any meta‐analysis. All studies were excluded due to inadequate methodologies. Authors' conclusions At present, there is no evidence for an effect of corticosteroid treatment in patients with IPF. On the other hand, other fibrotic lung diseases, such as non‐specific interstitial pneumonia (NSIP), are reported to show a better response to corticosteroids. Making a clear distinction between IPF and other entities grouped under the umbrella term interstitial lung disease is, therefore, essential as this may have therapeutic and prognostic implications. Plain language summary Currently there is no evidence to support the routine use of corticosteroids alone in the management of idiopathic pulmonary fibrosis. Idiopathic pulmonary fibrosis (IPF) is a chronic disorder of unknown cause that is progressive and leads to death. Existing evidence about the treatment of IPF is difficult to interpret because of evolving diagnostic criteria and classification schemes, grouping together diverse entities with markedly different natural histories and responses to therapy. Therefore, because the old studies did not include only IPF patients, their results cannot be extended to IPF as they are currently defined. In addition, methodologic problems mainly related to the lack of randomized placebo‐controlled treatment trials have made evidence‐based conclusions difficult. A systematic search for high quality placebo‐controlled randomised trials comparing corticosteroid treatment with placebo in subjects with a diagnosis of IPF was unable to identify any studies suitable for inclusion in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Richeldi, L; Davies, HRHR; Spagnolo, P; Luppi, F", "articleTypes": [], "doi": "10.1002/14651858.CD002880", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "c51c6e58-33d6-4160-b6db-066b291a8cd7", "pmid": "", "title": "Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries", "imported": false, "abstract": "Abstract - Background Protein Energy Malnutrition is an important cause of child morbidity and mortality in middle‐ and low‐income countries. It has been suggested that excessive free radical activity may be responsible for the clinical manifestation of kwashiorkor. Antioxidants may be able to curb excessive free radical activity and prevent the development of kwashiorkor in susceptible children. Objectives To evaluate the benefits of supplementation of vitamin E, selenium, cysteine and riboflavin (alone or in combination) in preventing kwashiorkor. Search methods We conducted searches of CENTRAL 2009 ( The Cochrane Library 2009 Issue 2), MEDLINE 1966 to 2009, EMBASE 1980 to 2009, CINAHL 1982 to 2009, LILACS 1982 to 2009, Meta register of Controlled trials, Open Sigle, African Index Medicus. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating vitamin E, selenium, cysteine and riboflavin alone or in combination in healthy pre‐school children in middle‐ and low‐income countries. Data collection and analysis Two authors extracted and independently analysed data. Main results One cluster‐RCT including 2372 children met our inclusion criteria. Children were randomised, based on household, either to a supplement containing all four micronutrients or to placebo. No statistically significant difference in the incidence of kwashiorkor between the intervention and control groups could be demonstrated at 20 weeks (RR 1.70; 95% CI 0.98 to 2.42). Nor could any statistically significant difference in all‐cause mortality be demonstrated (RR 0.75; 95% CI 0.17 to 3.36). Authors' conclusions Based on the one available trial, we could draw no firm conclusion for the effectiveness of supplementary antioxidant micronutrients for the prevention of kwashiorkor in pre‐school children. Plain language summary Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries Undernutrition is one of the leading underlying causes of childhood morbidity and mortality in developing countries. Providing antioxidants that would help curb excess free radicals in the body may help prevent the development of kwashiorkor. We identified one cluster‐RCT that attempted to investigate this. Based on the published evidence reviewed, we could draw no firm conclusions of the benefits of supplementary antioxidants for the prevention of kwashiorkor in pre‐school children. There is a need for further research in this area to be certain if antioxidant supplementation can help prevent kwashiorkor in young children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Odigwe, CC, Smedslund, G, Ejemot‐Nwadiaro, RI, Anyanechi, CC, Krawinkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD008147.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.133Z" }, { "id": "c5205448-0d16-4d3c-a2f5-f09db87028ea", "pmid": "", "title": "Guided imagery for treating hypertension in pregnancy", "imported": false, "abstract": "Abstract - Background Hypertension (high blood pressure) in pregnancy carries a high risk of maternal morbidity and mortality. Although antihypertensive drugs are commonly used, they have adverse effects on mothers and fetuses. Guided imagery is a non‐pharmacological technique that has the potential to lower blood pressure among pregnant women with hypertension. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. Objectives To determine the effect of guided imagery as a non‐pharmacological treatment of hypertension in pregnancy and its influence on perinatal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, and two trials registers (October 2018). We also searched relevant conference proceedings and journals, and scanned the reference lists of retrieved studies. Selection criteria We included randomised controlled trials (RCTs). We would have included RCTs using a cluster‐randomised design, but none were identified. We excluded quasi‐RCTs and cross‐over trials. We sought intervention studies of various guided imagery techniques performed during pregnancy in comparison with no intervention or other non‐pharmacological treatments for hypertension (e.g. quiet rest, music therapy, aromatherapy, relaxation therapy, acupuncture, acupressure, massage, device‐guided slow breathing, hypnosis, physical exercise, and yoga). Data collection and analysis Three review authors independently assessed the trials for inclusion, extracted data, and assessed risk of bias for the included studies. We checked extracted data for accuracy, and resolved differences in assessments by discussion. We assessed the certainty of the evidence using the GRADE approach. Main results We included two small trials (involving a total of 99 pregnant women) that compared guided imagery with quiet rest. The trials were conducted in Canada and the USA. We assessed both trials as at high risk of performance bias, and low risk of attrition bias; one trial was at low risk for selection, detection, and reporting bias, while the other was at unclear risk for the same domains. We could not perform a meta‐analysis because the two included studies reported different outcomes, and the frequency of the intervention was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks, or until the baby was born (whichever came first). In the other study, the intervention included guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for four total hours; the participants were instructed to practice the procedures twice daily and complete at least three relief relaxation breaks each day. The control groups were similar ‐ one was quiet rest, and the other was quiet rest as bed rest. None of our primary outcomes were reported in the included trials: severe hypertension (either systolic blood pressure of 160 mmHg or higher, or diastolic blood pressure of 110 mmHg or higher); severe pre‐eclampsia, or perinatal death (stillbirths plus deaths in the first week of life). Only one of the secondary outcomes was measured. Low‐certainty evidence from one trial (69 women) suggests that guided imagery may make little or no difference in the use of antihypertensive drugs (risk ratio 1.27, 95% confidence interval 0.72 to 2.22). Authors' conclusions There is insufficient evidence to inform practice about the use of guided imagery for hypertension in pregnancy. The available evidence for this review topic is sparse, and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. There was low‐certainty evidence that guided imagery made little or no difference to the use of antihypertensive drugs, downgraded because of imprecision. The two included trials did not report on any of the primary outcomes of this review. We did not identify any trials comparing guided imagery with no intervention, or with another non‐pharmacological method for hypertension. Large and well‐designed RCTs are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with short‐term and long‐term maternal and neonatal health. Trials could also consider utilisation and costs of health service. Plain language summary Guided imagery for treating hypertension in pregnancy What is the issue? Some women have long‐term high blood pressure, or hypertension, whereas approximately 10% of pregnant women develop high blood pressure as a complication of pregnancy. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. It can be performed by oneself, one‐to‐one, or in groups with an instructor using audio or scripts. Why is this important? High blood pressure during pregnancy is associated with an increased risk of the mother developing pre‐eclampsia with proteinuria, eclampsia with seizures and liver and blood disorders, and kidney failure. The baby of a pregnant woman with high blood pressure is more likely to be born too soon, be too small, and may need neonatal intensive care. High blood pressure drugs are recommended for women with severe high blood pressure and pre‐eclampsia because of the risk of life‐threatening complications, but such drugs can have adverse effects for the mother (including headache, decreased mental alertness, and exercise intolerance). Such drugs can also cross the placenta and may affect the unborn baby, and are not generally recommended for pregnant women with mild to moderate high blood pressure, which is when other ways of managing blood pressure are sought. Guided imagery is a non‐pharmacological technique that could potentially lower blood pressure among pregnant women with hypertension and improve pregnancy outcomes for the mother and her baby. What evidence did we find? We searched for evidence (October 2018) and found two trials (involving 99 women) conducted in Canada and the USA. Both trials compared guided imagery with quiet rest. There were no trials comparing guided imagery with no intervention, or other with another non‐pharmacological method for hypertension. The two included studies reported different outcomes and the Intervention frequency was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks or until the baby was born (whichever came first). The other study involved guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for a total of four hours; the women were instructed to practice the procedures twice daily and complete at least three relaxation breaks each day. The control groups between the two studies were similar ‐ one used quiet rest and the other used quiet rest as bed rest. Neither trial reported data for our main outcomes of interest: severe hypertension, severe pre‐eclampsia, or death of the baby during birth or within the first week of life. The trials provided data for only one of our secondary outcomes of interest. Low‐certainty evidence from the one trial (69 women) suggests that, compared with quiet rest, guided imagery may make little or no difference in the use of antihypertensive drugs. What does this mean? We included two small trials comparing guided imagery with quiet rest. We did not identify any trials comparing guided imagery with no intervention, or another non‐pharmacological treatment for hypertension. The available evidence for this review is sparse and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. The included trials did not report on any of the main outcomes in this review and only provided low‐certainty evidence on the uncertain effect on the use of antihypertensive drugs. There is insufficient evidence to inform practice about using guided imagery for hypertension in pregnancy. Large and well‐designed studies are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with the short‐term and long‐term health of mothers and their babies. The trials should also consider the use and costs of health services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Haruna, M; Matsuzaki, M; Ota, E; Shiraishi, M; Hanada, N; Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD011337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "c53084b0-7da5-4d5b-81e3-19594aa746e6", "pmid": "", "title": "Evaluation of a Nutritional Intervention With Dietary Supplements in People Who Have Recently Lost Weight: Effects on Body Composition, Emotional Health, and Gut Microbiota", "imported": false, "abstract": "This study aims to evaluate the effects of a 12-week nutritional intervention with dietary supplements on individuals who have experienced significant weight loss following the use of GLP-1 receptor agonists or similar weight-loss treatments. The study will investigate whether the combined supplementation protocol can improve body composition, emotional well-being, and gut microbiota diversity after discontinuation of pharmacological treatment.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.262Z" }, { "id": "c5568b2a-97b9-42b1-983a-efb202c6bc26", "pmid": "", "title": "Modafinil for people with schizophrenia or related disorders", "imported": false, "abstract": "Abstract - Background People with schizophrenia have a range of different symptoms, including positive symptoms (hallucinations and delusions), negative symptoms (such as social withdrawal and lack of affect), and cognitive impairment. The standard medication for people with schizophrenia is antipsychotics. However, these medications may not be effective for all symptoms of schizophrenia, as cognitive and negative symptoms are usually hard to treat. Additional therapies or medications are available for the management of these symptoms. Modafinil, a wakefulness‐promoting agent most frequently used in narcolepsy or shift work sleep disorder, is one intervention that is theorised to have an effect of these symptoms. Objectives The primary objective of this review was to assess the effects of modafinil for people with schizophrenia or related disorders. Search methods On 27 April 2015, 24 May 2017, and 31 October 2019, we searched the Cochrane Schizophrenia Group's register of trials, which is based on regular searches of CENTRAL, MEDLINE, Embase, AMED, BIOSIS, CINAHL, PsycINFO, PubMed, and registries of clinical trials. There are no language, time, document type, or publication status limitations for the inclusion of records in the register. Selection criteria We selected all randomised controlled trials comparing modafinil with placebo or other treatments for people with schizophrenia or schizophrenia‐spectrum disorders. Data collection and analysis We independently extracted data from the included studies. We analysed dichotomous data using risk ratios (RR) and 95% confidence intervals (CI). We analysed continuous data using mean difference (MD) with a 95% CI. We used a random‐effects model for the meta‐analysis. We used GRADE to complete a 'Summary of findings' table and assessed risk of bias for the included studies. Main results Eleven studies including a total of 422 participants contributed to data analyses. Most studies had a small population size (average 38 people per study) and were of short duration. We also detected a high risk of bias for selective outcome reporting in just under 50% of the trials. We therefore rated the overall methodological quality of the included studies as low. We considered seven main outcomes of interest: clinically important change in overall mental state, clinically important change in cognitive functioning, incidence of a clinically important adverse effect/event, clinically important change in global state, leaving the study early for any reason, clinically important change in quality of life, and hospital admission. All studies assessed the effects of adding modafinil to participants' usual antipsychotic treatment compared to adding placebo to usual antipsychotic treatment. Six studies found that adding modafinil to antipsychotic treatment may have little or no effect on overall mental state of people with schizophrenia, specifically the risk of worsening psychosis (RR 0.91, 95% CI 0.28 to 2.98; participants = 209; studies = 6, low‐quality evidence ). Regarding the effect of modafinil on cognitive function, the trials did not report clinically important change data, but one study reported endpoint scores on the MATRICS Consensus Cognitive Battery (MCCB): in this study we found no clear difference in scores between modafinil and placebo treatment groups (MD −3.10, 95% CI −10.9 to 4.7; participants = 48; studies = 1, very low‐quality evidence ). Only one study (N = 35) reported adverse effect/event data. In this study one serious adverse event occurred in each group (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). One study measured change in global state using the Clinical Global Impression ‐ Improvement Scale. This study found that adding modafinil to antipsychotic treatment may have little or no effect on global state (RR 6.36, 95% CI 0.94 to 43.07, participants = 21; studies = 1, very low‐quality evidence ). Nine studies found that modafinil has no effect on numbers of participants leaving the study early (RR 1.26, 95% CI 0.63 to 2.52 participants = 357; studies = 9, moderate‐quality evidence ). None of the trials reported clinically important change in quality of life, but one study did report quality of life using endpoint scores on the Quality of Life Inventory, finding no clear difference between treatment groups (MD −0.2, 95% CI −1.18 to 0.78; participants = 20; studies = 1, very low‐quality evidence ). Finally, one study reported data for number of participants needing hospitalisation: one participant in each group was hospitalised (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low‐quality evidence ). Authors' conclusions Due to methodological issues, low sample size, and short duration of the clinical trials as well as high risk of bias for outcome reporting, most of the evidence available for this review is of very low or low quality. For results where quality is low or very low, we are uncertain or very uncertain if the effect estimates are true effects, limiting our conclusions. Specifically, we found that modafinil is no better or worse than placebo at preventing worsening of psychosis; however, we are uncertain about this result. We have more confidence that participants receiving modafinil are no more likely to leave a trial early than participants receiving placebo. However, we are very uncertain about the remaining equivocal results between modafinil and placebo for outcomes such as improvement in global state or cognitive function, incidence of adverse events, and changes in quality of life. More high‐quality data are needed before firm conclusions regarding the effects of modafinil for people with schizophrenia or related disorders can be made. Plain language summary Modafinil for schizophrenia Review question: Is adding modafinil to antipsychotic treatment effective and safe for people with schizophrenia? Background Schizophrenia is a complicated and chronic mental disorder that usually presents with a wide range of symptoms. The standard treatment (antipsychotics) is considered to be effective for the positive symptoms (such as delusions and hallucinations or bizarre thoughts). However, there are negative and cognitive symptoms (such as social withdrawal, lack of affect, problems with memory) that are not adequately treated with these medications. These symptoms tend to be chronic and can therefore have a long‐term impact on an individual's quality of life. Additional treatments are often added to antipsychotic treatment, of which one is modafinil, a wakefulness‐promoting medication usually used for sleep disorders. Searching for evidence We ran an electronic search of Cochrane Schizophrenia's register of trials in April 2015, May 2017, and October 2019 for trials that randomised (allocated participants to treatment groups using a random method) people with schizophrenia to receive add‐on modafinil (modafinil added to their standard care) or to receive add‐on placebo. We identified 67 records that referred to 25 studies. Evidence found Eleven studies met the review requirements and reported data that could be used in analyses. However, the trials included small numbers of participants and were of short duration; schizophrenia is a long‐term health problem that ideally requires studies of longer duration. Our analysis of the data showed there is no clear difference between add‐on modafinil and add‐on placebo for improving mental state or global state, changing cognitive functioning, causing participants to leave a study early, producing adverse effects, or affecting rates of hospitalisation. However, most of these results were based on very low‐ or low‐quality data, therefore it is uncertain if these statistical effect sizes found by our data analyses are true effects. Conclusions The results of this review indicate no clear difference in effectiveness and safety between add‐on modafinil and add‐on placebo, however these results are not conclusive as they are based low‐ or very low‐quality evidence. Based on the current evidence we were unable to provide an answer to our review question as to whether modafinil is better than placebo for improving the symptoms of schizophrenia, or if it is safe to use for people with schizophrenia. More high‐quality research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ortiz-Orendain, J; Covarrubias-Castillo, SA; Vazquez-Alvarez, AO; Castiello-de Obeso, S; Arias Quiñones, GE; Seegers, M; Colunga-Lozano, LE", "articleTypes": [], "doi": "10.1002/14651858.CD008661.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "c55abdc0-52c5-41c0-a61e-d8f8d6856c3e", "pmid": "", "title": "Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years", "imported": false, "abstract": "Abstract - Background Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health. Objectives To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non‐dietary intervention. Secondary objectives were to assess the impact of ECEC‐based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality‐of‐life outcomes. We also report on cost and adverse consequences of ECEC‐based healthy eating interventions. Search methods We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers. Selection criteria We included randomised controlled trials (RCTs), including cluster‐RCTs, stepped‐wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross‐over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both. Data collection and analysis Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta‐analyses using a random‐effects model; otherwise, we described findings using vote‐counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes. Main results We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster‐RCTs. Twenty‐nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty‐eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC‐based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I 2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I 2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC‐based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI −0.01 to 0.25; P =0.08, I 2 = 70%; 13 studies, 3335 children). There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely result in little to no difference in children's consumption of non‐core (i.e. less healthy/discretionary) foods (SMD −0.05, 95% CI −0.17 to 0.08; P = 0.48, I 2 = 16%; 7 studies, 1369 children) or consumption of sugar‐sweetened beverages (SMD −0.10, 95% CI −0.34 to 0.14; P = 0.41, I 2 = 45%; 3 studies, 522 children). Thirty‐six studies measured BMI, BMI z‐score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC‐based healthy eating interventions may result in little to no difference in child BMI (MD −0.08, 95% CI −0.23 to 0.07; P = 0.30, I 2 = 65%; 15 studies, 3932 children) or in child BMI z‐score (MD −0.03, 95% CI −0.09 to 0.03; P = 0.36, I 2 = 0%; 17 studies; 4766 children). ECEC‐based healthy eating interventions may decrease child weight (MD −0.23, 95% CI −0.49 to 0.03; P = 0.09, I 2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I 2 = 0%; 5 studies, 1070 children). ECEC‐based healthy eating interventions may be cost‐effective but the evidence is very uncertain (6 studies). ECEC‐based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3). Authors' conclusions ECEC‐based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC‐based healthy eating interventions on vegetable consumption. ECEC‐based healthy eating interventions may result in little to no difference in child consumption of non‐core foods and sugar‐sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z‐scores. Future studies exploring the impact of specific intervention components, and describing cost‐effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC‐based healthy eating interventions. Plain language summary How successful are healthy eating programmes in preschools, kindergartens and childcare settings? Key messages • Healthy eating programmes delivered in early childhood education and care (ECEC) settings (e.g. preschools, kindergarten, family day care) may improve child diet quality, likely increase fruit consumption, may have favourable effects on vegetable consumption, and likely have no impact on consumption of less healthy foods and sugar‐sweetened drinks. They may have favourable effects on child weight and may reduce the risk of being overweight or obese. • We don't know if healthy eating interventions save money or cause unwanted effects because very few studies provided information about these points. • We found little evidence from low‐ and middle‐income countries, but healthy eating programmes in high‐income countries may benefit child health. We don't know how to support educators and staff to implement these programmes in practice. We need more research about delivering programmes and about their effect in low‐income countries. Why is it important to improve young children's diet? Having a poor diet puts people at risk of many long‐term diseases including heart disease, type 2 diabetes and certain types of cancers. Research estimates that over 11 million deaths worldwide are caused by having an unhealthy diet. Dietary behaviours and preferences are established early in life and persist into adulthood. What are healthy eating programmes? Healthy eating programmes aim to encourage children to eat a healthier diet. They may involve changes to lessons and the culture in preschools, kindergartens and day care centres (early childhood education and care (ECEC) settings), and working with children's families, teachers and healthcare staff. For example, introducing new fruits and vegetables to children, changing the menu to include healthier options or providing families with information about child healthy eating. Healthy eating programmes may establish lifelong healthy eating patterns, reduce excessive weight gain and improve overall health. What did we want to find out? We wanted to find out what impact healthy eating interventions have on child diet and health. We were interested in changes to diet, weight, language and cognitive performance, social, emotional and quality of life outcomes in children aged six months to six years attending preschool, long day care, nurseries, kindergartens and family day care services. We also wanted to know the cost of interventions and whether they had any potential unwanted effects. What did we do? We searched for studies that compared healthy eating programmes against no action, delayed delivery of the programme, or a programme that did not aim to change child diet. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 52 studies that looked at the effects of 58 healthy eating programmes in ECEC settings for children aged six months to six years. All studies were published in high and high‐middle‐income countries. The programmes were very different from each other. They: • lasted from 4 weeks to 3 years; • were delivered by a range of people including healthcare providers, ECEC staff, and researchers; • used different delivery methods (telephone, face‐to‐face, online, printed materials); and • measured results in a variety of ways (e.g. parent or staff surveys, observations of children's eating, and weighing foods before and after meals). Overall, the programmes aimed to: • change the ECEC environment (e.g. staff demonstrated healthy eating to children, and provided healthier foods); • change the curriculum (e.g. they provided lessons about foods and healthy eating); and • establish partnerships (e.g. they provided educational resources to families); and • increase children's physical activity (e.g. by structured physical activity lessons and encouraging less screen time). Healthy eating programmes may lead to small improvements in child diet quality, increase fruit consumption by 0.11 servings, potentially improve vegetable consumption by 0.12 servings and may have no effect on consumption of less healthy foods and sugar‐sweetened drinks. Further, we found child weight is potentially reduced by 230 g and for every 100 children, 19 would have better weight status. However, we found no evidence of impact on body mass index. The programmes may be cost‐effective and likely to have no unwanted effects, although few studies reported these points. Few studies reported on other learning, social and developmental outcomes. What are the limitations of the evidence? Our confidence in the evidence is low because the healthy eating programmes were conducted, delivered and assessed in different ways. Also, many of the people who received the healthy eating programmes were aware that they were being assessed and this can sometimes influence how they report their effects. For example, parents who reported their child's diet may have been more inclined to give positive answers because they felt they were doing what society expected or because they were grateful for the support and wanted to please the researchers. Also, not all studies provided information about everything we were interested in and there was often missing data when children were followed up after the study. How up‐to‐date is the evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yoong, SL, Lum, M, Wolfenden, L, Jackson, J, Barnes, C, Hall, AE, McCrabb, S, Pearson, N, Lane, C, Jones, JZ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013862.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.823Z" }, { "id": "c55c8a14-27f7-45f3-bbc7-1372e96cb9f1", "pmid": "", "title": "Desferrioxamine mesylate for managing transfusional iron overload in people with transfusion‐dependent thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. Desferrioxamine mesylate (desferrioxamine) is one of the most widely used iron chelators. Substantial data have shown the beneficial effects of desferrioxamine, although adherence to desferrioxamine therapy is a challenge. Alternative oral iron chelators, deferiprone and deferasirox, are now commonly used. Important questions exist about whether desferrioxamine, as monotherapy or in combination with an oral iron chelator, is the best treatment for iron chelation therapy. Objectives To determine the effectiveness (dose and method of administration) of desferrioxamine in people with transfusion‐dependent thalassaemia. To summarise data from trials on the clinical efficacy and safety of desferrioxamine for thalassaemia and to compare these with deferiprone and deferasirox. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We also searched MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus ongoing trials registers and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). All searches were updated to 5 March 2013. Selection criteria Randomised controlled trials comparing desferrioxamine with placebo, with another iron chelator, or comparing two schedules or doses of desferrioxamine, in people with transfusion‐dependent thalassaemia. Data collection and analysis Six authors working independently were involved in trial quality assessment and data extraction. For one trial, investigators supplied additional data upon request. Main results A total of 22 trials involving 2187 participants (range 11 to 586 people) were included. These trials included eight comparisons between desferrioxamine alone and deferiprone alone; five comparisons between desferrioxamine combined with deferiprone and deferiprone alone; eight comparisons between desferrioxamine alone and desferrioxamine combined with deferiprone; two comparisons of desferrioxamine with deferasirox; and two comparisons of different routes of desferrioxamine administration (bolus versus continuous infusion). Overall, few trials measured the same or long‐term outcomes. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage; none of these included a comparison with deferasirox. Five trials reported a total of seven deaths; three in patients who received desferrioxamine alone, two in patients who received desferrioxamine and deferiprone. A further death occurred in a patient who received deferiprone in another who received deferasirox alone. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. One trial planned five years of follow up but was stopped early due to the beneficial effects of a reduction in serum ferritin levels in those receiving combined desferrioxamine and deferiprone treatment compared with deferiprone alone. The results of this and three other trials suggest an advantage of combined therapy with desferrioxamine and deferiprone over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no evidence for the improved efficacy of combined desferrioxamine and deferiprone therapy against monotherapy from direct or indirect measures of liver iron. Earlier trials measuring the cardiac iron load indirectly by measurement of the magnetic resonance imaging T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, meta‐analysis of two trials showed a significantly lower left ventricular ejection fraction in patients who received desferrioxamine alone compared with those who received combination therapy using desferrioxamine with deferiprone. Adverse events were recorded by 18 trials. These occurred with all treatments, but were significantly less likely with desferrioxamine than deferiprone in one trial, relative risk 0.45 (95% confidence interval 0.24 to 0.84) and significantly less likely with desferrioxamine alone than desferrioxamine combined with deferiprone in two other trials, relative risk 0.33 (95% confidence interval 0.13 to 0.84). In particular, four studies reported permanent treatment withdrawal due to adverse events from deferiprone; only one of these reported permanent withdrawals associated with desferrioxamine. Adverse events also occurred at a higher frequency in patients who received deferasirox than desferrioxamine in one trial. Eight trials reported local adverse reactions at the site of desferrioxamine infusion including pain and swelling. Adverse events associated with deferiprone included joint pain, gastrointestinal disturbance, increases in liver enzymes and neutropenia; adverse events associated with deferasirox comprised increases in liver enzymes and renal impairment. Regular monitoring of white cell counts has been recommended for deferiprone and monitoring of liver and renal function for deferasirox. In summary, desferrioxamine and the oral iron chelators deferiprone and deferasirox produce significant reductions in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised clinical trials to suggest that any one of these has a greater reduction of clinically significant end organ damage, although in two trials, combination therapy with desferrioxamine and deferiprone showed a greater improvement in left ventricular ejection fraction than desferrioxamine used alone. Authors' conclusions Desferrioxamine is the recommended first‐line therapy for iron overload in people with thalassaemia major and deferiprone or deferasirox are indicated for treating iron overload when desferrioxamine is contraindicated or inadequate. Oral deferasirox has been licensed for use in children aged over six years who receive frequent blood transfusions and in children aged two to five years who receive infrequent blood transfusions. In the absence of randomised controlled trials with long‐term follow up, there is no compelling evidence to change this conclusion. Worsening iron deposition in the myocardium in patients receiving desferrioxamine alone would suggest a change of therapy by intensification of desferrioxamine treatment or the use of desferrioxamine and deferiprone combination therapy. Adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. People treated with all chelators must be kept under close medical supervision and treatment with deferiprone or deferasirox requires regular monitoring of neutrophil counts or renal function respectively. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcomes of deferiprone, deferasirox and desferrioxamine. Plain language summary Desferrioxamine mesylate (desferrioxamine) for managing excess iron levels in the blood of people with thalassaemia who depend on blood transfusions Haemoglobin carries oxygen in the blood. In thalassaemia, a genetic disease, sometimes the body cannot produce enough haemoglobin. This can be managed by receiving regular blood transfusions, but may lead to excess iron in the body which must be removed to prevent organ damage. Iron is removed by iron chelation therapy using a substance called an iron chelator. This works by sticking to excess iron molecules in the body. When patients go to the toilet, this excess iron leaves the body. Three iron chelators are commonly used. One (desferrioxamine) is injected and two (deferiprone and deferasirox) are taken orally. Deferasirox is licensed for use in children. Desferrioxamine is inconvenient and expensive; motivating researchers to find safe, effective oral iron chelators. We found 22 randomised controlled trials comparing iron chelators. These do not provide enough information about death or organ damage. However, they showed all three chelators performed similarly well in removing excess iron. Several trials found combining desferrioxamine and deferiprone removed more excess iron than using just one iron chelator. Trials showing side effects must be considered carefully. Side effects with desferrioxamine included pain or skin reactions at the injection site and joint pain. Side effects with deferiprone included joint pain, nausea, stomach upsets and low white blood cell count. Side effects with deferasirox included skin rashes, increases in liver enzymes and reduced kidney function. Low white blood cell count and reduced kidney function are important side effects and in patients receiving deferiprone or deferasirox these should be monitored regularly. Patients were three times more likely to experience a side effect when deferiprone and desferrioxamine were combined, compared with desferrioxamine alone. Three studies showed that patients using deferiprone were two and a half times more likely to have joint pain compared with using desferrioxamine alone. We have found no evidence for changing current treatment recommendations, which state that deferiprone or deferasirox should be used to remove excess iron when desferrioxamine cannot be used or is inadequate. The Food and Drug Administration in the United States of America have approved deferiprone only as \"last resort treatment of iron overload in thalassemia\". Larger randomised control trials of iron chelation therapy are needed, using standardised agreed measures of iron levels and organ damage to allow comparison of such valuable treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA, Brunskill, SJ, Doree, C, Gooding, S, Chowdhury, O, Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004450.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.820Z" }, { "id": "c562f623-e442-41d5-b37e-9912a4cee109", "pmid": "", "title": "Pimozide for schizophrenia or related psychoses", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Mothi, M, Sampson, S", "articleTypes": [], "doi": "10.1002/14651858.CD001949.pub3 AB - Abstract - Background Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been associated with cardiotoxicity and sudden unexplained death. Electrocardiogram monitoring is now required before and during use. Objectives To review the effects of pimozide for people with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medication. A secondary objective was to examine the effects of pimozide for people with delusional disorder. Search methods We searched the Cochrane Schizophrenia Group's Register (28 January 2013). Selection criteria We sought all relevant randomised clinical trials (RCTs) comparing pimozide with other treatments. Data collection and analysis Working independently, we inspected citations, ordered papers and then re‐inspected and assessed the quality of the studies and of extracted data. For homogeneous dichotomous data, we calculated the relative risk (RR), the 95% confidence interval (CI) and mean differences (MDs) for continuous data. We excluded data if loss to follow‐up was greater than 50%. We assessed risk of bias for included studies and used GRADE to rate the quality of the evidence. Main results We included 32 studies in total: Among the five studies that compared pimozide versus placebo, only one study provided data for global state relapse, for which no difference between groups was noted at medium term (1 RCT n = 20, RR 0.22 CI 0.03 to 1.78, very low quality of evidence ). None of the five studies provided data for no improvement or first‐rank symptoms in mental state. Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (1 RCT, n = 19, RR 5.50 CI 0.30 to 101.28, very low quality of evidence ) or at medium term (1 RCT n = 25, RR 1.33 CI 0.14 to 12.82, very low quality of evidence ), or for Parkinsonism (tremor) at medium term (1 RCT n = 25, RR 1 CI 0.2 to 4.95, very low quality of evidence ). No data were reported for quality of life at medium term. Of the 26 studies comparing pimozide versus any antipsychotic, seven studies provided data for global state relapse at medium term, for which no difference was noted (7 RCTs n = 227, RR 0.82 CI 0.57 to 1.17, moderate quality of evidence ). Data from one study demonstrated no difference in mental state (no improvement) at medium term (1 RCT n = 23, RR 1.09 CI 0.08 to 15.41, very low quality evidence ); another study demonstrated no difference in the presence of first‐rank symptoms at medium term (1 RCT n = 44, RR 0.53 CI 0.25 to 1.11, low quality of evidence ). Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (6 RCTs n = 186, RR 1.21 CI 0.71 to 2.05, low quality of evidence ) or medium term (5 RCTs n = 219, RR 1.12 CI 0.24 to 5.25, low quality of evidence ), or for Parkinsonism (tremor) at medium term (4 RCTs n = 174, RR 1.46 CI 0.68 to 3.11, very low quality of evidence ). No data were reported for quality of life at medium term. In the one study that compared pimozide plus any antipsychotic versus the same antipsychotic, significantly fewer relapses were noted in the augmented pimozide group at medium term (1 RCT n = 69, RR 0.28 CI 0.15 to 0.50, low quality evidence ). No data were reported for mental state outcomes or for extrapyramidal symptoms (EPS). Data were skewed for quality of life scores, which were not included in the meta‐analysis but were presented separately. Two studies compared pimozide plus any antipsychotics versus antipsychotic plus placebo; neither study reported data for outcomes of interest, apart from Parkinsonism at medium term and quality of life using the Specific Level of Functioning scale (SLOF); however, data were skewed. Only one study compared pimozide plus any antipsychotic versus antipsychotics plus antipsychotic; no data were reported for global state and mental state outcomes of interest. Data were provided for Parkinsonism (rigidity and tremor) using the Extrapyramidal Symptom Rating Scale (ESRS); however, these data were skewed. Authors' conclusions Although shortcomings in the data are evident, enough overall consistency over different outcomes and time scales is present to confirm that pimozide is a drug with efficacy similar to that of other, more commonly used antipsychotic drugs such as chlorpromazine for people with schizophrenia. No data support or refute its use for those with delusional disorder. Plain language summary Pimozide for schizophrenia or related psychoses People with schizophrenia have ‘positive symptoms’ such as hearing voices and seeing things (hallucinations) and fixed strange beliefs (delusions). People with schizophrenia also have ‘negative symptoms’ such as tiredness, apathy and loss of emotion. Antipsychotic drugs are the main treatment for the symptoms of schizophrenia and can be grouped into older drugs (first generation or ‘typical’) and newer drugs (second generation or ‘atypical’). Pimozide is a ‘typical’ antipsychotic drug that was first introduced in the late 1960s and was given to people with schizophrenia. Pimozide is thought to be effective in treating the positive and negative symptoms of schizophrenia or similar mental health problems such as delusional disorder, but it produces serious side effects such as muscle stiffness, tremors and slow body movements. Pimozide may also cause heart problems and has been linked to sudden unexplained death. Monitoring the heart via electrocardiogram is now required before and during treatment with pimozide. It is well known that people with mental health problems suffer from physical illnesses such as heart disease and diabetes and can die on average twenty years younger than those in the general population.
 An update search for this review was carried out 28 January 2013; the review now includes 32 studies that assess the effects of pimozide for people with schizophrenia or similar mental health problems. Pimozide was compared with other antipsychotic drugs, placebo (‘dummy’ treatment) or no treatment. Results suggest that pimozide is probably just as effective as other commonly used ‘typical’ antipsychotic drugs (for outcomes such as treating mental state, relapse, leaving the study early). No studies included delusional disorders, so no information is available on this group of people. No evidence was found to support the concern that pimozide causes heart problems (although this may be result of the fact that the studies were small and short term and the participants did not receive doses above recommended limits of 20 mg/d). Pimozide may cause less sleepiness than other typical antipsychotic drugs, but it may cause more tremors and uncontrollable shaking. The claim that pimozide is useful for treating people with negative symptoms also is not supported and proven. However, the quality of evidence in the main was low or very low quality, studies were small and of short duration and were poorly reported. Large‐scale, well‐conducted and well‐reported studies are required to assess the effectiveness of pimozide in the treatment of schizophrenia and other mental health problems such as delusional disorder. This plain language summary has been written by a consumer, Benjamin Gray (Service User and Service User Expert, Rethink Mental Illness).", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.134Z" }, { "id": "c58da349-bf49-40b6-979f-45eeebecfe2a", "pmid": "", "title": "Interventions for preventing osteoradionecrosis of the jaws in adults receiving head and neck radiotherapy", "imported": false, "abstract": "Abstract - Background Osteoradionecrosis (ORN) of the jaws is among the most serious oral complications of head and neck cancer radiotherapy, arising from radiation‐induced fibro‐atrophic tissue injury, manifested by necrosis of osseous tissues and failure to heal, often secondary to operative interventions in the oral cavity. It is associated with considerable morbidity and has important quality of life ramifications. Since ORN is very difficult to treat effectively, preventive measures to limit the onset of this disease are needed; however, the effects of various preventive interventions has not been adequately quantified. Objectives To assess the effects of interventions for preventing ORN of the jaws in adult patients with head and neck cancer undergoing curative or adjuvant (i.e. non‐palliative) radiotherapy. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 5 November 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 10) in the Cochrane Library (searched 5 November 2019), MEDLINE Ovid (1946 to 5 November 2019), Embase Ovid (1980 to 5 November 2019), Allied and Complementary Medicine (AMED) Ovid (1985 to 5 November 2019), Scopus (1966 to 5 November 2019), Proquest Dissertations and Theses International (1861 to 5 November 2019) and Web of Science Conference Proceedings (1990 to 5 November 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We selected randomised controlled trials (RCTs) or quasi‐RCTs of adult patients 18 years or older with head and neck cancer who had undergone curative or adjuvant radiotherapy to the head and neck, who had received an intervention to prevent the onset of ORN. Eligible patients were those subjected to pre‐ or post‐irradiation dental evaluation. Management of these patients was to be with interventions independent of their cancer therapy, including but not limited to local, systemic, or behavioural interventions. Data collection and analysis Two review authors independently selected trials from search results, assessed risk of bias, and extracted relevant data for inclusion in the review. Authors of included studies were contacted to request missing data. We used standard methodological procedures expected by Cochrane. Main results Four studies were identified that met pre‐determined eligibility criteria, evaluating a total of 342 adults. From the four studies, all assessed as at high risk of bias, three broad interventions were identified that may potentially reduce the risk of ORN development: one study showed no reduction in ORN when using platelet‐rich plasma placed in the extraction sockets of prophylactically removed healthy mandibular molar teeth prior to radiotherapy (odds ratio (OR) 3.32, 95% confidence interval (CI) 0.58 to 19.09; one trial, 44 participants; very low‐certainty evidence). Another study involved comparing fluoride gel and high‐content fluoride toothpaste (1350 parts per million (ppm)) in prevention of post‐radiation caries, and found no difference between their use as no cases of ORN were reported (one trial, 220 participants; very low‐certainty evidence). The other two studies involved the use of perioperative hyperbaric oxygen (HBO) therapy and antibiotics. One study showed that treatment with HBO caused a reduction in the development of ORN in comparison to patients treated with antibiotics following dental extractions (risk ratio (RR) 0.18, 95% CI 0.43 to 0.76; one trial, 74 participants; very low‐certainty evidence). Another study found no difference between combined HBO and antibiotics compared to antibiotics alone prior to dental implant placement (RR 3.00, 95% CI 0.14 to 65.16; one trial, 26 participants; very low‐certainty evidence). Adverse effects of the different interventions were not reported clearly or were not important. Authors' conclusions Given the suboptimal reporting and inadequate sample sizes of the included studies, evidence regarding the interventions evaluated by the trials included in this review is uncertain. More well‐designed RCTs with larger samples are required to make conclusive statements regarding the efficacy of these interventions. Plain language summary Dental treatments for preventing damage to the jawbones in people with cancer receiving radiotherapy to the head and neck Review question With this Cochrane Review we tried to find out the best way to prevent the death and exposure of bone in the jaws of people who have had radiotherapy for head and neck cancer. This is a condition called osteoradionecrosis (ORN). Background ORN of the jaws is a serious problem which can happen after people have radiotherapy as part of their treatment for head and neck cancer. ORN refers to the death and exposure of bone that result from damage to the tissues due to being exposed to radiation. ORN is very difficult to treat and it is important that steps are taken to prevent it. In this review, we looked at any treatments that have been used to prevent ORN. Study characteristics This review is up‐to‐date as of 5 November 2019. The review includes four studies involving 342 adults who had received radiotherapy for the treatment of head and neck cancer. The review looks at three different ways to prevent ORN: ‐ the use of platelet‐rich plasma (PRP) in bone after removal of healthy teeth prior to radiotherapy. Plasma is a part of blood that contains special proteins that help the blood to clot, and PRP is concentrated plasma which supports cell growth. Injecting PRP into damaged tissue may stimulate the body to grow new, healthy cells to make it heal more quickly; ‐ taking out teeth because of tooth decay makes the risk of developing ORN greater. Preventing tooth decay in people having radiotherapy is very important. We looked at a study comparing using fluoride gel with a toothpaste with a higher level of fluoride than normal to prevent tooth decay after radiotherapy; ‐ hyperbaric oxygen therapy is breathing oxygen in a pressurized chamber to improve blood supply, which may help heal damaged tissue. Two studies compared the use of hyperbaric oxygen therapy for taking out teeth or placing dental implants with antibiotics. Antibiotics are drugs which stop or slow the growth of bacteria. Key results One study showed no reduction in ORN when using platelet‐rich plasma in bone after the removal of healthy teeth. Another study found no difference between fluoride gel and toothpaste with a higher level of fluoride than normal as no cases of ORN were reported. A third study showed that treatment with hyperbaric oxygen therapy caused a reduction in the development of ORN in comparison to patients treated with antibiotics following the removal of teeth. The fourth study found no difference between combined hyperbaric oxygen therapy and antibiotics compared to antibiotics alone. Harmful effects of the different interventions were not reported clearly or were not important. Certainty of the evidence The level of certainty we have in these findings is very low. This was due to high risk of bias, not all studies mentioning important details, and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to stop ORN of the jaws from happening or making it less severe in adults receiving head and neck radiotherapy. We suggest that more, well‐conducted, and bigger studies including more people, should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "El‐Rabbany, M, Duchnay, M, Raziee, HR, Zych, M, Tenenbaum, H, Shah, PS, Azarpazhooh, A", "articleTypes": [], "doi": "10.1002/14651858.CD011559.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.103Z" }, { "id": "c59ae2d8-e7ae-4fd8-98f9-175bdcbc748b", "pmid": "", "title": "Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years", "imported": false, "abstract": "Abstract - Background Extensive evidence exists showing analgesic effects of sweet solutions for newborns and infants. It is less certain if the same analgesic effects exist for children one year to 16 years of age. This is an updated version of the original Cochrane review published in Issue 10, 2011 (Harrison 2011) titled Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. Objectives To determine the efficacy of sweet tasting solutions or substances for reducing needle‐related procedural pain in children beyond one year of age. Search methods Searches were run to the end of June 2014. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, the NHS Economic Evaluation Database, MEDLINE, EMBASE, PsycINFO, and ACP Journal Club (all via OvidSP), and CINAH (via EBSCOhost). We applied no language restrictions. Selection criteria Published or unpublished randomised controlled trials (RCT) in which children aged one year to 16 years, received a sweet tasting solution or substance for needle‐related procedural pain. Control conditions included water, non‐sweet tasting substances, pacifier, distraction, positioning/containment, breastfeeding, or no treatment. Data collection and analysis Outcome measures included crying duration, composite pain scores, physiological or behavioral pain indicators, self‐report of pain or parental or healthcare professional‐report of the child's pain. We reported mean differences (MD), weighted mean difference (WMD), or standardized mean difference (SMD) with 95% confidence intervals (CI) using fixed‐effect or random‐effects models as appropriate for continuous outcome measures. We reported risk ratio (RR), risk difference (RD), and the number needed to treat to benefit (NNTB) for dichotomous outcomes. We used the I 2 statistic to assess between‐study heterogeneity. Main results We included one unpublished and seven published studies (total of 808 participants); four more studies and 478 more participants than the 2011 review. Six trials included young children aged one to four years receiving sucrose or candy lollypops for immunisation pain compared with water or no treatment. Usual care included topical anaesthetics, upright parental holding, and distraction. All studies were well designed blinded RCTs, however, five of the six studies had a high risk of bias based on small sample sizes. Two studies included school‐aged children receiving sweet or unsweetened chewing gum before, or before and during, immunisation and blood collection. Both studies, conducted by the same author, had a high risk of bias based on small sample sizes. Results for the toddlers/pre‐school children were conflicting. Duration of cry, using a random‐effects model, was not significantly reduced by sweet taste (six trials, 520 children, WMD ‐15 seconds, 95% CI ‐54 to 24, I 2 = 94%). Composite pain score at time of first needle was reported in four studies (n = 121 children). The scores were not significantly different between the sucrose and control group (SMD ‐0.26, 95% CI ‐1.27 to 0.75, I 2 = 86%). A Children's Hospital of Eastern Ontario Pain Scale score > 4 was significantly less common in the sucrose group compared to the control group in one study (n = 472, RR 0.55, 95% CI 0.45 to 0.67; RD ‐0.29, 95% CI ‐0.37 to ‐0.20; NNTB 3, 95% CI 3 to 5; tests for heterogeneity not applicable. For school‐aged children, chewing sweet gum before needle‐related painful procedures (two studies, n = 111 children) or during the procedures (two studies, n = 103 children) did not significantly reduce pain scores. A comparison of the Faces Pain Scale scores in children chewing sweet gum before the procedures compared with scores of children chewing unsweetened gum revealed a WMD of ‐0.15 (95% CI ‐0.61 to 0.30). Similar results were found when comparing the chewing of sweet gum with unsweetened gum during the procedure (WMD 0.23, 95% CI ‐0.28 to 0.74). The Colored Analogue Scale for children chewing sweet gum compared to unsweetened gum before the procedure was not significantly different (WMD 0.24 (‐0.69 to 1.18)) nor was it different when children chewed the gum during the procedure (WMD 0.86 (95% CI ‐0.12 to 1.83)). There was no heterogeneity for any of these analyses in school‐aged children (I 2 = 0%). Authors' conclusions Based on the eight studies included in this systematic review update, two of which were subgroups of small numbers of eligible toddlers from larger studies, and three of which were pilot RCTs with small numbers of participants, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children between one and four years of age. Further rigorously conducted, adequately powered RCTs are warranted in this population. Based on the two studies by the same author, there was no evidence of analgesic effects of sweet taste in school‐aged children. As there are other effective evidence‐based strategies available to use in this age group, further trials are not warranted. Despite the addition of four studies in this review, conclusions have not changed since the last version of the review. Plain language summary Sweet taste to ease injection needle pain in children aged one to 16 years This is an updated version of the original Cochrane review published in Issue 10, 2011: Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. We re‐ran the search in October 2014. Review question: Do sweet tasting solutions reduce pain during needles in children aged from one to 16 years, compared to no treatment, water, other non‐sweet solutions, or other interventions such as non‐nutritive sucking (babies) or sweet foods or chewing gum (children), topical anaesthetics, music, and distraction? Background: Small amounts of sweet tasting sugar solutions given orally to babies before and during painful needles significantly reduces distress. However it was not known if the same pain‐reducing effects of sweet solutions occurred in children older than one year of age. We therefore examined studies looking at pain‐reducing effects of sweet solutions such as sucrose or glucose for painful needle procedures in children aged one to 16 years. Search date: We searched the literature for published and unpublished studies up to October 2014. Study characteristics : We found six studies focused on young children aged one to four years; two of these studies were included in the original review and four were new studies. The two studies included in the original review used a low concentration of sucrose, just 12%, which is not considered sweet enough for the pain reducing effects. Three of the four new studies were small pilot studies, conducted to inform full trials, and only one study of sweet solutions in young children included large numbers of children. When we compared results of all six studies, only two showed that sugar water (sucrose) reduced pain during injections. However, the four studies that showed no effect all included small numbers of children, therefore they were not considered large enough to detect significant differences in pain. Further well conducted trials with large enough numbers of young children are needed to work out if sweet taste effectively reduces their pain and distress during needles. For older school‐aged children, there were two studies published by the same author, both of which were included in the original review. Neither study showed that sweet taste helped to reduce pain. As other studies show that strategies such as distraction and topical anaesthetics can effectively reduce needle pain in school‐aged children, further studies of sweet taste for pain management in school‐aged children are not warranted. Study funding sources : Of the six studies including young children, two did not acknowledge receipt of research funding. For the remaining four: a state‐wide nursing fund supported two of the pilot studies, an internal research institute provided support for the remaining pilot study and another study was supported in part by a Maternal and Child Health grant. The two studies including school‐aged children, conducted by the same author, were supported by a grant from the Canadian Institutes of Health Research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Harrison, D, Yamada, J, Adams‐Webber, T, Ohlsson, A, Beyene, J, Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD008408.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.725Z" }, { "id": "c5a2c58c-bf72-44c4-81f9-bbd54aaaf061", "pmid": "", "title": "Nebuliser systems for drug delivery in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Nebuliser systems are used to deliver medications to the lungs, to control the symptoms and the progression of lung disease in people with cystic fibrosis (CF). There are many different nebulised‐medications prescribed for people with CF and there are many different types of nebuliser systems. Some of these nebulised medications are licenced for, and can be taken via only one type of nebuliser system; some are licensed for, and can be taken via more than one type of nebuliser system. This is an update to a previous systematic review. Objectives To assess the time efficiency, effectiveness, safety, cost and impact of use (e.g. burden of care, adherence, quality of life (QoL)) of different nebuliser systems, when used with different inhaled medications for people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching of relevant journals and abstract books containing conference proceedings. We searched the reference lists of each study for additional publications and approached the manufacturers of both nebuliser systems and nebulised medications for published and unpublished data. We also searched online trial registries. Date of the most recent search: 9 August 2023. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing nebuliser systems, including conventional nebulisers, vibrating mesh technology (VMT) systems, adaptive aerosol delivery (AAD) systems and ultrasonic nebuliser systems. Data collection and analysis Two review authors independently assessed studies for inclusion. They also independently extracted data and assessed the risk of bias. A third review author assessed studies where agreement could not be reached. They assessed the certainty of the evidence using GRADE. Main results The search identified 216 studies with 33 of these (2270 participants) included in the review. These studies compared the delivery of tobramycin, colistin, dornase alfa, hypertonic saline and other solutions through the different nebuliser systems in children and adults with CF. This review demonstrates variability in the delivery of medication depending on the nebuliser system used. The certainty of the evidence ranged from low to very low. Some conventional nebuliser systems providing higher flows, higher respirable fractions, and smaller particles decrease treatment time, increase deposition (the amount of drug reaching the lung), and may be preferred by people with CF, as compared to other conventional nebuliser systems providing lower flows, lower respirable fractions and larger particles. Newer nebuliser systems using AAD, or VMT (or both) reduce treatment time compared to conventional systems. Deposition (as a percentage of priming dose) with AAD is greater than with conventional systems. VMT systems may give greater deposition than conventional systems when measuring sputum levels. The available data indicate that these newer systems are safe when used with an appropriate priming dose, which may be different to the priming dose used for conventional systems. There is an indication that adherence is maintained or improved and that individuals prefer AAD or VMT systems, but also that some nebuliser systems using VMT may be subject to increased system failures. There is limited, unclear evidence on the impact of different nebuliser systems on lung function and a lack of data on the impact of different nebuliser systems on our outcomes of quality of life (QoL), adverse effects, respiratory exacerbations and related implications, adherence, satisfaction, cost and device reliability. Authors' conclusions Newer technologies e.g. AAD and VMT have advantages over conventional systems in terms of treatment time, deposition as a percentage of priming dose, preference and adherence. Data are lacking for all varieties of medications which are used in CF care, including different inhaled antibiotics or hypertonic saline, with all delivery (nebuliser system) possibilities. Long‐term RCTs are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as QoL and burden of care), safe and effective dosing levels of a wide variety of medications, clinical outcomes (such as hospitalisations and need for antibiotics), and an economic evaluation of their use. There are insufficient data to establish whether one nebuliser system is better than another overall. Clinicians should be aware of the variability in the performance of different nebuliser systems, compatibility with specific nebulised medication, and they must work with their patients to choose the best nebuliser system for each individual. This is likely to be an ongoing process as the needs and circumstances of each individual change over time. Plain language summary Nebulisers for giving medication for cystic fibrosis Key messages 1. Newer technologies have advantages over conventional systems in terms of treatment time, the amount of drug reaching the lung, preference, and adherence. 2. Not all medications used in treating cystic fibrosis can be delivered by the same nebuliser, and data are lacking for some of the different nebuliser and drug combinations. 3. Long‐term studies are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as quality of life, effective dosing levels, and hospitalisations). What is cystic fibrosis? People with cystic fibrosis have sticky mucus in their lungs which is difficult to get rid of and which can cause infection if it builds up. How are nebulisers used as part of cystic fibrosis treatment? Nebulisers are used to deliver medications to the lungs to control the symptoms and the progression of disease. They change a liquid medication into a mist, so it can be breathed in. Different types of nebuliser systems are used with different medications. 1. Conventional systems ‐ a machine pushes out a constant mist of medication at high speed. 2. Adaptive aerosol delivery systems ‐ like conventional systems, also monitor breathing and only deliver the medication while the person is breathing in. 3. Vibrating mesh technology systems move the liquid medication through a metal mesh to generate a mist with similar‐sized droplets which is delivered constantly. 4. Adaptive aerosol delivery systems with vibrating mesh technology combination between the two systems. 5. Ultrasonic systems use a crystal to vibrate the liquid medication at a high frequency and turn it into a mist which is delivered constantly. What did we want to find out? How well do the different nebuliser systems deliver each inhaled medication (how much medication is delivered into the lungs, and what is the impact on lung function)? Are they safe or do they have any side effects? We also wanted to know how these nebuliser systems affect people with cystic fibrosis in terms of treatment burden, adherence to treatment regimen and their quality of life. What did we do? We assessed 33 studies (2270 adults and children)and compared different types of nebuliser systems for delivering: tobramycin; colistin; dornase alfa; hypertonic saline; and other nebulised medications. What did we find? Conventional systems which have faster air flows and smaller medication droplets decrease treatment time and deliver more medication into the lung than other conventional systems, which have slower air flows and larger medication droplets. Nebulisers use newer technologies, e.g. adaptive aerosol delivery system or vibrating mesh technology, deliver the medication faster and may deliver more of the medication into the lung. These newer systems appear safe when used with the correct amount of medication, which may be different to that used in a conventional system. Some studies suggest that people with cystic fibrosis may prefer these newer systems and may take more of their medication when using them. However, more research is needed into what dose of medication is needed for the different systems, which medications suit which technologies best and how these newer nebuliser technologies affect quality of life, burden of treatment, additional treatment needed (such as oral or intravenous antibiotics) and treatment costs. What are the limitations of the evidence? There were lots of different systems studied, and often we only had a few studies for each comparison. Also, the studies we found were quite small and results varied. We had concerns around at least some aspects of the design of every study which affected our confidence in the results. How up to date is this evidence? We last looked for evidence on 9 August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Stanford, G, Morrison, L, Brown, C", "articleTypes": [], "doi": "10.1002/14651858.CD007639.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.807Z" }, { "id": "c5b881b0-1515-425a-b4aa-84891d07d4c9", "pmid": "", "title": "Thoracic imaging tests for the diagnosis of COVID‐19", "imported": false, "abstract": "Abstract - Background Our March 2021 edition of this review showed thoracic imaging computed tomography (CT) to be sensitive and moderately specific in diagnosing COVID‐19 pneumonia. This new edition is an update of the review. Objectives Our objectives were to evaluate the diagnostic accuracy of thoracic imaging in people with suspected COVID‐19; assess the rate of positive imaging in people who had an initial reverse transcriptase polymerase chain reaction (RT‐PCR) negative result and a positive RT‐PCR result on follow‐up; and evaluate the accuracy of thoracic imaging for screening COVID‐19 in asymptomatic individuals. The secondary objective was to assess threshold effects of index test positivity on accuracy. Search methods We searched the COVID‐19 Living Evidence Database from the University of Bern, the Cochrane COVID‐19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID‐19 publications through to 17 February 2021. We did not apply any language restrictions. Selection criteria We included diagnostic accuracy studies of all designs, except for case‐control, that recruited participants of any age group suspected to have COVID‐19. Studies had to assess chest CT, chest X‐ray, or ultrasound of the lungs for the diagnosis of COVID‐19, use a reference standard that included RT‐PCR, and report estimates of test accuracy or provide data from which we could compute estimates. We excluded studies that used imaging as part of the reference standard and studies that excluded participants with normal index test results. Data collection and analysis The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using QUADAS‐2. We presented sensitivity and specificity per study on paired forest plots, and summarized pooled estimates in tables. We used a bivariate meta‐analysis model where appropriate. Main results We included 98 studies in this review. Of these, 94 were included for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eight studies were included for assessing the rate of positive imaging in individuals with initial RT‐PCR negative results and positive RT‐PCR results on follow‐up, and 10 studies were included for evaluating the accuracy of thoracic imaging for imagining asymptomatic individuals. For all 98 included studies, risk of bias was high or unclear in 52 (53%) studies with respect to participant selection, in 64 (65%) studies with respect to reference standard, in 46 (47%) studies with respect to index test, and in 48 (49%) studies with respect to flow and timing. Concerns about the applicability of the evidence to: participants were high or unclear in eight (8%) studies; index test were high or unclear in seven (7%) studies; and reference standard were high or unclear in seven (7%) studies. Imaging in people with suspected COVID‐19 We included 94 studies. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All studies used RT‐PCR alone or in combination with other criteria (for example, clinical signs and symptoms, positive contacts) as the reference standard for the diagnosis of COVID‐19. For chest CT (69 studies, 28285 participants, 14,342 (51%) cases), sensitivities ranged from 45% to 100%, and specificities from 10% to 99%. The pooled sensitivity of chest CT was 86.9% (95% confidence interval (CI) 83.6 to 89.6), and pooled specificity was 78.3% (95% CI 73.7 to 82.3). Definition for index test positivity was a source of heterogeneity for sensitivity, but not specificity. Reference standard was not a source of heterogeneity. For chest X‐ray (17 studies, 8529 participants, 5303 (62%) cases), the sensitivity ranged from 44% to 94% and specificity from 24 to 93%. The pooled sensitivity of chest X‐ray was 73.1% (95% CI 64.1 to 80.5), and pooled specificity was 73.3% (95% CI 61.9 to 82.2). Definition for index test positivity was not found to be a source of heterogeneity. Definition for index test positivity and reference standard were not found to be sources of heterogeneity. For ultrasound of the lungs (15 studies, 2410 participants, 1158 (48%) cases), the sensitivity ranged from 73% to 94% and the specificity ranged from 21% to 98%. The pooled sensitivity of ultrasound was 88.9% (95% CI 84.9 to 92.0), and the pooled specificity was 72.2% (95% CI 58.8 to 82.5). Definition for index test positivity and reference standard were not found to be sources of heterogeneity. Indirect comparisons of modalities evaluated across all 94 studies indicated that chest CT and ultrasound gave higher sensitivity estimates than X‐ray (P = 0.0003 and P = 0.001, respectively). Chest CT and ultrasound gave similar sensitivities (P = 0.42). All modalities had similar specificities (CT versus X‐ray P = 0.36; CT versus ultrasound P = 0.32; X‐ray versus ultrasound P = 0.89). Imaging in PCR‐negative people who subsequently became positive For rate of positive imaging in individuals with initial RT‐PCR negative results, we included 8 studies (7 CT, 1 ultrasound) with a total of 198 participants suspected of having COVID‐19, all of whom had a final diagnosis of COVID‐19. Most studies (7/8) evaluated CT. Of 177 participants with initially negative RT‐PCR who had positive RT‐PCR results on follow‐up testing, 75.8% (95% CI 45.3 to 92.2) had positive CT findings. Imaging in asymptomatic PCR‐positive people For imaging asymptomatic individuals, we included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with a total of 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. For chest CT (7 studies, 3134 participants, 315 (10%) cases), the pooled sensitivity was 55.7% (95% CI 35.4 to 74.3) and the pooled specificity was 91.1% (95% CI 82.6 to 95.7). Authors' conclusions Chest CT and ultrasound of the lungs are sensitive and moderately specific in diagnosing COVID‐19. Chest X‐ray is moderately sensitive and moderately specific in diagnosing COVID‐19. Thus, chest CT and ultrasound may have more utility for ruling out COVID‐19 than for differentiating SARS‐CoV‐2 infection from other causes of respiratory illness. The uncertainty resulting from high or unclear risk of bias and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results. Plain language summary How accurate is chest imaging for diagnosing COVID‐19? Why is this question important? People with suspected COVID‐19 need to know quickly whether they are infected, so they can receive appropriate treatment, self‐isolate, and inform close contacts. Currently, a formal diagnosis of COVID‐19 requires a laboratory test (RT‐PCR) of nose and throat samples. RT‐PCR requires specialist equipment and takes at least 24 hours to produce a result. It is not completely accurate, and may require a second RT‐PCR or a different test to confirm diagnosis. Clinicians may use chest imaging to diagnose people who have COVID‐19 symptoms, while awaiting RT‐PCR results or when RT‐PCR results are negative, and the person has COVID‐19 symptoms. This is the fourth version of this review. What did we want to find out? We wanted to know whether chest imaging is accurate enough to diagnose COVID‐19 in people with suspected infection; we included studies in people with suspected COVID‐19 only and excluded studies in people with confirmed COVID‐19. We also wanted to assess the accuracy of chest imaging for screening asymptomatic people. The evidence is up to date to 17 February 2021. What are chest imaging tests? X‐rays or scans produce an image of the organs and structures in the chest. ‐ X‐rays (radiography) use radiation to produce a 2‐D image. Usually done in hospitals, using fixed equipment by a radiographer; they can also be done on portable machines. ‐ Computed tomography (CT) scans use a computer to merge 2‐D X‐ray images and convert them to a 3‐D image. They require highly‐specialized equipment and are done in hospital by a specialist radiographer. ‐ Ultrasound scans use high‐frequency sound waves to produce an image. They can be done in hospitals or other healthcare settings, such as a doctor’s office. What did we do? We searched for studies that assessed the accuracy of chest imaging to diagnose COVID‐19 in people of any age with suspected COVID‐19. We included studies with ‘symptomatic' or 'mixed populations'. What did we find? We found 94 studies with 37,631 participants (of whom 19,768 (53%) had a final diagnosis of COVID‐19) for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID‐19. Eighty‐seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All 94 studies used RT‐PCR either alone or in combination with other criteria (such as clinical signs and symptoms, or positive contacts) as the reference standard for the diagnosis of COVID‐19. Chest CT: suspected people Pooled results showed that chest CT (69 studies) correctly diagnosed COVID‐19 in 87% of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 21% of people who did not have COVID‐19. Chest X‐ray: suspected people Pooled results showed that chest X‐ray (17 studies) correctly diagnosed COVID‐19 in 73 % of people who had COVID‐19. However, it incorrectly identified COVID‐19 in 27% of people who did not have COVID‐19. Lung ultrasound: suspected people Pooled results showed that lung ultrasound (15 studies) correctly diagnosed COVID‐19 in 87% of people with COVID‐19. However, it incorrectly diagnosed COVID‐19 in 24% of people who did not have COVID‐19. Screening asymptomatic people We included 10 studies (7 CT, 1 X‐ray, 2 ultrasound) with 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID‐19. Pooled results of seven studies, showed that CT correctly diagnosed COVID‐19 in 56% of people who had COVID‐19, and incorrectly identified COVID‐19 in 8% of people who did not have COVID‐19. How reliable are the results? The studies differed from each other and used different methods to report their results. Very few studies directly compared one type of imaging test with another. Also, the risk of bias was high or unclear in about half of all included studies. Therefore, it is difficult to draw confident conclusions. What does this mean? The evidence suggests that chest CT and ultrasound are better at ruling out COVID‐19 infection than distinguishing it from other respiratory problems. So, their usefulness may be limited to excluding COVID‐19 infection rather than differentiating it from other causes of lung infection. In addition, chest CT imaging had poor sensitivity and high specificity for detecting asymptomatic individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ebrahimzadeh, S, Islam, N, Dawit, H, Salameh, J-P, Kazi, S, Fabiano, N, Treanor, L, Absi, M, Ahmad, F, Rooprai, P, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013639.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.805Z" }, { "id": "c5b98389-c066-45f5-828b-8eb22f94bb60", "pmid": "", "title": "Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia", "imported": false, "abstract": "Abstract - Background Fibromyalgia is a clinically defined chronic condition of unknown etiology characterized by chronic widespread pain that often co‐exists with sleep disturbances, cognitive dysfunction and fatigue. People with fibromyalgia often report high disability levels and poor quality of life. Drug therapy, for example, with serotonin and noradrenaline reuptake inhibitors (SNRIs), focuses on reducing key symptoms and improving quality of life. This review updates and extends the 2013 version of this systematic review. Objectives To assess the efficacy, tolerability and safety of serotonin and noradrenaline reuptake inhibitors (SNRIs) compared with placebo or other active drug(s) in the treatment of fibromyalgia in adults. Search methods For this update we searched CENTRAL, MEDLINE, Embase, the US National Institutes of Health and the World Health Organization (WHO) International Clinical Trials Registry Platform for published and ongoing trials and examined the reference lists of reviewed articles, to 8 August 2017. Selection criteria We selected randomized, controlled trials of any formulation of SNRIs against placebo or any other active treatment of fibromyalgia in adults. Data collection and analysis Three review authors independently extracted data, examined study quality, and assessed risk of bias. For efficacy, we calculated the number needed to treat for an additional beneficial outcome (NNTB) for pain relief of 50% or greater and of 30% or greater, patient's global impression to be much or very much improved, dropout rates due to lack of efficacy, and the standardized mean differences (SMD) for fatigue, sleep problems, health‐related quality of life, mean pain intensity, depression, anxiety, disability, sexual function, cognitive disturbances and tenderness. For tolerability we calculated number needed to treat for an additional harmful outcome (NNTH) for withdrawals due to adverse events and for nausea, insomnia and somnolence as specific adverse events. For safety we calculated NNTH for serious adverse events. We undertook meta‐analysis using a random‐effects model. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We added eight new studies with 1979 participants for a total of 18 included studies with 7903 participants. Seven studies investigated duloxetine and nine studies investigated milnacipran against placebo. One study compared desvenlafaxine with placebo and pregabalin. One study compared duloxetine with L‐carnitine. The majority of studies were at unclear or high risk of bias in three to five domains. The quality of evidence of all comparisons of desvenlafaxine, duloxetine and milnacipran versus placebo in studies with a parallel design was low due to concerns about publication bias and indirectness, and very low for serious adverse events due to concerns about publication bias, imprecision and indirectness. The quality of evidence of all comparisons of duloxetine and desvenlafaxine with other active drugs was very low due to concerns about publication bias, imprecision and indirectness. Duloxetine and milnacipran had no clinically relevant benefit over placebo for pain relief of 50% or greater: 1274 of 4104 (31%) on duloxetine and milnacipran reported pain relief of 50% or greater compared to 591 of 2814 (21%) participants on placebo (risk difference (RD) 0.09, 95% confidence interval (CI) 0.07 to 0.11; NNTB 11, 95% CI 9 to 14). Duloxetine and milnacipran had a clinically relevant benefit over placebo in patient's global impression to be much or very much improved: 888 of 1710 (52%) on duloxetine and milnacipran (RD 0.19, 95% CI 0.12 to 0.26; NNTB 5, 95% CI 4 to 8) reported to be much or very much improved compared to 354 of 1208 (29%) of participants on placebo. Duloxetine and milnacipran had a clinically relevant benefit compared to placebo for pain relief of 30% or greater. RD was 0.10; 95% CI 0.08 to 0.12; NNTB 10, 95% CI 8 to 12. Duloxetine and milnacipran had no clinically relevant benefit for fatigue (SMD ‐0.13, 95% CI ‐0.18 to ‐0.08; NNTB 18, 95% CI 12 to 29), compared to placebo. There were no differences between either duloxetine or milnacipran and placebo in reducing sleep problems (SMD ‐0.07; 95 % CI ‐0.15 to 0.01). Duloxetine and milnacipran had no clinically relevant benefit compared to placebo in improving health‐related quality of life (SMD ‐0.20, 95% CI ‐0.25 to ‐0.15; NNTB 11, 95% CI 8 to 14). There were 794 of 4166 (19%) participants on SNRIs who dropped out due to adverse events compared to 292 of 2863 (10%) of participants on placebo (RD 0.07, 95% CI 0.04 to 0.10; NNTH 14, 95% CI 10 to 25). There was no difference in serious adverse events between either duloxetine, milnacipran or desvenlafaxine and placebo (RD ‐0.00, 95% CI ‐0.01 to 0.00). There was no difference between desvenlafaxine and placebo in efficacy, tolerability and safety in one small trial. There was no difference between duloxetine and desvenlafaxine in efficacy, tolerability and safety in two trials with active comparators (L‐carnitine, pregabalin). Authors' conclusions The update did not change the major findings of the previous review. Based on low‐ to very low‐quality evidence, the SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in the frequency of pain relief of 50% or greater, but for patient's global impression to be much or very much improved and in the frequency of pain relief of 30% or greater there was a clinically relevant benefit. The SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in improving health‐related quality of life and in reducing fatigue. Duloxetine and milnacipran did not significantly differ from placebo in reducing sleep problems. The dropout rates due to adverse events were higher for duloxetine and milnacipran than for placebo. On average, the potential benefits of duloxetine and milnacipran in fibromyalgia were outweighed by their potential harms. However, a minority of people with fibromyalgia might experience substantial symptom relief without clinically relevant adverse events with duloxetine or milnacipran. We did not find placebo‐controlled studies with other SNRIs than desvenlafaxine, duloxetine and milnacipran. Plain language summary Serotonin and noradrenaline reuptake inhibitors for fibromyalgia Bottom line Duloxetine and milnacipran may reduce pain in people with fibromyalgia. However, some of these people may also experience side effects, such as nausea (feeling sick) and drowsiness. A minority of people with fibromyalgia experience symptom relief without side effects from duloxetine and milnacipran. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as problems with sleep, thinking and exhaustion. They often report poor health‐related quality of life. There is no cure for fibromyalgia at present, so the treatments aim to relieve the symptoms and to improve health‐related quality of life. Serotonin and noradrenaline are chemicals which are produced by the human body, involved in the regulation of pain, sleep and mood. Low concentrations of serotonin have been reported in people with fibromyalgia. Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a class of antidepressants that increase the concentration of serotonin and noradrenaline in the brain. Study characteristics In August 2017, we updated our searches for clinical trials in which SNRIs were used to treat symptoms of fibromyalgia in adults. We found eight new studies since the previous version of the review. In total, we found 18 studies with 7903 participants. The studies were four to 27 weeks long and compared the SNRIs desvenlafaxine, duloxetine and milnacipran against a fake medication (placebo). We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. Key results and quality of the evidence Duloxetine and milnacipran were better than placebo in reducing pain by 50% or more and in improving global well‐being (low‐quality evidence). Duloxetine and milnacipran were better than placebo in improving health‐related quality of life and in reducing fatigue (low‐quality evidence). Duloxetine and milnacipran were not better than placebo in reducing sleep problems (low‐quality evidence). More people dropped out of the trial due to side effects with duloxetine and milnacipran than with placebo (low‐quality evidence). More people reported nausea and drowsiness with duloxetine and milnacipran than with placebo (low‐quality evidence). Duloxetine, milnacipran and placebo did not differ in the frequency of serious side effects experienced (very low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Welsch, P; Üçeyler, N; Klose, P; Walitt, B; Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD010292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "c5c4bf11-8d56-401e-9c03-9bdba876390b", "pmid": "", "title": "Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long‐term central venous catheters in infants and children", "imported": false, "abstract": "Abstract - Background Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015. Objectives To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long‐term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC). Data collection and analysis Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random‐effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review. Main results We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin. Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC‐associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC‐associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low‐certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate‐certainty evidence), and not reported in the remaining studies. Authors' conclusions The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC‐associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains. Plain language summary Replacing heparin flushing with saline flushing to prevent complications in long‐term central venous catheters in children Background A central venous catheter (CVC) is a long, thin, flexible tube which is inserted into a large central vein. This enables access to the blood stream for people with serious medical conditions to receive medications and fluids, as well as the collection of blood specimens. Long‐term CVCs are used to access the blood system in children with complex medical conditions like cancer. To stop the catheter from becoming blocked it is usual to use heparin, a drug that prevents clots forming, to flush the catheter. However, some studies have shown that heparin is not necessary, and that normal saline (a sterile salt water solution) can be safely used instead. Heparin may be associated with complications, such as bleeding and infection, along with higher costs for healthcare providers. While the complications such as infections and occlusions are uncommon, practices vary around the world and there are many inconsistencies regarding the best flush solution to use to prevent complications in long‐term catheters. Study characteristics and key results This review included randomised controlled trials (clinical studies where people were randomly assigned into one of two or more treatment groups) that compared the use of saline and heparin to prevent blockage, and other complications related to long‐term catheters. The evidence is current to 9 April 2019. Two review authors independently reviewed the studies. We included four studies with a total of 255 participants in the review. The four trials were all undertaken in large teaching (tertiary) hospitals, and directly compared the use of saline and heparin. The studies were, however, very different in the way they compared saline and heparin, with different concentrations of heparin and different frequencies of flushes reported. We were able to combine the results of two studies: the analysis showed imprecise results for the blocking of catheters and blood stream infections for normal saline versus heparin. One study reported the duration of catheter placement to be similar between the two study arms. Certainty of the evidence The overall certainty of the evidence ranged from moderate to very low. There was high risk of bias for blinding, there were differences between the studies methods and interventions, inconsistent results between the studies, and not all studies reported all outcomes of interest. We found there was not enough evidence to determine which solution, saline or heparin, is more effective for reducing complications. Further research is required and is likely to have an important impact in this area. This review is an update of a review first published in 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bradford, NK; Edwards, RM; Chan, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD010996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "c5c6eff9-f45c-47ff-970a-b1d0932eeca3", "pmid": "", "title": "Mechanisms Underlying Predictors of Success From Obesity Surgery", "imported": false, "abstract": "The goal of this project is to identify predictors of success in the treatment of obesity after bariatric surgery. The specific aims of this proposal are to:", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.268Z" }, { "id": "c5cedf87-90b2-49fe-85a5-f2b8fcf0f789", "pmid": "", "title": "Immunostimulants for preventing respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are a major cause of childhood morbidity and mortality. Immunostimulants (IS) may reduce the incidence of ARTIs. Objectives To determine the efficacy and safety of IS in preventing ARTIs in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 1, which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to February week 4, 2011), EMBASE (1990 to February 2011), Google Scholar (2009 to February 2011), Scopus (2009 to February 2011), PASCAL (1990 to February 2010), SciSearch (1990 to February 2010) and IPA (1990 to February 2010). Selection criteria We included all comparative randomized controlled trials (RCTs) which enrolled participants less than 18 years of age. The intervention was IS medication, administered by any method, compared to placebo to prevent ARTIs. Data collection and analysis We analyzed the outcome on ARTIs both as the mean number of ARTIs by group and as a percent change in the rate of ARTIs. We undertook meta‐analyses using a random‐effects model and presented results as mean differences (MD) with 95% confidence intervals (CI). Two review authors independently assessed the search results and risk of bias, and extracted data. A funnel plot suggested there may be publication bias in the identified trials. Main results Thirty‐five placebo‐controlled trials (4060 participants) provided data in a form suitable for inclusion in the meta‐analyses. When compared with placebo, the use of IS was shown to reduce ARTIs measured as the total numbers of ARTIs (MD ‐1.24; 95% CI ‐1.54 to ‐0.94) and the difference in ARTI rates (MD ‐38.84%; 95% CI ‐46.37% to ‐31.31%). Trial quality was generally poor and a high level of statistical heterogeneity was evident. The subgroup analysis of bacterial IS, D53 and OM‐85 studies produced similar results, with lower heterogeneity. No difference in adverse events was evident between the placebo and IS groups. Authors' conclusions This review shows that IS reduce the incidence of ARTIs by 40% on average in susceptible children. Studies in healthy children are not available. Although the safety profile in the studies was good, some IS may be unsafe. ARTI‐susceptible children may benefit from IS treatment. Further high‐quality trials are needed and we encourage national health authorities to conduct large, multicentre, double‐blind, placebo‐controlled RCTs on the role of IS in preventing ARTIs in children. Plain language summary Immunostimulants to prevent acute respiratory tract infections in children Acute respiratory tract infections (ARTIs) are responsible for 19% of all deaths in children younger than five years of age, mainly in low‐income countries in Africa, Asia and Latin America. In high‐income countries ARTIs are among the most frequent illnesses, leading to 20% of medical consultations, 30% of days lost from work and 75% of antibiotic prescriptions. In the USA the total cost of non‐influenza‐related viral ARTIs is around $40 billion annually, while the corresponding cost for influenza is US $87.1 billion. The main signs and symptoms of ARTIs include sneezing, runny nose, sore throat, cough and malaise. Children living in rural communities, not attending daycare centres, suffer about seven ARTI episodes in the first year of life; eight ARTIs per year from the ages of one to four; six per year aged five to nine; and five per year aged 10 to 19. Children exposed to risks factors, such as attendance at daycare centres, overcrowding, contact with older siblings, smoking at home and lack of breast feeding, may suffer more ARTIs. Several treatments have been used to reduce the incidence of ARTIs (vitamin A, vitamin C, zinc, antibiotics). Among them are immunostimulants (herbal extracts, bacterial extracts, synthetic compounds), which aim to increase the immune defences of the respiratory tract. We searched for clinical trials of immunostimulants to prevent ARTIs in children compared to placebo. Our review includes 35 studies with 4060 participants. However, the quality of many of the studies was poor and the results were very diverse. By combining results, immunostimulants reduced 1.24 ARTIs in a six‐month period, equivalent to a 39% reduction in ARTIs compared to the placebo group. Only 20 studies provided adequate data on adverse events: the most frequent were rash, nausea, vomiting, abdominal pain and diarrhea. The main limitations of this review were the poor methodological quality and diverse trial results. We conclude that ARTI‐susceptible children may benefit from immunostimulants, but more high‐quality studies are needed. We suggest that national health authorities conduct high‐quality randomized controlled trials to assess the true effects of immunostimulant preparations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Del‐Rio‐Navarro, BE, Espinosa‐Rosales, FJ, Flenady, V, Sienra‐Monge, JJL", "articleTypes": [], "doi": "10.1002/14651858.CD004974.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.746Z" }, { "id": "c5e43cf9-6e9e-4d7e-aee0-97af6eba1865", "pmid": "", "title": "Fish oil for kidney transplant recipients", "imported": false, "abstract": "Abstract - Background Calcineurin inhibitors used in kidney transplantation for immunosuppression have adverse effects that may contribute to nephrotoxicity and increased cardiovascular risk profile. Fish oils are rich in very long chain omega‐3 fatty acids, which may reduce nephrotoxicity by improving endothelial function and reduce rejection rates through their immuno‐modulatory effects. They may also modify the cardiovascular risk profile. Hence, fish oils may potentially prolong graft survival and reduce cardiovascular mortality. Objectives This review aimed to look at the benefits and harms of fish oil treatment in ameliorating the kidney and cardiovascular adverse effects of CNI‐based immunosuppressive therapy in kidney transplant recipients. Search methods We searched the Cochrane Kidney and Transplant Specialised Register (up to 17 March 2016) through contact with the Information Specialist using search terms relevant to this review. Selection criteria All randomised controlled trials (RCTs) and quasi‐RCTs of fish oils in kidney transplant recipients on a calcineurin inhibitor‐based immunosuppressive regimen. RCTs of fish oil versus statins were included. Data collection and analysis Data was extracted and the quality of studies assessed by two authors, with differences resolved by discussion with a third independent author. Dichotomous outcomes were reported as risk ratio (RR) and continuous outcome measures were reported as the mean difference (MD) with 95% confidence intervals using the random effects model. Heterogeneity was assessed using a Chi 2 test on n‐1 degrees of freedom and the I 2 statistic. Data not suitable for pooling were tabulated and described. Main results Fifteen studies (733 patients) were suitable for analysis. All studies were small and had variable methodology. Fish oil did not significantly affect patient or graft survival, acute rejection rates, or calcineurin inhibitor toxicity when compared to placebo. Overall SCr was significantly lower in the fish oil group compared to placebo (5 studies, 237 participants: MD ‐30.63 µmol/L, 95% CI ‐59.74 to ‐1.53; I 2 = 88%). In the subgroup analysis, this was only significant in the long‐course (six months or more) group (4 studies, 157 participants: MD ‐37.41 µmol/L, 95% CI ‐69.89 to ‐4.94; I 2 = 82%). Fish oil treatment was associated with a lower diastolic blood pressure (4 studies, 200 participants: MD ‐4.53 mm Hg, 95% CI ‐7.60 to ‐1.45) compared to placebo. Patients receiving fish oil for more than six months had a modest increase in HDL (5 studies, 178 participants: MD 0.12 mmol/L, 95% CI 0.03 to 0.21; I 2 = 47%) compared to placebo. Fish oil effects on lipids were not significantly different from low‐dose statins. There was insufficient data to analyse cardiovascular outcomes. Fishy aftertaste and gastrointestinal upset were common but did not result in significant patient drop‐out. Authors' conclusions There is insufficient evidence from currently available RCTs to recommend fish oil therapy to improve kidney function, rejection rates, patient survival or graft survival. The improvements in HDL cholesterol and diastolic blood pressure were too modest to recommend routine use. To determine a benefit in clinical outcomes, future RCTs will need to be adequately powered with these outcomes in mind. Plain language summary Fish oil for kidney transplant recipients This review set out to assess any benefit or harm in using fish oil to reduce the risk of kidney damage and heart disease in people who have had a kidney transplant and are receiving standard drugs to prevent rejection. Information from 15 studies was used and showed that fish oils provide a slight improvement in HDL cholesterol and diastolic blood pressure. These studies did not provide enough information on the differences in the risk of death, heart disease, kidney transplant rejection or kidney function between patients receiving fish oils and those receiving placebo. There appeared to be no harmful effects of taking fish oil. The benefits of taking fish oil after a kidney transplant are a mild improvement in some heart disease risk factors. There was not enough information to show any benefit in preventing heart disease or reduction in kidney function. Larger, better studies are needed before regular use of fish oil can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lim, AKH, Manley, KJ, Roberts, MA, Fraenkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD005282.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.757Z" }, { "id": "c5f45b6e-3d1e-499e-93b3-402daf0c0345", "pmid": "", "title": "Zinc for the common cold", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Singh, M, Das, RR", "articleTypes": [], "doi": "10.1002/14651858.CD001364.pub5 AB - Reason for withdrawal from publication September 2016 updated withdrawal notice 
 This Cochrane Review was withdrawn in April 2015, and this withdrawal notice was updated in September 2016. The review was withdrawn as result of comments submitted via the Cochrane Library by Harri Hemilä in February 2015. Hemilä identified multiple errors in this Cochrane Review and made allegations of plagiarism of text and data from a previously published systematic review (Hemilä H. Zinc Lozenges may shorten the duration of colds: a systematic review. Open Respiratory Medicine Journal 2011;5:51‐58. dx.doi.org/10.2174/1874306401105010051). The comments referred to the version of this review first published in June 2013 (Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2013;(6):CD001364. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001364.pub4/full) . The Cochrane Acute Respiratory Infections Group, which maintains the review, withdrew the review in April 2015, pending an assessment of the errors reported, and the group referred the allegations of plagiarism to the Editor in Chief. The Editor in Chief notified the authors of the concerns, and followed the Committee for Publication Ethics (COPE) guidelines. Replication of text was identified in the Cochrane Review. This was limited to copying of short phrases and was acknowledged by the authors. The level of text plagiarism was minor and at a level that would be addressed by a correction. The Editor in Chief carried out further investigation into the alleged plagiarism of data, with the co‐operation of the review authors, who provided supplementary information in support of their work. The allegations related to the derivation of means and standard deviations of data from some of the included studies. Although the authors acknowledge and cite the Hemilä 2011 review, the Editor in Chief considered that the authors’ explanation regarding some similarities in presented data between the two reviews was not conclusive. This version of the review will therefore remain withdrawn. April 2015 withdrawal notice 
 This review was withdrawn due to concerns raised via the feedback mechanism regarding the calculation and analysis of data in the review in April 2015. Whilst it is not unusual for reviews to be withdrawn, the editorial group took the view that it would be better to take a cautious approach and explore the source and calculation of data used in the analysis in more detail, rather than keep the review on the Cochrane Database of Systematic Reviews for the time being. The editorial group responsible for this previously published document have withdrawn it from publication.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.059Z" }, { "id": "c60e3057-79ae-476b-bea0-f37f98b78945", "pmid": "", "title": "Smectite for acute infectious diarrhoea in children", "imported": false, "abstract": "Abstract - Background As mortality secondary to acute infectious diarrhoea has decreased worldwide, the focus shifts to adjuvant therapies to lessen the burden of disease. Smectite, a medicinal clay, could offer a complementary intervention to reduce the duration of diarrhoea. Objectives To assess the effects of smectite for treating acute infectious diarrhoea in children. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Pubmed), Embase (Ovid), LILACS, reference lists from studies and previous reviews, and conference abstracts, up to 27 June 2017. Selection criteria Randomized and quasi‐randomized trials comparing smectite to a control group in children aged one month to 18 years old with acute infectious diarrhoea. Data collection and analysis Two review authors independently screened abstracts and the full texts for inclusion, extracted data, and assessed risk of bias. Our primary outcomes were duration of diarrhoea and clinical resolution at day 3. We summarized continuous outcomes using mean differences (MD) and dichotomous outcomes using risk ratios (RR), with 95% confidence intervals (CI). Where appropriate, we pooled data in meta‐analyses and assessed heterogeneity. We explored publication bias using a funnel plot. Main results Eighteen trials with 2616 children met our inclusion criteria. Studies were conducted in both ambulatory and in‐hospital settings, and in both high‐income and low‐ or middle‐income countries. Most studies included children with rotavirus infections, and half included breastfed children. Smectite may reduce the duration of diarrhoea by approximately a day (MD ‐24.38 hours, 95% CI ‐30.91 to ‐17.85; 14 studies; 2209 children; low‐certainty evidence); may increase clinical resolution at day 3 (risk ratio (RR) 2.10, 95% CI 1.30 to 3.39; 5 trials; 312 children; low‐certainty evidence); and may reduce stool output (MD ‐11.37, 95% CI ‐21.94 to ‐0.79; 3 studies; 634 children; low‐certainty evidence). We are uncertain whether smectite reduces stool frequency, measured as depositions per day (MD ‐1.33, 95% CI ‐2.28 to ‐0.38; 3 studies; 954 children; very low‐certainty evidence). There was no evidence of an effect on need for hospitalization (RR 0.93, 95% CI 0.75 to 1.15; 2 studies; 885 children; low‐certainty evidence) and need for intravenous rehydration (RR 0.77, 95% CI 0.54 to 1.11; 1 study; 81 children; moderate‐certainty evidence). The most frequently reported side effect was constipation, which did not differ between groups (RR 4.71, 95% CI 0.56 to 39.19; 2 studies; 128 children; low‐certainty evidence). No deaths or serious adverse effects were reported. Authors' conclusions Based on low‐certainty evidence, smectite used as an adjuvant to rehydration therapy may reduce the duration of diarrhoea in children with acute infectious diarrhoea by a day; may increase cure rate by day 3; and may reduce stool output, but has no effect on hospitalization rates or need for intravenous therapy. 2 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (27 Jun, 2017) were included Plain language summary Smectite for treating children with acute diarrhoea What is the aim of this review? The aim of this Cochrane Review was to find out if smectite (or diosmectite), a medicinal clay commonly prescribed to people who have diarrhoea in order to reduce their stool output, helps children with acute diarrhoea. We collected and analysed all relevant studies to answer this question and found 18 relevant studies. Key messages Giving smectite to children with acute diarrhoea may reduce its duration. However, more high‐quality studies are still needed, including studies that assess different causes of diarrhoea and the economic effects of this treatment. What was studied in the review? Acute diarrhoea is one of the most common diseases in children. It is usually caused by a viral infection. The main aim of treatment is to maintain a good level of hydration. This is achieved with oral rehydration solutions, and few children need to be hospitalized or require intravenous rehydration. Still, even with proper hydration, having loose stools is a burden for both parents and patients. Smectite may help by reducing inflammation in the gut; by acting as a barrier to reduce the penetration of toxins; or by increasing water absorption. What are the main results? We found 18 relevant studies with 2616 children that were conducted in both high‐income and low‐ or middle‐income countries. These studies compared children receiving smectite with children receiving routine care or a placebo (a pill or liquid that contains no medicine). Eight studies were funded by the manufacturer. Smectite may reduce the duration of diarrhoea by one day (low‐certainty evidence); may increase the number of children cured by day 3 (low‐certainty evidence); and may slightly reduce the quantity of loose stools (low‐certainty evidence). We are uncertain whether smectite has an effect on how many stools children have (very low‐certainty evidence). It may not have an effect on how many children need to be hospitalized (low‐certainty evidence), and probably does not have an effect on how many children need intravenous rehydration (moderate‐certainty evidence). We found no reports of serious adverse effects. Minor adverse effects included constipation, vomiting, and bad taste, but these did not differ between groups. How up‐to‐date is this review? We searched for studies published up to 27 June 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pérez‐Gaxiola, G, Cuello‐García, CA, Florez, ID, Pérez‐Pico, VM", "articleTypes": [], "doi": "10.1002/14651858.CD011526.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.752Z" }, { "id": "c65c704b-976a-4124-9208-8bc063dcaa66", "pmid": "", "title": "A Multicenter, RandoMized, Double-blind, Parallel-grOup, Afluxin® Stick Pack vs. Inactive contRol Clinical Investigation to Evaluate the Performance and Safety in Patients With Gastroesophageal Reflux Disease (GERD)", "imported": false, "abstract": "Gastroesophageal Reflux Disease (GERD) is a chronic condition in which stomach acid flows back into the esophagus, causing irritation and inflammation. GERD is categorized into Nonerosive Reflux Disease (NERD), Erosive Esophagitis (EE), and Barrett's esophagus (BE). Common symptoms include heartburn and acid regurgitation. Lifestyle factors such as smoking, obesity, and Helicobacter pylori infection can increase the risk of developing GERD. The clinical management of GERD typically involves Proton Pump Inhibitors (PPIs) therapy, which, although effective, may not benefit all patients and can be associated with long-term risks. The American College of Gastroenterology (ACG) suggests PPIs discontinuation or on-demand therapy for uncomplicated GERD after an 8-week trial. However, evidence indicates that PPIs are used more frequently, often long-term and in high doses, and not necessarily according to recommendations. Moreover, the availability of Over-The-Counter (OTC) PPIs has led to prolonged use by patients without medical guidance. Concerns have been raised due to potential side effects of long-term PPIs use, including enteric, respiratory, and urinary tract infections, as well as an increased risk of vitamin and mineral deficiencies and osteoporosis.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.249Z" }, { "id": "c6605a2c-26c7-42e7-968d-8d1aaf149c72", "pmid": "", "title": "Interventions for the management of dry mouth: topical therapies", "imported": false, "abstract": "Abstract - Background Xerostomia (the feeling of dry mouth) is a common symptom especially in older adults. Causes of dry mouth include medications, autoimmune disease (Sjögren's Syndrome), radiotherapy or chemotherapy for cancer, hormone disorders and infections. Objectives To determine which topical treatments for dry mouth are effective in reducing this symptom. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (28 October 2011), The Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 4 2011), MEDLINE via OVID (1950 to 28 October 2011), EMBASE via OVID (1980 to 28 October 2011), CINAHL via EBSCO (1980 to 28 October 2011), AMED via OVID (1985 to 28 October 2011), CANCERLIT via PubMed (1950 to 28 October 2011). Selection criteria We included randomised controlled trials of topical interventions such as lozenges, sprays, mouthrinses, gels, oils, chewing gum or toothpastes for the treatment of dry mouth symptom. We classified interventions into two broad categories, saliva stimulants and saliva substitutes, and these were compared with either placebo or another intervention. We included both parallel group and crossover trials. Data collection and analysis Two or more review authors independently carried out data extraction and assessed risk of bias. Trial authors were contacted for additional information as required. Main results Thirty‐six randomised controlled trials involving 1597 participants met the inclusion criteria. Two trials compared saliva stimulants to placebo, nine trials compared saliva substitutes to placebo, five trials compared saliva stimulants directly with saliva substitutes, 18 trials directly compared two or more saliva substitutes, and two trials directly compared two or more saliva stimulants. Only one trial was at low risk of bias and 17 were at high risk of bias. Due to the range of interventions, comparisons and outcome measures in the trials, meta‐analysis was possible for only a few comparisons. Oxygenated glycerol triester (OGT) saliva substitute spray shows evidence of effectiveness compared to an electrolyte spray (standardised mean difference (SMD) 0.77, 95% confidence interval (CI) 0.38 to 1.15) which corresponds to approximately a mean difference of 2 points on a 10‐point visual analogue scale (VAS) for mouth dryness. Both integrated mouthcare systems (toothpaste + gel + mouthwash) and oral reservoir devices show promising results but there is insufficient evidence at present to recommend their use. Although chewing gum is associated with increased saliva production in the majority of those with residual capacity, there is no evidence that gum is more or less effective than saliva substitutes. Authors' conclusions There is no strong evidence from this review that any topical therapy is effective for relieving the symptom of dry mouth. OGT spray is more effective than an aqueous electrolyte spray (SMD 0.77, 95% CI 0.38 to 1.15) which is approximately equivalent to a mean difference of 2 points on a 10‐point VAS scale for mouth dryness. Chewing gums appear to increase saliva production in those with residual secretory capacity and may be preferred by patients, but there is no evidence that gum is better or worse than saliva substitutes. Integrated mouthcare systems and oral reservoir devices may be helpful but further research is required to confirm this. Well designed, adequately powered randomised controlled trials of topical interventions for dry mouth, which are designed and reported according to CONSORT guidelines, are required to provide evidence to guide clinical care. For many people the symptom of dry mouth is a chronic problem and trials should evaluate whether treatments are palatable, effective in reducing xerostomia, as well as the long‐term effects of treatments on quality of life of those with chronic dry mouth symptoms. Plain language summary Interventions for the management of dry mouth: topical therapies Dry mouth is a common problem with a range of causes. The symptom may be due to a reduction in the quantity of saliva produced, or a change in the composition of saliva, but a feeling of dry mouth may also be present in people with normal saliva production. Radiotherapy or chemotherapy for head and neck cancers, and diseases such as Sjögren's Syndrome, may result in reduced saliva production. Many commonly prescribed medications are associated with a feeling of dry mouth, despite normal saliva production. As well as difficulty in speaking, chewing and swallowing, prolonged dry mouth may result in increased risk of tooth decay and reduced quality of life. In many sufferers dry mouth cannot be cured, but effective ways for people to manage dry mouth symptoms are available. Many topical treatments (applied directly to the inside of the mouth) such as sprays, lozenges, mouthrinses, gels, oils, chewing gum or toothpastes have been evaluated in this review, but there is no strong evidence that any topical treatment is effective for relieving the sensation of dry mouth. Oxygenated glycerol triester (OGT) saliva substitute spray is more effective than a water based electrolyte spray. A gel‐releasing device worn in the mouth, or a mouthcare system might be effective but more research is needed. Chewing gum increases saliva production but there is no evidence that gum is better or worse than saliva substitutes. Acidic products and those containing sugar should be avoided.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Furness, S; Worthington, HV; Bryan, G; Birchenough, S; McMillan, R", "articleTypes": [], "doi": "10.1002/14651858.CD008934.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "c661df0e-8fd8-4208-9e69-645b0e9b881d", "pmid": "", "title": "Ipilimumab or FOLFOX in Combination With Nivolumab and Trastuzumab in Previously Untreated HER2 Positive Locally Advanced or Metastatic EsophagoGastric Adenocarcinoma", "imported": false, "abstract": "The INTEGA study assesses therapy Options for advanced or metastatic esophagogastric Adenocarcinoma in patients overexpressing human epidermal receptor type 2 (HER2 positive patients). Current treatment options in this situation include chemotherapy based palliative treatment in combination withTrastuzumab.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.157Z" }, { "id": "c6855976-ca45-46c8-b179-4670d3460a5a", "pmid": "", "title": "Zinc for the common cold", "imported": false, "abstract": "Reason for withdrawal from publication September 2016 updated withdrawal notice 
 This Cochrane Review was withdrawn in April 2015, and this withdrawal notice was updated in September 2016. The review was withdrawn as result of comments submitted via the Cochrane Library by Harri Hemilä in February 2015. Hemilä identified multiple errors in this Cochrane Review and made allegations of plagiarism of text and data from a previously published systematic review (Hemilä H. Zinc Lozenges may shorten the duration of colds: a systematic review. Open Respiratory Medicine Journal 2011;5:51‐58. dx.doi.org/10.2174/1874306401105010051). The comments referred to the version of this review first published in June 2013 (Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2013;(6):CD001364. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001364.pub4/full) . The Cochrane Acute Respiratory Infections Group, which maintains the review, withdrew the review in April 2015, pending an assessment of the errors reported, and the group referred the allegations of plagiarism to the Editor in Chief. The Editor in Chief notified the authors of the concerns, and followed the Committee for Publication Ethics (COPE) guidelines. Replication of text was identified in the Cochrane Review. This was limited to copying of short phrases and was acknowledged by the authors. The level of text plagiarism was minor and at a level that would be addressed by a correction. The Editor in Chief carried out further investigation into the alleged plagiarism of data, with the co‐operation of the review authors, who provided supplementary information in support of their work. The allegations related to the derivation of means and standard deviations of data from some of the included studies. Although the authors acknowledge and cite the Hemilä 2011 review, the Editor in Chief considered that the authors’ explanation regarding some similarities in presented data between the two reviews was not conclusive. This version of the review will therefore remain withdrawn. April 2015 withdrawal notice 
 This review was withdrawn due to concerns raised via the feedback mechanism regarding the calculation and analysis of data in the review in April 2015. Whilst it is not unusual for reviews to be withdrawn, the editorial group took the view that it would be better to take a cautious approach and explore the source and calculation of data used in the analysis in more detail, rather than keep the review on the Cochrane Database of Systematic Reviews for the time being. The editorial group responsible for this previously published document have withdrawn it from publication.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Singh, M; Das, RR", "articleTypes": [], "doi": "10.1002/14651858.CD001364.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "c6960d1f-6325-411f-88ed-ca3d17dd5314", "pmid": "", "title": "Immediate‐release versus controlled‐release carbamazepine in the treatment of epilepsy", "imported": false, "abstract": "Abstract - Background Carbamazepine (CBZ) is a commonly used drug for epilepsy that is associated with troublesome adverse events including dizziness, double vision, drowsiness, poor co‐ordination and unsteadiness. These adverse events often occur during peaks in drug plasma concentration. These adverse events may limit the daily dose of CBZ that can be tolerated and reduce the chances of seizure control in patients who require high doses. A controlled‐release formulation of CBZ delivers the same dose over a longer period of time when compared to a standard immediate‐release formulation, thereby reducing post‐dose peaks in CBZ plasma concentration and potentially reducing adverse events. This is an updated version of the original Cochrane review published in Issue 12, 2014. Objectives To determine the efficacy of immediate‐release CBZ (IR CBZ) versus controlled‐release CBZ (CR CBZ) in patients diagnosed with epilepsy. The following review questions were investigated.
 (1) For newly diagnosed patients commencing CBZ, how do IR and CR formulations compare for efficacy and tolerability?
 (2) For patients on established treatment with IR CBZ but experiencing unacceptable adverse events, what is the effect on seizure control and the tolerability of a switch to a CR formulation versus remaining on the IR formulation? Search methods We searched the Cochrane Epilepsy Group Specialized Register, CENTRAL, and MEDLINE (Ovid) from inception to 30 August 2016. Selection criteria Randomised controlled trials comparing IR CBZ to CR CBZ in patients commencing monotherapy and patients presently treated with IR CBZ but experiencing unacceptable adverse events. Primary outcome measures included measures of seizure frequency, incidence of adverse events, proportion of patients with treatment failure and quality of life measures. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted the data and recorded relevant information on a standardised data extraction form. We used the Cochrane risk of bias tool to assess the methodological quality of included studies. The heterogeneity of the included trials with respect to the reporting of outcomes resulted in only a narrative, descriptive analysis being possible for both the categorical and time‐to‐event data. Main results Ten trials (296 participants) fulfilled the criteria for inclusion in this review. Only one study had a low risk of bias. Two studies had a high risk of bias and the rest of the studies were rated as unclear risk of bias. One trial included patients with newly diagnosed epilepsy and nine included patients on treatment with IR CBZ. Eight trials reported heterogeneous measures of seizure frequency with conflicting results. A statistically significant difference was observed in only one trial, with patients prescribed CR CBZ experiencing fewer seizures than patients prescribed IR CBZ. Nine trials reported measures of adverse events. There was a trend in favour of CR CBZ with four trials reporting a statistically significant reduction in adverse events compared to IR CBZ. A further two trials reported fewer adverse events with CR CBZ but the reduction was not statistically significant. One trial found no difference in adverse events, and another trial reported more adverse events in the CR CBZ group than the IR CBZ group, although the increase was not statistically significant. Authors' conclusions For this update no new eligible studies were identified and the conclusions drawn from the initial review remain unchanged. At present, data from trials do not confirm or refute an advantage for CR CBZ over IR CBZ for seizure frequency or adverse events in patients with newly diagnosed epilepsy. For trials involving epilepsy patients already prescribed IR CBZ, no conclusions can be drawn concerning the superiority of CR CBZ with respect to seizure frequency. There is a trend for CR CBZ to be associated with fewer adverse events when compared to IR CBZ. A change to CR CBZ may therefore be a worthwhile strategy in patients with acceptable seizure control on IR CBZ but experiencing unacceptable adverse events. The included trials were of small size and of poor methodological quality limiting the validity of this conclusion. Randomised controlled trials comparing CR CBZ to IR CBZ and using clinically relevant outcomes are required to inform the choice of CBZ preparation for patients with newly diagnosed epilepsy. Plain language summary Fast‐release versus slow‐release carbamazepine as medication for patients with epilepsy Background Epilepsy is a common brain disorder that is often treated with carbamazepine. With treatment, people often have fewer seizures but many people experience side effects. When carbamazepine is swallowed it is taken into the blood stream quickly and there is a sharp rise of drug levels in the blood. These 'peaks' may be associated with side effects such as dizziness, double vision, drowsiness, unsteadiness and poor co‐ordination. A type of carbamazepine that releases the medication into the body slowly may lessen these 'peaks' in the blood levels, possibly meaning fewer side effects. This review compared studies looking at the differences between a 'fast‐release' carbamazepine and a 'slow‐release' carbamazepine. Participants To be included in this review, all participants had to be diagnosed with epilepsy and be either just starting carbamazepine treatment or be already on it but with intolerable side effects. The participants could be of any age or gender. Studies Ten trials with a total of 296 people with epilepsy were included in the review. All 10 trials were randomised controlled trials (patients were compared in randomly assigned groups). All of the studies had at least two groups, one group taking fast‐release carbamazepine and one group taking slow‐release carbamazepine, and some also had a control group (a group of non‐epileptic people). The evidence is current to August 2016. Results Just one of 10 studies found a significant difference between the two carbamazepine types in the number of seizures experienced, with patients prescribed the slow‐release carbamazepine experiencing fewer seizures than patients prescribed the fast‐release drug. Patients taking slow‐release carbamazepine tended to experience fewer side effects. Quality of the evidence Out of the 10 trials in the review, only one study was judged to be of 'good' quality, and so the evidence in this review was rated as low quality. It must be stressed that there are not many studies assessing the differences between these two carbamazepine types and more studies are needed before we can make a definitive conclusion about one over the other.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, G; Saunders, M; Rigby, A; Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007124.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "c6af2920-18a0-43b7-80c3-fec3b30cd8fa", "pmid": "", "title": "Interventions to reduce harm from continued tobacco use", "imported": false, "abstract": "Abstract - Background Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced‐exposure tobacco products (PREPs), as an alternative to cigarettes. Objectives To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long‐term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco? Search methods We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free‐text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. Selection criteria Randomized or quasi‐randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention. Data collection and analysis We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long‐term smoking abstinence), using fixed‐effect models. Where it was not possible to meta‐analyse data, we summarized findings narratively. Main results Twenty‐four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically‐heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as ‘low’ or ‘very low’, due to imprecision and indirectness. A ‘low’ grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A ‘very low’ grade means we are very uncertain about the estimate. Authors' conclusions People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high‐quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high‐quality RCTs are conducted, and that these also measure the long‐term health effects of treatments. Plain language summary Can smokers be helped to reduce the harm caused by cigarette smoking by smoking fewer cigarettes or using different tobacco products? Background The best thing to do to reduce the harms caused by smoking is to quit, but some people may not want to do this or may feel that they are unable to stop smoking completely. Cutting down the number of cigarettes smoked daily or using different tobacco products, such as chewing tobacco or low‐tar cigarettes, may reduce some of the harm caused by smoking. It may also help people to stop smoking completely in the long term. On the other hand, reducing smoking or using other tobacco products may not improve health and could reduce a person's motivation to quit smoking altogether. It is important that we review the evidence to find out whether these approaches could help smokers who do not want to or cannot quit to reduce the harm caused by their smoking. We were mainly interested in whether these approaches improved the health of smokers, but also looked at smoking reduction and quitting rates. Study characteristics We found 20 randomised controlled trials that tested ways to help people to cut down the number of cigarettes they smoked. Some of these just advised smokers to smoke less, but most also provided them with a product to help them cut down: nicotine replacement therapy (NRT), varenicline, bupropion, electronic cigarettes (ecigs), or snus (a form of smokeless, oral tobacco). We also found four randomized controlled trials that tested the effects of using cigarettes designed to reduce the damage caused by smoking: reduced tar, carbon or nicotine cigarettes. Most of the studies used NRT to help people to reduce their smoking. All of the studies included people who were not planning to quit smoking soon. The research is current to October 2015. Key results Eight studies (with 3081 smokers) found that using NRT roughly doubled the likelihood of halving the number of cigarettes smoked each day, compared to using a placebo. Using NRT in this way also nearly doubled the likelihood of quitting completely. One trial each tested bupropion, varenicline, ecigs and snus to help reduce the harms caused by smoking, and there was no evidence that any of these treatments helped smokers to reduce the number of cigarettes they were smoking each day. This may be because there has not yet been enough research into these methods. Only one of the trials testing cigarettes designed to reduce risk measured their effect on the number of people quitting smoking. It found that people were not more likely to quit smoking if they used reduced‐nicotine cigarettes than if they smoked their usual cigarettes. We did not find any trials which reported the long‐term health effects of the treatments, and so it remains uncertain how much health benefit there is from reducing the number of cigarettes smoked each day or smoking cigarettes designed to be less harmful. Quality of evidence The tobacco industry funded three of the included studies of cigarettes designed to reduce risk. None of the studies looked at whether there had been a long‐term change in the health of the users. We rate the quality of the evidence looking at how many people quit smoking as 'low' or 'very low', generally because the findings are based on a small number of studies. We need more studies to investigate methods of reducing the harm caused by continued smoking. These need to measure the health of the users over a long period.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lindson‐Hawley, N; Hartmann‐Boyce, J; Fanshawe, TR; Begh, R; Farley, A; Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD005231.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "c6be08ed-6f97-41e6-ad71-9bdcef2c972f", "pmid": "", "title": "Fortification of maize flour with iron for controlling anaemia and iron deficiency in populations", "imported": false, "abstract": "Abstract - Background Approximately 800 million women and children have anaemia, a condition thought to cause almost 9% of the global burden of years lived with disability. Around half this burden could be amenable to interventions that involve the provision of iron. Maize (corn) is one of the world's most important cereal grains and is cultivated across most of the globe. Several programmes around the world have fortified maize flour and other maize‐derived foodstuffs with iron and other vitamins and minerals to combat anaemia and iron deficiency. Objectives To assess the effects of iron fortification of maize flour, corn meal and fortified maize flour products for anaemia and iron status in the general population. Search methods We searched the following international and regional sources in December 2017 and January 2018: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE (R) In Process; Embase; Web of Science (both the Social Science Citation Index and the Science Citation Index); CINAHL Ebsco; POPLINE; AGRICOLA ( agricola.nal.usda.gov ); BIOSIS (ISI); Bibliomap and TRoPHI; IBECS; Scielo; Global Index Medicus ‐ AFRO (includes African Index Medicus); EMRO (includes Index Medicus for the Eastern Mediterranean Region); LILACS; PAHO (Pan American Health Library); WHOLIS (WHO Library); WPRO (includes Western Pacific Region Index Medicus); IMSEAR, Index Medicus for the South‐East Asian Region; IndMED, Indian medical journals; and the Native Health Research Database. We searched clinicaltrials.gov and the International Clinical Trials Registry Platform ( ICTRP ) for any ongoing or planned studies on 17 January 2018 and contacted authors of such studies to obtain further information or eligible data if available. For assistance in identifying ongoing or unpublished studies, we also contacted relevant international organisations and agencies working in food fortification on 9 August 2016. Selection criteria We included cluster‐ or individually randomised controlled trials and observational studies. Interventions included (central/industrial) fortification of maize flour or corn meal with iron alone or with other vitamins and minerals and provided to individuals over 2 years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies and assessed the risk of bias of the included studies. Trial designs with a comparison group were included to assess the effects of interventions. Trial designs without a control or comparison group (uncontrolled before‐and‐after studies) were included for completeness but were not considered in assessments of the overall effectiveness of interventions or used to draw conclusions regarding the effects of interventions in the review. Main results Our search yielded 4529 records. After initial screening of titles and abstracts, we reviewed the full text of 75 studies (80 records). We included 5 studies and excluded 70. All the included studies assessed the effects of providing maize products fortified with iron plus other vitamins and minerals versus unfortified maize flour. No studies compared this intervention to no intervention or looked at the relative effect of flour and products fortified with iron alone (without other vitamins and minerals). Three were randomised trials involving 2610 participants, and two were uncontrolled before‐and‐after studies involving 849 participants. Only three studies contributed data for the meta‐analysis and included children aged 2 to 11.9 years and women. Compared to unfortified maize flour, it is uncertain whether fortifying maize flour or corn meal with iron and other vitamins and minerals has any effect on anaemia (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.58 to 1.40; 2 studies; 1027 participants; very low‐certainty evidence), or on the risk of iron deficiency (RR 0.75, 95% CI 0.49 to 1.15; 2 studies; 1102 participants; very low‐certainty evidence), haemoglobin concentration (mean difference (MD) 1.25 g/L, 95% CI −2.36 to 4.86 g/L; 3 studies; 1144 participants; very low‐certainty evidence) or ferritin concentrations (MD 0.48 µg/L, 95% CI −0.37 to 1.33 µg/L; 1 study; 584 participants; very low‐certainty evidence). None of the studies reported on any adverse effects. We judged the certainty of the evidence to be very low based on GRADE, so we are uncertain whether the results reflect the true effect of the intervention. We downgraded evidence due to high risk of selection bias and unclear risk of performance bias in one of two included studies, high heterogeneity and wide CIs crossing the line of no effect for anaemia prevalence and haemoglobin concentration. Authors' conclusions It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of anaemia or iron deficiency in children aged over 2 years or in adults. Moreover, the evidence is too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population, as the certainty of the evidence is very low. No studies reported on any adverse effects. Public organisations funded three of the five included studies, while the private sector gave grants to universities to perform the other two. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. The reduced number of studies, including only two age groups (children and women of reproductive age), as well as the limited number of comparisons (only one out of the four planned) constitute the main limitations of this review. Plain language summary Fortification of maize flour with iron for preventing anaemia and iron deficiency What is the aim of this review? The aim of this Cochrane Review was to determine the effects of fortifying maize flour, corn meal and fortified‐maize flour products with iron for anaemia and iron status in the general population. We searched for relevant published studies to answer this question and analysed all relevant information. Key messages It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We do not know whether fortifying maize flour with iron reduces anaemia in the general population, as the evidence was very unreliable. No studies reported on any harmful effects. What was studied in the review? Approximately 496 million non‐pregnant women, 32 million pregnant women, and 273 million children were thought to be anaemic as of 2011. Iron deficiency is considered to be the single most prevalent nutrient deficiency worldwide, but at least half this burden is considered responsive to interventions that involve providing people with iron. Fortification means adding vitamins and minerals to foods to increase their nutritional value. In public health, fortifying staple foods is considered one way of reducing micronutrient deficiencies without changing usual and culturally acceptable diets. Maize (corn) is one of the world's most important cereal grains. In sub‐Saharan Africa, some parts of Southeast Asia and Latin America, where iron deficiency is endemic, maize is a dietary staple for more than 200 million people. Fortification of maize flour with iron (and in some cases, other nutrients) is mandatory in Brazil, Costa Rica, El Salvador, Kenya, Mexico, Nigeria, Rwanda, South Africa, Tanzania, Uganda, the USA and Venezuela. What are the main results of the review? We found five relevant studies, but none looked at the effects of maize flour or maize flour products fortified with iron alone. Five studies compared the effects of maize flour or maize‐flour products fortified with iron plus other vitamins and minerals versus unfortified maize flours or maize‐flour products (not containing iron or any other vitamin and minerals). Three of these five studies randomly divided a collective total of 2302 children aged 2 to 12 years and 130 indigenous women into groups receiving fortified versus unfortified maize flour or corn flour. One study was from Kenya and the other two took place in Mexico. The remaining two studies did not provide data to assess the effects of fortification relative to a comparison group. Three of five of the included studies were funded by public organisations and two by funds granted by private sector to universities. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency in the general population. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population. How up‐to‐date is this review? We searched for studies that had been published up to 17 January 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Garcia‐Casal, MN, Peña‐Rosas, JP, De‐Regil, LM, Gwirtz, JA, Pasricha, SR", "articleTypes": [], "doi": "10.1002/14651858.CD010187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.740Z" }, { "id": "c6e5e68e-c3ab-45b4-8aff-1ec801eda013", "pmid": "", "title": "Oncology, Undernutrition and Sensoriality: Links, Mechanisms and Levers for Action - Study ONDES", "imported": false, "abstract": "Cancers of the upper aerodigestive tract account for around 4% of all malignant tumours worldwide. Colon and liver cancer are the most common digestive cancers. The epidemiology of liver cancer is changing, and the number of deaths from liver cancer has increased by 25% worldwide (Huang 2022). In France, around 19,000 cancers of the upper aerodigestive tract and 88,000 new cases of digestive cancer are diagnosed each year (colon cancer remains the most common) (Globocan 2020). Patients with these two types of cancer are at particularly high risk of undernutrition (Pressoir 2010; Gyan 2018).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.153Z" }, { "id": "c6effe59-c1d7-4159-96b9-19efe61f0afb", "pmid": "", "title": "Tobacco packaging design for reducing tobacco use", "imported": false, "abstract": "Abstract - Background Tobacco use is the largest single preventable cause of death and disease worldwide. Standardised tobacco packaging is an intervention intended to reduce the promotional appeal of packs and can be defined as packaging with a uniform colour (and in some cases shape and size) with no logos or branding, apart from health warnings and other government‐mandated information, and the brand name in a prescribed uniform font, colour and size. Australia was the first country to implement standardised tobacco packaging between October and December 2012, France implemented standardised tobacco packaging on 1 January 2017 and several other countries are implementing, or intending to implement, standardised tobacco packaging. Objectives To assess the effect of standardised tobacco packaging on tobacco use uptake, cessation and reduction. Search methods We searched MEDLINE, Embase, PsycINFO and six other databases from 1980 to January 2016. We checked bibliographies and contacted study authors to identify additional peer‐reviewed studies. Selection criteria Primary outcomes included changes in tobacco use prevalence incorporating tobacco use uptake, cessation, consumption and relapse prevention. Secondary outcomes covered intermediate outcomes that can be measured and are relevant to tobacco use uptake, cessation or reduction. We considered multiple study designs: randomised controlled trials, quasi‐experimental and experimental studies, observational cross‐sectional and cohort studies. The review focused on all populations and people of any age; to be included, studies had to be published in peer‐reviewed journals. We examined studies that assessed the impact of changes in tobacco packaging such as colour, design, size and type of health warnings on the packs in relation to branded packaging. In experiments, the control condition was branded tobacco packaging but could include variations of standardised packaging. Data collection and analysis Screening and data extraction followed standard Cochrane methods. We used different 'Risk of bias' domains for different study types. We have summarised findings narratively. Main results Fifty‐one studies met our inclusion criteria, involving approximately 800,000 participants. The studies included were diverse, including observational studies, between‐ and within‐participant experimental studies, cohort and cross‐sectional studies, and time‐series analyses. Few studies assessed behavioural outcomes in youth and non‐smokers. Five studies assessed the primary outcomes: one observational study assessed smoking prevalence among 700,000 participants until one year after standardised packaging in Australia; four studies assessed consumption in 9394 participants, including a series of Australian national cross‐sectional surveys of 8811 current smokers, in addition to three smaller studies. No studies assessed uptake, cessation, or relapse prevention. Two studies assessed quit attempts. Twenty studies examined other behavioural outcomes and 45 studies examined non‐behavioural outcomes (e.g. appeal, perceptions of harm). In line with the challenges inherent in evaluating standardised tobacco packaging, a number of methodological imitations were apparent in the included studies and overall we judged most studies to be at high or unclear risk of bias in at least one domain. The one included study assessing the impact of standardised tobacco packaging on smoking prevalence in Australia found a 3.7% reduction in odds when comparing before to after the packaging change, or a 0.5 percentage point drop in smoking prevalence, when adjusting for confounders. Confidence in this finding is limited, due to the nature of the evidence available, and is therefore rated low by GRADE standards. Findings were mixed amongst the four studies assessing consumption, with some studies finding no difference and some studies finding evidence of a decrease; certainty in this outcome was rated very low by GRADE standards due to the limitations in study design. One national study of Australian adult smoker cohorts (5441 participants) found that quit attempts increased from 20.2% prior to the introduction of standardised packaging to 26.6% one year post‐implementation. A second study of calls to quitlines provides indirect support for this finding, with a 78% increase observed in the number of calls after the implementation of standardised packaging. Here again, certainty is low. Studies of other behavioural outcomes found evidence of increased avoidance behaviours when using standardised packs, reduced demand for standardised packs and reduced craving. Evidence from studies measuring eye‐tracking showed increased visual attention to health warnings on standardised compared to branded packs. Corroborative evidence for the latter finding came from studies assessing non‐behavioural outcomes, which in general found greater warning salience when viewing standardised, than branded packs. There was mixed evidence for quitting cognitions, whereas findings with youth generally pointed towards standardised packs being less likely to motivate smoking initiation than branded packs. We found the most consistent evidence for appeal, with standardised packs rating lower than branded packs. Tobacco in standardised packs was also generally perceived as worse‐tasting and lower quality than tobacco in branded packs. Standardised packaging also appeared to reduce misperceptions that some cigarettes are less harmful than others, but only when dark colours were used for the uniform colour of the pack. Authors' conclusions The available evidence suggests that standardised packaging may reduce smoking prevalence. Only one country had implemented standardised packaging at the time of this review, so evidence comes from one large observational study that provides evidence for this effect. A reduction in smoking behaviour is supported by routinely collected data by the Australian government. Data on the effects of standardised packaging on non‐behavioural outcomes (e.g. appeal) are clearer and provide plausible mechanisms of effect consistent with the observed decline in prevalence. As standardised packaging is implemented in different countries, research programmes should be initiated to capture long term effects on tobacco use prevalence, behaviour, and uptake. We did not find any evidence suggesting standardised packaging may increase tobacco use. Plain language summary Can the use of standardised packaging for tobacco products reduce the use of tobacco? Background Tobacco use kills more people worldwide than any other preventable cause of death. The best way to reduce tobacco use is by stopping people from starting to use tobacco and encouraging and helping existing users to stop. This can be done by introducing policies that can reach a wide number of people in a country, together with offering individual treatment and support to individuals who are already using tobacco to help them to stop. Many countries have introduced bans on tobacco advertising but have not controlled the look of the tobacco pack itself. Tobacco packs can be colourful and attractive, with exciting new shapes and sizes. Standardised tobacco packaging is a government policy which removes these bright designs by, for example, only allowing tobacco packs to be in one colour, shape or size. Standardised packaging generally involves the use of the same uniform colour on all tobacco packs, with no brand imagery, and the brand name written in a specified font, colour and size. Health warnings and other information that governments wish to put on the packs can remain. Australia was the first country to introduce standardised tobacco packaging by December 2012. France was the second by January 2017. Several other countries are introducing standardised packaging or planning to do so. We examined whether standardised packaging reduces tobacco use. Study characteristics We searched nine databases for articles evaluating standardised packaging that had been already reviewed by academics and published before January 2016. We also checked references in those papers to other studies and contacted the authors where necessary. Key results We found 51 studies involving approximately 800,000 participants. These studies varied considerably. Some studies focused on the effect of standardised packaging in Australia, and included looking at overall smoking levels, whether smokers altered their behaviour such as by cutting down the number of cigarettes they smoked, and whether smokers were making more quit attempts. We also included experiments in which people used or viewed standardised tobacco packs and examined their responses, compared to when they were viewing branded packs. We also included studies that assessed people’s eye movements when they looked at different packs and how willing people were to buy, and how much they were willing to pay for, standardised compared to branded packs. Only five studies looked at our key outcomes. One study in Australia looked at data from 700,000 people before and after standardised packaging was introduced. This study found that there was a half a percentage point drop in the proportion of people who used tobacco after the introduction of standardised packaging, compared to before, when adjusting for other factors which could affect this. Four other studies looked at whether current smokers changed the number of cigarettes they smoked. Two studies from Australia looked at this, one using surveys which included 8811 current smokers, and found no change in the number of cigarettes smoked. The three smaller studies found mixed results. Two further studies looked at quit attempts and observed increases in these in Australia after standardised packaging was introduced. The remainder of the studies looked at other outcomes, and the most consistent finding was that standardised packaging reduced how appealing people found the packs compared with branded packs. No studies reported the number of people who quit using tobacco, the number of people who started using tobacco, or the number of people who returned to using tobacco after quitting. Quality of the evidence Certainty in these findings is limited for several reasons, including the difficulties involved in studying national policies like standardised packaging. However, findings suggesting standardised packaging may decrease tobacco use are supported by routine data from the Australian government and studies looking at other outcomes. For example, in our included studies people consistently found standardised packs less appealing than branded packs. We did not find any evidence suggesting standardised packaging may increase tobacco use.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "McNeill, A, Gravely, S, Hitchman, SC, Bauld, L, Hammond, D, Hartmann‐Boyce, J", "articleTypes": [], "doi": "10.1002/14651858.CD011244.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.746Z" }, { "id": "c6f2c7f4-aa57-4000-ac42-1f4a140c395e", "pmid": "", "title": "Chinese medicinal herbs for asymptomatic carriers of hepatitis B virus infection", "imported": false, "abstract": "Abstract - Background About 350 million people are chronically infected carriers of hepatitis B virus and are at a higher risk of serious illness and death from cirrhosis of the liver and liver cancer. Chinese medicinal herbs have been used widely for more than 2000 years to treat chronic liver disease. Objectives To assess whether Chinese medicinal herbs are effective and safe for treating asymptomatic carriers of hepatitis B virus. Search methods The trials registers of The Cochrane Hepato‐Biliary Group , The Cochrane Library , and The Cochrane Complementary Medicine Field were searched in combination with MEDLINE , EMBASE , and handsearches of Chinese journals and conference proceedings (October 2000). Selection criteria Randomised or quasi‐randomised trials (minimum follow‐up three months) in asymptomatic carriers of hepatitis B virus. Chinese medicinal herbs (single herb or compound of herbs) compared with placebo, no intervention, general non‐specific treatment, or interferon treatment. Trials of Chinese medicinal herbs plus interferon versus interferon alone were also included. Data collection and analysis Data were extracted independently by two authors. Analysis was performed by intention‐to‐treat where possible. Pre‐specified subgroup analyses were: ethnic origin, age at time of infection, and single herb or compound of herbs. Main results Three randomised clinical trials (307 patients) that followed patients for three months or more after the end of treatment were included. The methodological quality was poor. The herbal compound 'Jianpi Wenshen recipe' had significant effects on viral markers compared to interferon: relative risk 2.40 (95% CI 1.01 to 5.72) for clearance of serum HBsAg, 2.03 (95% CI 0.98 to 4.20) for clearance of HBeAg, and 2.54 (95% CI 1.13 to 5.70) for seroconversion of HBeAg to anti‐HBe. Phyllanthus amarus and Astragalus membranaceus showed no significant antiviral effect compared with placebo. Analysis of pooling eight randomised clinical trials with less than three months follow‐up did not show a significant benefit of Chinese medicinal herbs on viral markers. Data on long‐term clinical outcomes and quality of life were lacking. Authors' conclusions Based on one low quality trial, the medicinal herb 'Jianpi Wenshen recipe' may have an antiviral activity in asymptomatic carriers of hepatitis B virus. However, rigorous randomised, double‐blind, placebo‐controlled trials are needed before herbs should be used for this condition. Plain language summary Firm evidence for effect of Chinese medicinal herbs for asymptomatic hepatitis B virus carriers is still awaited Chinese medicinal herbs have a long history in the treatment of liver diseases. Three randomised clinical trials were included. Due to their poor methodologic quality and the existing small number of trials, there is currently insufficient evidence for treating asymptomatic hepatitis B virus carriers with Chinese medicinal herbs like the herbal compound 'Jianpi Wenshen recipe', Phyllanthus amarus and Astragalus membranaceus. Methodologically better and larger randomised trials are needed comparing medicinal herbs versus placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Liu, JP; McIntosh, H; Lin, H", "articleTypes": [], "doi": "10.1002/14651858.CD002231", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "c6f4323f-5072-43be-985f-e4fd9e57e48d", "pmid": "", "title": "Reduced dietary salt for the prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review that was first published in 2011 of the effects of reducing dietary salt intake, through advice to reduce salt intake or low‐sodium salt substitution, on mortality and cardiovascular events. Objectives 1. To assess the long‐term effects of advice and salt substitution, aimed at reducing dietary salt, on mortality and cardiovascular morbidity. 2. To investigate whether a reduction in blood pressure is an explanatory factor in the effect of such dietary interventions on mortality and cardiovascular outcomes. Search methods We updated the searches of CENTRAL (2013, Issue 4), MEDLINE (OVID, 1946 to April week 3 2013), EMBASE (OVID, 1947 to 30 April 2013) and CINAHL (EBSCO, inception to 1 April 2013) and last ran these on 1 May 2013. We also checked the references of included studies and reviews. We applied no language restrictions. Selection criteria Trials fulfilled the following criteria: (1) randomised, with follow‐up of at least six months, (2) the intervention was reduced dietary salt (through advice to reduce salt intake or low‐sodium salt substitution), (3) participants were adults and (4) mortality or cardiovascular morbidity data were available. Two review authors independently assessed whether studies met these criteria. Data collection and analysis A single author extracted data and assessed study validity, and a second author checked this. We contacted trial authors where possible to obtain missing information. We extracted events and calculated risk ratios (RRs) and 95% confidence intervals (CIs). Main results Eight studies met the inclusion criteria: three in normotensives (n = 3518) and five in hypertensives or mixed populations of normo‐ and hypertensives (n = 3766). End of trial follow‐up ranged from six to 36 months and the longest observational follow‐up (after trial end) was 12.7 years. The risk ratios (RR) for all‐cause mortality in normotensives were imprecise and showed no evidence of reduction (end of trial RR 0.67, 95% confidence interval (CI) 0.40 to 1.12, 60 deaths; longest follow‐up RR 0.90, 95% CI 0.58 to 1.40, 79 deaths n=3518) or in hypertensives (end of trial RR 1.00, 95% CI 0.86 to 1.15, 565 deaths; longest follow‐up RR 0.99, 95% CI 0.87 to 1.14, 674 deaths n=3085). There was weak evidence of benefit for cardiovascular mortality (hypertensives: end of trial RR 0.67, 95% CI 0.45 to 1.01, 106 events n=2656) and for cardiovascular events (hypertensives: end of trial RR 0.76, 95% CI 0.57 to 1.01, 194 events, four studies, n = 3397; normotensives: at longest follow‐up RR 0.84, 95% CI 0.64 to 1.10, 200 events; hypertensives: RR 0.77, 95% CI 0.58 to 1.02, 192 events; pooled analysis of six trials (RR 0.81, 95% CI 0.66 to 0.98; n = 5762). These findings were driven by one trial among retirement home residents that reduced salt intake in the kitchens of the homes, thereby not requiring individual behaviour change. Advice to reduce salt showed small reductions in systolic blood pressure (mean difference (MD) ‐1.15 mmHg, 95% CI ‐2.32 to 0.02 n=2079) and diastolic blood pressure (MD ‐0.80 mmHg, 95% CI ‐1.37 to ‐0.23 n=2079) in normotensives and greater reductions in systolic blood pressure in hypertensives (MD ‐4.14 mmHg, 95% CI ‐5.84 to ‐2.43 n=675), but no difference in diastolic blood pressure (MD ‐3.74 mmHg, 95% CI ‐8.41 to 0.93 n=675). Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Health‐related quality of life was assessed in one trial in normotensives, which reported significant improvements in well‐being but no data were presented. Authors' conclusions Despite collating more event data than previous systematic reviews of randomised controlled trials, there is insufficient power to confirm clinically important effects of dietary advice and salt substitution on cardiovascular mortality in normotensive or hypertensive populations. Our estimates of the clinical benefits from advice to reduce dietary salt are imprecise, but are larger than would be predicted from the small blood pressure reductions achieved. Further well‐powered studies would be needed to obtain more precise estimates. Our findings do not support individual dietary advice as a means of restricting salt intake. It is possible that alternative strategies that do not require individual behaviour change may be effective and merit further trials. Plain language summary Reduced dietary salt for the prevention of cardiovascular disease Cardiovascular disease includes heart attacks and strokes and is a major cause of premature death and disability. This is an update of a review first published in 2011. This review sets out to assess whether intensive support and encouragement to cut down on salt in foods, and substituting low‐sodium salt, reduces the risk of death or cardiovascular disease. This update includes two new studies and eliminates one problematic study, giving a total of eight trials with 7284 participants. Dietary advice and salt substitution did reduce the amount of salt eaten, which led to a small reduction in blood pressure by six months. There was weak evidence of benefit for cardiovascular events, but these findings were inconclusive and were driven by a single trial among retirement home residents, which reduced salt intake in the kitchens of the homes. The findings of our review do not mean that advising people to reduce salt should be stopped. However, additional measures ‐ reducing the amount of hidden salt in processed foods, for example – will make it much easier for people to achieve a lower salt diet. Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Further evidence of the effects of different ways of reducing dietary salt on clinical events is needed from experimental and observational studies to underpin public health policies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Adler, AJ, Taylor, F, Martin, N, Gottlieb, S, Taylor, RS, Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD009217.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.793Z" }, { "id": "c6f828ec-3685-484f-9756-e33c476a68ef", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies for treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). Objectives To assess the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for treating patients with COVID‐19, compared to an active comparator, placebo, or no intervention. To maintain the currency of the evidence, we will use a living systematic review approach. A secondary objective is to track newly developed SARS‐CoV‐2‐targeting mAbs from first tests in humans onwards. Search methods We searched MEDLINE, Embase, the Cochrane COVID‐19 Study Register, and three other databases on 17 June 2021. We also checked references, searched citations, and contacted study authors to identify additional studies. Between submission and publication, we conducted a shortened randomised controlled trial (RCT)‐only search on 30 July 2021. Selection criteria We included studies that evaluated SARS‐CoV‐2‐neutralising mAbs, alone or combined, compared to an active comparator, placebo, or no intervention, to treat people with COVID‐19. We excluded studies on prophylactic use of SARS‐CoV‐2‐neutralising mAbs. Data collection and analysis Two authors independently assessed search results, extracted data, and assessed risk of bias using the Cochrane risk of bias tool (RoB2). Prioritised outcomes were all‐cause mortality by days 30 and 60, clinical progression, quality of life, admission to hospital, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We identified six RCTs that provided results from 17,495 participants with planned completion dates between July 2021 and December 2031. Target sample sizes varied from 1020 to 10,000 participants. Average age was 42 to 53 years across four studies of non‐hospitalised participants, and 61 years in two studies of hospitalised participants. Non‐hospitalised individuals with COVID‐19 Four studies evaluated single agents bamlanivimab (N = 465), sotrovimab (N = 868), regdanvimab (N = 307), and combinations of bamlanivimab/etesevimab (N = 1035), and casirivimab/imdevimab (N = 799). We did not identify data for mortality at 60 days or quality of life. Our certainty of the evidence is low for all outcomes due to too few events (very serious imprecision). Bamlanivimab compared to placebo No deaths occurred in the study by day 29. There were nine people admitted to hospital by day 29 out of 156 in the placebo group compared with one out of 101 in the group treated with 0.7 g bamlanivimab (risk ratio (RR) 0.17, 95% confidence interval (CI) 0.02 to 1.33), 2 from 107 in the group treated with 2.8 g (RR 0.32, 95% CI 0.07 to 1.47) and 2 from 101 in the group treated with 7.0 g (RR 0.34, 95% CI 0.08 to 1.56). Treatment with 0.7 g, 2.8 g and 7.0 g bamlanivimab may have similar rates of AEs as placebo (RR 0.99, 95% CI 0.66 to 1.50; RR 0.90, 95% CI 0.59 to 1.38; RR 0.81, 95% CI 0.52 to 1.27). The effect on SAEs is uncertain. Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Bamlanivimab/etesevimab compared to placebo There were 10 deaths in the placebo group and none in bamlanivimab/etesevimab group by day 30 (RR 0.05, 95% CI 0.00 to 0.81). Bamlanivimab/etesevimab may decrease hospital admission by day 29 (RR 0.30, 95% CI 0.16 to 0.59), may result in a slight increase in any grade AEs (RR 1.15, 95% CI 0.83 to 1.59) and may increase SAEs (RR 1.40, 95% CI 0.45 to 4.37). Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Casirivimab/imdevimab compared to placebo Casirivimab/imdevimab may reduce hospital admissions or death (2.4 g: RR 0.43, 95% CI 0.08 to 2.19; 8.0 g: RR 0.21, 95% CI 0.02 to 1.79). We are uncertain of the effect on grades 3‐4 AEs (2.4 g: RR 0.76, 95% CI 0.17 to 3.37; 8.0 g: RR 0.50, 95% CI 0.09 to 2.73) and SAEs (2.4 g: RR 0.68, 95% CI 0.19 to 2.37; 8.0 g: RR 0.34, 95% CI 0.07 to 1.65). Mortality by day 30 and clinical progression/improvement of symptoms or development of severe symptoms were not reported. Sotrovimab compared to placebo We are uncertain whether sotrovimab has an effect on mortality (RR 0.33, 95% CI 0.01 to 8.18) and invasive mechanical ventilation (IMV) requirement or death (RR 0.14, 95% CI 0.01 to 2.76). Treatment with sotrovimab may reduce the number of participants with oxygen requirement (RR 0.11, 95 % CI 0.02 to 0.45), hospital admission or death by day 30 (RR 0.14, 95% CI 0.04 to 0.48), grades 3‐4 AEs (RR 0.26, 95% CI 0.12 to 0.60), SAEs (RR 0.27, 95% CI 0.12 to 0.63) and may have little or no effect on any grade AEs (RR 0.87, 95% CI 0.66 to 1.16). Regdanvimab compared to placebo Treatment with either dose (40 or 80 mg/kg) compared with placebo may decrease hospital admissions or death (RR 0.45, 95% CI 0.14 to 1.42; RR 0.56, 95% CI 0.19 to 1.60, 206 participants), but may increase grades 3‐4 AEs (RR 2.62, 95% CI 0.52 to 13.12; RR 2.00, 95% CI 0.37 to 10.70). 80 mg/kg may reduce any grade AEs (RR 0.79, 95% CI 0.52 to 1.22) but 40 mg/kg may have little to no effect (RR 0.96, 95% CI 0.64 to 1.43). There were too few events to allow meaningful judgment for the outcomes mortality by 30 days, IMV requirement, and SAEs. Hospitalised individuals with COVID‐19 Two studies evaluating bamlanivimab as a single agent (N = 314) and casirivimab/imdevimab as a combination therapy (N = 9785) were included. Bamlanivimab compared to placebo We are uncertain whether bamlanivimab has an effect on mortality by day 30 (RR 1.39, 95% CI 0.40 to 4.83) and SAEs by day 28 (RR 0.93, 95% CI 0.27 to 3.14). Bamlanivimab may have little to no effect on time to hospital discharge (HR 0.97, 95% CI 0.78 to 1.20) and mortality by day 90 (HR 1.09, 95% CI 0.49 to 2.43). The effect of bamlanivimab on the development of severe symptoms at day 5 (RR 1.17, 95% CI 0.75 to 1.85) is uncertain. Bamlanivimab may increase grades 3‐4 AEs at day 28 (RR 1.27, 95% CI 0.81 to 1.98). We assessed the evidence as low certainty for all outcomes due to serious imprecision, and very low certainty for severe symptoms because of additional concerns about indirectness. Casirivimab/imdevimab with usual care compared to usual care alone Treatment with casirivimab/imdevimab compared to usual care probably has little or no effect on mortality by day 30 (RR 0.94, 95% CI 0.87 to 1.02), IMV requirement or death (RR 0.96, 95% CI 0.90 to 1.04), nor alive at hospital discharge by day 30 (RR 1.01, 95% CI 0.98 to 1.04). We assessed the evidence as moderate certainty due to study limitations (lack of blinding). AEs and SAEs were not reported. Authors' conclusions The evidence for each comparison is based on single studies. None of these measured quality of life. Our certainty in the evidence for all non‐hospitalised individuals is low, and for hospitalised individuals is very low to moderate. We consider the current evidence insufficient to draw meaningful conclusions regarding treatment with SARS‐CoV‐2‐neutralising mAbs. Further studies and long‐term data from the existing studies are needed to confirm or refute these initial findings, and to understand how the emergence of SARS‐CoV‐2 variants may impact the effectiveness of SARS‐CoV‐2‐neutralising mAbs. Publication of the 36 ongoing studies may resolve uncertainties about the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for the treatment of COVID‐19 and possible subgroup differences. Plain language summary Are laboratory‐made, COVID‐19‐specific monoclonal antibodies an effective treatment for COVID‐19? Key messages ‐ We do not know whether antibodies (the body’s natural defence against disease) made in a laboratory and all the same as one another (monoclonal) and designed to target COVID‐19, are an effective treatment for COVID‐19 because we assessed only six studies exploring different treatments in different types of patients. ‐ We identified 36 ongoing studies that will provide more evidence when completed. ‐ We will update this review regularly as more evidence becomes available. What are ‘monoclonal’ antibodies? Antibodies are made by the body as a defence against disease. However, they can also be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that are designed to target only one specific protein – in this case, a protein on the virus that causes COVID‐19 – are ‘monoclonal’. They attach to the COVID‐19 virus and stop it from entering and replicating in human cells, which helps to fight the infection. Monoclonal antibodies have been used successfully to treat other viruses. They are thought to cause fewer unwanted effects than convalescent plasma, which contains a variety of different antibodies. What did we want to find out? We wanted to know if COVID‐19 specific monoclonal antibodies are an effective treatment for COVID‐19. We looked at whether they: ‐ reduced the number of deaths from any cause; ‐ improved symptoms or made them worse; ‐ increased admissions to hospital; and ‐ caused any serious or other unwanted effects. What did we do? We searched for studies that investigated one or more monoclonal antibodies to treat people with confirmed COVID‐19 compared with placebo (sham treatment), another treatment or no treatment. Studies could take place anywhere globally and include participants of any age, gender or ethnicity, with mild, moderate or severe COVID‐19. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found six active studies including a total of 17,495 people. Four studies investigated non‐hospitalised people with no symptoms or mild COVID‐19. Two studies investigated hospitalised people with moderate to severe COVID‐19. Studies took place across the world. Three studies were funded by pharmaceutical companies. The monoclonal antibodies they studied were bamlanivimab, etesevimab, casirivimab and imdevimab, sotrovimab, regdanvimab. We did not identify data for mortality at 60 days and quality of life. Non‐hospitalised people, with no symptoms or mild COVID‐19 (four studies) One study investigated different doses of bamlanivimab (465 people), compared to placebo. We don’t know whether bamlanivimab: ‐ increases or reduces the number of deaths because no participants died within 30 days of treatment; ‐ causes more or fewer serious unwanted effects because there were few events. Bamlanivimab may reduce the number of admissions to hospital within 30 days of treatment compared to placebo. ‐ May cause slightly fewer unwanted effects than placebo. ‐ We did not find data for improved symptoms or worsened symptoms. One study investigated a combination of bamlanivimab and etesevimab (1035 people), compared to placebo. ‐ Bamlanivimab and etesevimab may reduce the number of deaths and admissions to hospital. ‐ May cause slightly more unwanted effects. ‐ May cause more serious unwanted effects. For treatment with bamlanivimab alone or in combination with etesevimab we did not find data for improved symptoms or worsened symptoms. One study (phase 1/2 with 799 people) investigated different doses of casirivimab combined with imdevimab, compared to placebo. ‐ Casirivimab combined with imdevimab may reduce the number of hospital admissions or death. ‐ We don't know whether casirivimab and imdevimab causes more unwanted (grades 3 and 4) and serious unwanted effects than placebo because there were too few deaths to allow us to make a judgment. ‐ We did not find data for the number of people who died at day 30 and development of severe symptoms. ‐ We did not include results from phase 3 (5607 people) of this study, because of high risk of bias, as it was not clear which participants were included in the analysis. One study (583 people) investigated sotrovimab, compared to placebo. We don't know whether sotrovimab: ‐ increases or reduces the number of deaths and people requiring invasive mechanical ventilation or dying, because there were too few deaths to allow us to make a judgment. ‐ Sotrovimab may reduce the number of people requiring oxygen, unwanted (grades 3 to 4) and serious unwanted effects; ‐ may have little or no effect on unwanted effects (all grades). Another study (327 people) investigated different doses of regdanvimab (40 mg/kg and 80 mg/kg), compared to placebo. ‐ Regdanvimab at either dose may reduce the number of admissions to hospital or death. ‐ May increase unwanted events (grades 3 to 4). ‐ Regdanvimab at a dose of 80 mg/kg may reduce unwanted effects (all grades) and 40 mg/kg may have little to no effect. ‐ We don't know whether regdanvimab increases or decreases the number of deaths, requirement for invasive mechanical ventilation, and serious unwanted effects, because there were too few events to allow us to make a judgment. Hospitalised people with moderate to severe COVID‐19 (2 studies) One study (314 people) investigated bamlanivimab compared to placebo. ‐ We don’t know whether bamlanivimab increases or decreases the number of deaths due to any cause up to 30 or 90 days after treatment because there were too few deaths to allow us to make a judgment (6 deaths with bamlanivimab and 4 deaths with placebo in 314 people). ‐ Bamlanivimab may slightly increase the development of severe COVID‐19 symptoms five days after treatment and the number of people with unwanted effects. ‐ Bamlanivimab may have little to no effect on time until discharge from hospital. ‐ We don’t know whether bamlanivimab causes serious unwanted effects by day 30 because the study was small and reported few serious unwanted effects. Another study (9785 people) investigated casirivimab combined with imdevimab, compared to standard of care. ‐ Casirivimab combined with imdevimab has probably little to no effect on the number of deaths, requirement for invasive mechanical ventilation or death, and hospital discharge alive. ‐ We did not find data for unwanted and serious unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is low because we found only six studies, and they did not report everything we were interested in, such as the number of deaths within 60 days and quality of life. We found 36 ongoing studies. When they are published, we will add their results to our review. These results are likely to change our conclusions and will also help us understand how new variants affect how well monoclonal antibodies work. How up to date is this evidence? The evidence is up to date to 17 June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Kreuzberger, N; Hirsch, C; Chai, KL; Tomlinson, E; Khosravi, Z; Popp, M; Neidhardt, M; Piechotta, V; Salomon, S; Valk, SJ; Monsef, I; Schmaderer, C; Wood, EM; So-Osman, C; Roberts, DJ; McQuilten, Z; Estcourt, LJ; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD013825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "c72c539a-09bc-488c-8a13-e4b4f11a956f", "pmid": "", "title": "Combined aclidinium bromide and long‐acting beta2‐agonist for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Several dual bronchodilator combinations of long‐acting beta 2 ‐agonist (LABA) and long‐acting muscarinic antagonist (LAMA) have been approved for treatment of stable chronic obstructive pulmonary disease (COPD). The current GOLD (Global Initiative for Chronic Obstructive Lung Disease) recommendations suggest the use of LABA/LAMA combinations in people with group B COPD with persistent symptoms, group C COPD with further exacerbations on LAMA therapy alone and group D COPD with or without inhaled corticosteroids (ICS). Fixed‐dose combination (FDC) of aclidinium/formoterol is one of the approved LABA/LAMA therapies for people with stable COPD. Objectives To assess the efficacy and safety of combined aclidinium bromide and long‐acting beta 2 ‐agonists in stable COPD. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov, World Health Organization (WHO) trials portal, United States Food and Drug Administration (FDA) and manufacturers' websites as well as the reference list of published trials up to 12 October 2018. Selection criteria Parallel‐group randomised controlled trials (RCTs) assessing combined aclidinium bromide and LABAs in people with stable COPD. Data collection and analysis We used standard methodological procedures expected by Cochrane for data collection and analysis. The primary outcomes were exacerbations requiring a short course of an oral steroid or antibiotic, or both; quality of life measured by a validated scale and non‐fatal serious adverse events (SAEs). Where the outcome or study details were not reported, we contacted the study investigators or pharmaceutical company trial co‐ordinators (or both) for missing data. Main results We identified RCTs comparing aclidinium/formoterol FDC versus aclidinium, formoterol or placebo only. We included seven multicentre trials of four to 52 weeks' duration conducted in outpatient settings. There were 5921 participants, whose mean age ranged from 60.7 to 64.7 years, mostly men with a mean smoking pack‐years of 46.4 to 61.3 of which 43.9% to 63.4% were current smokers. They had a moderate‐to‐severe degree of COPD with a mean postbronchodilator forced expiratory volume in one second (FEV 1 ) between 50.5% and 61% of predicted normal and the baseline mean FEV 1 of 1.23 L to 1.43 L. We assessed performance and detection biases as low for all studies whereas selection, attrition and reporting biases were either low or unclear. FDC versus aclidinium There was no evidence of a difference between FDC and aclidinium for exacerbations requiring steroids or antibiotics, or both (OR 0.95, 95% CI 0.71 to 1.27; 2 trials, 2156 participants; moderate‐certainty evidence); quality of life measured by St George's Respiratory Questionnaire (SGRQ) total score (MD –0.92, 95% CI –2.15 to 0.30); participants with significant improvement in SGRQ score (OR 1.17, 95% CI 0.97 to 1.41; 2 trials, 2002 participants; moderate‐certainty evidence); non‐fatal SAE (OR 1.19, 95% CI 0.79 to 1.80; 3 trials, 2473 participants; moderate‐certainty evidence); hospital admissions due to severe exacerbations (OR 0.62, 95% CI 0.29 to 1.29; 2 trials, 2156 participants; moderate‐certainty evidence) or adverse events (OR 0.95, 95% CI 0.76 to 1.18; 3 trials, 2473 participants; moderate‐certainty evidence). Compared with aclidinium, FDC improved symptoms (Transitional Dyspnoea Index (TDI) focal score: MD 0.37, 95% CI 0.07 to 0.68; 2 trials, 2013 participants) with a higher chance of achieving a minimal clinically important difference (MCID) of at least one unit improvement (OR 1.34, 95% CI 1.11 to 1.62; high‐certainty evidence); the number needed to treat for an additional beneficial outcome (NNTB) being 14 (95% CI 9 to 39). FDC versus formoterol When compared to formoterol, combination therapy reduced exacerbations requiring steroids or antibiotics, or both (OR 0.78, 95% CI 0.62 to 0.99; 3 trials, 2694 participants; high‐certainty evidence); may decrease SGRQ total score (MD –1.88, 95% CI –3.10 to –0.65; 2 trials, 2002 participants; low‐certainty evidence; MCID for SGRQ is 4 units); increased TDI focal score (MD 0.42, 95% CI 0.11 to 0.72; 2 trials, 2010 participants) with more participants attaining an MCID (OR 1.30, 95% CI 1.07 to 1.56; high‐certainty evidence) and an NNTB of 16 (95% CI 10 to 60). FDC lowered the risk of adverse events compared to formoterol (OR 0.78, 95% CI 0.65 to 0.93; 5 trials, 3140 participants; high‐certainty evidence; NNTB 22). However, there was no difference between FDC and formoterol for hospital admissions, all‐cause mortality and non‐fatal SAEs. FDC versus placebo Compared with placebo, FDC demonstrated no evidence of a difference in exacerbations requiring steroids or antibiotics, or both (OR 0.82, 95% CI 0.60 to 1.12; 2 trials, 1960 participants; moderate‐certainty evidence) or hospital admissions due to severe exacerbations (OR 0.55, 95% CI 0.25 to 1.18; 2 trials, 1960 participants; moderate‐certainty evidence), although estimates were uncertain. Quality of life measure by SGRQ total score was significantly better with FDC compared to placebo (MD –2.91, 95% CI –4.33 to –1.50; 2 trials, 1823 participants) resulting in a corresponding increase in SGRQ responders who achieved at least four units decrease in SGRQ total score (OR 1.72, 95% CI 1.39 to 2.13; high‐certainty evidence) with an NNTB of 7 (95% CI 5 to 12). FDC also improved symptoms measured by TDI focal score (MD 1.32, 95% CI 0.96 to 1.69; 2 studies, 1832 participants) with more participants attaining at least one unit improvement in TDI focal score (OR 2.51, 95% CI 2.02 to 3.11; high‐certainty evidence; NNTB 4). There were no differences in non‐fatal SAEs, adverse events and all‐cause mortality between FDC and placebo. Combination therapy significantly improved trough FEV 1 compared to aclidinium, formoterol or placebo. Authors' conclusions FDC improved dyspnoea and lung function compared to aclidinium, formoterol or placebo, and this translated into an increase in the number of responders on combination treatment. Quality of life was better with combination compared to formoterol or placebo. There was no evidence of a difference between FDC and monotherapy or placebo for exacerbations, hospital admissions, mortality, non‐fatal SAEs or adverse events. Studies reported a lower risk of moderate exacerbations and adverse events with FDC compared to formoterol; however, larger studies would yield a more precise estimate for these outcomes. Plain language summary Are combined aclidinium and long‐acting beta 2 ‐agonist inhalers effective and safe for people with stable COPD? Background Chronic obstructive pulmonary disease (COPD) is a disease of the lungs that causes airways to narrow. As a result, people with COPD experience symptoms of breathlessness and cough with sputum production which worsen over time. It is mainly caused by smoking or inhaling dust. In people with COPD, inhalers that contain medicines to widen the airways are generally given to relieve symptoms. Long‐acting medicines whose action lasts for at least half a day or one day are preferred. Aclidinium and formoterol (a long‐acting beta 2 ‐agonist medicine) are such inhalers. We wanted to find out how a combination of aclidinium and long‐acting beta 2 ‐agonist fare against either inhaler alone and dummy (placebo) inhaler. Study characteristics We could only identify studies on aclidinium and formoterol combination and included seven studies involving 5921 people with COPD which ranged from four weeks to one year long. Most participants were men in their 60s, moderate‐to‐heavy smokers, around half of whom were current smokers. They had moderate‐to‐severe symptoms of COPD when they started treatment. People in the studies took either combined inhalers containing aclidinium and formoterol or aclidinium or formoterol or placebo through a similar inhaler. Both people doing the research and people in the study did not know which treatment participants were getting. The conclusions of this review are current to October 2018. Key results People taking combined inhaler and aclidinium inhaler were not different in terms of flare‐ups that need additional medicines, quality of life, hospitalisations, side effects or serious side effects. However, they were less breathless than those taking aclidinium inhaler. Fourteen people with COPD would need to be treated with combined inhalers to have one additional person with a clinically significant improvement in breathlessness. People on combined inhalers were likely to have fewer flare‐ups, side effects and symptoms and a better quality of life compared to those taking formoterol inhaler. But, there was little or no difference in hospital admissions due to severe flare‐ups, serious side effects or the risk of dying. When compared to dummy inhalers, people taking combined inhalers experienced less breathlessness and better quality of life. Seven people with COPD would need to be treated with combined inhaler to achieve a significant improvement in quality of life than dummy inhaler. For flare‐ups, hospital admissions, side effects, serious side effects and death, there was no difference between combined and dummy inhalers. The lungs worked better in people taking combined inhalers than those taking only one drug or dummy inhaler. Quality of the evidence We had to interpret the results carefully as all the included studies were sponsored by pharmaceutical companies, which could have led to bias. However, the included studies were generally conducted in a systematic and acceptable manner. We are confident that combined inhalers are more effective than single or dummy inhalers at improving breathlessness and lung function. However, we are less certain about its effects on flare‐ups, hospital admissions, quality of life and side effects. Conclusion Combined inhalers are more effective than individual or dummy inhalers for relieving breathlessness and improving lung performance. They also lead to better quality of life than formoterol or dummy inhalers. However, they are not different from individual or dummy inhalers in terms of flare‐ups or hospital admissions. These combined inhalers have similar safety profiles as individual or dummy inhalers in terms of death, side effects or serious side effects. Combined inhalers probably had lesser side effects and moderate flare‐ups than formoterol, but further studies are needed to confidently support this finding. In summary, the combined inhalers are an effective option for treatment of COPD and appear to have a similar safety profile to individual or dummy inhalers.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ni, H; Moe, S; Soe, Z; Myint, KT; Viswanathan, KN", "articleTypes": [], "doi": "10.1002/14651858.CD011594.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "c76084e6-a157-46d3-945f-dbce5ff8aa56", "pmid": "", "title": "Nutritional support in children and young people with cancer undergoing chemotherapy", "imported": false, "abstract": "Abstract - Background It is well documented that malnutrition is a common complication of paediatric malignancy and its treatment. Malnutrition can often be a consequence of cancer itself or a result of chemotherapy. Nutritional support aims to reverse malnutrition seen at diagnosis, prevent malnutrition associated with treatment and promote weight gain and growth. The most effective and safe forms of nutritional support in children and young people with cancer are not known. Objectives To determine the effects of any form of parenteral (PN) or enteral (EN) nutritional support, excluding vitamin supplementation and micronutrient supplementation, in children and young people with cancer undergoing chemotherapy and to determine the effect of the nutritional content of PN and EN. This is an update of a previous Cochrane review. Search methods We searched the following databases for the initial review: CENTRAL ( The Cochrane Library , Issue 2, 2009), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), CINAHL (1982 to 2006), the National Research Register (2007) and Dissertations & Theses (2007). Experts in the field were also contacted for information on relevant trials. For this update, we searched the same electronic databases from 2006 to September 2013. We also scrutinised the reference lists of included articles to identify additional trials. Selection criteria Randomised or quasi‐randomised controlled trials comparing any form of nutritional support with another, or control, in children or young people with cancer undergoing chemotherapy. Data collection and analysis Two authors independently selected trials. At least two authors independently assessed quality and extracted data. We contacted trialists for missing information. Main results The current review included the eight trials from the initial review and six new trials which randomised 595 participants (< 21 years of age) with leukaemias or solid tumours undergoing chemotherapy. The trials were all of low quality with the exception of two of the trials looking at glutamine supplementation. One small trial found that compared to EN, PN significantly increased weight (mean difference (MD) 4.12, 95% CI 1.91 to 6.33), serum albumin levels (MD 0.70, 95% CI 0.14 to 1.26), calorie intake (MD 22.00, 95% CI 5.12 to 38.88) and protein intake (MD 0.80, 95% CI 0.45 to 1.15). One trial comparing peripheral PN and EN with central PN found that mean daily weight gain (MD ‐27.00, 95% CI ‐43.32 to ‐10.68) and energy intake (MD ‐15.00, 95% CI ‐26.81 to ‐3.19) were significantly less for the peripheral PN and EN group, whereas mean change in serum albumin was significantly greater for that group (MD 0.47, 95% CI 0.13 to 0.81, P = 0.008). Another trial with few participants found an increase in mean energy intake (% recommended daily amount) in children fed an energy dense feed compared to a standard calorie feed (MD +28%, 95% CI 17% to 39%). Three studies looked at glutamine supplementation. The evidence suggesting that glutamine reduces severity of mucositis was not statistically significant in two studies (RR 0.64, 95% CI 0.19 to 2.2 and RR 0.85, 95% CI 0.66 to 1.1) and differences in reduction of infection rates were also not significant in two studies (RR 1.0, 95% CI 0.72 to 1.4 and RR 0.98, 95% CI 0.63 to 1.51). Only one study compared olive oil based PN to standard lipid containing PN. Despite similar calorie contents in both feeds, the standard lipid formula lead to greater weight gain (MD ‐0.34 z‐scores, 95% CI ‐0.68 to 0.00). A single study compared standard EN with fructooligosaccharide containing EN. There was no difference in weight gain between groups (mean difference ‐0.12, 95% CI ‐0.57 to 0.33), with adverse effects (nausea) occurring equally between the groups (RR 0.92, 95% CI 0.48 to 1.74). Authors' conclusions There is limited evidence from individual trials to suggest that PN is more effective than EN in well‐nourished children and young people with cancer undergoing chemotherapy. The evidence for other methods of nutritional support remains unclear. Limited evidence suggests an energy dense feed increases mean daily energy intake and has a positive effect on weight gain. Evidence suggesting glutamine supplementation reduces incidence and severity of mucositis, infection rates and length of hospital stay is not statistically significant. Further research, incorporating larger sample sizes and rigorous methodology utilising valid and reliable outcome measures, is essential. Plain language summary Nutritional support in children and young people with cancer undergoing chemotherapy The provision of safe, appropriate and effective nutritional support for children and young people undergoing treatment for cancer is now well recognised as an important part of their care. It may help to reverse malnutrition seen at diagnosis, prevent malnutrition associated with the cancer, promote weight gain and growth and improve quality of life. Nutritional support may be provided by one of two methods: intravenous nutritional liquids delivered through a central or peripheral vein which bypass the gut (parenteral nutrition); or nutritional liquids or solids that pass through any part of the gut, regardless of method of delivery (e.g. orally or via a tube; enteral nutrition). We found evidence from one small trial to suggest that parenteral nutrition may result in an increase in weight, serum albumin levels and calorie and protein intake when compared to enteral nutrition (usual food intake). However, the effect of other methods of delivery of nutritional support remains unclear. Results from another small study suggested that the use of energy dense enteral feeds resulted in greater average daily energy intake and subsequently improved weight gain. Three studies looked at glutamine supplementation and did not show a benefit from its use. One study looked at the effect of using olive oil based parenteral feeds rather than those containing standard fats and found that it lead to less weight gain. One study considered the effect of adding fructooligosaccharide to enteral feeds and found that it did not effect the amount of weight gained or how often participants felt nauseated. No studies were identified that compared the nutritional content in either the PN or EN groups of studies. The trials were all of low quality and very different in terms of outcome measures used. In the future, much larger, rigorously conducted trials are needed in order to address this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Ward, EJ, Henry, LM, Friend, AJ, Wilkins, S, Phillips, RS", "articleTypes": [], "doi": "10.1002/14651858.CD003298.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.764Z" }, { "id": "c777cd74-ecbd-436b-ad9e-07ebca27fa88", "pmid": "", "title": "Interventions for treating oro‐antral communications and fistulae due to dental procedures", "imported": false, "abstract": "Abstract - Background An oro‐antral communication is an unnatural opening between the oral cavity and maxillary sinus. When it fails to close spontaneously, it remains patent and is epithelialized to develop into an oro‐antral fistula. Various surgical and non‐surgical techniques have been used for treating the condition. Surgical procedures include flaps, grafts and other techniques like re‐implantation of third molars. Non‐surgical techniques include allogenic materials and xenografts. This is an update of a review first published in May 2016. Objectives To assess the effectiveness and safety of various interventions for the treatment of oro‐antral communications and fistulae due to dental procedures. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 23 May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 4), MEDLINE Ovid (1946 to 23 May 2018), and Embase Ovid (1980 to 23 May 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the reference lists of included and excluded trials for any randomised controlled trials (RCTs). Selection criteria We included RCTs evaluating any intervention for treating oro‐antral communications or oro‐antral fistulae due to dental procedures. We excluded quasi‐RCTs and cross‐over trials. We excluded studies on participants who had oro‐antral communications, fistulae or both related to Caldwell‐Luc procedure or surgical excision of tumours. Data collection and analysis Two review authors independently selected trials. Two review authors assessed trial risk of bias and extracted data independently. We estimated risk ratios (RR) for dichotomous data, with 95% confidence intervals (CI). We assessed the overall quality of the evidence using the GRADE approach. Main results We included only one study in this review, which compared two surgical interventions: pedicled buccal fat pad flap and buccal flap for the treatment of oro‐antral communications. The study involved 20 participants. The risk of bias was unclear. The relevant outcome reported in this trial was successful (complete) closure of oro‐antral communication. The quality of the evidence for the primary outcome was very low. The study did not find evidence of a difference between interventions for the successful (complete) closure of an oro‐antral communication (RR 1.00, 95% Cl 0.83 to 1.20) one month after the surgery. All oro‐antral communications in both groups were successfully closed so there were no adverse effects due to treatment failure. We did not find trials evaluating any other intervention for treating oro‐antral communications or fistulae due to dental procedures. Authors' conclusions We found very low quality evidence from a single small study that compared pedicled buccal fat pad and buccal flap. The evidence was insufficient to judge whether there is a difference in the effectiveness of these interventions as all oro‐antral communications in the study were successfully closed by one month after surgery. Large, well‐conducted RCTs investigating different interventions for the treatment of oro‐antral communications and fistulae caused by dental procedures are needed to inform clinical practice. Plain language summary Treatment of communications between the oral cavity and the maxillary sinus due to dental procedures Review question What evidence is available for the safe and effective treatment of openings between the mouth and main sinus caused by dental procedures? Background The floor of the main sinus near the nose is thin and lies directly above the roots of the teeth at the back of the mouth. Sometimes following infection or dental treatment, this structure becomes damaged and openings or channels between the mouth and the sinus are formed. These are known as oro‐antral communications (OAC). If the OAC is left open (then described as an oro‐antral fistula (OAF), it may become permanent, leading to long‐lasting sinus infections. This condition can be treated surgically by using flaps, grafts and other techniques; or non‐surgically using a variety of methods and materials. There is little evidence for the most effective and safe treatments for closing OACs and OAFs and clinicians who treat these conditions have identified an urgent need for this. This is an update of a review first published in May 2016. Study characteristics We searched various databases until 23 May 2018. Only one study, which was conducted in Iran, is included in our review. The study ran for two years and involved 20 people with OAC aged between 25 and 56 years. Participants were divided into two groups and two surgical treatments were compared for treating oro‐antral communications; one group was treated with pedicled buccal fat pad flap (PBFPF) and the other with buccal flap (BF). Key results and quality of evidence The study did not find evidence of a difference between PBFPF and BF in terms of successful (complete) closure of OAC. Both interventions resulted in successful closure by one month after surgery. The study did not therefore report any adverse effects of treatment failure. It may not be possible to generalise these findings because the quality of the evidence was very low, due to unclear risk of bias and the small numbers studied in the single included trial. Conclusion The evidence currently available is insufficient to draw reliable conclusions regarding the effects of interventions used to treat OAC or fistulae due to dental procedures. More well‐designed and well‐reported trials evaluating different interventions are needed to provide reliable evidence to inform clinical decisions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Kiran Kumar Krishanappa, S, Eachempati, P, Kumbargere Nagraj, S, Shetty, NY, Moe, S, Aggarwal, H, Mathew, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD011784.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.749Z" }, { "id": "c77fc62a-0a4d-44c8-8e64-795173c4793d", "pmid": "", "title": "Combination inhaled steroid and long‐acting beta₂‐agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background The long‐acting bronchodilator tiotropium and single‐inhaler combination therapy of inhaled corticosteroids and long‐acting beta 2 ‐agonists (ICS/LABA) are commonly used for maintenance treatment of patients with chronic obstructive pulmonary disease (COPD). Combining these treatments, which have different mechanisms of action, may be more effective than administering the individual components. Objectives To assess relative effects of the following treatments on markers of exacerbations, symptoms, quality of life and lung function in patients with COPD. • Tiotropium plus LABA/ICS versus tiotropium. • Tiotropium plus LABA/ICS versus LABA/ICS. Search methods We searched the Cochrane Airways Group Specialised Register of Trials (April 2015), ClinicalTrials.gov ( www.ClinicalTrials.gov ), the World Health Organization (WHO) trials portal and reference lists of relevant articles. Selection criteria We included parallel, randomised controlled trials (RCTs) lasting three months or longer conducted to compare ICS and LABA combination therapy in addition to inhaled tiotropium versus tiotropium alone or combination therapy alone. Data collection and analysis We independently assessed trials for inclusion, then extracted data on trial quality and outcome results. We contacted study authors to ask for additional information. We collected trial information on adverse effects. Main results Tiotropium plus LABA/ICS versus tiotropium We included six studies (1902 participants) with low risk of bias that compared tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy versus tiotropium alone. We found no statistically significant differences in mortality between treatments (odds ratio (OR) 1.80, 95% confidence interval (CI) 0.55 to 5.91; two studies; 961 participants) as well as in the all‐cause hospitalisations (OR 0.84, 95% CI 0.53 to 1.33; two studies; 961 participants). The effect on exacerbations was heterogeneous among trials and was not meta‐analysed. Health‐related quality of life measured by St. George’s Respiratory Questionnaire (SGRQ) showed a statistically significant improvement in total scores with use of tiotropium + LABA/ICS compared with tiotropium alone (mean difference (MD) ‐3.46, 95% CI ‐5.05 to ‐1.87; four studies; 1446 participants). Lung function was significantly different in the combined therapy (tiotropium + LABA/ICS) group, although average benefit with this therapy was small. None of the included studies included exercise tolerance as an outcome. A pooled estimate of these studies did not show a statistically significant difference in adverse events (OR 1.16, 95% CI 0.92 to 1.47; four studies; 1363 participants), serious adverse events (OR 0.86, 95% CI 0.57 to 1.30; four studies; 1758 participants) and pneumonia (Peto OR 1.62, 95% CI 0.54 to 4.82; four studies; 1758 participants). Tiotropium plus LABA/ICS versus LABA/ICS One of the six studies (60 participants) also compared combined therapy (tiotropium + LABA/ICS) versus LABA/ICS therapy alone. This study was affected by lack of power; therefore results did not allow us to draw conclusions for this comparison. Authors' conclusions This review update includes three additional studies and provides new low quality evidence supporting the finding that tiotropium + LABA/ICS‐based therapy improves the disease‐specific quality of life. The current evidence is insufficient to support the benefit of tiotropium + LABA/ICS‐based therapy for mortality, hospital admission or exacerbations (moderate and low quality evidence). Compared with use of tiotropium alone, tiotropium + LABA/ICS‐based therapy does not seem to increase undesirable effects nor serious non‐fatal adverse events. Plain language summary Are tiotropium plus combination inhalers better than tiotropium or combination inhalers alone for the treatment of COPD? Background Chronic obstructive pulmonary disease (COPD) is a lung disease that includes the conditions chronic bronchitis and/or emphysema. COPD is characterised by narrowing of the airways and lung tissue destruction. Symptoms include breathlessness and long‐term cough. Symptoms of COPD are treatable, but the condition cannot be reversed or cured. It is usually brought on by airway irritants, such as smoking or inhaled dust. Inhalers with bronchodilators (which allow the airways in the lungs to relax and expand) and/or anti‐inflammatory agents are commonly used to ease symptoms and minimise the long‐term decline in health caused by COPD. Examples of these treatments are tiotropium, which is a bronchodilator, and combination inhalers, which contain another type of bronchodilator (long‐acting beta‐agonists) together with anti‐inflammatory agents (steroids). These treatments work in different ways and therefore might be more beneficial if used together. Study characteristics This review found six studies, involving 1902 participants, comparing the long‐term efficacy and side effects of tiotropium combined with combination inhalers for treatment of patients with COPD. Not all of the people included in these studies had COPD that was severe enough to be recommended for combined therapy according to current guidelines. Key results Current evidence shows potential benefits of treatment with tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy through increased health‐related quality of life and a small improvement i n lung function in patients receiving this combined therapy. However, this evidence does not allow us to draw conclusions about the effects of these treatments on mortality, hospitalisation for all causes and exacerbations. The frequency of serious and non‐serious adverse events was not increased in either of the two groups. Quality of the evidence Overall, we assessed the evidence presented in this review to be of moderate or low quality, which means we are reasonably confident in some of the findings, but less confident in others.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Rojas‐Reyes, MX; García Morales, OM; Dennis, RJ; Karner, C", "articleTypes": [], "doi": "10.1002/14651858.CD008532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "c789f6c3-0f5f-4fd6-a855-41be1e6f31b5", "pmid": "", "title": "Smectite for acute infectious diarrhoea in children", "imported": false, "abstract": "Abstract - Background As mortality secondary to acute infectious diarrhoea has decreased worldwide, the focus shifts to adjuvant therapies to lessen the burden of disease. Smectite, a medicinal clay, could offer a complementary intervention to reduce the duration of diarrhoea. Objectives To assess the effects of smectite for treating acute infectious diarrhoea in children. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Pubmed), Embase (Ovid), LILACS, reference lists from studies and previous reviews, and conference abstracts, up to 27 June 2017. Selection criteria Randomized and quasi‐randomized trials comparing smectite to a control group in children aged one month to 18 years old with acute infectious diarrhoea. Data collection and analysis Two review authors independently screened abstracts and the full texts for inclusion, extracted data, and assessed risk of bias. Our primary outcomes were duration of diarrhoea and clinical resolution at day 3. We summarized continuous outcomes using mean differences (MD) and dichotomous outcomes using risk ratios (RR), with 95% confidence intervals (CI). Where appropriate, we pooled data in meta‐analyses and assessed heterogeneity. We explored publication bias using a funnel plot. Main results Eighteen trials with 2616 children met our inclusion criteria. Studies were conducted in both ambulatory and in‐hospital settings, and in both high‐income and low‐ or middle‐income countries. Most studies included children with rotavirus infections, and half included breastfed children. Smectite may reduce the duration of diarrhoea by approximately a day (MD ‐24.38 hours, 95% CI ‐30.91 to ‐17.85; 14 studies; 2209 children; low‐certainty evidence); may increase clinical resolution at day 3 (risk ratio (RR) 2.10, 95% CI 1.30 to 3.39; 5 trials; 312 children; low‐certainty evidence); and may reduce stool output (MD ‐11.37, 95% CI ‐21.94 to ‐0.79; 3 studies; 634 children; low‐certainty evidence). We are uncertain whether smectite reduces stool frequency, measured as depositions per day (MD ‐1.33, 95% CI ‐2.28 to ‐0.38; 3 studies; 954 children; very low‐certainty evidence). There was no evidence of an effect on need for hospitalization (RR 0.93, 95% CI 0.75 to 1.15; 2 studies; 885 children; low‐certainty evidence) and need for intravenous rehydration (RR 0.77, 95% CI 0.54 to 1.11; 1 study; 81 children; moderate‐certainty evidence). The most frequently reported side effect was constipation, which did not differ between groups (RR 4.71, 95% CI 0.56 to 39.19; 2 studies; 128 children; low‐certainty evidence). No deaths or serious adverse effects were reported. Authors' conclusions Based on low‐certainty evidence, smectite used as an adjuvant to rehydration therapy may reduce the duration of diarrhoea in children with acute infectious diarrhoea by a day; may increase cure rate by day 3; and may reduce stool output, but has no effect on hospitalization rates or need for intravenous therapy. 2 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (27 Jun, 2017) were included Plain language summary Smectite for treating children with acute diarrhoea What is the aim of this review? The aim of this Cochrane Review was to find out if smectite (or diosmectite), a medicinal clay commonly prescribed to people who have diarrhoea in order to reduce their stool output, helps children with acute diarrhoea. We collected and analysed all relevant studies to answer this question and found 18 relevant studies. Key messages Giving smectite to children with acute diarrhoea may reduce its duration. However, more high‐quality studies are still needed, including studies that assess different causes of diarrhoea and the economic effects of this treatment. What was studied in the review? Acute diarrhoea is one of the most common diseases in children. It is usually caused by a viral infection. The main aim of treatment is to maintain a good level of hydration. This is achieved with oral rehydration solutions, and few children need to be hospitalized or require intravenous rehydration. Still, even with proper hydration, having loose stools is a burden for both parents and patients. Smectite may help by reducing inflammation in the gut; by acting as a barrier to reduce the penetration of toxins; or by increasing water absorption. What are the main results? We found 18 relevant studies with 2616 children that were conducted in both high‐income and low‐ or middle‐income countries. These studies compared children receiving smectite with children receiving routine care or a placebo (a pill or liquid that contains no medicine). Eight studies were funded by the manufacturer. Smectite may reduce the duration of diarrhoea by one day (low‐certainty evidence); may increase the number of children cured by day 3 (low‐certainty evidence); and may slightly reduce the quantity of loose stools (low‐certainty evidence). We are uncertain whether smectite has an effect on how many stools children have (very low‐certainty evidence). It may not have an effect on how many children need to be hospitalized (low‐certainty evidence), and probably does not have an effect on how many children need intravenous rehydration (moderate‐certainty evidence). We found no reports of serious adverse effects. Minor adverse effects included constipation, vomiting, and bad taste, but these did not differ between groups. How up‐to‐date is this review? We searched for studies published up to 27 June 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Pérez‐Gaxiola, G, Cuello‐García, CA, Florez, ID, Pérez‐Pico, VM", "articleTypes": [], "doi": "10.1002/14651858.CD011526.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.731Z" }, { "id": "c78cd416-79e1-4156-8908-d0cad31cd261", "pmid": "", "title": "Lifestyle interventions for chronic gout", "imported": false, "abstract": "Abstract - Background Although lifestyle interventions are commonly recommended in the management of patients with chronic gout, the evidence from trial data for their benefits and safety has not been previously examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with chronic gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies on 5 April 2013. We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials (RCTs or CCTs) which compared lifestyle interventions to another therapy (active or placebo) in patients with chronic gout. Outcomes of interest were changes in gout attack frequency, joint pain, serum urate levels, tophus size, function, quality of life and adverse effects. Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (120 participants), at moderate risk of bias, was included in the review. Patients were randomised to one of three interventions: either skim milk powder (SMP) enriched with glycomacropeptide (GMP) and G600, non‐enriched SMP or lactose powder, over a three‐month period. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the three‐month study period. Low quality evidence indicated that there was no difference between the SMP/GMP/G600 group and combined control groups (SMP and lactose powder) at three months (mean difference (MD) ‐0.21, 95% confidence interval (CI) ‐0.76 to 0.34). There were no significant between‐group differences in terms of withdrawals due to adverse effects (risk ratio (RR) 1.27, 95% CI 0.53 to 3.03), and serious adverse events resulting in hospitalisation (2/40 SMP/GMP/G600 group versus 3/80 controls; RR 1.33, 95% CI 0.23 to 7.66). Gastrointestinal adverse effects were the most commonly reported. Pain from self reported gout flares, measured on a 10‐point Likert scale, improved more in the SMP/GMP/G600 group compared to controls (MD ‐1.03, 95% CI ‐1.96 to ‐0.10), an absolute difference of 10% (absolute risk difference ‐0.10, 95% CI ‐0.20 to ‐0.01). This is unlikely to be of clinical significance. There was no significant difference in physical function between SMP/GMP/G600 and the control groups at three‐month followup (MD ‐0.03, 95% CI ‐0.14 to 0.08). Tophus regression and serum urate normalisation were not reported in this study. Authors' conclusions While there is good evidence from observational studies of an association between various lifestyle risk factors and gout development, there is a paucity of high‐quality evidence from randomised controlled trials to either support or refute the use of lifestyle modifications for improving outcomes in people with chronic gout. Plain language summary Lifestyle interventions for chronic gout This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with chronic gout. There was one study included in this review which looked at the benefits and safety of consuming skim milk powder (SMP) enriched with two components of dairy products (glycomacropeptide (GMP) and G600 milk fat extract) compared to standard skim milk or lactose powder in reducing the frequency of gout attacks over a three‐month period. The review shows that, in people with chronic gout : Compared with standard skim milk or lactose powder, SMP enriched with GMP and G600 may not reduce the frequency of gout attacks, may not improve physical function, but may reduce pain. We do not know if consuming these dairy preparations improves tophus size (tophi are gout crystal deposits commonly found in skin, on the surface of joints or in cartilage) or blood uric acid levels, as these were not reported. We do not have precise information about side effects and complications. Possible side effects may include nausea or diarrhoea. What is gout and what are lifestyle interventions? Gout is a very common form of painful joint inflammation (arthritis) caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness and swelling of affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic makeup, being overweight, ingesting certain medications (e.g. diuretics), having impaired kidney function and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Although medications are the mainstay of gout treatment, given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as losing weight, stopping smoking, exercising more, drinking more coffee and dairy products, and consuming less sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout. Best estimate of what happens to people with gout who consume enriched skim milk powder: Gout attacks People who consumed enriched skim milk powder had 0.21 fewer gout attacks per month at 3 months (or 2.5 fewer gout attacks per year) . ‐ People who consumed enriched skim milk powder had 0.49 gout attacks per month (or 6 gout attacks per year). ‐ People who consumed standard skim milk powder or lactose had 0.70 gout attacks per month (or 8 gout attacks per year). Withdrawals due to adverse events 4 more people out of 100 who consumed enriched skim milk powder discontinued the supplement at 3 months (4% more withdrawals absolute change, from 10% fewer to 18% more). ‐ 18 out of 100 stopped consuming enriched skim milk powder. ‐ 14 out of 100 stopped consuming standard skim milk powder or lactose. Pain (lower score means less pain) People who consumed enriched skim milk powder rated their pain 1 point lower on a 0 to 10 point pain scale (10% absolute improvement; 20% to 1% improvement) at 3 months. ‐ People who consumed enriched skim milk powder rated their pain to be 0.67 points on a scale of 0 to 10. ‐ People who consumed standard skim milk powder or lactose rated their pain to be 1.7 points on a scale of 0 to 10. Physical function (lower score means better function) People who consumed enriched skim milk powder rated their function 0.03 better (0.14 better to 0.08 worse) on a 0 to 3 point scale (1% absolute improvement; 5% improvement to 3% worse) at 3 months. ‐ People who consumed enriched skim milk powder rated their function to be 0.08 points on a scale of 0 to 3. ‐ People who consumed standard skim milk powder or lactose rated their function to be 0.11 points on a scale of 0 to 3. Serious adverse events 1 more person out of 100 who consumed enriched skim milk powder reported a serious adverse event. ‐ 5 out of 100 who consumed enriched skim milk powder had a serious adverse event. ‐ 4 out of 100 who consumed standard skim milk powder or lactose had a serious adverse event.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY; Sriranganathan, MK; Edwards, CJ; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "c7aa768a-63a6-4a1d-ae00-52dbd848d8a9", "pmid": "", "title": "Dietary advice with or without oral nutritional supplements for disease‐related malnutrition in adults", "imported": false, "abstract": "Abstract - Background Disease‐related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social‐care costs. Dietary advice (DA) encouraging consumption of energy‐ and nutrient‐rich foods rather than oral nutritional supplements (ONS) may be an initial treatment. Objectives To examine evidence that DA with/without ONS in adults with disease‐related malnutrition improves survival, weight, anthropometry and quality of life (QoL). Search methods We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021. Selection criteria Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease‐related malnutrition in any healthcare setting compared with no advice, ONS or DA alone. Data collection and analysis Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence. Main results We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity. Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years. DA versus no advice ‐ 24 RCTs (3523 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three‐month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI ‐0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat‐free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS ‐ 12 RCTs (852 participants) All outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD ‐0.14 kg (95% CI ‐2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS ‐ 22 RCTs (1286 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD ‐1.07 (95% CI ‐4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS ‐ 31 RCTs (3308 participants) Evidence was moderate‐ to low‐certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD ‐0.12 (95% CI ‐2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS ‐ 13 RCTs (1315 participants) Evidence was low‐ to very low‐certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD ‐1.81 (95% CI ‐3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI ‐0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point. Authors' conclusions We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow‐up required for benefits to emerge were inconsistent for all other outcomes. There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient‐centred and healthcare outcomes are needed to address the questions in this review. Plain language summary Advice on diet for adults with malnutrition that is the result of disease Review question Can dietary advice with or without oral nutritional supplements (ONS) improve disease‐related malnutrition in adults? Background Ill people often have a poor appetite or feel sick because of medicines or other treatments and eat less than usual. Eating less over a longer time can cause weight loss, malnutrition, more health problems and death. Healthcare professionals may offer advice about dietary changes to help people to re‐establish good eating habits. They might recommend high‐protein and high‐energy foods so that these people can gain weight and improve their nutrition and general health. It is common for sick people to be offered ONS with or without advice about changing their food intake. To find the best answer to our review question, we looked for studies that compared five different treatment options: dietary advice compared with no advice; dietary advice compared with ONS; dietary advice plus ONS compared with dietary advice; dietary advice plus ONS if appropriate compared with no dietary advice; and dietary advice plus ONS compared with no dietary advice and no ONS. To make these comparisons fair, we looked for randomised controlled trials (RCTs), where the people taking part had an equal chance (like the flip of a coin) of being in either group that was being compared. Search date The evidence is current to: 01 March 2021. Study characteristics We found 94 studies (with a total of 10,284 people) that we could include in our review. Although older people have a higher risk of malnutrition, the people in these studies ranged from 17 to over 80 years of age and they were living either at home, in the community, or in hospital. They had a wide range of health conditions, including cancer, dementia and kidney disease. The studies reported on the participants for the length of their hospital stay or in some people in the community for up to six and a half years. Key results There is no evidence that any of the treatments affected how long many of the people in the studies lived. They did report some positive changes in energy intake (measured in calories), protein intake, weight, muscle bulk and quality of life. There were some reductions in complications and the length of time spent in hospital. However, there is no clear evidence about which treatment is the most helpful or the time it takes to achieve any benefit. Few studies reported results separately for men and women and so we cannot comment on whether there were any overall differences by sex. No studies recorded information about adverse events (harms) so we cannot offer a summary about possible harms. More research is needed to work out the best ways to help people who are losing weight because of illness in order to improve their clinical outcomes and quality of life. Certainty of the evidence Overall we rated the certainty of the evidence as low for most results, which means that we cannot be confident about the findings we report. There were several reasons for this. Some of the treatment comparisons that we looked at had only a few studies and some of those had small numbers of participants. There were problems with the design of some studies that may have affected the results. Some people knew which treatment they were receiving. We think this may influence the way that they reported some changes, e.g. their energy and protein intake, body weight and quality of life. We think that the way the decision about which group a person went into at the start of the study may have affected the results for some outcomes, e.g. change in weight, change in muscle bulk and mortality. We needed to see particular results to help us understand whether adults living with disease‐related malnutrition can improve their survival, weight and general quality of life if they receive advice about diet with or without ONS. None of the studies reported all of the results that we needed to do this. We were not able to estimate whether participants gain any benefits from the treatments, such as shortening the length of hospital stay, lowering the risk of readmission to hospital or developing complications. The low certainty of evidence, with no evidence in many areas, means we cannot make statements about any benefits and the possible disadvantages of these treatments despite the fact they are being used extensively in clinical practice. We recommend that future studies should be designed to measure these important patient‐centred and healthcare outcomes as well as any potential harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Baldwin, C, de van der Schueren, MAE, Kruizenga, HM, Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD002008.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.822Z" }, { "id": "c7c44d7f-70bb-414d-b02d-5147c37aba5a", "pmid": "", "title": "Protein and energy supplementation in elderly people at risk from malnutrition", "imported": false, "abstract": "Abstract - Background Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. Objectives This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip‐feeds'. Search methods We searched The Cochrane Library , MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip‐feed' manufacturers. Selection criteria Randomised and quasi‐randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. Data collection and analysis Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. Main results Sixty‐two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97). The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (‐0.8 days, 95% CI ‐2.8 to 1.3). Adverse effects included nausea or diarrhoea. Authors' conclusions Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large‐scale multi‐centre trials are still required. Plain language summary Protein and energy supplementation in elderly people at risk from malnutrition Much emphasis is placed on the importance of good diet, usually in relation to concern about the health risks of obesity. However it has been generally agreed that the risk of undernutrition rather than overnutrition is the main cause for concern in elderly people, particularly those who are hospitalised or institutionalised. Malnutrition has been shown to have important effects on recovery in a broad range of patients and conditions. It has been associated strongly with impaired immune response, impaired muscle and respiratory function, delayed wound healing, overall increased complications, longer rehabilitation, greater length of hospital stay and increased mortality. Oral protein and energy supplements are potentially safer and easier to administer than nasogastric enteral feeds and are therefore particularly suited to elderly people and are also widely used. However, there may be problems with the willingness and ability of older people to consume oral supplements, and supplements may not be used effectively. Even if supplements are prescribed, they may not always be given, or are given but not consumed. In addition to taste, the composition and timing of administration in relation to meals may be important. Efforts also need to be made to provide normal meals and snacks which meet the needs of elderly people and to provide assistance with feeding if required. A total of 10,187 randomised participants from the 62 trials has been included. Maximum duration of intervention was 18 months. The reviewers suggest that supplementation appears to produce a small but consistent weight gain. There was no evidence in this updated review of a beneficial effect on mortality overall, but there may be a beneficial effect on mortality in people who are undernourished. Supplementation may also reduce the number of complications. The reported acceptance of supplements was variable between trials. Some adverse effects such as nausea or diarrhoea were reported. However, there were problems of study design and quality. More studies are required to confirm the beneficial effect on the number of complications, to establish whether there is a beneficial effect on mortality for undernourished elderly people and to provide evidence about whether protein and energy supplements can improve morbidity and functional status in frail older people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Milne, AC, Potter, J, Vivanti, A, Avenell, A", "articleTypes": [], "doi": "10.1002/14651858.CD003288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.075Z" }, { "id": "c7c5b924-8399-4d14-b384-0e8c3ddf7691", "pmid": "", "title": "Dual antibiotics for bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is a chronic respiratory disease characterised by abnormal and irreversible dilatation of the smaller airways and associated with a mortality rate greater than twice that of the general population. Antibiotics serve as front‐line therapy for managing bacterial load, but their use is weighed against the development of antibiotic resistance. Dual antibiotic therapy has the potential to suppress infection from multiple strains of bacteria, leading to more successful treatment of exacerbations, reduced symptoms, and improved quality of life. Further evidence is required on the efficacy of dual antibiotics in terms of management of exacerbations and extent of antibiotic resistance. Objectives To evaluate the effects of dual antibiotics in the treatment of adults and children with bronchiectasis. Search methods We identified studies from the Cochrane Airways Group Specialised Register (CAGR), which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED), and PsycINFO, as well as studies obtained by handsearching of journals/abstracts. We also searched the following trial registries: US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. We imposed no restriction on language of publication. We conducted our search in October 2017. Selection criteria We searched for randomised controlled trials comparing dual antibiotics versus a single antibiotic for short‐term (< 4 weeks) or long‐term management of bronchiectasis diagnosed in adults and/or children by bronchography, plain film chest radiography, or high‐resolution computed tomography. Primary outcomes included exacerbations, length of hospitalisation, and serious adverse events. Secondary outcomes were response rates, emergence of resistance to antibiotics, systemic markers of infection, sputum volume and purulence, measures of lung function, adverse events/effects, deaths, exercise capacity, and health‐related quality of life. We did not apply outcome measures as selection criteria. Data collection and analysis Two review authors independently screened the titles and abstracts of 287 records, along with the full text of seven reports. Two studies met review inclusion criteria. Two review authors independently extracted outcome data and assessed risk of bias . We extracted data from only one study and conducted GRADE assessments for the following outcomes: successful treatment of exacerbation; response rates; and serious adverse events. Main results Two randomised trials assessed the effectiveness of oral plus inhaled dual therapy versus oral monotherapy in a total of 118 adults with a mean age of 62.8 years. One multi‐centre trial compared inhaled tobramycin plus oral ciprofloxacin versus ciprofloxacin alone, and one single‐centre trial compared nebulised gentamicin plus systemic antibiotics versus a systemic antibiotic alone. Published papers did not report study funding sources. Effect estimates from one small study with 53 adults showed no evidence of treatment benefit with oral plus inhaled dual therapy for the following primary outcomes at the end of the study: successful management of exacerbation ‐ cure at day 42 (odds ratio (OR) 0.66, 95% confidence interval (CI) 0.22 to 2.01; 53 participants; one study; very low‐quality evidence); number of participants with Pseudomonas aeruginosa eradication at day 21 (OR 2.33, 95% CI 0.66 to 8.24; 53 participants; one study; very low‐quality evidence); and serious adverse events (OR 0.48, 95% CI 0.08 to 2.87; 53 participants; one study; very low‐quality evidence). Similarly, researchers provided no evidence of treatment benefit for the following secondary outcomes: clinical response rates ‐ relapse at day 42 (OR 0.57, 95% CI 0.12 to 2.69; 53 participants; one study; very low‐quality evidence); microbiological response rate at day 21 ‐ eradicated (OR 2.40, 95% CI 0.67 to 8.65; 53 participants; one study; very low‐quality evidence); and adverse events ‐ incidence of wheeze (OR 5.75, 95% CI 1.55 to 21.33). Data show no evidence of benefit in terms of sputum volume, lung function, or antibiotic resistance. Outcomes from a second small study with 65 adults, available only as an abstract, were not included in the quantitative data synthesis. The included studies did not report our other primary outcomes: duration; frequency; and time to next exacerbation; nor our secondary outcomes: systemic markers of infection; exercise capacity; and quality of life. We did not identify any trials that included children. Authors' conclusions A small number of studies in adults have generated high‐quality evidence that is insufficient to inform robust conclusions, and studies in children have provided no evidence. We identified only one dual‐therapy combination of oral and inhaled antibiotics. Results from this single trial of 53 adults that we were able to include in the quantitative synthesis showed no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, serious adverse events, sputum volume, lung function, and antibiotic resistance. Further high‐quality research is required to determine the efficacy and safety of other combinations of dual antibiotics for both adults and children with bronchiectasis, particularly in terms of antibiotic resistance. Plain language summary Dual antibiotics for bronchiectasis Background to the question Bronchiectasis is a lung disease involving abnormal airways, leading to repeated chest infections, and associated with a mortality rate more than twice that of the general population. Although previously considered a relatively rare disease, numbers appear to be increasing, particularly for those over 75 years in low/middle‐income countries. Antibiotics are the main therapy for chest infection, but their use must be weighed against potential side effects and the risk of increasing resistance to antibiotic therapy. One strategy to improve response and/or reduce antibiotic resistance involves giving two antibiotic agents at the same time: dual antibiotic therapy. This review therefore aimed to evaluate the effects of dual antibiotics for treatment of adults and children with bronchiectasis. Study characteristics In October 2017, we identified two relevant studies comparing oral plus inhaled dual therapy versus oral therapy alone. They included a total of 118 adults with an average age of 62.8 years. One study compared inhaled tobramycin plus oral ciprofloxacin with oral ciprofloxacin, and the second study compared inhaled gentamicin plus a systemic (affecting the whole body, rather than just the lungs) antibiotic with a systemic antibiotic alone. Only a research summary was available for the latter. Published papers did not report study funding sources Main results Results from one small trial of 53 adults show no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, the occurrence of serious unwanted events, amount of phlegm, lung function, or resistance to antibiotic treatment. However, we found insufficient evidence to permit confident conclusions about their use. Quality of the evidence The overall quality of the evidence was very poor, largely because one of the studies was not well described and included few participants. Information on exacerbations, exercise ability, and quality of life was not reported. We did not identify any trials that compared other types of dual antibiotic therapy, and we found none that included children. Therefore uncertainty remains concerning the use of dual antibiotics, and further high‐quality studies are needed to examine the role of dual antibiotics in the treatment of adults and children with bronchiectasis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Felix, LM, Grundy, S, Milan, SJ, Armstrong, R, Harrison, H, Lynes, D, Spencer, S", "articleTypes": [], "doi": "10.1002/14651858.CD012514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.776Z" }, { "id": "c7d2b883-da68-46fb-828e-4e5252fc102f", "pmid": "", "title": "Fluvoxamine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Fluvoxamine, one of the oldest selective serotonin reuptake inhibitors (SSRIs), is prescribed to patients with major depression in many countries. Several studies have previously reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are now outdated. Objectives Our objective is to evaluate the effectiveness, tolerability and side effect profile of fluvoxamine for major depression in comparison with other anti‐depressive agents, including tricyclics (TCAs), heterocyclics, other SSRIs, SNRIs, other newer agents and other conventional psychotropic drugs. Search methods We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register. Trial databases and ongoing trial registers in North America, Europe, Japan and Australia, were handsearched for randomised controlled trials. We checked reference lists of the articles included in the review, previous systematic reviews and major textbooks of affective disorder for published reports and citations of unpublished research. The date of last search was 31 August 2008. Selection criteria We included all randomised controlled trials, published in any language, that compared fluvoxamine with any other active antidepressants in the acute phase treatment of major depression. Data collection and analysis Two independent review authors inspected citations and abstracts, obtained papers, extracted data and assessed the risk of bias of included studies. We analysed dichotomous data using odds ratios (ORs) and continuous data using the standardised mean difference (SMD). A random effects model was used to combine studies. Main results A total of 54 randomised controlled trials (n = 5122) were included. No strong evidence was found to indicate that fluvoxamine was either superior or inferior to other antidepressants regarding response, remission and tolerability. However, differing side effect profiles were evident, especially with regard to gastrointestinal side effects of fluvoxamine when compared to other antidepressants. For example, fluvoxamine was generally associated with a higher incidence of vomiting/nausea (versus imipramine, OR 2.23, CI 1.59 to 3.14; versus clomipramine, OR 2.13, CI 1.06 to 4.27; versus amitriptyline, OR 2.86, CI 1.31 to 2.63). Authors' conclusions We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, differing side effect profiles were evident. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations, including these differences in side effect profiles. Plain language summary Fluvoxamine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Although pharmacological and psychological interventions are both effective for major depression, antidepressant (AD) drugs remain the mainstay for treatment of moderate or severe depression. Fluvoxamine is one of the oldest selective serotonin reuptake inhibitors (SSRIs) and is prescribed to patients with major depression in many countries. This review reports trials comparing fluvoxamine with other antidepressants for treatment of major depression. We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, there is evidence of differing side‐effect profiles, especially when comparing gastrointestinal side effects between fluvoxamine and tricyclic antidepressants (TCAs). Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including these differences in side effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Omori, IM; Watanabe, N; Nakagawa, A; Cipriani, A; Barbui, C; McGuire, H; Churchill, R; Furukawa, TA", "articleTypes": [], "doi": "10.1002/14651858.CD006114.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "c7de7cfc-98f6-4718-b652-817dc169a7ea", "pmid": "", "title": "The Effect of Seven Day Fenfluramine Administration on Cognition in Healthy Volunteers", "imported": false, "abstract": "In this study, the investigators will investigate the cognitive effects of fenfluramine, a drug that directly stimulates the release of serotonin in the brain and positively modulates σ1 function. The investigators will use fenfluramine to assess the cognitive effects of modulating serotonin and σ1 function in healthy volunteers using a battery of cognitive tasks that measure learning and memory, executive functioning, reward processing, and emotional processing. The study design is double-blind, and participants will be randomised to either seven days of fenfluramine or placebo administration. All participants will attend two screening visits to assess eligibility. There are two main study visits; during the first, participants will undertake cognitive tasks and questionnaires before taking the initial study dose. One the second study visit, participants will once again complete these tasks and questionnaires after a week of fenfluramine/placebo administration.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.153Z" }, { "id": "c7f65d96-dc19-4daf-9769-5b410f369729", "pmid": "", "title": "Environmental interventions to reduce the consumption of sugar‐sweetened beverages and their effects on health", "imported": false, "abstract": "Abstract - Background Frequent consumption of excess amounts of sugar‐sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB. Objectives To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar‐sweetened beverages and sugar‐sweetened milk, diet‐related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes. Search methods We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors. Selection criteria We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet‐related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) and interrupted‐time‐series (ITS) studies, implemented in real‐world settings with a combined length of intervention and follow‐up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB‐specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review. Data collection and analysis Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta‐analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented ‘Summary of findings’ tables. Main results We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow‐up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non‐randomised designs. The studies examine a broad range of interventions, and we present results for these separately. Labelling interventions (8 studies): We found moderate‐certainty evidence that traffic‐light labelling is associated with decreasing sales of SSBs, and low‐certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu‐board calorie labelling reported effects on SSB sales varied. Nutrition standards in public institutions (16 studies): We found low‐certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low‐certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied. Economic tools (7 studies): We found moderate‐certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low‐calorie beverages reported effects on SSB sales varied. Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied. Retail and food service interventions (7 studies): We found low‐certainty evidence that healthier default beverages in children’s menus in chain restaurants are associated with decreasing SSB sales, and moderate‐certainty evidence that in‐store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low‐certainty evidence that urban planning restrictions on new fast‐food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied. Intersectoral approaches (8 studies): We found moderate‐certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate‐certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied. Home‐based interventions (7 studies): We found moderate‐certainty evidence that improved availability of low‐calorie beverages in the home environment is associated with decreased SSB intake, and high‐certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs. Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low‐calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes. We analysed interventions targeting sugar‐sweetened milk separately, and found low‐ to moderate‐certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar‐sweetened milk. We found low‐certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar‐sweetened milk consumption. Authors' conclusions The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high‐quality evaluations using appropriate study designs, with a particular focus on the long‐term effects of approaches suitable for large‐scale implementation. Plain language summary Cutting back on sugar‐sweetened beverages: What works? What are sugar‐sweetened beverages? Sugar‐sweetened beverages (SSBs) are cold and hot drinks with added sugar. Common SSBs are non‐diet soft drinks, regular soda, iced tea, sports drinks, energy drinks, fruit punches, sweetened waters, and sweetened tea and coffee. Why are SSBs an important health topic? Research shows that people who drink a lot of SSBs often gain weight. Drinking a lot of SSBs can also increase the risk of diabetes, heart disease, and dental decay. Doctors therefore recommend that children, teenagers and adults drink fewer SSBs. Governments, businesses, schools and workplaces have taken various measures to support healthier beverage choices. What is the aim of this review? We wanted to find out whether the measures taken so far have been successful in helping people to drink fewer SSBs to improve their health. We focused on measures that change the environment in which people make beverage choices. We did not look at studies on educational programmes or on SSB taxes, as these are examined in separate reviews. (We did, however, examine price increases on SSB which were not due to taxes.) We searched for all available studies meeting clearly‐defined criteria to answer this question. This review reflects the state of the evidence up until January 2018. What studies did we find? We found 58 studies, which included more than one million adults, teenagers and children. Most studies lasted about one year, and were done in schools, stores or restaurants. Some studies used methods that are not very reliable. For example, in some studies participants were simply asked how much SSB they drank, which is not very reliable, as people sometimes forget how much SSB they drank. Some of the findings of our review may therefore change when more and better studies become available. What do these studies tell us? We have found some evidence that some of the measures implemented to help people drink fewer SSBs have been successful, including the following: ▪ Labels which are easy to understand, such as traffic‐light labels, and labels which rate the healthfulness of beverages with stars or numbers. ▪ Limits to the availability of SSB in schools (e.g. replacing SSBs with water in school cafeterias). ▪ Price increases on SSBs in restaurants, stores and leisure centres. ▪ Children’s menus in chain restaurants which include healthier beverages as their standard beverage. ▪ Promotion of healthier beverages in supermarkets. ▪ Government food benefits (e.g. food stamps) which cannot be used to buy SSBs. ▪ Community campaigns focused on SSBs. ▪ Measures that improve the availability of low‐calorie beverages at home, e.g. through home deliveries of bottled water and diet beverages. We have also found some evidence that improved availability of drinking water and diet beverages at home can help people lose weight. There are also other measures which may influence how much SSB people drink, but for these the available evidence is less certain. Some, but not all studies found that such measures can have effects which were not intended and which may be negative. Some studies reported that profits of stores and restaurants decreased when the measures were implemented, but other studies showed that profits increased or stayed the same. Children who get free drinking water in schools may drink less milk. Some studies reported that people were unhappy with the measures. We also looked at studies on sugar‐sweetened milk. We found that small prizes for children who chose plain milk in their school cafeteria, as well as emoticon labels, may help children drink less sugar‐sweetened milk. However, this may also drive up the share of milk which is wasted because children choose but do not drink it. What does this mean in practice? Our review shows that measures which change the environment in which people make beverage choices can help people drink less SSB. Based on our findings we suggest that such measures may be used more widely. Government officials, business people and health professionals implementing such measures should work together with researchers to find out more about their effects in the short and long term.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "von Philipsborn, P, Stratil, JM, Burns, J, Busert, LK, Pfadenhauer, LM, Polus, S, Holzapfel, C, Hauner, H, Rehfuess, E", "articleTypes": [], "doi": "10.1002/14651858.CD012292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.783Z" }, { "id": "c81a0a01-51e9-48c9-8be8-4c2c0710b82e", "pmid": "", "title": "Glutamine for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Crohn's disease is a chronic relapsing condition of the alimentary tract with a high morbidity secondary to bowel inflammation. Glutamine plays a key role in maintaining the integrity of the intestinal mucosa and has been shown to reduce inflammation and disease activity in experimental models of Crohn's disease. Objectives To evaluate the efficacy and safety of glutamine supplementation for induction of remission in Crohn's disease. Search methods We searched the following databases from inception to November 15, 2015: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane IBD Group Specialised Register. Study references were also searched for additional trials. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) that compared glutamine supplementation administered by any route to a placebo, active comparator or no intervention in people with active Crohn's disease were considered for inclusion. Data collection and analysis Two authors independently extracted data and assessed the methodological quality of the included studies. The Cochrane risk of bias tool was used to assess methodological quality. The primary outcome measure was clinical or endoscopic remission. Secondary outcomes included intestinal permeability, clinical response, quality of life, growth in children and adverse events. Risk ratios and 95% confidence intervals were calculated for dichotomous outcomes. The overall quality of the evidence supporting the primary outcome was evaluated using the GRADE criteria. Main results Two small RCTs (total 42 patients) met the inclusion criteria and were included in the review. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. The other study (24 patients) compared glutamine‐supplemented total parenteral nutrition to non‐supplemented total parenteral nutrition in adult patients (> 18 years of age) with acute exacerbation of inflammatory bowel disease. The paediatric study was rated as low risk of bias. The study in adult patients was rated as unclear risk of bias for blinding and low risk of bias for all other items. It was not possible to pool data for meta‐analysis because of significant differences in study populations, nature of interventions, and the way outcomes were assessed. Data from one study showed no statistically significant difference in clinical remission rates at four weeks. Forty‐four per cent (4/9) of patients who received a glutamine‐enriched polymeric diet achieved remission compared to 56% (5/9) of patients who received a standard low‐glutamine polymeric diet (RR 0.80, 95% CI 0.31 to 2.04). A GRADE analysis indicated that the overall quality of evidence for this outcome was low due to serious imprecision (9 events). In both included studies, no statistically significant changes in intestinal permeability were found between patients who received glutamine supplementation and those who did not. Neither study reported on clinical response, quality of life or growth in children. Adverse event data were not well documented. There were no serious adverse events in the paediatric study. The study in adult patients reported three central catheter infections with positive blood cultures in the glutamine group compared to none in the control group (RR 7.00, 95% CI 0.40 to 122.44). Authors' conclusions Currently there is insufficient evidence to allow firm conclusions regarding the efficacy and safety of glutamine for induction of remission in Crohn's disease. Data from two small studies suggest that glutamine supplementation may not be beneficial in active Crohn's disease but these results need to be interpreted with caution as they are based on small numbers of patients. This review highlights the need for adequately powered randomised controlled trials to investigate the efficacy and safety of glutamine for induction of remission in Crohn's disease. Plain language summary Glutamine for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disorder of the intestines which has periods of inactivity and periods when it flares up. Crohn's disease can affect any part of the digestive tract, from the mouth to the anus. The most common symptoms of the disease include abdominal pain, non‐bloody diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms of the disease it is said to be ‘active’; periods when the symptoms stop are called ‘remission’. What is glutamine? Glutamine is an amino acid that plays a key role in maintaining the integrity of the intestinal mucosa (lining of the intestines) and has been shown to reduce inflammation and disease activity in animal models of Crohn's disease. It has therefore been suggested that glutamine may reduce intestinal inflammation in people with Crohn's disease. What did the researchers investigate? The researchers investigated whether glutamine is effective for inducing remission in people with active Crohn's disease and whether this treatment causes any harms (side effects). The researchers searched the medical literature up to November 15, 2015. What did the researchers find? The researchers identified two randomised controlled trials (total 42 participants) that investigated the role of glutamine for the treatment of active Crohn's disease. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. Participants were encouraged to consume the diet orally. If this was not possible the diet was administered via a fine‐bore nasogastric tube. The other study (24 participants) compared glutamine‐supplemented total parenteral nutrition (TPN) to non‐supplemented TPN in adult patients (> 18 years of age) with sudden worsening of inflammatory bowel disease. The TPN diet was administered intravenously via a central catheter (a thin tube) for at least one week. Both studies were generally high quality. Neither study demonstrated any beneficial effects for glutamine. Side effects were not well documented in the two studies. There were no serious side effects noted in the paediatric study. The study in adult patients reported three central catheter‐related blood infections in the glutamine group compared to none in the non‐glutamine control group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and harms of glutamine for the treatment of active Crohn's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Akobeng, AK; Elawad, M; Gordon, M", "articleTypes": [], "doi": "10.1002/14651858.CD007348.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "c8342319-a320-4fde-8c0c-e52379d0c5eb", "pmid": "", "title": "Dietary sodium manipulation and asthma", "imported": false, "abstract": "Abstract - Background There is a wide geographical variation in the prevalence of asthma and observational studies have suggested that dietary sodium may play a role. Objectives To assess the effect of dietary sodium manipulation on asthma control. Search methods We carried out a search using the Cochrane Airways Group asthma register. We searched the bibliographies of included randomised controlled trials (RCTs) for additional studies. We carried out the most recent search in November 2010. Selection criteria We considered only RCTs that involved dietary sodium reduction or increased sodium intake in patients with asthma. Data collection and analysis Both review authors assessed study and extracted data. We conducted data analyses in RevMan 5 using mean differences and random effects. Main results We identified a total of nine studies in relation to sodium manipulation and asthma, of which five were in people with asthma (318 participants), and four in people with exercise‐induced asthma (63 participants). There were no significant benefits of salt restriction on the control of asthma. There was some evidence from the exercise‐induced asthma studies that a low sodium diet may improve lung function after exercise and possibly baseline lung function, but this is based on findings from a very small numbers of participants. Authors' conclusions This review did not find any evidence that dietary sodium reduction significantly improves asthma control. Although dietary sodium reduction may result in improvements in lung function in exercise‐induced asthma, the clinical significance of this effect is unclear. Plain language summary Does reducing the amount of salt in a diet improve asthma symptoms? A review of the current literature suggests that reduction in the amount of dietary sodium consumed has no significant effect on the symptoms of asthma but may be associated with improvements in some lung function measurements in exercise‐induced asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Pogson, Z, McKeever, T", "articleTypes": [], "doi": "10.1002/14651858.CD000436.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.740Z" }, { "id": "c838f03f-b457-47cc-94d0-3802f6f7a366", "pmid": "", "title": "Interventions for preventing oral mucositis for patients with cancer receiving treatment", "imported": false, "abstract": "Abstract - Background Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers). Objectives To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment. Search methods Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL ( The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Selection criteria Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer. Data collection and analysis Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random‐effects models. Main results A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta‐analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte‐colony stimulating factor (G‐CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate. Authors' conclusions Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent. Plain language summary Interventions for preventing oral mucositis for patients with cancer receiving treatment Treatment for cancer (including bone marrow transplant) can cause oral mucositis (severe ulcers in the mouth). This painful condition can cause difficulties in eating, drinking and swallowing, and may also be associated with infections which may require the patient to stay longer in hospital. Different strategies are used to try and prevent this condition, and the review of trials found that some of these are effective. Two interventions, cryotherapy (ice chips) and keratinocyte growth factor (palifermin®) showed some benefit in preventing mucositis. Sucralfate is effective in reducing the severity of mucositis, and a further seven interventions, aloe vera, amifostine, intravenous glutamine, granulocyte‐colony stimulating factor (G‐CSF), honey, laser and antibiotic lozenges containing polymixin/tobramycin/amphotericin (PTA) showed weaker evidence of benefit. These were evaluated in patients with different types of cancer, undergoing different types of cancer treatment. Benefits may be restricted to the disease and treatment combinations evaluated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Worthington, HV, Clarkson, JE, Bryan, G, Furness, S, Glenny, A-M, Littlewood, A, McCabe, MG, Meyer, S, Khalid, T, Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD000978.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.787Z" }, { "id": "c848d4be-0cb0-41ca-8d22-1b01b9f7a66c", "pmid": "", "title": "Palliative drug treatments for breathlessness in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is a life‐limiting autosomal recessive genetic illness. A feeling of shortness of breath is common in cystic fibrosis, especially as the disease progresses. Reversing the underlying cause is the priority when treating breathlessness (dyspnoea), but when it is not feasible, palliation (easing) becomes the primary goal to improve an individual's quality of life. A range of drugs administered by various routes have been used, but no definite guidelines are available. A systematic review is needed to evaluate such treatments. Objectives To assess the efficacy and safety of drugs used to ease breathlessness in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 18 November 2019. We searched databases (clinicaltrials.gov, the ISRCTN registry, the Clinical Trials Registry India and WHO ICTRP) for ongoing trials. These searches were last run on 06 March 2020. Selection criteria We planned to include randomised and quasi‐randomised controlled trials in people with cystic fibrosis (diagnosed by a positive sweat chloride test or genetic testing) who have breathlessness. We considered studies comparing any drugs used for easing breathlessness to another drug administered by any route (inhaled (nebulised), intravenous, oral, subcutaneous, transmucosal (including buccal, sublingual and intra‐nasal) and transdermal). Data collection and analysis The authors assessed the search results according to the pre‐defined inclusion criteria. Main results The new searches in 2020 yielded two ongoing studies that were not relevant to the review question. Previous searches had found only one study (cross‐over in design), which did not fulfil the inclusion criteria as no data were available from the first treatment period alone. Authors' conclusions Due to the lack of available evidence, this review cannot provide any information for clinical practice. The authors call for specific research in this area after taking into account relevant ethical considerations. The research should focus on the efficacy and safety of the drugs with efficacy being measured in terms of improvement in quality of life, dyspnoea scores and hospital stay. Plain language summary Drug treatments to ease breathlessness in cystic fibrosis Review question What is the evidence that drug treatments for breathlessness (also known as dyspnoea) in people with cystic fibrosis are effective and safe? Background Cystic fibrosis is a life‐limiting genetic disease. As the disease progresses, thick sticky mucus is formed in the lungs, pancreas and other organs. This thick mucus increases risk of infection, blocks the airways and causes severe breathlessness. Easing of this breathlessness is an important goal for care of people with cystic fibrosis. Many methods have been suggested to address this problem and many drugs have been reported to ease breathlessness. The drugs can be administered through various routes ‐ they might be inhaled, swallowed, injected under the skin, into muscle or into a vein or be absorbed through the skin (either on the body or through membranes inside the mouth or nose). Despite so many drugs being available, there are no defined guidelines for drug treatments aimed at easing breathlessness in people with cystic fibrosis. Search date The evidence from the Cochrane Cystic Fibrosis Trials Register is current to 18 November 2019; the searches of ongoing trial registries are current to 06 March 2020. Study characteristics We had planned to include studies comparing different treatments to ease breathlessness in people with cystic fibrosis where the participants were put into the different treatment groups at random. Our search found only one study in which seven people first received either a drug called hydrocodone or a placebo (dummy treatment) and then swapped to the other treatment; but this study did not report results separately for each treatment arm, so we are not able to include it in the review. Key results No studies fulfilled the inclusion criteria, therefore it is not possible to comment on the outcomes we wished to report on in this review. Until evidence becomes available, the review authors feel that it is advisable for doctors to follow any local or national guidelines. The authors recommend research in this area should take ethical considerations into account and should focus on the safety of the drugs, improvement in quality of life, breathlessness scores and length of hospital stay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Jaiswal, N, Singh, M, Agarwal, A, Chauhan, A, Jaiswal, N", "articleTypes": [], "doi": "10.1002/14651858.CD011855.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.768Z" }, { "id": "c84935b7-59ad-408a-a58c-4c64a0428af6", "pmid": "", "title": "Probiotics for treatment of chronic constipation in children", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wallace, C, Sinopoulou, V, Gordon, M, Akobeng, AK, Llanos-Chea, A, Hungria, G, Febo-Rodriguez, L, Fifi, A, Fernandez Valdes, L, Langshaw, A, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014257.pub2 AB - Abstract - Background Functional constipation is defined as chronic constipation with no identifiable underlying cause. It is a significant cause of morbidity in children, accounting for up to 25% of visits to paediatric gastroenterologists. Probiotic preparations may sufficiently alter the gut microbiome and promote normal gut physiology in a way that helps relieve functional constipation. Several studies have sought to address this hypothesis, as well as the role of probiotics in other functional gut disorders. Therefore, it is important to have a focused review to assess the evidence to date. Objectives To evaluate the efficacy and safety of probiotics for the management of chronic constipation without a physical explanation in children. Search methods On 28 June 2021, we searched CENTRAL, MEDLINE, Embase, CINAHL, AMED, WHO ICTR, and ClinicalTrials.gov, with no language, date, publication status, or document type limitations. Selection criteria We included randomised controlled trials (RCTs) that assessed probiotic preparations (including synbiotics) compared to placebo, no treatment or any other interventional preparation in people aged between 0 and 18 years old with a diagnosis of functional constipation according to consensus criteria (such as Rome IV). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 14 studies (1127 randomised participants): 12 studies assessed probiotics in the treatment of functional constipation, whilst two studies investigated synbiotic preparations. Three studies compared probiotics to placebo in relation to the frequency of defecation at study end, but we did not pool them as there was very significant unexplained heterogeneity. Four studies compared probiotics to placebo in relation to treatment success. There may be no difference in global improvement/treatment success (RR 1.29, 95% CI 0.73 to 2.26; 313 participants; low‐certainty evidence). Five studies compared probiotics to placebo in relation to withdrawals due to adverse events, with the pooled effect suggesting there may be no difference (RR 0.64, 95% CI 0.21 to 1.95; 357 participants; low‐certainty evidence). The pooled estimate from three studies that compared probiotics plus an osmotic laxative to osmotic laxative alone found there may be no difference in frequency of defecation (MD ‐0.01, 95% CI ‐0.57 to 0.56; 268 participants; low‐certainty evidence). Two studies compared probiotics plus an osmotic laxative to osmotic laxative alone in relation to global improvement/treatment success, and found there may be no difference between the treatments (RR 0.95, 95% CI 0.79 to 1.15; 139 participants; low‐certainty evidence). Three studies compared probiotics plus osmotic laxative to osmotic laxative alone in relation to withdrawals due to adverse events, but it is unclear if there is a difference between them (RR 2.86, 95% CI 0.12 to 68.35; 268 participants; very low‐certainty evidence). Two studies compared probiotics versus magnesium oxide. It is unclear if there is a difference in frequency of defecation (MD 0.28, 95% CI ‐0.58 to 1.14; 36 participants), treatment success (RR 1.08, 95% CI 0.74 to 1.57; 36 participants) or withdrawals due to adverse events (RR 0.50, 95% CI 0.05 to 5.04; 77 participants). The certainty of the evidence is very low for these outcomes. One study assessed the role of a synbiotic preparation in comparison to placebo. There may be higher treatment success in favour of synbiotics compared to placebo (RR 2.32, 95% CI 1.54 to 3.47; 155 participants; low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study assessed a synbiotic plus paraffin compared to paraffin alone. It is uncertain if there is a difference in frequency of defecation (MD 0.74, 95% CI ‐0.96, 2.44; 66 participants; very low‐certainty evidence), or treatment success (RR 0.91, 95% CI 0.71 to 1.17; 66 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study compared a synbiotic preparation to paraffin. It is uncertain if there is a difference in frequency of defecation (MD ‐1.53, 95% CI ‐3.00, ‐0.06; 60 participants; very low‐certainty evidence) or in treatment success (RR 0.86, 95% CI 0.65, 1.13; 60 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. All secondary outcomes were either not reported or reported in a way that did not allow for analysis. Authors' conclusions There is insufficient evidence to conclude whether probiotics are efficacious in successfully treating chronic constipation without a physical explanation in children or changing the frequency of defecation, or whether there is a difference in withdrawals due to adverse events when compared with placebo. There is limited evidence from one study to suggest a synbiotic preparation may be more likely than placebo to lead to treatment success, with no difference in withdrawals due to adverse events. There is insufficient evidence to draw efficacy or safety conclusions about the use of probiotics in combination with or in comparison to any of the other interventions reported. The majority of the studies that presented data on serious adverse events reported that no events occurred. Two studies did not report this outcome. Future studies are needed to confirm efficacy, but the research community requires guidance on the best context for probiotics in such studies, considering where they should be best considered in a potential treatment hierarchy and should align with core outcome sets to support future interpretation of findings. Plain language summary Probiotics for treatment of chronic constipation in children What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can be used to treat chronic constipation without a physical explanation in children (aged 0 to 18 years). We analysed data from 14 studies to answer this question. Key messages We were unable to draw conclusions when comparing probiotics to placebo for frequency of defecation in children treated for chronic constipation without a physical explanation. There may be no difference in treatment success between the two groups. There may not be a difference in frequency of defecation or treatment success when comparing probiotics and laxatives to using laxatives alone. We were unable to draw conclusions when comparing probiotics to magnesium oxide for frequency of defecation or treatment success. There may be a higher frequency of defecation in children treated with synbiotic preparations compared to placebo. There may not be a difference in participants withdrawing from the studies due to adverse events when comparing probiotic preparations to placebo. We were unable to draw conclusions on the safety of any of the other comparisons due to the low number of people who withdrew from the studies. What was studied in the review? Children often suffer from constipation for long periods of time, and when there is no underlying physical cause that can be found we call it 'functional constipation'. It has been suggested that probiotic and synbiotic preparations might help improve symptoms in these children. Probiotics are preparations that contain living bacteria that have been proposed to be beneficial to the digestive system. Synbiotics also include food substances that support the growth of these bacteria. There is currently no consensus about whether this is the case, or how these preparations are best used. What are the main results of the review? We searched for randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) comparing any probiotic or synbiotic treatment with any other treatment (such as dummy/placebo treatments) in children with chronic constipation without a physical explanation. We found 14 trials including a total of 1127 participants who were aged under 18. We made the following conclusions.
• There may be no difference in treatment success when comparing probiotics to placebo.
• We were unable to draw conclusions on whether there is a difference in the frequency of defecation.
• There may be no difference in treatment success when comparing probiotics and laxatives to laxatives alone.
• We were unable to draw conclusions on frequency of defecation or treatment success when comparing probiotics to magnesium oxide.
• Synbiotics may be better than placebo in improving the frequency of defection.
• There may be no difference in how many people withdrew from the trials because of side effects when comparing probiotics to placebo, or probiotics and laxative to laxative alone.
• We have limited confidence in the evidence because the studies only included a small number of children, and due to lack of detail on some of the methods used. All analyses were limited due to differences in the specific probiotics or the treatments they were compared with, low numbers of children included in the studies and, most importantly, the use of a range of different measures of success. This meant that combining studies was difficult, so the overall ability of this review to answer its core questions was limited. What next? Future studies are needed to find out how helpful probiotics are for childhood constipation. Researchers need to agree whether probiotics should be a first option therapy, an add‐on to other therapies, a second option after other therapies have failed, or a combination of all the above. Future research should measure the same items (known as a core outcome set) to ensure these results can support future reviews. How up‐to‐date is this review? This review is current to June 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.088Z" }, { "id": "c85229f0-14c8-425e-856f-0168a7b270c8", "pmid": "", "title": "Interventions for hand eczema", "imported": false, "abstract": "Abstract - Background Hand eczema is an inflammation of the skin of the hands that tends to run a chronic, relapsing course. This common condition is often associated with itch, social stigma, and impairment in employment. Many different interventions of unknown effectiveness are used to treat hand eczema. Objectives To assess the effects of topical and systemic interventions for hand eczema in adults and children. Search methods We searched the following up to April 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, AMED, LILACS, GREAT, and four trials registries. We checked the reference lists of included studies for further references to relevant trials. Selection criteria We included randomised controlled trials (RCTs) that compared interventions for hand eczema, regardless of hand eczema type and other affected sites, versus no treatment, placebo, vehicle, or active treatments. Data collection and analysis We used standard methodological procedures expected by Cochrane. Primary outcomes were participant‐ and investigator‐rated good/excellent control of symptoms, and adverse events. Main results We included 60 RCTs, conducted in secondary care (5469 participants with mild to severe chronic hand eczema). Most participants were over 18 years old. The duration of treatment was short, generally up to four months. Only 24 studies included a follow‐up period. Clinical heterogeneity in treatments and outcome measures was evident. Few studies performed head‐to‐head comparisons of different interventions. Risk of bias varied considerably, with only five studies at low risk in all domains. Twenty‐two studies were industry‐funded. Eighteen trials studied topical corticosteroids or calcineurin inhibitors; 10 studies, phototherapy; three studies, systemic immunosuppressives; and five studies, oral retinoids. Most studies compared an active intervention against no treatment, variants of the same medication, or placebo (or vehicle). Below, we present results from the main comparisons. Corticosteroid creams/ointments: when assessed 15 days after the start of treatment, clobetasol propionate 0.05% foam probably improves participant‐rated control of symptoms compared to vehicle (risk ratio (RR) 2.32, 95% confidence interval (CI) 1.38 to 3.91; number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 8; 1 study, 125 participants); the effect of clobetasol compared to vehicle for investigator‐rated improvement is less clear (RR 1.43, 95% CI 0.86 to 2.40). More participants had at least one adverse event with clobetasol (11/62 versus 5/63; RR 2.24, 95% CI 0.82 to 6.06), including application site burning/pruritus. This evidence was rated as moderate certainty. When assessed 36 weeks after the start of treatment, mometasone furoate cream used thrice weekly may slightly improve investigator‐rated symptom control compared to twice weekly (RR 1.23, 95% CI 0.94 to 1.61; 1 study, 72 participants) after remission is reached. Participant‐rated symptoms were not measured. Some mild atrophy was reported in both groups (RR 1.76, 95% CI 0.45 to 6.83; 5/35 versus 3/37). This evidence was rated as low certainty. Irradiation with ultraviolet (UV) light: local combination ultraviolet light therapy (PUVA) may lead to improvement in investigator‐rated symptom control when compared to local narrow‐band UVB after 12 weeks of treatment (RR 0.50, 95% CI 0.22 to 1.16; 1 study, 60 participants). However, the 95% CI indicates that PUVA might make little or no difference. Participant‐rated symptoms were not measured. Adverse events (mainly erythema) were reported by 9/30 participants in the narrow‐band UVB group versus none in the PUVA group. This evidence was rated as moderate certainty. Topical calcineurin inhibitors: tacrolimus 0.1% over two weeks probably improves investigator‐rated symptom control measured after three weeks compared to vehicle (14/14 tacrolimus versus 0/14 vehicle; 1 study). Participant‐rated symptoms were not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. A within‐participant study in 16 participants compared 0.1% tacrolimus to 0.1% mometasone furoate but did not measure investigator‐ or participant‐rated symptoms. Both treatments were well tolerated when assessed at two weeks during four weeks of treatment. Evidence from these studies was rated as moderate certainty. Oral interventions: oral cyclosporin 3 mg/kg/d probably slightly improves investigator‐rated (RR 1.88, 95% CI 0.88 to 3.99; 1 study, 34 participants) or participant‐rated (RR 1.25, 95% CI 0.69 to 2.27) control of symptoms compared to topical betamethasone dipropionate 0.05% after six weeks of treatment. The risk of adverse events such as dizziness was similar between groups (up to 36 weeks; RR 1.22, 95% CI 0.80 to 1.86, n = 55; 15/27 betamethasone versus 19/28 cyclosporin). The evidence was rated as moderate certainty. Alitretinoin 10 mg improves investigator‐rated symptom control compared with placebo (RR 1.58, 95% CI 1.20 to 2.07; NNTB 11, 95% CI 6.3 to 26.5; 2 studies, n = 781) and alitretinoin 30 mg also improves this outcome compared with placebo (RR 2.75, 95% CI 2.20 to 3.43; NNTB 4, 95% CI 3 to 5; 2 studies, n = 1210). Similar results were found for participant‐rated symptom control: alitretinoin 10 mg RR 1.73 (95% CI 1.25 to 2.40) and 30 mg RR 2.75 (95% CI 2.18 to 3.48). Evidence was rated as high certainty. The number of adverse events (including headache) probably did not differ between alitretinoin 10 mg and placebo (RR 1.01, 95% CI 0.66 to 1.55; 1 study, n = 158; moderate‐certainty evidence), but the risk of headache increased with alitretinoin 30 mg (RR 3.43, 95% CI 2.45 to 4.81; 2 studies, n = 1210; high‐certainty evidence). Outcomes were assessed between 48 and 72 weeks. Authors' conclusions Most findings were from single studies with low precision, so they should be interpreted with caution. Topical corticosteroids and UV phototherapy were two of the major standard treatments, but evidence is insufficient to support one specific treatment over another. The effect of topical calcineurin inhibitors is not certain. Alitretinoin is more effective than placebo in controlling symptoms, but advantages over other treatments need evaluating. Well‐designed and well‐reported, long‐term (more than three months), head‐to‐head studies comparing different treatments are needed. Consensus is required regarding the definition of hand eczema and its subtypes, and a standard severity scale should be established. The main limitation was heterogeneity between studies. Small sample size impacted our ability to detect differences between treatments. Plain language summary Treatments for hand eczema Review question We reviewed evidence on the effects of topical and systemic (oral or injected medicines that work throughout the entire body) treatments for hand eczema when compared against placebo (an identical but inactive treatment), no treatment, vehicle (inactive ingredients that help deliver an active treatment), or another treatment. We included 60 randomised trials (5469 participants) published up to April 2018. Background Hand eczema is an inflammation of the skin of the hands that can be caused by contact allergens (i.e. substances that cause an allergic reaction) such as rubber chemicals, but other external factors (e.g. irritants such as water or detergents) and atopic predisposition are often important triggers. Hand eczema can cause a reduction in quality of life leading to many work‐related problems. Various types of hand eczema exist, and different topical (creams, ointments, or lotions) and systemic treatments with unknown effectiveness can be used. Study characteristics Most participants were hospital outpatients over 18 years of age with mild to severe chronic hand eczema. Treatment was usually given for up to four months, and outcomes were mainly assessed after treatment. A large variety of treatments were studied and compared to no treatment, variants of the same medication, placebo, or vehicle. Twenty‐two studies were funded by pharmaceutical companies. Key results Limited data are available to support the best way of managing hand eczema due to varying study quality and inability to pool data from studies with similar interventions. Corticosteroid creams/ointments and phototherapy (irradiation with UV light) are the major treatment options, although comparisons between these options are lacking. Below, we present results for the main comparisons of interest. Corticosteroid creams/ointments: clobetasol propionate foam probably increases participant‐rated good/excellent control of hand eczema when compared to vehicle (516 versus 222 per 1000), but the difference between groups was less clear for investigator‐rated control, and more adverse events were reported with clobetasol propionate (178 versus 79 per 1000) (all based on moderate‐certainty evidence). Mometasone furoate cream used thrice weekly may slightly improve investigator‐rated good/excellent control compared to twice weekly treatment, and participant‐rated control was not measured. Mild skin thinning occurred in both groups, but cases were few (all based on low‐certainty evidence). Irradiation with UV light: various types of irradiation (i.e. exposure to radiation) were compared. Local PUVA may improve investigator‐rated good/excellent control compared to narrow‐band UVB (400 versus 200 per 1000); however, we are uncertain of this finding because results also show that local PUVA may make little or no difference. Participant‐rated symptoms were not measured. Nine out of 30 participants in the narrow‐band UVB group reported adverse events (mainly redness) compared to none in the PUVA group (all based on moderate‐certainty evidence). Topical calcineurin inhibitors: people receiving tacrolimus are probably more likely to achieve improved investigator‐rated good/excellent symptom control compared to those given vehicle (14/14 participants with tacrolimus compared to none with vehicle), but participant‐rated control of symptoms was not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. One small study compared tacrolimus to mometasone furoate, which were both well tolerated, but did not measure investigator‐ or participant‐rated control (all based on moderate‐certainty evidence). Oral interventions: oral immunosuppressant (a drug that hinders the immune response) cyclosporin probably slightly improves investigator‐ or participant‐rated control of good/excellent symptoms compared to topical betamethasone cream (a corticosteroid). The risk of adverse events such as dizziness was similar between groups (all based on moderate‐certainty evidence). The oral vitamin A derivative (retinoid) alitretinoin (10 mg) achieved investigator‐rated good/excellent symptom control in 307 compared to 194 participants per 1000 with placebo, and alitretinoin 30 mg achieved investigator‐rated control in 432 compared to 157 participants per 1000 with placebo. Similar results were shown for participant‐rated control (high‐certainty evidence). When the dosage of alitretinoin was increased to 30 mg, risk of headache was higher compared to placebo (74 versus 251 per 1000; high‐certainty evidence), but this probably does not differ between alitretinoin 10 mg and placebo (based on moderate‐certainty evidence). Quality of the evidence The quality of evidence was mainly moderate, with most analyses based on single studies that had small sample sizes; therefore, some results should be interpreted with care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Christoffers, WA, Coenraads, PJ, Svensson, Å, Diepgen, TL, Dickinson‐Blok, JL, Xia, J, Williams, HC", "articleTypes": [], "doi": "10.1002/14651858.CD004055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.815Z" }, { "id": "c856deec-961d-4473-97ae-ced274cea434", "pmid": "", "title": "Oral Astragalus (Huang qi) for preventing frequent episodes of acute respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common in children and can involve both upper and lower airways. Many children experience frequent ARTI episodes or recurrent respiratory tract infections (RRTIs) in early life, which creates challenges for paediatricians, primary care physicians, parents and carers of children. In China, Astragalus (Huang qi), alone or in combination with other herbs, is used by Traditional Chinese Medicine (TCM) practitioners in the form of a water extract, to reduce the risk of ARTIs; it is believed to stimulate the immune system. Better understanding of the therapeutic mechanisms of Astragalus may provide insights into ARTI prevention, and consequently reduced antibiotic use. Objectives To assess the effectiveness and safety of oral Astragalus for preventing frequent episodes of acute respiratory tract infections (ARTIs) in children in community settings. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2015), MEDLINE (Ovid) (1946 to 31 December 2015), Embase (Elsevier) (1974 to 31 December 2015), AMED (Ovid) (1985 to 31 December 2015), Chinese National Knowledge Infrastructure (CNKI) (1979 to 31 December 2015) and Chinese Scientific Journals full text database (CQVIP) (1989 to 31 December 2015), China Biology Medicine disc (CBM 1976 to 31 December 2015) and Wanfang Data Knowledge Service Platform (WanFang) (1998 to 31 December 2015). Selection criteria We included randomised controlled trials (RCTs) comparing oral Astragalus as a sole Chinese herbal preparation with placebo to prevent frequent episodes of ARTIs in children. Data collection and analysis We used standard Cochrane methodological procedures for this review. We assessed search results to identify relevant studies. We planned to extract data using standardised forms. Disagreements were to be resolved through discussion. Risk of bias was to be assessed using the Cochrane 'Risk of bias' tool. We planned to use mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) or odds ratio (OR) to analyse dichotomous data, both with 95% confidence intervals (CIs). Main results We identified 6080 records: 3352 from English language databases, 2724 from Chinese databases, and four from other sources. Following initial screening and deduplication, we obtained 120 full‐text papers for assessment. Of these, 21 were not RCTs; 55 did not meet the inclusion criteria because: participants were aged over 14 years; definition was not included for recurrent or frequent episodes; Astragalus preparation was not an intervention; Astragalus preparation was in the formula but was not the sole agent; the Astragalus preparation was not administered orally; or Astragalus was used for treatment rather than prevention of ARTI. A further 44 studies were excluded because they were not placebo‐controlled, although other inclusion criteria were fulfilled. No RCTs met our inclusion criteria. Authors' conclusions We found insufficient evidence to enable assessment of the effectiveness and safety of oral Astragalus as a sole intervention to prevent frequent ARTIs in children aged up to 14 years. Plain language summary Can oral Astragalus (Huang qi) prevent frequent acute respiratory tract infections in children? Review question We assessed evidence for the benefits and harms of oral Astragalus used alone to prevent frequent episodes of acute respiratory infections (ARTIs) in children aged up to 14 years, compared to a dummy treatment. ARTIs include colds, sore throats, laryngitis, influenza, bronchitis and pneumonia. Background Many therapies are used to prevent ARTIs, especially in children. Astragalus, is a widely used and available herbal therapy that has been used for thousands of years in China to help prevent ARTIs. It is thought to boost immunity. Almost one in five children experience frequent ARTIs and treatment accounts for up to 75% of all prescribed antibiotics for children. Because most ARTIs are caused by viruses, antibiotics are not effective in treating these illnesses. Search date We searched the literature up to 31 December 2015. Study characteristics We identified 6080 potentially relevant records. After removing duplicate records, and those that did not meet our inclusion criteria, we obtained 120 full‐text studies. We carefully assessed these studies for possible inclusion. We excluded most studies because: they presented unclear diagnosis criteria; Astragalus preparation was used with other agents; or Astragalus was not compared with a dummy treatment. No studies met our inclusion criteria and so we were unable to analyse any results. Study funding sources We could not assess study funding sources. Key results We did not find any studies that compared use of oral Astragalus alone with a dummy treatment to prevent frequent episodes of ARTI in children aged up to 14 years. Well‐designed, conducted and reported studies investigating this issue are needed to enable assessment in the future. Quality of the evidence We could not assess evidence quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Su, G; Chen, X; Liu, Z; Yang, L; Zhang, L; Stålsby Lundborg, C; Wen, Z; Guo, X; Qin, X; Liang, J; Liu, X", "articleTypes": [], "doi": "10.1002/14651858.CD011958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "c866017c-df0a-496b-b2f8-cc567529c2ed", "pmid": "", "title": "Chloral hydrate as a sedating agent for neurodiagnostic procedures in children", "imported": false, "abstract": "Abstract - Background This is an updated version of a Cochrane Review published in 2017. Paediatric neurodiagnostic investigations, including brain neuroimaging and electroencephalography (EEG), play an important role in the assessment of neurodevelopmental disorders. The use of an appropriate sedative agent is important to ensure the successful completion of the neurodiagnostic procedures, particularly in children, who are usually unable to remain still throughout the procedure. Objectives To assess the effectiveness and adverse effects of chloral hydrate as a sedative agent for non‐invasive neurodiagnostic procedures in children. Search methods We searched the following databases on 14 May 2020, with no language restrictions: the Cochrane Register of Studies (CRS Web) and MEDLINE (Ovid, 1946 to 12 May 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including Cochrane Epilepsy. Selection criteria Randomised controlled trials that assessed chloral hydrate agent against other sedative agent(s), non‐drug agent(s), or placebo. Data collection and analysis Two review authors independently evaluated studies identified by the search for their eligibility, extracted data, and assessed risk of bias. Results were expressed in terms of risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CIs). Main results We included 16 studies with a total of 2922 children. The methodological quality of the included studies was mixed. Blinding of the participants and personnel was not achieved in most of the included studies, and three of the 16 studies were at high risk of bias for selective reporting. Evaluation of the efficacy of the sedative agents was also underpowered, with all the comparisons performed in small studies. Fewer children who received oral chloral hydrate had sedation failure compared with oral promethazine (RR 0.11, 95% CI 0.01 to 0.82; 1 study; moderate‐certainty evidence). More children who received oral chloral hydrate had sedation failure after one dose compared to intravenous pentobarbital (RR 4.33, 95% CI 1.35 to 13.89; 1 study; low‐certainty evidence), but there was no clear difference after two doses (RR 3.00, 95% CI 0.33 to 27.46; 1 study; very low‐certainty evidence). Children with oral chloral hydrate had more sedation failure compared with rectal sodium thiopental (RR 1.33, 95% CI 0.60 to 2.96; 1 study; moderate‐certainty evidence) and music therapy (RR 17.00, 95% CI 2.37 to 122.14; 1 study; very low‐certainty evidence). Sedation failure rates were similar between groups for comparisons with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam and oral clonidine. Children who received oral chloral hydrate had a shorter time to adequate sedation compared with those who received oral dexmedetomidine (MD −3.86, 95% CI −5.12 to −2.6; 1 study), oral hydroxyzine hydrochloride (MD −7.5, 95% CI −7.85 to −7.15; 1 study), oral promethazine (MD −12.11, 95% CI −18.48 to −5.74; 1 study) (moderate‐certainty evidence for three aforementioned outcomes), rectal midazolam (MD −95.70, 95% CI −114.51 to −76.89; 1 study), and oral clonidine (MD −37.48, 95% CI −55.97 to −18.99; 1 study) (low‐certainty evidence for two aforementioned outcomes). However, children with oral chloral hydrate took longer to achieve adequate sedation when compared with intravenous pentobarbital (MD 19, 95% CI 16.61 to 21.39; 1 study; low‐certainty evidence), intranasal midazolam (MD 12.83, 95% CI 7.22 to 18.44; 1 study; moderate‐certainty evidence), and intranasal dexmedetomidine (MD 2.80, 95% CI 0.77 to 4.83; 1 study, moderate‐certainty evidence). Children who received oral chloral hydrate appeared significantly less likely to complete neurodiagnostic procedure with child awakening when compared with rectal sodium thiopental (RR 0.95, 95% CI 0.83 to 1.09; 1 study; moderate‐certainty evidence). Chloral hydrate was associated with a higher risk of the following adverse events: desaturation versus rectal sodium thiopental (RR 5.00, 95% 0.24 to 102.30; 1 study), unsteadiness versus intranasal dexmedetomidine (MD 10.21, 95% CI 0.58 to 178.52; 1 study), vomiting versus intranasal dexmedetomidine (MD 10.59, 95% CI 0.61 to 185.45; 1 study) (low‐certainty evidence for aforementioned three outcomes), and crying during administration of sedation versus intranasal dexmedetomidine (MD 1.39, 95% CI 1.08 to 1.80; 1 study, moderate‐certainty evidence). Chloral hydrate was associated with a lower risk of the following: diarrhoea compared with rectal sodium thiopental (RR 0.04, 95% CI 0.00 to 0.72; 1 study), lower mean diastolic blood pressure compared with sodium thiopental (MD 7.40, 95% CI 5.11 to 9.69; 1 study), drowsiness compared with oral clonidine (RR 0.44, 95% CI 0.30 to 0.64; 1 study), vertigo compared with oral clonidine (RR 0.15, 95% CI 0.01 to 2.79; 1 study) (moderate‐certainty evidence for aforementioned four outcomes), and bradycardia compared with intranasal dexmedetomidine (MD 0.17, 95% CI 0.05 to 0.59; 1 study; high‐certainty evidence). No other adverse events were significantly associated with chloral hydrate, although there was an increased risk of combined adverse events overall (RR 7.66, 95% CI 1.78 to 32.91; 1 study; low‐certainty evidence). Authors' conclusions The certainty of evidence for the comparisons of oral chloral hydrate against several other methods of sedation was variable. Oral chloral hydrate appears to have a lower sedation failure rate when compared with oral promethazine. Sedation failure was similar between groups for other comparisons such as oral dexmedetomidine, oral hydroxyzine hydrochloride, and oral midazolam. Oral chloral hydrate had a higher sedation failure rate when compared with intravenous pentobarbital, rectal sodium thiopental, and music therapy. Chloral hydrate appeared to be associated with higher rates of adverse events than intranasal dexmedetomidine. However, the evidence for the outcomes for oral chloral hydrate versus intravenous pentobarbital, rectal sodium thiopental, intranasal dexmedetomidine, and music therapy was mostly of low certainty, therefore the findings should be interpreted with caution. Further research should determine the effects of oral chloral hydrate on major clinical outcomes such as successful completion of procedures, requirements for an additional sedative agent, and degree of sedation measured using validated scales, which were rarely assessed in the studies included in this review. The safety profile of chloral hydrate should be studied further, especially for major adverse effects such as oxygen desaturation. Plain language summary The effectiveness of chloral hydrate as a sedative agent for children undergoing neurodiagnostic procedures Review question In children undergoing non‐invasive neurodiagnostic procedures, is chloral hydrate more effective at producing adequate sedation (slowing of brain activity) and safer than other ways of achieving sedation? Background Neurodiagnostic procedures are non‐invasive neurological investigations important for children with suspected neurological disorders. These investigations include brain imaging and brain electrical activity testing. For these tests to be successfully performed, the child needs to remain still for at least 30 to 45 minutes during the investigation period. Sedative agents are required for children, who are usually unable to remain still for this period of time. Search date The evidence is current to May 2020. Study characteristics We included 16 studies involving a total of 2922 children (age up to 18 years old) in the review. All of the included studies were performed in hospitals that provided neurodiagnostic services. Most studies assessed the following three main outcomes: proportion of children who were unsuccessfully sedated for the neurodiagnostic procedure; length of time taken for adequate sedation; and side effects associated with the sedative agent. The quality of the evidence was mixed, ranging from very low to high. The main reason for lowering the quality of the evidence was that those closely involved in the trials, such as the doctors giving the sedation or the parents of the child, were not masked to the sedative agent used in the child, which could have affected their recording or interpretation of the results. Key results We summarised the evidence of effectiveness and harms of oral chloral hydrate sedation when compared with other sedative agents. Our review suggests that oral chloral hydrate is just as effective a sedative agent with similar sedation failure rate when compared with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam, and oral clonidine; and probably a more effective sedative agent with a lower sedation failure rate when compared with oral promethazine. Whilst most of the included studies showed that chloral hydrate was safe with no increase in side effects when compared to other sedative agents, one study reported an increased risk of side effects with oral chloral hydrate when compared with intranasal dexmedetomidine. Quality of the evidence The quality of most of the evidence was poor due to flaws in study methods and the small sample size of each study, therefore our confidence in the results of the studies is reduced. Conclusions Apart from intravenous pentobarbital, rectal sodium thiopental, and music therapy, oral chloral hydrate is either just as effective or more effective as a sedating agent when compared to other sedating agents for children undergoing non‐invasive neurodiagnostic procedures. Given the poor quality of the evidence, we could draw no clear conclusions on the effectiveness or safety of any of the paediatric sedative agents studied in the review. Further study is needed to look at the side effects of oral chloral hydrate when compared to other sedatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Fong, CY, Lim, WK, Li, L, Lai, NM", "articleTypes": [], "doi": "10.1002/14651858.CD011786.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.781Z" }, { "id": "c867faab-c7b3-47c5-bb51-f8edcad91b88", "pmid": "", "title": "Antiamoebic drugs for treating amoebic colitis", "imported": false, "abstract": "Abstract - Background Infection with the protozoan Entamoeba histolytica is common in low‐ and middle‐income countries, and up to 100,000 people with severe disease die every year. Adequate therapy for amoebic colitis is necessary to reduce illness, prevent development of complicated disease and extraintestinal spread, and decrease transmission. Objectives To evaluate antiamoebic drugs for treating amoebic colitis. Search methods We searched the available literature up to 22 March 2018. We searched the Cochrane Infectious Diseases Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, m RCT, and conference proceedings. We contacted individual researchers, organizations, and pharmaceutical companies, and we checked reference lists. Selection criteria Randomized controlled trials of antiamoebic drugs given alone or in combination, compared with placebo or another antiamoebic drug, for treating adults and children with a diagnosis of amoebic colitis. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of trials and extracted and analysed the data. We calculated clinical and parasitological failure rates and rates of relapse and adverse events as risk ratios (RRs) with 95% confidence intervals (CIs), using a random‐effects model. We determined statistical heterogeneity and explored possible sources of heterogeneity using subgroup analyses. We carried out sensitivity analysis by using trial quality to assess the robustness of reported results. Main results In total, 41 trials (4999 participants) met the inclusion criteria of this review. In this update, we added four trials to the 37 trials included in the first published review version. Thirty trials were published over 20 years ago. Only one trial used adequate methods of randomization and allocation concealment, was blinded, and analysed all randomized participants. Only one trial used an E histolytica stool antigen test, and two trials used amoebic culture. Tinidazole may be more effective than metronidazole for reducing clinical failure (RR 0.28, 95% CI 0.15 to 0.51; 477 participants, eight trials; low‐certainty evidence) and is probably associated with fewer adverse events (RR 0.65, 95% CI 0.46 to 0.92; 477 participants, 8 trials; moderate‐certainty evidence). Compared with metronidazole, combination therapy may result in fewer parasitological failures (RR 0.36, 95% CI 0.15 to 0.86; 720 participants, 3 trials; low‐certainty evidence), but we are uncertain which combination is more effective than another. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Authors' conclusions Compared with metronidazole, tinidazole may be more effective in reducing clinical failure and may be associated with fewer adverse events. Combination drug therapy may be more effective for reducing parasitological failure compared with metronidazole alone. However, these results are based mostly on small trials conducted over 20 years ago with a variety of poorly defined outcomes. Tests that detect E histolytica more accurately are needed, particularly in countries where concomitant infection with other bacteria and parasites is common. 11 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (22 Mar, 2018) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Antiamoebic drugs for treating amoebic colitis What is the aim of this review? This Cochrane Review aims to determine the effectiveness and safety of drugs used to treat people with amoebic colitis, which is an infection of the large intestines caused by the parasite, Entamoeba histolytica . Cochrane researchers searched for all relevant studies to answer this question and included 41 relevant studies in this review. Key messages Tinidazole may be more effective than metronidazole for reducing clinical symptoms and may be associated with fewer adverse events. Combination therapy resulted in fewer parasitological failures than occurred with metronidazole alone. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Better quality randomized trials using accurate diagnostic methods and standardized outcomes are needed to evaluate the efficacy of drugs for treating individuals with amoebic colitis. What was studied in the review? Entamoeba histolytica is distributed throughout the world and is commonly acquired by ingestion of contaminated food or water. An estimated 40 to 50 million people infected with E histolytica develop amoebic colitis or extraintestinal abscesses, resulting in up to 100,000 deaths per year. Metronidazole is currently the standard therapy for treating adults and children with invasive amoebiasis, but it may not be sufficient to eliminate amoebic cysts from the intestine. Some unpleasant adverse effects have been associated with metronidazole, and the possibility of parasite resistance to metronidazole has led to the development of alternative drugs. Combinations of metronidazole with other drugs that eradicate surviving cysts in the intestines have been recommended, so evidence to support this approach needs to be assessed. This review compares different drugs used against amoebic colitis, alone or in combination, and also assesses single‐dose regimens versus longer regimens. What are the main results of the review? This review included 41 studies, most of which were conducted in countries considered to be highly endemic for amoebiasis. Most trials were old: 30 were conducted before 1998. Trials varied in the inclusion criteria used to enrol participants and in the definition and timing of measured outcomes. Stool microscopy with direct wet saline smear was the method used most often to detect the presence of E histolytica in stools. Study participants ranged in age from seven months to 80 years. Included trials reported a variety of comparisons and involved 25 individual drugs, two herbal products, and 15 different combinations. The review shows that in individuals with amoebic colitis, tinidazole may be better for reducing clinical symptoms (low‐certainty evidence) and probably results in fewer adverse events when compared with metronidazole (moderate‐certainty evidence). However, we do not know whether it is more effective for eradicating amoebae from the stools. Combination drug therapy may be more effective than metronidazole alone for eradicating amoebae (low‐certainty evidence), but we are uncertain which drug combination is most effective, and if combination treatment will lead to more rapid resolution of clinical symptoms or in more adverse events (very low‐certainty evidence). Evidence is insufficient to allow conclusions regarding efficacy of the other antiamoebic drugs. How up‐to‐date is this review? 
 The review authors searched for studies that had been published up to 22 March 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gonzales, MLM; Dans, LF; Sio‐Aguilar, J", "articleTypes": [], "doi": "10.1002/14651858.CD006085.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "c875092f-6595-4944-93aa-0470fd7e2ea9", "pmid": "", "title": "Vitamin D for the treatment of inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Vitamin D possesses immunomodulatory properties and has been implicated in the pathogenesis and severity of inflammatory bowel disease (IBD). Animal studies and emerging epidemiological evidence have demonstrated an association between vitamin D deficiency and worse disease activity. However, the role of vitamin D for the treatment of IBD is unclear. Objectives To evaluate the benefits and harms of vitamin D supplementation as a treatment for IBD. Search methods We used standard, extensive Cochrane search methods. The latest search date was Jun 2023. Selection criteria We included randomised controlled trials (RCTs) in people of all ages with active or inactive IBD comparing any dose of vitamin D with another dose of vitamin D, another intervention, placebo, or no intervention. We defined doses as: vitamin D (all doses), any‐treatment‐dose vitamin D (greater than 400 IU/day), high‐treatment‐dose vitamin D (greater than 1000 IU/day), low‐treatment‐dose vitamin D (400 IU/day to 1000 IU/day), and supplemental‐dose vitamin D (less than 400 IU/day). Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. clinical response for people with active disease, 2. clinical relapse for people in remission, 3. quality of life, and 4. withdrawals due to adverse events. Our secondary outcomes were 5. disease activity at end of study, 6. normalisation of vitamin D levels at end of study, and 7. total serious adverse events. We used GRADE to assess certainty of evidence for each outcome. Main results We included 22 RCTs with 1874 participants. Study duration ranged from four to 52 weeks. Ten studies enroled people with Crohn's disease (CD), five enroled people with ulcerative colitis (UC), and seven enroled people with CD and people with UC. Seventeen studies included adults, three included children, and two included both. Four studies enroled people with active disease, six enroled people in remission, and 12 enroled both. We assessed each study for risk of bias across seven individual domains. Five studies were at low risk of bias across all seven domains. Ten studies were at unclear risk of bias in at least one domain but with no areas of high risk of bias. Seven studies were at high risk of bias for blinding of participants and assessors. Vitamin D (all doses) versus placebo or no treatment Thirteen studies compared vitamin D against placebo or no treatment. We could not draw any conclusions on clinical response for UC as the certainty of the evidence was very low (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.51 to 10.57; 1 study, 60 participants). There were no data on CD. There may be fewer clinical relapses for IBD when using vitamin D compared to placebo or no treatment (RR 0.57, 95% CI 0.34 to 0.96; 3 studies, 310 participants). The certainty of the evidence was low. We could not draw any conclusions on quality of life for IBD (standardised mean difference (SMD) −0.13, 95% CI −3.10 to 2.83 (the SMD value indicates a negligent decrease in quality of life, and the corresponding CIs indicate that the effect can range from a large decrease to a large increase in quality of life); 2 studies, 243 participants) or withdrawals due to adverse events for IBD (RR 1.97, 95% CI 0.18 to 21.27; 12 studies, 1251 participants; note 11 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 12). The certainty of the evidence was very low. High‐treatment‐dose vitamin D versus low‐treatment‐dose vitamin D Five studies compared high treatment vitamin D doses against low treatment vitamin D doses. There were no data on clinical response. There may be no difference in clinical relapse for CD (RR 0.48, 95% CI 0.23 to 1.01; 1 study, 34 participants). The certainty of the evidence was low. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 0.89, 95% CI 0.06 to 13.08; 3 studies, 104 participants; note 2 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 3). The data on quality of life and disease activity could not be meta‐analysed, were of very low certainty, and no conclusions could be drawn. Any‐treatment‐dose vitamin D versus supplemental‐dose vitamin D Four studies compared treatment doses of vitamin D against supplemental doses. There were no data on clinical response and relapse. There were no data on quality of life that could be meta‐analysed. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 3.09, 95% CI 0.13 to 73.17; 4 studies, 233 participants; note 3 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 4). Authors' conclusions There may be fewer clinical relapses when comparing vitamin D with placebo, but we cannot draw any conclusions on differences in clinical response, quality of life, or withdrawals, due to very low‐certainty evidence. When comparing high and low doses of vitamin D, there were no data for clinical response, but there may be no difference in relapse for CD. We cannot draw conclusions on the other outcomes due to very low certainty evidence. Finally, comparing vitamin D (all doses) to supplemental‐dose vitamin D, there were no data on clinical relapse or response, and we could not draw conclusions on other outcomes due to very low certainty evidence or missing data. It is difficult to make any clear recommendations for future research on the basis of the findings of this review. Future studies must be clear on the baseline populations, the purpose of vitamin D treatment, and, therefore, study an appropriate dosing strategy. Stakeholders in the field may wish to reach consensus on such issues prior to new studies. Plain language summary Vitamin D for the treatment of inflammatory bowel disease Key messages The data we presently have for the use of vitamin D for the treatment of inflammatory bowel disease are of very low quality, and we do not know whether it works or if it is safe. What is inflammatory bowel disease? Inflammatory bowel disease is a life‐long disease that affects the gut. Its two main types are ulcerative colitis and Crohn's disease. Ulcerative colitis only affects the large intestine. Crohn's disease can affect any part of the gut, from mouth to bottom. Common symptoms include bloody poo, diarrhoea, stomach ache, fever, weight loss, and fatigue. We do not know exactly what causes it, but it is probably a mix of genes, problems with the immune system, bacteria in the gut, and something in the environment. There is no known cure, but the symptoms are usually managed with medicines, such as steroids and immune system medications, and sometimes surgery. Most people with inflammatory bowel disease have times when they have symptoms (called active disease) and other times when their symptoms are under control (called remission). When symptoms reappear after being in remission, it is called relapse. What did we want to find out? We wanted to find out if vitamin D works for the treatment of inflammatory bowel disease, and whether it is safe to use. Specifically, we looked at improvement of symptoms for people with active disease; relapse for people in remission; quality of life; and withdrawals from the trial because of side effects. What did we do? We searched for randomised controlled trials (studies where people are assigned to one of two or more treatment groups using a random method) comparing vitamin D with any other treatment, standard treatment, or different doses of vitamin D. What did we find? We found 22 trials with 1874 participants with inflammatory bowel disease. The studies lasted from four to 52 weeks. Ten studies were on Crohn's disease, five on ulcerative colitis, and seven on participants who had either of these. Seventeen studies were on adults, three on children, and two on both. Four included people with active disease, six in remission, and 12 on a mix of both. The studies included doses of vitamin D used to treat deficiency and doses given as supplements. Thirteen studies compared vitamin D (all doses) against placebo (dummy treatment) or no other treatment. There was low‐quality evidence that there may be fewer clinical relapses when using vitamin D compared to placebo or no treatment. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Five studies compared high‐treatment‐doses to low‐treatment‐doses of vitamin D. There were no data on improvement of symptoms. There was low‐quality evidence that there may be no difference on relapse in Crohn's disease, but there were no data on ulcerative colitis. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. Four studies compared treatment doses to supplement doses of vitamin D. There were no data on improvement of symptoms, relapses, or quality of life changes. We cannot say anything about any of the other measures we looked at because the quality of the evidence was very low. What are the limitations of the evidence? The evidence is mostly of very low and low quality. This is because of problems with the way the studies were carried out, and problems with how the results were reported. Additionally, the individual studies did not make the same measurements, meaning that we did not have enough numbers of people to strengthen the results of the measures we looked for. How up‐to‐date is this review? This review is up‐to‐date to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wallace, C; Gordon, M; Sinopoulou, V; Limketkai, BN", "articleTypes": [], "doi": "10.1002/14651858.CD011806.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "c88cfcf8-ede4-4ce0-abd6-996d2f1e04fa", "pmid": "", "title": "Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010. For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established. Objectives To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications. Search methods Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012. Selection criteria Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Data collection and analysis Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information. Main results One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012. Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study. Weight loss was greater for the NG group at six weeks post‐treatment than for the PEG group (P = 0.001). At six months post‐treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post‐treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively. We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review. Authors' conclusions There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required. Plain language summary Artificial tube feeding methods for use with patients with head and neck cancer who are receiving treatment with radiotherapy, chemotherapy or both Patients with cancer of the head and neck are at risk of malnutrition during radiotherapy treatment due to the side effects of this treatment and they may need tube feeding to meet their nutritional needs. Tube feeding can either be delivered via a nasogastric feeding tube, which is a fine tube inserted through the nose into the stomach, or a gastrostomy tube which is inserted through the skin of the abdomen directly into the stomach. Both of these methods allow the delivery of nutrients directly into the stomach. Tube feeding is essential to meet the nutritional needs of head and neck cancer patients as malnutrition can lead to a poorer prognosis for this patient group. There is debate over which method of tube feeding provides the most benefit to the patient for outcomes such as nutritional benefit and quality of life, as well as avoiding delays in radiotherapy treatment. Following our analysis of the available literature, only one clinical trial was eligible to be included in this review. The authors of this review found no evidence to support the use of any one method of tube feeding over another.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Nugent, B; Lewis, S; O'Sullivan, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007904.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "c88f9696-13a6-4d8f-b3fb-eb87dbc8e772", "pmid": "", "title": "Mindfulness‐enhanced parenting programmes for improving the psychosocial outcomes of children (0 to 18 years) and their parents", "imported": false, "abstract": "Abstract - Background Emotional and behavioural difficulties (EBD) in children are common, characterised by externalising or internalising behaviours that can be highly stable over time. EBD are an important cause of functional disability in childhood, and predictive of poorer psychosocial, academic, and occupational functioning into adolescence and adulthood. The prevalence, stability, and long‐term consequences of EBD highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Multiple factors contribute to the aetiology of EBD in children, and parenting plays an important role. The relationship between parenting and EBD has been described as bidirectional, with parents and children shaping one another’s behaviour. One consequence of bidirectionality is that parents with insufficient parenting skills may become involved in increasingly negative behaviours when dealing with non‐compliance in children. This can have a cyclical effect, exacerbating child behavioural difficulties and further increasing parental distress. Behavioural or skills‐based parenting training can be highly effective in addressing EBD in children. However, emotional dysregulation may intercept some parents' ability to implement parenting skills, and there is recognition that skills‐based interventions may benefit from adjunct components that better target parental emotional responses. Mindful parenting interventions have demonstrated some efficacy in improving child outcomes via improvements in parental emotion regulation, and there is potential for mindfulness training to enhance the effectiveness of standard parent training programmes. Objectives To assess the effectiveness of mindfulness‐enhanced parent training programmes on the psychosocial functioning of children (aged 0 to 18 years) and their parents. Search methods We searched the following databases up to April 2023: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, PsycINFO, Sociological Abstracts, Social Sciences Citation Index, Conference Proceedings Citation Index – Social Science & Humanities, AMED, ERIC, ProQuest Dissertations & Theses, Cochrane Database of Systematic Reviews, Campbell Collaboration Library of Systematic Reviews, as well as the following trials registers: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also contacted organisations/experts in the field. Selection criteria We included randomised and quasi‐randomised trials. Participants were parents or caregivers of children under the age of 18. The intervention was mindfulness‐enhanced parent training programmes compared with a no‐intervention, waitlist, or attentional control, or a parent training programme with no mindfulness component. The intervention must have combined mindfulness parent training with behavioural or skills‐based parent training. We defined parent training programmes in terms of the delivery of a standardised and manualised intervention over a specified and limited period, on a one‐to‐one or group‐basis, with a well‐defined mindfulness component. The mindfulness component must have included mindfulness training (breath, visualisation, listening, or other sensory focus) and an explicit focus on present‐focused attention and non‐judgemental acceptance. Data collection and analysis We followed standard Cochrane procedures. Main results Eleven studies met our inclusion criteria, including one ongoing study. The studies compared a mindfulness‐enhanced parent training programme with a no‐treatment, waitlist, or attentional control (2 studies); a parent training programme with no mindfulness component (5 studies); both a no‐treatment, waitlist, or attentional control and a parent training programme with no mindfulness component (4 studies). We assessed all studies as being at an unclear or high risk of bias across multiple domains. We pooled child and parent outcome data from 2118 participants to produce effect estimates. No study explicitly reported on self‐compassion, and no adverse effects were reported in any of the studies. Mindfulness‐enhanced parent training programmes compared to a no‐treatment, waitlist, or attentional control Very low certainty evidence suggests there may be a small to moderate postintervention improvement in child emotional and behavioural adjustment (standardised mean difference (SMD) −0.46, 95% confidence interval (CI) −0.96 to 0.03; P = 0.06, I 2 = 62%; 3 studies, 270 participants); a small improvement in parenting skills (SMD 0.22, 95% CI 0.06 to 0.39; P = 0.008, I 2 = 0%; 3 studies, 587 participants); and a moderate decrease in parental depression or anxiety (SMD −0.50, 95% CI −0.96 to −0.04; P = 0.03; 1 study, 75 participants). There may also be a moderate to large decrease in parenting stress (SMD −0.79, 95% CI −1.80 to 0.23; P = 0.13, I 2 = 82%; 2 studies, 112 participants) and a small improvement in parent mindfulness (SMD 0.21, 95% CI −0.14 to 0.56; P = 0.24, I 2 = 69%; 3 studies, 515 participants), but we were not able to exclude little to no effect for these outcomes. Mindfulness‐enhanced parent training programmes compared to parent training with no mindfulness component Very low certainty evidence suggests there may be little to no difference postintervention in child emotional and behavioural adjustment (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.71, I 2 = 64%; 5 studies, 203 participants); parenting skills (SMD 0.13, 95% CI −0.16 to 0.42; P = 0.37, I 2 = 16%; 3 studies, 319 participants); and parent mindfulness (SMD 0.11, 95% CI −0.19 to 0.41; P = 0.48, I 2 = 44%; 4 studies, 412 participants). There may be a slight decrease in parental depression or anxiety (SMD −0.24, 95% CI −0.83 to 0.34; P = 0.41; 1 study, 45 participants; very low certainty evidence), though we cannot exclude little to no effect, and a moderate decrease in parenting stress (SMD −0.51, 95% CI −0.84 to −0.18; P = 0.002, I 2 = 2%; 3 studies, 150 participants; low certainty evidence). Authors' conclusions Mindfulness‐enhanced parenting training may improve some parent and child outcomes, with no studies reporting adverse effects. Evidence for the added value of mindfulness training to skills‐based parenting training programmes is suggestive at present, with moderate reductions in parenting stress. Given the very low to low certainty evidence reviewed here, these estimates will likely change as more high‐quality studies are produced. Plain language summary Mindfulness‐enhanced parenting programs for improving outcomes for children and their parents Key messages • Mindfulness‐enhanced parent training programmes may improve some child and parent outcomes, including child emotional and behavioural adjustment, parenting skills, parental depression or anxiety, parenting stress, and parent mindfulness. • When mindfulness parent training is combined with a skills‐based parent training programme, this may decrease parenting stress. • The current body of evidence is limited, with more research needed to be confident in our findings. Children's emotional and behavioural difficulties Emotional and behavioural difficulties in children are common, and are characterised by a range of externalising and/or internalising behaviours that can be highly stable over time. They are an important cause of functional disability in childhood, and predictive of poor psychosocial, academic, and occupational functioning into adolescence and beyond. The prevalence, stability, and long‐term consequences of emotional and behavioural difficulties highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Why mindfulness‐enhanced parent training? Parenting plays an important role in the development and/or maintenance of emotional and behavioural difficulties in children. Traditional behavioural or skills‐based parent training programmes have been shown to have a positive impact on a range of child and parent outcomes, but they do not work for all parents. One reason for this might be that parents' emotional reactions could prevent them from using parenting skills effectively. Including additional components into parenting training that aim to improve parental emotional responses may enhance the outcomes of these programmes. Recent research shows that mindful parenting interventions may promote positive outcomes for parents and children by improving parents' ability to regulate emotions and stress. Combining mindful parenting approaches with traditional parent training programmes may therefore be beneficial for both parents and their children. What did we want to find out? We explored whether behavioural or skills‐based parent training programmes with a mindfulness component – 'mindfulness‐enhanced' parent training programmes – can improve outcomes for children and their caregivers. What did we do? We searched a range of sources for literature that evaluated the effectiveness of mindfulness‐enhanced parent training programmes, including electronic databases, trial registries, and organisations and experts in the field. We included studies evaluating these interventions using randomised controlled trials (studies where participants are randomly assigned to one of two or more treatment groups) or quasi experimental designs (where participants are assigned to different treatment groups using a method that is not truly random). We included studies that assessed child emotional and behavioural adjustment, and/or a range of parent outcomes, including parenting skills, parenting stress, depression or anxiety, mindfulness or self‐compassion. What did we find out? We included 11 studies and data from 2118 participants in the review. The studies compared the outcomes of children or parents (or both) who participated in a mindfulness‐enhanced parent training programme to the outcomes of children or parents (or both) who did not participate in parent training, or who participated in an alternate behavioural or skills‐based parent training programme. When we combined the findings from these studies, we found that mindfulness‐enhanced parent training, when compared to no intervention, may improve child emotional and behavioural adjustment, parenting skills, parenting stress, parental depression and anxiety, and mindfulness, but we are very uncertain about these results. Evidence for the added value of mindfulness training when included in a skills‐based parent training programme suggests that mindfulness training may further promote reductions in parenting stress, and may also further reduce parental depression or anxiety, but we are uncertain about these results. It is unclear from the current body of evidence whether adding mindfulness training to a skills‐based parent training intervention has any further effect on child emotional and behavioural adjustment, parenting skills, or mindfulness. No studies reported adverse effects or measured self‐compassion. What are the limitations of the evidence? We are not confident in the overall body of evidence. This is primarily because there was a lot of variation across the interventions and the participant groups, as well as how the outcomes were measured. The studies were also usually quite small, and participants were likely to be aware of what intervention they were receiving, which can sometimes influence the results. It is likely that these findings will change as more studies are undertaken in this area of research. How up‐to‐date is this evidence? We searched for and included research up to April 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Featherston, R; Barlow, J; Song, Y; Haysom, Z; Loy, B; Tufford, L; Shlonsky, A", "articleTypes": [], "doi": "10.1002/14651858.CD012445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "c8a4f2fb-b839-43ed-9613-895ce78746e0", "pmid": "", "title": "Chloroquine or hydroxychloroquine for prevention and treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The coronavirus disease 2019 (COVID‐19) pandemic has resulted in substantial mortality. Some specialists proposed chloroquine (CQ) and hydroxychloroquine (HCQ) for treating or preventing the disease. The efficacy and safety of these drugs have been assessed in randomized controlled trials. Objectives To evaluate the effects of chloroquine (CQ) or hydroxychloroquine (HCQ) for 1) treating people with COVID‐19 on death and time to clearance of the virus; 2) preventing infection in people at risk of SARS‐CoV‐2 exposure; 3) preventing infection in people exposed to SARS‐CoV‐2. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Current Controlled Trials (www.controlled‐trials.com), and the COVID‐19‐specific resources www.covid‐nma.com and covid‐19.cochrane.org, for studies of any publication status and in any language. We performed all searches up to 15 September 2020. We contacted researchers to identify unpublished and ongoing studies. Selection criteria We included randomized controlled trials (RCTs) testing chloroquine or hydroxychloroquine in people with COVID‐19, people at risk of COVID‐19 exposure, and people exposed to COVID‐19. Adverse events (any, serious, and QT‐interval prolongation on electrocardiogram) were also extracted. Data collection and analysis Two review authors independently assessed eligibility of search results, extracted data from the included studies, and assessed risk of bias using the Cochrane ‘Risk of bias’ tool. We contacted study authors for clarification and additional data for some studies. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). We performed meta‐analysis using a random‐effects model for outcomes where pooling of effect estimates was appropriate. Main results 1. Treatment of COVID‐19 disease We included 12 trials involving 8569 participants, all of whom were adults. Studies were from China (4); Brazil, Egypt, Iran, Spain, Taiwan, the UK, and North America (each 1 study); and a global study in 30 countries (1 study). Nine were in hospitalized patients, and three from ambulatory care. Disease severity, prevalence of comorbidities, and use of co‐interventions varied substantially between trials. We found potential risks of bias across all domains for several trials. Nine trials compared HCQ with standard care (7779 participants), and one compared HCQ with placebo (491 participants); dosing schedules varied. HCQ makes little or no difference to death due to any cause (RR 1.09, 95% CI 0.99 to 1.19; 8208 participants; 9 trials; high‐certainty evidence). A sensitivity analysis using modified intention‐to‐treat results from three trials did not influence the pooled effect estimate. HCQ may make little or no difference to the proportion of people having negative PCR for SARS‐CoV‐2 on respiratory samples at day 14 from enrolment (RR 1.00, 95% CI 0.91 to 1.10; 213 participants; 3 trials; low‐certainty evidence). HCQ probably results in little to no difference in progression to mechanical ventilation (RR 1.11, 95% CI 0.91 to 1.37; 4521 participants; 3 trials; moderate‐certainty evidence). HCQ probably results in an almost three‐fold increased risk of adverse events (RR 2.90, 95% CI 1.49 to 5.64; 1394 participants; 6 trials; moderate‐certainty evidence), but may make little or no difference to the risk of serious adverse events (RR 0.82, 95% CI 0.37 to 1.79; 1004 participants; 6 trials; low‐certainty evidence). We are very uncertain about the effect of HCQ on time to clinical improvement or risk of prolongation of QT‐interval on electrocardiogram (very low‐certainty evidence). One trial (22 participants) randomized patients to CQ versus lopinavir/ritonavir, a drug with unknown efficacy against SARS‐CoV‐2, and did not report any difference for clinical recovery or adverse events. One trial compared HCQ combined with azithromycin against standard care (444 participants). This trial did not detect a difference in death, requirement for mechanical ventilation, length of hospital admission, or serious adverse events. A higher risk of adverse events was reported in the HCQ‐and‐azithromycin arm; this included QT‐interval prolongation, when measured. One trial compared HCQ with febuxostat, another drug with unknown efficacy against SARS‐CoV‐2 (60 participants). There was no difference detected in risk of hospitalization or change in computed tomography (CT) scan appearance of the lungs; no deaths were reported. 2. Preventing COVID‐19 disease in people at risk of exposure to SARS‐CoV‐2 Ongoing trials are yet to report results for this objective. 3. Preventing COVID‐19 disease in people who have been exposed to SARS‐CoV‐2 One trial (821 participants) compared HCQ with placebo as a prophylactic agent in the USA (around 90% of participants) and Canada. Asymptomatic adults (66% healthcare workers; mean age 40 years; 73% without comorbidity) with a history of exposure to people with confirmed COVID‐19 were recruited. We are very uncertain about the effect of HCQ on the primary outcomes, for which few events were reported: 20/821 (2.4%) developed confirmed COVID‐19 at 14 days from enrolment, and 2/821 (0.2%) were hospitalized due to COVID‐19 (very low‐certainty evidence). HCQ probably increases the risk of adverse events compared with placebo (RR 2.39, 95% CI 1.83 to 3.11; 700 participants; 1 trial; moderate‐certainty evidence). HCQ may result in little or no difference in serious adverse events (no RR: no participants experienced serious adverse events; low‐certainty evidence). One cluster‐randomized trial (2525 participants) compared HCQ with standard care for the prevention of COVID‐19 in people with a history of exposure to SARS‐CoV‐2 in Spain. Most participants were working or residing in nursing homes; mean age was 49 years. There was no difference in the risk of symptomatic confirmed COVID‐19 or production of antibodies to SARS‐CoV‐2 between the two study arms. Authors' conclusions HCQ for people infected with COVID‐19 has little or no effect on the risk of death and probably no effect on progression to mechanical ventilation. Adverse events are tripled compared to placebo, but very few serious adverse events were found. No further trials of hydroxychloroquine or chloroquine for treatment should be carried out. These results make it less likely that the drug is effective in protecting people from infection, although this is not excluded entirely. It is probably sensible to complete trials examining prevention of infection, and ensure these are carried out to a high standard to provide unambiguous results. Plain language summary Is chloroquine or hydroxychloroquine useful in treating people with COVID‐19, or in preventing infection in people who have been exposed to the virus? What is the aim of this review? COVID‐19 is an infectious respiratory disease caused by a coronavirus called SARS‐CoV‐2. If the infection becomes severe, people may need intensive care and support in hospital, including mechanical ventilation. Drugs used for other diseases were tried out in COVID‐19, and this included chloroquine, used for malaria; and hydroxychloroquine used for rheumatic diseases, such as rheumatoid arthritis or systemic lupus erythematosus. We sought evidence of the effects of these drugs in treating people ill with the disease; in preventing the disease in people at risk of getting the disease, such as health workers; and people exposed to the virus developing the disease. Key messages Hydroxychloroquine does not reduce deaths from COVID‐19, and probably does not reduce the number of people needing mechanical ventilation. Hydroxychloroquine caused more unwanted effects than a placebo treatment, though it did not appear to increase the number of serious unwanted effects. We do not think new studies of hydroxychloroquine should be started for treatment of COVID‐19. What was studied in the review? We searched for studies that looked at giving chloroquine and hydroxychloroquine to people with COVID‐19; people at risk of being exposed to the virus; and people who have been exposed to the virus. We found 14 relevant studies: 12 studies of chloroquine or hydroxychloroquine used to treat COVID‐19 in 8569 adults; two studies of hydroxychloroquine to stop COVID‐19 in 3346 adults who had been exposed to the virus but had no symptoms of infection. We did not find any completed studies of these medicines to stop COVID‐19 in people who were at risk of exposure to the virus; studies are still under way. The studies took place in China, Brazil, Egypt, Iran, Taiwan, North America, and Europe; one study was worldwide. Some studies were partly funded by pharmaceutical companies that manufacture hydroxychloroquine. What are the main results of our review? Treating COVID‐19 Compared with usual care or placebo, hydroxychloroquine: · clearly did not affect how many people died (of any cause; 9 studies in 8208 people); · probably did not affect how many people needed mechanical ventilation (3 studies; 4521 people); · may not affect how many people still tested positive for the virus after 14 days (3 studies; 213 people). We are uncertain whether hydroxychloroquine affected the number of people whose symptoms improved after 28 days. Compared with other antiviral treatment (lopinavir plus ritonavir), chloroquine made little or no difference to the time taken for symptoms to improve (1 study; 22 people). Compared with usual care in one study in 444 people, hydroxychloroquine given with azithromycin (an antibiotic) made no difference to: · how many people died; · how many needed mechanical ventilation; or · time spent in hospital. Compared with febuxostat (a medicine to treat gout), hydroxychloroquine made no difference to how many people were admitted to hospital or to changes seen on scans of people's lungs; no deaths were reported (1 study; 60 people). Preventing COVID‐19 in people exposed to it We are uncertain whether hydroxychloroquine affected how many people developed COVID‐19, or how many people were admitted to hospital with COVID‐19, compared with those receiving a placebo treatment (1 study; 821 people). Compared with usual care, hydroxychloroquine made no difference to the risk of developing COVID‐19, or antibodies to the virus, in people exposed to it (1 study; 2525 people). Unwanted effects When used for treating COVID‐19, compared with usual care or placebo, hydroxychloroquine: · probably increases the risk of mild unwanted effects (6 studies; 1394 people); · may not increase the risk of serious harmful effects (6 studies; 1004 people). When given along with azithromycin, hydroxychloroquine increased the risk of any unwanted effects, but made no difference to the risk of serious unwanted effects (1 study; 444 people). Compared with lopinavir plus ritonavir, chloroquine made little or no difference to the risk of unwanted effects (1 study; 22 people). When used for preventing COVID‐19, hydroxychloroquine probably causes more unwanted effects than placebo, but may not increase the risk of serious, harmful unwanted effects (1 study; 700 people). How confident are we in our results? We are confident about our results for how many people died and moderately confident about how many needed mechanical ventilation. We are moderately confident about the unwanted effects of hydroxychloroquine treatment, but less confident about our results for serious unwanted effects; these results might change with further evidence. How up‐to‐date is this review? We included evidence published up to 15 September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Singh, B; Ryan, H; Kredo, T; Chaplin, M; Fletcher, T", "articleTypes": [], "doi": "10.1002/14651858.CD013587.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "c8a63a0d-785c-4086-a666-be80a6e838ed", "pmid": "", "title": "Nebuliser systems for drug delivery in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Nebuliser systems are used to deliver medications to the lungs, to control the symptoms and the progression of lung disease in people with cystic fibrosis (CF). There are many different nebulised‐medications prescribed for people with CF and there are many different types of nebuliser systems. Some of these nebulised medications are licenced for, and can be taken via only one type of nebuliser system; some are licensed for, and can be taken via more than one type of nebuliser system. This is an update to a previous systematic review. Objectives To assess the time efficiency, effectiveness, safety, cost and impact of use (e.g. burden of care, adherence, quality of life (QoL)) of different nebuliser systems, when used with different inhaled medications for people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching of relevant journals and abstract books containing conference proceedings. We searched the reference lists of each study for additional publications and approached the manufacturers of both nebuliser systems and nebulised medications for published and unpublished data. We also searched online trial registries. Date of the most recent search: 9 August 2023. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing nebuliser systems, including conventional nebulisers, vibrating mesh technology (VMT) systems, adaptive aerosol delivery (AAD) systems and ultrasonic nebuliser systems. Data collection and analysis Two review authors independently assessed studies for inclusion. They also independently extracted data and assessed the risk of bias. A third review author assessed studies where agreement could not be reached. They assessed the certainty of the evidence using GRADE. Main results The search identified 216 studies with 33 of these (2270 participants) included in the review. These studies compared the delivery of tobramycin, colistin, dornase alfa, hypertonic saline and other solutions through the different nebuliser systems in children and adults with CF. This review demonstrates variability in the delivery of medication depending on the nebuliser system used. The certainty of the evidence ranged from low to very low. Some conventional nebuliser systems providing higher flows, higher respirable fractions, and smaller particles decrease treatment time, increase deposition (the amount of drug reaching the lung), and may be preferred by people with CF, as compared to other conventional nebuliser systems providing lower flows, lower respirable fractions and larger particles. Newer nebuliser systems using AAD, or VMT (or both) reduce treatment time compared to conventional systems. Deposition (as a percentage of priming dose) with AAD is greater than with conventional systems. VMT systems may give greater deposition than conventional systems when measuring sputum levels. The available data indicate that these newer systems are safe when used with an appropriate priming dose, which may be different to the priming dose used for conventional systems. There is an indication that adherence is maintained or improved and that individuals prefer AAD or VMT systems, but also that some nebuliser systems using VMT may be subject to increased system failures. There is limited, unclear evidence on the impact of different nebuliser systems on lung function and a lack of data on the impact of different nebuliser systems on our outcomes of quality of life (QoL), adverse effects, respiratory exacerbations and related implications, adherence, satisfaction, cost and device reliability. Authors' conclusions Newer technologies e.g. AAD and VMT have advantages over conventional systems in terms of treatment time, deposition as a percentage of priming dose, preference and adherence. Data are lacking for all varieties of medications which are used in CF care, including different inhaled antibiotics or hypertonic saline, with all delivery (nebuliser system) possibilities. Long‐term RCTs are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as QoL and burden of care), safe and effective dosing levels of a wide variety of medications, clinical outcomes (such as hospitalisations and need for antibiotics), and an economic evaluation of their use. There are insufficient data to establish whether one nebuliser system is better than another overall. Clinicians should be aware of the variability in the performance of different nebuliser systems, compatibility with specific nebulised medication, and they must work with their patients to choose the best nebuliser system for each individual. This is likely to be an ongoing process as the needs and circumstances of each individual change over time. Plain language summary Nebulisers for giving medication for cystic fibrosis Key messages 1. Newer technologies have advantages over conventional systems in terms of treatment time, the amount of drug reaching the lung, preference, and adherence. 2. Not all medications used in treating cystic fibrosis can be delivered by the same nebuliser, and data are lacking for some of the different nebuliser and drug combinations. 3. Long‐term studies are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as quality of life, effective dosing levels, and hospitalisations). What is cystic fibrosis? People with cystic fibrosis have sticky mucus in their lungs which is difficult to get rid of and which can cause infection if it builds up. How are nebulisers used as part of cystic fibrosis treatment? Nebulisers are used to deliver medications to the lungs to control the symptoms and the progression of disease. They change a liquid medication into a mist, so it can be breathed in. Different types of nebuliser systems are used with different medications. 1. Conventional systems ‐ a machine pushes out a constant mist of medication at high speed. 2. Adaptive aerosol delivery systems ‐ like conventional systems, also monitor breathing and only deliver the medication while the person is breathing in. 3. Vibrating mesh technology systems move the liquid medication through a metal mesh to generate a mist with similar‐sized droplets which is delivered constantly. 4. Adaptive aerosol delivery systems with vibrating mesh technology combination between the two systems. 5. Ultrasonic systems use a crystal to vibrate the liquid medication at a high frequency and turn it into a mist which is delivered constantly. What did we want to find out? How well do the different nebuliser systems deliver each inhaled medication (how much medication is delivered into the lungs, and what is the impact on lung function)? Are they safe or do they have any side effects? We also wanted to know how these nebuliser systems affect people with cystic fibrosis in terms of treatment burden, adherence to treatment regimen and their quality of life. What did we do? We assessed 33 studies (2270 adults and children)and compared different types of nebuliser systems for delivering: tobramycin; colistin; dornase alfa; hypertonic saline; and other nebulised medications. What did we find? Conventional systems which have faster air flows and smaller medication droplets decrease treatment time and deliver more medication into the lung than other conventional systems, which have slower air flows and larger medication droplets. Nebulisers use newer technologies, e.g. adaptive aerosol delivery system or vibrating mesh technology, deliver the medication faster and may deliver more of the medication into the lung. These newer systems appear safe when used with the correct amount of medication, which may be different to that used in a conventional system. Some studies suggest that people with cystic fibrosis may prefer these newer systems and may take more of their medication when using them. However, more research is needed into what dose of medication is needed for the different systems, which medications suit which technologies best and how these newer nebuliser technologies affect quality of life, burden of treatment, additional treatment needed (such as oral or intravenous antibiotics) and treatment costs. What are the limitations of the evidence? There were lots of different systems studied, and often we only had a few studies for each comparison. Also, the studies we found were quite small and results varied. We had concerns around at least some aspects of the design of every study which affected our confidence in the results. How up to date is this evidence? We last looked for evidence on 9 August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Stanford, G, Morrison, L, Brown, C", "articleTypes": [], "doi": "10.1002/14651858.CD007639.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.124Z" }, { "id": "c8a89d8b-e1fd-4c1e-a262-83deb59d84db", "pmid": "", "title": "Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long‐term central venous catheters in infants and children", "imported": false, "abstract": "Abstract - Background Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015. Objectives To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long‐term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC). Data collection and analysis Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random‐effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review. Main results We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin. Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC‐associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC‐associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low‐certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate‐certainty evidence), and not reported in the remaining studies. Authors' conclusions The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long‐term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC‐associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains. Plain language summary Replacing heparin flushing with saline flushing to prevent complications in long‐term central venous catheters in children Background A central venous catheter (CVC) is a long, thin, flexible tube which is inserted into a large central vein. This enables access to the blood stream for people with serious medical conditions to receive medications and fluids, as well as the collection of blood specimens. Long‐term CVCs are used to access the blood system in children with complex medical conditions like cancer. To stop the catheter from becoming blocked it is usual to use heparin, a drug that prevents clots forming, to flush the catheter. However, some studies have shown that heparin is not necessary, and that normal saline (a sterile salt water solution) can be safely used instead. Heparin may be associated with complications, such as bleeding and infection, along with higher costs for healthcare providers. While the complications such as infections and occlusions are uncommon, practices vary around the world and there are many inconsistencies regarding the best flush solution to use to prevent complications in long‐term catheters. Study characteristics and key results This review included randomised controlled trials (clinical studies where people were randomly assigned into one of two or more treatment groups) that compared the use of saline and heparin to prevent blockage, and other complications related to long‐term catheters. The evidence is current to 9 April 2019. Two review authors independently reviewed the studies. We included four studies with a total of 255 participants in the review. The four trials were all undertaken in large teaching (tertiary) hospitals, and directly compared the use of saline and heparin. The studies were, however, very different in the way they compared saline and heparin, with different concentrations of heparin and different frequencies of flushes reported. We were able to combine the results of two studies: the analysis showed imprecise results for the blocking of catheters and blood stream infections for normal saline versus heparin. One study reported the duration of catheter placement to be similar between the two study arms. Certainty of the evidence The overall certainty of the evidence ranged from moderate to very low. There was high risk of bias for blinding, there were differences between the studies methods and interventions, inconsistent results between the studies, and not all studies reported all outcomes of interest. We found there was not enough evidence to determine which solution, saline or heparin, is more effective for reducing complications. Further research is required and is likely to have an important impact in this area. This review is an update of a review first published in 2015.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bradford, NK, Edwards, RM, Chan, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD010996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.771Z" }, { "id": "c8b1b6ec-05e2-4e60-a51b-cd960fe080c1", "pmid": "", "title": "Chinese medicinal herbs for the common cold", "imported": false, "abstract": "Abstract - Background Chinese medicinal herbs are frequently used to treat the common cold in China. Until now, their efficacy has not been systematically reviewed. Objectives To assess the effectiveness and safety of Chinese medicinal herbs for the common cold. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2008, issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to May 2008); EMBASE (1980 to May 2008); AMED (1985 to May 2008); the Chinese Biomedical Database (CBMdisc) (1978 to May 2008); and China National Knowledge Infrastructure (CNKI) (1994 to May 2008). Selection criteria Randomised controlled trials (RCTs) studying the efficacy of Chinese medicinal herb(s) for the treatment of the common cold. Data collection and analysis Four review authors telephoned the original trial authors of the RCTs identified by our searches to verify the randomisation procedure. Two review authors extracted and analysed data from trials which met the inclusion criteria. Main results We found17 studies involving 3212 patients. The methods of 15 studies were at high risk of bias. In only two studies was the risk of bias low. Trials used \"positive drugs\", of which the efficacy was not known, as controls. Different Chinese herbal preparations were tested in nearly all trials. In only one trial was a Chinese herbal preparation tested twice. In seven trials, six herbal preparations were found to be more effective at enhancing recovery than the control preparations. In the other 10 studies, seven herbal preparations were not shown to be significantly different from the control. One study did not describe the difference between the intervention and control groups. Authors' conclusions Chinese herbal medicines may shorten the symptomatic phase in patients with the common cold. However, the lack of trials of low enough risk of bias, or using a placebo or a drug clearly identified as a control, means that we are uncertain enough to be unable to recommend any kind of Chinese medicinal herbs for the common cold. Plain language summary Chinese medicinal herbs to treat the common cold The common cold is the most widespread acute respiratory tract illness affecting all age groups. Many Chinese herbal medicines are used to treat this illness in China. Although we included 17 trials, involving 3212 patients, in this review, the risk of bias was so high that the evidence did not support using any Chinese herbal preparation(s) for the common cold. Well‐designed clinical trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Zhang, X; Wu, T; Zhang, J; Yan, Q; Xie, L; Liu, GJ", "articleTypes": [], "doi": "10.1002/14651858.CD004782.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "c8dd2e81-334b-40b3-b54f-99180fc69be2", "pmid": "", "title": "Point‐of‐use fortification of foods with micronutrient powders containing iron in children of preschool and school‐age", "imported": false, "abstract": "Abstract - Background Approximately 600 million children of preschool and school age are anaemic worldwide. It is estimated that at least half of the cases are due to iron deficiency. Point‐of‐use fortification of foods with micronutrient powders (MNP) has been proposed as a feasible intervention to prevent and treat anaemia. It refers to the addition of iron alone or in combination with other vitamins and minerals in powder form, to energy‐containing foods (excluding beverages) at home or in any other place where meals are to be consumed. MNPs can be added to foods either during or after cooking or immediately before consumption without the explicit purpose of improving the flavour or colour. Objectives To assess the effects of point‐of‐use fortification of foods with iron‐containing MNP alone, or in combination with other vitamins and minerals on nutrition, health and development among children at preschool (24 to 59 months) and school (five to 12 years) age, compared with no intervention, a placebo or iron‐containing supplements. Search methods In December 2016, we searched the following databases: CENTRAL, MEDLINE, Embase, BIOSIS, Science Citation Index, Social Science Citation Index, CINAHL, LILACS, IBECS, Popline and SciELO. We also searched two trials registers in April 2017, and contacted relevant organisations to identify ongoing and unpublished trials. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs trials with either individual or cluster randomisation. Participants were children aged between 24 months and 12 years at the time of intervention. For trials with children outside this age range, we included studies where we were able to disaggregate the data for children aged 24 months to 12 years, or when more than half of the participants were within the requisite age range. We included trials with apparently healthy children; however, we included studies carried out in settings where anaemia and iron deficiency are prevalent, and thus participants may have had these conditions at baseline. Data collection and analysis Two review authors independently assessed the eligibility of trials against the inclusion criteria, extracted data from included trials, assessed the risk of bias of the included trials and graded the quality of the evidence. Main results We included 13 studies involving 5810 participants from Latin America, Africa and Asia. We excluded 38 studies and identified six ongoing/unpublished trials. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. No trials compared the effects of MNP versus iron‐containing supplements (as drops, tablets or syrup). The sample sizes in the included trials ranged from 90 to 2193 participants. Six trials included participants younger than 59 months of age only, four included only children aged 60 months or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. The iron doses varied from 2.5 mg to 30 mg of elemental iron. Four trials reported giving 10 mg of elemental iron as sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), chelated ferrous sulphate or microencapsulated ferrous fumarate. Three trials gave 12.5 mg of elemental iron as microencapsulated ferrous fumarate. Three trials gave 2.5 mg or 2.86 mg of elemental iron as NaFeEDTA. One trial gave 30 mg and one trial provided 14 mg of elemental iron as microencapsulated ferrous fumarate, while one trial gave 28 mg of iron as ferrous glycine phosphate. In comparison with receiving no intervention or a placebo, children receiving iron‐containing MNP for point‐of‐use fortification of foods had lower risk of anaemia prevalence ratio (PR) 0.66, 95% confidence interval (CI) 0.49 to 0.88, 10 trials, 2448 children; moderate‐quality evidence) and iron deficiency (PR 0.35, 95% CI 0.27 to 0.47, 5 trials, 1364 children; moderate‐quality evidence) and had higher haemoglobin (mean difference (MD) 3.37 g/L, 95% CI 0.94 to 5.80, 11 trials, 2746 children; low‐quality evidence). Only one trial with 115 children reported on all‐cause mortality (zero cases; low‐quality evidence). There was no effect on diarrhoea (risk ratio (RR) 0.97, 95% CI 0.53 to 1.78, 2 trials, 366 children; low‐quality evidence). Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children. However, information on mortality, morbidity, developmental outcomes and adverse effects is still scarce. Plain language summary Powdered vitamins and minerals added to foods at the point‐of‐use reduces anaemia and iron deficiency in preschool‐ and school‐age children Background to the question Approximately one billion people worldwide are deficient in at least one vitamin or mineral (also known of micronutrients). Iron, vitamin A, zinc and iodine deficiencies are very frequent among children of preschool (aged 24 months to less than 5 years) and school age (5 to 12 years of age), limiting their health and daily physical performance. Anaemia, the condition in which red blood cells have limited capacity to carry oxygen, frequently results after prolonged iron deficiency. Point‐of‐use fortification with powdered vitamins and minerals has been proposed as a public health intervention to reduce micronutrient deficiencies in children. In this process, a powdered premix containing iron, and possibly other vitamins and minerals, is added to foods either during or after cooking, or immediately before consumption to improve their nutritious value but not their flavour or colour. In some cases, point‐of‐use fortification is also known as home fortification. Review question What are the effects of point‐of‐use fortification of foods with iron‐containing micronutrient powders (MNP) alone, or in combination with other vitamins and minerals, on nutrition, health and development among children of preschool and school age (24 months to 12 years of age) compared with no intervention, a placebo (dummy pill) or regular iron‐containing supplements (as drops, tablets or syrup)? Study characteristics This review included 13 trials with 5810 participants from Latin America, Africa and Asia. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. Six trials included participants younger than 59 months of age only, four included only children aged 60 months of age or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. We searched existing clinical trials in December 2016 and ongoing trials in April 2017. We also contacted relevant institutions for additional information upon publication of the protocol and in April 2017. Key results The review found that children receiving iron‐containing MNP for point‐of‐use fortification of foods were at significantly lower risk of having anaemia and iron deficiency and had higher haemoglobin concentrations. We did not find any positive or negative effect on diarrhoea or mortality, but the data on these two outcomes were very limited. Quality of the evidence We rated the overall quality of the evidence for the provision of multiple MNP versus no intervention or placebo as moderate for anaemia, iron deficiency and adverse effects. We judged the evidence to be of low quality for haemoglobin, mortality and diarrhoea, and to be very low‐quality for ferritin. In general, the most common risk of bias in the studies was the lack of blinding for participants, personnel and outcome assessors. Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children and seems feasible for public health purposes. However, future research should aim to increase the body of evidence on mortality, morbidity, developmental outcomes and adverse effects. Due to the lack of trials, we were unable to determine at this time if this intervention has comparable effects to those observed with iron supplements (provided as drops, tablets or syrup).", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "De‐Regil, LM, Jefferds, MED, Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009666.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.765Z" }, { "id": "c8e33c06-465c-4d4c-9c49-6a07ee56d4d4", "pmid": "", "title": "Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease", "imported": false, "abstract": "Abstract - Background Catheter malfunction, including thrombosis, is associated with reduced dialysis adequacy, as well as an increased risk of catheter‐related bacteraemia and mortality. The role of anticoagulants in the prevention of catheter malfunction remains uncertain. Objectives This review aimed to compare the prophylactic effect of different anticoagulant agents, preparations, doses and administration on the incidence of central venous haemodialysis catheter‐related malfunction and sepsis in patients with end‐stage kidney disease (ESKD). Search methods We searched the Cochrane Renal Group's Specialised Register to 7 January 2016 through contact with the Trials' Search Co‐ordinator using search terms relevant to this review. Selection criteria We included all randomised controlled trials (RCT) assessing anticoagulants compared with conventional care for the prevention of catheter malfunction in adult patients receiving haemodialysis for ESKD. Data collection and analysis The primary outcome was catheter malfunction defined as a catheter blood flow of 200 mL/min or less, or as defined by study authors. Secondary outcomes were catheter‐related bacteraemia, all‐cause mortality and bleeding events. Relative risks (RR) with 95% confidence intervals (CI) for individual studies were pooled using random effects models within treatment classes. Analyses were conducted by class, with subgroup analyses performed of individual agents within classes. Main results We included 27 studies (3003 participants) that were followed up for a median of six months. Study interventions included alternative anticoagulant locking solutions (19 studies, 2216 patients), systemic agents (6 studies, 664 patients) and low or no dose heparin (2 studies, 123 patients). The most common comparison treatment was a locking solution of heparin 5000 IU/mL, used in 17 studies. No significant effect on catheter malfunction was observed for alternative anticoagulant locking solutions (RR 0.96, 95% CI 0.74 to 1.26), systemic agents (RR 0.59, 95% CI 0.28 to 1.23), or low or no dose heparin (RR 0.90, 95% CI 0.10 to 8.31). A significant reduction on incidence of catheter‐related bacteraemia was observed for alternative anticoagulant locking solutions (RR 0.46, 95% CI 0.32 to 0.66) but not systemic agents (RR 2.41, 95% CI 0.89 to 6.55), and could not be assessed in reports of low or no dose heparin studies. No significant effect on all‐cause mortality was observed for alternative anticoagulant locking solutions (RR 0.88, 95% CI 0.54 to 1.43) or systemic agents (RR 0.78, 95% CI 0.37 to 1.65), and was not reported in studies of low or no dose heparin. Bleeding events were only reported in eight studies, including only 2/5 studies of systemic warfarin, with no clear effect demonstrated (RR 1.43, 95% CI 0.86 to 2.39). For individual agents, recombinant tissue plasminogen (rt‐PA) was the only locking solution shown to reduce catheter malfunction (RR 0.58, 95% CI 0.37 to 0.91) based on the results of a single study. No significant on catheter malfunction was observed for other individual classes of alternative anticoagulant locking solutions (citrate: RR 1.14, 95% CI 0.76 to 1.69; antibiotic: RR 1.48, 95% CI 0.79 to 2.77; ethanol: RR 0.88, 95% CI 0.21 to 3.67). On the other hand, all individual classes of alternative anticoagulant locking solutions, except ethanol, reduced catheter‐related bacteraemia (citrate: RR 0.49, 95% CI 0.36 to 0.68; antibiotic: RR 0.27, 95% CI 0.11 to 0.70; rt‐PA: RR 0.35, 95% CI 0.13 to 0.93; ethanol: RR 0.33, 95% CI 0.03 to 4.05). No significant effect on all‐cause mortality was observed for any individual agent within the class of alternative locking solutions. Studies were mainly of low quality and underpowered with an average participant number of 75 and study duration of six months. The interpretation of the study evidence was further limited by the variation in tested interventions and outcome reporting. Authors' conclusions The relative net benefit of anticoagulant therapies for prevention of catheter malfunction remains uncertain. Multiple agents appear to reduce catheter‐related bacteraemia although the lack of clear assessment of harms and the limitations of study quality mean these results should be interpreted with caution. Methodological approaches can be used to avoid methods of reporting unduly affecting on the results of meta‐analyses incorporating studies employed mixed reporting methods. Further high quality randomised studies, including safety outcomes, are needed. Plain language summary Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease Background Patients with end‐stage kidney disease require vascular access during haemodialysis. Central venous haemodialysis catheters are frequently used when permanent vascular access is not available. Catheter problems contribute to greater morbidity and mortality. Catheter malfunction leads to requirements for additional interventions, increased risk of catheter‐related infection and hospitalisation. Standard care for the prevention of catheter malfunction is the use of heparin solutions as a post dialysis ‘lock’ in the catheter ports. The potential impact of heparin treatment on bleeding risk is an acknowledged concern. Therefore newer approaches have been proposed to seek improvements in catheter patency or treatment‐associated harm rates. Study characteristics This review focused on randomised controlled trials (RCTs) of anticoagulants compared with conventional care for the prevention of catheter malfunction patients receiving haemodialysis. Key results We found 27 studies, involving 3003 patients followed for an average six months, which assessed alternative anticoagulant locking solutions, systemic agents and low or no dose heparin. Catheter malfunction were not affected by any of these classes of agents. Subgroup analysis showed that the only agent reducing catheter malfunction was recombinant tissue plasminogen locking solution based on the results of a single study. A significant reduction was observed on the incidence of catheter‐related bacteraemia for alternative anticoagulant locking solutions. There was no evidence to suggest that alternative anticoagulants to heparin locking solutions had an effect on death rates or bleeding events, although only a small proportion of studies reported bleeding events. Quality of the evidence Further high quality information is needed on both potential benefits and safety of alternative approaches to maintaining dialysis access catheter function.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Wang, Y, Ivany, JN, Perkovic, V, Gallagher, MP, Woodward, M, Jardine, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD009631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.108Z" }, { "id": "c8e671cf-f10b-462d-9a56-48f1f3c312d9", "pmid": "", "title": "Probiotics for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "Abstract - Background The intestinal microflora has an essential role in providing a barrier against colonisation of pathogens, facilitating important metabolic functions, stimulating the development of the immune system, and maintaining intestinal motility. Probiotics are live microorganisms that can be administered to supplement the gut flora. Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be partly due to a disruption of the integrity of the gut and its intestinal microflora. There may be a role for probiotics in reducing the incidence of sepsis and improving intestinal motility, thus reducing morbidity and mortality and improving enteral feeding in neonates in the postoperative period. Objectives To evaluate the efficacy and safety of administering probiotics after gastrointestinal surgery for the postoperative management of neonates born from 35 weeks of gestation. Search methods We searched CENTRAL, MEDLINE, Embase, and trial registries in August 2023. We checked reference lists of included studies and relevant systematic reviews for additional studies. Selection criteria We included randomised controlled trials (RCTs) that investigated the postoperative administration of oral probiotics versus placebo or no treatment in neonates born from 35 weeks of gestation who had one or more gastrointestinal surgical procedures. We applied no restrictions regarding the type or dosage of probiotics or the duration of treatment. Data collection and analysis We used standard Cochrane methods, and we used GRADE to assess the certainty of evidence. Main results We identified one RCT that recruited 61 neonates with a gestational age of 35 weeks or more. All infants were admitted to a neonatal intensive care unit and had surgery for gastrointestinal pathologies. There may be little or no difference in proven sepsis (positive bacterial culture, local or systemic) between infants who receive probiotics compared with those who receive placebo (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.16 to 2.55; 61 infants; low‐certainty evidence). Probiotics compared to placebo may have little or no effect on time to full enteral feeds (mean difference (MD) 0.63 days, 95% CI −4.02 to 5.28; 61 infants; low‐certainty evidence). There were no reported deaths prior to discharge from hospital in either study arm. Two weeks after supplementation, the infants who received probiotics had a substantially higher relative abundance of non‐pathogenic intestinal microflora (Bifidobacteriaceae) than those who received placebo (MD 38.22, 95% CI 28.40 to 48.04; 39 infants; low‐certainty evidence). Authors' conclusions This review provides low‐certainty evidence from one small RCT that probiotics compared to placebo have little or no effect on the risk of proven sepsis (positive bacterial culture, local or systemic) or time to full‐enteral feeds in neonates who have undergone gastrointestinal surgery. Probiotics may substantially increase the abundance of beneficial bacterial in the intestine of these neonates, but the clinical implications of this finding are unknown. There is a need for adequately powered RCTs to assess the role of probiotics in this population. We identified two ongoing studies. As neither reported the gestational age of prospective study participants, we are unsure if they will be eligible for inclusion in this review. Plain language summary Benefits and harms of giving probiotics to newborns after digestive tract surgery Key message • Probiotics may have little or no effect on the risk of blood infection in infants born from 35 weeks of pregnancy who have undergone surgery of the digestive tract (food pipe, stomach, or bowel).
• Probiotics may increase the proportion of 'good' bacteria in the bowel, but we do not know if this has any real benefit for the infant. What are probiotics? Probiotics are live bacteria that may offer health benefits when consumed. There is evidence that probiotics can prevent an inflammatory disease of the bowel (necrotising enterocolitis) and infection in premature babies. What are some of the risks of bowel surgery in babies? Surgery of the digestive tract increases the risk of infection, and infection can increase the length of hospital stay. Treatment with antibiotics (medicines that treat bacterial infection) and the stress of surgery can diminish the 'good' bacteria in the bowel. What did we want to find out? We wanted to find out if giving probiotics to babies born from 35 weeks of pregnancy who underwent stomach or bowel surgery could improve rates of infection, length of hospital stay, rates of death, feeding, and the proportion of 'good' bacteria in the stomach and bowel. What did we do? We searched for studies that randomly assigned babies to experimental treatment (probiotics) or a control, which could be placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested) or no treatment. What did we find? We found one small study of 61 babies born from 35 weeks of pregnancy who had digestive tract surgery. Thirty babies received probiotics after the surgery, and 30 received a placebo. In the probiotics group, 13% of babies had a blood infection, compared with 19% in the placebo group. This difference is too small to be significant. On average, the babies in the probiotic group were receiving food into their stomach about 15 hours sooner than those in the placebo group. Again, this difference is not important. Among 39 infants who were tested, those in the probiotics group had considerably more 'good' bacteria in their bowel compared to the placebo group. What are the limitations of the evidence? We have little confidence in the evidence because it is based on a single study with few participants. The evidence is not strong enough to support giving probiotics routinely. Well‐designed and large studies are needed to determine the benefits and harms of giving probiotics to newborns after digestive tract surgery. How up to date is this evidence? The evidence is up to date to August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Trivedi, A; Teo, E; Walker, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012265.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "c8f1f0dd-1559-469a-bb40-f648b07474e1", "pmid": "", "title": "Enteral tube feeding for people with severe dementia", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Davies, N, Barrado-Martín, Y, Vickerstaff, V, Rait, G, Fukui, A, Candy, B, Smith, CH, Manthorpe, J, Moore, KJ, Sampson, EL", "articleTypes": [], "doi": "10.1002/14651858.CD013503.pub2 AB - Abstract - Background The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing. Objectives To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021. Selection criteria We included randomised controlled trials (RCTs), or controlled non‐randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post‐pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers. Data collection and analysis Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non‐randomised Studies of Interventions' (ROBINS‐I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre‐agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta‐analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study. Main results We found no eligible RCTs. We included fourteen controlled, non‐randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low‐certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate‐certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very‐low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low‐certainty evidence. Five studies reported a variety of harm‐related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia. Authors' conclusions We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here. Plain language summary Enteral tube feeding for people with severe dementia What are the advantages and problems of tube feeding people with severe dementia? Key messages Tube feeding may not increase the length of time people with severe dementia live compared to no tube feeding. The risk of developing a pressure sore is probably higher with a feeding tube than with no tube. No studies looked at quality of life.We need more and better studies to investigate tube feeding people with severe dementia. Future studies should focus on a broader range of outcomes including, pain, quality of life and the impact on carers What is tube feeding? Somebody who can’t eat or drink through their mouth may be given liquid food through a tube into their stomach. This is called enteral tube feeding. The tube passes through their nose into their stomach (a nasogastric tube), or is inserted into the stomach through a small cut in their belly (percutaneous endoscopic gastrostomy or PEG). Why is this important for people with dementia? People with dementia often have difficulties eating and drinking. During the early stages of dementia, they may forget to eat, chew food without swallowing, or be confused at mealtimes. Some people experience changes in the taste and smell of food. In the later stages of dementia, people often have difficulties swallowing. It can be difficult to ensure they receive appropriate food and fluids. People with severe dementia need full‐time care, and it is often their families who care for them. It is difficult to decide whether or not to tube‐feed someone with dementia because the feeding tube can be uncomfortable or even painful, and may cause other unwanted effects such as pneumonia, worsen bowel or bladder control, as well as bleeding, swelling and infection. People with severe dementia may be confused or distressed by the tube and may try to remove it. What did we want to find out? We wanted to know whether tube feeding helps people with severe dementia who have problems with eating and swallowing. We were interested in the effect of tube feeding on: how long people lived; their quality of life (well‐being); and the development or healing of pressure sores (also known as bed sores). What did we do? 
We searched for studies that investigated whether: PEG compared to no tube; a nasogastric tube compared to no tube; orPEG, nasogastric and other types of tube feeding compared to no tube was effective and whether tube feeding caused any unwanted effects in adults of any age with severe dementia and poor intake of food and drink. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 14 studies that included 49,714 participants. Of these, 6203 were tube‐fed and 43,511 were not. Participants with no feeding tube were given standard care or standard care with extra treatments to encourage eating and drinking. Main results In people with severe dementia, compared to no tube feeding: PEG may make no difference to how long people live (4 studies, 36,816 people), and leads to a small increase in the chance of developing pressure sores (1 study, 4421 people). we don’t know if nasogastric tube feeding increases the length of time people live or increases their chance of developing pressure sores, because none of our included studies gave information about these points. Studies of people with either PEG or nasogastric tubes showed tube feeding may increase the length of time people live (4 studies, 1696 people), and may slightly increase the chance of developing pressure sores (3 studies, 351 people). None of our included studies reported quality of life. What are the limitations of the evidence? We have moderate confidence in our finding that pressure ulcers were more common in people who were fed with a PEG tube. However, we have little to very little confidence for our other findings. Three main factors reduced our confidence in the evidence. Firstly, people in the studies were not randomly placed into different treatment groups. This means that differences between the groups could be due to differences between people rather than between the treatments. However, due to ethical considerations it would be very difficult to do this in future studies. Secondly, results were very inconsistent across the different studies. Finally, some studies were very small. The results of further research could differ from the results of this review. How up to date is this evidence? The evidence is up to date to 14 April 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.120Z" }, { "id": "c935d64b-d2be-4125-87af-c7d8bb53ee92", "pmid": "", "title": "Interventions for fatigue in peripheral neuropathy", "imported": false, "abstract": "Abstract - Background Persistent feelings of fatigue (or subjective fatigue), which may be experienced in the absence of physiological factors, affect many people with peripheral neuropathy. A variety of interventions for subjective fatigue are available, but little is known about their efficacy or the likelihood of any adverse effects for people with peripheral neuropathy. Objectives To assess the effects of drugs and physical, psychological or behavioural interventions for fatigue in adults or children with peripheral neuropathy. Search methods On 5 November 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, CINAHL Plus, LILACS and AMED. We also searched reference lists of all studies identified for inclusion and relevant reviews, and contacted the authors of included studies and known experts in the field to identify additional published or unpublished data. We also searched trials registries for ongoing studies. Selection criteria We considered for inclusion randomised controlled trials (RCTs) and quasi‐RCTs comparing any form of intervention for fatigue management in adults with peripheral neuropathy with placebo, no intervention or an alternative form of intervention for fatigue. Interventions considered included drugs, pacing and grading of physical activity, general or specific exercise, compensatory strategies such as orthotics, relaxation, counselling, cognitive and educational strategies. Data collection and analysis Two review authors independently assessed risk of bias and extracted study data. We contacted study authors for additional information. We collected information on adverse events from the included trials. Main results The review includes three trials, which were all at low risk of bias, involving 530 people with peripheral neuropathy. The effects of amantadine from one randomised, double‐blind, placebo‐controlled, cross‐over trial comparing amantadine with placebo for the treatment of fatigue in 80 people with Guillain‐Barré syndrome (GBS) were uncertain for the proportion of people achieving a favourable outcome six weeks post‐intervention (odds ratio (OR) 0.56 (95% confidence interval (CI) 0.22 to 1.35, N = 74, P = 0.16). We assessed the quality of this evidence as low. Two parallel‐group randomised double‐blind, placebo‐controlled trials comparing the effects of two doses of ascorbic acid with placebo for reducing fatigue in adults with Charcot‐Marie‐Tooth disease type 1A (CMT1A) showed that the effects of ascorbic acid at either dose are probably small (standardised mean difference (SMD) ‐0.12 (95% CI ‐0.32 to 0.08, n = 404, P = 0.25)) for change in fatigue after 12 to 24 months (moderate quality evidence). Neither ascorbic acid study measured fatigue at four to 12 weeks, which was our primary outcome measure. No serious adverse events were reported with amantadine. Serious adverse events were reported in the trials of ascorbic acid. However,risk of serious adverse events was similar with ascorbic acid and placebo. Authors' conclusions One small imprecise study in people with GBS showed uncertain effects of amantadine on fatigue. In two studies in people with CMT1A there is moderate‐quality evidence that ascorbic acid has little meaningful benefit on fatigue. Information about adverse effects was limited, although both treatments appear to be well tolerated and safe in these conditions. There was no evidence available from RCTs to evaluate the effect of other drugs or other interventions for fatigue in either GBS, CMT1A or other causes of peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future randomised clinical trials. Plain language summary Treatments for fatigue in peripheral neuropathy Review question To assess the effects of treatments for fatigue in people with peripheral neuropathy. Background Peripheral neuropathy is damage to the nerves outside the brain and spinal cord. Many people with peripheral neuropathy have feelings of severe tiredness (fatigue) that are not necessarily related to physical problems such as muscle weakness. Evidence in other long‐term illnesses where fatigue is a problem suggests that medicines and other forms of treatment may help. The aim of this review was to assess the effect of drugs and other treatments, such as general or specific exercise, orthotics (devices such as braces), relaxation, counselling and cognitive, behavioural and educational strategies on feelings of fatigue in people with peripheral neuropathy. Study characteristics From a wide search, we identified three RCTs that met our selection criteria. The trials involved a total of 530 adults with peripheral neuropathy. Treatments were ascorbic acid (vitamin C) in people with Charcot‐Marie‐Tooth disease in two trials, and amantadine in Guillain‐Barré syndrome in the third. Charcot‐Marie‐Tooth disease is an inherited nerve disease and Guillain‐Barré syndrome is a condition where there is inflammation of the peripheral nerves. We chose measures of fatigue at four to 12 weeks as our preferred measure of the effects of treatment. The amantadine trial but not the ascorbic acid trials provided data at this time point; the ascorbic acid trials provided data more than 12 months after the start of the intervention. Key results and quality of the evidence There was insufficient evidence to determine the effects of amantadine when compared with an inactive treatment (placebo) for fatigue. and there were no major unwanted effects. We found evidence that ascorbic acid probably has little meaningful benefit for fatigue. No major unwanted effects were identified, but the trials were small. We assessed the quality of this evidence as moderate because the results were imprecise, which means they do not rule out the possibility that the drugs could have an effect. We found no evidence from RCTs on other medicines or treatments for fatigue in peripheral neuropathy. There is insufficient evidence to determine the effect of amantadine for fatigue in GBS and ascorbic acid for fatigue in CMT1A. More high‐quality studies are needed to provide evidence on which to base management of feelings of fatigue in peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future RCTs. The evidence in this review is current to November 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "White, CM; van Doorn, PA; Garssen, MPJ; Stockley, RC", "articleTypes": [], "doi": "10.1002/14651858.CD008146.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "c94bcc02-4cd3-4a0d-948f-8b919dd3812f", "pmid": "", "title": "Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy", "imported": false, "abstract": "Abstract - Background In the past women have been advised that lowering their salt intake might reduce their risk of pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of advice to alter dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of dietary advice to alter salt intake compared to continuing a normal diet, on the risk of pre‐eclampsia and its consequences. Search methods We searched the register of trials maintained and updated by the Cochrane Pregnancy and Childbirth Group, and the Cochrane Controlled Trials Register Disc Issue 4, 1998. Selection criteria Studies were included if they were randomised trials of advice to either reduce or to increase dietary salt during pregnancy. Data collection and analysis All data were extracted independently by both reviewers. Main results Two trials were included, with 603 women. They compared advice about a low salt diet with no dietary advice. The confidence intervals for all of the outcomes reported were wide, and cross the no effect line. This includes pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). Even when taken together, these trials are insufficient to provide reliable information about the effects of advice on salt restriction during normal pregnancy. None of the trials included women with pre‐eclampsia, so this review provides no reliable information about changes in salt intake for treatment of pre‐eclampsia. Authors' conclusions Salt consumption during pregnancy should remain a matter of personal preference. Plain language summary Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy To be prepared.", "journal": "Cochrane Database of Systematic Reviews", "year": "1999", "authors": "Duley, L; Henderson‐Smart, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD001687", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "c94c19db-07fd-40e8-a848-17b49cfd139a", "pmid": "", "title": "Pharmacological treatments for Friedreich ataxia", "imported": false, "abstract": "Abstract - Rationale Friedreich ataxia (FRDA) is a rare inherited autosomal recessive neurological disorder, characterised initially by unsteadiness in standing and walking, and slowly progressing to wheelchair dependency, usually in the late teens or early twenties. Scoliosis, pes cavus and cardiomyopathy are often present at diagnosis. As the disease progresses, individuals usually develop slurred speech, auditory impairment (especially in a noisy environment), urinary tract morbidity, diabetes, anxiety, depression, muscle spasticity and visual disturbances. Cardiac abnormalities cause premature death in 60% of people with FRDA. There is no easily defined clinical or biochemical marker to assess progression and no known curative treatment. This is the third update of a review published in 2009 and updated in 2012 and 2016. Objectives To assess the effects of pharmacological treatments for people with Friedreich ataxia (FRDA) after 12 months of treatment. Search methods To identify studies for inclusion in this review, we searched CENTRAL, MEDLINE, Embase, CINAHL Plus, TRIP, Orphanet, WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. We also checked reference lists of relevant studies and contacted study authors. The most recent search was on 4 February 2025. Eligibility criteria We were interested in randomised controlled trials (RCTs) and quasi‐RCTs of pharmacological treatments (including vitamins) in people with genetically‐confirmed FRDA. To be included in the review, studies had to last at least 12 months. Outcomes We assessed the following outcomes after 12 months of treatment: change in score on a validated ataxia rating scale; change in interventricular septal thickness in diastole (IVSTd) by cardiac magnetic resonance imaging or echocardiogram; change in activities of daily living (ADL) using a validated questionnaire; change in upper limb dexterity; and change in cardiopulmonary exercise testing (CPET). We also assessed treatment‐related adverse events with medication continued for the study period, and treatment‐emergent adverse events leading to cessation of medication or death during the study period. Risk of bias Using the Cochrane risk of bias tool RoB 2, we assessed the risk of bias in the seven outcomes reported in our summary of findings tables. Synthesis methods We synthesised the results of the studies for each outcome using meta‐analysis, where possible. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and the risk ratio (RR) for dichotomous outcomes, all with 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for our prespecified outcomes as high, moderate, low or very low. Included studies We included eight RCTs in this updated review. We included seven of them in meta‐analysis, and these studies enroled a total of 574 participants, with sample sizes ranging from 29 to 232 participants per study. One study was international, with centres in North America, Europe and Australia. There were four other multicentre studies (three in Europe and one in North America). Single‐centre studies were conducted in the UK, Italy and France. Participants in the studies ranged from eight to 70 years of age at enrolment, with the mean age in each study being between 18 years and 35 years (with an unweighted pooled mean age across studies of 25.9 years). All of the studies enroled both males and females, with the proportion of female participants ranging from 21% to 58%. Sixty‐eight per cent of participants had severe ataxia, while the other 32% had moderate ataxia. The studies tested epoetin alpha, CoQ10 and vitamin E, idebenone, leriglitazone, omaveloxolone, and RT001. One study tested pioglitazone but has not published any results. Four of the studies were pharmaceutical‐industry‐controlled. Synthesis of results Meta‐analysis of seven studies demonstrated that pharmacological treatment probably makes little or no difference to scores on the ataxia rating scale after 12 months of treatment (SMD 0.02, 95% CI −0.23 to 0.26; I² = 42%; 7 studies, 513 participants; moderate‐certainty evidence). The evidence was very uncertain about the effects of treatment on IVSTd (MD −0.51, 95% CI −1.10 to 0.09; I² = 80%; 2 studies, 72 participants; very low‐certainty evidence) and on ADL (MD −0.59, 95% CI −1.39 to 0.21; I² = 24%; 3 studies, 167 participants; very low‐certainty evidence). Meta‐analysis of three studies showed that treatment probably improves upper limb dexterity (SMD −0.42, 95% CI −0.73 to −0.11; I² = 0%; 3 studies, 166 participants; moderate‐certainty evidence). We are very uncertain about the effect of pharmacological treatment on CPET (SMD −0.16, 95% CI −0.46 to 0.13; I² = 0%; 3 studies, 181 participants; very low‐certainty evidence). We are very uncertain whether pharmacological treatment has any effect on treatment‐related adverse events (RR 0.88, 95% CI 0.63 to 1.22; I² = 0%; 2 studies, 104 participants; very low‐certainty evidence). There were only 104 participants in this analysis out of a total of 545 participants, so the result may have little relevance. Meta‐analysis of six studies found that there may be little to no difference between pharmacological treatment and placebo in treatment‐emergent adverse events leading to cessation of medication or death (RR 1.24, 95% CI 0.44 to 3.48; I² = 0%; 6 studies, 313 participants; low‐certainty evidence). Our certainty in the evidence ranged from very low to moderate. We downgraded all outcomes by one or two levels for imprecision, with further downgrades for inconsistency (for the outcomes of IVSTd, ADL, CPET) and suspected publication bias (for the outcomes of IVSTd, ADL, CPET and adverse events). Authors' conclusions In this updated Cochrane systematic review, meta‐analysis of results on the ataxia rating scale showed that pharmacological treatments probably make little or no difference compared with placebo after 12 months of treatment. Given this result, the probable improvement that we found in upper limb dexterity was unexpected. Treatment‐emergent adverse events leading to cessation of medication or death may be no more common in treatment groups than placebo groups as there were few adverse events detected in the treated groups. However, the studies may not have detected all rare and serious adverse events. Funding The authors in this review received no funding. Registration Protocol (2009) DOI: 10.1002/14651858.CD007791 Original review (2009) DOI: 10.1002/14651858.CD99791.pub2 Update (2012) DOI: 10.1002/14651858.CD007791.pub3 Update (2016) DOI: 10.1002/14651858.CD007791.pub4 Plain language summary Does taking medicine help people with Friedreich ataxia? Key messages For people with a progressive genetic condition called Friedreich ataxia, which affects nerves and muscles, taking medicine for a year probably has little to no effect on measures of ataxia (problems with co‐ordination and balance) or speech, although it probably improves upper limb dexterity (the ability to co‐ordinate the action of the arms, hands and fingers). We are uncertain whether taking medicine has any effect on heart health, the ability to perform daily tasks, or the body's response to exercise in people with Friedreich ataxia. From the available evidence, it is very uncertain whether the medicines cause any unwanted effects. What is Friedreich ataxia? Friedreich ataxia is a rare inherited condition affecting the nerves and muscles, which usually appears in childhood, at between 5 and 15 years of age. It causes clumsiness of movement, which progresses to unsteadiness in standing and walking, and to being dependent on a wheelchair by the late teens or early twenties. It can be associated with a curved spine (scoliosis), foot deformity (a high arch) and heart problems. As the disease progresses, slurred speech, hearing difficulties, problems going to the toilet, muscle spasticity, depression, anxiety and visual disturbances are common. Heart problems are a cause of early death in nearly two‐thirds of people with Friedreich ataxia. Clinical examination and laboratory tests are not very useful for judging the progression of the disease, which makes it difficult to understand the results of studies with Friedreich ataxia patients. What are the possible options for treating Friedreich ataxia? There is currently no cure for Friedreich ataxia. Various medicines have been tried. A new medicine, omaveloxolone, was recently approved in the USA and Europe for people over 16 years of age with Friedreich ataxia. What did we want to find out? We wanted to know if any of the medicines tested in randomised clinical trials help improve the lives of people with Friedreich ataxia. Randomised clinical trials are studies where some people take medicine and others take placebo, which is a substance that has no medical benefit but looks the same as the active medicine. No‐one involved with the study knows who is taking medicine and who is taking placebo. This is the third update of a Cochrane review that was first published in 2009. What did we do? We searched for randomised clinical trials that compared medicine to placebo in people with Friedreich ataxia and lasted at least 12 months. We combined the results of the studies and rated our confidence in this evidence, based on factors such as study methods and the number of people involved. What did we find? We found eight studies, seven of which reported results after taking medicine or placebo for 12 months. The studies included a total of 574 people, whose average ages were between 18 and 35 years. Most of the participants (68%) had severe ataxia, while 32% had moderate ataxia. The studies took place in Europe, North America and Australia. Four of them were carried out by the pharmaceutical industry (i.e. by companies who make the medicines). Two studies used a medicine called idebenone, and each of the others used a different medicine: co‐Q10 with vitamin E, epoetin alpha, omaveloxolone, leriglitazone, pioglitazone, and RT001. We found that, after one year, there was probably little to no difference in the level of ataxia that people experienced, regardless of whether they took medicine or placebo (7 studies, 513 people). We are very uncertain whether medicine has any effect on heart health (based on measuring the thickness of the heart muscle) or the ability to do daily tasks or how people score on special tests designed to measure the body's response to exercise. We found that medicine probably improves upper limb dexterity after one year (3 studies (testing leriglitazone, epoetin alpha and omaveloxolone), 166 people). With regard to safety, we are very uncertain whether the medicines cause any more unwanted effects than placebo. We found that there may be little to no difference between people taking medicine and people taking placebo in terms of the number of who either stopped taking the medicine or placebo, or the number of who died during the study years (6 studies, 313 people). What are the limitations of the evidence? Our confidence in the effect of medicine on ataxia is only moderate. This is because the results were not very precise. We are only moderately confident about the effect of medicine on upper limb dexterity because this was only reported in small studies. We had very little confidence in the other outcomes because of the small numbers of people in the studies. The studies reported varied results, and some studies did not publish the results for all the assessments that were carried out. It is difficult to measure an individual's perceptions of the positive effects of any new medicine, which may vary depending on their expectations prior to starting the medicine and whether their illness is early or advanced. How up to date is this evidence? The evidence is current to 4 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lyons, S, Kearney, M, Fahey, MC, Janjal, P, Pandolfo, M, Patton, P", "articleTypes": [], "doi": "10.1002/14651858.CD007791.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.142Z" }, { "id": "c989f412-9828-402f-bc75-0a2baebbe30e", "pmid": "", "title": "Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Herpes zoster oticus (HZO) is a viral infection of the ear and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first‐line treatment for herpes zoster infections at other body sites and are thought to reduce or minimise nerve damage, thereby improving outcomes. It has been suggested that these agents improve the chance of facial weakness improving or resolving completely in patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy). Search methods We searched the Cochrane ENT Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medline (1950 ‐ 2007), PubMed 2007 ‐ 2008, EMBASE (1974 onwards) and other relevant databases. The date of the most recent search was June 2008. Selection criteria Two authors scrutinized all possible citations to identify randomised controlled trials in which antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) were given as treatment for Ramsay Hunt syndrome. We contacted an author for further information. Data collection and analysis Two reviewers independently assessed eligibility and trial quality. Main results Only one randomised, controlled trial was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, intravenous acyclovir and corticosteroids were compared with corticosteroids alone. Our analysis found no statistically significant difference between the two groups. Authors' conclusions We found no evidence that anti‐viral agents have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. The use of these drugs in patients with herpes zoster infections in other parts of the body might suggest that they have a role in herpes zoster oticus. As usual, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically under‐powered study) does not necessarily indicate that antivirals are ineffective. However, these drugs are associated with a number of adverse effects and this must be taken into consideration when undertaking the requisite risk‐benefit analysis before instigating treatment. Plain language summary Uncertainty about usefulness of antiviral drugs in Ramsay Hunt syndrome It seems logical that antiviral drugs might help patients with a herpes virus infection of the ear producing facial weakness (a condition known as 'Ramsay Hunt syndrome'). These drugs often help similar viral infections elsewhere in the body. However, trials that might address this issue have not been done and there is therefore some uncertainty about their usefulness. Since patients can experience side‐effects when taking these drugs, the risks of these have to be balanced with the unknown prospect of benefit when considering whether to use them in Ramsay Hunt syndrome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T, Doree, C, Chamberlain, IJ, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.072Z" }, { "id": "c98c1d30-679c-4fb9-8be0-f253fd1c5783", "pmid": "", "title": "Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years", "imported": false, "abstract": "Abstract - Background Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health. Objectives To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non‐dietary intervention. Secondary objectives were to assess the impact of ECEC‐based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality‐of‐life outcomes. We also report on cost and adverse consequences of ECEC‐based healthy eating interventions. Search methods We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers. Selection criteria We included randomised controlled trials (RCTs), including cluster‐RCTs, stepped‐wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross‐over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both. Data collection and analysis Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta‐analyses using a random‐effects model; otherwise, we described findings using vote‐counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes. Main results We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster‐RCTs. Twenty‐nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty‐eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC‐based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I 2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I 2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC‐based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI −0.01 to 0.25; P =0.08, I 2 = 70%; 13 studies, 3335 children). There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely result in little to no difference in children's consumption of non‐core (i.e. less healthy/discretionary) foods (SMD −0.05, 95% CI −0.17 to 0.08; P = 0.48, I 2 = 16%; 7 studies, 1369 children) or consumption of sugar‐sweetened beverages (SMD −0.10, 95% CI −0.34 to 0.14; P = 0.41, I 2 = 45%; 3 studies, 522 children). Thirty‐six studies measured BMI, BMI z‐score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC‐based healthy eating interventions may result in little to no difference in child BMI (MD −0.08, 95% CI −0.23 to 0.07; P = 0.30, I 2 = 65%; 15 studies, 3932 children) or in child BMI z‐score (MD −0.03, 95% CI −0.09 to 0.03; P = 0.36, I 2 = 0%; 17 studies; 4766 children). ECEC‐based healthy eating interventions may decrease child weight (MD −0.23, 95% CI −0.49 to 0.03; P = 0.09, I 2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I 2 = 0%; 5 studies, 1070 children). ECEC‐based healthy eating interventions may be cost‐effective but the evidence is very uncertain (6 studies). ECEC‐based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3). Authors' conclusions ECEC‐based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC‐based healthy eating interventions on vegetable consumption. ECEC‐based healthy eating interventions may result in little to no difference in child consumption of non‐core foods and sugar‐sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z‐scores. Future studies exploring the impact of specific intervention components, and describing cost‐effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC‐based healthy eating interventions. Plain language summary How successful are healthy eating programmes in preschools, kindergartens and childcare settings? Key messages • Healthy eating programmes delivered in early childhood education and care (ECEC) settings (e.g. preschools, kindergarten, family day care) may improve child diet quality, likely increase fruit consumption, may have favourable effects on vegetable consumption, and likely have no impact on consumption of less healthy foods and sugar‐sweetened drinks. They may have favourable effects on child weight and may reduce the risk of being overweight or obese. • We don't know if healthy eating interventions save money or cause unwanted effects because very few studies provided information about these points. • We found little evidence from low‐ and middle‐income countries, but healthy eating programmes in high‐income countries may benefit child health. We don't know how to support educators and staff to implement these programmes in practice. We need more research about delivering programmes and about their effect in low‐income countries. Why is it important to improve young children's diet? Having a poor diet puts people at risk of many long‐term diseases including heart disease, type 2 diabetes and certain types of cancers. Research estimates that over 11 million deaths worldwide are caused by having an unhealthy diet. Dietary behaviours and preferences are established early in life and persist into adulthood. What are healthy eating programmes? Healthy eating programmes aim to encourage children to eat a healthier diet. They may involve changes to lessons and the culture in preschools, kindergartens and day care centres (early childhood education and care (ECEC) settings), and working with children's families, teachers and healthcare staff. For example, introducing new fruits and vegetables to children, changing the menu to include healthier options or providing families with information about child healthy eating. Healthy eating programmes may establish lifelong healthy eating patterns, reduce excessive weight gain and improve overall health. What did we want to find out? We wanted to find out what impact healthy eating interventions have on child diet and health. We were interested in changes to diet, weight, language and cognitive performance, social, emotional and quality of life outcomes in children aged six months to six years attending preschool, long day care, nurseries, kindergartens and family day care services. We also wanted to know the cost of interventions and whether they had any potential unwanted effects. What did we do? We searched for studies that compared healthy eating programmes against no action, delayed delivery of the programme, or a programme that did not aim to change child diet. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 52 studies that looked at the effects of 58 healthy eating programmes in ECEC settings for children aged six months to six years. All studies were published in high and high‐middle‐income countries. The programmes were very different from each other. They: • lasted from 4 weeks to 3 years; • were delivered by a range of people including healthcare providers, ECEC staff, and researchers; • used different delivery methods (telephone, face‐to‐face, online, printed materials); and • measured results in a variety of ways (e.g. parent or staff surveys, observations of children's eating, and weighing foods before and after meals). Overall, the programmes aimed to: • change the ECEC environment (e.g. staff demonstrated healthy eating to children, and provided healthier foods); • change the curriculum (e.g. they provided lessons about foods and healthy eating); and • establish partnerships (e.g. they provided educational resources to families); and • increase children's physical activity (e.g. by structured physical activity lessons and encouraging less screen time). Healthy eating programmes may lead to small improvements in child diet quality, increase fruit consumption by 0.11 servings, potentially improve vegetable consumption by 0.12 servings and may have no effect on consumption of less healthy foods and sugar‐sweetened drinks. Further, we found child weight is potentially reduced by 230 g and for every 100 children, 19 would have better weight status. However, we found no evidence of impact on body mass index. The programmes may be cost‐effective and likely to have no unwanted effects, although few studies reported these points. Few studies reported on other learning, social and developmental outcomes. What are the limitations of the evidence? Our confidence in the evidence is low because the healthy eating programmes were conducted, delivered and assessed in different ways. Also, many of the people who received the healthy eating programmes were aware that they were being assessed and this can sometimes influence how they report their effects. For example, parents who reported their child's diet may have been more inclined to give positive answers because they felt they were doing what society expected or because they were grateful for the support and wanted to please the researchers. Also, not all studies provided information about everything we were interested in and there was often missing data when children were followed up after the study. How up‐to‐date is the evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yoong, SL; Lum, M; Wolfenden, L; Jackson, J; Barnes, C; Hall, AE; McCrabb, S; Pearson, N; Lane, C; Jones, JZ; Nolan, E; Dinour, L; McDonnell, T; Booth, D; Grady, A", "articleTypes": [], "doi": "10.1002/14651858.CD013862.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "c9b589ea-24e2-41fb-a569-8b2441e616fd", "pmid": "", "title": "Zinc supplementation for the promotion of growth and prevention of infections in infants less than six months of age", "imported": false, "abstract": "Abstract - Background Zinc is a vital micronutrient for humans and is essential for protein synthesis, cell growth, and differentiation. Severe zinc deficiency can lead to slower physical, cognitive and sexual growth, cause skin disorders, decrease immunity, increase incidence of acute illnesses in infants and children and contribute to childhood stunting. By estimation, 17.3% of the world population is at risk of inadequate zinc intake. Such nutritional impairment increases the risk of diarrhoea and pneumonia by 20%, as well as leads to a global loss of more than 16 million disability‐adjusted life years in children less than five years of age. Not only does zinc deficiency affect lives, it adds to the considerable financial burden on depleted resources in countries that are most affected. By preventing or curing this deficiency, we can improve childhood mortality, morbidity and growth. Objectives To assess the effectiveness of zinc supplementation for the promotion of growth, reduction in mortality, and the prevention of infections in infants less than six months of age. Search methods We used the standard search strategy of the Cochrane Neonatal Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 4), MEDLINE via PubMed (1966 to 18 May 2018), Embase (1980 to 18 May 2018), and CINAHL (1982 to 18 May 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi‐randomised trials . An updated search from 1 January 2018 to 29 January 2020 was run in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. Selection criteria All randomised controlled (individual and cluster randomised) and quasi‐randomised trials of zinc supplementation in healthy, term infants, less than six months of age comparing infant mortality, incidence of diarrhoea or respiratory illnesses, growth and/or serum zinc levels were eligible. Data collection and analysis Two review authors screened search results (title and abstracts) and relevant full texts. Studies fulfilling prespecified inclusion criteria were included with any disagreements resolved by consensus. Extraction and analysis were then conducted. We used the GRADE approach to assess the quality of evidence as indicated by certainty in effect estimates. Main results Eight studies (with 85,629 infants) were included and five studies were meta‐analysed, out of which four studies compared zinc with placebo, and one compared zinc plus riboflavin versus riboflavin. Certain growth outcomes after six months of intervention (Weight for Age Z‐scores (WAZ) (standardised mean difference) (SMD) 0.16, 95% CI 0.03 to 0.29; three studies, n = 955; fixed‐effect; heterogeneity Chi² P = 0.96); I² = 0%); change in WAZ (SMD 0.16, 95% CI 0.07 to 0.25; one study, n = 386; fixed‐effect); (Weight‐for‐Length Z‐score (WLZ) (SMD 0.15, 95% CI 0.02 to 0.28; three studies, n = 955; fixed‐effect; heterogeneity: Chi² P = 0.81); I² = 0%); (change in WLZ (SMD 0.17, 95% CI 0.06 to 0.28; one study, n = 386; fixed‐effect)) were positively affected by zinc supplementation compared to placebo. A single study reported no difference in the incidence of diarrhoea and lower respiratory tract infection with zinc supplementation. Zinc had no effect on mortality in children younger than 12 months. When zinc plus riboflavin was compared to riboflavin only, significant improvement was observed in the incidence of wasting at 24 months (risk ratio (RR) 0.59, 95% CI 0.37 to 0.96; one study, n = 296; fixed‐effect), but significant worsening of incidence of stunting was present at 21 months (RR 1.53, 95% CI 1.09 to 2.16; one study, n = 298; fixed‐effect). Authors' conclusions There was a significant positive impact of zinc supplementation on WAZ and WLZ after six months of intervention in infants compared to placebo. When a combined supplement of zinc and riboflavin was compared to riboflavin, there was a significant reduction in wasting at 24 months, but stunting at 21 months was negatively affected. Although included trials were of good‐to‐moderate quality, evidence that could be meta‐analysed was based on a few studies which affected the overall quality of results. Regardless, there is a need for strong trials conducted in infants younger than six months before a strong recommendation can be made supporting zinc supplementation in this age group. Plain language summary Zinc supplementation for improving the health and survival of infants less than six months old Review question: does zinc supplementation reduce mortality, morbidity and increase growth in infants aged less than six months old? Background: zinc deficiency is prevalent in the world. Adequate zinc levels are linked to decreased deaths, illnesses and improved growth in all populations particularly in developing countries. Zinc supplementation in older children has shown some positive effects. Study characteristics: we searched for studies through January 2020 that enrolled healthy infants aged less than six months old and provided at least six months of zinc supplementation. We included eight studies that covered zinc supplementation compared with placebo, zinc and riboflavin compared with riboflavin only, zinc, riboflavin and B complex vitamins compared with riboflavin and B complex vitamins. Key results and certainty of evidence: zinc had no effect on decreasing deaths or illnesses in children younger than 12 months. Moderate‐ to good‐certainty evidence from three studies suggested an increase in weight‐for‐age Z‐scores and weight‐for‐length Z‐scores after zinc supplementation for six months compared to placebo only. Only one study could be analysed for zinc and riboflavin supplementation compared to riboflavin only, and the results suggested a decrease in wasting after 24 months of supplementation and an increase in stunting after 21 months. Conclusion: with this evidence, we cannot strongly recommend clinicians to prescribe zinc supplements to children under six months of age. We also encourage the development of trials that will provide zinc as well as other micronutrients in this age group and for such trials to evaluate outcomes such as death, disease, side effects and growth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lassi, ZS; Kurji, J; Oliveira, CSD; Moin, A; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD010205.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "c9d3203a-3c5b-4c2a-b41f-d9cd7989fc75", "pmid": "", "title": "Anticholinergic therapy for chronic asthma in children over two years of age", "imported": false, "abstract": "Abstract - Background In the intrinsic system of controlling airway calibre, the cholinergic (muscarinic) sympathetic nervous system has an important role. Anticholinergic, anti muscarinic bronchodilators such as ipratropium bromide are frequently used in the management of childhood airway disease. In asthma, ipratropium is a less potent bronchodilator than beta‐2 adrenergic agents but it is known to be a useful adjunct to other therapies, particularly in status asthmaticus. What remains unclear is the role of anticholinergic drugs in the maintenance treatment of chronic asthma. Objectives To determine the effectiveness of anticholinergic drugs in chronic asthma in children over the age of 2 years. Search methods The Cochrane Airways Group Specialised Register and reference lists of articles were searched. The most recent search was carried out in Febuary 2010. Selection criteria Randomised controlled trials in which anticholinergic drugs were given for chronic asthma in children over 2 years of age were included. Studies including comparison of: anticholinergics with placebo, and anticholinergics with any other drug were included. Data collection and analysis Eligibility for inclusion and quality of trials were assessed independently by two reviewers. Main results Eight studies met the inclusion criteria. Three papers compared the effects of anticholinergic drugs with placebo, and a meta‐analysis of these results demonstrated no statistically significant benefit of the use of anticholinergic drugs over placebo in any of the outcome measures used. The results of one of these trials could not be included in the meta‐analysis but the authors did report significantly lower symptom scores with inhaled anticholinergics compared with placebo. However, there was no significant difference between ipratropium bromide and placebo in the percentage of symptom‐free nights or days. Two trials studied the effects of anticholinergics on bronchial hyper responsiveness to histamine, by measuring the provocation dose of histamine needed to cause a fall of 20 % in FEV1 (PD 20). One study (comparing anticholinergics with placebo) reported a statistically significant increase in PD 20 but this was not found in another study (comparing anticholinergics with a beta‐2 agonist). Both trials also examined the effect of anticholinergic drugs on diurnal variation in peak expiratory flow rate (PEFR) and reported no significant effect. Two studies compared the addition of an anticholinergic drug to a beta‐2 agonist with the beta‐2 agonist alone. Both trials failed to show any significant benefit from the long term use of combined anticholinergics with beta‐2 agonists compared with beta‐2 agonists alone. One trial compared the effects of oral and inhaled anticholinergic drugs with placebo. No statistically significant differences were found in any of the outcome measures except for a higher FEV1 / VC ratio and RV / TLC ratio with oral anticholinergic therapy when compared with placebo. Authors' conclusions The present review summarises the best evidence available to date. Although there were some small beneficial findings in favour of anticholinergic therapy, there is insufficient data to support the use of anticholinergic drugs in the maintenance treatment of chronic asthma in children. Plain language summary Anticholinergic drugs versus either placebo or other medications for children over two years of age with asthma Anticholinergic drugs are widely used in the management of both acute and chronic asthma in children. Their effect is achieved through relief of narrowing of the airways that occurs in asthma. Current guidelines for the management of chronic asthma advise that anticholinergic drugs may be used if children are already on high dose inhaled steroids. This study undertook a comprehensive search of the literature unrestricted by country of publication or language. Unfortunately small numbers of relevant trials were found and these were of variable quality. This review found that although anticholinergic drugs are well tolerated, in children over two years of age, there is not enough data to be sure if they are better than placebo in terms of effects on lung function or symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "McDonald, N, Bara, A, McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD003535", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.761Z" }, { "id": "c9d7a3f7-0c85-4b72-87d5-d7e0278a5421", "pmid": "", "title": "Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer", "imported": false, "abstract": "Abstract - Background Radioactive iodine treatment for differentiated thyroid cancer possibly results in xerostomia. Amifostine has been used to prevent the effects of irradiation to salivary glands. To date, the effects of amifostine on salivary glands in radioactive iodine treated differentiated thyroid cancer remain uncertain. Objectives To assess the effects of amifostine on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer. Search methods Studies were obtained from computerized searches of MEDLINE, EMBASE, The Cochrane Library and paper collections of conferences held in Chinese. Selection criteria Randomised controlled clinical trials and quasi‐randomised controlled clinical trials comparing the effects of amifostine on salivary glands after radioactive iodine treatment for differentiated thyroid cancer with placebo and a duration of follow up of at least three months. Data collection and analysis Two authors independently assessed risk of bias and extracted data. Main results Two trials with 130 patients (67 and 63 patients randomised to intervention versus control) were included. Both studies had a low risk of bias. Amifostine versus placebo showed no statistically significant differences in the incidence of xerostomia (130 patients, two studies), the decrease of scintigraphically measured uptake of technetium‐99m by salivary or submandibular glands at twelve months (80 patients, one study), and the reduction of blood pressure (130 patients, two studies). Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Meta‐analysis was not performed on the function of salivary glands measured by technetium‐99m scintigraphy at three months after high dose radioactive iodine treatment due to the highly inconsistent findings across studies (I 2 statistic 99%). None of the included trials investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions Results from two randomised controlled clinical trials suggest that the amifostine has no significant radioprotective effects on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer patients. Moreover, no health‐related quality of life and other patient‐oriented outcomes were evaluated in the two included trials. Randomised controlled clinical trials with low risk of bias investigating patient‐oriented outcomes are needed to guide treatment choice. Plain language summary Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer Thyroid cancer is the most common malignancy of the endocrine system consisting of several subtypes like papillary carcinoma (accounting for 80% of cases) and follicular carcinoma (accounting for 11% of cases). These are collectively referred to as 'differentiated thyroid cancer'. Treatment with radioactive iodine after surgery (ablation of the thyroid gland or 'thyroidectomy') is important for the detection of metastatic disease and for the destruction of the remaining thyroid tissue with microscopic cancer. After radioactive iodine treatment, adverse effects may happen in the salivary glands and cause salivary gland swelling and pain, usually involving the parotid. The symptoms may develop immediately after a therapeutic dose of radioactive iodine or months later and progress in intensity with time. Secondary complications reported include dry mouth ('xerostomia') and taste alterations. Amifostine is thought to be a radioprotector of salivary glands used in conjunction with radioiodine therapy. This medication is administered intravenously and was reported to ameliorate the damage of salivary glands caused by radioactive iodine therapy. We found only two randomised controlled trials in which the effects of amifostine were compared with placebo. The two randomised clinical trials investigated 130 patients treated with high dose radioactive iodine for thyroid cancer. Altogether data from the two trials suggest that amifostine has no obvious protective effects on the salivary glands in these patients. Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Until better data become available, the use of sour candy or lemon juice to increase salivation might be more appropriate during radioactive iodine treatment for patients with differentiated thyroid cancer. Patients should be well informed of the importance of hydration, acid stimulation and glandular massage after radioactive iodine treatment. In addition, early recognition and treatment of xerostomia may improve outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Ma, C, Xie, J, Chen, Q, Wang, G, Zuo, S", "articleTypes": [], "doi": "10.1002/14651858.CD007956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.734Z" }, { "id": "c9e223fa-c377-4d1a-a989-3bece2978112", "pmid": "", "title": "Zinc supplementation for the prevention of pneumonia in children aged 2 months to 59 months", "imported": false, "abstract": "Abstract - Background Pneumonia is a leading cause of morbidity and mortality in children younger than five years of age. Most deaths occur during infancy and in low‐income countries. Daily zinc supplements have been reported to prevent acute lower respiratory tract infection (LRTI) and reduce child mortality. This is an update of a review first published in 2010. Objectives To evaluate the effectiveness of zinc supplementation in the prevention of pneumonia in children aged two to 59 months. Search methods We searched CENTRAL (Issue 21 October 2016), MEDLINE (1966 to October 2016), Embase (1974 to October 2016), LILACS (1982 to October 2016), CINAHL (1981 to October 2016), Web of Science (1985 to October 2016) and IMSEAR (1980 to October 2016). Selection criteria Randomised controlled trials (RCTs) evaluating zinc supplementation for the prevention of pneumonia in children aged from 2 months to 59 months. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We did not identify any new studies for inclusion in this update. We included six studies that involved 5193 participants. Analysis showed that zinc supplementation reduced the incidence of pneumonia by 13% (fixed‐effect risk ratio (RR) 0.87; 95% confidence interval (CI) 0.81 to 0.94, six studies, low‐quality evidence) and prevalence of pneumonia by 41% (random‐effects RR 0.59; 95% CI 0.35 to 0.99, one study, n = 609, low‐quality evidence). On subgroup analysis, we found that zinc reduced the incidence of pneumonia defined by specific clinical criteria by 21% (i.e. confirmation by chest examination or chest radiograph) (fixed‐effect RR 0.79; 95% CI 0.71 to 0.88, four studies, n = 3261), but had no effect on lower specificity pneumonia case definition (i.e. age‐specific fast breathing with or without lower chest indrawing) (fixed‐effect RR 0.95; 95% CI 0.86 to 1.06, four studies, n = 1932). Authors' conclusions Zinc supplementation in children is associated with a reduction in the incidence and prevalence of pneumonia. Plain language summary Zinc supplementation for the prevention of pneumonia in children aged two to 59 months Review question We evaluated the effectiveness of zinc supplementation to prevent pneumonia in children aged from two to 59 months. Background Zinc is an essential element for children's growth and development. Too little zinc is associated with increased risk of infection, particularly diarrhoea and pneumonia. Children are more prone to zinc deficiency because they are less able to absorb dietary zinc and some children, especially in low‐income countries, may not have received enough zinc from their mothers before birth. Zinc supplements for children has been reported to prevent pneumonia. Search date We searched the literature up to October 2016. This is an update of a review published in 2010. We did not find any new studies for this update. Study characteristics We included six studies that investigated zinc supplements to prevent pneumonia. The studies were conducted in Bangladesh, India, Peru and South Africa and involved 5193 children aged from two to 59 months. Children received either zinc or a similar‐looking treatment that did not contain zinc. In two studies, children were also given vitamin A. Study funding sources All included studies were funded. Of these, three explicitly mentioned that funding agencies had no role in the design and results of the study. Key results Zinc supplementation was significantly associated with reducing the incidence and prevalence of pneumonia among children aged from two to 59 months. On subgroup analysis, we found that a more stringent diagnosis (radiological examination) increased the reduction in pneumonia incidence. Quality of the evidence Overall, evidence quality was assessed as low on GRADE assessment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lassi, ZS, Moin, A, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD005978.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.070Z" }, { "id": "c9e94256-cd20-4060-a9a4-e121d945c27a", "pmid": "", "title": "Complementary therapies for acne vulgaris", "imported": false, "abstract": "Abstract - Background Acne is a chronic skin disease characterised by inflamed spots and blackheads on the face, neck, back, and chest. Cysts and scarring can also occur, especially in more severe disease. People with acne often turn to complementary and alternative medicine (CAM), such as herbal medicine, acupuncture, and dietary modifications, because of their concerns about the adverse effects of conventional medicines. However, evidence for CAM therapies has not been systematically assessed. Objectives To assess the effects and safety of any complementary therapies in people with acne vulgaris. Search methods We searched the following databases from inception up to 22 January 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 , Issue 1 ), MEDLINE (from 1946), Embase (from 1974), PsycINFO (from 1806), AMED (from 1985), CINAHL (from 1981), Scopus (from 1966), and a number of other databases listed in the Methods section of the review. The Cochrane CAM Field Specialised Register was searched up to May 2014. We also searched five trials registers and checked the reference lists of articles for further references to relevant trials. Selection criteria We included parallel‐group randomised controlled trials (or the first phase data of randomised cross‐over trials) of any kind of CAM, compared with no treatment, placebo, or other active therapies, in people with a diagnosis of acne vulgaris. Data collection and analysis Three authors collected data from each included trial and evaluated the methodological quality independently. They resolved disagreements by discussion and, as needed, arbitration by another author. Main results We included 35 studies, with a total of 3227 participants. We evaluated the majority as having unclear risk of selection, attrition, reporting, detection, and other biases. Because of the clinical heterogeneity between trials and the incomplete data reporting, we could only include four trials in two meta‐analyses, with two trials in each meta‐analysis. The categories of CAM included herbal medicine, acupuncture, cupping therapy, diet, purified bee venom (PBV), and tea tree oil. A pharmaceutical company funded one trial; the other trials did not report their funding sources. Our main primary outcome was 'Improvement of clinical signs assessed through skin lesion counts', which we have reported as 'Change in inflammatory and non‐inflammatory lesion counts', 'Change of total skin lesion counts', 'Skin lesion scores', and 'Change of acne severity score'. For 'Change in inflammatory and non‐inflammatory lesion counts', we combined 2 studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD) at 12 weeks and found no clear evidence of a difference between the groups in change in non‐inflammatory lesion counts (mean difference (MD) ‐3.89, 95% confidence interval (CI) ‐10.07 to 2.29, P = 0.10, 75 participants, 2 trials, low quality of evidence). However, although data from 1 of these 2 trials showed benefit of LGLD for reducing inflammatory lesions (MD ‐7.60, 95% CI ‐13.52 to ‐1.68, 43 participants, 1 trial) and total skin lesion counts (MD ‐8.10, 95% CI ‐14.89 to ‐1.31, 43 participants, 1 trial) for people with acne vulgaris, data regarding inflammatory and total lesion counts from the other study were incomplete and unusable in synthesis. Data from a single trial showed potential benefit of tea tree oil compared with placebo in improving total skin lesion counts (MD ‐7.53, 95% CI ‐10.40 to ‐4.66, 60 participants, 1 trial, low quality of evidence) and acne severity scores (MD ‐5.75, 95% CI ‐9.51 to ‐1.99, 60 participants, 1 trial). Another trial showed pollen bee venom to be better than control in reducing numbers of skin lesions (MD ‐1.17, 95% CI ‐2.06 to ‐0.28, 12 participants, 1 trial). Results from the other 31 trials showed inconsistent effects in terms of whether acupuncture, herbal medicine, or wet‐cupping therapy were superior to controls in increasing remission or reducing skin lesions. Twenty‐six of the 35 included studies reported adverse effects; they did not report any severe adverse events, but specific included trials reported mild adverse effects from herbal medicines, wet‐cupping therapy, and tea tree oil gel. Thirty trials measured two of our secondary outcomes, which we combined and expressed as 'Number of participants with remission'. We were able to combine 2 studies (low quality of evidence), which compared Ziyin Qinggan Xiaocuo Granule and the antibiotic, minocycline (100 mg daily) (worst case = risk ratio (RR) 0.49, 95% CI 0.09 to 2.53, 2 trials, 206 participants at 4 weeks; best case = RR 2.82, 95% CI 0.82 to 9.06, 2 trials, 206 participants at 4 weeks), but there was no clear evidence of a difference between the groups. None of the included studies assessed 'Psychosocial function'. Two studies assessed 'Quality of life', and significant differences in favour of the complementary therapy were found in both of them on 'feelings of self‐worth' (MD 1.51, 95% CI 0.88 to 2.14, P < 0.00001, 1 trial, 70 participants; MD 1.26, 95% CI 0.20 to 2.32, 1 trial, 46 participants) and emotional functionality (MD 2.20, 95% CI 1.75 to 2.65, P < 0.00001, 1 trial, 70 participants; MD 0.93, 95% CI 0.17 to 1.69, 1 trial, 46 participants). Because of limitations and concerns about the quality of the included studies, we could not draw a robust conclusion for consistency, size, and direction of outcome effects in this review. Authors' conclusions There is some low‐quality evidence from single trials that LGLD, tea tree oil, and bee venom may reduce total skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs, such as herbal medicine, acupuncture, or wet‐cupping therapy, for the treatment of this condition. There is a potential for adverse effects from herbal medicines; however, future studies need to assess the safety of all of these CAM therapies. Methodological and reporting quality limitations in the included studies weakened any evidence. Future studies should be designed to ensure low risk of bias and meet current reporting standards for clinical trials. Plain language summary Complementary therapies for acne vulgaris Background Acne is a chronic skin disease, which causes spots to occur simultaneously on several areas of the body, including the face, neck, back, and chest. Besides the current commonly used treatments, complementary and alternative medicines (CAM) are of increasing interest to people who often use them in addition to conventional treatments as additive or single therapies to treat acne. The review question Can any complementary therapies improve the clinical symptoms of acne vulgaris? Study characteristics We searched relevant databases and trials registers up to 22 January 2014. We identified 35 randomised controlled trials, with 3227 participants, which used 6 kinds of CAM (herbal medicine, acupuncture, wet cupping, diet, purified bee venom, and tea tree oil). A pharmaceutical company funded one trial; the other trials did not report their funding sources. Key results For our primary outcome, we combined two studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD), but found no clear evidence of a difference between the 2 groups at 12 weeks for a change in non‐inflammatory lesion counts. Only one of these two trials provided usable data to show potential benefit of LGLD for reducing inflammatory and total skin lesion counts. Tea tree oil and pollen bee venom were found to reduce total skin lesion counts in single trials, respectively. The remaining 31 included trials gave mixed results about whether complementary therapies might reduce the total number of skin lesion counts. Twenty‐six trials reported adverse events. The herbal medicine group found some mild side‐effects, such as nausea, diarrhoea, and stomach upset. The acupuncture group found some itch or redness and pain following needle insertion. Participants who used tea tree oil reported itchiness, dryness, and flaking of the skin. None of the trials reported severe adverse effects. For our secondary outcome, there was no clear evidence of a difference in the number of participants with remission between Ziyin Qinggan Xiaocuo Granule and minocycline according to a meta‐analysis of two studies. Quality of the evidence There is some low‐quality evidence from single trials that a low‐glycaemic‐load diet, tea tree oil, and bee venom may reduce skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs. Methodological and reporting quality limitations in the included studies weakened any evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Cao, H, Yang, G, Wang, Y, Liu, JP, Smith, CA, Luo, H, Liu, Y", "articleTypes": [], "doi": "10.1002/14651858.CD009436.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.784Z" }, { "id": "c9f04dfa-d249-432c-9f25-6eebf24be218", "pmid": "", "title": "Interventions for erosive lichen planus affecting mucosal sites", "imported": false, "abstract": "Abstract - Background Erosive lichen planus (ELP) affecting mucosal surfaces is a chronic autoimmune disease of unknown aetiology. It is often more painful and debilitating than the non‐erosive types of lichen planus. Treatment of erosive lichen planus is difficult and aimed at palliation rather than cure. Several topical and systemic agents have been used with varying results. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth. Objectives To assess the effects of interventions in the treatment of erosive lichen planus affecting the oral, anogenital, and oesophageal regions. Search methods We searched the following databases up to September 2009: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched reference lists of articles and online trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) that evaluated the effectiveness of any topical or systemic interventions for ELP affecting either the mouth, genital region, or both areas, in participants of any age, gender, or race. Data collection and analysis The primary outcome measures were as follows: (a) Pain reduction using a visual analogue scale rated by participants; 
 (b) Physician Global Assessment; and
 (c) Participant global self‐assessment. Changes in scores at the end of therapy compared with baseline were analysed. Main results Fifteen RCTs were included, giving a total of 473 participants with ELP (study sizes ranged between 8‐94). All studies involved oral sites only. Six studies included participants with non‐erosive lichen planus but only the erosive subgroup was included for intended subgroup analysis. We were unable to pool data from any of the nine studies with only ELP participants or any of the six studies with the ELP subgroup, due to small numbers and the heterogeneity of the interventions, design methods, and outcome variables between studies. One study involving 50 participants found that 0.025% clobetasol propionate administered as liquid microspheres significantly reduced pain compared to ointment (Mean difference (MD) ‐18.30, 95% confidence interval (CI) ‐28.57 to ‐8.03), but outcome data was only available in 45 participants (high risk of performance bias for blinding of participants, low/unclear risk of bias overall). However, in another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (high risk of performance and detection bias due to likely lack of blinding, low/unclear risk of bias overall). Aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo in a study involving 45 ELP participants (Risk ratio (RR) 6.16, 95% CI 2.35 to 16.13) (low risk of bias overall). No significant difference was seen in Physician Global Assessment in these three studies. In a small single study involving 20 ELP participants, 1% pimecrolimus cream was 7 times more likely to result in a strong improvement as rated by the Physician Global Assessment when compared to vehicle cream (RR 7.00, 95% CI 1.04 to 46.95) (low risk of bias overall). In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease as rated by the Physician Global Assessment, in favour of the ciclosporin group when compared to the vehicle (MD ‐1.40, 95% CI ‐1.86 to ‐0.94) (unclear risk of selection bias for allocation concealment, overall risk of bias low). No statistically significant benefits were shown for topical tacrolimus or fluticasone spray in two separate studies of 29 and 44 participants respectively. There is no overwhelming evidence for the efficacy of a single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candidiasis and dyspepsia. Authors' conclusions This review suggests that there is only weak evidence for the effectiveness of any of the treatments for oral ELP, whilst no evidence was found for genital ELP. More RCTs on a larger scale are needed in the oral and genital ELP populations. We suggest that future studies should have standardised outcome variables that are clinically important to affected individuals. We recommend the measurement of a clinical severity score and a participant‐rated symptom score using agreed and validated severity scoring tools. We also recommend the development of a validated combined severity scoring tool for both oral and genital populations. Plain language summary Treatments for erosive lichen planus affecting mucosal sites Erosive lichen planus (ELP) is a condition that affects the mouth, oesophagus (food pipe or gullet), and anogenital region. It is caused by an over‐active immune system. It is often more painful and debilitating than the non‐erosive types of lichen planus. Depending on the site involved, affected individuals may experience pain, and difficulty eating; passing urine; or having sexual intercourse. Treatment is difficult and aimed at controlling symptoms, rather than cure. Several creams and tablets have been used with varying results. This review looked at the effectiveness of treatments for ELP and included 15 studies, with 473 participants with ELP. All involved oral, but not genital, disease. Many studies were excluded either because they were not randomised controlled trials (where participants are divided into two groups at random) or because they recruited participants with all types of lichen planus, rather than just the erosive subtypes. All of these studies recruited small numbers of participants (12 to 94) and used a variety of different assessment methods and timings; hence, it was not possible to combine or compare results between studies directly. We found only weak evidence for the effectiveness of any of the treatments for oral ELP. None of the studies involved genital or oesophageal disease; hence, no evidence was found for the treatment of these conditions. One small study found that 0.025% clobetasol propionate (a very potent topical steroid) administered as a spray significantly reduced pain when compared to ointment. In another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (a potent topical steroid). In a study involving 45 ELP participants, aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo. In a study involving a small subgroup of 8 ELP participants, a significant difference was seen for an improvement in the severity of the disease in favour of the ciclosporin group when compared to the vehicle. Several side‐effects were reported, but none were serious. With topical corticosteroids, the main side‐effects were oral candida (yeast) infection and pain or discomfort in the upper abdomen. Temporary burning was a common side‐effect reported with tacrolimus 0.1% ointment and pimecrolimus 0.1% cream. Overall, there was no overwhelming evidence for the effectiveness of any single treatment, including topical steroids, which are the widely accepted first‐line therapy for ELP. This was mainly due to the lack of good‐quality, well‐conducted trials and small participant numbers. Another Cochrane review has already assessed interventions for lichen planus affecting the mouth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cheng, S; Kirtschig, G; Cooper, S; Thornhill, M; Leonardi‐Bee, J; Murphy, R", "articleTypes": [], "doi": "10.1002/14651858.CD008092.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "ca12b9bc-9fd0-40d2-b10c-77b54ec74756", "pmid": "", "title": "Probiotics for the prevention of pediatric antibiotic‐associated diarrhea", "imported": false, "abstract": "Abstract - Background Antibiotics alter the microbial balance commonly resulting in antibiotic‐associated diarrhea (AAD). Probiotics may prevent AAD via providing gut barrier, restoration of the gut microflora, and other potential mechanisms of action. Objectives The primary objectives were to assess the efficacy and safety of probiotics (any specified strain or dose) used for the prevention of AAD in children. Search methods MEDLINE, Embase, CENTRAL, CINAHL, and the Web of Science (inception to 28 May 2018) were searched along with registers including the ISRCTN and Clinicaltrials.gov. We also searched the NICE Evidence Services database as well as reference lists from relevant articles. Selection criteria Randomized, parallel, controlled trials in children (0 to 18 years) receiving antibiotics, that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhea secondary to antibiotic use were considered for inclusion. Data collection and analysis Study selection, data extraction, and risk of bias assessment were conducted independently by two authors. Dichotomous data (incidence of AAD, adverse events) were combined using a pooled risk ratio (RR) or risk difference (RD), and continuous data (mean duration of diarrhea) as mean difference (MD), along with corresponding 95% confidence interval (95% CI). We calculated the number needed to treat for an additional beneficial outcome (NNTB) where appropriate. For studies reporting on microbiome characteristics using heterogeneous outcomes, we describe the results narratively. The certainty of the evidence was evaluated using GRADE. Main results Thirty‐three studies (6352 participants) were included. Probiotics assessed included Bacillus spp., Bifidobacterium spp., Clostridium butyricum , Lactobacilli spp. , Lactococcus spp., Leuconostoc cremoris , Saccharomyces spp., or Streptococcus spp., alone or in combination. The risk of bias was determined to be high in 20 studies and low in 13 studies. Complete case (patients who did not complete the studies were not included in the analysis) results from 33 trials reporting on the incidence of diarrhea show a precise benefit from probiotics compared to active, placebo or no treatment control. After 5 days to 12 weeks of follow‐up, the incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group (RR 0.45, 95% CI 0.36 to 0.56; I² = 57%, 6352 participants; NNTB 9, 95% CI 7 to 13; moderate certainty evidence). Nineteen studies had loss to follow‐up ranging from 1% to 46%. After making assumptions for those lost, the observed benefit was still statistically significant using an extreme plausible intention‐to‐treat (ITT) analysis, wherein the incidence of AAD in the probiotic group was 12% (436/3551) compared to 19% (664/3468) in the control group (7019 participants; RR 0.61; 95% CI 0.49 to 0.77; P <0.00001; I² = 70%). An a priori available case subgroup analysis exploring heterogeneity indicated that high dose (≥ 5 billion CFUs per day) is more effective than low probiotic dose (< 5 billion CFUs per day), interaction P value = 0.01. For the high dose studies the incidence of AAD in the probiotic group was 8% (162/2029) compared to 23% (462/2009) in the control group (4038 participants; RR 0.37; 95% CI 0.30 to 0.46; P = 0.06; moderate certainty evidence). For the low dose studies the incidence of AAD in the probiotic group was 8% (97/1155) compared to 13% (133/1059) in the control group (2214 participants; RR 0.68; 95% CI 0.46 to 1.01; P = 0.02). Again, assumptions for loss to follow‐up using an extreme plausible ITT analysis was statistically significant. For high dose studies the incidence of AAD in the probiotic group was 13% (278/2218) compared to 23% (503/2207) in control group (4425 participants; RR 0.54; 95% CI 0.42 to 0.70; P <0.00001; I² = 68%; moderate certainty evidence). None of the 24 trials (4415 participants) that reported on adverse events reported any serious adverse events attributable to probiotics. Adverse event rates were low. After 5 days to 4 weeks follow‐up, 4% (86/2229) of probiotics participants had an adverse event compared to 6% (121/2186) of control participants (RD 0.00; 95% CI ‐0.01 to 0.01; P < 0.00001; I² = 75%; low certainty evidence). Common adverse events included rash, nausea, gas, flatulence, abdominal bloating, and constipation. After 10 days to 12 weeks of follow‐up, eight studies recorded data on our secondary outcome, the mean duration of diarrhea; with probiotics reducing diarrhea duration by almost one day (MD ‐0.91; 95% CI ‐1.38 to ‐0.44; P <0.00001; low certainty evidence). One study reported on microbiome characteristics, reporting no difference in changes with concurrent antibiotic and probiotic use. Authors' conclusions The overall evidence suggests a moderate protective effect of probiotics for preventing AAD (NNTB 9, 95% CI 7 to 13). Using five criteria to evaluate the credibility of the subgroup analysis on probiotic dose, the results indicate the subgroup effect based on high dose probiotics (≥ 5 billion CFUs per day) was credible. Based on high‐dose probiotics, the NNTB to prevent one case of diarrhea is 6 (95% CI 5 to 9). The overall certainty of the evidence for the primary endpoint, incidence of AAD, based on high dose probiotics was moderate due to the minor issues with risk of bias and inconsistency related to a diversity of probiotic agents used. Evidence also suggests that probiotics may moderately reduce the duration of diarrhea, a reduction by almost one day. The benefit of high dose probiotics (e.g. Lactobacillus rhamnosus or Saccharomyces boulardii ) needs to be confirmed by a large well‐designed multi‐centered randomized trial. It is premature to draw firm conclusions about the efficacy and safety of 'other' probiotic agents as an adjunct to antibiotics in children. Adverse event rates were low and no serious adverse events were attributable to probiotics. Although no serious adverse events were observed among inpatient and outpatient children, including small studies conducted in the intensive care unit and in the neonatal unit, observational studies not included in this review have reported serious adverse events in severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter use and disorders associated with bacterial/fungal translocation. Plain language summary Probiotics for the prevention of antibiotic‐associated diarrhea in children What is antibiotic‐associated diarrhea? Antibiotic‐associated diarrhea (AAD) occurs when antibiotics disturb the natural balance of \"good\" and \"bad\" bacteria in the intestinal tract causing harmful bacteria to multiply beyond their normal numbers. The symptoms of AAD include frequent watery bowel movements and crampy abdominal pain. What are probiotics? Probiotics are found in dietary supplements or yogurts and contain potentially beneficial bacteria or yeast. Probiotics may restore the natural balance of bacteria in the intestinal tract. What did the researchers investigate? The researchers investigated whether probiotics prevent AAD in children receiving antibiotic therapy and whether probiotics causes any harms (side effects). The researchers searched the medical literature extensively up to May 28, 2018. What did the researchers find? Thirty‐three studies were reviewed and provide the best available evidence. The studies tested 6352 children (3 days to 17 years of age) who were receiving probiotics co‐administered with antibiotics to prevent AAD. The participants received probiotics ( Lactobacilli spp., Bifidobacterium spp., Streptococcus spp. , or Saccharomyces boulardii alone or in combination), placebo (pills not including probiotics), other treatments thought to prevent AAD (i.e. diosmectite or infant formula) or no treatment. The studies were short‐term, ranging in length from 5 days to 12 weeks. Analyses showed that probiotics are effective for preventing AAD. The incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group, demonstrating a moderate reduction (11% fewer will suffer diarrhea). For every 9 children treated, probiotics will prevent one case of diarrhea. Further, evidence suggests that higher dose probiotics (≥ 5 billion CFUs per day) reduce the incidence of AAD. Eight per cent (162/2029) of the high dose probiotics group had AAD compared to 23% (462/2009) in the control group, demonstrating a moderate to large reduction (15% fewer suffer diarrhea). Probiotics were generally well tolerated, and minor side effects (e.g. rash, nausea, gas, flatulence, abdominal bloating, constipation) occurred infrequently. . Evidence suggested that probiotics are effective for a moderate reduction in duration of diarrhea (almost one day). Among the various probiotics evaluated, Lactobacillus rhamnosus or Saccharomyces boulardii at 5 to 40 billion colony forming units/day appear most appropriate for preventing AAD in children receiving antibiotics. It is premature to draw conclusions about the effectiveness and safety of 'other' probiotic agents for preventing AAD. Although no serious probiotic‐related side effects were observed among the mostly otherwise healthy children who participated in the studies, serious side effects have been reported in observational studies not included in this review, including severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter (a flexible tube used to give medicines) use and disorders associated with bacterial or fungal translocation (the passage of bacteria from the gut to other areas of the body).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Guo, Q; Goldenberg, JZ; Humphrey, C; El Dib, R; Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD004827.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "ca216476-7585-414c-8c05-6383c3ecfda7", "pmid": "", "title": "Pain in Endometriosis And the Relation to Lifestyle: Effectiveness of a Dietary Intervention and Cognitive Behavioral Therapy in Endometriosis-associated Pain", "imported": false, "abstract": "The goal of this clinical trial is to investigate the effect of an anti-inflammatory diet and cognitive behavioral therapy (CBT) on pain symptoms, health related quality of life and the effect on inflammatory characteristics in serum and menstruum samples as well as the effect on the gut and vaginal microbiome in women with endometriosis. In addition, we want to investigate the differences in stress (measured by hair cortisol levels), inflammatory markers in peripheral blood, menstrual effluent, and the vaginal and intestinal microbiome between persons without and with endometriosis. Participants will be randomized between standard care (control group), standard care and an anti-inflammatory diet intervention, or standard care, an anti-inflammatory diet intervention and CBT or CBT alone. Participants will follow an anti-inflammatory diet based on the Dutch Dietary Guidelines or CBT or a combination of both interventions for 12 weeks. They will receive personalized dietary advice from a dietician and recipes will be available. cognitive behavioral therapy will be administered in a total of seven individual sessions led by a psychotherapist. The content of these sessions will be psycho-education regarding pain mechanisms (and diet).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.268Z" }, { "id": "ca54f9f4-3b8a-4b02-8dba-55c52aa663b4", "pmid": "", "title": "Surgical techniques for the removal of mandibular wisdom teeth", "imported": false, "abstract": "Abstract - Background Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short‐term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity. Objectives To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication. Selection criteria Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth. Data collection and analysis Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel‐group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross‐over or split‐mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split‐mouth studies in our analyses, and combined parallel‐group and split‐mouth studies using the generic inverse‐variance method. We used the fixed‐effect model for three studies or fewer, and random‐effects model for more than three studies. Main results We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low‐certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low‐certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low‐certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low‐certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand‐piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low‐certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low‐certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low‐certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low‐certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low‐certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported. Authors' conclusions In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future. Plain language summary Comparing different surgical techniques used to remove wisdom teeth from the lower jaw Background The removal of wisdom teeth is a common operation, but it can cause short‐ and long‐term side effects. People may have their wisdom teeth removed if they are causing pain or infection, or if they are damaging other teeth or not breaking through the gum properly. Surgery has a risk of complications. One of the most common is dry socket (also known as alveolar osteitis). This is when a blood clot fails to form in the socket that the tooth has come out of, or the clot is disturbed before the socket has properly healed. Because the bones and nerves underlying the socket are exposed, it can be a very painful condition. Review question We aimed to find out the benefits and harms of different surgical techniques used to remove wisdom teeth from the lower jaw, specifically how surgeons can reduce the risk of complications following surgery. We considered the most important outcomes to be: dry socket, wound infection, long‐term damage to the nerves supplying sensation to the tongue and skin of the lower lip and chin, and problems such as excessive bleeding or a broken jaw. Study characteristics We searched for relevant studies up to 8 July 2019. We included 62 studies with 4643 participants. Many studies excluded people who were not in excellent health so the participants in the trials may not be truly representative. Key results The available evidence is inconclusive. It is unclear if the position of the cut into the gum makes any difference to the outcomes. It is unclear whether it is possible to avoid damaging a nerve to the tongue by using a surgical instrument called a lingual retractor. It is unclear as to whether the type of surgical tool (a chisel or a rotating drill) used to remove bone from the jaw makes a difference to the likelihood of the wound becoming infected. It is unclear if the amount and method of delivering saltwater to clean the tooth socket after the extraction makes any difference to the outcomes. It is unclear whether different methods to stitch the gum after the tooth is removed makes any difference to the outcomes. Placing products that are derived from the patient’s own blood into the tooth socket may help to reduce the occurrence of dry socket (a condition that causes intense pain a few days after extraction). Another three surgical approaches were tested in the studies, but they did not measure the important outcomes. Certainty of the evidence None of the included studies were at low risk of bias. All of the studies were quite small. The quality of the studies varied, with most having flaws that could have biased their results. In addition, some of the results were very imprecise, with variation between them that could not be explained. For these reasons, we consider the available evidence to be uncertain. Future research may be able to provide dental surgeons and patients with clearer conclusions than those listed above.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bailey, E; Kashbour, W; Shah, N; Worthington, HV; Renton, TF; Coulthard, P", "articleTypes": [], "doi": "10.1002/14651858.CD004345.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "ca5e4d4e-e48b-4a55-a1ec-2dfea1087a6c", "pmid": "", "title": "The Real-world Treatment Satisfaction by Gefapixiant in Patients with Refractory Chronic Cough in Terms of Cough Improvement and Taste Disturbance. (The RESTORE Study)", "imported": false, "abstract": "Chronic cough has a high global prevalence and it is refractory to such treatments by approximately 20% of patients. Gafapixant is a P2X3 receptor antagonist that has demonstrated the reduction of cough in patients with refractory chronic cough(RCC). Taste disturbance is the most frequent adverse event by gefapixant (approximately 60-70%). Although gefapixant is well-tolerated even if taste disturbance has occurred, the impact of taste disturbance on cough-specific QoL remains to be unclear. Therefore, the investigator would like to evaluate factors related to treatment satisfaction by gefapixant in RCC patients. the investigator hypothesize that taste disturbance will be associated with the improvement of cough specific QoL and treatment satisfaction in RCC patients.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.256Z" }, { "id": "ca6926c7-4c71-4281-996c-843c58e7e0dc", "pmid": "", "title": "Venepuncture versus heel lance for blood sampling in term neonates", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Martins, G, Fiander, M, Taddio, A, Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD001452.pub5 AB - Abstract - Rationale Reducing procedural pain is a key priority in neonatal care, as even routine procedures for blood sampling can cause significant discomfort and pain to the neonate. This systematic review aims to compare venepuncture and heel lance for blood sampling, focusing on pain response, to guide clinical practice. Objectives To evaluate the benefits (degree of pain) and harms (need for more than one skin puncture) of venepuncture compared to heel lance in term neonates. Search methods We searched CENTRAL, MEDLINE, Embase, two trial registries and conference abstracts, and checked references of included studies and related systematic reviews up to 04 July 2025. Eligibility criteria We included randomized controlled trials (RCTs) and quasi‐RCTs that compared pain response from venepuncture versus heel lance. Neonates could receive a sweet‐tasting solution (such as glucose or sucrose), which is a commonly used analgesic in neonates for pain relief. We excluded studies that reported on pain using physiological parameters in isolation, as they are reflective of overall clinical status and non‐specific arousal. Outcomes Our outcomes of interest were pain reported using validated pain scores (measured using one or more of the following scales: Neonatal Facial Coding System, Neonatal Infant Pain scores, or the Premature Infant Pain Profile) and the need for more than one skin puncture. Risk of bias We used the Risk of bias 1 (RoB) tool to assess bias in the included RCTs. Synthesis methods We conducted a meta‐analysis where possible by calculating standardized mean difference (SMD) and risk ratio (RR) with their 95% confidence intervals (CIs) for continuous and dichotomous outcomes, respectively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included eight studies with 826 neonates. The studies were performed in six high‐, upper‐middle, or low‐income countries. Synthesis of results We judged the overall risk of bias in the eight studies to be high. Most studies had concerns related to blinding and allocation concealment. Venepuncture compared to heel lance (with no sweet‐tasting solution) Pain scores 
Venepuncture probably reduces pain compared to heel lance during the procedure when no sweet‐tasting solution is administered (SMD −1.34, 95% CI −1.55 to −1.14; I² = 94%; 6 studies, 488 participants; moderate‐certainty evidence). Need for more than one skin puncture 
Venepuncture probably reduces the need for more than one skin puncture compared to heel lance when no sweet tasting solution is administered (RR 0.63, 95% CI 0.40 to 0.97; I² = 20%; 6 studies, 397 participants; moderate‐certainty evidence) Venepuncture compared to heel lance (with sweet‐tasting solution) Pain scores 
Venepuncture may reduce pain compared to heel lance during the procedure when a sweet‐tasting solution is administered (SMD −0.38, 95% CI −0.69 to −0.07; I² = 79%; 3 studies, 170 participants; low‐certainty evidence). Need for more than one skin puncture 
The evidence is very uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture when a sweet‐tasting solution is used (RR 7.00, 95% CI 0.38 to 129.93; I² not applicable; 2 studies, 110 participants; very low‐certainty evidence). This is due to the small number of participants in each group. Authors' conclusions Based on moderate‐certainty evidence, venepuncture probably reduces pain during the procedure and the need for more than one skin puncture compared to heel lance when no sweet‐tasting solution is used. When sweet‐tasting solutions are administered, venepuncture may reduce pain during the procedure compared to heel lance, based on low‐certainty evidence. The evidence is very uncertain about the effect of venepuncture compared to heel lance on the number of skin punctures required in the presence of sweet‐tasting solutions. This is due to the small sample size, and hence we could not draw any meaningful conclusions. Further high‐quality studies are needed, particularly in settings where sweet‐tasting solutions are used, to better understand the comparative effectiveness of venepuncture and heel lance for neonatal blood sampling. Funding Cochrane Neonatal editorial support for this review update, as part of a suite of reviews addressing “The infant and family experience in the neonatal intensive care unit”, has been provided by a grant from The Gerber Foundation. The Gerber Foundation is a separately endowed, private, 501(c)(3) foundation not related to Gerber Products Company in any way. Registration Original review (2001): DOI 10.1002/14651858.CD001452
Review update (2004): DOI 10.1002/14651858.CD001452.pub2
Review update (2007): DOI 10.1002/14651858.CD001452.pub3
Review update (2011): DOI 10.1002/14651858.CD001452.pub4 Plain language summary Is using a needle (venepuncture) better than using a device (heel lance) for taking a blood sample from full‐term newborn babies? Key messages Venepuncture (inserting a needle into a vein) may be less painful than heel lance (using a special device to puncture the skin) for newborn babies when having a blood sample taken, with or without sugar water for pain relief, and may reduce the need for more than one skin puncture when no sugar water is given for pain relief. We don’t know whether venepuncture reduces the need for more than one skin puncture compared with heel lance when sugar water is given for pain relief. We need better designed and larger studies that fully report their results to show which method is better for babies. Why do we take blood samples from newborn babies? In most countries, a blood sample from newborn babies is needed for routine screening tests. Blood samples may also be needed for other blood tests to diagnose and manage diseases, such as jaundice or low blood sugar (hypoglycemia). However, taking blood from babies is painful. Untreated pain in newborn babies may affect their physical growth and brain development. A sweet, sugar solution (such as sucrose) can be given to babies before the procedure, which helps to reduce the pain. It is difficult to measure pain in babies, but we rely on things like facial expressions, crying, and changes in heart rate to assess their pain. How are blood samples taken? Venepuncture Venepuncture is a method of taking a blood sample where a person uses a needle to directly puncture the vein. The person who performs this must be well‐trained to help ensure they successfully take a blood sample. This technique is often used when 1 mL or more of blood is required, and to prevent repeated punctures to the skin and associated complications (such as skin infections) from heel lance. Heel lance Heel lance is the standard way of taking a blood sample from newborn babies in hospitals worldwide. It is commonly used when the blood sample required is less than 1 mL. It does not require special training or expertise for successful use. The procedure involves making a small puncture (between 1 mm and 2 mm deep) on the heel of the foot using a lancet, which is usually an automatic device. Following the puncture, the infant's heel is squeezed to collect the required blood sample, which causes further pain. What did we want to find out? We wanted to find out: whether venepuncture is less painful than heel lance for newborn babies; and which procedure works best first time, so a second skin puncture is not needed. What did we do? We searched for studies that compared venepuncture and heel lance for taking blood samples in newborn babies. The studies needed to measure pain responses and the number of skin punctures needed for a successful sample. They also needed to record whether babies were given sugar solution as pain relief. Babies in the studies had to be healthy and born at full term. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included eight studies involving 826 full‐term newborn babies. Three studies took place in Sweden, and one each in Japan, Malaysia, Nepal, Spain, and the UK. When no sweet‐tasting solution was given: venepuncture probably causes less pain compared to heel lance (6 studies, 488 babies); and venepuncture probably reduces the need for more than one skin puncture compared to heel lance (6 studies, 397 babies). When a sweet‐tasting solution was given: venepuncture may cause less pain compared to heel lance (3 studies, 170 babies); and we are uncertain about the effect of venepuncture compared to heel lance on the need for more than one skin puncture (2 studies, 110 babies). What are the limitations of the evidence? Our confidence in the evidence was limited, and ranged from moderate to very low. This is because all the studies had limitations in how they were carried out. These included issues with how babies were assigned to each group, how the studies reported their results, and the number of babies included in the studies. In addition, the people doing the procedures knew which sampling method each baby received, which could have influenced how the studies assessed pain. How up to date is this evidence? This review updates our 2011 Cochrane review. The evidence is up to date to July 2025.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.065Z" }, { "id": "ca745032-67fc-4c75-b264-e0f2c4719efd", "pmid": "", "title": "Sensitivity to 6-n-propylthiouracil (PROP) Association With Gustin (CA6) Gene Polymorphism, Salivary Zinc and BMI in Humans", "imported": false, "abstract": "The investigators evaluate the possible association of PROP taste with gustin gene polymorphism rs2274333 (A/G), salivary zinc ion concentration and BMI. In addition, it has also been evaluated PROP taste sensitivity by recording monophasic potentials from the tongue.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.146Z" }, { "id": "ca7a692c-54f1-4550-9ad9-d4a42bd85999", "pmid": "", "title": "Pharmacological treatment of gastro‐oesophageal reflux in children", "imported": false, "abstract": "Abstract - Background Gastro‐oesophageal reflux (GOR) is characterised by the regurgitation of gastric contents into the oesophagus. GOR is a common presentation in infancy, both in primary and secondary care, affecting approximately 50% of infants under three months old. The natural history of GOR in infancy is generally of a self‐limiting condition that improves with age, but older children and children with co‐existing medical conditions can have more protracted symptoms. The distinction between gastro‐oesophageal reflux disease (GORD) and GOR is debated. Current National Institute of Health and Care Excellence (NICE) guidelines define GORD as GOR causing symptoms severe enough to merit treatment. This is an update of a review first published in 2014. Objectives To assess the effects of pharmacological treatments for GOR in infants and children. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, and Web of Science up to 17 September 2022. We also searched for ongoing trials in clinical trials registries, contacted experts in the field, and searched the reference lists of trials and reviews for any additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any currently‐available pharmacological treatment for GOR in children with placebo or another medication. We excluded studies assessing dietary management of GORD and studies of thickened feeds. We included studies in infants and children up to 16 years old. Data collection and analysis We used standard methodology expected by Cochrane. Main results We included 36 RCTs involving 2251 children and infants. We were able to extract summary data from 14 RCTs; the remaining trials had insufficient data for extraction. We were unable to pool results in a meta‐analysis due to methodological differences in the included studies (including heterogeneous outcomes, study populations, and study design). We present the results in two groups by age: infants up to 12 months old, and children aged 12 months to 16 years old. Infants Omeprazole versus placebo: there is no clear effect on symptoms from omeprazole. One study (30 infants; very low‐certainty evidence) showed cry/fuss time in infants aged three to 12 months had altered from 246 ± 105 minutes/day at baseline (mean +/‐ standard deviation (SD)) to 191 ± 120 minutes/day in the omeprazole group and from 287 ± 132 minutes/day to 201 ± 100 minutes/day in the placebo group (mean difference (MD) 10 minutes/day lower (95% confidence interval (CI) ‐89.1 to 69.1)). The reflux index changed in the omeprazole group from 9.9 ± 5.8% in 24 hours to 1.0 ± 1.3% and in the placebo group from 7.2 ± 6.0% to 5.3 ± 4.9% in 24 hours (MD 7% lower, 95% CI ‐4.7 to ‐9.3). Omeprazole versus ranitidine: one study (76 infants; very low‐certainty evidence) showed omeprazole may or may not provide symptomatic benefit equivalent to ranitidine. Symptom scores in the omeprazole group changed from 51.9 ± 5.4 to 2.4 ± 1.2, and in the ranitidine group from 47 ± 5.6 to 2.5 ± 0.6 after two weeks: MD ‐4.97 (95% CI ‐7.33 to ‐2.61). Esomeprazole versus placebo: esomeprazole appeared to show no additional reduction in the number of GORD symptoms compared to placebo (1 study, 52 neonates; very low‐certainty evidence): both the esomeprazole group (184.7 ± 78.5 to 156.7 ± 75.1) and placebo group (183.1 ± 77.5 to 158.3 ± 75.9) improved: MD ‐3.2 (95% CI ‐4.6 to ‐1.8). Children Proton pump inhibitors (PPIs) at different doses may provide little to no symptomatic and endoscopic benefit. Rabeprazole given at different doses (0.5 mg/kg and 1 mg/kg) may provide similar symptom improvement (127 children in total; very low‐certainty evidence). In the lower‐dose group (0.5 mg/kg), symptom scores improved in both a low‐weight group of children (< 15 kg) (mean ‐10.6 ± SD 11.13) and a high‐weight group of children (> 15 kg) (mean ‐13.6 ± 13.1). In the higher‐dose groups (1 mg/kg), scores improved in the low‐weight (‐9 ± 11.2) and higher‐weight groups (‐8.3 ± 9.2). For the higher‐weight group, symptom score mean difference between the two different dosing regimens was 2.3 (95% CI ‐2 to 6.6), and for the lower‐weight group, symptom score MD was 4.6 (95% CI ‐2.9 to 12). Pantoprazole: pantoprazole may or may not improve symptom scores at 0.3 mg/kg, 0.6 mg/kg, and 1.2 mg/kg pantoprazole in children aged one to five years by week eight, with no difference between 0.3 mg/kg and 1.2 mg/kg dosing (0.3 mg/kg mean −2.4 ± 1.7; 1.2 mg/kg −1.7 ± 1.2: MD 0.7 (95% CI ‐0.4 to 1.8)) (one study, 60 children; very low‐certainty evidence). There were insufficient summary data to assess other medications. Authors' conclusions There is very low‐certainty evidence about symptom improvements and changes in pH indices for infants. There are no summary data for endoscopic changes. Medications may or may not provide a benefit (based on very low‐certainty evidence) for infants whose symptoms remain bothersome, despite nonmedical interventions or parental reassurance. If a medication is required, there is no clear evidence based on summary data for omeprazole, esomeprazole (in neonates), H₂antagonists, and alginates for symptom improvements (very low‐certainty evidence). Further studies with longer follow‐up are needed. In older children with GORD, in studies with summary data extracted, there is very low‐certainty evidence that PPIs (rabeprazole and pantoprazole) may or may not improve GORD outcomes. No robust data exist for other medications. Further RCT evidence is required in all areas, including subgroups (preterm babies and children with neurodisabilities). Plain language summary Medicines for children with reflux Review question What is the best and safest treatment for babies and children with gastro‐oesophageal reflux? Key messages: ‐ the evidence for medications for babies with gastro‐oesophageal reflux/reflux disease is very uncertain; ‐ for children with gastro‐oesophageal reflux disease, the evidence is very uncertain regarding the effects of proton pump inhibitors. There was no adequate evidence to draw conclusions regarding other medications. What is gastro‐oesophageal reflux? Gastro‐oesophageal reflux happens when stomach contents come back up into the oesophagus (food pipe). Most babies (under 1 year) grow out of reflux symptoms, but does medicine help? Children (older than 1 year) can have reflux just like adults. Reflux can be normal ('physiological reflux'), but in babies and children, it can cause symptoms, including pain or weight loss, as the oesophagus becomes inflamed (oesophagitis). Bothersome symptoms of reflux are called 'gastro‐oesophageal reflux disease' (GORD). How is gastro‐oesophageal reflux treated? Medicines can thicken the stomach contents (alginates), neutralise stomach acid (ranitidine, omeprazole, lansoprazole), or help the stomach to empty faster (domperidone, erythromycin). What did we want to find out? We wanted to learn the best way to reduce reflux in babies and children. We wanted to see if medicines help infants and children to feel better (symptom scores), heal the oesophagus (which is checked by using endoscopy, where a tiny camera is put down the oesophagus), or lower the time the oesophagus is exposed to stomach acid. We also investigated whether the medicines were safe by considering the harmful or unwanted effects reported in the studies. What did we do? We searched for studies testing gastro‐oesophageal reflux medicines in babies and children. We included all studies comparing these medicines, or comparing them to an inactive medicine (placebo). We assessed results which are important to doctors, nurses, and parents, and performed our own analysis of the results. We rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 36 suitable studies (involving 2251 babies and children), conducted worldwide, with most in the USA. The largest study recruited 268 babies, the smallest, 16 children. Fifteen studies compared an active medicine to placebo; 8 compared one active medication to another; and 11 studies gave the same medication at different doses. We found useable outcome information in 14 of the 36 studies. The remaining studies either did not report outcomes we were interested in or did not report them in a way we could analyse. We could not combine the results of any studies because they were too different (in terms of how long they followed participants up and the outcomes they investigated) to use in a meaningful way. Key results Babies. There is no clear effect on symptoms or measured acidity (one measure is reflux index, which is the percentage of time in 24 hours the oesophagus is exposed to stomach acid) between babies given omeprazole or placebo. One study (30 babies) showed cry/fuss time went down from 287 to 201 minutes/day in the placebo group and 246 to 191 minutes/day in the omeprazole group. Reflux index changed in the omeprazole group from 9.9% to 1.0% in 24 hours, and in the placebo group from 7.2% to 5.3%. One study (76 babies) showed that omeprazole and ranitidine may have a similar benefit for symptoms after 2 weeks: symptom scores (higher scores mean worse symptoms) in the omeprazole group dropped from 51.9 to 2.4, and in the ranitidine group, from 47 to 2.5. In one study of 52 newborn babies, esomeprazole appeared to show no reduction in the number of symptoms (184.7 to 156.7) compared to placebo (183.1 to 158.3). None of the studies reported harmful events or results about changes to babies' oesophaguses. Children. In children older than 1 year of age, no studies assessed medical treatment versus placebo. Proton pump inhibitors (PPIs), which block stomach acid production, at different doses may provide little to no improvements in symptoms or oesophagus healing. In one study (127 children), both lower‐weight and higher‐weight children given rabeprazole at lower and higher doses had both minimal – probably unimportant – changes in symptom scores and endoscopic scores (which indicate whether healing of the oesophagus has occurred). Pantoprazole may or may not improve symptom scores in children aged 1 to 5 years by week 8: there was no difference between lower and higher dosing in one study (60 children). Studies investigating other medications did not report enough information for us to assess their results properly. Quality of the evidence We are not confident in the evidence, which was mainly based on single studies with few babies and children. Several studies had pharmaceutical company help with manuscript writing. The question of how best to treat children with disabilities, and whether any PPIs are better than other medicines remain. The evidence is current to 17 September 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Tighe, MP; Andrews, E; Liddicoat, I; Afzal, NA; Hayen, A; Beattie, RM", "articleTypes": [], "doi": "10.1002/14651858.CD008550.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "ca7ca494-a87e-4a14-b064-425588e021ea", "pmid": "", "title": "Acetylcholinesterase inhibitors for autistic spectrum disorders", "imported": false, "abstract": "Abstract - Background Autism spectrum disorder (autism) is a neurodevelopmental condition characterised by impairments in social communication and interaction, plus restricted, repetitive patterns of behaviour and interests. Whilst some people embrace autism as part of their identity, others struggle with their difficulties, and some seek treatment. There are no current interventions that result in complete reduction of autism features. Acetylcholine is a neurotransmitter for the cholinergic system and has a role in attention, novelty seeking, and memory. Low levels of acetylcholine have been investigated as a potential contributor to autism symptomatology. Donepezil, galantamine, and rivastigmine (commonly referred to as acetylcholinesterase inhibitors) all inhibit acetylcholinesterase, and have slightly different modes of action and biological availability, so their effectiveness and side‐effect profiles may vary. The effect of various acetylcholinesterase inhibitor on core autism features across the lifespan, and possible adverse effects, have not been thoroughly investigated. Objectives To evaluate the efficacy and harms of acetylcholinesterase inhibitors for people with the core features (social interaction, communication, and restrictive and repetitive behaviours) of autism. To assess the effects of acetylcholinesterase inhibitors on non‐core features of autism. Search methods In November 2022, we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the reference lists of included studies and relevant reviews, and contacted authors of relevant studies. Selection criteria Randomised controlled trials (RCTs), comparing acetylcholinesterase inhibitors (e.g. galantamine, donepezil, or rivastigmine) of varying doses, delivered orally or via transdermal patch, either as monotherapy or adjunct therapy, with placebo. People of any age, with a clinical diagnosis of autism were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were core features of autism and adverse effects. Secondary outcomes were language, irritability, hyperactivity, and general health and function. We used GRADE to assess certainty of evidence. Main results We included two RCTs (74 participants). One study was conducted in Iran, the second in the USA, although exact location in the USA is unclear. Galantamine plus risperidone versus placebo plus risperidone One study compared the effects of galantamine plus risperidone to placebo plus risperidone (40 participants, aged 4 years to 12 years). Primary and secondary outcomes of interest were measured postintervention, using subscales of the Aberrant Behavior Checklist (score 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed there was little to no difference between the two groups postintervention for social communication (mean difference (MD) ‐2.75, 95% confidence interval (CI) ‐5.88 to 0.38), and restricted and repetitive behaviour (MD ‐0.55, 95% CI ‐3.47 to 2.37). Overall autism features were not assessed. Adverse events may be higher in the galantamine plus risperidone group (75%) compared with the placebo plus risperidone group (35%): odds ratio 5.57, 95% CI 1.42 to 21.86, low‐certainty evidence. No serious adverse events were reported. Low‐certainty evidence showed a small difference in irritability (MD ‐3.50, 95% CI ‐6.39 to ‐0.61), with the galantamine plus risperidone group showing a greater decline on the irritability subscale than the placebo group postintervention. There was no evidence of a difference between the groups in hyperactivity postintervention (MD ‐5.20, 95% CI ‐10.51 to 0.11). General health and function were not assessed. Donepezil versus placebo One study compared donepezil to placebo (34 participants aged 8 years to 17 years). Primary outcomes of interest were measured postintervention, using subscales of the Modified Version of The Real Life Rating Scale (scored 0 to 3; higher scores = greater impairment). Very low‐certainty evidence showed no evidence of group differences immediately postintervention in overall autism features (MD 0.07, 95% CI ‐0.19 to 0.33), or in the autism symptom domains of social communication (MD ‐0.02, 95% CI ‐0.34 to 0.30), and restricted and repetitive behaviours (MD 0.04, 95% CI ‐0.27 to 0.35). Significant adverse events leading to study withdrawal in at least one participant was implied in the data analysis section, but not explicitly reported. The evidence is very uncertain about the effect of donepezil, compared to placebo, on the secondary outcomes of interest, including irritability (MD 1.08, 95% CI ‐0.41 to 2.57), hyperactivity (MD 2.60, 95% CI 0.50 to 4.70), and general health and function (MD 0.03, 95% CI ‐0.48 to 0.54) postintervention. Across all analyses within this comparison, we judged the evidence to be very low‐certainty due to high risk of bias, and very serious imprecision (results based on one small study with wide confidence intervals). The study narratively reported adverse events for the study as a whole, rather than by treatment group. Authors' conclusions Evidence about the effectiveness of acetylcholinesterase inhibitors as a medication to improve outcomes for autistic adults is lacking, and for autistic children is very uncertain. There is a need for more evidence of improvement in outcomes of relevance to clinical care, autistic people, and their families. There are a number of ongoing studies involving acetylcholinesterase inhibitors, and future updates of this review may add to the current evidence. Plain language summary Do acetylcholinesterase inhibitors reduce the core impairments associated with autism spectrum disorder Key messages At present, it is unclear whether acetylcholinesterase inhibitors are effective in treating the core features of autism. This is because very few studies have been carried out. The two we found were small, and did not report the outcomes very well. However, there are a number of ongoing studies in this area. What is autism spectrum disorder? Autism spectrum disorder (autism) is a condition that affects the way a person thinks, feels, interacts with others, and experiences their environment. The core behaviours of autism include reduced sharing of interests, difficulties with nonverbal communication (for example, little eye contact), difficulties forming and maintaining relationships and restricted, or repetitive behaviours or interests. These behaviours can vary in severity, but they still interfere with the person's daily functioning and participation in activities. Medicines, called acetylcholinesterase inhibitors (chemicals that block the normal breakdown of nerve transmitters), have been used to treat Alzheimer's disease (for example, donepezil and galantamine). Recently, it has been suggested that they may also decrease some of the difficulties seen in people with autism. What did we want to find out? Do acetylcholinesterase inhibitors, alone or with other medicines, reduce the core features of autism (social communication and interaction, restrictive and repetitive behaviours) compared with a placebo (a dummy pill). We also wanted to find out if acetylcholinesterase inhibitors were associated with any unwanted side effects. What did we do? We searched for studies that explored whether there were any differences in autistic people's behaviours after they had taken acetylcholinesterase inhibitors compared to people who had taken placebo pills. We compared and summarised the results of the studies, and rated our confidence in the evidence, based on things, such how big and well carried out the studies were. What did we find? We found two relevant studies. One study looked at whether an acetylcholinesterase inhibitor called galantamine, combined with a drug called risperidone (traditionally used to treat psychosis), was better than a placebo combined with risperidone. The study included 40 children, aged between 4 and 12 years, with a diagnosis of autism. it took place over 10 weeks in Iran. A second study compared an acetylcholinesterase inhibitor called donepezil with placebo. It included 34 children, aged between 8 and 17 years, with a diagnosis of autism. It was carried out in the USA. All studies involved children attending outpatient clinics. What are the main results of the review? It is unclear if acetylcholinesterase inhibitors make any difference to the core features of autism in children or adults. Galantamine may cause little to no difference in social interaction and communication skills and irritability levels in children with autism after 10 weeks of treatment. There is no evidence that galantamine reduces difficulties associated with restricted or repetitive behaviours or hyperactivity. Galantamine may also cause some side effects, including nervousness, drowsiness, increased appetite, and tremor. There is no evidence that donepezil reduces difficulties associated with the core features of autism or associated secondary problems. We were unable to find out whether it causes unwanted side effects in children with autism, because the study did not report the results completely. What are the limitations of the evidence? We have little confidence in the evidence for using this medicine to treat problems associated with autism, because the evidence comes from only two small studies that were not very well carried out or reported. Each study looked at a different type of acetylcholinesterase inhibitor and delivered the medicine differently. They did not provide information about all the issues we were interested in, and they measured the side effects differently. If more studies are included in future reviews, these results may change. How up‐to‐date is this review? The evidence in this review is current to November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ure, A; Cox, GR; Haslam, R; Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD013851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "ca895e18-c1c8-48da-9b7f-983556f85fef", "pmid": "", "title": "Coblation versus other surgical techniques for tonsillectomy", "imported": false, "abstract": "Abstract - Background Tonsillectomy is a very common operation and is performed using various surgical methods. Coblation is a popular method because it purportedly causes less pain than other surgical methods. However, the superiority of coblation is unproven. Objectives To compare the effects of coblation tonsillectomy for chronic tonsillitis or tonsillar hypertrophy with other surgical techniques, both hot and cold, on intraoperative morbidity, postoperative morbidity and procedural cost. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2017, Issue 3); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 April 2017. Selection criteria Randomised controlled trials (RCTs) of children and adults undergoing tonsillectomy with coblation compared with any other surgical technique. This review is limited to trials of extracapsular (traditional) tonsillectomy and excludes trials of intracapsular tonsil removal (tonsillotomy). Data collection and analysis We used the standard Cochrane methods. Our primary outcomes were: patient‐reported pain using a validated pain scale at postoperative days 1, 3 and 7; intraoperative blood loss; primary postoperative bleeding (within 24 hours) and secondary postoperative bleeding (more than 24 hours after surgery). Secondary outcomes were: time until resumption of normal diet, time until resumption of normal activity, duration of surgery and adverse effects including blood transfusion and the need for reoperation. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 29 studies, with a total of 2561 participants. All studies had moderate or high risk of bias. Sixteen studies used an adequate randomisation technique, however the inability to mask the surgical teams and/or provide adequate methods to mitigate the risk of bias put nearly all studies at moderate or high risk of detection and measurement bias for intraoperative blood loss, and primary and secondary bleeding. In contrast most studies (20) were at low risk of bias for pain assessment. Most studies did not report data in a manner permitting meta‐analysis. Most studies did not clearly report the participant characteristics, surgical indications or whether patients underwent tonsillectomy or adenotonsillectomy. Most studies reported that tonsillitis (infection) and/or tonsillar hypertrophy (obstruction) were the indication for surgery. Seven studies included only adults, 16 studies included only children and six studies included both. Pain At postoperative day 1 there is very low quality evidence that patients in the coblation group had less pain, with a standardised mean difference (SMD) of ‐0.79 (95% confidence interval (CI) ‐1.38 to ‐0.19; 538 participants; six studies). This effect is reduced a SMD of ‐0.44 (95% CI ‐0.97 to 0.09; 401 participants; five studies; very low‐quality evidence ) at day 3, and at day 7 there is low quality evidence of little or no difference in pain (SMD ‐0.01, 95% CI ‐0.22 to 0.19; 420 participants; five studies). Although this suggests that pain may be slightly less in the coblation group between days 1 and 3, the clinical significance is unclear. Intraoperative blood loss Methodological differences between studies in the measurement of intraoperative blood loss precluded meta‐analysis. Primary and secondary bleeding The risk of primary bleeding was similar (risk ratio (RR) 0.99, 95% CI 0.48 to 2.05; 2055 participants; 25 studies; low‐quality evidence ). The risk of secondary bleeding was greater in the coblation group with a risk ratio of 1.36 (95% CI 0.95 to 1.95; 2118 participants; 25 studies; low‐quality evidence ). Using the median of the control group as the baseline risk, the absolute risk in the coblation group was 5% versus 3.6% in the control group. The difference of 1.3% has a 95% CI of 0.2% lower in the coblation group to 3.5% higher. Secondary outcomes Differences in study design and data reporting precluded the identification of differences in the time to resumption of normal diet or activity, or whether there was a difference in the duration of surgery. Although we could not feasibly compare the costs of equipment or operative facility, anaesthetic and surgical fees across different healthcare systems we used duration of surgery as a proxy for cost. Although this outcome was commonly reported in studies, it was not possible to pool the data to determine whether there was a difference. Adverse events other than bleeding were not well reported. It is unclear whether there is a difference in postoperative infections or the need for reoperation. Authors' conclusions The coblation technique may cause less pain on postoperative day 1, but the difference is small and may be clinically meaningless. By postoperative day 3, the difference decreases further and by postoperative day 7 there appears to be little or no difference. We found similar rates of primary bleeding but we cannot rule out a small increased risk of secondary bleeding with coblation. The evidence supporting these findings is of low or very low quality , i.e. there is a very high degree of uncertainty about the results. Moreover, for most outcomes data were only available from a few of the 29 included studies. The current evidence is of very low quality, therefore it is uncertain whether or not the coblation technique has any advantages over traditional tonsillectomy techniques. Despite the large number of studies, failure to use standardised or validated outcome measures precludes the ability to pool data across studies. Therefore, well‐conducted RCTs using consistent, validated outcome measures are needed to establish whether the coblation technique has a benefit over other methods. In the included studies we identified no clear difference in adverse events. However, given the rarity of these events, randomised trials lack the power to detect a difference. Data from large‐scale registries will provide a better estimate of any difference in these rare outcomes. Plain language summary Surgical removal of the tonsils (tonsillectomy) with coblation or another surgical method Review question This review compared the coblation method with other methods of tonsil removal to assess recovery following tonsillectomy or adenotonsillectomy. Background Surgical removal of the tonsils (tonsillectomy) is a very common operation. Patients may have pain for up to two weeks after surgery. Bleeding may occur either immediately after surgery ('primary bleeding' within 24 hours of surgery) or later ('secondary bleeding' more than 24 hours after surgery). There are many methods of tonsillectomy; the traditional method is with metal surgical instruments. Coblation is a new method where the surgeon uses an electrically powered handpiece that 'burns' tissues using low temperatures. Study characteristics This review included evidence available up to April 2017. We included 29 studies, with a total of 2561 participants. All studies had a moderate or high risk of bias. Seven studies included adults, 16 studies included children and six included both adults and children. Most studies measured pain using a patient‐reported scale (for example, asking people to rate their pain on a scale of 1 to 10). Key results The coblation technique may cause slightly less pain one day after surgery and three days after surgery, but it is unlikely that there is a difference in pain seven days after surgery. We are very uncertain whether the amount of pain reduction observed in days 1 to 3 after surgery would be important to patients. There is little or no difference in the risk of bleeding in the first day after surgery, but there may be a small increased risk of bleeding with coblation after the first day. For every 1000 patients having a tonsillectomy, 50 patients would have a bleed with coblation, compared to 36 with traditional surgical techniques. Quality of the evidence The evidence for the difference in pain is of low or very low quality and for the difference in bleeding after surgery it is of low quality . This means that we have little confidence in the results; the true effect may be very different ‐ we simply do not know at this stage.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Pynnonen, M; Brinkmeier, JV; Thorne, MC; Chong, LY; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "ca9d2aa0-f6ef-4069-a6d9-23318beb89a7", "pmid": "", "title": "Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide and its prevalence among children has significantly increased over the last two decades. Prevalence and severity are related to age, with children of school age most commonly affected. Objectives To assess the effectiveness and adverse event profile of antihistamines (oral or topical) used as an adjunct to topical nasal steroids for intermittent and persistent allergic rhinitis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 21 September 2009. Selection criteria Randomised controlled trials (RCTs) in children under the age of 18 with a history of allergic rhinitis, with or without allergic conjunctivitis or asthma, comparing topical nasal steroids with antihistamines to topical nasal steroids only. Data collection and analysis Two review authors independently screened studies, extracted data and assessed risk of bias. Main results One study including 24 participants met the inclusion criteria for this review. This study compared the administration of topical nasal steroids with oral antihistamines to topical nasal steroids only in children, but it did not provide sufficient data to address the clinical question of this review. Authors' conclusions In view of the lack of evidence for the benefit or lack of benefit of antihistamine add‐on therapy with topical nasal steroids for children with intermittent or persistent allergic rhinitis, it is important that clinicians are mindful of the adverse effects of antihistamines and the additional costs that may be incurred. Plain language summary Antihistamines as an addition to topical nasal steroids for allergic rhinitis in children Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide. Seasonal allergic rhinitis (hay fever) is most common around springtime. The symptoms are mostly sneezing, a runny nose and watery eyes. We looked for trials that compared antihistamines (either oral or topical) in addition to a topical nasal steroid with a topical nasal steroid alone in children who had allergic rhinitis. We wanted to know whether adding antihistamines (oral or topical) in the therapy of children with allergic rhinitis who already use topical nasal steroids would have additional benefits for them. We found one trial that had been carried out in children comparing oral antihistamines in addition to topical nasal steroids with topical nasal steroids alone but it did not provide sufficient data to draw any conclusions. Most of the trials focused only on adults or included a small number of children. Unfortunately, the trials which included children along with adults did not report whether there were any differences in the effect of treatment or adverse effects in children in comparison with adults. We are therefore unable to draw a conclusion as to whether or not this combination therapy has beneficial effect in children with allergic rhinitis or whether the benefits are acceptable in terms of the adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Nasser, M; Fedorowicz, Z; Aljufairi, H; McKerrow, W", "articleTypes": [], "doi": "10.1002/14651858.CD006989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "cac28568-ef96-4ac8-881d-ea87bc3e133d", "pmid": "", "title": "Eradication therapy for peptic ulcer disease in Helicobacter pylori‐positive people", "imported": false, "abstract": "Abstract - Background Peptic ulcer disease is the cause of dyspepsia in about 10% of people. Ninety‐five percent of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori . Eradication of H. pylori reduces the relapse rate of ulcers but the magnitude of this effect is uncertain. This is an update of Ford AC, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori ‐positive patients. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003840. DOI: 10.1002/14651858.CD003840.pub4. Objectives To assess the proportion of peptic ulcers healed and the proportion of participants who remained free from relapse with eradication therapy against placebo or other pharmacological therapies in H. pylori ‐positive people. To assess the proportion of participants that achieved complete relief of symptoms and improvement in quality of life scores. To compare the incidence of adverse effects/drop‐outs (total number for each drug) associated with the different treatments. To assess the proportion of participants in whom successful eradication was achieved. Search methods In this update, we identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1950 to March 2016) and Ovid EMBASE (1980 to March 2016). To identify further relevant trials, we handsearched reference lists from trials selected by electronic searching, and published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ). The search was last updated in March 2016. We contacted members of Cochrane Upper GI and Pancreatic Diseases, and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials of short‐ and long‐term treatment of peptic ulcer disease in H. pylori ‐positive adults. Participants received at least one week of H. pylori eradication compared with ulcer healing drug, placebo or no treatment. Trials were included if they reported assessment from two weeks onwards. Data collection and analysis We collected data on ulcer healing, recurrence, relief of symptoms and adverse effects. We calculated the risk ratio (RR) with 95% confidence intervals (CI) using both fixed‐effect and random‐effects models with Review Manager software (RevMan 5.3) based on intention‐to‐treat analysis as far as possible. Main results A total of 55 trials were included for one or more outcomes for this review. In duodenal ulcer healing, eradication therapy was superior to ulcer healing drug (UHD) (34 trials, 3910 participants, RR of ulcer persisting = 0.66, 95% confidence interval (CI) 0.58 to 0.76; 381/2286 (adjusted proportion: 12.4%) in eradication therapy plus UHD versus 304/1624 (18.7%) in UHD; low quality evidence) and no treatment (two trials, 207 participants, RR 0.37, 95% CI 0.26 to 0.53; 30/125 (adjusted proportion: 21.7%) in eradication therapy versus 48/82 (58.5%) in no treatment; low quality evidence). In gastric ulcer healing, the differences were imprecise between eradication therapy and UHD (15 trials, 1974 participants, RR 1.23, 95% CI 0.90 to 1.68; 220/1192 (adjusted proportion: 16.0%) in eradication therapy plus UHD versus 102/782 (13.0%) in UHD; very low quality evidence). In preventing duodenal ulcer recurrence the differences were imprecise between maintenance therapy with H.pylori eradication therapy and maintenance therapy with UHD (four trials, 319 participants, RR of ulcer recurring 0.73; 95% CI 0.42 to 1.25; 19/159 (adjusted proportion: 11.9%) in eradication therapy versus 26/160 (16.3%) in UHD; very low quality evidence), but eradication therapy was superior to no treatment (27 trials 2509 participants, RR 0.20, 95% CI 0.15 to 0.26; 215/1501 (adjusted proportion: 12.9%) in eradication therapy versus 649/1008 (64.4%) in no treatment; very low quality evidence). In preventing gastric ulcer recurrence, eradication therapy was superior to no treatment (12 trials, 1476 participants, RR 0.31, 95% CI 0.22 to 0.45; 116/697 (adjusted proportion: 16.3%) in eradication therapy versus 356/679 (52.4%) in no treatment; very low quality evidence). None of the trials reported proportion of people with gastric ulcer not healed after initial therapy between H.pylori eradication therapy and no active treatment or the proportion of people with recurrent gastric ulcer or peptic ulcers during maintenance therapy between H.pylori eradication therapy and ulcer healing drug therapy. Authors' conclusions Adding a one to two‐week course of H. pylori eradication therapy is an effective treatment for people with H. pylori‐ positive duodenal ulcer when compared to ulcer healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer healing drug. However, confidence intervals were wide and significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment, and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Plain language summary Antibiotics for people with peptic ulcers caused by Helicobacter pylori infection Review question Are antibiotics useful for the treatment of peptic ulcer (ulcers in the stomach or upper small intestine) in people with Helicobacter pylori ( H. pylori ) infection? Background Peptic ulcers are caused by acidic stomach juices damaging the lining of the stomach (gastric ulcer) or upper small intestine (duodenal ulcer). This causes pain, indigestion and sometimes, bleeding. Ulcers can return after being healed, especially if the person is infected with Helicobacter pylori (a lifelong infection unless treated). H. pylori causes most peptic ulcers. It is not clear whether eradicating H.pylori by treating with antibiotics as part of a combination of drugs ( H.pylori eradication therapy) is helpful in the treatment of people with peptic ulcers compared to no treatment or other medical treatments. This is an update of a previous Cochrane review published in 2006. Study characteristics Fifty‐five studies provided information for the review. Thirty‐four studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of duodenal ulcer. Two studies compared H. pylori eradication therapy against no treatment in the healing of duodenal ulcer. Fifteen studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of gastric ulcer. Three studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of peptic ulcer (gastric or duodenal ulcer). One study compared H. pylori eradication therapy against no treatment in the healing of peptic ulcer (gastric or duodenal ulcer). Four studies compared H. pylori eradication therapy against ulcer‐healing drug in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twenty‐seven studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twelve studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of gastric ulcer after initial ulcer had been healed, while one study compared H. pylori eradication therapy against no treatment in preventing the recurrence of peptic ulcer (gastric or duodenal ulcer) after initial ulcer had been healed. Four studies compared H. pylori eradication therapy plus ulcer‐healing drug versus comparison regimen in the relief of symptoms from peptic ulcer (gastric or duodenal ulcer). There were no studies comparing H. pylori eradication therapy against no treatment in the healing of gastric ulcer, H. pylori eradication therapy against ulcer‐healing drug as maintenance therapy in preventing the recurrence of gastric ulcer after initial ulcer had been healed, or H. pylori eradication therapy plus ulcer‐healing drug against no treatment or ulcer‐healing drug in the relief of symptoms in people with peptic ulcer. Some trials provided information for more than one comparison. The evidence is current until March 2016. Key results Adding a one to two‐week course of H. pylori eradication therapy speeds up ulcer healing for people with H. pylori‐ positive duodenal ulcer when compared to ulcer‐healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer (ulcer returning after initial healing) compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer‐healing drugs. However, because of the small number of studies included for the last two comparisons, significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Quality of the evidence The quality of evidence was low or very low because most of the studies had errors in study design. As a result, there is a lot of uncertainty regarding the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Ford, AC; Gurusamy, KS; Delaney, B; Forman, D; Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD003840.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "caf41ed3-ae66-4a9b-8d43-a3215419e772", "pmid": "", "title": "Tobacco packaging design for reducing tobacco use", "imported": false, "abstract": "Abstract - Background Tobacco use is the largest single preventable cause of death and disease worldwide. Standardised tobacco packaging is an intervention intended to reduce the promotional appeal of packs and can be defined as packaging with a uniform colour (and in some cases shape and size) with no logos or branding, apart from health warnings and other government‐mandated information, and the brand name in a prescribed uniform font, colour and size. Australia was the first country to implement standardised tobacco packaging between October and December 2012, France implemented standardised tobacco packaging on 1 January 2017 and several other countries are implementing, or intending to implement, standardised tobacco packaging. Objectives To assess the effect of standardised tobacco packaging on tobacco use uptake, cessation and reduction. Search methods We searched MEDLINE, Embase, PsycINFO and six other databases from 1980 to January 2016. We checked bibliographies and contacted study authors to identify additional peer‐reviewed studies. Selection criteria Primary outcomes included changes in tobacco use prevalence incorporating tobacco use uptake, cessation, consumption and relapse prevention. Secondary outcomes covered intermediate outcomes that can be measured and are relevant to tobacco use uptake, cessation or reduction. We considered multiple study designs: randomised controlled trials, quasi‐experimental and experimental studies, observational cross‐sectional and cohort studies. The review focused on all populations and people of any age; to be included, studies had to be published in peer‐reviewed journals. We examined studies that assessed the impact of changes in tobacco packaging such as colour, design, size and type of health warnings on the packs in relation to branded packaging. In experiments, the control condition was branded tobacco packaging but could include variations of standardised packaging. Data collection and analysis Screening and data extraction followed standard Cochrane methods. We used different 'Risk of bias' domains for different study types. We have summarised findings narratively. Main results Fifty‐one studies met our inclusion criteria, involving approximately 800,000 participants. The studies included were diverse, including observational studies, between‐ and within‐participant experimental studies, cohort and cross‐sectional studies, and time‐series analyses. Few studies assessed behavioural outcomes in youth and non‐smokers. Five studies assessed the primary outcomes: one observational study assessed smoking prevalence among 700,000 participants until one year after standardised packaging in Australia; four studies assessed consumption in 9394 participants, including a series of Australian national cross‐sectional surveys of 8811 current smokers, in addition to three smaller studies. No studies assessed uptake, cessation, or relapse prevention. Two studies assessed quit attempts. Twenty studies examined other behavioural outcomes and 45 studies examined non‐behavioural outcomes (e.g. appeal, perceptions of harm). In line with the challenges inherent in evaluating standardised tobacco packaging, a number of methodological imitations were apparent in the included studies and overall we judged most studies to be at high or unclear risk of bias in at least one domain. The one included study assessing the impact of standardised tobacco packaging on smoking prevalence in Australia found a 3.7% reduction in odds when comparing before to after the packaging change, or a 0.5 percentage point drop in smoking prevalence, when adjusting for confounders. Confidence in this finding is limited, due to the nature of the evidence available, and is therefore rated low by GRADE standards. Findings were mixed amongst the four studies assessing consumption, with some studies finding no difference and some studies finding evidence of a decrease; certainty in this outcome was rated very low by GRADE standards due to the limitations in study design. One national study of Australian adult smoker cohorts (5441 participants) found that quit attempts increased from 20.2% prior to the introduction of standardised packaging to 26.6% one year post‐implementation. A second study of calls to quitlines provides indirect support for this finding, with a 78% increase observed in the number of calls after the implementation of standardised packaging. Here again, certainty is low. Studies of other behavioural outcomes found evidence of increased avoidance behaviours when using standardised packs, reduced demand for standardised packs and reduced craving. Evidence from studies measuring eye‐tracking showed increased visual attention to health warnings on standardised compared to branded packs. Corroborative evidence for the latter finding came from studies assessing non‐behavioural outcomes, which in general found greater warning salience when viewing standardised, than branded packs. There was mixed evidence for quitting cognitions, whereas findings with youth generally pointed towards standardised packs being less likely to motivate smoking initiation than branded packs. We found the most consistent evidence for appeal, with standardised packs rating lower than branded packs. Tobacco in standardised packs was also generally perceived as worse‐tasting and lower quality than tobacco in branded packs. Standardised packaging also appeared to reduce misperceptions that some cigarettes are less harmful than others, but only when dark colours were used for the uniform colour of the pack. Authors' conclusions The available evidence suggests that standardised packaging may reduce smoking prevalence. Only one country had implemented standardised packaging at the time of this review, so evidence comes from one large observational study that provides evidence for this effect. A reduction in smoking behaviour is supported by routinely collected data by the Australian government. Data on the effects of standardised packaging on non‐behavioural outcomes (e.g. appeal) are clearer and provide plausible mechanisms of effect consistent with the observed decline in prevalence. As standardised packaging is implemented in different countries, research programmes should be initiated to capture long term effects on tobacco use prevalence, behaviour, and uptake. We did not find any evidence suggesting standardised packaging may increase tobacco use. Plain language summary Can the use of standardised packaging for tobacco products reduce the use of tobacco? Background Tobacco use kills more people worldwide than any other preventable cause of death. The best way to reduce tobacco use is by stopping people from starting to use tobacco and encouraging and helping existing users to stop. This can be done by introducing policies that can reach a wide number of people in a country, together with offering individual treatment and support to individuals who are already using tobacco to help them to stop. Many countries have introduced bans on tobacco advertising but have not controlled the look of the tobacco pack itself. Tobacco packs can be colourful and attractive, with exciting new shapes and sizes. Standardised tobacco packaging is a government policy which removes these bright designs by, for example, only allowing tobacco packs to be in one colour, shape or size. Standardised packaging generally involves the use of the same uniform colour on all tobacco packs, with no brand imagery, and the brand name written in a specified font, colour and size. Health warnings and other information that governments wish to put on the packs can remain. Australia was the first country to introduce standardised tobacco packaging by December 2012. France was the second by January 2017. Several other countries are introducing standardised packaging or planning to do so. We examined whether standardised packaging reduces tobacco use. Study characteristics We searched nine databases for articles evaluating standardised packaging that had been already reviewed by academics and published before January 2016. We also checked references in those papers to other studies and contacted the authors where necessary. Key results We found 51 studies involving approximately 800,000 participants. These studies varied considerably. Some studies focused on the effect of standardised packaging in Australia, and included looking at overall smoking levels, whether smokers altered their behaviour such as by cutting down the number of cigarettes they smoked, and whether smokers were making more quit attempts. We also included experiments in which people used or viewed standardised tobacco packs and examined their responses, compared to when they were viewing branded packs. We also included studies that assessed people’s eye movements when they looked at different packs and how willing people were to buy, and how much they were willing to pay for, standardised compared to branded packs. Only five studies looked at our key outcomes. One study in Australia looked at data from 700,000 people before and after standardised packaging was introduced. This study found that there was a half a percentage point drop in the proportion of people who used tobacco after the introduction of standardised packaging, compared to before, when adjusting for other factors which could affect this. Four other studies looked at whether current smokers changed the number of cigarettes they smoked. Two studies from Australia looked at this, one using surveys which included 8811 current smokers, and found no change in the number of cigarettes smoked. The three smaller studies found mixed results. Two further studies looked at quit attempts and observed increases in these in Australia after standardised packaging was introduced. The remainder of the studies looked at other outcomes, and the most consistent finding was that standardised packaging reduced how appealing people found the packs compared with branded packs. No studies reported the number of people who quit using tobacco, the number of people who started using tobacco, or the number of people who returned to using tobacco after quitting. Quality of the evidence Certainty in these findings is limited for several reasons, including the difficulties involved in studying national policies like standardised packaging. However, findings suggesting standardised packaging may decrease tobacco use are supported by routine data from the Australian government and studies looking at other outcomes. For example, in our included studies people consistently found standardised packs less appealing than branded packs. We did not find any evidence suggesting standardised packaging may increase tobacco use.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "McNeill, A, Gravely, S, Hitchman, SC, Bauld, L, Hammond, D, Hartmann‐Boyce, J", "articleTypes": [], "doi": "10.1002/14651858.CD011244.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.726Z" }, { "id": "cb24093f-dac6-46d3-a392-86e84f2fe7b9", "pmid": "", "title": "Homeopathic Oscillococcinum® for preventing and treating influenza and influenza‐like illness", "imported": false, "abstract": "Abstract - Background Influenza is a highly infectious viral disease that is particularly common in the winter months. Oscillococcinum ® is a patented homeopathic medicine that is made from a 1% solution of wild duck heart and liver extract, which is then serially diluted 200 times with water and alcohol. Objectives To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Search methods We searched CENTRAL (2014, Issue 8), MEDLINE (1966 to August week 4, 2014), MEDLINE In‐Process & Other Non‐Indexed Citations (4 September 2014), AMED (2006 to September 2014), Web of Science (1985 to September 2014), LILACS (1985 to September 2014) and EMBASE (1980 to September 2014). We contacted the manufacturers of Oscillococcinum ® for information on further trials. Selection criteria Randomised, placebo‐controlled trials of Oscillococcinum ® in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Data collection and analysis Three review authors independently extracted data and assessed risk of bias in the eligible trials. Main results No new trials were included in this 2014 update. We included six studies: two prophylaxis trials (327 young to middle‐aged adults in Russia) and four treatment trials (1196 teenagers and adults in France and Germany). The overall standard of trial reporting was poor and hence many important methodological aspects of the trials had unclear risk of bias. There was no statistically significant difference between the effects of Oscillococcinum ® and placebo in the prevention of influenza‐like illness: risk ratio (RR) 0.48, 95% confidence interval (CI) 0.17 to 1.34, P value = 0.16. Two treatment trials (judged as 'low quality') reported sufficient information to allow full data extraction: 48 hours after commencing treatment, there was an absolute risk reduction of 7.7% in the frequency of symptom relief with Oscillococcinum ® compared with that of placebo (risk difference (RD) 0.077, 95% CI 0.03 to 0.12); the RR was 1.86 (95% CI 1.27 to 2.73; P value = 0.001). A significant but lesser effect was observed at three days (RR 1.27, 95% CI 1.03 to 1.56; P value = 0.03), and no significant difference between the groups was noted at four days (RR 1.11, 95% CI 0.98 to 1.27; P value = 0.10) or at five days (RR 1.06, 95% CI 0.96 to 1.16; P value = 0.25). One of the six studies reported one patient who suffered an adverse effect (headache) from taking Oscillococcinum ® . Authors' conclusions There is insufficient good evidence to enable robust conclusions to be made about Oscillococcinum ® in the prevention or treatment of influenza and influenza‐like illness. Our findings do not rule out the possibility that Oscillococcinum ® could have a clinically useful treatment effect but, given the low quality of the eligible studies, the evidence is not compelling. There was no evidence of clinically important harms due to Oscillococcinum ® . Plain language summary Homeopathic Oscillococcinum ® for preventing and treating influenza and influenza‐like illness Review question 
 To determine whether homeopathic Oscillococcinum ® is more effective than placebo in the prevention and/or treatment of influenza and influenza‐like illness in adults or children. Background 
 Influenza ('the flu') is a highly infectious viral respiratory disease. Other than treatments for complications (such as pneumonia), the conventional medical strategies for the prevention or treatment of flu are not entirely effective or satisfactory. Oscillococcinum ® is a highly diluted homeopathic preparation manufactured from wild duck heart and liver, which may be reservoirs of flu viruses. Some people take Oscillococcinum ® regularly over the winter months either to prevent flu or as a treatment for flu symptoms. Study characteristics 
 We included six studies, which comprised two prevention trials (a total of 327 young to middle‐aged adults in Russia) and four treatment trials (a total of 1196 teenagers and adults in France and Germany). Key results 
 The findings from the two prevention trials did not show that Oscillococcinum ® can prevent the onset of flu. Although the results from the four other clinical trials suggested that Oscillococcinum ® relieved flu symptoms at 48 hours, this might be due to bias in the trial methods. One patient reported headache after taking Oscillococcinum ® . The evidence is current to September 2014. Quality of the evidence 
 The overall standard of research reporting was poor, and thus many aspects of the trials' methods and results were at unclear risk of bias. We therefore judged the evidence overall as low quality, preventing clear conclusions from being made about Oscillococcinum ® in the prevention or treatment of flu and flu‐like illness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mathie, RT; Frye, J; Fisher, P", "articleTypes": [], "doi": "10.1002/14651858.CD001957.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "cb292da3-9f97-4b7b-b89c-7033b4303272", "pmid": "", "title": "Interventions for increasing fruit and vegetable consumption in children aged five years and under", "imported": false, "abstract": "Abstract - Background Insufficient consumption of fruits and vegetables in childhood increases the risk of future non‐communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child‐feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden. Objectives To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. Search methods We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials. Selection criteria We included randomised controlled trials (RCTs), including cluster‐randomised controlled trials (C‐RCTs) and cross‐over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no‐intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random‐effects models in meta‐analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures. Main results We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child‐feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child‐focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate‐certainty evidence that child‐feeding practice interventions versus no‐intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as‐desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post‐intervention follow‐up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low‐certainty evidence). Multicomponent interventions versus no‐intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate‐certainty evidence; mean post‐intervention follow‐up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden‐based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low‐certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short‐term impact on child consumption of fruit and vegetables versus no‐intervention control (SMD 0.10, 95% CI ‐0.02 to 0.22; 14 trials, 4122 participants; low‐certainty evidence; mean post‐intervention follow‐up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low‐certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low‐certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding. Authors' conclusions There was moderate‐certainty evidence that child‐feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low‐ and middle‐income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. Plain language summary What are the benefits and harms of interventions to increase eating of fruit and vegetables among children aged five years and under? Key messages • Child‐feeding interventions probably lead to a small increase in eating of vegetables in children aged five years and under. • Multicomponent interventions probably lead to a small increase in eating of fruit and vegetables in children aged five years and under. • Parent nutrition education interventions may lead to little or no increase in eating of fruit and vegetables in children aged five years and under. Why is eating enough fruit and vegetables important? Not eating enough fruit and vegetables leads to a considerable health burden in developed countries. Eating adequate amounts of fruit and vegetables is associated with a reduced risk of future non‐communicable diseases (such as heart and circulatory disease) amongst other immediate health benefits. Early childhood is a critical period for the establishment of dietary habits that track into adulthood. Interventions to increase consumption of fruit and vegetables in early childhood may therefore be an effective strategy to reduce this disease burden. What did we want to find out? We wanted to know the benefits and harms of interventions designed to increase eating of fruit or vegetables or both amongst children aged five years and under. What did we do? We searched various electronic databases to find studies. We contacted the authors of the included studies for additional potentially relevant studies. Any randomised study (where participants have the same chance of being assigned to treatment or a no‐treatment control) of interventions aiming to increase the intake of fruit or vegetables or both by children aged five years and under, which measured intake, was eligible. Two review authors independently searched for and extracted information from studies. We searched up to March 2023. What did we find? We included 53 studies with 12,350 people taking part. Sixteen studies examined child‐feeding practice interventions (e.g. repeated exposure to vegetables); 20 examined multicomponent interventions (e.g. combining two or more interventions, such as preschool policy changes with parent nutrition education); 17 examined parent nutrition education interventions; two examined child nutrition education interventions; and one each examined child‐focused mindfulness or providing families with fruit and vegetable interventions. Child‐feeding practice interventions and multicomponent interventions probably lead to small increases in children's intake of fruit and vegetables in the short term (less than 12 months). Parent nutrition education interventions may lead to little to no increase in children's eating of fruit and vegetables. Limited information was available on cost and unintended harms. Of the studies that did report these, intervention costs ranged from 325 to 1500 US dollars (USD). No unintended harms were found in the two studies that reported assessing them. Studies reporting funding support received governmental or charitable funds, except for one study that received industry funding. What are the limitations of the evidence? No studies were conducted in low‐income countries and only one study was conducted in a middle‐income country. Our confidence in the current evidence is moderate for child feeding and multicomponent interventions, and low for parent nutrition education interventions. How up‐to‐date is this evidence? This evidence is up‐to‐date to March 2023. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Hodder, RK; O'Brien, KM; Wyse, RJ; Tzelepis, F; Yoong, S; Stacey, FG; Wolfenden, L", "articleTypes": [], "doi": "10.1002/14651858.CD008552.pub8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "cb437bf6-566a-4ab8-8413-3d6db9e3b585", "pmid": "", "title": "Graft interposition for preventing Frey's syndrome in patients undergoing parotidectomy", "imported": false, "abstract": "Abstract - Background Frey's syndrome is characterised by transient flushing and sometimes facial sweating in the area of the auriculotemporal nerve. It most commonly occurs after parotidectomy, but other causes may include submandibular gland surgery, mandibular condylar fracture, obstetric (forceps) trauma, sympathectomy and metabolic disease. Although the pathophysiology of Frey's syndrome remains controversial, the generally accepted hypothesis is that it occurs as the result of injury to the auriculotemporal nerve. There is currently no clear evidence to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome, therefore the prevention of this symptom during surgery is important. The main method used for prevention is the interposition of a graft between the skin flap and the parotid bed during surgery. Biomaterials, allograft or autograft can be used for this purpose. Objectives To evaluate the effects and safety of biomaterial, allograft or autograft interposition for the prevention of Frey's syndrome in patients undergoing parotidectomy, and to identify its effect on prevention and delayed occurrence. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Cochrane Register of Controlled Trials (CENTRAL; 2019, Issue 2); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 5 February 2019. Selection criteria We included randomised controlled trials (RCTs) in patients with parotid disease (including tumours, inflammation, trauma etc.) undergoing parotidectomy with a minimal follow‐up period of six months. We planned to include trials with interventions including biomaterial, allograft or autograft interposition alone or in combination with other surgical techniques. We included trials that compared any graft interposition and no graft interposition, or different graft interpositions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were incidence rate of Frey's syndrome assessed clinically (Minor's starch‐iodine test) and other complications (postoperative infection, subjective painful or restricted cervical movement, scar spread, rejection of the graft, complications related to the donor site such as accessory nerve injury and haematoma). Our secondary outcome measures were incidence rate of Frey's syndrome assessed by participants (by questionnaire) and sweating area assessed by Minor's starch‐iodine test. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included three RCTs (124 participants), two of which we assessed as at high risk of bias and one at unclear risk of bias. All studies were hospital‐based and recruited participants undergoing superficial parotidectomy. Most participants were diagnosed with benign lesions of the parotid gland. Participants were followed up for more than six months. The studies evaluated the two comparisons shown below: Sternocleidomastoid muscle flap versus no flap Two studies assessed this comparison. Both assessed the effects of the sternocleidomastoid muscle flap procedure on the incidence rate of Frey's syndrome assessed clinically but neither showed a significant difference between groups (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.23; 24 participants and RR 1.23, 95% CI 0.88 to 1.73; 36 participants; very low‐certainty evidence). We did not pool the data due to the high heterogeneity (I² = 87%). One study found that the sternocleidomastoid muscle flap may result in little or no difference in other complications including haematoma (RR 2.18, 95% CI 0.09 to 50.16; 36 participants; low‐certainty evidence), subjective painful or restricted cervical movement (RR 0.54, 95% CI 0.14 to 2.05; 36 participants; low‐certainty evidence) and scar spread in the cervical region (RR 0.71, 95% CI 0.05 to 10.54; 36 participants; low‐certainty evidence). Both studies reported the incidence rate of Frey's syndrome assessed by participants, with one reporting no events in either group and the other finding no evidence of a difference (RR 0.63, 95% CI 0.32 to 1.26; 36 participants; low‐certainty evidence). Acellular dermal matrix versus no graft Only one study assessed this comparison. Use of an acellular dermal matrix graft may result in little or no difference to the incidence rate of Frey's syndrome (assessed clinically) in comparison with the no graft group, but the evidence is very uncertain (RR 0.08, 95% CI 0.00 to 1.25; 30 participants; very low‐certainty evidence). Acellular dermal matrix may slightly increase the wound infection rate compared with control (RR 17.00, 95% CI 1.02 to 282.67; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence of seromas or sialoceles (RR 2.33, 95% CI 0.66 to 8.23; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence rate of Frey's syndrome (assessed by participants) in comparison with the no graft group (RR 0.33, 95% CI 0.04 to 3.04; 64 participants; low‐certainty evidence). Authors' conclusions The evidence for the effectiveness of graft interposition in preventing Frey's syndrome is of low or very low certainty. The use of acellular dermal matrix may be associated with an increase in the wound infection rate, and little or no difference in the incidence of seromas or sialoceles. Further studies are needed to draw reliable conclusions. Plain language summary Grafts for preventing Frey's syndrome after surgery to the parotid (salivary) glands Review question Does the use of a graft during surgery to the parotid glands prevent Frey's syndrome? Background The clinical symptoms of Frey's syndrome include sweating and flushing of the cheek when eating and chewing. It results from abnormal regrowth of damaged autonomic nerve fibres of the parotid glands, for example during surgery for parotid gland tumours. It is unclear whether placing a graft between the skin flap and the parotid bed during surgery can prevent this syndrome. Various types of grafts can be used, including biomaterial or skin, muscle or other tissue from the patient. These grafts may possibly hinder the abnormal connections of the nerves controlling the sweat glands and parotid glands when the cut nerves are re‐linking after surgery. Study characteristics We included three studies with 124 participants in this review, but the quality of these studies was not ideal. All of the participants in the studies had tumours of the parotid glands and were undergoing surgery to part of the glands. The studies assessed two types of grafts, tissue obtained from the sternocleidomastoid muscle and a biomaterial (a collagen framework without cells). Key results Two studies compared a tissue graft obtained from the sternocleidomastoid muscle to no graft. It is not known whether this type of tissue graft can prevent Frey's syndrome because the available evidence is very uncertain. One study compared a biomaterial graft to no graft. This type of graft may result in little or no difference to the incidence rate of Frey's syndrome, but the evidence is very uncertain. It may make the patient's wound slightly more likely to become infected. Certainty of the evidence The evidence in this review is mostly of low or very low certainty, because of the small number of studies on this question and the risk of bias in these studies. The findings must therefore be treated with caution and further studies are needed to draw reliable conclusions. The evidence in this review is up to date to 5 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ye, L, Cao, Y, Yang, W, Wu, F, Lin, J, Li, L, Li, C", "articleTypes": [], "doi": "10.1002/14651858.CD012323.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.751Z" }, { "id": "cb43cff1-4539-4e6c-8919-9ffc7b0810f7", "pmid": "", "title": "Nutritional interventions for reducing morbidity and mortality in people with HIV", "imported": false, "abstract": "Abstract - Background Adequate nutrition is important for optimal immune and metabolic function. Dietary support may, therefore, improve clinical outcomes in HIV‐infected individuals by reducing the incidence of HIV‐associated complications and attenuating progression of HIV disease, improving quality of life and ultimately reducing disease‐related mortality. Objectives To evaluate the effectiveness of various macronutrient interventions, given orally, in reducing morbidity and mortality in adults and children living with HIV infection. Search methods We searched CENTRAL (up to August 2011), MEDLINE (1966 to August 2011), EMBASE (1988 to August 2011), LILACS (up to February 2012), and Gateway (March 2006‐February 2010). We also scanned reference lists of articles and contacted authors of relevant studies and other researchers. Selection criteria Randomised controlled trials evaluating the effectiveness of macronutrient interventions compared with no nutritional supplements or placebo in the management of adults and children infected with HIV. Data collection and analysis Three reviewers independently applied study selection criteria, assessed study quality, and extracted data. Effects were assessed using mean difference and 95% confidence intervals. Homogenous studies were combined wherever it was clinically meaningful to do so and a meta‐analysis using the random effects model was conducted. Main results Fourteen trials (including 1725 HIV positive adults and 271 HIV positive children), were included in this review. Neither supplementary food nor daily supplement of Spirulina significantly altered the risk of death compared with no supplement or placebo in malnourished, ART naive adult participants in the two studies which reported on this outcome. A nutritional supplement enhanced with protein did not significantly alter the risk of death compared to standard nutritional care in children with prolonged diarrhoea. Supplementation with macronutrient formulas given to provide protein and/or energy and fortified with micronutrients, in conjunction with nutrition counselling, significantly improved energy intake (3 trials; n=131; MD 393.57 kcal/day; 95% CI: 224.66 to 562.47;p<0.00001) and protein intake (2 trials; n=81; MD 23.5 g/day; 95% CI: 12.68, 34.01; p<0.00001) compared with no nutritional supplementation or nutrition counselling alone in adult participants with weight loss. In general supplementation with specific macronutrients such as amino acids, whey protein concentration or Spirulina did not significantly alter clinical, anthropometric or immunological outcomes compared with placebo in HIV‐infected adults and children. Authors' conclusions Given the current evidence base, which is limited to fourteen relatively small trials all evaluating different macronutrient supplements in different populations at different stages of HIV infection and with varying treatment status, no firm conclusions can be drawn about the effects of macronutrient supplementation on morbidity and mortality in people living with HIV. It is, however, promising to see more studies being conducted in low‐income countries, and particularly in children, where macronutrient supplementation both pre‐antiretroviral treatment and in conjunction with antiretroviral treatment might prove to be beneficial. Plain language summary Nutritional interventions for reducing morbidity and mortality in people with HIV Achieving and maintaining optimal nutrition is considered an important adjunct in the clinical care of patients infected with HIV, as good nutrition can improve an individual's immune function, limit disease‐specific complications, and improve quality of life and survival. We sought to determine whether macronutrient interventions, either given to provide protein and/or energy or test the effect of specific macronutrients (i.e. ch as amino acids, whey protein concentrate or Spirulina), given orally, influence morbidity and mortality in adults and children living with HIV infection. Our review, based on fourteen small trials, evaluating different macronutrient supplements, found limited evidence that balanced macronutrient formulas increase protein and energy intake. However, we found no evidence that such supplementation translates into reductions in disease progression or HIV‐related complications, such as opportunistic infections or death.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grobler, L; Siegfried, N; Visser, ME; Mahlungulu, SSN; Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD004536.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "cb4e30fc-9181-4984-8961-74143912a823", "pmid": "", "title": "Zinc supplementation for the prevention of pneumonia in children aged 2 months to 59 months", "imported": false, "abstract": "Abstract - Background Pneumonia is a leading cause of morbidity and mortality in children younger than five years of age. Most deaths occur during infancy and in low‐income countries. Daily zinc supplements have been reported to prevent acute lower respiratory tract infection (LRTI) and reduce child mortality. This is an update of a review first published in 2010. Objectives To evaluate the effectiveness of zinc supplementation in the prevention of pneumonia in children aged two to 59 months. Search methods We searched CENTRAL (Issue 21 October 2016), MEDLINE (1966 to October 2016), Embase (1974 to October 2016), LILACS (1982 to October 2016), CINAHL (1981 to October 2016), Web of Science (1985 to October 2016) and IMSEAR (1980 to October 2016). Selection criteria Randomised controlled trials (RCTs) evaluating zinc supplementation for the prevention of pneumonia in children aged from 2 months to 59 months. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We did not identify any new studies for inclusion in this update. We included six studies that involved 5193 participants. Analysis showed that zinc supplementation reduced the incidence of pneumonia by 13% (fixed‐effect risk ratio (RR) 0.87; 95% confidence interval (CI) 0.81 to 0.94, six studies, low‐quality evidence) and prevalence of pneumonia by 41% (random‐effects RR 0.59; 95% CI 0.35 to 0.99, one study, n = 609, low‐quality evidence). On subgroup analysis, we found that zinc reduced the incidence of pneumonia defined by specific clinical criteria by 21% (i.e. confirmation by chest examination or chest radiograph) (fixed‐effect RR 0.79; 95% CI 0.71 to 0.88, four studies, n = 3261), but had no effect on lower specificity pneumonia case definition (i.e. age‐specific fast breathing with or without lower chest indrawing) (fixed‐effect RR 0.95; 95% CI 0.86 to 1.06, four studies, n = 1932). Authors' conclusions Zinc supplementation in children is associated with a reduction in the incidence and prevalence of pneumonia. Plain language summary Zinc supplementation for the prevention of pneumonia in children aged two to 59 months Review question We evaluated the effectiveness of zinc supplementation to prevent pneumonia in children aged from two to 59 months. Background Zinc is an essential element for children's growth and development. Too little zinc is associated with increased risk of infection, particularly diarrhoea and pneumonia. Children are more prone to zinc deficiency because they are less able to absorb dietary zinc and some children, especially in low‐income countries, may not have received enough zinc from their mothers before birth. Zinc supplements for children has been reported to prevent pneumonia. Search date We searched the literature up to October 2016. This is an update of a review published in 2010. We did not find any new studies for this update. Study characteristics We included six studies that investigated zinc supplements to prevent pneumonia. The studies were conducted in Bangladesh, India, Peru and South Africa and involved 5193 children aged from two to 59 months. Children received either zinc or a similar‐looking treatment that did not contain zinc. In two studies, children were also given vitamin A. Study funding sources All included studies were funded. Of these, three explicitly mentioned that funding agencies had no role in the design and results of the study. Key results Zinc supplementation was significantly associated with reducing the incidence and prevalence of pneumonia among children aged from two to 59 months. On subgroup analysis, we found that a more stringent diagnosis (radiological examination) increased the reduction in pneumonia incidence. Quality of the evidence Overall, evidence quality was assessed as low on GRADE assessment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lassi, ZS; Moin, A; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD005978.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "cb584a80-e17b-4ac8-9bbe-92bccc2225d4", "pmid": "", "title": "Sweet potato for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Sweet potato ( Ipomoea batatas ) is among the most nutritious subtropical and tropical vegetables. It is also used in traditional medicine practices for type 2 diabetes mellitus. Research in animal and human models suggests a possible role of sweet potato in glycaemic control. Objectives To assess the effects of sweet potato for type 2 diabetes mellitus. Search methods We searched several electronic databases, including The Cochrane Library (2013, Issue 1), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2013), combined with handsearches. No language restrictions were used. Selection criteria We included randomised controlled trials (RCTs) that compared sweet potato with a placebo or a comparator intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently selected the trials and extracted the data. We evaluated risk of bias by assessing randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. Main results Three RCTs met our inclusion criteria: these investigated a total of 140 participants and ranged from six weeks to five months in duration. All three studies were performed by the same trialist. Overall, the risk of bias of these trials was unclear or high. All RCTs compared the effect of sweet potato preparations with placebo on glycaemic control in type 2 diabetes mellitus. There was a statistically significant improvement in glycosylated haemoglobin A1c (HbA1c) at three to five months with 4 g/day sweet potato preparation compared to placebo (mean difference ‐0.3% (95% confidence interval ‐0.6 to ‐0.04); P = 0.02; 122 participants; 2 trials). No serious adverse effects were reported. Diabetic complications and morbidity, death from any cause, health‐related quality of life, well‐being, functional outcomes and costs were not investigated. Authors' conclusions There is insufficient evidence about the use of sweet potato for type 2 diabetes mellitus. In addition to improvement in trial methodology, issues of standardization and quality control of preparations ‐ including other varieties of sweet potato ‐ need to be addressed. Further observational trials and RCTs evaluating the effects of sweet potato are needed to guide any recommendations in clinical practice. Plain language summary Sweet potato for type 2 diabetes mellitus Sweet potato ( Ipomoea batatas ) is a plant found in the tropical and subtropical belts and is one of the most nutritious tropical and subtropical vegetables. As well as being popular in cooking in countries in Asia‐Pacific, Africa and North America, sweet potato is also used in traditional medicine for the treatment of diabetes mellitus. We decided to investigate whether there is enough evidence from medical trials to show whether sweet potato works as a treatment for diabetes. This review of randomised controlled trials found only three studies (with a total of 140 participants) that evaluated the effects of sweet potato for type 2 diabetes mellitus compared with a fake medicine (placebo). All these trials were of very low quality. Two studies with 122 participants showed improved long‐term metabolic control of blood sugar levels as measured by glycosylated haemoglobin A1c (HbA1c) which was moderately lowered by 0.3% in participants who were given 4 g sweet potato tablets a day for three to five months. The duration of treatment ranged from six weeks to five months. No study investigated diabetic complications, death from any cause, health‐related quality of life, well‐being, functional outcomes or costs. Adverse effects were mostly mild, and included abdominal distension and pain. There are many varieties of sweet potatoes and sweet potato preparations. More trials are needed to assess the quality of the various sweet potato preparations as well as to evaluate further the use of different varieties of sweet potato in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Ooi, CP, Loke, SC", "articleTypes": [], "doi": "10.1002/14651858.CD009128.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.821Z" }, { "id": "cb67b90f-dd79-4363-8eb2-c2f18179d8f2", "pmid": "", "title": "Nutritional interventions for reducing morbidity and mortality in people with HIV", "imported": false, "abstract": "Abstract - Background Adequate nutrition is important for optimal immune and metabolic function. Dietary support may, therefore, improve clinical outcomes in HIV‐infected individuals by reducing the incidence of HIV‐associated complications and attenuating progression of HIV disease, improving quality of life and ultimately reducing disease‐related mortality. Objectives To evaluate the effectiveness of various macronutrient interventions, given orally, in reducing morbidity and mortality in adults and children living with HIV infection. Search methods We searched CENTRAL (up to August 2011), MEDLINE (1966 to August 2011), EMBASE (1988 to August 2011), LILACS (up to February 2012), and Gateway (March 2006‐February 2010). We also scanned reference lists of articles and contacted authors of relevant studies and other researchers. Selection criteria Randomised controlled trials evaluating the effectiveness of macronutrient interventions compared with no nutritional supplements or placebo in the management of adults and children infected with HIV. Data collection and analysis Three reviewers independently applied study selection criteria, assessed study quality, and extracted data. Effects were assessed using mean difference and 95% confidence intervals. Homogenous studies were combined wherever it was clinically meaningful to do so and a meta‐analysis using the random effects model was conducted. Main results Fourteen trials (including 1725 HIV positive adults and 271 HIV positive children), were included in this review. Neither supplementary food nor daily supplement of Spirulina significantly altered the risk of death compared with no supplement or placebo in malnourished, ART naive adult participants in the two studies which reported on this outcome. A nutritional supplement enhanced with protein did not significantly alter the risk of death compared to standard nutritional care in children with prolonged diarrhoea. Supplementation with macronutrient formulas given to provide protein and/or energy and fortified with micronutrients, in conjunction with nutrition counselling, significantly improved energy intake (3 trials; n=131; MD 393.57 kcal/day; 95% CI: 224.66 to 562.47;p<0.00001) and protein intake (2 trials; n=81; MD 23.5 g/day; 95% CI: 12.68, 34.01; p<0.00001) compared with no nutritional supplementation or nutrition counselling alone in adult participants with weight loss. In general supplementation with specific macronutrients such as amino acids, whey protein concentration or Spirulina did not significantly alter clinical, anthropometric or immunological outcomes compared with placebo in HIV‐infected adults and children. Authors' conclusions Given the current evidence base, which is limited to fourteen relatively small trials all evaluating different macronutrient supplements in different populations at different stages of HIV infection and with varying treatment status, no firm conclusions can be drawn about the effects of macronutrient supplementation on morbidity and mortality in people living with HIV. It is, however, promising to see more studies being conducted in low‐income countries, and particularly in children, where macronutrient supplementation both pre‐antiretroviral treatment and in conjunction with antiretroviral treatment might prove to be beneficial. Plain language summary Nutritional interventions for reducing morbidity and mortality in people with HIV Achieving and maintaining optimal nutrition is considered an important adjunct in the clinical care of patients infected with HIV, as good nutrition can improve an individual's immune function, limit disease‐specific complications, and improve quality of life and survival. We sought to determine whether macronutrient interventions, either given to provide protein and/or energy or test the effect of specific macronutrients (i.e. ch as amino acids, whey protein concentrate or Spirulina), given orally, influence morbidity and mortality in adults and children living with HIV infection. Our review, based on fourteen small trials, evaluating different macronutrient supplements, found limited evidence that balanced macronutrient formulas increase protein and energy intake. However, we found no evidence that such supplementation translates into reductions in disease progression or HIV‐related complications, such as opportunistic infections or death.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grobler, L; Siegfried, N; Visser, ME; Mahlungulu, SSN; Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD004536.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "cb6996df-53ac-4be2-9048-059683fc6d2b", "pmid": "", "title": "Vigabatrin add‐on therapy for drug‐resistant focal epilepsy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane Review published in 2008 and updated in 2013. Epilepsy is a common neurological condition which affects up to 1% of the population. Approximately 30% of people with epilepsy do not respond to treatment with currently available drugs. The majority of these people have focal epilepsy. Vigabatrin is an antiepileptic drug licensed for use in drug‐resistant epilepsy. Objectives To assess the efficacy and tolerability of vigabatrin as an add‐on therapy for people with drug‐resistant focal epilepsy. Search methods For the latest update of this review, we searched the following databases on 1 November 2018: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid 1946 to 31 October 2018), ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL) are both included in the Cochrane Register of Studies (CRS Web). We checked reference lists of retrieved studies for additional reports of relevant studies and contacted Hoechst Marion Roussel (manufacturers of vigabatrin) in 2000. Selection criteria We included randomised, double‐blind, placebo‐controlled, fully published trials of vigabatrin in people of any age with drug‐resistant focal epilepsy. Data collection and analysis Two review authors assessed trials for inclusion and extracted data using the standard methodological procedures expected by Cochrane. Primary analysis was by intention‐to‐treat (ITT). We evaluated: 50% or greater reduction in seizure frequency, treatment withdrawal, adverse effects, dose‐response analysis, cognitive outcomes and quality of life. We presented results as risk ratios (RR) with 95% or 99% confidence intervals (CI). Main results We identified 11 trials that included 756 participants (age range: 10 to 64 years). The trials tested vigabatrin doses between 1 g/day and 6 g/day. All 11 trials displayed a risk of bias across at least three risk of bias domains. Predominantly, the risk of bias was associated with: allocation concealment (selection bias), blinding of outcome assessment (detection bias) and incomplete outcome data (attrition bias). Participants treated with vigabatrin may be two to three times more likely to obtain a 50% or greater reduction in seizure frequency compared with those treated with placebo (RR 2.60, 95% CI 1.87 to 3.63; 4 studies; low‐certainty evidence). Those treated with vigabatrin may also be three times more likely to have treatment withdrawn although we are uncertain (RR 2.86, 95% CI 1.25 to 6.55; 4 studies; very low‐certainty evidence). Compared to placebo, participants given vigabatrin were more likely to experience adverse effects: dizziness/light‐headedness (RR 1.74, 95% CI 1.05 to 2.87; 9 studies; low‐certainty evidence), fatigue (RR 1.65, 95% CI 1.08 to 2.51; 9 studies; low‐certainty evidence), drowsiness (RR 1.70, 95% CI 1.18 to 2.44; 8 studies) and depression (RR 3.28, 95% CI 1.30 to 8.27; 6 studies). Although the incidence rates were higher among participants receiving vigabatrin compared to those receiving placebo, the effect was not significant for the following adverse effects: ataxia (RR 2.76, 95% CI 0.96 to 7.94; 7 studies; very low‐certainty evidence), nausea (RR 3.57, 95% CI 0.63 to 20.30; 4 studies), abnormal vision (RR 1.64, 95% CI 0.67 to 4.02; 5 studies; very low‐certainty evidence), headache (RR 1.23, 95% CI 0.79 to 1.92; 9 studies), diplopia (RR 1.76, 99% CI 0.94 to 3.30) and nystagmus (RR 1.53, 99% CI 0.62 to 3.76; 2 studies; low‐certainty evidence). Vigabatrin had little to no effect on cognitive outcomes or quality of life. Authors' conclusions Vigabatrin may significantly reduce seizure frequency in people with drug‐resistant focal epilepsy. The results largely apply to adults and should not be extrapolated to children under 10 years old. Short‐term follow‐up of participants showed that some adverse effects were associated with its use. Analysis of longer‐term observational studies elsewhere, however, has demonstrated that vigabatrin use can lead to the development of visual field defects. Plain language summary Vigabatrin add‐on for drug‐resistant focal epilepsy Background Epilepsy is a common neurological disorder affecting approximately 1 in 100 people. Around 30% of these people cannot control their epilepsy with currently available antiepileptic medication and are said to have drug‐resistant epilepsy. Most often, drug‐resistant epilepsy is focal in nature, meaning that the seizures start in one specific area of the brain. Vigabatrin is an antiepileptic medication that can be used as an add‐on treatment for drug‐resistant focal epilepsy, meaning that it is taken in addition to other antiepileptic medications. Main results We found 11 clinical trials, involving 756 people, which investigated vigabatrin as an add‐on for people with drug‐resistant focal epilepsy. The people in the trials were aged between 10 to 64 years and were given doses of 1 g/day to 6 g/day vigabatrin. We found that people given vigabatrin may be two to three times more likely to experience a 50% or greater reduction in seizure frequency than people given placebo (a non‐active treatment). We also suggest that people given vigabatrin may be up to three times more likely to stop treatment than people given placebo. People given vigabatrin were more likely to experience side effects: dizziness/light‐headedness, fatigue, drowsiness and depression, than people given placebo. However, the evidence suggested that they should not be more likely to experience: ataxia (disorders that affect co‐ordination, balance and speech), feeling sick (nausea), abnormal vision, headache, seeing double (diplopia), or involuntary movement of the eyes (nystagmus) than people given placebo. Reliability of the evidence We judged that all studies had significant risk of bias. The studies did not explain how people were allocated to treatment groups and did not say whether investigators knew which treatment people were receiving. Alongside other reasons, this reduced our confidence (certainty) in the results. Overall, we are uncertain to very uncertain whether the results we have reported are reliable. The true effect of vigabatrin could be significantly different to that reported here. Conclusions Vigabatrin may significantly reduce seizure frequency for people with drug‐resistant focal epilepsy but we are uncertain. Most of the evidence was gathered from adults, therefore, the effects of vigabatrin could be different in children. All of the included trials were of short duration; therefore, we cannot report any long‐term effects of vigabatrin. Importantly, reviews of long‐term studies have reported that long‐term vigabatrin use can lead to the development of visual problems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bresnahan, R; Gianatsi, M; Maguire, MJ; Tudur Smith, C; Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "cb74e0c2-044f-448d-ae27-732ff2b92cff", "pmid": "", "title": "Corrector therapies (with or without potentiators) for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR variant F508del is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF)). The F508del variant lacks meaningful CFTR function ‐ faulty protein is degraded before reaching the cell membrane, where it needs to be to effect transepithelial salt transport. Corrective therapy could benefit many pwCF. This review evaluates single correctors (monotherapy) and any combination of correctors (most commonly lumacaftor, tezacaftor, elexacaftor, VX‐659, VX‐440 or VX‐152) and a potentiator (e.g. ivacaftor) (dual and triple therapies). Objectives To evaluate the effects of CFTR correctors (with or without potentiators) on clinically important benefits and harms in pwCF of any age with class II CFTR mutations (most commonly F508del). Search methods We searched the Cochrane CF Trials Register (28 November 2022), reference lists of relevant articles and online trials registries (3 December 2022). Selection criteria Randomised controlled trials (RCTs) (parallel design) comparing CFTR correctors to control in pwCF with class II mutations. Data collection and analysis Two authors independently extracted data, assessed risk of bias and judged evidence certainty (GRADE); we contacted investigators for additional data. Main results We included 34 RCTs (4781 participants), lasting between 1 day and 48 weeks; an extension of two lumacaftor‐ivacaftor studies provided additional 96‐week safety data (1029 participants). We assessed eight monotherapy RCTs (344 participants) (4PBA, CPX, lumacaftor, cavosonstat and FDL169), 16 dual‐therapy RCTs (2627 participants) (lumacaftor‐ivacaftor or tezacaftor‐ivacaftor) and 11 triple‐therapy RCTs (1804 participants) (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor). Participants in 21 RCTs had the genotype F508del/F508del, in seven RCTs they had F508del/minimal function (MF), in one RCT F508del/gating genotypes, in one RCT either F508del/F508del genotypes or F508del/residual function genotypes, in one RCT either F508del/gating or F508del/residual function genotypes, and in three RCTs either F508del/F508del genotypes or F508del/MF genotypes. Risk of bias judgements varied across different comparisons. Results from 16 RCTs may not be applicable to all pwCF due to age limits (e.g. adults only) or non‐standard designs (converting from monotherapy to combination therapy). Monotherapy Investigators reported no deaths or clinically relevant improvements in quality of life (QoL). There was insufficient evidence to determine effects on lung function. No placebo‐controlled monotherapy RCT demonstrated differences in mild, moderate or severe adverse effects (AEs); the clinical relevance of these events is difficult to assess due to their variety and few participants (all F508del/F508del). Dual therapy In a tezacaftor‐ivacaftor group there was one death (deemed unrelated to the study drug). QoL scores (respiratory domain) favoured both lumacaftor‐ivacaftor and tezacaftor‐ivacaftor therapy compared to placebo at all time points (moderate‐certainty evidence). At six months, relative change in forced expiratory volume in one second (FEV 1 ) % predicted improved with all dual combination therapies compared to placebo (high‐ to moderate‐certainty evidence). More pwCF reported early transient breathlessness with lumacaftor‐ivacaftor (odds ratio (OR) 2.05, 99% confidence interval (CI) 1.10 to 3.83; I 2 = 0%; 2 studies, 739 participants; high‐certainty evidence). Over 120 weeks (initial study period and follow‐up), systolic blood pressure rose by 5.1 mmHg and diastolic blood pressure by 4.1 mmHg with twice‐daily 400 mg lumacaftor‐ivacaftor (80 participants). The tezacaftor‐ivacaftor RCTs did not report these adverse effects. Pulmonary exacerbation rates decreased in pwCF receiving additional therapies to ivacaftor compared to placebo (all moderate‐certainty evidence): lumacaftor 600 mg (hazard ratio (HR) 0.70, 95% CI 0.57 to 0.87; I 2 = 0%; 2 studies, 739 participants); lumacaftor 400 mg (HR 0.61, 95% CI 0.49 to 0.76; I 2 = 0%; 2 studies, 740 participants); and tezacaftor (HR 0.64, 95% CI 0.46 to 0.89; 1 study, 506 participants). Triple therapy No study reported any deaths (high‐certainty evidence). All other evidence was low‐ to moderate‐certainty. QoL respiratory domain scores probably improved with triple therapy compared to control at six months (six studies). There was probably a greater relative and absolute change in FEV 1 % predicted with triple therapy (four studies each across all combinations). The absolute change in FEV 1 % predicted was probably greater for F508del/MF participants taking elexacaftor‐tezacaftor‐ivacaftor compared to placebo (mean difference 14.30, 95% CI 12.76 to 15.84; 1 study, 403 participants; moderate‐certainty evidence), with similar results for other drug combinations and genotypes. There was little or no difference in adverse events between triple therapy and control (10 studies). No study reported time to next pulmonary exacerbation, but fewer F508del/F508del participants experienced a pulmonary exacerbation with elexacaftor‐tezacaftor‐ivacaftor at four weeks (OR 0.17, 99% CI 0.06 to 0.45; 1 study, 175 participants) and 24 weeks (OR 0.29, 95% CI 0.14 to 0.60; 1 study, 405 participants); similar results were seen across other triple therapy and genotype combinations. Authors' conclusions There is insufficient evidence of clinically important effects from corrector monotherapy in pwCF with F508del/F508del. Additional data in this review reduced the evidence for efficacy of dual therapy; these agents can no longer be considered as standard therapy. Their use may be appropriate in exceptional circumstances (e.g. if triple therapy is not tolerated or due to age). Both dual therapies (lumacaftor‐ivacaftor, tezacaftor‐ivacaftor) result in similar small improvements in QoL and respiratory function with lower pulmonary exacerbation rates. While the effect sizes for QoL and FEV 1 still favour treatment, they have reduced compared to our previous findings. Lumacaftor‐ivacaftor was associated with an increase in early transient shortness of breath and longer‐term increases in blood pressure (not observed for tezacaftor‐ivacaftor). Tezacaftor‐ivacaftor has a better safety profile, although data are lacking in children under 12 years. In this population, lumacaftor‐ivacaftor had an important impact on respiratory function with no apparent immediate safety concerns, but this should be balanced against the blood pressure increase and shortness of breath seen in longer‐term adult data when considering lumacaftor‐ivacaftor. Data from triple therapy trials demonstrate improvements in several key outcomes, including FEV 1 and QoL. There is probably little or no difference in adverse events for triple therapy (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor) in pwCF with one or two F508del variants aged 12 years or older (moderate‐certainty evidence). Further RCTs are required in children under 12 years and those with more severe lung disease. Plain language summary CFTR correctors, a therapy for cystic fibrosis targeted at specific variants (most commonly F508del) Review question How do drugs (or drug combinations) for correcting the basic defect in the most common cystic fibrosis (CF)‐causing gene variant (F508del) impact on outcomes important to people with CF (pwCF), e.g. survival, quality of life (QoL), lung function and safety? Key messages There is a lack of evidence to support monotherapy and limited evidence to support dual therapy for pwCF who have the gene variant F508del. We found important differences across key outcomes, with fewer unwanted side effects in the triple therapy studies when compared to one dual therapy drug combination (lumacaftor plus ivacaftor). More research is needed to assess triple therapy combinations in children and to monitor their safety profiles over the longer term. How would drugs (or drug combinations) correct the basic defect in the most common CF‐causing gene variant (F508del)? The CF gene makes a protein that helps salts move across cells in many parts of the body. Over 80% of pwCF have at least one copy of the genetic variant F508del, meaning they make a full length of this protein, but it cannot move through the cell correctly. Laboratory experiments suggest that if this protein reaches the cell wall, it may be able to function, restore salt movement and correct the chronic problems that pwCF experience. What did we want to find out? How do drugs (or drug combinations) used to treat people of any age who have the genetic variant F508del impact their lives? Are these drugs associated with any unwanted side effects? What did we do? We searched for and included studies that looked at drugs (and drug combinations) used to treat pwCF who had at least one copy of the most common CF‐causing gene variant (F508del) compared to control medications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 34 studies that involved 4781 pwCF and which lasted between 1 day and 48 weeks; all studies compared an active drug treatment to a placebo (drug containing no active treatment). We do not have enough information to decide if 14 studies should be included or not and eight studies have not yet been completed. Eight studies looked at treatment with a single drug (monotherapy). These studies did not report any deaths or clinically relevant improvements in quality of life (QoL) scores. There was not enough evidence to show an effect on lung function. All studies reported side effects; there were a wide range of side effects each reported by a small number of participants in the studies. There were 16 studies assessing a combination of two drugs (dual therapy), either tezacaftor plus ivacaftor or lumacaftor plus ivacaftor. One participant taking tezacaftor plus ivacaftor died, but this was not thought to be related to the treatment. Both dual therapies resulted in improvements in QoL and lung function; rates of pulmonary exacerbations (a flare‐up of symptoms) were also lower. Neither dual therapy was linked to severe side effects, although people starting treatment with lumacaftor plus ivacaftor experienced shortness of breath for one to two weeks; this usually stopped without further treatment . More concerningly, in longer studies some people taking lumacaftor plus ivacaftor experienced a rise in blood pressure. Two people (out of over 500) even stopped lumacaftor plus ivacaftor treatment because of high blood pressure. These side effects were not reported for tezacaftor plus ivacaftor. There were 11 studies assessing different combinations of three drugs (triple therapy). The combinations were based on tezacaftor with ivacaftor (or deutivacaftor, which is a similar but chemically altered version of ivacaftor) and investigators then added either elexacaftor, VX‐659, VX‐440 or VX‐152 and compared these to either triple placebo, or tezacaftor with ivacaftor and one placebo. Some studies split groups by treatment and also by different genetic variants. No study reported any deaths. Triple therapies improved QoL scores and lung function in all comparisons, with no difference in the number or severity of side effects. Fewer people with two copies of F508del taking elexacaftor plus tezacaftor plus ivacaftor experienced a pulmonary exacerbation than those taking the control treatment. What are the limitations of the evidence? Our certainty in the evidence ranged from uncertain to very certain, but we were quite certain of the evidence for most results. While studies generally provided few details about their design, so we could not make clear judgements on potential biases, we had fewer concerns with the larger, more recent studies. Some of our findings are based on studies that were too small to show important effects and for 16 studies the results may not be applicable to all pwCF due to them only including people of certain ages (i.e. only adults or only children). Also, one study had an unusual design where people were given monotherapy and then later a dual therapy. How up‐to‐date is this evidence? This review updates our earlier review. We last looked for evidence on 28 November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Heneghan, M, Southern, KW, Murphy, J, Sinha, IP, Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD010966.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.801Z" }, { "id": "cb79e3a1-ab38-4b08-a088-85f9683f4fca", "pmid": "", "title": "Enteral nutrition for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Prevention of relapse is a major issue in the management of quiescent Crohn's disease (CD). Current therapies (e.g. methotrexate, biologics, 6‐mercaptopurine and azathioprine) may be effective for maintaining remission in CD, but these drugs may cause significant adverse events. Interventions that are effective and safe for maintenance of remission in CD are desirable. Objectives The primary objectives were to evaluate the efficacy and safety of enteral nutrition for the maintenance of remission in CD and to assess the impact of formula composition on effectiveness. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and clinicaltrials.gov from inception to 27 July 2018. We also searched references of retrieved studies and reviews. Selection criteria Randomised controlled trials (RCTs) including participants of any age with quiescent CD were considered for inclusion. Studies that compared enteral nutrition with no intervention, placebo or any other intervention were selected for review. Data collection and analysis Two authors independently screened studies for inclusion, extracted data and assessed methodological quality using the Cochrane risk of bias tool. The primary outcome was clinical or endoscopic relapse as defined by the primary studies. Secondary outcomes included anthropometric measures (i.e. height and weight), quality of life (QoL), adverse events, serious adverse events and withdrawal due to adverse events. We calculated the risk ratio and 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated the mean difference and 95% CI. A random‐effects model was used for the statistical analysis. We used the GRADE criteria to assess the overall certainty of the evidence supporting the primary outcome and selected secondary outcomes. Main results Four RCTs (262 adult participants) met the inclusion criteria. One study (N = 33) compared an elemental diet to a non‐elemental (polymeric) diet. One study (N = 51) compared a half elemental diet to a regular free diet. Another study (N = 95) compared an elemental diet to 6‐mercaptopurine (6‐MP) or a no treatment control group. One study (N= 83) compared a polymeric diet to mesalamine. Two studies were rated as high risk of bias due to lack of blinding or incomplete outcome data. The other two studies were judged to have an unclear risk of bias. The studies were not pooled due to differences in control interventions and the way outcomes were assessed. The effect of an elemental diet compared to a polymeric diet on remission rates or withdrawal due to adverse events is uncertain. Fifty‐eight per cent (11/19) of participants in the elemental diet group relapsed at 12 months compared to 57% (8/14) of participants in the polymeric diet group (RR 1.01, 95% CI 0.56 to 1.84; very low certainty evidence). Thirty‐two per cent (6/19) of participants in the elemental diet group were intolerant to the enteral nutritional formula because of taste or smell and were withdrawn from the study in the first 2 weeks compared to zero participants (0/14) in the polymeric diet group (RR 9.75, 95% CI 0.59 to 159.93; low certainty evidence). Anthropometric measures, QoL, adverse events and serious adverse events were not reported as outcomes. The effect of an elemental diet (half of total daily calorie requirements) compared to a normal free diet on relapse rates is uncertain. Thirty‐five per cent (9/26) of participants in the elemental diet group relapsed at 12 months compared to 64% (16/25) of participants in the free diet group (RR 0.54, 95% CI 0.30 to 0.99; very low certainty evidence). No adverse events were reported. This study reported no differences in weight change between the two diet groups. Height and QoL were not reported as outcomes. The effect of an elemental diet compared to 6‐MP on relapse rates or adverse events is uncertain. Thirty‐eight per cent (12/32) of participants in the elemental diet group relapsed at 12 months compared to 23% (7/30) of participants in the 6‐MP group (RR 1.61; 95% CI 0.73 to 3.53; very low certainty evidence). Three per cent (1/32) of participants in the elemental diet group had an adverse event compared to 13% (4/30) of participants in the 6‐MP group (RR 0.23, 95% CI 0.03 to 1.98; low certainty evidence). Adverse events in the elemental diet group included surgery due to worsening CD. Adverse events in the 6‐MP group included liver injury (n = 2), hair loss (n = 1) and surgery due to an abscess (n = 1). No serious adverse events or withdrawals due to adverse events were reported. Weight, height and QoL were not reported as outcomes The effect of a polymeric diet compared to mesalamine on relapse rates and weight is uncertain. Forty‐two per cent (18/43) of participants in the polymeric diet group relapsed at 6 months compared to 55% (22/40) of participants in the mesalamine group (RR 0.76; 95% CI 0.49 to 1.19; low certainty evidence). The mean difference in weight gain over the study period was 1.9 kg higher in the polymeric diet group compared to mesalamine (95% CI ‐4.62 to 8.42; low certainty evidence). Two participants in the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had an adverse event. Height, QoL, serious adverse events and withdrawal due to adverse events were not reported as outcomes. Authors' conclusions The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the efficacy and safety of enteral nutrition in quiescent CD can be drawn. More research is needed to determine the efficacy and safety of using enteral nutrition as maintenance therapy in CD. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available. Plain language summary Enteral nutrition (liquid feeds) for maintenance of remission in Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disease of the intestines that frequently occurs in the lower part of the small intestine (ileum). Symptoms include abdominal pain, diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms the disease is considered 'active'. When the symptoms stop, it is called 'remission'. When people in remission experience symptoms it is called a 'relapse'. What is enteral nutrition? Enteral nutrition is a feeding method where a person's daily caloric intake is delivered via a liquid diet using the GI tract. Enteral nutrition can be administered by mouth or by tube feeding, where a tube is inserted through the nose or abdomen into the stomach to deliver the liquid feed. Enteral nutrition is a form of nutritional therapy for Crohn's disease patients. The mechanism by which enteral nutrition may influence inflammation is unknown and is being studied. Enteral nutrition can be classified as elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets are composed of amino‐acids (organic compounds), fats, sugars, vitamins and minerals. Elemental diets are easily absorbed and digested. Non‐elemental diets are based on oligopeptide (organic compounds composed of 2 to 20 amino‐acids) or whole protein sources. Non‐elemental diets are best for people who can digest and absorb nutrients without difficulty. What is 6‐mercaptopurine? 6‐Mercaptopurine is an immunosuppressive drug that is thought to reduce inflammation in people with Crohn's disease by blocking the immune system. What is mesalamine? Mesalamine is a 5‐aminosalicylic acid drug. 5‐Aminosalicylic drugs are thought to treat Crohn's disease by reducing inflammation in the gastrointestinal tract. These drugs are usually taken by mouth. What did the researchers investigate? The researchers studied whether enteral nutrition helps to maintain remission in people with Crohn's disease. The researchers also investigated whether one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) for maintaining remission in people with Crohn's disease. What did the researchers find? Four studies including 262 adult participants with Crohn's disease in remission were included. One study (33 participants) compared an elemental diet to a non‐elemental (polymeric) diet. One study (51 participants) compared an elemental diet to a normal diet (no supplements). One study (95 participants) compared an elemental diet to 6‐mercaptopurine or a no treatment control group. One study (83 participants) compared a non‐elemental polymeric diet to mesalamine. The researchers searched the medical literature extensively up to 27 July 2018. The study comparing an elemental diet to a polymeric diet found no difference in remission rates at 12 months. Six elemental diet participants were not able to tolerate the enteral nutritional formula because of taste or smell and were withdrawn from the study. Participants who received half of their total daily calorie requirements as elemental diet and the remaining half by normal diet had a lower chance of relapse at 12 months compared to participants who received a free diet. No side effects were reported in this study. The study comparing an elemental diet to 6‐mercaptopurine did not show any difference in relapse rates at 12 months. There was no difference in side effect rates. The only side effect reported in the elemental diet group was surgery due to worsening Crohn's disease. Side effects in the 6‐mercaptopurine group included liver injury in two participants, hair loss in one participant and surgery to treat an abscess in one participant. The study comparing a polymeric diet to mesalamine found no difference in relapse rates at six months. Two participants the polymeric diet group experienced nausea and four had diarrhoea. It is unclear if any participants in the mesalamine group had side effects. No serious side effects were reported in any of the studies. The results for the outcomes assessed in this review are uncertain and no firm conclusions regarding the effectiveness and safety of enteral nutrition for maintenance of remission in Crohn's disease can be drawn. More research is needed to determine the effectiveness and safety of using enteral nutrition as maintenance therapy in Crohn's disease. Currently, there are four ongoing studies (estimated enrolment of 280 participants). This review will be updated when the results of these studies are available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Akobeng, AK; Zhang, D; Gordon, M; MacDonald, JK", "articleTypes": [], "doi": "10.1002/14651858.CD005984.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "cb8d6221-87f0-42c9-b5ba-6bb5a1bff2b4", "pmid": "", "title": "Taste Changes With Bariatric Surgery", "imported": false, "abstract": "It is commonly believed that a link exists between BMI and taste perception. One group of researchers observed that women who are obese experience reduced taste sensitivity when compared to normal-weight controls. Others have compared taste sensitivity between lean and obese subjects and found no significant differences. The inconsistencies in these studies demonstrate how much variation in taste sensitivity is possible when different factors are applied in research. Throughout several studies, one element remains constant - bariatric surgery causes appetite aversions. These changes in appetite and food preference likely have a large influence on the overall magnitude of post-surgical weight loss. Although many studies have investigated the changes in taste preference after bariatric surgery, few, if any, have focused on changes in sweet taste perception.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "cb9000c3-725d-4fc7-b49b-751524e0601e", "pmid": "", "title": "Interventions to improve adherence to antiretroviral therapy in children with HIV infection", "imported": false, "abstract": "Abstract - Background Achieving and maintaining high levels of medication adherence are required to achieve the full benefits of antiretroviral therapy (ART), yet suboptimal adherence among children is common in both developed and developing countries. Objectives To conduct a systematic review of the literature of evaluations of interventions for improving paediatric ART adherence. Search methods We created a comprehensive search strategy in order to identify all studies relevant to this topic. In July 2010, we searched the following electronic databases: EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, LILACS, Web of Science, Web of Social Science, NLM Gateway (supplemented by a manual search of the most recent abstracts not included in the Gateway database). We searched abstracts from the International AIDS Conference from 2002 to 2010, the International AIDS Society Conference on Pathogenesis, Treatment and Prevention from 2003 to 2009, and from the Conference on Retroviruses and Opportunistic Infections from 1997 to 2010. We used search strategies determined by the Cochrane Review Group on HIV/AIDS. We also contacted researchers who work in this field and checked reference lists of related systematic reviews and of all included studies. Selection criteria Randomised and non‐randomised controlled trials of interventions to improve adherence to ART among children and adolescents (age ≤18 years) were included. Studies had to report adherence to ART as an outcome. Data collection and analysis After one author performed an initial screening to exclude citations that did not meet the inclusion criteria, two authors did a second screening of those citations that likely met the criteria. For all articles that passed the second screening, full articles were pulled in order to make a final determination. Two authors then extracted data and graded methodological quality independently. Differences were resolved through discussion. Main results Four studies met the inclusion criteria. No single intervention was evaluated by more than one trial. Two studies were conducted in low‐income countries. Two studies were randomised controlled trials (RCT), and two were non‐randomised trials. An RCT of a home‐based nursing programme showed a positive effect of the intervention on knowledge and medication refills (p=.002), but no effect on CD4 count and viral load. A second RCT of caregiver medication diaries showed that the intervention group had fewer participants reporting no missed doses compared to the control group (85% vs. 92%, respectively), although this difference was not statistically significant (p=.08). The intervention had no effect on CD4 percentage or viral load. A non‐randomised trial of peer support group therapy for adolescents demonstrated no change in self‐reported adherence, yet the percentage of participants with suppressed viral load increased from 30% to 80% (p=.06). The second non‐randomised trial found that the percentage of children achieving >80% adherence was no different between children on a lopinavir‐ritonavir (LPV/r) regimen compared to children on a non‐nucleoside reverse transcriptase regimen (p=.781). However, the proportion of children achieving virological suppression was significantly greater for children on the LPV/r regimen than for children on the NNRTI‐containing regimen (p=.002). Authors' conclusions A home‐based nursing intervention has the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence or disease outcomes. Two interventions, an LPV/r‐containing regimen and peer support therapy for adolescents, did not demonstrate improvements in adherence, yet demonstrated greater viral load suppression compared to control groups, suggesting a different mechanism for improved health outcomes. Well‐designed evaluations of interventions to improve paediatric adherence to ART are needed. Plain language summary Interventions to improve adherence to ART in children and adolescents Achieving and maintaining high levels of medication adherence are required to realise the full benefits of antiretroviral therapy (ART). We identified four studies that evaluated interventions designed to improve adherence to ART among children and adolescents age 18 years and younger. These studies showed that home‐based nursing, peer support for adolescents and LPV/r‐containing regimens have the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence. There is a need for well‐designed evaluations of interventions to improve paediatric adherence to ART.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Bain‐Brickley, D, Butler, LM, Kennedy, GE, Rutherford, GW", "articleTypes": [], "doi": "10.1002/14651858.CD009513", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.738Z" }, { "id": "cb93ee37-16d5-404c-ac96-389dee5d8661", "pmid": "", "title": "Acute and Repeated Impact of Sweeteners and Sweetness Enhancers on Food Behaviour, Physiology & Health (SWEET Work Package 2 Phase 2)", "imported": false, "abstract": "This study aims to evaluate the acute (1-day) and repeated (2-week) effects of combinations of Sweeteners & Sweetness Enhancer blends on metabolic, sensory, neuro-behavioural and microbiota-mediated processes involved in satiety, consumer preferences and health.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "cbbf5654-4d92-434b-b133-87bc27a381d5", "pmid": "", "title": "Pharmacological interventions for promoting smoking cessation during pregnancy", "imported": false, "abstract": "Abstract - Background Tobacco smoking in pregnancy causes serious health problems for the developing fetus and mother. When used by non‐pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion, and varenicline) are effective for increasing smoking cessation, however their efficacy and safety in pregnancy remains unknown. Electronic cigarettes (ECs) are becoming widely used, but their efficacy and safety when used for smoking cessation in pregnancy are also unknown. Objectives To determine the efficacy and safety of smoking cessation pharmacotherapies and ECs used during pregnancy for smoking cessation in later pregnancy and after childbirth, and to determine adherence to smoking cessation pharmacotherapies and ECs for smoking cessation during pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2019), trial registers, and grey literature, and checked references of retrieved studies. Selection criteria Randomised controlled trials (RCTs) conducted in pregnant women, comparing smoking cessation pharmacotherapy or EC use with either placebo or no pharmacotherapy/EC control. We excluded quasi‐randomised, cross‐over, and within‐participant designs, and RCTs with additional intervention components not matched between trial arms. Data collection and analysis We followed standard Cochrane methods. The primary efficacy outcome was smoking cessation in later pregnancy; safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well‐being. We also collated data on adherence to trial treatments. We calculated the risk ratio (RR) or mean difference (MD) and the 95% confidence intervals (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta‐analyses where appropriate. Main results We included 11 trials that enrolled a total of 2412 pregnant women who smoked at enrolment, nine trials of NRT and two trials of bupropion as adjuncts to behavioural support, with comparable behavioural support provided in the control arms. No trials investigated varenicline or ECs. We assessed four trials as at low risk of bias overall. The overall certainty of the evidence was low across outcomes and comparisons as assessed using GRADE, with reductions in confidence due to risk of bias, imprecision, and inconsistency. Compared to placebo and non‐placebo (behavioural support only) controls, there was low‐certainty evidence that NRT increased the likelihood of smoking abstinence in later pregnancy (RR 1.37, 95% CI 1.08 to 1.74; I² = 34%, 9 studies, 2336 women). However, in subgroup analysis by comparator type, there was a subgroup difference between placebo‐controlled and non‐placebo controlled RCTs (test for subgroup differences P = 0.008). There was unclear evidence of an effect in placebo‐controlled RCTs (RR 1.21, 95% CI 0.95 to 1.55; I² = 0%, 6 studies, 2063 women), whereas non‐placebo‐controlled trials showed clearer evidence of a benefit (RR 8.55, 95% CI 2.05 to 35.71; I² = 0%, 3 studies, 273 women). An additional subgroup analysis in which studies were grouped by the type of NRT used found no difference in the effectiveness of NRT in those using patches or fast‐acting NRT (test for subgroup differences P = 0.08). There was no evidence of a difference between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities, or neonatal death. In one study infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' at two years of age compared to the placebo group. Non‐serious adverse effects observed with NRT included headache, nausea, and local reactions (e.g. skin irritation from patches or foul taste from gum), but data could not be pooled. Adherence to NRT treatment regimens was generally low. We identified low‐certainty evidence that there was no difference in smoking abstinence rates observed in later pregnancy in women using bupropion when compared to placebo control (RR 0.74, 95% CI 0.21 to 2.64; I² = 0%, 2 studies, 76 women). Evidence investigating the safety outcomes of bupropion use was sparse, but the existing evidence showed no difference between the bupropion and control group. Authors' conclusions NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy. However, this evidence is of low certainty, as the effect was not evident when potentially biased, non‐placebo‐controlled RCTs were excluded from the analysis. Future studies may therefore change this conclusion. We found no evidence that NRT has either positive or negative impacts on birth outcomes; however, the evidence for some of these outcomes was also judged to be of low certainty due to imprecision and inconsistency. We found no evidence that bupropion may be an effective aid for smoking cessation during pregnancy, and there was little evidence evaluating its safety in this population. Further research evidence on the efficacy and safety of pharmacotherapy and EC use for smoking cessation in pregnancy is needed, ideally from placebo‐controlled RCTs that achieve higher adherence rates and that monitor infants' outcomes into childhood. Future RCTs of NRT should investigate higher doses than those tested in the studies included in this review. Plain language summary Drug treatments and electronic cigarettes for stopping smoking in pregnancy What is the issue? Smoking during pregnancy harms women and infants. However, many women who smoke struggle to stop whilst pregnant. Medication for smoking cessation reduces the intensity of cravings, meaning that people trying to stop smoking are more likely to succeed in the long term. Providing pregnant women who smoke with these treatments could help them to stop smoking and have a positive impact on both their own health and the health of their infants. Why is this important? Medications commonly used to help people to stop smoking include nicotine replacement therapy (NRT), bupropion, and varenicline. Electronic cigarettes containing nicotine are also used by some who smoke to help avoid smoking. However, the safety and effectiveness of smoking cessation drugs and electronic cigarettes in pregnant women is unknown. We searched for studies looking at how good these aids were at helping pregnant women stop smoking and how safe they were when used during pregnancy. What evidence did we find? We searched for evidence on 20 May 2019 and identified 11 randomised studies (studies in which participants are assigned to one of two or more treatment groups using a random method) that enrolled a total of 2412 women. Nine studies tested NRT used alongside counselling to stop smoking, whilst the other two studies tested bupropion. Low‐quality evidence suggests that NRT combined with behavioural support might help women to stop smoking in later pregnancy more than behavioural support alone. Medication trials often use placebos, that is tablets or patches that look like the drug but do not actually include it, so that each comparison group has equal expectation of success and there is a fairer test of the benefits of the medicine itself. When just the higher‐quality, placebo‐controlled trials were analysed, the evidence suggested that NRT was more effective than placebo NRT. There was no evidence that either nicotine patches or fast‐acting NRT (such as gum or lozenge) was more effective than the other. Low‐quality evidence suggests that bupropion may be no more effective than placebo in helping women quit smoking later in pregnancy. We found no trials investigating other smoking cessation pharmacotherapies or electronic cigarettes. There was insufficient evidence to conclude whether NRT had either positive or negative impacts on rates of miscarriage, stillbirth, preterm birth (less than 37 weeks), mean birthweight, low birthweight (less than 2500 g), admissions of babies to neonatal intensive care, or newborn deaths. However, in one trial where infants were followed until two years of age, those infants born to women who had been randomised to NRT were more likely to have healthy development. Similarly, it is unclear whether bupropion had a positive or negative impact on birth outcomes. Studies that looked at whether women used their stop smoking medications as instructed found that use was generally low, and the majority of women used little of the NRT they were given. What does this mean? More research evidence is needed, in particular placebo‐controlled trials that test higher doses of NRT, encourage women to use sufficient medication, and follow infants into childhood. Furthermore, more studies are required investigating the effect and safety of bupropion, electronic cigarettes, and varenicline for giving up smoking during pregnancy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Claire, R; Chamberlain, C; Davey, MA; Cooper, SE; Berlin, I; Leonardi‐Bee, J; Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD010078.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "cbdf32c1-7618-454a-97d3-3f95f719b772", "pmid": "", "title": "Chinese herbal medicine for schizophrenia", "imported": false, "abstract": "Abstract - Background Traditional Chinese medicine (TCM) was the main form of treatment in China for psychiatric illnesses until the development of antipsychotic drugs in the 1950's. Antipsychotic drugs have become the primary intervention for schizophrenia, although herbal medicines can still form part of the treatment. Objectives To review Chinese herbal medicine, used alone or as part of a TCM approach, for people with schizophrenia and related psychoses. Search methods We undertook electronic searches of the Cochrane Schizophrenia Group's register (December 2003), the Traditional Chinese Medical Literature Analysis and Retrieval Database (TCMLARS) (October 2003), Chinese Biomedical Database (CBM) (December 2003), China National Knowledge Infrastructure Database (May 2004), Complementary Medicine Database (AMED) (December 2003). We contacted the Chinese Cochrane Centre, the Cochrane Complementary Medicine Field and first authors of included studies and inspected reference lists for additional studies. Selection criteria We included all relevant randomised controlled trials involving people with schizophrenia‐like illnesses, allocated to Chinese herbal medicine, including any Chinese herbs (single or mixture), compared with placebo/no treatment or antipsychotic drugs. We updated this search July 2012 and added 45 new trials to the awaiting classification section. Data collection and analysis We independently extracted data and calculated fixed effects relative risk (RR), the 95% confidence intervals (CI) for homogeneous dichotomous data, and, where appropriate, the number needed to treat (NNT) on an intention‐to‐treat basis. For continuous data, we calculated weighted mean differences (WMD). Main results Only one small trial of the seven included studies truly evaluated TCM for schizophrenia. The other trials evaluated Chinese herbs for schizophrenia. We found one study comparing Chinese herbal medicine with antipsychotic drugs. Data for the global state outcome 'no change/worse' favoured people allocated to antipsychotic medication (n=90, RR 1.88 CI 1.2 to 2.9, NNH 4 CI 2 to 12). Six trials compared Chinese herbal medicine in combination with antipsychotic with antipsychotic drugs alone. One trial found global state 'not improved/worse' favoured the herbal medicine/antipsychotic combination (n=123, RR 0.19 CI 0.1 to 0.6, NNT 6 CI 5 to 11). Two studies (n=103) also found short‐term data from the Clinical Global Impression scale favoured the herbal medicine plus antipsychotic group (WMD ‐0.46 CI ‐0.9 to ‐0.1) compared with those given only antipsychotics. Significantly fewer people in the experimental group left the study early compared with those given antipsychotics alone (n=1004, 6 RCTs, RR 0.30 CI 0.16 to 0.58, NNT 21 CI 18 to 35). Reports of constipation were significantly lower in the treatment group compared to those receiving antipsychotics (n=67, 1 RCT, RR 0.03 CI 0.0 to 0.5, NNH 2 CI 2 to 4). Authors' conclusions Chinese herbal medicines, given in a Western biomedical context, may be beneficial for people with schizophrenia when combined with antipsychotics. Traditional Chinese medicine is also under‐evaluated, but results from one pioneering study that attempted to evaluate TCM should encourage further trials. Note: the 45 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed. Plain language summary Chinese herbal medicine for schizophrenia Antipsychotic medication is the mainstay of treatment for people with schizophrenia, and although effective, still leaves some people with distressing symptoms and/or disabling adverse effects. Safer and more effective health care interventions are needed. Traditional Chinese medicine (TCM) has been used to treat mental health disorders, including schizophrenia, for more than 2000 years. Chinese herbs may also have antipsychotic properties when used in a Western biomedical context. In this review we sought and found trials relevant to the effects of both approaches for schizophrenia. Traditional Chinese medicine methodology has been evaluated for schizophrenia, but the one included study was too limited in terms of sample size and study length to guide good practice. However, this pioneering study does show that TCM can be evaluated for its efficacy for people with schizophrenia , and should encourage trialists to undertake further, more comprehensive trials in this area. The use of Chinese herbs in a Western medicine context, without incorporating TCM methodology, has been evaluated in six trials, although again these are limited by their sample size and study length. The results of these six trials suggest that using Chinese herbs alone for psychotic symptoms may not be indicated, but if used in conjunction with Western antipsychotic drugs, they may be beneficial in terms of mental state, global functioning and decrease of adverse effects. However, further trials are needed before the effects of TCM for people with schizophrenia can be evaluated with any real confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Rathbone, J, Zhang, L, Zhang, M, Xia, J, Liu, X, Yang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD003444.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.792Z" }, { "id": "cbe7d584-7f42-44f5-a617-a8f2f4cbc994", "pmid": "", "title": "Targeting Triple-negative Breast Cancer or ER-positive, PR Positive her2 Negative by Alkaline Glucosodiene Molecules Via a Metabolic Pathway Phase I Clinical Trial", "imported": false, "abstract": "The diverse group of breast tumors known as triple-negative breast cancer (TNBC) which is lethally and deadly type of breast cancer and insensitive to endocrine therapy and HER2-targeted therapy because it lacks the expression of estrogen, progesterone, and human epidermal growth factor receptors TNBC makes up almost 15% of all invasive breast cancers, and of all breast tumor subtypes, it has the worst overall survival and the highest rate of metastatic occurrence. Cytotoxic chemotherapy is the main established systemic therapy for early and advanced TNBC disease at the moment because there is no authorized targeted therapy. Despite the fact that chemotherapy greatly improves clinical outcomes for TNBC patients, recurrence rates are still high and TNBC cancers frequently develop chemotherapeutic drug resistance ). In light of the few available therapy choices, so few choices for this subtype of breast cancer, and many cases are resistant to chemotherapy and recurrent and with a risk of high metastasis from previous literature and many experimental studies, the target of glucose environment is a promising weapon against this deadly type of breast cancer so glucose deprivation from tumor cells may cut the glucose entry as fuel to these cancer cells so this study uses a substitute energy fuel by using alkaline glucosodiene which is chemically invented by Maher M.AKL", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "cc1b5078-fad3-4c16-bb21-23244062d4c8", "pmid": "", "title": "Ghrelin for the management of cachexia associated with cancer", "imported": false, "abstract": "Abstract - Background Cancer sufferers are amongst the most malnourished of all the patient groups. Studies have shown that ghrelin, a gut hormone can be a potential therapeutic agent for cachexia (wasting syndrome) associated with cancer. A variety of mechanisms of action of ghrelin in people with cancer cachexia have been proposed. However, safety and efficacy of ghrelin for cancer‐associated cachexia have not been systematically reviewed. The aim of this review was to assess whether ghrelin is associated with better food intake, body composition and survival than other options for adults with cancer cachexia. Objectives To assess the efficacy and safety of ghrelin in improving food intake, body composition and survival in people with cachexia associated with cancer. Search methods We searched CENTRAL, MEDLINE and Embase without language restrictions up to July 2017. We also searched for ongoing studies in trials registers, performed handsearching, checked bibliographic references of relevant articles and contacted authors and experts in the field to seek potentially relevant research. We applied no restrictions on language, date, or publication status. Selection criteria We included randomised controlled (parallel‐group or cross‐over) trials comparing ghrelin (any formulation or route of administration) with placebo or an active comparator in adults (aged 18 years and over) who met any of the international criteria for cancer cachexia. Data collection and analysis Two review authors independently assessed studies for eligibility. Two review authors then extracted data and assessed the risk of bias for individual studies using standard Cochrane methodology. For dichotomous variables, we planned to calculate risk ratio with 95% confidence intervals (CI) and for continuous data, we planned to calculate mean differences (MD) with 95% CI. We assessed the evidence using GRADE and created 'Summary of findings' tables. Main results We screened 926 individual references and identified three studies that satisfied the inclusion criteria. Fifty‐nine participants (37 men and 22 women) aged between 54 and 78 years were randomised initially, 47 participants completed the treatment. One study had a parallel design and two had a cross‐over design. The studies included people with a variety of cancers and also differed in the dosage, route of administration, frequency and duration of treatment. One trial, which compared ghrelin with placebo, found that ghrelin improved food intake (very low‐quality evidence) and had no adverse events (very low‐quality evidence). Due to unavailability of data we were unable to report on comparisons for ghrelin versus no treatment or alternative experimental treatment modalities, or ghrelin in combination with other treatments or ghrelin analogues/ghrelin mimetics/ghrelin potentiators. Two studies compared a higher dose of ghrelin with a lower dose of ghrelin, however due to differences in study designs and great diversity in the treatment provided we did not pool the results. In both trials, food intake did not differ between participants on higher‐dose and lower‐dose ghrelin. None of the included studies assessed data on body weight. One study reported higher adverse events with a higher dose as compared to a lower dose of ghrelin. All studies were at high risk of attrition bias and bias for size of the study. Risk of bias in other domains was unclear or low. We rated the overall quality of the evidence for primary outcomes (food intake, body weight, adverse events) as very low. We downgraded the quality of the evidence due to lack of data, high or unclear risk of bias of the studies and small study size. Authors' conclusions There is insufficient evidence to be able to support or refute the use of ghrelin in people with cancer cachexia. Adequately powered randomised controlled trials focusing on evaluation of safety and efficacy of ghrelin in people with cancer cachexia is warranted. Plain language summary Ghrelin, a hunger hormone for management of cancer patients with loss of appetite and weight loss Bottom line There is no good evidence to support or reject the suggestion that ghrelin is useful in the management of cancer patients with loss of appetite and weight loss. There is insufficient evidence to recommend it for clinical practice. Background Sixty to eighty percent of cancer patients suffer from loss of appetite and weight loss, which in turn is associated with decreased life expectancy and quality of life. Ghrelin, a hunger hormone is secreted by the stomach and other organs of the body. Studies have shown that ghrelin can be used in treatment for loss of appetite and weight loss in cancer patients. However, the effectiveness and safety of ghrelin in such people have not been assessed. In this review we set out to examine all evidence on the effectiveness and safety of ghrelin in improving appetite and body weight in cancer patients with loss of appetite and weight loss. Search date The evidence is current to 20th July 2017. Study characteristics We found three studies that recruited a total of 59 cancer patients (37 men and 22 women) aged between 54 and 78 years. Forty‐seven cancer patients completed the treatment. Studies differed in study design and included people with a variety of cancers. Studies also differed in dosage, route of injection, frequency and duration of treatment. One study compared ghrelin with a placebo while two studies compared different doses of ghrelin (higher dose with lower dose). Outcomes of interest to cancer patients with loss of appetite and weight loss, such as improvement in food intake and improvement in body weight, were not adequately reported. All three included studies were funded by government agencies. One study received an additional grant from a pharmaceutical company. Key findings We found insufficient evidence that using ghrelin demonstrated differences in food intake. We found no evidence that using ghrelin alone or in combination made any difference to body weight. We could not reach any conclusions about its side effects. The limited amount of information means that we could not draw any conclusions. Quality of the evidence We rated the quality of evidence from studies using four levels: high, moderate, low, or very low. High‐quality evidence means that we are very confident in the results. Very low‐quality evidence means that we are very uncertain about the results. The evidence in this review was of very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Khatib, MN; Shankar, AH; Kirubakaran, R; Gaidhane, A; Gaidhane, S; Simkhada, P; Quazi Syed, Z", "articleTypes": [], "doi": "10.1002/14651858.CD012229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "cc2188e8-3217-4ca1-8354-491c67f60e03", "pmid": "", "title": "Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users", "imported": false, "abstract": "Abstract - Background Prolonged treatment with benzodiazepines is common practice despite clinical recommendations of short‐term use. Benzodiazepines are used by approximately 4% of the general population, with increased prevalence in psychiatric populations and the elderly. After long‐term use it is often difficult to discontinue benzodiazepines due to psychological and physiological dependence. This review investigated if pharmacological interventions can facilitate benzodiazepine tapering. Objectives To assess the benefits and harms of pharmacological interventions to facilitate discontinuation of chronic benzodiazepine use. Search methods We searched the following electronic databases up to October 2017: Cochrane Drugs and Alcohol Group's Specialised Register of Trials, CENTRAL, PubMed, Embase, CINAHL, and ISI Web of Science. We also searched ClinicalTrials.gov, the WHO ICTRP, and ISRCTN registry, and checked the reference lists of included studies for further references to relevant randomised controlled trials. Selection criteria We included randomised controlled trials comparing pharmacological treatment versus placebo or no intervention or versus another pharmacological intervention in adults who had been treated with benzodiazepines for at least two months and/or fulfilled criteria for benzodiazepine dependence (any criteria). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 38 trials (involving 2543 participants), but we could only extract data from 35 trials with 2295 participants. Many different interventions were studied, and no single intervention was assessed in more than four trials. We extracted data on 18 different comparisons. The risk of bias was high in all trials but one. Trial Sequential Analysis showed imprecision for all comparisons. For benzodiazepine discontinuation, we found a potential benefit of valproate at end of intervention (1 study, 27 participants; risk ratio (RR) 2.55, 95% confidence interval (CI) 1.08 to 6.03; very low‐quality evidence) and of tricyclic antidepressants at longest follow���up (1 study, 47 participants; RR 2.20, 95% CI 1.27 to 3.82; low‐quality evidence). We found potentially positive effects on benzodiazepine withdrawal symptoms of pregabalin (1 study, 106 participants; mean difference (MD) ‐3.10 points, 95% CI ‐3.51 to ‐2.69; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐1.00 points, 95% CI ‐1.13 to ‐0.87; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐3.57 points, 95% CI ‐5.34 to ‐1.80; very low‐quality evidence), tricyclic antidepressants (1 study, 38 participants; MD ‐19.78 points, 95% CI ‐20.25 to ‐19.31; very low‐quality evidence), and flumazenil (3 studies, 58 participants; standardised mean difference ‐0.95, 95% CI ‐1.71 to ‐0.19; very low‐quality evidence) at end of intervention. However, the positive effect of paroxetine on benzodiazepine withdrawal symptoms did not persist until longest follow‐up (1 study, 54 participants; MD ‐0.13 points, 95% CI ‐4.03 to 3.77; very low‐quality evidence). The following pharmacological interventions reduced symptoms of anxiety at end of intervention: carbamazepine (1 study, 36 participants; MD ‐6.00 points, 95% CI ‐9.58 to ‐2.42; very low‐quality evidence), pregabalin (1 study, 106 participants; MD ‐4.80 points, 95% CI ‐5.28 to ‐4.32; very low‐quality evidence), captodiame (1 study, 81 participants; MD ‐5.70 points, 95% CI ‐6.05 to ‐5.35; very low‐quality evidence), paroxetine (2 studies, 99 participants; MD ‐6.75 points, 95% CI ‐9.64 to ‐3.86; very low‐quality evidence), and flumazenil (1 study, 18 participants; MD ‐1.30 points, 95% CI ‐2.28 to ‐0.32; very low‐quality evidence). Two pharmacological treatments seemed to reduce the proportion of participants that relapsed to benzodiazepine use: valproate (1 study, 27 participants; RR 0.31, 95% CI 0.11 to 0.90; very low‐quality evidence) and cyamemazine (1 study, 124 participants; RR 0.33, 95% CI 0.14 to 0.78; very low‐quality evidence). Alpidem decreased the proportion of participants with benzodiazepine discontinuation (1 study, 25 participants; RR 0.41, 95% CI 0.17 to 0.99; number needed to treat for an additional harmful outcome (NNTH) 2.3 participants; low‐quality evidence) and increased the occurrence of withdrawal syndrome (1 study, 145 participants; RR 4.86, 95% CI 1.12 to 21.14; NNTH 5.9 participants; low‐quality evidence). Likewise, magnesium aspartate decreased the proportion of participants discontinuing benzodiazepines (1 study, 144 participants; RR 0.80, 95% CI 0.66 to 0.96; NNTH 5.8; very low‐quality evidence). Generally, adverse events were insufficiently reported. Specifically, one of the flumazenil trials was discontinued due to severe panic reactions. Authors' conclusions Given the low or very low quality of the evidence for the reported outcomes, and the small number of trials identified with a limited number of participants for each comparison, it is not possible to draw firm conclusions regarding pharmacological interventions to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Due to poor reporting, adverse events could not be reliably assessed across trials. More randomised controlled trials are required with less risk of systematic errors ('bias') and of random errors ('play of chance') and better and full reporting of patient‐centred and long‐term clinical outcomes. Such trials ought to be conducted independently of industry involvement. Plain language summary Medications for discontinuation of long‐term benzodiazepine use Background Benzodiazepines are widely prescribed for long‐term use despite recommendations of only short‐term use. It is often difficult to discontinue benzodiazepines after more than a few weeks of treatment due to the development of physical and psychological dependence. This review aimed to assess the effect and safety of medications to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Search date The evidence is current to October 2017. Study characteristics We identified 38 randomised controlled trials involving 2543 participants who had either been treated for more than two months with benzodiazepines, or who had been diagnosed with benzodiazepine dependence. We included studies irrespective of whether benzodiazepines were prescribed for anxiety, insomnia, or any other condition. The average age of participants was around 50 years, and the majority of participants were women in most studies. Twenty‐four trials were conducted in Europe; eight trials in the US or Canada; and six trials in Asia. The trials involved a wide range of medications to facilitate reduction or discontinuation of benzodiazepine use. Fourteen of the 38 included studies were partly funded by the drug manufacturer; nine studies were funded by government agencies; and 15 studies did not state the source of funding. The duration of the trials ranged between 1 and 24 weeks; the average trial duration was 9 weeks. Key results We extracted data on 18 different comparisons in a total of 2295 participants. We are uncertain whether valproate and tricyclic antidepressants increase the chance of discontinuing benzodiazepines, and whether benzodiazepine withdrawal symptoms are reduced by pregabalin, captodiame, paroxetine, tricyclic antidepressants, and flumazenil, as we assessed the quality of the evidence as very low. We are uncertain as to whether symptoms of anxiety after withdrawal of benzodiazepines are reduced by carbamazepine, pregabalin, captodiame, paroxetine, and flumazenil, as we assessed the quality of the evidence as very low. The effects of the evaluated medications were too uncertain to inform clinical practice due to risk of bias (systematic errors with overestimation of benefits and underestimation of harms) and risk of chance occurrence (random errors giving any result). Tolerability and safety were poorly reported across the included studies, making it impossible to assess the balance between possible benefits and adverse effects. Consequently, no conclusions can be drawn about the effectiveness of the interventions. Quality of the evidence The quality of the evidence was generally low or very low due to the small number of trials including a limited number of participants for each comparison; dissimilar results across studies; poor study design; and pronounced financial involvement of the pharmaceutical industry. Randomised controlled trials are therefore needed without risk of bias and random significant results involving long‐term assessments of participants conducted without involvement of industry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Baandrup, L; Ebdrup, BH; Rasmussen, JØ; Lindschou, J; Gluud, C; Glenthøj, BY", "articleTypes": [], "doi": "10.1002/14651858.CD011481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "cc321d2e-8132-434b-a5cd-862d993e0d84", "pmid": "", "title": "Metformin for endometrial hyperplasia", "imported": false, "abstract": "Abstract - Background Endometrial cancer is one of the most common gynaecological cancers in the world. Rates of endometrial cancer are rising, in part because of rising obesity rates. Endometrial hyperplasia is a precancerous condition in women that can lead to endometrial cancer if left untreated. Endometrial hyperplasia occurs more commonly than endometrial cancer. Progesterone tablets that are currently used to treat women with endometrial hyperplasia are associated with adverse effects in up to 84% of women. A levonorgestrel intrauterine device may improve compliance, but it is invasive, is not acceptable to all women, and is associated with irregular vaginal bleeding in 82% of cases. Therefore, an alternative treatment for women with endometrial hyperplasia is needed. Metformin, a drug that is often used to treat people with diabetes, has been shown, in some human studies, to reverse endometrial hyperplasia. However, the effectiveness and safety of metformin for treatment of endometrial hyperplasia remain uncertain. This is an update of a review first published in 2017. Objectives To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia. Search methods We searched the Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, PubMed, Embase, Google Scholar, OpenGrey, LILACS, and two trials registers from inception to 5 September 2022. We searched the bibliographies of all relevant studies, and contacted experts in the field for any additional trials. Selection criteria We included randomised controlled trials (RCTs) and cross‐over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo, no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type. Data collection and analysis Two review authors independently assessed studies for eligibility, extracted data from included studies, assessed the risk of bias in the included studies, and assessed the certainty of the evidence for each outcome. We resolved disagreements by discussion or by deferring to a third review author. When study details were missing, review authors contacted the study authors. The primary outcome of this review was regression of endometrial hyperplasia histology (with or without atypia) towards normal histology. Main results We included seven RCTs, in which a total of 387 women took part. In the comparison, Metformin plus megestrol versus megestrol alone, we rated the certainty of the evidence as low for the outcome, regression of endometrial hyperplasia. We rated the quality of the evidence as very low for the rest of the outcomes, in all three comparisons. Although there was a low risk of selection bias, there was a high risk of bias in the blinding of personnel and outcome assessment (performance bias and detection bias) in many studies. This update identified four new RCTs and six ongoing RCTs. Metformin versus megestrol We are uncertain whether metformin increases the regression of endometrial hyperplasia towards normal histology over megestrol (odds ratio (OR) 4.89, 95% confidence interval (CI) 1.56 to 15.32; P = 0.006; 2 RCTs, 83 participants; I² = 7%; very low‐certainty evidence). This evidence suggests that if the rate of regression with megestrol is 61%, the rate of regression with metformin would be between 71% and 96%. It is unresolved whether metformin results in different rates of abnormal uterine bleeding or hysterectomy compared to megestrol. No study in this comparison reported progression of hyperplasia to endometrial cancer, recurrence of endometrial hyperplasia, health‐related quality of life, or adverse effects during treatment. Metformin plus megestrol versus megestrol monotherapy The combination of metformin and megestrol may enhance the regression of endometrial hyperplasia towards normal histology more than megestrol alone (OR 3.27, 95% CI 1.65 to 6.51; P = 0.0007; 4 RCTs, 258 participants; I² = 0%, low‐certainty evidence). This suggests that if the rate of regression with megestrol monotherapy is 54%, the rate of regression with the addition of metformin would be between 66% and 84%. In one study, 3/8 (37.5%) of participants who took metformin had nausea that settled without further treatment. It is unresolved whether the combination of metformin and megestrol results in different rates of recurrence of endometrial hyperplasia, progression of endometrial hyperplasia to endometrial cancer, or hysterectomy compared to megestrol monotherapy. No study in this comparison reported abnormal uterine bleeding, or health‐related quality of life. Metformin plus levonorgestrel (intrauterine system) versus levonorgestrel (intrauterine system) monotherapy We are uncertain whether there is a difference between groups in the regression of endometrial hyperplasia towards normal histology (OR 0.29, 95% CI 0.01 to 7.56; 1 RCT, 46 participants; very low‐certainty evidence). This evidence suggests that if the rate of regression with levonorgestrel monotherapy is 96%, the rate of regression with the addition of metformin would be between 73% and 100%. It is unresolved whether the combination of metformin and levonorgestrel results in different rates of abnormal uterine bleeding, hysterectomy, or the development of adverse effects during treatment compared to levonorgestrel monotherapy. No study in this comparison reported recurrence of endometrial hyperplasia, progression of hyperplasia to endometrial cancer, or health‐related quality of life. Authors' conclusions Review authors found insufficient evidence to either support or refute the use of metformin, specifically megestrol acetate, given alone or in combination with standard therapy, for the treatment of women with endometrial hyperplasia. Robustly designed and adequately powered randomised controlled trials, yielding long‐term outcome data are still needed to address this clinical question. Plain language summary Metformin for endometrial hyperplasia Review question Is metformin an effective and safe treatment for women with endometrial hyperplasia? Background Endometrial cancer (cancer of the lining of the womb) is a common cancer that affects the reproductive organs in women worldwide. Endometrial hyperplasia (thickening of the lining of the womb) is a precancerous condition in women that can lead to endometrial cancer if left untreated. Successful treatment of women with endometrial hyperplasia can prevent endometrial cancer. Endometrial hyperplasia is usually treated by providing progesterone hormone tablets, inserting a levonorgestrel‐releasing intrauterine system (LNG‐IUS) into the womb, advising women with extra weight to lose weight, or performing a hysterectomy for women who do not want a future pregnancy. However, progesterone tablets are associated with side effects in up to 84% of women, and this can prevent women from completing treatment. Also, progesterone tablets do not always work, and endometrial hyperplasia can return in up to 14% to 30% of women after treatment. The LNG‐IUS is associated with irregular vaginal bleeding in up to 82% of women. Many women find it painful to use, or find it otherwise unacceptable. Therefore, an alternative treatment for endometrial hyperplasia is required. Metformin, an oral tablet that is usually used to treat diabetes, has been shown to cure endometrial hyperplasia in some human studies. Although women taking metformin may experience side effects, treatment is usually well tolerated. If women experience fewer side effects when taking metformin rather than progesterone tablets, and if metformin effectively treats endometrial hyperplasia, women would be more willing to complete treatment, and the cure rate would improve. This could reduce the number of women who end up with endometrial cancer. However, the effectiveness and safety of metformin used to treat women with endometrial hyperplasia remain uncertain. Study characteristics We included seven randomised controlled trials in which a total of 387 women took part. Five studies compared metformin to megestrol (a form of progesterone), and one study compared metformin plus megestrol to megestrol alone. Women in all studies received treatment for three to six months. The evidence is current to 5 September 2022. Key results Studies on metformin alone versus megestrol alone provided insufficient evidence to show differences in effectiveness for curing endometrial hyperplasia. Studies on metformin plus megestrol versus megestrol alone found that metformin may improve the thickened walls of the womb, but the evidence is uncertain about other outcomes. One small study provided insufficient evidence to support or refute the use of metformin plus the LNG‐IUS or the LNG‐IUS alone. Certainty of the evidence We rated the certainty of the evidence as low to very‐low for all outcomes, because of limitations in the way the studies were designed, and small sample sizes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Shiwani, H; Clement, NS; Daniels, JP; Atiomo, W", "articleTypes": [], "doi": "10.1002/14651858.CD012214.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "cc607e53-7719-4b9d-a211-a7de499fe4d4", "pmid": "", "title": "Nitrous oxide‐based techniques versus nitrous oxide‐free techniques for general anaesthesia", "imported": false, "abstract": "Abstract - Background Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise. Objectives To determine if nitrous oxide‐based anaesthesia results in similar outcomes to nitrous oxide‐free anaesthesia in adults undergoing surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites ( http://clinicaltrials.gov/ , http://controlled‐trials.com/ , and http://www.centerwatch.com ). Selection criteria We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol‐based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay. Data collection and analysis Two review authors independently assessed trial quality and extracted the outcome data. We used meta‐analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed‐effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random‐effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Main results We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta‐analyses showed that nitrous oxide‐based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta‐analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide‐based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low. Authors' conclusions Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review. Plain language summary Nitrous oxide (laughing gas)‐based techniques versus nitrous oxide‐free techniques for general anaesthesia Review question We reviewed the evidence about the harmful effects of nitrous oxide on people undergoing general anaesthesia. Background Nitrous oxide is an anaesthetic gas which has been used for more than 160 years for inducing anaesthesia and keeping patients anaesthetized throughout an operation. It is also known as 'laughing gas'. It is a colourless non‐flammable gas with a pleasant, faint sweet odour and taste. Its low cost and low toxicity have made nitrous oxide by far the most commonly used general anaesthetic. However, some studies have reported that adding nitrous oxide may lead to harmful effects. This has led many anaesthetists to question its continued routine use in a variety of operating room settings. We wanted to discover whether using nitrous oxide in general anaesthesia was better or worse than not using nitrous oxide. Study characteristics We examined the evidence available up to 17 October 2014. We included 35 trials involving 13,872 adult participants, all of whom were randomized to either receive nitrous oxide or no nitrous oxide. The trials covered a variety of situations during general anaesthesia. Key results We found that general anaesthesia with nitrous oxide increased the risk of pulmonary atelectasis (i.e. failure of the lungs to expand fully). When we restricted the results to the highest quality studies only, we found evidence that nitrous oxide may potentially increase the risk of pneumonia and severe nausea and vomiting. However, nitrous oxide had no effect on the patients' survival, the incidence of heart attack, stroke, wound infection, the occurrence of blood clots within veins, the length of hospital stay, or the length of intensive care unit stay. Quality of the evidence The evidence related to survival of participants was of moderate quality because we did not have enough data. The evidence related to some harmful effects, such as failure of the lungs to expand fully and heart attack, was of high quality, while for other harmful effects, such as stroke and the occurrence of blood clots within veins, the evidence was of moderate quality. For others, such as pneumonia, severe nausea and vomiting, and wound infection, the evidence was of low quality. The evidence related to the length of time spend in hospital was of moderate quality. Authors conclusions The avoidance of nitrous oxide may be reasonable in participants with pre‐existing poor pulmonary function or at high risk of postoperative nausea and vomiting.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Sun, R; Jia, WQ; Zhang, P; Yang, K; Tian, JH; Ma, B; Liu, Y; Jia, RH; Luo, XF; Kuriyama, A", "articleTypes": [], "doi": "10.1002/14651858.CD008984.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "cc66e858-bf9e-421d-94dc-c5dc6391314a", "pmid": "", "title": "Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease", "imported": false, "abstract": "Abstract - Background Catheter malfunction, including thrombosis, is associated with reduced dialysis adequacy, as well as an increased risk of catheter‐related bacteraemia and mortality. The role of anticoagulants in the prevention of catheter malfunction remains uncertain. Objectives This review aimed to compare the prophylactic effect of different anticoagulant agents, preparations, doses and administration on the incidence of central venous haemodialysis catheter‐related malfunction and sepsis in patients with end‐stage kidney disease (ESKD). Search methods We searched the Cochrane Renal Group's Specialised Register to 7 January 2016 through contact with the Trials' Search Co‐ordinator using search terms relevant to this review. Selection criteria We included all randomised controlled trials (RCT) assessing anticoagulants compared with conventional care for the prevention of catheter malfunction in adult patients receiving haemodialysis for ESKD. Data collection and analysis The primary outcome was catheter malfunction defined as a catheter blood flow of 200 mL/min or less, or as defined by study authors. Secondary outcomes were catheter‐related bacteraemia, all‐cause mortality and bleeding events. Relative risks (RR) with 95% confidence intervals (CI) for individual studies were pooled using random effects models within treatment classes. Analyses were conducted by class, with subgroup analyses performed of individual agents within classes. Main results We included 27 studies (3003 participants) that were followed up for a median of six months. Study interventions included alternative anticoagulant locking solutions (19 studies, 2216 patients), systemic agents (6 studies, 664 patients) and low or no dose heparin (2 studies, 123 patients). The most common comparison treatment was a locking solution of heparin 5000 IU/mL, used in 17 studies. No significant effect on catheter malfunction was observed for alternative anticoagulant locking solutions (RR 0.96, 95% CI 0.74 to 1.26), systemic agents (RR 0.59, 95% CI 0.28 to 1.23), or low or no dose heparin (RR 0.90, 95% CI 0.10 to 8.31). A significant reduction on incidence of catheter‐related bacteraemia was observed for alternative anticoagulant locking solutions (RR 0.46, 95% CI 0.32 to 0.66) but not systemic agents (RR 2.41, 95% CI 0.89 to 6.55), and could not be assessed in reports of low or no dose heparin studies. No significant effect on all‐cause mortality was observed for alternative anticoagulant locking solutions (RR 0.88, 95% CI 0.54 to 1.43) or systemic agents (RR 0.78, 95% CI 0.37 to 1.65), and was not reported in studies of low or no dose heparin. Bleeding events were only reported in eight studies, including only 2/5 studies of systemic warfarin, with no clear effect demonstrated (RR 1.43, 95% CI 0.86 to 2.39). For individual agents, recombinant tissue plasminogen (rt‐PA) was the only locking solution shown to reduce catheter malfunction (RR 0.58, 95% CI 0.37 to 0.91) based on the results of a single study. No significant on catheter malfunction was observed for other individual classes of alternative anticoagulant locking solutions (citrate: RR 1.14, 95% CI 0.76 to 1.69; antibiotic: RR 1.48, 95% CI 0.79 to 2.77; ethanol: RR 0.88, 95% CI 0.21 to 3.67). On the other hand, all individual classes of alternative anticoagulant locking solutions, except ethanol, reduced catheter‐related bacteraemia (citrate: RR 0.49, 95% CI 0.36 to 0.68; antibiotic: RR 0.27, 95% CI 0.11 to 0.70; rt‐PA: RR 0.35, 95% CI 0.13 to 0.93; ethanol: RR 0.33, 95% CI 0.03 to 4.05). No significant effect on all‐cause mortality was observed for any individual agent within the class of alternative locking solutions. Studies were mainly of low quality and underpowered with an average participant number of 75 and study duration of six months. The interpretation of the study evidence was further limited by the variation in tested interventions and outcome reporting. Authors' conclusions The relative net benefit of anticoagulant therapies for prevention of catheter malfunction remains uncertain. Multiple agents appear to reduce catheter‐related bacteraemia although the lack of clear assessment of harms and the limitations of study quality mean these results should be interpreted with caution. Methodological approaches can be used to avoid methods of reporting unduly affecting on the results of meta‐analyses incorporating studies employed mixed reporting methods. Further high quality randomised studies, including safety outcomes, are needed. Plain language summary Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease Background Patients with end‐stage kidney disease require vascular access during haemodialysis. Central venous haemodialysis catheters are frequently used when permanent vascular access is not available. Catheter problems contribute to greater morbidity and mortality. Catheter malfunction leads to requirements for additional interventions, increased risk of catheter‐related infection and hospitalisation. Standard care for the prevention of catheter malfunction is the use of heparin solutions as a post dialysis ‘lock’ in the catheter ports. The potential impact of heparin treatment on bleeding risk is an acknowledged concern. Therefore newer approaches have been proposed to seek improvements in catheter patency or treatment‐associated harm rates. Study characteristics This review focused on randomised controlled trials (RCTs) of anticoagulants compared with conventional care for the prevention of catheter malfunction patients receiving haemodialysis. Key results We found 27 studies, involving 3003 patients followed for an average six months, which assessed alternative anticoagulant locking solutions, systemic agents and low or no dose heparin. Catheter malfunction were not affected by any of these classes of agents. Subgroup analysis showed that the only agent reducing catheter malfunction was recombinant tissue plasminogen locking solution based on the results of a single study. A significant reduction was observed on the incidence of catheter‐related bacteraemia for alternative anticoagulant locking solutions. There was no evidence to suggest that alternative anticoagulants to heparin locking solutions had an effect on death rates or bleeding events, although only a small proportion of studies reported bleeding events. Quality of the evidence Further high quality information is needed on both potential benefits and safety of alternative approaches to maintaining dialysis access catheter function.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Wang, Y; Ivany, JN; Perkovic, V; Gallagher, MP; Woodward, M; Jardine, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD009631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "cc6f27cc-eaaa-46a3-8d56-060d98f5e8ec", "pmid": "", "title": "Combined aclidinium bromide and long‐acting beta2‐agonist for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Several dual bronchodilator combinations of long‐acting beta 2 ‐agonist (LABA) and long‐acting muscarinic antagonist (LAMA) have been approved for treatment of stable chronic obstructive pulmonary disease (COPD). The current GOLD (Global Initiative for Chronic Obstructive Lung Disease) recommendations suggest the use of LABA/LAMA combinations in people with group B COPD with persistent symptoms, group C COPD with further exacerbations on LAMA therapy alone and group D COPD with or without inhaled corticosteroids (ICS). Fixed‐dose combination (FDC) of aclidinium/formoterol is one of the approved LABA/LAMA therapies for people with stable COPD. Objectives To assess the efficacy and safety of combined aclidinium bromide and long‐acting beta 2 ‐agonists in stable COPD. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov, World Health Organization (WHO) trials portal, United States Food and Drug Administration (FDA) and manufacturers' websites as well as the reference list of published trials up to 12 October 2018. Selection criteria Parallel‐group randomised controlled trials (RCTs) assessing combined aclidinium bromide and LABAs in people with stable COPD. Data collection and analysis We used standard methodological procedures expected by Cochrane for data collection and analysis. The primary outcomes were exacerbations requiring a short course of an oral steroid or antibiotic, or both; quality of life measured by a validated scale and non‐fatal serious adverse events (SAEs). Where the outcome or study details were not reported, we contacted the study investigators or pharmaceutical company trial co‐ordinators (or both) for missing data. Main results We identified RCTs comparing aclidinium/formoterol FDC versus aclidinium, formoterol or placebo only. We included seven multicentre trials of four to 52 weeks' duration conducted in outpatient settings. There were 5921 participants, whose mean age ranged from 60.7 to 64.7 years, mostly men with a mean smoking pack‐years of 46.4 to 61.3 of which 43.9% to 63.4% were current smokers. They had a moderate‐to‐severe degree of COPD with a mean postbronchodilator forced expiratory volume in one second (FEV 1 ) between 50.5% and 61% of predicted normal and the baseline mean FEV 1 of 1.23 L to 1.43 L. We assessed performance and detection biases as low for all studies whereas selection, attrition and reporting biases were either low or unclear. FDC versus aclidinium There was no evidence of a difference between FDC and aclidinium for exacerbations requiring steroids or antibiotics, or both (OR 0.95, 95% CI 0.71 to 1.27; 2 trials, 2156 participants; moderate‐certainty evidence); quality of life measured by St George's Respiratory Questionnaire (SGRQ) total score (MD –0.92, 95% CI –2.15 to 0.30); participants with significant improvement in SGRQ score (OR 1.17, 95% CI 0.97 to 1.41; 2 trials, 2002 participants; moderate‐certainty evidence); non‐fatal SAE (OR 1.19, 95% CI 0.79 to 1.80; 3 trials, 2473 participants; moderate‐certainty evidence); hospital admissions due to severe exacerbations (OR 0.62, 95% CI 0.29 to 1.29; 2 trials, 2156 participants; moderate‐certainty evidence) or adverse events (OR 0.95, 95% CI 0.76 to 1.18; 3 trials, 2473 participants; moderate‐certainty evidence). Compared with aclidinium, FDC improved symptoms (Transitional Dyspnoea Index (TDI) focal score: MD 0.37, 95% CI 0.07 to 0.68; 2 trials, 2013 participants) with a higher chance of achieving a minimal clinically important difference (MCID) of at least one unit improvement (OR 1.34, 95% CI 1.11 to 1.62; high‐certainty evidence); the number needed to treat for an additional beneficial outcome (NNTB) being 14 (95% CI 9 to 39). FDC versus formoterol When compared to formoterol, combination therapy reduced exacerbations requiring steroids or antibiotics, or both (OR 0.78, 95% CI 0.62 to 0.99; 3 trials, 2694 participants; high‐certainty evidence); may decrease SGRQ total score (MD –1.88, 95% CI –3.10 to –0.65; 2 trials, 2002 participants; low‐certainty evidence; MCID for SGRQ is 4 units); increased TDI focal score (MD 0.42, 95% CI 0.11 to 0.72; 2 trials, 2010 participants) with more participants attaining an MCID (OR 1.30, 95% CI 1.07 to 1.56; high‐certainty evidence) and an NNTB of 16 (95% CI 10 to 60). FDC lowered the risk of adverse events compared to formoterol (OR 0.78, 95% CI 0.65 to 0.93; 5 trials, 3140 participants; high‐certainty evidence; NNTB 22). However, there was no difference between FDC and formoterol for hospital admissions, all‐cause mortality and non‐fatal SAEs. FDC versus placebo Compared with placebo, FDC demonstrated no evidence of a difference in exacerbations requiring steroids or antibiotics, or both (OR 0.82, 95% CI 0.60 to 1.12; 2 trials, 1960 participants; moderate‐certainty evidence) or hospital admissions due to severe exacerbations (OR 0.55, 95% CI 0.25 to 1.18; 2 trials, 1960 participants; moderate‐certainty evidence), although estimates were uncertain. Quality of life measure by SGRQ total score was significantly better with FDC compared to placebo (MD –2.91, 95% CI –4.33 to –1.50; 2 trials, 1823 participants) resulting in a corresponding increase in SGRQ responders who achieved at least four units decrease in SGRQ total score (OR 1.72, 95% CI 1.39 to 2.13; high‐certainty evidence) with an NNTB of 7 (95% CI 5 to 12). FDC also improved symptoms measured by TDI focal score (MD 1.32, 95% CI 0.96 to 1.69; 2 studies, 1832 participants) with more participants attaining at least one unit improvement in TDI focal score (OR 2.51, 95% CI 2.02 to 3.11; high‐certainty evidence; NNTB 4). There were no differences in non‐fatal SAEs, adverse events and all‐cause mortality between FDC and placebo. Combination therapy significantly improved trough FEV 1 compared to aclidinium, formoterol or placebo. Authors' conclusions FDC improved dyspnoea and lung function compared to aclidinium, formoterol or placebo, and this translated into an increase in the number of responders on combination treatment. Quality of life was better with combination compared to formoterol or placebo. There was no evidence of a difference between FDC and monotherapy or placebo for exacerbations, hospital admissions, mortality, non‐fatal SAEs or adverse events. Studies reported a lower risk of moderate exacerbations and adverse events with FDC compared to formoterol; however, larger studies would yield a more precise estimate for these outcomes. Plain language summary Are combined aclidinium and long‐acting beta 2 ‐agonist inhalers effective and safe for people with stable COPD? Background Chronic obstructive pulmonary disease (COPD) is a disease of the lungs that causes airways to narrow. As a result, people with COPD experience symptoms of breathlessness and cough with sputum production which worsen over time. It is mainly caused by smoking or inhaling dust. In people with COPD, inhalers that contain medicines to widen the airways are generally given to relieve symptoms. Long‐acting medicines whose action lasts for at least half a day or one day are preferred. Aclidinium and formoterol (a long‐acting beta 2 ‐agonist medicine) are such inhalers. We wanted to find out how a combination of aclidinium and long‐acting beta 2 ‐agonist fare against either inhaler alone and dummy (placebo) inhaler. Study characteristics We could only identify studies on aclidinium and formoterol combination and included seven studies involving 5921 people with COPD which ranged from four weeks to one year long. Most participants were men in their 60s, moderate‐to‐heavy smokers, around half of whom were current smokers. They had moderate‐to‐severe symptoms of COPD when they started treatment. People in the studies took either combined inhalers containing aclidinium and formoterol or aclidinium or formoterol or placebo through a similar inhaler. Both people doing the research and people in the study did not know which treatment participants were getting. The conclusions of this review are current to October 2018. Key results People taking combined inhaler and aclidinium inhaler were not different in terms of flare‐ups that need additional medicines, quality of life, hospitalisations, side effects or serious side effects. However, they were less breathless than those taking aclidinium inhaler. Fourteen people with COPD would need to be treated with combined inhalers to have one additional person with a clinically significant improvement in breathlessness. People on combined inhalers were likely to have fewer flare‐ups, side effects and symptoms and a better quality of life compared to those taking formoterol inhaler. But, there was little or no difference in hospital admissions due to severe flare‐ups, serious side effects or the risk of dying. When compared to dummy inhalers, people taking combined inhalers experienced less breathlessness and better quality of life. Seven people with COPD would need to be treated with combined inhaler to achieve a significant improvement in quality of life than dummy inhaler. For flare‐ups, hospital admissions, side effects, serious side effects and death, there was no difference between combined and dummy inhalers. The lungs worked better in people taking combined inhalers than those taking only one drug or dummy inhaler. Quality of the evidence We had to interpret the results carefully as all the included studies were sponsored by pharmaceutical companies, which could have led to bias. However, the included studies were generally conducted in a systematic and acceptable manner. We are confident that combined inhalers are more effective than single or dummy inhalers at improving breathlessness and lung function. However, we are less certain about its effects on flare‐ups, hospital admissions, quality of life and side effects. Conclusion Combined inhalers are more effective than individual or dummy inhalers for relieving breathlessness and improving lung performance. They also lead to better quality of life than formoterol or dummy inhalers. However, they are not different from individual or dummy inhalers in terms of flare‐ups or hospital admissions. These combined inhalers have similar safety profiles as individual or dummy inhalers in terms of death, side effects or serious side effects. Combined inhalers probably had lesser side effects and moderate flare‐ups than formoterol, but further studies are needed to confidently support this finding. In summary, the combined inhalers are an effective option for treatment of COPD and appear to have a similar safety profile to individual or dummy inhalers.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Ni, H; Moe, S; Soe, Z; Myint, KT; Viswanathan, KN", "articleTypes": [], "doi": "10.1002/14651858.CD011594.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "cc912b32-5bef-4917-84b8-98d7acefa436", "pmid": "", "title": "Etude du contrôle hédonique de la Prise Alimentaire Par l'Analyse Des Potentiels évoqués Gustatifs", "imported": false, "abstract": "Taste perception plays an important role in maintaining nutritional balance. Gustatory evoked potentials (GEP) can be detected in response to an intermittent stimulation of the gustatory receptors by a primary flavour. GEP are non invaisve, painless and safe.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "cc912e01-68c2-4793-9b37-4aaf8633da9d", "pmid": "", "title": "Dietary advice with or without oral nutritional supplements for disease‐related malnutrition in adults", "imported": false, "abstract": "Abstract - Background Disease‐related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social‐care costs. Dietary advice (DA) encouraging consumption of energy‐ and nutrient‐rich foods rather than oral nutritional supplements (ONS) may be an initial treatment. Objectives To examine evidence that DA with/without ONS in adults with disease‐related malnutrition improves survival, weight, anthropometry and quality of life (QoL). Search methods We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021. Selection criteria Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease‐related malnutrition in any healthcare setting compared with no advice, ONS or DA alone. Data collection and analysis Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence. Main results We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity. Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years. DA versus no advice ‐ 24 RCTs (3523 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three‐month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI ‐0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat‐free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS ‐ 12 RCTs (852 participants) All outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD ‐0.14 kg (95% CI ‐2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS ‐ 22 RCTs (1286 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD ‐1.07 (95% CI ‐4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS ‐ 31 RCTs (3308 participants) Evidence was moderate‐ to low‐certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD ‐0.12 (95% CI ‐2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS ‐ 13 RCTs (1315 participants) Evidence was low‐ to very low‐certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD ‐1.81 (95% CI ‐3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI ‐0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point. Authors' conclusions We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow‐up required for benefits to emerge were inconsistent for all other outcomes. There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient‐centred and healthcare outcomes are needed to address the questions in this review. Plain language summary Advice on diet for adults with malnutrition that is the result of disease Review question Can dietary advice with or without oral nutritional supplements (ONS) improve disease‐related malnutrition in adults? Background Ill people often have a poor appetite or feel sick because of medicines or other treatments and eat less than usual. Eating less over a longer time can cause weight loss, malnutrition, more health problems and death. Healthcare professionals may offer advice about dietary changes to help people to re‐establish good eating habits. They might recommend high‐protein and high‐energy foods so that these people can gain weight and improve their nutrition and general health. It is common for sick people to be offered ONS with or without advice about changing their food intake. To find the best answer to our review question, we looked for studies that compared five different treatment options: dietary advice compared with no advice; dietary advice compared with ONS; dietary advice plus ONS compared with dietary advice; dietary advice plus ONS if appropriate compared with no dietary advice; and dietary advice plus ONS compared with no dietary advice and no ONS. To make these comparisons fair, we looked for randomised controlled trials (RCTs), where the people taking part had an equal chance (like the flip of a coin) of being in either group that was being compared. Search date The evidence is current to: 01 March 2021. Study characteristics We found 94 studies (with a total of 10,284 people) that we could include in our review. Although older people have a higher risk of malnutrition, the people in these studies ranged from 17 to over 80 years of age and they were living either at home, in the community, or in hospital. They had a wide range of health conditions, including cancer, dementia and kidney disease. The studies reported on the participants for the length of their hospital stay or in some people in the community for up to six and a half years. Key results There is no evidence that any of the treatments affected how long many of the people in the studies lived. They did report some positive changes in energy intake (measured in calories), protein intake, weight, muscle bulk and quality of life. There were some reductions in complications and the length of time spent in hospital. However, there is no clear evidence about which treatment is the most helpful or the time it takes to achieve any benefit. Few studies reported results separately for men and women and so we cannot comment on whether there were any overall differences by sex. No studies recorded information about adverse events (harms) so we cannot offer a summary about possible harms. More research is needed to work out the best ways to help people who are losing weight because of illness in order to improve their clinical outcomes and quality of life. Certainty of the evidence Overall we rated the certainty of the evidence as low for most results, which means that we cannot be confident about the findings we report. There were several reasons for this. Some of the treatment comparisons that we looked at had only a few studies and some of those had small numbers of participants. There were problems with the design of some studies that may have affected the results. Some people knew which treatment they were receiving. We think this may influence the way that they reported some changes, e.g. their energy and protein intake, body weight and quality of life. We think that the way the decision about which group a person went into at the start of the study may have affected the results for some outcomes, e.g. change in weight, change in muscle bulk and mortality. We needed to see particular results to help us understand whether adults living with disease‐related malnutrition can improve their survival, weight and general quality of life if they receive advice about diet with or without ONS. None of the studies reported all of the results that we needed to do this. We were not able to estimate whether participants gain any benefits from the treatments, such as shortening the length of hospital stay, lowering the risk of readmission to hospital or developing complications. The low certainty of evidence, with no evidence in many areas, means we cannot make statements about any benefits and the possible disadvantages of these treatments despite the fact they are being used extensively in clinical practice. We recommend that future studies should be designed to measure these important patient‐centred and healthcare outcomes as well as any potential harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Baldwin, C; de van der Schueren, MAE; Kruizenga, HM; Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD002008.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "cc96e4a4-d60c-4221-8bf0-1566f9d567c7", "pmid": "", "title": "Interventions to prevent obesity in children aged 12 to 18 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or ‘activity’ levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review. Objectives To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta‐analyses. Sixty studies were based in high‐income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty‐one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short‐term follow‐up (mean difference (MD) ‐0.18, 95% confidence interval (CI) ‐0.41 to 0.06; 3 studies, 605 participants), medium‐term follow‐up (MD ‐0.65, 95% CI ‐1.18 to ‐0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long‐term follow‐up (MD ‐0.14, 95% CI ‐0.38 to 0.10; 2 studies, 1089 participants); all very low‐certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long‐term follow‐up (MD ‐0.30, 95% CI ‐1.67 to 1.07; 1 study, 44 participants); zBMI at short‐term (MD ‐0.06, 95% CI ‐0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium‐term (MD 0.02, 95% CI ‐0.17 to 0.21; 1 study, 112 participants) follow‐up; all low‐certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low‐certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short‐term follow‐up (MD ‐0.64, 95% CI ‐1.86 to 0.58; 6 studies, 1780 participants; low‐certainty evidence) and probably do not reduce zBMI at medium‐ (MD 0, 95% CI ‐0.04 to 0.05; 6 studies, 5335 participants) or long‐term (MD ‐0.05, 95% CI ‐0.12 to 0.02; 1 study, 985 participants) follow‐up; both moderate‐certainty evidence. Activity interventions do not reduce zBMI at short‐term follow‐up (MD 0.02, 95% CI ‐0.01 to 0.05; 7 studies, 4718 participants; high‐certainty evidence), but may reduce BMI slightly at medium‐term (MD ‐0.32, 95% CI ‐0.53 to ‐0.11; 3 studies, 2143 participants) and long‐term (MD ‐0.28, 95% CI ‐0.51 to ‐0.05; 1 study, 985 participants) follow‐up; both low‐certainty evidence. Seven studies (5428 participants; low‐certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short‐term follow‐up (MD 0.03, 95% CI ‐0.07 to 0.13; 11 studies, 3429 participants; high‐certainty evidence), and probably do not reduce BMI at medium‐term (MD 0.01, 95% CI ‐0.09 to 0.11; 8 studies, 5612 participants; moderate‐certainty evidence) or long‐term (MD 0.06, 95% CI ‐0.04 to 0.16; 6 studies, 8736 participants; moderate‐certainty evidence) follow‐up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD ‐0.09, 95% CI ‐0.2 to 0.02; 3 studies, 515 participants; very low‐certainty evidence), and they may not reduce zBMI at medium‐term (MD ‐0.05, 95% CI ‐0.1 to 0.01; 6 studies, 3511 participants; low‐certainty evidence) or long‐term (MD ‐0.02, 95% CI ‐0.05 to 0.01; 7 studies, 8430 participants; low‐certainty evidence) follow‐up. Four studies (2394 participants) reported data on serious adverse events (very low‐certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect. Authors' conclusions The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low‐certainty evidence that activity interventions may have a small beneficial effect on BMI at medium‐ and long‐term follow‐up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples. Plain language summary Do dietary and activity strategies help prevent obesity in children and young people aged 12 to 18 years? Key messages ‐ Strategies to encourage adolescents to change their diet or activity levels (or both), to prevent them becoming overweight or developing obesity make no or very little difference to their body mass index (BMI; an estimate of the amount of body fat according to height and weight). ‐ Based on the very little information available about serious adverse events, there appears to be little or no effect of dietary or activity strategies, or both, to results in serious harms (e.g. injuries). ‐ Due to a lack of evidence, future research should focus on community settings (e.g. in youth clubs) and research involving adolescents with disabilities. Why is preventing obesity in children and young people important? More adolescents are developing overweight and obesity worldwide. Being overweight as an adolescent can cause health problems, and people may be affected psychologically and in their social life. Puberty and moving into adulthood is a challenging time, and many struggle with their mental health. Overweight adolescents are likely to be overweight or obese as adults and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help adolescents modify their diet or activity (or both) were effective at preventing obesity. We also wanted to know if these strategies were associated with any serious harms. What did we do? We searched scientific databases for studies that looked at ways of preventing obesity in children aged 12 to 18 years. We excluded studies aimed at adolescents who were already overweight or living with obesity. However, we included studies where the sample was a whole group (e.g. a school), which may have included those living with overweight or obesity. We only included studies if the methods they used aimed to change the children's diet, their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed children into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 74 studies involving 83,407 children and young people. Sixty studies were based in high‐income countries (e.g. USA and in Europe). In 57 studies, the strategies were tried in schools, although 12 were based at home or other places like community settings (five studies) such as youth groups. Fifty‐one strategies were implemented for fewer than nine months; the shortest intervention lasted one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five studies were partly funded by industry (food suppliers, a PlayStation manufacturer, a gym equipment supplier, a healthcare device manufacturer and a private healthcare facility). Our analyses included results from 54 studies of 46,358 adolescents (20 studies did not report their results in a way that could be included in our analyses). We found that adolescents who were helped with a strategy to change their diet or activity levels (or both) either did not reduce their BMI, or any reduction was meagre, compared to adolescents who were not given a strategy. Only a few studies reported any possible harms of the interventions, and none identified serious harms. What are the limitations of the evidence? Overall, we have limited confidence in the beneficial effects of these interventions in preventing obesity in children and adolescents. It is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. Many studies had limitations in how they were done (e.g. in some studies, the methods used to randomly place people into groups were not adequate or the results of some of the studies were not analysed correctly). 3. There were not enough studies reporting particular types of outcomes, such as BMI (an estimate of the amount of body fat according to height and weight) or zBMI (comparison of a child’s BMI with other children of the same age and sex) for a particular duration of follow‐up to be certain about the results for some comparisons. Also, certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way that we could include them in our analyses (e.g. without any detail of the difference in change between the intervention and control groups) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for adolescents with disabilities, or whether those implemented in community settings are effective. How up to date is this evidence? This review supersedes our previous review. The evidence is up‐to‐date until February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F, Tomlinson, E, Davies, AL, Moore, THM, Dawson, S, Breheny, K, Savović, J, Hodder, RK, Wolfenden, L, Higgins, JPT, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015330.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.786Z" }, { "id": "cca7c12f-fc55-4166-9279-5d17abe8a481", "pmid": "", "title": "Preprocedural mouth rinses for preventing transmission of infectious diseases through aerosols in dental healthcare providers", "imported": false, "abstract": "Abstract - Background Aerosols and spatter are generated in a dental clinic during aerosol‐generating procedures (AGPs) that use high‐speed hand pieces. Dental healthcare providers can be at increased risk of transmission of diseases such as tuberculosis, measles and severe acute respiratory syndrome (SARS) through droplets on mucosae, inhalation of aerosols or through fomites on mucosae, which harbour micro‐organisms. There are ways to mitigate and contain spatter and aerosols that may, in turn, reduce any risk of disease transmission. In addition to personal protective equipment (PPE) and aerosol‐reducing devices such as high‐volume suction, it has been hypothesised that the use of mouth rinse by patients before dental procedures could reduce the microbial load of aerosols that are generated during dental AGPs. Objectives To assess the effects of preprocedural mouth rinses used in dental clinics to minimise incidence of infection in dental healthcare providers and reduce or neutralise contamination in aerosols. Search methods We used standard, extensive Cochrane search methods. The latest search date was 4 February 2022. Selection criteria We included randomised controlled trials and excluded laboratory‐based studies. Study participants were dental patients undergoing AGPs. Studies compared any preprocedural mouth rinse used to reduce contaminated aerosols versus placebo, no mouth rinse or another mouth rinse. Our primary outcome was incidence of infection of dental healthcare providers and secondary outcomes were reduction in the level of contamination of the dental operatory environment, cost, change in mouth microbiota, adverse events, and acceptability and feasibility of the intervention. Data collection and analysis Two review authors screened search results, extracted data from included studies, assessed the risk of bias in the studies and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random‐effects meta‐analysis to combine data Main results We included 17 studies with 830 participants aged 18 to 70 years. We judged three trials at high risk of bias, two at low risk and 12 at unclear risk of bias. None of the studies measured our primary outcome of the incidence of infection in dental healthcare providers. The primary outcome in the studies was reduction in the level of bacterial contamination measured in colony‐forming units (CFUs) at distances of less than 2 m (intended to capture larger droplets) and 2 m or more (to capture droplet nuclei from aerosols arising from the participant's oral cavity). It is unclear what size of CFU reduction represents a clinically significant amount. There is low‐ to very low‐certainty evidence that chlorhexidine (CHX) may reduce bacterial contamination, as measured by CFUs, compared with no rinsing or rinsing with water. There were similar results when comparing cetylpyridinium chloride (CPC) with no rinsing and when comparing CPC, essential oils/herbal mouthwashes or boric acid with water. There is very low‐certainty evidence that tempered mouth rinses may provide a greater reduction in CFUs than cold mouth rinses. There is low‐certainty evidence that CHX may reduce CFUs more than essential oils/herbal mouthwashes. The evidence for other head‐to‐head comparisons was limited and inconsistent. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or adverse events such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess acceptability of the intervention to patients or feasibility of implementation for dentists. Authors' conclusions None of the included studies measured the incidence of infection among dental healthcare providers. The studies measured only reduction in level of bacterial contamination in aerosols. None of the studies evaluated viral or fungal contamination. We have only low to very low certainty for all findings. We are unable to draw conclusions regarding whether there is a role for preprocedural mouth rinses in reducing infection risk or the possible superiority of one preprocedural rinse over another. Studies are needed that measure the effect of rinses on infectious disease risk among dental healthcare providers and on contaminated aerosols at larger distances with standardised outcome measurement. Plain language summary Does use of mouth rinse before a dental procedure reduce the risk of infection transmission from patient to health professional? Why is this question important? Many dental procedures generate droplets that settle on a surface quickly. If high‐speed instruments, such as a drill, are used, aerosols are generated, which consist of tiny particles that remain suspended in the air and that can be inhaled or that settle farther away on surfaces. These aerosols contain a variety of micro‐organisms and may transmit infections either through direct contact or indirectly through the contaminated surfaces. To prevent the spread of infection, it may help to reduce the number of micro‐organisms that are present in these aerosols. The use of mouth rinses before a dental procedure ('preprocedural mouth rinse') has been suggested as a possible way to reduce the amount of contamination of these aerosols. Chlorhexidine, povidone iodine and cetylpyridinium chloride (CPC) are some of the commonly used mouth rinses. They act by killing or inactivating the micro‐organisms in the mouth and thereby reducing the level of contamination in the aerosol that is generated. We wanted to find out whether rinsing the mouth before a dental procedure reduces the contamination of aerosols produced during dental procedures in practice and helps prevent the transmission of infectious diseases. How did we identify and evaluate the evidence? We searched for all relevant studies that compared mouth rinses used before dental procedures against placebo (fake treatment), no intervention or another mouth rinse considered to be inactive. We then compared the results, and summarised the evidence from all the studies. Finally, we assessed our confidence in the evidence. To do this, we considered factors such as the way studies were conducted, study sizes and consistency of findings across studies. What did we find? We found 17 studies that met our inclusion criteria. These studies used chlorhexidine, CPC, essential oil/herbal mouth rinses, povidone iodine and boric acid in comparison to no rinsing, or rinsing with water, saline (salt water) or another mouth rinse. None of the studies measured the how often dental healthcare providers became infected with micro‐organisms. All the included studies measured the level of bacterial contamination in droplets or aerosols in the dental clinic. They did not examine contamination with viruses or fungi. Most rinses decreased bacterial contamination in aerosols to some extent, but there was considerable variation in the effects and we do not know what size of reduction is necessary to reduce infection risk. The studies did not provide any information on costs, change in micro‐organisms in the patient's mouth or side effects such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess whether patients were happy to use a mouth rinse or whether it was easy for dentists to implement. Overall, the results suggest that using a preprocedural mouth rinse may reduce the level of bacterial contamination in aerosols compared with no rinsing or rinsing with water, but we have only low or very low certainty that the evidence is reliable and we do not know how this reduction in contamination relates to the risk of infection. What does this mean? We have very little confidence in the evidence, and further studies may change the findings of our review. No studies measured infection risk or investigated viral or fungal contamination. How up‐to‐date is this review? The evidence in this Cochrane Review is current to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kumbargere Nagraj, S; Eachempati, P; Paisi, M; Nasser, M; Sivaramakrishnan, G; Francis, T; Verbeek, JH", "articleTypes": [], "doi": "10.1002/14651858.CD013826.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "ccdfca5e-1cda-4d49-b19f-f369ad2dc426", "pmid": "", "title": "Inhaled hyperosmolar agents for bronchiectasis", "imported": false, "abstract": "Abstract - Background Mucus retention in the lungs is a prominent feature of bronchiectasis. The stagnant mucus becomes chronically colonised with bacteria, which elicit a host neutrophilic response. This fails to eliminate the bacteria, and the large concentration of host‐derived protease may contribute to the airway damage. The sensation of retained mucus is itself a cause of suffering, and the failure to maintain airway sterility probably contributes to the frequent respiratory infections experienced by many patients. Hypertonic saline inhalation is known to accelerate tracheobronchial clearance in many conditions, probably by inducing a liquid flux into the airway surface, which alters mucus rheology in a way favourable to mucociliary clearance. Inhaled dry powder mannitol has a similar effect. Such agents are an attractive approach to the problem of mucostasis, and deserve further clinical evaluation. Objectives To determine whether inhaled hyperosmolar substances are effective in the treatment of bronchiectasis. Search methods We searched the Cochrane Airways Group Specialised Register, trials registries, and the reference lists of included studies and review articles. Searches are current up to April 2014. Selection criteria Any randomised controlled trial (RCT) using hyperosmolar inhalation in patients with bronchiectasis not caused by cystic fibrosis. Data collection and analysis Two review authors assessed studies for suitability. We used standard methods recommended by The Cochrane Collaboration. Main results Eleven studies met the inclusion criteria of the review (1021 participants). Five studies on 833 participants compared inhaled mannitol with placebo but poor outcome reporting meant we could pool very little data and most outcomes were reported by only one study. One 12‐month trial on 461 participants provided results for exacerbations and demonstrated an advantage for mannitol in terms of time to first exacerbation (median time to exacerbation 165 versus 124 days for mannitol and placebo respectively (hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.63 to 0.96, P = 0.022) and number of days on antibiotics for bronchiectasis exacerbations was significantly better with mannitol (risk ratio (RR) 0.76, 95%CI 0.58 to 1.00, P = 0.0496). However, exacerbation rate per year was not significantly different between mannitol and placebo (RR 0.92 95% CI 0.78 to 1.08). The quality of this evidence was rated as moderate. There was also an indication, from only three trials, again based on moderate quality evidence, that mannitol improves health‐related quality of life (mean difference (MD) ‐2.05; 95% CI ‐3.69 to ‐0.40). An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo (OR 0.96; 95% CI 0.61 to 1.51). Two additional small trials on 25 participants compared mannitol versus no treatment and the data from these studies were inconclusive. Four studies (combined N = 113) compared hypertonic saline versus isotonic saline. On most outcomes there were conflicting results and the opportunities for the statistical aggregation of data from studies was very limited. It is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Authors' conclusions There is an indication from a single, large, unpublished study that inhaled mannitol increases time to first exacerbation in patients with bronchiectasis. In patients with near normal lung function, spirometry does not change dramatically with mannitol and adverse events are not more frequent than placebo. Further investigation is required in a patient population with impaired lung function. It is not possible to draw firm conclusions regarding the effect of nebulised hypertonic saline due to significant differences in the methodology, patient groups, and findings amongst the limited data available. The data suggest that it is unlikely to have benefit over isotonic saline in patients with milder disease, and hence future studies should test its use in those with more severe disease Plain language summary Inhaled hyperosmolar agents for bronchiectasis Review question We wanted to know if inhaled hyperosmolar agents ‐ treatments which help people cough up sputum ‐ may be helpful for people with bronchiectasis. We only included trials on people who had bronchiectasis and who did not have cystic fibrosis. Therefore we are unable to draw any conclusions for people with cystic fibrosis. Background Bronchiectasis is a lung condition that usually develops after a series of lung problems (such as childhood infections, problems in the lung structure, tuberculosis, and cystic fibrosis). A lot of mucus (phlegm) collects in the lungs, causing discomfort and the need to cough it up. The phlegm also collects bacteria, which can add to breathing difficulties and make people very ill by causing recurring lung infections that are difficult to clear with antibiotics. Breathing in (inhaling) hypertonic saline (salt solutions with a greater salt content than blood) liquids may help clear this mucus, as may the drug mannitol (inhaled in dry powder form). This is because the concentrated salt or sugar (mannitol) draws water into the mucus in the lung and makes it thinner and easier to cough out. Study characteristics We found 11 randomised controlled trials on 1021 participants that compared inhaled hyperosmolar agents versus no mucolytic treatment. Five studies compared inhaled mannitol versus placebo (with a total of 883 participants) and two very small studies (with a total of just 25 participants) compared inhaled mannitol with no treatment. We also found four studies (with a total of 113 participants) that compared hypertonic saline with isotonic (normal) saline. Key results For the comparison between mannitol and placebo only one study (a 12‐month trial with 461 participants) provided information on the number of people who had an exacerbation (or flare up) over the course of a year. This study showed that people who were treated with mannitol had 8% fewer exacerbations on average compared with placebo. Overall, we felt the quality of this evidence was moderate and new trials would be likely to change either how effective we think the treatment is or how confident we are about it. Three trials assessed the effect of mannitol on health‐related quality of life, and again the quality of the evidence was rated as moderate. An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo The trials comparing hypertonic saline with isotonic saline had conflicting results for most of the outcomes of interest. Because we were unable to combine the data, it is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Our analysis of adverse events between hypertonic saline versus isotonic saline showed no significant difference however this was based on a single study and the quality of the evidence was moderate. Quality of the evidence Details of how the patients in the trials were allocated to receive mannitol or not was clearly described in only one of the studies, and similarly only one of the hypertonic saline versus isotonic saline studies provided this information. The general lack of information on this point was considered carefully in the review in relation to our level of uncertainty in interpreting the results. Taking this into account, the quality of evidence was generally regarded as moderate both for the mannitol and hypertonic saline studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hart, A; Sugumar, K; Milan, SJ; Fowler, SJ; Crossingham, I", "articleTypes": [], "doi": "10.1002/14651858.CD002996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "cce4d5eb-278d-4ea6-a922-d6b245cea3e1", "pmid": "", "title": "Sustained‐release naltrexone for opioid dependence", "imported": false, "abstract": "Abstract - Background Opioid dependence is a severe and often lifelong disorder with a high risk of overdose and premature death, as well as severe psychosocial difficulties. Sustained‐release naltrexone is a treatment option that works by blocking the euphoric and overdose effects of opioids. When injected intramuscularly, naltrexone provides blockade for one month, while the blocking effects with implants can last for up to six months. Objectives To assess the benefits and harms of sustained‐release naltrexone for the treatment of opioid dependence. Search methods For this update, we searched the following databases from 2007 up to 20 December 2023: the Cochrane Drugs and Alcohol Specialised Register of Trials, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, ISI Web of Science, LILACS, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We manually searched the reference lists of identified studies, published reviews and relevant websites. Selection criteria Randomised controlled trials comparing the effects of injectable or implantable naltrexone with other treatment, no treatment or placebo in adults with opioid dependence. Data collection and analysis Primary outcomes were illicit opioid use, retention in treatment, treatment acceptability and adverse events. Secondary outcomes were opioid craving, recreational use of substances other than opioids, mental health, quality of life and criminal activity. We assessed the risk of bias using the Cochrane risk of bias tool (RoB 1). We combined the results of individual trials through meta‐analysis where possible using a random‐effects model. Two review authors independently assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We identified 22 studies (3416 participants) that met our inclusion criteria. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. Sustained‐release naltrexone compared with opioid agonist treatment We found moderate‐certainty evidence that sustained‐release naltrexone probably increases in‐treatment illicit opioid use slightly (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.01 to 1.31; 1 study, 570 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 1.17, 95% CI 0.78 to 1.76; 3 studies, 773 participants) and treatment acceptability (RR 0.92, 95% CI 0.73 to 1.16; 3 studies, 773 participants). There was low‐certainty evidence that sustained‐release naltrexone may increase serious adverse events slightly in comparison with opioid agonist treatment for serious adverse events (RR 1.40, 95% CI 0.92 to 2.11; 2 studies, 713 participants). Sustained‐release naltrexone compared with oral naltrexone treatment We found low‐certainty evidence that sustained‐release naltrexone may reduce in‐treatment illicit opioid use (RR 0.65, 95% CI 0.45 to 0.93; 1 study, 69 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 2.40, 95% CI 1.64 to 3.52; 3 studies, 464 participants) and on serious adverse events (RR 1.25, 95% CI 0.46 to 3.36; 2 studies, 260 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in treatment acceptability in comparison with oral naltrexone treatment (RR 1.00, 95% CI 0.99 to 1.01; 3 studies, 474 participants). Sustained‐release naltrexone compared with placebo We found low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in in‐treatment illicit opioid use (RR 0.83, 95% CI 0.66 to 1.03; 3 studies, 443 participants), treatment acceptability (RR 1.00, 95% CI 0.98 to 1.02; 1 study, 204 participants) and serious adverse events (RR 0.74, 95% CI 0.17 to 3.23; 3 studies, 443 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment in comparison with placebo (RR 2.10, 95% CI 1.23 to 3.60; 4 studies, 594 participants). Sustained‐release naltrexone compared with treatment as usual We found high‐certainty evidence that sustained‐release naltrexone reduces in‐treatment illicit opioid use (RR 0.72, 95% CI 0.57 to 0.90; 4 studies, 479 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little or no difference in retention in treatment (RR 1.20, 95% CI 0.79 to 1.82; 3 studies, 126 participants) and that it may result in a slight reduction in treatment acceptability (RR 0.79, 95% CI 0.69 to 0.90; 8 studies, 1094 participants). There was moderate‐certainty evidence that sustained‐release naltrexone probably reduces serious adverse events in comparison with treatment as usual (RR 0.59, 95% CI 0.36 to 0.95; 6 studies, 1009 participants). Our primary outcome measures were not reported for sustained‐release naltrexone compared with psychosocial treatments. Amongst the most common methodological weaknesses were the risk of performance bias and imprecision due to few studies and small sample size for many outcomes. Authors' conclusions Sustained‐release naltrexone may slightly increase illicit opioid use and serious adverse events compared to opioid agonists, with uncertain effects on retention and acceptability. It may reduce illicit opioid use compared to oral naltrexone but has uncertain effects on other outcomes. Compared to placebo, it may have little to no impact on key outcomes. Compared to treatment as usual, it reduces illicit opioid use and may reduce serious adverse events but has little effect on retention and slightly reduces acceptability. Significant gaps remain in the evidence on sustained‐release naltrexone for opioid dependence. Future research should include comparisons with psychosocial treatments, larger and higher‐quality studies, and analyses of differences between formulations and comparator treatments. Improved study designs are needed to reduce bias, and more inclusive research should address under‐represented populations and synthetic opioid users. The lack of long‐term outcome data limits understanding of sustained effects, highlighting the need for extended follow‐up and exploration of diverse treatment settings and populations. Plain language summary What are the benefits and risks of sustained‐release (long‐acting) naltrexone for the treatment of dependence on opioid drugs (addiction)? Key messages • It is unclear whether people treated with sustained‐release naltrexone use illicit opioids, such as heroin, less frequently than people treated with opioid agonists, such as buprenorphine or methadone. • People treated with sustained‐release naltrexone may use illicit opioids less frequently than people treated with oral naltrexone, placebo or treatment as usual. • Treatment with sustained‐release naltrexone may be less safe than opioid agonist treatment, but safer than treatment as usual. • Clinicians and patients should weigh the availability and characteristics of treatment options, noting that sustained‐release naltrexone aids abstinence without restricting freedom but requires detoxification; more evidence is needed on long‐term safety and retention. What is dependence on opioid drugs? Opioid drugs, including heroin and prescription painkillers like oxycodone, carry the risk of addiction and serious health consequences. Treatment often involves replacing these opioids with safer alternatives such as methadone or buprenorphine, although other options like therapy or naltrexone are available. However, overcoming opioid dependence remains a persistent challenge due to its complex nature and the associated risks of relapse and overdose. What did we want to find out? In this review we sought to compare sustained‐release naltrexone treatment with other treatments or no treatment for opioid dependence. Naltrexone should not be confused with naloxone, which is a short‐acting drug used for opioid overdose reversal. Other treatments include opioid agonist treatment (such as methadone or buprenorphine), oral naltrexone (taken by mouth, tablets), placebo (sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested), treatment as usual and psychosocial treatments (therapeutic approaches that address both psychological and social aspects of mental health conditions, e.g. psychotherapy, psychoeducation and support groups). What did we do? We searched scientific databases for studies up to December 2023. We identified 22 randomised controlled trials (studies where people were allocated at random to one of two or more treatment or control conditions) involving 3416 adults and adolescents with opioid dependence. Seventy‐four per cent of the people in the studies were male, and they had an average age of 40 years. Twelve of the 22 studies were conducted in the USA or Canada, five in Russia, three in Norway, and one in the UK and Australia, respectively. The main outcomes we examined were opioid use and treatment safety. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. What did we find? We found that when comparing sustained‐release naltrexone to opioid agonist treatment, illicit opioid use probably increases slightly. On the other hand, when comparing sustained‐release naltrexone to treatment as usual, sustained‐release naltrexone reduces illicit opioid use. Compared to oral naltrexone, illicit opioid use may decrease, and compared to placebo, there may be little or no difference. We found no studies comparing sustained‐release naltrexone with psychosocial treatments for any of our primary outcomes. It is generally unclear whether people remain longer in sustained‐release naltrexone treatment than in other treatments or placebo. We do not know whether more people will initiate sustained‐release naltrexone treatment than opioid agonist treatment. When compared to oral naltrexone or placebo, there may be little or no difference in the proportion of people who will initiate treatment. Compared to treatment as usual, it may be that fewer people will initiate sustained‐release naltrexone treatment. Compared to opioid agonist treatment, sustained‐release naltrexone may increase serious adverse (unwanted or harmful) events slightly. It is unclear whether sustained‐release naltrexone results in more or fewer serious adverse events than oral naltrexone. When compared to placebo, there may be little or no difference in the proportion of people who will experience serious adverse events. Sustained‐release naltrexone probably reduces serious adverse events in comparison to treatment as usual. What were the limitations of the evidence? Overall, we have limited confidence in the evidence. One of the reasons is that it is very likely that participants knew which treatments they were assigned to, even if the researchers in many cases tried to conceal the assigned treatment condition for participants and treatment providers. Opioid dependence comes with strong drug cravings and an increased risk of relapse during any treatment. Therefore, participants experiencing cravings and those who maybe even tried to use drugs like heroin would have understood what type of treatment they were assigned to. Another major reason for our limited confidence in the evidence was that the number of studies, and people participating in them, was often too small to obtain precise results. Other reasons for lowering our confidence were inconsistencies in study results and national treatment policies in some studies that make it difficult to apply the results in other countries. How up‐to‐date is this evidence? The evidence is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kornør, H, Lobmaier, PPK, Kunøe, N", "articleTypes": [], "doi": "10.1002/14651858.CD006140.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.138Z" }, { "id": "cce89ad1-b29b-492b-bb22-d66c6743ec0a", "pmid": "", "title": "Ibuprofen for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non‐steroidal anti‐inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period. Objectives 1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled). Search methods We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023. Selection criteria We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules. Data collection and analysis We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence. Main results We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child‐reported pain intensity less than two hours postintervention compared to placebo (SMD −1.12, 95% CI −1.39 to −0.86; 3 studies, 259 children; moderate‐certainty evidence). Ibuprofen may reduce child‐reported pain intensity, two hours to less than 24 hours postintervention (SMD −1.01, 95% CI −1.24 to −0.78; 5 studies, 345 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low‐certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child‐reported pain intensity less than two hours postintervention compared to paracetamol (SMD −0.42, 95% CI −0.82 to −0.02; 2 studies, 100 children; moderate‐certainty evidence). Ibuprofen may slightly reduce child‐reported pain intensity two hours to 24 hours postintervention (SMD −0.21, 95% CI −0.40 to −0.02; 6 studies, 422 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low‐certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) −0.25, 95% CI −0.40 to −0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate‐certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD −0.29, 95% CI −0.53 to −0.04; NNTB 4; 1 study, 59 children; low‐certainty evidence). Authors' conclusions Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs. Plain language summary What are the benefits and harms of ibuprofen for managing pain after an operation in children? Key messages • Ibuprofen probably reduces pain intensity just after an operation up to two hours compared to a placebo (dummy) and compared to paracetamol. The evidence compared to other medicines and in the longer term is unclear or lacking. • Overall, we are uncertain about unwanted effects of ibuprofen, especially serious unwanted effects, since the studies in the review rarely measured them. • Future studies should examine ibuprofen compared to commonly used medications and measure benefits and unwanted effects for both short‐ and long‐term use. Why is pain management important? It is common for children to experience pain after an operation (postoperative pain). Pain causes suffering and agitation, and it can delay recovery. One way to manage pain in children is by using different medicines, for example, ibuprofen. Ibuprofen is a type of medicine called a 'non‐steroidal anti‐inflammatory drug' (NSAID) that can reduce inflammation and pain. What did we want to find out? We wanted to find out if ibuprofen is an effective pain treatment and whether it causes unwanted effects compared to other pain treatments. Also, the most effective way to deliver ibuprofen to children. What did we do? We searched for studies that compared ibuprofen to other treatment options for postoperative pain as well as for studies that looked at different ways to deliver ibuprofen to children. We summarised the results and rated our confidence in the evidence. What did we find? We found 43 studies with 4265 children with postoperative pain. We used data from 3935 children in this review. The largest study included 741 children and the smallest, 23 children. The studies were conducted in many countries around the world; most commonly the USA (12 studies). Children's ages ranged from 2.2 months up to 17 years. Studies used ibuprofen to manage postoperative pain in 10 different types of surgery: mostly dental procedures (21 studies); and ear, nose and throat procedures (11 studies). Main results Compared to placebo (a dummy medicine), ibuprofen probably reduces pain intensity less than two hours after the operation and may reduce pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol , ibuprofen probably reduces pain intensity less than two hours after the operation and probably reduces pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol, ibuprofen probably makes little difference to the chances of bleeding. Compared to morphine , ibuprofen probably leads to a reduction in any reported unwanted effects. Compared to ketorolac , ibuprofen may lead to a reduction in overall harms. No studies reported pain intensity or serious unwanted effects, such as lasting disability or hospitalisation for either morphine or ketorolac. We did not find any studies that compared different routes of administration of ibuprofen. What are the limitations of the evidence? We are uncertain about the overall evidence of ibuprofen use in postoperative pain in children, primarily because there were not enough large studies to be certain about any differences in ibuprofen when compared to other alternatives. In addition, only a few of the studies provided data about important benefits and unwanted effects for children experiencing pain following surgery, especially in the longer term. How up to date is this evidence? The evidence is up‐to‐date to August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Pessano, S, Gloeck, NR, Tancredi, L, Ringsten, M, Hohlfeld, A, Ebrahim, S, Albertella, M, Kredo, T, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.812Z" }, { "id": "ccef107c-19ef-4b3d-ab28-2521f3ca3c8c", "pmid": "", "title": "Padma 28 for intermittent claudication", "imported": false, "abstract": "Abstract - Background Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease that develops in a limb during exercise and is relieved with rest. Most drug treatments of IC have a limited effect in improving walking distance. Padma 28, a Tibetan herbal preparation, has been used to treat IC, but there is debate as to whether Padma 28 produces a clinical benefit beyond the placebo effect. This is an update of a review first published in 2013. Objectives To determine whether Padma 28 is effective, compared with placebo or other medications, in increasing pain‐free and maximum walking distance for patients with intermittent claudication. Search methods For this update the Cochrane Vascular Trials Search Co‐ordinator searched the Specialised Register (September 2015), the Cochrane Register of Studies ((CENTRAL) (2015, Issue 8)) and clinical trials databases. Selection criteria Randomised controlled trials of Padma 28 compared with placebo or other pharmacological treatments in people suffering from IC. Data collection and analysis All review authors independently assessed the selected studies and extracted the data. Risk of bias was evaluated independently by two review authors. Depending on the data provided in the individual trials, we extracted mean or median walking distance at the end of the trial, or change in walking distance over the course of the trial, or both. Where not provided, and whenever possible, the statistical significance of differences in these parameters between treatment and placebo groups in individual trials was calculated. Where possible, data were combined by meta‐analysis. Main results No new trials were identified in the search for this review update. In total five trials involving 365 participants were included in this review. All trials compared Padma 28 with placebo for at least 16 weeks of follow‐up. Pain‐free and maximum walking distances both increased significantly in the groups treated with Padma 28, with no significant change in the placebo group. In general, the studies presented results comparing the treatment arms before and after treatment but made no comparisons between the Padma 28 and placebo groups. Pooled data of maximum walking distance after treatment with Padma 28 and placebo from two studies (193 participants) indicated a higher maximum walking distance (mean difference (MD) 95.97 m, 95% confidence interval (CI) 79.07 m to 112.88 m, P < 0.00001, very low quality evidence) in the Padma 28 group compared with placebo. The clinical importance of these observed changes in walking distance is unclear as no quality of life data were reported. There was no effect on ankle brachial index (ABI): change in ABI values between baseline and six months follow up MD ‐0.01, 95% CI ‐0.07 to 0.05, 1 study, 56 participants, P = 0.72, very low quality evidence). Mild side effects, especially gastrointestinal discomfort, tiredness and skin eruption, were reported but this outcome was not different between the Padma 28 and placebo groups (odds ratio 1.09, 95% CI 0.42 to 2.83, four studies, 231 participants, P = 0.86, very low quality evidence). Authors' conclusions Some evidence exists from individual trials to suggest that Padma 28 may be effective in increasing walking distances, at least in the short term (four months), in people with IC. Side effects do not appear to be a problem. However, the longer term effects of treatment are unknown and the clinical significance of the improvements in walking distance are questionable. Moreover, the quality of the evidence is limited by the small sample size of the available trials, limited reporting of statistical analyses that compared treatment groups, and relatively high withdrawal rates that were linked to the outcome. That is, patients were withdrawn if they failed to improve walking distance. There was also evidence of publication bias. We therefore feel there is currently insufficient evidence to draw conclusions regards the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation. Plain language summary Padma 28 for intermittent claudication Background Intermittent claudication (IC) is pain in the leg that occurs on exercise and is relieved by rest. It is caused by an inadequate blood supply to the legs due to blockage of arteries. Conservative drug treatment is commonly used in an attempt to improve walking distance in these patients. Padma 28 is a Tibetan herbal preparation used for treating intermittent claudication. Study characteristics and key results This review on the effects of Padma 28 includes five trials with a total of 365 participants (current until September 2015). The review showed that Padma 28 has some beneficial effects in improving maximum and pain‐free walking distance. The groups treated with placebo did not show an improved maximum and pain‐free walking distance. Unfortunately the studies reported insufficient data to allow the comparison of the change in walking distances in the Padma 28 group with the change in walking distances in the placebo group. Combining the data of maximum walking distance after treatment in two studies showed that there was a longer maximum walking distance in the Padma 28 group compared with the placebo group after 16 weeks of treatment. No change in ankle brachial pressure was observed. Mild side effects such as gastrointestinal discomfort, tiredness and skin eruption were also noted but these were not different between the Padma 28 and placebo groups. Quality of the evidence Overall, the quality of the studies was low, with evidence of publication bias, small number of trials, limited reporting of the analyses that compared treatment groups and bias due to a high percentage of withdrawals in the placebo groups because of lack of improvement or deterioration of the overall condition. We therefore feel there is currently insufficient evidence to draw conclusions about the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stewart, M; Morling, JR; Maxwell, H", "articleTypes": [], "doi": "10.1002/14651858.CD007371.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "ccf3c5dc-b0cf-4a2d-b670-e274537d6826", "pmid": "", "title": "Oral zinc for treating diarrhoea in children", "imported": false, "abstract": "Abstract - Background In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). Objectives To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, m RCT, and reference lists up to 30 September 2016. We also contacted researchers. Selection criteria Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery. Data collection and analysis Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses (using either a fixed‐effect or random‐effects model) and assessed heterogeneity. We assessed the certainty of the evidence using the GRADE approach. Main results Thirty‐three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoea There is currently not enough evidence from well‐conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized ( very low certainty evidence ). In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD −11.46 hours, 95% CI −19.72 to −3.19; 2581 children, 9 trials, low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD −26.39 hours, 95% CI −36.54 to −16.23; 419 children, 5 trials, high certainty evidence ). Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI −4.00 to 14.45; 1334 children, 2 trials, low certainty evidence ), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, low certainty evidence ). None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence ; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence ). Persistent diarrhoea In children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD −15.84 hours, 95% CI −25.43 to −6.24; 529 children, 5 trials, moderate certainty evidence ). Authors' conclusions In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency. 12 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (30 Sep, 2016) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Oral zinc supplementation for treating diarrhoea in children In low‐ and middle‐income countries, millions of children suffer from severe diarrhoea every year and many die from dehydration. Giving fluids by mouth (using an oral rehydration solution (ORS)) has been shown to save children's lives, but it has no effect on the length of time the children suffer with diarrhoea. Zinc supplementation could help reduce the duration and the severity of diarrhoea, and therefore have an additional benefit over ORS in reducing children mortality. What is oral zinc and how may it shorten the duration and severity of diarrhoea Zinc is usually given as zinc sulphate, zinc acetate, or zinc gluconate, which are all water‐soluble compounds. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend 10 mg to 20 mg of zinc per day for children with diarrhoea. There are several mechanism of action of zinc on acute diarrhoea, some of which are specific to the gastrointestinal system: zinc restores mucosal barrier integrity and enterocyte brush‐border enzyme activity, it promotes the production of antibodies and circulating lymphocytes against intestinal pathogens, and has a direct effect on ion channels, acting as a potassium channel blocker of adenosine 3‐5‐cyclic monophosphate‐mediated chlorine secretion. Cochrane researchers examined the evidence available up to 30 September 2016. What the evidence in the review suggests Thirty‐three trials that included 10,841 children met the inclusion criteria of this review. Among children with acute diarrhoea, we don't know if treating children with zinc has an effect on death or number of children hospitalized ( very low certainty evidence ). In children older than six months, zinc supplementation may shorten the average duration of diarrhoea by around half a day ( low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven ( moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day ( high certainty evidence ). Conversely, in children younger than six months, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea ( low certainty evidence ), or the number of children who still have diarrhoea on day seven ( low certainty evidence ). Zinc supplementation increased the risk of vomiting in both age groups ( moderate certainty evidence ). No other adverse effects were reported. Among children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours ( moderate certainty ) but it probably increases the risk of vomiting ( moderate certainty evidence ). In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lazzerini, M, Wanzira, H", "articleTypes": [], "doi": "10.1002/14651858.CD005436.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.077Z" }, { "id": "cd022b9f-e1f3-493f-951c-ed86a38aebb3", "pmid": "", "title": "Mindfulness‐enhanced parenting programmes for improving the psychosocial outcomes of children (0 to 18 years) and their parents", "imported": false, "abstract": "Abstract - Background Emotional and behavioural difficulties (EBD) in children are common, characterised by externalising or internalising behaviours that can be highly stable over time. EBD are an important cause of functional disability in childhood, and predictive of poorer psychosocial, academic, and occupational functioning into adolescence and adulthood. The prevalence, stability, and long‐term consequences of EBD highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Multiple factors contribute to the aetiology of EBD in children, and parenting plays an important role. The relationship between parenting and EBD has been described as bidirectional, with parents and children shaping one another’s behaviour. One consequence of bidirectionality is that parents with insufficient parenting skills may become involved in increasingly negative behaviours when dealing with non‐compliance in children. This can have a cyclical effect, exacerbating child behavioural difficulties and further increasing parental distress. Behavioural or skills‐based parenting training can be highly effective in addressing EBD in children. However, emotional dysregulation may intercept some parents' ability to implement parenting skills, and there is recognition that skills‐based interventions may benefit from adjunct components that better target parental emotional responses. Mindful parenting interventions have demonstrated some efficacy in improving child outcomes via improvements in parental emotion regulation, and there is potential for mindfulness training to enhance the effectiveness of standard parent training programmes. Objectives To assess the effectiveness of mindfulness‐enhanced parent training programmes on the psychosocial functioning of children (aged 0 to 18 years) and their parents. Search methods We searched the following databases up to April 2023: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, PsycINFO, Sociological Abstracts, Social Sciences Citation Index, Conference Proceedings Citation Index – Social Science & Humanities, AMED, ERIC, ProQuest Dissertations & Theses, Cochrane Database of Systematic Reviews, Campbell Collaboration Library of Systematic Reviews, as well as the following trials registers: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also contacted organisations/experts in the field. Selection criteria We included randomised and quasi‐randomised trials. Participants were parents or caregivers of children under the age of 18. The intervention was mindfulness‐enhanced parent training programmes compared with a no‐intervention, waitlist, or attentional control, or a parent training programme with no mindfulness component. The intervention must have combined mindfulness parent training with behavioural or skills‐based parent training. We defined parent training programmes in terms of the delivery of a standardised and manualised intervention over a specified and limited period, on a one‐to‐one or group‐basis, with a well‐defined mindfulness component. The mindfulness component must have included mindfulness training (breath, visualisation, listening, or other sensory focus) and an explicit focus on present‐focused attention and non‐judgemental acceptance. Data collection and analysis We followed standard Cochrane procedures. Main results Eleven studies met our inclusion criteria, including one ongoing study. The studies compared a mindfulness‐enhanced parent training programme with a no‐treatment, waitlist, or attentional control (2 studies); a parent training programme with no mindfulness component (5 studies); both a no‐treatment, waitlist, or attentional control and a parent training programme with no mindfulness component (4 studies). We assessed all studies as being at an unclear or high risk of bias across multiple domains. We pooled child and parent outcome data from 2118 participants to produce effect estimates. No study explicitly reported on self‐compassion, and no adverse effects were reported in any of the studies. Mindfulness‐enhanced parent training programmes compared to a no‐treatment, waitlist, or attentional control Very low certainty evidence suggests there may be a small to moderate postintervention improvement in child emotional and behavioural adjustment (standardised mean difference (SMD) −0.46, 95% confidence interval (CI) −0.96 to 0.03; P = 0.06, I 2 = 62%; 3 studies, 270 participants); a small improvement in parenting skills (SMD 0.22, 95% CI 0.06 to 0.39; P = 0.008, I 2 = 0%; 3 studies, 587 participants); and a moderate decrease in parental depression or anxiety (SMD −0.50, 95% CI −0.96 to −0.04; P = 0.03; 1 study, 75 participants). There may also be a moderate to large decrease in parenting stress (SMD −0.79, 95% CI −1.80 to 0.23; P = 0.13, I 2 = 82%; 2 studies, 112 participants) and a small improvement in parent mindfulness (SMD 0.21, 95% CI −0.14 to 0.56; P = 0.24, I 2 = 69%; 3 studies, 515 participants), but we were not able to exclude little to no effect for these outcomes. Mindfulness‐enhanced parent training programmes compared to parent training with no mindfulness component Very low certainty evidence suggests there may be little to no difference postintervention in child emotional and behavioural adjustment (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.71, I 2 = 64%; 5 studies, 203 participants); parenting skills (SMD 0.13, 95% CI −0.16 to 0.42; P = 0.37, I 2 = 16%; 3 studies, 319 participants); and parent mindfulness (SMD 0.11, 95% CI −0.19 to 0.41; P = 0.48, I 2 = 44%; 4 studies, 412 participants). There may be a slight decrease in parental depression or anxiety (SMD −0.24, 95% CI −0.83 to 0.34; P = 0.41; 1 study, 45 participants; very low certainty evidence), though we cannot exclude little to no effect, and a moderate decrease in parenting stress (SMD −0.51, 95% CI −0.84 to −0.18; P = 0.002, I 2 = 2%; 3 studies, 150 participants; low certainty evidence). Authors' conclusions Mindfulness‐enhanced parenting training may improve some parent and child outcomes, with no studies reporting adverse effects. Evidence for the added value of mindfulness training to skills‐based parenting training programmes is suggestive at present, with moderate reductions in parenting stress. Given the very low to low certainty evidence reviewed here, these estimates will likely change as more high‐quality studies are produced. Plain language summary Mindfulness‐enhanced parenting programs for improving outcomes for children and their parents Key messages • Mindfulness‐enhanced parent training programmes may improve some child and parent outcomes, including child emotional and behavioural adjustment, parenting skills, parental depression or anxiety, parenting stress, and parent mindfulness. • When mindfulness parent training is combined with a skills‐based parent training programme, this may decrease parenting stress. • The current body of evidence is limited, with more research needed to be confident in our findings. Children's emotional and behavioural difficulties Emotional and behavioural difficulties in children are common, and are characterised by a range of externalising and/or internalising behaviours that can be highly stable over time. They are an important cause of functional disability in childhood, and predictive of poor psychosocial, academic, and occupational functioning into adolescence and beyond. The prevalence, stability, and long‐term consequences of emotional and behavioural difficulties highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Why mindfulness‐enhanced parent training? Parenting plays an important role in the development and/or maintenance of emotional and behavioural difficulties in children. Traditional behavioural or skills‐based parent training programmes have been shown to have a positive impact on a range of child and parent outcomes, but they do not work for all parents. One reason for this might be that parents' emotional reactions could prevent them from using parenting skills effectively. Including additional components into parenting training that aim to improve parental emotional responses may enhance the outcomes of these programmes. Recent research shows that mindful parenting interventions may promote positive outcomes for parents and children by improving parents' ability to regulate emotions and stress. Combining mindful parenting approaches with traditional parent training programmes may therefore be beneficial for both parents and their children. What did we want to find out? We explored whether behavioural or skills‐based parent training programmes with a mindfulness component – 'mindfulness‐enhanced' parent training programmes – can improve outcomes for children and their caregivers. What did we do? We searched a range of sources for literature that evaluated the effectiveness of mindfulness‐enhanced parent training programmes, including electronic databases, trial registries, and organisations and experts in the field. We included studies evaluating these interventions using randomised controlled trials (studies where participants are randomly assigned to one of two or more treatment groups) or quasi experimental designs (where participants are assigned to different treatment groups using a method that is not truly random). We included studies that assessed child emotional and behavioural adjustment, and/or a range of parent outcomes, including parenting skills, parenting stress, depression or anxiety, mindfulness or self‐compassion. What did we find out? We included 11 studies and data from 2118 participants in the review. The studies compared the outcomes of children or parents (or both) who participated in a mindfulness‐enhanced parent training programme to the outcomes of children or parents (or both) who did not participate in parent training, or who participated in an alternate behavioural or skills‐based parent training programme. When we combined the findings from these studies, we found that mindfulness‐enhanced parent training, when compared to no intervention, may improve child emotional and behavioural adjustment, parenting skills, parenting stress, parental depression and anxiety, and mindfulness, but we are very uncertain about these results. Evidence for the added value of mindfulness training when included in a skills‐based parent training programme suggests that mindfulness training may further promote reductions in parenting stress, and may also further reduce parental depression or anxiety, but we are uncertain about these results. It is unclear from the current body of evidence whether adding mindfulness training to a skills‐based parent training intervention has any further effect on child emotional and behavioural adjustment, parenting skills, or mindfulness. No studies reported adverse effects or measured self‐compassion. What are the limitations of the evidence? We are not confident in the overall body of evidence. This is primarily because there was a lot of variation across the interventions and the participant groups, as well as how the outcomes were measured. The studies were also usually quite small, and participants were likely to be aware of what intervention they were receiving, which can sometimes influence the results. It is likely that these findings will change as more studies are undertaken in this area of research. How up‐to‐date is this evidence? We searched for and included research up to April 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Featherston, R, Barlow, J, Song, Y, Haysom, Z, Loy, B, Tufford, L, Shlonsky, A", "articleTypes": [], "doi": "10.1002/14651858.CD012445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.794Z" }, { "id": "cd172d5f-83ff-4faf-83cf-c5ef470853aa", "pmid": "", "title": "Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015. Objectives To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate. Selection criteria We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non‐serious, general behaviour, and quality of life. Data collection and analysis Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel‐group trials and first‐period data from cross‐over trials formed the basis of our primary analyses. We undertook separate analyses using end‐of‐last period data from cross‐over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach. Main results We included 212 trials (16,302 participants randomised); 55 parallel‐group trials (8104 participants randomised), and 156 cross‐over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross‐over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male‐female ratio was 3:1. Most trials were carried out in high‐income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias. Primary outcomes: methylphenidate versus placebo or no intervention may improve teacher‐rated ADHD symptoms (standardised mean difference (SMD) −0.74, 95% confidence interval (CI) −0.88 to −0.61; I² = 38%; 21 trials; 1728 participants; very low‐certainty evidence). This corresponds to a mean difference (MD) of −10.58 (95% CI −12.58 to −8.72) on the ADHD Rating Scale (ADHD‐RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD‐RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68). Secondary outcomes: methylphenidate may cause more adverse events considered non‐serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher‐rated general behaviour versus placebo (SMD −0.62, 95% CI −0.91 to −0.33; I² = 68%; 7 trials 792 participants; very low‐certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI −0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low‐certainty evidence). Authors' conclusions The majority of our conclusions from the 2015 version of this review still apply. Our updated meta‐analyses suggest that methylphenidate versus placebo or no‐intervention may improve teacher‐rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non‐serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non‐serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes. Plain language summary Is methylphenidate an effective treatment for children and adolescents with attention deficit hyperactivity disorder (ADHD) and does it cause unwanted effects? Key messages ‐ Methylphenidate might reduce hyperactivity and impulsivity and might help children to concentrate. Methylphenidate might also help to improve general behaviour, but does not seem to affect quality of life. ‐ Methylphenidate does not seem to increase the risk of serious (life‐threatening) unwanted effects when used for periods of up to six months. However, it is associated with an increased risk of non‐serious unwanted effects like sleeping problems and decreased appetite. ‐ Future studies should focus more on reporting unwanted effects and should take place over longer periods of time. What is attention deficit hyperactivity disorder (ADHD)? ADHD is one of the most commonly diagnosed and treated childhood psychiatric disorders. Children with ADHD find it hard to concentrate. They are often hyperactive (fidgety, unable to sit still for long periods) and impulsive (doing things without stopping to think). ADHD can make it difficult for children to do well at school, because they find it hard to follow instructions and to concentrate. Their behavioural problems can interfere with their ability to get on well with family and friends, and they often get into more trouble than other children. How is ADHD treated? Methylphenidate (for example, Ritalin) is the medication most often prescribed to children and adolescents with ADHD. Methylphenidate is a stimulant that helps to increase activity in parts of the brain, such as those involved with concentration. Methylphenidate can be taken as a tablet or given as a skin patch. It can be formulated to have an immediate effect, or be delivered slowly, over a period of hours. Methylphenidate may cause unwanted effects, such as headaches, stomachaches and problems sleeping. It sometimes causes serious unwanted effects like heart problems, hallucinations, or facial 'tics' (twitches). What did we want to find out? We wanted to find out if methylphenidate improves children's ADHD symptoms (attention, hyperactivity) based mainly on teachers' ratings using various scales, and whether it causes serious unwanted effects, like death, hospitalisation, or disability. We were also interested in less serious unwanted effects like sleep problems and loss of appetite, and its effects on children's general behaviour and quality of life. What did we do? We searched for studies that investigated the use of methylphenidate in children and adolescents with ADHD. Participants in the studies had to be aged 18 years or younger and have a diagnosis of ADHD. They could have other disorders or illnesses and be taking other medication or undergoing behavioural treatments. They had to have a normal IQ (intelligence quotient). Studies could compare methylphenidate with placebo (something designed to look and taste the same as methylphenidate but with no active ingredient) or no treatment. Participants had to be randomly chosen to receive methylphenidate or not. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 212 studies with 16,302 children or adolescents with ADHD. Most of the trials compared methylphenidate with placebo. Most studies were small with around 70 children, with an average age of 10 years (ages ranged from 3 to 18 years). Most studies were short, lasting an average of around a month; the shortest study lasted just one day and the longest 425 days. Most studies were in the USA. Based on teachers' ratings, compared with placebo or no treatment, methylphenidate: ‐ may improve ADHD symptoms (21 studies, 1728 children) ‐ may make no difference to serious unwanted effects (26 studies, 3673 participants) ‐ may cause more non‐serious unwanted effects (35 studies, 5342 participants) ‐ may improve general behaviour (7 trials 792 participants) ‐ may not affect quality of life (4 trials, 608 participants) Limitations of the evidence Our confidence in the results of the review is limited for several reasons. It was often possible for people in the studies to know which treatment the children were taking, which could influence the results. The reporting of the results was not complete in many studies and for some outcomes the results varied across studies. Studies were small and they used different scales for measuring symptoms. And most of the studies only lasted for a short period of time, making it impossible to assess the long‐term effects of methylphenidate. Around 41% of studies were funded or partly funded by the pharmaceutical industry. How up to date is this evidence? This is an update of a review conducted in 2015. The evidence is current to March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Storebø, OJ, Storm, MR, Pereira Ribeiro, J, Skoog, M, Groth, C, Callesen, HE, Schaug, JP, Darling, P, Huus, C-ML, Zwi, M, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD009885.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.143Z" }, { "id": "cd352c2c-fa4d-4324-a6c3-201350b3c315", "pmid": "", "title": "Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Soil‐transmitted helminth (STH) infections are amongst the most common infectious diseases worldwide, with an estimated 24% of the world’s population currently infected. Mass drug administration (MDA) is the periodic medicinal treatment, without prior individual diagnosis, of at‐risk people living in endemic areas. The World Health Organization currently recommends MDA for STHs. MDA programmes are complex health interventions; achieving adherence is important to their success. Adherence is influenced by the target population's perceptions of the drug, the programme, and those delivering it. Objectives To synthesize qualitative research evidence about community experiences and perceptions of mass drug administration programmes for soil‐transmitted helminths. To assess whether our findings confirm, extend, enrich, or conflict with those of a 2022 Cochrane qualitative evidence review of mass drug administration programmes for lymphatic filariasis. Search methods We searched CENTRAL, MEDLINE, Embase, and four other databases up to 11 November 2024, together with reference checking, and citation searching. Selection criteria We synthesized qualitative and mixed‐methods studies. We included studies exploring community experiences and perceptions of MDA programmes for STHs in any country, conducted between 2001 and 2024. We included all participants of MDA programmes, regardless of disease status, individual participation, or other demographic information. We also included lay healthcare workers and formally qualified healthcare workers, if their perspectives were clearly separated from those of the general population. Data collection and analysis We collected data on study characteristics and programme delivery, including country, endemicity, drug regimen, how the drugs were delivered, use of health education and sensitization, and adherence monitoring. We conducted thematic analysis using a 'best‐fit' framework synthesis based on a framework developed in a 2022 Cochrane review exploring community views on mass drug administration for filariasis (a parasitic infection caused by filarial worms). We conducted a deductive phase, accommodating our data within the existing model, followed by an inductive phase, during which we explored data not accommodated by the framework. We used the GRADE‐CERQual approach to assess our confidence in the findings, and updated the filariasis review's conceptual model to display our findings. Main results We included 17 studies, conducted in Bangladesh, Benin, India, Kenya, Malawi, Nigeria, the Philippines, and Turkey. Four themes emerged, three of which were identified in the review of MDA for lymphatic filariasis. People weigh up the benefits and harms in their decision to participate in MDA, though some may not have a choice. Outcomes of individual participation in MDA may be positive, negative, or both. The decision to partake is a careful balance of risk, benefit, and feasibility (high confidence). Unpleasant associations become part of the narrative and spread rapidly through the community (moderate confidence). Physical and social barriers prevent some people from being able to access MDA even if they want to participate (moderate confidence). Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical legacies, rumours, and mistrust of people involved in the programme affect overall trust in drug distribution and influence whether people choose to participate. Past experiences can have a profound effect on people, and negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background and in‐depth training around the drug or the disease itself (moderate confidence). Some community members prefer distribution from people they know or trust (high confidence). However, others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors (CDDs) cannot answer their programme‐related questions (moderate confidence). Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign, which includes improved sanitation, is necessary to tackle STH burden (moderate confidence). One theme that the filariasis review identified was not substantiated by the findings in this review (Programmes expect compliance: this can result in coercion and blame). Authors' conclusions Despite the prevalence and undoubted impact of MDA programmes over the past 10 years, endemic hotspots and continued transmission are common, due in part to poor community adherence. The 2022 Cochrane review outlined several key community concerns and doubts that hinder the effective implementation of MDA for lymphatic filariasis. This review shows that most of these concerns and doubts are shared by communities targeted for MDA for STHs, indicating that there are fundamental challenges in the overall conceptualization and design of MDA programmes that need to be addressed. Funding TF, MT, RK, and the Cochrane Infectious Diseases Group editorial base were funded by UK aid from the UK Government for the benefit of low‐ and middle‐income countries (project number 300342‐104). The views expressed do not necessarily reflect the UK Government’s official policies. Registration The protocol for this review was published in January 2024 on the Cochrane Database of Systematic Reviews. Available at doi.org/10.1002/14651858.CD015794. Plain language summary Community views on mass drug administration for soil‐transmitted helminths: a qualitative evidence synthesis Key messages People consider several personal, social, and historical factors before deciding to take medicine. Within one community, different individuals will experience benefits and harms associated with treatment, which shape their decision to participate. The decision to adhere depends on the perceived benefits compared to harms, the trust built between communities and the programme, the competency of people delivering the drugs to provide reassurance to the community members, and the perceived organisation of the delivery programme. Our findings are largely consistent with those of a 2022 Cochrane review exploring people's views and experiences of mass drug administration (MDA) programmes for lymphatic filariasis. This evidence overlap suggests that there are key challenges in the design of MDA programmes in general that need to be addressed to increase adherence. What was studied in this synthesis? Mass drug administration (MDA) involves the periodic delivery of drugs to treat entire communities or groups, regardless of whether an individual has a particular disease. This method aims to prevent onward transmission of infection within the population. MDA is currently recommended for some disease‐control programmes in low‐ and middle‐income countries, including for soil‐transmitted helminth (STH) infections. STHs are a group of parasitic worms, including roundworm, hookworm, whipworm, and threadworm. These MDA programmes are usually delivered within a community or as a school‐based programme. Successfully stopping STH infections through MDA depends on community members being willing and able to participate. In this review, we looked for studies that explored how people view and experience mass drug administration programmes for STHs. We identified 17 studies relevant to this synthesis. What was the aim of this synthesis? In this synthesis of qualitative research, we searched for studies that explored people's views on MDA programmes for treating STHs in low‐ and middle‐income countries. We wanted to understand how people view and experience mass drug administration programmes for soil‐transmitted helminths. We were also interested in whether our findings would support, extend, or conflict with findings from a 2022 Cochrane review which looked at MDA programmes for lymphatic filariasis, another infectious disease caused by worms. What were the main findings? We included 17 studies in our analysis. The studies covered several countries in Africa and South‐East Asia, and one country in the Eastern Mediterranean region. The included studies explored the views and experiences of community members and those distributing the medicines in low‐income countries where STH infection is a considerable problem. From the data, four themes emerged. The 2022 Cochrane review of MDA for lymphatic filariasis identified three of these themes, highlighting the similarities between these programmes. One new theme emerged. 1. People weigh up benefits and harms in their decision to participate in MDA, though some may not have a choice. There are many outcomes to participating in the MDA programme, both positive and negative. For community members, several of these may exist at once, and the decision to partake is a careful balance of risk, benefit, and feasibility (we have high confidence in the evidence). Unpleasant experiences can quickly spread through the community (moderate confidence). Physical and social barriers (e.g. travel distance or not attending school, respectively) prevent some people from accessing treatment through the MDA programme (moderate confidence). 2. Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical experiences, rumours, and mistrust of people involved in the programme affect overall trust in the programme. Past experiences can have a strong effect on people; negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence). 3. The drug distributor's status in the community is often low, and they are not well‐equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background, and in‐depth training around the drug or the disease itself (moderate confidence). Whilst some community members prefer distribution from people who they know or trust (high confidence), others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors cannot answer their questions related to the programme (moderate confidence). 4. (New theme) Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign which includes improved sanitation is necessary to tackle STH burden (moderate confidence). How current is this evidence? The evidence is current to November 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fox, T; Shrestha, S; Kuehn, R; Taylor, M", "articleTypes": [], "doi": "10.1002/14651858.CD015794.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "cd3bcbef-bcc2-4c98-b54b-8d014319a63c", "pmid": "", "title": "Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer", "imported": false, "abstract": "Abstract - Background This is an updated version of a Cochrane Review last published in 2013. Long‐term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating people with cancer. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infections remain a common complication. These infections are mainly caused by gram‐positive bacteria. Antimicrobial prevention strategies aimed at these micro‐organisms could potentially decrease the majority of CVC‐related infections. The aim of this review was to evaluate the efficacy of prophylactic antibiotics for the prevention of gram‐positive infections in people with cancer who have long‐term CVCs. Objectives To assess the effects of administering antibiotics prior to the insertion of long‐term CVCs or as a flush/lock solution, or both during long‐term CVC access to prevent gram‐positive CVC‐related infections in adults and children receiving treatment for cancer. Search methods The search for this updated review was conducted on 19 November 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE via Ovid and Embase via Ovid. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform portal for additional articles. Selection criteria We included randomised controlled trials (RCTs) that compared either the administration of prophylactic antibiotics prior to long‐term CVC insertion versus no administration of antibiotics, or the use of an antibiotic versus a non‐antibiotic flush/lock solution in long‐term CVCs, in adults and children receiving treatment for cancer. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two authors independently selected studies, classified them and extracted data onto a predesigned data collection form. The outcomes of interest were gram‐positive catheter‐related infection events and total number of CVCs and CVC days. We pooled the data using a random‐effects model for meta‐analyses. We used the GRADE approach to assess the certainty of the evidence. Main results For this update, we identified 310 potentially relevant studies and screened them for eligibility. We included one additional RCT with 404 participants. The original review included 11 RCTs with a total of 840 people with cancer (adults and children). In total this review included 12 RCTs with 1244 participants. Antibiotics prior to insertion of the CVC 
Six trials compared the use of antibiotics (vancomycin, teicoplanin, ceftazidime or cefazolin) versus no antibiotics given before the insertion of a long‐term CVC. One study did not observe any CVC‐related infection events in either group was not included in the quantitative analysis as it was not possible to calculate a risk ratio. Administering an antibiotic prior to insertion of the CVC may not reduce gram‐positive CVC‐related infections (pooled risk ratio 0.67, confidence interval (CI) 95% 0.32 to 1.43; control versus intervention group risk 10.4% versus 7.3% of the participants; 5 studies, 648 participants; moderate‐certainty evidence). We sought adverse event data, but these were not described by the authors. The overall risk of bias was deemed low. Antibiotics as a flushing or locking solution 
Six trials compared a combined antibiotic (vancomycin, amikacin or taurolidine) and heparin solution with a heparin‐only solution for flushing or locking the long‐term CVC after use. One study did not observe any CVC‐related sepsis events (CRS) and was not included in this study in the quantitative analysis as it was not possible to calculate a risk ratio. Flushing and locking long‐term CVCs with a combined antibiotic and heparin solution likely reduced the risk of gram‐positive CVC‐related infections compared to a heparin‐only solution (pooled rate ratio 0.47, CI 95% 0.26 to 0.85; control versus intervention group rate ratio 0.66 versus 0.27 per 1000 CVC‐days; 5 studies, 443 participants; moderate‐certainty evidence). One trial reported a higher incidence of occlusions and participants in one trial reported an unpleasant taste after flushing associated with a combined antibiotic and heparin solution. The overall risk of bias was deemed low. Authors' conclusions Since the last version of this review, we included one additional study. There was no observed benefit of administering antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing or locking long‐term CVCs with an antibiotic solution likely reduces gram‐positive CVC‐related infections experienced in people at risk of neutropenia through chemotherapy or disease. However, a limitation of this review is heterogeneity between the studies for both outcomes. Insufficient data were available to evaluate if the conclusions apply equally for different CVC types and for adults versus children. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if the baseline CVC‐related infection rates are high. Further research is needed to identify high‐risk groups most likely to benefit from these antibiotic flush/lock solutions. Plain language summary Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer The issue 
People undergoing anti‐cancer treatment (chemotherapy) often have a catheter (tube) inserted into a large vein, through which their chemotherapy is given. This is known as a central venous catheter (CVC). As chemotherapy is usually administered over several months to years, long‐term CVCs are used. Despite sterile insertion and care afterwards, these CVCs often become infected by a type of bacteria called gram‐positive bacteria. Giving antibiotics as a preventive (prophylactic antibiotics) before the catheter is inserted, or using the antibiotics as a lock or flush solution, or both, may prevent these infections. A lock/flush solution is instilled in the catheter when it is not in use. This solution often contains heparin, saline, or both, to prevent a clot forming in the catheter. The aim of the review 
The aim of this review was to determine whether giving antibiotics before catheter insertion or as a lock/flush solution can prevent gram‐positive CVC‐related infections. What are the main findings? 
We searched databases to identify randomised controlled trials (RCTs ‐ clinical studies where people are randomly put into one of two or more treatment groups). We identified 12 relevant studies, which included a total of 1244 adults and children with cancer. We included six studies (756 people) that compared giving antibiotics before the insertion of the CVC against not giving antibiotics. We found that giving an antibiotic before CVC insertion did not prevent infections. The studies authors' did not describe side‐effects. We included six studies (488 people) that compared an antibiotic solution with a heparin‐only solution to flush/lock a CVC. We found that an antibiotic lock/flush solution reduced the number of CVC‐related infections. People in one study reported an unpleasant taste after flushing, and one study found there were fewer CVC obstructions (e.g. a clot) in people who received the combined antibiotic and anticoagulant solution. Certainty of the evidence 
We have moderate confidence in the evidence for giving antibiotics prior to CVC insertion and antibiotic lock/flush solutions since the studies were done in different people, used different types of catheters and antibiotics, and measured their results in different ways. What are the conclusions? 
We did not observe any benefit of giving antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing/locking long‐term CVCs with an antibiotic appeared to reduce gram‐positive CVC‐related infections in people with cancer. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if baseline CVC‐related infection rates are high. This review updates our previous review. The evidence is up to date to 19 November 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "van den Bosch, CH; van Woensel, J; van de Wetering, MD", "articleTypes": [], "doi": "10.1002/14651858.CD003295.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "cd4519c2-9cc5-478f-a0e1-737df7925944", "pmid": "", "title": "Complementary therapies for acne vulgaris", "imported": false, "abstract": "Abstract - Background Acne is a chronic skin disease characterised by inflamed spots and blackheads on the face, neck, back, and chest. Cysts and scarring can also occur, especially in more severe disease. People with acne often turn to complementary and alternative medicine (CAM), such as herbal medicine, acupuncture, and dietary modifications, because of their concerns about the adverse effects of conventional medicines. However, evidence for CAM therapies has not been systematically assessed. Objectives To assess the effects and safety of any complementary therapies in people with acne vulgaris. Search methods We searched the following databases from inception up to 22 January 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 , Issue 1 ), MEDLINE (from 1946), Embase (from 1974), PsycINFO (from 1806), AMED (from 1985), CINAHL (from 1981), Scopus (from 1966), and a number of other databases listed in the Methods section of the review. The Cochrane CAM Field Specialised Register was searched up to May 2014. We also searched five trials registers and checked the reference lists of articles for further references to relevant trials. Selection criteria We included parallel‐group randomised controlled trials (or the first phase data of randomised cross‐over trials) of any kind of CAM, compared with no treatment, placebo, or other active therapies, in people with a diagnosis of acne vulgaris. Data collection and analysis Three authors collected data from each included trial and evaluated the methodological quality independently. They resolved disagreements by discussion and, as needed, arbitration by another author. Main results We included 35 studies, with a total of 3227 participants. We evaluated the majority as having unclear risk of selection, attrition, reporting, detection, and other biases. Because of the clinical heterogeneity between trials and the incomplete data reporting, we could only include four trials in two meta‐analyses, with two trials in each meta‐analysis. The categories of CAM included herbal medicine, acupuncture, cupping therapy, diet, purified bee venom (PBV), and tea tree oil. A pharmaceutical company funded one trial; the other trials did not report their funding sources. Our main primary outcome was 'Improvement of clinical signs assessed through skin lesion counts', which we have reported as 'Change in inflammatory and non‐inflammatory lesion counts', 'Change of total skin lesion counts', 'Skin lesion scores', and 'Change of acne severity score'. For 'Change in inflammatory and non‐inflammatory lesion counts', we combined 2 studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD) at 12 weeks and found no clear evidence of a difference between the groups in change in non‐inflammatory lesion counts (mean difference (MD) ‐3.89, 95% confidence interval (CI) ‐10.07 to 2.29, P = 0.10, 75 participants, 2 trials, low quality of evidence). However, although data from 1 of these 2 trials showed benefit of LGLD for reducing inflammatory lesions (MD ‐7.60, 95% CI ‐13.52 to ‐1.68, 43 participants, 1 trial) and total skin lesion counts (MD ‐8.10, 95% CI ‐14.89 to ‐1.31, 43 participants, 1 trial) for people with acne vulgaris, data regarding inflammatory and total lesion counts from the other study were incomplete and unusable in synthesis. Data from a single trial showed potential benefit of tea tree oil compared with placebo in improving total skin lesion counts (MD ‐7.53, 95% CI ‐10.40 to ‐4.66, 60 participants, 1 trial, low quality of evidence) and acne severity scores (MD ‐5.75, 95% CI ‐9.51 to ‐1.99, 60 participants, 1 trial). Another trial showed pollen bee venom to be better than control in reducing numbers of skin lesions (MD ‐1.17, 95% CI ‐2.06 to ‐0.28, 12 participants, 1 trial). Results from the other 31 trials showed inconsistent effects in terms of whether acupuncture, herbal medicine, or wet‐cupping therapy were superior to controls in increasing remission or reducing skin lesions. Twenty‐six of the 35 included studies reported adverse effects; they did not report any severe adverse events, but specific included trials reported mild adverse effects from herbal medicines, wet‐cupping therapy, and tea tree oil gel. Thirty trials measured two of our secondary outcomes, which we combined and expressed as 'Number of participants with remission'. We were able to combine 2 studies (low quality of evidence), which compared Ziyin Qinggan Xiaocuo Granule and the antibiotic, minocycline (100 mg daily) (worst case = risk ratio (RR) 0.49, 95% CI 0.09 to 2.53, 2 trials, 206 participants at 4 weeks; best case = RR 2.82, 95% CI 0.82 to 9.06, 2 trials, 206 participants at 4 weeks), but there was no clear evidence of a difference between the groups. None of the included studies assessed 'Psychosocial function'. Two studies assessed 'Quality of life', and significant differences in favour of the complementary therapy were found in both of them on 'feelings of self‐worth' (MD 1.51, 95% CI 0.88 to 2.14, P < 0.00001, 1 trial, 70 participants; MD 1.26, 95% CI 0.20 to 2.32, 1 trial, 46 participants) and emotional functionality (MD 2.20, 95% CI 1.75 to 2.65, P < 0.00001, 1 trial, 70 participants; MD 0.93, 95% CI 0.17 to 1.69, 1 trial, 46 participants). Because of limitations and concerns about the quality of the included studies, we could not draw a robust conclusion for consistency, size, and direction of outcome effects in this review. Authors' conclusions There is some low‐quality evidence from single trials that LGLD, tea tree oil, and bee venom may reduce total skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs, such as herbal medicine, acupuncture, or wet‐cupping therapy, for the treatment of this condition. There is a potential for adverse effects from herbal medicines; however, future studies need to assess the safety of all of these CAM therapies. Methodological and reporting quality limitations in the included studies weakened any evidence. Future studies should be designed to ensure low risk of bias and meet current reporting standards for clinical trials. Plain language summary Complementary therapies for acne vulgaris Background Acne is a chronic skin disease, which causes spots to occur simultaneously on several areas of the body, including the face, neck, back, and chest. Besides the current commonly used treatments, complementary and alternative medicines (CAM) are of increasing interest to people who often use them in addition to conventional treatments as additive or single therapies to treat acne. The review question Can any complementary therapies improve the clinical symptoms of acne vulgaris? Study characteristics We searched relevant databases and trials registers up to 22 January 2014. We identified 35 randomised controlled trials, with 3227 participants, which used 6 kinds of CAM (herbal medicine, acupuncture, wet cupping, diet, purified bee venom, and tea tree oil). A pharmaceutical company funded one trial; the other trials did not report their funding sources. Key results For our primary outcome, we combined two studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD), but found no clear evidence of a difference between the 2 groups at 12 weeks for a change in non‐inflammatory lesion counts. Only one of these two trials provided usable data to show potential benefit of LGLD for reducing inflammatory and total skin lesion counts. Tea tree oil and pollen bee venom were found to reduce total skin lesion counts in single trials, respectively. The remaining 31 included trials gave mixed results about whether complementary therapies might reduce the total number of skin lesion counts. Twenty‐six trials reported adverse events. The herbal medicine group found some mild side‐effects, such as nausea, diarrhoea, and stomach upset. The acupuncture group found some itch or redness and pain following needle insertion. Participants who used tea tree oil reported itchiness, dryness, and flaking of the skin. None of the trials reported severe adverse effects. For our secondary outcome, there was no clear evidence of a difference in the number of participants with remission between Ziyin Qinggan Xiaocuo Granule and minocycline according to a meta‐analysis of two studies. Quality of the evidence There is some low‐quality evidence from single trials that a low‐glycaemic‐load diet, tea tree oil, and bee venom may reduce skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs. Methodological and reporting quality limitations in the included studies weakened any evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Cao, H, Yang, G, Wang, Y, Liu, JP, Smith, CA, Luo, H, Liu, Y", "articleTypes": [], "doi": "10.1002/14651858.CD009436.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.806Z" }, { "id": "cd5a1e6d-65da-4418-8872-485c6c7deeac", "pmid": "", "title": "Antidepressants for pain management in adults with chronic pain: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well‐being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients’ global impression of change for certain chronic pain conditions. However, there has not been a network meta‐analysis (NMA) examining all antidepressants across all chronic pain conditions. Objectives To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache). Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022. Selection criteria We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double‐blind. We included RCTs with active comparators that were unable to be double‐blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow‐up was less than two weeks and those with fewer than 10 participants in each arm. Data collection and analysis Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta‐analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta‐Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta‐analysis (ROB‐MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB‐MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal. Main results This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo‐controlled (83), and parallel−armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short‐term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest‐ranked antidepressant with moderate‐ to high‐certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate‐certainty evidence) and continuous pain intensity (standardised mean difference (SMD) −0.31, 95% CI −0.39 to −0.24; 18 studies, 4959 participants; moderate‐certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD −0.22, 95% CI −0.39 to 0.06; 4 studies, 1866 participants; moderate‐certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD −0.5, 95% CI −0.78 to −0.22; 1 study, 406 participants; low‐certainty evidence), while duloxetine showed a small effect (SMD −0.16, 95% CI −0.22 to −0.1; 26 studies, 7952 participants; moderate‐certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest‐ranked antidepressants with moderate‐certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low‐certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes. Authors' conclusions Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high‐quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long‐term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point. Plain language summary How effective are antidepressants used to treat chronic pain and do they cause unwanted effects? Key messages • We are only confident in the effectiveness of one antidepressant: duloxetine. We found that a standard dose (60 mg) was effective, and that there is no benefit to using a higher dose. • We are uncertain about unwanted effects for any antidepressant as the data for this were very poor. Future research should address this. • In clinical practice for chronic pain, a standard dose of duloxetine may be considered before trying other antidepressants. • Adopting a person‐centred approach is critical. Pain is a very individual experience and certain medications may work for people even while the research evidence is inconclusive or unavailable. Future studies should last longer and focus on unwanted effects of antidepressants. What is chronic pain? Chronic pain is pain of any kind that lasts for more than three months. Over one‐third of people across the world experience chronic pain. This often affects people's mood and well‐being, and their ability to work and carry out daily tasks. How do antidepressants treat chronic pain? Antidepressants are medications originally developed to treat depression. Different types of antidepressants work in different ways. Antidepressants that work in the same way are grouped into classes. The most common classes are selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and serotonin‐noradrenalin reuptake inhibitors (SNRIs). Research suggests that antidepressants may be effective for pain because the same chemicals that affect mood might also affect pain. What did we want to find out? We wanted to find out if antidepressants were effective for managing chronic pain and whether they cause unwanted effects. What did we do? We searched for studies that compared any antidepressant with any other treatment for any type of chronic pain (except headache). We compared all the treatments against each other using a statistical method called network meta‐analysis. This method allows us to rank the effectiveness of the different antidepressants from best to worst. What did we find? We found 176 studies including 28,664 people with chronic pain. These studies investigated 89 different types or combinations of treatment. Studies mainly investigated the effect of antidepressants on three different types of pain: fibromyalgia (59 studies), nerve pain (49 studies), and musculoskeletal pain (e.g. osteoarthritis or low back pain; 40 studies). The most common antidepressant classes investigated were SNRIs (74 studies), TCAs (72 studies), and SSRIs (34 studies). The most common antidepressants investigated were: amitriptyline (a TCA; 43 studies); duloxetine (an SNRI; 43 studies), and milnacipran (an SNRI; 18 studies). Of the 146 studies that reported where their funding came from, pharmaceutical companies funded 72 studies. The average study lasted 10 weeks. Most of the studies compared an antidepressant with a placebo (which looks like the real medicine but doesn’t have any medicine in it), but some studies compared an antidepressant against a different type of medicine, a different antidepressant, a different type of treatment (like physiotherapy), or different doses of the same antidepressant. Most of the studies in this review reported information on pain relief and unwanted effects. Fewer studies reported on quality of life, sleep, and physical function. Main results • Duloxetine probably has a moderate effect on reducing pain and improving physical function. It was the antidepressant that we have the most confidence in. Higher doses of duloxetine probably provided no extra benefits than standard doses. For every 1000 people taking standard‐dose duloxetine, 435 will experience 50% pain relief compared with 287 who will experience 50% pain relief taking placebo. • Milnacipran may reduce pain, but we are not as confident in this result as duloxetine because there were fewer studies with fewer people involved. • Most studies excluded people with mental health conditions, meaning that participants were already in the 'normal' ranges for anxiety and depression at the beginning of studies. This limited our analysis for mood. Mirtazapine and duloxetine may improve mood, but we are very uncertain about the results. • We do not know about unwanted effects of using antidepressants for chronic pain; there are not enough data to be certain about the results. What are the limitations of the evidence? There are still a number of questions that we were unable to answer: • Aside from duloxetine and milnacipran, we do not have confidence in the results from any other antidepressant included in this review because there are not enough studies. • We do not know whether antidepressants are effective at treating pain in the long term. The average length of studies was 10 weeks. • There was no reliable evidence on the safety of taking antidepressants for chronic pain, both short‐ and long‐term. • We do not know how effective antidepressants are for people with both chronic pain and depression as the most studies excluded participants with depression and anxiety. How up to date is this evidence? This review is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Birkinshaw, H; Friedrich, CM; Cole, P; Eccleston, C; Serfaty, M; Stewart, G; White, S; Moore, RA; Phillippo, D; Pincus, T", "articleTypes": [], "doi": "10.1002/14651858.CD014682.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "cd5c274a-1a79-4e76-a44b-3e28b508df77", "pmid": "", "title": "Topiramate for neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background Topiramate is an antiepileptic drug with multiple possible mechanisms of action. Antiepileptic drugs are widely used to treat chronic neuropathic pain (pain due to nerve damage) and fibromyalgia, and many guidelines recommend them. Objectives To assess the analgesic efficacy and associated adverse events of topiramate for chronic neuropathic pain and fibromyalgia in adults (aged 18 years and above). Search methods On 8 May 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We reviewed the bibliographies of all randomised trials identified and review articles, and also searched two clinical trial databases, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform, to identify additional published or unpublished data. Selection criteria We included randomised controlled trials (RCTs) with double‐blind assessment of participant outcomes following two weeks of treatment or longer (though the emphasis of the review was on studies of eight weeks or longer) that used a placebo or active comparator. Data collection and analysis We extracted efficacy and adverse event data, and two study authors examined issues of study quality independently. We performed analysis using two tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First tier studies did not use last‐observation‐carried‐forward (LOCF) or other imputation methods for dropouts. The second tier used data that failed to meet this standard; second tier results were therefore subject to potential bias. Main results We included four studies with 1684 participants. Three parallel‐group placebo comparisons were in painful diabetic neuropathy (1643 participants), and one cross‐over study with diphenhydramine as an active placebo (41 participants) was in lumbar radiculopathy. Doses of topiramate were titrated up to 200 mg/day or 400 mg/day. All studies had one or more sources of potential major bias, as they either used LOCF imputation or were of small size. No study provided first tier evidence for an efficacy outcome. There was no convincing evidence for efficacy of topiramate at 200 to 400 mg/day over placebo. Eighty‐two per cent of participants taking topiramate 200 to 400 mg/day experienced at least one adverse event, as did 71% with placebo, and the number needed to treat for an additional harmful effect (NNTH) was 8.6 (95% confidence interval (CI) 4.9 to 35). There was no difference in serious adverse events recorded (6.6% versus 7.5%). Adverse event withdrawals with 400 mg daily were much more common with topiramate (27%) than with placebo (8%), with an NNTH of 5.4 (95% CI 4.3 to 7.1). Lack of efficacy withdrawal was less frequent with topiramate (12%) than placebo (18%). Weight loss was a common event in most studies. No deaths attributable to treatment were reported. Authors' conclusions Topiramate is without evidence of efficacy in diabetic neuropathic pain, the only neuropathic condition in which it has been adequately tested. The data we have includes the likelihood of major bias due to LOCF imputation, where adverse event withdrawals are much higher with active treatment than placebo control. Despite the strong potential for bias, no difference in efficacy between topiramate and placebo was apparent. Plain language summary Topiramate for treating neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (for example from a fall, a cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in treating neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our knowledge about fibromyalgia is even less advanced, but fibromyalgia can respond to the same medicines as neuropathic pain. Topiramate is a medicine used to treat epilepsy, and so it might be a useful medicine for neuropathic pain or fibromyalgia. On 8 May 2013, we performed searches to look for clinical trials on the use of topiramate to treat neuropathic pain or fibromyalgia. We found four studies of reasonable quality that tested topiramate against placebo for a number of weeks. Almost all of the 1684 people in the studies had painful limbs because of damaged nerves caused by diabetes. Topiramate did not help the pain and was no different from placebo except in causing more side‐effects, which made many more people withdraw from the studies early. About 3 people in 10 withdrew because of side‐effects with topiramate compared with 1 in 10 with placebo. Topiramate has not been shown to work as a pain medicine in diabetic neuropathy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ; Derry, S; Lunn, MPT; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008314.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "cd70e6fe-86ab-4768-bdc6-689f91ed84af", "pmid": "", "title": "Reduced dietary salt for the prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review that was first published in 2011 of the effects of reducing dietary salt intake, through advice to reduce salt intake or low‐sodium salt substitution, on mortality and cardiovascular events. Objectives 1. To assess the long‐term effects of advice and salt substitution, aimed at reducing dietary salt, on mortality and cardiovascular morbidity. 2. To investigate whether a reduction in blood pressure is an explanatory factor in the effect of such dietary interventions on mortality and cardiovascular outcomes. Search methods We updated the searches of CENTRAL (2013, Issue 4), MEDLINE (OVID, 1946 to April week 3 2013), EMBASE (OVID, 1947 to 30 April 2013) and CINAHL (EBSCO, inception to 1 April 2013) and last ran these on 1 May 2013. We also checked the references of included studies and reviews. We applied no language restrictions. Selection criteria Trials fulfilled the following criteria: (1) randomised, with follow‐up of at least six months, (2) the intervention was reduced dietary salt (through advice to reduce salt intake or low‐sodium salt substitution), (3) participants were adults and (4) mortality or cardiovascular morbidity data were available. Two review authors independently assessed whether studies met these criteria. Data collection and analysis A single author extracted data and assessed study validity, and a second author checked this. We contacted trial authors where possible to obtain missing information. We extracted events and calculated risk ratios (RRs) and 95% confidence intervals (CIs). Main results Eight studies met the inclusion criteria: three in normotensives (n = 3518) and five in hypertensives or mixed populations of normo‐ and hypertensives (n = 3766). End of trial follow‐up ranged from six to 36 months and the longest observational follow‐up (after trial end) was 12.7 years. The risk ratios (RR) for all‐cause mortality in normotensives were imprecise and showed no evidence of reduction (end of trial RR 0.67, 95% confidence interval (CI) 0.40 to 1.12, 60 deaths; longest follow‐up RR 0.90, 95% CI 0.58 to 1.40, 79 deaths n=3518) or in hypertensives (end of trial RR 1.00, 95% CI 0.86 to 1.15, 565 deaths; longest follow‐up RR 0.99, 95% CI 0.87 to 1.14, 674 deaths n=3085). There was weak evidence of benefit for cardiovascular mortality (hypertensives: end of trial RR 0.67, 95% CI 0.45 to 1.01, 106 events n=2656) and for cardiovascular events (hypertensives: end of trial RR 0.76, 95% CI 0.57 to 1.01, 194 events, four studies, n = 3397; normotensives: at longest follow‐up RR 0.84, 95% CI 0.64 to 1.10, 200 events; hypertensives: RR 0.77, 95% CI 0.58 to 1.02, 192 events; pooled analysis of six trials (RR 0.81, 95% CI 0.66 to 0.98; n = 5762). These findings were driven by one trial among retirement home residents that reduced salt intake in the kitchens of the homes, thereby not requiring individual behaviour change. Advice to reduce salt showed small reductions in systolic blood pressure (mean difference (MD) ‐1.15 mmHg, 95% CI ‐2.32 to 0.02 n=2079) and diastolic blood pressure (MD ‐0.80 mmHg, 95% CI ‐1.37 to ‐0.23 n=2079) in normotensives and greater reductions in systolic blood pressure in hypertensives (MD ‐4.14 mmHg, 95% CI ‐5.84 to ‐2.43 n=675), but no difference in diastolic blood pressure (MD ‐3.74 mmHg, 95% CI ‐8.41 to 0.93 n=675). Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Health‐related quality of life was assessed in one trial in normotensives, which reported significant improvements in well‐being but no data were presented. Authors' conclusions Despite collating more event data than previous systematic reviews of randomised controlled trials, there is insufficient power to confirm clinically important effects of dietary advice and salt substitution on cardiovascular mortality in normotensive or hypertensive populations. Our estimates of the clinical benefits from advice to reduce dietary salt are imprecise, but are larger than would be predicted from the small blood pressure reductions achieved. Further well‐powered studies would be needed to obtain more precise estimates. Our findings do not support individual dietary advice as a means of restricting salt intake. It is possible that alternative strategies that do not require individual behaviour change may be effective and merit further trials. Plain language summary Reduced dietary salt for the prevention of cardiovascular disease Cardiovascular disease includes heart attacks and strokes and is a major cause of premature death and disability. This is an update of a review first published in 2011. This review sets out to assess whether intensive support and encouragement to cut down on salt in foods, and substituting low‐sodium salt, reduces the risk of death or cardiovascular disease. This update includes two new studies and eliminates one problematic study, giving a total of eight trials with 7284 participants. Dietary advice and salt substitution did reduce the amount of salt eaten, which led to a small reduction in blood pressure by six months. There was weak evidence of benefit for cardiovascular events, but these findings were inconclusive and were driven by a single trial among retirement home residents, which reduced salt intake in the kitchens of the homes. The findings of our review do not mean that advising people to reduce salt should be stopped. However, additional measures ‐ reducing the amount of hidden salt in processed foods, for example – will make it much easier for people to achieve a lower salt diet. Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Further evidence of the effects of different ways of reducing dietary salt on clinical events is needed from experimental and observational studies to underpin public health policies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Adler, AJ; Taylor, F; Martin, N; Gottlieb, S; Taylor, RS; Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD009217.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "cd71a8ca-6442-4ee2-847b-b0a19cb4f435", "pmid": "", "title": "Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder", "imported": false, "abstract": "Abstract - Background Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. Objectives To assess the effects ‐ and review the acceptability and tolerability ‐ of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. Selection criteria Double‐ or single‐blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. Data collection and analysis Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. Main results Thirty‐one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D‐cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP‐101,606 (1), decoglurant (1), MK‐0657 (1), N‐acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty‐eight studies were placebo‐controlled, and 48 were two‐arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild‐to‐moderate depression. Nineteen studies recruited only patients with treatment‐resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low‐certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) ‐0.87, 95% CI ‐1.26 to ‐0.48; n = 231, studies = 8, very low‐certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low‐certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low‐certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low‐certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and midazolam (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low‐certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate‐certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD ‐0.31, 95% CI ‐0.45 to ‐0.17; n = 824, studies = 4, moderate‐certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low‐certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate‐certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. Authors' conclusions Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta‐analyses for each comparison and the majority of comparisons included only one study. Long term non‐inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real‐world monitoring are needed to establish comprehensive data on safety and efficacy. Plain language summary Ketamine and other glutamate receptor modulators for depression in adults Why is this review important? Depression is one of the most common mental disorders, estimated to affect 350 million people worldwide. Antidepressant medication tends to be given as a first treatment for people with major depression. These drugs are however only effective in about one in four people at one year. Effective alternative medications to treat depression are needed, especially for rapid treatment. A new group of medications is called ‘glutamate receptor modulators’, which act on the glutamergic system. This group includes the medicine ketamine. In this review we examined the evidence for glutamate receptor modulators, including ketamine, as a treatment for depression. Who will be interested in this review? ‐ People with depression, their friends and families. ‐ General practitioners, psychiatrists, psychologists and pharmacists. ‐ Professionals working in adult mental health services. What questions does this review aim to answer? 1. Is treatment with ketamine and other glutamate receptor modulators more effective than treatment with placebo (dummy pill) or other drugs? 2. Is treatment with ketamine and other glutamate receptor modulators more acceptable than placebo or other drugs? Which studies were included in the review? We searched medical databases to find all relevant studies (specifically randomised controlled trials) completed up to 30 July 2020. To be included in the review, studies had to compare ketamine or other glutamate receptor modulators with placebo, other medicines or electroconvulsive therapy (ECT) for depression in adults (aged 18 and over). The studies also had to be single‐blind (the participant does not know which treatment they are receiving) or double‐blind (neither the participant or researcher know which treatment the participant is receiving), to attempt to reduce bias. We included 64 studies in the review, involving a total of 5299 people. The studies investigated16 different glutamate receptor modulator medications. The majority of participants had treatment‐resistant depression (depression which had not responded to two or more medications) at the start of the studies. Most studies were two‐armed, where the glutamate receptor modulator was compared with one other intervention. What does the evidence from the review tell us? Among the 16 drugs included in this review, only ketamine and esketamine were more effective than placebo at reducing symptoms of depression. The effects of ketamine lasted no more than one week after treatment and clearly disappeared after two weeks. Ketamine did, however, cause more side effects than placebo. The effects of esketamine were seen at 24 hours and could last up to four weeks with repeated doses. Esketamine caused a lot more side effects than placebo. The certainty of evidence varied considerably. There was no evidence of a difference between the other glutamate receptor modulators included in this review and placebo or other medications. What should happen next? Ketamine and esketamine appear to reduce the symptoms of depression. However, the trials were all short term so we do not know about the long‐term effects. It is important to note that in some trials attempts to prevent participants and investigators from knowing what medicine was being given were not successful and this may have inflated the positive effects of the active drugs. Future studies should examine what happens when people are repeatedly given the drug, with the aim to mimic the real‐world practice and assess longer‐term effects. More non‐inferiority trials should be conducted, where glutamate receptor modulators are compared with other active medications rather than placebo to find out whether they are better than alternative treatments. In most of the ketamine trials in this review, participants were given the drug by injection into a vein. This restricts the wide‐scale application of ketamine in clinical settings, so trials of ketamine by other routes are needed. Esketamine trials usually used nasal sprays, which are easier to use and could potentially be taken at home if further monitoring and trials found that it was safe to do so. Further studies assessing administration are needed in order to draw more reliable and firm conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Dean, RL, Hurducas, C, Hawton, K, Spyridi, S, Cowen, PJ, Hollingsworth, S, Marquardt, T, Barnes, A, Smith, R, McShane, R, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011612.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.813Z" }, { "id": "cda1975d-6a90-4d05-8bba-feb529574fac", "pmid": "", "title": "Toward Understanding Dopamine Receptor Contributions to Prediction Error and Reversal Learning in Anorexia Nervosa", "imported": false, "abstract": "Anorexia nervosa (AN) is an eating disorder associated with intense fear of weight gain, food refusal, and severe weight loss. AN has the highest mortality rate among the psychiatric disorders; however, little is known about biomarkers, and no medication has been approved for AN. Many individuals only partially recover, and treatment options, especially for the psychological components of the illness, are not very effective, highlighting the need for more effective treatments.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.235Z" }, { "id": "cdb7ddea-f714-447e-a2f0-2eccbf59726c", "pmid": "", "title": "Janus kinase inhibitors for the treatment of COVID‐19", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kramer, A, Prinz, C, Fichtner, F, Fischer, A-L, Thieme, V, Grundeis, F, Spagl, M, Seeber, C, Piechotta, V, Metzendorf, M-I, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015209 AB - Abstract - Background With potential antiviral and anti‐inflammatory properties, Janus kinase (JAK) inhibitors represent a potential treatment for symptomatic severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. They may modulate the exuberant immune response to SARS‐CoV‐2 infection. Furthermore, a direct antiviral effect has been described. An understanding of the current evidence regarding the efficacy and safety of JAK inhibitors as a treatment for coronavirus disease 2019 (COVID‐19) is required. Objectives To assess the effects of systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo) on clinical outcomes in individuals (outpatient or in‐hospital) with any severity of COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising MEDLINE, Embase, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform, medRxiv, and Cochrane Central Register of Controlled Trials), Web of Science, WHO COVID‐19 Global literature on coronavirus disease, and the US Department of Veterans Affairs Evidence Synthesis Program (VA ESP) Covid‐19 Evidence Reviews to identify studies up to February 2022. We monitor newly published randomised controlled trials (RCTs) weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials from this source until the first week of April 2022. Selection criteria We included RCTs that compared systemic JAK inhibitors plus standard of care to standard of care alone (plus/minus placebo) for the treatment of individuals with COVID‐19. We used the WHO definitions of illness severity for COVID‐19. Data collection and analysis We assessed risk of bias of primary outcomes using Cochrane's Risk of Bias 2 (RoB 2) tool. We used GRADE to rate the certainty of evidence for the following primary outcomes: all‐cause mortality (up to day 28), all‐cause mortality (up to day 60), improvement in clinical status: alive and without need for in‐hospital medical care (up to day 28), worsening of clinical status: new need for invasive mechanical ventilation or death (up to day 28), adverse events (any grade), serious adverse events, secondary infections. Main results We included six RCTs with 11,145 participants investigating systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo). Standard of care followed local protocols and included the application of glucocorticoids (five studies reported their use in a range of 70% to 95% of their participants; one study restricted glucocorticoid use to non‐COVID‐19 specific indications), antibiotic agents, anticoagulants, and antiviral agents, as well as non‐pharmaceutical procedures. At study entry, about 65% of participants required low‐flow oxygen, about 23% required high‐flow oxygen or non‐invasive ventilation, about 8% did not need any respiratory support, and only about 4% were intubated. We also identified 13 ongoing studies, and 9 studies that are completed or terminated and where classification is pending. Individuals with moderate to severe disease Four studies investigated the single agent baricitinib (10,815 participants), one tofacitinib (289 participants), and one ruxolitinib (41 participants). Systemic JAK inhibitors probably decrease all‐cause mortality at up to day 28 (95 of 1000 participants in the intervention group versus 131 of 1000 participants in the control group; risk ratio (RR) 0.72, 95% confidence interval (CI) 0.57 to 0.91; 6 studies, 11,145 participants; moderate‐certainty evidence), and decrease all‐cause mortality at up to day 60 (125 of 1000 participants in the intervention group versus 181 of 1000 participants in the control group; RR 0.69, 95% CI 0.56 to 0.86; 2 studies, 1626 participants; high‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in improvement in clinical status (discharged alive or hospitalised, but no longer requiring ongoing medical care) (801 of 1000 participants in the intervention group versus 778 of 1000 participants in the control group; RR 1.03, 95% CI 1.00 to 1.06; 4 studies, 10,802 participants; moderate‐certainty evidence). They probably decrease the risk of worsening of clinical status (new need for invasive mechanical ventilation or death at day 28) (154 of 1000 participants in the intervention group versus 172 of 1000 participants in the control group; RR 0.90, 95% CI 0.82 to 0.98; 2 studies, 9417 participants; moderate‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in the rate of adverse events (any grade) (427 of 1000 participants in the intervention group versus 441 of 1000 participants in the control group; RR 0.97, 95% CI 0.88 to 1.08; 3 studies, 1885 participants; moderate‐certainty evidence), and probably decrease the occurrence of serious adverse events (160 of 1000 participants in the intervention group versus 202 of 1000 participants in the control group; RR 0.79, 95% CI 0.68 to 0.92; 4 studies, 2901 participants; moderate‐certainty evidence). JAK inhibitors may make little or no difference to the rate of secondary infection (111 of 1000 participants in the intervention group versus 113 of 1000 participants in the control group; RR 0.98, 95% CI 0.89 to 1.09; 4 studies, 10,041 participants; low‐certainty evidence). Subgroup analysis by severity of COVID‐19 disease or type of JAK inhibitor did not identify specific subgroups which benefit more or less from systemic JAK inhibitors. Individuals with asymptomatic or mild disease We did not identify any trial for this population. Authors' conclusions In hospitalised individuals with moderate to severe COVID‐19, moderate‐certainty evidence shows that systemic JAK inhibitors probably decrease all‐cause mortality. Baricitinib was the most often evaluated JAK inhibitor. Moderate‐certainty evidence suggests that they probably make little or no difference in improvement in clinical status. Moderate‐certainty evidence indicates that systemic JAK inhibitors probably decrease the risk of worsening of clinical status and make little or no difference in the rate of adverse events of any grade, whilst they probably decrease the occurrence of serious adverse events. Based on low‐certainty evidence, JAK inhibitors may make little or no difference in the rate of secondary infection. Subgroup analysis by severity of COVID‐19 or type of agent failed to identify specific subgroups which benefit more or less from systemic JAK inhibitors. Currently, there is no evidence on the efficacy and safety of systemic JAK inhibitors for individuals with asymptomatic or mild disease (non‐hospitalised individuals). Plain language summary Are systemic Janus kinase inhibitors an effective treatment for people with COVID‐19? Key messages We found moderate‐ to high‐certainty evidence from 6 studies to conclude that systemic Janus kinase (JAK) inhibitors are an effective treatment for coronavirus disease 2019 (COVID‐19) in hospitalised people, because they resulted in fewer deaths and a lower rate of clinical deterioration. Evaluation of systemic JAK inhibitors is ongoing in 13 studies whilst the results of 9 further studies are awaiting publication. We will update this review and may adapt our conclusions when their results become available. What are JAK inhibitors? JAK inhibitors are medicines that block the activity of certain parts of the immune system that are sometimes problematic. They are taken orally (systemic) and usually are taken by people who suffer from autoimmune diseases, where the immune system attacks the body itself. JAK inhibitors might also be administered by inhalation but since this was not our focus, we refer to 'systemic JAK inhibitors' throughout the review. How might JAK inhibitors treat COVID‐19? In COVID‐19, the immune system sometimes overreacts, which can lead to a severe course of disease. JAK inhibitors can block parts of the immune system and counteract any clinical deteriorations. What did we want to find out? We wanted to know whether systemic JAK inhibitors, in addition to usual care, are effective for people with COVID‐19 when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in:
• number of deaths from any cause up to 60 days after treatment, or longer if reported;
• whether people got better or worse after treatment, based on their need for breathing support;
• unwanted effects of the treatment and infections acquired in hospital. What did we do? We searched for studies that reported on people with COVID‐19 who received systemic JAK inhibitors together with usual care, or usual care alone (plus/minus placebo). We compared and summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We found 6 suitable studies involving 11,145 people with COVID‐19. All studies compared systemic JAK inhibitors (baricitinib in 4 studies, tofacitinib in 1 study and ruxolitinib in 1 study) to usual care (in addition to placebo), and were performed in hospitalised people. We did not find studies performed in outpatients. Most participants needed oxygen supplementation through low‐flow devices (7220 participants) and few (463 participants) were mechanically ventilated at the study entry. We also identified 13 ongoing studies and 9 studies that are completed/terminated but unpublished yet. Main results Systemic JAK inhibitors plus usual care compared to usual care alone probably lead to fewer deaths from all causes at up to day 28 and lead to fewer deaths from all causes up to day 60 in the studies. It was not possible to identify subgroups of participants (according to severity of illness) who might benefit most from treatment with JAK inhibitors. Systemic JAK inhibitors probably make little or no difference in improvement in clinical status. They probably decrease the risk of worsening of clinical status. Systemic JAK inhibitors probably make little or no difference in the rate of unwanted effects, and probably decrease slightly the occurrence of serious unwanted effects. Systemic JAK inhibitors may result in little or no difference in the rate of infections acquired in hospital. What are the limitations of the evidence? As current studies on systemic JAK inhibitors in outpatients are lacking, evidence is limited in this group of people with COVID‐19. Studies used different ways to assess and report unwanted effects, especially in regard to infections acquired in hospital. In accordance with the living approach of this review, we will continually update our search and include eligible trials to fill this evidence gap. How up to date is this evidence? The evidence is up to date to February 2022. We monitor newly published studies weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials identified from this source until the first week of April 2022.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.820Z" }, { "id": "cdc69ab6-99a5-4c40-97f3-46bfd9d5fcf2", "pmid": "", "title": "Interventions for treating acute high altitude illness", "imported": false, "abstract": "Abstract - Background Acute high altitude illness is defined as a group of cerebral and pulmonary syndromes that can occur during travel to high altitudes. It is more common above 2500 metres, but can be seen at lower elevations, especially in susceptible people. Acute high altitude illness includes a wide spectrum of syndromes defined under the terms 'acute mountain sickness' (AMS), 'high altitude cerebral oedema' and 'high altitude pulmonary oedema'. There are several interventions available to treat this condition, both pharmacological and non‐pharmacological; however, there is a great uncertainty regarding their benefits and harms. Objectives To assess the clinical effectiveness, and safety of interventions (non‐pharmacological and pharmacological), as monotherapy or in any combination, for treating acute high altitude illness. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science, CINAHL, Wanfang database and the World Health Organization International Clinical Trials Registry Platform for ongoing studies on 10 August 2017. We did not apply any language restriction. Selection criteria We included randomized controlled trials evaluating the effects of pharmacological and non‐pharmacological interventions for individuals suffering from acute high altitude illness: acute mountain sickness, high altitude pulmonary oedema or high altitude cerebral oedema. Data collection and analysis Two review authors independently assessed the eligibility of study reports, the risk of bias for each and performed the data extraction. We resolved disagreements through discussion with a third author. We assessed the quality of evidence with GRADE. Main results We included 13 studies enrolling a total of 468 participants. We identified two ongoing studies. All studies included adults, and two studies included both teenagers and adults. The 13 studies took place in high altitude areas, mostly in the European Alps. Twelve studies included participants with acute mountain sickness, and one study included participants with high altitude pulmonary oedema. Follow‐up was usually less than one day. We downgraded the quality of the evidence in most cases due to risk of bias and imprecision. We report results for the main comparisons as follows. Non‐pharmacological interventions (3 studies, 124 participants) All‐cause mortality and complete relief of AMS symptoms were not reported in the three included trials. One study in 64 participants found that a simulated descent of 193 millibars versus 20 millibars may reduce the average of symptoms to 2.5 vs 3.1 units after 12 hours of treatment (clinical score ranged from 0 to 11 ‒ worse; reduction of 0.6 points on average with the intervention; low quality of evidence). In addition, no complications were found with use of hyperbaric chambers versus supplementary oxygen (one study; 29 participants; low‐quality evidence). Pharmacological interventions (11 trials, 375 participants) All‐cause mortality was not reported in the 11 included trials. One trial found a greater proportion of participants with complete relief of AMS symptoms after 12 and 16 hours when dexamethasone was administered in comparison with placebo (47.1% versus 0%, respectively; one study; 35 participants; low quality of evidence). Likewise, when acetazolamide was compared with placebo, the effects on symptom severity was uncertain (standardized mean difference (SMD) −1.15, 95% CI −2.56 to 0.27; 2 studies, 25 participants; low‐quality evidence). One trial of dexamethasone in comparison with placebo in 35 participants found a reduction in symptom severity (difference on change in the AMS score: 3.7 units reported by authors; moderate quality of evidence). The effects from two additional trials comparing gabapentin with placebo and magnesium with placebo on symptom severity at the end of treatment were uncertain. For gabapentin versus placebo: mean visual analogue scale (VAS) score of 2.92 versus 4.75, respectively; 24 participants; low quality of evidence. For magnesium versus placebo: mean scores of 9 and 10.3 units, respectively; 25 participants; low quality of evidence). The trials did not find adverse events from either treatment (low quality of evidence). One trial comparing magnesium sulphate versus placebo found that flushing was a frequent event in the magnesium sulphate arm (percentage of flushing: 75% versus 7.7%, respectively; one study; 25 participants; low quality of evidence). Authors' conclusions There is limited available evidence to determine the effects of non‐pharmacological and pharmacological interventions in treating acute high altitude illness. Low‐quality evidence suggests that dexamethasone and acetazolamide might reduce AMS score compared to placebo. However, the clinical benefits and harms related to these potential interventions remain unclear. Overall, the evidence is of limited practical significance in the clinical field. High‐quality research in this field is needed, since most trials were poorly conducted and reported. Plain language summary Treatments for high altitude (mountain) illness Background Acute high altitude illness, also known as acute mountain sickness, may present with a variety of symptoms. It is caused by the decreasing level of oxygen at increasingly high altitudes; and it can be experienced when reaching a high altitude when travelling, hiking or climbing mountains or other elevated areas. People going to altitudes over 4000 metres, females, people younger than mid‐adulthood , and people with a history of migraine are at greater risk of suffering from altitude sickness. The most common symptoms are headache, loss of appetite , insomnia, and nausea. However, severe forms can include confusion, difficulty walking, progressive cough, shortness of breath, and even death. Review question What are the benefits and risks of different treatments for people suffering from high altitude illness? Study characteristics We included 13 studies with a total of 468 participants. Most studies included participants with mild or moderate forms of mountain sickness, and only one study included the severe neurological (disorder of the nervous system) form. Follow‐up was usually less than one day. We also identified two ongoing studies. Key results We found studies evaluating the following interventions: simulated descent with a hyperbaric chamber (medical use of oxygen in a special chamber at greater than atmospheric pressure to increase the availability of oxygen in the body); oxygen; medicines: acetazolamide, dexamethasone, ibuprofen, paracetamol, gabapentin, sumatriptan, nitric oxide, and magnesium sulphate. None of the studies reported the effects of these interventions on all‐cause mortality. The report of complete relief from acute mountain sickness symptoms, and adverse events was infrequent. Studies related to simulated descent with the use of a hyperbaric chamber did not find additional benefits or harms related to this intervention (3 studies, 124 participants). In addition, studies related to administration of medicines found some benefits in terms of reduction of symptoms with the use of acetazolamide (2 studies, 25 participants), and dexamethasone (1 study, 35 participants), without an increase in side effects. Quality of the evidence The quality of the evidence we found was low, and thus our certainty in the findings is limited. There was insufficient information on how the studies were conducted, and in some cases there was evidence of tampering at some stages of the trials. Furthermore, the number of persons in each study was very small (< 30 participants), and therefore the results were not clear (imprecise). Some studies were not blinded (that is, participants knew what experimental treatment they were receiving), and this could have affected how the participants evaluated their own symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Simancas‐Racines, D, Arevalo‐Rodriguez, I, Osorio, D, Franco, JVA, Xu, Y, Hidalgo, R", "articleTypes": [], "doi": "10.1002/14651858.CD009567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.737Z" }, { "id": "ce100589-f9ae-4440-bdc4-d4c777bbd9a3", "pmid": "", "title": "Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery", "imported": false, "abstract": "Abstract - Background In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete. Objectives To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Date of the last search: 20 November 2014. Selection criteria Randomised and quasi‐randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention. Data collection and analysis Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta‐analyses were performed on available and relevant data. Main results Of the 16 identified trials, four (112 participants) were eligible for inclusion. Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon‐aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post‐operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re‐intervention was not reported by either trial. Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re‐intervention). In one trial a high‐dose rFVIIa regimen (90 μg/kg) was compared with a low‐dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety. Authors' conclusions There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well‐designed randomised controlled trials would be needed, in particular to address the cost‐effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies. Plain language summary Preventing bleeding in people with congenital bleeding disorders during and after surgery In haemophilia and other congenital bleeding disorders blood does not clot properly, which can cause excessive bleeding. This is particularly relevant during surgery, when the risk of bleeding depends on the type and severity of the clotting disorder and on the type of surgery. Therefore, during and after surgery, these individuals should receive treatment to improve the ability of their blood to clot and so prevent bleeding. Clotting factor concentrates (when available and appropriate in those individuals missing specific clotting proteins) or other non‐specific drugs for clotting, or a combination of both, are administered. It is not known what is the optimal dose or duration or method of administration of these treatments in these circumstances. We searched for randomised controlled trials comparing the efficacy (mortality, blood loss, need for re‐intervention, subjective assessment of efficacy, duration and dose of therapy) and the safety of any type of treatment given to people with congenital bleeding disorders during any type of surgery. We found four trials to be included in this review. Two trials evaluated 59 people with haemophilia A or B receiving antifibrinolytic drugs (agents that reduce the breakdown of clots) or placebo in addition to the initial standard treatment before dental extractions. The remaining two trials evaluated 53 people with haemophilia A or B and inhibitors (antibodies that act against the factor concentrate therapy) receiving an different clotting concentrate, recombinant activated factor VII, both during and after surgery. These two trials evaluated different treatment options: high‐dose compared with low‐dose and a single large (bolus) infusion compared with continuous infusion. The trials included in this review provide some information in two specific situations in people with congenital bleeding disorders undergoing surgery. However, on the whole, there is not enough evidence from trials to define the best treatments for the various types of disease and types of surgery. Further trials would be useful to improve our knowledge but are difficult to carry out and currently do not appear to be a clinical priority. Indeed, both major and minor surgery are safely performed in clinical practice in these individuals based on local experience and data from uncontrolled studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Coppola, A; Windyga, J; Tufano, A; Yeung, C; Di Minno, MND", "articleTypes": [], "doi": "10.1002/14651858.CD009961.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "ce28f995-4ea6-4ec0-be55-6a09955b177d", "pmid": "", "title": "A PHASE 2, NON RANDOMIZED, OPEN LABEL, SINGLE ARM, MULTI CENTER STUDY OF TALAZOPARIB FOR NEOADJUVANT TREATMENT OF GERMLINE BRCA1/2 MUTATION PATIENTS WITH EARLY HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR 2 NEGATIVE BREAST CANCER", "imported": false, "abstract": "A PHASE 2, NON RANDOMIZED, OPEN LABEL, SINGLE ARM, MULTI CENTER STUDY OF TALAZOPARIB FOR NEOADJUVANT TREATMENT OF GERMLINE BRCA1/2 MUTATION PATIENTS WITH EARLY HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR 2 NEGATIVE BREAST CANCER", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.265Z" }, { "id": "ce31d1e1-dd46-40f5-8d21-6a3932c59df9", "pmid": "", "title": "Beclomethasone versus placebo for chronic asthma", "imported": false, "abstract": "Abstract - Background Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti‐inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane‐134a (HFA) propellant which is free from chlorofluorocarbon (CFC). Objectives The objectives of this review were to: 
 (1) Compare the efficacy of BDP with placebo with both CFC and HFA propellants in the treatment of chronic asthma. 
 (2) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. 
 (3) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies. Search methods Electronic searches were current as of January 2003. Selection criteria Randomised parallel group design trials for a minimum period of four weeks, in children and adults comparing CFC‐BDP or HFA‐BDP with placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality. Data collection and analysis One reviewer extracted data; authors were contacted to clarify missing information. We analysed data with RevMan Analyses 1.0.2. Main results 60 studies recruiting 6542 participants met the inclusion criteria. CFC‐BDP (57 studies): In non‐oral steroid treated patients, at doses of 400mcg/day or less CFC‐BDP produced significant improvements from baseline in a number of efficacy measures compared with placebo, including forced expiratory volume in one second (FEV1) 360 ml (95% CI 260 to 460); FEV1 (% predicted) WMD 12.41% (95% CI 8.18 to 16.64) and morning peak expiratory flow rate (am PEF) WMD 35.95 L/min (95% CI 27.85 to 44.04). BDP also led to reductions in rescue beta‐2 agonist use compared with placebo of ‐2.32 puffs/d (95% CI ‐2.55 to ‐2.09) and reduced the relative risk (RR) of trial withdrawal due to an asthma exacerbation 0.25 (95% CI 0.12 to 0.51). Subgroup analyses based on treatment duration provide support to the proposal that a treatment period of greater than four weeks is required to realise a fuller treatment effect. In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD ‐4.91 mg/d (95% CI ‐5.88 to ‐3.94 mg/d) and greater likelihood of withdrawing oral steroid treatment RR 8.02 (95% CI 3.23 to 19.92). HFA‐BDP (3 studies): In non‐oral steroid‐treated patients, HFA‐BDP was significantly more effective than placebo in improving FEV1, morning and evening PEF, FEF25 to 75%, reduced asthma symptoms and beta2‐agonists daily consumption. Significant effects for such outcomes were apparent after six weeks of treatment. In oral steroid treated patients, HFA‐BDP improved significantly FEV1 and am PEF. The summary estimates for these outcomes suggested a high level of heterogeneity, and divergent aims of the studies may contribute to the variation we observed. Limited data on adverse events were reported. Authors' conclusions This review has quantified the efficacy of CFC‐BDP and HFA‐BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose‐response in people with severe asthma. Plain language summary Inhaled beclomethasone compared with placebo for chronic asthma During an asthma attack, the airways narrow, causing breathing problems, wheezing and coughing. Inhaled corticosteroids (ICS) are used to reduce swelling of the airways. Inhaled beclomethasone dipropionate (BDP) is commonly used. There is now a new formulation of the drug which uses a new propellant (HFA‐BDP). This review of trials found that BDP delivered with the old and new propellant is effective in helping people with chronic asthma. BDP at all doses improves airflow, reduces symptoms and the need for rescue bronchodilators. The review only included studies conducted for more than 4 weeks. The drug was well tolerated and the safety profile was comparable with placebo. The findings apply to both children and adults. The effects of the new propellant suggest that it could be more effective than the older version, although a different review will address that particular question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Adams, NP; Bestall, JC; Malouf, R; Lasserson, TJ; Jones, P", "articleTypes": [], "doi": "10.1002/14651858.CD002738.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "ce31dd22-81f1-439e-b615-9398c0e314e9", "pmid": "", "title": "Enteral nutritional therapy for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta‐analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review. Objectives To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts. Selection criteria Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review. Data collection and analysis Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random‐effects model was used to pool data. We performed intention‐to‐treat and per‐protocol analyses for the primary outcome. Heterogeneity was explored using the Chi 2 and I 2 statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes. Main results Twenty‐seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non‐elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non‐elemental diets differing in glutamine enrichment. Meta‐analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty‐four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non‐elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per‐protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non‐elemental diets (elemental, semi‐elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non‐elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating. Ten trials compared EN to steroid therapy. Meta‐analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per‐protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per‐protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet. Authors' conclusions Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy Plain language summary Enteral nutritional therapy for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a long‐term inflammation of the gastrointestinal (GI) tract, occurring anywhere from mouth to anus. Common symptoms of this condition include abdominal pain, diarrhea and weight loss. When Crohn's disease patients are experiencing symptoms, it is characterized to be 'active' disease. When the symptoms stop, it is called 'remission'. What is enteral nutrition? Enteral nutrition is a feeding method where all of a person's daily caloric intake is delivered using the GI tract. An example of this is nasogastric tube feeding, where a tube is inserted through a person's nose to deliver their daily nutritional requirements in liquid form. Enteral nutrition can be a form of nutritional therapy for Crohn's disease patients. Enteral nutrition is categorized into elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets come from amino‐acid sources, whereas non‐elemental diets come from oligopeptide or whole protein sources. What are corticosteroids? Corticosteroids are an effective treatment option for active Crohn's disease. These drugs that are taken by mouth and work as immunosuppressants. What did the researchers investigate? The researchers studied whether enteral nutrition is better than steroid therapy at producing remission in Crohn's disease patients. In addition, the investigators looked to see if one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) at producing remission in Crohn's disease. What did the researchers find? The researchers found twenty‐seven studies (1,011 participants) that fulfilled the search criteria. Eleven of these studies, which included 378 patients, compared elemental to non‐elemental diets at producing remission in Crohn's disease. Eight studies, which included 352 patients, investigated enteral nutrition compared to steroid therapy at inducing remission in Crohn's disease. The researchers searched the medical literature extensively up to July 5, 2017. Very low quality evidence suggests that steroids may be more effective than enteral nutrition for induction of remission in adults with active Crohn's disease. Very low quality evidence also suggests that enteral nutrition may be more effective than steroids for induction of remission in children with active Crohn's disease. There was no difference in remission rates between elemental and non‐elemental diets. An increase in side effects was not seen with elemental diets compared to non‐elemental diets, nor with enteral nutrition compared to steroids. Common side effects experienced with enteral nutrition included vomiting, diarrhea, heartburn and flatulence . Common side effects associated with steroid use included acne, moon facies, muscle weakness, hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) . Patients on enteral nutrition were more likely to withdraw from the study due to side effects than those on steroids. The most common reason for study withdrawal was inability to tolerate the taste of the enteral nutrition diet. Enteral nutrition should be considered in pediatric Crohn's patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient compliance with this therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Narula, N, Dhillon, A, Zhang, D, Sherlock, ME, Tondeur, M, Zachos, M", "articleTypes": [], "doi": "10.1002/14651858.CD000542.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.788Z" }, { "id": "ce340f6e-cfd3-4f4b-9ba2-f83f3cf11b36", "pmid": "", "title": "Oral stimulation for promoting oral feeding in preterm infants", "imported": false, "abstract": "Abstract - Background Preterm infants (< 37 weeks' post‐menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co‐ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review. Objectives To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA. Search methods Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi‐randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis. Selection criteria Randomised and quasi‐randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non‐oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes. Data collection and analysis Following the updated search, two review authors screened the titles and abstracts of studies and full‐text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non‐oral or sham intervention. We performed meta‐analysis using a fixed‐effect model. Main results We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) ‐4.07 days, 95% confidence interval (CI) ‐4.81 to ‐3.32 days, 6 studies, 292 infants; I 2 =85%, very low‐certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD ‐4.33, 95% CI ‐5.97 to ‐2.68 days, 5 studies, 249 infants; i 2 =68%, very low‐certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non‐oral intervention Following meta‐analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non‐oral intervention (MD ‐7.17, 95% CI ‐8.04 to ‐6.29 days, 10 studies, 574 infants; I 2 =80%, very low‐certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD ‐6.15, 95% CI ‐8.63 to ‐3.66 days, 10 studies, 591 infants; I 2 =0%, low‐certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD ‐2.85, 95% CI ‐6.13 to 0.42, 3 studies, 268 infants; very low‐certainty evidence due to serious risk of bias, inconsistency and imprecision). Authors' conclusions There remains uncertainty about the effects of oral stimulation (versus either standard care or a non‐oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta‐analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well‐designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions. Plain language summary Effects of oral stimulation for oral feeding in preterm infants Review questions Do oral stimulation interventions that involve finger stimulation protocols in preterm infants born before 37 weeks' gestation: Reduce time (days) taken to achieve exclusive oral feeding? Reduce time (days) spent in Neonatal Intensive Care (NICU)? Reduce length of time (days) spent in hospital? Reduce length of time (days) that an infant spends on tube feeding (parenteral nutrition)? Background This is an update of the 2016 review. Many preterm infants have delayed establishment of oral (suck) feeding and are fed at first with feeding tubes or with intravenous (parenteral) nutrition. Development of oral feeding skills needs careful co‐ordination of sucking, swallowing and breathing. In preterm infants, the development of oral feeding can be challenging because of long hospitalisations, breathing difficulties and other medical conditions associated with preterm birth. Unpleasant and invasive procedures such as ventilation or frequent suctioning of secretions from the mouth or nose can negatively impact feeding skills. International guidelines for the transition from tube feeding to oral feeding vary widely. Healthcare providers use a range of interventions to improve sucking and feeding skills in preterm infants, and studies report faster transition time from tube feeds to oral feeds, reduced length of stay in hospital and improvement in infants' sucking skills. The first review in 2016 showed that while oral stimulation interventions appear to reduce length of hospital stay, reduce need for tube feeding and accelerate time to oral feeding, the studies were of poor methodological quality leaving some uncertainty about overall effects. This update assessed whether current research supports these findings and if the quality of studies has improved, leading to increased certainty of results. Study characteristics This review included randomised controlled trials (RCTs) that explored oral stimulation by finger stimulation only in preterm infants. Review authors identified studies to be included by searching electronic databases, clinical trials registers, peer‐reviewed journals and published conference proceedings. Search is up‐to‐date as of March 2022. Key results For this update, we added 12 new studies of variable quality with small numbers of participants, making a total of 28 included studies. As the certainty of evidence was considered 'low' to 'very low', it remains uncertain whether oral stimulation interventions can shorten the transition to oral feeding, reduce length of hospital stay and decrease time spent on parenteral nutrition, although there may be some potential benefit. No studies reported length of stay in NICU. No studies looked at longer‐term outcomes of the interventions (i.e. beyond six months). Certainty of evidence The numbers of infants in these studies were small, the methods employed by researchers varied in quality and the certainty of evidence is estimated to be 'low' to 'very low'.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, Z, O'Donnell, CPF, Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD009720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.794Z" }, { "id": "ce3505ff-8e35-41ef-bba0-7512ca5cc5f1", "pmid": "", "title": "Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight", "imported": false, "abstract": "Abstract - Background The global prevalence of childhood and adolescent obesity is high. Lifestyle changes towards a healthy diet, increased physical activity and reduced sedentary activities are recommended to prevent and treat obesity. Evidence suggests that changing these health behaviours can benefit cognitive function and school achievement in children and adolescents in general. There are various theoretical mechanisms that suggest that children and adolescents with excessive body fat may benefit particularly from these interventions. Objectives To assess whether lifestyle interventions (in the areas of diet, physical activity, sedentary behaviour and behavioural therapy) improve school achievement, cognitive function (e.g. executive functions) and/or future success in children and adolescents with obesity or overweight, compared with standard care, waiting‐list control, no treatment, or an attention placebo control group. Search methods In February 2017, we searched CENTRAL, MEDLINE and 15 other databases. We also searched two trials registries, reference lists, and handsearched one journal from inception. We also contacted researchers in the field to obtain unpublished data. Selection criteria We included randomised and quasi‐randomised controlled trials (RCTs) of behavioural interventions for weight management in children and adolescents with obesity or overweight. We excluded studies in children and adolescents with medical conditions known to affect weight status, school achievement and cognitive function. We also excluded self‐ and parent‐reported outcomes. Data collection and analysis Four review authors independently selected studies for inclusion. Two review authors extracted data, assessed quality and risks of bias, and evaluated the quality of the evidence using the GRADE approach. We contacted study authors to obtain additional information. We used standard methodological procedures expected by Cochrane. Where the same outcome was assessed across different intervention types, we reported standardised effect sizes for findings from single‐study and multiple‐study analyses to allow comparison of intervention effects across intervention types. To ease interpretation of the effect size, we also reported the mean difference of effect sizes for single‐study outcomes. Main results We included 18 studies (59 records) of 2384 children and adolescents with obesity or overweight. Eight studies delivered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies delivered dietary interventions. We included five RCTs and 13 cluster‐RCTs. The studies took place in 10 different countries. Two were carried out in children attending preschool, 11 were conducted in primary/elementary school‐aged children, four studies were aimed at adolescents attending secondary/high school and one study included primary/elementary and secondary/high school‐aged children. The number of studies included for each outcome was low, with up to only three studies per outcome. The quality of evidence ranged from high to very low and 17 studies had a high risk of bias for at least one item. None of the studies reported data on additional educational support needs and adverse events. Compared to standard practice, analyses of physical activity‐only interventions suggested high‐quality evidence for improved mean cognitive executive function scores. The mean difference (MD) was 5.00 scale points higher in an after‐school exercise group compared to standard practice (95% confidence interval (CI) 0.68 to 9.32; scale mean 100, standard deviation 15; 116 children, 1 study). There was no statistically significant beneficial effect in favour of the intervention for mathematics, reading, or inhibition control. The standardised mean difference (SMD) for mathematics was 0.49 (95% CI ‐0.04 to 1.01; 2 studies, 255 children, moderate‐quality evidence) and for reading was 0.10 (95% CI ‐0.30 to 0.49; 2 studies, 308 children, moderate‐quality evidence). The MD for inhibition control was ‐1.55 scale points (95% CI ‐5.85 to 2.75; scale range 0 to 100; SMD ‐0.15, 95% CI ‐0.58 to 0.28; 1 study, 84 children, very low‐quality evidence). No data were available for average achievement across subjects taught at school. There was no evidence of a beneficial effect of physical activity interventions combined with healthy lifestyle education on average achievement across subjects taught at school, mathematics achievement, reading achievement or inhibition control. The MD for average achievement across subjects taught at school was 6.37 points lower in the intervention group compared to standard practice (95% CI ‐36.83 to 24.09; scale mean 500, scale SD 70; SMD ‐0.18, 95% CI ‐0.93 to 0.58; 1 study, 31 children, low‐quality evidence). The effect estimate for mathematics achievement was SMD 0.02 (95% CI ‐0.19 to 0.22; 3 studies, 384 children, very low‐quality evidence), for reading achievement SMD 0.00 (95% CI ‐0.24 to 0.24; 2 studies, 284 children, low‐quality evidence), and for inhibition control SMD ‐0.67 (95% CI ‐1.50 to 0.16; 2 studies, 110 children, very low‐quality evidence). No data were available for the effect of combined physical activity and healthy lifestyle education on cognitive executive functions. There was a moderate difference in the average achievement across subjects taught at school favouring interventions targeting the improvement of the school food environment compared to standard practice in adolescents with obesity (SMD 0.46, 95% CI 0.25 to 0.66; 2 studies, 382 adolescents, low‐quality evidence), but not with overweight. Replacing packed school lunch with a nutrient‐rich diet in addition to nutrition education did not improve mathematics (MD ‐2.18, 95% CI ‐5.83 to 1.47; scale range 0 to 69; SMD ‐0.26, 95% CI ‐0.72 to 0.20; 1 study, 76 children, low‐quality evidence) and reading achievement (MD 1.17, 95% CI ‐4.40 to 6.73; scale range 0 to 108; SMD 0.13, 95% CI ‐0.35 to 0.61; 1 study, 67 children, low‐quality evidence). Authors' conclusions Despite the large number of childhood and adolescent obesity treatment trials, we were only able to partially assess the impact of obesity treatment interventions on school achievement and cognitive abilities. School and community‐based physical activity interventions as part of an obesity prevention or treatment programme can benefit executive functions of children with obesity or overweight specifically. Similarly, school‐based dietary interventions may benefit general school achievement in children with obesity. These findings might assist health and education practitioners to make decisions related to promoting physical activity and healthy eating in schools. Future obesity treatment and prevention studies in clinical, school and community settings should consider assessing academic and cognitive as well as physical outcomes. Plain language summary Healthy weight interventions for improving thinking skills and school performance in children and teenagers with obesity What is the aim of this review? The aim of this Cochrane Review was to find out if healthy weight interventions can improve thinking skills and school performance in children and teenagers with obesity. Cochrane researchers collected and analysed all relevant studies to answer this question. What are the key messages? This updated review provides some evidence that school programmes that encourage healthier child weight may also provide ‘co‐benefits’ of thinking skills and school performance. However, we need more high‐quality healthy‐weight interventions that test thinking skills and school performance, as well as health outcomes. What was studied in this review? The number of children and teenagers with obesity is high worldwide. Some children and teenagers with obesity have health issues or are bullied because of their body weight. These experiences have been linked to problems in performing well in school, where they tend to perform less well in thinking tasks such as problem‐solving. Physical activity and healthy eating benefit a healthy body weight and improve thinking skills and school performance in children with a healthy weight. Studies found that healthy‐weight interventions can reduce obesity in children and teenagers, but it is unknown if and how well healthy‐weight interventions can improve thinking skills and school performance in children and teenagers with obesity. What are the main results of this review? The review authors found 18 studies which included a total of 2384 children and teenagers with obesity. Five studies assigned individual children to intervention or control groups. Thirteen studies allocated entire classes, school or school districts to the intervention and control group. Of the 18 studies, 11 involved children at primary/elementary‐school age. Eight studies offered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies offered dietary changes. The studies took place in 10 different countries. Seventeen studies had at least one flaw in how the study was done. This reduces the level of confidence we can have in the findings. Few studies shared the same type of school performance or thinking skills. Only three studies reported the same outcome. None of the studies reported on additional educational support needs and harmful events. We found that, compared with usual routine, physical activity interventions can lead to small improvements in problem‐solving skills. This finding was based on high‐quality evidence. Moderate‐quality findings showed that physical activity interventions do not improve mathematics and reading achievement in children with obesity. Very low‐quality evidence also suggested no benefits of physical activity interventions for improving uncontrolled behavioural responses. General school achievement was not reported in studies comparing physical activity interventions with standard practice. Studies that compared physical activity interventions plus healthy lifestyle education with standard practice were of low to very low quality. They showed no improvement in school achievement or uncontrolled behavioural responses in the intervention group compared to the control group. Problem‐solving skills were not reported in studies comparing physical activity plus healthy lifestyle education with standard practice. Our findings indicate that changing knowledge about nutrition, and changing the food offered in schools can lead to moderate improvements in general school achievement of teenagers with obesity, when compared to standard school practice. Replacing packed school lunch with a nutrient‐rich diet plus nutrition education did not improve mathematics and reading achievement of children with obesity. However, the quality of evidence for general school achievement, mathematics and reading was low. This means that future research is very likely to change the results, because included studies showed some methodological weaknesses (for example, small numbers of children and a high dropout of children from studies). Problem‐solving skills and uncontrolled behavioural responses were not reported for dietary intervention studies. How up‐to‐date is this review? The review authors searched the scientific literature for relevant studies in February 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Martin, A; Booth, JN; Laird, Y; Sproule, J; Reilly, JJ; Saunders, DH", "articleTypes": [], "doi": "10.1002/14651858.CD009728.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "ce3aa2e7-ccbc-4db1-8b9c-34a0e81d1428", "pmid": "", "title": "Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health services. Decay and gum disease can cause pain, eating and speaking difficulties, low self‐esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self‐administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area. Objectives To evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other. Search methods Cochrane Oral Health’s Information Specialist searched: Cochrane Oral Health’s Trials Register (to 16 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 12), MEDLINE Ovid (1946 to 16 January 2019), Embase Ovid (1980 to 16 January 2019) and CINAHL EBSCO (1937 to 16 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication. Selection criteria Randomised controlled trials (RCTs) that compared toothbrushing and a home‐use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks). Data collection and analysis At least two review authors independently screened searches, selected studies, extracted data, assessed studies' risk of bias, and assessed evidence certainty as high, moderate, low or very low, according to GRADE. We extracted indices measured on interproximal surfaces, where possible. We conducted random‐effects meta‐analyses, using mean differences (MDs) or standardised mean differences (SMDs). Main results We included 35 RCTs (3929 randomised adult participants). Studies were at high risk of performance bias as blinding of participants was not possible. Only two studies were otherwise at low risk of bias. Many participants had a low level of baseline gingival inflammation. Studies evaluated the following devices plus toothbrushing versus toothbrushing: floss (15 trials), interdental brushes (2 trials), wooden cleaning sticks (2 trials), rubber/elastomeric cleaning sticks (2 trials), oral irrigators (5 trials). Four devices were compared with floss: interdental brushes (9 trials), wooden cleaning sticks (3 trials), rubber/elastomeric cleaning sticks (9 trials) and oral irrigators (2 trials). Another comparison was rubber/elastomeric cleaning sticks versus interdental brushes (3 trials). No trials assessed interproximal caries, and most did not assess periodontitis. Gingivitis was measured by indices (most commonly, Löe‐Silness, 0 to 3 scale) and by proportion of bleeding sites. Plaque was measured by indices, most often Quigley‐Hein (0 to 5). Primary objective: comparisons against toothbrushing alone Low‐certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index (GI)) at one month (SMD ‐0.58, 95% confidence interval (CI) ‐1.12 to ‐0.04; 8 trials, 585 participants), three months or six months. The results for proportion of bleeding sites and plaque were inconsistent (very low‐certainty evidence). Very low‐certainty evidence suggested that using an interdental brush, plus toothbrushing, may reduce gingivitis (measured by GI) at one month (MD ‐0.53, 95% CI ‐0.83 to ‐0.23; 1 trial, 62 participants), though there was no clear difference in bleeding sites (MD ‐0.05, 95% CI ‐0.13 to 0.03; 1 trial, 31 participants). Low‐certainty evidence suggested interdental brushes may reduce plaque more than toothbrushing alone (SMD ‐1.07, 95% CI ‐1.51 to ‐0.63; 2 trials, 93 participants). Very low‐certainty evidence suggested that using wooden cleaning sticks, plus toothbrushing, may reduce bleeding sites at three months (MD ‐0.25, 95% CI ‐0.37 to ‐0.13; 1 trial, 24 participants), but not plaque (MD ‐0.03, 95% CI ‐0.13 to 0.07). Very low‐certainty evidence suggested that using rubber/elastomeric interdental cleaning sticks, plus toothbrushing, may reduce plaque at one month (MD ‐0.22, 95% CI ‐0.41 to ‐0.03), but this was not found for gingivitis (GI MD ‐0.01, 95% CI ‐0.19 to 0.21; 1 trial, 12 participants; bleeding MD 0.07, 95% CI ‐0.15 to 0.01; 1 trial, 30 participants). Very‐low certainty evidence suggested oral irrigators may reduce gingivitis measured by GI at one month (SMD ‐0.48, 95% CI ‐0.89 to ‐0.06; 4 trials, 380 participants), but not at three or six months. Low‐certainty evidence suggested that oral irrigators did not reduce bleeding sites at one month (MD ‐0.00, 95% CI ‐0.07 to 0.06; 2 trials, 126 participants) or three months, or plaque at one month (SMD ‐0.16, 95% CI ‐0.41 to 0.10; 3 trials, 235 participants), three months or six months, more than toothbrushing alone. Secondary objective: comparisons between devices Low‐certainty evidence suggested interdental brushes may reduce gingivitis more than floss at one and three months, but did not show a difference for periodontitis measured by probing pocket depth. Evidence for plaque was inconsistent. Low‐ to very low‐certainty evidence suggested oral irrigation may reduce gingivitis at one month compared to flossing, but very low‐certainty evidence did not suggest a difference between devices for plaque. Very low‐certainty evidence for interdental brushes or flossing versus interdental cleaning sticks did not demonstrate superiority of either intervention. Adverse events Studies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation. Authors' conclusions Using floss or interdental brushes in addition to toothbrushing may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low‐certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis. Plain language summary Home use of devices for cleaning between the teeth (in addition to toothbrushing) to prevent and control gum diseases and tooth decay Review question How effective are home‐use interdental cleaning devices, plus toothbrushing, compared with toothbrushing only or use of another device, for preventing and controlling periodontal (gum) diseases (gingivitis and periodontitis), tooth decay (dental caries) and plaque? Background Tooth decay and gum diseases affect most people. They can cause pain, difficulties with eating and speaking, low self‐esteem, and, in extreme cases, may lead to tooth loss and the need for surgery. The cost to health services of treating these diseases is very high. As dental plaque (a layer of bacteria in an organic matrix that forms on the teeth) is the root cause, it is important to remove plaque from teeth on a regular basis. While many people routinely brush their teeth to remove plaque up to the gum line, it is difficult for toothbrushes to reach into areas between teeth ('interdental'), so interdental cleaning is often recommended as an extra step in personal oral hygiene routines. Different tools can be used to clean interdentally, such as dental floss, interdental brushes, tooth cleaning sticks, and water pressure devices known as oral irrigators. Study characteristics Review authors working with Cochrane Oral Health searched for studies up to 16 January 2019. We identified 35 studies (3929 adult participants). Participants knew that they were in an experiment, which might have affected their teeth cleaning or eating behaviour. Some studies had other problems that might make their findings less reliable, such as people dropping out of the study or not using the assigned device. Studies evaluated the following devices plus toothbrushing compared to toothbrushing only: floss (15 studies), interdental brushes (2 studies), wooden cleaning sticks (2 studies), rubber/elastomeric cleaning sticks (2 studies) and oral irrigators (5 studies). Four devices were compared with floss: interdental brushes (9 studies), wooden cleaning sticks (3 studies), rubber/elastomeric cleaning sticks (9 studies), oral irrigators (2 studies). Three studies compared rubber/elastomeric cleaning sticks with interdental brushes. No studies evaluated decay, and few evaluated severe gum disease. Outcomes were measured at short (one month to six weeks) and medium term (three and six months). Key results We found that using floss, in addition to toothbrushing, may reduce gingivitis in the short and medium term. It is unclear if it reduces plaque. Using an interdental brush, in addition to a toothbrush, may reduce gingivitis and plaque in the short term. Using wooden tooth cleaning sticks may be better than toothbrushing only for reducing gingivitis (measured by bleeding sites) but not plaque in the medium term (only 24 participants). Using a tooth cleaning stick made of rubber or an elastomer may be better than toothbrushing only for reducing plaque but not gingivitis in the short term (only 30 participants). Toothbrushing plus oral irrigation (water pressure) may reduce gingivitis in the short term, but there was no evidence for this in the medium term. There was no evidence of a difference in plaque. Interdental brushes may be better than flossing for gingivitis at one and three months. The evidence for plaque is inconsistent. There was no evidence of a difference between the devices for periodontitis measured by probing pocket depth. There is some evidence that oral irrigation may be better than flossing for reducing gingivitis (but not plaque) in the short term. The available evidence for interdental cleaning sticks did not show them to be better or worse than floss or interdental brushes for controlling gingivitis or plaque. The studies that measured 'adverse events' found no serious effects and no evidence of differences between study groups in minor effects such as gum irritation. Certainty of the evidence The evidence is low to very low‐certainty. The effects observed may not be clinically important. Studies measured outcomes mostly in the short term and many participants had a low level of gum disease at the beginning of the studies. Future research Future studies should use the new periodontal diseases classification to describe the gum health of participants, and they should last long enough to measure periodontitis and tooth decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Worthington, HV, MacDonald, L, Poklepovic Pericic, T, Sambunjak, D, Johnson, TM, Imai, P, Clarkson, JE", "articleTypes": [], "doi": "10.1002/14651858.CD012018.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.790Z" }, { "id": "ce3e73c5-7572-4e8b-aee5-27ceda03bba6", "pmid": "", "title": "Systemic interventions for recurrent aphthous stomatitis (mouth ulcers)", "imported": false, "abstract": "Abstract - Background Recurrent aphthous stomatitis (RAS) is the most frequent form of oral ulceration, characterised by recurrent oral mucosal ulceration in an otherwise healthy individual. At its worst RAS can cause significant difficulties in eating and drinking. Treatment is primarily aimed at pain relief and the promotion of healing to reduce the duration of the disease or reduce the rate of recurrence. A variety of topical and systemic therapies have been utilised. Objectives To determine the clinical effect of systemic interventions in the reduction of pain associated with RAS, a reduction in episode duration or frequency. Search methods We undertook electronic searches of: Cochrane Oral Health Group and PaPaS Trials Registers (to 6 June 2012); CENTRAL via The Cochrane Library (to Issue 4, 2012); MEDLINE via OVID (1950 to 6 June 2012); EMBASE via OVID (1980 to 6 June 2012); CINAHL via EBSCO (1980 to 6 June 2012); and AMED via PubMed (1950 to 6 June 2012). We searched reference lists from relevant articles and contacted the authors of eligible trials to identify further trials and obtain additional information. Selection criteria We included randomised controlled trials (RCTs) in which the primary outcome measures assess a reduction of pain associated with RAS, a reduction in episode duration or a reduction in episode frequency. Trials were not restricted by outcome alone. We also included RCTs of a cross‐over design. Data collection and analysis Two review authors independently extracted data in duplicate. We contacted trial authors for details of randomisation, blindness and withdrawals. We carried out risk of bias assessment on six domains. We followed The Cochrane Collaboration statistical guidelines and risk ratio (RR) values were to be calculated using fixed‐effect models (if two or three trials in each meta‐analysis) or random‐effects models (if four or more trials in each meta‐analysis). Main results A total of 25 trials were included, 22 of which were placebo controlled and eight made head‐to‐head comparisons (five trials had more than two treatment arms). Twenty‐one different interventions were assessed. The interventions were grouped into two categories: immunomodulatory/anti‐inflammatory and uncertain. Only one study was assessed as being at low risk of bias. There was insufficient evidence to support or refute the use of any intervention. Authors' conclusions No single treatment was found to be effective and therefore the results remain inconclusive in regard to the best systemic intervention for RAS. This is likely to reflect the poor methodological rigour of trials, and lack of studies for certain drugs, rather than the true effect of the intervention. It is also recognised that in clinical practice, individual drugs appear to work for individual patients and so the interventions are likely to be complex in nature. In addition, it is acknowledged that systemic interventions are often reserved for those patients who have been unresponsive to topical treatments, and therefore may represent a select group of patients. Plain language summary Systemic interventions for recurrent aphthous stomatitis (mouth ulcers) Mouth ulcers (sores) are one of the most common oral problems and many people suffer with them repeatedly. These can be painful and slow to heal. At its worst, this can cause significant difficulties in eating and drinking. This review found that many different treatments were used to manage this condition, although the evidence of their effectiveness remains inconclusive.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Brocklehurst, P; Tickle, M; Glenny, AM; Lewis, MA; Pemberton, MN; Taylor, J; Walsh, T; Riley, P; Yates, JM", "articleTypes": [], "doi": "10.1002/14651858.CD005411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "ce43baa8-5c46-4dec-bed0-eb0577cef2c7", "pmid": "", "title": "Topical cystic fibrosis transmembrane conductance regulator gene replacement for cystic fibrosis‐related lung disease", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is caused by a defective gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR), and is characterised by chronic lung infection resulting in inflammation and progressive lung damage that results in a reduced life expectancy. Objectives To determine whether topical CFTR gene replacement therapy to the lungs in people with cystic fibrosis is associated with improvements in clinical outcomes, and to assess any adverse effects. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Date of most recent search: 05 May 2016. An additional search of the National Institutes for Health (NIH) Genetic Modification Clinical Research Information System (GeMCRIS) was also performed for the years 1992 to 2015. Date of most recent search: 20 April 2016. Selection criteria Randomised controlled studies comparing topical CFTR gene delivery to the lung, using either viral or non‐viral delivery systems, with placebo or an alternative delivery system in people with confirmed cystic fibrosis. Data collection and analysis The authors independently extracted data and assessed study quality. Authors of included studies were contacted and asked for any available additional data. Meta‐analysis was limited due to differing study designs. Main results Four randomised controlled studies met the inclusion criteria for this review, involving a total of 302 participants lasting from 29 days to 13 months; 14 studies were excluded. The included studies differed in terms of CFTR gene replacement agent and study design, which limited the meta‐analysis. One study only enrolled adult males, the remaining studies included both males and females aged 12 years and over. Risk of bias in the studies was moderate. Random sequence generation and allocation concealment was only described in the more recent study; the remaining three studies were judged to have an unclear risk of bias. All four studies documented double‐blinding to the intervention, but there is some uncertainty with regards to participant blinding in one study. Some outcome data were missing from all four studies. There were no differences in either the number of respiratory exacerbations or the number of participants with an exacerbation between replacement therapy or placebo groups at any time point. Meta‐analysis of most respiratory function tests showed no difference between treatment and placebo groups, but the smallest study (n = 16) reported forced vital capacity (litres) increased more in the placebo group at up to 24 hours. A further study reported a significant improvement in forced expiratory volume at one second (litres) at 30 days after participants had received their first dose of favouring the gene therapy agent, but this finding was not confirmed when combined with at second study in the meta‐analysis. The more recent study (n = 140) demonstrated a small improvement in forced vital capacity (per cent predicted) at two and three months and again at 11 and 12 months for participants receiving CFTR gene replacement therapy compared to those receiving placebo. The same study reported a significant difference in the relative change in forced expiratory volume at one second (per cent predicted) at two months, three months and 12 months. One small study reported significant concerns with \"influenza‐like\" symptoms in participants treated with CFTR gene replacement therapy; this was not reported on repeated use of the same agent in a larger recent study. There was no other evidence of positive impact on outcomes, in particular improved quality of life or reduced treatment burden. Two studies measured ion transport in the lower airways; one (n = 16) demonstrated significant changes toward normal values in the participants who received gene transfer agents (P < 0.0001), mean difference 6.86 (95% confidence interval 3.77 to 9.95). The second study (n = 140) also reported significant changes toward normal values (P = 0.032); however, aggregate data were not available for analysis. In the most recent study, there was also evidence of increased salt transport in cells obtained by brushing the lower airway. These outcomes, whilst important, are not of direct clinical relevance. Authors' conclusions One study of liposome‐based CFTR gene transfer therapy demonstrated some improvements in respiratory function in people with CF, but this limited evidence of efficacy does not support this treatment as a routine therapy at present. There was no evidence of efficacy for viral‐mediated gene delivery. Future studies need to investigate clinically important outcome measures. Plain language summary Replacing the defective gene is a potential treatment for progressive lung disease in people with cystic fibrosis Review question We reviewed the evidence about the effect of delivering the correct copy of the cystic fibrosis transmembrane conductance regulator (CFTR) gene directly to the lungs of people with cystic fibrosis in order to treat progressive lung disease. Background In cystic fibrosis the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. People with cystic fibrosis suffer from progressive lung infection and damage which reduces life expectancy. Agents which can deliver a correct copy of the faulty CFTR gene to cells in the lungs may be an effective treatment. Search date The evidence is current to: 20 April 2016. Study characteristics We found four studies with 302 people to include in this review. The studies lasted from 29 days to 13 months. Three of these studies included both men and women aged 12 years and over and one study only included adult men. The studies compare gene therapy to a dummy treatment (placebo) both of which are inhaled as a mist into the lungs. The studies were of different designs and used different agents. This meant we could not combine their results. Key results Three of the studies, including the largest and most recent study, showed an improvement in some measures of lung function in people with CF given gene therapy. We did not find that any more clinically relevant outcomes such as quality of life, treatment burden or flare‐up of lung disease had improved with treatment. In one study \"influenza‐like\" symptoms were more common in people who received CFTR gene transfer agents but this was not reported when the agent was used repeatedly in a larger study. In those people who took the gene transfer agents, molecules and salt in their lower airways moved more like they do in healthy people. The limited evidence of benefit does not support this as a routine therapy at present. We recommend that future studies are designed and reported clearly so that their results can be incorporated into a systematic review. Quality of the evidence The most recent study provided detailed information on how the people were put into different treatment groups completely at random, and so we are satisfied that those taking part in the study had an equal chance of being in either group (CFTR gene transfer agent or placebo) and that no one could work out which group the next person would be put into. The other studies reported that people were put into groups at random but did not specify how, so we cannot be sure that there was an equal chance of them being in either group. We believe that the clinicians running all the studies did not know which treatment the people taking part were receiving and that in three of the studies those taking part did not know either, but we could not be sure whether the people taking part in the latest study knew which treatment they were receiving and what effect this knowledge might have on results. Unfortunately, the studies did not report all their results clearly; sometimes results were not reported in a way that we could use for the review and sometimes they were not reported at all. This reduced the certainty with which we judged the overall results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Perry, LA, Penny‐Dimri, JC, Aslam, AA, Lee, TWR, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD005599.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.772Z" }, { "id": "ce721405-199b-4b41-8043-4033029a539d", "pmid": "", "title": "Antidepressants for pain management in adults with chronic pain: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well‐being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients’ global impression of change for certain chronic pain conditions. However, there has not been a network meta‐analysis (NMA) examining all antidepressants across all chronic pain conditions. Objectives To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache). Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022. Selection criteria We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double‐blind. We included RCTs with active comparators that were unable to be double‐blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow‐up was less than two weeks and those with fewer than 10 participants in each arm. Data collection and analysis Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta‐analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta‐Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta‐analysis (ROB‐MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB‐MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal. Main results This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo‐controlled (83), and parallel−armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short‐term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest‐ranked antidepressant with moderate‐ to high‐certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate‐certainty evidence) and continuous pain intensity (standardised mean difference (SMD) −0.31, 95% CI −0.39 to −0.24; 18 studies, 4959 participants; moderate‐certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD −0.22, 95% CI −0.39 to 0.06; 4 studies, 1866 participants; moderate‐certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD −0.5, 95% CI −0.78 to −0.22; 1 study, 406 participants; low‐certainty evidence), while duloxetine showed a small effect (SMD −0.16, 95% CI −0.22 to −0.1; 26 studies, 7952 participants; moderate‐certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest‐ranked antidepressants with moderate‐certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low‐certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes. Authors' conclusions Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high‐quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long‐term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point. Plain language summary How effective are antidepressants used to treat chronic pain and do they cause unwanted effects? Key messages • We are only confident in the effectiveness of one antidepressant: duloxetine. We found that a standard dose (60 mg) was effective, and that there is no benefit to using a higher dose. • We are uncertain about unwanted effects for any antidepressant as the data for this were very poor. Future research should address this. • In clinical practice for chronic pain, a standard dose of duloxetine may be considered before trying other antidepressants. • Adopting a person‐centred approach is critical. Pain is a very individual experience and certain medications may work for people even while the research evidence is inconclusive or unavailable. Future studies should last longer and focus on unwanted effects of antidepressants. What is chronic pain? Chronic pain is pain of any kind that lasts for more than three months. Over one‐third of people across the world experience chronic pain. This often affects people's mood and well‐being, and their ability to work and carry out daily tasks. How do antidepressants treat chronic pain? Antidepressants are medications originally developed to treat depression. Different types of antidepressants work in different ways. Antidepressants that work in the same way are grouped into classes. The most common classes are selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and serotonin‐noradrenalin reuptake inhibitors (SNRIs). Research suggests that antidepressants may be effective for pain because the same chemicals that affect mood might also affect pain. What did we want to find out? We wanted to find out if antidepressants were effective for managing chronic pain and whether they cause unwanted effects. What did we do? We searched for studies that compared any antidepressant with any other treatment for any type of chronic pain (except headache). We compared all the treatments against each other using a statistical method called network meta‐analysis. This method allows us to rank the effectiveness of the different antidepressants from best to worst. What did we find? We found 176 studies including 28,664 people with chronic pain. These studies investigated 89 different types or combinations of treatment. Studies mainly investigated the effect of antidepressants on three different types of pain: fibromyalgia (59 studies), nerve pain (49 studies), and musculoskeletal pain (e.g. osteoarthritis or low back pain; 40 studies). The most common antidepressant classes investigated were SNRIs (74 studies), TCAs (72 studies), and SSRIs (34 studies). The most common antidepressants investigated were: amitriptyline (a TCA; 43 studies); duloxetine (an SNRI; 43 studies), and milnacipran (an SNRI; 18 studies). Of the 146 studies that reported where their funding came from, pharmaceutical companies funded 72 studies. The average study lasted 10 weeks. Most of the studies compared an antidepressant with a placebo (which looks like the real medicine but doesn’t have any medicine in it), but some studies compared an antidepressant against a different type of medicine, a different antidepressant, a different type of treatment (like physiotherapy), or different doses of the same antidepressant. Most of the studies in this review reported information on pain relief and unwanted effects. Fewer studies reported on quality of life, sleep, and physical function. Main results • Duloxetine probably has a moderate effect on reducing pain and improving physical function. It was the antidepressant that we have the most confidence in. Higher doses of duloxetine probably provided no extra benefits than standard doses. For every 1000 people taking standard‐dose duloxetine, 435 will experience 50% pain relief compared with 287 who will experience 50% pain relief taking placebo. • Milnacipran may reduce pain, but we are not as confident in this result as duloxetine because there were fewer studies with fewer people involved. • Most studies excluded people with mental health conditions, meaning that participants were already in the 'normal' ranges for anxiety and depression at the beginning of studies. This limited our analysis for mood. Mirtazapine and duloxetine may improve mood, but we are very uncertain about the results. • We do not know about unwanted effects of using antidepressants for chronic pain; there are not enough data to be certain about the results. What are the limitations of the evidence? There are still a number of questions that we were unable to answer: • Aside from duloxetine and milnacipran, we do not have confidence in the results from any other antidepressant included in this review because there are not enough studies. • We do not know whether antidepressants are effective at treating pain in the long term. The average length of studies was 10 weeks. • There was no reliable evidence on the safety of taking antidepressants for chronic pain, both short‐ and long‐term. • We do not know how effective antidepressants are for people with both chronic pain and depression as the most studies excluded participants with depression and anxiety. How up to date is this evidence? This review is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Birkinshaw, H; Friedrich, CM; Cole, P; Eccleston, C; Serfaty, M; Stewart, G; White, S; Moore, RA; Phillippo, D; Pincus, T", "articleTypes": [], "doi": "10.1002/14651858.CD014682.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "ce826279-6376-4f49-99a3-744db2ac3221", "pmid": "", "title": "Gut microbiome‐based interventions for the management of obesity in children and adolescents aged up to 19 years", "imported": false, "abstract": "Abstract - Background The epidemic of overweight and obesity affects more than 390 million children and adolescents aged 5 to 19 years and 37 million children under five years of age. Overweight and obesity are associated with both short‐ and long‐term consequences, including chronic inflammation, metabolic diseases, as well as alterations in the gut microbiome composition. Gut microbiome‐based approaches may impact microbiome‐related metrics such as diversity or the abundance of intestinal bacteria, which may be linked to obesity‐related outcomes. However, evidence regarding the effect of gut microbiome‐based interventions for the management of obesity is limited. Objectives To assess the effects of gut microbiome‐based interventions in the management of overweight or obesity in children and adolescents in all their diversity aged 0 to 19 years. Search methods We searched CENTRAL, MEDLINE, CINAHL, Web of Science Core Collection, BIOSIS Previews, Global Index Medicus (all regions), IBECS, SciELO, PAHO, PAHO IRIS, WHO IRIS, WHOLIS, Bibliomap, TRoPHI as well as ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 24 January 2025. We did not apply any language restrictions. Selection criteria We included randomised controlled trials that evaluated gut microbiome‐based interventions [i.e. prebiotics, probiotics, synbiotics, short‐chain fatty acids (SCFAs), and faecal microbiota transplantation (FMT)] compared to standard‐of‐care, placebo, or control interventions in children and adolescents aged 0 to 19 years with overweight or obesity. Data collection and analysis Two review authors independently screened titles and abstracts and full texts, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias 2 tool and certainty of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE), a framework for assessing the certainty of evidence and making recommendations in systematic reviews. Random‐effects meta‐analyses were performed unless only one study per outcome was available, for which fixed‐effect analyses were performed. Main results We found 17 studies (838 participants) from various countries, evaluating the effects of prebiotics, probiotics, synbiotics, SCFAs, and FMT on body mass index (BMI), body weight, waist circumference, total body fat percentage (%TBF), systolic and diastolic blood pressure, and adverse events. Of the 17 studies included, five studies were in adolescents aged 10 to 19 years, and 12 studies were in children and adolescents spanning both age groups, 0 to 19 years. Upon contacting authors for data grouped by age of the participants, no studies provided separate outcomes data for children and adolescents. The included studies were funded by either academic funding sources or grants from the public and private sectors. Additionally, 15 studies were classified as currently being conducted ('ongoing'). The certainty of evidence throughout was very low. In adolescents 10 to 19 years of age, probiotics compared to placebo or no intervention may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events. Similarly, FMT compared to placebo may have little to no effect on waist circumference, %TBF, blood pressure, and adverse events in this age group. According to one study with 41 participants and in children and adolescents 0 to 19 years of age, intervention with prebiotics compared to placebo may result in a small reduction in BMI (mean difference = ‐0.70, 95% CI = ‐1.25 to ‐0.15) and body weight (mean difference = ‐1.5, 95% CI = ‐2.61 to ‐0.39). Prebiotics compared to placebo may have little to no effect on waist circumference, %TBF, systolic blood pressure, and adverse events. No data were available on the effect of prebiotics on diastolic blood pressure. Probiotics compared to placebo may have little to no effect on BMI, body weight, waist circumference, %TBF, blood pressure, and adverse events in children and adolescents (0 to 19 years). Synbiotics compared to placebo may result in a reduction in systolic blood pressure (mean difference = ‐40.00, 95% CI = ‐50.63 to ‐29.37) in children and adolescents (0 to 19 years); according to one study with 56 participants. The evidence is very uncertain about the effects of synbiotics compared to a placebo on BMI, body weight, waist circumference, blood pressure, and adverse events. No data were available on the effect of synbiotics compared to placebo on %TBF. Synbiotics, compared to probiotics, may have little to no effect on waist circumference, %TBF, and adverse events. No data were available on the effect of synbiotics compared to probiotics on BMI, body weight, and blood pressure. According to one study with 48 participants and very low‐certainty of evidence, SCFAs compared to placebo may result in a reduction in waist circumference (mean difference = ‐5.08, 95% CI = ‐7.40 to ‐2.76) and BMI (mean difference = ‐2.26, 95% CI = ‐3.24 to ‐1.28) in children and adolescents (0–19 years). SCFAs compared to placebo may have little to no effect on adverse events. No data were available on the effect of SCFAs on body weight, %TBF, and blood pressure. Adverse events, i.e. abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine, were reported in the prebiotics group but with very low incidence. Additionally, adverse events such as nausea and headache were reported in the SCFAs group, but with low incidence. Authors' conclusions In adolescents aged 10 to 19 years, gut microbiome‐based interventions may result in little to no difference in obesity‐related outcomes. In children and adolescents aged 0 to 19 years, prebiotics may result in a small reduction in BMI and body weight; synbiotics may result in a reduction in systolic blood pressure, and SCFAs may result in a reduction in BMI and waist circumference, albeit the certainty of evidence was very low. The evidence was of very low certainty due to few studies per comparison, small sample sizes, short intervention durations, and insufficient reporting of adverse events. More rigorous research examining different types of gut microbiome‐based interventions for the management of obesity is required in children and adolescents, both in clinical and community settings. Future trials should also report methods related to randomisation, blinding, and compliance, as well as include prespecified analysis plans. Plain language summary Review question How effective are the gut microbiome‐based interventions for the management of overweight or obesity in children and adolescents in all their diversity, aged 0 to 19 years? Key messages • It is unclear if gut microbiome‐based interventions (nutrition interventions targeting intestinal microbes) have an effect on body mass index (BMI), body weight, waist size, body fat percentage, measures of blood pressure, and adverse events in children and adolescents with overweight and obesity. • Further research, including larger trials, is required to understand the effects of gut microbiome‐based interventions for the management of overweight and obesity in children and adolescents. What is overweight or obesity? Overweight is a condition of excessive fat deposits, and obesity is a chronic disease characterised by excessive fat deposits that can affect most body systems, impair quality of life, and reduce life expectancy. BMI, calculated by dividing a person's weight in kilograms by their height in metres, squared, is often used to define overweight and obesity. How is overweight or obesity managed? Overweight or obesity may be managed through changes in diet, behavioural counselling for lifestyle modifications, medications, or surgery. Despite these approaches, this global epidemic affects more than 390 million children and adolescents aged 5 to 19 years, and 37 million children under five years of age as of 2022. Overweight or obesity is linked to abnormal metabolism and an imbalance in the gut microbiome. Published works have shown that nutrition interventions targeting the \"gut microbiome\" may have beneficial effects on body weight and body fat percentage. The gut microbiome is the community of harmless bacteria and other microorganisms in the human intestine needed for optimal health. What did we want to find out? We wanted to find out the effect of various nutritional interventions targeting the intestinal microbial community on BMI, body weight, waist circumference, total body fat percentage, blood pressure, and adverse events associated with the interventions amongst children and adolescents in all their diversity, aged 0 to 19 years. What did we do? We searched for studies that examined the effects of gut microbiome‐based interventions, including prebiotics (food ingredients that promote beneficial microbes in the gut), probiotics (live microbes that are good for health), synbiotics (a combination of both prebiotics and probiotics), short‐chain fatty acids (i.e. small fat molecules produced by intestinal bacteria by fermenting dietary fibre and non‐digestible carbohydrates), and faecal microbiota transplantation (i.e. a capsule containing stool microbes from a healthy donor), compared to standard‐of‐care (usual care), placebo, control, or no interventions in children and adolescents up to 19 years of age. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 17 studies involving 838 children and adolescents with overweight and obesity. The studies were conducted in different countries, including Spain, China, Taiwan, Canada, Mexico, Italy, Poland, Turkey, Iran, Thailand, Denmark, New Zealand, and the USA. Adolescents aged 10 to 19 years Nutrition interventions targeting intestinal microbes may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. Children and adolescents aged 0 to 19 years It is unclear if prebiotics have an effect on waist size, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that prebiotics compared to a dummy treatment (i.e. an intervention that does not contain any medicine but looks or tastes identical to the intervention being tested) may result in a small reduction in BMI and body weight, but the evidence is very uncertain. Probiotics compared to a dummy treatment may have little to no effect on BMI, body weight, waist size, body fat percentage, blood pressure, and adverse events, but the evidence is very uncertain. It is unclear if synbiotics have an effect on BMI, body weight, waist size, body fat percentage, diastolic blood pressure, and adverse events compared with a dummy treatment. One study found that synbiotics may result in a reduction in systolic blood pressure, but the evidence is very uncertain. It is unclear if short‐chain fatty acids have an effect on body weight, body fat percentage, blood pressure, and adverse events compared with a dummy treatment. One study found that short‐chain fatty acids may result in a reduction in BMI and waist circumference, but the evidence is very uncertain. Side effects of the interventions were generally not reported in the included studies, but one study noted potential side effects such as abdominal cramps, abdominal discomfort, abdominal pain, diarrhoea, vomiting, and migraine in the prebiotics group; however, the occurrence was very low. Nausea and headache were reported in another study in the short‐chain fatty acids group, but were minimal. What are the limitations of the evidence? The review's findings are limited by the small number of participants, the low number of available studies for each of the comparisons, the lack of long‐term data, and insufficient reporting of adverse effects. How up to date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Fahim, SM, Huey, SL, Palma Molina, XE, Agarwal, N, Ridwan, P, Ji, N, Kibbee, M, Kuriyan, R, Finkelstein, JL, Mehta, S", "articleTypes": [], "doi": "10.1002/14651858.CD015875", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.135Z" }, { "id": "ce8b43fc-b508-48af-bc64-0be24c200c91", "pmid": "", "title": "Lamotrigine for chronic neuropathic pain and fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This is an update of the original Cochrane review entitled Lamotrigine for acute and chronic pain published in Issue 2, 2007, and updated in Issue 2, 2011. Some antiepileptic medicines have a place in the treatment of neuropathic pain (pain due to nerve damage). This updated review adds no new additional studies looking at evidence for lamotrigine as an effective treatment for chronic neuropathic pain or fibromyalgia. The update uses higher standards of evidence than previously. Objectives To assess the analgesic efficacy of lamotrigine in the treatment of chronic neuropathic pain and fibromyalgia, and to evaluate adverse effects reported in the studies. Search methods We identified randomised controlled trials (RCTs) of lamotrigine for chronic neuropathic pain and fibromyalgia (including cancer pain) from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). We ran searches for the original review in 2006, in 2011 for the first update, and subsequent searches in August 2013 for this update. We sought additional studies from the reference lists of the retrieved papers. The original review and first update included acute pain, but no acute pain studies were identified. Selection criteria RCTs investigating the use of lamotrigine (any dose, by any route, and for any study duration) for the treatment of chronic neuropathic pain or fibromyalgia. Assessment of pain intensity or pain relief, or both, using validated scales. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. The first tier used data where studies reported the outcome of at least 50% pain reduction from baseline, lasted at least eight weeks, had a parallel group design, included 200 or more participants in the comparison, and reported an intention‐to‐treat analysis. First‐tier studies did not use last observation carried forward (LOCF) or other imputational methods for dropouts. The second tier used data that failed to meet this standard and second‐tier results were therefore subject to potential bias. Main results Twelve included studies in 11 publications (1511 participants), all with chronic neuropathic pain: central post‐stroke pain (1), chemotherapy‐induced neuropathic pain (1), diabetic neuropathy (4), HIV‐related neuropathy (2), mixed neuropathic pain (2), spinal cord injury‐related pain (1), and trigeminal neuralgia (1). We did not identify any additional studies. Participants were aged between 26 and 77 years. Study duration was two weeks in one study and at least six weeks in the remainder; eight were of eight‐week duration or longer. No study provided first‐tier evidence for an efficacy outcome. There was no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of 200 mg to 400 mg daily. Almost 10% of participants taking lamotrigine reported a skin rash. Authors' conclusions Large, high‐quality, long‐duration studies reporting clinically useful levels of pain relief for individual participants provided no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of about 200 to 400 mg daily. Given the availability of more effective treatments including antiepileptics and antidepressant medicines, lamotrigine does not have a significant place in therapy based on the available evidence. The adverse effect profile of lamotrigine is also of concern. Plain language summary Lamotrigine (an antiepileptic drug) for chronic neuropathic pain or fibromyalgia Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Our understanding of fibromyalgia (a condition of persistent, widespread pain and tenderness, sleep problems, and fatigue) is lacking, but fibromyalgia can respond to the same medicines as neuropathic pain. Lamotrigine is a medicine used to treat epilepsy, and so might be a useful medicine for neuropathic pain or fibromyalgia. On 26 November 2013 we performed searches to look for clinical trials where lamotrigine was used to treat neuropathic pain or fibromyalgia. We found 12 studies of reasonable quality that tested lamotrigine against placebo for a number of weeks. Almost half of the 1511 people in the studies had painful limbs because of damaged nerves caused by diabetes, and seven different painful neuropathic conditions were examined. No studies looked at fibromyalgia. Lamotrigine did not help the pain, and was no different from placebo except in causing more side effects. Adverse events were more frequent with lamotrigine than placebo, with rash in 1 person in 27.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wiffen, PJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD006044.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.773Z" }, { "id": "ceafdd6e-9a25-4470-8670-aa152b9cfc43", "pmid": "", "title": "Chinese medicinal herbs for cholelithiasis", "imported": false, "abstract": "Abstract - Background Cholelithiasis is a common disease of the biliary tract. Chinese medicinal herbs are being used widely as an alternative treatment in people with cholelithiasis, but their beneficial or harmful effects have not been assessed systematically. Objectives To assess the beneficial and harmful effects of Chinese medicinal herbs in people with cholelithiasis. Search methods We conducted searches in the Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, Science Citation Index Expanded, Chinese Medicine Conference Disc, and Chinese Bio‐Medicine Disc to January 2013. We handsearched four Chinese journals. No language or year of publication restrictions were applied. Selection criteria Randomised clinical trials studying Chinese medicinal herbs for treatment of cholelithiasis. Data collection and analysis Two review authors (SJ, TG) independently extracted data. For dichotomous data, we estimated the risk ratio (RR), and for continuous data, we calculated the mean difference. We also calculated 95% confidence intervals (CI). Main results Eleven randomised trials with 1205 participants with asymptomatic or mild‐to‐moderate cholelithiasis were included. None of the randomised clinical trials compared a single Chinese medicinal herb with a Western medicine or with surgery. No placebo‐controlled trials were identified. In the trials comparing one Chinese herbal medicine (Gandanxiaoshi tablet) versus another (Aihuodantong tablet), there was no significant difference in the improvement of upper abdominal pain after the end of treatment (RR 1.21; 95% CI 0.71 to 2.05), and the heterogeneity among trials was not substantial. No other outcomes could be assessed. The remaining trials of Chinese medicinal herbs (Qingdan capsule, Danshu capsule, Paishi capsule, Rongdanpaishi capsule), did not offer specific data on symptoms, signs, or change in gallstones that would permit assessment of significant differences in curative effects between the treatment and control groups. No serious adverse events were reported. Authors' conclusions This review reveals no strong evidence that the analysed Chinese medicinal herbs have any beneficial effects on asymptomatic or mild‐to‐moderate cholelithiasis. Definitive conclusions will require much better designed randomised trials to reduce risk of bias and allow detailed assessment of clinical outcomes. Plain language summary Chinese medicinal herbs for cholelithiasis Cholelithiasis (gallstone disease) causes significant morbidity, severe complications, and economic burden worldwide. Though current surgical therapies are effective for gallstones, some types of gallstones (e.g., calcium bilirubinate calculi) cannot easily be eradicated by surgery and they often recur in the bile duct system, putting people at high risk of severe complications. The objective of this review was to evaluate the benefits and harms of Chinese medicinal herbs for people with cholelithiasis. Though some Chinese medicinal herbs appear to be safe for people with asymptomatic, mild, or moderate disease, they have not been conclusively shown to have curative effects on gallstones due to the low methodological quality (high risk of bias) of the included trials. Thus, randomised clinical trials with low risk of bias should be conducted to assess the effects of Chinese medicinal herbs before they can be used widely in the clinic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Gan, T, Chen, J, Jin, SJ, Wang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD004547.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.760Z" }, { "id": "ceb3415c-6fd2-401b-a977-9eba60dbcdff", "pmid": "", "title": "Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their aetiology is unknown. The management of chronic rhinosinusitis with nasal polyps, aimed at improving these symptoms, includes both surgical and medical treatments, but there is no universally accepted management protocol. Objectives To assess the effectiveness of endonasal/endoscopic surgery versus medical treatment in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised controlled trials of any surgical intervention (e.g. polypectomy, endoscopic sinus surgery) versus any medical treatment (e.g. intranasal and/or systemic steroids), including placebo, in adult patients with chronic rhinosinusitis with nasal polyps. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Meta‐analysis was not possible due to the heterogeneity of the studies and the selective (incomplete) outcome reporting by the studies. Main results Four studies (231 participants randomised) are included in the review. No studies were at low risk of bias. The studies compared different types of surgery versus various types and doses of systemic and topical steroids and antibiotics. There were three comparison pairs: (1) endoscopic sinus surgery (ESS) versus systemic steroids (one study, n = 109), (2) polypectomy versus systemic steroids (two studies, n = 87); (3) ESS plus topical steroid versus antibiotics plus high‐dose topical steroid (one study, n = 35). All participants also received topical steroids but doses and types were the same between the treatment arms of each study, except for the study using antibiotics. In that study, the medical treatment arm had higher doses than the surgical arm. In two of the studies, the authors failed to report the outcomes of interest. Although there were important differences in the types of treatments and comparisons used in these studies, the results were similar. Primary outcomes: symptom scores and quality of life scores There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) failed to find a difference in generic health‐related quality of life scores. The quality of this evidence is low or very low . Endoscopic scores and other secondary outcomes Two studies reported endoscopic scores. One study (ESS versus systemic steroids) reported a large, significant effect size in the surgical group, with a mean difference (MD) in score of ‐1.5 (95% confidence interval (CI) ‐1.78 to ‐1.22, n = 95) on a scale of 0 to 3 (0 = no polyposis, 3 = severe polyposis). In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups (MD 2.3%, 95% CI ‐17.4% to 12.8%, n = 34). None of the included studies reported recurrence rates. No differences were found for any objective measurements or olfactory tests in those studies in which they were measured. Complications Complication rates were not reported in all studies, but rates of up to 21% for medical treatment and 14.3% for surgical treatment are described. Epistaxis was the most commonly reported complication with both medical and surgical treatments, with severe complications reported rarely. Authors' conclusions The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis with nasal polyps is of very low quality. The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. The one positive finding from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. As the overall evidence is of very low quality (serious methodological limitations, reporting bias, indirectness and imprecision) and insufficient to draw firm conclusions, further research to investigate this problem, which has significant implications for quality of life and healthcare service usage, is justified. Plain language summary Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps Background Nasal polyps are common, benign swellings of the lining of the nose. In some people they may cause no symptoms, but in others they may lead to nasal obstruction, congestion, facial pressure and anosmia (loss of sense of smell). The incidence of symptomatic nasal polyps increases with age and they are more common in men than in women. The cause of nasal polyps is not fully understood but they may be a result of chronic (long‐term) inflammation of the lining of the nose (termed 'chronic rhinosinusitis with nasal polyps'). Chronic rhinosinusitis with nasal polyps can be treated medically, for example with drugs such as topical (intranasal) steroid sprays, or with surgery (for example, nasal polypectomy with or without endoscopic sinus surgery (ESS)). However, it is unclear what is the most effective management strategy. Study characteristics Four randomised controlled trials, involving a total of 231 patients with chronic rhinosinusitis with nasal polyps, are included in this review. The number of patients in each study ranged from 34 to 109. The studies took place in ENT departments in several European countries. All patients were adults and most of the studies enrolled more men than women. In all studies the patients were randomly assigned to either surgery or medical treatment (such as antibiotics or steroid tablets or injections) in addition to topical steroids given as nasal sprays or drops. Both the type of surgery performed and the medical treatments used varied widely between the studies, and did not allow all of the studies to be looked at together. Rather, we considered the treatment groups in the four studies as three separate pairs of comparisons instead of simply 'surgical' versus 'medical' treatments. Key results The main outcome measures were patient‐reported disease‐specific symptom scores and health‐related quality of life scores, as well as generic health‐related quality of life scores. There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) did not find a difference in general health‐related quality of life scores. Two studies reported changes in polyp size (when looked at with an endoscope) using a score. One study (ESS versus systemic steroids) reported a significantly better score in the surgery group than in the steroids group at 12 months. In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups. There were no reported differences between the different medical and surgical treatment groups in any study for any other objective (clinician‐based) measurements. Complication rates were not reported in all studies, but nosebleeds (epistaxis) were the most commonly described complication with both medical and surgical treatment; severe complications were reported rarely in either group. Conclusion The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. One positive finding (polyps size scores) from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. There is not enough evidence to draw firm conclusions regarding the most appropriate treatment for this condition. Chronic rhinosinusitis with nasal polyps has significant implications for quality of life and the use of healthcare services. Further research to investigate this problem is justified. Quality of the evidence Overall, we found this evidence to be of low or very low quality. We have low confidence in the estimates of these studies; further research will very likely change these estimates. There were serious limitations in how the studies were carried out or reported (or both), and the number of participants involved was small. In addition, some of the treatment regimens used in the trials are no longer current standards of therapy for patients with chronic rhinosinusitis with nasal polyps. This evidence is up to date to 20 February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Rimmer, J; Fokkens, W; Chong, LY; Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "cec97487-4f06-4ba4-abd7-4fb05633cc86", "pmid": "", "title": "Quinine for muscle cramps", "imported": false, "abstract": "Abstract - Background Muscle cramps can occur anywhere and for many reasons. Quinine has been used to treat cramps of all causes. However, controversy continues about its efficacy and safety. This review was first published in 2010 and searches were updated in 2014. Objectives To assess the efficacy and safety of quinine‐based agents in treating muscle cramps. Search methods On 27 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE. We searched reference lists of articles up to 2014. We also searched for ongoing trials in November 2014. Selection criteria Randomised controlled trials of people of all ages with muscle cramps in any location and of any cause, treated with quinine or its derivatives. Data collection and analysis Three review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We contacted study authors for additional information. For comparisons including more than one trial, we assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Main results We identified 23 trials with a total of 1586 participants. Fifty‐eight per cent of these participants were from five unpublished studies. Quinine was compared to placebo (20 trials, n = 1140), vitamin E (four trials, n = 543), a quinine‐vitamin E combination (three trials, n = 510), a quinine‐theophylline combination (one trial, n = 77), and xylocaine injections into the gastrocnemius muscle (one trial, n = 24). The most commonly used quinine dosage was 300 mg/day (range 200 to 500 mg). We found no new trials for inclusion when searches were updated in 2014. The risk of bias in the trials varied considerably. All 23 trials claimed to be randomised, but only a minority described randomisation and allocation concealment adequately. Compared to placebo, quinine significantly reduced cramp number over two weeks by 28%, cramp intensity by 10%, and cramp days by 20%. Cramp duration was not significantly affected. A significantly greater number of people suffered minor adverse events on quinine than placebo (risk difference (RD) 3%, 95% confidence interval (CI) 0% to 6%), mainly gastrointestinal symptoms. Overdoses of quinine have been reported elsewhere to cause potentially fatal adverse effects, but in the included trials there was no significant difference in major adverse events compared with placebo (RD 0%, 95% CI ‐1% to 2%). One participant suffered from thrombocytopenia (0.12% risk) on quinine. A quinine‐vitamin E combination, vitamin E alone, and xylocaine injections into gastrocnemius were not significantly different to quinine across all outcomes, including adverse effects. Based on a single trial comparison, quinine alone was significantly less effective than a quinine‐theophylline combination but with no significant differences in adverse events. Authors' conclusions There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that with use up to 60 days, the incidence of serious adverse events is not significantly greater than for placebo in the identified trials, but because serious adverse events can be rarely fatal, in some countries prescription of quinine is severely restricted. Evidence from single trials suggests that theophylline combined with quinine improves cramps more than quinine alone, and the effects of xylocaine injections into gastrocnemius are not significantly different to quinine across all outcomes. Low or moderate quality evidence shows no significant difference between quinine and vitamin E or quinine and quinine‐vitamin E mixture. Further research into these alternatives, as well other pharmacological and non‐pharmacological treatments, is thus warranted. There is no evidence to judge optimal dosage or duration of quinine treatment. Further studies using different dosages and measurement of serum quinine levels will allow a therapeutic range to be defined for muscle cramp. Because serious adverse events are not common, large population studies are required to more accurately inform incidence. Longer lengths of follow‐up in future trials will help determine the duration of action following cessation of quinine as well as long‐term adverse events. The search for new therapies, pharmacological and nonpharmacological, should continue and further trials should compare vitamin E, quinine‐vitamin E combination, and quinine‐theophylline mixture with quinine. Plain language summary Quinine for muscle cramps Review question We reviewed the evidence about the effect of quinine on muscle cramps. Background Muscle cramps can occur anywhere and in anyone; however, leg cramps are especially common in older people. Quinine is a medicine which has been used to treat cramps for many years. There is conflicting evidence for its ability to reduce cramps. Quinine can cause serious, even fatal adverse events, especially in overdosage. Study characteristics This review includes 23 trials, with 1586 participants. The trials compared quinine or quinine‐based medicines against inactive treatment (placebo) or other active treatments. We found no new studies when we searched the medical literature again and updated the review in 2014. Key results and quality of the evidence The risk of bias in the included trials varied considerably. All 23 trials claimed to be randomised, but many failed to clearly describe how participants were assigned to treatments. There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that there are more minor adverse events with quinine compared to placebo but no increase in major adverse events. However, there are reliable reports from other sources that an overdose of quinine can cause serious harm including death. Low or moderate quality evidence shows there is no significant difference when comparing quinine to vitamin E or to a quinine‐vitamin E mixture. There is evidence from one trial that theophylline combined with quinine improves cramps more than quinine alone. In a single trial there was no significant difference when comparing quinine to xylocaine injections. More research is needed to clarify the best dose and duration of treatment, as well as alternatives to quinine for cramps. The evidence is current to October 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El‐Tawil, S; Al Musa, T; Valli, H; Lunn, MPT; Brassington, R; El‐Tawil, T; Weber, M", "articleTypes": [], "doi": "10.1002/14651858.CD005044.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "ceee88ae-6701-49a1-96bb-b2534f282a0e", "pmid": "", "title": "Inhaled corticosteroids for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Inhaled corticosteroids are well established for the long‐term treatment of inflammatory respiratory diseases such as asthma or chronic obstructive pulmonary disease. They have been investigated for the treatment of coronavirus disease 2019 (COVID‐19). The anti‐inflammatory action of inhaled corticosteroids might have the potential to reduce the risk of severe illness resulting from hyperinflammation in COVID‐19. Objectives To assess whether inhaled corticosteroids are effective and safe in the treatment of COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (which includes CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO ICTRP, and medRxiv), Web of Science (Science Citation Index, Emerging Citation Index), and the WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies to 7 October 2021. Selection criteria We included randomised controlled trials (RCTs) evaluating inhaled corticosteroids for COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We included the following interventions: any type or dose of inhaled corticosteroids. We included the following comparison: inhaled corticosteroids plus standard care versus standard care (with or without placebo). We excluded studies examining nasal or topical steroids. Data collection and analysis We followed standard Cochrane methodology. For risk of bias assessment, we used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the outcomes of mortality, admission to hospital or death, symptom resolution, time to symptom resolution, serious adverse events, adverse events, and infections. Main results Inhaled corticosteroids plus standard care versus standard care (with/without placebo) People with a confirmed diagnosis of moderate‐to‐severe COVID‐19 We found no studies that included people with a confirmed diagnosis of moderate‐to‐severe COVID‐19. People with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included three RCTs allocating 3607 participants, of whom 2490 had confirmed mild COVID‐19. We analysed a subset of the total number of participants recruited to the studies (2171, 52% female) as some trials had a platform design where not all participants were allocated to treatment groups simultaneously. The included studies were community‐based, recruiting people who were able to use inhaler devices to deliver steroids and relied on remote assessment and self‐reporting of outcomes. Most people were older than 50 years and had co‐morbidities such as hypertension, lung disease, or diabetes. The studies were conducted in high‐income countries prior to wide‐scale vaccination programmes. A total of 1057 participants were analysed in the inhaled corticosteroid arm (budesonide: 860 participants; ciclesonide: 197 participants), and 1075 participants in the control arm. No studies included people with asymptomatic SARS‐CoV‐2 infection. With respect to the following outcomes, inhaled corticosteroids compared to standard care: – may result in little to no difference in all‐cause mortality (at up to day 30) (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.22 to 1.67; 2132 participants; low‐certainty evidence). In absolute terms, this means that for every nine deaths per 1000 people not receiving inhaled corticosteroids, there were six deaths per 1000 people who did receive the intervention (95% CI 2 to 16 per 1000 people); – probably reduces admission to hospital or death (at up to 30 days) (RR 0.72, 95% CI 0.51 to 0.99; 2025 participants; moderate‐certainty evidence); – probably increases resolution of all initial symptoms at day 14 (RR 1.19, 95% CI 1.09 to 1.30; 1986 participants; moderate‐certainty evidence); – may reduce the duration to symptom resolution (at up to day 30) (by −4.00 days, 95% CI −6.22 to −1.78 less than control group rate of 12 days; 139 participants; low‐certainty evidence); – the evidence is very uncertain about the effect on serious adverse events (during study period) (RR 0.51, 95% CI 0.09 to 2.76; 1586 participants; very low‐certainty evidence); – may result in little to no difference in adverse events (at up to day 30) (RR 0.78, 95% CI 0.47 to 1.31; 400 participants; low‐certainty evidence); – may result in little to no difference in infections (during study period) (RR 0.88, 95% CI 0.30 to 2.58; 400 participants; low‐certainty evidence). As studies did not report outcomes for subgroups (e.g. age, ethnicity, sex), we did not perform subgroup analyses. Authors' conclusions In people with confirmed COVID‐19 and mild symptoms who are able to use inhaler devices, we found moderate‐certainty evidence that inhaled corticosteroids probably reduce the combined endpoint of admission to hospital or death and increase the resolution of all initial symptoms at day 14. Low‐certainty evidence suggests that corticosteroids make little to no difference in all‐cause mortality up to day 30 and may decrease the duration to symptom resolution. We do not know whether inhaled corticosteroids increase or decrease serious adverse events due to heterogeneity in the way they were reported across the studies. There is low‐certainty evidence that inhaled corticosteroids may decrease infections. The evidence we identified came from studies in high‐income settings using budesonide and ciclesonide prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, serious adverse events, and people with asymptomatic infection or with moderate‐to‐severe COVID‐19. The 10 ongoing and four completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. We monitor newly published results of RCTs on inhaled corticosteroids on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Are inhaled corticosteroids an effective treatment for people with mild COVID‐19? Key messages Inhaled corticosteroids (anti‐inflammatory medicines) given via the oral inhaled route are evaluated for treatment of coronavirus disease 2019 (COVID‐19). We identified three published studies for people with mild disease. Inhaled corticosteroids probably reduce the risk of people going to hospital or death (admission to hospital or death before hospital admission). Inhaled corticosteroids may lower the number of days people have symptoms of mild COVID‐19 and probably increase resolution of COVID‐19 symptoms at day 14. They may make little to no difference in death from any cause, and we do not have enough evidence to know whether they cause serious harms. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with moderate‐to‐severe COVID‐19. We found 10 ongoing and four completed unpublished studies. We will update this review when their results become available. What are inhaled corticosteroids? Inhaled corticosteroids are medicines that are breathed into the lower airways through an inhaler where they reduce inflammation in the lungs. They are commonly used to treat respiratory diseases like asthma and chronic obstructive pulmonary disease. Long‐term use and incorrect inhaler technique may lead to side effects that include a mouth infection called thrush, a change in voice, and an increased risk of lung infections. Good inhaler technique means the medicine does not stay in the mouth and throat. Why are inhaled corticosteroids possible treatments for COVID‐19? COVID‐19 mainly affects the lungs and airways. When the immune system fights the virus, the lungs and airways become inflamed. This inflammation causes breathing difficulties, and the lungs cannot easily move oxygen into the blood and remove carbon dioxide from the blood. What did we want to find out? People need more and better treatment options for asymptomatic SARS‐CoV‐2 infection (the virus that causes COVID‐19) or mild, moderate, or severe COVID‐19. We wanted to know if inhaled corticosteroids are an effective and helpful treatment option for COVID‐19 in any setting (for example, home or hospital) and whether they cause unwanted effects. We were interested in: – death from any cause up to day 30, day 60, or longer if reported; – admission to hospital or death within 30 days; – whether symptoms resolved and how fast; – quality of life; – unwanted effects. What did we do? We looked for studies where the investigators compared inhaled corticosteroids and usual care to usual care only, sometimes in addition to a dummy medicine that did not contain any active ingredients (placebo) but was given in the same way. To make the comparison least skewed and more fair, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the inhaled corticosteroids or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Three studies compared inhaled corticosteroids plus usual care compared to usual care with or without placebo in people with a confirmed diagnosis of mild COVID‐19. These studies analysed 2171 participants mostly older than 50 years and with other medical problems, 52% of them were female, of whom 1057 received inhaled corticosteroids in our analyses. We found no studies that included people with asymptomatic infection or confirmed diagnosis of moderate‐to‐severe COVID‐19. We also found 10 ongoing studies, and four completed studies without published results. Main results All studies compared inhaled corticosteroids with usual care or placebo. The studies included only people with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease. No studies looked at hospitalised people or people with asymptomatic SARS‐CoV‐2 infection. Inhaled corticosteroids – may make little to no difference in death from any cause up to day 30; – probably reduce the risk of admission to hospital or occurrence of death up to day 30; – probably increase resolution of COVID‐19 symptoms at day 14 and may reduce time to symptom resolution. We are very uncertain about a possible difference in serious unwanted effects. Moreover, inhaled corticosteroids may result in little to no difference in the number of any unwanted effects or additional infections. What are the limitations of the evidence? The studies were conducted in populations from wealthy countries, prior to the roll‐out of COVID‐19 vaccination programmes. We have moderate confidence in the evidence for the outcomes of symptom resolution at day 14 and hospital admission. We have low confidence in the evidence for the effects on deaths from any cause for people with mild COVID‐19 and time to symptom resolution. The confidence in the unwanted or serious unwanted effects and infections is low or very low, because of the differences in the way investigators recorded and reported results. There was no evidence for people with asymptomatic infection or moderate‐to‐severe COVID‐19 who were hospitalised. How up to date is this evidence? Our evidence is up‐to‐date to 7 October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Griesel, M, Wagner, C, Mikolajewska, A, Stegemann, M, Fichtner, F, Metzendorf, M-I, Nair, AAnil, Daniel, J, Fischer, A-L, Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015125", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.754Z" }, { "id": "cf0ba74a-2177-4258-b3b1-5a7a64f378cd", "pmid": "", "title": "Breastfeeding or breast milk for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Pain in the neonate is associated with acute behavioural and physiological changes. Cumulative pain is associated with morbidities, including adverse neurodevelopmental outcomes. Studies have shown a reduction in changes in physiological parameters and pain score measurements following pre‐emptive analgesic administration in neonates experiencing pain or stress. Non‐pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for analgesia. This is an update of a review first published in 2006 and updated in 2012. Objectives The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries (ICTRP, ISRCTN and clinicaltrials.gov) in August 2022; searches were limited from 2011 forwards. We checked the reference lists of included studies and relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates. We included both term (≥ 37 completed weeks postmenstrual age) and preterm infants (< 37 completed weeks' postmenstrual age) up to a maximum of 44 weeks' postmenstrual age. The study must have reported on either physiological markers of pain or validated pain scores. Data collection and analysis We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a mean difference (MD). We used the GRADE approach to assess the certainty of evidence. Main results Of the 66 included studies, 36 evaluated breastfeeding, 29 evaluated supplemental breast milk and one study compared them against each other. The procedures conducted in the studies were: heel lance (39), venipuncture (11), intramuscular vaccination (nine), eye examination for retinopathy of prematurity (four), suctioning (four) and adhesive tape removal as procedure (one). We noted marked heterogeneity in the control interventions and pain assessment measures amongst the studies. Since many studies included multiple arms with breastfeeding/supplemental breast milk as the main comparator, we were not able to synthesise all interventions together. Individual interventions are compared to breastfeeding/supplemental breast milk and reported. The numbers of studies/participants presented with the findings are not taken from pooled analyses (as is usual in Cochrane Reviews), but are the overall totals in each comparison. Overall, the included studies were at low risk of bias except for masking of intervention and outcome assessment, where nearly one‐third of studies were at high risk of bias. Breastfeeding versus control Breastfeeding may reduce the increase in heart rate compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration of sucrose/glucose (20% to 33%) with skin‐to‐skin contact (low‐certainty evidence, 8 studies, 784 participants). Breastfeeding likely reduces the duration of crying compared to no intervention, lying on table, rocking, heel warming, holding by mother, skin‐to‐skin contact, bottle feeding mother's milk and moderate concentration of glucose (moderate‐certainty evidence, 16 studies, 1866 participants). Breastfeeding may reduce percentage time crying compared to holding by mother, skin‐to‐skin contact, bottle feeding mother's milk, moderate concentration sucrose and moderate concentration of sucrose with skin‐to‐skin contact (low‐certainty evidence, 4 studies, 359 participants). Breastfeeding likely reduces the Neonatal Infant Pain Scale (NIPS) score compared to no intervention, holding by mother, heel warming, music, EMLA cream, moderate glucose concentration, swaddling, swaddling and holding (moderate‐certainty evidence, 12 studies, 1432 participants). Breastfeeding may reduce the Neonatal Facial Coding System (NFCS) score compared to no intervention, holding, pacifier and moderate concentration of glucose (low‐certainty evidence, 2 studies, 235 participants). Breastfeeding may reduce the Douleur Aigue Nouveau‐né (DAN) score compared to positioning, holding or placebo (low‐certainty evidence, 4 studies, 709 participants). In the majority of the other comparisons there was little or no difference between the breastfeeding and control group in any of the outcome measures. Supplemental breast milk versus control Supplemental breast milk may reduce the increase in heart rate compared to water or no intervention (low‐certainty evidence, 5 studies, 336 participants). Supplemental breast milk likely reduces the duration of crying compared to positioning, massage or placebo (moderate‐certainty evidence, 11 studies, 1283 participants). Supplemental breast milk results in little or no difference in percentage time crying compared to placebo or glycine (low‐certainty evidence, 1 study, 70 participants). Supplemental breast milk results in little or no difference in NIPS score compared to no intervention, pacifier, moderate concentration of sucrose, eye drops, gentle touch and verbal comfort, and breast milk odour and verbal comfort (low‐certainty evidence, 3 studies, 291 participants). Supplemental breast milk may reduce NFCS score compared to glycine (overall low‐certainty evidence, 1 study, 40 participants). DAN scores were lower when compared to massage and water; no different when compared to no intervention, EMLA and moderate concentration of sucrose; and higher when compared to rocking or pacifier (low‐certainty evidence, 2 studies, 224 participants). Due to the high number of comparator interventions, other measures of pain were assessed in a very small number of studies in both comparisons, rendering the evidence of low certainty. The majority of studies did not report on adverse events, considering the benign nature of the intervention. Those that reported on adverse events identified none in any participants. Subgroup analyses were not conducted due to the small number of studies. Authors' conclusions Moderate‐/low‐certainty evidence suggests that breastfeeding or supplemental breast milk may reduce pain in neonates undergoing painful procedures compared to no intervention/positioning/holding or placebo or non‐pharmacological interventions. Low‐certainty evidence suggests that moderate concentration (20% to 33%) glucose/sucrose may lead to little or no difference in reducing pain compared to breastfeeding. The effectiveness of breast milk for painful procedures should be studied in the preterm population, as there are currently a limited number of studies that have assessed its effectiveness in this population. Plain language summary Breastfeeding or breast milk for procedural pain in newborn babies Review question We investigated how well breastfeeding or supplemental breast milk (expressed breast milk given via feeding tube or by placing breast milk in baby's mouth) works as a pain reliever in newborn babies while they undergo painful procedures (e.g. vaccination, heel prick, blood sampling for tests or eye examinations). The babies' pain responses (e.g. changes in heart rate, oxygen level, blood pressure, percentages of crying time, duration of crying etc.) were assessed by health care professionals to measure the pain that babies are experiencing. Background Breastfeeding may provide pain relief for newborn babies undergoing painful procedures. Medication for pain relief is commonly given for major painful procedures, but may not be given for minor painful procedures such as blood sampling (by heel prick or taking a sample from a vein). There are different forms of non‐drug strategies that can be used to reduce pain in babies, such as holding or swaddling them, sucking on a pacifier, or giving sweet solutions (such as sucrose or glucose). Different studies done in newborn babies have shown that breastfeeding may be a good way to reduce the pain they feel when subjected to minor painful procedures. These studies have been done in full‐term babies, and they have shown that breastfeeding may be effective by demonstrating that it reduces babies' crying time and various pain scores that have been validated for babies. Breast milk given by syringe has not shown the same efficacy as breastfeeding itself. Very few studies have been done in preterm babies, and so new studies are needed to determine if the use of supplemental breast milk in these small babies is effective in reducing their pain. Study characteristics We searched the medical literature thoroughly up to 1 August 2022 for studies that investigated the pain‐relieving effect of breastfeeding or supplemental breast milk for minor medical procedures in newborn full‐term and preterm neonates We included randomised trials only, as they provide the most reliable medical evidence. We identified 66 studies that reported on a total of more than 6200 infants in this Cochrane Review. Thirty‐six studies evaluated breastfeeding, 29 studies evaluated supplemental breast milk, while one study compared both against each other. In over half of the studies, pain relief was during a heel prick procedure. In others, it was during vaccination, drawing blood from a vein or other procedures. The studies used a variety of comparative groups, for example, placebo, no intervention, maternal holding, skin‐to‐skin contact, similar volume of water, a pacifier, routine care, various concentrations of sucrose or glucose, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), swaddling, heel warmth, anaesthetic cream for the skin, or a combination of these. The studies used a wide variety of pain scales as well as changes in heart rate and blood pressure and cry duration to assess pain. Study funding sources The studies included in the review were not externally funded according to information given in the reports. Key results Newborn babies in the breastfeeding group experienced a lower heart rate, shorter duration of cry, lower percentage of cry time and lower scores on the Neonatal Infant Pain Scale than babies who received no intervention. Moderate concentrations of glucose/sucrose may have similar effectiveness to breastfeeding. Studies of supplemental breast milk showed variable results. Supplemental breast milk was found to have a lower increase in heart rate when compared to water, and a lower duration of crying when compared to placebo. What are the limitations of the evidence We are moderately confident that breastfeeding reduces pain as assessed by heart rate, cry duration or validated pain scale compared to no intervention. Supplemental breast milk for painful procedures may reduce pain when compared to no intervention or placebo. Due to the high number of comparator groups, other measures of pain were assessed in a very small number of studies. The majority of the studies did not report on any unwanted or harmful effects of treatment. Those that did this identified no unwanted or harmful effects of treatment in any infants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Shah, PS, Torgalkar, R, Shah, VS", "articleTypes": [], "doi": "10.1002/14651858.CD004950.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.754Z" }, { "id": "cf11a90b-1c28-4eef-82c3-a2bf5967fd0c", "pmid": "", "title": "Sensory Study: Taste and Tongue Biology", "imported": false, "abstract": "Researchers will investigate the correlation between a) self-reported dietary intake of foods and beverages, b) intensity of sucrose stimuli, and c) liking rating of sweet stimuli, with the relative expression of the taste receptor genes from human fungiform papillae (TAS1R2 and TAS1R3).", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "cf2f2510-79c2-44d3-9069-130ef4eab3ec", "pmid": "", "title": "Padma 28 for intermittent claudication", "imported": false, "abstract": "Abstract - Background Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease that develops in a limb during exercise and is relieved with rest. Most drug treatments of IC have a limited effect in improving walking distance. Padma 28, a Tibetan herbal preparation, has been used to treat IC, but there is debate as to whether Padma 28 produces a clinical benefit beyond the placebo effect. This is an update of a review first published in 2013. Objectives To determine whether Padma 28 is effective, compared with placebo or other medications, in increasing pain‐free and maximum walking distance for patients with intermittent claudication. Search methods For this update the Cochrane Vascular Trials Search Co‐ordinator searched the Specialised Register (September 2015), the Cochrane Register of Studies ((CENTRAL) (2015, Issue 8)) and clinical trials databases. Selection criteria Randomised controlled trials of Padma 28 compared with placebo or other pharmacological treatments in people suffering from IC. Data collection and analysis All review authors independently assessed the selected studies and extracted the data. Risk of bias was evaluated independently by two review authors. Depending on the data provided in the individual trials, we extracted mean or median walking distance at the end of the trial, or change in walking distance over the course of the trial, or both. Where not provided, and whenever possible, the statistical significance of differences in these parameters between treatment and placebo groups in individual trials was calculated. Where possible, data were combined by meta‐analysis. Main results No new trials were identified in the search for this review update. In total five trials involving 365 participants were included in this review. All trials compared Padma 28 with placebo for at least 16 weeks of follow‐up. Pain‐free and maximum walking distances both increased significantly in the groups treated with Padma 28, with no significant change in the placebo group. In general, the studies presented results comparing the treatment arms before and after treatment but made no comparisons between the Padma 28 and placebo groups. Pooled data of maximum walking distance after treatment with Padma 28 and placebo from two studies (193 participants) indicated a higher maximum walking distance (mean difference (MD) 95.97 m, 95% confidence interval (CI) 79.07 m to 112.88 m, P < 0.00001, very low quality evidence) in the Padma 28 group compared with placebo. The clinical importance of these observed changes in walking distance is unclear as no quality of life data were reported. There was no effect on ankle brachial index (ABI): change in ABI values between baseline and six months follow up MD ‐0.01, 95% CI ‐0.07 to 0.05, 1 study, 56 participants, P = 0.72, very low quality evidence). Mild side effects, especially gastrointestinal discomfort, tiredness and skin eruption, were reported but this outcome was not different between the Padma 28 and placebo groups (odds ratio 1.09, 95% CI 0.42 to 2.83, four studies, 231 participants, P = 0.86, very low quality evidence). Authors' conclusions Some evidence exists from individual trials to suggest that Padma 28 may be effective in increasing walking distances, at least in the short term (four months), in people with IC. Side effects do not appear to be a problem. However, the longer term effects of treatment are unknown and the clinical significance of the improvements in walking distance are questionable. Moreover, the quality of the evidence is limited by the small sample size of the available trials, limited reporting of statistical analyses that compared treatment groups, and relatively high withdrawal rates that were linked to the outcome. That is, patients were withdrawn if they failed to improve walking distance. There was also evidence of publication bias. We therefore feel there is currently insufficient evidence to draw conclusions regards the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation. Plain language summary Padma 28 for intermittent claudication Background Intermittent claudication (IC) is pain in the leg that occurs on exercise and is relieved by rest. It is caused by an inadequate blood supply to the legs due to blockage of arteries. Conservative drug treatment is commonly used in an attempt to improve walking distance in these patients. Padma 28 is a Tibetan herbal preparation used for treating intermittent claudication. Study characteristics and key results This review on the effects of Padma 28 includes five trials with a total of 365 participants (current until September 2015). The review showed that Padma 28 has some beneficial effects in improving maximum and pain‐free walking distance. The groups treated with placebo did not show an improved maximum and pain‐free walking distance. Unfortunately the studies reported insufficient data to allow the comparison of the change in walking distances in the Padma 28 group with the change in walking distances in the placebo group. Combining the data of maximum walking distance after treatment in two studies showed that there was a longer maximum walking distance in the Padma 28 group compared with the placebo group after 16 weeks of treatment. No change in ankle brachial pressure was observed. Mild side effects such as gastrointestinal discomfort, tiredness and skin eruption were also noted but these were not different between the Padma 28 and placebo groups. Quality of the evidence Overall, the quality of the studies was low, with evidence of publication bias, small number of trials, limited reporting of the analyses that compared treatment groups and bias due to a high percentage of withdrawals in the placebo groups because of lack of improvement or deterioration of the overall condition. We therefore feel there is currently insufficient evidence to draw conclusions about the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stewart, M; Morling, JR; Maxwell, H", "articleTypes": [], "doi": "10.1002/14651858.CD007371.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "cf44e6d2-524b-4331-9c08-82be93b10689", "pmid": "", "title": "Dietary advice with or without oral nutritional supplements for disease‐related malnutrition in adults", "imported": false, "abstract": "Abstract - Background Disease‐related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social‐care costs. Dietary advice (DA) encouraging consumption of energy‐ and nutrient‐rich foods rather than oral nutritional supplements (ONS) may be an initial treatment. Objectives To examine evidence that DA with/without ONS in adults with disease‐related malnutrition improves survival, weight, anthropometry and quality of life (QoL). Search methods We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021. Selection criteria Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease‐related malnutrition in any healthcare setting compared with no advice, ONS or DA alone. Data collection and analysis Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence. Main results We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity. Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years. DA versus no advice ‐ 24 RCTs (3523 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three‐month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI ‐0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat‐free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS ‐ 12 RCTs (852 participants) All outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD ‐0.14 kg (95% CI ‐2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS ‐ 22 RCTs (1286 participants) Most outcomes had low‐certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD ‐1.07 (95% CI ‐4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS ‐ 31 RCTs (3308 participants) Evidence was moderate‐ to low‐certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD ‐0.12 (95% CI ‐2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS ‐ 13 RCTs (1315 participants) Evidence was low‐ to very low‐certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD ‐1.81 (95% CI ‐3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI ‐0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point. Authors' conclusions We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow‐up required for benefits to emerge were inconsistent for all other outcomes. There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient‐centred and healthcare outcomes are needed to address the questions in this review. Plain language summary Advice on diet for adults with malnutrition that is the result of disease Review question Can dietary advice with or without oral nutritional supplements (ONS) improve disease‐related malnutrition in adults? Background Ill people often have a poor appetite or feel sick because of medicines or other treatments and eat less than usual. Eating less over a longer time can cause weight loss, malnutrition, more health problems and death. Healthcare professionals may offer advice about dietary changes to help people to re‐establish good eating habits. They might recommend high‐protein and high‐energy foods so that these people can gain weight and improve their nutrition and general health. It is common for sick people to be offered ONS with or without advice about changing their food intake. To find the best answer to our review question, we looked for studies that compared five different treatment options: dietary advice compared with no advice; dietary advice compared with ONS; dietary advice plus ONS compared with dietary advice; dietary advice plus ONS if appropriate compared with no dietary advice; and dietary advice plus ONS compared with no dietary advice and no ONS. To make these comparisons fair, we looked for randomised controlled trials (RCTs), where the people taking part had an equal chance (like the flip of a coin) of being in either group that was being compared. Search date The evidence is current to: 01 March 2021. Study characteristics We found 94 studies (with a total of 10,284 people) that we could include in our review. Although older people have a higher risk of malnutrition, the people in these studies ranged from 17 to over 80 years of age and they were living either at home, in the community, or in hospital. They had a wide range of health conditions, including cancer, dementia and kidney disease. The studies reported on the participants for the length of their hospital stay or in some people in the community for up to six and a half years. Key results There is no evidence that any of the treatments affected how long many of the people in the studies lived. They did report some positive changes in energy intake (measured in calories), protein intake, weight, muscle bulk and quality of life. There were some reductions in complications and the length of time spent in hospital. However, there is no clear evidence about which treatment is the most helpful or the time it takes to achieve any benefit. Few studies reported results separately for men and women and so we cannot comment on whether there were any overall differences by sex. No studies recorded information about adverse events (harms) so we cannot offer a summary about possible harms. More research is needed to work out the best ways to help people who are losing weight because of illness in order to improve their clinical outcomes and quality of life. Certainty of the evidence Overall we rated the certainty of the evidence as low for most results, which means that we cannot be confident about the findings we report. There were several reasons for this. Some of the treatment comparisons that we looked at had only a few studies and some of those had small numbers of participants. There were problems with the design of some studies that may have affected the results. Some people knew which treatment they were receiving. We think this may influence the way that they reported some changes, e.g. their energy and protein intake, body weight and quality of life. We think that the way the decision about which group a person went into at the start of the study may have affected the results for some outcomes, e.g. change in weight, change in muscle bulk and mortality. We needed to see particular results to help us understand whether adults living with disease‐related malnutrition can improve their survival, weight and general quality of life if they receive advice about diet with or without ONS. None of the studies reported all of the results that we needed to do this. We were not able to estimate whether participants gain any benefits from the treatments, such as shortening the length of hospital stay, lowering the risk of readmission to hospital or developing complications. The low certainty of evidence, with no evidence in many areas, means we cannot make statements about any benefits and the possible disadvantages of these treatments despite the fact they are being used extensively in clinical practice. We recommend that future studies should be designed to measure these important patient‐centred and healthcare outcomes as well as any potential harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Baldwin, C, de van der Schueren, MAE, Kruizenga, HM, Weekes, CE", "articleTypes": [], "doi": "10.1002/14651858.CD002008.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.140Z" }, { "id": "cf482acf-6c49-4f6b-a7ec-7efb9846b626", "pmid": "", "title": "Palliative drug treatments for breathlessness in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is a life‐limiting autosomal recessive genetic illness. A feeling of shortness of breath is common in cystic fibrosis, especially as the disease progresses. Reversing the underlying cause is the priority when treating breathlessness (dyspnoea), but when it is not feasible, palliation (easing) becomes the primary goal to improve an individual's quality of life. A range of drugs administered by various routes have been used, but no definite guidelines are available. A systematic review is needed to evaluate such treatments. Objectives To assess the efficacy and safety of drugs used to ease breathlessness in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 18 November 2019. We searched databases (clinicaltrials.gov, the ISRCTN registry, the Clinical Trials Registry India and WHO ICTRP) for ongoing trials. These searches were last run on 06 March 2020. Selection criteria We planned to include randomised and quasi‐randomised controlled trials in people with cystic fibrosis (diagnosed by a positive sweat chloride test or genetic testing) who have breathlessness. We considered studies comparing any drugs used for easing breathlessness to another drug administered by any route (inhaled (nebulised), intravenous, oral, subcutaneous, transmucosal (including buccal, sublingual and intra‐nasal) and transdermal). Data collection and analysis The authors assessed the search results according to the pre‐defined inclusion criteria. Main results The new searches in 2020 yielded two ongoing studies that were not relevant to the review question. Previous searches had found only one study (cross‐over in design), which did not fulfil the inclusion criteria as no data were available from the first treatment period alone. Authors' conclusions Due to the lack of available evidence, this review cannot provide any information for clinical practice. The authors call for specific research in this area after taking into account relevant ethical considerations. The research should focus on the efficacy and safety of the drugs with efficacy being measured in terms of improvement in quality of life, dyspnoea scores and hospital stay. Plain language summary Drug treatments to ease breathlessness in cystic fibrosis Review question What is the evidence that drug treatments for breathlessness (also known as dyspnoea) in people with cystic fibrosis are effective and safe? Background Cystic fibrosis is a life‐limiting genetic disease. As the disease progresses, thick sticky mucus is formed in the lungs, pancreas and other organs. This thick mucus increases risk of infection, blocks the airways and causes severe breathlessness. Easing of this breathlessness is an important goal for care of people with cystic fibrosis. Many methods have been suggested to address this problem and many drugs have been reported to ease breathlessness. The drugs can be administered through various routes ‐ they might be inhaled, swallowed, injected under the skin, into muscle or into a vein or be absorbed through the skin (either on the body or through membranes inside the mouth or nose). Despite so many drugs being available, there are no defined guidelines for drug treatments aimed at easing breathlessness in people with cystic fibrosis. Search date The evidence from the Cochrane Cystic Fibrosis Trials Register is current to 18 November 2019; the searches of ongoing trial registries are current to 06 March 2020. Study characteristics We had planned to include studies comparing different treatments to ease breathlessness in people with cystic fibrosis where the participants were put into the different treatment groups at random. Our search found only one study in which seven people first received either a drug called hydrocodone or a placebo (dummy treatment) and then swapped to the other treatment; but this study did not report results separately for each treatment arm, so we are not able to include it in the review. Key results No studies fulfilled the inclusion criteria, therefore it is not possible to comment on the outcomes we wished to report on in this review. Until evidence becomes available, the review authors feel that it is advisable for doctors to follow any local or national guidelines. The authors recommend research in this area should take ethical considerations into account and should focus on the safety of the drugs, improvement in quality of life, breathlessness scores and length of hospital stay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Jaiswal, N, Singh, M, Agarwal, A, Chauhan, A, Jaiswal, N", "articleTypes": [], "doi": "10.1002/14651858.CD011855.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.085Z" }, { "id": "cf4ce4b5-157d-4990-9d70-795a60b5c065", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background The anti‐inflammatory effects of n‐3 (omega‐3 fatty acids, fish oil) have been suggested to be beneficial in chronic inflammatory disorders such as inflammatory bowel disease. This review is an update of a previously published Cochrane review. Objectives To systematically review the efficacy and safety of n‐3 for maintenance of remission in Crohn's disease (CD). Search methods The following databases were searched from inception to November 2013 without language restriction: CENTRAL, MEDLINE, EMBASE, HealthSTAR, PubMed, and ACP journal club. Selection criteria Randomized placebo‐controlled trials (RCT) of n‐3 for maintenance of remission in CD were included. Studies must have enrolled patients of any age group, who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil or n‐3 given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. Data collection and analysis The primary outcome was the relapse rate and secondary outcomes included change in disease activity scores, time to first relapse and adverse events. Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality using the Cochrane risk of bias tool. The overall quality of the evidence supporting the primary and selected secondary outcomes was reassessed for the current update using the GRADE system. We used the RevMan software for analyses. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the hazard ratio and 95% CI for time‐to‐event outcomes. Random‐effects or fixed‐effect models were used according to degree of heterogeneity and sensitivity analyses were performed in an attempt to explore possible sources of heterogeneity. Main results Six studies with a total of 1039 patients were eligible for inclusion. The two largest studies were rated as low risk of bias for all assessed items. Four studies were rated as unclear risk of bias for randomization and allocation concealment. Two studies were rated as high risk of bias for incomplete outcome data and selective reporting. There was a marginal significant benefit of n‐3 therapy for maintenance of remission. Thirty‐nine per cent of patients in the n‐3 group relapsed at 12 months compared to 47% of placebo patients (6 studies, 1039 patients; RR 0.77, 95% CI 0.61 to 0.98). A GRADE analysis rated the overall quality of the evidence for the primary outcome (i.e. relapse) as very low due to unexplained heterogeneity (I 2 = 58%), publication bias, and a high or unknown risk of bias in four studies in the pooled analysis. When two large studies at low risk of bias were considered the benefit was no longer statistically significant. Thirty‐seven per cent of patients in the n‐3 group relapsed at 12 months compared to 42% of placebo patients (2 studies, 738 patients; RR 0.88, 95% CI 0.74 to 1.05). No significant heterogeneity was identified for this pooled analysis ( I 2 = 0%). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was moderate due to sparse data (294 events). No serious adverse events were recorded in any of the studies but in a pooled analyses there was a significantly higher rate of diarrhea (4 studies, 862 patients; RR 1.36 95% CI 1.01 to 1.84) and upper gastrointestinal tract symptoms (5 studies, 999 patients; RR 1.65, 95% CI 1.25 to 2.18) in the n‐3 treatment group. Authors' conclusions Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms. Plain language summary Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of Crohn's disease patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of capsules containing omega‐3 fatty acids to maintain remission in Crohn's disease were reviewed. Six studies including 1039 patients were included in the review. A pooled analysis of six studies suggests a marginal benefit for omega 3 fatty acids over placebo (i.e. fake medicine) in preventing relapse of disease at one year. However, these results need to be interpreted with caution due to differences across the studies in terms of induction of remission regimens (e.g. surgical remission versus drug therapy) patients (e.g. adult versus pediatric patients) and medication regimens (e.g. some studies used different placebos), the possibility of publication bias (i.e. only studies with positive results are published) and low methodological quality in four studies in the pooled analysis. When the two largest and highest quality studies were pooled the results showed no benefit to omega‐3 treatment over placebo. There were no serious side effects in any of the studies. Common side effects included unpleasant taste, bad breath, heartburn, nausea and diarrhea. Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Lev‐Tzion, R; Griffiths, AM; Ledder, O; Turner, D", "articleTypes": [], "doi": "10.1002/14651858.CD006320.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "cf509bfd-b563-43cd-8908-86bb1c3e11c4", "pmid": "", "title": "Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption", "imported": false, "abstract": "Abstract - Background Overconsumption of food, alcohol, and tobacco products increases the risk of non‐communicable diseases. Interventions to change characteristics of physical micro‐environments where people may select or consume these products ‐ including shops, restaurants, workplaces, and schools – are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers. Objectives 1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non‐alcoholic beverages), (b) alcohol, and (c) tobacco products. 2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii. participants. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches. Selection criteria We included randomised controlled trials with between‐participants (parallel group) or within‐participants (cross‐over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product. Data collection and analysis We used a novel semi‐automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random‐effects meta‐analysis and meta‐regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE. Main results We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between‐participants designs (19/24). All studies were conducted in high‐income countries, predominantly in the USA (14/24). Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less‐healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta‐analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD −1.13 (95% confidence interval (CI) −1.90 to −0.37) (low certainty evidence). For consumption outcomes, meta‐analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD −0.55 (95% CI −1.27 to 0.18) (low certainty evidence). Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD −0.65 (95% CI −1.29 to −0.01) (very low certainty evidence). For consumption outcomes, meta‐analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD −0.60 (95% CI −0.84 to −0.36) (low certainty evidence). Meta‐regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias. Authors' conclusions The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real‐world settings, intervening across a wider range of foods ‐ as well as alcohol and tobacco products ‐ and over sustained time periods. Plain language summary Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption Unhealthy patterns of consumption of food, alcohol, and tobacco products are important causes of ill health. Changing the availability (the range or amount of options, or both) of these products or their proximity (the distance at which they are positioned) to potential consumers could help people make healthier choices. What is the aim of this review? This review investigated whether altering the availability or proximity of food (including non‐alcoholic beverages), alcohol, and tobacco products changed people's selection (such as purchasing) or consumption of those products. We searched for all available evidence from randomised controlled trials (a type of study in which participants are assigned to one of two or more treatment groups using a random method) to answer this question, and found 24 studies, all of which were conducted in high‐income countries. What are the main results of the review? Six studies involved availability interventions, of which four changed the relative proportion of less‐healthy to healthier options, and two changed the absolute number of different options available. In statistical analyses that combined results from multiple studies, it was found that reducing the number of available options for a particular range or category of food(s) reduced selection of those food products (from analysing 154 participants) and possibly reduced consumption of those products (from 150 participants). However, the certainty of the evidence for these effects was low. Eighteen studies involved proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. One study found that this reduced selection of food (from analysing 41 participants), whilst in a statistical analysis combining results from multiple studies, it was found that placing food farther away reduced consumption of those food products (from analysing 1098 participants). However, the certainty of the evidence for these effects was very low and low, respectively. Key messages Mindful of its limitations, the current evidence suggests that changing the number of available food options or changing where foods are positioned could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes to food environments. However, more high‐quality studies in real‐world settings are needed to make this finding more certain. How up‐to‐date is this review? The evidence is current to 23 July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hollands, GJ, Carter, P, Anwer, S, King, SE, Jebb, SA, Ogilvie, D, Shemilt, I, Higgins, JPT, Marteau, TM", "articleTypes": [], "doi": "10.1002/14651858.CD012573.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.131Z" }, { "id": "cf6faf89-d1e7-4c97-9db4-fb03443261e6", "pmid": "", "title": "A Novel Compound for Alcoholism Treatment: A Translational Strategy - Part II", "imported": false, "abstract": "Background:", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.241Z" }, { "id": "cf7a5393-086f-41e7-ab57-e75fb7c8328d", "pmid": "", "title": "OTIS - Optimized Complementary Feeding Study", "imported": false, "abstract": "Dietary factors during infancy, e.g. high intakes of protein, fast carbohydrates and saturated fat increase the risk of adult obesity, type 2 diabetes and hypertension. However, current dietary recommendations to infants are based on traditions and experiences whereas research is basically lacking.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.149Z" }, { "id": "cf7a7bcf-8e4b-4d4d-9eac-cc17aea95ebc", "pmid": "", "title": "Xiao Chai Hu Tang, a herbal medicine, for chronic hepatitis B", "imported": false, "abstract": "Abstract - Background Chronic hepatitis B is associated with high morbidity and mortality. Chronic hepatitis B requires long‐term management aiming at reduction of the risks of hepatocellular inflammatory necrosis, liver fibrosis, decompensated liver cirrhosis, liver failure, and liver cancer, and improving health‐related quality of life. The Chinese herbal medicine formula Xiao Chai Hu Tang has been used to decrease discomfort and replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established with rigorous review methodology. Objectives To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and seven other databases to 1 March 2019. We also searched the World Health Organization International Clinical Trials Registry Platform ( www.who.int/ictrp ), ClinicalTrials.gov ( www.clinicaltrials.gov/ ), and the Chinese Clinical Trial Registry for ongoing or unpublished trials to 1 March 2019. Selection criteria We included randomised clinical trials, irrespective of publication status, language, and blinding, comparing Xiao Chai Hu Tang formula versus no intervention or placebo in people with chronic hepatitis B. We included participants of any sex and age, diagnosed with chronic hepatitis B according to guidelines or as defined by the trialists. We allowed co‐interventions when the co‐interventions were administered equally to all the intervention groups. Data collection and analysis Review authors independently retrieved data from reports and after correspondence with investigators. Our primary outcomes were all‐cause mortality, serious adverse events, and health‐related quality of life. Our secondary outcomes were hepatitis B‐related mortality, hepatitis B‐related morbidity, and adverse events considered 'not to be serious'. We presented the meta‐analysed results as risk ratios (RR) with 95% confidence intervals (CI). We assessed the risks of bias using risk of bias domains with predefined definitions. We used GRADE methodology to evaluate our certainty in the evidence. Main results We included 10 randomised clinical trials with 934 participants, but only five trials with 490 participants provided data for analysis. All the trials compared Xiao Chai Hu Tang formula with no intervention. All trials appeared to have been conducted and published only in China. The included trials assessed heterogeneous forms of Xiao Chai Hu Tang formula, administered for three to eight months. One trial included participants with hepatitis B and comorbid tuberculosis, and one trial included participants with hepatitis B and liver cirrhosis. The remaining trials included participants with hepatitis B only. All the trials were at high risk of bias, and the certainty of evidence for all outcomes that provided data for analyses was very low. We downgraded the evidence by one or two levels because of outcome risk of bias, inconsistency or heterogeneity of results (opposite direction of effect), indirectness of evidence (use of surrogate outcomes instead of clinically relevant outcomes), imprecision of results (the CIs were wide), and publication bias (small sample size of the trials). Additionally, 47 trials lacked the necessary methodological information needed to ensure the inclusion of these trials in our review. None of the included trials aimed to assess clinically relevant outcomes such as all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, or hepatitis B‐related morbidity. The effects of Xiao Chai Hu Tang formula on the proportion of participants with adverse events considered 'not to be serious' is uncertain (RR 0.43, 95% CI 0.02 to 11.98; I 2 = 69%; very low‐certainty evidence). Only three trials with 222 participants reported the proportion of people with detectable hepatitis B virus DNA (HBV‐DNA), but the evidence that Xiao Chai Hu Tang formula reduces the presence of HBV‐DNA in the blood (a surrogate outcome) is uncertain (RR 0.62, 95% CI 0.45 to 0.85; I 2 = 0%; very low‐certainty evidence). Only two trials with 160 participants reported the proportion of people with detectable hepatitis B virus e‐antigen (HBeAg; a surrogate outcome) (RR 0.72, 95% CI 0.50 to 1.02; I 2 = 38%; very low‐certainty evidence) and the evidence is uncertain. The evidence is also uncertain for separately reported adverse events considered 'not to be serious'. Funding: two of the 10 included trials received academic funding from government or hospital. None of the remaining eight trials reported information on funding. Authors' conclusions The clinical effects of Xiao Chai Hu Tang formula for chronic hepatitis B remain unclear. The included trials were small and of low methodological quality. Despite the wide use of Xiao Chai Hu Tang formula, we lack data on all‐cause mortality, serious adverse events, health‐related quality of life, hepatitis B‐related mortality, and hepatitis B‐related morbidity. The evidence in this systematic review comes from data obtained from a maximum three trials. We graded the certainty of evidence as very low for adverse events considered not to be serious and the surrogate outcomes HBeAg and HBV‐DNA. We found a large number of trials which lacked clear description of their design and conduct, and hence, these trials are not included in the present review. As all identified trials were conducted in China, there might be a concern about the applicability of this review outside China. Large‐sized, high‐quality randomised sham‐controlled trials with homogeneous groups of participants and transparent funding are lacking. Plain language summary Xiao Chai Hu Tang, a Chinese herbal medicine formula, for chronic hepatitis B Review question To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B virus infection. Background Chronic hepatitis B virus infection is a common liver disease, associated with high morbidity (illness) and death. It causes psychological stress and is a burden to people with chronic hepatitis B and their families. Xiao Chai Hu Tang formula has been used for treating people with chronic hepatitis B as it is believed that it decreases discomfort and prevents the replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established in reviews with rigorous review methodology. Search date The review includes trials published up to 1 March 2019. Study characteristics We included 10 randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) with 934 participants. All trials compared Xiao Chai Hu Tang formula with no treatment. The trials assessed different formulas and doses for three to eight months. One trial included participants with tuberculosis (a disease of the lungs that can make you cough mucous), and one trial included participants with liver cirrhosis (scarring). Only five trials with 490 participants provided data for analysis Study funding sources Two of the 10 included trials reported receiving academic funding. None of the remaining eight trials reported information of support or funding. Key results None of the 10 included trials reported data on all‐cause mortality (death from any cause), serious side effects (untoward medical occurrences that result in serious outcomes such as death or disability), health‐related quality of life (a measure of physical, mental, emotional, and social functioning a measure of a person's satisfaction with their life and health), hepatitis B‐related death, and hepatitis B‐related morbidity. We are uncertain whether Xiao Chai Hu Tang formula versus no intervention has a positive or negative effect regarding side effects considered 'not to be serious', the proportion of people with detectable HBeAg (a hepatitis B viral protein that indicates active viral replication), and separately reported side effects considered 'not to be serious'. Xiao Chai Hu Tang formula compared with no intervention seems to reduce the proportion of people with detectable HBV‐DNA (which is used to indicate how much hepatitis B virus is in the blood) but the reliability of this finding is low. Surrogate outcomes are markers that are used in research as a substitute for a clinically meaningful measure that directly measures patient outcomes. We cannot always be certain that such surrogate outcomes are reliable substitutes for important outcomes as they need to be officially examined. Caution is needed with this beneficial finding as the trials are at high risk of bias, and this outcome has not yet been proven relevant to patients. We identified an additional 47 studies as potential randomised clinical trials, but the data they reported were of no use. Accordingly, properly designed randomised clinical trials are needed before the benefits and harms of Xiao Chai Hu Tang formula for chronic hepatitis B can be determined. Reliability of the evidence The reliability of the evidence on the use of Xiao Chai Hu Tang formula in people with chronic hepatitis B virus in terms of its beneficial or harmful effects on death, health‐related quality of life, risk of dying due to hepatitis B virus infection, and serious side effects cannot be determined as no trials aimed to explore these. The reliability of the evidence that Xiao Chai Hu Tang formula, when compared with no intervention, in terms of side effects considered 'not to be serious', the proportion of people with detectable HBV‐DNA, and the proportion of people with detectable HBeAg is very low. These assessments of the reliability of the evidence are due to the poor design and reporting of the included trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kong, DZ; Liang, N; Yang, GL; Zhang, Z; Liu, Y; Li, J; Liu, X; Liang, S; Nikolova, D; Jakobsen, JC; Gluud, C; Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD013090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "cf8a342f-6946-413b-bc3f-6b4065202b2e", "pmid": "", "title": "Reduced dietary salt for the prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review that was first published in 2011 of the effects of reducing dietary salt intake, through advice to reduce salt intake or low‐sodium salt substitution, on mortality and cardiovascular events. Objectives 1. To assess the long‐term effects of advice and salt substitution, aimed at reducing dietary salt, on mortality and cardiovascular morbidity. 2. To investigate whether a reduction in blood pressure is an explanatory factor in the effect of such dietary interventions on mortality and cardiovascular outcomes. Search methods We updated the searches of CENTRAL (2013, Issue 4), MEDLINE (OVID, 1946 to April week 3 2013), EMBASE (OVID, 1947 to 30 April 2013) and CINAHL (EBSCO, inception to 1 April 2013) and last ran these on 1 May 2013. We also checked the references of included studies and reviews. We applied no language restrictions. Selection criteria Trials fulfilled the following criteria: (1) randomised, with follow‐up of at least six months, (2) the intervention was reduced dietary salt (through advice to reduce salt intake or low‐sodium salt substitution), (3) participants were adults and (4) mortality or cardiovascular morbidity data were available. Two review authors independently assessed whether studies met these criteria. Data collection and analysis A single author extracted data and assessed study validity, and a second author checked this. We contacted trial authors where possible to obtain missing information. We extracted events and calculated risk ratios (RRs) and 95% confidence intervals (CIs). Main results Eight studies met the inclusion criteria: three in normotensives (n = 3518) and five in hypertensives or mixed populations of normo‐ and hypertensives (n = 3766). End of trial follow‐up ranged from six to 36 months and the longest observational follow‐up (after trial end) was 12.7 years. The risk ratios (RR) for all‐cause mortality in normotensives were imprecise and showed no evidence of reduction (end of trial RR 0.67, 95% confidence interval (CI) 0.40 to 1.12, 60 deaths; longest follow‐up RR 0.90, 95% CI 0.58 to 1.40, 79 deaths n=3518) or in hypertensives (end of trial RR 1.00, 95% CI 0.86 to 1.15, 565 deaths; longest follow‐up RR 0.99, 95% CI 0.87 to 1.14, 674 deaths n=3085). There was weak evidence of benefit for cardiovascular mortality (hypertensives: end of trial RR 0.67, 95% CI 0.45 to 1.01, 106 events n=2656) and for cardiovascular events (hypertensives: end of trial RR 0.76, 95% CI 0.57 to 1.01, 194 events, four studies, n = 3397; normotensives: at longest follow‐up RR 0.84, 95% CI 0.64 to 1.10, 200 events; hypertensives: RR 0.77, 95% CI 0.58 to 1.02, 192 events; pooled analysis of six trials (RR 0.81, 95% CI 0.66 to 0.98; n = 5762). These findings were driven by one trial among retirement home residents that reduced salt intake in the kitchens of the homes, thereby not requiring individual behaviour change. Advice to reduce salt showed small reductions in systolic blood pressure (mean difference (MD) ‐1.15 mmHg, 95% CI ‐2.32 to 0.02 n=2079) and diastolic blood pressure (MD ‐0.80 mmHg, 95% CI ‐1.37 to ‐0.23 n=2079) in normotensives and greater reductions in systolic blood pressure in hypertensives (MD ‐4.14 mmHg, 95% CI ‐5.84 to ‐2.43 n=675), but no difference in diastolic blood pressure (MD ‐3.74 mmHg, 95% CI ‐8.41 to 0.93 n=675). Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Health‐related quality of life was assessed in one trial in normotensives, which reported significant improvements in well‐being but no data were presented. Authors' conclusions Despite collating more event data than previous systematic reviews of randomised controlled trials, there is insufficient power to confirm clinically important effects of dietary advice and salt substitution on cardiovascular mortality in normotensive or hypertensive populations. Our estimates of the clinical benefits from advice to reduce dietary salt are imprecise, but are larger than would be predicted from the small blood pressure reductions achieved. Further well‐powered studies would be needed to obtain more precise estimates. Our findings do not support individual dietary advice as a means of restricting salt intake. It is possible that alternative strategies that do not require individual behaviour change may be effective and merit further trials. Plain language summary Reduced dietary salt for the prevention of cardiovascular disease Cardiovascular disease includes heart attacks and strokes and is a major cause of premature death and disability. This is an update of a review first published in 2011. This review sets out to assess whether intensive support and encouragement to cut down on salt in foods, and substituting low‐sodium salt, reduces the risk of death or cardiovascular disease. This update includes two new studies and eliminates one problematic study, giving a total of eight trials with 7284 participants. Dietary advice and salt substitution did reduce the amount of salt eaten, which led to a small reduction in blood pressure by six months. There was weak evidence of benefit for cardiovascular events, but these findings were inconclusive and were driven by a single trial among retirement home residents, which reduced salt intake in the kitchens of the homes. The findings of our review do not mean that advising people to reduce salt should be stopped. However, additional measures ‐ reducing the amount of hidden salt in processed foods, for example – will make it much easier for people to achieve a lower salt diet. Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Further evidence of the effects of different ways of reducing dietary salt on clinical events is needed from experimental and observational studies to underpin public health policies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Adler, AJ; Taylor, F; Martin, N; Gottlieb, S; Taylor, RS; Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD009217.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "cf8c5c83-a603-4d69-962b-f4aa094b2d73", "pmid": "", "title": "Exposure to the smell and taste of milk to accelerate feeding in preterm infants", "imported": false, "abstract": "Abstract - Background Preterm infants (born before 37 weeks' gestation) are often unable to co‐ordinate sucking, swallowing, and breathing for oral feeding because of their immaturity. In such cases, initial nutrition is provided by orogastric or nasogastric tube feeding. Feeding intolerance is common and can delay attainment of full enteral and sucking feeds, prolonging the need for nutritional support and the hospital stay. Smell and taste play an important role in the activation of physiological pre‐absorptive processes that contribute to food digestion and absorption. However, during tube feeding, milk bypasses the nasal and oral cavities, limiting exposure to the smell and taste of milk. Provision of the smell and taste of milk with tube feeds offers a non‐invasive and low‐cost intervention that, if effective in accelerating the transition to enteral feeds and subsequently to sucking feeds, would bring considerable advantages to infants, their families, and healthcare systems. Objectives To assess whether exposure to the smell or taste (or both) of breastmilk or formula administered with tube feeds can accelerate the transition to full sucking feeds without adverse effects in preterm infants. Search methods We conducted searches in CENTRAL, MEDLINE, Embase, CINAHL, and Epistemonikos to 26 April 2023. We also searched clinical trial databases and conference proceedings. Selection criteria We included randomised and quasi‐randomised studies that evaluated exposure versus no exposure to the smell or taste of milk (or both) immediately before or at the time of tube feeds. Data collection and analysis Two review authors independently selected studies, assessed risk of bias, and extracted data according to Cochrane Neonatal methodology. We performed meta‐analyses using risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence. Main results We included eight studies (1277 preterm infants). Seven studies (1244 infants) contributed data for meta‐analysis. The evidence suggests that exposure to the smell and taste of milk with tube feeds has little to no effect on time taken to reach full sucking feeds (MD −1.07 days, 95% CI −2.63 to 0.50; 3 studies, 662 infants; very low‐certainty evidence). Two studies reported no adverse effects related to the intervention. The intervention may have little to no effect on duration of parenteral nutrition (MD 0.23 days, 95% CI −0.24 to 0.71; 3 studies, 977 infants; low‐certainty evidence), time to reach full enteral feeds (MD −0.16 days, 95% CI −0.45 to 0.12; 1 study, 736 infants; very low‐certainty evidence) or risk of necrotising enterocolitis (RR 0.93, 95% CI 0.47 to 1.84; 2 studies, 435 infants; low‐certainty evidence), although the evidence for time to reach full enteral feeds is very uncertain. Exposure to the smell and taste of milk with tube feeds probably has little to no effect on risk of late infection (RR 1.14, 95% CI 0.74 to 1.75; 2 studies, 436 infants; moderate‐certainty evidence). There were no data available to assess feeding intolerance. The included studies had small sample sizes and methodological limitations, including unclear or lack of randomisation (four studies), lack of blinding of participants and personnel (five studies), unclear or lack of blinding of the outcome assessor (all eight studies), and different inclusion criteria and methods of administering the interventions. Authors' conclusions The results of our meta‐analyses suggest that exposure to the smell and taste of milk with tube feeds may have little to no effect on time to reach full sucking feeds and time to reach full enteral feeds. We found no clear difference between exposure and no exposure to the smell or taste of milk on safety outcomes (adverse effects, necrotising enterocolitis, and late infection). Results from one ongoing study and two studies awaiting classification may alter the conclusions of this review. Future research should examine the effect of exposing preterm infants to the smell and taste of milk with tube feeds on health outcomes during hospitalisation, such as attainment of feeding skills, safety, feed tolerance, infection, and growth. Future studies should be powered to detect the effect of the intervention in infants of different gestational ages and on each sex separately. It is also important to determine the optimal method, frequency, and duration of exposure. Plain language summary Does exposure to the smell and taste of milk accelerate feeding in tube‐fed preterm infants? Key messages • Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time it takes preterm infants to reach full sucking feeds.
• We found no evidence of any unwanted effects of exposure to the smell and taste of milk with tube feeds in newborn infants. What is tube feeding? Infants born preterm (before 37 weeks of pregnancy) often need to be fed via a thin tube inserted through the mouth (orogastric tube) or nose (nasogastric tube) into the stomach until they are able to suck all of their feeds. Why is the smell and taste of milk important for tube‐fed babies? Initially, only small volumes of milk are given, and this is gradually increased depending on how well the babies tolerate the milk. Smell and taste have a significant role in helping with digestion and absorption of food, and since infants being fed by a tube may not experience the smell or taste of milk, they might be taking longer to tolerate larger volumes of milk. What did we want to find out? We wanted to find out if exposing infants to the smell and taste of milk before or while they were being fed through a tube could help them tolerate greater volumes of milk more quickly and improve their overall growth and development. We also wanted to know if this method had any unwanted effects. What did we do? We searched for studies that investigated exposing preterm infants to the smell or taste (or both) of milk with tube feeds, compared to no such exposure. We compared and summarised the results of the studies and rated the certainty of the evidence, based on factors such as study methods and number of infants included. What did we find? We identified eight completed studies involving 1277 preterm infants admitted to a neonatal intensive care unit. Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time to reach full sucking feeds, but the results are very uncertain. Two studies reported that no infants had any unwanted effects related to exposure to the smell and taste of milk with tube feeds. Exposure to the smell and taste of milk may have little to no effect on duration of intravenous nutrition (feeding through a vein), time to reach full enteral feeds (feeds though a tube into the stomach), or on the risk of necrotising enterocolitis (a serious intestinal disease), although the results for time to full enteral feeds are very uncertain. Exposure to the smell and taste of milk probably has little or no effect on the risk of developing an infection more than two days after birth. What are the limitations of the evidence? We have little confidence in the evidence because: • we identified few studies;
• most studies were small and provided different types of exposure to smell and taste;
• in many studies, clinicians and parents were aware of which treatment the infant was receiving; and
• the studies did not investigate all the outcomes we were interested in. How up‐to‐date is this evidence? This review is current to April 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Delgado Paramo, L; Bronnert, A; Lin, L; Bloomfield, FH; Muelbert, M; Harding, JE", "articleTypes": [], "doi": "10.1002/14651858.CD013038.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "cf8ca3e2-c701-4a5c-9b4c-7acf65116adc", "pmid": "", "title": "Topical anaesthetic or vasoconstrictor preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy", "imported": false, "abstract": "Abstract - Background Nasal pharyngolaryngoscopy (NPL) is performed as an outpatient and inpatient procedure on a daily basis, for a variety of indications. It frequently causes some degree of discomfort to the patient. Various different topical agents, which are intended to reduce this discomfort, are in common use. This review aimed to assess the effectiveness of the various agents. Objectives To assess the effectiveness of topical preparations used to reduce discomfort and facilitate NPL in adults. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 14 April 2010. Selection criteria Randomised controlled trials (RCTs) looking at the effect of topical anaesthetic or vasoconstrictor agents used reduce discomfort and facilitate NPL in adult patients. Data collection and analysis Two review authors independently selected studies, extracted data and assessed risk of bias. We contacted trial authors for further information where necessary. The primary outcome measured was pain/discomfort. Secondary outcomes that were looked at included side effects of the topical medications, ease of the procedure and the quality of the view from the operator's perspective. Main results We included eight RCTs (746 participants) in the review. The risk of bias in the studies was generally low. Five studies did not demonstrate any advantage in using a topical treatment prior to endoscopy. One study suggested that a vasoconstrictor alone should be used to reduce the general level of unpleasantness. Two studies did not compare treatment against placebo or no treatment, so it was not possible to draw meaningful conclusions from them. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. There was variation in the format of the outcome data and a lack of complete data; none of the included studies reported their results in a way that would allow pooling and we could not therefore perform meta‐analysis. Authors' conclusions The included studies do not demonstrate any evidence to support the use of topical treatments prior to the use of a fibre‐optic nasal endoscope. Some go as far as to suggest that these agents should not be used due to cost and unpleasant side effects. Five studies did not demonstrate any advantage in terms of reducing pain or discomfort when using a topical treatment prior to endoscopy. The absence of demonstrable effect may be due to relatively small patient groups. It is therefore possible that there is a small effect of using these sprays. Further research using standardised reporting methods is needed. Plain language summary Topical anaesthetic or vasoconstrictor (blood vessel narrowing) preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy Topical medications are often applied to the inside of a patient's nose prior to examining the nose, sinuses and throat with a flexible nasopharyngolaryngoscope. The aim of this is to reduce any discomfort the patient may feel and also to improve the adequacy of the examination. Types of preparation include lidocaine, phenylephrine and lidocaine, oxymetazoline, xylometazoline and cocaine and they are usually administered as a spray, although they may also be in the form of a solution which can be applied to cotton wool and placed in the nasal cavity, or as gels, pastes or creams. We looked for randomised controlled trials comparing any of these topical treatments with placebo, no treatment or another topical treatment in adult patients undergoing nasal pharyngolaryngoscopy (NPL). We included eight studies in the review (with a total of 746 patients). It was not possible to combine data from any of the studies, therefore we assessed the individual study results. Five of the studies did not demonstrate any advantage, in terms of reducing pain or discomfort, of using a topical treatment prior to endoscopy. One of these suggested that a vasoconstrictor (xylometazoline) alone reduced the level of \"general unpleasantness\". Two studies did not compare the treatment against placebo or no treatment. A final study actually suggested an increase in pain with the use of topical agents. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. Further standardised research is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Sunkaraneni, VS, Jones, SEM", "articleTypes": [], "doi": "10.1002/14651858.CD005606.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.748Z" }, { "id": "cf920d17-2cfb-443d-871a-1781c40956fc", "pmid": "", "title": "Citalopram versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Recent US and UK clinical practice guidelines recommend that second‐generation antidepressants should be considered amongst the best first‐line options when drug therapy is indicated for a depressive episode. Systematic reviews have already highlighted some differences in efficacy between second‐generation antidepressants. Citalopram, one of the first selective serotonin reuptake inhibitors (SSRI) introduced in the market, is one of these antidepressant drugs that clinicians use for routine depression care. Objectives To assess the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with tricyclics, heterocyclics, other SSRIs and other conventional and non‐conventional antidepressants in the acute‐phase treatment of major depression. Search methods We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to February 2012. No language restriction was applied. We contacted pharmaceutical companies and experts in this field for supplemental data. Selection criteria Randomised controlled trials allocating patients with major depression to citalopram versus any other antidepressants. Data collection and analysis Two reviewers independently extracted data. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (the number of patients who responded or remitted), patient acceptability (the number of patients who failed to complete the study) and tolerability (side‐effects). Main results Thirty‐seven trials compared citalopram with other antidepressants (such as tricyclics, heterocyclics, SSRIs and other antidepressants, either conventional ones, such as mirtazapine, venlafaxine and reboxetine, or non‐conventional, like hypericum ). Citalopram was shown to be significantly less effective than escitalopram in achieving acute response (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.08 to 2.02), but more effective than paroxetine (OR 0.65, 95% CI 0.44 to 0.96) and reboxetine (OR 0.63, 95% CI 0.43 to 0.91). Significantly fewer patients allocated to citalopram withdrew from trials due to adverse events compared with patients allocated to tricyclics (OR 0.54, 95% CI 0.38 to 0.78) and fewer patients allocated to citalopram reported at least one side effect than reboxetine or venlafaxine (OR 0.64, 95% CI 0.42 to 0.97 and OR 0.46, 95% CI 0.24 to 0.88, respectively). Authors' conclusions Some statistically significant differences between citalopram and other antidepressants for the acute phase treatment of major depression were found in terms of efficacy, tolerability and acceptability. Citalopram was more efficacious than paroxetine and reboxetine and more acceptable than tricyclics, reboxetine and venlafaxine, however, it seemed to be less efficacious than escitalopram. As with most systematic reviews in psychopharmacology, the potential for overestimation of treatment effect due to sponsorship bias and publication bias should be borne in mind when interpreting review findings. Economic analyses were not reported in the included studies, however, cost effectiveness information is needed in the field of antidepressant trials. Plain language summary Citalopram versus other antidepressants for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Antidepressant drugs remain the mainstay of treatment in moderate‐to‐severe major depression. During the last 20 years, selective serotonin reuptake inhibitors (SSRIs) have progressively become the most commonly prescribed antidepressants. Citalopram, one of the first SSRIs introduced in the market, is the racemic mixture of S‐ and R‐enantiomer. In the present review we assessed the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with all other antidepressants in the acute‐phase treatment of major depression. Thirty‐seven randomised controlled trials (more than 6000 participants) were included in the present review. In terms of efficacy, citalopram was more efficacious than other reference compounds like paroxetine or reboxetine, but worse than escitalopram. In terms of side effects, citalopram was more acceptable than older antidepressants, like tricyclics. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including differences in efficacy and side‐effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cipriani, A, Purgato, M, Furukawa, TA, Trespidi, C, Imperadore, G, Signoretti, A, Churchill, R, Watanabe, N, Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006534.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.767Z" }, { "id": "cf98242f-75ec-4e15-a18b-b3096944a6d0", "pmid": "", "title": "Factors influencing the uptake and use of nicotine replacement therapy and e‐cigarettes in pregnant women who smoke: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) delivers nicotine without the toxic chemicals present in tobacco smoke. It is an effective smoking cessation aid in non‐pregnant smokers, but there is less evidence of effectiveness in pregnancy. Systematic review evidence suggests that pregnant women do not adhere to NRT as prescribed, which might undermine effectiveness. Electronic cigarettes (e‐cigarettes) have grown in popularity, but effectiveness and safety in pregnancy are not yet established. The determinants of uptake and use of NRT and e‐cigarettes in pregnancy are unknown. Objectives To explore factors affecting uptake and use of NRT and e‐cigarettes in pregnancy. Search methods We searched MEDLINE(R), CINAHL and PsycINFO on 1 February 2019. We manually searched OpenGrey database and screened references of included studies and relevant reviews. We also conducted forward citation searches of included studies. Selection criteria We selected studies that used qualitative methods of data collection and analysis, included women who had smoked in pregnancy, and elicited participants' views about using NRT/e‐cigarettes for smoking cessation or harm reduction (i.e. to smoke fewer cigarettes) during pregnancy. Data collection and analysis We identified determinants of uptake and use of NRT/e‐cigarettes in pregnancy using a thematic synthesis approach. Two review authors assessed the quality of included studies with the Wallace tool. Two review authors used the CERQual approach to assess confidence in review findings. The contexts of studies from this review and the relevant Cochrane effectiveness review were not similar enough to fully integrate findings; however, we created a matrix to juxtapose findings from this review with the descriptions of behavioural support from trials in the effectiveness review. Main results We included 21 studies: 15 focused on NRT, 3 on e‐cigarettes, and 3 on both. Studies took place in five high‐income countries. Most studies contributed few relevant data; substantially fewer data were available on determinants of e‐cigarettes. Many studies focused predominantly on issues relating to smoking cessation, and determinants of NRT/e‐cigarette use was often presented as one of the themes. We identified six descriptive themes and 18 findings within those themes; from these we developed three overarching analytical themes representing key determinants of uptake and adherence to NRT and/or e‐cigarettes in pregnancy. The analytical themes show that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. Furthermore, women consider advice from health professionals when deciding whether to use NRT or e‐cigarettes; when health professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay for them to use these in pregnancy, women report feeling more confident about using them. Conversely, women who are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them during pregnancy feel less confident about using them. Women's past experiences with NRT can also affect their willingness to use NRT in pregnancy; women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. No trials on e‐cigarette use in pregnancy were included in the Cochrane effectiveness review, so we considered only NRT findings when integrating results from this review and the effectiveness review. No qualitative studies were conducted alongside trials, making full integration of the findings challenging. Women enrolled in trials would have agreed to being allocated to NRT or control group and would have received standardised information on NRT at the start of the trial. Overall, the findings of this synthesis are less relevant to women's decisions about starting NRT in trials and more likely to help explain trial participants' adherence to NRT after starting it. We considered most findings to be of moderate certainty; we assessed findings on NRT use as being of higher certainty than those on e‐cigarette use. This was mainly due to the limited data from fewer studies (only in the UK and USA) that contributed to e‐cigarette findings. Overall, we judged studies to be of acceptable quality with only minor methodological issues. Authors' conclusions Consistent messages from health professionals, based on high‐quality evidence and clearly explaining the safety of NRT and e‐cigarettes compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and subsequently encourage them to stay smoke‐free. Plain language summary Factors affecting use of nicotine replacement therapy and e‐cigarettes in pregnancy What was studied in this review? Nicotine replacement therapy (NRT) delivers nicotine without the harmful chemicals found in tobacco smoke. NRT helps some non‐pregnant adults to stop smoking, but it does not seem to work so well in pregnancy. This may be because pregnant women generally do not use NRT as prescribed. Studies show that some pregnant women use e‐cigarettes to help them cut down or quit, although their safety and effectiveness in pregnancy is not known. Little is known about the issues that influence pregnant women's use of NRT/e‐cigarettes. What is the aim of this review? To explore factors that affect whether women take up and use NRT or e‐cigarettes to reduce or quit smoking in pregnancy. What are the key messages of this review? Three main factors influence whether women take up and use NRT and e‐cigarettes in pregnancy: advice women receive from health professionals on using NRT or e‐cigarette in pregnancy, women's desire to protect their unborn baby from harm, and past personal experience with NRT. Each of these factors can either encourage or discourage women from using these products. What are the key findings? We included 21 studies; 15 of these focused on NRT, 3 on e‐cigarettes and 3 on both. Our findings suggest that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. They also consider the advice from their health professionals; when professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay to use them in pregnancy, their confidence about using them increases. When women are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them when they are pregnant, they feel less confident about using them. Women's past experiences with NRT will also affect how willing they are to use NRT in pregnancy. For example, women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. We conclude that consistent messages that are based on high‐quality research and clearly explain how safe NRT and e‐cigarettes are compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and encourage them to stay smoke‐free. How up‐to‐date is this review? We searched for studies that had been published before 1 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Campbell, K, Coleman-Haynes, T, Bowker, K, Cooper, SE, Connelly, S, Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD013629", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.104Z" }, { "id": "cfb5638c-9b52-44b4-aaac-c4cd06b39a51", "pmid": "", "title": "The Effectiveness of Cerebrolycin, a Multi-modal Neurotrophic Factor, for Treatment of Post-covid-19 Persistent Olfactory, Gustatory and Trigeminal Chemosensory Dysfunctions: A Pilot Study", "imported": false, "abstract": "The loss of smell and taste is a prominent symptom of COVID-19. Studies found that patterns of smell loss due to Covid-19 infection differ from that of other respiratory viruses being much more profound in the Covid-19 patents and did not associate with runny, congested, or blocked-up nose. The researchers suggest that smell and taste testing can be used for fast COVID-19 screening. Studies found that the Covid-19 virus has similarities with severe acute respiratory syndrome coronavirus (SARS-CoV), which has been reported to enter the brain, via smell receptors in the nose. The sudden onset and relatively fast recovery in some patients suggest that COVID-19 anosmia is not caused by damage to the central nervous system but rather by the loss of smell information before it gets to the brain (smell receptors). They also found that it has different behavior from other respiratory viruses as it causes over-reaction of the immune system (or a cytokine storm). Trials to treat post-COVID anosmia using local steroid applications, sniffing of strong odors or scents or use of different vitamins (for several weeks to months) did not provide rapid, satisfactory or even significant recovery of olfactory dysfunction. Fortunately, the olfactory neurons can regenerate, however, studies reported variable prognoses, some patients recovered within weeks which others may have persistent deficits for months or even a year. In this study, the researchers hypothesize that cerebrolysin, a drug of neurotrophic and neuroprotective properties, can be used to treat patients with persistent post-COVID anosmia or ageusia or promote functional recovery of smell and taste deficits.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.237Z" }, { "id": "cfbb4d75-7ea6-4da7-a3f1-1301afadf4fa", "pmid": "", "title": "Adhesives for fixed orthodontic bands", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Millett, DT, Glenny, AM, Mattick, RCR, Hickman, J, Mandall, NA", "articleTypes": [], "doi": "10.1002/14651858.CD004485.pub4 AB - Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. It has been shown that the quality of treatment result obtained with fixed appliances is much better than with removable appliances. Fixed appliances are, therefore, favoured by most orthodontists for treatment. The success of a fixed orthodontic appliance depends on the metal attachments (brackets and bands) being attached securely to the teeth so that they do not become loose during treatment. Brackets are usually attached to the front and side teeth, whereas bands (metal rings that go round the teeth) are more commonly used on the back teeth (molars). A number of adhesives are available to attach bands to teeth and it is important to understand which group of adhesives bond most reliably, as well as reducing or preventing dental decay during the treatment period. Objectives To evaluate the effectiveness of the adhesives used to attach bands to teeth during fixed appliance treatment, in terms of:
 (1) how often the bands come off during treatment; and
 (2) whether they protect the banded teeth against decay during fixed appliance treatment. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (searched 2 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 2 June 2016), MEDLINE Ovid (1946 to 2 June 2016) and EMBASE Ovid (1980 to 2 June 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised and controlled clinical trials (RCTs and CCTs) (including split‐mouth studies) of adhesives used to attach orthodontic bands to molar teeth were selected. Patients with full arch fixed orthodontic appliance(s) who had bands attached to molars were included. Data collection and analysis All review authors were involved in study selection, validity assessment and data extraction without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Five RCTs and three CCTs were identified as meeting the review's inclusion criteria. All the included trials were of split‐mouth design. Four trials compared chemically cured zinc phosphate and chemically cured glass ionomer; three trials compared chemically cured glass ionomer cement with light cured compomer; one trial compared chemically cured glass ionomer with a chemically cured glass phosphonate. Data analysis was often inappropriate within the studies meeting the inclusion criteria. Authors' conclusions There is insufficient high quality evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth. Further RCTs are required. Plain language summary Adhesives for fixed orthodontic bands There is insufficient evidence to determine the most effective adhesive for attaching orthodontic bands to molar teeth in patients with full arch fixed orthodontic appliances.
 Orthodontic treatment involves using fixed or removable appliances (braces) on teeth to correct their position. It has been shown that the quality of treatment result obtained with fixed dental appliances is much better than with removable appliances. The success of a fixed dental appliance depends on the metal attachments (brackets and bands) being securely attached to the teeth so that they do not become loose during treatment. Brackets are usually attached to teeth other than molars, where bands (metal rings that go round the teeth) are more commonly used. There is insufficient evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.731Z" }, { "id": "cfbba0cb-06a1-4af1-8ee1-2013e48cf85b", "pmid": "", "title": "Treatment for primary postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries. Objectives To assess the effectiveness and safety of any intervention used for the treatment of primary PPH. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013). Selection criteria Randomised controlled trials comparing any interventions for the treatment of primary PPH. Data collection and analysis We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information. Main results Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review. Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41). Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering. Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre‐specified outcomes. One study compared lower segment compression but was too small to assess impact on primary outcomes. We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics. Authors' conclusions Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first‐line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit. The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy. Plain language summary Treatment for excessive bleeding after childbirth After a woman gives birth, womb muscles contract, clamping down on the blood vessels and helping to limit bleeding when the placenta has detached. If the muscles do not contract strongly enough, very heavy bleeding (postpartum haemorrhage) can occur, which can be life threatening. These situations are common in resource‐poor countries, and maternal mortality is about 100 times higher than in resource‐rich countries. It is a very serious problem that requires effective treatments that might avoid the use of surgery to remove the womb (hysterectomy). This is often the last treatment option and leaves the woman unable to have more children. In most settings, women are given a drug at the time of birth (before excessive bleeding occurs) to reduce the likelihood of excessive blood loss. However, despite this intervention, some women bleed excessively, and this review looked to see what interventions might be used to reduce the amount of blood lost by these women. Treatment options include drugs to increase muscles contractions (such as oxytocin, ergometrine and prostaglandins like misoprostol), drugs to help with blood clotting (haemostatic drugs such as tranexamic acid and recombinant activated factor VII), surgical techniques (such as tying off or blocking of the uterine artery) and radiological interventions (to assist in blocking the main artery to the womb by using gel foams). The review identified 10 randomised controlled trials involving 4052 women. Seven of these trials looked at a drug called misoprostol, which is a prostaglandin and so works by increasing muscle contractions. Overall, the trials suggest that misoprostol does not work as well as oxytocin infusion, and it has more side effects. However, oxytocin needs to be kept in a refrigerator, and so in settings where refrigeration and infusions are not readily available, misoprostol can be used. Other clinical trials looked into using other types of drugs or squeezing the main artery that supplies blood to the woman. The number of women included in these studies was too small for any useful conclusions regarding their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Mousa, HA; Blum, J; Abou El Senoun, G; Shakur, H; Alfirevic, Z", "articleTypes": [], "doi": "10.1002/14651858.CD003249.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "cfda59ff-c8e1-45e7-800b-d29939743a1b", "pmid": "", "title": "Xylitol for preventing acute otitis media in children up to 12 years of age", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Azarpazhooh, A, Lawrence, HP, Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD007095.pub3 AB - Abstract - Background Acute otitis media (AOM) is the most common bacterial infection among young children in the United States. There are limitations and concerns over its treatment with antibiotics and surgery and so effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk of dental decay. Xylitol can reduce the adherence of Streptococcus pneumoniae ( S pneumoniae ) and Haemophilus influenzae ( H influenzae ) to nasopharyngeal cells in vitro. This is an update of a review first published in 2011. Objectives To assess the efficacy and safety of xylitol to prevent AOM in children aged up to 12 years. Search methods We searched CENTRAL (to Issue 12, 2015), MEDLINE (1950 to January 2016), Embase (1974 to January 2016), CINAHL (1981 to January 2016), LILACS (1982 to January 2016), Web of Science (2011 to January 2016) and International Pharmaceutical Abstracts (2000 to January 2016). Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs of children aged 12 years or younger where xylitol supplementation was compared with placebo or no treatment to prevent AOM. Data collection and analysis Two review authors independently selected trials from search results, assessed and rated study quality and extracted relevant data for inclusion in the review. We contacted trial authors to request missing data. We noted data on any adverse events of xylitol. We extracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR), risk difference (RD) and associated 95% confidence intervals (CI). Main results We identified five clinical trials that involved 3405 children for inclusion. For this 2016 update, we identified one new trial for inclusion. This trial was systematically reviewed but due to several sources of heterogeneity, was not included in the meta‐analysis. The remaining four trials were of adequate methodological quality. In three RCTs that involved a total of 1826 healthy Finnish children attending daycare, there is moderate quality evidence that xylitol (in any form) can reduce the risk of AOM from 30% to around 22% compared with the control group (RR 0.75, 95% CI 0.65 to 0.88). Among the reasons for dropouts, there were no significant differences in abdominal discomfort and rash between the xylitol and the control groups. Xylitol was not effective in reducing AOM among healthy children during a respiratory infection (RR 1.13, 95% CI 0.83 to 1.53; moderate quality evidence) or among otitis‐prone healthy children (RR 0.90, 95% CI 0.67 to 1.21; low‐quality evidence). Authors' conclusions There is moderate quality evidence showing that the prophylactic administration of xylitol among healthy children attending daycare centres can reduce the occurrence of AOM. There is inconclusive evidence with regard to the efficacy of xylitol in preventing AOM among children with respiratory infection, or among otitis‐prone children. The meta‐analysis was limited because data came from a small number of studies, and most were from the same research group. Plain language summary Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age Review question 
 We reviewed the evidence about the effectiveness and safety of xylitol to prevent acute middle ear infection (acute otitis media; AOM) in children up to 12 years old. Background 
 AOM is the most common bacterial infection among young children in the United States. Although serious complications are rare, this common childhood ailment imposes a huge impact on the healthcare system. In the United States, it accounted for almost 20 million office visits. Antibiotic treatment of AOM is costly and raises concerns about the development of antibiotic‐resistant strains of bacteria. Surgery is invasive and costly, and because of these factors, effective measures for preventing AOM are sought. An alternative treatment is xylitol or birch sugar. Xylitol has been used for decades as a natural non‐sugar sweetener principally in chewing gums, confectionery, toothpaste and medicines, and can reduce the risk of tooth decay. Search date We searched the literature up to January 2016. This is an update of a review that was last published in 2011. Study characteristics 
 We identified five clinical trials that involved 3405 children, mostly from the same research group. Four trials were conducted in Finland and enrolled healthy children (three trials) or children with an acute respiratory infection (one trial). The fifth trial was conducted in the USA and enrolled otitis‐prone children who were recruited from attendance at general medical practices. Study funding sources All five trials received governmental funding; and the Finnish study investigators have a US patent for the use of xylitol to treat respiratory infections. Key results Xylitol, administered in chewing gum, lozenges or syrup, can reduce the occurrence of AOM among healthy children with no acute upper respiratory infection from 30% to 22%. There is no difference in side effects (namely, abdominal discomfort and rash). Based on these results we would expect that out of 1000 children up to 12 years of age, 299 would experience an AOM compared with between 194 and 263 children who would experience an AOM if they are provided with xylitol chewing gum. The preventive effect among healthy children with respiratory infection or among otitis‐prone children is inconclusive. Quality of the evidence 
 The quality of evidence was moderate for healthy children and children with respiratory infections but low for otitis‐prone children.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.761Z" }, { "id": "cfdec52f-5067-492d-b23e-fd7afc705dcd", "pmid": "", "title": "Antibiotic strategies for eradicating Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Respiratory tract infections with Pseudomonas aeruginosa occur in most people with cystic fibrosis (CF). Established chronic P aeruginosa infection is virtually impossible to eradicate and is associated with increased mortality and morbidity. Early infection may be easier to eradicate. This is an updated review. Objectives Does giving antibiotics for P aeruginosa infection in people with CF at the time of new isolation improve clinical outcomes (e.g. mortality, quality of life and morbidity), eradicate P aeruginosa infection, and delay the onset of chronic infection, but without adverse effects, compared to usual treatment or an alternative antibiotic regimen? We also assessed cost‐effectiveness. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings. Latest search: 24 March 2022. We searched ongoing trials registries. Latest search: 6 April 2022. Selection criteria We included randomised controlled trials (RCTs) of people with CF, in whom P aeruginosa had recently been isolated from respiratory secretions. We compared combinations of inhaled, oral or intravenous (IV) antibiotics with placebo, usual treatment or other antibiotic combinations. We excluded non‐randomised trials and cross‐over trials. Data collection and analysis Two authors independently selected trials, assessed risk of bias and extracted data. We assessed the certainty of the evidence using GRADE. Main results We included 11 trials (1449 participants) lasting between 28 days and 27 months; some had few participants and most had relatively short follow‐up periods. Antibiotics in this review are: oral – ciprofloxacin and azithromycin; inhaled – tobramycin nebuliser solution for inhalation (TNS), aztreonam lysine (AZLI) and colistin; IV – ceftazidime and tobramycin. There was generally a low risk of bias from missing data. In most trials it was difficult to blind participants and clinicians to treatment. Two trials were supported by the manufacturers of the antibiotic used. TNS versus placebo TNS may improve eradication; fewer participants were still positive for P aeruginosa at one month (odds ratio (OR) 0.06, 95% confidence interval (CI) 0.02 to 0.18; 3 trials, 89 participants; low‐certainty evidence) and two months (OR 0.15, 95% CI 0.03 to 0.65; 2 trials, 38 participants). We are uncertain whether the odds of a positive culture decrease at 12 months (OR 0.02, 95% CI 0.00 to 0.67; 1 trial, 12 participants). TNS (28 days) versus TNS (56 days) One trial (88 participants) comparing 28 days to 56 days TNS treatment found duration of treatment may make little or no difference in time to next isolation (hazard ratio (HR) 0.81, 95% CI 0.37 to 1.76; low‐certainty evidence). Cycled TNS versus culture‐based TNS One trial (304 children, one to 12 years old) compared cycled TNS to culture‐based therapy and also ciprofloxacin to placebo. We found moderate‐certainty evidence of an effect favouring cycled TNS therapy (OR 0.51, 95% CI 0.31 to 0.82), although the trial publication reported age‐adjusted OR and no difference between groups. Ciprofloxacin versus placebo added to cycled and culture‐based TNS therapy One trial (296 participants) examined the effect of adding ciprofloxacin versus placebo to cycled and culture‐based TNS therapy. There is probably no difference between ciprofloxacin and placebo in eradicating P aeruginosa (OR 0.89, 95% CI 0.55 to 1.44; moderate‐certainty evidence). Ciprofloxacin and colistin versus TNS We are uncertain whether there is any difference between groups in eradication of P aeruginosa at up to six months (OR 0.43, 95% CI 0.15 to 1.23; 1 trial, 58 participants) or up to 24 months (OR 0.76, 95% CI 0.24 to 2.42; 1 trial, 47 participants); there was a low rate of short‐term eradication in both groups. Ciprofloxacin plus colistin versus ciprofloxacin plus TNS One trial (223 participants) found there may be no difference in positive respiratory cultures at 16 months between ciprofloxacin with colistin versus TNS with ciprofloxacin (OR 1.28, 95% CI 0.72 to 2.29; low‐certainty evidence). TNS plus azithromycin compared to TNS plus oral placebo Adding azithromycin may make no difference to the number of participants eradicating P aeruginosa after a three‐month treatment phase (risk ratio (RR) 1.01, 95% CI 0.75 to 1.35; 1 trial, 91 participants; low‐certainty evidence); there was also no evidence of any difference in the time to recurrence. Ciprofloxacin and colistin versus no treatment A single trial only reported one of our planned outcomes; there were no adverse effects in either group. AZLI for 14 days plus placebo for 14 days compared to AZLI for 28 days We are uncertain whether giving 14 or 28 days of AZLI makes any difference to the proportion of participants having a negative respiratory culture at 28 days (mean difference (MD) ‐7.50, 95% CI ‐24.80 to 9.80; 1 trial, 139 participants; very low‐certainty evidence). Ceftazidime with IV tobramycin compared with ciprofloxacin (both regimens in conjunction with three months colistin) IV ceftazidime with tobramycin compared with ciprofloxacin may make little or no difference to eradication of P aeruginosa at three months, sustained to 15 months, provided that inhaled antibiotics are also used (RR 0.84, 95 % CI 0.65 to 1.09; P = 0.18; 1 trial, 255 participants; high‐certainty evidence). The results do not support using IV antibiotics over oral therapy to eradicate P aeruginosa , based on both eradication rate and financial cost. Authors' conclusions We found that nebulised antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with P aeruginosa . Eradication may be sustained in the short term. There is insufficient evidence to determine whether these antibiotic strategies decrease mortality or morbidity, improve quality of life, or are associated with adverse effects compared to placebo or standard treatment. Four trials comparing two active treatments have failed to show differences in rates of eradication of P aeruginosa . One large trial showed that intravenous ceftazidime with tobramycin is not superior to oral ciprofloxacin when inhaled antibiotics are also used. There is still insufficient evidence to state which antibiotic strategy should be used for the eradication of early P aeruginosa infection in CF, but there is now evidence that intravenous therapy is not superior to oral antibiotics. Plain language summary Different ways of giving antibiotics to clear Pseudomonas aeruginosa infection in people with cystic fibrosis Key messages ‐ Cystic fibrosis (CF) is an inherited condition where the airways often become blocked with mucus, and people with CF are more likely to get chest infections which cause more damage to the lungs. ‐ Pseudomonas aeruginosa ( P aeruginosa ) is often the cause of infection and is difficult to get rid of; antibiotics are the main treatment, but there are many different antibiotics, and they can be given in different ways. ‐ Inhaled antibiotics may be better than no treatment allowing most people to remain free of P aeruginosa after one month. ‐ There seems to be little difference in the other treatments we compared regarding how well they clear P aeruginosa from the lungs. What is cystic fibrosis? CF is the most common inherited condition that is life‐limiting. Sticky mucus builds up in the lungs of people with CF, which makes it difficult to breathe and can lead to chest infections. These chest infections can cause further lung damage and lead to breathing failure and death. A germ called P aeruginosa is often the cause of infection and is difficult to treat successfully, once it has persisted for longer than six months. What did we want to find out? We wanted to compare different combinations of inhaled, oral and intravenous (IV) antibiotics for clearing P aeruginosa in people with CF, to see if any single treatment works best and is more cost‐effective. What did we find? The review includes 11 studies with a total of 1449 people with CF, of any age or sex, who had mild to severe lung disease. The studies lasted from 28 days to 27 months. We could not combine many results as studies used different treatments. There were 10 different comparisons of antibiotic treatments: three studies compared inhaled antibiotics with a placebo (dummy treatment); two studies compared inhaled antibiotics for different lengths of time; two studies compared inhaled tobramycin with or without oral antibiotics depending on how the infection was detected; two studies compared inhaled antibiotics plus an oral antibiotic with inhaled antibiotics plus a placebo; one study compared two different inhaled antibiotics plus an oral antibiotic; and one study compared IV antibiotics with oral antibiotics. Most of the studies showed how well the treatments got rid of P aeruginosa as well as how they affected lung function, other germs, worsening of flare‐ups, and side effects. Main results Three small studies (of 89 people) treating early infection showed that after one month, inhaled antibiotics were better than no treatment and cleared P aeruginosa in most people, but our confidence in the evidence is low. There is likely to be little difference in the other treatments regarding how well they clear P aeruginosa from the lungs, although we found that inhaled antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with Pseudomonas aeruginosa. A study of IV ceftazidime with tobramycin in comparison with oral ciprofloxacin also showed neither group was better at getting rid of P aeruginosa, but we are more certain of the results and this means that it may be just as effective to treat with oral antibiotics. What are the limitations of the evidence? Some studies were carried out up to 30 years ago and the results may not apply today, and some studies were small. Most studies were quite short, so we could not show whether treatment made people with CF feel better or live longer. Given the treatments used in most of the studies, it would have been easy for people to guess which treatment they were receiving, which might have influenced some of the results. Two studies were supported by the pharmaceutical industry. Further research is needed to see whether clearing the infection completely improves the well‐being and quality of life in people with CF and to establish which antibiotic combination is best at clearing P aeruginosa . Overall our confidence in the evidence was moderate to very low, so further research is likely to change our confidence in the results. However, we have higher confidence in one recently published study, which means we can be more sure of the results. How up to date is this evidence? The studies we have reported on are the most up‐to‐date we could find. We last searched the literature in April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Langton Hewer, SC; Smith, S; Rowbotham, NJ; Yule, A; Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD004197.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "cff1579e-d12e-4051-8e68-af2495ff187d", "pmid": "", "title": "Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight", "imported": false, "abstract": "Abstract - Background The global prevalence of childhood and adolescent obesity is high. Lifestyle changes towards a healthy diet, increased physical activity and reduced sedentary activities are recommended to prevent and treat obesity. Evidence suggests that changing these health behaviours can benefit cognitive function and school achievement in children and adolescents in general. There are various theoretical mechanisms that suggest that children and adolescents with excessive body fat may benefit particularly from these interventions. Objectives To assess whether lifestyle interventions (in the areas of diet, physical activity, sedentary behaviour and behavioural therapy) improve school achievement, cognitive function (e.g. executive functions) and/or future success in children and adolescents with obesity or overweight, compared with standard care, waiting‐list control, no treatment, or an attention placebo control group. Search methods In February 2017, we searched CENTRAL, MEDLINE and 15 other databases. We also searched two trials registries, reference lists, and handsearched one journal from inception. We also contacted researchers in the field to obtain unpublished data. Selection criteria We included randomised and quasi‐randomised controlled trials (RCTs) of behavioural interventions for weight management in children and adolescents with obesity or overweight. We excluded studies in children and adolescents with medical conditions known to affect weight status, school achievement and cognitive function. We also excluded self‐ and parent‐reported outcomes. Data collection and analysis Four review authors independently selected studies for inclusion. Two review authors extracted data, assessed quality and risks of bias, and evaluated the quality of the evidence using the GRADE approach. We contacted study authors to obtain additional information. We used standard methodological procedures expected by Cochrane. Where the same outcome was assessed across different intervention types, we reported standardised effect sizes for findings from single‐study and multiple‐study analyses to allow comparison of intervention effects across intervention types. To ease interpretation of the effect size, we also reported the mean difference of effect sizes for single‐study outcomes. Main results We included 18 studies (59 records) of 2384 children and adolescents with obesity or overweight. Eight studies delivered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies delivered dietary interventions. We included five RCTs and 13 cluster‐RCTs. The studies took place in 10 different countries. Two were carried out in children attending preschool, 11 were conducted in primary/elementary school‐aged children, four studies were aimed at adolescents attending secondary/high school and one study included primary/elementary and secondary/high school‐aged children. The number of studies included for each outcome was low, with up to only three studies per outcome. The quality of evidence ranged from high to very low and 17 studies had a high risk of bias for at least one item. None of the studies reported data on additional educational support needs and adverse events. Compared to standard practice, analyses of physical activity‐only interventions suggested high‐quality evidence for improved mean cognitive executive function scores. The mean difference (MD) was 5.00 scale points higher in an after‐school exercise group compared to standard practice (95% confidence interval (CI) 0.68 to 9.32; scale mean 100, standard deviation 15; 116 children, 1 study). There was no statistically significant beneficial effect in favour of the intervention for mathematics, reading, or inhibition control. The standardised mean difference (SMD) for mathematics was 0.49 (95% CI ‐0.04 to 1.01; 2 studies, 255 children, moderate‐quality evidence) and for reading was 0.10 (95% CI ‐0.30 to 0.49; 2 studies, 308 children, moderate‐quality evidence). The MD for inhibition control was ‐1.55 scale points (95% CI ‐5.85 to 2.75; scale range 0 to 100; SMD ‐0.15, 95% CI ‐0.58 to 0.28; 1 study, 84 children, very low‐quality evidence). No data were available for average achievement across subjects taught at school. There was no evidence of a beneficial effect of physical activity interventions combined with healthy lifestyle education on average achievement across subjects taught at school, mathematics achievement, reading achievement or inhibition control. The MD for average achievement across subjects taught at school was 6.37 points lower in the intervention group compared to standard practice (95% CI ‐36.83 to 24.09; scale mean 500, scale SD 70; SMD ‐0.18, 95% CI ‐0.93 to 0.58; 1 study, 31 children, low‐quality evidence). The effect estimate for mathematics achievement was SMD 0.02 (95% CI ‐0.19 to 0.22; 3 studies, 384 children, very low‐quality evidence), for reading achievement SMD 0.00 (95% CI ‐0.24 to 0.24; 2 studies, 284 children, low‐quality evidence), and for inhibition control SMD ‐0.67 (95% CI ‐1.50 to 0.16; 2 studies, 110 children, very low‐quality evidence). No data were available for the effect of combined physical activity and healthy lifestyle education on cognitive executive functions. There was a moderate difference in the average achievement across subjects taught at school favouring interventions targeting the improvement of the school food environment compared to standard practice in adolescents with obesity (SMD 0.46, 95% CI 0.25 to 0.66; 2 studies, 382 adolescents, low‐quality evidence), but not with overweight. Replacing packed school lunch with a nutrient‐rich diet in addition to nutrition education did not improve mathematics (MD ‐2.18, 95% CI ‐5.83 to 1.47; scale range 0 to 69; SMD ‐0.26, 95% CI ‐0.72 to 0.20; 1 study, 76 children, low‐quality evidence) and reading achievement (MD 1.17, 95% CI ‐4.40 to 6.73; scale range 0 to 108; SMD 0.13, 95% CI ‐0.35 to 0.61; 1 study, 67 children, low‐quality evidence). Authors' conclusions Despite the large number of childhood and adolescent obesity treatment trials, we were only able to partially assess the impact of obesity treatment interventions on school achievement and cognitive abilities. School and community‐based physical activity interventions as part of an obesity prevention or treatment programme can benefit executive functions of children with obesity or overweight specifically. Similarly, school‐based dietary interventions may benefit general school achievement in children with obesity. These findings might assist health and education practitioners to make decisions related to promoting physical activity and healthy eating in schools. Future obesity treatment and prevention studies in clinical, school and community settings should consider assessing academic and cognitive as well as physical outcomes. Plain language summary Healthy weight interventions for improving thinking skills and school performance in children and teenagers with obesity What is the aim of this review? The aim of this Cochrane Review was to find out if healthy weight interventions can improve thinking skills and school performance in children and teenagers with obesity. Cochrane researchers collected and analysed all relevant studies to answer this question. What are the key messages? This updated review provides some evidence that school programmes that encourage healthier child weight may also provide ‘co‐benefits’ of thinking skills and school performance. However, we need more high‐quality healthy‐weight interventions that test thinking skills and school performance, as well as health outcomes. What was studied in this review? The number of children and teenagers with obesity is high worldwide. Some children and teenagers with obesity have health issues or are bullied because of their body weight. These experiences have been linked to problems in performing well in school, where they tend to perform less well in thinking tasks such as problem‐solving. Physical activity and healthy eating benefit a healthy body weight and improve thinking skills and school performance in children with a healthy weight. Studies found that healthy‐weight interventions can reduce obesity in children and teenagers, but it is unknown if and how well healthy‐weight interventions can improve thinking skills and school performance in children and teenagers with obesity. What are the main results of this review? The review authors found 18 studies which included a total of 2384 children and teenagers with obesity. Five studies assigned individual children to intervention or control groups. Thirteen studies allocated entire classes, school or school districts to the intervention and control group. Of the 18 studies, 11 involved children at primary/elementary‐school age. Eight studies offered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies offered dietary changes. The studies took place in 10 different countries. Seventeen studies had at least one flaw in how the study was done. This reduces the level of confidence we can have in the findings. Few studies shared the same type of school performance or thinking skills. Only three studies reported the same outcome. None of the studies reported on additional educational support needs and harmful events. We found that, compared with usual routine, physical activity interventions can lead to small improvements in problem‐solving skills. This finding was based on high‐quality evidence. Moderate‐quality findings showed that physical activity interventions do not improve mathematics and reading achievement in children with obesity. Very low‐quality evidence also suggested no benefits of physical activity interventions for improving uncontrolled behavioural responses. General school achievement was not reported in studies comparing physical activity interventions with standard practice. Studies that compared physical activity interventions plus healthy lifestyle education with standard practice were of low to very low quality. They showed no improvement in school achievement or uncontrolled behavioural responses in the intervention group compared to the control group. Problem‐solving skills were not reported in studies comparing physical activity plus healthy lifestyle education with standard practice. Our findings indicate that changing knowledge about nutrition, and changing the food offered in schools can lead to moderate improvements in general school achievement of teenagers with obesity, when compared to standard school practice. Replacing packed school lunch with a nutrient‐rich diet plus nutrition education did not improve mathematics and reading achievement of children with obesity. However, the quality of evidence for general school achievement, mathematics and reading was low. This means that future research is very likely to change the results, because included studies showed some methodological weaknesses (for example, small numbers of children and a high dropout of children from studies). Problem‐solving skills and uncontrolled behavioural responses were not reported for dietary intervention studies. How up‐to‐date is this review? The review authors searched the scientific literature for relevant studies in February 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Martin, A, Booth, JN, Laird, Y, Sproule, J, Reilly, JJ, Saunders, DH", "articleTypes": [], "doi": "10.1002/14651858.CD009728.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.755Z" }, { "id": "cff4ba74-7e73-4234-ac2d-d06f37d402e1", "pmid": "", "title": "Intranasal corticosteroids for non‐allergic rhinitis", "imported": false, "abstract": "Abstract - Background Non‐allergic rhinitis is defined as dysfunction and non‐infectious inflammation of the nasal mucosa that is caused by provoking agents other than allergens or microbes. It is common, with an estimated prevalence of around 10% to 20%. Patients experience symptoms of nasal obstruction, anterior rhinorrhoea/post‐nasal drip and sneezing. Several subgroups of non‐allergic rhinitis can be distinguished, depending on the trigger responsible for symptoms; these include occupation, cigarette smoke, hormones, medication, food and age. On a cellular molecular level different disease mechanisms can also be identified. People with non‐allergic rhinitis often lack an effective treatment as a result of poor understanding and lack of recognition of the underlying disease mechanism. Intranasal corticosteroids are one of the most common types of medication prescribed in patients with rhinitis or rhinosinusitis symptoms, including those with non‐allergic rhinitis. However, it is unclear whether intranasal corticosteroids are truly effective in these patients. Objectives To assess the effects of intranasal corticosteroids in the management of non‐allergic rhinitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 7); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 July 2019. Selection criteria Randomised controlled trials (RCTs) comparing intranasal corticosteroids, delivered by any means and in any volume, with (a) placebo/no intervention or (b) other active treatments in adults and children (aged ≥ 12 years). Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were patient‐reported disease severity and a
 significant adverse effect ‐ epistaxis. Secondary outcomes were (disease‐specific) health‐related quality of life, objective measurements of airflow and other adverse events. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 34 studies (4452 participants); however, only 13 studies provided data for our main comparison, intranasal corticosteroids versus placebo. The participants were mainly defined as patients with perennial rhinitis symptoms and negative allergy tests. No distinction between different pheno‐ and endotypes could be made, although a few studies only included a specific phenotype such as pregnancy rhinitis, vasomotor rhinitis, rhinitis medicamentosa or senile rhinitis. Most studies were conducted in a secondary or tertiary healthcare setting. No studies reported outcomes beyond three months follow‐up. Intranasal corticosteroid dosage in the review ranged from 50 µg to 2000 µg daily. Intranasal corticosteroids versus placebo Thirteen studies (2045 participants) provided data for this comparison. These studies used different scoring systems for patient‐reported disease severity, so we pooled the data in each analysis using the standardised mean difference (SMD). Intranasal corticosteroid treatment may improve patient‐reported disease severity as measured by total nasal symptom score compared with placebo at up to four weeks (SMD ‐0.74, 95% confidence interval (CI) ‐1.15 to ‐0.33; 4 studies; 131 participants; I 2 = 22%) (low‐certainty evidence). However, between four weeks and three months the evidence is very uncertain (SMD ‐0.24, 95% CI ‐0.67 to 0.20; 3 studies; 85 participants; I 2 = 0%) (very low‐certainty evidence). Intranasal corticosteroid treatment may slightly improve patient‐reported disease severity as measured by total nasal symptom score change from baseline when compared with placebo at up to four weeks (SMD ‐0.15, 95% CI ‐0.25 to ‐0.05; 4 studies; 1465 participants; I 2 = 35%) (low‐certainty evidence) . All four studies evaluating the risk of epistaxis showed that there is probably a higher risk in the intranasal corticosteroids group (65 per 1000) compared to placebo (31 per 1000) (risk ratio (RR) 2.10, 95% CI 1.24 to 3.57; 4 studies; 1174 participants; I 2 = 0%) (moderate‐certainty evidence). The absolute risk difference (RD) was 0.04 with a number needed to treat for an additional harmful outcome (NNTH) of 25 (95% CI 16.7 to 100). Only one study reported numerical data for quality of life. It did report a higher quality of life score in the intranasal corticosteroids group (152.3 versus 145.6; SF‐12v2 range 0 to 800); however, this disappeared at longer‐term follow‐up (148.4 versus 145.6) (low‐certainty evidence). Only two studies provided data for the outcome objective measurements of airflow. These data could not be pooled because they used different methods of outcome measurement. Neither found a significant difference between the intranasal corticosteroids and placebo group (rhinomanometry SMD ‐0.46, 95% CI ‐1.06 to 0.14; 44 participants; peak expiratory flow rate SMD 0.78, 95% CI ‐0.47 to 2.03; 11 participants) (very low‐certainty evidence). Intranasal corticosteroids probably resulted in little or no difference in the risk of other adverse events compared to placebo (RR 0.99, 95% CI 0.87 to 1.12; 3 studies; 1130 participants; I 2 = 0%) (moderate‐certainty evidence) . Intranasal corticosteroids versus other treatments Only one or a few studies assessed each of the other comparisons (intranasal corticosteroids versus saline irrigation, intranasal antihistamine, capsaicin, cromoglycate sodium, ipratropium bromide, intranasal corticosteroids combined with intranasal antihistamine, intranasal corticosteroids combined with intranasal antihistamine and intranasal corticosteroids with saline compared to saline alone). It is therefore uncertain whether there are differences between intranasal corticosteroids and other active treatments for any of the outcomes reported. Authors' conclusions Overall, the certainty of the evidence for most outcomes in this review was low or very low. It is unclear whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. However, intranasal corticosteroids probably have a higher risk of the adverse effect epistaxis. There are very few studies comparing intranasal corticosteroids to other treatment modalities making it difficult to draw conclusions. Plain language summary Intranasal corticosteroids for non‐allergic rhinitis Review question We wanted to find out whether intranasal corticosteroids (steroids applied into the nose) are effective for the treatment of rhinitis that is not caused by allergy. Background Non‐allergic rhinitis is a chronic disease of the nose, which is not caused by infection or allergies. People with non‐allergic rhinitis experience symptoms that affect their quality of life, such as nasal obstruction, runny nose and sneezing. Non‐allergic rhinitis patients can be divided into different subgroups who have different underlying causes for their disease. The underlying causes of non‐allergic rhinitis are not fully understood, therefore treatment is often unsuccessful in these patients. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation. They are the most commonly prescribed drug in other chronic diseases of the nose and sinuses, such as allergic rhinitis and chronic rhinosinusitis. Intranasal corticosteroid treatment can be delivered with sprays or drops and for different time periods. Study characteristics We included 34 randomised controlled trials (RCTs) with a total of 4452 participants in this review. Most of the studies were relatively small, although the largest study had 983 patients in total. All of the patients were either adults or adolescents (aged between 12 and 18 years old) with non‐allergic rhinitis. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Nine studies were sponsored by the pharmaceutical industry or had commercial sponsors. One study was funded by the government. In several studies, the pharmaceutical industry or commercial sponsor may have provided medications, but the funding role was unclear. Funding was not reported in eight studies. Key results Intranasal corticosteroids compared with placebo It is uncertain whether intranasal corticosteroids reduce patient‐reported disease severity in non‐allergic rhinitis patients compared with placebo when measured at up to three months. They may improve patient‐reported disease severity compared with placebo at up to four weeks, however this evidence is of low certainty. Treatment with intranasal corticosteroids probably increases the risk of epistaxis (nosebleed) but there is no difference in the risk of other adverse effects. It is not possible to tell from this review whether there is a difference between the different concentrations, delivery methods or treatment plans of intranasal corticosteroids. There are no good‐quality studies assessing changes in quality of life with intranasal corticosteroids. Intranasal corticosteroids compared with other treatments There is not enough evidence to know whether intranasal corticosteroid treatment is better, worse or the same as using other treatment strategies such as saline irrigation, intranasal antihistamines, capsaicin or ipratropium bromide for non‐allergic rhinitis. Certainty of the evidence Overall, the evidence for intranasal corticosteroids compared with placebo for most outcomes was either low‐certainty (our confidence in the effect estimate is low) or very low‐certainty (our confidence in the effect estimate is very low). This was because most studies were very small and used different methods to measure the same outcome. This evidence is up to date to July 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Segboer, C; Gevorgyan, A; Avdeeva, K; Chusakul, S; Kanjanaumporn, J; Aeumjaturapat, S; Reeskamp, LF; Snidvongs, K; Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010592.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "cff75ba4-d444-4af7-a4bb-6f4c9309a9dd", "pmid": "", "title": "Expression of Bitter Taste Receptors in Oropharynx Carcinoma", "imported": false, "abstract": "The aim of this work is to investigate the expression of the bitter taste receptors in p16-positive and negative oropharyngeal carcinomas (in comparison to healthy, local tissue).", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.230Z" }, { "id": "d01a17e0-8866-4593-957e-fb8fef156364", "pmid": "", "title": "Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people", "imported": false, "abstract": "Abstract - Background There is evidence that water‐loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well‐being are compromised. Objectives To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water‐loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water‐loss dehydration was defined primarily as including everyone with either impending or current water‐loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). Search methods Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases ( The Cochrane Library ), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. Selection criteria Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. Data collection and analysis Diagnostic accuracy of each test was assessed against the best available reference standard for water‐loss dehydration (serum or plasma osmolality cut‐off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water‐loss dehydration (including either impending or current water‐loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water‐loss dehydration, but restricted to current dehydration in the final review. We conducted bivariate random‐effects meta‐analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre‐specified cut‐off points investigated. Pre‐set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre‐specifying three cut‐offs for each continuous test may have led to missing a cut‐off with useful sensitivity and specificity, we conducted post‐hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut‐off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. Main results There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water‐loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years. We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut‐offs for each continuous outcome) for diagnostic accuracy of water‐loss dehydration (primary target condition) and of current dehydration (secondary target condition). Only three tests showed any ability to diagnose water‐loss dehydration (including both impending and current water‐loss dehydration) as stand‐alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post‐hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study. Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97). There was sufficient evidence to suggest that several stand‐alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people. No tests were found consistently useful in diagnosing current water‐loss dehydration. Authors' conclusions There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water‐loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated. Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy. Plain language summary Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people Water‐loss dehydration results from drinking too little fluid. It is common in older people and associated with increased risk of many health problems. We wanted to find out whether simple tests (like skin turgor, dry mouth, urine colour and bioelectrical impedance) can usefully tell us whether an older person (aged at least 65 years) is drinking enough. Within the review we assessed 67 different tests, but no tests were consistently useful in telling us whether older people are drinking enough, or are dehydrated. Some tests did appear useful in some studies, and these promising tests should be re‐checked to see whether they are useful in specific older populations. There was sufficient evidence to suggest that some tests should not be used to indicate dehydration. Tests that should not be used include dry mouth, feeling thirsty, heart rate, urine colour, and urine volume.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hooper, L; Abdelhamid, A; Attreed, NJ; Campbell, WW; Channell, AM; Chassagne, P; Culp, KR; Fletcher, SJ; Fortes, MB; Fuller, N; Gaspar, PM; Gilbert, DJ; Heathcote, AC; Kafri, MW; Kajii, F; Lindner, G; Mack, GW; Mentes, JC; Merlani, P; Needham, RA; Olde Rikkert, MGM; Perren, A; Powers, J; Ranson, SC; Ritz, P; Rowat, AM; Sjöstrand, F; Smith, AC; Stookey, JJD; Stotts, NA; Thomas, DR; Vivanti, A; Wakefield, BJ; Waldréus, N; Walsh, NP; Ward, S; Potter, JF; Hunter, P", "articleTypes": [], "doi": "10.1002/14651858.CD009647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "d023fc33-733d-4bd0-9ee8-6dbd0bacc046", "pmid": "", "title": "Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five‐year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis. Objectives To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions. Search methods We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi‐randomised trials. The reference lists of relevant articles were also searched. Selection criteria All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded. Data collection and analysis Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author. Main results A total of 40 randomised or quasi‐randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials. For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights. Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects. Authors' conclusions There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials. Plain language summary Drug treatment for children with bedwetting (nocturnal enuresis) but not including the drug types desmopressin or tricyclics Bedwetting (nocturnal enuresis) is the involuntary loss of urine at night without an underlying organic disease as the cause. It can result in social problems, sibling teasing and lowered self esteem. It affects around 15% to 20% of five‐year olds, and up to 2% of adults. Many different types of drugs have been used to treat children with bed wetting. There is not enough reliable evidence to show that drugs other than desmopressin or tricyclics reduce bedwetting in children during treatment when used in isolation, despite their risk of unwanted side effects. In other Cochrane reviews, alarms triggered by wetting, desmopressin and tricyclic drugs have been shown to work during treatment. However, alarms have a more sustained effect than desmopressin and tricyclics after treatment has finished. The adverse effects of alarm therapy (tiredness and waking other members of the family) are relatively benign and self limiting compared with the adverse effects of drugs. One class of drugs (anticholinergic drugs) appears to improve the efficacy of other established treatments such as tricyclics, bedwetting alarms and desmopressin. The cost of treating children with bedwetting with alarm therapy or drugs may vary in different countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Deshpande, AV; Caldwell, PHY; Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "d02ba0f1-d3de-4e54-bcd6-7cd7668dbbab", "pmid": "", "title": "Sensitive Periods in Early Flavor Learning", "imported": false, "abstract": "Flavor is the primary dimension by which young children determine food acceptance. However, children are not merely miniature adults since sensory systems mature postnatally and their responses to certain tastes differ markedly from adults. Moreover, emerging research has revealed that there are sensitive periods during infancy such that early flavor experiences serve to modify later responses to flavors and foods. The proposed study aims to investigate this important issue by using as a model system a class of infant formulas which are hydrolyzed protein based and thus have very pronounced and distinctive flavors which are unpalatable to older-aged infants and adults. This research was initiated because of anecdotal reports by pediatricians that although it is easy to introduce this type of formula to infants during the first months of life, it becomes extremely difficult to do so later in infancy. Indeed, recent studies in the investigators' laboratory provided the first experimental demonstration that infants younger than 4 months of age willingly accept substantial amounts of, and satiate while feeding, a novel, protein hydrolysate formula. In marked contrast, infants older than 4 months reject the protein hydrolysate formula and this rejection occurs within the first minute of a feed, a finding that strongly suggests the sensory qualities of the formula are responsible, at least in part, for this rejection. Moreover, this rejection is not evident when the investigators test older-aged infants with other unfamiliar, but non-hydrolysate, formulas. In other words, the rejection appears to be in response to a particular component or components of protein hydrolysate formulas. This shift in acceptability can be ameliorated by prior exposure. That is, if these formulas are introduced to infants within the first few months of life and are fed continuously, they remain highly acceptable throughout infancy and early childhood. These observations implicate a sensitive period during development, occurring somewhere before 4 months of age, during which exposure to a formula, which is unpalatable to adults and infants over 4 months of age without exposure, renders it acceptable and presumably palatable. To the investigators' knowledge, this is the clearest example of a sensitive period in the development of responses to foods and flavors in humans thus far identified.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.240Z" }, { "id": "d03604fa-44b7-470d-8917-3fc0e1deb28f", "pmid": "", "title": "Cannabis and cannabinoids for symptomatic treatment for people with multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Filippini, G, Minozzi, S, Borrelli, F, Cinquini, M, Dwan, K", "articleTypes": [], "doi": "10.1002/14651858.CD013444.pub2 AB - Abstract - Background Spasticity and chronic neuropathic pain are common and serious symptoms in people with multiple sclerosis (MS). These symptoms increase with disease progression and lead to worsening disability, impaired activities of daily living and quality of life. Anti‐spasticity medications and analgesics are of limited benefit or poorly tolerated. Cannabinoids may reduce spasticity and pain in people with MS. Demand for symptomatic treatment with cannabinoids is high. A thorough understanding of the current body of evidence regarding benefits and harms of these drugs is required. Objectives To assess benefit and harms of cannabinoids, including synthetic, or herbal and plant‐derived cannabinoids, for reducing symptoms for adults with MS. Search methods We searched the following databases from inception to December 2021: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), CINAHL (EBSCO host), LILACS, the Physiotherapy Evidence Database (PEDro), the World Health Organisation International Clinical Trials Registry Platform, the US National Institutes of Health clinical trial register, the European Union Clinical Trials Register, the International Association for Cannabinoid Medicines databank. We hand searched citation lists of included studies and relevant reviews. Selection criteria We included randomised parallel or cross‐over trials (RCTs) evaluating any cannabinoid (including herbal C annabis, C annabis flowers, plant‐based cannabinoids, or synthetic cannabinoids) irrespective of dose, route, frequency, or duration of use for adults with MS. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane Risk of bias 2 tool for parallel RCTs and crossover trials. We rated the certainty of evidence using the GRADE approach for the following outcomes: reduction of 30% in the spasticity Numeric Rating Scale, pain relief of 50% or greater in the Numeric Rating Scale‐Pain Intensity, much or very much improvement in the Patient Global Impression of Change (PGIC), Health‐Related Quality of Life (HRQoL), withdrawals due to adverse events (AEs) (tolerability), serious adverse events (SAEs), nervous system disorders, psychiatric disorders, physical dependence. Main results We included 25 RCTs with 3763 participants of whom 2290 received cannabinoids. Age ranged from 18 to 60 years, and between 50% and 88% participants across the studies were female. The included studies were 3 to 48 weeks long and compared nabiximols, an oromucosal spray with a plant derived equal (1:1) combination of tetrahydrocannabinol (THC) and cannabidiol (CBD) (13 studies), synthetic cannabinoids mimicking THC (7 studies), an oral THC extract of C annabis sativa (2 studies), inhaled herbal C annabis (1 study) against placebo. One study compared dronabinol, THC extract of C annabis sativa and placebo, one compared inhaled herbal C annabis , dronabinol and placebo. We identified eight ongoing studies. Critical outcomes • Spasticity: nabiximols probably increases the number of people who report an important reduction of perceived severity of spasticity compared with placebo (odds ratio (OR) 2.51, 95% confidence interval (CI) 1.56 to 4.04; 5 RCTs, 1143 participants; I 2 = 67%; moderate‐certainty evidence). The absolute effect was 216 more people (95% CI 99 more to 332 more) per 1000 reporting benefit with cannabinoids than with placebo. • Chronic neuropathic pain: we found only one small trial that measured the number of participants reporting substantial pain relief with a synthetic cannabinoid compared with placebo (OR 4.23, 95% CI 1.11 to 16.17; 1 study, 48 participants; very low‐certainty evidence). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity. • Treatment discontinuation due to AEs: cannabinoids may increase slightly the number of participants who discontinue treatment compared with placebo (OR 2.41, 95% CI 1.51 to 3.84; 21 studies, 3110 participants; I² = 17%; low‐certainty evidence); the absolute effect is 39 more people (95% CI 15 more to 76 more) per 1000 people. Important outcomes • PGIC: cannabinoids probably increase the number of people who report 'very much' or 'much' improvement in health status compared with placebo (OR 1.80, 95% CI 1.37 to 2.36; 8 studies, 1215 participants; I² = 0%; moderate‐certainty evidence). The absolute effect is 113 more people (95% CI 57 more to 175 more) per 1000 people reporting improvement. • HRQoL: cannabinoids may have little to no effect on HRQoL (SMD ‐0.08, 95% CI ‐0.17 to 0.02; 8 studies, 1942 participants; I 2 = 0%; low‐certainty evidence); • SAEs: cannabinoids may result in little to no difference in the number of participants who have SAEs compared with placebo (OR 1.38, 95% CI 0.96 to 1.99; 20 studies, 3124 participants; I² = 0%; low‐certainty evidence); • AEs of the nervous system: cannabinoids may increase nervous system disorders compared with placebo (OR 2.61, 95% CI 1.53 to 4.44; 7 studies, 1154 participants; I² = 63%; low‐certainty evidence); • Psychiatric disorders: cannabinoids may increase psychiatric disorders compared with placebo (OR 1.94, 95% CI 1.31 to 2.88; 6 studies, 1122 participants; I² = 0%; low‐certainty evidence); • Drug tolerance: the evidence is very uncertain about the effect of cannabinoids on drug tolerance (OR 3.07, 95% CI 0.12 to 75.95; 2 studies, 458 participants; very low‐certainty evidence). Authors' conclusions Compared with placebo, nabiximols probably reduces the severity of spasticity in the short‐term in people with MS. We are uncertain about the effect on chronic neurological pain and health‐related quality of life. Cannabinoids may increase slightly treatment discontinuation due to AEs, nervous system and psychiatric disorders compared with placebo. We are uncertain about the effect on drug tolerance. The overall certainty of evidence is limited by short‐term duration of the included studies. Plain language summary Cannabis and cannabinoids for people with multiple sclerosis Key messages 
• Treatment with nabiximols likely results in improvement of spasticity and may not increase serious harmful effects compared with placebo • Compared with placebo, cannabinoids (nabiximols, C annabis extract, synthetic cannabinoids) likely improve well‐being when measured with patient‐reported outcomes • Due to a lack of robust evidence, the benefit of these medicines for treating chronic neuropathic pain is unclear. What is the issue? Many people with multiple sclerosis (MS) experience spasticity that causes also pain and impacts on the ability to carry out daily activities. Spasticity is a form of increased muscle tone. Cannabis ‐based medicines refer to the use of Cannabis , or its ingredients called cannabinoids, as medical therapies to alleviate spasticity, chronic pain and other symptoms in MS. An international survey found that MS was one of the five medical conditions for which C annabis was most often used. Another survey conducted in the UK found that more than one in five people with MS reported they had used C annabis to try to manage their symptoms. What did we want to find out? We wanted to find out if cannabinoids were better than placebo in adults with MS to improve: • spasticity; • chronic neuropathic pain; • well‐being, We also wanted to find out if cannabinoids were associated with: • treatment discontinuation due to unwanted effects; • serious harmful effects; • nervous system disorders or psychiatric disorders; • drug tolerance defined as a condition that occurs when the body gets used to a medicine so that more medicine is needed. What did we do? 
We searched for studies that compared cannabinoids against placebo in adult people with MS. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and certainty of evidence. What did we find? We found 25 studies that involved 3763 people with MS, 2290 of whom received cannabinoids. Fifteen studies were very short term or short‐term studies (two to 12 weeks), seven were intermediate term (12 to 26 weeks), and two were long term (50 and 156 weeks). One study reported results at three days only. The biggest study was conducted in 657 people and the smallest study involved 14 people. Most studies were done in European countries. Thirteen studies evaluated an oral spray (nabiximols) containing two compounds derived from the C annabis plant. The other studies compared different cannabinoids with placebo. Pharmaceutical companies funded 15 of the studies. Main results Compared with placebo, cannabinoids: • probably increase the number of people who report an important reduction of perceived severity of spasticity for up to 14 weeks (evidence from five studies in 1143 people); • may increase the number of people who report an important reduction of perceived severity of chronic neuropathic pain, but the evidence is very uncertain (evidence from one study in 48 people). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity: • probably increase the number of people who perceive their well‐being as 'very much' or 'much' improved (evidence from eight studies in 1215 people); • may increase slightly the number of people who discontinue treatment due to unwanted effects (evidence from 21 studies in 3110 people); • may result in little to no difference in the number of people who have serious harmful effects (evidence from 20 studies in 3124 people); • may increase nervous system disorders (evidence from seven studies in 1154 people) or psychiatric disorders (evidence from six studies in 1122 people); • may have little to no effect on the number of people who have drug tolerance, but the evidence is very uncertain (two studies in 458 people). What are the limitations of the evidence? There is no high‐quality evidence. We are moderately confident that cannabinoids work better versus no cannabinoids to improve severity of spasticity and well‐being in adults with MS. We have little confidence in our results for the effect on chronic neuropathic pain because the available evidence is limited. There is limited evidence to determine the effects of cannabinoids on serious harmful effects, nervous system or psychiatric disorders, and drug tolerance. How up to date is the evidence? 
The evidence is up‐to‐date to December 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.757Z" }, { "id": "d068571b-e7d8-4cef-97df-1471c2c161e2", "pmid": "", "title": "Interventions for treating iron deficiency anaemia in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease affects approximately seven million people globally. Iron deficiency anaemia can occur as a common systemic manifestation, with a prevalence of up to 90%, which can significantly affect quality of life, both during periods of active disease or in remission. It is important that iron deficiency anaemia is treated effectively and not be assumed to be a normal finding of inflammatory bowel disease. The various routes of iron administration, doses and preparations present varying advantages and disadvantages, and a significant proportion of people experience adverse effects with current therapies. Currently, no consensus has been reached amongst physicians as to which treatment path is most beneficial. Objectives The primary objective was to evaluate the efficacy and safety of the interventions for the treatment of iron deficiency anaemia in people with inflammatory bowel disease. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 21st November 2019. We also contacted experts in the field and searched references of trials for any additional trials. Selection criteria Randomised controlled trials investigating the effectiveness and safety of iron administration interventions compared to other iron administration interventions or placebo in the treatment of iron deficiency anaemia in inflammatory bowel disease. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors. Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We expressed dichotomous and continuous outcomes as risk ratios and mean differences with 95% confidence intervals. We assessed the certainty of the evidence using the GRADE methodology. Main results We included 11 studies (1670 randomised participants) that met the inclusion criteria. The studies compared intravenous iron sucrose vs oral iron sulphate (2 studies); oral iron sulphate vs oral iron hydroxide polymaltose complex (1 study); oral iron fumarate vs intravenous iron sucrose (1 study); intravenous ferric carboxymaltose vs intravenous iron sucrose (1 study); erythropoietin injection + intravenous iron sucrose vs intravenous iron sucrose + injection placebo (1 study); oral ferric maltol vs oral placebo (1 study); oral ferric maltol vs intravenous ferric carboxymaltose (1 study); intravenous ferric carboxymaltose vs oral iron sulphate (1 study); intravenous iron isomaltoside vs oral iron sulphate (1 study); erythropoietin injection vs oral placebo (1 study). All studies compared participants with CD and UC together, as well as considering a range of disease activity states. The primary outcome of number of responders, when defined, was stated to be an increase in haemoglobin of 20 g/L in all but two studies in which an increase in 10g/L was used. In one study comparing intravenous ferric carboxymaltose and intravenous iron sucrose, moderate‐certainty evidence was found that intravenous ferric carboxymaltose was probably superior to intravenous iron sucrose, although there were responders in both groups (150/244 versus 118/239, RR 1.25, 95% CI 1.06 to 1.46, number needed to treat for an additional beneficial outcome (NNTB) = 9). In one study comparing oral ferric maltol to placebo, there was low‐certainty evidence of superiority of the iron (36/64 versus 0/64, RR 73.00, 95% CI 4.58 to 1164.36). There were no other direct comparisons that found any difference in the primary outcomes, although certainty was low and very low for all outcomes, due to imprecision from sparse data and risk of bias varying between moderate and high risk. The reporting of secondary outcomes was inconsistent. The most common was the occurrence of serious adverse events or those requiring withdrawal of therapy. In no comparisons was there a difference seen between any of the intervention agents being studied, although the certainty was very low for all comparisons made, due to risk of bias and significant imprecision due to the low numbers of events. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes were reported in any of the studies. An analysis of all intravenous iron preparations to all oral iron preparations showed that intravenous administration may lead to more responders (368/554 versus 205/373, RR 1.17, 95% CI 1.05 to 1.31, NNTB = 11, low‐certainty due to risk of bias and inconsistency). Withdrawals due to adverse events may be greater in oral iron preparations vs intravenous (15/554 versus 31/373, RR 0.39, 95% CI 0.20 to 0.74, low‐certainty due to risk of bias, inconsistency and imprecision). Authors' conclusions Intravenous ferric carboxymaltose probably leads to more people having resolution of IDA (iron deficiency anaemia) than intravenous iron sucrose. Oral ferric maltol may lead to more people having resolution of IDA than placebo. We are unable to draw conclusions on which of the other treatments is most effective in IDA with IBD (inflammatory bowel disease) due to low numbers of studies in each comparison area and clinical heterogeneity within the studies. Therefore, there are no other conclusions regarding the treatments that can be made and certainty of all findings are low or very low. Overall, intravenous iron delivery probably leads to greater response in patients compared with oral iron, with a NNTB (number needed to treat) of 11. Whilst no serious adverse events were specifically elicited with any of the treatments studied, the numbers of reported events were low and the certainty of these findings very low for all comparisons, so no conclusions can be drawn. There may be more withdrawals due to such events when oral is compared with intravenous iron delivery. Other outcomes were poorly reported and once again no conclusions can be made as to the impact of IDA on any of these outcomes. Given the widespread use of many of these treatments in practice and the only guideline that exists recommending the use of intravenous iron in favour of oral iron, research to investigate this key issue is clearly needed. Considering the current ongoing trials identified in this review, these are more focussed on the impact in specific patient groups (young people) or on other symptoms (such as fatigue). Therefore, there is a need for studies to be performed to fill this evidence gap. Plain language summary Therapies for treating iron deficiency anaemia in Crohn's disease and ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether treatments in people with Crohn's disease and ulcerative colitis can improve iron deficiency anaemia. We analysed data from 11 studies to answer this question. Key messages Iron in the form of ferric carboxymaltose given intravenously is probably better than iron sucrose given intravenously in improving iron deficiency anaemia, although people improved taking both treatments. Oral iron in the form of ferric maltol may be better than placebo (dummy treatment). It is unclear whether any of the other treatments considered are better than each other, however, there is limited evidence due to low numbers of studies and issues due to low quality of the reporting of the research studies. What was studied in the review? People with both ulcerative colitis and Crohn's disease both commonly suffer with low iron levels that in turn lowers their haemoglobin (blood) levels (this is called anaemia). This can lead to a number of symptoms, including tiredness and pain. Several treatments exist to treat iron deficiency anaemia, consisting of delivering extra iron either orally or intravenously (through a vein). An additional treatment, erythropoietin, was also studied which stimulates the body to produce more blood itself. Currently, no consensus has been reached amongst physicians as to which treatment is better. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing any treatment with another or dummy treatment. We found 11 RCTs looking at 1670 participants. The trials looked at adult participants, with none considering children. 1) Intravenous iron in the form of ferric carboxymaltose probably leads to more people having an improvement in iron deficiency anaemia than intravenous iron sucrose (one extra person would improve for every 9 treated and five out of 10 people would improve with either therapy). 2) Oral iron as ferric maltol may lead to more people having resolution of iron deficiency than dummy treatment. 3) It is unclear whether there is any difference between any of the other treatments studied for treating iron deficiency anaemia. 4) It is unclear whether any therapy leads to a difference in adverse events (minor or serious) when compared to any other therapy. Conclusion Iron delivered via a vein as ferric carboxymaltose probably improves anaemia in more people that iron sucrose via a vein, although both groups of people improved. Oral iron as ferric maltol may improve more patients than dummy treatment. No conclusions can be drawn on other treatments due to lack of evidence and quality issues with the studies that were found. Further research is needed, particularly to investigate whether iron delivered through a vein is better than iron delivered orally and also how much treating anaemia in people with IBD makes a difference in terms of the symptoms they may experience. How up‐to‐date is this review? This review is up‐to‐date as of November 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gordon, M, Sinopoulou, V, Iheozor-Ejiofor, Z, Iqbal, T, Allen, P, Hoque, S, Engineer, J, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013529.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.788Z" }, { "id": "d0697863-47f0-44bb-bbff-e3c19e407d30", "pmid": "", "title": "Muscle relaxants for pain management in rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background Pain management is a high priority for patients with rheumatoid arthritis (RA). Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan) and non‐benzodiazepines such as metaxalone (Skelaxin) or a combination of paracetamol and orphenadrine (Muscol)) and drugs that prevent increased muscle tone (baclofen and dantrolene). Despite a paucity of evidence supporting their use, antispasmodic and antispasticity muscle relaxants have gained widespread clinical acceptance as adjuvants in the management of patients with chronic musculoskeletal pain. Objectives The aim of this review was to determine the efficacy and safety of muscle relaxants in pain management in patients with RA. The muscle relaxants that were included in this review are the antispasmodic benzodiazepines (alprazolam, bromazepam, chlordiazepoxide,cinolazepam, clonazepam, cloxazolam, clorazepate, diazepam, estazolam, flunitrazepam, flurazepam, flutoprazepam, halazepam, ketazolam, loprazolam, lorazepam, lormetazepam, medazepam, midazolam, nimetazepam, nitrazepam, nordazepam, oxazepam, pinazepam, prazepam, quazepam, temazepam, tetrazepam, triazolam), antispasmodic non‐benzodiazepines (cyclobenzaprine, carisoprodol, chlorzoxazone, meprobamate, methocarbamol, metaxalone, orphenadrine, tizanidine and zopiclone), and antispasticity drugs (baclofen and dantrolene sodium). Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library, 4th quarter 2010), MEDLINE (1950 to week 1 November 2010), EMBASE (Week 44 2010), and PsycINFO (1806 to week 2 November 2010). We also searched the 2008 to 2009 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of reference lists of relevant articles. Selection criteria We included randomised controlled trials which compared a muscle relaxant to another therapy (active, including non‐pharmacological therapies, or placebo) in adult patients with RA and that reported at least one clinically relevant outcome. Data collection and analysis Two blinded review authors independently extracted data and assessed the risk of bias in the trials. Meta‐analyses were used to examine the efficacy of muscle relaxants on pain, depression, sleep and function, as well as their safety. Main results Six trials (126 participants) were included in this review. All trials were rated at high risk of bias. Five cross‐over trials evaluated a benzodiazepine, four assessed diazepam (n = 71) and one assessed triazolam (n = 15). The sixth trial assessed zopiclone (a non‐benzodiazepine) (n = 40) and was a parallel group study. No trial duration was longer than two weeks while three single dose trials assessed outcomes at 24 hours only. Overall the included trials failed to find evidence of a beneficial effect of muscle relaxants over placebo, alone (at 24 hrs, 1 or 2 weeks) or in addition to non‐steroidal anti‐inflammatory drugs (NSAIDs) (at 24 hrs), on pain intensity, function, or quality of life. Data from two trials of longer than 24 hours duration (n = 74) (diazepam and zopiclone) found that participants who received a muscle relaxant had significantly more adverse events compared with those who received placebo (number needed to harm (NNTH) 3, 95% CI 2 to 7). These were predominantly central nervous system side effects, including dizziness and drowsiness (NNTH 3, 95% CI 2 to 11). Authors' conclusions Based upon the currently available evidence in patients with RA, benzodiazepines (diazepam and triazolam) do not appear to be beneficial in improving pain over 24 hours or one week. The non‐benzodiazepine agent zopiclone also did not significantly reduce pain over two weeks. However, even short term muscle relaxant use (24 hours to 2 weeks) is associated with significant adverse events, predominantly drowsiness and dizziness. Plain language summary Muscle relaxants for pain management in rheumatoid arthritis This summary of a Cochrane review presents what we know from research about the effect of muscle relaxants on pain in patients with rheumatoid arthritis. The review shows that in people with rheumatoid arthritis: ‐ Muscle relaxants may not improve pain when taken as a single dose or for up to a two week period ‐ We are uncertain whether muscle relaxants affect functional status because of the very low quality of the evidence ‐ No trials were found that evaluated whether muscle relaxants affect quality of life ‐ No trials were found that evaluated whether antidepressants affect sleep ‐ We are uncertain whether muscle relaxants affect mood because of the very low quality of the evidence We also do not have precise information about side effects and complications. This is particularly true for rare but serious side effects. Possible side effects may include feeling tired or nauseous, headaches, blurred vision, a dry mouth, sexual dysfunction, or becoming dizzy or constipated. Rare complications may include increased suicidal thinking, liver inflammation, or a reduced white cell count. What is rheumatoid arthritis and what are muscle relaxants? When you have rheumatoid arthritis your immune system, which normally fights infection, attacks the lining of your joints. This makes your joints swollen, stiff, and painful. The small joints of your hands and feet are usually affected first. There is no cure for rheumatoid arthritis at present, so the treatments aim to relieve pain and stiffness and improve your ability to move. Muscle relaxants can be used to treat anxiety and promote sleep, and some people believe they may also reduce pain by acting on the nerves that cause pain, but this remains controversial. Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), Xanax, Ativan and non‐benzodiazepines such as Skelaxin, Muscol) and drugs that prevent increased muscle tone (baclofen and dantrolene). Best estimates of what happens to people with rheumatoid arthritis who take muscle relaxants: Pain at 24 hours: ‐ Non‐significant result. Pain at 1 to 2 weeks: ‐ Non‐significant result. Withdrawal due to adverse events, after 2 weeks: ‐ Non‐significant result. Total adverse events: ‐ 49 more people out of 100 experienced an adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 49%), ‐ 52 out of 100 people who took a muscle relaxant suffered an adverse event, ‐ 3 out of 100 people who took a placebo suffered an adverse event. Central nervous system (CNS) adverse events: ‐ 33 more people out of 100 experienced a CNS adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 33%), ‐ 39 out of 100 people who took a muscle relaxant suffered a CNS adverse event, ‐ 6 out of 100 people who took a placebo relaxant suffered a CNS adverse event. This record should be cited as: This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in the Cochrane Database of Systematic Reviews [Issue and date] © [year] The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464‐780X).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Richards, BL, Whittle, SL, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD008922.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.774Z" }, { "id": "d07e4a37-501a-4415-8976-b7afa1c71b87", "pmid": "", "title": "Pharmacological treatment of gastro‐oesophageal reflux in children", "imported": false, "abstract": "Abstract - Background Gastro‐oesophageal reflux (GOR) is characterised by the regurgitation of gastric contents into the oesophagus. GOR is a common presentation in infancy, both in primary and secondary care, affecting approximately 50% of infants under three months old. The natural history of GOR in infancy is generally of a self‐limiting condition that improves with age, but older children and children with co‐existing medical conditions can have more protracted symptoms. The distinction between gastro‐oesophageal reflux disease (GORD) and GOR is debated. Current National Institute of Health and Care Excellence (NICE) guidelines define GORD as GOR causing symptoms severe enough to merit treatment. This is an update of a review first published in 2014. Objectives To assess the effects of pharmacological treatments for GOR in infants and children. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, and Web of Science up to 17 September 2022. We also searched for ongoing trials in clinical trials registries, contacted experts in the field, and searched the reference lists of trials and reviews for any additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any currently‐available pharmacological treatment for GOR in children with placebo or another medication. We excluded studies assessing dietary management of GORD and studies of thickened feeds. We included studies in infants and children up to 16 years old. Data collection and analysis We used standard methodology expected by Cochrane. Main results We included 36 RCTs involving 2251 children and infants. We were able to extract summary data from 14 RCTs; the remaining trials had insufficient data for extraction. We were unable to pool results in a meta‐analysis due to methodological differences in the included studies (including heterogeneous outcomes, study populations, and study design). We present the results in two groups by age: infants up to 12 months old, and children aged 12 months to 16 years old. Infants Omeprazole versus placebo: there is no clear effect on symptoms from omeprazole. One study (30 infants; very low‐certainty evidence) showed cry/fuss time in infants aged three to 12 months had altered from 246 ± 105 minutes/day at baseline (mean +/‐ standard deviation (SD)) to 191 ± 120 minutes/day in the omeprazole group and from 287 ± 132 minutes/day to 201 ± 100 minutes/day in the placebo group (mean difference (MD) 10 minutes/day lower (95% confidence interval (CI) ‐89.1 to 69.1)). The reflux index changed in the omeprazole group from 9.9 ± 5.8% in 24 hours to 1.0 ± 1.3% and in the placebo group from 7.2 ± 6.0% to 5.3 ± 4.9% in 24 hours (MD 7% lower, 95% CI ‐4.7 to ‐9.3). Omeprazole versus ranitidine: one study (76 infants; very low‐certainty evidence) showed omeprazole may or may not provide symptomatic benefit equivalent to ranitidine. Symptom scores in the omeprazole group changed from 51.9 ± 5.4 to 2.4 ± 1.2, and in the ranitidine group from 47 ± 5.6 to 2.5 ± 0.6 after two weeks: MD ‐4.97 (95% CI ‐7.33 to ‐2.61). Esomeprazole versus placebo: esomeprazole appeared to show no additional reduction in the number of GORD symptoms compared to placebo (1 study, 52 neonates; very low‐certainty evidence): both the esomeprazole group (184.7 ± 78.5 to 156.7 ± 75.1) and placebo group (183.1 ± 77.5 to 158.3 ± 75.9) improved: MD ‐3.2 (95% CI ‐4.6 to ‐1.8). Children Proton pump inhibitors (PPIs) at different doses may provide little to no symptomatic and endoscopic benefit. Rabeprazole given at different doses (0.5 mg/kg and 1 mg/kg) may provide similar symptom improvement (127 children in total; very low‐certainty evidence). In the lower‐dose group (0.5 mg/kg), symptom scores improved in both a low‐weight group of children (< 15 kg) (mean ‐10.6 ± SD 11.13) and a high‐weight group of children (> 15 kg) (mean ‐13.6 ± 13.1). In the higher‐dose groups (1 mg/kg), scores improved in the low‐weight (‐9 ± 11.2) and higher‐weight groups (‐8.3 ± 9.2). For the higher‐weight group, symptom score mean difference between the two different dosing regimens was 2.3 (95% CI ‐2 to 6.6), and for the lower‐weight group, symptom score MD was 4.6 (95% CI ‐2.9 to 12). Pantoprazole: pantoprazole may or may not improve symptom scores at 0.3 mg/kg, 0.6 mg/kg, and 1.2 mg/kg pantoprazole in children aged one to five years by week eight, with no difference between 0.3 mg/kg and 1.2 mg/kg dosing (0.3 mg/kg mean −2.4 ± 1.7; 1.2 mg/kg −1.7 ± 1.2: MD 0.7 (95% CI ‐0.4 to 1.8)) (one study, 60 children; very low‐certainty evidence). There were insufficient summary data to assess other medications. Authors' conclusions There is very low‐certainty evidence about symptom improvements and changes in pH indices for infants. There are no summary data for endoscopic changes. Medications may or may not provide a benefit (based on very low‐certainty evidence) for infants whose symptoms remain bothersome, despite nonmedical interventions or parental reassurance. If a medication is required, there is no clear evidence based on summary data for omeprazole, esomeprazole (in neonates), H₂antagonists, and alginates for symptom improvements (very low‐certainty evidence). Further studies with longer follow‐up are needed. In older children with GORD, in studies with summary data extracted, there is very low‐certainty evidence that PPIs (rabeprazole and pantoprazole) may or may not improve GORD outcomes. No robust data exist for other medications. Further RCT evidence is required in all areas, including subgroups (preterm babies and children with neurodisabilities). Plain language summary Medicines for children with reflux Review question What is the best and safest treatment for babies and children with gastro‐oesophageal reflux? Key messages: ‐ the evidence for medications for babies with gastro‐oesophageal reflux/reflux disease is very uncertain; ‐ for children with gastro‐oesophageal reflux disease, the evidence is very uncertain regarding the effects of proton pump inhibitors. There was no adequate evidence to draw conclusions regarding other medications. What is gastro‐oesophageal reflux? Gastro‐oesophageal reflux happens when stomach contents come back up into the oesophagus (food pipe). Most babies (under 1 year) grow out of reflux symptoms, but does medicine help? Children (older than 1 year) can have reflux just like adults. Reflux can be normal ('physiological reflux'), but in babies and children, it can cause symptoms, including pain or weight loss, as the oesophagus becomes inflamed (oesophagitis). Bothersome symptoms of reflux are called 'gastro‐oesophageal reflux disease' (GORD). How is gastro‐oesophageal reflux treated? Medicines can thicken the stomach contents (alginates), neutralise stomach acid (ranitidine, omeprazole, lansoprazole), or help the stomach to empty faster (domperidone, erythromycin). What did we want to find out? We wanted to learn the best way to reduce reflux in babies and children. We wanted to see if medicines help infants and children to feel better (symptom scores), heal the oesophagus (which is checked by using endoscopy, where a tiny camera is put down the oesophagus), or lower the time the oesophagus is exposed to stomach acid. We also investigated whether the medicines were safe by considering the harmful or unwanted effects reported in the studies. What did we do? We searched for studies testing gastro‐oesophageal reflux medicines in babies and children. We included all studies comparing these medicines, or comparing them to an inactive medicine (placebo). We assessed results which are important to doctors, nurses, and parents, and performed our own analysis of the results. We rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 36 suitable studies (involving 2251 babies and children), conducted worldwide, with most in the USA. The largest study recruited 268 babies, the smallest, 16 children. Fifteen studies compared an active medicine to placebo; 8 compared one active medication to another; and 11 studies gave the same medication at different doses. We found useable outcome information in 14 of the 36 studies. The remaining studies either did not report outcomes we were interested in or did not report them in a way we could analyse. We could not combine the results of any studies because they were too different (in terms of how long they followed participants up and the outcomes they investigated) to use in a meaningful way. Key results Babies. There is no clear effect on symptoms or measured acidity (one measure is reflux index, which is the percentage of time in 24 hours the oesophagus is exposed to stomach acid) between babies given omeprazole or placebo. One study (30 babies) showed cry/fuss time went down from 287 to 201 minutes/day in the placebo group and 246 to 191 minutes/day in the omeprazole group. Reflux index changed in the omeprazole group from 9.9% to 1.0% in 24 hours, and in the placebo group from 7.2% to 5.3%. One study (76 babies) showed that omeprazole and ranitidine may have a similar benefit for symptoms after 2 weeks: symptom scores (higher scores mean worse symptoms) in the omeprazole group dropped from 51.9 to 2.4, and in the ranitidine group, from 47 to 2.5. In one study of 52 newborn babies, esomeprazole appeared to show no reduction in the number of symptoms (184.7 to 156.7) compared to placebo (183.1 to 158.3). None of the studies reported harmful events or results about changes to babies' oesophaguses. Children. In children older than 1 year of age, no studies assessed medical treatment versus placebo. Proton pump inhibitors (PPIs), which block stomach acid production, at different doses may provide little to no improvements in symptoms or oesophagus healing. In one study (127 children), both lower‐weight and higher‐weight children given rabeprazole at lower and higher doses had both minimal – probably unimportant – changes in symptom scores and endoscopic scores (which indicate whether healing of the oesophagus has occurred). Pantoprazole may or may not improve symptom scores in children aged 1 to 5 years by week 8: there was no difference between lower and higher dosing in one study (60 children). Studies investigating other medications did not report enough information for us to assess their results properly. Quality of the evidence We are not confident in the evidence, which was mainly based on single studies with few babies and children. Several studies had pharmaceutical company help with manuscript writing. The question of how best to treat children with disabilities, and whether any PPIs are better than other medicines remain. The evidence is current to 17 September 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Tighe, MP, Andrews, E, Liddicoat, I, Afzal, NA, Hayen, A, Beattie, RM", "articleTypes": [], "doi": "10.1002/14651858.CD008550.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.813Z" }, { "id": "d0808160-214c-4833-8743-99024511b393", "pmid": "", "title": "Polyunsaturated fatty acid supplementation for schizophrenia", "imported": false, "abstract": "Abstract - Background Limited evidence supports a hypothesis suggesting that the symptoms of schizophrenia may be the result of altered neuronal membrane structure and metabolism. The structure and metabolism is dependent on blood plasma levels of certain essential fatty acids and their metabolites. Objectives To assess the effects of polyunsaturated fatty acids for people with schizophrenia. Search methods We have updated the initial searches of 1998, 2002 and 2005 with a search of the Cochrane Schizophrenia Group's Register, November 2008, which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. Where necessary, we contacted authors and relevant pharmaceutical companies for additional information. Selection criteria We included all randomised controlled trials of polyunsaturated fatty acid treatment for schizophrenia. Data collection and analysis Working independently, we selected studies for quality assessment and extracted relevant data. We analysed on an intention‐to‐treat basis. Where possible and appropriate we calculated the Relative Risk (RR) and their 95% confidence intervals (CI) and estimated the number needed to treat (NNT). For continuous data we calculated weighted mean differences (WMD) and their 95% confidence intervals. We also inspected the data for heterogeneity. Main results Eight studies are now included in this review. When any dose omega‐3 (E‐EPA or EPA) is compared with placebo, small short trials suggest that the need for neuroleptics appears to be reduced for people allocated omega‐3 supplementation (n=30, 1 RCT, RR 0.73 CI 0.54 to 1.00) and mental state may improve (n=30, 1 RCT, RR not gaining 25% change in PANSS scores 0.54 CI 0.30 to 0.96, NNT 3 CI 2 to 29). There are no differences in the number of people leaving the study early (n=595, 6 RCTs, RR 0.86 CI 0.50 to 1.48). There are few data on the comparison of any dose omega‐6 (GLA) with placebo. For movement disorder outcomes, the one small study we found does not show any difference for average short‐term endpoint AIMS score (n=16, 1 RCT, WMD 1.30 CI ‐1.96 to 4.56). When any dose omega‐3 (E‐EPA or EPA) is compared with any dose omega‐3 (DHA) there is no significant difference for mental state outcome of not gaining 25% change in PANSS scores (n=31, 1 RCT, RR 0.66 CI 0.39 to 1.11). When different doses of omega‐3 (E‐EPA) are compared with placebo there are no differences in measures of global and mental state between the studies. For the outcome of 'experiencing at least one adverse effect' no differences between groups are found for any dose (1 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.97 CI 0.60 to 1.56; 2 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.67 CI 0.37 to 1.20; 4 g/day E‐EPA vs placebo n=58, 1 RCT, RR 1.15 CI 0.72 to 1.82). Authors' conclusions Three updates of this review have resulted in more included studies and more people randomised but still relatively little useful additional data. The results remain inconclusive. The new trials all compare the omega‐3 polyunsaturated fatty acids, in particular eicosapentaenoic acid and its ester, ethyl‐eicosapentaenoic acid. The use of omega‐3 polyunsaturated fatty acids for schizophrenia still remains experimental and this review highlights the need for large, well designed, conducted and reported studies. Plain language summary Polyunsaturated fatty acid supplementation for schizophrenia Schizophrenia is a serious mental health problem that affects about one percent of any population. For some people it can become an illness that they have to live with for their entire life. Early research has suggested that supplementing the diet with omega 3 or omega 6 fatty acids may have a positive effect on the symptoms of schizophrenia. This review looks at randomised control trials where omega 3 or omega 6 were used in combination with antipsychotic medication, or as a treatment in their own right for schizophrenia. Eight studies were found which included a total of 517 people who had a diagnosis of schizophrenia or schizoaffective disorder (combined symptoms of schizophrenia and a mood disorder). They ranged from six to 16 weeks in length and were in both hospital and community settings. The majority of the trials compared two different types of omega 3 fatty acids, EPA (usually as E‐EPA) and DHA with placebo, in people with schizophrenia who are stable on antipsychotic medication. Some of these trials show some improvement in general functioning and in mental state but not to a statistically significant degree. In the longest trial there was no difference between the two groups at the end of the study. One trial compared E‐EPA with DHA and found a suggestion that E‐EPA works better than DHA, but again it was not statistically significant. Where EPA was compared to placebo as a first line treatment for schizophrenia (30 people), those taking EPA had a better overall outcome and improvement in mental state. However, this was a short trial with few people. Finally, one trial compared a type of omega 6 with placebo in men who had the movement disorder tardive dykinesia (16 people). There was no improvement in the symptoms of movement adverse effects in either group at the end of six weeks. These trials were both small and short. In addition most of the data they reported were not able to be used, and half of the trials were funded by the group supplying the trial medication. Therefore it is still not clear whether taking manufactured omega 3 or 6 improves overall functioning or mental state in people with schizophrenia. (Plain language summary prepared for this review by Janey Antoniou of RETHINK, UK www.rethink.org )", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Irving, CB; Mumby‐Croft, R; Joy, LA", "articleTypes": [], "doi": "10.1002/14651858.CD001257.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "d0824cf9-ca5a-447e-955d-0ae707706ac3", "pmid": "", "title": "Complementary therapies for acne vulgaris", "imported": false, "abstract": "Abstract - Background Acne is a chronic skin disease characterised by inflamed spots and blackheads on the face, neck, back, and chest. Cysts and scarring can also occur, especially in more severe disease. People with acne often turn to complementary and alternative medicine (CAM), such as herbal medicine, acupuncture, and dietary modifications, because of their concerns about the adverse effects of conventional medicines. However, evidence for CAM therapies has not been systematically assessed. Objectives To assess the effects and safety of any complementary therapies in people with acne vulgaris. Search methods We searched the following databases from inception up to 22 January 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 , Issue 1 ), MEDLINE (from 1946), Embase (from 1974), PsycINFO (from 1806), AMED (from 1985), CINAHL (from 1981), Scopus (from 1966), and a number of other databases listed in the Methods section of the review. The Cochrane CAM Field Specialised Register was searched up to May 2014. We also searched five trials registers and checked the reference lists of articles for further references to relevant trials. Selection criteria We included parallel‐group randomised controlled trials (or the first phase data of randomised cross‐over trials) of any kind of CAM, compared with no treatment, placebo, or other active therapies, in people with a diagnosis of acne vulgaris. Data collection and analysis Three authors collected data from each included trial and evaluated the methodological quality independently. They resolved disagreements by discussion and, as needed, arbitration by another author. Main results We included 35 studies, with a total of 3227 participants. We evaluated the majority as having unclear risk of selection, attrition, reporting, detection, and other biases. Because of the clinical heterogeneity between trials and the incomplete data reporting, we could only include four trials in two meta‐analyses, with two trials in each meta‐analysis. The categories of CAM included herbal medicine, acupuncture, cupping therapy, diet, purified bee venom (PBV), and tea tree oil. A pharmaceutical company funded one trial; the other trials did not report their funding sources. Our main primary outcome was 'Improvement of clinical signs assessed through skin lesion counts', which we have reported as 'Change in inflammatory and non‐inflammatory lesion counts', 'Change of total skin lesion counts', 'Skin lesion scores', and 'Change of acne severity score'. For 'Change in inflammatory and non‐inflammatory lesion counts', we combined 2 studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD) at 12 weeks and found no clear evidence of a difference between the groups in change in non‐inflammatory lesion counts (mean difference (MD) ‐3.89, 95% confidence interval (CI) ‐10.07 to 2.29, P = 0.10, 75 participants, 2 trials, low quality of evidence). However, although data from 1 of these 2 trials showed benefit of LGLD for reducing inflammatory lesions (MD ‐7.60, 95% CI ‐13.52 to ‐1.68, 43 participants, 1 trial) and total skin lesion counts (MD ‐8.10, 95% CI ‐14.89 to ‐1.31, 43 participants, 1 trial) for people with acne vulgaris, data regarding inflammatory and total lesion counts from the other study were incomplete and unusable in synthesis. Data from a single trial showed potential benefit of tea tree oil compared with placebo in improving total skin lesion counts (MD ‐7.53, 95% CI ‐10.40 to ‐4.66, 60 participants, 1 trial, low quality of evidence) and acne severity scores (MD ‐5.75, 95% CI ‐9.51 to ‐1.99, 60 participants, 1 trial). Another trial showed pollen bee venom to be better than control in reducing numbers of skin lesions (MD ‐1.17, 95% CI ‐2.06 to ‐0.28, 12 participants, 1 trial). Results from the other 31 trials showed inconsistent effects in terms of whether acupuncture, herbal medicine, or wet‐cupping therapy were superior to controls in increasing remission or reducing skin lesions. Twenty‐six of the 35 included studies reported adverse effects; they did not report any severe adverse events, but specific included trials reported mild adverse effects from herbal medicines, wet‐cupping therapy, and tea tree oil gel. Thirty trials measured two of our secondary outcomes, which we combined and expressed as 'Number of participants with remission'. We were able to combine 2 studies (low quality of evidence), which compared Ziyin Qinggan Xiaocuo Granule and the antibiotic, minocycline (100 mg daily) (worst case = risk ratio (RR) 0.49, 95% CI 0.09 to 2.53, 2 trials, 206 participants at 4 weeks; best case = RR 2.82, 95% CI 0.82 to 9.06, 2 trials, 206 participants at 4 weeks), but there was no clear evidence of a difference between the groups. None of the included studies assessed 'Psychosocial function'. Two studies assessed 'Quality of life', and significant differences in favour of the complementary therapy were found in both of them on 'feelings of self‐worth' (MD 1.51, 95% CI 0.88 to 2.14, P < 0.00001, 1 trial, 70 participants; MD 1.26, 95% CI 0.20 to 2.32, 1 trial, 46 participants) and emotional functionality (MD 2.20, 95% CI 1.75 to 2.65, P < 0.00001, 1 trial, 70 participants; MD 0.93, 95% CI 0.17 to 1.69, 1 trial, 46 participants). Because of limitations and concerns about the quality of the included studies, we could not draw a robust conclusion for consistency, size, and direction of outcome effects in this review. Authors' conclusions There is some low‐quality evidence from single trials that LGLD, tea tree oil, and bee venom may reduce total skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs, such as herbal medicine, acupuncture, or wet‐cupping therapy, for the treatment of this condition. There is a potential for adverse effects from herbal medicines; however, future studies need to assess the safety of all of these CAM therapies. Methodological and reporting quality limitations in the included studies weakened any evidence. Future studies should be designed to ensure low risk of bias and meet current reporting standards for clinical trials. Plain language summary Complementary therapies for acne vulgaris Background Acne is a chronic skin disease, which causes spots to occur simultaneously on several areas of the body, including the face, neck, back, and chest. Besides the current commonly used treatments, complementary and alternative medicines (CAM) are of increasing interest to people who often use them in addition to conventional treatments as additive or single therapies to treat acne. The review question Can any complementary therapies improve the clinical symptoms of acne vulgaris? Study characteristics We searched relevant databases and trials registers up to 22 January 2014. We identified 35 randomised controlled trials, with 3227 participants, which used 6 kinds of CAM (herbal medicine, acupuncture, wet cupping, diet, purified bee venom, and tea tree oil). A pharmaceutical company funded one trial; the other trials did not report their funding sources. Key results For our primary outcome, we combined two studies that compared a low‐ with a high‐glycaemic‐load diet (LGLD, HGLD), but found no clear evidence of a difference between the 2 groups at 12 weeks for a change in non‐inflammatory lesion counts. Only one of these two trials provided usable data to show potential benefit of LGLD for reducing inflammatory and total skin lesion counts. Tea tree oil and pollen bee venom were found to reduce total skin lesion counts in single trials, respectively. The remaining 31 included trials gave mixed results about whether complementary therapies might reduce the total number of skin lesion counts. Twenty‐six trials reported adverse events. The herbal medicine group found some mild side‐effects, such as nausea, diarrhoea, and stomach upset. The acupuncture group found some itch or redness and pain following needle insertion. Participants who used tea tree oil reported itchiness, dryness, and flaking of the skin. None of the trials reported severe adverse effects. For our secondary outcome, there was no clear evidence of a difference in the number of participants with remission between Ziyin Qinggan Xiaocuo Granule and minocycline according to a meta‐analysis of two studies. Quality of the evidence There is some low‐quality evidence from single trials that a low‐glycaemic‐load diet, tea tree oil, and bee venom may reduce skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs. Methodological and reporting quality limitations in the included studies weakened any evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Cao, H; Yang, G; Wang, Y; Liu, JP; Smith, CA; Luo, H; Liu, Y", "articleTypes": [], "doi": "10.1002/14651858.CD009436.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "d0e45e5b-8038-4596-8bb7-46c9df51fe8b", "pmid": "", "title": "Sweet potato for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Sweet potato ( Ipomoea batatas ) is among the most nutritious subtropical and tropical vegetables. It is also used in traditional medicine practices for type 2 diabetes mellitus. Research in animal and human models suggests a possible role of sweet potato in glycaemic control. Objectives To assess the effects of sweet potato for type 2 diabetes mellitus. Search methods We searched several electronic databases, including The Cochrane Library (2013, Issue 1), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2013), combined with handsearches. No language restrictions were used. Selection criteria We included randomised controlled trials (RCTs) that compared sweet potato with a placebo or a comparator intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently selected the trials and extracted the data. We evaluated risk of bias by assessing randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. Main results Three RCTs met our inclusion criteria: these investigated a total of 140 participants and ranged from six weeks to five months in duration. All three studies were performed by the same trialist. Overall, the risk of bias of these trials was unclear or high. All RCTs compared the effect of sweet potato preparations with placebo on glycaemic control in type 2 diabetes mellitus. There was a statistically significant improvement in glycosylated haemoglobin A1c (HbA1c) at three to five months with 4 g/day sweet potato preparation compared to placebo (mean difference ‐0.3% (95% confidence interval ‐0.6 to ‐0.04); P = 0.02; 122 participants; 2 trials). No serious adverse effects were reported. Diabetic complications and morbidity, death from any cause, health‐related quality of life, well‐being, functional outcomes and costs were not investigated. Authors' conclusions There is insufficient evidence about the use of sweet potato for type 2 diabetes mellitus. In addition to improvement in trial methodology, issues of standardization and quality control of preparations ‐ including other varieties of sweet potato ‐ need to be addressed. Further observational trials and RCTs evaluating the effects of sweet potato are needed to guide any recommendations in clinical practice. Plain language summary Sweet potato for type 2 diabetes mellitus Sweet potato ( Ipomoea batatas ) is a plant found in the tropical and subtropical belts and is one of the most nutritious tropical and subtropical vegetables. As well as being popular in cooking in countries in Asia‐Pacific, Africa and North America, sweet potato is also used in traditional medicine for the treatment of diabetes mellitus. We decided to investigate whether there is enough evidence from medical trials to show whether sweet potato works as a treatment for diabetes. This review of randomised controlled trials found only three studies (with a total of 140 participants) that evaluated the effects of sweet potato for type 2 diabetes mellitus compared with a fake medicine (placebo). All these trials were of very low quality. Two studies with 122 participants showed improved long‐term metabolic control of blood sugar levels as measured by glycosylated haemoglobin A1c (HbA1c) which was moderately lowered by 0.3% in participants who were given 4 g sweet potato tablets a day for three to five months. The duration of treatment ranged from six weeks to five months. No study investigated diabetic complications, death from any cause, health‐related quality of life, well‐being, functional outcomes or costs. Adverse effects were mostly mild, and included abdominal distension and pain. There are many varieties of sweet potatoes and sweet potato preparations. More trials are needed to assess the quality of the various sweet potato preparations as well as to evaluate further the use of different varieties of sweet potato in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Ooi, CP, Loke, SC", "articleTypes": [], "doi": "10.1002/14651858.CD009128.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.139Z" }, { "id": "d0e61b7c-de2b-419d-828b-3a53eb0505a5", "pmid": "", "title": "Ibuprofen for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non‐steroidal anti‐inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period. Objectives 1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled). Search methods We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023. Selection criteria We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules. Data collection and analysis We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence. Main results We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child‐reported pain intensity less than two hours postintervention compared to placebo (SMD −1.12, 95% CI −1.39 to −0.86; 3 studies, 259 children; moderate‐certainty evidence). Ibuprofen may reduce child‐reported pain intensity, two hours to less than 24 hours postintervention (SMD −1.01, 95% CI −1.24 to −0.78; 5 studies, 345 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low‐certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child‐reported pain intensity less than two hours postintervention compared to paracetamol (SMD −0.42, 95% CI −0.82 to −0.02; 2 studies, 100 children; moderate‐certainty evidence). Ibuprofen may slightly reduce child‐reported pain intensity two hours to 24 hours postintervention (SMD −0.21, 95% CI −0.40 to −0.02; 6 studies, 422 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low‐certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) −0.25, 95% CI −0.40 to −0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate‐certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD −0.29, 95% CI −0.53 to −0.04; NNTB 4; 1 study, 59 children; low‐certainty evidence). Authors' conclusions Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs. Plain language summary What are the benefits and harms of ibuprofen for managing pain after an operation in children? Key messages • Ibuprofen probably reduces pain intensity just after an operation up to two hours compared to a placebo (dummy) and compared to paracetamol. The evidence compared to other medicines and in the longer term is unclear or lacking. • Overall, we are uncertain about unwanted effects of ibuprofen, especially serious unwanted effects, since the studies in the review rarely measured them. • Future studies should examine ibuprofen compared to commonly used medications and measure benefits and unwanted effects for both short‐ and long‐term use. Why is pain management important? It is common for children to experience pain after an operation (postoperative pain). Pain causes suffering and agitation, and it can delay recovery. One way to manage pain in children is by using different medicines, for example, ibuprofen. Ibuprofen is a type of medicine called a 'non‐steroidal anti‐inflammatory drug' (NSAID) that can reduce inflammation and pain. What did we want to find out? We wanted to find out if ibuprofen is an effective pain treatment and whether it causes unwanted effects compared to other pain treatments. Also, the most effective way to deliver ibuprofen to children. What did we do? We searched for studies that compared ibuprofen to other treatment options for postoperative pain as well as for studies that looked at different ways to deliver ibuprofen to children. We summarised the results and rated our confidence in the evidence. What did we find? We found 43 studies with 4265 children with postoperative pain. We used data from 3935 children in this review. The largest study included 741 children and the smallest, 23 children. The studies were conducted in many countries around the world; most commonly the USA (12 studies). Children's ages ranged from 2.2 months up to 17 years. Studies used ibuprofen to manage postoperative pain in 10 different types of surgery: mostly dental procedures (21 studies); and ear, nose and throat procedures (11 studies). Main results Compared to placebo (a dummy medicine), ibuprofen probably reduces pain intensity less than two hours after the operation and may reduce pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol , ibuprofen probably reduces pain intensity less than two hours after the operation and probably reduces pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol, ibuprofen probably makes little difference to the chances of bleeding. Compared to morphine , ibuprofen probably leads to a reduction in any reported unwanted effects. Compared to ketorolac , ibuprofen may lead to a reduction in overall harms. No studies reported pain intensity or serious unwanted effects, such as lasting disability or hospitalisation for either morphine or ketorolac. We did not find any studies that compared different routes of administration of ibuprofen. What are the limitations of the evidence? We are uncertain about the overall evidence of ibuprofen use in postoperative pain in children, primarily because there were not enough large studies to be certain about any differences in ibuprofen when compared to other alternatives. In addition, only a few of the studies provided data about important benefits and unwanted effects for children experiencing pain following surgery, especially in the longer term. How up to date is this evidence? The evidence is up‐to‐date to August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Pessano, S; Gloeck, NR; Tancredi, L; Ringsten, M; Hohlfeld, A; Ebrahim, S; Albertella, M; Kredo, T; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "d0ee19c6-c34f-4add-8033-5a695fce67f0", "pmid": "", "title": "Eliciting adverse effects data from participants in clinical trials", "imported": false, "abstract": "Abstract - Background Analysis of drug safety in clinical trials involves assessing adverse events (AEs) individually or by aggregate statistical synthesis to provide evidence of likely adverse drug reactions (ADR). While some AEs may be ascertained from physical examinations or tests, there is great reliance on reports from participants to detect subjective symptoms, where he/she is often the only source of information. There is no consensus on how these reports should be elicited, although it is known that questioning methods influence the extent and nature of data detected. This leaves room for measurement error and undermines comparisons between studies and pooled analyses. This review investigated comparisons of methods used in trials to elicit participant‐reported AEs. This should contribute to knowledge about the methodological challenges and possible solutions for achieving better, or more consistent, AE ascertainment in trials. Objectives To systematically review the research that has compared methods used within clinical drug trials (or methods that would be specific for such trials) to elicit information about AEs defined in the protocol or in the planning for the trial. Search methods Databases (searched to March 2015 unless indicated otherwise) included: Embase; MEDLINE; MEDLINE in Process and Other Non‐Indexed Citations; Cochrane Methodology Register (July 2012); Cochrane Central Register of Controlled Trials (February 2015); Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects (January 2015); Health Technology Assessment database (January 2015); CINAHL; CAB Abstracts; BIOSIS (July 2013); Science Citation Index; Social Science Citation Index; Conference Proceedings Citation Index – Science. The search used thesaurus headings and synonyms for the following concepts: (A): Adverse events AND measurement; (B): Participants AND elicitation (also other synonyms for extraction of information about adverse effects from people); (C): Participants AND checklists (also other synonyms as for B). Pragmatic ways were used to limit the results whilst trying to maintain sensitivity. There were no date or sample size restrictions but only reports published in English were included fully, because of resource constraints as regards translation. Selection criteria Two types of studies were included: drug trials comparing two or more methods within‐ or between‐participants to elicit participant‐reported AEs, and research studies performed outside the context of a trial to compare methods which could be used in trials (evidenced by reference to such applicability). Primary outcome data included AEs elicited from participants taking part in any such clinical trial. We included any participant‐reported data relevant for an assessment of drug‐related harm, using the original authors' terminology (and definition, where available), with comment on whether the data were likely to be treatment‐emergent AEs or not. Data collection and analysis Titles and abstracts were independently reviewed for eligibility. Full texts of potentially eligible citations were independently reviewed for final eligibility. Relevant data were extracted and subjected to a 100% check. Disagreements were resolved by discussion, involving a third author. The risk of bias was independently assessed by two authors. The Cochrane 'Risk of bias' tool was used for reports comparing outcomes between participants, while for within‐participant comparisons, each study was critically evaluated in terms of potential impact of the design and conduct on findings using the framework of selection, performance, detection, attrition, reporting, and other biases. An attempt was made to contact authors to retrieve protocols or specific relevant missing information. Reports were not excluded on the basis of quality unless data for outcomes were impossible to compare (e.g. where denominators differed). A narrative synthesis was conducted because differences in study design and presentation meant that a quantitative meta‐analysis was not possible. Main results The 33 eligible studies largely compared open questions with checklist‐type questions or rating scales. Two included participant interviews. Despite different designs, populations and details of questioning methods, the narrative review showed that more specific questioning of participants led to more AEs detected compared to a more general enquiry. A subset of six studies suggested that more severe, bothersome, or otherwise clinically relevant AEs were reported when an initial open enquiry was used, while some less severe, bothersome, or clinically relevant AEs were only reported with a subsequent specific enquiry. However, two studies showed that quite severe or debilitating AEs were only detected by an interview, while other studies did not find a difference in the nature of AEs between elicitation methods. No conclusions could be made regarding the impact of question method on the ability to detect a statistically significant difference between study groups. There was no common statistical rubric, but we were able to represent some effect measures as a risk ratio of the proportion of participants with at least one AE. This showed a lower level of reporting for open questions (O) compared to checklists (CL), with a range for the risk ratios of 0.12 to 0.64. Authors' conclusions This review supports concerns that methods to elicit participant‐reported AEs influence the detection of these data. There was a risk for under‐detection of AEs in studies using a more general elicitation method compared to those using a comprehensive method. These AEs may be important from a clinical perspective or for patients. This under‐detection could compromise ability to pool AE data. However, the impact on the nature of the AE detected by different methods is unclear. The wide variety and low quality of methods to compare elicitation strategies limited this review. Future studies would be improved by using and reporting clear definitions and terminology for AEs (and other important variables), frequency and time period over which they were ascertained, how they were graded, assessed for a relationship to the study drug, coded, and tabulated/reported. While the many potential AE endpoints in a trial may preclude the development of general AE patient‐reported outcome measurement instruments, much could also be learnt from how these employ both quantitative and qualitative methods to better understand data elicited. Any chosen questioning method needs to be feasible for use by both staff and participants. Plain language summary Questioning clinical trial participants about their health in order to collect information on adverse effects of drugs Clinical drug trials or studies are usually conducted to assess how well the drug works but also whether it causes any harm (side effects or adverse effects). Adverse effects can be detected by the trial doctor examining participants or taking some blood samples or doing other kinds of tests. The trial staff can also ask participants about how they are feeling after taking the trial drug. However, the way participants are asked about their health can vary from trial to trial, or even within a trial. In some trials, participants may be asked a simple open question such as 'how have you been feeling?', while in other trials, participants may be asked about whether they have had any of a long list of possible symptoms (such as 'have you had a headache, stomach ache, or sore muscles?'). There has been concern that these different kinds of questions and how they are phrased will impact on what participants report about their health during a trial. This might then affect the trial's results and what we know about the side effects of drugs. We did this review to look at studies that compared different types of participant questioning methods in order to investigate these issues. We found 33 studies comparing mainly open questions with checklist‐type questions, but also some ratings scales and participant interviews. While the studies were all very different in terms of the types of disease, drugs, and patients studied, we found in general that, as would be expected, when a more specific type of question was asked (like a checklist), participants reported more symptoms. What is interesting is that, in those studies that looked more closely at the types of symptoms reported, it seems that an open question picks up the more severe or bothersome symptoms compared to a checklist‐type question. However, some studies found that even quite severe or bothersome symptoms were not reported when a participant is asked an open question and these severe symptoms will only be reported with the more specific question. This makes it difficult to say whether one method is better than any other and the different questioning methods may, in fact, be complementary and therefore should be used together. It is also difficult to say what a specific question should include, as it might take too long for a participant to have to answer a very long list. While more research is needed to resolve the remaining uncertainties, it is very important for trials to be clear about which kind of questioning was used when they publish their results. This will help readers understand the trial's findings about the side effects and make it easier to make accurate comparisons between trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Allen, EN, Chandler, CIR, Mandimika, N, Leisegang, C, Barnes, K", "articleTypes": [], "doi": "10.1002/14651858.MR000039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.790Z" }, { "id": "d0efee63-62fc-4bb6-9adf-3a865e6c311b", "pmid": "", "title": "Ribavirin monotherapy for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. A high proportion of patients never experience symptoms. Peginterferon plus ribavirin is the recommended treatment for chronic hepatitis C. However, ribavirin monotherapy may be considered for some patients. Objectives To assess the beneficial and harmful effects of ribavirin monotherapy for patients with chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included all randomised trials irrespective of blinding, language, or publication status comparing ribavirin versus no intervention, placebo, or interferon for chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained virological response (loss of hepatitis C virus RNA at least six months after treatment), liver‐related morbidity plus all‐cause mortality, and adverse events. Secondary outcome measures were end of treatment virological response, biochemical response (transaminase activity), and histological response. Randomisation methods, blinding, data handling, and funding were extracted as measures of bias control. Random‐effects and fixed‐effect meta‐analyses were performed for all outcomes. We only present the results of the fixed‐effect model if both models provide the same result regarding statistical significance. We present data as risk difference (RD) with 95% confidence intervals (CI). Main results We included 14 randomised trials with 657 patients. The majority of trials had unclear control of bias. Compared with placebo or no intervention, ribavirin had no significant effect on the sustained virological response (RD 0%, 95% CI ‐2% to 3%, five trials) or end of treatment virological response (RD 0% 95% CI ‐3% to 3%, ten trials). Ribavirin had no significant effect on liver‐related morbidity plus mortality (RD 0%, 95% CI ‐2% to 3%, 11 trials). Ribavirin significantly increased the risk of adverse reactions, including anaemia. Ribavirin significantly improved end of treatment biochemical and histological response but not the sustained biochemical response. Ribavirin was significantly inferior to interferon regarding virological and biochemical responses (five trials). Authors' conclusions Ribavirin seems without beneficial effects on serum virological response and liver‐related morbidity or mortality, and significantly increased the risk of adverse reactions. Ribavirin monotherapy seems significantly inferior to interferon monotherapy. The total number of included patients is small, and more trials are perhaps needed. The use of ribavirin monotherapy for chronic hepatitis C cannot be recommended outside randomised trials. Plain language summary Treatment of patients infected with hepatitis C virus Globally, about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behaviour, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die from it. Treatment with interferon clears hepatitis C virus from the blood in about 15% of the patients. Adding ribavirin to interferon (combination therapy) significantly improves the number that clears hepatitis C from the blood to about 40%. Not all patients are tolerant to interferon, and also interferon is costly. This is why ribavirin given as a single drug may be considered as an option for patients with chronic hepatitis C. This review identified 11 randomised trials comparing ribavirin with no antiviral treatment in patient with chronic hepatitis C. Combining the results from all identified trials ribavirin alone seemed without beneficial effects for patients with chronic hepatitis C. Moreover, ribavirin given alone was significantly inferior compared with interferon regarding clearing hepatitis C from the blood and regarding reducing liver enzymes activity in the blood. Furthermore, ribavirin given alone increased the risk of anaemia. Thus, ribavirin given alone cannot be recommended, but more trials may be needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brok, J, Gluud, LL, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005527.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.783Z" }, { "id": "d10ebc48-240d-49c9-8f41-95d1e1cf93ee", "pmid": "", "title": "Convalescent plasma for people with COVID‐19", "imported": false, "abstract": "Abstract - Rationale Convalescent plasma (CP) may reduce mortality in people with viral respiratory diseases, and is being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). A thorough understanding of the current body of evidence regarding the benefits and risks of this intervention is required. Objectives To assess the effectiveness and safety of convalescent plasma transfusion in the treatment of people with COVID‐19. Search methods To identify completed and ongoing studies, we searched CENTRAL, MEDLINE, Embase, the Epistemonikos COVID‐19 L*OVE Platform, and clinical trial registries to October 2024. Eligibility criteria We included randomised controlled trials (RCTs) evaluating convalescent plasma for people with COVID‐19, irrespective of disease severity, age, gender, or ethnicity. We excluded studies investigating other coronavirus diseases or standard immunoglobulin. Outcomes We used the GRADE approach to rate the certainty of evidence for the following outcomes: all‐cause mortality (up to day 28), worsening and improvement of clinical status (for individuals with moderate to severe disease), hospital admission or death, COVID‐19 symptoms resolution (for individuals with mild disease), quality of life (QoL), grade 3/4 adverse events, and serious adverse events. Risk of bias We used RoB 2 to assess bias in included studies. Synthesis methods We followed standard Cochrane methodology. Included studies We included 48 RCTs (24,518 participants), 15 of which were added in this update. We also identified 36 new ongoing studies and 33 completed studies awaiting classification. Synthesis of results Individuals with a confirmed diagnosis of COVID‐19 and moderate to severe disease Forty‐two RCTs investigated the use of CP for 21,393 participants with moderate to severe disease. Of these, 36 RCTs (20,798 participants) compared CP to placebo or standard care, five (604 participants) to standard plasma, and one (190 participants) to human immunoglobulin. In the full review, we performed subgroup analyses by antibody detection, time since symptom onset, country income level, and key comorbidities. Convalescent plasma versus placebo or standard care alone CP does not reduce all‐cause mortality at up to day 28 (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.90 to 1.03; 31 RCTs, 20,798 participants; high‐certainty evidence). It has little to no impact on the need for invasive mechanical ventilation, or death (RR 1.03, 95% CI 0.98 to 1.08; 8 RCTs, 15,189 participants; high‐certainty evidence) and has no impact on whether participants are discharged from hospital (RR 1.00, 95% CI 0.97 to 1.02; 9 RCTs, 13,930 participants; high‐certainty evidence). CP may have little to no impact on QoL (MD 1.00, 95% CI −2.14 to 4.14; 1 RCT, 483 participants; low‐certainty evidence). CP may have little to no impact on the risk of grade 3/4 adverse events (RR 1.17, 95% CI 0.96 to 1.42; 6 RCTs, 2392 participants; low‐certainty evidence). It probably has little to no effect on the risk of serious adverse events (RR 1.19, 95% CI 1.02 to 1.38; 11 studies, 5298 participants; moderate‐certainty evidence). Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.77, 95% CI 0.53 to 1.10; 5 RCTs, 604 participants; very low‐certainty evidence) and whether it increases the need for invasive mechanical ventilation, or death (RR 5.59, 95% CI 0.29 to 108.38; 1 study, 34 participants; very low‐certainty evidence). The evidence is uncertain about whether convalescent plasma reduces or increases the risk of grade 3/4 adverse events (1 RCT, 248 participants). The evidence is also uncertain about whether CP reduces the risk of serious adverse events (RR 0.82, 95% CI 0.57 to 1.17; 4 RCTs, 447 participants; very low‐certainty evidence). No studies in this comparison reported clinical improvement or QoL. Individuals with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease Six RCTs investigated the use of CP for 2761 participants with mild disease. Four RCTs (1164 participants) compared CP to placebo or standard care alone, and two (1597 participants) to standard plasma. Convalescent plasma versus placebo or standard care alone The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (odds ratio (OR) 1.24, 95% CI 0.33 to 4.60; 3 RCTs, 1004 participants; very low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.45, 95% CI 0.04 to 4.81; 2 RCTs, 493 participants; very low‐certainty evidence). It may have little to no impact on time to COVID‐19 symptom resolution (hazard ratio (HR) 1.05, 95% CI 0.85 to 1.30; 1 RCT, 376 participants) and on the risk of grade 3/4 adverse events (RR 1.29, 95% CI 0.75 to 2.19; 1 RCT, 376 participants), both with low‐certainty evidence. The evidence is uncertain about whether CP has an impact on the risk of serious adverse events (RR 0.84, 95% CI 0.56 to 1.26; 2 RCTs, 494 participants; very low‐certainty evidence). No studies in this comparison reported other critical outcomes. Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.41, 95% CI 0.05 to 3.06; 2 RCTs, 1597 participants; very low‐certainty evidence). It probably reduces admission to hospital or death within 28 days (RR 0.50, 95% CI 0.32 to 0.78; 2 RCTs, 1597 participants; moderate‐certainty evidence). CP may have little to no effect on initial symptom resolution at up to day 28 (RR 1.12, 95% CI 0.82 to 1.54; 1 RCT, 416 participants; low‐certainty evidence). Neither study in this comparison reported other critical outcomes. Authors' conclusions Compared with placebo or standard care, high‐certainty evidence shows that CP does not reduce mortality in individuals with moderate to severe disease and has little to no effect on clinical improvement or worsening. CP probably has little to no effect on serious adverse events. Publication of ongoing studies might resolve some of the uncertainties around CP therapy for people with asymptomatic or mild disease. This review was previously a living systematic review, from the first version published in 2020 until our last search in October 2024. The research question is no longer a priority for decision‐making, new studies are less frequently published, and research that might impact the conclusions of the review is no longer emerging. Funding The European Commission, Belgium SUPorting high quality evaluation of COVID‐19 convalescent plasma thrOughouT Europe (SUPPORT‐E, grant number 101015756) supported this review. Registration Protocol registered with the Center for Open Science on 17 April 2020 (DOI: 10.17605/OSF.IO/DWF53). Access the 2023 version of this review here: DOI: 10.1002/14651858.CD013600.pub6. Plain language summary Does plasma (a blood product) from people who have recovered from COVID‐19 help treat COVID‐19? Key messages We are very confident that plasma from the blood of people who have recovered from COVID‐19 (convalescent plasma) does not help people with moderate to severe COVID‐19. Convalescent plasma may make little or no difference to people with mild COVID‐19. We still need more evidence about people with mild COVID‐19, those with no symptoms, and those with a weaker immune system. What is convalescent plasma? The body produces antibodies as one of its defences against infection. Antibodies are found in part of the blood called plasma. Plasma from people who have recovered from the COVID‐19 virus contains COVID‐19 antibodies. It can be used to make convalescent plasma, which is plasma that contains these antibodies. Convalescent plasma has been used successfully to treat some viruses. This treatment (given by a drip or injection) is generally well‐tolerated, but can cause unwanted effects. What did we want to find out? We wanted to find out whether convalescent plasma helps people with confirmed COVID‐19. We looked at: deaths from any cause; worsening of people's condition, measured by the number of people who needed a ventilator (a machine that helps people breathe) or died; improvement in people's condition, measured by the number of people discharged from hospital; quality of life; unwanted effects. What did we do? We searched for studies that investigated convalescent plasma to treat people with COVID‐19. Studies could take place anywhere in the world and include people with mild, moderate, or severe COVID‐19. Where possible, we combined the studies’ results to analyse them. We rated our confidence in the evidence, based on factors such as study methods and the number of people included. What did we find? We found 48 studies with 24,518 participants. Of these, 42 studies included people with moderate to severe COVID‐19, and six studies included people with mild COVID‐19. The following findings compare convalescent plasma with placebo (a 'dummy' treatment that does not contain any medicine but is given in the same way as the medicine being tested) or the standard care given to people with COVID‐19. People with moderate to severe COVID‐19 In people with moderate to severe COVID‐19, convalescent plasma: makes no difference to deaths from any cause up to 28 days after treatment. About 230 of 1000 people given placebo or standard care died, compared to 220 of 1000 people given convalescent plasma (31 studies, 20,798 people). makes little to no difference to needing support from a ventilator or dying . About 291 of 1000 people given placebo or standard care needed a ventilator or died, compared to 300 of 1000 people given convalescent plasma (8 studies, 15,189 people). makes no difference to people being discharged from hospital. About 670 of 1000 people in both groups were discharged from hospital (9 studies, 13,930 people). may result in no difference in people's quality of life (1 study, 483 people). probably makes no difference to serious unwanted effects. About 109 of 1000 people given placebo or standard care had serious unwanted effects, compared to 129 of 1000 people given convalescent plasma (11 studies, 5298 people). People with mild COVID‐19 We are uncertain whether convalescent plasma reduces deaths from any cause up to 28 days after treatment. About 8 of 1000 people given placebo or standard care died, compared to 10 of 1000 people given convalescent plasma (3 studies, 1004 people). We are uncertain whether convalescent plasma reduces admission to hospital or death within 28 days after treatment. About 106 of 1000 people given placebo or standard care were admitted to hospital or died, compared to 48 of 1000 people given convalescent plasma (2 studies, 493 people). Convalescent plasma may result in no difference in the time until COVID‐19 symptoms resolved (1 study, 376 people). None of the studies measured people's quality of life. We are uncertain whether convalescent plasma has an impact on serious unwanted effects. About 174 of 1000 people given placebo or standard care had serious unwanted effects, compared to 150 of 1000 people given convalescent plasma (2 studies, 494 people). What are the limitations of the evidence? For people with moderate to severe COVID‐19, we are very confident in the evidence about the number of deaths from any cause, and whether people's condition worsened or improved, because the results are drawn from many high‐quality studies with consistent results. We are only moderately confident about the evidence for serious unwanted effects because studies often reported these effects only for people treated with convalescent plasma, or did not report them. For people with mild COVID‐19, we have little to no confidence in the evidence because we could not identify enough consistent results from many of the studies. We still have little evidence about quality of life and about the effects of convalescent plasma for people with mild disease. How up to date is this evidence? This updates our previous review published in 2023. The evidence is current to October 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Iannizzi, C; Chai, KL; Piechotta, V; Monsef, I; Wood, EM; Lamikanra, AA; Roberts, DJ; McQuilten, Z; So-Osman, C; Jindal, A; Estcourt, LJ; Skoetz, N; Kreuzberger, N", "articleTypes": [], "doi": "10.1002/14651858.CD013600.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "d119a7dc-41aa-49cd-94bf-dcaab2f93254", "pmid": "", "title": "Omega‐3 fatty acids supplementation for autism spectrum disorders (ASD)", "imported": false, "abstract": "Abstract - Background It has been suggested that impairments associated with autism spectrum disorders (ASD) may be partially explained by deficits of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. Objectives To review the efficacy of omega‐3 fatty acids for improving core features of ASD (for example, social interaction, communication, and stereotypies) and associated symptoms. Search methods We searched the following databases on 2 June 2010: CENTRAL (2010, Issue 2), MEDLINE (1950 to May Week 3 2010), EMBASE (1980 to 2010 Week 21), PsycINFO (1806 to current), BIOSIS (1985 to current), CINAHL (1982 to current), Science Citation Index (1970 to current), Social Science Citation Index (1970 to current), metaRegister of Controlled Trials (20 November 2008) and ClinicalTrials.gov (10 December 2010). Dissertation Abstracts International was searched on 10 December 2008, but was no longer available to the authors or editorial base in 2010. Selection criteria All randomised controlled trials of omega‐3 fatty acids supplementation compared to placebo in individuals with ASD. Data collection and analysis Three authors independently selected studies, assessed them for risk of bias and extracted relevant data. We conducted meta‐analysis of the included studies for three primary outcomes (social interaction, communication, and stereotypy) and one secondary outcome (hyperactivity). Main results We included two trials with a total of 37 children diagnosed with ASD who were randomised into groups that received either omega‐3 fatty acids supplementation or a placebo. We excluded six trials because they were either non‐randomised controlled trials, did not contain a control group, or the control group did not receive a placebo. Overall, there was no evidence that omega‐3 supplements had an effect on social interaction (mean difference (MD) 0.82, 95% confidence interval (CI) ‐2.84 to 4.48, I 2 = 0%), communication (MD 0.62, 95% CI ‐0.89 to 2.14, I 2 = 0%), stereotypy (MD 0.77, 95% CI ‐0.69 to 2.22, I 2 = 8%), or hyperactivity (MD 3.46, 95% CI ‐0.79 to 7.70, I 2 = 0%). Authors' conclusions To date there is no high quality evidence that omega‐3 fatty acids supplementation is effective for improving core and associated symptoms of ASD. Given the paucity of rigorous studies in this area, there is a need for large well‐conducted randomised controlled trials that examine both high and low functioning individuals with ASD, and that have longer follow‐up periods. Plain language summary Omega‐3 fatty acids for autism spectrum disorders (ASD) It has been suggested that difficulties associated with ASD may be explained in part by lack of omega‐3 fatty acids, and that supplementation of these essential fatty acids may lead to improvement of symptoms. The purpose of this review was to assess the evidence for the effectiveness of omega‐3 supplementation for core features of ASD and associated symptoms. We found only two small randomised controlled trials that evaluated omega‐3 fatty acids for ASD. There is insufficient evidence that omega‐3 fatty acids supplementation is an effective treatment for ASD. However, high quality large randomised controlled trials are needed before definite recommendations about this treatment can be made.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "James, S; Montgomery, P; Williams, K", "articleTypes": [], "doi": "10.1002/14651858.CD007992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "d11b35e5-787c-4d6d-8857-91019dc944dc", "pmid": "", "title": "Treatments for intractable constipation in childhood", "imported": false, "abstract": "Abstract - Background Constipation that is prolonged and does not resolve with conventional therapeutic measures is called intractable constipation. The treatment of intractable constipation is challenging, involving pharmacological or non‐pharmacological therapies, as well as surgical approaches. Unresolved constipation can negatively impact quality of life, with additional implications for health systems. Consequently, there is an urgent need to identify treatments that are efficacious and safe. Objectives To evaluate the efficacy and safety of treatments used for intractable constipation in children. Search methods We searched CENTRAL, MEDLINE, Embase, and two trials registers up to 23 June 2023. We also searched reference lists of included studies for relevant studies. Selection criteria We included randomised controlled trials (RCTs) comparing any pharmacological, non‐pharmacological, or surgical treatment to placebo or another active comparator, in participants aged between 0 and 18 years with functional constipation who had not responded to conventional medical therapy. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were symptom resolution, frequency of defecation, treatment success, and adverse events; secondary outcomes were stool consistency, painful defecation, quality of life, faecal incontinence frequency, abdominal pain, hospital admission for disimpaction, and school absence. We used GRADE to assess the certainty of evidence for each primary outcome. Main results This review included 10 RCTs with 1278 children who had intractable constipation. We assessed one study as at low risk of bias across all domains. There were serious concerns about risk of bias in six studies. One study compared the injection of 160 units botulinum toxin A (n = 44) to unspecified oral stool softeners (n = 44). We are very uncertain whether botulinum toxin A injection improves treatment success (risk ratio (RR) 37.00, 95% confidence interval (CI) 5.31 to 257.94; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Frequency of defecation was reported only for the botulinum toxin A injection group (mean interval of 2.6 days). The study reported no data for the other primary outcomes. One study compared erythromycin estolate (n = 6) to placebo (n = 8). The only primary outcome reported was adverse events , which were 0 in both groups. The evidence is of very low certainty due to concerns with risk of bias and serious imprecision. One study compared 12 or 24 μg oral lubiprostone (n = 404) twice a day to placebo (n = 202) over 12 weeks. There may be little to no difference in treatment success (RR 1.29, 95% CI 0.87 to 1.92; low certainty evidence). We also found that lubiprostone probably results in little to no difference in adverse events (RR 1.05, 95% CI 0.91 to 1.21; moderate certainty evidence). The study reported no data for the other primary outcomes. One study compared three‐weekly rectal sodium dioctyl sulfosuccinate and sorbitol enemas (n = 51) to 0.5 g/kg/day polyethylene glycol laxatives (n = 51) over a 52‐week period. We are very uncertain whether rectal sodium dioctyl sulfosuccinate and sorbitol enemas improve treatment success (RR 1.33, 95% CI 0.83 to 2.14; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Results of defecation frequency per week was reported only as modelled means using a linear mixed model. The study reported no data for the other primary outcomes. One study compared biofeedback therapy (n = 12) to no intervention (n = 12). We are very uncertain whether biofeedback therapy improves symptom resolution (RR 2.50, 95% CI 1.08 to 5.79; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). The study reported no data for the other primary outcomes. One study compared 20 minutes of intrarectal electromotive botulinum toxin A using 2800 Hz frequency and botulinum toxin A dose 10 international units/kg (n = 30) to 10 international units/kg botulinum toxin A injection (n = 30). We are very uncertain whether intrarectal electromotive botulinum toxin A improves symptom resolution (RR 0.96, 95% CI 0.76 to 1.22; very low certainty evidence) or if it increases the frequency of defecation (mean difference (MD) 0.00, 95% CI −1.87 to 1.87; very low certainty evidence). We are also very uncertain whether intrarectal electromotive botulinum toxin A has an improved safety profile (RR 0.20, 95% CI 0.01 to 4.00; very low certainty evidence). The evidence for these results is of very low certainty due to serious concerns with risk of bias and imprecision. The study did not report data on treatment success. One study compared the injection of 60 units botulinum toxin A (n = 21) to myectomy of the internal anal sphincter (n = 21). We are very uncertain whether botulinum toxin A injection improves treatment success (RR 1.00, 95% CI 0.75 to 1.34; very low certainty evidence). No adverse events were recorded. The study reported no data for the other primary outcomes. One study compared 0.04 mg/kg oral prucalopride (n = 107) once daily to placebo (n = 108) over eight weeks. Oral prucalopride probably results in little or no difference in defecation frequency (MD 0.50, 95% CI −0.06 to 1.06; moderate certainty evidence); treatment success (RR 0.96, 95% CI 0.53 to 1.72; moderate certainty evidence); and adverse events (RR 1.15, 95% CI 0.94 to 1.39; moderate certainty evidence). The study did not report data on symptom resolution. One study compared transcutaneous electrical stimulation to sham stimulation, and another study compared dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. These studies did not report any of our predefined primary outcomes. Authors' conclusions We identified low to moderate certainty evidence that oral lubiprostone may result in little to no difference in treatment success and adverse events compared to placebo. Based on moderate certainty evidence, there is probably little or no difference between oral prucalopride and placebo in defecation frequency, treatment success, or adverse events. For all other comparisons, the certainty of the evidence for our predefined primary outcomes is very low due to serious concerns with study limitations and imprecision. Consequently, no robust conclusions could be drawn. Plain language summary Management of intractable constipation in children Key messages • There may be little to no difference between lubiprostone and placebo (dummy treatment) in achieving treatment success in children with intractable constipation. We also found that lubiprostone is probably as safe as placebo. • There is probably little or no difference between prucalopride, also a laxative, and placebo in frequency of defecation per day, treatment success, and safety. • It is unclear whether any of the other treatments we looked at are helpful. The evidence is uncertain because of the very low number of study participants and problems with how the research was reported. • Currently, there is not an agreed‐upon definition for intractable constipation. To develop further evidence on therapies for intractable constipation, researchers must use the same definition. We would encourage further work to come up with an agreed‐upon definition. What is intractable constipation? Constipation in children is a common problem. If doctors cannot find an underlying cause for the symptoms, it is called functional constipation. The symptoms of constipation include lower frequency of defecation, bowel incontinence or soiling, and stomach pain. Constipation can be mild and respond well to standard treatments, such as behavioural changes or laxatives. However, it can also be more severe or last for a long time. We defined intractable constipation as constipation that persists despite standard treatments. What did we want to find out? We wanted to find out which treatments are helpful and safe for treating children (between 0 and 18 years of age) with constipation that has not responded to standard medical treatments (intractable constipation). This extreme level of constipation can impact a child's life in very negative ways, such as keeping them away from school and other daily activities; causing them pain, discomfort, and general distress; and requiring hospital visits for treatment. Consequently, there is a need to investigate if the tested therapies can help resolve the problem. What did we do? We considered any medication, surgical procedure, or therapy to help children with intractable constipation. Each study compared a specific treatment to placebo, no treatment, or another treatment. We were interested in whether the treatments increased the frequency of defecation, improved symptoms, or led to treatment success. We also wanted to know if the treatments were safe, so we looked at whether they caused side effects. We searched for randomised controlled trials (studies in which people are randomly assigned to one of two or more treatment groups) comparing any medical, surgical, or complementary therapy versus no treatment, placebo, or another treatment in children with intractable constipation. What did we find? We found 10 studies involving a total of 1278 children. The average age of study participants ranged from around 5 to 10 years. The studies were conducted in Iran, Brazil, Colombia, the USA, Canada, Australia, and several European countries. Studies lasted from one to six months. The studies made the following comparisons: • botox injection versus stool softeners; • erythromycin versus placebo; • lubiprostone versus placebo; • rectal sodium dioctyl sulfosuccinate and sorbitol versus oral polyethylene glycol laxatives; • biofeedback therapy versus no treatment; • intrarectal electromotive botox injection versus a usual botox injection; • botox injection versus myectomy of the internal anal sphincter; • prucalopride versus placebo; • transcutaneous electrical stimulation versus sham stimulation; and • dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. Main results • There may be little to no difference between lubiprostone and placebo in achieving treatment success, and there is probably little to no difference in adverse events for this comparison. • There is probably little or no difference between prucalopride and placebo in defecation frequency, treatment success, and adverse events. • We do not know whether any of the other treatments looked at in this review are safer or more beneficial than others. What are the limitations of the evidence? The evidence is limited due to small participant numbers in the included studies, and because each study looked at a different comparison, both of which resulted in the evidence being imprecise. There were also issues with the way the studies were conducted, which led to concerns that study results might be biased. How up‐to‐date is this evidence? This review is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gordon, M; Grafton-Clarke, C; Rajindrajith, S; Benninga, M; Sinopoulou, V; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD014580.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "d123c9cc-b7bc-40fe-a6b6-e10702fb34ba", "pmid": "", "title": "Laboratory‐based molecular test alternatives to RT‐PCR for the diagnosis of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Diagnosing people with a SARS‐CoV‐2 infection played a critical role in managing the COVID‐19 pandemic and remains a priority for the transition to long‐term management of COVID‐19. Initial shortages of extraction and reverse transcription polymerase chain reaction (RT‐PCR) reagents impaired the desired upscaling of testing in many countries, which led to the search for alternatives to RNA extraction/purification and RT‐PCR testing. Reference standard methods for diagnosing the presence of SARS‐CoV‐2 infection rely primarily on real‐time reverse transcription‐polymerase chain reaction (RT‐PCR). Alternatives to RT‐PCR could, if sufficiently accurate, have a positive impact by expanding the range of diagnostic tools available for the timely identification of people infected by SARS‐CoV‐2, access to testing and the use of resources. Objectives To assess the diagnostic accuracy of alternative (to RT‐PCR assays) laboratory‐based molecular tests for diagnosing SARS‐CoV‐2 infection. Search methods We searched the COVID‐19 Open Access Project living evidence database from the University of Bern until 30 September 2020 and the WHO COVID‐19 Research Database until 31 October 2022. We did not apply language restrictions. Selection criteria We included studies of people with suspected or known SARS‐CoV‐2 infection, or where tests were used to screen for infection, and studies evaluating commercially developed laboratory‐based molecular tests for the diagnosis of SARS‐CoV‐2 infection considered as alternatives to RT‐PCR testing. We also included all reference standards to define the presence or absence of SARS‐CoV‐2, including RT‐PCR tests and established clinical diagnostic criteria. Data collection and analysis Two authors independently screened studies and resolved disagreements by discussing them with a third author. Two authors independently extracted data and assessed the risk of bias and applicability of the studies using the QUADAS‐2 tool. We presented sensitivity and specificity, with 95% confidence intervals (CIs), for each test using paired forest plots and summarised results using average sensitivity and specificity using a bivariate random‐effects meta‐analysis. We illustrated the findings per index test category and assay brand compared to the WHO's acceptable sensitivity and specificity threshold for diagnosing SARS‐CoV‐2 infection using nucleic acid tests. Main results We included data from 64 studies reporting 94 cohorts of participants and 105 index test evaluations, with 74,753 samples and 7517 confirmed SARS‐CoV‐2 cases. We did not identify any published or preprint reports of accuracy for a considerable number of commercially produced NAAT assays. Most cohorts were judged at unclear or high risk of bias in more than three QUADAS‐2 domains. Around half of the cohorts were considered at high risk of selection bias because of recruitment based on COVID status. Three quarters of 94 cohorts were at high risk of bias in the reference standard domain because of reliance on a single RT‐PCR result to determine the absence of SARS‐CoV‐2 infection or were at unclear risk of bias due to a lack of clarity about the time interval between the index test assessment and the reference standard, the number of missing results, or the absence of a participant flow diagram. For index tests categories with four or more evaluations and when summary estimations were possible, we found that: a) For RT‐PCR assays designed to omit/adapt RNA extraction/purification, the average sensitivity was 95.1% (95% CI 91.1% to 97.3%), and the average specificity was 99.7% (95% CI 98.5% to 99.9%; based on 27 evaluations, 2834 samples and 1178 SARS‐CoV‐2 cases); b) For RT‐LAMP assays, the average sensitivity was 88.4% (95% CI 83.1% to 92.2%), and the average specificity was 99.7% (95% CI 98.7% to 99.9%; 24 evaluations, 29,496 samples and 2255 SARS‐CoV‐2 cases); c) for TMA assays, the average sensitivity was 97.6% (95% CI 95.2% to 98.8%), and the average specificity was 99.4% (95% CI 94.9% to 99.9%; 14 evaluations, 2196 samples and 942 SARS‐CoV‐2 cases); d) for digital PCR assays, the average sensitivity was 98.5% (95% CI 95.2% to 99.5%), and the average specificity was 91.4% (95% CI 60.4% to 98.7%; five evaluations, 703 samples and 354 SARS‐CoV‐2 cases); e) for RT‐LAMP assays omitting/adapting RNA extraction, the average sensitivity was 73.1% (95% CI 58.4% to 84%), and the average specificity was 100% (95% CI 98% to 100%; 24 evaluations, 14,342 samples and 1502 SARS‐CoV‐2 cases). Only two index test categories fulfil the WHO‐acceptable sensitivity and specificity requirements for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. In addition, WHO‐acceptable performance criteria were met for two assays out of 35 when tests were used according to manufacturer instructions. At 5% prevalence using a cohort of 1000 people suspected of SARS‐CoV‐2 infection, the positive predictive value of RT‐PCR assays omitting/adapting RNA extraction/purification will be 94%, with three in 51 positive results being false positives, and around two missed cases. For TMA assays, the positive predictive value of RT‐PCR assays will be 89%, with 6 in 55 positive results being false positives, and around one missed case. Authors' conclusions Alternative laboratory‐based molecular tests aim to enhance testing capacity in different ways, such as reducing the time, steps and resources needed to obtain valid results. Several index test technologies with these potential advantages have not been evaluated or have been assessed by only a few studies of limited methodological quality, so the performance of these kits was undetermined. Only two index test categories with enough evaluations for meta‐analysis fulfil the WHO set of acceptable accuracy standards for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. These assays might prove to be suitable alternatives to RT‐PCR for identifying people infected by SARS‐CoV‐2, especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence, including reliance on retrospective samples without information about the symptom status of participants and the timing of assessment. No extrapolation of found accuracy data for these two alternatives to any test brands using the same techniques can be made as, for both groups, one test brand with high accuracy was overrepresented with 21/26 and 12/14 included studies, respectively. Although we used a comprehensive search and had broad eligibility criteria to include a wide range of tests that could be alternatives to RT‐PCR methods, further research is needed to assess the performance of alternative COVID‐19 tests and their role in pandemic management. Plain language summary How accurate are alternative laboratory‐based molecular tests (to RT‐PCR with prior RNA extraction/purification) for identifying people infected by SARS‐CoV‐2? Key messages: * Transcription‐mediated amplification (TMA) tests and commercially available reverse transcription polymerase chain reaction (RT‐PCR) tests specifically designed to omit/adapt RNA extraction/purification appear accurate enough to replace the method of RT‐PCR with prior RNA (a molecule essential for most biological functions) extraction/purification for identifying people infected by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence. * The accuracy of other types of laboratory‐based molecular alternatives to RT‐PCR is below World Health Organisation (WHO) recommended standards or lacks a sufficient volume of evidence to draw reliable conclusions. *The extrapolation of accuracy data from the evaluated tests to any other test brand(s) using the same techniques will be challenging since main categories are overrepresented by highly accurate individual test brands. Further evaluation of these tests in real clinical practice scenarios is needed. What are alternative laboratory‐based molecular assays for identifying people infected by SARS‐CoV‐2? Laboratory‐based molecular assays (tests) aim to confirm or rule out SARS‐CoV‐2 infection in people. Alternatives to RT‐PCR assays have been developed to minimise the steps needed to process samples in the laboratory or use fewer resources to obtain the same valid results. For this review, we focus on tests commercially developed by a manufacturer, providing instructions for their professional use. Why is this question important? People with suspected SARS‐CoV‐2 infection should know if they are infected to self‐isolate, receive treatment, and inform close contacts. Failure to detect SARS‐CoV‐2 when it is present risks spreading infection and results in missed opportunities for prevention. Diagnosing SARS‐CoV‐2 infection when it is not present may lead to unnecessary self‐isolation and testing of close contacts. Currently, testing to confirm SARS‐CoV‐2 infection relies on a laboratory molecular test called RT‐PCR. This requires specialist equipment and can take 24 hours to produce a result. If assays that take less time or use readily available resources were sufficiently accurate to replace RT‐PCR testing, this could increase the number of tests that could be done, allow faster diagnosis and enable people to take appropriate action more quickly. What did we want to find out? We wanted to know whether commercially developed, alternative laboratory‐based molecular tests are accurate enough to diagnose SARS‐CoV‐2 infection compared to RT‐PCR. What did we do? We looked for studies investigating these tests in people (or samples) that were also tested for SARS‐CoV‐2 infection using RT‐PCR which modified RT‐PCR by removing or altering components of this testing process. What did we find? We included 105 evaluations evaluating alternatives to RT‐PCR in the review. The main results are based on 74,753 samples, and SARS‐CoV‐2 infection was confirmed in 7517 of these samples. Most evaluations (27/105) concerned various test types specifically designed to omit/adapt RNA extraction/purification. Twenty‐four of 105 evaluations concerned various test types operating at one temperature (isothermal tests) rather than cycling through different temperatures. Twenty‐four of 105 evaluations were concerned with various test types that combined these two alternative approaches. Main results Only tests specifically designed to omit/adapt RNA extraction/purification and TMA assays with RNA extraction (a type of isothermal test) met WHO‐acceptable standards for confirming and ruling out SARS‐CoV‐2. For illustration, the results of these studies indicate that in a group of 1000 people, 50 of whom (5%) actually have SARS‐CoV‐2: * For tests specifically designed to omit/adapt RNA extraction/purification: ‐51 people would test positive for SARS‐CoV‐2. Of these, three people (6%) would not have SARS‐CoV‐2 (false‐positive result). ‐949 people would test negative for SARS‐CoV‐2. Of these, two people (0.2%) would actually have SARS‐CoV‐2 (false‐negative result) *For TMA tests with RNA extraction: ‐55 people would test positive for SARS‐CoV‐2. Of these, six people (10%) would not have SARS‐CoV‐2 (false‐positive result). ‐945 people would test negative for SARS‐CoV‐2. Of these, one person (0.1%) would actually have SARS‐CoV‐2 (false‐negative result) What are the limitations of the evidence? Most included studies did not provide information on participants who underwent testing, such as whether they had symptoms or were close contacts of a SARS‐CoV‐2 case. We also had concerns about the method of recruiting participants for the majority of included studies, which may have resulted in an overestimation of the accuracy of these methods. In addition, the method used to determine whether individuals did not have SARS‐CoV‐2 infection was not considered reliable for most studies, which may have resulted in underestimating the accuracy of these methods. Some studies did not follow the manufacturers' instructions for using the test. Results from different test brands using the same technique varied. What does this mean? The studies included in this review suggest that two laboratory‐based molecular tests might be accurate enough to replace or supplement RT‐PCR tests with prior RNA extraction/purification for the diagnosis of SARS‐CoV‐2 infection: RT‐PCR tests developed to omit or adapt RNA extraction or purification and TMA isothermal tests (retaining an RNA extraction step). Other alternative tests to RT‐PCR were assessed just by a few studies of limited methodological quality, and their performance should be evaluated by additional studies. Furthermore, data in these studies mostly relied on samples acquired in the past (compared to current or future samples), thus further evaluation of these tests in real clinical practice scenarios is required. Also, decisions on the optimal test for a specific setting will be driven not only by diagnostic accuracy, but also by other factors such as test complexity, time to result, acceptability to those being tested, and the setting in which the tests are to be used. How up‐to‐date is this review? This review includes evidence published up to 31 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Arevalo-Rodriguez, I, Mateos-Haro, M, Dinnes, J, Ciapponi, A, Davenport, C, Buitrago-Garcia, D, Bennouna-Dalero, T, Roqué-Figuls, M, Van den Bruel, A, von Eije, KJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015618", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.794Z" }, { "id": "d13b931e-82a5-403f-92dd-420f59c1765e", "pmid": "", "title": "Interventions for protecting renal function in the perioperative period", "imported": false, "abstract": "Abstract - Background Various methods have been used to try to protect kidney function in patients undergoing surgery. These most often include pharmacological interventions such as dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants and erythropoietin (EPO). Objectives This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period. We considered the following questions: (1) Are any specific measures known to protect kidney function during the perioperative period? (2) Of measures used to protect the kidneys during the perioperative period, does any one method appear to be more effective than the others? (3) Of measures used to protect the kidneys during the perioperative period,does any one method appear to be safer than the others? Search methods In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 2, 2012), MEDLINE (Ovid SP) (1966 to August 2012) and EMBASE (Ovid SP) (1988 to August 2012). We originally handsearched six journals ( Anesthesia and Analgesi a, Anesthesiology , Annals of Surgery , British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery) (1985 to 2004). However, because these journals are properly indexed in MEDLINE, we decided to rely on electronic searches only without handsearching the journals from 2004 onwards. Selection criteria We selected all randomized controlled trials in adults undergoing surgery for which a treatment measure was used for the purpose of providing renal protection during the perioperative period. Data collection and analysis We selected 72 studies for inclusion in this review. Two review authors extracted data from all selected studies and entered them into RevMan 5.1; then the data were appropriately analysed. We performed subgroup analyses for type of intervention, type of surgical procedure and pre‐existing renal dysfunction. We undertook sensitivity analyses for studies with high and moderately good methodological quality. Main results The updated review included data from 72 studies, comprising a total of 4378 participants. Of these, 2291 received some form of treatment and 2087 acted as controls. The interventions consisted most often of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, NAC, ANP, sodium bicarbonate, antioxidants and EPO or selected hydration fluids. Some clinical heterogeneity and varying risk of bias were noted amongst the studies, although we were able to meaningfully interpret the data. Results showed significant heterogeneity and indicated that most interventions provided no benefit. Data on perioperative mortality were reported in 41 studies and data on acute renal injury in 44 studies (all interventions combined). Because of considerable clinical heterogeneity (different clinical scenarios, as well as considerable methodological variability amongst the studies), we did not perform a meta‐analysis on the combined data. Subgroup analysis of major interventions and surgical procedures showed no significant influence of interventions on reported mortality and acute renal injury. For the subgroup of participants who had pre‐existing renal damage, the risk of mortality from 10 trials (959 participants) was estimated as odds ratio (OR) 0.76, 95% confidence interval (CI) 0.38 to 1.52; the risk of acute renal injury (as reported in the trials) was estimated from 11 trials (979 participants) as OR 0.43, 95% CI 0.23 to 0.80. Subgroup analysis of studies that were rated as having low risk of bias revealed that 19 studies reported mortality numbers (1604 participants); OR was 1.01, 95% CI 0.54 to 1.90. Fifteen studies reported data on acute renal injury (criteria chosen by the individual studies; 1600 participants); OR was 1.03, 95% CI 0.54 to 1.97. Authors' conclusions No reliable evidence from the available literature suggests that interventions during surgery can protect the kidneys from damage. However, the criteria used to diagnose acute renal damage varied in many of the older studies selected for inclusion in this review, many of which suffered from poor methodological quality such as insufficient participant numbers and poor definitions of end points such as acute renal failure and acute renal injury. Recent methods of detecting renal damage such as the use of specific biomarkers and better defined criteria for identifying renal damage (RIFLE (risk, injury, failure, loss of kidney function and end‐stage renal failure) or AKI (acute kidney injury)) may have to be explored further to determine any possible benefit derived from interventions used to protect the kidneys during the perioperative period. Plain language summary No evidence indicates that any of the measures used to protect patients' kidneys during the perioperative period are beneficial The kidneys may be damaged during an operation as a result of direct and indirect insult. The reasons for this are multiple and include changes to physiology brought on by the surgery and by the body’s response to such insult. Damage to kidneys during the perioperative period is associated with significant morbidity and mortality. This updated Cochrane review looked at 72 randomized controlled trials (RCTs) with 4378 participants (search data until August 2012); interventions most often included pharmacological interventions (administration of dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine, atrial natriuretic peptide, sodium bicarbonate, antioxidants and erythropoietin) or selected hydration fluids. We attempted to identify any possible damage to the kidneys by evaluating kidney function up to seven days after the operation. No clear evidence from available RCTs suggests that any of the measures used to protect the kidneys during the perioperative period are beneficial. These findings held true in 14 studies of patients with pre‐existing renal damage and in 24 studies that were considered of good methodological quality. The primary outcomes of these studies were mortality and acute renal injury. Reported mortality in studies with low risk of bias was not different between intervention and control groups (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.52 to 1.97) or for acute renal injury (OR 1.05, 95% CI 0.55 to 2.03). The summary of findings revealed a similar picture. So we conclude that evidence suggests that none of the interventions used currently are helpful in protecting the kidneys during the perioperative period, nor do they cause increased harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zacharias, M; Mugawar, M; Herbison, GP; Walker, RJ; Hovhannisyan, K; Sivalingam, P; Conlon, NP", "articleTypes": [], "doi": "10.1002/14651858.CD003590.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "d1488bc9-480a-4a29-9a6a-c86ef63a7aa3", "pmid": "", "title": "Antibiotics prior to amniotomy for reducing infectious morbidity in mother and infant", "imported": false, "abstract": "Abstract - Background Amniotomy (the deliberate rupture of membranes) was described almost two centuries ago and since then has been used both for induction and augmentation of labour ‐ which are common obstetric practices. Trends have shown a rise in the induction rates over the last decade and data suggest that the rate of labour inductions is increasing faster than the rate of pregnancy complications. Recent years have seen the emergence of a variety of other methods of induction of labour but amniotomy combined with oxytocin infusion remains the most commonly used method of augmentation of labour. The newer agents for induction are expensive and in resource‐poor settings amniotomy is still the chosen method for both induction and augmentation. As with any invasive procedure amniotomy can lead to infection, ascending from the vagina into the uterine cavity and can contribute significantly to both maternal and neonatal infectious morbidity. Objectives The objective of this review was to evaluate the prophylactic use of antibiotics versus placebo or no treatment prior to amniotomy on maternal and neonatal infectious morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014), the International Clinical Trials Registry Platform ( ICTRP ) and ClinicalTrials.gov (12 September 2014). Selection criteria Randomised controlled trials or cluster‐randomised trials comparing antibiotics prior to amniotomy versus placebo (or no treatment) were eligible for inclusion in this review but none were identified. Quasi‐randomised trials or cross‐over trials were not eligible for inclusion. Data collection and analysis Two review authors independently assessed one trial report for inclusion. In future updates of this review, two review authors will independently assess risk of bias and carry out data extraction. Data will be checked for accuracy. Main results We identified one trial report but this was excluded. No studies met the inclusion criteria for this review. Authors' conclusions High‐quality trials are needed to justify or refute the routine use of antibiotics at amniotomy for prevention of infection in the mother and infant. Future studies should be conducted, especially in resource‐constrained settings where amniotomy is still used as a means of induction of labour, in order to evaluate the routine use of antibiotics at amniotomy in these settings. Future research in this area should include important maternal and infant outcomes listed in this review and also consider cost effectiveness and side effects of antibiotic use, including the emergence of antibiotic‐resistant strains. Plain language summary Antibiotic use before amniotomy (artificially rupturing the membranes) for reducing infections in mother and infant The artificial rupture of the membranes (amniotomy) is a common obstetrical procedure. It may be done to either initiate or to augment labour, with or without oxytocin. This invasive procedure allows vaginal micro‐organisms access into the uterine cavity, which can in turn lead to infections in both the mother and the infant. A greater time interval between rupture of membranes and delivery, as with induction of labour, increases the chances of an infection. The purpose of this review was to evaluate the routine use of antibiotics immediately prior to amniotomy for both initiation and augmentation of labour using randomised controlled trials. However, our search only identified one trial which did not meet the inclusion criteria for this review. Consequently, there is no evidence to support or refute the routine use of antibiotics prior to amniotomy. Randomised controlled trials on this topic are needed, especially in resource‐constrained settings where amniotomy is still used as a means of inducing labour, to evaluate the routine use of antibiotics at amniotomy in such settings. Future research in this area should also consider cost effectiveness and side effects of antibiotic use including the emergence of antibiotic‐resistant strains.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ray, A, Ray, S", "articleTypes": [], "doi": "10.1002/14651858.CD010626.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.775Z" }, { "id": "d15b8a2b-dcf4-4acd-b56c-d82770aacbee", "pmid": "", "title": "Topical cystic fibrosis transmembrane conductance regulator gene replacement for cystic fibrosis‐related lung disease", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is caused by a defective gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR), and is characterised by chronic lung infection resulting in inflammation and progressive lung damage that results in a reduced life expectancy. Objectives To determine whether topical CFTR gene replacement therapy to the lungs in people with cystic fibrosis is associated with improvements in clinical outcomes, and to assess any adverse effects. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Date of most recent search: 05 May 2016. An additional search of the National Institutes for Health (NIH) Genetic Modification Clinical Research Information System (GeMCRIS) was also performed for the years 1992 to 2015. Date of most recent search: 20 April 2016. Selection criteria Randomised controlled studies comparing topical CFTR gene delivery to the lung, using either viral or non‐viral delivery systems, with placebo or an alternative delivery system in people with confirmed cystic fibrosis. Data collection and analysis The authors independently extracted data and assessed study quality. Authors of included studies were contacted and asked for any available additional data. Meta‐analysis was limited due to differing study designs. Main results Four randomised controlled studies met the inclusion criteria for this review, involving a total of 302 participants lasting from 29 days to 13 months; 14 studies were excluded. The included studies differed in terms of CFTR gene replacement agent and study design, which limited the meta‐analysis. One study only enrolled adult males, the remaining studies included both males and females aged 12 years and over. Risk of bias in the studies was moderate. Random sequence generation and allocation concealment was only described in the more recent study; the remaining three studies were judged to have an unclear risk of bias. All four studies documented double‐blinding to the intervention, but there is some uncertainty with regards to participant blinding in one study. Some outcome data were missing from all four studies. There were no differences in either the number of respiratory exacerbations or the number of participants with an exacerbation between replacement therapy or placebo groups at any time point. Meta‐analysis of most respiratory function tests showed no difference between treatment and placebo groups, but the smallest study (n = 16) reported forced vital capacity (litres) increased more in the placebo group at up to 24 hours. A further study reported a significant improvement in forced expiratory volume at one second (litres) at 30 days after participants had received their first dose of favouring the gene therapy agent, but this finding was not confirmed when combined with at second study in the meta‐analysis. The more recent study (n = 140) demonstrated a small improvement in forced vital capacity (per cent predicted) at two and three months and again at 11 and 12 months for participants receiving CFTR gene replacement therapy compared to those receiving placebo. The same study reported a significant difference in the relative change in forced expiratory volume at one second (per cent predicted) at two months, three months and 12 months. One small study reported significant concerns with \"influenza‐like\" symptoms in participants treated with CFTR gene replacement therapy; this was not reported on repeated use of the same agent in a larger recent study. There was no other evidence of positive impact on outcomes, in particular improved quality of life or reduced treatment burden. Two studies measured ion transport in the lower airways; one (n = 16) demonstrated significant changes toward normal values in the participants who received gene transfer agents (P < 0.0001), mean difference 6.86 (95% confidence interval 3.77 to 9.95). The second study (n = 140) also reported significant changes toward normal values (P = 0.032); however, aggregate data were not available for analysis. In the most recent study, there was also evidence of increased salt transport in cells obtained by brushing the lower airway. These outcomes, whilst important, are not of direct clinical relevance. Authors' conclusions One study of liposome‐based CFTR gene transfer therapy demonstrated some improvements in respiratory function in people with CF, but this limited evidence of efficacy does not support this treatment as a routine therapy at present. There was no evidence of efficacy for viral‐mediated gene delivery. Future studies need to investigate clinically important outcome measures. Plain language summary Replacing the defective gene is a potential treatment for progressive lung disease in people with cystic fibrosis Review question We reviewed the evidence about the effect of delivering the correct copy of the cystic fibrosis transmembrane conductance regulator (CFTR) gene directly to the lungs of people with cystic fibrosis in order to treat progressive lung disease. Background In cystic fibrosis the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. People with cystic fibrosis suffer from progressive lung infection and damage which reduces life expectancy. Agents which can deliver a correct copy of the faulty CFTR gene to cells in the lungs may be an effective treatment. Search date The evidence is current to: 20 April 2016. Study characteristics We found four studies with 302 people to include in this review. The studies lasted from 29 days to 13 months. Three of these studies included both men and women aged 12 years and over and one study only included adult men. The studies compare gene therapy to a dummy treatment (placebo) both of which are inhaled as a mist into the lungs. The studies were of different designs and used different agents. This meant we could not combine their results. Key results Three of the studies, including the largest and most recent study, showed an improvement in some measures of lung function in people with CF given gene therapy. We did not find that any more clinically relevant outcomes such as quality of life, treatment burden or flare‐up of lung disease had improved with treatment. In one study \"influenza‐like\" symptoms were more common in people who received CFTR gene transfer agents but this was not reported when the agent was used repeatedly in a larger study. In those people who took the gene transfer agents, molecules and salt in their lower airways moved more like they do in healthy people. The limited evidence of benefit does not support this as a routine therapy at present. We recommend that future studies are designed and reported clearly so that their results can be incorporated into a systematic review. Quality of the evidence The most recent study provided detailed information on how the people were put into different treatment groups completely at random, and so we are satisfied that those taking part in the study had an equal chance of being in either group (CFTR gene transfer agent or placebo) and that no one could work out which group the next person would be put into. The other studies reported that people were put into groups at random but did not specify how, so we cannot be sure that there was an equal chance of them being in either group. We believe that the clinicians running all the studies did not know which treatment the people taking part were receiving and that in three of the studies those taking part did not know either, but we could not be sure whether the people taking part in the latest study knew which treatment they were receiving and what effect this knowledge might have on results. Unfortunately, the studies did not report all their results clearly; sometimes results were not reported in a way that we could use for the review and sometimes they were not reported at all. This reduced the certainty with which we judged the overall results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Perry, LA; Penny‐Dimri, JC; Aslam, AA; Lee, TWR; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD005599.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "d1611660-d6ef-4a37-90bc-6312341a749d", "pmid": "", "title": "Ginkgo biloba extract for age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Ginkgo is used in the treatment of peripheral vascular disease and 'cerebral insufficiency'. It is thought to have several potential mechanisms of action including increased blood flow, platelet activating factor antagonism, and prevention of membrane damage caused by free radicals. Vascular factors and oxidative damage are thought to be two potential mechanisms in the pathology of age‐related macular degeneration (AMD). Objectives The objective of this review was to determine the effect of Ginkgo biloba extract on the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2012), EMBASE (January 1980 to October 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to October 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 5 October 2012. We searched the reference lists of identified reports and the Science Citation Index. We also contacted investigators of included studies for additional information. Selection criteria All randomised trials in people with AMD where Ginkgo biloba extract had been compared to control were included. Data collection and analysis The review author extracted data using a standardised form. The data were verified with the trial investigators. Trial quality was assessed. Main results Two published trials were identified that randomised a total of 119 people. In one study conducted in France, 20 people were randomly allocated to Gingko biloba extract EGb 761 80 mg twice daily or placebo. In the other study conducted in Germany, 99 people were randomly allocated to two different doses of Ginkgo biloba extract EGb 761 (240 mg per day and 60 mg per day). Treatment duration in both studies was six months. Both trials reported some positive effects of Ginkgo biloba on vision however their results could not be pooled. Adverse effects and quality of life for people with AMD were not reported. Authors' conclusions The question as to whether people with AMD should take Ginkgo biloba extract to prevent progression of the disease has not been answered by research to date. Two small trials have suggested possible benefit of Gingko biloba on vision and further trials are warranted. Ginkgo biloba is widely used in China, Germany, and France. Future trials should be larger, and last longer, in order to provide a more robust measure of the effect of Gingko biloba extract on AMD. Plain language summary Use of Gingko biloba, an extract from the leaves of the maidenhair tree, for slowing the progression of age‐related macular degeneration Age‐related macular degeneration (AMD) is a condition affecting the central area of the retina (the back of the eye). The retina can deteriorate with age and some people get lesions that lead to loss of central vision. Gingko biloba, extracted from the leaves of the maidenhair tree, is used in Chinese herbal medicine to treat a variety of medical conditions, in particular circulatory problems. Ginkgo biloba extract contains two constituents (flavonoids and terpenoids) which have antioxidant properties. It is believed these may help to slow down the progression of AMD. The author identified two small randomised controlled studies (with a total of 119 participants); one in France and one in Germany. One trial compared Gingko biloba to placebo and the other compared two different doses of the extract. Although both trials reported some positive effects of Ginkgo biloba on vision, the trials were small and of short duration. Adverse effects and quality of life were not assessed. The overall conclusion of this review is that current research has not answered the question as to whether Ginkgo biloba is of benefit to people with AMD. Future trials need to include a larger number of participants and be conducted over a longer time.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD001775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "d17c0304-9b47-42de-9666-5773b25e586f", "pmid": "", "title": "Endometrial preparation for women undergoing embryo transfer with frozen embryos or embryos derived from donor oocytes", "imported": false, "abstract": "Abstract - Background A frozen embryo transfer (FET) cycle is when one or more embryos (frozen during a previous treatment cycle) are thawed and transferred to the uterus. Some women undergo fresh embryo transfer (ET) cycles with embryos derived from donated oocytes. In both situations, the endometrium is primed with oestrogen and progestogen in different doses and routes of administration. Objectives To evaluate the most effective endometrial preparation for women undergoing transfer with frozen embryos or embryos from donor oocytes with regard to the subsequent live birth rate (LBR). Search methods The Cochrane Gynaecology and Fertility Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, LILACS, trials registers and abstracts of reproductive societies' meetings were searched in June 2020 together with reference checking and contact with study authors and experts in the field to identify additional studies. Selection criteria Randomised controlled trials (RCTs) evaluating endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. Data collection and analysis We used standard methodological procedures recommended by Cochrane. We analysed all available interventions versus placebo, no treatment, or between each other. The primary review outcome was live birth rate. Secondary outcomes were clinical and multiple pregnancy, miscarriage, cycle cancellation, endometrial thickness and adverse effects. Main results Thirty‐one RCTs (5426 women) were included. Evidence was moderate to very low‐quality: the main limitations were serious risk of bias due to poor reporting of methods, and serious imprecision. Stimulated versus programmed cycle We are uncertain whether a letrozole‐stimulated cycle compared to a programmed cycle, for endometrial preparation, improves LBR (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.49 to 3.26; 100 participants; one study; very low‐quality evidence). Stimulating with follicle stimulating hormone (FSH), letrozole or clomiphene citrate may improve clinical pregnancy rate (CPR) (OR 1.63, 95% CI 1.12 to 2.38; 656 participants; five studies; I 2 = 11%; low‐quality evidence). We are uncertain if they reduce miscarriage rate (MR) (OR 0.79, 95% CI 0.36 to 1.71; 355 participants; three studies; I 2 = 0%; very low‐quality evidence). Endometrial thickness (ET) may be reduced with clomiphene citrate (mean difference(MD) ‐1.04, 95% CI ‐1.59 to ‐0.49; 92 participants; one study; low‐quality evidence). Other outcomes were not reported. Natural versus programmed cycle We are uncertain of the effect from a natural versus programmed cycle for LBR (OR 0.97, 95% CI 0.74 to 1.28; 1285 participants; four studies; I 2 = 0%; very low‐quality evidence) and CPR (OR 0.79, 95% CI 0.62 to 1.01; 1249 participants; five studies; I 2 = 60%; very low‐quality evidence), while a natural cycle probably reduces the cycle cancellation rate (CCR) (OR 0.60, 95% CI 0.44 to 0.82; 734 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and ET. No study reported other outcomes. Transdermal versus oral oestrogens From low‐quality evidence we are uncertain of the effect transdermal compared to oral oestrogens has on CPR (OR 0.86, 95% CI 0.59 to 1.25; 504 participants; three studies; I 2 = 58%) or MR (OR 0.55, 95% CI 0.27 to 1.09; 414 participants; two studies; I 2 = 0%). Other outcomes were not reported. Day of starting administration of progestogen When doing a fresh ET using donated oocytes in a synchronised cycle starting progestogen on the day of oocyte pick‐up (OPU) or the day after OPU, in comparison with recipients that start progestogen the day prior to OPU, probably increases the CPR (OR 1.87, 95% CI 1.13 to 3.08; 282 participants; one study, moderate‐quality evidence). We are uncertain of the effect on multiple pregnancy rate (MPR) or MR. It probably reduces the CCR (OR 0.28, 95% CI 0.11 to 0.74; 282 participants; one study; moderate‐quality evidence). No study reported other outcomes. Gonadotropin‐releasing hormone (GnRH) agonist versus control A cycle with GnRH agonist compared to without may improve LBR (OR 2.62, 95% CI 1.19 to 5.78; 234 participants; one study; low‐quality evidence). From low‐quality evidence we are uncertain of the effect on CPR (OR 1.08, 95% CI 0.82 to 1.43; 1289 participants; eight studies; I 2 = 20%), MR (OR 0.85, 95% CI 0.36 to 2.00; 828 participants; four studies; I 2 = 0%), CCR (OR 0.49, 95% CI 0.21 to 1.17; 530 participants; two studies; I 2 = 0%) and ET (MD ‐0.08, 95% CI ‐0.33 to 0.16; 697 participants; four studies; I 2 = 4%). No study reported other outcomes. Among different GnRH agonists From very low‐quality evidence we are uncertain if cycles among different GnRH agonists improves CPR or MR. No study reported other outcomes. GnRH agonists versus GnRH antagonists GnRH antagonists compared to agonists probably improves CPR (OR 0.62, 95% CI 0.42 to 0.90; 473 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and MPR. No study reported other outcomes. Aspirin versus control From very low‐quality evidence we are uncertain whether a cycle with aspirin versus without improves LBR, CPR, or ET. Steroids versus control From very low‐quality evidence we are uncertain whether a cycle with steroids compared to without improves LBR, CPR or MR. No study reported other outcomes. Authors' conclusions There is insufficient evidence on the use of any particular intervention for endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. In frozen embryo transfers, low‐quality evidence showed that clinical pregnancy rates may be improved in a stimulated cycle compared to a programmed one, and we are uncertain of the effect when comparing a programmed cycle to a natural cycle. Cycle cancellation rates are probably reduced in a natural cycle. Although administering a GnRH agonist, compared to without, may improve live birth rates, clinical pregnancy rates will probably be improved in a GnRH antagonist cycle over an agonist cycle. In fresh synchronised oocyte donor cycles, the clinical pregnancy rate is probably improved and cycle cancellation rates are probably reduced when starting progestogen the day of or day after donor oocyte retrieval. Adequately powered studies are needed to evaluate each treatment more accurately. Plain language summary Endometrial preparation for egg donor recipients or for frozen embryo transfers Review question What is the most effective method for endometrial preparation in women undergoing embryo transfers with frozen embryos or embryos derived from donor oocytes? Background Couples undergo infertility treatments due to male factor, female factors or unexplained infertility. After an unsuccessful fresh embryo transfer cycle, a frozen‐thawed embryo transfer can be performed when frozen embryos are available. Adequate hormonal preparation of the endometrium is of utmost importance for both egg donor and frozen embryo replacement cycles to provide the optimal chances of pregnancy. Many drugs and various modes of administration have been tried by several investigators in order to optimise implantation rates and consequently improve the success rates of the embryo transfer procedures: stimulated cycles (to generate endogenous oestradiol), programmed cycles (administering exogenous oestradiol) or natural cycles (allowing the ovaries to produce oestradiol without stimulation) are some of the options; avoiding spontaneous ovulation with gonadotropin‐releasing hormone (GnRH) agonists and antagonists could have some impact; or using some other drugs such as aspirin or steroids that could potentially enhance the endometrial receptivity were also evaluated. Study characteristics We found 31 randomised controlled trials comparing different interventions such as the dose and route of administration of oestrogens and progestogen, the use of drugs that stop the patient from ovulating prematurely (GnRH agonists), and the use of other medications to improve the endometrium in a total of 5426 women. The evidence is current to June 2020. Key results We are uncertain whether a stimulated cycle (with letrozole) compared to a programmed cycle, for endometrial preparation, improves live birth. The evidence suggests that if the chance of live birth following a programmed cycle is assumed to be 24%, the chance following a stimulated cycle would be between 13% and 51%. We are also uncertain of the impact on miscarriage rate and endometrial thickness. A stimulated cycle may improve clinical pregnancy rate. Data were lacking on multiple pregnancy, cycle cancellation and other adverse effects. We are uncertain whether a natural cycle improves the live birth rate, pregnancy rate, miscarriage rate and endometrial thickness in comparison with a programmed cycle. Data were lacking for all other outcomes. We are uncertain if transdermal (delivered via the skin) oestrogens compared with oral (by mouth) oestrogens improve clinical pregnancy rate and miscarriage rate. Data were lacking for all other outcomes in this comparison. Starting progestogen on the day of the donor oocyte retrieval or the day after probably increases the clinical pregnancy rate and probably reduces the cycle cancellation rate. We are uncertain if it reduces the miscarriage rate. Data were lacking for all other outcomes. A cycle with GnRH agonist compared to without may improve live birth rate. We are uncertain of the effect of a GnRH cycle compared to no GnRH for the outcomes of clinical pregnancy rate, miscarriage rate, and endometrial thickness. No study reported on the other outcomes for this comparison. We are uncertain if any GnRH agonist is better than other: a cycle with daily leuprolide or with deposit tryptorelin improves clinical pregnancy rate, or if daily acetate leuprolide or daily nafarelin reduces the miscarriage rate. Other outcomes were not reported. GnRH antagonists compared to agonists probably improve clinical pregnancy rate. We are uncertain of the effect on miscarriage rate and multiple pregnancy rate. No study reported the other outcomes. We are uncertain whether a cycle with aspirin compared to a cycle without improves live birth, clinical pregnancy rate or endometrial thickness. Data were lacking for all other outcomes. We are also uncertain whether a cycle with steroids compared to a cycle without steroids improves live birth rate, clinical pregnancy rate or miscarriage rate. No study reported on the other outcomes. Quality of the evidence The evidence was of moderate to very low‐quality. The main limitations in the evidence were poor reporting of study methods, and lack of precision in the findings for live birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Glujovsky, D; Pesce, R; Sueldo, C; Quinteiro Retamar, AM; Hart, RJ; Ciapponi, A", "articleTypes": [], "doi": "10.1002/14651858.CD006359.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "d1971bc4-cb73-423b-b3de-be70cd9ed7e6", "pmid": "", "title": "Alarm interventions for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs. Objectives To assess the effects of enuresis alarms for treating enuresis in children. Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old. Data collection and analysis Two review authors independently assessed risk of bias and extracted data. Main results We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) −2.68, 95% confidence interval (CI) −4.59 to −0.78; 4 trials, 127 children; low‐quality evidence). Low‐quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post‐treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low‐quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD −0.96, 95% CI −2.32 to 0.41; 1 trial, 47 children; very low‐quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low‐quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post‐treatment. Compared with control alarms, code‐word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate‐quality evidence) but there is probably little to no difference in the number of children remaining dry post‐treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate‐quality evidence). Very low‐quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry‐bed training, and star chart plus rewards) (MD ‐0.81, 95% CI ‐2.01 to 0.38; low‐quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low‐quality evidence) and may slightly increase the number of children remaining dry post‐treatment (RR 1.39, 95% CI 0.81 to 2.41; low‐quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD −0.64, 95% CI −1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low‐quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post‐treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate‐quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post‐treatment, because the quality of evidence is very low. Due to very low‐quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD −0.88, 95% CI −0.38 to −1.38; 2 trials, 156 children; low‐quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low‐quality evidence) and the number of children remaining dry post‐treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low‐quality evidence) compared with desmopressin alone. Alarm plus dry‐bed training may increase the number of children achieving a complete response compared to dry‐bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low‐quality evidence). It is unclear if there is any difference in the number of children remaining dry post‐treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low‐quality evidence). Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code‐word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate‐quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate‐quality evidence). Very low‐quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments. Authors' conclusions Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately‐powered trials with robust randomisation are still needed to determine the full effect of alarm therapy. Plain language summary Alarm interventions for nocturnal enuresis (bedwetting) in children Review question Is alarm training an effective treatment for bedwetting in children? Background Bedwetting is common in childhood and affects up to 20% of five‐year‐olds. Although children may spontaneously recover from this, bedwetting can have significant social, emotional and psychological effects on the child and their family. Treatments for bedwetting include alarms (activated by urination), behavioural interventions and drugs. How up‐to‐date is this review? The evidence is current up to 25 June 2018. Study characteristics This review includes 74 trials involving 5983 children. Study funding sources Three of the studies included in the review were funded or supported by a pharmaceutical company. Key results Alarms may be better than no treatment in terms of reducing the number of wet nights a week and increasing the number of children achieving 14 consecutive dry nights. Alarms may increase the number of children remaining dry after stopping treatment, compared to no treatment. We are uncertain if there is any difference between alarms and behavioural interventions (such as bladder training), or between alarms and desmopressin medication in terms of reducing the number of wet nights a week, increasing the number of children achieving 14 consecutive dry nights and increasing the number of children remaining dry after stopping treatment. We are uncertain whether alarms reduce the number of wet nights more than placebo drugs, other types of alarms, tricyclics medication, or various treatments such as hypnotherapy or restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin alone. It may increase the number of children achieving 14 consecutive dry nights and increase the number of children remaining dry after stopping treatment. Alarm plus dry‐bed training may increase the number of children achieving 14 consecutive dry nights compared to dry‐bed training alone, but we are uncertain if the response is maintained after stopping treatment. Due to very low‐quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Alarm therapy probably reduces the number of children experiencing adverse events compared with desmopressin. We think there is probably a slight increase in adverse events between code‐word alarms and standard alarms but until we have more evidence from more children we cannot be certain about this. We are uncertain about the safety of alarm therapy compared to other treatments, because the quality of evidence is very low. Quality of the evidence The quality of the evidence means that, in general, the level of certainty in our conclusions is low. Authors' conclusions Alarm therapy may be more effective than no treatment, but due to the low‐quality evidence we do not know how much alarm therapy is more effective than none at all. Adding alarm therapy to desmopressin may be more effective than desmopressin alone. Despite the large number of trials we identified, the low certainty of the evidence means that we cannot tell from these studies whether or not alarm therapy is better than most other therapies for reducing bedwetting in children. We cannot be sure about its effects until there are better‐designed trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Caldwell, PHY, Codarini, M, Stewart, F, Hahn, D, Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002911.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.814Z" }, { "id": "d1ac106b-e39c-4bf3-beb7-ae26a7159e81", "pmid": "", "title": "Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults", "imported": false, "abstract": "Abstract - Background Acetylcholinesterase inhibitors, such as neostigmine, have traditionally been used for reversal of non‐depolarizing neuromuscular blocking agents. However, these drugs have significant limitations, such as indirect mechanisms of reversal, limited and unpredictable efficacy, and undesirable autonomic responses. Sugammadex is a selective relaxant‐binding agent specifically developed for rapid reversal of non‐depolarizing neuromuscular blockade induced by rocuronium. Its potential clinical benefits include fast and predictable reversal of any degree of block, increased patient safety, reduced incidence of residual block on recovery, and more efficient use of healthcare resources. Objectives The main objective of this review was to compare the efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade caused by non‐depolarizing neuromuscular agents in adults. Search methods We searched the following databases on 2 May 2016: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (WebSPIRS Ovid SP), Embase (WebSPIRS Ovid SP), and the clinical trials registries www.controlled‐trials.com , clinicaltrials.gov , and www.centerwatch.com . We re‐ran the search on 10 May 2017. Selection criteria We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published, or language. We included adults, classified as American Society of Anesthesiologists (ASA) I to IV, who received non‐depolarizing neuromuscular blocking agents for an elective in‐patient or day‐case surgical procedure. We included all trials comparing sugammadex versus neostigmine that reported recovery times or adverse events. We included any dose of sugammadex and neostigmine and any time point of study drug administration. Data collection and analysis Two review authors independently screened titles and abstracts to identify trials for eligibility, examined articles for eligibility, abstracted data, assessed the articles, and excluded obviously irrelevant reports. We resolved disagreements by discussion between review authors and further disagreements through consultation with the last review author. We assessed risk of bias in 10 methodological domains using the Cochrane risk of bias tool and examined risk of random error through trial sequential analysis. We used the principles of the GRADE approach to prepare an overall assessment of the quality of evidence. For our primary outcomes (recovery times to train‐of‐four ratio (TOFR) > 0.9), we presented data as mean differences (MDs) with 95 % confidence intervals (CIs), and for our secondary outcomes (risk of adverse events and risk of serious adverse events), we calculated risk ratios (RRs) with CIs. Main results We included 41 studies (4206 participants) in this updated review, 38 of which were new studies. Twelve trials were eligible for meta‐analysis of primary outcomes (n = 949), 28 trials were eligible for meta‐analysis of secondary outcomes (n = 2298), and 10 trials (n = 1647) were ineligible for meta‐analysis. We compared sugammadex 2 mg/kg and neostigmine 0.05 mg/kg for reversal of rocuronium‐induced moderate neuromuscular blockade (NMB). Sugammadex 2 mg/kg was 10.22 minutes (6.6 times) faster then neostigmine 0.05 mg/kg (1.96 vs 12.87 minutes) in reversing NMB from the second twitch (T2) to TOFR > 0.9 (MD 10.22 minutes, 95% CI 8.48 to 11.96; I 2 = 84%; 10 studies, n = 835; GRADE: moderate quality). We compared sugammadex 4 mg/kg and neostigmine 0.07 mg/kg for reversal of rocuronium‐induced deep NMB. Sugammadex 4 mg/kg was 45.78 minutes (16.8 times) faster then neostigmine 0.07 mg/kg (2.9 vs 48.8 minutes) in reversing NMB from post‐tetanic count (PTC) 1 to 5 to TOFR > 0.9 (MD 45.78 minutes, 95% CI 39.41 to 52.15; I 2 = 0%; two studies, n = 114; GRADE: low quality). For our secondary outcomes, we compared sugammadex, any dose, and neostigmine, any dose, looking at risk of adverse and serious adverse events. We found significantly fewer composite adverse events in the sugammadex group compared with the neostigmine group (RR 0.60, 95% CI 0.49 to 0.74; I 2 = 40%; 28 studies, n = 2298; GRADE: moderate quality). Risk of adverse events was 28% in the neostigmine group and 16% in the sugammadex group, resulting in a number needed to treat for an additional beneficial outcome (NNTB) of 8. When looking at specific adverse events, we noted significantly less risk of bradycardia (RR 0.16, 95% CI 0.07 to 0.34; I 2 = 0%; 11 studies, n = 1218; NNTB 14; GRADE: moderate quality), postoperative nausea and vomiting (PONV) (RR 0.52, 95% CI 0.28 to 0.97; I 2 = 0%; six studies, n = 389; NNTB 16; GRADE: low quality) and overall signs of postoperative residual paralysis (RR 0.40, 95% CI 0.28 to 0.57; I 2 = 0%; 15 studies, n = 1474; NNTB 13; GRADE: moderate quality) in the sugammadex group when compared with the neostigmine group. Finally, we found no significant differences between sugammadex and neostigmine regarding risk of serious adverse events (RR 0.54, 95% CI 0.13 to 2.25; I 2 = 0%; 10 studies, n = 959; GRADE: low quality). Application of trial sequential analysis (TSA) indicates superiority of sugammadex for outcomes such as recovery time from T2 to TOFR > 0.9, adverse events, and overall signs of postoperative residual paralysis. Authors' conclusions Review results suggest that in comparison with neostigmine, sugammadex can more rapidly reverse rocuronium‐induced neuromuscular block regardless of the depth of the block. Sugammadex 2 mg/kg is 10.22 minutes (˜ 6.6 times) faster in reversing moderate neuromuscular blockade (T2) than neostigmine 0.05 mg/kg (GRADE: moderate quality), and sugammadex 4 mg/kg is 45.78 minutes (˜ 16.8 times) faster in reversing deep neuromuscular blockade (PTC 1 to 5) than neostigmine 0.07 mg/kg (GRADE: low quality). With an NNTB of 8 to avoid an adverse event, sugammadex appears to have a better safety profile than neostigmine. Patients receiving sugammadex had 40% fewer adverse events compared with those given neostigmine. Specifically, risks of bradycardia (RR 0.16, NNTB 14; GRADE: moderate quality), PONV (RR 0.52, NNTB 16; GRADE: low quality), and overall signs of postoperative residual paralysis (RR 0.40, NNTB 13; GRADE: moderate quality) were reduced. Both sugammadex and neostigmine were associated with serious adverse events in less than 1% of patients, and data showed no differences in risk of serious adverse events between groups (RR 0.54; GRADE: low quality). Plain language summary Benefits and harms of sugammadex versus neostigmine in reversing induced paralysis Background Different levels of induced paralysis are sometimes necessary when patients are put to sleep or are prepared for operations. When the operation is finished, paralysis should be reversed in a fast, reliable, and safe way. Neostigmine is a medication that is traditionally used to reverse induced paralysis. However, its use can be associated with incomplete or slow reversal as well as changes in lung function, heart function, and vomiting and nausea. Sugammadex is a relatively new medication specifically designed to reverse rocuronium‐induced paralysis in a faster, more reliable, and safer way when compared with neostigmine. Objective This review systematically sets out to compare the benefits and harms of sugammadex and neostigmine. The evidence is current up to May 2017. Study characteristics We identified 41 randomized controlled trials comparing sugammadex with neostigmine that provided suitable data on efficacy and safety. All of these trials included adults undergoing surgery and involved a total of 4206 participants. Key results Data indicate that sugammadex was 10.22 minutes (6.6 times) faster than neostigmine (1.96 vs 12.87 minutes) in reversing moderate induced paralysis. Sugammadex was 45.78 minutes (16.8 times) faster than neostigmine (2.9 vs 48.8 minutes) in reversing deep induced paralysis. Participants receiving sugammadex appeared to have a 40% reduced risk of experiencing harmful events than those given neostigmine. Statistically, eight persons can be treated with sugammadex as opposed to neostigmine to avoid one person experiencing a single random harmful event. The occurrence of serious harmful events was nearly non‐existent and data show no differences between compared groups. Conclusion Sugammadex is more efficient and safer than neostigmine for reversing moderate and deep induced paralysis. Quality of evidence We consider our overall findings on benefits and harms to provide evidence of moderate quality in favour of sugammadex.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Hristovska, AM, Duch, P, Allingstrup, M, Afshari, A", "articleTypes": [], "doi": "10.1002/14651858.CD012763", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.776Z" }, { "id": "d1c0ade9-4d23-425a-9738-e3db1ee92d2a", "pmid": "", "title": "Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants", "imported": false, "abstract": "Abstract - Background It is important to institute an effective supportive therapy to maintain or recover soft tissue health around dental implants. Different maintenance regimens have been suggested, however it is unclear which are the most effective. Objectives To assess the effects of different interventions for 1) maintaining and 2) recovering soft tissue health around osseointegrated dental implants. Search methods We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and to an Internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 2 June 2010. Selection criteria All randomised controlled trials comparing agents or interventions for maintaining or recovering healthy tissues around dental implants. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random‐effects models using standardised mean differences for continuous data and risk ratios for dichotomous data with 95% confidence intervals. Main results Five trials compared interventions for maintaining soft tissue health around implants and a further six trials compared interventions to recover soft tissue health where there was evidence of peri‐implant mucositis. No statistically significant differences were found between the effectiveness of powered versus manual toothbrushes for either maintaining or recovering soft tissue health. There was no statistically significant difference found between different types of self administered antimicrobials for maintaining soft tissue health (hyaluronic acid gel compared to chlorhexidine gel, amine fluoride/stannous fluoride mouthwash compared to chlorhexidine mouthwash) and triclosan dentifrice compared to sodium fluoride dentifrice showed no statistically significant difference in recovering soft tissue health. However chlorhexidine irrigation was more effective in reducing plaque and marginal bleeding scores compared to chlorhexidine mouthwash and Listerine mouthwash was found to be statistically significantly better than placebo with regard to reducing mean plaque scores and marginal bleeding scores. When interventions administered by dental professional were compared there was no statistically significant difference found between chlorhexidine and physiologic solutions as irrigants at second stage surgery to maintain health of soft tissues. In patients with peri‐implant mucositis two trials evaluated interventions performed by dental professionals. There was no statistically significant difference between mechanical debridement followed by either minocycline or chlorhexidine gel, or between debridement with a titanium curette compared to an ultrasonic debridement tool. Authors' conclusions There was only low quality evidence for which are the most effective interventions for maintaining or recovering health of peri‐implant soft tissues. The included RCTs had short follow‐up periods and few subjects and although overall the risk of bias of the studies was either low or unclear, only single trials were available for each outcome. There was no reliable evidence as to which regimens are most effective for long term maintenance. This should not be interpreted as meaning that current maintenance regimens are ineffective. There was weak evidence that antibacterial mouthrinses are effective in reducing plaque and marginal bleeding around implants. More RCTs should be conducted in this area. In particular, there is a definite need for trials powered to find possible differences, using primary outcome measures and with much longer follow up. Such trials should be reported according to the CONSORT guidelines ( www.consort‐statement.org/ ). Plain language summary Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants Missing teeth can be replaced by dental implants. However, keeping the gums around the implants healthy is important, as they can be negatively affected by dental plaque and its induced inflammation. Prevention of this may include daily implant cleaning techniques by patients and regular cleaning by dental professionals. Antibacterial mouthrinses may help reduce plaque and bleeding around dental implants, but there is no evidence that powered toothbrushes are better than manual toothbrushes or that brushing with a certain gel or dentifrice is better than another. Among the professionally administered treatments there is no evidence that phosphoric acid is more effective than scaling and polishing, that chlorhexidine enclosed in the inner part of implants is superior to physiologic solution or that a topical antibiotic inserted submucosally is better than a chlorhexidine gel.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Grusovin, MG, Coulthard, P, Worthington, HV, George, P, Esposito, M", "articleTypes": [], "doi": "10.1002/14651858.CD003069.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.731Z" }, { "id": "d1c8c6df-6621-47ba-b27f-650714073a7e", "pmid": "", "title": "Combination Therapies to Reduce the Nasopharyngeal Carriage of SARS-CoV-2 and Improve the Outcome of COVID-19 Infection in Ivory Coast (INTENSE-COV): a Phase IIb Randomized Clinical Trial", "imported": false, "abstract": "In January 2020, the new SARS-CoV-2 coronavirus was identified in China. The disease caused by this coronavirus was named COVID-19 by the World Health Organization (WHO). Since March 11, 2020, the WHO has described the global situation of COVID-19 as a pandemic. In Côte d'Ivoire, as in other African countries, the number of cases is increasing exponentially.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.269Z" }, { "id": "d1f68a3c-4823-4de4-af0e-dd8621d816cf", "pmid": "", "title": "CFTR modulator monotherapy for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a common, life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR gene variant, F508del, is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF) in some populations). The F508del variant lacks meaningful CFTR function: the faulty protein is degraded before reaching the cell membrane, where it would normally transport salt across the epithelial membrane. Corrective therapy with CFTR modulators could benefit many pwCF. This review evaluates treatment with single modulators (monotherapy). Objectives To evaluate the clinically important benefits and harms of CFTR modulator monotherapy in people of any age with cystic fibrosis with class II CFTR gene variants (most commonly F508del). Search methods We last searched the Cochrane CF Trials Register and online trials registries on 27 June 2025. We also checked the reference lists of relevant articles for additional studies. Eligibility criteria We included parallel‐group randomised controlled trials (RCTs) comparing any single CFTR modulator to placebo or any other single CFTR modulator in pwCF of any age or disease severity with class II variants. Outcomes Our critical outcomes were survival, quality of life (total score and respiratory domain), and forced expiratory volume in one second (FEV 1 % predicted; relative and absolute change from baseline). Our important outcomes included adverse effects and time to first pulmonary exacerbation. We planned to assess outcomes in the immediate term, short term, and longer term. Risk of bias We assessed risk of bias using the original Cochrane tool (RoB 1). Synthesis methods We analysed available data with RevMan using a fixed‐effect model. We reported odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. For adverse events, we reported 99% confidence intervals (CIs); for all other outcomes, we reported 95% CIs. Where we were unable to analyse data, we reported the results narratively. We used GRADE to assess the certainty of the evidence. Included studies We included 10 early‐phase placebo‐controlled RCTs (424 participants) assessing eight different drugs (4PBA, CPX, N6022, cavosonstat, lumacaftor, FDL169, GLPG2222, and riociguat) in adults; one 4PBA study additionally included adolescents (age ≥ 14 years). All participants were homozygous for F508del. The longest study lasted just 29 days, so we could only assess immediate‐term outcomes. Only two studies received no funding from pharmaceutical companies. Our main results are for lumacaftor and cavosonstat, which were the only drugs selected for further investigation in subsequent studies. Synthesis of results Investigators reported no deaths, but also no clinically relevant improvements in quality of life. There was insufficient evidence to determine effects on any measure of lung function. No studies demonstrated differences in the risk of mild, moderate, or severe adverse effects, including pulmonary exacerbations, between CFTR modulator monotherapy and placebo. The clinical relevance of adverse effects is difficult to assess, because each occurred in only a few participants per trial. We assessed the certainty of the evidence for two comparisons (lumacaftor versus placebo and cavosonstat versus placebo), rating the certainty of the evidence to be very low. Authors' conclusions There is a lack of evidence to support monotherapy with a CFTR modulator for pwCF who have two F508del variants (F508del/F508del). Funding This review was completed under a programme of work that is part of the CF Foundation grant funding for Cochrane CF. Registration The protocol was registered on PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/view/CRD420251090914 ). Plain language summary Can single‐medicine treatment with CFTR modulators (medicines that correct the faulty protein in cystic fibrosis) help people who have specific genetic variants of cystic fibrosis (most commonly F508del)? Key messages All the studies only included people with two copies of the most common cystic fibrosis‐causing gene variant (F508del). Most studies were entirely or partly funded by medicine companies. No studies reported any deaths. None of the single medicines we looked at were clearly better than placebo (dummy treatment) for improving quality of life or lung function, and there was no evidence of the medicines causing more harm than placebo. However, we are unsure about these results. The evidence for using a single CFTR modulator is weak, and future research is likely to focus on combination therapies. What is cystic fibrosis and how can it be treated? Cystic fibrosis is a serious inherited illness that shortens life. It damages many organs in the body, particularly the lungs, pancreas, and liver. In the lungs, it causes a build‐up of thick, sticky mucus that leads to repeated infections and progressive damage. Most people with cystic fibrosis experience breathing difficulties, poor nutrition, and a reduced quality of life. Cystic fibrosis is caused by a fault in a gene that makes a protein called CFTR. CFTR regulates the movement of salt and water across cell surfaces, keeping the mucus thin and slippery. The most common CFTR gene variant (found in over 80% of people with cystic fibrosis) is F508del, which is a class II variant. People with two copies of F508del usually have more severe disease than people with one copy. In people with class II variants, the CFTR protein is degraded and cannot move properly through the cell. Laboratory experiments suggest that if the protein reaches the cell wall, it may be able to function, restore salt movement, and correct the chronic problems people with cystic fibrosis experience. CFTR modulators are medicines that help the faulty CFTR protein reach the cell wall. What did we want to find out? We wanted to know if CFTR modulator monotherapy (single‐medicine treatment) can help people of any age with cystic fibrosis who have a class II variant. Specifically, we wanted to know if these medicines can improve survival, quality of life, lung function, and time to the first worsening of lung symptoms. We also wanted to know if this treatment is associated with any unwanted effects. What did we do? We searched for studies that investigated the effects of any single CFTR modulator compared with placebo (dummy treatment) or any other single CFTR modulator in people with cystic fibrosis who had at least one copy of a class II variant. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 10 studies (with 424 participants, all of whom had two copies of F508del) assessing eight different medicines given as monotherapy. Nine studies included only adults, and one study included people from age 14 years. All the studies were small (including between 18 and 89 participants) and lasted between one day and 29 days. They took place in North America (mainly the USA), Europe, and Australia. Our main findings are for two of the eight medicines, lumacaftor and cavosonstat, which have gone on to be evaluated in larger populations. Main findings No studies reported any deaths or meaningful improvements in quality of life. We did not find enough evidence to show any effect of CFTR modulators on lung function. The studies reported a wide range of unwanted effects, but each occurred in only a few participants per study. We did not find enough evidence to support using CFTR modulator monotherapy in people with cystic fibrosis who have two copies of F508del. What are the limitations of the evidence? We are not confident in the evidence, for the following reasons. The studies were small. Most results are based on evidence from a single study. The evidence is not applicable to children. Not all studies provided enough data for us to analyse the results. The evidence related to unwanted effects of treatment was based on very few events. How up‐to‐date is this evidence? This review updates our earlier review of single‐ and multiple‐medicine therapy. The evidence is current to 27 June 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Heneghan, M; Smith, S; Jahnke, N; Nevitt, S; Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD016290", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "d20c2069-7737-4006-a339-8ebdafa3982b", "pmid": "", "title": "A Randomized, Double Blind, Placebo-controlled Study to Investigate the Safety, Pharmacodynamics and Effect on Allergic Reactivity of Repeat Intranasal Administration of the TLR7 Agonist GSK2245035 in Subjects With Respiratory Allergies", "imported": false, "abstract": "The purpose of this study is to examine the safety and effects on the immune system of treatment with GSK2245035 in subjects who suffer from nasal symptoms caused by an allergy to pollen or perennial allergen, with or without mild asthma. In addition, the effect of treatment with GSK2245035 on the body's allergic response in test situations will be explored. Approximately 28 subjects will receive GSK2245035 (up to 14 subjects each receiving 80 nanograms [ng] GSK2245035 and up to 14 subjects each receiving 20 ng GSK2245035) and 14 subjects will receive the dummy drug (placebo) during the study. Assignment of a subject to GSK2245035 or placebo will be done by chance, like flipping a coin. Neither the subjects nor the clinic staff will know whether a subject is being dosed with GSK2245035 or placebo during the course of the study. The study will include (a) Screening phase where the eligibility of subjects for enrolment will be assessed (b) Treatment phase during which subjects will receive either 8 nasal sprays of GSK2245035 80 ng or a matching placebo once weekly for 8 weeks (each dose will be split between the two nostrils). Subjects participating in this study in 2014 will receive a reduced dose of 20 ng i.n. of GSK2245035 once weekly for eight administrations (c) Follow-up period where any GSK2245035 induced changes to the immune system and the effect of treatment on the body's allergic response in test situations will be monitored. The maximum planned study duration for all subjects, including the screening, treatment and follow-up periods, is approximately 180 days.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.261Z" }, { "id": "d21031c8-f2d5-4f2c-99e3-18819599ce61", "pmid": "", "title": "Fish oil for induction of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Fish oil supplements, which are rich in n‐3 fatty acids, may reduce inflammation, decrease the need for anti‐inflammatory drugs, and promote normal weight gain in people with ulcerative colitis. Objectives This review evaluates the efficacy of fish oil for induction of remission in ulcerative colitis using all available randomised controlled trials. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, EMBASE, CINAHL, the database of ongoing trials and the reference lists of all publications of included or excluded trials were searched. Selection criteria Randomised controlled trials and quasi‐randomised controlled trials with active ulcerative colitis patients who were treated with fish oil. Data collection and analysis The reviewers performed study selection, assessment of methodological quality by using different approaches: including Cochrane assessment of allocation concealment and Jadad quality assessment score. Data extraction forms were used by the two reviewers to extract the data independently. Authors were contacted for additional information. Main results Six studies were included. Three were of cross‐over design and three were of parallel design. No data were pooled for analysis due to differences in outcomes and methodology among the included studies. One small study shows a positive benefit for induction of remission (RR 19.00; 95% CI 1.27 to 284.24). Some of the other included studies show some positive benefits for secondary outcomes. However, these results need to be interpreted with caution due to small study size and poor study quality. Authors' conclusions The current data does not allow for a definitive conclusion regarding the efficacy of fish oil. There is no adequate information to make recommendations for clinical practice. More research is required. Plain language summary Fish oil for the treatment of active ulcerative colitis Ulcerative colitis is an inflammation of the large intestine that causes diarrhea, abdominal pain, rectal bleeding and fever. Since there is no cure for the disease the aim of treatment is to cause a reduction of the unpleasant and painful signs and symptoms. Current, proven, treatment options for active ulcerative colitis include corticosteroids, aminosalicylates, immunosuppressive and biological agents. However, these drugs can cause side effects. New treatments which cause fewer side effects are being sought. Fish oil, which is rich in omega‐3 fatty acids may reduce inflammation and decrease the need for anti‐inflammatory drugs in patients with ulcerative colitis. Six studies looking at the effects of fish oil in active ulcerative colitis were included in the review. Study quality was mostly poor. One small study showed a positive benefit for the treatment of active ulcerative colitis. However, this result should be interpreted with caution due to small study size and poor study quality. Due to limited data there is not enough information available to determine whether fish oil treatment is effective for induction of remission in ulcerative colitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "De Ley, M, de Vos, R, Hommes, DW, Stokkers, PC", "articleTypes": [], "doi": "10.1002/14651858.CD005986.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.733Z" }, { "id": "d21381cb-885e-41c7-863e-b7910c8bf840", "pmid": "", "title": "Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries", "imported": false, "abstract": "Abstract - Background Dental caries (tooth decay) and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health services. Decay and gum disease can cause pain, eating and speaking difficulties, low self‐esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self‐administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area. Objectives To evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other. Search methods Cochrane Oral Health’s Information Specialist searched: Cochrane Oral Health’s Trials Register (to 16 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 12), MEDLINE Ovid (1946 to 16 January 2019), Embase Ovid (1980 to 16 January 2019) and CINAHL EBSCO (1937 to 16 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication. Selection criteria Randomised controlled trials (RCTs) that compared toothbrushing and a home‐use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks). Data collection and analysis At least two review authors independently screened searches, selected studies, extracted data, assessed studies' risk of bias, and assessed evidence certainty as high, moderate, low or very low, according to GRADE. We extracted indices measured on interproximal surfaces, where possible. We conducted random‐effects meta‐analyses, using mean differences (MDs) or standardised mean differences (SMDs). Main results We included 35 RCTs (3929 randomised adult participants). Studies were at high risk of performance bias as blinding of participants was not possible. Only two studies were otherwise at low risk of bias. Many participants had a low level of baseline gingival inflammation. Studies evaluated the following devices plus toothbrushing versus toothbrushing: floss (15 trials), interdental brushes (2 trials), wooden cleaning sticks (2 trials), rubber/elastomeric cleaning sticks (2 trials), oral irrigators (5 trials). Four devices were compared with floss: interdental brushes (9 trials), wooden cleaning sticks (3 trials), rubber/elastomeric cleaning sticks (9 trials) and oral irrigators (2 trials). Another comparison was rubber/elastomeric cleaning sticks versus interdental brushes (3 trials). No trials assessed interproximal caries, and most did not assess periodontitis. Gingivitis was measured by indices (most commonly, Löe‐Silness, 0 to 3 scale) and by proportion of bleeding sites. Plaque was measured by indices, most often Quigley‐Hein (0 to 5). Primary objective: comparisons against toothbrushing alone Low‐certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index (GI)) at one month (SMD ‐0.58, 95% confidence interval (CI) ‐1.12 to ‐0.04; 8 trials, 585 participants), three months or six months. The results for proportion of bleeding sites and plaque were inconsistent (very low‐certainty evidence). Very low‐certainty evidence suggested that using an interdental brush, plus toothbrushing, may reduce gingivitis (measured by GI) at one month (MD ‐0.53, 95% CI ‐0.83 to ‐0.23; 1 trial, 62 participants), though there was no clear difference in bleeding sites (MD ‐0.05, 95% CI ‐0.13 to 0.03; 1 trial, 31 participants). Low‐certainty evidence suggested interdental brushes may reduce plaque more than toothbrushing alone (SMD ‐1.07, 95% CI ‐1.51 to ‐0.63; 2 trials, 93 participants). Very low‐certainty evidence suggested that using wooden cleaning sticks, plus toothbrushing, may reduce bleeding sites at three months (MD ‐0.25, 95% CI ‐0.37 to ‐0.13; 1 trial, 24 participants), but not plaque (MD ‐0.03, 95% CI ‐0.13 to 0.07). Very low‐certainty evidence suggested that using rubber/elastomeric interdental cleaning sticks, plus toothbrushing, may reduce plaque at one month (MD ‐0.22, 95% CI ‐0.41 to ‐0.03), but this was not found for gingivitis (GI MD ‐0.01, 95% CI ‐0.19 to 0.21; 1 trial, 12 participants; bleeding MD 0.07, 95% CI ‐0.15 to 0.01; 1 trial, 30 participants). Very‐low certainty evidence suggested oral irrigators may reduce gingivitis measured by GI at one month (SMD ‐0.48, 95% CI ‐0.89 to ‐0.06; 4 trials, 380 participants), but not at three or six months. Low‐certainty evidence suggested that oral irrigators did not reduce bleeding sites at one month (MD ‐0.00, 95% CI ‐0.07 to 0.06; 2 trials, 126 participants) or three months, or plaque at one month (SMD ‐0.16, 95% CI ‐0.41 to 0.10; 3 trials, 235 participants), three months or six months, more than toothbrushing alone. Secondary objective: comparisons between devices Low‐certainty evidence suggested interdental brushes may reduce gingivitis more than floss at one and three months, but did not show a difference for periodontitis measured by probing pocket depth. Evidence for plaque was inconsistent. Low‐ to very low‐certainty evidence suggested oral irrigation may reduce gingivitis at one month compared to flossing, but very low‐certainty evidence did not suggest a difference between devices for plaque. Very low‐certainty evidence for interdental brushes or flossing versus interdental cleaning sticks did not demonstrate superiority of either intervention. Adverse events Studies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation. Authors' conclusions Using floss or interdental brushes in addition to toothbrushing may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low‐certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis. Plain language summary Home use of devices for cleaning between the teeth (in addition to toothbrushing) to prevent and control gum diseases and tooth decay Review question How effective are home‐use interdental cleaning devices, plus toothbrushing, compared with toothbrushing only or use of another device, for preventing and controlling periodontal (gum) diseases (gingivitis and periodontitis), tooth decay (dental caries) and plaque? Background Tooth decay and gum diseases affect most people. They can cause pain, difficulties with eating and speaking, low self‐esteem, and, in extreme cases, may lead to tooth loss and the need for surgery. The cost to health services of treating these diseases is very high. As dental plaque (a layer of bacteria in an organic matrix that forms on the teeth) is the root cause, it is important to remove plaque from teeth on a regular basis. While many people routinely brush their teeth to remove plaque up to the gum line, it is difficult for toothbrushes to reach into areas between teeth ('interdental'), so interdental cleaning is often recommended as an extra step in personal oral hygiene routines. Different tools can be used to clean interdentally, such as dental floss, interdental brushes, tooth cleaning sticks, and water pressure devices known as oral irrigators. Study characteristics Review authors working with Cochrane Oral Health searched for studies up to 16 January 2019. We identified 35 studies (3929 adult participants). Participants knew that they were in an experiment, which might have affected their teeth cleaning or eating behaviour. Some studies had other problems that might make their findings less reliable, such as people dropping out of the study or not using the assigned device. Studies evaluated the following devices plus toothbrushing compared to toothbrushing only: floss (15 studies), interdental brushes (2 studies), wooden cleaning sticks (2 studies), rubber/elastomeric cleaning sticks (2 studies) and oral irrigators (5 studies). Four devices were compared with floss: interdental brushes (9 studies), wooden cleaning sticks (3 studies), rubber/elastomeric cleaning sticks (9 studies), oral irrigators (2 studies). Three studies compared rubber/elastomeric cleaning sticks with interdental brushes. No studies evaluated decay, and few evaluated severe gum disease. Outcomes were measured at short (one month to six weeks) and medium term (three and six months). Key results We found that using floss, in addition to toothbrushing, may reduce gingivitis in the short and medium term. It is unclear if it reduces plaque. Using an interdental brush, in addition to a toothbrush, may reduce gingivitis and plaque in the short term. Using wooden tooth cleaning sticks may be better than toothbrushing only for reducing gingivitis (measured by bleeding sites) but not plaque in the medium term (only 24 participants). Using a tooth cleaning stick made of rubber or an elastomer may be better than toothbrushing only for reducing plaque but not gingivitis in the short term (only 30 participants). Toothbrushing plus oral irrigation (water pressure) may reduce gingivitis in the short term, but there was no evidence for this in the medium term. There was no evidence of a difference in plaque. Interdental brushes may be better than flossing for gingivitis at one and three months. The evidence for plaque is inconsistent. There was no evidence of a difference between the devices for periodontitis measured by probing pocket depth. There is some evidence that oral irrigation may be better than flossing for reducing gingivitis (but not plaque) in the short term. The available evidence for interdental cleaning sticks did not show them to be better or worse than floss or interdental brushes for controlling gingivitis or plaque. The studies that measured 'adverse events' found no serious effects and no evidence of differences between study groups in minor effects such as gum irritation. Certainty of the evidence The evidence is low to very low‐certainty. The effects observed may not be clinically important. Studies measured outcomes mostly in the short term and many participants had a low level of gum disease at the beginning of the studies. Future research Future studies should use the new periodontal diseases classification to describe the gum health of participants, and they should last long enough to measure periodontitis and tooth decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Worthington, HV, MacDonald, L, Poklepovic Pericic, T, Sambunjak, D, Johnson, TM, Imai, P, Clarkson, JE", "articleTypes": [], "doi": "10.1002/14651858.CD012018.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.813Z" }, { "id": "d22093a3-6ae5-4ec9-9f1c-c9bef5da1105", "pmid": "", "title": "Lasers for caries removal in deciduous and permanent teeth", "imported": false, "abstract": "Abstract - Background Despite considerable improvements in oral health, dental caries continue to be a public health issue. The most frequently used, and universally accepted technique, to remove caries is through mechanical ablation of decayed tissues by means of rotating drills (diamond or tungsten carbide, or both). In the past few decades, the introduction of adhesive filling materials (resin composites) has affected cavity filling procedures by reducing its retention needs, with advantages for dental tissue conservation. Consequently, new minimally invasive strategies were introduced into dental practice, such as the use of lasers to perform highly controlled tissue ablation. Laser use has also raised expectations of limiting pain and discomfort compared to using drills, as well as overcoming drill phobia. Objectives The main objective of the review was to compare the effects of laser‐based methods to conventional mechanical methods for removing dental caries in deciduous and permanent teeth. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (searched 22 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 22 June 2016), MEDLINE Ovid (1946 to 22 June 2016), Embase Ovid (1980 to 22 June 2016), ProQuest Dissertations and Theses (1980 to 22 June 2016), Zetoc (limited to conference proceedings) (1993 to 22 June 2016), and ISI Web of Knowledge (limited to conference proceedings) (1990 to 22 June 2016). We checked the reference lists of relevant articles to identify additional studies. We searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. Selection criteria We included randomised controlled trials, split‐mouth trials and cluster‐randomised trials (irrespective of their language) comparing laser therapy to drill ablation of caries. We included participants of any age (children, adolescents and adults). Data collection and analysis Two review authors independently screened titles and abstracts of citations identified by the review search strategy. Two review authors independently evaluated the full text of relevant primary studies, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. Main results We included nine randomised trials, published between 1998 and 2014, involving 662 participants. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Four studies examined only permanent teeth, and five studies evaluated both deciduous and permanent teeth. Six trials used Er:YAG (erbium‐doped yttrium aluminium garnet) lasers, two trials employed Er,Cr:YSGG (erbium, chromium: yttrium‐scandium‐gallium‐garnet) lasers, and one trial used Nd:YAG (neodymium‐doped yttrium aluminium garnet) laser. Overall, the trials had small sample sizes, and the majority were at unclear or high risk of bias. The primary outcomes were evaluated in a limited number of trials (removal of caries (four trials (but only two reported quantitative data)); episodes of pain (five studies)). There was insufficient evidence to suggest that either lasers or drill were better at caries removal (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.99 to 1.01; 2 studies; 256 treated caries; P = 0.75; I 2 = 0%; low‐quality evidence). The incidence of moderate or high pain was greater in the drill group compared to the laser group (RR 0.40, 95% CI 0.28 to 0.57; 2 studies; 143 participants; P < 0.001; I 2 = 50%). Similarly, the need for anaesthesia was significantly higher in the drill group than in the laser group (RR 0.25, 95% CI 0.10 to 0.65; 3 studies; 217 children/adolescents; P = 0.004; I 2 = 0%). In terms of marginal integrity of restoration, there was no evidence of a difference between laser and drill comparisons evaluated at 6 months (RR 1.00, 95% CI 0.21 to 4.78; 3 studies), 1 year (RR 1.59, 95% CI 0.34 to 7.38; 2 studies), or 2 years (RR 1.00, 95% CI 0.21 to 4.74; 1 study). There was no evidence of a difference for durability of restoration between laser therapy or drill at 6 months' follow‐up (RR 2.40, 95% CI 0.65 to 8.77; 4 studies), at 1 year (RR 1.40, 95% CI 0.29 to 6.78; 2 studies) or at 2 years' follow‐up (RR 0.50, 95% CI 0.02 to 14.60; 1 study). Only two trials investigated the recurrence of caries, but no events occurred during 6 months' follow‐up. There was insufficient evidence of a difference between laser or drill in terms of pulpal inflammation or necrosis at 1 week (RR 1.51, 95% CI 0.26 to 8.75; 3 studies) and at 6 months (RR 0.99, 95% CI 0.10 to 9.41; 2 studies). Authors' conclusions Given the low quality of the body of evidence, we concluded that evidence was insufficient to support the use of laser as an alternative to traditional drill therapy for caries removal. We found some evidence in favour of laser therapy for pain control, need of anaesthesia and patient discomfort, but, again, the body of evidence was of low quality. Additional well‐designed, randomised trials investigating the most relevant outcomes are needed. Plain language summary Lasers for the removal of decay in first and permanent teeth Review question This review addressed the issue of whether there is an advantage to laser therapy for the removal of decay in teeth and patient pain, compared to a traditional drill, in children, adolescents and adults. Background Dental decay is a cavity formation in teeth resulting from the destruction of dental tissue caused by bacteria under certain conditions, including poor oral hygiene and excessive sugar intake. Symptoms may include pain and difficulty with eating, and complications may include tooth loss, infection or inflammation of the gum. Rotating drills are traditionally used to remove decay. However, this mechanical tool may have unexpected side effects, such as the removal of too much or too little decay, in addition to discomfort due to pain, noise and vibration. Laser therapy is a potential alternative to a mechanical drill. Study characteristics Cochrane Oral Health provided the search strategies and carried out the search in several electronic databases. We selected nine randomised trials for inclusion in this review that were conducted between 1998 and 2014. The evidence in the review is up to date as of 22 June 2016. The trials involved a total of 662 participants, with 1498 teeth treated. Three studies were conducted in the USA, one in Taiwan, one in China, one in Bulgaria, one in Germany, one in Turkey and one in the UK. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Key results Despite the number of included studies, only a few trials adequately and completely reported information on the primary outcomes. Two trials reported on removal of decay, and there was not enough evidence to conclude that either lasers or drills were better at decay removal. Only five trials reported on episodes of pain, which was significantly reduced in people treated with lasers. There was no difference in terms of side effects, such as inflammation or death of dental pulp, between the two interventions. Quality of the evidence The overall quality of the evidence for the nine studies was low. Only one study adequately randomised participants, and none of the included studies was at low risk of bias. This review highlights the need for high‐quality studies comparing laser therapy and mechanical drills in the treatment of dental decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Montedori, A, Abraha, I, Orso, M, D'Errico, PG, Pagano, S, Lombardo, G", "articleTypes": [], "doi": "10.1002/14651858.CD010229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.073Z" }, { "id": "d2291bac-4ff2-4294-a0e2-e3d6692e406c", "pmid": "", "title": "Management of gag reflex for patients undergoing dental treatment", "imported": false, "abstract": "Abstract - Background The gag reflex is an involuntary defence mechanism to protect the pharynx and throat from foreign objects. Gagging is a common problem encountered during dental treatment, making therapeutic procedures distressing and often difficult or even impossible to perform. Various interventions can be used to control the gag reflex: anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behavioural therapies, acupressure, acupuncture, laser, and prosthetic devices. This is an update of the Cochrane Review first published in 2015. Objectives To assess the effects of pharmacological and non‐pharmacological interventions for the management of gagging in people undergoing dental treatment. Search methods Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register (to 18 March 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2) in the Cochrane Library (searched 18 March 2019), MEDLINE Ovid (1946 to 18 March 2019), Embase Ovid (1980 to 18 March 2019), CINAHL EBSCO (1937 to 18 March 2019), AMED Ovid (1985 to 18 March 2019), and the proceedings of the International Association for Dental Research (IADR) online (2001 to 18 March 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We also conducted forwards citation searching on the included studies via Google Scholar. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs), involving people who were given a pharmacological or non‐pharmacological intervention to manage gagging that interfered with dental treatment. We excluded quasi‐RCTs. We excluded trials with participants who had central or peripheral nervous system disorders, who had oral lesions or were on systemic medications that might affect the gag sensation, or had undergone surgery which might alter anatomy permanently. Data collection and analysis We independently selected trials, extracted data, and assessed risk of bias. We followed Cochrane's statistical guidelines. We assessed the overall certainty of the evidence using GRADE. Main results We included four trials at unclear risk of bias with 328 participants (263 adults and 65 children who were four years or older), in which one trial compared acupuncture and acupressure (with thumb, device and sea band) at P6 (point located three‐finger breadths below the wrist on the inner forearm in between the two tendons) to sham acupuncture and acupressure with and without sedation. One trial compared acupuncture at P6 point to sham acupuncture. These trials reported both completion of dental procedure and reduction in gagging (assessor and patient reported) as their outcomes. One cross‐over and one split‐mouth trial studied the effect of laser at P6 point compared to control. One trial reported reduction in gagging and another reported presence or absence of gagging during dental procedure. Acupuncture at P6 showed uncertain evidence regarding the successful completion of dental procedure (RR 1.78, 95% CI 1.05 to 3.01; two trials, 59 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 2.57, 95% CI 1.12 to 5.89; one trial, 26 participants; very low‐certainty evidence) in comparison to sham acupuncture. Acupuncture at P6 with sedation did not show any difference when compared to sham acupuncture with sedation (RR 1.08, 95% CI 0.91 to 1.28; one trial, 34 participants; very low‐certainty evidence). Acupressure using thumb pressure with or without sedation showed no clear difference in completing dental procedure (RR 0.96, 95% CI 0.84 to 1.10; one trial, 39 participants; very low‐certainty evidence; and RR 0.85, 95% CI 0.50 to 1.46; one trial, 30 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 1.06, 95% CI 0.92 to 1.23; one trial, 39 participants; very low‐certainty evidence; and RR 0.92, 95% CI 0.60 to 1.41; one trial, 30 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Acupressure at P6 with device showed uncertain evidence regarding the successful completion of dental procedure (RR 2.63, 95% CI 1.33 to 5.18; one trial, 34 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 3.94, 95% CI 1.63 to 9.53; one trial, 34 participants; very low‐certainty evidence) when compared to sham acupressure. However, device combined with sedation showed no difference for either outcome (RR 1.16, 95% CI 0.90 to 1.48; one trial, 27 participants; very low‐certainty evidence; and RR 1.26, 95% CI 0.93 to 1.69; one trial, 27 participants; very low‐certainty evidence; respectively). Acupressure using a sea band with or without sedation showed no clear difference in completing dental procedure (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 1.80, 95% CI 0.63 to 5.16; one trial, 19 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 2.70, 95% CI 0.72 to 10.14; one trial, 19 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Laser at P6 showed a difference in absence of gagging (odds ratio (OR) 86.33, 95% CI 29.41 to 253.45; one trial, 40 participants; very low‐certainty evidence) and reduction in gagging (MD 1.80, 95% CI 1.53 to 2.07; one trial, 25 participants; very low‐certainty evidence) during dental procedure when compared to dummy laser application. No noteworthy adverse effects were reported. For acupuncture at P6, the trial authors were unsure whether the reported adverse effects were due to participant anxiety or due to the intervention. None of the trials on acupressure or laser reported on this outcome. We did not find trials evaluating any other interventions used to manage gagging in people undergoing dental treatment. Authors' conclusions We found very low‐certainty evidence from four trials that was insufficient to conclude if there is any benefit of acupuncture, acupressure or laser at P6 point in reducing gagging and allowing successful completion of dental procedures. We did not find any evidence on any other interventions for managing the gag reflex during dental treatment. More well‐designed and well‐reported trials evaluating different interventions are needed. Plain language summary Management of gagging in dental patients Review question With this Cochrane Review we tried to find out the best way to manage gagging in people having dental treatment. Background The gag reflex is a normal process to protect the throat and airway from foreign objects and prevent choking. Many people have an exaggerated gag reflex that causes distress during dental treatment. This can make it difficult or even impossible to perform the treatment. The interventions used to manage gagging include anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behaviour therapy and cognitive behaviour therapy, acupressure, acupuncture, laser, and prosthetic devices. We wanted to know how effective and safe these interventions are in helping people complete their dental treatment with less gagging. We compared them to no intervention or a placebo or to other interventions. Study characteristics This review is up‐to‐date as of 18 March 2019. We included four trials with 328 people (263 adults and 65 children who were 4 years or older). These people had nausea before when having dental treatment that caused the treatment to be stopped or not carried out properly. Key results Acupuncture at P6 point (a point located in the inside of the wrist) showed uncertain evidence regarding the successful completion of dental treatment and reduction in gagging when compared to sham (fake) acupuncture. The same intervention with sedation did not show a difference. Acupressure (with thumb or sea band (bands that fit around the wrist just like a sweat band with a pressure stud sewn inside)) at P6 point with or without sedation did not show any difference when compared to sham acupressure. Acupressure at P6 point with device showed a difference in completing dental treatment and reduction in gagging. It did not show a difference when combined with sedation. Laser at P6 point showed a difference in absence of gagging and reduction in gagging during dental treatment when compared to sham laser application. The included studies did not report any important harmful effects of the treatment. Certainty of the evidence The level of belief we have in these findings is very low. This was due to unclear risk of bias and the small number of people studied in the four included trials. Conclusion We do not have enough evidence to say which intervention works better to manage gagging in people having dental treatment. We suggest that more well‐conducted studies should be done in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Eachempati, P, Kumbargere Nagraj, S, Kiran Kumar Krishanappa, S, George, RP, Soe, HH, Karanth, L", "articleTypes": [], "doi": "10.1002/14651858.CD011116.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.075Z" }, { "id": "d2467927-6c59-48ed-bcbb-c42027ac9a29", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 2. Less commonly‐used drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of mainly cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres (˜ 8200 feet). Acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude ascent. In this second review, in a series of three about preventive strategies for HAI, we assessed the effectiveness of five of the less commonly used classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of five of the less commonly used pharmacological interventions for preventing acute HAI in participants who are at risk of developing high altitude illness in any setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in May 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text search terms. We scanned the reference lists and citations of included trials and any relevant systematic reviews that we identified for further references to additional trials. Selection criteria We included randomized controlled trials conducted in any setting where one of five classes of drugs was employed to prevent acute HAI: selective 5‐hydroxytryptamine(1) receptor agonists; N‐methyl‐D‐aspartate (NMDA) antagonist; endothelin‐1 antagonist; anticonvulsant drugs; and spironolactone. We included trials involving participants who are at risk of developing high altitude illness (AMS or HACE, or HAPE, or both). We included participants with and without a history of high altitude illness. We applied no age or gender restrictions. We included trials where the relevant medication was administered before the beginning of ascent. We excluded trials using these drugs during ascent or after ascent. Data collection and analysis We used the standard methodological procedures employed by Cochrane. Main results We included eight studies (334 participants, 9 references) in this review. Twelve studies are ongoing and will be considered in future versions of this review as appropriate. We have been unable to obtain full‐text versions of a further 12 studies and have designated them as 'awaiting classification'. Four studies were at a low risk of bias for randomization; two at a low risk of bias for allocation concealment. Four studies were at a low risk of bias for blinding of participants and personnel. We considered three studies at a low risk of bias for blinding of outcome assessors. We considered most studies at a high risk of selective reporting bias. We report results for the following four main comparisons. Sumatriptan versus placebo (1 parallel study; 102 participants) Data on sumatriptan showed a reduction of the risk of AMS when compared with a placebo (risk ratio (RR) = 0.43, CI 95% 0.21 to 0.84; 1 study, 102 participants; low quality of evidence). The one included study did not report events of HAPE, HACE or adverse events related to administrations of sumatriptan. Magnesium citrate versus placebo (1 parallel study; 70 participants) The estimated RR for AMS, comparing magnesium citrate tablets versus placebo, was 1.09 (95% CI 0.55 to 2.13; 1 study; 70 participants; low quality of evidence). In addition, the estimated RR for loose stools was 3.25 (95% CI 1.17 to 8.99; 1 study; 70 participants; low quality of evidence). The one included study did not report events of HAPE or HACE. Spironolactone versus placebo (2 parallel studies; 205 participants) Pooled estimation of RR for AMS was not performed due to considerable heterogeneity between the included studies (I² = 72%). RR from individual studies was 0.40 (95% CI 0.12 to 1.31) and 1.44 (95% CI 0.79 to 2.01; very low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Acetazolamide versus spironolactone (1 parallel study; 232 participants) Data on acetazolamide compared with spironolactone showed a reduction of the risk of AMS with the administration of acetazolamide (RR = 0.36, 95% CI 0.18 to 0.70; 232 participants; low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Authors' conclusions This Cochrane Review is the second in a series of three providing relevant information to clinicians and other interested parties on how to prevent high altitude illness. The assessment of five of the less commonly used classes of drugs suggests that there is a scarcity of evidence related to these interventions. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Overall, the evidence is limited due to the low number of studies identified (for most of the comparison only one study was identified); limitations in the quality of the evidence (moderate to low); and the number of studies pending classification (24 studies awaiting classification or ongoing). We lack the large and methodologically sound studies required to establish or refute the efficacy and safety of most of the pharmacological agents evaluated in this review. Plain language summary Medicines less commonly used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and lung conditions that can occur during travel to altitudes above 2500 metres (˜ 8200 feet). HAI‐related conditions are generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but primarily affect the brain (drowsiness, confusion or unconsciousness) or the lungs (cough, breathlessness) in different individuals. We assessed five classes of medicines less commonly used to prevent the onset of this illness in this review. Study characteristics The evidence is current to May 2017. We included eight studies and 334 participants related to five different classes of medicines sometimes recommended for HAI prevention. These medicines included those that mimic the action of serotonin at selected sites (selective 5‐hydroxytryptamine(1) receptor agonists), medicines that regulate the action of calcium (N‐methyl‐D‐aspartate (NMDA) antagonist), medicines that promote dilation of the blood vessels (endothelin‐1 antagonist), medicines that prevent a neuron (nerve cell) from 'firing' (initiating an action) and convulsions from developing (anticonvulsant medicines), as well as medicines that regulate the body´s sodium and water levels (spironolactone). All studies were undertaken in high altitude mountain areas. The participants ranged between 16 and 65 years of age. Only one study included people at a high risk of this condition due to their history of HAI. Four trials provided the intervention between one to three days prior to the ascent (50%), and three trials less than 24 hours prior (37.5%). The participants in all these studies reached a final altitude of between 3500 and 5895 metres above sea level. Only one of the eight included studies did not provide clear information about the source of funding (12.5%). Twenty‐four additional studies were classified as ongoing (12), or awaiting classification (12; unable to obtain full texts). Key results The assessment of the less commonly used pharmacological interventions suggest that there is a scarcity of evidence related to these interventions. For most of the assessed comparisons, we only found evidence from a single study. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Quality of the evidence The quality of the evidence was rated from low to very low. Several studies had quality shortcomings such as only having small sample sizes and therefore generating uncertain results. For most of the medicines evaluated, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Gonzalez Garay, AG, Molano Franco, D, Nieto Estrada, VH, Martí‐Carvajal, AJ, Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD012983", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.764Z" }, { "id": "d24cac30-2c71-4bed-a0d6-52973c0ba9b9", "pmid": "", "title": "Triptans for acute cluster headache", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 ( Law 2010 ). Cluster headache is an uncommon, severely painful, and disabling condition, with rapid onset. Validated treatment options are limited; first‐line therapy includes inhaled oxygen. Other therapies such as intranasal lignocaine and ergotamine are not as commonly used and are less well studied. Triptans are successfully used to treat migraine attacks and they may also be useful for cluster headache. Objectives To assess the efficacy and tolerability of the triptan class of drugs compared to placebo and other active interventions in the acute treatment of episodic and chronic cluster headache in adult patients. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ClinicalTrials.gov, and reference lists for studies from inception to 22 January 2010 for the original review, and from 2009 to 4 April 2013 for this update. Selection criteria Randomised, double‐blind, placebo‐controlled studies of triptans for acute treatment of cluster headache episodes. Data collection and analysis Two review authors independently assessed study quality and extracted data. Numbers of participants with different levels of pain relief, requiring rescue medication, and experiencing adverse events and headache‐associated symptoms in treatment and control groups were used to calculate relative risk and numbers needed to treat for benefit (NNT) and harm (NNH). Main results New searches in 2013 did not identify any relevant new studies. All six included studies used a single dose of triptan to treat an attack of moderate to severe pain intensity. Subcutaneous sumatriptan was given to 131 participants at a 6 mg dose, and 88 at a 12 mg dose. Oral or intranasal zolmitriptan was given to 231 participants at a 5 mg dose, and 223 at a 10 mg dose. Placebo was given to 326 participants. Triptans were more effective than placebo for headache relief and pain‐free responses. By 15 minutes after treatment with subcutaneous sumatriptan 6 mg, 48% of participants were pain‐free and 75% had no pain or mild pain (17% and 32% respectively with placebo). NNTs for subcutaneous sumatriptan 6 mg were 3.3 (95% CI 2.4 to 5.0) and 2.4 (1.9 to 3.2) respectively. Intranasal zolmitriptan 10 mg was of less benefit, with 12% of participants pain‐free and 28% with no or mild pain (3% and 7% respectively with placebo). NNTs for intranasal zolmitriptan 10 mg were 11 (6.4 to 49) and 4.9 (3.3 to 9.2) respectively. Authors' conclusions Based on limited data, subcutaneous sumatriptan 6 mg was superior to intranasal zolmitriptan 5 mg or 10 mg for rapid (15 minute) responses, which are important in this condition. Oral routes of administration are not appropriate. Plain language summary Triptans for acute cluster headache Cluster headaches are excruciating headaches of extreme intensity. They can last for several hours, are usually on one side of the head only, and affect men more than women. Multiple headaches can occur over several days. Fast pain relief is important because of the intense nature of the pain with cluster headache. Triptans are a type of drug used to treat migraine. Although migraine is different from cluster headache, there are reasons to believe that some forms of these drugs could be useful in cluster headache. Triptans can be given by injection under the skin (subcutaneously) or by a spray into the nose (intranasally) to produce fast pain relief. The review found six studies examining two different triptans. The number of people in the studies was limited. Within 15 minutes of using subcutaneous sumatriptan 6 mg, almost 8 in 10 participants had no worse than mild pain, and 5 in 10 were pain‐free. Within 15 minutes of using intranasal zolmitriptan 5 mg, about 3 in 10 had no worse than mild pain, and 1 in 10 was pain‐free. Adverse events were more common with a triptan than with placebo but they were generally of mild to moderate severity. Cluster headache is an awful thing to have. More research on how to get better pain relief faster, and to more patients, would be welcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Law, S; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008042.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "d256bdbc-f4af-44f0-ae46-5f8e7a3f553c", "pmid": "", "title": "Dietary supplements for dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Dysmenorrhoea refers to painful menstrual cramps and is a common gynaecological complaint. Conventional treatments include non‐steroidal anti‐inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs), which both reduce myometrial activity (contractions of the uterus). A suggested alternative approach is dietary supplements. We used the term 'dietary supplement' to include herbs or other botanical, vitamins, minerals, enzymes, and amino acids. We excluded traditional Chinese medicines. Objectives To determine the efficacy and safety of dietary supplements for treating dysmenorrhoea. Search methods We searched sources including the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, PsycINFO (all from inception to 23 March 2015), trial registries, and the reference lists of relevant articles. Selection criteria We included randomised controlled trials (RCTs) of dietary supplements for moderate or severe primary or secondary dysmenorrhoea. We excluded studies of women with an intrauterine device. Eligible comparators were other dietary supplements, placebo, no treatment, or conventional analgesia. Data collection and analysis Two review authors independently performed study selection, performed data extraction and assessed the risk of bias in the included trials. The primary outcomes were pain intensity and adverse effects. We used a fixed‐effect model to calculate odds ratios (ORs) for dichotomous data, and mean differences (MDs) or standardised mean differences (SMDs) for continuous data, with 95% confidence intervals (CIs). We presented data that were unsuitable for analysis either descriptively or in additional tables. We assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods. Main results We included 27 RCTs (3101 women). Most included studies were conducted amongst cohorts of students with primary dysmenorrhoea in their late teens or early twenties. Twenty‐two studies were conducted in Iran and the rest were performed in other middle‐income countries. Only one study addressed secondary dysmenorrhoea. Interventions included 12 different herbal medicines (German chamomile ( Matricaria chamomilla, M recutita, Chamomilla recutita) , cinnamon ( Cinnamomum zeylanicum, C. verum) , Damask rose ( Rosa damascena), dill ( Anethum graveolens ), fennel ( Foeniculum vulgare ), fenugreek ( Trigonella foenum‐graecum ), ginger ( Zingiber officinale ), guava ( Psidium guajava ), rhubarb ( Rheum emodi ), uzara ( Xysmalobium undulatum ), valerian ( Valeriana officinalis ), and zataria ( Zataria multiflora )) and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Comparators included other supplements, placebo, no treatment, and NSAIDs. We judged all the evidence to be of low or very low quality. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few studies reported adverse effects. Effectiveness of supplements for primary dysmenorrhoea We have presented pain scores (all on a visual analogue scale (VAS) 0 to 10 point scale) or rates of pain relief, or both, at the first post‐treatment follow‐up. Supplements versus placebo or no treatment There was no evidence of effectiveness for vitamin E (MD 0.00 points, 95% CI −0.34 to 0.34; two RCTs, 135 women). There was no consistent evidence of effectiveness for dill (MD ‐1.15 points, 95% CI −2.22 to −0.08, one RCT, 46 women), guava (MD 0.59, 95% CI −0.13 to 1.31; one RCT, 151 women); one RCT, 73 women), or fennel (MD −0.34 points, 95% CI −0.74 to 0.06; one RCT, 43 women). There was very limited evidence of effectiveness for fenugreek (MD −1.71 points, 95% CI −2.35 to −1.07; one RCT, 101 women), fish oil (MD 1.11 points, 95% CI 0.45 to 1.77; one RCT, 120 women), fish oil plus vitamin B1 (MD −1.21 points, 95% CI −1.79 to −0.63; one RCT, 120 women), ginger (MD −1.55 points, 95% CI −2.43 to −0.68; three RCTs, 266 women; OR 5.44, 95% CI 1.80 to 16.46; one RCT, 69 women), valerian (MD −0.76 points, 95% CI −1.44 to −0.08; one RCT, 100 women), vitamin B1 alone (MD −2.70 points, 95% CI −3.32 to −2.08; one RCT, 120 women), zataria (OR 6.66, 95% CI 2.66 to 16.72; one RCT, 99 women), and zinc sulphate (MD −0.95 points, 95% CI −1.54 to −0.36; one RCT, 99 women). Data on chamomile and cinnamon versus placebo were unsuitable for analysis. Supplements versus NSAIDS There was no evidence of any difference between NSAIDs and dill (MD 0.13 points, 95% CI −1.01 to 1.27; one RCT, 47 women), fennel (MD −0.70 points, 95% CI −1.81 to 0.41; one RCT, 59 women), guava (MD 1.19, 95% CI 0.42 to 1.96; one RCT, 155 women), rhubarb (MD −0.20 points, 95% CI −0.44 to 0.04; one RCT, 45 women), or valerian (MD points 0.62 , 95% CI 0.03 to 1.21; one RCT, 99 women), There was no consistent evidence of a difference between Damask rose and NSAIDs (MD −0.15 points, 95% CI −0.55 to 0.25; one RCT, 92 women). There was very limited evidence that chamomile was more effective than NSAIDs (MD −1.42 points, 95% CI −1.69 to −1.15; one RCT, 160 women). Supplements versus other supplements There was no evidence of a difference in effectiveness between ginger and zinc sulphate (MD 0.02 points, 95% CI −0.58 to 0.62; one RCT, 101 women). Vitamin B1 may be more effective than fish oil (MD −1.59 points, 95% CI −2.25 to −0.93; one RCT, 120 women). Effectiveness of supplements for secondary dysmenorrhoea There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis (data were unsuitable for analysis). Safety of supplements Only four of the 27 included studies reported adverse effects in both treatment groups. There was no evidence of a difference between the groups but data were too scanty to reach any conclusions about safety. Authors' conclusions There is no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety is lacking. However for several supplements there was some low quality evidence of effectiveness and more research is justified. Plain language summary Dietary supplements for pain during menstruation Review question Cochrane authors reviewed the evidence of the effect of dietary supplements (e.g. vitamins, minerals, herbs) on period pain (dysmenorrhoea). Background Dietary supplements have been used in the treatment of period pain. It is important to explore their benefits and harms. We investigated the effectiveness of dietary supplements compared to other supplements, placebo, no treatment or conventional analgesics (pain relief) in women with either primary dysmenorrhoea (not related to any other diagnosis) or secondary dysmenorrhoea (related to other causes, such as endometriosis). The evidence is current to 23 March 2015. Study characteristics We included 27 randomised controlled trials (3101 women). Most participants were students in their late teens or early twenties with primary dysmenorrhoea. Most studies were conducted in Iran. Interventions included 12 different herbal medicines (chamomile, cinnamon, Damask rose, dill, fennel, fenugreek, ginger, guava, rhubarb, uzara, valerian, and zataria), and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Supplements were compared with other supplements, placebo, no treatment, and non‐steroidal anti‐inflammatory drugs (NSAIDs). Key results There was no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety was lacking. However, for several supplements there was some low quality evidence of effectiveness. Supplements for which there was some very limited evidence to suggest a potential benefit were fenugreek, ginger, valerian, zataria, zinc sulphate, fish oil, and vitamin B1. There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis. Quality of the evidence The evidence was of low or very low quality for all comparisons. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few included studies reported adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pattanittum, P, Kunyanone, N, Brown, J, Sangkomkamhang, US, Barnes, J, Seyfoddin, V, Marjoribanks, J", "articleTypes": [], "doi": "10.1002/14651858.CD002124.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.757Z" }, { "id": "d26c484b-a5bf-4e3f-8805-d033a3bcde76", "pmid": "", "title": "Rinse‐free hand wash for reducing absenteeism among preschool and school children", "imported": false, "abstract": "Abstract - Background Illness‐related absenteeism is an important problem among preschool and school children for low‐, middle‐ and high‐ income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse‐free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness‐related absenteeism in preschool and school children. Objectives 1. To assess the effectiveness of rinse‐free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse‐free hand washing products are the most effective (if head‐to‐head comparisons exist), and what effect additional strategies in combination with rinse‐free hand washing have on the outcomes of interest. Search methods In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied. Selection criteria Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse‐free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions. Data collection and analysis Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings. Main results This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most‐notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse‐free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low‐certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse‐free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse‐free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low‐certainty evidence), which indicates rinse‐free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse‐free' group (eight days absent per 1000). There may be little to no difference between rinse‐free hand washing and 'no rinse‐free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low‐certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very‐low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse‐free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very‐low certainty evidence). Authors' conclusions The findings of this review may have identified a small yet potentially beneficial effect of rinse‐free hand washing regimes on illness‐related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse‐free hand washing regimens in order to provide more conclusive, higher‐certainty evidence regarding its impact. When considering the use of a rinse‐free hand washing program in a local setting, there needs to be consideration of the current rates of illness‐related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings. Plain language summary Rinse‐free hand wash for reducing absenteeism among preschool and school children Background Absenteeism from schooling is costly to parents, schools and governments and sustained absence is detrimental to student learning. Illness‐related absenteeism is a significant contributor to absenteeism from school, but can also result in parents missing work due to catching the illness themselves or having to stay home to care for their children. There are several strategies currently used to reduce illness‐related absenteeism, a common method is the implementation of appropriate hand hygiene practices. However, hand hygiene using soap and water is not always practical, and alternatives may prove to be more effective in reducing the overall rate of illness‐related absenteeism. One such alternative is the use of rinse‐free hand wash. Review question This review was designed to investigate if the use of rinse‐free hand wash can reduce the number of days spent absent from school in preschool and school children compared to no rinse‐free hand wash usage. Study characteristics The searches returned 19 relevant studies with a total of 30,747 participants. Eight studies were conducted in the USA, two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to14 years). These studies were quite varied in the composition and application of the rinse‐free hand washing program. Only two studies included information on the primary outcome (absenteeism due to any reason), whilst for absenteeism for any illness there were six studies that provided information. The evidence presented is up to date to February 2020. Key results The application of, and adherence to a rinse‐free hand wash, hand hygiene program may be associated with small, but potentially beneficial effects in reducing the number of days students were absent from school due to illness compared to no rinse‐free hand wash, hygiene program. However rinse‐free hand washing may be no different to controls at reducing absenteeism for any reason. There may also be no difference in the number of skin irritations between students who received the rinse‐free hand wash compared to those who used soap and water. Most students and teachers responded favorably to using rinse‐free hand wash and complied relatively well with its use. Certainty of the evidence The certainty of the evidence included in this review was low or very low, mainly due to the included studies using poor methods, providing imprecise data, and being very inconsistent from one another. This means that we have low and very‐low certainty, or confidence, in these results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Munn, Z, Tufanaru, C, Lockwood, C, Stern, C, McAneney, H, Barker, TH", "articleTypes": [], "doi": "10.1002/14651858.CD012566.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.104Z" }, { "id": "d2775074-779d-405f-9b92-b4a63d796f6b", "pmid": "", "title": "Chinese medicinal herbs for mumps", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Shu, M, Zhang, YQ, Li, Z, Liu, GJ, Wan, C, Wen, Y", "articleTypes": [], "doi": "10.1002/14651858.CD008578.pub3 AB - Abstract - Background Mumps is an infectious disease caused by the mumps virus. Chinese physicians generally believe that Chinese medicinal herbs are effective in alleviating symptoms and reducing the duration of mumps. Herbalists tend to develop a treatment plan according to the individual's symptoms. Objectives To evaluate the effectiveness and safety of Chinese medicinal herbs combined with routine treatments for mumps. Search methods We searched CENTRAL (2015, Issue 1), MEDLINE (1948 to January week 4, 2015), EMBASE (1974 to February 2015), CINAHL (1981 to February 2015), AMED (1985 to April 2014), the Chinese Biomedical Database (CBM) (1980 to February 2015), China National Knowledge Infrastructure (CNKI) (1979 to February 2015), VIP Information (1989 to February 2015), and relevant databases of ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs for mumps (with or without complications). Data collection and analysis Two review authors independently evaluated trial quality and conducted data extraction. We contacted the trial authors for missing data regarding participant allocation. Some trials allocated participants according to the participants' admission sequence, making it a pseudo‐random allocation. None of the trials concealed participants' allocation or used blinding. Main results We did not identify any eligible trials for inclusion. We identified 108 studies that claimed to use random allocation. We excluded 104 studies because the allocation methods the authors had used were not actually randomised. We were unable to contact the trial authors of the remaining four studies. These trials require further evaluation and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions We did not find any RCTs for or against Chinese herbal medicine used in the treatment of mumps. We hope more high‐quality RCTs will be conducted in the future. Plain language summary Chinese medicinal herbs for mumps Review question 
 We reviewed the evidence about the effect and safety of Chinese medicinal herbs for mumps. Background 
 Mumps (epidemic parotitis) is an infectious illness caused by the multiplication of the mumps virus in the upper respiratory tract. It can range from a mild upper respiratory disease to serious complications. Herbal medicines have been used in traditional Chinese medicine (TCM) as the main therapy to prevent and treat mumps for thousands of years. Many Chinese physicians believe that Chinese medicinal herbs are effective in treating mumps. Study characteristics 
 The evidence is current to February 2015. The review authors did not find any randomised controlled trials (RCTs) to provide reliable evidence for the effectiveness and safety of Chinese medicinal herbs for mumps. Although no trials were included, we reviewed the studies and found no reports of adverse events with Chinese medicinal herbs as a treatment for mumps. Key results 
 High‐quality trials are needed to answer these questions.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.763Z" }, { "id": "d27d699d-7500-4354-bd31-b3b24719a470", "pmid": "", "title": "Interventions to prevent obesity in children aged 12 to 18 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or ‘activity’ levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review. Objectives To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta‐analyses. Sixty studies were based in high‐income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty‐one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short‐term follow‐up (mean difference (MD) ‐0.18, 95% confidence interval (CI) ‐0.41 to 0.06; 3 studies, 605 participants), medium‐term follow‐up (MD ‐0.65, 95% CI ‐1.18 to ‐0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long‐term follow‐up (MD ‐0.14, 95% CI ‐0.38 to 0.10; 2 studies, 1089 participants); all very low‐certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long‐term follow‐up (MD ‐0.30, 95% CI ‐1.67 to 1.07; 1 study, 44 participants); zBMI at short‐term (MD ‐0.06, 95% CI ‐0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium‐term (MD 0.02, 95% CI ‐0.17 to 0.21; 1 study, 112 participants) follow‐up; all low‐certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low‐certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short‐term follow‐up (MD ‐0.64, 95% CI ‐1.86 to 0.58; 6 studies, 1780 participants; low‐certainty evidence) and probably do not reduce zBMI at medium‐ (MD 0, 95% CI ‐0.04 to 0.05; 6 studies, 5335 participants) or long‐term (MD ‐0.05, 95% CI ‐0.12 to 0.02; 1 study, 985 participants) follow‐up; both moderate‐certainty evidence. Activity interventions do not reduce zBMI at short‐term follow‐up (MD 0.02, 95% CI ‐0.01 to 0.05; 7 studies, 4718 participants; high‐certainty evidence), but may reduce BMI slightly at medium‐term (MD ‐0.32, 95% CI ‐0.53 to ‐0.11; 3 studies, 2143 participants) and long‐term (MD ‐0.28, 95% CI ‐0.51 to ‐0.05; 1 study, 985 participants) follow‐up; both low‐certainty evidence. Seven studies (5428 participants; low‐certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short‐term follow‐up (MD 0.03, 95% CI ‐0.07 to 0.13; 11 studies, 3429 participants; high‐certainty evidence), and probably do not reduce BMI at medium‐term (MD 0.01, 95% CI ‐0.09 to 0.11; 8 studies, 5612 participants; moderate‐certainty evidence) or long‐term (MD 0.06, 95% CI ‐0.04 to 0.16; 6 studies, 8736 participants; moderate‐certainty evidence) follow‐up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD ‐0.09, 95% CI ‐0.2 to 0.02; 3 studies, 515 participants; very low‐certainty evidence), and they may not reduce zBMI at medium‐term (MD ‐0.05, 95% CI ‐0.1 to 0.01; 6 studies, 3511 participants; low‐certainty evidence) or long‐term (MD ‐0.02, 95% CI ‐0.05 to 0.01; 7 studies, 8430 participants; low‐certainty evidence) follow‐up. Four studies (2394 participants) reported data on serious adverse events (very low‐certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect. Authors' conclusions The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low‐certainty evidence that activity interventions may have a small beneficial effect on BMI at medium‐ and long‐term follow‐up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples. Plain language summary Do dietary and activity strategies help prevent obesity in children and young people aged 12 to 18 years? Key messages ‐ Strategies to encourage adolescents to change their diet or activity levels (or both), to prevent them becoming overweight or developing obesity make no or very little difference to their body mass index (BMI; an estimate of the amount of body fat according to height and weight). ‐ Based on the very little information available about serious adverse events, there appears to be little or no effect of dietary or activity strategies, or both, to results in serious harms (e.g. injuries). ‐ Due to a lack of evidence, future research should focus on community settings (e.g. in youth clubs) and research involving adolescents with disabilities. Why is preventing obesity in children and young people important? More adolescents are developing overweight and obesity worldwide. Being overweight as an adolescent can cause health problems, and people may be affected psychologically and in their social life. Puberty and moving into adulthood is a challenging time, and many struggle with their mental health. Overweight adolescents are likely to be overweight or obese as adults and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help adolescents modify their diet or activity (or both) were effective at preventing obesity. We also wanted to know if these strategies were associated with any serious harms. What did we do? We searched scientific databases for studies that looked at ways of preventing obesity in children aged 12 to 18 years. We excluded studies aimed at adolescents who were already overweight or living with obesity. However, we included studies where the sample was a whole group (e.g. a school), which may have included those living with overweight or obesity. We only included studies if the methods they used aimed to change the children's diet, their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed children into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 74 studies involving 83,407 children and young people. Sixty studies were based in high‐income countries (e.g. USA and in Europe). In 57 studies, the strategies were tried in schools, although 12 were based at home or other places like community settings (five studies) such as youth groups. Fifty‐one strategies were implemented for fewer than nine months; the shortest intervention lasted one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five studies were partly funded by industry (food suppliers, a PlayStation manufacturer, a gym equipment supplier, a healthcare device manufacturer and a private healthcare facility). Our analyses included results from 54 studies of 46,358 adolescents (20 studies did not report their results in a way that could be included in our analyses). We found that adolescents who were helped with a strategy to change their diet or activity levels (or both) either did not reduce their BMI, or any reduction was meagre, compared to adolescents who were not given a strategy. Only a few studies reported any possible harms of the interventions, and none identified serious harms. What are the limitations of the evidence? Overall, we have limited confidence in the beneficial effects of these interventions in preventing obesity in children and adolescents. It is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. Many studies had limitations in how they were done (e.g. in some studies, the methods used to randomly place people into groups were not adequate or the results of some of the studies were not analysed correctly). 3. There were not enough studies reporting particular types of outcomes, such as BMI (an estimate of the amount of body fat according to height and weight) or zBMI (comparison of a child’s BMI with other children of the same age and sex) for a particular duration of follow‐up to be certain about the results for some comparisons. Also, certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way that we could include them in our analyses (e.g. without any detail of the difference in change between the intervention and control groups) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for adolescents with disabilities, or whether those implemented in community settings are effective. How up to date is this evidence? This review supersedes our previous review. The evidence is up‐to‐date until February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F, Tomlinson, E, Davies, AL, Moore, THM, Dawson, S, Breheny, K, Savović, J, Hodder, RK, Wolfenden, L, Higgins, JPT, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015330.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.126Z" }, { "id": "d27db393-6dad-43e8-ab3c-7334a6e991b2", "pmid": "", "title": "Ipilimumab or FOLFOX in Combination With Nivolumab and Trastuzumab in Previously Untreated HER2 Positive Locally Advanced or Metastatic EsophagoGastric Adenocarcinoma", "imported": false, "abstract": "The INTEGA study assesses therapy Options for advanced or metastatic esophagogastric Adenocarcinoma in patients overexpressing human epidermal receptor type 2 (HER2 positive patients). Current treatment options in this situation include chemotherapy based palliative treatment in combination withTrastuzumab.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.247Z" }, { "id": "d29cbdf3-3ceb-4b41-9165-298369c1f9aa", "pmid": "", "title": "Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Etidronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts – bone cells that break down bone tissue. This is an update of a Cochrane review first published in 2008. For clinical relevance, we investigated etidronate's effects on postmenopausal women stratified by fracture risk (low versus high). Objectives To assess the benefits and harms of intermittent/cyclic etidronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE, Embase, two clinical trial registers, the websites of drug approval agencies, and the bibliographies of relevant systematic reviews. We identified eligible trials published between 1966 and February 2023. Selection criteria We included randomized controlled trials that assessed the benefits and harms of etidronate in the prevention of fractures for postmenopausal women. Women in the experimental arms must have received at least one year of etidronate, with or without other anti‐osteoporotic drugs and concurrent calcium/vitamin D. Eligible comparators were placebo (i.e. no treatment; or calcium, vitamin D, or both) or another anti‐osteoporotic drug. Major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. We classified a study as secondary prevention if its population fulfilled one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (≤ ‐2.5), or aged 75 years or older. If none of these criteria were met, we considered the study to be primary prevention. Data collection and analysis We used standard methodological procedures expected by Cochrane. The review has three main comparisons: (1) etidronate 400 mg/day versus placebo; (2) etidronate 200 mg/day versus placebo; (3) etidronate at any dosage versus another anti‐osteoporotic agent. We stratified the analyses for each comparison into primary and secondary prevention studies. For major outcomes in the placebo‐controlled studies of etidronate 400 mg/day, we followed our original review by defining a greater than 15% relative change as clinically important. For all outcomes of interest, we extracted outcome measurements at the longest time point in the study. Main results Thirty studies met the review's eligibility criteria. Of these, 26 studies, with a total of 2770 women, reported data that we could extract and quantitatively synthesize. There were nine primary and 17 secondary prevention studies. We had concerns about at least one risk of bias domain in each study. None of the studies described appropriate methods for allocation concealment, although 27% described adequate methods of random sequence generation. We judged that only 8% of the studies avoided performance bias, and provided adequate descriptions of appropriate blinding methods. One‐quarter of studies that reported efficacy outcomes were at high risk of attrition bias, whilst 23% of studies reporting safety outcomes were at high risk in this domain. The 30 included studies compared (1) etidronate 400 mg/day to placebo (13 studies: nine primary and four secondary prevention); (2) etidronate 200 mg/day to placebo (three studies, all secondary prevention); or (3) etidronate (both dosing regimens) to another anti‐osteoporotic agent (14 studies: one primary and 13 secondary prevention). We discuss only the etidronate 400 mg/day versus placebo comparison here. For primary prevention, we collected moderate‐ to very low‐certainty evidence from nine studies (one to four years in length) including 740 postmenopausal women at lower risk of fractures. Compared to placebo, etidronate 400 mg/day probably results in little to no difference in non‐vertebral fractures (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.20 to 1.61); absolute risk reduction (ARR) 4.8% fewer, 95% CI 8.9% fewer to 6.1% more) and serious adverse events (RR 0.90, 95% CI 0.52 to 1.54; ARR 1.1% fewer, 95% CI 4.9% fewer to 5.3% more), based on moderate‐certainty evidence. Etidronate 400 mg/day may result in little to no difference in clinical vertebral fractures (RR 3.03, 95% CI 0.32 to 28.44; ARR 0.02% more, 95% CI 0% fewer to 0% more) and withdrawals due to adverse events (RR 1.41, 95% CI 0.81 to 2.47; ARR 2.3% more, 95% CI 1.1% fewer to 8.4% more), based on low‐certainty evidence. We do not know the effect of etidronate on hip fractures because the evidence is very uncertain (RR not estimable based on very low‐certainty evidence). Wrist fractures were not reported in the included studies. For secondary prevention, four studies (two to four years in length) including 667 postmenopausal women at higher risk of fractures provided the evidence. Compared to placebo, etidronate 400 mg/day may make little or no difference to non‐vertebral fractures (RR 1.07, 95% CI 0.72 to 1.58; ARR 0.9% more, 95% CI 3.8% fewer to 8.1% more), based on low‐certainty evidence. The evidence is very uncertain about etidronate's effects on hip fractures (RR 0.93, 95% CI 0.17 to 5.19; ARR 0.0% fewer, 95% CI 1.2% fewer to 6.3% more), wrist fractures (RR 0.90, 95% CI 0.13 to 6.04; ARR 0.0% fewer, 95% CI 2.5% fewer to 15.9% more), withdrawals due to adverse events (RR 1.09, 95% CI 0.54 to 2.18; ARR 0.4% more, 95% CI 1.9% fewer to 4.9% more), and serious adverse events (RR not estimable), compared to placebo. Clinical vertebral fractures were not reported in the included studies. Authors' conclusions This update echoes the key findings of our previous review that etidronate probably makes or may make little to no difference to vertebral and non‐vertebral fractures for both primary and secondary prevention. Plain language summary Does etidronate prevent fractures caused by osteoporosis in postmenopausal women? Key messages • For women with close to normal bone density (bone strength) and no previous broken spinal bones, etidronate probably makes little or no difference to the likelihood of having a hip or wrist fracture or a serious adverse (unwanted/harmful) event.
 • For women who have low bone density and are at risk for or have had a previous broken spinal bone, etidronate may make little or no difference in preventing fractures in bones other than the spine. What is osteoporosis? Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow, and old bone cells break down to make room for new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break, even after a minor injury, such as a slight bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. What is etidronate? Etidronate belongs to the class of medicines called bisphosphonates, which slow down the cells that break down the old bone. It is given by mouth in an intermittent or cyclical schedule; for example, a 400 mg tablet daily for two weeks every 90 days, followed by calcium or no treatment for the remainder of each 90‐day treatment cycle. What did we want to find out? We wanted to find out if etidronate was better than placebo (inactive or 'dummy' medicine) or another medicine for osteoporosis in preventing broken bones in postmenopausal women. For clinical relevance, we looked at etidronate's effects on women, as grouped by their risk of fracture (lower versus higher risk). We also wanted to find out if etidronate was associated with any unwanted effects. What did we do? We searched for studies comparing etidronate to placebo or another medicine for preventing osteoporosis. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Overall, we found 30 studies, but 4 studies provided insufficient information about their results. Thus, we were able to analyse the results of 26 studies involving 2770 women. Nine studies were interested in 'primary prevention' of osteoporosis‐based fractures, meaning they focused on women at lower fracture risk, who had bones with near‐to‐normal density/strength and no previous broken spinal bones. Seventeen studies were interested in 'secondary prevention' with etidronate, meaning they focused on women at higher fracture risk, who already had weak bones (low bone density), had a broken spinal bone, or both. Most studies mainly included white women. The studies lasted between 1 and 4 years. Some studies gave the women 400 mg/day of etidronate, whilst other studies gave 200 mg/day. Main results for primary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate: • probably makes little or no difference to non‐vertebral (non‐spinal) fractures and serious adverse events; • may make little or no difference to clinical vertebral fractures (that is, spinal fractures suggested by clinical signs and symptoms) and the number of women who left the studies due to adverse events. The evidence is very uncertain about the effect of etidronate on hip fractures. None of the studies reported on the effect on wrist fractures. Main results for secondary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate may make little or no difference in preventing fractures in bones other than the spine. The evidence is very uncertain about the effect of etidronate on hip and wrist fractures, the number of women who left the studies due to adverse events, and serious adverse events. None of the studies reported on etidronate's effect on clinical vertebral fractures. What are the limitations of the evidence? Our confidence in the evidence ranged from very low to moderate. In general, we have little confidence in the evidence because it is possible that the women in the studies were aware of which treatment they were getting, which could influence the results, and because many of the studies were very small. How up to date is this evidence? The evidence is current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Wells, GA; Hsieh, S-C; Peterson, J; Zheng, C; Kelly, SE; Shea, B; Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD003376.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "d2a1961e-22d2-45e0-bd77-5436aa2d6611", "pmid": "", "title": "Medically Utilized Tailored Traditional Meals to Optimize Nutrition in Heart Failure Pilot Trial", "imported": false, "abstract": "Study subjects with heart failure will receive either pre-prepared, home-delivered DASH/SRD-compliant meals incorporating local Navajo traditional foods or usual care for 30 days (14 meals weekly).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.250Z" }, { "id": "d2ae10dd-f2f7-4a1a-8f2e-c6f3d9b4674a", "pmid": "", "title": "Parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review on parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy (published in Issue 3, 2007). Salivary gland dysfunction is a predictable side effect of radiotherapy to the head and neck region. Pilocarpine hydrochloride (a choline ester) is licensed in many countries for the treatment of radiation‐induced salivary gland dysfunction. Other parasympathomimetics have also been used 'off licence' in the treatment of this condition. Objectives To determine the efficacy and tolerability of parasympathomimetic drugs in the treatment of radiation‐induced salivary gland dysfunction (specifically radiation‐induced xerostomia). Search methods For this update, we ran searches of the Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 6), MEDLINE, EMBASE, and CINAHL in July 2015. We checked the reference lists of retrieved articles for additional studies, contacted experts in the field for unpublished and ongoing trials, and contacted relevant pharmaceutical companies for unpublished and ongoing trials. Selection criteria The selection criteria for the review were: 1) randomised controlled trials; 2) people suffering from radiation‐induced salivary gland dysfunction; 3) people treated with parasympathomimetic drugs; and 4) assessable data available on primary outcome measure. Data collection and analysis The two review authors independently collected data from the full‐text version of relevant papers including: 1) citation details; 2) participants; 3) interventions; 4) assessments; 5) outcomes (that is efficacy, tolerability); and 6) quality issues. Due to a lack of appropriate data, we were unable to perform a meta‐analysis. Main results In the original review, three studies, including a total of 298 participants, fulfilled the inclusion criteria. All three studies involved the use of pilocarpine hydrochloride. We have included no additional studies in the update of the review; we have excluded eight additional studies. The data suggest that pilocarpine hydrochloride is more effective than placebo and at least as effective as artificial saliva. The response rate was 42% to 51%. The time to response was up to 12 weeks. The overall side effect rate was high, and side effects were the main reason for withdrawal (6% to 15% of participants taking 5 mg three times a day had to withdraw). The side effects were usually the result of generalised parasympathomimetic stimulation (for example sweating, headaches, urinary frequency, vasodilatation). Response rates were not dose dependent, but side effect rates were dose dependent. Authors' conclusions There is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced xerostomia. Currently, there is little evidence to support the use of other parasympathomimetic drugs in the treatment of radiation‐induced xerostomia. Available studies suggest that approximately half of patients will respond, but side effects can be problematic. The conclusions of the update are the same as the conclusions of the original review, since no new relevant studies have been published in the interim. Plain language summary Parasympathomimetic drugs for the treatment of 'dry mouth' due to radiotherapy This updated review found there is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced salivary gland dysfunction ('dry mouth'). Salivary gland damage is a frequent and important complication of radiotherapy to the head and neck area; it causes dryness of the mouth with resultant problems with eating, talking, and local infection. The parasympathomimetic group of drugs have been used to treat radiotherapy‐induced salivary gland damage. We identified three studies that involved a total of 289 participants, and they all used the drug pilocarpine. The review found that 42% to 51% of participants (4 to 5 in 10) responded to pilocarpine, although in some participants the response did not occur for up to 12 weeks. Pilocarpine was more effective than a placebo treatment, and at least as effective as an artificial saliva. Side effects were common with pilocarpine (for example sweating, headache, passing urine frequently, flushing), but were usually reported to be mild; 6% to 15% (0.6 to 1.5 in 10) participants had to stop taking pilocarpine due to side effects. The findings of this review are limited by the small number of good‐quality trials that have been performed in this area. The update of this review did not find any new information on this topic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Davies, AN, Thompson, J", "articleTypes": [], "doi": "10.1002/14651858.CD003782.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.774Z" }, { "id": "d2bed0e2-4114-495e-b2f1-2ca64ceeef55", "pmid": "", "title": "Activation and Inhibition of the Sweet Taste Receptor T1R2-T1R3 Differentially Affect Glucose Tolerance in Humans", "imported": false, "abstract": "In the present study, our objective was to determine whether T1R2-T1R3 influences glucose metabolism bidirectionally via hyperactivation with sucralose and inhibition with sodium lactisole in mixture with glucose loads during tolerance tests in humans. In 12 healthy participants we conducted oral glucose tolerance tests (OGTTs) of 75 g glucose with and without the addition of the T1R2-T1R3 agonist, sucralose (5 mM). We also conducted OGTTs in 10 healthy participants with and without the addition of a T1R2-T1R3 antagonist, sodium lactisole (2 mM). Plasma glucose, insulin, and glucagon were measured before, during, and after OGTTs up to 120 minutes post-prandially. We also assessed individual participants' sweet taste responses to sucralose, their sensitivities to sweetness inhibition by lactisole, and their BMIs.", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.233Z" }, { "id": "d2df1688-d8ad-44f7-b9a5-4aea13e4ba15", "pmid": "", "title": "Pharmacological treatment of gastro‐oesophageal reflux in children", "imported": false, "abstract": "Abstract - Background Gastro‐oesophageal reflux (GOR) is characterised by the regurgitation of gastric contents into the oesophagus. GOR is a common presentation in infancy, both in primary and secondary care, affecting approximately 50% of infants under three months old. The natural history of GOR in infancy is generally of a self‐limiting condition that improves with age, but older children and children with co‐existing medical conditions can have more protracted symptoms. The distinction between gastro‐oesophageal reflux disease (GORD) and GOR is debated. Current National Institute of Health and Care Excellence (NICE) guidelines define GORD as GOR causing symptoms severe enough to merit treatment. This is an update of a review first published in 2014. Objectives To assess the effects of pharmacological treatments for GOR in infants and children. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, and Web of Science up to 17 September 2022. We also searched for ongoing trials in clinical trials registries, contacted experts in the field, and searched the reference lists of trials and reviews for any additional trials. Selection criteria We included randomised controlled trials (RCTs) that compared any currently‐available pharmacological treatment for GOR in children with placebo or another medication. We excluded studies assessing dietary management of GORD and studies of thickened feeds. We included studies in infants and children up to 16 years old. Data collection and analysis We used standard methodology expected by Cochrane. Main results We included 36 RCTs involving 2251 children and infants. We were able to extract summary data from 14 RCTs; the remaining trials had insufficient data for extraction. We were unable to pool results in a meta‐analysis due to methodological differences in the included studies (including heterogeneous outcomes, study populations, and study design). We present the results in two groups by age: infants up to 12 months old, and children aged 12 months to 16 years old. Infants Omeprazole versus placebo: there is no clear effect on symptoms from omeprazole. One study (30 infants; very low‐certainty evidence) showed cry/fuss time in infants aged three to 12 months had altered from 246 ± 105 minutes/day at baseline (mean +/‐ standard deviation (SD)) to 191 ± 120 minutes/day in the omeprazole group and from 287 ± 132 minutes/day to 201 ± 100 minutes/day in the placebo group (mean difference (MD) 10 minutes/day lower (95% confidence interval (CI) ‐89.1 to 69.1)). The reflux index changed in the omeprazole group from 9.9 ± 5.8% in 24 hours to 1.0 ± 1.3% and in the placebo group from 7.2 ± 6.0% to 5.3 ± 4.9% in 24 hours (MD 7% lower, 95% CI ‐4.7 to ‐9.3). Omeprazole versus ranitidine: one study (76 infants; very low‐certainty evidence) showed omeprazole may or may not provide symptomatic benefit equivalent to ranitidine. Symptom scores in the omeprazole group changed from 51.9 ± 5.4 to 2.4 ± 1.2, and in the ranitidine group from 47 ± 5.6 to 2.5 ± 0.6 after two weeks: MD ‐4.97 (95% CI ‐7.33 to ‐2.61). Esomeprazole versus placebo: esomeprazole appeared to show no additional reduction in the number of GORD symptoms compared to placebo (1 study, 52 neonates; very low‐certainty evidence): both the esomeprazole group (184.7 ± 78.5 to 156.7 ± 75.1) and placebo group (183.1 ± 77.5 to 158.3 ± 75.9) improved: MD ‐3.2 (95% CI ‐4.6 to ‐1.8). Children Proton pump inhibitors (PPIs) at different doses may provide little to no symptomatic and endoscopic benefit. Rabeprazole given at different doses (0.5 mg/kg and 1 mg/kg) may provide similar symptom improvement (127 children in total; very low‐certainty evidence). In the lower‐dose group (0.5 mg/kg), symptom scores improved in both a low‐weight group of children (< 15 kg) (mean ‐10.6 ± SD 11.13) and a high‐weight group of children (> 15 kg) (mean ‐13.6 ± 13.1). In the higher‐dose groups (1 mg/kg), scores improved in the low‐weight (‐9 ± 11.2) and higher‐weight groups (‐8.3 ± 9.2). For the higher‐weight group, symptom score mean difference between the two different dosing regimens was 2.3 (95% CI ‐2 to 6.6), and for the lower‐weight group, symptom score MD was 4.6 (95% CI ‐2.9 to 12). Pantoprazole: pantoprazole may or may not improve symptom scores at 0.3 mg/kg, 0.6 mg/kg, and 1.2 mg/kg pantoprazole in children aged one to five years by week eight, with no difference between 0.3 mg/kg and 1.2 mg/kg dosing (0.3 mg/kg mean −2.4 ± 1.7; 1.2 mg/kg −1.7 ± 1.2: MD 0.7 (95% CI ‐0.4 to 1.8)) (one study, 60 children; very low‐certainty evidence). There were insufficient summary data to assess other medications. Authors' conclusions There is very low‐certainty evidence about symptom improvements and changes in pH indices for infants. There are no summary data for endoscopic changes. Medications may or may not provide a benefit (based on very low‐certainty evidence) for infants whose symptoms remain bothersome, despite nonmedical interventions or parental reassurance. If a medication is required, there is no clear evidence based on summary data for omeprazole, esomeprazole (in neonates), H₂antagonists, and alginates for symptom improvements (very low‐certainty evidence). Further studies with longer follow‐up are needed. In older children with GORD, in studies with summary data extracted, there is very low‐certainty evidence that PPIs (rabeprazole and pantoprazole) may or may not improve GORD outcomes. No robust data exist for other medications. Further RCT evidence is required in all areas, including subgroups (preterm babies and children with neurodisabilities). Plain language summary Medicines for children with reflux Review question What is the best and safest treatment for babies and children with gastro‐oesophageal reflux? Key messages: ‐ the evidence for medications for babies with gastro‐oesophageal reflux/reflux disease is very uncertain; ‐ for children with gastro‐oesophageal reflux disease, the evidence is very uncertain regarding the effects of proton pump inhibitors. There was no adequate evidence to draw conclusions regarding other medications. What is gastro‐oesophageal reflux? Gastro‐oesophageal reflux happens when stomach contents come back up into the oesophagus (food pipe). Most babies (under 1 year) grow out of reflux symptoms, but does medicine help? Children (older than 1 year) can have reflux just like adults. Reflux can be normal ('physiological reflux'), but in babies and children, it can cause symptoms, including pain or weight loss, as the oesophagus becomes inflamed (oesophagitis). Bothersome symptoms of reflux are called 'gastro‐oesophageal reflux disease' (GORD). How is gastro‐oesophageal reflux treated? Medicines can thicken the stomach contents (alginates), neutralise stomach acid (ranitidine, omeprazole, lansoprazole), or help the stomach to empty faster (domperidone, erythromycin). What did we want to find out? We wanted to learn the best way to reduce reflux in babies and children. We wanted to see if medicines help infants and children to feel better (symptom scores), heal the oesophagus (which is checked by using endoscopy, where a tiny camera is put down the oesophagus), or lower the time the oesophagus is exposed to stomach acid. We also investigated whether the medicines were safe by considering the harmful or unwanted effects reported in the studies. What did we do? We searched for studies testing gastro‐oesophageal reflux medicines in babies and children. We included all studies comparing these medicines, or comparing them to an inactive medicine (placebo). We assessed results which are important to doctors, nurses, and parents, and performed our own analysis of the results. We rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 36 suitable studies (involving 2251 babies and children), conducted worldwide, with most in the USA. The largest study recruited 268 babies, the smallest, 16 children. Fifteen studies compared an active medicine to placebo; 8 compared one active medication to another; and 11 studies gave the same medication at different doses. We found useable outcome information in 14 of the 36 studies. The remaining studies either did not report outcomes we were interested in or did not report them in a way we could analyse. We could not combine the results of any studies because they were too different (in terms of how long they followed participants up and the outcomes they investigated) to use in a meaningful way. Key results Babies. There is no clear effect on symptoms or measured acidity (one measure is reflux index, which is the percentage of time in 24 hours the oesophagus is exposed to stomach acid) between babies given omeprazole or placebo. One study (30 babies) showed cry/fuss time went down from 287 to 201 minutes/day in the placebo group and 246 to 191 minutes/day in the omeprazole group. Reflux index changed in the omeprazole group from 9.9% to 1.0% in 24 hours, and in the placebo group from 7.2% to 5.3%. One study (76 babies) showed that omeprazole and ranitidine may have a similar benefit for symptoms after 2 weeks: symptom scores (higher scores mean worse symptoms) in the omeprazole group dropped from 51.9 to 2.4, and in the ranitidine group, from 47 to 2.5. In one study of 52 newborn babies, esomeprazole appeared to show no reduction in the number of symptoms (184.7 to 156.7) compared to placebo (183.1 to 158.3). None of the studies reported harmful events or results about changes to babies' oesophaguses. Children. In children older than 1 year of age, no studies assessed medical treatment versus placebo. Proton pump inhibitors (PPIs), which block stomach acid production, at different doses may provide little to no improvements in symptoms or oesophagus healing. In one study (127 children), both lower‐weight and higher‐weight children given rabeprazole at lower and higher doses had both minimal – probably unimportant – changes in symptom scores and endoscopic scores (which indicate whether healing of the oesophagus has occurred). Pantoprazole may or may not improve symptom scores in children aged 1 to 5 years by week 8: there was no difference between lower and higher dosing in one study (60 children). Studies investigating other medications did not report enough information for us to assess their results properly. Quality of the evidence We are not confident in the evidence, which was mainly based on single studies with few babies and children. Several studies had pharmaceutical company help with manuscript writing. The question of how best to treat children with disabilities, and whether any PPIs are better than other medicines remain. The evidence is current to 17 September 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Tighe, MP; Andrews, E; Liddicoat, I; Afzal, NA; Hayen, A; Beattie, RM", "articleTypes": [], "doi": "10.1002/14651858.CD008550.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "d2ec8265-34e6-4c57-96e0-aeb094d89f6f", "pmid": "", "title": "Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Harmful alcohol use is defined as unhealthy alcohol use that results in adverse physical, psychological, social, or societal consequences and is among the leading risk factors for disease, disability and premature mortality globally. The burden of harmful alcohol use is increasing in low‐ and middle‐income countries (LMICs) and there remains a large unmet need for indicated prevention and treatment interventions to reduce harmful alcohol use in these settings. Evidence regarding which interventions are effective and feasible for addressing harmful and other patterns of unhealthy alcohol use in LMICs is limited, which contributes to this gap in services. Objectives To assess the efficacy and safety of psychosocial and pharmacologic treatment and indicated prevention interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs. Search methods We searched for randomized controlled trials (RCTs) indexed in the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, the Cochrane Clinical Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, and the Latin American and Caribbean Health Sciences Literature (LILACS) through 12 December 2021. We searched clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, Web of Science, and Opengrey database to identify unpublished or ongoing studies. We searched the reference lists of included studies and relevant review articles for eligible studies. Selection criteria All RCTs comparing an indicated prevention or treatment intervention (pharmacologic or psychosocial) versus a control condition for people with harmful alcohol use in LMICs were included. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 66 RCTs with 17,626 participants. Sixty‐two of these trials contributed to the meta‐analysis. Sixty‐three studies were conducted in middle‐income countries (MICs), and the remaining three studies were conducted in low‐income countries (LICs). Twenty‐five trials exclusively enrolled participants with alcohol use disorder. The remaining 51 trials enrolled participants with harmful alcohol use, some of which included both cases of alcohol use disorder and people reporting hazardous alcohol use patterns that did not meet criteria for disorder. Fifty‐two RCTs assessed the efficacy of psychosocial interventions; 27 were brief interventions primarily based on motivational interviewing and were compared to brief advice, information, or assessment only. We are uncertain whether a reduction in harmful alcohol use is attributable to brief interventions given the high levels of heterogeneity among included studies (Studies reporting continuous outcomes: Tau² = 0.15, Q =139.64, df =16, P<.001, I² = 89%, 3913 participants, 17 trials, very low certainty; Studies reporting dichotomous outcomes: Tau²=0.18, Q=58.26, df=3, P<.001, I² =95%, 1349 participants, 4 trials, very low certainty). The other types of psychosocial interventions included a range of therapeutic approaches such as behavioral risk reduction, cognitive‐behavioral therapy, contingency management, rational emotive therapy, and relapse prevention. These interventions were most commonly compared to usual care involving varying combinations of psychoeducation, counseling, and pharmacotherapy. We are uncertain whether a reduction in harmful alcohol use is attributable to psychosocial treatments due to high levels of heterogeneity among included studies (Heterogeneity: Tau² = 1.15; Q = 444.32, df = 11, P<.001; I²=98%, 2106 participants, 12 trials, very low certainty). Eight trials compared combined pharmacologic and psychosocial interventions with placebo, psychosocial intervention alone, or another pharmacologic treatment. The active pharmacologic study conditions included disulfiram, naltrexone, ondansetron, or topiramate. The psychosocial components of these interventions included counseling, encouragement to attend Alcoholics Anonymous, motivational interviewing, brief cognitive‐behavioral therapy, or other psychotherapy (not specified). Analysis of studies comparing a combined pharmacologic and psychosocial intervention to psychosocial intervention alone found that the combined approach may be associated with a greater reduction in harmful alcohol use (standardized mean difference (standardized mean difference (SMD))=‐0.43, 95% confidence interval (CI): ‐0.61 to ‐0.24; 475 participants; 4 trials; low certainty). Four trials compared pharmacologic intervention alone with placebo and three with another pharmacotherapy. Drugs assessed were: acamprosate, amitriptyline, baclofen disulfiram, gabapentin, mirtazapine, and naltrexone. None of these trials evaluated the primary clinical outcome of interest, harmful alcohol use. Thirty‐one trials reported rates of retention in the intervention. Meta‐analyses revealed that rates of retention between study conditions did not differ in any of the comparisons (pharmacologic risk ratio (RR) = 1.13, 95% CI: 0.89 to 1.44, 247 participants, 3 trials, low certainty; pharmacologic in addition to psychosocial intervention: RR = 1.15, 95% CI: 0.95 to 1.40, 363 participants, 3 trials, moderate certainty). Due to high levels of heterogeneity, we did not calculate pooled estimates comparing retention in brief (Heterogeneity: Tau² = 0.00; Q = 172.59, df = 11, P<.001; I 2 = 94%; 5380 participants; 12 trials, very low certainty) or other psychosocial interventions (Heterogeneity: Tau² = 0.01; Q = 34.07, df = 8, P<.001; I 2 = 77%; 1664 participants; 9 trials, very low certainty). Two pharmacologic trials and three combined pharmacologic and psychosocial trials reported on side effects. These studies found more side effects attributable to amitriptyline relative to mirtazapine, naltrexone and topiramate relative to placebo, yet no differences in side effects between placebo and either acamprosate or ondansetron. Across all intervention types there was substantial risk of bias. Primary threats to validity included lack of blinding and differential/high rates of attrition. Authors' conclusions In LMICs there is low‐certainty evidence supporting the efficacy of combined psychosocial and pharmacologic interventions on reducing harmful alcohol use relative to psychosocial interventions alone. There is insufficient evidence to determine the efficacy of pharmacologic or psychosocial interventions on reducing harmful alcohol use largely due to the substantial heterogeneity in outcomes, comparisons, and interventions that precluded pooling of these data in meta‐analyses. The majority of studies are brief interventions, primarily among men, and using measures that have not been validated in the target population. Confidence in these results is reduced by the risk of bias and significant heterogeneity among studies as well as the heterogeneity of results on different outcome measures within studies. More evidence on the efficacy of pharmacologic interventions, specific types of psychosocial interventions are needed to increase the certainty of these results. Plain language summary Interventions to reduce harmful alcohol use in low‐ and middle‐income countries Why is this review important? Harmful alcohol use is one of the main contributors to the global burden of disease. In low‐ and middle‐income countries, harmful alcohol use is increasing. However, services to prevent and treat harmful alcohol use are limited. One contributor to the lack of available services is the limited information about which intervention approaches are effective in reducing harmful alcohol use and whether these approaches are feasible and acceptable in low‐resource settings. In order to prevent the physical, psychological, and societal burden of harmful alcohol use, it is important that effective interventions are available to reduce alcohol‐related harm. What is the goal of this review? The goal of this review is to summarize evidence on whether psychosocial and pharmacologic interventions are able to reduce harmful alcohol use in low‐ and middle‐income countries. We also aim to evaluate the safety of treatments and how many people remain in treatment until its completion. What does the research say? We identified 66 randomized controlled trials that evaluated the effect of interventions on reducing harmful alcohol use. Most of these studies assessed psychosocial interventions (n = 52 studies), six assessed pharmacologic interventions alone, and eight assessed combined pharmacologic and psychosocial interventions. The majority of included trials were funded by government agencies (36 trials) followed by multiple public and private funders (8 trials) or private foundations (5 trials). Seventeen trials did not report the funding source. We are uncertain whether brief psychosocial interventions and other psychosocial interventions reduce harmful alcohol use. Combined pharmacologic and psychosocial interventions may reduce harmful alcohol use relative to psychosocial interventions combined with placebo, yet the certainty of the evidence has been assessed as low. No studies were found that looked at the effect of pharmacologic interventions alone on harmful alcohol use. We did not find evidence that rates of retention differed between study conditions for any of the intervention types. Certainty of evidence: The certainty of evidence on the effect of brief and other psychosocial interventions on harmful alcohol use was very low due to lack of masking, differential attrition and missing data, selective outcome reporting, high heterogeneity, and differences in patient populations. The certainty of evidence on the effect of combined pharmacologic and psychosocial interventions on harmful alcohol use was low due to lack of blinding, incomplete outcome data, and heterogeneity in the pharmacologic interventions under investigation. No studies evaluated the effect of pharmacologic interventions alone on harmful alcohol use. The evidence is current to 12 December 2021. What are the next steps? Future research on interventions to reduce harmful alcohol use is needed to address some of the limitations described in this review. Studies evaluating similar interventions across studies and contexts are needed to improve generalizability and understand the necessary characteristics of and conditions for effective intervention. Studies must utilize measurement tools that are valid in the population they are studying. Lastly, studies must be designed to reduce the risk of bias leading to the high degree of uncertainty in the results reported in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Greene, MC, Kane, J, Alto, M, Giusto, A, Lovero, K, Stockton, M, McClendon, J, Nicholson, T, Wainberg, ML., Johnson, RM, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013350.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.796Z" }, { "id": "d2fe9c01-d025-4be5-a442-bb25f494701d", "pmid": "", "title": "Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease", "imported": false, "abstract": "Abstract - Background Thyrotropin‐releasing hormones (TRH) added to prenatal corticosteroids has been suggested as a way to further reduce breathing problems and neonatal lung disease in infants born preterm. Objectives To assess the effects of giving prenatal TRH in addition to corticosteroids to women at risk of preterm birth for the prevention of neonatal respiratory disease. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013) and reference lists of retrieved studies. We also contacted trial authors. Selection criteria Randomised controlled trials in women at sufficient risk of preterm birth to warrant the use of prenatal corticosteroids to promote lung maturity. TRH and corticosteroids were compared with corticosteroids, with or without placebo. Data collection and analysis All assessments of trial eligibility, risk of bias and data extractions were independently carried out by at least two review authors. Main results Over 4600 women were recruited into the 15 trials included in the review, however two trials did not contribute any outcome data to the review. The trials had a moderate risk of bias. Overall, prenatal TRH, in addition to corticosteroids, did not reduce the risk of death prior to hospital discharge (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.86 to 1.27, six trials, 3694 infants), neonatal respiratory distress syndrome (average RR 1.05, 95% CI 0.91 to 1.22, nine trials, 3833 infants), or chronic lung disease (RR 1.01, 95% CI 0.85 to 1.19, five trials, 2511 infants), and did not improve any of the secondary fetal, neonatal or childhood outcomes assessed by intention‐to‐treat analyses. Indeed, the data showed prenatal TRH to have adverse effects for women and their infants. All side effects reported (nausea, vomiting, light headedness, urgency of micturition, facial flushing) were significantly more likely to occur in women receiving TRH. In the infants, prenatal TRH increased the risk of needing respiratory support (RR 1.16, 95% CI 1.03 to 1.29, three trials, 1969 infants), and of having a low Apgar score at five minutes (RR 1.48, 95% CI 1.14 to 1.92, three trials, 1969 infants). Only three trials provided data on childhood follow‐up, and while one trial suggested poorer outcomes for infants who were exposed to prenatal TRH, the other two trials, that assessed infants using an established developmental instrument, showed no clear differences between groups in follow‐up outcomes. Sensitivity analyses by trial quality, or subgroups with differing times from entry to birth, or different dose regimens of TRH, did not change these findings. Authors' conclusions Prenatal TRH in addition to corticosteroids, given to women at risk of preterm birth, does not improve infant outcomes and can cause maternal side effects. Plain language summary Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease Thyrotropin‐releasing hormone (TRH) given with corticosteroids does not improve the benefit of corticosteroids on the lungs of babies born too early, and may increase harm. Babies born preterm (before 37 weeks of pregnancy) are at risk of breathing difficulties (such as respiratory distress syndrome). TRH increases thyroid hormones in the baby and it has been thought that adding TRH to corticosteroids for women giving birth early may increase the benefit of corticosteroids on the baby's lungs. This review included 15 trials, of a moderate risk of bias, that involved over 4600 women and their babies. In this review, TRH, given with corticosteroids to women at risk of early birth, was not shown to further reduce the breathing difficulties for the babies. Babies born to mothers who had received TRH with corticosteroids, were more likely to require support for breathing than babies born to mothers who received only corticosteroids. Women receiving TRH were more likely to experience adverse side effects, such as nausea, vomiting and flushing than women who only received corticosteroids. Therefore, based on the current available evidence, TRH is not recommended to be given to women at risk of preterm birth for preventing neonatal respiratory disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Crowther, CA, Alfirevic, Z, Han, S, Haslam, RR", "articleTypes": [], "doi": "10.1002/14651858.CD000019.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.791Z" }, { "id": "d30f748d-c0c0-4024-9043-208250dddbd0", "pmid": "", "title": "Non‐nutritive sweeteners for diabetes mellitus", "imported": false, "abstract": "Abstract - Background Products sweetened with non‐nutritive sweeteners (NNS) are widely available. Many people with type 1 or type 2 diabetes use NNS as a replacement for nutritive sweeteners to control their carbohydrate and energy intake. Health outcomes associated with NNS use in diabetes are unknown. Objectives To assess the effects of non‐nutritive sweeteners in people with diabetes mellitus. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Scopus, the WHO ICTRP, and ClinicalTrials.gov. The date of the last search of all databases (except for Scopus) was May 2019. We last searched Scopus in January 2019. We did not apply any language restrictions. Selection criteria We included randomised controlled trials (RCTs) with a duration of four weeks or more comparing any type of NNS with usual diet, no intervention, placebo, water, a different NNS, or a nutritive sweetener in individuals with type 1 or type 2 diabetes. Trials with concomitant behaviour‐changing interventions, such as diet, exercise, or both, were eligible for inclusion, given that the concomitant interventions were the same in the intervention and comparator groups. Data collection and analysis Two review authors independently screened abstracts, full texts, and records retrieved from trials registries, assessed the certainty of the evidence, and extracted data. We used a random‐effects model to perform meta‐analysis, and calculated effect estimates as risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs). We assessed risk of bias using the Cochrane 'Risk of bias' tool and the certainty of evidence using the GRADE approach. Main results We included nine RCTs that randomised a total of 979 people with type 1 or type 2 diabetes. The intervention duration ranged from 4 to 10 months. We judged none of these trials as at low risk of bias for all ’Risk of bias’ domains; most of the included trials did not report the method of randomisation. Three trials compared the effects of a dietary supplement containing NNS with sugar: glycosylated haemoglobin A1c (HbA1c) was 0.4% higher in the NNS group (95% CI −0.5 to 1.2; P = 0.44; 3 trials; 72 participants; very low‐certainty evidence). The MD in weight change was −0.1 kg (95% CI −2.7 to 2.6; P = 0.96; 3 trials; 72 participants; very low‐certainty evidence). None of the trials with sugar as comparator reported on adverse events. Five trials compared NNS with placebo. The MD for HbA1c was 0%, 95% CI −0.1 to 0.1; P = 0.99; 4 trials; 360 participants; very low‐certainty evidence. The 95% prediction interval ranged between −0.3% and 0.3%. The comparison of NNS versus placebo showed a MD in body weight of −0.2 kg, 95% CI −1 to 0.6; P = 0.64; 2 trials; 184 participants; very low‐certainty evidence. Three trials reported the numbers of participants experiencing at least one non‐serious adverse event: 36/113 participants (31.9%) in the NNS group versus 42/118 participants (35.6%) in the placebo group (RR 0.78, 95% CI 0.39 to 1.56; P = 0.48; 3 trials; 231 participants; very low‐certainty evidence). One trial compared NNS with a nutritive low‐calorie sweetener (tagatose). HbA1c was 0.3% higher in the NNS group (95% CI 0.1 to 0.4; P = 0.01; 1 trial; 354 participants; very low‐certainty evidence). This trial did not report body weight data and adverse events. The included trials did not report data on health‐related quality of life, diabetes complications, all‐cause mortality, or socioeconomic effects. Authors' conclusions There is inconclusive evidence of very low certainty regarding the effects of NNS consumption compared with either sugar, placebo, or nutritive low‐calorie sweetener consumption on clinically relevant benefit or harm for HbA1c, body weight, and adverse events in people with type 1 or type 2 diabetes. Data on health‐related quality of life, diabetes complications, all‐cause mortality, and socioeconomic effects are lacking. Plain language summary Non‐nutritive sweeteners for diabetes mellitus Review question Are non‐nutritive sweeteners beneficial or harmful in people with diabetes? Background Non‐nutritive sweeteners are sweetening agents having higher sweetening intensity and lower calorie content per gram compared to caloric sweeteners like sucrose or corn syrups. Both the general population and diabetic people use non‐nutritive sweeteners as a caloric sweetener replacement to control their carbohydrate and energy intake. Most of the non‐nutritive sweeteners approved for human consumption are synthetic (artificial sweeteners); however, increasing numbers of natural non‐caloric sweeteners are becoming available for human consumption. Products sweetened with non‐nutritive sweeteners are widely available on the market: diet beverages, diet yoghourts, desserts, and chewing gums are the most common products containing non‐nutritive sweeteners. Non‐nutritive sweeteners are also available as table‐top sweeteners for use by consumers at home as a sweetening agent for beverages and for cooking and baking. There is very little information about the health consequences of this intensified non‐nutritive sweeteners consumption in people with diabetes. We wanted to find out whether non‐nutritive sweeteners consumption in people with diabetes has an effect on long‐term average blood sugar levels (glycosylated haemoglobin A1c ‐ HbA1c), body weight, side effects, diabetes complications (such as heart attack, eye or kidney disease), and health‐related quality of life. Study characteristics We found nine randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) that allocated people with diabetes to either a group that received a non‐nutritive sweetener or a comparator group. The comparator was usual diet with additional sugar in three studies; placebo (a dummy pill) in five studies; and tagatose (a nutritive low‐calorie sweetener) in one study. The studies included a total of 979 participants; most of the studies were small, with fewer than 100 participants. The length of the studies varied from 4 to 10 months. This evidence is up‐to‐date as of May 2019. Key results Data on health‐related quality of life, diabetes complications, death from any cause, and socioeconomic effects (such as absence from work, visits to general practitioner, medication consumption) were lacking, and data were generally sparse for all comparisons. The available data did not show a clear difference between non‐nutritive sweeteners and sugar, placebo, or the nutritive low‐calorie sweetener tagatose for HbA1c, body weight, and side effects. Certainty of the evidence We rated the overall certainty of the evidence as very low, mainly due to the small numbers of included studies and participants and methodological limitations of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lohner, S, Kuellenberg de Gaudry, D, Toews, I, Ferenci, T, Meerpohl, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD012885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.087Z" }, { "id": "d33a9192-f19e-4ca7-8ee7-746c8b221431", "pmid": "", "title": "Cannabinoids for fibromyalgia", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue affecting approximately 2% of the general population. People often report high disability levels and poor health‐related quality of life (HRQoL). Drug therapy focuses on reducing key symptoms and disability, and improving HRQoL. Cannabis has been used for millennia to reduce pain and other somatic and psychological symptoms. Objectives To assess the efficacy, tolerability and safety of cannabinoids for fibromyalgia symptoms in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE to April 2016, together with reference lists of retrieved papers and reviews, three clinical trial registries, and contact with trial authors. Selection criteria We selected randomised controlled trials of at least four weeks' duration of any formulation of cannabis products used for the treatment of adults with fibromyalgia. Data collection and analysis Two review authors independently extracted the data of all included studies and assessed risk of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs; at least 200 participants in the comparison, eight to 12 weeks' duration, parallel design), second tier evidence from data that did not meet one or more of these criteria and were considered at some risk of bias but with adequate numbers (i.e. data from at least 200 participants) in the comparison, and third tier evidence from data involving small numbers of participants that were considered very likely to be biased or used outcomes of limited clinical utility, or both. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Main results We included two studies with 72 participants. Overall, the two studies were at moderate risk of bias. The evidence was derived from group mean data and completer analysis (very low quality evidence overall). We rated the quality of all outcomes according to GRADE as very low due to indirectness, imprecision and potential reporting bias. The primary outcomes in our review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Nabilone was compared to placebo and to amitriptyline in one study each. Study sizes were 32 and 40 participants. One study used a cross‐over design and one used a parallel group design; study duration was four or six weeks. Both studies used nabilone, a synthetic cannabinoid, with a bedtime dosage of 1 mg/day. No study reported the proportion of participants experiencing at least 30% or 50% pain relief or who were very much improved. No study provided first or second tier (high to moderate quality) evidence for an outcome of efficacy, tolerability and safety. Third tier (very low quality) evidence indicated greater reduction of pain and limitations of HRQoL compared to placebo in one study. There were no significant differences to placebo noted for fatigue and depression (very low quality evidence). Third tier evidence indicated better effects of nabilone on sleep than amitriptyline (very low quality evidence). There were no significant differences between the two drugs noted for pain, mood and HRQoL (very low quality evidence). More participants dropped out due to adverse events in the nabilone groups (4/52 participants) than in the control groups (1/20 in placebo and 0/32 in amitriptyline group). The most frequent adverse events were dizziness, nausea, dry mouth and drowsiness (six participants with nabilone). Neither study reported serious adverse events during the period of both studies. We planned to create a GRADE 'Summary of findings' table, but due to the scarcity of data we were unable to do this. We found no relevant study with herbal cannabis, plant‐based cannabinoids or synthetic cannabinoids other than nabilone in fibromyalgia. Authors' conclusions We found no convincing, unbiased, high quality evidence suggesting that nabilone is of value in treating people with fibromyalgia. The tolerability of nabilone was low in people with fibromyalgia. Plain language summary Cannabis products for people with fibromyalgia Background Fibromyalgia is characterised by chronic (longer than three months) widespread pain that often co‐exists with sleep problems, problems with thinking and fatigue (exhaustion). People often report severe limitations of daily functioning and poor health‐related quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. Cannabis has been used for 3000 years to reduce pain and other symptoms, such as loss of appetite and anxiety. Key results and quality of the evidence In April 2016 we searched for reports of clinical trials that used cannabis products to treat symptoms in adults with fibromyalgia. We found two small, moderate quality studies, of four and six weeks long, including 72 participants. Both studies tested nabilone, a synthetic (man‐made) cannabis product, comparing it with placebo (a dummy pill) or amitriptyline (an antidepressant frequently used in the treatment of fibromyalgia). Nabilone did not convincingly relieve fibromyalgia symptoms (pain, sleep, fatigue) better than placebo or amitriptyline (very low quality evidence). Compared with placebo and amitriptyline, more people experienced side effects and left the study due to side effects (very low quality evidence). There were no serious side effects reported. We found no relevant study with herbal cannabis, plant‐based cannabinoids or other synthetic cannabinoids than nabilone in fibromyalgia. There was not enough high quality evidence available to draw any robust conclusions. We found no studies on medical cannabis in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B; Klose, P; Fitzcharles, M-A; Phillips, T; Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "d34b8d52-c168-4320-afdd-4c8b6f81c058", "pmid": "", "title": "Corticosteroids for treating sepsis in children and adults", "imported": false, "abstract": "Abstract - Background Sepsis occurs when an infection is complicated by organ failure. Sepsis may be complicated by impaired corticosteroid metabolism. Thus, providing corticosteroids may benefit patients. This is an update of a review originally published in 2004 and previously updated in 2010, 2015 and 2019. Objectives To examine the benefits and harms of corticosteroids in children and adults with sepsis. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, ISRCTN and the WHO Clinical Trials Search Portal on 31 December 2023. In addition, we conducted reference checking and citation research, and contacted study authors, to identify additional studies as needed. We updated this search in December 2024, but these results have not yet been incorporated. Selection criteria We included randomised controlled trials (RCTs) of corticosteroids versus placebo or usual care (antimicrobials, fluid replacement and vasopressor therapy as needed) in children and adults with sepsis. We also included RCTs of continuous infusion versus intermittent bolus of corticosteroids. Data collection and analysis We used the same methods in comparisons of corticosteroids versus placebo or usual care, and of continuous infusion versus intermittent bolus administration of corticosteroids. The primary outcome was all‐cause mortality at 28 days. The most critical secondary outcomes were (i) all‐cause mortality in the long term (last follow‐up from 90 days to one year) and in the hospital; (ii) length of stay in the intensive care unit and in hospital; (iii) adverse effects, i.e. superinfection and muscle weakness (within 28 days). All review authors screened and selected studies for inclusion. One review author extracted data, which was checked by the others, and by the lead author of the primary study when possible. For this update, we used Covidence software for screening and selection of studies and abstraction of data by paired review authors, with discrepancies resolved by a third review author. We obtained unpublished data from the authors of some trials. We assessed the risk of bias in trials using the Cochrane risk of bias tool (RoB 1) and applied GRADE to assess the certainty of evidence. The review authors did not contribute to the assessment of eligibility or risk of bias, nor to data extraction, for the trials they had participated in. Main results We included 87 trials (24,336 participants), of which six included only children, two included children and adults, and the remaining trials included only adults. Seventeen additional trials are ongoing and will be considered in future versions of this review. We judged 25 trials as being at low risk of bias. Corticosteroids versus placebo or usual care Compared to placebo or usual care, corticosteroids probably reduce 28‐day mortality (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.84 to 0.95; 72 trials, 22,915 participants; moderate‐certainty evidence). We downgraded the certainty of evidence for this outcome from high to moderate for inconsistency (significant heterogeneity across trial results). Corticosteroids may result in little to no difference in long‐term mortality (RR 0.97, 95% CI 0.91 to 1.03; 12 trials, 8468 participants; low‐certainty evidence) and probably reduce in‐hospital mortality (RR 0.90, 95% CI 0.84 to 0.97; 40 trials, 17,459 participants; moderate‐certainty evidence). Corticosteroids may reduce length of intensive care unit (ICU) stay for all participants (mean difference (MD) ‐0.86 days, 95% CI ‐1.67 to ‐0.05; 25 trials, 8069 participants; low‐certainty evidence) and may reduce length of hospital stay for all participants (MD ‐1.09 days, 95% CI ‐1.85 to ‐0.34; 31 trials, 16,954 participants; low‐certainty evidence). The evidence is uncertain about the effect of corticosteroids on the risk of muscle weakness (RR 1.09, 95% CI 0.78 to 1.53; 7 trials, 6729 participants; very low‐certainty evidence). Corticosteroids may result in little to no difference in the risk of superinfection (RR 0.96, 95% CI 0.86 to 1.07; 36 trials, 7961 participants; low‐certainty evidence). Continuous infusion of corticosteroids versus intermittent bolus Four trials reported data for this comparison, and the certainty of evidence for all outcomes was very low. We are uncertain about the effects of continuous infusion of corticosteroids compared with intermittent bolus administration on 28‐day mortality (RR 1.03, 95% CI 0.81 to 1.32; 3 trials, 310 participants). We downgraded the certainty of evidence to very low due to high risk of bias in all except one trial and due to imprecision. Compared to bolus administration, we are uncertain of the effects of continuous infusion of corticosteroids on long‐term mortality (RR 1.36, 95% CI 1.02 to 1.81; 1 trial, 70 participants; very low‐certainty evidence), in‐hospital mortality (RR 0.92, 95% CI 0.71 to 1.19; 3 trials, 352 participants; very low‐certainty evidence), ICU length of stay amongst all participants (MD ‐0.56 days, 95% CI ‐3.44 to 2.32; 4 trials, 422 participants; very low‐certainty evidence), hospital length of stay amongst all participants (MD ‐0.21 days, 95% CI ‐4.72 to 4.30; 4 trials, 422 participants; very low‐certainty evidence), risk of muscle weakness (RR 0.89, 95% CI 0.13 to 5.98; 1 trial, 70 participants; very low‐certainty evidence) and risk of superinfection (RR 1.12, 95% CI 0.37 to 3.33; 2 trials, 193 participants; very low‐certainty evidence). Authors' conclusions Moderate‐certainty evidence indicates that corticosteroids probably reduce 28‐day, 90‐day and hospital mortality amongst patients with sepsis. Corticosteroids may shorten ICU and hospital length of stay (low‐certainty evidence). There may be little or no difference in the risk of superinfection. The risk of muscle weakness is uncertain. The effects of continuous versus intermittent bolus administration of corticosteroids are uncertain. Plain language summary What are the benefits and harms of corticosteroids in the treatment of children and adults with sepsis? Key messages • Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days and of in‐hospital death, and may have little or no effect on the risk of dying beyond three months. • We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. • Future studies should measure the benefits and harms of corticosteroids for the treatment of specific populations, including children, patients with sepsis without shock or with a mild form of septic shock, patients with acute respiratory distress syndrome (ARDS) and patients with different types of infections. Defining the optimal methods for corticosteroid administration, including the types of molecule ‐ with or without producing sodium and fluid retention and potassium excretion (mineralocorticoid activity), timing of initiation, dose and duration, continuous infusion or intermittent intravenous boluses, and ending of treatment ‐ with or without gradually decreasing the dose to zero, also requires additional studies. Future studies should measure the longer‐term effects, i.e. longer than one year, on survival and complications of sepsis. What is sepsis? Sepsis is present when an infection is complicated by organ failure. People develop rapid breathing, hypotension (low blood pressure) and mental confusion. Sepsis can interfere with the effectiveness of the body’s corticosteroids, which control how your body recognises and defends itself against bacteria, viruses and substances that appear foreign and harmful. What are corticosteroids (medicine)? Corticosteroids are medicines used to stop excessive inflammation. However, these medicines may cause unwanted harms, such as increased blood sugar or salt levels, infections, bleeding in the stomach, agitation or delirium, and weakness of the limbs. Corticosteroids have been given for decades to people with infection resulting from various causes. What did we want to find out? We wanted to find out: • the benefits of using corticosteroids in children and adults with sepsis; and • the best ways to administer this treatment (including the best people to give it to). We also wanted to know if corticosteroids can cause any unwanted effects. What did we do? We searched for studies that compared: • corticosteroids administered intravenously against a 'dummy' treatment, or sham treatment, which does not contain any medicine but looks or tastes identical to corticosteroids, or usual care; or • continuous infusion against intermittent rapid intravenous injections (boluses) of corticosteroids administration. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? This review includes 87 trials (24,336 participants). The biggest study was of 3800 people and the smallest study was of 21 people. Eighty‐three trials compared corticosteroids to no corticosteroids (placebo or usual care in 59 and 24 trials, respectively). Four trials also compared continuous administration versus rapid intravenous injection (i.e. bolus) of corticosteroids given at fixed intervals of six or eight hours. Thirty‐three trials were conducted in Europe, 15 in North America, 22 in Asia, six in the Middle East, six in Africa and three in Latin America; four were multinational trials. Three trials were funded by a drug company, 27 by public organisations or through charitable funding and six by both a drug company and public organisations or charitable funding; 25 did not declare the source of funding. Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days by 10% (72 trials; 22,915 participants), with consistent treatment effects between children and adults. There may be little or no effect of corticosteroids on the risk of dying over the long term (longer than three months), but these results are less certain. Corticosteroids probably reduce the risk of dying in hospital. Corticosteroids may result in a reduction in the length of stay in the intensive care unit (ICU) and in hospital. They may not increase the risk of superinfection (second infection). The evidence is very uncertain about the effect of corticosteroids on the risk of muscle weakness. We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. Four studies reported data for this comparison, and the certainty of evidence for all outcomes was very low. What are the limitations of the evidence? • Corticosteroids versus placebo or usual care We have moderate confidence in our findings that corticosteroids reduced 28‐day mortality. We found some differences amongst the study populations, the types of corticosteroids and how they were given, and the use of additional medicines. • Continuous infusion versus bolus administration of corticosteroids We have very little confidence in our findings about the absence of a difference in 28‐day mortality between the administration of corticosteroids continuously and repeated rapid intravenous injections. We found only four studies that enrolled very few patients. How up‐to‐date is this evidence? The evidence provided in this review is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Annane, D, Briegel, J, Granton, D, Bellissant, E, Bollaert, PE, Keh, D, Kupfer, Y, Pirracchio, R, Rochwerg, B", "articleTypes": [], "doi": "10.1002/14651858.CD002243.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.824Z" }, { "id": "d35b4b09-211e-419f-b7fe-ac2d159bad3c", "pmid": "", "title": "Interventions for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is the most common, life‐limiting, genetically inherited disease. It affects multiple organs, particularly the respiratory system. However, gastrointestinal problems such as constipation and distal intestinal obstruction syndrome (DIOS) are also important and well‐recognised complications in CF. They share similar symptoms e.g. bloating, abdominal pain, but are distinct conditions. Constipation occurs when there is gradual faecal impaction of the colon, but DIOS occurs when there is an accumulation of faeces and sticky mucus, forming a mass in the distal part of the small intestine. The mass may partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). Symptoms of DIOS can affect quality of life and other aspects of CF health, such as airway clearance, exercise, sleep and nutritional status. Treatment of constipation and prevention of complete bowel obstruction are required for gastrointestinal management in CF. However, many different strategies are used in clinical practice and there is a lack of consensus. The importance of this topic was highlighted in a recent research priority setting exercise by the James Lind Alliance. Objectives To evaluate the effectiveness and safety of laxative agents of differing types for preventing DIOS (complete and incomplete) in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised and quasi‐randomised controlled parallel trials comparing laxative therapy for preventing DIOS (including osmotic agents, stimulants, mucolytics and substances with more than one action) at any dose to placebo, no treatment or an alternative laxative therapy, in people of any age with pancreatic sufficient or insufficient CF and any stage of lung disease. Randomised cross‐over trials were judged on an individual basis. Data collection and analysis Two authors independently assessed trials for inclusion, extracted outcome data and performed a risk of bias assessment for the included data. We judged the certainty of the evidence using GRADE criteria. Main results We included one cross‐over trial (17 participants) with a duration of 12 months, in which participants were randomly allocated to either cisapride (a gastro‐prokinetic agent) or placebo for six months each. The trial had an unclear risk of bias for most domains but had a high risk of reporting bias. Radiograph scores revealed no difference in occurrence of DIOS between cisapride and placebo (narrative report, no data provided). There were no adverse effects. Symptom scores were the only secondary outcome within the review that were reported. Total gastrointestinal symptom scores favoured cisapride with a statistically significant mean difference (MD) of ‐7.60 (95% confidence interval (CI) ‐14.73 to ‐0.47). There was no significant difference at six months between cisapride and placebo for abdominal distension, MD ‐0.90 (95% CI ‐2.39 to 0.59) or abdominal pain, MD ‐0.4 (95% CI ‐2.05 to 1.25). The global symptom scores (whether individuals felt better or worse) were reported in the paper to favour cisapride and be statistically significant (P < 0.05). We assessed the available data to be very low certainty. There was a great deal of missing data from the included trial and the investigators failed to report numerical data for many outcomes. The overall risk of bias of the trial was unclear and it had a high risk for reporting bias. There was also indirectness; the trial drug (cisapride) has since been removed from the market in several countries due to adverse effects, thus it has no current applicability for preventing DIOS. The included trial also had very few participants, which downgraded the certainty a further level for precision. Authors' conclusions There is an absence of evidence for interventions for the prevention of DIOS. As there was only one included trial, we could not perform a meta‐analysis of the data. Furthermore, the included trial compared a prokinetic agent (cisapride) that is no longer licensed for use in a number of countries due to the risk of serious cardiac events, a finding that came to light after the trial was conducted. Therefore, the limited findings from the trial are not applicable in current clinical practice. Overall, a great deal more research needs to be undertaken on gastrointestinal complications in CF, as this is a very poorly studied area compared to respiratory complications in CF. Plain language summary Which interventions are effective and safe for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis? Background Cystic fibrosis (CF) is an inherited, life‐long condition that causes organ systems in the body to produce large amounts of thick and sticky mucus. The most commonly affected area is the lungs, in which thick mucus leads to recurrent chest infections and breathing difficulties. Another commonly affected area is the digestive system. Many people with CF suffer from bloating and abdominal pain which may be caused by constipation or distal intestinal obstruction syndrome (DIOS). In DIOS, overproduction of thick mucus combines with stool and sticks to the intestinal wall. This mass can partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). The latter causes severe pain, vomiting and is treated as a medical emergency. As part of effective care for people with CF, constipation should therefore be treated and complete bowel obstruction be prevented. It is also important to recognise that constipation and DIOS impact on other aspects of CF health. Bloating, abdominal pain and nausea may affect airway clearance, exercise and sleep. Nutritional status may also be affected due to decreased appetite and malabsorption. DIOS may affect the absorption of other medications taken by people with CF. Overall, DIOS can significantly impair quality of life. Different laxatives are currently used in clinics, but prescribing practices differ and there is no consensus on optimal treatment strategies. Hence, this review aimed to analyse the evidence for the preventing DIOS. Search date We last searched for evidence: 12 October 2021. Trial characteristics We included one trial in the review, which included 17 people aged between 13 to 35 years. These people were randomly put into groups to take either a placebo drug (with no active medication) or cisapride for six months each and then to cross over and take the alternative treatment for a further six months. Key results The trial used radiography to diagnose DIOS, but did not provide any data and only stated that there was no difference between cisapride and placebo. The trial also stated that there were no adverse effects from the cisapride. The trial assessed participant‐reported total and individual gastrointestinal symptom scores. People in the cisapride group reported an improvement in total gastrointestinal symptom scores compared to those in the placebo group. However, there were no differences reported between groups for the individual symptom scores of abdominal pain and abdominal distension (swelling). Participants also reported global symptom scores, which showed that most people felt better taking cisapride compared to placebo. Certainty of the evidence The overall certainty of the evidence was very low. With one trial in this review, we could not combine data from different trials. The trial did not provide enough information about the methods used for allocating participants or about missing data and did not fully report certain results. The small number of participants also lowered the precision of the results. Since this trial was conducted, cisapride has been removed from the market in a number of countries due to rare but serious heart complications, therefore it has no applicability to current clinical practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carroll, W, Green, J, Gilchrist, FJ", "articleTypes": [], "doi": "10.1002/14651858.CD012619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.082Z" }, { "id": "d368d80c-cfd4-4784-aa45-7295bbc89915", "pmid": "", "title": "Inhaled hyperosmolar agents for bronchiectasis", "imported": false, "abstract": "Abstract - Background Mucus retention in the lungs is a prominent feature of bronchiectasis. The stagnant mucus becomes chronically colonised with bacteria, which elicit a host neutrophilic response. This fails to eliminate the bacteria, and the large concentration of host‐derived protease may contribute to the airway damage. The sensation of retained mucus is itself a cause of suffering, and the failure to maintain airway sterility probably contributes to the frequent respiratory infections experienced by many patients. Hypertonic saline inhalation is known to accelerate tracheobronchial clearance in many conditions, probably by inducing a liquid flux into the airway surface, which alters mucus rheology in a way favourable to mucociliary clearance. Inhaled dry powder mannitol has a similar effect. Such agents are an attractive approach to the problem of mucostasis, and deserve further clinical evaluation. Objectives To determine whether inhaled hyperosmolar substances are effective in the treatment of bronchiectasis. Search methods We searched the Cochrane Airways Group Specialised Register, trials registries, and the reference lists of included studies and review articles. Searches are current up to April 2014. Selection criteria Any randomised controlled trial (RCT) using hyperosmolar inhalation in patients with bronchiectasis not caused by cystic fibrosis. Data collection and analysis Two review authors assessed studies for suitability. We used standard methods recommended by The Cochrane Collaboration. Main results Eleven studies met the inclusion criteria of the review (1021 participants). Five studies on 833 participants compared inhaled mannitol with placebo but poor outcome reporting meant we could pool very little data and most outcomes were reported by only one study. One 12‐month trial on 461 participants provided results for exacerbations and demonstrated an advantage for mannitol in terms of time to first exacerbation (median time to exacerbation 165 versus 124 days for mannitol and placebo respectively (hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.63 to 0.96, P = 0.022) and number of days on antibiotics for bronchiectasis exacerbations was significantly better with mannitol (risk ratio (RR) 0.76, 95%CI 0.58 to 1.00, P = 0.0496). However, exacerbation rate per year was not significantly different between mannitol and placebo (RR 0.92 95% CI 0.78 to 1.08). The quality of this evidence was rated as moderate. There was also an indication, from only three trials, again based on moderate quality evidence, that mannitol improves health‐related quality of life (mean difference (MD) ‐2.05; 95% CI ‐3.69 to ‐0.40). An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo (OR 0.96; 95% CI 0.61 to 1.51). Two additional small trials on 25 participants compared mannitol versus no treatment and the data from these studies were inconclusive. Four studies (combined N = 113) compared hypertonic saline versus isotonic saline. On most outcomes there were conflicting results and the opportunities for the statistical aggregation of data from studies was very limited. It is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Authors' conclusions There is an indication from a single, large, unpublished study that inhaled mannitol increases time to first exacerbation in patients with bronchiectasis. In patients with near normal lung function, spirometry does not change dramatically with mannitol and adverse events are not more frequent than placebo. Further investigation is required in a patient population with impaired lung function. It is not possible to draw firm conclusions regarding the effect of nebulised hypertonic saline due to significant differences in the methodology, patient groups, and findings amongst the limited data available. The data suggest that it is unlikely to have benefit over isotonic saline in patients with milder disease, and hence future studies should test its use in those with more severe disease Plain language summary Inhaled hyperosmolar agents for bronchiectasis Review question We wanted to know if inhaled hyperosmolar agents ‐ treatments which help people cough up sputum ‐ may be helpful for people with bronchiectasis. We only included trials on people who had bronchiectasis and who did not have cystic fibrosis. Therefore we are unable to draw any conclusions for people with cystic fibrosis. Background Bronchiectasis is a lung condition that usually develops after a series of lung problems (such as childhood infections, problems in the lung structure, tuberculosis, and cystic fibrosis). A lot of mucus (phlegm) collects in the lungs, causing discomfort and the need to cough it up. The phlegm also collects bacteria, which can add to breathing difficulties and make people very ill by causing recurring lung infections that are difficult to clear with antibiotics. Breathing in (inhaling) hypertonic saline (salt solutions with a greater salt content than blood) liquids may help clear this mucus, as may the drug mannitol (inhaled in dry powder form). This is because the concentrated salt or sugar (mannitol) draws water into the mucus in the lung and makes it thinner and easier to cough out. Study characteristics We found 11 randomised controlled trials on 1021 participants that compared inhaled hyperosmolar agents versus no mucolytic treatment. Five studies compared inhaled mannitol versus placebo (with a total of 883 participants) and two very small studies (with a total of just 25 participants) compared inhaled mannitol with no treatment. We also found four studies (with a total of 113 participants) that compared hypertonic saline with isotonic (normal) saline. Key results For the comparison between mannitol and placebo only one study (a 12‐month trial with 461 participants) provided information on the number of people who had an exacerbation (or flare up) over the course of a year. This study showed that people who were treated with mannitol had 8% fewer exacerbations on average compared with placebo. Overall, we felt the quality of this evidence was moderate and new trials would be likely to change either how effective we think the treatment is or how confident we are about it. Three trials assessed the effect of mannitol on health‐related quality of life, and again the quality of the evidence was rated as moderate. An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo The trials comparing hypertonic saline with isotonic saline had conflicting results for most of the outcomes of interest. Because we were unable to combine the data, it is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. Our analysis of adverse events between hypertonic saline versus isotonic saline showed no significant difference however this was based on a single study and the quality of the evidence was moderate. Quality of the evidence Details of how the patients in the trials were allocated to receive mannitol or not was clearly described in only one of the studies, and similarly only one of the hypertonic saline versus isotonic saline studies provided this information. The general lack of information on this point was considered carefully in the review in relation to our level of uncertainty in interpreting the results. Taking this into account, the quality of evidence was generally regarded as moderate both for the mannitol and hypertonic saline studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hart, A; Sugumar, K; Milan, SJ; Fowler, SJ; Crossingham, I", "articleTypes": [], "doi": "10.1002/14651858.CD002996.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "d381ae3b-33c2-4a79-a2f6-9ba41e698ff1", "pmid": "", "title": "Effects of Lutein Supplementation on Macular Pigment Optical Density and Visual Acuity in Patients With Age-related Macular Degeneration", "imported": false, "abstract": "The macular pigment (MP) in humans consists of the yellow, blue-absorbing carotenoids lutein and zeaxanthin. The highest concentrations of lutein and zeaxanthin are found in the fovea. Since light entering the eye passes through the MP before reaching the photo receptors it absorbs a significant portion of short-wavelength light. There is evidence that this absorbing properties of the MP as well as the ability of inactivating highly reactive oxygen species are protective for the retina.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "d39500d9-28c9-4766-b48d-4786409c0eb9", "pmid": "", "title": "Pain relief in hysterosalpingography", "imported": false, "abstract": "Abstract - Background Hysterosalpingography (HSG) is a method of testing for tubal patency. However, women struggle to tolerate the procedure, as it is associated with some discomfort. Various pharmacological strategies are available that may reduce pain during the procedure, though there is no consensus as to the best method. Objectives To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing HSG for investigation of subfertility. Search methods This review has drawn on the search strategy developed for the Cochrane Menstrual Disorders and Subfertility Group (MDSG). We searched the following databases to 15 April 2015: MDSG Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO. Selection criteria All identified randomised controlled trials investigating pharmacological interventions for pain relief during HSG were investigated for selection. Data collection and analysis Four review authors independently extracted data. We combined data to calculate mean differences (MDs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I² statistic. We assessed the overall quality of the evidence for the main comparisons using GRADE methods. Main results The search identified 23 trials (1272 women) that were eligible for inclusion into the study. Oral opioid analgesia versus placebo/no treatment There was no evidence of effect for oral opioid analgesia in reducing pain during the procedure (MD −0.91, 95% CI −1.88 to 0.06, 1 study, n = 128, low quality evidence) or more than 30 minutes after the procedure (MD −0.99, 95% CI −1.75 to −0.23, 1 study, n = 128, moderate quality evidence) No studies reported on the effect of oral opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes after the procedure There was insufficient evidence to reach conclusions regarding adverse effects. Intravenous opioid analgesia versus placebo/no treatment There was evidence that intravenous opioids may improve pain relief during the procedure compared to no treatment (MD −3.53, 95% CI −4.29 to −2.77, 1 study, n = 62, moderate quality evidence) No studies reported on the effect of intravenous opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes and more than 30 minutes after the procedure In terms of adverse effects, one trial reported 1/32 participants had apnoea with intravenous remifentanil. Recovery time was nearly 4 minutes longer in the remifentanil group compared to the control. Oral non‐opioid analgesia versus placebo/no treatment There was no evidence of effect for oral non‐opioid analgesia in reducing pain during the procedure (MD −0.13, 95% CI −0.48 to 0.23, 3 studies, n = 133, I² = 61%, low quality evidence), less than 30 minutes after the procedure (MD −0.30, 95% CI −1.03 to 0.43, 2 studies, n = 45, I² = 97%, very low quality evidence), or more than 30 minutes after the procedure (MD −0.36, 95% CI −1.06 to 0.34, 3 studies, n = 133, I² = 58%, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Topical anaesthesia versus placebo/no treatment There was evidence that topical anaesthetics may reduce pain during the procedure (MD −0.63, 95% CI −1.06 to −0.19, 9 studies, n = 613, I² = 66%, low quality evidence). There was no evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD 0.42, 95% CI ‐0.03 to 0.86, 5 studies, n = 373, I² = 59%, very low quality evidence). There was evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain more than 30 minutes after the procedure (MD −1.38, 95% CI ‐3.44 to −0.68, 2 studies, n = 166, I² = 92%, very low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Locally injected anaesthesia versus placebo/no treatment There was evidence of effect that locally injected anaesthetic can reduce pain during the procedure (MD −1.31, 95% CI −1.55 to −1.07, 2 studies, n = 125, I² = 0%, very low quality evidence). There was no evidence of effect for locally injected anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD −1.31, 95% CI −2.14 to −0.49, 2 studies, n = 125, I² = 46%, low quality evidence). No studies were included into the analysis of the effect of locally injected anaesthesia, when injected prior to the procedure, in reducing pain more than 30 minutes after the procedure. There was insufficient evidence to reach conclusions regarding adverse effects. Any analgesic versus any other analgesic There was no evidence of a difference between the groups when oral non‐opioid analgesia was compared to opioid analgesia for pain relief during the procedure (MD 1.10, 95% CI −0.26 to 2.46, 1 study, n = 91, low quality evidence); less than 30 minutes following the procedure (MD −0.30, 95% CI −1.00 to 0.40, 1 study, n = 91, low quality evidence); and more than 30 minutes following the procedure (MD −0.60, 95% CI −1.56 to 0.36, 1 study, n = 91, low quality evidence). Topical anaesthetics were found to be more effective than paracervical block for pain relief during HSG (MD −2.73, 95% CI −3.86 to −1.60, 1 study, n = 20, moderate quality evidence). This benefit did not extend to within 30 minutes following HSG (MD −1.03, 95% CI −2.52 to 0.46, 1 study, n = 20, low quality evidence); or 30 minutes or more after HSG (MD 0.31, 95% CI −0.87 to 1.49, 1 study, n = 20, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Authors' conclusions Topical anaesthetic applied before the procedure may be associated with effective pain relief during HSG, though the quality of this evidence is low. Intravenous opioids may also be effective in pain relief, though this must be weighed against their side effects and their effects on the recovery time. There is insufficient evidence to draw conclusions on the efficacy of other analgesics for HSG, or to reach any other conclusions regarding adverse effects. Plain language summary Drug treatments for pain relief in hysterosalpingography Review question: Which pain‐killers are effective at reducing the discomfort experienced with hysterosalpingography? Background: Hysterosalpingography (HSG) is a test used in investigating infertility in women. HSG involves a dye being introduced into the uterus and the connecting tubes, which enables them to be visualised using an x‐ray, allowing the clinician to assess how open the connecting tubes are. This can be a painful procedure. There is disagreement regarding the best form of pain relief during the procedure. Study characteristics: We identified 19 randomised controlled trials that compared a specific drug treatment to a placebo/no treatment. Four trials compared two different drug treatments to establish if one was better. All studies took place in a clinical setting. Age of participants ranged from 18 to 42 years. Studies took place in India, Australia, United Kingdom, United States of America, Turkey, Israel, Netherlands, Italy, Iran, Nigeria, Spain, Brazil, and Belgium (1272 women in total). We included 15 of these trials in a meta‐analysis. The remaining eight trials, while eligible for inclusion, did not have data in a format that could be entered into meta‐analysis (seven compared a specific drug to a placebo/no treatment, one compared two different drug treatments). The evidence is current to April 2015. Key results : Topical anaesthetic was associated with a mild reduction in the pain experienced during HSG (low quality evidence). However, it has no effect on the discomfort experienced by participants following the procedure (very low quality evidence). Locally injected anaesthetics, on the other hand, were not associated with any benefit. Only one study investigated this (moderate quality evidence). One study directly compared locally injected anaesthetics to topical anaesthetics. This study found that topical anaesthesia was associated with improved pain relief during the procedure (moderate quality evidence) No oral drug was found to be effective in reducing pain experienced during the procedure. This was true for both opioid (low quality evidence) and non‐opioid (low quality evidence) analgesia. One trial however reported that tramadol may be of benefit in reducing the pain experienced more than 30 minutes after the procedure (moderate quality evidence). Quality of the evidence: The quality of the combined results was mainly downgraded for two reasons: 1) studies having methods that may be at risk of bias/inaccuracy; 2) substantially different conclusions between studies that investigate the same drug. The included studies did not report side effects in large enough numbers to make definitive conclusions regarding the side effects of particular drugs during the procedure. Conclusions: Only topical anaesthetics and intravenous opioids were found to be of benefit in reducing pain during the procedure, though the quality of this evidence is low to moderate, and there is no evidence that these are effective at relieving pain following the procedure. There is insufficient evidence for other drug treatments in reducing pain during HSG. There was insufficient evidence to reach any conclusions regarding adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hindocha, A; Beere, L; O'Flynn, H; Watson, A; Ahmad, G", "articleTypes": [], "doi": "10.1002/14651858.CD006106.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "d3a52dea-4524-42b0-b382-73b2cedc51e3", "pmid": "", "title": "Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)", "imported": false, "abstract": "Abstract - Background Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015. Objectives To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate. Selection criteria We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non‐serious, general behaviour, and quality of life. Data collection and analysis Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel‐group trials and first‐period data from cross‐over trials formed the basis of our primary analyses. We undertook separate analyses using end‐of‐last period data from cross‐over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach. Main results We included 212 trials (16,302 participants randomised); 55 parallel‐group trials (8104 participants randomised), and 156 cross‐over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross‐over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male‐female ratio was 3:1. Most trials were carried out in high‐income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias. Primary outcomes: methylphenidate versus placebo or no intervention may improve teacher‐rated ADHD symptoms (standardised mean difference (SMD) −0.74, 95% confidence interval (CI) −0.88 to −0.61; I² = 38%; 21 trials; 1728 participants; very low‐certainty evidence). This corresponds to a mean difference (MD) of −10.58 (95% CI −12.58 to −8.72) on the ADHD Rating Scale (ADHD‐RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD‐RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68). Secondary outcomes: methylphenidate may cause more adverse events considered non‐serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low‐certainty evidence). The TSA‐adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher‐rated general behaviour versus placebo (SMD −0.62, 95% CI −0.91 to −0.33; I² = 68%; 7 trials 792 participants; very low‐certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI −0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low‐certainty evidence). Authors' conclusions The majority of our conclusions from the 2015 version of this review still apply. Our updated meta‐analyses suggest that methylphenidate versus placebo or no‐intervention may improve teacher‐rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non‐serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non‐serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes. Plain language summary Is methylphenidate an effective treatment for children and adolescents with attention deficit hyperactivity disorder (ADHD) and does it cause unwanted effects? Key messages ‐ Methylphenidate might reduce hyperactivity and impulsivity and might help children to concentrate. Methylphenidate might also help to improve general behaviour, but does not seem to affect quality of life. ‐ Methylphenidate does not seem to increase the risk of serious (life‐threatening) unwanted effects when used for periods of up to six months. However, it is associated with an increased risk of non‐serious unwanted effects like sleeping problems and decreased appetite. ‐ Future studies should focus more on reporting unwanted effects and should take place over longer periods of time. What is attention deficit hyperactivity disorder (ADHD)? ADHD is one of the most commonly diagnosed and treated childhood psychiatric disorders. Children with ADHD find it hard to concentrate. They are often hyperactive (fidgety, unable to sit still for long periods) and impulsive (doing things without stopping to think). ADHD can make it difficult for children to do well at school, because they find it hard to follow instructions and to concentrate. Their behavioural problems can interfere with their ability to get on well with family and friends, and they often get into more trouble than other children. How is ADHD treated? Methylphenidate (for example, Ritalin) is the medication most often prescribed to children and adolescents with ADHD. Methylphenidate is a stimulant that helps to increase activity in parts of the brain, such as those involved with concentration. Methylphenidate can be taken as a tablet or given as a skin patch. It can be formulated to have an immediate effect, or be delivered slowly, over a period of hours. Methylphenidate may cause unwanted effects, such as headaches, stomachaches and problems sleeping. It sometimes causes serious unwanted effects like heart problems, hallucinations, or facial 'tics' (twitches). What did we want to find out? We wanted to find out if methylphenidate improves children's ADHD symptoms (attention, hyperactivity) based mainly on teachers' ratings using various scales, and whether it causes serious unwanted effects, like death, hospitalisation, or disability. We were also interested in less serious unwanted effects like sleep problems and loss of appetite, and its effects on children's general behaviour and quality of life. What did we do? We searched for studies that investigated the use of methylphenidate in children and adolescents with ADHD. Participants in the studies had to be aged 18 years or younger and have a diagnosis of ADHD. They could have other disorders or illnesses and be taking other medication or undergoing behavioural treatments. They had to have a normal IQ (intelligence quotient). Studies could compare methylphenidate with placebo (something designed to look and taste the same as methylphenidate but with no active ingredient) or no treatment. Participants had to be randomly chosen to receive methylphenidate or not. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 212 studies with 16,302 children or adolescents with ADHD. Most of the trials compared methylphenidate with placebo. Most studies were small with around 70 children, with an average age of 10 years (ages ranged from 3 to 18 years). Most studies were short, lasting an average of around a month; the shortest study lasted just one day and the longest 425 days. Most studies were in the USA. Based on teachers' ratings, compared with placebo or no treatment, methylphenidate: ‐ may improve ADHD symptoms (21 studies, 1728 children) ‐ may make no difference to serious unwanted effects (26 studies, 3673 participants) ‐ may cause more non‐serious unwanted effects (35 studies, 5342 participants) ‐ may improve general behaviour (7 trials 792 participants) ‐ may not affect quality of life (4 trials, 608 participants) Limitations of the evidence Our confidence in the results of the review is limited for several reasons. It was often possible for people in the studies to know which treatment the children were taking, which could influence the results. The reporting of the results was not complete in many studies and for some outcomes the results varied across studies. Studies were small and they used different scales for measuring symptoms. And most of the studies only lasted for a short period of time, making it impossible to assess the long‐term effects of methylphenidate. Around 41% of studies were funded or partly funded by the pharmaceutical industry. How up to date is this evidence? This is an update of a review conducted in 2015. The evidence is current to March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Storebø, OJ; Storm, MR; Pereira Ribeiro, J; Skoog, M; Groth, C; Callesen, HE; Schaug, JP; Darling, P; Huus, C-ML; Zwi, M; Kirubakaran, R; Simonsen, E; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD009885.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "d3a793eb-c4ff-47d3-b2b4-4fef23b8176d", "pmid": "", "title": "Systemic opioids versus other analgesics and sedatives for postoperative pain in neonates", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Kinoshita, M, Stempel, KS, Borges do Nascimento, IJ, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD014876.pub2 AB - Abstract - Background Neonates may undergo surgery because of malformations such as diaphragmatic hernia, gastroschisis, congenital heart disease, and hypertrophic pyloric stenosis, or complications of prematurity, such as necrotizing enterocolitis, spontaneous intestinal perforation, and retinopathy of prematurity that require surgical treatment. Options for treatment of postoperative pain include opioids, non‐pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported. The assessment of the effects of opioids is of utmost importance, especially for neonates in substantial pain during the postoperative period. Objectives To evaluate the benefits and harms of systemic opioid analgesics in neonates who underwent surgery on all‐cause mortality, pain, and significant neurodevelopmental disability compared to no intervention, placebo, non‐pharmacological interventions, different types of opioids, or other drugs. Search methods We searched Cochrane CENTRAL, MEDLINE via PubMed and CINAHL in May 2021. We searched the WHO ICTRP, clinicaltrials.gov, and ICTRP trial registries. We searched conference proceedings, and the reference lists of retrieved articles for RCTs and quasi‐RCTs. Selection criteria We included randomized controlled trials (RCTs) conducted in preterm and term infants of a postmenstrual age up to 46 weeks and 0 days with postoperative pain where systemic opioids were compared to 1) placebo or no intervention; 2) non‐pharmacological interventions; 3) different types of opioids; or 4) other drugs. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods, all‐cause mortality during initial hospitalization, major neurodevelopmental disability, and cognitive and educational outcomes in children more than five years old. We used the fixed‐effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) for continuous data. We used GRADE to assess the certainty of evidence for each outcome. Main results We included four RCTs enrolling 331 infants in four countries across different continents. Most studies considered patients undergoing large or medium surgical procedures (including major thoracic or abdominal surgery), who potentially required pain control through opioid administration after surgery. The randomized trials did not consider patients undergoing minor surgery (including inguinal hernia repair) and those individuals exposed to opioids before the beginning of the trial. Two RCTs compared opioids with placebo; one fentanyl with tramadol; and one morphine with paracetamol. No meta‐analyses could be performed because the included RCTs reported no more than three outcomes within the prespecified comparisons. Certainty of the evidence was very low for all outcomes due to imprecision of the estimates (downgrade by two levels) and study limitations (downgrade by one level). Comparison 1: opioids versus no treatment or placebo Two trials were included in this comparison, comparing either tramadol or tapentadol with placebo. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of tramadol compared with placebo on all‐cause mortality during initial hospitalization (RR 0.32, 95% Confidence Interval (CI) 0.01 to 7.70; RD ‐0.03, 95% CI ‐0.10 to 0.05, 71 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 2: opioids versus non‐pharmacological interventions No trials were included in this comparison. Comparison 3: head‐to‐head comparisons of different opioids One trial comparing fentanyl with tramadol was included in this comparison. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of fentanyl compared with tramadol on all‐cause mortality during initial hospitalization (RR 0.99, 95% CI 0.59 to 1.64; RD 0.00, 95% CI ‐0.13 to 0.13, 171 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 4: opioids versus other analgesics and sedatives One trial comparing morphine with paracetamol was included in this comparison. The evidence is very uncertain about the effect of morphine compared with paracetamol on COMFORT pain scores (MD 0.10, 95% CI ‐0.85 to 1.05; 71 participants, 1 study; I² = not applicable). No data were reported on the other critical outcomes, i.e. major neurodevelopmental disability; cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization; retinopathy of prematurity; or intraventricular hemorrhage. Authors' conclusions Limited evidence is available on opioid administration for postoperative pain in newborn infants compared to either placebo, other opioids, or paracetamol. We are uncertain whether tramadol reduces mortality compared to placebo; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether fentanyl reduces mortality compared to tramadol; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether morphine reduces pain compared to paracetamol; none of the studies reported major neurodevelopmental disability, cognitive and educational outcomes in children more than five years old, all‐cause mortality during initial hospitalization, retinopathy of prematurity, or intraventricular hemorrhage. We identified no studies comparing opioids versus non‐pharmacological interventions. Plain language summary Are opioids the best choice for managing pain in babies after surgery? Key messages • We did not find enough good‐quality evidence about the benefits and risks of opioids (a group of pain‐relieving medicines) to manage pain after surgery in babies. We found only four studies and they had not enrolled enough babies to give reliable results. • Larger, well‐designed studies are needed to give better estimates of the benefits and potential harms of opioids, other medicines and non‐medicine‐based treatments. Why are opioids given to manage pain after surgery in babies? Babies (particularly in the first four weeks after birth) often have to have surgeries. Similar to adults, they need constant pain management after these operations and opioids are commonly used for post‐surgery pain relief in babies. What did we want to find out? We wanted to find out the impact of giving opioids to babies having surgery, compared to: 1) no treatment or placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested); 2) non‐medicine‐based treatments (such as sweet solutions); 3) other medicines; or 4) different types of opioids. What did we do? We searched for studies that compared opioids with the four treatments described above. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included four studies that involved 331 babies. The biggest study was in 171 babies and the smallest study was in 15 babies. • Two studies compared opioids with placebo: it is unclear if opioids have an effect on mortality; no studies reported pain, long‐term development, vision problems (retinopathy of prematurity) or bleeding to the brain (intraventricular hemorrhage). • One study compared one type of opioid to another type of opioid: it is unclear if fentanyl has an effect on mortality compared to tramadol; no studies reported pain, long‐term development, vision problems or bleeding to the brain. • One study compared an opioid to a different type of pain‐relieving medicine: it is unclear if the opioid morphine has an effect on pain compared with paracetamol; no studies reported long‐term development, mortality, vision problems or bleeding to the brain. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results of our outcomes. Also, it is possible that people in the studies were aware of what treatment they were given. Not all the studies provided data about everything that we were interested in. How up‐to‐date is this review? 
We searched for studies that were available up to May 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.788Z" }, { "id": "d3a7b0a5-f220-4d10-a27b-84b1ba144a1a", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Omega‐3 fatty acids (n‐3, fish oil) have been shown to have anti‐inflammatory properties. Therefore, n‐3 therapy may be beneficial in chronic inflammatory disorders such as ulcerative colitis. Objectives To systematically review the efficacy and safety of n‐3 for maintaining remission in ulcerative colitis (UC). Search methods The following databases were searched from their inception without language restriction: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Healthstar, PubMed, and ACP journal club. Experts were contacted for unpublished data. Selection criteria Randomized placebo‐controlled trials (RCT) of fish oil for maintenance of remission in UC were included. Studies must have enrolled patients (of any age group) who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. The primary outcome was relapse rate and the secondary outcome was frequency of adverse events. Other outcomes to assess efficacy were change in disease activity scores and time to first relapse. Data collection and analysis Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality. Meta‐analysis weighted by the Mantel‐Haenszel method was performed using RevMan 4.2.8 software. Random or fixed effect models were used according to degree of heterogeneity and subgroup analyses were performed to explore heterogeneity. A sensitivity analysis was performed excluding a study of questionable quality . Main results The three studies that were included used different formulation and dosing of n‐3 but none used enteric coated capsules. The pooled analysis showed a similar relapse rate in the n‐3 treated patients and controls (RR 1.02; 95% CI 0.51 to 2.03; P = 0.96). Combining the studies resulted in virtually no statistical heterogeneity (P = 0.93, I 2 = 0%). Various subgroup and sensitivity analyses showed similar results. However, the total number of patients enrolled in these studies was small (n = 138). No significant adverse events were recorded in any of the studies and not enough data were available to pool the other secondary outcomes for meta‐analysis. Authors' conclusions No evidence was found that supports the use of omega 3 fatty acids for maintenance of remission in UC. Further studies using enteric coated capsules may be justified. Plain language summary Omega 3 fatty acids for maintenance of remission in ulcerative colitis Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of ulcerative colitis patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of omega‐3 fatty acids to maintain remission in ulcerative colitis were reviewed. Three studies were included of which none reported a reduction in the rate of disease relapse in comparison with placebo. When the studies were pooled for meta‐analysis there was no benefit for omega 3 fatty acids. There were no serious side effects in any of the studies. None of the studies used enteric coated capsules which allow release of the fish oil in the small bowel. Non‐enteric coated omega‐3 fatty acids (fish oil) seem safe but ineffective for maintaining remission in ulcerative colitis. Further studies of enteric coated capsules may be justified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Turner, D; Steinhart, AH; Griffiths, AM", "articleTypes": [], "doi": "10.1002/14651858.CD006443.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "d3a8991b-38af-4930-a163-7a106fda3198", "pmid": "", "title": "Over the counter (OTC) artificial tear drops for dry eye syndrome", "imported": false, "abstract": "Abstract - Background Over the counter (OTC) artificial tears historically have been the first line of treatment for dry eye syndrome and dry eye‐related conditions like contact lens discomfort, yet currently we know little regarding the overall efficacy of individual, commercially available artificial tears. This review provides a much needed meta‐analytical look at all randomized and quasi‐randomized clinical trials that have analyzed head‐to‐head comparisons of OTC artificial tears. Objectives To evaluate the effectiveness and toxicity of OTC artificial tear applications in the treatment of dry eye syndrome compared with another class of OTC artificial tears, no treatment, or placebo. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 12), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2015), EMBASE (January 1980 to December 2015), Latin American and Caribbean Health Sciences (LILACS) (January 1982 to December 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) and the US Food and Drugs Administration (FDA) website ( www.fda.gov ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 December 2015. We searched reference lists of included trials for any additional trials not identified by the electronic searches. Selection criteria This review includes randomized controlled trials with adult participants who were diagnosed with dry eye, regardless of race and gender. We included trials in which the age of participants was not reported, and clinical trials comparing OTC artificial tears with another class of OTC artificial tears, placebo, or no treatment. This review did not consider head‐to‐head comparisons of artificial tears with another type of dry‐eye therapy. Data collection and analysis We followed the standard methodological procedures expected by Cochrane. Two authors independently screened the search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. We performed meta‐analysis for trials that compared similar interventions and reported comparable outcomes with sufficient data. We summarized all other included trial results in the text. Main results We included 43 randomized controlled trials (3497 participants with dry eye). Due to the heterogeneity of study characteristics among the included trials with respect to types of diagnostic criteria, interventions, comparisons, and measurements taken, our ability to perform meta‐analyses was limited. The review found that, in general, there was uncertainty whether different OTC artificial tears provide similar relief of signs and symptoms when compared with each other or placebo. Nevertheless, we found that 0.2% polyacrylic acid‐based artificial tears were consistently more effective at treating dry eye symptoms than 1.4% polyvinyl alcohol‐based artificial tears in two trials assessing this comparison (175 participants). All other included artificial tears produced contradictory between‐group results or found no between‐group differences. Our review also found that OTC artificial tears may be generally safe, but not without adverse events. Overall, we assessed the quality of evidence as low due to high risks of bias among included trials and poor reporting of outcome measures which were insufficient for quantitative analysis. Furthermore, we identified an additional 18 potentially eligible trials that were reported only in clinical trial registers with no associated results or publications. These trials reportedly enrolled 2079 total participants for whom no data are available. Such lack of reporting of trial results represents a high risk of publication bias. Authors' conclusions OTC artificial tears may be safe and effective means for treating dry eye syndrome; the literature indicates that the majority of OTC artificial tears may have similar efficacies. This conclusion could be greatly skewed by the inconsistencies in study designs and inconsistencies in reporting trial results. Additional research is therefore needed before we can draw robust conclusions about the effectiveness of individual OTC artificial tear formulations. Plain language summary Efficacy of over the counter (OTC) artificial tears for dry eye syndrome Research question What is the effect of over the counter (OTC) artificial tears on dry eye syndrome? Background 
 Dry eye syndrome is a long‐term condition that is known to cause eye discomfort and visual disturbances like blurred vision. This condition affects millions of people around the world, and the first‐line treatment for dry eye is typically over the counter (OTC) artificial tears. OTC artificial tears are meant to replace or supplement the tears (fluid) that naturally cover the eye’s front surface (cornea and conjunctiva). There are a great number of commercially available artificial tears, yet there is currently no agreement about whether one formulation works better than another at treating dry eye. Our review attempts to bridge this knowledge gap. Study characteristics 
 This review included 43 randomized controlled trials (3497 people with dry eye) that compared OTC artificial tears with other OTC artificial tears, with no treatment, or with placebo. We considered participant symptoms to be the primary outcome for this review. We recorded other commonly performed dry eye tests as secondary outcomes (e.g. vision, tear stability). We measured primary and secondary outcomes at two and four weeks, although we also considered other time points in this review. We searched for trials up to December 2015. Key results 
 This review analyzed many OTC artificial tear formulations, and most of the literature indicates uncertainty as to which OTC artificial tear works best. The literature also shows that OTC artificial tears may be effective at treating dry eye symptoms and that OTC artificial tears are generally safe, although not without side effects. We also identified an additional 18 potentially eligible trials that were registered, but did not provide any results or publications. These trials may have enrolled 2079 total participants for whom no data are available. Without the results of these trials, the effects of the OTC artificial tears that they evaluated are unknown. Quality of the evidence The overall quality of the evidence was low for the various OTC artificial tear formulations compared in this review. This finding indicates that future published research may have an important impact on the conclusions currently provided in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pucker, AD; Ng, SM; Nichols, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD009729.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "d3aa0303-9f2b-4b0e-88ad-ff0b62474fc0", "pmid": "", "title": "Lycopene for the prevention of prostate cancer", "imported": false, "abstract": "Abstract - Background Prostate cancer is a common cause of death in developed countries, yet the benefits of screening for prostate cancer still remain controversial. A prostate‐specific antigen (PSA) test result greater than 4 ng/mL (nanograms/millilitre) has commonly been used as the cut‐off level for seeking further tests to diagnose the presence (or absence) of prostate cancer. An increase in PSA levels may not necessarily be associated with an increased risk of prostate cancer, as PSA levels may also be increased in men with benign prostatic hyperplasia and prostatitis. Despite the uncertainty of the net benefit of early detection and treatment, safe and effective methods to prevent prostate cancer are of value. Consumers, seeking greater involvement in their healthcare, are increasingly turning to lifestyle modification and complementary and alternative medicines (CAMs) to maintain their health and prevent disease. Lycopene is a member of the carotenoid family, which is found abundantly in tomatoes, tomato‐based products, strawberries, and watermelon. It has been hypothesised that lycopene is a strong antioxidant, which may lower the risk of cancer (including prostate cancer) in people who have diets rich in lycopene. Objectives To determine whether lycopene reduces the incidence of prostate cancer and prostate cancer‐specific mortality. Secondary objectives include changes in PSA levels, prostate symptoms and the nature of adverse events associated with lycopene use. Search methods Electronic searches were conducted across MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases. No language or other limitations were imposed. Selection criteria Randomised controlled trials (RCTs) that investigated the use of lycopene for the prevention of prostate cancer were eligible for inclusion in this review. Data collection and analysis A search of electronic databases, performed in August 2011, identified 64 citations. All articles were selected for full‐text review. From these citations, three studies were identified as meeting the inclusion criteria. Handsearching did not provide any additional studies. Main results Three RCTs, with a total of 154 participants were included in this review. None of the studies reported data on prostate cancer mortality. All of the included studies differed with respect to design, participants included and allocation of lycopene. This clinical heterogeneity limits the value on the pooled estimated of the meta‐analyses. The methodological quality of two of the three included studies was assessed as posing a 'high' risk of bias. Meta‐analysis indicated no statistical difference in PSA levels between men randomised to receive lycopene and the comparison group (MD (mean difference) ‐0.34, 95% CI (confidence interval) ‐2.01 to 1.32). Only one study reported incidence of prostate cancer (10% in the lycopene group versus 30% in control group). The level of lycopene was also not statistically different in men randomised to receive lycopene and the comparison group (MD 0.39 µg/mL (micrograms/millilitre), 95% CI ‐0.19 to 0.98). No other meta‐analyses were possible since other outcomes assessed only had one study contributing data. Authors' conclusions Given that only three RCTs were included in this systematic review, and the high risk of bias in two of the three studies, there is insufficient evidence to either support, or refute, the use of lycopene for the prevention of prostate cancer. Similarly, there is no robust evidence from RCTs to identify the impact of lycopene consumption upon the incidence of prostate cancer, prostate symptoms, PSA levels or adverse events. Plain language summary Lycopene for the prevention of prostate cancer Prostate cancer is a common form of cancer affecting men worldwide. Pharmaceutical interventions, such as 5‐alpha reductase inhibitors, have been identified as potentially preventing prostate cancer incidence in men. Many men modify lifestyle and consume complementary and alternative medicines to maintain better health and prevent disease. Lycopene is a supplement that has been suggested may assist in the prevention of prostate cancer due to its antioxidant effects. The objective of this systematic review was to identify the effectiveness of lycopene in the prevention of prostate cancer. This review identified 3 relevant studies, comprising 154 participants in total. Two of the studies were assessed to be of 'high' risk of bias. Meta‐analysis of two studies indicated no statistical difference in prostate specific antigen (PSA) levels between men randomised to receive lycopene and the comparison group (MD ‐0.34, 95% CI ‐2.01 to 1.32). None of the studies assessed prostate cancer mortality. No other meta‐analyses were possible since other outcomes assessed only had one study contributing data.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Ilic, D; Forbes, KM; Hassed, C", "articleTypes": [], "doi": "10.1002/14651858.CD008007.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "d3c8e3f6-52ae-4926-998b-e37ce8f0441b", "pmid": "", "title": "Magnesium for skeletal muscle cramps", "imported": false, "abstract": "Abstract - Background Skeletal muscle cramps are common and often occur in association with pregnancy, advanced age, exercise or motor neuron disorders (such as amyotrophic lateral sclerosis). Typically, such cramps have no obvious underlying pathology, and so are termed idiopathic. Magnesium supplements are marketed for the prophylaxis of cramps but the efficacy of magnesium for this purpose remains unclear. This is an update of a Cochrane Review first published in 2012, and performed to identify and incorporate more recent studies. Objectives To assess the effects of magnesium supplementation compared to no treatment, placebo control or other cramp therapies in people with skeletal muscle cramps. Search methods On 9 September 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, CINAHL Plus, AMED, and SPORTDiscus. We also searched WHO‐ICTRP and ClinicalTrials.gov for registered trials that might be ongoing or unpublished, and ISI Web of Science for studies citing the studies included in this review. Selection criteria Randomized controlled trials (RCTs) of magnesium supplementation (in any form) to prevent skeletal muscle cramps in any patient group (i.e. all clinical presentations of cramp). We considered comparisons of magnesium with no treatment, placebo control, or other therapy. Data collection and analysis Two review authors independently selected trials for inclusion and extracted data. Two review authors assessed risk of bias. We attempted to contact all study authors when questions arose and obtained participant‐level data for four of the included trials, one of which was unpublished. We collected all data on adverse effects from the included RCTs. Main results We identified 11 trials (nine parallel‐group, two cross‐over) enrolling a total of 735 individuals, amongst whom 118 cross‐over participants additionally served as their own controls. Five trials enrolled women with pregnancy‐associated leg cramps (408 participants) and five trials enrolled people with idiopathic cramps (271 participants, with 118 additionally crossed over to control). Another study enrolled 29 people with liver cirrhosis, only some of whom suffered muscle cramps. All trials provided magnesium as an oral supplement, except for one trial which provided magnesium as a series of slow intravenous infusions. Nine trials compared magnesium to placebo, one trial compared magnesium to no treatment, calcium carbonate or vitamin B, and another trial compared magnesium to vitamin E or calcium. We judged the single trial in people with liver cirrhosis and all five trials in participants with pregnancy‐associated leg cramps to be at high risk of bias. In contrast, we rated the risk of bias high in only one of five trials in participants with idiopathic rest cramps. For idiopathic cramps, largely in older adults (mean age 61.6 to 69.3 years) presumed to have nocturnal leg cramps (the commonest presentation), differences in measures of cramp frequency when comparing magnesium to placebo were small, not statistically significant, and showed minimal heterogeneity (I² = 0% to 12%). This includes the primary endpoint, percentage change from baseline in the number of cramps per week at four weeks (mean difference (MD) −9.59%, 95% confidence interval (CI) −23.14% to 3.97%; 3 studies, 177 participants; moderate‐certainty evidence); and the difference in the number of cramps per week at four weeks (MD −0.18 cramps/week, 95% CI −0.84 to 0.49; 5 studies, 307 participants; moderate‐certainty evidence). The percentage of individuals experiencing a 25% or better reduction in cramp rate from baseline was also no different (RR 1.04, 95% CI 0.84 to 1.29; 3 studies, 177 participants; high‐certainty evidence). Similarly, no statistically significant difference was found at four weeks in measures of cramp intensity or cramp duration. This includes the number of participants rating their cramps as moderate or severe at four weeks (RR 1.33, 95% CI 0.81 to 2.21; 2 studies, 91 participants; moderate‐certainty evidence); and the percentage of participants with the majority of cramp durations of one minute or more at four weeks (RR 1.83, 95% CI 0.74 to 4.53, 1 study, 46 participants; low‐certainty evidence). We were unable to perform meta‐analysis for trials of pregnancy‐associated leg cramps. The single study comparing magnesium to no treatment failed to find statistically significant benefit on a three‐point ordinal scale of overall treatment efficacy. Of the three trials comparing magnesium to placebo, one found no benefit on frequency or intensity measures, another found benefit for both, and a third reported inconsistent results for frequency that could not be reconciled. The single study in people with liver cirrhosis was small and had limited reporting of cramps, but found no difference in terms of cramp frequency or cramp intensity. Our analysis of adverse events pooled all studies, regardless of the setting in which cramps occurred. Major adverse events (occurring in 2 out of 72 magnesium recipients and 3 out of 68 placebo recipients), and withdrawals due to adverse events, were not significantly different from placebo. However, in the four studies for which it could be determined, more participants experienced minor adverse events in the magnesium group than in the placebo group (RR 1.51, 95% CI 0.98 to 2.33; 4 studies, 254 participants; low��certainty evidence). Overall, oral magnesium was associated with mostly gastrointestinal adverse events (e.g. diarrhoea), experienced by 11% (10% in control) to 37% (14% in control) of participants. Authors' conclusions It is unlikely that magnesium supplementation provides clinically meaningful cramp prophylaxis to older adults experiencing skeletal muscle cramps. In contrast, for those experiencing pregnancy‐associated rest cramps the literature is conflicting and further research in this population is needed. We found no RCTs evaluating magnesium for exercise‐associated muscle cramps or disease‐state‐associated muscle cramps (for example amyotrophic lateral sclerosis/motor neuron disease) other than a single small (inconclusive) study in people with liver cirrhosis, only some of whom suffered cramps. Plain language summary Magnesium for muscle cramps Review question We reviewed the evidence about the effect of magnesium supplements on muscle cramps, and included the widest possible range of studies. This meant including studies on anyone suffering muscle cramps, regardless of why they suffered them. It also meant including studies where magnesium was given in any of the ways available. This includes being swallowed as a pill or liquid, being injected slowly over a number of hours directly into the blood ('intravenous infusion'), and being injected into muscle ('intramuscular injection'). We included studies comparing magnesium to placebo, comparing magnesium to no treatment, and comparing magnesium to other existing cramp treatments. We found a total of 11 studies. To assess benefit, we examined the effect of magnesium on cramp frequency, cramp pain, and cramp duration, and we examined the number of participants whose cramp rate reduced by 25% or more. To assess for potential harm, we examined how often major and minor adverse health events occurred. Background Muscle cramps are common and occur in a wide range of settings. Older adults and pregnant women commonly complain of leg cramps while they are resting, athletes can cramp when they are pushing the limits of their endurance, and some people develop muscle cramps as a symptom of other medical conditions. One potential treatment that is already being marketed to prevent muscle cramps is magnesium supplementation. Magnesium is a common mineral in our diets and extra oral supplements of this mineral are available either over the Internet or in health food stores and pharmacies (usually in the form of tablets or powders to be dissolved in water). We wanted to combine studies to get the best estimate of magnesium's effect on cramping. We also wanted to examine the effect of magnesium in different categories of cramp sufferers, in case it might work in one setting, and not another. Study characteristics We searched for all high‐quality published studies evaluating the effectiveness of magnesium to prevent muscle cramps and found five studies in older adults, five studies in pregnant women, and one study in people with liver cirrhosis. The studies in older adults included 271 participants (61.6 to 69.3 years of age) and the studies in pregnant women included 408 participants. The single study in people with liver cirrhosis enrolled only 29 people, not all of whom experienced cramping. There were no studies of people who cramp while exercising. Magnesium was compared to placebo in nine of 11 studies, and compared to calcium, vitamin E, vitamins B₁ and B₆, and no treatment, in two studies of pregnant women. The included studies ranged from 14 to 56 days of treatment. Magnesium was given orally in 10 of 11 studies, and by four‐hour intravenous infusion on five consecutive days in one study. Funding for included studies came from a manufacturer of magnesium tablets in two studies, independent sources in three studies, and was not reported in six studies. Key results and certainty of the evidence The combined results of five seemingly reliable studies suggest, with moderate‐certainty, that magnesium is unlikely to reduce the frequency or severity of muscle cramps in older adults. In contrast, the five studies in pregnant women had important limitations to their reliability (both in study design and reporting of results), did not consistently show benefit, and could not be combined. As a result we are very uncertain as to whether pregnant women experiencing muscle cramps would benefit from magnesium. The single study in people with liver cirrhosis reported no difference in cramp frequency or intensity but was too small for conclusions to be drawn. More research on magnesium in pregnant women is needed. The same is true for those who suffer cramps associated with medical conditions, or while exercising. However older adult cramp sufferers appear unlikely to benefit from this therapy. Major side effects were infrequent and participants withdrew from the study at similar rates when given magnesium or placebo. However minor side effects, mostly diarrhoea (as would be expected from magnesium salts) and nausea, were common and affected roughly 11% (10% in control) to 37% (14% in control) of participants. The review is up to date to September 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Garrison, SR; Korownyk, CS; Kolber, MR; Allan, GM; Musini, VM; Sekhon, RK; Dugré, N", "articleTypes": [], "doi": "10.1002/14651858.CD009402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "d3e1ef53-7310-4fd7-8e24-4f25c9ba0719", "pmid": "", "title": "Chlorhexidine mouthrinse as an adjunctive treatment for gingival health", "imported": false, "abstract": "Abstract - Background Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build‐up of plaque thereby reducing gingivitis. Objectives To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day). To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs. Data collection and analysis Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random‐effects models for all meta‐analyses. Main results We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high‐quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high‐quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate‐quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies). Authors' conclusions There is high‐quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high‐quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies. Plain language summary Chlorhexidine mouthrinse to reduce gingivitis and plaque build‐up Review question Does the use of chlorhexidine mouthrinse (a broad spectrum antiseptic) in addition to other conventional tooth cleaning help to control and improve gingivitis (inflammation of the gums)? Does the frequency of rinsing or the concentration of the solution affect the result and are there any undesirable side effects? Background Gingivitis is a reversible condition when gums become red, swollen and can bleed easily. Gingivitis is also very common ‐ studies suggest that as many as 50% to 90% of adults in the UK and USA suffer from it. In susceptible people gingivitis may lead to periodontitis, which is not reversible. In periodontitis inflammation is accompanied by loss of ligaments and bone supporting the teeth. If untreated it may eventually lead to tooth loss. Severe periodontitis is the sixth most widespread disease globally. It is recognised that maintaining a high standard of oral hygiene is important for the prevention and treatment of gingivitis. Toothbrushing is the main method for maintaining good oral hygiene. Other cleaning methods commonly used include dental floss, interdental brushes and scaling and polishing carried out by a dental professional. Some people have difficulty controlling plaque build‐up and preventing gingivitis using only conventional tooth cleaning. Therefore people sometimes use mouthrinses containing chlorhexidine in addition to conventional tooth cleaning. These mouthrinses are readily available over the counter; prescriptions generally not being required outside the USA. Study characteristics We included 51 studies that analysed a total of 5345 participants. The evidence in this review is up to date as of 28 September 2016. Generally study participants were children and adults who had gingivitis or periodontitis, were able to use usual tooth cleaning methods and were healthy. We did not exclude studies where some or all participants had medical conditions or special care needs as we considered the use of mouthrinses with chlorhexidine to be particularly relevant to them. The included studies assessed the effects of chlorhexidine mouthrinse used for at least 4 weeks in addition to conventional tooth cleaning on gingivitis in children and adults. Key results There is high‐quality evidence that the use of mouthrinses containing chlorhexidine in addition to usual toothbrushing and cleaning for 4 to 6 weeks or 6 months leads to a large reduction in the build‐up of plaque. There is also high‐quality evidence of a moderate reduction in gingivitis in people with a mild level of it, although because the level of disease was already low this is not considered clinically important. The nature of the available evidence does not allow us to determine the level of reduction of gingivitis in people with moderate to severe levels of it. There was no evidence that one concentration or strength of chlorhexidine rinse was more effective than another. Rinsing for 4 weeks or longer causes tooth staining, which requires scaling and polishing carried out by a dental professional. Other side effects have been reported, including build‐up of calculus (tartar), temporary taste disturbance and temporary shedding of/damage to the lining of the mouth. Quality of the evidence One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "James, P; Worthington, HV; Parnell, C; Harding, M; Lamont, T; Cheung, A; Whelton, H; Riley, P", "articleTypes": [], "doi": "10.1002/14651858.CD008676.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "d3e32926-fd71-4ab1-9c70-2ff2f1c58b8a", "pmid": "", "title": "Listening to music for insomnia in adults", "imported": false, "abstract": "Abstract - Background Insomnia is a common problem in modern society. It is associated with reduced quality of life and impairments in physical and mental health. Listening to music is widely used as a sleep aid, but it remains unclear if it can actually improve insomnia in adults. This Cochrane Review is an update of a review published in 2015. Objectives To assess the effects of listening to music on sleep in adults with insomnia and to assess the influence of specific variables that may moderate the effect . Search methods For this update, we searched CENTRAL, MEDLINE, Embase, nine other databases and two trials registers up to December 2021. In addition, we handsearched reference lists of included studies, and contacted authors of published studies to identify additional studies eligible for inclusion, including any unpublished or ongoing trials. Selection criteria Randomised controlled trials comparing the effects of listening to music with no treatment or treatment as usual (TAU) in adults complaining of sleep difficulties. Data collection and analysis Two review authors independently screened records for eligibility, selected studies for inclusion, extracted data and assessed risk of bias of the included studies. We assessed the certainty of the evidence using GRADE. The primary outcomes were sleep quality, insomnia severity, sleep‐onset latency, total sleep time, sleep interruption, sleep efficiency and adverse events. Data on the predefined outcome measures were included in meta‐analyses when consistently reported by at least two studies that were homogeneous in terms of participants, interventions and outcomes. We undertook meta‐analyses using random‐effects models. Main results We included 13 studies (eight studies new to this update) comprising 1007 participants. The studies examined the effect of listening to prerecorded music daily, for 25 to 60 minutes, for a period of three days to three months. The risk of bias within the studies varied, with all studies being at high risk of performance bias, because of limited possibilities to blind participants to the music intervention. Some studies were at high risk of detection bias or other bias. Four studies reported funding from national research councils, three studies reported financial support from university sources and one study reported a grant from a private foundation. Five studies did not report any financial support. At the end of the intervention, we found moderate‐certainty evidence for improved sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI) in themusic groups compared to no intervention or TAU (mean difference (MD) −2.79, 95% confidence interval (CI) −3.86 to −1.72; 10 studies, 708 participants). The PSQI scale ranges from 0 to 21 with higher scores indicating poorer sleep. The size of the effect indicates an increase in sleep quality of the size of about one standard deviation in favour of the intervention. We found no clear evidence of a difference in the effects of listening to music compared to no treatment or TAU on insomnia severity (MD −6.96, 95% CI −15.21 to 1.28; 2 studies, 63 participants; very low‐certainty evidence). We found low‐certainty evidence that, compared to no treatment or TAU, listening to music may reduce problems with sleep‐onset latency (MD −0.60, 95% CI −0.83 to −0.37; 3 studies, 197 participants), total sleep time (MD −0.69, 95% CI −1.16 to −0.23; 3 studies, 197 participants) and sleep efficiency (MD −0.96, 95% CI −1.38 to −0.54; 3 studies, 197 participants), but may have no effect on perceived sleep interruption (MD −0.53, 95% CI −1.47 to 0.40; 3 studies, 197 participants). In addition, three studies (136 participants) included objective measures of sleep‐onset latency, total sleep time, sleep efficiency and sleep interruption and showed that listening to music may not improve these outcomes compared to no treatment or TAU. None of the included studies reported any adverse events. Authors' conclusions The findings of this review provide evidence that music may be effective for improving subjective sleep quality in adults with symptoms of insomnia. More research is needed to establish the effect of listening to music on other aspects of sleep as well as the daytime consequences of insomnia. Plain language summary Music for insomnia in adults Review question This review assessed the effects of listening to music on insomnia (sleep problems) in adults and the impact of factors that may influence the effect. Key messages We found a beneficial effect of music on sleep quality. For all the other outcomes, we did not find enough good‐quality evidence as there were too few participants and the people doing the scoring of the data were aware of the treatment. What is insomnia? Worldwide, millions of people experience insomnia. People can have difficulties getting to sleep, staying asleep or may experience poor sleep quality. Poor sleep affects people's physical and mental health. The consequences of poor sleep are costly, for both individuals and society. Many people listen to music to improve their sleep, but the effect of listening to music is unclear. What did we do? We searched electronic databases to identify relevant studies. We included 13 studies with 1007 participants. The studies compared the effect of listening to music to treatment as usual or no treatment. Treatment as usual could be sleep hygiene education (learning a set of rituals to help with sleep) or standard care for participants with insomnia related to chronic medical conditions. The studies examined the effect of listening to prerecorded music daily, for 25 to 50 minutes, for three days to three months. Seven of the included studies reported funding from national research councils or university sources, and one study reported funding from a private foundation. Five studies did not report any funding sources. What did we find? Ten studies measured sleep quality, and the results showed that music probably facilitates a large improvement in the quality of sleep compared to no treatment or treatment as usual. We do not know if listening to music has an effect on the severity of insomnia (difficulty in falling or staying asleep) or the number of times a person wakes up (broken sleep) compared to no treatment or treatment as usual. Listening to music may improve slightly sleep‐onset latency (how quickly a person falls asleep), sleep duration (length of time a person is asleep) and sleep efficiency (amount of a time a person is asleep compared to the total time spent in bed), compared to no treatment or treatment as usual. None of the studies reported any negative effects caused by listening to music. What are the limitations of the evidence? The quality of evidence from the 10 studies that examined sleep quality was moderate. Our confidence in the evidence for the quality of sleep is only moderate because the people in the studies were aware of which treatment they were getting and the people scoring the data were also sometimes aware of which treatment the participants were getting, which could introduce bias. We have little confidence in the evidence for the severity of insomnia because the studies were very small and were done in different types of people who knew which treatment they were getting. Our confidence in the evidence on sleep‐onset latency, sleep duration and sleep efficiency is low because the studies used very different methods to measure these outcomes, and the people in the studies were aware of the nature of the treatment. We have little confidence in the evidence on sleep interruption because the studies used different methods and showed different results. Furthermore, the participants in the studies knew which treatment they were getting. Future studies should assess other aspects of sleep as well as measures of daytime functioning, such as mood, fatigue, concentration, and quality of life. How up to date is this evidence? The evidence is current to 31 December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jespersen, KV; Pando-Naude, V; Koenig, J; Jennum, P; Vuust, P", "articleTypes": [], "doi": "10.1002/14651858.CD010459.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "d44625cd-d1dc-48bf-8df4-43c69f4e96d9", "pmid": "", "title": "Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide and its prevalence among children has significantly increased over the last two decades. Prevalence and severity are related to age, with children of school age most commonly affected. Objectives To assess the effectiveness and adverse event profile of antihistamines (oral or topical) used as an adjunct to topical nasal steroids for intermittent and persistent allergic rhinitis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 21 September 2009. Selection criteria Randomised controlled trials (RCTs) in children under the age of 18 with a history of allergic rhinitis, with or without allergic conjunctivitis or asthma, comparing topical nasal steroids with antihistamines to topical nasal steroids only. Data collection and analysis Two review authors independently screened studies, extracted data and assessed risk of bias. Main results One study including 24 participants met the inclusion criteria for this review. This study compared the administration of topical nasal steroids with oral antihistamines to topical nasal steroids only in children, but it did not provide sufficient data to address the clinical question of this review. Authors' conclusions In view of the lack of evidence for the benefit or lack of benefit of antihistamine add‐on therapy with topical nasal steroids for children with intermittent or persistent allergic rhinitis, it is important that clinicians are mindful of the adverse effects of antihistamines and the additional costs that may be incurred. Plain language summary Antihistamines as an addition to topical nasal steroids for allergic rhinitis in children Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide. Seasonal allergic rhinitis (hay fever) is most common around springtime. The symptoms are mostly sneezing, a runny nose and watery eyes. We looked for trials that compared antihistamines (either oral or topical) in addition to a topical nasal steroid with a topical nasal steroid alone in children who had allergic rhinitis. We wanted to know whether adding antihistamines (oral or topical) in the therapy of children with allergic rhinitis who already use topical nasal steroids would have additional benefits for them. We found one trial that had been carried out in children comparing oral antihistamines in addition to topical nasal steroids with topical nasal steroids alone but it did not provide sufficient data to draw any conclusions. Most of the trials focused only on adults or included a small number of children. Unfortunately, the trials which included children along with adults did not report whether there were any differences in the effect of treatment or adverse effects in children in comparison with adults. We are therefore unable to draw a conclusion as to whether or not this combination therapy has beneficial effect in children with allergic rhinitis or whether the benefits are acceptable in terms of the adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Nasser, M, Fedorowicz, Z, Aljufairi, H, McKerrow, W", "articleTypes": [], "doi": "10.1002/14651858.CD006989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.798Z" }, { "id": "d466fff5-8601-46e6-878d-c8dc7948cfa3", "pmid": "", "title": "Antibiotics for acute rhinosinusitis in adults", "imported": false, "abstract": "Abstract - Background Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear. We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging. Objectives To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings. Search methods We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines. Selection criteria Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis‐like signs or symptoms or sinusitis confirmed by imaging. Data collection and analysis Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required. Main results We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I² = 0%; 8 trials; high‐quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I² = 0%; 3 trials; moderate‐quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate‐quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I² = 0%; 3 trials; high‐quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I² = 16%; 10 trials; high‐quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I² = 21%; 12 trials; high‐quality evidence). A disease‐related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group). Authors' conclusions The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high‐quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate‐quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials. Plain language summary Antibiotics for sinus infection of short duration in adults Review question Do antibiotics cure sinus infection faster than no antibiotics in adults? Background A sinus is a cavity situated in the head. Adults with short‐duration sinus infection experience stuffy nose and thick, yellow discharge from the nose. People with sinus infection can feel slime in the back of the throat, facial pain, pain when bending forward, and pain in the upper teeth or when chewing. A short‐duration sinus infection may be suspected following physical examination and questions about symptoms. Blood examination or images of the sinuses can support diagnosis, but are not routinely recommended in most countries. Short‐duration sinus infections are mostly caused by viruses. Nevertheless, physicians tend to prescribe antibiotics, which should only be used to treat bacterial infections. Taking antibiotics unnecessarily results in antibiotic resistance against bacterial infections. We investigated whether antibiotics cure adults with short‐duration sinus infection faster than a dummy drug (placebo) or no treatment. Search date 18 January 2018. Study characteristics We included 15 studies in which adults with short‐duration sinus infection, whether or not confirmed by imaging, randomly received antibiotics, or a dummy drug or no treatment, in ambulatory care settings. The studies included a total of 3057 adults whose average age was 36 years; about 60% were female. Participants were followed until they were cured. Trial duration ranged from 8 to 28 days. Study funding sources Seven studies received financial support from government or academic institutions; six received grants from the pharmaceutical industry; and five did not state sources of support. Key results Without antibiotics, almost half of all participants were cured after one week, and two out of three were cured after 14 days. Five (diagnosis based on symptoms described to a doctor) to 11 (diagnosis confirmed by x‐ray) more people per 100 were cured faster with antibiotics. A computed tomography (CT) scan could better predict who would benefit from antibiotics, but routine use would cause health problems related to radiation exposure. Ten more people per 100 were relieved faster of thick, yellow discharge from the nose with antibiotics compared to a dummy drug or no treatment. Thirteen more people per 100 experienced side effects (mostly concerning stomach or intestines) with antibiotics compared to a dummy drug or no treatment. Compared with people who initially started antibiotics, five more people per 100 in the dummy drug or no treatment group had to start antibiotics because their condition worsened. Serious complications (e.g. brain abscess) were rare. We found that antibiotics are not a first‐choice treatment for adults with short‐duration sinus infection. We found no evidence relating to adults with severe sinusitis or with reduced immunity, or to children. Quality of evidence We found high‐quality evidence when the diagnosis was based on symptoms described to a doctor. We downgraded evidence quality to moderate when diagnosis was confirmed by x‐ray or CT scan because the number of participants was small, which makes the estimates less reliable.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Lemiengre, MB; van Driel, ML; Merenstein, D; Liira, H; Mäkelä, M; De Sutter, AIM", "articleTypes": [], "doi": "10.1002/14651858.CD006089.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "d4804171-242b-4f48-894f-1c7f0b5831ce", "pmid": "", "title": "A Novel Compound for Alcoholism Treatment: A Translational Strategy - Part II", "imported": false, "abstract": "Background:", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.152Z" }, { "id": "d492aa93-3e32-4615-9b03-a5fc2fee6047", "pmid": "", "title": "Oral treatments for fungal infections of the skin of the foot", "imported": false, "abstract": "Abstract - Background About 15% of the world population have fungal infections of the feet (tinea pedis or athlete's foot). There are many clinical presentations of tinea pedis, and most commonly, tinea pedis is seen between the toes (interdigital) and on the soles, heels, and sides of the foot (plantar). Plantar tinea pedis is known as moccasin foot. Once acquired, the infection can spread to other sites including the nails, which can be a source of re‐infection. Oral therapy is usually used for chronic conditions or when topical treatment has failed. Objectives To assess the effects of oral treatments for fungal infections of the skin of the foot (tinea pedis). Search methods For this update we searched the following databases to July 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library , MEDLINE (from 1946), EMBASE (from 1974), and CINAHL (from 1981). We checked the bibliographies of retrieved trials for further references to relevant trials, and we searched online trials registers. Selection criteria Randomised controlled trials of oral treatments in participants who have a clinically diagnosed tinea pedis, confirmed by microscopy and growth of dermatophytes (fungi) in culture. Data collection and analysis Two review authors independently undertook study selection, 'Risk of bias' assessment, and data extraction. Main results We included 15 trials, involving 1438 participants. The 2 trials (71 participants) comparing terbinafine and griseofulvin produced a pooled risk ratio (RR) of 2.26 (95% confidence interval (CI) 1.49 to 3.44) in favour of terbinafine's ability to cure infection. No significant difference was detected between terbinafine and itraconazole, fluconazole and itraconazole, fluconazole and ketoconazole, or between griseofulvin and ketoconazole, although the trials were generally small. Two trials showed that terbinafine and itraconazole were effective compared with placebo: terbinafine (31 participants, RR 24.54, 95% CI 1.57 to 384.32) and itraconazole (72 participants, RR 6.67, 95% CI 2.17 to 20.48). All drugs reported adverse effects, with gastrointestinal effects most commonly reported. Ten of the trials were published over 15 years ago, and this is reflected by the poor reporting of information from which to make a clear 'Risk of bias' assessment. Only one trial was at low risk of bias overall. The majority of the remaining trials were judged as 'unclear' risk of bias because of the lack of clear statements with respect to methods of generating the randomisation sequence and allocation concealment. More trials achieved blinding of participants and personnel than blinding of the outcome assessors, which was again poorly reported. Authors' conclusions The evidence suggests that terbinafine is more effective than griseofulvin, and terbinafine and itraconazole are more effective than no treatment. In order to produce more reliable data, a rigorous evaluation of different drug therapies needs to be undertaken with larger sample sizes to ensure they are large enough to show any real difference when two treatments are being compared. It is also important to continue to follow up and collect data, preferably for six months after the end of the intervention period, to establish whether or not the infection recurred. Plain language summary Oral antifungal drugs for treating athlete's foot (tinea pedis) Athlete's foot (tinea pedis) is a fungal infection of the feet that is easily spread and difficult to get rid of. This review compared different oral antifungal drugs (i.e. drugs taken by mouth), and it included 15 trials, involving 1438 participants. There are several different kinds of oral treatments, and the trials we found considered all the oral drugs used to treat athlete's foot. We found terbinafine and itraconazole to be more effective than placebo. And we found terbinafine to be more effective than griseofulvin. Griseofulvin is a treatment that was developed much earlier than the new treatments, such as terbinafine and itraconazole; these newer treatments tend to be most evaluated. Trials of other drugs were not large enough to show differences between them. All drugs had side‐effects; gastrointestinal effects were the most common. In future clinical trials, larger numbers of participants are needed to test different treatments in order to produce more reliable data. Also, future research should consider the costs of the different treatment approaches.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Bell‐Syer, SEM; Khan, SM; Torgerson, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD003584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "d493943d-cab2-4592-9bb0-eb6971a565d3", "pmid": "", "title": "Optimum duration of regimens for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background The optimal duration for Helicobacter pylori (H. pylori) eradication therapy is controversial, with recommendations ranging from 7 to 14 days. Several systematic reviews have attempted to address this issue but have given conflicting results and limited their analysis to proton pump inhibitor (PPI), two antibiotics (PPI triple) therapy. We performed a systematic review and meta‐analysis to investigate the optimal duration of multiple H. pylori eradication regimens. Objectives The primary objective was to assess the relative effectiveness of different durations (7, 10 or 14 days) of a variety of regimens for eradicating H. pylori . The primary outcome was H. pylori persistence. The secondary outcome was adverse events. Search methods The Cochrane Library , MEDLINE, EMBASE, and CINAHL were searched up to December 2011 to identify eligible randomised controlled trials (RCTs). We also searched the proceedings of six conferences from 1995 to 2011, dissertations and theses, and grey literature. There were no language restrictions applied to any search. Selection criteria Only parallel group RCTs assessing the efficacy of one to two weeks duration of first line H. pylori eradication regimens in adults were eligible. Within each regimen, the same combinations of drugs at the same dose were compared over different durations. Studies with at least two arms comparing 7, 10, or 14 days were eligible. Enrolled participants needed to be diagnosed with at least one positive test for H. pylori on the basis of a rapid urease test (RUT), histology, culture, urea breath test (UBT), or a stool antigen test (HpSA) before treatment. Eligible trials needed to confirm eradication of H. pylori as their primary outcome at least 28 days after completion of eradication treatment. Trials using only serology or a polymerase chain reaction (PCR) to determine H. pylori infection or eradication were excluded. Data collection and analysis Study eligibility and data extraction were performed by two independent review authors. Data analyses were performed within each type of intervention, for both primary and secondary outcomes. The relative risk (RR) and number needed to treat (NNT)/number needed to harm (NNTH) according to duration of therapy were calculated using the outcomes of H. pylori persistence and adverse events. A random‐effects model was used. Subgroup analyses and sensitivity analyses were planned a priori. Main results In total, 75 studies met the inclusion criteria. Eight types of regimens were reported with at least two comparative eligible durations. They included: PPI + two antibiotics triple therapy (n = 59), PPI bismuth‐based quadruple therapy (n = 6), PPI + three antibiotics quadruple therapy (n = 1), PPI dual therapy (n = 2), histamine H 2 ‐receptor antagonist (H 2 RA) bismuth quadruple therapy (n = 3), H 2 RA bismuth‐based triple therapy (n = 2), H 2 RA + two antibiotics triple therapy (n = 3), and bismuth + two antibiotics triple therapy (n = 2). Some studies provided data for more than one regimen or more than two durations. For the PPI triple therapy, 59 studies with five regimens were reported: PPI + clarithromycin + amoxicillin (PCA); PPI + clarithromycin + a nitroimidazole (PCN); PPI + amoxicillin + nitroimidazole (PAN); PPI + amoxicillin + a quinolone (PAQ); and PPI + amoxicillin + a nitrofuran (PANi). Regardless of type and dose of antibiotics, increased duration of PPI triple therapy from 7 to 14 days significantly increased the H. pylor i eradication rate (45 studies, 72.9% versus 81.9%), the RR for H. pylori persistence was 0.66 (95% CI 0.60 to 0.74), NNT was 11 (95% CI 9 to 14). Significant effects were seen in the subgroup of PCA (34 studies, RR 0.65, 95% CI 0.57 to 0.75; NNT 12, 95% CI 9 to 16); PAN (10 studies, RR 0.67, 95% CI 0.52 to 0.86; NNT = 11, 95% CI 8 to 25); and in PAQ (2 studies, RR 0.37, 95% CI 0.16 to 0.83; NNT 3, 95% CI 2 to 10); but not in PCN triple therapy (4 studies, RR 0.87, 95% CI 0.71 to 1.07). Significantly increased eradication rates were also seen for PPI triple therapy with 10 versus 7 days (24 studies, 79.9% versus 75.7%; RR 0.80, 95% CI 0.72 to 0.89; NNT 21, 95% CI 15 to 38) and 14 versus 10 days (12 studies, 84.4% versus 78.5%; RR 0.72, 95% CI 0.58 to 0.90; NNT 17, 95% CI 11 to 46); especially in the subgroup of PAC for 10 versus 7 days (17 studies, RR 0.80, 95% CI 0.70 to 0.91) and for 14 versus 10 days (10 studies, RR 0.69, 95% CI 0.52 to 0.91). A trend towards increased H. pylori eradication rates was seen with increased duration of PCN for 10 versus 7 days, and of PAN for 10 versus 7 days and 14 versus 10 days, though this was not statistical significant. The proportion of patients with adverse events, defined by authors, was marginally significantly increased only between 7 days and 14 days (15.5% versus 19.4%; RR 1.21, 95% CI 1.06 to 1.37; NNTH 31, 95% CI 18 to 104) but not for other duration comparisons. The proportion of patients discontinuing treatment due to adverse events was not significantly different between treatment durations. Only limited data were reported for different durations of regimens other than PPI triple therapy. No significant difference of the eradication rate was seen for all regimens according to different durations except for H 2 RA bismuth quadruple therapy, where a significantly higher eradication rate was seen for 14 days versus 7 days, however only one study reported outcome data. Authors' conclusions Increasing the duration of PPI‐based triple therapy increases H. pylori eradication rates. For PCA, prolonging treatment duration from 7 to 10 or from 10 to 14 days is associated with a significantly higher eradication rate. The optimal duration of therapy for PCA and PAN is at least 14 days. More data are needed to confirm if there is any benefit of increasing the duration of therapy for PCN therapy. Information is limited for regimens other than PPI triple therapy; more studies are needed to draw meaningful conclusions for optimal duration of other H. pylori eradication regimens. Plain language summary Ideal length of treatment for Helicobacter pylori ( H. pylori ) eradication The ideal duration of therapy for H. pylori eradication is controversial, with recommendations ranging from 7 to 14 days. A proton pump inhibitor (PPI) plus two antibiotics is the most commonly used first treatment to remove H. pylori infection. Current data suggest that increasing the length of treatment to 14 days of a PPI plus amoxicillin and clarithromycin or amoxicillin and a nitroimidazole significantly increases the eradication rate, while increasing the adverse events by a small amount. Based on the overall evidence, the ideal length of treatment with a PPI plus amoxicillin and clarithromycin is at least 14 days.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Yuan, Y, Ford, AC, Khan, KJ, Gisbert, JP, Forman, D, Leontiadis, GI, Tse, F, Calvet, X, Fallone, C, Fischbach, L, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD008337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.063Z" }, { "id": "d4bf3bbe-181a-4f90-918b-363ab0135969", "pmid": "", "title": "Interventions for fatigue management after traumatic brain injury", "imported": false, "abstract": "Abstract - Rationale Despite the high prevalence and medico‐social significance of fatigue in post‐traumatic brain injury (post‐TBI) populations, there are no validated management strategies to control this condition. It is timely to provide clinicians and patients with the best available evidence of the efficacy of current pharmacological and non‐pharmacological fatigue management practices. Objectives To assess the effectiveness of pharmacological and non‐pharmacological interventions for fatigue in people who have experienced a TBI. Search methods For this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO. We also searched relevant conference proceedings, and we searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for ongoing trials. The most recent searches were conducted on 12 February 2025. Eligibility criteria Eligible study designs were randomised controlled trials (RCTs) and randomised cross‐over trials (for pharmacological interventions only). Studies with participants of all ages (children and adults) with a TBI (of any severity) were included, where at least 75% of participants had a TBI. Any type of treatment for fatigue was considered. Four categories of interventions were prioritised: pharmacological, cognitive, stimulation/biofeedback, and psychoeducational. These interventions were compared to placebo groups, no treatment, or groups receiving other interventions. Outcomes The critical outcome was fatigue. Important outcomes include fatigue‐related outcomes of psychological functioning (depression and anxiety), cognitive functioning (processing speed), general quality of life, and daytime sleepiness. Risk of bias We assessed risk of bias using the original Cochrane risk of bias tool for RCTs (RoB 1). Synthesis methods We synthesised the results for each outcome by meta‐analysis where possible using mean differences (MDs) and standardised mean differences (SMDs) and a fixed‐effect model. Where meta‐analysis was not possible due to the nature of the data , we narratively reported the results. We used GRADE to assess the certainty of evidence for each outcome . We performed all statistical analyses using RevMan and presented results with 95% confidence intervals (CI). Included studies We included a total of 3518 trial participants (at baseline) across 40 studies, described in 49 publications. The 40 included studies are grouped by type of intervention. There were seven categories of interventions: pharmacological, cognitive, physical activity, stimulation/biofeedback, health visits, psychoeducational, and a final category for trials with multiple interventions (multi‐interventions). Four published studies identified in the most recent search are awaiting classification. Synthesis of results Pharmacological interventions (melatonin; recombinant human growth hormones (rhGH); psychostimulants; atorvastatin; monoaminergic stabiliser (‐)‐OSU6162) likely reduce fatigue slightly (SMD ‐0.25, 95% CI ‐0.44 to ‐0.06; 8 studies, 395 participants; moderate‐certainty evidence). Cognitive interventions (cognitive rehabilitation; technology‐enhanced training; functional skills training) may reduce fatigue slightly (MD ‐0.32, 95% CI ‐0.59 to ‐0.06; 6 studies, 222 participants; low‐certainty evidence). Stimulation/biofeedback interventions (light therapy; electrical/magnetic stimulation; acupressure) may reduce fatigue slightly, but the evidence is very uncertain (SMD ‐0.23, 95% CI ‐0.47 to 0.01; 8 studies, 295 participants; very low‐certainty evidence). Psychoeducation interventions (cognitive behavioural therapy; acceptance and commitment therapy; individualised occupational therapy; novel therapies) may reduce fatigue, but the evidence is very uncertain (SMD ‐0.55, 95% CI ‐0.74 to ‐0.35; 8 studies, 474 participants; very low‐certainty evidence). There may be little to no difference in psychological functioning (depression), psychological functioning (anxiety), cognitive functioning (processing speed), or daytime sleepiness. However, these results are very uncertain. Authors' conclusions There is very limited and moderate to very low‐certainty evidence from RCTs about treatments to reduce fatigue after TBI. Despite the prevalence of fatigue post‐TBI, we lack high‐quality studies that evaluate interventions to improve this disabling, but potentially treatable, symptom. There is a need for considerable further work to identify an effective treatment for fatigue in people with TBI. Funding This Cochrane review had no dedicated funding. Registration Protocol available via DOI: 10.1002/14651858.CD006448 Plain language summary Which treatments are effective for fatigue after traumatic brain injury? Key messages Medications (such as melatonin, growth hormones, brain stimulants, atorvastatin, or dopamine and serotonin regulators) likely reduce fatigue after a traumatic brain injury. Other treatments, such as talking therapies, sensory stimulation, and counselling, may reduce fatigue after a traumatic brain injury. Future studies should involve more people, including children and young people. They should investigate different kinds of treatments in different settings, and the severity and causes of traumatic brain injury. What is traumatic brain injury? Traumatic brain injury is damage to the brain following a bump or blow to the head. The injury might result from a traffic accident, fall, assault, sports injury, or an explosion. People with traumatic brain injury might experience headaches, become forgetful, and have difficulties sleeping and moving. They may also experience fatigue, which is defined as an overwhelming sense of tiredness unrelated to previous effort, which does not usually improve with rest. Fatigue makes it hard for people to concentrate and perform everyday activities, which affects their quality of life. How is fatigue after traumatic brain injury treated? Treatments for fatigue vary because the causes and symptoms of fatigue may be very different. Treatments include medication to stimulate or protect the brain, and hormones and antidepressants to help people sleep and improve their mood. Treatments that don’t involve medication include counselling, education, behavioural therapy and exercise. What did we want to find out? We mainly wanted to find out if different treatments reduce fatigue in people with traumatic brain injury. We were also interested in the effect of the treatments on people’s mood, memory or attention, quality of life, and sleepiness. What did we do? We searched for studies that randomly assigned people to receive treatment for fatigue, usual care (that is, no specific treatment for fatigue), or a placebo (dummy) treatment. We also looked at studies that compared different treatments. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 40 studies with 3518 adults and children living with traumatic brain injury. The studies took place in 12, mainly high‐income, countries in Europe, North America, and Oceania. They were conducted in different settings, including medical centres, rehabilitation clinics, military bases, clinical research facilities, and hospitals. Main results Fatigue Medications likely reduce fatigue after a traumatic brain injury (8 studies, 395 people). Medications included melatonin, growth hormones, psychostimulants, statins, and dopamine regulators. Other treatments (without medication) may reduce fatigue after a traumatic brain injury (31 studies, 2203 people). Treatments included cognitive behavioural therapy, technical‐enhanced training, functional skills training, sensory stimulation, electrical/magnetic stimulation, acupressure, counselling, acceptance and commitment therapy, individualised occupational therapy, cognitive symptom management rehabilitation therapy, aerobic exercise, prescribed light exercise, location of exercise, vestibular rehabilitation, health visits, and multi‐interventional therapies. For treatments with medication, there were some reported adverse (unwanted or harmful) events that are specific to particular studies. For other treatments (without medication), adverse events were often not reported. Fatigue‐related symptoms Medications may make little or no difference to depression, anxiety, processing speed, quality of life, and daytime sleepiness (21 studies, 1016 people). Of the treatments without medication, only cognitive therapy showed any noticeable effect; it may reduce anxiety (2 studies, 57 people). What are the limitations of the evidence? We have limited confidence in the evidence due to the small numbers of people in the different studies, and the variation in settings, treatments, ages of participants, and the severity and causes of traumatic brain injury. How up to date is this evidence? We searched for studies up to 12 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Senior, HE, Leung, JH, Meehan, B, Leao, S, Jordan, V, Barker-Collo, S, Crummey, S, Purdy, SC", "articleTypes": [], "doi": "10.1002/14651858.CD006448.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.135Z" }, { "id": "d4c50a14-b787-4962-8af0-8060aa5f91f7", "pmid": "", "title": "Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Herpes zoster oticus (HZO) is a viral infection of the ear and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first‐line treatment for herpes zoster infections at other body sites and are thought to reduce or minimise nerve damage, thereby improving outcomes. It has been suggested that these agents improve the chance of facial weakness improving or resolving completely in patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy). Search methods We searched the Cochrane ENT Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medline (1950 ‐ 2007), PubMed 2007 ‐ 2008, EMBASE (1974 onwards) and other relevant databases. The date of the most recent search was June 2008. Selection criteria Two authors scrutinized all possible citations to identify randomised controlled trials in which antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) were given as treatment for Ramsay Hunt syndrome. We contacted an author for further information. Data collection and analysis Two reviewers independently assessed eligibility and trial quality. Main results Only one randomised, controlled trial was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, intravenous acyclovir and corticosteroids were compared with corticosteroids alone. Our analysis found no statistically significant difference between the two groups. Authors' conclusions We found no evidence that anti‐viral agents have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. The use of these drugs in patients with herpes zoster infections in other parts of the body might suggest that they have a role in herpes zoster oticus. As usual, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically under‐powered study) does not necessarily indicate that antivirals are ineffective. However, these drugs are associated with a number of adverse effects and this must be taken into consideration when undertaking the requisite risk‐benefit analysis before instigating treatment. Plain language summary Uncertainty about usefulness of antiviral drugs in Ramsay Hunt syndrome It seems logical that antiviral drugs might help patients with a herpes virus infection of the ear producing facial weakness (a condition known as 'Ramsay Hunt syndrome'). These drugs often help similar viral infections elsewhere in the body. However, trials that might address this issue have not been done and there is therefore some uncertainty about their usefulness. Since patients can experience side‐effects when taking these drugs, the risks of these have to be balanced with the unknown prospect of benefit when considering whether to use them in Ramsay Hunt syndrome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T; Doree, C; Chamberlain, IJ; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006851.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "d4c5513a-140f-4652-ad73-3b1a5b07adc7", "pmid": "", "title": "Immunostimulants for preventing respiratory tract infection in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are a major cause of childhood morbidity and mortality. Immunostimulants (IS) may reduce the incidence of ARTIs. Objectives To determine the efficacy and safety of IS in preventing ARTIs in children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 1, which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to February week 4, 2011), EMBASE (1990 to February 2011), Google Scholar (2009 to February 2011), Scopus (2009 to February 2011), PASCAL (1990 to February 2010), SciSearch (1990 to February 2010) and IPA (1990 to February 2010). Selection criteria We included all comparative randomized controlled trials (RCTs) which enrolled participants less than 18 years of age. The intervention was IS medication, administered by any method, compared to placebo to prevent ARTIs. Data collection and analysis We analyzed the outcome on ARTIs both as the mean number of ARTIs by group and as a percent change in the rate of ARTIs. We undertook meta‐analyses using a random‐effects model and presented results as mean differences (MD) with 95% confidence intervals (CI). Two review authors independently assessed the search results and risk of bias, and extracted data. A funnel plot suggested there may be publication bias in the identified trials. Main results Thirty‐five placebo‐controlled trials (4060 participants) provided data in a form suitable for inclusion in the meta‐analyses. When compared with placebo, the use of IS was shown to reduce ARTIs measured as the total numbers of ARTIs (MD ‐1.24; 95% CI ‐1.54 to ‐0.94) and the difference in ARTI rates (MD ‐38.84%; 95% CI ‐46.37% to ‐31.31%). Trial quality was generally poor and a high level of statistical heterogeneity was evident. The subgroup analysis of bacterial IS, D53 and OM‐85 studies produced similar results, with lower heterogeneity. No difference in adverse events was evident between the placebo and IS groups. Authors' conclusions This review shows that IS reduce the incidence of ARTIs by 40% on average in susceptible children. Studies in healthy children are not available. Although the safety profile in the studies was good, some IS may be unsafe. ARTI‐susceptible children may benefit from IS treatment. Further high‐quality trials are needed and we encourage national health authorities to conduct large, multicentre, double‐blind, placebo‐controlled RCTs on the role of IS in preventing ARTIs in children. Plain language summary Immunostimulants to prevent acute respiratory tract infections in children Acute respiratory tract infections (ARTIs) are responsible for 19% of all deaths in children younger than five years of age, mainly in low‐income countries in Africa, Asia and Latin America. In high‐income countries ARTIs are among the most frequent illnesses, leading to 20% of medical consultations, 30% of days lost from work and 75% of antibiotic prescriptions. In the USA the total cost of non‐influenza‐related viral ARTIs is around $40 billion annually, while the corresponding cost for influenza is US $87.1 billion. The main signs and symptoms of ARTIs include sneezing, runny nose, sore throat, cough and malaise. Children living in rural communities, not attending daycare centres, suffer about seven ARTI episodes in the first year of life; eight ARTIs per year from the ages of one to four; six per year aged five to nine; and five per year aged 10 to 19. Children exposed to risks factors, such as attendance at daycare centres, overcrowding, contact with older siblings, smoking at home and lack of breast feeding, may suffer more ARTIs. Several treatments have been used to reduce the incidence of ARTIs (vitamin A, vitamin C, zinc, antibiotics). Among them are immunostimulants (herbal extracts, bacterial extracts, synthetic compounds), which aim to increase the immune defences of the respiratory tract. We searched for clinical trials of immunostimulants to prevent ARTIs in children compared to placebo. Our review includes 35 studies with 4060 participants. However, the quality of many of the studies was poor and the results were very diverse. By combining results, immunostimulants reduced 1.24 ARTIs in a six‐month period, equivalent to a 39% reduction in ARTIs compared to the placebo group. Only 20 studies provided adequate data on adverse events: the most frequent were rash, nausea, vomiting, abdominal pain and diarrhea. The main limitations of this review were the poor methodological quality and diverse trial results. We conclude that ARTI‐susceptible children may benefit from immunostimulants, but more high‐quality studies are needed. We suggest that national health authorities conduct high‐quality randomized controlled trials to assess the true effects of immunostimulant preparations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Del‐Rio‐Navarro, BE, Espinosa‐Rosales, FJ, Flenady, V, Sienra‐Monge, JJL", "articleTypes": [], "doi": "10.1002/14651858.CD004974.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.083Z" }, { "id": "d4c79f8e-64c3-4126-8f1b-3de438f26636", "pmid": "", "title": "Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is the most common life‐limiting autosomal recessive genetic disorder in white populations. Distal intestinal obstruction syndrome (DIOS) is an important morbidity in cystic fibrosis. It is the result of the accumulation of viscid faecal material within the bowel which combines with thick, sticky mucus produced in the intestines of people with cystic fibrosis. The intestine may be completely blocked (complete DIOS) or only partially blocked (incomplete DIOS). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the acute complete or incomplete faecal obstruction and ultimately prevent the need for surgical intervention . Objectives This review aimed to evaluate the effectiveness and safety of different treatment regimens for the treatment of DIOS (complete and incomplete) in children and adults with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised controlled trials, quasi‐randomised controlled trials (including cross‐over trials (to be judged on an individual basis)) comparing the use of laxative agents or surgery for treating DIOS in children, young people and adults with cystic fibrosis to each other, placebo or no intervention. Data collection and analysis Two authors independently screened papers, extracted trial details and assessed for risk of bias. The authors assessed the quality of evidence using GRADE. Main results There was one trial with 20 participants (16 females) included in the review. The mean age of participants was 13.1 years. The trial was a double‐blinded, randomised cross‐over trial which had a duration of 12 months in total and compared high‐dose and low‐dose pancreatic enzyme therapy. As only the abstract of the trial was available, the overall risk of bias was judged to be unclear. The trial did not address either of our primary outcomes (time until resolution of DIOS and treatment failure rate), but reported episodes of acute DIOS, presence of abdominal mass and abdominal pain. There were no numerical data available for these outcomes, but the authors stated that there was no difference between treatment with high‐dose or low‐dose pancreatic enzymes. The overall certainty of the evidence was found to be very low. Authors' conclusions There is a clear lack of evidence for the treatment of DIOS in people with cystic fibrosis. The included abstract did not address our primary outcome measures and did not provide numerical data for the two secondary outcomes it did address. Therefore, we cannot justify the use of high‐dose pancreatic enzymes for treating DIOS, nor can we comment on the efficacy and safety of other laxative agents. From our findings, it is clear that more randomised controlled trials need to be conducted in this area. Plain language summary Interventions for treating distal intestinal obstruction syndrome (DIOS) in cystic fibrosis Review question We reviewed the evidence about the effectiveness and safety of different treatments for distal intestinal obstruction syndrome (DIOS) in children and adults with cystic fibrosis. Background Cystic fibrosis is a common, life‐limiting, inherited disease. One of the main features of cystic fibrosis is the thick, sticky mucus produced by many organs including the lungs, pancreas and intestine. DIOS occurs when mucus in the intestine combines with faeces and builds up to produce a mass. This mass can partially or completely block the intestine and cause symptoms such as vomiting, severe abdominal pain and a swollen stomach (abdominal distension). Once a diagnosis of DIOS has been made, the goal of therapy is to relieve the complete or partial blockage and ultimately prevent the need for any surgical intervention. Search date The evidence is current to: 12 October 2021. Trial characteristics The review included one trial with 20 people with cystic fibrosis who were aged between 7.1 and 23.2 years of age (average 13.1 years old). The 12‐month trial compared a high dose of pancreatic enzymes with a low dose of pancreatic enzymes for treating chronic DIOS. Key results The trial did not report on our primary outcomes (time until DIOS successfully treated and treatment failure rate), but addressed two of our secondary outcomes; episodes of acute DIOS and the harmful effects that might occur in participants (the presence of an abdominal mass and abdominal pain). There were no numerical data available for these results, but the authors reported that there was no difference between high‐dose or low‐dose pancreatic enzymes. Certainty of the evidence We found the overall certainty of the evidence to be very low. The trial itself was only published as an abstract from a conference which did not include numerical data and it was not published as a full report. This meant that we do not know many details about the trial. We thought that the overall risk of bias was unclear, as the trial authors did not describe how participants were put into the treatment groups, whether any participants dropped out or whether the planned outcomes were the same as the reported outcomes. The trial also had a very small number of participants and a limited age range, making it difficult to draw conclusions about the relevance of the treatment for all people with cystic fibrosis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Gilchrist, FJ; Green, J; Carroll, W", "articleTypes": [], "doi": "10.1002/14651858.CD012798.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "d4cf51d5-ac13-44bc-a794-67fe5900462d", "pmid": "", "title": "Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Nedocromil sodium and sodium cromoglycate inhaled shortly before exercise appear to reduce the severity of exercise‐induced bronchoconstriction. There is some debate over which drug may be more effective. Objectives The objective of this review was to compare the effects on post‐exercise lung function between prophylactic doses of nedocromil sodium (NSG) and sodium cromoglycate (SCG) in persons diagnosed with exercise‐induced bronchoconstriction. Search methods Randomized controlled trials were identified from the Cochrane Airways Review Group Asthma Register. Bibliographies of relevant studies and review articles were searched and primary authors, content experts and manufacturers of drugs were contacted for additional relevant studies. No language restrictions were applied. Searches were current as of December 2007. Selection criteria Randomized controlled trials comparing NCS to SCG in prophylactic treatment of exercise‐induced bronchoconstriction were eligible. Studies were included if: the participants, aged 6 or over, had a confirmed diagnosis of asthma with exercise‐induced bronchoconstriction, were subjected to an exercise challenge sufficient to trigger bronchoconstriction, and the measures of lung function were reported as either changes in forced expiratory volume in one second or peak expiratory flow rate. Data collection and analysis Data extraction and methodological quality assessments were conducted independently by two reviewers using standard forms and validated assessment criteria. In some cases results were extrapolated from graphs. Results from similar studies were pooled and reported as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CI) using the random effects model. Main results Nine studies (162 participants) are included in this review. No significant difference was noted between NCS and SCG with respect to the maximum percent decrease in FEV1 (WMD = ‐0.88; 95% CI: ‐4.50, 2.74), complete protection (i.e. maximum % fall FEV1 still =>10%); OR = 0.95; 95% CI: 0.50 to 1.8, clinical protection (i.e. < 50% improvement over placebo); OR = 0.71; 95% CI: 0.36 to 1.39; unpleasant taste (OR = 6.85; 95% CI: 0.77, 60.73), or sore throat (OR = 3.46; 95% CI: 0.32, 37.48). For these pooled comparisons, no statistically significant heterogeneity was identified. Subgroup analyses based on age, dosage of medications and timing of exercise post‐inhalation were consistent with the overall pooled analyses. Authors' conclusions No significant differences were evident between the effect of NCS and SCG during the immediate post‐exercise period in adults and children with EIB with regards to pulmonary function �� specifically maximum percent decrease in FEV1, complete protection, clinical protection, or side effects. Plain language summary Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. Two drugs, nedocromil sodium (Tilade) and sodium cromoglycate are sometimes used before exercise to prevent asthma. The review of trials found that both were similarly effective in relieving exercise‐induced asthma for both children and adults. More people have sore throats and an unpleasant after‐taste after using nedocromil sodium.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Kelly, KD, Spooner, C, Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD002731", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.075Z" }, { "id": "d4d3e22c-db58-4897-95f0-27082478d5c9", "pmid": "", "title": "Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption", "imported": false, "abstract": "Abstract - Background Overconsumption of food, alcohol, and tobacco products increases the risk of non‐communicable diseases. Interventions to change characteristics of physical micro‐environments where people may select or consume these products ‐ including shops, restaurants, workplaces, and schools – are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers. Objectives 1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non‐alcoholic beverages), (b) alcohol, and (c) tobacco products. 2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii. participants. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches. Selection criteria We included randomised controlled trials with between‐participants (parallel group) or within‐participants (cross‐over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product. Data collection and analysis We used a novel semi‐automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random‐effects meta‐analysis and meta‐regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE. Main results We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between‐participants designs (19/24). All studies were conducted in high‐income countries, predominantly in the USA (14/24). Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less‐healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta‐analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD −1.13 (95% confidence interval (CI) −1.90 to −0.37) (low certainty evidence). For consumption outcomes, meta‐analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD −0.55 (95% CI −1.27 to 0.18) (low certainty evidence). Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD −0.65 (95% CI −1.29 to −0.01) (very low certainty evidence). For consumption outcomes, meta‐analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD −0.60 (95% CI −0.84 to −0.36) (low certainty evidence). Meta‐regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias. Authors' conclusions The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real‐world settings, intervening across a wider range of foods ‐ as well as alcohol and tobacco products ‐ and over sustained time periods. Plain language summary Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption Unhealthy patterns of consumption of food, alcohol, and tobacco products are important causes of ill health. Changing the availability (the range or amount of options, or both) of these products or their proximity (the distance at which they are positioned) to potential consumers could help people make healthier choices. What is the aim of this review? This review investigated whether altering the availability or proximity of food (including non‐alcoholic beverages), alcohol, and tobacco products changed people's selection (such as purchasing) or consumption of those products. We searched for all available evidence from randomised controlled trials (a type of study in which participants are assigned to one of two or more treatment groups using a random method) to answer this question, and found 24 studies, all of which were conducted in high‐income countries. What are the main results of the review? Six studies involved availability interventions, of which four changed the relative proportion of less‐healthy to healthier options, and two changed the absolute number of different options available. In statistical analyses that combined results from multiple studies, it was found that reducing the number of available options for a particular range or category of food(s) reduced selection of those food products (from analysing 154 participants) and possibly reduced consumption of those products (from 150 participants). However, the certainty of the evidence for these effects was low. Eighteen studies involved proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. One study found that this reduced selection of food (from analysing 41 participants), whilst in a statistical analysis combining results from multiple studies, it was found that placing food farther away reduced consumption of those food products (from analysing 1098 participants). However, the certainty of the evidence for these effects was very low and low, respectively. Key messages Mindful of its limitations, the current evidence suggests that changing the number of available food options or changing where foods are positioned could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes to food environments. However, more high‐quality studies in real‐world settings are needed to make this finding more certain. How up‐to‐date is this review? The evidence is current to 23 July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hollands, GJ, Carter, P, Anwer, S, King, SE, Jebb, SA, Ogilvie, D, Shemilt, I, Higgins, JPT, Marteau, TM", "articleTypes": [], "doi": "10.1002/14651858.CD012573.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.790Z" }, { "id": "d4fb7cd0-0029-448a-a040-3dc4f4103086", "pmid": "", "title": "Desipramine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Antidepressants are widely used to treat chronic neuropathic pain (pain due to nerve damage), usually in doses below those at which they exert antidepressant effects. An earlier review that included all antidepressants for neuropathic pain is being replaced by new reviews of individual drugs examining individual neuropathic pain conditions. Desipramine is a tricyclic antidepressant that is occasionally used for treating neuropathic pain. Objectives To assess the analgesic efficacy of desipramine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 29 April 2014, and the reference lists of retrieved papers and other reviews. We also used our own hand searched database to identify older studies, and two clinical trials databases for ongoing or unpublished studies. Selection criteria We included randomised, double‐blind studies of at least two weeks duration comparing desipramine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 years and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted the efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts, at least 200 participants in the comparison, 8 to 12 weeks duration, parallel design); second tier from data that failed to meet one or more of these criteria and were considered at some risk of bias but with adequate numbers in the comparison; and third tier from data involving small numbers of participants and considered very likely to be biased or that used outcomes of limited clinical utility, or both. Main results Five studies treated 177 participants with painful diabetic neuropathy (104) or postherpetic neuralgia (73). The mean or median ages in the studies were 55 to 72 years. Four studies used a cross‐over, and one a parallel group design; 145 participants were randomised to receive desipramine 12.5 mg to 250 mg daily, with most taking 100 mg to 150 mg daily following titration. Comparators were placebo in three studies (an 'active placebo' in two studies), fluoxetine, clomipramine (one study each), and amitriptyline (two studies), and treatment was for two to six weeks. All studies had one or more sources of potential major bias. No study provided first or second tier evidence for any outcome. No data were available on the proportion of people with at least 50% or 30% reduction in pain, but data were available from three studies for our other primary outcome of Patient Global Impression of Change, reported as patient evaluation of pain relief that was 'complete' or 'a lot'. No pooling of data was possible, but third tier evidence in individual studies indicated some improvement in pain relief with desipramine compared with placebo, although this was very low quality evidence, derived mainly from group mean data and completer analyses in small, short duration studies where major bias was possible. There were too few participants in comparisons of desipramine with another active treatment to draw any conclusions. All studies reported some information about adverse events, but reporting was inconsistent and fragmented. Participants taking desipramine experienced more adverse events, and a higher rate of withdrawal due to adverse events, than did participants taking placebo (very low quality evidence). Authors' conclusions This review found little evidence to support the use of desipramine to treat neuropathic pain. There was very low quality evidence of benefit and harm, but this came from studies that were methodologically flawed and potentially subject to major bias. Effective medicines with much greater supportive evidence are available. There may be a role for desipramine in patients who have not obtained pain relief from other treatments. Plain language summary Desipramine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not usually effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Desipramine is a tricyclic antidepressant from the same class of medicines as amitriptyline, which is widely recommended for treating neuropathic pain. Desipramine may also be useful in these painful conditions. In 2014, we performed searches to look for clinical trials where desipramine was used to treat neuropathic pain. Five small studies, each with 24 to 54 participants, included 177 participants in total with painful diabetic neuropathy or postherpetic neuralgia. Studies were randomised and double‐blind, but all had one or more sources of potential major bias that could lead to overestimation of efficacy. It was not possible to combine information from the different studies, but individually they indicated some benefit from desipramine (usually at a dose between 100 mg and 150 mg daily), compared with placebo, at the expense of increased adverse events. There was not enough information about other comparators to draw any conclusions. There was too little information, which was of inadequate quality, to be sure that desipramine works as a pain medicine in painful diabetic neuropathy or postherpetic neuralgia, and no information about other types of neuropathic pain. Other medicines have been shown to be effective as treatments of first choice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hearn, L, Moore, RA, Derry, S, Wiffen, PJ, Phillips, T", "articleTypes": [], "doi": "10.1002/14651858.CD011003.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.741Z" }, { "id": "d500a268-8400-40e9-adae-da00e5f57c95", "pmid": "", "title": "Antitumour antibiotic containing regimens for metastatic breast cancer", "imported": false, "abstract": "Abstract - Background Antitumour antibiotics are used in the management of metastatic breast cancer. Some of these agents have demonstrated higher tumour response rates than non‐antitumour antibiotic regimens, however a survival benefit has not been established in this setting. Objectives To review the randomised evidence comparing antitumour antibiotic containing chemotherapy regimens with regimens not containing an antitumour antibiotic in the management of women with metastatic breast cancer. Search methods The Specialised Register maintained by the Cochrane Breast Cancer Group was searched on 3rd October, 2006 using the codes for 'advanced breast cancer' and 'chemotherapy'. Details of the search strategy and coding applied by the Group to create the register are described in the Group's module on The Cochrane Library. Selection criteria Randomised trials comparing antitumour antibiotic containing regimens with regimens not containing antitumour antibiotics in women with metastatic breast cancer. Data collection and analysis Data were collected from published trials. Studies were assessed for eligibility and quality, and data were extracted by two independent reviewers. Hazard Ratios (HRs) were derived from time‐to‐event outcomes where possible, and a fixed effect model was used for meta‐analysis. Response rates were analysed as dichotomous variables. Quality of life and toxicity data were extracted where present. A primary analysis was conducted for all trials and by class of antitumour antibiotic. Main results Thirty‐four trials reporting on 46 treatment comparisons were identified. All trials published results for tumour response and 27 trials published time‐to‐event data for overall survival. The observed 4244 deaths in 5605 randomised women did not demonstrate a statistically significant difference in survival between regimens that contained antitumour antibiotics and those that did not (HR 0.96, 95% CI 0.90 to 1.02, P = 0.22) and no significant heterogeneity. Antitumour antibiotic regimens were favourably associated with time‐to‐progression (HR 0.84, 95% CI 0.77 to 0.91) and tumour response rates (odds ratio (OR) 1.33, 95% CI 1.21 to 1.48) although statistically significant heterogeneity was observed for these outcomes. These associations were consistent when the analysis was restricted to the 30 trials that reported on anthracyclines. Patients receiving anthracycline containing regimens were also more likely to experience toxic events compared to patients receiving non‐antitumour antibiotic regimens. No statistically significant difference was observed in any outcome between mitoxantrone containing and non‐antitumour antibiotic‐containing regimens. Authors' conclusions Compared to regimens without antitumour antibiotics, regimens that contained these agents showed a statistically significant advantage for tumour response and time to progression in women with metastatic breast cancer but were not associated with an improvement in overall survival. The favourable effect on tumour response and time to progression observed in anthracycline containing regimens was also associated with greater toxicity. Plain language summary Antitumour antibiotic containing regimens for metastatic breast cancer Advanced (metastatic) breast cancer is cancer that has spread beyond the breast. Treatment for metastatic disease usually involves some type of chemotherapy (anti‐cancer drugs) to try to reduce the cancer. Chemotherapy drugs can either be given as a single agent or in combination with other chemotherapy drugs. This is done according to a plan or a course of the drug referred to as a regimen. There are many types of chemotherapy drugs which work in various ways. Antitumour antibiotics work by damaging the cancer cells thereby preventing those cells from multiplying. Chemotherapy in general produces a range of side effects or adverse events related to the treatment. The known side effects of antitumour antibiotics include nausea, vomiting, a reduction in the number of white blood cells (known as leukopenia), and in some cases a toxic reaction which alters the working of the heart (called cardiotoxicity). This review sought to identify and review the randomised evidence comparing courses of chemotherapy containing antitumour antibiotics against courses not containing antitumour antibiotics. This review identified 34 eligible trials involving 5605 women. This review found that for women with advanced breast cancer, taking antitumour antibiotics did not result in better survival than women who took other types of chemotherapy drugs. Despite the lack of evidence of survival benefit, this review demonstrated that women taking these drugs had an advantage in time to progression (the length of time it takes for the cancer to progress after taking the drug) and tumour response (shrinking of the tumour) compared to women who did not take the antitumour antibiotic drugs. In addition however, the risks of side effects including cardiotoxicity, leukopenia and nausea/vomiting were all significantly increased in the women taking the antitumour antibiotics. Given that this review failed to show a benefit in survival for women taking this group of drugs but a higher rate of side effects, the use of these drugs in the management of metastatic breast cancer must be carefully weighed against the risk of these side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Lord, SJ; Ghersi, D; Gattellari, M; Wortley, S; Wilcken, N; Thornton, C; Simes, J", "articleTypes": [], "doi": "10.1002/14651858.CD003367.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "d5029be0-ddc7-4d55-a432-68e3724a1b47", "pmid": "", "title": "Omega‐3 fatty acids for depression in adults", "imported": false, "abstract": "Abstract - Background Major depressive disorder (MDD) is highly debilitating, difficult to treat, has a high rate of recurrence, and negatively impacts the individual and society as a whole. One potential treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, some other seafood, and some nuts and seeds. Various lines of evidence suggest a role for n‐3PUFAs in MDD, but the evidence is far from conclusive. Reviews and meta‐analyses clearly demonstrate heterogeneity between studies. Investigations of heterogeneity suggest different effects of n‐3PUFAs, depending on the severity of depressive symptoms, where no effects of n‐3PUFAs are found in studies of individuals with mild depressive symptomology, but possible benefit may be suggested in studies of individuals with more severe depressive symptomology. Hence it is important to establish their effectiveness in treating MDD. This review updates and incorporates an earlier review with the same research objective (Appleton 2015). Objectives To assess the effects of n‐3 polyunsaturated fatty acids (also known as omega‐3 fatty acids) versus a comparator (e.g. placebo, antidepressant treatment, standard care, no treatment, wait‐list control) for major depressive disorder (MDD) in adults. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO together with trial registries and grey literature sources (to 9 January 2021). We checked reference lists and contacted authors of included studies for additional information when necessary. Selection criteria We included studies in the review if they: used a randomised controlled trial design; provided n‐3PUFAs as an intervention; used a comparator; measured depressive symptomology as an outcome; and were conducted in adults with MDD. Primary outcomes were depressive symptomology (continuous data collected using a validated rating scale) and adverse events. Secondary outcomes were depressive symptomology (dichotomous data on remission and response), quality of life, and non‐completion of studies. Data collection and analysis We used standard methodological procedures as expected by Cochrane. We assessed the certainty of the evidence using GRADE criteria. Main results The review includes 35 relevant studies: 34 studies involving a total of 1924 participants investigated the impact of n‐3PUFA supplementation compared to placebo, and one study involving 40 participants investigated the impact of n‐3PUFA supplementation compared to antidepressant treatment. For the placebo comparison, n‐3PUFA supplementation resulted in a small to modest benefit for depressive symptomology, compared to placebo: standardised mean difference (SMD) (random‐effects model) −0.40 (95% confidence interval (CI) −0.64 to −0.16; 33 studies, 1848 participants; very low‐certainty evidence), but this effect is unlikely to be clinically meaningful. An SMD of 0.40 represents a difference between groups in scores on the HDRS (17‐item) of approximately 2.5 points (95% CI 1.0 to 4.0), where the minimal clinically important change score on this scale is 3.0 points. The confidence intervals include both a possible clinically important effect and a possible negligible effect, and there is considerable heterogeneity between studies. Sensitivity analyses, funnel plot inspection and comparison of our results with those of large well‐conducted trials also suggest that this effect estimate may be biased towards a positive finding for n‐3PUFAs. Although the numbers of individuals experiencing adverse events were similar in intervention and placebo groups (odds ratio (OR) 1.27, 95% CI 0.99 to 1.64; 24 studies, 1503 participants; very low‐certainty evidence), the confidence intervals include a small decrease to a modest increase in adverse events with n‐3PUFAs. There was no evidence for a difference between n‐3PUFA and placebo groups in remission rates (OR 1.13, 95% CI 0.74 to 1.72; 8 studies, 609 participants, low‐certainty evidence), response rates (OR 1.20, 95% CI 0.80 to 1.79; 17 studies, 794 participants; low‐certainty evidence), quality of life (SMD −0.38 (95% CI −0.82 to 0.06), 12 studies, 476 participants, very low‐certainty evidence), or trial non‐completion (OR 0.92, 95% CI 0.70 to 1.22; 29 studies, 1777 participants, very low‐certainty evidence). The evidence on which these results are based was also very limited, highly heterogeneous, and potentially biased. Only one study, involving 40 participants, was available for the antidepressant comparison. This study found no differences between treatment with n‐3PUFAs and treatment with antidepressants in depressive symptomology (mean difference (MD) −0.70, 95% CI −5.88 to 4.48), rates of response to treatment (OR 1.23, 95% CI 0.35 to 4.31), or trial non‐completion (OR 1.00, 95% CI 0.21 to 4.71). Confidence intervals are however very wide in all analyses, and do not rule out important beneficial or detrimental effects of n‐3PUFAs compared to antidepressants. Adverse events were not reported in a manner suitable for analysis, and rates of depression remission and quality of life were not reported. Authors' conclusions At present, we do not have sufficient high‐certainty evidence to determine the effects of n‐3PUFAs as a treatment for MDD. Our primary analyses may suggest a small‐to‐modest, non‐clinically beneficial effect of n‐3PUFAs on depressive symptomology compared to placebo; however the estimate is imprecise, and we judged the certainty of the evidence on which this result is based to be low to very low. Our data may also suggest similar rates of adverse events and trial non‐completion in n‐3PUFA and placebo groups, but again our estimates are very imprecise. Effects of n‐3PUFAs compared to antidepressants are very imprecise and uncertain. More complete evidence is required for both the potential positive and negative effects of n‐3PUFAs for MDD. Plain language summary Omega‐3 fatty acids for depression in adults Why is this review important? Major depressive disorder (MDD) is characterised by depressed mood or a markedly decreased pleasure or interest in all activities, or both. It has negative impacts on the individual and on society, often over the long term. One possible treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, in some other seafood and in some nuts and seeds. Various lines of evidence suggest that n‐3PUFAs may impact on depressive symptoms, but a lot of studies have different findings, making it difficult to draw conclusions. Who will be interested in this review? Health professionals, including general practitioners, mental health and psychiatric specialists; individuals with MDD; and the people around them. What questions does this review aim to answer? Do n‐3PUFAs, compared to an alternative, have an effect on depressive symptoms, negative side effects, rates of recovery, quality of life, and rates of study non‐completion, in individuals with MDD? Which studies were included in the review? This review is an update of earlier work (Appleton 2015), using the same methods. We searched scientific databases for all randomised controlled trials in adults with MDD, where individuals received either n‐3PUFAs or an alternative, that were completed up to January 2021. We have included 35 relevant studies: 34 of them involving 1924 people compared the effects of n‐3PUFAs with those of placebo, and one study involving 40 people compared the effects of n‐3PUFAs with those of antidepressants. All studies were of direct relevance to our review, but we considered the certainty of the evidence to be low to very low. What does the evidence from the review tell us? At present, we do not have enough high quality evidence to determine the effects of n‐3PUFAs as a treatment for MDD. We found a small‐to‐modest positive effect of n‐3PUFAs compared to placebo, but the size of this effect is unlikely to be meaningful to people with MDD, and we considered the evidence to be of low or very low certainty, with many differences between studies. There was also insufficient high quality evidence to determine the effects of n‐3PUFAs on negative side effects or numbers not completing studies. What should happen next? We need more evidence, particularly to explain the differences between study findings, e.g. by looking at individuals who may or may not benefit from n‐3PUFAs. Future studies should also compare n‐3PUFAs with usual antidepressant treatment, and investigate the way these treatments may work.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Appleton, KM, Voyias, PD, Sallis, HM, Dawson, S, Ness, AR, Churchill, R, Perry, R", "articleTypes": [], "doi": "10.1002/14651858.CD004692.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.744Z" }, { "id": "d5209a76-e6e7-40a9-b82b-55839198e658", "pmid": "", "title": "Statins for Smith‐Lemli‐Opitz syndrome", "imported": false, "abstract": "Abstract - Background Smith‐Lemli‐Opitz syndrome (SLOS) is a multiple congenital malformations syndrome caused by defective cholesterol biosynthesis. Affected individuals show cholesterol deficiency and accumulation of various precursor molecules, mainly 7‐dehydrocholesterol and 8‐dehydrocholesterol. There is currently no cure for SLOS, with cholesterol supplementation being primarily a biochemical therapy of limited evidence. However, several anecdotal reports and preclinical studies have highlighted statins as a potential therapy for SLOS. Objectives To evaluate the effects of statins, either alone or in combination with other non‐statin therapies (e.g. cholesterol, bile acid, or vitamin co‐supplementation), compared to cholesterol supplementation alone or in combination with other non‐statin therapies (e.g. bile acid or vitamin supplementation) on several important outcomes including overall survival, neurobehavioral features, and adverse effects in individuals with SLOS. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases and three trials registers on 15 February 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs with parallel or cross‐over designs, and non‐randomized studies of interventions (NRSIs) including non‐randomized trials, cohort studies, and controlled before‐and‐after studies, were eligible for inclusion in this review if they met our prespecified inclusion criteria, i.e. involved human participants with biochemically or genetically diagnosed SLOS receiving statin therapy or cholesterol supplementation, or both. Data collection and analysis Two authors screened titles and abstracts and subsequently full‐texts for all potentially‐relevant references. Both authors independently extracted relevant data from included studies and assessed the risks of bias. We analyzed the data extracted from the included NRSIs and cohort studies separately from the data extracted from the single included RCT. We used a random‐effects model to account for the inherent heterogeneity and methodological variation between these different study designs. We used GRADE to assess the certainty of evidence. Main results We included six studies (61 participants with SLOS); one RCT (N = 18), three prospective NRSIs (N = 20), and two retrospective NRSIs (N = 22). Five studies included only children, and two limited their participant inclusion by disease severity. Overall, there were nearly twice as many males as females. All six studies compared add‐on statin therapy to cholesterol supplementation alone. However, the dosages, formulations, and durations of treatment were highly variable across studies. We judged the RCT as having a high risk of bias due to missing data and selective reporting. All included NRSIs had a serious or critical overall risk of bias assessed by the Risk Of Bias In Non‐randomized Studies of Interventions tool (ROBINS‐I). None of the included studies evaluated survival or reported quality of life (QoL). Only the included RCT formally assessed changes in the neurobehavioral manifestations of SLOS, and we are uncertain whether statin therapy improves this outcome (very low‐certainty evidence). We are also uncertain whether the adverse events reported in the RCT were statin‐related (very low‐certainty evidence). In contrast, the adverse events reported in the NRSIs seem to be possibly due to statin therapy (risk ratio 13.00, 95% confidence interval 1.85 to 91.49; P = 0.01; low‐certainty evidence), with only one of the NRSIs retrospectively mentioning changes in the irritability of two of their participants. We are uncertain whether statins affect growth based on the RCT or NRSI results (very low‐certainty evidence). The RCT showed that statins may make little or no difference to plasma biomarker levels (low‐certainty evidence), while we are uncertain of their effects on such parameters in the NRSIs (very low‐certainty evidence). Authors' conclusions Currently, there is no evidence on the potential effects of statin therapy in people with SLOS regarding survival or QoL, and very limited evidence on the effects on neurobehavioral manifestations. Likewise, current evidence is insufficient and of very low certainty regarding the effects of statins on growth parameters in children with SLOS and plasma or cerebrospinal fluid (CSF) levels of various disease biomarkers. Despite these limitations, current evidence seemingly suggests that statins may increase the risk of adverse reactions in individuals with SLOS receiving statins compared to those who are not. Given the insufficient evidence on potential benefits of statins in individuals with SLOS, and their potential for causing adverse reactions, anyone considering this therapy should take these findings into consideration. Future studies should address the highlighted gaps in evidence on the use of statins in individuals with SLOS by collecting prospective data on survival and performing serial standardized assessments of neurobehavioral features, QoL, anthropometric measures, and plasma and CSF biomarker levels after statin introduction. Future studies should also attempt to use consistent dosages, formulations and durations of cholesterol and statin therapy. Plain language summary Statins for Smith‐Lemli‐Opitz syndrome Review question Is statin therapy, either alone or combined with cholesterol therapy, linked to better outcomes (e.g. survival, quality of life, severity or frequency of neurobehavioral abnormalities, changes in growth parameters or biomarker levels) compared to cholesterol therapy alone for people with Smith‐Lemli‐Opitz syndrome (SLOS), and what are the risks of harmful effects for either option? Background Smith‐Lemli‐Opitz syndrome is a genetic malformation syndrome, which occurs when cholesterol is not able to be produced by the body and there is a build up of several toxic molecules that would, under normal circumstances, go on to become cholesterol, such as 7DHC and 8DHC. This means that people with SLOS may fail to achieve normal physical growth, show various degrees of intellectual disability or developmental delay (or both), and show a range of possible behavioral abnormalities (e.g. irritability, aggressiveness, anxiety, attention‐deficit hyperactivity disorder (ADHD), impulsivity and sleep disturbances, among others). It is also notable that SLOS may cause various possible physical abnormalities and disability. There is currently no cure for SLOS, but cholesterol supplementation remains common practice among clinicians caring for people with SLOS. This is based solely on our current understanding of the underlying biochemistry of the disease itself. However, there has been evidence from studies in the laboratory and in single individuals suggesting that statins may be helpful for treating people with SLOS. Search date We conducted our latest search on 15 February 2022. Study characteristics In this review, we included six studies of different designs that included a total of 61 people with SLOS, mostly males. Five of the studies only included children (18 years old or younger). All studies compared a combination of statin and cholesterol therapy to cholesterol supplementation alone. However, the studies used different doses and formulations of statin or cholesterol therapy (or both), as well as different durations of treatment. Key results We found no evidence for the effects of combined statin and cholesterol supplementation, compared to cholesterol supplementation alone, on survival or quality of life in people with SLOS. We are also not sure if combined statin and cholesterol therapy has positive effects on neurobehavioral manifestations or growth in individuals with SLOS compared with cholesterol therapy alone, as we have low confidence in the evidence. We think people with SLOS receiving statin therapy in addition to cholesterol supplementation are more likely to experience adverse events that are usually associated with using statins, compared to those who are only receiving cholesterol supplementation. Finally, we are uncertain about the effects of statin therapy on the levels of various biomarkers usually measured in the blood of people with SLOS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Ballout, RA, Livinski, A, Fu, Y-P, Steiner, RD, Remaley, AT", "articleTypes": [], "doi": "10.1002/14651858.CD013521.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.796Z" }, { "id": "d54fcca1-527d-4696-ac61-c5fe212ff5e8", "pmid": "", "title": "Advice to reduce dietary salt for prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Restricting sodium intake in hypertensive patients over short periods of time reduces blood pressure. Long term effects (on mortality, morbidity or blood pressure) of advice to reduce salt in patients with elevated or normal blood pressure are unclear. Objectives To assess in adults the long term effects (mortality, cardiovascular events, blood pressure, quality of life, weight, urinary sodium excretion, other nutrients and use of anti‐hypertensive medications) of advice to restrict dietary sodium using all relevant randomised controlled trials. Search methods The Cochrane Library, MEDLINE, EMBASE, bibliographies of included studies and related systematic reviews were searched for unconfounded randomised trials in healthy adults aiming to reduce sodium intake over at least 6 months. Attempts were made to trace unpublished or missed studies and authors of all included trials were contacted. There were no language restrictions. Selection criteria Inclusion decisions were independently duplicated and based on the following criteria: 1) randomisation was adequate; 2) there was a usual or control diet group; 3) the intervention aimed to reduce sodium intake; 4) the intervention was not multifactorial; 5) the participants were not children, acutely ill, pregnant or institutionalised; 6) follow‐up was at least 26 weeks; 7) data on any of the outcomes of interest were available. Data collection and analysis Decisions on validity and data extraction were made independently by two reviewers, disagreements were resolved by discussion or if necessary by a third reviewer. Random effects meta‐analysis, sub‐grouping, sensitivity analysis and meta‐regression were performed. Main results Three trials in normotensives (n=2326), five in untreated hypertensives (n=387) and three in treated hypertensives (n=801) were included, with follow up from six months to seven years. The large, high quality (and therefore most informative) studies used intensive behavioural interventions. Deaths and cardiovascular events were inconsistently defined and reported; only 17 deaths equally distributed between intervention and control groups occurred. Systolic and diastolic blood pressures were reduced at 13 to 60 months in those given low sodium advice as compared with controls (systolic by 1.1 mm Hg, 95% CI 1.8 to 0.4, diastolic by 0.6 mm hg, 95% CI 1.5 to ‐0.3), as was urinary 24 hour sodium excretion (by 35.5 mmol/ 24 hours, 95% CI 47.2 to 23.9). Degree of reduction in sodium intake and change in blood pressure were not related. People on anti‐hypertensive medications were able to stop their medication more often on a reduced sodium diet as compared with controls, while maintaining similar blood pressure control. Authors' conclusions Intensive interventions, unsuited to primary care or population prevention programmes, provide only minimal reductions in blood pressure during long‐term trials. Further evaluations to assess effects on morbidity and mortality outcomes are needed for populations as a whole and for patients with elevated blood pressure. A low sodium diet may help in maintenance of lower blood pressure following withdrawal of antihypertensives. If this is confirmed, with no increase in cardiovascular events, then targeting of comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. Plain language summary The long term effects of advice to cut down on salt in food on deaths, cardiovascular disease and blood pressure in adults Intensive support and encouragement to reduce salt intake did lead to reduction in salt eaten. It also lowered blood pressure but only by a small amount (about 1 mmHg for systolic blood pressure, less for diastolic) after more than a year. This reduction was not enough to expect an important health benefit. It was also very hard to keep to a low salt diet. However, the reduction in blood pressure appeared larger for people with higher blood pressure. There was not enough information to assess the effect of these changes in salt intake on health or deaths. Evidence from a large and small trial showed that advice to reduce salt helps to maintain lower blood pressure following withdrawal of antihypertensive medication. If this is confirmed, with no increase in cardiovascular events, then comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. See also the Cochrane review of short‐term salt reduction trials: Jurgens 2003 .", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Hooper, L, Bartlett, C, Davey Smith, G, Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD003656.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.745Z" }, { "id": "d5543ff3-a223-46ea-835c-2808e7db0458", "pmid": "", "title": "Fortification of staple foods with zinc for improving zinc status and other health outcomes in the general population", "imported": false, "abstract": "Abstract - Background Zinc deficiency is a global nutritional problem, particularly in children and women residing in settings where diets are cereal based and monotonous. It has several negative health consequences. Fortification of staple foods with zinc may be an effective strategy for preventing zinc deficiency and improving zinc‐related health outcomes. Objectives To evaluate the beneficial and adverse effects of fortification of staple foods with zinc on health‐related outcomes and biomarkers of zinc status in the general population. Search methods We searched the following databases in April 2015: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3 of 12, 2015, the Cochrane Library), MEDLINE & MEDLINE In Process (OVID) (1950 to 8 April 2015), EMBASE (OVID) (1974 to 8 April 2015), CINAHL (1982 to April 2015), Web of Science (1900 to 9 April 2015), BIOSIS (1969 to 9 April 2015), POPLINE (1970 to April 2015), AGRICOLA, OpenGrey, BiblioMap, and Trials Register of Promoting Health Interventions (TRoPHI), besides regional databases (April 2015) and theses. We also searched clinical trial registries (17 March 2015) and contacted relevant organisations (May 2014) in order to identify ongoing and unpublished studies. Selection criteria We included randomised controlled trials, randomised either at the level of the individual or cluster. We also included non‐randomised trials at the level of the individual if there was a concurrent comparison group. We included non‐randomised cluster trials and controlled before‐after studies only if there were at least two intervention sites and two control sites. Interventions included fortification (central/industrial) of staple foods (cereal flours, edible fats, sugar, condiments, seasonings, milk and beverages) with zinc for a minimum period of two weeks. Participants were members of the general population who were over two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies, and assessed the risk of bias of the included studies. Main results We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Four trials compared the effect of zinc‐fortified staple foods with unfortified foods (comparison 1), and four compared zinc‐fortified staple foods in combination with other nutrients/factors with the same foods containing other nutrients or factors without zinc (comparison 2). The interventions lasted between one and nine months. We categorised most trials as having unclear or high risk of bias for randomisation, but low risk of bias for blinding and attrition. None of the studies in comparison 1 reported data on zinc deficiency. Foods fortified with zinc increased the serum or plasma zinc levels in comparison to foods without added zinc (mean difference (MD) 2.12 µmol/L, 95% confidence interval (CI) 1.25 to 3.00 µmol/L; 3 studies; 158 participants; low‐quality evidence). Participants consuming foods fortified with zinc versus participants consuming the same food without zinc had similar risk of underweight (average risk ratio 3.10, 95% CI 0.52 to 18.38; 2 studies; 397 participants; low‐quality evidence) and stunting (risk ratio (RR) 0.88, 95% CI 0.36 to 2.13; 2 studies; 397 participants; low‐quality evidence). A single trial of addition of zinc to iron in wheat flour did not find a reduction in proportion of zinc deficiency (RR 0.17, 95% CI 0.01 to 3.94; very low‐quality evidence). We did not find a difference in serum or plasma zinc levels in participants consuming foods fortified with zinc plus other micronutrients when compared with participants consuming the same foods with micronutrients but no added zinc (MD 0.03 µmol/L, 95% CI ‐0.67 to 0.72 µmol/L; 4 studies; 250 participants; low‐quality evidence). No trial in comparison 2 provided information about underweight or stunting. There was no reported adverse effect of fortification of foods with zinc on indicators of iron or copper status. Authors' conclusions Fortification of foods with zinc may improve the serum zinc status of populations if zinc is the only micronutrient used for fortification. If zinc is added to food in combination with other micronutrients, it may make little or no difference to the serum zinc status. Effects of fortification of foods with zinc on other outcomes including zinc deficiency, children’s growth, cognition, work capacity of adults, or on haematological indicators are unknown. Given the small number of trials and participants in each trial, further investigation of these outcomes is required. Plain language summary The effects of fortification of common foods with zinc on health outcomes Background It is believed that zinc deficiency is widespread globally, particularly in children and women living in low‐ and middle‐income countries. Cereal‐based foods are rich in dietary fibre and phytates, which reduce absorption of zinc from the intestine. As people in low‐income households eat a lot of cereal‐based foods, they are more likely to develop zinc deficiency. Fortification of common staple foods with zinc alone or in combination with other vitamins and minerals has been proposed as an intervention to increase intake of zinc in populations who consume these foods. Review question We evaluated the effects of fortification of staple foods with zinc on blood zinc levels and health‐related outcomes in the general population above two years of age. Study characteristics We included eight trials (709 participants); seven were from middle‐income countries of Asia, Africa, Europe, and Latin America where zinc deficiency is likely to be a public health problem. Key results and quality of the evidence The effect of fortification of foods with zinc on incidence of zinc deficiency is uncertain. Fortification of foods with zinc may slightly improve the blood zinc levels of populations if zinc is the only micronutrient used for fortification. Zinc added to food in combination with other micronutrients may make little or no difference to blood zinc levels. The fortification of foods with zinc may make little or no difference on incidence of underweight or stunting. The effects of fortification of foods with zinc on other outcomes, including wasting and weight/height, are unknown. Fortification of foods with zinc does not seem to have any adverse effect on indicators of iron or copper status. Most studies included in this review involved a small number of participants and were judged to be at low or unclear risk of bias. There were also some inconsistencies in the results across different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Shah, D; Sachdev, HS; Gera, T; De‐Regil, LM; Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010697.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "d5580b74-2c40-443d-bd6a-085c4452ed02", "pmid": "", "title": "Zinc supplementation for tinnitus", "imported": false, "abstract": "Abstract - Background Tinnitus is the perception of sound without external acoustic stimuli. Patients with severe tinnitus may have physical and psychological complaints and their tinnitus can cause deterioration in their quality of life. At present no specific therapy for tinnitus has been found to be satisfactory in all patients. In recent decades, a number of reports have suggested that oral zinc supplementation may be effective in the management of tinnitus. Since zinc has a role in cochlear physiology and in the synapses of the auditory system, there is a plausible mechanism of action for this treatment. Objectives To evaluate the effectiveness and safety of oral zinc supplementation in the management of patients with tinnitus. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 6); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 July 2016. Selection criteria Randomised controlled trials comparing zinc supplementation versus placebo in adults (18 years and over) with tinnitus. Data collection and analysis We used the standard methodological procedures recommended by Cochrane. Our primary outcome measures were improvement in tinnitus severity and disability, measured by a validated tinnitus‐specific questionnaire, and adverse effects. Secondary outcomes were quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters, change in tinnitus loudness, change in overall severity of tinnitus and change in thresholds on pure tone audiometry. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included three trials involving a total of 209 participants. The studies were at moderate to high risk of bias. All included studies had differences in participant selection criteria, length of follow‐up and outcome measurement, precluding a meta‐analysis. The participants were all adults over 18 years with subjective tinnitus, but one study conducted in 2013 (n = 109) included only elderly patients. Improvement in tinnitus severity and disability Only the study in elderly patients used a validated instrument (Tinnitus Handicap Questionnaire) for this primary outcome. The authors of this cross‐over study did not report the results of the two phases separately and found no significant differences in the proportion of patients reporting tinnitus improvement at four months of follow‐up: 5% (5/93) versus 2% (2/94) in the zinc and placebo groups, respectively (risk ratio (RR) 2.53, 95% confidence interval (CI) 0.50 to 12.70; very low‐quality evidence ). None of the included studies reported any significant adverse effects. Secondary outcomes For the secondary outcome change in tinnitus loudness, one study reported no significant difference between the zinc and placebo groups after eight weeks: mean difference in tinnitus loudness ‐9.71 dB (95% CI ‐25.53 to 6.11; very low‐quality evidence ). Another study also measured tinnitus loudness but used a 0‐ to 100‐point scale. The authors of this second study reported no significant difference between the zinc and placebo groups after four months: mean difference in tinnitus loudness rating scores 0.50 (95% CI ‐5.08 to 6.08; very low‐quality evidence ). Two studies used unvalidated instruments to assess tinnitus severity. One (with 50 participants) reported the severity of tinnitus using a non‐validated scale (0 to 7 points) and found no significant difference in subjective tinnitus scores between the zinc and placebo groups at the end of eight weeks of follow‐up (mean difference (MD) ‐1.41, 95% CI ‐2.97 to 0.15; very low‐quality evidence ). A third trial (n = 50) also evaluated the improvement of tinnitus using a non‐validated instrument (a 0 to 10 scale: 10 = severe and unbearable tinnitus). In this study, after eight weeks there was no difference in the proportion of patients with improvement in their tinnitus, 8.7% (2/23) treated with zinc versus 8% (2/25) of those who received a placebo (RR 1.09, 95% CI 0.17 to 7.10, very low‐quality evidence ). None of the included studies reported any of our other secondary outcomes (quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters or change in thresholds on pure tone audiometry). Authors' conclusions We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. Plain language summary Zinc supplements for tinnitus Background Tinnitus is the perceived sensation of sound in the ear or head. Severe tinnitus affects 1% to 2% of the population. People with severe tinnitus frequently have psychological changes and a decrease in their quality of life. Tinnitus is difficult to control and many doctors are testing new treatments to improve the quality of life of people who suffer from this problem. This review looked for high‐quality studies in the literature that involved zinc supplements as a possible treatment for tinnitus in adults. The aim was to evaluate whether oral zinc is effective in the treatment of tinnitus. Study characteristics We included a total of three trials involving 209 participants who were treated with oral zinc pills or placebo. All patients were adults over 18 years who had subjective tinnitus. All three studies investigated improvement in tinnitus as their primary outcome. One study assessed adverse effects and our secondary outcome 'change in overall severity of tinnitus'. Two studies assessed tinnitus loudness. Only one study, which enrolled only elderly patients, used a validated instrument (the Tinnitus Handicap Questionnaire (THQ)) to measure the primary outcome. The other two studies measured tinnitus using scales (from 0 to 7 and from 0 to 10), but these scales were not validated instruments for studying tinnitus. Key results All three included studies had differences in their participant selection, length of follow‐up and outcome measurement, which prevented a meta‐analysis (combining of results). Only one trial (conducted in 2013) used a validated instrument (the THQ) to measure improvement in tinnitus, our primary outcome. The authors reported no significant difference between the groups. Another study (2003) reported the severity of tinnitus using a non‐validated scale (0 to 7) and found a significant difference in the subjective tinnitus scores, which favoured the zinc group. However, this result may be biased because the losses were unbalanced and higher in the placebo group. A third study (1991) also evaluated improvement of tinnitus using a non‐validated instrument (a scale of 0 to 10) and found no significant difference between groups. There were no severe adverse effects associated with zinc. Three cases of mild adverse effects were reported in different participants (e.g. mild gastric symptoms). Two studies (2003 and 2013) assessed change in tinnitus loudness (one of our secondary outcomes), but did not find a difference between patients treated with zinc compared to those who took a placebo. Two studies assessed change in the overall severity of tinnitus. One study, published in 1991, did not find any difference for this outcome between the groups. The second study, published in 2003, reported a significant reduction in subjective tinnitus score in the zinc group and no difference in the placebo group. However, both studies used a non‐validated scale. Quality of the evidence The quality of the evidence is very low. We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. This evidence is up to date to 14 July 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Person, OC; Puga, MES; da Silva, EMK; Torloni, MR", "articleTypes": [], "doi": "10.1002/14651858.CD009832.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "d5647cba-e609-4044-baa8-493cad06cfa4", "pmid": "", "title": "Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years", "imported": false, "abstract": "Abstract - Background Extensive evidence exists showing analgesic effects of sweet solutions for newborns and infants. It is less certain if the same analgesic effects exist for children one year to 16 years of age. This is an updated version of the original Cochrane review published in Issue 10, 2011 (Harrison 2011) titled Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. Objectives To determine the efficacy of sweet tasting solutions or substances for reducing needle‐related procedural pain in children beyond one year of age. Search methods Searches were run to the end of June 2014. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, the NHS Economic Evaluation Database, MEDLINE, EMBASE, PsycINFO, and ACP Journal Club (all via OvidSP), and CINAH (via EBSCOhost). We applied no language restrictions. Selection criteria Published or unpublished randomised controlled trials (RCT) in which children aged one year to 16 years, received a sweet tasting solution or substance for needle‐related procedural pain. Control conditions included water, non‐sweet tasting substances, pacifier, distraction, positioning/containment, breastfeeding, or no treatment. Data collection and analysis Outcome measures included crying duration, composite pain scores, physiological or behavioral pain indicators, self‐report of pain or parental or healthcare professional‐report of the child's pain. We reported mean differences (MD), weighted mean difference (WMD), or standardized mean difference (SMD) with 95% confidence intervals (CI) using fixed‐effect or random‐effects models as appropriate for continuous outcome measures. We reported risk ratio (RR), risk difference (RD), and the number needed to treat to benefit (NNTB) for dichotomous outcomes. We used the I 2 statistic to assess between‐study heterogeneity. Main results We included one unpublished and seven published studies (total of 808 participants); four more studies and 478 more participants than the 2011 review. Six trials included young children aged one to four years receiving sucrose or candy lollypops for immunisation pain compared with water or no treatment. Usual care included topical anaesthetics, upright parental holding, and distraction. All studies were well designed blinded RCTs, however, five of the six studies had a high risk of bias based on small sample sizes. Two studies included school‐aged children receiving sweet or unsweetened chewing gum before, or before and during, immunisation and blood collection. Both studies, conducted by the same author, had a high risk of bias based on small sample sizes. Results for the toddlers/pre‐school children were conflicting. Duration of cry, using a random‐effects model, was not significantly reduced by sweet taste (six trials, 520 children, WMD ‐15 seconds, 95% CI ‐54 to 24, I 2 = 94%). Composite pain score at time of first needle was reported in four studies (n = 121 children). The scores were not significantly different between the sucrose and control group (SMD ‐0.26, 95% CI ‐1.27 to 0.75, I 2 = 86%). A Children's Hospital of Eastern Ontario Pain Scale score > 4 was significantly less common in the sucrose group compared to the control group in one study (n = 472, RR 0.55, 95% CI 0.45 to 0.67; RD ‐0.29, 95% CI ‐0.37 to ‐0.20; NNTB 3, 95% CI 3 to 5; tests for heterogeneity not applicable. For school‐aged children, chewing sweet gum before needle‐related painful procedures (two studies, n = 111 children) or during the procedures (two studies, n = 103 children) did not significantly reduce pain scores. A comparison of the Faces Pain Scale scores in children chewing sweet gum before the procedures compared with scores of children chewing unsweetened gum revealed a WMD of ‐0.15 (95% CI ‐0.61 to 0.30). Similar results were found when comparing the chewing of sweet gum with unsweetened gum during the procedure (WMD 0.23, 95% CI ‐0.28 to 0.74). The Colored Analogue Scale for children chewing sweet gum compared to unsweetened gum before the procedure was not significantly different (WMD 0.24 (‐0.69 to 1.18)) nor was it different when children chewed the gum during the procedure (WMD 0.86 (95% CI ‐0.12 to 1.83)). There was no heterogeneity for any of these analyses in school‐aged children (I 2 = 0%). Authors' conclusions Based on the eight studies included in this systematic review update, two of which were subgroups of small numbers of eligible toddlers from larger studies, and three of which were pilot RCTs with small numbers of participants, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children between one and four years of age. Further rigorously conducted, adequately powered RCTs are warranted in this population. Based on the two studies by the same author, there was no evidence of analgesic effects of sweet taste in school‐aged children. As there are other effective evidence‐based strategies available to use in this age group, further trials are not warranted. Despite the addition of four studies in this review, conclusions have not changed since the last version of the review. Plain language summary Sweet taste to ease injection needle pain in children aged one to 16 years This is an updated version of the original Cochrane review published in Issue 10, 2011: Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. We re‐ran the search in October 2014. Review question: Do sweet tasting solutions reduce pain during needles in children aged from one to 16 years, compared to no treatment, water, other non‐sweet solutions, or other interventions such as non‐nutritive sucking (babies) or sweet foods or chewing gum (children), topical anaesthetics, music, and distraction? Background: Small amounts of sweet tasting sugar solutions given orally to babies before and during painful needles significantly reduces distress. However it was not known if the same pain‐reducing effects of sweet solutions occurred in children older than one year of age. We therefore examined studies looking at pain‐reducing effects of sweet solutions such as sucrose or glucose for painful needle procedures in children aged one to 16 years. Search date: We searched the literature for published and unpublished studies up to October 2014. Study characteristics : We found six studies focused on young children aged one to four years; two of these studies were included in the original review and four were new studies. The two studies included in the original review used a low concentration of sucrose, just 12%, which is not considered sweet enough for the pain reducing effects. Three of the four new studies were small pilot studies, conducted to inform full trials, and only one study of sweet solutions in young children included large numbers of children. When we compared results of all six studies, only two showed that sugar water (sucrose) reduced pain during injections. However, the four studies that showed no effect all included small numbers of children, therefore they were not considered large enough to detect significant differences in pain. Further well conducted trials with large enough numbers of young children are needed to work out if sweet taste effectively reduces their pain and distress during needles. For older school‐aged children, there were two studies published by the same author, both of which were included in the original review. Neither study showed that sweet taste helped to reduce pain. As other studies show that strategies such as distraction and topical anaesthetics can effectively reduce needle pain in school‐aged children, further studies of sweet taste for pain management in school‐aged children are not warranted. Study funding sources : Of the six studies including young children, two did not acknowledge receipt of research funding. For the remaining four: a state‐wide nursing fund supported two of the pilot studies, an internal research institute provided support for the remaining pilot study and another study was supported in part by a Maternal and Child Health grant. The two studies including school‐aged children, conducted by the same author, were supported by a grant from the Canadian Institutes of Health Research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Harrison, D, Yamada, J, Adams‐Webber, T, Ohlsson, A, Beyene, J, Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD008408.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.746Z" }, { "id": "d564e37b-29ae-4566-bb69-6a5ddae20f4c", "pmid": "", "title": "Antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lassi, ZS, Padhani, ZA, Das, JK, Salam, RA, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD009576.pub3 AB - Abstract - Background Worldwide, pneumonia is the leading cause of death amongst children under five years of age, and accounts for approximately two million deaths annually. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, and the severity of the disease. Treatment is then tailored according to the classification. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. The WHO recommends treating non‐severe pneumonia with oral antibiotics. Pneumonia is more commonly caused by viruses that do not require antibiotic treatment, but pneumonia caused by bacteria needs management with antibiotics to avoid complications. There is no clear way to quickly distinguish between viral and bacterial pneumonia. It is considered safe to give antibiotics, however, this may lead to the development of antibiotic resistance, and thus, limit their use in future infections. Therefore, it is essential to explore the efficacy of antibiotics for children with WHO‐defined non‐severe pneumonia and wheeze. Objectives To evaluate the efficacy of antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO‐defined non‐severe pneumonia and wheeze. Search methods We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers (December 2020). Selection criteria We included randomised controlled trials (RCTs) evaluating the efficacy of antibiotic therapy versus no antibiotic therapy for children, aged 2 to 59 months, with non‐severe pneumonia and wheeze. We defined non‐severe pneumonia as 'a cough or difficulty in breathing, with rapid breathing (a respiratory rate of 50 breaths per minute or more for children aged 2 to 12 months, or a respiratory rate of 40 breaths per minute or more for children aged 12 to 59 months), chest indrawing and wheeze'. We excluded trials involving children with severe or very severe pneumonia, and non‐RCTs. Data collection and analysis Our primary outcomes were clinical cure and treatment failure; secondary outcomes were relapse, mortality, and treatment harms. We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Two review authors independently assessed the search results, extracted data, assessed risk of bias and the certainty of the evidence. We contacted the authors of two included trials and the author of the trial awaiting classification to obtain missing numerical outcome data. Main results We included three trials involving 3256 children aged between 2 to 59 months, who exhibited features of non‐severe pneumonia with wheeze. The included trials were multi‐centre, double‐blind, randomised, placebo‐controlled trials carried out in Malawi, Pakistan, and India. The children were treated with a three‐day course of amoxicillin or placebo, and were followed up for a total of two weeks. We assessed the included trials at overall low risk of bias for random sequence generation, allocation concealment, blinding, attrition bias, and selective reporting. Only one trial was assessed to be at high risk for blinding of outcome assessors. One trial is awaiting classification Antibiotic therapy may result in a reduction of treatment failure by 20% (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.68 to 0.94; three trials; 3222 participants; low‐certainty evidence). Antibiotic therapy probably results in little or no difference to clinical cure (RR 1.02, 95% CI 0.96 to 1.08; one trial; 456 participants; moderate‐certainty evidence), and in little or no difference to relapse (RR 1.00, 95% CI 0.74 to 1.34; three trials; 2795 participants; low‐certainty evidence), and treatment harms (RR 0.81, 95% CI 0.60 to 1.09; three trials, 3253 participants; low‐certainty evidence). Two trials (2112 participants ) reported on mortality; no deaths occurred in either group. One trial reported cases of hospitalisation, diarrhoea (with and without dehydration), rash (without itch), tremors, mild nausea and vomiting. Authors' conclusions We do not currently have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. There is a clear need for RCTs to address this question in children aged 2 to 59 months with 2014 WHO‐defined non‐severe pneumonia and wheeze. Plain language summary Comparing treatment of non‐severe pneumonia, in children aged 2 to 59 months, with and without antibiotics Review question 
We tried to identify whether there was a difference in the outcomes for children aged 2 to 59 months with non‐severe pneumonia and wheeze, treated with or without antibiotics. Background 
Pneumonia is an infection of the lungs. In children, it is one of the leading causes of deaths globally. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, severity of the disease and its treatment according to the severity. For non‐severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non‐severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. More commonly, pneumonia is caused by viruses that require supportive care rather than antibiotic treatment; however, pneumonia caused by bacteria should be treated with antibiotics to avoid complications. Since there is no clear way to quickly distinguish which organism actually caused the pneumonia, it is considered safe to give antibiotics. However, this may lead to the development of antibiotic resistance, and limit their use in future infections. The question is whether the use of antibiotics is justified in non‐severe pneumonia. Search date Our evidence is current to 23 December 2020. Study characteristics We included three trials (3256 children). They were conducted in four hospitals in three cities in Pakistan (Islamabad, Lahore and Rawalpindi), and in hospital outpatient departments in India and Malawi. The children were treated with a three‐day course of amoxicillin (antibiotic) or placebo, and followed up for two weeks. One trial is awaiting classification. Study funding source The included trials were supported by the USAID through INCLEN and IndiaClen; ARI Research Cell, Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and by a grant from the Bill & Melinda Gates Foundation. Key results Limited data showed a 20% reduction in treatment failure, however, no impact was observed on clinical cure, relapse, and treatment harms. No deaths were reported in either group. Our review did not have enough evidence to support or challenge the continued use of antibiotics for the treatment of non‐severe pneumonia. Certainty of the evidence The certainty of evidence for clinical cure was moderate. The certainty of evidence for treatment failure, relapse, and treatments harms was low, due to downgrading for imprecision and risk of bias.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.788Z" }, { "id": "d588e157-ed04-4471-8bec-9045d545c65d", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies for treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). Objectives To assess the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for treating patients with COVID‐19, compared to an active comparator, placebo, or no intervention. To maintain the currency of the evidence, we will use a living systematic review approach. A secondary objective is to track newly developed SARS‐CoV‐2‐targeting mAbs from first tests in humans onwards. Search methods We searched MEDLINE, Embase, the Cochrane COVID‐19 Study Register, and three other databases on 17 June 2021. We also checked references, searched citations, and contacted study authors to identify additional studies. Between submission and publication, we conducted a shortened randomised controlled trial (RCT)‐only search on 30 July 2021. Selection criteria We included studies that evaluated SARS‐CoV‐2‐neutralising mAbs, alone or combined, compared to an active comparator, placebo, or no intervention, to treat people with COVID‐19. We excluded studies on prophylactic use of SARS‐CoV‐2‐neutralising mAbs. Data collection and analysis Two authors independently assessed search results, extracted data, and assessed risk of bias using the Cochrane risk of bias tool (RoB2). Prioritised outcomes were all‐cause mortality by days 30 and 60, clinical progression, quality of life, admission to hospital, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We identified six RCTs that provided results from 17,495 participants with planned completion dates between July 2021 and December 2031. Target sample sizes varied from 1020 to 10,000 participants. Average age was 42 to 53 years across four studies of non‐hospitalised participants, and 61 years in two studies of hospitalised participants. Non‐hospitalised individuals with COVID‐19 Four studies evaluated single agents bamlanivimab (N = 465), sotrovimab (N = 868), regdanvimab (N = 307), and combinations of bamlanivimab/etesevimab (N = 1035), and casirivimab/imdevimab (N = 799). We did not identify data for mortality at 60 days or quality of life. Our certainty of the evidence is low for all outcomes due to too few events (very serious imprecision). Bamlanivimab compared to placebo No deaths occurred in the study by day 29. There were nine people admitted to hospital by day 29 out of 156 in the placebo group compared with one out of 101 in the group treated with 0.7 g bamlanivimab (risk ratio (RR) 0.17, 95% confidence interval (CI) 0.02 to 1.33), 2 from 107 in the group treated with 2.8 g (RR 0.32, 95% CI 0.07 to 1.47) and 2 from 101 in the group treated with 7.0 g (RR 0.34, 95% CI 0.08 to 1.56). Treatment with 0.7 g, 2.8 g and 7.0 g bamlanivimab may have similar rates of AEs as placebo (RR 0.99, 95% CI 0.66 to 1.50; RR 0.90, 95% CI 0.59 to 1.38; RR 0.81, 95% CI 0.52 to 1.27). The effect on SAEs is uncertain. Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Bamlanivimab/etesevimab compared to placebo There were 10 deaths in the placebo group and none in bamlanivimab/etesevimab group by day 30 (RR 0.05, 95% CI 0.00 to 0.81). Bamlanivimab/etesevimab may decrease hospital admission by day 29 (RR 0.30, 95% CI 0.16 to 0.59), may result in a slight increase in any grade AEs (RR 1.15, 95% CI 0.83 to 1.59) and may increase SAEs (RR 1.40, 95% CI 0.45 to 4.37). Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Casirivimab/imdevimab compared to placebo Casirivimab/imdevimab may reduce hospital admissions or death (2.4 g: RR 0.43, 95% CI 0.08 to 2.19; 8.0 g: RR 0.21, 95% CI 0.02 to 1.79). We are uncertain of the effect on grades 3‐4 AEs (2.4 g: RR 0.76, 95% CI 0.17 to 3.37; 8.0 g: RR 0.50, 95% CI 0.09 to 2.73) and SAEs (2.4 g: RR 0.68, 95% CI 0.19 to 2.37; 8.0 g: RR 0.34, 95% CI 0.07 to 1.65). Mortality by day 30 and clinical progression/improvement of symptoms or development of severe symptoms were not reported. Sotrovimab compared to placebo We are uncertain whether sotrovimab has an effect on mortality (RR 0.33, 95% CI 0.01 to 8.18) and invasive mechanical ventilation (IMV) requirement or death (RR 0.14, 95% CI 0.01 to 2.76). Treatment with sotrovimab may reduce the number of participants with oxygen requirement (RR 0.11, 95 % CI 0.02 to 0.45), hospital admission or death by day 30 (RR 0.14, 95% CI 0.04 to 0.48), grades 3‐4 AEs (RR 0.26, 95% CI 0.12 to 0.60), SAEs (RR 0.27, 95% CI 0.12 to 0.63) and may have little or no effect on any grade AEs (RR 0.87, 95% CI 0.66 to 1.16). Regdanvimab compared to placebo Treatment with either dose (40 or 80 mg/kg) compared with placebo may decrease hospital admissions or death (RR 0.45, 95% CI 0.14 to 1.42; RR 0.56, 95% CI 0.19 to 1.60, 206 participants), but may increase grades 3‐4 AEs (RR 2.62, 95% CI 0.52 to 13.12; RR 2.00, 95% CI 0.37 to 10.70). 80 mg/kg may reduce any grade AEs (RR 0.79, 95% CI 0.52 to 1.22) but 40 mg/kg may have little to no effect (RR 0.96, 95% CI 0.64 to 1.43). There were too few events to allow meaningful judgment for the outcomes mortality by 30 days, IMV requirement, and SAEs. Hospitalised individuals with COVID‐19 Two studies evaluating bamlanivimab as a single agent (N = 314) and casirivimab/imdevimab as a combination therapy (N = 9785) were included. Bamlanivimab compared to placebo We are uncertain whether bamlanivimab has an effect on mortality by day 30 (RR 1.39, 95% CI 0.40 to 4.83) and SAEs by day 28 (RR 0.93, 95% CI 0.27 to 3.14). Bamlanivimab may have little to no effect on time to hospital discharge (HR 0.97, 95% CI 0.78 to 1.20) and mortality by day 90 (HR 1.09, 95% CI 0.49 to 2.43). The effect of bamlanivimab on the development of severe symptoms at day 5 (RR 1.17, 95% CI 0.75 to 1.85) is uncertain. Bamlanivimab may increase grades 3‐4 AEs at day 28 (RR 1.27, 95% CI 0.81 to 1.98). We assessed the evidence as low certainty for all outcomes due to serious imprecision, and very low certainty for severe symptoms because of additional concerns about indirectness. Casirivimab/imdevimab with usual care compared to usual care alone Treatment with casirivimab/imdevimab compared to usual care probably has little or no effect on mortality by day 30 (RR 0.94, 95% CI 0.87 to 1.02), IMV requirement or death (RR 0.96, 95% CI 0.90 to 1.04), nor alive at hospital discharge by day 30 (RR 1.01, 95% CI 0.98 to 1.04). We assessed the evidence as moderate certainty due to study limitations (lack of blinding). AEs and SAEs were not reported. Authors' conclusions The evidence for each comparison is based on single studies. None of these measured quality of life. Our certainty in the evidence for all non‐hospitalised individuals is low, and for hospitalised individuals is very low to moderate. We consider the current evidence insufficient to draw meaningful conclusions regarding treatment with SARS‐CoV‐2‐neutralising mAbs. Further studies and long‐term data from the existing studies are needed to confirm or refute these initial findings, and to understand how the emergence of SARS‐CoV‐2 variants may impact the effectiveness of SARS‐CoV‐2‐neutralising mAbs. Publication of the 36 ongoing studies may resolve uncertainties about the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for the treatment of COVID‐19 and possible subgroup differences. Plain language summary Are laboratory‐made, COVID‐19‐specific monoclonal antibodies an effective treatment for COVID‐19? Key messages ‐ We do not know whether antibodies (the body’s natural defence against disease) made in a laboratory and all the same as one another (monoclonal) and designed to target COVID‐19, are an effective treatment for COVID‐19 because we assessed only six studies exploring different treatments in different types of patients. ‐ We identified 36 ongoing studies that will provide more evidence when completed. ‐ We will update this review regularly as more evidence becomes available. What are ‘monoclonal’ antibodies? Antibodies are made by the body as a defence against disease. However, they can also be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that are designed to target only one specific protein – in this case, a protein on the virus that causes COVID‐19 – are ‘monoclonal’. They attach to the COVID‐19 virus and stop it from entering and replicating in human cells, which helps to fight the infection. Monoclonal antibodies have been used successfully to treat other viruses. They are thought to cause fewer unwanted effects than convalescent plasma, which contains a variety of different antibodies. What did we want to find out? We wanted to know if COVID‐19 specific monoclonal antibodies are an effective treatment for COVID‐19. We looked at whether they: ‐ reduced the number of deaths from any cause; ‐ improved symptoms or made them worse; ‐ increased admissions to hospital; and ‐ caused any serious or other unwanted effects. What did we do? We searched for studies that investigated one or more monoclonal antibodies to treat people with confirmed COVID‐19 compared with placebo (sham treatment), another treatment or no treatment. Studies could take place anywhere globally and include participants of any age, gender or ethnicity, with mild, moderate or severe COVID‐19. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found six active studies including a total of 17,495 people. Four studies investigated non‐hospitalised people with no symptoms or mild COVID‐19. Two studies investigated hospitalised people with moderate to severe COVID‐19. Studies took place across the world. Three studies were funded by pharmaceutical companies. The monoclonal antibodies they studied were bamlanivimab, etesevimab, casirivimab and imdevimab, sotrovimab, regdanvimab. We did not identify data for mortality at 60 days and quality of life. Non‐hospitalised people, with no symptoms or mild COVID‐19 (four studies) One study investigated different doses of bamlanivimab (465 people), compared to placebo. We don’t know whether bamlanivimab: ‐ increases or reduces the number of deaths because no participants died within 30 days of treatment; ‐ causes more or fewer serious unwanted effects because there were few events. Bamlanivimab may reduce the number of admissions to hospital within 30 days of treatment compared to placebo. ‐ May cause slightly fewer unwanted effects than placebo. ‐ We did not find data for improved symptoms or worsened symptoms. One study investigated a combination of bamlanivimab and etesevimab (1035 people), compared to placebo. ‐ Bamlanivimab and etesevimab may reduce the number of deaths and admissions to hospital. ‐ May cause slightly more unwanted effects. ‐ May cause more serious unwanted effects. For treatment with bamlanivimab alone or in combination with etesevimab we did not find data for improved symptoms or worsened symptoms. One study (phase 1/2 with 799 people) investigated different doses of casirivimab combined with imdevimab, compared to placebo. ‐ Casirivimab combined with imdevimab may reduce the number of hospital admissions or death. ‐ We don't know whether casirivimab and imdevimab causes more unwanted (grades 3 and 4) and serious unwanted effects than placebo because there were too few deaths to allow us to make a judgment. ‐ We did not find data for the number of people who died at day 30 and development of severe symptoms. ‐ We did not include results from phase 3 (5607 people) of this study, because of high risk of bias, as it was not clear which participants were included in the analysis. One study (583 people) investigated sotrovimab, compared to placebo. We don't know whether sotrovimab: ‐ increases or reduces the number of deaths and people requiring invasive mechanical ventilation or dying, because there were too few deaths to allow us to make a judgment. ‐ Sotrovimab may reduce the number of people requiring oxygen, unwanted (grades 3 to 4) and serious unwanted effects; ‐ may have little or no effect on unwanted effects (all grades). Another study (327 people) investigated different doses of regdanvimab (40 mg/kg and 80 mg/kg), compared to placebo. ‐ Regdanvimab at either dose may reduce the number of admissions to hospital or death. ‐ May increase unwanted events (grades 3 to 4). ‐ Regdanvimab at a dose of 80 mg/kg may reduce unwanted effects (all grades) and 40 mg/kg may have little to no effect. ‐ We don't know whether regdanvimab increases or decreases the number of deaths, requirement for invasive mechanical ventilation, and serious unwanted effects, because there were too few events to allow us to make a judgment. Hospitalised people with moderate to severe COVID‐19 (2 studies) One study (314 people) investigated bamlanivimab compared to placebo. ‐ We don’t know whether bamlanivimab increases or decreases the number of deaths due to any cause up to 30 or 90 days after treatment because there were too few deaths to allow us to make a judgment (6 deaths with bamlanivimab and 4 deaths with placebo in 314 people). ‐ Bamlanivimab may slightly increase the development of severe COVID‐19 symptoms five days after treatment and the number of people with unwanted effects. ‐ Bamlanivimab may have little to no effect on time until discharge from hospital. ‐ We don’t know whether bamlanivimab causes serious unwanted effects by day 30 because the study was small and reported few serious unwanted effects. Another study (9785 people) investigated casirivimab combined with imdevimab, compared to standard of care. ‐ Casirivimab combined with imdevimab has probably little to no effect on the number of deaths, requirement for invasive mechanical ventilation or death, and hospital discharge alive. ‐ We did not find data for unwanted and serious unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is low because we found only six studies, and they did not report everything we were interested in, such as the number of deaths within 60 days and quality of life. We found 36 ongoing studies. When they are published, we will add their results to our review. These results are likely to change our conclusions and will also help us understand how new variants affect how well monoclonal antibodies work. How up to date is this evidence? The evidence is up to date to 17 June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Kreuzberger, N, Hirsch, C, Chai, KL, Tomlinson, E, Khosravi, Z, Popp, M, Neidhardt, M, Piechotta, V, Salomon, S, Valk, SJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.807Z" }, { "id": "d58fcdba-29a8-4134-9353-e1690507fb50", "pmid": "", "title": "Nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy", "imported": false, "abstract": "Abstract - Background Across the developed world, an estimated 150,000 to 300,000 people are treated annually with pelvic radiotherapy and 80% will develop gastrointestinal (GI) symptoms during treatment. Acute GI symptoms are associated with a greater risk of chronic, often debilitating, GI symptoms. Up to one‐third of patients are malnourished before pelvic radiotherapy and up to four‐fifths of patients lose weight during treatment. Malnutrition is linked to a higher risk of GI toxicity, which can lead to breaks in radiotherapy and early cessation of chemotherapy, thus compromising the efficacy of the primary cancer treatment. Objectives To assess the effects of nutritional interventions for reducing GI toxicity in adults undergoing radical pelvic radiotherapy. Search methods We searched the Cochrane Gynaecological Cancer Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 4, 2012, MEDLINE and EMBASE to May 2012. We handsearched the citation lists of included studies and previous systematic reviews identified to identify further relevant trials. Selection criteria We included studies if they were randomised controlled trials (RCTs) or non‐randomised studies with concurrent comparison groups including quasi‐randomised trials, cluster RCTs, non‐randomised trials, prospective and retrospective cohort studies, and case series of 30 or more patients. We only included studies if they assessed the effect of a nutritional intervention in adults aged 18 years or over undergoing radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic malignancy. We excluded patients with stomas and a previous history of inflammatory bowel disease. Nutritional support interventions could be provided at any stage before or during pelvic radiotherapy and included dietary counselling; dietary modification of fibre, lactose or fat; supplementary foods or drinks or fortified foods; standard oral nutrition supplements including polymeric‐, peptide‐ or amino acid‐based supplements and those where novel substrates have been added; enteral tube feeds; or parenteral nutrition (partial or total). We excluded probiotics, prebiotics and synbiotics. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors to obtain missing data. We assessed bias for each of the included studies using the bias assessment tables in the Cochrane software Review Manager5. We performed meta‐analysis, when indicated, using the Mantel‐Haenszel fixed‐effect method or inverse variance fixed‐effect method displayed with heterogeneity. We undertook meta‐analyses on trials evaluating dietary modification against standard treatment for diarrhoea at the end of radiotherapy and for change in weight from baseline to end of radiotherapy. Main results The searches identified 7558 titles, and we excluded 7513 during title and abstract searches. We reviewed 45 papers in full, and excluded 39. We identified four studies on handsearching of the references, which, along with the six eligible papers from the database search, led to 10 studies being included. Four studies, three of which were RCTs and one prospective study, investigated the effect of elemental diet on GI symptoms; one RCT investigated the effect of dietary modification and elemental diet; and five RCTs investigated dietary modification. Studies were varied in terms of risk of bias. Data were dichotomised for presence and absence of diarrhoea at the end of radiotherapy for four trials evaluating dietary modification comprising modified fat, lactose, fibre or combinations of these dietary changes. A reduction in diarrhoea was demonstrated with nutritional intervention (risk ratio (RR) 0.66; 95% confidence interval (CI) 0.51 to 0.87, four studies, 413 participants, moderate quality of evidence) with low heterogeneity (Chi 2 = 3.50, I 2 = 14%). Two trials evaluating dietary modification on weight change (comparing baseline and end of radiotherapy) showed no difference between intervention or control (mean difference (MD) ‐0.57 kg; 95% CI ‐1.22 to 0.09) with low heterogeneity (Chi 2 = 1.41, I 2 = 29%). Generally adverse effects were poorly reported in included studies. Elemental diet in particular was poorly tolerated. GI symptoms or toxicity > 6 months after radiotherapy was not reported in included studies Authors' conclusions There have been benefits demonstrated with dietary modification during pelvic radiotherapy to reduce diarrhoea. Those diets included single interventions or combinations of modified fat, lactose‐restriction, fat‐restriction and fibre supplementation. We were unable to meta‐analyse elemental diet, as data were not available. We considered some of the studies to be at high risk of bias. There have been recent advances in novel, more targeted radiotherapy techniques, such that the findings of older studies need to be interpreted with caution. In addition, there were problems with compliance and palatability with some of the interventions, particularly elemental diet, which limits its usefulness in clinical practice. Plain language summary Do nutritional interventions reduce gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy? Background Research has shown that nutrition and radiotherapy have effects on each other. People with malnutrition tend to get more bowel side effects during radiotherapy. It has also been shown that many people lose weight during radiotherapy due to the treatment side effects. These side effects can lead to some people needing gaps in their radiotherapy and sometimes they even need to stop it entirely. This can reduce the chance of cancer cure. This review looked at the literature for providing extra nourishment or changes in diet to patients before or during radiotherapy, to determine whether this is of benefit in terms of reducing bowel symptoms, improving nutritional status and quality of life. Study characteristics Searches of all relevant sources of medical information identified 7558 articles, and, after initial screening of all these articles, we selected 45 as being suitable for this review. On reading the summaries of these 45 trials, 10 were suitable to be included in this review. We included trials that looked at the effects of a nutritional intervention in adults aged 18 years or over having radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic cancer. We excluded patients with stomas and a previous history of inflammatory bowel disease. Key results Results showed that studies evaluating dietary changes, including changes in dietary fat, fibre and lactose, during radiotherapy reduced diarrhoea at the end of treatment. However, these dietary changes did not seem to improve patients' weights. Quality of the evidence While some changes to diet during radiotherapy may benefit patients by reducing diarrhoea, it is important to recognise that some of the studies reviewed were dated and there have been changes in radiotherapy technique since then that may give patients less diarrhoea anyway. In addition, many studies were of poor quality and, therefore, only a small number were able to be included in this review. Some interventions described, for example, having to take a liquid diet, were not acceptable as many patients found them difficult to tolerate and were unable to take them completely.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Henson, CC, Burden, S, Davidson, SE, Lal, S", "articleTypes": [], "doi": "10.1002/14651858.CD009896.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.751Z" }, { "id": "d5959c95-f85a-492e-ad26-8e3473e56c6a", "pmid": "", "title": "Antioxidant vitamin supplementation for preventing and slowing the progression of age‐related cataract", "imported": false, "abstract": "Abstract - Background Age‐related cataract is a major cause of visual impairment in the elderly. Oxidative stress has been implicated in its formation and progression. Antioxidant vitamin supplementation has been investigated in this context. Objectives To assess the effectiveness of antioxidant vitamin supplementation in preventing and slowing the progression of age‐related cataract. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 2), MEDLINE (January 1950 to March 2012), EMBASE (January 1980 to March 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to March 2012), Open Grey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 2 March 2012. We also checked the reference lists of included studies and ongoing trials and contacted investigators to identify eligible randomized trials. Selection criteria We included only randomized controlled trials in which supplementation with one or more antioxidant vitamins (beta‐carotene, vitamin C and vitamin E) in any form, dosage or combination for at least one year was compared to another antioxidant vitamin or to placebo. Data collection and analysis Two authors extracted data and assessed trial quality independently. We pooled results for the primary outcomes, i.e., incidence of cataract and incidence of cataract extraction. We did not pool results of the secondary outcomes ‐ progression of cataract and loss of visual acuity, because of differences in definitions of outcomes and data presentation. We pooled results by type of cataract when data were available. We did not perform a sensitivity analysis. Main results Nine trials involving 117,272 individuals of age 35 years or older are included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States, with duration of follow‐up ranging from 2.1 to 12 years. The doses of antioxidant vitamins were higher than the recommended daily allowance. There was no evidence of effect of antioxidant vitamin supplementation in reducing the risk of cataract, cataract extraction, progression of cataract or in slowing the loss of visual acuity. In the pooled analyses, there was no evidence of effect of beta‐carotene supplementation in reducing the risk of cataract (two trials) (relative risk (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.08; n = 57,703) or in reducing the risk of cataract extraction (three trials) (RR 1.00, 95% CI 0.91 to 1.10; n = 86,836) or of vitamin E supplementation in reducing the risk of cataract (three trials) (RR 0.97, 95% CI 0.91 to 1.04; n = 50,059) or of cataract extraction (five trials) (RR 0.98, 95% CI 0.91 to 1.05; n = 83,956). The proportion of participants developing hypercarotenodermia (yellowing of skin) while on beta‐carotene ranged from 7.4% to 15.8%. Authors' conclusions There is no evidence from RCTs that supplementation with antioxidant vitamins (beta‐carotene, vitamin C or vitamin E) prevents or slows the progression of age‐related cataract. We do not recommend any further studies to examine the role of antioxidant vitamins beta‐carotene, vitamin C and vitamin E in preventing or slowing the progression of age‐related cataract. Costs and adverse effects should be weighed carefully with unproven benefits before recommending their intake above recommended daily allowances. Plain language summary Antioxidant vitamins for preventing and slowing the progression of age‐related cataract A cataract occurs when the normally clear lens in the eye becomes cloudy. Cataracts are the leading cause of correctable reduced vision worldwide. Most cataracts develop slowly with normal aging. However, cataracts also may be related to genetic diseases and medical conditions such as diabetes. Other factors such as poor nutrition, sun damage, radiation, corticosteroids, smoking, alcohol, eye trauma or other eye surgery may influence cataract formation. Mild or early cataracts may not impair vision. In some cataracts, new eye‐glass prescriptions, brighter lighting or magnifying lenses may overcome the vision losses. When these interventions fail to improve poor vision due to cataracts, surgical removal (extraction) is the generally accepted effective treatment. However, cataract surgery is associated with some risks. The estimated annual costs for outpatient, inpatient and prescription drug services related to the treatment of cataract is USD 6.8 billion. Antioxidant vitamin supplementation has been studied as a means to prevent the formation or to slow the progression of cataract. Results from observational studies have been inconsistent. The review authors searched for randomized controlled trials in which supplementation with the antioxidant vitamins beta‐carotene (provitamin A), vitamin C and vitamin E was compared to inactive placebo or no supplement. Nine trials involving 117,272 adults of age 35 years or older were included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States and were of high methodological quality. The doses of antioxidants given in each trial were higher than the recommended daily allowances. The trials provided no evidence of effect of the antioxidant vitamins beta‐carotene, vitamin E and vitamin C given alone or in combination on the incidence of cataract, its extraction or progression and on the loss of visual acuity. Some participants (7% to 16%) on beta‐carotene developed yellowing of the skin (hypercarotenodermia).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mathew, MC; Ervin, AM; Tao, J; Davis, RM", "articleTypes": [], "doi": "10.1002/14651858.CD004567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "d59ed0dc-874b-41cf-9e73-eaa6519ef14f", "pmid": "", "title": "Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months", "imported": false, "abstract": "Abstract - Background Bronchiolitis is one of the most common respiratory problems in the first year of life. The sputum of infants with bronchiolitis has increased deoxyribonucleic acid (DNA) content, leading to mucous plugging and airway obstruction. Recombinant human deoxyribonuclease (rhDNase), an enzyme that digests extracellular DNA, might aid the clearance of mucus and relieve peripheral airway obstruction. Objectives To determine the effect of nebulised rhDNase on the severity and duration of viral bronchiolitis in children younger than 24 months of age in the hospital setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 7 which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July Week 4, 2012), EMBASE (1974 to August 2012) and LILACS (1982 to August 2012). Selection criteria Randomised controlled trials (RCTs) using nebulised rhDNase alone or with concomitant therapy in children younger than 24 months of age hospitalised with acute bronchiolitis. Data collection and analysis Two review authors independently performed literature searches, assessed trial quality and extracted data. We obtained unpublished data from trial authors. We used Review Manager 5.1 to pool treatment effects expressed as the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI). Main results Three RCTs (333 participants) were identified, two of which were multicentre trials comprising only participants positive for respiratory syncytial virus (RSV). The other trial enrolled participants clinically diagnosed with bronchiolitis from a hospital in Italy. All studies used 2.5 mL (1 mg/mL) of nebulised rhDNase compared with placebo either as a daily or a twice daily dose. Adjunctive therapy included nebulised salbutamol, steroids, supplemental oxygen, intravenous fluids or tube feeding, nasal washing, nasal decongestants and antibiotics. Overall, nebulised rhDNase showed no benefit in clinically meaningful outcomes. Meta‐analysis favoured the control group with a shorter duration of hospital stay (MD 0.50; 95% CI 0.10 to 0.90, P = 0.01) and better clinical score improvement (SMD ‐0.24; 95% CI ‐0.50 to 0.01, P = 0.06). The largest trial showed no difference in supplemental oxygen use or intensive care unit (ICU) admission. In one RCT, four out of 11 patients in the treatment group had atelectasis. Two of these patients showed distinctive clinical improvement after nebulised rhDNase. There was no significant difference in adverse events. These included temporary desaturation, temporary coughing, increased coughing, facial rash, hoarseness, dyspnoea and bad taste, reported in a total of 11 patients from both treatment groups. Authors' conclusions The results based on the three included studies in this review did not support the use of nebulised rhDNase in children under 24 months of age hospitalised with acute bronchiolitis. In these patients, treatment did not shorten the length of hospitalisation or improve clinical outcomes. It might have a role in severe bronchiolitis complicated by atelectasis, but further clinical studies would need to be performed. Plain language summary Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months Bronchiolitis is the most common respiratory illness leading to hospitalisations in infants. Viral infections, particularly respiratory syncytial virus, are the usual cause, which lead to blockage of the small airways of the lungs due to inflammation and increased mucus production. Afflicted children have fever, cough, wheezing and difficulty breathing. Treatment is usually supportive. In bronchiolitis, the mucus produced contains large amounts of DNA, which makes it thicker and stickier. Removal of this DNA facilitates clearance of the mucus. RhDNase is an enzyme that breaks down DNA and hence may improve symptoms. We performed this review to assess the effect of rhDNase delivered through a nebuliser in children under 24 months old hospitalised for bronchiolitis. We identified three randomised controlled trials involving 333 children up to 24 months of age hospitalised with bronchiolitis. All three studies compared nebulised rhDNase with placebo. Any additional treatments were given to both groups. Overall, the studies did not show that nebulised rhDNase shortened the duration of hospital admission, or improved the severity of symptoms. No serious side effects were reported by any of the studies. One study showed that in patients suffering from atelectasis, a severe complication of bronchiolitis wherein the lung does not expand completely, nebulised rhDNase treatment resulted in a distinct improvement within two days. To confirm this beneficial effect, further clinical studies in patients with severe bronchiolitis are needed. Currently, the use of this treatment in young children hospitalised with bronchiolitis is not recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Enriquez, A; Chu, IW; Mellis, C; Lin, WY", "articleTypes": [], "doi": "10.1002/14651858.CD008395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "d5b140d9-5c13-416f-9266-de918ef4f01d", "pmid": "", "title": "Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years", "imported": false, "abstract": "Abstract - Background Child and adolescent overweight and obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages. Objectives To assess the effects of diet, physical activity and behavioural interventions (behaviour‐changing interventions) for the treatment of overweight or obese children aged 6 to 11 years. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases. Selection criteria We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour‐changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow‐up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. Data collection and analysis Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta‐analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty‐five trials compared a behaviour‐changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour‐changing intervention. Sixty‐four trials were parallel RCTs, and four were cluster RCTs. Sixty‐four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2. Primary analyses demonstrated that behaviour‐changing interventions compared to no treatment/usual care control at longest follow‐up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was ‐0.53 kg/m 2 (95% confidence interval (CI) ‐0.82 to ‐0.24); P < 0.00001; 24 trials; 2785 participants; low‐quality evidence. MD in BMI z score was ‐0.06 units (95% CI ‐0.10 to ‐0.02); P = 0.001; 37 trials; 4019 participants; low‐quality evidence and MD in weight was ‐1.45 kg (95% CI ‐1.88 to ‐1.02); P < 0.00001; 17 trials; 1774 participants; low‐quality evidence. Thirty‐one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health‐related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI ‐12.88 to ‐0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all‐cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta‐analysed. As the meta‐analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post‐intervention follow‐up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post‐intervention was no longer evident at follow‐up at less than six months, which has to be investigated in further trials. Authors' conclusions Multi‐component behaviour‐changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short‐term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour‐changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour‐changing interventions on health‐related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer‐term follow‐up and further research on the most appropriate forms of post‐intervention maintenance in order to ensure intervention benefits are sustained over the longer term. Plain language summary Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years Review question How effective are diet, physical activity and behavioural interventions in reducing the weight of overweight or obese children aged 6 to 11 years? Background Across the world more children are becoming overweight and obese. These children are more likely to suffer from health problems, both while as children and in later life. More information is needed about what works best for treating this problem. Study characteristics We found 70 randomised controlled trials (clinical trials where people are randomly put into one of two or more treatment groups) comparing diet, physical activity, and behavioural (where habits are changed or improved) treatments to a variety of control groups delivered to 8461 overweight or obese children aged 6 to 11 years. We reported on the effects of 64 multicomponent interventions (different combinations of diet and physical activity and behaviour change), four physical activity interventions and two dietary interventions compared with no intervention, 'usual care’ or some other therapy if it was also delivered in the intervention arm. The children in the included studies were followed up between six months and three years. Key results The average age of the children was 10 years. Most studies reported the body mass index (BMI) z score: BMI is a measure of body fat and is calculated by dividing weight (in kilograms) by the square of the body height measured in metres (kg/m²). In children, BMI is often measured in a way that takes into account sex and age, weight, and height changes as children grow older (BMI z score). We summarised the results of 37 trials in 4019 children reporting the BMI z score, which on average was 0.06 units lower in the intervention groups compared with the control groups. We summarised the results of 24 trials in 2785 children reporting BMI, which on average was 0.53 kg/m 2 lower in the intervention groups compared with the control groups. We summarised the results of 17 trials in 1774 children reporting weight, which on average was 1.45 kg lower in the intervention groups compared with the control groups. Other effects of the interventions, such as improvements in health‐related quality of life were less clear. No study investigated death from any cause, morbidity or socioeconomic effects. Serious adverse events were rare: only two of 31 trials with data reported any serious adverse events (4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). This evidence is up to date as of July 2016. Quality of the evidence The overall quality of the evidence was low or very low, mainly because of limited confidence in how studies were performed, and the results were inconsistent between the studies. Also there were just a few studies for some outcomes, with small numbers of included children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Mead, E; Brown, T; Rees, K; Azevedo, LB; Whittaker, V; Jones, D; Olajide, J; Mainardi, GM; Corpeleijn, E; O'Malley, C; Beardsmore, E; Al‐Khudairy, L; Baur, L; Metzendorf, MI; Demaio, A; Ells, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012651", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "d5b5bd83-a336-467a-8aed-9278d13bb061", "pmid": "", "title": "Probiotics for induction of remission in ulcerative colitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Kaur, L, Gordon, M, Baines, PA, Iheozor-Ejiofor, Z, Sinopoulou, V, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD005573.pub3 AB - Abstract - Background Ulcerative colitis is an inflammatory condition affecting the colon, with an annual incidence of approximately 10 to 20 per 100,000 people. The majority of people with ulcerative colitis can be put into remission, leaving a group who do not respond to first‐ or second‐line therapies. There is a significant proportion of people who experience adverse effects with current therapies. Consequently, new alternatives for the treatment of ulcerative colitis are constantly being sought. Probiotics are live microbial feed supplements that may beneficially affect the host by improving intestinal microbial balance, enhancing gut barrier function and improving local immune response. Objectives To assess the efficacy of probiotics compared with placebo or standard medical treatment (5‐aminosalicylates, sulphasalazine or corticosteroids) for the induction of remission in people with active ulcerative colitis. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 31 October 2019. We contacted authors of relevant studies and manufacturers of probiotics regarding ongoing or unpublished trials that may be relevant to the review, and we searched ClinicalTrials.gov. We also searched references of trials for any additional trials. Selection criteria Randomised controlled trials (RCTs) investigating the effectiveness of probiotics compared to standard treatments or placebo in the induction of remission of active ulcerative colitis. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We analysed data using Review Manager 5. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE methodology. Main results In this review, we included 14 studies (865 randomised participants) that met the inclusion criteria. Twelve of the studies looked at adult participants and two studies looked at paediatric participants with mild to moderate ulcerative colitis, the average age was between 12.5 and 47.7 years. The studies compared probiotics to placebo, probiotics to 5‐ASA and a combination of probiotics plus 5‐ASA compared to 5‐ASA alone. Seven studies used a single probiotic strain and seven used a mixture of strains. The studies ranged from two weeks to 52 weeks. The risk of bias was high for all except two studies due to allocation concealment, blinding of participants, incomplete reports of outcome data and selective reporting. This led to GRADE ratings of the evidence ranging from moderate to very low. Probiotics versus placebo 
Probiotics may induce clinical remission when compared to placebo (RR 1.73, 95% CI 1.19 to 2.54; 9 studies, 594 participants; low‐certainty evidence; downgraded due to imprecision and risk of bias, number needed to treat for an additional beneficial outcome (NNTB) 5). Probiotics may lead to an improvement in clinical disease scores (RR 2.29, 95% CI 1.13 to 4.63; 2 studies, 54 participants; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.04, 95% CI 0.42 to 2.59; 7 studies, 520 participants). Reported adverse events included abdominal bloating and discomfort. Probiotics did not lead to any serious adverse events in any of the seven studies that reported on it, however five adverse events were reported in the placebo arm of one study (RR 0.09, CI 0.01 to 1.66; 1 study, 526 participants; very low‐certainty evidence; downgraded due to high risk of bias and imprecision). Probiotics may make little or no difference to withdrawals due to adverse events (RR 0.85, 95% CI 0.42 to 1.72; 4 studies, 401 participants; low‐certainty evidence). Probiotics versus 5‐ASA 
There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (RR 0.92, 95% CI 0.73 to 1.16; 1 study, 116 participants; low‐certainty evidence; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.33, 95% CI 0.53 to 3.33; 1 study, 116 participants). Reported adverse events included abdominal pain, nausea, headache and mouth ulcers. There were no serious adverse events with probiotics, however perforated sigmoid diverticulum and respiratory failure in a patient with severe emphysema were reported in the 5‐ASA arm (RR 0.21, 95% CI 0.01 to 4.22; 1 study, 116 participants; very low‐certainty evidence). Probiotics combined with 5‐ASA versus 5‐ASA alone 
Low‐certainty evidence from a single study shows that when combined with 5‐ASA, probiotics may slightly improve the induction of remission (based on the Sunderland disease activity index) compared to 5‐ASA alone (RR 1.22 CI 1.01 to 1.47; 1 study, 84 participants; low‐certainty evidence; downgraded due to unclear risk of bias and imprecision). No information about adverse events was reported. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes (progression to surgery, need for additional therapy, quality of life scores, or steroid withdrawal) were reported in any of the studies. Authors' conclusions Low‐certainty evidence suggests that probiotics may induce clinical remission in active ulcerative colitis when compared to placebo. There may be little or no difference in clinical remission with probiotics alone compared to 5‐ASA. There is limited evidence from a single study which failed to provide a definition of remission, that probiotics may slightly improve the induction of remission when used in combination with 5‐ASA. There was no evidence to assess whether probiotics are effective in people with severe and more extensive disease, or if specific preparations are superior to others. Further targeted and appropriately designed RCTs are needed to address the gaps in the evidence base. In particular, appropriate powering of studies and the use of standardised participant groups and outcome measures in line with the wider field are needed, as well as reporting to minimise risk of bias. Plain language summary Probiotics for the treatment of active ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can induce remission in people with ulcerative colitis. We analysed data from 14 studies to answer this question. Key messages Probiotics may be better at inducing remission than placebo (dummy treatment). It is unclear whether probiotics are better than 5‐aminosalicylic acid (5‐ASA, an anti‐inflammatory agent used to treat inflammatory bowel disease), however there is limited evidence that when both treatments are used as combined therapy they may be better than 5‐ASA alone in inducing remission. Most studies reported that no serious adverse events took place. For the studies that did report on it, serious adverse events did not occur in the probiotic group. Minor adverse events reported were bloating and diarrhoea. What was studied in the review? Ulcerative colitis is a relapsing and remitting disease which causes inflammation of the large bowel and leads to symptoms such as abdominal pain, diarrhoea and tiredness. There is some evidence to suggest that an imbalance in the bacteria of the gut is the cause of the disease, and therefore probiotics, which are live micro‐organisms, can alter the bacteria and possibly reduce the inflammation. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing probiotics with placebo, probiotics with 5‐ASA, and probiotics in combination with 5‐ASA. We found 14 RCTs looking at 865 participants. The trials looked at adult and paediatric participants. Eight studies allowed additional therapy to continue, whilst the other four studies were unclear about this. 1) Probiotics may improve induction of clinical remission when compared to placebo. 2) It is unclear whether probiotics lead to a difference in adverse events (minor and serious) when compared to placebo. 3) There is limited evidence to determine whether probiotics offer better disease improvement when compared to placebo. 4) There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (low‐certainty evidence). 5) There is limited evidence to suggest that when probiotics plus 5‐ASA are compared to 5‐ASA alone, probiotics may offer a slightly better chance of induction of remission. This is based on low‐certainty evidence from one study, and we are not sure of the type of remission studied. 6) Serious adverse events were reported when probiotics were compared with placebo, but only occurred in the placebo group. Conclusion Whilst the evidence suggests that probiotics may be better at improving induction than placebo, our confidence in the estimate is limited because of the low‐certainty evidence. This is attributed to the small number of participants in each study along with the unreliable methods utilised by the trials. With the evidence presented in these studies, we are unable to make strong conclusions into the effectiveness of probiotics; better designed studies with more participants are needed. How up‐to‐date is this review? This review is up‐to‐date as of October 2019.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.800Z" }, { "id": "d5b7999e-45bd-4bbd-b495-2d16b3cf02ab", "pmid": "", "title": "Horticultural therapy for schizophrenia", "imported": false, "abstract": "Abstract - Background Horticultural therapy is defined as the process of utilising fruits, vegetables, flowers and plants facilitated by a trained therapist or healthcare provider, to achieve specific treatment goals or to simply improve a person's well‐being. It can be used for therapy or rehabilitation programs for cognitive, physical, social, emotional, and recreational benefits, thus improving the person's body, mind and spirit. Between 5% to 15% of people with schizophrenia continue to experience symptoms in spite of medication, and may also develop undesirable adverse effects, horticultural therapy may be of value for these people. Objectives To evaluate the effects of horticultural therapy for people with schizophrenia or schizophrenia‐like illnesses compared with standard care or other additional psychosocial interventions. Search methods We searched the Cochrane Schizophrenia Group Trials Register (Janurary 2013) and supplemented this by contacting relevant study authors, and manually searching reference lists. Selection criteria We included one randomised controlled trial (RCT) comparing horticultural therapy plus standard care with standard care alone for people with schizophrenia. Data collection and analysis We reliably selected, quality assessed and extracted data. For continuous outcomes, we calculated a mean difference (MD) and for binary outcomes we calculated risk ratio (RR), both with 95% confidence intervals (CI). We assessed risk of bias and created a 'Summary of findings' table using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. Main results We included one single blind study (total n = 24). The overall risk of bias in the study was considered to be unclear although the randomisation was adequate. It compared a package of horticultural therapy which consisted of one hour per day of horticultural activity plus standard care with standard care alone over two weeks (10 consecutive days) with no long‐term follow‐up. Only two people were lost to follow‐up in the study, both in the horticultural therapy group (1 RCT n = 24,RR 5.00 95% CI 0.27 to 94.34, very low quality evidence ). There was no clear evidence of a difference in Personal Wellbeing Index (PWI‐C) change scores between groups, however confidence intervals were wide (1 RCT n = 22, MD ‐0.90 95% CI ‐10.35 to 8.55, very low quality evidence ). At the end of treatment, the Depression Anxiety Stress Scale (DASS21) change scores in horticultural therapy group were greater than that in the control group (1 RCT n = 22, MD ‐23.70 CI ‐35.37 to ‐ 12.03, very low quality evidence). The only included study did not report on adverse effects of interventions. Authors' conclusions Based on the current very low quality data, there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. This therapy remains unproven and more and larger randomised trials are needed to increase high quality evidence in this area. Plain language summary Gardening activity as a therapy for schizophrenia Horticultural therapy is based on the therapeutic value of participating in garden activities such as growing fruit or vegetables and/or flowers. Gardening is thought to improve people's well‐being through being a recreational and sociable activity which may lead to improvements in people's thinking, new friendships and more positive emotions. The benefits of gardening can also apply to people with serious mental illness such as schizophrenia. Gardening reduces stress, which is important because stress can often lead to mental illness. Gardening is also hard work and a physical activity, and so motivates people with mental illness who often feel tired and apathetic. Weight gain is common for people with mental illness and gardening is good physical exercise. Since 5% to 15% of people with schizophrenia experience symptoms in spite of taking antipsychotic drugs and also because these drugs have debilitating side effects, horticultural therapy may be of value to these people. This review focuses on the effects of horticultural therapy for people with schizophrenia. An electronic search for relevant randomised trials was run in January 2013. Only one trial was included, it randomised a total of 24 people with schizophrenia to received either their standard care plus horticultural therapy or standard care only. The trial only lasted 2 weeks (10 consecutive days) with no long‐term follow‐up. There are few results and the quality of evidence was rated by the review authors to be very low quality. Some of the information from this one study favoured horticultural therapy but there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. More large, better conducted and reported trials are required to determine the effectiveness and benefits of horticultural therapy. This plain language summary has been written by a consumer Ben Gray, Service User and Service User Expert, Rethink Mental Illness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Liu, Y, Li, B, Sampson, SJ, Roberts, S, Zhang, G, Wu, W", "articleTypes": [], "doi": "10.1002/14651858.CD009413.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.766Z" }, { "id": "d5bb94d9-36ad-40b4-a5a1-fe0d0c337ba2", "pmid": "", "title": "Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries", "imported": false, "abstract": "Abstract - Background Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low‐ and middle‐income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid‐based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition. Objectives To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low‐ and middle‐income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective. Search methods In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. Selection criteria We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before‐and‐after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low‐ and middle‐income countries. Data collection and analysis Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses using the random‐effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods. Main results Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care ‐ the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight‐for‐height (MD 0.20 z‐score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid‐based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses ‐ there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid‐based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non‐recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight‐for‐height, and mid‐upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid‐based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses ‐ no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid‐based nutrient supplements versus specific types of blended foods ‐ a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods ‐ in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet ‐ no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. Authors' conclusions In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short‐term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent. Plain language summary Specially formulated foods for treating children with moderate acute malnutrition in low‐ and middle‐income countries Moderate acute malnutrition (MAM) affects around 10% of children under five years of age in low‐ and middle‐income countries. Different food strategies have been used for the nutritional recovery of children with MAM, such as lipid‐based nutrient supplements or blended foods, which can be provided in full dose or in a low dose as a complement to the usual diet. However, there is no definitive consensus on the most effective way to treat children with MAM. We searched eight electronic databases and three trials registers (in October 2012 for all except Embase, which was searched in August 2012). We also searched the reference lists of relevant papers and contacted nutrition‐related organisations and researchers in this field. We found eight relevant randomised controlled trials, enrolling 10,037 children under five years of age. All but one study was conducted in Africa. The risk of bias in the studies was generally low, though two studies had a high dropout rate. The participants were aware which intervention group they were in and this may have influenced their behaviour but we thought it unlikely it would have influenced the results since the outcomes measured were objective ones. For four of the studies, we were unable to assess if the study authors reported all the outcomes they intended to measure. When any type of specially formulated food was compared to standard care (medical care and counselling without foods), the children treated with foods had a higher chance of recovering from moderate malnutrition (two studies), greater improvement in nutritional status (two studies), and a lower number of dropouts (one study). A reduction in mortality was not shown. When lipid‐based nutrient supplements (which are food with high energy density and high lipid content) at full dose were compared to blended foods at full dose (which are dry food mixtures without high lipid content), there was no difference between these two types of foods in terms of number of deaths (five studies), children progressing to severe acute malnutrition (three studies), and children dropping out (four studies). However, lipid‐based nutrient supplements increased the number recovered by 10% (five studies), decreased the number of children non‐recovering (three studies), and slightly improved the nutritional status among the recovered. One study observed more children vomiting when given lipid‐based nutrient supplements compared to blended foods, but this was not reported by the other studies. No other side effects were reported. Few studies evaluated foods at complementary dosage (i.e. foods given in low quantity, just to complement the diet and not to fully substitute it), and no conclusion could be drawn from these studies. When specific foods were compared to each other, a type of corn‐soy blended food called CSB++ compared to lipid‐based nutrient supplements resulted in similar outcomes, while results of another blended food (CSB pre‐mix) versus lipid‐based nutrient supplements were unclear. In one study, CSB++ did not show any significant benefit over locally‐made blended foods, for example, Misola. No study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. In conclusion, there is moderate to high quality evidence that both lipid‐based nutrient supplements and blended foods are effective in treating children with moderate acute malnutrition. Although lipid‐based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. There are no studies evaluating special recipes to improve the adequacy of the usual home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Lazzerini, M; Rubert, L; Pani, P", "articleTypes": [], "doi": "10.1002/14651858.CD009584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "d5d5bc15-b9ee-423d-8e4c-fc913a15472f", "pmid": "", "title": "Penicillamine for treating rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is a penicillin derived compound originally used to treat patients with rheumatoid arthritis (RA) in the 1950's. Although frequently used in the past, its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs) such as methotrexate. Objectives To estimate the short‐term effects of D‐penicillamine for the treatment of rheumatoid arthritis (RA). Search methods We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register (issue 3, 2000) and Medline up to and including August 2000 and Embase from 1988‐2000. We also carried out a handsearch of the reference lists of the trials retrieved from the electronic search. Selection criteria All randomized controlled trials and controlled clinical trials comparing D‐penicillamine against placebo in patients with rheumatoid arthritis. Data collection and analysis The methodological quality of the trials was assessed independently by two reviewers (CS, EB) and checked by a third (MS) using a validated quality assessment tool (Jadad 1996). Rheumatoid arthritis outcome measures were extracted from the publications for the six‐month endpoint and stratified according to D‐penicillamine dosages: low (<500mg/day), moderate (500 to <1000mg/day) and high (1000 mg/day or greater). Data was abstracted by one reviewer and checked by a second (CS, MS). The pooled analysis was performed using the standardized mean difference for joint counts, pain and global assessments. The weighted mean difference was used for erythrocyte sedimentation rate (ESR). Toxicity was evaluated with pooled odds ratios for withdrawals and adverse reactions. A chi‐square test was used to assess heterogeneity among trials. Fixed effects models were used throughout, since no statistical heterogeneity was found. Main results Six trials were identified, with 425 patients randomized to D‐penicillamine and 258 to placebo. A statistically significant benefit was observed for D‐penicillamine when compared to placebo for all three‐dose ranges and for most outcome measures including: tender joint counts, pain, physician's global assessments and ESR. The standardized weighted mean differences between treatment and placebo in moderate doses were ‐0.51 [95% CI ‐0.88, ‐0.14] for tender joint counts, ‐0.56 (95% CI ‐0.87, ‐0.26) for pain and ‐0.97 (95% CI ‐1.25, ‐0.70) for global assessment. The difference for ESR was ‐10.6 mm/hr. Similar results were observed for the higher dose group. Total withdrawals were significantly higher in the moderate and high dosage D‐penicillamine groups (OR=1.63 and 2.13 respectively), mostly due to increased adverse reactions (OR = 2.60 and 4.95 respectively), including renal and hematological abnormalities. Authors' conclusions D‐penicillamine appears to have a clinically and statistically significant benefit on the disease activity of patients with rheumatoid arthritis. Its efficacy appears to be similar to that of other disease modifying anti‐rheumatic drugs (DMARDs), but with a significantly higher toxicity. Its effects on long‐term functional status and radiological progression are not clear from this review. Plain language summary Penicillamine for treating rheumatoid arthritis Penicillamine is a penicillin derived compound. Studies showed that this could be used to treat rheumatoid arthritis originally in 1950. It was frequently used in the past, but its use has declined with the increasing use of other disease modifying anti‐rheumatic drugs (DMARDs), such as methotrexate. The purpose of this summary was to find out if penicillamine is helpful in the treatment of rheumatoid arthritis. Penicillamine was seen to be beneficial for all ranges of dosages for disease activity on tender joint pain, physician global assessment and sed rate. No major differences were observed between placebo and low dose penicillamine (<500 mg/day). For higher dosages, patients on penicillamine were twice as likely to withdraw than those receiving placebo 500 to <1000 mg/day. D‐penicillamine appears be have a clinical and statistical benefit on the disease activity of patients with rheumatoid arthritis. Its benefit is similar to that of other such drugs, such as disease modifying anti‐rheumatic drugs (DMARDs). More adverse reactions are seen in patients being treated with D‐penicillamine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Suarez‐Almazor, ME, Belseck, E, Spooner, C", "articleTypes": [], "doi": "10.1002/14651858.CD001460", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.064Z" }, { "id": "d5e1d3f8-647e-428d-bee3-b5cf4a571b3d", "pmid": "", "title": "Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer", "imported": false, "abstract": "Abstract - Background This is an updated version of a Cochrane Review last published in 2013. Long‐term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating people with cancer. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infections remain a common complication. These infections are mainly caused by gram‐positive bacteria. Antimicrobial prevention strategies aimed at these micro‐organisms could potentially decrease the majority of CVC‐related infections. The aim of this review was to evaluate the efficacy of prophylactic antibiotics for the prevention of gram‐positive infections in people with cancer who have long‐term CVCs. Objectives To assess the effects of administering antibiotics prior to the insertion of long‐term CVCs or as a flush/lock solution, or both during long‐term CVC access to prevent gram‐positive CVC‐related infections in adults and children receiving treatment for cancer. Search methods The search for this updated review was conducted on 19 November 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE via Ovid and Embase via Ovid. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform portal for additional articles. Selection criteria We included randomised controlled trials (RCTs) that compared either the administration of prophylactic antibiotics prior to long‐term CVC insertion versus no administration of antibiotics, or the use of an antibiotic versus a non‐antibiotic flush/lock solution in long‐term CVCs, in adults and children receiving treatment for cancer. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two authors independently selected studies, classified them and extracted data onto a predesigned data collection form. The outcomes of interest were gram‐positive catheter‐related infection events and total number of CVCs and CVC days. We pooled the data using a random‐effects model for meta‐analyses. We used the GRADE approach to assess the certainty of the evidence. Main results For this update, we identified 310 potentially relevant studies and screened them for eligibility. We included one additional RCT with 404 participants. The original review included 11 RCTs with a total of 840 people with cancer (adults and children). In total this review included 12 RCTs with 1244 participants. Antibiotics prior to insertion of the CVC 
Six trials compared the use of antibiotics (vancomycin, teicoplanin, ceftazidime or cefazolin) versus no antibiotics given before the insertion of a long‐term CVC. One study did not observe any CVC‐related infection events in either group was not included in the quantitative analysis as it was not possible to calculate a risk ratio. Administering an antibiotic prior to insertion of the CVC may not reduce gram‐positive CVC‐related infections (pooled risk ratio 0.67, confidence interval (CI) 95% 0.32 to 1.43; control versus intervention group risk 10.4% versus 7.3% of the participants; 5 studies, 648 participants; moderate‐certainty evidence). We sought adverse event data, but these were not described by the authors. The overall risk of bias was deemed low. Antibiotics as a flushing or locking solution 
Six trials compared a combined antibiotic (vancomycin, amikacin or taurolidine) and heparin solution with a heparin‐only solution for flushing or locking the long‐term CVC after use. One study did not observe any CVC‐related sepsis events (CRS) and was not included in this study in the quantitative analysis as it was not possible to calculate a risk ratio. Flushing and locking long‐term CVCs with a combined antibiotic and heparin solution likely reduced the risk of gram‐positive CVC‐related infections compared to a heparin‐only solution (pooled rate ratio 0.47, CI 95% 0.26 to 0.85; control versus intervention group rate ratio 0.66 versus 0.27 per 1000 CVC‐days; 5 studies, 443 participants; moderate‐certainty evidence). One trial reported a higher incidence of occlusions and participants in one trial reported an unpleasant taste after flushing associated with a combined antibiotic and heparin solution. The overall risk of bias was deemed low. Authors' conclusions Since the last version of this review, we included one additional study. There was no observed benefit of administering antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing or locking long‐term CVCs with an antibiotic solution likely reduces gram‐positive CVC‐related infections experienced in people at risk of neutropenia through chemotherapy or disease. However, a limitation of this review is heterogeneity between the studies for both outcomes. Insufficient data were available to evaluate if the conclusions apply equally for different CVC types and for adults versus children. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if the baseline CVC‐related infection rates are high. Further research is needed to identify high‐risk groups most likely to benefit from these antibiotic flush/lock solutions. Plain language summary Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer The issue 
People undergoing anti‐cancer treatment (chemotherapy) often have a catheter (tube) inserted into a large vein, through which their chemotherapy is given. This is known as a central venous catheter (CVC). As chemotherapy is usually administered over several months to years, long‐term CVCs are used. Despite sterile insertion and care afterwards, these CVCs often become infected by a type of bacteria called gram‐positive bacteria. Giving antibiotics as a preventive (prophylactic antibiotics) before the catheter is inserted, or using the antibiotics as a lock or flush solution, or both, may prevent these infections. A lock/flush solution is instilled in the catheter when it is not in use. This solution often contains heparin, saline, or both, to prevent a clot forming in the catheter. The aim of the review 
The aim of this review was to determine whether giving antibiotics before catheter insertion or as a lock/flush solution can prevent gram‐positive CVC‐related infections. What are the main findings? 
We searched databases to identify randomised controlled trials (RCTs ‐ clinical studies where people are randomly put into one of two or more treatment groups). We identified 12 relevant studies, which included a total of 1244 adults and children with cancer. We included six studies (756 people) that compared giving antibiotics before the insertion of the CVC against not giving antibiotics. We found that giving an antibiotic before CVC insertion did not prevent infections. The studies authors' did not describe side‐effects. We included six studies (488 people) that compared an antibiotic solution with a heparin‐only solution to flush/lock a CVC. We found that an antibiotic lock/flush solution reduced the number of CVC‐related infections. People in one study reported an unpleasant taste after flushing, and one study found there were fewer CVC obstructions (e.g. a clot) in people who received the combined antibiotic and anticoagulant solution. Certainty of the evidence 
We have moderate confidence in the evidence for giving antibiotics prior to CVC insertion and antibiotic lock/flush solutions since the studies were done in different people, used different types of catheters and antibiotics, and measured their results in different ways. What are the conclusions? 
We did not observe any benefit of giving antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing/locking long‐term CVCs with an antibiotic appeared to reduce gram‐positive CVC‐related infections in people with cancer. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if baseline CVC‐related infection rates are high. This review updates our previous review. The evidence is up to date to 19 November 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "van den Bosch, CH; van Woensel, J; van de Wetering, MD", "articleTypes": [], "doi": "10.1002/14651858.CD003295.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "d5e21c9f-dd07-4ca7-b4aa-37b2b6463938", "pmid": "", "title": "Lactoferrin for the postoperative management of term neonates after gastrointestinal surgery", "imported": false, "abstract": "Abstract - Background Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be due in part to disruption of the integrity of the gut and its altered intestinal microflora. Lactoferrin is a whey protein found in milk and is an important innate mammalian defence mechanism. Lactoferrin has been reported to have antimicrobial and anti‐inflammatory properties. It has also been reported to help establish a healthy gut microflora and aid in the intestinal immune system. Lactoferrin supplementation has been reported to decrease sepsis in preterm infants. There may be a role for lactoferrin to reduce the incidence of sepsis, thus reducing morbidity and mortality and improving enteral feeding in postoperative term neonates. Objectives The primary objective of this review was to evaluate the efficacy of administering lactoferrin on the incidence of sepsis and mortality in term neonates after gastrointestinal surgery. The secondary objective was to assess the impact of administering lactoferrin on time to full enteral feeds, the intestinal microflora, duration of hospital stay, and mortality before discharge in the same population. Search methods The Cochrane Neonatal Information Specialist searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase Ovid, CINAHL, the WHO ICTRP and ClinicalTrials.gov trials registries. The date of the last search was February 2023. There were no restrictions to language, publication year or publication type. We checked references of potentially relevant studies and systematic reviews. Selection criteria We planned to include randomised controlled trials that studied infants born at 37 or more weeks of gestation who had one or more episodes of gastrointestinal surgery within 28 days of birth, and compared administration of lactoferrin with a placebo. Data collection and analysis We used standard Cochrane methodological procedures. We planned to use the GRADE approach to assess the certainty of evidence for each outcome. Main results We identified no published randomised controlled studies that assessed the efficacy of lactoferrin for the postoperative management of term neonates following gastrointestinal surgery. Authors' conclusions There is currently no evidence available from randomised controlled trials to show whether lactoferrin is effective or ineffective for the postoperative management of term neonates after gastrointestinal surgery. There is a need for randomised controlled trials to be performed to assess the role of lactoferrin in this setting. Plain language summary What are the benefits and risks of giving lactoferrin to full‐term babies who had digestive tract surgery? Key message We found no medical studies that investigated the effects of giving lactoferrin (a protein found in milk) to babies born at full‐term (at or after 37 weeks of pregnancy) who had surgery of their digestive tract. What is lactoferrin? Lactoferrin is a protein found in milk that can protect against infection. Lactoferrin supplements are available and have been researched in premature babies. There is some evidence that lactoferrin can prevent infection in premature babies. What are some of the risks of digestive tract surgery in babies? Surgery of the digestive tract increases the risk of infection. Infections can increase the length of stay in hospital. Treatment with antibiotics (medicines that fight bacterial infections) and stress from surgery can disrupt good bacteria in the digestive tract. What did we want to find out? We wanted to find out if giving lactoferrin to full‐term babies, after digestive tract surgery, decreased rates of infection and death, and improved the presence of good bacteria in the digestive tract. What did we do? We searched for studies in which babies who had digestive tract surgery were assigned randomly to lactoferrin or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes the same as the medicine being tested). What did we find? We did not find any studies that compared giving lactoferrin to a placebo in full‐term babies who had digestive tract surgery. Well‐designed and large studies are needed to answer this question. How up to date is this evidence? The search is up‐to‐date as of February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Trivedi, A, Maheshwari, R, Tarnow-Mordi, WO, Saxena, N", "articleTypes": [], "doi": "10.1002/14651858.CD012218.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.798Z" }, { "id": "d5e40f5e-608b-4ba2-973f-ba5280aab754", "pmid": "", "title": "Chinese herbal medicine for primary dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Conventional treatment for primary dysmenorrhoea has a failure rate of 20% to 25% and may be contraindicated or not tolerated by some women. Chinese herbal medicine may be a suitable alternative. Objectives To determine the efficacy and safety of Chinese herbal medicine for primary dysmenorrhoea when compared with placebo, no treatment, and other treatment. Search methods The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007), EMBASE (1980 to January 2007), CINAHL (1982 to January 2007), AMED (1985 to January 2007), CENTRAL (The Cochrane Library issue 4, 2006), China National Knowledge Infrastructure (CNKI, 1990 to January 2007), Traditional Chinese Medicine Database System (TCMDS, 1990 to December 2006), and the Chinese BioMedicine Database (CBM, 1990 to December 2006) were searched. Citation lists of included trials were also reviewed. Selection criteria Any randomised controlled trials involving Chinese herbal medicine versus placebo, no treatment, conventional therapy, heat compression, another type of Chinese herbal medicine, acupuncture or massage. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra‐uterine contraceptive device. Data collection and analysis Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Data were combined for meta‐analysis using either Peto odds ratios or relative risk (RR) for dichotomous data or weighted mean difference for continuous data. A fixed‐effect statistical model was used, where suitable. If data were not suitable for meta‐analysis, any available data from the trial were extracted and presented as descriptive data. Main results Thirty‐nine randomised controlled trials involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for Chinese herbal medicine compared to placebo were unclear as data could not be combined (3 RCTs). Chinese herbal medicine resulted in significant improvements in pain relief (14 RCTs; RR 1.99, 95% CI 1.52 to 2.60), overall symptoms (6 RCTs; RR 2.17, 95% CI 1.73 to 2.73) and use of additional medication (2 RCTs; RR 1.58, 95% CI 1.30 to 1.93) when compared to use of pharmaceutical drugs. Self‐designed Chinese herbal formulae resulted in significant improvements in pain relief (18 RCTs; RR 2.06, 95% CI 1.80 to 2.36), overall symptoms (14 RCTs; RR 1.99, 95% CI 1.65 to 2.40) and use of additional medication (5 RCTs; RR 1.58, 95% CI 1.34 to 1.87) after up to three months of follow‐up when compared to commonly used Chinese herbal health products. Chinese herbal medicine also resulted in better pain relief than acupuncture (2 RCTs; RR 1.75, 95% CI 1.09 to 2.82) and heat compression (1 RCT; RR 2.08, 95% CI 2.06 to 499.18). Authors' conclusions The review found promising evidence supporting the use of Chinese herbal medicine for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials. Plain language summary Chinese herbal medicine may help reduce menstrual pain. Dysmenorrhoea is a very common complaint that refers to painful menstrual cramps in abdomen. Primary dysmenorrhoea refers to pain of an unknown cause (i.e. no medical condition is identified). Nonsteroidal anti‐inflammatory drugs or the contraceptive pill have been used successfully for treatment but more women are looking for non‐drug therapies. Chinese herbal medicine has been used for centuries in China and it is currently used in public hospitals in China for the treatment of primary dysmenorrhoea. The review found promising evidence for the use of Chinese herbal medicine in reducing menstrual pain in the treatment of primary dysmenorrhoea, compared to conventional medicine such as NSAIDs and the oral contraceptive pill, acupuncture and heat compression. No significant adverse effects were identified in this review. However the findings should be interpreted with caution due to the generally low methodological quality of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Zhu, X, Proctor, M, Bensoussan, A, Wu, E, Smith, CA", "articleTypes": [], "doi": "10.1002/14651858.CD005288.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.798Z" }, { "id": "d5e86de3-849a-4918-b655-30e9d12fa251", "pmid": "", "title": "Lycopene for the prevention of prostate cancer", "imported": false, "abstract": "Abstract - Background Prostate cancer is a common cause of death in developed countries, yet the benefits of screening for prostate cancer still remain controversial. A prostate‐specific antigen (PSA) test result greater than 4 ng/mL (nanograms/millilitre) has commonly been used as the cut‐off level for seeking further tests to diagnose the presence (or absence) of prostate cancer. An increase in PSA levels may not necessarily be associated with an increased risk of prostate cancer, as PSA levels may also be increased in men with benign prostatic hyperplasia and prostatitis. Despite the uncertainty of the net benefit of early detection and treatment, safe and effective methods to prevent prostate cancer are of value. Consumers, seeking greater involvement in their healthcare, are increasingly turning to lifestyle modification and complementary and alternative medicines (CAMs) to maintain their health and prevent disease. Lycopene is a member of the carotenoid family, which is found abundantly in tomatoes, tomato‐based products, strawberries, and watermelon. It has been hypothesised that lycopene is a strong antioxidant, which may lower the risk of cancer (including prostate cancer) in people who have diets rich in lycopene. Objectives To determine whether lycopene reduces the incidence of prostate cancer and prostate cancer‐specific mortality. Secondary objectives include changes in PSA levels, prostate symptoms and the nature of adverse events associated with lycopene use. Search methods Electronic searches were conducted across MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases. No language or other limitations were imposed. Selection criteria Randomised controlled trials (RCTs) that investigated the use of lycopene for the prevention of prostate cancer were eligible for inclusion in this review. Data collection and analysis A search of electronic databases, performed in August 2011, identified 64 citations. All articles were selected for full‐text review. From these citations, three studies were identified as meeting the inclusion criteria. Handsearching did not provide any additional studies. Main results Three RCTs, with a total of 154 participants were included in this review. None of the studies reported data on prostate cancer mortality. All of the included studies differed with respect to design, participants included and allocation of lycopene. This clinical heterogeneity limits the value on the pooled estimated of the meta‐analyses. The methodological quality of two of the three included studies was assessed as posing a 'high' risk of bias. Meta‐analysis indicated no statistical difference in PSA levels between men randomised to receive lycopene and the comparison group (MD (mean difference) ‐0.34, 95% CI (confidence interval) ‐2.01 to 1.32). Only one study reported incidence of prostate cancer (10% in the lycopene group versus 30% in control group). The level of lycopene was also not statistically different in men randomised to receive lycopene and the comparison group (MD 0.39 µg/mL (micrograms/millilitre), 95% CI ‐0.19 to 0.98). No other meta‐analyses were possible since other outcomes assessed only had one study contributing data. Authors' conclusions Given that only three RCTs were included in this systematic review, and the high risk of bias in two of the three studies, there is insufficient evidence to either support, or refute, the use of lycopene for the prevention of prostate cancer. Similarly, there is no robust evidence from RCTs to identify the impact of lycopene consumption upon the incidence of prostate cancer, prostate symptoms, PSA levels or adverse events. Plain language summary Lycopene for the prevention of prostate cancer Prostate cancer is a common form of cancer affecting men worldwide. Pharmaceutical interventions, such as 5‐alpha reductase inhibitors, have been identified as potentially preventing prostate cancer incidence in men. Many men modify lifestyle and consume complementary and alternative medicines to maintain better health and prevent disease. Lycopene is a supplement that has been suggested may assist in the prevention of prostate cancer due to its antioxidant effects. The objective of this systematic review was to identify the effectiveness of lycopene in the prevention of prostate cancer. This review identified 3 relevant studies, comprising 154 participants in total. Two of the studies were assessed to be of 'high' risk of bias. Meta‐analysis of two studies indicated no statistical difference in prostate specific antigen (PSA) levels between men randomised to receive lycopene and the comparison group (MD ‐0.34, 95% CI ‐2.01 to 1.32). None of the studies assessed prostate cancer mortality. No other meta‐analyses were possible since other outcomes assessed only had one study contributing data.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Ilic, D, Forbes, KM, Hassed, C", "articleTypes": [], "doi": "10.1002/14651858.CD008007.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.079Z" }, { "id": "d60466a0-32de-45d8-94a7-7c7e6dfbed49", "pmid": "", "title": "Antiviral treatment for preventing postherpetic neuralgia", "imported": false, "abstract": "Abstract - Background Postherpetic neuralgia (PHN) is a painful and refractory complication of herpes zoster. Treatments are either partially or totally ineffective for many people with PHN. Antiviral agents, used at the time of the rash, have been proposed as an intervention to prevent the development of PHN. This is the first update since the first publication of the review in 2009. Objectives To assess the effectiveness of antiviral agents in preventing PHN. Search methods On 26 April 2013, we updated the searches in the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and the Chinese Biomedical Retrieval System. We checked the references of published studies to identify additional trials, and contacted authors to obtain additional data. We searched other databases in The Cochrane Library for information for the Discussion and two clinical trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) of antiviral treatment given within 72 hours after the onset of herpes zoster for preventing PHN. There were no language restrictions. Data collection and analysis Two authors independently selected trials, evaluated the risk of bias in included trials, and extracted and analysed data. Main results Six RCTs with a total of 1211 participants were eligible; five trials evaluated oral aciclovir, and one, with 419 participants, evaluated oral famciclovir. We were able to conduct meta‐analyses as there were sufficient similarities in the included studies, such as the reporting of the presence of PHN, duration of rash before treatment initiation and treatment regimen. For our primary outcome, based on three trials (609 participants) we found no significant difference between the aciclovir and control groups in the incidence of PHN four months after the onset of the acute herpetic rash (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.51 to 1.11), nor was there a significant difference at six months (RR 1.05, 95% CI 0.87 to 1.27, two trials, 476 participants). In four of the trials (692 participants), there was some evidence for a reduction in the incidence of pain four weeks after the onset of rash. In the trial of famciclovir versus placebo, neither 500 mg nor 750 mg doses of famciclovir reduced the incidence of herpetic neuralgia significantly. The most commonly reported adverse events were nausea, vomiting, diarrhoea and headache for aciclovir, and headache and nausea for famciclovir. For neither treatment was the incidence of adverse events significantly different from placebo. None of the studies were at high risk of bias, although the risk of bias was unclear in at least one domain for all but one study. We found no new RCTs when we updated the searches in April 2013. Authors' conclusions There is high quality evidence that oral aciclovir does not reduce the incidence of PHN significantly. In addition, there is insufficient evidence to determine the effect of other antiviral treatments; therefore, further well‐designed RCTs are needed to investigate famciclovir or other new antiviral agents in preventing PHN. Future trials should pay more attention to the severity of pain and quality of life of participants, and should be conducted among different subgroups of people, such as people who are immunocompromised. Plain language summary Antiviral treatment for preventing nerve pain after shingles (postherpetic neuralgia) Review question We reviewed the evidence about the effect of antiviral medicines for preventing postherpetic neuralgia (PHN). Background PHN is a painful condition that can occur after shingles (herpes zoster) in the area where the rash occurred. Many people with PHN find that treatments work only a little or not at all. Attention has therefore turned to stopping the development of PHN. Some people suggested that medicines that target the virus that causes shingles (antiviral medicines), given at the time of the rash, might prevent PHN. The aim of this review was to assess the whether antiviral medicines are able to prevent PHN. Study characteristics We identified six clinical trials that met our standards for inclusion in the review. They included a total of 1319 participants. We decided that our main measure of whether antiviral medicines work in preventing PHN would be whether or not PHN had developed six months after a first attack of shingles (some of the studies we included of aciclovir measured PHN at four months). Key results and quality of the evidence Aciclovir, which is an antiviral medicine, was used in five trials (900 participants) and was not better than a placebo (dummy pill) in preventing PHN. In the other trial (419 participants), famciclovir, which is another antiviral drug, was no better than placebo in preventing pain following healing of the shingles rash. The number of side effects with aciclovir and famciclovir was not very different from the number with placebo. The trials did not have any major problems of design or conduct that put the results in doubt, although most of the reports did not provide enough information to fully assess every aspect. We conclude that according to high quality evidence, oral aciclovir was ineffective in reducing the incidence of PHN and there is not enough evidence on other antiviral treatments. There need to be further well‐designed trials of famciclovir or other new antiviral agents with a greater number of participants. Future trials should pay more attention to the severity of pain and quality of life of participants, and should include different groups of people, such as those who have lowered immunity. The evidence is current to April 2013, when the searches were last updated. Because new evidence on this topic is slow to emerge, we have scheduled the next update of this review for 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Chen, N; Li, Q; Yang, J; Zhou, M; Zhou, D; He, L", "articleTypes": [], "doi": "10.1002/14651858.CD006866.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "d60ea136-b0f7-42ad-8ac8-f4447ef50480", "pmid": "", "title": "Genetic Variability in Taste Perception", "imported": false, "abstract": "This proposal describes a pilot study aimed at determining whether genetic variations in taste receptors determine differential taste tolerability of pediatric medications.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.253Z" }, { "id": "d6192c77-a66c-4064-b85e-b75294d7ae4e", "pmid": "", "title": "Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)", "imported": false, "abstract": "Abstract - Background Idiopathic acute vestibular dysfunction (vestibular neuritis) is the second most common cause of peripheral vertigo after benign paroxysmal positional vertigo (BPPV) and accounts for 7% of the patients who present at outpatient clinics specialising in the treatment of dizziness. The exact aetiology of the condition is unknown and the effects of corticosteroids on the condition and its recovery are uncertain. Objectives To assess the effectiveness of corticosteroids in the management of patients with idiopathic acute vestibular dysfunction (vestibular neuritis). Search methods We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 28 December 2010. Selection criteria Randomised controlled trials comparing corticosteroids with placebo, no treatment or other active treatments, for adults diagnosed with idiopathic acute vestibular dysfunction. Data collection and analysis Two authors independently selected studies from the search results and extracted data. Three authors independently assessed risk of bias. Main results Four trials, involving a total of 149 participants, compared the effectiveness of oral corticosteroids against placebo. All the trials were small and of low methodological quality. Although there was an overall significant effect of corticosteroids compared with placebo medication on complete caloric recovery at one month (risk ratio (RR) of 2.81; 95% confidence interval (CI) 1.32 to 6.00, P = 0.007), no significant effect was seen on complete caloric recovery at 12 months (RR 1.58; 95% CI 0.45 to 5.62, P = 0.48), or on the extent of caloric recovery at either one month (mean difference (MD) 9.60%; 95% CI ‐20.66 to 39.86, P = 0.53) or at 12 months (MD 6.83%; 95% CI ‐27.69 to 41.36, P = 0.70). In addition, there was no significant difference between corticosteroids and placebo medication in the symptomatic recovery of vestibular function following idiopathic acute vestibular dysfunction with respect to vertigo at 24 hours (RR 0.39; 95% CI 0.04 to 3.57, P = 0.40) and use of the Dizziness Handicap Inventory score at one, three, six and 12 months. Authors' conclusions Overall, there is currently insufficient evidence from these trials to support the administration of corticosteroids to patients with idiopathic acute vestibular dysfunction. We found no trials with a low risk of methodological bias that used the highest level of diagnostic criteria and outcome measures. We recommend that future studies should include health‐related quality of life and symptom‐based outcome measures, in addition to objective measures of vestibular improvement, such as caloric testing and electronystagmography. Plain language summary Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis) Idiopathic acute vestibular dysfunction (vestibular neuritis) is a common condition of unknown cause. Patients with the condition often experience dizziness, nausea or vomiting, and trouble with vision, balance or mobility, but have normal hearing and no tinnitus. It has been proposed that a course of corticosteroids, if given early on, may improve recovery from the condition and long‐term patient outcome. However, corticosteroids can cause adverse effects (e.g. bleeding stomach ulcer, mood changes, etc.). This review identified four randomised controlled trials including 149 adult patients with idiopathic acute vestibular dysfunction (vestibular neuritis) treated with either corticosteroids or placebo. The studies were varied in that they used different drugs and different treatment regimens. On the basis of these studies, there is currently insufficient evidence in favour of corticosteroids over placebo medication in the symptomatic recovery and objective testing of vestibular function, both in the short‐term and long‐term. Further studies of higher quality are needed to test the effectiveness of corticosteroids in patients with the condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fishman, JM, Burgess, C, Waddell, A", "articleTypes": [], "doi": "10.1002/14651858.CD008607.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.785Z" }, { "id": "d628ab5c-94a2-47f5-8076-d9c02cb2678d", "pmid": "", "title": "A Multimodel Examination of Bromocriptine on Homeostatic and Hedonic Mechanisms of Food Intake in Individuals at High Risk for Type 2 Diabetes", "imported": false, "abstract": "The current project applies an integrative three-prong approach to investigate the potential of the dopamine D2 receptor (DRD2) agonist bromocriptine to: 1) increase homeostatic satiation signaling, 2) alter neural circuitry to reduce hedonically motivated food intake, and 3) examines a genetic predisposition that may markedly impact the effectiveness of this medication in those at high risk for T2DM.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.261Z" }, { "id": "d62eb402-d1d6-4bb7-9c08-5310601051aa", "pmid": "", "title": "Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2010 and previously updated in 2011. Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period. Objectives To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 4 July 2013. Selection criteria We included randomised controlled trials in which oral rinses, mouthwashes and sprays, used pre‐ and postoperatively, have been compared with placebo in adults or children undergoing tonsillectomy, with or without adenoidectomy. Data collection and analysis Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently. Main results We included seven trials (593 participants; 397 children and 196 adults). The period of follow‐up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre‐specified primary outcomes and none for the secondary outcomes. The risk of bias was high in most of the included trials. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage. Authors' conclusions Poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well‐constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data. Plain language summary Oral rinses, mouthwashes and sprays for improving outcomes following tonsillectomy Tonsillectomy is one of the most common operations performed in adults and children. Pain and bleeding following the operation are common. Postoperative tonsillectomy medication should aim to minimise some of these symptoms. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the period just after surgery. This review included seven studies involving 593 participants (397 children and 196 adults) and is up to date as of July 2013. The risk of bias was high in most of the included trials. We found that lidocaine spray appeared to be more effective than a placebo saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation when they used another spray containing benzydamine but this was not sufficient to discontinue its usage. Further research should aim to provide reliable evidence for people to make informed decisions as to whether these treatments can be effective in reducing the most common symptoms and complications following tonsillectomy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fedorowicz, Z, van Zuuren, EJ, Nasser, M, Carter, B, Al Langawi, JH", "articleTypes": [], "doi": "10.1002/14651858.CD007806.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.081Z" }, { "id": "d63780c3-52ff-473e-89a2-adb30f056c80", "pmid": "", "title": "Calcitonin for metastatic bone pain", "imported": false, "abstract": "Abstract - Background Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastases. The hormone calcitonin has the potential to relieve pain and also retain bone density, thus reducing the risk of fractures. This review is an update of a previously published review in the Cochrane Library (2003, Issue 3) which was also updated in 2006 (Issue 3) and in 2011 (Issue 9). Objectives The main objective of the review is to determine the effectiveness of calcitonin to reduce metastatic bone pain in patients with painful bone metastases. Secondary objectives are to assess the benefits of calcitonin in reducing the incidence of bone complications (hypercalcemia, fractures and nervous compression) and improving patient survival, and to report any adverse effects of the treatment. Search methods We updated the electronic searches in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2015. We also searched registers of clinical trials in progress up to February 2015. Selection criteria We included studies if they were randomised, double‐blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. Data collection and analysis Two independent review authors performed study selection and data extraction. Only two studies (90 participants) were eligible for inclusion in the review and therefore meta‐analysis of the data was not possible. We performed intention‐to‐treat (ITT) analysis by imputing all missing values as adverse effects. Main results The overall quality of the evidence was very low. In this update no new studies were identified for inclusion; one additional study was excluded. Of the two small included studies, one study showed a non‐significant effect of calcitonin on the number of patients with complete pain relief (risk ratio (RR) 2.50; 95% confidence interval (CI) 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; 95% CI 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases, for improving quality of life or for patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.50; 95% CI 0.77 to 15.88). Authors' conclusions Current available research evidence is of very low quality and there is a lack of evidence to support the use of calcitonin for managing bone pain from bone metastases. Since the last version of this review, we did not identify any additional studies. Plain language summary Calcitonin used to treat metastatic bone pain People who have cancer which has spread to their bones and the nerves adjacent to the bones often suffer severe pain. There are several treatments to help relieve this pain: radiotherapy, analgesic drugs (pain killers) such as opioids, and bone‐modulating drugs such as bisphosphonates and calcitonin. Calcitonin has the potential to relieve pain and maintain bone strength, thus reducing the risk of broken bones. This review looked at the effectiveness of calcitonin for controlling pain from bone metastases. However, only two studies were found with very low quality evidence to support the use of calcitonin for patients suffering from bone pain. We updated the review in 2015 and did not find any more studies. There were slightly more side effects for the patients given calcitonin. Unless new studies provide additional relevant information about this treatment, other therapeutic approaches should be considered.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Martinez-Zapata, MJ, Roqué i Figuls, M, Català, E, Roman, Y, Alonso Coello, P", "articleTypes": [], "doi": "10.1002/14651858.CD003223.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.778Z" }, { "id": "d64c4107-3a69-408c-a2d1-c109fcedc627", "pmid": "", "title": "Effects of Single-dose Semaglutide on Cognition and Energy in Healthy Volunteers", "imported": false, "abstract": "Semaglutide is a glucagon-like peptide 1 receptor agonist (GLP-1RA). It is a safe medication approved for use in type-2 diabetes mellitus (T2DM) and obesity. Primarily, it works by counteracting insulin-resistance and inducing weight loss. It also acts on several other interconnected neurobiological, immunological (esp. inflammatory), endocrine-metabolic, and gut-brain axis processes that play a role in depressive symptoms. Its effects on cognition and energy are currently unknown. In this study we are using semaglutide as an experimental tool to further investigate these relationships.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.152Z" }, { "id": "d64ee50b-e2e6-4d20-9aba-539715acbd4f", "pmid": "", "title": "Pharmacological interventions for smoking cessation: an overview and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Smoking is the leading preventable cause of illness and premature death worldwide. Some medications have been proven to help people to quit, with three licensed for this purpose in Europe and the USA: nicotine replacement therapy (NRT), bupropion, and varenicline. Cytisine (a treatment pharmacologically similar to varenicline) is also licensed for use in Russia and some of the former socialist economy countries. Other therapies, including nortriptyline, have also been tested for effectiveness. Objectives How do NRT, bupropion and varenicline compare with placebo and with each other in achieving long‐term abstinence (six months or longer)?
 How do the remaining treatments compare with placebo in achieving long‐term abstinence?
 How do the risks of adverse and serious adverse events (SAEs) compare between the treatments, and are there instances where the harms may outweigh the benefits? Methods The overview is restricted to Cochrane reviews, all of which include randomised trials. Participants are usually adult smokers, but we exclude reviews of smoking cessation for pregnant women and in particular disease groups or specific settings. We cover nicotine replacement therapy (NRT), antidepressants (bupropion and nortriptyline), nicotine receptor partial agonists (varenicline and cytisine), anxiolytics, selective type 1 cannabinoid receptor antagonists (rimonabant), clonidine, lobeline, dianicline, mecamylamine, Nicobrevin, opioid antagonists, nicotine vaccines, and silver acetate. Our outcome for benefit is continuous or prolonged abstinence at least six months from the start of treatment. Our outcome for harms is the incidence of serious adverse events associated with each of the treatments.
 We searched the Cochrane Database of Systematic Reviews (CDSR) in The Cochrane Library , for any reviews with 'smoking' in the title, abstract or keyword fields. The last search was conducted in November 2012. We assessed methodological quality using a revised version of the AMSTAR scale. For NRT, bupropion and varenicline we conducted network meta‐analyses, comparing each with the others and with placebo for benefit, and varenicline and bupropion for risks of serious adverse events. Main results We identified 12 treatment‐specific reviews. The analyses covered 267 studies, involving 101,804 participants. Both NRT and bupropion were superior to placebo (odds ratios (OR) 1.84; 95% credible interval (CredI) 1.71 to 1.99, and 1.82; 95% CredI 1.60 to 2.06 respectively). Varenicline increased the odds of quitting compared with placebo (OR 2.88; 95% CredI 2.40 to 3.47). Head‐to‐head comparisons between bupropion and NRT showed equal efficacy (OR 0.99; 95% CredI 0.86 to 1.13). Varenicline was superior to single forms of NRT (OR 1.57; 95% CredI 1.29 to 1.91), and to bupropion (OR 1.59; 95% CredI 1.29 to 1.96).
 Varenicline was more effective than nicotine patch (OR 1.51; 95% CredI 1.22 to 1.87), than nicotine gum (OR 1.72; 95% CredI 1.38 to 2.13), and than 'other' NRT (inhaler, spray, tablets, lozenges; OR 1.42; 95% CredI 1.12 to 1.79), but was not more effective than combination NRT (OR 1.06; 95% CredI 0.75 to 1.48). Combination NRT also outperformed single formulations. The four categories of NRT performed similarly against each other, apart from 'other' NRT, which was marginally more effective than NRT gum (OR 1.21; 95% CredI 1.01 to 1.46).
 Cytisine (a nicotine receptor partial agonist) returned positive findings (risk ratio (RR) 3.98; 95% CI 2.01 to 7.87), without significant adverse events or SAEs.
 Across the 82 included and excluded bupropion trials, our estimate of six seizures in the bupropion arms versus none in the placebo arms was lower than the expected rate (1:1000), at about 1:1500. SAE meta‐analysis of the bupropion studies demonstrated no excess of neuropsychiatric (RR 0.88; 95% CI 0.31 to 2.50) or cardiovascular events (RR 0.77; 95% CI 0.37 to 1.59). SAE meta‐analysis of 14 varenicline trials found no difference between the varenicline and placebo arms (RR 1.06; 95% CI 0.72 to 1.55), and subgroup analyses detected no significant excess of neuropsychiatric events (RR 0.53; 95% CI 0.17 to 1.67), or of cardiac events (RR 1.26; 95% CI 0.62 to 2.56).
 Nortriptyline increased the chances of quitting (RR 2.03; 95% CI 1.48 to 2.78). Neither nortriptyline nor bupropion were shown to enhance the effect of NRT compared with NRT alone. Clonidine increased the chances of quitting (RR 1.63; 95% CI 1.22 to 2.18), but this was offset by a dose‐dependent rise in adverse events. Mecamylamine in combination with NRT may increase the chances of quitting, but the current evidence is inconclusive. Other treatments failed to demonstrate a benefit compared with placebo. Nicotine vaccines are not yet licensed for use as an aid to smoking cessation or relapse prevention. Nicobrevin's UK license is now revoked, and the manufacturers of rimonabant, taranabant and dianicline are no longer supporting the development or testing of these treatments. Authors' conclusions NRT, bupropion, varenicline and cytisine have been shown to improve the chances of quitting. Combination NRT and varenicline are equally effective as quitting aids. Nortriptyline also improves the chances of quitting. On current evidence, none of the treatments appear to have an incidence of adverse events that would mitigate their use.
 Further research is warranted into the safety of varenicline and into cytisine's potential as an effective and affordable treatment, but not into the efficacy and safety of NRT. Plain language summary Medications to help people to stop smoking: an overview of reviews Background 
 Smoking is a main cause of early death throughout the world. There are a number of medications which can help people to quit smoking. Three of these, nicotine replacement therapy (NRT), bupropion and varenicline, are licensed for this purpose in the USA and Europe. Cytisine (similar to varenicline) is licensed for use in Russia and Eastern Europe. We reviewed studies of these and other treatments, including nortriptyline, to compare their benefits and risks.
 Methods 
 We found 12 Cochrane reviews of different treatments. The treatments include nicotine replacement therapy (NRT); antidepressants (bupropion and nortriptyline); nicotine receptor partial agonists (varenicline and cytisine); anxiolytics; selective type 1 cannabinoid receptor antagonists (rimonabant); clonidine; lobeline; dianicline; mecamylamine; Nicobrevin; opioid antagonists; nicotine vaccines; and silver acetate. The reviews were conducted between 2008 and 2012, and analysed 267 trials, covering more than 101,000 smokers. All the reviews used randomised controlled trials, and compared the active treatment with a placebo, and sometimes with other treatments. The outcomes were measured at least six months from the start of treatment, and the results were usually checked by testing breath, blood or urine. We also assessed the risk of harms from each treatment. We then compared NRT, bupropion and varenicline with each other, using a network meta‐analysis.
 Results 
 NRT and bupropion helped about 80% more people to quit than placebo; this means that for every 10 people who quit with placebo about 18 could be expected to quit with NRT or with bupropion. Varenicline more than doubled the chances of quitting compared with placebo, so that for every 10 who quit with placebo about 28 could be expected to quit with varenicline.
 Varenicline helped about 50% more people to quit than nicotine patch and 'other' NRT (tablets, sprays, lozenges and inhalers), and about 70% more people than nicotine gum. So for every 10 people who quit with NRT patch or with 'other' NRT, about 15 could be expected to quit with varenicline, and for every 10 who quit with NRT gum about 17 could be expected to quit with varenicline. Combining two type of NRT was as effective as using varenicline, and helped more people to quit than single types of NRT. There was little to choose between different types of NRT, apart from 'other' NRT, which helped slightly more people than nicotine gum; for every 10 people who quit with NRT gum, about 12 could be expected to quit with 'other' NRT.
 NRT combined with nortriptyline or with bupropion was not more effective than NRT alone.
 Both cytisine and nortriptyline compared with placebo improved the chances of quitting, with minimal risk of harms.
 
 Bupropion carries a known risk of seizures (about 1 per 1000 users), but we found fewer than expected in the included and excluded trials, at about 1 in 1500. Although there may be a marginal increase in the likelihood of any serious adverse event while taking bupropion, we did not find increased risks of neuropsychiatric or heart and circulatory problems in the bupropion studies. The evidence for the safety of varenicline is still under investigation; we found no evidence from the trials that it is linked to an increase in neuropsychiatric problems, or with increased heart and circulatory problems.
 
 Clonidine helped people to quit, but caused side effects. It is not clear whether or not mecamylamine used with NRT helps people to quit. Other treatments did not seem to help. So far, nicotine vaccines are not licensed for use anywhere in the world. Nicobrevin is no longer available in the UK, and rimonabant, taranabant and dianicline have all been withdrawn from the market.
 Conclusions 
 NRT, bupropion and varenicline all improve the chances of quitting, with a low risk of harms.
 Combination use of NRT is as effective as varenicline, and more effective than single types of NRT.
 Cytisine has potential as a safe, effective and affordable treatment.
 Nortriptyline improves the chances of quitting, with little evidence of harmful events.
 We need continued monitoring of the safety of varenicline.
 More research into NRT versus placebo is unlikely to change our understanding of the treatment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Cahill, K; Stevens, S; Perera, R; Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD009329.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "d651806a-559f-4fdc-a276-2f82f7403702", "pmid": "", "title": "Horticultural therapy for schizophrenia", "imported": false, "abstract": "Abstract - Background Horticultural therapy is defined as the process of utilising fruits, vegetables, flowers and plants facilitated by a trained therapist or healthcare provider, to achieve specific treatment goals or to simply improve a person's well‐being. It can be used for therapy or rehabilitation programs for cognitive, physical, social, emotional, and recreational benefits, thus improving the person's body, mind and spirit. Between 5% to 15% of people with schizophrenia continue to experience symptoms in spite of medication, and may also develop undesirable adverse effects, horticultural therapy may be of value for these people. Objectives To evaluate the effects of horticultural therapy for people with schizophrenia or schizophrenia‐like illnesses compared with standard care or other additional psychosocial interventions. Search methods We searched the Cochrane Schizophrenia Group Trials Register (Janurary 2013) and supplemented this by contacting relevant study authors, and manually searching reference lists. Selection criteria We included one randomised controlled trial (RCT) comparing horticultural therapy plus standard care with standard care alone for people with schizophrenia. Data collection and analysis We reliably selected, quality assessed and extracted data. For continuous outcomes, we calculated a mean difference (MD) and for binary outcomes we calculated risk ratio (RR), both with 95% confidence intervals (CI). We assessed risk of bias and created a 'Summary of findings' table using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. Main results We included one single blind study (total n = 24). The overall risk of bias in the study was considered to be unclear although the randomisation was adequate. It compared a package of horticultural therapy which consisted of one hour per day of horticultural activity plus standard care with standard care alone over two weeks (10 consecutive days) with no long‐term follow‐up. Only two people were lost to follow‐up in the study, both in the horticultural therapy group (1 RCT n = 24,RR 5.00 95% CI 0.27 to 94.34, very low quality evidence ). There was no clear evidence of a difference in Personal Wellbeing Index (PWI‐C) change scores between groups, however confidence intervals were wide (1 RCT n = 22, MD ‐0.90 95% CI ‐10.35 to 8.55, very low quality evidence ). At the end of treatment, the Depression Anxiety Stress Scale (DASS21) change scores in horticultural therapy group were greater than that in the control group (1 RCT n = 22, MD ‐23.70 CI ‐35.37 to ‐ 12.03, very low quality evidence). The only included study did not report on adverse effects of interventions. Authors' conclusions Based on the current very low quality data, there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. This therapy remains unproven and more and larger randomised trials are needed to increase high quality evidence in this area. Plain language summary Gardening activity as a therapy for schizophrenia Horticultural therapy is based on the therapeutic value of participating in garden activities such as growing fruit or vegetables and/or flowers. Gardening is thought to improve people's well‐being through being a recreational and sociable activity which may lead to improvements in people's thinking, new friendships and more positive emotions. The benefits of gardening can also apply to people with serious mental illness such as schizophrenia. Gardening reduces stress, which is important because stress can often lead to mental illness. Gardening is also hard work and a physical activity, and so motivates people with mental illness who often feel tired and apathetic. Weight gain is common for people with mental illness and gardening is good physical exercise. Since 5% to 15% of people with schizophrenia experience symptoms in spite of taking antipsychotic drugs and also because these drugs have debilitating side effects, horticultural therapy may be of value to these people. This review focuses on the effects of horticultural therapy for people with schizophrenia. An electronic search for relevant randomised trials was run in January 2013. Only one trial was included, it randomised a total of 24 people with schizophrenia to received either their standard care plus horticultural therapy or standard care only. The trial only lasted 2 weeks (10 consecutive days) with no long‐term follow‐up. There are few results and the quality of evidence was rated by the review authors to be very low quality. Some of the information from this one study favoured horticultural therapy but there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. More large, better conducted and reported trials are required to determine the effectiveness and benefits of horticultural therapy. This plain language summary has been written by a consumer Ben Gray, Service User and Service User Expert, Rethink Mental Illness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Liu, Y; Li, B; Sampson, SJ; Roberts, S; Zhang, G; Wu, W", "articleTypes": [], "doi": "10.1002/14651858.CD009413.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "d654b25d-c47f-4aae-9e87-5cacac7e4977", "pmid": "", "title": "Preventive lipid‐based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes", "imported": false, "abstract": "Abstract - Background One nutritional intervention advocated to prevent malnutrition among children is lipid‐based nutrient supplements (LNS). LNS provide a range of vitamins and minerals, but unlike most other micronutrient supplements, LNS also provide energy, protein and essential fatty acids. Alternative recipes and formulations to LNS include fortified blended foods (FBF), which are foods fortified with vitamins and minerals, and micronutrient powders (MNP), which are a combination of vitamins and minerals, Objectives To assess the effects and safety of preventive LNS given with complementary foods on health, nutrition and developmental outcomes of non‐hospitalised infants and children six to 23 months of age, and whether or not they are more effective than other foods (including FBF or MNP). This review did not assess the effects of LNS as supplementary foods or therapeutic foods in the management of moderate and severe acute malnutrition. Search methods In October 2018, we searched CENTRAL, MEDLINE, Embase, 21 other databases and two trials registers for relevant studies. We also checked the reference lists of included studies and relevant reviews and contacted the authors of studies and other experts in the area for any ongoing and unpublished studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs that evaluated the impact of LNS plus complementary foods given at point‐of‐use (for any dose, frequency, duration) to non‐hospitalised infants and young children aged six to 23 months in stable or emergency settings and compared to no intervention, other supplementary foods (i.e. FBF), nutrition counselling or multiple micronutrient supplements or powders for point‐of‐use fortification of complementary foods. Data collection and analysis Two review authors independently screened studies for relevance and, for those studies included in the review, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software. We used a random‐effects meta‐analysis for combining data as the interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables,. Main results Our search identified a total of 8124 records, from which we included 17 studies (54 papers) with 23,200 children in the review. The included studies reported on one or more of the pre‐specified primary outcomes, and five studies included multiple comparison groups. Overall, the majority of trials were at low risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias, but at high risk of bias for blinding of participants and personnel due to the nature of the intervention. Using the GRADE approach, we judged the quality of the evidence for most outcomes as low or moderate. LNS+complementary feeding compared with no intervention Thirteen studies compared LNS plus complementary feeding with no intervention. LNS plus complementary feeding reduced the prevalence of moderate stunting by 7% (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.88 to 0.98; nine studies, 13,372 participants; moderate‐quality evidence), severe stunting by 15% (RR 0.85, 95% CI 0.74 to 0.98; five studies, 6151 participants; moderate‐quality evidence), moderate wasting by 18% (RR 0.82, 95% CI 0.74 to 0.91; eight studies; 13,172 participants; moderate‐quality evidence), moderate underweight by 15% (RR 0.85, 95% CI 0.80 to 0.91; eight studies, 13,073 participants; moderate‐quality evidence), and anaemia by 21% (RR 0.79, 95% CI 0.69 to 0.90; five studies, 2332 participants; low‐quality evidence). There was no impact of LNS plus complementary feeding on severe wasting (RR 1.27, 95% CI 0.66 to 2.46; three studies, 2329 participants) and severe underweight (RR 0.78, 95%CI 0.54 to 1.13; two studies, 1729 participants). Adverse effects did not differ between the groups (RR 0.86, 95% CI 0.74 to 1.01; three studies, 3382 participants). LNS+complementary feeding compared with FBF Five studies compared LNS plus complementary feeding with other FBF, including corn soy blend and UNIMIX. We pooled four of the five studies in meta‐analyses and found that, when compared to other FBF, LNS plus complementary feeding significantly reduced the prevalence of moderate stunting (RR 0.89, 95% CI 0.82 to 0.97; three studies, 2828 participants; moderate‐quality evidence), moderate wasting (RR 0.79, 95% CI 0.65 to 0.97; two studies, 2290 participants; moderate‐quality evidence), and moderate underweight (RR 0.81, 95% CI 0.73 to 0.91; two studies, 2280 participants; moderate‐quality evidence). We found no difference between LNS plus complementary feeding and FBF for severe stunting (RR 0.41, 95% CI 0.12 to 1.42; two studies, 729 participants; low‐quality evidence), severe wasting (RR 0.64, 95% CI 0.19 to 2.81; two studies, 735 participants; moderate‐quality evidence), and severe underweight (RR 1.23, 95% CI 0.67 to 2.25; one study, 173 participants; low‐quality evidence). LNS+complementary feeding compared with MNP Four studies compared LNS plus complementary feeding with MNP. We pooled data from three of the four studies in meta‐analyses and found that compared to MNP, LNS plus complementary feeding significantly reduced the prevalence of moderate underweight (RR 0.88, 95% CI 0.78 to 0.99; two studies, 2004 participants; moderate‐quality evidence) and anaemia (RR 0.38, 95% CI 0.21 to 0.68; two studies, 557 participants; low‐quality evidence). There was no difference between LNS plus complementary feeding and MNP for moderate stunting (RR 0.92, 95% CI 0.82 to 1.02; three studies, 2365 participants) and moderate wasting (RR 0.97, 95% CI 0.77 to 1.23; two studies, 2004 participants). Authors' conclusions The findings of this review suggest that LNS plus complementary feeding compared to no intervention is effective at improving growth outcomes and anaemia without adverse effects among children aged six to 23 months in low‐ and middle‐income countries (LMIC) in Asia and Africa, and more effective if provided over a longer duration of time (over 12 months). Limited evidence also suggests that LNS plus complementary feeding is more effective than FBF and MNP at improving growth outcomes. Plain language summary Effect of lipid‐based nutrient supplementation on infants and young children Review question What is the impact of lipid‐based nutrient supplements (LNS) plus complementary foods on health, nutrition and developmental outcomes among infants and young children? Background LNS are food products which contain energy, minerals and vitamins that can improve growth in children. LNS provide vitamins, minerals and energy in the form of protein and essential fatty acids. We sought to assess the effect of LNS given jointly with complementary feeding, compared to no intervention, micronutrient powders (MNP; a mixture of vitamins and minerals that is sprinkled onto food) and other fortified blended food (FBF) products in healthy children. Study characteristics This review includes 17 studies (from 54 reports) with 23,200 children. Four of the included studies were conducted in Malawi, three in Bangladesh, two in Ghana and one each in Burkina Faso, Haiti, Honduras, Chad, Congo, Kenya, Niger, Peru, Guatemala, and Indonesia. Four included studies enrolled pregnant women and provided LNS plus complementary feeding during pregnancy and post‐partum, followed by infant supplementation starting at six months of age. The other studies provided LNS plus complementary feeding to children after six months of age. None of the included studies were conducted in emergency settings. Key results Findings of this review suggest that LNS plus complementary feeding is probably an effective intervention for improving growth outcomes and reducing the occurrence of children who are of short stature for their age (stunting), have low weight for their age (moderate underweight), have low weight for their height (moderate wasting) and anaemia. Additionally, LNS plus complementary feeding probably improves height and weight for age as well as mid‐upper arm circumference without adverse effects among children aged six to 23 months. The intervention seems to be more effective if provided for a duration longer than 12 months. Evidence also suggests that LNS plus complementary probably reduces moderate stunting, moderate wasting and moderate underweight, compared to other FBF. Furthermore, LNS plus complementary feeding is probably more effective than MNP at reducing moderate underweight and improving height and weight. Quality of evidence Overall, we considered most studies to be at high risk of bias for blinding of participants and personnel due to the nature of intervention. We rated the quality of the evidence for most outcomes as either low or moderate. Currentness of evidence The evidence is current to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Das, JK; Salam, RA; Hadi, YB; Sadiq Sheikh, S; Bhutta, AZ; Weise Prinzo, Z; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD012611.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "d66040d7-6f44-468f-8959-d640c73264d9", "pmid": "", "title": "Topiramate for the prophylaxis of episodic migraine in adults", "imported": false, "abstract": "Abstract - Background Some antiepileptic drugs but not others are useful in clinical practice for the prophylaxis of migraine. This might be explained by the variety of actions of these drugs in the central nervous system. The present review is part of an update of a Cochrane review first published in 2004, and previously updated (conclusions not changed) in 2007. Objectives To describe and assess the evidence from controlled trials on the efficacy and tolerability of topiramate for preventing migraine attacks in adult patients with episodic migraine. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2012, Issue 12), PubMed/MEDLINE (1966 to 15 January 2013), MEDLINE In‐Process (current week, 15 January 2013), and EMBASE (1974 to 15 January 2013) and handsearched Headache and Cephalalgia through January 2013. Selection criteria Studies were required to be prospective, controlled trials of topiramate taken regularly to prevent the occurrence of migraine attacks, to improve migraine‐related quality of life, or both. Data collection and analysis Two review authors independently selected studies and extracted data. For headache frequency data, we calculated mean differences (MDs) between topiramate and comparator (placebo, active control, or topiramate in a different dose) for individual studies and pooled these across studies. For dichotomous data on responders (patients with ≥ 50% reduction in headache frequency), we calculated odds ratios (ORs) and, in select cases, risk ratios (RRs); we also calculated numbers needed to treat (NNTs). We calculated MDs for selected quality of life instruments. Finally, we summarised data on adverse events from placebo‐controlled trials and calculated risk differences (RDs) and numbers needed to harm (NNHs). Main results Twenty papers describing 17 unique trials met the inclusion criteria. Analysis of data from nine trials (1737 participants) showed that topiramate reduced headache frequency by about 1.2 attacks per 28 days as compared to placebo (MD ‐1.20; 95% confidence interval (CI) ‐1.59 to ‐0.80). Data from nine trials (1190 participants) show that topiramate approximately doubled the proportion of responders relative to placebo (RR 2.02; 95% CI 1.57 to 2.60; NNT 4; 95% CI 3 to 6). Separate analysis of different topiramate doses produced similar MDs versus placebo at 50 mg (‐0.95; 95% CI ‐1.95 to 0.04; three studies; 520 participants), 100 mg (‐1.15; 95% CI ‐1.58 to ‐0.71; six studies; 1620 participants), and 200 mg (‐0.94; 95% CI ‐1.53 to ‐0.36; five studies; 804 participants). All three doses significantly increased the proportion of responders relative to placebo; ORs were as follows: for 50 mg, 2.35 (95% CI 1.60 to 3.44; three studies; 519 participants); for 100 mg, 3.49 (95% CI 2.23 to 5.45; five studies; 852 participants); and for 200 mg, 2.49 (95% CI 1.61 to 3.87; six studies; 1025 participants). All three doses also significantly improved three or more domains of quality of life as compared to placebo. Meta‐analysis of the three studies that included more than one dose of topiramate suggests that 200 mg is no more effective than 100 mg. With regard to mean headache frequency and/or responder rate, seven trials using active comparators found (a) no significant difference between topiramate and amitriptyline (one study, 330 participants); (b) no significant difference between topiramate and flunarizine (one study, 83 participants); (c) no significant difference between topiramate and propranolol (two studies, 342 participants); (d) no significant difference between topiramate and relaxation (one study, 61 participants); but (e) a slight significant advantage of topiramate over valproate (two studies, 120 participants). Relaxation improved migraine‐specific quality of life significantly more than topiramate. In trials of topiramate against placebo, seven adverse events (AEs) were reported by at least three studies. These were usually mild and of a non‐serious nature. Except for taste disturbance and weight loss, there were no significant differences in the frequency of AEs in general, or of the seven specific AEs, between placebo and topiramate 50 mg. AEs in general and all of the specific AEs except nausea were significantly more common on topiramate 100 mg than on placebo, with NNHs varying from 3 to 25, and the RDs versus placebo were even higher for topiramate 200 mg, with NNHs varying from 2 to 17. Authors' conclusions Meta‐analysis demonstrates that topiramate in a 100 mg/day dosage is effective in reducing headache frequency and reasonably well‐tolerated in adult patients with episodic migraine. This provides good evidence to support its use in routine clinical management. More studies designed specifically to compare the efficacy or safety of topiramate versus other interventions with proven efficacy in the prophylaxis of migraine are needed. Plain language summary Topiramate for preventing migraine attacks in adults Various medicines, collectively termed 'antiepileptics', are used to treat epilepsy. For several years, some of these drugs have also been used for preventing migraine attacks. For the present review, researchers in The Cochrane Collaboration reviewed the evidence about the effects of topiramate in adult patients (≥ 16 years of age) with 'episodic' migraine (headache on < 15 days per month). They examined research published up to 15 January 2013 and found 17 relevant studies. Compared with placebo, topiramate reduced the frequency of migraine headaches by approximately 1.2 per month (nine studies, 1737 participants). Patients were also about twice as likely to reduce the number of their migraine headaches by 50% or more with topiramate than with placebo (nine studies, 1190 participants). Side effects associated with topiramate were common but generally mild; topiramate can, however, cause birth defects and so should be used with caution in women of childbearing age. Further research is needed comparing topiramate with other active drugs used for preventing migraine attacks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Linde, M; Mulleners, WM; Chronicle, EP; McCrory, DC", "articleTypes": [], "doi": "10.1002/14651858.CD010610", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "d67eb650-3f79-484e-b589-796f9e044fa7", "pmid": "", "title": "Factors influencing the uptake and use of nicotine replacement therapy and e‐cigarettes in pregnant women who smoke: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) delivers nicotine without the toxic chemicals present in tobacco smoke. It is an effective smoking cessation aid in non‐pregnant smokers, but there is less evidence of effectiveness in pregnancy. Systematic review evidence suggests that pregnant women do not adhere to NRT as prescribed, which might undermine effectiveness. Electronic cigarettes (e‐cigarettes) have grown in popularity, but effectiveness and safety in pregnancy are not yet established. The determinants of uptake and use of NRT and e‐cigarettes in pregnancy are unknown. Objectives To explore factors affecting uptake and use of NRT and e‐cigarettes in pregnancy. Search methods We searched MEDLINE(R), CINAHL and PsycINFO on 1 February 2019. We manually searched OpenGrey database and screened references of included studies and relevant reviews. We also conducted forward citation searches of included studies. Selection criteria We selected studies that used qualitative methods of data collection and analysis, included women who had smoked in pregnancy, and elicited participants' views about using NRT/e‐cigarettes for smoking cessation or harm reduction (i.e. to smoke fewer cigarettes) during pregnancy. Data collection and analysis We identified determinants of uptake and use of NRT/e‐cigarettes in pregnancy using a thematic synthesis approach. Two review authors assessed the quality of included studies with the Wallace tool. Two review authors used the CERQual approach to assess confidence in review findings. The contexts of studies from this review and the relevant Cochrane effectiveness review were not similar enough to fully integrate findings; however, we created a matrix to juxtapose findings from this review with the descriptions of behavioural support from trials in the effectiveness review. Main results We included 21 studies: 15 focused on NRT, 3 on e‐cigarettes, and 3 on both. Studies took place in five high‐income countries. Most studies contributed few relevant data; substantially fewer data were available on determinants of e‐cigarettes. Many studies focused predominantly on issues relating to smoking cessation, and determinants of NRT/e‐cigarette use was often presented as one of the themes. We identified six descriptive themes and 18 findings within those themes; from these we developed three overarching analytical themes representing key determinants of uptake and adherence to NRT and/or e‐cigarettes in pregnancy. The analytical themes show that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. Furthermore, women consider advice from health professionals when deciding whether to use NRT or e‐cigarettes; when health professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay for them to use these in pregnancy, women report feeling more confident about using them. Conversely, women who are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them during pregnancy feel less confident about using them. Women's past experiences with NRT can also affect their willingness to use NRT in pregnancy; women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. No trials on e‐cigarette use in pregnancy were included in the Cochrane effectiveness review, so we considered only NRT findings when integrating results from this review and the effectiveness review. No qualitative studies were conducted alongside trials, making full integration of the findings challenging. Women enrolled in trials would have agreed to being allocated to NRT or control group and would have received standardised information on NRT at the start of the trial. Overall, the findings of this synthesis are less relevant to women's decisions about starting NRT in trials and more likely to help explain trial participants' adherence to NRT after starting it. We considered most findings to be of moderate certainty; we assessed findings on NRT use as being of higher certainty than those on e‐cigarette use. This was mainly due to the limited data from fewer studies (only in the UK and USA) that contributed to e‐cigarette findings. Overall, we judged studies to be of acceptable quality with only minor methodological issues. Authors' conclusions Consistent messages from health professionals, based on high‐quality evidence and clearly explaining the safety of NRT and e‐cigarettes compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and subsequently encourage them to stay smoke‐free. Plain language summary Factors affecting use of nicotine replacement therapy and e‐cigarettes in pregnancy What was studied in this review? Nicotine replacement therapy (NRT) delivers nicotine without the harmful chemicals found in tobacco smoke. NRT helps some non‐pregnant adults to stop smoking, but it does not seem to work so well in pregnancy. This may be because pregnant women generally do not use NRT as prescribed. Studies show that some pregnant women use e‐cigarettes to help them cut down or quit, although their safety and effectiveness in pregnancy is not known. Little is known about the issues that influence pregnant women's use of NRT/e‐cigarettes. What is the aim of this review? To explore factors that affect whether women take up and use NRT or e‐cigarettes to reduce or quit smoking in pregnancy. What are the key messages of this review? Three main factors influence whether women take up and use NRT and e‐cigarettes in pregnancy: advice women receive from health professionals on using NRT or e‐cigarette in pregnancy, women's desire to protect their unborn baby from harm, and past personal experience with NRT. Each of these factors can either encourage or discourage women from using these products. What are the key findings? We included 21 studies; 15 of these focused on NRT, 3 on e‐cigarettes and 3 on both. Our findings suggest that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. They also consider the advice from their health professionals; when professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay to use them in pregnancy, their confidence about using them increases. When women are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them when they are pregnant, they feel less confident about using them. Women's past experiences with NRT will also affect how willing they are to use NRT in pregnancy. For example, women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. We conclude that consistent messages that are based on high‐quality research and clearly explain how safe NRT and e‐cigarettes are compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and encourage them to stay smoke‐free. How up‐to‐date is this review? We searched for studies that had been published before 1 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Campbell, K, Coleman-Haynes, T, Bowker, K, Cooper, SE, Connelly, S, Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD013629", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.764Z" }, { "id": "d69b9a71-bf19-42d7-a139-1b243dd7c439", "pmid": "", "title": "Antibody tests for identification of current and past infection with SARS‐CoV‐2", "imported": false, "abstract": "Abstract - Background The diagnostic challenges associated with the COVID‐19 pandemic resulted in rapid development of diagnostic test methods for detecting SARS‐CoV‐2 infection. Serology tests to detect the presence of antibodies to SARS‐CoV‐2 enable detection of past infection and may detect cases of SARS‐CoV‐2 infection that were missed by earlier diagnostic tests. Understanding the diagnostic accuracy of serology tests for SARS‐CoV‐2 infection may enable development of effective diagnostic and management pathways, inform public health management decisions and understanding of SARS‐CoV‐2 epidemiology. Objectives To assess the accuracy of antibody tests, firstly, to determine if a person presenting in the community, or in primary or secondary care has current SARS‐CoV‐2 infection according to time after onset of infection and, secondly, to determine if a person has previously been infected with SARS‐CoV‐2. Sources of heterogeneity investigated included: timing of test, test method, SARS‐CoV‐2 antigen used, test brand, and reference standard for non‐SARS‐CoV‐2 cases. Search methods The COVID‐19 Open Access Project living evidence database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) was searched on 30 September 2020. We included additional publications from the Evidence for Policy and Practice Information and Co‐ordinating Centre (EPPI‐Centre) ‘COVID‐19: Living map of the evidence’ and the Norwegian Institute of Public Health ’NIPH systematic and living map on COVID‐19 evidence’. We did not apply language restrictions. Selection criteria We included test accuracy studies of any design that evaluated commercially produced serology tests, targeting IgG, IgM, IgA alone, or in combination. Studies must have provided data for sensitivity, that could be allocated to a predefined time period after onset of symptoms, or after a positive RT‐PCR test. Small studies with fewer than 25 SARS‐CoV‐2 infection cases were excluded. We included any reference standard to define the presence or absence of SARS‐CoV‐2 (including reverse transcription polymerase chain reaction tests (RT‐PCR), clinical diagnostic criteria, and pre‐pandemic samples). Data collection and analysis We use standard screening procedures with three reviewers. Quality assessment (using the QUADAS‐2 tool) and numeric study results were extracted independently by two people. Other study characteristics were extracted by one reviewer and checked by a second. We present sensitivity and specificity with 95% confidence intervals (CIs) for each test and, for meta‐analysis, we fitted univariate random‐effects logistic regression models for sensitivity by eligible time period and for specificity by reference standard group. Heterogeneity was investigated by including indicator variables in the random‐effects logistic regression models. We tabulated results by test manufacturer and summarised results for tests that were evaluated in 200 or more samples and that met a modification of UK Medicines and Healthcare products Regulatory Agency (MHRA) target performance criteria. Main results We included 178 separate studies (described in 177 study reports, with 45 as pre‐prints) providing 527 test evaluations. The studies included 64,688 samples including 25,724 from people with confirmed SARS‐CoV‐2; most compared the accuracy of two or more assays (102/178, 57%). Participants with confirmed SARS‐CoV‐2 infection were most commonly hospital inpatients (78/178, 44%), and pre‐pandemic samples were used by 45% (81/178) to estimate specificity. Over two‐thirds of studies recruited participants based on known SARS‐CoV‐2 infection status (123/178, 69%). All studies were conducted prior to the introduction of SARS‐CoV‐2 vaccines and present data for naturally acquired antibody responses. Seventy‐nine percent (141/178) of studies reported sensitivity by week after symptom onset and 66% (117/178) for convalescent phase infection. Studies evaluated enzyme‐linked immunosorbent assays (ELISA) (165/527; 31%), chemiluminescent assays (CLIA) (167/527; 32%) or lateral flow assays (LFA) (188/527; 36%). Risk of bias was high because of participant selection (172, 97%); application and interpretation of the index test (35, 20%); weaknesses in the reference standard (38, 21%); and issues related to participant flow and timing (148, 82%). We judged that there were high concerns about the applicability of the evidence related to participants in 170 (96%) studies, and about the applicability of the reference standard in 162 (91%) studies. Average sensitivities for current SARS‐CoV‐2 infection increased by week after onset for all target antibodies. Average sensitivity for the combination of either IgG or IgM was 41.1% in week one (95% CI 38.1 to 44.2; 103 evaluations; 3881 samples, 1593 cases), 74.9% in week two (95% CI 72.4 to 77.3; 96 evaluations, 3948 samples, 2904 cases) and 88.0% by week three after onset of symptoms (95% CI 86.3 to 89.5; 103 evaluations, 2929 samples, 2571 cases). Average sensitivity during the convalescent phase of infection (up to a maximum of 100 days since onset of symptoms, where reported) was 89.8% for IgG (95% CI 88.5 to 90.9; 253 evaluations, 16,846 samples, 14,183 cases), 92.9% for IgG or IgM combined (95% CI 91.0 to 94.4; 108 evaluations, 3571 samples, 3206 cases) and 94.3% for total antibodies (95% CI 92.8 to 95.5; 58 evaluations, 7063 samples, 6652 cases). Average sensitivities for IgM alone followed a similar pattern but were of a lower test accuracy in every time slot. Average specificities were consistently high and precise, particularly for pre‐pandemic samples which provide the least biased estimates of specificity (ranging from 98.6% for IgM to 99.8% for total antibodies). Subgroup analyses suggested small differences in sensitivity and specificity by test technology however heterogeneity in study results, timing of sample collection, and smaller sample numbers in some groups made comparisons difficult. For IgG, CLIAs were the most sensitive (convalescent‐phase infection) and specific (pre‐pandemic samples) compared to both ELISAs and LFAs (P < 0.001 for differences across test methods). The antigen(s) used (whether from the Spike‐protein or nucleocapsid) appeared to have some effect on average sensitivity in the first weeks after onset but there was no clear evidence of an effect during convalescent‐phase infection. Investigations of test performance by brand showed considerable variation in sensitivity between tests, and in results between studies evaluating the same test. For tests that were evaluated in 200 or more samples, the lower bound of the 95% CI for sensitivity was 90% or more for only a small number of tests (IgG, n = 5; IgG or IgM, n = 1; total antibodies, n = 4). More test brands met the MHRA minimum criteria for specificity of 98% or above (IgG, n = 16; IgG or IgM, n = 5; total antibodies, n = 7). Seven assays met the specified criteria for both sensitivity and specificity. In a low‐prevalence (2%) setting, where antibody testing is used to diagnose COVID‐19 in people with symptoms but who have had a negative PCR test, we would anticipate that 1 (1 to 2) case would be missed and 8 (5 to 15) would be falsely positive in 1000 people undergoing IgG or IgM testing in week three after onset of SARS‐CoV‐2 infection. In a seroprevalence survey, where prevalence of prior infection is 50%, we would anticipate that 51 (46 to 58) cases would be missed and 6 (5 to 7) would be falsely positive in 1000 people having IgG tests during the convalescent phase (21 to 100 days post‐symptom onset or post‐positive PCR) of SARS‐CoV‐2 infection. Authors' conclusions Some antibody tests could be a useful diagnostic tool for those in whom molecular‐ or antigen‐based tests have failed to detect the SARS‐CoV‐2 virus, including in those with ongoing symptoms of acute infection (from week three onwards) or those presenting with post‐acute sequelae of COVID‐19. However, antibody tests have an increasing likelihood of detecting an immune response to infection as time since onset of infection progresses and have demonstrated adequate performance for detection of prior infection for sero‐epidemiological purposes. The applicability of results for detection of vaccination‐induced antibodies is uncertain. Plain language summary What is the diagnostic accuracy of antibody tests for the detection of infection with the COVID‐19 virus? Background COVID‐19 is an infectious disease caused by the SARS‐CoV‐2 virus that spreads easily between people in a similar way to the common cold or ‘flu’. Most people with COVID‐19 have a mild‐to‐moderate respiratory illness, and some may have no symptoms (asymptomatic infection). Others experience severe symptoms and need specialist treatment and intensive care. In response to COVID‐19 infection, the immune system develops proteins called antibodies that can attack the virus as it circulates in their blood. People who have been vaccinated against COVID‐19 also produce these antibodies against the virus. Tests are available to detect antibodies in peoples' blood, which may indicate that they currently have COVID‐19 or have had it previously, or it may indicate that they have been vaccinated (although this group was not the focus of this review). Why are accurate tests important? Accurate testing allows identification of people who need to isolate themselves to prevent the spread of infection, or who might need treatment for their infection. Failure of diagnostic tests to detect infection with COVID‐19 when it is present (a false negative result) may delay treatment and risk further spread of infection to others. Incorrect diagnosis of COVID‐19 when it is not present (a false positive result) may lead to unnecessary further testing, treatment, and isolation of the person and close contacts. Accurate identification of people who have previously had COVID‐19 is important in measuring disease spread and assessing the success of public health interventions. To determine the accuracy of an antibody test in identifying COVID‐19, test results are compared in people known to have (or have had) COVID‐19 and in people known not to have (or have had) COVID‐19. The criteria used to determine whether people are known or not known to have COVID‐19 is called the ‘reference standard’. Many studies use a test called reverse transcriptase polymerase chain reaction (RT‐PCR) as the reference standard, with samples taken from the nose and throat. Additional tests that can be used include measuring symptoms, like coughing or high temperature, or ‘imaging’ tests like chest X‐rays. People known not to have COVID‐19 are sometimes identified from stored blood samples taken before COVID‐19 existed, or from patients with symptoms confirmed to be caused by other diseases. What did the review study? We wanted to find out whether antibody tests: ‐ are able to diagnose infection in people with or without symptoms of COVID‐19, and ‐ can be used to find out if someone has already had COVID‐19. The studies we included in our review looked at three types of antibodies. Most commonly, antibody tests measure two types known as IgG and IgM, but some tests only measure a single type of antibody or different combinations of the three types of antibodies (IgA, IgG, IgM). What did we do? We looked for studies that measured the diagnostic accuracy of antibody tests to detect current or past COVID‐19 infection and compared them with reference standard criteria. Since there are many antibody tests available, we included studies assessing any antibody test compared with any reference standard. People could be tested in hospital or in the community. The people tested may have been confirmed to have, or not to have, COVID‐19 infection, or they may be suspected of having COVID‐19. Study characteristics We found 178 relevant studies. Studies took place in Europe (94), Asia (45), North America (35), Australia (2), and South America (2). Seventy‐eight studies included people who were in hospital with suspected or confirmed COVID‐19 infection and 14 studies included people in community settings. Several studies included people from multiple settings (35) or did not report where the participants were recruited from (39). One hundred and forty‐one studies included recent infection cases (mainly week 1 to week 3 after onset of symptoms), and many also included people tested later (from day 21 onwards after infection) (117). Main results In participants that had COVID‐19 and were tested one week after symptoms developed, antibody tests detected only 27% to 41% of infections. In week 2 after first symptoms, 64% to 79% of infections were detected, rising to 78% to 88% in week 3. Tests that specifically detected IgG or IgM antibodies were the most accurate and, when testing people from 21 days after first symptoms, they detected 93% of people with COVID‐19. Tests gave false positive results for 1% of those without COVID‐19. Below we illustrate results for two different scenarios. If 1000 people were tested for IgG or IgM antibodies during the third week after onset of symptoms and only 20 (2%) of them actually had COVID‐19: ‐ 26 people would test positive. Of these, 8 people (31%) would not have COVID‐19 (false positive result). ‐ 974 people would test negative. Of these, 2 people (0.2%) would actually have COVID‐19 (false negative result). If 1000 people with no symptoms for COVID‐19 were tested for IgG antibodies and 500 (50%) of them had previously had COVID‐19 infection more than 21 days previously: ‐ 455 people would test positive. Of these, 6 people (1%) would not have been infected (false positive result). ‐ 545 people would test negative. Of these, 51 (9%) would actually have had a prior COVID‐19 infection (false negative result). How reliable were the results of the studies of this review? We have limited confidence in the evidence for several reasons. The number of samples contributed by studies for each week post‐symptom onset was often small, and there were sometimes problems with how studies were conducted. Participants included in the studies were often hospital patients who were more likely to have experienced severe symptoms of COVID‐19. The accuracy of antibody tests for detecting COVID‐19 in these patients may be different from the accuracy of the tests in people with mild or moderate symptoms. It is not possible to identify by how much the test results would differ in other populations. Who do the results of this review apply to? A high percentage of participants were in hospital with COVID‐19, so were likely to have more severe disease than people with COVID‐19 who were not hospitalised. Only a small number of studies assessed these tests in people with no symptoms. The results of the review may therefore be more applicable to those with severe disease than people with mild symptoms. Studies frequently did not report whether participants had symptoms at the time samples were taken for testing making it difficult to fully separate test results for early‐phase infection as opposed to later‐phase infections. The studies in our review assessed several test methods across a global population, therefore it is likely that test results would be similar in most areas of the world. What are the implications of this review? The review shows that antibody tests could have a useful role in detecting if someone has had COVID‐19, but the timing of test use is important. Some antibody tests may help to confirm COVID‐19 infection in people who have had symptoms for more than two weeks but who have been unable to confirm their infection using other methods. This is particularly useful if they are experiencing potentially serious symptoms that may be due to COVID‐19 as they may require specific treatment. Antibody tests may also be useful to determine how many people have had a previous COVID‐19 infection. We could not be certain about how well the tests work for people who have milder disease or no symptoms, or for detecting antibodies resulting from vaccination. How up‐to‐date is this review? This review updates our previous review. The evidence is up‐to‐date to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Fox, T; Geppert, J; Dinnes, J; Scandrett, K; Bigio, J; Sulis, G; Hettiarachchi, D; Mathangasinghe, Y; Weeratunga, P; Wickramasinghe, D; Bergman, H; Buckley, BS; Probyn, K; Sguassero, Y; Davenport, C; Cunningham, J; Dittrich, S; Emperador, D; Hooft, L; Leeflang, MMG; McInnes, MDF; Spijker, R; Struyf, T; Van den Bruel, A; Verbakel, JY; Takwoingi, Y; Taylor-Phillips, S; Deeks, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD013652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "d69d5bbc-331d-4a11-85c4-5e0f8acfeb80", "pmid": "", "title": "Treatments for iron‐deficiency anaemia in pregnancy", "imported": false, "abstract": "Abstract - Background Iron deficiency, the most common cause of anaemia in pregnancy worldwide, can be mild, moderate or severe. Severe anaemia can have very serious consequences for mothers and babies, but there is controversy about whether treating mild or moderate anaemia provides more benefit than harm. Objectives To assess the effects of different treatments for anaemia in pregnancy attributed to iron deficiency (defined as haemoglobin less than 11 g/dL or other equivalent parameters) on maternal and neonatal morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2011), CENTRAL (2011, Issue 5), PubMed (1966 to June 2011), the International Clinical Trials Registry Platform (ICTRP) (2 May 2011), Health Technology Assessment Program (HTA) (2 May 2011) and LATINREC (Colombia) (2 May 2011). Selection criteria Randomised controlled trials comparing treatments for anaemia in pregnancy attributed to iron deficiency. Data collection and analysis We identified 23 trials, involving 3.198 women. We assessed their risk of bias. Three further studies identified are awaiting classification. Main results Many of the trials were from low‐income countries; they were generally small and frequently methodologically poor. They covered a very wide range of differing drugs, doses and routes of administration, making it difficult to pool data. Oral iron in pregnancy showed a reduction in the incidence of anaemia (risk ratio 0.38, 95% confidence interval 0.26 to 0.55, one trial, 125 women) and better haematological indices than placebo (two trials). It was not possible to assess the effects of treatment by severity of anaemia. A trend was found between dose and reported adverse effects. Most trials reported no clinically relevant outcomes nor adverse effects. Although the intramuscular and intravenous routes produced better haematological indices in women than the oral route, no clinical outcomes were assessed and there were insufficient data on adverse effects, for example, on venous thrombosis and severe allergic reactions. Daily low‐dose iron supplements may be effective at treating anaemia in pregnancy with less gastrointestinal side effects compared with higher doses. Authors' conclusions Despite the high incidence and burden of disease associated with this condition, there is a paucity of good quality trials assessing clinical maternal and neonatal effects of iron administration in women with anaemia. Daily oral iron treatment improves haematological indices but causes frequent gastrointestinal adverse effects. Parenteral (intramuscular and intravenous) iron enhances haematological response, compared with oral iron, but there are concerns about possible important adverse effects (for intravenous treatment venous thrombosis and allergic reactions and for intramuscular treatment important pain, discolouration and allergic reactions). Large, good quality trials, assessing clinical outcomes (including adverse effects) as well as the effects of treatment by severity of anaemia are required. Plain language summary Treatments for anaemia in pregnancy thought to be due to iron deficiency When the blood has insufficient red cells, or the red cells carry insufficient haemoglobin to deliver adequate oxygen to the tissues, this is called anaemia. There is normally a reduction in the haemoglobin concentrations in the mother's blood during pregnancy, and this allows a better blood flow around the womb (uterus) and to the baby. This is sometime called physiological anaemia and needs no treatment. True anaemia, however, can be mild, moderate or severe and can cause weakness, tiredness and dizziness. Severe anaemia makes women at risk of cardiac failure and is very common in low‐income countries Anaemia has many causes including a shortage or iron, folic acid or vitamin B 12 . These are all required for making red cells and are available in a good diet. Iron shortage, however, is the most common cause of anaemia during pregnancy. Iron treatment can be given by mouth (oral), by injection into the muscle (intramuscular) or injection into the vein (intravenous). Blood transfusion or giving something which stimulates the body to produce more red cells (erythropoietin) are also possible treatments. In this review, we identified 23 trials involving 3198 pregnant women. Many of the trials were in low‐income countries and many treatment variations were studied. Oral iron reduced the incidence of anaemia but is known to sometimes cause constipation and nausea. Although the intramuscular and intravenous routes produced better levels of red cells and iron stores than the oral route, no clinical outcomes (such as pre‐eclampsia, preterm births, postpartum haemorrhage) were assessed and there were insufficient data on adverse effects. Intravenous treatment can cause venous thrombosis (blockages in the veins) and intramuscular treatment causes important pain and discolouration at the injection site. It was unclear if women and babies were healthier when women were given iron for mild or moderate anaemia during pregnancy. There were no studies on using blood transfusions. Overall, there was insufficient evidence to say when or how anaemia in pregnancy needs to or should be treated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Reveiz, L; Gyte, GML; Cuervo, LG; Casasbuenas, A", "articleTypes": [], "doi": "10.1002/14651858.CD003094.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "d6b3aac6-0d45-4536-9ea3-8cef13ada30c", "pmid": "", "title": "Nedocromil sodium for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Exercise‐induced bronchoconstriction (EIB) following strenuous physical exertion afflicts many people. It can be the cause of sub‐optimal performance, symptoms such as cough, dyspnea, wheeze and chest tightness, and can lead people to avoid physical activity. Management of EIB focuses on prevention through pharmacotherapy and alternate strategies. Single use, pre‐exercise, beta‐agonists and non‐steroidal antiinflammatory agents are recommended. Objectives Bronchodilator medications have been commonly used to prevent narrowing of airways after exercise, but anti‐inflammatory drugs such as nedocromil sodium have also been used. The objective of this review was to assess the effects of a single dose of nedocromil sodium to prevent exercise‐induced bronchoconstriction. Search methods We searched the Cochrane Airways Group Specialised Regsiter, the Cochrane Central Register of Controlled Trials, Current Contents, review articles, textbooks and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. Searches have been updated to August 2008. Selection criteria Randomised trials comparing a single dose of nedocromil sodium with placebo to prevent exercise‐induced bronchoconstriction in patients with EIB over six years of age. Data collection and analysis Trial quality assessment and data extraction were conducted independently by two reviewers. Study authors were contacted for confirmation of data. No new studies were identified in an update search conducted in August 2008. Main results The combined results from 20 randomised controlled trials involving 280 participants, show that 4 mg, of nedocromil sodium inhaled 15 to 60 minutes prior to exercise significantly reduce the severity and duration of EIB in both adults and children, when compared to placebo. The maximum percentage fall in FEV1 was improved significantly compared to placebo (weighted mean difference 15.5 %; 95% confidence interval:13.2 to 18.1). For the maximum percentage fall in peak expiratory flow rate (PEFR) the improvement was similar: WMD 15.0%, (95% CI 8.3 to 21.6). Nedocromil shortened the time to recover lung normal function from more than 30 minutes with placebo to less than 10 minutes with the drug. It had a greater effect on those patients with more severe exercise‐induced bronchoconstriction (defined as an exercise‐induced fall in lung function > 30% from baseline). There were no significant adverse effects reported with the short term use of nedocromil. A further search conducted in August 2005 did not yield any further studies. Authors' conclusions Nedocromil sodium used before exercise reduces the severity and duration of exercise‐induced bronchoconstriction. This effect appears to be more pronounced in people with severe exercise‐induced bronchoconstriction. Plain language summary Nedocromil sodium for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. The review of trials found that nedocromil sodium (Tilade) inhaled 15 to 60 minutes before exercise may reduce the severity and length of this kind of asthma for both adults and children, particularly those who have severe episodes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Spooner, C; Saunders, LD; Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD001183", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "d6bccffe-fd0b-4b22-84fc-84b35579a754", "pmid": "", "title": "Corticosteroids for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve are implicated in causing Bell's palsy. Corticosteroids have a potent anti‐inflammatory action that should minimise nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Objectives To determine the effectiveness and safety of corticosteroid therapy in people with Bell's palsy. Search methods On 4 March 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS. We reviewed the bibliographies of the randomised trials and contacted known experts in the field to identify additional published or unpublished trials. We also searched clinical trials registries for ongoing trials. Selection criteria Randomised trials and quasi‐randomised trials comparing different routes of administration and dosage schemes of corticosteroid or adrenocorticotrophic hormone therapy versus a control group receiving no therapy considered effective for this condition, unless the same therapy was given in a similar way to the experimental group. Data collection and analysis We used standard Cochrane methodology. The main outcome of interest was incomplete recovery of facial motor function (i.e. residual facial weakness). Secondary outcomes were cosmetically disabling persistent sequelae, development of motor synkinesis or autonomic dysfunction (i.e. hemifacial spasm, crocodile tears) and adverse effects of corticosteroid therapy manifested during follow‐up. Main results We identified seven trials, with 895 evaluable participants for this review. All provided data suitable for the primary outcome meta‐analysis. One of the trials was new since the last version of this Cochrane systematic review. Risk of bias in the older, smaller studies included some unclear‐ or high‐risk assessments, whereas we deemed the larger studies at low risk of bias. Overall, 79/452 (17%) participants allocated to corticosteroids had incomplete recovery of facial motor function six months or more after randomisation; significantly fewer than the 125/447 (28%) in the control group (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.50 to 0.80, seven trials, n = 895). The number of people who need to be treated with corticosteroids to avoid one incomplete recovery was 10 (95% CI 6 to 20). The reduction in the proportion of participants with cosmetically disabling sequelae six months after randomisation was very similar in the corticosteroid and placebo groups (RR 0.96, 95% CI 0.40 to 2.29, two trials, n = 75, low‐quality evidence). However, there was a significant reduction in motor synkinesis during follow‐up in participants receiving corticosteroids (RR 0.64, 95% CI 0.45 to 0.91, three trials, n = 485, moderate‐quality evidence). Three studies explicitly recorded the absence of adverse effects attributable to corticosteroids. One trial reported that three participants receiving prednisolone had temporary sleep disturbances and two trials gave a detailed account of adverse effects occurring in 93 participants, all non‐serious; the combined analysis of data from these three trials found no significant difference in adverse effect rates between people receiving corticosteroids and people receiving placebo (RR 1.04, 95% CI 0.71 to 1.51, n = 715). Authors' conclusions The available moderate‐ to high‐quality evidence from randomised controlled trials showed significant benefit from treating Bell's palsy with corticosteroids. Plain language summary Corticosteroids for Bell's palsy Review question What are the effects of corticosteroids on Bell's palsy? Background Bell's palsy is a paralysis or weakness of muscles in the face, usually on one side, with no certain cause. Symptoms usually recover, although not always. Reducing inflammation of the facial nerve using corticosteroid medicines (steroids) is thought to limit nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Study characteristics We identified seven clinical trials involving 895 people with one‐sided mild, moderate or severe Bell's palsy of unknown cause. All of these trials reported rates of incomplete recovery (the proportion of people left with facial weakness) and we were able to combine the results. People in the studies were aged from 2 to 84 years. They were treated with corticosteroids or placebo (inactive treatment), either alone or in combination with other therapies. One trial only involved children, from 24 months to 74 months old. The duration of the included studies for adults and children ranged from 157 days to 12 months. Key results and quality of the evidence Incomplete recovery According to moderate quality to high quality evidence, corticosteroids reduced the number of people left with facial weakness after Bell's palsy compared to placebo (a pretend medicine). This finding was based on data from seven studies involving 895 participants with Bell's palsy of varying degrees of severity. We calculated that to stop one person from being left with facial weakness, 10 people need to be treated. Five studies provided data on long‐term after‐effects of Bell's palsy following treatment. Two of the studies (75 participants) looked at persistent effects on facial appearance after six months or more. The effect was nearly the same for corticosteroids and placebo, showing that participants who had corticosteroids benefited slightly, although this evidence was low quality. Data from three studies (485 participants) showed clearly that people who received corticosteroids developed less motor synkinesis (unwanted facial movements) and crocodile tears (watery eyes when eating or chewing), compared with people who received placebo alone. This finding was based on moderate‐quality evidence. Side effects Three studies reported that no side effects could be attributed to corticosteroid treatment. Based on moderate‐quality evidence from three studies (715 participants), numbers experiencing side effects were similar with corticosteroids and placebo. The evidence is current to March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Madhok, VB; Gagyor, I; Daly, F; Somasundara, D; Sullivan, M; Gammie, F; Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001942.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "d6e90819-bb50-4760-991a-fa50b5dcf2ab", "pmid": "", "title": "Vitamin C for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Vitamin C (ascorbic acid) for preventing and treating the common cold has been a subject of controversy for 70 years. Objectives To find out whether vitamin C reduces the incidence, the duration or severity of the common cold when used either as a continuous regular supplementation every day or as a therapy at the onset of cold symptoms. Search methods We searched CENTRAL 2012, Issue 11, MEDLINE (1966 to November week 3, 2012), EMBASE (1990 to November 2012), CINAHL (January 2010 to November 2012), LILACS (January 2010 to November 2012) and Web of Science (January 2010 to November 2012). We also searched the U.S. National Institutes of Health trials register and WHO ICTRP on 29 November 2012. Selection criteria We excluded trials which used less than 0.2 g per day of vitamin C and trials without a placebo comparison. We restricted our review to placebo‐controlled trials. Data collection and analysis Two review authors independently extracted data. We assessed 'incidence' of colds during regular supplementation as the proportion of participants experiencing one or more colds during the study period. 'Duration' was the mean number of days of illness of cold episodes. Main results Twenty‐nine trial comparisons involving 11,306 participants contributed to the meta‐analysis on the risk ratio (RR) of developing a cold whilst taking vitamin C regularly over the study period. In the general community trials involving 10,708 participants, the pooled RR was 0.97 (95% confidence interval (CI) 0.94 to 1.00). Five trials involving a total of 598 marathon runners, skiers and soldiers on subarctic exercises yielded a pooled RR of 0.48 (95% CI 0.35 to 0.64). Thirty‐one comparisons examined the effect of regular vitamin C on common cold duration (9745 episodes). In adults the duration of colds was reduced by 8% (3% to 12%) and in children by 14% (7% to 21%). In children, 1 to 2 g/day vitamin C shortened colds by 18%. The severity of colds was also reduced by regular vitamin C administration. Seven comparisons examined the effect of therapeutic vitamin C (3249 episodes). No consistent effect of vitamin C was seen on the duration or severity of colds in the therapeutic trials. The majority of included trials were randomised, double‐blind trials. The exclusion of trials that were either not randomised or not double‐blind had no effect on the conclusions. Authors' conclusions The failure of vitamin C supplementation to reduce the incidence of colds in the general population indicates that routine vitamin C supplementation is not justified, yet vitamin C may be useful for people exposed to brief periods of severe physical exercise. Regular supplementation trials have shown that vitamin C reduces the duration of colds, but this was not replicated in the few therapeutic trials that have been carried out. Nevertheless, given the consistent effect of vitamin C on the duration and severity of colds in the regular supplementation studies, and the low cost and safety, it may be worthwhile for common cold patients to test on an individual basis whether therapeutic vitamin C is beneficial for them. Further therapeutic RCTs are warranted. Plain language summary Vitamin C for preventing and treating the common cold The common cold is a major cause of visits to a doctor in high‐income countries and of absenteeism from work and school. There are over 200 viruses which can cause the common cold symptoms including runny nose, congestion, sneezing, sore throat, cough, and sometimes headache, fever and red eyes. Symptoms vary from person to person and cold to cold. Since the common cold is usually caused by one of the respiratory viruses, antibiotics are useless and therefore other potential treatment options are of substantial public health interest. Vitamin C has been proposed for treating respiratory infections since it was isolated in the 1930s. It became particularly popular in the 1970s when Nobel laureate Linus Pauling concluded from earlier placebo‐controlled trials that vitamin C would prevent and alleviate the common cold. Over two dozen new trials were undertaken thereafter. Vitamin C has been widely sold and used as a preventive and therapeutic agent. This review is restricted to placebo‐controlled trials testing 0.2 g/day or more of vitamin C. Regular ingestion of vitamin C had no effect on common cold incidence in the ordinary population, based on 29 trial comparisons involving 11,306 participants. However, regular supplementation had a modest but consistent effect in reducing the duration of common cold symptoms, which is based on 31 study comparisons with 9745 common cold episodes. In five trials with 598 participants exposed to short periods of extreme physical stress (including marathon runners and skiers) vitamin C halved the common cold risk. The published trials have not reported adverse effects of vitamin C. Trials of high doses of vitamin C administered therapeutically, starting after the onset of symptoms, showed no consistent effect on the duration or severity of common cold symptoms. However, only a few therapeutic trials have been carried out and none have examined children, although the effect of prophylactic vitamin C has been greater in children. One large trial with adults reported benefit from an 8 g therapeutic dose at the onset of symptoms, and two therapeutic trials using five‐day supplementation reported benefit. More trials are necessary to settle the possible role of therapeutic vitamin C, meaning administration immediately after the onset of symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H, Chalker, E", "articleTypes": [], "doi": "10.1002/14651858.CD000980.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.735Z" }, { "id": "d6ee86a4-2d25-4f04-b7a4-6f8b122a033d", "pmid": "", "title": "Corticosteroids for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve are implicated in causing Bell's palsy. Corticosteroids have a potent anti‐inflammatory action that should minimise nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Objectives To determine the effectiveness and safety of corticosteroid therapy in people with Bell's palsy. Search methods On 4 March 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS. We reviewed the bibliographies of the randomised trials and contacted known experts in the field to identify additional published or unpublished trials. We also searched clinical trials registries for ongoing trials. Selection criteria Randomised trials and quasi‐randomised trials comparing different routes of administration and dosage schemes of corticosteroid or adrenocorticotrophic hormone therapy versus a control group receiving no therapy considered effective for this condition, unless the same therapy was given in a similar way to the experimental group. Data collection and analysis We used standard Cochrane methodology. The main outcome of interest was incomplete recovery of facial motor function (i.e. residual facial weakness). Secondary outcomes were cosmetically disabling persistent sequelae, development of motor synkinesis or autonomic dysfunction (i.e. hemifacial spasm, crocodile tears) and adverse effects of corticosteroid therapy manifested during follow‐up. Main results We identified seven trials, with 895 evaluable participants for this review. All provided data suitable for the primary outcome meta‐analysis. One of the trials was new since the last version of this Cochrane systematic review. Risk of bias in the older, smaller studies included some unclear‐ or high‐risk assessments, whereas we deemed the larger studies at low risk of bias. Overall, 79/452 (17%) participants allocated to corticosteroids had incomplete recovery of facial motor function six months or more after randomisation; significantly fewer than the 125/447 (28%) in the control group (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.50 to 0.80, seven trials, n = 895). The number of people who need to be treated with corticosteroids to avoid one incomplete recovery was 10 (95% CI 6 to 20). The reduction in the proportion of participants with cosmetically disabling sequelae six months after randomisation was very similar in the corticosteroid and placebo groups (RR 0.96, 95% CI 0.40 to 2.29, two trials, n = 75, low‐quality evidence). However, there was a significant reduction in motor synkinesis during follow‐up in participants receiving corticosteroids (RR 0.64, 95% CI 0.45 to 0.91, three trials, n = 485, moderate‐quality evidence). Three studies explicitly recorded the absence of adverse effects attributable to corticosteroids. One trial reported that three participants receiving prednisolone had temporary sleep disturbances and two trials gave a detailed account of adverse effects occurring in 93 participants, all non‐serious; the combined analysis of data from these three trials found no significant difference in adverse effect rates between people receiving corticosteroids and people receiving placebo (RR 1.04, 95% CI 0.71 to 1.51, n = 715). Authors' conclusions The available moderate‐ to high‐quality evidence from randomised controlled trials showed significant benefit from treating Bell's palsy with corticosteroids. Plain language summary Corticosteroids for Bell's palsy Review question What are the effects of corticosteroids on Bell's palsy? Background Bell's palsy is a paralysis or weakness of muscles in the face, usually on one side, with no certain cause. Symptoms usually recover, although not always. Reducing inflammation of the facial nerve using corticosteroid medicines (steroids) is thought to limit nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Study characteristics We identified seven clinical trials involving 895 people with one‐sided mild, moderate or severe Bell's palsy of unknown cause. All of these trials reported rates of incomplete recovery (the proportion of people left with facial weakness) and we were able to combine the results. People in the studies were aged from 2 to 84 years. They were treated with corticosteroids or placebo (inactive treatment), either alone or in combination with other therapies. One trial only involved children, from 24 months to 74 months old. The duration of the included studies for adults and children ranged from 157 days to 12 months. Key results and quality of the evidence Incomplete recovery According to moderate quality to high quality evidence, corticosteroids reduced the number of people left with facial weakness after Bell's palsy compared to placebo (a pretend medicine). This finding was based on data from seven studies involving 895 participants with Bell's palsy of varying degrees of severity. We calculated that to stop one person from being left with facial weakness, 10 people need to be treated. Five studies provided data on long‐term after‐effects of Bell's palsy following treatment. Two of the studies (75 participants) looked at persistent effects on facial appearance after six months or more. The effect was nearly the same for corticosteroids and placebo, showing that participants who had corticosteroids benefited slightly, although this evidence was low quality. Data from three studies (485 participants) showed clearly that people who received corticosteroids developed less motor synkinesis (unwanted facial movements) and crocodile tears (watery eyes when eating or chewing), compared with people who received placebo alone. This finding was based on moderate‐quality evidence. Side effects Three studies reported that no side effects could be attributed to corticosteroid treatment. Based on moderate‐quality evidence from three studies (715 participants), numbers experiencing side effects were similar with corticosteroids and placebo. The evidence is current to March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Madhok, VB, Gagyor, I, Daly, F, Somasundara, D, Sullivan, M, Gammie, F, Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001942.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.090Z" }, { "id": "d6f7081a-827c-4680-97de-7a4246ecd6f8", "pmid": "", "title": "Interventions for the prevention of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "Abstract - Background Loss of olfactory function is well recognised as a symptom of COVID‐19 infection, and the pandemic has resulted in a large number of individuals with abnormalities in their sense of smell. For many, the condition is temporary and resolves within two to four weeks. However, in a significant minority the symptoms persist. At present, it is not known whether early intervention with any form of treatment (such as medication or olfactory training) can promote recovery and prevent persisting olfactory disturbance. This is an update of the 2021 review with four studies added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with acute olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance, which had been present for less than four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the presence of normal olfactory function, serious adverse effects and change in sense of smell. Secondary outcomes were the prevalence of parosmia, change in sense of taste, disease‐related quality of life and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included five studies with 691 participants. The studies evaluated the following interventions: intranasal corticosteroid sprays, intranasal corticosteroid drops, intranasal hypertonic saline and zinc sulphate. Intranasal corticosteroid spray compared to no intervention/placebo We included three studies with 288 participants who had olfactory dysfunction for less than four weeks following COVID‐19. Presence of normal olfactory function The evidence is very uncertain about the effect of intranasal corticosteroid spray on both self‐rated recovery of olfactory function and recovery of olfactory function using psychophysical tests at up to four weeks follow‐up ( self‐rated : risk ratio (RR) 1.19, 95% confidence interval (CI) 0.85 to 1.68; 1 study; 100 participants; psychophysical testing : RR 2.3, 95% CI 1.16 to 4.63; 1 study; 77 participants; very low‐certainty evidence). Change in sense of smell The evidence is also very uncertain about the effect of intranasal corticosteroid spray on self‐rated change in the sense of smell ( at less than 4 weeks : mean difference (MD) 0.5 points lower, 95% CI 1.38 lower to 0.38 higher; 1 study; 77 participants; at > 4 weeks to 3 months : MD 2.4 points higher, 95% CI 1.32 higher to 3.48 higher; 1 study; 100 participants; very low‐certainty evidence, rated on a scale of 1 to 10, higher scores mean better olfactory function). Intranasal corticosteroids may make little or no difference to the change in sense of smell when assessed with psychophysical testing (MD 0.2 points, 95% CI 2.06 points lower to 2.06 points higher; 1 study; 77 participants; low‐certainty evidence, 0‐ to 24‐point scale, higher scores mean better olfactory function). Serious adverse effects The authors of one study reported no adverse effects, but their intention to collect these data was not pre‐specified so we are uncertain if these were systematically sought and identified. The remaining two studies did not report on adverse effects. Intranasal corticosteroid drops compared to no intervention/placebo We included one study with 248 participants who had olfactory dysfunction for ≤ 15 days following COVID‐19. Presence of normal olfactory function Intranasal corticosteroid drops may make little or no difference to self‐rated recovery at > 4 weeks to 3 months (RR 1.00, 95% CI 0.89 to 1.11; 1 study; 248 participants; low‐certainty evidence). No other outcomes were assessed by this study. Data on the use of hypertonic saline nasal irrigation and the use of zinc sulphate to prevent persistent olfactory dysfunction are included in the full text of the review. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for preventing persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the prevention of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important COVID‐19 has been found to cause problems with the sense of smell. Sometimes this is a reduction in the ability to smell things, and sometimes it is a complete loss of the sense of smell. For many people this recovers in a short time, but for others it may last for weeks or months. This review considers whether there are treatments that people might take as soon as they have lost their sense of smell (within four weeks of the symptoms starting), to try and stop this becoming a long‐standing problem. How we identified and assessed the evidence We searched for all relevant studies in the medical literature to summarise the results. We also looked at how certain the evidence was, considering things like the size of the studies and how they were carried out. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found five studies that had been completed. Intranasal corticosteroids compared to no treatment Three studies looked at this treatment. Nasal corticosteroid spray might make little or no difference to the sense of smell when measured with specific tests (rather than when asking people about their sense of smell). The rest of the evidence was of very low certainty, so we do not know whether a nasal corticosteroid spray is better or worse than no treatment at: ‐ helping the sense of smell get back to normal (either people feeling that their sense of smell is back to normal, or having a normal sense of smell according to specific tests); ‐ making people feel that their sense of smell has improved; ‐ causing any unwanted side effects. Intranasal corticosteroid drops compared to placebo (dummy treatment) One study looked at this treatment. Intranasal corticosteroid drops might not make any difference to the number of people who think their sense of smell has recovered at 30 days. We did find a number of other studies that are being carried out, but no results from these studies were available yet to be included in this review. What this means We do not know whether using a nasal corticosteroid spray or nasal drops has any benefit in preventing longer‐term loss of the sense of smell that is related to COVID‐19, or whether they may cause any harm. This review is a 'living systematic review' ‐ meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Webster, KE, O'Byrne, L, MacKeith, S, Philpott, C, Hopkins, C, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013877.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.747Z" }, { "id": "d6f95a41-3566-46b6-9354-ff71211dce3b", "pmid": "", "title": "Advice to reduce dietary salt for prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Restricting sodium intake in hypertensive patients over short periods of time reduces blood pressure. Long term effects (on mortality, morbidity or blood pressure) of advice to reduce salt in patients with elevated or normal blood pressure are unclear. Objectives To assess in adults the long term effects (mortality, cardiovascular events, blood pressure, quality of life, weight, urinary sodium excretion, other nutrients and use of anti‐hypertensive medications) of advice to restrict dietary sodium using all relevant randomised controlled trials. Search methods The Cochrane Library, MEDLINE, EMBASE, bibliographies of included studies and related systematic reviews were searched for unconfounded randomised trials in healthy adults aiming to reduce sodium intake over at least 6 months. Attempts were made to trace unpublished or missed studies and authors of all included trials were contacted. There were no language restrictions. Selection criteria Inclusion decisions were independently duplicated and based on the following criteria: 1) randomisation was adequate; 2) there was a usual or control diet group; 3) the intervention aimed to reduce sodium intake; 4) the intervention was not multifactorial; 5) the participants were not children, acutely ill, pregnant or institutionalised; 6) follow‐up was at least 26 weeks; 7) data on any of the outcomes of interest were available. Data collection and analysis Decisions on validity and data extraction were made independently by two reviewers, disagreements were resolved by discussion or if necessary by a third reviewer. Random effects meta‐analysis, sub‐grouping, sensitivity analysis and meta‐regression were performed. Main results Three trials in normotensives (n=2326), five in untreated hypertensives (n=387) and three in treated hypertensives (n=801) were included, with follow up from six months to seven years. The large, high quality (and therefore most informative) studies used intensive behavioural interventions. Deaths and cardiovascular events were inconsistently defined and reported; only 17 deaths equally distributed between intervention and control groups occurred. Systolic and diastolic blood pressures were reduced at 13 to 60 months in those given low sodium advice as compared with controls (systolic by 1.1 mm Hg, 95% CI 1.8 to 0.4, diastolic by 0.6 mm hg, 95% CI 1.5 to ‐0.3), as was urinary 24 hour sodium excretion (by 35.5 mmol/ 24 hours, 95% CI 47.2 to 23.9). Degree of reduction in sodium intake and change in blood pressure were not related. People on anti‐hypertensive medications were able to stop their medication more often on a reduced sodium diet as compared with controls, while maintaining similar blood pressure control. Authors' conclusions Intensive interventions, unsuited to primary care or population prevention programmes, provide only minimal reductions in blood pressure during long‐term trials. Further evaluations to assess effects on morbidity and mortality outcomes are needed for populations as a whole and for patients with elevated blood pressure. A low sodium diet may help in maintenance of lower blood pressure following withdrawal of antihypertensives. If this is confirmed, with no increase in cardiovascular events, then targeting of comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. Plain language summary The long term effects of advice to cut down on salt in food on deaths, cardiovascular disease and blood pressure in adults Intensive support and encouragement to reduce salt intake did lead to reduction in salt eaten. It also lowered blood pressure but only by a small amount (about 1 mmHg for systolic blood pressure, less for diastolic) after more than a year. This reduction was not enough to expect an important health benefit. It was also very hard to keep to a low salt diet. However, the reduction in blood pressure appeared larger for people with higher blood pressure. There was not enough information to assess the effect of these changes in salt intake on health or deaths. Evidence from a large and small trial showed that advice to reduce salt helps to maintain lower blood pressure following withdrawal of antihypertensive medication. If this is confirmed, with no increase in cardiovascular events, then comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. See also the Cochrane review of short‐term salt reduction trials: Jurgens 2003 .", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Hooper, L; Bartlett, C; Davey Smith, G; Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD003656.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "d77483ce-ff5d-470d-9a5f-1383aae78213", "pmid": "", "title": "Oral immunotherapy for milk allergy", "imported": false, "abstract": "Abstract - Background The mainstay of treatment of IgE‐mediated cow milk allergy (IMCMA) is an avoidance diet, which is especially difficult with a ubiquitous food like milk. Milk oral immunotherapy (MOIT) may be an alternative treatment, through desensitization or induction of tolerance. Objectives We aim to assess the clinical efficacy and safety of MOIT in children and adults with IMCMA as compared to a placebo treatment or avoidance strategy. Search methods We searched 13 databases for journal articles, conference proceedings, theses and unpublished trials, without language or date restrictions, using a combination of subject headings and text words. The search is up‐to‐date as of October 1, 2012. Selection criteria Only randomised controlled trials (RCT) were considered for inclusion. Blinded and open trial designs were included. Children and adults with IMCMA were included. MOIT administered by any protocol were included. Data collection and analysis A total of 2111 unique records were identified and screened for potential inclusion. Studies were selected, data extracted and methodological quality assessed independently by two reviewers. We attempted to contact the study investigators to inquire about data not published that was required for the analysis. Statistical heterogeneity was assessed using the I² test. We estimated a pooled risk ratio (RR) for each outcome using a Mantel‐Haenzel fixed‐effect model if statistical heterogeneity was low as evaluated by an I² value less than 50%. Main results Of 157 records reviewed, 16 were included, representing five trials. In general, the studies were small and had inconsistent methodological rigor. Overall, the quality of evidence was rated as low. Each study used a different MOIT protocol. A total of 196 patients were studied (106 MOIT, 90 control) and all were children. Three studies were blinded and two used an avoidance diet control. Sixty‐six patients (62%) in the MOIT group were able to tolerate a full serving of milk (about 200 mL) compared to seven (8%) of the control group (RR 6.61, 95% CI 3.51 to 12.44). In addition, 27 (25%) in the MOIT group could ingest a partial serving of milk (10 to 184 mL) while none could in the control group (RR 9.34, 95% CI 2.72 to 32.09). None of the studies assessed the patients following a period off immunotherapy. Adverse reactions were common (97 of 106 MOIT patients had at least one symptom), although most were local and mild. Because of variability in reporting methods, adverse effects could not be combined quantitatively. For every 11 patients receiving MOIT, one required intramuscular epinephrine. One patient required it on two occasions. Authors' conclusions Studies to date have involved small numbers of patients and the quality of evidence is generally low. The current evidence shows that MOIT can lead to desensitization in the majority of individuals with IMCMA although the development of long‐term tolerance has not been established. A major drawback of MOIT is the frequency of adverse effects, although most are mild and self‐limited. The use of parenteral epinephrine is not infrequent. Because there are no standardized protocols, guidelines would be required prior to incorporating desensitization into clinical practice. Plain language summary Repetitive, increasing doses of daily milk for treatment of milk allergy To date, the only option to treat food allergy is strict avoidance of the food and carrying an epinephrine injector (Epipen/Twinject) in case of an allergic reaction. For a food like cow's milk, avoidance is very difficult because it is found in many foods. The constant fear of accidentally eating or drinking cow's milk and anxiety related to carrying an injector has negative effects on quality of life. Accidentally having milk can cause life‐threatening reactions. Oral immunotherapy involves initially taking a very small amount of the allergen, in the case of milk allergy, cow's milk, and slowly increasing the amount each day until a full serving is reached. This may change the way the body's immune system sees the allergen, thereby increasing the amount of milk that can be eaten or drunk with no reaction. We identified randomized controlled trials that compared oral immunotherapy to placebo or continued avoidance diet in children and adults with cow's milk allergy. Five studies satisfied our inclusion criteria. In total there were 196 participants (106 in the treatment group and 90 in the control), all of whom were children. In general, the quality of the studies was low. Because the trials involved small numbers and there were problems with the way they were done, further research is needed. The current evidence shows that oral immunotherapy can help a majority of allergic children tolerate a full serving of milk, as long as they continue drinking this amount each day. However, it is not known if this protection is continued if the immunotherapy is stopped for some time. Side effects during oral immunotherapy are frequent and most patients will have at least some mild symptoms. In the studies we included, for every 11 patients who received oral immunotherapy, one needed to be treated with epinephrine injection at some point for a serious allergic reaction to the therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Yeung, JP, Kloda, LA, McDevitt, J, Ben‐Shoshan, M, Alizadehfar, R", "articleTypes": [], "doi": "10.1002/14651858.CD009542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.753Z" }, { "id": "d78f4af0-38a7-486a-a76e-7dd6e3ec1139", "pmid": "", "title": "Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Chronic obstructive pulmonary disease (COPD) is a chronic lung condition characterised by persistent respiratory symptoms and limited lung airflow, dyspnoea and recurrent exacerbations. Suboptimal therapy or non‐adherence may result in limited effectiveness of pharmacological treatments and subsequently poor health outcomes. Objectives To determine the efficacy and safety of interventions intended to improve adherence to single or combined pharmacological treatments compared with usual care or interventions that are not intended to improve adherence in people with COPD. Search methods We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register, CENTRAL, MEDLINE and Embase (search date 1 May 2020). We also searched web‐based clinical trial registers. Selection criteria RCTs included adults with COPD diagnosed by established criteria (e.g. Global Initiative for Obstructive Lung Disease). Interventions included change to pharmacological treatment regimens, adherence aids, education, behavioural or psychological interventions (e.g. cognitive behavioural therapy), communication or follow‐up by a health professional (e.g. telephone, text message or face‐to‐face), multi‐component interventions, and interventions to improve inhaler technique. Data collection and analysis We used standard Cochrane methodological procedures. Working in pairs, four review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We assessed confidence in the evidence for each primary outcome using GRADE. Primary outcomes were adherence, quality of life and hospital service utilisation. Adherence measures included the Adherence among Patients with Chronic Disease questionnaire (APCD). Quality of life measures included the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). Main results We included 14 trials (2191 participants) in the analysis with follow‐up ranging from six to 52 weeks. Age ranged from 54 to 75 years, and COPD severity ranged from mild to very severe. Trials were conducted in the USA, Spain, Germany, Japan, Jordan, Northern Ireland, Iran, South Korea, China and Belgium. Risk of bias was high due to lack of blinding. Evidence certainty was downgraded due to imprecision and small participant numbers. Single component interventions Six studies (55 to 212 participants) reported single component interventions including changes to pharmacological treatment (different roflumilast doses or different inhaler types), adherence aids (Bluetooth inhaler reminder device), educational (comprehensive verbal instruction), behavioural or psychological (motivational interview). Change in dose of roflumilast may result in little to no difference in adherence (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.22 to 1.99; studies = 1, participants = 55; low certainty). A Bluetooth inhaler reminder device did not improve adherence, but comprehensive verbal instruction from a health professional did improve mean adherence (prescription refills) (mean difference (MD) 1.00, 95% CI 0.46 to 1.54). Motivational interview improved mean adherence scores on the APCD scale (MD 22.22, 95% CI 8.42 to 36.02). Use of a single inhaler compared to two separate inhalers may have little to no impact on quality of life (SGRQ; MD 0.80, 95% CI –3.12 to 4.72; very low certainty). A Bluetooth inhaler monitoring device may provide a small improvement in quality of life on the CCQ (MD 0.40, 95% CI 0.07 to 0.73; very low certainty). Single inhaler use may have little to no impact on the number of people admitted to hospital compared to two separate inhalers (OR 1.47, 95% CI 0.75 to 2.90; very low certainty). Single component interventions may have little to no impact on the number of people expereincing adverse events (very low certainty evidence from studies of a change in pharmacotherapy or use of adherence aids). A change in pharmacotherapy may have little to no impact on exacerbations or deaths (very low certainty). Multi‐component interventions Eight studies (30 to 734 participants) reported multi‐component interventions including tailored care package that included adherence support as a key component or included inhaler technique as a component. A multi‐component intervention may result in more people adhering to pharmacotherapy compared to control at 40.5 weeks (risk ratio (RR) 1.37, 95% CI 1.18 to 1.59; studies = 4, participants = 446; I 2 = 0%; low certainty). There may be little to no impact on quality of life (SGRQ, Chronic Respiratory Disease Questionnaire, CAT) (studies = 3; low to very low certainty). Multi‐component interventions may help to reduce the number of people admitted to hospital for any cause (OR 0.37, 95% CI 0.22 to 0.63; studies = 2, participants = 877; low certainty), or COPD‐related hospitalisations (OR 0.15, 95% CI 0.07 to 0.34; studies = 2, participants = 220; moderate certainty). There may be a small benefit on people experiencing severe exacerbations. There may be little to no effect on adverse events, serious adverse events or deaths, but events were infrequently reported and were rare (low to very low certainty). Authors' conclusions Single component interventions (e.g. education or motivational interviewing provided by a health professional) can help to improve adherence to pharmacotherapy (low to very low certainty). There were slight improvements in quality of life with a Bluetooth inhaler device, but evidence is from one study and very low certainty. Change to pharmacotherapy (e.g. single inhaler instead of two, or different doses of roflumilast) has little impact on hospitalisations or exacerbations (very low certainty). There is no difference in people experiencing adverse events (all‐cause or COPD‐related), or deaths (very low certainty). Multi‐component interventions may improve adherence with education, motivational or behavioural components delivered by health professionals (low certainty). There is little to no impact on quality of life (low to very low certainty). They may help reduce the number of people admitted to hospital overall (specifically pharmacist‐led approaches) (low certainty), and fewer people may have COPD‐related hospital admissions (moderately certainty). There may be a small reduction in people experiencing severe exacerbations, but evidence is from one study (low certainty). Limited evidence found no difference in people experiencing adverse events, serious adverse events or deaths (low to very low certainty). The evidence presented should be interpreted with caution. Larger studies with more intervention types, especially single interventions, are needed. It is unclear which specific COPD subgroups would benefit, therefore discussions between health professionals and patients may help to determine whether they will help to improve health outcomes. Plain language summary Which approaches help people with COPD to maintain taking medication as prescribed? Review question Which approaches help people maintain taking prescribed medication(s), improve quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD)? Background COPD is a lung condition that can cause long‐term breathing problems and includes symptoms such as shortness of breath. Medications do exist that can help but sometimes people do not take them as prescribed. Different approaches could help people to take their medication as prescribed and help improve symptoms or quality of life and reduce hospital admissions. We wanted to find out if any approaches could help people with COPD take their medication(s) as prescribed. Studies identified and selected We searched databases to find the studies. Four people working in pairs looked at the lists of studies separately and agreed on which ones were included. The latest search for studies was conducted in May 2020. Study characteristics We included studies comparing simple ways to help improve medication use (e.g. different medication doses or single inhalers instead of two separate inhalers) to usual COPD care. We also included studies that tested combination approaches (e.g. information or training from nurses or pharmacists and monitoring medication use). What were the key results? We included 14 studies (2191 people) in our analysis. No studies were masked (people knew whether they were receiving an approach to help them with adherence or the alternative). Six studies used simple approaches (e.g. change to medication dosage, change to type of inhaler, or a Bluetooth inhaler reminder device), and eight studies used combined approaches (e.g. nurses or pharmacists giving advice or information about how to improve medication use). We were uncertain about the effects of a different medication dose on people adhering to medication because it was no different to usual care (one study). Two separate studies found that a Bluetooth inhaler reminder device or a change in oral medication dose did not help to improve adherence. Health professionals involved in giving information may help to improve adherence (one study). This was measured by prescription refills. Motivating people to change their behaviour could help to improve adherence their medication (one study). This was measured by people completing a questionnaire about adherence to their medication. One study found that a Bluetooth inhaler device might help to improve quality of life. There may be little to no difference between those using single inhalers in the number of people admitted to hospital compared to those using two separate inhalers (one study). We found no difference between single approaches and usual care on the number of people who had side effects. Combined approaches may help to improve the number of people taking their medication, but we were not confident of this finding (four studies). They may have little to no impact on quality of life (three studies). Combined approaches could be beneficial in reducing the number of people with COPD admitted to hospital for any reason or because of COPD symptoms (two studies). There was no difference between combined approaches and in the number of people who had adverse events. Take home message We could not say for certain that simple approaches are useful to help people with COPD to improve medication use because of very limited information. Combined approaches may help people to take their medication(s) as prescribed and can help to reduce the number of people admitted to hospital, however, more information is needed to help answer this question with confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Janjua, S, Pike, KC, Carr, R, Coles, A, Fortescue, R, Batavia, M", "articleTypes": [], "doi": "10.1002/14651858.CD013381.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.119Z" }, { "id": "d795a348-7c75-4226-bf48-9a0e47e9ff4b", "pmid": "", "title": "Honey for acute cough in children", "imported": false, "abstract": "Abstract - Background Cough causes concern for parents and is a major cause of outpatient visits. Cough can impact quality of life, cause anxiety, and affect sleep in children and their parents. Honey has been used to alleviate cough symptoms. This is an update of reviews previously published in 2014, 2012, and 2010. Objectives To evaluate the effectiveness of honey for acute cough in children in ambulatory settings. Search methods We searched CENTRAL (2018, Issue 2), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (2014 to 8 February 2018), Embase (2014 to 8 February 2018), CINAHL (2014 to 8 February 2018), EBSCO (2014 to 8 February 2018), Web of Science (2014 to 8 February 2018), and LILACS (2014 to 8 February 2018). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trial Registry Platform (WHO ICTRP) on 12 February 2018. The 2014 review included searches of AMED and CAB Abstracts, but these were not searched for this update due to lack of institutional access. Selection criteria Randomised controlled trials comparing honey alone, or in combination with antibiotics, versus no treatment, placebo, honey‐based cough syrup, or other over‐the‐counter cough medications for children aged 12 months to 18 years for acute cough in ambulatory settings. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included six randomised controlled trials involving 899 children; we added three studies (331 children) in this update. We assessed two studies as at high risk of performance and detection bias; three studies as at unclear risk of attrition bias; and three studies as at unclear risk of other bias. Studies compared honey with dextromethorphan, diphenhydramine, salbutamol, bromelin (an enzyme from the Bromeliaceae (pineapple) family), no treatment, and placebo. Five studies used 7‐point Likert scales to measure symptomatic relief of cough; one used an unclear 5‐point scale. In all studies, low score indicated better cough symptom relief. Using a 7‐point Likert scale, honey probably reduces cough frequency better than no treatment or placebo (no treatment: mean difference (MD) ‐1.05, 95% confidence interval (CI) ‐1.48 to ‐0.62; I² = 0%; 2 studies; 154 children; moderate‐certainty evidence; placebo: MD ‐1.62, 95% CI ‐3.02 to ‐0.22; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Honey may have a similar effect as dextromethorphan in reducing cough frequency (MD ‐0.07, 95% CI ‐1.07 to 0.94; I² = 87%; 2 studies; 149 children; low‐certainty evidence). Honey may be better than diphenhydramine in reducing cough frequency (MD ‐0.57, 95% CI ‐0.90 to ‐0.24; 1 study; 80 children; low‐certainty evidence). Giving honey for up to three days is probably more effective in relieving cough symptoms compared with placebo or salbutamol. Beyond three days honey probably had no advantage over salbutamol or placebo in reducing cough severity, bothersome cough, and impact of cough on sleep for parents and children (moderate‐certainty evidence). With a 5‐point cough scale, there was probably little or no difference between the effects of honey and bromelin mixed with honey in reducing cough frequency and severity. Adverse events included nervousness, insomnia, and hyperactivity, experienced by seven children (9.3%) treated with honey and two children (2.7%) treated with dextromethorphan (risk ratio (RR) 2.94, 95% Cl 0.74 to 11.71; I² = 0%; 2 studies; 149 children; low‐certainty evidence). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14, 95% Cl 0.01 to 2.68; 1 study; 80 children; low‐certainty evidence). When honey was compared with placebo, 34 children (12%) in the honey group and 13 (11%) in the placebo group complained of gastrointestinal symptoms (RR 1.91, 95% CI 1.12 to 3.24; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Four children who received salbutamol had rashes compared to one child in the honey group (RR 0.19, 95% CI 0.02 to 1.63; 1 study; 100 children; moderate‐certainty evidence). No adverse events were reported in the no‐treatment group. Authors' conclusions Honey probably relieves cough symptoms to a greater extent than no treatment, diphenhydramine, and placebo, but may make little or no difference compared to dextromethorphan. Honey probably reduces cough duration better than placebo and salbutamol. There was no strong evidence for or against using honey. Most of the children received treatment for one night, which is a limitation to the results of this review. There was no difference in occurrence of adverse events between the honey and control arms. Plain language summary Honey for acute cough in children Review question Can honey reduce cough symptoms caused by bacteria and viruses in children? Background Cough causes concern for parents and is a major reason for outpatient visits. Honey is believed to prevent growth of germs and reduce inflammation. Search date We searched databases to 8 February 2018 and trial registers to 12 February 2018. Study characteristics We included six small trials involving 899 children aged 12 months to 18 years conducted in Iran, Israel, the USA, Brazil, and Kenya. This update included three new trials conducted between 2007 and 2016 that involved 331 children. Study funding sources Two studies were supported by pharmaceutical manufacturers; one by a university research centre; one by the Honey Board of Israel and non‐government agencies; and one by USA National Honey Board. One study did not report funding sources. Key results We compared honey to over‐the‐counter cough preparations, bromelin (a pineapple enzyme) mixed with honey, fake treatment (placebo), and no treatment. Honey probably reduces cough symptoms more than placebo and salbutamol (a drug that opens lung airways) when given for up to three days. Honey is probably more effective at providing cough relief and reducing the impact of cough on children's sleep at night than no treatment. There may be little or no difference between the effects of honey and dextromethorphan (an ingredient in over‐the‐counter cough remedies) or honey and bromelin with honey on all cough symptoms. Honey may be better than diphenhydramine (an antihistamine) at relieving and reducing children's cough. The parents of seven children given honey and two given dextromethorphan reported side effects in their children, such as not falling asleep easily, restlessness, and becoming overexcited. The parents of three children in the diphenhydramine group reported that their children were often sleepy. The parents of nine children given salbutamol, seven given honey, and six given placebo reported diarrhoea. The parents of four children who received salbutamol and one child given honey reported rash. We found no evidence for or against the use of honey to relieve cough in children. Using honey for infants aged up to 12 months is not advised because of poor immunity against bacteria that may be present, which can cause paralysis. Most of the children received honey for just one night, which is a limitation to the results of this review. Quality of the evidence Overall, evidence quality was low to moderate. Some studies did not blind participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Oduwole, O, Udoh, EE, Oyo‐Ita, A, Meremikwu, MM", "articleTypes": [], "doi": "10.1002/14651858.CD007094.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.780Z" }, { "id": "d7b69503-8659-47ac-94d5-f0f0292f1cb9", "pmid": "", "title": "Interventions for reducing inflammation in familial Mediterranean fever", "imported": false, "abstract": "Abstract - Background Familial Mediterranean fever (FMF), a hereditary auto‐inflammatory disease, mainly affects ethnic groups living in the Mediterranean region. Early studies reported colchicine may potentially prevent FMF attacks. For people who are colchicine‐resistant or intolerant, drugs such as anakinra, rilonacept, canakinumab, etanercept, infliximab or adalimumab might be beneficial. This is an update of the review last published in 2018. Objectives To evaluate the efficacy and safety of interventions for reducing inflammation in people with FMF. Search methods We searched CENTRAL, MEDLINE, Embase and four Chinese databases on in August 2021. We searched clinical trials registries and references listed in relevant reports. The last search was 17 August 2021. Selection criteria We included randomized controlled trials (RCTs) of people with FMF, comparing active interventions (including colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (herbal dietary supplement)) with placebo or no treatment, or comparing active drugs to each other. Data collection and analysis We used standard Cochrane methodology. We assessed certainty of the evidence using GRADE. Main results We included 10 RCTs with 312 participants (aged three to 53 years), including five parallel and five cross‐over designed studies. Six studies used oral colchicine, one used oral ImmunoGuard, and the remaining three used rilonacept, anakinra or canakinumab as a subcutaneous injection. The duration of each study arm ranged from one to eight months. There were inadequacies in the design of the four older colchicine studies and the two studies comparing a single to a divided dose of colchicine. However, the four studies of ImmunoGuard, rilonacept, anakinra and canakinumab were generally well‐designed. We aimed to report on the number of participants experiencing an attack, the timing of attacks, the prevention of amyloid A amyloidosis, adverse drug reactions and the response of a number of biochemical markers from the acute phase of an attack; but no study reported on the prevention of amyloid A amyloidosis. Colchicine (oral) versus placebo After three months, colchicine 0.6 mg three times daily may reduce the number of people experiencing attacks (risk ratio (RR) 0.21, 95% confidence interval (CI) 0.05 to 0.95; 1 study, 10 participants; low‐certainty evidence). One study (20 participants) of colchicine 0.5 mg twice daily showed there may be no difference in the number of participants experiencing attacks at two months (RR 0.78, 95% CI 0.49 to 1.23; low‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; very low‐certainty evidence), or in the number of days between attacks: (narrative summary; very low‐certainty evidence). Regarding adverse drug reactions, one study reported loose stools and frequent bowel movements and a second reported diarrhea (narrative summary; both very low‐certainty evidence). There were no data on acute‐phase response. Rilonacept versus placebo There is probably no difference in the number of people experiencing attacks at three months (RR 0.87, 95% CI 0.59 to 1.26; moderate‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; low‐certainty evidence) or in the number of days between attacks (narrative summary; low‐certainty evidence). Regarding adverse drug reactions, the rilonacept study reported there may be no differences in gastrointestinal symptoms, hypertension, headache, respiratory tract infections, injection site reactions and herpes, compared to placebo (narrative summary; low‐certainty evidence). The study narratively reported there may be no differences in acute‐phase response indicators after three months (low‐certainty evidence). ImmunoGuard versus placebo The ImmunoGuard study observed there are probably no differences in adverse effects (moderate‐certainty evidence) or in acute‐phase response indicators after one month of treatment (moderate‐certainty evidence). No data were reported for the number of people experiencing an attack, duration of attacks or days between attacks. Anakinra versus placebo A study of anakinra given to 25 colchicine‐resistant participants found there is probably no difference in the number of participants experiencing an attack at four months (RR 0.76, 95% CI 0.54 to 1.07; moderate‐certainty evidence). There were no data for duration of attacks or days between attacks. There are probably no differences between anakinra and placebo with regards to injection site reaction, headache, presyncope, dyspnea and itching (narrative summary; moderate‐certainty evidence). For acute‐phase response, anakinra probably reduced C‐reactive protein (CRP) after four months (narrative summary; moderate‐certainty evidence). Canakinumab versus placebo Canakinumab probably reduces the number of participants experiencing an attack at 16 weeks (RR 0.41, 95% CI 0.26 to 0.65; 1 study, 63 colchicine‐resistant participants; moderate‐certainty evidence). There were no data for the duration of attacks or days between attacks. The included study reported the number of serious adverse events per 100 patient‐years was probably 42.7 with canakinumab versus 97.4 with placebo among people with colchicine‐resistant FMF (moderate‐certainty evidence). For acute‐phase response, canakinumab probably caused a higher proportion of participants to have a CRP level of 10 mg/L or less compared to placebo (68% with canakinumab versus 6% with placebo; 1 study, 63 participants; moderate‐certainty evidence). Colchicine single dose versus divided dose There is probably no difference in the duration of attacks at three months (MD −0.04 hours, 95% CI −10.91 to 10.83) or six months (MD 2.80 hours, 95% CI −5.39 to 10.99; moderate‐certainty evidence). There were no data for the number of participants experiencing an attack or days between attacks. There is probably no difference in adverse events (including anorexia, nausea, diarrhea, abdominal pain, vomiting and elevated liver enzymes) between groups (narrative summary; moderate‐certainty evidence). For acute‐phase response, there may be no evidence of a difference between groups (narrative summary; low‐ to moderate‐certainty evidence). Authors' conclusions There were limited RCTs assessing interventions for people with FMF. Based on the evidence, three times daily colchicine may reduce the number of people experiencing attacks, colchicine single dose and divided dose may not be different for children with FMF, canakinumab probably reduces the number of people experiencing attacks, and anakinra or canakinumab probably reduce CRP in colchicine‐resistant participants; however, only a few RCTs contributed data for analysis. Further RCTs examining active interventions, not only colchicine, are necessary before a comprehensive conclusion regarding the efficacy and safety of interventions for reducing inflammation in FMF can be drawn. Plain language summary Medicines for reducing inflammation in people with familial Mediterranean fever Review question Can treatments such as colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (a herbal supplement)) reduce inflammation in people with familial Mediterranean fever (FMF)? Background FMF is a hereditary inflammatory disease, with symptoms of an attack often including fever over 38 °C, pain and inflammation of the membrane surrounding the chest cavity, the joints or the lungs. We wanted to discover whether these medicines were better for reducing inflammation for people with FMF than placebo (a dummy treatment containing no active medicine) or no treatment, and also to compare these medicines with each other. Search date The evidence is current to 17 August 2021. Study characteristics The review included 10 studies with 312 people with FMF aged between three and 53 years. Eight studies compared five medicines, colchicine, rilonacept, ImmunoGuard, anakinra and canakinumab, with placebo. Participants received one medicine or placebo at random over one to four months. The remaining two studies compared colchicine 1 mg per day once daily with colchicine two or three times daily in children for six to eight months. Key results We aimed to report on the number of participants experiencing an attack, the timing of attacks, prevention of amyloid A amyloidosis (which is a reaction to a chronic inflammatory disease or infection leading to a build‐up of an abnormal protein called amyloid in organs and tissues throughout the body stopping them working properly), and any side effects of treatment and the levels of a number of markers of inflammation during an attack. Not all studies reported these outcomes. Given the differences in treatments and study design, it was not possible to combine any of the results that we did obtain from these studies. One study (15 participants) with oral colchicine 0.6 mg three times a day and another study (63 participants) with subcutaneous (under the skin) canakinumab 150 mg every four weeks for 16 weeks may help to reduce the numbers of people with attacks of FMF. However, oral colchicine 0.5 mg twice a day (20 participants), rilonacept (14 participants) or anakinra (25 participants) did not reduce the numbers of people with attacks. ImmunoGuard (24 participants) did not reduce levels of the markers of inflammation in the blood which are raised during the attack phase of FMF; these include the rate of fall of red blood cells when placed in a test tube, the white blood cell count and the presence of C‐reactive protein (a protein that is produced in the liver). Anakinra and canakinumab reduced C‐reactive protein levels. Colchicine taken once daily and two or three times daily might not result in different outcomes including the timing of attacks, sider effects of the medicine and acute‐phase response indicators. Quality of the evidence Four studies were well‐designed, while the others had some design problems that might have affected the results. Four studies did not report clearly how the people were assigned to each treatment group. Four studies did not report whether researchers, who assessed the study outcomes, knew which individuals were assigned to which treatment. Four studies did not clearly explain the reasons for people withdrawing from a study and one study had a high percentage of participants who did not complete study. We could not confirm whether each planned outcome was reported in five studies. Five studies did not report the severity of FMF in groups at the beginning of treatment. We judged the evidence for the reported outcomes to be of moderate to very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Yin, X; Tian, F; Wu, B; Xu, T", "articleTypes": [], "doi": "10.1002/14651858.CD010893.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "d7ef818a-7f51-46c4-9e71-8610539da417", "pmid": "", "title": "Omega‐3 fatty acid supplementation for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Studies suggest that a diet rich in omega‐3 essential fatty acids may have beneficial anti‐inflammatory effects for chronic conditions such as cystic fibrosis. This is an updated version of a previously published review. Objectives To determine whether there is evidence that omega‐3 polyunsaturated fatty acid supplementation reduces morbidity and mortality and to identify any adverse events associated with supplementation. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of last search: 01 April 2020. We also searched online study registries and contacted authors. Date of last search: 12 February 2020. Selection criteria Randomised controlled trials in people with cystic fibrosis comparing omega‐3 fatty acid supplements with placebo. Data collection and analysis Two authors independently selected studies for inclusion, extracted data and assessed the risk of bias of the studies. The quality of the evidence was assessed using GRADE. Main results The searches identified 23 studies; five studies with 106 participants (children and adults) were included; duration of studies and interventions differed. Two studies compared omega‐3 fatty acids to olive oil for six weeks; one study compared omega‐3 fatty acids and omega‐6 fatty acids to control capsules (customised fatty acid blends) for three months; one study compared a liquid dietary supplement containing omega‐3 fatty acids to one without for six months; and one study compared omega‐3 fatty acids to a placebo for 12 months. Three studies had a low risk of bias for randomisation, but the risk was unclear in the remaining two studies; all studies had an unclear risk of bias for allocation concealment. Three of the studies adequately blinded participants; the risk of bias for selective reporting was high in one study and unclear for four studies. Two studies reported the number of respiratory exacerbations. At three months, one study (43 participants) reported no change in antibiotic usage. At 12 months the second study (15 participants) reported a reduction in the number of pulmonary exacerbations and cumulative antibiotic days in the supplement group compared to the previous year (no data for the control group); very low‐quality evidence means we are unsure whether supplementation has any effect on this outcome. With regards to adverse events, one six‐week study (12 participants) reported no difference in diarrhoea between omega‐3 or placebo capsules; the very low‐quality evidence means we are unsure if supplementation has any effect on this outcome. Additionally, one study reported an increase in steatorrhoea requiring participants to increase their daily dose of pancreatic enzymes, but three studies had already increased pancreatic enzyme dose at study begin so as to reduce the incidence of steatorrhoea. One study (43 participants) reported stomach pains at three months (treatment or control group not specified). One six‐week study (19 participants) reported three asthma exacerbations leading to exclusion of participants since corticosteroid treatment could affect affect essential fatty acid metabolism. Four studies reported lung function. One six‐week study (19 participants) reported an increase in forced expiratory volume in one second (FEV 1 ) (L) and forced vital capacity (FVC) (L), but the very low‐quality evidence means we are unsure if supplementation has any effect on lung function. The remaining studies did not report any difference in lung function at three months (unit of measurement not specified) or at six months and one year (FEV 1 % predicted and FVC % predicted). No deaths were reported in any of the five studies. Four studies reported clinical variables. One study reported an increase in Schwachman score and weight alongside a reduction in sputum volume with supplementation compared to placebo at three months (data not analysable). However, three studies reported no differences in either weight at six weeks, in body mass index (BMI) standard deviation (SD) score at six months (very low‐quality evidence) or BMI Z score at 12 months. Three studies reported biochemical markers of fatty acid status. One study showed an increase from baseline in both EPA and DHA content of serum phospholipids in the omega‐3 group compared to placebo at three months and also a significant decrease in n‐6/n‐3 ratio in the supplement group compared to placebo; since the quality of the evidence is very low we are not certain that these changes are due to supplementation. One six‐month cross‐over study showed a higher EPA content of the neutrophil membrane in the supplement group compared to the placebo group, but, no difference in DHA membrane concentration. Furthermore, the leukotriene B 4 to leukotriene B 5 ratio was lower at six months in the omega‐3 group compared to placebo. A one‐year study reported a greater increase in the essential fatty acid profile and a decrease in AA levels in the treatment arm compared to placebo. Authors' conclusions This review found that regular omega‐3 supplements may provide some limited benefits for people with cystic fibrosis with relatively few adverse effects: however, the quality of the evidence across all outcomes was very low. The current evidence is insufficient to draw firm conclusions or recommend routine use of these supplements in people with cystic fibrosis. A large, long‐term, multicentre, randomised controlled study is needed to determine any significant therapeutic effect and to assess the influence of disease severity, dosage and duration of treatment. Future researchers should note the need for additional pancreatic enzymes when providing omega‐3 supplementation or olive oil placebo capsules. More research is required to determine the exact dose of pancreatic enzyme required. Plain language summary The use of omega‐3 supplements in people with cystic fibrosis Review question We reviewed the evidence about the effect of giving omega‐3 supplements to people with cystic fibrosis. Background In people with cystic fibrosis recurring cycles of infection and inflammation are thought to worsen lung function. Studies suggest that omega‐3 fatty acids, such as those derived from fish oils, may work to counter the inflammation and may be of benefit in chronic inflammatory diseases including cystic fibrosis. This is an updated version of the review. Search date The evidence is current to: 01 April 2020. Study characteristics This review includes five small studies which compare omega‐3 supplements to a different supplement without omega‐3. In total there were 106 participants, including both children and adults. The studies lasted between six weeks and 12 months. Key results Due to the very low‐quality evidence, we are uncertain whether the following effects are due to supplementation or not. One 12‐month study reported a reduction in pulmonary exacerbations and antibiotic use when taking omega‐3 supplementation compared to placebo and one three‐month study reported no change in antibiotic use during the study period. Few side effects were reported in any of the studies. One six‐week study reported that lung function and clinical status improved when taking omega‐3 supplements. Sputum levels were also noted to be reduced in this six‐week study. Three studies reported no difference in lung function when taking omega‐3 supplementation compared to placebo. Two longer studies found that people taking omega‐3 supplements showed definite increases in levels of essential fatty acids in their white blood cell membranes and also in levels of phospholipids (molecules that provide structure and protection to cells) measured in blood samples. We are uncertain whether regular omega‐3 supplements benefit people with cystic fibrosis and whether they cause side effects, or not. We are not able to draw firm conclusions or recommend the routine use of these supplements in people with cystic fibrosis. Larger and longer studies are needed to assess the clinical benefit of omega‐3 supplementation and to determine the appropriate dosage. Quality of the evidence We judged the quality of the evidence to be very low due to very low participant numbers, low event rates, limited reporting and poor study design. There was no consistency with regards to the time points when results were reported or the measurements used for the same outcome in different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Watson, H, Stackhouse, C", "articleTypes": [], "doi": "10.1002/14651858.CD002201.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.750Z" }, { "id": "d7f59335-2293-4328-a14e-4b6e31e5ed00", "pmid": "", "title": "Interventions for managing halitosis", "imported": false, "abstract": "Abstract - Background Halitosis or bad breath is a symptom in which a noticeably unpleasant breath odour is present due to an underlying oral or systemic disease. 50% to 60% of the world population has experienced this problem which can lead to social stigma and loss of self‐confidence. Multiple interventions have been tried to control halitosis ranging from mouthwashes and toothpastes to lasers. This new Cochrane Review incorporates Cochrane Reviews previously published on tongue scraping and mouthrinses for halitosis. Objectives The objectives of this review were to assess the effects of various interventions used to control halitosis due to oral diseases only. We excluded studies including patients with halitosis secondary to systemic disease and halitosis‐masking interventions. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 April 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3) in the Cochrane Library (searched 8 April 2019), MEDLINE Ovid (1946 to 8 April 2019), and Embase Ovid (1980 to 8 April 2019). We also searched LILACS BIREME (1982 to 19 April 2019), the National Database of Indian Medical Journals (1985 to 19 April 2019), OpenGrey (1992 to 19 April 2019), and CINAHL EBSCO (1937 to 19 April 2019). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (8 April 2019), the World Health Organization International Clinical Trials Registry Platform (8 April 2019), the ISRCTN Registry (19 April 2019), the Clinical Trials Registry ‐ India (19 April 2019), were searched for ongoing trials. We also searched the cross‐references of included studies and systematic reviews published on the topic. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs) which involved adults over the age of 16, and any intervention for managing halitosis compared to another or placebo, or no intervention. The active interventions or controls were administered over a minimum of one week and with no upper time limit. We excluded quasi‐randomised trials, trials comparing the results for less than one week follow‐up, and studies including advanced periodontitis. Data collection and analysis Two pairs of review authors independently selected trials, extracted data, and assessed risk of bias. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach. Main results We included 44 trials in the review with 1809 participants comparing an intervention with a placebo or a control. The age of participants ranged from 17 to 77 years. Most of the trials reported on short‐term follow‐up (ranging from one week to four weeks). Only one trial reported long‐term follow‐up (three months). Three studies were at low overall risk of bias, 16 at high overall risk of bias, and the remaining 25 at unclear overall risk of bias. We compared different types of interventions which were categorised as mechanical debridement, chewing gums, systemic deodorising agents, topical agents, toothpastes, mouthrinse/mouthwash, tablets, and combination methods. Mechanical debridement: for mechanical tongue cleaning versus no tongue cleaning, the evidence was very uncertain for the outcome dentist‐reported organoleptic test (OLT) scores (MD ‐0.20, 95% CI ‐0.34 to ‐0.07; 2 trials, 46 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Chewing gums: for 0.6% eucalyptus chewing gum versus placebo chewing gum, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.10, 95% CI ‐0.31 to 0.11; 1 trial, 65 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Systemic deodorising agents: for 1000 mg champignon versus placebo, the evidence was very uncertain for the outcome patient‐reported visual analogue scale (VAS) scores (MD ‐1.07, 95% CI ‐14.51 to 12.37; 1 trial, 40 participants; very low‐certainty evidence). No data were reported for dentist‐reported OLT score or adverse events. Topical agents: for hinokitiol gel versus placebo gel, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.27, 95% CI ‐1.26 to 0.72; 1 trial, 18 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Toothpastes: for 0.3% triclosan toothpaste versus control toothpaste, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐3.48, 95% CI ‐3.77 to ‐3.19; 1 trial, 81 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Mouthrinse/mouthwash: for mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.20, 95% CI ‐0.58 to 0.18; 1 trial, 44 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Tablets: no data were reported on key outcomes for this comparison. Combination methods: for brushing plus cetylpyridium mouthwash versus brushing, the evidence was uncertain for the outcome dentist‐reported OLT scores (MD ‐0.48, 95% CI ‐0.72 to ‐0.24; 1 trial, 70 participants; low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Authors' conclusions We found low‐ to very low‐certainty evidence to support the effectiveness of interventions for managing halitosis compared to placebo or control for the OLT and patient‐reported outcomes tested. We were unable to draw any conclusions regarding the superiority of any intervention or concentration. Well‐planned RCTs need to be conducted by standardising the interventions and concentrations. Plain language summary Interventions for managing bad breath Review question With this Cochrane Review we tried to find out the best way to control bad breath, also called halitosis, due to a disease within the mouth in adults. Background Bad breath or halitosis is caused by too much bacteria or small food parts left inside the mouth, most commonly at the back of the tongue. It can be a sign of a disease within the mouth or other body diseases. People with bad breath can have low self‐esteem and feel embarrassed. It can affect their personal relationships and work. In this review, we looked at treatments for bad breath due to a disease within the mouth and at treatments that aim to control not just mask bad breath. Study characteristics This review is up‐to‐date as of 8 April 2019. The review includes 44 studies involving 1809 people who were 17 to 77 years old. The review compared an intervention with another intervention, a placebo or a control. It looked at eight different ways to control bad breath: mechanical cleaning (e.g. tongue cleaners and toothbrushes), chewing gums, systemic deodorising agents (e.g. mushroom extract that you eat), topical agents (e.g. gel that you apply), toothpastes, mouthrinse/mouthwash, tablets, and combination of different treatments. Key results The evidence was very uncertain for mechanical tongue cleaning versus no tongue cleaning, 0.6% eucalyptus chewing gum versus placebo chewing gum, 1000 mg mushroom extract versus placebo, hinokitiol gel versus placebo gel, 0.3% triclosan toothpaste versus control toothpaste, mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, and brushing plus cetylpyridium mouthwash versus brushing. Harmful effects of the different interventions were not reported or were not important. Certainty of the evidence The level of certainty we have in these findings is low to very low. This was due mainly to risk of bias and the small number of people studied in the included trials. Conclusion We do not have enough evidence to say which intervention works better to control bad breath.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kumbargere Nagraj, S, Eachempati, P, Uma, E, Singh, VP, Ismail, NM, Varghese, E", "articleTypes": [], "doi": "10.1002/14651858.CD012213.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.742Z" }, { "id": "d7ff6737-4247-495e-ad60-0de0c8c1c879", "pmid": "", "title": "Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age", "imported": false, "abstract": "Abstract - Background Vitamin and mineral deficiencies, particularly those of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Multiple micronutrient powders (MNPs) are single‐dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi‐solid food for children six months of age or older. The use of MNPs for home or point‐of‐use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out‐of‐date. Objectives To assess the effects and safety of home (point‐of‐use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi‐solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point‐of‐use fortification. Search methods We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs with individual randomisation or cluster‐randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron‐containing supplements, which is standard practice. Data collection and analysis Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, and assessed the risk of bias of included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence. Main results We included 29 studies (33,147 children) conducted in low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty‐six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron‐only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate‐certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high‐certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low‐certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate‐certainty evidence) at follow‐up compared with children receiving the control intervention. We did not find an effect on weight‐for‐age (MD 0.02, 95% CI −0.03 to 0.07; 10 studies; 9287 children; moderate‐certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all‐cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low‐certainty evidence) and haemoglobin concentrations (MD −2.81 g/L, 95% CI −10.84 to 5.22; 2 studies; 278 children; very low‐certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low‐certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Authors' conclusions Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Plain language summary Using a vitamin and mineral powder, mixed into complementary foods, to improve health and nutrition in children under two years of age Review question Does using a vitamin and mineral powder, mixed into complementary foods, improve health and nutrition in children under two years of age? Background Deficiencies of vitamins and minerals, particularly of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Exclusive breastfeeding until six months of age, followed by complementary feeding combined with continued breastfeeding for at least two years, is recommended to maintain children's adequate health and nutrition. After six months of age, infants start to receive semi‐solid foods, but the quantities of vitamins and minerals can be insufficient to fulfil all of their requirements for growth and development. Multiple micronutrient powders (MNPs) are single‐dose packets of powder containing iron, vitamin A, zinc, and other vitamins and minerals that can be mixed into any semi‐solid food at home or at any other point of use, to increase the content of essential vitamins and minerals in the diet of infants and young children during this period. This is done without making any other changes to their usual diet. Study characteristics We searched up to July 2019 for all studies that assessed the use of MNP for improving the health and nutrition of children under two years of age. We included 29 studies that involved 33,147 infants and young children from low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean. Twenty‐six studies with 27,051 children contributed data. Of these 26 studies, 24 compared the use of MNP versus no intervention or placebo, and 2 compared the use of MNP versus an iron‐only supplement (iron drops) given daily. We found that a variety of MNP formulations containing between 5 and 22 vitamins and minerals were given for 2 to 44 months to infants and young children aged 6 to 23 months. Most studies were funded by government programmes or foundations; only 2 were funded by industry. Key results The use of MNP containing at least iron, zinc, and vitamin A for home fortification of foods was associated with reduced risk of anaemia of 18% and iron deficiency of 53% in children aged six months to two years compared with no intervention. Also, haemoglobin concentration and iron status improved. Studies did not find any effects on growth. There was no additional benefit in reducing risk of anaemia and improving haemoglobin concentration compared to usually recommended iron drops or syrups; however, only two studies compared these different interventions. No trials reported death attributable to the intervention. Information on deaths, side effects, and morbidity, including malaria and diarrhoea, was scarce. The use of MNP was beneficial for young children 6 to 23 months of age, independent of whether they lived in settings with different anaemia and malaria backgrounds and regardless of the length of the intervention. MNP is better than no intervention or placebo and may be comparable to daily iron supplementation.The benefits of this intervention as a child survival strategy or for developmental outcomes are still unclear, and further investigation is required. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Certainty of the evidence For the comparison of MNP versus no intervention or placebo, we judged the certainty of evidence to be moderate for anaemia and high for iron deficiency. The certainty of evidence for all other outcomes in this comparison was either low or moderate. Two trials that compared the use of MNP versus iron supplement showed similar effects on anaemia and haemoglobin but less diarrhoea; however, we judged the certainty of evidence as low for anaemia and very low for haemoglobin concentration due to the small number of study participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Suchdev, PS; Jefferds, MED; Ota, E; da Silva Lopes, K; De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD008959.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "d832d268-7857-4c02-a34c-46097323799c", "pmid": "", "title": "Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people", "imported": false, "abstract": "Abstract - Background Folate deficiency can result in congenital neural tube defects and megaloblastic anaemia. Low folate levels may be due to insufficient dietary intake or inefficient absorption, but impaired metabolic utilization also occurs. Because B12 deficiency can produce a similar anaemia to folate deficiency, there is a risk that folate supplementation can delay the diagnosis of B12 deficiency, which can cause irreversible neurological damage. Folic acid supplements may sometimes therefore include vitamin B12 supplements with simultaneous administration of vitamin B12. Lesser degrees of folate inadequacy are associated with high blood levels of the amino acid homocysteine which has been linked with the risk of arterial disease, dementia and Alzheimer's disease. There is therefore interest in whether dietary supplementation can improve cognitive function in the elderly. However, any apparent benefit from folic acid which was given in combination with B12 needs to be \"corrected\" for any effect of vitamin B12 alone. A separate Cochrane review of vitamin B12 and cognitive function has therefore been published. Objectives To examine the effects of folic acid supplementation, with or without vitamin B12, on elderly healthy or demented people, in preventing cognitive impairment or retarding its progress. Search methods Trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 10 October 2007 using the terms: folic acid, folate, vitamin B9, leucovorin, methyltetrahydrofolate, vitamin B12, cobalamin and cyanocobalamin. This Register contains references from all major health care databases and many ongoing trials databases. In addition MEDLINE, EMBASE, CINAHL, PsychINFO and LILACS were searched (years 2003‐2007) for additional trials of folate with or without vitamin B12 on healthy elderly people. Selection criteria All double‐blind, placebo‐controlled, randomized trials, in which supplements of folic acid with or without vitamin B12 were compared with placebo for elderly healthy people or people with any type of dementia or cognitive impairment. Data collection and analysis The reviewers independently applied the selection criteria and assessed study quality. One reviewer extracted and analysed the data. In comparing intervention with placebo, weighted mean differences and standardized mean difference or odds ratios were estimated. Main results Eight randomized controlled trials fulfilled the inclusion criteria for this review. Four trials enrolled healthy older people, and four recruited participants with mild to moderate cognitive impairment or dementia with or without diagnosed folate deficiency. Pooling the data was not possible owing to heterogeneity in sample selections, outcomes, trial duration, and dosage. Two studies involved a combination of folic acid and vitamin B12. There is no adequate evidence of benefit from folic acid supplemententation with or without vitamin B12 on cognitive function and mood of unselected healthy elderly people. However, in one trial enrolling a selected group of healthy elderly people with high homocysteine levels, 800 mcg/day folic acid supplementation over three years was associated with significant benefit in terms of global functioning (WMD 0.05, 95% CI 0.004 to 0.096, P = 0.033); memory storage (WMD 0.14, 95% CI 0.04 to 0.24, P = 0.006) and information‐processing speed (WMD 0.09, 95% CI 0.02 to 0.16, P = 0.016). Four trials involved people with cognitive impairment. In one pilot trial enrolling people with Alzheimer's disease, the overall response to cholinesterase inhibitors significantly improved with folic acid at a dose of 1mg/day (odds ratio: 4.06, 95% CI 1.22 to 13.53; P = 0.02) and there was a significant improvement in scores on the Instrumental Activities of Daily Living and the Social Behaviour subscale of the Nurse's Observation Scale for Geriatric Patients (WMD 4.01, 95% CI 0.50 to 7.52, P = 0.02). Other trials involving people with cognitive impairment did not show any benefit in measures of cognitive function from folic acid, with or without vitamin B12. Folic acid plus vitamin B12 was effective in reducing serum homocysteine concentrations (WMD ‐5.90, 95% CI ‐8.43 to ‐3.37, P < 0.00001). Folic acid was well tolerated and no adverse effects were reported. Authors' conclusions The small number of studies which have been done provide no consistent evidence either way that folic acid, with or without vitamin B12, has a beneficial effect on cognitive function of unselected healthy or cognitively impaired older people. In a preliminary study, folic acid was associated with improvement in the response of people with Alzheimer's disease to cholinesterase inhibitors. In another, long‐term use appeared to improve the cognitive function of healthy older people with high homocysteine levels. More studies are needed on this important issue. Plain language summary No evidence that folic acid with or without vitamin B12 improves cognitive function of unselected elderly people with or without dementia. Long‐term supplementation may benefit cognitive function of healthy older people with high homocysteine levels In the economically developed world, folate deficiency is one of the commonest vitamin deficiencies. Several reports suggest a higher prevalence of various psychiatric disorders in elderly people with folate deficiency. There is interest in whether dietary supplements of folic acid (an artificial chemical analogue of naturally occurring folates) can improve cognitive function of people at risk of cognitive decline associated with ageing or dementia, whether by affecting homocysteine metabolism or through other mechanisms. Eight trials met the criteria for inclusion. It was not possible to pool the data because the trials studied different populations, tested folic acid in different doses, and used different outcome measures. There were two trials of folic acid in conjunction with B12. The analysis showed significant benefit of folic acid over placebo in some measures of cognition in a long‐term trial recruiting elderly people with high homocysteine levels from a general population. In one pilot trial, 1 mg/day of folic acid was associated with significant improvement in behavioural response to cholinesterase inhibitors in people with Alzheimer's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Malouf, R, Grimley Evans, J", "articleTypes": [], "doi": "10.1002/14651858.CD004514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.785Z" }, { "id": "d832fe2f-daee-4485-a2da-353cefe2a52a", "pmid": "", "title": "Community‐based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries", "imported": false, "abstract": "Abstract - Background Supplementary feeding is defined as the provision of extra food to children or families beyond the normal ration of their home diets. The impact of food supplementation on child growth merits careful evaluation in view of the reliance of many states and non‐governmental organisations on this intervention to improve child health in low and middle income countries (LMIC). This is an update of a Cochrane review first published in 2005. Objectives To evaluate the effectiveness of community‐based supplementary feeding for promoting the physical growth of children under five years of age in LMIC. Search methods For this updated review we searched the following databases on 31 January 2011: CENTRAL ( The Cochrane Library ), MEDLINE (1948 to January week 3, 2011), EMBASE (1980 to week 3, 2011), CINAHL (1937 to 27 January 2011), LILACS (all years), WorldCat for dissertations and theses (all years) and ClinicalTrials.gov (all years). Selection criteria Randomised controlled trials (RCTs) evaluating supplementary feeding in comparison to a control group (no intervention or a placebo such as food with a very low number of nutrients and calories) in children from birth to five years of age in LMIC. Data collection and analysis Two review authors independently extracted and analysed the data. Main results We included eight RCTs (n = 1243 children) that were at relatively high risk of bias. We found high levels of clinical heterogeneity in the participants, interventions and outcome measures across studies. Nevertheless, in order to quantify pooled effects of supplementary feeding, we decided to combine studies according to prespecified characteristics. These were the children's age (younger or older than 24 months), their nutritional status at baseline (stunted or wasted, or not stunted or wasted) and the duration of the intervention (less or more than 12 months). A statistically significant difference of effect was only found for length during the intervention in children aged less than 12 months (two studies; 795 children; mean difference 0.19 cm; 95% confidence interval (CI) 0.07 to 0.31). Based on the summary statistic calculated for each study, the mean difference (MD) between intervention and control groups ranged from 0.48 cm (95% CI 0.07 to 0.89) to 1.3 cm (95% CI 0.03 to 2.57) after 3 and 12 months of intervention, respectively. Data on potential adverse effects were lacking. Authors' conclusions The scarcity of available studies and their heterogeneity makes it difficult to reach any firm conclusions. The review findings suggest supplementary feeding has a negligible impact on child growth; however, the pooled results should be interpreted with great caution because the studies included in the review are clinically diverse. Future studies should address issues of research design, including sample size calculation, to detect meaningful clinical effects and adequate intervention allocation concealment. In the meantime, families and children in need should be provided appropriate feeding, health care and sanitation without waiting for new RCTs to establish a research basis for feeding children. Plain language summary Providing extra food for children under five years of age in low and middle income countries Undernutrition is one of the underlying causes of childhood illness and death in low‐ and middle‐income countries. Providing extra food to children or families beyond what they normally have at home is an intervention aimed at supporting the nutritional wellbeing of the target population. We included eight studies where the participants were randomly assigned to two groups: one group received the extra food and the other group was a control, either receiving no food or food with very low nutritional content. Although the impact of supplementary feeding on child growth appeared to be negligible, it is not possible to draw any conclusions until we have studies that involve larger numbers and do not allow assessors to know who is receiving the intervention. Although it is difficult to determine whether community‐based supplementary feeding helps to promote the growth of children from birth to five years in low‐ and middle‐income countries, it is obviously vital to continue to provide food, health care and sanitation to those who need them.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Sguassero, Y, de Onis, M, Bonotti, AM, Carroli, G", "articleTypes": [], "doi": "10.1002/14651858.CD005039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.785Z" }, { "id": "d85566f2-438b-4e69-b633-fdb7a812ec75", "pmid": "", "title": "Interventions for the cessation of non‐nutritive sucking habits in children", "imported": false, "abstract": "Abstract - Background Comforting behaviours, such as the use of pacifiers (dummies, soothers), blankets and finger or thumb sucking, are common in babies and young children. These comforting habits, which can be referred to collectively as 'non‐nutritive sucking habits' (NNSHs), tend to stop as children get older, under their own impetus or with support from parents and carers. However, if the habit continues whilst the permanent dentition is becoming established, it can contribute to, or cause, development of a malocclusion (abnormal bite). A diverse variety of approaches has been used to help children with stopping a NNSH. These include advice, removal of the comforting object, fitting an orthodontic appliance to interfere with the habit, application of an aversive taste to the digit or behaviour modification techniques. Some of these interventions are easier to apply than others and less disturbing for the child and their parent; some are more applicable to a particular type of habit. Objectives The primary objective of the review was to evaluate the effects of different interventions for cessation of NNSHs in children. The secondary objectives were to determine which interventions work most quickly and are the most effective in terms of child and parent‐ or carer‐centred outcomes of least discomfort and psychological distress from the intervention, as well as the dental measures of malocclusion (reduction in anterior open bite, overjet and correction of posterior crossbite) and cost‐effectiveness. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 8 October 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2014, Issue 9), MEDLINE via OVID (1946 to 8 October 2014), EMBASE via OVID (1980 to 8 October 2014), PsycINFO via OVID (1980 to 8 October 2014) and CINAHL via EBSCO (1937 to 8 October 2014), the US National Institutes of Health Trials Register (Clinical Trials.gov) (to 8 October 2014) and the WHO International Clinical Trials Registry Platform (to 8 October 2014). There were no restrictions regarding language or date of publication in the searches of the electronic databases. We screened reference lists from relevant articles and contacted authors of eligible studies for further information where necessary. Selection criteria Randomised or quasi‐randomised controlled trials in children with a non‐nutritive sucking habit that compared one intervention with another intervention or a no‐intervention control group. The primary outcome of interest was cessation of the habit. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Three review authors were involved in screening the records identified; two undertook data extraction, two assessed risk of bias and two assessed overall quality of the evidence base. Most of the data could not be combined and only one meta‐analysis could be carried out. Main results We included six trials, which recruited 252 children (aged 2 and a half to 18 years), but presented follow‐up data on only 246 children. Digit sucking was the only NNSH assessed in the studies. Five studies compared single or multiple interventions with a no‐intervention or waiting list control group and one study made a head‐to‐head comparison. All the studies were at high risk of bias due to major limitations in methodology and reporting. There were small numbers of participants in the studies (20 to 38 participants per study) and follow‐up times ranged from 1 to 36 months. Short‐term outcomes were observed under one year post‐intervention and long‐term outcomes were observed at one year or more post‐intervention. Orthodontics appliance (with or without psychological intervention) versus no treatment Two trials that assessed this comparison evaluated our primary outcome of cessation of habit. One of the trials evaluated palatal crib and one used a mix of palatal cribs and arches. Both trials were at high risk of bias. The orthodontic appliance was more likely to stop digit sucking than no treatment, whether it was used over the short term (risk ratio (RR) 6.53, 95% confidence interval (CI) 1.67 to 25.53; 2 trials, 70 participants) or long term (RR 5.81, 95% CI 1.49 to 22.66; 1 trial, 37 participants) or used in combination with a psychological intervention (RR 6.36, 95% CI 0.97 to 41.96; 1 trial, 32 participants). Psychological intervention versus no treatment Two trials (78 participants) at high risk of bias evaluated positive reinforcement (alone or in combination with gaining the child's co‐operation) or negative reinforcement compared with no treatment. Pooling of data showed a statistically significant difference in favour of the psychological interventions in the short term (RR 6.16, 95% CI 1.18 to 32.10; I 2 = 0%). One study, with data from 57 participants, reported on the long‐term effect of positive and negative reinforcement on sucking cessation and found a statistically significant difference in favour of the psychological interventions (RR 6.25, 95% CI 1.65 to 23.65). Head‐to‐head comparisons Only one trial demonstrated a clear difference in effectiveness between different active interventions. This trial, which had only 22 participants, found a higher likelihood of cessation of habit with palatal crib than palatal arch (RR 0.13, 95% CI 0.03 to 0.59). Authors' conclusions This review found low‐quality evidence that orthodontic appliances (palatal arch and palatal crib) and psychological interventions (including positive and negative reinforcement) are effective at improving sucking cessation in children. There is very low‐quality evidence that palatal crib is more effective than palatal arch. This review has highlighted the need for high‐quality trials evaluating interventions to stop non‐nutritive sucking habits to be conducted and the need for a consolidated, standardised approach to reporting outcomes in these trials. Plain language summary Interventions for stopping dummy or finger or thumb sucking habits in children Review question This review has been produced to assess the effects of interventions to stop sucking habits in children, which are not linked to food. Important considerations are: which treatment or combination of treatments work most effectively, when should treatment be started, what is the optimum length of time for the intervention and what causes least upset to children and their parents? Background Often babies and children develop a habit of sucking objects to comfort and calm them. They frequently suck dummies (known as pacifiers in the USA), fingers, thumbs or other items like blankets. Eventually, most children grow out of the habit, or stop due to encouragement from their parents. Some children, however, continue sucking as a habit. If they continue to do so as their adult teeth start to grow through (around the age of six), there is a risk that these adult teeth will grow into the wrong position causing them to stick out too far or not meet properly when biting. As a result these children often need dental treatment to fix the problems caused by their sucking habit. Possible treatments to help children break their sucking habits examined in studies in this review include the use of two different braces in the mouth; giving advice and incentives for changing behaviour (known as psychological advice/treatment); applying a bitter, nasty tasting substance to the children’s thumbs/fingers or combinations of these treatments. None of the studies included looked at barrier methods, for example the use of gloves or plasters or withdrawal of dummies. Study characteristics Review authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 8 October 2014. The review includes six studies published from 1967 to 1997, which involved 252 children as participants (although data were supplied on only 246 of the children). Three of the studies were carried out in the USA, one in Canada, one in Sweden and one in Australia. Not all of the studies gave the ages of children involved; in four of the studies children were aged from two and a half to 18 years old, in one study they were aged four years and over and in another nine years and over. Results Use of an orthodontic brace (such as a palatal crib or arch) or a psychological intervention (such as use of positive or negative reinforcement), or both, was more likely to lead to cessation of the habit than no treatment. Most of the trials that compared two different interventions were inconclusive but one study suggested that, of two different types of braces,a palatal crib is more effective than a palatal arch design. Quality of the evidence The evidence presented is of low quality due to the small number of participants in the few available studies and problems with the way in which the studies were conducted. There was a high risk of bias across the studies. Conclusion Orthodontic braces or psychological intervention seems to be effective to help children stop sucking that does not have a feeding purpose but the evidence is low quality. Further high quality clinical trials are required to guide decision making for what is a common problem that can require lengthy and expensive dental treatment to correct.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Borrie, FRP; Bearn, DR; Innes, NPT; Iheozor-Ejiofor, Z", "articleTypes": [], "doi": "10.1002/14651858.CD008694.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "d8674a19-3da1-4046-82a9-93e9e4ca6fe4", "pmid": "", "title": "Capsaicin for non‐allergic rhinitis", "imported": false, "abstract": "Abstract - Background There are many forms of rhinitis. Patients are diagnosed with non‐allergic rhinitis when anatomic, infectious and allergic aetiologies have been excluded. The symptoms, including nasal congestion, blockage or obstruction, clear rhinorrhoea, sneezing and, less frequently, nasal itching, can range from mild to debilitating. It affects between 25% and 50% of patients with rhinitis. Several medications are widely used in the treatment of non‐allergic rhinitis, including oral and topical nasal antihistamines, intranasal and (rarely) systemic corticosteroids, and anticholinergics. Capsaicin, the active component of chili peppers, delivered intranasally, is considered a treatment option for non‐allergic rhinitis. Objectives To assess the effectiveness of capsaicin in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications, or two or more of the above therapies in combination, or different capsaicin regimens. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 5); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2015. Selection criteria Randomised controlled trials in adult patients with non‐allergic rhinitis comparing intranasal capsaicin with no therapy, placebo or other topical or systemic medications, or their combinations. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We included four studies (five publications) involving 302 participants with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe, idiopathic non‐allergic rhinitis who were between the ages of 16 and 65. Studies had follow‐up periods ranging from four to 38 weeks. The overall risk of bias in the studies was either high or unclear (two studies had overall high risk of bias, while two others had low to unclear risk of bias). Using the GRADE system we assessed the evidence as being of low to moderate quality. A meta‐analysis was not possible, given lack of similarity of the reported outcomes. Two studies compared capsaicin with placebo. One study reported that capsaicin resulted in an improvement of overall nasal symptoms (a primary outcome) measured on a visual analogue scale (VAS) of 0 to 10. There was a mean difference (MD) of ‐3.34 (95% confidence interval (CI) ‐5.24 to ‐1.44), MD ‐3.73 (95% CI ‐5.45 to ‐2.01) and MD ‐3.52 (95% CI ‐5.55 to ‐1.48) at two, 12 and 36 weeks post‐treatment, respectively. Another study reported that, compared to placebo, capsaicin (at 4 µg/puff) was more likely to produce overall symptom resolution (reduction in nasal blockage, sneezing/itching/coughing and nasal secretion measured with a daily record chart) at four weeks post‐treatment (a primary outcome). The risk ratio (RR) was 3.17 (95% CI 1.38 to 7.29). One study compared capsaicin to budesonide (an intranasal corticosteroid). This study found that patients treated with capsaicin had a better overall symptom score compared to those treated with budesonide (MD 2.50, 95% CI 1.06 to 3.94, VAS of 0 to 10). However, there were no differences in the individual symptom scores for headache, postnasal drip, rhinorrhoea, nasal blockage, sneezing and sore throat assessed during the last three days of a four‐week treatment. One study compared two different regimens of capsaicin administration: five treatments in one day versus five treatments given every two to three days during two weeks. Using daily record charts, the study reported significant improvement of individual symptom scores for rhinorrhoea in patients treated five times per day, however numerical data were not presented. There were no improvements in the other outcomes: rhinorrhoea, nasal obstruction, sneezing and overall nasal symptoms, measured on a VAS. Finally, one of these studies also compared three doses of capsaicin (to placebo). Patients treated with a 1 µg versus 4 µg per puff dose of capsaicin had a worse daily record chart overall symptom score resolution (RR 0.63, 95% CI 0.34 to 1.16). Only one study attempted to measure adverse effects (a primary outcome), however due to methodological issues with the assessment we are unable to draw any conclusions. We sought to include other secondary outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Authors' conclusions Capsaicin may be an option in the treatment of idiopathic non‐allergic rhinitis. It is given in the form of brief treatments, usually during the same day. It appears to have beneficial effects on overall nasal symptoms up to 36 weeks after treatment, based on a few, small studies (low‐quality evidence). Well‐conducted randomised controlled trials are required to further advance our understanding of the effectiveness of capsaicin in non‐allergic rhinitis, especially in patients with non‐allergic rhinitis of different types and severity, and using different methods of capsaicin application. Plain language summary Capsaicin for non‐allergic rhinitis Review question Is capsaicin applied into the nose (intranasal) effective in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications? Background Rhinitis means inflammation of the nose. It affects 30% to 40% of the general population. There are many forms of rhinitis: rhinosinusitis (or simply sinusitis), allergic rhinitis and non‐allergic rhinitis. Non‐allergic rhinitis is diagnosed in patients who have negative tests for allergies and also do not have sinusitis. The symptoms include congestion of the nose, a blocked or obstructed sensation in the nose that causes difficulty breathing, clear nasal discharge (runny nose), sneezing and nasal itching. There are several subtypes of non‐allergic rhinitis: occupational (from exposure to chemicals), smoking, gustatory (related to eating food or drinking fluid), hormonal (from changes in hormone levels in the body), pregnancy, senile or elderly (mostly affecting the older population), medication‐induced (for example, from overuse of decongestant nasal sprays) and local allergic (local allergy in the nose, while skin or blood allergy tests are negative). The most common subtype of non‐allergic rhinitis is 'idiopathic' or 'vasomotor' rhinitis, which results from imbalance of the neural (nerve) system that manages the function of the nose. The mechanisms of many of these subtypes remain unknown. Non‐allergic rhinitis affects about 25% to 50% of patients with rhinitis and is therefore very common. Capsaicin is the active ingredient of chili peppers. It has medicinal properties and is used elsewhere in medicine, for example for neuralgias (nerve pain) and psoriasis (a skin disease). The side effects of using capsaicin in the nose include irritation, burning, sneezing and coughing, however there are no known long‐term side effects of capsaicin use. Capsaicin is given in the form of brief treatments, usually during the same day. It works by down‐regulating transient receptor potential vanilloid (TRPV) receptor expression on C‐sensory fibres. TRPV represents special ion channels involved in the sensations of pain, cold, hotness, tastes, pressure and vision. C fibres help to conduct some of these sensations. There is ongoing research into the effects of capsaicin on these mechanisms and its clinical uses. Study characteristics We included four studies involving 302 patients with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe idiopathic non‐allergic rhinitis, who were between the ages of 16 and 65. The studies had a follow‐up ranging from four to 38 weeks after treatment. Key results Individually, the studies reported that the overall function of the nose in patients with non‐allergic rhinitis improved when treated with capsaicin compared to placebo. Capsaicin also seems to work better than another common type of nasal medication, budesonide (a steroid). The best knowledge that we have on capsaicin treatment supports giving it five times in one day, and to use doses of at least 4 micrograms in each puff. We could not combine the results together. The included studies did not have sufficient information to allow us to draw a conclusion about side effects. We also wanted to include other outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Quality of the evidence Overall, we judged the quality of the evidence to be of low to moderate quality. The evidence is up to date to June 2015. Conclusions Given that many other options do not work well in non‐allergic rhinitis, capsaicin is a reasonable option to try under physician supervision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Gevorgyan, A; Segboer, C; Gorissen, R; van Drunen, CM; Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010591.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "d86cc467-6f99-4dfa-a886-a3b978043847", "pmid": "", "title": "Opioids for restless legs syndrome", "imported": false, "abstract": "Abstract - Background Restless legs syndrome (RLS) is a distressing and common neurological disorder that may have a huge impact in the quality of life of those with frequent and intense symptoms. Patients complain of unpleasant sensations in the legs, at or before bedtime, and feel an urge to move the legs, which improves with movement, such as walking. Symptoms start with the patient at rest (e.g. sitting or lying down), and follow a circadian pattern, increasing during the evening or at night. Many pharmacological intervention are available for RLS, including drugs used to treat Parkinson's disease (L‐Dopa and dopaminergic agonists), epilepsy (anticonvulsants), anxiety (benzodiazepines), and pain (opioids). Dopaminergic drugs are those most frequently used for treatment of RLS, but some patients do not respond effectively and require other medication. Opioids, a class of medications used to treat severe pain, seem to be effective in treating RLS symptoms, and are recommended for patients with severe symptoms, because RLS and pain appear to share the same mechanism in the central nervous system. All available drugs are associated to some degree with side effects, which can impede treatment. Opioids are associated with adverse events such as constipation, tolerance, and dependence. This justifies the conduct of a systematic review to ascertain whether opioids are safe and effective for treatment of RLS. Objectives To asses the effects of opioids compared to placebo treatment for restless legs syndrome in adults. Search methods We searched the Cochrane Central Register of Controlled trials, CENTRAL 2016, issue 4 and MEDLINE, EMBASE, and LILACS up to April 2016, using a search strategy adapted by Cochraneto identify randomised clinical trials. We checked the references of each study and established personal communication with other authors to identify any additional studies. We considered publications in all languages. Selection criteria Randomised controlled clinical trials of opioid treatment in adults with idiopathic RLS. Data collection and analysis Two review authors independently screened articles, independently extracted data into a standard form, and assessed for risk of bias. If necessary, they discussed discrepancies with a third researcher to resolve any doubts. Main results We included one randomised clinical trial (N = 304 randomised; 204 completed; 276 analysed) that evaluated opioids (prolonged release oxycodone/naloxone) versus placebo. After 12 weeks, RSL symptoms had improved more in the drug group than in the placebo group (using the IRLSSS: MD ‐7.0; 95% CI ‐9.69 to ‐4.31 and the CGI: MD ‐1.11; 95% CI ‐1.49 to ‐0.73). More patients in the drug group than in the placebo group were drug responders (using the IRLSSS: RR 1.82; 95% CI 1.37 to 2.42 and the CGI: RR1.92; 95% ICI 1.49 to 2.48). The proportion of remitters was greater in the drug group than in the placebo group (using the IRLSSS: RR 2.14; 95% CI 1.45 to 3.16). Quality of life scores also improved more in the drug group than in the placebo group (MD ‐0.73; 95% CI ‐1.1 to ‐0.36). Quality of sleep was improved more in the drug group measured by sleep adequacy (MD ‐0.74; 95% CI ‐1.15 to ‐0.33), and sleep quantity (MD 0.89; 95% CI 0.52 to 1.26). There was no difference between groups for daytime somnolence, trouble staying awake during the day, or naps during the day. More adverse events were reported in the drug group (RR 1.22; 95% CI 1.07 to 1.39). The major adverse events were gastrointestinal problems, fatigue, and headache. Authors' conclusions Opioids seem to be effective for treating RLS symptoms, but there are no definitive data regarding the important problem of safety. This conclusion is based on only one study with a high dropout rate (low quality evidence). Plain language summary Opiods for restless legs syndrome Background Restless legs syndrome (RLS) is a very common neurological disorder in which patients complain of an intense need to move their legs, and unpleasant sensations felt deep in their legs, all occurring while at rest, mostly at bedtime. The number of patients complaining of RLS varies according to race, gender, age, country, and health status. About 5% to 10% of people are affected; , and, among these, 2% to 5% need continual pharmacological treatment (medication). When RLS does not respond to medications generally used for Parkinsons Disease and epilepsy, their doctors often prescribe opioids. Question Are opioids effective and safe for people with RLS? Methods We searched the literature for studies in any language, published or not, that considered opioids for the treatment of RLS Results We included one randomised controlled clinical trial with moderate risk of bias that tested a combination of oxycodone and naloxone against placebo capsules, taken twice daily in participants whodid not respond to more usual medications. Researchers used the International RLS severity scale to find out if patients were improved after 12 weeks of treatment. Particpants receiving the combined oxycodone and naloxone reported improvement in RLS symptoms, Quality of life, and sleep quality; 42% of the drug group were symptom‐free. Discussion The study was well designed overall, but was at a high risk of bias due to the high percentage of participants who withdrew from treatment (attrition bias). Eighty‐four percent of the drug group developed adverse events, which were mostly related to the gastrointestinal system, headache, fatigue, and sleepiness (somnolence); 9.8% left the study because of the adverse events. Conclusion The use of opioids for the treatment of RLS in patients resistant to conventional treatment is supported by low‐quality evidence. Prescription of these medications should be based on clinical experience, and caution used due to the potential for abuse, dependency, and adverse events. No patient on opioids complained that their symptoms worsened.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "de Oliveira, CO; Carvalho, LBC; Carlos, K; Conti, C; de Oliveira, MM; Prado, LBF; Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006941.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "d8710456-e3d0-45b5-8ecf-c104323f1a91", "pmid": "", "title": "Topical benzoyl peroxide for acne", "imported": false, "abstract": "Abstract - Background Acne is a common, economically burdensome condition that can cause psychological harm and, potentially, scarring. Topical benzoyl peroxide (BPO) is a widely used acne treatment; however, its efficacy and safety have not been clearly evaluated. Objectives To assess the effects of BPO for acne. Search methods We searched the following databases up to February 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of relevant randomised controlled trials (RCTs) and systematic reviews. Selection criteria We included RCTs that compared topical BPO used alone (including different formulations and concentrations of BPO) or as part of combination treatment against placebo, no treatment, or other active topical medications for clinically diagnosed acne (used alone or in combination with other topical drugs not containing BPO) on the face or trunk. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Primary outcome measures were 'participant global self‐assessment of acne improvement' and 'withdrawal due to adverse events in the whole course of a trial'. 'Percentage of participants experiencing any adverse event in the whole course of a trial' was a key secondary outcome. Main results We included 120 trials (29,592 participants randomised in 116 trials; in four trials the number of randomised participants was unclear). Ninety‐one studies included males and females. When reported, 72 trials included participants with mild to moderate acne, 26 included participants with severe acne, and the mean age of participants ranged from 18 to 30 years. Our included trials assessed BPO as monotherapy, as add‐on treatment, or combined with other active treatments, as well as BPO of different concentrations and BPO delivered through different vehicles. Comparators included different concentrations or formulations of BPO, placebo, no treatment, or other active treatments given alone or combined. Treatment duration in 80 trials was longer than eight weeks and was only up to 12 weeks in 108 trials. Industry funded 50 trials; 63 trials did not report funding. We commonly found high or unclear risk of performance, detection, or attrition bias. Trial setting was under‐reported but included hospitals, medical centres/departments, clinics, general practices, and student health centres. We reported on outcomes assessed at the end of treatment, and we classified treatment periods as short‐term (two to four weeks), medium‐term (five to eight weeks), or long‐term (longer than eight weeks). For 'participant‐reported acne improvement', BPO may be more effective than placebo or no treatment (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.12 to 1.45; 3 RCTs; 2234 participants; treatment for 10 to 12 weeks; low‐certainty evidence). Based on low‐certainty evidence, there may be little to no difference between BPO and adapalene (RR 0.99, 95% CI 0.90 to 1.10; 5 RCTs; 1472 participants; treatment for 11 to 12 weeks) or between BPO and clindamycin (RR 0.95, 95% CI 0.68 to 1.34; 1 RCT; 240 participants; treatment for 10 weeks) (outcome not reported for BPO versus erythromycin or salicylic acid). For 'withdrawal due to adverse effects', risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment (RR 2.13, 95% CI 1.55 to 2.93; 24 RCTs; 13,744 participants; treatment for 10 to 12 weeks; low‐certainty evidence); the most common causes of withdrawal were erythema, pruritus, and skin burning. Only very low‐certainty evidence was available for the following comparisons: BPO versus adapalene (RR 1.85, 95% CI 0.94 to 3.64; 11 RCTs; 3295 participants; treatment for 11 to 24 weeks; causes of withdrawal not clear), BPO versus clindamycin (RR 1.93, 95% CI 0.90 to 4.11; 8 RCTs; 3330 participants; treatment for 10 to 12 weeks; causes of withdrawal included local hypersensitivity, pruritus, erythema, face oedema, rash, and skin burning), erythromycin (RR 1.00, 95% CI 0.07 to 15.26; 1 RCT; 60 participants; treatment for 8 weeks; withdrawal due to dermatitis), and salicylic acid (no participants had adverse event‐related withdrawal; 1 RCT; 59 participants; treatment for 12 weeks). There may be little to no difference between these groups in terms of withdrawal; however, we are unsure of the results because the evidence is of very low certainty. For 'proportion of participants experiencing any adverse event', very low‐certainty evidence leaves us uncertain about whether BPO increased adverse events when compared with placebo or no treatment (RR 1.40, 95% CI 1.15 to 1.70; 21 RCTs; 11,028 participants; treatment for 10 to 12 weeks), with adapalene (RR 0.71, 95% CI 0.50 to 1.00; 7 RCTs; 2120 participants; treatment for 11 to 24 weeks), with erythromycin (no participants reported any adverse events; 1 RCT; 89 participants; treatment for 10 weeks), or with salicylic acid (RR 4.77, 95% CI 0.24 to 93.67; 1 RCT; 41 participants; treatment for 6 weeks). Moderate‐certainty evidence shows that the risk of adverse events may be increased for BPO versus clindamycin (RR 1.24, 95% CI 0.97 to 1.58; 6 RCTs; 3018 participants; treatment for 10 to 12 weeks); however, the 95% CI indicates that BPO might make little to no difference. Most reported adverse events were mild to moderate, and local dryness, irritation, dermatitis, erythema, application site pain, and pruritus were the most common. Authors' conclusions Current evidence suggests that BPO as monotherapy or add‐on treatment may be more effective than placebo or no treatment for improving acne, and there may be little to no difference between BPO and either adapalene or clindamycin. Our key efficacy evidence is based on participant self‐assessment; trials of BPO versus erythromycin or salicylic acid did not report this outcome. For adverse effects, the evidence is very uncertain regarding BPO compared with adapalene, erythromycin, or salicylic acid. However, risk of treatment discontinuation may be higher with BPO compared with placebo or no treatment. Withdrawal may be linked to tolerability rather than to safety. Risk of mild to moderate adverse events may be higher with BPO compared with clindamycin. Further trials should assess the comparative effects of different preparations or concentrations of BPO and combination BPO versus monotherapy. These trials should fully assess and report adverse effects and patient‐reported outcomes measured on a standardised scale. Plain language summary Topical benzoyl peroxide for acne Review question We reviewed the evidence showing effects and safety of topical benzoyl peroxide (BPO), used alone or in combination. Eligible comparisons included placebo (an identical but inactive treatment), no treatment, or other active (medical) topical medications for treating acne (used alone or in combination with other topical drugs not containing BPO) (evidence is current to February 2019). The main outcomes of interest in this review were participant‐reported acne improvement and withdrawal from the study due to any side effects. More generally, we also considered the percentage of participants experiencing any side effects over the whole course of a trial. Background As a common skin disease, acne vulgaris affects the physical, mental, and social well‐being of millions of adolescents and young adults. A wide range of treatments for acne vulgaris are available, and topical BPO has been recommended as a priority therapy to be used alone or combined with other topical or oral treatments, depending on acne severity. However, the benefits and harms of BPO have yet to be evaluated. Study characteristics We included 120 studies (which comprised 29,592 people randomised in 116 trials; in four trials the number of randomised participants was unclear). Through our search, we found studies assessing different concentrations of BPO, BPO delivered through various means, or BPO used alone or given with other treatments that may or may not be considered as the primary treatment. These studies compared treatments against different concentrations or formulations of BPO, placebo, no treatment, or other medical treatments given alone or in combination. Most of the studies included male and female participants with mild to moderate acne; only 67% of studies reported participant age, which ranged between 18 and 30 years. Participants were treated for over eight weeks in nearly two‐thirds of the trials. Industry financially supported approximately two‐fifths of the trials, and more than half of the trials did not report their funding sources. Few studies reported where they were set, but locations included hospitals, medical centres, national medical institutes, clinics, medical departments, and general practices. Key results We found low‐certainty evidence to suggest that long‐term (i.e. given for longer than eight weeks) BPO treatment may increase self‐reported treatment success compared to placebo or no BPO treatment (three studies), but there may be little to no difference when BPO treatment is compared to adapalene (five studies) or clindamycin (one study). This outcome was not reported by studies comparing BPO treatment to erythromycin or salicylic acid. Long‐term BPO may lead to an increased chance of treatment discontinuation compared to placebo or no treatment (24 studies), with the most common causes being redness, itch, and skin burning (low‐certainty evidence). When medium‐ to long‐term BPO was compared to adapalene (11 studies), clindamycin (eight studies), erythromycin (one study), or salicylic acid (one study), we found only very low‐certainty evidence, meaning that although there may be little to no difference in withdrawal between these groups, we are not sure of the results. It should be noted that participant withdrawal may be linked to issues around treatment acceptability (dermatitis, rash, facial swelling, sensitivity) rather than to safety. Very low‐certainty evidence means that we are uncertain if BPO leads to more side effects among participants receiving medium‐ to long‐term BPO than among those given no treatment/placebo (21 studies), adapalene (seven studies), erythromycin (one study), or salicylic acid (one study). Medium‐term treatment with BPO may lead to increased risk of side effects when compared against clindamycin, but the effects of this treatment vary, so the treatment chosen may make little to no difference (six studies; moderate‐certainty evidence). Side effects reported in these studies were usually mild to moderate, and the most common were local dryness, irritation, eczema, redness, pain at the site of application, and pruritus. Certainty of the evidence For our key comparisons, we rated the certainty of evidence for 'participant‐reported acne improvement' as low. For the outcomes 'withdrawal due to adverse effects' and ‘percentage of participants having any adverse events', the evidence was mainly of very low certainty. Included trials were at high or unclear risk of bias, participant numbers were small, results were not consistent across trials, and we suspected publication bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Yang, Z; Zhang, Y; Lazic Mosler, E; Hu, J; Li, H; Zhang, Y; Liu, J; Zhang, Q", "articleTypes": [], "doi": "10.1002/14651858.CD011154.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "d8723314-dcf0-4853-b517-ddd70565e277", "pmid": "", "title": "A Randomised Controlled Trial of a Duodenal Sleeve Bypass Device (EndoBarrier)Compared With Standard Medical Therapy for the Management of Obese Subjects With Type 2 Diabetes", "imported": false, "abstract": "The management of obesity is challenging and obesity surgery is by far the most effective treatment currently available. Recent medical research indicates that it also improves the management of blood glucose levels in people with type 2 diabetes. Obesity surgery carries different risks and benefits and it is important to balance these by choosing the right procedure for each patient. Therefore new effective strategies to prevent and reduce obesity and its complications such as type 2 diabetes mellitus are needed. This study is designed to see whether a new device called the EndoBarrier Gastrointestinal Liner helps patients manage their blood sugar levels and lose weight. It is a randomised, placebo controlled trial which compares the potential of the EndoBarrier device with conventional drug therapy, diet and exercise for obesity related type 2 diabetes, and their effectiveness on metabolic state (HbA1c reduced by 20% and blood pressure below 135/85), weight loss, and quality of life. It will further evaluate whether any other conditions that may be related to obesity could become less severe and collect information about complications to determine the safety of the device. The study will also perform various measurements and tests to understand the underlying mechanism of the device. After an initial screening visit to determine patients eligibility, they will be invited for 14 subsequent visits. Patients will be randomised into either having the EndoBarrier device or standard medical therapy treatment for 12 months followed by another 12 months follow-up period. They will also be routinely seen by specialist dietitian who will provide dietetic support throughout the study.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.161Z" }, { "id": "d8827a46-075a-422e-b848-25242cc01d9a", "pmid": "", "title": "Effect of Fructose and Glucose and TAS1R2 in Glucose, Triglycerides, Uremia, Oxidative Stress, Feelings Related to Food Intake of Individuals With Type 1 Diabetes", "imported": false, "abstract": "- BACKGROUND: Individuals with diabetes report innate preference for sweet foods, possibly due to genetic variants. In addition, studies have shown that ingestion of fructose promotes lower postprandial blood glucose, compared to glucose. However, excessive intake may increase triglycerides, uric acid and oxidative stress, due to oxidative priority.", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.151Z" }, { "id": "d88afd7e-185e-4769-b64d-67eb85c80526", "pmid": "", "title": "An Open-label, Non-randomized [11C]Carfentanil PET Study in Healthy Male Subjects to Investigate Brain Mu-opioid Receptor Occupancy, Pharmacokinetics, and Pharmacodynamics of Single Oral Doses of GSK1521498 and Naltrexone.", "imported": false, "abstract": "The purpose of this study is to determine whether GSK1521498 attaches to sites in the brain called mu-opioid receptors that are involved in the liking reactions to palatable high fat and high sugar foods. We hope that blocking these receptors may modify certain behaviours that may lead to obesity.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.238Z" }, { "id": "d8981913-8714-44ea-94f3-1e2c4f9562bd", "pmid": "", "title": "Diet or exercise, or both, for weight reduction in women after childbirth", "imported": false, "abstract": "Abstract - Background Weight retention after pregnancy may contribute to obesity. It is known that diet and exercise are recommended components of any weight loss programme in the general population. However, strategies to achieve healthy body weight among postpartum women have not been adequately evaluated. Objectives The objectives of this review were to evaluate the effect of diet, exercise or both for weight reduction in women after childbirth, and to assess the impact of these interventions on maternal body composition, cardiorespiratory fitness, breastfeeding performance and other child and maternal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012) and LILACS (31 January 2012). We scanned secondary references and contacted experts in the field. We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 30 April 2013 and added the results to the awaiting classification section of the review. Selection criteria All published and unpublished randomised controlled trials (RCTs) and quasi‐randomised trials of diet or exercise or both, among women during the postpartum period. Data collection and analysis Both review authors independently assessed trial quality and extracted data. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data. Data were analysed with a fixed‐effect model. A random‐effects model was used in the presence of heterogeneity. Main results Fourteen trials were included, but only 12 trials involving 910 women contributed data to outcome analysis. Women who exercised did not lose significantly more weight than women in the usual care group (two trials; n = 53; MD ‐0.10 kg; 95% confidence interval (CI) ‐1.90 to 1.71). Women who took part in a diet (one trial; n = 45; MD ‐1.70 kg; 95% CI ‐2.08 to ‐1.32), or diet plus exercise programme (seven trials; n = 573; MD ‐1.93 kg; 95% CI ‐2.96 to ‐0.89; random‐effects, T² = 1.09, I² = 71%), lost significantly more weight than women in the usual care group. There was no difference in the magnitude of weight loss between diet alone and diet plus exercise group (one trial; n = 43; MD 0.30 kg; 95% CI ‐0.06 to 0.66). The interventions seemed not to affect breastfeeding performance adversely. Authors' conclusions Evidence from this review suggests that both diet and exercise together and diet alone help women to lose weight after childbirth. Nevertheless, it may be preferable to lose weight through a combination of diet and exercise as this improves maternal cardiorespiratory fitness and preserves fat‐free mass, while diet alone reduces fat‐free mass. This needs confirmation in large trials of high methodological quality. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby. Plain language summary Diet or exercise, or both, for weight reduction in women carrying excess weight after childbirth Women naturally gain weight during pregnancy and many gradually lose it afterwards. Some women, though, find it difficult to lose the gained weight in the year or two following the birth of the baby and there is concern that this may be a health risk for them. The retention of weight gained during pregnancy may contribute to obesity, which can increase the risk of diabetes, heart disease and high blood pressure. It is suggested that women who return to their pre‐pregnancy weight by about six months have a lower risk of being overweight 10 years later. The review looked for randomised studies to assess the impact of dieting or exercise, or both, on women's weight loss in the months after giving birth. It paid particular attention to breastfeeding women to be sure that breastfeeding was not compromised. The review of trials found 14 studies, with 12 studies involving 910 women carrying excess weight after childbirth that contributed data for analysis. The findings suggest that diet combined with exercise or diet alone compared with usual care seemed to help with weight loss after giving birth. There is potential for these interventions to play a role in preventing future maternal obesity. There was not sufficient evidence to be sure that exercise or diet did not interfere with breastfeeding though it appeared not to in the included studies. It seems preferable to lose weight through a combination of dieting and exercise, compared to dieting alone, because exercise is thought to improve circulation and heart fitness, and to preserve lean body mass. Further research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Amorim Adegboye, AR, Linne, YM", "articleTypes": [], "doi": "10.1002/14651858.CD005627.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.090Z" }, { "id": "d89b8ad6-0a62-457b-9c22-648f2c22ee5f", "pmid": "", "title": "Beclomethasone versus placebo for chronic asthma", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Adams, NP, Bestall, JC, Malouf, R, Lasserson, TJ, Jones, P", "articleTypes": [], "doi": "10.1002/14651858.CD002738.pub2 AB - Abstract - Background Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti‐inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane‐134a (HFA) propellant which is free from chlorofluorocarbon (CFC). Objectives The objectives of this review were to: 
 (1) Compare the efficacy of BDP with placebo with both CFC and HFA propellants in the treatment of chronic asthma. 
 (2) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. 
 (3) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies. Search methods Electronic searches were current as of January 2003. Selection criteria Randomised parallel group design trials for a minimum period of four weeks, in children and adults comparing CFC‐BDP or HFA‐BDP with placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality. Data collection and analysis One reviewer extracted data; authors were contacted to clarify missing information. We analysed data with RevMan Analyses 1.0.2. Main results 60 studies recruiting 6542 participants met the inclusion criteria. CFC‐BDP (57 studies): In non‐oral steroid treated patients, at doses of 400mcg/day or less CFC‐BDP produced significant improvements from baseline in a number of efficacy measures compared with placebo, including forced expiratory volume in one second (FEV1) 360 ml (95% CI 260 to 460); FEV1 (% predicted) WMD 12.41% (95% CI 8.18 to 16.64) and morning peak expiratory flow rate (am PEF) WMD 35.95 L/min (95% CI 27.85 to 44.04). BDP also led to reductions in rescue beta‐2 agonist use compared with placebo of ‐2.32 puffs/d (95% CI ‐2.55 to ‐2.09) and reduced the relative risk (RR) of trial withdrawal due to an asthma exacerbation 0.25 (95% CI 0.12 to 0.51). Subgroup analyses based on treatment duration provide support to the proposal that a treatment period of greater than four weeks is required to realise a fuller treatment effect. In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD ‐4.91 mg/d (95% CI ‐5.88 to ‐3.94 mg/d) and greater likelihood of withdrawing oral steroid treatment RR 8.02 (95% CI 3.23 to 19.92). HFA‐BDP (3 studies): In non‐oral steroid‐treated patients, HFA‐BDP was significantly more effective than placebo in improving FEV1, morning and evening PEF, FEF25 to 75%, reduced asthma symptoms and beta2‐agonists daily consumption. Significant effects for such outcomes were apparent after six weeks of treatment. In oral steroid treated patients, HFA‐BDP improved significantly FEV1 and am PEF. The summary estimates for these outcomes suggested a high level of heterogeneity, and divergent aims of the studies may contribute to the variation we observed. Limited data on adverse events were reported. Authors' conclusions This review has quantified the efficacy of CFC‐BDP and HFA‐BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose‐response in people with severe asthma. Plain language summary Inhaled beclomethasone compared with placebo for chronic asthma During an asthma attack, the airways narrow, causing breathing problems, wheezing and coughing. Inhaled corticosteroids (ICS) are used to reduce swelling of the airways. Inhaled beclomethasone dipropionate (BDP) is commonly used. There is now a new formulation of the drug which uses a new propellant (HFA‐BDP). This review of trials found that BDP delivered with the old and new propellant is effective in helping people with chronic asthma. BDP at all doses improves airflow, reduces symptoms and the need for rescue bronchodilators. The review only included studies conducted for more than 4 weeks. The drug was well tolerated and the safety profile was comparable with placebo. The findings apply to both children and adults. The effects of the new propellant suggest that it could be more effective than the older version, although a different review will address that particular question.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.815Z" }, { "id": "d8a4841f-962e-4e1e-b772-cec7d7be0b3f", "pmid": "", "title": "Inhaled sodium cromoglycate for asthma in children", "imported": false, "abstract": "Abstract - Background Sodium cromoglycate has been recommended as maintenance treatment for childhood asthma for many years. Its use has decreased since 1990, when inhaled corticosteroids became popular, but it is still used in many countries. Objectives To determine the efficacy of sodium cromoglycate compared to placebo in the prophylactic treatment of children with asthma. Search methods We searched the Cochrane Airways Group Trials Register (October 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library Issue 3, 2009), MEDLINE (January 1966 to October 2009), EMBASE (January 1985 to October 2009) and reference lists of articles. We also contacted the pharmaceutical company manufacturing sodium cromoglycate. Selection criteria All double‐blind, placebo‐controlled randomised trials, which addressed the effectiveness of inhaled sodium cromoglycate as maintenance therapy, studying children aged 0 up to 18 years with asthma. Data collection and analysis Two authors independently assessed trial quality and extracted data. We pooled study results. Main results Of 3500 titles retrieved from the literature, 24 papers reporting on 23 studies could be included in the review. The studies were published between 1970 and 1997 and together included 1026 participants. Most were cross‐over studies. Few studies provided sufficient information to judge the concealment of allocation. Four studies provided results for the percentage of symptom‐free days. Pooling the results did not reveal a statistically significant difference between sodium cromoglycate and placebo. For the other pooled outcomes, most of the symptom‐related outcomes and bronchodilator use showed statistically significant results, but treatment effects were small. Considering the confidence intervals of the outcome measures, a clinically relevant effect of sodium cromoglycate cannot be excluded. The funnel plot showed an under‐representation of small studies with negative results, suggesting publication bias. Authors' conclusions There is insufficient evidence to be sure about the efficacy of sodium cromoglycate over placebo. Publication bias is likely to have overestimated the beneficial effects of sodium cromoglycate as maintenance therapy in childhood asthma. Plain language summary The effects of sodium cromoglycate compared with placebo for chronic asthma in children In this review we aimed to determine whether there is evidence for the effectiveness of inhaled sodium cromoglycate as maintenance treatment in children with chronic asthma. Most of the studies were carried out in small groups of patients. Furthermore, we suspect that not all studies undertaken have been published. The results show that there is insufficient evidence to be sure about the beneficial effect of sodium cromoglycate compared to placebo. However, for several outcome measures the results favoured sodium cromoglycate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "van der Wouden, JC, Uijen, JHJM, Bernsen, RMD, Tasche, MJA, de Jongste, JC, Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002173.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.094Z" }, { "id": "d8b1b9c4-373b-4839-af40-f603808772f6", "pmid": "", "title": "Cannabis and cannabinoids for symptomatic treatment for people with multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Filippini, G, Minozzi, S, Borrelli, F, Cinquini, M, Dwan, K", "articleTypes": [], "doi": "10.1002/14651858.CD013444.pub2 AB - Abstract - Background Spasticity and chronic neuropathic pain are common and serious symptoms in people with multiple sclerosis (MS). These symptoms increase with disease progression and lead to worsening disability, impaired activities of daily living and quality of life. Anti‐spasticity medications and analgesics are of limited benefit or poorly tolerated. Cannabinoids may reduce spasticity and pain in people with MS. Demand for symptomatic treatment with cannabinoids is high. A thorough understanding of the current body of evidence regarding benefits and harms of these drugs is required. Objectives To assess benefit and harms of cannabinoids, including synthetic, or herbal and plant‐derived cannabinoids, for reducing symptoms for adults with MS. Search methods We searched the following databases from inception to December 2021: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), CINAHL (EBSCO host), LILACS, the Physiotherapy Evidence Database (PEDro), the World Health Organisation International Clinical Trials Registry Platform, the US National Institutes of Health clinical trial register, the European Union Clinical Trials Register, the International Association for Cannabinoid Medicines databank. We hand searched citation lists of included studies and relevant reviews. Selection criteria We included randomised parallel or cross‐over trials (RCTs) evaluating any cannabinoid (including herbal C annabis, C annabis flowers, plant‐based cannabinoids, or synthetic cannabinoids) irrespective of dose, route, frequency, or duration of use for adults with MS. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane Risk of bias 2 tool for parallel RCTs and crossover trials. We rated the certainty of evidence using the GRADE approach for the following outcomes: reduction of 30% in the spasticity Numeric Rating Scale, pain relief of 50% or greater in the Numeric Rating Scale‐Pain Intensity, much or very much improvement in the Patient Global Impression of Change (PGIC), Health‐Related Quality of Life (HRQoL), withdrawals due to adverse events (AEs) (tolerability), serious adverse events (SAEs), nervous system disorders, psychiatric disorders, physical dependence. Main results We included 25 RCTs with 3763 participants of whom 2290 received cannabinoids. Age ranged from 18 to 60 years, and between 50% and 88% participants across the studies were female. The included studies were 3 to 48 weeks long and compared nabiximols, an oromucosal spray with a plant derived equal (1:1) combination of tetrahydrocannabinol (THC) and cannabidiol (CBD) (13 studies), synthetic cannabinoids mimicking THC (7 studies), an oral THC extract of C annabis sativa (2 studies), inhaled herbal C annabis (1 study) against placebo. One study compared dronabinol, THC extract of C annabis sativa and placebo, one compared inhaled herbal C annabis , dronabinol and placebo. We identified eight ongoing studies. Critical outcomes • Spasticity: nabiximols probably increases the number of people who report an important reduction of perceived severity of spasticity compared with placebo (odds ratio (OR) 2.51, 95% confidence interval (CI) 1.56 to 4.04; 5 RCTs, 1143 participants; I 2 = 67%; moderate‐certainty evidence). The absolute effect was 216 more people (95% CI 99 more to 332 more) per 1000 reporting benefit with cannabinoids than with placebo. • Chronic neuropathic pain: we found only one small trial that measured the number of participants reporting substantial pain relief with a synthetic cannabinoid compared with placebo (OR 4.23, 95% CI 1.11 to 16.17; 1 study, 48 participants; very low‐certainty evidence). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity. • Treatment discontinuation due to AEs: cannabinoids may increase slightly the number of participants who discontinue treatment compared with placebo (OR 2.41, 95% CI 1.51 to 3.84; 21 studies, 3110 participants; I² = 17%; low‐certainty evidence); the absolute effect is 39 more people (95% CI 15 more to 76 more) per 1000 people. Important outcomes • PGIC: cannabinoids probably increase the number of people who report 'very much' or 'much' improvement in health status compared with placebo (OR 1.80, 95% CI 1.37 to 2.36; 8 studies, 1215 participants; I² = 0%; moderate‐certainty evidence). The absolute effect is 113 more people (95% CI 57 more to 175 more) per 1000 people reporting improvement. • HRQoL: cannabinoids may have little to no effect on HRQoL (SMD ‐0.08, 95% CI ‐0.17 to 0.02; 8 studies, 1942 participants; I 2 = 0%; low‐certainty evidence); • SAEs: cannabinoids may result in little to no difference in the number of participants who have SAEs compared with placebo (OR 1.38, 95% CI 0.96 to 1.99; 20 studies, 3124 participants; I² = 0%; low‐certainty evidence); • AEs of the nervous system: cannabinoids may increase nervous system disorders compared with placebo (OR 2.61, 95% CI 1.53 to 4.44; 7 studies, 1154 participants; I² = 63%; low‐certainty evidence); • Psychiatric disorders: cannabinoids may increase psychiatric disorders compared with placebo (OR 1.94, 95% CI 1.31 to 2.88; 6 studies, 1122 participants; I² = 0%; low‐certainty evidence); • Drug tolerance: the evidence is very uncertain about the effect of cannabinoids on drug tolerance (OR 3.07, 95% CI 0.12 to 75.95; 2 studies, 458 participants; very low‐certainty evidence). Authors' conclusions Compared with placebo, nabiximols probably reduces the severity of spasticity in the short‐term in people with MS. We are uncertain about the effect on chronic neurological pain and health‐related quality of life. Cannabinoids may increase slightly treatment discontinuation due to AEs, nervous system and psychiatric disorders compared with placebo. We are uncertain about the effect on drug tolerance. The overall certainty of evidence is limited by short‐term duration of the included studies. Plain language summary Cannabis and cannabinoids for people with multiple sclerosis Key messages 
• Treatment with nabiximols likely results in improvement of spasticity and may not increase serious harmful effects compared with placebo • Compared with placebo, cannabinoids (nabiximols, C annabis extract, synthetic cannabinoids) likely improve well‐being when measured with patient‐reported outcomes • Due to a lack of robust evidence, the benefit of these medicines for treating chronic neuropathic pain is unclear. What is the issue? Many people with multiple sclerosis (MS) experience spasticity that causes also pain and impacts on the ability to carry out daily activities. Spasticity is a form of increased muscle tone. Cannabis ‐based medicines refer to the use of Cannabis , or its ingredients called cannabinoids, as medical therapies to alleviate spasticity, chronic pain and other symptoms in MS. An international survey found that MS was one of the five medical conditions for which C annabis was most often used. Another survey conducted in the UK found that more than one in five people with MS reported they had used C annabis to try to manage their symptoms. What did we want to find out? We wanted to find out if cannabinoids were better than placebo in adults with MS to improve: • spasticity; • chronic neuropathic pain; • well‐being, We also wanted to find out if cannabinoids were associated with: • treatment discontinuation due to unwanted effects; • serious harmful effects; • nervous system disorders or psychiatric disorders; • drug tolerance defined as a condition that occurs when the body gets used to a medicine so that more medicine is needed. What did we do? 
We searched for studies that compared cannabinoids against placebo in adult people with MS. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and certainty of evidence. What did we find? We found 25 studies that involved 3763 people with MS, 2290 of whom received cannabinoids. Fifteen studies were very short term or short‐term studies (two to 12 weeks), seven were intermediate term (12 to 26 weeks), and two were long term (50 and 156 weeks). One study reported results at three days only. The biggest study was conducted in 657 people and the smallest study involved 14 people. Most studies were done in European countries. Thirteen studies evaluated an oral spray (nabiximols) containing two compounds derived from the C annabis plant. The other studies compared different cannabinoids with placebo. Pharmaceutical companies funded 15 of the studies. Main results Compared with placebo, cannabinoids: • probably increase the number of people who report an important reduction of perceived severity of spasticity for up to 14 weeks (evidence from five studies in 1143 people); • may increase the number of people who report an important reduction of perceived severity of chronic neuropathic pain, but the evidence is very uncertain (evidence from one study in 48 people). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity: • probably increase the number of people who perceive their well‐being as 'very much' or 'much' improved (evidence from eight studies in 1215 people); • may increase slightly the number of people who discontinue treatment due to unwanted effects (evidence from 21 studies in 3110 people); • may result in little to no difference in the number of people who have serious harmful effects (evidence from 20 studies in 3124 people); • may increase nervous system disorders (evidence from seven studies in 1154 people) or psychiatric disorders (evidence from six studies in 1122 people); • may have little to no effect on the number of people who have drug tolerance, but the evidence is very uncertain (two studies in 458 people). What are the limitations of the evidence? There is no high‐quality evidence. We are moderately confident that cannabinoids work better versus no cannabinoids to improve severity of spasticity and well‐being in adults with MS. We have little confidence in our results for the effect on chronic neuropathic pain because the available evidence is limited. There is limited evidence to determine the effects of cannabinoids on serious harmful effects, nervous system or psychiatric disorders, and drug tolerance. How up to date is the evidence? 
The evidence is up‐to‐date to December 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.096Z" }, { "id": "d8bf3769-1730-4852-8dab-60e6caa50483", "pmid": "", "title": "New generation antidepressants for depression in children and adolescents: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Major depressive disorders have a significant impact on children and adolescents, including on educational and vocational outcomes, interpersonal relationships, and physical and mental health and well‐being. There is an association between major depressive disorder and suicidal ideation, suicide attempts, and suicide. Antidepressant medication is used in moderate to severe depression; there is now a range of newer generations of these medications. Objectives To investigate, via network meta‐analysis (NMA), the comparative effectiveness and safety of different newer generation antidepressants in children and adolescents with a diagnosed major depressive disorder (MDD) in terms of depression, functioning, suicide‐related outcomes and other adverse outcomes. The impact of age, treatment duration, baseline severity, and pharmaceutical industry funding was investigated on clinician‐rated depression (CDRS‐R) and suicide‐related outcomes. Search methods We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR)), together with Ovid Embase, MEDLINE and PsycINFO till March 2020. Selection criteria Randomised trials of six to 18 year olds of either sex and any ethnicity with clinically diagnosed major depressive disorder were included. Trials that compared the effectiveness of newer generation antidepressants with each other or with a placebo were included. Newer generation antidepressants included: selective serotonin reuptake inhibitors; selective norepinephrine reuptake inhibitors (SNRIs); norepinephrine reuptake inhibitors; norepinephrine dopamine reuptake inhibitors; norepinephrine dopamine disinhibitors (NDDIs); and tetracyclic antidepressants (TeCAs). Data collection and analysis Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed risk of bias. We analysed dichotomous data as Odds Ratios (ORs), and continuous data as Mean Difference (MD) for the following outcomes: depression symptom severity (clinician rated), response or remission of depression symptoms, depression symptom severity (self‐rated), functioning, suicide related outcomes and overall adverse outcomes. Random‐effects network meta‐analyses were conducted in a frequentist framework using multivariate meta‐analysis. Certainty of evidence was assessed using Confidence in Network Meta‐analysis (CINeMA). We used \"informative statements\" to standardise the interpretation and description of the results. Main results Twenty‐six studies were included. There were no data for the two primary outcomes (depressive disorder established via clinical diagnostic interview and suicide), therefore, the results comprise only secondary outcomes. Most antidepressants may be associated with a \"small and unimportant\" reduction in depression symptoms on the CDRS‐R scale (range 17 to 113) compared with placebo (high certainty evidence: paroxetine: MD ‐1.43, 95% CI ‐3.90, 1.04; vilazodone: MD ‐0.84, 95% CI ‐3.03, 1.35; desvenlafaxine MD ‐0.07, 95% CI ‐3.51, 3.36; moderate certainty evidence: sertraline: MD ‐3.51, 95% CI ‐6.99, ‐0.04; fluoxetine: MD ‐2.84, 95% CI ‐4.12, ‐1.56; escitalopram: MD ‐2.62, 95% CI ‐5.29, 0.04; low certainty evidence: duloxetine: MD ‐2.70, 95% CI ‐5.03, ‐0.37; vortioxetine: MD 0.60, 95% CI ‐2.52, 3.72; very low certainty evidence for comparisons between other antidepressants and placebo). There were \"small and unimportant\" differences between most antidepressants in reduction of depression symptoms (high‐ or moderate‐certainty evidence). Results were similar across other outcomes of benefit. In most studies risk of self‐harm or suicide was an exclusion criterion for the study. Proportions of suicide‐related outcomes were low for most included studies and 95% confidence intervals were wide for all comparisons. The evidence is very uncertain about the effects of mirtazapine (OR 0.50, 95% CI 0.03, 8.04), duloxetine (OR 1.15, 95% CI 0.72, 1.82), vilazodone (OR 1.01, 95% CI 0.68, 1.48), desvenlafaxine (OR 0.94, 95% CI 0.59, 1.52), citalopram (OR 1.72, 95% CI 0.76, 3.87) or vortioxetine (OR 1.58, 95% CI 0.29, 8.60) on suicide‐related outcomes compared with placebo. There is low certainty evidence that escitalopram may \"at least slightly\" reduce odds of suicide‐related outcomes compared with placebo (OR 0.89, 95% CI 0.43, 1.84). There is low certainty evidence that fluoxetine (OR 1.27, 95% CI 0.87, 1.86), paroxetine (OR 1.81, 95% CI 0.85, 3.86), sertraline (OR 3.03, 95% CI 0.60, 15.22), and venlafaxine (OR 13.84, 95% CI 1.79, 106.90) may \"at least slightly\" increase odds of suicide‐related outcomes compared with placebo. There is moderate certainty evidence that venlafaxine probably results in an \"at least slightly\" increased odds of suicide‐related outcomes compared with desvenlafaxine (OR 0.07, 95% CI 0.01, 0.56) and escitalopram (OR 0.06, 95% CI 0.01, 0.56). There was very low certainty evidence regarding other comparisons between antidepressants. Authors' conclusions Overall, methodological shortcomings of the randomised trials make it difficult to interpret the findings with regard to the efficacy and safety of newer antidepressant medications. Findings suggest that most newer antidepressants may reduce depression symptoms in a small and unimportant way compared with placebo. Furthermore, there are likely to be small and unimportant differences in the reduction of depression symptoms between the majority of antidepressants. However, our findings reflect the average effects of the antidepressants, and given depression is a heterogeneous condition, some individuals may experience a greater response. Guideline developers and others making recommendations might therefore consider whether a recommendation for the use of newer generation antidepressants is warranted for some individuals in some circumstances. Our findings suggest sertraline, escitalopram, duloxetine, as well as fluoxetine (which is currently the only treatment recommended for first‐line prescribing) could be considered as a first option. Children and adolescents considered at risk of suicide were frequently excluded from trials, so that we cannot be confident about the effects of these medications for these individuals. If an antidepressant is being considered for an individual, this should be done in consultation with the child/adolescent and their family/caregivers and it remains critical to ensure close monitoring of treatment effects and suicide‐related outcomes (combined suicidal ideation and suicide attempt) in those treated with newer generation antidepressants, given findings that some of these medications may be associated with greater odds of these events. Consideration of psychotherapy, particularly cognitive behavioural therapy, as per guideline recommendations, remains important. Plain language summary Newer generation antidepressants for depression in children and adolescents: a network meta‐analysis How well do newer formulations of antidepressants work for children and adolescents with clinical depression? Children and adolescents (6 to 18 years) with depression (also called ‘major depressive disorder’) experience a range of negative impacts in all areas of their lives and have an increased risk of suicide, suicidal thinking and suicide attempts. Antidepressants have been shown to reduce symptoms of depression, but can also increase the risk of suicide‐related outcomes. Who will be interested in this research? The research in this Cochrane Review will interest: ‐ people who decide policy, and influence decisions about the prescription of antidepressant medicines to children and adolescents; ‐ people who prescribe these medicines to children and adolescents; ‐ children and adolescents with depression; and ‐ those who support and care for them (including their parents and caregivers and clinicians who provide treatment). What did we want to find out? We wanted to find out how well newer formulations (called ‘new generation’) antidepressants work to improve depression in children and adolescents aged 6 to 18 years. New generation antidepressants are those that have been developed recently. They are sometimes referred to as ‘second‐‘ and ‘third‐generation’ antidepressants; they do not include older formulations (tricyclic antidepressants or monoamine oxidase inhibitors). We wanted to know how these antidepressants affect: ‐ symptoms of depression; ‐ recovery: no longer meeting diagnostic criteria for major depressive disorder; ‐ response or remission: scores on a scale indicating an important reduction in depression or no longer experiencing depression; ‐ ability to function in daily life; ‐ suicide‐related outcomes; and ‐ whether they cause any unwanted effects in children and adolescents. What did we do? We searched for studies that tested new generation antidepressants on children or adolescents (or both) who had been diagnosed with a major depressive disorder. We identified 26 such studies. We then assessed the trustworthiness of those studies, and synthesized the findings across the studies. What does the evidence from the review tell us? Most newer antidepressants probably reduce depression symptoms better than a placebo (a 'dummy' treatment that does not contain any medicine but looks identical to the medicine being tested). However, the reduction is small and may not be experienced as important by children and adolescents, their parents and caregivers, or clinicians. When different medications are compared against each other, there may be only small and unimportant differences between most of them for the reduction of symptoms. Our findings reflect what happens on average to individuals, but some individuals may experience a greater response. This might lead to recommendations being made for the use of antidepressants for some individuals in some circumstances. Our findings suggest that sertraline, escitalopram, duloxetine and fluoxetine can be used if medication is being considered. The impact of medication on depression symptoms should be closely monitored by those prescribing the medication, especially as suicide‐related thinking and behaviour may be increased in those taking these medications. Close monitoring of suicide‐related behaviours is vital in those treated with new generation antidepressants. What should happen next? The studies that provided this evidence largely excluded children and adolescents who: ‐ were already thinking about suicide and wanting to take their own lives (i.e. had suicidal ideation); ‐ were self‐harming; ‐ had other mental health conditions; and ‐ had psychosocial difficulties. Future research should aim to understand the impacts of these medicines in children and adolescents with these problems, who are more typical of those who request clinical services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Hetrick, SE; McKenzie, JE; Bailey, AP; Sharma, V; Moller, CI; Badcock, PB; Cox, GR; Merry, SN; Meader, N", "articleTypes": [], "doi": "10.1002/14651858.CD013674.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "d8dcf90f-a708-484e-83f7-c529e84801d0", "pmid": "", "title": "Melatonin in cancer treatment", "imported": false, "abstract": "Abstract - Rationale Preserving health‐related quality of life is an aspect of care that requires constant attention from the time of cancer diagnosis. Melatonin has been used to diminish treatment‐related side effects and cancer symptoms, and as a medication to regulate circadian rhythm. An up‐to‐date systematic review is needed to investigate the current evidence concerning possible beneficial effects of melatonin on quality of life and sleep in cancer patients. Objectives To evaluate the benefits and harms of melatonin for preserving health‐related quality of life and sleep in cancer patients. Search methods To identify studies for inclusion in this review, we used CENTRAL, MEDLINE, 10 other databases, and four trial registers, together with reference checking, citation searching, and contact with study authors. The latest search date was 10 September 2024. Eligibility criteria We included randomised controlled trials (RCTs) of adults (18 years or over) with histologically proven cancer of any stage that evaluated melatonin (alone or in combination with standard anticancer treatment) versus no treatment or placebo (alone or in combination with standard anticancer treatment), or standard anticancer treatment. Standard anticancer treatment refers to treatments to stop or prevent cancer, including chemotherapy, radiation therapy, surgery, immunotherapy, and hormonal therapies (such as androgen deprivation therapy). Outcomes The primary outcomes of interest were quality of life and sleep quality within three months, and melatonin‐related adverse events. Other outcomes included survival, disease‐free survival, progression‐free survival, tumour response, and anticancer treatment‐related harms. Risk of bias We used Cochrane's risk of bias tool (RoB 1) to assess the risk of bias in the studies included in the review. Synthesis methods We synthesised results for each outcome using random‐effects meta‐analysis. The effect size was presented as risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CI). If this was not possible, due to the nature of the data, we synthesised results in a narrative format. We used GRADE to assess the certainty of evidence for each outcome. Included studies We identified 30 RCTs (reported in 49 publications) involving 5093 adult participants with cancer (2470 males, 2228 females, 395 not reported). Studies were conducted in a hospital setting and took place in at least 10 countries. We assessed two studies at low risk of bias and the other 28 at high risk of bias. Synthesis of results Melatonin plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life score (MD 2.60, 95% CI −14.53 to 19.73; 1 study, 126 participants; very low certainty evidence), and sleep score (MD 2.80, 95% CI 0.18 to 5.42; 1 study, 50 participants; very low certainty evidence) within three months. We are also very uncertain about potential adverse effects of melatonin: headache (RR 2.77, 95% CI 0.33 to 23.14; 1 study, 25 participants; very low certainty evidence); fatigue (RR 1.02, 95% CI 0.90 to 1.17; 2 studies, 170 participants; very low certainty evidence); and nausea (RR 1.01, 95% CI 0.66 to 1.56; 1 study, 146 participants; very low certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of high risk of bias, small sample size, the width of the 95% confidence interval, and indirectness due to inadequate reporting of cancer type. Melatonin plus standard treatment versus standard treatment No data are available relating to quality of life and sleep within three months. The evidence is very uncertain about headaches (experienced by 15 of 820 participants in melatonin groups, with no data available for control groups; 2 studies, 1640 participants; very low certainty evidence). Melatonin likely reduces the incidence of fatigue (RR 0.46, 95% CI 0.39 to 0.55; 10 studies, 1359 participants; moderate‐certainty evidence) and may reduce nausea (RR 0.85, 95% CI 0.72 to 1.00; 6 studies, 710 participants; low‐certainty evidence). No data are available relating to dizziness. We downgraded the certainty of the evidence because of the high risk of bias and the width of the 95% confidence interval. Melatonin (topical use) plus standard treatment versus placebo plus standard treatment The evidence is very uncertain about the effect of melatonin on quality of life (one study reported no difference between groups, both having the same median score of 66.7; 48 participants; very low certainty evidence). No data are available relating to sleep and adverse events (including headache, dizziness, fatigue, and nausea). We downgraded the certainty of the evidence because of the high risk of bias, small sample size, and insufficient data. Authors' conclusions The available evidence is of very low certainty, so we are unable to draw conclusions about the effects of melatonin on quality of life and sleep at three months in people receiving treatment for cancer. There may be no difference in adverse events between melatonin plus standard treatment and placebo plus standard treatment, but the evidence is very uncertain. Data were lacking for some outcomes, such as dizziness. Melatonin used alongside standard treatment probably reduces the risk of fatigue and may reduce nausea when compared to standard treatment alone. Since the evidence base for melatonin in people with cancer is limited due to insufficient data and risks of bias in study design, the decision for or against using melatonin as an adjunct to cancer treatment cannot easily be made at the current time. Funding This Cochrane Review was partially funded by AG Biologische Krebstherapie, Deutsche Krebshilfe (grant numbers 70‐301 and 109863). The funding agency had no role in the design or conduct of the study. Registration The protocol for this review is available via DOI 10.1002/14651858.CD010145. Plain language summary For cancer patients, what are the benefits and risks of taking the hormone melatonin? Key messages Due to a lack of robust evidence, the effects of melatonin on quality of life and sleep quality in people receiving treatment for cancer are unclear. Melatonin might not increase the risk of adverse events, but the available evidence is not strong enough for us to be certain. Well designed studies using melatonin over a period of up to three months are needed to give better estimates of the benefits and risks. What is melatonin? Melatonin is a hormone produced in the body to regulate the daily sleep and wakefulness cycle. It has been suggested that melatonin may improve sleep quality and quality of life, which are very important in cancer treatment. Moreover, there is research suggesting that melatonin is effective against solid tumours and may be effective for the treatment of cancer. What did we want to find out? We wanted to find out if melatonin can be used in cancer treatment, particularly for preserving the quality of life and sleep quality of cancer patients. We also wanted to find out if melatonin causes any unwanted side effects ('adverse events'). What did we do? We searched for studies that looked at melatonin used with other standard cancer treatments compared with standard cancer treatments used alone or with placebo (fake treatment). What did we find? We found 30 studies that involved 5093 cancer patients, both men and women, with cancer of any type. The studies were conducted in 10 countries around the world. We focused on the effects of melatonin over a period of three months. When compared to placebo plus standard cancer treatments, it is unclear if melatonin has an effect on quality of life and sleep. Melatonin may have little to no effect on potential adverse events like headache, fatigue, and nausea, but we are very uncertain about these results. No results are available for dizziness. We found no studies to help us answer our questions about quality of life and sleep quality when melatonin is used with standard cancer treatments compared to the standard treatment alone. However, the studies did evaluate potential adverse events that might be related to melatonin, and they found that melatonin probably reduces the risk of tiredness (fatigue), and may reduce the risk of feeling sick (nausea). It is unclear if melatonin has an effect on headaches. No results are available for dizziness. When melatonin is used topically, such as in a cream to put on the skin or in a mouth wash, it is unclear if it has an effect on quality of life. We found no studies to help us answer our questions about sleep quality. No data are available for adverse events like headache, fatigue, nausea, and dizziness, as these are not relevant if the melatonin is used topically. It is unclear if melatonin has any other unwanted effects when used topically. What are the limitations of the evidence? We are not confident in the evidence because it is possible that people in the studies were aware of which treatment they were getting. The evidence relating to some benefits and risks we are interested in does not cover all cancer types, or it is based on only a few cases. How up to date is this evidence? The evidence is up‐to‐date to September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Yu, ZY; Peng, RY; Cheng, N; Wang, RT; Nan, MD; Milazzo, S; Pilkington, K; Seely, D; Horneber, M; Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010145.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "d8f167b1-91ed-4052-95f1-afedb69e500c", "pmid": "", "title": "Modifying the consistency of food and fluids for swallowing difficulties in dementia", "imported": false, "abstract": "Abstract - Background People with dementia can have feeding and swallowing difficulties (dysphagia). Modification of the consistency of food or fluids, or both, is a common management strategy. However, diet modification can affect quality of life and may lead to dehydration and malnutrition. Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia. Objectives To determine the effectiveness and adverse effects associated with modifying the consistency of food and fluids in improving oral intake and eliminating aspiration in adults with dysphagia and dementia. Search methods We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE via Ovid SP, Embase via Ovid SP, PsycINFO via Ovid SP, CINAHL via EBSCOhost, LILACS via BIREME, ClinicalTrials.gov and the World Health Organization (WHO) Portal on 9 May 2018. We also checked the reference lists of relevant articles to identify any additional studies. Selection criteria We included randomised controlled trials (RCTs), quasi‐RCTs and cluster‐RCTs published in any language that measured any of the outcomes of interest. We included trials with adults with a clinical diagnosis of dementia with symptoms and signs of dysphagia confirmed on instrumental assessment. We included participants with all types, stages and severities of dementia. Control groups received either no intervention or interventions not involving diet modification or modification to sensory properties of food. Data collection and analysis Two review authors independently assessed for inclusion all potential studies identified. Data were extracted independently along with assessment of methodological quality using standard Cochrane methods. We contacted study authors for additional unpublished information. Main results No trials on modification of food met the inclusion criteria. We included two studies that examined modification to fluids. Both were part of the same large multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. Participation in the second trial was determined by results from the first trial. With unpublished data supplied by study authors, we examined data from participants with dementia only. The first study, a cross‐over trial, investigated the immediate effects on aspiration of two viscosities of liquids (nectar thick and honey thick) compared to regular liquids in 351 participants with dementia using videofluoroscopy. Regular liquids with a chin down head posture, as well as regular liquids without any intervention were also compared. The sequence of interventions during videofluoroscopy may have influenced response to intervention. The second study, a parallel designed RCT, compared the effect of nectar and honey thick liquids with a chin down head posture over a three‐month period in a subgroup of 260 participants with dementia. Outcomes were pneumonia and adverse intervention effects. Honey thick liquids, which are more consistent with descriptors for 'spoon thick' or 'extremely thick' liquids, showed a more positive impact on immediate elimination of aspiration during videofluoroscopy, but this consistency showed more adverse effects in the second follow‐up study. During the second three‐month follow‐up trial, there were a greater number of incidents of pneumonia in participants receiving honey thick liquids than those receiving nectar thick liquids or taking regular liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of fluids prescribed. Neither trial addressed quality of life. Risk of bias for both studies is high. The overall quality of evidence for outcomes in this review is low. Authors' conclusions We are uncertain about the immediate and long‐term effects of modifying the consistency of fluid for swallowing difficulties in dementia as too few studies have been completed. There may be differences in outcomes depending on the grade of thickness of fluids and the sequence of interventions trialled in videofluoroscopy for people with dementia. Clinicians should be aware that while thickening fluids may have an immediate positive effect on swallowing, the long‐term impact of thickened fluids on the health of the person with dementia should be considered. Further high‐quality clinical trials are required. Plain language summary Modifying the consistency of food and fluids for swallowing difficulties in dementia Background Individuals with dementia often present with swallowing difficulties (dysphagia). The consequences can include choking, dehydration, malnutrition, weight loss, pneumonia and death. Modification of food and liquid is a popular management strategy. It is believed that increasing the viscosity of liquids or altering the consistency of food allows individuals a better opportunity to swallow, with a reduced risk of choking or liquids entering the airway. However, there is growing evidence suggesting that this strategy can lead to dehydration, malnutrition, negative psychological/social consequences, and can affect quality of life for the person with dementia. Review question We wished to find out if changing the viscosity or consistency of food or fluids, or both, makes swallowing safer and has positive outcomes for people with dementia in terms of respiratory status, nutritional status and quality of life. We wanted to examine if modifying food or fluids, or both, also had any adverse effects for the person with dementia. Study characteristics We found two studies, which were both part of the same multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. We included data on people with dementia only. The first of the two studies looked at the immediate effects of two viscosities of liquids compared to regular thin liquids on aspiration (entry of food or fluid into the lungs) in 351 people with dementia. This study also compared drinking regular thin liquids using a chin down head posture as well as drinking regular thin liquids without any changes to head position; the main outcome was fluid entering the lungs. Using a subgroup of 260 people with dementia from the first study, the second study compared the effect of the same liquid viscosities with a chin down head posture. The effectiveness of these interventions on the incidence of pneumonia and adverse effects of these interventions was examined over a three‐month period. Study results Honey thick viscosity liquids, which clinically are similar to descriptions of 'very thick liquids', had a more positive immediate impact on preventing fluid entering the lungs when examined during videofluoroscopy (specialised swallow x‐ray) examination. However, during the three‐month follow‐up period there were a greater number of incidents of pneumonia in the group of people with dementia receiving these honey thick liquids, than those receiving nectar thick liquids and those receiving regular thin liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of liquids that the person with dementia was receiving. Conclusion There were a number of methodological flaws in both studies in this review and these were acknowledged by the authors. While thickening fluids may have an immediate positive effect on swallow function, clinicians should consider the effects of this intervention on the person with dementia in the longer‐term. People with dementia on thickened fluids require long‐term follow‐up. The overall risk of bias of included studies is high. The quality of evidence is low. Further well‐designed research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Flynn, E, Smith, CH, Walsh, CD, Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD011077.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.080Z" }, { "id": "d8f6dd65-9809-4ff1-ae48-38adb66bbeea", "pmid": "", "title": "Ganoderma lucidum (Reishi mushroom) for cancer treatment", "imported": false, "abstract": "Abstract - Background Ganoderma lucidum is a natural medicine that is widely used and recommended by Asian physicians and naturopaths for its supporting effects on immune system. Laboratory research and a handful of preclinical trials have suggested that G. lucidum carries promising anticancer and immunomodulatory properties. The popularity of taking G. lucidum as an alternative medicine has been increasing in cancer patients. However, there is no systematic review that has been conducted to evaluate the actual benefits of G. lucidum in cancer treatment. Objectives To evaluate the clinical effects of G. lucidum on long‐term survival, tumour response, host immune functions and quality of life in cancer patients, as well as adverse events associated with its use. Search methods We searched an extensive set of databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, NIH, AMED, CBM, CNKI, CMCC and VIP Information/Chinese Scientific Journals Database was searched for randomised controlled trials (RCTs) in October 2011. Other strategies used were scanning the references of articles retrieved, handsearching of the International Journal of Medicinal Mushrooms and contact with herbal medicine experts and manufacturers of G. lucidum . For this update we updated the searches in February 2016. Selection criteria To be eligible for being included in this review, studies had to be RCTs comparing the efficacy of G. lucidum medications to active or placebo control in patients with cancer that had been diagnosed by pathology. All types and stages of cancer were eligible for inclusion. Trials were not restricted on the basis of language. Data collection and analysis Five RCTs met the inclusion criteria and were included in this review. Two independent review authors assessed the methodological quality of individual trials. Common primary outcomes were tumour response evaluated according to the World Health Organization (WHO) criteria, immune function parameters such as natural killer (NK)‐cell activity and T‐lymphocyte co‐receptor subsets, and quality of life measured by the Karnofsky scale score. No trial had recorded long‐term survival rates. Associated adverse events were reported in one study. A meta‐analysis was performed to pool available data from the primary trials. Results were gauged using relative risks (RR) and standard mean differences (SMD) for dichotomous and continuous data respectively, with a 95% confidence interval (CI). Main results The methodological quality of primary studies was generally unsatisfying and the results were reported inadequately in many aspects. Additional information was not available from primary trialists. The meta‐analysis results showed that patients who had been given G. lucidum alongside with chemo/radiotherapy were more likely to respond positively compared to chemo/radiotherapy alone (RR 1.50; 95% CI 0.90 to 2.51, P = 0.02). G. lucidum treatment alone did not demonstrate the same regression rate as that seen in combined therapy. The results for host immune function indicators suggested that G. lucidum simultaneously increases the percentage of CD3, CD4 and CD8 by 3.91% (95% CI 1.92% to 5.90%, P < 0.01), 3.05% (95% CI 1.00% to 5.11%, P < 0.01) and 2.02% (95% CI 0.21% to 3.84%, P = 0.03), respectively. In addition, leukocyte, NK‐cell activity and CD4/CD8 ratio were marginally elevated. Four studies showed that patients in the G. lucidum group had relatively improved quality of life in comparison to controls. One study recorded minimal side effects, including nausea and insomnia. No significant haematological or hepatological toxicity was reported. Authors' conclusions Our review did not find sufficient evidence to justify the use of G. lucidum as a first‐line treatment for cancer. It remains uncertain whether G. lucidum helps prolong long‐term cancer survival. However, G. lucidum could be administered as an alternative adjunct to conventional treatment in consideration of its potential of enhancing tumour response and stimulating host immunity. G. lucidum was generally well tolerated by most participants with only a scattered number of minor adverse events. No major toxicity was observed across the studies. Although there were few reports of harmful effect of G. lucidum , the use of its extract should be judicious, especially after thorough consideration of cost‐benefit and patient preference. Future studies should put emphasis on the improvement in methodological quality and further clinical research on the effect of G. lucidum on cancer long‐term survival are needed. An update to this review will be performed every two years. Plain language summary G. lucidum (Reishi mushroom) for cancer treatment There have been an increasing number of patients diagnosed with cancer each year. Certain malignancies have been a major cause of death in some populations. People who have been diagnosed with cancer want to do everything they can to combat the disease, manage its symptoms and cope with the side effects of radio/chemotherapy. Many turn to complementary and alternative medicine. G. lucidum extract is a medication that has been widely used by traditional Chinese medicine (TCM) practitioners for this regard. It is usually recommended as an immune system support supplement in cancer treatment. Latest laboratory research and preclinical trials of G. lucidum have shown promising results of its antitumour activity. However, clinical evidence of its efficacy is sparse and a systematic review is in need to provide collective information for health‐care consumers. Our review identified and subsequently included five relevant randomised controlled trials. A total of 373 subjects were analysed. A meta‐analysis was performed to pool available data from individual trials. Our results found that patients with G. lucidum extract in their anticancer regimen were 1.27 times more likely to respond to chemotherapy or radiotherapy than those without. However, the data failed to demonstrate significant effect on tumour shrinkage when it was used alone. In addition, G. lucidum could stimulate host immune functions by considerably increasing CD3, CD4 and CD8 lymphocyte percentages. Nevertheless, natural killer (NK)‐cell activity, which has been suggested to be an indicator of self‐defence against tumour cell, was marginally elevated. Patients in the G. lucidum group were found to have a relatively better quality of life after treatment than those in the control group. A few cases of minor side effect associated with G. lucidum treatment including nausea and insomnia were reported. There are limitations of the results from this systematic review. First, most included studies were small and there were concerns on the methodological quality of individual trials. Second, all participants in the individual trials were recruited from the Chinese population. Together, the robustness and applicability of the results were largely affected.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Jin, X; Ruiz Beguerie, J; Sze, DMY; Chan, GCF", "articleTypes": [], "doi": "10.1002/14651858.CD007731.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "d90965ad-1388-4f7f-9c0a-7dd4d2c38eb8", "pmid": "", "title": "Transitional discharge interventions for people with schizophrenia", "imported": false, "abstract": "Abstract - Background Schizophrenia is a chronic mental illness characterized by delusions, hallucinations, and important functional and social disability. Interventions labeled as 'transitional' add to care plans made during the hospital stay in preparation for discharge. They also include interventions developed after discharge to support people with serious mental illness as they make the transition from the hospital to the community. Transitional discharge interventions may anticipate the future needs of the patient after discharge by co‐ordinating the different levels of the health system that can effectively guarantee continuity of care in the community. This occurs through the provision of therapeutic relationships which give a safety net throughout the discharge and community reintegration processes to improve the general condition of users, level of functioning, use of health resources, and satisfaction with care. Objectives To assess the effects of transitional discharge interventions for people with schizophrenia. Search methods On 7 December 2022, we searched the Cochrane Schizophrenia Group's Study‐Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, PubMed, CINAHL, ClinicalTrials.gov, ISRCTN, PsycINFO, and WHO ICTRP. Selection criteria Randomized controlled trials (RCTs) evaluating the effects of transitional discharge interventions in people with schizophrenia and schizophrenia‐related disorders. Eligible interventions included three key elements: predischarge planning, co‐ordination of care and follow‐up, and postdischarge support. Data collection and analysis We used standard Cochrane methods. Outcomes of this review included global state (relapse), service use (hospitalization), general functioning, satisfaction with care, adverse effects/events, quality of life, and direct costs. For binary outcomes, we calculated risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardized mean difference (SMD) and their 95% CIs. We used GRADE to assess certainty of evidence. Main results We found 12 studies with 1748 participants comparing transitional discharge interventions to usual care. All were parallel‐group RCTs. No studies assessed global state (relapse) or reported data about adverse events/effects. All studies had a high risk of bias, mainly due to serious concerns about allocation concealment, deviations from intended interventions, measurement of the outcomes, and missing outcome data. Transitional discharge interventions may make little to no difference in service use (hospitalization) at short‐ and long‐term follow‐ups, but the evidence is very uncertain (RR 1.18, 95% CI 0.55 to 2.50; I 2 = 54%; 4 studies, 462 participants; very low‐certainty evidence). Transitional discharge intervention may increase the levels of functioning after discharge (clinically important change in general functioning) (SMD 0.95, 95% CI −0.06 to 1.97; I² = 95%; 4 studies, 437 participants; very low‐certainty evidence) and may increase the proportion of participants who are satisfied with the intervention (clinically important change in satisfaction) (RR 1.96, 95% CI 1.37 to 2.80; 1 study, 76 participants; very low‐certainty evidence), but for both outcomes the evidence is very uncertain. Transitional discharge intervention may make little to no difference in quality of life compared to treatment as usual (SMD 0.24, 95% CI −0.30 to 0.78; I² = 90%; 4 studies, 748 participants; very low‐certainty evidence), but we are very uncertain. For direct costs, one study with 124 participants did not report full details and thus the results were inconclusive. Authors' conclusions There is currently no clear evidence for or against implementing transitional discharge interventions for people with schizophrenia. Transitional discharge interventions may improve patient satisfaction and functionality, but this evidence is also very uncertain. For future research, it is important to improve the quality of the conduct and reporting of these trials, including using validated tools for measuring their outcomes. Plain language summary What are the benefits of transitional discharge care for people with schizophrenia? Key messages – Transitional discharge care (an intervention that supports a person move from a stay in hospital to the community) may make little to no difference in admissions to hospital and quality of life, and may improve how well a person functions in day‐to‐day life and how happy they are with their treatment when they return home, but we are very uncertain about the results. – The results on costs of running the transitional discharge care program are inconclusive, and the studies provided no information on relapse (a new mental health crisis) or unwanted effects. – We need more and better studies to investigate how to support people with schizophrenia or schizophrenia‐related disorders during the transition from hospital to community. What is schizophrenia? Schizophrenia is a persistent and severe mental health condition where people have hallucinations (where they hear, see, smell, taste, or feel things that appear to be real but only exist in their mind) and delusions (a strong belief in something that is untrue), among other debilitating symptoms, leading to poor quality of life. People with schizophrenia‐related disorders have symptoms that are similar to those of schizophrenia. The illness varies, with people having different symptoms at different times, often with them requiring admission to hospital for treatment. What happens when a person with schizophrenia or schizophrenia‐related disorders is discharged from hospital? People with schizophrenia or schizophrenia‐related disorders are sometimes admitted to hospital to improve their health, and afterward, they are discharged to their homes or other care facilities. This transition might be difficult and frightening for them and their carers, and they may need help to adapt. There are some interventions to support people with schizophrenia or schizophrenia‐related disorders after they leave the hospital, such as case management with an expert guide or continuous care with a nurse. What is transitional discharge care? Transitional discharge care is an intervention which provides support to people leaving hospital to cover their medical, practical, and emotional needs. This starts before hospital discharge and continues until people are confident in their homes or care facilities. This may include help with housing; communicating and co‐ordinating among healthcare staff, patients, and families; planning meetings; sessions with families; visits to the neighborhood; talking therapy sessions; telephone and face‐to‐face support; and support groups focusing on recreation, medication, shopping, cooking, and financial responsibilities. What did we want to find out? We wanted to know whether transitional discharge care helps people with schizophrenia or schizophrenia‐related disorders when leaving the hospital, especially if it reduces the rate of a new mental health crisis (relapse), repeat admissions to hospital, overall functioning in day‐to‐day life, satisfaction with the care they receive, quality of life, unwanted effects, and costs. What did we do? We searched for studies that investigated whether transitional discharge care, compared to no transitional discharge care or usual care, was effective in adults with schizophrenia or schizophrenia‐related disorders. What did we find? We found 12 studies with 1748 people that compared transitional discharge care to usual care. Transitional discharge care may make little to no difference to admissions to hospital (4 studies, 462 people). Transitional discharge care may improve functioning (4 studies, 437 people) and may increase people's satisfaction with care (1 study, 76 people), but we are very uncertain about the results. Transitional discharge care may make little to no difference to quality of life (4 studies, 748 people). The results on costs were inconclusive as the study did not fully report the methods (1 study, 124 people). ​​ None of the included studies provided data for relapse or unwanted effects of transitional discharge care. What are the limitations of the evidence? All 12 studies had problems with their methods and results were inconsistent. Some studies included people with other mental disorders, so the results might not apply directly to people with schizophrenia or schizophrenia‐related disorders. Therefore, we have very low confidence in our findings. How up to date is this evidence? The evidence is up to date to December 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Roson Rodriguez, P; Chen, X; Arancibia, M; Garegnani, L; Escobar Liquitay, CM; Mohammad, HA; Franco, JVA", "articleTypes": [], "doi": "10.1002/14651858.CD009788.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "d91598c3-61d2-4231-b391-09694f792226", "pmid": "", "title": "D‐penicillamine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is used for patients with primary biliary cirrhosis due to its hepatic copper decreasing and immunomodulatory potentials. The results from randomised clinical trials have been inconsistent. Objectives To systematically review the beneficial and harmful effects of D‐penicillamine for patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register (September 2003), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2003) , MEDLINE (January 1966 to September 2003) , EMBASE (January 1980 to September 2003) , The Chinese Biomedical CD Database (January 1979 to August 2003) , and LILACS (1982 to 2003); through manual searches of bibliographies; and by contacting authors of the trials and pharmaceutical companies. Selection criteria We included randomised clinical trials comparing D‐penicillamine with placebo/no intervention or other control intervention irrespective of language, year of publication, and publication status. Data collection and analysis Two reviewers independently assessed the methodological quality of the trials and extracted data, validated by a third reviewer. The primary outcomes were 1) mortality and 2) a combination of those who died or underwent liver transplantation. We analysed dichotomous outcomes as relative risk (RR) with 95% confidence interval (CI) by a fixed effect model and a random effects model. We investigated sources of heterogeneity by subgroup analyses and tested the robustness of our findings by sensitivity analyses. Main results We included seven trials randomising 706 patients with primary biliary cirrhosis. D‐penicillamine compared with placebo/no intervention tended to increase mortality (RR 1.34, 95% CI 1.09 to 1.64, fixed; RR 1.46, 95% CI 0.85 to 2.50, random). However, there was substantial heterogeneity. No significant differences were detected regarding the risks of mortality or liver transplantation, pruritus, liver complications, progression of liver histological stage, or the levels of liver biochemical variables (except alanine aminotransferase). D‐penicillamine versus placebo/no intervention significantly increased the risk of adverse events (RR 3.11, 95% CI 2.33 to 4.16, fixed; RR 4.18, 95% CI 1.38 to 12.69, random). Authors' conclusions D‐penicillamine did not appear to reduce the risk of mortality, but significantly increased the occurrences of adverse events in patients with primary biliary cirrhosis. We do not support the use of D‐penicillamine for patients with primary biliary cirrhosis. Plain language summary D‐penicillamine did not reduce the risk of mortality of patients with primary biliary cirrhosis but increased the occurrences of adverse events Primary biliary cirrhosis is an uncommon, chronic liver disease of unknown etiology. D‐penicillamine, a cupruretic drug, has been tested in randomised clinical trials and is used to treat patients with primary biliary cirrhosis. After combining results from seven trials, D‐penicillamine did not appear to improve survival of patients. D‐penicillamine was associated with a four‐time increase of adverse events. There were no significant differences between D‐penicillamine and placebo/no intervention with respect to clinical changes, liver histology, and liver biochemistry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y, Klingenberg, SL, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004789.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.752Z" }, { "id": "d9163293-2f68-4ac2-8245-d18c78447f26", "pmid": "", "title": "Prostaglandins for management of retained placenta", "imported": false, "abstract": "Abstract - Background Retained placenta affects 0.5% to 3% of women following delivery and it is a major cause of maternal death due to postpartum haemorrhage. Usually, retained placenta has been managed by manual removal or curettage under anaesthesia, which may be associated with haemorrhage, infection and uterine perforation. Medical management to facilitate the delivery of the retained placenta could be a safe alternative avoiding surgical intervention. Objectives To assess the effectiveness and safety of prostaglandins for the management of retained placenta. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013), LILACS (1982 to 1 December 2013), SciELO (1998 to 1 December 2013), Web of Science (2001 to 1 December 2013), openSIGLE (1997 to 1 December 2013 ) , World Health Organization International Clinical Trials Registry Platform ( ICTRP ) (1 December 2013) and the metaRegister of Controlled Trials ( mRCT ) (1 December 2013) . We also contacted authors of included studies and reviewed the reference lists of retrieved studies. Selection criteria Randomised controlled clinical trials comparing the use of prostaglandins (or prostaglandin analogues) with placebo, expectant management, tocolytic drugs, any other prostaglandins or surgical interventions for the management of retained placenta after vaginal delivery of singleton live infants of 20 or more weeks of gestation. Data collection and analysis Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. Any disagreements were resolved through consensus or consultation with a third review author when required. Authors of the included studies were contacted for additional information. Main results We included three trials, involving 244 women. The studies were considered to be at high risk of bias. The prostaglandins used were PG E2 analogue (sulprostone) in 50 participants and PG E1 analogue (misoprostol) in 194 participants at a dose of 250 mcg and 800 mcg respectively. The prostaglandins compared with placebo, were not superior in reducing the rate of manual removal of placenta (average risk ratio (RR) 0.82; 95% confidence interval (CI) 0.54 to 1.27), severe postpartum haemorrhage (RR 0.80; 95% CI 0.55 to 1.15), need for blood transfusion (RR 0.72; 95% CI 0.43 to 1.22), mean blood loss (mean difference (MD) ‐205.26 mL; 95% CI ‐536.31 to 125.79, random‐effects) and the mean time from injection to placental removal (MD ‐7.00 minutes; 95% CI ‐21.20 to 7.20). Side‐effects were no different between groups (vomiting, headache, pain and nausea between injection and discharge from the labour ward), with the exception of shivering, which was more frequent in women receiving prostaglandins (RR 10.00; 95% CI 1.40 to 71.49). We did not obtain any data for the primary outcomes of maternal mortality and the need to add another therapeutic uterotonic. Authors' conclusions Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes) or side‐effects (vomiting, headache, pain and nausea between injection and discharge from the labour ward) except for 'shivering' which was more frequent in women who received prostaglandin. The included studies were of poor quality and there is little confidence in the effect estimates; the true effect is likely to be substantially different. We can not make any recommendations about changes to clinical practice. More high‐quality research in this area is needed. Plain language summary Prostaglandins for management of retained placenta Medical research evidence is sparse and insufficient to support the routine use of the prostaglandins for the management of retained placenta. Retained placenta affects 0.5% to 3% of women following delivery and is a major cause of maternal death caused by postpartum haemorrhage. A retained placenta is usually managed by manual removal or curettage under anaesthesia (which is not always immediately available). Surgical procedures themselves can be associated with haemorrhage and also infection and uterine perforation. Prostaglandins or their analogues, administered by any route, could be an alternative treatment especially in developing countries. Such medical management may facilitate the delivery of the retained placenta and be a safer alternative to surgery. The review identified three randomised controlled studies (involving 244 women) that compared the use of prostaglandins with placebo. Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and need for blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes). The prostaglandin was administered by intravenous infusion (E2 analogue sulprostone) in one study including 50 women and was orally or sublingually administered (E1 analogue misoprostol) in the other two studies including 194 women. Shivering was more frequent in women receiving the prostaglandin but there were no clear differences in vomiting, headache, maternal pain or nausea compared with placebo. The trials were small and of poor methodological quality. The quality of evidence is very low due to study limitations, inconsistency and imprecise results (few women and outcome events with wide confidence intervals). Two studies were stopped early due to an apparent benefit.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Grillo‐Ardila, CF; Ruiz‐Parra, AI; Gaitán, HG; Rodriguez‐Malagon, N", "articleTypes": [], "doi": "10.1002/14651858.CD010312.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "d9311730-06c3-4b7d-bc67-6f331ac2ad16", "pmid": "", "title": "Interventions for the prevention of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "Abstract - Background Loss of olfactory function is well recognised as a symptom of COVID‐19 infection, and the pandemic has resulted in a large number of individuals with abnormalities in their sense of smell. For many, the condition is temporary and resolves within two to four weeks. However, in a significant minority the symptoms persist. At present, it is not known whether early intervention with any form of treatment (such as medication or olfactory training) can promote recovery and prevent persisting olfactory disturbance. This is an update of the 2021 review with four studies added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with acute olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance, which had been present for less than four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the presence of normal olfactory function, serious adverse effects and change in sense of smell. Secondary outcomes were the prevalence of parosmia, change in sense of taste, disease‐related quality of life and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included five studies with 691 participants. The studies evaluated the following interventions: intranasal corticosteroid sprays, intranasal corticosteroid drops, intranasal hypertonic saline and zinc sulphate. Intranasal corticosteroid spray compared to no intervention/placebo We included three studies with 288 participants who had olfactory dysfunction for less than four weeks following COVID‐19. Presence of normal olfactory function The evidence is very uncertain about the effect of intranasal corticosteroid spray on both self‐rated recovery of olfactory function and recovery of olfactory function using psychophysical tests at up to four weeks follow‐up ( self‐rated : risk ratio (RR) 1.19, 95% confidence interval (CI) 0.85 to 1.68; 1 study; 100 participants; psychophysical testing : RR 2.3, 95% CI 1.16 to 4.63; 1 study; 77 participants; very low‐certainty evidence). Change in sense of smell The evidence is also very uncertain about the effect of intranasal corticosteroid spray on self‐rated change in the sense of smell ( at less than 4 weeks : mean difference (MD) 0.5 points lower, 95% CI 1.38 lower to 0.38 higher; 1 study; 77 participants; at > 4 weeks to 3 months : MD 2.4 points higher, 95% CI 1.32 higher to 3.48 higher; 1 study; 100 participants; very low‐certainty evidence, rated on a scale of 1 to 10, higher scores mean better olfactory function). Intranasal corticosteroids may make little or no difference to the change in sense of smell when assessed with psychophysical testing (MD 0.2 points, 95% CI 2.06 points lower to 2.06 points higher; 1 study; 77 participants; low‐certainty evidence, 0‐ to 24‐point scale, higher scores mean better olfactory function). Serious adverse effects The authors of one study reported no adverse effects, but their intention to collect these data was not pre‐specified so we are uncertain if these were systematically sought and identified. The remaining two studies did not report on adverse effects. Intranasal corticosteroid drops compared to no intervention/placebo We included one study with 248 participants who had olfactory dysfunction for ≤ 15 days following COVID‐19. Presence of normal olfactory function Intranasal corticosteroid drops may make little or no difference to self‐rated recovery at > 4 weeks to 3 months (RR 1.00, 95% CI 0.89 to 1.11; 1 study; 248 participants; low‐certainty evidence). No other outcomes were assessed by this study. Data on the use of hypertonic saline nasal irrigation and the use of zinc sulphate to prevent persistent olfactory dysfunction are included in the full text of the review. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for preventing persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the prevention of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important COVID‐19 has been found to cause problems with the sense of smell. Sometimes this is a reduction in the ability to smell things, and sometimes it is a complete loss of the sense of smell. For many people this recovers in a short time, but for others it may last for weeks or months. This review considers whether there are treatments that people might take as soon as they have lost their sense of smell (within four weeks of the symptoms starting), to try and stop this becoming a long‐standing problem. How we identified and assessed the evidence We searched for all relevant studies in the medical literature to summarise the results. We also looked at how certain the evidence was, considering things like the size of the studies and how they were carried out. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found five studies that had been completed. Intranasal corticosteroids compared to no treatment Three studies looked at this treatment. Nasal corticosteroid spray might make little or no difference to the sense of smell when measured with specific tests (rather than when asking people about their sense of smell). The rest of the evidence was of very low certainty, so we do not know whether a nasal corticosteroid spray is better or worse than no treatment at: ‐ helping the sense of smell get back to normal (either people feeling that their sense of smell is back to normal, or having a normal sense of smell according to specific tests); ‐ making people feel that their sense of smell has improved; ‐ causing any unwanted side effects. Intranasal corticosteroid drops compared to placebo (dummy treatment) One study looked at this treatment. Intranasal corticosteroid drops might not make any difference to the number of people who think their sense of smell has recovered at 30 days. We did find a number of other studies that are being carried out, but no results from these studies were available yet to be included in this review. What this means We do not know whether using a nasal corticosteroid spray or nasal drops has any benefit in preventing longer‐term loss of the sense of smell that is related to COVID‐19, or whether they may cause any harm. This review is a 'living systematic review' ‐ meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Webster, KE; O'Byrne, L; MacKeith, S; Philpott, C; Hopkins, C; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013877.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "d945215c-1b4b-4568-b08f-f0700554c7c7", "pmid": "", "title": "Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease", "imported": false, "abstract": "Abstract - Background Catheter malfunction, including thrombosis, is associated with reduced dialysis adequacy, as well as an increased risk of catheter‐related bacteraemia and mortality. The role of anticoagulants in the prevention of catheter malfunction remains uncertain. Objectives This review aimed to compare the prophylactic effect of different anticoagulant agents, preparations, doses and administration on the incidence of central venous haemodialysis catheter‐related malfunction and sepsis in patients with end‐stage kidney disease (ESKD). Search methods We searched the Cochrane Renal Group's Specialised Register to 7 January 2016 through contact with the Trials' Search Co‐ordinator using search terms relevant to this review. Selection criteria We included all randomised controlled trials (RCT) assessing anticoagulants compared with conventional care for the prevention of catheter malfunction in adult patients receiving haemodialysis for ESKD. Data collection and analysis The primary outcome was catheter malfunction defined as a catheter blood flow of 200 mL/min or less, or as defined by study authors. Secondary outcomes were catheter‐related bacteraemia, all‐cause mortality and bleeding events. Relative risks (RR) with 95% confidence intervals (CI) for individual studies were pooled using random effects models within treatment classes. Analyses were conducted by class, with subgroup analyses performed of individual agents within classes. Main results We included 27 studies (3003 participants) that were followed up for a median of six months. Study interventions included alternative anticoagulant locking solutions (19 studies, 2216 patients), systemic agents (6 studies, 664 patients) and low or no dose heparin (2 studies, 123 patients). The most common comparison treatment was a locking solution of heparin 5000 IU/mL, used in 17 studies. No significant effect on catheter malfunction was observed for alternative anticoagulant locking solutions (RR 0.96, 95% CI 0.74 to 1.26), systemic agents (RR 0.59, 95% CI 0.28 to 1.23), or low or no dose heparin (RR 0.90, 95% CI 0.10 to 8.31). A significant reduction on incidence of catheter‐related bacteraemia was observed for alternative anticoagulant locking solutions (RR 0.46, 95% CI 0.32 to 0.66) but not systemic agents (RR 2.41, 95% CI 0.89 to 6.55), and could not be assessed in reports of low or no dose heparin studies. No significant effect on all‐cause mortality was observed for alternative anticoagulant locking solutions (RR 0.88, 95% CI 0.54 to 1.43) or systemic agents (RR 0.78, 95% CI 0.37 to 1.65), and was not reported in studies of low or no dose heparin. Bleeding events were only reported in eight studies, including only 2/5 studies of systemic warfarin, with no clear effect demonstrated (RR 1.43, 95% CI 0.86 to 2.39). For individual agents, recombinant tissue plasminogen (rt‐PA) was the only locking solution shown to reduce catheter malfunction (RR 0.58, 95% CI 0.37 to 0.91) based on the results of a single study. No significant on catheter malfunction was observed for other individual classes of alternative anticoagulant locking solutions (citrate: RR 1.14, 95% CI 0.76 to 1.69; antibiotic: RR 1.48, 95% CI 0.79 to 2.77; ethanol: RR 0.88, 95% CI 0.21 to 3.67). On the other hand, all individual classes of alternative anticoagulant locking solutions, except ethanol, reduced catheter‐related bacteraemia (citrate: RR 0.49, 95% CI 0.36 to 0.68; antibiotic: RR 0.27, 95% CI 0.11 to 0.70; rt‐PA: RR 0.35, 95% CI 0.13 to 0.93; ethanol: RR 0.33, 95% CI 0.03 to 4.05). No significant effect on all‐cause mortality was observed for any individual agent within the class of alternative locking solutions. Studies were mainly of low quality and underpowered with an average participant number of 75 and study duration of six months. The interpretation of the study evidence was further limited by the variation in tested interventions and outcome reporting. Authors' conclusions The relative net benefit of anticoagulant therapies for prevention of catheter malfunction remains uncertain. Multiple agents appear to reduce catheter‐related bacteraemia although the lack of clear assessment of harms and the limitations of study quality mean these results should be interpreted with caution. Methodological approaches can be used to avoid methods of reporting unduly affecting on the results of meta‐analyses incorporating studies employed mixed reporting methods. Further high quality randomised studies, including safety outcomes, are needed. Plain language summary Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end‐stage kidney disease Background Patients with end‐stage kidney disease require vascular access during haemodialysis. Central venous haemodialysis catheters are frequently used when permanent vascular access is not available. Catheter problems contribute to greater morbidity and mortality. Catheter malfunction leads to requirements for additional interventions, increased risk of catheter‐related infection and hospitalisation. Standard care for the prevention of catheter malfunction is the use of heparin solutions as a post dialysis ‘lock’ in the catheter ports. The potential impact of heparin treatment on bleeding risk is an acknowledged concern. Therefore newer approaches have been proposed to seek improvements in catheter patency or treatment‐associated harm rates. Study characteristics This review focused on randomised controlled trials (RCTs) of anticoagulants compared with conventional care for the prevention of catheter malfunction patients receiving haemodialysis. Key results We found 27 studies, involving 3003 patients followed for an average six months, which assessed alternative anticoagulant locking solutions, systemic agents and low or no dose heparin. Catheter malfunction were not affected by any of these classes of agents. Subgroup analysis showed that the only agent reducing catheter malfunction was recombinant tissue plasminogen locking solution based on the results of a single study. A significant reduction was observed on the incidence of catheter‐related bacteraemia for alternative anticoagulant locking solutions. There was no evidence to suggest that alternative anticoagulants to heparin locking solutions had an effect on death rates or bleeding events, although only a small proportion of studies reported bleeding events. Quality of the evidence Further high quality information is needed on both potential benefits and safety of alternative approaches to maintaining dialysis access catheter function.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Wang, Y; Ivany, JN; Perkovic, V; Gallagher, MP; Woodward, M; Jardine, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD009631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "d963422f-64fd-4c70-ba54-afafae3dc4d3", "pmid": "", "title": "Interventions for bullous pemphigoid", "imported": false, "abstract": "Abstract - Background Bullous pemphigoid (BP) is the most common autoimmune blistering disease. Oral steroids are the standard treatment. We have updated this review, which was first published in 2002, because several new treatments have since been tried. Objectives To assess the effects of treatments for bullous pemphigoid. Search methods We updated searches of the following databases to November 2021: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched five trial databases to January 2022, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria RCTs of treatments for immunofluorescence‐confirmed bullous pemphigoid. Data collection and analysis At least two review authors, working independently, evaluated the studies against the review's inclusion criteria and extracted data from included studies. Using GRADE methodology, we assessed the certainty of the evidence for each outcome in each comparison. Our primary outcomes were healing of skin lesions and mortality. Main results We identified 14 RCTs (1442 participants). The main treatment modalities assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Most studies reported mortality but adverse events and quality of life were not well reported. We decided to look at the primary outcomes 'disease control' and 'mortality'. Almost all studies investigated different comparisons; two studies were placebo‐controlled. The results are therefore based on a single study for each comparison except azathioprine. Most studies involved only small numbers of participants. We assessed the risk of bias for all key outcomes as having 'some concerns' or high risk, due to missing data, inappropriate analysis, or insufficient information. Clobetasol propionate cream versus oral prednisone Compared to oral prednisone, clobetasol propionate cream applied over the whole body probably increases skin healing at day 21 (risk ratio (RR 1.08, 95% confidence interval (CI) 1.03 to 1.13; 1 study, 341 participants; moderate‐certainty evidence). Skin healing at 21 days was seen in 99.8% of participants assigned to clobetasol and 92.4% of participants assigned to prednisone. Clobetasol propionate cream applied over the whole body compared to oral prednisone may reduce mortality at one year (RR 0.73, 95% CI 0.53 to 1.01; 1 study, 341 participants; low‐certainty evidence). Death occurred in 26.5% (45/170) of participants assigned to clobetasol and 36.3% (62/171) of participants assigned to oral prednisone. This study did not measure quality of life. Clobetasol propionate cream may reduce risk of severe complications by day 21 compared with oral prednisone (RR 0.65, 95% CI 0.50 to 0.86; 1 study, 341 participants; low‐certainty evidence). Mild clobetasol propionate cream regimen (10 to 30 g/day) versus standard clobetasol propionate cream regimen (40 g/day) A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen probably does not change skin healing at day 21 (RR 1.00, 95% CI 0.97 to 1.03; 1 study, 312 participants; moderate‐certainty evidence). Both groups showed complete healing of lesions at day 21 in 98% participants. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change mortality at one year (RR 1.00, 95% CI 0.75 to 1.32; 1 study, 312 participants; low‐certainty evidence), which occurred in 118/312 (37.9%) participants. This study did not measure quality of life. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change adverse events at one year (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 309 participants; low‐certainty evidence). Doxycycline versus prednisolone Compared to prednisolone (0.5 mg/kg/day), doxycycline (200 mg/day) induces less skin healing at six weeks (RR 0.81, 95% CI 0.72 to 0.92; 1 study, 213 participants; high‐certainty evidence). Complete skin healing was reported in 73.8% of participants assigned to doxycycline and 91.1% assigned to prednisolone. Doxycycline compared to prednisolone probably decreases mortality at one year (RR 0.25, 95% CI 0.07 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 14; 1 study, 234 participants; moderate‐certainty evidence). Mortality occurred in 2.3% (3/132) of participants with doxycycline and 9.1% (11/121) with prednisolone. Compared to prednisolone, doxycycline improved quality of life at one year (mean difference 1.8 points lower, which is more favourable on the Dermatology Life Quality Index, 95% CI 1.02 to 2.58 lower; 1 study, 234 participants; high‐certainty evidence). Doxycycline compared to prednisolone probably reduces severe or life‐threatening treatment‐related adverse events at one year (RR 0.59, 95% CI 0.35 to 0.99; 1 study, 234 participants; moderate‐certainty evidence). Prednisone plus azathioprine versus prednisone It is unclear whether azathioprine plus prednisone compared to prednisone alone affects skin healing or mortality because there was only very low‐certainty evidence from two trials (98 participants). These studies did not measure quality of life. Adverse events were reported in a total of 20/48 (42%) participants assigned to azathioprine plus prednisone and 15/44 (34%) participants assigned to prednisone. Nicotinamide plus tetracycline versus prednisone It is unclear whether nicotinamide plus tetracycline compared to prednisone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (18 participants). This study did not measure quality of life. Fewer adverse events were reported in the nicotinamide group. Methylprednisolone plus azathioprine versus methylprednisolone plus dapsone It is unclear whether azathioprine plus methylprednisolone compared to dapsone plus methylprednisolone affects skin healing or mortality because there was only very low‐certainty evidence from one trial (54 participants). This study did not measure quality of life. A total of 18 adverse events were reported in the azathioprine group and 13 in the dapsone group. Authors' conclusions Clobetasol propionate cream applied over the whole body is probably similarly effective as, and may cause less mortality than, oral prednisone for treating bullous pemphigoid. Lower‐dose clobetasol propionate cream applied over the whole body is probably similarly effective as standard‐dose clobetasol propionate cream and has similar mortality. Doxycycline is less effective but causes less mortality than prednisolone for treating bullous pemphigoid. Other treatments need further investigation. Plain language summary Treatments for bullous pemphigoid Which treatments work best for bullous pemphigoid (a rare, itchy skin disease that causes blisters)? Key messages • A cream, containing topical steroid clobetasol propionate, applied on the entire skin surface is as effective as oral steroids (prednisone), causes less severe unwanted or harmful effects, and may decrease deaths. • Initiating treatment with doxycycline (200 mg/day), an antibiotic with anti‐inflammatory effect, leads to an acceptable short‐term blister control compared to the oral steroid prednisolone (0.5 mg/kg/day), and is superior in long‐term safety aspects, including deaths. What is bullous pemphigoid? Bullous pemphigoid is the most common autoimmune blistering disease. In autoimmune diseases, the body's immune system mistakes its own tissues as foreign and attacks them. In bullous pemphigoid, this causes blisters on the skin. Bullous pemphigoid usually occurs in the elderly, but may also affect younger people. How is bullous pemphigoid treated? Until recently, the leading treatment for bullous pemphigoid was oral steroids which suppress inflammation and the body's own immune system. However, given over a long period of time, oral steroids will cause severe adverse (i.e. harmful) effects. This review assessed studies which investigated the effectiveness of other treatment options for bullous pemphigoid; for example, a steroid cream applied on the skin and the anti‐inflammatory antibiotic medicine, doxycycline. What did we want to find out? We wanted to find out which treatments work best for bullous pemphigoid with respect to the healing of blisters (efficacy) and reduction in adverse effects, such as death. What did we do? We searched for studies that looked at treatments for bullous pemphigoid. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 14 studies including 1442 people with bullous pemphigoid. The main treatments assessed were oral steroids, topical steroids, and the oral anti‐inflammatory antibiotic doxycycline. Other treatments tested were oral (i.e. taken by mouth) immunosuppressives (medicines that keep your immune system in check) and immunoglobulins (also called antibodies. Antibodies are proteins that your immune system makes to fight germs, for example). ‐ Topical steroid cream, clobetasol propionate, applied over the whole body (40 grams of cream applied per day, with the amount decreased over 12 months) is an effective and safe treatment for bullous pemphigoid. ‐ Treatment with a lower amount of clobetasol propionate cream (10 to 30 grams per day, decreased over 4 months) is equally effective and safe. ‐ Prednisolone, an oral corticosteroid, in the dose of 0.5 mg/kg/day, may be adequate to control disease in most people and reduces adverse effects compared to higher doses of oral corticosteroid. ‐ Initiating treatment with 200 mg/day of doxycycline leads to acceptable blister control compared to oral prednisolone (0.5 mg/kg/day) and is safer. ‐ A study with 20 participants suggests that nicotinamide (a form of vitamin B 3 )and tetracycline (an antibiotic used to treat a wide variety of infections) may be an effective alternative to prednisone and may decrease treatment‐associated death. ‐ Adding azathioprine, a drug which suppresses the immune system, to an oral corticosteroid does not improve disease control; it may lead to a reduced need for oral corticosteroid. ‐ Further research is needed to fully understand the effectiveness of alternatives to oral steroids (such as dapsone or immunoglobulins), as well as the effectiveness of giving other medicines alongside an oral steroid. What are the limitations of the evidence? Except for the studies on topical clobetasol cream and doxycycline, the studies included relatively few participants. The methodological quality of these studies was further limited because of unclear methods of allocating people to different treatment groups; lack of masking (participants and researchers knew which treatments were given to which people, which are not good conditions for fair assessment); and the exclusion of people who dropped out of the studies from treatment analysis. We are confident about the efficacy of initiating treatment with doxycycline and moderately confident about the efficacy of topical clobetasol cream for the treatment of bullous pemphigoid. How up to date is this evidence? The evidence is current to 11 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Singh, S; Kirtschig, G; Anchan, VN; Chi, C-C; Taghipour, K; Boyle, RJ; Murrell, DF", "articleTypes": [], "doi": "10.1002/14651858.CD002292.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "d99458b7-3112-4c75-b5b9-5024b9839f03", "pmid": "", "title": "Interventions for improving adherence to ocular hypotensive therapy", "imported": false, "abstract": "Abstract - Background Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open‐angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence. Objectives To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma. Data collection and analysis At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity. Main results Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow‐up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross‐over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive. Authors' conclusions Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes. Plain language summary Interventions for helping people use eye drops as prescribed for raised eye pressure or glaucoma A large number of people do not use eye drops as prescribed. Glaucoma is a slowly progressive eye disease, which can result in severe vision loss. Drops prescribed for raised eye pressure or glaucoma are aimed at lowering the pressure to assist in reducing the rate of progression, or preventing the conversion of raised eye pressure to glaucoma. It is important that these eye drops are used continually, usually for life. Approximately one‐third of people who are prescribed eye drops for the first time fail to continue collecting prescriptions within the first year and even when patients collect prescriptions they do not always use the drops as frequently as they should. A number of reasons are thought to be the cause, for example, forgetfulness, being prescribed a large number of medications, difficulties instilling drops, lack of knowledge about glaucoma, a busy lifestyle and seeing no benefit. This review is based on 16 studies (1565 participants) that tried out different methods to help people to use drops as prescribed. All the studies took place in industrialised countries (Belgium, Denmark, France, Greece, Iceland, Japan, Sweden, Switzerland, UK and USA) and recruited participants in outpatient clinics. The following interventions were included: simplifying drop routines, reminder devices, automated telephone service, providing information about glaucoma and offering advice regarding day to day issues with eye care. Those studies which combined the provision of information about glaucoma and eye drops with other interventions, such as helping people to fit instillation of eye drops into their daily routine, appear to be more successful. Unfortunately, not all of these studies were of high quality and, therefore, until more evidence is available we cannot recommend any particular method. Good quality research is needed in this area in order to develop a better understanding of patients' individual needs and to help us provide more effective eye care services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Waterman, H; Evans, JR; Gray, TA; Henson, D; Harper, R", "articleTypes": [], "doi": "10.1002/14651858.CD006132.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "d9a3a537-2150-44f2-b9b1-05277e072794", "pmid": "", "title": "Sensory stimulation for brain injured individuals in coma or vegetative state", "imported": false, "abstract": "Abstract - Background Coma and vegetative state follow traumatic brain injury in about one out of eight patients, and in patients with non traumatic injury the prognosis is worse. The use of sensory stimulation for coma and vegetative state has gained popularity during the 1980's but beliefs and opinions about its effectiveness vary substantially among health professionals. Objectives To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. Search methods We searched the Injuries Group specialised register, the Cochrane Controlled trials register, EMBASE, MEDLINE, CINAHL and PSYCHLIT from 1966 to January 2002, without language restriction. Reference lists of articles were scanned and we contacted experts in the area to find other relevant studies. Selection criteria Randomised or controlled trials that compared sensory stimulation programmes with standard rehabilitation in patients in coma or vegetative state. Data collection and analysis Abstracts and papers found were screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality resolving disagreement by consensus. Main results Three studies were identified with 68 patients in total. The overall methodological quality was poor and studies differed widely in terms of outcomes measures, study design and conduct. We therefore did not carry out any quantitative synthesis but reviewed results of available studies qualitatively. Authors' conclusions This systematic review indicates that there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state. Plain language summary No strong evidence about the effects of sensory stimulation for a brain‐injured person in a coma About half of people in a coma (deep unconsciousness) because of traumatic brain injury will wake within a year of the accident. Speeding recovery to allow people to wake sooner is a priority for them and their family. One type of treatment uses sensory stimulation to try to keep the person's brain working normally. Sensory stimulation methods vary greatly, from one or two hourly sessions of a day, through to shorter sessions every hour for 12 to 14 hours a day. The review found there is no strong evidence to determine whether sensory stimulation benefits people in comas.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Lombardi, FFL; Taricco, M; De Tanti, A; Telaro, E; Liberati, A", "articleTypes": [], "doi": "10.1002/14651858.CD001427", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "d9b43f1b-00dc-42c1-b462-90b97bba04f9", "pmid": "", "title": "Corticosteroids for treating sepsis in children and adults", "imported": false, "abstract": "Abstract - Background Sepsis occurs when an infection is complicated by organ failure. Sepsis may be complicated by impaired corticosteroid metabolism. Thus, providing corticosteroids may benefit patients. This is an update of a review originally published in 2004 and previously updated in 2010, 2015 and 2019. Objectives To examine the benefits and harms of corticosteroids in children and adults with sepsis. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, ISRCTN and the WHO Clinical Trials Search Portal on 31 December 2023. In addition, we conducted reference checking and citation research, and contacted study authors, to identify additional studies as needed. We updated this search in December 2024, but these results have not yet been incorporated. Selection criteria We included randomised controlled trials (RCTs) of corticosteroids versus placebo or usual care (antimicrobials, fluid replacement and vasopressor therapy as needed) in children and adults with sepsis. We also included RCTs of continuous infusion versus intermittent bolus of corticosteroids. Data collection and analysis We used the same methods in comparisons of corticosteroids versus placebo or usual care, and of continuous infusion versus intermittent bolus administration of corticosteroids. The primary outcome was all‐cause mortality at 28 days. The most critical secondary outcomes were (i) all‐cause mortality in the long term (last follow‐up from 90 days to one year) and in the hospital; (ii) length of stay in the intensive care unit and in hospital; (iii) adverse effects, i.e. superinfection and muscle weakness (within 28 days). All review authors screened and selected studies for inclusion. One review author extracted data, which was checked by the others, and by the lead author of the primary study when possible. For this update, we used Covidence software for screening and selection of studies and abstraction of data by paired review authors, with discrepancies resolved by a third review author. We obtained unpublished data from the authors of some trials. We assessed the risk of bias in trials using the Cochrane risk of bias tool (RoB 1) and applied GRADE to assess the certainty of evidence. The review authors did not contribute to the assessment of eligibility or risk of bias, nor to data extraction, for the trials they had participated in. Main results We included 87 trials (24,336 participants), of which six included only children, two included children and adults, and the remaining trials included only adults. Seventeen additional trials are ongoing and will be considered in future versions of this review. We judged 25 trials as being at low risk of bias. Corticosteroids versus placebo or usual care Compared to placebo or usual care, corticosteroids probably reduce 28‐day mortality (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.84 to 0.95; 72 trials, 22,915 participants; moderate‐certainty evidence). We downgraded the certainty of evidence for this outcome from high to moderate for inconsistency (significant heterogeneity across trial results). Corticosteroids may result in little to no difference in long‐term mortality (RR 0.97, 95% CI 0.91 to 1.03; 12 trials, 8468 participants; low‐certainty evidence) and probably reduce in‐hospital mortality (RR 0.90, 95% CI 0.84 to 0.97; 40 trials, 17,459 participants; moderate‐certainty evidence). Corticosteroids may reduce length of intensive care unit (ICU) stay for all participants (mean difference (MD) ‐0.86 days, 95% CI ‐1.67 to ‐0.05; 25 trials, 8069 participants; low‐certainty evidence) and may reduce length of hospital stay for all participants (MD ‐1.09 days, 95% CI ‐1.85 to ‐0.34; 31 trials, 16,954 participants; low‐certainty evidence). The evidence is uncertain about the effect of corticosteroids on the risk of muscle weakness (RR 1.09, 95% CI 0.78 to 1.53; 7 trials, 6729 participants; very low‐certainty evidence). Corticosteroids may result in little to no difference in the risk of superinfection (RR 0.96, 95% CI 0.86 to 1.07; 36 trials, 7961 participants; low‐certainty evidence). Continuous infusion of corticosteroids versus intermittent bolus Four trials reported data for this comparison, and the certainty of evidence for all outcomes was very low. We are uncertain about the effects of continuous infusion of corticosteroids compared with intermittent bolus administration on 28‐day mortality (RR 1.03, 95% CI 0.81 to 1.32; 3 trials, 310 participants). We downgraded the certainty of evidence to very low due to high risk of bias in all except one trial and due to imprecision. Compared to bolus administration, we are uncertain of the effects of continuous infusion of corticosteroids on long‐term mortality (RR 1.36, 95% CI 1.02 to 1.81; 1 trial, 70 participants; very low‐certainty evidence), in‐hospital mortality (RR 0.92, 95% CI 0.71 to 1.19; 3 trials, 352 participants; very low‐certainty evidence), ICU length of stay amongst all participants (MD ‐0.56 days, 95% CI ‐3.44 to 2.32; 4 trials, 422 participants; very low‐certainty evidence), hospital length of stay amongst all participants (MD ‐0.21 days, 95% CI ‐4.72 to 4.30; 4 trials, 422 participants; very low‐certainty evidence), risk of muscle weakness (RR 0.89, 95% CI 0.13 to 5.98; 1 trial, 70 participants; very low‐certainty evidence) and risk of superinfection (RR 1.12, 95% CI 0.37 to 3.33; 2 trials, 193 participants; very low‐certainty evidence). Authors' conclusions Moderate‐certainty evidence indicates that corticosteroids probably reduce 28‐day, 90‐day and hospital mortality amongst patients with sepsis. Corticosteroids may shorten ICU and hospital length of stay (low‐certainty evidence). There may be little or no difference in the risk of superinfection. The risk of muscle weakness is uncertain. The effects of continuous versus intermittent bolus administration of corticosteroids are uncertain. Plain language summary What are the benefits and harms of corticosteroids in the treatment of children and adults with sepsis? Key messages • Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days and of in‐hospital death, and may have little or no effect on the risk of dying beyond three months. • We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. • Future studies should measure the benefits and harms of corticosteroids for the treatment of specific populations, including children, patients with sepsis without shock or with a mild form of septic shock, patients with acute respiratory distress syndrome (ARDS) and patients with different types of infections. Defining the optimal methods for corticosteroid administration, including the types of molecule ‐ with or without producing sodium and fluid retention and potassium excretion (mineralocorticoid activity), timing of initiation, dose and duration, continuous infusion or intermittent intravenous boluses, and ending of treatment ‐ with or without gradually decreasing the dose to zero, also requires additional studies. Future studies should measure the longer‐term effects, i.e. longer than one year, on survival and complications of sepsis. What is sepsis? Sepsis is present when an infection is complicated by organ failure. People develop rapid breathing, hypotension (low blood pressure) and mental confusion. Sepsis can interfere with the effectiveness of the body’s corticosteroids, which control how your body recognises and defends itself against bacteria, viruses and substances that appear foreign and harmful. What are corticosteroids (medicine)? Corticosteroids are medicines used to stop excessive inflammation. However, these medicines may cause unwanted harms, such as increased blood sugar or salt levels, infections, bleeding in the stomach, agitation or delirium, and weakness of the limbs. Corticosteroids have been given for decades to people with infection resulting from various causes. What did we want to find out? We wanted to find out: • the benefits of using corticosteroids in children and adults with sepsis; and • the best ways to administer this treatment (including the best people to give it to). We also wanted to know if corticosteroids can cause any unwanted effects. What did we do? We searched for studies that compared: • corticosteroids administered intravenously against a 'dummy' treatment, or sham treatment, which does not contain any medicine but looks or tastes identical to corticosteroids, or usual care; or • continuous infusion against intermittent rapid intravenous injections (boluses) of corticosteroids administration. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? This review includes 87 trials (24,336 participants). The biggest study was of 3800 people and the smallest study was of 21 people. Eighty‐three trials compared corticosteroids to no corticosteroids (placebo or usual care in 59 and 24 trials, respectively). Four trials also compared continuous administration versus rapid intravenous injection (i.e. bolus) of corticosteroids given at fixed intervals of six or eight hours. Thirty‐three trials were conducted in Europe, 15 in North America, 22 in Asia, six in the Middle East, six in Africa and three in Latin America; four were multinational trials. Three trials were funded by a drug company, 27 by public organisations or through charitable funding and six by both a drug company and public organisations or charitable funding; 25 did not declare the source of funding. Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days by 10% (72 trials; 22,915 participants), with consistent treatment effects between children and adults. There may be little or no effect of corticosteroids on the risk of dying over the long term (longer than three months), but these results are less certain. Corticosteroids probably reduce the risk of dying in hospital. Corticosteroids may result in a reduction in the length of stay in the intensive care unit (ICU) and in hospital. They may not increase the risk of superinfection (second infection). The evidence is very uncertain about the effect of corticosteroids on the risk of muscle weakness. We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. Four studies reported data for this comparison, and the certainty of evidence for all outcomes was very low. What are the limitations of the evidence? • Corticosteroids versus placebo or usual care We have moderate confidence in our findings that corticosteroids reduced 28‐day mortality. We found some differences amongst the study populations, the types of corticosteroids and how they were given, and the use of additional medicines. • Continuous infusion versus bolus administration of corticosteroids We have very little confidence in our findings about the absence of a difference in 28‐day mortality between the administration of corticosteroids continuously and repeated rapid intravenous injections. We found only four studies that enrolled very few patients. How up‐to‐date is this evidence? The evidence provided in this review is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Annane, D; Briegel, J; Granton, D; Bellissant, E; Bollaert, PE; Keh, D; Kupfer, Y; Pirracchio, R; Rochwerg, B", "articleTypes": [], "doi": "10.1002/14651858.CD002243.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "d9c43374-1f33-4590-886c-f321e74847ab", "pmid": "", "title": "Anticholinergic agents for chronic asthma in adults", "imported": false, "abstract": "Abstract - Background Anticholinergic agents such as ipratropium bromide are sometimes used in the treatment of chronic asthma. They effect bronchodilation and have also been used in combination with ß2 ‐agonists in the management of chronic asthma. Objectives To examine the effectiveness of anticholinergic agents versus placebo and in comparison with ß2 ‐agonists or as adjunctive therapy to ß2 ‐agonists. Search methods The Cochrane Airways Group asthma and wheeze database was searched with a pre‐defined search strategy. Searches were current as of August 2008. Reference lists of articles were also examined. Selection criteria Randomised trials or quasi‐randomised trials were considered for inclusion. Studies assessing an anticholinergic agent versus placebo or in combination/comparison with ß2 ‐agonists were included. In practice, all ß2 ‐agonists were short acting. Short‐term (less than 24 hours duration) were not considered for this review. Data collection and analysis Two reviewers independently assessed abstracts for retrieval of full text articles. Papers were then assessed for suitability for inclusion in the review. Data from included studies were extracted by two reviewers and entered into the software package (RevMan 4.2). We contacted authors for missing data and some responded. Adverse effect data were analysed if reported in the included studies. Main results The studies analysed were in two groups: those comparing anticholinergics with placebo and those comparing the combination of anticholinergics with short acting ß2 ‐agonists versus short acting ß2 ‐agonists alone. The former group had 13 studies involving 205 participants included in this review, and the latter 9 studies involving 440 patients. Generally methodological quality was poorly reported, and there were some reservations with respect to the quality of the studies. Despite the limited number of studies that could be combined, anticholinergic agents in comparison with placebo resulted in more favourable symptom scores particularly in respect of daytime dyspnoea (WMD ‐0.09 (95%CI ‐0.14, ‐0.04, 3 studies, 59 patients). Daily peak flow measurements also showed a statistically significant improvement for the anticholinergic (e.g. morning PEF: WMD =14.38 litres/min (95%CI 7.69, 21.08; 3 studies, 59 patients). However the clinical significance is small and in terms of peak flow measurements equates to approximately a 7% increase over placebo. The more clinically relevant comparison of a combination of anticholinergic plus short acting ß2 ‐agonist versus short acting ß2 ‐agonist alone gave no evidence in respect of symptom scores or peak flow rates of any significant differences between the two regimes. Again there are reservations with respect to the quality of the information from which these conclusions are drawn. An update search in August 2004 did not identify any new studies. Authors' conclusions Overall this review provides no justification for routinely introducing anticholinergics as part of add‐on treatment for patients whose asthma is not well controlled on standard therapies. This does not exclude the possibility that there may be a sub‐group of patients who derive some benefit and a trial of treatment in individual patients may still be justified. The role of long term anticholinergics such as tiotropium bromide has yet to be established in patients with asthma and any future trials might draw on the messages derived from this review. Plain language summary Anticholinergic agents for chronic asthma in adults Anticholinergic agents such as Atrovent are sometimes used to treat people with asthma as a bronchodilator that opens up the airways in the lungs. This review found that although this treatment was better than placebo, the size of the effect was rather small. When the drug was used in combination with more widely used bronchodilators (beta‐agonists such as fenoterol), it did not appear to add much benefit. However, there are concerns about the quality of the studies that have been analysed. It could be that there are some adults with chronic asthma who respond to treatment with anticholinergic drugs, but the review has not been able to identify their common characteristics.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Westby, MJ, Benson, MK, Gibson, PG", "articleTypes": [], "doi": "10.1002/14651858.CD003269.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.737Z" }, { "id": "d9c59b8e-a02a-43d1-a4f1-6a37f8d51771", "pmid": "", "title": "Interventions for hand eczema", "imported": false, "abstract": "Abstract - Background Hand eczema is an inflammation of the skin of the hands that tends to run a chronic, relapsing course. This common condition is often associated with itch, social stigma, and impairment in employment. Many different interventions of unknown effectiveness are used to treat hand eczema. Objectives To assess the effects of topical and systemic interventions for hand eczema in adults and children. Search methods We searched the following up to April 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, AMED, LILACS, GREAT, and four trials registries. We checked the reference lists of included studies for further references to relevant trials. Selection criteria We included randomised controlled trials (RCTs) that compared interventions for hand eczema, regardless of hand eczema type and other affected sites, versus no treatment, placebo, vehicle, or active treatments. Data collection and analysis We used standard methodological procedures expected by Cochrane. Primary outcomes were participant‐ and investigator‐rated good/excellent control of symptoms, and adverse events. Main results We included 60 RCTs, conducted in secondary care (5469 participants with mild to severe chronic hand eczema). Most participants were over 18 years old. The duration of treatment was short, generally up to four months. Only 24 studies included a follow‐up period. Clinical heterogeneity in treatments and outcome measures was evident. Few studies performed head‐to‐head comparisons of different interventions. Risk of bias varied considerably, with only five studies at low risk in all domains. Twenty‐two studies were industry‐funded. Eighteen trials studied topical corticosteroids or calcineurin inhibitors; 10 studies, phototherapy; three studies, systemic immunosuppressives; and five studies, oral retinoids. Most studies compared an active intervention against no treatment, variants of the same medication, or placebo (or vehicle). Below, we present results from the main comparisons. Corticosteroid creams/ointments: when assessed 15 days after the start of treatment, clobetasol propionate 0.05% foam probably improves participant‐rated control of symptoms compared to vehicle (risk ratio (RR) 2.32, 95% confidence interval (CI) 1.38 to 3.91; number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 8; 1 study, 125 participants); the effect of clobetasol compared to vehicle for investigator‐rated improvement is less clear (RR 1.43, 95% CI 0.86 to 2.40). More participants had at least one adverse event with clobetasol (11/62 versus 5/63; RR 2.24, 95% CI 0.82 to 6.06), including application site burning/pruritus. This evidence was rated as moderate certainty. When assessed 36 weeks after the start of treatment, mometasone furoate cream used thrice weekly may slightly improve investigator‐rated symptom control compared to twice weekly (RR 1.23, 95% CI 0.94 to 1.61; 1 study, 72 participants) after remission is reached. Participant‐rated symptoms were not measured. Some mild atrophy was reported in both groups (RR 1.76, 95% CI 0.45 to 6.83; 5/35 versus 3/37). This evidence was rated as low certainty. Irradiation with ultraviolet (UV) light: local combination ultraviolet light therapy (PUVA) may lead to improvement in investigator‐rated symptom control when compared to local narrow‐band UVB after 12 weeks of treatment (RR 0.50, 95% CI 0.22 to 1.16; 1 study, 60 participants). However, the 95% CI indicates that PUVA might make little or no difference. Participant‐rated symptoms were not measured. Adverse events (mainly erythema) were reported by 9/30 participants in the narrow‐band UVB group versus none in the PUVA group. This evidence was rated as moderate certainty. Topical calcineurin inhibitors: tacrolimus 0.1% over two weeks probably improves investigator‐rated symptom control measured after three weeks compared to vehicle (14/14 tacrolimus versus 0/14 vehicle; 1 study). Participant‐rated symptoms were not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. A within‐participant study in 16 participants compared 0.1% tacrolimus to 0.1% mometasone furoate but did not measure investigator‐ or participant‐rated symptoms. Both treatments were well tolerated when assessed at two weeks during four weeks of treatment. Evidence from these studies was rated as moderate certainty. Oral interventions: oral cyclosporin 3 mg/kg/d probably slightly improves investigator‐rated (RR 1.88, 95% CI 0.88 to 3.99; 1 study, 34 participants) or participant‐rated (RR 1.25, 95% CI 0.69 to 2.27) control of symptoms compared to topical betamethasone dipropionate 0.05% after six weeks of treatment. The risk of adverse events such as dizziness was similar between groups (up to 36 weeks; RR 1.22, 95% CI 0.80 to 1.86, n = 55; 15/27 betamethasone versus 19/28 cyclosporin). The evidence was rated as moderate certainty. Alitretinoin 10 mg improves investigator‐rated symptom control compared with placebo (RR 1.58, 95% CI 1.20 to 2.07; NNTB 11, 95% CI 6.3 to 26.5; 2 studies, n = 781) and alitretinoin 30 mg also improves this outcome compared with placebo (RR 2.75, 95% CI 2.20 to 3.43; NNTB 4, 95% CI 3 to 5; 2 studies, n = 1210). Similar results were found for participant‐rated symptom control: alitretinoin 10 mg RR 1.73 (95% CI 1.25 to 2.40) and 30 mg RR 2.75 (95% CI 2.18 to 3.48). Evidence was rated as high certainty. The number of adverse events (including headache) probably did not differ between alitretinoin 10 mg and placebo (RR 1.01, 95% CI 0.66 to 1.55; 1 study, n = 158; moderate‐certainty evidence), but the risk of headache increased with alitretinoin 30 mg (RR 3.43, 95% CI 2.45 to 4.81; 2 studies, n = 1210; high‐certainty evidence). Outcomes were assessed between 48 and 72 weeks. Authors' conclusions Most findings were from single studies with low precision, so they should be interpreted with caution. Topical corticosteroids and UV phototherapy were two of the major standard treatments, but evidence is insufficient to support one specific treatment over another. The effect of topical calcineurin inhibitors is not certain. Alitretinoin is more effective than placebo in controlling symptoms, but advantages over other treatments need evaluating. Well‐designed and well‐reported, long‐term (more than three months), head‐to‐head studies comparing different treatments are needed. Consensus is required regarding the definition of hand eczema and its subtypes, and a standard severity scale should be established. The main limitation was heterogeneity between studies. Small sample size impacted our ability to detect differences between treatments. Plain language summary Treatments for hand eczema Review question We reviewed evidence on the effects of topical and systemic (oral or injected medicines that work throughout the entire body) treatments for hand eczema when compared against placebo (an identical but inactive treatment), no treatment, vehicle (inactive ingredients that help deliver an active treatment), or another treatment. We included 60 randomised trials (5469 participants) published up to April 2018. Background Hand eczema is an inflammation of the skin of the hands that can be caused by contact allergens (i.e. substances that cause an allergic reaction) such as rubber chemicals, but other external factors (e.g. irritants such as water or detergents) and atopic predisposition are often important triggers. Hand eczema can cause a reduction in quality of life leading to many work‐related problems. Various types of hand eczema exist, and different topical (creams, ointments, or lotions) and systemic treatments with unknown effectiveness can be used. Study characteristics Most participants were hospital outpatients over 18 years of age with mild to severe chronic hand eczema. Treatment was usually given for up to four months, and outcomes were mainly assessed after treatment. A large variety of treatments were studied and compared to no treatment, variants of the same medication, placebo, or vehicle. Twenty‐two studies were funded by pharmaceutical companies. Key results Limited data are available to support the best way of managing hand eczema due to varying study quality and inability to pool data from studies with similar interventions. Corticosteroid creams/ointments and phototherapy (irradiation with UV light) are the major treatment options, although comparisons between these options are lacking. Below, we present results for the main comparisons of interest. Corticosteroid creams/ointments: clobetasol propionate foam probably increases participant‐rated good/excellent control of hand eczema when compared to vehicle (516 versus 222 per 1000), but the difference between groups was less clear for investigator‐rated control, and more adverse events were reported with clobetasol propionate (178 versus 79 per 1000) (all based on moderate‐certainty evidence). Mometasone furoate cream used thrice weekly may slightly improve investigator‐rated good/excellent control compared to twice weekly treatment, and participant‐rated control was not measured. Mild skin thinning occurred in both groups, but cases were few (all based on low‐certainty evidence). Irradiation with UV light: various types of irradiation (i.e. exposure to radiation) were compared. Local PUVA may improve investigator‐rated good/excellent control compared to narrow‐band UVB (400 versus 200 per 1000); however, we are uncertain of this finding because results also show that local PUVA may make little or no difference. Participant‐rated symptoms were not measured. Nine out of 30 participants in the narrow‐band UVB group reported adverse events (mainly redness) compared to none in the PUVA group (all based on moderate‐certainty evidence). Topical calcineurin inhibitors: people receiving tacrolimus are probably more likely to achieve improved investigator‐rated good/excellent symptom control compared to those given vehicle (14/14 participants with tacrolimus compared to none with vehicle), but participant‐rated control of symptoms was not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. One small study compared tacrolimus to mometasone furoate, which were both well tolerated, but did not measure investigator‐ or participant‐rated control (all based on moderate‐certainty evidence). Oral interventions: oral immunosuppressant (a drug that hinders the immune response) cyclosporin probably slightly improves investigator‐ or participant‐rated control of good/excellent symptoms compared to topical betamethasone cream (a corticosteroid). The risk of adverse events such as dizziness was similar between groups (all based on moderate‐certainty evidence). The oral vitamin A derivative (retinoid) alitretinoin (10 mg) achieved investigator‐rated good/excellent symptom control in 307 compared to 194 participants per 1000 with placebo, and alitretinoin 30 mg achieved investigator‐rated control in 432 compared to 157 participants per 1000 with placebo. Similar results were shown for participant‐rated control (high‐certainty evidence). When the dosage of alitretinoin was increased to 30 mg, risk of headache was higher compared to placebo (74 versus 251 per 1000; high‐certainty evidence), but this probably does not differ between alitretinoin 10 mg and placebo (based on moderate‐certainty evidence). Quality of the evidence The quality of evidence was mainly moderate, with most analyses based on single studies that had small sample sizes; therefore, some results should be interpreted with care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Christoffers, WA; Coenraads, PJ; Svensson, Å; Diepgen, TL; Dickinson‐Blok, JL; Xia, J; Williams, HC", "articleTypes": [], "doi": "10.1002/14651858.CD004055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "d9e17790-eb59-41b8-a848-4c8458a19c88", "pmid": "", "title": "Spironolactone in Alcohol Use Disorder (SAUD): A Double-Blind, Placebo-Controlled, Ascending Dose, Phase 1b Study", "imported": false, "abstract": "Background:", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.264Z" }, { "id": "d9ebae59-1bba-402e-bc37-37752f7e3837", "pmid": "", "title": "Antibiotics for induction and maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Several antibiotics have been evaluated in Crohn's disease (CD), however randomised controlled trials (RCTs) have produced conflicting results. Objectives To assess the efficacy and safety of antibiotics for induction and maintenance of remission in CD. Search methods We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register and Clinicaltrials.gov database from inception to 28 February 2018. We also searched reference lists and conference proceedings. Selection criteria RCTs comparing antibiotics to placebo or an active comparator in adult (> 15 years) CD patients were considered for inclusion. Data collection and analysis Two authors screened search results and extracted data. Bias was evaluated using the Cochrane risk of bias tool. The primary outcomes were failure to achieve clinical remission and relapse. Secondary outcomes included clinical response, endoscopic response, endoscopic remission, endoscopic relapse, histologic response, histologic remission, adverse events (AEs), serious AEs, withdrawal due to AEs and quality of life. Remission is commonly defined as a Crohn's disease activity index (CDAI) of < 150. Clinical response is commonly defined as a decrease in CDAI from baseline of 70 or 100 points. Relapse is defined as a CDAI > 150. For studies that enrolled participants with fistulizing CD, response was defined as a 50% reduction in draining fistulas. Remission was defined as complete closure of fistulas. We calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for dichotomous outcomes. We calculated the mean difference (MD) and corresponding 95% CI for continuous outcomes. GRADE was used to assess the certainty of the evidence. Main results Thirteen RCTs (N = 1303 participants) were eligible. Two trials were rated as high risk of bias (no blinding). Seven trials were rated as unclear risk of bias and four trials were rated as low risk of bias. Comparisons included ciprofloxacin (500 mg twice daily) versus placebo, rifaximin (800 to 2400 mg daily) versus placebo, metronidazole (400 mg to 500 mg twice daily) versus placebo, clarithromycin (1 g/day) versus placebo, cotrimoxazole (960 mg twice daily) versus placebo, ciprofloxacin (500 mg twice daily) and metronidazole (250 mg four time daily) versus methylprednisolone (0.7 to 1 mg/kg daily), ciprofloxacin (500 mg daily), metronidazole (500 mg daily) and budesonide (9 mg daily) versus placebo with budesonide (9 mg daily), ciprofloxacin (500 mg twice daily) versus mesalazine (2 g twice daily), ciprofloxacin (500 mg twice daily) with adalimumab versus placebo with adalimumab, ciprofloxacin (500 mg twice daily) with infliximab versus placebo with infliximab, clarithromycin (750 mg daily) and antimycobacterial versus placebo, and metronidazole (400 mg twice daily) and cotrimoxazole (960 mg twice daily) versus placebo. We pooled all antibiotics as a class versus placebo and antibiotics with anti‐tumour necrosis factor (anti‐TNF) versus placebo with anti‐TNF. The effect of individual antibiotics on CD was generally uncertain due to imprecision. When we pooled antibiotics as a class, 55% (289/524) of antibiotic participants failed to achieve remission at 6 to 10 weeks compared with 64% (149/231) of placebo participants (RR 0.86, 95% CI 0.76 to 0.98; 7 studies; high certainty evidence). At 10 to 14 weeks, 41% (174/428) of antibiotic participants failed to achieve a clinical response compared to 49% (93/189) of placebo participants (RR 0.77, 95% CI 0.64 to 0.93; 5 studies; moderate certainty evidence). The effect of antibiotics on relapse in uncertain. Forty‐five per cent (37/83) of antibiotic participants relapsed at 52 weeks compared to 57% (41/72) of placebo participants (RR 0.87, 95% CI 0.52 to 1.47; 2 studies; low certainty evidence). Relapse of endoscopic remission was not reported in the included studies. Antibiotics do not appear to increase the risk of AEs. Thirty‐eight per cent (214/568) of antibiotic participants had at least one adverse event compared to 45% (128/284) of placebo participants (RR 0.87, 95% CI 0.75 to 1.02; 9 studies; high certainty evidence). The effect of antibiotics on serious AEs and withdrawal due to AEs was uncertain. Two per cent (6/377) of antibiotic participants had at least one adverse event compared to 0.7% (1/143) of placebo participants (RR 1.70, 95% CI 0.29 to 10.01; 3 studies; low certainty evidence). Nine per cent (53/569) of antibiotic participants withdrew due to AEs compared to 12% (36/289) of placebo participants (RR 0.86, 95% CI 0.57 to 1.29; 9 studies; low certainty evidence) is uncertain. Common adverse events in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation and headache, change in taste and paraesthesia When we pooled antibiotics used with anti‐TNF, 21% (10/48) of patients on combination therapy failed to achieve a clinical response(50% closure of fistulas) or remission (closure of fistulas) at week 12 compared with 36% (19/52) of placebo and anti‐TNF participants (RR 0.57, 95% CI 0.29 to 1.10; 2 studies; low certainty evidence). These studies did not assess the effect of antibiotics and anti‐TNF on clinical or endoscopic relapse. Seventy‐seven per cent (37/48) of antibiotics and anti‐TNF participants had an AE compared to 83% (43/52) of anti‐TNF and placebo participants (RR 0.93, 95% CI 0.76 to 1.12; 2 studies, moderate certainty evidence). The effect of antibiotics and anti‐TNF on withdrawal due to AEs is uncertain. Six per cent (3/48) of antibiotics and anti‐TNF participants withdrew due to an AE compared to 8% (4/52) of anti‐TNF and placebo participants (RR 0.82, 95% CI 0.19 to 3.45; 2 studies, low certainty evidence). Common adverse events included nausea, vomiting, upper respiratory tract infections, change in taste, fatigue and headache Authors' conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be modest and may not be clinically meaningful. High quality evidence suggests that there is no increased risk of adverse events with antibiotics compared to placebo. The effect of antibiotics on the risk of serious adverse events is uncertain. The effect of antibiotics on maintenance of remission in CD is uncertain. Thus, no firm conclusions regarding the efficacy and safety of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the efficacy and safety of antibiotics as therapy in CD Plain language summary Antibiotics for the treatment of Crohn's disease What is Crohn's disease? Crohn's disease (CD) is an inflammatory disorder that can affect any segment of the gastrointestinal tract from the mouth to the anus. Common symptoms of CD include fever, diarrhea, abdominal pain and weight loss. CD is characterized by periods of relapse when people experience symptoms and periods of remission when the symptoms stop. What are antibiotics? Antibiotics are medications used to treat bacterial infections. Antibiotics are designed to target specific bacterial populations and have different mechanisms of action to stop a bacterial population from growing or eradicate the bacteria. What is the purpose this study? Antibiotics are commonly used for managing patients with CD because the inflammatory process in the bowel was believed to be triggered by a specific bacterial pathogen. Elimination of this bacterial target would allow the inflammatory process to resolve. However, current clinical guidelines do not recommend use of antibiotic agents to induce or maintain clinical remission in patients with CD because there is no definitive evidence to suggest a benefit to using antibiotics in this way. How was this study performed? A systematic review of current literature was performed to determine whether antibiotic therapy is effective to induce or maintain remission in CD. An electronic search of several databases was performed and studies that met our inclusion criteria were selected for further evaluation. Statistical analyses were performed to determine which specific antibiotics had an overall benefit. What were the results? Several antibiotics, including ciprofloxacin, metronidazole, clarithromycin, rifaximin and cotrimoxazole, have been studied in CD. Most of the included studies were small in size. When we pooled antibiotics as a class, these drugs provided a modest benefit over placebo (i.e. a fake drug such as a sugar pill) for induction of remission and improvement of CD symptoms. For example, remission rates were 45% (253/542) in participants who received antibiotics compared to 36% (82/231) in participants who received placebo. We rated the quality of evidence supporting this outcome as high. Few studies assessed the use of antibiotics for maintenance of remission in CD. The impact of antibiotics on preventing relapse in CD is uncertain. Antibiotics do not appear to increase the risk of side effects when compared to placebo. Common side effects reported in the studies included gastrointestinal upset, upper respiratory tract infection, abscess formation, headache, change in taste and paraesthesia (pins and needles in the extremities). Serious side effects were not well reported in the studies and the impact of antibiotics on the risk of serious side effects is uncertain. Conclusions Moderate to high quality evidence suggests that any benefit provided by antibiotics in active CD is likely to be very modest. High quality evidence suggests that there is no increased risk of side effects with antibiotics compared to placebo. The effect of antibiotics on the risk of serious side effects is uncertain. The effect of antibiotics on preventing relapse in CD is uncertain. Thus, no firm conclusions regarding the benefits and harms of antibiotics for maintenance of remission in CD can be drawn. More research is needed to determine the harms and benefits of antibiotic therapy in CD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Townsend, CM, Parker, CE, MacDonald, JK, Nguyen, TM, Jairath, V, Feagan, BG, Khanna, R", "articleTypes": [], "doi": "10.1002/14651858.CD012730.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.731Z" }, { "id": "da02098a-6597-47c3-8ef3-1236b9d36082", "pmid": "", "title": "Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background The anti‐inflammatory effects of n‐3 (omega‐3 fatty acids, fish oil) have been suggested to be beneficial in chronic inflammatory disorders such as inflammatory bowel disease. This review is an update of a previously published Cochrane review. Objectives To systematically review the efficacy and safety of n‐3 for maintenance of remission in Crohn's disease (CD). Search methods The following databases were searched from inception to November 2013 without language restriction: CENTRAL, MEDLINE, EMBASE, HealthSTAR, PubMed, and ACP journal club. Selection criteria Randomized placebo‐controlled trials (RCT) of n‐3 for maintenance of remission in CD were included. Studies must have enrolled patients of any age group, who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil or n‐3 given in pre‐defined dosage. Co‐interventions were allowed only if they were balanced between the study groups. Data collection and analysis The primary outcome was the relapse rate and secondary outcomes included change in disease activity scores, time to first relapse and adverse events. Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality using the Cochrane risk of bias tool. The overall quality of the evidence supporting the primary and selected secondary outcomes was reassessed for the current update using the GRADE system. We used the RevMan software for analyses. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the hazard ratio and 95% CI for time‐to‐event outcomes. Random‐effects or fixed‐effect models were used according to degree of heterogeneity and sensitivity analyses were performed in an attempt to explore possible sources of heterogeneity. Main results Six studies with a total of 1039 patients were eligible for inclusion. The two largest studies were rated as low risk of bias for all assessed items. Four studies were rated as unclear risk of bias for randomization and allocation concealment. Two studies were rated as high risk of bias for incomplete outcome data and selective reporting. There was a marginal significant benefit of n‐3 therapy for maintenance of remission. Thirty‐nine per cent of patients in the n‐3 group relapsed at 12 months compared to 47% of placebo patients (6 studies, 1039 patients; RR 0.77, 95% CI 0.61 to 0.98). A GRADE analysis rated the overall quality of the evidence for the primary outcome (i.e. relapse) as very low due to unexplained heterogeneity (I 2 = 58%), publication bias, and a high or unknown risk of bias in four studies in the pooled analysis. When two large studies at low risk of bias were considered the benefit was no longer statistically significant. Thirty‐seven per cent of patients in the n‐3 group relapsed at 12 months compared to 42% of placebo patients (2 studies, 738 patients; RR 0.88, 95% CI 0.74 to 1.05). No significant heterogeneity was identified for this pooled analysis ( I 2 = 0%). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was moderate due to sparse data (294 events). No serious adverse events were recorded in any of the studies but in a pooled analyses there was a significantly higher rate of diarrhea (4 studies, 862 patients; RR 1.36 95% CI 1.01 to 1.84) and upper gastrointestinal tract symptoms (5 studies, 999 patients; RR 1.65, 95% CI 1.25 to 2.18) in the n‐3 treatment group. Authors' conclusions Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms. Plain language summary Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease Fish oil contains omega 3 fatty acids that may be beneficial in reducing inflammation, such as seen in the bowel of Crohn's disease patients. Randomized placebo‐controlled studies that evaluated the effect of daily intake of capsules containing omega‐3 fatty acids to maintain remission in Crohn's disease were reviewed. Six studies including 1039 patients were included in the review. A pooled analysis of six studies suggests a marginal benefit for omega 3 fatty acids over placebo (i.e. fake medicine) in preventing relapse of disease at one year. However, these results need to be interpreted with caution due to differences across the studies in terms of induction of remission regimens (e.g. surgical remission versus drug therapy) patients (e.g. adult versus pediatric patients) and medication regimens (e.g. some studies used different placebos), the possibility of publication bias (i.e. only studies with positive results are published) and low methodological quality in four studies in the pooled analysis. When the two largest and highest quality studies were pooled the results showed no benefit to omega‐3 treatment over placebo. There were no serious side effects in any of the studies. Common side effects included unpleasant taste, bad breath, heartburn, nausea and diarrhea. Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Lev‐Tzion, R; Griffiths, AM; Ledder, O; Turner, D", "articleTypes": [], "doi": "10.1002/14651858.CD006320.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "da053e2c-18d7-4b31-881e-5ebdc3d1200a", "pmid": "", "title": "Interventions for the prevention and management of oropharyngeal candidiasis associated with HIV infection in adults and children", "imported": false, "abstract": "Abstract - Background Oral candidiasis (OC) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Left untreated, these lesions contribute considerably to the morbidity associated with HIV infection. Interventions aimed at preventing and treating HIV‐associated oral candidal lesions form an integral component of maintaining the quality of life for affected individuals. Objectives To determine the effects of any intervention in preventing or treating OC in children and adults with HIV infection. Search methods The search strategy was based on that of the Cochrane HIV/AIDS Review Group. The following electronic databases were searched for randomised controlled trials for the years 1982 to 2005: Medline, AIDSearch, EMBASE and CINAHL. The Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectiveness, and the Cochrane Central Register of Controlled Trials (CENTRAL) were also searched through May 2005. The abstracts of relevant conferences, including the International Conferences on AIDS and the Conference on Retroviruses and Opportunistic Infections, as indexed by AIDSLINE, were also reviewed. The strategy was iterative, in that references of included studies were searched for additional references. All languages were included. The updated database search was done for the period 2005 up to 2009. The following databases were searched: Medline, EMBASE, the Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectivenes s and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library. AIDSearch was not searched for the updated search as it ceased publication during 2008. Selection criteria Randomised controlled trials (RCTs) of palliative, preventative or curative therapy were considered, irrespective of whether the control group received a placebo. Participants were HIV positive adults and children. Data collection and analysis Two authors independently assessed the methodological quality of the trials and extracted data. Study authors were contacted for additional data where necessary. Main results For the first publication of the review in 2006, forty studies were retrieved. Twenty eight trials (n=3225) met inclusion criteria. During the update search for the review a, further six studies were identified. Of these, five met the inclusion criteria and were included in the review. The review now includes 33 studies (n=3445): 22 assessing treatment and 11 assessing prevention of oropharyngeal candidiasis. Six studies were done in developing countries, 16 in the United States of America and the remainder in Europe. Treatment 
 Treatment was assessed in the majority of trials looking at both clinical and mycological cures. In the majority of comparisons there was only one trial. Compared to nystatin, fluconazole favoured clinical cure in adults (1 RCT; n=167; RR 1.69; 95% CI 1.27 to 2.23). There was no difference with regard to clinical cure between fluconazole compared to ketoconazole (2 RCTs; n=83; RR 1.27; 95% CI 0.97 to 1.66), itraconazole (2 RCTs; n=434; RR 1.05; 95% CI 0.94 to 1.16), clotrimazole (2 RCTs; n=358; RR 1.14; 95% CI 0.92 to 1.42) or posaconazole (1 RCT; n=366; RR1.32; 95% CI 0.36 to 4.83). Two trials compared different dosages of fluconazole with no difference in clinical cure. When compared with clotrimazole, both fluconazole (2 RCTs; n=358; RR 1.47; 95% CI 1.16 to 1.87) and itraconazole (1 RCT; n=123; RR 2.20; 95% CI 1.43 to3.39) proved to be better for mycological cure. Both gentian violet (1 RCT; n=96; RR 5.28; 95% CI 1.23 to 22.55) and ketoconazole (1 RCT; n=92; RR 5.22; 95% CI 1.21 to 22.53) were superior to nystatin in bringing about clinical cure. A single trial compared gentian violet with lemon juice and lemon grass with no significant difference in clinical cure between the groups. 
 
 Prevention 
 Successful prevention was defined as the prevention of a relapse while receiving prophylaxis. Fluconazole was compared with placebo in five studies (5 RCTs; n=599; RR 0.61; 95% CI 0.5 to 0.74) and with no treatment in another (1 RCT; n=65; RR 0.16; 95% CI 0.08 to 0.34). In both instances the prevention of clinical episodes was favoured by fluconazole. Comparing continuous fluconazole treatment with intermittent treatment (2 RCTs; n=891; RR 0.65; 95% CI 0.23 to 1.83), there was no significant difference between the two treatment arms. Chlorhexidine was compared with normal saline in a single study with no significant difference between the treatment arms. Authors' conclusions Five new studies were added to the review, but their results do not alter the final conclusion of the review. Implications for practice 
 Due to there being only one study in children, it is not possible to make recommendations for treatment or prevention of OC in children. Amongst adults, there were few studies per comparison. Due to insufficient evidence, no conclusion could be made about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole or ketoconazole with regard to OC prophylaxis. In comparison to placebo, fluconazole is an effective preventative intervention. However, the potential for resistant Candida organisms to develop, as well as the cost of prophylaxis, might impact the feasibility of implementation. No studies were found comparing fluconazole with other interventions. The direction of findings suggests that ketoconazole, fluconazole, itraconazole and clotrimazole improved the treatment outcomes. Implications for research 
 It is encouraging that low‐cost alternatives are being tested, but more research needs to be on in this area and on interventions like gentian violet and other less expensive anti‐fungal drugs to treat OC. More well‐designed treatment trials with larger samples are needed to allow for sufficient power to detect differences in not only clinical, but also mycological, response and relapse rates. There is also a strong need for more research to be done on the treatment and prevention of OC in children as it is reported that OC is the most frequent fungal infection in children and adolescents who are HIV positive. More research on the effectiveness of less expensive interventions also needs to be done in resource‐poor settings. Currently few trials report outcomes related to quality of life, nutrition, or survival. Future researchers should consider measuring these when planning trials. Development of resistance remains under‐studied and more work must be done in this area. It is recommended that trials be more standardised and conform more closely to CONSORT. Plain language summary Interventions for the prevention and management of oral thrush associated with HIV infection in adults and children Oral candidiasis (thrush) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Interventions aimed at preventing and treating HIV‐associated oral thrush form an integral component of maintaining the quality of life for affected individuals. This review evaluated the effects of interventions in preventing or treating oral thrush in children and adults with HIV infection. Thirty three trials (n=3445) were included. Twenty two trials investigated treatment and eleven trials investigate prevention. There was no difference with regard to clinical cure between fluconazole compared to ketoconazole, itraconazole, clotrimazole and posaconazole. Fluconazole, gentian violet and ketoconazole were superior to nystatin. Compared to placebo and no treatment, fluconazole was effective in preventing clinical episodes from occurring. Continuous fluconazole was better than intermittent treatment. Insufficient evidence was found to come to any conclusion about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole, ketoconazole or chlorhexidine with regard to OC prophylaxis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Pienaar, ED; Young, T; Holmes, H", "articleTypes": [], "doi": "10.1002/14651858.CD003940.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "da09c157-bd58-4f92-8e00-b3af7fef96d2", "pmid": "", "title": "Music‐based therapeutic interventions for people with dementia", "imported": false, "abstract": "Abstract - Background Dementia is a clinical syndrome with a number of different causes. It is characterised by deterioration in cognitive, behavioural, social and emotional functioning. Pharmacological interventions are available but have limited effect on many of the syndrome's features. However, receptivity to music may remain until the late phases of dementia, and music‐based therapeutic interventions (which include, but are not limited to, music therapy) are suitable for people with advanced dementia. As there is uncertainty about the effectiveness of music‐based therapeutic interventions, trials are being conducted to evaluate this. This review updates one last published in 2018 and examines the current evidence for the effects of music‐based interventions for people with dementia. Objectives To assess the effects of music‐based therapeutic interventions for people with dementia on emotional well‐being (including quality of life), mood disturbance or negative affect (i.e. depressive symptoms and anxiety), behavioural problems (i.e. overall behavioural problems or neuropsychiatric symptoms, and more specifically agitation or aggression), social behaviour and cognition, at the end of therapy and four or more weeks after the end of treatment, and to assess any adverse effects. Search methods We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organisation's meta‐register‐the International Clinical Trials Registry Platform on 30 November 2023. Selection criteria We included randomised controlled trials of music‐based therapeutic interventions (of at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music. Data collection and analysis Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data from included studies and assess their risk of bias. If necessary, we contacted trial authors to ask for additional data, such as relevant subscales. We pooled data using the random‐effects model. We assessed the certainty of the evidence for our two comparisons and our main outcomes of interest using GRADE. Main results We included 30 studies with 1720 randomised participants that were conducted in 15 countries. Twenty‐eight studies with 1366 participants contributed data to meta‐analyses. Ten studies contributed data to long‐term outcomes. Participants had dementia of varying degrees of severity and resided in institutions in most of the studies. Seven studies delivered an individual intervention; the other studies delivered the intervention to groups. Most interventions involved both active and receptive elements of musical experience. The studies were at high risk of performance bias and some were at high risk of detection or other bias. For music‐based therapeutic interventions compared to usual care, we found moderate‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions probably improved depressive symptoms slightly (standardised mean difference (SMD) −0.23, 95% confidence interval (CI) −0.42 to −0.04; 9 studies, 441 participants), and we found low‐certainty evidence that it may have improved overall behavioural problems (SMD −0.31, 95% CI −0.60 to −0.02; 10 studies, 385 participants). We found moderate‐certainty evidence that music‐based therapeutic interventions likely did not improve agitation or aggression (SMD −0.05, 95% CI −0.27 to 0.17; 11 studies, 503 participants). Low to very low certainty evidence showed that they did not improve emotional well‐being (SMD 0.14, 95% CI ‐0.29 to 0.56; 4 studies, 154 participants), anxiety (SMD −0.15, 95% CI −0.39 to 0.09; 7 studies, 282 participants), social behaviour (SMD 0.22, 95% CI −0.14 to 0.57; 2 studies; 121 participants) or cognition (SMD 0.19, 95% CI −0.02 to 0.41; 7 studies, 353 participants). Low or very‐low ‐certainty evidence showed that music‐based therapeutic interventions may not have been more effective than usual care in the long term (four weeks or more after the end of treatment) for any of the outcomes. For music‐based therapeutic interventions compared to other interventions, we found low‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions may have been more effective than the other activities for social behaviour (SMD 0.52, 95% CI 0.08 to 0.96; 4 studies, 84 participants). We found very low‐certainty evidence of a positive effect on anxiety (SMD −0.75, 95% CI −1.27 to −0.24; 10 studies, 291 participants). For all other outcomes, low‐certainty evidence showed no evidence of an effect: emotional well‐being (SMD 0.20, 95% CI −0.09 to 0.49; 9 studies, 298 participants); depressive symptoms (SMD −0.14, 95% CI ‐0.36 to 0.08; 10 studies, 359 participants); agitation or aggression (SMD 0.01, 95% CI −0.31 to 0.32; 6 studies, 168 participants); overall behavioural problems (SMD −0.08, 95% CI −0.33 to 0.17; 8 studies, 292 participants) and cognition (SMD 0.12, 95% CI −0.21 to 0.45; 5 studies; 147 participants). We found low or very‐low certainty evidence that music‐based therapeutic interventions may not have been more effective than other interventions in the long term (four weeks or more after the end of treatment) for any of the outcomes. Adverse effects were inconsistently measured or recorded, but no serious adverse events were reported. Authors' conclusions When compared to usual care, providing people with dementia with at least five sessions of a music‐based therapeutic intervention probably improves depressive symptoms and may improve overall behavioural problems at the end of treatment. When compared to other activities, music‐based therapeutic interventions may improve social behaviour at the end of treatment. No conclusions can be reached about the outcome of anxiety as the certainty of the evidence is very low. There may be no effects on other outcomes at the end of treatment. There was no evidence of long‐term effects from music‐based therapeutic interventions. Adverse effects may be rare, but the studies were inconsistent in their reporting of adverse effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions. Plain language summary Does music‐based therapy help people with dementia? Key messages · Compared to usual care (i.e. without specific activities), providing people with dementia with music‐based therapy sessions probably improves depression, and may improve overall behavioural problems. · Compared to other activities, music‐based therapy may improve social behaviour, but we are unsure if it improves anxiety. · These effects may not last beyond the end of treatment. · There is no evidence that music‐based therapy makes a difference to the emotional well‐being, agitation or cognition (e.g. thinking and remembering) of people with dementia, although there is uncertainty about this. · There is uncertainty in the evidence for long‐term effects, but no long‐term effects were observed in the studies. · Adverse effects (unwanted side effects) may be rare, but the studies were inconsistent in their reporting, so we need more evidence before we can reach reliable conclusions. Why offer music‐based therapy to people with dementia? People with dementia gradually develop increasing difficulty with thinking and daily activities. Dementia is often associated with emotional and behavioural problems and may decrease a person's quality of life. In the later stages of dementia, it may be difficult for people to communicate with words, but even when they can no longer speak, they may still be able to hum or play along with music. Therapy involving music may therefore be especially suitable for people with dementia to improve their lives. Who provides music‐based therapy? Music therapists are certified to work with individuals or groups of people, using music to try to help meet their physical, psychological and social needs. Other professionals may also be trained to provide similar therapies. What did we want to find out? We wanted to find out if, for people with dementia, music‐based therapy works better than usual care or other activities, such as painting. We were interested in whether the therapy changed these outcomes at the end of treatment: · emotional well‐being including quality of life; · depression and anxiety; · agitation or aggression and overall behavioural problems; · social behaviour; and · cognition (e.g. thinking and remembering). We also wanted to find out if there were any long‐term effects after therapy ended or any unwanted effects. What did we do? We searched for studies in which people with dementia were randomly allocated to receive music‐based therapy (of at least five sessions) or to a comparison group with no activities or different activities. We combined the results of the studies to estimate the effects of music‐based therapy as accurately as possible. We also rated our level of confidence in the findings. What did we find? We found 30 studies performed in 15 countries. The studies involved 1720 people with dementia of varying severity. In most of the studies, the participants lived in nursing homes. Seven studies delivered the music‐based therapy to individuals; the other studies delivered the intervention to groups. We were able to use results from 28 studies involving 1366 people with dementia for one or more outcomes at the end of treatment. Ten studies contributed information about long‐term results. Main results At the end of treatment Music‐based therapy probably improves depression and may improve overall behavioural problems, compared with providing usual care. Music‐based therapy may improve social behaviour compared to other activities. We were less confident about the effects of music‐based therapy on anxiety compared to other activities. The available evidence does not suggest any benefit of music‐based therapy for emotional well‐being (including quality of life), agitation and aggression, or cognition, but the evidence is limited and there is uncertainty about this. In the longer term Some studies measured outcomes four weeks or more after treatment ended. We did not find any lasting effects, but there were fewer results measured in the longer term, and we are uncertain about this evidence. Further studies are likely to have a significant impact on what we know about the effects of music‐based therapy for people with dementia, so it is important that research continues. What are the limitations of the evidence? There was variation in the quality of the studies and how well they were reported. In all studies, participants and personnel might have known which treatment participants were getting, and in some, the assessors might have known this as well. This could have affected the results. Regarding effects at the end of music‐based therapy, we are moderately confident in the evidence for the beneficial effect on depression compared to usual care. We have little confidence in the effects or lack of effects on any of the other outcomes. Adverse effects were rarely reported. How up to date is this evidence? This review updates our previous review. We added eight new studies and reached new conclusions. The evidence is current to 30 November 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "van der Steen, JT, van der Wouden, JC, Methley, AM, Smaling, HJ A, Vink, AC, Bruinsma, MS", "articleTypes": [], "doi": "10.1002/14651858.CD003477.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.766Z" }, { "id": "da44de5c-f7ef-4959-8f75-22a9876cd679", "pmid": "", "title": "Nicotine replacement therapy versus control for smoking cessation", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence. Objectives To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long‐term smoking cessation, compared to placebo or 'no NRT' interventions. Search methods We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017. Selection criteria Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow‐up of less than six months. We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews. Data collection and analysis Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow‐up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta‐analysis using a Mantel‐Haenszel fixed‐effect model. Main results We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non‐NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare. Authors' conclusions There is high‐quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non‐ischaemic chest pain and palpitations. Plain language summary Can nicotine replacement therapy (NRT) help people quit smoking? Background We reviewed the evidence about whether NRT helps people who want to quit smoking to stop smoking at six months or longer. NRT aims to reduce withdrawal symptoms associated with stopping smoking by replacing the nicotine from cigarettes. NRT is available as skin patches that deliver nicotine slowly, and chewing gum, nasal and oral sprays, inhalators, and lozenges/tablets, all of which deliver nicotine to the brain more quickly than skin patches, but less rapidly than from smoking cigarettes. Study characteristics This review includes 136 trials of NRT, with 64,640 people in the main analysis. All studies were conducted in people who wanted to quit smoking. Most studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. The evidence is current to July 2017. Trials lasted for at least six months. Key results We found evidence that all forms of NRT made it more likely that a person's attempt to quit smoking would succeed. The chances of stopping smoking were increased by 50% to 60%. NRT works with or without additional counselling, and does not need to be prescribed by a doctor. Side effects from using NRT are related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. There is no evidence that NRT increases the risk of heart attacks. Quality of evidence The overall quality of the evidence is high, meaning that further research is very unlikely to change our conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hartmann‐Boyce, J; Chepkin, SC; Ye, W; Bullen, C; Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD000146.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "da47060e-88dc-4400-8d71-792582f7d4d0", "pmid": "", "title": "Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age", "imported": false, "abstract": "Abstract - Background According to global prevalence analysis studies, acute upper respiratory tract infections (URTIs) are the most common acute infectious disease in children, especially in preschool children. Acute URTIs lead to an economic burden on families and society. Vitamin A refers to the fat‐soluble compound all‐trans‐retinol and also represents retinol and its active metabolites. Vitamin A interacts with both the innate immune system and the adaptive immune system and improves the host's defences against infections. Correlation studies show that serum retinol deficiency was associated with a higher risk of respiratory tract infections. Therefore, vitamin A supplementation may be important in preventing acute URTIs. Objectives To assess the effectiveness and safety of vitamin A supplements for preventing acute upper respiratory tract infections in children up to seven years of age. Search methods We searched CENTRAL, MEDLINE, Embase, the Chinese Biomedical Literature Database, and two trial registration platforms to 8 June 2023. We also checked the reference lists of all primary studies and reviewed relevant systematic reviews and trials for additional references. We imposed no language or publication restrictions. Selection criteria We included randomised controlled trials (RCTs), which evaluated the role of vitamin A supplementation in the prevention of acute URTIs in children up to seven years of age. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Main results We included six studies (27,351 participants). Four studies were RCTs and two were cluster‐RCTs. The included studies were all conducted in lower‐middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas with a high local prevalence of malnutrition and xerophthalmia. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. We judged the included studies to be at either a high or unclear risk of bias for random sequence generation, incomplete outcome data, and blinding. Primary outcomes Six studies reported the incidence of acute URTIs during the study period. Five studies reported the number of acute URTIs over a period of time, but there was population heterogeneity and the results were presented in different forms, therefore only three studies were meta‐analysed. We are uncertain of the effect of vitamin A supplementation on the number of acute URTIs over two weeks (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.92 to 1.09; I 2 = 44%; 3 studies, 22,668 participants; low‐certainty evidence). Two studies reported the proportion of participants with an acute URTI. We are uncertain of the effect of vitamin A supplementation on the proportion of participants with an acute URTI (2 studies, 15,535 participants; low‐certainty evidence). Only one study (116 participants) reported adverse events. No infant in either the placebo or vitamin A group was found to have feeding difficulties (failure to feed or vomiting), a bulging fontanelle, or neurological signs before or after vitamin A administration (very low‐certainty evidence). Secondary outcomes Two studies (296 participants) reported the severity of subjective symptoms, presented by the mean duration of acute URTI. Vitamin A may have little to no effect on the mean duration of acute URTI (very low‐certainty evidence). Authors' conclusions The evidence for the use of vitamin A supplementation to prevent acute URTI is uncertain, because population, dose and duration of interventions, and outcomes vary between studies. From generally very low‐ to low‐certainty evidence, we found that there may be no benefit in the use of vitamin A supplementation to prevent acute URTI in children up to seven years of age. More RCTs are needed to strengthen the current evidence. Future research should report over longer time frames using validated tools and consistent reporting, and ensure adequate power calculations, to allow for easier synthesis of data. Finally, it is important to assess vitamin A supplementation for preschool children with vitamin A deficiency. Plain language summary Oral vitamin A supplements to prevent acute upper respiratory tract infections in children up to seven years of age Background Acute upper respiratory tract infections (URTIs) are the most common acute infectious diseases in children, especially in preschool children. Vitamin A has a positive role in the immune system and may improve the host's defences against infections. Studies show that children with vitamin deficiency are more likely to suffer from respiratory tract infections. Therefore, we assessed the role of vitamin A supplementation in the prevention of acute upper respiratory tract infections in preschool children (up to seven years of age). Review question What is the role of vitamin A supplementation in the prevention of acute URTIs in preschool children (up to seven years of age), compared to no supplementation? Search date We searched for evidence up to 8 June 2023. Study characteristics All included studies were conducted in lower‐ and middle‐income countries (two in India, two in South Africa, one in Ecuador, and one in Haiti). Three studies included healthy children who had no vitamin A deficiency, one study included children born to HIV‐infected women, one study included low‐birthweight neonates, and one study included children in areas more likely to experience malnutrition and dry eye. In two studies, vitamin E was a co‐treatment administered in addition to vitamin A. Key results We included six studies involving 27,351 participants. We have very low to low confidence in the evidence provided by the studies. Five studies reported the number of acute URTIs over a period of time. The included studies varied by population and the results were presented in different forms, so we could only combine three studies together (meta‐analysis). We are uncertain if vitamin A supplementation lowers the number of acute URTIs over a two‐week period (three studies, 22,668 participants). Two studies reported the proportion of participants with acute URTI. The effect of vitamin A supplementation on the proportion of participants with acute URTI is uncertain (two studies, 15,535 participants). Only one study (116 participants) reported adverse events and none occurred in infants in the placebo or vitamin A groups. Two studies (296 participants) reported the severity of subjective symptoms, presented by the average duration of acute URTIs. Vitamin A may have little to no effect on the average duration of acute URTIs. Authors' conclusions From evidence in which we have very low to low confidence, we found that there may be no benefit in using vitamin A supplementation to prevent acute URTIs in children up to seven years of age. High‐quality studies focusing on preschool children with vitamin A deficiency are needed to identify whether vitamin A supplementation may be effective.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Cheng, X, Li, D, Yang, C, Chen, B, Xu, P, Zhang, L", "articleTypes": [], "doi": "10.1002/14651858.CD015306.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.123Z" }, { "id": "da494598-6215-41da-a852-6c54d0de114d", "pmid": "", "title": "Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background It is unclear whether patients with type 2 diabetes who have poor glycaemic control despite maximal oral hypoglycaemic agents (OHAs) should be commenced on insulin as monotherapy, or insulin combined with oral hypoglycaemic agents (insulin‐OHA combination therapy). Objectives To assess the effects of insulin monotherapy versus insulin‐OHA combinations therapy. Search methods Eligible studies were identified by searching MEDLINE, EMBASE, and The Cochrane Library . Selection criteria Randomised controlled trials (RCTs) with 2 months minimum follow‐up duration comparing insulin monotherapy (all schemes) with insulin‐OHA combination therapy. Data collection and analysis Data extraction and assessment of study quality were undertaken by three reviewers in pairs. Main results Twenty RCTs (mean trial duration 10 months) including 1,811 participants, with mean age 59.8 years and mean known duration of diabetes 9.6 years. Overall, study methodological quality was low. Twenty‐eight comparisons in 20 RCTs were ordered according to clinical considerations. No studies assessed diabetes‐related morbidity, mortality or total mortality. From 13 studies (21 comparisons), sufficient data were extracted to calculate pooled effects on glycaemic control. Insulin‐OHA combination therapy had statistically significant benefits on glycaemic control over insulin monotherapy only when the latter was applied as a once‐daily injection of NPH insulin. Conversely, twice‐daily insulin monotherapy (NPH or mixed insulin) provided superior glycaemic control to insulin‐OHA combination therapy regimens where insulin was administered as a single morning injection. In more conventional comparisons, regimens utilising OHAs with bedtime NPH insulin provided comparable glycaemic control to insulin monotherapy (administered as twice daily, or multiple daily injections). Overall, insulin‐OHA combination therapy was associated with a 43% relative reduction in total daily insulin requirement compared to insulin monotherapy. Of the 14 studies (22 comparisons) reporting hypoglycaemia, 13 demonstrated no significant difference in the frequency of symptomatic or biochemical hypoglycaemia between insulin and combination therapy regimens. No significant differences in quality of life related issues were detected. Combination therapy with bedtime NPH insulin resulted in statistically significantly less weight gain compared to insulin monotherapy, provided metformin was used ± sulphonylurea. In all other comparisons no significant differences with respect to weight gain were detected. Authors' conclusions Bedtime NPH insulin combined with oral hypoglycaemic agents provides comparable glycaemic control to insulin monotherapy and is associated with less weight gain if metformin is used. Plain language summary Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus Simple application of a single daily insulin injection in addition to oral hypoglycaemic agents may facilitate the initiation of insulin therapy in type 2 diabetes mellitus.This review examined 20 trials including 1,811 participants which compared insulin monotherapy with insulin in combination with oral hypoglycaemic agents (OHA) in insulin‐requiring patients with type 2 diabetes. The results suggest that a bedtime NPH insulin‐oral hypoglycaemic agent combination therapy regimen provides comparable glycaemic control to insulin monotherapy. Due to lack of studies it remains unclear whether insulin‐OHA combination regimens with metformin alone are superior to those with metformin plus a sulphonylurea. In most cases no significant differences in hypoglycaemic events were observed between insulin mono‐ and OHA combination therapy. No study assessed diabetes‐related morbidity or mortality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Goudswaard, AN; Furlong, NJ; Valk, GD; Stolk, RP; Rutten, GEHM", "articleTypes": [], "doi": "10.1002/14651858.CD003418.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "da5e5efe-3ec0-498b-afbb-9929bbcbf73c", "pmid": "", "title": "Interventions for protecting renal function in the perioperative period", "imported": false, "abstract": "Abstract - Background Various methods have been used to try to protect kidney function in patients undergoing surgery. These most often include pharmacological interventions such as dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants and erythropoietin (EPO). Objectives This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period. We considered the following questions: (1) Are any specific measures known to protect kidney function during the perioperative period? (2) Of measures used to protect the kidneys during the perioperative period, does any one method appear to be more effective than the others? (3) Of measures used to protect the kidneys during the perioperative period,does any one method appear to be safer than the others? Search methods In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 2, 2012), MEDLINE (Ovid SP) (1966 to August 2012) and EMBASE (Ovid SP) (1988 to August 2012). We originally handsearched six journals ( Anesthesia and Analgesi a, Anesthesiology , Annals of Surgery , British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery) (1985 to 2004). However, because these journals are properly indexed in MEDLINE, we decided to rely on electronic searches only without handsearching the journals from 2004 onwards. Selection criteria We selected all randomized controlled trials in adults undergoing surgery for which a treatment measure was used for the purpose of providing renal protection during the perioperative period. Data collection and analysis We selected 72 studies for inclusion in this review. Two review authors extracted data from all selected studies and entered them into RevMan 5.1; then the data were appropriately analysed. We performed subgroup analyses for type of intervention, type of surgical procedure and pre‐existing renal dysfunction. We undertook sensitivity analyses for studies with high and moderately good methodological quality. Main results The updated review included data from 72 studies, comprising a total of 4378 participants. Of these, 2291 received some form of treatment and 2087 acted as controls. The interventions consisted most often of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, NAC, ANP, sodium bicarbonate, antioxidants and EPO or selected hydration fluids. Some clinical heterogeneity and varying risk of bias were noted amongst the studies, although we were able to meaningfully interpret the data. Results showed significant heterogeneity and indicated that most interventions provided no benefit. Data on perioperative mortality were reported in 41 studies and data on acute renal injury in 44 studies (all interventions combined). Because of considerable clinical heterogeneity (different clinical scenarios, as well as considerable methodological variability amongst the studies), we did not perform a meta‐analysis on the combined data. Subgroup analysis of major interventions and surgical procedures showed no significant influence of interventions on reported mortality and acute renal injury. For the subgroup of participants who had pre‐existing renal damage, the risk of mortality from 10 trials (959 participants) was estimated as odds ratio (OR) 0.76, 95% confidence interval (CI) 0.38 to 1.52; the risk of acute renal injury (as reported in the trials) was estimated from 11 trials (979 participants) as OR 0.43, 95% CI 0.23 to 0.80. Subgroup analysis of studies that were rated as having low risk of bias revealed that 19 studies reported mortality numbers (1604 participants); OR was 1.01, 95% CI 0.54 to 1.90. Fifteen studies reported data on acute renal injury (criteria chosen by the individual studies; 1600 participants); OR was 1.03, 95% CI 0.54 to 1.97. Authors' conclusions No reliable evidence from the available literature suggests that interventions during surgery can protect the kidneys from damage. However, the criteria used to diagnose acute renal damage varied in many of the older studies selected for inclusion in this review, many of which suffered from poor methodological quality such as insufficient participant numbers and poor definitions of end points such as acute renal failure and acute renal injury. Recent methods of detecting renal damage such as the use of specific biomarkers and better defined criteria for identifying renal damage (RIFLE (risk, injury, failure, loss of kidney function and end‐stage renal failure) or AKI (acute kidney injury)) may have to be explored further to determine any possible benefit derived from interventions used to protect the kidneys during the perioperative period. Plain language summary No evidence indicates that any of the measures used to protect patients' kidneys during the perioperative period are beneficial The kidneys may be damaged during an operation as a result of direct and indirect insult. The reasons for this are multiple and include changes to physiology brought on by the surgery and by the body’s response to such insult. Damage to kidneys during the perioperative period is associated with significant morbidity and mortality. This updated Cochrane review looked at 72 randomized controlled trials (RCTs) with 4378 participants (search data until August 2012); interventions most often included pharmacological interventions (administration of dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine, atrial natriuretic peptide, sodium bicarbonate, antioxidants and erythropoietin) or selected hydration fluids. We attempted to identify any possible damage to the kidneys by evaluating kidney function up to seven days after the operation. No clear evidence from available RCTs suggests that any of the measures used to protect the kidneys during the perioperative period are beneficial. These findings held true in 14 studies of patients with pre‐existing renal damage and in 24 studies that were considered of good methodological quality. The primary outcomes of these studies were mortality and acute renal injury. Reported mortality in studies with low risk of bias was not different between intervention and control groups (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.52 to 1.97) or for acute renal injury (OR 1.05, 95% CI 0.55 to 2.03). The summary of findings revealed a similar picture. So we conclude that evidence suggests that none of the interventions used currently are helpful in protecting the kidneys during the perioperative period, nor do they cause increased harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zacharias, M, Mugawar, M, Herbison, GP, Walker, RJ, Hovhannisyan, K, Sivalingam, P, Conlon, NP", "articleTypes": [], "doi": "10.1002/14651858.CD003590.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.761Z" }, { "id": "da645cc0-af56-42be-afa6-718882b98108", "pmid": "", "title": "Optimisation of antiretroviral therapy in HIV‐infected children under 3 years of age", "imported": false, "abstract": "Abstract - Background In the absence of antiretroviral therapy (ART), over 50% of HIV‐infected infants progress to AIDS and death by 2 years of age. However, there are challenges to initiation of ART in early life, including the possibility of drug resistance in the context of prevention of mother‐to‐child transmission (PMTCT) programs, a paucity of drug choices , uncertain dosing for some medications and long‐term toxicities. Key management decisions include when to start ART, what regimen to start, and whether and when to substitute drugs or interrupt therapy. This review, an update of a previous review, aims to summarize the currently available evidence on this topic and inform the ART management in HIV‐infected children less than 3 years of age. Objectives To evaluate 1) when to start ART in young children (less than 3 years); 2) what ART to start with, comparing first‐line non‐nucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI)‐based regimens; and 3) whether alternative strategies should be used to optimize antiretroviral treatment in this population: induction (initiation with 4 drugs rather than 3 drugs) followed by maintenance ART, interruption of ART and substitution of PI with NNRTI drugs once virological suppression is achieved on a PI‐based regimen. Search methods Search methods We searched for published studies in the Cochrane HIV/AIDS Review Group Trials Register, The Cochrane Library, Pubmed, EMBASE and CENTRAL. We screened abstracts from relevant conference proceedings and searched for unpublished and ongoing trials in clinical trial registries (ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform). Selection criteria We identified RCTs that recruited perinatally HIV‐infected children under 3 years of age without restriction of setting. We rejected trials that did not include children less than 3 years of age, did not provide stratified outcomes for those less than 3 years or did not evaluate either timing of ART initiation, choice of drug regimen or treatment switch/interruption strategy. Data collection and analysis Two reviewers independently applied study selection criteria, assessed study quality and extracted data. Effects were assessed using the hazard ratio (HR) for time‐to‐event outcomes, relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes. Main results A search of the databases identified a total of 735 unique, previously unreviewed studies, of which 731 were excluded to leave 4 new studies to incorporate into the review. Four additional studies were identified in conference proceedings, for a total of 8 studies addressing when to start treatment (n=2), what to start (n=3), whether to substitute lopinavir/ritonavir (LPV/r) with nevirapine (NVP) (n=1), whether to use an induction‐maintenance ART strategy (n=1) and whether to interrupt treatment (n=1). Treatment initiation in asymptomatic infants with good immunological status was associated with a 75% reduction (HR=0.25; 95%CI 0.12‐0.51; p=0.0002) in mortality or disease progression in the one trial with sufficient power to address this question. In a smaller pilot trial, median CD4 cell count was not significantly different between early and deferred treatment groups 12 months after ART. Regardless of previous exposure to nevirapine for PMTCT, the hazard for treatment failure at 24 weeks was 1.79 (95%CI 1.33, 2.41) times higher in children starting ART with a NVP‐based regimen compared to those starting with a LPV/r‐based regimen (p=0.0001) with no clear difference in the effect observed for children younger or older than 1 year. The hazard for virological failure at 24 weeks was overall 1.84 (95%CI 1.29, 2.63) times higher for children starting ART with a NVP‐based regimen compared to those starting with a LPV/r‐based regimen (p=0.0008) with a larger difference in time to virological failure (or death) between the NVP and LPV/r‐based regimens when ART was initiated in the first year of life. Infants starting a LPV/r regimen and achieving sustained virological suppression who then substituted LPV/r with NVP after median 9 months on LPV/r were less likely to develop virological failure (defined as at least one VL greater than 50 copies/mL) compared with infants who started and stayed on LPV/r (HR=0.62, 95%CI 0.41, 0.92, p=0.02). However the hazard for confirmed failure at a higher viral load (>1000 copies/mL) was greater among children who switched to NVP compared to those who remained on LPV/r (HR=10.19, 95% CI 2.36, 43.94, p=0.002). Children undergoing an induction‐maintenance ART approach with a 4‐drug NNRTI‐based regimen for 36 weeks, followed by 3‐drug ART, had significantly greater CD4 rise than children receiving a standard 3‐drug NNRTI‐based ART at 36 weeks (mean difference 1.70 [95%CI 0.61, 2.79] p=0.002) and significantly better viral load response at 24 weeks (OR 1.99 [95%CI 1.09, 3.62] p=0.02). However, the immunological and virological benefits were short‐term. The one trial of treatment interruption that compared children initiating continuous ART from infancy with children interrupting ART was terminated early because the duration of treatment interruption was less than 3 months in most infants. Children interrupting treatment had similar growth and occurrence of serious adverse events as those in the continuous arm. Authors' conclusions ART initiation in asymptomatic children under 1 year of age reduces morbidity and mortality, but it remains unclear whether there are clinical benefits to starting ART in asymptomatic children diagnosed with HIV infection between 1‐3 years. The available evidence shows that a LPV/r‐based first‐line regimen is more efficacious than a NVP‐based regimen, regardless of PMTCT exposure status. New formulations of LPV/r are urgently required to enable new WHO recommendations to be implemented. An alternative approach to long‐term LPV/r is substituting LPV/r with NVP once virological suppression is achieved. This strategy looked promising in the one trial undertaken, but may be difficult to implement in the absence of routine viral load testing. A 4‐drug induction‐maintenance approach showed short‐term virological and immunological benefits during the induction phase but, in the absence of sustained benefits, is not recommended as a routine treatment strategy. Treatment interruption following early ART initiation in infancy was challenging for children who were severely immunocompromised in the context of poor clinical immunological condition at ART initiation due to the short duration of interruption, and is therefore not practical in ART treatment programmes where close monitoring is not feasible. Plain language summary Using antiretroviral drugs to treat children under 3 years old who have HIV infection Children under 3 years of age who have HIV infection have a high risk of dying without antiretroviral therapy (ART). However, treatment in this age group is challenging because there are high levels of virus in the blood and few suitable drug choices. Results from this systematic review show that ART soon after birth is preferable to delaying treatment, because infants are less likely to die or become sick. Starting a first‐line treatment regimen that includes lopinavir/ritonavir rather than nevirapine is preferable, because infants and young children are less likely to have to stop treatment, whether or not they had previously been exposed to nevirapine. However, lopinavir/ritonavir is more expensive than nevirapine. It is also currently only available as an inconvenient liquid, which tastes bitter and has to be refrigerated, making it challenging to implement in all parts of the world. While waiting for better formulations to become available, it may be possible to switch from lopinavir/ritonavir to nevirapine once the HIV virus levels become undetectable. However, based on the evidence currently available, a viral load test would be required to identify those children who could safely substitute lopinavir/ritonavir with nevirapine. Viral loads are expensive and not widely available in most countries in sub‐Saharan Africa. An alternative treatment approach is to give a stronger drug combination (four different drugs together) when treatment is first started, then reduce down to three drugs after a short while. However, this strategy did not appear to have long‐term benefits. A 'treatment interruption' strategy, in which infants start ART soon after birth but then stop medication after 1‐2 years, is difficult to implement. Children stopping ART need to restart it very quickly to prevent them becoming sick, and monitoring a child off treatment is challenging in settings with few resources.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Penazzato, M, Prendergast, AJ, Muhe, LM, Tindyebwa, D, Abrams, E", "articleTypes": [], "doi": "10.1002/14651858.CD004772.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.133Z" }, { "id": "da6c88b5-d715-4ae5-93c5-fa8298caec20", "pmid": "", "title": "Antibiotics for the induction and maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Antibiotics have been considered to treat ulcerative colitis (UC) due to their antimicrobial properties against intestinal bacteria linked to inflammation. However, there are concerns about their efficacy and safety. Objectives To determine whether antibiotic therapy is safe and effective for the induction and maintenance of remission in people with UC. Search methods We searched five electronic databases on 10 December 2021 for randomised controlled trials (RCTs) comparing antibiotic therapy to placebo or an active comparator. Selection criteria We considered people with UC of all ages, treated with antibiotics of any type, dose, and route of administration for inclusion. Induction studies required a minimum duration of two weeks for inclusion. Maintenance studies required a minimum duration of three months to be considered for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcome for induction studies was failure to achieve remission and for maintenance studies was relapse, as defined by the primary studies. Main results We included 12 RCTs (847 participants). One maintenance of remission study used sole antibiotic therapy compared with 5‐aminosalicylic acid (5‐ASA). All other trials used concurrent medications or standard care regimens and antibiotics as an adjunct therapy or compared antibiotics with other adjunct therapies to examine the effect on induction of remission. There is high certainty evidence that antibiotics (154/304 participants) compared to placebo (175/304 participants) result in no difference in failure to achieve clinical remission (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.06). A subgroup analysis found no differences when steroids, steroids plus 5‐ASA, or steroids plus 5‐ASA plus probiotics were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (102/168 participants) compared to placebo (121/175 participants) may result in no difference in failure to achieve clinical response (RR 0.75, 95% CI 0.47 to 1.22). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (6/342 participants) compared to placebo (5/349 participants) may result in no difference in serious adverse events (RR 1.19, 95% CI 0.38 to 3.71). A subgroup analysis found no differences when steroids were additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (3/342 participants) compared to placebo (1/349 participants) may result in no difference in withdrawals due to adverse events (RR 2.06, 95% CI 0.27 to 15.72). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were additional therapies to antibiotics and placebo. It is unclear if there is any difference between antibiotics in combination with probiotics compared to no treatment or placebo for failure to achieve clinical remission (RR 0.68, 95% CI 0.39 to 1.19), serious adverse events (RR 1.00, 95% CI 0.07 to 15.08), or withdrawals due to adverse events (RR 1.00, 95% CI 0.07 to 15.08). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to achieve clinical remission (RR 2.20, 95% CI 1.17 to 4.14). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to probiotics for failure to achieve clinical remission (RR 0.47, 95% CI 0.23 to 0.94). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to maintain clinical remission (RR 0.71, 95% CI 0.47 to 1.06). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to no treatment for failure to achieve clinical remission in a mixed population of people with active and inactive disease (RR 0.56, 95% CI 0.29 to 1.07). The certainty of the evidence is very low. For all other outcomes, no effects could be estimated due to a lack of data. Authors' conclusions There is high certainty evidence that there is no difference between antibiotics and placebo in the proportion of people who achieve clinical remission at the end of the intervention period. However, there is evidence that there may be a greater proportion of people who achieve clinical remission and probably a greater proportion who achieve clinical response with antibiotics when compared with placebo at 12 months. There may be no difference in serious adverse events or withdrawals due to adverse events between antibiotics and placebo. No clear conclusions can be drawn for any other comparisons. A clear direction for future research appears to be comparisons of antibiotics and placebo (in addition to standard therapies) with longer‐term measurement of outcomes. Additionally. As there were single studies of other head‐to‐head comparisons, there may be scope for future studies in this area. Plain language summary The use of antibiotics in the treatment of ulcerative colitis What was the aim of this review? This Cochrane Review aimed to determine whether antibiotics are useful and safe for people with ulcerative colitis (UC) in achieving or maintaining remission. Key messages We found that antibiotics, when added to standard therapies, are similar to placebo in how often they fail to achieve remission or disease improvement for people with UC, measured up to three months from taking them. We found that antibiotics when compared to placebo may be useful in achieving remission or some improvement of UC symptoms, measured at 12 months from taking them. In terms of safety, the evidence is of low certainty, but antibiotics may be as safe as placebo. We have confidence in the findings up to three months, but have less confidence in the evidence at 12 months due to low numbers of study participants. What is ulcerative colitis? UC is a chronic (long term) inflammatory disease that affects the large bowel. The most common symptoms include bloody diarrhoea, abdominal pain, and a sudden almost uncontrollable urge to pass stool. Some people have other symptoms including sore joints, mouth sores, and inflammation in their eyes. When someone is experiencing symptoms of UC, they are said to have 'active' disease. When symptoms improve with treatment, the disease is said to be responding to therapy. When symptoms stop, the disease is said to be in 'remission'. People with UC in remission are often given therapy with medicines to try and prolong (maintain) their remission or response to therapy. What did the review study? This review studied the use of antibiotics in the treatment of UC. Eleven studies considered antibiotics as a therapy for achieving remission and one study as therapy for maintaining remission. Antibiotics could theoretically be helpful as they might be able to fight harmful bacteria in the gut that are thought to be a partial cause for the presence of UC symptoms. Currently, most doctors do not recommend the use of antibiotics unless the patient has an infection. What were the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing antibiotics with another treatment or dummy treatment. We found 12 RCTs including 847 participants. The trials looked at people of all ages; using different types and doses of antibiotics; and at antibiotics taken as tablets, injections, or any other way. The main results from our review are as follows. 1. Antibiotics, when added to standard therapies, are no different from placebo in failing to achieve remission or improve disease symptoms for people with UC when measured up to three months from taking them. 2. Antibiotics probably fail less than placebo in achieving remission or some improvement of UC symptoms measured at 12 months from taking them. 3. In terms of safety, antibiotics may be similar to placebo, but the evidence is of low certainty. 4. We are uncertain about how antibiotics compare to other treatments because there is not enough good evidence to make a judgement. Conclusion There is no difference between antibiotics and placebo when added to standard therapies to achieve remission or improvement of symptoms in the short term. However, they may help to lessen the number of people who do not achieve remission, and they probably lead to fewer numbers of people who have not achieved improvement of symptoms at 12 months. No conclusions can be drawn on other treatments or safety due to lack of evidence, even though there may be a possibility that antibiotics are as safe as placebo. Further research would be needed to clarify the usefulness of antibiotics in the treatment of UC; however, such studies should focus on longer‐term outcomes given the findings of this review. How up‐to‐date is this review? This review is up‐to‐date as of December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Gordon, M; Sinopoulou, V; Grafton-Clarke, C; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "da83538b-5c3e-4a65-950b-7f1003648424", "pmid": "", "title": "Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Nedocromil sodium and sodium cromoglycate inhaled shortly before exercise appear to reduce the severity of exercise‐induced bronchoconstriction. There is some debate over which drug may be more effective. Objectives The objective of this review was to compare the effects on post‐exercise lung function between prophylactic doses of nedocromil sodium (NSG) and sodium cromoglycate (SCG) in persons diagnosed with exercise‐induced bronchoconstriction. Search methods Randomized controlled trials were identified from the Cochrane Airways Review Group Asthma Register. Bibliographies of relevant studies and review articles were searched and primary authors, content experts and manufacturers of drugs were contacted for additional relevant studies. No language restrictions were applied. Searches were current as of December 2007. Selection criteria Randomized controlled trials comparing NCS to SCG in prophylactic treatment of exercise‐induced bronchoconstriction were eligible. Studies were included if: the participants, aged 6 or over, had a confirmed diagnosis of asthma with exercise‐induced bronchoconstriction, were subjected to an exercise challenge sufficient to trigger bronchoconstriction, and the measures of lung function were reported as either changes in forced expiratory volume in one second or peak expiratory flow rate. Data collection and analysis Data extraction and methodological quality assessments were conducted independently by two reviewers using standard forms and validated assessment criteria. In some cases results were extrapolated from graphs. Results from similar studies were pooled and reported as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CI) using the random effects model. Main results Nine studies (162 participants) are included in this review. No significant difference was noted between NCS and SCG with respect to the maximum percent decrease in FEV1 (WMD = ‐0.88; 95% CI: ‐4.50, 2.74), complete protection (i.e. maximum % fall FEV1 still =>10%); OR = 0.95; 95% CI: 0.50 to 1.8, clinical protection (i.e. < 50% improvement over placebo); OR = 0.71; 95% CI: 0.36 to 1.39; unpleasant taste (OR = 6.85; 95% CI: 0.77, 60.73), or sore throat (OR = 3.46; 95% CI: 0.32, 37.48). For these pooled comparisons, no statistically significant heterogeneity was identified. Subgroup analyses based on age, dosage of medications and timing of exercise post‐inhalation were consistent with the overall pooled analyses. Authors' conclusions No significant differences were evident between the effect of NCS and SCG during the immediate post‐exercise period in adults and children with EIB with regards to pulmonary function ‐ specifically maximum percent decrease in FEV1, complete protection, clinical protection, or side effects. Plain language summary Nedocromil sodium versus sodium cromoglycate for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. Two drugs, nedocromil sodium (Tilade) and sodium cromoglycate are sometimes used before exercise to prevent asthma. The review of trials found that both were similarly effective in relieving exercise‐induced asthma for both children and adults. More people have sore throats and an unpleasant after‐taste after using nedocromil sodium.", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Kelly, KD; Spooner, C; Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD002731", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "da9fb1e1-a06e-4fb1-a104-a8459329c677", "pmid": "", "title": "Colchicine for pericarditis", "imported": false, "abstract": "Abstract - Background Pericarditis is the inflammation of the pericardium, the membranous sac surrounding the heart. Recurrent pericarditis is the most common complication of acute pericarditis, causing severe and disabling chest pains. Recurrent pericarditis affects one in three patients with acute pericarditis within the first 18 months. Colchicine has been suggested to be beneficial in preventing recurrent pericarditis. Objectives To review all randomised controlled trials (RCTs) that assess the effects of colchicine alone or combined, compared to any other intervention to prevent further recurrences of pericarditis, in people with acute or recurrent pericarditis. Search methods We searched the following bibliographic databases on 4 August 2014: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2014 on The Cochrane Library ), MEDLINE (OVID, 1946 to July week 4, 2014), EMBASE (OVID, 1947 to 2014 week 31), and the Conference Proceedings Citation Index ‐ Science on Web of Science (Thomson Reuters) 1990 to 1 Aug 2014. We did not apply any language or time restrictions. Selection criteria RCTs of people with acute or recurrent pericarditis who are receiving colchicine compared to any other treatment, in order to prevent recurrences. Data collection and analysis Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The first primary outcome was the time to recurrence, measured by calculating the hazard ratios (HRs). The second primary outcome was the adverse effects of colchicine. Secondary outcomes were the rate of recurrences at 6, 12 and 18 months, and symptom relief. Main results We included four RCTs, involving 564 participants in this review. We compared the effects of colchicine in addition to a non‐steroidal anti‐inflammatory drug (NSAID) such as ibuprofen, aspirin or indomethacin to the effects of the NSAID alone. Two comparable trials studied the effects of colchicine in 204 participants with recurrent pericarditis and two trials studied 360 people with acute pericarditis. All trials had a moderate quality for the primary outcomes. We identified two on‐going trials; one of these trials examines acute pericarditis and the other assesses recurrent pericarditis. There was moderate quality evidence that colchicine reduces episodes of pericarditis in people with recurrent pericarditis over 18 months follow‐up (HR 0.37; 95% confidence interval (CI) 0.24 to 0.58). It is expected that at 18 months, the number needed to treat (NNT) is 4. In people with acute pericarditis, there was moderate quality evidence that colchicine reduces recurrence (HR 0.40; 95% CI 0.27 to 0.61) at 18 months follow‐up. Colchicine led to a greater chance of symptom relief at 72 hours (risk ratio (RR) 1.4; 95% CI 1.26 to 1.56; low quality evidence). Adverse effects were mainly gastrointestinal and included abdominal pain and diarrhoea. The pooled RR for adverse events was 1.26 (95% CI 0.75 to 2.12). While the number of people experiencing adverse effects was higher in the colchicine than the control groups (9% versus 7%), the quality of evidence was low owing to imprecision, and there was no statistically significant difference between the treatment groups (P = 0.42). There was moderate quality evidence that treatment with colchicine led to more people stopping treatment due to adverse events (RR 1.87; 95% CI 1.02 to 3.41). Authors' conclusions Colchicine, as adjunctive therapy to NSAIDs, is effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis. However, evidence is based on a limited number of small trials. Patients with multiple resistant recurrences were not represented in any published or on‐going trials, and it is these patients that are in the most need for treatment. Plain language summary Systematic review of randomised controlled trials about the efficacy and safety of colchicine in people with pericarditis Pericarditis is the inflammation and swelling of the tissue covering the outer layer of the heart. Pericarditis causes severe and disabling chest pain and fever, however the main issue is the repeated recurrence of pericarditis attacks. Colchicine is an ancient medication that has been used in the treatment of other inflammatory diseases such as gout. We wanted to discover whether colchicine alone or added to other medications is better or worse than alternative therapies in preventing pericarditis. We have reviewed all randomised controlled trials about the effect of colchicine in preventing recurrence of pericarditis in people with pericarditis. We found four trials involving 564 participants, who were followed up for at least 18 months. Two studies examined the use of colchicine in people with recurrent pericarditis and two examined the use of colchicine in people with a first episode of pericarditis. The evidence is current to August 2014. The trials showed that people taking colchicine have a lower risk of developing pericarditis recurrence and a higher proportion experience symptom relief. It is expected that at 18 months, one pericarditis recurrence can be avoided for every four people receiving colchicine with NSAIDs rather than NSAIDs alone. Adverse effects were reported in all trials and affected 15 people (9%) of the 162 taking colchicine. Adverse effects included abdominal pain, nausea and vomiting. Two studies were designed so that participants knew the type of intervention they were taking and people in the comparison group had no dummy pill. The results of these studies could exaggerate the effects of the drug. The evidence suggests beneficial effects of colchicine in preventing recurrence of pericarditis, however this is based on a limited number of small trials. More trials are currently being done and we await their results to see if the benefits of colchicine can be further confirmed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Alabed, S, Cabello, JB, Irving, GJ, Qintar, M, Burls, A", "articleTypes": [], "doi": "10.1002/14651858.CD010652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.089Z" }, { "id": "daa000ae-3f23-4e74-9818-d1dd21835690", "pmid": "", "title": "Interventions for fatigue management after traumatic brain injury", "imported": false, "abstract": "Abstract - Rationale Despite the high prevalence and medico‐social significance of fatigue in post‐traumatic brain injury (post‐TBI) populations, there are no validated management strategies to control this condition. It is timely to provide clinicians and patients with the best available evidence of the efficacy of current pharmacological and non‐pharmacological fatigue management practices. Objectives To assess the effectiveness of pharmacological and non‐pharmacological interventions for fatigue in people who have experienced a TBI. Search methods For this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO. We also searched relevant conference proceedings, and we searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for ongoing trials. The most recent searches were conducted on 12 February 2025. Eligibility criteria Eligible study designs were randomised controlled trials (RCTs) and randomised cross‐over trials (for pharmacological interventions only). Studies with participants of all ages (children and adults) with a TBI (of any severity) were included, where at least 75% of participants had a TBI. Any type of treatment for fatigue was considered. Four categories of interventions were prioritised: pharmacological, cognitive, stimulation/biofeedback, and psychoeducational. These interventions were compared to placebo groups, no treatment, or groups receiving other interventions. Outcomes The critical outcome was fatigue. Important outcomes include fatigue‐related outcomes of psychological functioning (depression and anxiety), cognitive functioning (processing speed), general quality of life, and daytime sleepiness. Risk of bias We assessed risk of bias using the original Cochrane risk of bias tool for RCTs (RoB 1). Synthesis methods We synthesised the results for each outcome by meta‐analysis where possible using mean differences (MDs) and standardised mean differences (SMDs) and a fixed‐effect model. Where meta‐analysis was not possible due to the nature of the data , we narratively reported the results. We used GRADE to assess the certainty of evidence for each outcome . We performed all statistical analyses using RevMan and presented results with 95% confidence intervals (CI). Included studies We included a total of 3518 trial participants (at baseline) across 40 studies, described in 49 publications. The 40 included studies are grouped by type of intervention. There were seven categories of interventions: pharmacological, cognitive, physical activity, stimulation/biofeedback, health visits, psychoeducational, and a final category for trials with multiple interventions (multi‐interventions). Four published studies identified in the most recent search are awaiting classification. Synthesis of results Pharmacological interventions (melatonin; recombinant human growth hormones (rhGH); psychostimulants; atorvastatin; monoaminergic stabiliser (‐)‐OSU6162) likely reduce fatigue slightly (SMD ‐0.25, 95% CI ‐0.44 to ‐0.06; 8 studies, 395 participants; moderate‐certainty evidence). Cognitive interventions (cognitive rehabilitation; technology‐enhanced training; functional skills training) may reduce fatigue slightly (MD ‐0.32, 95% CI ‐0.59 to ‐0.06; 6 studies, 222 participants; low‐certainty evidence). Stimulation/biofeedback interventions (light therapy; electrical/magnetic stimulation; acupressure) may reduce fatigue slightly, but the evidence is very uncertain (SMD ‐0.23, 95% CI ‐0.47 to 0.01; 8 studies, 295 participants; very low‐certainty evidence). Psychoeducation interventions (cognitive behavioural therapy; acceptance and commitment therapy; individualised occupational therapy; novel therapies) may reduce fatigue, but the evidence is very uncertain (SMD ‐0.55, 95% CI ‐0.74 to ‐0.35; 8 studies, 474 participants; very low‐certainty evidence). There may be little to no difference in psychological functioning (depression), psychological functioning (anxiety), cognitive functioning (processing speed), or daytime sleepiness. However, these results are very uncertain. Authors' conclusions There is very limited and moderate to very low‐certainty evidence from RCTs about treatments to reduce fatigue after TBI. Despite the prevalence of fatigue post‐TBI, we lack high‐quality studies that evaluate interventions to improve this disabling, but potentially treatable, symptom. There is a need for considerable further work to identify an effective treatment for fatigue in people with TBI. Funding This Cochrane review had no dedicated funding. Registration Protocol available via DOI: 10.1002/14651858.CD006448 Plain language summary Which treatments are effective for fatigue after traumatic brain injury? Key messages Medications (such as melatonin, growth hormones, brain stimulants, atorvastatin, or dopamine and serotonin regulators) likely reduce fatigue after a traumatic brain injury. Other treatments, such as talking therapies, sensory stimulation, and counselling, may reduce fatigue after a traumatic brain injury. Future studies should involve more people, including children and young people. They should investigate different kinds of treatments in different settings, and the severity and causes of traumatic brain injury. What is traumatic brain injury? Traumatic brain injury is damage to the brain following a bump or blow to the head. The injury might result from a traffic accident, fall, assault, sports injury, or an explosion. People with traumatic brain injury might experience headaches, become forgetful, and have difficulties sleeping and moving. They may also experience fatigue, which is defined as an overwhelming sense of tiredness unrelated to previous effort, which does not usually improve with rest. Fatigue makes it hard for people to concentrate and perform everyday activities, which affects their quality of life. How is fatigue after traumatic brain injury treated? Treatments for fatigue vary because the causes and symptoms of fatigue may be very different. Treatments include medication to stimulate or protect the brain, and hormones and antidepressants to help people sleep and improve their mood. Treatments that don’t involve medication include counselling, education, behavioural therapy and exercise. What did we want to find out? We mainly wanted to find out if different treatments reduce fatigue in people with traumatic brain injury. We were also interested in the effect of the treatments on people’s mood, memory or attention, quality of life, and sleepiness. What did we do? We searched for studies that randomly assigned people to receive treatment for fatigue, usual care (that is, no specific treatment for fatigue), or a placebo (dummy) treatment. We also looked at studies that compared different treatments. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 40 studies with 3518 adults and children living with traumatic brain injury. The studies took place in 12, mainly high‐income, countries in Europe, North America, and Oceania. They were conducted in different settings, including medical centres, rehabilitation clinics, military bases, clinical research facilities, and hospitals. Main results Fatigue Medications likely reduce fatigue after a traumatic brain injury (8 studies, 395 people). Medications included melatonin, growth hormones, psychostimulants, statins, and dopamine regulators. Other treatments (without medication) may reduce fatigue after a traumatic brain injury (31 studies, 2203 people). Treatments included cognitive behavioural therapy, technical‐enhanced training, functional skills training, sensory stimulation, electrical/magnetic stimulation, acupressure, counselling, acceptance and commitment therapy, individualised occupational therapy, cognitive symptom management rehabilitation therapy, aerobic exercise, prescribed light exercise, location of exercise, vestibular rehabilitation, health visits, and multi‐interventional therapies. For treatments with medication, there were some reported adverse (unwanted or harmful) events that are specific to particular studies. For other treatments (without medication), adverse events were often not reported. Fatigue‐related symptoms Medications may make little or no difference to depression, anxiety, processing speed, quality of life, and daytime sleepiness (21 studies, 1016 people). Of the treatments without medication, only cognitive therapy showed any noticeable effect; it may reduce anxiety (2 studies, 57 people). What are the limitations of the evidence? We have limited confidence in the evidence due to the small numbers of people in the different studies, and the variation in settings, treatments, ages of participants, and the severity and causes of traumatic brain injury. How up to date is this evidence? We searched for studies up to 12 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Senior, HE; Leung, JH; Meehan, B; Leao, S; Jordan, V; Barker-Collo, S; Crummey, S; Purdy, SC", "articleTypes": [], "doi": "10.1002/14651858.CD006448.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "dac079ba-28eb-45e1-bafa-a7843a0cd980", "pmid": "", "title": "Sustained‐release naltrexone for opioid dependence", "imported": false, "abstract": "Abstract - Background Opioid dependence is a severe and often lifelong disorder with a high risk of overdose and premature death, as well as severe psychosocial difficulties. Sustained‐release naltrexone is a treatment option that works by blocking the euphoric and overdose effects of opioids. When injected intramuscularly, naltrexone provides blockade for one month, while the blocking effects with implants can last for up to six months. Objectives To assess the benefits and harms of sustained‐release naltrexone for the treatment of opioid dependence. Search methods For this update, we searched the following databases from 2007 up to 20 December 2023: the Cochrane Drugs and Alcohol Specialised Register of Trials, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, ISI Web of Science, LILACS, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We manually searched the reference lists of identified studies, published reviews and relevant websites. Selection criteria Randomised controlled trials comparing the effects of injectable or implantable naltrexone with other treatment, no treatment or placebo in adults with opioid dependence. Data collection and analysis Primary outcomes were illicit opioid use, retention in treatment, treatment acceptability and adverse events. Secondary outcomes were opioid craving, recreational use of substances other than opioids, mental health, quality of life and criminal activity. We assessed the risk of bias using the Cochrane risk of bias tool (RoB 1). We combined the results of individual trials through meta‐analysis where possible using a random‐effects model. Two review authors independently assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We identified 22 studies (3416 participants) that met our inclusion criteria. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. Sustained‐release naltrexone compared with opioid agonist treatment We found moderate‐certainty evidence that sustained‐release naltrexone probably increases in‐treatment illicit opioid use slightly (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.01 to 1.31; 1 study, 570 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 1.17, 95% CI 0.78 to 1.76; 3 studies, 773 participants) and treatment acceptability (RR 0.92, 95% CI 0.73 to 1.16; 3 studies, 773 participants). There was low‐certainty evidence that sustained‐release naltrexone may increase serious adverse events slightly in comparison with opioid agonist treatment for serious adverse events (RR 1.40, 95% CI 0.92 to 2.11; 2 studies, 713 participants). Sustained‐release naltrexone compared with oral naltrexone treatment We found low‐certainty evidence that sustained‐release naltrexone may reduce in‐treatment illicit opioid use (RR 0.65, 95% CI 0.45 to 0.93; 1 study, 69 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 2.40, 95% CI 1.64 to 3.52; 3 studies, 464 participants) and on serious adverse events (RR 1.25, 95% CI 0.46 to 3.36; 2 studies, 260 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in treatment acceptability in comparison with oral naltrexone treatment (RR 1.00, 95% CI 0.99 to 1.01; 3 studies, 474 participants). Sustained‐release naltrexone compared with placebo We found low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in in‐treatment illicit opioid use (RR 0.83, 95% CI 0.66 to 1.03; 3 studies, 443 participants), treatment acceptability (RR 1.00, 95% CI 0.98 to 1.02; 1 study, 204 participants) and serious adverse events (RR 0.74, 95% CI 0.17 to 3.23; 3 studies, 443 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment in comparison with placebo (RR 2.10, 95% CI 1.23 to 3.60; 4 studies, 594 participants). Sustained‐release naltrexone compared with treatment as usual We found high‐certainty evidence that sustained‐release naltrexone reduces in‐treatment illicit opioid use (RR 0.72, 95% CI 0.57 to 0.90; 4 studies, 479 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little or no difference in retention in treatment (RR 1.20, 95% CI 0.79 to 1.82; 3 studies, 126 participants) and that it may result in a slight reduction in treatment acceptability (RR 0.79, 95% CI 0.69 to 0.90; 8 studies, 1094 participants). There was moderate‐certainty evidence that sustained‐release naltrexone probably reduces serious adverse events in comparison with treatment as usual (RR 0.59, 95% CI 0.36 to 0.95; 6 studies, 1009 participants). Our primary outcome measures were not reported for sustained‐release naltrexone compared with psychosocial treatments. Amongst the most common methodological weaknesses were the risk of performance bias and imprecision due to few studies and small sample size for many outcomes. Authors' conclusions Sustained‐release naltrexone may slightly increase illicit opioid use and serious adverse events compared to opioid agonists, with uncertain effects on retention and acceptability. It may reduce illicit opioid use compared to oral naltrexone but has uncertain effects on other outcomes. Compared to placebo, it may have little to no impact on key outcomes. Compared to treatment as usual, it reduces illicit opioid use and may reduce serious adverse events but has little effect on retention and slightly reduces acceptability. Significant gaps remain in the evidence on sustained‐release naltrexone for opioid dependence. Future research should include comparisons with psychosocial treatments, larger and higher‐quality studies, and analyses of differences between formulations and comparator treatments. Improved study designs are needed to reduce bias, and more inclusive research should address under‐represented populations and synthetic opioid users. The lack of long‐term outcome data limits understanding of sustained effects, highlighting the need for extended follow‐up and exploration of diverse treatment settings and populations. Plain language summary What are the benefits and risks of sustained‐release (long‐acting) naltrexone for the treatment of dependence on opioid drugs (addiction)? Key messages • It is unclear whether people treated with sustained‐release naltrexone use illicit opioids, such as heroin, less frequently than people treated with opioid agonists, such as buprenorphine or methadone. • People treated with sustained‐release naltrexone may use illicit opioids less frequently than people treated with oral naltrexone, placebo or treatment as usual. • Treatment with sustained‐release naltrexone may be less safe than opioid agonist treatment, but safer than treatment as usual. • Clinicians and patients should weigh the availability and characteristics of treatment options, noting that sustained‐release naltrexone aids abstinence without restricting freedom but requires detoxification; more evidence is needed on long‐term safety and retention. What is dependence on opioid drugs? Opioid drugs, including heroin and prescription painkillers like oxycodone, carry the risk of addiction and serious health consequences. Treatment often involves replacing these opioids with safer alternatives such as methadone or buprenorphine, although other options like therapy or naltrexone are available. However, overcoming opioid dependence remains a persistent challenge due to its complex nature and the associated risks of relapse and overdose. What did we want to find out? In this review we sought to compare sustained‐release naltrexone treatment with other treatments or no treatment for opioid dependence. Naltrexone should not be confused with naloxone, which is a short‐acting drug used for opioid overdose reversal. Other treatments include opioid agonist treatment (such as methadone or buprenorphine), oral naltrexone (taken by mouth, tablets), placebo (sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested), treatment as usual and psychosocial treatments (therapeutic approaches that address both psychological and social aspects of mental health conditions, e.g. psychotherapy, psychoeducation and support groups). What did we do? We searched scientific databases for studies up to December 2023. We identified 22 randomised controlled trials (studies where people were allocated at random to one of two or more treatment or control conditions) involving 3416 adults and adolescents with opioid dependence. Seventy‐four per cent of the people in the studies were male, and they had an average age of 40 years. Twelve of the 22 studies were conducted in the USA or Canada, five in Russia, three in Norway, and one in the UK and Australia, respectively. The main outcomes we examined were opioid use and treatment safety. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. What did we find? We found that when comparing sustained‐release naltrexone to opioid agonist treatment, illicit opioid use probably increases slightly. On the other hand, when comparing sustained‐release naltrexone to treatment as usual, sustained‐release naltrexone reduces illicit opioid use. Compared to oral naltrexone, illicit opioid use may decrease, and compared to placebo, there may be little or no difference. We found no studies comparing sustained‐release naltrexone with psychosocial treatments for any of our primary outcomes. It is generally unclear whether people remain longer in sustained‐release naltrexone treatment than in other treatments or placebo. We do not know whether more people will initiate sustained‐release naltrexone treatment than opioid agonist treatment. When compared to oral naltrexone or placebo, there may be little or no difference in the proportion of people who will initiate treatment. Compared to treatment as usual, it may be that fewer people will initiate sustained‐release naltrexone treatment. Compared to opioid agonist treatment, sustained‐release naltrexone may increase serious adverse (unwanted or harmful) events slightly. It is unclear whether sustained‐release naltrexone results in more or fewer serious adverse events than oral naltrexone. When compared to placebo, there may be little or no difference in the proportion of people who will experience serious adverse events. Sustained‐release naltrexone probably reduces serious adverse events in comparison to treatment as usual. What were the limitations of the evidence? Overall, we have limited confidence in the evidence. One of the reasons is that it is very likely that participants knew which treatments they were assigned to, even if the researchers in many cases tried to conceal the assigned treatment condition for participants and treatment providers. Opioid dependence comes with strong drug cravings and an increased risk of relapse during any treatment. Therefore, participants experiencing cravings and those who maybe even tried to use drugs like heroin would have understood what type of treatment they were assigned to. Another major reason for our limited confidence in the evidence was that the number of studies, and people participating in them, was often too small to obtain precise results. Other reasons for lowering our confidence were inconsistencies in study results and national treatment policies in some studies that make it difficult to apply the results in other countries. How up‐to‐date is this evidence? The evidence is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kornør, H, Lobmaier, PPK, Kunøe, N", "articleTypes": [], "doi": "10.1002/14651858.CD006140.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.797Z" }, { "id": "dac6a3d3-8a00-4fc1-bf8c-26b7e5ecf234", "pmid": "", "title": "Interventions for treating people with symptoms of bladder pain syndrome: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide‐ranging treatment options, used alone or in combination, with limited evidence. A network meta‐analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS. Objectives To conduct a network meta‐analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS). Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible. Data collection and analysis We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random‐effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta‐analysis of head‐to‐head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories. Main results We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low‐certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD ‐1.27, 95% CrI ‐3.25 to 0.71; low‐certainty evidence), daytime frequency (MD ‐2.41, 95% CrI ‐6.85 to 2.05; very low‐certainty evidence) or nocturia (MD 0.01, 95% CrI ‐2.53 to 2.50; very low‐certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low‐certainty evidence) or reduced pain (MD 0.42, 95% CrI ‐1.04 to 1.91; low‐certainty evidence), frequency (MD ‐0.37, 95% CrI ‐5.00 to 3.44; very low‐certainty evidence) or nocturia (MD ‐1.20, 95% CrI ‐3.62 to 1.28; very low‐certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD ‐0.33, 95% CrI ‐1.71 to 1.03), frequency (MD ‐0.91, 95% CrI ‐3.24, 1.29) or nocturia (MD ‐0.04, 95% CrI ‐1.35 to 1.27). The certainty of this evidence was always very low. Authors' conclusions We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base. Plain language summary Treatments for people with bladder pain syndrome What is bladder pain syndrome? Bladder pain syndrome (BPS; also called painful bladder syndrome or interstitial cystitis) is a long‐term painful condition that affects the bladder. ‘Syndrome’ refers to a collection of symptoms. In BPS, these symptoms include: intense pain in the pelvis (felt below the bellybutton); sudden strong urges to urinate; needing to urinate more often than usual; and waking up several times during the night to urinate. BPS is more common in women. We do not know what causes it or how to cure it. Symptoms sometimes come and go in phases. BPS can significantly affect lifestyle, work, emotional health and relationships. Treatments for BPS Lifestyle changes are usually tried first, then medicines and supportive therapies. Surgery may be needed as a last resort. Medicines used include pentosan polysulfate sodium – which may help to restore the inner surface of the bladder – anti‐inflammatories, antidepressants and antihistamines. Medicines that block the connection between nerves and muscles can be injected into the bladder muscle to try to relax it (‘neuromuscular blockade’). Supportive therapies and treatments include behavioural therapy, physiotherapy, bladder re‐training, psychological therapy and transcutaneous electrical nerve stimulation (TENS). Review question In this Cochrane Review, we wanted to find out which treatments work best to treat BPS. What did we do? We searched for studies that looked at any type of treatment for BPS. We looked for randomised controlled studies, in which the treatment people receive is randomly decided, because these studies usually give the most reliable evidence about treatments. Search date We included evidence published up to 11 May 2018. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. What we found We found 81 studies involving 4674 people with BPS. The biggest study included 369 people, and the smallest study included 10 people. Most studies lasted around three months; only six studies lasted 12 months or longer. Twenty‐four studies were funded by pharmaceutical companies. We found 65 treatments for BPS, which we grouped into 31 categories based on how the treatments worked. In most studies, a treatment for BPS was compared with a placebo (or dummy) treatment. We compared all treatments with each other using a mathematical method called network meta‐analysis. What are the results of our review? After 12 months, antidepressants or neuromuscular blockade (and some other treatments) may improve symptoms of BPS more than placebo, but we are not certain about this result. We did not find enough evidence to know if pentosan polysulfate sodium improves symptoms. We are uncertain whether 12 months of treatment with antidepressants, neuromuscular blockade or pentosan polysulfate sodium reduced pain (as measured on a scale); the number of times people had to urinate during the day; or the number of times people had to get up to urinate during the night. Our confidence in the results We are uncertain about our results because we did not find enough reliable evidence. Although we obtained results from 81 studies, most of these studies were small and did not include enough people for us to be certain of their results. Some of the studies (30%) were conducted by pharmaceutical companies, and this may have affected how the studies were designed, conducted and reported. Our results may change when results from more, and larger, studies become available. Conclusions We did not find enough reliable evidence about how well medicines, behavioural therapy, physiotherapy and neuromuscular blockade worked to treat all, or any, of the symptoms of BPS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Imamura, M; Scott, NW; Wallace, SA; Ogah, JA; Ford, AA; Dubos, YA; Brazzelli, M", "articleTypes": [], "doi": "10.1002/14651858.CD013325.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "dafa74fe-bc25-4210-bb81-230c4d333d83", "pmid": "", "title": "Interventions for perceptual disorders following stroke", "imported": false, "abstract": "Abstract - Background Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non‐invasive brain stimulation, pharmacological and surgical approaches. Objectives To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living. Search methods We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors. Selection criteria We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain. Data collection and analysis One review author assessed titles, with two review authors independently screening abstracts and full‐text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB‐1 tool, and quality of evidence using GRADE. A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update. Main results We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch‐somatosensory disorders. None addressed stroke‐related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non‐invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL): Somatosensory disorders : one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure. Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention. Visual perception disorders : no trials measuring ADL compared an intervention with no treatment or control. In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials). Authors' conclusions Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high‐quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer‐term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines. Plain language summary Interventions for perceptual disorders following stroke Key messages Stroke can affect a person’s ability to process and understand information from their senses, including hearing, smell, somatosensation (sense of body temperature, position, and movement), taste, touch, and vision. Processing and understanding information from these senses is known as perception. Little research has been carried out to find out whether any treatments for stroke‐related problems with perception are helpful. People with stroke‐related problems with hearing, smell, somatosensation, taste, touch, and vision should continue to participate in rehabilitation as recommended by clinical guidelines. Healthcare professionals should continue to offer rehabilitation for stroke‐related perceptual problems in keeping with current clinical guidelines and recommendations. What is a perceptual disorder? Before a stroke, adults gather information about the world through their senses: hearing, smell, somatosensation, taste, touch, and vision. Somatosensation refers to sensation arising from the skin, muscles, or joints, and includes perception of pressure, vibration, temperature, and position. Information gathered might include the colour, shape, and size of objects that they see. Together with memories and cultural experiences, a person can understand how someone is feeling from seeing their facial expression. Other examples are how different odours can be identified through the sense of smell and how different textures can be felt through the sense of touch. A stroke can affect these abilities. How are perceptual disorders treated? Healthcare professionals, including occupational therapists, physiotherapists, and psychologists, may offer different therapies. Treatments might include medicine, stimulation of the brain, or perceptual rehabilitation through activities, puzzles, strategies, or intensive repetition of tasks. What did we want to find out? We wanted to find out whether receiving any perceptual disorder treatment was better than no treatment at all. We measured improvement by looking at how well people could carry out their daily activities. We measured whether treatments also helped other things, such as quality of life, mental health, and perception. We looked for information on when things did not go well. We also explored whether one treatment was more beneficial than another. What did we do? We searched for all relevant research. We assessed the quality of 18 studies and summarised their results. What did we find out? The studies we found were about different perceptual disorders: three studies looked at disorders of touch perception, seven looked at somatosensation, seven studies looked at vision, and one looked at several perceptual problems at the same time. The treatments used in these studies included paper‐and‐pencil copying tasks to improve visual memory and using robots to help improve a person’s sense of where their body is positioned. We found no information to show that any treatment worked. Why are we still uncertain? We found few studies. Each study included a small number of people with a perceptual problem after a stroke. With small numbers of people involved, the results were not clear. Each study looked at different interventions. Less than half the studies (seven) measured the ability to carry out everyday activities. How up to date is this information? Our information is up to date as of August 2021. Based on the information we gathered, we are still unclear about the benefits or harms of treatments for perceptual problems after stroke. People with perceptual problems after stroke should continue to be offered rehabilitation as recommended in clinical guidelines.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hazelton, C, Thomson, K, Todhunter-Brown, A, Campbell, P, Chung, CSY, Dorris, L, Gillespie, DC, Hunter, SM, McGill, K, Nicolson, DJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD007039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.726Z" }, { "id": "db068291-e3b3-4704-be09-a38f38e6f45e", "pmid": "", "title": "Chinese herbal medicine for menopausal symptoms", "imported": false, "abstract": "Abstract - Background Chinese herbal medicine (CHM) usage is expected to increase as women suffering from menopausal symptoms are seeking alternative therapy due to concerns from the adverse effects (AEs) associated with hormone therapy (HT). Scientific evidence for their effectiveness and safety is needed. Objectives To evaluate the effectiveness and safety of CHM in the treatment of menopausal symptoms. Search methods We searched the Gynaecology and Fertility Group's Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), MEDLINE, Embase, CINAHL, AMED, and PsycINFO (from inception to March 2015). Others included Current Control Trials, Citation Indexes, conference abstracts in the ISI Web of Knowledge, LILACS database, PubMed, OpenSIGLE database, and China National Knowledge Infrastructure database (CNKI, 1999 to 2015). Other resources included reference lists of articles as well as direct contact with authors. Selection criteria Randomised controlled trials (RCTs) comparing the effectiveness of CHM with placebo, HT, pharmaceutical drugs, acupuncture, or another CHM formula in women over 18 years of age, and suffering from menopausal symptoms. Data collection and analysis Two review authors independently assessed 864 studies for eligibility. Data extractions were performed by them with disagreements resolved through group discussion and clarification of data or direct contact with the study authors. Data analyses were performed in accordance with Cochrane Collaboration guidelines. Main results We included 22 RCTs (2902 women). Participants were from different ethnic backgrounds with the majority of Chinese origin. When CHM was compared with placebo (eight RCTs), there was little or no evidence of a difference between the groups for the following pooled outcomes: hot flushes per day (MD 0.00, 95% CI ‐0.88 to 0.89; 2 trials, 199 women; moderate quality evidence); hot flushes per day assessed by an overall hot flush score in which a difference of one point equates to one mild hot flush per day (MD ‐0.81 points, 95% CI ‐2.08 to 0.45; 3 RCTs, 263 women; low quality evidence); and overall vasomotor symptoms per month measured by the Menopause‐Specific Quality of Life questionnaire (MENQOL, scale 0 to 6) (MD ‐0.42 points; 95% CI ‐1.52 to 0.68; 3 RCTs, 256 women; low quality evidence). In addition, results from individual studies suggested there was no evidence of a difference between the groups for daily hot flushes assessed by severity (MD ‐0.70 points, 95% CI ‐1.00, ‐0.40; 1 RCT, 108 women; moderate quality evidence); or overall monthly hot flushes scores (MD ‐2.80 points, 95% CI ‐8.93 to 3.33; 1 RCT, 84 women; very low quality evidence); or overall daily night sweats scores (MD 0.07 points, 95% CI ‐0.19 to 0.33, 1 RCT, 64 women; low quality evidence); or overall monthly night sweats scores (MD 1.30 points, 95% CI ‐1.76 to 4.36, 1 RCT, 84 women; very low quality evidence). However one study using the Kupperman Index reported that overall monthly vasomotor symptom scores were lower in the CHM group (MD ‐4.79 points, 95% CI ‐5.52 to ‐4.06; 1 RCT, 69 women; low quality evidence). When CHM was compared with hormone therapy (HT) (10 RCTs), only two RCTs reported monthly vasomotor symptoms using MENQOL. It was uncertain whether CHM reduces vasomotor symptoms (MD 0.47 points, 95% CI ‐0.50 to 1.44; 2 RCTs, 127 women; very low quality evidence). Adverse effects were not fully reported in the included studies. Adverse events reported by women taking CHM included mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects were inconclusive because of imprecise estimates of effects: CHM versus placebo (RR 1.51; 95% CI 0.69 to 3.33; 7 trials, 705 women; I² = 40%); CHM versus HT (RR 0.96; 95% CI 0.66 to 1.39; 2 RCTs, 864 women; I² = 0%); and CHM versus specific conventional medications (such as Fluoxetine and Estazolam) (RR 0.20; 95% CI 0.03 to 1.17; 2 RCTs, 139 women; I² = 61%). Authors' conclusions We found insufficient evidence that Chinese herbal medicines were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Effects on safety were inconclusive. The quality of the evidence ranged from very low to moderate; there is a need for well‐designed randomised controlled studies. Plain language summary Title: Chinese herbal medicines for menopausal symptoms Review Question: Are Chinese herbal medicines effective and safe for relieving menopausal symptoms? Background: Menopause usually takes place when a woman is around 51 years of age. Women can experience symptoms such as hot flushes, sweats, poor sleep, joint pains, anxiousness, dry skin and vagina when the organs which produce female hormones slow down. Usually hormone therapy (HT) is prescribed to reduce the symptoms. Due to concerns on long term use of HT resulting in adverse effects, women have been looking for alternative treatments to relieve their symptoms. Chinese herbal medicines (CHM) is one of the popular choices. Although CHM has been used for a very long time clinically, its effectiveness and long‐term safety remained unanswered from a scientific perspective. Study characteristics: This review examined 22 randomised clinical trials where 2902 women took part in the studies; 1499 in the CHM group and 1403 in the control group which might include a placebo (non‐active compound made to look, taste and smell the same as the study compound) or a drug or HT or another CHM formula (different from the one being tested). Most of the studies had a trial period for 12 weeks. The data are current to March 2015. Key results: We found insufficient evidence that CHM were any more or less effective than placebo or HT for the relief of vasomotor symptoms. Adverse effects were not well reported, some women taking CHM reported mild diarrhoea, breast tenderness, gastric discomfort and an unpleasant taste. Effects on safety were inconclusive. Quality of the evidence: The quality of the evidence ranged from very low to moderate. The studies did not produce good quality evidence to allow the authors to draw a conclusive statement regarding the effectiveness or safety of CHM.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Zhu, X; Liew, Y; Liu, ZL", "articleTypes": [], "doi": "10.1002/14651858.CD009023.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "db0a134d-14b1-4aed-9d44-1478dc264889", "pmid": "", "title": "Vitamin and mineral supplementation for maintaining cognitive function in cognitively healthy people in mid and late life", "imported": false, "abstract": "Abstract - Background Vitamins and minerals play multiple functions within the central nervous system which may help to maintain brain health and optimal cognitive functioning. Supplementation of the diet with various vitamins and minerals has been suggested as a means of maintaining cognitive function, or even of preventing dementia, in later life. Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function in cognitively healthy people aged 40 years or more. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov and the WHO Portal/ICTRP from inception to 26th January 2018. Selection criteria We included randomised controlled trials that evaluated the cognitive effects on people aged 40 years or more of any vitamin or mineral supplements taken by mouth for at least three months. Data collection and analysis Study selection, data extraction, and quality assessments were done in duplicate. Vitamins were considered broadly in the categories of B vitamins, antioxidant vitamins, and combinations of both. Minerals were considered separately, where possible. If interventions and outcomes were considered sufficiently similar, then data were pooled. In order to separate short‐term cognitive effects from possible longer‐term effects on the trajectory of cognitive decline, data were pooled for various treatment durations from 3 months to 12 months and up to 10 years or more. Main results In total, we included 28 studies with more than 83,000 participants. There were some general limitations of the evidence. Most participants were enrolled in studies which were not designed primarily to assess cognition. These studies often had no baseline cognitive assessment and used only brief cognitive assessments at follow‐up. Very few studies assessed the incidence of dementia. Most study reports did not mention adverse events or made only very general statements about them. Only 10 studies had a mean follow‐up > 5 years. Only two studies had participants whose mean age was < 60 years at baseline. The risk of bias in the included studies was generally low, other than a risk of attrition bias for longer‐term outcomes. We considered the certainty of the evidence behind almost all results to be moderate or low. We included 14 studies with 27,882 participants which compared folic acid, vitamin B12, vitamin B6, or a combination of these to placebo. The majority of participants were aged over 60 years and had a history of cardio‐ or cerebrovascular disease. We found that giving B vitamin supplements to cognitively healthy adults, mainly in their 60s and 70s, probably has little or no effect on global cognitive function at any time point up to 5 years (SMD values from ‐0.03 to 0.06) and may also have no effect at 5‐10 years (SMD ‐0.01). There were very sparse data on adverse effects or on incidence of cognitive impairment or dementia. We included 8 studies with 47,840 participants in which the active intervention was one or more of the antioxidant vitamins: ß‐carotene, vitamin C or vitamin E. Results were mixed. For overall cognitive function, there was low‐certainty evidence of benefit associated with ß‐carotene after a mean of 18 years of treatment (MD 0.18 TICS points, 95% CI 0.01 to 0.35) and of vitamin C after 5 years to 10 years (MD 0.46 TICS points, 95% CI 0.14 to 0.78), but not at earlier time points. From two studies which reported on dementia incidence, there was low‐certainty evidence of no effect of an antioxidant vitamin combination or of vitamin E, either alone or combined with selenium. One of the included studies had been designed to look for effects on the incidence of prostate cancer; it found a statistically significant increase in prostate cancer diagnoses among men taking vitamin E. One trial with 4143 participants compared vitamin D3 (400 IU/day) and calcium supplements to placebo. We found low‐ to moderate‐certainty evidence of no effect of vitamin D3 and calcium supplements at any time‐point up to 10 years on overall cognitive function (MD after a mean of 7.8 years ‐0.1 MMSE points, 95% CI ‐0.81 to 0.61) or the incidence of dementia (HR 0.94, 95% CI 0.72 to 1.24). A pilot study with 60 participants used a higher dose of vitamin D3 (4000 IU on alternate days) and found preliminary evidence that this dose probably has no effect on cognitive function over six months. We included data from one trial of zinc and copper supplementation with 1072 participants. There was moderate‐certainty evidence of little or no effect on overall cognitive function (MD 0.6 MMSE points, 95% CI ‐0.19 to 1.39) or on the incidence of cognitive impairment after 5 years to 10 years. A second smaller trial provided no usable data, but reported no cognitive effects of six months of supplementation with zinc gluconate. From one study with 3711 participants, there was low‐certainty evidence of no effect of approximately five years of selenium supplementation on the incidence of dementia (HR 0.83, 95% CI 0.61 to 1.13). Finally, we included three trials of complex supplements (combinations of B vitamins, antioxidant vitamins, and minerals) with 6306 participants. From the one trial which assessed overall cognitive function, there was low‐certainty evidence of little or no effect on the TICS (MD after a mean of 8.5 years 0.12, 95% CI ‐0.14 to 0.38). Authors' conclusions We did not find evidence that any vitamin or mineral supplementation strategy for cognitively healthy adults in mid or late life has a meaningful effect on cognitive decline or dementia, although the evidence does not permit definitive conclusions. There were very few data on supplementation starting in midlife (< 60 years); studies designed to assess cognitive outcomes tended to be too short to assess maintenance of cognitive function; longer studies often had other primary outcomes and used cognitive measures which may have lacked sensitivity. The only positive signals of effect came from studies of long‐term supplementation with antioxidant vitamins. These may be the most promising for further research. Plain language summary Vitamin and mineral supplementation for preventing cognitive deterioration in cognitively healthy people in mid and late life Review question This review aimed to find out whether people aged 40 years or older could maintain their mental abilities or reduce their risk of dementia by taking vitamin or mineral supplements. Background There is great interest in anything people might do to keep themselves mentally healthy as they age and, especially, to reduce their risk of developing dementia. Various vitamin and mineral supplements have been suggested as ways to do this. Vitamins and minerals have many functions in the body and the ways they might affect brain health are not well understood. Therefore, we were interested in the effects of any vitamins or minerals, either alone or in combination. What we did We searched up to January 2018 for all trials which had studied the effect on cognition (thinking and remembering) of any vitamin or mineral supplements in people aged 40 years or more who had no cognitive problems at the beginning of the study. The studies had to include a comparison group which had not taken the supplement being studied and, to be sure the comparison was fair, it should have been decided at random whether people got the supplement or not. What we found We grouped the 28 included trials according to the kind of supplement they used and how it might work. Most of the trials were not originally designed to study cognition or dementia and used only simple measures of cognition. Very few studies investigated whether participants developed dementia. Long‐term studies are probably needed to find effects on the risk of dementia or cognitive decline but only 10 studies had an average length of follow‐up longer than five years. The studies were generally well‐conducted although the longer trials had difficulty following up all of the participants and this could have biased some of the longer‐term results. There were 14 trials of B vitamins (folic acid, vitamin B6, vitamin B12) with nearly 28,000 participants, mainly in their 60s and 70s. Most of these trials were quite short (less than two years). We found no evidence that B vitamins had any effect on cognition. There were 8 trials of antioxidant vitamins (beta‐carotene/vitamin A, vitamin C, vitamin E) with approximately 47,000 participants. These trials tended to be longer than the B vitamin trials so may have had more chance of detecting effects on dementia and cognitive decline. The results were mixed. We found low‐certainty evidence of better overall cognitive function after an average of 18 years taking beta‐carotene and after five years to 10 years taking vitamin C, but no effects after shorter periods of treatment. There were also small benefits of beta‐carotene, vitamin C, and antioxidant combinations on memory at some time points but not others. There was no evidence of any benefits from vitamin E alone. Two studies examined the risk of developing dementia. One found no effect of a combination of antioxidant vitamins and the other found no effect of vitamin E, either alone or combined with the mineral selenium. Most of the studies did not report any information about harmful effects. One included trial was designed to look for an effect on the risk of prostate cancer; it found a higher risk among the men taking vitamin E. There was a small trial of vitamin D supplements which found they probably had no effect on cognition over six months. There were longer trials of vitamin D with calcium (one trial), zinc and copper (one trial), and complex multivitamins (three trials). All lasted between five and 10 years, but none of them found any evidence of beneficial effects on cognition. One trial found no effect of selenium taken for approximately five years on the risk of developing dementia. Conclusions We found no good evidence to suggest that middle‐aged or older people can preserve cognitive function or prevent dementia by taking vitamin or mineral supplements. There were a few positive results associated with long‐term use of antioxidant vitamins, particularly beta‐carotene and vitamin C, although the effects were small. Further research into the effects of these vitamins may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rutjes, AWS, Denton, DA, Di Nisio, M, Chong, LY, Abraham, RP, Al‐Assaf, AS, Anderson, JL, Malik, MA, Vernooij, RWM, Martínez, G, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011906.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.113Z" }, { "id": "db2d8603-ced7-4e75-ac50-c9e9a7a772b9", "pmid": "", "title": "The Functional Significance of Gut-expressed Taste Receptors in the Secretion of Glucagon-like Peptide-1 and Peptide YY", "imported": false, "abstract": "The purpose of this study is to determine the functional significance of sweet taste receptors in the secretion of GI satiety peptides by using a specific sweet taste receptor antagonist to block sweet taste perception in the gut.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.254Z" }, { "id": "db3cd85e-c69e-4389-a537-6db6cc1579b2", "pmid": "", "title": "Muscle relaxants for pain management in rheumatoid arthritis", "imported": false, "abstract": "Abstract - Background Pain management is a high priority for patients with rheumatoid arthritis (RA). Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan) and non‐benzodiazepines such as metaxalone (Skelaxin) or a combination of paracetamol and orphenadrine (Muscol)) and drugs that prevent increased muscle tone (baclofen and dantrolene). Despite a paucity of evidence supporting their use, antispasmodic and antispasticity muscle relaxants have gained widespread clinical acceptance as adjuvants in the management of patients with chronic musculoskeletal pain. Objectives The aim of this review was to determine the efficacy and safety of muscle relaxants in pain management in patients with RA. The muscle relaxants that were included in this review are the antispasmodic benzodiazepines (alprazolam, bromazepam, chlordiazepoxide,cinolazepam, clonazepam, cloxazolam, clorazepate, diazepam, estazolam, flunitrazepam, flurazepam, flutoprazepam, halazepam, ketazolam, loprazolam, lorazepam, lormetazepam, medazepam, midazolam, nimetazepam, nitrazepam, nordazepam, oxazepam, pinazepam, prazepam, quazepam, temazepam, tetrazepam, triazolam), antispasmodic non‐benzodiazepines (cyclobenzaprine, carisoprodol, chlorzoxazone, meprobamate, methocarbamol, metaxalone, orphenadrine, tizanidine and zopiclone), and antispasticity drugs (baclofen and dantrolene sodium). Search methods We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library, 4th quarter 2010), MEDLINE (1950 to week 1 November 2010), EMBASE (Week 44 2010), and PsycINFO (1806 to week 2 November 2010). We also searched the 2008 to 2009 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of reference lists of relevant articles. Selection criteria We included randomised controlled trials which compared a muscle relaxant to another therapy (active, including non‐pharmacological therapies, or placebo) in adult patients with RA and that reported at least one clinically relevant outcome. Data collection and analysis Two blinded review authors independently extracted data and assessed the risk of bias in the trials. Meta‐analyses were used to examine the efficacy of muscle relaxants on pain, depression, sleep and function, as well as their safety. Main results Six trials (126 participants) were included in this review. All trials were rated at high risk of bias. Five cross‐over trials evaluated a benzodiazepine, four assessed diazepam (n = 71) and one assessed triazolam (n = 15). The sixth trial assessed zopiclone (a non‐benzodiazepine) (n = 40) and was a parallel group study. No trial duration was longer than two weeks while three single dose trials assessed outcomes at 24 hours only. Overall the included trials failed to find evidence of a beneficial effect of muscle relaxants over placebo, alone (at 24 hrs, 1 or 2 weeks) or in addition to non‐steroidal anti‐inflammatory drugs (NSAIDs) (at 24 hrs), on pain intensity, function, or quality of life. Data from two trials of longer than 24 hours duration (n = 74) (diazepam and zopiclone) found that participants who received a muscle relaxant had significantly more adverse events compared with those who received placebo (number needed to harm (NNTH) 3, 95% CI 2 to 7). These were predominantly central nervous system side effects, including dizziness and drowsiness (NNTH 3, 95% CI 2 to 11). Authors' conclusions Based upon the currently available evidence in patients with RA, benzodiazepines (diazepam and triazolam) do not appear to be beneficial in improving pain over 24 hours or one week. The non‐benzodiazepine agent zopiclone also did not significantly reduce pain over two weeks. However, even short term muscle relaxant use (24 hours to 2 weeks) is associated with significant adverse events, predominantly drowsiness and dizziness. Plain language summary Muscle relaxants for pain management in rheumatoid arthritis This summary of a Cochrane review presents what we know from research about the effect of muscle relaxants on pain in patients with rheumatoid arthritis. The review shows that in people with rheumatoid arthritis: ‐ Muscle relaxants may not improve pain when taken as a single dose or for up to a two week period ‐ We are uncertain whether muscle relaxants affect functional status because of the very low quality of the evidence ‐ No trials were found that evaluated whether muscle relaxants affect quality of life ‐ No trials were found that evaluated whether antidepressants affect sleep ‐ We are uncertain whether muscle relaxants affect mood because of the very low quality of the evidence We also do not have precise information about side effects and complications. This is particularly true for rare but serious side effects. Possible side effects may include feeling tired or nauseous, headaches, blurred vision, a dry mouth, sexual dysfunction, or becoming dizzy or constipated. Rare complications may include increased suicidal thinking, liver inflammation, or a reduced white cell count. What is rheumatoid arthritis and what are muscle relaxants? When you have rheumatoid arthritis your immune system, which normally fights infection, attacks the lining of your joints. This makes your joints swollen, stiff, and painful. The small joints of your hands and feet are usually affected first. There is no cure for rheumatoid arthritis at present, so the treatments aim to relieve pain and stiffness and improve your ability to move. Muscle relaxants can be used to treat anxiety and promote sleep, and some people believe they may also reduce pain by acting on the nerves that cause pain, but this remains controversial. Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), Xanax, Ativan and non‐benzodiazepines such as Skelaxin, Muscol) and drugs that prevent increased muscle tone (baclofen and dantrolene). Best estimates of what happens to people with rheumatoid arthritis who take muscle relaxants: Pain at 24 hours: ‐ Non‐significant result. Pain at 1 to 2 weeks: ‐ Non‐significant result. Withdrawal due to adverse events, after 2 weeks: ‐ Non‐significant result. Total adverse events: ‐ 49 more people out of 100 experienced an adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 49%), ‐ 52 out of 100 people who took a muscle relaxant suffered an adverse event, ‐ 3 out of 100 people who took a placebo suffered an adverse event. Central nervous system (CNS) adverse events: ‐ 33 more people out of 100 experienced a CNS adverse event, after 1 to 2 weeks, when they took a muscle relaxant (absolute difference 33%), ‐ 39 out of 100 people who took a muscle relaxant suffered a CNS adverse event, ‐ 6 out of 100 people who took a placebo relaxant suffered a CNS adverse event. This record should be cited as: This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in the Cochrane Database of Systematic Reviews [Issue and date] © [year] The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464‐780X).", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Richards, BL, Whittle, SL, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD008922.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.091Z" }, { "id": "db54d2c4-650d-43d1-ab94-e282ae8c2d05", "pmid": "", "title": "Progesterone receptor modulators for endometriosis", "imported": false, "abstract": "Abstract - Rationale Endometriosis is defined as the presence of endometrium‐like tissue developing outside the uterine cavity. This condition is oestrogen‐dependent and thus is seen primarily during the reproductive years. Owing to their antiproliferative effects on the endometrium, progesterone receptor modulators (PRMs) have been advocated for the treatment of endometriosis. This is an update of a Cochrane review previously published in 2017. Objectives To assess the effectiveness and safety of progesterone receptor modulators (PRMs) in the management of endometriosis. Search methods To identify studies, we searched online sources, including the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, ClinicalTrials.gov and the WHO (World Health Organization) trial registry up to 16 April 2026. We also checked reference lists and contacted study authors and experts. Eligibility criteria We included randomised controlled trials (RCTs) comparing PRMs with placebo, no treatment or other medical treatment, in women with symptomatic endometriosis. Outcomes Our critical outcomes were overall pain; improvement in the most troublesome symptom, including dysmenorrhoea and dyspareunia; and adverse events resulting from the PRM intervention. Our important outcomes included quality of life (QoL) and patient satisfaction with treatment. Risk of bias We used the Cochrane tool RoB 2 to assess the risk of bias in the outcomes of this review. Synthesis methods Two review authors independently assessed studies against the inclusion criteria, extracted data and assessed risk of bias, consulting a third review author where required. We analysed dichotomous outcomes using Mantel‐Haenszel odds ratios (ORs), 95% confidence intervals (CIs) and the fixed‐effect model. We analysed continuous outcomes using the mean difference (MD) between groups, presented with 95% CIs. We employed the GRADE approach to assess the certainty of the evidence as high, moderate, low or very low. Included studies No new studies were eligible for inclusion in this update. Of the nine studies (922 women) already included in the review, two compared mifepristone versus placebo or compared different doses of mifepristone, and four either compared gestrinone versus danazol, gestrinone versus gonadotropin‐releasing hormone (GnRH) analogues or compared different doses of gestrinone. One study compared asoprisnil versus placebo. The asoprisnil study did not provide extractable numerical data and was included in the narrative synthesis only. Two of the studies did not report any of the review's prespecified outcomes. Synthesis of results Certainty of the evidence We judged the certainty of evidence as low to very low. The main limitations of the evidence were serious risk of bias (associated with poor reporting of methods and high or unclear rates of attrition), very serious imprecision (associated with low event rates and wide confidence intervals, with some large effect estimates) and serious indirectness (outcomes assessed in selected subgroups). PRM versus placebo Mifepristone versus placebo These results are based on one study (360 participants) that measured outcomes after three months. The study did not report overall pain. At three months, mifepristone may improve dysmenorrhoea (OR 0.07, 95% CI 0.03 to 0.15; 1 study, 342 participants; low‐certainty evidence), suggesting that if 40% of women taking placebo experience dysmenorrhoea, then between 3% and 10% of women taking mifepristone will do so. We are uncertain whether mifepristone improves dyspareunia (OR 0.23, 95% CI 0.10 to 0.51; 1 study, 223 participants; very low‐certainty evidence). However, mifepristone may increase hot flushes (OR 28.79, 95% CI 3.93 to 210.73; 1 study, 360 participants; low‐certainty evidence). Mifepristone may make little or no difference after three months of treatment to the prevalence of nausea (OR 1.72, 95% CI 0.20 to 15.03; 1 study, 360 participants; low‐certainty evidence). PRM versus other medical treatment Gestrinone versus danazol These results are based on two studies (302 participants) that measured outcomes after six months. We are uncertain of the effects of gestrinone relative to danazol on the improvement of overall pain (dichotomous outcome: participants reporting no or mild pelvic pain counted as 'improved') (OR 0.47, 95% CI 0.04 to 5.70; 1 study, 38 participants), dysmenorrhoea (Not estimable; 1 study, 38 participants), or dyspareunia (OR 1.00, 95% CI 0.13 to 7.94; 1 study, 38 participants (all very low‐certainty evidence). We are uncertain about the effects of gestrinone relative to danazol on hot flushes (OR 0.79, 95% CI 0.50 to 1.26; 2 studies, 302 participants; very low‐certainty evidence). There may be little or no difference between gestrinone and danazol in rates of nausea (OR 1.36, 95% CI 0.84 to 2.19; 2 studies, 302 participants; low‐certainty evidence). Gestrinone versus a GnRH analogue (leuprorelin) These results are based on one study (55 participants) that measured outcomes after six months. There may be little to no difference between gestrinone and leuprorelin in non‐menstrual pain (MD −0.41, 95% CI −1.76 to 0.94; 1 study, 55 participants; low‐certainty evidence). Women taking gestrinone may have higher dysmenorrhoea scores than those taking leuprorelin (MD 0.82, 95% CI 0.15 to 1.49; 1 study, 55 participants; low‐certainty evidence), but gestrinone may improve dyspareunia more than leuprorelin (MD −1.16, 95% CI −2.08 to −0.24; 1 study, 52 participants; low‐certainty evidence). There may be lower rates of hot flushes with gestrinone than leuprorelin (OR 0.20, 95% CI 0.06 to 0.63; 1 study, 55 participants; low‐certainty evidence). There may be little or no difference between gestrinone and leuprorelin in rates of nausea (OR 1.04, 95% CI 0.06 to 17.49; 1 study, 55 participants; low‐certainty evidence). Authors' conclusions Mifepristone may improve dysmenorrhoea in women with endometriosis, but it might increase the prevalence of adverse events, such as hot flushes. The evidence is very uncertain regarding its effect on dyspareunia. Gestrinone may be less effective than leuprorelin in treating dysmenorrhoea, but it may improve dyspareunia. It may be associated with lower rates of hot flushes and similar rates of nausea. We are uncertain about the effect of gestrinone compared to danazol. We found insufficient evidence to permit firm conclusions about the safety and effectiveness of other progesterone receptor modulators. Funding This Cochrane review had no dedicated funding. Registration Protocol (2012) DOI: 10.1002/14651858.CD009881 Review (2017) DOI: 10.1002/14651858.CD009881.pub2 Plain language summary What are the benefits and risks of medicines called progesterone receptor modulators (PRMs) for treating endometriosis (a condition where tissue grows outside the womb)? Key messages In the management of endometriosis (a condition where tissue grows outside the womb), studies that compared a progesterone receptor modulator (PRM; a medicine that changes how the hormone progesterone acts in the body) against placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested) found that a PRM called mifepristone may improve painful periods. However, it may cause hot flushes. A PRM called gestrinone may be less effective than medicines known as gonadotropin‐releasing hormone (GnRH) analogues (which reduce the amount of oestrogen made by the ovaries) for treating painful periods, but may improve pain during sex. Gestrinone may also cause fewer hot flushes. We do not know how gestrinone compares to a treatment called danazol in terms of pain not related to periods, painful periods or pain during sex. We do not know whether gestrinone or danazol causes more unwanted effects. Future studies should compare progesterone receptor modulators with medicines currently used to treat endometriosis symptoms and focus on assessing pain using recognised and reliable methods. Larger, well‐designed studies are also needed to assess the benefits and unwanted effects of progesterone receptor modulators other than mifepristone and gestrinone. What is endometriosis? Endometriosis is a condition where tissue similar to the lining of the womb (uterus) grows outside the womb. Endometriosis is oestrogen‐dependent and thus is seen mainly during the reproductive years. It can cause pain in the tummy area (abdomen), generally during periods (menstruation) or associated with sexual intercourse. Endometriosis is treated through different types of medical or surgical treatment. Progesterone receptor modulators (PRMs) are medicines that change how the hormone progesterone acts in the body. PRMs include mifepristone, gestrinone, ulipristal acetate, vilaprisan and asoprisnil. Because they can slow down or stop the growth of tissue in the lining of the uterus, they have been suggested as a treatment for endometriosis. What did we want to find out? We wanted to know whether, in patients with endometriosis, PRMs are better than placebo ('dummy' treatment), no treatment or other medical treatment for improving overall pain, pain during periods and pain during sexual intercourse. We also wanted to know if these medications were safe by assessing unwanted effects experienced by patients, such as hot flushes and feeling sick (nausea). What did we do? We searched for studies that investigated the effectiveness of PRMs for symptoms associated with endometriosis and whether they caused unwanted effects. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included nine studies involving 922 women aged 18 to 45 years. Most studies tested the PRMs mifepristone or gestrinone. One study tested asoprisnil, but the study was published only as a short summary without results that we could use. Two of the studies did not measure any of the effects we were interested in. Main results Progesterone receptor modulators versus placebo When compared to a placebo, mifepristone: may reduce painful periods after three months of treatment (based on 1 study of 342 women); may cause more unwanted effects, such as hot flushes (1 study, 360 women); may make little or no difference to nausea (1 study, 360 women); and we are uncertain whether mifepristone reduces pain during sex (1 study, 223 women). Progesterone receptor modulators versus other medical treatment When compared to danazol, one study of 38 women showed that: we do not know whether gestrinone improves pain symptoms after six months of treatment (1 study, 38 women); we do not know whether gestrinone causes more or fewer hot flushes or makes no difference (2 studies, 302 women); and gestrinone and danazol may cause similar rates of nausea, but the results are very uncertain (2 studies, 302 women). When compared to a GnRH analogue (leuprorelin), one study of 55 women found that: gestrinone may be less efficient in treating painful periods after six months of treatment (1 study, 55 women); but gestrinone may reduce pain during sex (1 study, 52 women); gestrinone may be similar to leuprorelin in terms of general pain experienced (1 study, 55 women); gestrinone may cause fewer hot flushes and similar levels of nausea (1 study, 55 women). What are the limitations of the evidence? Our confidence in the evidence is low to very low, mainly because some studies had one or more of these problems: they did not have many people taking part; they focused on specific settings or populations; they used methods likely to introduce errors in their results; they did not clearly report how they were conducted; they did not clearly report whether the people taking part knew which treatment they had received, which could have affected the study results. How up to date is this evidence? This review updates a previous review. The evidence is up to date to April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Grammatis, AL, Gibbons, T, Anucha, EN, Becker, CM", "articleTypes": [], "doi": "10.1002/14651858.CD009881.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.821Z" }, { "id": "db5f6e20-9959-4fd8-b96a-447264497ea3", "pmid": "", "title": "Dual antibiotics for bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is a chronic respiratory disease characterised by abnormal and irreversible dilatation of the smaller airways and associated with a mortality rate greater than twice that of the general population. Antibiotics serve as front‐line therapy for managing bacterial load, but their use is weighed against the development of antibiotic resistance. Dual antibiotic therapy has the potential to suppress infection from multiple strains of bacteria, leading to more successful treatment of exacerbations, reduced symptoms, and improved quality of life. Further evidence is required on the efficacy of dual antibiotics in terms of management of exacerbations and extent of antibiotic resistance. Objectives To evaluate the effects of dual antibiotics in the treatment of adults and children with bronchiectasis. Search methods We identified studies from the Cochrane Airways Group Specialised Register (CAGR), which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED), and PsycINFO, as well as studies obtained by handsearching of journals/abstracts. We also searched the following trial registries: US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. We imposed no restriction on language of publication. We conducted our search in October 2017. Selection criteria We searched for randomised controlled trials comparing dual antibiotics versus a single antibiotic for short‐term (< 4 weeks) or long‐term management of bronchiectasis diagnosed in adults and/or children by bronchography, plain film chest radiography, or high‐resolution computed tomography. Primary outcomes included exacerbations, length of hospitalisation, and serious adverse events. Secondary outcomes were response rates, emergence of resistance to antibiotics, systemic markers of infection, sputum volume and purulence, measures of lung function, adverse events/effects, deaths, exercise capacity, and health‐related quality of life. We did not apply outcome measures as selection criteria. Data collection and analysis Two review authors independently screened the titles and abstracts of 287 records, along with the full text of seven reports. Two studies met review inclusion criteria. Two review authors independently extracted outcome data and assessed risk of bias . We extracted data from only one study and conducted GRADE assessments for the following outcomes: successful treatment of exacerbation; response rates; and serious adverse events. Main results Two randomised trials assessed the effectiveness of oral plus inhaled dual therapy versus oral monotherapy in a total of 118 adults with a mean age of 62.8 years. One multi‐centre trial compared inhaled tobramycin plus oral ciprofloxacin versus ciprofloxacin alone, and one single‐centre trial compared nebulised gentamicin plus systemic antibiotics versus a systemic antibiotic alone. Published papers did not report study funding sources. Effect estimates from one small study with 53 adults showed no evidence of treatment benefit with oral plus inhaled dual therapy for the following primary outcomes at the end of the study: successful management of exacerbation ‐ cure at day 42 (odds ratio (OR) 0.66, 95% confidence interval (CI) 0.22 to 2.01; 53 participants; one study; very low‐quality evidence); number of participants with Pseudomonas aeruginosa eradication at day 21 (OR 2.33, 95% CI 0.66 to 8.24; 53 participants; one study; very low‐quality evidence); and serious adverse events (OR 0.48, 95% CI 0.08 to 2.87; 53 participants; one study; very low‐quality evidence). Similarly, researchers provided no evidence of treatment benefit for the following secondary outcomes: clinical response rates ‐ relapse at day 42 (OR 0.57, 95% CI 0.12 to 2.69; 53 participants; one study; very low‐quality evidence); microbiological response rate at day 21 ‐ eradicated (OR 2.40, 95% CI 0.67 to 8.65; 53 participants; one study; very low‐quality evidence); and adverse events ‐ incidence of wheeze (OR 5.75, 95% CI 1.55 to 21.33). Data show no evidence of benefit in terms of sputum volume, lung function, or antibiotic resistance. Outcomes from a second small study with 65 adults, available only as an abstract, were not included in the quantitative data synthesis. The included studies did not report our other primary outcomes: duration; frequency; and time to next exacerbation; nor our secondary outcomes: systemic markers of infection; exercise capacity; and quality of life. We did not identify any trials that included children. Authors' conclusions A small number of studies in adults have generated high‐quality evidence that is insufficient to inform robust conclusions, and studies in children have provided no evidence. We identified only one dual‐therapy combination of oral and inhaled antibiotics. Results from this single trial of 53 adults that we were able to include in the quantitative synthesis showed no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, serious adverse events, sputum volume, lung function, and antibiotic resistance. Further high‐quality research is required to determine the efficacy and safety of other combinations of dual antibiotics for both adults and children with bronchiectasis, particularly in terms of antibiotic resistance. Plain language summary Dual antibiotics for bronchiectasis Background to the question Bronchiectasis is a lung disease involving abnormal airways, leading to repeated chest infections, and associated with a mortality rate more than twice that of the general population. Although previously considered a relatively rare disease, numbers appear to be increasing, particularly for those over 75 years in low/middle‐income countries. Antibiotics are the main therapy for chest infection, but their use must be weighed against potential side effects and the risk of increasing resistance to antibiotic therapy. One strategy to improve response and/or reduce antibiotic resistance involves giving two antibiotic agents at the same time: dual antibiotic therapy. This review therefore aimed to evaluate the effects of dual antibiotics for treatment of adults and children with bronchiectasis. Study characteristics In October 2017, we identified two relevant studies comparing oral plus inhaled dual therapy versus oral therapy alone. They included a total of 118 adults with an average age of 62.8 years. One study compared inhaled tobramycin plus oral ciprofloxacin with oral ciprofloxacin, and the second study compared inhaled gentamicin plus a systemic (affecting the whole body, rather than just the lungs) antibiotic with a systemic antibiotic alone. Only a research summary was available for the latter. Published papers did not report study funding sources Main results Results from one small trial of 53 adults show no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, the occurrence of serious unwanted events, amount of phlegm, lung function, or resistance to antibiotic treatment. However, we found insufficient evidence to permit confident conclusions about their use. Quality of the evidence The overall quality of the evidence was very poor, largely because one of the studies was not well described and included few participants. Information on exacerbations, exercise ability, and quality of life was not reported. We did not identify any trials that compared other types of dual antibiotic therapy, and we found none that included children. Therefore uncertainty remains concerning the use of dual antibiotics, and further high‐quality studies are needed to examine the role of dual antibiotics in the treatment of adults and children with bronchiectasis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Felix, LM; Grundy, S; Milan, SJ; Armstrong, R; Harrison, H; Lynes, D; Spencer, S", "articleTypes": [], "doi": "10.1002/14651858.CD012514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "db82ab0d-d9da-4c06-920e-528c29b3ef07", "pmid": "", "title": "A Randomized, Double-Blind, Placebo-Controlled Phase III Clinical Trial of Pembrolizumab (MK-3475) in Combination With Cisplatin and 5-Fluorouracil Versus Placebo in Combination With Cisplatin and 5-Fluorouracil as First-Line Treatment in Subjects With Advanced/Metastatic Esophageal Carcinoma (KEYNOTE-590)", "imported": false, "abstract": "The purpose of this trial is to evaluate efficacy and safety of pembrolizumab plus standard of care (SOC) chemotherapy with cisplatin and 5-fluorouracil (5-FU) versus placebo plus SOC chemotherapy with cisplatin and 5-FU as first-line treatment in participants with locally advanced or metastatic esophageal carcinoma.", "journal": "", "year": "2017", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.161Z" }, { "id": "db83f232-aa2d-425f-be0a-96a4f0e87bad", "pmid": "", "title": "Environmental enrichment for stroke and other non‐progressive brain injury", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Qin, H, Reid, I, Gorelik, A, Ng, L", "articleTypes": [], "doi": "10.1002/14651858.CD011879.pub2 AB - Abstract - Background Rehabilitation is effective for recovery after stroke and other non‐progressive brain injuries but it is unclear if the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. Environmental enrichment is a relatively new concept within rehabilitation for humans. In this review, this is defined as an intervention designed to facilitate physical (motor and sensory), cognitive and social activity by the provision of equipment and organisation of a structured, stimulating environment. The environment should be designed to encourage (but not force) activities without additional specialised rehabilitation input. Objectives To assess the effects of environmental enrichment on well‐being, functional recovery, activity levels and quality of life in people who have stroke or non‐progressive brain injury. Search methods We conducted the search on 26 October 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers. Selection criteria We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services. Data collection and analysis Two review authors independently assessed eligible studies, extracted data, and assessed study quality. Any disagreements were resolved through discussion with a third review author. We determined the risk of bias for the included study and performed a 'best evidence' synthesis using the GRADE approach. Main results We identified one RCT, involving 53 participants with stroke, comparing environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. We excluded five studies, found two studies awaiting classification and one ongoing study which described environmental enrichment in their interventions. Of the excluded studies, three were non‐RCTs and two described co‐interventions with a significant component of rehabilitation. Based on the single small included RCT at high risk of bias, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the provision of environmental enrichment. Authors' conclusions The gap in current research should not, however, be interpreted as proof that environmental enrichment is ineffective. Further research is needed with robust study designs, such as cluster RCTs, and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (inpatient versus outpatient), the relative effectiveness of various components of environmental enrichment, cost‐effectiveness, and safety of the intervention in people following stroke or other non‐progressive brain injuries. It should be noted, however, that it is challenging to randomise or double‐blind trials of environmental enrichment given the nature of the intervention. Plain language summary Treatment using environmental enrichment for supporting rehabilitation following stroke and other brain injuries which do not get worse over time (non‐progressive brain injury) Background Rehabilitation helps with recovery after stroke and other non‐progressive brain injuries through therapy. However, outside of therapy hours, people may have very little to keep them stimulated. Environmental enrichment is a relatively new concept in rehabilitation where the environment itself is designed to be engaging and to include physical, thinking, and social activities like exercises and games. For example, a nursery for babies may be interesting and stimulating but a hospital environment for adults is generally not. The design of the environment alone should encourage (but not force) activities without additional specialised rehabilitation. Review question 
We wanted to find out whether treatment with environmental enrichment is better or worse than alternatives. Search date 
The evidence is current to 26 October 2020. Study characteristics 
Population: we planned to include studies in which participants were adults who had had a stroke or a non‐progressive brain injury (such as traumatic brain injury but not dementia, Alzheimer's diease, or multiple sclerosis). Intervention: environmental enrichment interventions will usually include multiple activities, such as computers plus gaming technology plus music and reading. Comparison: we planned to compare environmental interventions with usual care (regular physiotherapy, speech therapy, occupational therapy) or alternative treatment. Outcomes: we divided outcomes into primary and secondary outcomes. Primary outcomes focused on psychological well‐being (anxiety, depression, stress) and coping. Secondary outcomes focused on quality of life, physical function, communication and cognitive function, and activity levels. We also planned to report adverse events. Key results 
We found one trial that compared environmental intervention alone with usual care or alternative treatment. The trial included 53 participants who had had a stroke and was based in a hospital rehabilitation ward. The trial compared environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services. The main outcomes related to psychological well‐being and coping. We were uncertain of the results because the trial was very small and highly prone to bias. Conclusion 
The gap in current research does not mean that environmental enrichment is ineffective. Further research is needed with strong study designs and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (in hospital versus out of hospital), which components of environmental enrichment are effective, whether environmental enrichment is cost‐effective, and if it is safe for people following stroke or other non‐progressive brain injuries.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.116Z" }, { "id": "db9790d6-f497-40c9-9919-97232ca9d14f", "pmid": "", "title": "Interventions for the prevention of recurrent erysipelas and cellulitis", "imported": false, "abstract": "Abstract - Background Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. Objectives To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. Search methods We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. Selection criteria Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. Data collection and analysis Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. Main results We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study. Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow‐up period of up to one and a half to two years. Four studies were single‐centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria. Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate. Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate‐certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate‐certainty evidence). The protective effects of antibiotic did not last after prophylaxis had been stopped ('post‐prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty. Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years. We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay. The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin). None of the included studies assessed the development of antimicrobial resistance or quality‐of‐life measures. With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. Authors' conclusions In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate‐certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low‐certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low‐certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high‐quality studies are warranted, including long‐term follow‐up and other prophylactic measures. Plain language summary Preventive treatments for repeated episodes of cellulitis and erysipelas Background Cellulitis and erysipelas are both bacterial infections of the skin that most commonly affect the leg. Erysipelas affects the upper layers of the skin, and cellulitis affects its deeper parts, but in practice it is often hard to tell the difference between them, so we consider them together for this review (and refer to them as 'cellulitis'). Up to 50% of people with cellulitis experience repeated episodes. Despite the burden of this condition, there is a lack of high‐certainty, evidence‐based information about the desirable treatment for the prevention of recurrent cellulitis. Review question What are the best available treatments to prevent repeated episodes of cellulitis in adults aged over 16 years compared to no treatment, placebo, another intervention, or the same intervention with a different plan of treatment, and what are their side effects? Study characteristics We searched relevant databases and registers up to June 2016. We identified six trials, with 573 participants, who had an average age between 50 and 70. Both genders were included, but there were nearly twice as many women. Five trials used antibiotic treatment (four penicillin and one erythromycin), which was compared to either no treatment or placebo, and one trial used selenium compared to physiological salt solution. Treatments lasted from six to 18 months. The most common setting was the hospital, and two studies were multicentre. The studies were conducted in the UK, Sweden, Tunisia, Israel, and Austria. There was a small number of previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes in each study. The antibiotic trials assessed prevention with antibiotics in people with cellulitis of the legs, and the selenium trial assessed people with cellulitis of the arms. Key results Our main outcome was prevention of repeated episodes of cellulitis. Our other outcomes included the number of repeated attacks of cellulitis, time to next attack, hospitalisation, quality of life, development of antibiotic resistance, adverse reactions and death. Combining the results of all five trials that used antibiotics, we found moderate‐certainty evidence that for those people under preventative treatment, antibiotic treatment in general, and penicillin in particular, is probably both effective and safe for the prevention of repeated episodes of leg cellulitis when compared with no treatment or placebo. The analyses showed that, compared with no treatment or placebo, taking antibiotics decreased the risk of future episodes by 69%, reduced their number by more than 50%, and significantly reduced the rate until the next attack (moderate‐certainty evidence). However, we found low‐certainty evidence that the protective effect of antibiotics for these three outcomes tailed off over time after treatment had been stopped. In addition, the beneficial effect of antibiotics was relevant for people with at least two past episodes of cellulitis within a time frame of up to three years. We found low‐certainty evidence that there is no difference between antibiotics and no treatment/placebo for side effects and hospitalisation. The evidence did not allow for full exploration of the treatment's effect on length of hospital stay. No serious adverse effects were reported, and common side effects included diarrhoea, nausea, rash (severe skin adverse reactions were not reported) and thrush. In three studies, adverse effects caused those taking part to stop taking the antibiotic. Three people taking erythromycin had abdominal pain and nausea, causing them to stop taking the treatment and to take penicillin instead. In one study, two people withdrew from treatment with penicillin because of diarrhoea or nausea. In another study, because of pain at the site of injection, around 10% of those taking part stopped taking intramuscular injections of benzathine penicillin. None of the included studies measured quality of life or the development of antibiotic resistance. Certainty of evidence Evidence for the effects of antibiotics compared with no treatment or placebo on the recurrence, incidence rate and time to next episode of cellulitis under preventive treatment was of moderate certainty, and was limited by the small number of participants and events. Evidence for the remaining reported outcomes was of low certainty for the same reasons, as well as imprecise results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Dalal, A; Eskin‐Schwartz, M; Mimouni, D; Ray, S; Days, W; Hodak, E; Leibovici, L; Paul, M", "articleTypes": [], "doi": "10.1002/14651858.CD009758.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "db9aef7f-5d6d-42c7-97b5-4494be9786ab", "pmid": "", "title": "Inhaled anti‐pseudomonal antibiotics for long‐term therapy in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review. Objectives To evaluate the effects of long‐term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug‐sensitivity reactions and survival). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022. Selection criteria We selected trials where people with cystic fibrosis received inhaled anti‐pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi‐randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). Data collection and analysis Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system. Main results The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta‐analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low‐certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) ‐5.30 days, 95% CI ‐8.59 to ‐2.01; 1 trial, 245 participants; low‐certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta‐analyses. We are uncertain of the effect of the intervention on adverse events (very low‐certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEV 1 ) % predicted compared to tobramycin (MD ‐3.40%, 95% CI ‐6.63 to ‐0.17; 1 trial, 273 participants; moderate‐certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate‐certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high‐certainty evidence). Important treatment‐related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high. Authors' conclusions Long‐term treatment with inhaled anti‐pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer‐term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes. Plain language summary Inhaling antibiotics to treat lung infection in people with cystic fibrosis Review question Are inhaled antibiotics helpful against persistent infection with Pseudomonas aeruginosa in people with cystic fibrosis (CF)? Key messages As people with CF get older, they are more likely to become infected on a long‐term basis with Pseudomonas aeruginosa. This is the most common cause of chronic lung infection in people with CF . We wanted to find out whether antibiotics targeting Pseudomonas aeruginosa would reduce the effects of infection when they are breathed into the lungs. We wanted to learn whether this treatment would improve lung function, quality of life and survival. We also looked for any harmful effects. What is CF? Cystic fibrosis is an inherited disease which results in abnormal mucus in several parts of the body and mainly affects the lungs, which are susceptible to infection by certain bacteria. Infection causes inflammation which results in progressive damage to the lungs. What did we find? The review includes 18 trials with 3042 people with CF aged between five and 45 years of age . The trials lasted from three to 33 months. In 11 trials investigators compared inhaled antibiotics with a placebo (an inhaled substance without the medication in it) and people were selected for one treatment or the other randomly. Eight trials compared one inhaled antibiotic with either a different inhaled antibiotic or a different schedule of the same inhaled antibiotic. One of the trials compared an antibiotic both to placebo and to a different antibiotic and so fell into both groups. Main results Results from four trials showed that when compared to placebo, inhaled antibiotics may improve lung function and reduce the number of times the people with CF had a worsening of symptoms (exacerbation). Inhaled antibiotics may also mean fewer days off school or work (a measure of quality of life). They did not seem to have an effect on survival. We are not sure of the side effects of inhaled antibiotics, but tinnitus and changes in voice were reported more often in people inhaling antibiotics rather than the placebo. We did not find enough evidence to be able to comment on how inhaled antibiotics affect height and weight. Where the trials compared different inhaled antibiotics or schedules, there was only one trial in each of the eight different comparisons. The only differences we found in all these comparisons were for two outcomes. In one trial we found that aztreonam lysine probably improved lung function more than tobramycin, but no important differences were found in the other trials with regard to lung function. Aztreonam lysine also probably led to fewer people needing additional courses of antibiotics than tobramycin and there were fewer hospitalisations after levofloxacin compared to placebo. We noted that important side effects that were related to the treatment were not very common in the trials, but they were less common with tobramycin than with other antibiotics. What are the limitations of the evidence? The trials that we included in this review measured lung function in different ways and also how often people experienced a sudden worsening of symptoms. That made it difficult for us to combine the results of different trials to strengthen our evidence. We thought the overall certainty of evidence was low for most outcomes, mainly due to risks of bias within the trials and low event rates meaning results were not precise. How up to date is this evidence? The evidence is current to: 28 June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Smith, S; Rowbotham, NJ", "articleTypes": [], "doi": "10.1002/14651858.CD001021.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "dba22b36-9755-4202-90b0-8389b2b9dfeb", "pmid": "", "title": "Oral xanthines as maintenance treatment for asthma in children", "imported": false, "abstract": "Abstract - Background Xanthines have been used in the treatment of asthma as a bronchodilator, though they may also have anti‐inflammatory effects. The current role of xanthines in the long‐term treatment of childhood asthma needs to be reassessed. Objectives To determine the efficacy of xanthines (e.g. theophylline) in the maintenance treatment of paediatric asthma. Search methods A search of the Cochrane Airways Group Specialised Register was undertaken with predefined search terms. Searches are current to May 2008. Selection criteria Randomised controlled trials, lasting at least four weeks comparing a xanthine with placebo, regular short‐acting beta‐agonist (SABA), inhaled corticosteroids (ICS), cromoglycate (SCG), ketotifen (KET) or leukotriene antagonist, in children with diagnosed with chronic asthma between 18 months and 18 years old. Data collection and analysis Two reviewers independently selected each study for inclusion in the review and extracted data. Primary outcome was percentage of symptom‐free days. Main results Thirty‐six studies (2838 participants) were included. Xanthine versus placebo (18 studies): The proportion of symptom free days was larger with xanthine compared with placebo (7.97% [95% CI 3.41, 12.53]). Rescue medication usage was lower with xanthine, with no significant difference in symptom scores or hospitalisations. FEV 1 , and PEF were better with xanthine. Xanthine was associated with non ‐ specific side‐effects. Data from behavioural scores were inconclusive. Xanthine versus ICS (four studies) : Exacerbations were less frequent with ICS, but no significant difference on lung function was observed. Individual studies reported significant improvements in symptom measures in favour of steroids, and one study reported a difference in growth rate in favour of xanthine. No difference was observed for study withdrawal or tremor. Xanthine was associated with more frequent headache and nausea. Xanthine versus regular SABA (10 studies): No significant difference in symptoms, rescue medication usage and spirometry. Individual studies reported improvement in PEF with beta‐agonist. Beta‐agonist treatment led to fewer hospitalisations and headaches. Xanthine was associated with less tremor. Xanthine versus SCG (six studies ): No significant difference in symptoms, exacerbations and rescue medication. Sodium cromoglycate was associated with fewer gastro‐intestinal side‐effects than xanthine. Xanthine versus KET (one study): No statistical tests of significance between xanthine and ketotifen were reported. : Xanthine + ICS versus placebo + same dose ICS (three studies) : Results were conflicting due to clinical/methodological differences, and could not be aggregated. Xanthine + ICS versus ICS + leukotriene (one study): Results from one trial One small parallel study did not measure the primary outcome of symptoms; differences between treatments in end of treatment values were not statistically significant. Authors' conclusions Xanthines as first‐line preventer alleviate symptoms and reduce requirement for rescue medication in children with mild to moderate asthma. When compared with ICS they were less effective in preventing exacerbations. Xanthines had similar efficacy as single preventative agent compared with regular SABA and SCG. Evidence on AEs (adverse effects) was equivocal: there was evidence for increased AEs overall, but no evidence that any specific AE (including effects on behaviour and attention) occurred more frequently than with placebo. There is insufficient evidence from available studies to make firm conclusions about the effectiveness of xanthines as add‐on preventative treatment to ICS, and there are no published paediatric studies comparing xanthines with alternatives in this role. Our data suggest that xanthines are only suitable as first‐line preventative asthma therapy in children when ICS are not available. Pre‐trial exposure to the agents assessed may have pre‐disposed the trial populations to tolerate the drug, and may have threatened blinding. They may have a role as add‐on therapy in more severe asthma not controlled by ICS, but further studies are needed to examine this, and to define the risk‐benefit ratio compared with other agents. Plain language summary The effects of oral xanthines (e.g. theophylline) for chronic asthma in children Xanthines (e.g. theophylline) are a group of drugs thought to have helpful preventative and reliever properties in the treatment of asthma in children. This review of studies has established that there is evidence for useful effects of these drugs in terms of symptom relief and lung function, but also some evidence of side‐effects. As a primary preventative therapy , whilst there is evidence that xanthines are effective, this review suggests that more effective alternative treatment options (inhaled steroids) are available. In children with more severe asthma, the role of xanthines as an add‐on therapy has only been assessed in a small number of trials, which report mixed effects. More studies in this area would help to generate a more reliable overview of the effects of treatment in these children. Xanthines are an effective preventative treatment in childhood asthma, but less effective than inhaled steroids, and with a less favourable side‐effect profile. There is insufficient evidence at present to assess their role as \"add‐on\" preventer treatment versus newer alternatives. Some of the trials exposed the children they recruited to a pre‐trial phase of xanthine in order to maintain effective dosing during the trial. This could have made the trial participants less representative of the general population by making them more inclined to tolerate the study drug. This exposure also may have meant that they could recognise what drug they were taking during the blinded phase of the study.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Seddon, P, Bara, A, Lasserson, TJ, Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.746Z" }, { "id": "dbaa02c4-0a12-4c91-b3a2-87b82b88dee4", "pmid": "", "title": "Taste Physiology in Healthy, Normal-weight Volunteers", "imported": false, "abstract": "Taste physiology describes five main taste qualities in humans: sweet, sour, salty, umami and bitter. The receptors found on the tongue are also found in the entire gut. The correlation of stimulation of these gut receptors and brain activity has not yet been examined. The objectives are to investigate the effect of different taste substances on i) regional brain activity and ii) satiation peptide release.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.144Z" }, { "id": "dbdc6d33-42fb-431f-b3d9-40d7fe6dab69", "pmid": "", "title": "Dual antibiotics for bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is a chronic respiratory disease characterised by abnormal and irreversible dilatation of the smaller airways and associated with a mortality rate greater than twice that of the general population. Antibiotics serve as front‐line therapy for managing bacterial load, but their use is weighed against the development of antibiotic resistance. Dual antibiotic therapy has the potential to suppress infection from multiple strains of bacteria, leading to more successful treatment of exacerbations, reduced symptoms, and improved quality of life. Further evidence is required on the efficacy of dual antibiotics in terms of management of exacerbations and extent of antibiotic resistance. Objectives To evaluate the effects of dual antibiotics in the treatment of adults and children with bronchiectasis. Search methods We identified studies from the Cochrane Airways Group Specialised Register (CAGR), which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED), and PsycINFO, as well as studies obtained by handsearching of journals/abstracts. We also searched the following trial registries: US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. We imposed no restriction on language of publication. We conducted our search in October 2017. Selection criteria We searched for randomised controlled trials comparing dual antibiotics versus a single antibiotic for short‐term (< 4 weeks) or long‐term management of bronchiectasis diagnosed in adults and/or children by bronchography, plain film chest radiography, or high‐resolution computed tomography. Primary outcomes included exacerbations, length of hospitalisation, and serious adverse events. Secondary outcomes were response rates, emergence of resistance to antibiotics, systemic markers of infection, sputum volume and purulence, measures of lung function, adverse events/effects, deaths, exercise capacity, and health‐related quality of life. We did not apply outcome measures as selection criteria. Data collection and analysis Two review authors independently screened the titles and abstracts of 287 records, along with the full text of seven reports. Two studies met review inclusion criteria. Two review authors independently extracted outcome data and assessed risk of bias . We extracted data from only one study and conducted GRADE assessments for the following outcomes: successful treatment of exacerbation; response rates; and serious adverse events. Main results Two randomised trials assessed the effectiveness of oral plus inhaled dual therapy versus oral monotherapy in a total of 118 adults with a mean age of 62.8 years. One multi‐centre trial compared inhaled tobramycin plus oral ciprofloxacin versus ciprofloxacin alone, and one single‐centre trial compared nebulised gentamicin plus systemic antibiotics versus a systemic antibiotic alone. Published papers did not report study funding sources. Effect estimates from one small study with 53 adults showed no evidence of treatment benefit with oral plus inhaled dual therapy for the following primary outcomes at the end of the study: successful management of exacerbation ‐ cure at day 42 (odds ratio (OR) 0.66, 95% confidence interval (CI) 0.22 to 2.01; 53 participants; one study; very low‐quality evidence); number of participants with Pseudomonas aeruginosa eradication at day 21 (OR 2.33, 95% CI 0.66 to 8.24; 53 participants; one study; very low‐quality evidence); and serious adverse events (OR 0.48, 95% CI 0.08 to 2.87; 53 participants; one study; very low‐quality evidence). Similarly, researchers provided no evidence of treatment benefit for the following secondary outcomes: clinical response rates ‐ relapse at day 42 (OR 0.57, 95% CI 0.12 to 2.69; 53 participants; one study; very low‐quality evidence); microbiological response rate at day 21 ‐ eradicated (OR 2.40, 95% CI 0.67 to 8.65; 53 participants; one study; very low‐quality evidence); and adverse events ‐ incidence of wheeze (OR 5.75, 95% CI 1.55 to 21.33). Data show no evidence of benefit in terms of sputum volume, lung function, or antibiotic resistance. Outcomes from a second small study with 65 adults, available only as an abstract, were not included in the quantitative data synthesis. The included studies did not report our other primary outcomes: duration; frequency; and time to next exacerbation; nor our secondary outcomes: systemic markers of infection; exercise capacity; and quality of life. We did not identify any trials that included children. Authors' conclusions A small number of studies in adults have generated high‐quality evidence that is insufficient to inform robust conclusions, and studies in children have provided no evidence. We identified only one dual‐therapy combination of oral and inhaled antibiotics. Results from this single trial of 53 adults that we were able to include in the quantitative synthesis showed no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, serious adverse events, sputum volume, lung function, and antibiotic resistance. Further high‐quality research is required to determine the efficacy and safety of other combinations of dual antibiotics for both adults and children with bronchiectasis, particularly in terms of antibiotic resistance. Plain language summary Dual antibiotics for bronchiectasis Background to the question Bronchiectasis is a lung disease involving abnormal airways, leading to repeated chest infections, and associated with a mortality rate more than twice that of the general population. Although previously considered a relatively rare disease, numbers appear to be increasing, particularly for those over 75 years in low/middle‐income countries. Antibiotics are the main therapy for chest infection, but their use must be weighed against potential side effects and the risk of increasing resistance to antibiotic therapy. One strategy to improve response and/or reduce antibiotic resistance involves giving two antibiotic agents at the same time: dual antibiotic therapy. This review therefore aimed to evaluate the effects of dual antibiotics for treatment of adults and children with bronchiectasis. Study characteristics In October 2017, we identified two relevant studies comparing oral plus inhaled dual therapy versus oral therapy alone. They included a total of 118 adults with an average age of 62.8 years. One study compared inhaled tobramycin plus oral ciprofloxacin with oral ciprofloxacin, and the second study compared inhaled gentamicin plus a systemic (affecting the whole body, rather than just the lungs) antibiotic with a systemic antibiotic alone. Only a research summary was available for the latter. Published papers did not report study funding sources Main results Results from one small trial of 53 adults show no evidence of treatment benefit with oral plus inhaled dual therapy in terms of successful treatment of exacerbations, the occurrence of serious unwanted events, amount of phlegm, lung function, or resistance to antibiotic treatment. However, we found insufficient evidence to permit confident conclusions about their use. Quality of the evidence The overall quality of the evidence was very poor, largely because one of the studies was not well described and included few participants. Information on exacerbations, exercise ability, and quality of life was not reported. We did not identify any trials that compared other types of dual antibiotic therapy, and we found none that included children. Therefore uncertainty remains concerning the use of dual antibiotics, and further high‐quality studies are needed to examine the role of dual antibiotics in the treatment of adults and children with bronchiectasis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Felix, LM; Grundy, S; Milan, SJ; Armstrong, R; Harrison, H; Lynes, D; Spencer, S", "articleTypes": [], "doi": "10.1002/14651858.CD012514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "dbeaee3b-8881-49a0-a5cf-c048cebb4865", "pmid": "", "title": "Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age", "imported": false, "abstract": "Abstract - Background Vitamin and mineral deficiencies, particularly those of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Multiple micronutrient powders (MNPs) are single‐dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi‐solid food for children six months of age or older. The use of MNPs for home or point‐of‐use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out‐of‐date. Objectives To assess the effects and safety of home (point‐of‐use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi‐solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point‐of‐use fortification. Search methods We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs with individual randomisation or cluster‐randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron‐containing supplements, which is standard practice. Data collection and analysis Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, and assessed the risk of bias of included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence. Main results We included 29 studies (33,147 children) conducted in low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty‐six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron‐only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate‐certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high‐certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low‐certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate‐certainty evidence) at follow‐up compared with children receiving the control intervention. We did not find an effect on weight‐for‐age (MD 0.02, 95% CI −0.03 to 0.07; 10 studies; 9287 children; moderate‐certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all‐cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low‐certainty evidence) and haemoglobin concentrations (MD −2.81 g/L, 95% CI −10.84 to 5.22; 2 studies; 278 children; very low‐certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low‐certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Authors' conclusions Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Plain language summary Using a vitamin and mineral powder, mixed into complementary foods, to improve health and nutrition in children under two years of age Review question Does using a vitamin and mineral powder, mixed into complementary foods, improve health and nutrition in children under two years of age? Background Deficiencies of vitamins and minerals, particularly of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Exclusive breastfeeding until six months of age, followed by complementary feeding combined with continued breastfeeding for at least two years, is recommended to maintain children's adequate health and nutrition. After six months of age, infants start to receive semi‐solid foods, but the quantities of vitamins and minerals can be insufficient to fulfil all of their requirements for growth and development. Multiple micronutrient powders (MNPs) are single‐dose packets of powder containing iron, vitamin A, zinc, and other vitamins and minerals that can be mixed into any semi‐solid food at home or at any other point of use, to increase the content of essential vitamins and minerals in the diet of infants and young children during this period. This is done without making any other changes to their usual diet. Study characteristics We searched up to July 2019 for all studies that assessed the use of MNP for improving the health and nutrition of children under two years of age. We included 29 studies that involved 33,147 infants and young children from low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean. Twenty‐six studies with 27,051 children contributed data. Of these 26 studies, 24 compared the use of MNP versus no intervention or placebo, and 2 compared the use of MNP versus an iron‐only supplement (iron drops) given daily. We found that a variety of MNP formulations containing between 5 and 22 vitamins and minerals were given for 2 to 44 months to infants and young children aged 6 to 23 months. Most studies were funded by government programmes or foundations; only 2 were funded by industry. Key results The use of MNP containing at least iron, zinc, and vitamin A for home fortification of foods was associated with reduced risk of anaemia of 18% and iron deficiency of 53% in children aged six months to two years compared with no intervention. Also, haemoglobin concentration and iron status improved. Studies did not find any effects on growth. There was no additional benefit in reducing risk of anaemia and improving haemoglobin concentration compared to usually recommended iron drops or syrups; however, only two studies compared these different interventions. No trials reported death attributable to the intervention. Information on deaths, side effects, and morbidity, including malaria and diarrhoea, was scarce. The use of MNP was beneficial for young children 6 to 23 months of age, independent of whether they lived in settings with different anaemia and malaria backgrounds and regardless of the length of the intervention. MNP is better than no intervention or placebo and may be comparable to daily iron supplementation.The benefits of this intervention as a child survival strategy or for developmental outcomes are still unclear, and further investigation is required. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Certainty of the evidence For the comparison of MNP versus no intervention or placebo, we judged the certainty of evidence to be moderate for anaemia and high for iron deficiency. The certainty of evidence for all other outcomes in this comparison was either low or moderate. Two trials that compared the use of MNP versus iron supplement showed similar effects on anaemia and haemoglobin but less diarrhoea; however, we judged the certainty of evidence as low for anaemia and very low for haemoglobin concentration due to the small number of study participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Suchdev, PS, Jefferds, MED, Ota, E, da Silva Lopes, K, De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD008959.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.110Z" }, { "id": "dbf4ca1f-a208-4bdd-8366-7f11cd39671d", "pmid": "", "title": "Lasers for caries removal in deciduous and permanent teeth", "imported": false, "abstract": "Abstract - Background Despite considerable improvements in oral health, dental caries continue to be a public health issue. The most frequently used, and universally accepted technique, to remove caries is through mechanical ablation of decayed tissues by means of rotating drills (diamond or tungsten carbide, or both). In the past few decades, the introduction of adhesive filling materials (resin composites) has affected cavity filling procedures by reducing its retention needs, with advantages for dental tissue conservation. Consequently, new minimally invasive strategies were introduced into dental practice, such as the use of lasers to perform highly controlled tissue ablation. Laser use has also raised expectations of limiting pain and discomfort compared to using drills, as well as overcoming drill phobia. Objectives The main objective of the review was to compare the effects of laser‐based methods to conventional mechanical methods for removing dental caries in deciduous and permanent teeth. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (searched 22 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 22 June 2016), MEDLINE Ovid (1946 to 22 June 2016), Embase Ovid (1980 to 22 June 2016), ProQuest Dissertations and Theses (1980 to 22 June 2016), Zetoc (limited to conference proceedings) (1993 to 22 June 2016), and ISI Web of Knowledge (limited to conference proceedings) (1990 to 22 June 2016). We checked the reference lists of relevant articles to identify additional studies. We searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. Selection criteria We included randomised controlled trials, split‐mouth trials and cluster‐randomised trials (irrespective of their language) comparing laser therapy to drill ablation of caries. We included participants of any age (children, adolescents and adults). Data collection and analysis Two review authors independently screened titles and abstracts of citations identified by the review search strategy. Two review authors independently evaluated the full text of relevant primary studies, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. Main results We included nine randomised trials, published between 1998 and 2014, involving 662 participants. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Four studies examined only permanent teeth, and five studies evaluated both deciduous and permanent teeth. Six trials used Er:YAG (erbium‐doped yttrium aluminium garnet) lasers, two trials employed Er,Cr:YSGG (erbium, chromium: yttrium‐scandium‐gallium‐garnet) lasers, and one trial used Nd:YAG (neodymium‐doped yttrium aluminium garnet) laser. Overall, the trials had small sample sizes, and the majority were at unclear or high risk of bias. The primary outcomes were evaluated in a limited number of trials (removal of caries (four trials (but only two reported quantitative data)); episodes of pain (five studies)). There was insufficient evidence to suggest that either lasers or drill were better at caries removal (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.99 to 1.01; 2 studies; 256 treated caries; P = 0.75; I 2 = 0%; low‐quality evidence). The incidence of moderate or high pain was greater in the drill group compared to the laser group (RR 0.40, 95% CI 0.28 to 0.57; 2 studies; 143 participants; P < 0.001; I 2 = 50%). Similarly, the need for anaesthesia was significantly higher in the drill group than in the laser group (RR 0.25, 95% CI 0.10 to 0.65; 3 studies; 217 children/adolescents; P = 0.004; I 2 = 0%). In terms of marginal integrity of restoration, there was no evidence of a difference between laser and drill comparisons evaluated at 6 months (RR 1.00, 95% CI 0.21 to 4.78; 3 studies), 1 year (RR 1.59, 95% CI 0.34 to 7.38; 2 studies), or 2 years (RR 1.00, 95% CI 0.21 to 4.74; 1 study). There was no evidence of a difference for durability of restoration between laser therapy or drill at 6 months' follow‐up (RR 2.40, 95% CI 0.65 to 8.77; 4 studies), at 1 year (RR 1.40, 95% CI 0.29 to 6.78; 2 studies) or at 2 years' follow‐up (RR 0.50, 95% CI 0.02 to 14.60; 1 study). Only two trials investigated the recurrence of caries, but no events occurred during 6 months' follow‐up. There was insufficient evidence of a difference between laser or drill in terms of pulpal inflammation or necrosis at 1 week (RR 1.51, 95% CI 0.26 to 8.75; 3 studies) and at 6 months (RR 0.99, 95% CI 0.10 to 9.41; 2 studies). Authors' conclusions Given the low quality of the body of evidence, we concluded that evidence was insufficient to support the use of laser as an alternative to traditional drill therapy for caries removal. We found some evidence in favour of laser therapy for pain control, need of anaesthesia and patient discomfort, but, again, the body of evidence was of low quality. Additional well‐designed, randomised trials investigating the most relevant outcomes are needed. Plain language summary Lasers for the removal of decay in first and permanent teeth Review question This review addressed the issue of whether there is an advantage to laser therapy for the removal of decay in teeth and patient pain, compared to a traditional drill, in children, adolescents and adults. Background Dental decay is a cavity formation in teeth resulting from the destruction of dental tissue caused by bacteria under certain conditions, including poor oral hygiene and excessive sugar intake. Symptoms may include pain and difficulty with eating, and complications may include tooth loss, infection or inflammation of the gum. Rotating drills are traditionally used to remove decay. However, this mechanical tool may have unexpected side effects, such as the removal of too much or too little decay, in addition to discomfort due to pain, noise and vibration. Laser therapy is a potential alternative to a mechanical drill. Study characteristics Cochrane Oral Health provided the search strategies and carried out the search in several electronic databases. We selected nine randomised trials for inclusion in this review that were conducted between 1998 and 2014. The evidence in the review is up to date as of 22 June 2016. The trials involved a total of 662 participants, with 1498 teeth treated. Three studies were conducted in the USA, one in Taiwan, one in China, one in Bulgaria, one in Germany, one in Turkey and one in the UK. The population consisted of both children and adolescents in four trials, only adults in four trials, and both children/adolescents and adults in one trial. Key results Despite the number of included studies, only a few trials adequately and completely reported information on the primary outcomes. Two trials reported on removal of decay, and there was not enough evidence to conclude that either lasers or drills were better at decay removal. Only five trials reported on episodes of pain, which was significantly reduced in people treated with lasers. There was no difference in terms of side effects, such as inflammation or death of dental pulp, between the two interventions. Quality of the evidence The overall quality of the evidence for the nine studies was low. Only one study adequately randomised participants, and none of the included studies was at low risk of bias. This review highlights the need for high‐quality studies comparing laser therapy and mechanical drills in the treatment of dental decay.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Montedori, A; Abraha, I; Orso, M; D'Errico, PG; Pagano, S; Lombardo, G", "articleTypes": [], "doi": "10.1002/14651858.CD010229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "dc0fcd43-13d3-47ad-b465-05cd64afa8d5", "pmid": "", "title": "Interventions to reduce harm from continued tobacco use", "imported": false, "abstract": "Abstract - Background Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced‐exposure tobacco products (PREPs), as an alternative to cigarettes. Objectives To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long‐term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco? Search methods We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free‐text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. Selection criteria Randomized or quasi‐randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention. Data collection and analysis We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long‐term smoking abstinence), using fixed‐effect models. Where it was not possible to meta‐analyse data, we summarized findings narratively. Main results Twenty‐four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically‐heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as ‘low’ or ‘very low’, due to imprecision and indirectness. A ‘low’ grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A ‘very low’ grade means we are very uncertain about the estimate. Authors' conclusions People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high‐quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high‐quality RCTs are conducted, and that these also measure the long‐term health effects of treatments. Plain language summary Can smokers be helped to reduce the harm caused by cigarette smoking by smoking fewer cigarettes or using different tobacco products? Background The best thing to do to reduce the harms caused by smoking is to quit, but some people may not want to do this or may feel that they are unable to stop smoking completely. Cutting down the number of cigarettes smoked daily or using different tobacco products, such as chewing tobacco or low‐tar cigarettes, may reduce some of the harm caused by smoking. It may also help people to stop smoking completely in the long term. On the other hand, reducing smoking or using other tobacco products may not improve health and could reduce a person's motivation to quit smoking altogether. It is important that we review the evidence to find out whether these approaches could help smokers who do not want to or cannot quit to reduce the harm caused by their smoking. We were mainly interested in whether these approaches improved the health of smokers, but also looked at smoking reduction and quitting rates. Study characteristics We found 20 randomised controlled trials that tested ways to help people to cut down the number of cigarettes they smoked. Some of these just advised smokers to smoke less, but most also provided them with a product to help them cut down: nicotine replacement therapy (NRT), varenicline, bupropion, electronic cigarettes (ecigs), or snus (a form of smokeless, oral tobacco). We also found four randomized controlled trials that tested the effects of using cigarettes designed to reduce the damage caused by smoking: reduced tar, carbon or nicotine cigarettes. Most of the studies used NRT to help people to reduce their smoking. All of the studies included people who were not planning to quit smoking soon. The research is current to October 2015. Key results Eight studies (with 3081 smokers) found that using NRT roughly doubled the likelihood of halving the number of cigarettes smoked each day, compared to using a placebo. Using NRT in this way also nearly doubled the likelihood of quitting completely. One trial each tested bupropion, varenicline, ecigs and snus to help reduce the harms caused by smoking, and there was no evidence that any of these treatments helped smokers to reduce the number of cigarettes they were smoking each day. This may be because there has not yet been enough research into these methods. Only one of the trials testing cigarettes designed to reduce risk measured their effect on the number of people quitting smoking. It found that people were not more likely to quit smoking if they used reduced‐nicotine cigarettes than if they smoked their usual cigarettes. We did not find any trials which reported the long‐term health effects of the treatments, and so it remains uncertain how much health benefit there is from reducing the number of cigarettes smoked each day or smoking cigarettes designed to be less harmful. Quality of evidence The tobacco industry funded three of the included studies of cigarettes designed to reduce risk. None of the studies looked at whether there had been a long‐term change in the health of the users. We rate the quality of the evidence looking at how many people quit smoking as 'low' or 'very low', generally because the findings are based on a small number of studies. We need more studies to investigate methods of reducing the harm caused by continued smoking. These need to measure the health of the users over a long period.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lindson‐Hawley, N; Hartmann‐Boyce, J; Fanshawe, TR; Begh, R; Farley, A; Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD005231.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "dc49aaa2-305a-4838-9808-701a48dec9b8", "pmid": "", "title": "Ginkgo biloba extract for age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Ginkgo is used in the treatment of peripheral vascular disease and 'cerebral insufficiency'. It is thought to have several potential mechanisms of action including increased blood flow, platelet activating factor antagonism, and prevention of membrane damage caused by free radicals. Vascular factors and oxidative damage are thought to be two potential mechanisms in the pathology of age‐related macular degeneration (AMD). Objectives The objective of this review was to determine the effect of Ginkgo biloba extract on the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2012), EMBASE (January 1980 to October 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to October 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 5 October 2012. We searched the reference lists of identified reports and the Science Citation Index. We also contacted investigators of included studies for additional information. Selection criteria All randomised trials in people with AMD where Ginkgo biloba extract had been compared to control were included. Data collection and analysis The review author extracted data using a standardised form. The data were verified with the trial investigators. Trial quality was assessed. Main results Two published trials were identified that randomised a total of 119 people. In one study conducted in France, 20 people were randomly allocated to Gingko biloba extract EGb 761 80 mg twice daily or placebo. In the other study conducted in Germany, 99 people were randomly allocated to two different doses of Ginkgo biloba extract EGb 761 (240 mg per day and 60 mg per day). Treatment duration in both studies was six months. Both trials reported some positive effects of Ginkgo biloba on vision however their results could not be pooled. Adverse effects and quality of life for people with AMD were not reported. Authors' conclusions The question as to whether people with AMD should take Ginkgo biloba extract to prevent progression of the disease has not been answered by research to date. Two small trials have suggested possible benefit of Gingko biloba on vision and further trials are warranted. Ginkgo biloba is widely used in China, Germany, and France. Future trials should be larger, and last longer, in order to provide a more robust measure of the effect of Gingko biloba extract on AMD. Plain language summary Use of Gingko biloba, an extract from the leaves of the maidenhair tree, for slowing the progression of age‐related macular degeneration Age‐related macular degeneration (AMD) is a condition affecting the central area of the retina (the back of the eye). The retina can deteriorate with age and some people get lesions that lead to loss of central vision. Gingko biloba, extracted from the leaves of the maidenhair tree, is used in Chinese herbal medicine to treat a variety of medical conditions, in particular circulatory problems. Ginkgo biloba extract contains two constituents (flavonoids and terpenoids) which have antioxidant properties. It is believed these may help to slow down the progression of AMD. The author identified two small randomised controlled studies (with a total of 119 participants); one in France and one in Germany. One trial compared Gingko biloba to placebo and the other compared two different doses of the extract. Although both trials reported some positive effects of Ginkgo biloba on vision, the trials were small and of short duration. Adverse effects and quality of life were not assessed. The overall conclusion of this review is that current research has not answered the question as to whether Ginkgo biloba is of benefit to people with AMD. Future trials need to include a larger number of participants and be conducted over a longer time.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD001775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.066Z" }, { "id": "dc576663-993a-4bd0-9fbf-0b9a5e6c62cf", "pmid": "", "title": "Nebuliser systems for drug delivery in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Nebuliser systems are used to deliver medications to the lungs, to control the symptoms and the progression of lung disease in people with cystic fibrosis (CF). There are many different nebulised‐medications prescribed for people with CF and there are many different types of nebuliser systems. Some of these nebulised medications are licenced for, and can be taken via only one type of nebuliser system; some are licensed for, and can be taken via more than one type of nebuliser system. This is an update to a previous systematic review. Objectives To assess the time efficiency, effectiveness, safety, cost and impact of use (e.g. burden of care, adherence, quality of life (QoL)) of different nebuliser systems, when used with different inhaled medications for people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching of relevant journals and abstract books containing conference proceedings. We searched the reference lists of each study for additional publications and approached the manufacturers of both nebuliser systems and nebulised medications for published and unpublished data. We also searched online trial registries. Date of the most recent search: 9 August 2023. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing nebuliser systems, including conventional nebulisers, vibrating mesh technology (VMT) systems, adaptive aerosol delivery (AAD) systems and ultrasonic nebuliser systems. Data collection and analysis Two review authors independently assessed studies for inclusion. They also independently extracted data and assessed the risk of bias. A third review author assessed studies where agreement could not be reached. They assessed the certainty of the evidence using GRADE. Main results The search identified 216 studies with 33 of these (2270 participants) included in the review. These studies compared the delivery of tobramycin, colistin, dornase alfa, hypertonic saline and other solutions through the different nebuliser systems in children and adults with CF. This review demonstrates variability in the delivery of medication depending on the nebuliser system used. The certainty of the evidence ranged from low to very low. Some conventional nebuliser systems providing higher flows, higher respirable fractions, and smaller particles decrease treatment time, increase deposition (the amount of drug reaching the lung), and may be preferred by people with CF, as compared to other conventional nebuliser systems providing lower flows, lower respirable fractions and larger particles. Newer nebuliser systems using AAD, or VMT (or both) reduce treatment time compared to conventional systems. Deposition (as a percentage of priming dose) with AAD is greater than with conventional systems. VMT systems may give greater deposition than conventional systems when measuring sputum levels. The available data indicate that these newer systems are safe when used with an appropriate priming dose, which may be different to the priming dose used for conventional systems. There is an indication that adherence is maintained or improved and that individuals prefer AAD or VMT systems, but also that some nebuliser systems using VMT may be subject to increased system failures. There is limited, unclear evidence on the impact of different nebuliser systems on lung function and a lack of data on the impact of different nebuliser systems on our outcomes of quality of life (QoL), adverse effects, respiratory exacerbations and related implications, adherence, satisfaction, cost and device reliability. Authors' conclusions Newer technologies e.g. AAD and VMT have advantages over conventional systems in terms of treatment time, deposition as a percentage of priming dose, preference and adherence. Data are lacking for all varieties of medications which are used in CF care, including different inhaled antibiotics or hypertonic saline, with all delivery (nebuliser system) possibilities. Long‐term RCTs are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as QoL and burden of care), safe and effective dosing levels of a wide variety of medications, clinical outcomes (such as hospitalisations and need for antibiotics), and an economic evaluation of their use. There are insufficient data to establish whether one nebuliser system is better than another overall. Clinicians should be aware of the variability in the performance of different nebuliser systems, compatibility with specific nebulised medication, and they must work with their patients to choose the best nebuliser system for each individual. This is likely to be an ongoing process as the needs and circumstances of each individual change over time. Plain language summary Nebulisers for giving medication for cystic fibrosis Key messages 1. Newer technologies have advantages over conventional systems in terms of treatment time, the amount of drug reaching the lung, preference, and adherence. 2. Not all medications used in treating cystic fibrosis can be delivered by the same nebuliser, and data are lacking for some of the different nebuliser and drug combinations. 3. Long‐term studies are needed to evaluate different nebuliser systems to determine patient‐focused outcomes (such as quality of life, effective dosing levels, and hospitalisations). What is cystic fibrosis? People with cystic fibrosis have sticky mucus in their lungs which is difficult to get rid of and which can cause infection if it builds up. How are nebulisers used as part of cystic fibrosis treatment? Nebulisers are used to deliver medications to the lungs to control the symptoms and the progression of disease. They change a liquid medication into a mist, so it can be breathed in. Different types of nebuliser systems are used with different medications. 1. Conventional systems ‐ a machine pushes out a constant mist of medication at high speed. 2. Adaptive aerosol delivery systems ‐ like conventional systems, also monitor breathing and only deliver the medication while the person is breathing in. 3. Vibrating mesh technology systems move the liquid medication through a metal mesh to generate a mist with similar‐sized droplets which is delivered constantly. 4. Adaptive aerosol delivery systems with vibrating mesh technology combination between the two systems. 5. Ultrasonic systems use a crystal to vibrate the liquid medication at a high frequency and turn it into a mist which is delivered constantly. What did we want to find out? How well do the different nebuliser systems deliver each inhaled medication (how much medication is delivered into the lungs, and what is the impact on lung function)? Are they safe or do they have any side effects? We also wanted to know how these nebuliser systems affect people with cystic fibrosis in terms of treatment burden, adherence to treatment regimen and their quality of life. What did we do? We assessed 33 studies (2270 adults and children)and compared different types of nebuliser systems for delivering: tobramycin; colistin; dornase alfa; hypertonic saline; and other nebulised medications. What did we find? Conventional systems which have faster air flows and smaller medication droplets decrease treatment time and deliver more medication into the lung than other conventional systems, which have slower air flows and larger medication droplets. Nebulisers use newer technologies, e.g. adaptive aerosol delivery system or vibrating mesh technology, deliver the medication faster and may deliver more of the medication into the lung. These newer systems appear safe when used with the correct amount of medication, which may be different to that used in a conventional system. Some studies suggest that people with cystic fibrosis may prefer these newer systems and may take more of their medication when using them. However, more research is needed into what dose of medication is needed for the different systems, which medications suit which technologies best and how these newer nebuliser technologies affect quality of life, burden of treatment, additional treatment needed (such as oral or intravenous antibiotics) and treatment costs. What are the limitations of the evidence? There were lots of different systems studied, and often we only had a few studies for each comparison. Also, the studies we found were quite small and results varied. We had concerns around at least some aspects of the design of every study which affected our confidence in the results. How up to date is this evidence? We last looked for evidence on 9 August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Stanford, G; Morrison, L; Brown, C", "articleTypes": [], "doi": "10.1002/14651858.CD007639.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "dc669727-67b1-490f-a447-df208cdc88b4", "pmid": "", "title": "D‐penicillamine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background D‐penicillamine is used for patients with primary biliary cirrhosis due to its hepatic copper decreasing and immunomodulatory potentials. The results from randomised clinical trials have been inconsistent. Objectives To systematically review the beneficial and harmful effects of D‐penicillamine for patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register (September 2003), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2003) , MEDLINE (January 1966 to September 2003) , EMBASE (January 1980 to September 2003) , The Chinese Biomedical CD Database (January 1979 to August 2003) , and LILACS (1982 to 2003); through manual searches of bibliographies; and by contacting authors of the trials and pharmaceutical companies. Selection criteria We included randomised clinical trials comparing D‐penicillamine with placebo/no intervention or other control intervention irrespective of language, year of publication, and publication status. Data collection and analysis Two reviewers independently assessed the methodological quality of the trials and extracted data, validated by a third reviewer. The primary outcomes were 1) mortality and 2) a combination of those who died or underwent liver transplantation. We analysed dichotomous outcomes as relative risk (RR) with 95% confidence interval (CI) by a fixed effect model and a random effects model. We investigated sources of heterogeneity by subgroup analyses and tested the robustness of our findings by sensitivity analyses. Main results We included seven trials randomising 706 patients with primary biliary cirrhosis. D‐penicillamine compared with placebo/no intervention tended to increase mortality (RR 1.34, 95% CI 1.09 to 1.64, fixed; RR 1.46, 95% CI 0.85 to 2.50, random). However, there was substantial heterogeneity. No significant differences were detected regarding the risks of mortality or liver transplantation, pruritus, liver complications, progression of liver histological stage, or the levels of liver biochemical variables (except alanine aminotransferase). D‐penicillamine versus placebo/no intervention significantly increased the risk of adverse events (RR 3.11, 95% CI 2.33 to 4.16, fixed; RR 4.18, 95% CI 1.38 to 12.69, random). Authors' conclusions D‐penicillamine did not appear to reduce the risk of mortality, but significantly increased the occurrences of adverse events in patients with primary biliary cirrhosis. We do not support the use of D‐penicillamine for patients with primary biliary cirrhosis. Plain language summary D‐penicillamine did not reduce the risk of mortality of patients with primary biliary cirrhosis but increased the occurrences of adverse events Primary biliary cirrhosis is an uncommon, chronic liver disease of unknown etiology. D‐penicillamine, a cupruretic drug, has been tested in randomised clinical trials and is used to treat patients with primary biliary cirrhosis. After combining results from seven trials, D‐penicillamine did not appear to improve survival of patients. D‐penicillamine was associated with a four‐time increase of adverse events. There were no significant differences between D‐penicillamine and placebo/no intervention with respect to clinical changes, liver histology, and liver biochemistry.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y; Klingenberg, SL; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004789.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "dcc335a1-2283-48c4-b0c3-33e7a7103201", "pmid": "", "title": "Interventions for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is the most common, life‐limiting, genetically inherited disease. It affects multiple organs, particularly the respiratory system. However, gastrointestinal problems such as constipation and distal intestinal obstruction syndrome (DIOS) are also important and well‐recognised complications in CF. They share similar symptoms e.g. bloating, abdominal pain, but are distinct conditions. Constipation occurs when there is gradual faecal impaction of the colon, but DIOS occurs when there is an accumulation of faeces and sticky mucus, forming a mass in the distal part of the small intestine. The mass may partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). Symptoms of DIOS can affect quality of life and other aspects of CF health, such as airway clearance, exercise, sleep and nutritional status. Treatment of constipation and prevention of complete bowel obstruction are required for gastrointestinal management in CF. However, many different strategies are used in clinical practice and there is a lack of consensus. The importance of this topic was highlighted in a recent research priority setting exercise by the James Lind Alliance. Objectives To evaluate the effectiveness and safety of laxative agents of differing types for preventing DIOS (complete and incomplete) in children and adults with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of search: 09 September 2021. We also searched online trial registries. Date of last search: 12 October 2021. Selection criteria Randomised and quasi‐randomised controlled parallel trials comparing laxative therapy for preventing DIOS (including osmotic agents, stimulants, mucolytics and substances with more than one action) at any dose to placebo, no treatment or an alternative laxative therapy, in people of any age with pancreatic sufficient or insufficient CF and any stage of lung disease. Randomised cross‐over trials were judged on an individual basis. Data collection and analysis Two authors independently assessed trials for inclusion, extracted outcome data and performed a risk of bias assessment for the included data. We judged the certainty of the evidence using GRADE criteria. Main results We included one cross‐over trial (17 participants) with a duration of 12 months, in which participants were randomly allocated to either cisapride (a gastro‐prokinetic agent) or placebo for six months each. The trial had an unclear risk of bias for most domains but had a high risk of reporting bias. Radiograph scores revealed no difference in occurrence of DIOS between cisapride and placebo (narrative report, no data provided). There were no adverse effects. Symptom scores were the only secondary outcome within the review that were reported. Total gastrointestinal symptom scores favoured cisapride with a statistically significant mean difference (MD) of ‐7.60 (95% confidence interval (CI) ‐14.73 to ‐0.47). There was no significant difference at six months between cisapride and placebo for abdominal distension, MD ‐0.90 (95% CI ‐2.39 to 0.59) or abdominal pain, MD ‐0.4 (95% CI ‐2.05 to 1.25). The global symptom scores (whether individuals felt better or worse) were reported in the paper to favour cisapride and be statistically significant (P < 0.05). We assessed the available data to be very low certainty. There was a great deal of missing data from the included trial and the investigators failed to report numerical data for many outcomes. The overall risk of bias of the trial was unclear and it had a high risk for reporting bias. There was also indirectness; the trial drug (cisapride) has since been removed from the market in several countries due to adverse effects, thus it has no current applicability for preventing DIOS. The included trial also had very few participants, which downgraded the certainty a further level for precision. Authors' conclusions There is an absence of evidence for interventions for the prevention of DIOS. As there was only one included trial, we could not perform a meta‐analysis of the data. Furthermore, the included trial compared a prokinetic agent (cisapride) that is no longer licensed for use in a number of countries due to the risk of serious cardiac events, a finding that came to light after the trial was conducted. Therefore, the limited findings from the trial are not applicable in current clinical practice. Overall, a great deal more research needs to be undertaken on gastrointestinal complications in CF, as this is a very poorly studied area compared to respiratory complications in CF. Plain language summary Which interventions are effective and safe for preventing distal intestinal obstruction syndrome (DIOS) in cystic fibrosis? Background Cystic fibrosis (CF) is an inherited, life‐long condition that causes organ systems in the body to produce large amounts of thick and sticky mucus. The most commonly affected area is the lungs, in which thick mucus leads to recurrent chest infections and breathing difficulties. Another commonly affected area is the digestive system. Many people with CF suffer from bloating and abdominal pain which may be caused by constipation or distal intestinal obstruction syndrome (DIOS). In DIOS, overproduction of thick mucus combines with stool and sticks to the intestinal wall. This mass can partially block the intestine (incomplete DIOS) or completely block the intestine (complete DIOS). The latter causes severe pain, vomiting and is treated as a medical emergency. As part of effective care for people with CF, constipation should therefore be treated and complete bowel obstruction be prevented. It is also important to recognise that constipation and DIOS impact on other aspects of CF health. Bloating, abdominal pain and nausea may affect airway clearance, exercise and sleep. Nutritional status may also be affected due to decreased appetite and malabsorption. DIOS may affect the absorption of other medications taken by people with CF. Overall, DIOS can significantly impair quality of life. Different laxatives are currently used in clinics, but prescribing practices differ and there is no consensus on optimal treatment strategies. Hence, this review aimed to analyse the evidence for the preventing DIOS. Search date We last searched for evidence: 12 October 2021. Trial characteristics We included one trial in the review, which included 17 people aged between 13 to 35 years. These people were randomly put into groups to take either a placebo drug (with no active medication) or cisapride for six months each and then to cross over and take the alternative treatment for a further six months. Key results The trial used radiography to diagnose DIOS, but did not provide any data and only stated that there was no difference between cisapride and placebo. The trial also stated that there were no adverse effects from the cisapride. The trial assessed participant‐reported total and individual gastrointestinal symptom scores. People in the cisapride group reported an improvement in total gastrointestinal symptom scores compared to those in the placebo group. However, there were no differences reported between groups for the individual symptom scores of abdominal pain and abdominal distension (swelling). Participants also reported global symptom scores, which showed that most people felt better taking cisapride compared to placebo. Certainty of the evidence The overall certainty of the evidence was very low. With one trial in this review, we could not combine data from different trials. The trial did not provide enough information about the methods used for allocating participants or about missing data and did not fully report certain results. The small number of participants also lowered the precision of the results. Since this trial was conducted, cisapride has been removed from the market in a number of countries due to rare but serious heart complications, therefore it has no applicability to current clinical practice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carroll, W, Green, J, Gilchrist, FJ", "articleTypes": [], "doi": "10.1002/14651858.CD012619.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.744Z" }, { "id": "dcd3267b-1dbb-49ff-a505-c2b74f0bc6b6", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies to prevent COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as potential prophylaxis to prevent coronavirus disease 2019 (COVID‐19). Objectives To assess the effects of SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, to prevent infection with SARS‐CoV‐2 causing COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register, MEDLINE, Embase, and three other databases on 27 April 2022. We checked references, searched citations, and contacted study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that evaluated SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, alone or combined, versus an active comparator, placebo, or no intervention, for pre‐exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) of COVID‐19. We excluded studies of SARS‐CoV‐2‐neutralising mAbs to treat COVID‐19, as these are part of another review. Data collection and analysis Two review authors independently assessed search results, extracted data, and assessed risk of bias using Cochrane RoB 2. Prioritised outcomes were infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, all‐cause mortality, admission to hospital, quality of life, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We included four RCTs of 9749 participants who were previously uninfected and unvaccinated at baseline. Median age was 42 to 76 years. Around 20% to 77.5% of participants in the PrEP studies and 35% to 100% in the PEP studies had at least one risk factor for severe COVID‐19. At baseline, 72.8% to 82.2% were SARS‐CoV‐2 antibody seronegative. We identified four ongoing studies, and two studies awaiting classification. Pre‐exposure prophylaxis Tixagevimab/cilgavimab versus placebo One study evaluated tixagevimab/cilgavimab versus placebo in participants exposed to SARS‐CoV‐2 wild‐type, Alpha, Beta, and Delta variant. About 39.3% of participants were censored for efficacy due to unblinding and 13.8% due to vaccination. Within six months, tixagevimab/cilgavimab probably decreases infection with SARS‐CoV‐2 (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.29 to 0.70; 4685 participants; moderate‐certainty evidence), decreases development of clinical COVID‐19 symptoms (RR 0.18, 95% CI 0.09 to 0.35; 5172 participants; high‐certainty evidence), and may decrease admission to hospital (RR 0.03, 95% CI 0 to 0.59; 5197 participants; low‐certainty evidence). Tixagevimab/cilgavimab may result in little to no difference on mortality within six months, all‐grade AEs, and SAEs (low‐certainty evidence). Quality of life was not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and Delta variant. About 36.5% of participants opted for SARS‐CoV‐2 vaccination and had a mean of 66.1 days between last dose of intervention and vaccination. Within six months, casirivimab/imdevimab may decrease infection with SARS‐CoV‐2 (RR 0.01, 95% CI 0 to 0.14; 825 seronegative participants; low‐certainty evidence) and may decrease development of clinical COVID‐19 symptoms (RR 0.02, 95% CI 0 to 0.27; 969 participants; low‐certainty evidence). We are uncertain whether casirivimab/imdevimab affects mortality regardless of the SARS‐CoV‐2 antibody serostatus. Casirivimab/imdevimab may increase all‐grade AEs slightly (RR 1.14, 95% CI 0.98 to 1.31; 969 participants; low‐certainty evidence). The evidence is very uncertain about the effects on grade 3 to 4 AEs and SAEs within six months. Admission to hospital and quality of life were not reported. Postexposure prophylaxis Bamlanivimab versus placebo One study evaluated bamlanivimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type. Bamlanivimab probably decreases infection with SARS‐CoV‐2 versus placebo by day 29 (RR 0.76, 95% CI 0.59 to 0.98; 966 participants; moderate‐certainty evidence), may result in little to no difference on all‐cause mortality by day 60 (R 0.83, 95% CI 0.25 to 2.70; 966 participants; low‐certainty evidence), may increase all‐grade AEs by week eight (RR 1.12, 95% CI 0.86 to 1.46; 966 participants; low‐certainty evidence), and may increase slightly SAEs (RR 1.46, 95% CI 0.73 to 2.91; 966 participants; low‐certainty evidence). Development of clinical COVID‐19 symptoms, admission to hospital within 30 days, and quality of life were not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and potentially, but less likely to Delta variant. Within 30 days, casirivimab/imdevimab decreases infection with SARS‐CoV‐2 (RR 0.34, 95% CI 0.23 to 0.48; 1505 participants; high‐certainty evidence), development of clinical COVID‐19 symptoms (broad‐term definition) (RR 0.19, 95% CI 0.10 to 0.35; 1505 participants; high‐certainty evidence), may result in little to no difference on mortality (RR 3.00, 95% CI 0.12 to 73.43; 1505 participants; low‐certainty evidence), and may result in little to no difference in admission to hospital. Casirivimab/imdevimab may slightly decrease grade 3 to 4 AEs (RR 0.50, 95% CI 0.24 to 1.02; 2617 participants; low‐certainty evidence), decreases all‐grade AEs (RR 0.70, 95% CI 0.61 to 0.80; 2617 participants; high‐certainty evidence), and may result in little to no difference on SAEs in participants regardless of SARS‐CoV‐2 antibody serostatus. Quality of life was not reported. Authors' conclusions For PrEP, there is a decrease in development of clinical COVID‐19 symptoms (high certainty), infection with SARS‐CoV‐2 (moderate certainty), and admission to hospital (low certainty) with tixagevimab/cilgavimab. There is low certainty of a decrease in infection with SARS‐CoV‐2, and development of clinical COVID‐19 symptoms; and a higher rate for all‐grade AEs with casirivimab/imdevimab. For PEP, there is moderate certainty of a decrease in infection with SARS‐CoV‐2 and low certainty for a higher rate for all‐grade AEs with bamlanivimab. There is high certainty of a decrease in infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, and a higher rate for all‐grade AEs with casirivimab/imdevimab. Although there is high‐to‐moderate certainty evidence for some outcomes, it is insufficient to draw meaningful conclusions. These findings only apply to people unvaccinated against COVID‐19. They are only applicable to the variants prevailing during the study and not other variants (e.g. Omicron). In vitro, tixagevimab/cilgavimab is effective against Omicron, but there are no clinical data. Bamlanivimab and casirivimab/imdevimab are ineffective against Omicron in vitro. Further studies are needed and publication of four ongoing studies may resolve the uncertainties. Plain language summary Are laboratory‐made COVID‐19‐specific monoclonal antibodies effective to prevent COVID‐19 in adults? Key messages Pre‐exposure prophylaxis of COVID‐19: – tixagevimab/cilgavimab probably reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may reduce number of people admitted to hospital; – casirivimab/imdevimab may reduce number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may increase number of unwanted effects (any severity) slightly. Postexposure prophylaxis of COVID‐19: – bamlanivimab probably reduces number of people infected with COVID‐19; – casirivimab/imdevimab reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and reduces number of unwanted effects (any severity). What are 'monoclonal' antibodies? The body makes antibodies to defend against disease. However, they may be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that target only one specific protein – in this case, a protein on the SARS‐CoV‐2 virus (that causes COVID‐19) – are 'monoclonal'. They attach to the virus and stop it from entering and replicating in human cells to prevent and fight infection. They are relevant for people who do not respond or respond poorly to vaccinations. What did we want to find out? We wanted to know if COVID‐19‐specific monoclonal antibodies are effective at preventing COVID‐19 in people exposed to the virus or are at high risk of being exposed to the virus. We looked at: – confirmed COVID‐19 infections; – development of COVID‐19 symptoms; – death from any cause; – hospital admission; – quality of life; – unwanted effects, such as infections and cardiac disorders; – serious unwanted effects, such as life‐threatening, hospitalisation, disability, or death. What did we do? We searched for studies comparing monoclonal antibodies (e.g. bamlanivimab, tixagevimab/cilgavimab, and casirivimab/imdevimab) with placebo (sham treatment), another treatment, or no treatment to prevent COVID‐19 in people of any age, gender, or ethnicity. We summarised data and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? Four studies including 9749 people; two investigated people before being exposed to SARS‐CoV‐2 (pre‐exposure prophylaxis) and two investigated people who were in contact with an infected person (postexposure prophylaxis). Studies were conducted before the emergence of the Omicron variant and before or during widespread vaccine roll‐out. Participants were unvaccinated at baseline. Pre‐exposure prophylaxis One study (5197 people) compared tixagevimab/cilgavimab to placebo. Participants had been exposed to wild‐type, Alpha, Beta, and Delta variants. Tixagevimab/cilgavimab: – reduces development of symptoms; – probably reduces number of people infected; – may reduce number of hospital admissions; – may have little or no effect on deaths from any cause, unwanted effects (any severity), and serious unwanted effect. We found no data for quality of life, or mild and severe unwanted effects. One study (969 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and Delta variants. Casirivimab/imdevimab: – may reduce number of people infected and development of symptoms; – resulted in no deaths; – may increase unwanted effects (any severity) slightly; – we are uncertain whether casirivimab/imdevimab may have an effect on severe and serious unwanted effects. We found no data for number of people with COVID‐19 within 30 days, development of symptoms within 30 days, hospital admissions within 30 days, quality of life, and mild unwanted effects. Postexposure prophylaxis (two studies) One study (966 people) compared bamlanivimab to placebo. Participants may have been exposed to wild‐type variants. Bamlanivimab: – probably reduces number of people infected; – may have little or no effect on deaths from any cause; – may increase unwanted effects (any severity) and serious unwanted effects slightly. We found no data for number of people who developed symptoms, hospital admissions, quality of life, mild, and severe unwanted effects. One study (2617 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and potentially, but unlikely Delta variants. Casirivimab/ imdevimab: – reduces number of people infected, development of symptoms, and unwanted effects (any severity); – may slightly reduce severe unwanted effects; – may have little or no effect on deaths, hospital admissions, and serious unwanted effects. We found no data for quality of life and mild unwanted effects. What are the limitations of the evidence? One study reported each comparison. All participants were unvaccinated at the beginning of the studies, which were conducted prior to the occurrence of Omicron. Our confidence in the evidence is high to very low. Although we have high confidence in the evidence found for relevant outcomes, the findings are not transferable to vaccinated people and variants that occurred outside the study periods, such as Omicron. Although laboratory studies have shown that tixagevimab/cilgavimab is effective against Omicron, there are no data from clinical studies. The other monoclonal antibodies included in this review were ineffective against Omicron in laboratory studies. Four ongoing studies are likely to change our conclusions and may help us understand how new variants and COVID‐19 vaccines affect the effectiveness of monoclonal antibodies in preventing COVID‐19. How up to date is this evidence? The evidence is up‐to‐date to 27 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hirsch, C; Park, YS; Piechotta, V; Chai, KL; Estcourt, LJ; Monsef, I; Salomon, S; Wood, EM; So-Osman, C; McQuilten, Z; Spinner, CD; Malin, JJ; Stegemann, M; Skoetz, N; Kreuzberger, N", "articleTypes": [], "doi": "10.1002/14651858.CD014945.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "dcd6235d-fc8c-41d3-a6ff-be94a7c6c103", "pmid": "", "title": "Citalopram versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Recent US and UK clinical practice guidelines recommend that second‐generation antidepressants should be considered amongst the best first‐line options when drug therapy is indicated for a depressive episode. Systematic reviews have already highlighted some differences in efficacy between second‐generation antidepressants. Citalopram, one of the first selective serotonin reuptake inhibitors (SSRI) introduced in the market, is one of these antidepressant drugs that clinicians use for routine depression care. Objectives To assess the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with tricyclics, heterocyclics, other SSRIs and other conventional and non‐conventional antidepressants in the acute‐phase treatment of major depression. Search methods We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to February 2012. No language restriction was applied. We contacted pharmaceutical companies and experts in this field for supplemental data. Selection criteria Randomised controlled trials allocating patients with major depression to citalopram versus any other antidepressants. Data collection and analysis Two reviewers independently extracted data. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (the number of patients who responded or remitted), patient acceptability (the number of patients who failed to complete the study) and tolerability (side‐effects). Main results Thirty‐seven trials compared citalopram with other antidepressants (such as tricyclics, heterocyclics, SSRIs and other antidepressants, either conventional ones, such as mirtazapine, venlafaxine and reboxetine, or non‐conventional, like hypericum ). Citalopram was shown to be significantly less effective than escitalopram in achieving acute response (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.08 to 2.02), but more effective than paroxetine (OR 0.65, 95% CI 0.44 to 0.96) and reboxetine (OR 0.63, 95% CI 0.43 to 0.91). Significantly fewer patients allocated to citalopram withdrew from trials due to adverse events compared with patients allocated to tricyclics (OR 0.54, 95% CI 0.38 to 0.78) and fewer patients allocated to citalopram reported at least one side effect than reboxetine or venlafaxine (OR 0.64, 95% CI 0.42 to 0.97 and OR 0.46, 95% CI 0.24 to 0.88, respectively). Authors' conclusions Some statistically significant differences between citalopram and other antidepressants for the acute phase treatment of major depression were found in terms of efficacy, tolerability and acceptability. Citalopram was more efficacious than paroxetine and reboxetine and more acceptable than tricyclics, reboxetine and venlafaxine, however, it seemed to be less efficacious than escitalopram. As with most systematic reviews in psychopharmacology, the potential for overestimation of treatment effect due to sponsorship bias and publication bias should be borne in mind when interpreting review findings. Economic analyses were not reported in the included studies, however, cost effectiveness information is needed in the field of antidepressant trials. Plain language summary Citalopram versus other antidepressants for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Antidepressant drugs remain the mainstay of treatment in moderate‐to‐severe major depression. During the last 20 years, selective serotonin reuptake inhibitors (SSRIs) have progressively become the most commonly prescribed antidepressants. Citalopram, one of the first SSRIs introduced in the market, is the racemic mixture of S‐ and R‐enantiomer. In the present review we assessed the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with all other antidepressants in the acute‐phase treatment of major depression. Thirty‐seven randomised controlled trials (more than 6000 participants) were included in the present review. In terms of efficacy, citalopram was more efficacious than other reference compounds like paroxetine or reboxetine, but worse than escitalopram. In terms of side effects, citalopram was more acceptable than older antidepressants, like tricyclics. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including differences in efficacy and side‐effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cipriani, A; Purgato, M; Furukawa, TA; Trespidi, C; Imperadore, G; Signoretti, A; Churchill, R; Watanabe, N; Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006534.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "dcdd7f42-31ba-426e-b644-0c25422965f3", "pmid": "", "title": "Oral xanthines as maintenance treatment for asthma in children", "imported": false, "abstract": "Abstract - Background Xanthines have been used in the treatment of asthma as a bronchodilator, though they may also have anti‐inflammatory effects. The current role of xanthines in the long‐term treatment of childhood asthma needs to be reassessed. Objectives To determine the efficacy of xanthines (e.g. theophylline) in the maintenance treatment of paediatric asthma. Search methods A search of the Cochrane Airways Group Specialised Register was undertaken with predefined search terms. Searches are current to May 2008. Selection criteria Randomised controlled trials, lasting at least four weeks comparing a xanthine with placebo, regular short‐acting beta‐agonist (SABA), inhaled corticosteroids (ICS), cromoglycate (SCG), ketotifen (KET) or leukotriene antagonist, in children with diagnosed with chronic asthma between 18 months and 18 years old. Data collection and analysis Two reviewers independently selected each study for inclusion in the review and extracted data. Primary outcome was percentage of symptom‐free days. Main results Thirty‐six studies (2838 participants) were included. Xanthine versus placebo (18 studies): The proportion of symptom free days was larger with xanthine compared with placebo (7.97% [95% CI 3.41, 12.53]). Rescue medication usage was lower with xanthine, with no significant difference in symptom scores or hospitalisations. FEV 1 , and PEF were better with xanthine. Xanthine was associated with non ‐ specific side‐effects. Data from behavioural scores were inconclusive. Xanthine versus ICS (four studies) : Exacerbations were less frequent with ICS, but no significant difference on lung function was observed. Individual studies reported significant improvements in symptom measures in favour of steroids, and one study reported a difference in growth rate in favour of xanthine. No difference was observed for study withdrawal or tremor. Xanthine was associated with more frequent headache and nausea. Xanthine versus regular SABA (10 studies): No significant difference in symptoms, rescue medication usage and spirometry. Individual studies reported improvement in PEF with beta‐agonist. Beta‐agonist treatment led to fewer hospitalisations and headaches. Xanthine was associated with less tremor. Xanthine versus SCG (six studies ): No significant difference in symptoms, exacerbations and rescue medication. Sodium cromoglycate was associated with fewer gastro‐intestinal side‐effects than xanthine. Xanthine versus KET (one study): No statistical tests of significance between xanthine and ketotifen were reported. : Xanthine + ICS versus placebo + same dose ICS (three studies) : Results were conflicting due to clinical/methodological differences, and could not be aggregated. Xanthine + ICS versus ICS + leukotriene (one study): Results from one trial One small parallel study did not measure the primary outcome of symptoms; differences between treatments in end of treatment values were not statistically significant. Authors' conclusions Xanthines as first‐line preventer alleviate symptoms and reduce requirement for rescue medication in children with mild to moderate asthma. When compared with ICS they were less effective in preventing exacerbations. Xanthines had similar efficacy as single preventative agent compared with regular SABA and SCG. Evidence on AEs (adverse effects) was equivocal: there was evidence for increased AEs overall, but no evidence that any specific AE (including effects on behaviour and attention) occurred more frequently than with placebo. There is insufficient evidence from available studies to make firm conclusions about the effectiveness of xanthines as add‐on preventative treatment to ICS, and there are no published paediatric studies comparing xanthines with alternatives in this role. Our data suggest that xanthines are only suitable as first‐line preventative asthma therapy in children when ICS are not available. Pre‐trial exposure to the agents assessed may have pre‐disposed the trial populations to tolerate the drug, and may have threatened blinding. They may have a role as add‐on therapy in more severe asthma not controlled by ICS, but further studies are needed to examine this, and to define the risk‐benefit ratio compared with other agents. Plain language summary The effects of oral xanthines (e.g. theophylline) for chronic asthma in children Xanthines (e.g. theophylline) are a group of drugs thought to have helpful preventative and reliever properties in the treatment of asthma in children. This review of studies has established that there is evidence for useful effects of these drugs in terms of symptom relief and lung function, but also some evidence of side‐effects. As a primary preventative therapy , whilst there is evidence that xanthines are effective, this review suggests that more effective alternative treatment options (inhaled steroids) are available. In children with more severe asthma, the role of xanthines as an add‐on therapy has only been assessed in a small number of trials, which report mixed effects. More studies in this area would help to generate a more reliable overview of the effects of treatment in these children. Xanthines are an effective preventative treatment in childhood asthma, but less effective than inhaled steroids, and with a less favourable side‐effect profile. There is insufficient evidence at present to assess their role as \"add‐on\" preventer treatment versus newer alternatives. Some of the trials exposed the children they recruited to a pre‐trial phase of xanthine in order to maintain effective dosing during the trial. This could have made the trial participants less representative of the general population by making them more inclined to tolerate the study drug. This exposure also may have meant that they could recognise what drug they were taking during the blinded phase of the study.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Seddon, P, Bara, A, Lasserson, TJ, Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.083Z" }, { "id": "dce4c101-f4e2-446b-990a-061d7796fdee", "pmid": "", "title": "Vasodilators for primary Raynaud's phenomenon", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Su, KYC, Sharma, M, Kim, HJ, Kaganov, E, Hughes, I, Abdeen, MH, Ng, JH", "articleTypes": [], "doi": "10.1002/14651858.CD006687.pub4 AB - Abstract - Background Numerous agents have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered to be the drugs of choice, evidence of the effects of alternative pharmacological treatments is limited. This is an update of a review first published in 2008. Objectives To assess the effects of drugs with vasodilator effects on primary Raynaud's phenomenon as determined by frequency, severity, and duration of vasospastic attacks; quality of life; adverse events; and Raynauds Condition Score. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trial register to November 16, 2020. Selection criteria We included randomized controlled trials evaluating effects of oral, intravenous, and topical formulations of any drug with vasodilator effects on subjective symptoms, severity scores, and radiological outcomes in primary Raynaud's phenomenon. Treatment with calcium channel blockers was not assessed in this review, nor were these agents compared. Data collection and analysis Two review authors independently selected studies for inclusion, assessed studies using the Cochrane \"Risk of bias\" tool, and extracted study data. Outcomes of interest included frequency, severity, and duration of attacks; quality of life (QoL); adverse events (AEs); and the Raynaud Condition Score (RCS). We assessed the certainty of the evidence using GRADE. Main results We identified seven new studies for this update. In total, we included 15 studies involving 635 participants. These studies compared different vasodilators to placebo. Individual studies used different methods and measures to report different outcomes. Angiotensin‐converting enzyme (ACE) inhibitors Combining data from three studies revealed a possible small increase in the frequency of attacks per week after treatment (captopril or enalapril) compared to placebo (mean difference [MD] 0.79, 95% confidence interval [CI] 0.43 to 1.17; low‐certainty evidence). There was no evidence of a difference between groups in severity of attacks (MD ‐0.17, 95% CI ‐4.66 to 4.31; 34 participants, 2 studies; low‐certainty evidence); duration of attacks (MD 0.54, 95% CI ‐2.42 to 1.34; 14 participants, 1 study; low‐certainty evidence); or AEs (risk ratio [RR] 1.35, 95% CI 0.67 to 2.73; 46 participants, 3 studies; low‐certainty evidence). QoL and RCS were not reported. Alpha blockers Two studies used alpha blockers (buflomedil or moxisylyte). We were unable to combine data due to the way results were presented. Buflomedil probably reduced the frequency of attacks compared to placebo (MD ‐8.82, 95% CI ‐11.04 to ‐6.60; 31 participants, 1 study; moderate‐certainty evidence) and may improve severity scores (MD ‐0.41, 95% CI ‐0.62 to ‐0.30; moderate‐certainty evidence). With moxisylyte, investigators reported fewer attacks (P < 0.02), less severe symptoms (P < 0.01), and shorter duration of attacks, but the clinical relevance of these results is unclear. No evidence of a difference in AEs between buflomedil and placebo groups was noted (RR 1.41, 95% CI 0.27 to 7.28; 31 participants, 1 study; moderate‐certainty evidence). More AEs were observed in participants in the moxisylyte group than in the placebo group. Prostaglandin/prostacyclin analogues One study compared beraprost versus placebo. There was no evidence of benefit for frequency (MD 2.00, 95% CI ‐0.35 to 4.35; 118 participants, low‐certainty evidence) or severity (MD ‐0.06, 95% CI ‐0.34 to 0.22; 118 participants, low‐certainty evidence) of attacks. Overall, more AEs were noted in the beraprost group (RR 1.59, 95% CI 1.05 to 2.42; 125 participants; low‐certainty evidence). This study did not report on duration of attacks, QoL, or RCS. Thromboxane synthase inhibitors One study compared a thromboxane synthase inhibitor (dazoxiben) versus placebo. There was no evidence of benefit for frequency of attacks (MD 0.8, 95% CI ‐1.81 to 3.41; 6 participants; very low‐certainty evidence). Adverse events were not reported in subgroup analyses of participants with primary Raynaud's phenomenon, and the study did not report on duration of attacks, severity of symptoms, QoL, or RCS. Selective serotonin reuptake inhibitors One study compared ketanserin with placebo. There may be a slight reduction in the number of attacks per week with ketanserin compared to placebo (MD ‐14.0, 95% CI ‐27.72 to ‐0.28; 41 participants; very low‐certainty evidence) and reduced severity score (MD ‐133.00, 95% CI ‐162.40 to ‐103.60; 41 participants; very low‐certainty evidence). There was no evidence that ketanserin reduced the duration of attacks (MD ‐4.00, 95% CI ‐14.82 to 6.82; 41 participants; very low‐certainty evidence), or that AEs were increased in either group (RR 1.54, 95% CI 0.89 to 2.65; 41 participants; very low‐certainty evidence). This study did not report on QoL or RCS. Nitrate/nitrate derivatives Four studies compared topical treatments of nitroglycerin or glyceryl trinitrate versus placebo, each reporting on limited outcomes. Meta‐analysis demonstrated no evidence of effect on frequency of attacks per week (MD ‐1.57, 95% CI ‐4.31 to 1.17; 86 participants, 2 studies; very low‐certainty evidence). We were unable to pool any data for the remaining outcomes. Phosphodiesterase inhibitors Three studies compared phosphodiesterase inhibitors (vardenafil, cilostazol or PF‐00489791) to an equivalent placebo. Results showed no evidence of a difference in frequency of attacks (standardized MD [SMD] ‐0.05, 95% CI ‐6.71 to 6.61; 111 participants, 2 studies; low‐certainty evidence), severity of attacks (MD ‐0.03, 95% CI ‐1.04 to 0.97; 111 participants, 2 studies; very low‐certainty evidence), duration of attacks (MD ‐1.60, 95% CI ‐7.51 to 4.31; 73 participants, 1 study; low‐certainty evidence), or RCS (SMD ‐0.8, 95% CI ‐1.74 to 0.13; 79 participants, 2 studies; low‐certainty evidence). Study authors reported that 35% of participants on cilostazol complained of headaches, which were not reported in the placebo group. PF‐00489791 caused 34 of 54 participants to experience AEs versus 43 of 102 participants receiving placebo (RR 1.49). Headache was most common, affecting 14 participants (PF‐00489791) versus nine participants (placebo). Authors' conclusions The included studies investigated several different vasodilators (topical and oral) for treatment of primary Raynaud's phenomenon. Small sample sizes, limited data, and variability in outcome reporting yielded evidence of very low to moderate certainty. Evidence is insufficient to support the use of vasodilators and suggests that vasodilator use may even worsen disease. Plain language summary Vasodilator drugs to reduce the symptoms of primary Raynaud's phenomenon Background Raynaud's phenomenon (RP) is a condition affecting the small blood vessels in the extremities, usually in the fingers but also in the toes and other body parts. It is caused by temporary narrowing of the blood vessels, which leads to color changes with associated numbness, tingling, and pain. Various triggers for this condition are known, such as stress, cold, and use of vibrational hand tools. Conservative measures to control this condition include stopping smoking and maintaining both peripheral and ambient warmth. Medications that dilate the blood vessels such as calcium channel blockers (CCBs) may be used but can have side effects. This review aims to investigate the effectiveness and safety of drugs that dilate the blood vessels other than CCBs. Study characteristics and key results We found seven new studies for this update, bringing the total to 15 (search was good to November 16, 2020). This update now includes other routes of administration such as through the veins (intravenous) and the skin (topical), in contrast to previous reviews, which focused on oral forms of treatment. The studies were published between 1989 and 2013 and involved a total of 635 participants randomly assigned to receive treatment or placebo control. Many studies did not describe various aspects of study methods such as randomization, allocation concealment, and blinding. Treatment duration varied between two weeks and six months.
Angiotensin‐converting enzyme (ACE) inhibitors as a drug class, specifically enalapril and captopril in this review, in general increased the frequency of Raynaud's attacks per week but did not affect the severity of the attacks. Enalapril worsened subjective assessment of improvement, and captopril did not improve subjective outcomes or digital blood flow. Buflomedil showed a small reduction in the frequency and severity of attacks with increased side effects. Beraprost and dazoxiben did not demonstrate any change in frequency or severity of attacks nor in disability score and were associated with increased side effects. Ketanserin did not demonstrate improvement in frequency or duration of attacks nor in digital blood flow but did demonstrate improvement in severity scoring of RP. In a small study, moxisylyte was shown to reduce the frequency and severity of attacks to a small degree but with increased side effects. Topical glyceryl trinitrate did not show any effect on reducing the frequency of attacks per week. One study reported subjective improvement in Raynaud Condition Score (RCS). One small study reported improvements in frequency and severity of attacks as subjective changes. Headaches were the most significant and common side effect of treatment. Phosphodiesterase inhibitors did not cause a reduction in frequency, severity, or duration of attacks and did not improve RCS. One study reported in favor of vardenafil alone to reduce RCS but found that the effect is likely small. One study reported that cilostazol increased the frequency and severity of attacks; more research is needed to confirm this finding. Risk of headache as a side effect of treatment was increased with cilostazol use. PF‐00489791 at a dose of 20 mg was found to slightly improve all subjective outcome measures and RCS. Reliability of the evidence We have very low to moderate confidence in these results, so we cannot make any firm conclusions about the benefit of these drugs for improving symptoms of primary RP. We cannot be confident because of the small numbers of participants involved in studies, issues with how studies were designed, and differences in how they measured whether or not treatments were effective. Therefore, the clinical importance of these results is difficult to assess, especially when placebo response is high. It is also pertinent that the results for each drug class and for individual drugs within each drug class must be interpreted in the context that they may have varying pharmacologic effects in addition to vasodilation. This must be taken into consideration when any conclusions are made about the overall effects of each drug class and/or individual drug.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.786Z" }, { "id": "dcf81041-a931-4893-acea-83d802850d2a", "pmid": "", "title": "Interventions for latent autoimmune diabetes (LADA) in adults", "imported": false, "abstract": "Abstract - Background Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes. Objectives To compare interventions used for LADA. Search methods Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta‐analysis or descriptive methods. Main results Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow‐up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: ‐1.3% (95% confidence interval (CI) ‐2.4 to ‐0.1; P = 0.03, 160 participants, four studies, follow‐up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C‐peptide, but insulin maintained stimulated C‐peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow‐up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C‐peptide levels (20 μg group) were maintained after five years. Short term (three months) follow‐up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C‐peptide levels compared to insulin alone (0.07 µg/L (95% CI ‐0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C‐peptide levels in the vitamin D group but declining fasting C‐peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow‐up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health‐related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes). Authors' conclusions Two studies show SU leading to earlier insulin dependence and a meta‐analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 μg) have been suggested to maintain fasting and stimulated C‐peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA. Plain language summary Interventions for latent autoimmune diabetes (LADA) in adults LADA is a condition that at diagnosis looks like type 2 diabetes (non‐insulin requiring diabetes mellitus) but actually is a type 1 diabetes, where the patient will become insulin requiring. In the UK approximately 3.6% of people who look like they have type 2 diabetes actually have type 1 diabetes, while other studies suggest the prevalence is higher and treatment for these patients may need to be different from that used in type 2 diabetes. 
 We identified 15 publications (10 studies) looking at 1019 patients who were followed between three months to 10 years. We found many of the publications had poor quality of reporting and had small numbers of participants. However, there does seem to be evidence from this review that the drug sulphonylurea (like glibenclamide or glyburide, gliclazide) could make patients insulin dependent sooner and it does not control blood sugar as well as insulin. Therefore, this suggests that this drug should not be a first line treatment for patients with LADA. In addition, insulin combined with vitamin D, or Chinese herbs may maintain natural insulin production better than insulin alone. Similarly, glutamic acid decarboxylase (GAD65) may maintain natural insulin production. However, there was no conclusive evidence that any of the other remaining treatment methods were better than each other. Studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic attacks. This review represents very early days of our understanding of the best way to treat LADA. It is limited by the poor reporting quality of the studies, small sample sizes, no clear single definition of LADA and many of the studies being carried out in different ethnic groups (China, Japan, Cuba, UK, Sweden) with different clinical care systems. 
 None of the publications reported on complications of diabetes, health‐related quality of life, costs or health service utilisation. All but one of the publications reported there were no deaths. 
 In summary, this review demonstrates that insulin treatment may be preferable compared to sulphonylurea treatment but there is little evidence regarding other forms of treatment. Future studies are needed, should have a clear definition of LADA, investigate patient‐important outcomes and use a common method of measuring stimulated C‐peptide (a marker of natural insulin production reflecting improved beta‐cell function of the pancreas).", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Brophy, S; Davies, H; Mannan, S; Brunt, H; Williams, R", "articleTypes": [], "doi": "10.1002/14651858.CD006165.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "dd060d41-a9aa-4b60-82ed-bcc6d7a16e4b", "pmid": "", "title": "Metabolic and bariatric surgery in adults with obesity and diabetes mellitus: a network meta‐analysis", "imported": false, "abstract": "Abstract - Rationale Obesity and its associated comorbidities, particularly type 2 diabetes (T2D), have reached epidemic dimensions globally. Both conditions are related to an increased risk of serious health outcomes and impose a substantial burden on those affected. Metabolic and bariatric surgery (MBS) may offer a therapeutic option for achieving sustained weight loss, improving comorbidities and thereby enhancing long‐term quality of life. Objectives To investigate the medium‐ and long‐term benefits and harms of different MBS procedures compared with each other and to non‐surgical treatment on outcomes relevant to adults with obesity and T2D, and to obtain a clinically meaningful ranking of these interventions by considering both randomised controlled trials (RCTs) and cohort studies. Search methods We searched MEDLINE, Cochrane CENTRAL, CINAHL, LILACS, BASE as well as the WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 25 June 2024. We did not apply any language restrictions. Eligibility criteria We included RCTs and both prospective and retrospective cohort studies with a minimum follow‐up of three years in adults (≥ 18 years) with obesity (body mass index ≥ 30 kg/m² or ethnic‐specific cut‐off values) and T2D. Eligible interventions include MBS procedures (i.e. laparoscopic adjustable gastric banding [LAGB], sleeve gastrectomy [SG], Roux‐en‐Y gastric bypass [RYGB], one‐anastomosis gastric bypass [OAGB], gastric plication [GCP], biliopancreatic diversion with duodenal switch, and their variations) or non‐surgical treatment (i.e. lifestyle intervention, medical treatment [LI/MT]). Outcomes Critical outcomes were medium‐ (≥ 3 to < 5 years) and long‐term (≥ 5 years) weight loss (%), waist circumference (cm), T2D remission (complete, partial), and serious adverse events (SAE). Important outcomes included all‐cause mortality, T2D complications, glycaemic control (glycated haemoglobin (HbA1c) in %) and health‐related quality of life (HRQoL). Risk of bias We used the Risk of Bias 2 (RoB 2) tool for RCTs and Risk Of Bias In Non‐randomized Studies – of Interventions (ROBINS‐I) for cohort studies. Synthesis methods We performed random‐effects network meta‐analyses based on the frequentist approach and ranked treatments by P scores. We rated the certainty of evidence according to the GRADE approach for long‐term outcomes (≥ 5 years). Included studies We included 18 studies (with 70 reports) with 15,282 participants in this review. Of these, 13 studies were RCTs (n = 911) and five were cohort studies (n = 14,371). Two RCTs compared MBS with LI/MT, ten compared two or three different MBS procedures and one with a 3‐arm design investigated two different MBS procedures as well as LI/MT. All cohort studies compared different MBS procedures. The networks were based on the following MBS procedures: RYGB, SG, OAGB, LAGB, GCP, and LI/MT. Synthesis of results NMA results (8 RCTs; n = 491) suggest greater long‐term weight loss after RYGB compared to LI/MT (MD ‐16.95%; 95% CI ‐24.19 to ‐9.71). OAGB (MD ‐12.10%; 95% CI ‐22.85 to ‐1.34) and SG (MD ‐9.40 %; 95% CI ‐17.45 to ‐1.34) may also result in greater weight loss compared to LI/MT, but the evidence is very uncertain. A reduction in waist circumference at long‐term follow‐up (6 RCTs; n = 348) is likely higher after RYGB compared to LI/MT (MD ‐12.34 cm; 95% CI ‐17.88 to ‐6.81). OAGB (MD: ‐13.28 cm; 95% CI ‐22.04 to ‐4.53) and SG (MD‐9.08 cm; 95% CI ‐15.74 to ‐2.43) may also lead to a higher reduction in waist circumference compared to LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effects of MBS procedures compared to LI/MT on long‐term complete T2D remission (9 RCTs; n = 536). All MBS procedures (8 RCTs; n = 588) may result more often in partial T2D remissions than LI/MT, but the evidence is very uncertain. The evidence is very uncertain about the effect of all MBS procedures compared to LI/MT on SAE (9 RCTs; n = 598) and all‐cause mortality in the long term (7 RCTs; n = 520). RYGB may reduce total long‐term T2D complications compared to LI/MT (Rate ratio (RaR) 0.17; 95% CI 0.03 to 0.89; 5 RCTs; n = 356), but the evidence is very uncertain. Based on NMA results (10 RCTs; n = 612), RYGB may reduce HbA1c compared to LI/MT (MD ‐1.44%; 95% CI ‐2.26 to ‐0.63). OAGB (MD ‐2.01%; 95%CI ‐3.42 to ‐0.60) and SG (MD ‐1.01%; 95%CI ‐1.94 to ‐0.08) may also reduce HbA1c compared to LI/MT, but the evidence is every uncertain. Both RYGB and SG may increase mental and physical components of HRQoL compared to LI/MT (both 2 RCTs; n = 118), but evidence is very uncertain. The inclusion of cohort studies in the analyses of percentage weight loss, partial type 2 diabetes remission, SAE, and all‐cause mortality confirmed the main findings. For most outcomes, the main reasons for downgrading certainty of evidence were related to risk of bias and imprecision. Authors' conclusions In people with obesity and T2D, RYGB, OAGB and, to a lesser extent, SG may lead to long‐term improvements in body weight, waist circumference, partial T2D remission, and HbA1c compared with LI/MT. However, due to imprecise results, the magnitude of the effects often remains uncertain or very uncertain. For other outcomes, especially complete T2D remission, SAE, all‐cause mortality and T2D complications, the evidence is mainly very uncertain, due to a low numbers of participants and events. When interpreting these findings, it should be noted that cohort studies were not, as originally planned, included in the certainty of evidence assessment, as these studies were judged to have a high or critical risk of bias. Larger and well‐designed studies may contribute to diminishing the existing uncertainties and enhancing our confidence in the findings. Funding This Cochrane review was funded by the German Federal Ministry of Education and Research (BMBF) (grant number: 01KG2201). Registration Protocol (2024) DOI: https://doi.org/10.1002/14651858.CD015622 PROSPERO ID: CRD42023457363 Plain language summary Review question What are the long‐term benefits and risks of different types of weight loss surgery (also called metabolic and bariatric surgery) to treat obesity and type 2 diabetes in adults? Key messages In people with obesity and type 2 diabetes, gastric (stomach) bypass (i.e. Roux‐en‐Y gastric bypass and one‐anastomosis gastric bypass) may be most beneficial for improving body weight, waist circumference, type 2 diabetes status and long‐term blood sugar levels at least five years after surgery, but for one‐anastomosis gastric bypass, we are very uncertain about the results. It is unclear whether the different surgical procedures have an effect on risks such as serious unwanted health effects and death from any cause at least five years after surgery. Larger and well‐designed studies may help reduce the existing uncertainties and increase our confidence in the findings. What are obesity and type 2 diabetes? 
Obesity is a condition with too many fat deposits that can damage health. In type 2 diabetes, the body has difficulty controlling blood sugar levels because the hormone insulin does not work properly. Type 2 diabetes often occurs in people with obesity, and both conditions increase the risk of premature death and other health problems, such as cardiovascular disease. How are obesity and type 2 diabetes treated? Lifestyle interventions such as nutrition, exercise, and behavioural programmes, along with medicines, are often used first for weight loss and improvement of diabetes status. When these do not work well, metabolic and bariatric surgery may be considered as an additional treatment option. There are a number of different types of bariatric surgery: gastric (stomach) banding; gastric sleeve (removal of a part of the stomach); Roux‐en‐Y gastric bypass (RYGB); one‐anastomosis gastric bypass, or mini‐gastric bypass; gastric plication (folding to make the stomach smaller); biliopancreatic diversion with duodenal switch. What did we want to find out? Which of the different types of surgery are the safest and most beneficial ones by comparing them with each other and with lifestyle and medication therapy regarding their long‐term (at least 5 years follow‐up) benefits and risks. Whether these surgical procedures improve body weight, waist circumference, type 2 diabetes status, long‐term blood sugar levels, and quality of life at least five years after surgery. Whether surgery affects serious unwanted health effects, death from any cause, and type 2 diabetes complications over this period. What did we do? 
We searched for studies involving people with obesity and type 2 diabetes. We included studies that compared at least two different surgical procedures, or surgery with lifestyle and medication treatment. We summarised and compared all treatments using a method called network meta‐analysis, and we rated our confidence in the results based on factors such as study methods and sample size. What did we find? 
We found 18 studies, including 15,282 people with obesity and type 2 diabetes. In 13 of these studies (including 911 people), participants were assigned randomly to two or more treatment groups. This is the best way to ensure that groups of people are similar. Five studies (with 14,371 people) used ‘real‐life’ observational data. The studies investigated surgical procedures such as gastric band, gastric sleeve, Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, and gastric plication. We found that: Roux‐en‐Y gastric bypass, may improve body weight and likely reduce waist circumference compared with lifestyle and medication treatment in the long term. One‐anastomosis gastric bypass and, to a lesser extent, gastric sleeve, may also improve body weight and waist circumference, but we are very uncertain about the results. Roux‐en‐Y gastric bypass, one‐anastomosis gastric bypass, gastric sleeve, and gastric band may improve type 2 diabetes status, but we are very uncertain about the results. It is unclear whether the types of surgery have an effect on serious unwanted health effects or death from any cause. Roux‐en‐Y gastric bypass may reduce type 2 diabetes complications in the long term compared to non‐surgical treatments, but we are very uncertain about the results. Roux‐en‐Y gastric bypass may improve blood sugar levels compared to non‐surgical treatments. One‐anastomosis gastric bypass and gastric sleeve may also improve blood sugar levels, but we are very uncertain about the results. RYGB and SG may lead to a greater increase in health‐related quality of life than non‐surgical treatments, but again, we are very uncertain about the results. What are the limitations of the evidence? 
Our confidence in the evidence is often low to very low because the studies included only small numbers of people, and the results for some outcomes, especially serious unwanted health effects, death from any cause, and type 2 diabetes complications, were based on very few events. Moreover, for several surgical procedures, there were not enough studies to be certain about the outcomes. It is important to note that rating our confidence in findings was based only on studies in which participants were randomly assigned to groups and did not include observational studies. How up to date is this evidence? 
This evidence is up to date as of June 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Kiesswetter, E; Gorenflo, L; Schwarzer, G; Stadelmaier, J; Wallerer, S; Marjanovic, G; Fink, JM; Lehane, C; Metzendorf, MI; Meerpohl, J; Schwingshackl, L", "articleTypes": [], "doi": "10.1002/14651858.CD015622.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "dd1ba880-e4f4-46f3-aa6d-78b2e7aa298e", "pmid": "", "title": "Local interventions for the management of alveolar osteitis (dry socket)", "imported": false, "abstract": "Abstract - Background Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012. Objectives To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction. Search methods An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies. Selection criteria We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews. Data collection and analysis We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random‐effects models. For some of the split‐mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence. Main results We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate‐certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively. Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate‐certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low‐certainty evidence). The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low‐certainty evidence). A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) ‐1.40, 95% CI ‐1.75 to ‐1.04; P < 0.00001; 2 studies, 80 participants; very low‐certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects. Authors' conclusions Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate‐certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. Plain language summary What treatments can be used to prevent and treat alveolar osteitis (dry socket)? Key messages ‐ Rinsing with chlorhexidine mouthwash before a dental extraction or beginning 24 hours after may help to prevent a dry socket.
‐ Placing a chlorhexidine gel directly into the socket immediately after tooth extraction may help to prevent a dry socket.
‐ Chlorhexidine rinses cause some minor adverse (unwanted) effects; chlorhexidine intrasocket gels do not appear to cause adverse effects.
‐ Alvogyl reduces the pain of a dry socket when compared to zinc oxide eugenol, but the evidence for this is very uncertain.
‐ Alvogyl does not appear to cause unwanted effects.
‐ We need future studies to strengthen the evidence and investigate the best ways to prevent and treat dry socket in all teeth. What is dry socket? Dry socket is a painful condition that sometimes arises after a tooth has been extracted and is more likely to occur following extraction of wisdom teeth in the lower jaw. What causes dry socket? It is thought to be linked to the loss of some or all of the blood clot that forms at the bottom of a tooth socket after a tooth is taken out. How can we prevent dry socket? An option for prevention of dry socket is to reduce debris and the bacterial load in the mouth, though dry socket is not bacterial in origin. People with poor oral hygiene (food debris and plaque) are at greater risk of dry socket. Improved oral hygiene and rinsing before a dental extraction or beginning 24 hours after may reduce the likelihood of dry socket. How can we treat dry socket ? Options for treating dry socket largely focus on reducing pain locally around the tooth extraction site by placing an obtundent (a soothing medicated dressing). What did we want to find out ? We wanted to find out if antiseptic rinses, gels, or healing patches could help to prevent dry socket. We also wanted to find out if placing a medicated dressing could treat a dry socket and whether any unwanted side effects were produced. What did we do? We searched for studies that compared antiseptic rinses or intrasocket gels with a placebo (dummy) rinse or nothing and a placebo (dummy) intrasocket gel or nothing. To find the best way to treat dry socket we searched for studies that compared different soothing agents with a placebo (dummy) with other soothing agents or with nothing. We compared the results of the studies and summarised the findings. We made an assessment of our confidence in the evidence based on the design of the study and the number of patients recruited. What did we find? We identified 49 trials; 39 trials (6219 participants) investigated prevention of dry socket and 10 trials (552 participants) investigated the treatment of dry socket. We found that: ‐ rinsing both before and after tooth extraction (commencing 24 hours after extraction) with chlorhexidine gluconate rinse (at 0.12% and 0.2% strength) probably results in a reduction in dry socket;
‐ placing chlorhexidine gel (0.2% strength) in the socket of an extracted tooth probably results in a reduction in dry socket;
‐ chlorhexidine rinses and gels are equally effective at reducing dry socket, but the evidence for this comparison is very uncertain;
‐ chlorhexidine rinses produced some minor unwanted effects; chlorhexidine intrasocket gels appeared to produce no unwanted effects;
‐ there was a small amount of evidence of very low certainty from two studies that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. This evidence relates to the old formulation of Alvogyl which is no longer available. It should be noted that the formulation of Alvogyl has changed, it is now called Alveogyl. Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. What are the limitations of the evidence? The main limitation of the evidence are that studies: ‐ reported mostly on tooth extractions involving lower wisdom teeth;
‐ were undertaken in ways that introduced errors in the conduct of the study leading to errors in the results; and
‐ produced imprecise results when they were combined. Due to these errors we have some confidence in the results relating to chlorhexidine rinses and gels but further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. How up to date is this evidence? The search for existing studies was completed by 28 September 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Daly, BJM; Sharif, MO; Jones, K; Worthington, HV; Beattie, A", "articleTypes": [], "doi": "10.1002/14651858.CD006968.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "dd24484c-6a34-473a-b8e6-257aa8f4cebd", "pmid": "", "title": "Antibiotic treatment for the sexual partners of women with bacterial vaginosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Amaya‐Guio, J, Viveros‐Carreño, DA, Sierra‐Barrios, EM, Martinez‐Velasquez, MY, Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD011701.pub2 AB - Abstract - Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of BV after antibiotic treatment. Therefore, the treatment of sexual partners could decrease the recurrence of infection and possibly the burden of the disease. Objectives To assess the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for BV. Search methods We searched the Cochrane Sexually Transmitted Infections Group Specialized Register (23 July 2016), CENTRAL (1991 to 23 July 2016), MEDLINE (1946 to 23 July 2016), Embase (1974 to 23 July 2016), LILACS (1982 to 23 July 2016), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (23 July 2016), ClinicalTrials.gov (23 July 2016) and the Web of Science™ (2001 to 23 July 2016). We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) that compared the concurrent use of any antibiotic treatment with placebo, no intervention or any other intervention by the sexual partners of women treated for BV. Data collection and analysis Three review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach. Main results Seven RCTs (1026 participants) met our inclusion criteria, and pharmaceutical industry funded four of these trials. Five trials (854 patients) compared any antibiotic treatment of sexual partners with placebo. Based on high quality evidence, antibiotic treatment does not increase the rate of clinical or symptomatic improvement in women during the first week (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.96 to 1.03; 712 participants, four studies; RR 1.06, 95% CI 1.00 to 1.12; 577 patients, three studies, respectively), between the first and fourth week (RR 1.02, 95% CI 0.94 to 1.11; 590 participants, three studies; RR 0.93, 95% CI 0.84 to 1.03; 444 participants, two studies; respectively) or after the fourth week (RR 0.98, 95% CI 0.90 to 1.07; 572 participants, four studies; RR 1.03, 95% CI 0.90 to 1.17; 296 participants, two studies; respectively). Antibiotic treatment does not led to a lower recurrence during the first and fourth week (RR 1.28, 95% CI 0.68 to 2.43; 218 participants, one study; low quality evidence) or after the fourth week of treatment (RR 1.00, 95% CI 0.67 to 1.52; 372 participants, three studies; low quality evidence) in women, but increases the frequency of adverse events (most frequently gastrointestinal symptoms) reported by sexual partners (RR 2.55, 95% CI 1.55 to 4.18; 477 participants, three studies; low quality evidence).
 
 Two trials (172 participants) compared any antibiotic treatment for sexual partners with no intervention. When we compared it with no intervention, the effects of antibiotic treatment on recurrence rate after the fourth week (RR 1.71, 95% CI 0.65 to 4.55; 51 participants, one study), clinical improvement between the first and fourth week (RR 0.93, 95% CI 0.70 to 1.25; 152 participants, two studies) and symptomatic improvement after the fourth week (RR 0.66, 95% CI 0.39 to 1.11; 70 participants, one study) were imprecise and there were no differences between groups. We downgraded the quality of the evidence to low or very low. Authors' conclusions High quality evidence shows that antibiotic treatment for sexual partners of women with BV, compared with placebo, does not increase the rate of clinical or symptomatic improvement during the first, between the first and fourth or after the fourth week into the women. Low quality evidence suggests that antibiotic treatment does not led to a lower recurrence rate during the first and fourth or after the fourth week of treatment into the women, but increases the frequency of adverse events reported by sexual partners. Finally, compared with no intervention, antibiotic treatment does not decrease the recurrence rate after the fourth week and does not increase the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week into the women, respectively. Plain language summary Antibiotic treatment for the sexual partners of women with bacterial vaginosis Review question We assessed the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for bacterial vaginosis (BV). Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of infection after antibiotic treatment. Therefore, the treatment of sexual partners could offer the advantages of decreasing the recurrence of infection and possibly reducing the burden of the disease. Trial characteristics Cochrane researchers searched the available literature up to the 23 July 2016 and included seven trials with 1026 participants. The trials included sexually‐active non‐pregnant women between 17 and 56 years of age, either single or married, with symptomatic BV. Four studies only included women involved into a monogamous heterosexual relationship and there was no information about this for the remaining trials. Six trials used 5‐nitroimidazoles to treat the sexual partner, four trials used metronidazole and two trials used tinidazole; only one study used a lincosamide for treatment. Five trials compared antibiotic versus placebo (854 participants) and two trials compared antibiotic treatment with no intervention (172 participants). Pharmaceutical companies funded four of the included trials. Key results Compared with placebo, antibiotic treatment for the sexual partners of women treated for BV had no effects on clinical or symptomatic improvement in women, regardless of the time period over which the trials assessed these outcomes (during the first, between the first and fourth, or after the fourth week). Furthermore, antibiotic treatment of the sexual partner may have no effect on the recurrence of BV up to 12 weeks after treatment, but may increase the frequency of minor adverse events reported by sexual partners. Compared with no intervention, treatment of sexual partners of women with BV may have no effect on decreasing the recurrence rate or over the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week, respectively. Quality of evidence The quality of evidence was high for the outcomes of clinical and symptomatic improvement. The quality of evidence was very low for recurrence due to some limitations regarding risk of bias and imprecision.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.762Z" }, { "id": "dd245632-3e95-4a1c-8d31-b151efb3147c", "pmid": "", "title": "Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants)", "imported": false, "abstract": "Abstract - Background 'Immediate' implants are placed in dental sockets just after tooth extraction. 'Immediate‐delayed' implants are those implants inserted after weeks up to about a couple of months to allow for soft tissue healing. 'Delayed' implants are those placed thereafter in partially or completely healed bone. The potential advantages of immediate implants are that treatment time can be shortened and that bone volumes might be partially maintained thus possibly providing good aesthetic results. The potential disadvantages are an increased risk of infection and failures. After implant placement in postextractive sites, gaps can be present between the implant and the bony walls. It is possible to fill these gaps and to augment bone simultaneously to implant placement. There are many techniques to achieve this but it is unclear when augmentation is needed and which could be the best augmentation technique. Objectives To evaluate success, complications, aesthetics and patient satisfaction between 'immediate', 'immediate‐delayed' and 'delayed' implants. To evaluate whether and when augmentation procedures are necessary and which is the most effective technique. Search methods The Cochrane Oral Health Group's Trials Register (to 2 June 2010), CENTRAL ( The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 ‐ 2 June 2010) and EMBASE via OVID (1980 ‐ 2 June 2010) were searched. Several dental journals were handsearched. Selection criteria Randomised controlled trials (RCTs) comparing immediate, immediate‐delayed, and delayed implants, or comparing various bone augmentation procedures around the inserted implants, reporting the outcome of the interventions to at least 1 year after functional loading. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Trial authors were contacted for any missing information. Results were expressed as random‐effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). The statistical unit of the analysis was the patient. Main results Fourteen eligible RCTs were identified but only seven trials could be included. Four RCTs evaluated implant placement timing. Two RCTs compared immediate versus delayed implants in 126 patients and found no statistically significant differences. One RCT compared immediate‐delayed versus delayed implants in 46 patients. After 2 years patients in the immediate‐delayed group perceived the time to functional loading significantly shorter, were more satisfied and independent blinded assessor judged the level of the perimplant marginal mucosa in relation to that of the adjacent teeth as more appropriate (RR = 1.68; 95% CI 1.04 to 2.72). These differences disappeared 5 years after loading but significantly more complications occurred in the immediate‐delayed group (RR = 4.20; 95% CI 1.01 to 17.43). One RCT compared immediate with immediately delayed implants in 16 patients for 2 years and found no differences. Three RCTs evaluated different techniques of bone grafting for implants immediately placed in extraction sockets. No statistically significant difference was observed when evaluating whether autogenous bone is needed in postextractive sites (1 trial with 26 patients) or which was the most effective augmentation technique (2 trials with 56 patients). Authors' conclusions There is insufficient evidence to determine possible advantages or disadvantages of immediate, immediate‐delayed or delayed implants, therefore these preliminary conclusions are based on few underpowered trials often judged to be at high risk of bias. There is a suggestion that immediate and immediate‐delayed implants may be at higher risks of implant failures and complications than delayed implants on the other hand the aesthetic outcome might be better when placing implants just after teeth extraction. There is not enough reliable evidence supporting or refuting the need for augmentation procedures at immediate implants placed in fresh extraction sockets or whether any of the augmentation techniques is superior to the others. Plain language summary Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants) Dental implants can be placed in sockets just after tooth extraction (immediate implants) or after a couple of weeks up to a couple of months (immediate‐delayed implants) or thereafter (delayed implants). This review looked at which was the best time to place dental implants and whether it would be advantageous to augment sites with gaps present at implant placement. It also tried to determine the most effective bone augmentation procedure. The seven identified studies included too few patients to answer the questions. Four studies evaluated which is the best time to place implants. One study evaluated whether bone grafting is advantageous at implant placement and two studies evaluated which are the best grafting techniques. There is currently too little evidence to draw any reliable conclusions, however, the aesthetic outcome could be slightly better when placing implants early after tooth extraction, though early placed implants might be at a higher risk of failure. There is not enough evidence supporting or refusing the need of bone augmentation when extracted teeth are immediately replaced with dental implants, nor it is known whether any augmentation procedure is better than the others. Bone substitutes (anorganic bovine bone) can be used instead of self generated (autogenous) bone graft.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Esposito, M; Grusovin, MG; Polyzos, IP; Felice, P; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD005968.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "dd2c6a10-942c-4f96-949f-1403df0d3d7a", "pmid": "", "title": "Paracetamol (acetaminophen) for prevention or treatment of pain in newborns", "imported": false, "abstract": "Abstract - Background Newborn infants have the ability to experience pain. Hospitalised infants are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Objectives To determine the efficacy and safety of paracetamol for the prevention or treatment of procedural/postoperative pain or pain associated with clinical conditions in neonates. To review the effects of various doses and routes of administration (enteral, intravenous or rectal) of paracetamol for the prevention or treatment of pain in neonates. Search methods We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 4), MEDLINE via PubMed (1966 to 9 May 2016), Embase (1980 to 9 May 2016), and CINAHL (1982 to 9 May 2016). We searched clinical trials' databases, Google Scholar, conference proceedings, and the reference lists of retrieved articles. Selection criteria We included randomised and quasi‐randomised controlled trials of paracetamol for the prevention/treatment of pain in neonates (≤ 28 days of age). Data collection and analysis Two review authors independently extracted data from the articles using pre‐designed forms. We used this form to decide trial inclusion/exclusion, to extract data from eligible trials and to request additional published information from authors of the original reports. We entered and cross‐checked data using RevMan 5 software. When noted, we resolved differences by mutual discussion and consensus. We used the GRADE approach to assess the quality of evidence. Main results We included nine trials with low risk of bias, which assessed paracetamol for the treatment of pain in 728 infants. Painful procedures studied included heel lance, assisted vaginal birth, eye examination for retinopathy of prematurity assessment and postoperative care. Results of individual studies could not be combined in meta‐analyses as the painful conditions, the use of paracetamol and comparison interventions and the outcome measures differed. Paracetamol compared with water, cherry elixir or EMLA cream (eutectic mixture of lidocaine and prilocaine) did not significantly reduce pain following heel lance. The Premature Infant Pain Profile score (PIPP) within three minutes following lancing was higher in the paracetamol group than in the oral glucose group (mean difference (MD) 2.21, 95% confidence interval (CI) 0.72 to 3.70; one study, 38 infants). Paracetamol did not reduce \"modified facies scores\" after assisted vaginal birth (one study, 119 infants). In another study (n = 123), the Échelle de Douleur et d'Inconfort du Nouveau‐Né score at two hours of age was significantly higher in the group that received paracetamol suppositories than in the placebo suppositories group (MD 1.00, 95% CI 0.60 to 1.40). In that study, when infants were subjected to a heel lance at two to three days of age, Bernese Pain Scale for Neonates scores were higher in the paracetamol group than in the placebo group, and infants spent a longer time crying (MD 19 seconds, 95% CI 14 to 24). For eye examinations, no significant reduction in PIPP scores in the first or last 45 seconds of eye examination was reported, nor at five minutes after the eye examination. In one study (n = 81), the PIPP score was significantly higher in the paracetamol group than in the 24% sucrose group (MD 3.90, 95% CI 2.92 to 4.88). In one study (n = 114) the PIPP score during eye examination was significantly lower in the paracetamol group than in the water group (MD −2.70, 95% CI −3.55 to 1.85). For postoperative care following major surgery, the total amount of morphine (µg/kg) administered over 48 hours was significantly less among infants assigned to the paracetamol group than to the morphine group (MD −157 µg/kg, 95% CI −27 to −288). No adverse events were noted in any study. The quality of evidence according to GRADE was low. Authors' conclusions The paucity and low quality of existing data do not provide sufficient evidence to establish the role of paracetamol in reducing the effects of painful procedures in neonates. Paracetamol given after assisted vaginal birth may increase the response to later painful exposures. Paracetamol may reduce the total need for morphine following major surgery, and for this aspect of paracetamol use, further research is needed. Plain language summary Paracetamol (acetaminophen) for prevention or treatment of pain in newborns Review question: Is paracetamol effective and safe for the prevention or treatment of procedural or postoperative pain or pain associated with clinical conditions in newborn infants? Background: Newborn infants have the ability to experience pain. Newborns treated in neonatal intensive care units are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Study characteristics: We identified nine studies that reported comparisons in 728 infants of paracetamol versus placebo or other pain‐reducing interventions. The literature search was updated in May 2016. Key results: Paracetamol for heel lance did not reduce pain compared with placebo (water or cherry elixir) or compared with EMLA cream (eutectic mixture of lidocaine and prilocaine). Paracetamol use was associated with a stronger response to pain than was seen with glucose. Paracetamol did not reduce pain in infants exposed to vacuum extraction or forceps at birth, and their response to a subsequent heel lance at two to three days of life was increased compared with placebo. For eye examination, paracetamol was effective in reducing pain compared with water in one study, but the pain response was stronger among paracetamol‐treated infants than in infants given 24% sucrose. In infants treated with paracetamol and morphine compared with morphine alone, the total amount of morphine required during the first 48 hours following major surgery to the chest or the abdomen was less in the paracetamol group. Paracetamol did not significantly reduce pain during heel lance. Paracetamol following assisted birth may increase the response to later exposure to painful interventions. Paraetamol may reduce the total need for morphine following major surgery, and further research is needed into this aspect of paracetamol use. Quality of evidence: In general the studies were of good quality but the numbers of infants enrolled in the different studies were small. The overall quality of evidence was low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ohlsson, A, Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD011219.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.141Z" }, { "id": "dd3b6b92-d9c9-437c-bf93-bb05069252c6", "pmid": "", "title": "Topical antibiotics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection (involving more than one micro‐organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms are ear discharge and hearing loss. Topical antibiotics, the most common treatment for CSOM, aim to kill or inhibit the growth of micro‐organisms that may be responsible for the infection. Antibiotics can be used alone or with other treatments for CSOM, such as antiseptics or ear cleaning (aural toileting). This is an update of a Cochrane review first published in 2020 and one of a suite of seven reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To evaluate the benefits and harms of topical antibiotics (without steroids) for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials with at least a one week of follow‐up involving adults and children with chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antibiotic(s) of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic compared to placebo or no intervention, and compared to another topical antibiotic (e.g. topical antibiotic A versus topical antibiotic B). Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks and up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This update found one new study (100 participants). Overall, we included 18 studies with 1783 participants (in 16 studies), plus 108 ears that could not be accounted for in participant numbers (in two studies). 1. Topical antibiotics versus placebo or no treatment (with aural toilet in both arms and no other background treatment) One study (50 participants, data unavailable for 15 participants) compared a topical antibiotic (ciprofloxacin) with placebo (saline). All participants received aural toilet. Topical ciprofloxacin may increase resolution of discharge at one to up to two weeks compared with placebo (84% with antibiotic versus 12% with placebo; risk ratio (RR) 6.74, 95% confidence interval (CI) 1.82 to 24.99; 35 participants; very low‐certainty evidence). The study authors reported \"no medical side‐effects and worsening of audiological measurements related to this topical medication were detected.\" 2. Topical antibiotics versus placebo or no treatment (with use of oral antibiotics in both arms) Four studies (438 participants) compared topical antibiotics versus no treatment, with oral antibiotics in both arms. These compared topical ciprofloxacin to no treatment (3 studies, 190 participants) or topical ceftizoxime to no treatment (1 study, 248 participants). In each study, all participants received the same antibiotic systemically (oral ciprofloxacin or injected ceftizoxime). In at least one study, all participants received aural toilet. There were no useable data comparing topical ceftizoxime to no treatment. Topical antibiotics in addition to systemic antibiotics may increase resolution of ear discharge at one to up to two weeks compared with systemic antibiotics alone (resolution of discharge occurring in 88% with topical antibiotics versus 60% without topical antibiotics; RR 1.47, 95% CI 1.14 to 1.88; 1 study, 100 participants; low‐certainty evidence). One study (40 participants) stated \"no side effect was recorded in any patient\" (low‐certainty evidence). 3. Comparisons of different topical antibiotics Eight studies (794 participants, plus 40 ears) compared aminoglycosides (gentamicin, neomycin, or tobramycin) with quinolones (ciprofloxacin or ofloxacin). Resolution of discharge at one to up to two weeks may be higher in the quinolones group, but the evidence is very uncertain (RR 1.92, 95% CI 1.00 to 3.67; 7 studies, 794 participants; very low‐certainty evidence). There was considerable heterogeneity (I 2 = 97%). One study (308 participants) stated there were no differences between the different groups for resolution of ear discharge after four weeks (low‐certainty evidence). The evidence is very uncertain about the effects of topical antibiotics on ear pain (1 study reported no differences between groups). The evidence is very uncertain about the effects of topical antibiotics on hearing loss (2 studies reported no differences between groups). 4. Other comparisons We assessed five studies (501 participants, plus 68 ears) over the following three additional comparisons: quinolones versus aminoglycosides/polymyxin B with/without gramicidin, aminoglycosides versus trimethoprim‐sulphacetamide‐polymixin B, and rifampicin versus chloramphenicol. However, these results have not been included in the abstract. Authors' conclusions We are very uncertain about the effectiveness of topical antibiotics in improving resolution of ear discharge in people with CSOM because of the limited amount of low‐ or very low‐certainty evidence available. This was mostly due to risk of bias and imprecision. However, amongst this uncertainty, there is some evidence to suggest that the use of topical antibiotics may be effective when compared to placebo, or when used in addition to a systemic antibiotic. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine whether quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, harmful effects were poorly reported. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and harms of using topical antibiotics to treat chronic suppurative otitis media? Key messages – We are uncertain whether topical antibiotics reduce ear discharge of people with swelling and infection of the middle ear (called chronic suppurative otitis media). – Topical antibiotics may reduce ear discharge compared to placebo (a salt solution), but we are very uncertain. Topical antibiotics used in addition to an antibiotic given by mouth may reduce ear discharge. – Overall, we are very uncertain which type of topical antibiotic is the most effective. What is chronic suppurative otitis media? Chronic suppurative otitis media, also known as chronic otitis media, is a swelling and infection of the middle ear that lasts for two weeks or more. People with chronic suppurative otitis media usually have ear discharge that is difficult to get rid of or keeps coming back (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Topical antibiotics (administered into the ear canal as ear drops, ointments, sprays, or creams) are the most commonly used treatment for chronic suppurative otitis media. Topical antibiotics kill or stop the growth of the bacteria (germs) that may be responsible for the infection. Topical antibiotics can be used on their own or be added to other treatments for chronic suppurative otitis media, such as antiseptics (which also kill germs) or ear cleaning (aural toileting) or systemic antibiotics (antibiotics taken either by mouth or by an injection into a muscle or vein). What was the aim of this review? We wanted to find out how effective topical antibiotics are for people with chronic suppurative otitis media, and whether they cause unwanted effects. We also wanted to know whether one type of topical antibiotic was more beneficial or harmful than any other. In particular, we wanted to know whether topical antibiotics stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found one new study (100 participants). Overall, we found 18 studies examining at least 1783 people, but it was difficult to determine precisely how many people were included as some studies did not clearly report the number. Two studies included \"mainly children,\" three included only adults, whilst the remainder appeared to include both children and adults. None of the studies reported the inclusion of people considered at high risk of having chronic suppurative otitis media (for example, people with cleft palate (where the roof of the mouth of a baby does not join together during pregnancy) or Down's syndrome; or people whose immune system does not work well enough to fight germs). The studies used different types of antibiotics and combinations of antibiotics. Comparison of topical antibiotics to placebo or no treatment One study (50 people) compared topical antibiotics to a saline (salt water) ear wash. Topical antibiotics may reduce ear discharge more than the saline ear wash when assessed one to up to two weeks after treatment, but we are very uncertain. The evidence is very uncertain about unwanted effects and worsening of hearing measurements. The study did not measure quality of life and reported that there were no serious complications. Comparison of topical antibiotics in addition to systemic (oral or injected) antibiotics Four studies (438 people) compared treatment with topical antibiotic (ciprofloxacin) drops in addition to a systemic (oral or injected) antibiotic, but one study did not contribute data. Topical plus oral antibiotics may reduce ear discharge more than oral antibiotics alone at one to up to two weeks and two to up to four weeks. One study stated there were no unwanted effects. The studies did not measure quality of life and did not report any serious complications. Comparisons of different topical antibiotics Eight studies (794 participants plus 40 ears) compared an aminoglycoside antibiotic (gentamicin, neomycin, or tobramycin) with a quinolone antibiotic (ciprofloxacin or ofloxacin). Quinolones may reduce ear discharge better than aminoglycosides, but the evidence is very uncertain. One study (100 people) measured ear pain and reported no difference between the groups, but the evidence is very uncertain. Two studies measured hearing loss, but the evidence is very uncertain. What are the limitations of the evidence? There were several limitations with the studies. For example, the results varied widely between studies, there were small numbers of people included, there was a lack of recent data, and limited information on groups of people who are more likely to have chronic suppurative otitis media. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Brennan-Jones, CG, Head, K, Chong, LY, Daw, J, Veselinović, T, Schilder, AGM, Bhutta, MF", "articleTypes": [], "doi": "10.1002/14651858.CD013051.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.789Z" }, { "id": "dd3bb9c9-30fd-4950-b803-6469e0708bbf", "pmid": "", "title": "Blood pressure lowering efficacy of diuretics as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Diuretics are widely prescribed for hypertension not only as a first‐line drug but also as a second‐line drug. Therefore, it is essential to determine the effects of diuretics on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a second‐line drug. Objectives To quantify the additional reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of diuretic therapy as a second‐line drug in patients with primary hypertension Search methods CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (1966‐July 2008), EMBASE (1988‐July 2008) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized, controlled trials evaluating the BP lowering efficacy of a diuretic in combination therapy with another class of anti‐hypertensive drugs compared with the respective monotherapy (without a diuretic) for a duration of 3 to 12 weeks in patients with primary hypertension. Data collection and analysis Two review authors independently extracted the data and assessed trial quality. Main results Fifty‐three double‐blind RCTs evaluating a thiazide in 15129 hypertensive patients (baseline BP of 156/101 mmHg) were included. Hydrochlorothiazide was the thiazide used in 49/53 (92%) of the included studies. The additional BP reduction caused by the thiazide as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. Thiazides as a second‐line drug reduced BP by 6/3 and 8/4 mmHg at doses of 1 and 2 times the manufacturer's recommended starting dose respectively. The BP lowering effect was dose related. The effect was similar to that obtained when thiazides are used as a single agent. Only 3 double‐blind RCTs evaluating loop diuretics were identified. These RCTs showed a BP lowering effect of a starting dose of about 6/3 mmHg. Authors' conclusions Thiazides when given as a second‐line drug have a dose related effect to lower blood pressure that is similar to when they are added as a first‐line drug. This means that the BP lowering effect of thiazides is additive. Loop diuretics appear to have a similar blood pressure lowering effect as thiazides at 1 times the recommended starting dose. Because of the short duration of the trials and lack of reporting of adverse events, this review does not provide a good estimate of the incidence of adverse effects of diuretics given as a second‐line drug. Plain language summary Diuretics effective in lowering blood pressure when given as a second drug Diuretics are a good first‐line treatment for high blood pressure (BP). Diuretics include loop diuretics and thiazides. We asked how much do diuretics reduce BP when used as the second drug to treat hypertension. We performed a search of the available scientific literature to find all trial evidence to assess this question. Fifty‐six trials were found. Fifty‐three trials involved thiazide diuretics (92% with the drug hydrochlorothiazide) and included a total of 15310 participants. Adding a thiazide to another anti‐hypertensive drug further reduces the BP by an additional 6/3 mmHg when given at the starting dose and reduces BP by 8/4 mmHg at 2 times the starting dose. This is approximately the same effect as when the drugs are used alone. A good estimate of the harms associated with diuretics cannot be estimated in this review because of the lack of reporting and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Chen, JMH; Heran, BS; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "dd410d1a-e818-425d-98ff-54528d4caa21", "pmid": "", "title": "Pharmacotherapy for hypertension‐induced left ventricular hypertrophy", "imported": false, "abstract": "Abstract - Background Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension‐induced LVH. Objectives To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension‐induced LVH. Search methods Cochrane Hypertension’s Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) with at least 12 months’ follow‐up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension‐induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all‐cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. Data collection and analysis Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. Main results We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow‐up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention‐to‐treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add‐on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low‐certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low‐certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low‐certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low‐certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low‐certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. Authors' conclusions We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low‐certainty evidence requires that caution be used when interpreting the findings. High‐quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension‐induced LVH are warranted. Plain language summary What are the main benefits and risks of drugs for reducing blood pressure in the treatment of people with thickening of the heart muscle caused by high blood pressure? Key messages Given the lack of robust evidence, the benefits and risks of adding additional drugs for reducing blood pressure to treat people with thickening of the heart muscle and high blood pressure are unclear. It is unclear if adding drugs for reducing blood pressure causes more serious harms in patients than placebo (dummy treatment) or no treatment; however, it may increase treatment discontinuation due to unwanted effects. There is a need for future studies to better understand the benefits and harms of adding drugs for reducing blood pressure in people with thickening of the heart muscle caused by high blood pressure. What is thickening of the heart muscle? Thickening of the heart muscle is a condition where the muscle gets bigger and affects the function of the heart. This can happen when the heart has worked too hard over time and is mainly caused by high blood pressure. People with thickening of the heart muscle can experience shortness of breath, fatigue, chest pain, heart palpitations, and dizziness or fainting. How is thickening of the heart muscle treated? Thickening of the heart muscle can be treated with drugs for reducing blood pressure. What did we want to find out? We wanted to find out if adding drugs for reducing blood pressure was better than placebo or no drug treatment at preventing illness and death in people with thickening of the heart muscle and high blood pressure. We also wanted to learn if the addition of drugs for reducing blood pressure was associated with any unwanted or harmful effects. What did we do? We searched for studies that investigated the addition of drugs for reducing blood pressure compared with placebo or no drug treatment. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as methods and sizes of participant groups. What did we find? We found 3 studies that involved 930 people with thickening of the heart muscle and high blood pressure. The largest study was in 692 people, and the smallest study was in 15 people. Study participants were of both genders and on average between 66 and 75 years old. Participants were followed for between three and four years. The studies were conducted in several countries in Europe, Asia, and North and South America. One study received pharmaceutical industry funding. It is uncertain if adding drugs for reducing blood pressure has an effect on death, development of heart and blood vessel diseases, or on hospitalisation for heart failure. It is unclear if adding drugs for reducing blood pressure causes more serious harms than placebo or no drug treatment, but it may increase treatment discontinuations due to unwanted effects. It is unclear if adding drugs for reducing blood pressure has an effect on heart muscle mass. What are the limitations of the evidence? Our confidence in the evidence is lacking because of the small number of identified studies. The available evidence is based on a small percentage of people with thickening of the heart muscle and high blood pressure identified from larger populations in the included studies. Further evidence may change our results. How up‐to‐date is the evidence? The evidence is current to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Leache, L, Gutiérrez-Valencia, M, Finizola, RM, Infante, E, Finizola, B, Pardo Pardo, J, Flores, Y, Granero, R, Arai, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD012039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.123Z" }, { "id": "dd4e9e65-f0a0-40e7-baf0-1fec486a26bd", "pmid": "", "title": "Sensory environment on health‐related outcomes of hospital patients", "imported": false, "abstract": "Abstract - Background Hospital environments have recently received renewed interest, with considerable investments into building and renovating healthcare estates. Understanding the effectiveness of environmental interventions is important for resource utilisation and providing quality care. Objectives To assess the effect of hospital environments on adult patient health‐related outcomes. Search methods We searched: the Cochrane Central Register of Controlled Trials (last searched January 2006); MEDLINE (1902 to December 2006); EMBASE (January 1980 to February 2006); 14 other databases covering health, psychology, and the built environment; reference lists; and organisation websites. This review is currently being updated (MEDLINE last search October 2010), see Studies awaiting classification. Selection criteria Randomised and non‐randomised controlled trials, controlled before‐and‐after studies, and interrupted times series of environmental interventions in adult hospital patients reporting health‐related outcomes. Data collection and analysis Two review authors independently undertook data extraction and 'Risk of bias' assessment. We contacted authors to obtain missing information. For continuous variables, we calculated a mean difference (MD) or standardized mean difference (SMD), and 95% confidence intervals (CI) for each study. For dichotomous variables, we calculated a risk ratio (RR) with 95% confidence intervals (95% CI). When appropriate, we used a random‐effects model of meta‐analysis. Heterogeneity was explored qualitatively and quantitatively based on risk of bias, case mix, hospital visit characteristics, and country of study. Main results Overall, 102 studies have been included in this review. Interventions explored were: 'positive distracters', to include aromas (two studies), audiovisual distractions (five studies), decoration (one study), and music (85 studies); interventions to reduce environmental stressors through physical changes, to include air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), and temperature (one study); and multifaceted interventions (two studies). We did not find any studies meeting the inclusion criteria to evaluate: art, access to nature for example, through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music may improve patient‐reported outcomes such as anxiety; however, the benefit for physiological outcomes, and medication consumption has less support. There are few studies to support or refute the implementation of physical changes, and except for air quality, the included studies demonstrated that physical changes to the hospital environment at least did no harm. Authors' conclusions Music may improve patient‐reported outcomes in certain circumstances, so support for this relatively inexpensive intervention may be justified. For some environmental interventions, well designed research studies have yet to take place. Plain language summary Sensory environment on health‐related outcomes of hospital patients The hospital environment (such as sounds, pictures, aromas, design, air quality, furnishings, architecture, and layout), may have an impact on the health of patients within it. This review aims to summarise the best available evidence on hospital environments, in order to help people involved in the design of hospital environments make decisions that will benefit patients' health. The review identified 102 relevant studies, 85 of which were on the use of music in hospital. Other environmental aspects considered were: aromas (two studies), audiovisual distractions (five studies), decoration (one study), air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), temperature (one study), and multiple design changes (two studies). No studies meeting the inclusion criteria were found to evaluate: art, access to nature for example through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music in hospital may help improve patient‐reported outcomes such as anxiety; however, there is less evidence to support the use of music for physiological outcomes (such as reducing heart rate and blood pressure) and for reducing the use of medications. For other aspects of hospital environments, there are not very many well designed studies to help with making evidence‐based design decisions. The studies that have been included in this review show that physical changes made to 'improve' the hospital environment on the whole do no harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Drahota, A; Ward, D; Mackenzie, H; Stores, R; Higgins, B; Gal, D; Dean, TP", "articleTypes": [], "doi": "10.1002/14651858.CD005315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "dd844c4c-f9bd-496e-ad9b-51cb8eef6655", "pmid": "", "title": "Medical interventions for treating anthracycline‐induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer", "imported": false, "abstract": "Abstract - Background Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline‐induced cardiotoxicity. This review is an update of a previously published Cochrane review. Objectives To compare the effect of medical interventions on anthracycline‐induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions, or no treatment. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 8), MEDLINE/PubMed (1949 to September 2015), and EMBASE/Ovid (1980 to September 2015) for potentially relevant articles. In addition, we searched reference lists of relevant articles, conference proceedings of the International Society for Paediatric Oncology (SIOP), the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), the International Conference on Long‐Term Complications of Treatment of Children & Adolescents for Cancer, and the European Symposium on Late Complications from Childhood Cancer (from 2005 to 2015), and ongoing trial databases (the ISRCTN Register, the National Institutes of Health (NIH) Register, and the trials register of the World Health Organization (WHO); all searched in September 2015). Selection criteria Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline‐induced cardiotoxicity with either placebo, other medical interventions, or no treatment. Data collection and analysis Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments, which another review author checked. We performed analyses according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results In the original version of the review we identified two RCTs; in this update we identified no additional studies. One trial (135 participants) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline‐induced cardiac dysfunction. The other trial (68 participants) compared a two‐week treatment of phosphocreatine with a control treatment (vitamin C, adenosine triphosphate, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline‐induced cardiotoxicity. Both studies had methodological limitations. The RCT on enalapril showed no statistically significant differences in overall survival, mortality due to heart failure, development of clinical heart failure, and quality of life between treatment and control groups. A post‐hoc analysis showed a decrease (that is improvement) in one measure of cardiac function (left ventricular end‐systolic wall stress (LVESWS): ‐8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Participants treated with enalapril had a higher risk of dizziness or hypotension (risk ratio 7.17, 95% confidence interval 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013). The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function, and adverse events between treatment and control groups. Authors' conclusions Only one trial evaluated the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side effects of enalapril in childhood cancer survivors with asymptomatic anthracycline‐induced cardiotoxicity. Only one trial evaluated the effect of phosphocreatine in childhood cancer patients with anthracycline‐induced cardiotoxicity. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatments on echocardiographic function and clinical outcomes. We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors. High‐quality studies should be performed. Plain language summary Treatment for cardiac problems caused by anthracycline chemotherapy for childhood cancer Anthracyclines are anticancer drugs used in the treatment of different types of childhood cancer. An important adverse effect of anthracyclines is damage to the heart, which can lead to asymptomatic (without complaints) or symptomatic (with complaints) cardiac problems during and after cancer treatment. While there are several drugs available to treat other types of cardiac problems in adults, it is not known if these drugs are beneficial in treating cardiac problems caused by anthracyclines in childhood cancer patients and survivors. A physician confronted with a childhood cancer patient or survivor with anthracycline‐induced cardiac problems should be able to make an informed decision on how to treat this patient based on high‐quality evidence about the beneficial and adverse effects of the treatment options. We searched for and summarised studies that evaluated drugs for treating anthracycline‐induced cardiac problems in childhood cancer patients and survivors. We identified two randomised studies evaluating two different drugs in two different types of patients. One of these drugs, an angiotensin‐converting enzyme (ACE) inhibitor (enalapril), had a short‐term beneficial effect on heart function in survivors of childhood cancer with asymptomatic cardiac problems caused by anthracyclines compared with placebo. However, the drug had no significant beneficial effect on other important outcomes and was associated with side effects such as dizziness and fatigue. This study was of reasonable/good quality. The other study was of low quality and found no effect of a short treatment with phosphocreatine in childhood leukaemia patients with symptomatic or asymptomatic cardiac problems compared with a control treatment with vitamin C, adenosine triphosphate, vitamin E, and oral coenzyme Q10. We could make no definitive conclusions about treatment options for anthracycline‐induced cardiac problems in childhood cancer patients and survivors. High‐quality studies are needed to determine if there are drugs that improve heart function in these patients.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cheuk, DKL; Sieswerda, E; van Dalen, EC; Postma, A; Kremer, LCM", "articleTypes": [], "doi": "10.1002/14651858.CD008011.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "dda05a1d-5a4d-4654-9134-6313045ac696", "pmid": "", "title": "Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco", "imported": false, "abstract": "Abstract - Background Overeating and harmful alcohol and tobacco use have been linked to the aetiology of various non‐communicable diseases, which are among the leading global causes of morbidity and premature mortality. As people are repeatedly exposed to varying sizes and shapes of food, alcohol and tobacco products in environments such as shops, restaurants, bars and homes, this has stimulated public health policy interest in product size and shape as potential targets for intervention. Objectives 1) To assess the effects of interventions involving exposure to different sizes or sets of physical dimensions of a portion, package, individual unit or item of tableware on unregulated selection or consumption of food, alcohol or tobacco products in adults and children. 2) To assess the extent to which these effects may be modified by study, intervention and participant characteristics. Search methods We searched CENTRAL, MEDLINE, EMBASE, PsycINFO, eight other published or grey literature databases, trial registries and key websites up to November 2012, followed by citation searches and contacts with study authors. This original search identified eligible studies published up to July 2013, which are fully incorporated into the review. We conducted an updated search up to 30 January 2015 but further eligible studies are not yet fully incorporated due to their minimal potential to change the conclusions. Selection criteria Randomised controlled trials with between‐subjects (parallel‐group) or within‐subjects (cross‐over) designs, conducted in laboratory or field settings, in adults or children. Eligible studies compared at least two groups of participants, each exposed to a different size or shape of a portion of a food (including non‐alcoholic beverages), alcohol or tobacco product, its package or individual unit size, or of an item of tableware used to consume it, and included a measure of unregulated selection or consumption of food, alcohol or tobacco. Data collection and analysis We applied standard Cochrane methods to select eligible studies for inclusion and to collect data and assess risk of bias. We calculated study‐level effect sizes as standardised mean differences (SMDs) between comparison groups, measured as quantities selected or consumed. We combined these results using random‐effects meta‐analysis models to estimate summary effect sizes (SMDs with 95% confidence intervals (CIs)) for each outcome for size and shape comparisons. We rated the overall quality of evidence using the GRADE system. Finally, we used meta‐regression analysis to investigate statistical associations between summary effect sizes and variant study, intervention or participant characteristics. Main results The current version of this review includes 72 studies, published between 1978 and July 2013, assessed as being at overall unclear or high risk of bias with respect to selection and consumption outcomes. Ninety‐six per cent of included studies (69/72) manipulated food products and 4% (3/72) manipulated cigarettes. No included studies manipulated alcohol products. Forty‐nine per cent (35/72) manipulated portion size, 14% (10/72) package size and 21% (15/72) tableware size or shape. More studies investigated effects among adults (76% (55/72)) than children and all studies were conducted in high‐income countries ‐ predominantly in the USA (81% (58/72)). Sources of funding were reported for the majority of studies, with no evidence of funding by agencies with possible commercial interests in their results. A meta‐analysis of 86 independent comparisons from 58 studies (6603 participants) found a small to moderate effect of portion, package, individual unit or tableware size on consumption of food (SMD 0.38, 95% CI 0.29 to 0.46), providing moderate quality evidence that exposure to larger sizes increased quantities of food consumed among children (SMD 0.21, 95% CI 0.10 to 0.31) and adults (SMD 0.46, 95% CI 0.40 to 0.52). The size of this effect suggests that, if sustained reductions in exposure to larger‐sized food portions, packages and tableware could be achieved across the whole diet, this could reduce average daily energy consumed from food by between 144 and 228 kcal (8.5% to 13.5% from a baseline of 1689 kcal) among UK children and adults. A meta‐analysis of six independent comparisons from three studies (108 participants) found low quality evidence for no difference in the effect of cigarette length on consumption (SMD 0.25, 95% CI ‐0.14 to 0.65). One included study (50 participants) estimated a large effect on consumption of exposure to differently shaped tableware (SMD 1.17, 95% CI 0.57 to 1.78), rated as very low quality evidence that exposure to shorter, wider bottles (versus taller, narrower bottles) increased quantities of water consumed by young adult participants. A meta‐analysis of 13 independent comparisons from 10 studies (1164 participants) found a small to moderate effect of portion or tableware size on selection of food (SMD 0.42, 95% CI 0.24 to 0.59), rated as moderate quality evidence that exposure to larger sizes increased the quantities of food people selected for subsequent consumption. This effect was present among adults (SMD 0.55, 95% CI 0.35 to 0.75) but not children (SMD 0.14, 95% CI ‐0.06 to 0.34). In addition, a meta‐analysis of three independent comparisons from three studies (232 participants) found a very large effect of exposure to differently shaped tableware on selection of non‐alcoholic beverages (SMD 1.47, 95% CI 0.52 to 2.43), rated as low quality evidence that exposure to shorter, wider (versus taller, narrower) glasses or bottles increased the quantities selected for subsequent consumption among adults (SMD 2.31, 95% CI 1.79 to 2.83) and children (SMD 1.03, 95% CI 0.41 to 1.65). Authors' conclusions This review found that people consistently consume more food and drink when offered larger‐sized portions, packages or tableware than when offered smaller‐sized versions. This suggests that policies and practices that successfully reduce the size, availability and appeal of larger‐sized portions, packages, individual units and tableware can contribute to meaningful reductions in the quantities of food (including non‐alcoholic beverages) people select and consume in the immediate and short term. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. We are unable to highlight clear implications for tobacco or alcohol policy due to identified gaps in the current evidence base. Plain language summary Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco Review question We reviewed the evidence to establish by how much the amounts of food, alcohol or tobacco adults and children select or consume change in response to being presented with larger or smaller‐sized (or differently shaped) portions or packages of these products, or of items of tableware (such as plates or glasses) used to consume them. Study characteristics This review includes 72 randomised controlled trials (RCTs) published up to July 2013 that compared at least two groups of participants, each presented with a different size of a portion, package or item of tableware. Included studies measured the amounts of food, alcohol or tobacco selected and/or consumed by participants, typically over a period of one day or less. Almost all of the included studies investigated food, with only three tobacco studies and no alcohol studies found. Almost all assessed participants' responses to different sizes rather than different shapes. The average age of participants in the different studies ranged from three to 55 years, with more studies involving adults than children and most conducted in the USA. Sources of funding were reported for the majority of studies and there was no evidence of study funding by agencies with commercial interests in their results. Key findings and quality of evidence Effects of size on consumption: We found evidence that people consistently ate more food or drank more non‐alcoholic drinks when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. We estimate the size of this effect to be small to moderate among both children and adults. If an effect of this size were sustained across the whole diet it would be equivalent to around a 12% to 16% change in average daily energy intake from food among UK adults. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations arising from incomplete or unclear reporting of methods and procedures. From three tobacco studies, we found no effect of longer compared with shorter cigarettes on the amounts of tobacco consumed. We rated the overall quality of evidence for this effect as low due to concerns about study limitations and not having enough evidence. Effects of shape on consumption: One study found that adults provided with shorter, wider bottles drank larger amounts of water from them, having already poured more, compared with those provided with taller, narrower bottles. However, we rated the quality of this evidence as very low, due to very serious concerns about study limitations and not having enough evidence (only one study with outcome data from 50 participants). Effects of size on selection: We further found that adults, but not children, consistently chose (selected) more food (including non‐alcoholic drinks) when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. The estimated size of this effect was again small to moderate. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations. Effects of shape on selection: Evidence from three studies suggested that adults and children provided with shorter, wider bottles or glasses selected increased quantities of non‐alcoholic beverages for subsequent consumption, compared with those provided with taller, narrower bottles or glasses. We rated the quality of this evidence as low, again due to concerns about study limitations and unexplained variation in effects between the three studies. Conclusions Overall, this review provides the most conclusive evidence to date that acting to reduce the size, availability and appeal of larger‐sized portions, packages and tableware has potential to reduce the quantities of food that people select and consume by meaningful amounts. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. Our findings highlight the need for further research that aims to reduce uncertainties about these effects and address identified gaps in the evidence base, including not having enough evidence for longer‐term effects and the absence of evidence about alcohol products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hollands, GJ, Shemilt, I, Marteau, TM, Jebb, SA, Lewis, HB, Wei, Y, Higgins, JPT, Ogilvie, D", "articleTypes": [], "doi": "10.1002/14651858.CD011045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.792Z" }, { "id": "ddb76dcb-f0e3-46c2-a79b-e8d785a3eb00", "pmid": "", "title": "Chloroquine or hydroxychloroquine for prevention and treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The coronavirus disease 2019 (COVID‐19) pandemic has resulted in substantial mortality. Some specialists proposed chloroquine (CQ) and hydroxychloroquine (HCQ) for treating or preventing the disease. The efficacy and safety of these drugs have been assessed in randomized controlled trials. Objectives To evaluate the effects of chloroquine (CQ) or hydroxychloroquine (HCQ) for 1) treating people with COVID‐19 on death and time to clearance of the virus; 2) preventing infection in people at risk of SARS‐CoV‐2 exposure; 3) preventing infection in people exposed to SARS‐CoV‐2. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Current Controlled Trials (www.controlled‐trials.com), and the COVID‐19‐specific resources www.covid‐nma.com and covid‐19.cochrane.org, for studies of any publication status and in any language. We performed all searches up to 15 September 2020. We contacted researchers to identify unpublished and ongoing studies. Selection criteria We included randomized controlled trials (RCTs) testing chloroquine or hydroxychloroquine in people with COVID‐19, people at risk of COVID‐19 exposure, and people exposed to COVID‐19. Adverse events (any, serious, and QT‐interval prolongation on electrocardiogram) were also extracted. Data collection and analysis Two review authors independently assessed eligibility of search results, extracted data from the included studies, and assessed risk of bias using the Cochrane ‘Risk of bias’ tool. We contacted study authors for clarification and additional data for some studies. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). We performed meta‐analysis using a random‐effects model for outcomes where pooling of effect estimates was appropriate. Main results 1. Treatment of COVID‐19 disease We included 12 trials involving 8569 participants, all of whom were adults. Studies were from China (4); Brazil, Egypt, Iran, Spain, Taiwan, the UK, and North America (each 1 study); and a global study in 30 countries (1 study). Nine were in hospitalized patients, and three from ambulatory care. Disease severity, prevalence of comorbidities, and use of co‐interventions varied substantially between trials. We found potential risks of bias across all domains for several trials. Nine trials compared HCQ with standard care (7779 participants), and one compared HCQ with placebo (491 participants); dosing schedules varied. HCQ makes little or no difference to death due to any cause (RR 1.09, 95% CI 0.99 to 1.19; 8208 participants; 9 trials; high‐certainty evidence). A sensitivity analysis using modified intention‐to‐treat results from three trials did not influence the pooled effect estimate. HCQ may make little or no difference to the proportion of people having negative PCR for SARS‐CoV‐2 on respiratory samples at day 14 from enrolment (RR 1.00, 95% CI 0.91 to 1.10; 213 participants; 3 trials; low‐certainty evidence). HCQ probably results in little to no difference in progression to mechanical ventilation (RR 1.11, 95% CI 0.91 to 1.37; 4521 participants; 3 trials; moderate‐certainty evidence). HCQ probably results in an almost three‐fold increased risk of adverse events (RR 2.90, 95% CI 1.49 to 5.64; 1394 participants; 6 trials; moderate‐certainty evidence), but may make little or no difference to the risk of serious adverse events (RR 0.82, 95% CI 0.37 to 1.79; 1004 participants; 6 trials; low‐certainty evidence). We are very uncertain about the effect of HCQ on time to clinical improvement or risk of prolongation of QT‐interval on electrocardiogram (very low‐certainty evidence). One trial (22 participants) randomized patients to CQ versus lopinavir/ritonavir, a drug with unknown efficacy against SARS‐CoV‐2, and did not report any difference for clinical recovery or adverse events. One trial compared HCQ combined with azithromycin against standard care (444 participants). This trial did not detect a difference in death, requirement for mechanical ventilation, length of hospital admission, or serious adverse events. A higher risk of adverse events was reported in the HCQ‐and‐azithromycin arm; this included QT‐interval prolongation, when measured. One trial compared HCQ with febuxostat, another drug with unknown efficacy against SARS‐CoV‐2 (60 participants). There was no difference detected in risk of hospitalization or change in computed tomography (CT) scan appearance of the lungs; no deaths were reported. 2. Preventing COVID‐19 disease in people at risk of exposure to SARS‐CoV‐2 Ongoing trials are yet to report results for this objective. 3. Preventing COVID‐19 disease in people who have been exposed to SARS‐CoV‐2 One trial (821 participants) compared HCQ with placebo as a prophylactic agent in the USA (around 90% of participants) and Canada. Asymptomatic adults (66% healthcare workers; mean age 40 years; 73% without comorbidity) with a history of exposure to people with confirmed COVID‐19 were recruited. We are very uncertain about the effect of HCQ on the primary outcomes, for which few events were reported: 20/821 (2.4%) developed confirmed COVID‐19 at 14 days from enrolment, and 2/821 (0.2%) were hospitalized due to COVID‐19 (very low‐certainty evidence). HCQ probably increases the risk of adverse events compared with placebo (RR 2.39, 95% CI 1.83 to 3.11; 700 participants; 1 trial; moderate‐certainty evidence). HCQ may result in little or no difference in serious adverse events (no RR: no participants experienced serious adverse events; low‐certainty evidence). One cluster‐randomized trial (2525 participants) compared HCQ with standard care for the prevention of COVID‐19 in people with a history of exposure to SARS‐CoV‐2 in Spain. Most participants were working or residing in nursing homes; mean age was 49 years. There was no difference in the risk of symptomatic confirmed COVID‐19 or production of antibodies to SARS‐CoV‐2 between the two study arms. Authors' conclusions HCQ for people infected with COVID‐19 has little or no effect on the risk of death and probably no effect on progression to mechanical ventilation. Adverse events are tripled compared to placebo, but very few serious adverse events were found. No further trials of hydroxychloroquine or chloroquine for treatment should be carried out. These results make it less likely that the drug is effective in protecting people from infection, although this is not excluded entirely. It is probably sensible to complete trials examining prevention of infection, and ensure these are carried out to a high standard to provide unambiguous results. Plain language summary Is chloroquine or hydroxychloroquine useful in treating people with COVID‐19, or in preventing infection in people who have been exposed to the virus? What is the aim of this review? COVID‐19 is an infectious respiratory disease caused by a coronavirus called SARS‐CoV‐2. If the infection becomes severe, people may need intensive care and support in hospital, including mechanical ventilation. Drugs used for other diseases were tried out in COVID‐19, and this included chloroquine, used for malaria; and hydroxychloroquine used for rheumatic diseases, such as rheumatoid arthritis or systemic lupus erythematosus. We sought evidence of the effects of these drugs in treating people ill with the disease; in preventing the disease in people at risk of getting the disease, such as health workers; and people exposed to the virus developing the disease. Key messages Hydroxychloroquine does not reduce deaths from COVID‐19, and probably does not reduce the number of people needing mechanical ventilation. Hydroxychloroquine caused more unwanted effects than a placebo treatment, though it did not appear to increase the number of serious unwanted effects. We do not think new studies of hydroxychloroquine should be started for treatment of COVID‐19. What was studied in the review? We searched for studies that looked at giving chloroquine and hydroxychloroquine to people with COVID‐19; people at risk of being exposed to the virus; and people who have been exposed to the virus. We found 14 relevant studies: 12 studies of chloroquine or hydroxychloroquine used to treat COVID‐19 in 8569 adults; two studies of hydroxychloroquine to stop COVID‐19 in 3346 adults who had been exposed to the virus but had no symptoms of infection. We did not find any completed studies of these medicines to stop COVID‐19 in people who were at risk of exposure to the virus; studies are still under way. The studies took place in China, Brazil, Egypt, Iran, Taiwan, North America, and Europe; one study was worldwide. Some studies were partly funded by pharmaceutical companies that manufacture hydroxychloroquine. What are the main results of our review? Treating COVID‐19 Compared with usual care or placebo, hydroxychloroquine: · clearly did not affect how many people died (of any cause; 9 studies in 8208 people); · probably did not affect how many people needed mechanical ventilation (3 studies; 4521 people); · may not affect how many people still tested positive for the virus after 14 days (3 studies; 213 people). We are uncertain whether hydroxychloroquine affected the number of people whose symptoms improved after 28 days. Compared with other antiviral treatment (lopinavir plus ritonavir), chloroquine made little or no difference to the time taken for symptoms to improve (1 study; 22 people). Compared with usual care in one study in 444 people, hydroxychloroquine given with azithromycin (an antibiotic) made no difference to: · how many people died; · how many needed mechanical ventilation; or · time spent in hospital. Compared with febuxostat (a medicine to treat gout), hydroxychloroquine made no difference to how many people were admitted to hospital or to changes seen on scans of people's lungs; no deaths were reported (1 study; 60 people). Preventing COVID‐19 in people exposed to it We are uncertain whether hydroxychloroquine affected how many people developed COVID‐19, or how many people were admitted to hospital with COVID‐19, compared with those receiving a placebo treatment (1 study; 821 people). Compared with usual care, hydroxychloroquine made no difference to the risk of developing COVID‐19, or antibodies to the virus, in people exposed to it (1 study; 2525 people). Unwanted effects When used for treating COVID‐19, compared with usual care or placebo, hydroxychloroquine: · probably increases the risk of mild unwanted effects (6 studies; 1394 people); · may not increase the risk of serious harmful effects (6 studies; 1004 people). When given along with azithromycin, hydroxychloroquine increased the risk of any unwanted effects, but made no difference to the risk of serious unwanted effects (1 study; 444 people). Compared with lopinavir plus ritonavir, chloroquine made little or no difference to the risk of unwanted effects (1 study; 22 people). When used for preventing COVID‐19, hydroxychloroquine probably causes more unwanted effects than placebo, but may not increase the risk of serious, harmful unwanted effects (1 study; 700 people). How confident are we in our results? We are confident about our results for how many people died and moderately confident about how many needed mechanical ventilation. We are moderately confident about the unwanted effects of hydroxychloroquine treatment, but less confident about our results for serious unwanted effects; these results might change with further evidence. How up‐to‐date is this review? We included evidence published up to 15 September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Singh, B; Ryan, H; Kredo, T; Chaplin, M; Fletcher, T", "articleTypes": [], "doi": "10.1002/14651858.CD013587.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "ddb9e1d0-2c6a-4d90-950b-2a3547a60f9f", "pmid": "", "title": "Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age", "imported": false, "abstract": "Abstract - Background Vitamin and mineral deficiencies, particularly those of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Multiple micronutrient powders (MNPs) are single‐dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi‐solid food for children six months of age or older. The use of MNPs for home or point‐of‐use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out‐of‐date. Objectives To assess the effects and safety of home (point‐of‐use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi‐solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point‐of‐use fortification. Search methods We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs with individual randomisation or cluster‐randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron‐containing supplements, which is standard practice. Data collection and analysis Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, and assessed the risk of bias of included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence. Main results We included 29 studies (33,147 children) conducted in low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty‐six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron‐only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate‐certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high‐certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low‐certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate‐certainty evidence) at follow‐up compared with children receiving the control intervention. We did not find an effect on weight‐for‐age (MD 0.02, 95% CI −0.03 to 0.07; 10 studies; 9287 children; moderate‐certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all‐cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low‐certainty evidence) and haemoglobin concentrations (MD −2.81 g/L, 95% CI −10.84 to 5.22; 2 studies; 278 children; very low‐certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low‐certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Authors' conclusions Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Plain language summary Using a vitamin and mineral powder, mixed into complementary foods, to improve health and nutrition in children under two years of age Review question Does using a vitamin and mineral powder, mixed into complementary foods, improve health and nutrition in children under two years of age? Background Deficiencies of vitamins and minerals, particularly of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Exclusive breastfeeding until six months of age, followed by complementary feeding combined with continued breastfeeding for at least two years, is recommended to maintain children's adequate health and nutrition. After six months of age, infants start to receive semi‐solid foods, but the quantities of vitamins and minerals can be insufficient to fulfil all of their requirements for growth and development. Multiple micronutrient powders (MNPs) are single‐dose packets of powder containing iron, vitamin A, zinc, and other vitamins and minerals that can be mixed into any semi‐solid food at home or at any other point of use, to increase the content of essential vitamins and minerals in the diet of infants and young children during this period. This is done without making any other changes to their usual diet. Study characteristics We searched up to July 2019 for all studies that assessed the use of MNP for improving the health and nutrition of children under two years of age. We included 29 studies that involved 33,147 infants and young children from low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean. Twenty‐six studies with 27,051 children contributed data. Of these 26 studies, 24 compared the use of MNP versus no intervention or placebo, and 2 compared the use of MNP versus an iron‐only supplement (iron drops) given daily. We found that a variety of MNP formulations containing between 5 and 22 vitamins and minerals were given for 2 to 44 months to infants and young children aged 6 to 23 months. Most studies were funded by government programmes or foundations; only 2 were funded by industry. Key results The use of MNP containing at least iron, zinc, and vitamin A for home fortification of foods was associated with reduced risk of anaemia of 18% and iron deficiency of 53% in children aged six months to two years compared with no intervention. Also, haemoglobin concentration and iron status improved. Studies did not find any effects on growth. There was no additional benefit in reducing risk of anaemia and improving haemoglobin concentration compared to usually recommended iron drops or syrups; however, only two studies compared these different interventions. No trials reported death attributable to the intervention. Information on deaths, side effects, and morbidity, including malaria and diarrhoea, was scarce. The use of MNP was beneficial for young children 6 to 23 months of age, independent of whether they lived in settings with different anaemia and malaria backgrounds and regardless of the length of the intervention. MNP is better than no intervention or placebo and may be comparable to daily iron supplementation.The benefits of this intervention as a child survival strategy or for developmental outcomes are still unclear, and further investigation is required. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Certainty of the evidence For the comparison of MNP versus no intervention or placebo, we judged the certainty of evidence to be moderate for anaemia and high for iron deficiency. The certainty of evidence for all other outcomes in this comparison was either low or moderate. Two trials that compared the use of MNP versus iron supplement showed similar effects on anaemia and haemoglobin but less diarrhoea; however, we judged the certainty of evidence as low for anaemia and very low for haemoglobin concentration due to the small number of study participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Suchdev, PS, Jefferds, MED, Ota, E, da Silva Lopes, K, De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD008959.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.792Z" }, { "id": "ddc18373-5df0-4f8a-a357-d3431f2556dd", "pmid": "", "title": "Probiotics for the prevention of pediatric antibiotic‐associated diarrhea", "imported": false, "abstract": "Abstract - Background Antibiotics alter the microbial balance commonly resulting in antibiotic‐associated diarrhea (AAD). Probiotics may prevent AAD via providing gut barrier, restoration of the gut microflora, and other potential mechanisms of action. Objectives The primary objectives were to assess the efficacy and safety of probiotics (any specified strain or dose) used for the prevention of AAD in children. Search methods MEDLINE, Embase, CENTRAL, CINAHL, and the Web of Science (inception to 28 May 2018) were searched along with registers including the ISRCTN and Clinicaltrials.gov. We also searched the NICE Evidence Services database as well as reference lists from relevant articles. Selection criteria Randomized, parallel, controlled trials in children (0 to 18 years) receiving antibiotics, that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhea secondary to antibiotic use were considered for inclusion. Data collection and analysis Study selection, data extraction, and risk of bias assessment were conducted independently by two authors. Dichotomous data (incidence of AAD, adverse events) were combined using a pooled risk ratio (RR) or risk difference (RD), and continuous data (mean duration of diarrhea) as mean difference (MD), along with corresponding 95% confidence interval (95% CI). We calculated the number needed to treat for an additional beneficial outcome (NNTB) where appropriate. For studies reporting on microbiome characteristics using heterogeneous outcomes, we describe the results narratively. The certainty of the evidence was evaluated using GRADE. Main results Thirty‐three studies (6352 participants) were included. Probiotics assessed included Bacillus spp., Bifidobacterium spp., Clostridium butyricum , Lactobacilli spp. , Lactococcus spp., Leuconostoc cremoris , Saccharomyces spp., or Streptococcus spp., alone or in combination. The risk of bias was determined to be high in 20 studies and low in 13 studies. Complete case (patients who did not complete the studies were not included in the analysis) results from 33 trials reporting on the incidence of diarrhea show a precise benefit from probiotics compared to active, placebo or no treatment control. After 5 days to 12 weeks of follow‐up, the incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group (RR 0.45, 95% CI 0.36 to 0.56; I² = 57%, 6352 participants; NNTB 9, 95% CI 7 to 13; moderate certainty evidence). Nineteen studies had loss to follow‐up ranging from 1% to 46%. After making assumptions for those lost, the observed benefit was still statistically significant using an extreme plausible intention‐to‐treat (ITT) analysis, wherein the incidence of AAD in the probiotic group was 12% (436/3551) compared to 19% (664/3468) in the control group (7019 participants; RR 0.61; 95% CI 0.49 to 0.77; P <0.00001; I² = 70%). An a priori available case subgroup analysis exploring heterogeneity indicated that high dose (≥ 5 billion CFUs per day) is more effective than low probiotic dose (< 5 billion CFUs per day), interaction P value = 0.01. For the high dose studies the incidence of AAD in the probiotic group was 8% (162/2029) compared to 23% (462/2009) in the control group (4038 participants; RR 0.37; 95% CI 0.30 to 0.46; P = 0.06; moderate certainty evidence). For the low dose studies the incidence of AAD in the probiotic group was 8% (97/1155) compared to 13% (133/1059) in the control group (2214 participants; RR 0.68; 95% CI 0.46 to 1.01; P = 0.02). Again, assumptions for loss to follow‐up using an extreme plausible ITT analysis was statistically significant. For high dose studies the incidence of AAD in the probiotic group was 13% (278/2218) compared to 23% (503/2207) in control group (4425 participants; RR 0.54; 95% CI 0.42 to 0.70; P <0.00001; I² = 68%; moderate certainty evidence). None of the 24 trials (4415 participants) that reported on adverse events reported any serious adverse events attributable to probiotics. Adverse event rates were low. After 5 days to 4 weeks follow‐up, 4% (86/2229) of probiotics participants had an adverse event compared to 6% (121/2186) of control participants (RD 0.00; 95% CI ‐0.01 to 0.01; P < 0.00001; I² = 75%; low certainty evidence). Common adverse events included rash, nausea, gas, flatulence, abdominal bloating, and constipation. After 10 days to 12 weeks of follow‐up, eight studies recorded data on our secondary outcome, the mean duration of diarrhea; with probiotics reducing diarrhea duration by almost one day (MD ‐0.91; 95% CI ‐1.38 to ‐0.44; P <0.00001; low certainty evidence). One study reported on microbiome characteristics, reporting no difference in changes with concurrent antibiotic and probiotic use. Authors' conclusions The overall evidence suggests a moderate protective effect of probiotics for preventing AAD (NNTB 9, 95% CI 7 to 13). Using five criteria to evaluate the credibility of the subgroup analysis on probiotic dose, the results indicate the subgroup effect based on high dose probiotics (≥ 5 billion CFUs per day) was credible. Based on high‐dose probiotics, the NNTB to prevent one case of diarrhea is 6 (95% CI 5 to 9). The overall certainty of the evidence for the primary endpoint, incidence of AAD, based on high dose probiotics was moderate due to the minor issues with risk of bias and inconsistency related to a diversity of probiotic agents used. Evidence also suggests that probiotics may moderately reduce the duration of diarrhea, a reduction by almost one day. The benefit of high dose probiotics (e.g. Lactobacillus rhamnosus or Saccharomyces boulardii ) needs to be confirmed by a large well‐designed multi‐centered randomized trial. It is premature to draw firm conclusions about the efficacy and safety of 'other' probiotic agents as an adjunct to antibiotics in children. Adverse event rates were low and no serious adverse events were attributable to probiotics. Although no serious adverse events were observed among inpatient and outpatient children, including small studies conducted in the intensive care unit and in the neonatal unit, observational studies not included in this review have reported serious adverse events in severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter use and disorders associated with bacterial/fungal translocation. Plain language summary Probiotics for the prevention of antibiotic‐associated diarrhea in children What is antibiotic‐associated diarrhea? Antibiotic‐associated diarrhea (AAD) occurs when antibiotics disturb the natural balance of \"good\" and \"bad\" bacteria in the intestinal tract causing harmful bacteria to multiply beyond their normal numbers. The symptoms of AAD include frequent watery bowel movements and crampy abdominal pain. What are probiotics? Probiotics are found in dietary supplements or yogurts and contain potentially beneficial bacteria or yeast. Probiotics may restore the natural balance of bacteria in the intestinal tract. What did the researchers investigate? The researchers investigated whether probiotics prevent AAD in children receiving antibiotic therapy and whether probiotics causes any harms (side effects). The researchers searched the medical literature extensively up to May 28, 2018. What did the researchers find? Thirty‐three studies were reviewed and provide the best available evidence. The studies tested 6352 children (3 days to 17 years of age) who were receiving probiotics co‐administered with antibiotics to prevent AAD. The participants received probiotics ( Lactobacilli spp., Bifidobacterium spp., Streptococcus spp. , or Saccharomyces boulardii alone or in combination), placebo (pills not including probiotics), other treatments thought to prevent AAD (i.e. diosmectite or infant formula) or no treatment. The studies were short‐term, ranging in length from 5 days to 12 weeks. Analyses showed that probiotics are effective for preventing AAD. The incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group, demonstrating a moderate reduction (11% fewer will suffer diarrhea). For every 9 children treated, probiotics will prevent one case of diarrhea. Further, evidence suggests that higher dose probiotics (≥ 5 billion CFUs per day) reduce the incidence of AAD. Eight per cent (162/2029) of the high dose probiotics group had AAD compared to 23% (462/2009) in the control group, demonstrating a moderate to large reduction (15% fewer suffer diarrhea). Probiotics were generally well tolerated, and minor side effects (e.g. rash, nausea, gas, flatulence, abdominal bloating, constipation) occurred infrequently. . Evidence suggested that probiotics are effective for a moderate reduction in duration of diarrhea (almost one day). Among the various probiotics evaluated, Lactobacillus rhamnosus or Saccharomyces boulardii at 5 to 40 billion colony forming units/day appear most appropriate for preventing AAD in children receiving antibiotics. It is premature to draw conclusions about the effectiveness and safety of 'other' probiotic agents for preventing AAD. Although no serious probiotic‐related side effects were observed among the mostly otherwise healthy children who participated in the studies, serious side effects have been reported in observational studies not included in this review, including severely debilitated or immuno‐compromised children with underlying risk factors including central venous catheter (a flexible tube used to give medicines) use and disorders associated with bacterial or fungal translocation (the passage of bacteria from the gut to other areas of the body).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Guo, Q, Goldenberg, JZ, Humphrey, C, El Dib, R, Johnston, BC", "articleTypes": [], "doi": "10.1002/14651858.CD004827.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.759Z" }, { "id": "ddcd343f-322b-40ff-abdd-421d350ea42a", "pmid": "", "title": "Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder", "imported": false, "abstract": "Abstract - Background Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. Objectives To assess the effects ‐ and review the acceptability and tolerability ‐ of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. Selection criteria Double‐ or single‐blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. Data collection and analysis Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. Main results Thirty‐one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D‐cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP‐101,606 (1), decoglurant (1), MK‐0657 (1), N‐acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty‐eight studies were placebo‐controlled, and 48 were two‐arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild‐to‐moderate depression. Nineteen studies recruited only patients with treatment‐resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low‐certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) ‐0.87, 95% CI ‐1.26 to ‐0.48; n = 231, studies = 8, very low‐certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low‐certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low‐certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low‐certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and midazolam (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low‐certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate‐certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD ‐0.31, 95% CI ‐0.45 to ‐0.17; n = 824, studies = 4, moderate‐certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low‐certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate‐certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. Authors' conclusions Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta‐analyses for each comparison and the majority of comparisons included only one study. Long term non‐inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real‐world monitoring are needed to establish comprehensive data on safety and efficacy. Plain language summary Ketamine and other glutamate receptor modulators for depression in adults Why is this review important? Depression is one of the most common mental disorders, estimated to affect 350 million people worldwide. Antidepressant medication tends to be given as a first treatment for people with major depression. These drugs are however only effective in about one in four people at one year. Effective alternative medications to treat depression are needed, especially for rapid treatment. A new group of medications is called ‘glutamate receptor modulators’, which act on the glutamergic system. This group includes the medicine ketamine. In this review we examined the evidence for glutamate receptor modulators, including ketamine, as a treatment for depression. Who will be interested in this review? ‐ People with depression, their friends and families. ‐ General practitioners, psychiatrists, psychologists and pharmacists. ‐ Professionals working in adult mental health services. What questions does this review aim to answer? 1. Is treatment with ketamine and other glutamate receptor modulators more effective than treatment with placebo (dummy pill) or other drugs? 2. Is treatment with ketamine and other glutamate receptor modulators more acceptable than placebo or other drugs? Which studies were included in the review? We searched medical databases to find all relevant studies (specifically randomised controlled trials) completed up to 30 July 2020. To be included in the review, studies had to compare ketamine or other glutamate receptor modulators with placebo, other medicines or electroconvulsive therapy (ECT) for depression in adults (aged 18 and over). The studies also had to be single‐blind (the participant does not know which treatment they are receiving) or double‐blind (neither the participant or researcher know which treatment the participant is receiving), to attempt to reduce bias. We included 64 studies in the review, involving a total of 5299 people. The studies investigated16 different glutamate receptor modulator medications. The majority of participants had treatment‐resistant depression (depression which had not responded to two or more medications) at the start of the studies. Most studies were two‐armed, where the glutamate receptor modulator was compared with one other intervention. What does the evidence from the review tell us? Among the 16 drugs included in this review, only ketamine and esketamine were more effective than placebo at reducing symptoms of depression. The effects of ketamine lasted no more than one week after treatment and clearly disappeared after two weeks. Ketamine did, however, cause more side effects than placebo. The effects of esketamine were seen at 24 hours and could last up to four weeks with repeated doses. Esketamine caused a lot more side effects than placebo. The certainty of evidence varied considerably. There was no evidence of a difference between the other glutamate receptor modulators included in this review and placebo or other medications. What should happen next? Ketamine and esketamine appear to reduce the symptoms of depression. However, the trials were all short term so we do not know about the long‐term effects. It is important to note that in some trials attempts to prevent participants and investigators from knowing what medicine was being given were not successful and this may have inflated the positive effects of the active drugs. Future studies should examine what happens when people are repeatedly given the drug, with the aim to mimic the real‐world practice and assess longer‐term effects. More non‐inferiority trials should be conducted, where glutamate receptor modulators are compared with other active medications rather than placebo to find out whether they are better than alternative treatments. In most of the ketamine trials in this review, participants were given the drug by injection into a vein. This restricts the wide‐scale application of ketamine in clinical settings, so trials of ketamine by other routes are needed. Esketamine trials usually used nasal sprays, which are easier to use and could potentially be taken at home if further monitoring and trials found that it was safe to do so. Further studies assessing administration are needed in order to draw more reliable and firm conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Dean, RL; Hurducas, C; Hawton, K; Spyridi, S; Cowen, PJ; Hollingsworth, S; Marquardt, T; Barnes, A; Smith, R; McShane, R; Turner, EH; Cipriani, A", "articleTypes": [], "doi": "10.1002/14651858.CD011612.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "ddcd981e-db9c-4e29-a31e-65cfdb18f214", "pmid": "", "title": "Chewing gum for postoperative recovery of gastrointestinal function", "imported": false, "abstract": "Abstract - Background Ileus commonly occurs after abdominal surgery, and is associated with complications and increased length of hospital stay (LOHS). Onset of ileus is considered to be multifactorial, and a variety of preventative methods have been investigated. Chewing gum (CG) is hypothesised to reduce postoperative ileus by stimulating early recovery of gastrointestinal (GI) function, through cephalo‐vagal stimulation. There is no comprehensive review of this intervention in abdominal surgery. Objectives To examine whether chewing gum after surgery hastens the return of gastrointestinal function. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), MEDLINE (via PubMed), EMBASE (via Ovid), CINAHL (via EBSCO) and ISI Web of Science (June 2014). We hand‐searched reference lists of identified studies and previous reviews and systematic reviews, and contacted CG companies to ask for information on any studies using their products. We identified proposed and ongoing studies from clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform and meta Register of Controlled Trials. Selection criteria We included completed randomised controlled trials (RCTs) that used postoperative CG as an intervention compared to a control group. Data collection and analysis Two authors independently collected data and assessed study quality using an adapted Cochrane risk of bias (ROB) tool, and resolved disagreements by discussion. We assessed overall quality of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Studies were split into subgroups: colorectal surgery (CRS), caesarean section (CS) and other surgery (OS). We assessed the effect of CG on time to first flatus (TFF), time to bowel movement (TBM), LOHS and time to bowel sounds (TBS) through meta‐analyses using a random‐effects model. We investigated the influence of study quality, reviewers’ methodological estimations and use of Enhanced Recovery After Surgery (ERAS) programmes using sensitivity analyses. We used meta‐regression to explore if surgical site or ROB scores predicted the extent of the effect estimate of the intervention on continuous outcomes. We reported frequency of complications, and descriptions of tolerability of gum and cost. Main results We identified 81 studies that comprised 9072 participants for inclusion in our review. We categorised many studies at high or unclear risk of the bias' assessed. There was statistical evidence that use of CG reduced TFF [overall reduction of 10.4 hours (95% CI: ‐11.9, ‐8.9): 12.5 hours (95% CI: ‐17.2, ‐7.8) in CRS, 7.9 hours (95% CI: –10.0, ‐5.8) in CS, 10.6 hours (95% CI: ‐12.7, ‐8.5) in OS]. There was also statistical evidence that use of CG reduced TBM [overall reduction of 12.7 hours (95% CI: ‐14.5, ‐10.9): 18.1 hours (95% CI: ‐25.3, ‐10.9) in CRS, 9.1 hours (95% CI: ‐11.4, ‐6.7) in CS, 12.3 hours (95% CI: ‐14.9, ‐9.7) in OS]. There was statistical evidence that use of CG slightly reduced LOHS [overall reduction of 0.7 days (95% CI: ‐0.8, ‐0.5): 1.0 days in CRS (95% CI: ‐1.6, ‐0.4), 0.2 days (95% CI: ‐0.3, ‐0.1) in CS, 0.8 days (95% CI: ‐1.1, ‐0.5) in OS]. There was statistical evidence that use of CG slightly reduced TBS [overall reduction of 5.0 hours (95% CI: ‐6.4, ‐3.7): 3.21 hours (95% CI: ‐7.0, 0.6) in CRS, 4.4 hours (95% CI: ‐5.9, ‐2.8) in CS, 6.3 hours (95% CI: ‐8.7, ‐3.8) in OS]. Effect sizes were largest in CRS and smallest in CS. There was statistical evidence of heterogeneity in all analyses other than TBS in CRS. There was little difference in mortality, infection risk and readmission rate between the groups. Some studies reported reduced nausea and vomiting and other complications in the intervention group. CG was generally well‐tolerated by participants. There was little difference in cost between the groups in the two studies reporting this outcome. Sensitivity analyses by quality of studies and robustness of review estimates revealed no clinically important differences in effect estimates. Sensitivity analysis of ERAS studies showed a smaller effect size on TFF, larger effect size on TBM, and no difference between groups for LOHS. Meta‐regression analyses indicated that surgical site is associated with the extent of the effect size on LOHS (all surgical subgroups), and TFF and TBM (CS and CRS subgroups only). There was no evidence that ROB score predicted the extent of the effect size on any outcome. Neither variable explained the identified heterogeneity between studies. Authors' conclusions This review identified some evidence for the benefit of postoperative CG in improving recovery of GI function. However, the research to date has primarily focussed on CS and CRS, and largely consisted of small, poor quality trials. Many components of the ERAS programme also target ileus, therefore the benefit of CG alongside ERAS may be reduced, as we observed in this review. Therefore larger, better quality RCTS in an ERAS setting in wider surgical disciplines would be needed to improve the evidence base for use of CG after surgery. Plain language summary Chewing gum after surgery to help recovery of the digestive system Background When people have surgery on their abdomen, the digestive system can stop working for a few days. This is called ileus, and can be painful and uncomfortable. There are different causes of ileus, and several ways of treating or preventing it. One possible way of preventing ileus is by chewing gum. The idea is that chewing gum tricks the body into thinking it is eating, causing the digestive system to start working again. It is important to do this review because ileus is common: it is estimated that up to a third of people having bowel surgery suffer from ileus. Main Findings This review found 81 relevant studies that recruited over 9000 participants in total. The studies mainly focussed on people having bowel surgery or caesarean section, but there were some studies of other surgery types. There were few studies of children. Most studies were of poor quality, which may mean their results are less reliable. We found some evidence that people who chewed gum after an operation were able to pass wind and have bowel movements sooner than people who did not chew gum. We also found some evidence that people who chewed gum after an operation had bowel sounds (gurgling sounds heard using a stethoscope held to the abdomen) slightly sooner than people who did not chew gum. There was a small difference in how long people stayed in hospital between people who did or did not chew gum. There were no differences in complications (such as infection or death) between people who did or did not chew gum. There was also no difference in the overall cost of treatment between people who did or did not chew gum. Conclusions There is some evidence that chewing gum after surgery may help the digestive system to recover. However, the studies included in this review are generally of poor quality, which meant that their results may not be reliable. We also know that there are many factors affecting ileus, and that modern treatment plans attempt to reduce risk of ileus. Therefore to further explore using chewing gum after surgery, more studies would be needed which are larger, of better quality, include different types of surgery, and consider recent changes in health care systems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Short, V, Herbert, G, Perry, R, Atkinson, C, Ness, AR, Penfold, C, Thomas, S, Andersen, HK, Lewis, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD006506.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.775Z" }, { "id": "ddd22dc6-4882-4863-9999-e7303edd1dbe", "pmid": "", "title": "Oral versus intravenous steroids for treatment of relapses in multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Burton, JM, O'Connor, PW, Hohol, M, Beyene, J", "articleTypes": [], "doi": "10.1002/14651858.CD006921.pub3 AB - Abstract - Background This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD006921. DOI: 10.1002/14651858.CD006921.pub2). Multiple sclerosis (MS), a chronic inflammatory and neurodegenerative disease of the central nervous system (CNS), is characterized by recurrent relapses of CNS inflammation ranging from mild to severely disabling. Relapses have long been treated with steroids to reduce inflammation and hasten recovery. However, the commonly used intravenous methylprednisolone (IVMP) requires repeated infusions with the added costs of homecare or hospitalization, and may interfere with daily responsibilities. Oral steroids have been used in place of intravenous steroids, with lower direct and indirect costs. Objectives The primary objective was to compare efficacy of oral versus intravenous steroids in promoting disability recovery in MS relapses <= six weeks. Secondary objectives included subsequent relapse rate, disability, ambulation, hospitalization, immunological markers, radiological markers, and quality of life. Search methods A literature search was performed using Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group's Trials Register (January 2012), abstracts from meetings of the American Academy of Neurology (2008‐2012), the European Federation of Neurological Sciences (2008‐2012), the European Committee for Treatment and Research in Multiple Sclerosis and American Committee for Treatment and Research in Multiple Sclerosis (2008‐2012) handsearching. No language restrictions were applied. Selection criteria Randomized or quasi‐randomized trials comparing oral versus intravenous steroids for acute relapses (<= six weeks) in patients with clinically definite MSover age 16 were eligible. Data collection and analysis Three review authors (JB, PO and MH) participated in the independent assessment of all published articles as potentially relevant to the review. Any disagreement was resolved by discussion among review authors. We contacted study authors for additional information. Methodological quality was assessed by the same three review authors. Relevant data were extracted, and effect size was reported as mean difference (MD), mean difference (MD), odds ratio (OR) and absolute risk difference (ARD). Main results With this current update, a total of five eligible studies (215 patients) were identified. Only one outcome, the proportion of patients with Expanded Disability Status Scale (EDSS) improvement at four weeks, was common to three trials, while two trials examined magnetic resonance imaging (MRI) outcomes. The results of this review shows there is no significant difference in relapse recovery at week four (MD ‐0.22, 95% confidence interval (95% CI), 0.71 to 0.26, P = 0.20) nor differences in magnetic resonance imaging (MRI) gadolinium enhancement activity based on oral versus intravenous steroid treatment. However, only two of the five studies employed more current and rigorous methodological techniques, so these results must be taken with some caution. The Oral Megadose Corticosteroid Therapy of Acute Exacerbations of Multiple Sclerosis (OMEGA) trial and the \"Efficacy and Safety of Methylprednisolone Per os Versus IV for the Treatment of Multiple Sclerosis (MS) Relapses\" (COPOUSEP) trial, designed to address such limitations, are currently underway. Authors' conclusions The analysis of the five included trials comparing intravenous versus oral steroid therapy for MS relapses do not demonstrate any significant differences in clinical (benefits and adverse events), radiological or pharmacological outcomes. Based on the evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy in the treatment of MS relapses. Plain language summary A comparison of the efficacy of oral versus intravenous steroids in relapsing‐remitting multiple sclerosis (RRMS) RRMS is characterized by periods of disability (relapse) due to inflammation in the central nervous system. All research has shown that a \"speeding up\" of recovery is obtained by use of corticosteroids, given most often in intravenous form. If oral steroids worked as well as intravenous ones for relapse events, they would be easier to take and are more affordable. 
 
 The objective of this review was to assess if oral and intravenous steroids are equally effective and safe in aiding in the recovery from relapses. Among the pertinent literature, only five studies met the inclusion criteria, comprising a total of 215 participants. Despite some limitations in the methods used to conduct the studies (i.e. incomplete reporting of the participants who dropped out the studies and appropriateness of the sample size) and in the analysis of the data, all five studies found that there were no significant differences in term of benefits and adverse events and in the pharmacological and radiological outcomes in patients taking oral or intravenous steroids. Both treatments appear to be equally effective and safe. Based on this evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy for the treatment of MS relapses.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.103Z" }, { "id": "ddd94d12-c0fc-44b6-9629-7e2a319d5ea4", "pmid": "", "title": "Immunosuppressive agents for myasthenia gravis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Hart, IK, Sathasivam, S, Sharshar, T", "articleTypes": [], "doi": "10.1002/14651858.CD005224.pub2 AB - Abstract - Background The benefits of different immunosuppressants for myasthenia gravis (MG) are unclear. Objectives Assessment of immunosuppressant drug efficacy in MG. Search methods We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to July 2007), EMBASE (from January 1980 to July 2007), review and trial bibliographies and contacted trial authors. Selection criteria Types of studies: Randomised and quasi‐randomised controlled trials. Types of participants: Any age, any type or severity of MG regardless of concomitant treatment. Types of interventions: Any immunosuppressive agent. Types of outcome measures: Primary: 
 (1) Improvement or not at six months Secondary: 
 (1) Improvement or not at one year 
 (2) Need for other treatment, for example corticosteroid dose, at six months 
 (3) Number of exacerbations during the first year 
 (4) Acetylcholine receptor antibody titre after at least six months 
 (5) Occurrence of one or more adverse events at any time after the introduction of treatment. Data collection and analysis One author extracted and two checked the data. Main results Seven trials are included but few reported the outcomes selected for this review. A meta‐analysis of ciclosporin versus placebo from two trials (59 participants) ‐ one as monotherapy (20 participants) and the other with corticosteroids (39 participants) ‐ showed that it resulted in improvement of participants in the ciclosporin group compared with those in the placebo group, with a relative rate of improvement of 2.44 (95% confidence interval (CI) 1.13 to 5.27). In addition the weighted mean difference in QMG score between the ciclosporin and placebo groups was ‐0.34 (95% CI ‐0.52 to ‐0.17). Azathioprine (plus prednisolone for first month) had no significant benefit over prednisolone alone (41 participants). The effects of azathioprine plus prednisolone versus prednisolone plus placebo were similar (34 participants). Cyclophosphamide was reported to be statistically more efficacious than placebo at 12 months in corticosteroid‐dependent participants (23 participants), but no raw data were available. Trials of mycophenolate mofetil and tacrolimus did not provide relevant endpoint data for this review. All trials had low numbers of participants. Adverse event reporting was variable. Trial protocol heterogeneity prevented comparison of the different immunosuppressants. Authors' conclusions In generalised MG, limited evidence from small RCTs suggests that ciclosporin, as monotherapy or with corticosteroids, or cyclophosphamide with corticosteroids, significantly improve MG. 
 Limited evidence from RCTs shows no significant benefit from azathioprine (as monotherapy or with steroids), mycophenolate mofetil (as monotherapy or with either corticosteroids or ciclosporin) or tacrolimus (with corticosteroids or plasma exchange). Bigger, better‐designed, longer trials are needed. Plain language summary A review of the use of drugs that suppress the immune system (immunosuppressants) in myasthenia gravis. Myasthenia gravis (MG) is caused by antibodies produced by the immune system that impair the transmission of nerve impulses to muscles. This results in muscle weakness that characteristically fluctuates. About one person in every 10 000 ‐ 50 000 develops MG each year. The natural history of the disorder is typically a series of exacerbations and remissions. Severe attacks can be life‐threatening because of weakness of muscles involved in swallowing causing choking, and chest muscles causing difficulty with breathing. In MG, immunosuppressant drugs act mainly by reducing the production of antibodies. There were seven randomised controlled trials to include in this review. Each trial compared different interventions in generalised MG: (1) azathioprine plus initial prednisolone versus prednisolone ‐ 41 participants; (2) azathioprine plus prednisolone versus prednisolone plus placebo (dummy treatment) ‐ 34 participants; (3) ciclosporin monotherapy versus placebo ‐ 20 participants; (4) ciclosporin plus prednisolone versus prednisolone plus placebo ‐ 39 participants; (5) cyclophosphamide plus prednisolone versus prednisolone plus placebo ‐ 23 participants; (6) mycophenolate mofetil plus either ciclosporin or prednisolone or no immunosuppressants versus placebo plus either ciclosporin or prednisolone or no immunosuppressants trial ‐ 14 participants; (7) tacrolimus plus corticosteroids with or without plasma exchange versus no tacrolimus plus corticosteroids with or without plasma exchange trial ‐ 34 participants. It is difficult to draw useful clinical conclusions from this small number of often short‐term, randomised controlled trials. Each trial had relatively few participants and different trials used different study designs. The limited evidence available found that MG improved significantly with either ciclosporin (alone or in combination with corticosteroids) or cyclophosphamide (in combination with corticosteroids) compared with placebo. There is no clear evidence from randomised controlled trials of benefit for any of the immunosuppressant drugs used more commonly in MG ‐ azathioprine (alone or in combination with corticosteroids), mycophenolate mofetil (as monotherapy or in combination with either corticosteroids or ciclosporin) or tacrolimus (in combination with corticosteroids or plasma exchange or both). There is no randomised controlled trial of methotrexate in MG. Long‐term studies of the potentially formidable toxic effects of all of these drugs are lacking in MG.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.777Z" }, { "id": "ddf0b1be-36da-4796-8ee4-32aefa382f1d", "pmid": "", "title": "Colchicine for acute gout", "imported": false, "abstract": "Abstract - Background This is an updated Cochrane Review, first published in 2006 and updated in 2014. Gout is one of the most common rheumatic diseases worldwide. Despite the use of colchicine as one of the first‐line therapies for the treatment of acute gout, evidence for its benefits and harms is relatively limited. Objectives To update the available evidence of the benefits and harms of colchicine for the treatment of acute gout. Search methods We updated the search of CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICTRP registries to 28 August 2020. We did not impose any date or language restrictions in the search. Selection criteria We considered published randomised controlled trials (RCTs) and quasi‐randomised controlled trials (quasi‐RCTs) evaluating colchicine therapy compared with another therapy (placebo or active) in acute gout; low‐dose colchicine at clinically relevant doses compared with placebo was the primary comparison. The major outcomes were pain, participant global assessment of treatment success (proportion with 50% or greater decrease in pain from baseline up to 32 to 36 hours), reduction of inflammation, function of target joint, serious adverse events, total adverse events and withdrawals due to adverse events. Data collection and analysis We used standard methodological procedures as expected by Cochrane in this review update. Main results We included four trials (803 randomised participants), including two new trials, in this updated review. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We did not identify any trials comparing colchicine to glucocorticoids (by any route). The mean age of participants ranged from 51.2 to 70 years, and trial duration from 48 hours to 12 weeks. Two trials were at low risk of bias, one was possibly susceptible to selection bias (random sequence generation), reporting bias and other bias, and one open‐label trial was at high risk of performance and detection bias. For the primary comparison, low‐quality evidence from one trial (103 participants, downgraded for imprecision and bias) suggests low‐dose colchicine may improve treatment outcome compared to placebo with little or no increased risk of adverse events. The number of people who reported treatment success (50% or greater pain reduction) at 32 to 36 hours was slightly larger with low‐dose colchicine (418 per 1000) compared with placebo (172 per 1000; risk ratio (RR) 2.43, 95% confidence interval (CI) 1.05 to 5.64; absolute improvement 25% more reported success (7% more to 42% more, the 95% CIs include both a clinically important and unimportant benefit); relative change of 143% more people reported treatment success (5% more to 464% more). The incidence of total adverse events was 364 per 1000 with low‐dose colchicine compared with 276 per 1000 with placebo: RR 1.32, 95% CI 0.68 to 2.56; absolute difference 9% more events with low‐dose colchicine (9% fewer to 43% more, the 95% CIs include both a clinically important effect and no effect); relative change of 32% more events (32% fewer to 156% more). No participants withdrew due to adverse events or reported any serious adverse events. Pain, inflammation and function were not reported. Low‐quality evidence (downgraded for imprecision and bias) from two trials (124 participants) suggests that high‐dose colchicine compared to placebo may improve symptoms, but with increased risk of harms. More participants reported treatment success at 32 to 36 hours with high‐dose colchicine (518 per 1000) compared with placebo (240 per 1000): RR 2.16, 95% CI 1.28 to 3.65, absolute improvement 28% (8% more to 46% more); more also had reduced inflammation at this time point with high‐dose colchicine (504 per 1000) compared with placebo (48 per 1000): RR 10.50, 95% CI 1.48 to 74.38; absolute improvement 45% greater (22% greater to 68% greater); but more adverse events were reported with high‐dose colchicine (829 per 1000 compared with 260 per 1000): RR 3.21, 95% CI 2.01 to 5.11, absolute difference 57% (26% more to 74% more). Pain and function were not reported. Low‐quality evidence from a single trial comparing high‐dose to low‐dose colchicine indicates there may be little or no difference in benefit in terms of treatment success at 32 to 36 hours but more adverse events associated with the higher dose. Similarly, low‐quality evidence from a single trial indicates there may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction at seven days, with a similar number of adverse events reported at four weeks follow‐up. Reduction of inflammation, function of target joint and withdrawals due to adverse events were not reported in either of these trials, and pain was not reported in the high‐dose versus low‐dose colchicine trial. We were unable to estimate the risk of serious adverse events for most comparisons as there were few events reported in the trials. One trial (399 participants) reported three serious adverse (one in a participant receiving low‐dose colchicine and two in participants receiving NSAIDs), due to reasons unrelated to the trial (low‐quality evidence downgraded for bias and imprecision). Authors' conclusions We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve pain when compared to placebo, low‐quality evidence suggests that high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo, while low‐quality evidence indicates that the number of adverse events may be similar with low‐dose colchicine and NSAIDs. Further trials comparing colchicine to placebo or other treatment will likely have an important impact on our confidence in the effect estimates and may change the conclusions of this review. There are no trials reporting the effect of colchicine in populations with comorbidities or in comparison with other commonly used treatments, such as glucocorticoids. Plain language summary Colchicine for treating acute gout flares Background Gout is a very common cause of inflammatory arthritis (pain, redness, warmth and swelling of affected joints) and is caused by urate crystals forming either within or around joints. Uric acid is a normal waste product that is usually excreted with urine. However, in the case of gout, there is either excessive production of uric acid, or the body is not able to excrete it quickly enough, or a combination of both. An attack of gout usually occurs rapidly and usually resolves within 7 to 10 days. Colchicine is a drug that is used mainly in gout to treat an acute attack or to prevent an attack while starting uric acid‐lowering therapy. Study characteristics This Cochrane Review is current to August 2020. We included four trials (803 randomised participants) in this updated review, including two new trials. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (fake medicine) (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We selected low‐dose colchicine compared with placebo as the primary comparison; the low dose is consistent with doses used in practice. Trials were performed in hospital and multicentre settings in four countries, the majority of participants were male, and mean age ranged between 51.2 and 70 years. One trial received funding from a pharmaceutical company that was involved in the study design, data collection, data analysis, and manuscript writing. Key results Compared with placebo medication, low‐dose colchicine for people with acute gout may slightly improve treatment outcomes with little or no increased risk of adverse events at 32 to 36 hours. Proportion of participants reporting treatment success (defined as 50% or more reduction in pain) 25% more people (7% more to 42% more) reported success, or 25 more out of 100 ‐ 42 people out of 100 reported treatment success with colchicine ‐ 17 people out of 100 reported treatment success with placebo Total adverse events (diarrhoea, vomiting or nausea) 6% more people reported adverse events (13% more to 23% more), or 6 more out of 100 ‐ 26 people out of 100 reported side effects with colchicine ‐ 20 people out of 100 reported side effects with placebo Pain, reduction of inflammation, function of target joint, serious adverse events or withdrawals due to adverse events were not reported for this comparison. Other comparisons are briefly summarised here: High‐dose colchicine may improve symptoms compared with placebo, but with more adverse events. High‐dose may have little or no benefit over low‐dose colchicine but more adverse events. There may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction, with a similar number of adverse events. There were no trials that compared colchicine to glucocorticoids. Quality of the evidence We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve treatment success when compared to placebo, high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo while the number of adverse events may be similar with low‐dose colchicine compared with NSAIDs. Further research is very likely to have an important impact on our confidence in the estimate of effect and may change the estimate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "McKenzie, BJ; Wechalekar, MD; Johnston, RV; Schlesinger, N; Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD006190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "de0bc2fc-9004-46e6-a6f9-9a8f6b0a250e", "pmid": "", "title": "Optimizing Naltrexone for Individuals of East Asian Descent", "imported": false, "abstract": "This study will elucidate the pharmacogenetic effects of the Asn40Asp SNP of the OPRM1 gene on biobehavioral and neural markers of response to naltrexone in individuals of East Asian descent, an ethnic group most likely to express the positive predictive allele.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.263Z" }, { "id": "de0bd585-5ade-445f-b74c-df1bf3e9388d", "pmid": "", "title": "Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID‐19", "imported": false, "abstract": "Abstract - Background COVID‐19 illness is highly variable, ranging from infection with no symptoms through to pneumonia and life‐threatening consequences. Symptoms such as fever, cough, or loss of sense of smell (anosmia) or taste (ageusia), can help flag early on if the disease is present. Such information could be used either to rule out COVID‐19 disease, or to identify people who need to go for COVID‐19 diagnostic tests. This is the second update of this review, which was first published in 2020. Objectives To assess the diagnostic accuracy of signs and symptoms to determine if a person presenting in primary care or to hospital outpatient settings, such as the emergency department or dedicated COVID‐19 clinics, has COVID‐19. Search methods We undertook electronic searches up to 10 June 2021 in the University of Bern living search database. In addition, we checked repositories of COVID‐19 publications. We used artificial intelligence text analysis to conduct an initial classification of documents. We did not apply any language restrictions. Selection criteria Studies were eligible if they included people with clinically suspected COVID‐19, or recruited known cases with COVID‐19 and also controls without COVID‐19 from a single‐gate cohort. Studies were eligible when they recruited people presenting to primary care or hospital outpatient settings. Studies that included people who contracted SARS‐CoV‐2 infection while admitted to hospital were not eligible. The minimum eligible sample size of studies was 10 participants. All signs and symptoms were eligible for this review, including individual signs and symptoms or combinations. We accepted a range of reference standards. Data collection and analysis Pairs of review authors independently selected all studies, at both title and abstract, and full‐text stage. They resolved any disagreements by discussion with a third review author. Two review authors independently extracted data and assessed risk of bias using the QUADAS‐2 checklist, and resolved disagreements by discussion with a third review author. Analyses were restricted to prospective studies only. We presented sensitivity and specificity in paired forest plots, in receiver operating characteristic (ROC) space and in dumbbell plots. We estimated summary parameters using a bivariate random‐effects meta‐analysis whenever five or more primary prospective studies were available, and whenever heterogeneity across studies was deemed acceptable. Main results We identified 90 studies; for this update we focused on the results of 42 prospective studies with 52,608 participants. Prevalence of COVID‐19 disease varied from 3.7% to 60.6% with a median of 27.4%. Thirty‐five studies were set in emergency departments or outpatient test centres (46,878 participants), three in primary care settings (1230 participants), two in a mixed population of in‐ and outpatients in a paediatric hospital setting (493 participants), and two overlapping studies in nursing homes (4007 participants). The studies did not clearly distinguish mild COVID‐19 disease from COVID‐19 pneumonia, so we present the results for both conditions together. Twelve studies had a high risk of bias for selection of participants because they used a high level of preselection to decide whether reverse transcription polymerase chain reaction (RT‐PCR) testing was needed, or because they enrolled a non‐consecutive sample, or because they excluded individuals while they were part of the study base. We rated 36 of the 42 studies as high risk of bias for the index tests because there was little or no detail on how, by whom and when, the symptoms were measured. For most studies, eligibility for testing was dependent on the local case definition and testing criteria that were in effect at the time of the study, meaning most people who were included in studies had already been referred to health services based on the symptoms that we are evaluating in this review. The applicability of the results of this review iteration improved in comparison with the previous reviews. This version has more studies of people presenting to ambulatory settings, which is where the majority of assessments for COVID‐19 take place. Only three studies presented any data on children separately, and only one focused specifically on older adults. We found data on 96 symptoms or combinations of signs and symptoms. Evidence on individual signs as diagnostic tests was rarely reported, so this review reports mainly on the diagnostic value of symptoms. Results were highly variable across studies. Most had very low sensitivity and high specificity. RT‐PCR was the most often used reference standard (40/42 studies). Only cough (11 studies) had a summary sensitivity above 50% (62.4%, 95% CI 50.6% to 72.9%)); its specificity was low (45.4%, 95% CI 33.5% to 57.9%)). Presence of fever had a sensitivity of 37.6% (95% CI 23.4% to 54.3%) and a specificity of 75.2% (95% CI 56.3% to 87.8%). The summary positive likelihood ratio of cough was 1.14 (95% CI 1.04 to 1.25) and that of fever 1.52 (95% CI 1.10 to 2.10). Sore throat had a summary positive likelihood ratio of 0.814 (95% CI 0.714 to 0.929), which means that its presence increases the probability of having an infectious disease other than COVID‐19. Dyspnoea (12 studies) and fatigue (8 studies) had a sensitivity of 23.3% (95% CI 16.4% to 31.9%) and 40.2% (95% CI 19.4% to 65.1%) respectively. Their specificity was 75.7% (95% CI 65.2% to 83.9%) and 73.6% (95% CI 48.4% to 89.3%). The summary positive likelihood ratio of dyspnoea was 0.96 (95% CI 0.83 to 1.11) and that of fatigue 1.52 (95% CI 1.21 to 1.91), which means that the presence of fatigue slightly increases the probability of having COVID‐19. Anosmia alone (7 studies), ageusia alone (5 studies), and anosmia or ageusia (6 studies) had summary sensitivities below 50% but summary specificities over 90%. Anosmia had a summary sensitivity of 26.4% (95% CI 13.8% to 44.6%) and a specificity of 94.2% (95% CI 90.6% to 96.5%). Ageusia had a summary sensitivity of 23.2% (95% CI 10.6% to 43.3%) and a specificity of 92.6% (95% CI 83.1% to 97.0%). Anosmia or ageusia had a summary sensitivity of 39.2% (95% CI 26.5% to 53.6%) and a specificity of 92.1% (95% CI 84.5% to 96.2%). The summary positive likelihood ratios of anosmia alone and anosmia or ageusia were 4.55 (95% CI 3.46 to 5.97) and 4.99 (95% CI 3.22 to 7.75) respectively, which is just below our arbitrary definition of a 'red flag', that is, a positive likelihood ratio of at least 5. The summary positive likelihood ratio of ageusia alone was 3.14 (95% CI 1.79 to 5.51). Twenty‐four studies assessed combinations of different signs and symptoms, mostly combining olfactory symptoms. By combining symptoms with other information such as contact or travel history, age, gender, and a local recent case detection rate, some multivariable prediction scores reached a sensitivity as high as 90%. Authors' conclusions Most individual symptoms included in this review have poor diagnostic accuracy. Neither absence nor presence of symptoms are accurate enough to rule in or rule out the disease. The presence of anosmia or ageusia may be useful as a red flag for the presence of COVID‐19. The presence of cough also supports further testing. There is currently no evidence to support further testing with PCR in any individuals presenting only with upper respiratory symptoms such as sore throat, coryza or rhinorrhoea. Combinations of symptoms with other readily available information such as contact or travel history, or the local recent case detection rate may prove more useful and should be further investigated in an unselected population presenting to primary care or hospital outpatient settings. The diagnostic accuracy of symptoms for COVID‐19 is moderate to low and any testing strategy using symptoms as selection mechanism will result in both large numbers of missed cases and large numbers of people requiring testing. Which one of these is minimised, is determined by the goal of COVID‐19 testing strategies, that is, controlling the epidemic by isolating every possible case versus identifying those with clinically important disease so that they can be monitored or treated to optimise their prognosis. The former will require a testing strategy that uses very few symptoms as entry criterion for testing, the latter could focus on more specific symptoms such as fever and anosmia. Plain language summary How accurate are symptoms and medical examination to diagnose COVID‐19? Key messages ‐ The results suggest that a single symptom included in this review cannot accurately diagnose COVID‐19. ‐ Loss of sense of taste or smell could be a 'red flag' for the presence of COVID‐19. Cough or fever might be useful to identify people who might have COVID‐19. These symptoms might be useful to prompt further testing when they are present. ‐ We need more research to investigate combinations of symptoms and signs with other information such as recent contact or travel history, or vaccination status, and in children, and adults aged 65 years and over. What are symptoms or signs of COVID‐19? Symptoms are experienced by patients. COVID‐19 symptoms include cough, sore throat, high temperature, diarrhoea, headache, muscle or joint pain, fatigue, and loss of sense of smell and taste. Signs are measured by healthcare workers during clinical examination. They include lung sounds, blood pressure, blood oxygen level and heart rate. Symptoms and signs of COVID‐19 might be important to help people know whether they and the people they come into contact with should isolate at home, undergo testing with a rapid lateral flow test or PCR (laboratory‐based) test, or be hospitalised. What did we want to find out? Symptoms and signs of COVID‐19 are varied and may indicate other diseases, not just COVID‐19. We wanted to know how accurate diagnosis of COVID‐19 is, based on symptoms and signs from medical examination. We were interested in people with suspected COVID‐19, who go to their doctor, outpatient test centres or hospital. What did we do? We searched for studies that assessed the accuracy of symptoms and signs to diagnose COVID‐19. Studies had to be conducted in general practice, outpatient test centres or hospital outpatient settings only. We only included studies of people in hospital if signs and symptoms were recorded when they were admitted to the hospital, for example through the emergency department. What did we find? We focused on 42 studies with 52,608 participants in this review. The studies assessed 96 separate or combined symptoms and signs. Thirty‐five studies were conducted in emergency departments or outpatient COVID‐19 test centres (46,878 participants), 3 studies in general practice (1230 participants), 2 studies in children’s hospitals (493 in‐ and outpatients), and 2 studies in nursing homes (4007 participants). The studies were conducted in 18 different countries around the world. Twenty‐three studies were conducted in Europe, 8 in North‐America, 5 in Asia, and 3 in South‐America and 3 in Australia. We didn’t find any studies conducted in Africa. Three focused specifically on children, and only 1 focused on adults aged 65 years and over. Most studies did not clearly distinguish between mild and severe COVID‐19, so we present the results for mild, moderate and severe disease together. Few studies reported individual signs as diagnostic tests, so we focus mainly on the diagnostic value of symptoms. The most frequently reported symptoms were cough, fever, shortness of breath and sore throat. According to the studies in our review, in a group of 1000 people with suspected COVID‐19 of whom 270 (27%) would actually have COVID‐19, around 567 people would have a cough. Of these 567, 168 would actually have COVID‐19. Of the 433 who do not have a cough, 102 would have COVID‐19. In the same 1000 people, around 283 people would have a fever. Of these 283, 102 would actually have COVID‐19. Of the 717 people without fever, 168 would have COVID‐19. Someone who has lost their sense of smell or taste is five times more likely to have COVID‐19 than someone who hasn’t. Other symptoms, such as a sore throat or runny nose, are more likely to indicate the presence of an infectious disease other than COVID‐19. In the same 1000 people as described above, around 362 people would have a sore throat. Of these, only 84 would actually have COVID‐19. Of the 638 patients without sore throat, 186 would have COVID‐19. We found similar figures for having a runny nose. What are the limitations of the evidence? The results of this updated review are more reliable than those in previous versions as we included more high‐quality studies. However, the accuracy of individual symptoms varied across studies and the diagnostic value of symptoms such as fever, cough or other respiratory symptoms might still be overestimated, as most studies deliberately included participants because they had these symptoms. The results do not clearly differentiate between people with mild, moderate or severe COVID‐19. Only a few studies investigated the symptom‐based diagnosis of COVID‐19 in children or older adults. How up to date is this review? This review updates our previous review. The evidence is up to date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Struyf, T; Deeks, JJ; Dinnes, J; Takwoingi, Y; Davenport, C; Leeflang, MMG; Spijker, R; Hooft, L; Emperador, D; Domen, J; Tans, A; Janssens, S; Wickramasinghe, D; Lannoy, V; Horn, SR A; Van den Bruel, A", "articleTypes": [], "doi": "10.1002/14651858.CD013665.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "de0f3e73-b294-4985-a5cd-74df534000b4", "pmid": "", "title": "Fluvoxamine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Fluvoxamine, one of the oldest selective serotonin reuptake inhibitors (SSRIs), is prescribed to patients with major depression in many countries. Several studies have previously reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are now outdated. Objectives Our objective is to evaluate the effectiveness, tolerability and side effect profile of fluvoxamine for major depression in comparison with other anti‐depressive agents, including tricyclics (TCAs), heterocyclics, other SSRIs, SNRIs, other newer agents and other conventional psychotropic drugs. Search methods We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register. Trial databases and ongoing trial registers in North America, Europe, Japan and Australia, were handsearched for randomised controlled trials. We checked reference lists of the articles included in the review, previous systematic reviews and major textbooks of affective disorder for published reports and citations of unpublished research. The date of last search was 31 August 2008. Selection criteria We included all randomised controlled trials, published in any language, that compared fluvoxamine with any other active antidepressants in the acute phase treatment of major depression. Data collection and analysis Two independent review authors inspected citations and abstracts, obtained papers, extracted data and assessed the risk of bias of included studies. We analysed dichotomous data using odds ratios (ORs) and continuous data using the standardised mean difference (SMD). A random effects model was used to combine studies. Main results A total of 54 randomised controlled trials (n = 5122) were included. No strong evidence was found to indicate that fluvoxamine was either superior or inferior to other antidepressants regarding response, remission and tolerability. However, differing side effect profiles were evident, especially with regard to gastrointestinal side effects of fluvoxamine when compared to other antidepressants. For example, fluvoxamine was generally associated with a higher incidence of vomiting/nausea (versus imipramine, OR 2.23, CI 1.59 to 3.14; versus clomipramine, OR 2.13, CI 1.06 to 4.27; versus amitriptyline, OR 2.86, CI 1.31 to 2.63). Authors' conclusions We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, differing side effect profiles were evident. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations, including these differences in side effect profiles. Plain language summary Fluvoxamine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Although pharmacological and psychological interventions are both effective for major depression, antidepressant (AD) drugs remain the mainstay for treatment of moderate or severe depression. Fluvoxamine is one of the oldest selective serotonin reuptake inhibitors (SSRIs) and is prescribed to patients with major depression in many countries. This review reports trials comparing fluvoxamine with other antidepressants for treatment of major depression. We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, there is evidence of differing side‐effect profiles, especially when comparing gastrointestinal side effects between fluvoxamine and tricyclic antidepressants (TCAs). Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including these differences in side effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Omori, IM; Watanabe, N; Nakagawa, A; Cipriani, A; Barbui, C; McGuire, H; Churchill, R; Furukawa, TA", "articleTypes": [], "doi": "10.1002/14651858.CD006114.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "de363408-c7f1-4a8e-a4c0-5d827f5d46c1", "pmid": "", "title": "Obesity and Lipids: a Matter of Taste? Impact of Bariatric Surgery on Taste Receptors", "imported": false, "abstract": "The purpose of the protocol is to determine the impact of bariatric surgery on taste receptors and taste perceptions and to precise the factors implicated in taste alterations in 50 obese patients before and 6 months after bariatric surgery (25 Roux Y gastric bypass and 25 sleeve gastrectomy).", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.141Z" }, { "id": "de4a0815-8cac-4359-b3df-364df24810fe", "pmid": "", "title": "Interventions for improving adherence to ocular hypotensive therapy", "imported": false, "abstract": "Abstract - Background Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open‐angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence. Objectives To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma. Data collection and analysis At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity. Main results Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow‐up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross‐over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive. Authors' conclusions Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes. Plain language summary Interventions for helping people use eye drops as prescribed for raised eye pressure or glaucoma A large number of people do not use eye drops as prescribed. Glaucoma is a slowly progressive eye disease, which can result in severe vision loss. Drops prescribed for raised eye pressure or glaucoma are aimed at lowering the pressure to assist in reducing the rate of progression, or preventing the conversion of raised eye pressure to glaucoma. It is important that these eye drops are used continually, usually for life. Approximately one‐third of people who are prescribed eye drops for the first time fail to continue collecting prescriptions within the first year and even when patients collect prescriptions they do not always use the drops as frequently as they should. A number of reasons are thought to be the cause, for example, forgetfulness, being prescribed a large number of medications, difficulties instilling drops, lack of knowledge about glaucoma, a busy lifestyle and seeing no benefit. This review is based on 16 studies (1565 participants) that tried out different methods to help people to use drops as prescribed. All the studies took place in industrialised countries (Belgium, Denmark, France, Greece, Iceland, Japan, Sweden, Switzerland, UK and USA) and recruited participants in outpatient clinics. The following interventions were included: simplifying drop routines, reminder devices, automated telephone service, providing information about glaucoma and offering advice regarding day to day issues with eye care. Those studies which combined the provision of information about glaucoma and eye drops with other interventions, such as helping people to fit instillation of eye drops into their daily routine, appear to be more successful. Unfortunately, not all of these studies were of high quality and, therefore, until more evidence is available we cannot recommend any particular method. Good quality research is needed in this area in order to develop a better understanding of patients' individual needs and to help us provide more effective eye care services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Waterman, H, Evans, JR, Gray, TA, Henson, D, Harper, R", "articleTypes": [], "doi": "10.1002/14651858.CD006132.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.783Z" }, { "id": "de57d1cb-efce-4906-a8b9-be73a94d5fec", "pmid": "", "title": "Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women", "imported": false, "abstract": "Abstract - Background Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions, particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia. However, its long‐term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teeth staining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation for preventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent. Objectives To assess the effects of intermittent oral iron supplementation, alone or in combination with other nutrients, on anaemia and its associated impairments among menstruating women, compared with no intervention, a placebo, or daily supplementation. Search methods In February 2018, we searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers. In March 2018, we also searched LILACS, IBECS and IMBIOMED. In addition, we examined reference lists, and contacted authors and known experts to identify additional studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs with either individual or cluster randomisation. Participants were menstruating women; that is, women beyond menarche and prior to menopause who were not pregnant or lactating and did not have a known condition that impeded the presence of menstrual periods. The intervention was the use of iron supplements intermittently (one, two or three times a week on non‐consecutive days) compared with placebo, no intervention, or the same supplements provided on a daily basis. Data collection and analysis Both review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy, assessed the risk of bias of the included studies, and rated the quality of the evidence using GRADE. Main results We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessing risk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one third of the included studies did not provide a funding source. Although quality across studies was variable, the results consistently showed that intermittent iron supplementation (alone or with any other vitamins and minerals) compared with no intervention or a placebo, reduced the risk of having anaemia (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.49 to 0.87; 11 studies, 3135 participants; low‐quality evidence), and improved the concentration of haemoglobin (mean difference (MD) 5.19 g/L, 95% CI 3.07 to 7.32; 15 studies, 2886 participants; moderate‐quality evidence), and ferritin (MD 7.46 μg/L, 95% CI 5.02 to 9.90; 7 studies, 1067 participants; low‐quality evidence). Intermittent regimens may also reduce the risk of having iron deficiency (RR 0.50, 95% CI 0.24 to 1.04; 3 studies, 624 participants; low‐quality evidence), but evidence was inconclusive regarding iron deficiency anaemia (RR 0.07, 95% CI 0.00 to 1.16; 1 study, 97 participants; very low‐quality evidence) and all‐cause morbidity (RR 1.12, 95% CI 0.82 to 1.52; 1 study, 119 participants; very low‐quality evidence). Women in the control group were less likely to have any adverse side effects than those receiving intermittent iron supplements (RR 1.98, 95% CI 0.31 to 12.72; 3 studies, 630 participants; moderate‐quality evidence). In comparison with daily supplementation, results showed that intermittent supplementation (alone or with any other vitamins and minerals) produced similar effects to daily supplementation (alone or with any other vitamins and minerals) on anaemia (RR 1.09, 95% CI 0.93 to 1.29; 8 studies, 1749 participants; moderate‐quality evidence). Intermittent supplementation may produce similar haemoglobin concentrations (MD 0.43 g/L, 95% CI −1.44 to 2.31; 10 studies, 2127 participants; low‐quality evidence) but lower ferritin concentrations on average (MD −6.07 μg/L, 95% CI −10.66 to −1.48; 4 studies, 988 participants; low‐quality evidence) compared to daily supplementation. Compared to daily regimens, intermittent regimens may also reduce the risk of having iron deficiency (RR 4.30, 95% CI 0.56 to 33.20; 1 study, 198 participants; very low‐quality evidence). Women receiving iron supplements intermittently were less likely to have any adverse side effects than those receiving iron supplements daily (RR 0.41, 95% CI 0.21 to 0.82; 6 studies, 1166 participants; moderate‐quality evidence). No studies reported on the effect of intermittent regimens versus daily regimens on iron deficiency anaemia and all‐cause morbidity. Information on disease outcomes, adherence, economic productivity, and work performance was scarce, and evidence about the effects of intermittent supplementation on these outcomes unclear. Overall, whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline did not seem to affect the findings. Furthermore, the response did not differ in areas where malaria was frequent, although very few trials were conducted in these settings. Authors' conclusions Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations with different anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittently is probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base ranged from very low to moderate quality, suggesting that we are uncertain about these effects. Plain language summary Iron supplements taken one, two or three times a week for preventing anaemia, and its consequences in menstruating women What is the issue? Across the globe, approximately one out of three non‐pregnant women of reproductive age are anaemic; i.e. have fewer red blood cells or less haemoglobin (a red substance that combines with oxygen and carries it around the body) in each red blood cell than normal. Although there are several causes of anaemia, it very often results from sustained iron deficiency. The standard practice to prevent or treat anaemia in women has been daily iron supplementation (sometimes combined with folic acid and other vitamins and minerals) for three months. However, it is frequently associated with side effects such as nausea or constipation. Intermittent supplementation (that is, the consumption of supplements one, two or three times a week on non‐consecutive days) has been proposed as an effective and safer alternative to daily supplementation. Why is this important? Women with anaemia may have less energy for physical work and become more prone to infections. Most women throughout the world enter pregnancy with anaemia, putting them at greater risk of having low birth‐weight babies and other complications during delivery. Some scientists believe that taking iron a few times a week – instead of every day – can help women with anaemia to feel better and improve their haemoglobin without giving them as many side effects. If women have fewer side effects, they may be more likely to take iron supplements more regularly and for longer periods. What evidence did we find? We reviewed the evidence in February 2018. We included 25 randomised controlled trials (a type of experiment in which participants are randomly assigned to one or more treatment groups) involving 10,996 women. We included studies examining the administration of intermittent iron supplements versus no intervention, a placebo (dummy pill) or the same supplements given on a daily basis. Most studies were implemented in school settings and were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one‐third of the included studies did not provide a funding source. The findings show that women receiving intermittent supplementation with iron alone, or in combination with folic acid or other nutrients, were less likely to be anaemic or iron deficient than those women who received no iron supplements or a placebo. They also had higher concentrations of haemoglobin and ferritin (a protein that carries iron) but reported more side effects. In addition, the findings indicate that intermittent supplementation was as effective as daily supplementation in reducing the prevalence of anaemia and increasing haemoglobin concentrations, with fewer side effects. It may have reduced the risk of having iron deficiency also, but it had no effect on raising ferritin concentrations more than the daily dose. We found scarce evidence on the effect of intermittent supplementation compared to placebo or daily supplementation on iron deficiency anaemia, all‐cause morbidity, disease outcomes, adherence, economic productivity, and work performance. What does this mean? Intermittent iron supplementation in menstruating women may be an effective intervention for reducing anaemia and improving haemoglobin concentrations compared to no treatment, placebo or daily supplementation. Intermittent supplementation may be associated with fewer side effects compared to daily supplementation. The findings were not affected by whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline (starting point for comparisons). The evidence base was of overall low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fernández-Gaxiola, AC, De-Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD009218.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.127Z" }, { "id": "de763874-c444-4d66-9819-4b62da1a9021", "pmid": "", "title": "Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Das, RR, Singh, M, Naik, SS", "articleTypes": [], "doi": "10.1002/14651858.CD011597.pub3 AB - Abstract - Background Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases children's risk of developing pneumonia. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited. This is an update of a Cochrane Review first published in 2018. Objectives To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia. Search methods We searched CENTRAL, MEDLINE, Embase, and two trial registries on 28 December 2021. We applied no language restrictions. Selection criteria We included randomised controlled trials (RCTs) that compared vitamin D supplementation with placebo in children (aged one month to five years) hospitalised with acute community‐acquired pneumonia, as defined by the World Health Organization (WHO) acute respiratory infection guidelines. For this update, we reappraised eligible trials according to research integrity criteria, excluding RCTs published from April 2018 that were not prospectively registered in a trials registry according to WHO or Clinical Trials Registry – India (CTRI) guidelines (it was not mandatory to register clinical trials in India before April 2018). Data collection and analysis Two review authors independently assessed trials for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with number of participants in each group. We used standard methodological procedures expected by Cochrane. Main results In this update, we included three new trials involving 468 children, bringing the total number of trials to seven, with 1601 children (631 with pneumonia and 970 with severe or very severe pneumonia). We categorised three previously included studies and three new studies as 'awaiting classification' based on the research integrity screen.
Five trials used a single bolus dose of vitamin D (300,000 IU in one trial and 100,000 IU in four trials) at the onset of illness or within 24 hours of hospital admission; one used a daily dose of oral vitamin D (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used variable doses (on day 1, 20,000 IU in children younger than six months, 50,000 IU in children aged six to 12 months, and 100,000 IU in children aged 13 to 59 months; followed by 10,000 IU/day for four days or until discharge). Three trials performed microbiological diagnosis of pneumonia, radiological diagnosis of pneumonia, or both. Vitamin D probably has little or no effect on the time to resolution of acute illness (mean difference (MD) −1.28 hours, 95% confidence interval (CI) −5.47 to 2.91; 5 trials, 1188 children; moderate‐certainty evidence). We do not know if vitamin D has an effect on the duration of hospitalisation (MD 4.96 hours, 95% CI −8.28 to 18.21; 5 trials, 1023 children; very low‐certainty evidence). We do not know if vitamin D has an effect on mortality rate (risk ratio (RR) 0.69, 95% CI 0.44 to 1.07; 3 trials, 584 children; low‐certainty evidence). The trials reported no major adverse events. According to GRADE criteria, the evidence was of very low‐to‐moderate certainty for all outcomes, owing to serious trial limitations, inconsistency, indirectness, and imprecision. Three trials received funding: one from the New Zealand Aid Corporation, one from an institutional grant, and one from multigovernment organisations (Bangladesh, Sweden, and UK). The remaining four trials were unfunded. Authors' conclusions Based on the available evidence, we are uncertain whether vitamin D supplementation has important effects on outcomes of acute pneumonia when used as an adjunct to antibiotics. The trials reported no major adverse events. Uncertainty in the evidence is due to imprecision, risk of bias, inconsistency, and indirectness. Plain language summary Is vitamin D an effective and safe addition to antibiotics for treating children with acute pneumonia? What is pneumonia, and how can it be treated? Pneumonia is inflammation (swelling) of the lungs caused by an infection. Treatment for pneumonia includes antibiotics, providing oxygen through a mask, and other supportive therapies. Vitamin D boosts immune defences and reduces excessive inflammation: these effects may help children recover from an episode of pneumonia. What did we want to find out? We wanted to find out if vitamin D, taken together with antibiotics, can help children to recover from an episode of pneumonia. What did we do? We searched for trials that looked at vitamin D compared with placebo (dummy treatment) in children aged between one month and five years who had pneumonia. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. Study characteristics We included seven trials involving 1601 children from low‐ and middle‐income countries. In five trials, children received a single large dose of vitamin D when they joined the trial or within 24 hours of admission to hospital. In two trials, children received vitamin D for five days. One trial excluded children with normal vitamin D levels. Two trials reported the cause of children's pneumonia. Key results Vitamin D probably has little or no effect on the time it takes children to get better from pneumonia. We do not know if vitamin D has an effect on the time children spend in hospital or the number of children who die. The studies reported no major harmful events. What are the limitations of the evidence? We have only moderate confidence in the evidence on the time it took children to recover from pneumonia, because all children in this comparison were from low‐income regions, so the results may not apply to higher‐income populations. We have little confidence in the evidence on death rate, because of the same applicability problem outlined above, and because the result was compatible with both appreciable benefit and harm. We have very little confidence in the evidence on time spent in hospital, because of the same applicability problem outlined above, because the children and health providers in one study knew what the allocated treatment was, and because the results were very inconsistent across the studies included in the comparison. How up to date is the evidence? The evidence is current to 28 December 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.781Z" }, { "id": "de8e3209-19a5-4a86-b2f7-98fcdcd0b42c", "pmid": "", "title": "Inhaled mannitol for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Several agents are used to clear secretions from the airways of people with cystic fibrosis. Mannitol increases mucociliary clearance, but its exact mechanism of action is unknown. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents which require delivery via a nebuliser. Phase III trials of inhaled dry powder mannitol for the treatment of cystic fibrosis have been completed and it is now available in Australia and some countries in Europe. This is an update of a previous review. Objectives To assess whether inhaled dry powder mannitol is well tolerated, whether it improves the quality of life and respiratory function in people with cystic fibrosis and which adverse events are associated with the treatment. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic databases, handsearching relevant journals and abstracts from conferences. Date of last search: 12 December 2019. Selection criteria All randomised controlled studies comparing mannitol with placebo, active inhaled comparators (for example, hypertonic saline or dornase alfa) or with no treatment. Data collection and analysis Authors independently assessed studies for inclusion, carried out data extraction and assessed the risk of bias in included studies. The quality of the evidence was assessed using GRADE. Main results Six studies (reported in 36 unique publications) were included with a total of 784 participants. Duration of treatment in the included studies ranged from 12 days to six months, with open‐label treatment for an additional six months in two of the studies. Five studies compared mannitol with control (a very low dose of mannitol or non‐respirable mannitol) and the final study compared mannitol to dornase alfa alone and to mannitol plus dornase alfa. Two large studies had a similar parallel design and provided data for 600 participants, which could be pooled where data for a particular outcome and time point were available. The remaining studies had much smaller sample sizes (ranging from 22 to 95) and data could not be pooled due to differences in design, interventions and population. Pooled evidence from the two large parallel studies was judged to be of low to moderate quality and from the smaller studies was judged to be of low to very low quality. In all studies, there was an initial test to see if participants tolerated mannitol, with only those who could tolerate the drug being randomised; therefore, the study results are not applicable to the cystic fibrosis population as a whole. While the published papers did not provide all the data required for our analysis, additional unpublished data were provided by the drug's manufacturer and the author of one of the studies. Pooling the large parallel studies comparing mannitol to control, up to and including six months, lung function (forced expiratory volume at one second) measured in both mL and % predicted was significantly improved in the mannitol group compared to the control group (moderate‐quality evidence). Beneficial results were observed in these studies in adults and in both concomitant dornase alfa users and non‐users in these studies. In the smaller studies, statistically significant improvements in lung function were also observed in the mannitol groups compared to the non‐respirable mannitol groups; however, we judged this evidence to be of low to very low quality. For the comparisons of mannitol and control, we found no consistent differences in health‐related quality of life in any of the domains except for burden of treatment, which was less for mannitol up to four months in the two pooled studies of a similar design; this difference was not maintained at six months. It should be noted that the tool used to measure health‐related quality of life was not designed to assess mucolytics and pooling of the age‐appropriate tools (as done in some of the included studies) may not be valid so results were judged to be low to very low quality and should be interpreted with caution. Cough, haemoptysis, bronchospasm, pharyngolaryngeal pain and post‐tussive vomiting were the most commonly reported side effects in both treatment groups. Where rates of adverse events could be compared, statistically no significant differences were found between mannitol and control groups; although some of these events may have clinical relevance for people with CF. For the comparisons of mannitol to dornase alfa alone and to mannitol plus dornase alfa, very low‐quality evidence from a 12‐week cross‐over study of 28 participants showed no statistically significant differences in the recorded domains of health‐related quality of life or measures of lung function. Cough was the most common side effect in the mannitol alone arm but there was no occurrence of cough in the dornase alfa alone arm and the most commonly reported reason of withdrawal from the mannitol plus dornase alfa arm was pulmonary exacerbations. In terms of secondary outcomes of the review (pulmonary exacerbations, hospitalisations, symptoms, sputum microbiology), evidence provided by the included studies was more limited. For all comparisons, no consistent statistically significant and clinically meaningful differences were observed between mannitol and control treatments (including dornase alfa). Authors' conclusions There is moderate‐quality evidence to show that treatment with mannitol over a six‐month period is associated with an improvement in some measures of lung function in people with cystic fibrosis compared to control. There is low to very low‐quality evidence suggesting no difference in quality of life for participants taking mannitol compared to control. This review provides very low‐quality evidence suggesting no difference in lung function or quality of life comparing mannitol to dornase alfa alone and to mannitol plus dornase alfa. The clinical implications from this review suggest that mannitol could be considered as a treatment in cystic fibrosis; but further research is required in order to establish who may benefit most and whether this benefit is sustained in the longer term. Furthermore, studies comparing its efficacy against other (established) mucolytic therapies need to be undertaken before it can be considered for mainstream practice. Plain language summary Mannitol, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of inhaling mannitol to treat lung disease in people with cystic fibrosis. Background Cystic fibrosis is a genetic disorder that affects the exocrine glands (sweat glands and others). Lung infections produce thick mucus (phlegm) which can block air passages and cause more infection and repeated inflammation. In turn, this progressively damages the lungs and can eventually cause respiratory failure. There are several drugs that are used to clear mucus from the airways of people with cystic fibrosis and inhaled dry powder mannitol is a new one that may improve their lung function. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents delivered by a nebuliser (e.g. hypertonic saline). Mannitol is available in Australia and some European countries. This is an updated version of the review. Search date The evidence is current to: 12 December 2019. Study characteristics We included six studies (with a total of 784 adults and children) in this review. Five studies compared a standard dose of mannitol with control (a very low dose of mannitol or a version of mannitol which did not allow the active drug to reach the lungs) and the sixth study compared mannitol with nebulised recombinant human deoxyribonuclease (dornase alfa), both alone and taken together. Participants could continue using dornase alfa and other standard therapies, but were excluded from the five of the six studies if they were using hypertonic saline. Treatment in these studies lasted from 12 days to six months. Five studies provided the treatments to people as outpatients and in one study, the children treated were in hospital due to pulmonary exacerbations (flare ups of disease). Key results It was difficult to combine evidence from the studies in this review due to differences in the designs of the studies, treatments examined and the settings (hospital or outpatients). Some additional information was obtained from the drug manufacturer and one study author to aid the review. The review found low‐ to very low‐quality evidence that there is no difference between mannitol and control treatments or mannitol given either with or without additional dornase alfa in terms of quality of life. There was moderate‐quality evidence of improvements in some measures of lung function across the larger studies comparing mannitol to control. Beneficial effects were also seen in the subgroup of adults and in both those who were using dornase alfa and those who were not. Cough (including coughing up blood), contraction of the airways, pain in the pharynx or larynx and post‐treatment vomiting were the most commonly reported side effects on both treatments, but there was no evidence to suggest that these side effects occurred more on mannitol than on control treatments or on dornase alfa. None of the studies compared mannitol to nebulised hypertonic saline and so we can not comment on which agent is better for airway clearance. More research is needed to answer this question. Quality of the evidence We judged the quality of the evidence from this review to be of very low to moderate quality, depending on the outcome measured. We do not think that the way the studies were designed affected the results. We judged that everyone taking part had equal chances of being in either of the treatment groups and would not have known in advance or during the study which treatment they were receiving. However, the numbers of people who dropped out of the studies might affect how the results are interpreted, as well as how many people were recruited into the studies and how they were selected from all people with cystic fibrosis who could have been included. Although some of these issues were resolved when the drug's manufacturer (who also sponsored the studies) provided some additional information. It is important to realise that before people started the study, they took a test to see if they could tolerate mannitol and only those who did could carry on. This means that the results of the studies only apply to those people with cystic fibrosis who can tolerate mannitol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Nevitt, SJ, Thornton, J, Murray, CS, Dwyer, T", "articleTypes": [], "doi": "10.1002/14651858.CD008649.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.758Z" }, { "id": "deb2250a-0562-45e8-bf91-862f176e5b5b", "pmid": "", "title": "Inhaled anti‐pseudomonal antibiotics for long‐term therapy in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review. Objectives To evaluate the effects of long‐term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug‐sensitivity reactions and survival). Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022. Selection criteria We selected trials where people with cystic fibrosis received inhaled anti‐pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi‐randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). Data collection and analysis Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system. Main results The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta‐analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low‐certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) ‐5.30 days, 95% CI ‐8.59 to ‐2.01; 1 trial, 245 participants; low‐certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta‐analyses. We are uncertain of the effect of the intervention on adverse events (very low‐certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEV 1 ) % predicted compared to tobramycin (MD ‐3.40%, 95% CI ‐6.63 to ‐0.17; 1 trial, 273 participants; moderate‐certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate‐certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high‐certainty evidence). Important treatment‐related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high. Authors' conclusions Long‐term treatment with inhaled anti‐pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer‐term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes. Plain language summary Inhaling antibiotics to treat lung infection in people with cystic fibrosis Review question Are inhaled antibiotics helpful against persistent infection with Pseudomonas aeruginosa in people with cystic fibrosis (CF)? Key messages As people with CF get older, they are more likely to become infected on a long‐term basis with Pseudomonas aeruginosa. This is the most common cause of chronic lung infection in people with CF . We wanted to find out whether antibiotics targeting Pseudomonas aeruginosa would reduce the effects of infection when they are breathed into the lungs. We wanted to learn whether this treatment would improve lung function, quality of life and survival. We also looked for any harmful effects. What is CF? Cystic fibrosis is an inherited disease which results in abnormal mucus in several parts of the body and mainly affects the lungs, which are susceptible to infection by certain bacteria. Infection causes inflammation which results in progressive damage to the lungs. What did we find? The review includes 18 trials with 3042 people with CF aged between five and 45 years of age . The trials lasted from three to 33 months. In 11 trials investigators compared inhaled antibiotics with a placebo (an inhaled substance without the medication in it) and people were selected for one treatment or the other randomly. Eight trials compared one inhaled antibiotic with either a different inhaled antibiotic or a different schedule of the same inhaled antibiotic. One of the trials compared an antibiotic both to placebo and to a different antibiotic and so fell into both groups. Main results Results from four trials showed that when compared to placebo, inhaled antibiotics may improve lung function and reduce the number of times the people with CF had a worsening of symptoms (exacerbation). Inhaled antibiotics may also mean fewer days off school or work (a measure of quality of life). They did not seem to have an effect on survival. We are not sure of the side effects of inhaled antibiotics, but tinnitus and changes in voice were reported more often in people inhaling antibiotics rather than the placebo. We did not find enough evidence to be able to comment on how inhaled antibiotics affect height and weight. Where the trials compared different inhaled antibiotics or schedules, there was only one trial in each of the eight different comparisons. The only differences we found in all these comparisons were for two outcomes. In one trial we found that aztreonam lysine probably improved lung function more than tobramycin, but no important differences were found in the other trials with regard to lung function. Aztreonam lysine also probably led to fewer people needing additional courses of antibiotics than tobramycin and there were fewer hospitalisations after levofloxacin compared to placebo. We noted that important side effects that were related to the treatment were not very common in the trials, but they were less common with tobramycin than with other antibiotics. What are the limitations of the evidence? The trials that we included in this review measured lung function in different ways and also how often people experienced a sudden worsening of symptoms. That made it difficult for us to combine the results of different trials to strengthen our evidence. We thought the overall certainty of evidence was low for most outcomes, mainly due to risks of bias within the trials and low event rates meaning results were not precise. How up to date is this evidence? The evidence is current to: 28 June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Smith, S, Rowbotham, NJ", "articleTypes": [], "doi": "10.1002/14651858.CD001021.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.749Z" }, { "id": "dec20833-d2c1-41fd-bce7-4053cb9f6a05", "pmid": "", "title": "Paracetamol (acetaminophen) for prevention or treatment of pain in newborns", "imported": false, "abstract": "Abstract - Background Newborn infants have the ability to experience pain. Hospitalised infants are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Objectives To determine the efficacy and safety of paracetamol for the prevention or treatment of procedural/postoperative pain or pain associated with clinical conditions in neonates. To review the effects of various doses and routes of administration (enteral, intravenous or rectal) of paracetamol for the prevention or treatment of pain in neonates. Search methods We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 4), MEDLINE via PubMed (1966 to 9 May 2016), Embase (1980 to 9 May 2016), and CINAHL (1982 to 9 May 2016). We searched clinical trials' databases, Google Scholar, conference proceedings, and the reference lists of retrieved articles. Selection criteria We included randomised and quasi‐randomised controlled trials of paracetamol for the prevention/treatment of pain in neonates (≤ 28 days of age). Data collection and analysis Two review authors independently extracted data from the articles using pre‐designed forms. We used this form to decide trial inclusion/exclusion, to extract data from eligible trials and to request additional published information from authors of the original reports. We entered and cross‐checked data using RevMan 5 software. When noted, we resolved differences by mutual discussion and consensus. We used the GRADE approach to assess the quality of evidence. Main results We included nine trials with low risk of bias, which assessed paracetamol for the treatment of pain in 728 infants. Painful procedures studied included heel lance, assisted vaginal birth, eye examination for retinopathy of prematurity assessment and postoperative care. Results of individual studies could not be combined in meta‐analyses as the painful conditions, the use of paracetamol and comparison interventions and the outcome measures differed. Paracetamol compared with water, cherry elixir or EMLA cream (eutectic mixture of lidocaine and prilocaine) did not significantly reduce pain following heel lance. The Premature Infant Pain Profile score (PIPP) within three minutes following lancing was higher in the paracetamol group than in the oral glucose group (mean difference (MD) 2.21, 95% confidence interval (CI) 0.72 to 3.70; one study, 38 infants). Paracetamol did not reduce \"modified facies scores\" after assisted vaginal birth (one study, 119 infants). In another study (n = 123), the Échelle de Douleur et d'Inconfort du Nouveau‐Né score at two hours of age was significantly higher in the group that received paracetamol suppositories than in the placebo suppositories group (MD 1.00, 95% CI 0.60 to 1.40). In that study, when infants were subjected to a heel lance at two to three days of age, Bernese Pain Scale for Neonates scores were higher in the paracetamol group than in the placebo group, and infants spent a longer time crying (MD 19 seconds, 95% CI 14 to 24). For eye examinations, no significant reduction in PIPP scores in the first or last 45 seconds of eye examination was reported, nor at five minutes after the eye examination. In one study (n = 81), the PIPP score was significantly higher in the paracetamol group than in the 24% sucrose group (MD 3.90, 95% CI 2.92 to 4.88). In one study (n = 114) the PIPP score during eye examination was significantly lower in the paracetamol group than in the water group (MD −2.70, 95% CI −3.55 to 1.85). For postoperative care following major surgery, the total amount of morphine (µg/kg) administered over 48 hours was significantly less among infants assigned to the paracetamol group than to the morphine group (MD −157 µg/kg, 95% CI −27 to −288). No adverse events were noted in any study. The quality of evidence according to GRADE was low. Authors' conclusions The paucity and low quality of existing data do not provide sufficient evidence to establish the role of paracetamol in reducing the effects of painful procedures in neonates. Paracetamol given after assisted vaginal birth may increase the response to later painful exposures. Paracetamol may reduce the total need for morphine following major surgery, and for this aspect of paracetamol use, further research is needed. Plain language summary Paracetamol (acetaminophen) for prevention or treatment of pain in newborns Review question: Is paracetamol effective and safe for the prevention or treatment of procedural or postoperative pain or pain associated with clinical conditions in newborn infants? Background: Newborn infants have the ability to experience pain. Newborns treated in neonatal intensive care units are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Study characteristics: We identified nine studies that reported comparisons in 728 infants of paracetamol versus placebo or other pain‐reducing interventions. The literature search was updated in May 2016. Key results: Paracetamol for heel lance did not reduce pain compared with placebo (water or cherry elixir) or compared with EMLA cream (eutectic mixture of lidocaine and prilocaine). Paracetamol use was associated with a stronger response to pain than was seen with glucose. Paracetamol did not reduce pain in infants exposed to vacuum extraction or forceps at birth, and their response to a subsequent heel lance at two to three days of life was increased compared with placebo. For eye examination, paracetamol was effective in reducing pain compared with water in one study, but the pain response was stronger among paracetamol‐treated infants than in infants given 24% sucrose. In infants treated with paracetamol and morphine compared with morphine alone, the total amount of morphine required during the first 48 hours following major surgery to the chest or the abdomen was less in the paracetamol group. Paracetamol did not significantly reduce pain during heel lance. Paracetamol following assisted birth may increase the response to later exposure to painful interventions. Paraetamol may reduce the total need for morphine following major surgery, and further research is needed into this aspect of paracetamol use. Quality of evidence: In general the studies were of good quality but the numbers of infants enrolled in the different studies were small. The overall quality of evidence was low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ohlsson, A; Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD011219.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "dec3dbc5-c17c-4205-b5d6-0752fe240dd3", "pmid": "", "title": "Oral antifungal medication for toenail onychomycosis", "imported": false, "abstract": "Abstract - Background Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence‐based choice for treatment. Objectives To assess the effects of oral antifungal treatments for toenail onychomycosis. Search methods We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies. Selection criteria RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years. We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high‐risk domain was 'blinding of personnel and participants'. We found high‐quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine‐treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate‐quality evidence). There was high‐quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu‐like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate‐quality evidence). Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low‐quality evidence). There is moderate‐quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate‐quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low‐quality evidence). Common adverse events in both groups included headache, viral infection, and nausea. Moderate‐quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate‐quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin‐treated participants) along with nausea and vomiting (in azole‐treated participants). Very low‐quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants). There is low‐quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low‐quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin‐treated participants) as well as taste loss and nausea (in terbinafine‐treated participants). No studies addressed recurrence rate for this comparison. No study addressed quality of life. Authors' conclusions We found high‐quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate‐quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate‐quality evidence). Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate‐quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low‐quality evidence). Only four comparisons assessed recurrence rate: low‐quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them. Only a limited number of studies reported adverse events, and the severity of the events was not taken into account. Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding. Plain language summary What is the best medication for a fungal infection of the toenail? Review question We aimed to find out which medications, taken by mouth for at least six weeks, are the most effective at curing fungal infection of the toenail, a condition that is known as onychomycosis, in people of any age. We compared these medications to each other or placebo (an inactive drug or treatment). Background Fungal infection of the toenails is a common condition, which has a low risk of complications and associated health risks. However, for those severely affected, it might affect normal daily activities. Medication taken by mouth appears to cure the condition more quickly and effectively than topical treatment. There are three main antifungal medications: griseofulvin, different medications in the azole group (itraconazole, fluconazole, albaconazole, posaconazole, ravuconazole), and terbinafine. We wanted to assess the following two main outcomes. 1. Does the nail look normal after treatment (clinical cure)?
 2. Is the nail free from fungus at a microscopic level (mycological cure)? Study characteristics We identified 48 studies with 10,200 participants of both sexes. The average age of the participants across studies ranged from 36 to 68; most studies included participants aged 18 and over. Our included studies compared the three main groups of medication against each other or to placebo. Most studies took place in outpatient dermatology settings in the USA and Europe. The participants mainly had fungal infection under the toenails. A small number of studies included a specific group of participants, such as those with diabetes. All but one study looked at fungal infections caused by dermatophyte, which are fungi that digest keratin. Study duration ranged from 4 months to 2 years, with most lasting 12 to 15 months. Key results The evidence is current to October 2016. We found high‐quality evidence that compared with placebo, both terbinafine and azoles are more effective for achieving a normal‐looking nail and curing the toenail infection (i.e. looking at the microscopic level to see if the fungus is gone). Terbinafine or azoles may also prevent the infection reoccurring more than placebo (low‐quality evidence). There was probably no significant difference in the risk of adverse events reported when comparing either azoles or terbinafine with placebo (moderate‐quality evidence). The most common adverse events amongst terbinafine‐treated and azole‐treated participants included stomach problems and headache. We found that compared to azoles, terbinafine was probably more effective in curing the nails in terms of appearance and infection (moderate‐quality evidence). The risk of side effects was probably the same for both treatments (moderate‐quality evidence), and the most common adverse events in both groups were headache, viral infection, and rash. There may be no difference in recurrence rate (low‐quality evidence). A third type of treatment, griseofulvin, was probably as effective as the azole medications in curing the nails in terms of appearance and infection (moderate‐quality evidence), but it may be less effective than terbinafine when assessing the same outcomes (low‐quality evidence). Griseofulvin caused more side effects than the other two treatments, although the quality of the evidence was moderate (compared to azole) to low (compared to terbinafine). The most common adverse events in both groups included stomach problems and feeling sick. We are uncertain about the effect of griseofulvin compared to azoles on the rate of recurrence, and studies comparing terbinafine and griseofulvin did not assess this outcome. Quality of the evidence The evidence for the primary outcomes of cure (in terms of appearance and infection) was high to moderate quality except for the comparisons of griseofulvin versus terbinafine (low quality) and combination terbinafine plus azole versus terbinafine alone (very low quality). The evidence quality for side effects was mainly moderate, but two comparisons had low evidence for this outcome. Not all comparisons measured recurrence rate, and the available evidence was based on low‐ to very low‐quality evidence. No studies reported on participants' quality of life. Many studies had problems in the study design: it was often unclear how they decided which participants would receive which treatment or ensured that participants weren't aware of the treatment allocation. Many studies also did not use a placebo.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kreijkamp‐Kaspers, S; Hawke, K; Guo, L; Kerin, G; Bell‐Syer, SEM; Magin, P; Bell‐Syer, SV; van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD010031.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "ded7aaf7-7db1-4f15-b05c-29e44bd48942", "pmid": "", "title": "Childhood adversity and 5-HTTLPR across mental health outcomes: A transdiagnostic meta-analysis", "imported": false, "abstract": "Background Childhood maltreatment is associated with increased risk for various psychiatric disorders, although individual responses to early adversity vary. The serotonin transporter-linked polymorphic region (5-HTTLPR) has been examined as a potential moderator of sensitivity to environmental stress, but findings across studies have been inconsistent. Objective This meta-analysis examined whether 5-HTTLPR polymorphisms moderate the association between childhood adversity and clinically diagnosed psychiatric disorders. Participants and settings Fourteen studies (N = 3479) were included, representing community, population-based, and clinical samples from multiple regions. Childhood adversity was assessed using validated interviews, questionnaires, or official electronic records. Methods Systematic searches of eight databases (last updated 3 December 2025) identified studies reporting 5-HTTLPR genotype, childhood adversity, and psychiatric diagnoses. Ratio-of-odds-ratios (ROR) quantifies differences in adversity effects between S-allele carriers and LL homozygotes. Multilevel random-effects models generated pooled estimates. Sensitivity, moderator, and publication-bias analyses were performed. Study quality was assessed using the Newcastle–Ottawa Scale, and certainty of evidence using GRADE. Results Pooled analyses indicated no statistically significant interaction between childhood adversity and 5-HTTLPR genotype (ROR = 1.11, 95% CI 0.89–1.37). Analyses restricted to SS-only or SL-only groups and sexual abuse-specific subgroups produced similar results. Heterogeneity was moderate, and small-study effects were borderline. Moderator analyses did not identify consistent influences of diagnosis or ancestry. Conclusion Across available studies, evidence for an interaction between childhood adversity and 5-HTTLPR genotype was limited. Unlike previous meta-analyses that focused primarily on symptom-level or trait-based measures, the present study evaluates clinically diagnosed outcomes, offering evidence that 5-HTTLPR is unlikely to represent a robust moderator of adversity effects. These findings may suggest that, within current research parameters, 5-HTTLPR does not show a consistent moderating role in clinically diagnosed psychiatric outcomes.", "journal": "Child Abuse & Neglect", "year": "2026", "authors": "Shivam, Vishnu", "articleTypes": [], "doi": "https://doi.org/10.1016/j.chiabu.2026.107901", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:23.371Z" }, { "id": "ded823e9-a2be-4969-a211-bfcbf0f9e0c4", "pmid": "", "title": "Helminth therapy (worms) for allergic rhinitis", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a disorder of the nasal membranes and surrounding tissues, and a worldwide cause of illness and disability. Helminths are complex tissue‐dwelling or lumen‐dwelling organisms that inhabit larger organisms and are frequently asymptomatic. Helminths modulate the natural immune responses of their human hosts, and may prevent or cure immune‐mediated or allergic diseases (e.g. allergic rhinitis) in the host. Non‐randomised studies support this hypothesis. Objectives To assess the safety and effectiveness of helminth therapy in people with allergic rhinitis. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2011. Selection criteria All randomised controlled trials where the intervention was any helminth species or combination of helminth species, administered to people with allergic rhinitis in any dose, by any route and for any duration of exposure. We accepted both intermittent and persistent allergic rhinitis patients. Data collection and analysis We independently extracted data and assessed eligibility and risk of bias using a standardised data collection form. We resolved any disagreement through discussion. We combined dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), presenting both with 95% confidence intervals (CI). Main results We found five reports of two single‐centre, placebo‐controlled, double‐blinded studies (130 participants). Participants in both studies were a mix of adults with either intermittent or persistent allergic rhinitis. Both studies had a low risk of bias. One study, with 12 weeks’ follow‐up, used a single percutaneous application of 10 Necator americanus (i.e. human hookworm) larvae. The other study, with 24 weeks’ follow‐up, used three‐weekly oral dosing with 2500 Trichuris suis (i.e. pig whipworm) eggs in aqueous suspension. Of 17 outcomes evaluated in this review, eight were positive (i.e. favoured helminths). Participants taking helminths had no reduction in allergic rhinitis symptoms, percentage of well days (i.e. days with minimal symptoms and no use of medication for allergic rhinitis), lung function measures and quality of life scores. Total use of medication for allergic rhinitis (eye drops, nasal sprays, tablets) did not change; however, in the helminth group there was a statistically significant reduction in the percentage of days during the grass pollen season when participants needed to take tablets as rescue medication for their allergic rhinitis symptoms (MD –14.0%, 95% CI –26.6 to –1.40); in a typical 60‐day pollen season this 14% reduction translates into 19 days when tablets would be needed in the helminth group versus 27 days when tablets would be needed in the placebo group. Participants taking helminths percutaneously (i.e. as hookworm larvae) had local skin itching and redness in the first few days after administration. Participants taking helminths were more likely to report any gastrointestinal adverse event (RR 1.79, 95% CI 1.31 to 2.45), moderate or severe abdominal pain (RR 7.67, 95% CI 1.87 to 31.57), moderate or severe flatulence (RR 2.01, 95% CI 1.06 to 3.81) and moderate or severe diarrhoea (RR 1.99, 95% CI 1.18 to 3.37). There was no difference between the helminth and placebo groups in the incidence of serious adverse events, and in study withdrawals. Authors' conclusions There is currently insufficient evidence on the efficacy, tolerability and likely costs of helminth therapy to support its use in the routine management of allergic rhinitis. Administered to humans in carefully measured doses, helminths appear to be safe. More preclinical studies should be performed, before larger and extended duration trials of helminths for allergic rhinitis are carried out. Future studies should collect and report comparative data on the costs of helminth therapy versus conventional pharmacotherapy. Plain language summary Helminth therapy (worms) for allergic rhinitis Allergic rhinitis is a common health problem affecting about 500 million people worldwide; its prevalence is increasing. The symptoms of allergic rhinitis include sneezing, and an itchy, runny and blocked nose. Several classes of drugs are used to treat allergic rhinitis, but these drugs may be ineffective, and some drug classes have side effects after long‐term use. Drugs may also be relatively expensive. Helminths are complex multicellular organisms that inhabit larger organisms, and in humans are often symptomless. Helminths modulate (that is, optimally adjust) the immune systems of their hosts and it is thought that this property of helminths could be used therapeutically, to prevent or treat allergic diseases, such as allergic rhinitis. We included two well‐designed studies with a total of 130 adult participants, each study using a different species of gastrointestinal helminth (human hookworm in one study and pig whipworm in the other) as the intervention. Both studies found no significant efficacy from helminths, although one helminth species ( Trichuris suis , the pig whipworm) reduced the need for participants to take tablets as ‘rescue medication’ during the grass pollen season. Adverse events such as abdominal pain and flatulence were commoner in the helminth group, but the two helminths species studied did not cause serious adverse reactions. Currently there is insufficient evidence to support the use of helminths for allergic rhinitis in routine clinical practice. More preclinical studies are needed, before larger and extended duration clinical trials of helminths for allergic rhinitis are performed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Croft, AM; Bager, P; Garg, SK", "articleTypes": [], "doi": "10.1002/14651858.CD009238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "defb4928-9040-48a4-8664-27342b22b0d1", "pmid": "", "title": "Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years", "imported": false, "abstract": "Abstract - Background Extensive evidence exists showing analgesic effects of sweet solutions for newborns and infants. It is less certain if the same analgesic effects exist for children one year to 16 years of age. This is an updated version of the original Cochrane review published in Issue 10, 2011 (Harrison 2011) titled Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. Objectives To determine the efficacy of sweet tasting solutions or substances for reducing needle‐related procedural pain in children beyond one year of age. Search methods Searches were run to the end of June 2014. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, the NHS Economic Evaluation Database, MEDLINE, EMBASE, PsycINFO, and ACP Journal Club (all via OvidSP), and CINAH (via EBSCOhost). We applied no language restrictions. Selection criteria Published or unpublished randomised controlled trials (RCT) in which children aged one year to 16 years, received a sweet tasting solution or substance for needle‐related procedural pain. Control conditions included water, non‐sweet tasting substances, pacifier, distraction, positioning/containment, breastfeeding, or no treatment. Data collection and analysis Outcome measures included crying duration, composite pain scores, physiological or behavioral pain indicators, self‐report of pain or parental or healthcare professional‐report of the child's pain. We reported mean differences (MD), weighted mean difference (WMD), or standardized mean difference (SMD) with 95% confidence intervals (CI) using fixed‐effect or random‐effects models as appropriate for continuous outcome measures. We reported risk ratio (RR), risk difference (RD), and the number needed to treat to benefit (NNTB) for dichotomous outcomes. We used the I 2 statistic to assess between‐study heterogeneity. Main results We included one unpublished and seven published studies (total of 808 participants); four more studies and 478 more participants than the 2011 review. Six trials included young children aged one to four years receiving sucrose or candy lollypops for immunisation pain compared with water or no treatment. Usual care included topical anaesthetics, upright parental holding, and distraction. All studies were well designed blinded RCTs, however, five of the six studies had a high risk of bias based on small sample sizes. Two studies included school‐aged children receiving sweet or unsweetened chewing gum before, or before and during, immunisation and blood collection. Both studies, conducted by the same author, had a high risk of bias based on small sample sizes. Results for the toddlers/pre‐school children were conflicting. Duration of cry, using a random‐effects model, was not significantly reduced by sweet taste (six trials, 520 children, WMD ‐15 seconds, 95% CI ‐54 to 24, I 2 = 94%). Composite pain score at time of first needle was reported in four studies (n = 121 children). The scores were not significantly different between the sucrose and control group (SMD ‐0.26, 95% CI ‐1.27 to 0.75, I 2 = 86%). A Children's Hospital of Eastern Ontario Pain Scale score > 4 was significantly less common in the sucrose group compared to the control group in one study (n = 472, RR 0.55, 95% CI 0.45 to 0.67; RD ‐0.29, 95% CI ‐0.37 to ‐0.20; NNTB 3, 95% CI 3 to 5; tests for heterogeneity not applicable. For school‐aged children, chewing sweet gum before needle‐related painful procedures (two studies, n = 111 children) or during the procedures (two studies, n = 103 children) did not significantly reduce pain scores. A comparison of the Faces Pain Scale scores in children chewing sweet gum before the procedures compared with scores of children chewing unsweetened gum revealed a WMD of ‐0.15 (95% CI ‐0.61 to 0.30). Similar results were found when comparing the chewing of sweet gum with unsweetened gum during the procedure (WMD 0.23, 95% CI ‐0.28 to 0.74). The Colored Analogue Scale for children chewing sweet gum compared to unsweetened gum before the procedure was not significantly different (WMD 0.24 (‐0.69 to 1.18)) nor was it different when children chewed the gum during the procedure (WMD 0.86 (95% CI ‐0.12 to 1.83)). There was no heterogeneity for any of these analyses in school‐aged children (I 2 = 0%). Authors' conclusions Based on the eight studies included in this systematic review update, two of which were subgroups of small numbers of eligible toddlers from larger studies, and three of which were pilot RCTs with small numbers of participants, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children between one and four years of age. Further rigorously conducted, adequately powered RCTs are warranted in this population. Based on the two studies by the same author, there was no evidence of analgesic effects of sweet taste in school‐aged children. As there are other effective evidence‐based strategies available to use in this age group, further trials are not warranted. Despite the addition of four studies in this review, conclusions have not changed since the last version of the review. Plain language summary Sweet taste to ease injection needle pain in children aged one to 16 years This is an updated version of the original Cochrane review published in Issue 10, 2011: Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. We re‐ran the search in October 2014. Review question: Do sweet tasting solutions reduce pain during needles in children aged from one to 16 years, compared to no treatment, water, other non‐sweet solutions, or other interventions such as non‐nutritive sucking (babies) or sweet foods or chewing gum (children), topical anaesthetics, music, and distraction? Background: Small amounts of sweet tasting sugar solutions given orally to babies before and during painful needles significantly reduces distress. However it was not known if the same pain‐reducing effects of sweet solutions occurred in children older than one year of age. We therefore examined studies looking at pain‐reducing effects of sweet solutions such as sucrose or glucose for painful needle procedures in children aged one to 16 years. Search date: We searched the literature for published and unpublished studies up to October 2014. Study characteristics : We found six studies focused on young children aged one to four years; two of these studies were included in the original review and four were new studies. The two studies included in the original review used a low concentration of sucrose, just 12%, which is not considered sweet enough for the pain reducing effects. Three of the four new studies were small pilot studies, conducted to inform full trials, and only one study of sweet solutions in young children included large numbers of children. When we compared results of all six studies, only two showed that sugar water (sucrose) reduced pain during injections. However, the four studies that showed no effect all included small numbers of children, therefore they were not considered large enough to detect significant differences in pain. Further well conducted trials with large enough numbers of young children are needed to work out if sweet taste effectively reduces their pain and distress during needles. For older school‐aged children, there were two studies published by the same author, both of which were included in the original review. Neither study showed that sweet taste helped to reduce pain. As other studies show that strategies such as distraction and topical anaesthetics can effectively reduce needle pain in school‐aged children, further studies of sweet taste for pain management in school‐aged children are not warranted. Study funding sources : Of the six studies including young children, two did not acknowledge receipt of research funding. For the remaining four: a state‐wide nursing fund supported two of the pilot studies, an internal research institute provided support for the remaining pilot study and another study was supported in part by a Maternal and Child Health grant. The two studies including school‐aged children, conducted by the same author, were supported by a grant from the Canadian Institutes of Health Research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Harrison, D; Yamada, J; Adams‐Webber, T; Ohlsson, A; Beyene, J; Stevens, B", "articleTypes": [], "doi": "10.1002/14651858.CD008408.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "df07816a-4110-45d4-8c1c-3b94fcad7017", "pmid": "", "title": "Antibiotic treatment for the sexual partners of women with bacterial vaginosis", "imported": false, "abstract": "Abstract - Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of BV after antibiotic treatment. Therefore, the treatment of sexual partners could decrease the recurrence of infection and possibly the burden of the disease. Objectives To assess the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for BV. Search methods We searched the Cochrane Sexually Transmitted Infections Group Specialized Register (23 July 2016), CENTRAL (1991 to 23 July 2016), MEDLINE (1946 to 23 July 2016), Embase (1974 to 23 July 2016), LILACS (1982 to 23 July 2016), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (23 July 2016), ClinicalTrials.gov (23 July 2016) and the Web of Science™ (2001 to 23 July 2016). We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) that compared the concurrent use of any antibiotic treatment with placebo, no intervention or any other intervention by the sexual partners of women treated for BV. Data collection and analysis Three review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach. Main results Seven RCTs (1026 participants) met our inclusion criteria, and pharmaceutical industry funded four of these trials. Five trials (854 patients) compared any antibiotic treatment of sexual partners with placebo. Based on high quality evidence, antibiotic treatment does not increase the rate of clinical or symptomatic improvement in women during the first week (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.96 to 1.03; 712 participants, four studies; RR 1.06, 95% CI 1.00 to 1.12; 577 patients, three studies, respectively), between the first and fourth week (RR 1.02, 95% CI 0.94 to 1.11; 590 participants, three studies; RR 0.93, 95% CI 0.84 to 1.03; 444 participants, two studies; respectively) or after the fourth week (RR 0.98, 95% CI 0.90 to 1.07; 572 participants, four studies; RR 1.03, 95% CI 0.90 to 1.17; 296 participants, two studies; respectively). Antibiotic treatment does not led to a lower recurrence during the first and fourth week (RR 1.28, 95% CI 0.68 to 2.43; 218 participants, one study; low quality evidence) or after the fourth week of treatment (RR 1.00, 95% CI 0.67 to 1.52; 372 participants, three studies; low quality evidence) in women, but increases the frequency of adverse events (most frequently gastrointestinal symptoms) reported by sexual partners (RR 2.55, 95% CI 1.55 to 4.18; 477 participants, three studies; low quality evidence).
 
 Two trials (172 participants) compared any antibiotic treatment for sexual partners with no intervention. When we compared it with no intervention, the effects of antibiotic treatment on recurrence rate after the fourth week (RR 1.71, 95% CI 0.65 to 4.55; 51 participants, one study), clinical improvement between the first and fourth week (RR 0.93, 95% CI 0.70 to 1.25; 152 participants, two studies) and symptomatic improvement after the fourth week (RR 0.66, 95% CI 0.39 to 1.11; 70 participants, one study) were imprecise and there were no differences between groups. We downgraded the quality of the evidence to low or very low. Authors' conclusions High quality evidence shows that antibiotic treatment for sexual partners of women with BV, compared with placebo, does not increase the rate of clinical or symptomatic improvement during the first, between the first and fourth or after the fourth week into the women. Low quality evidence suggests that antibiotic treatment does not led to a lower recurrence rate during the first and fourth or after the fourth week of treatment into the women, but increases the frequency of adverse events reported by sexual partners. Finally, compared with no intervention, antibiotic treatment does not decrease the recurrence rate after the fourth week and does not increase the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week into the women, respectively. Plain language summary Antibiotic treatment for the sexual partners of women with bacterial vaginosis Review question We assessed the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for bacterial vaginosis (BV). Background Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of infection after antibiotic treatment. Therefore, the treatment of sexual partners could offer the advantages of decreasing the recurrence of infection and possibly reducing the burden of the disease. Trial characteristics Cochrane researchers searched the available literature up to the 23 July 2016 and included seven trials with 1026 participants. The trials included sexually‐active non‐pregnant women between 17 and 56 years of age, either single or married, with symptomatic BV. Four studies only included women involved into a monogamous heterosexual relationship and there was no information about this for the remaining trials. Six trials used 5‐nitroimidazoles to treat the sexual partner, four trials used metronidazole and two trials used tinidazole; only one study used a lincosamide for treatment. Five trials compared antibiotic versus placebo (854 participants) and two trials compared antibiotic treatment with no intervention (172 participants). Pharmaceutical companies funded four of the included trials. Key results Compared with placebo, antibiotic treatment for the sexual partners of women treated for BV had no effects on clinical or symptomatic improvement in women, regardless of the time period over which the trials assessed these outcomes (during the first, between the first and fourth, or after the fourth week). Furthermore, antibiotic treatment of the sexual partner may have no effect on the recurrence of BV up to 12 weeks after treatment, but may increase the frequency of minor adverse events reported by sexual partners. Compared with no intervention, treatment of sexual partners of women with BV may have no effect on decreasing the recurrence rate or over the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week, respectively. Quality of evidence The quality of evidence was high for the outcomes of clinical and symptomatic improvement. The quality of evidence was very low for recurrence due to some limitations regarding risk of bias and imprecision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Amaya‐Guio, J; Viveros‐Carreño, DA; Sierra‐Barrios, EM; Martinez‐Velasquez, MY; Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD011701.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "df198ffa-cf04-4310-b9aa-89468ff7b1b3", "pmid": "", "title": "Sucrose for analgesia in newborn infants undergoing painful procedures", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose with and without non‐nutritive sucking is the most frequently studied non‐pharmacological intervention for procedural pain relief in neonates. Objectives To determine the efficacy, effect of dose, method of administration and safety of sucrose for relieving procedural pain in neonates as assessed by validated composite pain scores, physiological pain indicators (heart rate, respiratory rate, saturation of peripheral oxygen in the blood, transcutaneous oxygen and carbon dioxide (gas exchange measured across the skin ‐ TcpO 2 , TcpCO 2 ), n ear i nfra r ed s pectroscopy (NIRS), e lectro e ncephalo g ram (EEG), or behavioural pain indicators (cry duration, proportion of time crying, proportion of time facial actions (e.g. grimace) are present), or a combination of these and long‐term neurodevelopmental outcomes. Search methods We used the standard methods of the Cochrane Neonatal. We performed electronic and manual literature searches in February 2016 for published randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library , Issue 1, 2016), MEDLINE (1950 to 2016), EMBASE (1980 to 2016), and CINAHL (1982 to 2016) . We did not impose language restrictions. Selection criteria RCTs in which term or preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age), or both, received sucrose for procedural pain. Control interventions included no treatment, water, glucose, breast milk, breastfeeding, local anaesthetic, pacifier, positioning/containing or acupuncture. Data collection and analysis Our main outcome measures were composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We reported a mean difference (MD) or weighted MD (WMD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. For categorical data we used risk ratio (RR) and risk difference. We assessed heterogeneity by the I 2 test. We assessed the risk of bias of included trials using the Cochrane 'Risk of bias' tool, and assessed the quality of the evidence using the GRADE system. Main results Seventy‐four studies enrolling 7049 infants were included. Results from only a few studies could be combined in meta‐analyses and for most analyses the GRADE assessments indicated low‐ or moderate‐quality evidence. There was high‐quality evidence for the beneficial effect of sucrose (24%) with non‐nutritive sucking (pacifier dipped in sucrose) or 0.5 mL of sucrose orally in preterm and term infants: Premature Infant Pain Profile (PIPP) 30 s after heel lance WMD ‐1.70 (95% CI ‐2.13 to ‐1.26; I 2 = 0% (no heterogeneity); 3 studies, n = 278); PIPP 60 s after heel lance WMD ‐2.14 (95% CI ‐3.34 to ‐0.94; I 2 = 0% (no heterogeneity; 2 studies, n = 164). There was high‐quality evidence for the use of 2 mL 24% sucrose prior to venipuncture: PIPP during venipuncture WMD ‐2.79 (95% CI ‐3.76 to ‐1.83; I 2 = 0% (no heterogeneity; 2 groups in 1 study, n = 213); and intramuscular injections: PIPP during intramuscular injection WMD ‐1.05 (95% CI ‐1.98 to ‐0.12; I 2 = 0% (2 groups in 1 study, n = 232). Evidence from studies that could not be included in RevMan‐analyses supported these findings. Reported adverse effects were minor and similar in the sucrose and control groups. Sucrose is not effective in reducing pain from circumcision. The effectiveness of sucrose for reducing pain/stress from other interventions such as arterial puncture, subcutaneous injection, insertion of nasogastric or orogastric tubes, bladder catherization, eye examinations and echocardiography examinations are inconclusive. Most trials indicated some benefit of sucrose use but that the evidence for other painful procedures is of lower quality as it is based on few studies of small sample sizes. The effects of sucrose on long‐term neurodevelopmental outcomes are unknown. Authors' conclusions Sucrose is effective for reducing procedural pain from single events such as heel lance, venipuncture and intramuscular injection in both preterm and term infants. No serious side effects or harms have been documented with this intervention. We could not identify an optimal dose due to inconsistency in effective sucrose dosage among studies. Further investigation of repeated administration of sucrose in neonates is needed. There is some moderate‐quality evidence that sucrose in combination with other non‐pharmacological interventions such as non‐nutritive sucking is more effective than sucrose alone, but more research of this and sucrose in combination with pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing painful procedures Review question Cochrane reviewers investigated how well sucrose (table sugar) works as a reliever of pain in newborn babies who are having painful procedures (e.g. an injection, or heel lance, or insertion of a needle to obtain a blood sample (venipuncture), or eye examinations). The babies' pain responses (e.g. crying, grimacing) were assessed by scoring systems for pain used by health care professionals to measure the pain that babies are experiencing. In addition, the reviewers wanted to investigate whether the level of pain relief is related to the dose of sucrose, or the method of delivery (e.g. as a solution squirted into the mouth, or on a pacifier (also called a soother or dummy), and whether there are any safety concerns about using sucrose to relieve pain. Background Although there are ways to manage the pain of surgery, medical illness and major procedures, ways of preventing or reducing pain from minor medical procedures (e.g. heel lance and venipuncture) have, until relatively recently, been lacking. Sucrose has been examined for its calming effects in crying newborns and its pain‐relieving effects for invasive procedures in full‐term and premature newborns. Study characteristics We searched the medical literature widely up to February 2016 for studies that investigated the pain‐relieving effect of sucrose for minor medical procedures in newborn full‐term and premature babies. We included randomised controlled trials only, as these provide the most reliable medical evidence. We identified 74 studies that reported on a total of more than 7000 infants in this Cochrane Review. Thirty‐eight studies included full‐term babies only, 31 included premature babies only, and five included both full‐term and premature babies. Heel lance was the painful procedure in 38 studies, and venipuncture in nine; the remaining studies investigated a wide variety of other minor painful procedures. The studies used a variety of delivery methods for the sucrose solution (oral syringe, dropper or sucrose‐dipped pacifier), as well as a range of concentrations and volumes of dose. Sucrose treatment was compared with giving the babies a similar volume of water, a pacifier, routine care, breastfeeding, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), laser acupuncture, swaddling, warmth, anaesthetic cream for the skin (EMLA), or a combination of these. The studies used a range of pain assessment scales to measure their results. Study funding sources We did not identify any studies that received funding from the industry. Key results There was high‐quality evidence that sucrose reduces different measures of newborn pain during heel lance, venipuncture and intramuscular injection. However, sucrose does not provide effective pain relief during circumcision. There is conflicting evidence for whether sucrose reduces pain for other minor painful procedures and further research is needed to investigate these more thoroughly. Twenty‐nine studies reported on adverse events (harms of the sucrose and other treatments) and found that the number of minor adverse events (e.g. choking or gagging) was very low, and was similar in the different groups (so not attributable to the sucrose treatment). No major adverse events were reported. Quality of evidence Although sucrose has been widely studied as a pain reliever for newborn babies, most studies have included few babies and have used many different measures of pain to assess its effectiveness. We identified high‐quality evidence that sucrose reduces pain for heel lance, venipuncture and intramuscular injection. The quality of evidence was low or moderate in favour for the use of sucrose for other painful procedures.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stevens, B; Yamada, J; Ohlsson, A; Haliburton, S; Shorkey, A", "articleTypes": [], "doi": "10.1002/14651858.CD001069.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "df21e3ce-94b6-42f8-8fc5-41645fb9e92f", "pmid": "", "title": "Impacts of Sugar-Sweetened Beverage Consumption on Body Weight Regulation", "imported": false, "abstract": "The obesity epidemic is a major public health problem. Weight gain is strongly associated with an increase in the incidence of complex health conditions such as type 2 diabetes (T2D), cardiovascular disease, stroke, and cancers. Behaviours linked to food and beverage consumption can greatly affect body weight. Frequent consumption of sugar-sweetened beverages such as carbonated soft-drinks, energy and sport drinks, fruit juices from concentrate, soda and flavoured milk and water is considered to be an unhealthy dietary behaviour.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.256Z" }, { "id": "df36d81e-0830-4a50-9fd5-ea6990dfdea7", "pmid": "", "title": "Folic acid for fragile X syndrome", "imported": false, "abstract": "Abstract - Background It has been argued that individuals with fragile X syndrome could have low folate levels in their bodies and that supplementing their dietary intake might remediate the adverse developmental and behavioural effects of the condition. Objectives To review the efficacy and safety of folic acid in the treatment of people with fragile X syndrome. Search methods We searched four databases in November 2010: CENTRAL, PubMed, EMBASE and PsycINFO. Selection criteria Randomised controlled trials. Data collection and analysis Two review authors independently extracted data and assessed risk of bias using the Cochrane 'Risk of bias' tool. Main results We included five trials, which were published between 1986 and 1992. Overall, they included 67 patients, all male, with ages ranging from one to 54 years. Intellectual disability in participants varied from borderline to severe and some studies included patients with an additional diagnosis of autism or autistic behaviour. Four of the studies were placebo‐controlled cross‐over trials and one study was a parallel design. The duration of follow‐up ranged from two months to 12 months and the period on folic acid or placebo ranged from two to eight months. Doses of folic acid ranged from 10 mg to 250 mg per day, 10 mg per day being the most common. Most of the younger patients involved were also taking part in special education programmes (usually involving language and occupational therapy). We were not able to perform meta‐analysis to combine results but none of the individual studies found evidence of clinical benefit with the use of folic acid medication in fragile X syndrome patients on any of the areas of interest, either psychological and learning capabilities or behaviour and social performance, as measured with standardised tools. Separate analysis of evidence for patients of different age groups, i.e. prepubertal children and postpubertal young people, found some statistically significant results, but did not show clear evidence of benefit for either group. Adverse effects of folic acid treatment were rare, not serious and transient. Studies were generally poorly reported and we classified only one study as being at low risk of bias. Authors' conclusions The quality of available evidence is low and not suitable for drawing conclusions about the effect of folic acid on fragile X syndrome patients. It consists of few studies with small samples of patients, all of them male, with little statistical power to detect anything other than huge effects. Plain language summary Folic acid for fragile X syndrome People with fragile X syndrome (or FXS) have intellectual limitations that can range from mild to severe. Fragile X syndrome is considered the most common form of inherited intellectual disability and it has been estimated that it affects approximately 1 in 4000 males and 1 in 8000 females. Folate is particularly important during the early development of the brain and in later life is involved in methylation processes that are essential for the maintenance of normal brain function. It was observed that cells from patients with fragile X syndrome cultured in solutions deficient in folic acid revealed a fragile site at the X chromosome; consequently it was thought that individuals with fragile X syndrome had low folate levels in their bodies, which may be due to insufficient dietary intake, inefficient absorption or impaired metabolic utilisation. It was argued that supplementing their dietary intake might help improve the adverse developmental and behavioural effects of the condition. This review asks whether folic acid helps improve symptoms in people with fragile X syndrome and whether it has any side effects. We found five randomised controlled trials, all of which were published between 1986 and 1992. These studies included 69 people, all male. One of the studies compared a folic acid group with a control group; the other four used a cross‐over design (i.e. participants received first one treatment and then the other). The quality of reporting of the trials was generally poor, particularly the methods used, which made it difficult to assess the risk of bias in the studies. The results of the few published studies did not find significant differences in the effects of folic acid or placebo on psychological or learning capabilities, behaviour or social performance, as measured by standardised tools. There is therefore no evidence to support the recommendation of supplementing dietary intake with folic acid medication for people with fragile X syndrome. However, due to the number and quality of the studies, it is not possible to conclude with any certainty that folic acid does not help. Given that intellectual, behavioural, emotional and/or learning performance in people with fragile X syndrome are strongly influenced by different social factors, future studies should also pay attention to the evaluation of non‐pharmacological interventions, such as modifications in the home environment, tailored behavioural interventions and classroom environments, or language and occupational therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Rueda, JR, Ballesteros, J, Guillen, V, Tejada, MI, Solà, I", "articleTypes": [], "doi": "10.1002/14651858.CD008476.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.761Z" }, { "id": "df464fe3-4043-457a-aaa7-822086df7582", "pmid": "", "title": "Treatments for intractable constipation in childhood", "imported": false, "abstract": "Abstract - Background Constipation that is prolonged and does not resolve with conventional therapeutic measures is called intractable constipation. The treatment of intractable constipation is challenging, involving pharmacological or non‐pharmacological therapies, as well as surgical approaches. Unresolved constipation can negatively impact quality of life, with additional implications for health systems. Consequently, there is an urgent need to identify treatments that are efficacious and safe. Objectives To evaluate the efficacy and safety of treatments used for intractable constipation in children. Search methods We searched CENTRAL, MEDLINE, Embase, and two trials registers up to 23 June 2023. We also searched reference lists of included studies for relevant studies. Selection criteria We included randomised controlled trials (RCTs) comparing any pharmacological, non‐pharmacological, or surgical treatment to placebo or another active comparator, in participants aged between 0 and 18 years with functional constipation who had not responded to conventional medical therapy. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were symptom resolution, frequency of defecation, treatment success, and adverse events; secondary outcomes were stool consistency, painful defecation, quality of life, faecal incontinence frequency, abdominal pain, hospital admission for disimpaction, and school absence. We used GRADE to assess the certainty of evidence for each primary outcome. Main results This review included 10 RCTs with 1278 children who had intractable constipation. We assessed one study as at low risk of bias across all domains. There were serious concerns about risk of bias in six studies. One study compared the injection of 160 units botulinum toxin A (n = 44) to unspecified oral stool softeners (n = 44). We are very uncertain whether botulinum toxin A injection improves treatment success (risk ratio (RR) 37.00, 95% confidence interval (CI) 5.31 to 257.94; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Frequency of defecation was reported only for the botulinum toxin A injection group (mean interval of 2.6 days). The study reported no data for the other primary outcomes. One study compared erythromycin estolate (n = 6) to placebo (n = 8). The only primary outcome reported was adverse events , which were 0 in both groups. The evidence is of very low certainty due to concerns with risk of bias and serious imprecision. One study compared 12 or 24 μg oral lubiprostone (n = 404) twice a day to placebo (n = 202) over 12 weeks. There may be little to no difference in treatment success (RR 1.29, 95% CI 0.87 to 1.92; low certainty evidence). We also found that lubiprostone probably results in little to no difference in adverse events (RR 1.05, 95% CI 0.91 to 1.21; moderate certainty evidence). The study reported no data for the other primary outcomes. One study compared three‐weekly rectal sodium dioctyl sulfosuccinate and sorbitol enemas (n = 51) to 0.5 g/kg/day polyethylene glycol laxatives (n = 51) over a 52‐week period. We are very uncertain whether rectal sodium dioctyl sulfosuccinate and sorbitol enemas improve treatment success (RR 1.33, 95% CI 0.83 to 2.14; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Results of defecation frequency per week was reported only as modelled means using a linear mixed model. The study reported no data for the other primary outcomes. One study compared biofeedback therapy (n = 12) to no intervention (n = 12). We are very uncertain whether biofeedback therapy improves symptom resolution (RR 2.50, 95% CI 1.08 to 5.79; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). The study reported no data for the other primary outcomes. One study compared 20 minutes of intrarectal electromotive botulinum toxin A using 2800 Hz frequency and botulinum toxin A dose 10 international units/kg (n = 30) to 10 international units/kg botulinum toxin A injection (n = 30). We are very uncertain whether intrarectal electromotive botulinum toxin A improves symptom resolution (RR 0.96, 95% CI 0.76 to 1.22; very low certainty evidence) or if it increases the frequency of defecation (mean difference (MD) 0.00, 95% CI −1.87 to 1.87; very low certainty evidence). We are also very uncertain whether intrarectal electromotive botulinum toxin A has an improved safety profile (RR 0.20, 95% CI 0.01 to 4.00; very low certainty evidence). The evidence for these results is of very low certainty due to serious concerns with risk of bias and imprecision. The study did not report data on treatment success. One study compared the injection of 60 units botulinum toxin A (n = 21) to myectomy of the internal anal sphincter (n = 21). We are very uncertain whether botulinum toxin A injection improves treatment success (RR 1.00, 95% CI 0.75 to 1.34; very low certainty evidence). No adverse events were recorded. The study reported no data for the other primary outcomes. One study compared 0.04 mg/kg oral prucalopride (n = 107) once daily to placebo (n = 108) over eight weeks. Oral prucalopride probably results in little or no difference in defecation frequency (MD 0.50, 95% CI −0.06 to 1.06; moderate certainty evidence); treatment success (RR 0.96, 95% CI 0.53 to 1.72; moderate certainty evidence); and adverse events (RR 1.15, 95% CI 0.94 to 1.39; moderate certainty evidence). The study did not report data on symptom resolution. One study compared transcutaneous electrical stimulation to sham stimulation, and another study compared dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. These studies did not report any of our predefined primary outcomes. Authors' conclusions We identified low to moderate certainty evidence that oral lubiprostone may result in little to no difference in treatment success and adverse events compared to placebo. Based on moderate certainty evidence, there is probably little or no difference between oral prucalopride and placebo in defecation frequency, treatment success, or adverse events. For all other comparisons, the certainty of the evidence for our predefined primary outcomes is very low due to serious concerns with study limitations and imprecision. Consequently, no robust conclusions could be drawn. Plain language summary Management of intractable constipation in children Key messages • There may be little to no difference between lubiprostone and placebo (dummy treatment) in achieving treatment success in children with intractable constipation. We also found that lubiprostone is probably as safe as placebo. • There is probably little or no difference between prucalopride, also a laxative, and placebo in frequency of defecation per day, treatment success, and safety. • It is unclear whether any of the other treatments we looked at are helpful. The evidence is uncertain because of the very low number of study participants and problems with how the research was reported. • Currently, there is not an agreed‐upon definition for intractable constipation. To develop further evidence on therapies for intractable constipation, researchers must use the same definition. We would encourage further work to come up with an agreed‐upon definition. What is intractable constipation? Constipation in children is a common problem. If doctors cannot find an underlying cause for the symptoms, it is called functional constipation. The symptoms of constipation include lower frequency of defecation, bowel incontinence or soiling, and stomach pain. Constipation can be mild and respond well to standard treatments, such as behavioural changes or laxatives. However, it can also be more severe or last for a long time. We defined intractable constipation as constipation that persists despite standard treatments. What did we want to find out? We wanted to find out which treatments are helpful and safe for treating children (between 0 and 18 years of age) with constipation that has not responded to standard medical treatments (intractable constipation). This extreme level of constipation can impact a child's life in very negative ways, such as keeping them away from school and other daily activities; causing them pain, discomfort, and general distress; and requiring hospital visits for treatment. Consequently, there is a need to investigate if the tested therapies can help resolve the problem. What did we do? We considered any medication, surgical procedure, or therapy to help children with intractable constipation. Each study compared a specific treatment to placebo, no treatment, or another treatment. We were interested in whether the treatments increased the frequency of defecation, improved symptoms, or led to treatment success. We also wanted to know if the treatments were safe, so we looked at whether they caused side effects. We searched for randomised controlled trials (studies in which people are randomly assigned to one of two or more treatment groups) comparing any medical, surgical, or complementary therapy versus no treatment, placebo, or another treatment in children with intractable constipation. What did we find? We found 10 studies involving a total of 1278 children. The average age of study participants ranged from around 5 to 10 years. The studies were conducted in Iran, Brazil, Colombia, the USA, Canada, Australia, and several European countries. Studies lasted from one to six months. The studies made the following comparisons: • botox injection versus stool softeners; • erythromycin versus placebo; • lubiprostone versus placebo; • rectal sodium dioctyl sulfosuccinate and sorbitol versus oral polyethylene glycol laxatives; • biofeedback therapy versus no treatment; • intrarectal electromotive botox injection versus a usual botox injection; • botox injection versus myectomy of the internal anal sphincter; • prucalopride versus placebo; • transcutaneous electrical stimulation versus sham stimulation; and • dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. Main results • There may be little to no difference between lubiprostone and placebo in achieving treatment success, and there is probably little to no difference in adverse events for this comparison. • There is probably little or no difference between prucalopride and placebo in defecation frequency, treatment success, and adverse events. • We do not know whether any of the other treatments looked at in this review are safer or more beneficial than others. What are the limitations of the evidence? The evidence is limited due to small participant numbers in the included studies, and because each study looked at a different comparison, both of which resulted in the evidence being imprecise. There were also issues with the way the studies were conducted, which led to concerns that study results might be biased. How up‐to‐date is this evidence? This review is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gordon, M; Grafton-Clarke, C; Rajindrajith, S; Benninga, M; Sinopoulou, V; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD014580.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "df63535b-75e4-4b62-ba39-70b8369e9beb", "pmid": "", "title": "Chinese herbal medicine for schizophrenia", "imported": false, "abstract": "Abstract - Background Traditional Chinese medicine (TCM) was the main form of treatment in China for psychiatric illnesses until the development of antipsychotic drugs in the 1950's. Antipsychotic drugs have become the primary intervention for schizophrenia, although herbal medicines can still form part of the treatment. Objectives To review Chinese herbal medicine, used alone or as part of a TCM approach, for people with schizophrenia and related psychoses. Search methods We undertook electronic searches of the Cochrane Schizophrenia Group's register (December 2003), the Traditional Chinese Medical Literature Analysis and Retrieval Database (TCMLARS) (October 2003), Chinese Biomedical Database (CBM) (December 2003), China National Knowledge Infrastructure Database (May 2004), Complementary Medicine Database (AMED) (December 2003). We contacted the Chinese Cochrane Centre, the Cochrane Complementary Medicine Field and first authors of included studies and inspected reference lists for additional studies. Selection criteria We included all relevant randomised controlled trials involving people with schizophrenia‐like illnesses, allocated to Chinese herbal medicine, including any Chinese herbs (single or mixture), compared with placebo/no treatment or antipsychotic drugs. We updated this search July 2012 and added 45 new trials to the awaiting classification section. Data collection and analysis We independently extracted data and calculated fixed effects relative risk (RR), the 95% confidence intervals (CI) for homogeneous dichotomous data, and, where appropriate, the number needed to treat (NNT) on an intention‐to‐treat basis. For continuous data, we calculated weighted mean differences (WMD). Main results Only one small trial of the seven included studies truly evaluated TCM for schizophrenia. The other trials evaluated Chinese herbs for schizophrenia. We found one study comparing Chinese herbal medicine with antipsychotic drugs. Data for the global state outcome 'no change/worse' favoured people allocated to antipsychotic medication (n=90, RR 1.88 CI 1.2 to 2.9, NNH 4 CI 2 to 12). Six trials compared Chinese herbal medicine in combination with antipsychotic with antipsychotic drugs alone. One trial found global state 'not improved/worse' favoured the herbal medicine/antipsychotic combination (n=123, RR 0.19 CI 0.1 to 0.6, NNT 6 CI 5 to 11). Two studies (n=103) also found short‐term data from the Clinical Global Impression scale favoured the herbal medicine plus antipsychotic group (WMD ‐0.46 CI ‐0.9 to ‐0.1) compared with those given only antipsychotics. Significantly fewer people in the experimental group left the study early compared with those given antipsychotics alone (n=1004, 6 RCTs, RR 0.30 CI 0.16 to 0.58, NNT 21 CI 18 to 35). Reports of constipation were significantly lower in the treatment group compared to those receiving antipsychotics (n=67, 1 RCT, RR 0.03 CI 0.0 to 0.5, NNH 2 CI 2 to 4). Authors' conclusions Chinese herbal medicines, given in a Western biomedical context, may be beneficial for people with schizophrenia when combined with antipsychotics. Traditional Chinese medicine is also under‐evaluated, but results from one pioneering study that attempted to evaluate TCM should encourage further trials. Note: the 45 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed. Plain language summary Chinese herbal medicine for schizophrenia Antipsychotic medication is the mainstay of treatment for people with schizophrenia, and although effective, still leaves some people with distressing symptoms and/or disabling adverse effects. Safer and more effective health care interventions are needed. Traditional Chinese medicine (TCM) has been used to treat mental health disorders, including schizophrenia, for more than 2000 years. Chinese herbs may also have antipsychotic properties when used in a Western biomedical context. In this review we sought and found trials relevant to the effects of both approaches for schizophrenia. Traditional Chinese medicine methodology has been evaluated for schizophrenia, but the one included study was too limited in terms of sample size and study length to guide good practice. However, this pioneering study does show that TCM can be evaluated for its efficacy for people with schizophrenia , and should encourage trialists to undertake further, more comprehensive trials in this area. The use of Chinese herbs in a Western medicine context, without incorporating TCM methodology, has been evaluated in six trials, although again these are limited by their sample size and study length. The results of these six trials suggest that using Chinese herbs alone for psychotic symptoms may not be indicated, but if used in conjunction with Western antipsychotic drugs, they may be beneficial in terms of mental state, global functioning and decrease of adverse effects. However, further trials are needed before the effects of TCM for people with schizophrenia can be evaluated with any real confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Rathbone, J; Zhang, L; Zhang, M; Xia, J; Liu, X; Yang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD003444.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "df7673a7-cdf7-4e3e-8af9-c09cc700861e", "pmid": "", "title": "Evaluation of Balance Tablets in Reducing Vitamin and Mineral Deficiencies in Patients Using GLP-1 Receptor Agonists for Weight Loss", "imported": false, "abstract": "Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), including Ozempic (semaglutide) and Saxenda (liraglutide), are gaining traction in treating obesity and its associated diseases due to their capacity to facilitate substantial weight loss through mechanisms such as appetite suppression and delayed gastric emptying. Clinical trials have consistently shown that patients prescribed GLP-1 RAs can achieve significant body weight reductions when combined with appropriate dosing and lifestyle modifications.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.149Z" }, { "id": "df7ac887-bd3a-4ea1-ba63-5deaa5848929", "pmid": "", "title": "Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Rationale Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Alendronate belongs to the bisphosphonate class of drugs, which inhibit bone resorption by interfering with the activity of osteoclasts (bone cells that break down bone tissue). This is an update of a Cochrane review first published in 2008. Objectives To assess the benefits and harms of alendronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched Evidence‐Based Medicine Reviews (which includes CENTRAL), MEDLINE, Embase, two trial registers, drug approval agency websites, and the bibliographies of relevant systematic reviews to identify the studies included in this review. The latest search date was 01 February 2023. We imposed no restrictions on language, date, form of publication, or reported outcomes. Eligibility criteria We included only randomized controlled trials that assessed the effects of alendronate on postmenopausal women. Targeted participants must have received at least one year of alendronate. We classified a study as secondary prevention if its population met one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (‐2.5 or lower), and 75 years old or older. If a study population met none of those criteria, we classified it as a primary prevention study. Outcomes Our major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. Risk of bias We used the Cochrane risk of bias 1 tool. Synthesis methods We used standard methodological procedures expected by Cochrane. Based on the previous review experience, in which the clinical and methodological characteristics in the primary and secondary prevention studies were homogeneous, we used a fixed‐effect model for meta‐analysis and estimated effects using the risk ratio (RR) for dichotomous outcomes. Our base case analyses included all eligible placebo‐controlled studies with usable data. We selected the data available for the longest treatment period. We consider a relative change exceeding 15% as clinically important. Included studies We included 119 studies, of which 102 studies provided data for quantitative synthesis. Of these, we classified 34 studies (15,188 participants) as primary prevention and 68 studies (29,577 participants) as secondary prevention. We had concerns about risks of bias in most studies. Selection bias was the most frequently overlooked domain, with only 20 studies (19%) describing appropriate methods for both sequence generation and allocation concealment. Eight studies (8%) were at low risk of bias in all seven domains. Synthesis of results The base case analyses included 16 primary prevention studies (one to five years in length; 10,057 women) and 20 secondary prevention studies (one to three years in length; 7375 women) which compared alendronate 10 mg/day (or 70 mg/week) to placebo, no treatment, or both. Indirectness, imprecision, and risk of bias emerged as the main factors contributing to the downgrading of the certainty of the evidence. For primary prevention, alendronate may lead to a clinically important reduction in clinical vertebral fractures (16/1190 in the alendronate group versus 24/926 in the placebo group; RR 0.45, 95% confidence interval [CI] 0.25 to 0.84; absolute risk reduction [ARR] 1.4% fewer, 95% CI 1.9% fewer to 0.4% fewer; low‐certainty evidence) and non‐vertebral fractures (RR 0.83, 95% CI 0.72 to 0.97; ARR 1.6% fewer, 95% CI 2.6% fewer to 0.3% fewer; low‐certainty evidence). However, clinically important differences were not observed for the following outcomes: hip fractures (RR 0.76, 95% CI 0.43 to 1.32; ARR 0.2% fewer, 95% CI 0.4% fewer to 0.2% more; low‐certainty evidence); wrist fractures (RR 1.12, 95% CI 0.84 to 1.49; ARR 0.3% more, 95% CI 0.4% fewer to 1.1% more; low‐certainty evidence); withdrawals due to adverse events (RR 1.03, 95% CI 0.89 to 1.18; ARR 0.2% more, 95% CI 0.9% fewer to 1.5% more; low‐certainty evidence); and serious adverse events (RR 1.08, 95% CI 0.82 to 1.43; ARR 0.5% more, 95% CI 1.2% fewer to 2.8% more; low‐certainty evidence). For secondary prevention, alendronate probably results in a clinically important reduction in clinical vertebral fractures (24/1114 in the alendronate group versus 51/1055 in the placebo group; RR 0.45, 95% CI 0.28 to 0.73; ARR 2.7% fewer, 95% CI 3.5% fewer to 1.3% fewer; moderate‐certainty evidence). It may lead to a clinically important reduction in non‐vertebral fractures (RR 0.80, 95% CI 0.64 to 0.99; ARR 2.8% fewer, 95% CI 5.1% fewer to 0.1% fewer; low‐certainty evidence); hip fractures (RR 0.49, 95% CI 0.25 to 0.96; ARR 1.0% fewer, 95% CI 1.5% fewer to 0.1% fewer; low‐certainty evidence); wrist fractures (RR 0.54, 95% CI 0.33 to 0.90; ARR 1.8% fewer, 95% CI 2.6% fewer to 0.4% fewer; low‐certainty evidence); and serious adverse events (RR 0.75, 95% CI 0.59 to 0.96; ARR 3.5% fewer, 95% CI 5.8% fewer to 0.6% fewer; low‐certainty evidence). However, the effects of alendronate for withdrawals due to adverse events are uncertain (RR 0.95, 95% CI 0.78 to 1.16; ARR 0.4% fewer, 95% CI 1.7% fewer to 1.3% more; very low‐certainty evidence). Furthermore, the updated evidence for the safety risks of alendronate suggests that, irrespective of participants' risk of fracture, alendronate may lead to little or no difference for gastrointestinal adverse events. Zero incidents of osteonecrosis of the jaw and atypical femoral fracture were observed. Authors' conclusions For primary prevention, compared to placebo, alendronate 10 mg/day may reduce clinical vertebral and non‐vertebral fractures, but it might make little or no difference to hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. For secondary prevention, alendronate probably reduces clinical vertebral fractures, and may reduce non‐vertebral, hip, and wrist fractures, and serious adverse events, compared to placebo. The evidence is very uncertain about the effect of alendronate on withdrawals due to adverse events. Funding This Cochrane review had no dedicated funding. Registration This review is an update of the previous review (DOI: 10.1002/14651858.CD001155). Plain language summary Does alendronate help prevent fractures caused by osteoporosis in postmenopausal women? Key messages • Alendronate used for up to five years may prevent spinal fractures in women who are at lower risk for fractures, or in those who have not yet had a fracture of the spine. • Alendronate used for up to three years in women diagnosed with osteoporosis, with low bone density, or who have already had a fracture of the spine, probably prevents fractures of the spine. What is osteoporosis? Osteoporosis is a disease which makes bones weak and fragile. Bone is living tissue that is constantly being broken down and replaced. In osteoporosis, old bone breaks down faster than new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones more likely to break even after a minor injury, such as a bump or fall. Women are more likely to get osteoporosis after menopause. What is alendronate? Alendronate is a bisphosphonate, a type of medicine which slows down the cells that break down the old bone. What did we want to find out? We aimed to find out if alendronate is better than placebo (an inactive or 'dummy' medicine) or other medicines in preventing or reducing fractures in postmenopausal women. What did we do? We searched for studies that compared alendronate with placebo or other anti‐osteoporotic medicines for osteoporosis in postmenopausal women. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 119 eligible studies. Of these, 102 studies provided usable data, and 40 studies compared alendronate to placebo (dummy pill). Key findings In women who are at a lower risk for fractures because they have bone density closer to normal, or they may not yet have a fracture in the bones of their spine, alendronate used for up to five years: may prevent clinical spinal fractures – that is, fractures indicated by clinical signs and symptoms, without radiographic evidence; may prevent fractures in bones other than the spine. However, specifically in hip and wrist fractures, alendronate may make no difference; may make no difference to the number of women who withdrew from the study due to adverse events – that is, unwanted, harmful events; may make no difference to the number of women experiencing serious adverse events. In women who are at a higher risk for fractures because they have already been diagnosed with osteoporosis, have low bone density, or have already had a spinal fracture, alendronate used for up to three years: probably prevents clinical spinal fractures; may prevent fractures in bones other than the spine; may prevent hip and wrist fractures; may reduce serious adverse events; We do not know if alendronate reduces withdrawals due to adverse events in this group of women. The best estimates for women at lower fracture risk taking alendronate or placebo are as follows. For clinical spinal fractures, evidence suggests that if 3 out of 100 women taking placebo experience a fracture, only 1 out of 100 women taking alendronate will. If 10 out of 100 women on placebo have a fracture in bones other than the spine, only 8 out of 100 on alendronate are likely to. For hip and wrist fractures, there may be no difference between the two groups in the number of women experiencing fractures. The best estimates for women at higher fracture risk taking alendronate or placebo are as follows. If 5 out of 100 women on placebo have a clinical spinal fracture, only 2 out of 100 women on alendronate are likely to. If 14 out of 100 women on placebo have a fracture in bones other than the spine, only 11 out of 100 on alendronate are likely to. If 2 out of 100 women on placebo have a hip fracture, only 1 out of 100 on alendronate are likely to. If 4 out of 100 women on placebo have a wrist fracture, only 2 out of 100 on alendronate are likely to. What are the limitations of the evidence? For most findings, our confidence in the evidence was low, because it is possible that the women in the studies, and the researchers assessing outcomes, were aware of which treatment the women received. Additionally, some of the evidence focused on specific alendronate doses, whereas the question we wanted to answer was broader. Finally, for some fracture outcomes, the evidence was based on few cases. How current is the evidence? The evidence is current to 1 February 2023. This is an update of a Cochrane review originally published in 2008.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Wells, GA, Hsieh, SC, Peterson, J, Zheng, C, Kelly, SE, Shea, B, Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD001155.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.795Z" }, { "id": "df7b06d8-6d2c-442c-b8d1-fb3386318977", "pmid": "", "title": "Salty Taste: Assessing a Strategy to Reduce Children's Preference", "imported": false, "abstract": "The goals of the proposed research are to determine whether repeated exposure to a low sodium food will result in reduced preference for salt in that food among children; and to determine whether such reductions in preference are related to dietary intake of salt, taste receptor genotype, and anthropometric and physiological measures.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.144Z" }, { "id": "df83d141-236b-4513-8ddb-3ccdfeb2e327", "pmid": "", "title": "Antidepressants for pain management in adults with chronic pain: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well‐being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients’ global impression of change for certain chronic pain conditions. However, there has not been a network meta‐analysis (NMA) examining all antidepressants across all chronic pain conditions. Objectives To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache). Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022. Selection criteria We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double‐blind. We included RCTs with active comparators that were unable to be double‐blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow‐up was less than two weeks and those with fewer than 10 participants in each arm. Data collection and analysis Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta‐analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta‐Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta‐analysis (ROB‐MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB‐MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal. Main results This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo‐controlled (83), and parallel−armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short‐term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest‐ranked antidepressant with moderate‐ to high‐certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate‐certainty evidence) and continuous pain intensity (standardised mean difference (SMD) −0.31, 95% CI −0.39 to −0.24; 18 studies, 4959 participants; moderate‐certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD −0.22, 95% CI −0.39 to 0.06; 4 studies, 1866 participants; moderate‐certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD −0.5, 95% CI −0.78 to −0.22; 1 study, 406 participants; low‐certainty evidence), while duloxetine showed a small effect (SMD −0.16, 95% CI −0.22 to −0.1; 26 studies, 7952 participants; moderate‐certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest‐ranked antidepressants with moderate‐certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low‐certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes. Authors' conclusions Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high‐quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long‐term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point. Plain language summary How effective are antidepressants used to treat chronic pain and do they cause unwanted effects? Key messages • We are only confident in the effectiveness of one antidepressant: duloxetine. We found that a standard dose (60 mg) was effective, and that there is no benefit to using a higher dose. • We are uncertain about unwanted effects for any antidepressant as the data for this were very poor. Future research should address this. • In clinical practice for chronic pain, a standard dose of duloxetine may be considered before trying other antidepressants. • Adopting a person‐centred approach is critical. Pain is a very individual experience and certain medications may work for people even while the research evidence is inconclusive or unavailable. Future studies should last longer and focus on unwanted effects of antidepressants. What is chronic pain? Chronic pain is pain of any kind that lasts for more than three months. Over one‐third of people across the world experience chronic pain. This often affects people's mood and well‐being, and their ability to work and carry out daily tasks. How do antidepressants treat chronic pain? Antidepressants are medications originally developed to treat depression. Different types of antidepressants work in different ways. Antidepressants that work in the same way are grouped into classes. The most common classes are selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and serotonin‐noradrenalin reuptake inhibitors (SNRIs). Research suggests that antidepressants may be effective for pain because the same chemicals that affect mood might also affect pain. What did we want to find out? We wanted to find out if antidepressants were effective for managing chronic pain and whether they cause unwanted effects. What did we do? We searched for studies that compared any antidepressant with any other treatment for any type of chronic pain (except headache). We compared all the treatments against each other using a statistical method called network meta‐analysis. This method allows us to rank the effectiveness of the different antidepressants from best to worst. What did we find? We found 176 studies including 28,664 people with chronic pain. These studies investigated 89 different types or combinations of treatment. Studies mainly investigated the effect of antidepressants on three different types of pain: fibromyalgia (59 studies), nerve pain (49 studies), and musculoskeletal pain (e.g. osteoarthritis or low back pain; 40 studies). The most common antidepressant classes investigated were SNRIs (74 studies), TCAs (72 studies), and SSRIs (34 studies). The most common antidepressants investigated were: amitriptyline (a TCA; 43 studies); duloxetine (an SNRI; 43 studies), and milnacipran (an SNRI; 18 studies). Of the 146 studies that reported where their funding came from, pharmaceutical companies funded 72 studies. The average study lasted 10 weeks. Most of the studies compared an antidepressant with a placebo (which looks like the real medicine but doesn’t have any medicine in it), but some studies compared an antidepressant against a different type of medicine, a different antidepressant, a different type of treatment (like physiotherapy), or different doses of the same antidepressant. Most of the studies in this review reported information on pain relief and unwanted effects. Fewer studies reported on quality of life, sleep, and physical function. Main results • Duloxetine probably has a moderate effect on reducing pain and improving physical function. It was the antidepressant that we have the most confidence in. Higher doses of duloxetine probably provided no extra benefits than standard doses. For every 1000 people taking standard‐dose duloxetine, 435 will experience 50% pain relief compared with 287 who will experience 50% pain relief taking placebo. • Milnacipran may reduce pain, but we are not as confident in this result as duloxetine because there were fewer studies with fewer people involved. • Most studies excluded people with mental health conditions, meaning that participants were already in the 'normal' ranges for anxiety and depression at the beginning of studies. This limited our analysis for mood. Mirtazapine and duloxetine may improve mood, but we are very uncertain about the results. • We do not know about unwanted effects of using antidepressants for chronic pain; there are not enough data to be certain about the results. What are the limitations of the evidence? There are still a number of questions that we were unable to answer: • Aside from duloxetine and milnacipran, we do not have confidence in the results from any other antidepressant included in this review because there are not enough studies. • We do not know whether antidepressants are effective at treating pain in the long term. The average length of studies was 10 weeks. • There was no reliable evidence on the safety of taking antidepressants for chronic pain, both short‐ and long‐term. • We do not know how effective antidepressants are for people with both chronic pain and depression as the most studies excluded participants with depression and anxiety. How up to date is this evidence? This review is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Birkinshaw, H, Friedrich, CM, Cole, P, Eccleston, C, Serfaty, M, Stewart, G, White, S, Moore, RA, Phillippo, D, Pincus, T", "articleTypes": [], "doi": "10.1002/14651858.CD014682.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.130Z" }, { "id": "df8583e3-c111-4f40-bad1-e4570010ee2e", "pmid": "", "title": "Chinese medicinal herbs for mumps", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Shu, M, Zhang, YQ, Li, Z, Liu, GJ, Wan, C, Wen, Y", "articleTypes": [], "doi": "10.1002/14651858.CD008578.pub3 AB - Abstract - Background Mumps is an infectious disease caused by the mumps virus. Chinese physicians generally believe that Chinese medicinal herbs are effective in alleviating symptoms and reducing the duration of mumps. Herbalists tend to develop a treatment plan according to the individual's symptoms. Objectives To evaluate the effectiveness and safety of Chinese medicinal herbs combined with routine treatments for mumps. Search methods We searched CENTRAL (2015, Issue 1), MEDLINE (1948 to January week 4, 2015), EMBASE (1974 to February 2015), CINAHL (1981 to February 2015), AMED (1985 to April 2014), the Chinese Biomedical Database (CBM) (1980 to February 2015), China National Knowledge Infrastructure (CNKI) (1979 to February 2015), VIP Information (1989 to February 2015), and relevant databases of ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs for mumps (with or without complications). Data collection and analysis Two review authors independently evaluated trial quality and conducted data extraction. We contacted the trial authors for missing data regarding participant allocation. Some trials allocated participants according to the participants' admission sequence, making it a pseudo‐random allocation. None of the trials concealed participants' allocation or used blinding. Main results We did not identify any eligible trials for inclusion. We identified 108 studies that claimed to use random allocation. We excluded 104 studies because the allocation methods the authors had used were not actually randomised. We were unable to contact the trial authors of the remaining four studies. These trials require further evaluation and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions We did not find any RCTs for or against Chinese herbal medicine used in the treatment of mumps. We hope more high‐quality RCTs will be conducted in the future. Plain language summary Chinese medicinal herbs for mumps Review question 
 We reviewed the evidence about the effect and safety of Chinese medicinal herbs for mumps. Background 
 Mumps (epidemic parotitis) is an infectious illness caused by the multiplication of the mumps virus in the upper respiratory tract. It can range from a mild upper respiratory disease to serious complications. Herbal medicines have been used in traditional Chinese medicine (TCM) as the main therapy to prevent and treat mumps for thousands of years. Many Chinese physicians believe that Chinese medicinal herbs are effective in treating mumps. Study characteristics 
 The evidence is current to February 2015. The review authors did not find any randomised controlled trials (RCTs) to provide reliable evidence for the effectiveness and safety of Chinese medicinal herbs for mumps. Although no trials were included, we reviewed the studies and found no reports of adverse events with Chinese medicinal herbs as a treatment for mumps. Key results 
 High‐quality trials are needed to answer these questions.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.079Z" }, { "id": "df86ad75-2e5c-4b02-8898-5b9d838a47ef", "pmid": "", "title": "Hyperbaric oxygen therapy for late radiation tissue injury", "imported": false, "abstract": "Abstract - Background This is the third update of the original Cochrane Review published in July 2005 and updated previously in 2012 and 2016. Cancer is a significant global health issue. Radiotherapy is a treatment modality for many malignancies, and about 50% of people having radiotherapy will be long‐term survivors. Some will experience late radiation tissue injury (LRTI), developing months or years following radiotherapy. Hyperbaric oxygen therapy (HBOT) has been suggested as a treatment for LRTI based on the ability to improve the blood supply to these tissues. It is postulated that HBOT may result in both healing of tissues and the prevention of complications following surgery and radiotherapy. Objectives To evaluate the benefits and harms of hyperbaric oxygen therapy (HBOT) for treating or preventing late radiation tissue injury (LRTI) compared to regimens that excluded HBOT. Search methods We used standard, extensive Cochrane search methods. The latest search date was 24 January 2022. Selection criteria We included randomised controlled trials (RCTs) comparing the effect of HBOT versus no HBOT on LRTI prevention or healing. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. survival from time of randomisation to death from any cause; 2. complete or substantial resolution of clinical problem; 3. site‐specific outcomes; and 4. adverse events. Our secondary outcomes were 5. resolution of pain; 6. improvement in quality of life, function, or both; and 7. site‐specific outcomes. We used GRADE to assess certainty of evidence. Main results Eighteen studies contributed to this review (1071 participants) with publications ranging from 1985 to 2022. We added four new studies to this updated review and evidence for the treatment of radiation proctitis, radiation cystitis, and the prevention and treatment of osteoradionecrosis (ORN). HBOT may not prevent death at one year (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.47 to 1.83; I 2 = 0%; 3 RCTs, 166 participants; low‐certainty evidence). There is some evidence that HBOT may result in complete resolution or provide significant improvement of LRTI (RR 1.39, 95% CI 1.02 to 1.89; I 2 = 64%; 5 RCTs, 468 participants; low‐certainty evidence) and HBOT may result in a large reduction in wound dehiscence following head and neck soft tissue surgery (RR 0.24, 95% CI 0.06 to 0.94; I 2 = 70%; 2 RCTs, 264 participants; low‐certainty evidence). In addition, pain scores in ORN improve slightly after HBOT at 12 months (mean difference (MD) −10.72, 95% CI −18.97 to −2.47; I 2 = 40%; 2 RCTs, 157 participants; moderate‐certainty evidence). Regarding adverse events, HBOT results in a higher risk of a reduction in visual acuity (RR 4.03, 95% CI 1.65 to 9.84; 5 RCTs, 438 participants; high‐certainty evidence). There was a risk of ear barotrauma in people receiving HBOT when no sham pressurisation was used for the control group (RR 9.08, 95% CI 2.21 to 37.26; I 2 = 0%; 4 RCTs, 357 participants; high‐certainty evidence), but no such increase when a sham pressurisation was employed (RR 1.07, 95% CI 0.52 to 2.21; I 2 = 74%; 2 RCTs, 158 participants; high‐certainty evidence). Authors' conclusions These small studies suggest that for people with LRTI affecting tissues of the head, neck, bladder and rectum, HBOT may be associated with improved outcomes (low‐ to moderate‐certainty evidence). HBOT may also result in a reduced risk of wound dehiscence and a modest reduction in pain following head and neck irradiation. However, HBOT is unlikely to influence the risk of death in the short term. HBOT also carries a risk of adverse events, including an increased risk of a reduction in visual acuity (usually temporary) and of ear barotrauma on compression. Hence, the application of HBOT to selected participants may be justified. The small number of studies and participants, and the methodological and reporting inadequacies of some of the primary studies included in this review demand a cautious interpretation. More information is required on the subset of disease severity and tissue type affected that is most likely to benefit from this therapy, the time for which we can expect any benefits to persist and the most appropriate oxygen dose. Further research is required to establish the optimum participant selection and timing of any therapy. An economic evaluation should also be undertaken. Plain language summary Hyperbaric oxygen therapy for the treatment of the late effects of radiotherapy Key message – In selected people and areas of the body hyperbaric oxygen therapy (HBOT) may help resolve symptoms associated with late radiation tissue injury (LRTI) but further research is required to establish which people may respond and the best timing of such therapy. What are the problems after radiation treatment and how can it be treated? There is a risk of serious complications developing in the months and years after radiation treatment (radiotherapy) for cancer. These problems are collectively called LRTI and are due to progressive damage to normal tissue (cells within the body) that has been exposed to radiation. These problems can be very difficult to resolve, and there is some doubt as to the best approaches to treatment. HBOT involves breathing oxygen in a specially designed pressurised chamber. It is used to improve oxygen supply to damaged tissue and support healing. What did we want to find out? We wanted to find out if HBOT results in both healing of tissues and the prevention of complications following surgery in an irradiated field and radiotherapy for cancer. What did we do? We searched medical databases for clinical studies reporting the evidence for or against the ability of HBOT to improve these complications compared to either no treatment or alternative treatments. What were the main findings? There was some evidence that HBOT may improve outcomes in LRTI affecting both bone and soft tissues of the head and neck, the bladder and the lower bowel. There was also some evidence that HBOT may reduce wound breakdown and improve pain following LRTI. HBOT did not affect the risk of dying over the short time that these studies followed their patients. HBOT is generally safe and well‐tolerated, but there is a risk of becoming temporarily short‐sighted from the oxygen exposure and of injury to the ear drum on compression. What are the limitations of the evidence? The evidence was mainly limited by small numbers of people and studies, poor reporting of methods and results, and uncertainty as to the exact degree of improvement with HBOT. A study of costs would also be useful. How up to date is this evidence? The evidence is current to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lin, ZC; Bennett, MH; Hawkins, GC; Azzopardi, CP; Feldmeier, J; Smee, R; Milross, C", "articleTypes": [], "doi": "10.1002/14651858.CD005005.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "df955971-0dad-45f9-b9f1-0a27d12c9750", "pmid": "", "title": "Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their aetiology is unknown. The management of chronic rhinosinusitis with nasal polyps, aimed at improving these symptoms, includes both surgical and medical treatments, but there is no universally accepted management protocol. Objectives To assess the effectiveness of endonasal/endoscopic surgery versus medical treatment in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised controlled trials of any surgical intervention (e.g. polypectomy, endoscopic sinus surgery) versus any medical treatment (e.g. intranasal and/or systemic steroids), including placebo, in adult patients with chronic rhinosinusitis with nasal polyps. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Meta‐analysis was not possible due to the heterogeneity of the studies and the selective (incomplete) outcome reporting by the studies. Main results Four studies (231 participants randomised) are included in the review. No studies were at low risk of bias. The studies compared different types of surgery versus various types and doses of systemic and topical steroids and antibiotics. There were three comparison pairs: (1) endoscopic sinus surgery (ESS) versus systemic steroids (one study, n = 109), (2) polypectomy versus systemic steroids (two studies, n = 87); (3) ESS plus topical steroid versus antibiotics plus high‐dose topical steroid (one study, n = 35). All participants also received topical steroids but doses and types were the same between the treatment arms of each study, except for the study using antibiotics. In that study, the medical treatment arm had higher doses than the surgical arm. In two of the studies, the authors failed to report the outcomes of interest. Although there were important differences in the types of treatments and comparisons used in these studies, the results were similar. Primary outcomes: symptom scores and quality of life scores There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) failed to find a difference in generic health‐related quality of life scores. The quality of this evidence is low or very low . Endoscopic scores and other secondary outcomes Two studies reported endoscopic scores. One study (ESS versus systemic steroids) reported a large, significant effect size in the surgical group, with a mean difference (MD) in score of ‐1.5 (95% confidence interval (CI) ‐1.78 to ‐1.22, n = 95) on a scale of 0 to 3 (0 = no polyposis, 3 = severe polyposis). In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups (MD 2.3%, 95% CI ‐17.4% to 12.8%, n = 34). None of the included studies reported recurrence rates. No differences were found for any objective measurements or olfactory tests in those studies in which they were measured. Complications Complication rates were not reported in all studies, but rates of up to 21% for medical treatment and 14.3% for surgical treatment are described. Epistaxis was the most commonly reported complication with both medical and surgical treatments, with severe complications reported rarely. Authors' conclusions The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis with nasal polyps is of very low quality. The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. The one positive finding from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. As the overall evidence is of very low quality (serious methodological limitations, reporting bias, indirectness and imprecision) and insufficient to draw firm conclusions, further research to investigate this problem, which has significant implications for quality of life and healthcare service usage, is justified. Plain language summary Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps Background Nasal polyps are common, benign swellings of the lining of the nose. In some people they may cause no symptoms, but in others they may lead to nasal obstruction, congestion, facial pressure and anosmia (loss of sense of smell). The incidence of symptomatic nasal polyps increases with age and they are more common in men than in women. The cause of nasal polyps is not fully understood but they may be a result of chronic (long‐term) inflammation of the lining of the nose (termed 'chronic rhinosinusitis with nasal polyps'). Chronic rhinosinusitis with nasal polyps can be treated medically, for example with drugs such as topical (intranasal) steroid sprays, or with surgery (for example, nasal polypectomy with or without endoscopic sinus surgery (ESS)). However, it is unclear what is the most effective management strategy. Study characteristics Four randomised controlled trials, involving a total of 231 patients with chronic rhinosinusitis with nasal polyps, are included in this review. The number of patients in each study ranged from 34 to 109. The studies took place in ENT departments in several European countries. All patients were adults and most of the studies enrolled more men than women. In all studies the patients were randomly assigned to either surgery or medical treatment (such as antibiotics or steroid tablets or injections) in addition to topical steroids given as nasal sprays or drops. Both the type of surgery performed and the medical treatments used varied widely between the studies, and did not allow all of the studies to be looked at together. Rather, we considered the treatment groups in the four studies as three separate pairs of comparisons instead of simply 'surgical' versus 'medical' treatments. Key results The main outcome measures were patient‐reported disease‐specific symptom scores and health‐related quality of life scores, as well as generic health‐related quality of life scores. There were no important differences between groups in either the patient‐reported disease‐specific symptom scores or the health‐related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high‐dose topical steroid, the other ESS versus systemic steroids) did not find a difference in general health‐related quality of life scores. Two studies reported changes in polyp size (when looked at with an endoscope) using a score. One study (ESS versus systemic steroids) reported a significantly better score in the surgery group than in the steroids group at 12 months. In the other study (ESS plus topical steroid versus antibiotics plus high‐dose topical steroid) no difference was found between the groups. There were no reported differences between the different medical and surgical treatment groups in any study for any other objective (clinician‐based) measurements. Complication rates were not reported in all studies, but nosebleeds (epistaxis) were the most commonly described complication with both medical and surgical treatment; severe complications were reported rarely in either group. Conclusion The evidence does not show that one treatment is better than another in terms of patient‐reported symptom scores and quality of life measurements. One positive finding (polyps size scores) from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain. There is not enough evidence to draw firm conclusions regarding the most appropriate treatment for this condition. Chronic rhinosinusitis with nasal polyps has significant implications for quality of life and the use of healthcare services. Further research to investigate this problem is justified. Quality of the evidence Overall, we found this evidence to be of low or very low quality. We have low confidence in the estimates of these studies; further research will very likely change these estimates. There were serious limitations in how the studies were carried out or reported (or both), and the number of participants involved was small. In addition, some of the treatment regimens used in the trials are no longer current standards of therapy for patients with chronic rhinosinusitis with nasal polyps. This evidence is up to date to 20 February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Rimmer, J; Fokkens, W; Chong, LY; Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "df9a1bd3-b404-4cae-8087-66246c0a4e56", "pmid": "", "title": "Protein substitute for children and adults with phenylketonuria", "imported": false, "abstract": "Abstract - Background Phenylketonuria is an inherited metabolic disorder characterised by an absence or deficiency of the enzyme phenylalanine hydroxylase. The aim of treatment is to lower blood phenylalanine concentrations to the recommended therapeutic range to prevent developmental delay and support normal growth. Current treatment consists of a low‐phenylalanine diet in combination with a protein substitute which is free from or low in phenylalanine. Guidance regarding the use, dosage, and distribution of dosage of the protein substitute over a 24‐hour period is unclear, and there is variation in recommendations among treatment centres. This is an update of a Cochrane review first published in 2005, and previously updated in 2008. Objectives To assess the benefits and adverse effects of protein substitute, its dosage, and distribution of dose in children and adults with phenylketonuria who are adhering to a low‐phenylalanine diet. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which consists of references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. We also contacted manufacturers of the phenylalanine‐free and low‐phenylalanine protein substitutes for any data from published and unpublished randomised controlled trials. Date of the most recent search of the Group's Inborn Errors of Metabolism Trials Register: 03 April 2014. Selection criteria All randomised or quasi‐randomised controlled trials comparing: any dose of protein substitute with no protein substitute; an alternative dosage; or the same dose, but given as frequent small doses throughout the day compared with the same total daily dose given as larger boluses less frequently. Data collection and analysis Both authors independently extracted data and assessed trial quality. Main results Three trials (69 participants) are included in this review. One trial investigated the use of protein substitute in 16 participants, while a further two trials investigated the dosage of protein substitute in a total of 53 participants. Due to issues with data presentation in each trial, described in full in the review, formal statistical analyses of the data were impossible. Investigators will be contacted for further information. Authors' conclusions No conclusions could be drawn about the short‐ or long‐term use of protein substitute in phenylketonuria due to the lack of adequate or analysable trial data. Additional data and randomised controlled trials are needed to investigate the use of protein substitute in phenylketonuria. Until further evidence is available, current practice in the use of protein substitute should continue to be monitored with care. Plain language summary The impact of protein substitute on the nutrition status, growth, and neuropsychological performance of children and adults with phenylketonuria People with phenylketonuria (PKU) who follow a low‐phenylalanine diet are required to take protein substitute to ensure adequate consumption of protein, energy, and other nutrients. The need for protein substitute has been established through clinical experience and observational data. Randomised, controlled trials are needed to confirm this need as well as its proper dosage and frequency of use. We performed a systematic review of randomised control trials investigating the impact of the use, dosage, and distribution of protein substitute on physical and neuropsychological outcomes in the treatment of PKU. Trials of children and adults diagnosed with PKU in the newborn period who were treated early and continuously were included. We planned to pool the results of the trials to estimate treatment effect. Three trials met the inclusion criteria for the review. One trial evaluated the impact of protein substitute versus no protein substitute on neuropsychological status, plasma amino acid concentrations, and nutrient intake. The remaining two trials investigated the impact of differing dosages of protein substitute on plasma amino acid concentrations and nutrient intake. No trials investigating daily protein substitute distribution were eligible for inclusion in the review. Results are presented in text form only since adequate information for data pooling was not provided. The investigators will be contacted for further information. Currently data are insufficient to reach any conclusions regarding the use, dosage, and distribution of protein substitute in the treatment of PKU. Further randomized or controlled clinical trials are needed to provide evidence for the effectiveness, dosage, and distribution of protein substitute in the treatment of PKU.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Yi, SHL, Singh, RH", "articleTypes": [], "doi": "10.1002/14651858.CD004731.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.769Z" }, { "id": "df9a76f9-314f-463f-a206-3f2e2a6e49e6", "pmid": "", "title": "Zinc supplementation for the prevention of pneumonia in children aged 2 months to 59 months", "imported": false, "abstract": "Abstract - Background Pneumonia is a leading cause of morbidity and mortality in children younger than five years of age. Most deaths occur during infancy and in low‐income countries. Daily zinc supplements have been reported to prevent acute lower respiratory tract infection (LRTI) and reduce child mortality. This is an update of a review first published in 2010. Objectives To evaluate the effectiveness of zinc supplementation in the prevention of pneumonia in children aged two to 59 months. Search methods We searched CENTRAL (Issue 21 October 2016), MEDLINE (1966 to October 2016), Embase (1974 to October 2016), LILACS (1982 to October 2016), CINAHL (1981 to October 2016), Web of Science (1985 to October 2016) and IMSEAR (1980 to October 2016). Selection criteria Randomised controlled trials (RCTs) evaluating zinc supplementation for the prevention of pneumonia in children aged from 2 months to 59 months. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We did not identify any new studies for inclusion in this update. We included six studies that involved 5193 participants. Analysis showed that zinc supplementation reduced the incidence of pneumonia by 13% (fixed‐effect risk ratio (RR) 0.87; 95% confidence interval (CI) 0.81 to 0.94, six studies, low‐quality evidence) and prevalence of pneumonia by 41% (random‐effects RR 0.59; 95% CI 0.35 to 0.99, one study, n = 609, low‐quality evidence). On subgroup analysis, we found that zinc reduced the incidence of pneumonia defined by specific clinical criteria by 21% (i.e. confirmation by chest examination or chest radiograph) (fixed‐effect RR 0.79; 95% CI 0.71 to 0.88, four studies, n = 3261), but had no effect on lower specificity pneumonia case definition (i.e. age‐specific fast breathing with or without lower chest indrawing) (fixed‐effect RR 0.95; 95% CI 0.86 to 1.06, four studies, n = 1932). Authors' conclusions Zinc supplementation in children is associated with a reduction in the incidence and prevalence of pneumonia. Plain language summary Zinc supplementation for the prevention of pneumonia in children aged two to 59 months Review question We evaluated the effectiveness of zinc supplementation to prevent pneumonia in children aged from two to 59 months. Background Zinc is an essential element for children's growth and development. Too little zinc is associated with increased risk of infection, particularly diarrhoea and pneumonia. Children are more prone to zinc deficiency because they are less able to absorb dietary zinc and some children, especially in low‐income countries, may not have received enough zinc from their mothers before birth. Zinc supplements for children has been reported to prevent pneumonia. Search date We searched the literature up to October 2016. This is an update of a review published in 2010. We did not find any new studies for this update. Study characteristics We included six studies that investigated zinc supplements to prevent pneumonia. The studies were conducted in Bangladesh, India, Peru and South Africa and involved 5193 children aged from two to 59 months. Children received either zinc or a similar‐looking treatment that did not contain zinc. In two studies, children were also given vitamin A. Study funding sources All included studies were funded. Of these, three explicitly mentioned that funding agencies had no role in the design and results of the study. Key results Zinc supplementation was significantly associated with reducing the incidence and prevalence of pneumonia among children aged from two to 59 months. On subgroup analysis, we found that a more stringent diagnosis (radiological examination) increased the reduction in pneumonia incidence. Quality of the evidence Overall, evidence quality was assessed as low on GRADE assessment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lassi, ZS; Moin, A; Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD005978.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "df9eb0d1-4304-43b3-b3f5-13813c7a25e9", "pmid": "", "title": "Interventions for treating people with symptoms of bladder pain syndrome: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide‐ranging treatment options, used alone or in combination, with limited evidence. A network meta‐analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS. Objectives To conduct a network meta‐analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS). Search methods We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible. Data collection and analysis We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random‐effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta‐analysis of head‐to‐head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories. Main results We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low‐certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD ‐1.27, 95% CrI ‐3.25 to 0.71; low‐certainty evidence), daytime frequency (MD ‐2.41, 95% CrI ‐6.85 to 2.05; very low‐certainty evidence) or nocturia (MD 0.01, 95% CrI ‐2.53 to 2.50; very low‐certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low‐certainty evidence) or reduced pain (MD 0.42, 95% CrI ‐1.04 to 1.91; low‐certainty evidence), frequency (MD ‐0.37, 95% CrI ‐5.00 to 3.44; very low‐certainty evidence) or nocturia (MD ‐1.20, 95% CrI ‐3.62 to 1.28; very low‐certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD ‐0.33, 95% CrI ‐1.71 to 1.03), frequency (MD ‐0.91, 95% CrI ‐3.24, 1.29) or nocturia (MD ‐0.04, 95% CrI ‐1.35 to 1.27). The certainty of this evidence was always very low. Authors' conclusions We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base. Plain language summary Treatments for people with bladder pain syndrome What is bladder pain syndrome? Bladder pain syndrome (BPS; also called painful bladder syndrome or interstitial cystitis) is a long‐term painful condition that affects the bladder. ‘Syndrome’ refers to a collection of symptoms. In BPS, these symptoms include: intense pain in the pelvis (felt below the bellybutton); sudden strong urges to urinate; needing to urinate more often than usual; and waking up several times during the night to urinate. BPS is more common in women. We do not know what causes it or how to cure it. Symptoms sometimes come and go in phases. BPS can significantly affect lifestyle, work, emotional health and relationships. Treatments for BPS Lifestyle changes are usually tried first, then medicines and supportive therapies. Surgery may be needed as a last resort. Medicines used include pentosan polysulfate sodium – which may help to restore the inner surface of the bladder – anti‐inflammatories, antidepressants and antihistamines. Medicines that block the connection between nerves and muscles can be injected into the bladder muscle to try to relax it (‘neuromuscular blockade’). Supportive therapies and treatments include behavioural therapy, physiotherapy, bladder re‐training, psychological therapy and transcutaneous electrical nerve stimulation (TENS). Review question In this Cochrane Review, we wanted to find out which treatments work best to treat BPS. What did we do? We searched for studies that looked at any type of treatment for BPS. We looked for randomised controlled studies, in which the treatment people receive is randomly decided, because these studies usually give the most reliable evidence about treatments. Search date We included evidence published up to 11 May 2018. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review. What we found We found 81 studies involving 4674 people with BPS. The biggest study included 369 people, and the smallest study included 10 people. Most studies lasted around three months; only six studies lasted 12 months or longer. Twenty‐four studies were funded by pharmaceutical companies. We found 65 treatments for BPS, which we grouped into 31 categories based on how the treatments worked. In most studies, a treatment for BPS was compared with a placebo (or dummy) treatment. We compared all treatments with each other using a mathematical method called network meta‐analysis. What are the results of our review? After 12 months, antidepressants or neuromuscular blockade (and some other treatments) may improve symptoms of BPS more than placebo, but we are not certain about this result. We did not find enough evidence to know if pentosan polysulfate sodium improves symptoms. We are uncertain whether 12 months of treatment with antidepressants, neuromuscular blockade or pentosan polysulfate sodium reduced pain (as measured on a scale); the number of times people had to urinate during the day; or the number of times people had to get up to urinate during the night. Our confidence in the results We are uncertain about our results because we did not find enough reliable evidence. Although we obtained results from 81 studies, most of these studies were small and did not include enough people for us to be certain of their results. Some of the studies (30%) were conducted by pharmaceutical companies, and this may have affected how the studies were designed, conducted and reported. Our results may change when results from more, and larger, studies become available. Conclusions We did not find enough reliable evidence about how well medicines, behavioural therapy, physiotherapy and neuromuscular blockade worked to treat all, or any, of the symptoms of BPS.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Imamura, M; Scott, NW; Wallace, SA; Ogah, JA; Ford, AA; Dubos, YA; Brazzelli, M", "articleTypes": [], "doi": "10.1002/14651858.CD013325.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "dfa3ef5a-30d5-4cec-9e09-6478a5ae1da4", "pmid": "", "title": "The effects of antimicrobial therapy on bacterial vaginosis in non‐pregnant women", "imported": false, "abstract": "Abstract - Background Bacterial vaginosis (BV) is a very common cause of vaginitis that has been associated with a high incidence of obstetric and gynaecologic complications and increased risk of HIV‐1 transmission. This has led to renewed research interest in its treatment. Objectives To assess the effects of antimicrobial agents on BV in non‐pregnant women. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library ), MEDLINE, EMBASE, LILACS, and African Healthline (December 2007); and proceedings of relevant international conferences (from 1981 to date). Selection criteria Randomised controlled trials comparing any two or more antimicrobial agents, or antimicrobial agents with placebo or no treatment, in women with clinical or Gram‐stain criteria of BV. Data collection and analysis Two authors independently assessed trial quality and extracted data from the original publications while the third author cross checked the data. Main results Twenty‐four trials involving 4422 participants were reviewed. Most examined symptomatic women only. Only seven trials analysed results by intention to treat; we re‐analysed the remainder. Compared with placebo, clindamycin showed a lower rate of treatment failure (relative risk (RR) 0.25, 95% confidence interval (CI) 0.16 to 0.37). Clindamycin and metronidazole showed identical rates of treatment failure, irrespective of regimen type, at two and four‐week follow up (RR 1.01, 95% CI 0.69 to 1.46; RR 0.91, 95% CI 0.70 to 1.18, respectively). Clindamycin tended to cause a lower rate of adverse events (RR 0.75, 95% CI 0.56 to 1.02); metallic taste, and nausea and vomiting were more common in the metronidazole group (RR 0.08, 95% CI 0.1 to 0.59; RR 0.23, 95% CI 0.10 to 0.51, respectively). Given intravaginally as gelatin tablets, lactobacillus was more effective than oral metronidazole (RR 0.20, 95% CI 0.05 to 0.08). Similarly, oral lactobacillus combined with metronidazole was more effective than metronidazole alone (RR 0.33, 95% CI 0.14 to 0.77). Clindamycin showed a lower rate of clinical failure than triple sulfonamide cream (RR 0.46, 95% CI 0.29 to 0.72). Hydrogen peroxide douche showed a higher rate of clinical failure (RR 1.75, 95% CI 1.02 to 3.00) and adverse events (RR 2.33, 95% CI 1.21 to 4.52) than a single 2 g dose of metronidazole. Authors' conclusions Clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus were effective for bacterial vaginosis. Hydrogen peroxide douche and triple sulphonamide cream were ineffective. Metronidazole caused metallic taste, nausea and vomiting. We need better‐designed trials with larger sample sizes to test the effectiveness of promising drugs. Plain language summary The effects of antimicrobial treatment on bacterial vaginosis in non‐pregnant women Bacterial vaginosis (BV) is a very common cause of symptomatic and asymptomatic vaginal infection. It has been associated with a high incidence of obstetric and gynaecologic complications and an increased risk of transmission of HIV (human immunodeficiency virus). This review evaluated the effectiveness and adverse effects of antimicrobial agents used to treat BV in non‐pregnant women. Twenty‐four trials involving 4422 women were reviewed. With regard to less treatment failure, clindamycin was superior to placebo but comparable to metronidazole, irrespective of the dose regimen. Metronidazole tended to cause a higher rate of adverse events, such as metallic taste and nausea and vomiting, than did clindamycin. Oral lactobacillus combined with metronidazole was more effective than metronidazole alone. Administered in an intravaginal gelatin tablet, lactobacillus was also more effective than oral metronidazole. Triple sulfonamide cream was less effective compared with clindamycin. Hydrogen peroxide douche was not as effective as a single 2 g dose of metronidazole yet caused more harms. Only one trial involved asymptomatic women and the result was not conclusive. There was insufficient evidence to reach a conclusion on the effectiveness of other promising drugs. Drugs effective for bacterial vaginosis include clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus. Adverse effects of metronidazole include metallic taste, and nausea and vomiting. Information on possible side effects of lactobacillus preparations is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Oduyebo, OO, Anorlu, RI, Ogunsola, FT", "articleTypes": [], "doi": "10.1002/14651858.CD006055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.730Z" }, { "id": "dfafcd83-fc7a-45c7-84ff-b57ea008d241", "pmid": "", "title": "Chinese medicinal herbs for influenza", "imported": false, "abstract": "Abstract - Background Influenza is a communicable acute respiratory infection which, during epidemics, can cause high morbidity and mortality rates. Traditional Chinese medicinal herbs, often administered following a particular Chinese medical theory, may be a potential treatment of choice. Objectives To assess the effect of Chinese medicinal herbs used to prevent and treat influenza and to estimate the frequency of adverse effects. Search methods We searched CENTRAL (2012, Issue 11), MEDLINE (January 1966 to November week 2, 2012), EMBASE (January 1988 to November 2012) and CNKI (January 1988 to 29 March 2012). We also searched reference lists of articles and the WHO ICTRP search portal (November 2012). Selection criteria Randomised controlled trials (RCTs) comparing traditional Chinese medicinal herbs with placebo, no treatment or conventional medicine normally used in preventing and treating uncomplicated influenza. Data collection and analysis Two review authors independently extracted data and assessed trial quality. Main results We included 18 studies involving 2521 participants. The methodological quality of 17 included studies was poor. Included RCTs separately compared medicinal herbs with different antiviral drugs, precluding any pooling of results. Only three indicated that compared with antiviral drugs, Chinese medicinal herbs may be effective in preventing influenza and alleviating influenza symptoms. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and speeding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. Ten studies reported mild adverse reactions. Authors' conclusions Most Chinese medical herbs in the included studies showed similar effects to antiviral drugs in preventing or treating influenza. Few were shown to be superior to antiviral drugs. No obvious adverse events were reported in the included studies. However, current evidence remains weak due to methodological limitations of the trials. More high‐quality RCTs with larger numbers of participants and clear reporting are needed. Plain language summary Chinese medicinal herbs for influenza Influenza is a viral respiratory infection that causes an acute febrile illness with myalgia, headache and cough, and can result in high morbidity and mortality rates during an epidemic. Annual epidemics are thought to result in between three and five million cases of severe influenza and between 250,000 and 500,000 deaths worldwide. Currently, annual vaccination is the primary strategy for preventing influenza, and four influenza antiviral agents (amantadine, rimantadine, zanamivir and oseltamivir) have been approved for treatment of influenza. However, high levels of drug resistance have been recorded. Many Chinese medicinal herbs are used to treat and prevent this condition. This updated review assessed the therapeutic effects and safety of Chinese medicinal herbs as an alternative and adjunctive therapy to other commonly used drugs for influenza. Eighteen studies involving 2521 participants were included in the review. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and aiding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. The remaining 17 Chinese herbal trials showed a similar effect to antiviral drugs in preventing or treating influenza. However, since these included studies were of poor quality, the evidence does not support or reject the use of any Chinese herbal preparations for influenza. High‐quality trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Jiang, L; Deng, L; Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD004559.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "dfb30021-c764-4d58-8a34-f9e752aedfc7", "pmid": "", "title": "Modifying the consistency of food and fluids for swallowing difficulties in dementia", "imported": false, "abstract": "Abstract - Background People with dementia can have feeding and swallowing difficulties (dysphagia). Modification of the consistency of food or fluids, or both, is a common management strategy. However, diet modification can affect quality of life and may lead to dehydration and malnutrition. Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia. Objectives To determine the effectiveness and adverse effects associated with modifying the consistency of food and fluids in improving oral intake and eliminating aspiration in adults with dysphagia and dementia. Search methods We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE via Ovid SP, Embase via Ovid SP, PsycINFO via Ovid SP, CINAHL via EBSCOhost, LILACS via BIREME, ClinicalTrials.gov and the World Health Organization (WHO) Portal on 9 May 2018. We also checked the reference lists of relevant articles to identify any additional studies. Selection criteria We included randomised controlled trials (RCTs), quasi‐RCTs and cluster‐RCTs published in any language that measured any of the outcomes of interest. We included trials with adults with a clinical diagnosis of dementia with symptoms and signs of dysphagia confirmed on instrumental assessment. We included participants with all types, stages and severities of dementia. Control groups received either no intervention or interventions not involving diet modification or modification to sensory properties of food. Data collection and analysis Two review authors independently assessed for inclusion all potential studies identified. Data were extracted independently along with assessment of methodological quality using standard Cochrane methods. We contacted study authors for additional unpublished information. Main results No trials on modification of food met the inclusion criteria. We included two studies that examined modification to fluids. Both were part of the same large multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. Participation in the second trial was determined by results from the first trial. With unpublished data supplied by study authors, we examined data from participants with dementia only. The first study, a cross‐over trial, investigated the immediate effects on aspiration of two viscosities of liquids (nectar thick and honey thick) compared to regular liquids in 351 participants with dementia using videofluoroscopy. Regular liquids with a chin down head posture, as well as regular liquids without any intervention were also compared. The sequence of interventions during videofluoroscopy may have influenced response to intervention. The second study, a parallel designed RCT, compared the effect of nectar and honey thick liquids with a chin down head posture over a three‐month period in a subgroup of 260 participants with dementia. Outcomes were pneumonia and adverse intervention effects. Honey thick liquids, which are more consistent with descriptors for 'spoon thick' or 'extremely thick' liquids, showed a more positive impact on immediate elimination of aspiration during videofluoroscopy, but this consistency showed more adverse effects in the second follow‐up study. During the second three‐month follow‐up trial, there were a greater number of incidents of pneumonia in participants receiving honey thick liquids than those receiving nectar thick liquids or taking regular liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of fluids prescribed. Neither trial addressed quality of life. Risk of bias for both studies is high. The overall quality of evidence for outcomes in this review is low. Authors' conclusions We are uncertain about the immediate and long‐term effects of modifying the consistency of fluid for swallowing difficulties in dementia as too few studies have been completed. There may be differences in outcomes depending on the grade of thickness of fluids and the sequence of interventions trialled in videofluoroscopy for people with dementia. Clinicians should be aware that while thickening fluids may have an immediate positive effect on swallowing, the long‐term impact of thickened fluids on the health of the person with dementia should be considered. Further high‐quality clinical trials are required. Plain language summary Modifying the consistency of food and fluids for swallowing difficulties in dementia Background Individuals with dementia often present with swallowing difficulties (dysphagia). The consequences can include choking, dehydration, malnutrition, weight loss, pneumonia and death. Modification of food and liquid is a popular management strategy. It is believed that increasing the viscosity of liquids or altering the consistency of food allows individuals a better opportunity to swallow, with a reduced risk of choking or liquids entering the airway. However, there is growing evidence suggesting that this strategy can lead to dehydration, malnutrition, negative psychological/social consequences, and can affect quality of life for the person with dementia. Review question We wished to find out if changing the viscosity or consistency of food or fluids, or both, makes swallowing safer and has positive outcomes for people with dementia in terms of respiratory status, nutritional status and quality of life. We wanted to examine if modifying food or fluids, or both, also had any adverse effects for the person with dementia. Study characteristics We found two studies, which were both part of the same multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. We included data on people with dementia only. The first of the two studies looked at the immediate effects of two viscosities of liquids compared to regular thin liquids on aspiration (entry of food or fluid into the lungs) in 351 people with dementia. This study also compared drinking regular thin liquids using a chin down head posture as well as drinking regular thin liquids without any changes to head position; the main outcome was fluid entering the lungs. Using a subgroup of 260 people with dementia from the first study, the second study compared the effect of the same liquid viscosities with a chin down head posture. The effectiveness of these interventions on the incidence of pneumonia and adverse effects of these interventions was examined over a three‐month period. Study results Honey thick viscosity liquids, which clinically are similar to descriptions of 'very thick liquids', had a more positive immediate impact on preventing fluid entering the lungs when examined during videofluoroscopy (specialised swallow x‐ray) examination. However, during the three‐month follow‐up period there were a greater number of incidents of pneumonia in the group of people with dementia receiving these honey thick liquids, than those receiving nectar thick liquids and those receiving regular thin liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of liquids that the person with dementia was receiving. Conclusion There were a number of methodological flaws in both studies in this review and these were acknowledged by the authors. While thickening fluids may have an immediate positive effect on swallow function, clinicians should consider the effects of this intervention on the person with dementia in the longer‐term. People with dementia on thickened fluids require long‐term follow‐up. The overall risk of bias of included studies is high. The quality of evidence is low. Further well‐designed research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Flynn, E; Smith, CH; Walsh, CD; Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD011077.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "dfc14b32-1be8-4631-89ae-8a0343edb29b", "pmid": "", "title": "Toward Understanding Dopamine Receptor Contributions to Prediction Error and Reversal Learning in Anorexia Nervosa", "imported": false, "abstract": "Anorexia nervosa (AN) is an eating disorder associated with intense fear of weight gain, food refusal, and severe weight loss. AN has the highest mortality rate among the psychiatric disorders; however, little is known about biomarkers, and no medication has been approved for AN. Many individuals only partially recover, and treatment options, especially for the psychological components of the illness, are not very effective, highlighting the need for more effective treatments.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.146Z" }, { "id": "dff9ec36-961d-4ef3-9949-b8f7dcf0e910", "pmid": "", "title": "Antipsychotics for fibromyalgia in adults", "imported": false, "abstract": "Abstract - Background This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well‐defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co‐exists with sleep problems and fatigue. It affects approximately 2% of the general population. Up to 70% of patients with fibromyalgia meet the criteria for a depressive or anxiety disorder. People often report high disability levels and poor health‐related quality of life. Drug therapy focuses on reducing key symptoms and disability, and improving health‐related quality of life. Antipsychotics might reduce fibromyalgia and associated mental health symptoms. Objectives To assess the efficacy, tolerability and safety of antipsychotics in fibromyalgia in adults. Search methods We searched CENTRAL (2016, Issue 4), MEDLINE and EMBASE to 20 May 2016, together with reference lists of retrieved papers and reviews and two clinical trial registries. We also contacted trial authors. Selection criteria We selected controlled trials of at least four weeks duration of any formulation of antipsychotics used for the treatment of fibromyalgia in adults. Data collection and analysis We extracted the data from all included studies and two review authors independently assessed study risks of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. We derived first tier evidence from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for drop‐outs, at least 200 participants in the comparison, eight to 12 weeks duration, parallel design), second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison, and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. We rated the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main results We included a total of four studies with 296 participants. Three studies with 206 participants compared quetiapine, an atypical (second‐generation) antipsychotic, with placebo. One study used a cross‐over design and two studies a parallel‐group design. Study duration was eight or 12 weeks. Quetiapine was used in all studies with a bedtime dosage between 50 and 300 mg/day. All studies had one or more sources of potential major bias and we judged them to be at moderate risk of bias overall. The primary outcomes in this review were participant‐reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety). Second tier evidence indicated that quetiapine was not statistically superior to placebo in the number of participants with a 50% or more pain reduction (very low quality evidence). No study reported data on PGIC. A greater proportion of participants on quetiapine reported a 30% or more pain reduction (risk difference (RD) 0.12, 95% confidence interval (CI) 0.00 to 0.23; number needed to treat for an additional benefit (NNTB) 8, 95% CI 5 to 100) (very low quality evidence). A greater proportion of participants on quetiapine reported a clinically relevant improvement of health‐related quality of life compared to placebo ( RD 0.18, 95% CI 0.05 to 0.31; NNTB 5, 95% CI 3 to 20) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing sleep problems (standardised mean difference (SMD) ‐0.67, 95% CI ‐1.10 to ‐0.23), depression (SMD ‐0.39, 95% CI ‐0.74 to ‐0.04) and anxiety (SMD ‐0.40, 95% CI ‐0.69 to ‐0.11) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing the risk of withdrawing from the study due to a lack of efficacy (RD ‐0.14, 95% CI ‐0.23 to ‐0.05) (very low quality evidence). There was no statistically significant difference between quetiapine and placebo in the proportion of participants withdrawing due to adverse events (tolerability) (very low quality evidence), in the frequency of serious adverse events (safety) (very low quality evidence) and in the proportion of participants reporting dizziness and somnolence as an adverse event (very low quality evidence). In more participants in the quetiapine group a substantial weight gain was noted (RD 0.08, 95% CI 0.02 to 0.15; number needed to treat for an additional harm (NNTH) 12, 95% CI 6 to 50) (very low quality evidence). We downgraded the quality of evidence by three levels to a very low quality rating because of limitations of study design, indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). One parallel design study with 90 participants compared quetiapine (50 to 300 mg/day flexible at bedtime) to amitriptyline (10 to 75 mg/day flexible at bedtime). The study had three major risks of bias and we judged it to be at moderate risk of bias overall. We downgraded the quality of evidence by two levels to a low quality rating because of indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). Third tier evidence indicated no statistically significant differences between the two drugs. Both drugs did not statistically significantly differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life and in the proportion of participants reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared to amitriptyline, more participants left the study due to adverse events (low quality evidence). No serious adverse events were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia. Authors' conclusions Very low quality evidence suggests that quetiapine may be considered for a time‐limited trial (4 to 12 weeks) to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits in shared decision making with the patient. Plain language summary Antipsychotics for fibromyalgia symptoms in adults Bottom line Quetiapine may be considered for 4 to 12 weeks to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits. Background People with fibromyalgia often have chronic (longer than three months) widespread pain, as well as sleep problems, problems with thinking and exhaustion. They often report severe limitations of daily functioning and poor quality of life. Therapies focus on reducing key symptoms and disability, and improving health‐related quality of life. In addition, many patients with fibromyalgia suffer from depression. Medicines used to treat depression can reduce the main symptoms in some people with fibromyalgia. Quetiapine is a drug for the treatment of psychosis (an abnormal condition of the mind described as involving a loss of contact with reality), which is also licensed for the treatment of major depression in some countries. Study characteristics In May 2016, we searched for clinical trials in which antipsychotics were used to treat symptoms of fibromyalgia in adults. We found a total of four studies with 298 participants. We found three studies with 208 participants, which were eight and 12 weeks long and compared quetiapine, an antipsychotic, against a fake medication (placebo). One hundred and sixty‐six participants were diagnosed with major depression. We also found one study comprising 90 patients that compared quetiapine to an antidepressant named amitriptyline, which is frequently used in the treatment of fibromyalgia. Five people in this study were diagnosed with major depression. Key results and quality of the evidence Quetiapine was not better than a fake medication in achieving a pain reduction of 50% or more (very low quality evidence). Quetiapine was better than the fake medication in achieving a pain reduction of 30% or more, reducing sleep problems, and improving depressed mood and anxiety (very low quality evidence). Quetiapine was better than the fake medication in improving health‐related quality of life. Fewer participants dropped out of the trial due to lack of efficacy with quetiapine than with fake medication (very low quality evidence). There was no difference in tolerability and safety between quetiapine and a fake medication (very low quality evidence). For some people, quetiapine led to substantial weight gain and somnolence (sleepiness). Quetiapine and amitriptyline (an antidepressant which is frequently used to improve sleep and reduce pain in people with fibromyalgia) did not differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health‐related quality of life. Both drugs did not differ in the proportion of patients reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared with amitriptyline, more people experienced side effects and left the study due to side effects with quetiapine (low quality evidence). No serious side effects with either drug were reported (low quality evidence). We found no relevant study with other antipsychotics than quetiapine in fibromyalgia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Walitt, B; Klose, P; Üçeyler, N; Phillips, T; Häuser, W", "articleTypes": [], "doi": "10.1002/14651858.CD011804.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "e0261726-04d8-47d9-b0f8-be7920f618c1", "pmid": "", "title": "Antioxidant vitamin and mineral supplements for slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Age‐related macular degeneration (AMD) is a degenerative condition of the back of the eye that occurs in people over the age of 50 years. Antioxidants may prevent cellular damage in the retina by reacting with free radicals that are produced in the process of light absorption. Higher dietary levels of antioxidant vitamins and minerals may reduce the risk of progression of AMD. This is the third update of the review. Objectives To assess the effects of antioxidant vitamin and mineral supplements on the progression of AMD in people with AMD. Search methods We searched CENTRAL, MEDLINE, Embase, one other database, and three trials registers, most recently on 29 November 2022. Selection criteria We included randomised controlled trials (RCTs) that compared antioxidant vitamin or mineral supplementation to placebo or no intervention, in people with AMD. Data collection and analysis We used standard methods expected by Cochrane. Main results We included 26 studies conducted in the USA, Europe, China, and Australia. These studies enroled 11,952 people aged 65 to 75 years and included slightly more women (on average 56% women). We judged the studies that contributed data to the review to be at low or unclear risk of bias. Thirteen studies compared multivitamins with control in people with early and intermediate AMD. Most evidence came from the Age‐Related Eye Disease Study (AREDS) in the USA. People taking antioxidant vitamins were less likely to progress to late AMD (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.58 to 0.90; 3 studies, 2445 participants; moderate‐certainty evidence). In people with early AMD, who are at low risk of progression, this means there would be approximately four fewer cases of progression to late AMD for every 1000 people taking vitamins (one fewer to six fewer cases). In people with intermediate AMD at higher risk of progression, this corresponds to approximately 78 fewer cases of progression for every 1000 people taking vitamins (26 fewer to 126 fewer). AREDS also provided evidence of a lower risk of progression for both neovascular AMD (OR 0.62, 95% CI 0.47 to 0.82; moderate‐certainty evidence) and geographic atrophy (OR 0.75, 95% CI 0.51 to 1.10; moderate‐certainty evidence), and a lower risk of losing 3 or more lines of visual acuity (OR 0.77, 95% CI 0.62 to 0.96; moderate‐certainty evidence). Low‐certainty evidence from one study of 110 people suggested higher quality of life scores (measured with the Visual Function Questionnaire) in treated compared with non‐treated people after 24 months (mean difference (MD) 12.30, 95% CI 4.24 to 20.36). In exploratory subgroup analyses in the follow‐on study to AREDS (AREDS2), replacing beta‐carotene with lutein/zeaxanthin gave hazard ratios (HR) of 0.82 (95% CI 0.69 to 0.96), 0.78 (95% CI 0.64 to 0.94), 0.94 (95% CI 0.70 to 1.26), and 0.88 (95% CI 0.75 to 1.03) for progression to late AMD, neovascular AMD, geographic atrophy, and vision loss, respectively. Six studies compared lutein (with or without zeaxanthin) with placebo and one study compared a multivitamin including lutein/zeaxanthin with multivitamin alone. The duration of supplementation and follow‐up ranged from six months to five years. Most evidence came from the AREDS2 study in the USA; almost all participants in AREDS2 also took the original AREDS supplementation formula. People taking lutein/zeaxanthin may have similar or slightly reduced risk of progression to late AMD (RR 0.94, 95% CI 0.87 to 1.01), neovascular AMD (RR 0.92, 95% CI 0.84 to 1.02), and geographic atrophy (RR 0.92, 95% CI 0.80 to 1.05) compared with control (1 study, 4176 participants, 6891 eyes; low‐certainty evidence). A similar risk of progression to visual loss of 15 or more letters was seen in the lutein/zeaxanthin and control groups (RR 0.98, 95% CI 0.91 to 1.05; 6656 eyes; low‐certainty evidence). Quality of life (Visual Function Questionnaire) was similar between groups (MD 1.21, 95% CI ‐2.59 to 5.01; 2 studies, 308 participants; moderate‐certainty evidence).
One study in Australia randomised 1204 people to vitamin E or placebo with four years of follow‐up; 19% of participants had AMD. The number of late AMD events was low (N = 7) and the estimate of effect was uncertain (RR 1.36, 95% CI 0.31 to 6.05; very low‐certainty evidence). There was no evidence of any effect of treatment on visual loss (RR 1.04, 95% CI 0.74 to 1.47; low‐certainty evidence). There were no data on neovascular AMD, geographic atrophy, or quality of life.
Five studies compared zinc with placebo. Evidence largely drawn from the largest study (AREDS) found a lower progression to late AMD over six years (OR 0.83, 95% CI 0.70 to 0.98; 3 studies, 3790 participants; moderate‐certainty evidence), neovascular AMD (OR 0.76, 95% CI 0.62 to 0.93; moderate‐certainty evidence), geographic atrophy (OR 0.84, 95% CI 0.64 to 1.10; moderate‐certainty evidence), or visual loss (OR 0.87, 95% CI 0.75 to 1.00; 2 studies, 3791 participants; moderate‐certainty evidence). There were no data on quality of life. Gastrointestinal symptoms were the main reported adverse effect. In AREDS, zinc was associated with a higher risk of genitourinary problems in men, but no difference was seen between high‐ and low‐dose zinc groups in AREDS2. Most studies were too small to detect rare adverse effects. Data from larger studies (AREDS/AREDS2) suggested there may be little or no effect on mortality with multivitamin (HR 0.87, 95% CI 0.60 to 1.25; low‐certainty evidence) or lutein/zeaxanthin supplementation (HR 1.06, 95% CI 0.87 to 1.31; very low‐certainty evidence), but confirmed the increased risk of lung cancer with beta‐carotene, mostly in former smokers. Authors' conclusions Moderate‐certainty evidence suggests that antioxidant vitamin and mineral supplementation (AREDS: vitamin C, E, beta‐carotene, and zinc) probably slows down progression to late AMD. People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than people with early AMD. Although low‐certainty evidence suggested little effect with lutein/zeaxanthin alone compared with placebo, exploratory subgroup analyses from one large American study support the view that lutein/zeaxanthin may be a suitable replacement for the beta‐carotene used in the original AREDS formula. Plain language summary Do antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD)? Key messages 
‐ Taking an antioxidant multivitamin supplement may slow down the progression of age‐related macular degeneration (AMD), an eye disease that blurs your central vision. ‐ People with intermediate AMD have a higher chance of benefiting from antioxidant supplements because their risk of progression is higher than for people with early AMD. ‐ Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence as to safety as they were generally too small. What is age‐related macular degeneration? Age‐related macular degeneration (AMD) is an eye disease that blurs your central vision. It is usually only diagnosed in people aged 50 years and above. AMD affects the central area (macula) of the back of the eye (retina), as the macula degenerates with age. In early AMD, yellow spots (called drusen) can be seen under the retina by an eye health professional. The affected person will probably be unaware that they have a problem. As the disease progresses, the drusen become larger (intermediate AMD). In the later stages of the disease, there may be loss of the cells – needed for vision – in the back of the eye. This is known as geographic atrophy. Sometimes, new (harmful) blood vessels grow in the macula. These new blood vessels may bleed and cause scarring. This is known as neovascular AMD. Neovascular AMD and geographic atrophy are known as late AMD. Why might antioxidant vitamins and minerals be helpful? Antioxidant vitamins and minerals may help to protect the macula against this deterioration and loss of vision. Antioxidants are natural molecules that may prevent or delay some types of cell damage. Vitamins C and E, beta‐carotene, lutein, zeaxanthin, and zinc are examples of antioxidants commonly found in dietary supplements. What did we want to find out? 
We wanted to find out whether antioxidant vitamin and mineral supplements slow down the progression of age‐related macular degeneration (AMD) and prevent visual loss. What did we do? We searched for studies that compared antioxidant vitamin and mineral supplements with placebo (a ‘dummy’ treatment not containing any supplements) or no treatment. We only looked at the effects of these supplements in people with AMD. There is another Cochrane Review on the effects of these supplements in people who do not already have AMD. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 26 studies from the USA, Europe, China, and Australia that enroled 11,952 people with AMD. These studies compared multivitamin supplements, zinc, vitamin E, lutein (with or without zeaxanthin) with placebo. Participants were aged 65 to 75 years and there were slightly more women than men in the studies. Main findings • Taking an antioxidant multivitamin supplement (AREDS formula containing vitamins E and C, beta‐carotene plus zinc) probably slows down the progression of AMD to late AMD and vision loss. This may result in a small improvement in quality of life. • People with intermediate AMD have a higher risk of progression to late AMD and so may be more likely to benefit from supplements (78 fewer cases of progression for every 1000 people taking supplements). People with early AMD have a low risk of progression and so may be less likely to benefit (4 fewer cases of progression to late AMD for every 1000 people taking supplements). • Lutein with or without zeaxanthin may have little or no effect on progression to late AMD but may be a suitable replacement for beta‐carotene in the AREDS formula. Beta‐carotene may increase the chance of lung cancer in people who have smoked. • The effects of vitamin E alone on the progression to late AMD and vision loss are uncertain. Although vitamin supplements are generally regarded as safe, the studies included in this review did not provide good evidence about safety because most of the studies were small and reported on harmful effects inconsistently. What are the limitations of the evidence? Our confidence in the evidence ranged from moderate to very low. This is because most of the included studies were small, and they did not cover all the comparisons and outcomes we were interested in. How up to date is this review? 
This review updates our previous version. The evidence is up to date to 29 November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Evans, JR; Lawrenson, JG", "articleTypes": [], "doi": "10.1002/14651858.CD000254.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "e02e0f1c-ea6b-469f-8762-d1daceaee01f", "pmid": "", "title": "Interventions for the eradication of meticillin‐resistant Staphylococcus aureus (MRSA) in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a genetic disorder characterised by recurrent and persistent pulmonary infections from resistant organisms, resulting in deterioration of lung function and early mortality. Meticillin‐resistant Staphylococcus aureus (MRSA) is an important infection in hospital patients and harmful to people with CF (pwCF). Chronic pulmonary MRSA infection may confer a worse clinical outcome on pwCF and result in a faster decline in lung function. Robust evidence clearly guiding MRSA eradication in CF is urgently needed. This is an updated review. Objectives To evaluate the effectiveness of antibiotic treatment designed to eradicate MRSA, to determine whether eradication confers better clinical and microbiological outcomes for pwCF, and to ascertain whether attempts at eradicating MRSA lead to increased acquisition of other resistant organisms (including Pseudomonas aeruginosa ), increased adverse effects from drugs, or both. Search methods We searched the Cochrane CF's Trials Register, PubMed, MEDLINE and three trials registries; handsearched article reference lists; and contacted experts in the field. We last searched Cochrane CF's Trials Register and the trials registries on 28 April 2026. Eligibility criteria Randomised controlled trials (RCTs) or quasi‐RCTs of any combination of topical, inhaled, oral or intravenous antibiotics for treating MRSA compared with placebo, standard treatment or no treatment in pwCF, regardless of age or disease severity. Outcomes We planned to assess these outcomes at up to 12 months following therapy: eradication of MRSA from respiratory cultures, time until next positive MRSA isolate, quality of life (QoL), change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted, change in weight (kg), frequency of pulmonary exacerbations and adverse effects of treatment. Risk of bias Using the original Cochrane risk of bias tool, we assessed individual domains and produced an overall risk of bias for each trial. Synthesis methods We followed Cochrane's standard methodology, conducting fixed‐effect meta‐analyses or reporting narratively. We assessed evidence certainty using GRADE. Included studies We included five RCTs (410 participants). Synthesis of results Oral antibiotics versus no treatment Two trials (106 participants) compared observation to oral trimethoprim plus sulfamethoxazole combined with rifampicin; in one trial for two weeks alongside topical decontamination and a three‐week environmental decontamination, and in a second for 21 days alongside intranasal mupirocin (five days); 29 participants withdrew from the second trial by the end of follow‐up. Oral antibiotics have little or no effect on any outcome reported below, in contrast to one study (45 participants) which was terminated early due to results clearly favouring treatment. In one trial defining eradication as negative MRSA respiratory cultures at day 28 and remaining so at day 168 (45 participants), treatment may result in more negative cultures than observation (odds ratio (OR) 12.6 (95% confidence interval (CI) 2.84 to 55.84; low‐certainty). There may be little to no difference between groups by day 168 of follow‐up (OR 1.17, 95% CI 0.31 to 4.42), and also in one trial defining successful eradication as no MRSA in at least three cultures over six months follow‐up (OR 2.74, 95% CI 0.64 to 11.75; low‐certainty). Treatment may result in an increase in FEV 1 % predicted from baseline (MD 5.67%, 95% CI 1.43 to 9.90; 2 trials, 58 participants; low‐certainty evidence). There may be little to no differences between groups in QoL, frequency of pulmonary exacerbations (although one study reported a lower hospitalisation rate through day 168 with treatment (P = 0.01)), adverse effects, or weight (all low‐certainty evidence). Nebulised antibiotics versus placebo Two trials (275 participants randomised, 251 analysed) compared a standard dose of vancomycin (one trial additionally compared a high dose) to placebo. The multi‐arm trial reported a decrease in MRSA colony forming units (CFUs) at each time point, up to one month. There were no differences in most lung function results in either trial, but treatment probably increased FEV 1 % predicted at 20 weeks (MD 3.55%, 95% CI 0.33 to 6.77; P = 0.03; 1 trial, 133 participants; moderate‐certainty evidence). This trial also reported no difference in pulmonary exacerbation frequency, while the multi‐arm trial reported a longer time to the next exacerbation with the lower vancomycin dose (no placebo data available). Evidence from both trials suggests that nebulised antibiotics may make little or no difference in QoL (high to low‐certainty), or frequency of adverse outcomes or of exacerbations (low‐to‐moderate‐certainty evidence). Oral antibiotics plus nebulised antibiotics (vancomycin) versus oral antibiotics plus placebo One trial (29 participants randomised, 25 participants analysed) compared combination antibiotic treatment (inhaled plus oral) to oral antibiotics plus inhaled placebo, defining eradication as a negative MRSA respiratory sample at one month following treatment. Combination antibiotic treatment may result in little or no difference in MRSA eradication at three months (OR 1.63, 95% CI 0.19 to 13.93; low‐certainty evidence), lung function (no data available for analysis) or adverse effects (low‐certainty evidence), in QoL (very low‐certainty evidence) or nasal colonisation with MRSA. Authors' conclusions Early eradication of MRSA is possible in pwCF; evidence from one trial suggested active MRSA treatment may result in a higher proportion of MRSA‐negative respiratory cultures after one month compared with observation. However, longer follow‐up showed treatment may make little or no difference in the proportion of participants remaining MRSA‐negative. One trial of nebulised antibiotics alone compared to placebo reported a decrease in MRSA CFUs with a higher antibiotic dose. The longer‐term clinical consequences of any treatment option – in terms of lung function, mortality and cost of care – remain unclear. We judged the evidence to range from high to very low‐certainty, due to potential biases from trial design, high attrition rates and small sample sizes. While early eradication of respiratory MRSA in pwCF may be possible, the currently available evidence does not demonstrate that routine treatment of respiratory MRSA in pwCF is effective. Research is needed to assess MRSA infection and treatment in the age of modulator therapies. Funding The 2025 update was undertaken as part of Cochrane CF funding from the UK CF Trust and the CF Foundation. Registration Protocol (2012) DOI: 10.1002/14651858.CD009650. Original review (2013) DOI: 10.1002/14651858.CD009650.pub2. Review updates: (2015) DOI: 10.1002/14651858.CD009650.pub3; (2018) DOI: 10.1002/14651858.CD123456.pub4; (2022) DOI: 10.1002/14651858.CD009650.pub5. Plain language summary Can treatment with antibiotics clear the 'superbug' MRSA from the lungs of people with cystic fibrosis? Key messages Early treatment of meticillin‐resistant Staphylococcus aureus (MRSA) (a type of bacteria which are resistant to some antibiotics) infection in people with cystic fibrosis (CF) seems possible, but we are unsure about the effectiveness of current routine treatment. Longer‐term implications of treatment are not clear. Research is needed to assess MRSA infection and treatment in the age of cystic fibrosis transmembrane conductance regulator (CFTR) modulators (drugs that fix the broken protein made by the CF gene so salt and water can move correctly across cells and help move mucus from the lungs). What is cystic fibrosis (CF)? CF is an inherited condition which causes thick mucus to build up in the lungs and other organs. It is very difficult for people with CF to cough up this thick mucus, making it an ideal breeding ground for germs (including MRSA), and making them more prone to chest infections. CF worsens over time. Although there is currently no cure, many people with CF can lead active and full lives. What is MRSA and how is it treated? MRSA (meticillin‐resistant Staphyloccocus aureus) are bacteria which cause infection that is treated with antibiotics. However, MRSA are resistant to some types of antibiotics, making the infection hard to treat. They are sometimes called 'superbugs' and infection with MRSA is particularly worrying for people with CF, as it is thought that MRSA can cause more damage than other bacteria which are not resistant to antibiotics. MRSA is usually treated with a combination of antibiotics, taken orally (by mouth) or inhaled, alongside decontamination treatment (antibiotic creams applied to the skin and nasal cavities). What did we want to find out? We wanted to know whether treatment with antibiotics: can get rid of MRSA infection in the lungs of children or adults with CF; does not cause infection with other resistant bacteria; does not cause unwanted effects. What did we do? We looked for studies that investigated antibiotics (oral or inhaled) to treat MRSA infections in people with CF. Studies had to compare antibiotic treatment with either no treatment, placebo (sham treatment) or other type of antibiotics. People had to have CF and current infection with MRSA. What did we find? We found five studies which recruited 410 people with CF and a diagnosed MRSA infection. Studies took place in Italy or North America and lasted from eight weeks to six months. People in the studies (equal numbers of males and females) were young (average age ranged from 11 to 25 years). Oral antibiotics compared to no treatment (2 studies, 106 people) One group of people with CF were treated with oral antibiotics (trimethoprim, sulfamethoxazole and rifampicin or co‐trimoxazole and rifampicin), plus decontamination treatment; the other group received no treatment. Oral antibiotics may clear MRSA. One trial stopped early due to clear benefits of antibiotics, but some people cleared the infection with no treatment. In six months, there was no difference between groups in the number of people who still had MRSA. Antibiotics may increase lung function. There may be little to no difference between groups in quality of life, frequency of flare‐ups of the disease (although one study reported fewer people taking antibiotics were admitted to hospital in the first six months), unwanted effects of treatment, or changes in weight. Inhaled antibiotics compared to placebo (2 studies, 251 people) Both studies compared a standard dose of vancomycin (an inhaled antibiotic) to placebo (a dummy drug) and one study also compared a standard dose of vancomycin to a high dose. Inhaled antibiotics probably make no difference to lung function compared to placebo (2 studies), but results from one study indicated that inhaled antibiotics probably lead to a small increase after 20 weeks. A standard dose of vancomycin probably makes no difference to the frequency of flare‐ups compared to placebo (2 studies); One study reported a longer time to the next flare‐up with the lower dose of vancomycin; One study reported a decrease in MRSA bacteria levels with a higher dose of vancomycin for up to one month; Neither study reported any differences in quality of life or unwanted effects. Oral plus inhaled antibiotics compared to oral antibiotics plus placebo (1 study, 25 people) One study compared a combination of oral plus inhaled antibiotics to inhaled antibiotics plus placebo. We are uncertain if either treatment made any difference to MRSA clearance; There may be few or no differences between groups in lung function, quality of life or unwanted effects; The study did not report changes in weight or frequency of flare‐ups. What are the limitations of the evidence? Our confidence in the results ranged from high to very low. This was due to potential issues with the trial designs (people knew which treatment they were receiving), or because there were small numbers of people in each trial and many of them dropped out. How up to date is this evidence? This review updates our previous review published in 2022. The evidence is current to 28 April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lo, DKH, Jahnke, N, Smith, S, Muhlebach, MS, Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD009650.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.800Z" }, { "id": "e0334ae4-a57f-49a7-91cd-40aee23334ee", "pmid": "", "title": "Momordica charantia for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Momordica charantia (bitter gourd) is not only a nutritious vegetable but it is also used in traditional medical practices to treat type 2 diabetes mellitus. Experimental studies with animals and humans suggested that the vegetable has a possible role in glycaemic control. Objectives To assess the effects of mormodica charantia for type 2 diabetes mellitus. Search methods Several electronic databases were searched, among these were The Cochrane Library (Issue 1, 2012), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2012), combined with handsearches. No language restriction was used. Selection criteria We included randomised controlled trials (RCTs) that compared momordica charantia with placebo or a control intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently extracted data. Risk of bias of the trials was evaluated using the parameters of randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. A meta‐analysis was not performed given the quality of data and the variability of preparations of momordica charantia used in the interventions (no similar preparation was tested twice). Main results Four randomised controlled trials with up to three months duration and investigating 479 participants met the inclusion criteria. Risk of bias of these trials (only two studies were published as a full peer‐reviewed publication) was generally high. Two RCTs compared the effects of preparations from different parts of the momordica charantia plant with placebo on glycaemic control in type 2 diabetes mellitus. There was no statistically significant difference in the glycaemic control with momordica charantia preparations compared to placebo. When momordica charantia was compared to metformin or glibenclamide, there was also no significant change in reliable parameters of glycaemic control. No serious adverse effects were reported in any trial. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions There is insufficient evidence on the effects of momordica charantia for type 2 diabetes mellitus. Further studies are therefore required to address the issues of standardization and the quality control of preparations. For medical nutritional therapy, further observational trials evaluating the effects of momordica charantia are needed before RCTs are established to guide any recommendations in clinical practice. Plain language summary Momordica charantia for type 2 diabetes mellitus Mormordica charantia (bitter gourd or bitter melon) is a climbing perennial that is characterized by elongated, warty fruit‐like gourds or cucumbers and is native to the tropical belt. Although momordica charantia is commonly used in traditional medical practices, along with research suggesting its benefits for people with type 2 diabetes, the current evidence does not warrant using the plant in treating this disease. This review of trials found only four studies which had an overall low quality. Three trials showed no significant differences between momordica charantia and placebo or antidiabetic drugs (glibenclamide and metformin) in the blood sugar response. The duration of treatment ranged from four weeks to three months, and altogether 479 patients with type 2 diabetes mellitus participated. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Adverse effects were mostly moderate, including diarrhoea and abdominal pain. However, reporting of adverse effects was incomplete in the included studies. There are many varieties of preparations of momordica charantia, as well as variations in its use as a vegetable. Further studies are needed to assess the quality of the various momordica charantia preparations as well as to further evaluate its use in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Ooi, CP, Yassin, Z, Hamid, TA", "articleTypes": [], "doi": "10.1002/14651858.CD007845.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.734Z" }, { "id": "e0377b9d-92d9-4f96-a801-6cbab6b879d5", "pmid": "", "title": "Topical cystic fibrosis transmembrane conductance regulator gene replacement for cystic fibrosis‐related lung disease", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is caused by a defective gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR), and is characterised by chronic lung infection resulting in inflammation and progressive lung damage that results in a reduced life expectancy. Objectives To determine whether topical CFTR gene replacement therapy to the lungs in people with cystic fibrosis is associated with improvements in clinical outcomes, and to assess any adverse effects. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Date of most recent search: 05 May 2016. An additional search of the National Institutes for Health (NIH) Genetic Modification Clinical Research Information System (GeMCRIS) was also performed for the years 1992 to 2015. Date of most recent search: 20 April 2016. Selection criteria Randomised controlled studies comparing topical CFTR gene delivery to the lung, using either viral or non‐viral delivery systems, with placebo or an alternative delivery system in people with confirmed cystic fibrosis. Data collection and analysis The authors independently extracted data and assessed study quality. Authors of included studies were contacted and asked for any available additional data. Meta‐analysis was limited due to differing study designs. Main results Four randomised controlled studies met the inclusion criteria for this review, involving a total of 302 participants lasting from 29 days to 13 months; 14 studies were excluded. The included studies differed in terms of CFTR gene replacement agent and study design, which limited the meta‐analysis. One study only enrolled adult males, the remaining studies included both males and females aged 12 years and over. Risk of bias in the studies was moderate. Random sequence generation and allocation concealment was only described in the more recent study; the remaining three studies were judged to have an unclear risk of bias. All four studies documented double‐blinding to the intervention, but there is some uncertainty with regards to participant blinding in one study. Some outcome data were missing from all four studies. There were no differences in either the number of respiratory exacerbations or the number of participants with an exacerbation between replacement therapy or placebo groups at any time point. Meta‐analysis of most respiratory function tests showed no difference between treatment and placebo groups, but the smallest study (n = 16) reported forced vital capacity (litres) increased more in the placebo group at up to 24 hours. A further study reported a significant improvement in forced expiratory volume at one second (litres) at 30 days after participants had received their first dose of favouring the gene therapy agent, but this finding was not confirmed when combined with at second study in the meta‐analysis. The more recent study (n = 140) demonstrated a small improvement in forced vital capacity (per cent predicted) at two and three months and again at 11 and 12 months for participants receiving CFTR gene replacement therapy compared to those receiving placebo. The same study reported a significant difference in the relative change in forced expiratory volume at one second (per cent predicted) at two months, three months and 12 months. One small study reported significant concerns with \"influenza‐like\" symptoms in participants treated with CFTR gene replacement therapy; this was not reported on repeated use of the same agent in a larger recent study. There was no other evidence of positive impact on outcomes, in particular improved quality of life or reduced treatment burden. Two studies measured ion transport in the lower airways; one (n = 16) demonstrated significant changes toward normal values in the participants who received gene transfer agents (P < 0.0001), mean difference 6.86 (95% confidence interval 3.77 to 9.95). The second study (n = 140) also reported significant changes toward normal values (P = 0.032); however, aggregate data were not available for analysis. In the most recent study, there was also evidence of increased salt transport in cells obtained by brushing the lower airway. These outcomes, whilst important, are not of direct clinical relevance. Authors' conclusions One study of liposome‐based CFTR gene transfer therapy demonstrated some improvements in respiratory function in people with CF, but this limited evidence of efficacy does not support this treatment as a routine therapy at present. There was no evidence of efficacy for viral‐mediated gene delivery. Future studies need to investigate clinically important outcome measures. Plain language summary Replacing the defective gene is a potential treatment for progressive lung disease in people with cystic fibrosis Review question We reviewed the evidence about the effect of delivering the correct copy of the cystic fibrosis transmembrane conductance regulator (CFTR) gene directly to the lungs of people with cystic fibrosis in order to treat progressive lung disease. Background In cystic fibrosis the gene encoding a protein called the cystic fibrosis transmembrane conductance regulator (CFTR) is faulty. People with cystic fibrosis suffer from progressive lung infection and damage which reduces life expectancy. Agents which can deliver a correct copy of the faulty CFTR gene to cells in the lungs may be an effective treatment. Search date The evidence is current to: 20 April 2016. Study characteristics We found four studies with 302 people to include in this review. The studies lasted from 29 days to 13 months. Three of these studies included both men and women aged 12 years and over and one study only included adult men. The studies compare gene therapy to a dummy treatment (placebo) both of which are inhaled as a mist into the lungs. The studies were of different designs and used different agents. This meant we could not combine their results. Key results Three of the studies, including the largest and most recent study, showed an improvement in some measures of lung function in people with CF given gene therapy. We did not find that any more clinically relevant outcomes such as quality of life, treatment burden or flare‐up of lung disease had improved with treatment. In one study \"influenza‐like\" symptoms were more common in people who received CFTR gene transfer agents but this was not reported when the agent was used repeatedly in a larger study. In those people who took the gene transfer agents, molecules and salt in their lower airways moved more like they do in healthy people. The limited evidence of benefit does not support this as a routine therapy at present. We recommend that future studies are designed and reported clearly so that their results can be incorporated into a systematic review. Quality of the evidence The most recent study provided detailed information on how the people were put into different treatment groups completely at random, and so we are satisfied that those taking part in the study had an equal chance of being in either group (CFTR gene transfer agent or placebo) and that no one could work out which group the next person would be put into. The other studies reported that people were put into groups at random but did not specify how, so we cannot be sure that there was an equal chance of them being in either group. We believe that the clinicians running all the studies did not know which treatment the people taking part were receiving and that in three of the studies those taking part did not know either, but we could not be sure whether the people taking part in the latest study knew which treatment they were receiving and what effect this knowledge might have on results. Unfortunately, the studies did not report all their results clearly; sometimes results were not reported in a way that we could use for the review and sometimes they were not reported at all. This reduced the certainty with which we judged the overall results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Perry, LA, Penny‐Dimri, JC, Aslam, AA, Lee, TWR, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD005599.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.112Z" }, { "id": "e04207c7-4ba8-4662-b406-99d314a495bf", "pmid": "", "title": "Celiac Disease and Vitamin Status: Evaluation of the Effect of Supplementation With a Probiotic (VIVOMIXX®) on Vitamin B6, B12, 25'OH D, Folic Acid and Omocystein Levels, Metabolic and Inflammatory Status, and Gut Microbiota Metabolomics in a Cohoort of Celiac Patients", "imported": false, "abstract": "Celiac disease is a disorder caused by a disregulation of the immune system which leads to immune response to gluten. Diet therapy is the gold standard of treatment, and the only effective one. Macronutrients and micronutrients deficiency (vitamin D, folic acid, vitamin B12, vitamin B6, iron and zinc), which is in any case far more common in patients who don't follow gluten free diet, can persist in a subset of patients who follow gluten-free diet. Supplementation of vitamins in these patients may have a beneficial role. A recent study in a murine model showed that supplementation with probiotic VIVOMIXX® leads to an increase in expression of vitamin D receptors in proximal and distal colon.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.154Z" }, { "id": "e045dd87-b8ef-444f-b654-39f89fee660d", "pmid": "", "title": "Ghrelin for the management of cachexia associated with cancer", "imported": false, "abstract": "Abstract - Background Cancer sufferers are amongst the most malnourished of all the patient groups. Studies have shown that ghrelin, a gut hormone can be a potential therapeutic agent for cachexia (wasting syndrome) associated with cancer. A variety of mechanisms of action of ghrelin in people with cancer cachexia have been proposed. However, safety and efficacy of ghrelin for cancer‐associated cachexia have not been systematically reviewed. The aim of this review was to assess whether ghrelin is associated with better food intake, body composition and survival than other options for adults with cancer cachexia. Objectives To assess the efficacy and safety of ghrelin in improving food intake, body composition and survival in people with cachexia associated with cancer. Search methods We searched CENTRAL, MEDLINE and Embase without language restrictions up to July 2017. We also searched for ongoing studies in trials registers, performed handsearching, checked bibliographic references of relevant articles and contacted authors and experts in the field to seek potentially relevant research. We applied no restrictions on language, date, or publication status. Selection criteria We included randomised controlled (parallel‐group or cross‐over) trials comparing ghrelin (any formulation or route of administration) with placebo or an active comparator in adults (aged 18 years and over) who met any of the international criteria for cancer cachexia. Data collection and analysis Two review authors independently assessed studies for eligibility. Two review authors then extracted data and assessed the risk of bias for individual studies using standard Cochrane methodology. For dichotomous variables, we planned to calculate risk ratio with 95% confidence intervals (CI) and for continuous data, we planned to calculate mean differences (MD) with 95% CI. We assessed the evidence using GRADE and created 'Summary of findings' tables. Main results We screened 926 individual references and identified three studies that satisfied the inclusion criteria. Fifty‐nine participants (37 men and 22 women) aged between 54 and 78 years were randomised initially, 47 participants completed the treatment. One study had a parallel design and two had a cross‐over design. The studies included people with a variety of cancers and also differed in the dosage, route of administration, frequency and duration of treatment. One trial, which compared ghrelin with placebo, found that ghrelin improved food intake (very low‐quality evidence) and had no adverse events (very low‐quality evidence). Due to unavailability of data we were unable to report on comparisons for ghrelin versus no treatment or alternative experimental treatment modalities, or ghrelin in combination with other treatments or ghrelin analogues/ghrelin mimetics/ghrelin potentiators. Two studies compared a higher dose of ghrelin with a lower dose of ghrelin, however due to differences in study designs and great diversity in the treatment provided we did not pool the results. In both trials, food intake did not differ between participants on higher‐dose and lower‐dose ghrelin. None of the included studies assessed data on body weight. One study reported higher adverse events with a higher dose as compared to a lower dose of ghrelin. All studies were at high risk of attrition bias and bias for size of the study. Risk of bias in other domains was unclear or low. We rated the overall quality of the evidence for primary outcomes (food intake, body weight, adverse events) as very low. We downgraded the quality of the evidence due to lack of data, high or unclear risk of bias of the studies and small study size. Authors' conclusions There is insufficient evidence to be able to support or refute the use of ghrelin in people with cancer cachexia. Adequately powered randomised controlled trials focusing on evaluation of safety and efficacy of ghrelin in people with cancer cachexia is warranted. Plain language summary Ghrelin, a hunger hormone for management of cancer patients with loss of appetite and weight loss Bottom line There is no good evidence to support or reject the suggestion that ghrelin is useful in the management of cancer patients with loss of appetite and weight loss. There is insufficient evidence to recommend it for clinical practice. Background Sixty to eighty percent of cancer patients suffer from loss of appetite and weight loss, which in turn is associated with decreased life expectancy and quality of life. Ghrelin, a hunger hormone is secreted by the stomach and other organs of the body. Studies have shown that ghrelin can be used in treatment for loss of appetite and weight loss in cancer patients. However, the effectiveness and safety of ghrelin in such people have not been assessed. In this review we set out to examine all evidence on the effectiveness and safety of ghrelin in improving appetite and body weight in cancer patients with loss of appetite and weight loss. Search date The evidence is current to 20th July 2017. Study characteristics We found three studies that recruited a total of 59 cancer patients (37 men and 22 women) aged between 54 and 78 years. Forty‐seven cancer patients completed the treatment. Studies differed in study design and included people with a variety of cancers. Studies also differed in dosage, route of injection, frequency and duration of treatment. One study compared ghrelin with a placebo while two studies compared different doses of ghrelin (higher dose with lower dose). Outcomes of interest to cancer patients with loss of appetite and weight loss, such as improvement in food intake and improvement in body weight, were not adequately reported. All three included studies were funded by government agencies. One study received an additional grant from a pharmaceutical company. Key findings We found insufficient evidence that using ghrelin demonstrated differences in food intake. We found no evidence that using ghrelin alone or in combination made any difference to body weight. We could not reach any conclusions about its side effects. The limited amount of information means that we could not draw any conclusions. Quality of the evidence We rated the quality of evidence from studies using four levels: high, moderate, low, or very low. High‐quality evidence means that we are very confident in the results. Very low‐quality evidence means that we are very uncertain about the results. The evidence in this review was of very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Khatib, MN, Shankar, AH, Kirubakaran, R, Gaidhane, A, Gaidhane, S, Simkhada, P, Quazi Syed, Z", "articleTypes": [], "doi": "10.1002/14651858.CD012229.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.798Z" }, { "id": "e05bef96-e572-4c2d-88d1-47220046e9a3", "pmid": "", "title": "Momordica charantia for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Momordica charantia (bitter gourd) is not only a nutritious vegetable but it is also used in traditional medical practices to treat type 2 diabetes mellitus. Experimental studies with animals and humans suggested that the vegetable has a possible role in glycaemic control. Objectives To assess the effects of mormodica charantia for type 2 diabetes mellitus. Search methods Several electronic databases were searched, among these were The Cochrane Library (Issue 1, 2012), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2012), combined with handsearches. No language restriction was used. Selection criteria We included randomised controlled trials (RCTs) that compared momordica charantia with placebo or a control intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently extracted data. Risk of bias of the trials was evaluated using the parameters of randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. A meta‐analysis was not performed given the quality of data and the variability of preparations of momordica charantia used in the interventions (no similar preparation was tested twice). Main results Four randomised controlled trials with up to three months duration and investigating 479 participants met the inclusion criteria. Risk of bias of these trials (only two studies were published as a full peer‐reviewed publication) was generally high. Two RCTs compared the effects of preparations from different parts of the momordica charantia plant with placebo on glycaemic control in type 2 diabetes mellitus. There was no statistically significant difference in the glycaemic control with momordica charantia preparations compared to placebo. When momordica charantia was compared to metformin or glibenclamide, there was also no significant change in reliable parameters of glycaemic control. No serious adverse effects were reported in any trial. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions There is insufficient evidence on the effects of momordica charantia for type 2 diabetes mellitus. Further studies are therefore required to address the issues of standardization and the quality control of preparations. For medical nutritional therapy, further observational trials evaluating the effects of momordica charantia are needed before RCTs are established to guide any recommendations in clinical practice. Plain language summary Momordica charantia for type 2 diabetes mellitus Mormordica charantia (bitter gourd or bitter melon) is a climbing perennial that is characterized by elongated, warty fruit‐like gourds or cucumbers and is native to the tropical belt. Although momordica charantia is commonly used in traditional medical practices, along with research suggesting its benefits for people with type 2 diabetes, the current evidence does not warrant using the plant in treating this disease. This review of trials found only four studies which had an overall low quality. Three trials showed no significant differences between momordica charantia and placebo or antidiabetic drugs (glibenclamide and metformin) in the blood sugar response. The duration of treatment ranged from four weeks to three months, and altogether 479 patients with type 2 diabetes mellitus participated. No trial investigated death from any cause, morbidity, health‐related quality of life or costs. Adverse effects were mostly moderate, including diarrhoea and abdominal pain. However, reporting of adverse effects was incomplete in the included studies. There are many varieties of preparations of momordica charantia, as well as variations in its use as a vegetable. Further studies are needed to assess the quality of the various momordica charantia preparations as well as to further evaluate its use in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Ooi, CP, Yassin, Z, Hamid, TA", "articleTypes": [], "doi": "10.1002/14651858.CD007845.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.755Z" }, { "id": "e0760db4-70e5-40d2-aa1f-c4b7d5fa9ff0", "pmid": "", "title": "Adverse events in people taking macrolide antibiotics versus placebo for any indication", "imported": false, "abstract": "Abstract - Background Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment‐specific, rather than disease‐specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases. Objectives To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides. Selection criteria We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups. Data collection and analysis Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide‐resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta‐analysis when three or more included studies reported a specific adverse event. Main results We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events or at least stated that no adverse events were observed. Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low‐quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low‐quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate‐quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate‐quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate‐quality evidence) were also reported more often in participants taking macrolides compared to placebo. The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000. The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting. There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration. Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low‐quality evidence). Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low‐quality evidence). We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low‐quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low‐quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low‐quality evidence) compared to placebo. We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo. Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate‐quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate‐quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate‐quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non‐significant. There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low‐quality evidence). Only 24 studies (13%) provided useful data on macrolide‐resistant bacteria. Macrolide‐resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent. Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials. Authors' conclusions The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as \"none were observed\". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance. Plain language summary Adverse events in people taking macrolide antibiotics Review question We wanted to find out if people treated with a macrolide antibiotic experienced more adverse events than those treated with placebo. Background Macrolide antibiotics are a group of antibiotics that are commonly used to treat both acute and chronic infections. The four most frequently used macrolides are: azithromycin, clarithromycin, erythromycin, and roxithromycin. People taking macrolide antibiotics are at risk of experiencing adverse events such as nausea, diarrhoea, or rash. Search date We searched the literature up to May 2018. Study characteristics We included 183 studies with a total of 252,886 participants. Most studies were conducted in the hospital setting. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events, or at least stated that no adverse events were observed. Study funding sources Drug companies supplied trial medications or funding, or both, in 91 studies. Funding sources were unclear in 59 studies. Key results People treated with a macrolide antibiotic experienced gastrointestinal adverse events such as nausea, vomiting, abdominal pain, and diarrhoea more often than those treated with placebo. Taste disturbances were reported more often by people taking macrolides than those taking a placebo. However, as very few studies reported on these adverse events, these results should be interpreted with caution. Hearing loss was reported more often by people taking macrolide antibiotics, however only four studies reported this outcome. Macrolides caused less cough and fewer respiratory tract infections than placebo. We did not find any evidence that macrolides caused more cardiac disorders, liver disorders, blood infections, skin and soft tissue infections, changes in liver enzymes, appetite loss, dizziness, headache, respiratory symptoms, itching, or rashes than placebo. We did not find more deaths in people treated with macrolides than in those treated with placebo. Very limited information was available to assess if people treated with a macrolide antibiotic were at greater risk of developing resistant bacteria than those treated with placebo. However, bacteria that did not respond to macrolide antibiotics were more commonly identified immediately after treatment in people taking a macrolide than in those taking a placebo, but differences in resistance thereafter were inconsistent. Quality of the evidence The quality of the evidence ranged from very low (cardiac disorders, change in liver enzymes, liver disorders) to low (abdominal pain, death, diarrhoea, dizziness, hearing loss, skin and soft tissue infections, taste disturbance, wheeze) to moderate (appetite loss, blood infection, cough, fever, headache, itching, nausea, rash, respiratory symptoms, respiratory tract infections, vomiting).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hansen, MP, Scott, AM, McCullough, A, Thorning, S, Aronson, JK, Beller, EM, Glasziou, PP, Hoffmann, TC, Clark, J, Del Mar, CB", "articleTypes": [], "doi": "10.1002/14651858.CD011825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.730Z" }, { "id": "e0936865-f360-4dda-a6d4-0b7a65b5a5d9", "pmid": "", "title": "A Pilot Study of Facial Recognition Software to Assess Palatability in Pediatric Patients", "imported": false, "abstract": "The study is designed to see if, after tasting specific things, whether a child's facial pattern and voice pattern can determine the difference in something that has a sweet taste, no taste, and a bitter taste. The investigators will do this by comparing video recordings of a child's facial expression and voice to the child's response to follow-up questions after tasting three (3) different substances.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.147Z" }, { "id": "e0976dc7-e708-4371-8a9a-7294aa5088cc", "pmid": "", "title": "Topical lidocaine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Lidocaine is a local anaesthetic that is sometimes used on the skin to treat neuropathic pain. Objectives To assess the analgesic efficacy of topical lidocaine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 1 July 2014, together with the reference lists of retrieved papers and other reviews. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal to identify additional published or unpublished data. Selection criteria We included randomised, double‐blind studies of at least two weeks' duration comparing any formulation of topical lidocaine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts; at least 200 participants in the comparison, 8 to 12 weeks' duration, parallel design); second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison; and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. Main results We included 12 studies (508 participants) in comparisons with placebo or an active control. Six studies enrolled participants with moderate or severe postherpetic neuralgia, and the remaining studies enrolled different, or mixed, neuropathic pain conditions, including trigeminal neuralgia and postsurgical or post‐traumatic neuralgia. Four different formulations were used: 5% medicated patch, 5% cream, 5% gel, and 8% spray. Most studies used a cross‐over design, and two used a parallel‐group design. Two studies used enriched enrolment with randomised withdrawal. Seven studies used multiple doses, with one to four‐week treatment periods, and five used single applications. We judged all of the studies at high risk of bias because of small size or incomplete outcome assessment, or both. There was no first or second tier evidence, and no pooling of data was possible for efficacy outcomes. Only one multiple‐dose study reported our primary outcome of participants with ≥ 50% or ≥ 30% pain intensity reduction. Three single‐dose studies reported participants who were pain‐free at a particular time point, or had a 2‐point (of 10) reduction in pain intensity. The two enriched enrolment, randomised withdrawal studies reported time to loss of efficacy. In all but one study, third tier (very low quality) evidence indicated that lidocaine was better than placebo for some measure of pain relief. Pooling multiple‐dose studies across conditions demonstrated no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals, but there were few events and the withdrawal phase of enriched enrolment designs is not suitable to assess the true impact of adverse events (very low quality evidence). Authors' conclusions This review found no evidence from good quality randomised controlled studies to support the use of topical lidocaine to treat neuropathic pain, although individual studies indicated that it was effective for relief of pain. Clinical experience also supports efficacy in some patients. Several large ongoing studies, of adequate duration, with clinically useful outcomes should provide more robust conclusions about both efficacy and harm. Plain language summary Topical lidocaine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It differs from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are usually not effective in neuropathic pain, while medicines that are sometimes used to treat epilepsy or depression can be very effective in some people with neuropathic pain. Other possible treatments include the use of local anaesthetic applied to the skin. Lidocaine is a local anaesthetic. It is available in plasters (or patches), sprays, and creams, as topical lidocaine. These contain high concentrations of lidocaine because it crosses the skin poorly. Treatment with plasters usually involves applying one, two, or three plasters for up to 12 hours a day. In July 2014 we performed searches to look for clinical trials where topical lidocaine was used to treat neuropathic pain. We found 12 small studies of modest quality that tested topical lidocaine against topical placebo for a number of weeks. One study also tested a cream containing amitriptyline, which is an antidepressant. The 508 people in the studies had different types of neuropathic pain, with pain after herpes zoster infection the most common. There was some indication that topical lidocaine was beneficial in these studies (very low quality evidence). There was no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals (very low quality evidence). A number of studies of topical lidocaine in neuropathic pain are ongoing. Several are large and of long duration. They will be of great help in working out the benefits of topical lidocaine when they are completed and results can be incorporated in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Derry, S, Wiffen, PJ, Moore, RA, Quinlan, J", "articleTypes": [], "doi": "10.1002/14651858.CD010958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.752Z" }, { "id": "e09c04cf-63a8-407d-8c1f-0183d5bba122", "pmid": "", "title": "Interventions for oropharyngeal dysphagia in children with neurological impairment", "imported": false, "abstract": "Abstract - Background Oropharyngeal dysphagia encompasses problems with the oral preparatory phase of swallowing (chewing and preparing the food), oral phase (moving the food or fluid posteriorly through the oral cavity with the tongue into the back of the throat) and pharyngeal phase (swallowing the food or fluid and moving it through the pharynx to the oesophagus). Populations of children with neurological impairment who commonly experience dysphagia include, but are not limited to, those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). Objectives To examine the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. Search methods We searched the following electronic databases in October 2011: CENTRAL 2011(3), MEDLINE (1948 to September Week 4 2011), EMBASE (1980 to 2011 Week 40)
, CINAHL (1937 to current)
, ERIC (1966 to current), PsycINFO (1806 to October Week 1 2011), Science Citation Index (1970 to 7 October 2011), Social Science Citation Index (1970 to 7 October 2011), Cochrane Database of Systematic Reviews, 2011(3), DARE 2011(3), Current Controlled Trials (ISRCTN Register) (15 October 2011), ClinicalTrials.gov (15 October 2011) and WHO ICTRP (15 October 2011). We searched for dissertations and theses using Networked Digital Library of Theses and Dissertations, Australasian Digital Theses Program and DART‐Europe E‐theses Portal (11 October 2011). Finally, additional references were also obtained from reference lists from articles. Selection criteria The review included randomised controlled trials and quasi‐randomised controlled trials for children with oropharyngeal dysphagia and neurological impairment. Data collection and analysis All three review authors (AM, PD and EW) independently screened titles and abstracts for inclusion and discussed results. In cases of uncertainty over whether an abstract met inclusion criterion, review authors obtained the full‐text article and independently evaluated each paper for inclusion. The data were categorised for comparisons depending on the nature of the control group (for example, oral sensorimotor treatment versus no treatment). Effectiveness of the oropharyngeal dysphagia intervention was assessed by considering primary outcomes of physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency a child is able to consume. Secondary outcomes were changes in growth, child’s level of participation in the mealtime routine and the level of parent or carer stress associated with feeding. Main results Three studies met the inclusion criteria for the review. Two studies were based on oral sensorimotor interventions for participants with cerebral palsy compared to standard care and a third study trialled lip strengthening exercises for children with myotonic dystrophy type 1 compared to no treatment ( Sjogreen 2010 ). A meta‐analysis combining results across the three studies was not possible because one of the studies had participants with a different condition, and the remaining two, although using oral sensorimotor treatments, used vastly different approaches with different intensities and durations. The decision not to combine these was in line with our protocol. In this review, we present the results from individual studies for four outcomes: physiological functions of the oropharyngeal mechanism for swallowing, the presence of chest infection and pneumonia, diet consistency, and changes in growth. However, it is not possible to reach definitive conclusions on the effectiveness of particular interventions for oropharyngeal dysphagia based on these studies. One study had a high risk of attrition bias owing to missing data, had statistically significant differences (in weight) across experimental and control groups at baseline, and did not describe other aspects of the trial sufficiently to enable assessment of other potential risks of bias. Another study was at high risk of detection bias as some outcomes were assessed by parents who knew whether their child was in the intervention or control group. The third study overall seemed to be at low risk of bias, but like the other two studies, suffered from a small sample size. Authors' conclusions The review demonstrates that there is currently insufficient high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials to provide conclusive results about the effectiveness of any particular type of oral‐motor therapy for children with neurological impairment. There is an urgent need for larger‐scale (appropriately statistically powered), randomised trials to evaluate the efficacy of interventions for oropharyngeal dysphagia. Plain language summary Interventions for swallowing difficulty in children with neurological impairment Oropharyngeal dysphagia, or swallowing difficulty, can be defined as problems with chewing and preparing food, difficulty moving food through the mouth to the back of the tongue, and difficulty with swallowing and movement of food through the 'throat' or pharynx. Many children with neurological impairment experience swallowing difficulties, including those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). This review examined the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. The three studies included in the review examined oral sensorimotor treatments and lip strengthening interventions. We were interested in three primary outcomes, which were physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency, and three secondary outcomes, which were changes in growth, child's level of participation in the mealtime routine, and the level of parent or carer stress associated with feeding. We concluded that there is currently not enough high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials for any particular type of oropharyngeal dysphagia intervention in this population of children. There is a need for larger‐scale randomised controlled trials to evaluate the effects of interventions for oropharyngeal dysphagia in children with neurological impairment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Morgan, AT; Dodrill, P; Ward, EC", "articleTypes": [], "doi": "10.1002/14651858.CD009456.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "e09d914f-f8e4-4103-b2b1-ff8f238fbbb8", "pmid": "", "title": "Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women", "imported": false, "abstract": "Abstract - Background Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions, particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia. However, its long‐term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teeth staining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation for preventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent. Objectives To assess the effects of intermittent oral iron supplementation, alone or in combination with other nutrients, on anaemia and its associated impairments among menstruating women, compared with no intervention, a placebo, or daily supplementation. Search methods In February 2018, we searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers. In March 2018, we also searched LILACS, IBECS and IMBIOMED. In addition, we examined reference lists, and contacted authors and known experts to identify additional studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs with either individual or cluster randomisation. Participants were menstruating women; that is, women beyond menarche and prior to menopause who were not pregnant or lactating and did not have a known condition that impeded the presence of menstrual periods. The intervention was the use of iron supplements intermittently (one, two or three times a week on non‐consecutive days) compared with placebo, no intervention, or the same supplements provided on a daily basis. Data collection and analysis Both review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy, assessed the risk of bias of the included studies, and rated the quality of the evidence using GRADE. Main results We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessing risk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one third of the included studies did not provide a funding source. Although quality across studies was variable, the results consistently showed that intermittent iron supplementation (alone or with any other vitamins and minerals) compared with no intervention or a placebo, reduced the risk of having anaemia (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.49 to 0.87; 11 studies, 3135 participants; low‐quality evidence), and improved the concentration of haemoglobin (mean difference (MD) 5.19 g/L, 95% CI 3.07 to 7.32; 15 studies, 2886 participants; moderate‐quality evidence), and ferritin (MD 7.46 μg/L, 95% CI 5.02 to 9.90; 7 studies, 1067 participants; low‐quality evidence). Intermittent regimens may also reduce the risk of having iron deficiency (RR 0.50, 95% CI 0.24 to 1.04; 3 studies, 624 participants; low‐quality evidence), but evidence was inconclusive regarding iron deficiency anaemia (RR 0.07, 95% CI 0.00 to 1.16; 1 study, 97 participants; very low‐quality evidence) and all‐cause morbidity (RR 1.12, 95% CI 0.82 to 1.52; 1 study, 119 participants; very low‐quality evidence). Women in the control group were less likely to have any adverse side effects than those receiving intermittent iron supplements (RR 1.98, 95% CI 0.31 to 12.72; 3 studies, 630 participants; moderate‐quality evidence). In comparison with daily supplementation, results showed that intermittent supplementation (alone or with any other vitamins and minerals) produced similar effects to daily supplementation (alone or with any other vitamins and minerals) on anaemia (RR 1.09, 95% CI 0.93 to 1.29; 8 studies, 1749 participants; moderate‐quality evidence). Intermittent supplementation may produce similar haemoglobin concentrations (MD 0.43 g/L, 95% CI −1.44 to 2.31; 10 studies, 2127 participants; low‐quality evidence) but lower ferritin concentrations on average (MD −6.07 μg/L, 95% CI −10.66 to −1.48; 4 studies, 988 participants; low‐quality evidence) compared to daily supplementation. Compared to daily regimens, intermittent regimens may also reduce the risk of having iron deficiency (RR 4.30, 95% CI 0.56 to 33.20; 1 study, 198 participants; very low‐quality evidence). Women receiving iron supplements intermittently were less likely to have any adverse side effects than those receiving iron supplements daily (RR 0.41, 95% CI 0.21 to 0.82; 6 studies, 1166 participants; moderate‐quality evidence). No studies reported on the effect of intermittent regimens versus daily regimens on iron deficiency anaemia and all‐cause morbidity. Information on disease outcomes, adherence, economic productivity, and work performance was scarce, and evidence about the effects of intermittent supplementation on these outcomes unclear. Overall, whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline did not seem to affect the findings. Furthermore, the response did not differ in areas where malaria was frequent, although very few trials were conducted in these settings. Authors' conclusions Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations with different anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittently is probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base ranged from very low to moderate quality, suggesting that we are uncertain about these effects. Plain language summary Iron supplements taken one, two or three times a week for preventing anaemia, and its consequences in menstruating women What is the issue? Across the globe, approximately one out of three non‐pregnant women of reproductive age are anaemic; i.e. have fewer red blood cells or less haemoglobin (a red substance that combines with oxygen and carries it around the body) in each red blood cell than normal. Although there are several causes of anaemia, it very often results from sustained iron deficiency. The standard practice to prevent or treat anaemia in women has been daily iron supplementation (sometimes combined with folic acid and other vitamins and minerals) for three months. However, it is frequently associated with side effects such as nausea or constipation. Intermittent supplementation (that is, the consumption of supplements one, two or three times a week on non‐consecutive days) has been proposed as an effective and safer alternative to daily supplementation. Why is this important? Women with anaemia may have less energy for physical work and become more prone to infections. Most women throughout the world enter pregnancy with anaemia, putting them at greater risk of having low birth‐weight babies and other complications during delivery. Some scientists believe that taking iron a few times a week – instead of every day – can help women with anaemia to feel better and improve their haemoglobin without giving them as many side effects. If women have fewer side effects, they may be more likely to take iron supplements more regularly and for longer periods. What evidence did we find? We reviewed the evidence in February 2018. We included 25 randomised controlled trials (a type of experiment in which participants are randomly assigned to one or more treatment groups) involving 10,996 women. We included studies examining the administration of intermittent iron supplements versus no intervention, a placebo (dummy pill) or the same supplements given on a daily basis. Most studies were implemented in school settings and were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one‐third of the included studies did not provide a funding source. The findings show that women receiving intermittent supplementation with iron alone, or in combination with folic acid or other nutrients, were less likely to be anaemic or iron deficient than those women who received no iron supplements or a placebo. They also had higher concentrations of haemoglobin and ferritin (a protein that carries iron) but reported more side effects. In addition, the findings indicate that intermittent supplementation was as effective as daily supplementation in reducing the prevalence of anaemia and increasing haemoglobin concentrations, with fewer side effects. It may have reduced the risk of having iron deficiency also, but it had no effect on raising ferritin concentrations more than the daily dose. We found scarce evidence on the effect of intermittent supplementation compared to placebo or daily supplementation on iron deficiency anaemia, all‐cause morbidity, disease outcomes, adherence, economic productivity, and work performance. What does this mean? Intermittent iron supplementation in menstruating women may be an effective intervention for reducing anaemia and improving haemoglobin concentrations compared to no treatment, placebo or daily supplementation. Intermittent supplementation may be associated with fewer side effects compared to daily supplementation. The findings were not affected by whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline (starting point for comparisons). The evidence base was of overall low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fernández-Gaxiola, AC, De-Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD009218.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.787Z" }, { "id": "e09fd41e-fb9a-40e8-b42f-59f05c8f40f8", "pmid": "", "title": "Chloral hydrate as a sedating agent for neurodiagnostic procedures in children", "imported": false, "abstract": "Abstract - Background This is an updated version of a Cochrane Review published in 2017. Paediatric neurodiagnostic investigations, including brain neuroimaging and electroencephalography (EEG), play an important role in the assessment of neurodevelopmental disorders. The use of an appropriate sedative agent is important to ensure the successful completion of the neurodiagnostic procedures, particularly in children, who are usually unable to remain still throughout the procedure. Objectives To assess the effectiveness and adverse effects of chloral hydrate as a sedative agent for non‐invasive neurodiagnostic procedures in children. Search methods We searched the following databases on 14 May 2020, with no language restrictions: the Cochrane Register of Studies (CRS Web) and MEDLINE (Ovid, 1946 to 12 May 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including Cochrane Epilepsy. Selection criteria Randomised controlled trials that assessed chloral hydrate agent against other sedative agent(s), non‐drug agent(s), or placebo. Data collection and analysis Two review authors independently evaluated studies identified by the search for their eligibility, extracted data, and assessed risk of bias. Results were expressed in terms of risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals (CIs). Main results We included 16 studies with a total of 2922 children. The methodological quality of the included studies was mixed. Blinding of the participants and personnel was not achieved in most of the included studies, and three of the 16 studies were at high risk of bias for selective reporting. Evaluation of the efficacy of the sedative agents was also underpowered, with all the comparisons performed in small studies. Fewer children who received oral chloral hydrate had sedation failure compared with oral promethazine (RR 0.11, 95% CI 0.01 to 0.82; 1 study; moderate‐certainty evidence). More children who received oral chloral hydrate had sedation failure after one dose compared to intravenous pentobarbital (RR 4.33, 95% CI 1.35 to 13.89; 1 study; low‐certainty evidence), but there was no clear difference after two doses (RR 3.00, 95% CI 0.33 to 27.46; 1 study; very low‐certainty evidence). Children with oral chloral hydrate had more sedation failure compared with rectal sodium thiopental (RR 1.33, 95% CI 0.60 to 2.96; 1 study; moderate‐certainty evidence) and music therapy (RR 17.00, 95% CI 2.37 to 122.14; 1 study; very low‐certainty evidence). Sedation failure rates were similar between groups for comparisons with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam and oral clonidine. Children who received oral chloral hydrate had a shorter time to adequate sedation compared with those who received oral dexmedetomidine (MD −3.86, 95% CI −5.12 to −2.6; 1 study), oral hydroxyzine hydrochloride (MD −7.5, 95% CI −7.85 to −7.15; 1 study), oral promethazine (MD −12.11, 95% CI −18.48 to −5.74; 1 study) (moderate‐certainty evidence for three aforementioned outcomes), rectal midazolam (MD −95.70, 95% CI −114.51 to −76.89; 1 study), and oral clonidine (MD −37.48, 95% CI −55.97 to −18.99; 1 study) (low‐certainty evidence for two aforementioned outcomes). However, children with oral chloral hydrate took longer to achieve adequate sedation when compared with intravenous pentobarbital (MD 19, 95% CI 16.61 to 21.39; 1 study; low‐certainty evidence), intranasal midazolam (MD 12.83, 95% CI 7.22 to 18.44; 1 study; moderate‐certainty evidence), and intranasal dexmedetomidine (MD 2.80, 95% CI 0.77 to 4.83; 1 study, moderate‐certainty evidence). Children who received oral chloral hydrate appeared significantly less likely to complete neurodiagnostic procedure with child awakening when compared with rectal sodium thiopental (RR 0.95, 95% CI 0.83 to 1.09; 1 study; moderate‐certainty evidence). Chloral hydrate was associated with a higher risk of the following adverse events: desaturation versus rectal sodium thiopental (RR 5.00, 95% 0.24 to 102.30; 1 study), unsteadiness versus intranasal dexmedetomidine (MD 10.21, 95% CI 0.58 to 178.52; 1 study), vomiting versus intranasal dexmedetomidine (MD 10.59, 95% CI 0.61 to 185.45; 1 study) (low‐certainty evidence for aforementioned three outcomes), and crying during administration of sedation versus intranasal dexmedetomidine (MD 1.39, 95% CI 1.08 to 1.80; 1 study, moderate‐certainty evidence). Chloral hydrate was associated with a lower risk of the following: diarrhoea compared with rectal sodium thiopental (RR 0.04, 95% CI 0.00 to 0.72; 1 study), lower mean diastolic blood pressure compared with sodium thiopental (MD 7.40, 95% CI 5.11 to 9.69; 1 study), drowsiness compared with oral clonidine (RR 0.44, 95% CI 0.30 to 0.64; 1 study), vertigo compared with oral clonidine (RR 0.15, 95% CI 0.01 to 2.79; 1 study) (moderate‐certainty evidence for aforementioned four outcomes), and bradycardia compared with intranasal dexmedetomidine (MD 0.17, 95% CI 0.05 to 0.59; 1 study; high‐certainty evidence). No other adverse events were significantly associated with chloral hydrate, although there was an increased risk of combined adverse events overall (RR 7.66, 95% CI 1.78 to 32.91; 1 study; low‐certainty evidence). Authors' conclusions The certainty of evidence for the comparisons of oral chloral hydrate against several other methods of sedation was variable. Oral chloral hydrate appears to have a lower sedation failure rate when compared with oral promethazine. Sedation failure was similar between groups for other comparisons such as oral dexmedetomidine, oral hydroxyzine hydrochloride, and oral midazolam. Oral chloral hydrate had a higher sedation failure rate when compared with intravenous pentobarbital, rectal sodium thiopental, and music therapy. Chloral hydrate appeared to be associated with higher rates of adverse events than intranasal dexmedetomidine. However, the evidence for the outcomes for oral chloral hydrate versus intravenous pentobarbital, rectal sodium thiopental, intranasal dexmedetomidine, and music therapy was mostly of low certainty, therefore the findings should be interpreted with caution. Further research should determine the effects of oral chloral hydrate on major clinical outcomes such as successful completion of procedures, requirements for an additional sedative agent, and degree of sedation measured using validated scales, which were rarely assessed in the studies included in this review. The safety profile of chloral hydrate should be studied further, especially for major adverse effects such as oxygen desaturation. Plain language summary The effectiveness of chloral hydrate as a sedative agent for children undergoing neurodiagnostic procedures Review question In children undergoing non‐invasive neurodiagnostic procedures, is chloral hydrate more effective at producing adequate sedation (slowing of brain activity) and safer than other ways of achieving sedation? Background Neurodiagnostic procedures are non‐invasive neurological investigations important for children with suspected neurological disorders. These investigations include brain imaging and brain electrical activity testing. For these tests to be successfully performed, the child needs to remain still for at least 30 to 45 minutes during the investigation period. Sedative agents are required for children, who are usually unable to remain still for this period of time. Search date The evidence is current to May 2020. Study characteristics We included 16 studies involving a total of 2922 children (age up to 18 years old) in the review. All of the included studies were performed in hospitals that provided neurodiagnostic services. Most studies assessed the following three main outcomes: proportion of children who were unsuccessfully sedated for the neurodiagnostic procedure; length of time taken for adequate sedation; and side effects associated with the sedative agent. The quality of the evidence was mixed, ranging from very low to high. The main reason for lowering the quality of the evidence was that those closely involved in the trials, such as the doctors giving the sedation or the parents of the child, were not masked to the sedative agent used in the child, which could have affected their recording or interpretation of the results. Key results We summarised the evidence of effectiveness and harms of oral chloral hydrate sedation when compared with other sedative agents. Our review suggests that oral chloral hydrate is just as effective a sedative agent with similar sedation failure rate when compared with oral dexmedetomidine, oral hydroxyzine hydrochloride, oral midazolam, and oral clonidine; and probably a more effective sedative agent with a lower sedation failure rate when compared with oral promethazine. Whilst most of the included studies showed that chloral hydrate was safe with no increase in side effects when compared to other sedative agents, one study reported an increased risk of side effects with oral chloral hydrate when compared with intranasal dexmedetomidine. Quality of the evidence The quality of most of the evidence was poor due to flaws in study methods and the small sample size of each study, therefore our confidence in the results of the studies is reduced. Conclusions Apart from intravenous pentobarbital, rectal sodium thiopental, and music therapy, oral chloral hydrate is either just as effective or more effective as a sedating agent when compared to other sedating agents for children undergoing non‐invasive neurodiagnostic procedures. Given the poor quality of the evidence, we could draw no clear conclusions on the effectiveness or safety of any of the paediatric sedative agents studied in the review. Further study is needed to look at the side effects of oral chloral hydrate when compared to other sedatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Fong, CY, Lim, WK, Li, L, Lai, NM", "articleTypes": [], "doi": "10.1002/14651858.CD011786.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.121Z" }, { "id": "e0a4e6a0-7ffa-452d-8876-ae1f3b1d8ac9", "pmid": "", "title": "Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants)", "imported": false, "abstract": "Abstract - Background 'Immediate' implants are placed in dental sockets just after tooth extraction. 'Immediate‐delayed' implants are those implants inserted after weeks up to about a couple of months to allow for soft tissue healing. 'Delayed' implants are those placed thereafter in partially or completely healed bone. The potential advantages of immediate implants are that treatment time can be shortened and that bone volumes might be partially maintained thus possibly providing good aesthetic results. The potential disadvantages are an increased risk of infection and failures. After implant placement in postextractive sites, gaps can be present between the implant and the bony walls. It is possible to fill these gaps and to augment bone simultaneously to implant placement. There are many techniques to achieve this but it is unclear when augmentation is needed and which could be the best augmentation technique. Objectives To evaluate success, complications, aesthetics and patient satisfaction between 'immediate', 'immediate‐delayed' and 'delayed' implants. To evaluate whether and when augmentation procedures are necessary and which is the most effective technique. Search methods The Cochrane Oral Health Group's Trials Register (to 2 June 2010), CENTRAL ( The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 ‐ 2 June 2010) and EMBASE via OVID (1980 ‐ 2 June 2010) were searched. Several dental journals were handsearched. Selection criteria Randomised controlled trials (RCTs) comparing immediate, immediate‐delayed, and delayed implants, or comparing various bone augmentation procedures around the inserted implants, reporting the outcome of the interventions to at least 1 year after functional loading. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Trial authors were contacted for any missing information. Results were expressed as random‐effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). The statistical unit of the analysis was the patient. Main results Fourteen eligible RCTs were identified but only seven trials could be included. Four RCTs evaluated implant placement timing. Two RCTs compared immediate versus delayed implants in 126 patients and found no statistically significant differences. One RCT compared immediate‐delayed versus delayed implants in 46 patients. After 2 years patients in the immediate‐delayed group perceived the time to functional loading significantly shorter, were more satisfied and independent blinded assessor judged the level of the perimplant marginal mucosa in relation to that of the adjacent teeth as more appropriate (RR = 1.68; 95% CI 1.04 to 2.72). These differences disappeared 5 years after loading but significantly more complications occurred in the immediate‐delayed group (RR = 4.20; 95% CI 1.01 to 17.43). One RCT compared immediate with immediately delayed implants in 16 patients for 2 years and found no differences. Three RCTs evaluated different techniques of bone grafting for implants immediately placed in extraction sockets. No statistically significant difference was observed when evaluating whether autogenous bone is needed in postextractive sites (1 trial with 26 patients) or which was the most effective augmentation technique (2 trials with 56 patients). Authors' conclusions There is insufficient evidence to determine possible advantages or disadvantages of immediate, immediate‐delayed or delayed implants, therefore these preliminary conclusions are based on few underpowered trials often judged to be at high risk of bias. There is a suggestion that immediate and immediate‐delayed implants may be at higher risks of implant failures and complications than delayed implants on the other hand the aesthetic outcome might be better when placing implants just after teeth extraction. There is not enough reliable evidence supporting or refuting the need for augmentation procedures at immediate implants placed in fresh extraction sockets or whether any of the augmentation techniques is superior to the others. Plain language summary Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants) Dental implants can be placed in sockets just after tooth extraction (immediate implants) or after a couple of weeks up to a couple of months (immediate‐delayed implants) or thereafter (delayed implants). This review looked at which was the best time to place dental implants and whether it would be advantageous to augment sites with gaps present at implant placement. It also tried to determine the most effective bone augmentation procedure. The seven identified studies included too few patients to answer the questions. Four studies evaluated which is the best time to place implants. One study evaluated whether bone grafting is advantageous at implant placement and two studies evaluated which are the best grafting techniques. There is currently too little evidence to draw any reliable conclusions, however, the aesthetic outcome could be slightly better when placing implants early after tooth extraction, though early placed implants might be at a higher risk of failure. There is not enough evidence supporting or refusing the need of bone augmentation when extracted teeth are immediately replaced with dental implants, nor it is known whether any augmentation procedure is better than the others. Bone substitutes (anorganic bovine bone) can be used instead of self generated (autogenous) bone graft.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Esposito, M; Grusovin, MG; Polyzos, IP; Felice, P; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD005968.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "e0bd80a1-57a5-451b-90e3-01b9cbb08cbb", "pmid": "", "title": "Beclomethasone versus placebo for chronic asthma", "imported": false, "abstract": "Abstract - Background Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti‐inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane‐134a (HFA) propellant which is free from chlorofluorocarbon (CFC). Objectives The objectives of this review were to: 
 (1) Compare the efficacy of BDP with placebo with both CFC and HFA propellants in the treatment of chronic asthma. 
 (2) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. 
 (3) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies. Search methods Electronic searches were current as of January 2003. Selection criteria Randomised parallel group design trials for a minimum period of four weeks, in children and adults comparing CFC‐BDP or HFA‐BDP with placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality. Data collection and analysis One reviewer extracted data; authors were contacted to clarify missing information. We analysed data with RevMan Analyses 1.0.2. Main results 60 studies recruiting 6542 participants met the inclusion criteria. CFC‐BDP (57 studies): In non‐oral steroid treated patients, at doses of 400mcg/day or less CFC‐BDP produced significant improvements from baseline in a number of efficacy measures compared with placebo, including forced expiratory volume in one second (FEV1) 360 ml (95% CI 260 to 460); FEV1 (% predicted) WMD 12.41% (95% CI 8.18 to 16.64) and morning peak expiratory flow rate (am PEF) WMD 35.95 L/min (95% CI 27.85 to 44.04). BDP also led to reductions in rescue beta‐2 agonist use compared with placebo of ‐2.32 puffs/d (95% CI ‐2.55 to ‐2.09) and reduced the relative risk (RR) of trial withdrawal due to an asthma exacerbation 0.25 (95% CI 0.12 to 0.51). Subgroup analyses based on treatment duration provide support to the proposal that a treatment period of greater than four weeks is required to realise a fuller treatment effect. In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD ‐4.91 mg/d (95% CI ‐5.88 to ‐3.94 mg/d) and greater likelihood of withdrawing oral steroid treatment RR 8.02 (95% CI 3.23 to 19.92). HFA‐BDP (3 studies): In non‐oral steroid‐treated patients, HFA‐BDP was significantly more effective than placebo in improving FEV1, morning and evening PEF, FEF25 to 75%, reduced asthma symptoms and beta2‐agonists daily consumption. Significant effects for such outcomes were apparent after six weeks of treatment. In oral steroid treated patients, HFA‐BDP improved significantly FEV1 and am PEF. The summary estimates for these outcomes suggested a high level of heterogeneity, and divergent aims of the studies may contribute to the variation we observed. Limited data on adverse events were reported. Authors' conclusions This review has quantified the efficacy of CFC‐BDP and HFA‐BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose‐response in people with severe asthma. Plain language summary Inhaled beclomethasone compared with placebo for chronic asthma During an asthma attack, the airways narrow, causing breathing problems, wheezing and coughing. Inhaled corticosteroids (ICS) are used to reduce swelling of the airways. Inhaled beclomethasone dipropionate (BDP) is commonly used. There is now a new formulation of the drug which uses a new propellant (HFA‐BDP). This review of trials found that BDP delivered with the old and new propellant is effective in helping people with chronic asthma. BDP at all doses improves airflow, reduces symptoms and the need for rescue bronchodilators. The review only included studies conducted for more than 4 weeks. The drug was well tolerated and the safety profile was comparable with placebo. The findings apply to both children and adults. The effects of the new propellant suggest that it could be more effective than the older version, although a different review will address that particular question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Adams, NP; Bestall, JC; Malouf, R; Lasserson, TJ; Jones, P", "articleTypes": [], "doi": "10.1002/14651858.CD002738.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "e0c72e45-86c9-4eb5-8690-935dbb490b62", "pmid": "", "title": "Dornase alfa for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Dornase alfa is currently used as a mucolytic to treat pulmonary disease (the major cause of morbidity and mortality) in cystic fibrosis. It reduces mucus viscosity in the lungs, promoting improved clearance of secretions. This is an update of a previously published review. Objectives To determine whether the use of dornase alfa in cystic fibrosis is associated with improved mortality and morbidity compared to placebo or other medications that improve airway clearance, and to identify any adverse events associated with its use. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstracts from conferences. Date of the most recent search of the Group's Cystic Fibrosis Register: 12 October 2020. Clinicaltrials.gov and the International Clinical Trials Registry Platform were also searched to identify unpublished or ongoing trials. Date of most recent search: 08 February 2021. Selection criteria All randomised and quasi‐randomised controlled trials comparing dornase alfa to placebo, standard therapy or other medications that improve airway clearance. Data collection and analysis Authors independently assessed trials against the inclusion criteria; two authors carried out analysis of methodological quality and data extraction. GRADE was used to assess the level of evidence. Main results The searches identified 74 trials, of which 19 (2565 participants) met our inclusion criteria. 15 trials compared dornase alfa to placebo or no dornase alfa (2447 participants); two compared daily dornase to hypertonic saline (32 participants); one compared daily dornase alfa to hypertonic saline and alternate day dornase alfa (48 participants); one compared dornase alfa to mannitol and the combination of both drugs (38 participants). Trial duration varied from six days to three years. Dornase alfa compared to placebo or no treatment Dornase alfa probably improved forced expiratory volume at one second (FEV 1 ) at one month (four trials, 248 participants), three months (one trial, 320 participants; moderate‐quality evidence), six months (one trial, 647 participants; high‐quality evidence) and two years (one trial, 410 participants). Limited low‐quality evidence showed treatment may make little or no difference in quality of life. Dornase alfa probably reduced the number of pulmonary exacerbations in trials of up to two years (moderate‐quality evidence). One trial that examined the cost of care, including the cost of dornase alfa, found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa: daily versus alternate day One cross‐over trial (43 children) found little or no difference between treatment regimens for lung function, quality of life or pulmonary exacerbations (low‐quality evidence). Dornase alfa compared to other medications that improve airway clearance Results for these comparisons were mixed. One trial (43 children) showed dornase alfa may lead to a greater improvement in FEV 1 compared to hypertonic saline (low‐quality evidence), and one trial (23 participants) reported little or no differences in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol (low‐quality evidence). One trial (23 participants) found dornase alfa may improve quality of life compared to dornase alfa plus mannitol (low‐quality evidence); other comparisons found little or no difference in this outcome (low‐quality evidence). No trials in any comparison reported any difference between groups in the number of pulmonary exacerbations (low‐quality evidence). When all comparisons are assessed, dornase alfa did not cause significantly more adverse effects than other treatments, except voice alteration and rash. Authors' conclusions There is evidence to show that, compared with placebo, therapy with dornase alfa may improve lung function in people with cystic fibrosis in trials lasting from one month to two years. There was a decrease in pulmonary exacerbations in trials of six months or longer, probably due to treatment. Voice alteration and rash appear to be the only adverse events reported with increased frequency in randomised controlled trials. There is not enough evidence to firmly conclude if dornase alfa is superior to other hyperosmolar agents in improving lung function. Plain language summary Dornase alfa, an inhaled drug, for treating lung disease in cystic fibrosis Review question We reviewed the evidence about the effect of using inhaled dornase alfa for treating lung disease in people with cystic fibrosis. Background Cystic fibrosis is an inherited condition which affects the movement of salt across cells in the body and affects, for example, the sweat glands, airways, pancreas and male reproductive system. Lung disease is the most common cause of death in people with cystic fibrosis and although the average life expectancy has increased over the last 30 years, it is still only 48.5 years in high‐income countries. People with cystic fibrosis develop chronic lung disease because of thick mucus that builds up in the lungs which causes infections and inflammation. Dornase alfa was developed to thin out this mucus, so it is easier for people to cough it up from their lungs; this in turn should decrease the number of infections and amount of inflammation and prevent chronic lung disease. Search date The evidence is current to: 12 October 2020. Study characteristics We included 19 trials with 2565 people with cystic fibrosis; 15 trials (2447 people) compared dornase alfa to placebo (a dummy treatment with no active medication) or no dornase alfa treatment; two trials (32 people) compared daily dornase to hypertonic saline; one trial (48 people) compared daily dornase alfa with hypertonic saline and alternate day dornase alfa; and one trial (38 people) compared dornase alfa to mannitol and the combination of both drugs. People from all age groups (infants through to adults) took part in the trials which lasted from six days to three years. Key results Dornase alfa compared to placebo or no treatment We found that dornase alfa probably improves lung function within one month when compared to a placebo or no treatment and this improvement was also seen in longer trials lasting from six months to two years (eight trials; 1708 participants). There were also fewer pulmonary exacerbations (flare up of lung inflammation) in these longer trials. One trial found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa ‐ daily versus alternate day One trial (43 children) found no differences between treatment schedules for lung function, quality of life or pulmonary exacerbations. Dornase alfa compared to other medications that improve airway clearance The results from trials comparing dornase alfa to hypertonic saline or mannitol were mixed. One trial (43 children) showed a greater improvement in lung function with dornase alfa compared to hypertonic saline and one trial (23 participants) reported no difference in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol. In one trial (23 participants) quality of life scores were better with dornase alfa alone than with dornase alfa plus mannitol; other drug comparisons found no difference between treatments for quality of life. No trials in any comparison of treatments reported any difference between groups in the number of pulmonary exacerbations. Overall, no serious side effects were reported, with only rash and a change in voice seen more frequently in those people taking dornase alfa. However, it is not definitively clear from the current evidence if dornase alfa is better than other medications such as hypertonic saline or mannitol. Quality of the evidence The quality of evidence from the trials comparing dornase alfa to placebo or no treatment was moderate to high for lung function results, but only one trial reported any changes in quality of life so the evidence for this outcome is limited. Also, there were few trials comparing different treatment schedules of dornase alfa (e.g. once a day versus twice a day) or comparing dornase alfa to other medications which help with clearing secretions, so current evidence from these trials is limited and of low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Yang, C; Montgomery, M", "articleTypes": [], "doi": "10.1002/14651858.CD001127.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "e0e5c355-23a0-4da9-9b03-713aa4f007f3", "pmid": "", "title": "Pimozide for schizophrenia or related psychoses", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Mothi, M, Sampson, S", "articleTypes": [], "doi": "10.1002/14651858.CD001949.pub3 AB - Abstract - Background Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been associated with cardiotoxicity and sudden unexplained death. Electrocardiogram monitoring is now required before and during use. Objectives To review the effects of pimozide for people with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medication. A secondary objective was to examine the effects of pimozide for people with delusional disorder. Search methods We searched the Cochrane Schizophrenia Group's Register (28 January 2013). Selection criteria We sought all relevant randomised clinical trials (RCTs) comparing pimozide with other treatments. Data collection and analysis Working independently, we inspected citations, ordered papers and then re‐inspected and assessed the quality of the studies and of extracted data. For homogeneous dichotomous data, we calculated the relative risk (RR), the 95% confidence interval (CI) and mean differences (MDs) for continuous data. We excluded data if loss to follow‐up was greater than 50%. We assessed risk of bias for included studies and used GRADE to rate the quality of the evidence. Main results We included 32 studies in total: Among the five studies that compared pimozide versus placebo, only one study provided data for global state relapse, for which no difference between groups was noted at medium term (1 RCT n = 20, RR 0.22 CI 0.03 to 1.78, very low quality of evidence ). None of the five studies provided data for no improvement or first‐rank symptoms in mental state. Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (1 RCT, n = 19, RR 5.50 CI 0.30 to 101.28, very low quality of evidence ) or at medium term (1 RCT n = 25, RR 1.33 CI 0.14 to 12.82, very low quality of evidence ), or for Parkinsonism (tremor) at medium term (1 RCT n = 25, RR 1 CI 0.2 to 4.95, very low quality of evidence ). No data were reported for quality of life at medium term. Of the 26 studies comparing pimozide versus any antipsychotic, seven studies provided data for global state relapse at medium term, for which no difference was noted (7 RCTs n = 227, RR 0.82 CI 0.57 to 1.17, moderate quality of evidence ). Data from one study demonstrated no difference in mental state (no improvement) at medium term (1 RCT n = 23, RR 1.09 CI 0.08 to 15.41, very low quality evidence ); another study demonstrated no difference in the presence of first‐rank symptoms at medium term (1 RCT n = 44, RR 0.53 CI 0.25 to 1.11, low quality of evidence ). Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (6 RCTs n = 186, RR 1.21 CI 0.71 to 2.05, low quality of evidence ) or medium term (5 RCTs n = 219, RR 1.12 CI 0.24 to 5.25, low quality of evidence ), or for Parkinsonism (tremor) at medium term (4 RCTs n = 174, RR 1.46 CI 0.68 to 3.11, very low quality of evidence ). No data were reported for quality of life at medium term. In the one study that compared pimozide plus any antipsychotic versus the same antipsychotic, significantly fewer relapses were noted in the augmented pimozide group at medium term (1 RCT n = 69, RR 0.28 CI 0.15 to 0.50, low quality evidence ). No data were reported for mental state outcomes or for extrapyramidal symptoms (EPS). Data were skewed for quality of life scores, which were not included in the meta‐analysis but were presented separately. Two studies compared pimozide plus any antipsychotics versus antipsychotic plus placebo; neither study reported data for outcomes of interest, apart from Parkinsonism at medium term and quality of life using the Specific Level of Functioning scale (SLOF); however, data were skewed. Only one study compared pimozide plus any antipsychotic versus antipsychotics plus antipsychotic; no data were reported for global state and mental state outcomes of interest. Data were provided for Parkinsonism (rigidity and tremor) using the Extrapyramidal Symptom Rating Scale (ESRS); however, these data were skewed. Authors' conclusions Although shortcomings in the data are evident, enough overall consistency over different outcomes and time scales is present to confirm that pimozide is a drug with efficacy similar to that of other, more commonly used antipsychotic drugs such as chlorpromazine for people with schizophrenia. No data support or refute its use for those with delusional disorder. Plain language summary Pimozide for schizophrenia or related psychoses People with schizophrenia have ‘positive symptoms’ such as hearing voices and seeing things (hallucinations) and fixed strange beliefs (delusions). People with schizophrenia also have ‘negative symptoms’ such as tiredness, apathy and loss of emotion. Antipsychotic drugs are the main treatment for the symptoms of schizophrenia and can be grouped into older drugs (first generation or ‘typical’) and newer drugs (second generation or ‘atypical’). Pimozide is a ‘typical’ antipsychotic drug that was first introduced in the late 1960s and was given to people with schizophrenia. Pimozide is thought to be effective in treating the positive and negative symptoms of schizophrenia or similar mental health problems such as delusional disorder, but it produces serious side effects such as muscle stiffness, tremors and slow body movements. Pimozide may also cause heart problems and has been linked to sudden unexplained death. Monitoring the heart via electrocardiogram is now required before and during treatment with pimozide. It is well known that people with mental health problems suffer from physical illnesses such as heart disease and diabetes and can die on average twenty years younger than those in the general population.
 An update search for this review was carried out 28 January 2013; the review now includes 32 studies that assess the effects of pimozide for people with schizophrenia or similar mental health problems. Pimozide was compared with other antipsychotic drugs, placebo (‘dummy’ treatment) or no treatment. Results suggest that pimozide is probably just as effective as other commonly used ‘typical’ antipsychotic drugs (for outcomes such as treating mental state, relapse, leaving the study early). No studies included delusional disorders, so no information is available on this group of people. No evidence was found to support the concern that pimozide causes heart problems (although this may be result of the fact that the studies were small and short term and the participants did not receive doses above recommended limits of 20 mg/d). Pimozide may cause less sleepiness than other typical antipsychotic drugs, but it may cause more tremors and uncontrollable shaking. The claim that pimozide is useful for treating people with negative symptoms also is not supported and proven. However, the quality of evidence in the main was low or very low quality, studies were small and of short duration and were poorly reported. Large‐scale, well‐conducted and well‐reported studies are required to assess the effectiveness of pimozide in the treatment of schizophrenia and other mental health problems such as delusional disorder. This plain language summary has been written by a consumer, Benjamin Gray (Service User and Service User Expert, Rethink Mental Illness).", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.817Z" }, { "id": "e0f49d0e-21da-402f-9324-64dda7e93b99", "pmid": "", "title": "Diclofenac for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically cyclo‐oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain. Objectives To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled'). Search methods We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022. Selection criteria We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI). Main results We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low‐certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate‐certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child‐reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD ‐0.45, 95% CI ‐0.74 to ‐0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD ‐0.64, 95% CI ‐0.89 to ‐0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low‐certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low‐certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results. Authors' conclusions We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non‐pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered. Plain language summary What are the benefits and harms of diclofenac for managing children's pain after they have had an operation? Key messages • Due to a lack of robust evidence, the benefits and harms of diclofenac for managing children's pain after they've had an operation are unclear. • Diclofenac probably reduces nausea and vomiting, but probably increases the risk of bleeding, compared to opioids (such as morphine). • Well‐designed and comprehensively‐reported studies are needed to shed light on the benefits and harms of diclofenac compared to opioids or other medicines, or for different ways of giving diclofenac to children. Postoperative pain management Pain after surgery or a procedure is common and can influence recovery and return to normal activities. There are many ways to reduce pain after an operation, including medicines such as diclofenac. Diclofenac is part of a class of medicines called non‐steroidal anti‐inflammatory drugs (NSAIDs) that can reduce inflammation and pain. They can be given by different routes, such as by mouth or through the anus into the rectum (back passage), and before, during, and after an operation. What did we want to find out? We wanted to find out the benefits and harms of diclofenac compared to other treatments, as well as the most effective way to deliver diclofenac to children. What did we do? We searched for studies that compared (a) diclofenac to other treatments for postoperative pain; or (b) different ways of delivering diclofenac to children. We summarised the results and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found 32 studies that included 2250 children with postoperative pain. The largest study included 183 children and the smallest, 31 children. The studies were conducted in many countries around the world; the most common location was the United Kingdom (10 studies). The average age of the children was between 2 and 14 years. Diclofenac was used to manage postoperative pain in 12 different types of surgery; most commonly, ear, nose, and throat surgery (9 studies) or eye surgery (6 studies). Main results It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor and serious harms compared to a placebo (a 'dummy' or sham treatment that does not contain any medicine but looks or tastes identical to the medicine being tested). It is unclear if diclofenac given before, during, or after surgery has an effect on pain relief or pain intensity compared to other medicines, such as opioids, paracetamol, or bupivacaine. Diclofenac probably results in less nausea and vomiting compared to opioids (7 studies involving 463 children), but probably increases the risk of any bleeding (2 studies involving 222 children), but we are very unsure about serious harms (death, long‐term disability, or hospitalisation). It is thus unclear if diclofenac given before, during, or after surgery has an effect on pain relief, pain intensity, or minor or serious harms compared to placebo or other medicines other than opioids. It is also unclear which route (by mouth or rectal delivery) is the most effective way to manage pain after surgery in children. What are the limitations of the evidence? We are not confident in the evidence because of study design limitations, and none of the studies measured some of our main outcomes of interest. There were also not enough large studies to be certain about the results. How up to date is this evidence? The evidence is current to April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ringsten, M, Kredo, T, Ebrahim, S, Hohlfeld, A, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015087.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.800Z" }, { "id": "e0f560db-afa2-43bd-a191-789454dbd314", "pmid": "", "title": "Progesterone receptor modulators for endometriosis", "imported": false, "abstract": "Abstract - Rationale Endometriosis is defined as the presence of endometrium‐like tissue developing outside the uterine cavity. This condition is oestrogen‐dependent and thus is seen primarily during the reproductive years. Owing to their antiproliferative effects on the endometrium, progesterone receptor modulators (PRMs) have been advocated for the treatment of endometriosis. This is an update of a Cochrane review previously published in 2017. Objectives To assess the effectiveness and safety of progesterone receptor modulators (PRMs) in the management of endometriosis. Search methods To identify studies, we searched online sources, including the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, ClinicalTrials.gov and the WHO (World Health Organization) trial registry up to 16 April 2026. We also checked reference lists and contacted study authors and experts. Eligibility criteria We included randomised controlled trials (RCTs) comparing PRMs with placebo, no treatment or other medical treatment, in women with symptomatic endometriosis. Outcomes Our critical outcomes were overall pain; improvement in the most troublesome symptom, including dysmenorrhoea and dyspareunia; and adverse events resulting from the PRM intervention. Our important outcomes included quality of life (QoL) and patient satisfaction with treatment. Risk of bias We used the Cochrane tool RoB 2 to assess the risk of bias in the outcomes of this review. Synthesis methods Two review authors independently assessed studies against the inclusion criteria, extracted data and assessed risk of bias, consulting a third review author where required. We analysed dichotomous outcomes using Mantel‐Haenszel odds ratios (ORs), 95% confidence intervals (CIs) and the fixed‐effect model. We analysed continuous outcomes using the mean difference (MD) between groups, presented with 95% CIs. We employed the GRADE approach to assess the certainty of the evidence as high, moderate, low or very low. Included studies No new studies were eligible for inclusion in this update. Of the nine studies (922 women) already included in the review, two compared mifepristone versus placebo or compared different doses of mifepristone, and four either compared gestrinone versus danazol, gestrinone versus gonadotropin‐releasing hormone (GnRH) analogues or compared different doses of gestrinone. One study compared asoprisnil versus placebo. The asoprisnil study did not provide extractable numerical data and was included in the narrative synthesis only. Two of the studies did not report any of the review's prespecified outcomes. Synthesis of results Certainty of the evidence We judged the certainty of evidence as low to very low. The main limitations of the evidence were serious risk of bias (associated with poor reporting of methods and high or unclear rates of attrition), very serious imprecision (associated with low event rates and wide confidence intervals, with some large effect estimates) and serious indirectness (outcomes assessed in selected subgroups). PRM versus placebo Mifepristone versus placebo These results are based on one study (360 participants) that measured outcomes after three months. The study did not report overall pain. At three months, mifepristone may improve dysmenorrhoea (OR 0.07, 95% CI 0.03 to 0.15; 1 study, 342 participants; low‐certainty evidence), suggesting that if 40% of women taking placebo experience dysmenorrhoea, then between 3% and 10% of women taking mifepristone will do so. We are uncertain whether mifepristone improves dyspareunia (OR 0.23, 95% CI 0.10 to 0.51; 1 study, 223 participants; very low‐certainty evidence). However, mifepristone may increase hot flushes (OR 28.79, 95% CI 3.93 to 210.73; 1 study, 360 participants; low‐certainty evidence). Mifepristone may make little or no difference after three months of treatment to the prevalence of nausea (OR 1.72, 95% CI 0.20 to 15.03; 1 study, 360 participants; low‐certainty evidence). PRM versus other medical treatment Gestrinone versus danazol These results are based on two studies (302 participants) that measured outcomes after six months. We are uncertain of the effects of gestrinone relative to danazol on the improvement of overall pain (dichotomous outcome: participants reporting no or mild pelvic pain counted as 'improved') (OR 0.47, 95% CI 0.04 to 5.70; 1 study, 38 participants), dysmenorrhoea (Not estimable; 1 study, 38 participants), or dyspareunia (OR 1.00, 95% CI 0.13 to 7.94; 1 study, 38 participants (all very low‐certainty evidence). We are uncertain about the effects of gestrinone relative to danazol on hot flushes (OR 0.79, 95% CI 0.50 to 1.26; 2 studies, 302 participants; very low‐certainty evidence). There may be little or no difference between gestrinone and danazol in rates of nausea (OR 1.36, 95% CI 0.84 to 2.19; 2 studies, 302 participants; low‐certainty evidence). Gestrinone versus a GnRH analogue (leuprorelin) These results are based on one study (55 participants) that measured outcomes after six months. There may be little to no difference between gestrinone and leuprorelin in non‐menstrual pain (MD −0.41, 95% CI −1.76 to 0.94; 1 study, 55 participants; low‐certainty evidence). Women taking gestrinone may have higher dysmenorrhoea scores than those taking leuprorelin (MD 0.82, 95% CI 0.15 to 1.49; 1 study, 55 participants; low‐certainty evidence), but gestrinone may improve dyspareunia more than leuprorelin (MD −1.16, 95% CI −2.08 to −0.24; 1 study, 52 participants; low‐certainty evidence). There may be lower rates of hot flushes with gestrinone than leuprorelin (OR 0.20, 95% CI 0.06 to 0.63; 1 study, 55 participants; low‐certainty evidence). There may be little or no difference between gestrinone and leuprorelin in rates of nausea (OR 1.04, 95% CI 0.06 to 17.49; 1 study, 55 participants; low‐certainty evidence). Authors' conclusions Mifepristone may improve dysmenorrhoea in women with endometriosis, but it might increase the prevalence of adverse events, such as hot flushes. The evidence is very uncertain regarding its effect on dyspareunia. Gestrinone may be less effective than leuprorelin in treating dysmenorrhoea, but it may improve dyspareunia. It may be associated with lower rates of hot flushes and similar rates of nausea. We are uncertain about the effect of gestrinone compared to danazol. We found insufficient evidence to permit firm conclusions about the safety and effectiveness of other progesterone receptor modulators. Funding This Cochrane review had no dedicated funding. Registration Protocol (2012) DOI: 10.1002/14651858.CD009881 Review (2017) DOI: 10.1002/14651858.CD009881.pub2 Plain language summary What are the benefits and risks of medicines called progesterone receptor modulators (PRMs) for treating endometriosis (a condition where tissue grows outside the womb)? Key messages In the management of endometriosis (a condition where tissue grows outside the womb), studies that compared a progesterone receptor modulator (PRM; a medicine that changes how the hormone progesterone acts in the body) against placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested) found that a PRM called mifepristone may improve painful periods. However, it may cause hot flushes. A PRM called gestrinone may be less effective than medicines known as gonadotropin‐releasing hormone (GnRH) analogues (which reduce the amount of oestrogen made by the ovaries) for treating painful periods, but may improve pain during sex. Gestrinone may also cause fewer hot flushes. We do not know how gestrinone compares to a treatment called danazol in terms of pain not related to periods, painful periods or pain during sex. We do not know whether gestrinone or danazol causes more unwanted effects. Future studies should compare progesterone receptor modulators with medicines currently used to treat endometriosis symptoms and focus on assessing pain using recognised and reliable methods. Larger, well‐designed studies are also needed to assess the benefits and unwanted effects of progesterone receptor modulators other than mifepristone and gestrinone. What is endometriosis? Endometriosis is a condition where tissue similar to the lining of the womb (uterus) grows outside the womb. Endometriosis is oestrogen‐dependent and thus is seen mainly during the reproductive years. It can cause pain in the tummy area (abdomen), generally during periods (menstruation) or associated with sexual intercourse. Endometriosis is treated through different types of medical or surgical treatment. Progesterone receptor modulators (PRMs) are medicines that change how the hormone progesterone acts in the body. PRMs include mifepristone, gestrinone, ulipristal acetate, vilaprisan and asoprisnil. Because they can slow down or stop the growth of tissue in the lining of the uterus, they have been suggested as a treatment for endometriosis. What did we want to find out? We wanted to know whether, in patients with endometriosis, PRMs are better than placebo ('dummy' treatment), no treatment or other medical treatment for improving overall pain, pain during periods and pain during sexual intercourse. We also wanted to know if these medications were safe by assessing unwanted effects experienced by patients, such as hot flushes and feeling sick (nausea). What did we do? We searched for studies that investigated the effectiveness of PRMs for symptoms associated with endometriosis and whether they caused unwanted effects. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included nine studies involving 922 women aged 18 to 45 years. Most studies tested the PRMs mifepristone or gestrinone. One study tested asoprisnil, but the study was published only as a short summary without results that we could use. Two of the studies did not measure any of the effects we were interested in. Main results Progesterone receptor modulators versus placebo When compared to a placebo, mifepristone: may reduce painful periods after three months of treatment (based on 1 study of 342 women); may cause more unwanted effects, such as hot flushes (1 study, 360 women); may make little or no difference to nausea (1 study, 360 women); and we are uncertain whether mifepristone reduces pain during sex (1 study, 223 women). Progesterone receptor modulators versus other medical treatment When compared to danazol, one study of 38 women showed that: we do not know whether gestrinone improves pain symptoms after six months of treatment (1 study, 38 women); we do not know whether gestrinone causes more or fewer hot flushes or makes no difference (2 studies, 302 women); and gestrinone and danazol may cause similar rates of nausea, but the results are very uncertain (2 studies, 302 women). When compared to a GnRH analogue (leuprorelin), one study of 55 women found that: gestrinone may be less efficient in treating painful periods after six months of treatment (1 study, 55 women); but gestrinone may reduce pain during sex (1 study, 52 women); gestrinone may be similar to leuprorelin in terms of general pain experienced (1 study, 55 women); gestrinone may cause fewer hot flushes and similar levels of nausea (1 study, 55 women). What are the limitations of the evidence? Our confidence in the evidence is low to very low, mainly because some studies had one or more of these problems: they did not have many people taking part; they focused on specific settings or populations; they used methods likely to introduce errors in their results; they did not clearly report how they were conducted; they did not clearly report whether the people taking part knew which treatment they had received, which could have affected the study results. How up to date is this evidence? This review updates a previous review. The evidence is up to date to April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Grammatis, AL; Gibbons, T; Anucha, EN; Becker, CM", "articleTypes": [], "doi": "10.1002/14651858.CD009881.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "e0f60c1c-3a8f-4a36-9712-9617c2a5fbe6", "pmid": "", "title": "Citalopram versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Recent US and UK clinical practice guidelines recommend that second‐generation antidepressants should be considered amongst the best first‐line options when drug therapy is indicated for a depressive episode. Systematic reviews have already highlighted some differences in efficacy between second‐generation antidepressants. Citalopram, one of the first selective serotonin reuptake inhibitors (SSRI) introduced in the market, is one of these antidepressant drugs that clinicians use for routine depression care. Objectives To assess the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with tricyclics, heterocyclics, other SSRIs and other conventional and non‐conventional antidepressants in the acute‐phase treatment of major depression. Search methods We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to February 2012. No language restriction was applied. We contacted pharmaceutical companies and experts in this field for supplemental data. Selection criteria Randomised controlled trials allocating patients with major depression to citalopram versus any other antidepressants. Data collection and analysis Two reviewers independently extracted data. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (the number of patients who responded or remitted), patient acceptability (the number of patients who failed to complete the study) and tolerability (side‐effects). Main results Thirty‐seven trials compared citalopram with other antidepressants (such as tricyclics, heterocyclics, SSRIs and other antidepressants, either conventional ones, such as mirtazapine, venlafaxine and reboxetine, or non‐conventional, like hypericum ). Citalopram was shown to be significantly less effective than escitalopram in achieving acute response (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.08 to 2.02), but more effective than paroxetine (OR 0.65, 95% CI 0.44 to 0.96) and reboxetine (OR 0.63, 95% CI 0.43 to 0.91). Significantly fewer patients allocated to citalopram withdrew from trials due to adverse events compared with patients allocated to tricyclics (OR 0.54, 95% CI 0.38 to 0.78) and fewer patients allocated to citalopram reported at least one side effect than reboxetine or venlafaxine (OR 0.64, 95% CI 0.42 to 0.97 and OR 0.46, 95% CI 0.24 to 0.88, respectively). Authors' conclusions Some statistically significant differences between citalopram and other antidepressants for the acute phase treatment of major depression were found in terms of efficacy, tolerability and acceptability. Citalopram was more efficacious than paroxetine and reboxetine and more acceptable than tricyclics, reboxetine and venlafaxine, however, it seemed to be less efficacious than escitalopram. As with most systematic reviews in psychopharmacology, the potential for overestimation of treatment effect due to sponsorship bias and publication bias should be borne in mind when interpreting review findings. Economic analyses were not reported in the included studies, however, cost effectiveness information is needed in the field of antidepressant trials. Plain language summary Citalopram versus other antidepressants for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Antidepressant drugs remain the mainstay of treatment in moderate‐to‐severe major depression. During the last 20 years, selective serotonin reuptake inhibitors (SSRIs) have progressively become the most commonly prescribed antidepressants. Citalopram, one of the first SSRIs introduced in the market, is the racemic mixture of S‐ and R‐enantiomer. In the present review we assessed the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with all other antidepressants in the acute‐phase treatment of major depression. Thirty‐seven randomised controlled trials (more than 6000 participants) were included in the present review. In terms of efficacy, citalopram was more efficacious than other reference compounds like paroxetine or reboxetine, but worse than escitalopram. In terms of side effects, citalopram was more acceptable than older antidepressants, like tricyclics. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including differences in efficacy and side‐effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Cipriani, A; Purgato, M; Furukawa, TA; Trespidi, C; Imperadore, G; Signoretti, A; Churchill, R; Watanabe, N; Barbui, C", "articleTypes": [], "doi": "10.1002/14651858.CD006534.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "e102be3d-de50-4b58-a97a-eea4968fc18a", "pmid": "", "title": "Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2010 and previously updated in 2011. Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period. Objectives To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 4 July 2013. Selection criteria We included randomised controlled trials in which oral rinses, mouthwashes and sprays, used pre‐ and postoperatively, have been compared with placebo in adults or children undergoing tonsillectomy, with or without adenoidectomy. Data collection and analysis Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently. Main results We included seven trials (593 participants; 397 children and 196 adults). The period of follow‐up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre‐specified primary outcomes and none for the secondary outcomes. The risk of bias was high in most of the included trials. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage. Authors' conclusions Poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well‐constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data. Plain language summary Oral rinses, mouthwashes and sprays for improving outcomes following tonsillectomy Tonsillectomy is one of the most common operations performed in adults and children. Pain and bleeding following the operation are common. Postoperative tonsillectomy medication should aim to minimise some of these symptoms. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the period just after surgery. This review included seven studies involving 593 participants (397 children and 196 adults) and is up to date as of July 2013. The risk of bias was high in most of the included trials. We found that lidocaine spray appeared to be more effective than a placebo saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation when they used another spray containing benzydamine but this was not sufficient to discontinue its usage. Further research should aim to provide reliable evidence for people to make informed decisions as to whether these treatments can be effective in reducing the most common symptoms and complications following tonsillectomy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fedorowicz, Z, van Zuuren, EJ, Nasser, M, Carter, B, Al Langawi, JH", "articleTypes": [], "doi": "10.1002/14651858.CD007806.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.765Z" }, { "id": "e10bebf7-9ff8-4ae5-b032-447d51118691", "pmid": "", "title": "A Study on the Correlation Between Oral Health and Delirium in Surgical Inpatients", "imported": false, "abstract": "Delirium is a clinical syndrome characterized by acute attention deficits, altered consciousness, and fluctuating cognitive dysfunction, typically triggered by multifactorial causes such as physical illness, medication use, or postoperative stress . As the most common complication in hospitalized patients, delirium is highly prevalent among elderly surgical populations, with postoperative delirium (POD) occurring in 7.5%-27.5% of cases, and rates rising to 50%-70% in intensive care unit (ICU) patients . Its onset is closely associated with poor prognoses, including long-term postoperative cognitive decline , increased mortality, prolonged hospitalization, and elevated healthcare costs (annual costs in the United States ranging from 38billionto152 billion) . Early prevention and screening of POD are therefore critical to improving patient outcomes and reducing healthcare burdens.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.268Z" }, { "id": "e10f3c9a-7fd0-4fd2-b320-f2e84edf7eb7", "pmid": "", "title": "Selenium for preventing cancer", "imported": false, "abstract": "Abstract - Background This review is the third update of the Cochrane review \"Selenium for preventing cancer\". Selenium is a naturally occurring element with both nutritional and toxicological properties. Higher selenium exposure and selenium supplements have been suggested to protect against several types of cancer. Objectives To gather and present evidence needed to address two research questions: 1. What is the aetiological relationship between selenium exposure and cancer risk in humans?
 2. Describe the efficacy of selenium supplementation for cancer prevention in humans. Search methods We updated electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), MEDLINE (Ovid, 2013 to January 2017, week 4), and Embase (2013 to 2017, week 6), as well as searches of clinical trial registries. Selection criteria We included randomised controlled trials (RCTs) and longitudinal observational studies that enrolled adult participants. Data collection and analysis We performed random‐effects (RE) meta‐analyses when two or more RCTs were available for a specific outcome. We conducted RE meta‐analyses when five or more observational studies were available for a specific outcome. We assessed risk of bias in RCTs and in observational studies using Cochrane's risk assessment tool and the Newcastle‐Ottawa Scale, respectively. We considered in the primary analysis data pooled from RCTs with low risk of bias. We assessed the certainty of evidence by using the GRADE approach. Main results We included 83 studies in this updated review: two additional RCTs (10 in total) and a few additional trial reports for previously included studies. RCTs involved 27,232 participants allocated to either selenium supplements or placebo. For analyses of RCTs with low risk of bias, the summary risk ratio (RR) for any cancer incidence was 1.01 (95% confidence interval (CI) 0.93 to 1.10; 3 studies, 19,475 participants; high‐certainty evidence). The RR for estimated cancer mortality was 1.02 (95% CI 0.80 to 1.30; 1 study, 17,448 participants). For the most frequently investigated site‐specific cancers, investigators provided little evidence of any effect of selenium supplementation. Two RCTs with 19,009 participants indicated that colorectal cancer was unaffected by selenium administration (RR 0.99, 95% CI 0.69 to 1.43), as were non‐melanoma skin cancer (RR 1.16, 95% CI 0.30 to 4.42; 2 studies, 2027 participants), lung cancer (RR 1.16, 95% CI 0.89 to 1.50; 2 studies, 19,009 participants), breast cancer (RR 2.04, 95% CI 0.44 to 9.55; 1 study, 802 participants), bladder cancer (RR 1.07, 95% CI 0.76 to 1.52; 2 studies, 19,009 participants), and prostate cancer (RR 1.01, 95% CI 0.90 to 1.14; 4 studies, 18,942 participants). Certainty of the evidence was high for all of these cancer sites, except for breast cancer, which was of moderate certainty owing to imprecision, and non‐melanoma skin cancer, which we judged as moderate certainty owing to high heterogeneity. RCTs with low risk of bias suggested increased melanoma risk. Results for most outcomes were similar when we included all RCTs in the meta‐analysis, regardless of risk of bias. Selenium supplementation did not reduce overall cancer incidence (RR 0.99, 95% CI 0.86 to 1.14; 5 studies, 21,860 participants) nor mortality (RR 0.81, 95% CI 0.49 to 1.32; 2 studies, 18,698 participants). Summary RRs for site‐specific cancers showed limited changes compared with estimates from high‐quality studies alone, except for liver cancer, for which results were reversed. In the largest trial, the Selenium and Vitamin E Cancer Trial, selenium supplementation increased risks of alopecia and dermatitis, and for participants with highest background selenium status, supplementation also increased risk of high‐grade prostate cancer. RCTs showed a slightly increased risk of type 2 diabetes associated with supplementation. A hypothesis generated by the Nutritional Prevention of Cancer Trial ‐ that individuals with low blood selenium levels could reduce their risk of cancer (particularly prostate cancer) by increasing selenium intake ‐ has not been confirmed. As RCT participants have been overwhelmingly male (88%), we could not assess the potential influence of sex or gender. We included 15 additional observational cohort studies (70 in total; over 2,360,000 participants). We found that lower cancer incidence (summary odds ratio (OR) 0.72, 95% CI 0.55 to 0.93; 7 studies, 76,239 participants) and lower cancer mortality (OR 0.76, 95% CI 0.59 to 0.97; 7 studies, 183,863 participants) were associated with the highest category of selenium exposure compared with the lowest. Cancer incidence was lower in men (OR 0.72, 95% CI 0.46 to 1.14, 4 studies, 29,365 men) than in women (OR 0.90, 95% CI 0.45 to 1.77, 2 studies, 18,244 women). Data show a decrease in risk of site‐specific cancers for stomach, colorectal, lung, breast, bladder, and prostate cancers. However, these studies have major weaknesses due to study design, exposure misclassification, and potential unmeasured confounding due to lifestyle or nutritional factors covarying with selenium exposure beyond those taken into account in multi‐variable analyses. In addition, no evidence of a dose‐response relation between selenium status and cancer risk emerged. Certainty of evidence was very low for each outcome. Some studies suggested that genetic factors might modify the relation between selenium and cancer risk ‐ an issue that merits further investigation. Authors' conclusions Well‐designed and well‐conducted RCTs have shown no beneficial effect of selenium supplements in reducing cancer risk (high certainty of evidence). Some RCTs have raised concerns by reporting a higher incidence of high‐grade prostate cancer and type 2 diabetes in participants with selenium supplementation. No clear evidence of an influence of baseline participant selenium status on outcomes has emerged in these studies. Observational longitudinal studies have shown an inverse association between selenium exposure and risk of some cancer types, but null and direct relations have also been reported, and no systematic pattern suggesting dose‐response relations has emerged. These studies suffer from limitations inherent to the observational design, including exposure misclassification and unmeasured confounding. Overall, there is no evidence to suggest that increasing selenium intake through diet or supplementation prevents cancer in humans. However, more research is needed to assess whether selenium may modify the risk of cancer in individuals with a specific genetic background or nutritional status, and to investigate possible differential effects of various forms of selenium. Plain language summary Selenium for preventing cancer Review question 
 We reviewed the evidence investigating the relation between selenium intake and cancer prevention. This review updates the most recent Cochrane review on this topic ( Vinceti 2014) , which was an update of Dennert 2011 . Background 
 Selenium is a naturally occurring element that individuals are exposed to mainly through food consumption, although exposure can also occur through air, drinking water, and dietary supplements. Small amounts of selenium are essential for certain biological functions in humans, but slightly higher amounts can pose a toxicity risk, making selenium an element with a narrow, but as yet not well‐defined, safe range of exposure. Selenium occurs in many different chemical forms with different biological activity. From the late 1960s, a few observational studies reported that people with high levels of selenium in their diet or in their body tissues had lower risk of cancer, and some laboratory studies showed that selenium could inhibit the growth of cancer cells. This led to widespread interest in selenium supplements and claims that taking such supplements could prevent cancer. Since that time, many more observational studies have been conducted to compare cancer rates among individuals with high and low selenium exposure. More recently, several randomised controlled trials designed to assess whether selenium supplementation can prevent cancer have been carried out. These trials played a major role in enhancing our understanding of the relation between selenium and cancer risk as a result of their stronger study design as compared with observational studies. The most recent trials in particular have shown high methodological quality and statistical power. Several trials focused on whether selenium could prevent prostate cancer. Study characteristics 
 This review includes 10 trials in which adults were randomly assigned to receive selenium supplements or placebo, and 70 observational studies in which adults were followed over time to determine whether their baseline selenium status was associated with their risk of cancer. The evidence is current to January 2017. Key results 
 All of the high‐quality randomised trials reported no effect of selenium on reducing overall risk of cancer or risk of particular cancers, including the most investigated outcome ‐ prostate cancer. Some trials unexpectedly suggested that selenium may increase risks of high‐grade prostate cancer, type 2 diabetes, and dermatological abnormalities. Observational studies have yielded inconsistent evidence of a possible effect of selenium exposure on cancer risk, with no evidence of a dose‐response relation. When we pooled results of these studies, overall they suggested an inverse relation between cancer exposure and subsequent incidence of any cancer or some specific cancers, such as colon and prostate cancer. However, observational studies have major weaknesses. The selenium exposure status of participants could have been misclassified owing to limitations of the indicators of selenium exposure used, as well as to uncertainty regarding the particular selenium species contributing to overall exposure. In addition, unmeasured confounding from lifestyle or nutritional factors ‐ a major and well‐known source of bias in nutritional epidemiology studies of observational design ‐ could have been present. Therefore, the internal validity of these studies is limited. Currently, the hypothesis that increasing selenium intake may reduce cancer risk is not supported by epidemiological evidence. Additional research is needed to assess whether selenium may affect the risk of cancer in individuals with specific genetic backgrounds or nutritional status, and to determine how the various chemical forms of selenium compounds may have different effects on cancer risk.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Vinceti, M; Filippini, T; Del Giovane, C; Dennert, G; Zwahlen, M; Brinkman, M; Zeegers, MPA; Horneber, M; D'Amico, R; Crespi, CM", "articleTypes": [], "doi": "10.1002/14651858.CD005195.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "e151a255-2cd4-4779-8711-2e97a3add342", "pmid": "", "title": "Zinc supplementation for tinnitus", "imported": false, "abstract": "Abstract - Background Tinnitus is the perception of sound without external acoustic stimuli. Patients with severe tinnitus may have physical and psychological complaints and their tinnitus can cause deterioration in their quality of life. At present no specific therapy for tinnitus has been found to be satisfactory in all patients. In recent decades, a number of reports have suggested that oral zinc supplementation may be effective in the management of tinnitus. Since zinc has a role in cochlear physiology and in the synapses of the auditory system, there is a plausible mechanism of action for this treatment. Objectives To evaluate the effectiveness and safety of oral zinc supplementation in the management of patients with tinnitus. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 6); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 July 2016. Selection criteria Randomised controlled trials comparing zinc supplementation versus placebo in adults (18 years and over) with tinnitus. Data collection and analysis We used the standard methodological procedures recommended by Cochrane. Our primary outcome measures were improvement in tinnitus severity and disability, measured by a validated tinnitus‐specific questionnaire, and adverse effects. Secondary outcomes were quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters, change in tinnitus loudness, change in overall severity of tinnitus and change in thresholds on pure tone audiometry. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included three trials involving a total of 209 participants. The studies were at moderate to high risk of bias. All included studies had differences in participant selection criteria, length of follow‐up and outcome measurement, precluding a meta‐analysis. The participants were all adults over 18 years with subjective tinnitus, but one study conducted in 2013 (n = 109) included only elderly patients. Improvement in tinnitus severity and disability Only the study in elderly patients used a validated instrument (Tinnitus Handicap Questionnaire) for this primary outcome. The authors of this cross‐over study did not report the results of the two phases separately and found no significant differences in the proportion of patients reporting tinnitus improvement at four months of follow‐up: 5% (5/93) versus 2% (2/94) in the zinc and placebo groups, respectively (risk ratio (RR) 2.53, 95% confidence interval (CI) 0.50 to 12.70; very low‐quality evidence ). None of the included studies reported any significant adverse effects. Secondary outcomes For the secondary outcome change in tinnitus loudness, one study reported no significant difference between the zinc and placebo groups after eight weeks: mean difference in tinnitus loudness ‐9.71 dB (95% CI ‐25.53 to 6.11; very low‐quality evidence ). Another study also measured tinnitus loudness but used a 0‐ to 100‐point scale. The authors of this second study reported no significant difference between the zinc and placebo groups after four months: mean difference in tinnitus loudness rating scores 0.50 (95% CI ‐5.08 to 6.08; very low‐quality evidence ). Two studies used unvalidated instruments to assess tinnitus severity. One (with 50 participants) reported the severity of tinnitus using a non‐validated scale (0 to 7 points) and found no significant difference in subjective tinnitus scores between the zinc and placebo groups at the end of eight weeks of follow‐up (mean difference (MD) ‐1.41, 95% CI ‐2.97 to 0.15; very low‐quality evidence ). A third trial (n = 50) also evaluated the improvement of tinnitus using a non‐validated instrument (a 0 to 10 scale: 10 = severe and unbearable tinnitus). In this study, after eight weeks there was no difference in the proportion of patients with improvement in their tinnitus, 8.7% (2/23) treated with zinc versus 8% (2/25) of those who received a placebo (RR 1.09, 95% CI 0.17 to 7.10, very low‐quality evidence ). None of the included studies reported any of our other secondary outcomes (quality of life, change in socioeconomic impact associated with work, change in anxiety and depression disorders, change in psychoacoustic parameters or change in thresholds on pure tone audiometry). Authors' conclusions We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. Plain language summary Zinc supplements for tinnitus Background Tinnitus is the perceived sensation of sound in the ear or head. Severe tinnitus affects 1% to 2% of the population. People with severe tinnitus frequently have psychological changes and a decrease in their quality of life. Tinnitus is difficult to control and many doctors are testing new treatments to improve the quality of life of people who suffer from this problem. This review looked for high‐quality studies in the literature that involved zinc supplements as a possible treatment for tinnitus in adults. The aim was to evaluate whether oral zinc is effective in the treatment of tinnitus. Study characteristics We included a total of three trials involving 209 participants who were treated with oral zinc pills or placebo. All patients were adults over 18 years who had subjective tinnitus. All three studies investigated improvement in tinnitus as their primary outcome. One study assessed adverse effects and our secondary outcome 'change in overall severity of tinnitus'. Two studies assessed tinnitus loudness. Only one study, which enrolled only elderly patients, used a validated instrument (the Tinnitus Handicap Questionnaire (THQ)) to measure the primary outcome. The other two studies measured tinnitus using scales (from 0 to 7 and from 0 to 10), but these scales were not validated instruments for studying tinnitus. Key results All three included studies had differences in their participant selection, length of follow‐up and outcome measurement, which prevented a meta‐analysis (combining of results). Only one trial (conducted in 2013) used a validated instrument (the THQ) to measure improvement in tinnitus, our primary outcome. The authors reported no significant difference between the groups. Another study (2003) reported the severity of tinnitus using a non‐validated scale (0 to 7) and found a significant difference in the subjective tinnitus scores, which favoured the zinc group. However, this result may be biased because the losses were unbalanced and higher in the placebo group. A third study (1991) also evaluated improvement of tinnitus using a non‐validated instrument (a scale of 0 to 10) and found no significant difference between groups. There were no severe adverse effects associated with zinc. Three cases of mild adverse effects were reported in different participants (e.g. mild gastric symptoms). Two studies (2003 and 2013) assessed change in tinnitus loudness (one of our secondary outcomes), but did not find a difference between patients treated with zinc compared to those who took a placebo. Two studies assessed change in the overall severity of tinnitus. One study, published in 1991, did not find any difference for this outcome between the groups. The second study, published in 2003, reported a significant reduction in subjective tinnitus score in the zinc group and no difference in the placebo group. However, both studies used a non‐validated scale. Quality of the evidence The quality of the evidence is very low. We found no evidence that the use of oral zinc supplementation improves symptoms in adults with tinnitus. This evidence is up to date to 14 July 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Person, OC; Puga, MES; da Silva, EMK; Torloni, MR", "articleTypes": [], "doi": "10.1002/14651858.CD009832.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "e151c9a6-023f-409b-ba9f-b8775a634985", "pmid": "", "title": "Nebulised hypertonic saline for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Hypertonic saline enhances mucociliary clearance and may lessen the destructive inflammatory process in the airways. This is an update of a previously published review. Objectives To investigate efficacy and tolerability of nebulised hypertonic saline treatment in people with cystic fibrosis (CF) compared to placebo or other treatments that enhance mucociliary clearance. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also searched ongoing trials databases. Most recent search: 25 April 2022. Selection criteria We included randomised and quasi‐randomised controlled trials assessing hypertonic saline compared to placebo or other mucolytic therapy, for any duration or dose regimen in people with CF (any age or disease severity). Data collection and analysis Two authors independently reviewed all identified trials and data, and assessed trial quality. We assessed the certainty of the evidence using GRADE. For cross‐over trials we stipulated a one‐week washout period. We planned to use results from a paired analysis in the review, but this was only possible in one trial. For other cross‐over trials, we chose to treat the trials as if they were parallel. Main results We included 24 trials (1318 participants, aged one month to 56 years); we excluded 29 trials, two trials are ongoing and six are awaiting classification. We judged 15 of the 24 included trials to have a high risk of bias due to participants' ability to discern the taste of the solutions. Hypertonic saline 3% to 7% versus placebo (stable disease) We are uncertain whether the regular use of nebulised hypertonic saline in stable lung disease leads to an improvement in forced expiratory volume in one second (FEV 1 ) % predicted at four weeks, (mean difference (MD) 3.30%, 95% confidence interval (CI) 0.71 to 5.89; 4 trials, 246 participants; very low‐certainty evidence). In preschool children we found no difference in lung clearance index (LCI) at four weeks, but a small improvement after 48 weeks of treatment with hypertonic saline compared to isotonic saline (MD ‐0.60, 95% CI ‐1.00 to ‐0.19; 2 trials, 192 participants). We are also uncertain whether hypertonic saline made a difference to mucociliary clearance, pulmonary exacerbations or adverse events compared to placebo. Hypertonic saline versus control (acute exacerbation) Two trials compared hypertonic saline to control, but only one provided data. There may be little or no difference in lung function measured by FEV 1 % predicted after hypertonic saline compared to isotonic saline (MD 5.10%, 95% CI ‐14.67 to 24.87; 1 trial, 130 participants). Neither trial reported any deaths or measures of sputum clearance. There were no serious adverse events. Hypertonic saline versus rhDNase Three trials compared a similar dose of hypertonic saline to recombinant deoxyribonuclease (rhDNase); two trials (61 participants) provided data for inclusion in the review. We are uncertain whether there was an effect of hypertonic saline on FEV 1 % predicted after three weeks (MD 1.60%, 95% CI ‐7.96 to 11.16; 1 trial, 14 participants; very low‐certainty evidence). At three months, rhDNase may lead to a greater increase in FEV 1 % predicted than hypertonic saline (5 mL twice daily) at 12 weeks in participants with moderate to severe lung disease (MD 8.00%, 95% CI 2.00 to 14.00; low‐certainty evidence). We are uncertain whether adverse events differed between the two treatments. No deaths were reported. Hypertonic saline versus amiloride One trial (12 participants) compared hypertonic saline to amiloride but did not report on most of our outcomes. The trial found that there was no difference between treatments in measures of sputum clearance (very low‐certainty evidence). Hypertonic saline compared with sodium‐2‐mercaptoethane sulphonate (Mistabron®) One trial (29 participants) compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate. The trial did not measure our primary outcomes. There was no difference between treatments in any measures of sputum clearance, courses of antibiotics or adverse events (very low‐certainty evidence). Hypertonic saline versus mannitol One trial (12 participants) compared hypertonic saline to mannitol, but did not report lung function at relevant time points for this review; there were no differences in sputum clearance, but mannitol was reported to be more 'irritating' (very low‐certainty evidence). Hypertonic saline versus xylitol Two trials compared hypertonic saline to xylitol, but we are uncertain whether there is any difference in FEV 1 % predicted or median time to exacerbation between groups (very low‐certainty evidence). No other outcomes were reported in the review. Hypertonic saline 7% versus hypertonic saline 3% We are uncertain whether there was an improvement in FEV 1 % predicted after treatment with 7% hypertonic saline compared with 3% (very low‐certainty evidence). Authors' conclusions We are very uncertain if regular use of nebulised hypertonic saline by adults and children over the age of 12 years with CF results in an improvement in lung function after four weeks (three trials; very low‐certainty evidence); there was no difference seen at 48 weeks (one trial; low‐certainty evidence). Hypertonic saline improved LCI modestly in children under the age of six years. Evidence from one small cross‐over trial in children indicates that rhDNase may lead to better lung function than hypertonic saline at three months; qualifying this, we highlight that while the study did demonstrate that the improvement in FEV 1 was greater with daily rhDNase, there were no differences seen in any of the secondary outcomes. Hypertonic saline does appear to be an effective adjunct to physiotherapy during acute exacerbations of lung disease in adults. However, for the outcomes assessed, the certainty of the evidence ranged from very low to low at best, according to the GRADE criteria. The role of hypertonic saline in conjunction with cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy now needs to be considered, and future research needs to focus on this aspect. Plain language summary Hypertonic saline (salt water with at least 3% salt) nebulised as a fine mist through a mask or mouthpiece for cystic fibrosis Review question Is inhaling hypertonic saline (salt water with at least 3% salt) as a mist through a mask or mouthpiece better for improving mucus clearance in the lungs of people with cystic fibrosis (CF) than a placebo (a mist with no or very little salt) or other agents? Background People with CF produce large amounts of thick mucus which is difficult to clear and blocks up their airways. Chest physiotherapy or medication, e.g. hypertonic saline, or both combined, are used to try and clear this mucus from the airways. Hypertonic saline is water with a concentration of 3% to 7% salt and is inhaled as a fine mist. This is an update of an earlier review. Key messages • We are uncertain whether inhaling nebulised hypertonic saline regularly improves lung function compared to placebo. • Nebulised hypertonic saline does seem to work well as an add‐on to physiotherapy. What did we do? We searched for studies that looked at the use of nebulised hypertonic saline compared to either a placebo or a different type of treatment for clearing mucus from the lungs. We compared the size and methods of the studies and stated how confident we were in the results. What did we find? We included 24 trials with 1318 people with CF aged between one month and 56 years. Two thirds of the trials compared hypertonic saline to a placebo (a dummy treatment); the remaining trials compared hypertonic saline to another type of mucus clearing treatment (including mannitol; rhDNase (Pulmozyme®); amiloride; Mistabron®; xylitol); and one trial compared 7% hypertonic saline with 3% hypertonic saline. Trials assessed different concentrations of hypertonic saline with different nebulisers and different treatment schedules; the most common treatment was twice‐daily 7% hypertonic saline and the most common nebuliser was ultrasonic. Most trials treated people with a bronchodilator to widen the airways before giving the hypertonic saline. Main results Hypertonic saline 3% to 7% versus placebo We are not sure whether hypertonic saline leads to an improvement in lung function in stable disease after four weeks. Two trials showed that there may be a small improvement in lung function (measured using the lung clearance index) with hypertonic saline compared to placebo in preschool children. We are also unsure whether hypertonic saline makes a difference to clearing mucus from the lungs, exacerbations or side effects compared to placebo. During exacerbations, we found that there may be little or no difference in lung function after hypertonic saline compared to placebo. The trials did not report any serious side effects and there were no deaths. One study compared 7% hypertonic saline with a lower concentration of hypertonic saline (3%); we are uncertain whether the higher concentration improved lung function. Hypertonic saline versus mucus mobilising treatments Three trials compared hypertonic saline with rhDNase and found that rhDNase may lead to an improvement in lung function compared to hypertonic saline after three months. We are unsure whether there is any difference in side effects. One trial compared hypertonic saline to amiloride and a further trial compared hypertonic saline to sodium‐2‐mercaptoethane sulphonate (Mistabron®), but neither of the trials gave information about the effect of the treatments on lung function. Similarly, a trial comparing hypertonic saline with mannitol did not give information about the effects on lung function, but they did report that there was no difference between treatments in clearing mucus from the lungs. People taking mannitol said it was more irritating than hypertonic saline. Two trials compared hypertonic saline with xylitol, but we are unsure if there is any difference in lung function and none of our other outcomes were measured. What are the limitations of this evidence? We are not confident in the evidence from these trials. There is a high risk that people knew which treatment they were receiving in half the trials as they could taste the difference between the solutions. Other factors that made us unsure of the results were the small numbers of people taking part in the trials combined with a wide variation in results; also, some trials limited participants to those who could tolerate hypertonic saline or to certain age groups. How up to date is this evidence? The evidence is current to 25 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Wark, P; McDonald, VM; Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD001506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "e15fd591-2a75-46d2-813f-b92179823476", "pmid": "", "title": "Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women", "imported": false, "abstract": "Abstract - Background Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions, particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia. However, its long‐term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teeth staining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation for preventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent. Objectives To assess the effects of intermittent oral iron supplementation, alone or in combination with other nutrients, on anaemia and its associated impairments among menstruating women, compared with no intervention, a placebo, or daily supplementation. Search methods In February 2018, we searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers. In March 2018, we also searched LILACS, IBECS and IMBIOMED. In addition, we examined reference lists, and contacted authors and known experts to identify additional studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs with either individual or cluster randomisation. Participants were menstruating women; that is, women beyond menarche and prior to menopause who were not pregnant or lactating and did not have a known condition that impeded the presence of menstrual periods. The intervention was the use of iron supplements intermittently (one, two or three times a week on non‐consecutive days) compared with placebo, no intervention, or the same supplements provided on a daily basis. Data collection and analysis Both review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy, assessed the risk of bias of the included studies, and rated the quality of the evidence using GRADE. Main results We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessing risk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one third of the included studies did not provide a funding source. Although quality across studies was variable, the results consistently showed that intermittent iron supplementation (alone or with any other vitamins and minerals) compared with no intervention or a placebo, reduced the risk of having anaemia (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.49 to 0.87; 11 studies, 3135 participants; low‐quality evidence), and improved the concentration of haemoglobin (mean difference (MD) 5.19 g/L, 95% CI 3.07 to 7.32; 15 studies, 2886 participants; moderate‐quality evidence), and ferritin (MD 7.46 μg/L, 95% CI 5.02 to 9.90; 7 studies, 1067 participants; low‐quality evidence). Intermittent regimens may also reduce the risk of having iron deficiency (RR 0.50, 95% CI 0.24 to 1.04; 3 studies, 624 participants; low‐quality evidence), but evidence was inconclusive regarding iron deficiency anaemia (RR 0.07, 95% CI 0.00 to 1.16; 1 study, 97 participants; very low‐quality evidence) and all‐cause morbidity (RR 1.12, 95% CI 0.82 to 1.52; 1 study, 119 participants; very low‐quality evidence). Women in the control group were less likely to have any adverse side effects than those receiving intermittent iron supplements (RR 1.98, 95% CI 0.31 to 12.72; 3 studies, 630 participants; moderate‐quality evidence). In comparison with daily supplementation, results showed that intermittent supplementation (alone or with any other vitamins and minerals) produced similar effects to daily supplementation (alone or with any other vitamins and minerals) on anaemia (RR 1.09, 95% CI 0.93 to 1.29; 8 studies, 1749 participants; moderate‐quality evidence). Intermittent supplementation may produce similar haemoglobin concentrations (MD 0.43 g/L, 95% CI −1.44 to 2.31; 10 studies, 2127 participants; low‐quality evidence) but lower ferritin concentrations on average (MD −6.07 μg/L, 95% CI −10.66 to −1.48; 4 studies, 988 participants; low‐quality evidence) compared to daily supplementation. Compared to daily regimens, intermittent regimens may also reduce the risk of having iron deficiency (RR 4.30, 95% CI 0.56 to 33.20; 1 study, 198 participants; very low‐quality evidence). Women receiving iron supplements intermittently were less likely to have any adverse side effects than those receiving iron supplements daily (RR 0.41, 95% CI 0.21 to 0.82; 6 studies, 1166 participants; moderate‐quality evidence). No studies reported on the effect of intermittent regimens versus daily regimens on iron deficiency anaemia and all‐cause morbidity. Information on disease outcomes, adherence, economic productivity, and work performance was scarce, and evidence about the effects of intermittent supplementation on these outcomes unclear. Overall, whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline did not seem to affect the findings. Furthermore, the response did not differ in areas where malaria was frequent, although very few trials were conducted in these settings. Authors' conclusions Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations with different anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittently is probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base ranged from very low to moderate quality, suggesting that we are uncertain about these effects. Plain language summary Iron supplements taken one, two or three times a week for preventing anaemia, and its consequences in menstruating women What is the issue? Across the globe, approximately one out of three non‐pregnant women of reproductive age are anaemic; i.e. have fewer red blood cells or less haemoglobin (a red substance that combines with oxygen and carries it around the body) in each red blood cell than normal. Although there are several causes of anaemia, it very often results from sustained iron deficiency. The standard practice to prevent or treat anaemia in women has been daily iron supplementation (sometimes combined with folic acid and other vitamins and minerals) for three months. However, it is frequently associated with side effects such as nausea or constipation. Intermittent supplementation (that is, the consumption of supplements one, two or three times a week on non‐consecutive days) has been proposed as an effective and safer alternative to daily supplementation. Why is this important? Women with anaemia may have less energy for physical work and become more prone to infections. Most women throughout the world enter pregnancy with anaemia, putting them at greater risk of having low birth‐weight babies and other complications during delivery. Some scientists believe that taking iron a few times a week – instead of every day – can help women with anaemia to feel better and improve their haemoglobin without giving them as many side effects. If women have fewer side effects, they may be more likely to take iron supplements more regularly and for longer periods. What evidence did we find? We reviewed the evidence in February 2018. We included 25 randomised controlled trials (a type of experiment in which participants are randomly assigned to one or more treatment groups) involving 10,996 women. We included studies examining the administration of intermittent iron supplements versus no intervention, a placebo (dummy pill) or the same supplements given on a daily basis. Most studies were implemented in school settings and were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one‐third of the included studies did not provide a funding source. The findings show that women receiving intermittent supplementation with iron alone, or in combination with folic acid or other nutrients, were less likely to be anaemic or iron deficient than those women who received no iron supplements or a placebo. They also had higher concentrations of haemoglobin and ferritin (a protein that carries iron) but reported more side effects. In addition, the findings indicate that intermittent supplementation was as effective as daily supplementation in reducing the prevalence of anaemia and increasing haemoglobin concentrations, with fewer side effects. It may have reduced the risk of having iron deficiency also, but it had no effect on raising ferritin concentrations more than the daily dose. We found scarce evidence on the effect of intermittent supplementation compared to placebo or daily supplementation on iron deficiency anaemia, all‐cause morbidity, disease outcomes, adherence, economic productivity, and work performance. What does this mean? Intermittent iron supplementation in menstruating women may be an effective intervention for reducing anaemia and improving haemoglobin concentrations compared to no treatment, placebo or daily supplementation. Intermittent supplementation may be associated with fewer side effects compared to daily supplementation. The findings were not affected by whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline (starting point for comparisons). The evidence base was of overall low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fernández-Gaxiola, AC; De-Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD009218.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "e165fd7c-7a67-48da-931b-326b781f13fc", "pmid": "", "title": "Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries", "imported": false, "abstract": "Abstract - Background Protein Energy Malnutrition is an important cause of child morbidity and mortality in middle‐ and low‐income countries. It has been suggested that excessive free radical activity may be responsible for the clinical manifestation of kwashiorkor. Antioxidants may be able to curb excessive free radical activity and prevent the development of kwashiorkor in susceptible children. Objectives To evaluate the benefits of supplementation of vitamin E, selenium, cysteine and riboflavin (alone or in combination) in preventing kwashiorkor. Search methods We conducted searches of CENTRAL 2009 ( The Cochrane Library 2009 Issue 2), MEDLINE 1966 to 2009, EMBASE 1980 to 2009, CINAHL 1982 to 2009, LILACS 1982 to 2009, Meta register of Controlled trials, Open Sigle, African Index Medicus. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating vitamin E, selenium, cysteine and riboflavin alone or in combination in healthy pre‐school children in middle‐ and low‐income countries. Data collection and analysis Two authors extracted and independently analysed data. Main results One cluster‐RCT including 2372 children met our inclusion criteria. Children were randomised, based on household, either to a supplement containing all four micronutrients or to placebo. No statistically significant difference in the incidence of kwashiorkor between the intervention and control groups could be demonstrated at 20 weeks (RR 1.70; 95% CI 0.98 to 2.42). Nor could any statistically significant difference in all‐cause mortality be demonstrated (RR 0.75; 95% CI 0.17 to 3.36). Authors' conclusions Based on the one available trial, we could draw no firm conclusion for the effectiveness of supplementary antioxidant micronutrients for the prevention of kwashiorkor in pre‐school children. Plain language summary Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries Undernutrition is one of the leading underlying causes of childhood morbidity and mortality in developing countries. Providing antioxidants that would help curb excess free radicals in the body may help prevent the development of kwashiorkor. We identified one cluster‐RCT that attempted to investigate this. Based on the published evidence reviewed, we could draw no firm conclusions of the benefits of supplementary antioxidants for the prevention of kwashiorkor in pre‐school children. There is a need for further research in this area to be certain if antioxidant supplementation can help prevent kwashiorkor in young children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Odigwe, CC; Smedslund, G; Ejemot‐Nwadiaro, RI; Anyanechi, CC; Krawinkel, MB", "articleTypes": [], "doi": "10.1002/14651858.CD008147.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "e17ee349-5eb1-49f3-a7fb-ecba6f5240e6", "pmid": "", "title": "Topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antiseptics, a possible treatment for CSOM, inhibit the micro‐organisms that may be responsible for the infection. Antiseptics can be used alone or in addition to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). However, the effects of topical antiseptics for CSOM remain unclear. This is an update of a review last published in 2020, with one new study added. It is one of a suite of seven Cochrane reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To assess the effects of topical antiseptics for people with CSOM. Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The date of the latest search was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antiseptic agent of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antiseptics (a) compared to placebo or no intervention, and (b) compared to another topical antiseptic (e.g. topical antiseptic A versus topical antiseptic B). Within each comparison, we separated studies into (a) those in which both groups of participants had received aural toileting in addition to the topical antiseptics, and those where neither group had received aural toileting, and (b) those in which both groups had received some other concomitant treatment (such as antibiotics) and those with no such concomitant treatment. Data collection and analysis We used standard Cochrane methodological procedures. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results We found one new study (32 participants) in this update, for a total of six included studies with 435 participants (over four studies), plus 222 ears that could not be accounted for in participant numbers (in two studies). Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics (boric acid versus acetic acid, and boric acid versus hydrogen peroxide). The two core comparisons of interest are reported below; other comparisons are described in the Results section of the review. No study measured health‐related quality of life or ear pain. 1. Topical antiseptic versus placebo or no treatment Three studies (297 participants plus 174 ears) compared topical antiseptics with no treatment. Evidence from one study (unclear number of participants, 174 ears) is very uncertain about the effect of a single application of povidone iodine in hydroxypropyl methyl‐cellulose (HPMC) on resolution of ear discharge at one week compared to HPMC alone; however, these results were only provided by ear (rather than by participant) and therefore could not be used quantitatively (very low‐certainty evidence). One study (254 children; cluster‐RCT) found that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge after four weeks compared with dry mopping alone, but the evidence is very uncertain (risk ratio (RR) 1.73, 95% confidence interval (CI) 1.21 to 2.47; 180 participants; very low‐certainty evidence). We made adjustments to the data to account for the intracluster correlation. This study narratively described no clear differences in suspected ototoxicity or hearing outcomes between study arms, but the evidence is very uncertain (very low‐certainty evidence). Evidence from one study (43 children; 58 ears) is very uncertain about the effect of antiseptics on serious complications. The study reported one case of mastoiditis and one of meningitis with focal encephalitis; however, it was unclear whether these were detected pre‐randomisation or during/after treatment. 2. Topical antiseptics versus no treatment/placebo, where both study arms received systemic antibiotics One study (32 participants) compared topical povidone iodine with placebo (saline) in conjunction with oral amoxicillin and dry mopping. Topical povidone iodine with oral amoxicillin and dry mopping may increase resolution of ear discharge at one to two weeks (RR 3.25, 95% CI 1.35 to 7.84; 32 participants; low‐certainty evidence). The study narratively reported no ototoxicity in the topical antiseptic arm; however, this was unclear for the placebo group, so we do not know if povidone iodine increases suspected ototoxicity (low‐certainty evidence). The study did not assess resolution of ear discharge after four weeks, hearing, or serious complications. Authors' conclusions We are very uncertain about the effect of topical antiseptics on improving resolution of ear discharge in people with CSOM given the low and very low certainty of the evidence, which was mostly due to risk of bias and imprecision. However, there is some evidence suggesting that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge compared with dry mopping alone, and that topical povidone iodine may be more effective than placebo (where both arms used systemic beta‐lactam antibiotics and dry mopping). There is insufficient evidence to draw any conclusions about harmful effects. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and risks of topical antiseptics for treating long‐term middle ear infection (chronic suppurative otitis media)? Key messages • Due to a lack of studies, we are very uncertain of the benefits and risks of topical antiseptics in the treatment of chronic suppurative otitis media (long‐term middle ear infection). • We need more information about possible harmful effects of topical antiseptics, as these were not well reported in the studies. What was studied in the review? Chronic suppurative otitis media (CSOM) is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (eardrum). The main symptoms are ear discharge and hearing loss. Topical antiseptics (antiseptics put directly into the ear as ear drops or as a powder) are sometimes used to treat CSOM. Topical antiseptics kill or stop the growth of the micro‐organisms that may be responsible for the infection. Topical antiseptics can be used on their own or added to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). Applying topical antiseptics can cause irritation of the skin within the outer ear, which may result in discomfort, pain, or itching. Some antiseptics (such as alcohol) can be toxic to the inner ear (ototoxicity), which means they may cause irreparable hearing loss (sensorineural), dizziness, or ringing in the ear (tinnitus). What is the aim of this review? The aim of this Cochrane review was to find out the benefits and risks of topical antiseptics compared to placebo (dummy medicine) or no treatment for CSOM. We also wanted to know whether one topical antiseptic was more effective than another. We collected and analysed all relevant studies to answer this question. This is an update of a review last published in 2020, with one new study added. What are the main results of the review? We included a total of six studies in the review. The total number of people in the studies was unclear, as two studies only reported how many ears were treated. However, there were 435 participants plus 222 ears (between 111 and 222 participants) that could not be accounted for in participant numbers. Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics. Different types of antiseptics were used, some in the form of ear drops and others as powders. No study measured health‐related quality of life or ear pain. Topical antiseptic versus placebo or no treatment (with a background treatment of ear cleaning) Three studies (297 participants plus 174 ears) compared topical antiseptics with placebo/no treatment. Based on evidence from one study (unclear number of participants, 174 ears), we do not know if a single application of antiseptic (povidone iodine plus hydroxypropyl methyl‐cellulose) resolves ear discharge at one to two weeks compared with no treatment. Another study (180 children) compared topical antiseptics (boric acid in alcohol ear drops) with no topical antiseptics. All children also had their ears cleaned daily using cotton wool sticks (dry mopping). It is unclear if antiseptics (boric acid) led to an increase in resolution of ear discharge at four weeks or at three to four months compared with no antiseptics. The same study (254 participants) also reported no clear difference between groups in hearing or suspected ototoxicity (hearing or balance problems that develop as a result of taking a medicine), but the evidence is very uncertain. A third study (43 children; 58 ears) found no clear evidence that antiseptics have any effect on serious complications, but it is not known if this was assessed before, during, or after treatment. Topical antiseptic (povidone iodine) versus no treatment/placebo, where both study groups received systemic antibiotics One study (32 participants) compared one antiseptic (povidone iodine) with placebo (saline). All participants also received oral antibiotics (amoxicillin) and ear cleaning. This study found that topical povidone iodine, when given in addition to antibiotics and ear cleaning, may increase the number of people with resolution of ear discharge at between one and two weeks, compared with placebo plus antibiotics and ear cleaning. We do not know if povidone iodine increases suspected ototoxicity. In their report, the study authors stated there was no ototoxicity in participants in the topical antiseptic group, but this was unclear for the placebo group. There was no information on resolution of ear discharge after four weeks, hearing, or serious complications. What are the limitations of the evidence? There is limited information on certain population groups or treatments. Also, the evidence in the review comes from studies that were not conducted recently. How up‐to‐date is the review? The evidence is current to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K; Chong, LY; Bhutta, MF; Daw, J; Veselinović, T; Morris, PS; Vijayasekaran, S; Schilder, AGM; Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013055.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "e185a8c1-d8c4-443a-ad0f-a4e4152f168c", "pmid": "", "title": "Topical anaesthetics for pain control during repair of dermal laceration", "imported": false, "abstract": "Abstract - Background Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine‐free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017. Objectives To assess whether benefits of non‐invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single‐component or multi‐component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine. Search methods For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta‐registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010. Selection criteria We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence. Main results The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self‐reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine‐phenylephrine (PP) was higher than the mean self‐reported VAS (0 to 100 mm) score for topical tetracaine‐epinephrine‐cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine‐free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self‐limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine‐based or cocaine‐free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Authors' conclusions We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously. Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non‐invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine‐based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well‐designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. Plain language summary Local anaesthesia (numbing medicine) that is directly applied to the skin can provide pain control for repair of skin lacerations Background : Pain control during suturing of torn skin is generally achieved by injecting medication into the skin (infiltration) to numb the area. This injection itself may cause pain, but topical anaesthetics are applied directly to the skin and are painless to administer. Cocaine was one of the first anaesthetics to be successfully applied topically. Concerns over adverse effects of cocaine, its potential misuse and the administrative burden of dispensing a controlled substance led to the development of cocaine‐free topical anaesthetics. Multiple cocaine‐free topical anaesthetics have been found to provide effective anaesthesia for repair of dermal lacerations. Study characteristics : The evidence is current to December 2016. We included in this review 25 randomized controlled trials involving 3278 participants. Studies included both adults and children. Fifteen of the included trials used self‐reporting of pain intensity by trial participants to determine the effectiveness of local anaesthetics. Key results : Study results suggest that directly applying local anaesthetics to the skin is an effective, non‐invasive way of providing pain control during suturing or stapling of skin lacerations. Study findings on the efficacy of individual topical anaesthetics were limited by study design, and data on the efficacy of each topical agent were obtained mostly from single trials. Researchers reported no serious side effects following the use of cocaine‐containing or cocaine‐free topical anaesthetics. The overall broadly comparable effectiveness of cocaine‐free topical anaesthetics for skin laceration repair brings into question the necessity to include cocaine as a component of local anaesthetic solutions. The small number of trials in each comparison group and the range of outcome measures assessed prevented pooling and quantitative analysis of data for all but the single outcome of pain intensity. Additional studies are necessary to directly compare the effectiveness of different formulations of topical anaesthetics. Our review was limited to pain control for repair of superficial lacerations, and our results might not be generalizable to deeper lacerations or more complex procedures performed on intact skin. Further research is needed to strengthen the evidence and to overcome the weakness of the included studies. Quality of the evidence : The overall quality of the evidence was low owing to limitations in study design, ways that studies were carried out (implementation), imprecision of results and high probability of selective data reporting. Most of the trials that compared infiltrated and topical anaesthetics were at high risk of bias, and this was likely to influence measured effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Tayeb, BO, Eidelman, A, Eidelman, CL, McNicol, ED, Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD005364.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.777Z" }, { "id": "e1941908-d9ed-4102-90b2-51feae046fd9", "pmid": "", "title": "Vigabatrin add‐on therapy for drug‐resistant focal epilepsy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane Review published in 2008 and updated in 2013. Epilepsy is a common neurological condition which affects up to 1% of the population. Approximately 30% of people with epilepsy do not respond to treatment with currently available drugs. The majority of these people have focal epilepsy. Vigabatrin is an antiepileptic drug licensed for use in drug‐resistant epilepsy. Objectives To assess the efficacy and tolerability of vigabatrin as an add‐on therapy for people with drug‐resistant focal epilepsy. Search methods For the latest update of this review, we searched the following databases on 1 November 2018: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid 1946 to 31 October 2018), ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL) are both included in the Cochrane Register of Studies (CRS Web). We checked reference lists of retrieved studies for additional reports of relevant studies and contacted Hoechst Marion Roussel (manufacturers of vigabatrin) in 2000. Selection criteria We included randomised, double‐blind, placebo‐controlled, fully published trials of vigabatrin in people of any age with drug‐resistant focal epilepsy. Data collection and analysis Two review authors assessed trials for inclusion and extracted data using the standard methodological procedures expected by Cochrane. Primary analysis was by intention‐to‐treat (ITT). We evaluated: 50% or greater reduction in seizure frequency, treatment withdrawal, adverse effects, dose‐response analysis, cognitive outcomes and quality of life. We presented results as risk ratios (RR) with 95% or 99% confidence intervals (CI). Main results We identified 11 trials that included 756 participants (age range: 10 to 64 years). The trials tested vigabatrin doses between 1 g/day and 6 g/day. All 11 trials displayed a risk of bias across at least three risk of bias domains. Predominantly, the risk of bias was associated with: allocation concealment (selection bias), blinding of outcome assessment (detection bias) and incomplete outcome data (attrition bias). Participants treated with vigabatrin may be two to three times more likely to obtain a 50% or greater reduction in seizure frequency compared with those treated with placebo (RR 2.60, 95% CI 1.87 to 3.63; 4 studies; low‐certainty evidence). Those treated with vigabatrin may also be three times more likely to have treatment withdrawn although we are uncertain (RR 2.86, 95% CI 1.25 to 6.55; 4 studies; very low‐certainty evidence). Compared to placebo, participants given vigabatrin were more likely to experience adverse effects: dizziness/light‐headedness (RR 1.74, 95% CI 1.05 to 2.87; 9 studies; low‐certainty evidence), fatigue (RR 1.65, 95% CI 1.08 to 2.51; 9 studies; low‐certainty evidence), drowsiness (RR 1.70, 95% CI 1.18 to 2.44; 8 studies) and depression (RR 3.28, 95% CI 1.30 to 8.27; 6 studies). Although the incidence rates were higher among participants receiving vigabatrin compared to those receiving placebo, the effect was not significant for the following adverse effects: ataxia (RR 2.76, 95% CI 0.96 to 7.94; 7 studies; very low‐certainty evidence), nausea (RR 3.57, 95% CI 0.63 to 20.30; 4 studies), abnormal vision (RR 1.64, 95% CI 0.67 to 4.02; 5 studies; very low‐certainty evidence), headache (RR 1.23, 95% CI 0.79 to 1.92; 9 studies), diplopia (RR 1.76, 99% CI 0.94 to 3.30) and nystagmus (RR 1.53, 99% CI 0.62 to 3.76; 2 studies; low‐certainty evidence). Vigabatrin had little to no effect on cognitive outcomes or quality of life. Authors' conclusions Vigabatrin may significantly reduce seizure frequency in people with drug‐resistant focal epilepsy. The results largely apply to adults and should not be extrapolated to children under 10 years old. Short‐term follow‐up of participants showed that some adverse effects were associated with its use. Analysis of longer‐term observational studies elsewhere, however, has demonstrated that vigabatrin use can lead to the development of visual field defects. Plain language summary Vigabatrin add‐on for drug‐resistant focal epilepsy Background Epilepsy is a common neurological disorder affecting approximately 1 in 100 people. Around 30% of these people cannot control their epilepsy with currently available antiepileptic medication and are said to have drug‐resistant epilepsy. Most often, drug‐resistant epilepsy is focal in nature, meaning that the seizures start in one specific area of the brain. Vigabatrin is an antiepileptic medication that can be used as an add‐on treatment for drug‐resistant focal epilepsy, meaning that it is taken in addition to other antiepileptic medications. Main results We found 11 clinical trials, involving 756 people, which investigated vigabatrin as an add‐on for people with drug‐resistant focal epilepsy. The people in the trials were aged between 10 to 64 years and were given doses of 1 g/day to 6 g/day vigabatrin. We found that people given vigabatrin may be two to three times more likely to experience a 50% or greater reduction in seizure frequency than people given placebo (a non‐active treatment). We also suggest that people given vigabatrin may be up to three times more likely to stop treatment than people given placebo. People given vigabatrin were more likely to experience side effects: dizziness/light‐headedness, fatigue, drowsiness and depression, than people given placebo. However, the evidence suggested that they should not be more likely to experience: ataxia (disorders that affect co‐ordination, balance and speech), feeling sick (nausea), abnormal vision, headache, seeing double (diplopia), or involuntary movement of the eyes (nystagmus) than people given placebo. Reliability of the evidence We judged that all studies had significant risk of bias. The studies did not explain how people were allocated to treatment groups and did not say whether investigators knew which treatment people were receiving. Alongside other reasons, this reduced our confidence (certainty) in the results. Overall, we are uncertain to very uncertain whether the results we have reported are reliable. The true effect of vigabatrin could be significantly different to that reported here. Conclusions Vigabatrin may significantly reduce seizure frequency for people with drug‐resistant focal epilepsy but we are uncertain. Most of the evidence was gathered from adults, therefore, the effects of vigabatrin could be different in children. All of the included trials were of short duration; therefore, we cannot report any long‐term effects of vigabatrin. Importantly, reviews of long‐term studies have reported that long‐term vigabatrin use can lead to the development of visual problems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bresnahan, R, Gianatsi, M, Maguire, MJ, Tudur Smith, C, Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.763Z" }, { "id": "e197e080-4d26-4522-b8dd-6efb0aebf88a", "pmid": "", "title": "Nutritional interventions for reducing morbidity and mortality in people with HIV", "imported": false, "abstract": "Abstract - Background Adequate nutrition is important for optimal immune and metabolic function. Dietary support may, therefore, improve clinical outcomes in HIV‐infected individuals by reducing the incidence of HIV‐associated complications and attenuating progression of HIV disease, improving quality of life and ultimately reducing disease‐related mortality. Objectives To evaluate the effectiveness of various macronutrient interventions, given orally, in reducing morbidity and mortality in adults and children living with HIV infection. Search methods We searched CENTRAL (up to August 2011), MEDLINE (1966 to August 2011), EMBASE (1988 to August 2011), LILACS (up to February 2012), and Gateway (March 2006‐February 2010). We also scanned reference lists of articles and contacted authors of relevant studies and other researchers. Selection criteria Randomised controlled trials evaluating the effectiveness of macronutrient interventions compared with no nutritional supplements or placebo in the management of adults and children infected with HIV. Data collection and analysis Three reviewers independently applied study selection criteria, assessed study quality, and extracted data. Effects were assessed using mean difference and 95% confidence intervals. Homogenous studies were combined wherever it was clinically meaningful to do so and a meta‐analysis using the random effects model was conducted. Main results Fourteen trials (including 1725 HIV positive adults and 271 HIV positive children), were included in this review. Neither supplementary food nor daily supplement of Spirulina significantly altered the risk of death compared with no supplement or placebo in malnourished, ART naive adult participants in the two studies which reported on this outcome. A nutritional supplement enhanced with protein did not significantly alter the risk of death compared to standard nutritional care in children with prolonged diarrhoea. Supplementation with macronutrient formulas given to provide protein and/or energy and fortified with micronutrients, in conjunction with nutrition counselling, significantly improved energy intake (3 trials; n=131; MD 393.57 kcal/day; 95% CI: 224.66 to 562.47;p<0.00001) and protein intake (2 trials; n=81; MD 23.5 g/day; 95% CI: 12.68, 34.01; p<0.00001) compared with no nutritional supplementation or nutrition counselling alone in adult participants with weight loss. In general supplementation with specific macronutrients such as amino acids, whey protein concentration or Spirulina did not significantly alter clinical, anthropometric or immunological outcomes compared with placebo in HIV‐infected adults and children. Authors' conclusions Given the current evidence base, which is limited to fourteen relatively small trials all evaluating different macronutrient supplements in different populations at different stages of HIV infection and with varying treatment status, no firm conclusions can be drawn about the effects of macronutrient supplementation on morbidity and mortality in people living with HIV. It is, however, promising to see more studies being conducted in low‐income countries, and particularly in children, where macronutrient supplementation both pre‐antiretroviral treatment and in conjunction with antiretroviral treatment might prove to be beneficial. Plain language summary Nutritional interventions for reducing morbidity and mortality in people with HIV Achieving and maintaining optimal nutrition is considered an important adjunct in the clinical care of patients infected with HIV, as good nutrition can improve an individual's immune function, limit disease‐specific complications, and improve quality of life and survival. We sought to determine whether macronutrient interventions, either given to provide protein and/or energy or test the effect of specific macronutrients (i.e. ch as amino acids, whey protein concentrate or Spirulina), given orally, influence morbidity and mortality in adults and children living with HIV infection. Our review, based on fourteen small trials, evaluating different macronutrient supplements, found limited evidence that balanced macronutrient formulas increase protein and energy intake. However, we found no evidence that such supplementation translates into reductions in disease progression or HIV‐related complications, such as opportunistic infections or death.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Grobler, L, Siegfried, N, Visser, ME, Mahlungulu, SSN, Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD004536.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.764Z" }, { "id": "e1a3fb38-97f2-41d8-a56b-06b5edfc8e1a", "pmid": "", "title": "Helminth therapy (worms) for induction of remission in inflammatory bowel disease", "imported": false, "abstract": "Abstract - Background Inflammatory bowel disease (IBD) is a chronic, globally‐occurring gastrointestinal disorder and a major cause of illness and disability. It is conventionally classified into Crohn’s disease (CD) and ulcerative colitis (UC). Helminths are parasitic worms with complex life cycles involving tissue‐ or lumen‐dwelling stages in their hosts, and causing long‐lasting or chronic infections that are frequently asymptomatic. Helminths modulate immune responses of their hosts, and many observational and experimental studies support the hypothesis that helminths suppress immune‐mediated chronic inflammation that occurs in asthma, allergy and IBD. Objectives The objective was to evaluate the efficacy and safety of helminth treatment for induction of remission in IBD. Search methods We searched the following databases from inception to 13 July 2013: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Inflammatory Bowel Disease Group Specialized Trials Register. We also searched four online trials registries, and abstracts from major meetings. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) where the intervention was any helminth species or combination of helminth species, administered in any dose and by any route and for any duration of exposure to people with active CD or UC, confirmed through any combination of clinical, endoscopic and histological criteria were eligible for inclusion. Data collection and analysis Two authors independently extracted data and assessed eligibility using a standardized data collection form. We used the RevMan software for analyses. The primary outcome was induction of remission as defined by the included studies. Secondary outcomes included clinical, histologic, or endoscopic improvement as defined by the authors, endoscopic mucosal healing, change in disease activity index score, change in quality of life score, hospital admissions, requirement for intravenous corticosteroids, surgery, study withdrawal and the incidence of adverse events. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. We calculated the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria. Main results Two RCTs (90 participants) were included. One trial assessed the efficacy and safety of Trichuris suis ( T. suis ) ova in patients with UC (n = 54). The other RCT was a phase one that assessed the safety and tolerability of T. suis ova in patients with CD (n = 36). The risk of bias in both studies was judged to be low. In the UC study, during the 12‐week study period, participants in the active arm received 2‐weekly aliquots of 2500 T. suis eggs, added to 0.8 mL of saline; those in the placebo arm received 0.8 mL saline only. There were sparse data available for the outcomes clinical remission and clinical improvement. Ten per cent (3/30) of patients in the T. suis arm entered remission compared to 4% (1/24) of patients in the placebo arm (RR 2.40, 95% CI 0.27 to 21.63). Forty‐three per cent (13/30) of patients in the T. suis group achieved clinical improvement compared to 17% (4/24) of placebo patients (RR 2.60, 95% CI 0.97 to 6.95). The mean ulcerative colitis disease activity index (UCDAI) score was lower in the T. suis group (6.1 +/‐ 0.61) compared to the placebo group (7.5 +/‐ 0.66) after 12 weeks of treatment (MD ‐1.40, 95% CI ‐1.75 to ‐1.05). There was only limited evidence relating to the proportion of patients who experienced an adverse event. Three per cent (1/30) of patients in the T. suis group experienced at least one adverse event compared to 12% (3/24) of placebo patients (RR 0.27, 95% CI 0.03 to 2.40). None of the adverse events reported in this study were judged to be related to the study treatment. GRADE analyses rated the overall quality of the evidence for the primary and secondary outcomes (i.e. clinical remission and improvement) as low due to serious imprecision. In the CD study, participants received a single treatment of T. suis ova at a dosage of 500 (n = 9), 2500 (n = 9), or 7500 (n = 9) embryonated eggs or matching placebo (n = 9). The CD study did not assess clinical remission or improvement as outcomes. There were sparse data on adverse events at two weeks. Thirty‐seven per cent (10/27) of patients in the T. suis group experienced at least one adverse event compared to 44% (4/9) of placebo patients (RR 0.83, 95% CI 0.35 to 2.01). Only one adverse event (dysgeusia) was judged to be possibly related to treatment in this study. Dysgeusia was reported in one patient in the T. suis group and in one patient in the placebo group. Authors' conclusions Currently, there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of helminths used to treat patients with IBD. The evidence for our primary efficacy outcomes in this review comes from one small study and is of low quality due to serious imprecision. We do not have enough evidence to determine whether helminths are safe when used in patients with UC and CD. Further RCTs are required to assess the efficacy and safety of helminth therapy in IBD. Plain language summary Helminth therapy (worms) for induction of remission in inflammatory bowel disease Inflammatory bowel disease (IBD) is comprised of two disorders: ulcerative colitis and Crohn’s disease. These disorders have both distinct and overlapping symptoms, but the underlying cause remains incompletely understood. Standard therapy for IBD includes sulfasalazine, 5‐ASA drugs, steroids, immunosuppressives such as azathioprine, 6‐mercaptopurine and methotrexate and biological agents such as infliximab. Helminths are worm‐like parasites, that inhabit larger organisms. Helminths cause changes in the immune systems of their hosts including an altered immunological response to antigens and this has implications for the treatment of inflammatory bowel disease which is thought to be caused by immune dysregulation. The purpose of this systematic review was to examine the effectiveness and safety of helminth therapy for inducing remission in people with IBD. This review identified two randomised controlled trials including a total of 90 participants. One study compared twice weekly treatment with helminths (an 0.8 mL solution containing 2500 live eggs of the helminth Trichuris suis ) for 12 weeks to a matching placebo (an 0.8 ml identical looking solution with no Trichuris suis eggs) in 54 patients with active ulcerative colitis. Few remissions occurred during the trial and helminth treatment had no detectable effect on these remissions. Ten per cent (3/30) of patients in the helminth group achieved remission compared to four per cent (1/24) of placebo patients. A higher proportion of patients in the helminth group (43% or 13/30) improved clinically compared to the placebo group (17% or 4/24). However, this difference could be a chance effect. We could not determine whether the proportion of patients who had a side effect was higher in either group. No observed side effects were thought to be related to treatment were reported in this study. The other study compared one treatment with various doses of helminths (a solution of 500, 2500 or 7500 Trichuris suis eggs) to a matching placebo in 36 patients with Crohn's disease. This study was designed to assess side effects and did not measure clinical remission or improvement. There amount of information available on side‐effects at two weeks was limited and the results were uncertain due to the small number of participants in the study. The only side effect that was judged to be possibly related to the study treatment was dysgeusia (a distortion of the sense of taste). This was reported in one patient in the helminth group and in one patient in the placebo group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and safety of helminths used to treat patients with IBD. The only information available relating to clinical improvement in patients with active ulcerative colitis comes from one small study. We do not know how safe helminths are when used in patients with ulcerative colitis and Crohn's disease. Further randomised controlled trials are required to assess the efficacy and safety of helminth therapy in IBD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Garg, SK; Croft, AM; Bager, P", "articleTypes": [], "doi": "10.1002/14651858.CD009400.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "e1b9adb8-0b86-474f-9969-bce9990419d3", "pmid": "", "title": "Topical medication instillation techniques for glaucoma", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Xu, L, Wang, X, Wu, M", "articleTypes": [], "doi": "10.1002/14651858.CD010520.pub2 AB - Abstract - Background Glaucoma is a leading cause of irreversible blindness worldwide and the second most common cause of blindness after cataracts. The primary treatment for glaucoma aims to lower intraocular pressure (IOP) with the use of topical medicines. Topical medication instillation techniques, such as eyelid closure and nasolacrimal occlusion when instilling drops, have been proposed as potential methods to increase ocular absorption and decrease systemic absorption of the drops. Objectives To investigate the effectiveness of topical medication instillation techniques compared with usual care or another method of instillation of topical medication in the management of glaucoma or ocular hypertension. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 8 December 2016), Embase Ovid (1947 to 8 December 2016), PubMed (1948 to 8 December 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 8 December 2016), International Pharmaceutical Abstracts Database (1970 to 8 December 2016), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ) (last searched 13 May 2013), ClinicalTrials.gov ( www.clinicaltrials.gov ) (searched 8 December 2016) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) (searched 8 December 2016). We did not use any date or language restrictions in the electronic searches for trials. Selection criteria We included randomized controlled trials which had compared any topical medication instillation technique with usual care or a different method of instillation of topical medication. Data collection and analysis Two review authors independently screened records from the searches for eligibility, assessed the risk of bias, and extracted data. We followed methods recommended by Cochrane. Main results We identified two trials (122 eyes of 61 participants) that had evaluated a topical medication instillation technique. We also identified two ongoing trials. Both included trials used a within‐person design and administered prostaglandin monotherapy for glaucoma or ocular hypertension. Because the trials evaluated different instillation techniques and assessed different outcomes, we performed no meta‐analysis. One trial, conducted in the US, evaluated the effect of eyelid closure (one and three minutes) versus no eyelid closure on lowering IOP. At one to two weeks' follow‐up, reduction in IOP was similar in the eyelid closure group and the no eyelid closure group (mean difference (MD) ‐0.33 mmHg, 95% confidence interval (CI) ‐0.8 to 1.5; 51 participants; moderate‐certainty evidence). The second trial, conducted in Italy, evaluated the effect of using an absorbent cloth to wipe excess fluid after instillation (fluid removal) versus not using an absorbent cloth (no removal) on reducing dermatologic adverse events. At four months' follow‐up, eyelashes were shorter among eyes in the fluid removal group compared with the no fluid removal group (MD ‐1.70 mm, 95% CI ‐3.46 to 0.06; 10 participants; low‐certainty evidence). Fewer eyes showed skin hyperpigmentation in the eyelid region towards the nose in the fluid removal group compared with the no removal group (RR 0.07, 95% CI 0.01 to 0.84; 10 participants; low‐certainty evidence); however, the difference was uncertain in the eyelid region towards the temples (RR 0.44, 95% CI 0.07 to 2.66; 10 participants; low‐certainty evidence). The effect hypertrichosis (excessive hair growth) was uncertain between groups (RR 1.00, 95% CI 0.17 to 5.98; 10 participants; low‐certainty evidence). Neither trial reported other outcomes specified for this review, including the proportion of participants with IOP less than 21 mmHg; participant‐reported outcomes related to the ease, convenience, and comfort of instillation techniques; physiologic measurements of systemic absorption; escalation of therapy; mean change in visual fields; optic nerve progression; mean change in best‐corrected visual acuity; proportion in whom glaucoma developed; quality of life outcomes; or cost‐effectiveness outcomes. Neither trial reported data at follow‐up times of more than four months. Authors' conclusions Evidence to evaluate the effectiveness of topical medication instillation techniques for treatment of glaucoma is lacking. It is unclear what, if any, effects instillation techniques have on topical medical therapy for glaucoma. Plain language summary Topical medicine instillation techniques for glaucoma What is the aim of this review? 
 The aim of this Cochrane Review was to find out if the way that people with glaucoma put eye drops in makes a difference in how well the eye drops work. Cochrane researchers collected and analyzed all relevant studies to answer this question and found two studies. Key messages 
 It is unclear if the way that people with glaucoma put their eye drops in makes a difference in how well the drops work. What did this review study? 
 Glaucoma is a leading cause of blindness worldwide. In eyes with glaucoma, the ability to see may be lost because of damage to the optic nerve. The optic nerve is the part of the eye that sends visual information from the eye to the brain. Sometimes such damage occurs when there is too much pressure in the eye (called intraocular pressure or IOP). Sometimes eyes may have too much pressure without damage to the optic nerve (called ocular hypertension). The main goal of glaucoma and ocular hypertension treatment is to lower IOP. Topical medicines, such as eye drops, are most often used as the first treatment. Encouraging specific ways of applying the drops, such as closing your eyes or nasolacrimal occlusion (closing the eye and pressing a finger on the inside corner, by the nose) aims to increase how much medicine is absorbed into the eye and reduce how much medicine is absorbed into the body. What are the main results of the review? 
 We found two studies that compared different ways of putting in eye drops. Both studies used prostaglandin alone for glaucoma or ocular hypertension. One study, in the US, evaluated the effect of closing the eyes for one and three minutes after putting in eye drops on lowering IOP. The second study, in Italy, looked at whether wiping off the excess fluid, after putting in the eye drops, led to fewer changes in the skin surrounding the eye. After one to two weeks in the US study, closing the eyelid for one to three minutes after putting in the eye drops found no difference on IOP compared with not closing the eyelid for a specified amount of time. After four months in the Italian study, eyelashes were shorter when participants had wiped their eyes to remove excess fluid when compared with participants who did not wipe their eyes. We found two ongoing studies that do not have results yet. Based on only two studies and uncertain results, it is unclear if different ways of putting in eye drops have any effect on people with glaucoma. How up‐to‐date is this review? 
 Cochrane researchers searched for studies that had been published up to 8 December 2016.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.771Z" }, { "id": "e1bac2e5-6766-4a8e-a846-3d0071e69a82", "pmid": "", "title": "Enteral tube feeding for people with severe dementia", "imported": false, "abstract": "Abstract - Background The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing. Objectives To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021. Selection criteria We included randomised controlled trials (RCTs), or controlled non‐randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post‐pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers. Data collection and analysis Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non‐randomised Studies of Interventions' (ROBINS‐I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre‐agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta‐analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study. Main results We found no eligible RCTs. We included fourteen controlled, non‐randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low‐certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate‐certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very‐low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low‐certainty evidence. Five studies reported a variety of harm‐related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia. Authors' conclusions We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here. Plain language summary Enteral tube feeding for people with severe dementia What are the advantages and problems of tube feeding people with severe dementia? Key messages Tube feeding may not increase the length of time people with severe dementia live compared to no tube feeding. The risk of developing a pressure sore is probably higher with a feeding tube than with no tube. No studies looked at quality of life.We need more and better studies to investigate tube feeding people with severe dementia. Future studies should focus on a broader range of outcomes including, pain, quality of life and the impact on carers What is tube feeding? Somebody who can’t eat or drink through their mouth may be given liquid food through a tube into their stomach. This is called enteral tube feeding. The tube passes through their nose into their stomach (a nasogastric tube), or is inserted into the stomach through a small cut in their belly (percutaneous endoscopic gastrostomy or PEG). Why is this important for people with dementia? People with dementia often have difficulties eating and drinking. During the early stages of dementia, they may forget to eat, chew food without swallowing, or be confused at mealtimes. Some people experience changes in the taste and smell of food. In the later stages of dementia, people often have difficulties swallowing. It can be difficult to ensure they receive appropriate food and fluids. People with severe dementia need full‐time care, and it is often their families who care for them. It is difficult to decide whether or not to tube‐feed someone with dementia because the feeding tube can be uncomfortable or even painful, and may cause other unwanted effects such as pneumonia, worsen bowel or bladder control, as well as bleeding, swelling and infection. People with severe dementia may be confused or distressed by the tube and may try to remove it. What did we want to find out? We wanted to know whether tube feeding helps people with severe dementia who have problems with eating and swallowing. We were interested in the effect of tube feeding on: how long people lived; their quality of life (well‐being); and the development or healing of pressure sores (also known as bed sores). What did we do? 
We searched for studies that investigated whether: PEG compared to no tube; a nasogastric tube compared to no tube; orPEG, nasogastric and other types of tube feeding compared to no tube was effective and whether tube feeding caused any unwanted effects in adults of any age with severe dementia and poor intake of food and drink. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 14 studies that included 49,714 participants. Of these, 6203 were tube‐fed and 43,511 were not. Participants with no feeding tube were given standard care or standard care with extra treatments to encourage eating and drinking. Main results In people with severe dementia, compared to no tube feeding: PEG may make no difference to how long people live (4 studies, 36,816 people), and leads to a small increase in the chance of developing pressure sores (1 study, 4421 people). we don’t know if nasogastric tube feeding increases the length of time people live or increases their chance of developing pressure sores, because none of our included studies gave information about these points. Studies of people with either PEG or nasogastric tubes showed tube feeding may increase the length of time people live (4 studies, 1696 people), and may slightly increase the chance of developing pressure sores (3 studies, 351 people). None of our included studies reported quality of life. What are the limitations of the evidence? We have moderate confidence in our finding that pressure ulcers were more common in people who were fed with a PEG tube. However, we have little to very little confidence for our other findings. Three main factors reduced our confidence in the evidence. Firstly, people in the studies were not randomly placed into different treatment groups. This means that differences between the groups could be due to differences between people rather than between the treatments. However, due to ethical considerations it would be very difficult to do this in future studies. Secondly, results were very inconsistent across the different studies. Finally, some studies were very small. The results of further research could differ from the results of this review. How up to date is this evidence? The evidence is up to date to 14 April 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Davies, N; Barrado-Martín, Y; Vickerstaff, V; Rait, G; Fukui, A; Candy, B; Smith, CH; Manthorpe, J; Moore, KJ; Sampson, EL", "articleTypes": [], "doi": "10.1002/14651858.CD013503.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "e1e36912-419a-451b-90f4-1f463043df5a", "pmid": "", "title": "Homeopathic medicinal products for preventing and treating acute respiratory tract infections in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common and may lead to complications. Most children experience between three and six ARTIs annually. Although most infections are self‐limiting, symptoms can be distressing. Many treatments are used to control symptoms and shorten illness duration. Most treatments have minimal benefit and may lead to adverse events. Oral homeopathic medicinal products could play a role in childhood ARTI management if evidence for their effectiveness is established. This is an update of a review first published in 2018. Objectives To assess the effectiveness and safety of oral homeopathic medicinal products compared with placebo or conventional therapy to prevent and treat ARTIs in children. Search methods We searched CENTRAL (2022, Issue 3), including the Cochrane Acute Respiratory Infections Specialised Register, MEDLINE (1946 to 16 March 2022), Embase (2010 to 16 March 2022), CINAHL (1981 to 16 March 2022), AMED (1985 to 16 March 2022), CAMbase (searched 16 March 2022), and British Homeopathic Library (searched 26 June 2013 ‐ no longer operating). We also searched the WHO ICTRP and ClinicalTrials.gov (16 March 2022), checked references, and contacted study authors to identify additional studies. Selection criteria We included double‐blind randomised controlled trials (RCTs) or double‐blind cluster‐RCTs comparing oral homeopathy medicinal products with identical placebo or self‐selected conventional treatments to prevent or treat ARTIs in children aged 0 to 16 years. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results In this 2022 update, we identified three new RCTs involving 251 children, for a total of 11 included RCTs with 1813 children receiving oral homeopathic medicinal products or a control treatment (placebo or conventional treatment) for ARTIs. All studies focused on upper respiratory tract infections (URTIs), with only one study including some lower respiratory tract infections (LRTIs). Six treatment studies examined the effect on URTI recovery, and five studies investigated the effect on preventing URTIs after one to four months of treatment. Two treatment and three prevention studies involved homeopaths individualising treatment. The other studies used predetermined, non‐individualised treatments. All studies involved highly diluted homeopathic medicinal products, with dilutions ranging from 1 x 10 ‐4 to 1 x 10 ‐200 . We identified several limitations to the included studies, in particular methodological inconsistencies and high attrition rates, failure to conduct intention‐to‐treat analysis, selective reporting, and apparent protocol deviations. We assessed three studies as at high risk of bias in at least one domain, and many studies had additional domains with unclear risk of bias. Four studies received funding from homeopathy manufacturers; one study support from a non‐government organisation; two studies government support; one study was co‐sponsored by a university; and three studies did not report funding support. Methodological inconsistencies and significant clinical and statistical heterogeneity precluded robust quantitative meta‐analysis. Only four outcomes were common to more than one study and could be combined for analysis. Odds ratios (OR) were generally small with wide confidence intervals (CI), and the contributing studies found conflicting effects, so there was little certainty that the efficacy of the intervention could be ascertained. All studies assessed as at low risk of bias showed no benefit from oral homeopathic medicinal products, whilst trials at unclear or high risk of bias reported beneficial effects. For the comparison of individualised homeopathy versus placebo or usual care for the prevention of ARTIs, two trials reported on disease severity; due to heterogeneity the data were not combined, but neither study demonstrated a clinically significant difference. We combined data from two trials for the outcome need for antibiotics (OR 0.79, 95% CI 0.35 to 1.76; low‐certainty evidence). For the comparison of non‐individualised homeopathy versus placebo or usual care for the prevention of ARTIs, only the outcome recurrence of ARTI was reported by more than one trial; data from three studies were combined for this outcome (OR 0.60, 95% CI 0.21 to 1.72; low‐certainty evidence). For the comparison of both individualised and non‐individualised homeopathy versus placebo or usual care for the treatment of ARTIs, two studies provided data on short‐term cure (OR 1.31, 95% CI 0.09 to 19.54) and long‐term cure (OR 1.01, 95% CI 0.10 to 9.96; very low‐certainty evidence). The studies demonstrated an opposite direction of effect for both outcomes. Six studies reported on disease severity but were not combined as they used different scoring systems and scales. Three studies reported adverse events (OR 0.79, 95% CI 0.16 to 4.03; low‐certainty evidence). Authors' conclusions Pooling of five prevention and six treatment studies did not show any consistent benefit of homeopathic medicinal products compared to placebo on ARTI recurrence or cure rates in children. We assessed the certainty of the evidence as low to very low for the majority of outcomes. We found no evidence to support the efficacy of homeopathic medicinal products for ARTIs in children. Adverse events were poorly reported, and we could not draw conclusions regarding safety. Plain language summary What are the benefits and risks of oral homeopathic medicines in preventing and treating acute respiratory tract infections in children? Key messages Homeopathy is a type of complementary and alternative medicine. It is based on two main ideas: that substances that may cause illness or symptoms in a healthy person can, in very small doses, treat those symptoms in a person who is unwell; and that molecules in highly diluted substances retain a memory of the original substance. Due to a lack of solid evidence, the benefits and risks of oral homeopathic medicines for preventing and treating acute respiratory tract infections (ARTIs) in children are unclear. Studies of lower quality in design and reporting often suggest a possible benefit for oral homeopathic medicines, but studies of higher quality do not find benefit. What are respiratory tract infections? Respiratory infections are commonly caused by viruses, especially colds and influenza, though some lung and ear infections are caused by bacteria. It may be difficult to tell these infections apart, and sometimes they occur together. Most such infections improve without treatment, but sometimes symptoms persist after the initial infection has gone. Treatment is therefore aimed at relieving symptoms. Why is this important in children? Children have on average three to six respiratory tract infections each year. Although most are mild and treatable, they are sometimes acute (serious, swift, or sudden onset) respiratory tract infections that may require hospital treatment, but very rarely result in death. How are ARTIs treated? Antibiotic medicines taken orally (by mouth/swallowed, usually in the form of a tablet, pill, lozenge, or liquid) are often prescribed for ARTIs, even though they are ineffective against viruses. Homeopathic medicines may treat ARTIs with few side effects, but their effectiveness and safety has not been well researched. What did we want to find out? We wanted to know whether homeopathic medicines help children with ARTIs. We were interested in the effect of homeopathic medicines compared to placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) or to usual care therapies for ARTIs. We were also interested in the effect of homeopathic medicines on improvement in the severity or symptoms of infection, the need for antibiotics, duration of illness (that would affect days off school or days off work for parents), symptom reappearance, and any medicine adverse effects. What did we do? We searched for randomised controlled trials (studies where people are randomly assigned to one of two or more treatment groups) that investigated whether oral homeopathic medicines, compared to placebo or usual care ARTI therapies, were effective in the prevention or treatment of ARTIs in children aged up to 16 years. We compared and summarised the results of the studies, and rated our confidence in the evidence based on factors such as study methods and number of participants. What did we find? We found 11 studies involving 1813 children (5 studies for prevention and 6 studies for treatment of ARTIs). All studies investigated upper respiratory tract (from the nose to the windpipe (trachea)) infections, but one study combined reporting of upper and lower respiratory tract (from the windpipe to the lungs and pleura (membranes covering the lungs)) infections, so the numbers of children with upper or lower ARTIs is unknown. Main results In the treatment or prevention of ARTIs in children, homeopathic medicines showed little or no beneficial effects, whether individualised by a trained homeopath or a standard commercially available homeopathic therapy (11 studies, 1813 children). Where results could be combined, there was little or no difference between groups for short‐term cure (2 studies, 155 participants) or long‐term cure (2 studies, 155 participants), but the evidence is very uncertain. There may be little or no difference between groups for prevention of ARTI (3 studies, 735 participants). There was no important difference between homeopathy and placebo groups for parents' time off work, antibiotic use, or adverse events. We are unsure about the safety of homeopathic medicines because data on adverse events were poorly reported. Overall, the findings of this review do not support the use of homeopathic medicinal products for ARTIs in children. What are the limitations of the evidence? We have little confidence in the evidence because the studies involved only small numbers of children, used different types of homeopathic medicines for various ARTIs, contained numerous biases, and failed to report information about important outcomes. Further research could provide results that differ from the results of this review. How up‐to‐date is this evidence? The evidence is current to 16 March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hawke, K, King, D, van Driel, ML, McGuire, TM", "articleTypes": [], "doi": "10.1002/14651858.CD005974.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.747Z" }, { "id": "e1f11439-3593-43af-abe0-1512456bf3fb", "pmid": "", "title": "Topiramate for essential tremor", "imported": false, "abstract": "Abstract - Background Essential tremor (ET) is one of the most common movement disorders. The management is primarily based on pharmacological agents and in clinical practice propranolol and primidone are considered the first‐line therapy. However, these treatments can be ineffective in 25% to 55% of people and are frequently associated with serious adverse events (AEs). For these reasons, it is worthwhile evaluating other treatments for ET. Topiramate has been suggested as a potentially useful agent for the treatment of ET but there is uncertainty about its efficacy and safety. Objectives To assess the efficacy and safety of topiramate in the treatment of ET. Search methods We carried out a systematic search without language restrictions to identify all relevant trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to January 2017), Embase (January 1988 to January 2017), National Institute for Health and Care Excellence (1999 to January 2017), ClinicalTrials.gov (1997 to January 2017) and World Health Organization International Clinical Trials Registry Platform (ICTRP; 2004 to January 2017). We searched BIOSIS Citation Index (2000 to January 2017) for conference proceedings. We handsearched grey literature and the reference lists of identified studies and reviews. Selection criteria We included all randomised controlled trials (RCTs) of topiramate versus placebo/open control or any other treatments. We included studies in which the diagnosis of ET was made according to accepted and validated diagnostic criteria. We excluded studies conducted in people presenting with secondary forms of tremor or reporting only neurophysiological parameters to assess outcomes. Data collection and analysis Two review authors independently collected and extracted data using a data collection form. We assessed the risk of bias and the quality of evidence. We used a fixed‐effect meta‐analysis for data synthesis. Main results This review included three trials comparing topiramate to placebo (309 participants). They were all at high overall risk of bias. The quality of evidence ranged from very low to low. Compared to placebo, participants treated with topiramate showed a significant improvement in functional disability and an increased risk of withdrawal (risk ratio (RR) 1.78, 95% confidence interval (CI) 1.23 to 2.60). There were more AEs for topiramate‐treated participants, particularly paraesthesia, weight loss, appetite decrease and memory difficulty. Authors' conclusions This systematic review highlighted the presence of limited data and very low to low quality evidence to support the apparent efficacy and the occurrence of treatment‐limiting AEs in people with ET treated with topiramate. Further research to assess topiramate efficacy and safety on ET is needed. Plain language summary Use of topiramate for the treatment of essential tremor Review question The authors of this review tried to assess the effectiveness and safety of topiramate in people with essential tremor. Background Essential tremor is a type of uncontrollable shaking or trembling of parts of the body. Although it is not harmful in terms of its effect on life expectancy, it generally gets worse and may be disabling. Treatment is usually with medicines (called propranolol and primidone), which may not work in a quarter to a half of people with essential tremor. Some specialists have suggested that another medicine, topiramate, could be useful for treating the condition. Study characteristics We searched medical databases for studies of topiramate compared with placebo (a pretend tablet) or any other medicine in adults with essential tremor. We found three studies comparing topiramate versus placebo, involving 309 participants with moderate to severe essential tremor. Key results The effect of topiramate on daily activities, risk of stopping treatment and side effects was uncertain because the quality of evidence was very low to low. Quality of evidence We only found a few studies that had problems with their methods so we could not make firm conclusions about how well topiramate works and if it has side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Bruno, E, Nicoletti, A, Quattrocchi, G, Allegra, R, Filippini, G, Colosimo, C, Zappia, M", "articleTypes": [], "doi": "10.1002/14651858.CD009683.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.094Z" }, { "id": "e200a7bb-7d44-4900-9828-e714e39b12fb", "pmid": "", "title": "Pharmacological interventions for people with borderline personality disorder", "imported": false, "abstract": "Abstract - Background Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off‐label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods. Objectives To assess the effects of pharmacological treatment for people with BPD. Search methods For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. Selection criteria Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events. Data collection and analysis At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. Main results We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty‐nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD ‐0.18, 95% confidence interval (CI) ‐0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD −0.27, 95% CI −0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD −0.07, 95% CI −0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self‐harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale‐Modified‐Self‐Injury item (0‐5 points), 95% CI −10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide‐related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI −0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD −0.26, 95% CI −1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD −0.36, 95% CI −1.96 to 1.25; 2 trials, 44 participants). Very low‐certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD −0.16, 95% CI −0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD −0.25, 95% CI ‐0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD −0.01, 95% CI ‐0.28 to 0.26; 2 trials, 214 participants). Low‐certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD −0.21, 95% CI −0.34 to ‐0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD −0.58, 95% CI ‐1.14 to ‐0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD −0.07, 95% CI ‐0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low‐certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non‐standardised. The available evidence on non‐serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified. Authors' conclusions This review included 18 more trials than the 2010 version, so larger meta‐analyses with more statistical power were feasible. We found mostly very low‐certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma‐related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples. Plain language summary What are the benefits and risks of medication for people with borderline personality disorder? Key messages This review is an update of a previous review on the same topic published in 2010. Although this review includes an additional 18 studies, the conclusions remain the same: there are probably no benefits and risks of medications for borderline personality disorder (BDP), but the evidence is unclear. Better and larger studies comparing the effects of medication with placebo are needed. Such studies should focus on men, adolescents and those with additional psychiatric diagnoses. What is BPD? BPD affects how a person interacts with others and understands one's self. Although its exact causes are unclear, it is thought to result from a combination of genetic and environmental factors (e.g. stressful or traumatic life events when growing up). Approximately 2% of adults and 3% of adolescents are affected. The symptoms of BPD can be grouped into four categories. Instability in mood: People with BPD may experience intense feelings that change rapidly and are difficult to control. They may also feel empty and abandoned much of the time. Cognitive distortions (disturbed patterns of thinking): People with BPD often have upsetting thoughts (e.g. they may think that they are a terrible person). They can have brief episodes of strange experiences (e.g. paranoid ideations or stress‐induced dissociative experiences (i.e. feeling detached from the world around them). Impulsive behaviour: People with BPD may act impulsively and do things that could harm themselves (e.g. when sad and depressed, they may self‐harm or have suicidal feelings). They might also engage in reckless behaviour (e.g. drug misuse). Intense but unstable relationships: People with BPD may find it difficult to keep stable relationships (e.g. they may feel very worried about being abandoned and might constantly text or call, or make threats to harm or kill themselves if the person leaves them). A person only needs to experience five out of nine criteria across these categories to be given a diagnosis of BPD. How is BPD treated? No medication has been approved for the treatment of BPD. Nonetheless, a large proportion of people with BPD are given medications for sustained periods of time to alleviate their symptoms. The type of medication given is chosen based on its known effects on other disorders with similar symptoms. Review question We wanted to find out whether medications to treat BPD work better or worse than placebo; whether one medication works better than another; or whether one combination of medications work better than another combination of medications. We wanted to look at how well medications worked on BPD severity, self‐harm, suicide‐related outcomes, and functioning (how well a person performs in everyday life). We also wanted to find out if medications are associated with any unwanted side effects. What did we do? We searched for studies that compared the effects of different medications with placebo, another medication, or a combination of medications, in people diagnosed with BPD. We compared and summarised the results and rated our confidence in the evidence based on factors such as sample size and methods used. Below, we present the findings from our key comparison: medication versus placebo. What did we find? We found 46 studies that involved 2769 people with BPD. The smallest study had 13 participants and the largest 451 participants. There were four studies with more than 100 participants. Except for one study that included men only, all studies included women. The average age of the participants ranged from 16 years to 39 years. Most studies were conducted in outpatient settings (31 studies) in Europe (20 studies) and lasted between four and 52 weeks. Pharmaceutical companies fully or partially funded 16 studies. The studies looked at the effects of 27 different medications, mostly classified as: 1) antipsychotics (drugs to treat psychosis where a person’s thoughts and mood are so impaired that the person has lost contact with reality); 2) antidepressants (drugs to treat depression); or 3) mood stabilisers (drugs to control and even out mood swings, reducing both high moods (mania) and low moods (depression)). Compared with placebo, medications seem to make little to no difference to BPD severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. They may make little to no difference as to whether a person continues in a study or drops out. Compared to placebo, antipsychotics and mood stabilisers may make little to no difference to the occurrence of unwanted or harmful effects. No study reported on the side effects of antidepressants. What are the limitations of the evidence? Our confidence in the evidence varied between very low and low. The results of future research could differ from the results of this review. Four main factors reduced our confidence in the evidence. First, not all of the studies provided data about everything that we were interested in. Second, the results were very inconsistent across the different studies. Third, there were not enough studies to be certain about the results of our outcomes. Fourth, many studies did not clearly report how they were conducted. How up‐to‐date is this evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Stoffers-Winterling, JM; Storebø, OJ; Pereira Ribeiro, J; Kongerslev, MT; Völlm, BA; Mattivi, JT; Faltinsen, E; Todorovac, A; Jørgensen, MS; Callesen, HE; Sales, CP; Schaug, JP; Simonsen, E; Lieb, K", "articleTypes": [], "doi": "10.1002/14651858.CD012956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "e211e7b6-1ec3-4b3e-aeb0-681baa903453", "pmid": "", "title": "Ibuprofen for acute postoperative pain in children", "imported": false, "abstract": "Abstract - Background Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non‐steroidal anti‐inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period. Objectives 1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled). Search methods We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023. Selection criteria We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules. Data collection and analysis We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence. Main results We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child‐reported pain intensity less than two hours postintervention compared to placebo (SMD −1.12, 95% CI −1.39 to −0.86; 3 studies, 259 children; moderate‐certainty evidence). Ibuprofen may reduce child‐reported pain intensity, two hours to less than 24 hours postintervention (SMD −1.01, 95% CI −1.24 to −0.78; 5 studies, 345 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low‐certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child‐reported pain intensity less than two hours postintervention compared to paracetamol (SMD −0.42, 95% CI −0.82 to −0.02; 2 studies, 100 children; moderate‐certainty evidence). Ibuprofen may slightly reduce child‐reported pain intensity two hours to 24 hours postintervention (SMD −0.21, 95% CI −0.40 to −0.02; 6 studies, 422 children; low‐certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low‐certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) −0.25, 95% CI −0.40 to −0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate‐certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD −0.29, 95% CI −0.53 to −0.04; NNTB 4; 1 study, 59 children; low‐certainty evidence). Authors' conclusions Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs. Plain language summary What are the benefits and harms of ibuprofen for managing pain after an operation in children? Key messages • Ibuprofen probably reduces pain intensity just after an operation up to two hours compared to a placebo (dummy) and compared to paracetamol. The evidence compared to other medicines and in the longer term is unclear or lacking. • Overall, we are uncertain about unwanted effects of ibuprofen, especially serious unwanted effects, since the studies in the review rarely measured them. • Future studies should examine ibuprofen compared to commonly used medications and measure benefits and unwanted effects for both short‐ and long‐term use. Why is pain management important? It is common for children to experience pain after an operation (postoperative pain). Pain causes suffering and agitation, and it can delay recovery. One way to manage pain in children is by using different medicines, for example, ibuprofen. Ibuprofen is a type of medicine called a 'non‐steroidal anti‐inflammatory drug' (NSAID) that can reduce inflammation and pain. What did we want to find out? We wanted to find out if ibuprofen is an effective pain treatment and whether it causes unwanted effects compared to other pain treatments. Also, the most effective way to deliver ibuprofen to children. What did we do? We searched for studies that compared ibuprofen to other treatment options for postoperative pain as well as for studies that looked at different ways to deliver ibuprofen to children. We summarised the results and rated our confidence in the evidence. What did we find? We found 43 studies with 4265 children with postoperative pain. We used data from 3935 children in this review. The largest study included 741 children and the smallest, 23 children. The studies were conducted in many countries around the world; most commonly the USA (12 studies). Children's ages ranged from 2.2 months up to 17 years. Studies used ibuprofen to manage postoperative pain in 10 different types of surgery: mostly dental procedures (21 studies); and ear, nose and throat procedures (11 studies). Main results Compared to placebo (a dummy medicine), ibuprofen probably reduces pain intensity less than two hours after the operation and may reduce pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol , ibuprofen probably reduces pain intensity less than two hours after the operation and probably reduces pain intensity up to 24 hours. We are unsure about differences for any unwanted effects. No studies reported serious unwanted effects, such as lasting disability or hospitalisation. Compared to paracetamol, ibuprofen probably makes little difference to the chances of bleeding. Compared to morphine , ibuprofen probably leads to a reduction in any reported unwanted effects. Compared to ketorolac , ibuprofen may lead to a reduction in overall harms. No studies reported pain intensity or serious unwanted effects, such as lasting disability or hospitalisation for either morphine or ketorolac. We did not find any studies that compared different routes of administration of ibuprofen. What are the limitations of the evidence? We are uncertain about the overall evidence of ibuprofen use in postoperative pain in children, primarily because there were not enough large studies to be certain about any differences in ibuprofen when compared to other alternatives. In addition, only a few of the studies provided data about important benefits and unwanted effects for children experiencing pain following surgery, especially in the longer term. How up to date is this evidence? The evidence is up‐to‐date to August 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Pessano, S, Gloeck, NR, Tancredi, L, Ringsten, M, Hohlfeld, A, Ebrahim, S, Albertella, M, Kredo, T, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD015432.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.129Z" }, { "id": "e2206d7f-6226-4bb5-a285-963e8932cd82", "pmid": "", "title": "Short‐course oral steroids alone for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of oral corticosteroids compared with placebo/no intervention or other pharmacological interventions (intranasal corticosteroids, antibiotics, antifungals) for chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids with placebo or no treatment or compared with other pharmacological interventions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included eight RCTs (474 randomised participants), which compared oral corticosteroids with placebo or no intervention. All trials only recruited adults with chronic rhinosinusitis with nasal polyps. All trials reported outcomes at two to three weeks, at the end of the short‐course oral steroid treatment period. Three trials additionally reported outcomes at three to six months. Two of these studies prescribed intranasal steroids to patients in both arms of the trial at the end of the oral steroid treatment period. Oral steroids versus placebo or no intervention Disease‐specific health‐related quality of life was reported by one study. This study reported improved quality of life after treatment (two to three weeks) in the group receiving oral steroids compared with the group who received placebo (standardised mean difference (SMD) ‐1.24, 95% confidence interval (CI) ‐1.92 to ‐0.56, 40 participants, modified RSOM‐31), which corresponds to a large effect size. We assessed the evidence to be low quality (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). Disease severity as measured by patient‐reported symptom scores was reported by two studies, which allowed the four key symptoms used to define chronic rhinosinusitis (nasal blockage, nasal discharge, facial pressure, hyposmia) to be combined into one score. The results at the end of treatment (two to three weeks) showed an improvement in patients receiving oral steroids compared to placebo, both when presented as a mean final value (SMD ‐2.84, 95% CI ‐4.09 to ‐1.59, 22 participants) and as a change from baseline (SMD ‐2.28, 95% CI ‐2.76 to ‐1.80, 114 participants). These correspond to large effect sizes but we assessed the evidence to be low quality. One study (114 participants) followed patients for 10 weeks after the two‐week treatment period. All patients in both arms received intranasal steroids at the end of the oral steroid treatment period. The results showed that the initial results after treatment were not sustained (SMD ‐0.22, 95% CI ‐0.59 to 0.15, 114 participants, percentage improvement from baseline). This corresponds to a small effect size and we assessed the evidence to be low quality. There was an increase in adverse events in people receiving orals steroids compared with placebo for gastrointestinal disturbances (risk ratio (RR) 3.45, 95% CI 1.11 to 10.78; 187 participants; three studies) and insomnia (RR 3.63, 95% CI 1.10 to 11.95; 187 participants; three studies). There was no significant impact of oral steroids on mood disturbances at the dosage used in the included study (risk ratio (RR) 2.50, 95% CI 0.55 to 11.41; 40 participants; one study). We assessed the evidence to be low quality due to the lack of definitions of the adverse events and the small number of events or sample size, or both). Other comparisons No studies that compared short‐course oral steroids with other treatment for chronic rhinosinusitis met the inclusion criteria. Authors' conclusions At the end of the treatment course (two to three weeks) there is an improvement in health‐related quality of life and symptom severity in patients with chronic rhinosinusitis with nasal polyps taking oral corticosteroids compared with placebo or no treatment. The quality of the evidence supporting this finding is low. At three to six months after the end of the oral steroid treatment period, there is little or no improvement in health‐related quality of life or symptom severity for patients taking an initial course of oral steroids compared with placebo or no treatment. The data on the adverse effects associated with short courses of oral corticosteroids indicate that there may be an increase in insomnia and gastrointestinal disturbances but it is not clear whether there is an increase in mood disturbances. All of the adverse events results are based on low quality evidence. More research in this area, particularly research evaluating patients with chronic rhinosinusitis without nasal polyps, longer‐term outcomes and adverse effects, is required. There is no evidence for oral steroids compared with other treatments. Plain language summary Short‐term oral corticosteroids compared with no treatment or other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of a short course (typically up to 21 days) of corticosteroid given by mouth to people with chronic rhinosinusitis compared with giving a placebo or no treatment, or another type of treatment. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling the inflammatory response and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included eight randomised controlled trials with a total of 474 participants. All of the patients were adults who had chronic rhinosinusitis with nasal polyps. All of the studies followed patients until the end of treatment (two to three weeks) and three studies (210 participants) followed up people for three to six months after the initial treatment had ended. Five of the eight reports mentioned how the trial was funded. None of the funding sources were pharmaceutical companies. Key results At the end of a two‐ or three‐week treatment course, people who took oral steroids may have had a better quality of life, less severe symptoms and smaller nasal polyps than people who had placebo or did not receive any treatment. After three to six months, there was little or no difference in quality of life, symptom severity or nasal polyps between the people who had oral steroids and the people who had placebo or no intervention. The people who took oral steroids may have had more gastrointestinal disturbances and insomnia than the people who had placebo or no intervention. It is not clear if the people who took oral steroids had more mood disturbances than the people who had placebo or no intervention. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate), as the some of the results are only from one or two studies, which do not have a lot of participants. Most of the trials do not have a high risk of bias, but only people with nasal polyps were included in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K; Chong, LY; Hopkins, C; Philpott, C; Burton, MJ; Schilder, AGM", "articleTypes": [], "doi": "10.1002/14651858.CD011991.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "e24f15d6-64d9-4037-a5f4-643ed45d378f", "pmid": "", "title": "The Effect of Seven Day Fenfluramine Administration on Cognition in Healthy Volunteers", "imported": false, "abstract": "In this study, the investigators will investigate the cognitive effects of fenfluramine, a drug that directly stimulates the release of serotonin in the brain and positively modulates σ1 function. The investigators will use fenfluramine to assess the cognitive effects of modulating serotonin and σ1 function in healthy volunteers using a battery of cognitive tasks that measure learning and memory, executive functioning, reward processing, and emotional processing. The study design is double-blind, and participants will be randomised to either seven days of fenfluramine or placebo administration. All participants will attend two screening visits to assess eligibility. There are two main study visits; during the first, participants will undertake cognitive tasks and questionnaires before taking the initial study dose. One the second study visit, participants will once again complete these tasks and questionnaires after a week of fenfluramine/placebo administration.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.243Z" }, { "id": "e2585e24-759b-43a5-bd00-0a3fe2cb8076", "pmid": "", "title": "Treatment of U.S. Veterans With Mild Traumatic Brain Injury With Hyperbaric Oxygen Therapy", "imported": false, "abstract": "Mild traumatic brain (mTBI) injury affects 400,000 U.S. Veterans resulting in physical, cognitive and mental health symptoms. The Department of Defense (DoD) reported 26 suicides a day from mTBI despite ongoing care for the Veterans. The purpose of this pilot research study is to evaluate the effect of treating Veterans suffering from mTBI or persistent post-concussion syndrome with hyperbaric oxygen therapy (HBOT).", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "e27ff9ed-04cb-4c9f-8763-0c6ed4a7e19e", "pmid": "", "title": "Omega‐3 fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids from oily fish (long‐chain omega‐3 (LCn3)), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha‐linolenic acid (ALA)) may benefit cardiovascular health. Guidelines recommend increasing omega‐3‐rich foods, and sometimes supplementation, but recent trials have not confirmed this. Objectives To assess the effects of increased intake of fish‐ and plant‐based omega‐3 fats for all‐cause mortality, cardiovascular events, adiposity and lipids. Search methods We searched CENTRAL, MEDLINE and Embase to February 2019, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to August 2019, with no language restrictions. We handsearched systematic review references and bibliographies and contacted trial authors. Selection criteria We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation or advice to increase LCn3 or ALA intake, or both, versus usual or lower intake. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed validity. We performed separate random‐effects meta‐analysis for ALA and LCn3 interventions, and assessed dose‐response relationships through meta‐regression. Main results We included 86 RCTs (162,796 participants) in this review update and found that 28 were at low summary risk of bias. Trials were of 12 to 88 months' duration and included adults at varying cardiovascular risk, mainly in high‐income countries. Most trials assessed LCn3 supplementation with capsules, but some used LCn3‐ or ALA‐rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5 g a day to more than 5 g a day (19 RCTs gave at least 3 g LCn3 daily). Meta‐analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all‐cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.93 to 1.01; 143,693 participants; 11,297 deaths in 45 RCTs; high‐certainty evidence), cardiovascular mortality (RR 0.92, 95% CI 0.86 to 0.99; 117,837 participants; 5658 deaths in 29 RCTs; moderate‐certainty evidence), cardiovascular events (RR 0.96, 95% CI 0.92 to 1.01; 140,482 participants; 17,619 people experienced events in 43 RCTs; high‐certainty evidence), stroke (RR 1.02, 95% CI 0.94 to 1.12; 138,888 participants; 2850 strokes in 31 RCTs; moderate‐certainty evidence) or arrhythmia (RR 0.99, 95% CI 0.92 to 1.06; 77,990 participants; 4586 people experienced arrhythmia in 30 RCTs; low‐certainty evidence). Increasing LCn3 may slightly reduce coronary heart disease mortality (number needed to treat for an additional beneficial outcome (NNTB) 334 , RR 0.90, 95% CI 0.81 to 1.00; 127,378 participants; 3598 coronary heart disease deaths in 24 RCTs, low‐certainty evidence) and coronary heart disease events ( NNTB 167 , RR 0.91, 95% CI 0.85 to 0.97; 134,116 participants; 8791 people experienced coronary heart disease events in 32 RCTs, low‐certainty evidence). Overall, effects did not differ by trial duration or LCn3 dose in pre‐planned subgrouping or meta‐regression. There is little evidence of effects of eating fish. Increasing ALA intake probably makes little or no difference to all‐cause mortality (RR 1.01, 95% CI 0.84 to 1.20; 19,327 participants; 459 deaths in 5 RCTs, moderate‐certainty evidence), cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25; 18,619 participants; 219 cardiovascular deaths in 4 RCTs; moderate‐certainty evidence), coronary heart disease mortality (RR 0.95, 95% CI 0.72 to 1.26; 18,353 participants; 193 coronary heart disease deaths in 3 RCTs; moderate‐certainty evidence) and coronary heart disease events (RR 1.00, 95% CI 0.82 to 1.22; 19,061 participants; 397 coronary heart disease events in 4 RCTs; low‐certainty evidence). However, increased ALA may slightly reduce risk of cardiovascular disease events ( NNTB 500 , RR 0.95, 95% CI 0.83 to 1.07; but RR 0.91, 95% CI 0.79 to 1.04 in RCTs at low summary risk of bias; 19,327 participants; 884 cardiovascular disease events in 5 RCTs; low‐certainty evidence), and probably slightly reduces risk of arrhythmia ( NNTB 91 , RR 0.73, 95% CI 0.55 to 0.97; 4912 participants; 173 events in 2 RCTs; moderate‐certainty evidence). Effects on stroke are unclear . Increasing LCn3 and ALA had little or no effect on serious adverse events, adiposity, lipids and blood pressure, except increasing LCn3 reduced triglycerides by ˜15% in a dose‐dependent way (high‐certainty evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐3 fats on cardiovascular health to date. Moderate‐ and low‐certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials). Increasing ALA slightly reduces risk of cardiovascular events and arrhythmia. Plain language summary Omega‐3 intake for cardiovascular disease Review question We reviewed randomised trials (where participants have an equal chance of being assigned to either treatment) examining effects of increasing fish‐ and plant‐based omega‐3 fats on heart and circulatory disease (called cardiovascular diseases, which include heart attacks and stroke), fatness and blood fats (lipids, including cholesterol, triglycerides, high‐density lipoprotein (HDL – 'good' cholesterol) and low‐density lipoprotein (LDL – 'bad' cholesterol)). Background The main types of omega‐3 fats are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), both found in fish, and alpha‐linolenic acid (ALA) found in plant foods. Many people believe that taking omega‐3 supplements reduces risk of heart disease, stroke and death. Trial characteristics The evidence is current to February 2019. The review included 86 trials involving 162,796 people. These trials assessed effects of greater omega‐3 intake versus lower omega‐3 intake for at least a year on heart and circulatory disease. Twenty‐eight trials were very trustworthy (well‐designed so as not to give biased results). Participants were adults, some with existing illness and some healthy, living in North America, Europe, Australia and Asia. Most EPA and DHA trials provided capsules, few gave oily fish. Key results Increasing EPA and DHA has little or no effect on deaths and cardiovascular events (high‐certainty evidence) and probably makes little or no difference to cardiovascular death, stroke, or heart irregularities (moderate‐certainty evidence). However, increasing EPA and DHA may slightly reduce risk of coronary death and coronary events (low‐certainty evidence, coronary events are illnesses of arteries supplying the heart). To prevent one person having a coronary event, 167 people would need to increase their EPA and DHA, and 334 people would need to increase their EPA and DHA to prevent one person dying from coronary disease. EPA and DHA reduce triglycerides by about 15% but do not affect fatness or other lipids (high‐certainty evidence). Eating more ALA (for example, by increasing walnuts or enriched margarine) probably makes little or no difference to all‐cause, cardiovascular or coronary deaths or coronary events but probably slightly reduces cardiovascular events and heart irregularities (moderate‐ or low‐certainty evidence). To prevent one person having a coronary event, 500 people would need to increase their ALA, 91 people to prevent one person having arrhythmia. There is little evidence of effects of eating fish. EPA and DHA reduce triglycerides. EPA, DHA and ALA may be slightly protective of some heart and circulatory diseases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Abdelhamid, AS; Brown, TJ; Brainard, JS; Biswas, P; Thorpe, GC; Moore, HJ; Deane, KHO; Summerbell, CD; Worthington, HV; Song, F; Hooper, L", "articleTypes": [], "doi": "10.1002/14651858.CD003177.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "e288e099-ef4f-41af-9c2b-c5c8a08359d4", "pmid": "", "title": "Roselle for hypertension in adults", "imported": false, "abstract": "Abstract - Background Hypertension is considered to be a serious health problem worldwide. Controlling and lowering blood pressure are of significant benefit to people with hypertension because hypertension is a risk factor for stroke, heart disease, and cardiovascular disease. Roselle, the tropical plant Hibiscus sabdariffa , also commonly called sour tea or red tea, has been used as both a thirst‐quenching drink and for medicinal purposes. Objectives To assess the effect of Roselle on blood pressure in people with primary hypertension. Search methods For this update, the Cochrane Hypertension Information Specialist searched the following databases and trials registers for randomised controlled trials (RCTs): the Cochrane Hypertension Specialised Register (to 6 August 2021), Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), MEDLINE Ovid (1946 to 5 August 2021), Embase Ovid (1974 to 5 August 2021), ProQuest Dissertations & Theses (to 6 August 2021), Web of Science Clarivate (to 7 August 2021), Food Science and Technology Abstracts Clarivate (to 7 August 2021), the WHO International Clinical Trials Registry Platform (to 6 August 2021), and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (to 6 August 2021). We searched Google Scholar and OpenSIGLE. We also handsearched local and regional Chinese databases: CBM, CMCC, TCMLARS, CNKI, CMAC, and the Index to Chinese Periodical Literature (to 14 September 2020), as well as Thai databases (ThaiJO, CUIR, TDC, CMU e‐Theses, TCTR) (to 3 October 2020). There were no language or publication date restrictions. Selection criteria We sought RCTs evaluating the use of any forms of Roselle with placebo or no treatment in adults with hypertension. Our primary outcome was change in trough and/or peak systolic and diastolic blood pressure (SBP, DBP). Secondary outcomes were withdrawals due to adverse effects, change in pulse pressure, and change in heart rate. Data collection and analysis All search results were managed using Covidence and re‐checked for the number of records, inclusion and exclusion of studies with Mendeley reference management software. We used standard methodological procedures expected by Cochrane. Two review authors worked independently in parallel for screening (titles and abstracts, and full reports), data extraction, risk of bias assessment, and assessment of the certainty of the evidence using the GRADE approach. Any disagreements were resolved by discussion or by consultation with the third review author if necessary. We presented mean difference (MD) of change in SBP and DBP with their corresponding 95% confidence interval (CI). Main results For this update, only one RCT with a parallel‐group design involving 60 participants with type 2 diabetes mellitus fulfilled the inclusion criteria. This study investigated the effect of Roselle extract capsules (total dose of 5600 mg) compared with placebo (lactose) at eight weeks. The study was at low risk of selection bias, performance bias, and detection bias. Conversely, it was at high risk of attrition bias, reporting bias, and other bias (baseline imbalance). We have very little confidence in the effect estimate of Roselle on change‐from‐baseline in both SBP and DBP between the two groups. The MD of change in SBP was 1.65, 95% CI −7.89 to 11.19 mmHg, 52 participants, very low‐certainty evidence. The MD of change in DBP was 4.60, 95% CI −1.38 to 10.58 mmHg, 52 participants, very low‐certainty evidence. Our secondary outcomes of withdrawals due to adverse effects, change in pulse pressure, and change in heart rate were not reported. Due to the limited available data, no secondary analyses were performed (subgroup and sensitivity analysis). Authors' conclusions The evidence is currently insufficient to determine the effectiveness of Roselle compared to placebo for controlling or lowering blood pressure in people with hypertension. The certainty of evidence was very low due to methodological limitations, imprecision, and indirectness. There is a need for rigorous RCTs that address the review question. Plain language summary Red tea (Roselle) for lowering blood pressure in adults Key messages: We don't know if taking Roselle lowers blood pressure in people with hypertension (high blood pressure). We don’t know if Roselle is safe for people with hypertension to consume or if it affects heart rate or pulse pressure. What did we want to find out? We wanted to know if red tea (Roselle) is a safe and effective treatment for lowering blood pressure in adults with high blood pressure when compared to placebo (dummy treatment) or no treatment. Roselle contains substances known as anthocyanins which have been shown to have lowered blood pressure in studies carried out in animals and humans. What did we do? We searched for studies that compared Roselle to placebo or no treatment in people with hypertension. What did we find? We included one study with 60 participants with type 2 diabetes and hypertension. Participants consumed either a capsule of pure Roselle extract or a placebo containing lactose for eight weeks. We are not sure if Roselle has an effect on blood pressure and the study did not report on the safety of Roselle or on changes to heart rate. What are the main limitations of the evidence? We found only one trial which included a small number of participants, all of whom had diabetes. More studies with various types of participants and different ways of taking Roselle (forms, amounts, and time of day, length of use) are needed. How up to date is the evidence? The review updates our previous review. We searched for randomised controlled trials (studies in which participants are randomly assigned to one of two or more treatment groups) in core databases up to August 2021, and searched local and regional Chinese and Thai databases by hand up to October 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Pattanittum, P, Ngamjarus, C, Buttramee, F, Somboonporn, C", "articleTypes": [], "doi": "10.1002/14651858.CD007894.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.763Z" }, { "id": "e2abca32-d6a7-4eac-a5a8-08055c281f1a", "pmid": "", "title": "Interventions for reducing inflammation in familial Mediterranean fever", "imported": false, "abstract": "Abstract - Background Familial Mediterranean fever (FMF), a hereditary auto‐inflammatory disease, mainly affects ethnic groups living in the Mediterranean region. Early studies reported colchicine may potentially prevent FMF attacks. For people who are colchicine‐resistant or intolerant, drugs such as anakinra, rilonacept, canakinumab, etanercept, infliximab or adalimumab might be beneficial. This is an update of the review last published in 2018. Objectives To evaluate the efficacy and safety of interventions for reducing inflammation in people with FMF. Search methods We searched CENTRAL, MEDLINE, Embase and four Chinese databases on in August 2021. We searched clinical trials registries and references listed in relevant reports. The last search was 17 August 2021. Selection criteria We included randomized controlled trials (RCTs) of people with FMF, comparing active interventions (including colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (herbal dietary supplement)) with placebo or no treatment, or comparing active drugs to each other. Data collection and analysis We used standard Cochrane methodology. We assessed certainty of the evidence using GRADE. Main results We included 10 RCTs with 312 participants (aged three to 53 years), including five parallel and five cross‐over designed studies. Six studies used oral colchicine, one used oral ImmunoGuard, and the remaining three used rilonacept, anakinra or canakinumab as a subcutaneous injection. The duration of each study arm ranged from one to eight months. There were inadequacies in the design of the four older colchicine studies and the two studies comparing a single to a divided dose of colchicine. However, the four studies of ImmunoGuard, rilonacept, anakinra and canakinumab were generally well‐designed. We aimed to report on the number of participants experiencing an attack, the timing of attacks, the prevention of amyloid A amyloidosis, adverse drug reactions and the response of a number of biochemical markers from the acute phase of an attack; but no study reported on the prevention of amyloid A amyloidosis. Colchicine (oral) versus placebo After three months, colchicine 0.6 mg three times daily may reduce the number of people experiencing attacks (risk ratio (RR) 0.21, 95% confidence interval (CI) 0.05 to 0.95; 1 study, 10 participants; low‐certainty evidence). One study (20 participants) of colchicine 0.5 mg twice daily showed there may be no difference in the number of participants experiencing attacks at two months (RR 0.78, 95% CI 0.49 to 1.23; low‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; very low‐certainty evidence), or in the number of days between attacks: (narrative summary; very low‐certainty evidence). Regarding adverse drug reactions, one study reported loose stools and frequent bowel movements and a second reported diarrhea (narrative summary; both very low‐certainty evidence). There were no data on acute‐phase response. Rilonacept versus placebo There is probably no difference in the number of people experiencing attacks at three months (RR 0.87, 95% CI 0.59 to 1.26; moderate‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; low‐certainty evidence) or in the number of days between attacks (narrative summary; low‐certainty evidence). Regarding adverse drug reactions, the rilonacept study reported there may be no differences in gastrointestinal symptoms, hypertension, headache, respiratory tract infections, injection site reactions and herpes, compared to placebo (narrative summary; low‐certainty evidence). The study narratively reported there may be no differences in acute‐phase response indicators after three months (low‐certainty evidence). ImmunoGuard versus placebo The ImmunoGuard study observed there are probably no differences in adverse effects (moderate‐certainty evidence) or in acute‐phase response indicators after one month of treatment (moderate‐certainty evidence). No data were reported for the number of people experiencing an attack, duration of attacks or days between attacks. Anakinra versus placebo A study of anakinra given to 25 colchicine‐resistant participants found there is probably no difference in the number of participants experiencing an attack at four months (RR 0.76, 95% CI 0.54 to 1.07; moderate‐certainty evidence). There were no data for duration of attacks or days between attacks. There are probably no differences between anakinra and placebo with regards to injection site reaction, headache, presyncope, dyspnea and itching (narrative summary; moderate‐certainty evidence). For acute‐phase response, anakinra probably reduced C‐reactive protein (CRP) after four months (narrative summary; moderate‐certainty evidence). Canakinumab versus placebo Canakinumab probably reduces the number of participants experiencing an attack at 16 weeks (RR 0.41, 95% CI 0.26 to 0.65; 1 study, 63 colchicine‐resistant participants; moderate‐certainty evidence). There were no data for the duration of attacks or days between attacks. The included study reported the number of serious adverse events per 100 patient‐years was probably 42.7 with canakinumab versus 97.4 with placebo among people with colchicine‐resistant FMF (moderate‐certainty evidence). For acute‐phase response, canakinumab probably caused a higher proportion of participants to have a CRP level of 10 mg/L or less compared to placebo (68% with canakinumab versus 6% with placebo; 1 study, 63 participants; moderate‐certainty evidence). Colchicine single dose versus divided dose There is probably no difference in the duration of attacks at three months (MD −0.04 hours, 95% CI −10.91 to 10.83) or six months (MD 2.80 hours, 95% CI −5.39 to 10.99; moderate‐certainty evidence). There were no data for the number of participants experiencing an attack or days between attacks. There is probably no difference in adverse events (including anorexia, nausea, diarrhea, abdominal pain, vomiting and elevated liver enzymes) between groups (narrative summary; moderate‐certainty evidence). For acute‐phase response, there may be no evidence of a difference between groups (narrative summary; low‐ to moderate‐certainty evidence). Authors' conclusions There were limited RCTs assessing interventions for people with FMF. Based on the evidence, three times daily colchicine may reduce the number of people experiencing attacks, colchicine single dose and divided dose may not be different for children with FMF, canakinumab probably reduces the number of people experiencing attacks, and anakinra or canakinumab probably reduce CRP in colchicine‐resistant participants; however, only a few RCTs contributed data for analysis. Further RCTs examining active interventions, not only colchicine, are necessary before a comprehensive conclusion regarding the efficacy and safety of interventions for reducing inflammation in FMF can be drawn. Plain language summary Medicines for reducing inflammation in people with familial Mediterranean fever Review question Can treatments such as colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (a herbal supplement)) reduce inflammation in people with familial Mediterranean fever (FMF)? Background FMF is a hereditary inflammatory disease, with symptoms of an attack often including fever over 38 °C, pain and inflammation of the membrane surrounding the chest cavity, the joints or the lungs. We wanted to discover whether these medicines were better for reducing inflammation for people with FMF than placebo (a dummy treatment containing no active medicine) or no treatment, and also to compare these medicines with each other. Search date The evidence is current to 17 August 2021. Study characteristics The review included 10 studies with 312 people with FMF aged between three and 53 years. Eight studies compared five medicines, colchicine, rilonacept, ImmunoGuard, anakinra and canakinumab, with placebo. Participants received one medicine or placebo at random over one to four months. The remaining two studies compared colchicine 1 mg per day once daily with colchicine two or three times daily in children for six to eight months. Key results We aimed to report on the number of participants experiencing an attack, the timing of attacks, prevention of amyloid A amyloidosis (which is a reaction to a chronic inflammatory disease or infection leading to a build‐up of an abnormal protein called amyloid in organs and tissues throughout the body stopping them working properly), and any side effects of treatment and the levels of a number of markers of inflammation during an attack. Not all studies reported these outcomes. Given the differences in treatments and study design, it was not possible to combine any of the results that we did obtain from these studies. One study (15 participants) with oral colchicine 0.6 mg three times a day and another study (63 participants) with subcutaneous (under the skin) canakinumab 150 mg every four weeks for 16 weeks may help to reduce the numbers of people with attacks of FMF. However, oral colchicine 0.5 mg twice a day (20 participants), rilonacept (14 participants) or anakinra (25 participants) did not reduce the numbers of people with attacks. ImmunoGuard (24 participants) did not reduce levels of the markers of inflammation in the blood which are raised during the attack phase of FMF; these include the rate of fall of red blood cells when placed in a test tube, the white blood cell count and the presence of C‐reactive protein (a protein that is produced in the liver). Anakinra and canakinumab reduced C‐reactive protein levels. Colchicine taken once daily and two or three times daily might not result in different outcomes including the timing of attacks, sider effects of the medicine and acute‐phase response indicators. Quality of the evidence Four studies were well‐designed, while the others had some design problems that might have affected the results. Four studies did not report clearly how the people were assigned to each treatment group. Four studies did not report whether researchers, who assessed the study outcomes, knew which individuals were assigned to which treatment. Four studies did not clearly explain the reasons for people withdrawing from a study and one study had a high percentage of participants who did not complete study. We could not confirm whether each planned outcome was reported in five studies. Five studies did not report the severity of FMF in groups at the beginning of treatment. We judged the evidence for the reported outcomes to be of moderate to very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Yin, X; Tian, F; Wu, B; Xu, T", "articleTypes": [], "doi": "10.1002/14651858.CD010893.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "e2b3cc2f-8b69-432f-9371-cdbf4305ebc9", "pmid": "", "title": "Antibiotic strategies for eradicating Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Respiratory tract infections with Pseudomonas aeruginosa occur in most people with cystic fibrosis (CF). Established chronic P aeruginosa infection is virtually impossible to eradicate and is associated with increased mortality and morbidity. Early infection may be easier to eradicate. This is an updated review. Objectives Does giving antibiotics for P aeruginosa infection in people with CF at the time of new isolation improve clinical outcomes (e.g. mortality, quality of life and morbidity), eradicate P aeruginosa infection, and delay the onset of chronic infection, but without adverse effects, compared to usual treatment or an alternative antibiotic regimen? We also assessed cost‐effectiveness. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings. Latest search: 24 March 2022. We searched ongoing trials registries. Latest search: 6 April 2022. Selection criteria We included randomised controlled trials (RCTs) of people with CF, in whom P aeruginosa had recently been isolated from respiratory secretions. We compared combinations of inhaled, oral or intravenous (IV) antibiotics with placebo, usual treatment or other antibiotic combinations. We excluded non‐randomised trials and cross‐over trials. Data collection and analysis Two authors independently selected trials, assessed risk of bias and extracted data. We assessed the certainty of the evidence using GRADE. Main results We included 11 trials (1449 participants) lasting between 28 days and 27 months; some had few participants and most had relatively short follow‐up periods. Antibiotics in this review are: oral – ciprofloxacin and azithromycin; inhaled – tobramycin nebuliser solution for inhalation (TNS), aztreonam lysine (AZLI) and colistin; IV – ceftazidime and tobramycin. There was generally a low risk of bias from missing data. In most trials it was difficult to blind participants and clinicians to treatment. Two trials were supported by the manufacturers of the antibiotic used. TNS versus placebo TNS may improve eradication; fewer participants were still positive for P aeruginosa at one month (odds ratio (OR) 0.06, 95% confidence interval (CI) 0.02 to 0.18; 3 trials, 89 participants; low‐certainty evidence) and two months (OR 0.15, 95% CI 0.03 to 0.65; 2 trials, 38 participants). We are uncertain whether the odds of a positive culture decrease at 12 months (OR 0.02, 95% CI 0.00 to 0.67; 1 trial, 12 participants). TNS (28 days) versus TNS (56 days) One trial (88 participants) comparing 28 days to 56 days TNS treatment found duration of treatment may make little or no difference in time to next isolation (hazard ratio (HR) 0.81, 95% CI 0.37 to 1.76; low‐certainty evidence). Cycled TNS versus culture‐based TNS One trial (304 children, one to 12 years old) compared cycled TNS to culture‐based therapy and also ciprofloxacin to placebo. We found moderate‐certainty evidence of an effect favouring cycled TNS therapy (OR 0.51, 95% CI 0.31 to 0.82), although the trial publication reported age‐adjusted OR and no difference between groups. Ciprofloxacin versus placebo added to cycled and culture‐based TNS therapy One trial (296 participants) examined the effect of adding ciprofloxacin versus placebo to cycled and culture‐based TNS therapy. There is probably no difference between ciprofloxacin and placebo in eradicating P aeruginosa (OR 0.89, 95% CI 0.55 to 1.44; moderate‐certainty evidence). Ciprofloxacin and colistin versus TNS We are uncertain whether there is any difference between groups in eradication of P aeruginosa at up to six months (OR 0.43, 95% CI 0.15 to 1.23; 1 trial, 58 participants) or up to 24 months (OR 0.76, 95% CI 0.24 to 2.42; 1 trial, 47 participants); there was a low rate of short‐term eradication in both groups. Ciprofloxacin plus colistin versus ciprofloxacin plus TNS One trial (223 participants) found there may be no difference in positive respiratory cultures at 16 months between ciprofloxacin with colistin versus TNS with ciprofloxacin (OR 1.28, 95% CI 0.72 to 2.29; low‐certainty evidence). TNS plus azithromycin compared to TNS plus oral placebo Adding azithromycin may make no difference to the number of participants eradicating P aeruginosa after a three‐month treatment phase (risk ratio (RR) 1.01, 95% CI 0.75 to 1.35; 1 trial, 91 participants; low‐certainty evidence); there was also no evidence of any difference in the time to recurrence. Ciprofloxacin and colistin versus no treatment A single trial only reported one of our planned outcomes; there were no adverse effects in either group. AZLI for 14 days plus placebo for 14 days compared to AZLI for 28 days We are uncertain whether giving 14 or 28 days of AZLI makes any difference to the proportion of participants having a negative respiratory culture at 28 days (mean difference (MD) ‐7.50, 95% CI ‐24.80 to 9.80; 1 trial, 139 participants; very low‐certainty evidence). Ceftazidime with IV tobramycin compared with ciprofloxacin (both regimens in conjunction with three months colistin) IV ceftazidime with tobramycin compared with ciprofloxacin may make little or no difference to eradication of P aeruginosa at three months, sustained to 15 months, provided that inhaled antibiotics are also used (RR 0.84, 95 % CI 0.65 to 1.09; P = 0.18; 1 trial, 255 participants; high‐certainty evidence). The results do not support using IV antibiotics over oral therapy to eradicate P aeruginosa , based on both eradication rate and financial cost. Authors' conclusions We found that nebulised antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with P aeruginosa . Eradication may be sustained in the short term. There is insufficient evidence to determine whether these antibiotic strategies decrease mortality or morbidity, improve quality of life, or are associated with adverse effects compared to placebo or standard treatment. Four trials comparing two active treatments have failed to show differences in rates of eradication of P aeruginosa . One large trial showed that intravenous ceftazidime with tobramycin is not superior to oral ciprofloxacin when inhaled antibiotics are also used. There is still insufficient evidence to state which antibiotic strategy should be used for the eradication of early P aeruginosa infection in CF, but there is now evidence that intravenous therapy is not superior to oral antibiotics. Plain language summary Different ways of giving antibiotics to clear Pseudomonas aeruginosa infection in people with cystic fibrosis Key messages ‐ Cystic fibrosis (CF) is an inherited condition where the airways often become blocked with mucus, and people with CF are more likely to get chest infections which cause more damage to the lungs. ‐ Pseudomonas aeruginosa ( P aeruginosa ) is often the cause of infection and is difficult to get rid of; antibiotics are the main treatment, but there are many different antibiotics, and they can be given in different ways. ‐ Inhaled antibiotics may be better than no treatment allowing most people to remain free of P aeruginosa after one month. ‐ There seems to be little difference in the other treatments we compared regarding how well they clear P aeruginosa from the lungs. What is cystic fibrosis? CF is the most common inherited condition that is life‐limiting. Sticky mucus builds up in the lungs of people with CF, which makes it difficult to breathe and can lead to chest infections. These chest infections can cause further lung damage and lead to breathing failure and death. A germ called P aeruginosa is often the cause of infection and is difficult to treat successfully, once it has persisted for longer than six months. What did we want to find out? We wanted to compare different combinations of inhaled, oral and intravenous (IV) antibiotics for clearing P aeruginosa in people with CF, to see if any single treatment works best and is more cost‐effective. What did we find? The review includes 11 studies with a total of 1449 people with CF, of any age or sex, who had mild to severe lung disease. The studies lasted from 28 days to 27 months. We could not combine many results as studies used different treatments. There were 10 different comparisons of antibiotic treatments: three studies compared inhaled antibiotics with a placebo (dummy treatment); two studies compared inhaled antibiotics for different lengths of time; two studies compared inhaled tobramycin with or without oral antibiotics depending on how the infection was detected; two studies compared inhaled antibiotics plus an oral antibiotic with inhaled antibiotics plus a placebo; one study compared two different inhaled antibiotics plus an oral antibiotic; and one study compared IV antibiotics with oral antibiotics. Most of the studies showed how well the treatments got rid of P aeruginosa as well as how they affected lung function, other germs, worsening of flare‐ups, and side effects. Main results Three small studies (of 89 people) treating early infection showed that after one month, inhaled antibiotics were better than no treatment and cleared P aeruginosa in most people, but our confidence in the evidence is low. There is likely to be little difference in the other treatments regarding how well they clear P aeruginosa from the lungs, although we found that inhaled antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with Pseudomonas aeruginosa. A study of IV ceftazidime with tobramycin in comparison with oral ciprofloxacin also showed neither group was better at getting rid of P aeruginosa, but we are more certain of the results and this means that it may be just as effective to treat with oral antibiotics. What are the limitations of the evidence? Some studies were carried out up to 30 years ago and the results may not apply today, and some studies were small. Most studies were quite short, so we could not show whether treatment made people with CF feel better or live longer. Given the treatments used in most of the studies, it would have been easy for people to guess which treatment they were receiving, which might have influenced some of the results. Two studies were supported by the pharmaceutical industry. Further research is needed to see whether clearing the infection completely improves the well‐being and quality of life in people with CF and to establish which antibiotic combination is best at clearing P aeruginosa . Overall our confidence in the evidence was moderate to very low, so further research is likely to change our confidence in the results. However, we have higher confidence in one recently published study, which means we can be more sure of the results. How up to date is this evidence? The studies we have reported on are the most up‐to‐date we could find. We last searched the literature in April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Langton Hewer, SC; Smith, S; Rowbotham, NJ; Yule, A; Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD004197.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "e2b78354-6dc4-44a0-b2b8-6d75a1cc0b9f", "pmid": "", "title": "Vitamin D supplementation for chronic liver diseases in adults", "imported": false, "abstract": "Abstract - Background Vitamin D deficiency is often reported in people with chronic liver diseases. Improving vitamin D status could therefore be beneficial for people with chronic liver diseases. Objectives To assess the beneficial and harmful effects of vitamin D supplementation in adults with chronic liver diseases. Search methods We searched the Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index‐Science. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We scanned bibliographies of relevant publications and enquired experts and pharmaceutical companies as to additional trials. All searches were up to November 2020. Selection criteria Randomised clinical trials that compared vitamin D at any dose, duration, and route of administration versus placebo or no intervention in adults with chronic liver diseases. Vitamin D could have been administered as supplemental vitamin D (vitamin D 3 (cholecalciferol) or vitamin D 2 (ergocalciferol)), or an active form of vitamin D (1α‐hydroxyvitamin D (alfacalcidol), 25‐hydroxyvitamin D (calcidiol), or 1,25‐dihydroxyvitamin D (calcitriol)). Data collection and analysis We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of evidence. Main results We included 27 randomised clinical trials with 1979 adult participants. This review update added 12 trials with 945 participants. We assessed all trials at high risk of bias. All trials had a parallel‐group design. Eleven trials were conducted in high‐income countries and 16 trials in middle‐income countries. Ten trials included participants with chronic hepatitis C, five trials participants with liver cirrhosis, 11 trials participants with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. All of the included trials reported the baseline vitamin D status of participants. Participants in nine trials had baseline serum 25‐hydroxyvitamin D levels at or above vitamin D adequacy (20 ng/mL), whilst participants in the remaining 18 trials were vitamin D insufficient (less than 20 ng/mL). Twenty‐four trials administered vitamin D orally, two trials intramuscularly, and one trial intramuscularly and orally. In all 27 trials, the mean duration of vitamin D supplementation was 6 months, and the mean follow‐up of participants from randomisation was 7 months. Twenty trials (1592 participants; 44% women; mean age 48 years) tested vitamin D 3 (cholecalciferol); three trials (156 participants; 28% women; mean age 54 years) tested vitamin D 2 ; four trials (291 participants; 60% women; mean age 52 years) tested 1,25‐dihydroxyvitamin D; and one trial (18 participants; 0% women; mean age 52 years) tested 25‐hydroxyvitamin D. One trial did not report the form of vitamin D. Twelve trials used a placebo, whilst the other 15 trials used no intervention in the control group. Fourteen trials appeared to be free of vested interest. Eleven trials did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on all‐cause mortality (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.51 to 1.45; 27 trials; 1979 participants). The mean follow‐up was 7 months (range 1 to 18 months). We are very uncertain regarding the effect of vitamin D versus placebo or no intervention on liver‐related mortality (RR 1.62, 95% CI 0.08 to 34.66; 1 trial; 18 participants) (follow‐up: 12 months); serious adverse events such as hypercalcaemia (RR 5.00, 95% CI 0.25 to 100.8; 1 trial; 76 participants); myocardial infarction (RR 0.75, 95% CI 0.08 to 6.81; 2 trials; 86 participants); thyroiditis (RR 0.33, 95% CI 0.01 to 7.91; 1 trial; 68 participants); circular haemorrhoidal prolapse (RR 3.00, 95% CI 0.14 to 65.9; 1 trial; 20 participants); bronchopneumonia (RR 0.33, 95% CI 0.02 to 7.32; 1 trial 20 participants); and non‐serious adverse events. The certainty of evidence for all outcomes is very low. We found no data on liver‐related morbidity such as gastrointestinal bleeding, hepatic encephalopathy, hepatorenal syndrome, ascites, or liver cancer. There were also no data on health‐related quality of life. The evidence is also very uncertain regarding the effect of vitamin D versus placebo or no intervention on rapid, early, and sustained virological response in people with chronic hepatitis C. Authors' conclusions Given the high risk of bias and insufficient power of the included trials and the very low certainty of the available evidence, vitamin D supplementation versus placebo or no intervention may increase or reduce all‐cause mortality, liver‐related mortality, serious adverse events, or non‐serious adverse events in adults with chronic liver diseases. There is a lack of data on liver‐related morbidity and health‐related quality of life. Further evidence on clinically important outcomes analysed in this review is needed. Plain language summary Vitamin D supplementation for chronic liver diseases Review question Is vitamin D supplementation beneficial or harmful for adults with chronic liver diseases? Background The available evidence on vitamin D and chronic liver diseases in adults is inconclusive. The aim of this systematic review (a summary of results of available healthcare trials) was to analyse the benefits and harms of the different forms of vitamin D in people with chronic liver diseases. Study characteristics Twenty‐seven trials with 1979 adult participants provided data for this review. This review update added 12 trials with 945 participants. The 1979 trial participants were randomly assigned to vitamin D compared with placebo (dummy pill) or no treatment. Eleven trials were conducted in high‐income countries, and 16 trials in middle‐income countries. The age range of the participants was 28 years to 61 years, and on average 44% were women. Ten trials included people with chronic hepatitis C, five trials people with liver cirrhosis, 11 trials people with non‐alcoholic fatty liver disease, and one trial liver transplant recipients. There were no trials including people with chronic hepatitis B or inherited liver diseases. All of the included trials reported the baseline vitamin D status of participants. Vitamin D administration lasted on average six months, and most trials used the cholecalciferol (vitamin D 3 ) form. Funding Fourteen trials appeared to be free of vested interest that could bias the trial results. Eleven trials may not have been free of vested interest, as they did not provide any information on clinical trial support or sponsorship. Two trials were funded by industry. We found no difference between trials without industry support compared to trials at risk of industry support in our analysis. Key results There is not enough evidence to determine whether vitamin D has beneficial or harmful effects, or has little to no effect on chronic liver diseases in adults. There were too few participants in the individual trials as well as in our evidence synthesis. The trials were at high risk of bias so we lack fair assessments of the benefits and harms of vitamin D in this population. Neither benefits nor harms of vitamin D supplementation in people with chronic liver diseases can be excluded. There were no trials including people with chronic hepatitis B and inherited liver diseases. Quality of the evidence We judged all trials to be at high risk of bias (that is an underestimation or overestimation of the true intervention effect). The certainty of evidence is very low. Currentness of evidence The evidence is current to November 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Bjelakovic, M, Nikolova, D, Bjelakovic, G, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD011564.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.789Z" }, { "id": "e2bebbfe-a131-45a0-abb4-b9f6d1efa477", "pmid": "", "title": "Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Chronic infection with Pseudomonas aeruginosa (PA) in cystic fibrosis (CF) is a source of much morbidity and mortality. Eradication of early PA infection is possible, but can recur in many individuals. We sought to examine strategies to delay the time to PA recurrence in people with CF. Objectives To establish whether secondary prevention strategies, using antibiotics or other therapies, increase the chances of people with CF remaining free from PA infection following successful eradication therapy. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries and the reference lists of relevant articles and reviews. Date of last search: 21 August 2019. Selection criteria Randomised controlled trials (and quasi‐randomised trials where the risk of bias was low) comparing any treatment modality aimed at preventing recurrence of PA infection with placebo, standard therapy or any other treatment modality in people with CF who have undergone successful eradication of PA. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias. Quality of the evidence was assessed using GRADE. Conflicts were resolved by discussion and the opinion of a third review author was sought where necessary. Only a subset of participants in the included trial were eligible, therefore individual participant data were requested and obtained from the trial investigators. Main results We included one trial (n = 306) in the review; however, only 253 participants had undergone successful eradication of PA, so fulfilling the inclusion criteria for our review. Information presented relates only to the included subset of participants. The trial recruited children aged one to 12 years (mean (standard deviation (SD)) age of 5.8 (3.5) years), 129 participants (51.0%) were female and the median follow‐up was 494 days. We compared cycled therapy with tobramycin inhalation solution (TIS), in which participants underwent 28 days of TIS every three months, with culture‐based therapy, in which participants were only prescribed medication when a quarterly sputum sample was positive for PA. Reasons for downgrading the quality of the evidence included applicability (only included children), incomplete outcome data and a small number of participants. The time to next isolation of PA was probably shorter with cycled TIS therapy than with culture‐based therapy, hazard ratio (HR) 2.04 days (95% confidence interval (CI) 1.28 to 3.26) (moderate‐quality evidence). This is in contrast to the main publication of the only included trial, which examined rate of PA positivity rather than time to PA infection and included participants not eligible for inclusion in this review. At the end of the trial, there was no difference between the cycled and culture‐based groups in the change from baseline in forced expiratory volume in one second (FEV 1 ) L, mean difference (MD) 0.0 L (95% CI ‐0.09 to 0.09) or in FEV 1 % predicted, MD 0.70% (95% CI ‐4.33 to 5.73) (both very low‐quality evidence). There was no difference in the change from baseline for FVC between the groups. There was also no difference in the frequency of pulmonary exacerbations between groups, MD ‐0.18 (95% CI ‐0.51 to 0.14) (moderate‐quality evidence). Similarly, there was no difference between groups in the risk of participants developing novel resistant bacteria, RR 1.00 (95% CI 0.67 to 1.5) (moderate‐quality evidence). There were more severe adverse events in the cycled group, but the type of treatment probably makes little or no difference to the results, RR 0.65 (95% CI 0.39 to 1.11) (moderate‐quality evidence). There was no difference between groups in the change in weight or height from baseline or in rates of adherence to tobramycin or all trial medicines. The included trial did not assess changes in quality of life, the time to chronic infection with PA or the cost‐effectiveness of treatment. Authors' conclusions Cycled TIS therapy may be beneficial in prolonging the time to recurrence of PA after successful eradication, but further trials are required, specifically addressing this question and in both adults and children. Plain language summary Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis Review question We reviewed evidence about the effect of treatments given to people with cystic fibrosis (CF) to prevent recurrence of infection with bacteria called Pseudomonas aeruginosa (PA) after it has been successfully treated. Background People with CF experience frequent, severe chest infections. These infections may be caused by bacteria that do not cause disease in healthy people, such as PA. PA is an important infection in CF since if it is not treated early it cannot be cleared from the lungs (termed chronic PA). When it cannot be cleared from the lungs, it causes ongoing damage to the lung tissue as well as worse chest infections. People with CF who have chronic PA may be more unwell than those without it. Early treatment can remove PA from the lungs of people with CF, but infection can happen again and is difficult to prevent. We want to know if giving extra treatment after the PA has been successfully treated, can prolong the time to the next infection. The treatment could be antibiotics or another treatment, for example something that helps the person's immune system fight the PA. Search date The evidence is current to: 21 August 2019. Trial characteristics We included one trial with 306 participants. Only 253 of these people had had successful treatment of PA and so could be included in our review. There were only children in the trial who were aged between one and 12 years old; 51% were girls. The trial compared treatment with one month of an inhaled antibiotic every three months ('cycled treatment') with antibiotic treatment given only when the person was found to have PA ('culture‐based treatment'). People were selected randomly to have either cycled or culture‐based treatment. The trial followed people up for an average of 70 weeks. Key results Taking into the account the certainty of the evidence, we believe that the time to the next isolation of PA was probably shorter with cycled therapy than with culture‐based therapy. We found that PA recurred in a quarter of participants in the culture‐based group by 249 days but in the cycled group it took 505 days; giving cycled treatment doubled the time to a new infection with PA compared with culture‐based treatment. This is in contrast to the main publication of the only included trial, which looked at the rate of positive PA cultures rather than the time to a new infection of PA and included participants not eligible for inclusion in this review. There was no difference between the groups in: pulmonary function (a measure of how well someone's lungs are working); in the number of people having chest infections; in the change in height and weight from the beginning to th end of the trial; in how many people took all the doses of the medications; in how many people developed infections with new bacteria; or in how many people had a serious complication. The trial did not give information about the effect of the two treatments on individuals' quality of life, the time until the development of chronic PA or the cost‐effectiveness of the treatment. Quality of the evidence The quality of most of the evidence was moderate. As the trial only included children, we cannot be sure if the cycled treatment would have the same effect in teenagers or adults with CF. Further trials including both adults and children are needed to help answer the question. Trials designed to specifically answer this question are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Palser, S; Smith, S; Nash, EF; Agarwal, A; Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD012300.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "e2c4b66c-bb27-4b3f-8c58-770151739bad", "pmid": "", "title": "Nutritional interventions for survivors of childhood cancer", "imported": false, "abstract": "Abstract - Background Childhood cancer survivors are at a higher risk of developing health conditions such as osteoporosis, and cardiovascular disease than their peers. Health‐promoting behaviour, such as consuming a healthy diet, could lessen the impact of these chronic issues, yet the prevalence rate of health‐protecting behaviour amongst survivors of childhood cancer is similar to that of the general population. Targeted nutritional interventions may prevent or reduce the incidence of these chronic diseases. Objectives The primary aim of this review was to assess the efficacy of a range of nutritional interventions designed to improve the nutritional intake of childhood cancer survivors, as compared to a control group of childhood cancer survivors who did not receive the intervention. Secondary objectives were to assess metabolic and cardiovascular risk factors, measures of weight and body fat distribution, behavioural change, changes in knowledge regarding disease risk and nutritional intake, participants' views of the intervention, measures of health status and quality of life, measures of harm associated with the process or outcomes of the intervention, and cost‐effectiveness of the intervention Search methods We searched the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 3), MEDLINE/PubMed (from 1945 to April 2013), and Embase/Ovid (from 1980 to April 2013). We ran the search again in August 2015; we have not yet fully assessed these results, but we have identified one ongoing trial. We conducted additional searching of ongoing trial registers ‐ the International Standard Randomised Controlled Trial Number register and the National Institutes of Health register (both screened in the first half of 2013) ‐ reference lists of relevant articles and reviews, and conference proceedings of the International Society for Paediatric Oncology and the International Conference on Long‐Term Complications of Treatment of Children and Adolescents for Cancer (both 2008 to 2012). Selection criteria We included all randomised controlled trials (RCTs) that compared the effects of a nutritional intervention with a control group which did not receive the intervention in this review. Participants were childhood cancer survivors of any age, diagnosed with any type of cancer when less than 18 years of age. Participating childhood cancer survivors had completed their treatment with curative intent prior to the intervention. Data collection and analysis Two review authors independently selected and extracted data from each identified study, using a standardised form. We assessed the validity of each identified study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Intervention s. We used the GRADE criteria to assess the quality of each trial. Main results Three RCTs were eligible for review. A total of 616 participants were included in the analysis. One study included participants who had been treated for acute lymphoblastic leukaemia (ALL) (275 participants). Two studies included participants who had all forms of paediatric malignancies (266 and 75 participants). All participants were less than 21 years of age at study entry. The follow‐up ranged from one month to 36 months from the initial assessment. All intended outcomes were not evaluated by each included study. All studies looked at different interventions, and so we were unable to pool results. We could not rule out the presence of bias in any of the studies. There was no clear evidence of a difference in calcium intake at one month between those who received the single, half‐day, group‐based education that focused on bone health, and those who received standard care (mean difference (MD) 111.60, 95% confidence interval (CI) ‐258.97 to 482.17; P = 0.56, low quality evidence). A regression analysis, adjusting for baseline calcium intake and changes in knowledge and self‐efficacy, showed a significantly greater calcium intake for the intervention as compared with the control group at the one‐month follow‐up (beta coefficient 4.92, 95% CI 0.33 to 9.52; P = 0.04). There was statistically significant higher, self‐reported milk consumption (MD 0.43, 95% CI 0.07 to 0.79; P = 0.02, low quality evidence), number of days on calcium supplementation (MD 11.42, 95% CI 7.11 to 15.73; P < 0.00001, low quality evidence), and use of any calcium supplementation (risk ratio (RR) 3.35, 95% CI 1.86 to 6.04; P < 0.0001, low quality evidence), with those who received this single, face‐to‐face, group‐based, health behaviour session. There was no clear evidence of a difference in bone density Z‐scores measured with a dual‐energy X‐ray absorptiometry (DEXA) scan at 36 months follow‐up (MD ‐0.05, 95% CI ‐0.26 to 0.16; P = 0.64, moderate quality evidence) between those who received calcium and vitamin D supplementation combined with nutrition education and those who received nutrition education alone. There was also no clear evidence of a difference in bone mineral density between the intervention and the control group at the 12‐month (median difference ‐0.17, P = 0.99) and 24‐month follow‐up (median difference ‐0.04, P = 0.54). A single multi‐component health behaviour change intervention, focusing on general healthy eating principles, with two telephone follow‐ups brought about a 0.17 lower score on the four‐point Likert scale of self‐reported junk food intake compared with the control group (MD ‐0.17, 95% CI ‐0.33 to ‐0.01; P = 0.04, low quality evidence); this result was statistically significant. There was no clear evidence of a difference between the groups in the self‐reported use of nutrition as a health protective behaviour (MD ‐0.05, 95% CI ‐0.24 to 0.14; P = 0.60, low quality evidence). Authors' conclusions Due to a paucity of studies, and the heterogeneity of the studies included in this review, we are unable to draw conclusions regarding the effectiveness of nutritional interventions for use with childhood cancer survivors. Although there is low quality evidence for the improvement in health behaviours using health behaviour change interventions, there remains no evidence as to whether this translates into an improvement in dietary intake. There was also no evidence that the studies reduced the risk of cardiovascular and metabolic disorders in childhood cancer survivors, although no evidence of effect is not the same as evidence of no effect. This review highlights the need for further well designed trials to be implemented in this population. Plain language summary Nutritional interventions for survivors of childhood cancer Background Survivors of childhood cancer are at a higher risk of chronic health conditions such as, osteoporosis, metabolic syndrome (including obesity and type II diabetes), and cardiovascular disease. These diseases have the potential to be reduced or prevented with targeted nutritional interventions. Objective This review looks at three randomised controlled trials that studied the effects of interventions designed to improve the dietary intake of children who have completed treatment for cancer. Study Characteristics The three studies included 616 participants who had completed their therapy for childhood cancer. All of the participants were less than 21 years of age at study entry. The interventions ranged from the promotion of health behaviours to vitamin and mineral supplementation. The follow‐up ranged from one month to 36 months from the initial assessment. Key results There was low quality evidence that those who received a health behaviour intervention decreased their self‐reported intake of “junk food”. They also increased their intake of dairy foods, as well as increasing their calcium supplementation. The interventions did not appear to translate to an improvement in their dietary intake, body composition, or bone mineral density. Quality of the evidence The results from this review do not provide enough evidence regarding the effectiveness of nutritional interventions for childhood cancer survivors. There was low quality evidence overall. Further well designed research is needed in this area.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cohen, JE, Wakefield, CE, Cohn, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD009678.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.109Z" }, { "id": "e2c81396-85b5-4b62-bd05-d187265001be", "pmid": "", "title": "Interventions for the management of dry mouth: topical therapies", "imported": false, "abstract": "Abstract - Background Xerostomia (the feeling of dry mouth) is a common symptom especially in older adults. Causes of dry mouth include medications, autoimmune disease (Sjögren's Syndrome), radiotherapy or chemotherapy for cancer, hormone disorders and infections. Objectives To determine which topical treatments for dry mouth are effective in reducing this symptom. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (28 October 2011), The Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 4 2011), MEDLINE via OVID (1950 to 28 October 2011), EMBASE via OVID (1980 to 28 October 2011), CINAHL via EBSCO (1980 to 28 October 2011), AMED via OVID (1985 to 28 October 2011), CANCERLIT via PubMed (1950 to 28 October 2011). Selection criteria We included randomised controlled trials of topical interventions such as lozenges, sprays, mouthrinses, gels, oils, chewing gum or toothpastes for the treatment of dry mouth symptom. We classified interventions into two broad categories, saliva stimulants and saliva substitutes, and these were compared with either placebo or another intervention. We included both parallel group and crossover trials. Data collection and analysis Two or more review authors independently carried out data extraction and assessed risk of bias. Trial authors were contacted for additional information as required. Main results Thirty‐six randomised controlled trials involving 1597 participants met the inclusion criteria. Two trials compared saliva stimulants to placebo, nine trials compared saliva substitutes to placebo, five trials compared saliva stimulants directly with saliva substitutes, 18 trials directly compared two or more saliva substitutes, and two trials directly compared two or more saliva stimulants. Only one trial was at low risk of bias and 17 were at high risk of bias. Due to the range of interventions, comparisons and outcome measures in the trials, meta‐analysis was possible for only a few comparisons. Oxygenated glycerol triester (OGT) saliva substitute spray shows evidence of effectiveness compared to an electrolyte spray (standardised mean difference (SMD) 0.77, 95% confidence interval (CI) 0.38 to 1.15) which corresponds to approximately a mean difference of 2 points on a 10‐point visual analogue scale (VAS) for mouth dryness. Both integrated mouthcare systems (toothpaste + gel + mouthwash) and oral reservoir devices show promising results but there is insufficient evidence at present to recommend their use. Although chewing gum is associated with increased saliva production in the majority of those with residual capacity, there is no evidence that gum is more or less effective than saliva substitutes. Authors' conclusions There is no strong evidence from this review that any topical therapy is effective for relieving the symptom of dry mouth. OGT spray is more effective than an aqueous electrolyte spray (SMD 0.77, 95% CI 0.38 to 1.15) which is approximately equivalent to a mean difference of 2 points on a 10‐point VAS scale for mouth dryness. Chewing gums appear to increase saliva production in those with residual secretory capacity and may be preferred by patients, but there is no evidence that gum is better or worse than saliva substitutes. Integrated mouthcare systems and oral reservoir devices may be helpful but further research is required to confirm this. Well designed, adequately powered randomised controlled trials of topical interventions for dry mouth, which are designed and reported according to CONSORT guidelines, are required to provide evidence to guide clinical care. For many people the symptom of dry mouth is a chronic problem and trials should evaluate whether treatments are palatable, effective in reducing xerostomia, as well as the long‐term effects of treatments on quality of life of those with chronic dry mouth symptoms. Plain language summary Interventions for the management of dry mouth: topical therapies Dry mouth is a common problem with a range of causes. The symptom may be due to a reduction in the quantity of saliva produced, or a change in the composition of saliva, but a feeling of dry mouth may also be present in people with normal saliva production. Radiotherapy or chemotherapy for head and neck cancers, and diseases such as Sjögren's Syndrome, may result in reduced saliva production. Many commonly prescribed medications are associated with a feeling of dry mouth, despite normal saliva production. As well as difficulty in speaking, chewing and swallowing, prolonged dry mouth may result in increased risk of tooth decay and reduced quality of life. In many sufferers dry mouth cannot be cured, but effective ways for people to manage dry mouth symptoms are available. Many topical treatments (applied directly to the inside of the mouth) such as sprays, lozenges, mouthrinses, gels, oils, chewing gum or toothpastes have been evaluated in this review, but there is no strong evidence that any topical treatment is effective for relieving the sensation of dry mouth. Oxygenated glycerol triester (OGT) saliva substitute spray is more effective than a water based electrolyte spray. A gel‐releasing device worn in the mouth, or a mouthcare system might be effective but more research is needed. Chewing gum increases saliva production but there is no evidence that gum is better or worse than saliva substitutes. Acidic products and those containing sugar should be avoided.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Furness, S, Worthington, HV, Bryan, G, Birchenough, S, McMillan, R", "articleTypes": [], "doi": "10.1002/14651858.CD008934.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.750Z" }, { "id": "e2ce35ff-43f8-4ee4-bc94-9c59f74e7981", "pmid": "", "title": "A Phase 3, Global, Multi-center, Double-blind, Randomized Study of ASP2138 Plus Chemotherapy (CAPOX or mFOLFOX6) With Pembrolizumab vs Placebo Plus Chemotherapy With or Without Pembrolizumab in First-line Treatment of Locally Advanced Unresectable or Metastatic Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma in Participants Whose Tumors Are HER2-negative and Claudin (CLDN) 18.2-positive", "imported": false, "abstract": "Claudin 18.2 or CLDN18.2 is a protein found on cells in the digestive system. It is also found in some tumors. Researchers are looking at ways to attack CLDN18.2 to help control tumors. ASP2138 is thought to bind to CLDN18.2 and a type of immune cell called a T cell. This \"tells\" the immune system to attack the tumor. ASP2138 is a potential treatment for people with gastric cancer (also known as stomach cancer) or gastroesophageal junction cancer (GEJ cancer). GEJ is where the tube that carries food (esophagus) joins the stomach.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.251Z" }, { "id": "e2d8f7ef-599f-4c94-9c19-2d626e5a1065", "pmid": "", "title": "Sensory stimulation for brain injured individuals in coma or vegetative state", "imported": false, "abstract": "Abstract - Background Coma and vegetative state follow traumatic brain injury in about one out of eight patients, and in patients with non traumatic injury the prognosis is worse. The use of sensory stimulation for coma and vegetative state has gained popularity during the 1980's but beliefs and opinions about its effectiveness vary substantially among health professionals. Objectives To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. Search methods We searched the Injuries Group specialised register, the Cochrane Controlled trials register, EMBASE, MEDLINE, CINAHL and PSYCHLIT from 1966 to January 2002, without language restriction. Reference lists of articles were scanned and we contacted experts in the area to find other relevant studies. Selection criteria Randomised or controlled trials that compared sensory stimulation programmes with standard rehabilitation in patients in coma or vegetative state. Data collection and analysis Abstracts and papers found were screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality resolving disagreement by consensus. Main results Three studies were identified with 68 patients in total. The overall methodological quality was poor and studies differed widely in terms of outcomes measures, study design and conduct. We therefore did not carry out any quantitative synthesis but reviewed results of available studies qualitatively. Authors' conclusions This systematic review indicates that there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state. Plain language summary No strong evidence about the effects of sensory stimulation for a brain‐injured person in a coma About half of people in a coma (deep unconsciousness) because of traumatic brain injury will wake within a year of the accident. Speeding recovery to allow people to wake sooner is a priority for them and their family. One type of treatment uses sensory stimulation to try to keep the person's brain working normally. Sensory stimulation methods vary greatly, from one or two hourly sessions of a day, through to shorter sessions every hour for 12 to 14 hours a day. The review found there is no strong evidence to determine whether sensory stimulation benefits people in comas.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Lombardi, FFL; Taricco, M; De Tanti, A; Telaro, E; Liberati, A", "articleTypes": [], "doi": "10.1002/14651858.CD001427", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "e34ccb1c-4e36-4825-8185-f35e01293284", "pmid": "", "title": "Interventions for palliative symptom control in COVID‐19 patients", "imported": false, "abstract": "Abstract - Background Individuals dying of coronavirus disease 2019 (COVID‐19) may experience distressing symptoms such as breathlessness or delirium. Palliative symptom management can alleviate symptoms and improve the quality of life of patients. Various treatment options such as opioids or breathing techniques have been discussed for use in COVID‐19 patients. However, guidance on symptom management of COVID‐19 patients in palliative care has often been derived from clinical experiences and guidelines for the treatment of patients with other illnesses. An understanding of the effectiveness of pharmacological and non‐pharmacological palliative interventions to manage specific symptoms of COVID‐19 patients is required. Objectives To assess the efficacy and safety of pharmacological and non‐pharmacological interventions for palliative symptom control in individuals with COVID‐19. Search methods We searched the Cochrane COVID‐19 Study Register (including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), Embase, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), medRxiv); Web of Science Core Collection (Science Citation Index Expanded, Emerging Sources); CINAHL; WHO COVID‐19 Global literature on coronavirus disease; and COAP Living Evidence on COVID‐19 to identify completed and ongoing studies without language restrictions until 23 March 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. Selection criteria We followed standard Cochrane methodology as outlined in the Cochrane Handbook for Systematic Reviews of Interventions . We included studies evaluating palliative symptom management for individuals with a confirmed diagnosis of COVID‐19 receiving interventions for palliative symptom control, with no restrictions regarding comorbidities, age, gender, or ethnicity. Interventions comprised pharmacological as well as non‐pharmacological treatment (e.g. acupressure, physical therapy, relaxation, or breathing techniques). We searched for the following types of studies: randomized controlled trials (RCT), quasi‐RCTs, controlled clinical trials, controlled before‐after studies, interrupted time series (with comparison group), prospective cohort studies, retrospective cohort studies, (nested) case‐control studies, and cross‐sectional studies. We searched for studies comparing pharmacological and non‐pharmacological interventions for palliative symptom control with standard care. We excluded studies evaluating palliative interventions for symptoms caused by other terminal illnesses. If studies enrolled populations with or exposed to multiple diseases, we would only include these if the authors provided subgroup data for individuals with COVID‐19. We excluded studies investigating interventions for symptom control in a curative setting, for example patients receiving life‐prolonging therapies such as invasive ventilation. Data collection and analysis We used a modified version of the Newcastle Ottawa Scale for non‐randomized studies of interventions (NRSIs) to assess bias in the included studies. We included the following outcomes: symptom relief (primary outcome); quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We rated the certainty of evidence using the GRADE approach. As meta‐analysis was not possible, we used tabulation to synthesize the studies and histograms to display the outcomes. Main results Overall, we identified four uncontrolled retrospective cohort studies investigating pharmacological interventions for palliative symptom control in hospitalized patients and patients in nursing homes. None of the studies included a comparator. We rated the risk of bias high across all studies. We rated the certainty of the evidence as very low for the primary outcome symptom relief, downgrading mainly for high risk of bias due to confounding and unblinded outcome assessors. Pharmacological interventions for palliative symptom control We identified four uncontrolled retrospective cohort studies (five references) investigating pharmacological interventions for palliative symptom control. Two references used the same register to form their cohorts, and study investigators confirmed a partial overlap of participants. We therefore do not know the exact number of participants, but individual reports included 61 to 2105 participants. Participants received multimodal pharmacological interventions: opioids, neuroleptics, anticholinergics, and benzodiazepines for relieving dyspnea (breathlessness), delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms. Primary outcome: symptom relief All identified studies reported this outcome. For all symptoms (dyspnea, delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms), a majority of interventions were rated as completely or partially effective by outcome assessors (treating clinicians or nursing staff). Interventions used in the studies were opioids, neuroleptics, anticholinergics, and benzodiazepines. We are very uncertain about the effect of pharmacological interventions on symptom relief (very low‐certainty evidence). The initial rating of the certainty of evidence was low since we only identified uncontrolled NRSIs. Our main reason for downgrading the certainty of evidence was high risk of bias due to confounding and unblinded outcome assessors. We therefore did not find evidence to confidently support or refute whether pharmacological interventions may be effective for palliative symptom relief in COVID‐19 patients. Secondary outcomes We planned to include the following outcomes: quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We did not find any data for these outcomes, or any other information on the efficacy and safety of used interventions. Non‐pharmacological interventions for palliative symptom control None of the identified studies used non‐pharmacological interventions for palliative symptom control. Authors' conclusions We found very low certainty evidence for the efficacy of pharmacological interventions for palliative symptom relief in COVID‐19 patients. We found no evidence on the safety of pharmacological interventions or efficacy and safety of non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. The evidence presented here has no specific implications for palliative symptom control in COVID‐19 patients because we cannot draw any conclusions about the effectiveness or safety based on the identified evidence. More evidence is needed to guide clinicians, nursing staff, and caregivers when treating symptoms of COVID‐19 patients at the end of life. Specifically, future studies ought to investigate palliative symptom control in prospectively registered studies, using an active‐controlled setting, assess patient‐reported outcomes, and clearly define interventions. The publication of the results of ongoing studies will necessitate an update of this review. The conclusions of an updated review could differ from those of the present review and may allow for a better judgement regarding pharmacological and non‐pharmacological interventions for palliative symptom control in COVID‐19 patients. Plain language summary Which treatments are best for symptoms in COVID‐19 patients at the end of life? The burden of symptoms at the end of life of COVID‐19 patients and helpful treatments COVID‐19 patients may show symptoms such as breathlessness or delirium at the end of life. The goal of palliative medicine is to relieve such symptoms with specific treatments. Treatments can be drugs, for example opioids, or non‐drugs, such as breathing techniques or relaxation. What was the aim of our review? To explore how well different interventions (drugs and non‐drugs) work for the treatment of palliative symptoms in COVID‐19 patients at the end of life. We included patients of all ages and with all comorbidities (additional medical conditions). What type of studies did we search for? We searched selected medical databases and trial registries until 23 March 2021. We included studies looking at how well different palliative treatments work to relieve COVID‐19‐associated symptoms at the end of life. We wanted to compare studies investigating different medicines or therapies, but we only found studies without a comparison group. Only one study reported the specific drugs used for individual symptoms. Key results We found four studies that were published in five papers. Individual papers included between 61 and 2105 participants, and two papers partially reported on the same participants. All of the included studies investigated different drug treatments for palliative symptom management in people with COVID‐19. Drugs for symptom control at the end of life All of the included studies reported on the effectiveness of palliative care for symptom relief. In all studies, clinicians or nursing staff rated symptom relief rather than the patients themselves. Since the quality of the evidence was very low, we do not know the true effect of drug treatments on symptom relief and have very low confidence in the results of the studies. We did not find any data on quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; or safety of the drug treatments. Non‐drug therapies for symptom control at the end of life We did not find any data on the benefits and harms of non‐drug therapies for symptom control of COVID‐19 patients at the end of life. Conclusions Based on our findings, we could not draw any conclusions on palliative symptom control of people with COVID‐19. Future studies need to be designed better so that we can determine which treatments work for symptom control in people with COVID‐19.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Andreas, M; Piechotta, V; Skoetz, N; Grummich, K; Becker, M; Joos, L; Becker, G; Meissner, W; Boehlke, C", "articleTypes": [], "doi": "10.1002/14651858.CD015061", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "e35919a4-a18c-44c4-a74c-2ccaf668aba2", "pmid": "", "title": "Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer", "imported": false, "abstract": "Abstract - Background Radioactive iodine treatment for differentiated thyroid cancer possibly results in xerostomia. Amifostine has been used to prevent the effects of irradiation to salivary glands. To date, the effects of amifostine on salivary glands in radioactive iodine treated differentiated thyroid cancer remain uncertain. Objectives To assess the effects of amifostine on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer. Search methods Studies were obtained from computerized searches of MEDLINE, EMBASE, The Cochrane Library and paper collections of conferences held in Chinese. Selection criteria Randomised controlled clinical trials and quasi‐randomised controlled clinical trials comparing the effects of amifostine on salivary glands after radioactive iodine treatment for differentiated thyroid cancer with placebo and a duration of follow up of at least three months. Data collection and analysis Two authors independently assessed risk of bias and extracted data. Main results Two trials with 130 patients (67 and 63 patients randomised to intervention versus control) were included. Both studies had a low risk of bias. Amifostine versus placebo showed no statistically significant differences in the incidence of xerostomia (130 patients, two studies), the decrease of scintigraphically measured uptake of technetium‐99m by salivary or submandibular glands at twelve months (80 patients, one study), and the reduction of blood pressure (130 patients, two studies). Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Meta‐analysis was not performed on the function of salivary glands measured by technetium‐99m scintigraphy at three months after high dose radioactive iodine treatment due to the highly inconsistent findings across studies (I 2 statistic 99%). None of the included trials investigated death from any cause, morbidity, health‐related quality of life or costs. Authors' conclusions Results from two randomised controlled clinical trials suggest that the amifostine has no significant radioprotective effects on salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer patients. Moreover, no health‐related quality of life and other patient‐oriented outcomes were evaluated in the two included trials. Randomised controlled clinical trials with low risk of bias investigating patient‐oriented outcomes are needed to guide treatment choice. Plain language summary Amifostine for salivary glands in high‐dose radioactive iodine treated differentiated thyroid cancer Thyroid cancer is the most common malignancy of the endocrine system consisting of several subtypes like papillary carcinoma (accounting for 80% of cases) and follicular carcinoma (accounting for 11% of cases). These are collectively referred to as 'differentiated thyroid cancer'. Treatment with radioactive iodine after surgery (ablation of the thyroid gland or 'thyroidectomy') is important for the detection of metastatic disease and for the destruction of the remaining thyroid tissue with microscopic cancer. After radioactive iodine treatment, adverse effects may happen in the salivary glands and cause salivary gland swelling and pain, usually involving the parotid. The symptoms may develop immediately after a therapeutic dose of radioactive iodine or months later and progress in intensity with time. Secondary complications reported include dry mouth ('xerostomia') and taste alterations. Amifostine is thought to be a radioprotector of salivary glands used in conjunction with radioiodine therapy. This medication is administered intravenously and was reported to ameliorate the damage of salivary glands caused by radioactive iodine therapy. We found only two randomised controlled trials in which the effects of amifostine were compared with placebo. The two randomised clinical trials investigated 130 patients treated with high dose radioactive iodine for thyroid cancer. Altogether data from the two trials suggest that amifostine has no obvious protective effects on the salivary glands in these patients. Two patients in one study collapsed after initiation of amifostine therapy and had to be treated by withdrawing the infusion and volume substitution. Both patients recovered without sequelae. Until better data become available, the use of sour candy or lemon juice to increase salivation might be more appropriate during radioactive iodine treatment for patients with differentiated thyroid cancer. Patients should be well informed of the importance of hydration, acid stimulation and glandular massage after radioactive iodine treatment. In addition, early recognition and treatment of xerostomia may improve outcomes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Ma, C, Xie, J, Chen, Q, Wang, G, Zuo, S", "articleTypes": [], "doi": "10.1002/14651858.CD007956.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.071Z" }, { "id": "e35cd01c-0cc8-4f41-a4fa-7fe00defed5c", "pmid": "", "title": "Sweet potato for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Sweet potato ( Ipomoea batatas ) is among the most nutritious subtropical and tropical vegetables. It is also used in traditional medicine practices for type 2 diabetes mellitus. Research in animal and human models suggests a possible role of sweet potato in glycaemic control. Objectives To assess the effects of sweet potato for type 2 diabetes mellitus. Search methods We searched several electronic databases, including The Cochrane Library (2013, Issue 1), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2013), combined with handsearches. No language restrictions were used. Selection criteria We included randomised controlled trials (RCTs) that compared sweet potato with a placebo or a comparator intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently selected the trials and extracted the data. We evaluated risk of bias by assessing randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. Main results Three RCTs met our inclusion criteria: these investigated a total of 140 participants and ranged from six weeks to five months in duration. All three studies were performed by the same trialist. Overall, the risk of bias of these trials was unclear or high. All RCTs compared the effect of sweet potato preparations with placebo on glycaemic control in type 2 diabetes mellitus. There was a statistically significant improvement in glycosylated haemoglobin A1c (HbA1c) at three to five months with 4 g/day sweet potato preparation compared to placebo (mean difference ‐0.3% (95% confidence interval ‐0.6 to ‐0.04); P = 0.02; 122 participants; 2 trials). No serious adverse effects were reported. Diabetic complications and morbidity, death from any cause, health‐related quality of life, well‐being, functional outcomes and costs were not investigated. Authors' conclusions There is insufficient evidence about the use of sweet potato for type 2 diabetes mellitus. In addition to improvement in trial methodology, issues of standardization and quality control of preparations ‐ including other varieties of sweet potato ‐ need to be addressed. Further observational trials and RCTs evaluating the effects of sweet potato are needed to guide any recommendations in clinical practice. Plain language summary Sweet potato for type 2 diabetes mellitus Sweet potato ( Ipomoea batatas ) is a plant found in the tropical and subtropical belts and is one of the most nutritious tropical and subtropical vegetables. As well as being popular in cooking in countries in Asia‐Pacific, Africa and North America, sweet potato is also used in traditional medicine for the treatment of diabetes mellitus. We decided to investigate whether there is enough evidence from medical trials to show whether sweet potato works as a treatment for diabetes. This review of randomised controlled trials found only three studies (with a total of 140 participants) that evaluated the effects of sweet potato for type 2 diabetes mellitus compared with a fake medicine (placebo). All these trials were of very low quality. Two studies with 122 participants showed improved long‐term metabolic control of blood sugar levels as measured by glycosylated haemoglobin A1c (HbA1c) which was moderately lowered by 0.3% in participants who were given 4 g sweet potato tablets a day for three to five months. The duration of treatment ranged from six weeks to five months. No study investigated diabetic complications, death from any cause, health‐related quality of life, well‐being, functional outcomes or costs. Adverse effects were mostly mild, and included abdominal distension and pain. There are many varieties of sweet potatoes and sweet potato preparations. More trials are needed to assess the quality of the various sweet potato preparations as well as to evaluate further the use of different varieties of sweet potato in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Ooi, CP, Loke, SC", "articleTypes": [], "doi": "10.1002/14651858.CD009128.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.798Z" }, { "id": "e3897fe7-26b6-446c-a76b-8e2eb2f47915", "pmid": "", "title": "Probiotic treatment for women with gestational diabetes to improve maternal and infant health and well‐being", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance first recognised during pregnancy and associated with complications for mothers and babies. Probiotics are naturally occurring micro‐organisms, which when ingested in adequate amounts, may confer health benefits. Evidence of the role of probiotics as treatment for GDM is limited. Objectives To evaluate the safety and effectiveness of probiotics in treating women with GDM on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth’s Trials Register ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (24 July 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing the use of probiotics versus placebo/standard care for the treatment of GDM. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, checked data accuracy, and assessed risk of bias of included trials. The certainty of evidence for selected maternal and infant/child outcomes was assessed using GRADE. Main results Nine RCTs (695 pregnant women with GDM) comparing probiotics versus placebo were identified. The overall risk of bias in the nine RCTs was low to unclear and the evidence was downgraded for imprecision due to the small numbers of women participating in the trials. The trials were carried out in hospitals and universities in Iran (seven trials), Thailand (one trial) and Ireland (one trial). All trials compared probiotics with placebo. Maternal outcomes We are uncertain if probiotics have any effect compared with placebo on hypertensive disorders of pregnancy, (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.64 to 3.53; participants = 256; studies = 3; low‐certainty evidence) and mode of birth as caesareans (average RR 0.64, 95% CI 0.30 to 1.35; participants = 267; studies = 3; low‐certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm . No trials reported primary outcomes of: mode of birth as vaginal/assisted and subsequent development of type 2 diabetes. We are uncertain if probiotics have any effect compared with placebo on induction of labour (RR 1.33, 95% CI 0.74 to 2.37; participants = 127; studies = 1; very low‐certainty evidence). For other secondary maternal outcomes, we are uncertain if there are differences between probiotics and placebo for: postpartum haemorrhage; weight gain during pregnancy intervention and total gestational weight gain; fasting plasma glucose and need for extra pharmacotherapy (insulin). Probiotics may be associated with a slight reduction in triglycerides and total cholesterol. In probiotics compared with placebo, there was evidence of reduction in markers for insulin resistance (HOMA‐IR) and HOMA‐B; and insulin secretion. There was also an increase in quantitative insulin sensitivity check index (QUICKI). Probiotics were associated with minor benefits in relevant bio‐markers with evidence of a reduction in inflammatory markers high‐sensitivity C‐reactive protein (hs‐CRP), interleukin 6 (IL‐6), and marker of oxidative stress malondialdehyde; and an increase in antioxidant total glutathione, but we are uncertain if there is any difference in total antioxidant capacity. No trials reported secondary outcomes: perineal trauma, postnatal weight retention or return to pre‐pregnancy weight and postnatal depression. Infant/child/adult outcomes We are uncertain if probiotics have any effect, compared with placebo, on the risk of large‐for‐gestational‐age babies (RR 0.73, 95% CI 0.35 to 1.52; participants = 174; studies = 2; low‐certainty evidence) or infant hypoglycaemia (RR 0.85, 95% CI 0.39 to 1.84; participants = 177; studies = 3; low ‐ certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm. No trials reported primary outcomes of: perinatal (fetal/neonatal) mortality; or neurosensory disability. For other secondary outcomes, we are uncertain if there is any difference between probiotics and placebo in gestational age at birth, preterm birth, macrosomia, birthweight, head circumference, length, infant hypoglycaemia, and neonatal intensive care unit (NICU) admissions. There was evidence of a reduction in infant hyperbilirubinaemia with probiotics compared with placebo. No trials reported secondary outcomes: infant adiposity, and later childhood adiposity. There were no adverse events reported by any of the trials. Authors' conclusions Low‐certainty evidence means we are not certain if there is any difference between probiotic and placebo groups in maternal hypertensive disorders of pregnancy, caesareans; and large‐for‐gestational‐age babies . There were no adverse events reported by the trials. Due to the variability of probiotics used and small sample sizes of trials, evidence from this review has limited ability to inform practice. Well‐designed adequately‐powered trials are needed to identify whether probiotics may improve maternal blood glucose levels and/or infant/child/adult outcomes; and whether they can be used to treat GDM. Plain language summary Probiotics as an added treatment for gestational diabetes to improve mother and baby outcomes What is the issue? Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in high blood glucose levels, first recognised during pregnancy. Pregnant women with GDM are at risk of high blood pressure, labour induction, and caesareans. Their babies are at risk of being born large, birth difficulties, respiratory distress, low blood glucose at birth and jaundice that can cause brain injury. There is increased risks of having long‐term diabetes in the mother, and the baby being overweight. Probiotics are micro‐organisms naturally in food and are in fermented milk, yogurt, or capsules. There are many different probiotics; the two most used are Lactobacillus and Bifidobacterium, and if consumed in adequate amounts may confer health benefits. Why is this important? Probiotics need to be safe and maternal blood glucose levels carefully managed during pregnancy. Women with GDM may receive dietary and physical activity education with monitoring blood glucose levels as initial management. When blood glucose levels are above a certain threshold, women with GDM are prescribed glucose‐lowering medications including metformin and/or insulin. This review aimed to determine the safety and effectiveness of probiotics in treating women with GDM. What evidence did we find? We searched for evidence for randomised controlled trials (latest July 2019). We identified nine studies, involving 695 women with GDM. All trials compared probiotics with placebo. The certainty of the evidence was assessed as very low or low. The overall risk of bias was low to unclear. Seven trials were conducted in Iran; one in Thailand, and one in Ireland. Trials took place in hospitals and universities. We are uncertain if there is any difference between probiotic and placebo in rates of: high blood‐pressure disorders (three studies, 256 participants, low‐certainty evidence); caesarean section (three studies, 267 women, low‐certainty evidence ); and large‐for‐gestational‐age babies (two studies, 174 participants, low‐certainty evidence). We are uncertain if there is any difference between probiotic and placebo for induction of labour (one study, 127 participants, very low‐certainty evidence) and low blood glucose levels in the newborn (three studies, 177 participants, low‐certainty evidence). We are also uncertain if there is any difference between probiotics and placebo for heavy bleeding immediately after birth, weight gain during pregnancy or total gestational weight gain. We are uncertain if there is any difference in fasting blood glucose between probiotics and placebo (seven studies, 554 participants). Probiotics may be assoicated with a slight reduction in triglycerides and total cholesterol (four studies, 320 participants). There was reduction in insulin secretion with probiotics (seven studies, 505 participants). One trial (60 participants) showed no difference between groups in need for insulin. Biomarkers, did show a reduction in insulin resistance (HOMA‐IR), (seven studies, 505 participants) and insulin resistance and β cell function (HOMA‐B) (two studies,130 participants) with probiotics. Quantitative insulin sensitivity check index (QUICKI) increased (four studies, 276 participants) with probiotics. Inflammatory markers, hs‐CRP (four studies, 248 participants) and interleukin 6 (two studies, 128 participants) were reduced with probiotics. Antioxidant total glutathione was increased (two studies, 120 participants) and the oxidative stress biomarker malondialdehyde was reduced with probiotics (three studies, 176 participants). We are uncertain if there is any difference in total antioxidant capacity (four studies 266 participants). For the newborn baby, we are uncertain if there is any difference between groups for: birthweight, gestational age at birth, preterm births, large babies, head circumference and length scores, or need for admission to the neonatal intensive care unit. The number of babies with high levels of bilirubin was reduced with probiotics. No adverse events were reported by the trials. What does this mean? Based on the clinical trials available, the evidence is limited to support the use of probiotics as treatment for women with GDM to improve pregnancy outcomes for mothers and their babies. Larger well‐designed randomised controlled trials are needed to assess the effects of probiotics on management of glucose levels and when available, they can be included in the update of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Okesene-Gafa, KAM; Moore, AE; Jordan, V; McCowan, L; Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD012970.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "e38a31de-1c63-4cd1-a574-3cdb88849e48", "pmid": "", "title": "Antibiotics for community‐acquired pneumonia in adult outpatients", "imported": false, "abstract": "Abstract - Background Lower respiratory tract infection (LRTI) is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Community‐acquired pneumonia (CAP) is a common condition that causes a significant disease burden for the community, particularly in children younger than five years, the elderly and immunocompromised people. Antibiotics are the standard treatment for CAP. However, increasing antibiotic use is associated with the development of bacterial resistance and side effects for the patient. Several studies have been published regarding optimal antibiotic treatment for CAP but many of these data address treatments in hospitalised patients. This is an update of our 2009 Cochrane Review and addresses antibiotic therapies for CAP in outpatient settings. Objectives To compare the efficacy and safety of different antibiotic treatments for CAP in participants older than 12 years treated in outpatient settings with respect to clinical, radiological and bacteriological outcomes. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (January 1966 to March week 3, 2014), EMBASE (January 1974 to March 2014), CINAHL (2009 to March 2014), Web of Science (2009 to March 2014) and LILACS (2009 to March 2014). Selection criteria We looked for randomised controlled trials (RCTs), fully published in peer‐reviewed journals, of antibiotics versus placebo as well as antibiotics versus another antibiotic for the treatment of CAP in outpatient settings in participants older than 12 years of age. However, we did not find any studies of antibiotics versus placebo. Therefore, this review includes RCTs of one or more antibiotics, which report the diagnostic criteria and describe the clinical outcomes considered for inclusion in this review. Data collection and analysis Two review authors (LMB, TJMV) independently assessed study reports in the first publication. In the 2009 update, LMB performed study selection, which was checked by TJMV and MMK. In this 2014 update, two review authors (SP, SM) independently performed and checked study selection. We contacted trial authors to resolve any ambiguities in the study reports. We compiled and analysed the data. We resolved differences between review authors by discussion and consensus. Main results We included 11 RCTs in this review update (3352 participants older than 12 years with a diagnosis of CAP); 10 RCTs assessed nine antibiotic pairs (3321 participants) and one RCT assessed four antibiotics (31 participants) in people with CAP. The study quality was generally good, with some differences in the extent of the reporting. A variety of clinical, bacteriological and adverse events were reported. Overall, there was no significant difference in the efficacy of the various antibiotics. Studies evaluating clarithromycin and amoxicillin provided only descriptive data regarding the primary outcome. Though the majority of adverse events were similar between all antibiotics, nemonoxacin demonstrated higher gastrointestinal and nervous system adverse events when compared to levofloxacin, while cethromycin demonstrated significantly more nervous system side effects, especially dysgeusia, when compared to clarithromycin. Similarly, high‐dose amoxicillin (1 g three times a day) was associated with higher incidence of gastritis and diarrhoea compared to clarithromycin, azithromycin and levofloxacin. Authors' conclusions Available evidence from recent RCTs is insufficient to make new evidence‐based recommendations for the choice of antibiotic to be used for the treatment of CAP in outpatient settings. Pooling of study data was limited by the very low number of studies assessing the same antibiotic pairs. Individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups. However, two studies did find significantly more adverse events with use of cethromycin as compared to clarithromycin and nemonoxacin when compared to levofloxacin. Multi‐drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations. Further studies focusing on diagnosis, management, cost‐effectiveness and misuse of antibiotics in CAP and LRTI are warranted in high‐, middle‐ and low‐income countries. Plain language summary Antibiotics for community‐acquired pneumonia in adolescent and adult outpatients Review question This review studied the effects of antibiotics on adolescents and adults with pneumonia acquired and treated in the community (as opposed to acquiring pneumonia in hospital and/or being treated for pneumonia in hospital). The evidence is current to March 2014. Background Lower respiratory tract infection is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Pneumonia, or infection of the lungs, is a common condition representing a significant disease burden for the community. Pneumonia is especially life‐threatening in children younger than five years, in older people and in people with other illnesses that may affect their immune system (such as diabetes or HIV/AIDS, or solid organ transplant recipients). Antibiotics are the most common treatment for pneumonia and these can vary in their effectiveness and adverse effects. Study characteristics We identified 11 trials (with 3352 participants older than 12 years with a diagnosis of community‐acquired pneumonia), fully published in peer‐reviewed journals, focused on treatment of pneumonia in adolescents and adults treated in the community in outpatient settings. This included five new trials included since our last review published in 2009. None of the trials included antibiotics versus placebo; all trials included one or more antibiotics. All participants were diagnosed with pneumonia based upon clinical diagnosis by the physician and chest X‐ray. Study funding sources All included trials were well conducted; nine of the 11 trials were sponsored by bio‐pharmaceutical companies manufacturing the antibiotics used in the study, or their authors were closely linked with the company. Key results Nine of the included trials compared different antibiotics and, hence, we could not combine the results of the individual trials to present our overall conclusion. There were some notable adverse events in seven studies: 1) erythromycin demonstrated significant gastrointestinal side effects compared to clarithromycin in two studies; 2) nemonoxacin demonstrated higher gastrointestinal (nausea, diarrhoea) and nervous system (dizziness, headache) adverse events compared to levofloxacin; 3) cethromycin demonstrated more side effects, especially a distortion of the sense of taste, than clarithromycin; 4) gastritis and diarrhoea were more common in the high‐dose amoxicillin group (1 g three times a day) compared to the other three antibiotic groups (clarithromycin, azithromycin and levofloxacin). Conclusion Unfortunately, there were not enough trials to compare the effects of different antibiotics for pneumonia acquired and treated in the community.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Pakhale, S; Mulpuru, S; Verheij, TJM; Kochen, MM; Rohde, GGU; Bjerre, LM", "articleTypes": [], "doi": "10.1002/14651858.CD002109.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "e390b286-a80d-44ac-8f87-7d0662e5aabc", "pmid": "", "title": "Iodine fortification of foods and condiments, other than salt, for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency disorders (IDD) affect close to 1.9 billion people worldwide, and are a major public health concern in many countries. Among children, iodine deficiency is the main cause of potentially preventable deficits of central nervous system development and impairment of cognitive function, as well as goitre and hypothyroidism in people of all ages. Salt iodisation is the preferred strategy for IDD prevention and control, however, in some instances where salt is not the major condiment, alternate vehicles for iodine fortification have been considered. Objectives To assess the effects of fortifying foods, beverages, condiments, or seasonings other than salt with iodine alone or in conjunction with other micronutrients, on iodine status and health‐related outcomes in all populations. Search methods Studies were identified through systematic searches of the following databases from their start date to January 2018: Cochrane Public Health Group Specialised Register; CENTRAL; MEDLINE; MEDLINE in Process; Embase; Web of Science; CINAHL; POPLINE; AGRICOLA; BIOSIS; Food Science and Technology Abstracts; OpenGrey; Bibliomap and TRoPHI; AGRIS; IBECS; Scielo; Global Index Medicus‐AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched reference list of relevant articles, conference proceedings, and databases of ongoing trials, and contacted experts and relevant organisations to identify any unpublished work. We applied no language or date restrictions. Selection criteria Studies were eligible if they were randomised or quasi‐randomised controlled trials (RCT) with randomisation at either the individual or cluster level (including cross‐over trials), non‐randomised RCTs, or prospective observational studies with a control group, such as cohort studies, controlled before‐and‐after studies, and interrupted time series. We included studies that examined the effects of fortification of food, beverage, condiment, or seasoning with iodine alone, or in combination with other micronutrients versus the same unfortified food, or no intervention. We considered the following measures: death (all‐cause), goitre, physical development, mental development, cognitive function and motor skill development, cretinism, hypothyroidism, adverse effects (any reported by trialists), urinary iodine concentration, thyroid‐stimulating hormone (TSH) concentration, and serum thyroglobulin concentration. We included all populations, including pregnant women, from any country. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias of included studies. We used random‐effects meta‐analyses to combine data and generate an overall estimate of treatment effect, when more than one study examined the same outcome measure. The overall effect estimate was calculated as the mean difference (MD) or standardised mean difference (SMD) between the intervention group and the comparison group for continuous outcomes, and as odds ratio (OR) for dichotomous outcomes. We assessed the level of heterogeneity through the I² statistic. We conducted post‐hoc subgroup analyses to explore possible sources of heterogeneity, and sensitivity analyses to check the robustness of the findings from the primary analyses. We assessed the quality of the evidence for each outcome using the GRADE framework. Where it was not possible to pool the results in a meta‐analysis, we provided a narrative summary of the outcomes. Main results Eleven studies met the criteria, providing 14 comparisons, and capturing data on 4317 participants. Seven studies were RCTs, three were cluster non‐RCTs, and one was a randomised cross‐over design. Seven studies were carried out among school children (N = 3636), three among women of reproductive age (N = 648), and one among infants (N = 33). The studies used diverse types of food as vehicle for iodine delivery: biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. Daily amounts of iodine provided ranged from 35 µg/day to 220 µg/day; trial duration ranged from 11 days to 48 weeks. Five studies examined the effect of iodine fortification alone, two against the same unfortified food, and three against no intervention. Six studies evaluated the effect of cofortification of iodine with other micronutrients versus the same food without iodine but with different levels of other micronutrients. We assessed one study to be at low risk of bias for all bias domains, three at low risk of bias for all domains apart from selective reporting, and seven at an overall rating of high risk of bias. No study assessed the primary outcomes of death, mental development, cognitive function, cretinism, or hypothyroidism, or secondary outcomes of TSH or serum thyroglobulin concentration. Two studies reported the effects on goitre, one on physical development measures, and one on adverse effects. All studies assessed urinary iodine concentration. The effects of iodine fortification compared to control on goitre prevalence (OR 1.60, 95% CI 0.60 to 4.31; 1 non‐RCT, 83 participants; very low‐quality evidence), and five physical development measures were uncertain (1 non‐RCT, 83 participants; very low‐quality evidence): weight (MD 0.23 kg, 95% CI ‐6.30 to 6.77); height (MD ‐0.66 cm, 95% CI ‐4.64 to 3.33); weight‐for‐age (MD 0.05, 95% CI ‐0.59 to 0.69); height‐for‐age (MD ‐0.30, 95% CI ‐0.75 to 0.15); and weight‐for‐height (MD ‐0.21, 95% CI ‐0.51 to 0.10). One study reported that there were no adverse events observed during the cross‐over trial (low‐quality evidence). Pooled results from RCTs showed that urinary iodine concentration significantly increased following iodine fortification (SMD 0.59, 95% CI 0.37 to 0.81; 6 RCTs, 2032 participants; moderate‐quality evidence). This is equivalent to an increase of 38.32 µg/L (95% CI 24.03 to 52.61 µg/L). This effect was not observed in the meta‐analysis of non‐RCTs (SMD 0.25, 95% CI ‐0.16 to 0.66; 3 non‐RCTs, 262 participants; very low‐quality evidence). Sensitivity analyses did not change the effect observed in the primary analyses. Authors' conclusions The evidence on the effect of iodine fortification of foods, beverages, condiments, or seasonings other than salt on reducing goitre, improving physical development measures, and any adverse effects is uncertain. However, our findings suggest that the intervention likely increases urinary iodine concentration. Additional, adequately powered, high‐quality studies on the effects of iodine fortification of foods on these, and other important outcomes, as well as its efficacy and safety, are required. Plain language summary Adding iodine to foods, other than salt, to prevent diseases caused by inadequate iodine intake Background and review question Many people around the world do not consume enough iodine. This is a problem because iodine is important for normal childhood growth and brain development, and for ensuring a healthy adult population. Inadequate intake of iodine can lead to health problems, such as intellectual disability and goitre (enlargement of the thyroid gland). Currently, the main strategy to increase the amount of iodine consumed in populations recommended by the World Health Organization is adding iodine to salt. However, in some areas where salt is not the major condiment, adding iodine to other foods has also been explored. The aim of our study was to examine the effect of adding iodine to foods, beverages, condiments, or seasonings, other than salt, on iodine nutrition status and health‐related outcomes in all populations. Study characteristics We searched for articles from different sources including published research papers, unpublished reports, and through direct communication with experts and organisations working to address iodine and micronutrient deficiency. We last searched the databases in January 2018. Eleven studies, which captured data on 4317 participants (3636 children, 648 women of reproductive age, and 33 infants), met our inclusion criteria. The type of foods used as vehicle to deliver iodine differed between the studies, and included biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. The amount of iodine provided to participants ranged from 35 µg/day to 220 µg/day, and study duration ranged from 11 days to 48 weeks. Of the 11 studies included, five examined the effect of adding iodine alone to foods compared to either no intervention or the same foods without iodine; while six evaluated the effect of adding iodine plus other micronutrients to foods compared to the same foods without iodine, but with different levels of other micronutrients. Key results No study evaluated the effect of adding iodine to foods on death, mental development, cognitive function, cretinism (a condition characterized by impaired control of physical movement and intellectual disability), hypothyroidism (underactive thyroid), thyroid‐stimulating hormone concentration, or serum thyroglobulin concentration (these are biological markers that indicate the presence of iodine deficiency when concentration in the blood is high). Two studies reported on the effect of the intervention on goitre, one study assessed five physical development measures (weight, height, weight‐for‐age, height‐for‐age, and weight‐for‐height scores), and one examined adverse effects. All studies assessed urinary iodine concentration (the concentration of iodine secreted in the urine, which indicates the presence of iodine deficiency when concentration is low in a population group, rather than in an individual). We combined the data that met our requirements in these studies in a meta‐analysis. We are uncertain of the effects of iodine fortification on the proportion of participants with goitre, or on any of the five physical development measures. One study reported narratively that no adverse effects were observed during the trial. We found a significant increase of 38.32 µg/L in urinary iodine concentration after adding iodine to foods, compared to the groups that did not have iodine added, from studies of higher quality. Quality of the evidence Using GRADE, we rated the quality of the evidence as very low for goitre and physical development measures, due to study limitations (risk of bias) and imprecise results, and low for adverse events due to indirectness and imprecise results. We rated the quality of the evidence for urinary iodine concentration, from studies in which participants were allocated to treatment groups at random (gold standard design for clinical research), as moderate. On the other hand, quality of the evidence for urinary iodine concentration from studies without this random element was rated as very low, due to study limitations and imprecise results. Conclusion Overall, there is no clear evidence on the effect of the intervention on reducing the proportion of people with goitre, improving physical growth, or adverse events. However, our results show that adding iodine to foods likely increases urinary iodine concentration. Additional studies to better quantify the effect of the intervention on these outcomes, as well as other outcomes, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Santos, JAR; Christoforou, A; Trieu, K; McKenzie, BL; Downs, S; Billot, L; Webster, J; Li, M", "articleTypes": [], "doi": "10.1002/14651858.CD010734.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "e394541f-2bb3-49f0-bc5e-64cb5ba5dbff", "pmid": "", "title": "A Randomized, Double-Blind, Placebo-Controlled, Multicenter Phase IIb Clinical Trial to Evaluate the Efficacy and Safety of Oral VG081821AC Tablets Monotherapy (Without Concomitant Levodopa) in Patients With Early to Mid-Stage Parkinson's Disease", "imported": false, "abstract": "This study is testing a new oral medication called VG081821AC to see if it can help improve movement symptoms in people with early to mid-stage Parkinson's disease. VG081821AC works by blocking a protein in the brain called the adenosine A2A receptor, which may help improve motor function without using levodopa. The main goal is to measure changes in movement symptoms using a standard rating scale called the MDS-UPDRS Part III (Motor Examination). This scale evaluates how well participants can move, walk, and perform daily activities. The study will compare the scores before and after 12 weeks of treatment to see if VG081821AC improves movement symptoms better than the placebo. Currently, levodopa is the most common treatment for Parkinson's disease, but it can cause side effects over time. If VG081821AC works well, it could offer a new treatment option for people in the early to mid-stages of Parkinson's disease who want to delay or avoid starting levodopa. A total of 152 adults (aged 18-80 years) will be enrolled in this trial in China. Participants will be randomly assigned (like flipping a coin) to one of four groups:", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.242Z" }, { "id": "e3af37cc-6668-4e42-8de2-01e38670c737", "pmid": "", "title": "Effects of opioid, hypnotic and sedating medications on sleep‐disordered breathing in adults with obstructive sleep apnoea", "imported": false, "abstract": "Abstract - Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by partial or complete upper airway occlusion during sleep, leading to intermittent cessation (apnoea) or reduction (hypopnoea) of airflow and dips in arterial oxygen saturation during sleep. Many patients with recognised and unrecognised OSA receive hypnotics, sedatives and opiates/opioids to treat conditions including pain, anxiety and difficulty sleeping. Concerns have been expressed that administration of these drugs to people with co‐existing OSA may worsen OSA. Objectives To investigate whether administration of sedative and hypnotic drugs exacerbates the severity of OSA (as measured by the apnoea‐hypopnoea index (AHI) or the 4% oxygen desaturation index (ODI)) in people with known OSA. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR) of trials. The search was current as of March 2015. Selection criteria Randomised, placebo‐controlled trials including adult participants with confirmed OSA, where participants were randomly assigned to use opiates or opioids, sedatives, hypnotics or placebo. We included participants already using continuous positive airway pressure (CPAP) or a mandibular advancement device. Data collection and analysis We used standard methodological procedures as recommended by The Cochrane Collaboration. Main results Fourteen studies examining the effects of 10 drugs and including a total of 293 participants contributed to this review. Trials were small, with only two trials, which used sodium oxybate, recruiting more than 40 participants, and all but three trials were of only one to three nights in duration. Most participants had mild to moderate OSA with a mean AHI of 11 to 25 events/h, and only two trials recruited patients with severe OSA. Two trials investigating the effects of ramelteon, a treatment option for insomnia, recruited adults over 60 years of age with OSA and concomitant insomnia. The drugs studied in this review included remifentanil (infusion) 0.75 mcg/kg/h, eszopiclone 3 mg, zolpidem 10 and 20 mg, brotizolam 0.25 mg, flurazepam 30 mg, nitrazepam 10 mg to 15 mg, temazepam 10 mg, triazolam 0.25 mg, ramelteon 8 mg and 16 mg and sodium oxybate 4.5 g and 9 g. We were unable to pool most of the data, with the exception of data for eszopiclone and ramelteon. None of the drugs in this review produced a significant increase in AHI or ODI. Two trials have shown a beneficial effect on OSA. One study showed that a single administration of eszopiclone 3 mg significantly decreased AHI compared with placebo (24 ± 4 vs 31 ± 5; P value < 0.05), and a second study of sodium oxybate 4.5 g showed a significant decrease in AHI compared with placebo (mean difference (MD) ‐7.41, 95% confidence interval (CI) ‐14.17 to ‐0.65; N = 48). Only four trials reported outcome data on ODI. No significant increase, in comparison with placebo, was shown with eszopiclone (21 (22 to 37) vs 28.0 (15 to 36); P value = NS), zolpidem (0.81 ± 0.29 vs 1.46 ± 0.53; P value = NS), flurazepam (18.6 ± 19 vs 19.6 ± 15.9; P value = NS) and temazepam (6.53 ± 9.4 vs 6.56 ± 8.3; P value = 0.98). A significant decrease in minimum nocturnal peripheral capillary oxygen saturation (SpO 2 ) was observed with zolpidem 20 mg (76.8 vs 85.2; P value = 0.002), flurazepam 30 mg (81.7 vs 85.2; P value = 0.002), remifentanil infusion (MD ‐7.00, 95% CI ‐11.95 to ‐2.05) and triazolam 0.25 mg in both rapid eye movement (REM) and non‐REM (NREM) sleep (MD ‐14.00, 95% CI ‐21.84 to ‐6.16; MD ‐10.20, 95% CI ‐16.08 to ‐4.32, respectively. One study investigated the effect of an opiate (remifentanil) on patients with moderate OSA. Remifentanil infusion did not significantly change AHI (MD 10.00, 95% CI ‐9.83 to 29.83); however it did significantly decrease the number of obstructive apnoeas (MD ‐9.00, 95% CI ‐17.40 to ‐0.60) and significantly increased the number of central apnoeas (MD 16.00, 95% CI ‐2.21 to 34.21). Similarly, although without significant effect on obstructive apnoeas, central apnoeas were increased in the sodium oxybate 9 g treatment group (MD 7.3 (18); P value = 0.005) in a cross‐over trial. Drugs studied in this review were generally well tolerated, apart from adverse events reported in 19 study participants prescribed remifentanil (n = 1), eszopiclone (n = 6), sodium oxybate (n = 9) or ramelteon (n = 3). Authors' conclusions The findings of this review show that currently no evidence suggests that the pharmacological compounds assessed have a deleterious effect on the severity of OSA as measured by change in AHI or ODI. Significant clinical and statistical decreases in minimum overnight SpO 2 were observed with remifentanil, zolpidem 20 mg and triazolam 0.25 mg. Eszopiclone 3 mg and sodium oxybate 4.5 g showed a beneficial effect on the severity of OSA with a reduction in AHI and may merit further assessment as a potential therapeutic option for a subgroup of patients with OSA. Only one trial assessed the effect of an opioid (remifentanil); some studies included CPAP treatment, whilst in a significant number of participants, previous treatment with CPAP was not stated and thus a residual treatment effect of CPAP could not be excluded. Most studies were small and of short duration, with indiscernible methodological quality.Caution is therefore required when such agents are prescribed for patients with OSA, especially outside the severity of the OSA cohorts and the corresponding dose of compounds given in the particular studies. Larger, longer trials involving patients across a broader spectrum of OSA severity are needed to clarify these results. Plain language summary Effects of opioid, hypnotic and sedating medications on obstructive sleep apnoea (OSA) in adults with known OSA Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by intermittent apnoeas (pauses in breathing) leading to dips in oxygen levels in the blood during sleep. Many people with known or unknown (undiagnosed) OSA receive hypnotics, sedatives and opiate/opioid drugs to treat other conditions including pain, anxiety and difficulty sleeping. Opiates/opioids are commonly prescribed to treat pain after major surgery. These drugs might make sleep apnoea worse ‐ increasing the frequency and duration of apnoeas. Review question We set out to look at evidence derived from randomised placebo‐controlled trials to identify the risks of these drugs for patients with known OSA. What we did We searched and reviewed all randomised placebo‐controlled trials involving adult patients with known OSA who received these drugs. Most of the trials were short at just one or two nights' duration, involved only a small number of patients and used poorly described methodology. Therefore it was difficult to find out the exact effects of these drugs on patients with OSA. Results We found 14 studies examining the effects of 10 drugs in trials including 293 people. Opiates and opioids (treatment of acute and chronic pain) Remifentanil infusion Remifentanil infusion did not significantly change severity of OSA as measured by numbers and duration of pauses in breathing during sleep, but it significantly lowered minimum oxygen levels during the night when compared with placebo. Sedatives and hypnotics 'Z drugs' (a treatment for insomnia, inability to fall asleep or inability to maintain sleep) Eszopiclone and zolpidem Eszopiclone did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, it reduced the severity of OSA, and it might be beneficial in treating this condition, although further studies are needed to assess this effect. Zolpidem did not significantly worsen OSA as measured by the numbers and duration of pauses in breathing during sleep, but in one trial, it significantly lowered minimum oxygen levels during the night when compared with placebo. Benzodiazepines (short‐term relief of severe anxiety, behavioural disturbance or agitation and panic disorders) Brotizolam, flurazepam, nitrazepam, temazepam and triazolam None of the drugs examined had significantly worsened OSA as measured by the numbers and duration of pauses in breathing during sleep. In small, single‐night studies, zolpidem 20 mg, flurazepam 20 mg and triazolam 0.25 mg showed a tendency to increase numbers and duration of pauses during sleep, which was not statistically significant, but these drugs significantly lowered minimum oxygen levels during the night when compared with placebo. Sodium oxybate (a treatment for narcolepsy, a condition causing excessive sleepiness during the day) Sodium oxybate was compared with placebo in two trials. Results showed that sodium oxybate did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, sodium oxybate 4.5 g reduced the severity of OSA and might have proved beneficial in treating this condition, although further studies are needed to assess this effect. Melatonin and melatonin‐related drugs Ramelteon (a treatment drug for insomnia) Ramelteon was assessed in older adults, over 60 years of age, with OSA and insomnia and was found not to worsen OSA. Results of this review show that the drugs studied do not worsen the severity of OSA as measured by the numbers and duration of pauses in breathing during sleep, but significant clinical and statistical decreases in minimum oxygen levels during the night were observed with remifentanil, zolpidem and triazolam; therefore prescribing these drugs for patients with OSA still warrants caution. Sodium oxybate 4.5 g and eszopiclone reduced the severity of OSA and might be beneficial in treating this condition; nonetheless further studies are needed to support these results. Bottom line The long‐term effect and potential side effects of sedative drugs in people with OSA need to be assessed in larger, longer and methodologically robust studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mason, M; Cates, CJ; Smith, I", "articleTypes": [], "doi": "10.1002/14651858.CD011090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "e3b27bda-83f6-46df-bbd7-6a990a5654b0", "pmid": "", "title": "A Randomized, Double-Blind, Placebo-Controlled, Multicenter Phase IIb Clinical Trial to Evaluate the Efficacy and Safety of Oral VG081821AC Tablets Monotherapy (Without Concomitant Levodopa) in Patients With Early to Mid-Stage Parkinson's Disease", "imported": false, "abstract": "This study is testing a new oral medication called VG081821AC to see if it can help improve movement symptoms in people with early to mid-stage Parkinson's disease. VG081821AC works by blocking a protein in the brain called the adenosine A2A receptor, which may help improve motor function without using levodopa. The main goal is to measure changes in movement symptoms using a standard rating scale called the MDS-UPDRS Part III (Motor Examination). This scale evaluates how well participants can move, walk, and perform daily activities. The study will compare the scores before and after 12 weeks of treatment to see if VG081821AC improves movement symptoms better than the placebo. Currently, levodopa is the most common treatment for Parkinson's disease, but it can cause side effects over time. If VG081821AC works well, it could offer a new treatment option for people in the early to mid-stages of Parkinson's disease who want to delay or avoid starting levodopa. A total of 152 adults (aged 18-80 years) will be enrolled in this trial in China. Participants will be randomly assigned (like flipping a coin) to one of four groups:", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.261Z" }, { "id": "e3cc381b-7a2d-4a4d-8099-2266277b2c60", "pmid": "", "title": "Omega‐6 fats for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐6 fats are polyunsaturated fats vital for many physiological functions, but their effect on cardiovascular disease (CVD) risk is debated. Objectives To assess effects of increasing omega‐6 fats (linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA)) on CVD and all‐cause mortality. Search methods We searched CENTRAL, MEDLINE and Embase to May 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher versus lower omega‐6 fat intake in adults with or without CVD, assessing effects over at least 12 months. We included full texts, abstracts, trials registry entries and unpublished studies. Outcomes were all‐cause mortality, CVD mortality, CVD events, risk factors (blood lipids, adiposity, blood pressure), and potential adverse events. We excluded trials where we could not separate omega‐6 fat effects from those of other dietary, lifestyle or medication interventions. Data collection and analysis Two authors independently screened titles/abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias of included trials. We wrote to authors of included studies. Meta‐analyses used random‐effects analysis, while sensitivity analyses used fixed‐effects and limited analyses to trials at low summary risk of bias. We assessed GRADE quality of evidence for 'Summary of findings' tables. Main results We included 19 RCTs in 6461 participants who were followed for one to eight years. Seven trials assessed the effects of supplemental GLA and 12 of LA, none DGLA or AA; the omega‐6 fats usually displaced dietary saturated or monounsaturated fats. We assessed three RCTs as being at low summary risk of bias. Primary outcomes : we found low‐quality evidence that increased intake of omega‐6 fats may make little or no difference to all‐cause mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.88 to 1.12, 740 deaths, 4506 randomised, 10 trials) or CVD events (RR 0.97, 95% CI 0.81 to 1.15, 1404 people experienced events of 4962 randomised, 7 trials). We are uncertain whether increasing omega‐6 fats affects CVD mortality (RR 1.09, 95% CI 0.76 to 1.55, 472 deaths, 4019 randomised, 7 trials), coronary heart disease events (RR 0.88, 95% CI 0.66 to 1.17, 1059 people with events of 3997 randomised, 7 trials), major adverse cardiac and cerebrovascular events (RR 0.84, 95% CI 0.59 to 1.20, 817 events, 2879 participants, 2 trials) or stroke (RR 1.36, 95% CI 0.45 to 4.11, 54 events, 3730 participants, 4 trials), as we assessed the evidence as being of very low quality. We found no evidence of dose‐response or duration effects for any primary outcome, but there was a suggestion of greater protection in participants with lower baseline omega‐6 intake across outcomes. Additional key outcomes : we found increased intake of omega‐6 fats may reduce myocardial infarction (MI) risk (RR 0.88, 95% CI 0.76 to 1.02, 609 events, 4606 participants, 7 trials, low‐quality evidence). High‐quality evidence suggests increasing omega‐6 fats reduces total serum cholesterol a little in the long term (mean difference (MD) −0.33 mmol/L, 95% CI −0.50 to −0.16, I 2 = 81%; heterogeneity partially explained by dose, 4280 participants, 10 trials). Increasing omega‐6 fats probably has little or no effect on adiposity (body mass index (BMI) MD −0.20 kg/m 2 , 95% CI −0.56 to 0.16, 371 participants, 1 trial, moderate‐quality evidence). It may make little or no difference to serum triglycerides (MD −0.01 mmol/L, 95% CI −0.23 to 0.21, 834 participants, 5 trials), HDL (MD −0.01 mmol/L, 95% CI −0.03 to 0.02, 1995 participants, 4 trials) or low‐density lipoprotein (MD −0.04 mmol/L, 95% CI −0.21 to 0.14, 244 participants, 2 trials, low‐quality evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐6 fats on cardiovascular health, mortality, lipids and adiposity to date, using previously unpublished data. We found no evidence that increasing omega‐6 fats reduces cardiovascular outcomes other than MI, where 53 people may need to increase omega‐6 fat intake to prevent 1 person from experiencing MI. Although benefits of omega‐6 fats remain to be proven, increasing omega‐6 fats may be of benefit in people at high risk of MI. Increased omega‐6 fats reduce serum total cholesterol but not other blood fat fractions or adiposity. Plain language summary Omega‐6 fats to prevent and treat heart and circulatory diseases Review question We reviewed randomised trials (participants had an equal chance to be assigned to either treatment) examining effects of higher omega‐6 fats compared to lower omega‐6 fats on deaths and heart and circulatory diseases (cardiovascular diseases (CVD), which include heart attacks and strokes). Background Omega‐6 fats are essential, we must obtain some from food. They are important for regulating energy production (part of metabolism), bone, skin and hair health. Many foods contain omega‐6 fats, particularly vegetable oils and nuts. Omega‐6 fats include linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA). Some evidence suggests that a higher intake of omega‐6 fats, along with a lower intake of saturated fat (from animal sources such as meat and cheese) can reduce coronary heart disease. In contrast, there is concern that high levels of omega‐6 fats may worsen cardiovascular risk by increasing inflammation. Overall, there is no conclusive evidence on the benefits or harms of omega‐6 fat intake on heart and circulatory diseases or on other health outcomes. Study characteristics Evidence in this review is current to May 2017. We found 19 studies recruiting 6461 adults. These studies assessed the effects of higher compared to lower omega‐6 fat intake on heart and circulatory diseases as well as deaths. We found that three trials were highly trustworthy (with good designs that produce reliable evidence). Studies took place in North America, Asia, Europe and Australia, and eight were funded only by national or charitable agencies. Participants increased their omega‐6 fats or maintained their usual fats for at least one year and up to eight years. Key results We found that increasing omega‐6 fats may make little or no difference to deaths or cardiovascular events but may reduce risk of heart attacks (low‐quality evidence). Evidence was weakened by study design problems, small numbers of events, low numbers of participants from developing countries, and few women. Evidence suggests that increasing omega‐6 fats reduces blood cholesterol (high‐quality evidence), probably has little or no effect on body weight adjusted for height (all moderate‐quality evidence), and may make little or no difference to triglycerides, high‐density lipoprotein (HDL, the 'good' cholesterol) or low‐density lipoprotein (LDL, the 'bad' cholesterol, low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hooper, L; Al‐Khudairy, L; Abdelhamid, AS; Rees, K; Brainard, JS; Brown, TJ; Ajabnoor, SM; O'Brien, AT; Winstanley, LE; Donaldson, DH; Song, F; Deane, KHO", "articleTypes": [], "doi": "10.1002/14651858.CD011094.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "e3d15440-73be-472f-a18e-6c5e4eb659a3", "pmid": "", "title": "Antioxidant supplementation for lung disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Airway infection leads to progressive damage of the lungs in cystic fibrosis (CF) and oxidative stress has been implicated in the etiology. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, beta‐carotene and selenium) or N‐acetylcysteine (NAC) as a source of glutathione, may therefore potentially help maintain an oxidant‐antioxidant balance. Glutathione or NAC can also be inhaled and if administered in this way can also have a mucolytic effect besides the antioxidant effect. Current literature suggests a relationship between oxidative status and lung function. This is an update of a previously published review. Objectives To synthesise existing knowledge on the effect of antioxidants such as vitamin C, vitamin E, beta‐carotene, selenium and glutathione (or NAC as precursor of glutathione) on lung function through inflammatory and oxidative stress markers in people with CF. Search methods The Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and PubMed were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies. We also searched online trials registries. Last search of Cystic Fibrosis Trials Register: 08 January 2019. Selection criteria Randomised and quasi‐randomised controlled studies comparing antioxidants as listed above (individually or in combination) in more than a single administration to placebo or standard care in people with CF. Data collection and analysis Two authors independently selected studies, extracted data and assessed the risk of bias in the included studies. We contacted study investigators to obtain missing information. If meta‐analysed, studies were subgrouped according to supplement, method of administration and the duration of supplementation. We assessed the quality of the evidence using GRADE. Main results One quasi‐randomised and 19 randomised controlled studies (924 children and adults) were included; 16 studies (n = 639) analysed oral antioxidant supplementation and four analysed inhaled supplements (n = 285). Only one of the 20 included studies was judged to be free of bias. Oral supplements versus control The change from baseline in forced expiratory volume in one second (FEV 1 ) % predicted at three months and six months was only reported for the comparison of NAC to control. Four studies (125 participants) reported at three months; we are uncertain whether NAC improved FEV 1 % predicted as the quality of the evidence was very low, mean difference (MD) 2.83% (95% confidence interval (CI) ‐2.16 to 7.83). However, at six months two studies (109 participants) showed that NAC probably increased FEV 1 % predicted from baseline (moderate‐quality evidence), MD 4.38% (95% CI 0.89 to 7.87). A study of a combined vitamin and selenium supplement (46 participants) reported a greater change from baseline in FEV 1 % predicted in the control group at two months, MD ‐4.30% (95% CI ‐5.64 to ‐2.96). One study (61 participants) found that NAC probably makes little or no difference in the change from baseline in quality of life (QoL) at six months (moderate‐quality evidence), standardised mean difference (SMD) ‐0.03 (95% CI ‐0.53 to 0.47), but the two‐month combined vitamin and selenium study reported a small difference in QoL in favour of the control group, SMD ‐0.66 (95% CI ‐1.26 to ‐0.07). The NAC study reported on the change from baseline in body mass index (BMI) (62 participants) and similarly found that NAC probably made no difference between groups (moderate‐quality evidence). One study (69 participants) found that a mixed vitamin and mineral supplement may lead to a slightly lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) provided information on adverse events, but did not find any clear and consistent evidence of differences between treatment or control groups with the quality of the evidence ranging from low to moderate. Studies of β‐carotene and vitamin E consistently reported greater plasma levels of the respective antioxidants. Inhaled supplements versus control Two studies (258 participants) showed inhaled glutathione probably improves FEV 1 % predicted at three months, MD 3.50% (95% CI 1.38 to 5.62), but not at six months compared to placebo, MD 2.30% (95% CI ‐0.12 to 4.71) (moderate‐quality evidence). The same studies additionally reported an improvement in FEV 1 L in the treated group compared to placebo at both three and six months. One study (153 participants) reported inhaled glutathione probably made little or no difference to the change in QoL from baseline, MD 0.80 (95% CI ‐1.63 to 3.23) (moderate‐quality evidence). No study reported on the change from baseline in BMI at six months, but one study (16 participants) reported at two months and a further study (105 participants) at 12 months; neither study found any difference at either time point. One study (153 participants) reported no difference in the time to the first pulmonary exacerbation at six months. Two studies (223 participants) reported treatment may make little or no difference in adverse events (low‐quality evidence), a further study (153 participants) reported that the number of serious adverse events were similar across groups. Authors' conclusions With regards to micronutrients, there does not appear to be a positive treatment effect of antioxidant micronutrients on clinical end‐points; however, oral supplementation with glutathione showed some benefit to lung function and nutritional status. Based on the available evidence, inhaled and oral glutathione appear to improve lung function, while oral administration decreases oxidative stress; however, due to the very intensive antibiotic treatment and other concurrent treatments that people with CF take, the beneficial effect of antioxidants remains difficult to assess in those with chronic infection without a very large population sample and a long‐term study period. Further studies, especially in very young children, using outcome measures such as lung clearance index and the bronchiectasis scores derived from chest scans, with improved focus on study design variables (such as dose levels and timing), and elucidating clear biological pathways by which oxidative stress is involved in CF, are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn. The benefit of antioxidants in people with CF who receive CFTR modulators therapies should also be assessed in the future. Plain language summary How do vitamins E and C, beta‐carotene, selenium and glutathione affect lung disease in people with cystic fibrosis? Background Frequent chest infections cause long‐term lung inflammation; inflammation‐causing cells produce an oxygen molecule (reactive oxygen species (ROS)), which may harm body tissue (oxidative damage); the body uses antioxidants to protect itself. People with cystic fibrosis (CF) have high levels of ROS compared to low levels of antioxidants. Antioxidant supplements might reduce oxidative damage and build up levels of antioxidants. Given difficulties in absorbing fat, people with CF have low levels of fat‐soluble antioxidants (vitamin E and beta‐carotene). Water‐soluble vitamin C decreases with age in people with CF. Glutathione, one of the most abundant antioxidants in cells, is not released properly into the lungs of people with CF. Some enzymes that help antioxidants work depend on the mineral selenium, so selenium supplements aim to stimulate antioxidant action. Most supplements are swallowed, but glutathione and N‐acetylcysteine (NAC) (which the body uses to make glutathione) can also be inhaled; these may affect lung function as antioxidants, but also due to thinning mucus when inhaled (allowing easier mucus clearance). Search date Last search for this updated review: 08 January 2019. Study characteristics We included 20 studies (924 people with CF, almost equal gender split, aged six months to 59 years); 16 studies compared oral supplements to placebo ('dummy' treatment) and four compared inhaled supplements to placebo. Key results Oral supplements We are uncertain whether NAC changes lung function (forced expiratory volume in one second (FEV 1 ) % predicted) at three months (four studies, 125 participants, very low‐quality evidence), but at six months two studies (109 participants) reported NAC probably improved FEV 1 % predicted (moderate‐quality evidence). One study (46 participants) reported a greater change in FEV 1 % predicted with placebo than with a combined vitamin and selenium supplement after two months. One study (61 participants) reported little or no difference in quality of life (QoL) scores between NAC and control after six months (moderate‐quality evidence), but the two‐month combined vitamin and selenium study reported slightly better QoL scores in the control group. NAC probably made no difference to body mass index (BMI) (one study, 62 participants, moderate‐quality evidence). One study (69 participants) reported that a mixed vitamin and mineral supplement may lead to a lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low‐quality evidence). Nine studies (366 participants) did not find any clear and consistent differences in side effects between groups (evidence ranged from low to moderate quality). Vitamin E and β‐carotene studies consistently reported greater levels of these antioxidants in blood samples. Inhaled supplements In two studies (258 participants), inhaled glutathione probably improved FEV 1 % predicted compared to placebo at three months but not at six months (moderate‐quality evidence); these studies also reported a greater improvement in FEV 1 litres with glutathione compared to placebo at both time points. Two studies (258 participants) found little or no difference in the change in QoL scores (moderate‐quality evidence). One two‐month study (16 participants) and a 12‐month study (105 participants) reported no difference between groups in the change in BMI. There was no difference in the time to the first pulmonary exacerbation in one six‐month study. Two studies (223 participants) reported no difference between groups in side effects (low‐quality evidence) and another study (153 participants) reported that the number of serious side effects were similar across groups. Conclusions Vitamin and mineral supplements do not seem to improve clinical outcomes. Inhaled glutathione appears to improve lung function, while oral administration lowers oxidative stress, with benefits to lung function and nutritional measures. Intensive antibiotic and other concurrent treatments for people with CF and chronic infection mean it is difficult to assess the effect of antioxidants without a very large and long study. Future research should look at how antioxidants affect people with CF taking CFTR modulator therapies. Quality of the evidence Evidence ranged from very low to moderate quality. All but one study had some bias; mostly because data were not fully reported (likely to affect our results). We were also largely unsure if participants knew which treatment they received, both in advance and once the studies started (unsure how this might affect our results).", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ciofu, O, Smith, S, Lykkesfeldt, J", "articleTypes": [], "doi": "10.1002/14651858.CD007020.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.763Z" }, { "id": "e3d7fb4e-35f0-445a-a87e-c1ac26c1969b", "pmid": "", "title": "Optimizing Naltrexone for Individuals of East Asian Descent", "imported": false, "abstract": "This study will elucidate the pharmacogenetic effects of the Asn40Asp SNP of the OPRM1 gene on biobehavioral and neural markers of response to naltrexone in individuals of East Asian descent, an ethnic group most likely to express the positive predictive allele.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.153Z" }, { "id": "e3e86ae0-e6c0-4428-9da1-565ccbeec20b", "pmid": "", "title": "Evaluation of the Efficacy of CANNABIDIOL on the Pruritus in Children With Hereditary Epidermolysis Bullosa", "imported": false, "abstract": "Hereditary epidermolysis bullosa (HEB) is a heterogeneous group of rare genetic diseases, characterized by fragility of the skin and mucous membranes, which results in the appearance of mucocutaneous bullae and erosions during minimal trauma. Pruritus is a neuropathic pain mainly related to activation of unmyelinated cutaneous C nerve fibers and is very common in patients with HEB. It is the cause of trophic disorders, aggravation of certain wounds, appearance of new bubbles. In addition, this chronic pruritus can also have a major psychological impact on the patient and his family. However, these therapies used in the pruritus of patients with HEB have often proven to be ineffective.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.245Z" }, { "id": "e3ea9b8c-3140-4756-a089-f1c961189f02", "pmid": "", "title": "Antidepressants for pain management in adults with chronic pain: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well‐being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients’ global impression of change for certain chronic pain conditions. However, there has not been a network meta‐analysis (NMA) examining all antidepressants across all chronic pain conditions. Objectives To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache). Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022. Selection criteria We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double‐blind. We included RCTs with active comparators that were unable to be double‐blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow‐up was less than two weeks and those with fewer than 10 participants in each arm. Data collection and analysis Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta‐analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta‐Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta‐analysis (ROB‐MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB‐MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal. Main results This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo‐controlled (83), and parallel−armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short‐term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest‐ranked antidepressant with moderate‐ to high‐certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate‐certainty evidence) and continuous pain intensity (standardised mean difference (SMD) −0.31, 95% CI −0.39 to −0.24; 18 studies, 4959 participants; moderate‐certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD −0.22, 95% CI −0.39 to 0.06; 4 studies, 1866 participants; moderate‐certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD −0.5, 95% CI −0.78 to −0.22; 1 study, 406 participants; low‐certainty evidence), while duloxetine showed a small effect (SMD −0.16, 95% CI −0.22 to −0.1; 26 studies, 7952 participants; moderate‐certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest‐ranked antidepressants with moderate‐certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low‐certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes. Authors' conclusions Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high‐quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long‐term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point. Plain language summary How effective are antidepressants used to treat chronic pain and do they cause unwanted effects? Key messages • We are only confident in the effectiveness of one antidepressant: duloxetine. We found that a standard dose (60 mg) was effective, and that there is no benefit to using a higher dose. • We are uncertain about unwanted effects for any antidepressant as the data for this were very poor. Future research should address this. • In clinical practice for chronic pain, a standard dose of duloxetine may be considered before trying other antidepressants. • Adopting a person‐centred approach is critical. Pain is a very individual experience and certain medications may work for people even while the research evidence is inconclusive or unavailable. Future studies should last longer and focus on unwanted effects of antidepressants. What is chronic pain? Chronic pain is pain of any kind that lasts for more than three months. Over one‐third of people across the world experience chronic pain. This often affects people's mood and well‐being, and their ability to work and carry out daily tasks. How do antidepressants treat chronic pain? Antidepressants are medications originally developed to treat depression. Different types of antidepressants work in different ways. Antidepressants that work in the same way are grouped into classes. The most common classes are selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and serotonin‐noradrenalin reuptake inhibitors (SNRIs). Research suggests that antidepressants may be effective for pain because the same chemicals that affect mood might also affect pain. What did we want to find out? We wanted to find out if antidepressants were effective for managing chronic pain and whether they cause unwanted effects. What did we do? We searched for studies that compared any antidepressant with any other treatment for any type of chronic pain (except headache). We compared all the treatments against each other using a statistical method called network meta‐analysis. This method allows us to rank the effectiveness of the different antidepressants from best to worst. What did we find? We found 176 studies including 28,664 people with chronic pain. These studies investigated 89 different types or combinations of treatment. Studies mainly investigated the effect of antidepressants on three different types of pain: fibromyalgia (59 studies), nerve pain (49 studies), and musculoskeletal pain (e.g. osteoarthritis or low back pain; 40 studies). The most common antidepressant classes investigated were SNRIs (74 studies), TCAs (72 studies), and SSRIs (34 studies). The most common antidepressants investigated were: amitriptyline (a TCA; 43 studies); duloxetine (an SNRI; 43 studies), and milnacipran (an SNRI; 18 studies). Of the 146 studies that reported where their funding came from, pharmaceutical companies funded 72 studies. The average study lasted 10 weeks. Most of the studies compared an antidepressant with a placebo (which looks like the real medicine but doesn’t have any medicine in it), but some studies compared an antidepressant against a different type of medicine, a different antidepressant, a different type of treatment (like physiotherapy), or different doses of the same antidepressant. Most of the studies in this review reported information on pain relief and unwanted effects. Fewer studies reported on quality of life, sleep, and physical function. Main results • Duloxetine probably has a moderate effect on reducing pain and improving physical function. It was the antidepressant that we have the most confidence in. Higher doses of duloxetine probably provided no extra benefits than standard doses. For every 1000 people taking standard‐dose duloxetine, 435 will experience 50% pain relief compared with 287 who will experience 50% pain relief taking placebo. • Milnacipran may reduce pain, but we are not as confident in this result as duloxetine because there were fewer studies with fewer people involved. • Most studies excluded people with mental health conditions, meaning that participants were already in the 'normal' ranges for anxiety and depression at the beginning of studies. This limited our analysis for mood. Mirtazapine and duloxetine may improve mood, but we are very uncertain about the results. • We do not know about unwanted effects of using antidepressants for chronic pain; there are not enough data to be certain about the results. What are the limitations of the evidence? There are still a number of questions that we were unable to answer: • Aside from duloxetine and milnacipran, we do not have confidence in the results from any other antidepressant included in this review because there are not enough studies. • We do not know whether antidepressants are effective at treating pain in the long term. The average length of studies was 10 weeks. • There was no reliable evidence on the safety of taking antidepressants for chronic pain, both short‐ and long‐term. • We do not know how effective antidepressants are for people with both chronic pain and depression as the most studies excluded participants with depression and anxiety. How up to date is this evidence? This review is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Birkinshaw, H, Friedrich, CM, Cole, P, Eccleston, C, Serfaty, M, Stewart, G, White, S, Moore, RA, Phillippo, D, Pincus, T", "articleTypes": [], "doi": "10.1002/14651858.CD014682.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.790Z" }, { "id": "e3fee9fc-d8b7-42ba-a0dd-546568441a6a", "pmid": "", "title": "WIthdrawal of DUpilumab in Severe Asthma: a Randomized Non-inferiority-controlled Trial", "imported": false, "abstract": "Asthma management has been revolutionised by the development of biological therapies. Dupilumab is an anti-interleukin4 receptor marketed in 2020 for severe asthmatic patients with 2 exacerbations or more within the last 12 months. Although data showed that safety and efficacy of dupilumab are sustained when treatment is extended up to 3 years, no study has emerged regarding dupilumab discontinuation. This study aims to demonstrate the non-inferiority regarding strategy failure at 24 months of stopping dupilumab (intervention group) compared with its continuation (control group) in controlled asthma patients receiving this drug for at least 3 years.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.246Z" }, { "id": "e3ff2919-22df-4134-a6db-a02acbf6d04f", "pmid": "", "title": "Chinese medicinal herbs for mumps", "imported": false, "abstract": "Abstract - Background Mumps is an infectious disease caused by the mumps virus. Chinese physicians generally believe that Chinese medicinal herbs are effective in alleviating symptoms and reducing the duration of mumps. Herbalists tend to develop a treatment plan according to the individual's symptoms. Objectives To evaluate the effectiveness and safety of Chinese medicinal herbs combined with routine treatments for mumps. Search methods We searched CENTRAL (2015, Issue 1), MEDLINE (1948 to January week 4, 2015), EMBASE (1974 to February 2015), CINAHL (1981 to February 2015), AMED (1985 to April 2014), the Chinese Biomedical Database (CBM) (1980 to February 2015), China National Knowledge Infrastructure (CNKI) (1979 to February 2015), VIP Information (1989 to February 2015), and relevant databases of ongoing trials. Selection criteria Randomised controlled trials (RCTs) of Chinese medicinal herbs for mumps (with or without complications). Data collection and analysis Two review authors independently evaluated trial quality and conducted data extraction. We contacted the trial authors for missing data regarding participant allocation. Some trials allocated participants according to the participants' admission sequence, making it a pseudo‐random allocation. None of the trials concealed participants' allocation or used blinding. Main results We did not identify any eligible trials for inclusion. We identified 108 studies that claimed to use random allocation. We excluded 104 studies because the allocation methods the authors had used were not actually randomised. We were unable to contact the trial authors of the remaining four studies. These trials require further evaluation and have been allocated to the 'Studies awaiting classification' section. Authors' conclusions We did not find any RCTs for or against Chinese herbal medicine used in the treatment of mumps. We hope more high‐quality RCTs will be conducted in the future. Plain language summary Chinese medicinal herbs for mumps Review question 
 We reviewed the evidence about the effect and safety of Chinese medicinal herbs for mumps. Background 
 Mumps (epidemic parotitis) is an infectious illness caused by the multiplication of the mumps virus in the upper respiratory tract. It can range from a mild upper respiratory disease to serious complications. Herbal medicines have been used in traditional Chinese medicine (TCM) as the main therapy to prevent and treat mumps for thousands of years. Many Chinese physicians believe that Chinese medicinal herbs are effective in treating mumps. Study characteristics 
 The evidence is current to February 2015. The review authors did not find any randomised controlled trials (RCTs) to provide reliable evidence for the effectiveness and safety of Chinese medicinal herbs for mumps. Although no trials were included, we reviewed the studies and found no reports of adverse events with Chinese medicinal herbs as a treatment for mumps. Key results 
 High‐quality trials are needed to answer these questions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Shu, M; Zhang, YQ; Li, Z; Liu, GJ; Wan, C; Wen, Y", "articleTypes": [], "doi": "10.1002/14651858.CD008578.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "e4271822-45cb-4d6d-bb19-37a471022a32", "pmid": "", "title": "Mindfulness‐enhanced parenting programmes for improving the psychosocial outcomes of children (0 to 18 years) and their parents", "imported": false, "abstract": "Abstract - Background Emotional and behavioural difficulties (EBD) in children are common, characterised by externalising or internalising behaviours that can be highly stable over time. EBD are an important cause of functional disability in childhood, and predictive of poorer psychosocial, academic, and occupational functioning into adolescence and adulthood. The prevalence, stability, and long‐term consequences of EBD highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Multiple factors contribute to the aetiology of EBD in children, and parenting plays an important role. The relationship between parenting and EBD has been described as bidirectional, with parents and children shaping one another’s behaviour. One consequence of bidirectionality is that parents with insufficient parenting skills may become involved in increasingly negative behaviours when dealing with non‐compliance in children. This can have a cyclical effect, exacerbating child behavioural difficulties and further increasing parental distress. Behavioural or skills‐based parenting training can be highly effective in addressing EBD in children. However, emotional dysregulation may intercept some parents' ability to implement parenting skills, and there is recognition that skills‐based interventions may benefit from adjunct components that better target parental emotional responses. Mindful parenting interventions have demonstrated some efficacy in improving child outcomes via improvements in parental emotion regulation, and there is potential for mindfulness training to enhance the effectiveness of standard parent training programmes. Objectives To assess the effectiveness of mindfulness‐enhanced parent training programmes on the psychosocial functioning of children (aged 0 to 18 years) and their parents. Search methods We searched the following databases up to April 2023: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, PsycINFO, Sociological Abstracts, Social Sciences Citation Index, Conference Proceedings Citation Index – Social Science & Humanities, AMED, ERIC, ProQuest Dissertations & Theses, Cochrane Database of Systematic Reviews, Campbell Collaboration Library of Systematic Reviews, as well as the following trials registers: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also contacted organisations/experts in the field. Selection criteria We included randomised and quasi‐randomised trials. Participants were parents or caregivers of children under the age of 18. The intervention was mindfulness‐enhanced parent training programmes compared with a no‐intervention, waitlist, or attentional control, or a parent training programme with no mindfulness component. The intervention must have combined mindfulness parent training with behavioural or skills‐based parent training. We defined parent training programmes in terms of the delivery of a standardised and manualised intervention over a specified and limited period, on a one‐to‐one or group‐basis, with a well‐defined mindfulness component. The mindfulness component must have included mindfulness training (breath, visualisation, listening, or other sensory focus) and an explicit focus on present‐focused attention and non‐judgemental acceptance. Data collection and analysis We followed standard Cochrane procedures. Main results Eleven studies met our inclusion criteria, including one ongoing study. The studies compared a mindfulness‐enhanced parent training programme with a no‐treatment, waitlist, or attentional control (2 studies); a parent training programme with no mindfulness component (5 studies); both a no‐treatment, waitlist, or attentional control and a parent training programme with no mindfulness component (4 studies). We assessed all studies as being at an unclear or high risk of bias across multiple domains. We pooled child and parent outcome data from 2118 participants to produce effect estimates. No study explicitly reported on self‐compassion, and no adverse effects were reported in any of the studies. Mindfulness‐enhanced parent training programmes compared to a no‐treatment, waitlist, or attentional control Very low certainty evidence suggests there may be a small to moderate postintervention improvement in child emotional and behavioural adjustment (standardised mean difference (SMD) −0.46, 95% confidence interval (CI) −0.96 to 0.03; P = 0.06, I 2 = 62%; 3 studies, 270 participants); a small improvement in parenting skills (SMD 0.22, 95% CI 0.06 to 0.39; P = 0.008, I 2 = 0%; 3 studies, 587 participants); and a moderate decrease in parental depression or anxiety (SMD −0.50, 95% CI −0.96 to −0.04; P = 0.03; 1 study, 75 participants). There may also be a moderate to large decrease in parenting stress (SMD −0.79, 95% CI −1.80 to 0.23; P = 0.13, I 2 = 82%; 2 studies, 112 participants) and a small improvement in parent mindfulness (SMD 0.21, 95% CI −0.14 to 0.56; P = 0.24, I 2 = 69%; 3 studies, 515 participants), but we were not able to exclude little to no effect for these outcomes. Mindfulness‐enhanced parent training programmes compared to parent training with no mindfulness component Very low certainty evidence suggests there may be little to no difference postintervention in child emotional and behavioural adjustment (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.71, I 2 = 64%; 5 studies, 203 participants); parenting skills (SMD 0.13, 95% CI −0.16 to 0.42; P = 0.37, I 2 = 16%; 3 studies, 319 participants); and parent mindfulness (SMD 0.11, 95% CI −0.19 to 0.41; P = 0.48, I 2 = 44%; 4 studies, 412 participants). There may be a slight decrease in parental depression or anxiety (SMD −0.24, 95% CI −0.83 to 0.34; P = 0.41; 1 study, 45 participants; very low certainty evidence), though we cannot exclude little to no effect, and a moderate decrease in parenting stress (SMD −0.51, 95% CI −0.84 to −0.18; P = 0.002, I 2 = 2%; 3 studies, 150 participants; low certainty evidence). Authors' conclusions Mindfulness‐enhanced parenting training may improve some parent and child outcomes, with no studies reporting adverse effects. Evidence for the added value of mindfulness training to skills‐based parenting training programmes is suggestive at present, with moderate reductions in parenting stress. Given the very low to low certainty evidence reviewed here, these estimates will likely change as more high‐quality studies are produced. Plain language summary Mindfulness‐enhanced parenting programs for improving outcomes for children and their parents Key messages • Mindfulness‐enhanced parent training programmes may improve some child and parent outcomes, including child emotional and behavioural adjustment, parenting skills, parental depression or anxiety, parenting stress, and parent mindfulness. • When mindfulness parent training is combined with a skills‐based parent training programme, this may decrease parenting stress. • The current body of evidence is limited, with more research needed to be confident in our findings. Children's emotional and behavioural difficulties Emotional and behavioural difficulties in children are common, and are characterised by a range of externalising and/or internalising behaviours that can be highly stable over time. They are an important cause of functional disability in childhood, and predictive of poor psychosocial, academic, and occupational functioning into adolescence and beyond. The prevalence, stability, and long‐term consequences of emotional and behavioural difficulties highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Why mindfulness‐enhanced parent training? Parenting plays an important role in the development and/or maintenance of emotional and behavioural difficulties in children. Traditional behavioural or skills‐based parent training programmes have been shown to have a positive impact on a range of child and parent outcomes, but they do not work for all parents. One reason for this might be that parents' emotional reactions could prevent them from using parenting skills effectively. Including additional components into parenting training that aim to improve parental emotional responses may enhance the outcomes of these programmes. Recent research shows that mindful parenting interventions may promote positive outcomes for parents and children by improving parents' ability to regulate emotions and stress. Combining mindful parenting approaches with traditional parent training programmes may therefore be beneficial for both parents and their children. What did we want to find out? We explored whether behavioural or skills‐based parent training programmes with a mindfulness component – 'mindfulness‐enhanced' parent training programmes – can improve outcomes for children and their caregivers. What did we do? We searched a range of sources for literature that evaluated the effectiveness of mindfulness‐enhanced parent training programmes, including electronic databases, trial registries, and organisations and experts in the field. We included studies evaluating these interventions using randomised controlled trials (studies where participants are randomly assigned to one of two or more treatment groups) or quasi experimental designs (where participants are assigned to different treatment groups using a method that is not truly random). We included studies that assessed child emotional and behavioural adjustment, and/or a range of parent outcomes, including parenting skills, parenting stress, depression or anxiety, mindfulness or self‐compassion. What did we find out? We included 11 studies and data from 2118 participants in the review. The studies compared the outcomes of children or parents (or both) who participated in a mindfulness‐enhanced parent training programme to the outcomes of children or parents (or both) who did not participate in parent training, or who participated in an alternate behavioural or skills‐based parent training programme. When we combined the findings from these studies, we found that mindfulness‐enhanced parent training, when compared to no intervention, may improve child emotional and behavioural adjustment, parenting skills, parenting stress, parental depression and anxiety, and mindfulness, but we are very uncertain about these results. Evidence for the added value of mindfulness training when included in a skills‐based parent training programme suggests that mindfulness training may further promote reductions in parenting stress, and may also further reduce parental depression or anxiety, but we are uncertain about these results. It is unclear from the current body of evidence whether adding mindfulness training to a skills‐based parent training intervention has any further effect on child emotional and behavioural adjustment, parenting skills, or mindfulness. No studies reported adverse effects or measured self‐compassion. What are the limitations of the evidence? We are not confident in the overall body of evidence. This is primarily because there was a lot of variation across the interventions and the participant groups, as well as how the outcomes were measured. The studies were also usually quite small, and participants were likely to be aware of what intervention they were receiving, which can sometimes influence the results. It is likely that these findings will change as more studies are undertaken in this area of research. How up‐to‐date is this evidence? We searched for and included research up to April 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Featherston, R; Barlow, J; Song, Y; Haysom, Z; Loy, B; Tufford, L; Shlonsky, A", "articleTypes": [], "doi": "10.1002/14651858.CD012445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "e42be690-ca5e-4e8a-8b40-be1193d84f8e", "pmid": "", "title": "Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco", "imported": false, "abstract": "Abstract - Background Overeating and harmful alcohol and tobacco use have been linked to the aetiology of various non‐communicable diseases, which are among the leading global causes of morbidity and premature mortality. As people are repeatedly exposed to varying sizes and shapes of food, alcohol and tobacco products in environments such as shops, restaurants, bars and homes, this has stimulated public health policy interest in product size and shape as potential targets for intervention. Objectives 1) To assess the effects of interventions involving exposure to different sizes or sets of physical dimensions of a portion, package, individual unit or item of tableware on unregulated selection or consumption of food, alcohol or tobacco products in adults and children. 2) To assess the extent to which these effects may be modified by study, intervention and participant characteristics. Search methods We searched CENTRAL, MEDLINE, EMBASE, PsycINFO, eight other published or grey literature databases, trial registries and key websites up to November 2012, followed by citation searches and contacts with study authors. This original search identified eligible studies published up to July 2013, which are fully incorporated into the review. We conducted an updated search up to 30 January 2015 but further eligible studies are not yet fully incorporated due to their minimal potential to change the conclusions. Selection criteria Randomised controlled trials with between‐subjects (parallel‐group) or within‐subjects (cross‐over) designs, conducted in laboratory or field settings, in adults or children. Eligible studies compared at least two groups of participants, each exposed to a different size or shape of a portion of a food (including non‐alcoholic beverages), alcohol or tobacco product, its package or individual unit size, or of an item of tableware used to consume it, and included a measure of unregulated selection or consumption of food, alcohol or tobacco. Data collection and analysis We applied standard Cochrane methods to select eligible studies for inclusion and to collect data and assess risk of bias. We calculated study‐level effect sizes as standardised mean differences (SMDs) between comparison groups, measured as quantities selected or consumed. We combined these results using random‐effects meta‐analysis models to estimate summary effect sizes (SMDs with 95% confidence intervals (CIs)) for each outcome for size and shape comparisons. We rated the overall quality of evidence using the GRADE system. Finally, we used meta‐regression analysis to investigate statistical associations between summary effect sizes and variant study, intervention or participant characteristics. Main results The current version of this review includes 72 studies, published between 1978 and July 2013, assessed as being at overall unclear or high risk of bias with respect to selection and consumption outcomes. Ninety‐six per cent of included studies (69/72) manipulated food products and 4% (3/72) manipulated cigarettes. No included studies manipulated alcohol products. Forty‐nine per cent (35/72) manipulated portion size, 14% (10/72) package size and 21% (15/72) tableware size or shape. More studies investigated effects among adults (76% (55/72)) than children and all studies were conducted in high‐income countries ‐ predominantly in the USA (81% (58/72)). Sources of funding were reported for the majority of studies, with no evidence of funding by agencies with possible commercial interests in their results. A meta‐analysis of 86 independent comparisons from 58 studies (6603 participants) found a small to moderate effect of portion, package, individual unit or tableware size on consumption of food (SMD 0.38, 95% CI 0.29 to 0.46), providing moderate quality evidence that exposure to larger sizes increased quantities of food consumed among children (SMD 0.21, 95% CI 0.10 to 0.31) and adults (SMD 0.46, 95% CI 0.40 to 0.52). The size of this effect suggests that, if sustained reductions in exposure to larger‐sized food portions, packages and tableware could be achieved across the whole diet, this could reduce average daily energy consumed from food by between 144 and 228 kcal (8.5% to 13.5% from a baseline of 1689 kcal) among UK children and adults. A meta‐analysis of six independent comparisons from three studies (108 participants) found low quality evidence for no difference in the effect of cigarette length on consumption (SMD 0.25, 95% CI ‐0.14 to 0.65). One included study (50 participants) estimated a large effect on consumption of exposure to differently shaped tableware (SMD 1.17, 95% CI 0.57 to 1.78), rated as very low quality evidence that exposure to shorter, wider bottles (versus taller, narrower bottles) increased quantities of water consumed by young adult participants. A meta‐analysis of 13 independent comparisons from 10 studies (1164 participants) found a small to moderate effect of portion or tableware size on selection of food (SMD 0.42, 95% CI 0.24 to 0.59), rated as moderate quality evidence that exposure to larger sizes increased the quantities of food people selected for subsequent consumption. This effect was present among adults (SMD 0.55, 95% CI 0.35 to 0.75) but not children (SMD 0.14, 95% CI ‐0.06 to 0.34). In addition, a meta‐analysis of three independent comparisons from three studies (232 participants) found a very large effect of exposure to differently shaped tableware on selection of non‐alcoholic beverages (SMD 1.47, 95% CI 0.52 to 2.43), rated as low quality evidence that exposure to shorter, wider (versus taller, narrower) glasses or bottles increased the quantities selected for subsequent consumption among adults (SMD 2.31, 95% CI 1.79 to 2.83) and children (SMD 1.03, 95% CI 0.41 to 1.65). Authors' conclusions This review found that people consistently consume more food and drink when offered larger‐sized portions, packages or tableware than when offered smaller‐sized versions. This suggests that policies and practices that successfully reduce the size, availability and appeal of larger‐sized portions, packages, individual units and tableware can contribute to meaningful reductions in the quantities of food (including non‐alcoholic beverages) people select and consume in the immediate and short term. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. We are unable to highlight clear implications for tobacco or alcohol policy due to identified gaps in the current evidence base. Plain language summary Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco Review question We reviewed the evidence to establish by how much the amounts of food, alcohol or tobacco adults and children select or consume change in response to being presented with larger or smaller‐sized (or differently shaped) portions or packages of these products, or of items of tableware (such as plates or glasses) used to consume them. Study characteristics This review includes 72 randomised controlled trials (RCTs) published up to July 2013 that compared at least two groups of participants, each presented with a different size of a portion, package or item of tableware. Included studies measured the amounts of food, alcohol or tobacco selected and/or consumed by participants, typically over a period of one day or less. Almost all of the included studies investigated food, with only three tobacco studies and no alcohol studies found. Almost all assessed participants' responses to different sizes rather than different shapes. The average age of participants in the different studies ranged from three to 55 years, with more studies involving adults than children and most conducted in the USA. Sources of funding were reported for the majority of studies and there was no evidence of study funding by agencies with commercial interests in their results. Key findings and quality of evidence Effects of size on consumption: We found evidence that people consistently ate more food or drank more non‐alcoholic drinks when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. We estimate the size of this effect to be small to moderate among both children and adults. If an effect of this size were sustained across the whole diet it would be equivalent to around a 12% to 16% change in average daily energy intake from food among UK adults. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations arising from incomplete or unclear reporting of methods and procedures. From three tobacco studies, we found no effect of longer compared with shorter cigarettes on the amounts of tobacco consumed. We rated the overall quality of evidence for this effect as low due to concerns about study limitations and not having enough evidence. Effects of shape on consumption: One study found that adults provided with shorter, wider bottles drank larger amounts of water from them, having already poured more, compared with those provided with taller, narrower bottles. However, we rated the quality of this evidence as very low, due to very serious concerns about study limitations and not having enough evidence (only one study with outcome data from 50 participants). Effects of size on selection: We further found that adults, but not children, consistently chose (selected) more food (including non‐alcoholic drinks) when offered larger‐sized portions, packages or items of tableware than when offered smaller‐sized versions. The estimated size of this effect was again small to moderate. We rated the overall quality of the evidence for this effect as moderate, due to concern about study limitations. Effects of shape on selection: Evidence from three studies suggested that adults and children provided with shorter, wider bottles or glasses selected increased quantities of non‐alcoholic beverages for subsequent consumption, compared with those provided with taller, narrower bottles or glasses. We rated the quality of this evidence as low, again due to concerns about study limitations and unexplained variation in effects between the three studies. Conclusions Overall, this review provides the most conclusive evidence to date that acting to reduce the size, availability and appeal of larger‐sized portions, packages and tableware has potential to reduce the quantities of food that people select and consume by meaningful amounts. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. Our findings highlight the need for further research that aims to reduce uncertainties about these effects and address identified gaps in the evidence base, including not having enough evidence for longer‐term effects and the absence of evidence about alcohol products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hollands, GJ, Shemilt, I, Marteau, TM, Jebb, SA, Lewis, HB, Wei, Y, Higgins, JPT, Ogilvie, D", "articleTypes": [], "doi": "10.1002/14651858.CD011045.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.132Z" }, { "id": "e42fc618-cfe5-424f-9e30-855bc7508c46", "pmid": "", "title": "Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years", "imported": false, "abstract": "Abstract - Background Child and adolescent overweight and obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages. Objectives To assess the effects of diet, physical activity and behavioural interventions (behaviour‐changing interventions) for the treatment of overweight or obese children aged 6 to 11 years. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases. Selection criteria We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour‐changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow‐up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. Data collection and analysis Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta‐analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty‐five trials compared a behaviour‐changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour‐changing intervention. Sixty‐four trials were parallel RCTs, and four were cluster RCTs. Sixty‐four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2. Primary analyses demonstrated that behaviour‐changing interventions compared to no treatment/usual care control at longest follow‐up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was ‐0.53 kg/m 2 (95% confidence interval (CI) ‐0.82 to ‐0.24); P < 0.00001; 24 trials; 2785 participants; low‐quality evidence. MD in BMI z score was ‐0.06 units (95% CI ‐0.10 to ‐0.02); P = 0.001; 37 trials; 4019 participants; low‐quality evidence and MD in weight was ‐1.45 kg (95% CI ‐1.88 to ‐1.02); P < 0.00001; 17 trials; 1774 participants; low‐quality evidence. Thirty‐one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health‐related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI ‐12.88 to ‐0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all‐cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta‐analysed. As the meta‐analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post‐intervention follow‐up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post‐intervention was no longer evident at follow‐up at less than six months, which has to be investigated in further trials. Authors' conclusions Multi‐component behaviour‐changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short‐term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour‐changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour‐changing interventions on health‐related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer‐term follow‐up and further research on the most appropriate forms of post‐intervention maintenance in order to ensure intervention benefits are sustained over the longer term. Plain language summary Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years Review question How effective are diet, physical activity and behavioural interventions in reducing the weight of overweight or obese children aged 6 to 11 years? Background Across the world more children are becoming overweight and obese. These children are more likely to suffer from health problems, both while as children and in later life. More information is needed about what works best for treating this problem. Study characteristics We found 70 randomised controlled trials (clinical trials where people are randomly put into one of two or more treatment groups) comparing diet, physical activity, and behavioural (where habits are changed or improved) treatments to a variety of control groups delivered to 8461 overweight or obese children aged 6 to 11 years. We reported on the effects of 64 multicomponent interventions (different combinations of diet and physical activity and behaviour change), four physical activity interventions and two dietary interventions compared with no intervention, 'usual care’ or some other therapy if it was also delivered in the intervention arm. The children in the included studies were followed up between six months and three years. Key results The average age of the children was 10 years. Most studies reported the body mass index (BMI) z score: BMI is a measure of body fat and is calculated by dividing weight (in kilograms) by the square of the body height measured in metres (kg/m²). In children, BMI is often measured in a way that takes into account sex and age, weight, and height changes as children grow older (BMI z score). We summarised the results of 37 trials in 4019 children reporting the BMI z score, which on average was 0.06 units lower in the intervention groups compared with the control groups. We summarised the results of 24 trials in 2785 children reporting BMI, which on average was 0.53 kg/m 2 lower in the intervention groups compared with the control groups. We summarised the results of 17 trials in 1774 children reporting weight, which on average was 1.45 kg lower in the intervention groups compared with the control groups. Other effects of the interventions, such as improvements in health‐related quality of life were less clear. No study investigated death from any cause, morbidity or socioeconomic effects. Serious adverse events were rare: only two of 31 trials with data reported any serious adverse events (4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). This evidence is up to date as of July 2016. Quality of the evidence The overall quality of the evidence was low or very low, mainly because of limited confidence in how studies were performed, and the results were inconsistent between the studies. Also there were just a few studies for some outcomes, with small numbers of included children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Mead, E, Brown, T, Rees, K, Azevedo, LB, Whittaker, V, Jones, D, Olajide, J, Mainardi, GM, Corpeleijn, E, O'Malley, C, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012651", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.144Z" }, { "id": "e43afffe-c42d-408f-8029-1556aefad9c1", "pmid": "", "title": "Colchicine for acute gout", "imported": false, "abstract": "Abstract - Background This is an updated Cochrane Review, first published in 2006 and updated in 2014. Gout is one of the most common rheumatic diseases worldwide. Despite the use of colchicine as one of the first‐line therapies for the treatment of acute gout, evidence for its benefits and harms is relatively limited. Objectives To update the available evidence of the benefits and harms of colchicine for the treatment of acute gout. Search methods We updated the search of CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICTRP registries to 28 August 2020. We did not impose any date or language restrictions in the search. Selection criteria We considered published randomised controlled trials (RCTs) and quasi‐randomised controlled trials (quasi‐RCTs) evaluating colchicine therapy compared with another therapy (placebo or active) in acute gout; low‐dose colchicine at clinically relevant doses compared with placebo was the primary comparison. The major outcomes were pain, participant global assessment of treatment success (proportion with 50% or greater decrease in pain from baseline up to 32 to 36 hours), reduction of inflammation, function of target joint, serious adverse events, total adverse events and withdrawals due to adverse events. Data collection and analysis We used standard methodological procedures as expected by Cochrane in this review update. Main results We included four trials (803 randomised participants), including two new trials, in this updated review. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We did not identify any trials comparing colchicine to glucocorticoids (by any route). The mean age of participants ranged from 51.2 to 70 years, and trial duration from 48 hours to 12 weeks. Two trials were at low risk of bias, one was possibly susceptible to selection bias (random sequence generation), reporting bias and other bias, and one open‐label trial was at high risk of performance and detection bias. For the primary comparison, low‐quality evidence from one trial (103 participants, downgraded for imprecision and bias) suggests low‐dose colchicine may improve treatment outcome compared to placebo with little or no increased risk of adverse events. The number of people who reported treatment success (50% or greater pain reduction) at 32 to 36 hours was slightly larger with low‐dose colchicine (418 per 1000) compared with placebo (172 per 1000; risk ratio (RR) 2.43, 95% confidence interval (CI) 1.05 to 5.64; absolute improvement 25% more reported success (7% more to 42% more, the 95% CIs include both a clinically important and unimportant benefit); relative change of 143% more people reported treatment success (5% more to 464% more). The incidence of total adverse events was 364 per 1000 with low‐dose colchicine compared with 276 per 1000 with placebo: RR 1.32, 95% CI 0.68 to 2.56; absolute difference 9% more events with low‐dose colchicine (9% fewer to 43% more, the 95% CIs include both a clinically important effect and no effect); relative change of 32% more events (32% fewer to 156% more). No participants withdrew due to adverse events or reported any serious adverse events. Pain, inflammation and function were not reported. Low‐quality evidence (downgraded for imprecision and bias) from two trials (124 participants) suggests that high‐dose colchicine compared to placebo may improve symptoms, but with increased risk of harms. More participants reported treatment success at 32 to 36 hours with high‐dose colchicine (518 per 1000) compared with placebo (240 per 1000): RR 2.16, 95% CI 1.28 to 3.65, absolute improvement 28% (8% more to 46% more); more also had reduced inflammation at this time point with high‐dose colchicine (504 per 1000) compared with placebo (48 per 1000): RR 10.50, 95% CI 1.48 to 74.38; absolute improvement 45% greater (22% greater to 68% greater); but more adverse events were reported with high‐dose colchicine (829 per 1000 compared with 260 per 1000): RR 3.21, 95% CI 2.01 to 5.11, absolute difference 57% (26% more to 74% more). Pain and function were not reported. Low‐quality evidence from a single trial comparing high‐dose to low‐dose colchicine indicates there may be little or no difference in benefit in terms of treatment success at 32 to 36 hours but more adverse events associated with the higher dose. Similarly, low‐quality evidence from a single trial indicates there may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction at seven days, with a similar number of adverse events reported at four weeks follow‐up. Reduction of inflammation, function of target joint and withdrawals due to adverse events were not reported in either of these trials, and pain was not reported in the high‐dose versus low‐dose colchicine trial. We were unable to estimate the risk of serious adverse events for most comparisons as there were few events reported in the trials. One trial (399 participants) reported three serious adverse (one in a participant receiving low‐dose colchicine and two in participants receiving NSAIDs), due to reasons unrelated to the trial (low‐quality evidence downgraded for bias and imprecision). Authors' conclusions We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve pain when compared to placebo, low‐quality evidence suggests that high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo, while low‐quality evidence indicates that the number of adverse events may be similar with low‐dose colchicine and NSAIDs. Further trials comparing colchicine to placebo or other treatment will likely have an important impact on our confidence in the effect estimates and may change the conclusions of this review. There are no trials reporting the effect of colchicine in populations with comorbidities or in comparison with other commonly used treatments, such as glucocorticoids. Plain language summary Colchicine for treating acute gout flares Background Gout is a very common cause of inflammatory arthritis (pain, redness, warmth and swelling of affected joints) and is caused by urate crystals forming either within or around joints. Uric acid is a normal waste product that is usually excreted with urine. However, in the case of gout, there is either excessive production of uric acid, or the body is not able to excrete it quickly enough, or a combination of both. An attack of gout usually occurs rapidly and usually resolves within 7 to 10 days. Colchicine is a drug that is used mainly in gout to treat an acute attack or to prevent an attack while starting uric acid‐lowering therapy. Study characteristics This Cochrane Review is current to August 2020. We included four trials (803 randomised participants) in this updated review, including two new trials. One three‐arm trial compared high‐dose colchicine (52 participants), low‐dose colchicine (74 participants) and placebo (fake medicine) (59 participants); one trial compared high‐dose colchicine with placebo (43 participants); one trial compared low‐dose colchicine with non‐steroidal anti‐inflammatory drugs (NSAIDs) (399 participants); and one trial compared low‐dose colchicine with Chuanhu anti‐gout mixture (traditional Chinese Medicine compound) (176 participants). We selected low‐dose colchicine compared with placebo as the primary comparison; the low dose is consistent with doses used in practice. Trials were performed in hospital and multicentre settings in four countries, the majority of participants were male, and mean age ranged between 51.2 and 70 years. One trial received funding from a pharmaceutical company that was involved in the study design, data collection, data analysis, and manuscript writing. Key results Compared with placebo medication, low‐dose colchicine for people with acute gout may slightly improve treatment outcomes with little or no increased risk of adverse events at 32 to 36 hours. Proportion of participants reporting treatment success (defined as 50% or more reduction in pain) 25% more people (7% more to 42% more) reported success, or 25 more out of 100 ‐ 42 people out of 100 reported treatment success with colchicine ‐ 17 people out of 100 reported treatment success with placebo Total adverse events (diarrhoea, vomiting or nausea) 6% more people reported adverse events (13% more to 23% more), or 6 more out of 100 ‐ 26 people out of 100 reported side effects with colchicine ‐ 20 people out of 100 reported side effects with placebo Pain, reduction of inflammation, function of target joint, serious adverse events or withdrawals due to adverse events were not reported for this comparison. Other comparisons are briefly summarised here: High‐dose colchicine may improve symptoms compared with placebo, but with more adverse events. High‐dose may have little or no benefit over low‐dose colchicine but more adverse events. There may also be little or no benefit of low‐dose colchicine over NSAIDs in terms of treatment success and pain reduction, with a similar number of adverse events. There were no trials that compared colchicine to glucocorticoids. Quality of the evidence We found low‐quality evidence that low‐dose colchicine may be an effective treatment for acute gout when compared to placebo and low‐quality evidence that its benefits may be similar to NSAIDs. We downgraded the evidence for bias and imprecision. While both high‐ and low‐dose colchicine improve treatment success when compared to placebo, high‐dose (but not low‐dose) colchicine may increase the number of adverse events compared to placebo while the number of adverse events may be similar with low‐dose colchicine compared with NSAIDs. Further research is very likely to have an important impact on our confidence in the estimate of effect and may change the estimate.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "McKenzie, BJ, Wechalekar, MD, Johnston, RV, Schlesinger, N, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD006190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.797Z" }, { "id": "e442e641-0fd5-44e8-afb6-5d92f706781b", "pmid": "", "title": "Endometrial preparation for women undergoing embryo transfer with frozen embryos or embryos derived from donor oocytes", "imported": false, "abstract": "Abstract - Background A frozen embryo transfer (FET) cycle is when one or more embryos (frozen during a previous treatment cycle) are thawed and transferred to the uterus. Some women undergo fresh embryo transfer (ET) cycles with embryos derived from donated oocytes. In both situations, the endometrium is primed with oestrogen and progestogen in different doses and routes of administration. Objectives To evaluate the most effective endometrial preparation for women undergoing transfer with frozen embryos or embryos from donor oocytes with regard to the subsequent live birth rate (LBR). Search methods The Cochrane Gynaecology and Fertility Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, LILACS, trials registers and abstracts of reproductive societies' meetings were searched in June 2020 together with reference checking and contact with study authors and experts in the field to identify additional studies. Selection criteria Randomised controlled trials (RCTs) evaluating endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. Data collection and analysis We used standard methodological procedures recommended by Cochrane. We analysed all available interventions versus placebo, no treatment, or between each other. The primary review outcome was live birth rate. Secondary outcomes were clinical and multiple pregnancy, miscarriage, cycle cancellation, endometrial thickness and adverse effects. Main results Thirty‐one RCTs (5426 women) were included. Evidence was moderate to very low‐quality: the main limitations were serious risk of bias due to poor reporting of methods, and serious imprecision. Stimulated versus programmed cycle We are uncertain whether a letrozole‐stimulated cycle compared to a programmed cycle, for endometrial preparation, improves LBR (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.49 to 3.26; 100 participants; one study; very low‐quality evidence). Stimulating with follicle stimulating hormone (FSH), letrozole or clomiphene citrate may improve clinical pregnancy rate (CPR) (OR 1.63, 95% CI 1.12 to 2.38; 656 participants; five studies; I 2 = 11%; low‐quality evidence). We are uncertain if they reduce miscarriage rate (MR) (OR 0.79, 95% CI 0.36 to 1.71; 355 participants; three studies; I 2 = 0%; very low‐quality evidence). Endometrial thickness (ET) may be reduced with clomiphene citrate (mean difference(MD) ‐1.04, 95% CI ‐1.59 to ‐0.49; 92 participants; one study; low‐quality evidence). Other outcomes were not reported. Natural versus programmed cycle We are uncertain of the effect from a natural versus programmed cycle for LBR (OR 0.97, 95% CI 0.74 to 1.28; 1285 participants; four studies; I 2 = 0%; very low‐quality evidence) and CPR (OR 0.79, 95% CI 0.62 to 1.01; 1249 participants; five studies; I 2 = 60%; very low‐quality evidence), while a natural cycle probably reduces the cycle cancellation rate (CCR) (OR 0.60, 95% CI 0.44 to 0.82; 734 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and ET. No study reported other outcomes. Transdermal versus oral oestrogens From low‐quality evidence we are uncertain of the effect transdermal compared to oral oestrogens has on CPR (OR 0.86, 95% CI 0.59 to 1.25; 504 participants; three studies; I 2 = 58%) or MR (OR 0.55, 95% CI 0.27 to 1.09; 414 participants; two studies; I 2 = 0%). Other outcomes were not reported. Day of starting administration of progestogen When doing a fresh ET using donated oocytes in a synchronised cycle starting progestogen on the day of oocyte pick‐up (OPU) or the day after OPU, in comparison with recipients that start progestogen the day prior to OPU, probably increases the CPR (OR 1.87, 95% CI 1.13 to 3.08; 282 participants; one study, moderate‐quality evidence). We are uncertain of the effect on multiple pregnancy rate (MPR) or MR. It probably reduces the CCR (OR 0.28, 95% CI 0.11 to 0.74; 282 participants; one study; moderate‐quality evidence). No study reported other outcomes. Gonadotropin‐releasing hormone (GnRH) agonist versus control A cycle with GnRH agonist compared to without may improve LBR (OR 2.62, 95% CI 1.19 to 5.78; 234 participants; one study; low‐quality evidence). From low‐quality evidence we are uncertain of the effect on CPR (OR 1.08, 95% CI 0.82 to 1.43; 1289 participants; eight studies; I 2 = 20%), MR (OR 0.85, 95% CI 0.36 to 2.00; 828 participants; four studies; I 2 = 0%), CCR (OR 0.49, 95% CI 0.21 to 1.17; 530 participants; two studies; I 2 = 0%) and ET (MD ‐0.08, 95% CI ‐0.33 to 0.16; 697 participants; four studies; I 2 = 4%). No study reported other outcomes. Among different GnRH agonists From very low‐quality evidence we are uncertain if cycles among different GnRH agonists improves CPR or MR. No study reported other outcomes. GnRH agonists versus GnRH antagonists GnRH antagonists compared to agonists probably improves CPR (OR 0.62, 95% CI 0.42 to 0.90; 473 participants; one study; moderate‐quality evidence). We are uncertain of the effect on MR and MPR. No study reported other outcomes. Aspirin versus control From very low‐quality evidence we are uncertain whether a cycle with aspirin versus without improves LBR, CPR, or ET. Steroids versus control From very low‐quality evidence we are uncertain whether a cycle with steroids compared to without improves LBR, CPR or MR. No study reported other outcomes. Authors' conclusions There is insufficient evidence on the use of any particular intervention for endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers. In frozen embryo transfers, low‐quality evidence showed that clinical pregnancy rates may be improved in a stimulated cycle compared to a programmed one, and we are uncertain of the effect when comparing a programmed cycle to a natural cycle. Cycle cancellation rates are probably reduced in a natural cycle. Although administering a GnRH agonist, compared to without, may improve live birth rates, clinical pregnancy rates will probably be improved in a GnRH antagonist cycle over an agonist cycle. In fresh synchronised oocyte donor cycles, the clinical pregnancy rate is probably improved and cycle cancellation rates are probably reduced when starting progestogen the day of or day after donor oocyte retrieval. Adequately powered studies are needed to evaluate each treatment more accurately. Plain language summary Endometrial preparation for egg donor recipients or for frozen embryo transfers Review question What is the most effective method for endometrial preparation in women undergoing embryo transfers with frozen embryos or embryos derived from donor oocytes? Background Couples undergo infertility treatments due to male factor, female factors or unexplained infertility. After an unsuccessful fresh embryo transfer cycle, a frozen‐thawed embryo transfer can be performed when frozen embryos are available. Adequate hormonal preparation of the endometrium is of utmost importance for both egg donor and frozen embryo replacement cycles to provide the optimal chances of pregnancy. Many drugs and various modes of administration have been tried by several investigators in order to optimise implantation rates and consequently improve the success rates of the embryo transfer procedures: stimulated cycles (to generate endogenous oestradiol), programmed cycles (administering exogenous oestradiol) or natural cycles (allowing the ovaries to produce oestradiol without stimulation) are some of the options; avoiding spontaneous ovulation with gonadotropin‐releasing hormone (GnRH) agonists and antagonists could have some impact; or using some other drugs such as aspirin or steroids that could potentially enhance the endometrial receptivity were also evaluated. Study characteristics We found 31 randomised controlled trials comparing different interventions such as the dose and route of administration of oestrogens and progestogen, the use of drugs that stop the patient from ovulating prematurely (GnRH agonists), and the use of other medications to improve the endometrium in a total of 5426 women. The evidence is current to June 2020. Key results We are uncertain whether a stimulated cycle (with letrozole) compared to a programmed cycle, for endometrial preparation, improves live birth. The evidence suggests that if the chance of live birth following a programmed cycle is assumed to be 24%, the chance following a stimulated cycle would be between 13% and 51%. We are also uncertain of the impact on miscarriage rate and endometrial thickness. A stimulated cycle may improve clinical pregnancy rate. Data were lacking on multiple pregnancy, cycle cancellation and other adverse effects. We are uncertain whether a natural cycle improves the live birth rate, pregnancy rate, miscarriage rate and endometrial thickness in comparison with a programmed cycle. Data were lacking for all other outcomes. We are uncertain if transdermal (delivered via the skin) oestrogens compared with oral (by mouth) oestrogens improve clinical pregnancy rate and miscarriage rate. Data were lacking for all other outcomes in this comparison. Starting progestogen on the day of the donor oocyte retrieval or the day after probably increases the clinical pregnancy rate and probably reduces the cycle cancellation rate. We are uncertain if it reduces the miscarriage rate. Data were lacking for all other outcomes. A cycle with GnRH agonist compared to without may improve live birth rate. We are uncertain of the effect of a GnRH cycle compared to no GnRH for the outcomes of clinical pregnancy rate, miscarriage rate, and endometrial thickness. No study reported on the other outcomes for this comparison. We are uncertain if any GnRH agonist is better than other: a cycle with daily leuprolide or with deposit tryptorelin improves clinical pregnancy rate, or if daily acetate leuprolide or daily nafarelin reduces the miscarriage rate. Other outcomes were not reported. GnRH antagonists compared to agonists probably improve clinical pregnancy rate. We are uncertain of the effect on miscarriage rate and multiple pregnancy rate. No study reported the other outcomes. We are uncertain whether a cycle with aspirin compared to a cycle without improves live birth, clinical pregnancy rate or endometrial thickness. Data were lacking for all other outcomes. We are also uncertain whether a cycle with steroids compared to a cycle without steroids improves live birth rate, clinical pregnancy rate or miscarriage rate. No study reported on the other outcomes. Quality of the evidence The evidence was of moderate to very low‐quality. The main limitations in the evidence were poor reporting of study methods, and lack of precision in the findings for live birth.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Glujovsky, D, Pesce, R, Sueldo, C, Quinteiro Retamar, AM, Hart, RJ, Ciapponi, A", "articleTypes": [], "doi": "10.1002/14651858.CD006359.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.779Z" }, { "id": "e4493bbd-ac1a-41ac-a522-24ad4e469715", "pmid": "", "title": "Helminth therapy (worms) for allergic rhinitis", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a disorder of the nasal membranes and surrounding tissues, and a worldwide cause of illness and disability. Helminths are complex tissue‐dwelling or lumen‐dwelling organisms that inhabit larger organisms and are frequently asymptomatic. Helminths modulate the natural immune responses of their human hosts, and may prevent or cure immune‐mediated or allergic diseases (e.g. allergic rhinitis) in the host. Non‐randomised studies support this hypothesis. Objectives To assess the safety and effectiveness of helminth therapy in people with allergic rhinitis. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2011. Selection criteria All randomised controlled trials where the intervention was any helminth species or combination of helminth species, administered to people with allergic rhinitis in any dose, by any route and for any duration of exposure. We accepted both intermittent and persistent allergic rhinitis patients. Data collection and analysis We independently extracted data and assessed eligibility and risk of bias using a standardised data collection form. We resolved any disagreement through discussion. We combined dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), presenting both with 95% confidence intervals (CI). Main results We found five reports of two single‐centre, placebo‐controlled, double‐blinded studies (130 participants). Participants in both studies were a mix of adults with either intermittent or persistent allergic rhinitis. Both studies had a low risk of bias. One study, with 12 weeks’ follow‐up, used a single percutaneous application of 10 Necator americanus (i.e. human hookworm) larvae. The other study, with 24 weeks’ follow‐up, used three‐weekly oral dosing with 2500 Trichuris suis (i.e. pig whipworm) eggs in aqueous suspension. Of 17 outcomes evaluated in this review, eight were positive (i.e. favoured helminths). Participants taking helminths had no reduction in allergic rhinitis symptoms, percentage of well days (i.e. days with minimal symptoms and no use of medication for allergic rhinitis), lung function measures and quality of life scores. Total use of medication for allergic rhinitis (eye drops, nasal sprays, tablets) did not change; however, in the helminth group there was a statistically significant reduction in the percentage of days during the grass pollen season when participants needed to take tablets as rescue medication for their allergic rhinitis symptoms (MD –14.0%, 95% CI –26.6 to –1.40); in a typical 60‐day pollen season this 14% reduction translates into 19 days when tablets would be needed in the helminth group versus 27 days when tablets would be needed in the placebo group. Participants taking helminths percutaneously (i.e. as hookworm larvae) had local skin itching and redness in the first few days after administration. Participants taking helminths were more likely to report any gastrointestinal adverse event (RR 1.79, 95% CI 1.31 to 2.45), moderate or severe abdominal pain (RR 7.67, 95% CI 1.87 to 31.57), moderate or severe flatulence (RR 2.01, 95% CI 1.06 to 3.81) and moderate or severe diarrhoea (RR 1.99, 95% CI 1.18 to 3.37). There was no difference between the helminth and placebo groups in the incidence of serious adverse events, and in study withdrawals. Authors' conclusions There is currently insufficient evidence on the efficacy, tolerability and likely costs of helminth therapy to support its use in the routine management of allergic rhinitis. Administered to humans in carefully measured doses, helminths appear to be safe. More preclinical studies should be performed, before larger and extended duration trials of helminths for allergic rhinitis are carried out. Future studies should collect and report comparative data on the costs of helminth therapy versus conventional pharmacotherapy. Plain language summary Helminth therapy (worms) for allergic rhinitis Allergic rhinitis is a common health problem affecting about 500 million people worldwide; its prevalence is increasing. The symptoms of allergic rhinitis include sneezing, and an itchy, runny and blocked nose. Several classes of drugs are used to treat allergic rhinitis, but these drugs may be ineffective, and some drug classes have side effects after long‐term use. Drugs may also be relatively expensive. Helminths are complex multicellular organisms that inhabit larger organisms, and in humans are often symptomless. Helminths modulate (that is, optimally adjust) the immune systems of their hosts and it is thought that this property of helminths could be used therapeutically, to prevent or treat allergic diseases, such as allergic rhinitis. We included two well‐designed studies with a total of 130 adult participants, each study using a different species of gastrointestinal helminth (human hookworm in one study and pig whipworm in the other) as the intervention. Both studies found no significant efficacy from helminths, although one helminth species ( Trichuris suis , the pig whipworm) reduced the need for participants to take tablets as ‘rescue medication’ during the grass pollen season. Adverse events such as abdominal pain and flatulence were commoner in the helminth group, but the two helminths species studied did not cause serious adverse reactions. Currently there is insufficient evidence to support the use of helminths for allergic rhinitis in routine clinical practice. More preclinical studies are needed, before larger and extended duration clinical trials of helminths for allergic rhinitis are performed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Croft, AM, Bager, P, Garg, SK", "articleTypes": [], "doi": "10.1002/14651858.CD009238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.103Z" }, { "id": "e458e482-8aa3-4068-a8a3-7d4696e654a2", "pmid": "", "title": "Sustained‐release naltrexone for opioid dependence", "imported": false, "abstract": "Abstract - Background Opioid dependence is a severe and often lifelong disorder with a high risk of overdose and premature death, as well as severe psychosocial difficulties. Sustained‐release naltrexone is a treatment option that works by blocking the euphoric and overdose effects of opioids. When injected intramuscularly, naltrexone provides blockade for one month, while the blocking effects with implants can last for up to six months. Objectives To assess the benefits and harms of sustained‐release naltrexone for the treatment of opioid dependence. Search methods For this update, we searched the following databases from 2007 up to 20 December 2023: the Cochrane Drugs and Alcohol Specialised Register of Trials, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, ISI Web of Science, LILACS, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We manually searched the reference lists of identified studies, published reviews and relevant websites. Selection criteria Randomised controlled trials comparing the effects of injectable or implantable naltrexone with other treatment, no treatment or placebo in adults with opioid dependence. Data collection and analysis Primary outcomes were illicit opioid use, retention in treatment, treatment acceptability and adverse events. Secondary outcomes were opioid craving, recreational use of substances other than opioids, mental health, quality of life and criminal activity. We assessed the risk of bias using the Cochrane risk of bias tool (RoB 1). We combined the results of individual trials through meta‐analysis where possible using a random‐effects model. Two review authors independently assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We identified 22 studies (3416 participants) that met our inclusion criteria. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. Sustained‐release naltrexone compared with opioid agonist treatment We found moderate‐certainty evidence that sustained‐release naltrexone probably increases in‐treatment illicit opioid use slightly (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.01 to 1.31; 1 study, 570 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 1.17, 95% CI 0.78 to 1.76; 3 studies, 773 participants) and treatment acceptability (RR 0.92, 95% CI 0.73 to 1.16; 3 studies, 773 participants). There was low‐certainty evidence that sustained‐release naltrexone may increase serious adverse events slightly in comparison with opioid agonist treatment for serious adverse events (RR 1.40, 95% CI 0.92 to 2.11; 2 studies, 713 participants). Sustained‐release naltrexone compared with oral naltrexone treatment We found low‐certainty evidence that sustained‐release naltrexone may reduce in‐treatment illicit opioid use (RR 0.65, 95% CI 0.45 to 0.93; 1 study, 69 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 2.40, 95% CI 1.64 to 3.52; 3 studies, 464 participants) and on serious adverse events (RR 1.25, 95% CI 0.46 to 3.36; 2 studies, 260 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in treatment acceptability in comparison with oral naltrexone treatment (RR 1.00, 95% CI 0.99 to 1.01; 3 studies, 474 participants). Sustained‐release naltrexone compared with placebo We found low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in in‐treatment illicit opioid use (RR 0.83, 95% CI 0.66 to 1.03; 3 studies, 443 participants), treatment acceptability (RR 1.00, 95% CI 0.98 to 1.02; 1 study, 204 participants) and serious adverse events (RR 0.74, 95% CI 0.17 to 3.23; 3 studies, 443 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment in comparison with placebo (RR 2.10, 95% CI 1.23 to 3.60; 4 studies, 594 participants). Sustained‐release naltrexone compared with treatment as usual We found high‐certainty evidence that sustained‐release naltrexone reduces in‐treatment illicit opioid use (RR 0.72, 95% CI 0.57 to 0.90; 4 studies, 479 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little or no difference in retention in treatment (RR 1.20, 95% CI 0.79 to 1.82; 3 studies, 126 participants) and that it may result in a slight reduction in treatment acceptability (RR 0.79, 95% CI 0.69 to 0.90; 8 studies, 1094 participants). There was moderate‐certainty evidence that sustained‐release naltrexone probably reduces serious adverse events in comparison with treatment as usual (RR 0.59, 95% CI 0.36 to 0.95; 6 studies, 1009 participants). Our primary outcome measures were not reported for sustained‐release naltrexone compared with psychosocial treatments. Amongst the most common methodological weaknesses were the risk of performance bias and imprecision due to few studies and small sample size for many outcomes. Authors' conclusions Sustained‐release naltrexone may slightly increase illicit opioid use and serious adverse events compared to opioid agonists, with uncertain effects on retention and acceptability. It may reduce illicit opioid use compared to oral naltrexone but has uncertain effects on other outcomes. Compared to placebo, it may have little to no impact on key outcomes. Compared to treatment as usual, it reduces illicit opioid use and may reduce serious adverse events but has little effect on retention and slightly reduces acceptability. Significant gaps remain in the evidence on sustained‐release naltrexone for opioid dependence. Future research should include comparisons with psychosocial treatments, larger and higher‐quality studies, and analyses of differences between formulations and comparator treatments. Improved study designs are needed to reduce bias, and more inclusive research should address under‐represented populations and synthetic opioid users. The lack of long‐term outcome data limits understanding of sustained effects, highlighting the need for extended follow‐up and exploration of diverse treatment settings and populations. Plain language summary What are the benefits and risks of sustained‐release (long‐acting) naltrexone for the treatment of dependence on opioid drugs (addiction)? Key messages • It is unclear whether people treated with sustained‐release naltrexone use illicit opioids, such as heroin, less frequently than people treated with opioid agonists, such as buprenorphine or methadone. • People treated with sustained‐release naltrexone may use illicit opioids less frequently than people treated with oral naltrexone, placebo or treatment as usual. • Treatment with sustained‐release naltrexone may be less safe than opioid agonist treatment, but safer than treatment as usual. • Clinicians and patients should weigh the availability and characteristics of treatment options, noting that sustained‐release naltrexone aids abstinence without restricting freedom but requires detoxification; more evidence is needed on long‐term safety and retention. What is dependence on opioid drugs? Opioid drugs, including heroin and prescription painkillers like oxycodone, carry the risk of addiction and serious health consequences. Treatment often involves replacing these opioids with safer alternatives such as methadone or buprenorphine, although other options like therapy or naltrexone are available. However, overcoming opioid dependence remains a persistent challenge due to its complex nature and the associated risks of relapse and overdose. What did we want to find out? In this review we sought to compare sustained‐release naltrexone treatment with other treatments or no treatment for opioid dependence. Naltrexone should not be confused with naloxone, which is a short‐acting drug used for opioid overdose reversal. Other treatments include opioid agonist treatment (such as methadone or buprenorphine), oral naltrexone (taken by mouth, tablets), placebo (sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested), treatment as usual and psychosocial treatments (therapeutic approaches that address both psychological and social aspects of mental health conditions, e.g. psychotherapy, psychoeducation and support groups). What did we do? We searched scientific databases for studies up to December 2023. We identified 22 randomised controlled trials (studies where people were allocated at random to one of two or more treatment or control conditions) involving 3416 adults and adolescents with opioid dependence. Seventy‐four per cent of the people in the studies were male, and they had an average age of 40 years. Twelve of the 22 studies were conducted in the USA or Canada, five in Russia, three in Norway, and one in the UK and Australia, respectively. The main outcomes we examined were opioid use and treatment safety. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. What did we find? We found that when comparing sustained‐release naltrexone to opioid agonist treatment, illicit opioid use probably increases slightly. On the other hand, when comparing sustained‐release naltrexone to treatment as usual, sustained‐release naltrexone reduces illicit opioid use. Compared to oral naltrexone, illicit opioid use may decrease, and compared to placebo, there may be little or no difference. We found no studies comparing sustained‐release naltrexone with psychosocial treatments for any of our primary outcomes. It is generally unclear whether people remain longer in sustained‐release naltrexone treatment than in other treatments or placebo. We do not know whether more people will initiate sustained‐release naltrexone treatment than opioid agonist treatment. When compared to oral naltrexone or placebo, there may be little or no difference in the proportion of people who will initiate treatment. Compared to treatment as usual, it may be that fewer people will initiate sustained‐release naltrexone treatment. Compared to opioid agonist treatment, sustained‐release naltrexone may increase serious adverse (unwanted or harmful) events slightly. It is unclear whether sustained‐release naltrexone results in more or fewer serious adverse events than oral naltrexone. When compared to placebo, there may be little or no difference in the proportion of people who will experience serious adverse events. Sustained‐release naltrexone probably reduces serious adverse events in comparison to treatment as usual. What were the limitations of the evidence? Overall, we have limited confidence in the evidence. One of the reasons is that it is very likely that participants knew which treatments they were assigned to, even if the researchers in many cases tried to conceal the assigned treatment condition for participants and treatment providers. Opioid dependence comes with strong drug cravings and an increased risk of relapse during any treatment. Therefore, participants experiencing cravings and those who maybe even tried to use drugs like heroin would have understood what type of treatment they were assigned to. Another major reason for our limited confidence in the evidence was that the number of studies, and people participating in them, was often too small to obtain precise results. Other reasons for lowering our confidence were inconsistencies in study results and national treatment policies in some studies that make it difficult to apply the results in other countries. How up‐to‐date is this evidence? The evidence is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kornør, H; Lobmaier, PPK; Kunøe, N", "articleTypes": [], "doi": "10.1002/14651858.CD006140.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "e45d3366-fe9d-4698-b330-384fa8fb9e63", "pmid": "", "title": "Effect of adrenergic agonist oral decongestants on blood pressure", "imported": false, "abstract": "Abstract - Background Adrenergic agonist oral decongestants are commonly taken daily over long periods of time to relieve sinus and nasal congestion. The mechanism of action of decongestants potentially increases blood pressure, and these effects may be acute or chronic. However, no systematic reviews to date have comprehensively assessed the chronic blood pressure effects of adrenergic agonist oral decongestants as a drug class, despite their widespread non‐prescription availability. Objectives Primary objective To assess the effects of adrenergic agonist oral decongestants on systolic and diastolic blood pressure compared to placebo. Secondary objective To assess the effects of adrenergic agonist oral decongestants on heart rate and withdrawals due to adverse effects. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCT) up to July 2024: Cochrane Hypertension Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Register of Studies, Ovid MEDLINE, Ovid Embase, and ClinicalTrials.gov. There were no language, publication year, or publication status restrictions. Selection criteria We included RCTs of at least seven days' duration with parallel groups (intervention and placebo) comparing adrenergic agonist oral decongestants versus placebo on blood pressure in people aged over six years. Data collection and analysis Two review authors (JJC and MC) independently assessed the trials for inclusion, extracted the data, and assessed the risk of bias from the included trials. In cases where there were disagreements, the third review author (JMW) adjudicated. For any missing or unclear information in the studies, we contacted the study author to request the missing information or seek clarification. The primary outcomes were systolic blood pressure and diastolic blood pressure. Secondary outcomes were heart rate and withdrawal due to adverse effects. We used a fixed‐effect model to combine the effect sizes from all studies. We assessed the certainty of the evidence using GRADE. Main results Five RCTs randomizing 882 participants met the inclusion criteria. The shortest study duration was one week, and the longest study duration was 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The largest study included 568 people, and the smallest study included 18 people. The mean age of participants was 20.0 years, with 326 males and 591 females. The studies were conducted in the USA and Europe; most were set in the USA. Pharmaceutical companies funded three of the five included studies. The findings are relevant to all people using adrenergic agonist oral decongestants for seven days or longer regardless of comorbidities or pre‐existing conditions. The adrenergic agonist oral decongestants included were ephedrine (one RCT), pseudoephedrine (one RCT), and phenylpropanolamine (three RCTs). Compared to placebo, adrenergic agonist oral decongestants may have little to no effect on systolic blood pressure , but the evidence is very uncertain (mean difference [MD] 0.91 mmHg, 95% confidence interval [CI] −0.57 to 2.38; 4 RCTs, 784 participants; I 2 = 54%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on diastolic blood pressure (MD 0.44 mmHg, 95% CI −0.59 to 1.48; 5 RCTs, 882 participants; I 2 = 30%; low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on heart rate, but the evidence is very uncertain (MD 1.92 beats per minute, 95% CI −0.62 to 4.47; 2 RCTs, 190 participants; I 2 = 79%; very low‐certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on the number of withdrawals due to adverse effects (risk ratio [RR] 1.20, 95% CI 0.37 to 3.88; 4 RCTs, 806 participants; low‐certainty evidence; note 1 study reported withdrawals due to adverse effects but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 3 studies rather than 4). Four studies were at overall high risk of bias, and one study was at overall low risk of bias. Authors' conclusions In this systematic review, chronic daily intake of adrenergic agonist oral decongestants had little to no effect on blood pressure, heart rate, and withdrawals due to adverse effects. People making decisions about using these medicines should consider the very low certainty of evidence and the theoretical risk of increased blood pressure. Independent trials free from biases that are designed to answer this question are required. The evidence was limited due to the small number of studies, and the blood pressure and heart rate not being measured at the optimal time after drug ingestion. Plain language summary What are the effects of oral decongestants on blood pressure? Key messages – We found no evidence that taking oral decongestants (medicine taken by mouth to relieve a stuffy nose) daily for a week or more changes blood pressure or heart rate or causes people to stop taking them due to unwanted effects. – There were only a few studies, and they were not well designed. More well‐conducted studies are needed. – Given that oral decongestants are sometimes taken daily for weeks or months, and have the potential to increase blood pressure, people should consider this potential risk alongside the limited evidence from this review when deciding whether to use these medicines. What are oral decongestants? Oral decongestants are medications taken by mouth to relieve nasal congestion (stuffy or blocked nose), often caused by colds, allergies, or sinus infections (small, empty spaces behind the cheekbones and forehead that are connected to the nose). They typically include medicines called pseudoephedrine or phenylephrine. How do oral decongestants work? These medicines shrink swollen blood vessels in the nasal passages. This reduces swelling and allows air to flow more freely, helping you breathe easier. What is hypertension? Hypertension (high blood pressure) is when resting blood pressure is consistently above 140/90 mmHg. It can lead to unwanted effects such as stroke (where the blood supply to parts of the brain is reduced or stopped) and heart attack (where the blood supply to the heart is reduced or stopped). Lowering blood pressure is the easiest way to reduce these diseases. How is hypertension treated? Treating hypertension involves lifestyle measures and taking blood pressure‐lowering medicines. Here, we focused on the effects of daily intake of oral decongestants. While these medicines help with nasal congestion, they may also increase blood pressure. What do we want to find out? We wanted to find out whether long‐term use of oral decongestants (for seven days or longer) increases blood pressure and has any unwanted effects. We also evaluated their effectiveness in relieving nasal congestion. This provides essential insights into their benefits and risks to guide informed use. What did we do? We searched for studies that compared the blood pressure effects of oral decongestants with placebo. A placebo is a substance or treatment with no active ingredients that is used in medical research to compare against the effects of real medications. We then compared and summarized the results, and rated our confidence in the evidence depending on the study design and methods. What did we find? We found five studies involving 882 children and adults (326 males and 591 females). The shortest study lasted one week, with the longest study lasting 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The size of the studies ranged from 18 to 568 people, and most were done in the USA. Pharmaceutical companies funded three studies. We found no clear evidence that taking oral decongestants daily changes blood pressure or heart rate, or causes people to stop taking them due to unwanted effects. What are the limitations of the evidence? There was a limited number of studies, and they were not well designed. None of the studies were primarily designed to assess the long‐term effects of oral decongestants on blood pressure. Trials designed to answer this question are needed. How up to date is the evidence? The evidence is up to date to July 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Chan, JJ, Chan, M, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007895.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.797Z" }, { "id": "e4681ba2-7162-4dcc-a070-ba7993f21195", "pmid": "", "title": "Antiviral treatment for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gagyor, I, Madhok, VB, Daly, F, Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001869.pub9 AB - Abstract - Background Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. This review was first published in 2001 and most recently updated in 2015. Since a significant benefit of corticosteroids for the early management of Bell's palsy has been demonstrated, the main focus of this update, as in the previous version, was to determine the effect of adding antivirals to corticosteroid treatment. We undertook this update to integrate additional evidence and to better assess the robustness of findings, taking risk of bias fully into account. Objectives To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy. Search methods We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS in July 2019. We reviewed the bibliographies of the identified trials and contacted trial authors to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies. Selection criteria We considered randomised controlled trials (RCTs) or quasi‐RCTs of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that followed‐up participants for less than three months. Data collection and analysis We independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures. We performed sensitivity analyses excluding trials at high or unclear risk of bias in at least five domains, and reported these data as the primary analyses. Main results Fourteen trials, including 2488 participants, met the inclusion criteria. Most were small, and most were at high or unclear risk of bias in multiple domains. We included four new studies at this update. Incomplete recovery A combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in people with Bell's palsy compared to corticosteroids alone (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.38 to 1.74; 3 trials, N = 766; random‐effects; low‐certainty evidence). We excluded 10 trials that were at high or unclear risk of bias in several domains from this analysis and limited all analyses to studies at lower risk of bias. Recovery rates were better in participants receiving corticosteroids alone than antivirals alone (RR 2.69, 95% CI 0.73 to 10.01; 2 trials, N = 667; random‐effects), but the result was imprecise and allowed for the possibility of no effect. The rate of incomplete recovery was lower with antivirals plus corticosteroids than with placebo or no treatment (RR 0.56, 95% CI 0.42 to 0.76; 2 trials, N = 658; random‐effects). Antivirals alone had no clear effect on incomplete recovery rates compared with placebo, but the result was imprecise (RR 1.10, 95% CI 0.87 to 1.40; 2 trials, N = 658; fixed‐effect). For people with severe Bell's palsy (House‐Brackmann score of 5 and 6, or equivalent on other scales), we found that the combination of antivirals and corticosteroids had no clear effect on incomplete recovery at month six compared to corticosteroids alone, although the result was again imprecise (RR 0.82, 95% CI 0.57 to 1.17; 2 trials, N = 98; random‐effects). Motor synkinesis or crocodile tears Antivirals plus corticosteroids reduced the proportion of participants who experienced these long‐term sequelae from Bell's palsy compared to placebo plus corticosteroids (RR 0.56, 95% CI 0.36 to 0.87; 2 trials, N = 469; fixed‐effect; moderate‐certainty evidence). Antivirals plus corticosteroids reduced long‐term sequelae compared to placebo but there was no clear difference in this outcome with antivirals alone compared to placebo. Adverse events Adverse event data were available in four studies providing data on 1592 participants. None of the four comparisons showed clear differences in adverse events between treatment and comparison arms (very low‐certainty evidence); for the comparison of antivirals plus corticosteroids and corticosteroids alone in studies at lower risk of bias, the RR was 1.17 (95% CI 0.81 to 1.69; 2 trials, N = 656; fixed‐effect; very low‐certainty evidence). Authors' conclusions The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, or in people with severe Bell's palsy, but the results were very imprecise. Corticosteroids alone were probably more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no clear benefit from antivirals alone over placebo. The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone. Studies also showed fewer episodes of long‐term sequelae in corticosteroid‐treated participants than antiviral‐treated participants. We found no clear difference in adverse events from the use of antivirals compared with either placebo or corticosteroids, but the evidence is too uncertain for us to draw conclusions. An adequately powered RCT in people with Bell’s palsy that compares different antiviral agents may be indicated. Plain language summary Antiviral treatment for Bell's palsy Review question We reviewed the evidence about the effect of antiviral therapy (drugs used specifically to treat viral infections), alone or in combination with any other therapy, on Bell's palsy. Our focus in this updated review was combined therapy with antiviral drugs and corticosteroids (which are drugs used to reduce inflammation) as there is already good evidence that corticosteroids can reduce rates of incomplete recovery from Bell's palsy. Background Bell's palsy is a disease of the facial nerve that causes one side of the face to be paralysed. Some studies have suggested that it is caused by the same viral infections that cause cold sores or shingles and investigated the effect of antiviral therapy. Earlier versions of this review have found that antivirals alone are not helpful compared to a dummy pill, and are less effective than corticosteroids alone. However, studies of antiviral treatment in combination with corticosteroids have conflicting results. Study characteristics We identified 14 trials, which included 2488 participants with mild, moderate, or severe one‐sided Bell's palsy of unknown cause. Participants were aged from 14 to 84 years. The trials compared:
 ‐ antivirals plus corticosteroids to corticosteroids alone or in combination with placebo;
 ‐ antivirals alone or in combination with placebo to placebo or no treatment;
 ‐ antivirals alone or in combination with placebo to corticosteroid treatment alone or in combination with placebo; or
 ‐ antivirals plus corticosteroids to placebo or no treatment. For the majority of the studies, no information on funding was given. The remaining were mostly partly public funded, and one trial was funded by a pharmaceutical company. Eleven studies had high or uncertain risk of bias from various factors that can systematically affect trial results. We chose to base our conclusions only on data from three studies at a lower risk of bias. Key results and certainty of the evidence The review showed that there may be no clear difference in rates of incomplete recovery from Bell's palsy after treatment with the combination of antivirals and corticosteroids, compared to corticosteroids alone. This finding was of low certainty and was based on data from three trials involving 766 people with Bell's palsy of various degrees of severity. We excluded data from 10 trials with multiple potential sources of bias. However, we can be moderately confident that the combined therapy reduced the number of people left with long‐term effects of Bell's palsy (excessive tearing of the eyes or an abnormal facial movement) compared to corticosteroid treatment alone. Data from two studies (98 participants) showed that in people with severe Bell's palsy (complete or almost complete facial paralysis), combined antivirals and corticosteroids had no clear effect on recovery compared with corticosteroid treatment alone. Corticosteroids alone were more effective than antivirals alone on rates of incomplete recovery (667 participants, 2 trials); antivirals and corticosteroids combined were more effective than placebo or no treatment (658 participants, 2 trials); and there was no clear benefit from antivirals alone over placebo (658 participants, 2 trials). Although, based on data from two trials (656 participants), we found no clear difference in the occurrence of side effects between people receiving both antivirals and corticosteroids, compared to those receiving corticosteroids alone, this evidence is too uncertain for us to draw conclusions. Large studies in people with Bell's palsy comparing additional antiviral agents may be indicated in the future.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.098Z" }, { "id": "e4795b4a-9b49-427d-92b5-4df6643cdbc1", "pmid": "", "title": "Progesterone receptor modulators for endometriosis", "imported": false, "abstract": "Abstract - Rationale Endometriosis is defined as the presence of endometrium‐like tissue developing outside the uterine cavity. This condition is oestrogen‐dependent and thus is seen primarily during the reproductive years. Owing to their antiproliferative effects on the endometrium, progesterone receptor modulators (PRMs) have been advocated for the treatment of endometriosis. This is an update of a Cochrane review previously published in 2017. Objectives To assess the effectiveness and safety of progesterone receptor modulators (PRMs) in the management of endometriosis. Search methods To identify studies, we searched online sources, including the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, ClinicalTrials.gov and the WHO (World Health Organization) trial registry up to 16 April 2026. We also checked reference lists and contacted study authors and experts. Eligibility criteria We included randomised controlled trials (RCTs) comparing PRMs with placebo, no treatment or other medical treatment, in women with symptomatic endometriosis. Outcomes Our critical outcomes were overall pain; improvement in the most troublesome symptom, including dysmenorrhoea and dyspareunia; and adverse events resulting from the PRM intervention. Our important outcomes included quality of life (QoL) and patient satisfaction with treatment. Risk of bias We used the Cochrane tool RoB 2 to assess the risk of bias in the outcomes of this review. Synthesis methods Two review authors independently assessed studies against the inclusion criteria, extracted data and assessed risk of bias, consulting a third review author where required. We analysed dichotomous outcomes using Mantel‐Haenszel odds ratios (ORs), 95% confidence intervals (CIs) and the fixed‐effect model. We analysed continuous outcomes using the mean difference (MD) between groups, presented with 95% CIs. We employed the GRADE approach to assess the certainty of the evidence as high, moderate, low or very low. Included studies No new studies were eligible for inclusion in this update. Of the nine studies (922 women) already included in the review, two compared mifepristone versus placebo or compared different doses of mifepristone, and four either compared gestrinone versus danazol, gestrinone versus gonadotropin‐releasing hormone (GnRH) analogues or compared different doses of gestrinone. One study compared asoprisnil versus placebo. The asoprisnil study did not provide extractable numerical data and was included in the narrative synthesis only. Two of the studies did not report any of the review's prespecified outcomes. Synthesis of results Certainty of the evidence We judged the certainty of evidence as low to very low. The main limitations of the evidence were serious risk of bias (associated with poor reporting of methods and high or unclear rates of attrition), very serious imprecision (associated with low event rates and wide confidence intervals, with some large effect estimates) and serious indirectness (outcomes assessed in selected subgroups). PRM versus placebo Mifepristone versus placebo These results are based on one study (360 participants) that measured outcomes after three months. The study did not report overall pain. At three months, mifepristone may improve dysmenorrhoea (OR 0.07, 95% CI 0.03 to 0.15; 1 study, 342 participants; low‐certainty evidence), suggesting that if 40% of women taking placebo experience dysmenorrhoea, then between 3% and 10% of women taking mifepristone will do so. We are uncertain whether mifepristone improves dyspareunia (OR 0.23, 95% CI 0.10 to 0.51; 1 study, 223 participants; very low‐certainty evidence). However, mifepristone may increase hot flushes (OR 28.79, 95% CI 3.93 to 210.73; 1 study, 360 participants; low‐certainty evidence). Mifepristone may make little or no difference after three months of treatment to the prevalence of nausea (OR 1.72, 95% CI 0.20 to 15.03; 1 study, 360 participants; low‐certainty evidence). PRM versus other medical treatment Gestrinone versus danazol These results are based on two studies (302 participants) that measured outcomes after six months. We are uncertain of the effects of gestrinone relative to danazol on the improvement of overall pain (dichotomous outcome: participants reporting no or mild pelvic pain counted as 'improved') (OR 0.47, 95% CI 0.04 to 5.70; 1 study, 38 participants), dysmenorrhoea (Not estimable; 1 study, 38 participants), or dyspareunia (OR 1.00, 95% CI 0.13 to 7.94; 1 study, 38 participants (all very low‐certainty evidence). We are uncertain about the effects of gestrinone relative to danazol on hot flushes (OR 0.79, 95% CI 0.50 to 1.26; 2 studies, 302 participants; very low‐certainty evidence). There may be little or no difference between gestrinone and danazol in rates of nausea (OR 1.36, 95% CI 0.84 to 2.19; 2 studies, 302 participants; low‐certainty evidence). Gestrinone versus a GnRH analogue (leuprorelin) These results are based on one study (55 participants) that measured outcomes after six months. There may be little to no difference between gestrinone and leuprorelin in non‐menstrual pain (MD −0.41, 95% CI −1.76 to 0.94; 1 study, 55 participants; low‐certainty evidence). Women taking gestrinone may have higher dysmenorrhoea scores than those taking leuprorelin (MD 0.82, 95% CI 0.15 to 1.49; 1 study, 55 participants; low‐certainty evidence), but gestrinone may improve dyspareunia more than leuprorelin (MD −1.16, 95% CI −2.08 to −0.24; 1 study, 52 participants; low‐certainty evidence). There may be lower rates of hot flushes with gestrinone than leuprorelin (OR 0.20, 95% CI 0.06 to 0.63; 1 study, 55 participants; low‐certainty evidence). There may be little or no difference between gestrinone and leuprorelin in rates of nausea (OR 1.04, 95% CI 0.06 to 17.49; 1 study, 55 participants; low‐certainty evidence). Authors' conclusions Mifepristone may improve dysmenorrhoea in women with endometriosis, but it might increase the prevalence of adverse events, such as hot flushes. The evidence is very uncertain regarding its effect on dyspareunia. Gestrinone may be less effective than leuprorelin in treating dysmenorrhoea, but it may improve dyspareunia. It may be associated with lower rates of hot flushes and similar rates of nausea. We are uncertain about the effect of gestrinone compared to danazol. We found insufficient evidence to permit firm conclusions about the safety and effectiveness of other progesterone receptor modulators. Funding This Cochrane review had no dedicated funding. Registration Protocol (2012) DOI: 10.1002/14651858.CD009881 Review (2017) DOI: 10.1002/14651858.CD009881.pub2 Plain language summary What are the benefits and risks of medicines called progesterone receptor modulators (PRMs) for treating endometriosis (a condition where tissue grows outside the womb)? Key messages In the management of endometriosis (a condition where tissue grows outside the womb), studies that compared a progesterone receptor modulator (PRM; a medicine that changes how the hormone progesterone acts in the body) against placebo (a 'dummy' treatment, or sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested) found that a PRM called mifepristone may improve painful periods. However, it may cause hot flushes. A PRM called gestrinone may be less effective than medicines known as gonadotropin‐releasing hormone (GnRH) analogues (which reduce the amount of oestrogen made by the ovaries) for treating painful periods, but may improve pain during sex. Gestrinone may also cause fewer hot flushes. We do not know how gestrinone compares to a treatment called danazol in terms of pain not related to periods, painful periods or pain during sex. We do not know whether gestrinone or danazol causes more unwanted effects. Future studies should compare progesterone receptor modulators with medicines currently used to treat endometriosis symptoms and focus on assessing pain using recognised and reliable methods. Larger, well‐designed studies are also needed to assess the benefits and unwanted effects of progesterone receptor modulators other than mifepristone and gestrinone. What is endometriosis? Endometriosis is a condition where tissue similar to the lining of the womb (uterus) grows outside the womb. Endometriosis is oestrogen‐dependent and thus is seen mainly during the reproductive years. It can cause pain in the tummy area (abdomen), generally during periods (menstruation) or associated with sexual intercourse. Endometriosis is treated through different types of medical or surgical treatment. Progesterone receptor modulators (PRMs) are medicines that change how the hormone progesterone acts in the body. PRMs include mifepristone, gestrinone, ulipristal acetate, vilaprisan and asoprisnil. Because they can slow down or stop the growth of tissue in the lining of the uterus, they have been suggested as a treatment for endometriosis. What did we want to find out? We wanted to know whether, in patients with endometriosis, PRMs are better than placebo ('dummy' treatment), no treatment or other medical treatment for improving overall pain, pain during periods and pain during sexual intercourse. We also wanted to know if these medications were safe by assessing unwanted effects experienced by patients, such as hot flushes and feeling sick (nausea). What did we do? We searched for studies that investigated the effectiveness of PRMs for symptoms associated with endometriosis and whether they caused unwanted effects. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We included nine studies involving 922 women aged 18 to 45 years. Most studies tested the PRMs mifepristone or gestrinone. One study tested asoprisnil, but the study was published only as a short summary without results that we could use. Two of the studies did not measure any of the effects we were interested in. Main results Progesterone receptor modulators versus placebo When compared to a placebo, mifepristone: may reduce painful periods after three months of treatment (based on 1 study of 342 women); may cause more unwanted effects, such as hot flushes (1 study, 360 women); may make little or no difference to nausea (1 study, 360 women); and we are uncertain whether mifepristone reduces pain during sex (1 study, 223 women). Progesterone receptor modulators versus other medical treatment When compared to danazol, one study of 38 women showed that: we do not know whether gestrinone improves pain symptoms after six months of treatment (1 study, 38 women); we do not know whether gestrinone causes more or fewer hot flushes or makes no difference (2 studies, 302 women); and gestrinone and danazol may cause similar rates of nausea, but the results are very uncertain (2 studies, 302 women). When compared to a GnRH analogue (leuprorelin), one study of 55 women found that: gestrinone may be less efficient in treating painful periods after six months of treatment (1 study, 55 women); but gestrinone may reduce pain during sex (1 study, 52 women); gestrinone may be similar to leuprorelin in terms of general pain experienced (1 study, 55 women); gestrinone may cause fewer hot flushes and similar levels of nausea (1 study, 55 women). What are the limitations of the evidence? Our confidence in the evidence is low to very low, mainly because some studies had one or more of these problems: they did not have many people taking part; they focused on specific settings or populations; they used methods likely to introduce errors in their results; they did not clearly report how they were conducted; they did not clearly report whether the people taking part knew which treatment they had received, which could have affected the study results. How up to date is this evidence? This review updates a previous review. The evidence is up to date to April 2026.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Grammatis, AL; Gibbons, T; Anucha, EN; Becker, CM", "articleTypes": [], "doi": "10.1002/14651858.CD009881.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "e4aa5c03-a819-46c1-ad93-d752b82b2b45", "pmid": "", "title": "Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID‐19", "imported": false, "abstract": "Abstract - Background COVID‐19 illness is highly variable, ranging from infection with no symptoms through to pneumonia and life‐threatening consequences. Symptoms such as fever, cough, or loss of sense of smell (anosmia) or taste (ageusia), can help flag early on if the disease is present. Such information could be used either to rule out COVID‐19 disease, or to identify people who need to go for COVID‐19 diagnostic tests. This is the second update of this review, which was first published in 2020. Objectives To assess the diagnostic accuracy of signs and symptoms to determine if a person presenting in primary care or to hospital outpatient settings, such as the emergency department or dedicated COVID‐19 clinics, has COVID‐19. Search methods We undertook electronic searches up to 10 June 2021 in the University of Bern living search database. In addition, we checked repositories of COVID‐19 publications. We used artificial intelligence text analysis to conduct an initial classification of documents. We did not apply any language restrictions. Selection criteria Studies were eligible if they included people with clinically suspected COVID‐19, or recruited known cases with COVID‐19 and also controls without COVID‐19 from a single‐gate cohort. Studies were eligible when they recruited people presenting to primary care or hospital outpatient settings. Studies that included people who contracted SARS‐CoV‐2 infection while admitted to hospital were not eligible. The minimum eligible sample size of studies was 10 participants. All signs and symptoms were eligible for this review, including individual signs and symptoms or combinations. We accepted a range of reference standards. Data collection and analysis Pairs of review authors independently selected all studies, at both title and abstract, and full‐text stage. They resolved any disagreements by discussion with a third review author. Two review authors independently extracted data and assessed risk of bias using the QUADAS‐2 checklist, and resolved disagreements by discussion with a third review author. Analyses were restricted to prospective studies only. We presented sensitivity and specificity in paired forest plots, in receiver operating characteristic (ROC) space and in dumbbell plots. We estimated summary parameters using a bivariate random‐effects meta‐analysis whenever five or more primary prospective studies were available, and whenever heterogeneity across studies was deemed acceptable. Main results We identified 90 studies; for this update we focused on the results of 42 prospective studies with 52,608 participants. Prevalence of COVID‐19 disease varied from 3.7% to 60.6% with a median of 27.4%. Thirty‐five studies were set in emergency departments or outpatient test centres (46,878 participants), three in primary care settings (1230 participants), two in a mixed population of in‐ and outpatients in a paediatric hospital setting (493 participants), and two overlapping studies in nursing homes (4007 participants). The studies did not clearly distinguish mild COVID‐19 disease from COVID‐19 pneumonia, so we present the results for both conditions together. Twelve studies had a high risk of bias for selection of participants because they used a high level of preselection to decide whether reverse transcription polymerase chain reaction (RT‐PCR) testing was needed, or because they enrolled a non‐consecutive sample, or because they excluded individuals while they were part of the study base. We rated 36 of the 42 studies as high risk of bias for the index tests because there was little or no detail on how, by whom and when, the symptoms were measured. For most studies, eligibility for testing was dependent on the local case definition and testing criteria that were in effect at the time of the study, meaning most people who were included in studies had already been referred to health services based on the symptoms that we are evaluating in this review. The applicability of the results of this review iteration improved in comparison with the previous reviews. This version has more studies of people presenting to ambulatory settings, which is where the majority of assessments for COVID‐19 take place. Only three studies presented any data on children separately, and only one focused specifically on older adults. We found data on 96 symptoms or combinations of signs and symptoms. Evidence on individual signs as diagnostic tests was rarely reported, so this review reports mainly on the diagnostic value of symptoms. Results were highly variable across studies. Most had very low sensitivity and high specificity. RT‐PCR was the most often used reference standard (40/42 studies). Only cough (11 studies) had a summary sensitivity above 50% (62.4%, 95% CI 50.6% to 72.9%)); its specificity was low (45.4%, 95% CI 33.5% to 57.9%)). Presence of fever had a sensitivity of 37.6% (95% CI 23.4% to 54.3%) and a specificity of 75.2% (95% CI 56.3% to 87.8%). The summary positive likelihood ratio of cough was 1.14 (95% CI 1.04 to 1.25) and that of fever 1.52 (95% CI 1.10 to 2.10). Sore throat had a summary positive likelihood ratio of 0.814 (95% CI 0.714 to 0.929), which means that its presence increases the probability of having an infectious disease other than COVID‐19. Dyspnoea (12 studies) and fatigue (8 studies) had a sensitivity of 23.3% (95% CI 16.4% to 31.9%) and 40.2% (95% CI 19.4% to 65.1%) respectively. Their specificity was 75.7% (95% CI 65.2% to 83.9%) and 73.6% (95% CI 48.4% to 89.3%). The summary positive likelihood ratio of dyspnoea was 0.96 (95% CI 0.83 to 1.11) and that of fatigue 1.52 (95% CI 1.21 to 1.91), which means that the presence of fatigue slightly increases the probability of having COVID‐19. Anosmia alone (7 studies), ageusia alone (5 studies), and anosmia or ageusia (6 studies) had summary sensitivities below 50% but summary specificities over 90%. Anosmia had a summary sensitivity of 26.4% (95% CI 13.8% to 44.6%) and a specificity of 94.2% (95% CI 90.6% to 96.5%). Ageusia had a summary sensitivity of 23.2% (95% CI 10.6% to 43.3%) and a specificity of 92.6% (95% CI 83.1% to 97.0%). Anosmia or ageusia had a summary sensitivity of 39.2% (95% CI 26.5% to 53.6%) and a specificity of 92.1% (95% CI 84.5% to 96.2%). The summary positive likelihood ratios of anosmia alone and anosmia or ageusia were 4.55 (95% CI 3.46 to 5.97) and 4.99 (95% CI 3.22 to 7.75) respectively, which is just below our arbitrary definition of a 'red flag', that is, a positive likelihood ratio of at least 5. The summary positive likelihood ratio of ageusia alone was 3.14 (95% CI 1.79 to 5.51). Twenty‐four studies assessed combinations of different signs and symptoms, mostly combining olfactory symptoms. By combining symptoms with other information such as contact or travel history, age, gender, and a local recent case detection rate, some multivariable prediction scores reached a sensitivity as high as 90%. Authors' conclusions Most individual symptoms included in this review have poor diagnostic accuracy. Neither absence nor presence of symptoms are accurate enough to rule in or rule out the disease. The presence of anosmia or ageusia may be useful as a red flag for the presence of COVID‐19. The presence of cough also supports further testing. There is currently no evidence to support further testing with PCR in any individuals presenting only with upper respiratory symptoms such as sore throat, coryza or rhinorrhoea. Combinations of symptoms with other readily available information such as contact or travel history, or the local recent case detection rate may prove more useful and should be further investigated in an unselected population presenting to primary care or hospital outpatient settings. The diagnostic accuracy of symptoms for COVID‐19 is moderate to low and any testing strategy using symptoms as selection mechanism will result in both large numbers of missed cases and large numbers of people requiring testing. Which one of these is minimised, is determined by the goal of COVID‐19 testing strategies, that is, controlling the epidemic by isolating every possible case versus identifying those with clinically important disease so that they can be monitored or treated to optimise their prognosis. The former will require a testing strategy that uses very few symptoms as entry criterion for testing, the latter could focus on more specific symptoms such as fever and anosmia. Plain language summary How accurate are symptoms and medical examination to diagnose COVID‐19? Key messages ‐ The results suggest that a single symptom included in this review cannot accurately diagnose COVID‐19. ‐ Loss of sense of taste or smell could be a 'red flag' for the presence of COVID‐19. Cough or fever might be useful to identify people who might have COVID‐19. These symptoms might be useful to prompt further testing when they are present. ‐ We need more research to investigate combinations of symptoms and signs with other information such as recent contact or travel history, or vaccination status, and in children, and adults aged 65 years and over. What are symptoms or signs of COVID‐19? Symptoms are experienced by patients. COVID‐19 symptoms include cough, sore throat, high temperature, diarrhoea, headache, muscle or joint pain, fatigue, and loss of sense of smell and taste. Signs are measured by healthcare workers during clinical examination. They include lung sounds, blood pressure, blood oxygen level and heart rate. Symptoms and signs of COVID‐19 might be important to help people know whether they and the people they come into contact with should isolate at home, undergo testing with a rapid lateral flow test or PCR (laboratory‐based) test, or be hospitalised. What did we want to find out? Symptoms and signs of COVID‐19 are varied and may indicate other diseases, not just COVID‐19. We wanted to know how accurate diagnosis of COVID‐19 is, based on symptoms and signs from medical examination. We were interested in people with suspected COVID‐19, who go to their doctor, outpatient test centres or hospital. What did we do? We searched for studies that assessed the accuracy of symptoms and signs to diagnose COVID‐19. Studies had to be conducted in general practice, outpatient test centres or hospital outpatient settings only. We only included studies of people in hospital if signs and symptoms were recorded when they were admitted to the hospital, for example through the emergency department. What did we find? We focused on 42 studies with 52,608 participants in this review. The studies assessed 96 separate or combined symptoms and signs. Thirty‐five studies were conducted in emergency departments or outpatient COVID‐19 test centres (46,878 participants), 3 studies in general practice (1230 participants), 2 studies in children’s hospitals (493 in‐ and outpatients), and 2 studies in nursing homes (4007 participants). The studies were conducted in 18 different countries around the world. Twenty‐three studies were conducted in Europe, 8 in North‐America, 5 in Asia, and 3 in South‐America and 3 in Australia. We didn’t find any studies conducted in Africa. Three focused specifically on children, and only 1 focused on adults aged 65 years and over. Most studies did not clearly distinguish between mild and severe COVID‐19, so we present the results for mild, moderate and severe disease together. Few studies reported individual signs as diagnostic tests, so we focus mainly on the diagnostic value of symptoms. The most frequently reported symptoms were cough, fever, shortness of breath and sore throat. According to the studies in our review, in a group of 1000 people with suspected COVID‐19 of whom 270 (27%) would actually have COVID‐19, around 567 people would have a cough. Of these 567, 168 would actually have COVID‐19. Of the 433 who do not have a cough, 102 would have COVID‐19. In the same 1000 people, around 283 people would have a fever. Of these 283, 102 would actually have COVID‐19. Of the 717 people without fever, 168 would have COVID‐19. Someone who has lost their sense of smell or taste is five times more likely to have COVID‐19 than someone who hasn’t. Other symptoms, such as a sore throat or runny nose, are more likely to indicate the presence of an infectious disease other than COVID‐19. In the same 1000 people as described above, around 362 people would have a sore throat. Of these, only 84 would actually have COVID‐19. Of the 638 patients without sore throat, 186 would have COVID‐19. We found similar figures for having a runny nose. What are the limitations of the evidence? The results of this updated review are more reliable than those in previous versions as we included more high‐quality studies. However, the accuracy of individual symptoms varied across studies and the diagnostic value of symptoms such as fever, cough or other respiratory symptoms might still be overestimated, as most studies deliberately included participants because they had these symptoms. The results do not clearly differentiate between people with mild, moderate or severe COVID‐19. Only a few studies investigated the symptom‐based diagnosis of COVID‐19 in children or older adults. How up to date is this review? This review updates our previous review. The evidence is up to date to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Struyf, T, Deeks, JJ, Dinnes, J, Takwoingi, Y, Davenport, C, Leeflang, MMG, Spijker, R, Hooft, L, Emperador, D, Domen, J, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013665.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.758Z" }, { "id": "e4ad0a07-a86d-4bd9-86f5-4f83cd6966db", "pmid": "", "title": "Nedocromil sodium for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Exercise‐induced bronchoconstriction (EIB) following strenuous physical exertion afflicts many people. It can be the cause of sub‐optimal performance, symptoms such as cough, dyspnea, wheeze and chest tightness, and can lead people to avoid physical activity. Management of EIB focuses on prevention through pharmacotherapy and alternate strategies. Single use, pre‐exercise, beta‐agonists and non‐steroidal antiinflammatory agents are recommended. Objectives Bronchodilator medications have been commonly used to prevent narrowing of airways after exercise, but anti‐inflammatory drugs such as nedocromil sodium have also been used. The objective of this review was to assess the effects of a single dose of nedocromil sodium to prevent exercise‐induced bronchoconstriction. Search methods We searched the Cochrane Airways Group Specialised Regsiter, the Cochrane Central Register of Controlled Trials, Current Contents, review articles, textbooks and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. Searches have been updated to August 2008. Selection criteria Randomised trials comparing a single dose of nedocromil sodium with placebo to prevent exercise‐induced bronchoconstriction in patients with EIB over six years of age. Data collection and analysis Trial quality assessment and data extraction were conducted independently by two reviewers. Study authors were contacted for confirmation of data. No new studies were identified in an update search conducted in August 2008. Main results The combined results from 20 randomised controlled trials involving 280 participants, show that 4 mg, of nedocromil sodium inhaled 15 to 60 minutes prior to exercise significantly reduce the severity and duration of EIB in both adults and children, when compared to placebo. The maximum percentage fall in FEV1 was improved significantly compared to placebo (weighted mean difference 15.5 %; 95% confidence interval:13.2 to 18.1). For the maximum percentage fall in peak expiratory flow rate (PEFR) the improvement was similar: WMD 15.0%, (95% CI 8.3 to 21.6). Nedocromil shortened the time to recover lung normal function from more than 30 minutes with placebo to less than 10 minutes with the drug. It had a greater effect on those patients with more severe exercise‐induced bronchoconstriction (defined as an exercise‐induced fall in lung function > 30% from baseline). There were no significant adverse effects reported with the short term use of nedocromil. A further search conducted in August 2005 did not yield any further studies. Authors' conclusions Nedocromil sodium used before exercise reduces the severity and duration of exercise‐induced bronchoconstriction. This effect appears to be more pronounced in people with severe exercise‐induced bronchoconstriction. Plain language summary Nedocromil sodium for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. The review of trials found that nedocromil sodium (Tilade) inhaled 15 to 60 minutes before exercise may reduce the severity and length of this kind of asthma for both adults and children, particularly those who have severe episodes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Spooner, C, Saunders, LD, Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD001183", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.745Z" }, { "id": "e4c1be49-fe67-44e2-bbfc-cb23867dd85a", "pmid": "", "title": "A Multicenter, Open-label, Randomized Study to Evaluate the Efficacy and Safety of Ropeginterferon Alfa-2b in the Treatment of Patients With Moderate COVID-19", "imported": false, "abstract": "To evaluate the efficacy of subcutaneous ropeginterferon alfa 2b ( P1101combined with standard of care (SOC) compared with standard care alone in hospitalized adults with moderate COVID 19.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.261Z" }, { "id": "e4c89f5d-7511-488d-92e9-2fff66d58aa0", "pmid": "", "title": "Genetic Variability in Taste Perception", "imported": false, "abstract": "This proposal describes a pilot study aimed at determining whether genetic variations in taste receptors determine differential taste tolerability of pediatric medications.", "journal": "", "year": "2013", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.141Z" }, { "id": "e4cef54f-836b-4ee6-b8c4-ba28c87e3eef", "pmid": "", "title": "Genital ulcer disease treatment for reducing sexual acquisition of HIV", "imported": false, "abstract": "Abstract - Background Genital ulcer disease by virtue of disruption of the mucosal surfaces may enhance HIV acquisition. Genital ulcer disease treatment with resolution of the ulcers may therefore contribute in reducing the sexual acquisition of HIV. Objectives To determine the effects of treatment of genital ulcer disease on sexual acquisition of HIV. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, LILACS, NLM Gateway, Web of Science, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and reference lists of relevant publications for eligible studies published between 1980 and August 2011. Selection criteria Randomized controlled trials of any treatment intervention aimed at curing genital ulcer disease compared with an alternative treatment, placebo, or no treatment. We included only trials whose unit of randomization was the individual with confirmed genital ulcer. Data collection and analysis We independently selected studies and extracted data in duplicate; resolving discrepancies by discussion, consensus, and arbitration by third review author. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI). Main results There were three randomized controlled trials that met our inclusion criteria recruited HIV‐negative participants with chancroid (two trials with 143 participants) and primary syphilis (one trial with 30 participants). The syphilis study, carried out in the US between 1995 and 1997, randomized participants to receive a single 2.0 g oral dose of azithromycin (11 participants); two 2.0 g oral doses of azithromycin administered six to eight days apart (eight participants); or benzathine penicillin G administered as either 2.4 million units intramuscular injection once or twice seven days apart (11 participants). No participant in the trial seroconverted during 12 months of follow‐up. The chancroid trials, conducted in Kenya by 1990, found no significant differences in HIV seroconversion rates during four to 12 weeks of follow‐up between 400 and 200 mg single oral doses of fleroxacin (one trial, 45 participants; RR 3.00; 95% CI 0.29 to 30.69), or between 400 mg fleroxacin and 800 mg sulfamethoxazole plus 160 mg trimethoprim (one trial, 98 participants; RR 0.33; 95% CI 0.04 to 3.09). Adverse events reported were mild to moderate in severity, and included Jarisch‐Herxheimer reactions and gastrointestinal symptoms. The differences between the treatment arms in the incidence of adverse events were not significant. The quality of this evidence on the effectiveness of genital ulcer disease treatment in reducing sexual acquisition of HIV, according to GRADE methodology, is of very low quality. Authors' conclusions At present, there is insufficient evidence to determine whether curative treatment of genital ulcer disease would reduce the risk of HIV acquisition. The very low quality of the evidence implies that the true effect of genital ulcer disease treatment on sexual acquisition of HIV may be substantially different from the effect estimated from currently available data. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not. Plain language summary Genital ulcer disease treatment for reducing sexual acquisition of HIV The presence of a genital ulcer would provide an entry point for the HIV virus if an HIV‐negative individual with an ulcer has unprotected sexual intercourse with an HIV‐infected person. Treatment of the condition causing the genital ulcer would allow the ulcer to heal and therefore reduce the chances of HIV acquisition. This review assessed whether giving treatment for diseases that present with ulcers in the genital region would reduce sexual acquisition of HIV. Three studies were identified involving 173 HIV‐negative patients with genital ulcers. These studies did not provide sufficient evidence that treatment of genital ulcer diseases reduces sexual acquisition of HIV infection. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mutua, FM; M'Imunya, JM; Wiysonge, CS", "articleTypes": [], "doi": "10.1002/14651858.CD007933.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "e4d66ff5-861b-4c60-97fb-cb6c71fc21bc", "pmid": "", "title": "Prophylactic drug management for febrile seizures in children", "imported": false, "abstract": "Abstract - Background Febrile seizures occurring in a child older than one month during an episode of fever affect 2‐4% of children in Great Britain and the United States and recur in 30%. Rapid‐acting antiepileptics and antipyretics given during subsequent fever episodes have been used to avoid the adverse effects of continuous antiepileptic drugs. This is an updated version of a Cochrane Review previously published in 2017. Objectives To evaluate primarily the effectiveness and safety of antiepileptic and antipyretic drugs used prophylactically to treat children with febrile seizures; and also to evaluate any other drug intervention where there is a sound biological rationale for its use. Search methods For the latest update we searched the following databases on 3 February 2020: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to 31 January 2020). CRS Web includes randomised or quasi‐randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the specialised registers of Cochrane Review Groups including the Cochrane Epilepsy Group. We imposed no language restrictions and contacted researchers to identify continuing or unpublished studies. Selection criteria Trials using randomised or quasi‐randomised participant allocation that compared the use of antiepileptics, antipyretics or recognised Central Nervous System active agents with each other, placebo, or no treatment. Data collection and analysis For the original review, two review authors independently applied predefined criteria to select trials for inclusion and extracted the predefined relevant data, recording methods for randomisation, blinding, and exclusions. For the 2016 update, a third review author checked all original inclusions, data analyses, and updated the search. For the 2020 update, one review author updated the search and performed the data analysis following a peer‐review process with the original review authors. We assessed seizure recurrence at 6, 12, 18, 24, 36, 48 months, and where data were available at age 5 to 6 years along with recorded adverse effects. We evaluated the presence of publication bias using funnel plots. Main results We included 42 articles describing 32 randomised trials, with 4431 randomised participants used in the analysis of this review. We analysed 15 interventions of continuous or intermittent prophylaxis and their control treatments. Methodological quality was moderate to poor in most studies. We found no significant benefit for intermittent phenobarbital, phenytoin, valproate, pyridoxine, ibuprofen, or zinc sulfate versus placebo or no treatment; nor for diclofenac versus placebo followed by ibuprofen, paracetamol, or placebo; nor for continuous phenobarbital versus diazepam, intermittent rectal diazepam versus intermittent valproate, or oral diazepam versus clobazam. There was a significant reduction of recurrent febrile seizures with intermittent diazepam versus placebo or no treatment at six months (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.48 to 0.85; 6 studies, 1151 participants; moderate‐certainty evidence), 12 months (RR 0.69, 95% CI 0.56 to 0.84; 8 studies, 1416 participants; moderate‐certainty evidence), 18 months (RR 0.37, 95% CI 0.23 to 0.60; 1 study, 289 participants; low‐certainty evidence), 24 months (RR 0.73, 95% CI 0.56 to 0.95; 4 studies, 739 participants; high‐certainty evidence), 36 months (RR 0.58, 95% CI 0.40 to 0.85; 1 study, 139 participants; low‐certainty evidence), 48 months (RR 0.36, 95% CI 0.15 to 0.89; 1 study, 110 participants; moderate‐certainty evidence), with no benefit at 60 to 72 months (RR 0.08, 95% CI 0.00 to 1.31; 1 study, 60 participants; very low‐certainty evidence). Phenobarbital versus placebo or no treatment reduced seizures at six months (RR 0.59, 95% CI 0.42 to 0.83; 6 studies, 833 participants; moderate‐certainty evidence), 12 months (RR 0.54, 95% CI 0.42 to 0.70; 7 studies, 807 participants; low‐certainty evidence), and 24 months (RR 0.69, 95% CI 0.53 to 0.89; 3 studies, 533 participants; moderate‐certainty evidence), but not at 18 months (RR 0.77, 95% CI 0.56 to 1.05; 2 studies, 264 participants) or 60 to 72 months follow‐up (RR 1.50, 95% CI 0.61 to 3.69; 1 study, 60 participants; very low‐certainty evidence). Intermittent clobazam compared to placebo at six months resulted in a RR of 0.36 (95% CI 0.20 to 0.64; 1 study, 60 participants; low‐certainty evidence), an effect found against an extremely high (83.3%) recurrence rate in the controls, a result that needs replication. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months (RR 0.45, 95% CI 0.18 to 1.15; 1 study, 60 participants; very‐low certainty evidence). When compared to placebo, intermittent oral levetiracetam significantly reduced recurrent seizures at 12 months (RR 0.27, 95% CI 0.15 to 0.52; 1 study, 115 participants; very low‐certainty evidence). The recording of adverse effects was variable. Two studies reported lower comprehension scores in phenobarbital‐treated children. Adverse effects were recorded in up to 30% of children in the phenobarbital‐treated groups and 36% in benzodiazepine‐treated groups. We found evidence of publication bias in the meta‐analyses of comparisons for phenobarbital versus placebo (seven studies) at 12 months but not at six months (six studies); and valproate versus placebo (four studies) at 12 months. There were too few studies to identify publication bias for the other comparisons. The methodological quality of most of the included studies was low or very low. Methods of randomisation and allocation concealment often did not meet current standards, and 'treatment versus no treatment' was more commonly seen than 'treatment versus placebo', leading to obvious risks of bias. Authors' conclusions We found reduced recurrence rates for intermittent diazepam and continuous phenobarbital, with adverse effects in up to 30% of children. The apparent benefit for clobazam treatment in one trial needs to be replicated. Levetiracetam also shows benefit with a good safety profile; however, further study is required. Given the benign nature of recurrent febrile seizures, and the high prevalence of adverse effects of these drugs, parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. Plain language summary Prophylactic drug management for febrile seizures in children Background Seizures occurring with a fever (febrile seizures) in children are common and affect about one in 30 children under the age of six years. On average, one out of three children who have had a febrile seizure will have at least one more. We reviewed the evidence about the effect of drugs to prevent seizures (antiepileptics), drugs to lower temperature (antipyretics), and zinc in children with febrile seizures. Objective We wanted to know in how many children these drugs would prevent a recurrence of febrile seizures or cause unwanted effects. Methods We included 32 studies with a total of 4431 children in the review. Children who had had at least one febrile seizure were assigned to one of two or more treatment groups. The studies recorded any further seizures at various time intervals between six months and up to six years of age in each group. Unwanted medication effects were also noted. Results The study design and evidence quality in the studies of antiepileptic drugs was often low or very low. Poor methods known to lead to obvious risks of bias were used. One issue was with the methods used to assign children to study groups and how random this allocation was. Other issues included whether the parents or doctors, or both, knew which group each child was in or if a treatment was compared to no treatment with no placebo (dummy pill) used. The quality of the trials of antipyretics or zinc was better, with the evidence assessed as moderate to high. Zinc therapy was found to provide no benefit. We also found no benefit in treating children just at the time of the fever with either antipyretic drugs or most antiepileptic drugs. A significant result was noted in some instances. For example, at times between 6 and 48 months follow‐up, intermittent diazepam (an antiepileptic drug) led to a reduction in the number of recurrent seizures by about a third. Continuous phenobarbital resulted in significantly fewer recurrences at 6, 12, and 24 months, but not at 18 and 60 to 72 months. One study showed that intermittent oral levetiracetam compared to placebo significantly reduced recurrent seizures at 12 months. When compared to intermittent diazepam, intermittent oral melatonin did not significantly reduce seizures at six months. However, as recurrent seizures are only seen in about a third of children, this means that up to 16 children would have to be treated over a year or two to save just one child a further seizure. As febrile seizures are not harmful, we viewed these significant findings to be unimportant, in particular because adverse effects of the medications were common. Lower comprehension scores in phenobarbital‐treated children were found in two studies. In general, adverse effects were recorded in up to about a third of children in both the phenobarbital‐ and benzodiazepine‐treated groups. The benefit found for treatment with clobazam in one study published in 2011 needs to be repeated to test its reliability. Levetiracetam may be useful in treating children where family anxiety over possible seizure recurrence is high, but further study is required. Authors' conclusions There is currently insufficient evidence to support the use of continuous or intermittent treatment with zinc, antiepileptic or antipyretic drugs for children with febrile seizures. Febrile seizures can be frightening to witness. Parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management, and, most importantly, the benign nature of the phenomenon. The evidence is current to February 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Offringa, M; Newton, R; Nevitt, SJ; Vraka, K", "articleTypes": [], "doi": "10.1002/14651858.CD003031.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "e5094dba-0c35-43a9-aea6-d323ee44e099", "pmid": "", "title": "Eradication therapy for peptic ulcer disease in Helicobacter pylori‐positive people", "imported": false, "abstract": "Abstract - Background Peptic ulcer disease is the cause of dyspepsia in about 10% of people. Ninety‐five percent of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori . Eradication of H. pylori reduces the relapse rate of ulcers but the magnitude of this effect is uncertain. This is an update of Ford AC, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori ‐positive patients. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003840. DOI: 10.1002/14651858.CD003840.pub4. Objectives To assess the proportion of peptic ulcers healed and the proportion of participants who remained free from relapse with eradication therapy against placebo or other pharmacological therapies in H. pylori ‐positive people. To assess the proportion of participants that achieved complete relief of symptoms and improvement in quality of life scores. To compare the incidence of adverse effects/drop‐outs (total number for each drug) associated with the different treatments. To assess the proportion of participants in whom successful eradication was achieved. Search methods In this update, we identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1950 to March 2016) and Ovid EMBASE (1980 to March 2016). To identify further relevant trials, we handsearched reference lists from trials selected by electronic searching, and published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ). The search was last updated in March 2016. We contacted members of Cochrane Upper GI and Pancreatic Diseases, and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials of short‐ and long‐term treatment of peptic ulcer disease in H. pylori ‐positive adults. Participants received at least one week of H. pylori eradication compared with ulcer healing drug, placebo or no treatment. Trials were included if they reported assessment from two weeks onwards. Data collection and analysis We collected data on ulcer healing, recurrence, relief of symptoms and adverse effects. We calculated the risk ratio (RR) with 95% confidence intervals (CI) using both fixed‐effect and random‐effects models with Review Manager software (RevMan 5.3) based on intention‐to‐treat analysis as far as possible. Main results A total of 55 trials were included for one or more outcomes for this review. In duodenal ulcer healing, eradication therapy was superior to ulcer healing drug (UHD) (34 trials, 3910 participants, RR of ulcer persisting = 0.66, 95% confidence interval (CI) 0.58 to 0.76; 381/2286 (adjusted proportion: 12.4%) in eradication therapy plus UHD versus 304/1624 (18.7%) in UHD; low quality evidence) and no treatment (two trials, 207 participants, RR 0.37, 95% CI 0.26 to 0.53; 30/125 (adjusted proportion: 21.7%) in eradication therapy versus 48/82 (58.5%) in no treatment; low quality evidence). In gastric ulcer healing, the differences were imprecise between eradication therapy and UHD (15 trials, 1974 participants, RR 1.23, 95% CI 0.90 to 1.68; 220/1192 (adjusted proportion: 16.0%) in eradication therapy plus UHD versus 102/782 (13.0%) in UHD; very low quality evidence). In preventing duodenal ulcer recurrence the differences were imprecise between maintenance therapy with H.pylori eradication therapy and maintenance therapy with UHD (four trials, 319 participants, RR of ulcer recurring 0.73; 95% CI 0.42 to 1.25; 19/159 (adjusted proportion: 11.9%) in eradication therapy versus 26/160 (16.3%) in UHD; very low quality evidence), but eradication therapy was superior to no treatment (27 trials 2509 participants, RR 0.20, 95% CI 0.15 to 0.26; 215/1501 (adjusted proportion: 12.9%) in eradication therapy versus 649/1008 (64.4%) in no treatment; very low quality evidence). In preventing gastric ulcer recurrence, eradication therapy was superior to no treatment (12 trials, 1476 participants, RR 0.31, 95% CI 0.22 to 0.45; 116/697 (adjusted proportion: 16.3%) in eradication therapy versus 356/679 (52.4%) in no treatment; very low quality evidence). None of the trials reported proportion of people with gastric ulcer not healed after initial therapy between H.pylori eradication therapy and no active treatment or the proportion of people with recurrent gastric ulcer or peptic ulcers during maintenance therapy between H.pylori eradication therapy and ulcer healing drug therapy. Authors' conclusions Adding a one to two‐week course of H. pylori eradication therapy is an effective treatment for people with H. pylori‐ positive duodenal ulcer when compared to ulcer healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer healing drug. However, confidence intervals were wide and significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment, and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Plain language summary Antibiotics for people with peptic ulcers caused by Helicobacter pylori infection Review question Are antibiotics useful for the treatment of peptic ulcer (ulcers in the stomach or upper small intestine) in people with Helicobacter pylori ( H. pylori ) infection? Background Peptic ulcers are caused by acidic stomach juices damaging the lining of the stomach (gastric ulcer) or upper small intestine (duodenal ulcer). This causes pain, indigestion and sometimes, bleeding. Ulcers can return after being healed, especially if the person is infected with Helicobacter pylori (a lifelong infection unless treated). H. pylori causes most peptic ulcers. It is not clear whether eradicating H.pylori by treating with antibiotics as part of a combination of drugs ( H.pylori eradication therapy) is helpful in the treatment of people with peptic ulcers compared to no treatment or other medical treatments. This is an update of a previous Cochrane review published in 2006. Study characteristics Fifty‐five studies provided information for the review. Thirty‐four studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of duodenal ulcer. Two studies compared H. pylori eradication therapy against no treatment in the healing of duodenal ulcer. Fifteen studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of gastric ulcer. Three studies compared H. pylori eradication therapy plus ulcer‐healing drug against ulcer‐healing drug alone in the healing of peptic ulcer (gastric or duodenal ulcer). One study compared H. pylori eradication therapy against no treatment in the healing of peptic ulcer (gastric or duodenal ulcer). Four studies compared H. pylori eradication therapy against ulcer‐healing drug in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twenty‐seven studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of duodenal ulcer after initial ulcer had been healed. Twelve studies compared H. pylori eradication therapy against no treatment in preventing the recurrence of gastric ulcer after initial ulcer had been healed, while one study compared H. pylori eradication therapy against no treatment in preventing the recurrence of peptic ulcer (gastric or duodenal ulcer) after initial ulcer had been healed. Four studies compared H. pylori eradication therapy plus ulcer‐healing drug versus comparison regimen in the relief of symptoms from peptic ulcer (gastric or duodenal ulcer). There were no studies comparing H. pylori eradication therapy against no treatment in the healing of gastric ulcer, H. pylori eradication therapy against ulcer‐healing drug as maintenance therapy in preventing the recurrence of gastric ulcer after initial ulcer had been healed, or H. pylori eradication therapy plus ulcer‐healing drug against no treatment or ulcer‐healing drug in the relief of symptoms in people with peptic ulcer. Some trials provided information for more than one comparison. The evidence is current until March 2016. Key results Adding a one to two‐week course of H. pylori eradication therapy speeds up ulcer healing for people with H. pylori‐ positive duodenal ulcer when compared to ulcer‐healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer (ulcer returning after initial healing) compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer‐healing drugs. However, because of the small number of studies included for the last two comparisons, significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out. Quality of the evidence The quality of evidence was low or very low because most of the studies had errors in study design. As a result, there is a lot of uncertainty regarding the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Ford, AC, Gurusamy, KS, Delaney, B, Forman, D, Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD003840.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.730Z" }, { "id": "e50ffd2a-9ae0-4906-8eda-e6815351afe0", "pmid": "", "title": "Colchicine for primary biliary cirrhosis", "imported": false, "abstract": "Abstract - Background Colchicine has been used for patients with primary biliary cirrhosis because of its immunomodulatory and antifibrotic potential. The therapeutical responses to colchicine in randomised clinical trials were inconsistent. Objectives To evaluate the beneficial and harmful effects of colchicine in patients with primary biliary cirrhosis. Search methods We identified trials through electronic searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials on The Cochrane Library , MEDLINE, EMBASE (September 2003) , and manual searches of bibliographies. We contacted authors of trials and pharmaceutical companies. Selection criteria Randomised clinical trials comparing colchicine with any kind of control therapy were included irrespective of language, year of publication, and publication status. Data collection and analysis The primary outcomes were the number of deaths and the number of death and/or patients who underwent liver transplantation. Dichotomous outcomes were reported as relative risk (RR) with 95% confidence interval (CI). We examined intervention effects by using both a fixed effect model and a random effects model. Heterogeneity was investigated by subgroup analyses and sensitivity analyses. Main results Eleven randomised clinical trials involving 716 patients with primary biliary cirrhosis fulfilled the inclusion criteria. No significant differences were detected between colchicine and placebo/no intervention on the number of deaths (RR 1.21, 95% CI 0.71 to 2.06), the number of deaths and/or patients who underwent liver transplantation (RR 1.00, 95% CI 0.67 to 1.49), liver complications, liver biochemical variables, liver histological measurements, and adverse events. Trial methodology was generally low and some trials had high drop‐out rate. A best‐worst‐case‐scenario analysis showed no significant effect of colchicine on mortality (RR 0.59, 95%CI 0.30 to 1.15), while a worst‐best‐case‐scenario analysis showed a significant detrimental effect of colchicine on mortality (RR 2.28, 95% CI 1.17 to 4.44). Colchicine significantly decreased the number of patients without improvement of pruritus (RR 0.75, 95% CI 0.65 to 0.87). However, this estimate was based on only 156 patients from three trials. The effect of the combined treatment with ursodeoxycholic acid was not significantly different from that of colchicine alone. Authors' conclusions We did not find evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis. As we are not able to exclude a detrimental effect of colchicine, we suggest that it is only used in randomised clinical trials. Plain language summary No convincing evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis Primary biliary cirrhosis is a rare, chronic liver disease of unknown etiology. Colchicine, a plant alkaloid, has been used to treat patients with primary biliary cirrhosis and was tested in randomised clinical trials. When all identified trials were combined, colchicine appeared to be not significantly different from placebo/no intervention in respect to mortality, mortality and/or patients who underwent liver transplantation, liver complications, liver biochemistry, liver histology, and the occurrences of adverse events. Colchicine may reduce pruritus, but this finding may be due to bias. The addition of ursodeoxycholic acid did not significantly influence the effect of colchicine.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Gong, Y, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD004481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.800Z" }, { "id": "e5151175-9da7-4cfd-abbc-2ab01526c8ee", "pmid": "", "title": "Laboratory‐based molecular test alternatives to RT‐PCR for the diagnosis of SARS‐CoV‐2 infection", "imported": false, "abstract": "Abstract - Background Diagnosing people with a SARS‐CoV‐2 infection played a critical role in managing the COVID‐19 pandemic and remains a priority for the transition to long‐term management of COVID‐19. Initial shortages of extraction and reverse transcription polymerase chain reaction (RT‐PCR) reagents impaired the desired upscaling of testing in many countries, which led to the search for alternatives to RNA extraction/purification and RT‐PCR testing. Reference standard methods for diagnosing the presence of SARS‐CoV‐2 infection rely primarily on real‐time reverse transcription‐polymerase chain reaction (RT‐PCR). Alternatives to RT‐PCR could, if sufficiently accurate, have a positive impact by expanding the range of diagnostic tools available for the timely identification of people infected by SARS‐CoV‐2, access to testing and the use of resources. Objectives To assess the diagnostic accuracy of alternative (to RT‐PCR assays) laboratory‐based molecular tests for diagnosing SARS‐CoV‐2 infection. Search methods We searched the COVID‐19 Open Access Project living evidence database from the University of Bern until 30 September 2020 and the WHO COVID‐19 Research Database until 31 October 2022. We did not apply language restrictions. Selection criteria We included studies of people with suspected or known SARS‐CoV‐2 infection, or where tests were used to screen for infection, and studies evaluating commercially developed laboratory‐based molecular tests for the diagnosis of SARS‐CoV‐2 infection considered as alternatives to RT‐PCR testing. We also included all reference standards to define the presence or absence of SARS‐CoV‐2, including RT‐PCR tests and established clinical diagnostic criteria. Data collection and analysis Two authors independently screened studies and resolved disagreements by discussing them with a third author. Two authors independently extracted data and assessed the risk of bias and applicability of the studies using the QUADAS‐2 tool. We presented sensitivity and specificity, with 95% confidence intervals (CIs), for each test using paired forest plots and summarised results using average sensitivity and specificity using a bivariate random‐effects meta‐analysis. We illustrated the findings per index test category and assay brand compared to the WHO's acceptable sensitivity and specificity threshold for diagnosing SARS‐CoV‐2 infection using nucleic acid tests. Main results We included data from 64 studies reporting 94 cohorts of participants and 105 index test evaluations, with 74,753 samples and 7517 confirmed SARS‐CoV‐2 cases. We did not identify any published or preprint reports of accuracy for a considerable number of commercially produced NAAT assays. Most cohorts were judged at unclear or high risk of bias in more than three QUADAS‐2 domains. Around half of the cohorts were considered at high risk of selection bias because of recruitment based on COVID status. Three quarters of 94 cohorts were at high risk of bias in the reference standard domain because of reliance on a single RT‐PCR result to determine the absence of SARS‐CoV‐2 infection or were at unclear risk of bias due to a lack of clarity about the time interval between the index test assessment and the reference standard, the number of missing results, or the absence of a participant flow diagram. For index tests categories with four or more evaluations and when summary estimations were possible, we found that: a) For RT‐PCR assays designed to omit/adapt RNA extraction/purification, the average sensitivity was 95.1% (95% CI 91.1% to 97.3%), and the average specificity was 99.7% (95% CI 98.5% to 99.9%; based on 27 evaluations, 2834 samples and 1178 SARS‐CoV‐2 cases); b) For RT‐LAMP assays, the average sensitivity was 88.4% (95% CI 83.1% to 92.2%), and the average specificity was 99.7% (95% CI 98.7% to 99.9%; 24 evaluations, 29,496 samples and 2255 SARS‐CoV‐2 cases); c) for TMA assays, the average sensitivity was 97.6% (95% CI 95.2% to 98.8%), and the average specificity was 99.4% (95% CI 94.9% to 99.9%; 14 evaluations, 2196 samples and 942 SARS‐CoV‐2 cases); d) for digital PCR assays, the average sensitivity was 98.5% (95% CI 95.2% to 99.5%), and the average specificity was 91.4% (95% CI 60.4% to 98.7%; five evaluations, 703 samples and 354 SARS‐CoV‐2 cases); e) for RT‐LAMP assays omitting/adapting RNA extraction, the average sensitivity was 73.1% (95% CI 58.4% to 84%), and the average specificity was 100% (95% CI 98% to 100%; 24 evaluations, 14,342 samples and 1502 SARS‐CoV‐2 cases). Only two index test categories fulfil the WHO‐acceptable sensitivity and specificity requirements for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. In addition, WHO‐acceptable performance criteria were met for two assays out of 35 when tests were used according to manufacturer instructions. At 5% prevalence using a cohort of 1000 people suspected of SARS‐CoV‐2 infection, the positive predictive value of RT‐PCR assays omitting/adapting RNA extraction/purification will be 94%, with three in 51 positive results being false positives, and around two missed cases. For TMA assays, the positive predictive value of RT‐PCR assays will be 89%, with 6 in 55 positive results being false positives, and around one missed case. Authors' conclusions Alternative laboratory‐based molecular tests aim to enhance testing capacity in different ways, such as reducing the time, steps and resources needed to obtain valid results. Several index test technologies with these potential advantages have not been evaluated or have been assessed by only a few studies of limited methodological quality, so the performance of these kits was undetermined. Only two index test categories with enough evaluations for meta‐analysis fulfil the WHO set of acceptable accuracy standards for SARS‐CoV‐2 nucleic acid tests: RT‐PCR assays designed to omit/adapt RNA extraction/purification and TMA assays. These assays might prove to be suitable alternatives to RT‐PCR for identifying people infected by SARS‐CoV‐2, especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence, including reliance on retrospective samples without information about the symptom status of participants and the timing of assessment. No extrapolation of found accuracy data for these two alternatives to any test brands using the same techniques can be made as, for both groups, one test brand with high accuracy was overrepresented with 21/26 and 12/14 included studies, respectively. Although we used a comprehensive search and had broad eligibility criteria to include a wide range of tests that could be alternatives to RT‐PCR methods, further research is needed to assess the performance of alternative COVID‐19 tests and their role in pandemic management. Plain language summary How accurate are alternative laboratory‐based molecular tests (to RT‐PCR with prior RNA extraction/purification) for identifying people infected by SARS‐CoV‐2? Key messages: * Transcription‐mediated amplification (TMA) tests and commercially available reverse transcription polymerase chain reaction (RT‐PCR) tests specifically designed to omit/adapt RNA extraction/purification appear accurate enough to replace the method of RT‐PCR with prior RNA (a molecule essential for most biological functions) extraction/purification for identifying people infected by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), especially when the alternative would be not having access to testing. However, these findings need to be interpreted and used with caution because of several limitations in the evidence. * The accuracy of other types of laboratory‐based molecular alternatives to RT‐PCR is below World Health Organisation (WHO) recommended standards or lacks a sufficient volume of evidence to draw reliable conclusions. *The extrapolation of accuracy data from the evaluated tests to any other test brand(s) using the same techniques will be challenging since main categories are overrepresented by highly accurate individual test brands. Further evaluation of these tests in real clinical practice scenarios is needed. What are alternative laboratory‐based molecular assays for identifying people infected by SARS‐CoV‐2? Laboratory‐based molecular assays (tests) aim to confirm or rule out SARS‐CoV‐2 infection in people. Alternatives to RT‐PCR assays have been developed to minimise the steps needed to process samples in the laboratory or use fewer resources to obtain the same valid results. For this review, we focus on tests commercially developed by a manufacturer, providing instructions for their professional use. Why is this question important? People with suspected SARS‐CoV‐2 infection should know if they are infected to self‐isolate, receive treatment, and inform close contacts. Failure to detect SARS‐CoV‐2 when it is present risks spreading infection and results in missed opportunities for prevention. Diagnosing SARS‐CoV‐2 infection when it is not present may lead to unnecessary self‐isolation and testing of close contacts. Currently, testing to confirm SARS‐CoV‐2 infection relies on a laboratory molecular test called RT‐PCR. This requires specialist equipment and can take 24 hours to produce a result. If assays that take less time or use readily available resources were sufficiently accurate to replace RT‐PCR testing, this could increase the number of tests that could be done, allow faster diagnosis and enable people to take appropriate action more quickly. What did we want to find out? We wanted to know whether commercially developed, alternative laboratory‐based molecular tests are accurate enough to diagnose SARS‐CoV‐2 infection compared to RT‐PCR. What did we do? We looked for studies investigating these tests in people (or samples) that were also tested for SARS‐CoV‐2 infection using RT‐PCR which modified RT‐PCR by removing or altering components of this testing process. What did we find? We included 105 evaluations evaluating alternatives to RT‐PCR in the review. The main results are based on 74,753 samples, and SARS‐CoV‐2 infection was confirmed in 7517 of these samples. Most evaluations (27/105) concerned various test types specifically designed to omit/adapt RNA extraction/purification. Twenty‐four of 105 evaluations concerned various test types operating at one temperature (isothermal tests) rather than cycling through different temperatures. Twenty‐four of 105 evaluations were concerned with various test types that combined these two alternative approaches. Main results Only tests specifically designed to omit/adapt RNA extraction/purification and TMA assays with RNA extraction (a type of isothermal test) met WHO‐acceptable standards for confirming and ruling out SARS‐CoV‐2. For illustration, the results of these studies indicate that in a group of 1000 people, 50 of whom (5%) actually have SARS‐CoV‐2: * For tests specifically designed to omit/adapt RNA extraction/purification: ‐51 people would test positive for SARS‐CoV‐2. Of these, three people (6%) would not have SARS‐CoV‐2 (false‐positive result). ‐949 people would test negative for SARS‐CoV‐2. Of these, two people (0.2%) would actually have SARS‐CoV‐2 (false‐negative result) *For TMA tests with RNA extraction: ‐55 people would test positive for SARS‐CoV‐2. Of these, six people (10%) would not have SARS‐CoV‐2 (false‐positive result). ‐945 people would test negative for SARS‐CoV‐2. Of these, one person (0.1%) would actually have SARS‐CoV‐2 (false‐negative result) What are the limitations of the evidence? Most included studies did not provide information on participants who underwent testing, such as whether they had symptoms or were close contacts of a SARS‐CoV‐2 case. We also had concerns about the method of recruiting participants for the majority of included studies, which may have resulted in an overestimation of the accuracy of these methods. In addition, the method used to determine whether individuals did not have SARS‐CoV‐2 infection was not considered reliable for most studies, which may have resulted in underestimating the accuracy of these methods. Some studies did not follow the manufacturers' instructions for using the test. Results from different test brands using the same technique varied. What does this mean? The studies included in this review suggest that two laboratory‐based molecular tests might be accurate enough to replace or supplement RT‐PCR tests with prior RNA extraction/purification for the diagnosis of SARS‐CoV‐2 infection: RT‐PCR tests developed to omit or adapt RNA extraction or purification and TMA isothermal tests (retaining an RNA extraction step). Other alternative tests to RT‐PCR were assessed just by a few studies of limited methodological quality, and their performance should be evaluated by additional studies. Furthermore, data in these studies mostly relied on samples acquired in the past (compared to current or future samples), thus further evaluation of these tests in real clinical practice scenarios is required. Also, decisions on the optimal test for a specific setting will be driven not only by diagnostic accuracy, but also by other factors such as test complexity, time to result, acceptability to those being tested, and the setting in which the tests are to be used. How up‐to‐date is this review? This review includes evidence published up to 31 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Arevalo-Rodriguez, I; Mateos-Haro, M; Dinnes, J; Ciapponi, A; Davenport, C; Buitrago-Garcia, D; Bennouna-Dalero, T; Roqué-Figuls, M; Van den Bruel, A; von Eije, KJ; Emperador, D; Hooft, L; Spijker, R; Leeflang, MMG; Takwoingi, Y; Deeks, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD015618", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "e519f52a-3878-460c-8615-3207c4341c08", "pmid": "", "title": "Desmopressin for nocturnal enuresis in children", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) affects up to 20% of five‐year‐old children and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Desmopressin has been used to treat bedwetting since the 1970s. This is an update of a Cochrane review first published in 2000 and last updated in 2006. Objectives To assess the effects of desmopressin on treating nocturnal enuresis in children. Search methods We searched Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched January 2023) and reference lists of relevant articles. Selection criteria We included randomised or quasi‐randomised trials of desmopressin or desmopressin combined with another intervention for treating nocturnal enuresis in children between five and 16 years old. Data collection and analysis Three review authors independently extracted data and assessed the risk of bias in the eligible trials. We used standard methodological procedures expected by Cochrane. Main results We identified 50 new studies for this review, which now includes 95 studies (8473) participants, of whom 5434 received desmopressin. In this review we continued the assessment of the effect of combination therapy involving desmopressin. The majority of the trials were in children between the ages of five to 16 years in an outpatient setting. The quality of the evidence was assessed as low or very low. The first comparison was desmopressin versus placebo. Desmopressin may reduce the mean number of wet nights per week compared with placebo (MD ‐1.81, 95% CI ‐2.24 to ‐1.39; participants = 1267; studies = 16; low‐certainty evidence). Desmopressin probably leads to more children achieving 14 consecutive dry nights by the end of treatment compared with placebo (RR 3.18, 95% CI 1.75 to 5.80; participants = 922: studies = 11; moderate‐certainty evidence). There may be little to no difference in children experiencing adverse effects with desmopressin compared to placebo (RR 1.11, 95% CI 0.81 to 1.52; participants = 269; studies = 3; low‐certainty evidence). Desmopressin was compared with alarm therapy. It is uncertain if there is any difference between desmopressin compared with alarm training in reducing the number of wet nights per week (MD 0.63, 95% CI ‐0.49 to 1.75; participants = 285; studies = 4; I 2 = 82%; very low‐certainty evidence). There may be little or no difference between desmopressin and alarm therapy in the number of children achieving 14 consecutive dry nights (RR 0.98, 95% CI 0.88 to 1.09; participants = 1530; studies = 15; low‐certainty evidence). There may be little to no difference in children experiencing side effects with desmopressin therapy compared with alarm therapy (RR 1.50, 95% CI 0.33 to 6.78; participants = 461, studies = 4; low‐certainty evidence). We compared desmopressin with other medications, including tricyclics and anticholinergics. It is uncertain if there is any difference between desmopressin compared to tricyclics in reducing the mean number of wet nights per week (MD 0.23, 95% CI ‐ 0.88 to 1.33; participants = 331; studies = 4; I 2 = 79%; very low‐certainty evidence) or in the number of children achieving 14 consecutive dry nights at the end of treatment (RR 0.94, 95% CI 0.63 to 1.38; participants = 371; studies = 7; I 2 = 71%; very low‐certainty evidence). It is uncertain whether children experience more side effects with desmopressin compared with tricyclics (RR 0.29, 95%CI 0.06 to 1.39; participants = 351; studies = 4, very low‐certainty evidence). This review included studies with combination therapies. It is uncertain if desmopressin combined with alarm therapy reduces the mean number of wet nights at the end of treatment compared with alarm monotherapy (MD ‐0.80, 95% CI ‐1.34 to ‐0.25; participants = 528; studies = 6; I 2 = 84%; very low‐certainty evidence); or if it increases the number of children achieving 14 consecutive dry nights (RR 1.25, 95% CI 0.96 to 1.63; participants = 822; studies = 10; very low‐certainty evidence). Desmopressin plus alarm therapy may make little to no difference in children experiencing side effects compared with alarm therapy alone (RR 1.05 95% CI 0.07 to 16.56; participants = 207; studies = 1; low‐certainty evidence). Combining desmopressin with alarm therapy probably reduces the number of wet nights at the end of treatment (MD ‐0.88; 95%CI ‐1.38 to ‐0.38; participants = 156; studies = 2; moderate‐certainty evidence), and may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin monotherapy (RR 1.26, 95% CI 1.06 to 1.51; participants = 370; studies = 5; low‐certainty evidence). It is uncertain if combined desmopressin and anticholinergic therapy versus desmopressin monotherapy reduces the mean number of wet nights at the end of therapy (MD ‐0.50; 95% CI ‐1.05 to 0.06; participants = 188; studies = 3; I 2 = 66%; very low‐certainty evidence); or if it may increase the number of children achieving 14 consecutive dry nights at the end of treatment (RR 1.53, 95% CI 1.10 to 2.11; participants = 611; studies = 8; low‐certainty evidence). There may be little to no difference in adverse events between desmopressin plus anticholinergics and desmopressin monotherapy (RR 1.51 95% CI 0.73 to 3.09, participants = 187; studies =2; low‐certainty evidence). Minor adverse effects were common for desmopressin, including dizziness, headache, mood changes, gastrointestinal discomfort, nasal discomfort, hyponatraemia and one report of a convulsion. Authors' conclusions Desmopressin compared with placebo may increase the number of dry nights per week at the end of treatment in children. Desmopressin therapy may be as effective as alarm therapy at the end of treatment. However, the quality of evidence was assessed as low or very low. Alarm therapy compared to desmopressin may improve the number of children who are dry at follow‐up (moderate‐certainty evidence). Plain language summary Desmopressin for bedwetting in children Review question Is desmopressin an effective treatment for bedwetting in children? Key messages: Desmopressin may improve bedwetting. Only one study assessed quality of life. Further studies with good patient numbers are required. What is enuresis? What does desmopressin do ? Enuresis or bedwetting is involuntary wetting during sleep at an age when a child should be dry, usually at age five. The generally quoted prevalence rates (that is the proportion of a population with bedwetting in a given time period) are 15% to 20% of five‐year‐olds, 7% of seven‐year‐olds, 5% of 10‐year‐old children, and 2% to 3% of teenagers. Various treatments have been used to treat bedwetting. Desmopressin is a man‐made form of vasopressin, a chemical released from the brain that helps control the amount of urine made by the kidneys. Desmopressin is used to control bedwetting at night and reduces the number of bedwetting episodes. Why was it important to do this review? Although bedwetting is not a harmful condition and, with time, stops spontaneously, it is stigmatising and can impact the child’s quality of life, emotional and psychological wellbeing. It is a condition that unsettles the whole family and the affected children may suffer parental discontentment, teasing and may be at risk of physical or emotional abuse. Successful therapies that reduce bedwetting improve the child's self‐esteem and, therefore, it is important to see if desmopressin is as effective as other known treatments. How is the condition treated ? • Desmopressin therapy • Alarm therapy • Anticholinergic medications • Combination therapy – such as desmopressin and alarm therapy compared to desmopressin therapy There are several other therapies, such as behavioural therapies and laser therapy, though we have concentrated on the main therapies utilised. What did we want to find out? We wanted to see if desmopressin: • was effective in reducing the episodes of wet nights children may have; • was as effective as other treatments such as alarm therapy in treating bedwetting; • worked in combination with other treatments; • was associated with any unwanted effects. What did we do? We searched for studies where people were randomly placed into different treatment groups. We searched for and included studies that compared: • desmopressin with no treatment or placebo; • desmopressin and alarm therapy; • combination treatments of desmopressin and alarm. We compared and analysed our results, then rated our confidence in the evidence based on factors such as study methods and size of the studies. What did we find? We found 98 studies with 8699 participants, of whom 5616 received desmopressin. Main results • We found the use of desmopressin compared with placebo may improve wetting by giving children one more dry night a week while receiving treatment. This suggests that more children may stop wetting while using desmopressin (28% versus 1% who are given placebo or no treatment). • More children who received desmopressin therapy compared with placebo probably achieved 14 consecutive dry nights at the end of treatment. • We found that, when desmopressin was compared with alarm therapy, there was little to no difference in the number of children achieving 14 dry nights in a row. The evidence is also uncertain if desmopressin versus alarm therapy reduces the number of dry nights per week. • We found that combining desmopressin with alarm therapy may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin alone. • We found that side effects were commonly reported for desmopressin. These included dizziness, headache, mood changes, abdominal discomfort, nasal discomfort, hyponatraemia (low sodium level) and one report of a seizure. Thirty‐two studies reported no adverse effects occurring, and 25 studies omitted to report or mention adverse effects. What are the limitations of the evidence? We, however, have little confidence in the evidence as, in several studies, participants were aware of the therapy they were receiving, and several studies were very small. How up‐to‐date is this review? The evidence is current up to January 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hahn, D, Stewart, F, Raman, G", "articleTypes": [], "doi": "10.1002/14651858.CD002112.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.123Z" }, { "id": "e5328a51-4744-49db-83d9-712b4282ad2e", "pmid": "", "title": "Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis", "imported": false, "abstract": "Abstract - Background Seasonal/perennial allergic conjunctivitis is the most common allergic conjunctivitis, usually with acute manifestations when a person is exposed to allergens and with typical signs and symptoms including itching, redness, and tearing. The clinical signs and symptoms of allergic conjunctivitis are mediated by the release of histamine by mast cells. Histamine antagonists (also called antihistamines) inhibit the action of histamine by blocking histamine H1 receptors, antagonising the vasoconstrictor, and to a lesser extent, the vasodilator effects of histamine. Mast cell stabilisers inhibit degranulation and consequently the release of histamine by interrupting the normal chain of intracellular signals.
 
 Topical treatments include eye drops with antihistamines, mast cell stabilisers, non‐steroidal anti‐inflammatory drugs, combinations of the previous treatments, and corticosteroids. Standard treatment is based on topical antihistamines alone or topical mast cell stabilisers alone or a combination of treatments. There is clinical uncertainty about the relative efficacy and safety of topical treatment. Objectives The objective of this review was to assess the effects of topical antihistamines and mast cell stabilisers, alone or in combination, for use in treating seasonal and perennial allergic conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2014, Issue 7), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2014), EMBASE (January 1980 to July 2014), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 July 2014. We also searched the reference lists of review articles and relevant trial reports for details of further relevant publications. Selection criteria We included randomised controlled trials (RCTs) comparing topical antihistamine and mast cell stabilisers, alone or in combination, with placebo, no treatment or to any other antihistamine or mast cell stabiliser, or both, that examined people with seasonal or perennial allergic conjunctivitis, or both. The primary outcome was any participant‐reported evaluation (by questionnaire) of severity of four main ocular symptoms: itching, irritation, watering eye (tearing), and photophobia (dislike of light), both separately and, if possible, by an overall symptom score. We considered any follow‐up time between one week and one year. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Disagreements were resolved by discussion among review authors and the involvement of a third review author. We followed standard methodological approaches used by Cochrane. Main results We identified 30 trials with a total of 4344 participants randomised, with 17 different drugs or treatment comparisons. The following antihistamines and mast cell stabilisers were evaluated in at least one RCT: nedocromil sodium or sodium cromoglycate, olopatadine, ketotifen, azelastine, emedastine, levocabastine (or levocabastine), mequitazine, bepotastine besilate, combination of antazoline and tetryzoline, combination of levocabastine and pemirolast potassium. The most common comparison was azelastine versus placebo (nine studies). We observed a large variability in reporting outcomes. The quality of the studies and reporting was variable, but overall the risk of bias was low. Trials evaluated only short‐term effects, with a range of treatment of one to eight weeks. Meta‐analysis was only possible in one comparison (olopatadine versus ketotifen). There was some evidence to support that topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo. There were no reported serious adverse events related to the use of topical antihistamine and mast cell stabilisers treatment. Authors' conclusions It seems that all reported topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo in the short term. However, there is no long‐term data on their efficacy. Direct comparisons of different antihistamines and mast cell stabilisers need to be interpreted with caution. Overall, topical antihistamines and mast cell stabilisers appear to be safe and well tolerated. We observed a large variability in outcomes reported. Poor quality of reporting challenged the synthesis of evidence. Plain language summary Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis Review question 
 Are treatments with eye drops of antihistamines and mast cell stabilisers, alone or in combination, effective and safe in people with seasonal and allergic conjunctivitis? The main outcome measure was eye symptoms reported by participants, including eye itching, irritation (burning sensation), watering eyes (tearing), and photophobia (dislike of light). We found 30 trials. Background 
 Conjunctivitis refers to inflammation of the conjunctiva, which is the thin tissue that covers the sclera (white part of the eye). Seasonal and perennial allergic conjunctivitis is the most common type of allergic conjunctivitis. Although this condition does not cause sight loss, it can cause intense itching and eye watering. Eye drops with antihistamines or mast cell stabilisers, or both are commonly used. Study characteristics 
 The evidence is current to July 2014. Among the 30 studies reviewed there were 17 different comparisons, including 4344 participants ranging in age between 4 and 85 years. The duration of treatment ranged from one to eight weeks. Ten out of 30 studies were funded by the drug manufacturer (8 totally and 2 partially funded); 20 studies did not report any source of funding. There was inconsistency in the way the effect of treatment was measured and reported. Overall risk of bias was low. Key results 
 Topical antihistamines and mast cell stabilisers, alone or in combination, are safe and effective for reducing symptoms of seasonal and perennial allergic conjunctivitis. We found insufficient evidence to discern which topical antihistamines and mast cell stabilisers are the most effective.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Castillo, M; Scott, NW; Mustafa, MZ; Mustafa, MS; Azuara‐Blanco, A", "articleTypes": [], "doi": "10.1002/14651858.CD009566.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "e53e307f-d517-43ce-a4b6-a7d4db0c2456", "pmid": "", "title": "Melatonin and agomelatine for preventing seasonal affective disorder", "imported": false, "abstract": "Abstract - Background Seasonal affective disorder (SAD) is a seasonal pattern of recurrent major depressive episodes that most commonly starts in autumn or winter and remits in spring. The prevalence of SAD depends on latitude and ranges from 1.5% to 9%. The predictable seasonal aspect of SAD provides a promising opportunity for prevention in people who have a history of SAD. This is one of four reviews on the efficacy and safety of interventions to prevent SAD; we focus on agomelatine and melatonin as preventive interventions. Objectives To assess the efficacy and safety of agomelatine and melatonin (in comparison with each other, placebo, second‐generation antidepressants, light therapy, psychological therapy or lifestyle interventions) in preventing SAD and improving person‐centred outcomes among adults with a history of SAD. Search methods We searched Ovid MEDLINE (1950‐ ), Embase (1974‐ ), PsycINFO (1967‐ ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 19 June 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD‐CTR) (all years to 11 August 2015). Furthermore, we searched the Cumulative Index to Nursing and Allied Health Literature, Web of Science, the Cochrane Library , the Allied and Complementary Medicine Database and international trial registers (to 19 June 2018). We also conducted a grey literature search and handsearched the reference lists of included studies and pertinent review articles. Selection criteria To examine efficacy, we included randomised controlled trials (RCTs) on adults with a history of winter‐type SAD who were free of symptoms at the beginning of the study. For adverse events, we intended also to include non‐randomised studies. We planned to include studies that compared agomelatine versus melatonin, or agomelatine or melatonin versus placebo, any second‐generation antidepressant, light therapy, psychological therapies or lifestyle changes. We also intended to compare melatonin or agomelatine in combination with any of the comparator interventions mentioned above versus the same comparator intervention as monotherapy. Data collection and analysis Two review authors screened abstracts and full‐text publications, abstracted data and assessed risk of bias of included studies independently. We intended to pool data in a meta‐analysis using a random‐effects model, but included only one study. Main results We identified 3745 citations through electronic searches and reviews of reference lists after deduplication of search results. We excluded 3619 records during title and abstract review and assessed 126 full‐text papers for inclusion in the review. Only one study, providing data of 225 participants, met our eligibility criteria and compared agomelatine (25 mg/day) with placebo. We rated it as having high risk of attrition bias because nearly half of the participants left the study before completion. We rated the certainty of the evidence as very low for all outcomes, because of high risk of bias, indirectness, and imprecision. The main analysis based on data of 199 participants rendered an indeterminate result with wide confidence intervals (CIs) that may encompass both a relevant reduction as well as a relevant increase of SAD incidence by agomelatine (risk ratio (RR) 0.83, 95% CI 0.51 to 1.34; 199 participants; very low‐certainty evidence). Also the severity of SAD may be similar in both groups at the end of the study with a mean SIGH‐SAD (Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders) score of 8.3 (standard deviation (SD) 9.4) in the agomelatine group and 10.1 (SD 10.6) in the placebo group (mean difference (MD) ‐1.80, 95% CI ‐4.58 to 0.98; 199 participants; very low‐certainty evidence). The incidence of adverse events and serious adverse events may be similar in both groups. In the agomelatine group, 64 out of 112 participants experienced at least one adverse event, while 61 out of 113 did in the placebo group (RR 1.06, 95% CI 0.84 to 1.34; 225 participants; very low‐certainty evidence). Three out of 112 patients experienced serious adverse events in the agomelatine group, compared to 4 out of 113 in the placebo group (RR 0.76, 95% CI 0.17 to 3.30; 225 participants; very low‐certainty evidence). No data on quality of life or interpersonal functioning were reported. We did not identify any studies on melatonin. Authors' conclusions Given the uncertain evidence on agomelatine and the absence of studies on melatonin, no conclusion about efficacy and safety of agomelatine and melatonin for prevention of SAD can currently be drawn. The decision for or against initiating preventive treatment of SAD and the treatment selected should consider patient preferences and reflect on the evidence base of all available treatment options. Plain language summary Melatonin and agomelatine for prevention of winter depression Why is this review important? Many people in northern latitudes suffer from seasonal affective disorder (SAD), which occurs as a reaction to reduced sunlight. Three‐quarters of those affected are women. Lethargy, overeating, craving for carbohydrates and depressed mood are common symptoms. In some people, SAD becomes depression that seriously affects their daily lives. Up to two‐thirds experience depressive symptoms every winter. Who might be interested in this review? General practitioners, psychiatrists, pharmacists, other health professionals working in adult mental health services, and researchers could be interested in the results of this review. Anyone who has experienced winter depression, or who has friends or relatives who have experienced winter depression might also be interested. What questions does this review aim to answer? Because of the seasonal pattern and high recurrence of SAD, melatonin or agomelatine could be used to prevent the onset of depressed mood. The goal of this report is to examine whether benefits outweigh harms of melatonin or agomelatine when used to prevent onset of a new depressive episode in people with a history of SAD who were free of symptoms when the preventive intervention started. To date, this question has not been examined in a systematic way. This is one of four reviews on the efficacy and potential harms of interventions to prevent SAD. Which studies were included in the review? We searched databases up to June 2018 for studies on melatonin or agomelatine for prevention of winter depression. Among 3745 records, we found one randomised controlled study comparing agomelatine with placebo for one year. All 225 participants had a history of winter depression but were not depressed when the prevention study started. What does evidence from the review reveal? The included study showed neither a clear effect in favour nor against agomelatine as a preventive treatment. In addition, the certainty of evidence for all outcomes was very low, making it impossible to draw any conclusions about the efficacy and safety of agomelatine for the prevention of winter depression. No evidence on melatonin for prevention of SAD was identified. Doctors need to discuss with persons with a history of SAD that currently evidence on agomelatine or melatonin for preventive treatment options for SAD is inconclusive, therefore treatment selection should be strongly based on peoples' preferences and reflect on the evidence base of all available treatment options. What should happen next? Review authors recommend that future studies should evaluate the efficacy of agomelatine or melatonin in preventing SAD and should directly compare these interventions against other treatment options, such as light therapy, antidepressants, or psychological therapies to determine the best treatment option for prevention of SAD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nussbaumer‐Streit, B, Greenblatt, A, Kaminski‐Hartenthaler, A, Van Noord, MG, Forneris, CA, Morgan, LC, Gaynes, BN, Wipplinger, J, Lux, LJ, Winkler, D, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011271.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.761Z" }, { "id": "e54316d2-5951-4ba8-b60c-4c4a579463ab", "pmid": "", "title": "Honey and lozenges for children with non‐specific cough", "imported": false, "abstract": "Abstract - Background Chronic non‐specific cough is a chronic, dry cough of in the absence of identifiable respiratory disease or known aetiology. Although it is usually not reflective of an underlying severe illness, it does cause significant morbidity, and as such relief from it is often sought. The use of honey and lozenges to soothe upper respiratory tract irritation is common, inexpensive, and potentially more effective in treating the symptoms than pharmacological interventions. Objectives To evaluate the efficacy of honey and/or lozenges in the management of children with chronic non‐specific cough. Search methods The Cochrane Airways Group searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, OLDMEDLINE, and EMBASE databases in October 2010. Selection criteria All randomised controlled trials comparing honey or lozenges with a placebo in treating children with chronic non‐specific cough. Data collection and analysis The results of the searches were assessed according to the pre‐determined criteria. None of the trials identified by the searches were eligible for inclusion, leaving no data available for analysis in this review. Main results The search did not provide any applicable randomised controlled trials that investigated the efficacy of honey and lozenges in treating children with non‐specific chronic cough. Data from acute studies suggest a potential role for honey in relieving cough, but whether this is applicable to chronic cough is unknown. Authors' conclusions Clinically, this review was unable to provide any justifiable recommendation for or against honey and/or lozenges due to the lack of evidence. The absence of applicable studies highlights the need for further research into the area of treating children with chronic non‐specific coughs with honey and/or lozenges. These treatments are not recommended when managing very young children (as lozenges are a potential choking hazard, and honey may cause infant botulism in children under one year of age). Plain language summary Honey and lozenges for children with non‐specific cough Symptomatic relief is often sought for children with chronic non‐specific cough (which is defined as a dry, non‐productive cough with no known cause lasting longer than four consecutive weeks). This review aimed to assess the efficacy of treating children with such coughs using honey or lozenges, as these options are inexpensive. No randomised controlled trials were found to be applicable to this review, primarily due to the participants in the studies not fulfilling the inclusion criteria. However, studies on the efficacy of these treatments in treating acute cough in children showed that honey has the potential to be beneficial in children over a year old. Further research evaluating the efficacy of honey and lozenges in treating chronic non‐specific coughs in children is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Mulholland, S, Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD007523.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.767Z" }, { "id": "e551d9e7-9623-4a30-ab35-2c8f8f68b909", "pmid": "", "title": "Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Chronic infection with Pseudomonas aeruginosa (PA) in cystic fibrosis (CF) is a source of much morbidity and mortality. Eradication of early PA infection is possible, but can recur in many individuals. We sought to examine strategies to delay the time to PA recurrence in people with CF. Objectives To establish whether secondary prevention strategies, using antibiotics or other therapies, increase the chances of people with CF remaining free from PA infection following successful eradication therapy. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries and the reference lists of relevant articles and reviews. Date of last search: 21 August 2019. Selection criteria Randomised controlled trials (and quasi‐randomised trials where the risk of bias was low) comparing any treatment modality aimed at preventing recurrence of PA infection with placebo, standard therapy or any other treatment modality in people with CF who have undergone successful eradication of PA. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias. Quality of the evidence was assessed using GRADE. Conflicts were resolved by discussion and the opinion of a third review author was sought where necessary. Only a subset of participants in the included trial were eligible, therefore individual participant data were requested and obtained from the trial investigators. Main results We included one trial (n = 306) in the review; however, only 253 participants had undergone successful eradication of PA, so fulfilling the inclusion criteria for our review. Information presented relates only to the included subset of participants. The trial recruited children aged one to 12 years (mean (standard deviation (SD)) age of 5.8 (3.5) years), 129 participants (51.0%) were female and the median follow‐up was 494 days. We compared cycled therapy with tobramycin inhalation solution (TIS), in which participants underwent 28 days of TIS every three months, with culture‐based therapy, in which participants were only prescribed medication when a quarterly sputum sample was positive for PA. Reasons for downgrading the quality of the evidence included applicability (only included children), incomplete outcome data and a small number of participants. The time to next isolation of PA was probably shorter with cycled TIS therapy than with culture‐based therapy, hazard ratio (HR) 2.04 days (95% confidence interval (CI) 1.28 to 3.26) (moderate‐quality evidence). This is in contrast to the main publication of the only included trial, which examined rate of PA positivity rather than time to PA infection and included participants not eligible for inclusion in this review. At the end of the trial, there was no difference between the cycled and culture‐based groups in the change from baseline in forced expiratory volume in one second (FEV 1 ) L, mean difference (MD) 0.0 L (95% CI ‐0.09 to 0.09) or in FEV 1 % predicted, MD 0.70% (95% CI ‐4.33 to 5.73) (both very low‐quality evidence). There was no difference in the change from baseline for FVC between the groups. There was also no difference in the frequency of pulmonary exacerbations between groups, MD ‐0.18 (95% CI ‐0.51 to 0.14) (moderate‐quality evidence). Similarly, there was no difference between groups in the risk of participants developing novel resistant bacteria, RR 1.00 (95% CI 0.67 to 1.5) (moderate‐quality evidence). There were more severe adverse events in the cycled group, but the type of treatment probably makes little or no difference to the results, RR 0.65 (95% CI 0.39 to 1.11) (moderate‐quality evidence). There was no difference between groups in the change in weight or height from baseline or in rates of adherence to tobramycin or all trial medicines. The included trial did not assess changes in quality of life, the time to chronic infection with PA or the cost‐effectiveness of treatment. Authors' conclusions Cycled TIS therapy may be beneficial in prolonging the time to recurrence of PA after successful eradication, but further trials are required, specifically addressing this question and in both adults and children. Plain language summary Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis Review question We reviewed evidence about the effect of treatments given to people with cystic fibrosis (CF) to prevent recurrence of infection with bacteria called Pseudomonas aeruginosa (PA) after it has been successfully treated. Background People with CF experience frequent, severe chest infections. These infections may be caused by bacteria that do not cause disease in healthy people, such as PA. PA is an important infection in CF since if it is not treated early it cannot be cleared from the lungs (termed chronic PA). When it cannot be cleared from the lungs, it causes ongoing damage to the lung tissue as well as worse chest infections. People with CF who have chronic PA may be more unwell than those without it. Early treatment can remove PA from the lungs of people with CF, but infection can happen again and is difficult to prevent. We want to know if giving extra treatment after the PA has been successfully treated, can prolong the time to the next infection. The treatment could be antibiotics or another treatment, for example something that helps the person's immune system fight the PA. Search date The evidence is current to: 21 August 2019. Trial characteristics We included one trial with 306 participants. Only 253 of these people had had successful treatment of PA and so could be included in our review. There were only children in the trial who were aged between one and 12 years old; 51% were girls. The trial compared treatment with one month of an inhaled antibiotic every three months ('cycled treatment') with antibiotic treatment given only when the person was found to have PA ('culture‐based treatment'). People were selected randomly to have either cycled or culture‐based treatment. The trial followed people up for an average of 70 weeks. Key results Taking into the account the certainty of the evidence, we believe that the time to the next isolation of PA was probably shorter with cycled therapy than with culture‐based therapy. We found that PA recurred in a quarter of participants in the culture‐based group by 249 days but in the cycled group it took 505 days; giving cycled treatment doubled the time to a new infection with PA compared with culture‐based treatment. This is in contrast to the main publication of the only included trial, which looked at the rate of positive PA cultures rather than the time to a new infection of PA and included participants not eligible for inclusion in this review. There was no difference between the groups in: pulmonary function (a measure of how well someone's lungs are working); in the number of people having chest infections; in the change in height and weight from the beginning to th end of the trial; in how many people took all the doses of the medications; in how many people developed infections with new bacteria; or in how many people had a serious complication. The trial did not give information about the effect of the two treatments on individuals' quality of life, the time until the development of chronic PA or the cost‐effectiveness of the treatment. Quality of the evidence The quality of most of the evidence was moderate. As the trial only included children, we cannot be sure if the cycled treatment would have the same effect in teenagers or adults with CF. Further trials including both adults and children are needed to help answer the question. Trials designed to specifically answer this question are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Palser, S, Smith, S, Nash, EF, Agarwal, A, Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD012300.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.778Z" }, { "id": "e55ad4c1-9bc6-4f1a-829a-2548f2198424", "pmid": "", "title": "Souvenaid for Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Souvenaid is a dietary supplement with a patented composition (Fortasyn Connect™)which is intended to be used by people with Alzheimer's disease (AD). It has been designed to support the formation and function of synapses in the brain, which are thought to be strongly correlated with cognitive function. If effective, it might improve symptoms of Alzheimer's disease and also prevent the progression from prodromal Alzheimer's disease to dementia. We sought in this review to examine the evidence for this proposition. Objectives To assess the effects of Souvenaid on incidence of dementia, cognition, functional performance, and safety in people with Alzheimer's disease. Search methods We searched ALOIS, i.e. the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science (ISI Web of Science), Cinahl (EBSCOhost), Lilacs (BIREME), and clinical trials registries up to 24 June 2020. We also reviewed citations of reference lists of landmark papers, reviews, and included studies for additional studies and assessed their suitability for inclusion in the review. Selection criteria We included randomised, placebo‐controlled trials which evaluated Souvenaid in people diagnosed with mild cognitive impairment (MCI) due to AD (also termed prodromal AD) or with dementia due to AD, and with a treatment duration of at least 16 weeks. Data collection and analysis Our primary outcome measures were incidence of dementia, global and specific cognitive function, functional performance, combined cognitive‐functional outcomes and adverse events. We selected studies, extracted data, assessed the quality of trials and intended to conduct meta‐analyses according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We present all outcomes grouped by stage of AD. Main results We included three randomised, placebo‐controlled trials investigating Souvenaid in 1097 community‐dwelling participants with Alzheimer's disease. One study each included participants with prodromal AD, mild AD dementia and mild‐to‐moderate AD dementia. We rated the risks of bias of all trials as low. One study (in prodromal AD) was funded by European grants. The other two studies were funded by the manufacturer of Souvenaid. One trial investigated the incidence of dementia in people with prodromal AD at baseline, and found little to no difference between the Souvenaid group and the placebo group after 24 months (RR 1.09, 95% CI 0.82 to 1.43; 1 trial, 311 participants; moderate quality of evidence). In prodromal AD, and in mild and mild‐to‐moderate Alzheimer's disease dementia, Souvenaid probably results in little or no difference in global or specific cognitive functions (moderate quality of evidence). Everyday function, or the ability to perform activities of daily living, were measured in mild and mild‐to‐moderate AD dementia. Neither study found evidence of a difference between the groups after 24 weeks of treatment (moderate quality of evidence). Two studies investigated combined cognitive‐functional outcomes with the Clinical Dementia Rating Sum of Boxes and observed conflicting results. Souvenaid probably results in slight improvement, which is below estimates of meaningful change, in participants with prodromal Alzheimer's disease after 24 months (moderate quality of evidence), but probably has little to no effect in mild‐to‐moderate Alzheimer's disease dementia after 24 weeks (moderate quality of evidence). Adverse effects observed were low in all trials, and the available data were insufficient to determine any connection with Souvenaid. Authors' conclusions Two years of treatment with Souvenaid probably does not reduce the risk of progression to dementia in people with prodromal AD. There is no convincing evidence that Souvenaid affects other outcomes important to people with AD in the prodromal stage or mild‐to‐moderate stages of dementia. Conflicting evidence on combined cognitive‐functional outcomes in prodromal AD and mild AD dementia warrants further investigation. Adverse effects of Souvenaid seem to be uncommon, but the evidence synthesised in this review does not permit us to make a definitive statement on the long‐term tolerability of Souvenaid. The effects of Souvenaid in more severe AD dementia or in people with AD at risk of nutritional deficiencies remain unclear. Plain language summary The dietary supplement Souvenaid for preventing dementia or delaying cognitive decline in people with Alzheimer's disease Review question We investigated whether people with mild cognitive impairment (MCI) due to Alzheimer's disease (AD) can reduce their risk of developing dementia with a patented dietary supplement called Souvenaid. We also investigated the effect of Souvenaid on memory or other thinking skills, ability to carry out daily activities, and side effects in people with MCI or any stage of dementia due to AD. Background Alzheimer's disease is a brain disease. It is the commonest cause of dementia among older people. A person is said to have dementia when there has been a decline in their memory and thinking skills which is severe enough to stop them being fully independent in all their daily activities. Because AD develops slowly, it is also possible to pick up symptoms before dementia is fully developed. This pre‐dementia stage, when people with AD have a detectable decline in memory and thinking skills but are still able to manage their usual activities independently, is known as mild cognitive impairment due to AD, or 'prodromal' AD. Souvenaid is a patented mix of vitamins and minerals (Fortasyn Connect™) which was designed to improve brain function in AD. It is a drink which is to be taken once a day. It is intended to be consumed under medical supervision, in addition to the usual diet. Search for evidence We systematically searched for randomised controlled trials (RCTs) which were published up to June 2020 and which compared treatment with Souvenaid for at least 16 weeks with treatment with a dummy supplement (a placebo). For the comparison to be fair, it had to be decided randomly whether each participant was given Souvenaid or the placebo. Key results We found three RCTs with a total of 1097 participants to include in the review. Two of the trials investigated Souvenaid in people with dementia over a treatment period of 24 weeks. One of these included 527 participants with mild‐to‐moderate dementia due to AD and the other included 259 participants with mild dementia due to AD. The third trial investigated the use of Souvenaid for two years in 311 people with prodromal AD. We considered all of the trials to be well‐designed, but because of differences between them in the severity of the participants' symptoms and in the way the researchers measured their results, we were not able to combine the data numerically from the single trials. All the results we report are therefore based on single trials, which leads us to have only moderate confidence in the findings of this review. This means that results could be changed by further research. We found that people with prodromal AD who took Souvenaid daily for two years were probably no more or less likely than those taking placebo to develop dementia. Souvenaid probably had little or no effect on measures of memory or other thinking skills in people with prodromal AD (after two years of treatment) or with mild or mild‐to‐moderate dementia due to AD (after 24 weeks of treatment). It also probably had little or no effect on the ability of people with mild or mild‐to‐moderate dementia due to AD to manage everyday activities (again after 24 weeks). Two studies used an outcome scale which combined memory and thinking skills with practical skills (described as a combined cognitive‐functional outcome). There was probably a small benefit of Souvenaid on this outcome among people with prodromal AD who took Souvenaid for two years. However, there was probably little or no effect of Souvenaid on this outcome among people with mild‐to‐moderate AD dementia who took it for 24 weeks. There were only a few adverse events reported in the trials, and it was not possible to know whether any of them were side effects of Souvenaid. Study funding sources Two studies were funded by the manufacturer of Souvenaid. The third study (in prodromal AD) was funded by European grants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Burckhardt, M, Watzke, S, Wienke, A, Langer, G, Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD011679.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.756Z" }, { "id": "e56437f0-a174-4714-884e-e5c3f032362e", "pmid": "", "title": "Skin‐to‐skin care for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Skin‐to‐skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal‐infant contact, is one non‐pharmacological intervention for pain control in infants. Objectives The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonates The secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants. Search methods For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi‐randomized trials. Selection criteria Studies with randomisation or quasi‐randomisation, double‐ or single‐blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals. Data collection and analysis The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed‐effect model was reported for continuous outcome measures. We included variations on type of tissue‐damaging procedure, provider of care, and duration of SSC. Main results Twenty‐five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes. Seventeen studies (n = 810) compared SSC to a no‐treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of −10.78 beats per minute (95% CI −13.63 to −7.93) favouring SSC. Meta‐analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI −4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta‐analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta‐analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = −34.16, 95% CI −42.86 to −25.45), and two (n = 100) following IM injection (MD = −8.83, 95% CI −14.63 to −3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD −3.21, 95% CI −3.94 to −2.47), at 60 seconds (3 studies; n = 156) (MD −1.64, 95% CI −2.86 to −0.43), and at 90 seconds (n = 156) (MD −1.28, 95% CI −2.53 to −0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI −1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta‐analysis findings. Eight studies compared SSC to another intervention with or without a no‐treatment control. Two cross‐over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no‐treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies. Authors' conclusions SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother‐providers to others, with non‐significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long‐term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions. Plain language summary Skin‐to‐skin care with newborns cuts down procedural pain Review question: Is skin‐to‐skin care effective in cutting down pain from procedures in newborns? Are there any safety issues? Background: Newborns wearing only a diaper being held next to their mother's bare chest is referred to as skin‐to‐skin contact and is also sometimes called 'kangaroo care' because of its similarity to the way kangaroo mothers care for their young. Newborns, especially those who must spend time in a Neonatal Intensive Care Unit, must have various tests and procedures as part of their care, for example heel stick, venous puncture, and injections. Giving analgesic drugs for these procedures can often pose problems so that alternatives to drugs must be found. Study characteristics: Twenty‐eight studies in which newborn babies who were by chance in the kangaroo care group or condition were included from an extensive search of the literature. Skin‐to‐skin care was clearly defined and could have been compared to no pain‐reducing strategies or other pain‐reducing strategies such as sweet taste. Studies were examined which examined well‐established signs of pain, both physiological and behavioural, as well as a combination of physiological and behavioural signs. Different providers of skin‐to‐skin care other than the mother were included. Key results: Kangaroo care appears to reduce the pain response to, and recovery from, these frequent procedures, although few studies could be combined to provide strong evidence. As far as it has been reported, skin‐to‐skin care is safe. Although it appears that skin‐to‐skin care is effective, the size of the benefit remains uncertain. Quality of evidence: The quality of evidence in these studies was generally low for the response to the actual procedure but was moderate for recovery from the procedure.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Johnston, C; Campbell‐Yeo, M; Disher, T; Benoit, B; Fernandes, A; Streiner, D; Inglis, D; Zee, R", "articleTypes": [], "doi": "10.1002/14651858.CD008435.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "e591ba7c-e722-45db-85d0-53b4bcb58bbd", "pmid": "", "title": "Zinc supplementation for improving pregnancy and infant outcome", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Carducci, B, Keats, EC, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD000230.pub6 AB - Abstract - Background It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy, such as prolonged labour, atonic postpartum haemorrhage, pregnancy‐induced hypertension, preterm labour and post‐term pregnancies, although these associations have not yet been established. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Objectives 1. To compare the effects on maternal, fetal, neonatal and infant outcomes in healthy pregnant women receiving zinc supplementation versus no zinc supplementation, or placebo.
2. To assess the above outcomes in a subgroup analysis reviewing studies performed in women who are, or are likely to be, zinc‐deficient. Search methods For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (3 July 2020), and reference lists of retrieved studies. Selection criteria Randomised trials of zinc supplementation versus no zinc supplementation or placebo administration during pregnancy, earlier than 27 weeks' gestation. We excluded quasi‐randomised controlled trials. We intended to include studies presented only as abstracts, if they provided enough information or, if necessary, by contacting authors to analyse them against our criteria; we did not find any such studies. Data collection and analysis Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information. We assessed the certainty of the evidence using GRADE. Main results For this update, we included 25 randomised controlled trials (RCTs) involving over 18,000 women and their babies. The overall risk of bias was low in half of the studies. The evidence suggests that zinc supplementation may result in little or no difference in reducing preterm births (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.74 to 1.03; 21 studies, 9851 participants; low‐certainty evidence). Further, zinc supplementation may make little or no difference in reducing the risk of stillbirth (RR 1.22, 95% CI 0.80 to 1.88; 7 studies, 3295 participants; low‐certainty evidence), or perinatal deaths (RR 1.10, 95% CI 0.81 to 1.51; 2 studies, 2489 participants; low‐certainty evidence). It is unclear whether zinc supplementation reduces neonatal death, because the certainty of the evidence is very low. Finally, for other birth outcomes, zinc supplementation may make little or no difference to mean birthweight (MD 13.83, 95% CI ‐15.81 to 43.46; 22 studies, 7977 participants; low‐certainty evidence), and probably makes little or no difference in reducing the risk of low birthweight (RR 0.94, 95% CI 0.79 to 1.13; 17 studies, 7399 participants; moderate‐certainty evidence) and small‐for‐gestational age babies when compared to placebo or no zinc supplementation (RR 1.02, 95% CI 0.92 to 1.12; 9 studies, 5330 participants; moderate‐certainty evidence). We did not conduct subgroup analyses, as very few studies used normal zinc populations. Authors' conclusions There is not enough evidence that zinc supplementation during pregnancy results in improvements in maternal or neonatal outcomes. Future research to address ways of improving the overall nutritional status of pregnant women, particularly in low‐income regions, and not looking at zinc in isolation, should be an urgent priority. Plain language summary Zinc supplementation for improving pregnancy and infant outcome What is the issue? In low‐ and middle‐income countries, many women have poor diets and are deficient in key micronutrients that are required for good health. This is especially concerning during pregnancy, when energy and nutrient needs are greater for both the mother and the growing baby. Zinc plays a critical role in normal growth and development. Deficiency in zinc could lead to adverse health outcomes, such as being born too soon or too small. This is an update of a review first published in 1997 and subsequently updated in 2007, 2012 and 2015. Why is this important? Although severe zinc deficiency is rare, it is estimated that mild‐to‐moderate deficiency is common in several regions of the world. Studies of human pregnancy and zinc supplementation, including those from low‐ and middle‐income countries, have failed to document a consistent beneficial effect on fetal growth, length of gestation, and early newborn survival. What evidence did we find? We searched for studies in July 2020. This updated review now includes 25 randomised controlled trials, involving over 18,000 women and their babies. We found that zinc supplementation in pregnancy may make little to no difference in reducing the risk of preterm births, stillbirths, or deaths around the time of birth, when compared to no zinc supplementation or placebo. Zinc supplementation may make little or no difference to the birthweight of babies, and probably makes little or no difference to the number of babies born either with a low birthweight or small for their gestational age, when compared with no zinc supplementation, or with giving a placebo. We cannot be sure whether zinc supplementation reduces death in newborns, because the certainty of the evidence is very low. What does this mean? There is not enough evidence that zinc supplementation during pregnancy results in better outcomes for women and their babies. Finding ways to improve women's overall nutritional status, particularly in low‐income areas, will do more to improve the health of mothers and babies than supplementing pregnant women with zinc alone. This should be an urgent research priority for the future.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.757Z" }, { "id": "e592b19a-41a3-4460-9e4a-e5929f36c030", "pmid": "", "title": "Optimisation of antiretroviral therapy in HIV‐infected children under 3 years of age", "imported": false, "abstract": "Abstract - Background In the absence of antiretroviral therapy (ART), over 50% of HIV‐infected infants progress to AIDS and death by 2 years of age. However, there are challenges to initiation of ART in early life, including the possibility of drug resistance in the context of prevention of mother‐to‐child transmission (PMTCT) programs, a paucity of drug choices , uncertain dosing for some medications and long‐term toxicities. Key management decisions include when to start ART, what regimen to start, and whether and when to substitute drugs or interrupt therapy. This review, an update of a previous review, aims to summarize the currently available evidence on this topic and inform the ART management in HIV‐infected children less than 3 years of age. Objectives To evaluate 1) when to start ART in young children (less than 3 years); 2) what ART to start with, comparing first‐line non‐nucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI)‐based regimens; and 3) whether alternative strategies should be used to optimize antiretroviral treatment in this population: induction (initiation with 4 drugs rather than 3 drugs) followed by maintenance ART, interruption of ART and substitution of PI with NNRTI drugs once virological suppression is achieved on a PI‐based regimen. Search methods Search methods We searched for published studies in the Cochrane HIV/AIDS Review Group Trials Register, The Cochrane Library, Pubmed, EMBASE and CENTRAL. We screened abstracts from relevant conference proceedings and searched for unpublished and ongoing trials in clinical trial registries (ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform). Selection criteria We identified RCTs that recruited perinatally HIV‐infected children under 3 years of age without restriction of setting. We rejected trials that did not include children less than 3 years of age, did not provide stratified outcomes for those less than 3 years or did not evaluate either timing of ART initiation, choice of drug regimen or treatment switch/interruption strategy. Data collection and analysis Two reviewers independently applied study selection criteria, assessed study quality and extracted data. Effects were assessed using the hazard ratio (HR) for time‐to‐event outcomes, relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes. Main results A search of the databases identified a total of 735 unique, previously unreviewed studies, of which 731 were excluded to leave 4 new studies to incorporate into the review. Four additional studies were identified in conference proceedings, for a total of 8 studies addressing when to start treatment (n=2), what to start (n=3), whether to substitute lopinavir/ritonavir (LPV/r) with nevirapine (NVP) (n=1), whether to use an induction‐maintenance ART strategy (n=1) and whether to interrupt treatment (n=1). Treatment initiation in asymptomatic infants with good immunological status was associated with a 75% reduction (HR=0.25; 95%CI 0.12‐0.51; p=0.0002) in mortality or disease progression in the one trial with sufficient power to address this question. In a smaller pilot trial, median CD4 cell count was not significantly different between early and deferred treatment groups 12 months after ART. Regardless of previous exposure to nevirapine for PMTCT, the hazard for treatment failure at 24 weeks was 1.79 (95%CI 1.33, 2.41) times higher in children starting ART with a NVP���based regimen compared to those starting with a LPV/r‐based regimen (p=0.0001) with no clear difference in the effect observed for children younger or older than 1 year. The hazard for virological failure at 24 weeks was overall 1.84 (95%CI 1.29, 2.63) times higher for children starting ART with a NVP‐based regimen compared to those starting with a LPV/r‐based regimen (p=0.0008) with a larger difference in time to virological failure (or death) between the NVP and LPV/r‐based regimens when ART was initiated in the first year of life. Infants starting a LPV/r regimen and achieving sustained virological suppression who then substituted LPV/r with NVP after median 9 months on LPV/r were less likely to develop virological failure (defined as at least one VL greater than 50 copies/mL) compared with infants who started and stayed on LPV/r (HR=0.62, 95%CI 0.41, 0.92, p=0.02). However the hazard for confirmed failure at a higher viral load (>1000 copies/mL) was greater among children who switched to NVP compared to those who remained on LPV/r (HR=10.19, 95% CI 2.36, 43.94, p=0.002). Children undergoing an induction‐maintenance ART approach with a 4‐drug NNRTI‐based regimen for 36 weeks, followed by 3‐drug ART, had significantly greater CD4 rise than children receiving a standard 3‐drug NNRTI‐based ART at 36 weeks (mean difference 1.70 [95%CI 0.61, 2.79] p=0.002) and significantly better viral load response at 24 weeks (OR 1.99 [95%CI 1.09, 3.62] p=0.02). However, the immunological and virological benefits were short‐term. The one trial of treatment interruption that compared children initiating continuous ART from infancy with children interrupting ART was terminated early because the duration of treatment interruption was less than 3 months in most infants. Children interrupting treatment had similar growth and occurrence of serious adverse events as those in the continuous arm. Authors' conclusions ART initiation in asymptomatic children under 1 year of age reduces morbidity and mortality, but it remains unclear whether there are clinical benefits to starting ART in asymptomatic children diagnosed with HIV infection between 1‐3 years. The available evidence shows that a LPV/r‐based first‐line regimen is more efficacious than a NVP‐based regimen, regardless of PMTCT exposure status. New formulations of LPV/r are urgently required to enable new WHO recommendations to be implemented. An alternative approach to long‐term LPV/r is substituting LPV/r with NVP once virological suppression is achieved. This strategy looked promising in the one trial undertaken, but may be difficult to implement in the absence of routine viral load testing. A 4‐drug induction‐maintenance approach showed short‐term virological and immunological benefits during the induction phase but, in the absence of sustained benefits, is not recommended as a routine treatment strategy. Treatment interruption following early ART initiation in infancy was challenging for children who were severely immunocompromised in the context of poor clinical immunological condition at ART initiation due to the short duration of interruption, and is therefore not practical in ART treatment programmes where close monitoring is not feasible. Plain language summary Using antiretroviral drugs to treat children under 3 years old who have HIV infection Children under 3 years of age who have HIV infection have a high risk of dying without antiretroviral therapy (ART). However, treatment in this age group is challenging because there are high levels of virus in the blood and few suitable drug choices. Results from this systematic review show that ART soon after birth is preferable to delaying treatment, because infants are less likely to die or become sick. Starting a first‐line treatment regimen that includes lopinavir/ritonavir rather than nevirapine is preferable, because infants and young children are less likely to have to stop treatment, whether or not they had previously been exposed to nevirapine. However, lopinavir/ritonavir is more expensive than nevirapine. It is also currently only available as an inconvenient liquid, which tastes bitter and has to be refrigerated, making it challenging to implement in all parts of the world. While waiting for better formulations to become available, it may be possible to switch from lopinavir/ritonavir to nevirapine once the HIV virus levels become undetectable. However, based on the evidence currently available, a viral load test would be required to identify those children who could safely substitute lopinavir/ritonavir with nevirapine. Viral loads are expensive and not widely available in most countries in sub‐Saharan Africa. An alternative treatment approach is to give a stronger drug combination (four different drugs together) when treatment is first started, then reduce down to three drugs after a short while. However, this strategy did not appear to have long‐term benefits. A 'treatment interruption' strategy, in which infants start ART soon after birth but then stop medication after 1‐2 years, is difficult to implement. Children stopping ART need to restart it very quickly to prevent them becoming sick, and monitoring a child off treatment is challenging in settings with few resources.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Penazzato, M; Prendergast, AJ; Muhe, LM; Tindyebwa, D; Abrams, E", "articleTypes": [], "doi": "10.1002/14651858.CD004772.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "e59d8295-98f7-4ee5-b5ba-d71efd5eba06", "pmid": "", "title": "ATATURK UNİVERSITY", "imported": false, "abstract": "'Pandemic' is a medical term that has become a ubiquitous part of the global vocabulary over the last year. Although pandemics have occurred throughout human history, their sociocultural, economic, and psychological impact can leave lasting damage. In the current COVID-19 pandemic, more than 200 million confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported to date. While most people present with mild symptoms such as loss of taste and smell, sore throat, joint pain, and headache, it can cause serious morbidity and mortality, especially in individuals over 65 years of age and those with comorbidities .", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.160Z" }, { "id": "e5ab59b3-0e82-408e-bde4-007168080a28", "pmid": "", "title": "Effects of Lutein Supplementation on Macular Pigment Optical Density and Visual Acuity in Patients With Age-related Macular Degeneration", "imported": false, "abstract": "The macular pigment (MP) in humans consists of the yellow, blue-absorbing carotenoids lutein and zeaxanthin. The highest concentrations of lutein and zeaxanthin are found in the fovea. Since light entering the eye passes through the MP before reaching the photo receptors it absorbs a significant portion of short-wavelength light. There is evidence that this absorbing properties of the MP as well as the ability of inactivating highly reactive oxygen species are protective for the retina.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "e5b25379-380e-48ce-9816-a7c387a75915", "pmid": "", "title": "Ibuprofen, a Phenylpropanoic Acid Nonsteroidal Anti-inflammatory Drug, Inhibits Human Sweet Taste and Glucose Detection", "imported": false, "abstract": "The sweet taste receptor, TAS1R2-TAS1R3, is expressed both orally, where it signals sweet taste, and extraorally in the intestine and pancreas, where it may affect glucose absorption and metabolism. Recently, ibuprofen and naproxen have been identified to inhibit human T1R3 when heterologously expressed in cells. In the present study, the initial objective was to determine if ibuprofen and naproxen inhibit interactions of sugars with human sweet taste receptor under normal, physiological conditions. Ten healthy participants were asked to rate sweetness intensity for a range of sweet stimuli (sucrose, fructose, sucralose) after a prerinse of ibuprofen, naproxen or water. Both ibuprofen and naproxen inhibited sweet taste intensity in a dose-dependent manner. In association studies, ibuprofen use has been linked to preserved metabolic function, as its use is correlated with lower rates of Alzheimer's disease, diabetes and colon cancer. Here the investigators present a potential novel pathway for systemic ibuprofen to impact these metabolic diseases.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.141Z" }, { "id": "e5e158e3-b5c5-4b54-8252-ee6b633f671b", "pmid": "", "title": "Effects of Gymnemic Acids Lozenge on Reward Region Response to Receipt and Anticipated Receipt of High-Sugar Food, High-Sugar Food Pictures, and Ad Lib Candy Intake", "imported": false, "abstract": "The purpose of the research is to test whether a gymnemic acids (GA) lozenge will reduce reward region response to intake of high-sugar food and ad lib candy intake and whether the GA lozenge reduced reward region response to anticipated intake of high-sugar food and high-sugar food pictures relative to a placebo lozenge.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.145Z" }, { "id": "e5f46105-f8dd-4c8f-9fef-3b12ce427276", "pmid": "", "title": "Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia", "imported": false, "abstract": "Abstract - Background In a review and meta‐analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion‐focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect. Objectives To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic. Search methods We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the `awaiting classification' section of this review. Selection criteria We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion‐focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post‐surgery. Data collection and analysis One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion. Where possible we used random‐effects meta‐analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges' g) to combine data from different outcome measures. If data were not available in a form suitable for meta‐analysis we performed a narrative review. Main results Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty‐one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta‐analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD ‐0.20, 95% confidence interval (CI) ‐0.35 to ‐0.06), length of stay (mean difference ‐0.52 days, 95% CI ‐0.82 to ‐0.22) and negative affect (SMD ‐0.35, 95% CI ‐0.54 to ‐0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached. Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall,we rated the quality of evidence for each outcome as ‘low’ because of the high level of heterogeneity in meta‐analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta‐analysis, so we rated the quality of evidence as `very low'. Authors' conclusions The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well‐conducted and clearly reported research. Plain language summary The effect of psychological preparation on pain, behavioural recovery, negative emotion and length of stay after surgery Background The way people think and feel before surgery can affect how they feel and what they do after surgery. For example, research shows that people who feel more anxious before their surgery experience more pain after it. A review conducted in 1993 looked at the impact of psychological preparation on outcomes after surgery. The term `psychological preparation' includes a range of techniques that aim to change what people think, how they feel or what they do. This 1993 review found that psychological preparation techniques reduced pain after surgery, improved behavioural recovery (how quickly people return to activities), decreased length of stay in hospital and reduced negative emotion (e.g. feelings of anxiety or depression). We aimed to carry out an up‐to‐date review using Cochrane methodology to learn whether there are helpful (or harmful) effects of psychological preparation for people undergoing surgery, and which outcomes (pain after surgery, behavioural recovery, negative emotion or length of stay) are improved. Study characteristics We included studies of adults who received planned surgery with general anaesthesia. We looked at seven psychological preparation techniques: procedural information (information about what, when and how processes will happen); sensory information (what the experience will feel like and what other sensations they may have, e.g. taste, smell); behavioural instruction (telling patients what they need to do); cognitive intervention (techniques that aim to change how people think); relaxation techniques; hypnosis; and emotion‐focused interventions (techniques that aim to help people to manage their feelings). The psychological preparation had to be delivered before surgery for the study to be included in the review. We included studies that looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion after surgery (within one month). Studies were included in the review up to the search date of 4 May 2014. We updated the search on 7 July 2015 and will incorporate the 38 studies found in this later search when the review is updated. We included 105 studies from 115 papers, with 10,302 participants taking part. Sixty‐one studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative emotion. In accordance with the review protocol, we did not record details about funding sources. Key results In this review we included 105 studies, which were reported in 115 papers. A total of 10,302 participants were randomized in these studies. For pain, length of stay and negative emotion we combined numerical findings from the studies. We found that psychological preparation before surgery seemed to reduce pain and negative emotion after the operation and may reduce the time spent in hospital by around half a day but the quality of the evidence was low. Also, the studies used many different psychological preparation techniques (often in different combinations) so it was not possible to discover which techniques were better. We could not statistically combine numerical findings for behavioural recovery because few studies provided sufficient details and studies used different ways of measuring how quickly people returned to usual activities. In reviewing the studies, we found that psychological preparation, in particular behavioural instruction, may have the potential to improve behavioural recovery. However, the quality of this evidence was very low. We looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion in this review and did not find evidence to suggest that psychological preparation might lead to harm in these outcomes. However, as we did not look at other outcomes it is possible that we did not identify potential harm. Quality of the evidence Many studies were poorly reported, so we could not be confident that findings were reliable. For this reason and because of the large variation in psychological techniques, types of surgery and measures used, we graded the quality of the evidence as `low' for the outcomes pain, negative emotion and length of stay; we cannot be confident that these techniques help patients to recover from surgery. For behavioural recovery, we further downgraded the quality of the evidence to `very low' because of problems with measurement and reporting of the outcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, R; Scott, NW; Manyande, A; Bruce, J; Vögele, C; Byrne‐Davis, LMT; Unsworth, M; Osmer, C; Johnston, M", "articleTypes": [], "doi": "10.1002/14651858.CD008646.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "e5f70522-d219-4e1a-a4a2-b45b7ba2f2f6", "pmid": "", "title": "Cranberries for preventing urinary tract infections", "imported": false, "abstract": "Abstract - Background Cranberries contain proanthocyanidins (PACs), which inhibit the adherence of p‐fimbriated Escherichia coli to the urothelial cells lining the bladder. Cranberry products have been used widely for several decades to prevent urinary tract infections (UTIs). This is the fifth update of a review first published in 1998 and updated in 2003, 2004, 2008, and 2012. Objectives To assess the effectiveness of cranberry products in preventing UTIs in susceptible populations. Search methods We searched the Cochrane Kidney and Transplant Specialised Register up to 13 March 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria All randomised controlled trials (RCTs) or quasi‐RCTs of cranberry products compared with placebo, no specific treatment or other intervention (antibiotics, probiotics) for the prevention of UTIs were included. Data collection and analysis At least two authors independently assessed and extracted data. Information was collected on methods, participants, interventions and outcomes (incidence of symptomatic UTIs, positive culture results, side effects, adherence to therapy). Risk ratios (RR) with 95% confidence intervals (CI) were calculated where appropriate. Study quality was assessed using the Cochrane risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results For this update, 26 new studies were added, bringing the total number of included studies to 50 (8857 randomised participants). The risk of bias for sequence generation and allocation concealment was low for 29 and 28 studies, respectively. Thirty‐six studies were at low risk of performance bias, and 23 studies were at low risk of detection bias. Twenty‐seven, 41, and 17 studies were at low risk of attrition bias, reporting bias and other bias, respectively. Forty‐five studies compared cranberry products with placebo, water or no specific treatment in six different groups of participants. Twenty‐six of these 45 studies could be meta‐analysed for the outcome of symptomatic, culture‐verified UTIs. In moderate certainty evidence, cranberry products reduced the risk of UTIs (6211 participants: RR 0.70, 95% CI 0.58 to 0.84; I² = 69%). When studies were divided into groups according to the treatment indication, cranberry products probably reduced the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs (8 studies, 1555 participants: RR 0.74, 95% CI 0.55 to 0.99; I² = 54%), in children (5 studies, 504 participants: RR 0.46, 95% CI 0.32 to 0.68; I² = 21%) and in people with a susceptibility to UTIs due to an intervention (6 studies, 1434 participants: RR 0.47, 95% CI 0.37 to 0.61; I² = 0%). However, there may be little or no benefit in elderly institutionalised men and women (3 studies, 1489 participants: RR 0.93, 95% CI 0.67 to 1.30; I² = 9%; moderate certainty evidence), pregnant women (3 studies, 765 participants: RR 1.06, 95% CI 0.75 to 1.50; I² = 3%; moderate certainty evidence), or adults with neuromuscular bladder dysfunction with incomplete bladder emptying (3 studies, 464 participants: RR 0.97, 95% CI 0.78 to 1.19; I² = 0%; low certainty evidence). Other comparisons were cranberry products with probiotics (three studies) or antibiotics (six studies), cranberry tablets with cranberry liquid (one study), and different doses of PACs (two studies). Compared to antibiotics, cranberry products may make little or no difference to the risk of symptomatic, culture‐verified UTIs (2 studies, 385 participants: RR 1.03, 95% CI 0.80 to 1.33; I² = 0%) or the risk of clinical symptoms without culture (2 studies, 336 participants: RR 1.30, 95% CI 0.79 to 2.14; I² = 68%). Compared to probiotics, cranberry products may reduce the risk of symptomatic, culture‐verified UTIs (3 studies, 215 participants: RR 0.39, 95% CI 0.27 to 0.56; I = 0%). It is unclear whether efficacy differs between cranberry juice and tablets or between different doses of PACs, as the certainty of the evidence was very low. The number of participants with gastrointestinal side effects probably does not differ between those taking cranberry products and those receiving a placebo or no specific treatment (10 studies, 2166 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%; moderate certainty evidence). There was no clear relationship between compliance with therapy and the risk for repeat UTIs. No difference in the risk for UTIs could be demonstrated between low, moderate and high doses of PACs. Authors' conclusions This update adds a further 26 studies, taking the total number of studies to 50 with 8857 participants. These data support the use of cranberry products to reduce the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs, in children, and in people susceptible to UTIs following interventions. The evidence currently available does not support its use in the elderly, patients with bladder emptying problems, or pregnant women. Plain language summary Cranberries for preventing urinary tract infections What is the issue? Cranberries (as cranberry juice, tablets or capsules) have been used for many years to prevent urinary tract infections (UTIs). Cranberries contain proanthocyanidins (PACs), substances that can prevent bacteria from sticking to the walls of the bladder. This may help prevent infections and reduce the need for working people to take time for medical appointments. However, there is currently no established regimen for what PACs dose to use and no formal regulation by health authorities of cranberry products. In particular, the dose suggested may not be included on the package. What did we do? We analysed the results of randomised controlled trials (RCTs), which compared the occurrence of UTIs in people taking a cranberry product with those taking a placebo or no treatment. We also analysed the results of RCTs comparing a cranberry product with other treatments such as antibiotics or probiotics. What did we find? We found 50 RCTs involving 8857 people. Forty‐five RCTs compared cranberry with a placebo or no treatment. Taking cranberries as a juice, tablets or capsules reduced the number of UTIs in women with recurrent UTIs, in children with UTIs and in people susceptible to UTIs following an intervention such as bladder radiotherapy. However, UTIs did not appear to be reduced in elderly institutionalised men and women, in adults with neuromuscular bladder dysfunction and incomplete bladder emptying, or in pregnant women. Few people reported any side effects with the most common being tummy pain. We did not find enough information to determine if cranberry products are more or less effective compared with antibiotics or probiotics in preventing further UTIs. Conclusions Cranberry products may help to prevent UTIs which cause symptoms in women with frequent UTIs, in children with UTIs and in people who have undergone an intervention involving the bladder. However, further assessment is required in well‐designed and prospectively registered RCTs to clarify further who with UTIs would benefit from cranberry products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Williams, G; Stothart, CI; Hahn, D; Stephens, JH; Craig, JC; Hodson, EM", "articleTypes": [], "doi": "10.1002/14651858.CD001321.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "e5f9cb3c-8ce5-473f-8e97-27ecf55d8af4", "pmid": "", "title": "Corticosteroids for treating sepsis in children and adults", "imported": false, "abstract": "Abstract - Background Sepsis occurs when an infection is complicated by organ failure. Sepsis may be complicated by impaired corticosteroid metabolism. Thus, providing corticosteroids may benefit patients. This is an update of a review originally published in 2004 and previously updated in 2010, 2015 and 2019. Objectives To examine the benefits and harms of corticosteroids in children and adults with sepsis. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, ISRCTN and the WHO Clinical Trials Search Portal on 31 December 2023. In addition, we conducted reference checking and citation research, and contacted study authors, to identify additional studies as needed. We updated this search in December 2024, but these results have not yet been incorporated. Selection criteria We included randomised controlled trials (RCTs) of corticosteroids versus placebo or usual care (antimicrobials, fluid replacement and vasopressor therapy as needed) in children and adults with sepsis. We also included RCTs of continuous infusion versus intermittent bolus of corticosteroids. Data collection and analysis We used the same methods in comparisons of corticosteroids versus placebo or usual care, and of continuous infusion versus intermittent bolus administration of corticosteroids. The primary outcome was all‐cause mortality at 28 days. The most critical secondary outcomes were (i) all‐cause mortality in the long term (last follow‐up from 90 days to one year) and in the hospital; (ii) length of stay in the intensive care unit and in hospital; (iii) adverse effects, i.e. superinfection and muscle weakness (within 28 days). All review authors screened and selected studies for inclusion. One review author extracted data, which was checked by the others, and by the lead author of the primary study when possible. For this update, we used Covidence software for screening and selection of studies and abstraction of data by paired review authors, with discrepancies resolved by a third review author. We obtained unpublished data from the authors of some trials. We assessed the risk of bias in trials using the Cochrane risk of bias tool (RoB 1) and applied GRADE to assess the certainty of evidence. The review authors did not contribute to the assessment of eligibility or risk of bias, nor to data extraction, for the trials they had participated in. Main results We included 87 trials (24,336 participants), of which six included only children, two included children and adults, and the remaining trials included only adults. Seventeen additional trials are ongoing and will be considered in future versions of this review. We judged 25 trials as being at low risk of bias. Corticosteroids versus placebo or usual care Compared to placebo or usual care, corticosteroids probably reduce 28‐day mortality (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.84 to 0.95; 72 trials, 22,915 participants; moderate‐certainty evidence). We downgraded the certainty of evidence for this outcome from high to moderate for inconsistency (significant heterogeneity across trial results). Corticosteroids may result in little to no difference in long‐term mortality (RR 0.97, 95% CI 0.91 to 1.03; 12 trials, 8468 participants; low‐certainty evidence) and probably reduce in‐hospital mortality (RR 0.90, 95% CI 0.84 to 0.97; 40 trials, 17,459 participants; moderate‐certainty evidence). Corticosteroids may reduce length of intensive care unit (ICU) stay for all participants (mean difference (MD) ‐0.86 days, 95% CI ‐1.67 to ‐0.05; 25 trials, 8069 participants; low‐certainty evidence) and may reduce length of hospital stay for all participants (MD ‐1.09 days, 95% CI ‐1.85 to ‐0.34; 31 trials, 16,954 participants; low‐certainty evidence). The evidence is uncertain about the effect of corticosteroids on the risk of muscle weakness (RR 1.09, 95% CI 0.78 to 1.53; 7 trials, 6729 participants; very low‐certainty evidence). Corticosteroids may result in little to no difference in the risk of superinfection (RR 0.96, 95% CI 0.86 to 1.07; 36 trials, 7961 participants; low‐certainty evidence). Continuous infusion of corticosteroids versus intermittent bolus Four trials reported data for this comparison, and the certainty of evidence for all outcomes was very low. We are uncertain about the effects of continuous infusion of corticosteroids compared with intermittent bolus administration on 28‐day mortality (RR 1.03, 95% CI 0.81 to 1.32; 3 trials, 310 participants). We downgraded the certainty of evidence to very low due to high risk of bias in all except one trial and due to imprecision. Compared to bolus administration, we are uncertain of the effects of continuous infusion of corticosteroids on long‐term mortality (RR 1.36, 95% CI 1.02 to 1.81; 1 trial, 70 participants; very low‐certainty evidence), in‐hospital mortality (RR 0.92, 95% CI 0.71 to 1.19; 3 trials, 352 participants; very low‐certainty evidence), ICU length of stay amongst all participants (MD ‐0.56 days, 95% CI ‐3.44 to 2.32; 4 trials, 422 participants; very low‐certainty evidence), hospital length of stay amongst all participants (MD ‐0.21 days, 95% CI ‐4.72 to 4.30; 4 trials, 422 participants; very low‐certainty evidence), risk of muscle weakness (RR 0.89, 95% CI 0.13 to 5.98; 1 trial, 70 participants; very low‐certainty evidence) and risk of superinfection (RR 1.12, 95% CI 0.37 to 3.33; 2 trials, 193 participants; very low‐certainty evidence). Authors' conclusions Moderate‐certainty evidence indicates that corticosteroids probably reduce 28‐day, 90‐day and hospital mortality amongst patients with sepsis. Corticosteroids may shorten ICU and hospital length of stay (low‐certainty evidence). There may be little or no difference in the risk of superinfection. The risk of muscle weakness is uncertain. The effects of continuous versus intermittent bolus administration of corticosteroids are uncertain. Plain language summary What are the benefits and harms of corticosteroids in the treatment of children and adults with sepsis? Key messages • Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days and of in‐hospital death, and may have little or no effect on the risk of dying beyond three months. • We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. • Future studies should measure the benefits and harms of corticosteroids for the treatment of specific populations, including children, patients with sepsis without shock or with a mild form of septic shock, patients with acute respiratory distress syndrome (ARDS) and patients with different types of infections. Defining the optimal methods for corticosteroid administration, including the types of molecule ‐ with or without producing sodium and fluid retention and potassium excretion (mineralocorticoid activity), timing of initiation, dose and duration, continuous infusion or intermittent intravenous boluses, and ending of treatment ‐ with or without gradually decreasing the dose to zero, also requires additional studies. Future studies should measure the longer‐term effects, i.e. longer than one year, on survival and complications of sepsis. What is sepsis? Sepsis is present when an infection is complicated by organ failure. People develop rapid breathing, hypotension (low blood pressure) and mental confusion. Sepsis can interfere with the effectiveness of the body’s corticosteroids, which control how your body recognises and defends itself against bacteria, viruses and substances that appear foreign and harmful. What are corticosteroids (medicine)? Corticosteroids are medicines used to stop excessive inflammation. However, these medicines may cause unwanted harms, such as increased blood sugar or salt levels, infections, bleeding in the stomach, agitation or delirium, and weakness of the limbs. Corticosteroids have been given for decades to people with infection resulting from various causes. What did we want to find out? We wanted to find out: • the benefits of using corticosteroids in children and adults with sepsis; and • the best ways to administer this treatment (including the best people to give it to). We also wanted to know if corticosteroids can cause any unwanted effects. What did we do? We searched for studies that compared: • corticosteroids administered intravenously against a 'dummy' treatment, or sham treatment, which does not contain any medicine but looks or tastes identical to corticosteroids, or usual care; or • continuous infusion against intermittent rapid intravenous injections (boluses) of corticosteroids administration. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? This review includes 87 trials (24,336 participants). The biggest study was of 3800 people and the smallest study was of 21 people. Eighty‐three trials compared corticosteroids to no corticosteroids (placebo or usual care in 59 and 24 trials, respectively). Four trials also compared continuous administration versus rapid intravenous injection (i.e. bolus) of corticosteroids given at fixed intervals of six or eight hours. Thirty‐three trials were conducted in Europe, 15 in North America, 22 in Asia, six in the Middle East, six in Africa and three in Latin America; four were multinational trials. Three trials were funded by a drug company, 27 by public organisations or through charitable funding and six by both a drug company and public organisations or charitable funding; 25 did not declare the source of funding. Compared to placebo or usual care, corticosteroids probably reduce the risk of death at 28 days by 10% (72 trials; 22,915 participants), with consistent treatment effects between children and adults. There may be little or no effect of corticosteroids on the risk of dying over the long term (longer than three months), but these results are less certain. Corticosteroids probably reduce the risk of dying in hospital. Corticosteroids may result in a reduction in the length of stay in the intensive care unit (ICU) and in hospital. They may not increase the risk of superinfection (second infection). The evidence is very uncertain about the effect of corticosteroids on the risk of muscle weakness. We are uncertain about the effects of continuous intravenous infusion of corticosteroids compared with intermittent intravenous bolus (rapid injection) administration. Four studies reported data for this comparison, and the certainty of evidence for all outcomes was very low. What are the limitations of the evidence? • Corticosteroids versus placebo or usual care We have moderate confidence in our findings that corticosteroids reduced 28‐day mortality. We found some differences amongst the study populations, the types of corticosteroids and how they were given, and the use of additional medicines. • Continuous infusion versus bolus administration of corticosteroids We have very little confidence in our findings about the absence of a difference in 28‐day mortality between the administration of corticosteroids continuously and repeated rapid intravenous injections. We found only four studies that enrolled very few patients. How up‐to‐date is this evidence? The evidence provided in this review is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Annane, D; Briegel, J; Granton, D; Bellissant, E; Bollaert, PE; Keh, D; Kupfer, Y; Pirracchio, R; Rochwerg, B", "articleTypes": [], "doi": "10.1002/14651858.CD002243.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "e6005364-6357-403f-ad86-82c6773d20fb", "pmid": "", "title": "Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants)", "imported": false, "abstract": "Abstract - Background 'Immediate' implants are placed in dental sockets just after tooth extraction. 'Immediate‐delayed' implants are those implants inserted after weeks up to about a couple of months to allow for soft tissue healing. 'Delayed' implants are those placed thereafter in partially or completely healed bone. The potential advantages of immediate implants are that treatment time can be shortened and that bone volumes might be partially maintained thus possibly providing good aesthetic results. The potential disadvantages are an increased risk of infection and failures. After implant placement in postextractive sites, gaps can be present between the implant and the bony walls. It is possible to fill these gaps and to augment bone simultaneously to implant placement. There are many techniques to achieve this but it is unclear when augmentation is needed and which could be the best augmentation technique. Objectives To evaluate success, complications, aesthetics and patient satisfaction between 'immediate', 'immediate‐delayed' and 'delayed' implants. To evaluate whether and when augmentation procedures are necessary and which is the most effective technique. Search methods The Cochrane Oral Health Group's Trials Register (to 2 June 2010), CENTRAL ( The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 ‐ 2 June 2010) and EMBASE via OVID (1980 ‐ 2 June 2010) were searched. Several dental journals were handsearched. Selection criteria Randomised controlled trials (RCTs) comparing immediate, immediate‐delayed, and delayed implants, or comparing various bone augmentation procedures around the inserted implants, reporting the outcome of the interventions to at least 1 year after functional loading. Data collection and analysis Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Trial authors were contacted for any missing information. Results were expressed as random‐effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). The statistical unit of the analysis was the patient. Main results Fourteen eligible RCTs were identified but only seven trials could be included. Four RCTs evaluated implant placement timing. Two RCTs compared immediate versus delayed implants in 126 patients and found no statistically significant differences. One RCT compared immediate‐delayed versus delayed implants in 46 patients. After 2 years patients in the immediate‐delayed group perceived the time to functional loading significantly shorter, were more satisfied and independent blinded assessor judged the level of the perimplant marginal mucosa in relation to that of the adjacent teeth as more appropriate (RR = 1.68; 95% CI 1.04 to 2.72). These differences disappeared 5 years after loading but significantly more complications occurred in the immediate‐delayed group (RR = 4.20; 95% CI 1.01 to 17.43). One RCT compared immediate with immediately delayed implants in 16 patients for 2 years and found no differences. Three RCTs evaluated different techniques of bone grafting for implants immediately placed in extraction sockets. No statistically significant difference was observed when evaluating whether autogenous bone is needed in postextractive sites (1 trial with 26 patients) or which was the most effective augmentation technique (2 trials with 56 patients). Authors' conclusions There is insufficient evidence to determine possible advantages or disadvantages of immediate, immediate‐delayed or delayed implants, therefore these preliminary conclusions are based on few underpowered trials often judged to be at high risk of bias. There is a suggestion that immediate and immediate‐delayed implants may be at higher risks of implant failures and complications than delayed implants on the other hand the aesthetic outcome might be better when placing implants just after teeth extraction. There is not enough reliable evidence supporting or refuting the need for augmentation procedures at immediate implants placed in fresh extraction sockets or whether any of the augmentation techniques is superior to the others. Plain language summary Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate‐delayed and delayed implants) Dental implants can be placed in sockets just after tooth extraction (immediate implants) or after a couple of weeks up to a couple of months (immediate‐delayed implants) or thereafter (delayed implants). This review looked at which was the best time to place dental implants and whether it would be advantageous to augment sites with gaps present at implant placement. It also tried to determine the most effective bone augmentation procedure. The seven identified studies included too few patients to answer the questions. Four studies evaluated which is the best time to place implants. One study evaluated whether bone grafting is advantageous at implant placement and two studies evaluated which are the best grafting techniques. There is currently too little evidence to draw any reliable conclusions, however, the aesthetic outcome could be slightly better when placing implants early after tooth extraction, though early placed implants might be at a higher risk of failure. There is not enough evidence supporting or refusing the need of bone augmentation when extracted teeth are immediately replaced with dental implants, nor it is known whether any augmentation procedure is better than the others. Bone substitutes (anorganic bovine bone) can be used instead of self generated (autogenous) bone graft.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Esposito, M, Grusovin, MG, Polyzos, IP, Felice, P, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD005968.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.112Z" }, { "id": "e63f1187-b9ca-47b8-a4d0-83024753ad04", "pmid": "", "title": "Enteral nutritional therapy for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta‐analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review. Objectives To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts. Selection criteria Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review. Data collection and analysis Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random‐effects model was used to pool data. We performed intention‐to‐treat and per‐protocol analyses for the primary outcome. Heterogeneity was explored using the Chi 2 and I 2 statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes. Main results Twenty‐seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non‐elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non‐elemental diets differing in glutamine enrichment. Meta‐analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty‐four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non‐elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per‐protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non‐elemental diets (elemental, semi‐elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non‐elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating. Ten trials compared EN to steroid therapy. Meta‐analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per‐protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per‐protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet. Authors' conclusions Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy Plain language summary Enteral nutritional therapy for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a long‐term inflammation of the gastrointestinal (GI) tract, occurring anywhere from mouth to anus. Common symptoms of this condition include abdominal pain, diarrhea and weight loss. When Crohn's disease patients are experiencing symptoms, it is characterized to be 'active' disease. When the symptoms stop, it is called 'remission'. What is enteral nutrition? Enteral nutrition is a feeding method where all of a person's daily caloric intake is delivered using the GI tract. An example of this is nasogastric tube feeding, where a tube is inserted through a person's nose to deliver their daily nutritional requirements in liquid form. Enteral nutrition can be a form of nutritional therapy for Crohn's disease patients. Enteral nutrition is categorized into elemental and non‐elemental (semi‐elemental and polymeric) diets. Elemental diets come from amino‐acid sources, whereas non‐elemental diets come from oligopeptide or whole protein sources. What are corticosteroids? Corticosteroids are an effective treatment option for active Crohn's disease. These drugs that are taken by mouth and work as immunosuppressants. What did the researchers investigate? The researchers studied whether enteral nutrition is better than steroid therapy at producing remission in Crohn's disease patients. In addition, the investigators looked to see if one type of enteral nutrition was better than another (e.g. elemental vs.non‐elemental) at producing remission in Crohn's disease. What did the researchers find? The researchers found twenty‐seven studies (1,011 participants) that fulfilled the search criteria. Eleven of these studies, which included 378 patients, compared elemental to non‐elemental diets at producing remission in Crohn's disease. Eight studies, which included 352 patients, investigated enteral nutrition compared to steroid therapy at inducing remission in Crohn's disease. The researchers searched the medical literature extensively up to July 5, 2017. Very low quality evidence suggests that steroids may be more effective than enteral nutrition for induction of remission in adults with active Crohn's disease. Very low quality evidence also suggests that enteral nutrition may be more effective than steroids for induction of remission in children with active Crohn's disease. There was no difference in remission rates between elemental and non‐elemental diets. An increase in side effects was not seen with elemental diets compared to non‐elemental diets, nor with enteral nutrition compared to steroids. Common side effects experienced with enteral nutrition included vomiting, diarrhea, heartburn and flatulence . Common side effects associated with steroid use included acne, moon facies, muscle weakness, hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) . Patients on enteral nutrition were more likely to withdraw from the study due to side effects than those on steroids. The most common reason for study withdrawal was inability to tolerate the taste of the enteral nutrition diet. Enteral nutrition should be considered in pediatric Crohn's patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient compliance with this therapy.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Narula, N; Dhillon, A; Zhang, D; Sherlock, ME; Tondeur, M; Zachos, M", "articleTypes": [], "doi": "10.1002/14651858.CD000542.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "e653ee40-bf9c-4848-b4fe-1ceae913864d", "pmid": "", "title": "Interventions for the treatment of Frey's syndrome", "imported": false, "abstract": "Abstract - Background Frey's syndrome is a rare disorder, the symptoms of which include sweating, flushing and warming over the preauricular and temporal areas following a gustatory stimulus. It often occurs in patients who have undergone parotidectomy, submandibular gland surgery, radical neck dissection, infection and traumatic injury in the parotid region, and is caused by the aberrant regrowth of facial autonomic nerve fibres. Currently there are several options used to treat patients with Frey's syndrome; for example, the topical application of anticholinergics and antiperspirants, and the intradermal injection of botulinum toxin. It is uncertain which treatment is most effective and safe. Objectives To assess the efficacy and safety of different interventions for the treatment of Frey's syndrome. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; ICTRP and additional sources for published and unpublished trials. The date of the search was 28 April 2014. Selection criteria We included randomised or quasi‐randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome using a clinical standard such as Minor's starch‐iodine test. We planned to include trials in which participants received any intervention versus no treatment (observation) or an alternative intervention, with or without a second active treatment. Our primary outcome measures were success rate (as assessed clinically by Minor's starch‐iodine test, the iodine‐sublimated paper histogram method, blotting paper technique or another method) and adverse events. Our secondary outcome measure was success rate as assessed by patients (disappearance or improvement of symptoms). Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no RCTs or quasi‐RCTs that fulfilled the inclusion criteria. Our searches retrieved eight potentially relevant studies, but after assessment of the full‐text reports we excluded all of them due to the absence of randomisation or because the patients did not have Frey's syndrome. We excluded one randomised controlled trial that compared two different doses of botulinum toxin in patients with Frey's syndrome because the comparator was not an alternative treatment. Authors' conclusions We are unable to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome. RCTs are urgently needed to assess the effectiveness of interventions for the treatment of Frey's syndrome. Future RCTs should include patients with Frey's syndrome of different ranges of severity and report these patients separately. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective assessment of Frey's syndrome should be considered as one of the outcome measures. Plain language summary Interventions for the treatment of Frey's syndrome Background Frey's syndrome is a rare disorder, the symptoms of which include sweating and flushing of the facial skin when eating, smelling, thinking or even dreaming about food. It usually happens in patients who have undergone surgery to the parotid (salivary) gland. This problem may have an impact on quality of life (for example, restricting normal activity such as eating in public). Many methods are currently used to treat Frey's syndrome, including topical application of anticholinergics and antiperspirants, and intradermal (into the skin) injections of botulinum toxin. This systematic review aimed to assess the efficacy and safety of these different methods for the treatment of Frey's syndrome. Study characteristics We carried out a comprehensive search for randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome. We planned to include trials in which participants received any intervention compared to no treatment (observation) or an alternative intervention, with or without a second active treatment. Despite extensive searching, we were unable to identify any studies that met our inclusion criteria. Key results There is no high‐quality evidence to establish which type of treatment is most effective for the treatment of Frey's syndrome. High‐quality clinical trials in this area should be urgently conducted. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective (patient) assessment of Frey's syndrome should be one of the outcome measures used. Quality of the evidence This review is up to date to 28 April 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Li, C; Wu, F; Zhang, Q; Gao, Q; Shi, Z; Li, L", "articleTypes": [], "doi": "10.1002/14651858.CD009959.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "e675c4b2-b684-4e2e-baec-7bec74d4afd0", "pmid": "", "title": "Exercise-induced Erythropoiesis: the Mechanistic of Angiotensin II", "imported": false, "abstract": "The major aims are to determine the effect of acute (single dose) blockade of ANGII receptor 1 (AT1) on the EPO response to a single session of endurance exercise, as well as determine the effect of chronic (8-week) blockade of AT1 on ET-induced adaptations in total circulating red blood volume and hemoglobin.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "e6891b41-bdee-41c1-a380-d8e6d295a578", "pmid": "", "title": "Interventions to improve adherence to antiretroviral therapy in children with HIV infection", "imported": false, "abstract": "Abstract - Background Achieving and maintaining high levels of medication adherence are required to achieve the full benefits of antiretroviral therapy (ART), yet suboptimal adherence among children is common in both developed and developing countries. Objectives To conduct a systematic review of the literature of evaluations of interventions for improving paediatric ART adherence. Search methods We created a comprehensive search strategy in order to identify all studies relevant to this topic. In July 2010, we searched the following electronic databases: EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, LILACS, Web of Science, Web of Social Science, NLM Gateway (supplemented by a manual search of the most recent abstracts not included in the Gateway database). We searched abstracts from the International AIDS Conference from 2002 to 2010, the International AIDS Society Conference on Pathogenesis, Treatment and Prevention from 2003 to 2009, and from the Conference on Retroviruses and Opportunistic Infections from 1997 to 2010. We used search strategies determined by the Cochrane Review Group on HIV/AIDS. We also contacted researchers who work in this field and checked reference lists of related systematic reviews and of all included studies. Selection criteria Randomised and non‐randomised controlled trials of interventions to improve adherence to ART among children and adolescents (age ≤18 years) were included. Studies had to report adherence to ART as an outcome. Data collection and analysis After one author performed an initial screening to exclude citations that did not meet the inclusion criteria, two authors did a second screening of those citations that likely met the criteria. For all articles that passed the second screening, full articles were pulled in order to make a final determination. Two authors then extracted data and graded methodological quality independently. Differences were resolved through discussion. Main results Four studies met the inclusion criteria. No single intervention was evaluated by more than one trial. Two studies were conducted in low‐income countries. Two studies were randomised controlled trials (RCT), and two were non‐randomised trials. An RCT of a home‐based nursing programme showed a positive effect of the intervention on knowledge and medication refills (p=.002), but no effect on CD4 count and viral load. A second RCT of caregiver medication diaries showed that the intervention group had fewer participants reporting no missed doses compared to the control group (85% vs. 92%, respectively), although this difference was not statistically significant (p=.08). The intervention had no effect on CD4 percentage or viral load. A non‐randomised trial of peer support group therapy for adolescents demonstrated no change in self‐reported adherence, yet the percentage of participants with suppressed viral load increased from 30% to 80% (p=.06). The second non‐randomised trial found that the percentage of children achieving >80% adherence was no different between children on a lopinavir‐ritonavir (LPV/r) regimen compared to children on a non‐nucleoside reverse transcriptase regimen (p=.781). However, the proportion of children achieving virological suppression was significantly greater for children on the LPV/r regimen than for children on the NNRTI‐containing regimen (p=.002). Authors' conclusions A home‐based nursing intervention has the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence or disease outcomes. Two interventions, an LPV/r‐containing regimen and peer support therapy for adolescents, did not demonstrate improvements in adherence, yet demonstrated greater viral load suppression compared to control groups, suggesting a different mechanism for improved health outcomes. Well‐designed evaluations of interventions to improve paediatric adherence to ART are needed. Plain language summary Interventions to improve adherence to ART in children and adolescents Achieving and maintaining high levels of medication adherence are required to realise the full benefits of antiretroviral therapy (ART). We identified four studies that evaluated interventions designed to improve adherence to ART among children and adolescents age 18 years and younger. These studies showed that home‐based nursing, peer support for adolescents and LPV/r‐containing regimens have the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence. There is a need for well‐designed evaluations of interventions to improve paediatric adherence to ART.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Bain‐Brickley, D, Butler, LM, Kennedy, GE, Rutherford, GW", "articleTypes": [], "doi": "10.1002/14651858.CD009513", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.075Z" }, { "id": "e6945338-9b4e-4484-bacf-cb225f4d0328", "pmid": "", "title": "Omega‐3 fatty acids for bipolar disorder", "imported": false, "abstract": "Abstract - Background Bipolar disorder is a complex psychiatric disorder and is amongst the top thirty causes of worldwide disability. Mood stabilisers are the primary pharmacological intervention, both in the treatment of acute episodes and in prophylaxis. There is, however, mounting evidence that dietary supplementation with omega‐3 fatty acids may be beneficial in psychiatric conditions, particularly those involving disturbances of mood. Objectives To review the efficacy of omega‐3 fatty acids as either a monotherapy or an adjunctive treatment for bipolar disorder. Search methods Electronic searches of the following databases were performed: CCDANCTR‐Studies and CCDANCTR‐References were searched on 12/2/2008, Supplementary searches were carried out on Biological Abstracts, CINAHL, The Cochrane Library, CCDAN Register, EMBASE, MEDLINE, and PsycINFO. The search strategy also included cited reference searching, personal contact with all authors of studies initially included and contact with the omega‐3 producing pharmaceutical companies. Selection criteria All relevant randomised controlled trials were included in the review. Studies involving males and females of all ages with a diagnosis of bipolar disorder qualified for inclusion. Studies using any type or dose of omega‐3 fatty acid treatment as monotherapy or in addition to standard pharmacotherapy were eligible. The primary outcome was symptom severity; and secondary outcomes were adverse effects, dropout and satisfaction with treatment. Data collection and analysis Two review authors independently inspected the citations identified from the search. Potentially relevant abstracts were identified and full papers ordered and reassessed for inclusion and methodological quality. All relevant data were extracted. The weighted mean difference (WMD) was used for continuous outcome data, with 95% confidence intervals (CI). Main results Five studies met inclusion criteria for the review, however, methodological quality was highly variable. Only one study, involving 75 participants, provided data for analysis, and showed a benefit of active treatment over control for depression symptom levels (WMD ‐3.93, 95% CI ‐7.00 to ‐0.86)and Clinical Global Impression scores (WMD ‐0.75, 95% CI ‐1.33 to ‐0.17) but not for mania (WMD ‐2.81, 95% CI ‐7.68 to 1.90). No serious adverse effects were reported in the five studies. The pattern of dropout was highly variable between studies. Authors' conclusions Results from one study showed positive effects of omega‐3 as an adjunctive treatment for depressive but not manic symptoms in bipolar disorder. These findings must be regarded with caution owing to the limited data available. There is an acute need for well‐designed and executed randomised controlled trials in this field. Plain language summary Omega‐3 fatty acids for bipolar disorder This systematic review investigated the efficacy of omega‐3 fatty acids for bipolar disorder. Five randomised controlled trials met inclusion criteria for the review. Only one trial provided data that could be analysed, investigating ethyl‐EPA as an adjunctive treatment in a mixed outpatient population. Some positive benefits were found for depressive symptoms but not for mania, and no adverse events were reported. There is currently insufficient evidence on which to base any clear recommendations concerning omega‐3 fatty acids for bipolar disorder. However, given the general health benefits and safety of omega‐3, the preliminary evidence from this review provides a strong case for well‐powered, high‐quality trials in specific index populations.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Montgomery, P, Richardson, AJ", "articleTypes": [], "doi": "10.1002/14651858.CD005169.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.745Z" }, { "id": "e6a3fc22-6cc0-4180-8f23-97b12257bd0f", "pmid": "", "title": "Antibiotic strategies for eradicating Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Respiratory tract infections with Pseudomonas aeruginosa occur in most people with cystic fibrosis (CF). Established chronic P aeruginosa infection is virtually impossible to eradicate and is associated with increased mortality and morbidity. Early infection may be easier to eradicate. This is an updated review. Objectives Does giving antibiotics for P aeruginosa infection in people with CF at the time of new isolation improve clinical outcomes (e.g. mortality, quality of life and morbidity), eradicate P aeruginosa infection, and delay the onset of chronic infection, but without adverse effects, compared to usual treatment or an alternative antibiotic regimen? We also assessed cost‐effectiveness. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings. Latest search: 24 March 2022. We searched ongoing trials registries. Latest search: 6 April 2022. Selection criteria We included randomised controlled trials (RCTs) of people with CF, in whom P aeruginosa had recently been isolated from respiratory secretions. We compared combinations of inhaled, oral or intravenous (IV) antibiotics with placebo, usual treatment or other antibiotic combinations. We excluded non‐randomised trials and cross‐over trials. Data collection and analysis Two authors independently selected trials, assessed risk of bias and extracted data. We assessed the certainty of the evidence using GRADE. Main results We included 11 trials (1449 participants) lasting between 28 days and 27 months; some had few participants and most had relatively short follow‐up periods. Antibiotics in this review are: oral – ciprofloxacin and azithromycin; inhaled – tobramycin nebuliser solution for inhalation (TNS), aztreonam lysine (AZLI) and colistin; IV – ceftazidime and tobramycin. There was generally a low risk of bias from missing data. In most trials it was difficult to blind participants and clinicians to treatment. Two trials were supported by the manufacturers of the antibiotic used. TNS versus placebo TNS may improve eradication; fewer participants were still positive for P aeruginosa at one month (odds ratio (OR) 0.06, 95% confidence interval (CI) 0.02 to 0.18; 3 trials, 89 participants; low‐certainty evidence) and two months (OR 0.15, 95% CI 0.03 to 0.65; 2 trials, 38 participants). We are uncertain whether the odds of a positive culture decrease at 12 months (OR 0.02, 95% CI 0.00 to 0.67; 1 trial, 12 participants). TNS (28 days) versus TNS (56 days) One trial (88 participants) comparing 28 days to 56 days TNS treatment found duration of treatment may make little or no difference in time to next isolation (hazard ratio (HR) 0.81, 95% CI 0.37 to 1.76; low‐certainty evidence). Cycled TNS versus culture‐based TNS One trial (304 children, one to 12 years old) compared cycled TNS to culture‐based therapy and also ciprofloxacin to placebo. We found moderate‐certainty evidence of an effect favouring cycled TNS therapy (OR 0.51, 95% CI 0.31 to 0.82), although the trial publication reported age‐adjusted OR and no difference between groups. Ciprofloxacin versus placebo added to cycled and culture‐based TNS therapy One trial (296 participants) examined the effect of adding ciprofloxacin versus placebo to cycled and culture‐based TNS therapy. There is probably no difference between ciprofloxacin and placebo in eradicating P aeruginosa (OR 0.89, 95% CI 0.55 to 1.44; moderate‐certainty evidence). Ciprofloxacin and colistin versus TNS We are uncertain whether there is any difference between groups in eradication of P aeruginosa at up to six months (OR 0.43, 95% CI 0.15 to 1.23; 1 trial, 58 participants) or up to 24 months (OR 0.76, 95% CI 0.24 to 2.42; 1 trial, 47 participants); there was a low rate of short‐term eradication in both groups. Ciprofloxacin plus colistin versus ciprofloxacin plus TNS One trial (223 participants) found there may be no difference in positive respiratory cultures at 16 months between ciprofloxacin with colistin versus TNS with ciprofloxacin (OR 1.28, 95% CI 0.72 to 2.29; low‐certainty evidence). TNS plus azithromycin compared to TNS plus oral placebo Adding azithromycin may make no difference to the number of participants eradicating P aeruginosa after a three‐month treatment phase (risk ratio (RR) 1.01, 95% CI 0.75 to 1.35; 1 trial, 91 participants; low‐certainty evidence); there was also no evidence of any difference in the time to recurrence. Ciprofloxacin and colistin versus no treatment A single trial only reported one of our planned outcomes; there were no adverse effects in either group. AZLI for 14 days plus placebo for 14 days compared to AZLI for 28 days We are uncertain whether giving 14 or 28 days of AZLI makes any difference to the proportion of participants having a negative respiratory culture at 28 days (mean difference (MD) ‐7.50, 95% CI ‐24.80 to 9.80; 1 trial, 139 participants; very low‐certainty evidence). Ceftazidime with IV tobramycin compared with ciprofloxacin (both regimens in conjunction with three months colistin) IV ceftazidime with tobramycin compared with ciprofloxacin may make little or no difference to eradication of P aeruginosa at three months, sustained to 15 months, provided that inhaled antibiotics are also used (RR 0.84, 95 % CI 0.65 to 1.09; P = 0.18; 1 trial, 255 participants; high‐certainty evidence). The results do not support using IV antibiotics over oral therapy to eradicate P aeruginosa , based on both eradication rate and financial cost. Authors' conclusions We found that nebulised antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with P aeruginosa . Eradication may be sustained in the short term. There is insufficient evidence to determine whether these antibiotic strategies decrease mortality or morbidity, improve quality of life, or are associated with adverse effects compared to placebo or standard treatment. Four trials comparing two active treatments have failed to show differences in rates of eradication of P aeruginosa . One large trial showed that intravenous ceftazidime with tobramycin is not superior to oral ciprofloxacin when inhaled antibiotics are also used. There is still insufficient evidence to state which antibiotic strategy should be used for the eradication of early P aeruginosa infection in CF, but there is now evidence that intravenous therapy is not superior to oral antibiotics. Plain language summary Different ways of giving antibiotics to clear Pseudomonas aeruginosa infection in people with cystic fibrosis Key messages ‐ Cystic fibrosis (CF) is an inherited condition where the airways often become blocked with mucus, and people with CF are more likely to get chest infections which cause more damage to the lungs. ‐ Pseudomonas aeruginosa ( P aeruginosa ) is often the cause of infection and is difficult to get rid of; antibiotics are the main treatment, but there are many different antibiotics, and they can be given in different ways. ‐ Inhaled antibiotics may be better than no treatment allowing most people to remain free of P aeruginosa after one month. ‐ There seems to be little difference in the other treatments we compared regarding how well they clear P aeruginosa from the lungs. What is cystic fibrosis? CF is the most common inherited condition that is life‐limiting. Sticky mucus builds up in the lungs of people with CF, which makes it difficult to breathe and can lead to chest infections. These chest infections can cause further lung damage and lead to breathing failure and death. A germ called P aeruginosa is often the cause of infection and is difficult to treat successfully, once it has persisted for longer than six months. What did we want to find out? We wanted to compare different combinations of inhaled, oral and intravenous (IV) antibiotics for clearing P aeruginosa in people with CF, to see if any single treatment works best and is more cost‐effective. What did we find? The review includes 11 studies with a total of 1449 people with CF, of any age or sex, who had mild to severe lung disease. The studies lasted from 28 days to 27 months. We could not combine many results as studies used different treatments. There were 10 different comparisons of antibiotic treatments: three studies compared inhaled antibiotics with a placebo (dummy treatment); two studies compared inhaled antibiotics for different lengths of time; two studies compared inhaled tobramycin with or without oral antibiotics depending on how the infection was detected; two studies compared inhaled antibiotics plus an oral antibiotic with inhaled antibiotics plus a placebo; one study compared two different inhaled antibiotics plus an oral antibiotic; and one study compared IV antibiotics with oral antibiotics. Most of the studies showed how well the treatments got rid of P aeruginosa as well as how they affected lung function, other germs, worsening of flare‐ups, and side effects. Main results Three small studies (of 89 people) treating early infection showed that after one month, inhaled antibiotics were better than no treatment and cleared P aeruginosa in most people, but our confidence in the evidence is low. There is likely to be little difference in the other treatments regarding how well they clear P aeruginosa from the lungs, although we found that inhaled antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with Pseudomonas aeruginosa. A study of IV ceftazidime with tobramycin in comparison with oral ciprofloxacin also showed neither group was better at getting rid of P aeruginosa, but we are more certain of the results and this means that it may be just as effective to treat with oral antibiotics. What are the limitations of the evidence? Some studies were carried out up to 30 years ago and the results may not apply today, and some studies were small. Most studies were quite short, so we could not show whether treatment made people with CF feel better or live longer. Given the treatments used in most of the studies, it would have been easy for people to guess which treatment they were receiving, which might have influenced some of the results. Two studies were supported by the pharmaceutical industry. Further research is needed to see whether clearing the infection completely improves the well‐being and quality of life in people with CF and to establish which antibiotic combination is best at clearing P aeruginosa . Overall our confidence in the evidence was moderate to very low, so further research is likely to change our confidence in the results. However, we have higher confidence in one recently published study, which means we can be more sure of the results. How up to date is this evidence? The studies we have reported on are the most up‐to‐date we could find. We last searched the literature in April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Langton Hewer, SC, Smith, S, Rowbotham, NJ, Yule, A, Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD004197.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.129Z" }, { "id": "e6a974b4-7a7c-4504-9921-0eef7bfab0a0", "pmid": "", "title": "Smell, Taste, Salivary Flow, and Oral Health in Patient Receiving Dialysis: A Before and After Study", "imported": false, "abstract": "Studies show that the change of smell and taste, also dry mouth are the most common symptoms in end stage renal disease patients, the accumulation of uremic toxins would damage the intrinsinc antioxidant systems of the olfactory epithelium and olfactory bulb, which leads to smell dysfunction compared to healthy group. Previous studies show different results about if getting rid of uremic toxins would help improve smell, even if they say olfactory identification is improved after hemodialysis episode, but there's no short term reliability of Sniffin'sticks to prove the credibility of the findings. Reduction of the whole saliva and unstimulated salivary flow rate cause dry mouth, also change oral environment, which makes dental plaque easily attach to teeth. And the accumulation of uremic in oral cavity causes oral odor, plus lack of zinc iron and reduction of saliva would affect the tastants transferred to its receptors which leads to taste dysfunction. Besides, when the patients has olfactory dysfunction, the taste will be affected as well, plus the accumulation of uremic toxin in the oral cavity also stops the conjunction of smell and taste receptors which affects taste. To understand smell, taste and oral condition in end stage renal disease patients, and due to there's no short term reliability of Sniffin'sticks, plus it's expensive and time-consuming to implement the taste assessment tool. Thus the main purpose of this study is: 1. To investigate smell and taste function, salivary secretion, oral condition, plaque index and dry mouth in end stage renal disease patients who haven't been under hemodialysis. 2. To investigate the short term reliability of Sniffin'sticks, the measuring tool of olfactory with 3-4 hours interval. 3. To investigate if Taste and Smell Survey could be the tool which detects abnormality of taste 4. To investigate the change of smell, taste and salivary secretion within 24 hours after the first episode of hemodialysis.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.146Z" }, { "id": "e6b12f29-2759-4e9b-8c4f-d92985eca4aa", "pmid": "", "title": "Antitumour antibiotic containing regimens for metastatic breast cancer", "imported": false, "abstract": "Abstract - Background Antitumour antibiotics are used in the management of metastatic breast cancer. Some of these agents have demonstrated higher tumour response rates than non‐antitumour antibiotic regimens, however a survival benefit has not been established in this setting. Objectives To review the randomised evidence comparing antitumour antibiotic containing chemotherapy regimens with regimens not containing an antitumour antibiotic in the management of women with metastatic breast cancer. Search methods The Specialised Register maintained by the Cochrane Breast Cancer Group was searched on 3rd October, 2006 using the codes for 'advanced breast cancer' and 'chemotherapy'. Details of the search strategy and coding applied by the Group to create the register are described in the Group's module on The Cochrane Library. Selection criteria Randomised trials comparing antitumour antibiotic containing regimens with regimens not containing antitumour antibiotics in women with metastatic breast cancer. Data collection and analysis Data were collected from published trials. Studies were assessed for eligibility and quality, and data were extracted by two independent reviewers. Hazard Ratios (HRs) were derived from time‐to‐event outcomes where possible, and a fixed effect model was used for meta‐analysis. Response rates were analysed as dichotomous variables. Quality of life and toxicity data were extracted where present. A primary analysis was conducted for all trials and by class of antitumour antibiotic. Main results Thirty‐four trials reporting on 46 treatment comparisons were identified. All trials published results for tumour response and 27 trials published time‐to‐event data for overall survival. The observed 4244 deaths in 5605 randomised women did not demonstrate a statistically significant difference in survival between regimens that contained antitumour antibiotics and those that did not (HR 0.96, 95% CI 0.90 to 1.02, P = 0.22) and no significant heterogeneity. Antitumour antibiotic regimens were favourably associated with time‐to‐progression (HR 0.84, 95% CI 0.77 to 0.91) and tumour response rates (odds ratio (OR) 1.33, 95% CI 1.21 to 1.48) although statistically significant heterogeneity was observed for these outcomes. These associations were consistent when the analysis was restricted to the 30 trials that reported on anthracyclines. Patients receiving anthracycline containing regimens were also more likely to experience toxic events compared to patients receiving non‐antitumour antibiotic regimens. No statistically significant difference was observed in any outcome between mitoxantrone containing and non‐antitumour antibiotic‐containing regimens. Authors' conclusions Compared to regimens without antitumour antibiotics, regimens that contained these agents showed a statistically significant advantage for tumour response and time to progression in women with metastatic breast cancer but were not associated with an improvement in overall survival. The favourable effect on tumour response and time to progression observed in anthracycline containing regimens was also associated with greater toxicity. Plain language summary Antitumour antibiotic containing regimens for metastatic breast cancer Advanced (metastatic) breast cancer is cancer that has spread beyond the breast. Treatment for metastatic disease usually involves some type of chemotherapy (anti‐cancer drugs) to try to reduce the cancer. Chemotherapy drugs can either be given as a single agent or in combination with other chemotherapy drugs. This is done according to a plan or a course of the drug referred to as a regimen. There are many types of chemotherapy drugs which work in various ways. Antitumour antibiotics work by damaging the cancer cells thereby preventing those cells from multiplying. Chemotherapy in general produces a range of side effects or adverse events related to the treatment. The known side effects of antitumour antibiotics include nausea, vomiting, a reduction in the number of white blood cells (known as leukopenia), and in some cases a toxic reaction which alters the working of the heart (called cardiotoxicity). This review sought to identify and review the randomised evidence comparing courses of chemotherapy containing antitumour antibiotics against courses not containing antitumour antibiotics. This review identified 34 eligible trials involving 5605 women. This review found that for women with advanced breast cancer, taking antitumour antibiotics did not result in better survival than women who took other types of chemotherapy drugs. Despite the lack of evidence of survival benefit, this review demonstrated that women taking these drugs had an advantage in time to progression (the length of time it takes for the cancer to progress after taking the drug) and tumour response (shrinking of the tumour) compared to women who did not take the antitumour antibiotic drugs. In addition however, the risks of side effects including cardiotoxicity, leukopenia and nausea/vomiting were all significantly increased in the women taking the antitumour antibiotics. Given that this review failed to show a benefit in survival for women taking this group of drugs but a higher rate of side effects, the use of these drugs in the management of metastatic breast cancer must be carefully weighed against the risk of these side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Lord, SJ, Ghersi, D, Gattellari, M, Wortley, S, Wilcken, N, Thornton, C, Simes, J", "articleTypes": [], "doi": "10.1002/14651858.CD003367.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.774Z" }, { "id": "e6c1a1b5-68ee-479b-b1c2-758d16abbf2a", "pmid": "", "title": "Cranberries for preventing urinary tract infections", "imported": false, "abstract": "Abstract - Background Cranberries contain proanthocyanidins (PACs), which inhibit the adherence of p‐fimbriated Escherichia coli to the urothelial cells lining the bladder. Cranberry products have been used widely for several decades to prevent urinary tract infections (UTIs). This is the fifth update of a review first published in 1998 and updated in 2003, 2004, 2008, and 2012. Objectives To assess the effectiveness of cranberry products in preventing UTIs in susceptible populations. Search methods We searched the Cochrane Kidney and Transplant Specialised Register up to 13 March 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria All randomised controlled trials (RCTs) or quasi‐RCTs of cranberry products compared with placebo, no specific treatment or other intervention (antibiotics, probiotics) for the prevention of UTIs were included. Data collection and analysis At least two authors independently assessed and extracted data. Information was collected on methods, participants, interventions and outcomes (incidence of symptomatic UTIs, positive culture results, side effects, adherence to therapy). Risk ratios (RR) with 95% confidence intervals (CI) were calculated where appropriate. Study quality was assessed using the Cochrane risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results For this update, 26 new studies were added, bringing the total number of included studies to 50 (8857 randomised participants). The risk of bias for sequence generation and allocation concealment was low for 29 and 28 studies, respectively. Thirty‐six studies were at low risk of performance bias, and 23 studies were at low risk of detection bias. Twenty‐seven, 41, and 17 studies were at low risk of attrition bias, reporting bias and other bias, respectively. Forty‐five studies compared cranberry products with placebo, water or no specific treatment in six different groups of participants. Twenty‐six of these 45 studies could be meta‐analysed for the outcome of symptomatic, culture‐verified UTIs. In moderate certainty evidence, cranberry products reduced the risk of UTIs (6211 participants: RR 0.70, 95% CI 0.58 to 0.84; I² = 69%). When studies were divided into groups according to the treatment indication, cranberry products probably reduced the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs (8 studies, 1555 participants: RR 0.74, 95% CI 0.55 to 0.99; I² = 54%), in children (5 studies, 504 participants: RR 0.46, 95% CI 0.32 to 0.68; I² = 21%) and in people with a susceptibility to UTIs due to an intervention (6 studies, 1434 participants: RR 0.47, 95% CI 0.37 to 0.61; I² = 0%). However, there may be little or no benefit in elderly institutionalised men and women (3 studies, 1489 participants: RR 0.93, 95% CI 0.67 to 1.30; I² = 9%; moderate certainty evidence), pregnant women (3 studies, 765 participants: RR 1.06, 95% CI 0.75 to 1.50; I² = 3%; moderate certainty evidence), or adults with neuromuscular bladder dysfunction with incomplete bladder emptying (3 studies, 464 participants: RR 0.97, 95% CI 0.78 to 1.19; I² = 0%; low certainty evidence). Other comparisons were cranberry products with probiotics (three studies) or antibiotics (six studies), cranberry tablets with cranberry liquid (one study), and different doses of PACs (two studies). Compared to antibiotics, cranberry products may make little or no difference to the risk of symptomatic, culture‐verified UTIs (2 studies, 385 participants: RR 1.03, 95% CI 0.80 to 1.33; I² = 0%) or the risk of clinical symptoms without culture (2 studies, 336 participants: RR 1.30, 95% CI 0.79 to 2.14; I² = 68%). Compared to probiotics, cranberry products may reduce the risk of symptomatic, culture‐verified UTIs (3 studies, 215 participants: RR 0.39, 95% CI 0.27 to 0.56; I = 0%). It is unclear whether efficacy differs between cranberry juice and tablets or between different doses of PACs, as the certainty of the evidence was very low. The number of participants with gastrointestinal side effects probably does not differ between those taking cranberry products and those receiving a placebo or no specific treatment (10 studies, 2166 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%; moderate certainty evidence). There was no clear relationship between compliance with therapy and the risk for repeat UTIs. No difference in the risk for UTIs could be demonstrated between low, moderate and high doses of PACs. Authors' conclusions This update adds a further 26 studies, taking the total number of studies to 50 with 8857 participants. These data support the use of cranberry products to reduce the risk of symptomatic, culture‐verified UTIs in women with recurrent UTIs, in children, and in people susceptible to UTIs following interventions. The evidence currently available does not support its use in the elderly, patients with bladder emptying problems, or pregnant women. Plain language summary Cranberries for preventing urinary tract infections What is the issue? Cranberries (as cranberry juice, tablets or capsules) have been used for many years to prevent urinary tract infections (UTIs). Cranberries contain proanthocyanidins (PACs), substances that can prevent bacteria from sticking to the walls of the bladder. This may help prevent infections and reduce the need for working people to take time for medical appointments. However, there is currently no established regimen for what PACs dose to use and no formal regulation by health authorities of cranberry products. In particular, the dose suggested may not be included on the package. What did we do? We analysed the results of randomised controlled trials (RCTs), which compared the occurrence of UTIs in people taking a cranberry product with those taking a placebo or no treatment. We also analysed the results of RCTs comparing a cranberry product with other treatments such as antibiotics or probiotics. What did we find? We found 50 RCTs involving 8857 people. Forty‐five RCTs compared cranberry with a placebo or no treatment. Taking cranberries as a juice, tablets or capsules reduced the number of UTIs in women with recurrent UTIs, in children with UTIs and in people susceptible to UTIs following an intervention such as bladder radiotherapy. However, UTIs did not appear to be reduced in elderly institutionalised men and women, in adults with neuromuscular bladder dysfunction and incomplete bladder emptying, or in pregnant women. Few people reported any side effects with the most common being tummy pain. We did not find enough information to determine if cranberry products are more or less effective compared with antibiotics or probiotics in preventing further UTIs. Conclusions Cranberry products may help to prevent UTIs which cause symptoms in women with frequent UTIs, in children with UTIs and in people who have undergone an intervention involving the bladder. However, further assessment is required in well‐designed and prospectively registered RCTs to clarify further who with UTIs would benefit from cranberry products.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Williams, G; Stothart, CI; Hahn, D; Stephens, JH; Craig, JC; Hodson, EM", "articleTypes": [], "doi": "10.1002/14651858.CD001321.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "e6c81513-d061-4c72-9062-00a55a005b92", "pmid": "", "title": "Treatments for iron‐deficiency anaemia in pregnancy", "imported": false, "abstract": "Abstract - Background Iron deficiency, the most common cause of anaemia in pregnancy worldwide, can be mild, moderate or severe. Severe anaemia can have very serious consequences for mothers and babies, but there is controversy about whether treating mild or moderate anaemia provides more benefit than harm. Objectives To assess the effects of different treatments for anaemia in pregnancy attributed to iron deficiency (defined as haemoglobin less than 11 g/dL or other equivalent parameters) on maternal and neonatal morbidity and mortality. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2011), CENTRAL (2011, Issue 5), PubMed (1966 to June 2011), the International Clinical Trials Registry Platform (ICTRP) (2 May 2011), Health Technology Assessment Program (HTA) (2 May 2011) and LATINREC (Colombia) (2 May 2011). Selection criteria Randomised controlled trials comparing treatments for anaemia in pregnancy attributed to iron deficiency. Data collection and analysis We identified 23 trials, involving 3.198 women. We assessed their risk of bias. Three further studies identified are awaiting classification. Main results Many of the trials were from low‐income countries; they were generally small and frequently methodologically poor. They covered a very wide range of differing drugs, doses and routes of administration, making it difficult to pool data. Oral iron in pregnancy showed a reduction in the incidence of anaemia (risk ratio 0.38, 95% confidence interval 0.26 to 0.55, one trial, 125 women) and better haematological indices than placebo (two trials). It was not possible to assess the effects of treatment by severity of anaemia. A trend was found between dose and reported adverse effects. Most trials reported no clinically relevant outcomes nor adverse effects. Although the intramuscular and intravenous routes produced better haematological indices in women than the oral route, no clinical outcomes were assessed and there were insufficient data on adverse effects, for example, on venous thrombosis and severe allergic reactions. Daily low‐dose iron supplements may be effective at treating anaemia in pregnancy with less gastrointestinal side effects compared with higher doses. Authors' conclusions Despite the high incidence and burden of disease associated with this condition, there is a paucity of good quality trials assessing clinical maternal and neonatal effects of iron administration in women with anaemia. Daily oral iron treatment improves haematological indices but causes frequent gastrointestinal adverse effects. Parenteral (intramuscular and intravenous) iron enhances haematological response, compared with oral iron, but there are concerns about possible important adverse effects (for intravenous treatment venous thrombosis and allergic reactions and for intramuscular treatment important pain, discolouration and allergic reactions). Large, good quality trials, assessing clinical outcomes (including adverse effects) as well as the effects of treatment by severity of anaemia are required. Plain language summary Treatments for anaemia in pregnancy thought to be due to iron deficiency When the blood has insufficient red cells, or the red cells carry insufficient haemoglobin to deliver adequate oxygen to the tissues, this is called anaemia. There is normally a reduction in the haemoglobin concentrations in the mother's blood during pregnancy, and this allows a better blood flow around the womb (uterus) and to the baby. This is sometime called physiological anaemia and needs no treatment. True anaemia, however, can be mild, moderate or severe and can cause weakness, tiredness and dizziness. Severe anaemia makes women at risk of cardiac failure and is very common in low‐income countries Anaemia has many causes including a shortage or iron, folic acid or vitamin B 12 . These are all required for making red cells and are available in a good diet. Iron shortage, however, is the most common cause of anaemia during pregnancy. Iron treatment can be given by mouth (oral), by injection into the muscle (intramuscular) or injection into the vein (intravenous). Blood transfusion or giving something which stimulates the body to produce more red cells (erythropoietin) are also possible treatments. In this review, we identified 23 trials involving 3198 pregnant women. Many of the trials were in low‐income countries and many treatment variations were studied. Oral iron reduced the incidence of anaemia but is known to sometimes cause constipation and nausea. Although the intramuscular and intravenous routes produced better levels of red cells and iron stores than the oral route, no clinical outcomes (such as pre‐eclampsia, preterm births, postpartum haemorrhage) were assessed and there were insufficient data on adverse effects. Intravenous treatment can cause venous thrombosis (blockages in the veins) and intramuscular treatment causes important pain and discolouration at the injection site. It was unclear if women and babies were healthier when women were given iron for mild or moderate anaemia during pregnancy. There were no studies on using blood transfusions. Overall, there was insufficient evidence to say when or how anaemia in pregnancy needs to or should be treated.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Reveiz, L; Gyte, GML; Cuervo, LG; Casasbuenas, A", "articleTypes": [], "doi": "10.1002/14651858.CD003094.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "e6cd1417-97ff-4748-9119-d1693e6855c6", "pmid": "", "title": "Identifying the Mechanisms of Gut-brain Axis to Sweet Sensing in Patients With Type 2 Diabetes Using Neuroimaging Techniques", "imported": false, "abstract": "Diabetes is a global challenge and the number of people affected by diabetes is expected to rise to 5.5 million by 2030, of which 90% are type 2 diabetes (T2D). Habitual high consumption of sugars is an important risk factor in the development, and progression, of type 2 diabetes (T2D). Several studies have now shown that individuals with T2D have reduced lingual sweet taste sensation and this in turns increases their sugar intake to achieve the same hedonic reward values compared to the healthy population. This subsequently will lead to development of diabetes or worsening of the blood sugar control.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.236Z" }, { "id": "e6d3925d-6a26-4d19-b873-850f63dfb621", "pmid": "", "title": "Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery", "imported": false, "abstract": "Abstract - Background Postoperative pain may lead to adverse effects on the body, which might result in an increase in morbidity. Its management therefore poses a unique challenge for the clinician. Major shoulder surgery is associated with severe postoperative pain, and different modalities are available to manage such pain, including opioid and non‐opioid analgesics, local anaesthetics infiltrated into and around the shoulder joint and regional anaesthesia. All of these techniques, alone or in combination, have been used to treat the postoperative pain of major shoulder surgery but with varying success. Objectives The objective of this review was to compare the analgesic efficacy of continuous interscalene brachial plexus block (ISBPB) with parenteral opioid analgesia for pain relief after major shoulder surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12), MEDLINE (1950 to December 2012), EMBASE (1980 to December 2012), Web of Science (1954 to December 2012), CINAHL (1982 to December 2012) and bibliographies of published studies. Selection criteria We included randomized controlled trials assessing the effectiveness of continuous ISBPB compared with different forms of parenteral opioid analgesia in relieving pain in adult participants undergoing elective major shoulder surgery. Data collection and analysis Two review authors independently assessed trial quality and extracted outcome data. Main results We included two randomized controlled trials (147 participants). A total of 17 participants were excluded from one trial because of complications related to continuous ISBPB (16) or parenteral opioid analgesia (one). Thus we have information on 130 participants (66 in the continuous ISBPB group and 64 in the parenteral opioid group). The studies were clinically heterogeneous. No meta‐analysis was undertaken. However, results of the two included studies showed better pain relief with continuous ISBPB following major shoulder surgery and a lower incidence of complications when interscalene block is performed under ultrasound guidance rather than without it. Authors' conclusions Because of the small number of studies (two) relevant to the subject and the high risk of bias of the selected studies, no reasonable conclusion can be drawn. Plain language summary Comparison of an upper limb nerve block using local anaesthetic with opioid analgesia for pain relief following major shoulder surgery Pain following surgical procedures can sometimes increase the incidence of complications in the body. It is important to manage this pain effectively. Major shoulder surgery can cause severe pain. Effectively treating this pain will help reduce complications and will promote early mobilization. A wide range of methods are used to treat pain after major shoulder surgery, including administration of opioid (derived from opium) and non‐opioid pain killers and administration of drugs that produce numbness and hence pain relief in and around the shoulder joint or around the nerves supplying the upper limb. We compared the usefulness of a continuous upper limb nerve block performed by injecting local anaesthetic into the neck close to where the nerves originate (interscalene brachial plexus block—ISBPB group) with the administration of opioid pain killers into a vein, into a muscle or under the skin (any route other than by mouth)—the parenteral opioid group. Evidence obtained is current to December 2012. We included two studies involving 147 participants. Seventeen participants were excluded (16 from the ISBPB group and one from the other), leaving 130 participants: 66 in the ISBPB group and 64 in the parenteral opioid group. The studies were of medium to low quality because of issues with study design, and one of the trials was sponsored by a drug company. The severity of pain was assessed by the patient using a numerical scale on which zero was considered as no pain and 10 or 100 as the worst imaginable pain for 72 hours in one study and 48 hours in the other. The severity of postoperative pain was significantly less for the ISBPB group at all time points in one study and at all but one time point in the other study. No concrete conclusions can be drawn because of the small number of studies, which were not of high quality. However, from the available evidence, it can be seen that in one of the trials, the requirement for additional painkiller (piritramide) was significantly higher in the parenteral opioid group, whereas the other trial did not mention this. The incidence of nausea and vomiting was significantly less in the ISBPB group when compared with the parenteral opioid group. Complications related to ISBPB were virtually eliminated when ultrasound was used to perform ISBPB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ullah, H; Samad, K; Khan, FA", "articleTypes": [], "doi": "10.1002/14651858.CD007080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "e6e10026-25f2-4ad9-bbe3-0ba6d20f4508", "pmid": "", "title": "Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under", "imported": false, "abstract": "Abstract - Background Although complementary feeding is a universal practice, the methods and manner in which it is practiced vary between cultures, individuals and socioeconomic classes. The period of complementary feeding is a critical time of transition in the life of an infant, and inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. Educational interventions are widely acknowledged as effective in promoting public health strategy, and those aimed at improving complementary feeding practices provide information about proper complementary feeding practices to caregivers of infants/children. It is therefore important to summarise evidence on the effectiveness of educational interventions to improve the complementary feeding practices of caregivers of infants. Objectives To assess the effectiveness of educational interventions for improving the complementary feeding (weaning) practices of primary caregivers of children of complementary feeding age, and related health and growth outcomes in infants. Search methods In November 2017, we searched CENTRAL, MEDLINE, Embase, 10 other databases and two trials registers. We also searched the reference lists of relevant studies and reviews to identify any additional studies. We did not limit the searches by date, language or publication status. Selection criteria Randomised controlled trials (RCTs), comparing educational interventions to no intervention, usual practice, or educational interventions provided in conjunction with another intervention, so long as the educational intervention was only available in the experimental group and the adjunctive intervention was available to the control group. Study participants included caregivers of infants aged 4 to 24 months undergoing complementary feeding. Pregnant women who were expected to give birth and commence complementary feeding during the period of the study were also included. Data collection and analysis Two review authors independently extracted data on participants, settings, interventions, methodology and outcomes using a specifically‐developed and piloted data extraction form. We calculated risk ratios (RR) and 95% confidence intervals (CIs) for dichotomous data, and mean differences (MD) and 95% CIs for continuous data. Where data permitted, we conducted a meta‐analysis using a random‐effects model. We assessed the included studies for risk of bias and also assessed the quality of evidence using the GRADE approach. Main results We included 23 studies (from 35 reports) with a total of 11,170 caregiver‐infant pairs who were randomly assigned to receive an educational intervention delivered to the caregiver or usual care. Nineteen of the included studies were community‐based studies while four were facility‐based studies. In addition, 13 of the included studies were cluster‐randomised while the others were individually randomised. Generally, the interventions were focused on the introduction of complementary feeding at the appropriate time, the types and amount of complementary foods to be fed to infants, and hygiene. Using the GRADE criteria, we assessed the quality of the evidence as moderate, mostly due to inadequate allocation concealment and insufficient blinding. Educational interventions led to improvements in complementary feeding practices for age at introduction of complementary foods (average RR 0.88, 95% CI 0.83 to 0.94; 4 studies, 1738 children; moderate‐quality evidence) and hygiene practices (average RR 1.38, 95% CI 1.23 to 1.55; 4 studies, 2029 participants; moderate‐quality evidence). For duration of exclusive breastfeeding, pooled results were compatible with both a reduction and an increase in the outcome (average RR 1.58, 95% CI 0.77 to 3.22; 3 studies, 1544 children; very low‐quality evidence). There was limited (low to very low‐quality) evidence of an effect for all growth outcomes. Quality of evidence There is moderate to very low‐quality evidence that educational interventions can improve complementary feeding practices but insufficient evidence to conclude that it impacts growth outcomes. Authors' conclusions Overall, we found evidence that education improves complementary feeding practices. Plain language summary Educational interventions for improving complementary feeding practices Background Complementary feeding is the period when an infant moves from taking only breast milk or breast‐milk substitutes (such as infant formula) to family food. It is a critical period in the life of an infant. Inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. This is because inappropriate complementary feeding practices, such as introduction of semi‐solid foods too early (before six months of age), poor hygiene or giving foods that do not contain adequate nutrients, are all major causes of illness. Such illnesses include malnutrition, diarrhoea, poor growth, infections and poor mental development of children. Education has been proposed as an effective means of improving complementary feeding practices. Review question Does education improve complementary feeding practices of caregivers of infants as well as the health and growth of the infants? Study characteristics We searched for randomised controlled trials (a type of experiment in which people are randomly allocated to one or more treatment groups) up until November 2017. The search identified 23 studies involving a total of 11,170 caregivers and their children. The ages of the children ranged from birth to 24 months. The caregivers received educational interventions alone while the control group received no intervention, usual care or any other non‐educational intervention. The educational methods included printed materials such as leaflets, counselling, teaching sessions, peer support, videos and practical demonstrations. Generally, the education messages were focused on the introduction of semi‐solid foods at the appropriate age, the types and amount of complementary foods to be fed to infants, and hygiene. Key results Education reduced the number of caregivers that introduced semi‐solid foods to their infants before six months of age by up to 12% (moderate‐quality evidence). Hygiene practices of caregivers who received education also showed some improvement compared to those that did not (moderate‐quality evidence). In studies conducted in the community, education increased the duration of exclusive breastfeeding, but not in studies conducted in health facilities. There was no convincing evidence of an effect of education on the growth of children (low to very low‐quality evidence). We could not combine the results from different studies for diarrhoea, knowledge of caregivers and adequacy of complementary food. However, from the individual reports of the study authors, education led to a reduction in diarrhoea and an improvement in the knowledge of caregivers. It also led to improvement in the quality and quantity of complementary foods fed to infants. Overall, we found evidence that education improves complementary feeding practices.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Arikpo, D, Edet, ES, Chibuzor, MT, Odey, F, Caldwell, DM", "articleTypes": [], "doi": "10.1002/14651858.CD011768.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.143Z" }, { "id": "e6f1ba7b-558d-4ff2-848d-6d31fb81a654", "pmid": "", "title": "Antihypertensive drug therapy for mild to moderate hypertension during pregnancy", "imported": false, "abstract": "Abstract - Background Antihypertensive drugs are often used in the belief that lowering blood pressure will prevent progression to more severe disease, and thereby improve pregnancy outcome. This Cochrane Review is an updated review, first published in 2001 and subsequently updated in 2007 and 2014. Objectives To assess the effects of antihypertensive drug treatments for women with mild to moderate hypertension during pregnancy. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (13 September 2017), and reference lists of retrieved studies. Selection criteria All randomised trials evaluating any antihypertensive drug treatment for mild to moderate hypertension during pregnancy, defined as systolic blood pressure 140 to 169 mmHg and/or diastolic blood pressure 90 to 109 mmHg. Comparisons were of one or more antihypertensive drug(s) with placebo, with no antihypertensive drug, or with another antihypertensive drug, and where treatment was planned to continue for at least seven days. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results For this update, we included 63 trials (data from 58 trials, 5909 women), with moderate to high risk of bias overall. We carried out GRADE assessments for the main 'antihypertensive drug versus placebo/no antihypertensive drug' comparison only. Evidence was graded from very low to moderate certainty, with downgrading mainly due to design limitations and imprecision.For many outcomes, trials contributing data evaluated different hypertensive drugs; while we did not downgrade for this indirectness, results should be interpreted with caution. Antihypertensive drug versus placebo/no antihypertensive drug (31 trials, 3485 women) Primary outcomes: moderate‐certainty evidence suggests that use of antihypertensive drug(s) probably halves the risk of developing severe hypertension (risk ratio (RR) 0.49; 95% confidence interval (CI) 0.40 to 0.60; 20 trials, 2558 women), but may have little or no effect on the risk of proteinuria/pre‐eclampsia (average risk ratio (aRR) 0.92; 95% CI 0.75 to 1.14; 23 trials, 2851 women; low‐certainty evidence). Moderate‐certainty evidence also shows that antihypertensive drug(s) probably have little or no effect in the risk of total reported fetal or neonatal death (including miscarriage) (aRR 0.72; 95% CI 0.50 to 1.04; 29 trials, 3365 women), small‐for‐gestational‐age babies (aRR 0.96; 95% CI 0.78 to 1.18; 21 trials, 2686 babies) or preterm birth less than 37 weeks (aRR 0.96; 95% CI 0.83 to 1.12; 15 trials, 2141 women). Secondary outcomes: we are uncertain of the effect of antihypertensive drug(s) on the risk of maternal death , severe pre‐eclampsia , or eclampsia, or impaired long‐term growth and development of the baby in infancy and childhood , because the certainty of this evidence is very low. There may be little or no effect on the risk of changed/stopped drugs due to maternal side‐effects, or admission to neonatal or intensive care nursery (low‐certainty evidence). There is probably little or no difference in the risk of elective delivery (moderate‐certainty evidence). Antihypertensive drug versus another antihypertensive drug (29 trials, 2774 women) Primary outcomes: beta blockers and calcium channel blockers together in the meta‐analysis appear to be more effective than methyldopa in avoiding an episode of severe hypertension (RR 0.70; 95% CI 0.56 to 0.88; 11 trials, 638 women). There was also an increase in this risk when other antihypertensive drugs were compared with calcium channel blockers (RR 1.86; 95% CI 1.09 to 3.15; 5 trials, 223 women), but no evidence of a difference when methyldopa and calcium channel blockers together were compared with beta blockers (RR1.18, 95% CI 0.95 to 1.48; 10 trials, 692 women). No evidence of a difference in the risk of proteinuria/pre‐eclampsia was found when alternative drugs were compared with methyldopa (aRR 0.78; 95% CI 0.58 to 1.06; 11 trials, 997 women), with calcium channel blockers (aRR: 1.24, 95% CI 0.70 to 2.19; 5 trials, 375 women), or with beta blockers (aRR 1.21, 95% CI 0.88 to 1.67; 12 trials, 1107 women). For the babies, we found no evidence of a difference in the risk of total reported fetal or neonatal death (including miscarriage) when comparing other antihypertensive drugs with methyldopa (aRR 0.77, 95% CI 0.52 to 1.14; 22 trials, 1791 babies), with calcium channel blockers (aRR 0.90, 95% CI 0.52 to 1.57; nine trials, 700 babies), or with beta blockers (aRR: 1.23, 95% CI 0.81 to 1.88; 19 trials, 1652 babies); nor in the risk for small‐for‐gestational age in the comparison with methyldopa (aRR 0.79, 95% CI 0.52 to 1.20; seven trials, 597 babies), with calcium channel blockers (aRR 1.05, 95% CI 0.64 to 1.73; four trials, 200 babies), or with beta blockers (average RR 1.13, 95% CI 0.80 to 1.60; 7 trials, 680 babies). No evidence of an overall difference among groups in the risk of preterm birth (less than 37 weeks) was found in the comparison with methyldopa (aRR: 0.91; 95% CI 0.68 to 1.22; 11 trials, 835 women), with calcium channel blockers (aRR 0.85, 95% CI 0.59 to 1.23; six trials, 330 women), or with beta blockers (aRR 1.22, 95% CI 0.90 to 1.66; 9 trials, 806 women). Secondary outcomes: There were no cases of maternal death and eclampsia. There is no evidence of a difference in the risk of severe pre‐eclampsia , changed/stopped drug due to maternal side‐effects , elective delivery, admission to neonatal or intensive care nursery when other antihypertensive drugs are compared with methyldopa, calcium channel blockers or beta blockers. Impaired long‐term growth and development in infancy and childhood was not reported for these comparisons. Authors' conclusions Antihypertensive drug therapy for mild to moderate hypertension during pregnancy reduces the risk of severe hypertension. The effect on other clinically important outcomes remains unclear. If antihypertensive drugs are used, beta blockers and calcium channel blockers appear to be more effective than the alternatives for preventing severe hypertension. High‐quality large sample‐sized randomised controlled trials are required in order to provide reliable estimates of the benefits and adverse effects of antihypertensive treatment for mild to moderate hypertension for both mother and baby, as well as costs to the health services, women and their families. Plain language summary Antihypertensive drug therapy for mild to moderate hypertension during pregnancy What is the issue? The aim of this review was to determine the benefits and adverse effects of blood pressure‐lowering drugs (antihypertensive drugs) for pregnant women with mild to moderate hypertension (high blood pressure). The other aim was to assess the benefits and adverse effects of these drugs for their babies. Why is this important? During pregnancy, up to one in 10 women have blood pressure readings that are above normal. For some women, their blood pressure remains slightly high (termed ‘mild to moderate high blood pressure’), with no apparent complications. Some of these women go on to develop very high blood pressure. Very high blood pressure can result in a medical emergency if it affects the woman’s organs (such as her liver, or brain in the form of a stroke). Also, it can seriously affect the growth and health of her baby. Drugs that lower blood pressure are used to treat mild to moderate high blood pressure, in the belief that this treatment will prevent the blood pressure from continuing to rise. Over the years, information from good quality research studies has been contradictory, so we cannot be sure if this drug treatment is worthwhile. What evidence did we find? This Cochrane Review is an update of a review that was first published in 2001 and updated in 2007 and 2014. We searched for randomised controlled trials in September 2017, and this review now includes data from 58 trials involving more than 5900 women. A total of 31 trials with 3485 women compared a number of different blood pressure‐lowering drugs to a placebo or no treatment. There were a further 29 trials involving 2774 women which compared one blood pressure‐lowering drug with another one. The evidence showed that treating pregnant women who had moderately raised blood pressure with blood pressure‐lowering drugs probably halved the number of the women developing severe high blood pressure (20 trials, 2558 women). However, blood pressure‐lowering drugs probably had little or no effect on the risk of the baby dying (29 trials, 3365 women), and there is insufficient data on maternal deaths to make a judgement on whether this risk is lowered (five trials, 525 women). The use of blood pressure‐lowering drugs may have little or no effect on the number of the women developing pre‐eclampsia (23 trials, 2851 women), or the number of women who had to change drugs because of side‐effects (16 trials, 1503 women). We found no difference in the number of babies born preterm, that is before 37 weeks (15 trials, 2141 women). There was also no difference in the number of babies born small for their gestational age (21 trials, 2686 babies). The quality of the evidence was mostly moderate (but for pre‐eclampsia it was low). This was due to a number of small studies, and problems with the way the studies were undertaken. The available evidence is still insufficient to demonstrate if there is any antihypertensive drug that is better than another. However, beta blockers and calcium channel blockers seem to be better than the alternative drugs for blood pressure control. What does this mean? More research is needed in order to confirm the true effect of antihypertensive drugs in mothers and in their babies, and to identify the drug which would be best.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abalos, E; Duley, L; Steyn, DW; Gialdini, C", "articleTypes": [], "doi": "10.1002/14651858.CD002252.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "e70cd015-bab1-4d51-a2fa-c50c109176b0", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies for treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). Objectives To assess the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for treating patients with COVID‐19, compared to an active comparator, placebo, or no intervention. To maintain the currency of the evidence, we will use a living systematic review approach. A secondary objective is to track newly developed SARS‐CoV‐2‐targeting mAbs from first tests in humans onwards. Search methods We searched MEDLINE, Embase, the Cochrane COVID‐19 Study Register, and three other databases on 17 June 2021. We also checked references, searched citations, and contacted study authors to identify additional studies. Between submission and publication, we conducted a shortened randomised controlled trial (RCT)‐only search on 30 July 2021. Selection criteria We included studies that evaluated SARS‐CoV‐2‐neutralising mAbs, alone or combined, compared to an active comparator, placebo, or no intervention, to treat people with COVID‐19. We excluded studies on prophylactic use of SARS‐CoV‐2‐neutralising mAbs. Data collection and analysis Two authors independently assessed search results, extracted data, and assessed risk of bias using the Cochrane risk of bias tool (RoB2). Prioritised outcomes were all‐cause mortality by days 30 and 60, clinical progression, quality of life, admission to hospital, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We identified six RCTs that provided results from 17,495 participants with planned completion dates between July 2021 and December 2031. Target sample sizes varied from 1020 to 10,000 participants. Average age was 42 to 53 years across four studies of non‐hospitalised participants, and 61 years in two studies of hospitalised participants. Non‐hospitalised individuals with COVID‐19 Four studies evaluated single agents bamlanivimab (N = 465), sotrovimab (N = 868), regdanvimab (N = 307), and combinations of bamlanivimab/etesevimab (N = 1035), and casirivimab/imdevimab (N = 799). We did not identify data for mortality at 60 days or quality of life. Our certainty of the evidence is low for all outcomes due to too few events (very serious imprecision). Bamlanivimab compared to placebo No deaths occurred in the study by day 29. There were nine people admitted to hospital by day 29 out of 156 in the placebo group compared with one out of 101 in the group treated with 0.7 g bamlanivimab (risk ratio (RR) 0.17, 95% confidence interval (CI) 0.02 to 1.33), 2 from 107 in the group treated with 2.8 g (RR 0.32, 95% CI 0.07 to 1.47) and 2 from 101 in the group treated with 7.0 g (RR 0.34, 95% CI 0.08 to 1.56). Treatment with 0.7 g, 2.8 g and 7.0 g bamlanivimab may have similar rates of AEs as placebo (RR 0.99, 95% CI 0.66 to 1.50; RR 0.90, 95% CI 0.59 to 1.38; RR 0.81, 95% CI 0.52 to 1.27). The effect on SAEs is uncertain. Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Bamlanivimab/etesevimab compared to placebo There were 10 deaths in the placebo group and none in bamlanivimab/etesevimab group by day 30 (RR 0.05, 95% CI 0.00 to 0.81). Bamlanivimab/etesevimab may decrease hospital admission by day 29 (RR 0.30, 95% CI 0.16 to 0.59), may result in a slight increase in any grade AEs (RR 1.15, 95% CI 0.83 to 1.59) and may increase SAEs (RR 1.40, 95% CI 0.45 to 4.37). Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Casirivimab/imdevimab compared to placebo Casirivimab/imdevimab may reduce hospital admissions or death (2.4 g: RR 0.43, 95% CI 0.08 to 2.19; 8.0 g: RR 0.21, 95% CI 0.02 to 1.79). We are uncertain of the effect on grades 3‐4 AEs (2.4 g: RR 0.76, 95% CI 0.17 to 3.37; 8.0 g: RR 0.50, 95% CI 0.09 to 2.73) and SAEs (2.4 g: RR 0.68, 95% CI 0.19 to 2.37; 8.0 g: RR 0.34, 95% CI 0.07 to 1.65). Mortality by day 30 and clinical progression/improvement of symptoms or development of severe symptoms were not reported. Sotrovimab compared to placebo We are uncertain whether sotrovimab has an effect on mortality (RR 0.33, 95% CI 0.01 to 8.18) and invasive mechanical ventilation (IMV) requirement or death (RR 0.14, 95% CI 0.01 to 2.76). Treatment with sotrovimab may reduce the number of participants with oxygen requirement (RR 0.11, 95 % CI 0.02 to 0.45), hospital admission or death by day 30 (RR 0.14, 95% CI 0.04 to 0.48), grades 3‐4 AEs (RR 0.26, 95% CI 0.12 to 0.60), SAEs (RR 0.27, 95% CI 0.12 to 0.63) and may have little or no effect on any grade AEs (RR 0.87, 95% CI 0.66 to 1.16). Regdanvimab compared to placebo Treatment with either dose (40 or 80 mg/kg) compared with placebo may decrease hospital admissions or death (RR 0.45, 95% CI 0.14 to 1.42; RR 0.56, 95% CI 0.19 to 1.60, 206 participants), but may increase grades 3‐4 AEs (RR 2.62, 95% CI 0.52 to 13.12; RR 2.00, 95% CI 0.37 to 10.70). 80 mg/kg may reduce any grade AEs (RR 0.79, 95% CI 0.52 to 1.22) but 40 mg/kg may have little to no effect (RR 0.96, 95% CI 0.64 to 1.43). There were too few events to allow meaningful judgment for the outcomes mortality by 30 days, IMV requirement, and SAEs. Hospitalised individuals with COVID‐19 Two studies evaluating bamlanivimab as a single agent (N = 314) and casirivimab/imdevimab as a combination therapy (N = 9785) were included. Bamlanivimab compared to placebo We are uncertain whether bamlanivimab has an effect on mortality by day 30 (RR 1.39, 95% CI 0.40 to 4.83) and SAEs by day 28 (RR 0.93, 95% CI 0.27 to 3.14). Bamlanivimab may have little to no effect on time to hospital discharge (HR 0.97, 95% CI 0.78 to 1.20) and mortality by day 90 (HR 1.09, 95% CI 0.49 to 2.43). The effect of bamlanivimab on the development of severe symptoms at day 5 (RR 1.17, 95% CI 0.75 to 1.85) is uncertain. Bamlanivimab may increase grades 3‐4 AEs at day 28 (RR 1.27, 95% CI 0.81 to 1.98). We assessed the evidence as low certainty for all outcomes due to serious imprecision, and very low certainty for severe symptoms because of additional concerns about indirectness. Casirivimab/imdevimab with usual care compared to usual care alone Treatment with casirivimab/imdevimab compared to usual care probably has little or no effect on mortality by day 30 (RR 0.94, 95% CI 0.87 to 1.02), IMV requirement or death (RR 0.96, 95% CI 0.90 to 1.04), nor alive at hospital discharge by day 30 (RR 1.01, 95% CI 0.98 to 1.04). We assessed the evidence as moderate certainty due to study limitations (lack of blinding). AEs and SAEs were not reported. Authors' conclusions The evidence for each comparison is based on single studies. None of these measured quality of life. Our certainty in the evidence for all non‐hospitalised individuals is low, and for hospitalised individuals is very low to moderate. We consider the current evidence insufficient to draw meaningful conclusions regarding treatment with SARS‐CoV‐2‐neutralising mAbs. Further studies and long‐term data from the existing studies are needed to confirm or refute these initial findings, and to understand how the emergence of SARS‐CoV‐2 variants may impact the effectiveness of SARS‐CoV‐2‐neutralising mAbs. Publication of the 36 ongoing studies may resolve uncertainties about the effectiveness and safety of SARS‐CoV‐2‐neutralising mAbs for the treatment of COVID‐19 and possible subgroup differences. Plain language summary Are laboratory‐made, COVID‐19‐specific monoclonal antibodies an effective treatment for COVID‐19? Key messages ‐ We do not know whether antibodies (the body’s natural defence against disease) made in a laboratory and all the same as one another (monoclonal) and designed to target COVID‐19, are an effective treatment for COVID‐19 because we assessed only six studies exploring different treatments in different types of patients. ‐ We identified 36 ongoing studies that will provide more evidence when completed. ‐ We will update this review regularly as more evidence becomes available. What are ‘monoclonal’ antibodies? Antibodies are made by the body as a defence against disease. However, they can also be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that are designed to target only one specific protein – in this case, a protein on the virus that causes COVID‐19 – are ‘monoclonal’. They attach to the COVID‐19 virus and stop it from entering and replicating in human cells, which helps to fight the infection. Monoclonal antibodies have been used successfully to treat other viruses. They are thought to cause fewer unwanted effects than convalescent plasma, which contains a variety of different antibodies. What did we want to find out? We wanted to know if COVID‐19 specific monoclonal antibodies are an effective treatment for COVID‐19. We looked at whether they: ‐ reduced the number of deaths from any cause; ‐ improved symptoms or made them worse; ‐ increased admissions to hospital; and ‐ caused any serious or other unwanted effects. What did we do? We searched for studies that investigated one or more monoclonal antibodies to treat people with confirmed COVID‐19 compared with placebo (sham treatment), another treatment or no treatment. Studies could take place anywhere globally and include participants of any age, gender or ethnicity, with mild, moderate or severe COVID‐19. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We found six active studies including a total of 17,495 people. Four studies investigated non‐hospitalised people with no symptoms or mild COVID‐19. Two studies investigated hospitalised people with moderate to severe COVID‐19. Studies took place across the world. Three studies were funded by pharmaceutical companies. The monoclonal antibodies they studied were bamlanivimab, etesevimab, casirivimab and imdevimab, sotrovimab, regdanvimab. We did not identify data for mortality at 60 days and quality of life. Non‐hospitalised people, with no symptoms or mild COVID‐19 (four studies) One study investigated different doses of bamlanivimab (465 people), compared to placebo. We don’t know whether bamlanivimab: ‐ increases or reduces the number of deaths because no participants died within 30 days of treatment; ‐ causes more or fewer serious unwanted effects because there were few events. Bamlanivimab may reduce the number of admissions to hospital within 30 days of treatment compared to placebo. ‐ May cause slightly fewer unwanted effects than placebo. ‐ We did not find data for improved symptoms or worsened symptoms. One study investigated a combination of bamlanivimab and etesevimab (1035 people), compared to placebo. ‐ Bamlanivimab and etesevimab may reduce the number of deaths and admissions to hospital. ‐ May cause slightly more unwanted effects. ‐ May cause more serious unwanted effects. For treatment with bamlanivimab alone or in combination with etesevimab we did not find data for improved symptoms or worsened symptoms. One study (phase 1/2 with 799 people) investigated different doses of casirivimab combined with imdevimab, compared to placebo. ‐ Casirivimab combined with imdevimab may reduce the number of hospital admissions or death. ‐ We don't know whether casirivimab and imdevimab causes more unwanted (grades 3 and 4) and serious unwanted effects than placebo because there were too few deaths to allow us to make a judgment. ‐ We did not find data for the number of people who died at day 30 and development of severe symptoms. ‐ We did not include results from phase 3 (5607 people) of this study, because of high risk of bias, as it was not clear which participants were included in the analysis. One study (583 people) investigated sotrovimab, compared to placebo. We don't know whether sotrovimab: ‐ increases or reduces the number of deaths and people requiring invasive mechanical ventilation or dying, because there were too few deaths to allow us to make a judgment. ‐ Sotrovimab may reduce the number of people requiring oxygen, unwanted (grades 3 to 4) and serious unwanted effects; ‐ may have little or no effect on unwanted effects (all grades). Another study (327 people) investigated different doses of regdanvimab (40 mg/kg and 80 mg/kg), compared to placebo. ‐ Regdanvimab at either dose may reduce the number of admissions to hospital or death. ‐ May increase unwanted events (grades 3 to 4). ‐ Regdanvimab at a dose of 80 mg/kg may reduce unwanted effects (all grades) and 40 mg/kg may have little to no effect. ‐ We don't know whether regdanvimab increases or decreases the number of deaths, requirement for invasive mechanical ventilation, and serious unwanted effects, because there were too few events to allow us to make a judgment. Hospitalised people with moderate to severe COVID‐19 (2 studies) One study (314 people) investigated bamlanivimab compared to placebo. ‐ We don’t know whether bamlanivimab increases or decreases the number of deaths due to any cause up to 30 or 90 days after treatment because there were too few deaths to allow us to make a judgment (6 deaths with bamlanivimab and 4 deaths with placebo in 314 people). ‐ Bamlanivimab may slightly increase the development of severe COVID‐19 symptoms five days after treatment and the number of people with unwanted effects. ‐ Bamlanivimab may have little to no effect on time until discharge from hospital. ‐ We don’t know whether bamlanivimab causes serious unwanted effects by day 30 because the study was small and reported few serious unwanted effects. Another study (9785 people) investigated casirivimab combined with imdevimab, compared to standard of care. ‐ Casirivimab combined with imdevimab has probably little to no effect on the number of deaths, requirement for invasive mechanical ventilation or death, and hospital discharge alive. ‐ We did not find data for unwanted and serious unwanted effects. What are the limitations of the evidence? Our confidence in the evidence is low because we found only six studies, and they did not report everything we were interested in, such as the number of deaths within 60 days and quality of life. We found 36 ongoing studies. When they are published, we will add their results to our review. These results are likely to change our conclusions and will also help us understand how new variants affect how well monoclonal antibodies work. How up to date is this evidence? The evidence is up to date to 17 June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Kreuzberger, N, Hirsch, C, Chai, KL, Tomlinson, E, Khosravi, Z, Popp, M, Neidhardt, M, Piechotta, V, Salomon, S, Valk, SJ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013825.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.785Z" }, { "id": "e7140059-52d8-4903-aee0-fd04df365bec", "pmid": "", "title": "Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, rhinorrhoea, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. The use of topical (intranasal) corticosteroids has been widely advocated for the treatment of chronic rhinosinusitis given the belief that inflammation is a major component of this condition. Objectives To assess the effects of intranasal corticosteroids in people with chronic rhinosinusitis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) with a follow‐up period of at least three months comparing intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) against placebo or no treatment in patients with chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity and the commonest adverse event ‐ epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation or other systemic adverse events. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included 18 RCTs with a total of 2738 participants. Fourteen studies had participants with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. Intranasal corticosteroids versus placebo or no intervention Only one study (20 adult participants without polyps) measured our primary outcome disease‐specific HRQL using the Rhinosinusitis Outcome Measures‐31 (RSOM‐31). They reported no significant difference (numerical data not available) ( very low quality evidence). Our second primary outcome, disease severity , was measured using the Chronic Sinusitis Survey in a second study (134 participants without polyps), which found no important difference (mean difference (MD) 2.84, 95% confidence interval (CI) ‐5.02 to 10.70; scale 0 to 100). Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group (RR 2.78, 95% CI 1.76 to 4.40; 109 participants). The quality of the evidence was low . Six studies provided data on at least two of the individual symptoms used in the EPOS 2012 criteria to define chronic rhinosinusitis (nasal blockage, rhinorrhoea, loss of sense of smell and facial pain/pressure). When all four symptoms in the EPOS criteria were available on a scale of 0 to 3 (higher = more severe symptoms), the average MD in change from baseline was ‐0.26 (95% CI ‐0.37 to ‐0.15; 243 participants; two studies; low quality evidence). Although there were more studies and participants when only nasal blockage and rhinorrhoea were considered (MD ‐0.31, 95% CI ‐0.38 to ‐0.24; 1702 participants; six studies), the MD was almost identical to when loss of sense of smell was also considered (1345 participants, four studies; moderate quality evidence). When considering the results for the individual symptoms, benefit was shown in the intranasal corticosteroids group. The effect size was larger for nasal blockage (MD ‐0.40, 95% CI ‐0.52 to ‐0.29; 1702 participants; six studies) than for rhinorrhoea (MD ‐0.25, 95% CI ‐0.33 to ‐0.17; 1702 participants; six studies) or loss of sense of smell (MD ‐0.19, 95% CI ‐0.28 to ‐0.11; 1345 participants; four studies). There was heterogeneity in the analysis for facial pain/pressure (MD ‐0.27, 95% CI ‐0.56 to 0.02; 243 participants; two studies). The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure. There was an increased risk of epistaxis with intranasal corticosteroids (risk ratio (RR) 2.74, 95% CI 1.88 to 4.00; 2508 participants; 13 studies; high quality evidence). Considering our secondary outcome, general HRQL, one study (134 participants without polyps) measured this using the SF‐36 and reported a statistically significant benefit only on the general health subscale. The quality of the evidence was very low . It is unclear whether there is a difference in the risk of local irritation (RR 0.94, 95% CI 0.53 to 1.64; 2124 participants; 11 studies) ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis or stunted growth (children). Other comparisons We identified no other studies that compared intranasal corticosteroids plus co‐intervention A versus placebo plus co‐intervention A. Authors' conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life ( very low quality evidence). For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of epistaxis is increased ( high quality evidence), but these data included all levels of severity; small streaks of blood may not be a major concern for patients. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) . Plain language summary Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of intranasal (in the nose) steroids given to people with chronic rhinosinusitis. Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose (rhinorrhoea), pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation in order to improve patient symptoms. Study characteristics We included 18 randomised controlled trials (RCTs) with a total of 2738 participants in this review. Most studies were relatively small, with as few as 9 or 10 patients per intervention arm. The largest study had 748 patients in total. Most were conducted in tertiary referral centres in northern Europe, the US and Canada. Fourteen studies only included participants with chronic rhinosinusitis with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. The studies looked at a range of types, doses and methods of administration (e.g. spray, drops) of intranasal corticosteroids. Key results and quality of the evidence One study (20 participants) reported no statistically significant difference in disease‐specific health‐related quality of life. Another measured general health‐related quality of life and reported a statistically significant benefit only on a subscale for general health. Both studies recruited participants with chronic rhinosinusitis without nasal polyps. The quality of the evidence was very low (we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect). Disease severity was measured in one study (chronic rhinosinusitis without nasal polyps, 134 participants), which found no important difference. Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group. The quality of the evidence was low (our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect). When each type of symptom was measured separately (nasal blockage, rhinorrhoea, loss of sense of smell, facial pain/pressure), benefit was shown in the intranasal corticosteroids group. The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure (moderate quality evidence means we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different). There was an increased risk of nosebleeds (epistaxis) with intranasal corticosteroids ( high quality evidence). However, it was unclear whether there was a difference in the risk of local (nose or throat) irritation ( low quality evidence). None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis (fragile bones) or stunted growth (in children). Conclusions Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life and the quality of this evidence is very low . For disease severity, there seems to be improvement for all symptoms ( low quality evidence), a moderate‐sized benefit for nasal blockage and a small benefit for rhinorrhoea ( moderate quality evidence). The risk of nosebleeds is increased ( high quality evidence), but this included all levels of severity; for some patients small streaks of blood may not be a major concern. It is unclear whether there is a difference in the risk of local irritation ( low quality evidence) .", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Chong, LY, Head, K, Hopkins, C, Philpott, C, Schilder, AGM, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011996.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.801Z" }, { "id": "e73ee21a-c752-4aff-9d8d-27a93966f945", "pmid": "", "title": "Carbetocin for preventing postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Postpartum haemorrhage (PPH) is one of the major contributors to maternal mortality and morbidity worldwide. Active management of the third stage of labour has been proven to be effective in the prevention of PPH. Syntometrine is more effective than oxytocin but is associated with more side effects. Carbetocin, a long‐acting oxytocin agonist, appears to be a promising agent for the prevention of PPH. Objectives To determine if the use of oxytocin agonist is as effective as conventional uterotonic agents for the prevention of PPH, and assess the best routes of administration and optimal doses of oxytocin agonist. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2011, Issue 1 of 4), MEDLINE (1966 to 1 March 2011) and EMBASE (1974 to 1 March 2011). We checked references of articles and communicated with authors and pharmaceutical industry contacts. Selection criteria Randomised controlled trials which compared oxytocin agonist (carbetocin) with other uterotonic agents or with placebo or no treatment for the prevention of PPH. Data collection and analysis Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Main results We included 11 studies (2635 women) in the review. Six trials compared carbetocin with oxytocin; four of these were conducted for women undergoing caesarean deliveries, one was for women following vaginal deliveries and one did not state the mode of delivery clearly. The carbetocin was administered as 100 µg intravenous dosage across the trials, while oxytocin was administered intravenously but at varied dosages. Four trials compared intramuscular carbetocin and intramuscular syntometrine for women undergoing vaginal deliveries. Three of the trials were on women with no risk factor for PPH, while one trial was on women with risk factors for PPH. One trial compared the use of intravenous carbetocin with placebo. Use of carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics (risk ratio (RR) 0.62; 95% confidence interval (CI) 0.44 to 0.88; four trials, 1173 women) compared to oxytocin for those who underwent caesarean section, but not for vaginal delivery. Compared to oxytocin, carbetocin was associated with a reduced need for uterine massage following both caesarean delivery (RR 0.54; 95% CI 0.37 to 0.79; two trials, 739 women) and vaginal delivery (RR 0.70; 95% CI 0.51 to 0.94; one trial, 160 women). There were no statistically significant differences between carbetocin and oxytocin in terms of risk of any PPH (blood loss greater than 500 ml) or in risk of severe PPH (blood loss greater than 1000 ml). Comparison between carbetocin and syntometrine showed a lower mean blood loss in women who received carbetocin compared to syntometrine (mean difference (MD) ‐48.84 ml; 95% CI ‐94.82 to ‐2.85; four trials, 1030 women). There was no statistically significant difference in terms of the need for therapeutic uterotonic agents, but the risk of adverse effects such as nausea and vomiting were significantly lower in the carbetocin group: nausea (RR 0.24; 95% CI 0.15 to 0.40; four trials, 1030 women); vomiting (RR 0.21; 95% CI 0.11 to 0.39; four trials, 1030 women). The incidence of postpartum hypertension was also significantly lower in women who received carbetocin compared to those who received syntometrine. Cost‐effectiveness of carbetocin was investigated by one study published as an abstract, with limited data. Authors' conclusions For women who undergo caesarean section, carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics compared to oxytocin, but there is no difference in the incidence of postpartum haemorrhage. Carbetocin is associated with less blood loss compared to syntometrine in the prevention of PPH for women who have vaginal deliveries and is associated with significantly fewer adverse effects. Further research is needed to analyse the cost‐effectiveness of carbetocin as a uterotonic agent. Plain language summary Carbetocin for preventing postpartum haemorrhage In low‐ and middle‐income countries, postpartum haemorrhage is a major cause of maternal deaths and ill health. In high‐income countries, the problems are much less but there is still a small risk of major bleeding problems for women after giving birth. Active management of the third stage of labour, which is generally used to reduce blood loss at birth, consists of giving the mother a drug that helps the uterus to contract, early cord clamping and controlled cord traction to deliver the placenta. Different drugs have been tried and generally either intramuscular oxytocin or intramuscular syntometrine is given. Carbetocin is an oxytocin agonist. Oxytocin agonists are a group of drugs that mimic the oxytocin action, oxytocin being the natural hormone that helps to reduce blood loss at birth. This review includes 11 randomised controlled trials involving 2635 women. The trials compared carbetocin against either oxytocin or syntometrine given after delivery, vaginally or by caesarean section. The comparison between intramuscular carbetocin and oxytocin showed that there was no difference in the risk of heavy bleeding, but that women who received carbetocin were less likely to require other medications to produce uterine contractions following caesarean sections. Comparisons between carbetocin and syntometrine showed that women who received carbetocin had less blood loss compared to women who received syntometrine after vaginal delivery, and were much less likely to experience side effects such as nausea and vomiting. The incidence of hypertension at 30 and 60 minutes post delivery was also significantly lower in women who received carbetocin compared to those who received syntometrine. Five of the 11 studies were known to be supported by a pharmaceutical company.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Su, LL; Chong, YS; Samuel, M", "articleTypes": [], "doi": "10.1002/14651858.CD005457.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "e760a9be-52bb-42b6-a0dc-ef2d585f9764", "pmid": "", "title": "Interventions for drooling in children with cerebral palsy", "imported": false, "abstract": "Abstract - Background Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation ( Blasco 1992 ; Van der Burg 2006 ). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP. Objectives (1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning. Search methods We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts. We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled‐trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts. Selection criteria Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included. Data collection and analysis Data were extracted independently by MW, MS and LP and differences resolved through discussion. Main results Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin‐A (BoNT‐A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro‐motor and oro‐sensory therapies, behavioural interventions, intra‐oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta‐analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies. Authors' conclusions It was not possible to reach a conclusion on the effectiveness and safety of either BoNT‐A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided. Plain language summary Interventions for drooling in children with cerebral palsy Many children with CP have difficulty controlling saliva. Drooling varies in severity and can be distressing for the children, families and caregivers. Excessive drooling can cause constant damp soiled clothing, unpleasant odour, irritated, chapped or sore skin around the mouth and chin, skin and mouth infections, dehydration, difficulties chewing, interference with speech, damage to books, communication aids, computer and audio equipment. There is also risk of social rejection and social isolation for these children. Many interventions are used to reduce or eliminate drooling. These include surgery, medications, botulinum toxin (BoNT‐A and BoNT‐B)), physical therapies, therapies to improve sensory function, behavioural therapies to assist the child in managing his/her own drooling, appliances placed in the mouth, and acupuncture. There is no clear consensus on which interventions are safe and effective in managing drooling in children with CP. This makes it hard to decide which intervention will be safest and most effective. Only RCTs and CCTs were included in this review. Trials were identified by electronic searches of databases, searches of clinical trials registers, peer reviewed journals, published conference proceedings and reference lists of relevant articles. Six trials were found. Four examined the safety and efficacy of BoNT‐A and two examined benztropine and glycopyrrolate. No trials were found on other interventions. The quality of trials was variable. The trials all differed in the children recruited, the product used, how the product was delivered and how its effectiveness was measured. All trials reported a positive reduction in drooling and all showed some statistically significant change for treatment groups up to 1 month post intervention. Few studies examined client and/or carer satisfaction with the intervention. Some looked at side effects of the intervention but no study examined the effect of interventions on the child's quality of life or psychological well being. There is insufficient evidence to support the use of one intervention over another. As trials on just two kinds of interventions were retrieved, and given the variation and quality of these studies, it is not possible to conclude that one intervention is more effective than another. The lack of trials on other interventions does not suggest that these interventions are ineffective. Adequately powered well designed trials are required across all interventions. In addition to using sensitive measures looking at change in salivary flow, measures are needed that examine client and carer satisfaction, changes in quality of life, psychological well being and in unwanted symptoms associated with drooling.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Walshe, M; Smith, M; Pennington, L", "articleTypes": [], "doi": "10.1002/14651858.CD008624.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "e76c4852-4d0d-443c-ae36-57fe625ebb19", "pmid": "", "title": "Interventions for oropharyngeal dysphagia in children with neurological impairment", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Morgan, AT, Dodrill, P, Ward, EC", "articleTypes": [], "doi": "10.1002/14651858.CD009456.pub2 AB - Abstract - Background Oropharyngeal dysphagia encompasses problems with the oral preparatory phase of swallowing (chewing and preparing the food), oral phase (moving the food or fluid posteriorly through the oral cavity with the tongue into the back of the throat) and pharyngeal phase (swallowing the food or fluid and moving it through the pharynx to the oesophagus). Populations of children with neurological impairment who commonly experience dysphagia include, but are not limited to, those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). Objectives To examine the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. Search methods We searched the following electronic databases in October 2011: CENTRAL 2011(3), MEDLINE (1948 to September Week 4 2011), EMBASE (1980 to 2011 Week 40)
, CINAHL (1937 to current)
, ERIC (1966 to current), PsycINFO (1806 to October Week 1 2011), Science Citation Index (1970 to 7 October 2011), Social Science Citation Index (1970 to 7 October 2011), Cochrane Database of Systematic Reviews, 2011(3), DARE 2011(3), Current Controlled Trials (ISRCTN Register) (15 October 2011), ClinicalTrials.gov (15 October 2011) and WHO ICTRP (15 October 2011). We searched for dissertations and theses using Networked Digital Library of Theses and Dissertations, Australasian Digital Theses Program and DART‐Europe E‐theses Portal (11 October 2011). Finally, additional references were also obtained from reference lists from articles. Selection criteria The review included randomised controlled trials and quasi‐randomised controlled trials for children with oropharyngeal dysphagia and neurological impairment. Data collection and analysis All three review authors (AM, PD and EW) independently screened titles and abstracts for inclusion and discussed results. In cases of uncertainty over whether an abstract met inclusion criterion, review authors obtained the full‐text article and independently evaluated each paper for inclusion. The data were categorised for comparisons depending on the nature of the control group (for example, oral sensorimotor treatment versus no treatment). Effectiveness of the oropharyngeal dysphagia intervention was assessed by considering primary outcomes of physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency a child is able to consume. Secondary outcomes were changes in growth, child’s level of participation in the mealtime routine and the level of parent or carer stress associated with feeding. Main results Three studies met the inclusion criteria for the review. Two studies were based on oral sensorimotor interventions for participants with cerebral palsy compared to standard care and a third study trialled lip strengthening exercises for children with myotonic dystrophy type 1 compared to no treatment ( Sjogreen 2010 ). A meta‐analysis combining results across the three studies was not possible because one of the studies had participants with a different condition, and the remaining two, although using oral sensorimotor treatments, used vastly different approaches with different intensities and durations. The decision not to combine these was in line with our protocol. In this review, we present the results from individual studies for four outcomes: physiological functions of the oropharyngeal mechanism for swallowing, the presence of chest infection and pneumonia, diet consistency, and changes in growth. However, it is not possible to reach definitive conclusions on the effectiveness of particular interventions for oropharyngeal dysphagia based on these studies. One study had a high risk of attrition bias owing to missing data, had statistically significant differences (in weight) across experimental and control groups at baseline, and did not describe other aspects of the trial sufficiently to enable assessment of other potential risks of bias. Another study was at high risk of detection bias as some outcomes were assessed by parents who knew whether their child was in the intervention or control group. The third study overall seemed to be at low risk of bias, but like the other two studies, suffered from a small sample size. Authors' conclusions The review demonstrates that there is currently insufficient high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials to provide conclusive results about the effectiveness of any particular type of oral‐motor therapy for children with neurological impairment. There is an urgent need for larger‐scale (appropriately statistically powered), randomised trials to evaluate the efficacy of interventions for oropharyngeal dysphagia. Plain language summary Interventions for swallowing difficulty in children with neurological impairment Oropharyngeal dysphagia, or swallowing difficulty, can be defined as problems with chewing and preparing food, difficulty moving food through the mouth to the back of the tongue, and difficulty with swallowing and movement of food through the 'throat' or pharynx. Many children with neurological impairment experience swallowing difficulties, including those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy). This review examined the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment. The three studies included in the review examined oral sensorimotor treatments and lip strengthening interventions. We were interested in three primary outcomes, which were physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency, and three secondary outcomes, which were changes in growth, child's level of participation in the mealtime routine, and the level of parent or carer stress associated with feeding. We concluded that there is currently not enough high‐quality evidence from randomised controlled trials or quasi‐randomised controlled trials for any particular type of oropharyngeal dysphagia intervention in this population of children. There is a need for larger‐scale randomised controlled trials to evaluate the effects of interventions for oropharyngeal dysphagia in children with neurological impairment.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.800Z" }, { "id": "e77e86a0-516d-42f8-95a1-05a7f4dcc1b2", "pmid": "", "title": "Evaluation of a Nutritional Intervention With Dietary Supplements in People Who Have Recently Lost Weight: Effects on Body Composition, Emotional Health, and Gut Microbiota", "imported": false, "abstract": "This study aims to evaluate the effects of a 12-week nutritional intervention with dietary supplements on individuals who have experienced significant weight loss following the use of GLP-1 receptor agonists or similar weight-loss treatments. The study will investigate whether the combined supplementation protocol can improve body composition, emotional well-being, and gut microbiota diversity after discontinuation of pharmacological treatment.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.153Z" }, { "id": "e7834818-75cb-48a0-9cb3-fd7d57ac948f", "pmid": "", "title": "Optimum duration of regimens for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background The optimal duration for Helicobacter pylori (H. pylori) eradication therapy is controversial, with recommendations ranging from 7 to 14 days. Several systematic reviews have attempted to address this issue but have given conflicting results and limited their analysis to proton pump inhibitor (PPI), two antibiotics (PPI triple) therapy. We performed a systematic review and meta‐analysis to investigate the optimal duration of multiple H. pylori eradication regimens. Objectives The primary objective was to assess the relative effectiveness of different durations (7, 10 or 14 days) of a variety of regimens for eradicating H. pylori . The primary outcome was H. pylori persistence. The secondary outcome was adverse events. Search methods The Cochrane Library , MEDLINE, EMBASE, and CINAHL were searched up to December 2011 to identify eligible randomised controlled trials (RCTs). We also searched the proceedings of six conferences from 1995 to 2011, dissertations and theses, and grey literature. There were no language restrictions applied to any search. Selection criteria Only parallel group RCTs assessing the efficacy of one to two weeks duration of first line H. pylori eradication regimens in adults were eligible. Within each regimen, the same combinations of drugs at the same dose were compared over different durations. Studies with at least two arms comparing 7, 10, or 14 days were eligible. Enrolled participants needed to be diagnosed with at least one positive test for H. pylori on the basis of a rapid urease test (RUT), histology, culture, urea breath test (UBT), or a stool antigen test (HpSA) before treatment. Eligible trials needed to confirm eradication of H. pylori as their primary outcome at least 28 days after completion of eradication treatment. Trials using only serology or a polymerase chain reaction (PCR) to determine H. pylori infection or eradication were excluded. Data collection and analysis Study eligibility and data extraction were performed by two independent review authors. Data analyses were performed within each type of intervention, for both primary and secondary outcomes. The relative risk (RR) and number needed to treat (NNT)/number needed to harm (NNTH) according to duration of therapy were calculated using the outcomes of H. pylori persistence and adverse events. A random‐effects model was used. Subgroup analyses and sensitivity analyses were planned a priori. Main results In total, 75 studies met the inclusion criteria. Eight types of regimens were reported with at least two comparative eligible durations. They included: PPI + two antibiotics triple therapy (n = 59), PPI bismuth‐based quadruple therapy (n = 6), PPI + three antibiotics quadruple therapy (n = 1), PPI dual therapy (n = 2), histamine H 2 ‐receptor antagonist (H 2 RA) bismuth quadruple therapy (n = 3), H 2 RA bismuth‐based triple therapy (n = 2), H 2 RA + two antibiotics triple therapy (n = 3), and bismuth + two antibiotics triple therapy (n = 2). Some studies provided data for more than one regimen or more than two durations. For the PPI triple therapy, 59 studies with five regimens were reported: PPI + clarithromycin + amoxicillin (PCA); PPI + clarithromycin + a nitroimidazole (PCN); PPI + amoxicillin + nitroimidazole (PAN); PPI + amoxicillin + a quinolone (PAQ); and PPI + amoxicillin + a nitrofuran (PANi). Regardless of type and dose of antibiotics, increased duration of PPI triple therapy from 7 to 14 days significantly increased the H. pylor i eradication rate (45 studies, 72.9% versus 81.9%), the RR for H. pylori persistence was 0.66 (95% CI 0.60 to 0.74), NNT was 11 (95% CI 9 to 14). Significant effects were seen in the subgroup of PCA (34 studies, RR 0.65, 95% CI 0.57 to 0.75; NNT 12, 95% CI 9 to 16); PAN (10 studies, RR 0.67, 95% CI 0.52 to 0.86; NNT = 11, 95% CI 8 to 25); and in PAQ (2 studies, RR 0.37, 95% CI 0.16 to 0.83; NNT 3, 95% CI 2 to 10); but not in PCN triple therapy (4 studies, RR 0.87, 95% CI 0.71 to 1.07). Significantly increased eradication rates were also seen for PPI triple therapy with 10 versus 7 days (24 studies, 79.9% versus 75.7%; RR 0.80, 95% CI 0.72 to 0.89; NNT 21, 95% CI 15 to 38) and 14 versus 10 days (12 studies, 84.4% versus 78.5%; RR 0.72, 95% CI 0.58 to 0.90; NNT 17, 95% CI 11 to 46); especially in the subgroup of PAC for 10 versus 7 days (17 studies, RR 0.80, 95% CI 0.70 to 0.91) and for 14 versus 10 days (10 studies, RR 0.69, 95% CI 0.52 to 0.91). A trend towards increased H. pylori eradication rates was seen with increased duration of PCN for 10 versus 7 days, and of PAN for 10 versus 7 days and 14 versus 10 days, though this was not statistical significant. The proportion of patients with adverse events, defined by authors, was marginally significantly increased only between 7 days and 14 days (15.5% versus 19.4%; RR 1.21, 95% CI 1.06 to 1.37; NNTH 31, 95% CI 18 to 104) but not for other duration comparisons. The proportion of patients discontinuing treatment due to adverse events was not significantly different between treatment durations. Only limited data were reported for different durations of regimens other than PPI triple therapy. No significant difference of the eradication rate was seen for all regimens according to different durations except for H 2 RA bismuth quadruple therapy, where a significantly higher eradication rate was seen for 14 days versus 7 days, however only one study reported outcome data. Authors' conclusions Increasing the duration of PPI‐based triple therapy increases H. pylori eradication rates. For PCA, prolonging treatment duration from 7 to 10 or from 10 to 14 days is associated with a significantly higher eradication rate. The optimal duration of therapy for PCA and PAN is at least 14 days. More data are needed to confirm if there is any benefit of increasing the duration of therapy for PCN therapy. Information is limited for regimens other than PPI triple therapy; more studies are needed to draw meaningful conclusions for optimal duration of other H. pylori eradication regimens. Plain language summary Ideal length of treatment for Helicobacter pylori ( H. pylori ) eradication The ideal duration of therapy for H. pylori eradication is controversial, with recommendations ranging from 7 to 14 days. A proton pump inhibitor (PPI) plus two antibiotics is the most commonly used first treatment to remove H. pylori infection. Current data suggest that increasing the length of treatment to 14 days of a PPI plus amoxicillin and clarithromycin or amoxicillin and a nitroimidazole significantly increases the eradication rate, while increasing the adverse events by a small amount. Based on the overall evidence, the ideal length of treatment with a PPI plus amoxicillin and clarithromycin is at least 14 days.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Yuan, Y; Ford, AC; Khan, KJ; Gisbert, JP; Forman, D; Leontiadis, GI; Tse, F; Calvet, X; Fallone, C; Fischbach, L; Oderda, G; Bazzoli, F; Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD008337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "e784bc92-0c1f-4e19-b958-57218c2a3163", "pmid": "", "title": "Prostaglandins for management of retained placenta", "imported": false, "abstract": "Abstract - Background Retained placenta affects 0.5% to 3% of women following delivery and it is a major cause of maternal death due to postpartum haemorrhage. Usually, retained placenta has been managed by manual removal or curettage under anaesthesia, which may be associated with haemorrhage, infection and uterine perforation. Medical management to facilitate the delivery of the retained placenta could be a safe alternative avoiding surgical intervention. Objectives To assess the effectiveness and safety of prostaglandins for the management of retained placenta. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013), LILACS (1982 to 1 December 2013), SciELO (1998 to 1 December 2013), Web of Science (2001 to 1 December 2013), openSIGLE (1997 to 1 December 2013 ) , World Health Organization International Clinical Trials Registry Platform ( ICTRP ) (1 December 2013) and the metaRegister of Controlled Trials ( mRCT ) (1 December 2013) . We also contacted authors of included studies and reviewed the reference lists of retrieved studies. Selection criteria Randomised controlled clinical trials comparing the use of prostaglandins (or prostaglandin analogues) with placebo, expectant management, tocolytic drugs, any other prostaglandins or surgical interventions for the management of retained placenta after vaginal delivery of singleton live infants of 20 or more weeks of gestation. Data collection and analysis Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. Any disagreements were resolved through consensus or consultation with a third review author when required. Authors of the included studies were contacted for additional information. Main results We included three trials, involving 244 women. The studies were considered to be at high risk of bias. The prostaglandins used were PG E2 analogue (sulprostone) in 50 participants and PG E1 analogue (misoprostol) in 194 participants at a dose of 250 mcg and 800 mcg respectively. The prostaglandins compared with placebo, were not superior in reducing the rate of manual removal of placenta (average risk ratio (RR) 0.82; 95% confidence interval (CI) 0.54 to 1.27), severe postpartum haemorrhage (RR 0.80; 95% CI 0.55 to 1.15), need for blood transfusion (RR 0.72; 95% CI 0.43 to 1.22), mean blood loss (mean difference (MD) ‐205.26 mL; 95% CI ‐536.31 to 125.79, random‐effects) and the mean time from injection to placental removal (MD ‐7.00 minutes; 95% CI ‐21.20 to 7.20). Side‐effects were no different between groups (vomiting, headache, pain and nausea between injection and discharge from the labour ward), with the exception of shivering, which was more frequent in women receiving prostaglandins (RR 10.00; 95% CI 1.40 to 71.49). We did not obtain any data for the primary outcomes of maternal mortality and the need to add another therapeutic uterotonic. Authors' conclusions Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes) or side‐effects (vomiting, headache, pain and nausea between injection and discharge from the labour ward) except for 'shivering' which was more frequent in women who received prostaglandin. The included studies were of poor quality and there is little confidence in the effect estimates; the true effect is likely to be substantially different. We can not make any recommendations about changes to clinical practice. More high‐quality research in this area is needed. Plain language summary Prostaglandins for management of retained placenta Medical research evidence is sparse and insufficient to support the routine use of the prostaglandins for the management of retained placenta. Retained placenta affects 0.5% to 3% of women following delivery and is a major cause of maternal death caused by postpartum haemorrhage. A retained placenta is usually managed by manual removal or curettage under anaesthesia (which is not always immediately available). Surgical procedures themselves can be associated with haemorrhage and also infection and uterine perforation. Prostaglandins or their analogues, administered by any route, could be an alternative treatment especially in developing countries. Such medical management may facilitate the delivery of the retained placenta and be a safer alternative to surgery. The review identified three randomised controlled studies (involving 244 women) that compared the use of prostaglandins with placebo. Currently there is limited, very low‐quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and need for blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings. Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes). The prostaglandin was administered by intravenous infusion (E2 analogue sulprostone) in one study including 50 women and was orally or sublingually administered (E1 analogue misoprostol) in the other two studies including 194 women. Shivering was more frequent in women receiving the prostaglandin but there were no clear differences in vomiting, headache, maternal pain or nausea compared with placebo. The trials were small and of poor methodological quality. The quality of evidence is very low due to study limitations, inconsistency and imprecise results (few women and outcome events with wide confidence intervals). Two studies were stopped early due to an apparent benefit.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Grillo‐Ardila, CF; Ruiz‐Parra, AI; Gaitán, HG; Rodriguez‐Malagon, N", "articleTypes": [], "doi": "10.1002/14651858.CD010312.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "e792e3b5-23c2-466c-99bb-033df94d806f", "pmid": "", "title": "Inhaled corticosteroids for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background Inhaled corticosteroids are well established for the long‐term treatment of inflammatory respiratory diseases such as asthma or chronic obstructive pulmonary disease. They have been investigated for the treatment of coronavirus disease 2019 (COVID‐19). The anti‐inflammatory action of inhaled corticosteroids might have the potential to reduce the risk of severe illness resulting from hyperinflammation in COVID‐19. Objectives To assess whether inhaled corticosteroids are effective and safe in the treatment of COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (which includes CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO ICTRP, and medRxiv), Web of Science (Science Citation Index, Emerging Citation Index), and the WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies to 7 October 2021. Selection criteria We included randomised controlled trials (RCTs) evaluating inhaled corticosteroids for COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We included the following interventions: any type or dose of inhaled corticosteroids. We included the following comparison: inhaled corticosteroids plus standard care versus standard care (with or without placebo). We excluded studies examining nasal or topical steroids. Data collection and analysis We followed standard Cochrane methodology. For risk of bias assessment, we used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the outcomes of mortality, admission to hospital or death, symptom resolution, time to symptom resolution, serious adverse events, adverse events, and infections. Main results Inhaled corticosteroids plus standard care versus standard care (with/without placebo) People with a confirmed diagnosis of moderate‐to‐severe COVID‐19 We found no studies that included people with a confirmed diagnosis of moderate‐to‐severe COVID‐19. People with a confirmed diagnosis of asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 We included three RCTs allocating 3607 participants, of whom 2490 had confirmed mild COVID‐19. We analysed a subset of the total number of participants recruited to the studies (2171, 52% female) as some trials had a platform design where not all participants were allocated to treatment groups simultaneously. The included studies were community‐based, recruiting people who were able to use inhaler devices to deliver steroids and relied on remote assessment and self‐reporting of outcomes. Most people were older than 50 years and had co‐morbidities such as hypertension, lung disease, or diabetes. The studies were conducted in high‐income countries prior to wide‐scale vaccination programmes. A total of 1057 participants were analysed in the inhaled corticosteroid arm (budesonide: 860 participants; ciclesonide: 197 participants), and 1075 participants in the control arm. No studies included people with asymptomatic SARS‐CoV‐2 infection. With respect to the following outcomes, inhaled corticosteroids compared to standard care: – may result in little to no difference in all‐cause mortality (at up to day 30) (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.22 to 1.67; 2132 participants; low‐certainty evidence). In absolute terms, this means that for every nine deaths per 1000 people not receiving inhaled corticosteroids, there were six deaths per 1000 people who did receive the intervention (95% CI 2 to 16 per 1000 people); – probably reduces admission to hospital or death (at up to 30 days) (RR 0.72, 95% CI 0.51 to 0.99; 2025 participants; moderate‐certainty evidence); – probably increases resolution of all initial symptoms at day 14 (RR 1.19, 95% CI 1.09 to 1.30; 1986 participants; moderate‐certainty evidence); – may reduce the duration to symptom resolution (at up to day 30) (by −4.00 days, 95% CI −6.22 to −1.78 less than control group rate of 12 days; 139 participants; low‐certainty evidence); – the evidence is very uncertain about the effect on serious adverse events (during study period) (RR 0.51, 95% CI 0.09 to 2.76; 1586 participants; very low‐certainty evidence); – may result in little to no difference in adverse events (at up to day 30) (RR 0.78, 95% CI 0.47 to 1.31; 400 participants; low‐certainty evidence); – may result in little to no difference in infections (during study period) (RR 0.88, 95% CI 0.30 to 2.58; 400 participants; low‐certainty evidence). As studies did not report outcomes for subgroups (e.g. age, ethnicity, sex), we did not perform subgroup analyses. Authors' conclusions In people with confirmed COVID‐19 and mild symptoms who are able to use inhaler devices, we found moderate‐certainty evidence that inhaled corticosteroids probably reduce the combined endpoint of admission to hospital or death and increase the resolution of all initial symptoms at day 14. Low‐certainty evidence suggests that corticosteroids make little to no difference in all‐cause mortality up to day 30 and may decrease the duration to symptom resolution. We do not know whether inhaled corticosteroids increase or decrease serious adverse events due to heterogeneity in the way they were reported across the studies. There is low‐certainty evidence that inhaled corticosteroids may decrease infections. The evidence we identified came from studies in high‐income settings using budesonide and ciclesonide prior to vaccination roll‐outs. We identified a lack of evidence concerning quality of life assessments, serious adverse events, and people with asymptomatic infection or with moderate‐to‐severe COVID‐19. The 10 ongoing and four completed, unpublished RCTs that we identified in trial registries address similar settings and research questions as in the current body of evidence. We expect to incorporate the findings of these studies in future versions of this review. We monitor newly published results of RCTs on inhaled corticosteroids on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Are inhaled corticosteroids an effective treatment for people with mild COVID‐19? Key messages Inhaled corticosteroids (anti‐inflammatory medicines) given via the oral inhaled route are evaluated for treatment of coronavirus disease 2019 (COVID‐19). We identified three published studies for people with mild disease. Inhaled corticosteroids probably reduce the risk of people going to hospital or death (admission to hospital or death before hospital admission). Inhaled corticosteroids may lower the number of days people have symptoms of mild COVID‐19 and probably increase resolution of COVID‐19 symptoms at day 14. They may make little to no difference in death from any cause, and we do not have enough evidence to know whether they cause serious harms. There are no data for people with COVID‐19 with no symptoms (asymptomatic) or people with moderate‐to‐severe COVID‐19. We found 10 ongoing and four completed unpublished studies. We will update this review when their results become available. What are inhaled corticosteroids? Inhaled corticosteroids are medicines that are breathed into the lower airways through an inhaler where they reduce inflammation in the lungs. They are commonly used to treat respiratory diseases like asthma and chronic obstructive pulmonary disease. Long‐term use and incorrect inhaler technique may lead to side effects that include a mouth infection called thrush, a change in voice, and an increased risk of lung infections. Good inhaler technique means the medicine does not stay in the mouth and throat. Why are inhaled corticosteroids possible treatments for COVID‐19? COVID‐19 mainly affects the lungs and airways. When the immune system fights the virus, the lungs and airways become inflamed. This inflammation causes breathing difficulties, and the lungs cannot easily move oxygen into the blood and remove carbon dioxide from the blood. What did we want to find out? People need more and better treatment options for asymptomatic SARS‐CoV‐2 infection (the virus that causes COVID‐19) or mild, moderate, or severe COVID‐19. We wanted to know if inhaled corticosteroids are an effective and helpful treatment option for COVID‐19 in any setting (for example, home or hospital) and whether they cause unwanted effects. We were interested in: – death from any cause up to day 30, day 60, or longer if reported; – admission to hospital or death within 30 days; – whether symptoms resolved and how fast; – quality of life; – unwanted effects. What did we do? We looked for studies where the investigators compared inhaled corticosteroids and usual care to usual care only, sometimes in addition to a dummy medicine that did not contain any active ingredients (placebo) but was given in the same way. To make the comparison least skewed and more fair, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the inhaled corticosteroids or the other treatment. The studies could include people of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Three studies compared inhaled corticosteroids plus usual care compared to usual care with or without placebo in people with a confirmed diagnosis of mild COVID‐19. These studies analysed 2171 participants mostly older than 50 years and with other medical problems, 52% of them were female, of whom 1057 received inhaled corticosteroids in our analyses. We found no studies that included people with asymptomatic infection or confirmed diagnosis of moderate‐to‐severe COVID‐19. We also found 10 ongoing studies, and four completed studies without published results. Main results All studies compared inhaled corticosteroids with usual care or placebo. The studies included only people with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease. No studies looked at hospitalised people or people with asymptomatic SARS‐CoV‐2 infection. Inhaled corticosteroids – may make little to no difference in death from any cause up to day 30; – probably reduce the risk of admission to hospital or occurrence of death up to day 30; – probably increase resolution of COVID‐19 symptoms at day 14 and may reduce time to symptom resolution. We are very uncertain about a possible difference in serious unwanted effects. Moreover, inhaled corticosteroids may result in little to no difference in the number of any unwanted effects or additional infections. What are the limitations of the evidence? The studies were conducted in populations from wealthy countries, prior to the roll‐out of COVID‐19 vaccination programmes. We have moderate confidence in the evidence for the outcomes of symptom resolution at day 14 and hospital admission. We have low confidence in the evidence for the effects on deaths from any cause for people with mild COVID‐19 and time to symptom resolution. The confidence in the unwanted or serious unwanted effects and infections is low or very low, because of the differences in the way investigators recorded and reported results. There was no evidence for people with asymptomatic infection or moderate‐to‐severe COVID‐19 who were hospitalised. How up to date is this evidence? Our evidence is up‐to‐date to 7 October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Griesel, M, Wagner, C, Mikolajewska, A, Stegemann, M, Fichtner, F, Metzendorf, M-I, Nair, AAnil, Daniel, J, Fischer, A-L, Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015125", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.775Z" }, { "id": "e7a6c708-f94d-408f-bfbb-117f087889fb", "pmid": "", "title": "COVID-19: Why Are Children Less Affected", "imported": false, "abstract": "Observational Study of Infants Fed on DHA (Breast Source or Milk Formula Source ) and Its Effect on COVID-19 Severity", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.249Z" }, { "id": "e7a80705-426e-408d-9493-80d3853eee8d", "pmid": "", "title": "Intranasal steroids for acute sinusitis", "imported": false, "abstract": "Abstract - Background Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school. Objectives We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis in adults and children. Search methods We searched CENTRAL 2013, Issue 4, MEDLINE (January 1966 to May week 2, 2013), EMBASE (1990 to May 2013) and bibliographies of included studies. Selection criteria Randomised controlled trials (RCTs) comparing INCS treatment to placebo or no intervention in adults and children with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop‐outs before the end of the study, rates of relapse, complications and return to school or work. Data collection and analysis Two review authors independently extracted data, assessed trial quality and resolved discrepancies by consensus. Main results No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well‐designed and double‐blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow‐up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta‐analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% confidence interval (CI) 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop‐out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS. Authors' conclusions Current evidence is limited for acute sinusitis confirmed by radiology or nasal endoscopy but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy. Plain language summary Steroids for acute sinusitis in adults and children Acute sinusitis is a common reason for primary care visits; it is one of the 10 most common diagnoses in outpatient clinics, presenting with various symptoms and signs that include purulent nasal discharge and congestion and cough lasting beyond the typical seven to 10 days of a viral upper respiratory infection. There have been suggestions, based on studies of allergic rhinitis and chronic sinusitis, that intranasal corticosteroids (INCS) may relieve symptoms and hasten recovery in acute sinusitis due to their anti‐inflammatory properties. A critical systematic review of the literature found four well‐conducted, randomised, placebo‐controlled intervention studies, involving 1943 participants treated for 15 or 21 days. The results suggest that there may be a modest effect with INCS in the resolution or improvement of symptoms. Only minor adverse events such as epistaxis, headache and nasal itching were reported. Given the small number of studies included in this review, it is recommended that further randomised controlled trials be conducted. The evidence is up to date as of May 2013.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zalmanovici Trestioreanu, A; Yaphe, J", "articleTypes": [], "doi": "10.1002/14651858.CD005149.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "e7cb2e9b-3f70-44f2-b18b-20d91489073b", "pmid": "", "title": "Colchicine for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background The development of severe coronavirus disease 2019 (COVID‐19) and poor clinical outcomes are associated with hyperinflammation and a complex dysregulation of the immune response. Colchicine is an anti‐inflammatory medicine and is thought to improve disease outcomes in COVID‐19 through a wide range of anti‐inflammatory mechanisms. Patients and healthcare systems need more and better treatment options for COVID‐19 and a thorough understanding of the current body of evidence. Objectives To assess the effectiveness and safety of Colchicine as a treatment option for COVID‐19 in comparison to an active comparator, placebo, or standard care alone in any setting, and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising CENTRAL, MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv), Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index), and WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions to 21 May 2021. Selection criteria We included randomised controlled trials evaluating colchicine for the treatment of people with COVID‐19, irrespective of disease severity, age, sex, or ethnicity. We excluded studies investigating the prophylactic effects of colchicine for people without severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection but at high risk of SARS‐CoV‐2 exposure. Data collection and analysis We followed standard Cochrane methodology. We used the Cochrane risk of bias tool (ROB 2) to assess bias in included studies and GRADE to rate the certainty of evidence for the following prioritised outcome categories considering people with moderate or severe COVID‐19: all‐cause mortality, worsening and improvement of clinical status, quality of life, adverse events, and serious adverse events and for people with asymptomatic infection or mild disease: all‐cause mortality, admission to hospital or death, symptom resolution, duration to symptom resolution, quality of life, adverse events, serious adverse events. Main results We included three RCTs with 11,525 hospitalised participants (8002 male) and one RCT with 4488 (2067 male) non‐hospitalised participants. Mean age of people treated in hospital was about 64 years, and was 55 years in the study with non‐hospitalised participants. Further, we identified 17 ongoing studies and 11 studies completed or terminated, but without published results. Colchicine plus standard care versus standard care (plus/minus placebo) Treatment of hospitalised people with moderate to severe COVID‐19 All‐cause mortality : colchicine plus standard care probably results in little to no difference in all‐cause mortality up to 28 days compared to standard care alone (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.93 to 1.08; 2 RCTs, 11,445 participants; moderate‐certainty evidence). Worsening of clinical status : colchicine plus standard care probably results in little to no difference in worsening of clinical status assessed as new need for invasive mechanical ventilation or death compared to standard care alone (RR 1.02, 95% CI 0.96 to 1.09; 2 RCTs, 10,916 participants; moderate‐certainty evidence). Improvement of clinical status : colchicine plus standard care probably results in little to no difference in improvement of clinical status, assessed as number of participants discharged alive up to day 28 without clinical deterioration or death compared to standard care alone (RR 0.99, 95% CI 0.96 to 1.01; 1 RCT, 11,340 participants; moderate‐certainty evidence). Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is very uncertain about the effect of colchicine on adverse events compared to placebo (RR 1.00, 95% CI 0.56 to 1.78; 1 RCT, 72 participants; very low‐certainty evidence). Serious adverse events : the evidence is very uncertain about the effect of colchicine plus standard care on serious adverse events compared to standard care alone (0 events observed in 1 RCT of 105 participants; very low‐certainty evidence). Treatment of non‐hospitalised people with asymptomatic SARS‐CoV‐2 infection or mild COVID‐19 All‐cause mortality : the evidence is uncertain about the effect of colchicine on all‐cause mortality at 28 days (Peto odds ratio (OR) 0.57, 95% CI 0.20 to 1.62; 1 RCT, 4488 participants; low‐certainty evidence). Admission to hospital or death within 28 days : colchicine probably slightly reduces the need for hospitalisation or death within 28 days compared to placebo (RR 0.80, 95% CI 0.62 to 1.03; 1 RCT, 4488 participants; moderate‐certainty evidence). Symptom resolution : we identified no studies reporting this outcome. Quality of lif e , including fatigue and neurological status : we identified no studies reporting this outcome. Adverse events : the evidence is uncertain about the effect of colchicine on adverse events compared to placebo . Results are from one RCT reporting treatment‐related events only in 4412 participants (low‐certainty evidence). Serious adverse events : colchicine probably slightly reduces serious adverse events (RR 0.78, 95% CI 0.61 to 1.00; 1 RCT, 4412 participants; moderate‐certainty evidence). Colchicine versus another active treatment (e.g. corticosteroids, anti‐viral drugs, monoclonal antibodies) No studies evaluated this comparison. Different formulations, doses, or schedules of colchicine No studies assessed this. Authors' conclusions Based on the current evidence, in people hospitalised with moderate to severe COVID‐19 the use of colchicine probably has little to no influence on mortality or clinical progression in comparison to placebo or standard care alone. We do not know whether colchicine increases the risk of (serious) adverse events. We are uncertain about the evidence of the effect of colchicine on all‐cause mortality for people with asymptomatic infection or mild disease. However, colchicine probably results in a slight reduction of hospital admissions or deaths within 28 days, and the rate of serious adverse events compared with placebo. None of the studies reported data on quality of life or compared the benefits and harms of colchicine versus other drugs, or different dosages of colchicine. We identified 17 ongoing and 11 completed but not published RCTs, which we expect to incorporate in future versions of this review as their results become available. Editorial note: due to the living approach of this work, we monitor newly published results of RCTs on colchicine on a weekly basis and will update the review when the evidence or our certainty in the evidence changes. Plain language summary Is colchicine an effective treatment for people with COVID‐19? Key messages ○ In hospitalised people with moderate to severe COVID‐19, colchicine probably has little to no benefit; we are uncertain about its side effects. ○In non‐hospitalised people with no symptoms or mild COVID‐19, we are uncertain whether colchicine prevents deaths or side effects, however it probably reduces the need for hospitalisation or death and serious side effects slightly. ○ Future studies should assess quality of life in people with no symptoms or mild COVID‐19 and non‐serious side effects and compare colchicine to other medicines for COVID‐19, such as corticosteroids. What is colchicine? Colchicine is a medicine used to reduce swelling and inflammation and may consequently relieve pain. It is often used to treat gout, a condition where people’s joints become swollen and painful. On the other hand, colchicine can be harmful to people with some health conditions, such as kidney or liver problems, or if you take too much of it. How might colchicine treat COVID‐19? Since colchicine is an anti‐inflammatory drug; researchers are interested in whether it might help with reducing inflammation caused by COVID‐19. What did we want to find out? We wanted to know whether colchicine is an effective treatment for people with COVID‐19 compared to placebo (a treatment that looks and tastes the same as colchicine but with no active ingredient) or usual care alone. We looked at people with moderate or severe disease being treated in hospital or with mild disease being treated in the community. We were particularly interested in the effects of colchicine on: ○ number of deaths; ○ whether people’s condition worsened or improved; ○ quality of life; ○ serious and non‐serious side effects What did we do? We searched for studies that compared colchicine together with usual care to usual care (plus/minus placebo). Studies could take place anywhere in the world and include people with mild or no symptoms, moderate or severe COVID‐19, of any age, sex, or ethnicity. We compared and summarised the results of the studies and rated our certainty in the evidence, based on factors such as study methods and sizes. What did we find? We identified four eligible randomised trials. Three included 11,525 hospitalised people and one included 4488 non‐hospitalised people. For hospitalised people, the average age was 64 years, and for non‐hospitalised people, the average age was 55 years. Two studies compared colchicine and usual care with usual care alone and 2 studies compared colchicine with usual care and placebo. None of the studies reported quality of life. We also found 17 ongoing studies and 11 completed but unpublished studies. Main results Hospitalised people with moderate to severe COVID‐19 (3 studies, 11,525 people) ○Colchicine probably does not reduce deaths in the 28 days after treatment (2 studies, 11,445 people). ○Colchicine probably does not prevent the worsening of patients’ condition (2 studies, 10,916 people) and probably does not improve it (1 study, 11,340 people). ○We are very uncertain about the effect of colchicine on side effects and serious side effects (2 studies, 177 people). Non‐hospitalised people with no symptoms or mild COVID‐19 (1 study, 4488 people) ○We are uncertain whether colchicine prevents deaths up to 28 days after treatment. ○Colchicine probably slightly reduces the risk of hospitalisation or death. ○We are uncertain about the effect of colchicine on side effects, but it probably slightly reduces serious side effects. What are the limitations of the evidence? Our certainty in the evidence is limited. Two studies did not use a placebo, so everybody knew who was treated with colchicine, which could influence the results. There were too few events for non‐hospitalised people, such as admissions to hospital and deaths, to be certain about the evidence. Studies used different ways to assess and report unwanted effects, so we could not combine studies into a single result to make a judgement. How up to date is this evidence? The evidence is up to date to 21 May 2021. Editorial note: this is a living systematic review. We search for new evidence every week and update the review when we identify relevant new evidence. Refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Mikolajewska, A, Fischer, A-L, Piechotta, V, Mueller, A, Metzendorf, M-I, Becker, M, Dorando, E, Pacheco, RL, Martimbianco, ALC, Riera, R, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015045", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.820Z" }, { "id": "e7e7df13-1fe5-4092-8f63-79b254c5e0d5", "pmid": "", "title": "Topical medication instillation techniques for glaucoma", "imported": false, "abstract": "Abstract - Background Glaucoma is a leading cause of irreversible blindness worldwide and the second most common cause of blindness after cataracts. The primary treatment for glaucoma aims to lower intraocular pressure (IOP) with the use of topical medicines. Topical medication instillation techniques, such as eyelid closure and nasolacrimal occlusion when instilling drops, have been proposed as potential methods to increase ocular absorption and decrease systemic absorption of the drops. Objectives To investigate the effectiveness of topical medication instillation techniques compared with usual care or another method of instillation of topical medication in the management of glaucoma or ocular hypertension. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 8 December 2016), Embase Ovid (1947 to 8 December 2016), PubMed (1948 to 8 December 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 8 December 2016), International Pharmaceutical Abstracts Database (1970 to 8 December 2016), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ) (last searched 13 May 2013), ClinicalTrials.gov ( www.clinicaltrials.gov ) (searched 8 December 2016) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ) (searched 8 December 2016). We did not use any date or language restrictions in the electronic searches for trials. Selection criteria We included randomized controlled trials which had compared any topical medication instillation technique with usual care or a different method of instillation of topical medication. Data collection and analysis Two review authors independently screened records from the searches for eligibility, assessed the risk of bias, and extracted data. We followed methods recommended by Cochrane. Main results We identified two trials (122 eyes of 61 participants) that had evaluated a topical medication instillation technique. We also identified two ongoing trials. Both included trials used a within‐person design and administered prostaglandin monotherapy for glaucoma or ocular hypertension. Because the trials evaluated different instillation techniques and assessed different outcomes, we performed no meta‐analysis. One trial, conducted in the US, evaluated the effect of eyelid closure (one and three minutes) versus no eyelid closure on lowering IOP. At one to two weeks' follow‐up, reduction in IOP was similar in the eyelid closure group and the no eyelid closure group (mean difference (MD) ‐0.33 mmHg, 95% confidence interval (CI) ‐0.8 to 1.5; 51 participants; moderate‐certainty evidence). The second trial, conducted in Italy, evaluated the effect of using an absorbent cloth to wipe excess fluid after instillation (fluid removal) versus not using an absorbent cloth (no removal) on reducing dermatologic adverse events. At four months' follow‐up, eyelashes were shorter among eyes in the fluid removal group compared with the no fluid removal group (MD ‐1.70 mm, 95% CI ‐3.46 to 0.06; 10 participants; low‐certainty evidence). Fewer eyes showed skin hyperpigmentation in the eyelid region towards the nose in the fluid removal group compared with the no removal group (RR 0.07, 95% CI 0.01 to 0.84; 10 participants; low‐certainty evidence); however, the difference was uncertain in the eyelid region towards the temples (RR 0.44, 95% CI 0.07 to 2.66; 10 participants; low‐certainty evidence). The effect hypertrichosis (excessive hair growth) was uncertain between groups (RR 1.00, 95% CI 0.17 to 5.98; 10 participants; low‐certainty evidence). Neither trial reported other outcomes specified for this review, including the proportion of participants with IOP less than 21 mmHg; participant‐reported outcomes related to the ease, convenience, and comfort of instillation techniques; physiologic measurements of systemic absorption; escalation of therapy; mean change in visual fields; optic nerve progression; mean change in best‐corrected visual acuity; proportion in whom glaucoma developed; quality of life outcomes; or cost‐effectiveness outcomes. Neither trial reported data at follow‐up times of more than four months. Authors' conclusions Evidence to evaluate the effectiveness of topical medication instillation techniques for treatment of glaucoma is lacking. It is unclear what, if any, effects instillation techniques have on topical medical therapy for glaucoma. Plain language summary Topical medicine instillation techniques for glaucoma What is the aim of this review? 
 The aim of this Cochrane Review was to find out if the way that people with glaucoma put eye drops in makes a difference in how well the eye drops work. Cochrane researchers collected and analyzed all relevant studies to answer this question and found two studies. Key messages 
 It is unclear if the way that people with glaucoma put their eye drops in makes a difference in how well the drops work. What did this review study? 
 Glaucoma is a leading cause of blindness worldwide. In eyes with glaucoma, the ability to see may be lost because of damage to the optic nerve. The optic nerve is the part of the eye that sends visual information from the eye to the brain. Sometimes such damage occurs when there is too much pressure in the eye (called intraocular pressure or IOP). Sometimes eyes may have too much pressure without damage to the optic nerve (called ocular hypertension). The main goal of glaucoma and ocular hypertension treatment is to lower IOP. Topical medicines, such as eye drops, are most often used as the first treatment. Encouraging specific ways of applying the drops, such as closing your eyes or nasolacrimal occlusion (closing the eye and pressing a finger on the inside corner, by the nose) aims to increase how much medicine is absorbed into the eye and reduce how much medicine is absorbed into the body. What are the main results of the review? 
 We found two studies that compared different ways of putting in eye drops. Both studies used prostaglandin alone for glaucoma or ocular hypertension. One study, in the US, evaluated the effect of closing the eyes for one and three minutes after putting in eye drops on lowering IOP. The second study, in Italy, looked at whether wiping off the excess fluid, after putting in the eye drops, led to fewer changes in the skin surrounding the eye. After one to two weeks in the US study, closing the eyelid for one to three minutes after putting in the eye drops found no difference on IOP compared with not closing the eyelid for a specified amount of time. After four months in the Italian study, eyelashes were shorter when participants had wiped their eyes to remove excess fluid when compared with participants who did not wipe their eyes. We found two ongoing studies that do not have results yet. Based on only two studies and uncertain results, it is unclear if different ways of putting in eye drops have any effect on people with glaucoma. How up‐to‐date is this review? 
 Cochrane researchers searched for studies that had been published up to 8 December 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Xu, L; Wang, X; Wu, M", "articleTypes": [], "doi": "10.1002/14651858.CD010520.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "e7f1698c-ca20-436b-832f-32fd7c9c6138", "pmid": "", "title": "Antithyroid drug regimen for treating Graves' hyperthyroidism", "imported": false, "abstract": "Abstract - Background Antithyroid drugs are widely used in the therapy of hyperthyroidism. There are wide variations in the dose, regimen or duration of treatment used by health professionals. Objectives To assess the effects of dose, regimen and duration of antithyroid drug therapy for Graves' hyperthyroidism. Search methods We searched seven databases and reference lists. Selection criteria Randomised and quasi‐randomised trials of antithyroid medication for Graves' hyperthyroidism. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Pooling of data for primary outcomes, and select exploratory analyses were undertaken. Main results Twenty‐six randomised trials involving 3388 participants were included. Overall the quality of trials, as reported, was poor. None of the studies investigated incidence of hypothyroidism, changes in weight, health‐related quality of life, ophthalmopathy progression or economic outcomes. Four trials examined the effect of duration of therapy on relapse rates, and when using the titration regimen 12 months was superior to six months, but there was no benefit in extending treatment beyond 18 months. Twelve trials examined the effect of block‐replace versus titration block‐regimens. The relapse rates were similar in both groups at 51% in the block‐replace group and 54% in the titration block‐group (OR 0.86, 95% confidence interval (CI) 0.68 to1.08) though adverse effects (rashes (10% versus 6%) and withdrawing due to side effects (16% versus 9%)) were significantly higher in the block‐replace group. Three studies considered the addition of thyroxine with continued low dose antithyroid therapy after initial therapy with antithyroid drugs. There was significant heterogeneity between the studies and the difference between the two groups was not significant (OR 0.58, 95% CI 0.05 to 6.21). Four studies considered the addition of thyroxine alone after initial therapy with antithyroid drugs. There was no significant difference in the relapse rates between the groups after 12 months follow‐up (OR 1.15, 95% CI 0.79 to 1.67). Two studies considered the addition of immunosuppressive agents. The results which were in favour of the interventions would need to be validated in other populations. Authors' conclusions The evidence suggests that the optimal duration of antithyroid drug therapy for the titration regimen is 12 to 18 months. The titration (low dose) regimen had fewer adverse effects than the block‐replace (high dose) regimen and was no less effective. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Immunosuppressive therapies need further evaluation. Plain language summary Antithyroid drug regimen for treating Graves' hyperthyroidism People who have Graves' hyperthyroidism have thyroid glands which are releasing too much thyroid hormone. This can cause goitres (swelling in the neck around the thyroid gland), sweating, bowel or menstrual problems, and other, especially eye symptoms (ophthalmopathy). Treatments include anti‐thyroid drugs, surgery or radiation to reduce thyroid tissue. There are several choices to be made when considering the drug treatment of Graves' hyperthyroidism including the choice of drug, dose, duration of therapy, addition of thyroid hormone (thyroxine) and when to discontinue therapy. The antithyroid drugs which were used in the included randomised controlled trials (RCTs) comprised carbimazole, propylthiouracil and methimazole. Twenty‐six RCTs involving 3388 participants were identified. The majority of participants in all the studies were female (83% in the studies reporting sex distribution). The mean age was 40 years. The duration of follow up was between two to five years in eleven trials. In high dose ('block‐replace') versus low dose ('titration') studies the duration of therapy was six months in two studies, 18 months in four studies and 12 months in the remaining trials. The main outcome was the relapse rate of hyperthyroidism over one year after completion of drug treatment and this was the primary outcome in all the studies assessed. There were no deaths reported in any of the studies. None of the studies detailed incidence of hypothyroidism, changes in weight during the course of therapy, health‐related quality of life, ophthalmopathy progression or economic outcomes. The evidence (based on four studies) suggests that the optimal duration of antithyroid drug therapy for the low dose regimen is 12 to 18 months. The low dose regimen had fewer adverse effects than the high dose regimen and was no less effective in trials (based on 12 trials) of equal duration. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. Studies using immunosuppressive agents need further validation of safety and efficacy in controlled trials among different populations. Data regarding side effects and number of participants withdrawn from therapy due to side effects were available in seven studies. The number of participants reporting rashes was significantly higher in the high versus low dose group (10% versus 6%). The number of participants withdrawing due to side effects were also significantly higher in the high versus low dose group (16% versus 9%).", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Abraham, P, Avenell, A, McGeoch, SC, Clark, LF, Bevan, JS", "articleTypes": [], "doi": "10.1002/14651858.CD003420.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.777Z" }, { "id": "e7fc9b24-3546-4e15-a63b-56d0784c75bb", "pmid": "", "title": "Acupuncture for acute management and rehabilitation of traumatic brain injury", "imported": false, "abstract": "Abstract - Background Traumatic brain injury (TBI) can be life threatening depending on the severity of the insult to the brain. It can also cause a range of debilitating sequelae which require cognitive, motor, communication, emotional, or behavioral rehabilitation of varying intensity and duration. A number of studies conducted and published in China have suggested that acupuncture may be beneficial in the acute treatment and rehabilitation of TBI. Objectives To determine the efficacy and safety of acupuncture in the acute management or rehabilitation (or both) of patients with a TBI, including cognitive, neurological, motor, communication, emotional, or behavioral complications, or a combination of such complications. Search methods We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials ( The Cochrane Library ), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO and others. We also searched the Chinese Acupuncture Studies Register, the Studies Register of the Cochrane Complementary Medicine Field, NCCAM, and NIH Clinical Studies Database. Three major Mainland Chinese academic literature databases (CNKI, VIP and Wang Fang Data) were also searched using keywords in simplified Chinese. We searched all databases through December 2009, and some searches have been updated to October 2012. Selection criteria Randomized controlled studies evaluating different variants of acupuncture and involving participants of any age who had suffered a TBI. Included trials compared acupuncture with placebo or sham treatment, or acupuncture plus other treatments compared with the same other treatments. We excluded trials that only compared different variants of acupuncture or compared acupuncture alone against other treatments alone, as they did not yield the net effect of acupuncture. Data collection and analysis Two review authors identified potential articles from the literature search and extracted data independently using a data extraction form. We performed methodological assessment of included studies using the Cochrane Collaboration's tool for assessing risk of bias. We were unable to perform quantitative data analysis due to insufficient included studies and available data. Main results Four RCTs, including 294 participants, reported outcomes specified by this review. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The results seem to suggest that acupuncture is efficacious for these indications, however the low methodological quality of these studies renders the results questionable. No adverse effects of acupuncture were reported in any of the studies. Authors' conclusions The low methodological quality of the included studies does not allow us to make conclusive judgments on the efficacy and safety of acupuncture in either the acute treatment and/or rehabilitation of TBI. Its beneficial role for these indications remains uncertain. Further research with high quality trials is required. Plain language summary Acupuncture for acute management and rehabilitation of traumatic brain injury Acupuncture used for the acute treatment, rehabilitation (or both) of traumatic brain injury (TBI) has been studied in China. We conducted a systematic review to evaluate the efficacy and safety of acupuncture for these conditions. Four randomized controlled trials were eligible for inclusion in this review, involving 294 patients. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The studies were of low methodological quality and were diverse in their objectives, participant characteristics, acupuncture modalities and strategies, and outcome measures. The small number of studies together with their low methodological quality means that they are inadequate to allow any conclusion to be drawn about the efficacy and safety of acupuncture in the treatment of TBI. Further methodologically robust studies are needed to generate evidence‐based conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wong, V; Cheuk, DKL; Lee, S; Chu, V", "articleTypes": [], "doi": "10.1002/14651858.CD007700.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "e807d8fe-02f7-4f28-8a99-30aaa4311485", "pmid": "", "title": "Foetal haemoglobin inducers for reducing blood transfusion in non‐transfusion‐dependent beta‐thalassaemias", "imported": false, "abstract": "Abstract - Background Non‐transfusion‐dependent β‐thalassaemia (NTDβT) is a subset of inherited haemoglobin disorders characterised by reduced production of the β‐globin chain of haemoglobin leading to anaemia of varying severity. Although blood transfusion is not a necessity for survival, it may be required to prevent complications of chronic anaemia, such as impaired growth and hypercoagulability. People with NTDβT also experience iron overload due to increased iron absorption from food sources which becomes more pronounced in those requiring blood transfusion. People with a higher foetal haemoglobin (HbF) level have been found to require fewer blood transfusions, thus leading to the emergence of treatments that could increase its level. HbF inducers stimulate HbF production without altering any gene structures. Evidence for the possible benefits and harms of these inducers is important for making an informed decision on their use. Objectives To compare the effectiveness and safety of the following for reducing blood transfusion for people with NTDβT: 1. HbF inducers versus usual care or placebo; 2. single HbF inducer with another HbF inducer, and single dose with another dose; and 3. combination of HbF inducers versus usual care or placebo, or single HbF inducer. Search methods We used standard, extensive Cochrane search methods. The latest search date was 21 August 2022. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs comparing single HbF inducer with placebo or usual care, with another single HbF inducer or with a combination of HbF inducers; or comparing different doses of the same HbF inducer. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were blood transfusion and haemoglobin levels. Our secondary outcomes were HbF levels, the long‐term sequelae of NTDβT, quality of life and adverse events. Main results We included seven RCTs involving 291 people with NTDβT, aged two to 49 years, from five countries. We reported 10 comparisons using eight different HbF inducers (four pharmacological and four natural): three RCTs compared a single HbF inducer to placebo and seven to another HbF inducer. The duration of the intervention lasted from 56 days to six months. Most studies did not adequately report the randomisation procedures or whether and how blinding was achieved. HbF inducer against placebo or usual care Three HbF inducers, HQK‐1001, Radix Astragali or a 3‐in‐1 combined natural preparation (CNP), were compared with a placebo. None of the comparisons reported the frequency of blood transfusion. We are uncertain whether Radix Astragali and CNP increase haemoglobin at three months (mean difference (MD) 1.33 g/dL, 95% confidence interval (CI) 0.54 to 2.11; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). We are uncertain whether Radix Astragali and CNP have any effect on HbF (MD 12%, 95% CI −0.74% to 24.75%; 1 study, 2 interventions, 35 participants; very low‐certainty evidence). Only medians on haemoglobin and HbF levels were reported for HQK‐1001. Adverse effects reported for HQK‐1001 were nausea, vomiting, dizziness and suprapubic pain. There were no prespecified adverse effects for Radix Astragali and CNP. HbF inducer versus another HbF inducer Four studies compared a single inducer with another over three to six months. Comparisons included hydroxyurea versus resveratrol, hydroxyurea versus thalidomide, hydroxyurea versus decitabine and Radix Astragali versus CNP. No study reported our prespecified outcomes on blood transfusion. Haemoglobin and HbF were reported for the comparison Radix Astragali versus CNP, but we are uncertain whether there were any differences (1 study, 24 participants; low‐certainty evidence). Different doses of the same HbF inducer Two studies compared two different types of HbF inducers at different doses over two to six months. Comparisons included hydroxyurea 20 mg/kg/day versus 10 mg/kg/day and HQK‐1001 10 mg/kg/day, 20 mg/kg/day, 30 mg/kg/day and 40 mg/kg/day. Blood transfusion, as prespecified, was not reported. In one study (61 participants) we are uncertain whether the lower levels of both haemoglobin and HbF at 24 weeks were due to the higher dose of hydroxyurea (haemoglobin: MD −2.39 g/dL, 95% CI −2.80 to −1.98; very low‐certainty evidence; HbF: MD −10.20%, 95% CI −16.28% to −4.12%; very low‐certainty evidence). The study of the four different doses of HQK‐1001 did not report results for either haemoglobin or HbF. We are not certain if major adverse effects may be more common with higher hydroxyurea doses (neutropenia: risk ratio (RR) 9.93, 95% CI 1.34 to 73.97; thrombocytopenia: RR 3.68, 95% CI 1.12 to 12.07; very low‐certainty evidence). Taking HQK‐1001 20 mg/kg/day may result in the fewest adverse effects. A combination of HbF inducers versus a single HbF inducer Two studies compared three combinations of two inducers with a single inducer over six months: hydroxyurea plus resveratrol versus resveratrol or hydroxyurea alone, and hydroxyurea plus l‐carnitine versus hydroxyurea alone. Blood transfusion was not reported. Hydroxyurea plus resveratrol may reduce haemoglobin compared with either resveratrol or hydroxyurea alone (MD −0.74 g/dL, 95% CI −1.45 to −0.03; 1 study, 54 participants; low‐certainty evidence). We are not certain whether the gastrointestinal disturbances, headache and malaise more commonly reported with hydroxyurea plus resveratrol than resveratrol alone were due to the interventions. We are uncertain whether hydroxyurea plus l‐carnitine compared with hydroxyurea alone may increase mean haemoglobin, and reduce pulmonary hypertension (1 study, 60 participants; very low‐certainty evidence). Adverse events were reported but not in the intervention group. None of the comparisons reported the outcome of HbF. Authors' conclusions We are uncertain whether any of the eight HbF inducers in this review have a beneficial effect on people with NTDβT. For each of these HbF inducers, we found only one or at the most two small studies. There is no information on whether any of these HbF inducers have an effect on our primary outcome, blood transfusion. For the second primary outcome, haemoglobin, there may be small differences between intervention groups, but these may not be clinically meaningful and are of low‐ to very low‐certainty evidence. Data on adverse effects and optimal doses are limited. Five studies are awaiting classification, but none are ongoing. Plain language summary Medicines to increase foetal haemoglobin levels and reduce the need for blood transfusion in people with non‐transfusion‐dependent thalassaemia Review question Do medicines that increase foetal haemoglobin (HbF) levels in people with non‐transfusion‐dependent β‐thalassaemia (NTDβT) reduce their need for blood transfusion? What is thalassaemia? Thalassaemia is a genetic (inherited) blood disorder that causes defects in adult haemoglobin (the oxygen carrying component of red blood cells) leading to destruction of the red blood cells and anaemia with different degrees of severity. Persistent anaemia can affect general health and reduce quality of life. People with NTDβT may require periodic blood transfusion to replace the red blood cells and this could lead to excess iron being deposited in various organs in the body, affecting their function. People with NTDβT have higher levels of HbF (the main form of haemoglobin found during the development of a baby before birth) which persists after birth. The amount of HbF that persists varies and people with a higher HbF level require less frequent blood transfusions. What are HbF inducers? HbF inducers are substances which increase HbF levels without alteration to the gene. They may reduce the need for blood transfusion in people with NTDβT. However, it is not known which HbF inducers are effective and safe, and if so, what the optimal dose is and at what age treatment should be started. What did we do? We searched medical databases for studies comparing single HbF inducer with placebo (dummy treatment) or usual care, with another inducer or with a combination of inducers; or comparing different doses for a same inducer. What did we find? We found seven very small randomised controlled trials (where people taking part in the trial had equal chances of being in the treatment or the control group), involving 291 people with NTDβT, aged between two and 49 years, from five countries. These studies varied widely in the type of HbF inducers investigated and their comparison, the doses and how outcomes were reported. The duration of the trials ranged from two to six months. The inducers used include hydroxyurea, decitabine, HQK‐1001, thalidomide, Radix Astragali, resveratrol, l‐carnitine and combined natural preparation (CNP). Main results None of the studies reported our main outcome of changes to the frequency of blood transfusion. All inducers may have caused a small increase in haemoglobin and HbF when compared to placebo, but we are very uncertain about this. Four studies compared a single HbF inducer against another, for three to six months. There were changes to haemoglobin and HbF, but we cannot be certain if a single HbF inducer or a combination of HbF inducers would work better than another. Two studies, each compared a different dose of the same inducer. Lower doses of hydroxyurea appeared to increase haemoglobin and HbF levels more than the higher doses, but we are very uncertain. The other study used four different doses of HQK‐1001 but did not actually look for a difference in the effect of these four different doses on haemoglobin or HbF. Two studies compared a combination of two HbF inducers with a single HbF inducer for six months. We are very uncertain whether the combination or a single inducer improves haemoglobin. None of the studies reported whether HbF inducers have any effect on quality of life. Adverse (unwanted) drug effects were reported for each HbF inducer, but there was little information available to guide us on the safety of these substances. What are the limitations of the evidence? The main reason we are very uncertain about the effects of HbF inducers are because the studies were all very small and had weaknesses in their design. None of the studies lasted long enough to provide meaningful information for many of the outcomes we measured. How up to date is this evidence? The evidence is current to 21 August 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Foong, WC; Loh, CK; Ho, JJ; Lau, DSC", "articleTypes": [], "doi": "10.1002/14651858.CD013767.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "e82416e6-a3f3-4c4b-b97f-27a92c18841d", "pmid": "", "title": "Drugs for preventing malaria in pregnant women in endemic areas: any drug regimen versus placebo or no treatment", "imported": false, "abstract": "Abstract - Background Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. To reduce these effects, the World Health Organization recommends that pregnant women living in malaria endemic areas sleep under insecticide‐treated bednets, are treated for malaria illness and anaemia, and receive chemoprevention with an effective antimalarial drug during the second and third trimesters. Objectives To assess the effects of malaria chemoprevention given to pregnant women living in malaria endemic areas on substantive maternal and infant health outcomes. We also summarised the effects of intermittent preventive treatment with sulfadoxine‐pyrimethamine (SP) alone, and preventive regimens for Plasmodium vivax. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and reference lists up to 1 June 2014. Selection criteria Randomized controlled trials (RCTs) and quasi‐RCTs of any antimalarial drug regimen for preventing malaria in pregnant women living in malaria‐endemic areas compared to placebo or no intervention. In the mother, we sought outcomes that included mortality, severe anaemia, and severe malaria; anaemia, haemoglobin values, and malaria episodes; indicators of malaria infection, and adverse events. In the baby, we sought foetal loss, perinatal, neonatal and infant mortality; preterm birth and birthweight measures; and indicators of malaria infection. We included regimens that were known to be effective against the malaria parasite at the time but may no longer be used because of parasite drug resistance. Data collection and analysis Two review authors applied inclusion criteria, assessed risk of bias and extracted data. Dichotomous outcomes were compared using risk ratios (RR), and continuous outcomes using mean differences (MD); both are presented with 95% confidence intervals (CI). We assessed the quality of evidence using the GRADE approach. Main results Seventeen trials enrolling 14,481 pregnant women met our inclusion criteria. These trials were conducted between 1957 and 2008, in Nigeria (three trials), The Gambia (three trials), Kenya (three trials), Mozambique (two trials), Uganda (two trials), Cameroon (one trial), Burkina Faso (one trial), and Thailand (two trials). Six different antimalarials were evaluated against placebo or no intervention; chloroquine (given weekly), pyrimethamine (weekly or monthly), proguanil (daily), pyrimethamine‐dapsone (weekly or fortnightly), and mefloquine (weekly), or intermittent preventive therapy with SP (given twice, three times or monthly). Trials recruited women in their first or second pregnancy (eight trials); only multigravid women (one trial); or all women (eight trials). Only six trials had adequate allocation concealment. For women in their first or second pregnancy, malaria chemoprevention reduces the risk of moderate to severe anaemia by around 40% (RR 0.60, 95% CI 0.47 to 0.75; three trials, 2503 participants, high quality evidence ), and the risk of any anaemia by around 17% (RR 0.83, 95% CI 0.74 to 0.93; five trials,, 3662 participants, high quality evidence ). Malaria chemoprevention reduces the risk of antenatal parasitaemia by around 61% (RR 0.39, 95% CI 0.26 to 0.58; seven trials, 3663 participants, high quality evidence ), and two trials reported a reduction in febrile illness ( low quality evidence ). There were only 16 maternal deaths and these trials were underpowered to detect an effect on maternal mortality ( very low quality evidence ). For infants of women in their first and second pregnancies, malaria chemoprevention probably increases mean birthweight by around 93 g (MD 92.72 g, 95% CI 62.05 to 123.39; nine trials, 3936 participants, moderate quality evidence ), reduces low birthweight by around 27% (RR 0.73, 95% CI 0.61 to 0.87; eight trials, 3619 participants, moderate quality evidence ), and reduces placental parasitaemia by around 46% (RR 0.54, 95% CI 0.43 to 0.69; seven trials, 2830 participants, high quality evidence ). Fewer trials evaluated spontaneous abortions, still births, perinatal deaths, or neonatal deaths, and these analyses were underpowered to detect clinically important differences. In multigravid women, chemoprevention has similar effects on antenatal parasitaemia (RR 0.38, 95% CI 0.28 to 0.50; three trials, 977 participants, high quality evidence )but there are too few trials to evaluate effects on other outcomes. In trials giving chemoprevention to all pregnant women irrespective of parity, the average effects of chemoprevention measured in all women indicated it may prevent severe anaemia (defined by authors, but at least < 8 g/L: RR 0.19, 95% CI 0.05 to 0.75; two trials, 1327 participants, low quality evidence), but consistent benefits have not been shown for other outcomes. In an analysis confined only to intermittent preventive therapy with SP, the estimates of effect and the quality of the evidence were similar. A summary of a single trial in Thailand of prophylaxis against P. vivax showed chloroquine prevented vivax infection (RR 0.01, 95% CI 0.00 to 0.20; one trial, 942 participants). Authors' conclusions Routine chemoprevention to prevent malaria and its consequences has been extensively tested in RCTs, with clinically important benefits on anaemia and parasitaemia in the mother, and on birthweight in infants. 8 May 2019 No update planned Review superseded The intervention is clearly effective. The questions now are around head‐to‐head comparisons not included in this review. Plain language summary The effect of taking antimalarial drugs routinely to prevent malaria in pregnancy Pregnancy increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. For this reason, women are encouraged to try and prevent malaria infection during pregnancy by sleeping under mosquito bed‐nets, and by taking drugs effective against malaria throughout pregnancy as chemoprevention. This Cochrane Review looked at all drug regimens compared to placebo. The review authors sought to summarise and quantify the overall effects of chemoprevention. Seventeen trials were included, all conducted between 1957 and 2008, and all but two in countries of Africa. For women in their first or second pregnancy, malaria chemoprevention prevents moderate to severe anaemia ( high quality evidence ); and prevents malaria parasites being detected in the blood ( high quality evidence ). It may also prevent malaria illness. We don't know if it prevents maternal deaths, as this would require very large studies to detect an effect. In their infants, malaria chemoprevention improves the average birthweight ( moderate quality evidence ), and reduces the number of low birthweight infants ( moderate quality evidence ). We are not sure if chemoprevention reduces mortality of babies in the first week, month and year, as again studies would need to be very large to show these effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Radeva‐Petrova, D, Kayentao, K, ter Kuile, FO, Sinclair, D, Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD000169.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.758Z" }, { "id": "e828cc8e-7379-4e07-a9df-3ce7283bc196", "pmid": "", "title": "Blood pressure lowering efficacy of beta‐blockers as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Beta‐blockers are one of the more commonly prescribed classes of anti‐hypertensive drugs, both as first‐line and second‐line. Objectives To quantify the effect on systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and withdrawals due to adverse effects of beta‐blocker therapy when given as a second‐line drug in adult patients with primary hypertension. Search methods CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1966‐Aug 2009), EMBASE (1988‐Aug 2009) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized controlled trials comparing a beta‐blocker in combination with a drug from another class of anti‐hypertensive drugs compared with that drug alone for a duration of 3 to 12 weeks in patients with primary hypertension were included. Data collection and analysis Two reviewers independently extracted the data and assessed trial quality of each included study. Main results 20 double‐blind RCTs evaluated the BP lowering efficacy of beta‐blockers as second‐line drug in 3744 hypertensive patients (baseline BP of 158/102 mmHg; mean duration of 7 weeks). The BP reduction from adding a beta‐blocker as the second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. A reduction in BP was seen with adding a beta‐blocker to thiazide diuretics or calcium channel blockers at doses as low as 0.25 times the manufacturer's recommended starting dose. The BP lowering efficacy of beta‐blockers as a second drug was 6/4 mmHg at 1 times the starting dose and 8/6 mmHg at 2 times the starting dose. Beta‐blockers reduced heart rate by 10 beats/min at 1 to 2 times the starting dose. Beta‐blockers did not statistically significantly increase withdrawals due to adverse effects but this was likely due to the lack of reporting of this outcome in 35% of the included RCTs. Authors' conclusions Addition of a beta‐blocker to diuretics or calcium‐channel blockers reduces BP by 6/4mmHg at 1 times the starting dose and by 8/6 mmHg at 2 times the starting dose. When the blood pressure lowering effect of beta‐blockers from this review was compared to that of thiazide diuretics from our previous review ( Chen 2009 ), second‐line beta‐blockers reduce systolic BP to the same extent as second‐line thiazide diuretics, but reduce diastolic BP to a greater degree. The different effect on diastolic BP means that beta‐blockers have little or no effect on pulse pressure whereas thiazides cause a significant dose‐related decrease in pulse pressure. This difference in the pattern of BP lowering with beta‐blockers as compared to thiazides might be the explanation for the fact that beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than thiazide diuretics, particularly in older individuals. Plain language summary Beta‐blockers lower blood pressure when given as a second drug Beta‐blockers are commonly used in the treatment for high blood pressure (BP). In this review, we asked how much do beta‐blockers reduce BP when used as the second drug to treat hypertension. Twenty trials lasting an average of 7 weeks were found in the world scientific literature to answer this question. The data showed that the addition of a beta‐blocker to thiazide diuretics or calcium channel blockers reduced BP by 8/6 mmHg when given at doses 2 times the recommended starting dose. When we compared these results with our previous review of the blood pressure lowering effect of thiazide diuretics as second line drug, we found that beta‐blockers have a different pattern of BP lowering. This different pattern of effect on blood pressure might explain why first‐line beta‐blockers appear to be less effective at reducing adverse cardiovascular outcomes than first‐line thiazide diuretics, particularly in older individuals.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, JMH; Heran, BS; Perez, MI; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007185.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "e82e2b39-8a6e-4048-8eba-6c2626fbb5f6", "pmid": "", "title": "Fortification of maize flour with iron for controlling anaemia and iron deficiency in populations", "imported": false, "abstract": "Abstract - Background Approximately 800 million women and children have anaemia, a condition thought to cause almost 9% of the global burden of years lived with disability. Around half this burden could be amenable to interventions that involve the provision of iron. Maize (corn) is one of the world's most important cereal grains and is cultivated across most of the globe. Several programmes around the world have fortified maize flour and other maize‐derived foodstuffs with iron and other vitamins and minerals to combat anaemia and iron deficiency. Objectives To assess the effects of iron fortification of maize flour, corn meal and fortified maize flour products for anaemia and iron status in the general population. Search methods We searched the following international and regional sources in December 2017 and January 2018: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE (R) In Process; Embase; Web of Science (both the Social Science Citation Index and the Science Citation Index); CINAHL Ebsco; POPLINE; AGRICOLA ( agricola.nal.usda.gov ); BIOSIS (ISI); Bibliomap and TRoPHI; IBECS; Scielo; Global Index Medicus ‐ AFRO (includes African Index Medicus); EMRO (includes Index Medicus for the Eastern Mediterranean Region); LILACS; PAHO (Pan American Health Library); WHOLIS (WHO Library); WPRO (includes Western Pacific Region Index Medicus); IMSEAR, Index Medicus for the South‐East Asian Region; IndMED, Indian medical journals; and the Native Health Research Database. We searched clinicaltrials.gov and the International Clinical Trials Registry Platform ( ICTRP ) for any ongoing or planned studies on 17 January 2018 and contacted authors of such studies to obtain further information or eligible data if available. For assistance in identifying ongoing or unpublished studies, we also contacted relevant international organisations and agencies working in food fortification on 9 August 2016. Selection criteria We included cluster‐ or individually randomised controlled trials and observational studies. Interventions included (central/industrial) fortification of maize flour or corn meal with iron alone or with other vitamins and minerals and provided to individuals over 2 years of age (including pregnant and lactating women) from any country. Data collection and analysis Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies and assessed the risk of bias of the included studies. Trial designs with a comparison group were included to assess the effects of interventions. Trial designs without a control or comparison group (uncontrolled before‐and‐after studies) were included for completeness but were not considered in assessments of the overall effectiveness of interventions or used to draw conclusions regarding the effects of interventions in the review. Main results Our search yielded 4529 records. After initial screening of titles and abstracts, we reviewed the full text of 75 studies (80 records). We included 5 studies and excluded 70. All the included studies assessed the effects of providing maize products fortified with iron plus other vitamins and minerals versus unfortified maize flour. No studies compared this intervention to no intervention or looked at the relative effect of flour and products fortified with iron alone (without other vitamins and minerals). Three were randomised trials involving 2610 participants, and two were uncontrolled before‐and‐after studies involving 849 participants. Only three studies contributed data for the meta‐analysis and included children aged 2 to 11.9 years and women. Compared to unfortified maize flour, it is uncertain whether fortifying maize flour or corn meal with iron and other vitamins and minerals has any effect on anaemia (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.58 to 1.40; 2 studies; 1027 participants; very low‐certainty evidence), or on the risk of iron deficiency (RR 0.75, 95% CI 0.49 to 1.15; 2 studies; 1102 participants; very low‐certainty evidence), haemoglobin concentration (mean difference (MD) 1.25 g/L, 95% CI −2.36 to 4.86 g/L; 3 studies; 1144 participants; very low‐certainty evidence) or ferritin concentrations (MD 0.48 µg/L, 95% CI −0.37 to 1.33 µg/L; 1 study; 584 participants; very low‐certainty evidence). None of the studies reported on any adverse effects. We judged the certainty of the evidence to be very low based on GRADE, so we are uncertain whether the results reflect the true effect of the intervention. We downgraded evidence due to high risk of selection bias and unclear risk of performance bias in one of two included studies, high heterogeneity and wide CIs crossing the line of no effect for anaemia prevalence and haemoglobin concentration. Authors' conclusions It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of anaemia or iron deficiency in children aged over 2 years or in adults. Moreover, the evidence is too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population, as the certainty of the evidence is very low. No studies reported on any adverse effects. Public organisations funded three of the five included studies, while the private sector gave grants to universities to perform the other two. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. The reduced number of studies, including only two age groups (children and women of reproductive age), as well as the limited number of comparisons (only one out of the four planned) constitute the main limitations of this review. Plain language summary Fortification of maize flour with iron for preventing anaemia and iron deficiency What is the aim of this review? The aim of this Cochrane Review was to determine the effects of fortifying maize flour, corn meal and fortified‐maize flour products with iron for anaemia and iron status in the general population. We searched for relevant published studies to answer this question and analysed all relevant information. Key messages It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We do not know whether fortifying maize flour with iron reduces anaemia in the general population, as the evidence was very unreliable. No studies reported on any harmful effects. What was studied in the review? Approximately 496 million non‐pregnant women, 32 million pregnant women, and 273 million children were thought to be anaemic as of 2011. Iron deficiency is considered to be the single most prevalent nutrient deficiency worldwide, but at least half this burden is considered responsive to interventions that involve providing people with iron. Fortification means adding vitamins and minerals to foods to increase their nutritional value. In public health, fortifying staple foods is considered one way of reducing micronutrient deficiencies without changing usual and culturally acceptable diets. Maize (corn) is one of the world's most important cereal grains. In sub‐Saharan Africa, some parts of Southeast Asia and Latin America, where iron deficiency is endemic, maize is a dietary staple for more than 200 million people. Fortification of maize flour with iron (and in some cases, other nutrients) is mandatory in Brazil, Costa Rica, El Salvador, Kenya, Mexico, Nigeria, Rwanda, South Africa, Tanzania, Uganda, the USA and Venezuela. What are the main results of the review? We found five relevant studies, but none looked at the effects of maize flour or maize flour products fortified with iron alone. Five studies compared the effects of maize flour or maize‐flour products fortified with iron plus other vitamins and minerals versus unfortified maize flours or maize‐flour products (not containing iron or any other vitamin and minerals). Three of these five studies randomly divided a collective total of 2302 children aged 2 to 12 years and 130 indigenous women into groups receiving fortified versus unfortified maize flour or corn flour. One study was from Kenya and the other two took place in Mexico. The remaining two studies did not provide data to assess the effects of fortification relative to a comparison group. Three of five of the included studies were funded by public organisations and two by funds granted by private sector to universities. The presence of industry funding for some of these trials did not appear to positively influence results from these studies. It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of iron deficiency in the general population. The evidence is also too uncertain to conclude whether iron‐fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population. We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population. How up‐to‐date is this review? We searched for studies that had been published up to 17 January 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Garcia‐Casal, MN, Peña‐Rosas, JP, De‐Regil, LM, Gwirtz, JA, Pasricha, SR", "articleTypes": [], "doi": "10.1002/14651858.CD010187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.761Z" }, { "id": "e832e772-9dbd-4083-86c4-08d19ff0e4ef", "pmid": "", "title": "Sumatriptan (oral route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Objectives To determine the efficacy and tolerability of oral sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using oral sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Sixty‐one studies (37,250 participants) compared oral sumatriptan with placebo or an active comparator. Most of the data were for the 50 mg and 100 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 50 mg versus placebo the NNTs were 6.1, 7.5, and 4.0 for pain‐free at two hours and headache relief at one and two hours, respectively. NNTs for sustained pain‐free and sustained headache relief during the 24 hours postdose were 9.5 and 6.0, respectively. For sumatriptan 100 mg versus placebo the NNTs were 4.7, 6.8, 3.5, 6.5, and 5.2, respectively, for the same outcomes. Results for the 25 mg dose were similar to the 50 mg dose, while sumatriptan 100 mg was significantly better than 50 mg for pain‐free and headache relief at two hours, and for sustained pain‐free during 24 hours. Treating early, during the mild pain phase, gave significantly better NNTs for pain‐free at two hours and sustained pain‐free during 24 hours than did treating established attacks with moderate or severe pain intensity. Relief of associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than with placebo. For the most part, adverse events were transient and mild and were more common with the sumatriptan than with placebo, with a clear dose response relationship (25 mg to 100 mg). Sumatriptan was compared directly with a number of active treatments, including other triptans, paracetamol (acetaminophen), acetylsalicylic acid, non‐steroidal anti‐inflammatory drugs (NSAIDs), and ergotamine combinations. Authors' conclusions Oral sumatriptan is effective as an abortive treatment for migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (oral route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is widely available as an oral tablet. This review found that a single dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in about 3 in 10 people (32%) taking sumatriptan 100 mg, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 6 in 10 people (61%) taking sumatriptan 100 mg, compared with about 3 in 10 (32%) taking placebo. Almost a quarter (24%) of people taking sumatriptan 100 mg had freedom from pain at two hours which was sustained during 24 hours without the use of rescue medication, compared with fewer than 1 in 10 (8%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events were mostly of short duration and mild or moderate in severity, and were experienced by about 4 in 10 (43%) of people taking sumatriptan 100 mg, and by 2 in 10 (23%) taking placebo. The 50 mg dose had slightly lower efficacy, but was associated with fewer adverse events. Treating attacks while pain was still mild was more effective than treating established attacks with moderate or severe pain intensity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008615.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "e84a7eae-fea6-455c-a934-64325277c1ab", "pmid": "", "title": "Pharmacological interventions for self‐harm in adults", "imported": false, "abstract": "Abstract - Background Self‐harm (SH; intentional self‐poisoning or self‐injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm. Objectives To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta‐analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients. Search methods For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co‐ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013. Selection criteria We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services. Data collection and analysis We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta‐analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow‐up. For this analysis, we pooled data using a random‐effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach. Main results We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low‐dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported. Authors' conclusions Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment. Plain language summary Drugs and natural products for self‐harm in adults We have reviewed the international literature regarding pharmacological (drug) and natural product (dietary supplementation) treatment trials in this field. A total of seven trials meeting our inclusion criteria were identified. There is little evidence of beneficial effects of either pharmacological or natural product treatments. However, few trials have been conducted and those that have are small, meaning that possible beneficial effects of some therapies cannot be ruled out. Why is this review important? Self‐harm (SH), which includes intentional self‐poisoning/overdose and self‐injury, is a major problem in many countries and is strongly linked to suicide. It is therefore important that effective treatments for SH patients are developed. Whilst there has been an increase in the use of psychosocial interventions for SH in adults (which is the focus of a separate review), drug treatments are frequently used in clinical practice. It is therefore important to assess the evidence for their effectiveness. Who will be interested in this review? Clinicians working with patients who engage in SH, patients themselves, and their relatives. What questions does this review aim to answer? This review is an update of a previous Cochrane review from 1999 which found little evidence of beneficial effects of drug treatments on repetition of SH apart from for flupenthixol. This update aims to further evaluate the evidence for effectiveness of drugs and natural products for patients with SH with a broader range of outcomes. Which studies were included in the review? To be included in the review, studies had to be randomised controlled trials of drug treatments for adults who had recently engaged in SH. What does the evidence from the review tell us? There is currently no clear evidence for the effectiveness of antidepressants, antipsychotics, mood stabilisers, or natural products in preventing repetition of SH. What should happen next? We recommend further trials of drugs for SH patients, possibly in combination with psychological treatment.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hawton, K; Witt, KG; Taylor Salisbury, TL; Arensman, E; Gunnell, D; Hazell, P; Townsend, E; van Heeringen, K", "articleTypes": [], "doi": "10.1002/14651858.CD011777", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "e858972b-508b-461d-b111-c153cddc432d", "pmid": "", "title": "Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Romero, L, Huerfano, C, Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD012492.pub2 AB - Abstract - Background Chancroid is a genital ulcerative disease caused by Haemophilus ducreyi . This microorganism is endemic in Africa, where it can cause up to 10% of genital ulcers. Macrolides may be an effective alternative to treat chancroid and, based on their oral administration and duration of therapy, could be considered as first line therapy. Objectives To assess the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults. Search methods We searched the Cochrane STI Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, WHO ICTRP, ClinicalTrials.gov and Web of Science to 30 October 2017. We also handsearched conference proceedings and reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) comparing macrolides in different regimens or with other therapeutic alternatives for chancroid. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We resolved disagreements through consensus. We used the GRADE approach to assess the quality of the evidence. Main results Seven RCTs (875 participants) met our inclusion criteria, of which four were funded by industry. Five studies (664 participants) compared macrolides with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Low quality evidence suggested there was no difference between the groups after treatment in terms of clinical cure (risk ratio (RR) 1.09, 95% confidence interval (CI) 0.97 to 1.21; 2 studies, 340 participants with syndromic approach and RR 1.06, 95% CI 0.98 to 1.15; 5 studies, 348 participants with aetiological diagnosis) or improvement (RR 0.89, 95% CI 0.52 to 1.52; 2 studies, 340 participants with syndromic approach and RR 0.80, 95% CI 0.42 to 1.51; 3 studies, 187 participants with aetiological diagnosis). Based on low and very low quality evidence, there was no difference between macrolides and any other antibiotic treatments for microbiological cure (RR 0.93, 95% CI 0.74 to 1.16; 1 study, 45 participants) and minor adverse effects (RR 1.34, 95% CI 0.24 to 7.51; 3 studies, 412 participants). Two trials (269 participants) compared erythromycin with any other macrolide type. Low quality evidence suggested that, compared with azithromycin or rosaramicin, long courses of erythromycin did not increase clinical cure (RR 1.00, 95% CI 0.91 to 1.10; 2 studies, 269 participants with syndromic approach and RR 1.04, 95% CI 0.93 to 1.16; 2 studies, 211 participants with aetiological diagnosis), with a similar frequency of minor adverse effects between the groups (RR 1.14, 95% CI 0.63 to 2.06; 1 trial, 101 participants). For this comparison, subgroup analysis found no difference between HIV‐positive participants (RR 1.02, 95% CI 0.73 to 1.43; 1 study, 38 participants) and HIV‐negative participants (RR 1.04, 95% CI 0.94 to 1.14; 1 study, 89 participants). We downgraded the quality of evidence to low, because of imprecision, some limitations on risk of bias and heterogeneity. None of the trials reported serious adverse events, cost effectiveness and participant satisfaction. Authors' conclusions At present, the quality of the evidence on the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults is low, implying that we are uncertain about the estimated treatment effect. There is no statistically significant difference between the available therapeutic alternatives for the treatment of sexually active adults with genital ulcers compatible with chancroid. Low quality evidence suggests that azithromycin could be considered as the first therapeutic alternative, based on their mono‐dose oral administration, with a similar safety and effectiveness profile, when it is compared with long‐term erythromycin use. Due to sparse available evidence about the safety and effectiveness of macrolides to treat H ducreyi infection in people with HIV, these results should be taken with caution. Plain language summary Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults Review question 
 In this Cochrane Review, we assess the effectiveness and safety of macrolides in different regimens or with other treatments for H ducreyi infection in adults. Background Chancroid is a sexually transmitted infection (STI) caused by infection with a bacteria called Haemophilus ducreyi . It causes ulcers in the genital area and is endemic in some low‐income countries. Control and eradication of chancroid could reduce transmission of the STI from one sexual partner to another. Macrolides are antibiotics that could be effective and safe for treating H ducreyi infection. Trial characteristics We searched the available literature up to 30 October 2017 and we included seven trials with 875 participants. The trials recruited men and non‐pregnant women over the age of 16 years who presented with genital ulcers compatible with chancroid. Three studies included people with high‐risk sexual behaviour as migrant mine workers, sex workers and men with prostitute contact. All the trials tested for other STIs, and discarded people who were also infected with syphilis and herpes simple virus. One study included people with HIV. The most frequent antibiotic treatment was erythromycin with azithromycin as an alternative. They were compared with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Five studies compared two types of antibiotic and two studies compared different ways of treating with macrolides. Four trials were funded by pharmaceutical companies. Key results There was no difference between the types of antibiotics in sexually active adults with genital ulcers compatible with chancroid. Erythromycin is usually the first choice for treatment but low quality evidence suggested that azithromycin (as a single dose, oral (by mouth) administration) had similar safety and effectiveness. Because of sparse evidence about the safety and effectiveness of macrolides to treat Haemophilus ducreyi infection in people with HIV, these results should be taken with caution. Quality of evidence The quality of evidence was low as there was a risk of bias due to poor methods, people dropping out of the study and pharmaceutical companies sponsored four studies.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.794Z" }, { "id": "e8801a0d-c7db-4497-a535-d3b646e62cf0", "pmid": "", "title": "Dietary supplements for dysmenorrhoea", "imported": false, "abstract": "Abstract - Background Dysmenorrhoea refers to painful menstrual cramps and is a common gynaecological complaint. Conventional treatments include non‐steroidal anti‐inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs), which both reduce myometrial activity (contractions of the uterus). A suggested alternative approach is dietary supplements. We used the term 'dietary supplement' to include herbs or other botanical, vitamins, minerals, enzymes, and amino acids. We excluded traditional Chinese medicines. Objectives To determine the efficacy and safety of dietary supplements for treating dysmenorrhoea. Search methods We searched sources including the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, PsycINFO (all from inception to 23 March 2015), trial registries, and the reference lists of relevant articles. Selection criteria We included randomised controlled trials (RCTs) of dietary supplements for moderate or severe primary or secondary dysmenorrhoea. We excluded studies of women with an intrauterine device. Eligible comparators were other dietary supplements, placebo, no treatment, or conventional analgesia. Data collection and analysis Two review authors independently performed study selection, performed data extraction and assessed the risk of bias in the included trials. The primary outcomes were pain intensity and adverse effects. We used a fixed‐effect model to calculate odds ratios (ORs) for dichotomous data, and mean differences (MDs) or standardised mean differences (SMDs) for continuous data, with 95% confidence intervals (CIs). We presented data that were unsuitable for analysis either descriptively or in additional tables. We assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods. Main results We included 27 RCTs (3101 women). Most included studies were conducted amongst cohorts of students with primary dysmenorrhoea in their late teens or early twenties. Twenty‐two studies were conducted in Iran and the rest were performed in other middle‐income countries. Only one study addressed secondary dysmenorrhoea. Interventions included 12 different herbal medicines (German chamomile ( Matricaria chamomilla, M recutita, Chamomilla recutita) , cinnamon ( Cinnamomum zeylanicum, C. verum) , Damask rose ( Rosa damascena), dill ( Anethum graveolens ), fennel ( Foeniculum vulgare ), fenugreek ( Trigonella foenum‐graecum ), ginger ( Zingiber officinale ), guava ( Psidium guajava ), rhubarb ( Rheum emodi ), uzara ( Xysmalobium undulatum ), valerian ( Valeriana officinalis ), and zataria ( Zataria multiflora )) and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Comparators included other supplements, placebo, no treatment, and NSAIDs. We judged all the evidence to be of low or very low quality. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few studies reported adverse effects. Effectiveness of supplements for primary dysmenorrhoea We have presented pain scores (all on a visual analogue scale (VAS) 0 to 10 point scale) or rates of pain relief, or both, at the first post‐treatment follow‐up. Supplements versus placebo or no treatment There was no evidence of effectiveness for vitamin E (MD 0.00 points, 95% CI −0.34 to 0.34; two RCTs, 135 women). There was no consistent evidence of effectiveness for dill (MD ‐1.15 points, 95% CI −2.22 to −0.08, one RCT, 46 women), guava (MD 0.59, 95% CI −0.13 to 1.31; one RCT, 151 women); one RCT, 73 women), or fennel (MD −0.34 points, 95% CI −0.74 to 0.06; one RCT, 43 women). There was very limited evidence of effectiveness for fenugreek (MD −1.71 points, 95% CI −2.35 to −1.07; one RCT, 101 women), fish oil (MD 1.11 points, 95% CI 0.45 to 1.77; one RCT, 120 women), fish oil plus vitamin B1 (MD −1.21 points, 95% CI −1.79 to −0.63; one RCT, 120 women), ginger (MD −1.55 points, 95% CI −2.43 to −0.68; three RCTs, 266 women; OR 5.44, 95% CI 1.80 to 16.46; one RCT, 69 women), valerian (MD −0.76 points, 95% CI −1.44 to −0.08; one RCT, 100 women), vitamin B1 alone (MD −2.70 points, 95% CI −3.32 to −2.08; one RCT, 120 women), zataria (OR 6.66, 95% CI 2.66 to 16.72; one RCT, 99 women), and zinc sulphate (MD −0.95 points, 95% CI −1.54 to −0.36; one RCT, 99 women). Data on chamomile and cinnamon versus placebo were unsuitable for analysis. Supplements versus NSAIDS There was no evidence of any difference between NSAIDs and dill (MD 0.13 points, 95% CI −1.01 to 1.27; one RCT, 47 women), fennel (MD −0.70 points, 95% CI −1.81 to 0.41; one RCT, 59 women), guava (MD 1.19, 95% CI 0.42 to 1.96; one RCT, 155 women), rhubarb (MD −0.20 points, 95% CI −0.44 to 0.04; one RCT, 45 women), or valerian (MD points 0.62 , 95% CI 0.03 to 1.21; one RCT, 99 women), There was no consistent evidence of a difference between Damask rose and NSAIDs (MD −0.15 points, 95% CI −0.55 to 0.25; one RCT, 92 women). There was very limited evidence that chamomile was more effective than NSAIDs (MD −1.42 points, 95% CI −1.69 to −1.15; one RCT, 160 women). Supplements versus other supplements There was no evidence of a difference in effectiveness between ginger and zinc sulphate (MD 0.02 points, 95% CI −0.58 to 0.62; one RCT, 101 women). Vitamin B1 may be more effective than fish oil (MD −1.59 points, 95% CI −2.25 to −0.93; one RCT, 120 women). Effectiveness of supplements for secondary dysmenorrhoea There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis (data were unsuitable for analysis). Safety of supplements Only four of the 27 included studies reported adverse effects in both treatment groups. There was no evidence of a difference between the groups but data were too scanty to reach any conclusions about safety. Authors' conclusions There is no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety is lacking. However for several supplements there was some low quality evidence of effectiveness and more research is justified. Plain language summary Dietary supplements for pain during menstruation Review question Cochrane authors reviewed the evidence of the effect of dietary supplements (e.g. vitamins, minerals, herbs) on period pain (dysmenorrhoea). Background Dietary supplements have been used in the treatment of period pain. It is important to explore their benefits and harms. We investigated the effectiveness of dietary supplements compared to other supplements, placebo, no treatment or conventional analgesics (pain relief) in women with either primary dysmenorrhoea (not related to any other diagnosis) or secondary dysmenorrhoea (related to other causes, such as endometriosis). The evidence is current to 23 March 2015. Study characteristics We included 27 randomised controlled trials (3101 women). Most participants were students in their late teens or early twenties with primary dysmenorrhoea. Most studies were conducted in Iran. Interventions included 12 different herbal medicines (chamomile, cinnamon, Damask rose, dill, fennel, fenugreek, ginger, guava, rhubarb, uzara, valerian, and zataria), and five non‐herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Supplements were compared with other supplements, placebo, no treatment, and non‐steroidal anti‐inflammatory drugs (NSAIDs). Key results There was no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety was lacking. However, for several supplements there was some low quality evidence of effectiveness. Supplements for which there was some very limited evidence to suggest a potential benefit were fenugreek, ginger, valerian, zataria, zinc sulphate, fish oil, and vitamin B1. There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis. Quality of the evidence The evidence was of low or very low quality for all comparisons. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few included studies reported adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Pattanittum, P; Kunyanone, N; Brown, J; Sangkomkamhang, US; Barnes, J; Seyfoddin, V; Marjoribanks, J", "articleTypes": [], "doi": "10.1002/14651858.CD002124.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "e88baf3a-b007-48fa-be1f-ecf548f7a2ef", "pmid": "", "title": "The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents", "imported": false, "abstract": "Abstract - Background Erythropoiesis‐stimulating agents (ESAs) are commonly used to treat chemotherapy‐induced anemia (CIA). However, about half of patients do not benefit. Objectives To evaluate the benefits and harms related to the use of iron as a supplement to ESA and iron alone compared with ESA alone in the management of CIA. Search methods We searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1 January 2016), MEDLINE (1950 to February 2016), and www.clinicaltrials.gov without using any language limits. Selection criteria All randomized controlled trials (RCTs) comparing 'iron plus ESA' or 'iron alone' versus 'ESA alone' in people with CIA were eligible for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included eight RCTs (12 comparisons) comparing ESA plus iron versus ESA alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone in people with CIA. None of the included RCTs reported overall survival. There was a beneficial effect of iron supplementation to ESAs compared with ESAs alone on hematopoietic response (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.09 to 1.26; P < 0.0001; 1712 participants; 11 comparisons; high‐quality evidence). Assuming a baseline risk of 35% to 80% for hematopoietic response without iron supplementation, between seven and 16 patients should be treated to achieve hematopoietic response in one patient. In subgroup analyses, RCTs that used intravenous (IV) iron favored ESAs and iron (RR 1.20 (95% CI 1.10 to 1.31); P < 0.00001; 1321 participants; eight comparisons), whereas we found no evidence for a difference in hematopoietic response in RCTs using oral iron (RR 1.04 (95% CI 0.87 to 1.24); P = 0.68; 391 participants; three comparisons). There was no evidence for a difference between the subgroups of IV and oral iron (P = 0.16). There was no evidence for a difference between the subgroups of types of iron (P = 0.31) and types of ESAs (P = 0.16) for hematopoietic response. The iron supplementation to ESAs might be beneficial as fewer participants treated with iron supplementation required red blood cell (RBC) transfusions compared to the number of participants treated with ESAs alone (RR 0.74 (95% CI 0.60 to 0.92); P = 0.007; 1719 participants; 11 comparisons; moderate‐quality evidence). Assuming a baseline risk of 7% to 40% for RBC transfusion without iron supplementation, between 10 and 57 patients should be treated to avoid RBC transfusion in one patient. We found no evidence for a difference in the median time to hematopoietic response with addition of iron to ESAs (hazard ratio (HR) 0.93 (95% CI 0.67 to 1.28); P = 0.65; 1042 participants; seven comparisons; low‐quality evidence). In subgroup analyses, RCTs in which dextran (HR 0.95 (95% CI 0.36 to 2.52); P = 0.92; 340 participants; three comparisons), sucrose iron (HR 1.15 (95% CI 0.60 to 2.21); P = 0.67; 102 participants; one comparison) and sulfate iron (HR 1.24 (95% CI 0.99 to 1.56); P = 0.06; 55 participants; one comparison) were used showed no evidence for difference between iron supplementation versus ESAs alone compared with RCTs in which gluconate (HR 0.78 (95% CI 0.65 to 0.94); P = 0.01; 464 participants; two comparisons) was used for median time to hematopoietic response (P = 0.02). There was no evidence for a difference between the subgroups of route of iron administration (P = 0.13) and types of ESAs (P = 0.46) for median time to hematopoietic response. Our results indicated that there could be improvement in the hemoglobin (Hb) levels with addition of iron to ESAs (mean difference (MD) 0.48 (95% CI 0.10 to 0.86); P = 0.01; 827 participants; seven comparisons; low‐quality evidence). In RCTs in which IV iron was used there was evidence for a difference (MD 0.84 (95% CI 0.21 to 1.46); P = 0.009; 436 participants; four comparisons) compared with oral iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) for mean change in Hb level (P = 0.03). RCTs in which dextran (MD 1.55 (95% CI 0.62 to 2.47); P = 0.001; 102 participants; two comparisons) was used showed evidence for a difference with iron supplementation versus ESAs alone compared with RCTs in which gluconate (MD 0.54 (95% CI ‐0.15 to 1.22); P = 0.12; 334 participants; two comparisons) and sulfate iron (MD 0.07 (95% CI ‐0.19 to 0.34); P = 0.59; 391 participants; three comparisons) were used for mean change in Hb level (P = 0.007). RCTs in which epoetin was used showed evidence for a difference with iron supplementation versus ESAs alone (MD 0.77 (95% CI 0.25 to 1.29); P = 0.004; 337 participants; five comparisons) compared with darbepoetin use (MD 0.10 (95% CI ‐0.13 to 0.33); P = 0.38; 490 participants; two comparisons) for mean change in Hb level (P = 0.02). We found no evidence for a difference in quality of life with addition of iron to ESAs (standardized mean difference 0.01 (95% CI ‐0.10 to 0.12); P = 0.88; 1124 participants; three RCTs; high‐quality evidence). We found no evidence for a difference in risk of grade III‐IV thromboembolic events (RR 0.95 (95% CI 0.54 to 1.65); P = 0.85; 783 participants; three RCTs; moderate‐quality evidence). The incidence of treatment‐related mortality (TRM) was 0% (997 participants; four comparisons; high‐quality evidence). Other common adverse events included vomiting, asthenia, and leukopenia, and were similar in both arms. Overall the risk of bias across outcomes was high to low. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown. Our main reasons for downgrading the quality of evidence were inconsistency across the included studies and imprecision of results. Authors' conclusions Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation. Plain language summary The role of iron in the management of chemotherapy‐induced anemia in cancer patients receiving erythropoiesis‐stimulating agents Review question: Is iron alone or iron as a supplement to erythropoiesis‐stimulating agents (ESAs) superior to ESAs alone in the management of people diagnosed with chemotherapy‐induced anemia (CIA)? Background: The current treatment of CIA is ESAs, which increase the production of red blood cells (erythropoiesis), and in some cases ESAs and iron. In some cases, strategies such as no therapy or wait and watch with clinical oversight and red blood cell transfusion may be safe and suitable options. We conducted a systematic review to evaluate the benefits and harms of iron in the management of CIA. Search date: The evidence is current to February 2016. Study characteristics: We included eight industry‐funded randomized controlled trials (RCTs) comparing ESAs plus iron versus ESAs alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone. Study funding source: All the included trials were industry funded. Key results: Adding iron to ESAs improves the hematopoietic response in people with CIA. Use of iron with ESAs might reduce the risk of blood transfusions and improve hemoglobin. We found no improvement in quality of life with addition of iron. We found no evidence for a difference in time to hematopoietic response and risk of development of blood clot in veins of people with CIA treated with iron and ESAs compared with ESAs alone. There were zero treatment‐related deaths among 997 participants in the four trials that reported this outcome. Other harms included constipation, vomiting, and diarrhea, and were similar with ESAs and iron compared with ESAs alone. None of the trials reported data on survival. Quality of evidence: The quality of evidence for hematopoietic response was high. The quality of evidence for red blood cell transfusion was moderate, as the pooled estimate had large variation. The quality of evidence for change in hemoglobin and time to hematopoietic response was low, as the pooled estimates had large variation and results were not similar across studies. The quality of evidence for quality of life was high. The quality of evidence for risk of blood clots in veins was moderate due to variation in pooled estimate. Since the included RCTs had shorter follow‐up duration (up to 20 weeks), the long‐term effects of iron supplementation are unknown.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Mhaskar, R, Wao, H, Miladinovic, B, Kumar, A, Djulbegovic, B", "articleTypes": [], "doi": "10.1002/14651858.CD009624.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.778Z" }, { "id": "e8a3f221-bb12-4e64-816f-ad68c818d648", "pmid": "", "title": "Fortification of staple foods with vitamin A for vitamin A deficiency", "imported": false, "abstract": "Abstract - Background Vitamin A deficiency is a significant public health problem in many low‐ and middle‐income countries, especially affecting young children, women of reproductive age, and pregnant women. Fortification of staple foods with vitamin A has been used to increase vitamin A consumption among these groups. Objectives To assess the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving health‐related outcomes in the general population older than two years of age. Search methods We searched the following international databases with no language or date restrictions: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library; MEDLINE and MEDLINE In Process OVID; Embase OVID; CINAHL Ebsco; Web of Science (ISI) SCI, SSCI, CPCI‐exp and CPCI‐SSH; BIOSIS (ISI); POPLINE; Bibliomap; TRoPHI; ASSIA (Proquest); IBECS; SCIELO; Global Index Medicus ‐ AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched clinicaltrials.gov and the International Clinical Trials Registry Platform to identify ongoing and unpublished studies. The date of the last search was 19 July 2018. Selection criteria We included individually or cluster‐randomised controlled trials (RCTs) in this review. The intervention included fortification of staple foods (sugar, edible oils, edible fats, maize flour or corn meal, wheat flour, milk and dairy products, and condiments and seasonings) with vitamin A alone or in combination with other vitamins and minerals. We included the general population older than two years of age (including pregnant and lactating women) from any country. Data collection and analysis Two authors independently screened and assessed eligibility of studies for inclusion, extracted data from included studies and assessed their risk of bias. We used standard Cochrane methodology to carry out the review. Main results We included 10 randomised controlled trials involving 4455 participants. All the studies were conducted in low‐ and upper‐middle income countries where vitamin A deficiency was a public health issue. One of the included trials did not contribute data to the outcomes of interest. Three trials compared provision of staple foods fortified with vitamin A versus unfortified staple food, five trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus unfortified staple foods, and two trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus no intervention. No studies compared staple foods fortified with vitamin A alone versus no intervention. The duration of interventions ranged from three to nine months. We assessed six studies at high risk of bias overall. Government organisations, non‐governmental organisations, the private sector, and academic institutions funded the included studies; funding source does not appear to have distorted the results. Staple food fortified with vitamin A versus unfortified staple food We are uncertain whether fortifying staple foods with vitamin A alone makes little or no difference for serum retinol concentration (mean difference (MD) 0.03 μmol/L, 95% CI −0.06 to 0.12; 3 studies, 1829 participants; I² = 90%, very low‐certainty evidence ). It is uncertain whether vitamin A alone reduces the risk of subclinical vitamin A deficiency (risk ratio (RR) 0.45, 95% CI 0.19 to 1.05; 2 studies; 993 participants; I² = 33%, very low‐certainty evidence ). The certainty of the evidence was mainly affected by risk of bias, imprecision and inconsistency. It is uncertain whether vitamin A fortification reduces clinical vitamin A deficiency, defined as night blindness (RR 0.11, 95% CI 0.01 to 1.98; 1 study, 581 participants, very low‐certainty evidence ). The certainty of the evidence was mainly affected by imprecision, inconsistency, and risk of bias. Staple foods fortified with vitamin A versus no intervention No studies provided data for this comparison. Staple foods fortified with vitamin A plus other micronutrients versus same unfortified staple foods Fortifying staple foods with vitamin A plus other micronutrients may not increase the serum retinol concentration (MD 0.08 μmol/L, 95% CI ‐0.06 to 0.22; 4 studies; 1009 participants; I² = 95%, low‐certainty evidence ). The certainty of the evidence was mainly affected by serious inconsistency and risk of bias. In comparison to unfortified staple foods, fortification with vitamin A plus other micronutrients probably reduces the risk of subclinical vitamin A deficiency (RR 0.27, 95% CI 0.16 to 0.49; 3 studies; 923 participants; I² = 0%; moderate‐certainty evidence ). The certainty of the evidence was mainly affected by serious risk of bias. Staple foods fortified with vitamin A plus other micronutrients versus no intervention Fortification of staple foods with vitamin A plus other micronutrients may increase serum retinol concentration (MD 0.22 μmol/L, 95% CI 0.15 to 0.30; 2 studies; 318 participants; I² = 0%; low‐certainty evidence ). When compared to no intervention, it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency (RR 0.71, 95% CI 0.52 to 0.98; 2 studies; 318 participants; I² = 0%; very low‐certainty evidence ) . The certainty of the evidence was affected mainly by serious imprecision and risk of bias. No trials reported on the outcomes of all‐cause morbidity, all‐cause mortality, adverse effects, food intake, congenital anomalies (for pregnant women), or breast milk concentration (for lactating women). Authors' conclusions Fortifying staple foods with vitamin A alone may make little or no difference to serum retinol concentrations or the risk of subclinical vitamin A deficiency. In comparison with provision of unfortified foods, provision of staple foods fortified with vitamin A plus other micronutrients may not increase serum retinol concentration but probably reduces the risk of subclinical vitamin A deficiency. Compared to no intervention, staple foods fortified with vitamin A plus other micronutrients may increase serum retinol concentration, although it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency as the certainty of the evidence has been assessed as very low. It was not possible to estimate the effect of staple food fortification on outcomes such as mortality, morbidity, adverse effects, congenital anomalies, or breast milk vitamin A, as no trials included these outcomes. The type of funding source for the studies did not appear to distort the results from the analysis. Plain language summary Fortification of staple foods with vitamin A for vitamin A deficiency What is the aim of the review? We wanted to investigate the effects of fortifying common staple foods with vitamin A, with or without other micronutrients, in populations two years of age and older. Staple foods used in public health fortification programmes have included refined sugar, edible vegetable oils and fats, rice, wheat flour, maize flours and corn meals, condiments and seasonings, and powdered or liquid milk. We searched for all the possible information on this question and found 10 eligible studies. Key messages Fortifiying staple foods with vitamin A plus other micronutrients may increase the serum retinol concentrations (an indicator of vitamin A stores in the body) and reduce the risk of subclinical vitamin A deficiency (those without clinical eye signs for risk of blinding undernutrition, detected through a serum/plasma retinol 70 μmol/L or less). However, adding vitamin A alone to the staple foods may have little or no effect on vitamin A status or deficiency. What was studied in this review? Vitamin A is an essential nutrient vital for good vision, cell growth, and immunity. Many people in low‐ and middle‐income countries have vitamin A deficiency, especially young children, pregnant women, and women of reproductive age, who may not get enough to eat to cover their increased nutritional demands. Long‐term deprivation of vitamin A could lead to visual impairment, blindness, common infections of the upper respiratory tract, diarrhoea, and measles. There are several strategies to combat the vitamin A deficiency, such as supplementing the diet with vitamin A capsules, adding vitamins and minerals in powder form to energy‐containing foods, eating more vitamin A‐rich foods, and fortifying staple foods with vitamin A during processing. This review focused on the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving the health of the general population older than two years of age. What are the main results of the review? We found 10 relevant studies (involving 4455 participants) from China, India, the Philippines, Bangladesh, Thailand, and Mexico. Three studies provided one study group with staple foods fortified with vitamin A alone, and another group with the same unfortified staple foods. Five studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus the same unfortified staple food, and two studies compared staple foods fortified with vitamin A plus other vitamins and minerals versus no intervention. No studies compared staple foods fortified with vitamin A versus no intervention. Government agencies, private agencies, non‐governmental organisations, the private sector, and academic institutions funded the studies. The source of funding does not appear to have distorted the results. The effect of fortification of staple foods with vitamin A alone on vitamin A stores and on subclinical vitamin A deficiency is uncertain. It is uncertain whether this intervention might reduce clinical vitamin A deficiency (night blindness). We are moderately confident that fortifying staple foods with vitamin A and other micronutrients may not improve vitamin A status. However, children and adolescents in low‐ and middle‐income populations who eat foods fortified with vitamin A and other micronutrients may have a lower risk of subclinical vitamin A deficiency compared to those receiving unfortified staple foods. We do not know how vitamin A fortification affects other health indicators, such as the rate of disease in the population, mortality, adverse effects, food intake, birth defects (for pregnant women), or breast milk concentration for lactating women. We considered six of the included studies to be of poor methodological quality. The review authors searched for published studies up to July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hombali, AS; Solon, JA; Venkatesh, BT; Nair, NS; Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD010068.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "e8c1fc1b-bf40-45a0-bf85-0acec6f4c3ff", "pmid": "", "title": "Rituximab for people with multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Filippini, G, Kruja, J, Del Giovane, C", "articleTypes": [], "doi": "10.1002/14651858.CD013874.pub3 AB - Abstract - Background Multiple sclerosis (MS) is the most common neurological cause of disability in young adults. Off‐label rituximab for MS is used in most countries surveyed by the International Federation of MS, including high‐income countries where on‐label disease‐modifying treatments (DMTs) are available. This updates the 2021 version of the review. Objectives To assess the benefits and harms of rituximab as 'first choice' and 'switching' treatment for adults with any form of MS. Search methods We searched CENTRAL , MEDLINE, Embase, CINAHL, and three trials registers on 31 December 2023, together with reference checking and contacting study authors to identify unpublished studies. Selection criteria We included randomised controlled trials (RCTs) and controlled non‐randomised studies of interventions (NRSIs) comparing rituximab with placebo or another DMT for adults with any form of MS. Data collection and analysis We followed standard Cochrane methods. We used RoB 1 to assess risk of bias in RCTs and ROBINS‐I in NRSIs. We assessed the certainty of evidence for critical and important prioritised outcomes using GRADE: disability worsening, relapse, serious adverse events (SAEs), health‐related quality of life (HRQoL), common infections, cancer, and mortality. We conducted separate analyses for rituximab as 'first choice' or as 'switching' treatment, relapsing or progressive MS, comparison with placebo or another DMT, and RCTs or NRSIs. Main results In this update, the number of study participants increased from 16,429 (15 studies) to 37,443 (28 studies; 13 new studies: 1 RCT and 12 NRSIs). The studies were conducted worldwide; most originated from high‐income countries (25 studies). Public institutions funded 22 (79%) of the studies. Most studies investigated the effects of rituximab on people with relapsing MS (19 studies; 27,500 (73%) participants). We identified 12 ongoing studies. Rituximab as 'first choice' for active relapsing MS None of the included studies compared rituximab to placebo. One RCT compared rituximab to dimethyl fumarate, with 24 months' follow‐up. Rituximab may reduce the recurrence of relapse (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.04 to 0.57; 195 participants; low‐certainty evidence). The evidence is very uncertain on disability worsening and SAEs. Rituximab may result in little to no difference in upper respiratory tract infections (rate ratio (RR) 1.03, 95% CI 0.79 to 1.34; low‐certainty evidence). The evidence is very uncertain for urinary tract, skin, and viral infections. HRQoL, cancer, and mortality were not reported. One NRSI compared rituximab to other DMTs, with 24 months' follow‐up. Disability worsening was not reported. Compared with interferon beta or glatiramer acetate, rituximab likely delays relapse (hazard ratio (HR) 0.14, 95% CI 0.05 to 0.39; 1 study, 335 participants; moderate‐certainty evidence). Compared with dimethyl fumarate and natalizumab, rituximab may delay relapse (dimethyl fumarate: HR 0.29, 95% CI 0.08 to 1.00; 1 study, 206 participants; low‐certainty evidence; natalizumab: HR 0.24, 95% CI 0.06 to 1.00; 1 study, 170 participants; low‐certainty evidence). The evidence for relapse is very uncertain when comparing rituximab to fingolimod. The effect on SAEs is uncertain due to very few events in all the comparison groups. No deaths were reported. HRQoL, common infections, and cancer were not reported. Rituximab as 'first choice' for primary progressive MS One RCT compared rituximab to placebo, with 24 months' follow‐up. Rituximab likely results in little or no difference in disability worsening (OR 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate‐certainty evidence). The evidence is very uncertain on relapse, SAEs, common infections, cancer, and mortality. HRQoL was not reported. None of the included studies compared rituximab as 'first choice' treatment to other DMTs for primary or secondary progressive MS. Rituximab as 'switching' treatment for relapsing MS One small RCT compared rituximab to placebo, with 12 months' follow‐up. Disability worsening was not reported. Rituximab may reduce recurrence of relapses (OR 0.38, 95% CI 0.16 to 0.93; 1 study, 104 participants; low‐certainty evidence). The evidence is very uncertain regarding SAEs, common infections, cancer, and mortality. HRQoL was not reported. Twelve NRSIs compared rituximab to other DMTs, with 24 months' follow‐up. The evidence on disability worsening is very uncertain in comparison with interferons or glatiramer acetate, natalizumab, alemtuzumab, and ocrelizumab. Rituximab likely delays time to relapse in comparison with interferons or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 study, 1383 participants; moderate‐certainty evidence), fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 study, 256 participants; moderate‐certainty evidence), and may result in little or no difference compared with natalizumab (HR 0.96, 95% CI 0.83 to 1.10; 3 studies, 1922 participants; low‐certainty evidence). The evidence is very uncertain on relapse in comparison with alemtuzumab. There is uncertainty regarding SAEs when comparing rituximab to natalizumab and fingolimod. Rituximab likely increases serious common infections when compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 study, 5477 participants; moderate‐certainty evidence) and natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 studies, 5001 participants; moderate‐certainty evidence). The evidence for common infections is very uncertain when comparing rituximab to fingolimod and ocrelizumab. Rituximab may slightly reduce the risk of cancer compared with natalizumab (HR 0.79, 95% CI 0.62 to 0.99; 2 studies, 6202 participants; low‐certainty evidence), whereas the evidence is very uncertain in comparison with fingolimod. The effect of rituximab on mortality is very uncertain due to very few events in all the comparison groups. HRQoL was not reported. Authors' conclusions For preventing relapses in relapsing MS, rituximab as 'first choice' and 'switching' treatment compares favourably with a wide range of approved DMTs. The protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab on primary progressive MS. There is limited evidence for long‐term adverse events of rituximab in people with MS. Evidence for serious adverse events, cancer, and mortality was of very low certainty due to few events. There is an increased risk of serious (hospital‐treated) infections with rituximab compared with other DMTs, although the absolute risk is low. High‐quality (prospectively registered) NRSIs should be conducted to draw more reliable conclusions about the potential benefits and harms of rituximab in people with MS. Plain language summary Is rituximab better for people with multiple sclerosis than other disease‐modifying medicines? Key messages • We are uncertain whether rituximab prevents disability worsening in people with any form of multiple sclerosis (MS). 
• Rituximab may offer moderate‐to‐large benefit against a range of other medicines in preventing relapses in relapsing MS, both in people treated with rituximab for the first time and in those given rituximab after other medicines failed to work or became unsuitable.
• Very few people given rituximab in the studies had serious unwanted/harmful events, developed cancer, or died over 24 months' follow‐up. What is multiple sclerosis (MS)? MS is a disease affecting the central nervous system, in which the body’s immune system mistakenly attacks the protective covering of nerve fibres, which leads to inflammation and damage. Communication between the brain and the rest of the body is affected, resulting in a wide range of symptoms. There are two main types: (1) relapsing MS, where someone has periods of relapse (worsening of symptoms) followed by remissions (improvement or complete recovery); and (2) progressive MS, where symptoms worsen over time, without distinct periods of improvement. Relapsing MS is more common. How is MS treated? There is no cure for MS, so the goal of treatment is to manage symptoms, reduce disease activity, slow progression, and improve quality of life. This involves giving people with MS disease‐modifying treatments (DMTs), in contrast to treatments which only manage symptoms. There are different kinds of disease‐modifying treatments for MS, including rituximab. Rituximab is: • a medicine given slowly via a needle in a vein (intravenous infusion) that can suppress certain immune cells;
• included in the World Health Organization (WHO) Model List of Essential Medicines for MS, which makes rituximab available worldwide. Rituximab is not always reimbursed by health systems because it is not licensed for MS by marketing authorities;
• a highly effective treatment. It's cheaper and is given less often than other approved medicines for MS. Treatment with rituximab requires specialist care and infusion facilities, but other approved medicines do too. What did we want to find out? We wanted to find out the effects of rituximab on people with any form of MS on: • disability worsening, relapse, and quality of life;
• unwanted effects, such as serious harmful effects, serious common infections, cancer, and death. What did we do? We searched for studies that compared rituximab with other infused medicines (e.g. natalizumab), injectable medicines (e.g. interferon beta, glatiramer acetate), and oral medicines (e.g. fingolimod, dimethyl fumarate). We compared and summarised the results of the included studies, and rated our confidence in the evidence, based on factors such as study methods and quality. What did we find? We found 28 studies that involved 37,443 people with MS and lasted one or two years. The biggest study involved 8600 people and the smallest, 27 people. Most people (27,500, 73% of all participants) had a relapsing form of MS, while only 813 (2%) had a progressive form. Three studies included 9130 (24%) people with all forms of MS. Most studies originated from high‐income countries. Public institutions funded 22 (79%) of the studies. MAIN RESULTS Relapsing forms of MS • We do not know if rituximab has an effect on long‐term disability worsening due to the short follow‐up period of the studies.
• For people treated with rituximab for the first time as well as those given rituximab after other medicines failed to work or became unsuitable, rituximab may reduce the risk of relapses compared with interferon beta or glatiramer acetate, dimethyl fumarate, fingolimod, and natalizumab (evidence from 16 studies). 
• Serious unwanted effects of rituximab are very few. However, we do not know if rituximab has an effect on long‐term serious unwanted effects due to the short follow‐up period of the studies.
• Rituximab likely increases serious common infections (i.e. hospital‐treated infections) compared with other approved medicines for MS. However, the likelihood of serious common infections occurring is low in terms of the total number of people being considered. Progressive forms of MS We do not know if rituximab has benefits for people with primary progressive MS. What are the main limitations of the evidence? Our confidence in the evidence is limited because of three main factors. First, people were not randomly placed into different treatment groups in most of the studies. This means that differences between the groups could be due to differences between participants rather than between the comparison treatments. Second, we found few studies in which participants were assigned randomly to different treatment groups. These studies were small and used methods likely to introduce errors in their results. Third, results originated from short‐term studies. This is an important issue for people with a lifelong disease such as MS, who need to know the long‐term benefits and unwanted effects of a medicine. How current is the evidence? This review updates our previous review. The evidence is current to 31 December 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.136Z" }, { "id": "e8d2cd25-42d3-4757-8caa-e996777e1ccc", "pmid": "", "title": "Dietary sodium manipulation and asthma", "imported": false, "abstract": "Abstract - Background There is a wide geographical variation in the prevalence of asthma and observational studies have suggested that dietary sodium may play a role. Objectives To assess the effect of dietary sodium manipulation on asthma control. Search methods We carried out a search using the Cochrane Airways Group asthma register. We searched the bibliographies of included randomised controlled trials (RCTs) for additional studies. We carried out the most recent search in November 2010. Selection criteria We considered only RCTs that involved dietary sodium reduction or increased sodium intake in patients with asthma. Data collection and analysis Both review authors assessed study and extracted data. We conducted data analyses in RevMan 5 using mean differences and random effects. Main results We identified a total of nine studies in relation to sodium manipulation and asthma, of which five were in people with asthma (318 participants), and four in people with exercise‐induced asthma (63 participants). There were no significant benefits of salt restriction on the control of asthma. There was some evidence from the exercise‐induced asthma studies that a low sodium diet may improve lung function after exercise and possibly baseline lung function, but this is based on findings from a very small numbers of participants. Authors' conclusions This review did not find any evidence that dietary sodium reduction significantly improves asthma control. Although dietary sodium reduction may result in improvements in lung function in exercise‐induced asthma, the clinical significance of this effect is unclear. Plain language summary Does reducing the amount of salt in a diet improve asthma symptoms? A review of the current literature suggests that reduction in the amount of dietary sodium consumed has no significant effect on the symptoms of asthma but may be associated with improvements in some lung function measurements in exercise‐induced asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Pogson, Z; McKeever, T", "articleTypes": [], "doi": "10.1002/14651858.CD000436.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "e8d31a7e-cdba-4846-bfeb-457e4622b33e", "pmid": "", "title": "Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis", "imported": false, "abstract": "Abstract - Background Chronic infection with Pseudomonas aeruginosa (PA) in cystic fibrosis (CF) is a source of much morbidity and mortality. Eradication of early PA infection is possible, but can recur in many individuals. We sought to examine strategies to delay the time to PA recurrence in people with CF. Objectives To establish whether secondary prevention strategies, using antibiotics or other therapies, increase the chances of people with CF remaining free from PA infection following successful eradication therapy. Search methods We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries and the reference lists of relevant articles and reviews. Date of last search: 21 August 2019. Selection criteria Randomised controlled trials (and quasi‐randomised trials where the risk of bias was low) comparing any treatment modality aimed at preventing recurrence of PA infection with placebo, standard therapy or any other treatment modality in people with CF who have undergone successful eradication of PA. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias. Quality of the evidence was assessed using GRADE. Conflicts were resolved by discussion and the opinion of a third review author was sought where necessary. Only a subset of participants in the included trial were eligible, therefore individual participant data were requested and obtained from the trial investigators. Main results We included one trial (n = 306) in the review; however, only 253 participants had undergone successful eradication of PA, so fulfilling the inclusion criteria for our review. Information presented relates only to the included subset of participants. The trial recruited children aged one to 12 years (mean (standard deviation (SD)) age of 5.8 (3.5) years), 129 participants (51.0%) were female and the median follow‐up was 494 days. We compared cycled therapy with tobramycin inhalation solution (TIS), in which participants underwent 28 days of TIS every three months, with culture‐based therapy, in which participants were only prescribed medication when a quarterly sputum sample was positive for PA. Reasons for downgrading the quality of the evidence included applicability (only included children), incomplete outcome data and a small number of participants. The time to next isolation of PA was probably shorter with cycled TIS therapy than with culture‐based therapy, hazard ratio (HR) 2.04 days (95% confidence interval (CI) 1.28 to 3.26) (moderate‐quality evidence). This is in contrast to the main publication of the only included trial, which examined rate of PA positivity rather than time to PA infection and included participants not eligible for inclusion in this review. At the end of the trial, there was no difference between the cycled and culture‐based groups in the change from baseline in forced expiratory volume in one second (FEV 1 ) L, mean difference (MD) 0.0 L (95% CI ‐0.09 to 0.09) or in FEV 1 % predicted, MD 0.70% (95% CI ‐4.33 to 5.73) (both very low‐quality evidence). There was no difference in the change from baseline for FVC between the groups. There was also no difference in the frequency of pulmonary exacerbations between groups, MD ‐0.18 (95% CI ‐0.51 to 0.14) (moderate‐quality evidence). Similarly, there was no difference between groups in the risk of participants developing novel resistant bacteria, RR 1.00 (95% CI 0.67 to 1.5) (moderate‐quality evidence). There were more severe adverse events in the cycled group, but the type of treatment probably makes little or no difference to the results, RR 0.65 (95% CI 0.39 to 1.11) (moderate‐quality evidence). There was no difference between groups in the change in weight or height from baseline or in rates of adherence to tobramycin or all trial medicines. The included trial did not assess changes in quality of life, the time to chronic infection with PA or the cost‐effectiveness of treatment. Authors' conclusions Cycled TIS therapy may be beneficial in prolonging the time to recurrence of PA after successful eradication, but further trials are required, specifically addressing this question and in both adults and children. Plain language summary Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis Review question We reviewed evidence about the effect of treatments given to people with cystic fibrosis (CF) to prevent recurrence of infection with bacteria called Pseudomonas aeruginosa (PA) after it has been successfully treated. Background People with CF experience frequent, severe chest infections. These infections may be caused by bacteria that do not cause disease in healthy people, such as PA. PA is an important infection in CF since if it is not treated early it cannot be cleared from the lungs (termed chronic PA). When it cannot be cleared from the lungs, it causes ongoing damage to the lung tissue as well as worse chest infections. People with CF who have chronic PA may be more unwell than those without it. Early treatment can remove PA from the lungs of people with CF, but infection can happen again and is difficult to prevent. We want to know if giving extra treatment after the PA has been successfully treated, can prolong the time to the next infection. The treatment could be antibiotics or another treatment, for example something that helps the person's immune system fight the PA. Search date The evidence is current to: 21 August 2019. Trial characteristics We included one trial with 306 participants. Only 253 of these people had had successful treatment of PA and so could be included in our review. There were only children in the trial who were aged between one and 12 years old; 51% were girls. The trial compared treatment with one month of an inhaled antibiotic every three months ('cycled treatment') with antibiotic treatment given only when the person was found to have PA ('culture‐based treatment'). People were selected randomly to have either cycled or culture‐based treatment. The trial followed people up for an average of 70 weeks. Key results Taking into the account the certainty of the evidence, we believe that the time to the next isolation of PA was probably shorter with cycled therapy than with culture‐based therapy. We found that PA recurred in a quarter of participants in the culture‐based group by 249 days but in the cycled group it took 505 days; giving cycled treatment doubled the time to a new infection with PA compared with culture‐based treatment. This is in contrast to the main publication of the only included trial, which looked at the rate of positive PA cultures rather than the time to a new infection of PA and included participants not eligible for inclusion in this review. There was no difference between the groups in: pulmonary function (a measure of how well someone's lungs are working); in the number of people having chest infections; in the change in height and weight from the beginning to th end of the trial; in how many people took all the doses of the medications; in how many people developed infections with new bacteria; or in how many people had a serious complication. The trial did not give information about the effect of the two treatments on individuals' quality of life, the time until the development of chronic PA or the cost‐effectiveness of the treatment. Quality of the evidence The quality of most of the evidence was moderate. As the trial only included children, we cannot be sure if the cycled treatment would have the same effect in teenagers or adults with CF. Further trials including both adults and children are needed to help answer the question. Trials designed to specifically answer this question are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Palser, S; Smith, S; Nash, EF; Agarwal, A; Smyth, AR", "articleTypes": [], "doi": "10.1002/14651858.CD012300.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "e8d7d638-9583-4616-b31b-7307bf88d846", "pmid": "", "title": "Immunosuppressive agents for myasthenia gravis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Hart, IK, Sathasivam, S, Sharshar, T", "articleTypes": [], "doi": "10.1002/14651858.CD005224.pub2 AB - Abstract - Background The benefits of different immunosuppressants for myasthenia gravis (MG) are unclear. Objectives Assessment of immunosuppressant drug efficacy in MG. Search methods We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to July 2007), EMBASE (from January 1980 to July 2007), review and trial bibliographies and contacted trial authors. Selection criteria Types of studies: Randomised and quasi‐randomised controlled trials. Types of participants: Any age, any type or severity of MG regardless of concomitant treatment. Types of interventions: Any immunosuppressive agent. Types of outcome measures: Primary: 
 (1) Improvement or not at six months Secondary: 
 (1) Improvement or not at one year 
 (2) Need for other treatment, for example corticosteroid dose, at six months 
 (3) Number of exacerbations during the first year 
 (4) Acetylcholine receptor antibody titre after at least six months 
 (5) Occurrence of one or more adverse events at any time after the introduction of treatment. Data collection and analysis One author extracted and two checked the data. Main results Seven trials are included but few reported the outcomes selected for this review. A meta‐analysis of ciclosporin versus placebo from two trials (59 participants) ‐ one as monotherapy (20 participants) and the other with corticosteroids (39 participants) ‐ showed that it resulted in improvement of participants in the ciclosporin group compared with those in the placebo group, with a relative rate of improvement of 2.44 (95% confidence interval (CI) 1.13 to 5.27). In addition the weighted mean difference in QMG score between the ciclosporin and placebo groups was ‐0.34 (95% CI ‐0.52 to ‐0.17). Azathioprine (plus prednisolone for first month) had no significant benefit over prednisolone alone (41 participants). The effects of azathioprine plus prednisolone versus prednisolone plus placebo were similar (34 participants). Cyclophosphamide was reported to be statistically more efficacious than placebo at 12 months in corticosteroid‐dependent participants (23 participants), but no raw data were available. Trials of mycophenolate mofetil and tacrolimus did not provide relevant endpoint data for this review. All trials had low numbers of participants. Adverse event reporting was variable. Trial protocol heterogeneity prevented comparison of the different immunosuppressants. Authors' conclusions In generalised MG, limited evidence from small RCTs suggests that ciclosporin, as monotherapy or with corticosteroids, or cyclophosphamide with corticosteroids, significantly improve MG. 
 Limited evidence from RCTs shows no significant benefit from azathioprine (as monotherapy or with steroids), mycophenolate mofetil (as monotherapy or with either corticosteroids or ciclosporin) or tacrolimus (with corticosteroids or plasma exchange). Bigger, better‐designed, longer trials are needed. Plain language summary A review of the use of drugs that suppress the immune system (immunosuppressants) in myasthenia gravis. Myasthenia gravis (MG) is caused by antibodies produced by the immune system that impair the transmission of nerve impulses to muscles. This results in muscle weakness that characteristically fluctuates. About one person in every 10 000 ‐ 50 000 develops MG each year. The natural history of the disorder is typically a series of exacerbations and remissions. Severe attacks can be life‐threatening because of weakness of muscles involved in swallowing causing choking, and chest muscles causing difficulty with breathing. In MG, immunosuppressant drugs act mainly by reducing the production of antibodies. There were seven randomised controlled trials to include in this review. Each trial compared different interventions in generalised MG: (1) azathioprine plus initial prednisolone versus prednisolone ‐ 41 participants; (2) azathioprine plus prednisolone versus prednisolone plus placebo (dummy treatment) ‐ 34 participants; (3) ciclosporin monotherapy versus placebo ‐ 20 participants; (4) ciclosporin plus prednisolone versus prednisolone plus placebo ‐ 39 participants; (5) cyclophosphamide plus prednisolone versus prednisolone plus placebo ‐ 23 participants; (6) mycophenolate mofetil plus either ciclosporin or prednisolone or no immunosuppressants versus placebo plus either ciclosporin or prednisolone or no immunosuppressants trial ‐ 14 participants; (7) tacrolimus plus corticosteroids with or without plasma exchange versus no tacrolimus plus corticosteroids with or without plasma exchange trial ‐ 34 participants. It is difficult to draw useful clinical conclusions from this small number of often short‐term, randomised controlled trials. Each trial had relatively few participants and different trials used different study designs. The limited evidence available found that MG improved significantly with either ciclosporin (alone or in combination with corticosteroids) or cyclophosphamide (in combination with corticosteroids) compared with placebo. There is no clear evidence from randomised controlled trials of benefit for any of the immunosuppressant drugs used more commonly in MG ‐ azathioprine (alone or in combination with corticosteroids), mycophenolate mofetil (as monotherapy or in combination with either corticosteroids or ciclosporin) or tacrolimus (in combination with corticosteroids or plasma exchange or both). There is no randomised controlled trial of methotrexate in MG. Long‐term studies of the potentially formidable toxic effects of all of these drugs are lacking in MG.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.117Z" }, { "id": "e92cc43d-a98f-4aa2-b970-59e57d4b6d6c", "pmid": "", "title": "Chinese medicinal herbs for the common cold", "imported": false, "abstract": "Abstract - Background Chinese medicinal herbs are frequently used to treat the common cold in China. Until now, their efficacy has not been systematically reviewed. Objectives To assess the effectiveness and safety of Chinese medicinal herbs for the common cold. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2008, issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to May 2008); EMBASE (1980 to May 2008); AMED (1985 to May 2008); the Chinese Biomedical Database (CBMdisc) (1978 to May 2008); and China National Knowledge Infrastructure (CNKI) (1994 to May 2008). Selection criteria Randomised controlled trials (RCTs) studying the efficacy of Chinese medicinal herb(s) for the treatment of the common cold. Data collection and analysis Four review authors telephoned the original trial authors of the RCTs identified by our searches to verify the randomisation procedure. Two review authors extracted and analysed data from trials which met the inclusion criteria. Main results We found17 studies involving 3212 patients. The methods of 15 studies were at high risk of bias. In only two studies was the risk of bias low. Trials used \"positive drugs\", of which the efficacy was not known, as controls. Different Chinese herbal preparations were tested in nearly all trials. In only one trial was a Chinese herbal preparation tested twice. In seven trials, six herbal preparations were found to be more effective at enhancing recovery than the control preparations. In the other 10 studies, seven herbal preparations were not shown to be significantly different from the control. One study did not describe the difference between the intervention and control groups. Authors' conclusions Chinese herbal medicines may shorten the symptomatic phase in patients with the common cold. However, the lack of trials of low enough risk of bias, or using a placebo or a drug clearly identified as a control, means that we are uncertain enough to be unable to recommend any kind of Chinese medicinal herbs for the common cold. Plain language summary Chinese medicinal herbs to treat the common cold The common cold is the most widespread acute respiratory tract illness affecting all age groups. Many Chinese herbal medicines are used to treat this illness in China. Although we included 17 trials, involving 3212 patients, in this review, the risk of bias was so high that the evidence did not support using any Chinese herbal preparation(s) for the common cold. Well‐designed clinical trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "Zhang, X; Wu, T; Zhang, J; Yan, Q; Xie, L; Liu, GJ", "articleTypes": [], "doi": "10.1002/14651858.CD004782.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "e93a1675-446e-4b90-8999-328e9fa8df98", "pmid": "", "title": "Sensitivity to 6-n-propylthiouracil (PROP) Association With Gustin (CA6) Gene Polymorphism, Salivary Zinc and BMI in Humans", "imported": false, "abstract": "The investigators evaluate the possible association of PROP taste with gustin gene polymorphism rs2274333 (A/G), salivary zinc ion concentration and BMI. In addition, it has also been evaluated PROP taste sensitivity by recording monophasic potentials from the tongue.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.234Z" }, { "id": "e945fab5-d7af-4897-9d5c-88d673aadd91", "pmid": "", "title": "Neuraminidase inhibitors for preventing and treating influenza in adults and children", "imported": false, "abstract": "Abstract - Background Neuraminidase inhibitors (NIs) are stockpiled and recommended by public health agencies for treating and preventing seasonal and pandemic influenza. They are used clinically worldwide. Objectives To describe the potential benefits and harms of NIs for influenza in all age groups by reviewing all clinical study reports of published and unpublished randomised, placebo‐controlled trials and regulatory comments. Search methods We searched trial registries, electronic databases (to 22 July 2013) and regulatory archives, and corresponded with manufacturers to identify all trials. We also requested clinical study reports. We focused on the primary data sources of manufacturers but we checked that there were no published randomised controlled trials (RCTs) from non‐manufacturer sources by running electronic searches in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE (Ovid), EMBASE, Embase.com, PubMed (not MEDLINE), the Database of Reviews of Effects, the NHS Economic Evaluation Database and the Health Economic Evaluations Database. Selection criteria Randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Data collection and analysis We extracted clinical study reports and assessed risk of bias using purpose‐built instruments. We analysed the effects of zanamivir and oseltamivir on time to first alleviation of symptoms, influenza outcomes, complications, hospitalisations and adverse events in the intention‐to‐treat (ITT) population. All trials were sponsored by the manufacturers. Main results We obtained 107 clinical study reports from the European Medicines Agency (EMA), GlaxoSmithKline and Roche. We accessed comments by the US Food and Drug Administration (FDA), EMA and Japanese regulator. We included 53 trials in Stage 1 (a judgement of appropriate study design) and 46 in Stage 2 (formal analysis), including 20 oseltamivir (9623 participants) and 26 zanamivir trials (14,628 participants). Inadequate reporting put most of the zanamivir studies and half of the oseltamivir studies at a high risk of selection bias. There were inadequate measures in place to protect 11 studies of oseltamivir from performance bias due to non‐identical presentation of placebo. Attrition bias was high across the oseltamivir studies and there was also evidence of selective reporting for both the zanamivir and oseltamivir studies. The placebo interventions in both sets of trials may have contained active substances. Time to first symptom alleviation . For the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.8 hours (95% confidence interval (CI) 8.4 to 25.1 hours, P < 0.0001). This represents a reduction in the time to first alleviation of symptoms from 7 to 6.3 days. There was no effect in asthmatic children, but in otherwise healthy children there was (reduction by a mean difference of 29 hours, 95% CI 12 to 47 hours, P = 0.001). Zanamivir reduced the time to first alleviation of symptoms in adults by 0.60 days (95% CI 0.39 to 0.81 days, P < 0.00001), equating to a reduction in the mean duration of symptoms from 6.6 to 6.0 days. The effect in children was not significant. In subgroup analysis we found no evidence of a difference in treatment effect for zanamivir on time to first alleviation of symptoms in adults in the influenza‐infected and non‐influenza‐infected subgroups (P = 0.53). Hospitalisations . Treatment of adults with oseltamivir had no significant effect on hospitalisations: risk difference (RD) 0.15% (95% CI ‐0.78 to 0.91). There was also no significant effect in children or in prophylaxis. Zanamivir hospitalisation data were unreported. Serious influenza complications or those leading to study withdrawal . In adult treatment trials, oseltamivir did not significantly reduce those complications classified as serious or those which led to study withdrawal (RD 0.07%, 95% CI ‐0.78 to 0.44), nor in child treatment trials; neither did zanamivir in the treatment of adults or in prophylaxis. There were insufficient events to compare this outcome for oseltamivir in prophylaxis or zanamivir in the treatment of children. Pneumonia . Oseltamivir significantly reduced self reported, investigator‐mediated, unverified pneumonia (RD 1.00%, 95% CI 0.22 to 1.49); number needed to treat to benefit (NNTB) = 100 (95% CI 67 to 451) in the treated population. The effect was not significant in the five trials that used a more detailed diagnostic form for pneumonia. There were no definitions of pneumonia (or other complications) in any trial. No oseltamivir treatment studies reported effects on radiologically confirmed pneumonia. There was no significant effect on unverified pneumonia in children. There was no significant effect of zanamivir on either self reported or radiologically confirmed pneumonia. In prophylaxis, zanamivir significantly reduced the risk of self reported, investigator‐mediated, unverified pneumonia in adults (RD 0.32%, 95% CI 0.09 to 0.41); NNTB = 311 (95% CI 244 to 1086), but not oseltamivir. Bronchitis, sinusitis and otitis media . Zanamivir significantly reduced the risk of bronchitis in adult treatment trials (RD 1.80%, 95% CI 0.65 to 2.80); NNTB = 56 (36 to 155), but not oseltamivir. Neither NI significantly reduced the risk of otitis media and sinusitis in both adults and children. Harms of treatment . Oseltamivir in the treatment of adults increased the risk of nausea (RD 3.66%, 95% CI 0.90 to 7.39); number needed to treat to harm (NNTH) = 28 (95% CI 14 to 112) and vomiting (RD 4.56%, 95% CI 2.39 to 7.58); NNTH = 22 (14 to 42). The proportion of participants with four‐fold increases in antibody titre was significantly lower in the treated group compared to the control group (RR 0.92, 95% CI 0.86 to 0.97, I 2 statistic = 0%) (5% absolute difference between arms). Oseltamivir significantly decreased the risk of diarrhoea (RD 2.33%, 95% CI 0.14 to 3.81); NNTB = 43 (95% CI 27 to 709) and cardiac events (RD 0.68%, 95% CI 0.04 to 1.0); NNTB = 148 (101 to 2509) compared to placebo during the on‐treatment period. There was a dose‐response effect on psychiatric events in the two oseltamivir \"pivotal\" treatment trials, WV15670 and WV15671, at 150 mg (standard dose) and 300 mg daily (high dose) (P = 0.038). In the treatment of children, oseltamivir induced vomiting (RD 5.34%, 95% CI 1.75 to 10.29); NNTH = 19 (95% CI 10 to 57). There was a significantly lower proportion of children on oseltamivir with a four‐fold increase in antibodies (RR 0.90, 95% CI 0.80 to 1.00, I 2 = 0%). Prophylaxis . In prophylaxis trials, oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals (oseltamivir: RD 3.05% (95% CI 1.83 to 3.88); NNTB = 33 (26 to 55); zanamivir: RD 1.98% (95% CI 0.98 to 2.54); NNTB = 51 (40 to 103)) and in households (oseltamivir: RD 13.6% (95% CI 9.52 to 15.47); NNTB = 7 (6 to 11); zanamivir: RD 14.84% (95% CI 12.18 to 16.55); NNTB = 7 (7 to 9)). There was no significant effect on asymptomatic influenza (oseltamivir: RR 1.14 (95% CI 0.39 to 3.33); zanamivir: RR 0.97 (95% CI 0.76 to 1.24)). Non‐influenza, influenza‐like illness could not be assessed due to data not being fully reported. In oseltamivir prophylaxis studies, psychiatric adverse events were increased in the combined on‐ and off‐treatment periods (RD 1.06%, 95% CI 0.07 to 2.76); NNTH = 94 (95% CI 36 to 1538) in the study treatment population. Oseltamivir increased the risk of headaches whilst on treatment (RD 3.15%, 95% CI 0.88 to 5.78); NNTH = 32 (95% CI 18 to 115), renal events whilst on treatment (RD 0.67%, 95% CI ‐2.93 to 0.01); NNTH = 150 (NNTH 35 to NNTB > 1000) and nausea whilst on treatment (RD 4.15%, 95% CI 0.86 to 9.51); NNTH = 25 (95% CI 11 to 116). Authors' conclusions Oseltamivir and zanamivir have small, non‐specific effects on reducing the time to alleviation of influenza symptoms in adults, but not in asthmatic children. Using either drug as prophylaxis reduces the risk of developing symptomatic influenza. Treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced, because of a lack of diagnostic definitions. The use of oseltamivir increases the risk of adverse effects, such as nausea, vomiting, psychiatric effects and renal events in adults and vomiting in children. The lower bioavailability may explain the lower toxicity of zanamivir compared to oseltamivir. The balance between benefits and harms should be considered when making decisions about use of both NIs for either the prophylaxis or treatment of influenza. The influenza virus‐specific mechanism of action proposed by the producers does not fit the clinical evidence. Plain language summary Regulatory information on trials of oseltamivir (Tamiflu) and zanamivir (Relenza) for influenza in adults and children Oseltamivir and zanamivir have been stockpiled in many countries to treat and prevent seasonal and pandemic influenza, before an influenza vaccine matched to the circulating virus becomes available. Oseltamivir is classified by the World Health Organization as an essential medicine. How this review has been approached We have updated and combined our reviews on the antiviral drugs zanamivir and oseltamivir for influenza in adults and children on the basis of the manufacturers' reports to regulators (clinical study reports) and the regulators' comments. We have called these comments and reports 'regulatory information'. Clinical study reports are unpublished, extensive documents with great detail on the trials that formed the basis for market approval. They include the protocols, methods and results. Clinical study reports have until now been confidential, seen only by the manufacturers and regulators. Why we have taken this approach In previous versions of this review we identified unresolved discrepancies in the data presented in published trial reports and substantial publication bias. As a consequence, we elected not to use data from journal articles but included the documents generated during licensing processes. We have accessed such data from the UK, USA, European Medicines Agency (EMA), Japanese regulators and clinical study reports from the manufacturers (after a protracted media campaign). This has enabled us to verify information from the randomised, placebo‐controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Based on our assessments of the regulatory documents (in excess of 160,000 pages), we came to the conclusion that there were substantial problems with the design, conduct, reporting and availability of information from many of the trials. What we have found We have used data from 46 trials (20 oseltamivir and 26 zanamivir studies) in this review. We identified problems in the design of many of the studies that we included, which affects our confidence in their results. We found that both drugs shorten the duration of symptoms of influenza‐like illness (unconfirmed influenza or 'the flu') by less than a day. Oseltamivir did not affect the number of hospitalisations, based on the data from all the people enrolled in treatment trials of oseltamivir. Zanamivir trials did not record this outcome. The effects on pneumonia and other complications of influenza, such as bronchitis, middle ear infection (otitis media) and sinusitis, were unreliably reported, as shown by the case report form in the trial documents. Some forms showed limitations in the diagnostic criteria for pneumonia. Regulatory comments noted problems with missing follow‐up diary cards from participants. In children with asthma there was no clear effect on the time to first alleviation of symptoms. Prophylaxis trials showed that oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals and households. There was no evidence of an effect on asymptomatic influenza or on non‐influenza, influenza‐like illness, but trial conduct problems prevent any definitive conclusion. Oseltamivir use was associated with nausea, vomiting, headaches, renal and psychiatric events; these last three were when it was used to prevent influenza (prophylaxis). Its effect on the heart is unclear: it may reduce cardiac symptoms, but may induce serious heart rhythm problems. In adult treatment trials of zanamivir there was no increased risk of reported adverse events. The evidence on the possible harms associated with the treatment of children with zanamivir was sparse. Agreement with other findings The lack of good evidence demonstrating an effect on complications agrees with the conservative conclusions on both drugs drawn by the US Food and Drug Administration (FDA). The FDA only allowed claims of effectiveness of both drugs for the prevention and treatment of symptoms of influenza and not for other effects (including the interruption of person‐to‐person spread of the influenza virus or prevention of pneumonia). The FDA described the overall performance of both drugs as 'modest'. Mechanism of action for beneficial effects These findings all suggest that the low immune response with low levels of pro‐inflammatory cytokines, which is induced by the action of oseltamivir carboxylate, may reduce the symptoms of influenza unrelated to an inhibition of influenza virus replication. The potential hypothermic or antipyretic effect of oseltamivir as a central nervous system depressant may also contribute to the apparent reduction of host symptoms. Statements made on the capacity of oseltamivir to interrupt viral transmission and reduce complications are not supported by any data we have been able to access. The mechanism of action proposed by the producers (influenza virus‐specific) does not fit the clinical evidence which suggests a multi‐system and central action.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Jefferson, T, Jones, MA, Doshi, P, Del Mar, CB, Hama, R, Thompson, MJ, Spencer, EA, Onakpoya, IJ, Mahtani, KR, Nunan, D, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD008965.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.140Z" }, { "id": "e96f035d-5a96-4c71-aa46-79b9f5993869", "pmid": "", "title": "Corticosteroids for the long‐term treatment in multiple sclerosis", "imported": false, "abstract": "Abstract - Background Short term high dose corticosteroid treatment improves symptoms and short term disability after an acute exacerbation of multiple sclerosis (MS) but it is unknown whether its long‐term use can reduce the accumulation of disability. Objectives To determine the efficacy and safety of long‐term corticosteroid use in MS. Search methods We searched The Cochrane MS Group Trials Register (February 2007),the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to February 2007) and EMBASE (1980 to February 2007). In an effort to identify further published, unpublished and ongoing trials we searched reference lists and contacted trial authors and one pharmaceutical company. Selection criteria We considered controlled, randomised trials (RCTs), with or without blinding, of long term treatment (i.e. longer than 6 months) of any type of corticosteroid in MS, irrespective of disease course. Data collection and analysis Reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Three trials, all classified at high risk of bias, contributed to this review (Miller 1961; BPSM 1995; Zivadinov 2001) resulting in a total of 183 participants (91 treated). Corticosteroid therapy did not reduce the risk of being worse at the end of follow‐up (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.26 to 1.02) but there was a substantial heterogeneity between studies (I 2 : 78.4%). I. v. periodic high dose methylprednisolone (MP) was associated with a significant reduction in the risk of disability progression at 5 years in relapsing‐remitting (RR) MS (OR 0.26, 95% CI 0.10 to 0.66), while oral continuous low dose prednisolone was not associated with any risk reduction in disability progression at 18 months (OR 1.23, 95% CI 0.43 to 3.56). Risk of experiencing at least one exacerbation at end of follow‐up was not significantly reduced with corticosteroid treatment (OR 0.36; 95% CI 0.10 to 1.25). 
 Only one study recorded adverse events: in one patient i. v. MP was discontinued after the fourth pulse when he developed acute glomerulonephritis; a second patient was removed from the study after the fifth i. v. MP pulse because of severe osteoporosis. Authors' conclusions There is no enough evidence that long‐term corticosteroid treatment delays progression of long term disability in patients with MS. Since one study at high risk of bias showed that the administration of pulsed high dose i. v. MP is associated with a significant reduction in the risk of long term disability progression in patients with RR MS, an adequately powered, high quality RCT is needed to investigate this finding. Plain language summary The long‐term use of anti‐inflammatory corticosteroids for treating multiple sclerosis Multiple sclerosis is an inflammatory disease affecting the brain and spinal cord. It results in episodes of neurological deficit which recover (relapses) as well as accumulation of sustained disability with the passage of time. Corticosteroids are potent anti‐inflammatory drugs. It is postulated that long‐term use of steroids may reduce the accumulation of disability. The reviewers found three studies addressing this issue. A meta‐analysis showed a trend towards a beneficial effect of long‐term corticosteroids on accumulation of disability; however only two small studies contributed to this result. It was not possible to reliably comment on the effect of long‐term corticosteroids on the frequency of relapses. Side effects were poorly documented. Therefore rigorous randomised controlled trials of this treatment are warranted.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Ciccone, A; Beretta, S; Brusaferri, F; Galea, I; Protti, A; Spreafico, C", "articleTypes": [], "doi": "10.1002/14651858.CD006264.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "e978e3e1-eca7-433c-9c40-25a6df3d8e5f", "pmid": "", "title": "Laxatives for the management of constipation in people receiving palliative care", "imported": false, "abstract": "Abstract - Background This article describes the second update of a Cochrane review on the effectiveness of laxatives for the management of constipation in people receiving palliative care. Previous versions were published in 2006 and 2010 where we also evaluated trials of methylnaltrexone; these trials have been removed as they are included in another review in press. In these earlier versions, we drew no conclusions on individual effectiveness of different laxatives because of the limited number of evaluations. This is despite constipation being common in palliative care, generating considerable suffering due to the unpleasant physical symptoms and the availability of a wide range of laxatives with known differences in effect in other populations. Objectives To determine the effectiveness and differential efficacy of laxatives used to manage constipation in people receiving palliative care. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library ), MEDLINE, EMBASE, CINAHL and Web of Science (SCI & CPCI‐S) for trials to September 2014. Selection criteria Randomised controlled trials (RCTs) evaluating laxatives for constipation in people receiving palliative care. Data collection and analysis Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity. Main results We identified five studies involving the laxatives lactulose, senna, co‐danthramer, misrakasneham, docusate and magnesium hydroxide with liquid paraffin. Overall, the study findings were at an unclear risk of bias. As all five studies compared different laxatives or combinations of laxatives, it was not possible to perform a meta‐analysis. There was no evidence on whether individual laxatives were more effective than others or caused fewer adverse effects. Authors' conclusions This second update found that laxatives were of similar effectiveness but the evidence remains limited due to insufficient data from a few small RCTs. None of the studies evaluated polyethylene glycol or any intervention given rectally. There is a need for more trials to evaluate the effectiveness of laxatives in palliative care populations. Extrapolating findings on the effectiveness of laxatives evaluated in other populations should proceed with caution. This is because of the differences inherent in people receiving palliative care that may impact, in a likely negative way, on the effect of a laxative. Plain language summary Laxatives for the management of constipation in people receiving palliative care Background People with an incurable illness may receive palliative care, which involves making the person as comfortable as possible by controlling pain and other distressing symptoms. People receiving palliative care commonly experience constipation. This is as a result of the use of medicines (e.g. morphine) for pain control, as well as disease, dietary and mobility factors. There is a wide range of laxatives available. The aim of this review was to determine what we know about the effectiveness of laxatives for the management of constipation in people receiving palliative care. Study characteristics We searched medical databases for clinical trials of the use of laxatives for constipation in people receiving palliative care. Two review authors assessed study quality and extracted data. Key results and quality of evidence We identified five studies involving 370 people. The laxatives evaluated were lactulose, senna, co‐danthramer combined with poloxamer, docusate and magnesium hydroxide combined with liquid paraffin. Misrakasneham was also evaluated; this is a traditional Indian medicine and is used as a laxative, containing castor oil, ghee, milk and 21 types of herbs. There was no evidence on which laxative provided the best treatment. However, the review was limited as the evidence was from only five small trials and patient preference and cost were under evaluated. Further rigorous, independent trials are needed to evaluate the effectiveness of laxatives.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Candy, B, Jones, L, Larkin, PJ, Vickerstaff, V, Tookman, A, Stone, P", "articleTypes": [], "doi": "10.1002/14651858.CD003448.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.781Z" }, { "id": "e97adbf5-bad2-4408-9ef6-55413e86344c", "pmid": "", "title": "A 6-month Multicenter, Randomized, Double-blind, Placebo-controlled Study to Evaluate the Efficacy, Safety and PK/PD of an age-and Body Weight-adjusted Oral Finerenone Regimen, in Addition to an ACEI or ARB, for the Treatment of Children, 6 Months to <18 Years of Age, With Chronic Kidney Disease and Proteinuria", "imported": false, "abstract": "Researchers are looking for a better way to treat children who have chronic kidney disease (CKD), which is long-term kidney disease, and proteinuria, a condition in which a person´s kidneys leak protein into the urine.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.264Z" }, { "id": "e97db858-77dd-401f-82c6-55e558da8f1e", "pmid": "", "title": "Tobacco packaging design for reducing tobacco use", "imported": false, "abstract": "Abstract - Background Tobacco use is the largest single preventable cause of death and disease worldwide. Standardised tobacco packaging is an intervention intended to reduce the promotional appeal of packs and can be defined as packaging with a uniform colour (and in some cases shape and size) with no logos or branding, apart from health warnings and other government‐mandated information, and the brand name in a prescribed uniform font, colour and size. Australia was the first country to implement standardised tobacco packaging between October and December 2012, France implemented standardised tobacco packaging on 1 January 2017 and several other countries are implementing, or intending to implement, standardised tobacco packaging. Objectives To assess the effect of standardised tobacco packaging on tobacco use uptake, cessation and reduction. Search methods We searched MEDLINE, Embase, PsycINFO and six other databases from 1980 to January 2016. We checked bibliographies and contacted study authors to identify additional peer‐reviewed studies. Selection criteria Primary outcomes included changes in tobacco use prevalence incorporating tobacco use uptake, cessation, consumption and relapse prevention. Secondary outcomes covered intermediate outcomes that can be measured and are relevant to tobacco use uptake, cessation or reduction. We considered multiple study designs: randomised controlled trials, quasi‐experimental and experimental studies, observational cross‐sectional and cohort studies. The review focused on all populations and people of any age; to be included, studies had to be published in peer‐reviewed journals. We examined studies that assessed the impact of changes in tobacco packaging such as colour, design, size and type of health warnings on the packs in relation to branded packaging. In experiments, the control condition was branded tobacco packaging but could include variations of standardised packaging. Data collection and analysis Screening and data extraction followed standard Cochrane methods. We used different 'Risk of bias' domains for different study types. We have summarised findings narratively. Main results Fifty‐one studies met our inclusion criteria, involving approximately 800,000 participants. The studies included were diverse, including observational studies, between‐ and within‐participant experimental studies, cohort and cross‐sectional studies, and time‐series analyses. Few studies assessed behavioural outcomes in youth and non‐smokers. Five studies assessed the primary outcomes: one observational study assessed smoking prevalence among 700,000 participants until one year after standardised packaging in Australia; four studies assessed consumption in 9394 participants, including a series of Australian national cross‐sectional surveys of 8811 current smokers, in addition to three smaller studies. No studies assessed uptake, cessation, or relapse prevention. Two studies assessed quit attempts. Twenty studies examined other behavioural outcomes and 45 studies examined non‐behavioural outcomes (e.g. appeal, perceptions of harm). In line with the challenges inherent in evaluating standardised tobacco packaging, a number of methodological imitations were apparent in the included studies and overall we judged most studies to be at high or unclear risk of bias in at least one domain. The one included study assessing the impact of standardised tobacco packaging on smoking prevalence in Australia found a 3.7% reduction in odds when comparing before to after the packaging change, or a 0.5 percentage point drop in smoking prevalence, when adjusting for confounders. Confidence in this finding is limited, due to the nature of the evidence available, and is therefore rated low by GRADE standards. Findings were mixed amongst the four studies assessing consumption, with some studies finding no difference and some studies finding evidence of a decrease; certainty in this outcome was rated very low by GRADE standards due to the limitations in study design. One national study of Australian adult smoker cohorts (5441 participants) found that quit attempts increased from 20.2% prior to the introduction of standardised packaging to 26.6% one year post‐implementation. A second study of calls to quitlines provides indirect support for this finding, with a 78% increase observed in the number of calls after the implementation of standardised packaging. Here again, certainty is low. Studies of other behavioural outcomes found evidence of increased avoidance behaviours when using standardised packs, reduced demand for standardised packs and reduced craving. Evidence from studies measuring eye‐tracking showed increased visual attention to health warnings on standardised compared to branded packs. Corroborative evidence for the latter finding came from studies assessing non‐behavioural outcomes, which in general found greater warning salience when viewing standardised, than branded packs. There was mixed evidence for quitting cognitions, whereas findings with youth generally pointed towards standardised packs being less likely to motivate smoking initiation than branded packs. We found the most consistent evidence for appeal, with standardised packs rating lower than branded packs. Tobacco in standardised packs was also generally perceived as worse‐tasting and lower quality than tobacco in branded packs. Standardised packaging also appeared to reduce misperceptions that some cigarettes are less harmful than others, but only when dark colours were used for the uniform colour of the pack. Authors' conclusions The available evidence suggests that standardised packaging may reduce smoking prevalence. Only one country had implemented standardised packaging at the time of this review, so evidence comes from one large observational study that provides evidence for this effect. A reduction in smoking behaviour is supported by routinely collected data by the Australian government. Data on the effects of standardised packaging on non‐behavioural outcomes (e.g. appeal) are clearer and provide plausible mechanisms of effect consistent with the observed decline in prevalence. As standardised packaging is implemented in different countries, research programmes should be initiated to capture long term effects on tobacco use prevalence, behaviour, and uptake. We did not find any evidence suggesting standardised packaging may increase tobacco use. Plain language summary Can the use of standardised packaging for tobacco products reduce the use of tobacco? Background Tobacco use kills more people worldwide than any other preventable cause of death. The best way to reduce tobacco use is by stopping people from starting to use tobacco and encouraging and helping existing users to stop. This can be done by introducing policies that can reach a wide number of people in a country, together with offering individual treatment and support to individuals who are already using tobacco to help them to stop. Many countries have introduced bans on tobacco advertising but have not controlled the look of the tobacco pack itself. Tobacco packs can be colourful and attractive, with exciting new shapes and sizes. Standardised tobacco packaging is a government policy which removes these bright designs by, for example, only allowing tobacco packs to be in one colour, shape or size. Standardised packaging generally involves the use of the same uniform colour on all tobacco packs, with no brand imagery, and the brand name written in a specified font, colour and size. Health warnings and other information that governments wish to put on the packs can remain. Australia was the first country to introduce standardised tobacco packaging by December 2012. France was the second by January 2017. Several other countries are introducing standardised packaging or planning to do so. We examined whether standardised packaging reduces tobacco use. Study characteristics We searched nine databases for articles evaluating standardised packaging that had been already reviewed by academics and published before January 2016. We also checked references in those papers to other studies and contacted the authors where necessary. Key results We found 51 studies involving approximately 800,000 participants. These studies varied considerably. Some studies focused on the effect of standardised packaging in Australia, and included looking at overall smoking levels, whether smokers altered their behaviour such as by cutting down the number of cigarettes they smoked, and whether smokers were making more quit attempts. We also included experiments in which people used or viewed standardised tobacco packs and examined their responses, compared to when they were viewing branded packs. We also included studies that assessed people’s eye movements when they looked at different packs and how willing people were to buy, and how much they were willing to pay for, standardised compared to branded packs. Only five studies looked at our key outcomes. One study in Australia looked at data from 700,000 people before and after standardised packaging was introduced. This study found that there was a half a percentage point drop in the proportion of people who used tobacco after the introduction of standardised packaging, compared to before, when adjusting for other factors which could affect this. Four other studies looked at whether current smokers changed the number of cigarettes they smoked. Two studies from Australia looked at this, one using surveys which included 8811 current smokers, and found no change in the number of cigarettes smoked. The three smaller studies found mixed results. Two further studies looked at quit attempts and observed increases in these in Australia after standardised packaging was introduced. The remainder of the studies looked at other outcomes, and the most consistent finding was that standardised packaging reduced how appealing people found the packs compared with branded packs. No studies reported the number of people who quit using tobacco, the number of people who started using tobacco, or the number of people who returned to using tobacco after quitting. Quality of the evidence Certainty in these findings is limited for several reasons, including the difficulties involved in studying national policies like standardised packaging. However, findings suggesting standardised packaging may decrease tobacco use are supported by routine data from the Australian government and studies looking at other outcomes. For example, in our included studies people consistently found standardised packs less appealing than branded packs. We did not find any evidence suggesting standardised packaging may increase tobacco use.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "McNeill, A; Gravely, S; Hitchman, SC; Bauld, L; Hammond, D; Hartmann‐Boyce, J", "articleTypes": [], "doi": "10.1002/14651858.CD011244.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "e997c535-859f-4718-ba1a-b0777c473c76", "pmid": "", "title": "Convalescent plasma for people with COVID‐19", "imported": false, "abstract": "Abstract - Rationale Convalescent plasma (CP) may reduce mortality in people with viral respiratory diseases, and is being investigated as a potential therapy for coronavirus disease 2019 (COVID‐19). A thorough understanding of the current body of evidence regarding the benefits and risks of this intervention is required. Objectives To assess the effectiveness and safety of convalescent plasma transfusion in the treatment of people with COVID‐19. Search methods To identify completed and ongoing studies, we searched CENTRAL, MEDLINE, Embase, the Epistemonikos COVID‐19 L*OVE Platform, and clinical trial registries to October 2024. Eligibility criteria We included randomised controlled trials (RCTs) evaluating convalescent plasma for people with COVID‐19, irrespective of disease severity, age, gender, or ethnicity. We excluded studies investigating other coronavirus diseases or standard immunoglobulin. Outcomes We used the GRADE approach to rate the certainty of evidence for the following outcomes: all‐cause mortality (up to day 28), worsening and improvement of clinical status (for individuals with moderate to severe disease), hospital admission or death, COVID‐19 symptoms resolution (for individuals with mild disease), quality of life (QoL), grade 3/4 adverse events, and serious adverse events. Risk of bias We used RoB 2 to assess bias in included studies. Synthesis methods We followed standard Cochrane methodology. Included studies We included 48 RCTs (24,518 participants), 15 of which were added in this update. We also identified 36 new ongoing studies and 33 completed studies awaiting classification. Synthesis of results Individuals with a confirmed diagnosis of COVID‐19 and moderate to severe disease Forty‐two RCTs investigated the use of CP for 21,393 participants with moderate to severe disease. Of these, 36 RCTs (20,798 participants) compared CP to placebo or standard care, five (604 participants) to standard plasma, and one (190 participants) to human immunoglobulin. In the full review, we performed subgroup analyses by antibody detection, time since symptom onset, country income level, and key comorbidities. Convalescent plasma versus placebo or standard care alone CP does not reduce all‐cause mortality at up to day 28 (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.90 to 1.03; 31 RCTs, 20,798 participants; high‐certainty evidence). It has little to no impact on the need for invasive mechanical ventilation, or death (RR 1.03, 95% CI 0.98 to 1.08; 8 RCTs, 15,189 participants; high‐certainty evidence) and has no impact on whether participants are discharged from hospital (RR 1.00, 95% CI 0.97 to 1.02; 9 RCTs, 13,930 participants; high‐certainty evidence). CP may have little to no impact on QoL (MD 1.00, 95% CI −2.14 to 4.14; 1 RCT, 483 participants; low‐certainty evidence). CP may have little to no impact on the risk of grade 3/4 adverse events (RR 1.17, 95% CI 0.96 to 1.42; 6 RCTs, 2392 participants; low‐certainty evidence). It probably has little to no effect on the risk of serious adverse events (RR 1.19, 95% CI 1.02 to 1.38; 11 studies, 5298 participants; moderate‐certainty evidence). Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.77, 95% CI 0.53 to 1.10; 5 RCTs, 604 participants; very low‐certainty evidence) and whether it increases the need for invasive mechanical ventilation, or death (RR 5.59, 95% CI 0.29 to 108.38; 1 study, 34 participants; very low‐certainty evidence). The evidence is uncertain about whether convalescent plasma reduces or increases the risk of grade 3/4 adverse events (1 RCT, 248 participants). The evidence is also uncertain about whether CP reduces the risk of serious adverse events (RR 0.82, 95% CI 0.57 to 1.17; 4 RCTs, 447 participants; very low‐certainty evidence). No studies in this comparison reported clinical improvement or QoL. Individuals with a confirmed diagnosis of SARS‐CoV‐2 infection and mild disease Six RCTs investigated the use of CP for 2761 participants with mild disease. Four RCTs (1164 participants) compared CP to placebo or standard care alone, and two (1597 participants) to standard plasma. Convalescent plasma versus placebo or standard care alone The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (odds ratio (OR) 1.24, 95% CI 0.33 to 4.60; 3 RCTs, 1004 participants; very low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.45, 95% CI 0.04 to 4.81; 2 RCTs, 493 participants; very low‐certainty evidence). It may have little to no impact on time to COVID‐19 symptom resolution (hazard ratio (HR) 1.05, 95% CI 0.85 to 1.30; 1 RCT, 376 participants) and on the risk of grade 3/4 adverse events (RR 1.29, 95% CI 0.75 to 2.19; 1 RCT, 376 participants), both with low‐certainty evidence. The evidence is uncertain about whether CP has an impact on the risk of serious adverse events (RR 0.84, 95% CI 0.56 to 1.26; 2 RCTs, 494 participants; very low‐certainty evidence). No studies in this comparison reported other critical outcomes. Convalescent plasma versus standard plasma The evidence is uncertain about whether CP reduces all‐cause mortality at up to day 28 (RR 0.41, 95% CI 0.05 to 3.06; 2 RCTs, 1597 participants; very low‐certainty evidence). It probably reduces admission to hospital or death within 28 days (RR 0.50, 95% CI 0.32 to 0.78; 2 RCTs, 1597 participants; moderate‐certainty evidence). CP may have little to no effect on initial symptom resolution at up to day 28 (RR 1.12, 95% CI 0.82 to 1.54; 1 RCT, 416 participants; low‐certainty evidence). Neither study in this comparison reported other critical outcomes. Authors' conclusions Compared with placebo or standard care, high‐certainty evidence shows that CP does not reduce mortality in individuals with moderate to severe disease and has little to no effect on clinical improvement or worsening. CP probably has little to no effect on serious adverse events. Publication of ongoing studies might resolve some of the uncertainties around CP therapy for people with asymptomatic or mild disease. This review was previously a living systematic review, from the first version published in 2020 until our last search in October 2024. The research question is no longer a priority for decision‐making, new studies are less frequently published, and research that might impact the conclusions of the review is no longer emerging. Funding The European Commission, Belgium SUPorting high quality evaluation of COVID‐19 convalescent plasma thrOughouT Europe (SUPPORT‐E, grant number 101015756) supported this review. Registration Protocol registered with the Center for Open Science on 17 April 2020 (DOI: 10.17605/OSF.IO/DWF53). Access the 2023 version of this review here: DOI: 10.1002/14651858.CD013600.pub6. Plain language summary Does plasma (a blood product) from people who have recovered from COVID‐19 help treat COVID‐19? Key messages We are very confident that plasma from the blood of people who have recovered from COVID‐19 (convalescent plasma) does not help people with moderate to severe COVID‐19. Convalescent plasma may make little or no difference to people with mild COVID‐19. We still need more evidence about people with mild COVID‐19, those with no symptoms, and those with a weaker immune system. What is convalescent plasma? The body produces antibodies as one of its defences against infection. Antibodies are found in part of the blood called plasma. Plasma from people who have recovered from the COVID‐19 virus contains COVID‐19 antibodies. It can be used to make convalescent plasma, which is plasma that contains these antibodies. Convalescent plasma has been used successfully to treat some viruses. This treatment (given by a drip or injection) is generally well‐tolerated, but can cause unwanted effects. What did we want to find out? We wanted to find out whether convalescent plasma helps people with confirmed COVID‐19. We looked at: deaths from any cause; worsening of people's condition, measured by the number of people who needed a ventilator (a machine that helps people breathe) or died; improvement in people's condition, measured by the number of people discharged from hospital; quality of life; unwanted effects. What did we do? We searched for studies that investigated convalescent plasma to treat people with COVID‐19. Studies could take place anywhere in the world and include people with mild, moderate, or severe COVID‐19. Where possible, we combined the studies’ results to analyse them. We rated our confidence in the evidence, based on factors such as study methods and the number of people included. What did we find? We found 48 studies with 24,518 participants. Of these, 42 studies included people with moderate to severe COVID‐19, and six studies included people with mild COVID‐19. The following findings compare convalescent plasma with placebo (a 'dummy' treatment that does not contain any medicine but is given in the same way as the medicine being tested) or the standard care given to people with COVID‐19. People with moderate to severe COVID‐19 In people with moderate to severe COVID‐19, convalescent plasma: makes no difference to deaths from any cause up to 28 days after treatment. About 230 of 1000 people given placebo or standard care died, compared to 220 of 1000 people given convalescent plasma (31 studies, 20,798 people). makes little to no difference to needing support from a ventilator or dying . About 291 of 1000 people given placebo or standard care needed a ventilator or died, compared to 300 of 1000 people given convalescent plasma (8 studies, 15,189 people). makes no difference to people being discharged from hospital. About 670 of 1000 people in both groups were discharged from hospital (9 studies, 13,930 people). may result in no difference in people's quality of life (1 study, 483 people). probably makes no difference to serious unwanted effects. About 109 of 1000 people given placebo or standard care had serious unwanted effects, compared to 129 of 1000 people given convalescent plasma (11 studies, 5298 people). People with mild COVID‐19 We are uncertain whether convalescent plasma reduces deaths from any cause up to 28 days after treatment. About 8 of 1000 people given placebo or standard care died, compared to 10 of 1000 people given convalescent plasma (3 studies, 1004 people). We are uncertain whether convalescent plasma reduces admission to hospital or death within 28 days after treatment. About 106 of 1000 people given placebo or standard care were admitted to hospital or died, compared to 48 of 1000 people given convalescent plasma (2 studies, 493 people). Convalescent plasma may result in no difference in the time until COVID‐19 symptoms resolved (1 study, 376 people). None of the studies measured people's quality of life. We are uncertain whether convalescent plasma has an impact on serious unwanted effects. About 174 of 1000 people given placebo or standard care had serious unwanted effects, compared to 150 of 1000 people given convalescent plasma (2 studies, 494 people). What are the limitations of the evidence? For people with moderate to severe COVID‐19, we are very confident in the evidence about the number of deaths from any cause, and whether people's condition worsened or improved, because the results are drawn from many high‐quality studies with consistent results. We are only moderately confident about the evidence for serious unwanted effects because studies often reported these effects only for people treated with convalescent plasma, or did not report them. For people with mild COVID‐19, we have little to no confidence in the evidence because we could not identify enough consistent results from many of the studies. We still have little evidence about quality of life and about the effects of convalescent plasma for people with mild disease. How up to date is this evidence? This updates our previous review published in 2023. The evidence is current to October 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Iannizzi, C; Chai, KL; Piechotta, V; Monsef, I; Wood, EM; Lamikanra, AA; Roberts, DJ; McQuilten, Z; So-Osman, C; Jindal, A; Estcourt, LJ; Skoetz, N; Kreuzberger, N", "articleTypes": [], "doi": "10.1002/14651858.CD013600.pub7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "e9a28f87-f661-45b9-9e83-514884185066", "pmid": "", "title": "Graft interposition for preventing Frey's syndrome in patients undergoing parotidectomy", "imported": false, "abstract": "Abstract - Background Frey's syndrome is characterised by transient flushing and sometimes facial sweating in the area of the auriculotemporal nerve. It most commonly occurs after parotidectomy, but other causes may include submandibular gland surgery, mandibular condylar fracture, obstetric (forceps) trauma, sympathectomy and metabolic disease. Although the pathophysiology of Frey's syndrome remains controversial, the generally accepted hypothesis is that it occurs as the result of injury to the auriculotemporal nerve. There is currently no clear evidence to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome, therefore the prevention of this symptom during surgery is important. The main method used for prevention is the interposition of a graft between the skin flap and the parotid bed during surgery. Biomaterials, allograft or autograft can be used for this purpose. Objectives To evaluate the effects and safety of biomaterial, allograft or autograft interposition for the prevention of Frey's syndrome in patients undergoing parotidectomy, and to identify its effect on prevention and delayed occurrence. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Cochrane Register of Controlled Trials (CENTRAL; 2019, Issue 2); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 5 February 2019. Selection criteria We included randomised controlled trials (RCTs) in patients with parotid disease (including tumours, inflammation, trauma etc.) undergoing parotidectomy with a minimal follow‐up period of six months. We planned to include trials with interventions including biomaterial, allograft or autograft interposition alone or in combination with other surgical techniques. We included trials that compared any graft interposition and no graft interposition, or different graft interpositions. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were incidence rate of Frey's syndrome assessed clinically (Minor's starch‐iodine test) and other complications (postoperative infection, subjective painful or restricted cervical movement, scar spread, rejection of the graft, complications related to the donor site such as accessory nerve injury and haematoma). Our secondary outcome measures were incidence rate of Frey's syndrome assessed by participants (by questionnaire) and sweating area assessed by Minor's starch‐iodine test. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included three RCTs (124 participants), two of which we assessed as at high risk of bias and one at unclear risk of bias. All studies were hospital‐based and recruited participants undergoing superficial parotidectomy. Most participants were diagnosed with benign lesions of the parotid gland. Participants were followed up for more than six months. The studies evaluated the two comparisons shown below: Sternocleidomastoid muscle flap versus no flap Two studies assessed this comparison. Both assessed the effects of the sternocleidomastoid muscle flap procedure on the incidence rate of Frey's syndrome assessed clinically but neither showed a significant difference between groups (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.23; 24 participants and RR 1.23, 95% CI 0.88 to 1.73; 36 participants; very low‐certainty evidence). We did not pool the data due to the high heterogeneity (I² = 87%). One study found that the sternocleidomastoid muscle flap may result in little or no difference in other complications including haematoma (RR 2.18, 95% CI 0.09 to 50.16; 36 participants; low‐certainty evidence), subjective painful or restricted cervical movement (RR 0.54, 95% CI 0.14 to 2.05; 36 participants; low‐certainty evidence) and scar spread in the cervical region (RR 0.71, 95% CI 0.05 to 10.54; 36 participants; low‐certainty evidence). Both studies reported the incidence rate of Frey's syndrome assessed by participants, with one reporting no events in either group and the other finding no evidence of a difference (RR 0.63, 95% CI 0.32 to 1.26; 36 participants; low‐certainty evidence). Acellular dermal matrix versus no graft Only one study assessed this comparison. Use of an acellular dermal matrix graft may result in little or no difference to the incidence rate of Frey's syndrome (assessed clinically) in comparison with the no graft group, but the evidence is very uncertain (RR 0.08, 95% CI 0.00 to 1.25; 30 participants; very low‐certainty evidence). Acellular dermal matrix may slightly increase the wound infection rate compared with control (RR 17.00, 95% CI 1.02 to 282.67; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence of seromas or sialoceles (RR 2.33, 95% CI 0.66 to 8.23; 64 participants; low‐certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence rate of Frey's syndrome (assessed by participants) in comparison with the no graft group (RR 0.33, 95% CI 0.04 to 3.04; 64 participants; low‐certainty evidence). Authors' conclusions The evidence for the effectiveness of graft interposition in preventing Frey's syndrome is of low or very low certainty. The use of acellular dermal matrix may be associated with an increase in the wound infection rate, and little or no difference in the incidence of seromas or sialoceles. Further studies are needed to draw reliable conclusions. Plain language summary Grafts for preventing Frey's syndrome after surgery to the parotid (salivary) glands Review question Does the use of a graft during surgery to the parotid glands prevent Frey's syndrome? Background The clinical symptoms of Frey's syndrome include sweating and flushing of the cheek when eating and chewing. It results from abnormal regrowth of damaged autonomic nerve fibres of the parotid glands, for example during surgery for parotid gland tumours. It is unclear whether placing a graft between the skin flap and the parotid bed during surgery can prevent this syndrome. Various types of grafts can be used, including biomaterial or skin, muscle or other tissue from the patient. These grafts may possibly hinder the abnormal connections of the nerves controlling the sweat glands and parotid glands when the cut nerves are re‐linking after surgery. Study characteristics We included three studies with 124 participants in this review, but the quality of these studies was not ideal. All of the participants in the studies had tumours of the parotid glands and were undergoing surgery to part of the glands. The studies assessed two types of grafts, tissue obtained from the sternocleidomastoid muscle and a biomaterial (a collagen framework without cells). Key results Two studies compared a tissue graft obtained from the sternocleidomastoid muscle to no graft. It is not known whether this type of tissue graft can prevent Frey's syndrome because the available evidence is very uncertain. One study compared a biomaterial graft to no graft. This type of graft may result in little or no difference to the incidence rate of Frey's syndrome, but the evidence is very uncertain. It may make the patient's wound slightly more likely to become infected. Certainty of the evidence The evidence in this review is mostly of low or very low certainty, because of the small number of studies on this question and the risk of bias in these studies. The findings must therefore be treated with caution and further studies are needed to draw reliable conclusions. The evidence in this review is up to date to 5 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Ye, L, Cao, Y, Yang, W, Wu, F, Lin, J, Li, L, Li, C", "articleTypes": [], "doi": "10.1002/14651858.CD012323.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.730Z" }, { "id": "e9a3e5df-7949-4ad5-b444-3ec16e5b8240", "pmid": "", "title": "Point‐of‐use fortification of foods with micronutrient powders containing iron in children of preschool and school‐age", "imported": false, "abstract": "Abstract - Background Approximately 600 million children of preschool and school age are anaemic worldwide. It is estimated that at least half of the cases are due to iron deficiency. Point‐of‐use fortification of foods with micronutrient powders (MNP) has been proposed as a feasible intervention to prevent and treat anaemia. It refers to the addition of iron alone or in combination with other vitamins and minerals in powder form, to energy‐containing foods (excluding beverages) at home or in any other place where meals are to be consumed. MNPs can be added to foods either during or after cooking or immediately before consumption without the explicit purpose of improving the flavour or colour. Objectives To assess the effects of point‐of‐use fortification of foods with iron‐containing MNP alone, or in combination with other vitamins and minerals on nutrition, health and development among children at preschool (24 to 59 months) and school (five to 12 years) age, compared with no intervention, a placebo or iron‐containing supplements. Search methods In December 2016, we searched the following databases: CENTRAL, MEDLINE, Embase, BIOSIS, Science Citation Index, Social Science Citation Index, CINAHL, LILACS, IBECS, Popline and SciELO. We also searched two trials registers in April 2017, and contacted relevant organisations to identify ongoing and unpublished trials. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs trials with either individual or cluster randomisation. Participants were children aged between 24 months and 12 years at the time of intervention. For trials with children outside this age range, we included studies where we were able to disaggregate the data for children aged 24 months to 12 years, or when more than half of the participants were within the requisite age range. We included trials with apparently healthy children; however, we included studies carried out in settings where anaemia and iron deficiency are prevalent, and thus participants may have had these conditions at baseline. Data collection and analysis Two review authors independently assessed the eligibility of trials against the inclusion criteria, extracted data from included trials, assessed the risk of bias of the included trials and graded the quality of the evidence. Main results We included 13 studies involving 5810 participants from Latin America, Africa and Asia. We excluded 38 studies and identified six ongoing/unpublished trials. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. No trials compared the effects of MNP versus iron‐containing supplements (as drops, tablets or syrup). The sample sizes in the included trials ranged from 90 to 2193 participants. Six trials included participants younger than 59 months of age only, four included only children aged 60 months or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. The iron doses varied from 2.5 mg to 30 mg of elemental iron. Four trials reported giving 10 mg of elemental iron as sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), chelated ferrous sulphate or microencapsulated ferrous fumarate. Three trials gave 12.5 mg of elemental iron as microencapsulated ferrous fumarate. Three trials gave 2.5 mg or 2.86 mg of elemental iron as NaFeEDTA. One trial gave 30 mg and one trial provided 14 mg of elemental iron as microencapsulated ferrous fumarate, while one trial gave 28 mg of iron as ferrous glycine phosphate. In comparison with receiving no intervention or a placebo, children receiving iron‐containing MNP for point‐of‐use fortification of foods had lower risk of anaemia prevalence ratio (PR) 0.66, 95% confidence interval (CI) 0.49 to 0.88, 10 trials, 2448 children; moderate‐quality evidence) and iron deficiency (PR 0.35, 95% CI 0.27 to 0.47, 5 trials, 1364 children; moderate‐quality evidence) and had higher haemoglobin (mean difference (MD) 3.37 g/L, 95% CI 0.94 to 5.80, 11 trials, 2746 children; low‐quality evidence). Only one trial with 115 children reported on all‐cause mortality (zero cases; low‐quality evidence). There was no effect on diarrhoea (risk ratio (RR) 0.97, 95% CI 0.53 to 1.78, 2 trials, 366 children; low‐quality evidence). Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children. However, information on mortality, morbidity, developmental outcomes and adverse effects is still scarce. Plain language summary Powdered vitamins and minerals added to foods at the point‐of‐use reduces anaemia and iron deficiency in preschool‐ and school‐age children Background to the question Approximately one billion people worldwide are deficient in at least one vitamin or mineral (also known of micronutrients). Iron, vitamin A, zinc and iodine deficiencies are very frequent among children of preschool (aged 24 months to less than 5 years) and school age (5 to 12 years of age), limiting their health and daily physical performance. Anaemia, the condition in which red blood cells have limited capacity to carry oxygen, frequently results after prolonged iron deficiency. Point‐of‐use fortification with powdered vitamins and minerals has been proposed as a public health intervention to reduce micronutrient deficiencies in children. In this process, a powdered premix containing iron, and possibly other vitamins and minerals, is added to foods either during or after cooking, or immediately before consumption to improve their nutritious value but not their flavour or colour. In some cases, point‐of‐use fortification is also known as home fortification. Review question What are the effects of point‐of‐use fortification of foods with iron‐containing micronutrient powders (MNP) alone, or in combination with other vitamins and minerals, on nutrition, health and development among children of preschool and school age (24 months to 12 years of age) compared with no intervention, a placebo (dummy pill) or regular iron‐containing supplements (as drops, tablets or syrup)? Study characteristics This review included 13 trials with 5810 participants from Latin America, Africa and Asia. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. Six trials included participants younger than 59 months of age only, four included only children aged 60 months of age or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. We searched existing clinical trials in December 2016 and ongoing trials in April 2017. We also contacted relevant institutions for additional information upon publication of the protocol and in April 2017. Key results The review found that children receiving iron‐containing MNP for point‐of‐use fortification of foods were at significantly lower risk of having anaemia and iron deficiency and had higher haemoglobin concentrations. We did not find any positive or negative effect on diarrhoea or mortality, but the data on these two outcomes were very limited. Quality of the evidence We rated the overall quality of the evidence for the provision of multiple MNP versus no intervention or placebo as moderate for anaemia, iron deficiency and adverse effects. We judged the evidence to be of low quality for haemoglobin, mortality and diarrhoea, and to be very low‐quality for ferritin. In general, the most common risk of bias in the studies was the lack of blinding for participants, personnel and outcome assessors. Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children and seems feasible for public health purposes. However, future research should aim to increase the body of evidence on mortality, morbidity, developmental outcomes and adverse effects. Due to the lack of trials, we were unable to determine at this time if this intervention has comparable effects to those observed with iron supplements (provided as drops, tablets or syrup).", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "De‐Regil, LM, Jefferds, MED, Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009666.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.787Z" }, { "id": "e9a4bd39-5227-4a18-9cfe-604b4fd2fb0d", "pmid": "", "title": "Community‐based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries", "imported": false, "abstract": "Abstract - Background Supplementary feeding is defined as the provision of extra food to children or families beyond the normal ration of their home diets. The impact of food supplementation on child growth merits careful evaluation in view of the reliance of many states and non‐governmental organisations on this intervention to improve child health in low and middle income countries (LMIC). This is an update of a Cochrane review first published in 2005. Objectives To evaluate the effectiveness of community‐based supplementary feeding for promoting the physical growth of children under five years of age in LMIC. Search methods For this updated review we searched the following databases on 31 January 2011: CENTRAL ( The Cochrane Library ), MEDLINE (1948 to January week 3, 2011), EMBASE (1980 to week 3, 2011), CINAHL (1937 to 27 January 2011), LILACS (all years), WorldCat for dissertations and theses (all years) and ClinicalTrials.gov (all years). Selection criteria Randomised controlled trials (RCTs) evaluating supplementary feeding in comparison to a control group (no intervention or a placebo such as food with a very low number of nutrients and calories) in children from birth to five years of age in LMIC. Data collection and analysis Two review authors independently extracted and analysed the data. Main results We included eight RCTs (n = 1243 children) that were at relatively high risk of bias. We found high levels of clinical heterogeneity in the participants, interventions and outcome measures across studies. Nevertheless, in order to quantify pooled effects of supplementary feeding, we decided to combine studies according to prespecified characteristics. These were the children's age (younger or older than 24 months), their nutritional status at baseline (stunted or wasted, or not stunted or wasted) and the duration of the intervention (less or more than 12 months). A statistically significant difference of effect was only found for length during the intervention in children aged less than 12 months (two studies; 795 children; mean difference 0.19 cm; 95% confidence interval (CI) 0.07 to 0.31). Based on the summary statistic calculated for each study, the mean difference (MD) between intervention and control groups ranged from 0.48 cm (95% CI 0.07 to 0.89) to 1.3 cm (95% CI 0.03 to 2.57) after 3 and 12 months of intervention, respectively. Data on potential adverse effects were lacking. Authors' conclusions The scarcity of available studies and their heterogeneity makes it difficult to reach any firm conclusions. The review findings suggest supplementary feeding has a negligible impact on child growth; however, the pooled results should be interpreted with great caution because the studies included in the review are clinically diverse. Future studies should address issues of research design, including sample size calculation, to detect meaningful clinical effects and adequate intervention allocation concealment. In the meantime, families and children in need should be provided appropriate feeding, health care and sanitation without waiting for new RCTs to establish a research basis for feeding children. Plain language summary Providing extra food for children under five years of age in low and middle income countries Undernutrition is one of the underlying causes of childhood illness and death in low‐ and middle‐income countries. Providing extra food to children or families beyond what they normally have at home is an intervention aimed at supporting the nutritional wellbeing of the target population. We included eight studies where the participants were randomly assigned to two groups: one group received the extra food and the other group was a control, either receiving no food or food with very low nutritional content. Although the impact of supplementary feeding on child growth appeared to be negligible, it is not possible to draw any conclusions until we have studies that involve larger numbers and do not allow assessors to know who is receiving the intervention. Although it is difficult to determine whether community‐based supplementary feeding helps to promote the growth of children from birth to five years in low‐ and middle‐income countries, it is obviously vital to continue to provide food, health care and sanitation to those who need them.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Sguassero, Y; de Onis, M; Bonotti, AM; Carroli, G", "articleTypes": [], "doi": "10.1002/14651858.CD005039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "e9ad71ae-b60b-425d-8763-09ac33a69830", "pmid": "", "title": "Efficacy of Cannabidiol in Combination With Red Algae (CBDRA60) to Prevent or Reduce Symptoms of COVID-19 and Post-Acute Sequelae of SARS-CoV-2 Infection PASC", "imported": false, "abstract": "Coronavirus disease (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents a major threat to human health. SARS-CoV-2 is highly infectious and is associated with extensive morbidity and mortality. Our study shares important features with other clinical trials using supplements or other widely available medications (e.g., Ascorbic Acid, Zinc, Vitamin D, Vitamin C). Our study shares two important elements with these previous studies, including:", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.267Z" }, { "id": "e9c63c37-fd24-49da-b2e1-467a4a9b3d03", "pmid": "", "title": "A Randomized, Double-blind, Placebo-controlled, Crossover Study to Evaluate the Influence of the A118G Polymorphism in the mu Opioid Receptor Gene (OPRM1) on Effects of GSK1521498 and Naltrexone on Physiological and Behavioural Markers of Brain Function in Healthy Social Drinkers", "imported": false, "abstract": "A total of at least 48 healthy subjects with a history of social drinking will be recruited into this single-centre, randomized, double-blind, cross-over study. Subjects will be genetically stratified to result in equal numbers of A118G 'AA' homozygotes (n=24) and A118G 'G' carriers (n=24).", "journal": "", "year": "2012", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.239Z" }, { "id": "e9e24cf7-154c-406b-8297-2d1f198cec21", "pmid": "", "title": "Nasal decongestants in monotherapy for the common cold", "imported": false, "abstract": "Abstract - Background Many treatments for the common cold exist and are sold over‐the‐counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited. Objectives To assess the efficacy, and short‐ and long‐term safety, of nasal decongestants used in monotherapy to alleviate symptoms of the common cold in adults and children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6, June 2016), which contains the Cochrane Acute Respiratory Infections (ARI) Specialised Register, MEDLINE (1946 to July 2016), Embase (2010 to 15 July 2016), CINAHL (1981 to 15 July 2016), LILACS (1982 to July 2016), Web of Science (1955 to July 2016) and clinical trials registers. Selection criteria Randomised controlled trials (RCTs) and cluster‐RCTs investigating the effectiveness and adverse effects of nasal decongestants compared with placebo for treating the common cold in adults and children. We excluded quasi‐RCTs. Data collection and analysis Three review authors independently extracted and summarised data on subjective measures of nasal congestion, overall patient well‐being score, objective measures of nasal airway resistance, adverse effects and general recovery. One review author acted as arbiter in cases of disagreement. We categorised trials as single and multi‐dose and analysed data both separately and together. We also analysed studies using an oral or topical nasal decongestant separately and together. Main results We included 15 trials with 1838 participants. Fourteen studies included adult participants only (aged 18 years and over). In six studies the intervention was a single dose and in nine studies multiple doses were used. Nine studies used pseudoephedrine and three studies used oxymetazoline. Other decongestants included phenylpropanolamine, norephedrine and xylometazoline. Phenylpropanolamine (or norephedrine) is no longer available on the market therefore we did not include the results of these studies in the meta‐analyses. Eleven studies used oral decongestants; four studies used topical decongestants. Participants were included after contracting the common cold. The duration of symptoms differed among studies; in 10 studies participants had symptoms for less than three days, in three studies symptoms were present for less than five days, one study counted the number of colds over one year, and one study experimentally induced the common cold. In the single‐dose studies, the effectiveness of a nasal decongestant was measured on the same day, whereas the follow‐up in multi‐dose studies ranged between one and 10 days. Most studies were conducted in university settings (N = eight), six at a specific university common cold centre. Three studies were conducted at a university in collaboration with a hospital and two in a hospital only setting. In two studies the setting was unclear. There were large differences in the reporting of outcomes and the reporting of methods in most studies was limited. Therefore, we judged most studies to be at low or unclear risk of bias. Pooling was possible for a limited number of studies only; measures of effect are expressed as standardised mean differences (SMDs). A positive SMD represents an improvement in congestion. There is no defined minimal clinically important difference for measures of subjective improvement in nasal congestion, therefore we used the SMDs as a guide to assess whether an effect was small (0.2 to 0.49), moderate (0.5 to 0.79) or large (≥ 0.8). Single‐dose decongestant versus placebo: 10 studies compared a single dose of nasal decongestant with placebo and their effectiveness was tested between 15 minutes and 10 hours after dosing. Seven of 10 studies reported subjective symptom scores for nasal congestion; none reported overall patient well‐being. However, pooling was not possible due to the large diversity in the measurement and reporting of symptoms of congestion. Two studies recorded adverse events. Both studies used an oral decongestant and each of them showed that there was no statistical difference between the number of adverse events in the treatment group versus the placebo group. Multi‐dose decongestant versus placebo: nine studies compared multiple doses of nasal decongestants with placebo, but only five reported on the primary outcome, subjective symptom scores for nasal congestion. Only one study used a topical decongestant; none reported overall patient well‐being. Subjective measures of congestion were significantly better for the treatment group compared with placebo approximately three hours after the last dose (SMD 0.49, 95% confidence interval (CI) 0.07 to 0.92; P = 0.02; GRADE: low‐quality evidence). However, the SMD of 0.49 only indicates a small clinical effect. Pooling was based on two studies, one oral and one topical, therefore we were unable to assess the effects of oral and topical decongestants separately. Seven studies reported adverse events (six oral and one topical decongestant); meta‐analysis showed that there was no statistical difference between the number of adverse events in the treatment group (125 per 1000) compared to the placebo group (126 per 1000). The odds ratio (OR) for adverse events in the treatment group was 0.98 (95% CI 0.68 to 1.40; P = 0.90; GRADE: low‐quality evidence). The results remained the same when we only considered studies using an oral decongestant (OR 0.95, 95% CI 0.65 to 1.39; P = 0.80; GRADE: low‐quality evidence). Authors' conclusions We were unable to draw conclusions on the effectiveness of single‐dose nasal decongestants due to the limited evidence available. For multiple doses of nasal decongestants, the current evidence suggests that these may have a small positive effect on subjective measures of nasal congestion in adults with the common cold. However, the clinical relevance of this small effect is unknown and there is insufficient good‐quality evidence to draw any firm conclusions. Due to the small number of studies that used a topical nasal decongestant, we were also unable to draw conclusions on the effectiveness of oral versus topical decongestants. Nasal decongestants do not seem to increase the risk of adverse events in adults in the short term. The effectiveness and safety of nasal decongestants in children and the clinical relevance of their small effect in adults is yet to be determined. Plain language summary Do nasal decongestants used alone relieve cold symptoms? Review question We wanted to find out if nasal decongestants used alone can ease nasal congestion symptoms in people with colds. Background Colds, although not serious, are common illnesses responsible for many visits to family doctors and days lost from work and school. Cold symptoms include runny nose, sore throat and sneezing, and they can last up to two weeks. There is no cure for colds; treatments only ease the symptoms. Many people use over‐the‐counter medicines such as nasal decongestants to treat cold symptoms. However, there is little evidence that nasal decongestants actually work. We wanted to find out if nasal decongestants help ease congestion caused by colds. We considered studies that used a nasal decongestant as the only treatment for colds. We looked at subjective symptoms of congestion ‐ this means that symptoms and overall well‐being were self‐rated by patients. Search date We searched for studies in July 2016. Study characteristics We included 15 studies with 1838 participants; 14 included only adults aged 18 years or over. Six studies used a single‐dose nasal decongestant and measured the effects on the day it was administered. Nine studies used multiple doses and the effects were measured between one and 10 days after first administration. Eleven studies used tablets or syrup and four studies used nasal sprays. Eight studies were conducted at universities, three at universities in collaboration with hospitals and two in hospitals. The setting was unclear in two studies. Study funding sources Nine studies were funded by drug manufacturers or agencies with commercial interests in the study results. Funding sources were unclear in six studies. Key results We were unable to draw conclusions about single‐dose nasal decongestants. We found a small benefit in the relief of nasal congestion from multiple doses, but it was unclear if this was beneficial for patients. No studies reported overall patient well‐being. There was no difference in the numbers of adverse events between people who used a nasal decongestant and those who did not. We could not determine if there was a difference in effects between decongestant tablets and nasal sprays. The results relate to adults; there was no evidence on the effectiveness or safety of nasal decongestants for children. Quality of the evidence We assessed the quality of the evidence for subjective cold symptoms as low for the multi‐dose studies ‐ there were few data and reporting was unclear. We also assessed the quality of the evidence for adverse events as low because of unclear reporting and because the estimates were not precise (there were wide confidence intervals ‐ a measure of statistical uncertainty).", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Deckx, L; De Sutter, AIM; Guo, L; Mir, NA; van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009612.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "e9ebbbb6-d58b-4ae5-bd7a-cd4d28a75ee2", "pmid": "", "title": "Vitamin B12 supplementation during pregnancy for maternal and child health outcomes", "imported": false, "abstract": "Abstract - Background Vitamin B 12 deficiency is a major public health problem worldwide, with the highest burden in elderly people, pregnant women, and young children. Due to its role in DNA synthesis and methylation, folate metabolism, and erythropoiesis, vitamin B 12 supplementation during pregnancy may confer longer‐term benefits to maternal and child health outcomes. Objectives To evaluate the benefits and harms of oral vitamin B 12 supplementation during pregnancy on maternal and child health outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov , the World Health Organization International Clinical Trials Registry Platform ( ICTRP ) on 2 June 2023, and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs), quasi‐RCTs, or cluster‐RCTs evaluating the effects of oral vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation during pregnancy. Data collection and analysis We used standard Cochrane methods. Four review authors independently assessed trial eligibility. Two review authors independently extracted data from included studies and conducted checks for accuracy. Three review authors independently assessed the risk of bias of the included studies using the Cochrane RoB 1 tool. We used GRADE to evaluate the certainty of evidence for primary outcomes. Main results The review included five trials with 984 pregnant women. All trials were conducted in low‐ and middle‐income countries, including India, Bangladesh, South Africa, and Croatia. At enrolment, 26% to 51% of pregnant women had vitamin B 12 deficiency (less than 150 pmol/L), and the prevalence of anaemia (haemoglobin less than 11.0 g/dL) ranged from 30% to 46%. The dosage of vitamin B 12 supplementation varied from 5 μg/day to 250 μg/day, with administration beginning at 8 to 28 weeks' gestation through to delivery or three months' postpartum, and the duration of supplementation ranged from 8 to 16 weeks to 32 to 38 weeks. Three trials, involving 609 pregnant women, contributed data for meta‐analyses of the effects of vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation. Maternal anaemia: there may be little to no difference for maternal anaemia by intervention group, but the evidence is very uncertain (70.9% versus 65.0%; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.93 to 1.26; 2 trials, 284 women; very low‐certainty evidence). Maternal vitamin B 12 status: vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain (25.9% versus 67.9%; RR 0.38, 95% CI 0.28 to 0.51; 2 trials, 272 women; very low‐certainty evidence). Women who received vitamin B 12 supplements during pregnancy may have higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (mean difference (MD) 60.89 pmol/L, 95% CI 40.86 to 80.92; 3 trials, 412 women). However, there was substantial heterogeneity (I 2 = 85%). Adverse pregnancy outcomes: the evidence is uncertain about the effect on adverse pregnancy outcomes, including preterm birth (RR 0.97, 95% CI 0.55 to 1.74; 2 trials, 340 women; low‐certainty evidence), and low birthweight (RR 1.50, 95% CI 0.93 to 2.43; 2 trials, 344 women; low‐certainty evidence). Two trials reported data on spontaneous abortion (or miscarriage); however, the trials did not report quantitative data for meta‐analysis and there was no clear definition of spontaneous abortion in the study reports. No trials evaluated the effects of vitamin B 12 supplementation during pregnancy on neural tube defects. Infant vitamin B 12 status: children born to women who received vitamin B 12 supplementation had higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (MD 71.89 pmol/L, 95% CI 20.23 to 123.54; 2 trials, 144 children). Child cognitive outcomes : three ancillary analyses of one trial reported child cognitive outcomes; however, data were not reported in a format that could be included in quantitative meta‐analyses. In one study, maternal vitamin B 12 supplementation did not improve neurodevelopment status (e.g. cognitive, language (receptive and expressive), motor (fine and gross), social‐emotional, or adaptive (conceptual, social, practical) domains) in children compared to placebo (9 months, Bayley Scales of Infant and Toddler Development Third Edition (BSID‐III); 1 trial; low‐certainty evidence) or neurophysiological outcomes (72 months, event‐related potential measures; 1 trial; low‐certainty evidence), though children born to women who received vitamin B 12 supplementation had improved expressive language domain compared to placebo (30 months, BSID‐III; 1 trial; low‐certainty evidence). Authors' conclusions Oral vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency and may improve maternal vitamin B 12 concentrations during pregnancy or postpartum compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain. The effects of vitamin B 12 supplementation on other primary outcomes assessed in this review were not reported, or were not reported in a format for inclusion in quantitative analyses. Vitamin B 12 supplementation during pregnancy may improve maternal and infant vitamin B 12 status, but the potential impact on longer‐term clinical and functional maternal and child health outcomes has not yet been established. Plain language summary Vitamin B 12 supplementation for women during pregnancy Key messages – Women who took vitamin B 12 supplements during pregnancy may have improved vitamin B 12 status during pregnancy or postpartum, including less vitamin B 12 deficiency and higher vitamin B 12 levels, compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. – The effects of taking vitamin B 12 supplements during pregnancy on other health outcomes in pregnant women or their children are not known. Public health implications Vitamin B 12 is an important nutrient that helps keep your body's blood and nerve cells healthy. Vitamin B 12 deficiency is an important public health problem, particularly in low‐ and middle‐income countries, with a high burden amongst pregnant women and children. Lower vitamin B 12 levels in pregnancy have been linked to greater risk of some adverse pregnancy outcomes such as miscarriage, poor growth of the baby in the womb, problems with the baby's brain or spinal cord (called neural tube defects), and lower vitamin B 12 status in infants. Vitamin B 12 supplementation during pregnancy may help improve the health and nutrition of women and their babies. However, this has not been examined in well‐conducted reviews, and vitamin B 12 is not part of supplements recommended by the World Health Organization (WHO; a specialised agency of the United Nations responsible for international public health) for women during pregnancy. What did we want to find out? We wanted to find out if taking vitamin B 12 supplements during pregnancy would improve the health and nutrition of women and their babies. What did we do? We searched for clinical trials that looked at vitamin B 12 supplementation during pregnancy. We compared and summarised the results of the trials and rated our confidence in the information, based on factors such as trial methods and sizes. What did we find? We included five trials with 984 pregnant women. Three trials, including 609 pregnant women, had data included in analyses. Women who took vitamin B 12 supplements during pregnancy had less vitamin B 12 deficiency and higher vitamin B 12 levels compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. There were no differences between groups for maternal anaemia. We could not assess the effects of vitamin B 12 supplementation on other outcomes such as miscarriage, neural tube defects, and child cognition (a child's ability to gain knowledge through thought, understanding, and the senses) due to limited or no availability of results for analysis. What are the limitations of the evidence? The small number of trials and small size of trials were limitations in this review. Not all the trials provided data about the outcomes we were interested in. We are very unsure about the results. How up to date is this evidence? The evidence is up to date as of June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Finkelstein, JL; Fothergill, A; Venkatramanan, S; Layden, AJ; Williams, JL; Crider, KS; Qi, YP", "articleTypes": [], "doi": "10.1002/14651858.CD013823.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "e9f9ac23-4ad7-46d4-b2c1-452b99dae1cd", "pmid": "", "title": "The Functional Significance of Gut-expressed Taste Receptors in the Secretion of Glucagon-like Peptide-1 and Peptide YY", "imported": false, "abstract": "The purpose of this study is to determine the functional significance of sweet taste receptors in the secretion of GI satiety peptides by using a specific sweet taste receptor antagonist to block sweet taste perception in the gut.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.231Z" }, { "id": "ea0a6b36-c352-4745-9ed9-9dc09e919bad", "pmid": "", "title": "Antiemetics for adults for prevention of nausea and vomiting caused by moderately or highly emetogenic chemotherapy: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background About 70% to 80% of adults with cancer experience chemotherapy‐induced nausea and vomiting (CINV). CINV remains one of the most distressing symptoms associated with cancer therapy and is associated with decreased adherence to chemotherapy. Combining 5‐hydroxytryptamine‐3 (5‐HT₃) receptor antagonists with corticosteroids or additionally with neurokinin‐1 (NK₁) receptor antagonists is effective in preventing CINV among adults receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Various treatment options are available, but direct head‐to‐head comparisons do not allow comparison of all treatments versus another. Objectives • In adults with solid cancer or haematological malignancy receiving HEC ‐ To compare the effects of antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids on prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting in network meta‐analysis (NMA) ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy • In adults with solid cancer or haematological malignancy receiving MEC ‐ To compare whether antiemetic treatment combinations including NK₁ receptor antagonists, 5‐HT₃ receptor antagonists, and corticosteroids are superior for prevention of acute phase (Day 1), delayed phase (Days 2 to 5), and overall (Days 1 to 5) chemotherapy‐induced nausea and vomiting to treatment combinations including 5‐HT₃ receptor antagonists and corticosteroids solely, in network meta‐analysis ‐ To generate a clinically meaningful treatment ranking according to treatment safety and efficacy Search methods We searched CENTRAL, MEDLINE, Embase, conference proceedings, and study registries from 1988 to February 2021 for randomised controlled trials (RCTs). Selection criteria We included RCTs including adults with any cancer receiving HEC or MEC (according to the latest definition) and comparing combination therapies of NK₁ and 5‐HT₃ inhibitors and corticosteroids for prevention of CINV. Data collection and analysis We used standard methodological procedures expected by Cochrane. We expressed treatment effects as risk ratios (RRs). Prioritised outcomes were complete control of vomiting during delayed and overall phases, complete control of nausea during the overall phase, quality of life, serious adverse events (SAEs), and on‐study mortality. We assessed GRADE and developed 12 'Summary of findings' tables. We report results of most crucial outcomes in the abstract, that is, complete control of vomiting during the overall phase and SAEs. For a comprehensive illustration of results, we randomly chose aprepitant plus granisetron as exemplary reference treatment for HEC, and granisetron as exemplary reference treatment for MEC. Main results Highly emetogenic chemotherapy ( HEC) We included 73 studies reporting on 25,275 participants and comparing 14 treatment combinations with NK₁ and 5‐HT₃ inhibitors. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 704 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with aprepitant + granisetron. Evidence from NMA (39 RCTs, 21,642 participants; 12 treatment combinations with NK₁ and 5‐HT₃ inhibitors) suggests that the following drug combinations are more efficacious than aprepitant + granisetron for completely controlling vomiting during the overall treatment phase (one to five days): fosnetupitant + palonosetron (810 of 1000; RR 1.15, 95% confidence interval (CI) 0.97 to 1.37; moderate certainty), aprepitant + palonosetron (753 of 1000; RR 1.07, 95% CI 1.98 to 1.18; low‐certainty), aprepitant + ramosetron (753 of 1000; RR 1.07, 95% CI 0.95 to 1.21; low certainty), and fosaprepitant + palonosetron (746 of 1000; RR 1.06, 95% CI 0.96 to 1.19; low certainty). Netupitant + palonosetron (704 of 1000; RR 1.00, 95% CI 0.93 to 1.08; high‐certainty) and fosaprepitant + granisetron (697 of 1000; RR 0.99, 95% CI 0.93 to 1.06; high‐certainty) have little to no impact on complete control of vomiting during the overall treatment phase (one to five days) when compared to aprepitant + granisetron, respectively. Evidence further suggests that the following drug combinations are less efficacious than aprepitant + granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): aprepitant + ondansetron (676 of 1000; RR 0.96, 95% CI 0.88 to 1.05; low certainty), fosaprepitant + ondansetron (662 of 1000; RR 0.94, 95% CI 0.85 to 1.04; low certainty), casopitant + ondansetron (634 of 1000; RR 0.90, 95% CI 0.79 to 1.03; low certainty), rolapitant + granisetron (627 of 1000; RR 0.89, 95% CI 0.78 to 1.01; moderate certainty), and rolapitant + ondansetron (598 of 1000; RR 0.85, 95% CI 0.65 to 1.12; low certainty). We could not include two treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 35 of 1000 participants experience any SAEs when treated with aprepitant + granisetron. Evidence from NMA (23 RCTs, 16,065 participants; 11 treatment combinations) suggests that fewer participants may experience SAEs when treated with the following drug combinations than with aprepitant + granisetron: fosaprepitant + ondansetron (8 of 1000; RR 0.23, 95% CI 0.05 to 1.07; low certainty), casopitant + ondansetron (8 of 1000; RR 0.24, 95% CI 0.04 to 1.39; low certainty), netupitant + palonosetron (9 of 1000; RR 0.27, 95% CI 0.05 to 1.58; low certainty), fosaprepitant + granisetron (13 of 1000; RR 0.37, 95% CI 0.09 to 1.50; low certainty), and rolapitant + granisetron (20 of 1000; RR 0.57, 95% CI 0.19 to 1.70; low certainty). Evidence is very uncertain about the effects of aprepitant + ondansetron (8 of 1000; RR 0.22, 95% CI 0.04 to 1.14; very low certainty), aprepitant + ramosetron (11 of 1000; RR 0.31, 95% CI 0.05 to 1.90; very low certainty), fosaprepitant + palonosetron (12 of 1000; RR 0.35, 95% CI 0.04 to 2.95; very low certainty), fosnetupitant + palonosetron (13 of 1000; RR 0.36, 95% CI 0.06 to 2.16; very low certainty), and aprepitant + palonosetron (17 of 1000; RR 0.48, 95% CI 0.05 to 4.78; very low certainty) on the risk of SAEs when compared to aprepitant + granisetron, respectively. We could not include three treatment combinations (ezlopitant + granisetron, aprepitant + tropisetron, rolapitant + ondansetron) in NMA for this outcome because of missing direct comparisons. Moderately emetogenic chemotherapy (MEC) We included 38 studies reporting on 12,038 participants and comparing 15 treatment combinations with NK₁ and 5‐HT₃ inhibitors, or 5‐HT₃ inhibitors solely. All treatment combinations included corticosteroids. Complete control of vomiting during the overall phase We estimated that 555 of 1000 participants achieve complete control of vomiting in the overall treatment phase (one to five days) when treated with granisetron. Evidence from NMA (22 RCTs, 7800 participants; 11 treatment combinations) suggests that the following drug combinations are more efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days): aprepitant + palonosetron (716 of 1000; RR 1.29, 95% CI 1.00 to 1.66; low certainty), netupitant + palonosetron (694 of 1000; RR 1.25, 95% CI 0.92 to 1.70; low certainty), and rolapitant + granisetron (660 of 1000; RR 1.19, 95% CI 1.06 to 1.33; high certainty). Palonosetron (588 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) and aprepitant + granisetron (577 of 1000; RR 1.06, 95% CI 0.85 to 1.32; low certainty) may or may not increase complete response in the overall treatment phase (one to five days) when compared to granisetron, respectively. Azasetron (560 of 1000; RR 1.01, 95% CI 0.76 to 1.34; low certainty) may result in little to no difference in complete response in the overall treatment phase (one to five days) when compared to granisetron. Evidence further suggests that the following drug combinations are less efficacious than granisetron in completely controlling vomiting during the overall treatment phase (one to five days) (ordered by decreasing efficacy): fosaprepitant + ondansetron (500 of 1000; RR 0.90, 95% CI 0.66 to 1.22; low certainty), aprepitant + ondansetron (477 of 1000; RR 0.86, 95% CI 0.64 to 1.17; low certainty), casopitant + ondansetron (461 of 1000; RR 0.83, 95% CI 0.62 to 1.12; low certainty), and ondansetron (433 of 1000; RR 0.78, 95% CI 0.59 to 1.04; low certainty). We could not include five treatment combinations (fosaprepitant + granisetron, azasetron, dolasetron, ramosetron, tropisetron) in NMA for this outcome because of missing direct comparisons. Serious adverse events We estimated that 153 of 1000 participants experience any SAEs when treated with granisetron. Evidence from pair‐wise comparison (1 RCT, 1344 participants) suggests that more participants may experience SAEs when treated with rolapitant + granisetron (176 of 1000; RR 1.15, 95% CI 0.88 to 1.50; low certainty). NMA was not feasible for this outcome because of missing direct comparisons. Certainty of evidence Our main reason for downgrading was serious or very serious imprecision (e.g. due to wide 95% CIs crossing or including unity, few events leading to wide 95% CIs, or small information size). Additional reasons for downgrading some comparisons or whole networks were serious study limitations due to high risk of bias or moderate inconsistency within networks. Authors' conclusions This field of supportive cancer care is very well researched. However, new drugs or drug combinations are continuously emerging and need to be systematically researched and assessed. For people receiving HEC, synthesised evidence does not suggest one superior treatment for prevention and control of chemotherapy‐induced nausea and vomiting. For people receiving MEC, synthesised evidence does not suggest superiority for treatments including both NK₁ and 5‐HT₃ inhibitors when compared to treatments including 5‐HT₃ inhibitors only. Rather, the results of our NMA suggest that the choice of 5‐HT₃ inhibitor may have an impact on treatment efficacy in preventing CINV. When interpreting the results of this systematic review, it is important for the reader to understand that NMAs are no substitute for direct head‐to‐head comparisons, and that results of our NMA do not necessarily rule out differences that could be clinically relevant for some individuals. Plain language summary Which drug combinations are best for prevention of nausea and vomiting caused by chemotherapy in adults with cancer? The burden of nausea and vomiting caused by chemotherapy and what helps to prevent it? In about 70% to 80% of adults with cancer, chemotherapy induces nausea and vomiting (CINV). Depending on the type of chemotherapy, treatment can cause strong or moderate sickness (hereafter referred to as HEC (highly emetogenic chemotherapy) and MEC (moderately emetogenic chemotherapy)). Multiple drug combinations have showed high benefit for CINV among adults receiving HEC or MEC. What was the aim of our review? Using a network meta‐analysis, we aimed to compare the benefits and harms of different drug combinations for prevention of CINV among people receiving HEC or MEC, and to identify treatment ranking. A network meta‐analysis is a technique used to compare different treatments described in already published trials, even when the original individual trial does not describe such comparisons. What studies did we look at? We searched selected medical databases and trial registries until February 2021. We included studies comparing multiple drug combinations for prevention of CINV among adults with any type of cancer receiving HEC or MEC that is commonly used in clinical practice. In particular, we looked at drugs inhibiting two specific biochemical receptors (neurokinin receptor and serotonin receptor) that trigger nausea and vomiting after chemotherapy. We looked at the preventative effects of these treatments over five days. This is the period during which the maximum intensity of CINV and further peaks of intensity are expected, after the start of chemotherapy. Our key results... ...for people receiving HEC We found 73 studies that reported on the experience of 25,275 participants and compared 14 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped to prevent any vomiting in 60% to 81% of people on average. Those individuals also had no need for rescue medicines, which are used in case nausea and vomiting occur even though prophylactic treatment has been given. The results of our analysis suggest some differences in effectiveness of different treatments, but overall we had little confidence that those differences would be reflected in real‐world observations. Harms. We estimated that 1% to 4% of people experience serious side effects. The differences between treatments were small. ...for people receiving MEC We found 38 studies that reported on the experience of 12,038 participants and compared 15 treatment combinations of our interest. Benefits. Over five days, investigated treatments helped prevent any vomiting in 43% to 72% of people on average. Those individuals also had no need for rescue medicines. The results of our analysis suggest some differences in the effectiveness of different treatments, but overall, we had little confidence that those differences would be reflected in real‐world observations. Harms. Few studies reported serious side effects. The ones that did suggest that on average 15% to 18% of people experience such events. Differences between treatments were small. However, we think that future research is needed to rule out potential differences between treatments. Our confidence in the findings We assessed how confident we were that there are differences between compared treatments. We had low or very low confidence that one treatment is better or worse than another in preventing CINV. Our confidence in differences between statistical results was mainly limited because measures of variation were wide apart and included both potential advantages and disadvantages, although measures of precision showed no or little effect. We also identified limitations in some of the included studies, which further limited our confidence in the effects. This was mainly the case when study personnel and participants knew which treatments were given and therefore may not adhere to the planned intervention, or may perceive or report effects differently. Our conclusions The results of our analysis suggest that there is no superior drug combination for prevention of CINV for people receiving HEC or MEC. However, results suggest that the choice of drugs targeting the serotonin receptor may impact effectiveness, irrespective of whether given with or without a drug targeting the neurokinin receptor. However, when interpreting these results, it is important for the reader to understand that these kinds of multiple‐comparison analyses are no substitute for head‐to‐head comparisons, and that the results do not necessarily rule out differences that could be clinically relevant for some individuals. How up‐to‐date is this evidence? Evidence is up‐to‐date to 2 February 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Piechotta, V, Adams, A, Haque, M, Scheckel, B, Kreuzberger, N, Monsef, I, Jordan, K, Kuhr, K, Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD012775.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.798Z" }, { "id": "ea112a91-50fd-4672-a7d0-6196627f6088", "pmid": "", "title": "Probiotics for the prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer", "imported": false, "abstract": "Abstract - Background Treament‐related diarrhoea is one of the most common and troublesome adverse effects related to chemotherapy or radiotherapy in people with cancer. Its reported incidence has been as high as 50% to 80%. Severe treatment‐related diarrhoea can lead to fluid and electrolyte losses and nutritional deficiencies and could adversely affect quality of life (QoL). It is also associated with increased risk of infection in people with neutropenia due to anticancer therapy and often leads to treatment delays, dose reductions, or treatment discontinuation. Probiotics may be effective in preventing or treating chemotherapy‐ or radiotherapy‐induced diarrhoea. Objectives To evaluate the clinical effectiveness and side effects of probiotics used alone or combined with other agents for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 7), MEDLINE (1946 to July week 2, 2017), and Embase (1980 to 2017, week 30). We also searched prospective clinical trial registers and the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) investigating the effects of probiotics for prevention or treatment of chemotherapy‐ or radiotherapy‐related diarrhoea in people with cancer. Data collection and analysis Two review authors independently selected studies, extracted data, and assessed risk of bias. We used random‐effects models for all meta‐analyses. If meta‐analysis was not possible, we summarised the results narratively. Main results We included 12 studies involving 1554 participants. Eleven studies were prevention studies, of which seven compared probiotics with placebo (887 participants), one compared two doses of probiotics with each other and with placebo (246 participants), and three compared probiotics with another active agent (216 participants).The remaining study assessed the effectiveness of probiotics compared with placebo for treatment of radiotherapy‐related diarrhoea (205 participants). For prevention of radiotherapy (with or without chemotherapy)‐induced diarrhoea, review authors identified five heterogeneous placebo‐controlled studies (with 926 participants analysed). Owing to heterogeneity, we could not carry out a meta‐analysis, except for two outcomes. For occurrence of any diarrhoea, risk ratios (RRs) ranged from 0.35 (95% confidence interval (CI) 0.26 to 0.47) to 1.0 (95% CI 0.94 to 1.06) (three studies; low‐certainty evidence). A beneficial effect of probiotics on quality of life could neither be demonstrated nor refuted (two studies; low‐certainty evidence). For occurrence of grade 2 or higher diarrhoea, the pooled RR was 0.75 (95% CI 0.55 to 1.03; four studies; 420 participants; low‐certainty evidence), and for grade 3 or higher diarrhoea, RRs ranged from 0.11 (95% CI 0.06 to 0.23) to 1.24 (95% CI 0.74 to 2.08) (three studies; low‐certainty evidence). For probiotic users, time to rescue medication was 36 hours longer in one study (95% CI 34.7 to 37.3), but another study reported no difference (moderate‐certainty evidence). For the need for rescue medication, the pooled RR was 0.50 (95% CI 0.15 to 1.66; three studies; 194 participants; very low‐certainty evidence). No study reported major differences between groups with respect to adverse effects. Although not mentioned explicitly, no studies reported deaths, except one in which one participant in the probiotics group died of myocardial infarction after three sessions of radiotherapy. Three placebo‐controlled studies, with 128 analysed participants, addressed prevention of chemotherapy‐induced diarrhoea. For occurrence of any diarrhoea, the pooled RR was 0.59 (95% CI 0.36 to 0.96; two studies; 106 participants; low‐certainty evidence). For all other outcomes, a beneficial effect of probiotics could be neither demonstrated nor refuted (one to two studies; 46 to 106 participants; all low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. Three studies compared probiotics with another intervention in 213 participants treated with radiotherapy (with or without chemotherapy). One very small study (21 participants) reported less diarrhoea six weeks after treatment when dietary counselling was provided (RR 0.30, 95% CI 0.11 to 0.81; very low‐certainty evidence). In another study (148 participants), grade 3 or 4 diarrhoea occurred less often in the probiotics group than in the control group (guar gum containing nutritional supplement) (odds ratio (OR) 0.38, 95% CI 0.16 to 0.89; low‐certainty evidence), and two studies (63 participants) found less need for rescue medication of probiotics versus another active treatment (RR 0.44, 95% CI 0.22 to 0.86; very low‐certainty evidence). Studies did not address quality of life nor time to rescue medication. One placebo‐controlled study with 205 participants addressed treatment for radiotherapy‐induced diarrhoea and could not demonstrate or refute a beneficial effect of probiotics on average diarrhoea grade, time to rescue medication for diarrhoea (13 hours longer in the probiotics group; 95% CI ‐0.9 to 26.9 hours), or need for rescue medication (RR 0.74, 95% CI 0.53 to 1.03; moderate‐certainty evidence). This study did not address quality of life. No studies reported serious adverse events or diarrhoea‐related deaths. Authors' conclusions This review presents limited low‐ or very low‐certainty evidence supporting the effects of probiotics for prevention and treatment of diarrhoea related to radiotherapy (with or without chemotherapy) or chemotherapy alone, need for rescue medication, or occurrence of adverse events. All studies were underpowered and heterogeneous. Severe side effects were absent from all studies. Robust evidence on this topic must be provided by future methodologically well‐designed trials. Plain language summary Live micro‐organisms for prevention or treatment of diarrhoea in people with cancer who are treated with chemotherapy or radiotherapy Background 
 Up to 80% of people treated with chemotherapy or radiotherapy for cancer suffer from diarrhoea ‐ one of the most common and troublesome side effects. Severe diarrhoea can lead to dehydration (fluid and salts loss) and malnutrition from changes to digestion and bowel habits and could adversely affect quality of life. It is also associated with increased risk of infection in people with low white cell blood count related to cancer treatment. Diarrhoea often leads to delays in cancer treatment or the need to lower the dose or even discontinue cancer treatment. Foods containing live bacteria or yeast (probiotics) might have a beneficial effect on the occurrence and severity of diarrhoea. Aim of the review 
 To evaluate the effects of live micro‐organisms (probiotics) in preventing the occurrence or reducing the severity of diarrhoea in people with cancer who are receiving chemotherapy or radiotherapy. Main findings 
 Overall, the studies we found do not give a clear answer on whether probiotics reduce the occurrence or severity of diarrhoea, improve quality of life, or reduce the need for other medication. However, an analysis of only well‐performed studies demonstrated a beneficial effect for some outcomes. With regard to prevention of diarrhoea compared with placebo in participants treated with radiotherapy with or without chemotherapy, we are not able to conclude whether use of probiotics would be beneficial based on the five relevant studies. For prevention of diarrhoea due to chemotherapy alone, three studies suggested that use of probiotics may not reduce diarrhoea, and one study reported use of less rescue medication for diarrhoea. Three studies that compared probiotics with another agent for preventing diarrhoea in patients treated with radiotherapy with or without chemotherapy found beneficial effects of probiotics for the occurrence and severity of diarrhoea and the need for rescue medication. With respect to treatment of diarrhoea due to radiotherapy, we found only one study that did not demonstrate a clear effect of probiotics compared with placebo. No study reported serious adverse events nor deaths related to diarrhoea. Certainty of the evidence 
 The quality (certainty) of the evidence in prevention studies was low to very low. For the only study that assessed the effects of probiotics on treatment for diarrhoea, the certainty of the evidence was moderate. What are the conclusions? 
 Evidence supporting the effects of probiotics in preventing or treating diarrhoea related to cancer treatment is insufficient. However, probiotics appear to be safe, as no studies have found severe side effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Wei, D; Heus, P; van de Wetering, FT; van Tienhoven, G; Verleye, L; Scholten, RJPM", "articleTypes": [], "doi": "10.1002/14651858.CD008831.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "ea12f8ea-cd79-476f-abbd-0517517b8699", "pmid": "", "title": "Corticosteroids for hospitalised children with acute asthma", "imported": false, "abstract": "Abstract - Background Systemic corticosteroids are used routinely in the management of children with severe acute asthma. There is a lack of consensus regarding the agent, dose and route of corticosteroid administration. Objectives To determine the benefit of systemic corticosteroids (oral, intravenous, or intramuscular) compared to placebo and inhaled steroids in acute paediatric asthma. Search methods All controlled trials were identified from the Cochrane Airways Review Group Register, hand searching of respiratory journals, reference lists and contacts with experts and pharmaceutical companies. Selection criteria Studies were included if they described a randomised controlled trial (RCT) involving children aged 1‐18 years with severe acute asthma who received oral, inhaled, intravenous or intramuscular corticosteroids. Only studies in which patients required hospital admission were included. Data collection and analysis Two reviewers using a standard form extracted all data. All data, numeric calculations and graphic extrapolations were independently confirmed. Main results Seven trials were included with a total of 426 children studied (274 with oral prednisone vs. placebo, 106 with intravenous steroids vs placebo and 46 with nebulised budesonide vs prednisolone). A significant number of steroid treated children were discharged early after admission (>4 hours) with an OR of 7.00 (95% CI: 2.98 to 16.45) and NNT of 3 (95%CI: 2 to 8). The length of stay was shorter in the steroid groups with a WMD of ‐8.75 hours (95% CI: ‐19.23 to 1.74). There were no significant differences between groups in pulmonary function or oxygen saturation measurements. Children treated with steroids in hospital were less likely to relapse within one to three months with OR 0.19 (95%CI: 0.07 to 0.55) and NNT of 3 (95%CI: 2 to 7). The single small study that compared nebulised budesonide to oral prednisone failed to demonstrate equivalence or a difference between each therapy. Authors' conclusions Systemic corticosteroids produce some improvements for children admitted to hospital with acute asthma. The benefits may include earlier discharge and fewer relapses. Inhaled or nebulised corticosteroids cannot be recommended as equivalent to systemic steroids at this time. Further studies examining differing doses and routes of administration for corticosteroids will clarify the optimal therapy. Plain language summary Corticosteroids for hospitalised children with acute asthma An acute asthma attack in a child often results in a trip to the hospital. In the emergency department steroid drugs are given which may improve the child's condition and allow them to be sent home after a few hours observation. However, some children require continued treatment in hospital. This review asked the question \"do steroid drugs help children admitted to hospital with asthma?\" We found that steroids given by mouth or through an intravenous tube help children recover from acute asthma. The benefits may include earlier discharge or a shorter stay in hospital. Children were less likely to come back to hospital in the one to three months following the admission. However, the evidence was not overwhelming due to the limited number of studies available and different medicines used. Further research needs to concentrate on the best medications to use and the best route of administration.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Smith, M; Iqbal, SMSI; Rowe, BH; N'Diaye, T", "articleTypes": [], "doi": "10.1002/14651858.CD002886", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "ea1e1f55-8133-4554-9ce5-5f16d85eb8e5", "pmid": "", "title": "A Randomized, Double-Blind, Placebo-Controlled, Multicenter Phase IIb Clinical Trial to Evaluate the Efficacy and Safety of Oral VG081821AC Tablets Monotherapy (Without Concomitant Levodopa) in Patients With Early to Mid-Stage Parkinson's Disease", "imported": false, "abstract": "This study is testing a new oral medication called VG081821AC to see if it can help improve movement symptoms in people with early to mid-stage Parkinson's disease. VG081821AC works by blocking a protein in the brain called the adenosine A2A receptor, which may help improve motor function without using levodopa. The main goal is to measure changes in movement symptoms using a standard rating scale called the MDS-UPDRS Part III (Motor Examination). This scale evaluates how well participants can move, walk, and perform daily activities. The study will compare the scores before and after 12 weeks of treatment to see if VG081821AC improves movement symptoms better than the placebo. Currently, levodopa is the most common treatment for Parkinson's disease, but it can cause side effects over time. If VG081821AC works well, it could offer a new treatment option for people in the early to mid-stages of Parkinson's disease who want to delay or avoid starting levodopa. A total of 152 adults (aged 18-80 years) will be enrolled in this trial in China. Participants will be randomly assigned (like flipping a coin) to one of four groups:", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.152Z" }, { "id": "ea24941b-93c6-44cf-b2ae-4c9ef60f54f1", "pmid": "", "title": "Interventions for perceptual disorders following stroke", "imported": false, "abstract": "Abstract - Background Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non‐invasive brain stimulation, pharmacological and surgical approaches. Objectives To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living. Search methods We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors. Selection criteria We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain. Data collection and analysis One review author assessed titles, with two review authors independently screening abstracts and full‐text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB‐1 tool, and quality of evidence using GRADE. A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update. Main results We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch‐somatosensory disorders. None addressed stroke‐related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non‐invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL): Somatosensory disorders : one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure. Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention. Visual perception disorders : no trials measuring ADL compared an intervention with no treatment or control. In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials). Authors' conclusions Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high‐quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer‐term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines. Plain language summary Interventions for perceptual disorders following stroke Key messages Stroke can affect a person’s ability to process and understand information from their senses, including hearing, smell, somatosensation (sense of body temperature, position, and movement), taste, touch, and vision. Processing and understanding information from these senses is known as perception. Little research has been carried out to find out whether any treatments for stroke‐related problems with perception are helpful. People with stroke‐related problems with hearing, smell, somatosensation, taste, touch, and vision should continue to participate in rehabilitation as recommended by clinical guidelines. Healthcare professionals should continue to offer rehabilitation for stroke‐related perceptual problems in keeping with current clinical guidelines and recommendations. What is a perceptual disorder? Before a stroke, adults gather information about the world through their senses: hearing, smell, somatosensation, taste, touch, and vision. Somatosensation refers to sensation arising from the skin, muscles, or joints, and includes perception of pressure, vibration, temperature, and position. Information gathered might include the colour, shape, and size of objects that they see. Together with memories and cultural experiences, a person can understand how someone is feeling from seeing their facial expression. Other examples are how different odours can be identified through the sense of smell and how different textures can be felt through the sense of touch. A stroke can affect these abilities. How are perceptual disorders treated? Healthcare professionals, including occupational therapists, physiotherapists, and psychologists, may offer different therapies. Treatments might include medicine, stimulation of the brain, or perceptual rehabilitation through activities, puzzles, strategies, or intensive repetition of tasks. What did we want to find out? We wanted to find out whether receiving any perceptual disorder treatment was better than no treatment at all. We measured improvement by looking at how well people could carry out their daily activities. We measured whether treatments also helped other things, such as quality of life, mental health, and perception. We looked for information on when things did not go well. We also explored whether one treatment was more beneficial than another. What did we do? We searched for all relevant research. We assessed the quality of 18 studies and summarised their results. What did we find out? The studies we found were about different perceptual disorders: three studies looked at disorders of touch perception, seven looked at somatosensation, seven studies looked at vision, and one looked at several perceptual problems at the same time. The treatments used in these studies included paper‐and‐pencil copying tasks to improve visual memory and using robots to help improve a person’s sense of where their body is positioned. We found no information to show that any treatment worked. Why are we still uncertain? We found few studies. Each study included a small number of people with a perceptual problem after a stroke. With small numbers of people involved, the results were not clear. Each study looked at different interventions. Less than half the studies (seven) measured the ability to carry out everyday activities. How up to date is this information? Our information is up to date as of August 2021. Based on the information we gathered, we are still unclear about the benefits or harms of treatments for perceptual problems after stroke. People with perceptual problems after stroke should continue to be offered rehabilitation as recommended in clinical guidelines.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hazelton, C; Thomson, K; Todhunter-Brown, A; Campbell, P; Chung, CSY; Dorris, L; Gillespie, DC; Hunter, SM; McGill, K; Nicolson, DJ; Williams, LJ; Brady, MC", "articleTypes": [], "doi": "10.1002/14651858.CD007039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "ea26c9ca-cbaf-4fd2-88f8-2e1d52977feb", "pmid": "", "title": "Sucrose and Non Nutritive Suck as Analgesia for Babies Undergoing Retinopathy of Prematurity Screening; a Randomised Placebo Controlled Trial", "imported": false, "abstract": "Retinopathy of Prematurity (ROP) screening is one of many potentially painful diagnostic and therapeutic procedures performed routinely on preterm infants in the Neonatal Intensive Care Unit. Therefore strategies for stress reduction and pain management are essential to promote growth and development and minimize long-term sequelae. Procedural analgesia should include concepts of developmental care, non nutritive suck (NNS), pharmacological and non-pharmacological agents. Sucrose is thought to stimulate the body's activation of lingual sweet taste receptors and release of endogenous opioids, when combined with NNS, non-opioid mechanisms are also activated. The administration of sucrose or the combination of sucrose and non-nutritive sucking is one of the most frequently studied non-pharmacological interventions for relief of pain in neonates and oral sucrose has been shown to be an effective and safe therapy for common neonatal procedures such as heal lance, blood-letting and venepuncture. There is conflicting evidence on the benefit of sucrose in ROP screening. Therefore the purpose of this study is to determine the efficacy of sucrose combined with NNS as a potential regime for reduction of pain associated with retinopathy of prematurity screening.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.244Z" }, { "id": "ea53b0c4-dc4b-4d4a-b578-f18213337d58", "pmid": "", "title": "Treatment and prevention of pouchitis after ileal pouch‐anal anastomosis for chronic ulcerative colitis", "imported": false, "abstract": "Abstract - Background Pouchitis occurs in approximately 50% of patients following ileal pouch‐anal anastomosis (IPAA) for chronic ulcerative colitis (UC). Objectives The primary objective was to determine the efficacy and safety of medical therapies for prevention or treatment of acute or chronic pouchitis. Search methods We searched MEDLINE, Embase and CENTRAL from inception to 25 July 2018. We also searched references, trials registers, and conference proceedings. Selection criteria Randomized controlled trials of prevention or treatment of acute or chronic pouchitis in adults who underwent IPAA for UC were considered for inclusion. Data collection and analysis Two authors independently screened studies for eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was evaluated using GRADE. The primary outcome was clinical improvement or remission in participants with acute or chronic pouchitis, or the proportion of participants with no episodes of pouchitis after IPAA. Adverse events (AEs) was a secondary outcome. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for each dichotomous outcome. Main results Fifteen studies (547 participants) were included. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Three studies were low risk of bias. Three studies were high risk of bias and the other studies were unclear. Acute pouchitis: All ciprofloxacin participants (7/7) achieved remission at two weeks compared to 33% (3/9) of metronidazole participants (RR 2.68, 95% CI 1.13 to 6.35, very low certainty evidence). No ciprofloxacin participants (0/7) had an AE compared to 33% (3/9) of metronidazole participants (RR 0.18, 95% CI 0.01 to 2.98; very low certainty evidence). AEs included vomiting, dysgeusia or transient peripheral neuropathy. Forty‐three per cent (6/14) of metronidazole participants achieved remission at 6 weeks compared to 50% (6/12) of budesonide enema participants (RR 0.86, 95% CI 0.37 to 1.96, very low certainty evidence). Fifty per cent (7/14) of metronidazole participants improved clinically at 6 weeks compared to 58% (7/12) of budesonide enema participants (RR 0.86, 95% CI 0.42 to 1.74, very low certainty evidence). Fifty‐seven per cent (8/14) of metronidazole participants had an AE compared to 25% (3/12) of budesonide enema participants (RR 2.29, 95% CI 0.78 to 6.73, very low certainty evidence). AEs included anorexia, nausea, headache, asthenia, metallic taste, vomiting, paraesthesia, and depression. Twenty‐five per cent (2/8) of rifaximin participants achieved remission at 4 weeks compared to 0% (0/10) of placebo participants (RR 6.11, 95% CI 0.33 to 111.71, very low certainty evidence). Thirty‐eight per cent (3/8) of rifaximin participants improved clinically at 4 weeks compared to 30% (3/10) of placebo participants (RR 1.25, 95% CI 0.34 to 4.60, very low certainty evidence). Seventy‐five per cent (6/8) of rifaximin participants had an AE compared to 50% (5/10) of placebo participants (RR 1.50, 95% CI 0.72 to 3.14, very low certainty evidence). AEs included diarrhea, flatulence, nausea, proctalgia, vomiting, thirst, candida, upper respiratory tract infection, increased hepatic enzyme, and cluster headache. Ten per cent (1/10) of Lactobacillus GG participants improved clinically at 12 weeks compared to 0% (0/10) of placebo participants (RR 3.00, 95% CI 0.14 to 65.90, very low certainty evidence). Chronic pouchitis: Eighty‐five per cent (34/40) of De Simone Formulation (a probiotic formulation) participants maintained remission at 9 to 12 months compared to 3% (1/36) of placebo participants (RR 20.24, 95% CI 4.28 to 95.81, 2 studies; low certainty evidence). Two per cent (1/40) of De Simone Formulation participants had an AE compared to 0% (0/36) of placebo participants (RR 2.43, 95% CI 0.11 to 55.89; low certainty evidence). AEs included abdominal cramps, vomiting and diarrhea. Fifty per cent (3/6) of adalimumab patients achieved clinical improvement at 4 weeks compared to 43% (3/7) of placebo participants (RR, 1.17, 95% CI 0.36 to 3.76, low certainty evidence). Sixty per cent (6/10) of glutamine participants maintained remission at 3 weeks compared to 33% (3/9) of butyrate participants (RR 1.80, 95% CI 0.63 to 5.16, very low certainty evidence). Forty‐five per cent (9/20) of patients treated with bismuth carbomer foam enema improved clinically at 3 weeks compared to 45% (9/20) of placebo participants (RR 1.00, 95% CI 0.50 to 1.98, very low certainty evidence). Twenty‐five per cent (5/20) of participants in the bismuth carbomer foam enema group had an AE compared to 35% (7/20) of placebo participants (RR 0.71, 95% CI 0.27 to 1.88, very low certainty evidence). Adverse events included diarrhea, worsening symptoms, cramping, sinusitis, and abdominal pain. Prevention: At 12 months, 90% (18/20) of De Simone Formulation participants had no episodes of acute pouchitis compared to 60% (12/20) of placebo participants (RR 1.50, 95% CI 1.02 to 2.21, low certainty evidence). Another study found 100% (16/16) of De Simone Formulation participants had no episodes of acute pouchitis at 12 months compared to 92% (11/12) of the no treatment control group (RR 1.10, 95% 0.89 to 1.36, very low certainty evidence). Eighty‐six per cent (6/7) of Bifidobacterium longum participants had no episodes of acute pouchitis at 6 months compared to 60% (3/5) of placebo participants (RR 1.43, 95% CI 0.66 to 3.11, very low certainty evidence). Eleven per cent (1/9) of Clostridium butyricum MIYAIRI participants had no episodes of acute pouchitis at 24 months compared to 50% (4/8) of placebo participants (RR 0.22, 95% CI 0.03 to 1.60, very low certainty evidence). Forty‐six per cent (43/94) of allopurinol participants had no episodes of pouchitis at 24 months compared to 43% (39/90) of placebo participants (RR 1.06, 95% CI 0.76 to 1.46; low certainty evidence). Eighty‐one per cent (21/26) of tinidazole participants had no episodes of pouchitis over 12 months compared to 58% (7/12) of placebo participants (RR 1.38, 95% CI 0.83 to 2.31, very low certainty evidence). Authors' conclusions The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. Well designed, adequately powered studies are needed to determine the optimal therapy for the treatment and prevention of pouchitis. Plain language summary Therapy for treatment and prevention of pouchitis What is pouchitis? Some people with ulcerative colitis have their colon and rectum removed with construction of a pouch (made from a loop of small intestine) in place of the rectum ‐ known as ileal pouch‐anal anastomosis (IPAA) surgery. Pouchitis is inflammation of the surgically‐constructed pouch. Symptoms of active pouchitis include diarrhea, increased stool frequency, abdominal cramping, fecal urgency, tenesmus (feeling of constantly needing to pass stools), and incontinence. Acute refers to symptoms that last less than four weeks while chronic refers to symptoms that last more than four weeks. Periods when symptoms stop are called 'remission'. What therapies are used for pouchitis? Therapies used for pouchitis include antibiotics (drugs for bacteria infections), budesonide enemas (a steroid drug), probiotics (helpful bacteria), biologic agents that target tumor necrosis factor, glutamine suppositories (an amino acid), butyrate suppositories (short chain fatty acid), bismuth enemas (diarrhea medication), allopurinol (a purine analogue drug), and tinidazole (an anti‐parasitic drug). What did the researchers investigate? The researchers investigated whether these medications produce remission in people with active pouchitis, maintain remission in people with inactive pouchitis or prevent pouchitis in people who've had IPAA surgery. Side effects were also assessed. The medical literature was searched up to 25 July 2018. What did the researchers find? We found 15 studies with a total of 547 participants. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Acute pouchitis: It is uncertain whether ciprofloxacin is more effective than metronidazole for treatment of acute pouchitis (1 study, 16 participants). Side effects included vomiting, metallic taste and temporary damage to nerves. It is unclear whether there are any differences between metronidazole and budesonide enemas in terms of clinical remission, symptom improvement or side effects (1 study, 26 participants). Side effects included anorexia, nausea, headache, lack of energy and strength, metallic taste, vomiting, pins and needles, and depression. It is uncertain whether there are any differences between rifaximin and placebo in terms of clinical remission, symptom improvement, or side effects (1 study, 18 participants). Side effects included diarrhea, flatulence, nausea, rectal pain, vomiting, thirst, yeast infection, common cold, increased liver enzymes, and cluster headache. It is uncertain whether there is any difference between Lactobacillus GG and placebo in symptom improvement (1 study, 20 participants. The results of these studies are uncertain due to low event numbers caused by the small numbers of people who participated in the studies. Chronic pouchitis: It is uncertain whether De Simone Formulation (a probiotic formulation) is more effective than placebo for maintaining remission in people with inactive disease (2 studies, 76 participants). Side effects included abdominal cramps, vomiting and diarrhea. It is unclear whether there is any difference in effectiveness between adalimumab and placebo for treating chronic pouchitis(1 study, 13 participants). It is unclear whether there is any difference between glutamine and butyrate suppositories for maintenance of remission (1 study, 19 participants). It is unclear whether there are any differences in symptom improvement or side effects between bismuth carbomer foam enemas and placebo (1 study, 40 participants). Side effects included diarrhea, worsening symptoms, cramping, sinus infection, and abdominal pain. The results of these studies are uncertain due to the small number of people who participated in the studies. Prevention of pouchitis: It is uncertain whether De Simone Formulation is more effective than placebo for prevention of pouchitis (1 study, 40 participants). However, it is unclear whether there is any difference in prevention of pouchitis between De Simone Formulation and a no treatment control group (1 study, 28 participants). It is unclear whether there are any differences in prevention of pouchitis between Clostridium butyricum MIYAIRI and placebo (1 study, 17 participants) , Bifidobacterium longum and placebo (1 study, 12 participants) , allopurinol and placebo (1 study, 184 participants) and tinidazole and placebo (1 study, 38 participants). The results of these studies are uncertain due to the small number of people who participated in the studies. The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. More research is needed to determine which of these different medications are best for treatment of pouchitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nguyen, N; Zhang, B; Holubar, SD; Pardi, DS; Singh, S", "articleTypes": [], "doi": "10.1002/14651858.CD001176.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "ea550577-9404-4e85-8d9e-975dd5a5f2c4", "pmid": "", "title": "Aclidinium bromide for stable chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background Bronchodilators are the mainstay for symptom relief in the management of stable chronic obstructive pulmonary disease (COPD). Aclidinium bromide is a new long‐acting muscarinic antagonist (LAMA) that differs from tiotropium by its higher selectivity for M3 muscarinic receptors with a faster onset of action. However, the duration of action of aclidinium is shorter than for tiotropium. It has been approved as maintenance therapy for stable, moderate to severe COPD, but its efficacy and safety in the management of COPD is uncertain compared to other bronchodilators. Objectives To assess the efficacy and safety of aclidinium bromide in stable COPD. Search methods We identified randomised controlled trials (RCT) from the Cochrane Airways Group Specialised Register of trials (CAGR), as well as www.clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), US Food and Drug Administration (FDA) website and Almirall Clinical Trials Registry and Results. We contacted Forest Laboratories for any unpublished trials and checked the reference lists of identified articles for additional information. The last search was performed on 7 April 2014 for CAGR and 11 April 2014 for other sources. Selection criteria Parallel‐group RCTs of aclidinium bromide compared with placebo, long‐acting beta 2 ‐agonists (LABA) or LAMA in adults with stable COPD. Data collection and analysis Two review authors independently selected studies, assessed the risk of bias, and extracted data. We sought missing data from the trial authors as well as manufacturers of aclidinium. We used odds ratios (OR) for dichotomous data and mean difference (MD) for continuous data, and reported both with their 95% confidence intervals (CI). We used standard methodological procedures expected by The Cochrane Collaboration. We applied the GRADE approach to summarise results and to assess the overall quality of evidence. Main results This review included 12 multicentre RCTs randomly assigning 9547 participants with stable COPD. All the studies were industry‐sponsored and had similar inclusion criteria with relatively good methodological quality. All but one study included in the meta‐analysis were double‐blind and scored low risk of bias. The study duration ranged from four weeks to 52 weeks. Participants were more often males, mainly Caucasians, mean age ranging from 61.7 to 65.6 years, and with a smoking history of 10 or more pack years. They had moderate to severe symptoms at randomisation; the mean post‐bronchodilator forced expiratory volume in one second (FEV1) was between 46% and 57.6% of the predicted normal value, and the mean St George's Respiratory Questionnaire score (SGRQ) ranged from 45.1 to 50.4 when reported. There was no difference between aclidinium and placebo in all‐cause mortality (low quality) and number of patients with exacerbations requiring a short course of oral steroids or antibiotics, or both (moderate quality). Aclidinium improved quality of life by lowering the SGRQ total score with a mean difference of ‐2.34 (95% CI ‐3.18 to ‐1.51; I 2 = 48%, 7 trials, 4442 participants) when compared to placebo. More patients on aclidinium achieved a clinically meaningful improvement of at least four units decrease in SGRQ total score (OR 1.49; 95% CI 1.31 to 1.70; I 2 = 34%; number needed to treat (NNT) = 10, 95% CI 8 to 15, high quality evidence) over 12 to 52 weeks than on placebo. Aclidinium also resulted in a significantly greater improvement in pre‐dose FEV1 than placebo with a mean difference of 0.09 L (95% CI 0.08 to 0.10; I 2 = 39%, 9 trials, 4963 participants). No trials assessed functional capacity. Aclidinium reduced the number of patients with exacerbations requiring hospitalisation by 4 to 20 fewer per 1000 over 4 to 52 weeks (OR 0.64; 95% CI 0.46 to 0.88; I 2 = 0%, 10 trials, 5624 people; NNT = 77, 95% CI 51 to 233, high quality evidence) compared to placebo. There was no difference in non‐fatal serious adverse events (moderate quality evidence) between aclidinium and placebo. Compared to tiotropium, aclidinium did not demonstrate significant differences for exacerbations requiring oral steroids or antibiotics, or both, exacerbation‐related hospitalisations and non‐fatal serious adverse events (very low quality evidence). Inadequate data prevented the comparison of aclidinium to formoterol or other LABAs. Authors' conclusions Aclidinium is associated with improved quality of life and reduced hospitalisations due to severe exacerbations in patients with moderate to severe stable COPD compared to placebo. Overall, aclidinium did not significantly reduce mortality, serious adverse events or exacerbations requiring oral steroids or antibiotics, or both. Currently, the available data are insufficient and of very low quality in comparisons of the efficacy of aclidinium versus tiotropium. The efficacy of aclidinium versus LABAs cannot be assessed due to inaccurate data. Thus additional trials are recommended to assess the efficacy and safety of aclidinium compared to other LAMAs or LABAs. Plain language summary Effectiveness and safety of inhalers containing the drug aclidinium bromide for managing patients with stable COPD Review question We reviewed the evidence on the effectiveness and safety of aclidinium inhalers used by people with chronic obstructive pulmonary disease (COPD). Background COPD, also known as 'smoker's lung disease', includes conditions called emphysema and chronic bronchitis where there is airway narrowing that cannot be fully corrected. It is a progressive disease. COPD patients usually have breathing problems and a cough that produces a lot of phlegm. It is diagnosed by international guidelines set by the Global Initiative for Obstructive Lung Disease (GOLD). Symptoms may worsen during flare‐ups. The main aims of treating COPD patients are to relieve symptoms, reduce flare‐ups and improve quality of life. Aclidinium is a new inhaled drug that widens the airways (a bronchodilator). It is delivered by an inhaler called Genuair or Pressair. We wanted to discover whether aclidinium was better or worse than using other inhalers or a dummy inhaler. Study characteristics The evidence was current to 7 April 2014. We included 12 studies involving 9547 COPD patients over a period of four to 52 weeks. These studies were sponsored by drug companies and were well designed. Both patients and the people doing the research did not know which treatment the patients were getting; although in one study one treatment was known to both parties. More men than women took part, and they were mostly Caucasians. They were in their 60s and had smoked a lot in their lives. These people had moderate to severe symptoms when they started treatment. Key results Aclidinium did not reduce the number of people with flare‐ups that need additional drugs. There was little or no difference in deaths or serious side effects between aclidinium and a dummy inhaler. Aclidinium inhalers improved quality of life more than the dummy inhalers. People who took aclidinium had fewer hospital admissions due to serious flare‐ups. Based on our results, among 1000 COPD patients using a dummy inhaler over four weeks to one year 37 would have severe flare‐ups needing hospital admission. Only 17 to 33 patients out of 1000 would require hospital admission if they were using aclidinium inhalers. We also set out to compare this new medication with tiotropium, which is already used to treat COPD. There were only two studies for this comparison thus we could not be sure how aclidinium compared to tiotropium. We also could not compare aclidinium with another well known inhaler that contains the drug formoterol because of unreliable data. Quality of the evidence For the comparison of aclidinium inhalers and dummy inhalers, we are confident that there are benefits in terms of the number of hospitalisations and patients' quality of life; we are less certain about the numbers of flare‐ups needing additional drugs and serious side effects. We do not have enough information to assess any effect on the number of deaths. We did not have enough information to reliably compare aclidinium with tiotropium or formoterol.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ni, H, Soe, Z, Moe, S", "articleTypes": [], "doi": "10.1002/14651858.CD010509.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.786Z" }, { "id": "ea57d3d2-9e6a-48d9-a427-4526e45845bc", "pmid": "", "title": "Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis", "imported": false, "abstract": "Abstract - Background Seasonal/perennial allergic conjunctivitis is the most common allergic conjunctivitis, usually with acute manifestations when a person is exposed to allergens and with typical signs and symptoms including itching, redness, and tearing. The clinical signs and symptoms of allergic conjunctivitis are mediated by the release of histamine by mast cells. Histamine antagonists (also called antihistamines) inhibit the action of histamine by blocking histamine H1 receptors, antagonising the vasoconstrictor, and to a lesser extent, the vasodilator effects of histamine. Mast cell stabilisers inhibit degranulation and consequently the release of histamine by interrupting the normal chain of intracellular signals.
 
 Topical treatments include eye drops with antihistamines, mast cell stabilisers, non‐steroidal anti‐inflammatory drugs, combinations of the previous treatments, and corticosteroids. Standard treatment is based on topical antihistamines alone or topical mast cell stabilisers alone or a combination of treatments. There is clinical uncertainty about the relative efficacy and safety of topical treatment. Objectives The objective of this review was to assess the effects of topical antihistamines and mast cell stabilisers, alone or in combination, for use in treating seasonal and perennial allergic conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2014, Issue 7), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2014), EMBASE (January 1980 to July 2014), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 July 2014. We also searched the reference lists of review articles and relevant trial reports for details of further relevant publications. Selection criteria We included randomised controlled trials (RCTs) comparing topical antihistamine and mast cell stabilisers, alone or in combination, with placebo, no treatment or to any other antihistamine or mast cell stabiliser, or both, that examined people with seasonal or perennial allergic conjunctivitis, or both. The primary outcome was any participant‐reported evaluation (by questionnaire) of severity of four main ocular symptoms: itching, irritation, watering eye (tearing), and photophobia (dislike of light), both separately and, if possible, by an overall symptom score. We considered any follow‐up time between one week and one year. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Disagreements were resolved by discussion among review authors and the involvement of a third review author. We followed standard methodological approaches used by Cochrane. Main results We identified 30 trials with a total of 4344 participants randomised, with 17 different drugs or treatment comparisons. The following antihistamines and mast cell stabilisers were evaluated in at least one RCT: nedocromil sodium or sodium cromoglycate, olopatadine, ketotifen, azelastine, emedastine, levocabastine (or levocabastine), mequitazine, bepotastine besilate, combination of antazoline and tetryzoline, combination of levocabastine and pemirolast potassium. The most common comparison was azelastine versus placebo (nine studies). We observed a large variability in reporting outcomes. The quality of the studies and reporting was variable, but overall the risk of bias was low. Trials evaluated only short‐term effects, with a range of treatment of one to eight weeks. Meta‐analysis was only possible in one comparison (olopatadine versus ketotifen). There was some evidence to support that topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo. There were no reported serious adverse events related to the use of topical antihistamine and mast cell stabilisers treatment. Authors' conclusions It seems that all reported topical antihistamines and mast cell stabilisers reduce symptoms and signs of seasonal allergic conjunctivitis when compared with placebo in the short term. However, there is no long‐term data on their efficacy. Direct comparisons of different antihistamines and mast cell stabilisers need to be interpreted with caution. Overall, topical antihistamines and mast cell stabilisers appear to be safe and well tolerated. We observed a large variability in outcomes reported. Poor quality of reporting challenged the synthesis of evidence. Plain language summary Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis Review question 
 Are treatments with eye drops of antihistamines and mast cell stabilisers, alone or in combination, effective and safe in people with seasonal and allergic conjunctivitis? The main outcome measure was eye symptoms reported by participants, including eye itching, irritation (burning sensation), watering eyes (tearing), and photophobia (dislike of light). We found 30 trials. Background 
 Conjunctivitis refers to inflammation of the conjunctiva, which is the thin tissue that covers the sclera (white part of the eye). Seasonal and perennial allergic conjunctivitis is the most common type of allergic conjunctivitis. Although this condition does not cause sight loss, it can cause intense itching and eye watering. Eye drops with antihistamines or mast cell stabilisers, or both are commonly used. Study characteristics 
 The evidence is current to July 2014. Among the 30 studies reviewed there were 17 different comparisons, including 4344 participants ranging in age between 4 and 85 years. The duration of treatment ranged from one to eight weeks. Ten out of 30 studies were funded by the drug manufacturer (8 totally and 2 partially funded); 20 studies did not report any source of funding. There was inconsistency in the way the effect of treatment was measured and reported. Overall risk of bias was low. Key results 
 Topical antihistamines and mast cell stabilisers, alone or in combination, are safe and effective for reducing symptoms of seasonal and perennial allergic conjunctivitis. We found insufficient evidence to discern which topical antihistamines and mast cell stabilisers are the most effective.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Castillo, M; Scott, NW; Mustafa, MZ; Mustafa, MS; Azuara‐Blanco, A", "articleTypes": [], "doi": "10.1002/14651858.CD009566.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "ea6ed116-0b7c-43d0-944b-477297214dbd", "pmid": "", "title": "Prophylactic Treatment of Episodic Cluster Headache With an Angiotensin II Receptor Blocker (Candesartan Cilexetil); a Randomized, Placebo Controlled Parallel Study", "imported": false, "abstract": "The purpose of this study is to determine whether candesartan cilexetil are effective prophylactic treatment of episodic Cluster headache", "journal": "", "year": "2005", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.237Z" }, { "id": "ea85b7f8-08d8-40f8-b043-30be938add1c", "pmid": "", "title": "Oral deferiprone for iron chelation in people with thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. A commonly used iron chelator, deferiprone, has been found to be pharmacologically efficacious. However, important questions exist about the efficacy and safety of deferiprone compared to another iron chelator, desferrioxamine. Objectives To summarise data from trials on the clinical efficacy and safety of deferiprone and to compare the clinical efficacy and safety of deferiprone with desferrioxamine for thalassaemia. Search methods We searched the Cochrane Cystic fibrosis and Genetic Disorders Group's Haemoglobinopathies trials Register and MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus registers of ongoing trials and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). We also contacted the manufacturers of deferiprone and desferrioxamine. All searches were updated to 05 March 2013. Selection criteria Randomised controlled trials comparing deferiprone with another iron chelator; or comparing two schedules or doses of deferiprone, in people with transfusion‐dependent thalassaemia. Data collection and analysis Two authors independently assessed trials for risk of bias and extracted data. Missing data were requested from the original investigators. Main results A total of 17 trials involving 1061 participants (range 13 to 213 participants per trial) were included. Of these, 16 trials compared either deferiprone alone with desferrioxamine alone, or a combined therapy of deferiprone and desferrioxamine with either deferiprone alone or desferrioxamine alone; one compared different schedules of deferiprone. There was little consistency between outcomes and limited information to fully assess the risk of bias of most of the included trials. Four trials reported mortality; each reported the death of one individual receiving deferiprone with or without desferrioxamine. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage. Earlier trials measuring the cardiac iron load indirectly by magnetic resonance imaging (MRI) T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, a meta‐analysis of two trials suggested that left ventricular ejection fraction was significantly reduced in patients who received desferrioxamine alone compared with combination therapy. One trial, which planned five years of follow up, was stopped early due to the beneficial effects of combined treatment compared with deferiprone alone in terms of serum ferritin levels reduction. The results of this and three other trials suggest an advantage of combined therapy over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no conclusive or consistent evidence for the improved efficacy of combined deferiprone and desferrioxamine therapy over monotherapy from direct or indirect measures of liver iron. Both deferiprone and desferrioxamine produce a significant reduction in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised controlled trials to suggest that either has a greater reduction of clinically significant end organ damage. Evidence of adverse events were observed in all treatment groups. Occurrence of any adverse event was significantly more likely with deferiprone than desferrioxamine in one trial, RR 2.24 (95% CI 1.19 to 4.23). Meta‐analysis of a further two trials showed a significant increased risk of adverse events associated with combined deferiprone and desferrioxamine compared with desferrioxamine alone, RR 3.04 (95% CI 1.18 to 7.83). The most commonly reported adverse event was joint pain, which occurred significantly more frequently in patients receiving deferiprone than desferrioxamine, RR 2.64 (95% CI 1.21 to 5.77). Other common adverse events included gastrointestinal disturbances as well as neutropenia or leucopenia, or both. Authors' conclusions In the absence of data from randomised controlled trials, there is no evidence to suggest the need for a change in current treatment recommendations; namely that deferiprone is indicated for treating iron overload in people with thalassaemia major when desferrioxamine is contraindicated or inadequate. Intensified desferrioxamine treatment (by either subcutaneous or intravenous route) or use of other oral iron chelators, or both, remains the established treatment to reverse cardiac dysfunction due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently only gave support for deferiprone to be used as a last resort for treating iron overload in thalassaemia, myelodysplasia and sickle cell disease. However, there is evidence that adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcome of deferiprone with desferrioxamine. Plain language summary The use of the iron chelator deferiprone in people with thalassaemia who are dependent on blood transfusions In thalassaemia sometimes the body cannot produce enough haemoglobin. Regular blood transfusions can manage this, but may lead to excess iron in the body, which, if not removed, may damage major organs. Iron chelation therapy removes excess iron; one common chelator is deferiprone. Questions exist about whether deferiprone is as good and safe as the most widely‐used iron chelator, desferrioxamine. Desferrioxamine is administered by a needle under the skin or into a vein, and was the standard monotherapy for 20 years. Seventeen randomised controlled trials compared deferiprone with desferrioxamine. They report little data on death or end organ damage, so we report the effects of therapy using mainly other markers. Removing excess iron was assessed by iron concentration in the blood and liver; heart function; and the amount of iron passed in urine. However, the amount of iron removed with either deferiprone or desferrioxamine was not consistent; one reason being that outcomes were measured differently. This makes it difficult to compare results between trials. Adverse events included joint pain, nausea, stomach upsets and low white blood cell count with deferiprone and pain or skin reactions at the injection site and joint pain with desferrioxamine. In one trial, the risk of an adverse event with deferiprone was twice that of the risk with desferrioxamine. Two further trials showed a three‐fold increased risk of an adverse event with combined deferiprone and desferrioxamine therapy compared with desferrioxamine alone. We found no evidence to change current recommendations to treat iron overload in thalassaemia with deferiprone when desferrioxamine cannot be used or is inadequate. Intensified desferrioxamine treatment or use of other oral iron chelators (or both of these) remains the established treatment to reverse heart problems due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently gave support for deferiprone only to be used as a last resort treatment in patients with thalassaemia, myelodysplasia and sickle cell disease. The danger of raised liver enzymes or a very low white blood cell count with deferiprone means that this treatment should not be used unless close monitoring of full blood counts and liver function is possible. Large trials of chelation therapy with standardised measures of iron stores and end organ damage are needed so valuable trial data can be compared and analysed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA; Brunskill, SJ; Doree, C; Chowdhury, O; Gooding, S; Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004839.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "ea8976c8-cb06-4b2f-954b-d5c689127ee1", "pmid": "", "title": "Helicobacter pylori eradication for the prevention of gastric neoplasia", "imported": false, "abstract": "Abstract - Background Gastric cancer is the third most common cause of cancer death worldwide. Individuals infected with Helicobacter pylori have a higher likelihood of developing gastric cancer than individuals who are not infected. Eradication of H. pylori in healthy asymptomatic individuals in the general population may reduce the incidence of gastric cancer, but the magnitude of this effect is unclear. Objectives To assess the effectiveness of eradication of H. pylori in healthy asymptomatic individuals in the general population in reducing the incidence of gastric cancer. Search methods We identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 1), MEDLINE (1946 to February 2020), and EMBASE (1974 to February 2020). We handsearched reference lists from trials selected by electronic searching to identify further relevant trials. We handsearched published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut ) and Digestive Disease Week (published in Gastroenterology ) between 2001 and 2019. We contacted members of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. Selection criteria We analysed randomised controlled trials comparing at least one week of H. pylori therapy with placebo or no treatment in preventing subsequent development of gastric cancer in otherwise healthy and asymptomatic H. pylori ‐positive adults. Trials had to follow up participants for at least two years and needed to have at least two participants with gastric cancer as an outcome. We defined gastric cancer as any gastric adenocarcinoma, including intestinal (differentiated) or diffuse (undifferentiated) type, with or without specified histology. Data collection and analysis We collected data on incidence of gastric cancer, incidence of oesophageal cancer, deaths from gastric cancer, deaths from any cause, and adverse effects arising due to therapy. Main results Six trials met all our eligibility criteria and provided extractable data in the previous version. Following our updated search, one new RCT was identified, meaning that seven trials were included in this updated review. In addition, one previously included trial provided fully published data out to 10 years, and another previously included trial provided fully published data out to 22 years of follow‐up. Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. Six trials were conducted in Asian populations. In preventing development of subsequent gastric cancer, H. pylori eradication therapy was superior to placebo or no treatment (RR 0.54, 95% confidence interval (CI) 0.40 to 0.72, 7 trials, 8323 participants, moderate certainty evidence). Only two trials reported the effect of eradication of H. pylori on the development of subsequent oesophageal cancer. Sixteen (0.8%) of 1947 participants assigned to eradication therapy subsequently developed oesophageal cancer compared with 13 (0.7%) of 1941 participants allocated to placebo (RR 1.22, 95% CI 0.59 to 2.54, moderate certainty evidence). H. pylori eradication reduced mortality from gastric cancer compared with placebo or no treatment (RR 0.61, 95% CI 0.40 to 0.92, 4 trials, 6301 participants, moderate certainty evidence). There was little or no evidence in all‐cause mortality (RR 0.97, 95% CI 0.85 to 1.12, 5 trials, 7079 participants, moderate certainty evidence). Adverse events data were poorly reported. Authors' conclusions We found moderate certainty evidence that searching for and eradicating H. pylori reduces the incidence of gastric cancer and death from gastric cancer in healthy asymptomatic infected Asian individuals, but we cannot necessarily extrapolate this data to other populations. Plain language summary Helicobacter pylori treatment for the prevention of stomach cancer Review question Whether testing healthy people for Helicobacter pylori and treating those infected with a course of antibiotics decreases the number of new cases of gastric cancer. Background Helicobacter pylori ( H. pylori ) is a bacteria that lives in the lining of the stomach with people usually not aware they are carrying the infection. People with H. pylori infection are more likely to develop gastric cancer than people who are not infected with the bacterium. For this reason, H. pylori is classed as carcinogenic (causing cancer) to humans. Many people worldwide die of gastric cancer every year, because by the time those affected seek the opinion of a doctor, the condition is often advanced. However, H. pylori infection is easily treatable with a one‐week course of antibiotics. Study characteristics A literature search up to 02 Feburary 2020 found seven trials (containing 8323 participants, four trials at low risk of bias). Six of the studies were based in Asia. Key results We found that antibiotics for H. pylori have a small benefit in preventing gastric cancer (68 (1.6%) of 4206 participants given treatment developed gastric cancer subsequently, compared with 125 (3.0%) of 4117 given no treatment or a placebo), and in decreasing the number of deaths from gastric cancer (36 (1.1%) of 3154, compared with 59 (1.9%) of 3147); but it is unclear whether or not they increase or decrease the number of deaths due to any cause, or increase or decrease the number of cases of oesophageal cancer. Data about side effects of treatment were poorly reported. Quality of the evidence Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. One study was at high risk of bias because no placebo was used for the active eradication therapy regimen, and so this part of the trial was unblinded, and the other study was at high risk of bias due to inconsistencies in data reporting at the two points of follow‐up. We were unable to resolve this discrepancy despite contacting the original authors. As a result, we downgraded the quality of evidence from high to moderate due to serious risk of bias.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ford, AC; Yuan, Y; Forman, D; Hunt, R; Moayyedi, P", "articleTypes": [], "doi": "10.1002/14651858.CD005583.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "ea8c3567-4f10-420c-a4c9-3c3459fa9e8a", "pmid": "", "title": "Combination inhaled steroid and long‐acting beta₂‐agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background The long‐acting bronchodilator tiotropium and single‐inhaler combination therapy of inhaled corticosteroids and long‐acting beta 2 ‐agonists (ICS/LABA) are commonly used for maintenance treatment of patients with chronic obstructive pulmonary disease (COPD). Combining these treatments, which have different mechanisms of action, may be more effective than administering the individual components. Objectives To assess relative effects of the following treatments on markers of exacerbations, symptoms, quality of life and lung function in patients with COPD. • Tiotropium plus LABA/ICS versus tiotropium. • Tiotropium plus LABA/ICS versus LABA/ICS. Search methods We searched the Cochrane Airways Group Specialised Register of Trials (April 2015), ClinicalTrials.gov ( www.ClinicalTrials.gov ), the World Health Organization (WHO) trials portal and reference lists of relevant articles. Selection criteria We included parallel, randomised controlled trials (RCTs) lasting three months or longer conducted to compare ICS and LABA combination therapy in addition to inhaled tiotropium versus tiotropium alone or combination therapy alone. Data collection and analysis We independently assessed trials for inclusion, then extracted data on trial quality and outcome results. We contacted study authors to ask for additional information. We collected trial information on adverse effects. Main results Tiotropium plus LABA/ICS versus tiotropium We included six studies (1902 participants) with low risk of bias that compared tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy versus tiotropium alone. We found no statistically significant differences in mortality between treatments (odds ratio (OR) 1.80, 95% confidence interval (CI) 0.55 to 5.91; two studies; 961 participants) as well as in the all‐cause hospitalisations (OR 0.84, 95% CI 0.53 to 1.33; two studies; 961 participants). The effect on exacerbations was heterogeneous among trials and was not meta‐analysed. Health‐related quality of life measured by St. George’s Respiratory Questionnaire (SGRQ) showed a statistically significant improvement in total scores with use of tiotropium + LABA/ICS compared with tiotropium alone (mean difference (MD) ‐3.46, 95% CI ‐5.05 to ‐1.87; four studies; 1446 participants). Lung function was significantly different in the combined therapy (tiotropium + LABA/ICS) group, although average benefit with this therapy was small. None of the included studies included exercise tolerance as an outcome. A pooled estimate of these studies did not show a statistically significant difference in adverse events (OR 1.16, 95% CI 0.92 to 1.47; four studies; 1363 participants), serious adverse events (OR 0.86, 95% CI 0.57 to 1.30; four studies; 1758 participants) and pneumonia (Peto OR 1.62, 95% CI 0.54 to 4.82; four studies; 1758 participants). Tiotropium plus LABA/ICS versus LABA/ICS One of the six studies (60 participants) also compared combined therapy (tiotropium + LABA/ICS) versus LABA/ICS therapy alone. This study was affected by lack of power; therefore results did not allow us to draw conclusions for this comparison. Authors' conclusions This review update includes three additional studies and provides new low quality evidence supporting the finding that tiotropium + LABA/ICS‐based therapy improves the disease‐specific quality of life. The current evidence is insufficient to support the benefit of tiotropium + LABA/ICS‐based therapy for mortality, hospital admission or exacerbations (moderate and low quality evidence). Compared with use of tiotropium alone, tiotropium + LABA/ICS‐based therapy does not seem to increase undesirable effects nor serious non‐fatal adverse events. Plain language summary Are tiotropium plus combination inhalers better than tiotropium or combination inhalers alone for the treatment of COPD? Background Chronic obstructive pulmonary disease (COPD) is a lung disease that includes the conditions chronic bronchitis and/or emphysema. COPD is characterised by narrowing of the airways and lung tissue destruction. Symptoms include breathlessness and long‐term cough. Symptoms of COPD are treatable, but the condition cannot be reversed or cured. It is usually brought on by airway irritants, such as smoking or inhaled dust. Inhalers with bronchodilators (which allow the airways in the lungs to relax and expand) and/or anti‐inflammatory agents are commonly used to ease symptoms and minimise the long‐term decline in health caused by COPD. Examples of these treatments are tiotropium, which is a bronchodilator, and combination inhalers, which contain another type of bronchodilator (long‐acting beta‐agonists) together with anti‐inflammatory agents (steroids). These treatments work in different ways and therefore might be more beneficial if used together. Study characteristics This review found six studies, involving 1902 participants, comparing the long‐term efficacy and side effects of tiotropium combined with combination inhalers for treatment of patients with COPD. Not all of the people included in these studies had COPD that was severe enough to be recommended for combined therapy according to current guidelines. Key results Current evidence shows potential benefits of treatment with tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy through increased health‐related quality of life and a small improvement i n lung function in patients receiving this combined therapy. However, this evidence does not allow us to draw conclusions about the effects of these treatments on mortality, hospitalisation for all causes and exacerbations. The frequency of serious and non‐serious adverse events was not increased in either of the two groups. Quality of the evidence Overall, we assessed the evidence presented in this review to be of moderate or low quality, which means we are reasonably confident in some of the findings, but less confident in others.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Rojas‐Reyes, MX, García Morales, OM, Dennis, RJ, Karner, C", "articleTypes": [], "doi": "10.1002/14651858.CD008532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.094Z" }, { "id": "eac236df-0c30-47c4-a07a-d0d728892964", "pmid": "", "title": "Oral nicotine pouches for cessation or reduction of use of other tobacco or nicotine products", "imported": false, "abstract": "Abstract - Rationale Oral nicotine pouches (ONP) emerged in the late 2000s, but have gained popularity since their introduction to the global market in 2016, with claims about their harm reduction potential. Objectives Primary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from combustible tobacco use (smoking). • To evaluate the impact of ONP on the prevalence of combustible tobacco use. Secondary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from other non‐combustible tobacco/commercial nicotine product use. • To evaluate the impact of ONP on the prevalence of use of other non‐combustible tobacco/commercial nicotine products. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO from 2000 to 13 January 2025. We also covered ClinicalTrials.gov and the WHO ICTRP through our search of CENTRAL. Eligibility criteria We included randomised controlled trials (RCTs) of ONP in people using tobacco or other non‐combustible tobacco/non‐pharmaceutical nicotine products. RCTs must have reported tobacco/nicotine use at 4+ weeks or biomarkers or adverse events at 1+ weeks. We also sought interrupted/multiple time‐series studies of ONP's population‐level effects on the prevalence of use of other tobacco/nicotine products. Outcomes Our critical outcomes were: smoking abstinence at 4+ weeks; number of people reporting serious adverse events (SAEs) at 1+ weeks; and change in the prevalence of smoking. Important outcomes included tobacco‐specific nitrosamines (TSNAs), carboxyhaemoglobin (COHb), metals, and inflammatory markers detected in human biosamples. Risk of bias We used the Cochrane RoB 1 tool to assess risk of bias. Synthesis methods We synthesised results using random‐effects meta‐analysis where possible. We used I 2 to quantify statistical heterogeneity. Where meta‐analysis was not possible, we graphically plotted available data in forest plots. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CI). We assessed the certainty of evidence using GRADE. Included studies We included four small studies (n < 150 for each, total n = 284; 3 independent, 1 industry‐funded; 3 at high risk of bias and 1 at unclear risk of bias). All were RCTs in people who smoked combustible cigarettes at baseline. Three were conducted in the USA, and one in New Zealand. Two compared higher‐ versus lower‐nicotine dose ONP. Two compared ONP to instructions to continue smoking as usual. One each compared ONP to electronic cigarettes (e‐cigarettes), snus, and pharmaceutical nicotine replacement therapy (NRT). Synthesis of results Smoking abstinence Smoking abstinence may be slightly higher in people randomised to ONP compared to no intervention at eight‐week follow‐up (RR 1.58, 95% CI 0.07 to 35.32; 1 study, 27 participants; very low‐certainty evidence (risk of bias and imprecision; CI incorporated possibility of no difference)), but the evidence is very uncertain. Low‐certainty evidence (serious imprecision; CI incorporated possibility of no difference) suggests there may be lower abstinence rates in those randomised to ONP compared to e‐cigarettes (RR 0.25, 95% CI 0.03 to 2.02; 1 study, 36 participants). Evidence from one study (n = 30) comparing higher‐ versus lower‐dose ONP found a higher quit rate in the higher‐dose arm, but again with wide CI encompassing the possibility of no difference and of higher quit rates in the lower‐dose arm (RR 5.00, 95% CI 0.26 to 96.13; evidence certainty not assessed). Serious adverse events No SAEs occurred in the three studies reporting this outcome. Data were available for the comparisons ONP versus minimal control (2 studies, 124 participants; very low‐certainty evidence (risk of bias and serious imprecision)) and ONP versus e‐cigarettes (1 study, 26 participants; low‐certainty evidence (serious imprecision)). TSNA One study reported on a TSNA (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol (NNAL)) comparing ONP with instructions to continue smoking. There may be lower levels with ONP (MD −265.30 ng/g creatinine, 95% CI −350.64 to −179.96; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. Data from two studies suggested no difference in NNAL levels between higher‐ and lower‐dose ONP (SMD −0.16, 95% CI −1.87 to 1.56; I 2 = 0%; 77 participants; evidence certainty not assessed). COHb Based on one study, there may be lower levels of COHb with ONP compared to instructions to continue smoking (MD −6.7%, 95% CI −8.33 to −5.07; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. When comparing higher‐ versus lower‐dose ONP, the same study found very slightly lower levels in the higher‐dose group, with the 95% CI incorporating the possibility of no difference (MD −0.40%, 95% CI −1.19 to 0.39; evidence certainty not assessed). No studies reported on prevalence, inflammatory markers, metals, or use of tobacco/nicotine products other than cigarettes. Authors' conclusions There is limited evidence on the use of ONP for cessation or reduction of cigarette use. There is no evidence on the use of ONP for cessation or reduction of other tobacco or nicotine products or on the effects of ONP on prevalence of tobacco use/nicotine vaping. Low‐certainty evidence suggests that people randomised to ONP may be slightly less likely to quit smoking than those randomised to e‐cigarettes, but data were from one small study and therefore imprecise. Limited, short‐term data did not identify any serious health harms from ONP when used to help people transition away from tobacco smoking. More research on the effects of ONP for cessation or reduction of use of other tobacco or non‐pharmaceutical nicotine products is urgently needed. Future trials should prioritise comparing ONP to other active interventions (e.g. NRT and e‐cigarettes). Funding This Cochrane review was funded by the National Cancer Institute of the National Institutes of Health (NIH) and FDA Center for Tobacco Products (CTP) under Award Number 2U54CA229974. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food & Drug Administration. Registration Registration: Cochrane, via protocol available via DOI:10.1002/14651858.CD016220. Plain language summary What are the benefits and risks of oral nicotine pouches when used to help people stop smoking, vaping nicotine, or using other forms of tobacco? Key messages Limited evidence from three small studies found no short‐term serious health harms of oral nicotine pouches in people who smoke. We are uncertain if oral nicotine pouches help people quit smoking compared to instructions to continue smoking as usual or no support to quit. Future research is needed, in particular comparing oral nicotine pouches to other active treatments (e.g. nicotine replacement therapy and e‐cigarettes). What are oral nicotine pouches? Oral nicotine pouches are preportioned pouches containing nicotine, sold in various flavours and nicotine strengths. They are similar in appearance and use to snus. Snus is a form of smokeless tobacco placed between the gum and lip that is popular in Nordic countries, but whose sale is banned in the UK and European Union countries excluding Sweden. Unlike snus, nicotine pouches do not contain tobacco leaf. Like nicotine e‐cigarettes and pharmaceutical forms of nicotine replacement therapy (such as nicotine patches and gums), oral nicotine pouches may be able to help people transition away from harmful forms of tobacco/nicotine product use by replacing them with a product that does not contain tobacco leaf and which, unlike e‐cigarettes, does not involve inhaling vapour into the lungs. Common brand names of oral nicotine pouches include Zyn, Velo, and Nordic Spirit. What did we want to find out? We wanted to find out if oral nicotine pouches can help people transition away from smoking, nicotine vaping, or other forms of tobacco use. We also wanted to know if oral nicotine pouches caused any unwanted effects when used for this purpose. What did we do? We searched for studies where people who smoked, vaped, or used other tobacco products were given oral nicotine pouches as a way to quit. We included studies if they tracked tobacco use or vaping for at least four weeks or looked at unwanted effects or chemical changes in the blood, breath, or urine for at least one week. What did we find? We found four studies including a total of 284 people who were smokers at study start. The studies were conducted between 2006 and 2023, and in those that reported race or ethnicity, were conducted in majority white populations. The average age across studies ranged from 34 to 50 years. The average number of cigarettes smoked by participants at study start was between 14 and 23 per day. The longest study ran for eight weeks. Three studies were independently funded, and one was funded by a tobacco manufacturer. Based on two small studies, it was not clear whether using nicotine pouches helped more people to quit smoking compared to instructions to continue smoking as usual or no support to quit, and there may be lower quit rates in those using nicotine pouches compared to those using a nicotine e‐cigarette (vaping). No serious health harms occurred in any group in the three studies that reported this information, so it is unclear if using nicotine pouches affects the chances of experiencing a serious health harm. We also looked at certain chemicals measured in blood, breath, or urine that can signal exposures to harmful substances. Tobacco use exposes the body to cancer‐causing chemicals. NNAL (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol), a chemical formed when these cancer‐causing chemicals enter the body, measures exposure to harmful ingredients in tobacco smoke. One small study reported lower levels of NNAL in people using oral nicotine pouches compared to those given no specific treatment to stop smoking. Combined evidence from two studies suggested no difference in NNAL levels between people receiving higher‐ versus lower‐dose nicotine pouches. Carbon monoxide is a poisonous gas present in tobacco smoke. When carbon monoxide binds with blood haemoglobin, it forms a substance called carboxyhaemoglobin. Carboxyhaemoglobin measures how much carbon monoxide a person has been exposed to in their blood. One study found lower levels of carboxyhaemoglobin in people using oral nicotine pouches compared to those who continued smoking. When comparing higher‐ versus lower‐dose nicotine pouches, the same study found very slightly lower carboxyhaemoglobin levels in the higher‐dose group. What are the limitations of the evidence? We have little to very low confidence in the evidence because the studies were relatively small, and there are not enough studies to be certain about the results. Also, some studies had issues with the way they were designed that could have affected their results. Many studies are currently underway, and we plan to update this review when their findings become available. How up‐to‐date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hartmann-Boyce, J; Tattan-Birch, H; Brown, J; Shahab, L; Goniewicz, ML; Ma, CL; Wu, AD; Travis, N; Jarman, H; Livingstone-Banks, J; Lindson, N", "articleTypes": [], "doi": "10.1002/14651858.CD016220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "ead44db3-8f4e-412a-ae38-54b41a312d6e", "pmid": "", "title": "The Acute and Chronic Effects of OliPhenolia® Supplementation on Exercise Induced Inflammation and Functional Movement in Healthy Adult Humans.", "imported": false, "abstract": "This research proposal follows on from previously undertaken work investigating a commercially available olive derived product (OliPhenolia®) on potential exercise / functional benefits for healthy adults. Previous research investigated a dose response bioavailability of the main polyphenol in OliPhenolia® and related metabolites. Based on this data, the current study will aim to investigate, for the first time, whether the polyphenols in the product can positively influence exercise specific inflammation which may be pertinent to improving exercise recovery and is of current scientific interest. As such this research aims to understand the short term (Phase 1) and longer term (Phase 2) use of OliPhenolia® on acute recovery from a standard exercise bout.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.236Z" }, { "id": "eaee1407-f771-4d6c-aa5d-7f81ccb0b45f", "pmid": "", "title": "Interventions for hirsutism (excluding laser and photoepilation therapy alone)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "van Zuuren, EJ, Fedorowicz, Z, Carter, B, Pandis, N", "articleTypes": [], "doi": "10.1002/14651858.CD010334.pub2 AB - Abstract - Background Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen‐sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective. Objectives To assess the effects of interventions (except laser and light‐based therapies alone) for hirsutism. Search methods We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014. Selection criteria Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism. Data collection and analysis Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses. Main results We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty‐eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow‐up above 40%. Primary outcomes, 'participant‐reported improvement of hirsutism' and 'change in health‐related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin‐releasing hormone (GnRH) analogues)). Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one‐third of studies. The quality of evidence was moderate to very low for most outcomes. There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman‐Gallwey scores. The mean difference (MD) was ‐1.84 (95% confidence interval (CI) ‐3.86 to 0.18). There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman‐Gallwey scores more effectively than placebo (MD ‐7.60, 95% CI ‐10.53 to ‐4.67 and MD ‐7.20, 95% CI ‐10.15 to ‐4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87). Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman‐Gallwey scores (MD ‐7.69, 95% CI ‐10.12 to ‐5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD ‐1.90, 95% CI ‐5.01 to 1.21 and MD 0.49, 95% CI ‐1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI ‐0.58 to 3.56 and MD 0.40, 95% CI ‐1.18 to 1.98) (low quality evidence). Although there was very low quality evidence of a difference in reduction of Ferriman‐Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD ‐5.73, 95% CI ‐6.87 to ‐4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached. Metformin demonstrated no benefit over placebo in reduction of Ferriman‐Gallwey scores (MD 0.05, 95% CI ‐1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements. We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman‐Gallwey scores. Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman‐Gallwey scores (low quality evidence). Ferriman‐Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD ‐6.30, 95% CI ‐9.83 to ‐2.77) (very low quality evidence). Data showing reductions in Ferriman‐Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%). Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman‐Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs. Authors' conclusions Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision‐making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects. Further research should consist of well‐designed, rigorously reported, head‐to‐head trials examining OCPs combined with antiandrogens or 5α‐reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α‐reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment. Plain language summary Treatments for unwanted male pattern hair growth in women Background 
 Up to 5% to 10% of women are hirsute (hair in areas where normally only men have hairs such as moustache, beard area, chest, belly, back etc). The most common cause is polycystic ovary syndrome. Hirsutism can lead to psychological distress, low self esteem, decreased self image, depression, feelings of shame and social difficulties. Review question 
 Which treatments (except laser and light‐based therapies alone) work best for hirsutism? Study characteristics 
 We included 157 studies published up to June 2014, which examined 10,550 people. Participants included women with a mean age of 25 years. There was considerable variation in the quality of how the studies were conducted; more than half were not blinded and this may have had an impact on the reporting of the outcomes. Most studies were carried out in single centres in Europe and lasted six to 12 months. A range of treatments were evaluated, mostly in single studies. These included a few topical treatments, lifestyle modification, oral contraceptive pills (OCPs), medication to inhibit the effect of hormones that are responsible for male traits, and combination therapies. Participant‐assessed improvement and impact on quality of life were evaluated in a minority of the studies, whilst the majority of the studies measured physician‐assessed reduction in hirsutism, as well as androgen levels in the blood. Half of the studies reported adverse events and around one‐third other signs and symptoms, e.g. oily skin and menstrual irregularities that might be due to an increase of androgen levels in the blood. Key results 
 Oral contraceptive pills reduced the amount of hairs, but the reduction was not consistent across the studies, although two OCPs (ethinyl estradiol 35 µg + cyproterone acetate 2 mg compared to ethinyl estradiol 30 µg + desogestrel 0.15 mg) appeared to be effective in a way that can be considered important for women with hirsutism. Of the antiandrogen drugs, flutamide was considered to be more effective than placebo by both the women and the doctors. Spironolactone was also effective, but data were only available for the physicians' assessments. Finasteride did not show convincing effectiveness based on the evaluations of the hirsute women and those made by the investigators. The addition of cyproterone acetate (an antiandrogen) to OCP seemed to enhance the beneficial effect of OCPs on hair reduction. Insulin sensitisers (antidiabetic drugs) and lifestyle modification did not have any demonstrable benefit in terms of the severity of hirsutism. Unfortunately, the self assessments by the women, as well as the impact of hirsutism on their quality of life, were outcomes that were insufficiently addressed in the studies. The adverse events reported with the different drugs are well known, i.e. pain in the stomach and intestines, breast tenderness, reduced libido and dry skin with flutamide and finasteride; irregular bleeding with spironolactone; nausea, diarrhoea and abdominal bloating with metformin; and hot flushes, decreased libido, vaginal dryness, breast tenderness and headaches with the GnRH analogues. There were no important differences in blood androgen levels between the different treatment groups, OCPs had a positive effect on acne, and similarly insulin sensitisers improved the menstrual pattern. We were expecting to find evidence that combined therapies of an OCP with an antiandrogen were more effective than, for example, OCPs alone, but the lack of studies did not allow us to draw these conclusions. Overall we concluded that OCPs (especially with antiandrogenic activity), OCPs combined with cyproterone acetate, flutamide and spironolactone are effective in treating hirsutism. However, additional cosmetic measures (epilating, waxing, bleaching, electrolysis, laser and photoepilation) are generally required because all treatments need at least six to 12 months to reach the optimum effect. In addition, because of the distress associated with hirsutism and its impact on quality of life psychological support should be part of the treatment approach. Quality of the evidence 
 The overall quality of the evidence for the different outcomes was on average rated as moderate to very low. Important reasons for this were that studies were not blinded, or had a small sample size.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.142Z" }, { "id": "eaef78dd-c920-4c9f-9753-bec2eb1f9994", "pmid": "", "title": "Interventions for leg cramps in pregnancy", "imported": false, "abstract": "Abstract - Background Many women experience leg cramps in pregnancy. They become more common as pregnancy progresses and are especially troublesome at night. Objectives The objective of this review was to assess methods of preventing and treating leg cramps in pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2001). We updated this search on 4 July 2011 and added the results to the awaiting classification section. Selection criteria Randomised trials of treatments for leg cramps in pregnancy. Data collection and analysis Trial quality was assessed and data were extracted independently by two reviewers. Main results Five trials involving 352 women were included. The trials were of moderate quality. The only placebo‐controlled trial of calcium treatment showed no evidence of benefit. Trials comparing sodium chloride with placebo (odds ratio 0.54, 95% confidence interval 0.23 to 1.29) and calcium with sodium chloride (odds ratio 1.23, 95% confidence intervals 0.47 to 3.27 ) showed no evidence of benefit. Placebo controlled trials of multivitamin with mineral supplements (odds ratio 0.23, 95% confidence intervals 0.05 to 1.01) and magnesium (odds ratio 0.18, 95% confidence intervals 0.05 to 0.60) provided some suggestion of benefit. Authors' conclusions The evidence that calcium reduces cramp is weak and seems to depend on placebo effect. The evidence for sodium chloride is stronger but the results of the sodium chloride trial may no longer be relevant because of dietary changes which include an increased sodium intake in the general population. It is not possible to recommend multivitamins with mineral supplementation, as it is not clear which ingredient, if any, is helping. If a woman finds cramp troublesome in pregnancy, the best evidence is for magnesium lactate or citrate taken as 5mmol in the morning and 10mmol in the evening. [Note: The five citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.] Plain language summary Interventions for leg cramps in pregnancy Sodium supplements may decrease the number of cramp attacks experienced by women in pregnancy but the effect is slight. Calcium is of no benefit. The evidence of benefit for magnesium is stronger. Multivitamin and mineral supplements also seem to help but the relevance of this is unclear as the preparation used contained twelve separate constituents and it is not possible to discover which of these was effective, or indeed if there was synergy between constituents. There is a theoretical risk that sodium supplementation could raise blood pressure. It is unlikely that magnesium supplementation would be harmful at the suggested doses.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Young, G; Jewell, D", "articleTypes": [], "doi": "10.1002/14651858.CD000121", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "eaf31b5e-c546-4161-9e4d-d36b09c3e357", "pmid": "", "title": "Efficacy Of Bovine Colostrum In The Treatment Of Severe Alcohol-Associated Hepatitis: A Randomized Controlled Trial", "imported": false, "abstract": "Severe alcohol-associated hepatitis (sAH)is associated with hepatocellular necrosis, inflammation, hyperactivated immune system, paradoxical immune exhaustion, leaky gut, and alteration in the gut microbiome. The leading cause of mortality is a bacterial infection with multi-organ failure.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.269Z" }, { "id": "eb0c7270-6feb-4ed7-9353-e2cac6b6aa1b", "pmid": "", "title": "Synbiotics, prebiotics and probiotics for people with chronic kidney disease", "imported": false, "abstract": "Abstract - Background Chronic kidney disease (CKD) is a major public health problem affecting 13% of the global population. Prior research has indicated that CKD is associated with gut dysbiosis. Gut dysbiosis may lead to the development and/or progression of CKD, which in turn may in turn lead to gut dysbiosis as a result of uraemic toxins, intestinal wall oedema, metabolic acidosis, prolonged intestinal transit times, polypharmacy (frequent antibiotic exposures) and dietary restrictions used to treat CKD. Interventions such as synbiotics, prebiotics, and probiotics may improve the balance of the gut flora by altering intestinal pH, improving gut microbiota balance and enhancing gut barrier function (i.e. reducing gut permeability). Objectives This review aimed to evaluate the benefits and harms of synbiotics, prebiotics, and probiotics for people with CKD. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria We included randomised controlled trials (RCTs) measuring and reporting the effects of synbiotics, prebiotics, or probiotics in any combination and any formulation given to people with CKD (CKD stages 1 to 5, including dialysis and kidney transplant). Two authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. Data collection and analysis Data extraction was independently carried out by two authors using a standard data extraction form. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross‐checked by another. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results Forty‐five studies (2266 randomised participants) were included in this review. Study participants were adults (two studies in children) with CKD ranging from stages 1 to 5, with patients receiving and not receiving dialysis, of whom half also had diabetes and hypertension. No studies investigated the same synbiotic, prebiotic or probiotic of similar strains, doses, or frequencies. Most studies were judged to be low risk for selection bias, performance bias and reporting bias, unclear risk for detection bias and for control of confounding factors, and high risk for attrition and other biases. Compared to prebiotics, it is uncertain whether synbiotics improve estimated glomerular filtration rate (eGFR) at four weeks (1 study, 34 participants: MD ‐3.80 mL/min/1.73 m², 95% CI ‐17.98 to 10.38), indoxyl sulfate at four weeks (1 study, 42 participants: MD 128.30 ng/mL, 95% CI ‐242.77 to 499.37), change in gastrointestinal (GI) upset (borborymgi) at four weeks (1 study, 34 participants: RR 15.26, 95% CI 0.99 to 236.23), or change in GI upset (Gastrointestinal Symptom Rating Scale) at 12 months (1 study, 56 participants: MD 0.00, 95% CI ‐0.27 to 0.27), because the certainty of the evidence was very low. Compared to certain strains of prebiotics, it is uncertain whether a different strain of prebiotics improves eGFR at 12 weeks (1 study, 50 participants: MD 0.00 mL/min, 95% CI ‐1.73 to 1.73), indoxyl sulfate at six weeks (2 studies, 64 participants: MD ‐0.20 μg/mL, 95% CI ‐1.01 to 0.61; I² = 0%) or change in any GI upset, intolerance or microbiota composition, because the certainty of the evidence was very low. Compared to certain strains of probiotics, it is uncertain whether a different strain of probiotic improves eGFR at eight weeks (1 study, 30 participants: MD ‐0.64 mL/min, 95% CI ‐9.51 to 8.23; very low certainty evidence). Compared to placebo or no treatment, it is uncertain whether synbiotics improve eGFR at six or 12 weeks (2 studies, 98 participants: MD 1.42 mL/min, 95% CI 0.65 to 2.2) or change in any GI upset or intolerance at 12 weeks because the certainty of the evidence was very low. Compared to placebo or no treatment, it is uncertain whether prebiotics improves indoxyl sulfate at eight weeks (2 studies, 75 participants: SMD ‐0.14 mg/L, 95% CI ‐0.60 to 0.31; very low certainty evidence) or microbiota composition because the certainty of the evidence is very low. Compared to placebo or no treatment, it is uncertain whether probiotics improve eGFR at eight, 12 or 15 weeks (3 studies, 128 participants: MD 2.73 mL/min, 95% CI ‐2.28 to 7.75; I² = 78%), proteinuria at 12 or 24 weeks (1 study, 60 participants: MD ‐15.60 mg/dL, 95% CI ‐34.30 to 3.10), indoxyl sulfate at 12 or 24 weeks (2 studies, 83 participants: MD ‐4.42 mg/dL, 95% CI ‐9.83 to 1.35; I² = 0%), or any change in GI upset or intolerance because the certainty of the evidence was very low. Probiotics may have little or no effect on albuminuria at 12 or 24 weeks compared to placebo or no treatment (4 studies, 193 participants: MD 0.02 g/dL, 95% CI ‐0.08 to 0.13; I² = 0%; low certainty evidence). For all comparisons, adverse events were poorly reported and were minimal (flatulence, nausea, diarrhoea, abdominal pain) and non‐serious, and withdrawals were not related to the study treatment. Authors' conclusions We found very few studies that adequately test biotic supplementation as alternative treatments for improving kidney function, GI symptoms, dialysis outcomes, allograft function, patient‐reported outcomes, CVD, cancer, reducing uraemic toxins, and adverse effects. We are not certain whether synbiotics, prebiotics, or probiotics are more or less effective compared to one another, antibiotics, or standard care for improving patient outcomes in people with CKD. Adverse events were uncommon and mild. Plain language summary Prebiotics (dietary fibre), probiotics (good bacteria) or synbiotics (prebiotics plus probiotics) for people with chronic kidney disease Key messages Chronic kidney disease (CKD) is a serious health problem that affects over 850 million people worldwide. People with kidney disease have an unhealthy balance of good and bad bacteria in their guts, called 'gut dysbiosis'. This imbalance arises because of the effects of reduced kidney function (retained toxic waste products, fluid retention causing the gut wall to swell), drugs frequently used in people with CKD (especially antibiotics), and dietary restrictions placed on people with CKD. Gut dysbiosis can, in turn, cause or worsen CKD because bacteria can produce toxins that cross the bowel wall and damage the kidneys. Gut dysbiosis can also cause stomach problems (like bloating, cramping, constipation and diarrhoea) and reduce quality of life. To improve the balance of the gut flora, good bacteria can be taken in tablets of high doses of prebiotics and probiotics. Prebiotics, or indigestible plant fibre, can encourage the growth of good bacteria. Synbiotics are a combination of prebiotics and probiotics. Some research suggests that taking high doses of the good bacteria can re‐balance the good bacteria in people's gut, thereby improving bowel symptoms and the conditions that lead to worsening of CKD. What did we do? We reviewed all of the evidence on synbiotics, prebiotics and probiotics to see whether they can improve outcomes in people who have CKD (all stages 1 to 5). What did we find? We found 45 studies randomising 2266 participants. Half of these looked at participants receiving dialysis (mostly haemodialysis), and the other half not receiving dialysis. Half also had diabetes and hypertension. We are uncertain whether synbiotics, prebiotics, or probiotics improve bowel outcomes, quality of life, kidney toxin levels or kidney function. The quality of the evidence that we found is low quality and very low certainty. All studies were conducted using moderate to poor‐quality methods with too few patients. Summary Currently, we do not have enough information from trials to know whether synbiotics, prebiotics or probiotics work to improve bowel symptoms, quality of life, kidney toxin levels, or kidney function in people with CKD. Ten studies are currently ongoing; therefore, it is possible that findings may change with the inclusion of these studies in future updates. The evidence is up to date to 9 October 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Cooper, TE; Khalid, R; Chan, S; Craig, JC; Hawley, CM; Howell, M; Johnson, DW; Jaure, A; Teixeira-Pinto, A; Wong, G", "articleTypes": [], "doi": "10.1002/14651858.CD013631.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "eb1688c9-4342-487f-aa8a-92d1b11a1ddb", "pmid": "", "title": "Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults", "imported": false, "abstract": "Abstract - Background Chancroid is a genital ulcerative disease caused by Haemophilus ducreyi . This microorganism is endemic in Africa, where it can cause up to 10% of genital ulcers. Macrolides may be an effective alternative to treat chancroid and, based on their oral administration and duration of therapy, could be considered as first line therapy. Objectives To assess the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults. Search methods We searched the Cochrane STI Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, WHO ICTRP, ClinicalTrials.gov and Web of Science to 30 October 2017. We also handsearched conference proceedings and reference lists of retrieved studies. Selection criteria Randomized controlled trials (RCTs) comparing macrolides in different regimens or with other therapeutic alternatives for chancroid. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We resolved disagreements through consensus. We used the GRADE approach to assess the quality of the evidence. Main results Seven RCTs (875 participants) met our inclusion criteria, of which four were funded by industry. Five studies (664 participants) compared macrolides with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Low quality evidence suggested there was no difference between the groups after treatment in terms of clinical cure (risk ratio (RR) 1.09, 95% confidence interval (CI) 0.97 to 1.21; 2 studies, 340 participants with syndromic approach and RR 1.06, 95% CI 0.98 to 1.15; 5 studies, 348 participants with aetiological diagnosis) or improvement (RR 0.89, 95% CI 0.52 to 1.52; 2 studies, 340 participants with syndromic approach and RR 0.80, 95% CI 0.42 to 1.51; 3 studies, 187 participants with aetiological diagnosis). Based on low and very low quality evidence, there was no difference between macrolides and any other antibiotic treatments for microbiological cure (RR 0.93, 95% CI 0.74 to 1.16; 1 study, 45 participants) and minor adverse effects (RR 1.34, 95% CI 0.24 to 7.51; 3 studies, 412 participants). Two trials (269 participants) compared erythromycin with any other macrolide type. Low quality evidence suggested that, compared with azithromycin or rosaramicin, long courses of erythromycin did not increase clinical cure (RR 1.00, 95% CI 0.91 to 1.10; 2 studies, 269 participants with syndromic approach and RR 1.04, 95% CI 0.93 to 1.16; 2 studies, 211 participants with aetiological diagnosis), with a similar frequency of minor adverse effects between the groups (RR 1.14, 95% CI 0.63 to 2.06; 1 trial, 101 participants). For this comparison, subgroup analysis found no difference between HIV‐positive participants (RR 1.02, 95% CI 0.73 to 1.43; 1 study, 38 participants) and HIV‐negative participants (RR 1.04, 95% CI 0.94 to 1.14; 1 study, 89 participants). We downgraded the quality of evidence to low, because of imprecision, some limitations on risk of bias and heterogeneity. None of the trials reported serious adverse events, cost effectiveness and participant satisfaction. Authors' conclusions At present, the quality of the evidence on the effectiveness and safety of macrolides for treatment of H ducreyi infection in sexually active adults is low, implying that we are uncertain about the estimated treatment effect. There is no statistically significant difference between the available therapeutic alternatives for the treatment of sexually active adults with genital ulcers compatible with chancroid. Low quality evidence suggests that azithromycin could be considered as the first therapeutic alternative, based on their mono‐dose oral administration, with a similar safety and effectiveness profile, when it is compared with long‐term erythromycin use. Due to sparse available evidence about the safety and effectiveness of macrolides to treat H ducreyi infection in people with HIV, these results should be taken with caution. Plain language summary Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults Review question 
 In this Cochrane Review, we assess the effectiveness and safety of macrolides in different regimens or with other treatments for H ducreyi infection in adults. Background Chancroid is a sexually transmitted infection (STI) caused by infection with a bacteria called Haemophilus ducreyi . It causes ulcers in the genital area and is endemic in some low‐income countries. Control and eradication of chancroid could reduce transmission of the STI from one sexual partner to another. Macrolides are antibiotics that could be effective and safe for treating H ducreyi infection. Trial characteristics We searched the available literature up to 30 October 2017 and we included seven trials with 875 participants. The trials recruited men and non‐pregnant women over the age of 16 years who presented with genital ulcers compatible with chancroid. Three studies included people with high‐risk sexual behaviour as migrant mine workers, sex workers and men with prostitute contact. All the trials tested for other STIs, and discarded people who were also infected with syphilis and herpes simple virus. One study included people with HIV. The most frequent antibiotic treatment was erythromycin with azithromycin as an alternative. They were compared with ceftriaxone, ciprofloxacin, spectinomycin or thiamphenicol. Five studies compared two types of antibiotic and two studies compared different ways of treating with macrolides. Four trials were funded by pharmaceutical companies. Key results There was no difference between the types of antibiotics in sexually active adults with genital ulcers compatible with chancroid. Erythromycin is usually the first choice for treatment but low quality evidence suggested that azithromycin (as a single dose, oral (by mouth) administration) had similar safety and effectiveness. Because of sparse evidence about the safety and effectiveness of macrolides to treat Haemophilus ducreyi infection in people with HIV, these results should be taken with caution. Quality of evidence The quality of evidence was low as there was a risk of bias due to poor methods, people dropping out of the study and pharmaceutical companies sponsored four studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Romero, L; Huerfano, C; Grillo‐Ardila, CF", "articleTypes": [], "doi": "10.1002/14651858.CD012492.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "eb1cc587-c363-4521-bfe0-00f256c52a3d", "pmid": "", "title": "The Effects of GLP-1 Receptor Agonists on Sensory Systems and Ingestive Behavior", "imported": false, "abstract": "The goal of this study is to explore whether of GLP-1 receptor agonist use is associated with differences in taste, smell, food preferences, appetite, food cravings, and responses to food cues in adults. The study includes adults who are not currently taking a GLP-1 receptor agonist but may be eligible to use one, and adults who are already taking a GLP-1 receptor agonist as part of their regular medical care for approximately 1 month or approximately 6 months.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.231Z" }, { "id": "eb30bd83-f6d2-4c21-9a40-fc84b1c7d1e1", "pmid": "", "title": "Short courses of antibiotics for children and adults with bronchiectasis", "imported": false, "abstract": "Abstract - Background Bronchiectasis is an important cause of respiratory morbidity in both developing and developed countries. Antibiotics are considered standard therapy in the treatment of this condition but it is unknown whether short courses (four weeks or less) are efficacious. Objectives To determine whether short courses of antibiotics (i.e. less than or equal to four weeks) for treatment of acute and stable state bronchiectasis, in adults and children, are efficacious when compared to placebo or usual care. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library ), MEDLINE, EMBASE, OLDMEDLINE, CINAHL, AMED and PsycINFO and handsearching of respiratory journals and meeting abstracts were performed by the Cochrane Airways Group up to February 2011. Selection criteria Only randomised controlled trials were considered. Adults and children with bronchiectasis (defined clinically or radiologically) were included. Patients with cystic fibrosis were excluded. Data collection and analysis Two review authors independently reviewed the titles, abstracts and citations to assess eligibility for inclusion. Only one study fulfilled the inclusion criteria and thus meta‐analysis could not be performed. Main results The single eligible study showed a small benefit, when compared to placebo, of four weeks of inhaled antibiotic therapy in adults with bronchiectasis and pseudomonas in their sputum. There were no studies in children and no studies on oral or intravenous antibiotics. Authors' conclusions There is insufficient evidence in the current literature to make reasonable conclusions about the efficacy of short course antibiotics in the management of adults and children with bronchiectasis. Until further evidence is available, adherence to current treatment guidelines is recommended. Plain language summary Short courses of antibiotics for children and adults with bronchiectasis There is a paucity of evidence to conclude whether short courses of antibiotics (i.e. less than or equal to four weeks) are equivalent or superior to placebo in the treatment of stable or exacerbation state bronchiectasis. One single study showed some benefit of short‐course inhaled antibiotics over placebo, in terms of microbiological response and subjective improvement in medical condition, although this was balanced against an increase in adverse effects and antimicrobial resistance in the treatment group. Given the potential benefits of shorter duration antibiotic therapy in bronchiectasis, further RCTs are clearly needed to answer this important question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Wurzel, D; Marchant, JM; Yerkovich, ST; Upham, JW; Masters, IB; Chang, AB", "articleTypes": [], "doi": "10.1002/14651858.CD008695.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "eb57d4f6-5d8c-4a44-bca4-cee136117f47", "pmid": "", "title": "Interventions for chronic blepharitis", "imported": false, "abstract": "Abstract - Background Blepharitis, an inflammatory condition associated with itchiness, redness, flaking, and crusting of the eyelids, is a common eye condition that affects both children and adults. It is common in all ethnic groups and across all ages. Although infrequent, blepharitis can lead to permanent alterations to the eyelid margin or vision loss from superficial keratopathy (abnormality of the cornea), corneal neovascularization, and ulceration. Most importantly, blepharitis frequently causes significant ocular symptoms such as burning sensation, irritation, tearing, and red eyes as well as visual problems such as photophobia and blurred vision. The exact etiopathogenesis is unknown, but suspected to be multifactorial, including chronic low‐grade infections of the ocular surface with bacteria, infestations with certain parasites such as demodex, and inflammatory skin conditions such as atopy and seborrhea. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. Objectives To examine the effectiveness of interventions in the treatment of chronic blepharitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 1), MEDLINE (January 1950 to February 2012), EMBASE (January 1980 to February 2012), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 9 February 2012. Selection criteria We included randomized controlled trials (RCTs) and quasi‐randomized controlled trials (CCTs) in which participants were adults aged 16 years or older and clinically diagnosed with chronic blepharitis. We also included trials where participants with chronic blepharitis were a subset of the participants included in the study and data were reported separately for these participants. Interventions within the scope of this review included medical treatment and lid hygiene measures. Data collection and analysis Two authors independently assessed search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. Data were meta‐analyzed for studies comparing similar interventions and reporting comparable outcomes with the same timing. Otherwise, results for included studies were summarized in the text. Main results There were 34 studies (2169 participants with blepharitis) included in this review: 20 studies (14 RCTs and 6 CCTs) included 1661 participants with anterior or mixed blepharitis and 14 studies (12 RCTs and 2 CCTs) included 508 participants with posterior blepharitis (MGD). Due to the heterogeneity of study characteristics among the included studies, with respect to follow‐up periods and types of interventions, comparisons, and condition of participants, our ability to perform meta‐analyses was limited. Topical antibiotics were shown to provide some symptomatic relief and were effective in eradicating bacteria from the eyelid margin for anterior blepharitis. Lid hygiene may provide symptomatic relief for anterior and posterior blepharitis. The effectiveness of other treatments for blepharitis, such as topical steroids and oral antibiotics, were inconclusive. Authors' conclusions Despite identifying 34 trials related to treatments for blepharitis, there is no strong evidence for any of the treatments in terms of curing chronic blepharitis. Commercial products are marketed to consumers and prescribed to patients without substantial evidence of effectiveness. Further research is needed to evaluate the effectiveness of such treatments. Any RCT designed for this purpose should separate participants by type of condition (e.g. staphylococcal blepharitis or MGD) in order to minimize imbalances between groups (type I errors) and to achieve statistical power for analyses (prevent type II errors). Medical interventions and commercial products should be compared with conventional lid hygiene measures, such as warm compresses and eyelid margin washing, to determine effectiveness, as well as head‐to‐head to show comparative effectiveness between treatments. Outcomes of interest should be patient‐centered and measured using validated questionnaires or scales. It is important that participants be followed long‐term, at least one year, to assess chronic outcomes properly. Plain language summary Interventions for blepharitis Blepharitis, defined as inflammation of the eyelids, is a common eye condition and affects both children and adults. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. There were 34 studies (2169 participants with blepharitis) included in the review, 20 of which included participants with anterior blepharitis and 14 of which included participants with posterior blepharitis. For anterior blepharitis, topical antibiotics provided some symptomatic relief and were effective in clearing bacteria from the eyelid margins. There was no difference between the types of topical antibiotics used. Topical steroids also provided some symptomatic relief; however, they were ineffective in eliminating bacteria. Lid hygiene, including warm compresses and lid scrubs, showed some symptomatic relief in both anterior and posterior blepharitis. Overall, there was no strong evidence for any of the treatments in terms of curing chronic blepharitis. Further research should be done to evaluate the effectiveness of treatments for blepharitis, with particular attention paid to adequate diagnosis and classification of the disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lindsley, K, Matsumura, S, Hatef, E, Akpek, EK", "articleTypes": [], "doi": "10.1002/14651858.CD005556.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.749Z" }, { "id": "eb5cfb78-3a35-4fc5-af4f-519d1f48e768", "pmid": "", "title": "Oral zinc for treating diarrhoea in children", "imported": false, "abstract": "Abstract - Background In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). Objectives To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, m RCT, and reference lists up to 30 September 2016. We also contacted researchers. Selection criteria Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery. Data collection and analysis Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta‐analyses (using either a fixed‐effect or random‐effects model) and assessed heterogeneity. We assessed the certainty of the evidence using the GRADE approach. Main results Thirty‐three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoea There is currently not enough evidence from well‐conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized ( very low certainty evidence ). In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD −11.46 hours, 95% CI −19.72 to −3.19; 2581 children, 9 trials, low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD −26.39 hours, 95% CI −36.54 to −16.23; 419 children, 5 trials, high certainty evidence ). Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI −4.00 to 14.45; 1334 children, 2 trials, low certainty evidence ), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, low certainty evidence ). None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence ; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence ). Persistent diarrhoea In children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD −15.84 hours, 95% CI −25.43 to −6.24; 529 children, 5 trials, moderate certainty evidence ). Authors' conclusions In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency. 12 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (30 Sep, 2016) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Oral zinc supplementation for treating diarrhoea in children In low‐ and middle‐income countries, millions of children suffer from severe diarrhoea every year and many die from dehydration. Giving fluids by mouth (using an oral rehydration solution (ORS)) has been shown to save children's lives, but it has no effect on the length of time the children suffer with diarrhoea. Zinc supplementation could help reduce the duration and the severity of diarrhoea, and therefore have an additional benefit over ORS in reducing children mortality. What is oral zinc and how may it shorten the duration and severity of diarrhoea Zinc is usually given as zinc sulphate, zinc acetate, or zinc gluconate, which are all water‐soluble compounds. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend 10 mg to 20 mg of zinc per day for children with diarrhoea. There are several mechanism of action of zinc on acute diarrhoea, some of which are specific to the gastrointestinal system: zinc restores mucosal barrier integrity and enterocyte brush‐border enzyme activity, it promotes the production of antibodies and circulating lymphocytes against intestinal pathogens, and has a direct effect on ion channels, acting as a potassium channel blocker of adenosine 3‐5‐cyclic monophosphate‐mediated chlorine secretion. Cochrane researchers examined the evidence available up to 30 September 2016. What the evidence in the review suggests Thirty‐three trials that included 10,841 children met the inclusion criteria of this review. Among children with acute diarrhoea, we don't know if treating children with zinc has an effect on death or number of children hospitalized ( very low certainty evidence ). In children older than six months, zinc supplementation may shorten the average duration of diarrhoea by around half a day ( low certainty evidence ), and probably reduces the number of children whose diarrhoea persists until day seven ( moderate certainty evidence ). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day ( high certainty evidence ). Conversely, in children younger than six months, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea ( low certainty evidence ), or the number of children who still have diarrhoea on day seven ( low certainty evidence ). Zinc supplementation increased the risk of vomiting in both age groups ( moderate certainty evidence ). No other adverse effects were reported. Among children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours ( moderate certainty ) but it probably increases the risk of vomiting ( moderate certainty evidence ). In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well‐nourished children, and in settings where children are at low risk of zinc deficiency.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lazzerini, M, Wanzira, H", "articleTypes": [], "doi": "10.1002/14651858.CD005436.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.761Z" }, { "id": "eb7be275-4aa1-4277-b366-def4cf896c9f", "pmid": "", "title": "Herbal medicines for fatty liver diseases", "imported": false, "abstract": "Abstract - Background Fatty liver disease is potentially a reversible condition that may lead to end‐stage liver disease. Since herbal medicines such as Crataegus pinnatifida and Salvia miltiorrhiza have increasingly been used in the management of fatty liver disease, a systematic review on herbal medicine for fatty liver disease is needed. Objectives To assess the beneficial and harmful effects of herbal medicines for people with alcoholic or non‐alcoholic fatty liver disease. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2012), MEDLINE, EMBASE, and Science Citation Index Expanded to 1 March 2012. We also searched the Chinese BioMedical Database, Traditional Chinese Medical Literature Analysis and Retrieval System, China National Knowledge Infrastructure, Chinese VIP Information, Chinese Academic Conference Papers Database and Chinese Dissertation Database, and the Allied and Complementary Medicine Database to 2 March 2012. Selection criteria We included randomised clinical trials comparing herbal medicines with placebo, no treatment, a pharmacological intervention, or a non‐pharmacological intervention such as diet or lifestyle, or Western interventions in participants with fatty liver disease. Data collection and analysis Two review authors extracted data independently. We used the 'risk of bias' tool to assess the risk of bias of the included trials. We assessed the following domains: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. We presented the effects estimates as risk ratios (RR) with 95% confidence intervals (CI) or as mean differences (MD) with 95% CI, depending on the variables of the outcome measures. Main results We included 77 randomised clinical trials, which included 6753 participants with fatty liver disease. The risks of bias (overestimation of benefits and underestimation of harms) was high in all trials. The mean sample size was 88 participants (ranging from 40 to 200 participants) per trial. Seventy‐five different herbal medicine products were tested. Herbal medicines tested in the randomised trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca) , proprietary herbal medicines commercially available, and combination formulas prescribed by practitioners. The most commonly used herbs were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia, Astragalus membranaceous, and Rheum palmatum . None of the trials reported death, hepatic‐related morbidity, quality of life, or costs. A large number of trials reported positive effects on putative surrogate outcomes such as serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases, ultrasound, and computed tomography scan. Twenty‐seven trials reported adverse effects and found no significant difference between herbal medicines versus control. However, the risk of bias of the included trials was high. The outcomes were ultrasound findings in 22 trials, liver computed tomography findings in eight trials, aspartate aminotransferase levels in 64 trials, alanine aminotransferase activity in 77 trials, and glutamyltransferase activities in 44 trials. Six herbal medicines showed statistically significant beneficial effects on ultrasound, four on liver computed tomography, 42 on aspartate aminotransferase activity, 49 on alanine aminotransferase activity, three on alkaline phosphatases activity, and 32 on glutamyltransferase activity compared with control interventions. Authors' conclusions Some herbal medicines seemed to have positive effects on aspartate aminotransferase, alanine aminotransferase, ultrasound, and computed tomography. We found no significant difference on adverse effects between herbal medicine and control groups. The findings are not conclusive due to the high risk of bias of the included trials and the limited number of trials testing individual herbal medicines. Accordingly, there is also high risk of random errors. Plain language summary Herbal medicines for fatty liver diseases Fatty liver disease is a potentially reversible illness where fat builds up within the cells of the liver. It may lead to the liver no longer being able to function properly; this is called end‐stage liver disease. This systematic review evaluated the effects and safety of herbal medicines (single herbs, branded herbal medicines, and prescribed formulas) for treating fatty liver disease. We included 77 randomised clinical trials in this review, which tested 75 herbal medicines. All trials had high risk of systematic errors (ie, bias or risk of overestimation of benefits and overestimation of harms) as well as high risks of random errors (ie, play of chance) due to the small number of people in the trials. Herbal medicines tested in the randomised clinical trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca ), commercially available branded herbal medicines, and combination formulas prescribed by practitioners. Herbs most commonly included as an ingredient in different products were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia , Astragalus membranaceous , and Rheum palmatum . We could not combine the results of the trials due to the range of different herbs used. We could not reach any conclusions about the use of herbal medicines for people with fatty liver disease as none of the trials reported results on death, liver‐related illnesses, quality of life, or costs. A number of trials showed positive effects of herbal medicines compared with control interventions on enzyme activity (enzymes are proteins that cause chemical reactions in the body; eg, serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases), ultrasound scan findings, and computed tomography scan findings. No serious adverse effects were reported for herbal medicines. However, the methodology of the trials had high risk of systematic errors (bias). Furthermore, the individual herbs were seldomly retested, and all trials had relatively low numbers of people, which increases the risk of random errors (play of chance). Therefore, the findings are inconclusive, and rigorously conducted randomised clinical trials are required to establish the benefits and harms of herbal medicines for fatty liver disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Liu, ZL; Xie, LZ; Zhu, J; Li, GQ; Grant, SJ; Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009059.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "eb8227df-e8bb-4162-9cbe-40d2e37f6ac5", "pmid": "", "title": "Eliciting adverse effects data from participants in clinical trials", "imported": false, "abstract": "Abstract - Background Analysis of drug safety in clinical trials involves assessing adverse events (AEs) individually or by aggregate statistical synthesis to provide evidence of likely adverse drug reactions (ADR). While some AEs may be ascertained from physical examinations or tests, there is great reliance on reports from participants to detect subjective symptoms, where he/she is often the only source of information. There is no consensus on how these reports should be elicited, although it is known that questioning methods influence the extent and nature of data detected. This leaves room for measurement error and undermines comparisons between studies and pooled analyses. This review investigated comparisons of methods used in trials to elicit participant‐reported AEs. This should contribute to knowledge about the methodological challenges and possible solutions for achieving better, or more consistent, AE ascertainment in trials. Objectives To systematically review the research that has compared methods used within clinical drug trials (or methods that would be specific for such trials) to elicit information about AEs defined in the protocol or in the planning for the trial. Search methods Databases (searched to March 2015 unless indicated otherwise) included: Embase; MEDLINE; MEDLINE in Process and Other Non‐Indexed Citations; Cochrane Methodology Register (July 2012); Cochrane Central Register of Controlled Trials (February 2015); Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects (January 2015); Health Technology Assessment database (January 2015); CINAHL; CAB Abstracts; BIOSIS (July 2013); Science Citation Index; Social Science Citation Index; Conference Proceedings Citation Index – Science. The search used thesaurus headings and synonyms for the following concepts: (A): Adverse events AND measurement; (B): Participants AND elicitation (also other synonyms for extraction of information about adverse effects from people); (C): Participants AND checklists (also other synonyms as for B). Pragmatic ways were used to limit the results whilst trying to maintain sensitivity. There were no date or sample size restrictions but only reports published in English were included fully, because of resource constraints as regards translation. Selection criteria Two types of studies were included: drug trials comparing two or more methods within‐ or between‐participants to elicit participant‐reported AEs, and research studies performed outside the context of a trial to compare methods which could be used in trials (evidenced by reference to such applicability). Primary outcome data included AEs elicited from participants taking part in any such clinical trial. We included any participant‐reported data relevant for an assessment of drug‐related harm, using the original authors' terminology (and definition, where available), with comment on whether the data were likely to be treatment‐emergent AEs or not. Data collection and analysis Titles and abstracts were independently reviewed for eligibility. Full texts of potentially eligible citations were independently reviewed for final eligibility. Relevant data were extracted and subjected to a 100% check. Disagreements were resolved by discussion, involving a third author. The risk of bias was independently assessed by two authors. The Cochrane 'Risk of bias' tool was used for reports comparing outcomes between participants, while for within‐participant comparisons, each study was critically evaluated in terms of potential impact of the design and conduct on findings using the framework of selection, performance, detection, attrition, reporting, and other biases. An attempt was made to contact authors to retrieve protocols or specific relevant missing information. Reports were not excluded on the basis of quality unless data for outcomes were impossible to compare (e.g. where denominators differed). A narrative synthesis was conducted because differences in study design and presentation meant that a quantitative meta‐analysis was not possible. Main results The 33 eligible studies largely compared open questions with checklist‐type questions or rating scales. Two included participant interviews. Despite different designs, populations and details of questioning methods, the narrative review showed that more specific questioning of participants led to more AEs detected compared to a more general enquiry. A subset of six studies suggested that more severe, bothersome, or otherwise clinically relevant AEs were reported when an initial open enquiry was used, while some less severe, bothersome, or clinically relevant AEs were only reported with a subsequent specific enquiry. However, two studies showed that quite severe or debilitating AEs were only detected by an interview, while other studies did not find a difference in the nature of AEs between elicitation methods. No conclusions could be made regarding the impact of question method on the ability to detect a statistically significant difference between study groups. There was no common statistical rubric, but we were able to represent some effect measures as a risk ratio of the proportion of participants with at least one AE. This showed a lower level of reporting for open questions (O) compared to checklists (CL), with a range for the risk ratios of 0.12 to 0.64. Authors' conclusions This review supports concerns that methods to elicit participant‐reported AEs influence the detection of these data. There was a risk for under‐detection of AEs in studies using a more general elicitation method compared to those using a comprehensive method. These AEs may be important from a clinical perspective or for patients. This under‐detection could compromise ability to pool AE data. However, the impact on the nature of the AE detected by different methods is unclear. The wide variety and low quality of methods to compare elicitation strategies limited this review. Future studies would be improved by using and reporting clear definitions and terminology for AEs (and other important variables), frequency and time period over which they were ascertained, how they were graded, assessed for a relationship to the study drug, coded, and tabulated/reported. While the many potential AE endpoints in a trial may preclude the development of general AE patient‐reported outcome measurement instruments, much could also be learnt from how these employ both quantitative and qualitative methods to better understand data elicited. Any chosen questioning method needs to be feasible for use by both staff and participants. Plain language summary Questioning clinical trial participants about their health in order to collect information on adverse effects of drugs Clinical drug trials or studies are usually conducted to assess how well the drug works but also whether it causes any harm (side effects or adverse effects). Adverse effects can be detected by the trial doctor examining participants or taking some blood samples or doing other kinds of tests. The trial staff can also ask participants about how they are feeling after taking the trial drug. However, the way participants are asked about their health can vary from trial to trial, or even within a trial. In some trials, participants may be asked a simple open question such as 'how have you been feeling?', while in other trials, participants may be asked about whether they have had any of a long list of possible symptoms (such as 'have you had a headache, stomach ache, or sore muscles?'). There has been concern that these different kinds of questions and how they are phrased will impact on what participants report about their health during a trial. This might then affect the trial's results and what we know about the side effects of drugs. We did this review to look at studies that compared different types of participant questioning methods in order to investigate these issues. We found 33 studies comparing mainly open questions with checklist‐type questions, but also some ratings scales and participant interviews. While the studies were all very different in terms of the types of disease, drugs, and patients studied, we found in general that, as would be expected, when a more specific type of question was asked (like a checklist), participants reported more symptoms. What is interesting is that, in those studies that looked more closely at the types of symptoms reported, it seems that an open question picks up the more severe or bothersome symptoms compared to a checklist‐type question. However, some studies found that even quite severe or bothersome symptoms were not reported when a participant is asked an open question and these severe symptoms will only be reported with the more specific question. This makes it difficult to say whether one method is better than any other and the different questioning methods may, in fact, be complementary and therefore should be used together. It is also difficult to say what a specific question should include, as it might take too long for a participant to have to answer a very long list. While more research is needed to resolve the remaining uncertainties, it is very important for trials to be clear about which kind of questioning was used when they publish their results. This will help readers understand the trial's findings about the side effects and make it easier to make accurate comparisons between trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Allen, EN; Chandler, CIR; Mandimika, N; Leisegang, C; Barnes, K", "articleTypes": [], "doi": "10.1002/14651858.MR000039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "eb8f6d39-cdc2-4f58-906a-f9383d702826", "pmid": "", "title": "Effect of alcohol on blood pressure", "imported": false, "abstract": "Abstract - Background Alcohol is consumed by over 2 billion people worldwide. It is a common substance of abuse and its use can lead to more than 200 disorders including hypertension. Alcohol has both acute and chronic effects on blood pressure. This review aimed to quantify the acute effects of different doses of alcohol over time on blood pressure and heart rate in an adult population. Objectives Primary objective To determine short‐term dose‐related effects of alcohol versus placebo on systolic blood pressure and diastolic blood pressure in healthy and hypertensive adults over 18 years of age. Secondary objective To determine short‐term dose‐related effects of alcohol versus placebo on heart rate in healthy and hypertensive adults over 18 years of age. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to March 2019: the Cochrane Hypertension Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2), in the Cochrane Library; MEDLINE (from 1946); Embase (from 1974); the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. We also contacted authors of relevant articles regarding further published and unpublished work. These searches had no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing effects of a single dose of alcohol versus placebo on blood pressure (BP) or heart rate (HR) in adults (≥ 18 years of age). Data collection and analysis Two review authors (ST and CT) independently extracted data and assessed the quality of included studies. We also contacted trial authors for missing or unclear information. Mean difference (MD) from placebo with 95% confidence interval (CI) was the outcome measure, and a fixed‐effect model was used to combine effect sizes across studies. Main results We included 32 RCTs involving 767 participants. Most of the study participants were male (N = 642) and were healthy. The mean age of participants was 33 years, and mean body weight was 78 kilograms. Low‐dose alcohol (< 14 g) within six hours (2 RCTs, N = 28) did not affect BP but did increase HR by 5.1 bpm (95% CI 1.9 to 8.2) (moderate‐certainty evidence). Medium‐dose alcohol (14 to 28 g) within six hours (10 RCTs, N = 149) decreased systolic blood pressure (SBP) by 5.6 mmHg (95% CI ‐8.3 to ‐3.0) and diastolic blood pressure (DBP) by 4.0 mmHg (95% CI ‐6.0 to ‐2.0) and increased HR by 4.6 bpm (95% CI 3.1 to 6.1) (moderate‐certainty evidence for all). Medium‐dose alcohol within 7 to 12 hours (4 RCTs, N = 54) did not affect BP or HR. Medium‐dose alcohol > 13 hours after consumption (4 RCTs, N = 66) did not affect BP or HR. High‐dose alcohol (> 30 g) within six hours (16 RCTs, N = 418) decreased SBP by 3.5 mmHg (95% CI ‐6.0 to ‐1.0), decreased DBP by 1.9 mmHg (95% CI‐3.9 to 0.04), and increased HR by 5.8 bpm (95% CI 4.0 to 7.5). The certainty of evidence was moderate for SBP and HR, and was low for DBP. High‐dose alcohol within 7 to 12 hours of consumption (3 RCTs, N = 54) decreased SBP by 3.7 mmHg (95% CI ‐7.0 to ‐0.5) and DBP by 1.7 mmHg (95% CI –4.6 to 1.8) and increased HR by 6.2 bpm (95% CI 3.0 to 9.3). The certainty of evidence was moderate for SBP and HR, and low for DBP. High‐dose alcohol ≥ 13 hours after consumption (4 RCTs, N = 154) increased SBP by 3.7 mmHg (95% CI 2.3 to 5.1), DBP by 2.4 mmHg (95% CI 0.2 to 4.5), and HR by 2.7 bpm (95% CI 0.8 to 4.6) (moderate‐certainty evidence for all). Authors' conclusions High‐dose alcohol has a biphasic effect on BP; it decreases BP up to 12 hours after consumption and increases BP > 13 hours after consumption. High‐dose alcohol increases HR at all times up to 24 hours. Findings of this review are relevant mainly to healthy males, as only small numbers of women were included in the included trials. Plain language summary Alcohol has a biphasic effect on blood pressure and increases heart rate Review question We reviewed available evidence about the short‐term effects of different doses of alcoholic drinks compared to non‐alcoholic drinks on blood pressure and heart rate in adults (≥ 18 years) with both normal and raised blood pressure. Background Drinking excessive alcohol is considered one of the most common causes of raised blood pressure. We wanted to quantify the effects of a single dose of alcohol on blood pressure and heart rate within 24 hours of consumption. Study characteristics We included 32 randomised controlled trials involving 767 participants published up to March 2019. Although these trials included adults from 18 to 96 years of age with various health conditions, most study participants were young healthy males. The source of funding was not reported for a majority of the studies. Key results For low doses of alcohol, we found that one glass of alcohol had little to no effect on blood pressure and increased heart rate within six hours of drinking. We are moderately certain that medium‐dose alcohol decreased blood pressure and increased heart rate within six hours of consumption. We did not see any significant change in blood pressure or heart rate after that, but the evidence was limited. We are also moderately certain that high‐dose alcohol decreased blood pressure within six hours, and the effect lasted up to 12 hours. After that, blood pressure was found to be increased. Heart rate increased significantly after alcohol consumption and remained increased at all times measured. Thus alcohol decreases blood pressure initially (up to 12 hours after ingestion) and increases blood pressure after that. Alcohol consistently increases heart rate at all times within 24 hours of consumption.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Tasnim, S, Tang, C, Musini, VM, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD012787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.768Z" }, { "id": "eb915b24-630a-4d53-a4ee-07066b39f9d8", "pmid": "", "title": "Probiotics for treatment of chronic constipation in children", "imported": false, "abstract": "Abstract - Background Functional constipation is defined as chronic constipation with no identifiable underlying cause. It is a significant cause of morbidity in children, accounting for up to 25% of visits to paediatric gastroenterologists. Probiotic preparations may sufficiently alter the gut microbiome and promote normal gut physiology in a way that helps relieve functional constipation. Several studies have sought to address this hypothesis, as well as the role of probiotics in other functional gut disorders. Therefore, it is important to have a focused review to assess the evidence to date. Objectives To evaluate the efficacy and safety of probiotics for the management of chronic constipation without a physical explanation in children. Search methods On 28 June 2021, we searched CENTRAL, MEDLINE, Embase, CINAHL, AMED, WHO ICTR, and ClinicalTrials.gov, with no language, date, publication status, or document type limitations. Selection criteria We included randomised controlled trials (RCTs) that assessed probiotic preparations (including synbiotics) compared to placebo, no treatment or any other interventional preparation in people aged between 0 and 18 years old with a diagnosis of functional constipation according to consensus criteria (such as Rome IV). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 14 studies (1127 randomised participants): 12 studies assessed probiotics in the treatment of functional constipation, whilst two studies investigated synbiotic preparations. Three studies compared probiotics to placebo in relation to the frequency of defecation at study end, but we did not pool them as there was very significant unexplained heterogeneity. Four studies compared probiotics to placebo in relation to treatment success. There may be no difference in global improvement/treatment success (RR 1.29, 95% CI 0.73 to 2.26; 313 participants; low‐certainty evidence). Five studies compared probiotics to placebo in relation to withdrawals due to adverse events, with the pooled effect suggesting there may be no difference (RR 0.64, 95% CI 0.21 to 1.95; 357 participants; low‐certainty evidence). The pooled estimate from three studies that compared probiotics plus an osmotic laxative to osmotic laxative alone found there may be no difference in frequency of defecation (MD ‐0.01, 95% CI ‐0.57 to 0.56; 268 participants; low‐certainty evidence). Two studies compared probiotics plus an osmotic laxative to osmotic laxative alone in relation to global improvement/treatment success, and found there may be no difference between the treatments (RR 0.95, 95% CI 0.79 to 1.15; 139 participants; low‐certainty evidence). Three studies compared probiotics plus osmotic laxative to osmotic laxative alone in relation to withdrawals due to adverse events, but it is unclear if there is a difference between them (RR 2.86, 95% CI 0.12 to 68.35; 268 participants; very low‐certainty evidence). Two studies compared probiotics versus magnesium oxide. It is unclear if there is a difference in frequency of defecation (MD 0.28, 95% CI ‐0.58 to 1.14; 36 participants), treatment success (RR 1.08, 95% CI 0.74 to 1.57; 36 participants) or withdrawals due to adverse events (RR 0.50, 95% CI 0.05 to 5.04; 77 participants). The certainty of the evidence is very low for these outcomes. One study assessed the role of a synbiotic preparation in comparison to placebo. There may be higher treatment success in favour of synbiotics compared to placebo (RR 2.32, 95% CI 1.54 to 3.47; 155 participants; low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study assessed a synbiotic plus paraffin compared to paraffin alone. It is uncertain if there is a difference in frequency of defecation (MD 0.74, 95% CI ‐0.96, 2.44; 66 participants; very low‐certainty evidence), or treatment success (RR 0.91, 95% CI 0.71 to 1.17; 66 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study compared a synbiotic preparation to paraffin. It is uncertain if there is a difference in frequency of defecation (MD ‐1.53, 95% CI ‐3.00, ‐0.06; 60 participants; very low‐certainty evidence) or in treatment success (RR 0.86, 95% CI 0.65, 1.13; 60 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. All secondary outcomes were either not reported or reported in a way that did not allow for analysis. Authors' conclusions There is insufficient evidence to conclude whether probiotics are efficacious in successfully treating chronic constipation without a physical explanation in children or changing the frequency of defecation, or whether there is a difference in withdrawals due to adverse events when compared with placebo. There is limited evidence from one study to suggest a synbiotic preparation may be more likely than placebo to lead to treatment success, with no difference in withdrawals due to adverse events. There is insufficient evidence to draw efficacy or safety conclusions about the use of probiotics in combination with or in comparison to any of the other interventions reported. The majority of the studies that presented data on serious adverse events reported that no events occurred. Two studies did not report this outcome. Future studies are needed to confirm efficacy, but the research community requires guidance on the best context for probiotics in such studies, considering where they should be best considered in a potential treatment hierarchy and should align with core outcome sets to support future interpretation of findings. Plain language summary Probiotics for treatment of chronic constipation in children What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can be used to treat chronic constipation without a physical explanation in children (aged 0 to 18 years). We analysed data from 14 studies to answer this question. Key messages We were unable to draw conclusions when comparing probiotics to placebo for frequency of defecation in children treated for chronic constipation without a physical explanation. There may be no difference in treatment success between the two groups. There may not be a difference in frequency of defecation or treatment success when comparing probiotics and laxatives to using laxatives alone. We were unable to draw conclusions when comparing probiotics to magnesium oxide for frequency of defecation or treatment success. There may be a higher frequency of defecation in children treated with synbiotic preparations compared to placebo. There may not be a difference in participants withdrawing from the studies due to adverse events when comparing probiotic preparations to placebo. We were unable to draw conclusions on the safety of any of the other comparisons due to the low number of people who withdrew from the studies. What was studied in the review? Children often suffer from constipation for long periods of time, and when there is no underlying physical cause that can be found we call it 'functional constipation'. It has been suggested that probiotic and synbiotic preparations might help improve symptoms in these children. Probiotics are preparations that contain living bacteria that have been proposed to be beneficial to the digestive system. Synbiotics also include food substances that support the growth of these bacteria. There is currently no consensus about whether this is the case, or how these preparations are best used. What are the main results of the review? We searched for randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) comparing any probiotic or synbiotic treatment with any other treatment (such as dummy/placebo treatments) in children with chronic constipation without a physical explanation. We found 14 trials including a total of 1127 participants who were aged under 18. We made the following conclusions.
• There may be no difference in treatment success when comparing probiotics to placebo.
• We were unable to draw conclusions on whether there is a difference in the frequency of defecation.
• There may be no difference in treatment success when comparing probiotics and laxatives to laxatives alone.
• We were unable to draw conclusions on frequency of defecation or treatment success when comparing probiotics to magnesium oxide.
• Synbiotics may be better than placebo in improving the frequency of defection.
• There may be no difference in how many people withdrew from the trials because of side effects when comparing probiotics to placebo, or probiotics and laxative to laxative alone.
• We have limited confidence in the evidence because the studies only included a small number of children, and due to lack of detail on some of the methods used. All analyses were limited due to differences in the specific probiotics or the treatments they were compared with, low numbers of children included in the studies and, most importantly, the use of a range of different measures of success. This meant that combining studies was difficult, so the overall ability of this review to answer its core questions was limited. What next? Future studies are needed to find out how helpful probiotics are for childhood constipation. Researchers need to agree whether probiotics should be a first option therapy, an add‐on to other therapies, a second option after other therapies have failed, or a combination of all the above. Future research should measure the same items (known as a core outcome set) to ensure these results can support future reviews. How up‐to‐date is this review? This review is current to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wallace, C; Sinopoulou, V; Gordon, M; Akobeng, AK; Llanos-Chea, A; Hungria, G; Febo-Rodriguez, L; Fifi, A; Fernandez Valdes, L; Langshaw, A; Saps, M", "articleTypes": [], "doi": "10.1002/14651858.CD014257.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "eba90f67-449b-40c4-bd21-767dc784575b", "pmid": "", "title": "Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia", "imported": false, "abstract": "Abstract - Background In a review and meta‐analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion‐focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect. Objectives To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic. Search methods We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the `awaiting classification' section of this review. Selection criteria We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion‐focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post‐surgery. Data collection and analysis One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion. Where possible we used random‐effects meta‐analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges' g) to combine data from different outcome measures. If data were not available in a form suitable for meta‐analysis we performed a narrative review. Main results Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty‐one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta‐analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD ‐0.20, 95% confidence interval (CI) ‐0.35 to ‐0.06), length of stay (mean difference ‐0.52 days, 95% CI ‐0.82 to ‐0.22) and negative affect (SMD ‐0.35, 95% CI ‐0.54 to ‐0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached. Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall,we rated the quality of evidence for each outcome as ‘low’ because of the high level of heterogeneity in meta‐analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta‐analysis, so we rated the quality of evidence as `very low'. Authors' conclusions The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well‐conducted and clearly reported research. Plain language summary The effect of psychological preparation on pain, behavioural recovery, negative emotion and length of stay after surgery Background The way people think and feel before surgery can affect how they feel and what they do after surgery. For example, research shows that people who feel more anxious before their surgery experience more pain after it. A review conducted in 1993 looked at the impact of psychological preparation on outcomes after surgery. The term `psychological preparation' includes a range of techniques that aim to change what people think, how they feel or what they do. This 1993 review found that psychological preparation techniques reduced pain after surgery, improved behavioural recovery (how quickly people return to activities), decreased length of stay in hospital and reduced negative emotion (e.g. feelings of anxiety or depression). We aimed to carry out an up‐to‐date review using Cochrane methodology to learn whether there are helpful (or harmful) effects of psychological preparation for people undergoing surgery, and which outcomes (pain after surgery, behavioural recovery, negative emotion or length of stay) are improved. Study characteristics We included studies of adults who received planned surgery with general anaesthesia. We looked at seven psychological preparation techniques: procedural information (information about what, when and how processes will happen); sensory information (what the experience will feel like and what other sensations they may have, e.g. taste, smell); behavioural instruction (telling patients what they need to do); cognitive intervention (techniques that aim to change how people think); relaxation techniques; hypnosis; and emotion‐focused interventions (techniques that aim to help people to manage their feelings). The psychological preparation had to be delivered before surgery for the study to be included in the review. We included studies that looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion after surgery (within one month). Studies were included in the review up to the search date of 4 May 2014. We updated the search on 7 July 2015 and will incorporate the 38 studies found in this later search when the review is updated. We included 105 studies from 115 papers, with 10,302 participants taking part. Sixty‐one studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative emotion. In accordance with the review protocol, we did not record details about funding sources. Key results In this review we included 105 studies, which were reported in 115 papers. A total of 10,302 participants were randomized in these studies. For pain, length of stay and negative emotion we combined numerical findings from the studies. We found that psychological preparation before surgery seemed to reduce pain and negative emotion after the operation and may reduce the time spent in hospital by around half a day but the quality of the evidence was low. Also, the studies used many different psychological preparation techniques (often in different combinations) so it was not possible to discover which techniques were better. We could not statistically combine numerical findings for behavioural recovery because few studies provided sufficient details and studies used different ways of measuring how quickly people returned to usual activities. In reviewing the studies, we found that psychological preparation, in particular behavioural instruction, may have the potential to improve behavioural recovery. However, the quality of this evidence was very low. We looked at the effect of psychological preparation on pain, behavioural recovery, length of stay and negative emotion in this review and did not find evidence to suggest that psychological preparation might lead to harm in these outcomes. However, as we did not look at other outcomes it is possible that we did not identify potential harm. Quality of the evidence Many studies were poorly reported, so we could not be confident that findings were reliable. For this reason and because of the large variation in psychological techniques, types of surgery and measures used, we graded the quality of the evidence as `low' for the outcomes pain, negative emotion and length of stay; we cannot be confident that these techniques help patients to recover from surgery. For behavioural recovery, we further downgraded the quality of the evidence to `very low' because of problems with measurement and reporting of the outcome.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Powell, R, Scott, NW, Manyande, A, Bruce, J, Vögele, C, Byrne‐Davis, LMT, Unsworth, M, Osmer, C, Johnston, M", "articleTypes": [], "doi": "10.1002/14651858.CD008646.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.814Z" }, { "id": "ebcf361b-78b4-49d8-ae62-a7b33f960fbb", "pmid": "", "title": "Medical interventions for treating anthracycline‐induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer", "imported": false, "abstract": "Abstract - Background Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline‐induced cardiotoxicity. This review is an update of a previously published Cochrane review. Objectives To compare the effect of medical interventions on anthracycline‐induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions, or no treatment. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 8), MEDLINE/PubMed (1949 to September 2015), and EMBASE/Ovid (1980 to September 2015) for potentially relevant articles. In addition, we searched reference lists of relevant articles, conference proceedings of the International Society for Paediatric Oncology (SIOP), the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), the International Conference on Long‐Term Complications of Treatment of Children & Adolescents for Cancer, and the European Symposium on Late Complications from Childhood Cancer (from 2005 to 2015), and ongoing trial databases (the ISRCTN Register, the National Institutes of Health (NIH) Register, and the trials register of the World Health Organization (WHO); all searched in September 2015). Selection criteria Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline‐induced cardiotoxicity with either placebo, other medical interventions, or no treatment. Data collection and analysis Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments, which another review author checked. We performed analyses according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results In the original version of the review we identified two RCTs; in this update we identified no additional studies. One trial (135 participants) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline‐induced cardiac dysfunction. The other trial (68 participants) compared a two‐week treatment of phosphocreatine with a control treatment (vitamin C, adenosine triphosphate, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline‐induced cardiotoxicity. Both studies had methodological limitations. The RCT on enalapril showed no statistically significant differences in overall survival, mortality due to heart failure, development of clinical heart failure, and quality of life between treatment and control groups. A post‐hoc analysis showed a decrease (that is improvement) in one measure of cardiac function (left ventricular end‐systolic wall stress (LVESWS): ‐8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Participants treated with enalapril had a higher risk of dizziness or hypotension (risk ratio 7.17, 95% confidence interval 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013). The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function, and adverse events between treatment and control groups. Authors' conclusions Only one trial evaluated the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side effects of enalapril in childhood cancer survivors with asymptomatic anthracycline‐induced cardiotoxicity. Only one trial evaluated the effect of phosphocreatine in childhood cancer patients with anthracycline‐induced cardiotoxicity. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatments on echocardiographic function and clinical outcomes. We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors. High‐quality studies should be performed. Plain language summary Treatment for cardiac problems caused by anthracycline chemotherapy for childhood cancer Anthracyclines are anticancer drugs used in the treatment of different types of childhood cancer. An important adverse effect of anthracyclines is damage to the heart, which can lead to asymptomatic (without complaints) or symptomatic (with complaints) cardiac problems during and after cancer treatment. While there are several drugs available to treat other types of cardiac problems in adults, it is not known if these drugs are beneficial in treating cardiac problems caused by anthracyclines in childhood cancer patients and survivors. A physician confronted with a childhood cancer patient or survivor with anthracycline‐induced cardiac problems should be able to make an informed decision on how to treat this patient based on high‐quality evidence about the beneficial and adverse effects of the treatment options. We searched for and summarised studies that evaluated drugs for treating anthracycline‐induced cardiac problems in childhood cancer patients and survivors. We identified two randomised studies evaluating two different drugs in two different types of patients. One of these drugs, an angiotensin‐converting enzyme (ACE) inhibitor (enalapril), had a short‐term beneficial effect on heart function in survivors of childhood cancer with asymptomatic cardiac problems caused by anthracyclines compared with placebo. However, the drug had no significant beneficial effect on other important outcomes and was associated with side effects such as dizziness and fatigue. This study was of reasonable/good quality. The other study was of low quality and found no effect of a short treatment with phosphocreatine in childhood leukaemia patients with symptomatic or asymptomatic cardiac problems compared with a control treatment with vitamin C, adenosine triphosphate, vitamin E, and oral coenzyme Q10. We could make no definitive conclusions about treatment options for anthracycline‐induced cardiac problems in childhood cancer patients and survivors. High‐quality studies are needed to determine if there are drugs that improve heart function in these patients.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cheuk, DKL, Sieswerda, E, van Dalen, EC, Postma, A, Kremer, LCM", "articleTypes": [], "doi": "10.1002/14651858.CD008011.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.109Z" }, { "id": "ebda0b54-9342-4697-a3b3-b1d77aefe238", "pmid": "", "title": "Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years", "imported": false, "abstract": "Abstract - Background Child and adolescent overweight and obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages. Objectives To assess the effects of diet, physical activity and behavioural interventions (behaviour‐changing interventions) for the treatment of overweight or obese children aged 6 to 11 years. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases. Selection criteria We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour‐changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow‐up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. Data collection and analysis Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta‐analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty‐five trials compared a behaviour‐changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour‐changing intervention. Sixty‐four trials were parallel RCTs, and four were cluster RCTs. Sixty‐four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2. Primary analyses demonstrated that behaviour‐changing interventions compared to no treatment/usual care control at longest follow‐up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was ‐0.53 kg/m 2 (95% confidence interval (CI) ‐0.82 to ‐0.24); P < 0.00001; 24 trials; 2785 participants; low‐quality evidence. MD in BMI z score was ‐0.06 units (95% CI ‐0.10 to ‐0.02); P = 0.001; 37 trials; 4019 participants; low‐quality evidence and MD in weight was ‐1.45 kg (95% CI ‐1.88 to ‐1.02); P < 0.00001; 17 trials; 1774 participants; low‐quality evidence. Thirty‐one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health‐related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI ‐12.88 to ‐0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all‐cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta‐analysed. As the meta‐analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post‐intervention follow‐up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post‐intervention was no longer evident at follow‐up at less than six months, which has to be investigated in further trials. Authors' conclusions Multi‐component behaviour‐changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short‐term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour‐changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour‐changing interventions on health‐related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer‐term follow‐up and further research on the most appropriate forms of post‐intervention maintenance in order to ensure intervention benefits are sustained over the longer term. Plain language summary Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years Review question How effective are diet, physical activity and behavioural interventions in reducing the weight of overweight or obese children aged 6 to 11 years? Background Across the world more children are becoming overweight and obese. These children are more likely to suffer from health problems, both while as children and in later life. More information is needed about what works best for treating this problem. Study characteristics We found 70 randomised controlled trials (clinical trials where people are randomly put into one of two or more treatment groups) comparing diet, physical activity, and behavioural (where habits are changed or improved) treatments to a variety of control groups delivered to 8461 overweight or obese children aged 6 to 11 years. We reported on the effects of 64 multicomponent interventions (different combinations of diet and physical activity and behaviour change), four physical activity interventions and two dietary interventions compared with no intervention, 'usual care’ or some other therapy if it was also delivered in the intervention arm. The children in the included studies were followed up between six months and three years. Key results The average age of the children was 10 years. Most studies reported the body mass index (BMI) z score: BMI is a measure of body fat and is calculated by dividing weight (in kilograms) by the square of the body height measured in metres (kg/m²). In children, BMI is often measured in a way that takes into account sex and age, weight, and height changes as children grow older (BMI z score). We summarised the results of 37 trials in 4019 children reporting the BMI z score, which on average was 0.06 units lower in the intervention groups compared with the control groups. We summarised the results of 24 trials in 2785 children reporting BMI, which on average was 0.53 kg/m 2 lower in the intervention groups compared with the control groups. We summarised the results of 17 trials in 1774 children reporting weight, which on average was 1.45 kg lower in the intervention groups compared with the control groups. Other effects of the interventions, such as improvements in health‐related quality of life were less clear. No study investigated death from any cause, morbidity or socioeconomic effects. Serious adverse events were rare: only two of 31 trials with data reported any serious adverse events (4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). This evidence is up to date as of July 2016. Quality of the evidence The overall quality of the evidence was low or very low, mainly because of limited confidence in how studies were performed, and the results were inconsistent between the studies. Also there were just a few studies for some outcomes, with small numbers of included children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Mead, E, Brown, T, Rees, K, Azevedo, LB, Whittaker, V, Jones, D, Olajide, J, Mainardi, GM, Corpeleijn, E, O'Malley, C, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012651", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.803Z" }, { "id": "ec0c545b-cb4e-4fbe-96e4-34316858cd91", "pmid": "", "title": "Omega‐3 fatty acids for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐3 polyunsaturated fatty acids from oily fish (long‐chain omega‐3 (LCn3)), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha‐linolenic acid (ALA)) may benefit cardiovascular health. Guidelines recommend increasing omega‐3‐rich foods, and sometimes supplementation, but recent trials have not confirmed this. Objectives To assess the effects of increased intake of fish‐ and plant‐based omega‐3 fats for all‐cause mortality, cardiovascular events, adiposity and lipids. Search methods We searched CENTRAL, MEDLINE and Embase to February 2019, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to August 2019, with no language restrictions. We handsearched systematic review references and bibliographies and contacted trial authors. Selection criteria We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation or advice to increase LCn3 or ALA intake, or both, versus usual or lower intake. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed validity. We performed separate random‐effects meta‐analysis for ALA and LCn3 interventions, and assessed dose‐response relationships through meta‐regression. Main results We included 86 RCTs (162,796 participants) in this review update and found that 28 were at low summary risk of bias. Trials were of 12 to 88 months' duration and included adults at varying cardiovascular risk, mainly in high‐income countries. Most trials assessed LCn3 supplementation with capsules, but some used LCn3‐ or ALA‐rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5 g a day to more than 5 g a day (19 RCTs gave at least 3 g LCn3 daily). Meta‐analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all‐cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.93 to 1.01; 143,693 participants; 11,297 deaths in 45 RCTs; high‐certainty evidence), cardiovascular mortality (RR 0.92, 95% CI 0.86 to 0.99; 117,837 participants; 5658 deaths in 29 RCTs; moderate‐certainty evidence), cardiovascular events (RR 0.96, 95% CI 0.92 to 1.01; 140,482 participants; 17,619 people experienced events in 43 RCTs; high‐certainty evidence), stroke (RR 1.02, 95% CI 0.94 to 1.12; 138,888 participants; 2850 strokes in 31 RCTs; moderate‐certainty evidence) or arrhythmia (RR 0.99, 95% CI 0.92 to 1.06; 77,990 participants; 4586 people experienced arrhythmia in 30 RCTs; low‐certainty evidence). Increasing LCn3 may slightly reduce coronary heart disease mortality (number needed to treat for an additional beneficial outcome (NNTB) 334 , RR 0.90, 95% CI 0.81 to 1.00; 127,378 participants; 3598 coronary heart disease deaths in 24 RCTs, low‐certainty evidence) and coronary heart disease events ( NNTB 167 , RR 0.91, 95% CI 0.85 to 0.97; 134,116 participants; 8791 people experienced coronary heart disease events in 32 RCTs, low‐certainty evidence). Overall, effects did not differ by trial duration or LCn3 dose in pre‐planned subgrouping or meta‐regression. There is little evidence of effects of eating fish. Increasing ALA intake probably makes little or no difference to all‐cause mortality (RR 1.01, 95% CI 0.84 to 1.20; 19,327 participants; 459 deaths in 5 RCTs, moderate‐certainty evidence), cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25; 18,619 participants; 219 cardiovascular deaths in 4 RCTs; moderate‐certainty evidence), coronary heart disease mortality (RR 0.95, 95% CI 0.72 to 1.26; 18,353 participants; 193 coronary heart disease deaths in 3 RCTs; moderate‐certainty evidence) and coronary heart disease events (RR 1.00, 95% CI 0.82 to 1.22; 19,061 participants; 397 coronary heart disease events in 4 RCTs; low‐certainty evidence). However, increased ALA may slightly reduce risk of cardiovascular disease events ( NNTB 500 , RR 0.95, 95% CI 0.83 to 1.07; but RR 0.91, 95% CI 0.79 to 1.04 in RCTs at low summary risk of bias; 19,327 participants; 884 cardiovascular disease events in 5 RCTs; low‐certainty evidence), and probably slightly reduces risk of arrhythmia ( NNTB 91 , RR 0.73, 95% CI 0.55 to 0.97; 4912 participants; 173 events in 2 RCTs; moderate‐certainty evidence). Effects on stroke are unclear . Increasing LCn3 and ALA had little or no effect on serious adverse events, adiposity, lipids and blood pressure, except increasing LCn3 reduced triglycerides by ˜15% in a dose‐dependent way (high‐certainty evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐3 fats on cardiovascular health to date. Moderate‐ and low‐certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials). Increasing ALA slightly reduces risk of cardiovascular events and arrhythmia. Plain language summary Omega‐3 intake for cardiovascular disease Review question We reviewed randomised trials (where participants have an equal chance of being assigned to either treatment) examining effects of increasing fish‐ and plant‐based omega‐3 fats on heart and circulatory disease (called cardiovascular diseases, which include heart attacks and stroke), fatness and blood fats (lipids, including cholesterol, triglycerides, high‐density lipoprotein (HDL – 'good' cholesterol) and low‐density lipoprotein (LDL – 'bad' cholesterol)). Background The main types of omega‐3 fats are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), both found in fish, and alpha‐linolenic acid (ALA) found in plant foods. Many people believe that taking omega‐3 supplements reduces risk of heart disease, stroke and death. Trial characteristics The evidence is current to February 2019. The review included 86 trials involving 162,796 people. These trials assessed effects of greater omega‐3 intake versus lower omega‐3 intake for at least a year on heart and circulatory disease. Twenty‐eight trials were very trustworthy (well‐designed so as not to give biased results). Participants were adults, some with existing illness and some healthy, living in North America, Europe, Australia and Asia. Most EPA and DHA trials provided capsules, few gave oily fish. Key results Increasing EPA and DHA has little or no effect on deaths and cardiovascular events (high‐certainty evidence) and probably makes little or no difference to cardiovascular death, stroke, or heart irregularities (moderate‐certainty evidence). However, increasing EPA and DHA may slightly reduce risk of coronary death and coronary events (low‐certainty evidence, coronary events are illnesses of arteries supplying the heart). To prevent one person having a coronary event, 167 people would need to increase their EPA and DHA, and 334 people would need to increase their EPA and DHA to prevent one person dying from coronary disease. EPA and DHA reduce triglycerides by about 15% but do not affect fatness or other lipids (high‐certainty evidence). Eating more ALA (for example, by increasing walnuts or enriched margarine) probably makes little or no difference to all‐cause, cardiovascular or coronary deaths or coronary events but probably slightly reduces cardiovascular events and heart irregularities (moderate‐ or low‐certainty evidence). To prevent one person having a coronary event, 500 people would need to increase their ALA, 91 people to prevent one person having arrhythmia. There is little evidence of effects of eating fish. EPA and DHA reduce triglycerides. EPA, DHA and ALA may be slightly protective of some heart and circulatory diseases.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Abdelhamid, AS; Brown, TJ; Brainard, JS; Biswas, P; Thorpe, GC; Moore, HJ; Deane, KHO; Summerbell, CD; Worthington, HV; Song, F; Hooper, L", "articleTypes": [], "doi": "10.1002/14651858.CD003177.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "ec205b9e-555a-4620-9a9d-158e342c6476", "pmid": "", "title": "Oral protein‐based supplements versus placebo or no treatment for people with chronic kidney disease requiring dialysis", "imported": false, "abstract": "Abstract - Background Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein‐based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein‐based nutritional supplements in this population is limited. Objectives The aims of this review were to determine the benefits and harms of using oral protein‐based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein‐based nutritional supplements to no oral protein‐based nutritional supplements or placebo. Data collection and analysis Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random‐effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes. Main results Twenty‐two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow‐up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self‐reported outcomes. Oral protein‐based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I 2 = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein‐based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I 2 = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein‐based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid‐arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein‐based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI ‐0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD ‐0.04 kg/m 2 , 95% CI ‐0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI ‐1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein‐based nutritional supplements affect triceps skinfold thickness, mid‐arm circumference, C‐reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein‐based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies. Authors' conclusions Overall, it is likely that oral protein‐based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid‐arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well‐designed RCTs in this population are required. Plain language summary Oral protein‐based nutritional supplement in people with chronic kidney disease requiring dialysis What is the issue? People with chronic kidney disease requiring dialysis are at risk of developing malnutrition for many reasons and often do not eat enough because their appetite is poor. Oral nutritional supplements are commonly provided to people who do not eat enough to meet their needs. Provision of nutritional supplements to dialysis patients requires careful consideration of potassium, phosphate and fluid limits. What did we do? We aimed to determine if giving oral protein‐based nutritional supplements improved serum albumin levels and other measures of nutrition. What did we find? A total of 1278 people took part in 22 studies that were included in this review to investigate the effects of oral protein‐based nutritional supplements. All participants were adults on maintenance dialysis (79% haemodialysis and 21% peritoneal dialysis). The studies lasted from one to 12 months. The findings suggest that giving oral protein‐based nutritional supplementation probably results in a slightly greater increase in albumin level and may improve prealbumin level and mid‐arm muscle circumference. The increase in albumin level was more evident in participants who were on haemodialysis and in those who were malnourished. It is uncertain whether oral protein‐based nutritional supplementation affects potassium and phosphate levels. Oral protein‐based nutritional supplements may result in little or no difference in the risk of developing abdominal symptoms.There were some differences between the quality of the studies and their designs. Conclusions The authors conclude that oral protein‐based nutritional supplements appear to be effective in improving some nutritional markers in people who need dialysis; however, it remains uncertain whether these results translate to meaningful outcomes for this population. More research is required to determine the cost‐effectiveness of this treatment, and if it can bring benefit to patients such as feeling better and living longer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Mah, JY; Choy, SW; Roberts, MA; Desai, AM; Corken, M; Gwini, SM; McMahon, LP", "articleTypes": [], "doi": "10.1002/14651858.CD012616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "ec3b4389-3118-4e90-a45b-cf0b835c346c", "pmid": "", "title": "Topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antiseptics, a possible treatment for CSOM, inhibit the micro‐organisms that may be responsible for the infection. Antiseptics can be used alone or in addition to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). However, the effects of topical antiseptics for CSOM remain unclear. This is an update of a review last published in 2020, with one new study added. It is one of a suite of seven Cochrane reviews evaluating the effects of non‐surgical interventions for CSOM. Objectives To assess the effects of topical antiseptics for people with CSOM. Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The date of the latest search was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antiseptic agent of any class, applied directly into the ear canal as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antiseptics (a) compared to placebo or no intervention, and (b) compared to another topical antiseptic (e.g. topical antiseptic A versus topical antiseptic B). Within each comparison, we separated studies into (a) those in which both groups of participants had received aural toileting in addition to the topical antiseptics, and those where neither group had received aural toileting, and (b) those in which both groups had received some other concomitant treatment (such as antibiotics) and those with no such concomitant treatment. Data collection and analysis We used standard Cochrane methodological procedures. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results We found one new study (32 participants) in this update, for a total of six included studies with 435 participants (over four studies), plus 222 ears that could not be accounted for in participant numbers (in two studies). Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics (boric acid versus acetic acid, and boric acid versus hydrogen peroxide). The two core comparisons of interest are reported below; other comparisons are described in the Results section of the review. No study measured health‐related quality of life or ear pain. 1. Topical antiseptic versus placebo or no treatment Three studies (297 participants plus 174 ears) compared topical antiseptics with no treatment. Evidence from one study (unclear number of participants, 174 ears) is very uncertain about the effect of a single application of povidone iodine in hydroxypropyl methyl‐cellulose (HPMC) on resolution of ear discharge at one week compared to HPMC alone; however, these results were only provided by ear (rather than by participant) and therefore could not be used quantitatively (very low‐certainty evidence). One study (254 children; cluster‐RCT) found that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge after four weeks compared with dry mopping alone, but the evidence is very uncertain (risk ratio (RR) 1.73, 95% confidence interval (CI) 1.21 to 2.47; 180 participants; very low‐certainty evidence). We made adjustments to the data to account for the intracluster correlation. This study narratively described no clear differences in suspected ototoxicity or hearing outcomes between study arms, but the evidence is very uncertain (very low‐certainty evidence). Evidence from one study (43 children; 58 ears) is very uncertain about the effect of antiseptics on serious complications. The study reported one case of mastoiditis and one of meningitis with focal encephalitis; however, it was unclear whether these were detected pre‐randomisation or during/after treatment. 2. Topical antiseptics versus no treatment/placebo, where both study arms received systemic antibiotics One study (32 participants) compared topical povidone iodine with placebo (saline) in conjunction with oral amoxicillin and dry mopping. Topical povidone iodine with oral amoxicillin and dry mopping may increase resolution of ear discharge at one to two weeks (RR 3.25, 95% CI 1.35 to 7.84; 32 participants; low‐certainty evidence). The study narratively reported no ototoxicity in the topical antiseptic arm; however, this was unclear for the placebo group, so we do not know if povidone iodine increases suspected ototoxicity (low‐certainty evidence). The study did not assess resolution of ear discharge after four weeks, hearing, or serious complications. Authors' conclusions We are very uncertain about the effect of topical antiseptics on improving resolution of ear discharge in people with CSOM given the low and very low certainty of the evidence, which was mostly due to risk of bias and imprecision. However, there is some evidence suggesting that boric acid in alcohol ear drops with dry mopping may help resolution of ear discharge compared with dry mopping alone, and that topical povidone iodine may be more effective than placebo (where both arms used systemic beta‐lactam antibiotics and dry mopping). There is insufficient evidence to draw any conclusions about harmful effects. Limitations of the review include lack of recency in data, and limited information on certain population groups or interventions. Plain language summary What are the benefits and risks of topical antiseptics for treating long‐term middle ear infection (chronic suppurative otitis media)? Key messages • Due to a lack of studies, we are very uncertain of the benefits and risks of topical antiseptics in the treatment of chronic suppurative otitis media (long‐term middle ear infection). • We need more information about possible harmful effects of topical antiseptics, as these were not well reported in the studies. What was studied in the review? Chronic suppurative otitis media (CSOM) is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (eardrum). The main symptoms are ear discharge and hearing loss. Topical antiseptics (antiseptics put directly into the ear as ear drops or as a powder) are sometimes used to treat CSOM. Topical antiseptics kill or stop the growth of the micro‐organisms that may be responsible for the infection. Topical antiseptics can be used on their own or added to other treatments for CSOM, such as antibiotics or ear cleaning (aural toileting). Applying topical antiseptics can cause irritation of the skin within the outer ear, which may result in discomfort, pain, or itching. Some antiseptics (such as alcohol) can be toxic to the inner ear (ototoxicity), which means they may cause irreparable hearing loss (sensorineural), dizziness, or ringing in the ear (tinnitus). What is the aim of this review? The aim of this Cochrane review was to find out the benefits and risks of topical antiseptics compared to placebo (dummy medicine) or no treatment for CSOM. We also wanted to know whether one topical antiseptic was more effective than another. We collected and analysed all relevant studies to answer this question. This is an update of a review last published in 2020, with one new study added. What are the main results of the review? We included a total of six studies in the review. The total number of people in the studies was unclear, as two studies only reported how many ears were treated. However, there were 435 participants plus 222 ears (between 111 and 222 participants) that could not be accounted for in participant numbers. Four studies compared topical antiseptics with no treatment or placebo, and two studies compared two different topical antiseptics. Different types of antiseptics were used, some in the form of ear drops and others as powders. No study measured health‐related quality of life or ear pain. Topical antiseptic versus placebo or no treatment (with a background treatment of ear cleaning) Three studies (297 participants plus 174 ears) compared topical antiseptics with placebo/no treatment. Based on evidence from one study (unclear number of participants, 174 ears), we do not know if a single application of antiseptic (povidone iodine plus hydroxypropyl methyl‐cellulose) resolves ear discharge at one to two weeks compared with no treatment. Another study (180 children) compared topical antiseptics (boric acid in alcohol ear drops) with no topical antiseptics. All children also had their ears cleaned daily using cotton wool sticks (dry mopping). It is unclear if antiseptics (boric acid) led to an increase in resolution of ear discharge at four weeks or at three to four months compared with no antiseptics. The same study (254 participants) also reported no clear difference between groups in hearing or suspected ototoxicity (hearing or balance problems that develop as a result of taking a medicine), but the evidence is very uncertain. A third study (43 children; 58 ears) found no clear evidence that antiseptics have any effect on serious complications, but it is not known if this was assessed before, during, or after treatment. Topical antiseptic (povidone iodine) versus no treatment/placebo, where both study groups received systemic antibiotics One study (32 participants) compared one antiseptic (povidone iodine) with placebo (saline). All participants also received oral antibiotics (amoxicillin) and ear cleaning. This study found that topical povidone iodine, when given in addition to antibiotics and ear cleaning, may increase the number of people with resolution of ear discharge at between one and two weeks, compared with placebo plus antibiotics and ear cleaning. We do not know if povidone iodine increases suspected ototoxicity. In their report, the study authors stated there was no ototoxicity in participants in the topical antiseptic group, but this was unclear for the placebo group. There was no information on resolution of ear discharge after four weeks, hearing, or serious complications. What are the limitations of the evidence? There is limited information on certain population groups or treatments. Also, the evidence in the review comes from studies that were not conducted recently. How up‐to‐date is the review? The evidence is current to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K, Chong, LY, Bhutta, MF, Daw, J, Veselinović, T, Morris, PS, Vijayasekaran, S, Schilder, AGM, Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013055.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.757Z" }, { "id": "ec575133-64a2-4971-9e80-acfa2ad15e36", "pmid": "", "title": "Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background It is unclear whether patients with type 2 diabetes who have poor glycaemic control despite maximal oral hypoglycaemic agents (OHAs) should be commenced on insulin as monotherapy, or insulin combined with oral hypoglycaemic agents (insulin‐OHA combination therapy). Objectives To assess the effects of insulin monotherapy versus insulin‐OHA combinations therapy. Search methods Eligible studies were identified by searching MEDLINE, EMBASE, and The Cochrane Library . Selection criteria Randomised controlled trials (RCTs) with 2 months minimum follow‐up duration comparing insulin monotherapy (all schemes) with insulin‐OHA combination therapy. Data collection and analysis Data extraction and assessment of study quality were undertaken by three reviewers in pairs. Main results Twenty RCTs (mean trial duration 10 months) including 1,811 participants, with mean age 59.8 years and mean known duration of diabetes 9.6 years. Overall, study methodological quality was low. Twenty‐eight comparisons in 20 RCTs were ordered according to clinical considerations. No studies assessed diabetes‐related morbidity, mortality or total mortality. From 13 studies (21 comparisons), sufficient data were extracted to calculate pooled effects on glycaemic control. Insulin‐OHA combination therapy had statistically significant benefits on glycaemic control over insulin monotherapy only when the latter was applied as a once‐daily injection of NPH insulin. Conversely, twice‐daily insulin monotherapy (NPH or mixed insulin) provided superior glycaemic control to insulin‐OHA combination therapy regimens where insulin was administered as a single morning injection. In more conventional comparisons, regimens utilising OHAs with bedtime NPH insulin provided comparable glycaemic control to insulin monotherapy (administered as twice daily, or multiple daily injections). Overall, insulin‐OHA combination therapy was associated with a 43% relative reduction in total daily insulin requirement compared to insulin monotherapy. Of the 14 studies (22 comparisons) reporting hypoglycaemia, 13 demonstrated no significant difference in the frequency of symptomatic or biochemical hypoglycaemia between insulin and combination therapy regimens. No significant differences in quality of life related issues were detected. Combination therapy with bedtime NPH insulin resulted in statistically significantly less weight gain compared to insulin monotherapy, provided metformin was used ± sulphonylurea. In all other comparisons no significant differences with respect to weight gain were detected. Authors' conclusions Bedtime NPH insulin combined with oral hypoglycaemic agents provides comparable glycaemic control to insulin monotherapy and is associated with less weight gain if metformin is used. Plain language summary Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus Simple application of a single daily insulin injection in addition to oral hypoglycaemic agents may facilitate the initiation of insulin therapy in type 2 diabetes mellitus.This review examined 20 trials including 1,811 participants which compared insulin monotherapy with insulin in combination with oral hypoglycaemic agents (OHA) in insulin‐requiring patients with type 2 diabetes. The results suggest that a bedtime NPH insulin‐oral hypoglycaemic agent combination therapy regimen provides comparable glycaemic control to insulin monotherapy. Due to lack of studies it remains unclear whether insulin‐OHA combination regimens with metformin alone are superior to those with metformin plus a sulphonylurea. In most cases no significant differences in hypoglycaemic events were observed between insulin mono‐ and OHA combination therapy. No study assessed diabetes‐related morbidity or mortality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Goudswaard, AN; Furlong, NJ; Valk, GD; Stolk, RP; Rutten, GEHM", "articleTypes": [], "doi": "10.1002/14651858.CD003418.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "ec6c65c3-ec6a-41f5-a970-d9e32fb712d3", "pmid": "", "title": "Serenoa repens for the treatment of lower urinary tract symptoms due to benign prostatic enlargement", "imported": false, "abstract": "Abstract - Background Benign prostatic hyperplasia (BPH) is a non‐malignant enlargement of the prostate, which can lead to obstructive and irritative lower urinary tract symptoms (LUTS). The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS associated with BPH is common. The extract of the berry of the American saw palmetto or dwarf palm plant, Serenoa repens (SR), which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of BPH. Objectives To assess the effects of Serenoa repens in the treatment of men with LUTS consistent with BPH. Search methods We performed a comprehensive search of multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to 16 September 2022, with no restrictions on language or publication status. Selection criteria We included randomized controlled trials of participants with BPH who were treated with Serenoa repens or placebo/no treatment. Data collection and analysis Two review authors independently assessed studies for inclusion at each stage and undertook data extraction and risk of bias assessment and GRADE assessment of the certainty of the evidence. We considered review outcomes measured up to 12 months after randomization as short term, and beyond 12 months as long term. Our main outcomes included urologic symptom scores, quality of life, and adverse events. Main results For this update, we narrowed the review question to only comparisons with placebo. We included 27 studies (of which 9 were new) involving a total of 4656 participants, 19 studies comparing Serenoa repens with placebo, and 8 studies comparing Serenoa repens in combination with other phytotherapeutic agents versus placebo. Most studies included men aged > 50 (mean age range 52 to 68) with moderate urologic symptoms (International Prostate Symptom Score [IPSS] range 8 to 19). Ten studies were funded by the pharmaceutical industry; two studies were funded by government agencies; and the remaining studies did not specify funding sources. Serenoa repens versus placebo or no intervention Results for this comparison are based on predefined sensitivity analyses limited to studies at low risk of bias. Serenoa repens results in little to no difference in urologic symptoms at short‐term follow‐up (3 to 6 months; IPSS score range 0 to 35, higher scores indicate worse symptoms; mean difference (MD) −0.90, 95% confidence interval (CI) −1.74 to −0.07; I 2 = 68%; 9 studies, 1681 participants; high‐certainty evidence). Serenoa repens results in little to no difference in the quality of life at short‐term follow‐up (3 to 6 months; IPSS quality of life domain range 0 to 6, higher scores indicate worse quality of life; MD −0.20, 95% CI −0.40 to −0.00; I 2 = 39%; 5 studies, 1001 participants; high‐certainty evidence). Serenoa repens probably results in little to no difference in adverse events (1 to 17 months; risk ratio (RR) 1.01, 95% CI 0.77 to 1.31; I 2 = 18%; 12 studies, 2399 participants; moderate‐certainty evidence). Based on 164 cases per 1000 men in the placebo group, this corresponds to 2 more (38 fewer to 51 more) per 1000 men in the Serenoa repens group. Serenoa repens results in little to no difference in urologic symptoms at long‐term follow‐up (12 to 17 months, IPSS score, MD 0.07, 95% CI −0.75 to 0.88; I 2 = 34%; 3 studies, 898 participants; high‐certainty evidence). Serenoa repens results in little to no difference in quality of life at long‐term follow‐up (12 to 17 months, IPSS quality of life, MD −0.11, 95% CI −0.41 to 0.19; I 2 = 65%; 3 studies, 882 participants; high‐certainty evidence). There were no data on long‐term adverse events for this comparison. Serenoa repens in combination with other phytotherapy versus placebo or no intervention Different phytotherapeutic agents that include Serenoa repens may result in little to no difference in urologic symptoms compared to placebo at short‐term follow‐up (12 to 24 weeks, IPSS score, MD −2.41, 95% CI −4.54 to −0.29; I 2 = 67%; 4 studies, 460 participants; low‐certainty evidence). We are very uncertain about the effects of these agents on quality of life (very low‐certainty evidence). These agents may result in little to no difference in the occurrence of adverse events; however, the CIs included substantial benefits and harms (12 to 48 weeks, RR 0.91, 95% CI 0.58 to 1.41; I 2 = 0%; 4 studies, 481 participants; low‐certainty evidence). Based on 132 cases per 1000 men in the placebo group, this corresponds to 12 fewer (55 fewer to 54 more) per 1000 men in the combined phytotherapeutic agents with Serenoa repens group. Authors' conclusions Serenoa repens alone provides little to no benefits for men with lower urinary tract symptoms due to benign prostatic enlargement. There is more uncertainty about the role of Serenoa repens in combination with other phytotherapeutic agents. Plain language summary Serenoa repens for benign prostatic hyperplasia Review question Does Serenoa repens alone or in combination with other phytotherapeutic agents improve symptoms in men with benign prostatic enlargement? Background An enlarged prostate may cause bothersome urinary tract symptoms, such as having to urinate often during the day or night, having a weak stream, and the feeling of not completely emptying the bladder. Besides other common drug interventions, using plants and herbs (phytotherapy) is common and has been growing steadily in most Western countries. The extract of the berry of the American saw palmetto, or dwarf palm plant, Serenoa repens , which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of this condition. Study characteristics We found 27 studies with 4656 men comparing Serenoa repens alone or in combination with other herbal products to a placebo (participants are made to believe they received treatment when in fact they did not). Most studies included men over 50 with moderate symptoms. Ten studies were funded by pharmaceutical organizations; two studies received government funding; and the remaining studies did not specify funding sources. Key results Based on the most trustworthy studies, Serenoa repens alone results in little to no difference in urinary tract symptoms or quality of life compared to placebo at three to six months. This treatment is also likely not associated with adverse events. Results were similar at 12 to 17 months. Serenoa repens in combination with other herbal products may result in little to no difference in urinary tract symptoms, but there is more uncertainty about effects on quality of life and adverse events. The findings of this review are current to 16 September 2022. Certainty of the evidence The certainty of the evidence is primarily high or moderate for Serenoa repens alone, but low for Serenoa repens in combination with other agents, meaning our confidence in the results is high, moderate, or low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Franco, JVA; Trivisonno, L; Sgarbossa, NJ; Alvez, GA; Fieiras, C; Escobar Liquitay, CM; Jung, JH", "articleTypes": [], "doi": "10.1002/14651858.CD001423.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "eca69dc2-a164-484e-8c09-5e2fde59909c", "pmid": "", "title": "Nedocromil sodium for preventing exercise‐induced bronchoconstriction", "imported": false, "abstract": "Abstract - Background Exercise‐induced bronchoconstriction (EIB) following strenuous physical exertion afflicts many people. It can be the cause of sub‐optimal performance, symptoms such as cough, dyspnea, wheeze and chest tightness, and can lead people to avoid physical activity. Management of EIB focuses on prevention through pharmacotherapy and alternate strategies. Single use, pre‐exercise, beta‐agonists and non‐steroidal antiinflammatory agents are recommended. Objectives Bronchodilator medications have been commonly used to prevent narrowing of airways after exercise, but anti‐inflammatory drugs such as nedocromil sodium have also been used. The objective of this review was to assess the effects of a single dose of nedocromil sodium to prevent exercise‐induced bronchoconstriction. Search methods We searched the Cochrane Airways Group Specialised Regsiter, the Cochrane Central Register of Controlled Trials, Current Contents, review articles, textbooks and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. Searches have been updated to August 2008. Selection criteria Randomised trials comparing a single dose of nedocromil sodium with placebo to prevent exercise‐induced bronchoconstriction in patients with EIB over six years of age. Data collection and analysis Trial quality assessment and data extraction were conducted independently by two reviewers. Study authors were contacted for confirmation of data. No new studies were identified in an update search conducted in August 2008. Main results The combined results from 20 randomised controlled trials involving 280 participants, show that 4 mg, of nedocromil sodium inhaled 15 to 60 minutes prior to exercise significantly reduce the severity and duration of EIB in both adults and children, when compared to placebo. The maximum percentage fall in FEV1 was improved significantly compared to placebo (weighted mean difference 15.5 %; 95% confidence interval:13.2 to 18.1). For the maximum percentage fall in peak expiratory flow rate (PEFR) the improvement was similar: WMD 15.0%, (95% CI 8.3 to 21.6). Nedocromil shortened the time to recover lung normal function from more than 30 minutes with placebo to less than 10 minutes with the drug. It had a greater effect on those patients with more severe exercise‐induced bronchoconstriction (defined as an exercise‐induced fall in lung function > 30% from baseline). There were no significant adverse effects reported with the short term use of nedocromil. A further search conducted in August 2005 did not yield any further studies. Authors' conclusions Nedocromil sodium used before exercise reduces the severity and duration of exercise‐induced bronchoconstriction. This effect appears to be more pronounced in people with severe exercise‐induced bronchoconstriction. Plain language summary Nedocromil sodium for preventing exercise‐induced bronchoconstriction Exercise‐induced asthma can limit people's endurance, prolong recovery time after exercise, and lead to people avoiding exercise. The episode involves symptoms such as coughing, wheezing, shortness of breath and chest tightness. The review of trials found that nedocromil sodium (Tilade) inhaled 15 to 60 minutes before exercise may reduce the severity and length of this kind of asthma for both adults and children, particularly those who have severe episodes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Spooner, C; Saunders, LD; Rowe, BH", "articleTypes": [], "doi": "10.1002/14651858.CD001183", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "ecb175ff-3e2c-4202-8d4f-e6c42263bd8d", "pmid": "", "title": "Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve due to viral infection by the herpes zoster virus are implicated in the aetiology and clinical manifestation of Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Corticosteroids, with their powerful anti‐inflammatory effect, have a potential role to play in the reduction or minimisation of nerve damage when administered together with antiviral therapy, and therefore may improve the outcome for patients with Ramsay Hunt syndrome. Objectives To determine the effectiveness of corticosteroids as an adjuvant to antiviral therapy in adult patients with Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Search methods We searched the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 4, 2007), MEDLINE (1950 to December 2007) and EMBASE (1974 to December 2007), CINAHL (1982 to December 2007), LILACS, KoreaMed, IndMed, PakMediNet, ZETOC, Cambridge Scientific Abstracts (Conference Proceedings Database), ISI Proceedings (Web of Science), the National Research Register (NRR), the UK Clinical Research Network Portfolio Database (UKCRN), the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Research Findings Register (ReFeR) and the metaRegister of Controlled Trials (mRCT). Selection criteria All randomised controlled trials in which corticosteroids (by any route of administration at any dosage) were given as an adjuvant to antiviral agents in the treatment of Ramsay Hunt syndrome. Data collection and analysis Two reviewers independently assessed eligibility and trial quality of the available studies, whether they were published or unpublished. No trials were found and therefore no data were analysed. Main results This is an empty review as no trials were found that fulfilled the inclusion criteria. Authors' conclusions Since no randomised controlled trials investigating the use of corticosteroids as an adjuvant to antiviral treatment in Ramsay Hunt syndrome were identified, such studies are needed to assess the effects of such therapy. Plain language summary Corticosteroids used in addition to antiviral drugs in patients with Ramsay Hunt syndrome Ramsay Hunt syndrome (also known as herpes zoster oticus) consists of weakness of the face due to infection with the varicella zoster virus. Five cases arise per 100,000 of the population per year in the US. It is more common among those over 60 and rare in children. Other symptoms may include severe ear pain and small blisters on the outer ear or in the mouth. Prompt diagnosis and treatment (ideally within 72 hours of the onset of symptoms) are crucial to secure the best outcomes. In cases where treatment has been started within this time period, facial weakness recovers in up to 75% of patients. Standard treatment is with antiviral therapy (most commonly acyclovir). Corticosteroids are known for their anti‐inflammatory properties and are commonly used together with antivirals to reduce the inflammation in the facial nerve. This is thought to be the cause of the facial weakness. The aim of the review was to see if corticosteroids, used at the same time as antiviral drugs, improved outcomes in patients with Ramsay Hunt syndrome. However the review found no trials matching the inclusion criteria, and no conclusions can be drawn about the effectiveness of using corticosteroids in this way. It is recommended that high‐quality randomised controlled trials be undertaken to address this issue.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Uscategui, T; Doree, C; Chamberlain, IJ; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD006852.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "ecb4b481-2aa3-4fe1-8c87-9a18a1649c99", "pmid": "", "title": "Antibiotics versus placebo for acute bacterial conjunctivitis", "imported": false, "abstract": "Abstract - Background Acute bacterial conjunctivitis is an infection of the conjunctiva and is one of the most common ocular disorders in primary care. Antibiotics are generally prescribed on the basis that they may speed recovery, reduce persistence, and prevent keratitis. However, many cases of acute bacterial conjunctivitis are self‐limited, resolving without antibiotic therapy. This Cochrane Review was first published in The Cochrane Library in 1999, then updated in 2006, 2012, and 2022. Objectives To assess the benefits and side effects of antibiotic therapy in the management of acute bacterial conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2022, Issue 5), MEDLINE (January 1950 to May 2022), Embase (January 1980 to May 2022), the meta Register of Controlled Trials ( m RCT) ( www.controlled-trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ), and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases in May 2022. Selection criteria We included randomized controlled trials (RCTs) in which any form of antibiotic treatment, with or without steroid, had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical and systemic antibiotic treatments. Data collection and analysis Two authors independently reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies and determined the included RCTs, which were further assessed for risk of bias using Cochrane methodology. We performed data extraction in a standardized manner and conducted random‐effects meta‐analyses using RevMan Web. Main results We included 21 eligible RCTs, 10 of which were newly identified in this update. A total of 8805 participants were randomized. All treatments were topical in the form of drops or ointment. The trials were heterogeneous in terms of their eligibility criteria, the nature of the intervention (antibiotic drug class, which included fluoroquinolones [FQs] and non‐FQs; dosage frequency; duration of treatment), the outcomes assessed and the time points of assessment. We judged one trial to be of high risk of bias, four as low risk of bias, and the others as raising some concerns. Based on intention‐to‐treat (ITT) population, antibiotics likely improved clinical cure (resolution of clinical symptoms or signs) by 26% (RR 1.26, 95% CI 1.09 to 1.46; 5 trials, 1474 participants; moderate certainty) as compared with placebo. Subgroup analysis showed no differences by antibiotic class (P = 0.67) or treatment duration (P = 0.60). In the placebo group, 55.5% (408/735) of participants had spontaneous clinical resolution by days 4 to 9 versus 68.2% (504/739) of participants treated with an antibiotic. Based on modified ITT population, in which participants were analyzed after randomization on the basis of positive microbiological culture, antibiotics likely increased microbiological cure (RR 1.53, 95% CI 1.34 to 1.74; 10 trials, 2827 participants) compared with placebo at the end of therapy; there were no subgroup differences by drug class (P = 0.60). No study evaluated the cost‐effectiveness of antibiotic treatment. Patients receiving antibiotics had a lower risk of treatment incompletion than those in the placebo group (RR 0.64, 95% CI 0.52 to 0.78; 13 trials, 5573 participants; moderate certainty) and were 27% less likely to have persistent clinical infection (RR 0.73, 95% CI 0.65 to 0.81; 19 trials, 5280 participants; moderate certainty). There was no evidence of serious systemic side effects reported in either the antibiotic or placebo group (very low certainty). When compared with placebo, FQs (RR 0.70, 95% CI 0.54 to 0.90) but not non‐FQs (RR 4.05, 95% CI 1.36 to 12.00) may result in fewer participants with ocular side effects. However, the estimated effects were of very low certainty. Authors' conclusions The findings of this update suggest that the use of topical antibiotics is associated with a modestly improved chance of resolution in comparison to the use of placebo. Since no evidence of serious side effects was reported, use of antibiotics may therefore be considered to achieve better clinical and microbiologic efficacy than placebo. Increasing the proportion of participants with clinical cure or increasing the speed of recovery or both are important for individual return to work or school, allowing people to regain quality of life. Future studies may examine antiseptic treatments with topical antibiotics for reasons of cost and growing antibiotic resistance. Plain language summary What are the benefits and harms of antibiotics for acute bacterial conjunctivitis? Key messages Topical antibiotics may improve signs and symptoms as well as bacterial clearance in participants with acute bacterial conjunctivitis. However, some antibiotics can cause unwanted effects on the eyes or eyelids; no evidence suggests that antibiotics cause unwanted effects in other parts of the body. What is acute bacterial conjunctivitis? Acute bacterial conjunctivitis is a condition in which the thin layer over the white areas and the inside lining of the eyelids of one or both eyes becomes red and inflamed from a bacterial infection. Acute bacterial conjunctivitis is usually contagious and hence children and working adults are advised to avoid going to school or work when affected. Fortunately, it resolves spontaneously in most cases. How is acute bacterial conjunctivitis treated? People with acute bacterial conjunctivitis are often given treatment at the site of the infection, usually as antibiotic eye drops or ointment, to speed recovery. However, the benefits of antibiotics have been questioned when considering they can cause irritation or allergic reaction in and around the eyes or surrounding skin. What did we want to find out? We examined whether antibiotics alone or in combination with steroid, can improve signs and symptoms of conjunctivitis or help clear the associated bacteria. We also evaluated whether antibiotics would result in undesirable effects on the eyes. What did we do? We performed a systematic review by searching for studies that compared antibiotics in eyedrop, ointment, or tablet form with inactive controls. We summarized these study findings and reported the results together with our level of confidence in them based on how studies were conducted. What did we find? We found that antibiotics likely increase clinical cure and microbiological cure after a course of treatment in comparison with placebo. Antibiotic use also is associated with fewer participants stopping their treatment earlier than they are supposed to. However, for some individuals, non‐fluroquinolone but not fluoroquinolone antibiotics, may result in more unwanted effects on the eyes or eyelids than placebo though we were very uncertain about the relevant evidence. There was no evidence that antibiotics were associated with systemic side effects such as headache or altered sense of smell. What are the limitations of the evidence? The current update focused on adults and children aged one month or older. Therefore, the evidence does not pertain to antibiotic treatment for neonatal conjunctivitis in neonates younger than one month old. We did not find studies that compared effects of the same antibiotics used in short versus long duration. Therefore, the current review was unable to suggest for or against the prescription duration for acute bacterial conjunctivitis. How up‐to‐date is this evidence? The evidence is up‐to‐date as of April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Chen, Y-Y, Liu, A-HS, Nurmatov, U, van Schayck, OCP, Kuo, IC", "articleTypes": [], "doi": "10.1002/14651858.CD001211.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.760Z" }, { "id": "eccabcbd-392a-47aa-b13a-90630b210fc6", "pmid": "", "title": "Interventions for preventing oral mucositis in patients with cancer receiving treatment: cytokines and growth factors", "imported": false, "abstract": "Abstract - Background Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulceration can lead to severe pain and difficulty with eating and drinking, which may necessitate opioid analgesics, hospitalisation and supplemental nutrition. These complications may disrupt cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining of the mouth, thus preventing or reducing oral mucositis and its negative effects. Objectives To assess the effects of cytokines and growth factors for preventing oral mucositis in patients with cancer who are receiving treatment. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (searched 10 May 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4) in the Cochrane Library (searched 10 May 2017); MEDLINE Ovid (1946 to 10 May 2017); Embase Ovid (7 December 2015 to 10 May 2017); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 10 May 2017); and CANCERLIT PubMed (1950 to 10 May 2017). The US National Institutes of Health Ongoing Trials Register ( ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. Selection criteria We included parallel‐design randomised controlled trials (RCTs) assessing the effects of cytokines and growth factors in patients with cancer receiving treatment. Data collection and analysis Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random‐effects meta‐analyses. We reported adverse effects in a narrative format. Main results We included 35 RCTs analysing 3102 participants. Thirteen studies were at low risk of bias, 12 studies were at unclear risk of bias, and 10 studies were at high risk of bias. Our main findings were regarding keratinocyte growth factor (KGF) and are summarised as follows. There might be a reduction in the risk of moderate to severe oral mucositis in adults receiving bone marrow/stem cell transplantation after conditioning therapy for haematological cancers (RR 0.89, 95% CI 0.80 to 0.99; 6 studies; 852 participants; low‐quality evidence). We would need to treat 11 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 6 to 112). There might be a reduction in the risk of severe oral mucositis in this population, but there is also some possibility of an increase in risk (RR 0.85, 95% CI 0.65 to 1.11; 6 studies; 852 participants; low‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to prevent the outcome to 14 to cause the outcome). There is probably a reduction in the risk of moderate to severe oral mucositis in adults receiving radiotherapy to the head and neck with cisplatin or fluorouracil (RR 0.91, 95% CI 0.83 to 1.00; 3 studies; 471 participants; moderate‐quality evidence). We would need to treat 12 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 7 to infinity). It is very likely that there is a reduction in the risk of severe oral mucositis in this population (RR 0.79, 95% CI 0.69 to 0.90; 3 studies; 471 participants; high‐quality evidence). We would need to treat 7 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to 15). It is likely that there is a reduction in the risk of moderate to severe oral mucositis in adults receiving chemotherapy alone for mixed solid and haematological cancers (RR 0.56, 95% CI 0.45 to 0.70; 4 studies; 344 participants; moderate‐quality evidence). We would need to treat 4 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 3 to 6). There might be a reduction in the risk of severe oral mucositis in this population (RR 0.30, 95% CI 0.14 to 0.65; 3 studies; 263 participants; low ‐quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 8 to 19). Due to the low volume of evidence, single‐study comparisons and insufficient sample sizes, we found no compelling evidence of a benefit for any other cytokines or growth factors and there was no evidence on children. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Authors' conclusions We are confident that KGF is beneficial in the prevention of oral mucositis in adults who are receiving: a) radiotherapy to the head and neck with cisplatin or fluorouracil; or b) chemotherapy alone for mixed solid and haematological cancers. We are less confident about a benefit for KGF in adults receiving bone marrow/stem cell transplant after conditioning therapy for haematological cancers because of multiple factors involved in that population, such as whether or not they received total body irradiation (TBI) and whether the transplant was autologous (the patients' own cells) or allogeneic (cells from a donor). KGF appears to be a relatively safe intervention. Due to limited research, we are not confident that there are any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Plain language summary Can cytokines and growth factors help prevent mouth soreness and ulcers (oral mucositis) in patients being treated for cancer? Review question This review has been produced to assess whether or not the use of cytokines and growth factors during cancer treatment, can help prevent mouth soreness and ulcers. Background Sore mouth and ulcers (oral mucositis) is a side effect of treatment for cancer including chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high‐risk patients. Ulcers can lead to severe pain and difficulty with eating and drinking. Sufferers may need strong painkillers, possibly have to go into hospital and even be fed through a tube into their stomach or their veins. These complications may disrupt their cancer therapy, meaning they are not receiving the best treatment, which may reduce survival. Cancer patients have weakened immune systems due to their treatment and are less able to fight infections. An ulcer is an open wound and there is a risk that bacteria can enter the body leading to infection or sepsis (a dangerous inflammatory reaction of the body to infection). Mouth soreness and ulcers can be costly to healthcare systems, yet there are few preventive interventions or treatments proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining the mouth, thus preventing or reducing oral mucositis and its negative effects. Study characteristics Authors from Cochrane Oral Health carried out this review of existing studies and the evidence is current up to 10 May 2017. It includes 35 studies (published between 1993 and 2017) with 3102 participants, all patients being treated for cancer, aged from 1 to 87 years old. Review authors included studies comparing cytokines and growth factors for the prevention of oral mucositis. The studies were carried out all over the world and often featured multiple sites, although most took place in high‐income countries. Main results The main findings were regarding keratinocyte growth factor (KGF). KGF is likely to reduce the risk of oral mucositis in adults who are receiving either radiotherapy to the head and neck with chemotherapy (cisplatin or fluorouracil), or chemotherapy alone for mixed solid and blood cancers. KGF may also reduce the risk of oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, but these results are less clear because of multiple complicating factors. KGF appears to be a relatively safe intervention. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. Due to limited research, review authors are uncertain of any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children. Quality of the evidence For reducing oral mucositis in adults receiving radiotherapy to the head and neck with chemotherapy, review authors rated the evidence for KGF as moderate to high quality. For reducing oral mucositis in adults receiving chemotherapy alone for mixed solid and blood cancers, they rated the evidence for KGF as low to moderate quality. This evidence was downgraded due to there not being enough data and because some results have not yet been published. For reducing oral mucositis in adults receiving bone marrow/stem cell transplant after conditioning therapy for blood cancers, they rated the evidence for KGF as low quality because results were not similar across the studies and some results have not yet been published. Evidence on side effects of KGF was poorly reported and inconsistent.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Riley, P; Glenny, AM; Worthington, HV; Littlewood, A; Fernandez Mauleffinch, LM; Clarkson, JE; McCabe, MG", "articleTypes": [], "doi": "10.1002/14651858.CD011990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "eccfe598-fa5c-4d92-a1c2-3eecdd05f729", "pmid": "", "title": "Antibiotics for acute rhinosinusitis in adults", "imported": false, "abstract": "Abstract - Background Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear. We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging. Objectives To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings. Search methods We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines. Selection criteria Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis‐like signs or symptoms or sinusitis confirmed by imaging. Data collection and analysis Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required. Main results We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I² = 0%; 8 trials; high‐quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I² = 0%; 3 trials; moderate‐quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate‐quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I² = 0%; 3 trials; high‐quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I² = 16%; 10 trials; high‐quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I² = 21%; 12 trials; high‐quality evidence). A disease‐related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group). Authors' conclusions The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high‐quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate‐quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials. Plain language summary Antibiotics for sinus infection of short duration in adults Review question Do antibiotics cure sinus infection faster than no antibiotics in adults? Background A sinus is a cavity situated in the head. Adults with short‐duration sinus infection experience stuffy nose and thick, yellow discharge from the nose. People with sinus infection can feel slime in the back of the throat, facial pain, pain when bending forward, and pain in the upper teeth or when chewing. A short‐duration sinus infection may be suspected following physical examination and questions about symptoms. Blood examination or images of the sinuses can support diagnosis, but are not routinely recommended in most countries. Short‐duration sinus infections are mostly caused by viruses. Nevertheless, physicians tend to prescribe antibiotics, which should only be used to treat bacterial infections. Taking antibiotics unnecessarily results in antibiotic resistance against bacterial infections. We investigated whether antibiotics cure adults with short‐duration sinus infection faster than a dummy drug (placebo) or no treatment. Search date 18 January 2018. Study characteristics We included 15 studies in which adults with short‐duration sinus infection, whether or not confirmed by imaging, randomly received antibiotics, or a dummy drug or no treatment, in ambulatory care settings. The studies included a total of 3057 adults whose average age was 36 years; about 60% were female. Participants were followed until they were cured. Trial duration ranged from 8 to 28 days. Study funding sources Seven studies received financial support from government or academic institutions; six received grants from the pharmaceutical industry; and five did not state sources of support. Key results Without antibiotics, almost half of all participants were cured after one week, and two out of three were cured after 14 days. Five (diagnosis based on symptoms described to a doctor) to 11 (diagnosis confirmed by x‐ray) more people per 100 were cured faster with antibiotics. A computed tomography (CT) scan could better predict who would benefit from antibiotics, but routine use would cause health problems related to radiation exposure. Ten more people per 100 were relieved faster of thick, yellow discharge from the nose with antibiotics compared to a dummy drug or no treatment. Thirteen more people per 100 experienced side effects (mostly concerning stomach or intestines) with antibiotics compared to a dummy drug or no treatment. Compared with people who initially started antibiotics, five more people per 100 in the dummy drug or no treatment group had to start antibiotics because their condition worsened. Serious complications (e.g. brain abscess) were rare. We found that antibiotics are not a first‐choice treatment for adults with short‐duration sinus infection. We found no evidence relating to adults with severe sinusitis or with reduced immunity, or to children. Quality of evidence We found high‐quality evidence when the diagnosis was based on symptoms described to a doctor. We downgraded evidence quality to moderate when diagnosis was confirmed by x‐ray or CT scan because the number of participants was small, which makes the estimates less reliable.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Lemiengre, MB, van Driel, ML, Merenstein, D, Liira, H, Mäkelä, M, De Sutter, AIM", "articleTypes": [], "doi": "10.1002/14651858.CD006089.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.780Z" }, { "id": "ecd2e71c-1c12-440a-8822-d62c062d3ae8", "pmid": "", "title": "Impact of active placebo controls on estimated drug effects in randomised trials: a systematic review of trials with both active placebo and standard placebo", "imported": false, "abstract": "Abstract - Background An estimated 60% of pharmacological randomised trials use placebo control interventions to blind (i.e. mask) participants. However, standard placebos do not control for perceptible non‐therapeutic effects (i.e. side effects) of the experimental drug, which may unblind participants. Trials rarely use active placebo controls, which contain pharmacological compounds designed to mimic the non‐therapeutic experimental drug effects in order to reduce the risk of unblinding. A relevant improvement in the estimated effects of active placebo compared with standard placebo would imply that trials with standard placebo may overestimate experimental drug effects. Objectives We aimed to estimate the difference in drug effects when an experimental drug is compared with an active placebo versus a standard placebo control intervention, and to explore causes for heterogeneity. In the context of a randomised trial, this difference in drug effects can be estimated by directly comparing the effect difference between the active placebo and standard placebo intervention. Search methods We searched PubMed, CENTRAL, Embase, two other databases, and two trial registries up to October 2020. We also searched reference lists and citations and contacted trial authors. Selection criteria We included randomised trials that compared an active placebo versus a standard placebo intervention. We considered trials both with and without a matching experimental drug arm. Data collection and analysis We extracted data, assessed risk of bias, scored active placebos for adequacy and risk of unintended therapeutic effect, and categorised active placebos as unpleasant, neutral, or pleasant. We requested individual participant data from the authors of four cross‐over trials published after 1990 and one unpublished trial registered after 1990. Our primary inverse‐variance, random‐effects meta‐analysis used standardised mean differences (SMDs) of active versus standard placebo for participant‐reported outcomes at earliest post‐treatment assessment. A negative SMD favoured the active placebo. We stratified analyses by trial type (clinical or preclinical) and supplemented with sensitivity and subgroup analyses and meta‐regression. In secondary analyses, we investigated observer‐reported outcomes, harms, attrition, and co‐intervention outcomes. Main results We included 21 trials (1462 participants). We obtained individual participant data from four trials. Our primary analysis of participant‐reported outcomes at earliest post‐treatment assessment resulted in a pooled SMD of −0.08 (95% confidence interval (CI) −0.20 to 0.04; I 2 = 31%; 14 trials), with no clear difference between clinical and preclinical trials. Individual participant data contributed 43% of the weight of this analysis. Two of seven sensitivity analyses found more pronounced and statistically significant differences; for example, in the five trials with low overall risk of bias, the pooled SMD was −0.24 (95% CI −0.34 to −0.13). The pooled SMD of observer‐reported outcomes was similar to the primary analysis. The pooled odds ratio (OR) for harms was 3.08 (95% CI 1.56 to 6.07), and for attrition, 1.22 (95% CI 0.74 to 2.03). Co‐intervention data were limited. Meta‐regression found no statistically significant association with adequacy of the active placebo or risk of unintended therapeutic effect. Authors' conclusions We did not find a statistically significant difference between active and standard placebo control interventions in our primary analysis, but the result was imprecise and the CI compatible with a difference ranging from important to irrelevant. Furthermore, the result was not robust, because two sensitivity analyses produced a more pronounced and statistically significant difference. We suggest that trialists and users of information from trials carefully consider the type of placebo control intervention in trials with high risk of unblinding, such as those with pronounced non‐therapeutic effects and participant‐reported outcomes. Plain language summary Do treatment effects in randomised trials differ when using active placebo compared to standard placebo? Key messages 1. We found no clear difference in effect between active and standard placebos, but we are very uncertain about the results. 2. We suggest that researchers carefully consider the type of placebo when investigating medicines with clear side effects. What are standard placebos and active placebos? Blinding (or masking) is an important part of randomised trials and ensures that participants and healthcare providers are not influenced by knowing whether the participant is receiving the experimental treatment. If they had this knowledge, they might unintentionally overestimate (or underestimate) the effect of the treatment. One method of blinding is to give the non‐treated group of participants a placebo, which looks like the medicine (e.g. a tablet of similar shape, colour, smell, taste, and texture) but does not contain its active ingredients. Blinding with a placebo may not always be successful. The treatment may have side effects that distinguish it from the placebo so that the treatment effect is still not measured accurately. For this reason, some trials use active placebos, which mimic some of the side effects of the experimental medicine. However, it is unclear whether the choice of placebo type actually makes a difference to the treatment effects. What did we want to find out? We wanted to find out whether treatment effects in randomised trials differ when using active placebos compared to standard placebos. What did we do? We collected and analysed trials that directly compared the two types of placebo, or that compared both placebos with an experimental medicine. If people receiving active placebo experience better results than those receiving standard placebo, this difference might be due to them believing that they are receiving the experimental medicine. It would also mean that in trials that compare a medicine with standard placebo, the beneficial effect of the medicine is exaggerated. This is important if the measured benefits of the treatment are small or moderate and thus especially sensitive to changes in the methods used for the trial. What did we find? We included 21 trials in this review, covering subjects such as pain and psychiatry. We found no clear difference between the two types of placebo in participant‐reported outcomes (such as pain intensity). However, because the result was uncertain, the possible range of this result included both no difference and a potentially important difference in favour of active placebo. When we limited our analysis to higher‐quality trials, active placebos were more beneficial than standard placebos, but these trials were not typical clinical trials and might not be applicable to clinical scenarios.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Laursen, DRT, Nejstgaard, CH, Bjørkedal, E, Frost, AD, Hansen, MR, Paludan-Müller, AS, Prosenz, J, Werner, CP, Hróbjartsson, A", "articleTypes": [], "doi": "10.1002/14651858.MR000055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.079Z" }, { "id": "ecda547e-7872-43da-8f49-45c88cc46c22", "pmid": "", "title": "Efficacy Of Bovine Colostrum In The Treatment Of Severe Alcohol-Associated Hepatitis: A Randomized Controlled Trial", "imported": false, "abstract": "Severe alcohol-associated hepatitis (sAH)is associated with hepatocellular necrosis, inflammation, hyperactivated immune system, paradoxical immune exhaustion, leaky gut, and alteration in the gut microbiome. The leading cause of mortality is a bacterial infection with multi-organ failure.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.249Z" }, { "id": "ece24105-9741-47d4-a964-c2e9e2b87f2c", "pmid": "", "title": "Vitamin B12 supplementation during pregnancy for maternal and child health outcomes", "imported": false, "abstract": "Abstract - Background Vitamin B 12 deficiency is a major public health problem worldwide, with the highest burden in elderly people, pregnant women, and young children. Due to its role in DNA synthesis and methylation, folate metabolism, and erythropoiesis, vitamin B 12 supplementation during pregnancy may confer longer‐term benefits to maternal and child health outcomes. Objectives To evaluate the benefits and harms of oral vitamin B 12 supplementation during pregnancy on maternal and child health outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov , the World Health Organization International Clinical Trials Registry Platform ( ICTRP ) on 2 June 2023, and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs), quasi‐RCTs, or cluster‐RCTs evaluating the effects of oral vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation during pregnancy. Data collection and analysis We used standard Cochrane methods. Four review authors independently assessed trial eligibility. Two review authors independently extracted data from included studies and conducted checks for accuracy. Three review authors independently assessed the risk of bias of the included studies using the Cochrane RoB 1 tool. We used GRADE to evaluate the certainty of evidence for primary outcomes. Main results The review included five trials with 984 pregnant women. All trials were conducted in low‐ and middle‐income countries, including India, Bangladesh, South Africa, and Croatia. At enrolment, 26% to 51% of pregnant women had vitamin B 12 deficiency (less than 150 pmol/L), and the prevalence of anaemia (haemoglobin less than 11.0 g/dL) ranged from 30% to 46%. The dosage of vitamin B 12 supplementation varied from 5 μg/day to 250 μg/day, with administration beginning at 8 to 28 weeks' gestation through to delivery or three months' postpartum, and the duration of supplementation ranged from 8 to 16 weeks to 32 to 38 weeks. Three trials, involving 609 pregnant women, contributed data for meta‐analyses of the effects of vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation. Maternal anaemia: there may be little to no difference for maternal anaemia by intervention group, but the evidence is very uncertain (70.9% versus 65.0%; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.93 to 1.26; 2 trials, 284 women; very low‐certainty evidence). Maternal vitamin B 12 status: vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain (25.9% versus 67.9%; RR 0.38, 95% CI 0.28 to 0.51; 2 trials, 272 women; very low‐certainty evidence). Women who received vitamin B 12 supplements during pregnancy may have higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (mean difference (MD) 60.89 pmol/L, 95% CI 40.86 to 80.92; 3 trials, 412 women). However, there was substantial heterogeneity (I 2 = 85%). Adverse pregnancy outcomes: the evidence is uncertain about the effect on adverse pregnancy outcomes, including preterm birth (RR 0.97, 95% CI 0.55 to 1.74; 2 trials, 340 women; low‐certainty evidence), and low birthweight (RR 1.50, 95% CI 0.93 to 2.43; 2 trials, 344 women; low‐certainty evidence). Two trials reported data on spontaneous abortion (or miscarriage); however, the trials did not report quantitative data for meta‐analysis and there was no clear definition of spontaneous abortion in the study reports. No trials evaluated the effects of vitamin B 12 supplementation during pregnancy on neural tube defects. Infant vitamin B 12 status: children born to women who received vitamin B 12 supplementation had higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (MD 71.89 pmol/L, 95% CI 20.23 to 123.54; 2 trials, 144 children). Child cognitive outcomes : three ancillary analyses of one trial reported child cognitive outcomes; however, data were not reported in a format that could be included in quantitative meta‐analyses. In one study, maternal vitamin B 12 supplementation did not improve neurodevelopment status (e.g. cognitive, language (receptive and expressive), motor (fine and gross), social‐emotional, or adaptive (conceptual, social, practical) domains) in children compared to placebo (9 months, Bayley Scales of Infant and Toddler Development Third Edition (BSID‐III); 1 trial; low‐certainty evidence) or neurophysiological outcomes (72 months, event‐related potential measures; 1 trial; low‐certainty evidence), though children born to women who received vitamin B 12 supplementation had improved expressive language domain compared to placebo (30 months, BSID‐III; 1 trial; low‐certainty evidence). Authors' conclusions Oral vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency and may improve maternal vitamin B 12 concentrations during pregnancy or postpartum compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain. The effects of vitamin B 12 supplementation on other primary outcomes assessed in this review were not reported, or were not reported in a format for inclusion in quantitative analyses. Vitamin B 12 supplementation during pregnancy may improve maternal and infant vitamin B 12 status, but the potential impact on longer‐term clinical and functional maternal and child health outcomes has not yet been established. Plain language summary Vitamin B 12 supplementation for women during pregnancy Key messages – Women who took vitamin B 12 supplements during pregnancy may have improved vitamin B 12 status during pregnancy or postpartum, including less vitamin B 12 deficiency and higher vitamin B 12 levels, compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. – The effects of taking vitamin B 12 supplements during pregnancy on other health outcomes in pregnant women or their children are not known. Public health implications Vitamin B 12 is an important nutrient that helps keep your body's blood and nerve cells healthy. Vitamin B 12 deficiency is an important public health problem, particularly in low‐ and middle‐income countries, with a high burden amongst pregnant women and children. Lower vitamin B 12 levels in pregnancy have been linked to greater risk of some adverse pregnancy outcomes such as miscarriage, poor growth of the baby in the womb, problems with the baby's brain or spinal cord (called neural tube defects), and lower vitamin B 12 status in infants. Vitamin B 12 supplementation during pregnancy may help improve the health and nutrition of women and their babies. However, this has not been examined in well‐conducted reviews, and vitamin B 12 is not part of supplements recommended by the World Health Organization (WHO; a specialised agency of the United Nations responsible for international public health) for women during pregnancy. What did we want to find out? We wanted to find out if taking vitamin B 12 supplements during pregnancy would improve the health and nutrition of women and their babies. What did we do? We searched for clinical trials that looked at vitamin B 12 supplementation during pregnancy. We compared and summarised the results of the trials and rated our confidence in the information, based on factors such as trial methods and sizes. What did we find? We included five trials with 984 pregnant women. Three trials, including 609 pregnant women, had data included in analyses. Women who took vitamin B 12 supplements during pregnancy had less vitamin B 12 deficiency and higher vitamin B 12 levels compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. There were no differences between groups for maternal anaemia. We could not assess the effects of vitamin B 12 supplementation on other outcomes such as miscarriage, neural tube defects, and child cognition (a child's ability to gain knowledge through thought, understanding, and the senses) due to limited or no availability of results for analysis. What are the limitations of the evidence? The small number of trials and small size of trials were limitations in this review. Not all the trials provided data about the outcomes we were interested in. We are very unsure about the results. How up to date is this evidence? The evidence is up to date as of June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Finkelstein, JL, Fothergill, A, Venkatramanan, S, Layden, AJ, Williams, JL, Crider, KS, Qi, YP", "articleTypes": [], "doi": "10.1002/14651858.CD013823.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.771Z" }, { "id": "ed048909-a8b5-469b-9222-01be6cb9e081", "pmid": "", "title": "Treatment for primary postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries. Objectives To assess the effectiveness and safety of any intervention used for the treatment of primary PPH. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013). Selection criteria Randomised controlled trials comparing any interventions for the treatment of primary PPH. Data collection and analysis We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information. Main results Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review. Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41). Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering. Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre‐specified outcomes. One study compared lower segment compression but was too small to assess impact on primary outcomes. We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics. Authors' conclusions Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first‐line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit. The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy. Plain language summary Treatment for excessive bleeding after childbirth After a woman gives birth, womb muscles contract, clamping down on the blood vessels and helping to limit bleeding when the placenta has detached. If the muscles do not contract strongly enough, very heavy bleeding (postpartum haemorrhage) can occur, which can be life threatening. These situations are common in resource‐poor countries, and maternal mortality is about 100 times higher than in resource‐rich countries. It is a very serious problem that requires effective treatments that might avoid the use of surgery to remove the womb (hysterectomy). This is often the last treatment option and leaves the woman unable to have more children. In most settings, women are given a drug at the time of birth (before excessive bleeding occurs) to reduce the likelihood of excessive blood loss. However, despite this intervention, some women bleed excessively, and this review looked to see what interventions might be used to reduce the amount of blood lost by these women. Treatment options include drugs to increase muscles contractions (such as oxytocin, ergometrine and prostaglandins like misoprostol), drugs to help with blood clotting (haemostatic drugs such as tranexamic acid and recombinant activated factor VII), surgical techniques (such as tying off or blocking of the uterine artery) and radiological interventions (to assist in blocking the main artery to the womb by using gel foams). The review identified 10 randomised controlled trials involving 4052 women. Seven of these trials looked at a drug called misoprostol, which is a prostaglandin and so works by increasing muscle contractions. Overall, the trials suggest that misoprostol does not work as well as oxytocin infusion, and it has more side effects. However, oxytocin needs to be kept in a refrigerator, and so in settings where refrigeration and infusions are not readily available, misoprostol can be used. Other clinical trials looked into using other types of drugs or squeezing the main artery that supplies blood to the woman. The number of women included in these studies was too small for any useful conclusions regarding their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Mousa, HA; Blum, J; Abou El Senoun, G; Shakur, H; Alfirevic, Z", "articleTypes": [], "doi": "10.1002/14651858.CD003249.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "ed1db1da-052a-4bd2-bc9a-d8788d37c83d", "pmid": "", "title": "Environmental interventions to reduce the consumption of sugar‐sweetened beverages and their effects on health", "imported": false, "abstract": "Abstract - Background Frequent consumption of excess amounts of sugar‐sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB. Objectives To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar‐sweetened beverages and sugar‐sweetened milk, diet‐related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes. Search methods We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors. Selection criteria We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet‐related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) and interrupted‐time‐series (ITS) studies, implemented in real‐world settings with a combined length of intervention and follow‐up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB‐specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review. Data collection and analysis Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta‐analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented ‘Summary of findings’ tables. Main results We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow‐up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non‐randomised designs. The studies examine a broad range of interventions, and we present results for these separately. Labelling interventions (8 studies): We found moderate‐certainty evidence that traffic‐light labelling is associated with decreasing sales of SSBs, and low‐certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu‐board calorie labelling reported effects on SSB sales varied. Nutrition standards in public institutions (16 studies): We found low‐certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low‐certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied. Economic tools (7 studies): We found moderate‐certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low‐calorie beverages reported effects on SSB sales varied. Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied. Retail and food service interventions (7 studies): We found low‐certainty evidence that healthier default beverages in children’s menus in chain restaurants are associated with decreasing SSB sales, and moderate‐certainty evidence that in‐store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low‐certainty evidence that urban planning restrictions on new fast‐food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied. Intersectoral approaches (8 studies): We found moderate‐certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate‐certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied. Home‐based interventions (7 studies): We found moderate‐certainty evidence that improved availability of low‐calorie beverages in the home environment is associated with decreased SSB intake, and high‐certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs. Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low‐calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes. We analysed interventions targeting sugar‐sweetened milk separately, and found low‐ to moderate‐certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar‐sweetened milk. We found low‐certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar‐sweetened milk consumption. Authors' conclusions The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high‐quality evaluations using appropriate study designs, with a particular focus on the long‐term effects of approaches suitable for large‐scale implementation. Plain language summary Cutting back on sugar‐sweetened beverages: What works? What are sugar‐sweetened beverages? Sugar‐sweetened beverages (SSBs) are cold and hot drinks with added sugar. Common SSBs are non‐diet soft drinks, regular soda, iced tea, sports drinks, energy drinks, fruit punches, sweetened waters, and sweetened tea and coffee. Why are SSBs an important health topic? Research shows that people who drink a lot of SSBs often gain weight. Drinking a lot of SSBs can also increase the risk of diabetes, heart disease, and dental decay. Doctors therefore recommend that children, teenagers and adults drink fewer SSBs. Governments, businesses, schools and workplaces have taken various measures to support healthier beverage choices. What is the aim of this review? We wanted to find out whether the measures taken so far have been successful in helping people to drink fewer SSBs to improve their health. We focused on measures that change the environment in which people make beverage choices. We did not look at studies on educational programmes or on SSB taxes, as these are examined in separate reviews. (We did, however, examine price increases on SSB which were not due to taxes.) We searched for all available studies meeting clearly‐defined criteria to answer this question. This review reflects the state of the evidence up until January 2018. What studies did we find? We found 58 studies, which included more than one million adults, teenagers and children. Most studies lasted about one year, and were done in schools, stores or restaurants. Some studies used methods that are not very reliable. For example, in some studies participants were simply asked how much SSB they drank, which is not very reliable, as people sometimes forget how much SSB they drank. Some of the findings of our review may therefore change when more and better studies become available. What do these studies tell us? We have found some evidence that some of the measures implemented to help people drink fewer SSBs have been successful, including the following: ▪ Labels which are easy to understand, such as traffic‐light labels, and labels which rate the healthfulness of beverages with stars or numbers. ▪ Limits to the availability of SSB in schools (e.g. replacing SSBs with water in school cafeterias). ▪ Price increases on SSBs in restaurants, stores and leisure centres. ▪ Children’s menus in chain restaurants which include healthier beverages as their standard beverage. ▪ Promotion of healthier beverages in supermarkets. ▪ Government food benefits (e.g. food stamps) which cannot be used to buy SSBs. ▪ Community campaigns focused on SSBs. ▪ Measures that improve the availability of low‐calorie beverages at home, e.g. through home deliveries of bottled water and diet beverages. We have also found some evidence that improved availability of drinking water and diet beverages at home can help people lose weight. There are also other measures which may influence how much SSB people drink, but for these the available evidence is less certain. Some, but not all studies found that such measures can have effects which were not intended and which may be negative. Some studies reported that profits of stores and restaurants decreased when the measures were implemented, but other studies showed that profits increased or stayed the same. Children who get free drinking water in schools may drink less milk. Some studies reported that people were unhappy with the measures. We also looked at studies on sugar‐sweetened milk. We found that small prizes for children who chose plain milk in their school cafeteria, as well as emoticon labels, may help children drink less sugar‐sweetened milk. However, this may also drive up the share of milk which is wasted because children choose but do not drink it. What does this mean in practice? Our review shows that measures which change the environment in which people make beverage choices can help people drink less SSB. Based on our findings we suggest that such measures may be used more widely. Government officials, business people and health professionals implementing such measures should work together with researchers to find out more about their effects in the short and long term.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "von Philipsborn, P, Stratil, JM, Burns, J, Busert, LK, Pfadenhauer, LM, Polus, S, Holzapfel, C, Hauner, H, Rehfuess, E", "articleTypes": [], "doi": "10.1002/14651858.CD012292.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.123Z" }, { "id": "ed24813e-cc1b-4b2e-a6a7-82c243fd2725", "pmid": "", "title": "Treatments for intractable constipation in childhood", "imported": false, "abstract": "Abstract - Background Constipation that is prolonged and does not resolve with conventional therapeutic measures is called intractable constipation. The treatment of intractable constipation is challenging, involving pharmacological or non‐pharmacological therapies, as well as surgical approaches. Unresolved constipation can negatively impact quality of life, with additional implications for health systems. Consequently, there is an urgent need to identify treatments that are efficacious and safe. Objectives To evaluate the efficacy and safety of treatments used for intractable constipation in children. Search methods We searched CENTRAL, MEDLINE, Embase, and two trials registers up to 23 June 2023. We also searched reference lists of included studies for relevant studies. Selection criteria We included randomised controlled trials (RCTs) comparing any pharmacological, non‐pharmacological, or surgical treatment to placebo or another active comparator, in participants aged between 0 and 18 years with functional constipation who had not responded to conventional medical therapy. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were symptom resolution, frequency of defecation, treatment success, and adverse events; secondary outcomes were stool consistency, painful defecation, quality of life, faecal incontinence frequency, abdominal pain, hospital admission for disimpaction, and school absence. We used GRADE to assess the certainty of evidence for each primary outcome. Main results This review included 10 RCTs with 1278 children who had intractable constipation. We assessed one study as at low risk of bias across all domains. There were serious concerns about risk of bias in six studies. One study compared the injection of 160 units botulinum toxin A (n = 44) to unspecified oral stool softeners (n = 44). We are very uncertain whether botulinum toxin A injection improves treatment success (risk ratio (RR) 37.00, 95% confidence interval (CI) 5.31 to 257.94; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Frequency of defecation was reported only for the botulinum toxin A injection group (mean interval of 2.6 days). The study reported no data for the other primary outcomes. One study compared erythromycin estolate (n = 6) to placebo (n = 8). The only primary outcome reported was adverse events , which were 0 in both groups. The evidence is of very low certainty due to concerns with risk of bias and serious imprecision. One study compared 12 or 24 μg oral lubiprostone (n = 404) twice a day to placebo (n = 202) over 12 weeks. There may be little to no difference in treatment success (RR 1.29, 95% CI 0.87 to 1.92; low certainty evidence). We also found that lubiprostone probably results in little to no difference in adverse events (RR 1.05, 95% CI 0.91 to 1.21; moderate certainty evidence). The study reported no data for the other primary outcomes. One study compared three‐weekly rectal sodium dioctyl sulfosuccinate and sorbitol enemas (n = 51) to 0.5 g/kg/day polyethylene glycol laxatives (n = 51) over a 52‐week period. We are very uncertain whether rectal sodium dioctyl sulfosuccinate and sorbitol enemas improve treatment success (RR 1.33, 95% CI 0.83 to 2.14; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Results of defecation frequency per week was reported only as modelled means using a linear mixed model. The study reported no data for the other primary outcomes. One study compared biofeedback therapy (n = 12) to no intervention (n = 12). We are very uncertain whether biofeedback therapy improves symptom resolution (RR 2.50, 95% CI 1.08 to 5.79; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). The study reported no data for the other primary outcomes. One study compared 20 minutes of intrarectal electromotive botulinum toxin A using 2800 Hz frequency and botulinum toxin A dose 10 international units/kg (n = 30) to 10 international units/kg botulinum toxin A injection (n = 30). We are very uncertain whether intrarectal electromotive botulinum toxin A improves symptom resolution (RR 0.96, 95% CI 0.76 to 1.22; very low certainty evidence) or if it increases the frequency of defecation (mean difference (MD) 0.00, 95% CI −1.87 to 1.87; very low certainty evidence). We are also very uncertain whether intrarectal electromotive botulinum toxin A has an improved safety profile (RR 0.20, 95% CI 0.01 to 4.00; very low certainty evidence). The evidence for these results is of very low certainty due to serious concerns with risk of bias and imprecision. The study did not report data on treatment success. One study compared the injection of 60 units botulinum toxin A (n = 21) to myectomy of the internal anal sphincter (n = 21). We are very uncertain whether botulinum toxin A injection improves treatment success (RR 1.00, 95% CI 0.75 to 1.34; very low certainty evidence). No adverse events were recorded. The study reported no data for the other primary outcomes. One study compared 0.04 mg/kg oral prucalopride (n = 107) once daily to placebo (n = 108) over eight weeks. Oral prucalopride probably results in little or no difference in defecation frequency (MD 0.50, 95% CI −0.06 to 1.06; moderate certainty evidence); treatment success (RR 0.96, 95% CI 0.53 to 1.72; moderate certainty evidence); and adverse events (RR 1.15, 95% CI 0.94 to 1.39; moderate certainty evidence). The study did not report data on symptom resolution. One study compared transcutaneous electrical stimulation to sham stimulation, and another study compared dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. These studies did not report any of our predefined primary outcomes. Authors' conclusions We identified low to moderate certainty evidence that oral lubiprostone may result in little to no difference in treatment success and adverse events compared to placebo. Based on moderate certainty evidence, there is probably little or no difference between oral prucalopride and placebo in defecation frequency, treatment success, or adverse events. For all other comparisons, the certainty of the evidence for our predefined primary outcomes is very low due to serious concerns with study limitations and imprecision. Consequently, no robust conclusions could be drawn. Plain language summary Management of intractable constipation in children Key messages • There may be little to no difference between lubiprostone and placebo (dummy treatment) in achieving treatment success in children with intractable constipation. We also found that lubiprostone is probably as safe as placebo. • There is probably little or no difference between prucalopride, also a laxative, and placebo in frequency of defecation per day, treatment success, and safety. • It is unclear whether any of the other treatments we looked at are helpful. The evidence is uncertain because of the very low number of study participants and problems with how the research was reported. • Currently, there is not an agreed‐upon definition for intractable constipation. To develop further evidence on therapies for intractable constipation, researchers must use the same definition. We would encourage further work to come up with an agreed‐upon definition. What is intractable constipation? Constipation in children is a common problem. If doctors cannot find an underlying cause for the symptoms, it is called functional constipation. The symptoms of constipation include lower frequency of defecation, bowel incontinence or soiling, and stomach pain. Constipation can be mild and respond well to standard treatments, such as behavioural changes or laxatives. However, it can also be more severe or last for a long time. We defined intractable constipation as constipation that persists despite standard treatments. What did we want to find out? We wanted to find out which treatments are helpful and safe for treating children (between 0 and 18 years of age) with constipation that has not responded to standard medical treatments (intractable constipation). This extreme level of constipation can impact a child's life in very negative ways, such as keeping them away from school and other daily activities; causing them pain, discomfort, and general distress; and requiring hospital visits for treatment. Consequently, there is a need to investigate if the tested therapies can help resolve the problem. What did we do? We considered any medication, surgical procedure, or therapy to help children with intractable constipation. Each study compared a specific treatment to placebo, no treatment, or another treatment. We were interested in whether the treatments increased the frequency of defecation, improved symptoms, or led to treatment success. We also wanted to know if the treatments were safe, so we looked at whether they caused side effects. We searched for randomised controlled trials (studies in which people are randomly assigned to one of two or more treatment groups) comparing any medical, surgical, or complementary therapy versus no treatment, placebo, or another treatment in children with intractable constipation. What did we find? We found 10 studies involving a total of 1278 children. The average age of study participants ranged from around 5 to 10 years. The studies were conducted in Iran, Brazil, Colombia, the USA, Canada, Australia, and several European countries. Studies lasted from one to six months. The studies made the following comparisons: • botox injection versus stool softeners; • erythromycin versus placebo; • lubiprostone versus placebo; • rectal sodium dioctyl sulfosuccinate and sorbitol versus oral polyethylene glycol laxatives; • biofeedback therapy versus no treatment; • intrarectal electromotive botox injection versus a usual botox injection; • botox injection versus myectomy of the internal anal sphincter; • prucalopride versus placebo; • transcutaneous electrical stimulation versus sham stimulation; and • dietitian‐prescribed Mediterranean diet with written instructions versus written instructions. Main results • There may be little to no difference between lubiprostone and placebo in achieving treatment success, and there is probably little to no difference in adverse events for this comparison. • There is probably little or no difference between prucalopride and placebo in defecation frequency, treatment success, and adverse events. • We do not know whether any of the other treatments looked at in this review are safer or more beneficial than others. What are the limitations of the evidence? The evidence is limited due to small participant numbers in the included studies, and because each study looked at a different comparison, both of which resulted in the evidence being imprecise. There were also issues with the way the studies were conducted, which led to concerns that study results might be biased. How up‐to‐date is this evidence? This review is current to June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gordon, M, Grafton-Clarke, C, Rajindrajith, S, Benninga, M, Sinopoulou, V, Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD014580.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.747Z" }, { "id": "ed2e3a1d-901f-4c52-9710-c9685cc517e7", "pmid": "", "title": "Nasal decongestants in monotherapy for the common cold", "imported": false, "abstract": "Abstract - Background Many treatments for the common cold exist and are sold over‐the‐counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited. Objectives To assess the efficacy, and short‐ and long‐term safety, of nasal decongestants used in monotherapy to alleviate symptoms of the common cold in adults and children. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6, June 2016), which contains the Cochrane Acute Respiratory Infections (ARI) Specialised Register, MEDLINE (1946 to July 2016), Embase (2010 to 15 July 2016), CINAHL (1981 to 15 July 2016), LILACS (1982 to July 2016), Web of Science (1955 to July 2016) and clinical trials registers. Selection criteria Randomised controlled trials (RCTs) and cluster‐RCTs investigating the effectiveness and adverse effects of nasal decongestants compared with placebo for treating the common cold in adults and children. We excluded quasi‐RCTs. Data collection and analysis Three review authors independently extracted and summarised data on subjective measures of nasal congestion, overall patient well‐being score, objective measures of nasal airway resistance, adverse effects and general recovery. One review author acted as arbiter in cases of disagreement. We categorised trials as single and multi‐dose and analysed data both separately and together. We also analysed studies using an oral or topical nasal decongestant separately and together. Main results We included 15 trials with 1838 participants. Fourteen studies included adult participants only (aged 18 years and over). In six studies the intervention was a single dose and in nine studies multiple doses were used. Nine studies used pseudoephedrine and three studies used oxymetazoline. Other decongestants included phenylpropanolamine, norephedrine and xylometazoline. Phenylpropanolamine (or norephedrine) is no longer available on the market therefore we did not include the results of these studies in the meta‐analyses. Eleven studies used oral decongestants; four studies used topical decongestants. Participants were included after contracting the common cold. The duration of symptoms differed among studies; in 10 studies participants had symptoms for less than three days, in three studies symptoms were present for less than five days, one study counted the number of colds over one year, and one study experimentally induced the common cold. In the single‐dose studies, the effectiveness of a nasal decongestant was measured on the same day, whereas the follow‐up in multi‐dose studies ranged between one and 10 days. Most studies were conducted in university settings (N = eight), six at a specific university common cold centre. Three studies were conducted at a university in collaboration with a hospital and two in a hospital only setting. In two studies the setting was unclear. There were large differences in the reporting of outcomes and the reporting of methods in most studies was limited. Therefore, we judged most studies to be at low or unclear risk of bias. Pooling was possible for a limited number of studies only; measures of effect are expressed as standardised mean differences (SMDs). A positive SMD represents an improvement in congestion. There is no defined minimal clinically important difference for measures of subjective improvement in nasal congestion, therefore we used the SMDs as a guide to assess whether an effect was small (0.2 to 0.49), moderate (0.5 to 0.79) or large (≥ 0.8). Single‐dose decongestant versus placebo: 10 studies compared a single dose of nasal decongestant with placebo and their effectiveness was tested between 15 minutes and 10 hours after dosing. Seven of 10 studies reported subjective symptom scores for nasal congestion; none reported overall patient well‐being. However, pooling was not possible due to the large diversity in the measurement and reporting of symptoms of congestion. Two studies recorded adverse events. Both studies used an oral decongestant and each of them showed that there was no statistical difference between the number of adverse events in the treatment group versus the placebo group. Multi‐dose decongestant versus placebo: nine studies compared multiple doses of nasal decongestants with placebo, but only five reported on the primary outcome, subjective symptom scores for nasal congestion. Only one study used a topical decongestant; none reported overall patient well‐being. Subjective measures of congestion were significantly better for the treatment group compared with placebo approximately three hours after the last dose (SMD 0.49, 95% confidence interval (CI) 0.07 to 0.92; P = 0.02; GRADE: low‐quality evidence). However, the SMD of 0.49 only indicates a small clinical effect. Pooling was based on two studies, one oral and one topical, therefore we were unable to assess the effects of oral and topical decongestants separately. Seven studies reported adverse events (six oral and one topical decongestant); meta‐analysis showed that there was no statistical difference between the number of adverse events in the treatment group (125 per 1000) compared to the placebo group (126 per 1000). The odds ratio (OR) for adverse events in the treatment group was 0.98 (95% CI 0.68 to 1.40; P = 0.90; GRADE: low‐quality evidence). The results remained the same when we only considered studies using an oral decongestant (OR 0.95, 95% CI 0.65 to 1.39; P = 0.80; GRADE: low‐quality evidence). Authors' conclusions We were unable to draw conclusions on the effectiveness of single‐dose nasal decongestants due to the limited evidence available. For multiple doses of nasal decongestants, the current evidence suggests that these may have a small positive effect on subjective measures of nasal congestion in adults with the common cold. However, the clinical relevance of this small effect is unknown and there is insufficient good‐quality evidence to draw any firm conclusions. Due to the small number of studies that used a topical nasal decongestant, we were also unable to draw conclusions on the effectiveness of oral versus topical decongestants. Nasal decongestants do not seem to increase the risk of adverse events in adults in the short term. The effectiveness and safety of nasal decongestants in children and the clinical relevance of their small effect in adults is yet to be determined. Plain language summary Do nasal decongestants used alone relieve cold symptoms? Review question We wanted to find out if nasal decongestants used alone can ease nasal congestion symptoms in people with colds. Background Colds, although not serious, are common illnesses responsible for many visits to family doctors and days lost from work and school. Cold symptoms include runny nose, sore throat and sneezing, and they can last up to two weeks. There is no cure for colds; treatments only ease the symptoms. Many people use over‐the‐counter medicines such as nasal decongestants to treat cold symptoms. However, there is little evidence that nasal decongestants actually work. We wanted to find out if nasal decongestants help ease congestion caused by colds. We considered studies that used a nasal decongestant as the only treatment for colds. We looked at subjective symptoms of congestion ‐ this means that symptoms and overall well‐being were self‐rated by patients. Search date We searched for studies in July 2016. Study characteristics We included 15 studies with 1838 participants; 14 included only adults aged 18 years or over. Six studies used a single‐dose nasal decongestant and measured the effects on the day it was administered. Nine studies used multiple doses and the effects were measured between one and 10 days after first administration. Eleven studies used tablets or syrup and four studies used nasal sprays. Eight studies were conducted at universities, three at universities in collaboration with hospitals and two in hospitals. The setting was unclear in two studies. Study funding sources Nine studies were funded by drug manufacturers or agencies with commercial interests in the study results. Funding sources were unclear in six studies. Key results We were unable to draw conclusions about single‐dose nasal decongestants. We found a small benefit in the relief of nasal congestion from multiple doses, but it was unclear if this was beneficial for patients. No studies reported overall patient well‐being. There was no difference in the numbers of adverse events between people who used a nasal decongestant and those who did not. We could not determine if there was a difference in effects between decongestant tablets and nasal sprays. The results relate to adults; there was no evidence on the effectiveness or safety of nasal decongestants for children. Quality of the evidence We assessed the quality of the evidence for subjective cold symptoms as low for the multi‐dose studies ‐ there were few data and reporting was unclear. We also assessed the quality of the evidence for adverse events as low because of unclear reporting and because the estimates were not precise (there were wide confidence intervals ‐ a measure of statistical uncertainty).", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Deckx, L, De Sutter, AIM, Guo, L, Mir, NA, van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD009612.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.795Z" }, { "id": "ed38f255-90bd-4aef-afa8-b7b69d5cca23", "pmid": "", "title": "Systemic administration of local anesthetic agents to relieve neuropathic pain", "imported": false, "abstract": "Abstract - Background Lidocaine, mexiletine, tocainide, and flecainide are local anesthetics which give an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain. Interest reappeared decades later when patient series and clinical trials reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients. With the recent publication of clinical trials with high quality standards, we have reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to update our knowledge, to measure their benefit and harm, and to better define their role in therapy. Objectives To evaluate pain relief and adverse effect rates between systemic local anesthetic‐type drugs and other control interventions. Search methods We searched MEDLINE (1966 through 15 May 2004), EMBASE (January 1980 to December 2002), Cancer Lit (through 15 December 2002), Cochrane Central Register of Controlled Trials (2nd Quarter, 2004), System for Information on Grey Literature in Europe (SIGLE), and LILACS, from January 1966 through March 2001. We also hand searched conference proceedings, textbooks, original articles and reviews. Selection criteria We included trials with random allocation, that were double blinded, with a parallel or crossover design. The control intervention was a placebo or an analgesic drug for neuropathic pain from any cause. Data collection and analysis We collected efficacy and safety data from all published and unpublished trials. We calculated combined effect sizes using continuous and binary data for pain relief and adverse effects as primary and secondary outcome measurements, respectively. Main results Thirty‐two controlled clinical trials met the selection criteria; two were duplicate articles. The treatment drugs were intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (one trial), and tocainide (one trial). Twenty‐one trials were crossover studies, and nine were parallel. Lidocaine and mexiletine were superior to placebo [weighted mean difference (WMD) = ‐11; 95% CI: ‐15 to ‐7; P < 0.00001], and limited data showed no difference in efficacy (WMD = ‐0.6; 95% CI: ‐7 to 6), or adverse effects versus carbamazepine, amantadine, gabapentin or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life‐threatening toxicities. Sensitivity analysis identified data distribution in three trials as a probable source of heterogeneity. There was no publication bias. Authors' conclusions Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. Future trials should enroll specific diseases and test novel lidocaine analogs with better toxicity profiles. More emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful. Plain language summary Systemic administration of local anesthetic agents to relieve neuropathic pain Intravenous lidocaine and oral derivatives relieve pain from damage to the nervous system (neuropathic pain). In early reports, intravenous lidocaine and its oral analogs mexiletine and tocainide relieved neuropathic pain, a type of pain caused by disease in the nervous system. However, the evidence was conflicting. The authors reviewed all randomized studies comparing these drugs with placebo or with other analgesics and found that: local anesthetics were superior to placebo in decreasing intensity of neuropathic pain; limited data showed no difference in efficacy or adverse effects between local anesthetics and carbamazepine, amantadine, gabapentin or morphine; local anesthetics had more adverse effects than placebo; and local anesthetics were safe.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Challapalli, V, Tremont-Lukats, IW, McNicol, ED, Lau, J, Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD003345.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.095Z" }, { "id": "ed40eb06-864b-40f2-9405-0e205c8c0760", "pmid": "", "title": "Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption", "imported": false, "abstract": "Abstract - Background Overconsumption of food, alcohol, and tobacco products increases the risk of non‐communicable diseases. Interventions to change characteristics of physical micro‐environments where people may select or consume these products ‐ including shops, restaurants, workplaces, and schools – are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers. Objectives 1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non‐alcoholic beverages), (b) alcohol, and (c) tobacco products. 2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii. participants. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches. Selection criteria We included randomised controlled trials with between‐participants (parallel group) or within‐participants (cross‐over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product. Data collection and analysis We used a novel semi‐automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random‐effects meta‐analysis and meta‐regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE. Main results We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between‐participants designs (19/24). All studies were conducted in high‐income countries, predominantly in the USA (14/24). Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less‐healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta‐analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD −1.13 (95% confidence interval (CI) −1.90 to −0.37) (low certainty evidence). For consumption outcomes, meta‐analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD −0.55 (95% CI −1.27 to 0.18) (low certainty evidence). Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD −0.65 (95% CI −1.29 to −0.01) (very low certainty evidence). For consumption outcomes, meta‐analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD −0.60 (95% CI −0.84 to −0.36) (low certainty evidence). Meta‐regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias. Authors' conclusions The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real‐world settings, intervening across a wider range of foods ‐ as well as alcohol and tobacco products ‐ and over sustained time periods. Plain language summary Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption Unhealthy patterns of consumption of food, alcohol, and tobacco products are important causes of ill health. Changing the availability (the range or amount of options, or both) of these products or their proximity (the distance at which they are positioned) to potential consumers could help people make healthier choices. What is the aim of this review? This review investigated whether altering the availability or proximity of food (including non‐alcoholic beverages), alcohol, and tobacco products changed people's selection (such as purchasing) or consumption of those products. We searched for all available evidence from randomised controlled trials (a type of study in which participants are assigned to one of two or more treatment groups using a random method) to answer this question, and found 24 studies, all of which were conducted in high‐income countries. What are the main results of the review? Six studies involved availability interventions, of which four changed the relative proportion of less‐healthy to healthier options, and two changed the absolute number of different options available. In statistical analyses that combined results from multiple studies, it was found that reducing the number of available options for a particular range or category of food(s) reduced selection of those food products (from analysing 154 participants) and possibly reduced consumption of those products (from 150 participants). However, the certainty of the evidence for these effects was low. Eighteen studies involved proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. One study found that this reduced selection of food (from analysing 41 participants), whilst in a statistical analysis combining results from multiple studies, it was found that placing food farther away reduced consumption of those food products (from analysing 1098 participants). However, the certainty of the evidence for these effects was very low and low, respectively. Key messages Mindful of its limitations, the current evidence suggests that changing the number of available food options or changing where foods are positioned could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes to food environments. However, more high‐quality studies in real‐world settings are needed to make this finding more certain. How up‐to‐date is this review? The evidence is current to 23 July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hollands, GJ; Carter, P; Anwer, S; King, SE; Jebb, SA; Ogilvie, D; Shemilt, I; Higgins, JPT; Marteau, TM", "articleTypes": [], "doi": "10.1002/14651858.CD012573.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "ed43d569-1bb0-4f6d-b688-04f7dbcabc59", "pmid": "", "title": "Interventions to reduce harm from continued tobacco use", "imported": false, "abstract": "Abstract - Background Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced‐exposure tobacco products (PREPs), as an alternative to cigarettes. Objectives To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long‐term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco? Search methods We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free‐text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. Selection criteria Randomized or quasi‐randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention. Data collection and analysis We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long‐term smoking abstinence), using fixed‐effect models. Where it was not possible to meta‐analyse data, we summarized findings narratively. Main results Twenty‐four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically‐heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as ‘low’ or ‘very low’, due to imprecision and indirectness. A ‘low’ grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A ‘very low’ grade means we are very uncertain about the estimate. Authors' conclusions People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high‐quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high‐quality RCTs are conducted, and that these also measure the long‐term health effects of treatments. Plain language summary Can smokers be helped to reduce the harm caused by cigarette smoking by smoking fewer cigarettes or using different tobacco products? Background The best thing to do to reduce the harms caused by smoking is to quit, but some people may not want to do this or may feel that they are unable to stop smoking completely. Cutting down the number of cigarettes smoked daily or using different tobacco products, such as chewing tobacco or low‐tar cigarettes, may reduce some of the harm caused by smoking. It may also help people to stop smoking completely in the long term. On the other hand, reducing smoking or using other tobacco products may not improve health and could reduce a person's motivation to quit smoking altogether. It is important that we review the evidence to find out whether these approaches could help smokers who do not want to or cannot quit to reduce the harm caused by their smoking. We were mainly interested in whether these approaches improved the health of smokers, but also looked at smoking reduction and quitting rates. Study characteristics We found 20 randomised controlled trials that tested ways to help people to cut down the number of cigarettes they smoked. Some of these just advised smokers to smoke less, but most also provided them with a product to help them cut down: nicotine replacement therapy (NRT), varenicline, bupropion, electronic cigarettes (ecigs), or snus (a form of smokeless, oral tobacco). We also found four randomized controlled trials that tested the effects of using cigarettes designed to reduce the damage caused by smoking: reduced tar, carbon or nicotine cigarettes. Most of the studies used NRT to help people to reduce their smoking. All of the studies included people who were not planning to quit smoking soon. The research is current to October 2015. Key results Eight studies (with 3081 smokers) found that using NRT roughly doubled the likelihood of halving the number of cigarettes smoked each day, compared to using a placebo. Using NRT in this way also nearly doubled the likelihood of quitting completely. One trial each tested bupropion, varenicline, ecigs and snus to help reduce the harms caused by smoking, and there was no evidence that any of these treatments helped smokers to reduce the number of cigarettes they were smoking each day. This may be because there has not yet been enough research into these methods. Only one of the trials testing cigarettes designed to reduce risk measured their effect on the number of people quitting smoking. It found that people were not more likely to quit smoking if they used reduced‐nicotine cigarettes than if they smoked their usual cigarettes. We did not find any trials which reported the long‐term health effects of the treatments, and so it remains uncertain how much health benefit there is from reducing the number of cigarettes smoked each day or smoking cigarettes designed to be less harmful. Quality of evidence The tobacco industry funded three of the included studies of cigarettes designed to reduce risk. None of the studies looked at whether there had been a long‐term change in the health of the users. We rate the quality of the evidence looking at how many people quit smoking as 'low' or 'very low', generally because the findings are based on a small number of studies. We need more studies to investigate methods of reducing the harm caused by continued smoking. These need to measure the health of the users over a long period.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lindson‐Hawley, N, Hartmann‐Boyce, J, Fanshawe, TR, Begh, R, Farley, A, Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD005231.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.754Z" }, { "id": "ed509fd4-46ab-4fda-b1fb-be0eed16cd5f", "pmid": "", "title": "Folic acid supplementation and malaria susceptibility and severity among people taking antifolate antimalarial drugs in endemic areas", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Qi, YP, Crider, KS, Gutman, J, Centeno-Tablante, E, Fothergill, A, Daniels, K, Yeung, LF, Mai, CT, Mehta, S, Williams, JL, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014217.pub2 AB - Abstract - Background Malaria is an infectious disease transmitted by female Anopheles mosquitoes, with ongoing transmission in over 80 countries. The malaria parasite requires folate for survival and growth; antifolate antimalarial medications used for prevention and treatment target enzymes in folate metabolism as their mechanism of action. Periconceptional folic acid (synthetic form of folate) supplementation (400 μg/day) is the standard of care for neural tube defect prevention. Concerns have been raised about the potential effects of folic acid (including above the tolerable upper intake level (UL) > 1.0 mg/day) in the context of malaria prevention and treatment, including the efficacy of antimalarial medications. Examining the potential impact of folic acid on malaria risk and severity amongst people taking antifolate antimalarial medications may inform public health programmes in malaria‐endemic areas. Objectives To examine the effects of folic acid supplementation on the risk and severity of malaria infection amongst people taking antifolate antimalarials and living in areas with malaria endemicity. Prevention: Amongst uninfected people taking antifolate antimalarial medications for malaria prevention, does folic acid supplementation increase susceptibility or severity of malaria infection? Treatment: Amongst people with malaria infection who are being treated with antifolate antimalarial drugs, does folic acid supplementation reduce parasite clearance or increase the risk of treatment failure? Search methods We searched databases including CENTRAL, MEDLINE, Embase, CINAHL, Scopus, and trial registries (September 13, 2024), grey literature, and reference searches to identify additional studies. Selection criteria Randomised trials evaluating the effects of folic acid supplementation (alone or in combination with iron or other vitamins and minerals) amongst individuals taking antifolate antimalarial medications in malaria‐endemic areas. Data collection and analysis Primary outcomes included uncomplicated malaria or severe malaria, parasite clearance, and treatment failure. Cochrane RoB 2 was used to evaluate the risk of bias. Certainty of evidence was assessed using GRADE for primary outcomes. We performed meta‐analyses using random‐effects models for all outcomes. Main results Eight trials with 3486 participants were included: three malaria prevention trials and five malaria treatment trials. Most treatment trials included folic acid doses above the UL ( > 1.0 mg/d); one trial included 400 μg per day. Antifolate antimalarials included sulfadoxine‐pyrimethamine (SP; five trials), sulfisoxazole plus pyrimethamine (one trial), atovaquone‐proguanil (one trial), and proguanil (one trial). Some studies had unclear or high risk of bias due to missing outcome data. Malaria prevention Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medications. Data for primary outcomes, uncomplicated and severe malaria, were not reported. One trial reported laboratory parasitaemia; there was little to no difference in malaria parasitaemia amongst pregnant women receiving folic acid (with iron) and antifolate antimalarials compared to iron and antifolate antimalarials (Risk Ratio (RR) 1.21; 95% CI 0.56 to 2.62; P = 0.63; 1 trial, 643 individuals). Comparisons 2–4: No studies reported data for Comparisons 2–4. Malaria treatment 
 Comparison 1: Folic acid (alone or in combination with other vitamins and minerals) + antifolate antimalarial medications versus placebo/no folic acid with antifolate antimalarials. People receiving folic acid (alone or with iron) and antifolate antimalarials were less likely to clear malaria parasites (day 3) compared to individuals who did not receive folic acid (RR 0.89; 95% CI 0.84 to 0.95, 4 trials, 929 individuals, moderate‐certainty evidence); and had increased risk of treatment failure on day 7 (RR 2.12; 95% CI 1.41 to 3.19, 4 trials, 1062 individuals, moderate‐certainty evidence), day 14 (RR 1.97; 95% CI 1.44 to 2.70, 3 trials; 891 individuals; moderate‐certainty evidence), and day 28 (RR 1.35; 95% CI 1.21 to 1.51; 4 trials; 1012 individuals, moderate‐certainty evidence). Comparison 2: Folic acid alone + antifolate antimalarials versus placebo/no folic acid + antifolate antimalarial medication. Folic acid supplementation with antifolate antimalarials likely had lower parasite clearance (day 3) (RR 0.87; 95% CI 0.79 to 0.96, 2 trials, 229 individuals, moderate certainty of the evidence), and increased treatment failure (day 7: RR 2.58; 95% CI 0.89 to 7.45; P = 0.08; 2 trials; 344 individuals, moderate‐certainty evidence; day 14: RR 4.15; 95% CI 0.92 to 18.65; P = 0.06; 1 trial; 173 individuals, moderate‐certainty evidence; and day 28: RR 1.47; 95% CI 0.86 to 2.49; P = 0.16; 2 trials; 294 individuals, moderate‐certainty evidence), compared to no folic acid and antifolate antimalarials. Comparison 3: Folic acid with iron + antifolate antimalarial medication versus placebo/no folic acid with iron + antifolate antimalarial medication. People receiving folic acid with iron and antifolate antimalarials were less likely to clear malaria parasites (day 3: RR 0.90; 95% CI 0.83 to 0.98; P = 0.02; 2 trials; 700 individuals, moderate‐certainty evidence), and had increased treatment failure (day 7: RR 1.96; 95% CI 1.05 to 3.65; P = 0.03; 2 trials; 718 individuals; day 14: RR 1.90; 95% CI 1.35 to 2.67; 2 trials; 718 individuals; day 28: RR 1.17; 95% CI 0.79 to 1.74; 2 trials; 578 individuals; all moderate‐certainty evidence), compared to iron and antifolate antimalarials. Comparison 4: No studies reported data. Authors' conclusions Malaria prevention: None of the included trials reported primary outcomes. Malaria treatment: People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to clear malaria parasitaemia (day 3), and had increased treatment failure (days 7, 14, 28). Most of the included trials provided folic acid with doses above the tolerable UL ( > 1.0 mg). One trial included folic acid at a dose of 400 μg/d (recommended dose for preventing neural tube defects) and showed little to no difference in parasite clearance or treatment failure. Plain language summary Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common? Review question 
Does taking folic acid (folate) supplements affect the risk or severity of malaria infection amongst people who are taking (antifolate) medications to prevent or treat malaria, in areas where malaria is common?

 Key messages 
° People who received folic acid supplementation (alone or with iron) and antifolate antimalarial treatment were less likely to eliminate malaria parasites and had increased treatment failure. 
° There were not enough studies to examine whether taking folic acid supplementation at a lower dose, like 400 μg, might affect the risk of malaria infection or health outcomes if infected. This low dose is currently recommended before and during early pregnancy for the prevention of neural tube defects. Malaria and the importance of folate 
Malaria is a disease spread by the bite of certain types of female mosquitoes and is found in over 80 countries. The malaria parasite needs folate to grow and survive, and some medicines used to prevent and treat malaria target folate. Folic acid (the synthetic form of folate) is recommended at a dose of 400 μg daily to prevent neural tube defects. There are some concerns that folic acid (particularly higher doses) may affect malaria and how well some medicines work to prevent and treat malaria. What did we want to find out? 
This review was done to see how folic acid affects malaria risk and severity amongst people taking antifolate antimalarial medications and living in areas where malaria is common. Specifically, we aimed to answer the following questions: Prevention: For people who do not have malaria and are taking antimalarial drugs to prevent malaria, do folic acid supplements increase their risk of getting malaria or having worse outcomes? Treatment: For people who have malaria and are being treated with antifolate antimalarial medications, does taking folic acid supplements affect how well the drugs work to treat malaria? What did we do? 
We searched for trials that looked at folic acid supplementation in people taking antifolate antimalarial medications to prevent or treat malaria. We compared and summarised the results of the trials and rated our confidence in the information based on how the study was done. What did we find? 
We included eight trials (3486 people); three were prevention trials and five were treatment trials. Most trials used higher folic acid doses ( > 1.0 mg) and included the medication sulfadoxine‐pyrimethamine (SP). The prevention studies did not include the main outcomes we were trying to assess. In the treatment studies, people who took folic acid and antifolate antimalarial drugs were less likely to clear malaria parasites from their bodies (day 3) and were more likely to have treatment failure (up to 28 days after treatment) compared to the same treatment but without folic acid. Most of the included trials provided the antimalarial SP and folic acid with doses above the tolerable upper intake level (upper limit; > 1.0 mg). Only one trial included folic acid at a dose of 400 μg per day (the recommended daily dose of folic acid for prevention of neural tube defects); there were no differences in parasite clearance or treatment failure between the arm with 400 μg per day of folic acid and the arm with no folic acid. What are the limitations of the evidence? 
The small number of trials and the size of the studies were limitations of this review, and no prevention studies reported main outcomes. How up to date is this evidence? 
The evidence is up‐to‐date as of September 13, 2024.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.127Z" }, { "id": "ed550016-d3ca-4b68-8e3f-88f63ca4be5e", "pmid": "", "title": "Benperidol for schizophrenia", "imported": false, "abstract": "Abstract - Background Benperidol is a relatively old antipsychotic drug that has been marketed since 1966. It has been used in Germany for 30 years but is also available in Belgium, Greece, Italy, the Netherlands and the UK. Benperidol is a butyrophenone antipsychotic, with the highest neuroleptic potency in terms of D2 receptor blockade. Those taking it are therefore reputed to be at high risk of extrapyramidal side‐effects, but benperidol's unusual profile may render it valuable to certain subgroups of people with schizophrenia. Objectives To examine the clinical effects and safety of benperidol for those with schizophrenia and schizophrenia‐like psychoses. Search methods We searched the Cochrane Schizophrenia Group's register (March 2009) for this update. Selection criteria We included all randomised controlled trials that compared benperidol with other treatments for people with schizophrenia, or schizophrenia‐like psychoses. Data collection and analysis We reliably selected studies, quality rated them and extracted data. We independently extracted data but excluded data if loss to follow up was greater than 50%. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention‐to‐treat analysis. Main results The update yielded no further studies for inclusion in the review. We identified only one unpublished poorly randomised controlled trial (N=40, duration 30 days, comparison perphenazine). Although benperidol was inferior to perphenazine (1 RCT, N=40, global state no better or worse RR 8.0 CI 2.1 to 30, NNH 1.4 CI 1 to 2) poor reporting suggests that an overestimate of effect is likely. It was not possible to report other outcomes. Authors' conclusions Currently, there are insufficient data from randomised trials to assess the clinical effects of benperidol. This compound merits further research interest. Plain language summary Benperidol for schizophrenia Benperidol is a relatively old drug that is used for the treatment of schizophrenia in several European countries. We identified only one small, poorly reported, unpublished, randomised trial comparing benperidol with another antipsychotic. Unfortunately the quality of reporting is so poor that the results cannot be considered reliable. Although benperidol was first marketed in 1966, more trials on this drug are justified as with the advent of new compounds there is a danger that inexpensive drugs such as benperidol remain under‐researched and overlooked.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Schwarz, C, Hartung, B, Leucht, S", "articleTypes": [], "doi": "10.1002/14651858.CD003083.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.776Z" }, { "id": "ed7cd1ee-0761-4040-be7e-dc89d5123c86", "pmid": "", "title": "Sensory stimulation for brain injured individuals in coma or vegetative state", "imported": false, "abstract": "Abstract - Background Coma and vegetative state follow traumatic brain injury in about one out of eight patients, and in patients with non traumatic injury the prognosis is worse. The use of sensory stimulation for coma and vegetative state has gained popularity during the 1980's but beliefs and opinions about its effectiveness vary substantially among health professionals. Objectives To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. Search methods We searched the Injuries Group specialised register, the Cochrane Controlled trials register, EMBASE, MEDLINE, CINAHL and PSYCHLIT from 1966 to January 2002, without language restriction. Reference lists of articles were scanned and we contacted experts in the area to find other relevant studies. Selection criteria Randomised or controlled trials that compared sensory stimulation programmes with standard rehabilitation in patients in coma or vegetative state. Data collection and analysis Abstracts and papers found were screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality resolving disagreement by consensus. Main results Three studies were identified with 68 patients in total. The overall methodological quality was poor and studies differed widely in terms of outcomes measures, study design and conduct. We therefore did not carry out any quantitative synthesis but reviewed results of available studies qualitatively. Authors' conclusions This systematic review indicates that there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state. Plain language summary No strong evidence about the effects of sensory stimulation for a brain‐injured person in a coma About half of people in a coma (deep unconsciousness) because of traumatic brain injury will wake within a year of the accident. Speeding recovery to allow people to wake sooner is a priority for them and their family. One type of treatment uses sensory stimulation to try to keep the person's brain working normally. Sensory stimulation methods vary greatly, from one or two hourly sessions of a day, through to shorter sessions every hour for 12 to 14 hours a day. The review found there is no strong evidence to determine whether sensory stimulation benefits people in comas.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Lombardi, FFL; Taricco, M; De Tanti, A; Telaro, E; Liberati, A", "articleTypes": [], "doi": "10.1002/14651858.CD001427", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "ed800649-a356-440c-a589-1c70fa41f8a6", "pmid": "", "title": "Determination of Perinatal Exposure to Non-caloric Sweeteners. Implications for the Development of Preferences for Sweet Taste, and Weight Gain During the First Year of Life", "imported": false, "abstract": "During last years, non-caloric sweeteners (NCSs) have been increasingly incorporated into foodstuffs in replacement of sucrose in Chile. This situation has reached a point where it is currently difficult to find sugary foods without NCSs. As a result, the voluntary and involuntary consumption of these additives is growing significantly in the population, increasing the risk of exceeding the acceptable daily intake (ADI), especially for children. This situation is worrying as recent evidence suggests that NCSs are not inert in the body and can trigger adverse metabolic effects. For example, the consumption of beverages with NCSs has been shown to favor the development of obesity and type-2 diabetes in children and adults, and a recent study reported that the intake of NCSs during pregnancy was associated with a greater weight gain of the child at one year. It is likely that certain NCSs pass into the amniotic fluid and that the fetus is exposed to some of these compounds during pregnancy. This situation would persist in the infant through breast milk, as some studies detected sucralose and acesulfame-K in this fluid, even in mothers who claimed not to consume them. However, the real impact of NCS exposure during the neonatal period on the child health has been few studied. Therefore, the aim of this study is to determine the concentration of NCSs in samples of amniotic liquid and breastmilk and to correlate these data with the NCS intake by the mothers. Mothers/children will be classified in quintiles according to the results obtained. In the children from quintiles 1 and 5, we will also study whether neonatal exposure to NCSs may affect the sweet taste threshold and the preferences for this taste, the levels of salivary insulin and the weight gain in the first year. Breastmilk microbiota and child fecal microbiota will be also evaluated.", "journal": "", "year": "2019", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.257Z" }, { "id": "ed804d06-3946-49a7-95ba-270a8e0d1b9e", "pmid": "", "title": "Perioperative nutrition interventions for women with ovarian cancer", "imported": false, "abstract": "Abstract - Background Women with ovarian cancer have been shown to be at significant risk of malnutrition with incidence rates described as being between 28% to 67%. Nutrition interventions may improve clinical outcomes positively, nutritional status or quality of life measures in this patient group. Objectives This review was conducted to assess the effects of nutrition interventions during the perioperative period for women with ovarian cancer. Search methods Electronic searches were conducted of the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 7), Medline (1946 to July week 4 2012), Embase (1980 to 2012 week 31), DARE (to 7th August 2012) AMED (1985 to April 2012), BNI (1992 to April 2012), CINAHL (to April 2012). We also searched trials databases, conference proceedings and related citation lists. Reference listings were handsearched. No restrictions were applied on language or date. Selection criteria Randomised controlled trials (RCTs) in which women 18 years and over with any stage of ovarian cancer, including recurrent cancer, were in the perioperative phase of treatment and received any type of nutrition intervention. Data collection and analysis Titles and abstracts were screened by two review authors with study selection discussed by a team. Pairs of review authors worked independently on data collection and compared findings. Main results A total of 4092 titles were screened and 14 full text reports reviewed; a single small study met the inclusion criteria. In the included RCT, 40 women (35 with ovarian cancer) had extensive elective surgery including bowel resection for treatment of gynaecological malignancy. Randomisation was made to either early oral feeding (oral fluids in the first 24 hours, solid foods on the following day) or to a 'traditional' feeding regimen where oral fluids and foods were delayed until there was evidence of bowel function. Most women in the early feeding group (14/18) were able to resume eating solid food one day after surgery. This resulted in a significantly shorter hospital stay with no increase in postoperative complications or change in quality of life measures in comparison with the women on the 'traditional' feeding regimen. The incidence of nausea and vomiting during the postoperative stay was similar in both groups and was noted in slightly more than half of the women. Overall survival was evaluated until 30 days following discharge from hospital; in this period, there was one death of a woman who had been in the 'traditional oral feeding' group, cause of death was not noted. We assessed risk of bias and found no high risk of bias was identified in the methodology and reporting of the included study, although there was an increased risk of bias due to the small size of the study in which not all of the women had ovarian cancer. Authors' conclusions Although women with ovarian cancer have been shown to be at risk of malnutrition, there is a lack of evidence derived from RCTs evaluating the identification, assessment and treatment of malnutrition during the perioperative phase of treatment. There is evidence from one small study that some women with ovarian cancer undergoing surgery with associated bowel resection may safely commence oral fluids within 24 hours of surgery and solid foods on the following day. Further research is required, including a RCT, to generate guidance concerning the treatment of malnutrition in this patient group. Plain language summary Nutrition for women who are having surgery for ovarian cancer Women who have ovarian cancer, (a cancer which develops in the two organs (ovaries) that produce eggs in women) are more likely to have difficulties with food and with eating a nourishing diet in comparison to women with other types of gynaecological cancers. One reason may be because the symptoms of ovarian cancer can be difficult to recognise. Women may have a lack of interest in food, feel full, feel sick or have a painful or swollen abdomen. Some women become thinner in parts of their bodies while becoming bigger around their abdomen due to an abnormal build up of fluid or large tumours. There may be no change in body weight or weight may increase, this can make it difficult to know which women are developing problems due to a poor food intake. Women who are unable to eat and drink well are at risk of becoming malnourished and may then have more complications from the treatments for ovarian cancer than women who are not malnourished. It is recommended that people who are having difficulties with eating and drinking should be identified and helped when they receive hospital care. Currently, there is no agreed method for finding and treating nutritional problems for women with ovarian cancer. In this review, the authors looked for studies (randomised controlled trials (RCTs)) from around the world to find out how women with ovarian cancer were assessed to see if they were eating and drinking well and what help they may be given with nutrition before or after surgery. A lack of information was found on this topic. One RCT was found where a small group of women (40 including 35 with ovarian cancer) requiring extensive elective surgery for gynaecological cancer including surgery to the gut, were able to restart eating normal foods on the day after surgery. They were able to leave hospital earlier and did not have more complications in the month after surgery than women who were not allowed to resume eating normal foods until at least three days after the operation. More studies are needed to confirm whether restarting normal eating one day after surgery can be recommended for women having surgery for ovarian cancer. More research is needed to provide information about how to identify and treat problems of malnutrition in women with ovarian cancer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Billson, HA; Holland, C; Curwell, J; Davey, VL; Kinsey, L; Lawton, LJ; Whitworth, AJ; Burden, S", "articleTypes": [], "doi": "10.1002/14651858.CD009884.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "ed8f2ea6-4255-45e7-81f0-7909aafdafb4", "pmid": "", "title": "New generation antidepressants for depression in children and adolescents: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Major depressive disorders have a significant impact on children and adolescents, including on educational and vocational outcomes, interpersonal relationships, and physical and mental health and well‐being. There is an association between major depressive disorder and suicidal ideation, suicide attempts, and suicide. Antidepressant medication is used in moderate to severe depression; there is now a range of newer generations of these medications. Objectives To investigate, via network meta‐analysis (NMA), the comparative effectiveness and safety of different newer generation antidepressants in children and adolescents with a diagnosed major depressive disorder (MDD) in terms of depression, functioning, suicide‐related outcomes and other adverse outcomes. The impact of age, treatment duration, baseline severity, and pharmaceutical industry funding was investigated on clinician‐rated depression (CDRS‐R) and suicide‐related outcomes. Search methods We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR)), together with Ovid Embase, MEDLINE and PsycINFO till March 2020. Selection criteria Randomised trials of six to 18 year olds of either sex and any ethnicity with clinically diagnosed major depressive disorder were included. Trials that compared the effectiveness of newer generation antidepressants with each other or with a placebo were included. Newer generation antidepressants included: selective serotonin reuptake inhibitors; selective norepinephrine reuptake inhibitors (SNRIs); norepinephrine reuptake inhibitors; norepinephrine dopamine reuptake inhibitors; norepinephrine dopamine disinhibitors (NDDIs); and tetracyclic antidepressants (TeCAs). Data collection and analysis Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed risk of bias. We analysed dichotomous data as Odds Ratios (ORs), and continuous data as Mean Difference (MD) for the following outcomes: depression symptom severity (clinician rated), response or remission of depression symptoms, depression symptom severity (self‐rated), functioning, suicide related outcomes and overall adverse outcomes. Random‐effects network meta‐analyses were conducted in a frequentist framework using multivariate meta‐analysis. Certainty of evidence was assessed using Confidence in Network Meta‐analysis (CINeMA). We used \"informative statements\" to standardise the interpretation and description of the results. Main results Twenty‐six studies were included. There were no data for the two primary outcomes (depressive disorder established via clinical diagnostic interview and suicide), therefore, the results comprise only secondary outcomes. Most antidepressants may be associated with a \"small and unimportant\" reduction in depression symptoms on the CDRS‐R scale (range 17 to 113) compared with placebo (high certainty evidence: paroxetine: MD ‐1.43, 95% CI ‐3.90, 1.04; vilazodone: MD ‐0.84, 95% CI ‐3.03, 1.35; desvenlafaxine MD ‐0.07, 95% CI ‐3.51, 3.36; moderate certainty evidence: sertraline: MD ‐3.51, 95% CI ‐6.99, ‐0.04; fluoxetine: MD ‐2.84, 95% CI ‐4.12, ‐1.56; escitalopram: MD ‐2.62, 95% CI ‐5.29, 0.04; low certainty evidence: duloxetine: MD ‐2.70, 95% CI ‐5.03, ‐0.37; vortioxetine: MD 0.60, 95% CI ‐2.52, 3.72; very low certainty evidence for comparisons between other antidepressants and placebo). There were \"small and unimportant\" differences between most antidepressants in reduction of depression symptoms (high‐ or moderate‐certainty evidence). Results were similar across other outcomes of benefit. In most studies risk of self‐harm or suicide was an exclusion criterion for the study. Proportions of suicide‐related outcomes were low for most included studies and 95% confidence intervals were wide for all comparisons. The evidence is very uncertain about the effects of mirtazapine (OR 0.50, 95% CI 0.03, 8.04), duloxetine (OR 1.15, 95% CI 0.72, 1.82), vilazodone (OR 1.01, 95% CI 0.68, 1.48), desvenlafaxine (OR 0.94, 95% CI 0.59, 1.52), citalopram (OR 1.72, 95% CI 0.76, 3.87) or vortioxetine (OR 1.58, 95% CI 0.29, 8.60) on suicide‐related outcomes compared with placebo. There is low certainty evidence that escitalopram may \"at least slightly\" reduce odds of suicide‐related outcomes compared with placebo (OR 0.89, 95% CI 0.43, 1.84). There is low certainty evidence that fluoxetine (OR 1.27, 95% CI 0.87, 1.86), paroxetine (OR 1.81, 95% CI 0.85, 3.86), sertraline (OR 3.03, 95% CI 0.60, 15.22), and venlafaxine (OR 13.84, 95% CI 1.79, 106.90) may \"at least slightly\" increase odds of suicide‐related outcomes compared with placebo. There is moderate certainty evidence that venlafaxine probably results in an \"at least slightly\" increased odds of suicide‐related outcomes compared with desvenlafaxine (OR 0.07, 95% CI 0.01, 0.56) and escitalopram (OR 0.06, 95% CI 0.01, 0.56). There was very low certainty evidence regarding other comparisons between antidepressants. Authors' conclusions Overall, methodological shortcomings of the randomised trials make it difficult to interpret the findings with regard to the efficacy and safety of newer antidepressant medications. Findings suggest that most newer antidepressants may reduce depression symptoms in a small and unimportant way compared with placebo. Furthermore, there are likely to be small and unimportant differences in the reduction of depression symptoms between the majority of antidepressants. However, our findings reflect the average effects of the antidepressants, and given depression is a heterogeneous condition, some individuals may experience a greater response. Guideline developers and others making recommendations might therefore consider whether a recommendation for the use of newer generation antidepressants is warranted for some individuals in some circumstances. Our findings suggest sertraline, escitalopram, duloxetine, as well as fluoxetine (which is currently the only treatment recommended for first‐line prescribing) could be considered as a first option. Children and adolescents considered at risk of suicide were frequently excluded from trials, so that we cannot be confident about the effects of these medications for these individuals. If an antidepressant is being considered for an individual, this should be done in consultation with the child/adolescent and their family/caregivers and it remains critical to ensure close monitoring of treatment effects and suicide‐related outcomes (combined suicidal ideation and suicide attempt) in those treated with newer generation antidepressants, given findings that some of these medications may be associated with greater odds of these events. Consideration of psychotherapy, particularly cognitive behavioural therapy, as per guideline recommendations, remains important. Plain language summary Newer generation antidepressants for depression in children and adolescents: a network meta‐analysis How well do newer formulations of antidepressants work for children and adolescents with clinical depression? Children and adolescents (6 to 18 years) with depression (also called ‘major depressive disorder’) experience a range of negative impacts in all areas of their lives and have an increased risk of suicide, suicidal thinking and suicide attempts. Antidepressants have been shown to reduce symptoms of depression, but can also increase the risk of suicide‐related outcomes. Who will be interested in this research? The research in this Cochrane Review will interest: ‐ people who decide policy, and influence decisions about the prescription of antidepressant medicines to children and adolescents; ‐ people who prescribe these medicines to children and adolescents; ‐ children and adolescents with depression; and ‐ those who support and care for them (including their parents and caregivers and clinicians who provide treatment). What did we want to find out? We wanted to find out how well newer formulations (called ‘new generation’) antidepressants work to improve depression in children and adolescents aged 6 to 18 years. New generation antidepressants are those that have been developed recently. They are sometimes referred to as ‘second‐‘ and ‘third‐generation’ antidepressants; they do not include older formulations (tricyclic antidepressants or monoamine oxidase inhibitors). We wanted to know how these antidepressants affect: ‐ symptoms of depression; ‐ recovery: no longer meeting diagnostic criteria for major depressive disorder; ‐ response or remission: scores on a scale indicating an important reduction in depression or no longer experiencing depression; ‐ ability to function in daily life; ‐ suicide‐related outcomes; and ‐ whether they cause any unwanted effects in children and adolescents. What did we do? We searched for studies that tested new generation antidepressants on children or adolescents (or both) who had been diagnosed with a major depressive disorder. We identified 26 such studies. We then assessed the trustworthiness of those studies, and synthesized the findings across the studies. What does the evidence from the review tell us? Most newer antidepressants probably reduce depression symptoms better than a placebo (a 'dummy' treatment that does not contain any medicine but looks identical to the medicine being tested). However, the reduction is small and may not be experienced as important by children and adolescents, their parents and caregivers, or clinicians. When different medications are compared against each other, there may be only small and unimportant differences between most of them for the reduction of symptoms. Our findings reflect what happens on average to individuals, but some individuals may experience a greater response. This might lead to recommendations being made for the use of antidepressants for some individuals in some circumstances. Our findings suggest that sertraline, escitalopram, duloxetine and fluoxetine can be used if medication is being considered. The impact of medication on depression symptoms should be closely monitored by those prescribing the medication, especially as suicide‐related thinking and behaviour may be increased in those taking these medications. Close monitoring of suicide‐related behaviours is vital in those treated with new generation antidepressants. What should happen next? The studies that provided this evidence largely excluded children and adolescents who: ‐ were already thinking about suicide and wanting to take their own lives (i.e. had suicidal ideation); ‐ were self‐harming; ‐ had other mental health conditions; and ‐ had psychosocial difficulties. Future research should aim to understand the impacts of these medicines in children and adolescents with these problems, who are more typical of those who request clinical services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Hetrick, SE, McKenzie, JE, Bailey, AP, Sharma, V, Moller, CI, Badcock, PB, Cox, GR, Merry, SN, Meader, N", "articleTypes": [], "doi": "10.1002/14651858.CD013674.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.814Z" }, { "id": "edaea231-3006-46fe-801b-6b1c8b960baf", "pmid": "", "title": "Interventions for recurrent idiopathic epistaxis (nosebleeds) in children", "imported": false, "abstract": "Abstract - Background Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified. Although nosebleeds are very common in children, and most cases are self limiting or settle with simple measures (such as pinching the nose), more severe recurrent cases can require treatment from a healthcare professional. However, there is no consensus on the effectiveness of the different clinical interventions currently used in managing this condition. Objectives To assess the effects of different interventions for the management of recurrent idiopathic epistaxis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 5 March 2012. Selection criteria We identified all randomised controlled trials (RCTs) (with or without blinding) in which any surgical or medical intervention for the treatment of recurrent idiopathic epistaxis in children was evaluated in comparison with either no treatment, a placebo or another intervention, and in which the frequency and severity of episodes of nasal bleeding following treatment was stated or calculable. The two authors reviewed the full‐text articles of all retrieved trials of possible relevance and applied the inclusion criteria independently. Data collection and analysis We graded trials for risk of bias using the Cochrane approach. One author performed data extraction in a standardised manner and this was rechecked by the other author. Where necessary we contacted investigators to obtain missing information. We did not undertake a meta‐analysis because of the heterogeneity of the treatments, procedures and quality of the included trials. A narrative overview of the results is therefore presented. Main results Five studies (four RCTs and one quasi‐randomised controlled trial) involving 468 participants satisfied the inclusion criteria. The identified RCTs compared 0.5% neomycin + 0.1% chlorhexidine (Naseptin®) cream with no treatment, Vaseline® petroleum jelly with no treatment, 75% with 95% silver nitrate nasal cautery, and silver nitrate cautery combined with Naseptin® against Naseptin® alone; the quasi‐randomised controlled trial compared Naseptin® antiseptic cream with silver nitrate cautery. Overall results were inconclusive, with no statistically significant difference found between the compared treatments upon completion of the trials, however 75% silver nitrate was more effective than 95% silver nitrate at two weeks following application. The group treated with 75% silver nitrate had 88% complete resolution of epistaxis compared to 65% in the group treated with 95% silver nitrate (P = 0.01). No serious adverse effects were reported from any of the interventions, although children receiving silver nitrate cautery reported that it was a painful experience (despite the use of local anaesthetic). The pain scores were significantly less in those treated with 75% silver nitrate, the mean score being 1 compared to a mean score of 5 in those treated with 95% silver nitrate; this was statistically significant (P = 0.001). We carried out a 'Risk of bias' assessment of each study according to the Cochrane methodology and judged that two randomised controlled trials had a low risk of bias, two had an unclear risk of bias and the quasi‐randomised controlled trial had a high risk of bias. Authors' conclusions The optimal management of children with recurrent idiopathic epistaxis is unknown, however if silver nitrate nasal cautery is undertaken 75% is preferable to 95% as it is more effective in the short term and causes less pain. High‐quality randomised controlled trials comparing interventions either with placebo or no treatment, and with a follow‐up period of at least a year, are needed to assess the relative merits of the various treatments currently in use. Plain language summary Interventions for recurrent nosebleeds of unknown cause in children Nosebleeds in children usually just stop by themselves or after pinching the nose. However, some children get repeated nosebleeds with no specific cause (recurrent idiopathic epistaxis). The most common treatments are cautery or antiseptic cream, or both. Cautery (a method of sealing) can be painful even with local anaesthetic, and usually involves using a silver nitrate stick to seal off a visible blood vessel inside the nose that may be rupturing. Other options include ointments and nasal sprays. The review of trials found that there is not enough evidence to compare the effectiveness of different treatment options, however using a lower concentration of silver nitrate cautery is more effective in the short term and less painful. More research is needed to show the best options for reducing recurrent nosebleeds of unknown cause in children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Qureishi, A, Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004461.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.749Z" }, { "id": "edc05cd6-4e2a-44f5-a010-5c1038ec3610", "pmid": "", "title": "Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta‐analyses", "imported": false, "abstract": "Abstract - Background Tobacco smoking is the leading preventable cause of death and disease worldwide. Stopping smoking can reduce this harm and many people would like to stop. There are a number of medicines licenced to help people quit globally, and e‐cigarettes are used for this purpose in many countries. Typically treatments work by reducing cravings to smoke, thus aiding initial abstinence and preventing relapse. More information on comparative effects of these treatments is needed to inform treatment decisions and policies. Objectives To investigate the comparative benefits, harms and tolerability of different smoking cessation pharmacotherapies and e‐cigarettes, when used to help people stop smoking tobacco. Search methods We identified studies from recent updates of Cochrane Reviews investigating our interventions of interest. We updated the searches for each review using the Cochrane Tobacco Addiction Group (TAG) specialised register to 29 April 2022. Selection criteria We included randomised controlled trials (RCTs), cluster‐RCTs and factorial RCTs, which measured smoking cessation at six months or longer, recruited adults who smoked combustible cigarettes at enrolment (excluding pregnant people) and randomised them to approved pharmacotherapies and technologies used for smoking cessation worldwide (varenicline, cytisine, nortriptyline, bupropion, nicotine replacement therapy (NRT) and e‐cigarettes) versus no pharmacological intervention, placebo (control) or another approved pharmacotherapy. Studies providing co‐interventions (e.g. behavioural support) were eligible if the co‐intervention was provided equally to study arms. Data collection and analysis We followed standard Cochrane methods for screening, data extraction and risk of bias (RoB) assessment (using the RoB 1 tool). Primary outcome measures were smoking cessation at six months or longer, and the number of people reporting serious adverse events (SAEs). We also measured withdrawals due to treatment. We used Bayesian component network meta‐analyses (cNMA) to examine intervention type, delivery mode, dose, duration, timing in relation to quit day and tapering of nicotine dose, using odds ratios (OR) and 95% credibility intervals (CrIs). We calculated an effect estimate for combination NRT using an additive model. We evaluated the influence of population and study characteristics, provision of behavioural support and control arm rates using meta‐regression. We evaluated certainty using GRADE. Main results Of our 332 eligible RCTs, 319 (835 study arms, 157,179 participants) provided sufficient data to be included in our cNMA. Of these, we judged 51 to be at low risk of bias overall, 104 at high risk and 164 at unclear risk, and 118 reported pharmaceutical or e‐cigarette/tobacco industry funding. Removing studies at high risk of bias did not change our interpretation of the results. Benefits We found high‐certainty evidence that nicotine e‐cigarettes (OR 2.37, 95% CrI 1.73 to 3.24; 16 RCTs, 3828 participants), varenicline (OR 2.33, 95% CrI 2.02 to 2.68; 67 RCTs, 16,430 participants) and cytisine (OR 2.21, 95% CrI 1.66 to 2.97; 7 RCTs, 3848 participants) were associated with higher quit rates than control. In absolute terms, this might lead to an additional eight (95% CrI 4 to 13), eight (95% CrI 6 to 10) and seven additional quitters per 100 (95% CrI 4 to 12), respectively. These interventions appeared to be more effective than the other interventions apart from combination NRT (patch and a fast‐acting form of NRT), which had a lower point estimate (calculated additive effect) but overlapping 95% CrIs (OR 1.93, 95% CrI 1.61 to 2.34). There was also high‐certainty evidence that nicotine patch alone (OR 1.37, 95% CrI 1.20 to 1.56; 105 RCTs, 37,319 participants), fast‐acting NRT alone (OR 1.41, 95% CrI 1.29 to 1.55; 120 RCTs, 31,756 participants) and bupropion (OR 1.43, 95% CrI 1.26 to 1.62; 71 RCTs, 14,759 participants) were more effective than control, resulting in two (95% CrI 1 to 3), three (95% CrI 2 to 3) and three (95% CrI 2 to 4) additional quitters per 100 respectively. Nortriptyline is probably associated with higher quit rates than control (OR 1.35, 95% CrI 1.02 to 1.81; 10 RCTs, 1290 participants; moderate‐certainty evidence), resulting in two (CrI 0 to 5) additional quitters per 100. Non‐nicotine/placebo e‐cigarettes (OR 1.16, 95% CrI 0.74 to 1.80; 8 RCTs, 1094 participants; low‐certainty evidence), equating to one additional quitter (95% CrI ‐2 to 5), had point estimates favouring the intervention over control, but CrIs encompassed the potential for no difference and harm. There was low‐certainty evidence that tapering the dose of NRT prior to stopping treatment may improve effectiveness; however, 95% CrIs also incorporated the null (OR 1.14, 95% CrI 1.00 to 1.29; 111 RCTs, 33,156 participants). This might lead to an additional one quitter per 100 (95% CrI 0 to 2). Harms There were insufficient data to include nortriptyline and non‐nicotine EC in the final SAE model. Overall rates of SAEs for the remaining treatments were low (average 3%). Low‐certainty evidence did not show a clear difference in the number of people reporting SAEs for nicotine e‐cigarettes, varenicline, cytisine or NRT when compared to no pharmacotherapy/e‐cigarettes or placebo. Bupropion may slightly increase rates of SAEs, although the CrI also incorporated no difference (moderate certainty). In absolute terms bupropion may cause one more person in 100 to experience an SAE (95% CrI 0 to 2). Authors' conclusions The most effective interventions were nicotine e‐cigarettes, varenicline and cytisine (all high certainty), as well as combination NRT (additive effect, certainty not rated). There was also high‐certainty evidence for the effectiveness of nicotine patch, fast‐acting NRT and bupropion. Less certain evidence of benefit was present for nortriptyline (moderate certainty), non‐nicotine e‐cigarettes and tapering of nicotine dose (both low certainty). There was moderate‐certainty evidence that bupropion may slightly increase the frequency of SAEs, although there was also the possibility of no increased risk. There was no clear evidence that any other tested interventions increased SAEs. Overall, SAE data were sparse with very low numbers of SAEs, and so further evidence may change our interpretation and certainty. Future studies should report SAEs to strengthen certainty in this outcome. More head‐to‐head comparisons of the most effective interventions are needed, as are tests of combinations of these. Future work should unify data from behavioural and pharmacological interventions to inform approaches to combined support for smoking cessation. Plain language summary How effective are medications and e‐cigarettes for quitting smoking, and what works best? Key messages Some medicines and e‐cigarettes (handheld devices that work by heating liquid that usually contains nicotine and flavourings) can help people to quit smoking for six months or longer. E‐cigarettes, and the medicines cytisine (otherwise known as Tabex) and varenicline (otherwise known as Chantix and Champix), appear to help the most people to quit smoking, followed by using two types of nicotine replacement therapy at once (nicotine patch and another type, such as gum or lozenge). We need more evidence on possible long‐term harms of e‐cigarettes and medicines to help people quit smoking, but there were very low numbers of serious harms found. Stopping smoking Tobacco smoking is bad for people's health and stopping can lead to significant improvements. Most people would like to quit smoking and there are medicines and e‐cigarettes available to help people to do that. These medicines are called nicotine replacement therapy, cytisine, varenicline, bupropion (sometimes known as Zyban or Wellbutrin) and nortriptyline (sometimes known as Norpress). Nortriptyline is only available for quitting smoking in New Zealand, and cytisine is not available in many countries. At time of writing, there are shortages of varenicline due to a manufacturing issue. These medicines and e‐cigarettes can be provided alongside behavioural support, such as counselling. Stop smoking medications and e‐cigarettes are designed to reduce people's craving to smoke. By finding out more information on how these treatments compare to each other, we hope this review will be used to decide the best treatments to help people stop smoking. Why we did this Cochrane Review We wanted to find out: ‐ which treatments (medicines and e‐cigarettes) help people to stop smoking; ‐ how these treatments compare to each other; ‐ whether there are ways of providing these treatments that mean they are more likely to help people stop smoking (e.g. different doses or treatment lengths); ‐ whether these treatments are likely to cause serious harms; and ‐ whether certain treatments are better tolerated, as indicated by fewer people leaving a study due to treatment. What did we do? We searched for studies that looked at these treatments to help adults quit smoking. We looked for randomised controlled trials, where the treatments people received were decided at random. This type of study usually gives the most reliable evidence about the effects of treatments. We compared all treatments with each other using a method called network meta‐analysis. Search date: 29 April 2022 What we found We found 332 studies that met our criteria and 319 of these provided information that we could use in our analyses. These included 157,179 adults who smoked tobacco cigarettes. Most of the studies took place in the USA or Europe. The studies compared the effects of the stop smoking treatments listed above with: ‐ no medicine/e‐cigarettes for stopping smoking; ‐ e‐cigarettes that did not contain nicotine; ‐ placebo (a dummy medication); and ‐ other types of stop smoking medicine or e‐cigarettes. What are the main results of our review? E‐cigarettes, varenicline and cytisine were most likely to help people quit smoking. For every 100 people, 10 to 19 are likely to quit using an e‐cigarette; 12 to 16 using varenicline; and 10 to 18 using cytisine. This is compared to the 6 in 100 people likely to quit when using no medicine/e‐cigarette or placebo. People using two forms of nicotine replacement therapy at the same time, for example, a combination of nicotine patch and nicotine gum, seemed to have similar rates of quitting to people using e‐cigarettes, varenicline and cytisine. Nicotine patches alone, another form of nicotine replacement therapy alone (such as gum, lozenge) and bupropion appeared to help fewer people quit but still work better than no medicine/e‐cigarette or placebo (8, 9 and 9 people per 100, respectively). Nortriptyline appeared to result in the lowest number of people quitting smoking; for every 100 people using nortriptyline 6 to 11 are likely to quit. We are moderately confident that bupropion could rarely cause some serious health effects. The information we have for other treatments does not provide clear evidence of serious harms. For all treatments, findings suggest very few people experience serious harms when using them. How confident are we in our results? We are confident that e‐cigarettes, cytisine, varenicline, nicotine replacement therapy and bupropion help people stop smoking. We do not expect more evidence will change these results. However, more evidence on how these treatments compare to one another, particularly in relation to harms, would be useful. Due to the nature of our analyses we were not able to judge our confidence in the evidence for combination nicotine replacement therapy (two types used together). We are moderately confident that nortriptyline also helps people to stop smoking, but are less confident in our results for non‐nicotine e‐cigarettes and for potential harms of most of the treatments. We still need more evidence on potential harms and hope more studies will report on these in future; however, nicotine replacement therapy has been used since the 1980s with no evidence of serious harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lindson, N, Theodoulou, A, Ordóñez-Mena, JM, Fanshawe, TR, Sutton, AJ, Livingstone-Banks, J, Hajizadeh, A, Zhu, S, Aveyard, P, Freeman, SC, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015226.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.061Z" }, { "id": "edeaf033-f9a6-41e2-a295-8abaf32a5bb2", "pmid": "", "title": "Xylitol for preventing acute otitis media in children up to 12 years of age", "imported": false, "abstract": "Abstract - Background Acute otitis media (AOM) is the most common bacterial infection among young children in the United States. There are limitations and concerns over its treatment with antibiotics and surgery and so effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk of dental decay. Xylitol can reduce the adherence of Streptococcus pneumoniae ( S pneumoniae ) and Haemophilus influenzae ( H influenzae ) to nasopharyngeal cells in vitro. This is an update of a review first published in 2011. Objectives To assess the efficacy and safety of xylitol to prevent AOM in children aged up to 12 years. Search methods We searched CENTRAL (to Issue 12, 2015), MEDLINE (1950 to January 2016), Embase (1974 to January 2016), CINAHL (1981 to January 2016), LILACS (1982 to January 2016), Web of Science (2011 to January 2016) and International Pharmaceutical Abstracts (2000 to January 2016). Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs of children aged 12 years or younger where xylitol supplementation was compared with placebo or no treatment to prevent AOM. Data collection and analysis Two review authors independently selected trials from search results, assessed and rated study quality and extracted relevant data for inclusion in the review. We contacted trial authors to request missing data. We noted data on any adverse events of xylitol. We extracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR), risk difference (RD) and associated 95% confidence intervals (CI). Main results We identified five clinical trials that involved 3405 children for inclusion. For this 2016 update, we identified one new trial for inclusion. This trial was systematically reviewed but due to several sources of heterogeneity, was not included in the meta‐analysis. The remaining four trials were of adequate methodological quality. In three RCTs that involved a total of 1826 healthy Finnish children attending daycare, there is moderate quality evidence that xylitol (in any form) can reduce the risk of AOM from 30% to around 22% compared with the control group (RR 0.75, 95% CI 0.65 to 0.88). Among the reasons for dropouts, there were no significant differences in abdominal discomfort and rash between the xylitol and the control groups. Xylitol was not effective in reducing AOM among healthy children during a respiratory infection (RR 1.13, 95% CI 0.83 to 1.53; moderate quality evidence) or among otitis‐prone healthy children (RR 0.90, 95% CI 0.67 to 1.21; low‐quality evidence). Authors' conclusions There is moderate quality evidence showing that the prophylactic administration of xylitol among healthy children attending daycare centres can reduce the occurrence of AOM. There is inconclusive evidence with regard to the efficacy of xylitol in preventing AOM among children with respiratory infection, or among otitis‐prone children. The meta‐analysis was limited because data came from a small number of studies, and most were from the same research group. Plain language summary Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age Review question 
 We reviewed the evidence about the effectiveness and safety of xylitol to prevent acute middle ear infection (acute otitis media; AOM) in children up to 12 years old. Background 
 AOM is the most common bacterial infection among young children in the United States. Although serious complications are rare, this common childhood ailment imposes a huge impact on the healthcare system. In the United States, it accounted for almost 20 million office visits. Antibiotic treatment of AOM is costly and raises concerns about the development of antibiotic‐resistant strains of bacteria. Surgery is invasive and costly, and because of these factors, effective measures for preventing AOM are sought. An alternative treatment is xylitol or birch sugar. Xylitol has been used for decades as a natural non‐sugar sweetener principally in chewing gums, confectionery, toothpaste and medicines, and can reduce the risk of tooth decay. Search date We searched the literature up to January 2016. This is an update of a review that was last published in 2011. Study characteristics 
 We identified five clinical trials that involved 3405 children, mostly from the same research group. Four trials were conducted in Finland and enrolled healthy children (three trials) or children with an acute respiratory infection (one trial). The fifth trial was conducted in the USA and enrolled otitis‐prone children who were recruited from attendance at general medical practices. Study funding sources All five trials received governmental funding; and the Finnish study investigators have a US patent for the use of xylitol to treat respiratory infections. Key results Xylitol, administered in chewing gum, lozenges or syrup, can reduce the occurrence of AOM among healthy children with no acute upper respiratory infection from 30% to 22%. There is no difference in side effects (namely, abdominal discomfort and rash). Based on these results we would expect that out of 1000 children up to 12 years of age, 299 would experience an AOM compared with between 194 and 263 children who would experience an AOM if they are provided with xylitol chewing gum. The preventive effect among healthy children with respiratory infection or among otitis‐prone children is inconclusive. Quality of the evidence 
 The quality of evidence was moderate for healthy children and children with respiratory infections but low for otitis‐prone children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Azarpazhooh, A; Lawrence, HP; Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD007095.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "edec1b87-de08-4e8f-aa25-15b6c14ddbbe", "pmid": "", "title": "Probiotics for treatment of chronic constipation in children", "imported": false, "abstract": "Abstract - Background Functional constipation is defined as chronic constipation with no identifiable underlying cause. It is a significant cause of morbidity in children, accounting for up to 25% of visits to paediatric gastroenterologists. Probiotic preparations may sufficiently alter the gut microbiome and promote normal gut physiology in a way that helps relieve functional constipation. Several studies have sought to address this hypothesis, as well as the role of probiotics in other functional gut disorders. Therefore, it is important to have a focused review to assess the evidence to date. Objectives To evaluate the efficacy and safety of probiotics for the management of chronic constipation without a physical explanation in children. Search methods On 28 June 2021, we searched CENTRAL, MEDLINE, Embase, CINAHL, AMED, WHO ICTR, and ClinicalTrials.gov, with no language, date, publication status, or document type limitations. Selection criteria We included randomised controlled trials (RCTs) that assessed probiotic preparations (including synbiotics) compared to placebo, no treatment or any other interventional preparation in people aged between 0 and 18 years old with a diagnosis of functional constipation according to consensus criteria (such as Rome IV). Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 14 studies (1127 randomised participants): 12 studies assessed probiotics in the treatment of functional constipation, whilst two studies investigated synbiotic preparations. Three studies compared probiotics to placebo in relation to the frequency of defecation at study end, but we did not pool them as there was very significant unexplained heterogeneity. Four studies compared probiotics to placebo in relation to treatment success. There may be no difference in global improvement/treatment success (RR 1.29, 95% CI 0.73 to 2.26; 313 participants; low‐certainty evidence). Five studies compared probiotics to placebo in relation to withdrawals due to adverse events, with the pooled effect suggesting there may be no difference (RR 0.64, 95% CI 0.21 to 1.95; 357 participants; low‐certainty evidence). The pooled estimate from three studies that compared probiotics plus an osmotic laxative to osmotic laxative alone found there may be no difference in frequency of defecation (MD ‐0.01, 95% CI ‐0.57 to 0.56; 268 participants; low‐certainty evidence). Two studies compared probiotics plus an osmotic laxative to osmotic laxative alone in relation to global improvement/treatment success, and found there may be no difference between the treatments (RR 0.95, 95% CI 0.79 to 1.15; 139 participants; low‐certainty evidence). Three studies compared probiotics plus osmotic laxative to osmotic laxative alone in relation to withdrawals due to adverse events, but it is unclear if there is a difference between them (RR 2.86, 95% CI 0.12 to 68.35; 268 participants; very low‐certainty evidence). Two studies compared probiotics versus magnesium oxide. It is unclear if there is a difference in frequency of defecation (MD 0.28, 95% CI ‐0.58 to 1.14; 36 participants), treatment success (RR 1.08, 95% CI 0.74 to 1.57; 36 participants) or withdrawals due to adverse events (RR 0.50, 95% CI 0.05 to 5.04; 77 participants). The certainty of the evidence is very low for these outcomes. One study assessed the role of a synbiotic preparation in comparison to placebo. There may be higher treatment success in favour of synbiotics compared to placebo (RR 2.32, 95% CI 1.54 to 3.47; 155 participants; low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study assessed a synbiotic plus paraffin compared to paraffin alone. It is uncertain if there is a difference in frequency of defecation (MD 0.74, 95% CI ‐0.96, 2.44; 66 participants; very low‐certainty evidence), or treatment success (RR 0.91, 95% CI 0.71 to 1.17; 66 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. One study compared a synbiotic preparation to paraffin. It is uncertain if there is a difference in frequency of defecation (MD ‐1.53, 95% CI ‐3.00, ‐0.06; 60 participants; very low‐certainty evidence) or in treatment success (RR 0.86, 95% CI 0.65, 1.13; 60 participants; very low‐certainty evidence). The study reported that there were no withdrawals due to adverse effects in either group. All secondary outcomes were either not reported or reported in a way that did not allow for analysis. Authors' conclusions There is insufficient evidence to conclude whether probiotics are efficacious in successfully treating chronic constipation without a physical explanation in children or changing the frequency of defecation, or whether there is a difference in withdrawals due to adverse events when compared with placebo. There is limited evidence from one study to suggest a synbiotic preparation may be more likely than placebo to lead to treatment success, with no difference in withdrawals due to adverse events. There is insufficient evidence to draw efficacy or safety conclusions about the use of probiotics in combination with or in comparison to any of the other interventions reported. The majority of the studies that presented data on serious adverse events reported that no events occurred. Two studies did not report this outcome. Future studies are needed to confirm efficacy, but the research community requires guidance on the best context for probiotics in such studies, considering where they should be best considered in a potential treatment hierarchy and should align with core outcome sets to support future interpretation of findings. Plain language summary Probiotics for treatment of chronic constipation in children What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can be used to treat chronic constipation without a physical explanation in children (aged 0 to 18 years). We analysed data from 14 studies to answer this question. Key messages We were unable to draw conclusions when comparing probiotics to placebo for frequency of defecation in children treated for chronic constipation without a physical explanation. There may be no difference in treatment success between the two groups. There may not be a difference in frequency of defecation or treatment success when comparing probiotics and laxatives to using laxatives alone. We were unable to draw conclusions when comparing probiotics to magnesium oxide for frequency of defecation or treatment success. There may be a higher frequency of defecation in children treated with synbiotic preparations compared to placebo. There may not be a difference in participants withdrawing from the studies due to adverse events when comparing probiotic preparations to placebo. We were unable to draw conclusions on the safety of any of the other comparisons due to the low number of people who withdrew from the studies. What was studied in the review? Children often suffer from constipation for long periods of time, and when there is no underlying physical cause that can be found we call it 'functional constipation'. It has been suggested that probiotic and synbiotic preparations might help improve symptoms in these children. Probiotics are preparations that contain living bacteria that have been proposed to be beneficial to the digestive system. Synbiotics also include food substances that support the growth of these bacteria. There is currently no consensus about whether this is the case, or how these preparations are best used. What are the main results of the review? We searched for randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) comparing any probiotic or synbiotic treatment with any other treatment (such as dummy/placebo treatments) in children with chronic constipation without a physical explanation. We found 14 trials including a total of 1127 participants who were aged under 18. We made the following conclusions.
• There may be no difference in treatment success when comparing probiotics to placebo.
• We were unable to draw conclusions on whether there is a difference in the frequency of defecation.
• There may be no difference in treatment success when comparing probiotics and laxatives to laxatives alone.
• We were unable to draw conclusions on frequency of defecation or treatment success when comparing probiotics to magnesium oxide.
• Synbiotics may be better than placebo in improving the frequency of defection.
• There may be no difference in how many people withdrew from the trials because of side effects when comparing probiotics to placebo, or probiotics and laxative to laxative alone.
• We have limited confidence in the evidence because the studies only included a small number of children, and due to lack of detail on some of the methods used. All analyses were limited due to differences in the specific probiotics or the treatments they were compared with, low numbers of children included in the studies and, most importantly, the use of a range of different measures of success. This meant that combining studies was difficult, so the overall ability of this review to answer its core questions was limited. What next? Future studies are needed to find out how helpful probiotics are for childhood constipation. Researchers need to agree whether probiotics should be a first option therapy, an add‐on to other therapies, a second option after other therapies have failed, or a combination of all the above. Future research should measure the same items (known as a core outcome set) to ensure these results can support future reviews. How up‐to‐date is this review? This review is current to June 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wallace, C; Sinopoulou, V; Gordon, M; Akobeng, AK; Llanos-Chea, A; Hungria, G; Febo-Rodriguez, L; Fifi, A; Fernandez Valdes, L; Langshaw, A; Saps, M", "articleTypes": [], "doi": "10.1002/14651858.CD014257.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "edf69a33-7ee9-4a79-8dc2-7bd7e9c0aa8b", "pmid": "", "title": "Vasodilators for primary Raynaud's phenomenon", "imported": false, "abstract": "Abstract - Background Numerous agents have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered to be the drugs of choice, evidence of the effects of alternative pharmacological treatments is limited. This is an update of a review first published in 2008. Objectives To assess the effects of drugs with vasodilator effects on primary Raynaud's phenomenon as determined by frequency, severity, and duration of vasospastic attacks; quality of life; adverse events; and Raynauds Condition Score. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trial register to November 16, 2020. Selection criteria We included randomized controlled trials evaluating effects of oral, intravenous, and topical formulations of any drug with vasodilator effects on subjective symptoms, severity scores, and radiological outcomes in primary Raynaud's phenomenon. Treatment with calcium channel blockers was not assessed in this review, nor were these agents compared. Data collection and analysis Two review authors independently selected studies for inclusion, assessed studies using the Cochrane \"Risk of bias\" tool, and extracted study data. Outcomes of interest included frequency, severity, and duration of attacks; quality of life (QoL); adverse events (AEs); and the Raynaud Condition Score (RCS). We assessed the certainty of the evidence using GRADE. Main results We identified seven new studies for this update. In total, we included 15 studies involving 635 participants. These studies compared different vasodilators to placebo. Individual studies used different methods and measures to report different outcomes. Angiotensin‐converting enzyme (ACE) inhibitors Combining data from three studies revealed a possible small increase in the frequency of attacks per week after treatment (captopril or enalapril) compared to placebo (mean difference [MD] 0.79, 95% confidence interval [CI] 0.43 to 1.17; low‐certainty evidence). There was no evidence of a difference between groups in severity of attacks (MD ‐0.17, 95% CI ‐4.66 to 4.31; 34 participants, 2 studies; low‐certainty evidence); duration of attacks (MD 0.54, 95% CI ‐2.42 to 1.34; 14 participants, 1 study; low‐certainty evidence); or AEs (risk ratio [RR] 1.35, 95% CI 0.67 to 2.73; 46 participants, 3 studies; low‐certainty evidence). QoL and RCS were not reported. Alpha blockers Two studies used alpha blockers (buflomedil or moxisylyte). We were unable to combine data due to the way results were presented. Buflomedil probably reduced the frequency of attacks compared to placebo (MD ‐8.82, 95% CI ‐11.04 to ‐6.60; 31 participants, 1 study; moderate‐certainty evidence) and may improve severity scores (MD ‐0.41, 95% CI ‐0.62 to ‐0.30; moderate‐certainty evidence). With moxisylyte, investigators reported fewer attacks (P < 0.02), less severe symptoms (P < 0.01), and shorter duration of attacks, but the clinical relevance of these results is unclear. No evidence of a difference in AEs between buflomedil and placebo groups was noted (RR 1.41, 95% CI 0.27 to 7.28; 31 participants, 1 study; moderate‐certainty evidence). More AEs were observed in participants in the moxisylyte group than in the placebo group. Prostaglandin/prostacyclin analogues One study compared beraprost versus placebo. There was no evidence of benefit for frequency (MD 2.00, 95% CI ‐0.35 to 4.35; 118 participants, low‐certainty evidence) or severity (MD ‐0.06, 95% CI ‐0.34 to 0.22; 118 participants, low‐certainty evidence) of attacks. Overall, more AEs were noted in the beraprost group (RR 1.59, 95% CI 1.05 to 2.42; 125 participants; low‐certainty evidence). This study did not report on duration of attacks, QoL, or RCS. Thromboxane synthase inhibitors One study compared a thromboxane synthase inhibitor (dazoxiben) versus placebo. There was no evidence of benefit for frequency of attacks (MD 0.8, 95% CI ‐1.81 to 3.41; 6 participants; very low‐certainty evidence). Adverse events were not reported in subgroup analyses of participants with primary Raynaud's phenomenon, and the study did not report on duration of attacks, severity of symptoms, QoL, or RCS. Selective serotonin reuptake inhibitors One study compared ketanserin with placebo. There may be a slight reduction in the number of attacks per week with ketanserin compared to placebo (MD ‐14.0, 95% CI ‐27.72 to ‐0.28; 41 participants; very low‐certainty evidence) and reduced severity score (MD ‐133.00, 95% CI ‐162.40 to ‐103.60; 41 participants; very low‐certainty evidence). There was no evidence that ketanserin reduced the duration of attacks (MD ‐4.00, 95% CI ‐14.82 to 6.82; 41 participants; very low‐certainty evidence), or that AEs were increased in either group (RR 1.54, 95% CI 0.89 to 2.65; 41 participants; very low‐certainty evidence). This study did not report on QoL or RCS. Nitrate/nitrate derivatives Four studies compared topical treatments of nitroglycerin or glyceryl trinitrate versus placebo, each reporting on limited outcomes. Meta‐analysis demonstrated no evidence of effect on frequency of attacks per week (MD ‐1.57, 95% CI ‐4.31 to 1.17; 86 participants, 2 studies; very low‐certainty evidence). We were unable to pool any data for the remaining outcomes. Phosphodiesterase inhibitors Three studies compared phosphodiesterase inhibitors (vardenafil, cilostazol or PF‐00489791) to an equivalent placebo. Results showed no evidence of a difference in frequency of attacks (standardized MD [SMD] ‐0.05, 95% CI ‐6.71 to 6.61; 111 participants, 2 studies; low‐certainty evidence), severity of attacks (MD ‐0.03, 95% CI ‐1.04 to 0.97; 111 participants, 2 studies; very low‐certainty evidence), duration of attacks (MD ‐1.60, 95% CI ‐7.51 to 4.31; 73 participants, 1 study; low‐certainty evidence), or RCS (SMD ‐0.8, 95% CI ‐1.74 to 0.13; 79 participants, 2 studies; low‐certainty evidence). Study authors reported that 35% of participants on cilostazol complained of headaches, which were not reported in the placebo group. PF‐00489791 caused 34 of 54 participants to experience AEs versus 43 of 102 participants receiving placebo (RR 1.49). Headache was most common, affecting 14 participants (PF‐00489791) versus nine participants (placebo). Authors' conclusions The included studies investigated several different vasodilators (topical and oral) for treatment of primary Raynaud's phenomenon. Small sample sizes, limited data, and variability in outcome reporting yielded evidence of very low to moderate certainty. Evidence is insufficient to support the use of vasodilators and suggests that vasodilator use may even worsen disease. Plain language summary Vasodilator drugs to reduce the symptoms of primary Raynaud's phenomenon Background Raynaud's phenomenon (RP) is a condition affecting the small blood vessels in the extremities, usually in the fingers but also in the toes and other body parts. It is caused by temporary narrowing of the blood vessels, which leads to color changes with associated numbness, tingling, and pain. Various triggers for this condition are known, such as stress, cold, and use of vibrational hand tools. Conservative measures to control this condition include stopping smoking and maintaining both peripheral and ambient warmth. Medications that dilate the blood vessels such as calcium channel blockers (CCBs) may be used but can have side effects. This review aims to investigate the effectiveness and safety of drugs that dilate the blood vessels other than CCBs. Study characteristics and key results We found seven new studies for this update, bringing the total to 15 (search was good to November 16, 2020). This update now includes other routes of administration such as through the veins (intravenous) and the skin (topical), in contrast to previous reviews, which focused on oral forms of treatment. The studies were published between 1989 and 2013 and involved a total of 635 participants randomly assigned to receive treatment or placebo control. Many studies did not describe various aspects of study methods such as randomization, allocation concealment, and blinding. Treatment duration varied between two weeks and six months.
Angiotensin‐converting enzyme (ACE) inhibitors as a drug class, specifically enalapril and captopril in this review, in general increased the frequency of Raynaud's attacks per week but did not affect the severity of the attacks. Enalapril worsened subjective assessment of improvement, and captopril did not improve subjective outcomes or digital blood flow. Buflomedil showed a small reduction in the frequency and severity of attacks with increased side effects. Beraprost and dazoxiben did not demonstrate any change in frequency or severity of attacks nor in disability score and were associated with increased side effects. Ketanserin did not demonstrate improvement in frequency or duration of attacks nor in digital blood flow but did demonstrate improvement in severity scoring of RP. In a small study, moxisylyte was shown to reduce the frequency and severity of attacks to a small degree but with increased side effects. Topical glyceryl trinitrate did not show any effect on reducing the frequency of attacks per week. One study reported subjective improvement in Raynaud Condition Score (RCS). One small study reported improvements in frequency and severity of attacks as subjective changes. Headaches were the most significant and common side effect of treatment. Phosphodiesterase inhibitors did not cause a reduction in frequency, severity, or duration of attacks and did not improve RCS. One study reported in favor of vardenafil alone to reduce RCS but found that the effect is likely small. One study reported that cilostazol increased the frequency and severity of attacks; more research is needed to confirm this finding. Risk of headache as a side effect of treatment was increased with cilostazol use. PF‐00489791 at a dose of 20 mg was found to slightly improve all subjective outcome measures and RCS. Reliability of the evidence We have very low to moderate confidence in these results, so we cannot make any firm conclusions about the benefit of these drugs for improving symptoms of primary RP. We cannot be confident because of the small numbers of participants involved in studies, issues with how studies were designed, and differences in how they measured whether or not treatments were effective. Therefore, the clinical importance of these results is difficult to assess, especially when placebo response is high. It is also pertinent that the results for each drug class and for individual drugs within each drug class must be interpreted in the context that they may have varying pharmacologic effects in addition to vasodilation. This must be taken into consideration when any conclusions are made about the overall effects of each drug class and/or individual drug.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Su, KYC; Sharma, M; Kim, HJ; Kaganov, E; Hughes, I; Abdeen, MH; Ng, JH", "articleTypes": [], "doi": "10.1002/14651858.CD006687.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "edf9cbde-72cc-4d9d-ab07-973e6cd0d731", "pmid": "", "title": "Post COVID-19 Syndrome: A Pilot Study to Explore the Gut-lung Axis", "imported": false, "abstract": "The outbreak of the novel coronavirus (SARS-CoV-2)-infected disease (COVID-19) began in December 2019, spread throughout China in early 2020 and developed as a pandemic thereafter.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.237Z" }, { "id": "ee0a08fd-714a-4195-b482-89ece7099e68", "pmid": "", "title": "Macrolide antibiotics (including azithromycin) for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a life‐limiting genetic condition, affecting over 90,000 people worldwide. CF affects several organs in the body, but airway damage has the most profound impact on quality of life (QoL) and survival. Causes of lower airway infection in people with CF are, most notably, Staphylococcus aureus in the early course of the disease and Pseudomonas aeruginosa at a later stage. Macrolide antibiotics, e.g. azithromycin and clarithromycin, are usually taken orally, have a broad spectrum of action against gram‐positive (e.g. S aureus ) and some gram‐negative bacteria (e.g. Haemophilus influenzae ), and may have a modifying role in diseases involving airway infection and inflammation such as CF. They are well‐tolerated and relatively inexpensive, but widespread use has resulted in the emergence of resistant bacteria. This is an updated review. Objectives To assess the potential effects of macrolide antibiotics on clinical status in terms of benefit and harm in people with CF. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals, and abstract books of conference proceedings. We last searched the Group's Cystic Fibrosis Trials Register on 2 November 2022. We last searched the trial registries WHO ICTRP and clinicaltrials.gov on 9 November 2022. We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow‐up data, where possible. Selection criteria We included randomised controlled trials of macrolide antibiotics in adults and children with CF. We compared them to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose or type of administration. Data collection and analysis Two authors independently extracted data and assessed risk of bias. We assessed the certainty of evidence using GRADE. Main results We included 14 studies (1467 participants) lasting 28 days to 36 months. All the studies assessed azithromycin: 11 compared oral azithromycin to placebo (1167 participants); one compared a high dose to a low dose (47 participants); one compared nebulised to oral azithromycin (45 participants); and one looked at weekly versus daily dose (208 participants). Oral azithromycin versus placebo There is a slight improvement in forced expiratory volume (FEV 1 % predicted) in one second in the azithromycin group at up to six months compared to placebo (mean difference (MD) 3.97, 95% confidence interval (CI) 1.74 to 6.19; high‐certainty evidence), although there is probably no difference at three months, (MD 2.70%, 95% CI ‐0.12 to 5.52), or 12 months (MD ‐0.13, 95% CI ‐4.96 to 4.70). Participants in the azithromycin group are probably at a decreased risk of pulmonary exacerbation with a longer time to exacerbation (hazard ratio (HR) 0.61, 95% CI 0.50 to 0.75; moderate‐certainty evidence). Mild side effects were common, but there was no difference between groups (moderate‐certainty evidence). There is no difference in hospital admissions at six months (odds ratio (OR) 0.61, 95% CI 0.36 to 1.04; high‐certainty evidence), or in new acquisition of P aeruginosa at 12 months (HR 1.00, 95% CI 0.64 to 1.55; moderate‐certainty evidence). High‐dose versus low‐dose azithromycin We are uncertain whether there is any difference in FEV 1 % predicted at six months between the two groups (no data available) or in the rate of exacerbations per child per month (MD ‐0.05 (95% CI ‐0.20 to 0.10)); very low‐certainty evidence for both outcomes. Only children were included in the study and the study did not report on any of our other clinically important outcomes. Nebulised azithromycin versus oral azithromycin We were unable to include any of the data into our analyses and have reported findings directly from the paper; we graded all evidence as being of very low certainty. The authors reported that there was a greater mean change in FEV 1 % predicted at one month in the nebulised azithromycin group (P < 0.001). We are uncertain whether there was a change in P aeruginosa count. Weekly azithromycin versus daily azithromycin There is probably a lower mean change in FEV 1 % predicted at six months in the weekly group compared to the daily group (MD ‐0.70, 95% CI ‐0.95 to ‐0.45) and probably also a longer period of time until first exacerbation in the weekly group (MD 17.30 days, 95% CI 4.32 days to 30.28 days). Gastrointestinal side effects are probably more common in the weekly group and there is likely no difference in admissions to hospital or QoL. We graded all evidence as moderate certainty. Authors' conclusions Azithromycin therapy is associated with a small but consistent improvement in respiratory function, a decreased risk of exacerbation and longer time to exacerbation at six months; but evidence for treatment efficacy beyond six months remains limited. Azithromycin appears to have a good safety profile (although a weekly dose was associated with more gastrointestinal side effects, which makes it less acceptable for long‐term therapy), with a relatively minimal treatment burden for people with CF, and it is inexpensive. A wider concern may be the emergence of macrolide resistance reported in the most recent study which, combined with the lack of long‐term data, means we do not feel that the current evidence is strong enough to support azithromycin therapy for all people with CF. Future research should report over longer time frames using validated tools and consistent reporting, to allow for easier synthesis of data. In particular, future trials should report important adverse events such as hearing impairment or liver disease. More data on the effects of azithromycin given in different ways and reporting on our primary outcomes would benefit decision‐making on whether and how to give macrolide antibiotics. Finally, it is important to assess azithromycin therapy for people with CF who are established on the relatively new cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies which correct the underlying molecular defect associated with CF (none of the trials included in the review are relevant to this population). Plain language summary Treatment with macrolide antibiotics (including azithromycin) for people with cystic fibrosis Review question What are the effects of macrolide antibiotics in people with cystic fibrosis (CF) and infection of their airways? Key messages ‐ People with CF are more prone to chest infections caused by bacteria that can be hard to treat. ‐ Macrolide antibiotics (such as azithromycin and clarithromycin) may lessen the effects of bacteria. ‐ One macrolide antibiotic, azithromycin, can improve lung function at six months compared to a placebo (treatment with no active ingredient) and may reduce the risk of getting a flare‐up of lung infection. We are not sure whether a higher dose of azithromycin is any better than a lower dose, or if azithromycin when inhaled is any better than azithromycin when swallowed (oral). Oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. ‐ Current evidence does not support longer‐term use of azithromycin for all people with CF. Introduction People with CF suffer from infections in their airways, often caused by the bug Pseudomonas aeruginosa , which is resistant to nearly all antibiotics that can be swallowed (oral). Macrolide antibiotics, e.g. azithromycin and clarithromycin, have no direct killing effect on Pseudomonas aeruginosa , but they may reduce the activity of these bacteria. What did we want to find out? We wanted to discover whether the use of macrolide antibiotics (usually taken orally) affected the health of people with CF and whether these drugs have any side effects. What did we do? We searched for studiesthat looked at the effects of macrolide antibiotics in children and adults with CF and summarised the evidence. What did we find? We found 14 studies, which put the total of 1467 children and adults into different treatment groups at random, which we included in this review. Eleven studies compared azithromycin to placebo, one compared two different doses of azithromycin (high versus low dose), one compared inhaled azithromycin to oral azithromycin, and one compared oral azithromycin once a week to once a day. Main results We found that there was a slight improvement in lung function in people that were given azithromycin compared to a placebo at six months and also that the risk of a flare‐up of infection was lower. The risk of side effects (such as vomiting, diarrhoea and headache) was similar in both groups, as was the chance of a new infection with Pseudomonas aeruginosa. In terms of lung function and flare‐up of infection, we were unsure whether a higher dose of azithromycin is better than a lower dose (but only one study in children examined dose), or whether inhaled azithromycin is better than oral azithromycin. Taking oral azithromycin once a week compared to every day probably leads to less of an improvement in lung function, but there is probably a longer time to a flare‐up in the weekly group. What are the limitations of the evidence? We were unable to combine all the study results because they were measured in different ways and at different time points; future trials should address this issue. Also, now that many people with CF are being treated with the new modulator therapies (e.g. elexacaftor‐tezacaftor‐ivacaftor), it is important to assess how macrolide antibiotics affect the health of these people. In the studies we found for this review, none of the people taking part were being treated with modulator therapies. We are able to report the results of the studies that compared azithromycin to placebo with certainty as the studies were well conducted and included a larger number of participants. The evidence from the studies comparing high and low doses or nebulised and oral azithromycin was much less certain because the studies were small and there was risk of bias in the way they were carried out. We were moderately certain of the results of the study comparing weekly azithromycin to daily azithromycin. How up to date is this evidence? The studies we have reported are the most up to date we could find. We last searched for studies in November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Southern, KW, Solis-Moya, A, Kurz, D, Smith, S", "articleTypes": [], "doi": "10.1002/14651858.CD002203.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.120Z" }, { "id": "ee3d482c-b2be-4c2c-9344-28aa804c09e3", "pmid": "", "title": "Nicotine replacement therapy versus control for smoking cessation", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence. Objectives To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long‐term smoking cessation, compared to placebo or 'no NRT' interventions. Search methods We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017. Selection criteria Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow‐up of less than six months. We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews. Data collection and analysis Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow‐up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta‐analysis using a Mantel‐Haenszel fixed‐effect model. Main results We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non‐NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare. Authors' conclusions There is high‐quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non‐ischaemic chest pain and palpitations. Plain language summary Can nicotine replacement therapy (NRT) help people quit smoking? Background We reviewed the evidence about whether NRT helps people who want to quit smoking to stop smoking at six months or longer. NRT aims to reduce withdrawal symptoms associated with stopping smoking by replacing the nicotine from cigarettes. NRT is available as skin patches that deliver nicotine slowly, and chewing gum, nasal and oral sprays, inhalators, and lozenges/tablets, all of which deliver nicotine to the brain more quickly than skin patches, but less rapidly than from smoking cigarettes. Study characteristics This review includes 136 trials of NRT, with 64,640 people in the main analysis. All studies were conducted in people who wanted to quit smoking. Most studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. The evidence is current to July 2017. Trials lasted for at least six months. Key results We found evidence that all forms of NRT made it more likely that a person's attempt to quit smoking would succeed. The chances of stopping smoking were increased by 50% to 60%. NRT works with or without additional counselling, and does not need to be prescribed by a doctor. Side effects from using NRT are related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. There is no evidence that NRT increases the risk of heart attacks. Quality of evidence The overall quality of the evidence is high, meaning that further research is very unlikely to change our conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hartmann‐Boyce, J, Chepkin, SC, Ye, W, Bullen, C, Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD000146.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.745Z" }, { "id": "ee44da20-4453-46a8-b09b-31044fcd4c90", "pmid": "", "title": "Mindfulness‐enhanced parenting programmes for improving the psychosocial outcomes of children (0 to 18 years) and their parents", "imported": false, "abstract": "Abstract - Background Emotional and behavioural difficulties (EBD) in children are common, characterised by externalising or internalising behaviours that can be highly stable over time. EBD are an important cause of functional disability in childhood, and predictive of poorer psychosocial, academic, and occupational functioning into adolescence and adulthood. The prevalence, stability, and long‐term consequences of EBD highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Multiple factors contribute to the aetiology of EBD in children, and parenting plays an important role. The relationship between parenting and EBD has been described as bidirectional, with parents and children shaping one another’s behaviour. One consequence of bidirectionality is that parents with insufficient parenting skills may become involved in increasingly negative behaviours when dealing with non‐compliance in children. This can have a cyclical effect, exacerbating child behavioural difficulties and further increasing parental distress. Behavioural or skills‐based parenting training can be highly effective in addressing EBD in children. However, emotional dysregulation may intercept some parents' ability to implement parenting skills, and there is recognition that skills‐based interventions may benefit from adjunct components that better target parental emotional responses. Mindful parenting interventions have demonstrated some efficacy in improving child outcomes via improvements in parental emotion regulation, and there is potential for mindfulness training to enhance the effectiveness of standard parent training programmes. Objectives To assess the effectiveness of mindfulness‐enhanced parent training programmes on the psychosocial functioning of children (aged 0 to 18 years) and their parents. Search methods We searched the following databases up to April 2023: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, PsycINFO, Sociological Abstracts, Social Sciences Citation Index, Conference Proceedings Citation Index – Social Science & Humanities, AMED, ERIC, ProQuest Dissertations & Theses, Cochrane Database of Systematic Reviews, Campbell Collaboration Library of Systematic Reviews, as well as the following trials registers: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also contacted organisations/experts in the field. Selection criteria We included randomised and quasi‐randomised trials. Participants were parents or caregivers of children under the age of 18. The intervention was mindfulness‐enhanced parent training programmes compared with a no‐intervention, waitlist, or attentional control, or a parent training programme with no mindfulness component. The intervention must have combined mindfulness parent training with behavioural or skills‐based parent training. We defined parent training programmes in terms of the delivery of a standardised and manualised intervention over a specified and limited period, on a one‐to‐one or group‐basis, with a well‐defined mindfulness component. The mindfulness component must have included mindfulness training (breath, visualisation, listening, or other sensory focus) and an explicit focus on present‐focused attention and non‐judgemental acceptance. Data collection and analysis We followed standard Cochrane procedures. Main results Eleven studies met our inclusion criteria, including one ongoing study. The studies compared a mindfulness‐enhanced parent training programme with a no‐treatment, waitlist, or attentional control (2 studies); a parent training programme with no mindfulness component (5 studies); both a no‐treatment, waitlist, or attentional control and a parent training programme with no mindfulness component (4 studies). We assessed all studies as being at an unclear or high risk of bias across multiple domains. We pooled child and parent outcome data from 2118 participants to produce effect estimates. No study explicitly reported on self‐compassion, and no adverse effects were reported in any of the studies. Mindfulness‐enhanced parent training programmes compared to a no‐treatment, waitlist, or attentional control Very low certainty evidence suggests there may be a small to moderate postintervention improvement in child emotional and behavioural adjustment (standardised mean difference (SMD) −0.46, 95% confidence interval (CI) −0.96 to 0.03; P = 0.06, I 2 = 62%; 3 studies, 270 participants); a small improvement in parenting skills (SMD 0.22, 95% CI 0.06 to 0.39; P = 0.008, I 2 = 0%; 3 studies, 587 participants); and a moderate decrease in parental depression or anxiety (SMD −0.50, 95% CI −0.96 to −0.04; P = 0.03; 1 study, 75 participants). There may also be a moderate to large decrease in parenting stress (SMD −0.79, 95% CI −1.80 to 0.23; P = 0.13, I 2 = 82%; 2 studies, 112 participants) and a small improvement in parent mindfulness (SMD 0.21, 95% CI −0.14 to 0.56; P = 0.24, I 2 = 69%; 3 studies, 515 participants), but we were not able to exclude little to no effect for these outcomes. Mindfulness‐enhanced parent training programmes compared to parent training with no mindfulness component Very low certainty evidence suggests there may be little to no difference postintervention in child emotional and behavioural adjustment (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.71, I 2 = 64%; 5 studies, 203 participants); parenting skills (SMD 0.13, 95% CI −0.16 to 0.42; P = 0.37, I 2 = 16%; 3 studies, 319 participants); and parent mindfulness (SMD 0.11, 95% CI −0.19 to 0.41; P = 0.48, I 2 = 44%; 4 studies, 412 participants). There may be a slight decrease in parental depression or anxiety (SMD −0.24, 95% CI −0.83 to 0.34; P = 0.41; 1 study, 45 participants; very low certainty evidence), though we cannot exclude little to no effect, and a moderate decrease in parenting stress (SMD −0.51, 95% CI −0.84 to −0.18; P = 0.002, I 2 = 2%; 3 studies, 150 participants; low certainty evidence). Authors' conclusions Mindfulness‐enhanced parenting training may improve some parent and child outcomes, with no studies reporting adverse effects. Evidence for the added value of mindfulness training to skills‐based parenting training programmes is suggestive at present, with moderate reductions in parenting stress. Given the very low to low certainty evidence reviewed here, these estimates will likely change as more high‐quality studies are produced. Plain language summary Mindfulness‐enhanced parenting programs for improving outcomes for children and their parents Key messages • Mindfulness‐enhanced parent training programmes may improve some child and parent outcomes, including child emotional and behavioural adjustment, parenting skills, parental depression or anxiety, parenting stress, and parent mindfulness. • When mindfulness parent training is combined with a skills‐based parent training programme, this may decrease parenting stress. • The current body of evidence is limited, with more research needed to be confident in our findings. Children's emotional and behavioural difficulties Emotional and behavioural difficulties in children are common, and are characterised by a range of externalising and/or internalising behaviours that can be highly stable over time. They are an important cause of functional disability in childhood, and predictive of poor psychosocial, academic, and occupational functioning into adolescence and beyond. The prevalence, stability, and long‐term consequences of emotional and behavioural difficulties highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Why mindfulness‐enhanced parent training? Parenting plays an important role in the development and/or maintenance of emotional and behavioural difficulties in children. Traditional behavioural or skills‐based parent training programmes have been shown to have a positive impact on a range of child and parent outcomes, but they do not work for all parents. One reason for this might be that parents' emotional reactions could prevent them from using parenting skills effectively. Including additional components into parenting training that aim to improve parental emotional responses may enhance the outcomes of these programmes. Recent research shows that mindful parenting interventions may promote positive outcomes for parents and children by improving parents' ability to regulate emotions and stress. Combining mindful parenting approaches with traditional parent training programmes may therefore be beneficial for both parents and their children. What did we want to find out? We explored whether behavioural or skills‐based parent training programmes with a mindfulness component – 'mindfulness‐enhanced' parent training programmes – can improve outcomes for children and their caregivers. What did we do? We searched a range of sources for literature that evaluated the effectiveness of mindfulness‐enhanced parent training programmes, including electronic databases, trial registries, and organisations and experts in the field. We included studies evaluating these interventions using randomised controlled trials (studies where participants are randomly assigned to one of two or more treatment groups) or quasi experimental designs (where participants are assigned to different treatment groups using a method that is not truly random). We included studies that assessed child emotional and behavioural adjustment, and/or a range of parent outcomes, including parenting skills, parenting stress, depression or anxiety, mindfulness or self‐compassion. What did we find out? We included 11 studies and data from 2118 participants in the review. The studies compared the outcomes of children or parents (or both) who participated in a mindfulness‐enhanced parent training programme to the outcomes of children or parents (or both) who did not participate in parent training, or who participated in an alternate behavioural or skills‐based parent training programme. When we combined the findings from these studies, we found that mindfulness‐enhanced parent training, when compared to no intervention, may improve child emotional and behavioural adjustment, parenting skills, parenting stress, parental depression and anxiety, and mindfulness, but we are very uncertain about these results. Evidence for the added value of mindfulness training when included in a skills‐based parent training programme suggests that mindfulness training may further promote reductions in parenting stress, and may also further reduce parental depression or anxiety, but we are uncertain about these results. It is unclear from the current body of evidence whether adding mindfulness training to a skills‐based parent training intervention has any further effect on child emotional and behavioural adjustment, parenting skills, or mindfulness. No studies reported adverse effects or measured self‐compassion. What are the limitations of the evidence? We are not confident in the overall body of evidence. This is primarily because there was a lot of variation across the interventions and the participant groups, as well as how the outcomes were measured. The studies were also usually quite small, and participants were likely to be aware of what intervention they were receiving, which can sometimes influence the results. It is likely that these findings will change as more studies are undertaken in this area of research. How up‐to‐date is this evidence? We searched for and included research up to April 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Featherston, R; Barlow, J; Song, Y; Haysom, Z; Loy, B; Tufford, L; Shlonsky, A", "articleTypes": [], "doi": "10.1002/14651858.CD012445.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "ee48648f-448a-4bc4-bc91-b2cf8448ce5e", "pmid": "", "title": "Homeopathic medicinal products for preventing and treating acute respiratory tract infections in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common and may lead to complications. Most children experience between three and six ARTIs annually. Although most infections are self‐limiting, symptoms can be distressing. Many treatments are used to control symptoms and shorten illness duration. Most treatments have minimal benefit and may lead to adverse events. Oral homeopathic medicinal products could play a role in childhood ARTI management if evidence for their effectiveness is established. This is an update of a review first published in 2018. Objectives To assess the effectiveness and safety of oral homeopathic medicinal products compared with placebo or conventional therapy to prevent and treat ARTIs in children. Search methods We searched CENTRAL (2022, Issue 3), including the Cochrane Acute Respiratory Infections Specialised Register, MEDLINE (1946 to 16 March 2022), Embase (2010 to 16 March 2022), CINAHL (1981 to 16 March 2022), AMED (1985 to 16 March 2022), CAMbase (searched 16 March 2022), and British Homeopathic Library (searched 26 June 2013 ‐ no longer operating). We also searched the WHO ICTRP and ClinicalTrials.gov (16 March 2022), checked references, and contacted study authors to identify additional studies. Selection criteria We included double‐blind randomised controlled trials (RCTs) or double‐blind cluster‐RCTs comparing oral homeopathy medicinal products with identical placebo or self‐selected conventional treatments to prevent or treat ARTIs in children aged 0 to 16 years. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results In this 2022 update, we identified three new RCTs involving 251 children, for a total of 11 included RCTs with 1813 children receiving oral homeopathic medicinal products or a control treatment (placebo or conventional treatment) for ARTIs. All studies focused on upper respiratory tract infections (URTIs), with only one study including some lower respiratory tract infections (LRTIs). Six treatment studies examined the effect on URTI recovery, and five studies investigated the effect on preventing URTIs after one to four months of treatment. Two treatment and three prevention studies involved homeopaths individualising treatment. The other studies used predetermined, non‐individualised treatments. All studies involved highly diluted homeopathic medicinal products, with dilutions ranging from 1 x 10 ‐4 to 1 x 10 ‐200 . We identified several limitations to the included studies, in particular methodological inconsistencies and high attrition rates, failure to conduct intention‐to‐treat analysis, selective reporting, and apparent protocol deviations. We assessed three studies as at high risk of bias in at least one domain, and many studies had additional domains with unclear risk of bias. Four studies received funding from homeopathy manufacturers; one study support from a non‐government organisation; two studies government support; one study was co‐sponsored by a university; and three studies did not report funding support. Methodological inconsistencies and significant clinical and statistical heterogeneity precluded robust quantitative meta‐analysis. Only four outcomes were common to more than one study and could be combined for analysis. Odds ratios (OR) were generally small with wide confidence intervals (CI), and the contributing studies found conflicting effects, so there was little certainty that the efficacy of the intervention could be ascertained. All studies assessed as at low risk of bias showed no benefit from oral homeopathic medicinal products, whilst trials at unclear or high risk of bias reported beneficial effects. For the comparison of individualised homeopathy versus placebo or usual care for the prevention of ARTIs, two trials reported on disease severity; due to heterogeneity the data were not combined, but neither study demonstrated a clinically significant difference. We combined data from two trials for the outcome need for antibiotics (OR 0.79, 95% CI 0.35 to 1.76; low‐certainty evidence). For the comparison of non‐individualised homeopathy versus placebo or usual care for the prevention of ARTIs, only the outcome recurrence of ARTI was reported by more than one trial; data from three studies were combined for this outcome (OR 0.60, 95% CI 0.21 to 1.72; low‐certainty evidence). For the comparison of both individualised and non‐individualised homeopathy versus placebo or usual care for the treatment of ARTIs, two studies provided data on short‐term cure (OR 1.31, 95% CI 0.09 to 19.54) and long‐term cure (OR 1.01, 95% CI 0.10 to 9.96; very low‐certainty evidence). The studies demonstrated an opposite direction of effect for both outcomes. Six studies reported on disease severity but were not combined as they used different scoring systems and scales. Three studies reported adverse events (OR 0.79, 95% CI 0.16 to 4.03; low‐certainty evidence). Authors' conclusions Pooling of five prevention and six treatment studies did not show any consistent benefit of homeopathic medicinal products compared to placebo on ARTI recurrence or cure rates in children. We assessed the certainty of the evidence as low to very low for the majority of outcomes. We found no evidence to support the efficacy of homeopathic medicinal products for ARTIs in children. Adverse events were poorly reported, and we could not draw conclusions regarding safety. Plain language summary What are the benefits and risks of oral homeopathic medicines in preventing and treating acute respiratory tract infections in children? Key messages Homeopathy is a type of complementary and alternative medicine. It is based on two main ideas: that substances that may cause illness or symptoms in a healthy person can, in very small doses, treat those symptoms in a person who is unwell; and that molecules in highly diluted substances retain a memory of the original substance. Due to a lack of solid evidence, the benefits and risks of oral homeopathic medicines for preventing and treating acute respiratory tract infections (ARTIs) in children are unclear. Studies of lower quality in design and reporting often suggest a possible benefit for oral homeopathic medicines, but studies of higher quality do not find benefit. What are respiratory tract infections? Respiratory infections are commonly caused by viruses, especially colds and influenza, though some lung and ear infections are caused by bacteria. It may be difficult to tell these infections apart, and sometimes they occur together. Most such infections improve without treatment, but sometimes symptoms persist after the initial infection has gone. Treatment is therefore aimed at relieving symptoms. Why is this important in children? Children have on average three to six respiratory tract infections each year. Although most are mild and treatable, they are sometimes acute (serious, swift, or sudden onset) respiratory tract infections that may require hospital treatment, but very rarely result in death. How are ARTIs treated? Antibiotic medicines taken orally (by mouth/swallowed, usually in the form of a tablet, pill, lozenge, or liquid) are often prescribed for ARTIs, even though they are ineffective against viruses. Homeopathic medicines may treat ARTIs with few side effects, but their effectiveness and safety has not been well researched. What did we want to find out? We wanted to know whether homeopathic medicines help children with ARTIs. We were interested in the effect of homeopathic medicines compared to placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) or to usual care therapies for ARTIs. We were also interested in the effect of homeopathic medicines on improvement in the severity or symptoms of infection, the need for antibiotics, duration of illness (that would affect days off school or days off work for parents), symptom reappearance, and any medicine adverse effects. What did we do? We searched for randomised controlled trials (studies where people are randomly assigned to one of two or more treatment groups) that investigated whether oral homeopathic medicines, compared to placebo or usual care ARTI therapies, were effective in the prevention or treatment of ARTIs in children aged up to 16 years. We compared and summarised the results of the studies, and rated our confidence in the evidence based on factors such as study methods and number of participants. What did we find? We found 11 studies involving 1813 children (5 studies for prevention and 6 studies for treatment of ARTIs). All studies investigated upper respiratory tract (from the nose to the windpipe (trachea)) infections, but one study combined reporting of upper and lower respiratory tract (from the windpipe to the lungs and pleura (membranes covering the lungs)) infections, so the numbers of children with upper or lower ARTIs is unknown. Main results In the treatment or prevention of ARTIs in children, homeopathic medicines showed little or no beneficial effects, whether individualised by a trained homeopath or a standard commercially available homeopathic therapy (11 studies, 1813 children). Where results could be combined, there was little or no difference between groups for short‐term cure (2 studies, 155 participants) or long‐term cure (2 studies, 155 participants), but the evidence is very uncertain. There may be little or no difference between groups for prevention of ARTI (3 studies, 735 participants). There was no important difference between homeopathy and placebo groups for parents' time off work, antibiotic use, or adverse events. We are unsure about the safety of homeopathic medicines because data on adverse events were poorly reported. Overall, the findings of this review do not support the use of homeopathic medicinal products for ARTIs in children. What are the limitations of the evidence? We have little confidence in the evidence because the studies involved only small numbers of children, used different types of homeopathic medicines for various ARTIs, contained numerous biases, and failed to report information about important outcomes. Further research could provide results that differ from the results of this review. How up‐to‐date is this evidence? The evidence is current to 16 March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hawke, K; King, D; van Driel, ML; McGuire, TM", "articleTypes": [], "doi": "10.1002/14651858.CD005974.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "ee5a804c-a52b-488f-84b8-508c74928b7c", "pmid": "", "title": "Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment", "imported": false, "abstract": "Abstract - Background Vitamins and minerals have many functions in the nervous system which are important for brain health. It has been suggested that various different vitamin and mineral supplements might be useful in maintaining cognitive function and delaying the onset of dementia. In this review, we sought to examine the evidence for this in people who already had mild cognitive impairment (MCI). Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function and the incidence of dementia in people with mild cognitive impairment. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CENTRAL, CINAHL, LILACs, Web of Science Core Collection, ClinicalTrials.gov, and the WHO Portal/ICTRP, from inception to 25 January 2018. Selection criteria We included randomised or quasi‐randomised, placebo‐controlled trials which evaluated orally administered vitamin or mineral supplements in participants with a diagnosis of mild cognitive impairment and which assessed the incidence of dementia or cognitive outcomes, or both. We were interested in studies applicable to the general population of older people and therefore excluded studies in which participants had severe vitamin or mineral deficiencies. Data collection and analysis We sought data on our primary outcomes of dementia incidence and overall cognitive function and on secondary outcomes of episodic memory, executive function, speed of processing, quality of life, functional performance, clinical global impression, adverse events, and mortality. We conducted data collection and analysis according to standard Cochrane systematic review methods. We assessed the risk of bias of included studies using the Cochrane 'Risk of bias' assessment tool. We grouped vitamins and minerals according to their putative mechanism of action and, where we considered it to be clinically appropriate, we pooled data using random‐effects methods. We used GRADE methods to assess the overall quality of evidence for each comparison and outcome. Main results We included five trials with 879 participants which investigated B vitamin supplements. In four trials, the intervention was a combination of vitamins B6, B12, and folic acid; in one, it was folic acid only. Doses varied. We considered there to be some risks of performance and attrition bias and of selective outcome reporting among these trials. Our primary efficacy outcomes were the incidence of dementia and scores on measures of overall cognitive function. None of the trials reported the incidence of dementia and the evidence on overall cognitive function was of very low‐quality. There was probably little or no effect of B vitamins taken for six to 24 months on episodic memory, executive function, speed of processing, or quality of life. The evidence on our other secondary clinical outcomes, including harms, was very sparse or very low‐quality. There was evidence from one study that there may be a slower rate of brain atrophy over two years in participants taking B vitamins. The same study reported subgroup analyses based on the level of serum homocysteine (tHcy) at baseline and found evidence that B vitamins may improve episodic memory in those with tHcy above the median at baseline. We included one trial (n = 516) of vitamin E supplementation. Vitamin E was given as 1000 IU of alpha‐tocopherol twice daily. We considered this trial to be at risk of attrition and selective reporting bias. There was probably no effect of vitamin E on the probability of progression from MCI to Alzheimer's dementia over three years (HR 1.02; 95% CI 0.74 to 1.41; n = 516; 1 study, moderate‐quality evidence). There was also no evidence of an effect at intermediate time points. The available data did not allow us to conduct analyses, but the authors reported no significant effect of three years of supplementation with vitamin E on overall cognitive function, episodic memory, speed of processing, clinical global impression, functional performance, adverse events, or mortality (five deaths in each group). We considered this to be low‐quality evidence. We included one trial (n = 256) of combined vitamin E and vitamin C supplementation and one trial (n = 26) of supplementation with chromium picolinate. In both cases, there was a single eligible cognitive outcome, but we considered the evidence to be very low‐quality and so could not be sure of any effects. Authors' conclusions The evidence on vitamin and mineral supplements as treatments for MCI is very limited. Three years of treatment with high‐dose vitamin E probably does not reduce the risk of progression to dementia, but we have no data on this outcome for other supplements. Only B vitamins have been assessed in more than one RCT. There is no evidence for beneficial effects on cognition of supplementation with B vitamins for six to 24 months. Evidence from a single study of a reduced rate of brain atrophy in participants taking vitamin B and a beneficial effect of vitamin B on episodic memory in those with higher tHcy at baseline warrants attempted replication. Plain language summary Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment Review question This review investigated whether people with mild cognitive impairment can reduce their risk of developing dementia, or can prevent their memory or other thinking skills from deteriorating further, by taking vitamin or mineral supplements. Background Slight changes in memory and thinking skills are common as people get older. When these changes are worse than can be expected in normal ageing, but are not bad enough to make a person's usual activities difficult to manage, then the person is said to have mild cognitive impairment (MCI). People with MCI are at increased risk of developing dementia in the future. Vitamins and minerals are naturally occurring substances which are needed in the diet to maintain health. They have lots of different functions in the body and many are essential to keep the brain working properly. It has been suggested that supplementing a person's normal diet with extra doses of these vitamins or minerals might help to maintain thinking skills or prevent dementia. Study characteristics We found eight randomised controlled trials (RCTs), which investigated four different types of vitamin or mineral pills by comparing them to a placebo (a dummy pill). The vitamins tested were B vitamins (vitamin B6, vitamin B12 and folic acid), vitamin E, and vitamin E and C given together. The only mineral tested was chromium. Key results and quality of the evidence Vitamin B combination versus placebo Five trials with a total of 879 participants compared B vitamins with placebo. Four used combinations of vitamin B6, vitamin B12, and folic acid; one small study tested folic acid on its own. None of these studies reported whether or not participants developed dementia. These studies did not find that memory or thinking skills differed between the group of people who took vitamin B supplements and those who took placebo after treatment lasting six months to two years. Our confidence in the results on different tests used in the studies varied from moderate to very low. Two years of vitamin B supplements did seem to help memory in a small subgroup of participants in one study who could be identified by a particular blood test at the start of the trial. One study found that there was probably no effect on participants' quality of life. One study scanned the brains of some participants and reported that B vitamins may slow the rate of brain shrinkage. Harmful effects and deaths were reported in very few participants and we cannot conclude whether or not there are harms from taking these or similar combinations of B vitamins. Vitamin E versus placebo. One study with 516 participants compared a relatively high dose of vitamin E (2000 IU a day) to placebo in people who were also taking a multivitamin containing 15 IU of vitamin E (the daily requirement for vitamin E is approximately 30 IU). The risk of developing dementia due to Alzheimer’s disease (the commonest form of dementia) is probably not affected by three years of treatment with high‐dose vitamin E. The quality of the evidence for other outcomes was lower, but there may also be no effect of this dose of vitamin E on specific memory or thinking skills or on how well people could manage their daily activities. Vitamin E and C versus placebo One study with 256 participants compared a combination of vitamins C and E with placebo. It found no effect on overall memory and thinking skills, but we had little confidence in this result because of the quality of the evidence. Chromium picolinate versus placebo Only one very small study with 26 participants investigated the effect of chromium supplements. This study was too small for us to be able to draw any conclusions. Conclusions The amount and quality of research evidence about vitamin and mineral supplements for treating MCI in people without nutritional deficiency is limited. At the moment, it is not possible to identify any supplements which can reduce the risk of people with MCI developing dementia or which can effectively treat their symptoms. More research is needed before we can answer our review question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "McCleery, J, Abraham, RP, Denton, DA, Rutjes, AWS, Chong, LY, Al‐Assaf, AS, Griffith, DJ, Rafeeq, S, Yaman, H, Malik, MA, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011905.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.114Z" }, { "id": "ee6d5aba-28b5-468e-8bd4-a647ae1b787e", "pmid": "", "title": "Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder", "imported": false, "abstract": "Abstract - Background Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. Objectives To assess the effects ‐ and review the acceptability and tolerability ‐ of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. Selection criteria Double‐ or single‐blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. Data collection and analysis Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. Main results Thirty‐one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D‐cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP‐101,606 (1), decoglurant (1), MK‐0657 (1), N‐acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty‐eight studies were placebo‐controlled, and 48 were two‐arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild‐to‐moderate depression. Nineteen studies recruited only patients with treatment‐resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low‐certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) ‐0.87, 95% CI ‐1.26 to ‐0.48; n = 231, studies = 8, very low‐certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low‐certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low‐certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low‐certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and midazolam (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low‐certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate‐certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD ‐0.31, 95% CI ‐0.45 to ‐0.17; n = 824, studies = 4, moderate‐certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low‐certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate‐certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. Authors' conclusions Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta‐analyses for each comparison and the majority of comparisons included only one study. Long term non‐inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real‐world monitoring are needed to establish comprehensive data on safety and efficacy. Plain language summary Ketamine and other glutamate receptor modulators for depression in adults Why is this review important? Depression is one of the most common mental disorders, estimated to affect 350 million people worldwide. Antidepressant medication tends to be given as a first treatment for people with major depression. These drugs are however only effective in about one in four people at one year. Effective alternative medications to treat depression are needed, especially for rapid treatment. A new group of medications is called ‘glutamate receptor modulators’, which act on the glutamergic system. This group includes the medicine ketamine. In this review we examined the evidence for glutamate receptor modulators, including ketamine, as a treatment for depression. Who will be interested in this review? ‐ People with depression, their friends and families. ‐ General practitioners, psychiatrists, psychologists and pharmacists. ‐ Professionals working in adult mental health services. What questions does this review aim to answer? 1. Is treatment with ketamine and other glutamate receptor modulators more effective than treatment with placebo (dummy pill) or other drugs? 2. Is treatment with ketamine and other glutamate receptor modulators more acceptable than placebo or other drugs? Which studies were included in the review? We searched medical databases to find all relevant studies (specifically randomised controlled trials) completed up to 30 July 2020. To be included in the review, studies had to compare ketamine or other glutamate receptor modulators with placebo, other medicines or electroconvulsive therapy (ECT) for depression in adults (aged 18 and over). The studies also had to be single‐blind (the participant does not know which treatment they are receiving) or double‐blind (neither the participant or researcher know which treatment the participant is receiving), to attempt to reduce bias. We included 64 studies in the review, involving a total of 5299 people. The studies investigated16 different glutamate receptor modulator medications. The majority of participants had treatment‐resistant depression (depression which had not responded to two or more medications) at the start of the studies. Most studies were two‐armed, where the glutamate receptor modulator was compared with one other intervention. What does the evidence from the review tell us? Among the 16 drugs included in this review, only ketamine and esketamine were more effective than placebo at reducing symptoms of depression. The effects of ketamine lasted no more than one week after treatment and clearly disappeared after two weeks. Ketamine did, however, cause more side effects than placebo. The effects of esketamine were seen at 24 hours and could last up to four weeks with repeated doses. Esketamine caused a lot more side effects than placebo. The certainty of evidence varied considerably. There was no evidence of a difference between the other glutamate receptor modulators included in this review and placebo or other medications. What should happen next? Ketamine and esketamine appear to reduce the symptoms of depression. However, the trials were all short term so we do not know about the long‐term effects. It is important to note that in some trials attempts to prevent participants and investigators from knowing what medicine was being given were not successful and this may have inflated the positive effects of the active drugs. Future studies should examine what happens when people are repeatedly given the drug, with the aim to mimic the real‐world practice and assess longer‐term effects. More non‐inferiority trials should be conducted, where glutamate receptor modulators are compared with other active medications rather than placebo to find out whether they are better than alternative treatments. In most of the ketamine trials in this review, participants were given the drug by injection into a vein. This restricts the wide‐scale application of ketamine in clinical settings, so trials of ketamine by other routes are needed. Esketamine trials usually used nasal sprays, which are easier to use and could potentially be taken at home if further monitoring and trials found that it was safe to do so. Further studies assessing administration are needed in order to draw more reliable and firm conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Dean, RL; Hurducas, C; Hawton, K; Spyridi, S; Cowen, PJ; Hollingsworth, S; Marquardt, T; Barnes, A; Smith, R; McShane, R; Turner, EH; Cipriani, A", "articleTypes": [], "doi": "10.1002/14651858.CD011612.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "ee77630e-09f8-4795-b2b1-9bca5a0c80c4", "pmid": "", "title": "Interventions for protecting renal function in the perioperative period", "imported": false, "abstract": "Abstract - Background Various methods have been used to try to protect kidney function in patients undergoing surgery. These most often include pharmacological interventions such as dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants and erythropoietin (EPO). Objectives This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period. We considered the following questions: (1) Are any specific measures known to protect kidney function during the perioperative period? (2) Of measures used to protect the kidneys during the perioperative period, does any one method appear to be more effective than the others? (3) Of measures used to protect the kidneys during the perioperative period,does any one method appear to be safer than the others? Search methods In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , Issue 2, 2012), MEDLINE (Ovid SP) (1966 to August 2012) and EMBASE (Ovid SP) (1988 to August 2012). We originally handsearched six journals ( Anesthesia and Analgesi a, Anesthesiology , Annals of Surgery , British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery) (1985 to 2004). However, because these journals are properly indexed in MEDLINE, we decided to rely on electronic searches only without handsearching the journals from 2004 onwards. Selection criteria We selected all randomized controlled trials in adults undergoing surgery for which a treatment measure was used for the purpose of providing renal protection during the perioperative period. Data collection and analysis We selected 72 studies for inclusion in this review. Two review authors extracted data from all selected studies and entered them into RevMan 5.1; then the data were appropriately analysed. We performed subgroup analyses for type of intervention, type of surgical procedure and pre‐existing renal dysfunction. We undertook sensitivity analyses for studies with high and moderately good methodological quality. Main results The updated review included data from 72 studies, comprising a total of 4378 participants. Of these, 2291 received some form of treatment and 2087 acted as controls. The interventions consisted most often of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, NAC, ANP, sodium bicarbonate, antioxidants and EPO or selected hydration fluids. Some clinical heterogeneity and varying risk of bias were noted amongst the studies, although we were able to meaningfully interpret the data. Results showed significant heterogeneity and indicated that most interventions provided no benefit. Data on perioperative mortality were reported in 41 studies and data on acute renal injury in 44 studies (all interventions combined). Because of considerable clinical heterogeneity (different clinical scenarios, as well as considerable methodological variability amongst the studies), we did not perform a meta‐analysis on the combined data. Subgroup analysis of major interventions and surgical procedures showed no significant influence of interventions on reported mortality and acute renal injury. For the subgroup of participants who had pre‐existing renal damage, the risk of mortality from 10 trials (959 participants) was estimated as odds ratio (OR) 0.76, 95% confidence interval (CI) 0.38 to 1.52; the risk of acute renal injury (as reported in the trials) was estimated from 11 trials (979 participants) as OR 0.43, 95% CI 0.23 to 0.80. Subgroup analysis of studies that were rated as having low risk of bias revealed that 19 studies reported mortality numbers (1604 participants); OR was 1.01, 95% CI 0.54 to 1.90. Fifteen studies reported data on acute renal injury (criteria chosen by the individual studies; 1600 participants); OR was 1.03, 95% CI 0.54 to 1.97. Authors' conclusions No reliable evidence from the available literature suggests that interventions during surgery can protect the kidneys from damage. However, the criteria used to diagnose acute renal damage varied in many of the older studies selected for inclusion in this review, many of which suffered from poor methodological quality such as insufficient participant numbers and poor definitions of end points such as acute renal failure and acute renal injury. Recent methods of detecting renal damage such as the use of specific biomarkers and better defined criteria for identifying renal damage (RIFLE (risk, injury, failure, loss of kidney function and end‐stage renal failure) or AKI (acute kidney injury)) may have to be explored further to determine any possible benefit derived from interventions used to protect the kidneys during the perioperative period. Plain language summary No evidence indicates that any of the measures used to protect patients' kidneys during the perioperative period are beneficial The kidneys may be damaged during an operation as a result of direct and indirect insult. The reasons for this are multiple and include changes to physiology brought on by the surgery and by the body’s response to such insult. Damage to kidneys during the perioperative period is associated with significant morbidity and mortality. This updated Cochrane review looked at 72 randomized controlled trials (RCTs) with 4378 participants (search data until August 2012); interventions most often included pharmacological interventions (administration of dopamine and its analogues, diuretics, calcium channel blockers, angiotensin‐converting enzyme (ACE) inhibitors, N ‐acetyl cysteine, atrial natriuretic peptide, sodium bicarbonate, antioxidants and erythropoietin) or selected hydration fluids. We attempted to identify any possible damage to the kidneys by evaluating kidney function up to seven days after the operation. No clear evidence from available RCTs suggests that any of the measures used to protect the kidneys during the perioperative period are beneficial. These findings held true in 14 studies of patients with pre‐existing renal damage and in 24 studies that were considered of good methodological quality. The primary outcomes of these studies were mortality and acute renal injury. Reported mortality in studies with low risk of bias was not different between intervention and control groups (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.52 to 1.97) or for acute renal injury (OR 1.05, 95% CI 0.55 to 2.03). The summary of findings revealed a similar picture. So we conclude that evidence suggests that none of the interventions used currently are helpful in protecting the kidneys during the perioperative period, nor do they cause increased harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Zacharias, M; Mugawar, M; Herbison, GP; Walker, RJ; Hovhannisyan, K; Sivalingam, P; Conlon, NP", "articleTypes": [], "doi": "10.1002/14651858.CD003590.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "ee83f828-4584-4c38-b110-cc28b4c6174e", "pmid": "", "title": "Zolmitriptan for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a common, disabling condition and a burden for the individual, health services, and society. Zolmitriptan is an abortive medication for migraine attacks, belonging to the triptan family. These medicines work in a different way to analgesics such as paracetamol and ibuprofen. Objectives To determine the efficacy and tolerability of zolmitriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library , MEDLINE, EMBASE, and the Oxford Pain Relief Database, together with three online databases ( www.astrazenecaclinicaltrials.com , www.clinicaltrials.gov , and apps.who.int/trialsearch ) for studies to 12 March 2014. We also searched the reference lists of included studies and relevant reviews. Selection criteria We included randomised, double‐blind, placebo‐ or active‐controlled studies, with at least 10 participants per treatment arm, using zolmitriptan to treat a migraine headache episode. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate risk ratios and numbers needed to treat for an additional beneficial effect (NNT) or harmful effect (NNH) compared with placebo or a different active treatment. Main results Twenty‐five studies (20,162 participants) compared zolmitriptan with placebo or an active comparator. The evidence from placebo‐controlled studies was of high quality for all outcomes except 24 hour outcomes and serious adverse events where only limited data were available. The majority of included studies were at a low risk of performance, detection and attrition biases, but did not adequately describe methods of randomisation and concealment. Most of the data were for the 2.5 mg and 5 mg doses compared with placebo, for treatment of moderate to severe pain. For all efficacy outcomes, zolmitriptan surpassed placebo. For oral zolmitriptan 2.5 mg versus placebo, the NNTs were 5.0, 3.2, 7.7, and 4.1 for pain‐free at two hours, headache relief at two hours, sustained pain‐free during the 24 hours postdose, and sustained headache relief during the 24 hours postdose, respectively. Results for the oral 5 mg dose were similar to the 2.5 mg dose, while zolmitriptan 10 mg was significantly more effective than 5 mg for pain‐free and headache relief at two hours. For headache relief at one and two hours and sustained headache relief during the 24 hours postdose, but not pain‐free at two hours, zolmitriptan 5 mg nasal spray was significantly more effective than the 5 mg oral tablet. For the most part, adverse events were transient and mild and were more common with zolmitriptan than placebo, with a clear dose response relationship (1 mg to 10 mg). High quality evidence from two studies showed that oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people as oral sumatriptan 50 mg (66%, 67%, and 68% respectively), although not necessarily the same individuals. There was no significant difference in numbers experiencing adverse events. Single studies reported on other active treatment comparisons but are not described further because of the small amount of data. Authors' conclusions Zolmitriptan is effective as an abortive treatment for migraine attacks for some people, but is associated with increased adverse events compared to placebo. Zolmitriptan 2.5 mg and 5 mg benefited the same proportion of people as sumatriptan 50 mg, although not necessarily the same individuals, for headache relief at two hours. Plain language summary Zolmitriptan for acute migraine attacks in adults Migraine is a complex condition with a wide variety of symptoms. It affects about 1 person in 8, mainly women aged 30 to 50 years. For many people, the main feature is a painful, and often disabling, headache. Other symptoms include feeling sick, vomiting, disturbed vision, and sensitivity to light, sound, and smells. Zolmitriptan is one of the triptan family of drugs. It is used to treat migraine attacks when they occur, not to prevent attacks occurring. It is available as an oral tablet to swallow whole, an oral tablet to dissolve in the mouth, and a nasal spray. This review looked at 25 studies that involved over 20,000 participants reporting the effects of zolmitriptan on migraine attacks. Most information was for tablets taken by mouth. Overall methodological quality of the included studies was good, and treatment group sizes were large enough to avoid major bias. There were inconsistencies in the way use of rescue medication and adverse events were reported. A single oral dose of zolmitriptan relieved migraine headache pain in some people. Several different pain outcomes were reported. One outcome was pain reduced from moderate or severe to no pain at all two hours after taking treatment. An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 3 in 10 people (30%), compared with about 1 in 10 (10%) taking placebo. Another outcome was pain reduced from moderate or severe to no worse than mild pain two hours after taking treatment (called headache relief). An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 6 in 10 people (61%), compared with 3 in 10 (29%) taking placebo. Slightly better results were obtained with higher doses of 5 mg or 10 mg oral tablets, but the 10 mg dose was associated with more adverse events, most of which were of short duration and mild or moderate in severity. Results for the 5 mg nasal spray were generally similar to those for the oral tablet, but it was significantly better than the tablet at 1 hour. People with migraine want treatment that eliminates the headache and any associated symptoms quickly (maximum two hours) and prevents it returning (within 24 hours). Results indicate that with the 5 mg dose only 14% of those treated were pain‐free at 2 hours with no headache recurrence within 24 hours. Oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people (2 in 3) as oral sumatriptan 50 mg, with no difference in numbers experiencing adverse events. The individuals who respond to each drug may not be the same.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Bird, S; Derry, S; Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008616.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "ee8f4a6b-ea5d-4a9e-a411-73ec3abb4088", "pmid": "", "title": "A Phase II, Single Arm, Open Label, Study on the Safety, Efficacy, Pharmacokinetics & Pharmacodynamics of Quizartinib + Chemotherapy and as Single-agent After High Dose Therapy in Newly Diagnosed Pediatric FLT3-ITD+ and NPM1wt AML Patients", "imported": false, "abstract": "The CHIP-AML22 Master protocol has the overall aim of increasing the cure rate in newly diagnosed pediatric de novo AML patients, while avoiding unnecessary toxicity. The linked Quizartinib trial (CHIP-AML22/Quizartinib) is a phase II, single arm, open label, study on the safety, efficacy, pharmacokinetics and pharmacodynamics of quizartinib in combination with chemotherapy and as single-agent after high dose therapy in newly diagnosed pediatric AML patients with a FLT3-ITD mutation and NPM1 wild-type.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.270Z" }, { "id": "eea5a6b5-5851-427b-bf2c-d43453039e54", "pmid": "", "title": "Aversive smoking for smoking cessation", "imported": false, "abstract": "Abstract - Background Aversion therapy pairs the pleasurable stimulus of smoking a cigarette with some unpleasant stimulus. The objective is to extinguish the urge to smoke. Objectives This review has two aims: First, to determine the efficacy of rapid smoking and other aversive methods in helping smokers to stop smoking; Second, to determine whether there is a dose‐response effect on smoking cessation at different levels of aversive stimulation. Search methods We searched the Cochrane Tobacco Addiction Group specialised register (latest search date October 2009) for studies which evaluated any technique of aversive smoking. Selection criteria Randomized trials which compared aversion treatments with 'inactive' procedures or which compared aversion treatments of different intensity for smoking cessation. Trials must have reported follow up of least six months from beginning of treatment. Data collection and analysis We extracted data in duplicate on the study population, the type of aversion treatment, the outcome measure, method of randomization and completeness of follow up. The outcome measure was abstinence from smoking at maximum follow up, using the strictest measure reported by the authors. Subjects lost to follow up were regarded as smokers. Where appropriate, we performed meta‐analysis using a fixed effect model. Main results Twenty‐five trials met the inclusion criteria. Twelve included rapid smoking and nine used other aversion methods. Ten trials included two or more conditions allowing assessment of a dose‐response to aversive stimulation. The odds ratio (OR) for abstinence following rapid smoking compared to control was 2.01 (95% confidence intervals (CI): 1.36 to 2.95). Several factors suggest that this finding should be interpreted cautiously. A funnel plot of included studies was asymmetric, due to the relative absence of small studies with negative results. Most trials had a number of serious methodological problems likely to lead to spurious positive results. The only trial using biochemical validation of all self reported cessation gave a non‐significant result. Other aversion methods were not shown to be effective (OR 1.15, 95% CI 0.73 to 1.82). There was a borderline dose‐response to the level of aversive stimulation (OR 1.67, 95% CI 0.99 to 2.81). Authors' conclusions The existing studies provide insufficient evidence to determine the efficacy of rapid smoking, or whether there is a dose‐response to aversive stimulation. Milder versions of aversive smoking seem to lack specific efficacy. Rapid smoking is an unproven method with sufficient indications of promise to warrant evaluation using modern rigorous methodology. Plain language summary Does smoking in a way that is unpleasant help smokers to quit Aversion treatments pair undesirable behaviours with negative sensations. In smoking cessation, several approaches have been suggested such as rapid smoking, which requires smokers to take a puff every few seconds to make smoking unpleasant. The results of the existing trials suggest that this may be effective, but the evidence is not conclusive because most of the studies of this approach have methodological problems. A recent laboratory study also suggests that the method has an active ingredient. Further research may be worthwhile.", "journal": "Cochrane Database of Systematic Reviews", "year": "2001", "authors": "Hajek, P; Stead, LF", "articleTypes": [], "doi": "10.1002/14651858.CD000546.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "eecb1b6c-817f-427f-9241-53f974e0475c", "pmid": "", "title": "Listening to music for insomnia in adults", "imported": false, "abstract": "Abstract - Background Insomnia is a common problem in modern society. It is associated with reduced quality of life and impairments in physical and mental health. Listening to music is widely used as a sleep aid, but it remains unclear if it can actually improve insomnia in adults. This Cochrane Review is an update of a review published in 2015. Objectives To assess the effects of listening to music on sleep in adults with insomnia and to assess the influence of specific variables that may moderate the effect . Search methods For this update, we searched CENTRAL, MEDLINE, Embase, nine other databases and two trials registers up to December 2021. In addition, we handsearched reference lists of included studies, and contacted authors of published studies to identify additional studies eligible for inclusion, including any unpublished or ongoing trials. Selection criteria Randomised controlled trials comparing the effects of listening to music with no treatment or treatment as usual (TAU) in adults complaining of sleep difficulties. Data collection and analysis Two review authors independently screened records for eligibility, selected studies for inclusion, extracted data and assessed risk of bias of the included studies. We assessed the certainty of the evidence using GRADE. The primary outcomes were sleep quality, insomnia severity, sleep‐onset latency, total sleep time, sleep interruption, sleep efficiency and adverse events. Data on the predefined outcome measures were included in meta‐analyses when consistently reported by at least two studies that were homogeneous in terms of participants, interventions and outcomes. We undertook meta‐analyses using random‐effects models. Main results We included 13 studies (eight studies new to this update) comprising 1007 participants. The studies examined the effect of listening to prerecorded music daily, for 25 to 60 minutes, for a period of three days to three months. The risk of bias within the studies varied, with all studies being at high risk of performance bias, because of limited possibilities to blind participants to the music intervention. Some studies were at high risk of detection bias or other bias. Four studies reported funding from national research councils, three studies reported financial support from university sources and one study reported a grant from a private foundation. Five studies did not report any financial support. At the end of the intervention, we found moderate‐certainty evidence for improved sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI) in themusic groups compared to no intervention or TAU (mean difference (MD) −2.79, 95% confidence interval (CI) −3.86 to −1.72; 10 studies, 708 participants). The PSQI scale ranges from 0 to 21 with higher scores indicating poorer sleep. The size of the effect indicates an increase in sleep quality of the size of about one standard deviation in favour of the intervention. We found no clear evidence of a difference in the effects of listening to music compared to no treatment or TAU on insomnia severity (MD −6.96, 95% CI −15.21 to 1.28; 2 studies, 63 participants; very low‐certainty evidence). We found low‐certainty evidence that, compared to no treatment or TAU, listening to music may reduce problems with sleep‐onset latency (MD −0.60, 95% CI −0.83 to −0.37; 3 studies, 197 participants), total sleep time (MD −0.69, 95% CI −1.16 to −0.23; 3 studies, 197 participants) and sleep efficiency (MD −0.96, 95% CI −1.38 to −0.54; 3 studies, 197 participants), but may have no effect on perceived sleep interruption (MD −0.53, 95% CI −1.47 to 0.40; 3 studies, 197 participants). In addition, three studies (136 participants) included objective measures of sleep‐onset latency, total sleep time, sleep efficiency and sleep interruption and showed that listening to music may not improve these outcomes compared to no treatment or TAU. None of the included studies reported any adverse events. Authors' conclusions The findings of this review provide evidence that music may be effective for improving subjective sleep quality in adults with symptoms of insomnia. More research is needed to establish the effect of listening to music on other aspects of sleep as well as the daytime consequences of insomnia. Plain language summary Music for insomnia in adults Review question This review assessed the effects of listening to music on insomnia (sleep problems) in adults and the impact of factors that may influence the effect. Key messages We found a beneficial effect of music on sleep quality. For all the other outcomes, we did not find enough good‐quality evidence as there were too few participants and the people doing the scoring of the data were aware of the treatment. What is insomnia? Worldwide, millions of people experience insomnia. People can have difficulties getting to sleep, staying asleep or may experience poor sleep quality. Poor sleep affects people's physical and mental health. The consequences of poor sleep are costly, for both individuals and society. Many people listen to music to improve their sleep, but the effect of listening to music is unclear. What did we do? We searched electronic databases to identify relevant studies. We included 13 studies with 1007 participants. The studies compared the effect of listening to music to treatment as usual or no treatment. Treatment as usual could be sleep hygiene education (learning a set of rituals to help with sleep) or standard care for participants with insomnia related to chronic medical conditions. The studies examined the effect of listening to prerecorded music daily, for 25 to 50 minutes, for three days to three months. Seven of the included studies reported funding from national research councils or university sources, and one study reported funding from a private foundation. Five studies did not report any funding sources. What did we find? Ten studies measured sleep quality, and the results showed that music probably facilitates a large improvement in the quality of sleep compared to no treatment or treatment as usual. We do not know if listening to music has an effect on the severity of insomnia (difficulty in falling or staying asleep) or the number of times a person wakes up (broken sleep) compared to no treatment or treatment as usual. Listening to music may improve slightly sleep‐onset latency (how quickly a person falls asleep), sleep duration (length of time a person is asleep) and sleep efficiency (amount of a time a person is asleep compared to the total time spent in bed), compared to no treatment or treatment as usual. None of the studies reported any negative effects caused by listening to music. What are the limitations of the evidence? The quality of evidence from the 10 studies that examined sleep quality was moderate. Our confidence in the evidence for the quality of sleep is only moderate because the people in the studies were aware of which treatment they were getting and the people scoring the data were also sometimes aware of which treatment the participants were getting, which could introduce bias. We have little confidence in the evidence for the severity of insomnia because the studies were very small and were done in different types of people who knew which treatment they were getting. Our confidence in the evidence on sleep‐onset latency, sleep duration and sleep efficiency is low because the studies used very different methods to measure these outcomes, and the people in the studies were aware of the nature of the treatment. We have little confidence in the evidence on sleep interruption because the studies used different methods and showed different results. Furthermore, the participants in the studies knew which treatment they were getting. Future studies should assess other aspects of sleep as well as measures of daytime functioning, such as mood, fatigue, concentration, and quality of life. How up to date is this evidence? The evidence is current to 31 December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jespersen, KV, Pando-Naude, V, Koenig, J, Jennum, P, Vuust, P", "articleTypes": [], "doi": "10.1002/14651858.CD010459.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.804Z" }, { "id": "eede2a36-4cf5-4ef6-8802-90a94d4b2597", "pmid": "", "title": "Sodium channel blockers for cystic fibrosis", "imported": false, "abstract": "Abstract - Background People with cystic fibrosis (CF) have increased transport of the salt, sodium across their airway lining. Over‐absorption of sodium results in the dehydration of the liquid that lines the airway surface and (along with defective chloride secretion) is a primary defect in people with CF. Objectives To determine whether the topical administration of drugs that block sodium transport improves the respiratory condition of people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We contacted principal investigators known to work in the field, previous authors and pharmaceutical companies who manufacture ion transport agents for unpublished or follow‐up data. Most recent search of the Group's register: 19 December 2013. Selection criteria Published or unpublished randomised controlled trials (RCTs) or quasi‐randomised controlled trials of sodium channel blockers compared to placebo or another sodium channel blocker or the same sodium channel blocker at a different dosing regimen. Data collection and analysis Two authors independently extracted data. Meta‐analysis was limited due to differing study designs. Main results Five RCTs, with a total of 226 participants, examining the topical administration of the short‐acting sodium channel blocker, amiloride, compared to placebo were identified as eligible for inclusion in the review. In three studies over six months, there was a significant difference found in the difference in relative change in FVC in favour of placebo (weighted mean difference 1.51% (95% confidence interval ‐2.77 to ‐0.25), although heterogeneity was evident. A two‐week study demonstrated that hypertonic saline with amiloride pre‐treatment did not result in a significant improvement in respiratory function or mucus clearance, in contrast to pre‐treatment with placebo. There were no significant differences identified in other clinically relevant outcomes. Authors' conclusions We found no evidence that the topical administration of a short‐acting sodium channel blocker improves respiratory condition in people with cystic fibrosis and some limited evidence of deterioration in lung function. Plain language summary Drugs to control the movement of salt in the lungs of people with cystic fibrosis Usually salt is absorbed from liquid on the surface of the lungs to stop fluid building up there. In cystic fibrosis too much salt is absorbed and there is little liquid left on the airway surfaces. As a result people with cystic fibrosis have problems clearing their lungs of sticky secretions. Thus the lungs are left open to infection. Drugs applied directly to the lungs may prevent too much salt being absorbed. This may lead to better clearance of mucus and less lung infection and damage. The review includes five studies with a total of 226 participants. All studies looked at short‐acting drugs applied directly to the lungs compared to placebo. When the results from three studies over six months were combined, the placebo group showed a slower rate of decline in forced vital capacity than the treatment group. However, each of these differed in their results. A further study showed that people receiving a sodium channel blocker before receiving hypertonic saline did not achieve better lung function or mucus clearance than those receiving placebo before hypertonic saline. We found no evidence that short‐acting sodium channel blockers administered directly to the lungs improve respiratory status in people with cystic fibrosis. There was even some limited evidence of a decline in lung function. Trials of long‐acting sodium channel blockers are ongoing.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Burrows, EF, Southern, KW, Noone, PG", "articleTypes": [], "doi": "10.1002/14651858.CD005087.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.735Z" }, { "id": "eee81556-aa43-4af6-ab6b-890a59b4e6da", "pmid": "", "title": "Serotonin-receptor Agonism in Reward Processing", "imported": false, "abstract": "There is growing animal and human evidence for role of 5HT1A receptor agonism in treating depression and reward deficits. The next step is to translate this evidence directly into humans by characterising the effects of buspirone, as a 5HT1A agonist, on cognitive models of reward and emotional processing.", "journal": "", "year": "2022", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.147Z" }, { "id": "eef0a151-241f-47ab-84b5-aeeca81c0b2d", "pmid": "", "title": "Desipramine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Antidepressants are widely used to treat chronic neuropathic pain (pain due to nerve damage), usually in doses below those at which they exert antidepressant effects. An earlier review that included all antidepressants for neuropathic pain is being replaced by new reviews of individual drugs examining individual neuropathic pain conditions. Desipramine is a tricyclic antidepressant that is occasionally used for treating neuropathic pain. Objectives To assess the analgesic efficacy of desipramine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 29 April 2014, and the reference lists of retrieved papers and other reviews. We also used our own hand searched database to identify older studies, and two clinical trials databases for ongoing or unpublished studies. Selection criteria We included randomised, double‐blind studies of at least two weeks duration comparing desipramine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 years and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted the efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence was derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts, at least 200 participants in the comparison, 8 to 12 weeks duration, parallel design); second tier from data that failed to meet one or more of these criteria and were considered at some risk of bias but with adequate numbers in the comparison; and third tier from data involving small numbers of participants and considered very likely to be biased or that used outcomes of limited clinical utility, or both. Main results Five studies treated 177 participants with painful diabetic neuropathy (104) or postherpetic neuralgia (73). The mean or median ages in the studies were 55 to 72 years. Four studies used a cross‐over, and one a parallel group design; 145 participants were randomised to receive desipramine 12.5 mg to 250 mg daily, with most taking 100 mg to 150 mg daily following titration. Comparators were placebo in three studies (an 'active placebo' in two studies), fluoxetine, clomipramine (one study each), and amitriptyline (two studies), and treatment was for two to six weeks. All studies had one or more sources of potential major bias. No study provided first or second tier evidence for any outcome. No data were available on the proportion of people with at least 50% or 30% reduction in pain, but data were available from three studies for our other primary outcome of Patient Global Impression of Change, reported as patient evaluation of pain relief that was 'complete' or 'a lot'. No pooling of data was possible, but third tier evidence in individual studies indicated some improvement in pain relief with desipramine compared with placebo, although this was very low quality evidence, derived mainly from group mean data and completer analyses in small, short duration studies where major bias was possible. There were too few participants in comparisons of desipramine with another active treatment to draw any conclusions. All studies reported some information about adverse events, but reporting was inconsistent and fragmented. Participants taking desipramine experienced more adverse events, and a higher rate of withdrawal due to adverse events, than did participants taking placebo (very low quality evidence). Authors' conclusions This review found little evidence to support the use of desipramine to treat neuropathic pain. There was very low quality evidence of benefit and harm, but this came from studies that were methodologically flawed and potentially subject to major bias. Effective medicines with much greater supportive evidence are available. There may be a role for desipramine in patients who have not obtained pain relief from other treatments. Plain language summary Desipramine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not usually effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain. Desipramine is a tricyclic antidepressant from the same class of medicines as amitriptyline, which is widely recommended for treating neuropathic pain. Desipramine may also be useful in these painful conditions. In 2014, we performed searches to look for clinical trials where desipramine was used to treat neuropathic pain. Five small studies, each with 24 to 54 participants, included 177 participants in total with painful diabetic neuropathy or postherpetic neuralgia. Studies were randomised and double‐blind, but all had one or more sources of potential major bias that could lead to overestimation of efficacy. It was not possible to combine information from the different studies, but individually they indicated some benefit from desipramine (usually at a dose between 100 mg and 150 mg daily), compared with placebo, at the expense of increased adverse events. There was not enough information about other comparators to draw any conclusions. There was too little information, which was of inadequate quality, to be sure that desipramine works as a pain medicine in painful diabetic neuropathy or postherpetic neuralgia, and no information about other types of neuropathic pain. Other medicines have been shown to be effective as treatments of first choice.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Hearn, L; Moore, RA; Derry, S; Wiffen, PJ; Phillips, T", "articleTypes": [], "doi": "10.1002/14651858.CD011003.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "ef0c2fd5-2494-458c-a641-238c9320ae0e", "pmid": "", "title": "Donepezil for dementia due to Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Alzheimer's disease is the most common cause of dementia in older people. One approach to symptomatic treatment of Alzheimer's disease is to enhance cholinergic neurotransmission in the brain by blocking the action of the enzyme responsible for the breakdown of the neurotransmitter acetylcholine. This can be done by a group of drugs known as cholinesterase inhibitors. Donepezil is a cholinesterase inhibitor. This review is an updated version of a review first published in 1998. Objectives To assess the clinical efficacy and safety of donepezil in people with mild, moderate or severe dementia due to Alzheimer's disease; to compare the efficacy and safety of different doses of donepezil; and to assess the effect of donepezil on healthcare resource use and costs. Search methods We searched Cochrane Dementia and Cognitive Improvement’s Specialized Register, MEDLINE, Embase, PsycINFO and a number of other sources on 20 May 2017 to ensure that the search was as comprehensive and up‐to‐date as possible. In addition, we contacted members of the Donepezil Study Group and Eisai Inc. Selection criteria We included all double‐blind, randomised controlled trials in which treatment with donepezil was administered to people with mild, moderate or severe dementia due to Alzheimer's disease for 12 weeks or more and its effects compared with those of placebo in a parallel group of patients, or where two different doses of donepezil were compared. Data collection and analysis One reviewer (JSB) extracted data on cognitive function, activities of daily living, behavioural symptoms, global clinical state, quality of life, adverse events, deaths and healthcare resource costs. Where appropriate and possible, we estimated pooled treatment effects. We used GRADE methods to assess the quality of the evidence for each outcome. Main results Thirty studies involving 8257 participants met the inclusion criteria of the review, of which 28 studies reported results in sufficient detail for the meta‐analyses. Most studies were of six months' duration or less. Only one small trial lasted 52 weeks. The studies tested mainly donepezil capsules at a dose of 5 mg/day or 10 mg/day. Two studies tested a slow‐release oral formulation that delivered 23 mg/day. Participants in 21 studies had mild to moderate disease, in five studies moderate to severe, and in four severe disease. Seventeen studies were industry funded or sponsored, four studies were funded independently of industry and for nine studies there was no information on source of funding. Our main analysis compared the safety and efficacy of donepezil 10 mg/day with placebo at 24 to 26 weeks of treatment. Thirteen studies contributed data from 3396 participants to this analysis. Eleven of these studies were multicentre studies. Seven studies recruited patients with mild to moderate Alzheimer's disease, two with moderate to severe, and four with severe Alzheimer's disease, with a mean age of about 75 years. Almost all evidence was of moderate quality, downgraded due to study limitations. After 26 weeks of treatment, donepezil compared with placebo was associated with better outcomes for cognitive function measured with the Alzheimer's Disease Assessment Scale‐Cognitive (ADAS‐Cog, range 0 to 70) (mean difference (MD) ‐2.67, 95% confidence interval (CI) ‐3.31 to ‐2.02, 1130 participants, 5 studies), the Mini‐Mental State Examination (MMSE) score (MD 1.05, 95% CI 0.73 to 1.37, 1757 participants, 7 studies) and the Severe Impairment Battery (SIB, range 0 to 100) (MD 5.92, 95% CI 4.53 to 7.31, 1348 participants, 5 studies). Donepezil was also associated with better function measured with the Alzheimer's Disease Cooperative Study activities of daily living score for severe Alzheimer's disease (ADCS‐ADL‐sev) (MD 1.03, 95% CI 0.21 to 1.85, 733 participants, 3 studies). A higher proportion of participants treated with donepezil experienced improvement on the clinician‐rated global impression of change scale (odds ratio (OR) 1.92, 95% CI 1.54 to 2.39, 1674 participants, 6 studies). There was no difference between donepezil and placebo for behavioural symptoms measured by the Neuropsychiatric Inventory (NPI) (MD ‐1.62, 95% CI ‐3.43 to 0.19, 1035 participants, 4 studies) or by the Behavioural Pathology in Alzheimer's Disease (BEHAVE‐AD) scale (MD 0.4, 95% CI ‐1.28 to 2.08, 194 participants, 1 study). There was also no difference between donepezil and placebo for Quality of Life (QoL) (MD ‐2.79, 95% CI ‐8.15 to 2.56, 815 participants, 2 studies). Participants receiving donepezil were more likely to withdraw from the studies before the end of treatment (24% versus 20%, OR 1.25, 95% CI 1.05 to 1.50, 2846 participants, 12 studies) or to experience an adverse event during the studies (72% vs 65%, OR 1.59, 95% 1.31 to 1.95, 2500 participants, 10 studies). There was no evidence of a difference between donepezil and placebo for patient total healthcare resource utilisation. Three studies compared donepezil 10 mg/day to donepezil 5 mg/day over 26 weeks. The 5 mg dose was associated with slightly worse cognitive function on the ADAS‐Cog, but not on the MMSE or SIB, with slightly better QoL and with fewer adverse events and withdrawals from treatment. Two studies compared donepezil 10 mg/day to donepezil 23 mg/day. There were no differences on efficacy outcomes, but fewer participants on 10 mg/day experienced adverse events or withdrew from treatment. Authors' conclusions There is moderate‐quality evidence that people with mild, moderate or severe dementia due to Alzheimer's disease treated for periods of 12 or 24 weeks with donepezil experience small benefits in cognitive function, activities of daily living and clinician‐rated global clinical state. There is some evidence that use of donepezil is neither more nor less expensive compared with placebo when assessing total healthcare resource costs. Benefits on 23 mg/day were no greater than on 10 mg/day, and benefits on the 10 mg/day dose were marginally larger than on the 5 mg/day dose, but the rates of withdrawal and of adverse events before end of treatment were higher the higher the dose. Plain language summary Donepezil for people with dementia due to Alzheimer's disease Review question What effects (benefits or harms) does donepezil have on people with dementia due to Alzheimer's disease? Background Alzheimer's disease is the most common cause of dementia. As the disease progresses, people lose the ability to remember, communicate, think clearly and perform the activities of daily living. Their behaviour may also change. In severe Alzheimer's disease people lose the ability to care for themselves. The most commonly used treatment for Alzheimer's disease are medicines known as acetylcholinesterase inhibitors. Donepezil is one of these medicines. It is taken as a pill once a day. In Alzheimer's disease, one of the changes in the brain is a reduced number of nerve cells called cholinergic neurones. These are nerve cells that signal to other cells using a chemical called acetylcholine. Acetylcholinesterase inhibitors, such as donepezil, work by preventing acetylcholine from being broken down. This may improve the symptoms of dementia. However, acetylcholine is also found elsewhere in the body and so drugs of this type may have unwanted effects. Review methods In this review we examined evidence about benefits and harms from studies that compared donepezil, taken for at least 12 weeks, to placebo (a dummy pill), or that compared different doses of donepezil. The studies had to be double‐blind and randomised, that is, the decision whether people taking part got donepezil or placebo had to be made randomly and neither they nor the researchers should have known which treatment they were getting while the trial was going on. This was to make the comparison as unbiased, or fair, as possible. We searched for studies up to May 2017. We assessed the quality of all the studies we included. When it was sensible to do so, we analysed the results of studies together to get an overall result. Key results We included 30 studies with 8257 participants. Most of the people in the studies had mild or moderate dementia due to Alzheimer's disease, but in nine studies they had moderate or severe dementia. Almost all of the studies lasted six months or less. The majority of the studies were known to have been funded by the manufacturer of donepezil. We found that people with Alzheimer's disease who took 10 mg of donepezil a day for six months did slightly better than people taking placebo, on scales measuring their cognitive function (e.g. thinking and remembering), how well they could manage their daily activities, and the overall impression of a trained researcher. We did not find any effect on behaviour or quality of life. People taking donepezil were more likely than those taking placebo to report side effects and to drop out of the studies. Most side effects were described as mild. Nausea, vomiting and diarrhoea were most common. Comparing 5 mg of donepezil a day with 10 mg/day, people on 5 mg had fewer side effects, but did slightly less well on cognitive function tests. A higher dose (23 mg/day) offered no advantages and was associated with more side effects. There is some evidence that use of donepezil is neither more nor less expensive than placebo when total health care costs are taken into account. Quality of the evidence In general, we thought that the quality of the evidence was moderate. The main factor reducing our confidence was concern that the results of some studies might have been biased by the way they were done. We cannot be sure that the results apply to treatment longer than six months. Conclusions After six months of treatment, there are benefits of donepezil that are large enough to measure in studies. It is associated with side effects that are mainly mild, but that may cause people to stop treatment. Being able to stabilise cognitive performance or ability to maintain activities of daily living may be important clinically. In terms of total healthcare costs the use of donepezil appears cost neutral. However, there does not appear to be an effect on quality of life. More data are still required from longer‐term clinical studies examining measures of disease progression or time to needing full time care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Birks, JS, Harvey, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD001190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.099Z" }, { "id": "ef303732-ec0b-4149-bd43-324318e846e6", "pmid": "", "title": "Dietary Pistachio Intake and Nutrition-Related Outcomes in Individuals Using GLP-1 Receptor Agonists: A Randomized Controlled Trial", "imported": false, "abstract": "In this study will look at how eating pistachios every day might affect participants weight, how healthy their diet is, and how they feel when eating. Investigators want to see if adding pistachios to meals for 12 weeks helps participants feel fuller, have more energy, and improve body composition. The study will include adults who have been taking GLP-1 medicines like semaglutide or tirzepatide for at least three months. Investigators also want to see if eating pistachios improves overall diet quality and health markers like tiredness and certain levels in blood.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.241Z" }, { "id": "ef5f24bd-f2d0-449a-ac52-28f9aed278ff", "pmid": "", "title": "Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents", "imported": false, "abstract": "Abstract - Background Vomiting is a common manifestation of acute gastroenteritis in children and adolescents. When untreated it can be a hindrance to oral rehydration therapy, which is the cornerstone in the management of acute gastroenteritis. Evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in acute gastroenteritis in children. Objectives To assess the safety and effectiveness of antiemetics on gastroenteritis induced vomiting in children and adolescents. Search methods We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conferences.The search was re‐run and is up to date as on 20 July 2010. Selection criteria Randomized controlled trials comparing antiemetics with placebo or no treatment, in children and adolescents under the age of 18, for vomiting due to gastroenteritis. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We included seven trials involving 1,020 participants. Mean time to cessation of vomiting in one study was 0.34 days less with dimenhydrinate suppository compared to placebo (P value = 0.036). Pooled data from three studies comparing oral ondansetron with placebo showed: a reduction in the immediate hospital admission rate (RR 0.40, NNT 17, 95% CI 10 to 100) but no difference between the hospitalization rates at 72 hours after discharge from the Emergency Department (ED); a reduction in IV rehydration rates both during the ED stay (RR 0.41, NNT 5, 95% CI 4 to 8), and in follow‐up to 72 hours after discharge from the ED stay (worst‐best scenario for ondansetron RR 0.57, NNT 6, 95% CI 4 to 13) and an increase in the proportion of patients with cessation of vomiting (RR 1.34, NNT 5, 95% CI 3 to 7)). No significant difference was noted in the revisit rates or adverse events, although diarrhea was reported as a side effect in four of the five ondansetron studies. In one study the proportion of patients with cessation of vomiting in 24 hours was (58%) with IV ondansetron, (17%) placebo and (33%) in the metoclopramide group (P value = 0.039). Authors' conclusions Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting. Plain language summary Anti‐sickness medication for vomiting in acute stomach upsets in children Vomiting caused by acute gastroenteritis is very common in children and adolescents. Treatment of vomiting in children with acute gastroenteritis can be problematic and there is lack of agreement among clinicians on the indications for the use of antiemetics. There have also been concerns expressed about apparently unacceptable levels of side effects with some of the older generation of antiemetics. The small number of included trials provided evidence which appeared to favour the use of antiemetics over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. A single oral dose of ondansetron given to children with mild to moderate dehydration can control vomiting, avoid hospitalization and intravenous fluid administration which would otherwise be needed. There were no major side effects other than a few reports of increased frequency of diarrhea.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fedorowicz, Z; Jagannath, VA; Carter, B", "articleTypes": [], "doi": "10.1002/14651858.CD005506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "ef6cfa2c-e665-4f53-8187-953b779c63b8", "pmid": "", "title": "Antibiotics to prevent complications following tooth extractions", "imported": false, "abstract": "Abstract - Background The most frequent indications for tooth extractions, generally performed by general dental practitioners, are dental caries and periodontal infections. Systemic antibiotics may be prescribed to patients undergoing extractions to prevent complications due to infection. This is an update of a review first published in 2012. Objectives To determine the effect of systemic antibiotic prophylaxis on the prevention of infectious complications following tooth extractions. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 16 April 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 3), MEDLINE Ovid (1946 to 16 April 2020), Embase Ovid (1980 to 16 April 2020), and LILACS (1982 to 16 April 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov ) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised, double‐blind, placebo‐controlled trials of systemic antibiotic prophylaxis in patients undergoing tooth extraction(s) for any indication. Data collection and analysis At least two review authors independently performed data extraction and 'Risk of bias' assessment for the included studies. We contacted trial authors for further details where these were unclear. For dichotomous outcomes, we calculated risk ratios (RR) and 95% confidence intervals (CI) using random‐effects models. For continuous outcomes, we used mean differences (MD) with 95% CI using random‐effects models. We examined potential sources of heterogeneity. We assessed the certainty of the body of evidence for key outcomes as high, moderate, low, or very low, using the GRADE approach. Main results We included 23 trials that randomised approximately 3206 participants (2583 analysed) to prophylactic antibiotics or placebo. Although general dentists perform dental extractions because of severe dental caries or periodontal infection, only one of the trials evaluated the role of antibiotic prophylaxis in groups of patients affected by those clinical conditions. We assessed 16 trials as being at high risk of bias, three at low risk, and four as unclear. Compared to placebo, antibiotics may reduce the risk of postsurgical infectious complications in patients undergoing third molar extractions by approximately 66% (RR 0.34, 95% CI 0.19 to 0.64; 1728 participants; 12 studies; low‐certainty evidence), which means that 19 people (95% CI 15 to 34) need to be treated with antibiotics to prevent one infection following extraction of impacted wisdom teeth. Antibiotics may also reduce the risk of dry socket by 34% (RR 0.66, 95% CI 0.45 to 0.97; 1882 participants; 13 studies; low‐certainty evidence), which means that 46 people (95% CI 29 to 62) need to take antibiotics to prevent one case of dry socket following extraction of impacted wisdom teeth. The evidence for our other outcomes is uncertain: pain, whether measured dichotomously as presence or absence (RR 0.59, 95% CI 0.31 to 1.12; 675 participants; 3 studies) or continuously using a visual analogue scale (0‐to‐10‐centimetre scale, where 0 is no pain) (MD −0.26, 95% CI −0.59 to 0.07; 422 participants; 4 studies); fever (RR 0.66, 95% CI 0.24 to 1.79; 475 participants; 4 studies); and adverse effects, which were mild and transient (RR 1.46, 95% CI 0.81 to 2.64; 1277 participants; 8 studies) (very low‐certainty evidence). We found no clear evidence that the timing of antibiotic administration (preoperative, postoperative, or both) was important. The included studies enrolled a subset of patients undergoing dental extractions, that is healthy people who had surgical extraction of third molars. Consequently, the results of this review may not be generalisable to all people undergoing tooth extractions. Authors' conclusions The vast majority (21 out of 23) of the trials included in this review included only healthy patients undergoing extraction of impacted third molars, often performed by oral surgeons. None of the studies evaluated tooth extraction in immunocompromised patients. We found low‐certainty evidence that prophylactic antibiotics may reduce the risk of infection and dry socket following third molar extraction when compared to placebo, and very low‐certainty evidence of no increase in the risk of adverse effects. On average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection. It is unclear whether the evidence in this review is generalisable to patients with concomitant illnesses or patients at a higher risk of infection. Due to the increasing prevalence of bacteria that are resistant to antibiotic treatment, clinicians should evaluate if and when to prescribe prophylactic antibiotic therapy before a dental extraction for each patient on the basis of the patient's clinical conditions (healthy or affected by systemic pathology) and level of risk from infective complications. Immunocompromised patients, in particular, need an individualised approach in consultation with their treating medical specialist. Plain language summary Are antibiotics an effective way to prevent infection following tooth removal? What is the problem? Teeth that are affected by decay or gum disease or painful wisdom teeth are often removed (extracted) by dentists. Tooth extraction is a surgical procedure that leaves a wound in the mouth that can become infected. Infection can lead to swelling, pain, development of pus, fever, as well as ‘dry socket’ (where the tooth socket is not filled by a blood clot, and there is severe pain and bad odour). These complications are unpleasant for patients and may cause difficulty with chewing, speaking, and teeth cleaning, and may even result in days off work or study. Treatment of infection is generally simple and involves drainage of the infection from the wound and patients receiving antibiotics. Why is this question important? Antibiotics work by killing the bacteria that cause infections, or by slowing their growth. However, some infections clear up by themselves. Taking antibiotics unnecessarily may stop them working effectively in future. This ‘antimicrobial resistance’ is a growing problem throughout the world. Antibiotics may also cause unwanted effects such as diarrhoea and nausea. Some patients may be allergic to antibiotics, and antibiotics may not mix well with other medicines. Dentists frequently give patients antibiotics at the time of the extraction as a precaution in order to prevent infection occurring in the first place. This may be unnecessary and may lead to unwanted effects. What did we want to find out? We wanted to know whether giving antibiotics as a preventive measure reduces infection and other complications after tooth extraction. We also wanted to understand whether antibiotics work differently in healthy people compared with people with health conditions such as diabetes or HIV. What did we do? We searched for studies that assessed the effectiveness of antibiotics compared to placebo (sham medicine), given when no infection was present in order to prevent infection following tooth extraction. Studies could include people of any age undergoing tooth extraction. Where possible, we pooled the studies’ results and analysed them together. We also assessed the quality of each study to judge the reliability (certainty) of evidence of individual studies and the body of evidence. What we found We found 23 included studies with a total of more than 3200 participants, who received either antibiotics (of different kinds and dosages) or placebo immediately before or just after tooth extraction, or both. Four studies were conducted in Spain, three each in Brazil, Sweden, and the UK, two in India, and one each in Colombia, Denmark, Finland, France, Poland, New Zealand, Nigeria, and the USA. All but one study included healthy patients in their 20s. Twenty‐one studies assessed the removal of wisdom teeth in hospital dental departments, one assessed the removal of other teeth and one assessed complex oral surgery. None of the included studies assessed tooth extraction in general dental practice for the removal of decayed teeth. Main results Antibiotics given just before or just after surgery (or both) may reduce the risk of infection and dry socket after the removal of wisdom teeth by oral surgeons. However, antibiotics may cause more (generally brief and minor) unwanted effects for these patients. We found no evidence that antibiotics prevent pain, fever, swelling, or problems with restricted mouth opening in patients who have had wisdom teeth removed. There was no evidence to judge the effects of preventive antibiotics for extractions of severely decayed teeth, teeth in diseased gums, or extractions in patients who are sick or have low immunity to infection. How reliable are the results? Our confidence in the results is limited because we had concerns about aspects of the design and reporting of all of the included studies. What does this mean? We did not find studies in patients with depressed immune systems, other illnesses, or in young children or older patients, therefore the results of our review probably do not apply to people who may be at high risk of infection. Also, extractions were mainly carried out by oral surgeons, so the review may not apply to dentists working in general practice. Another concern, which cannot be assessed by clinical studies (i.e. studies testing new medical approaches in people), is that widespread use of antibiotics by people who do not have an infection is likely to contribute to the development of antimicrobial resistance. We concluded that antibiotics given to healthy people when they are having teeth extracted may help prevent infection, but the decision to use an antibiotic should be judged on an individual patient basis based on their state of health and possible complications of getting an infection. How up‐to‐date is this review? This is an updated review. The evidence is current to April 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Lodi, G, Azzi, L, Varoni, EM, Pentenero, M, Del Fabbro, M, Carrassi, A, Sardella, A, Manfredi, M", "articleTypes": [], "doi": "10.1002/14651858.CD003811.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.790Z" }, { "id": "ef9dbef9-e60d-42c6-942d-d1ad1f3d04b6", "pmid": "", "title": "Vitamin C for preventing and treating pneumonia", "imported": false, "abstract": "Abstract - Background Pneumonia is one of the most common serious infections, causing two million deaths annually among young children in low‐income countries. In high‐income countries pneumonia is most significantly a problem of the elderly. Objectives To assess the prophylactic and therapeutic effects of vitamin C on pneumonia. Search methods We searched CENTRAL 2013, Issue 3, MEDLINE (1950 to March week 4, 2013), EMBASE (1974 to April 2013) and Web of Science (1955 to April 2013). Selection criteria To assess the therapeutic effects of vitamin C, we selected placebo‐controlled trials. To assess prophylactic effects, we selected controlled trials with or without a placebo. Data collection and analysis Two review authors independently read the trial reports and extracted data. Main results We identified three prophylactic trials which recorded 37 cases of community‐acquired pneumonia in 2335 people. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. Two trials examined military recruits and the third studied boys from \"lower wage‐earning classes\" attending a boarding school in the UK during World War II. Each of these three trials found a statistically significant (80% or greater) reduction in pneumonia incidence in the vitamin C group. We identified two therapeutic trials involving 197 community‐acquired pneumonia patients. Only one was satisfactorily randomised, double‐blind and placebo‐controlled. That trial studied elderly patients in the UK and found lower mortality and reduced severity in the vitamin C group; however, the benefit was restricted to the most ill patients. The other therapeutic trial studied adults with a wide age range in the former Soviet Union and found a dose‐dependent reduction in the duration of pneumonia with two vitamin C doses. We identified one prophylactic trial recording 13 cases of hospital‐acquired pneumonia in 37 severely burned patients; one‐day administration of vitamin C had no effect on pneumonia incidence. The identified studies are clinically heterogeneous which limits their comparability. The included studies did not find adverse effects of vitamin C. Authors' conclusions The prophylactic use of vitamin C to prevent pneumonia should be further investigated in populations who have a high incidence of pneumonia, especially if dietary vitamin C intake is low. Similarly, the therapeutic effects of vitamin C should be studied, especially in patients with low plasma vitamin C levels. The current evidence is too weak to advocate prophylactic use of vitamin C to prevent pneumonia in the general population. Nevertheless, therapeutic vitamin C supplementation may be reasonable for pneumonia patients who have low vitamin C plasma levels because its cost and risks are low. Plain language summary Vitamin C for preventing and treating pneumonia Pneumonia is an infection of the lungs usually caused by bacteria and viruses. Its clinical diagnosis is sometimes difficult. Pneumonia is more common in young children and in the aged. In low‐income countries it causes two million deaths annually among young children. In the USA it is the most common cause of death from infection. Vitamin C was identified in the early 1900s and suggestions that one of its biological roles may be to resist infections are supported by numerous animal studies. We looked for studies in humans and found three trials with a total of 2335 participants that looked at whether vitamin C prevents pneumonia in the community. Two of these preventive trials studied soldiers while the third studied boys in a UK boarding school in the 1940s. Two therapeutic trials with a total of 197 pneumonia patients looked at whether vitamin C might be beneficial for pneumonia patients. One studied patients aged 66 to 94 years in the UK with pneumonia. The other therapeutic trial was conducted in the former Soviet Union but the social and nutritional backgrounds of the patients were not described. One study with 37 burns patients examined the effect of vitamin C on hospital‐acquired pneumonia. Our searches were up‐date‐as of April 2013. Five of the identified trials found preventive or therapeutic benefits of vitamin C against pneumonia but the study on hospital‐acquired pneumonia found no effect. The overall quality of the studies was good. However, the five trials with positive findings were carried out in such extraordinary conditions that the results should not be extrapolated to the general population. Therefore, more research is needed. In the meantime, supplementing pneumonia patients who have low plasma vitamin C levels may be reasonable because of its safety and low cost. None of the five trials reported noteworthy adverse effects of vitamin C.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H, Louhiala, P", "articleTypes": [], "doi": "10.1002/14651858.CD005532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.068Z" }, { "id": "ef9e0ad7-6c66-40d4-836c-ffc46f198a4a", "pmid": "", "title": "Interventions for latent autoimmune diabetes (LADA) in adults", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Brophy, S, Davies, H, Mannan, S, Brunt, H, Williams, R", "articleTypes": [], "doi": "10.1002/14651858.CD006165.pub3 AB - Abstract - Background Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes. Objectives To compare interventions used for LADA. Search methods Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta‐analysis or descriptive methods. Main results Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow‐up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: ‐1.3% (95% confidence interval (CI) ‐2.4 to ‐0.1; P = 0.03, 160 participants, four studies, follow‐up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C‐peptide, but insulin maintained stimulated C‐peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow‐up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C‐peptide levels (20 μg group) were maintained after five years. Short term (three months) follow‐up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C‐peptide levels compared to insulin alone (0.07 µg/L (95% CI ‐0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C‐peptide levels in the vitamin D group but declining fasting C‐peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow‐up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health‐related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes). Authors' conclusions Two studies show SU leading to earlier insulin dependence and a meta‐analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 μg) have been suggested to maintain fasting and stimulated C‐peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA. Plain language summary Interventions for latent autoimmune diabetes (LADA) in adults LADA is a condition that at diagnosis looks like type 2 diabetes (non‐insulin requiring diabetes mellitus) but actually is a type 1 diabetes, where the patient will become insulin requiring. In the UK approximately 3.6% of people who look like they have type 2 diabetes actually have type 1 diabetes, while other studies suggest the prevalence is higher and treatment for these patients may need to be different from that used in type 2 diabetes. 
 We identified 15 publications (10 studies) looking at 1019 patients who were followed between three months to 10 years. We found many of the publications had poor quality of reporting and had small numbers of participants. However, there does seem to be evidence from this review that the drug sulphonylurea (like glibenclamide or glyburide, gliclazide) could make patients insulin dependent sooner and it does not control blood sugar as well as insulin. Therefore, this suggests that this drug should not be a first line treatment for patients with LADA. In addition, insulin combined with vitamin D, or Chinese herbs may maintain natural insulin production better than insulin alone. Similarly, glutamic acid decarboxylase (GAD65) may maintain natural insulin production. However, there was no conclusive evidence that any of the other remaining treatment methods were better than each other. Studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic attacks. This review represents very early days of our understanding of the best way to treat LADA. It is limited by the poor reporting quality of the studies, small sample sizes, no clear single definition of LADA and many of the studies being carried out in different ethnic groups (China, Japan, Cuba, UK, Sweden) with different clinical care systems. 
 None of the publications reported on complications of diabetes, health‐related quality of life, costs or health service utilisation. All but one of the publications reported there were no deaths. 
 In summary, this review demonstrates that insulin treatment may be preferable compared to sulphonylurea treatment but there is little evidence regarding other forms of treatment. Future studies are needed, should have a clear definition of LADA, investigate patient‐important outcomes and use a common method of measuring stimulated C‐peptide (a marker of natural insulin production reflecting improved beta‐cell function of the pancreas).", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.786Z" }, { "id": "efad1385-7ff7-4706-8c83-38ffcb887918", "pmid": "", "title": "COVID-19: Why Are Children Less Affected", "imported": false, "abstract": "Observational Study of Infants Fed on DHA (Breast Source or Milk Formula Source ) and Its Effect on COVID-19 Severity", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.268Z" }, { "id": "efcdbe54-13c8-48ae-a76f-70e10897d151", "pmid": "", "title": "Combination inhaled steroid and long‐acting beta₂‐agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease", "imported": false, "abstract": "Abstract - Background The long‐acting bronchodilator tiotropium and single‐inhaler combination therapy of inhaled corticosteroids and long‐acting beta 2 ‐agonists (ICS/LABA) are commonly used for maintenance treatment of patients with chronic obstructive pulmonary disease (COPD). Combining these treatments, which have different mechanisms of action, may be more effective than administering the individual components. Objectives To assess relative effects of the following treatments on markers of exacerbations, symptoms, quality of life and lung function in patients with COPD. • Tiotropium plus LABA/ICS versus tiotropium. • Tiotropium plus LABA/ICS versus LABA/ICS. Search methods We searched the Cochrane Airways Group Specialised Register of Trials (April 2015), ClinicalTrials.gov ( www.ClinicalTrials.gov ), the World Health Organization (WHO) trials portal and reference lists of relevant articles. Selection criteria We included parallel, randomised controlled trials (RCTs) lasting three months or longer conducted to compare ICS and LABA combination therapy in addition to inhaled tiotropium versus tiotropium alone or combination therapy alone. Data collection and analysis We independently assessed trials for inclusion, then extracted data on trial quality and outcome results. We contacted study authors to ask for additional information. We collected trial information on adverse effects. Main results Tiotropium plus LABA/ICS versus tiotropium We included six studies (1902 participants) with low risk of bias that compared tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy versus tiotropium alone. We found no statistically significant differences in mortality between treatments (odds ratio (OR) 1.80, 95% confidence interval (CI) 0.55 to 5.91; two studies; 961 participants) as well as in the all‐cause hospitalisations (OR 0.84, 95% CI 0.53 to 1.33; two studies; 961 participants). The effect on exacerbations was heterogeneous among trials and was not meta‐analysed. Health‐related quality of life measured by St. George’s Respiratory Questionnaire (SGRQ) showed a statistically significant improvement in total scores with use of tiotropium + LABA/ICS compared with tiotropium alone (mean difference (MD) ‐3.46, 95% CI ‐5.05 to ‐1.87; four studies; 1446 participants). Lung function was significantly different in the combined therapy (tiotropium + LABA/ICS) group, although average benefit with this therapy was small. None of the included studies included exercise tolerance as an outcome. A pooled estimate of these studies did not show a statistically significant difference in adverse events (OR 1.16, 95% CI 0.92 to 1.47; four studies; 1363 participants), serious adverse events (OR 0.86, 95% CI 0.57 to 1.30; four studies; 1758 participants) and pneumonia (Peto OR 1.62, 95% CI 0.54 to 4.82; four studies; 1758 participants). Tiotropium plus LABA/ICS versus LABA/ICS One of the six studies (60 participants) also compared combined therapy (tiotropium + LABA/ICS) versus LABA/ICS therapy alone. This study was affected by lack of power; therefore results did not allow us to draw conclusions for this comparison. Authors' conclusions This review update includes three additional studies and provides new low quality evidence supporting the finding that tiotropium + LABA/ICS‐based therapy improves the disease‐specific quality of life. The current evidence is insufficient to support the benefit of tiotropium + LABA/ICS‐based therapy for mortality, hospital admission or exacerbations (moderate and low quality evidence). Compared with use of tiotropium alone, tiotropium + LABA/ICS‐based therapy does not seem to increase undesirable effects nor serious non‐fatal adverse events. Plain language summary Are tiotropium plus combination inhalers better than tiotropium or combination inhalers alone for the treatment of COPD? Background Chronic obstructive pulmonary disease (COPD) is a lung disease that includes the conditions chronic bronchitis and/or emphysema. COPD is characterised by narrowing of the airways and lung tissue destruction. Symptoms include breathlessness and long‐term cough. Symptoms of COPD are treatable, but the condition cannot be reversed or cured. It is usually brought on by airway irritants, such as smoking or inhaled dust. Inhalers with bronchodilators (which allow the airways in the lungs to relax and expand) and/or anti‐inflammatory agents are commonly used to ease symptoms and minimise the long‐term decline in health caused by COPD. Examples of these treatments are tiotropium, which is a bronchodilator, and combination inhalers, which contain another type of bronchodilator (long‐acting beta‐agonists) together with anti‐inflammatory agents (steroids). These treatments work in different ways and therefore might be more beneficial if used together. Study characteristics This review found six studies, involving 1902 participants, comparing the long‐term efficacy and side effects of tiotropium combined with combination inhalers for treatment of patients with COPD. Not all of the people included in these studies had COPD that was severe enough to be recommended for combined therapy according to current guidelines. Key results Current evidence shows potential benefits of treatment with tiotropium in addition to inhaled corticosteroid and long‐acting beta2‐agonist combination therapy through increased health‐related quality of life and a small improvement i n lung function in patients receiving this combined therapy. However, this evidence does not allow us to draw conclusions about the effects of these treatments on mortality, hospitalisation for all causes and exacerbations. The frequency of serious and non‐serious adverse events was not increased in either of the two groups. Quality of the evidence Overall, we assessed the evidence presented in this review to be of moderate or low quality, which means we are reasonably confident in some of the findings, but less confident in others.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Rojas‐Reyes, MX; García Morales, OM; Dennis, RJ; Karner, C", "articleTypes": [], "doi": "10.1002/14651858.CD008532.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "efe0ae21-787f-42f8-8b13-90fc42cdb3e6", "pmid": "", "title": "Supplementation with multiple micronutrients for breastfeeding women for improving outcomes for the mother and baby", "imported": false, "abstract": "Abstract - Background Globally, more than two billion people are estimated to be deficient in key vitamins and minerals, particularly iodine, iron and zinc. The majority of these people live in low‐income settings and are typically deficient in more than one micronutrient. However, micronutrient deficiency among breastfeeding mothers and their infants also remains an issue in high‐income settings, specifically among women who avoid meat and/or milk, women who may lack sufficient supplies of vitamin B12 and vitamin D, and/or women who are iron‐deficient. Young children, pregnant and lactating women are particularly vulnerable to micronutrient deficiencies. They not only have a relatively greater need for vitamins and minerals because of their physiological state, but are also more susceptible to the harmful consequences of deficiencies. Multiple‐micronutrient supplementation might be an option to solve these problems. Objectives The objective of this review was to evaluate the effects of multiple‐micronutrient supplementation in breastfeeding mothers on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. Selection criteria Randomised controlled trials of multiple‐micronutrient supplementation of three or more micronutrients versus placebo, no supplementation or supplementation with two or fewer micronutrients, irrespective of dosage of micronutrients, in breastfeeding mothers. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We found no studies that compared multiple‐micronutrient supplementation (with three or more micronutrients) versus supplementation with two or fewer micronutrients. Two small studies (involving a total of 52 women) were included. One study compared multiple micronutrients with placebo and the other study compared multiple micronutrients with a group who received no supplementation. The studies were carried out in Brazil (36 adolescent mothers) and the USA (16 women) and included women with a low socioeconomic status. A lack of information in the study reports meant that risk of bias could not be adequately assessed (unclear risk of bias for many domains). There were no quantitative data for any of this review's outcomes so meta‐analysis was not possible. Neither of the studies reported on the primary outcomes of interest in this review: maternal morbidity (febrile illness, respiratory tract infection, diarrhoea) , adverse effects of micronutrients within three days of receiving the supplement , infant mortality (defined as a child dying before completing the first year of age) . One study reported qualitatively on maternal anaemia (a secondary outcome of this review) ‐ the study found that multiple‐micronutrient supplementation was effective for recuperating from anaemia but there were no data for inclusion in our analyses. Maternal satisfaction was not reported in the included studies. Similarly, none of this review's infant secondary outcomes were reported in the included studies: clinical micronutrient deficiency ; morbidity episodes (febrile illness, respiratory tract infection, diarrhoea, other) , adverse effects of micronutrients within three days of receiving the supplement . Authors' conclusions We found no evidence to quantitatively assess the effectiveness of multiple‐micronutrient supplementation in improving health outcomes in mother and baby. The results of this review are limited by the small numbers of studies available, small sample sizes and the studies not reporting on the outcomes of interest in this review. There is no evidence to evaluate potential adverse effects of multiple‐micronutrient supplements, particularly excess dosages. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Further research should focus on whether multiple‐micronutrient supplementation during lactation compared with none, a placebo or supplementation with fewer than two micronutrients is beneficial to maternal and infant health outcomes. Future studies should collect data on outcomes beyond micronutrient concentrations, for example: maternal and infant morbidity, adverse effects, maternal satisfaction, the risks of excess supplementation, and potential adverse interactions between the micronutrients and the other outcomes. This would help to bridge the gap between research on intermediary outcomes and health outcomes in order to develop sound policy in this field. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these affect maternal and infant health outcomes. Larger studies with longer follow‐up would improve the quality of studies and provide stronger evidence. In most of the included studies, bias could not be adequately assessed due to lack of information, therefore attention should be given to adequate methods of randomisation and allocation concealment, adequate methods of blinding of the participants, providers and the outcome assessors to improve the methodological quality of studies in this field. Plain language summary Multiple micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby The benefits and risks of multiple‐micronutrient supplementation during lactation are not clear from randomised controlled studies. Key vitamins and minerals, particularly iodine, iron and zinc, are required in small amounts to ensure normal body metabolism, physical growth and development. Nutrient deficiency affects nearly one third of the world’s population, especially in low‐ and middle‐income countries. Breastfeeding mothers need higher levels than usual in order to provide sufficient vitamins and minerals for their own health and that of their babies, particularly for normal functioning and the growth and development of the baby. Previous studies have assessed supplementation of individual micronutrients. This review looked at the use of multiple‐micronutrient supplements for breastfeeding women for improving outcomes for the mother and her baby. We searched for studies on 30 September 2015 and identified two small studies (involving 52 women) for inclusion in this review. The studies were carried out in Brazil and the USA and included women who had a low socioeconomic status. The studies were poorly reported and this lack of information made it difficult to determine whether the studies were at risk of bias. Neither of the studies provided data for any of this review's important outcomes: maternal illness (fever, respiratory infection, diarrhoea), adverse effects of micronutrients within three days of taking them, infant death (defined as a child dying before reaching one year of age). Similarly, there were no data for any of the other outcomes that we were interested in. For the mother, these outcomes were maternal anaemia, and women's satisfaction. For the baby, these outcomes were micronutrient deficiency; illness episodes (fever, respiratory infection, diarrhoea, other), adverse effects of micronutrients within three days of the woman receiving the supplement. However, one of the included studies reported that multiple‐micronutrient supplementation was effective for lactating women recuperating from anaemia. There is a need for high‐quality studies to assess the effectiveness and safety of multiple‐micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Larger studies with longer‐term follow‐up would improve the quality of studies and provide stronger evidence. Further research should focus on whether multiple‐micronutrient supplementation during lactation (compared with no supplementation, a placebo or supplementation with fewer than two micronutrients) is beneficial to the mother and her baby and any associated adverse effects of the intervention. Futher studies should report on important outcomes such as those listed in this review and consider the risks of excess supplementation. Future studies could more precisely assess a variety of multiple‐micronutrient combinations and different dosages and look at how these effect outcomes for the mother and her baby.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Abe, SK; Balogun, OO; Ota, E; Takahashi, K; Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD010647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "efebf4db-5970-49b5-a07c-b3859e6cdd4a", "pmid": "", "title": "Selenium for preventing cancer", "imported": false, "abstract": "Abstract - Background This review is the third update of the Cochrane review \"Selenium for preventing cancer\". Selenium is a naturally occurring element with both nutritional and toxicological properties. Higher selenium exposure and selenium supplements have been suggested to protect against several types of cancer. Objectives To gather and present evidence needed to address two research questions: 1. What is the aetiological relationship between selenium exposure and cancer risk in humans?
 2. Describe the efficacy of selenium supplementation for cancer prevention in humans. Search methods We updated electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), MEDLINE (Ovid, 2013 to January 2017, week 4), and Embase (2013 to 2017, week 6), as well as searches of clinical trial registries. Selection criteria We included randomised controlled trials (RCTs) and longitudinal observational studies that enrolled adult participants. Data collection and analysis We performed random‐effects (RE) meta‐analyses when two or more RCTs were available for a specific outcome. We conducted RE meta‐analyses when five or more observational studies were available for a specific outcome. We assessed risk of bias in RCTs and in observational studies using Cochrane's risk assessment tool and the Newcastle‐Ottawa Scale, respectively. We considered in the primary analysis data pooled from RCTs with low risk of bias. We assessed the certainty of evidence by using the GRADE approach. Main results We included 83 studies in this updated review: two additional RCTs (10 in total) and a few additional trial reports for previously included studies. RCTs involved 27,232 participants allocated to either selenium supplements or placebo. For analyses of RCTs with low risk of bias, the summary risk ratio (RR) for any cancer incidence was 1.01 (95% confidence interval (CI) 0.93 to 1.10; 3 studies, 19,475 participants; high‐certainty evidence). The RR for estimated cancer mortality was 1.02 (95% CI 0.80 to 1.30; 1 study, 17,448 participants). For the most frequently investigated site‐specific cancers, investigators provided little evidence of any effect of selenium supplementation. Two RCTs with 19,009 participants indicated that colorectal cancer was unaffected by selenium administration (RR 0.99, 95% CI 0.69 to 1.43), as were non‐melanoma skin cancer (RR 1.16, 95% CI 0.30 to 4.42; 2 studies, 2027 participants), lung cancer (RR 1.16, 95% CI 0.89 to 1.50; 2 studies, 19,009 participants), breast cancer (RR 2.04, 95% CI 0.44 to 9.55; 1 study, 802 participants), bladder cancer (RR 1.07, 95% CI 0.76 to 1.52; 2 studies, 19,009 participants), and prostate cancer (RR 1.01, 95% CI 0.90 to 1.14; 4 studies, 18,942 participants). Certainty of the evidence was high for all of these cancer sites, except for breast cancer, which was of moderate certainty owing to imprecision, and non‐melanoma skin cancer, which we judged as moderate certainty owing to high heterogeneity. RCTs with low risk of bias suggested increased melanoma risk. Results for most outcomes were similar when we included all RCTs in the meta‐analysis, regardless of risk of bias. Selenium supplementation did not reduce overall cancer incidence (RR 0.99, 95% CI 0.86 to 1.14; 5 studies, 21,860 participants) nor mortality (RR 0.81, 95% CI 0.49 to 1.32; 2 studies, 18,698 participants). Summary RRs for site‐specific cancers showed limited changes compared with estimates from high‐quality studies alone, except for liver cancer, for which results were reversed. In the largest trial, the Selenium and Vitamin E Cancer Trial, selenium supplementation increased risks of alopecia and dermatitis, and for participants with highest background selenium status, supplementation also increased risk of high‐grade prostate cancer. RCTs showed a slightly increased risk of type 2 diabetes associated with supplementation. A hypothesis generated by the Nutritional Prevention of Cancer Trial ‐ that individuals with low blood selenium levels could reduce their risk of cancer (particularly prostate cancer) by increasing selenium intake ‐ has not been confirmed. As RCT participants have been overwhelmingly male (88%), we could not assess the potential influence of sex or gender. We included 15 additional observational cohort studies (70 in total; over 2,360,000 participants). We found that lower cancer incidence (summary odds ratio (OR) 0.72, 95% CI 0.55 to 0.93; 7 studies, 76,239 participants) and lower cancer mortality (OR 0.76, 95% CI 0.59 to 0.97; 7 studies, 183,863 participants) were associated with the highest category of selenium exposure compared with the lowest. Cancer incidence was lower in men (OR 0.72, 95% CI 0.46 to 1.14, 4 studies, 29,365 men) than in women (OR 0.90, 95% CI 0.45 to 1.77, 2 studies, 18,244 women). Data show a decrease in risk of site‐specific cancers for stomach, colorectal, lung, breast, bladder, and prostate cancers. However, these studies have major weaknesses due to study design, exposure misclassification, and potential unmeasured confounding due to lifestyle or nutritional factors covarying with selenium exposure beyond those taken into account in multi‐variable analyses. In addition, no evidence of a dose‐response relation between selenium status and cancer risk emerged. Certainty of evidence was very low for each outcome. Some studies suggested that genetic factors might modify the relation between selenium and cancer risk ‐ an issue that merits further investigation. Authors' conclusions Well‐designed and well‐conducted RCTs have shown no beneficial effect of selenium supplements in reducing cancer risk (high certainty of evidence). Some RCTs have raised concerns by reporting a higher incidence of high‐grade prostate cancer and type 2 diabetes in participants with selenium supplementation. No clear evidence of an influence of baseline participant selenium status on outcomes has emerged in these studies. Observational longitudinal studies have shown an inverse association between selenium exposure and risk of some cancer types, but null and direct relations have also been reported, and no systematic pattern suggesting dose‐response relations has emerged. These studies suffer from limitations inherent to the observational design, including exposure misclassification and unmeasured confounding. Overall, there is no evidence to suggest that increasing selenium intake through diet or supplementation prevents cancer in humans. However, more research is needed to assess whether selenium may modify the risk of cancer in individuals with a specific genetic background or nutritional status, and to investigate possible differential effects of various forms of selenium. Plain language summary Selenium for preventing cancer Review question 
 We reviewed the evidence investigating the relation between selenium intake and cancer prevention. This review updates the most recent Cochrane review on this topic ( Vinceti 2014) , which was an update of Dennert 2011 . Background 
 Selenium is a naturally occurring element that individuals are exposed to mainly through food consumption, although exposure can also occur through air, drinking water, and dietary supplements. Small amounts of selenium are essential for certain biological functions in humans, but slightly higher amounts can pose a toxicity risk, making selenium an element with a narrow, but as yet not well‐defined, safe range of exposure. Selenium occurs in many different chemical forms with different biological activity. From the late 1960s, a few observational studies reported that people with high levels of selenium in their diet or in their body tissues had lower risk of cancer, and some laboratory studies showed that selenium could inhibit the growth of cancer cells. This led to widespread interest in selenium supplements and claims that taking such supplements could prevent cancer. Since that time, many more observational studies have been conducted to compare cancer rates among individuals with high and low selenium exposure. More recently, several randomised controlled trials designed to assess whether selenium supplementation can prevent cancer have been carried out. These trials played a major role in enhancing our understanding of the relation between selenium and cancer risk as a result of their stronger study design as compared with observational studies. The most recent trials in particular have shown high methodological quality and statistical power. Several trials focused on whether selenium could prevent prostate cancer. Study characteristics 
 This review includes 10 trials in which adults were randomly assigned to receive selenium supplements or placebo, and 70 observational studies in which adults were followed over time to determine whether their baseline selenium status was associated with their risk of cancer. The evidence is current to January 2017. Key results 
 All of the high‐quality randomised trials reported no effect of selenium on reducing overall risk of cancer or risk of particular cancers, including the most investigated outcome ‐ prostate cancer. Some trials unexpectedly suggested that selenium may increase risks of high‐grade prostate cancer, type 2 diabetes, and dermatological abnormalities. Observational studies have yielded inconsistent evidence of a possible effect of selenium exposure on cancer risk, with no evidence of a dose‐response relation. When we pooled results of these studies, overall they suggested an inverse relation between cancer exposure and subsequent incidence of any cancer or some specific cancers, such as colon and prostate cancer. However, observational studies have major weaknesses. The selenium exposure status of participants could have been misclassified owing to limitations of the indicators of selenium exposure used, as well as to uncertainty regarding the particular selenium species contributing to overall exposure. In addition, unmeasured confounding from lifestyle or nutritional factors ‐ a major and well‐known source of bias in nutritional epidemiology studies of observational design ‐ could have been present. Therefore, the internal validity of these studies is limited. Currently, the hypothesis that increasing selenium intake may reduce cancer risk is not supported by epidemiological evidence. Additional research is needed to assess whether selenium may affect the risk of cancer in individuals with specific genetic backgrounds or nutritional status, and to determine how the various chemical forms of selenium compounds may have different effects on cancer risk.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Vinceti, M; Filippini, T; Del Giovane, C; Dennert, G; Zwahlen, M; Brinkman, M; Zeegers, MPA; Horneber, M; D'Amico, R; Crespi, CM", "articleTypes": [], "doi": "10.1002/14651858.CD005195.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "eff59c5b-a2e0-4af3-9bce-607cbfe852bd", "pmid": "", "title": "Janus kinase inhibitors for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background With potential antiviral and anti‐inflammatory properties, Janus kinase (JAK) inhibitors represent a potential treatment for symptomatic severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. They may modulate the exuberant immune response to SARS‐CoV‐2 infection. Furthermore, a direct antiviral effect has been described. An understanding of the current evidence regarding the efficacy and safety of JAK inhibitors as a treatment for coronavirus disease 2019 (COVID‐19) is required. Objectives To assess the effects of systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo) on clinical outcomes in individuals (outpatient or in‐hospital) with any severity of COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising MEDLINE, Embase, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform, medRxiv, and Cochrane Central Register of Controlled Trials), Web of Science, WHO COVID‐19 Global literature on coronavirus disease, and the US Department of Veterans Affairs Evidence Synthesis Program (VA ESP) Covid‐19 Evidence Reviews to identify studies up to February 2022. We monitor newly published randomised controlled trials (RCTs) weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials from this source until the first week of April 2022. Selection criteria We included RCTs that compared systemic JAK inhibitors plus standard of care to standard of care alone (plus/minus placebo) for the treatment of individuals with COVID‐19. We used the WHO definitions of illness severity for COVID‐19. Data collection and analysis We assessed risk of bias of primary outcomes using Cochrane's Risk of Bias 2 (RoB 2) tool. We used GRADE to rate the certainty of evidence for the following primary outcomes: all‐cause mortality (up to day 28), all‐cause mortality (up to day 60), improvement in clinical status: alive and without need for in‐hospital medical care (up to day 28), worsening of clinical status: new need for invasive mechanical ventilation or death (up to day 28), adverse events (any grade), serious adverse events, secondary infections. Main results We included six RCTs with 11,145 participants investigating systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo). Standard of care followed local protocols and included the application of glucocorticoids (five studies reported their use in a range of 70% to 95% of their participants; one study restricted glucocorticoid use to non‐COVID‐19 specific indications), antibiotic agents, anticoagulants, and antiviral agents, as well as non‐pharmaceutical procedures. At study entry, about 65% of participants required low‐flow oxygen, about 23% required high‐flow oxygen or non‐invasive ventilation, about 8% did not need any respiratory support, and only about 4% were intubated. We also identified 13 ongoing studies, and 9 studies that are completed or terminated and where classification is pending. Individuals with moderate to severe disease Four studies investigated the single agent baricitinib (10,815 participants), one tofacitinib (289 participants), and one ruxolitinib (41 participants). Systemic JAK inhibitors probably decrease all‐cause mortality at up to day 28 (95 of 1000 participants in the intervention group versus 131 of 1000 participants in the control group; risk ratio (RR) 0.72, 95% confidence interval (CI) 0.57 to 0.91; 6 studies, 11,145 participants; moderate‐certainty evidence), and decrease all‐cause mortality at up to day 60 (125 of 1000 participants in the intervention group versus 181 of 1000 participants in the control group; RR 0.69, 95% CI 0.56 to 0.86; 2 studies, 1626 participants; high‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in improvement in clinical status (discharged alive or hospitalised, but no longer requiring ongoing medical care) (801 of 1000 participants in the intervention group versus 778 of 1000 participants in the control group; RR 1.03, 95% CI 1.00 to 1.06; 4 studies, 10,802 participants; moderate‐certainty evidence). They probably decrease the risk of worsening of clinical status (new need for invasive mechanical ventilation or death at day 28) (154 of 1000 participants in the intervention group versus 172 of 1000 participants in the control group; RR 0.90, 95% CI 0.82 to 0.98; 2 studies, 9417 participants; moderate‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in the rate of adverse events (any grade) (427 of 1000 participants in the intervention group versus 441 of 1000 participants in the control group; RR 0.97, 95% CI 0.88 to 1.08; 3 studies, 1885 participants; moderate‐certainty evidence), and probably decrease the occurrence of serious adverse events (160 of 1000 participants in the intervention group versus 202 of 1000 participants in the control group; RR 0.79, 95% CI 0.68 to 0.92; 4 studies, 2901 participants; moderate‐certainty evidence). JAK inhibitors may make little or no difference to the rate of secondary infection (111 of 1000 participants in the intervention group versus 113 of 1000 participants in the control group; RR 0.98, 95% CI 0.89 to 1.09; 4 studies, 10,041 participants; low‐certainty evidence). Subgroup analysis by severity of COVID‐19 disease or type of JAK inhibitor did not identify specific subgroups which benefit more or less from systemic JAK inhibitors. Individuals with asymptomatic or mild disease We did not identify any trial for this population. Authors' conclusions In hospitalised individuals with moderate to severe COVID‐19, moderate‐certainty evidence shows that systemic JAK inhibitors probably decrease all‐cause mortality. Baricitinib was the most often evaluated JAK inhibitor. Moderate‐certainty evidence suggests that they probably make little or no difference in improvement in clinical status. Moderate‐certainty evidence indicates that systemic JAK inhibitors probably decrease the risk of worsening of clinical status and make little or no difference in the rate of adverse events of any grade, whilst they probably decrease the occurrence of serious adverse events. Based on low‐certainty evidence, JAK inhibitors may make little or no difference in the rate of secondary infection. Subgroup analysis by severity of COVID‐19 or type of agent failed to identify specific subgroups which benefit more or less from systemic JAK inhibitors. Currently, there is no evidence on the efficacy and safety of systemic JAK inhibitors for individuals with asymptomatic or mild disease (non‐hospitalised individuals). Plain language summary Are systemic Janus kinase inhibitors an effective treatment for people with COVID‐19? Key messages We found moderate‐ to high‐certainty evidence from 6 studies to conclude that systemic Janus kinase (JAK) inhibitors are an effective treatment for coronavirus disease 2019 (COVID‐19) in hospitalised people, because they resulted in fewer deaths and a lower rate of clinical deterioration. Evaluation of systemic JAK inhibitors is ongoing in 13 studies whilst the results of 9 further studies are awaiting publication. We will update this review and may adapt our conclusions when their results become available. What are JAK inhibitors? JAK inhibitors are medicines that block the activity of certain parts of the immune system that are sometimes problematic. They are taken orally (systemic) and usually are taken by people who suffer from autoimmune diseases, where the immune system attacks the body itself. JAK inhibitors might also be administered by inhalation but since this was not our focus, we refer to 'systemic JAK inhibitors' throughout the review. How might JAK inhibitors treat COVID‐19? In COVID‐19, the immune system sometimes overreacts, which can lead to a severe course of disease. JAK inhibitors can block parts of the immune system and counteract any clinical deteriorations. What did we want to find out? We wanted to know whether systemic JAK inhibitors, in addition to usual care, are effective for people with COVID‐19 when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in:
• number of deaths from any cause up to 60 days after treatment, or longer if reported;
• whether people got better or worse after treatment, based on their need for breathing support;
• unwanted effects of the treatment and infections acquired in hospital. What did we do? We searched for studies that reported on people with COVID‐19 who received systemic JAK inhibitors together with usual care, or usual care alone (plus/minus placebo). We compared and summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We found 6 suitable studies involving 11,145 people with COVID‐19. All studies compared systemic JAK inhibitors (baricitinib in 4 studies, tofacitinib in 1 study and ruxolitinib in 1 study) to usual care (in addition to placebo), and were performed in hospitalised people. We did not find studies performed in outpatients. Most participants needed oxygen supplementation through low‐flow devices (7220 participants) and few (463 participants) were mechanically ventilated at the study entry. We also identified 13 ongoing studies and 9 studies that are completed/terminated but unpublished yet. Main results Systemic JAK inhibitors plus usual care compared to usual care alone probably lead to fewer deaths from all causes at up to day 28 and lead to fewer deaths from all causes up to day 60 in the studies. It was not possible to identify subgroups of participants (according to severity of illness) who might benefit most from treatment with JAK inhibitors. Systemic JAK inhibitors probably make little or no difference in improvement in clinical status. They probably decrease the risk of worsening of clinical status. Systemic JAK inhibitors probably make little or no difference in the rate of unwanted effects, and probably decrease slightly the occurrence of serious unwanted effects. Systemic JAK inhibitors may result in little or no difference in the rate of infections acquired in hospital. What are the limitations of the evidence? As current studies on systemic JAK inhibitors in outpatients are lacking, evidence is limited in this group of people with COVID‐19. Studies used different ways to assess and report unwanted effects, especially in regard to infections acquired in hospital. In accordance with the living approach of this review, we will continually update our search and include eligible trials to fill this evidence gap. How up to date is this evidence? The evidence is up to date to February 2022. We monitor newly published studies weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials identified from this source until the first week of April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kramer, A; Prinz, C; Fichtner, F; Fischer, A-L; Thieme, V; Grundeis, F; Spagl, M; Seeber, C; Piechotta, V; Metzendorf, M-I; Golinski, M; Moerer, O; Stephani, C; Mikolajewska, A; Kluge, S; Stegemann, M; Laudi, S; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015209", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "eff90f69-bcb3-496c-b147-c067a055f733", "pmid": "", "title": "Genital ulcer disease treatment for reducing sexual acquisition of HIV", "imported": false, "abstract": "Abstract - Background Genital ulcer disease by virtue of disruption of the mucosal surfaces may enhance HIV acquisition. Genital ulcer disease treatment with resolution of the ulcers may therefore contribute in reducing the sexual acquisition of HIV. Objectives To determine the effects of treatment of genital ulcer disease on sexual acquisition of HIV. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, LILACS, NLM Gateway, Web of Science, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and reference lists of relevant publications for eligible studies published between 1980 and August 2011. Selection criteria Randomized controlled trials of any treatment intervention aimed at curing genital ulcer disease compared with an alternative treatment, placebo, or no treatment. We included only trials whose unit of randomization was the individual with confirmed genital ulcer. Data collection and analysis We independently selected studies and extracted data in duplicate; resolving discrepancies by discussion, consensus, and arbitration by third review author. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI). Main results There were three randomized controlled trials that met our inclusion criteria recruited HIV‐negative participants with chancroid (two trials with 143 participants) and primary syphilis (one trial with 30 participants). The syphilis study, carried out in the US between 1995 and 1997, randomized participants to receive a single 2.0 g oral dose of azithromycin (11 participants); two 2.0 g oral doses of azithromycin administered six to eight days apart (eight participants); or benzathine penicillin G administered as either 2.4 million units intramuscular injection once or twice seven days apart (11 participants). No participant in the trial seroconverted during 12 months of follow‐up. The chancroid trials, conducted in Kenya by 1990, found no significant differences in HIV seroconversion rates during four to 12 weeks of follow‐up between 400 and 200 mg single oral doses of fleroxacin (one trial, 45 participants; RR 3.00; 95% CI 0.29 to 30.69), or between 400 mg fleroxacin and 800 mg sulfamethoxazole plus 160 mg trimethoprim (one trial, 98 participants; RR 0.33; 95% CI 0.04 to 3.09). Adverse events reported were mild to moderate in severity, and included Jarisch‐Herxheimer reactions and gastrointestinal symptoms. The differences between the treatment arms in the incidence of adverse events were not significant. The quality of this evidence on the effectiveness of genital ulcer disease treatment in reducing sexual acquisition of HIV, according to GRADE methodology, is of very low quality. Authors' conclusions At present, there is insufficient evidence to determine whether curative treatment of genital ulcer disease would reduce the risk of HIV acquisition. The very low quality of the evidence implies that the true effect of genital ulcer disease treatment on sexual acquisition of HIV may be substantially different from the effect estimated from currently available data. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not. Plain language summary Genital ulcer disease treatment for reducing sexual acquisition of HIV The presence of a genital ulcer would provide an entry point for the HIV virus if an HIV‐negative individual with an ulcer has unprotected sexual intercourse with an HIV‐infected person. Treatment of the condition causing the genital ulcer would allow the ulcer to heal and therefore reduce the chances of HIV acquisition. This review assessed whether giving treatment for diseases that present with ulcers in the genital region would reduce sexual acquisition of HIV. Three studies were identified involving 173 HIV‐negative patients with genital ulcers. These studies did not provide sufficient evidence that treatment of genital ulcer diseases reduces sexual acquisition of HIV infection. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mutua, FM; M'Imunya, JM; Wiysonge, CS", "articleTypes": [], "doi": "10.1002/14651858.CD007933.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "f00314c7-b02a-4ba2-8f53-c6b047361762", "pmid": "", "title": "Pharmacological and non‐pharmacological strategies for obese women with subfertility", "imported": false, "abstract": "Abstract - Background Clinicians primarily recommend weight loss for obese women seeking pregnancy. The effectiveness of interventions aimed at weight loss in obese women with subfertility is unclear. Objectives To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for achieving weight loss in obese women with subfertility. Search methods We searched the CGF Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and AMED from inception to 18 August 2020. We also checked reference lists and contacted experts in the field for additional relevant papers. Selection criteria We included published and unpublished randomised controlled trials in which weight loss was the main goal of the intervention. Our primary effectiveness outcomes were live birth or ongoing pregnancy and primary safety outcomes were miscarriage and adverse events. Secondary outcomes included clinical pregnancy, weight change, quality of life, and mental health outcome. Data collection and analysis Review authors followed standard Cochrane methodology. Main results This review includes 10 trials. Evidence was of very low to low quality: the main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision. Non‐pharmacological intervention versus no intervention or placebo Evidence is insufficient to determine whether a diet or lifestyle intervention compared to no intervention affects live birth (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.65 to 1.11; 918 women, 3 studies; I² = 78%; low‐quality evidence). This suggests that if the chance of live birth following no intervention is assumed to be 43%, the chance following diet or lifestyle changes would be 33% to 46%. We are uncertain if lifestyle change compared with no intervention affects miscarriage rate (OR 1.54, 95% CI 0.99 to 2.39; 917 women, 3 studies; I² = 0%; very low‐quality evidence). Evidence is insufficient to determine whether lifestyle change compared with no intervention affects clinical pregnancy (OR 1.06, 95% CI 0.81 to 1.40; 917 women, 3 studies; I² = 73%; low‐quality evidence). Lifestyle intervention resulted in a decrease in body mass index (BMI), but data were not pooled due to heterogeneity in effect (mean difference (MD) ‐3.70, 95% CI ‐4.10 to ‐3.30; 305 women, 1 study; low‐quality evidence; and MD ‐1.80, 95% CI ‐2.67 to ‐0.93; 43 women, 1 study; very low‐quality evidence). Non‐pharmacological versus non‐pharmacological intervention We are uncertain whether intensive weight loss interventions compared to standard care nutrition counselling affects live birth (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low‐quality evidence), BMI (MD ‐3.00, 95% CI ‐5.37 to ‐0.63; 11 women, 1 study; very low‐quality evidence), weight change (MD ‐9.00, 95% CI ‐15.50 to ‐2.50; 11 women, 1 study; very low‐quality evidence), quality of life (MD 0.06, 95% CI ‐0.03 to 0.15; 11 women, 1 study; very low‐quality evidence), or mental health (MD ‐7.00, 95% CI ‐13.92 to ‐0.08; 11 women, 1 study; very low‐quality evidence). No study reported on adverse events . Pharmacological versus pharmacological intervention For metformin plus liraglutide compared to metformin we are uncertain of an effect on the adverse events nausea (OR 7.22, 95% CI 0.72 to 72.7; 28 women, 1 study; very low‐quality evidence), diarrhoea (OR 0.31, 95% CI 0.01 to 8.3; 28 women, 1 study; very low‐quality evidence), and headache (OR 5.80, 95% CI 0.25 to 133; 28 women, 1 study; very low‐quality evidence). We are uncertain if a combination of metformin plus liraglutide vs metformin affects BMI (MD 2.1, 95% CI ‐0.42 to 2.62; 28 women, 1 study; very low‐quality evidence) and total body fat (MD ‐0.50, 95% CI ‐4.65 to 3.65; 28 women, 1 study; very low‐quality evidence). For metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo, we are uncertain of an effect on miscarriage (OR 3.58, 95% CI 0.73 to 17.55; 274 women, 1 study; very low‐quality evidence), clinical pregnancy (OR 5.56, 95% CI 2.57 to 12.02; 274 women, 1 study; very low‐quality evidence) or BMI (MD ‐0.3, 95% CI 1.17 to 0.57, 274 women, 1 study, very low‐quality evidence). We are uncertain if dexfenfluramine versus placebo affects weight loss in kilograms (MD ‐0.10, 95% CI ‐2.77 to 2.57; 21 women, 1 study; very low‐quality evidence). No study reported on live birth, quality of life, or mental health outcomes. Pharmacological intervention versus no intervention or placebo We are uncertain if metformin compared with placebo affects live birth (OR 1.57, 95% CI 0.44 to 5.57; 65 women, 1 study; very low‐quality evidence). This suggests that if the chance of live birth following placebo is assumed to be 15%, the chance following metformin would be 7% to 50%. We are uncertain if metformin compared with placebo affects gastrointestinal adverse events (OR 0.91, 95% CI 0.32 to 2.57; 65 women, 1 study; very low‐quality evidence) or miscarriage (OR 0.50, 95% CI 0.04 to 5.80; 65 women, 1 study; very low‐quality evidence) or clinical pregnancy (OR 2.67, 95% CI 0.90 to 7.93; 96 women, 2 studies; I² = 48%; very low‐quality evidence). We are also uncertain if diet combined with metformin versus diet and placebo affects BMI (MD ‐0.30, 95% CI ‐2.16 to 1.56; 143 women, 1 study; very low‐quality evidence) or waist‐to‐hip ratio (WHR) (MD 2.00, 95% CI ‐2.21 to 6.21; 143 women, 1 study; very low‐quality evidence). Pharmacological versus non‐pharmacological intervention No study undertook this comparison. Authors' conclusions Evidence is insufficient to support the use of pharmacological and non‐pharmacological strategies for obese women with subfertility. No data are available for the comparison of pharmacological versus non‐pharmacological strategies. We are uncertain whether pharmacological or non‐pharmacological strategies effect live birth, ongoing pregnancy, adverse events, clinical pregnancy, quality of life, or mental health outcomes. However, for obese women with subfertility, a lifestyle intervention may reduce BMI. Future studies should compare a combination of pharmacological and lifestyle interventions for obese women with subfertility. Plain language summary Do pharmacological and non‐pharmacological strategies reduce weight in obese women with subfertility? To assess the effectiveness and safety of pharmacological and non‐pharmacological strategies compared with each other, placebo, or no treatment for weight reduction in obese women with subfertility. Background To prevent the adverse effects of obesity, weight loss is recommended as the first line of treatment for obese women seeking pregnancy. The effectiveness of pharmacological and non‐pharmacological interventions for obese women with subfertility is unclear. Study characteristics We found 10 randomised trials comparing pharmacological and non‐pharmacological strategies in 1490 obese women with subfertility. Key results Lack of data is a major concern in interpretation of these data. Only 10 studies were included in the analysis. Three studies compared non‐pharmacological intervention versus no intervention or placebo. We are uncertain whether diet versus no intervention improves live birth, ongoing pregnancy, clinical pregnancy, or adverse events. A diet or lifestyle intervention may result in body mass index (BMI) weight change. Evidence was insufficient to show a difference in waist‐to‐hip ratio (WHR) with diet or lifestyle change compared to no intervention. No study reported on quality of life, or mental health outcomes for this comparison. One study compared non‐pharmacological interventions ‐ intensive weight loss intervention versus standard of care nutrition counselling; however due to the very low quality of evidence, we are uncertain whether intensive weight loss interventions improve live birth, clinical pregnancy, quality of life, or mental health outcomes. No study reported on adverse events, or weight changes, for this comparison. Three studies reported on pharmacological versus pharmacological interventions. Evidence was insufficient to show a difference in adverse events between metformin compared to metformin plus liraglutide. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for miscarriage. Evidence was insufficient to reveal a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo or metformin plus liraglutide versus metformin in clinical pregnancy. Evidence was insufficient to demonstrate a difference between the combination of metformin, clomiphene, and L‐carnitine versus metformin, clomiphene, and placebo for weight change using BMI. Moreover, evidence was insufficient to reveal a difference between dexfenfluramine versus placebo or metformin plus liraglutide versus metformin for weight loss in kilograms, or per cent of total body fat. No study reported on live birth and change in quality of life or mental health outcomes for this comparison. In the comparison of pharmacological intervention versus no intervention or placebo, three studies were included. Evidence was insufficient to show a difference between metformin and control groups related to live birth. Evidence was insufficient to reveal a difference between metformin compared to placebo in live birth, clinical pregnancy, or adverse events. Evidence was insufficient to demonstrate a difference between diet combined with metformin versus diet combined with placebo for weight change using BMI or WHR. No study reported on quality of life or mental health outcomes for this comparison. We found no study comparing non‐pharmacological with pharmacological interventions. Quality of the evidence The evidence was of very low to low quality. The main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading of evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Taghavi, SA; van Wely, M; Jahanfar, S; Bazarganipour, F", "articleTypes": [], "doi": "10.1002/14651858.CD012650.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "f0057f92-0004-47fe-8d4e-3d477fea54be", "pmid": "", "title": "Interventions to prevent obesity in children aged 12 to 18 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or ‘activity’ levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review. Objectives To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta‐analyses. Sixty studies were based in high‐income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty‐one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short‐term follow‐up (mean difference (MD) ‐0.18, 95% confidence interval (CI) ‐0.41 to 0.06; 3 studies, 605 participants), medium‐term follow‐up (MD ‐0.65, 95% CI ‐1.18 to ‐0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long‐term follow‐up (MD ‐0.14, 95% CI ‐0.38 to 0.10; 2 studies, 1089 participants); all very low‐certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long‐term follow‐up (MD ‐0.30, 95% CI ‐1.67 to 1.07; 1 study, 44 participants); zBMI at short‐term (MD ‐0.06, 95% CI ‐0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium‐term (MD 0.02, 95% CI ‐0.17 to 0.21; 1 study, 112 participants) follow‐up; all low‐certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low‐certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short‐term follow‐up (MD ‐0.64, 95% CI ‐1.86 to 0.58; 6 studies, 1780 participants; low‐certainty evidence) and probably do not reduce zBMI at medium‐ (MD 0, 95% CI ‐0.04 to 0.05; 6 studies, 5335 participants) or long‐term (MD ‐0.05, 95% CI ‐0.12 to 0.02; 1 study, 985 participants) follow‐up; both moderate‐certainty evidence. Activity interventions do not reduce zBMI at short‐term follow‐up (MD 0.02, 95% CI ‐0.01 to 0.05; 7 studies, 4718 participants; high‐certainty evidence), but may reduce BMI slightly at medium‐term (MD ‐0.32, 95% CI ‐0.53 to ‐0.11; 3 studies, 2143 participants) and long‐term (MD ‐0.28, 95% CI ‐0.51 to ‐0.05; 1 study, 985 participants) follow‐up; both low‐certainty evidence. Seven studies (5428 participants; low‐certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short‐term follow‐up (MD 0.03, 95% CI ‐0.07 to 0.13; 11 studies, 3429 participants; high‐certainty evidence), and probably do not reduce BMI at medium‐term (MD 0.01, 95% CI ‐0.09 to 0.11; 8 studies, 5612 participants; moderate‐certainty evidence) or long‐term (MD 0.06, 95% CI ‐0.04 to 0.16; 6 studies, 8736 participants; moderate‐certainty evidence) follow‐up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD ‐0.09, 95% CI ‐0.2 to 0.02; 3 studies, 515 participants; very low‐certainty evidence), and they may not reduce zBMI at medium‐term (MD ‐0.05, 95% CI ‐0.1 to 0.01; 6 studies, 3511 participants; low‐certainty evidence) or long‐term (MD ‐0.02, 95% CI ‐0.05 to 0.01; 7 studies, 8430 participants; low‐certainty evidence) follow‐up. Four studies (2394 participants) reported data on serious adverse events (very low‐certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect. Authors' conclusions The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low‐certainty evidence that activity interventions may have a small beneficial effect on BMI at medium‐ and long‐term follow‐up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples. Plain language summary Do dietary and activity strategies help prevent obesity in children and young people aged 12 to 18 years? Key messages ‐ Strategies to encourage adolescents to change their diet or activity levels (or both), to prevent them becoming overweight or developing obesity make no or very little difference to their body mass index (BMI; an estimate of the amount of body fat according to height and weight). ‐ Based on the very little information available about serious adverse events, there appears to be little or no effect of dietary or activity strategies, or both, to results in serious harms (e.g. injuries). ‐ Due to a lack of evidence, future research should focus on community settings (e.g. in youth clubs) and research involving adolescents with disabilities. Why is preventing obesity in children and young people important? More adolescents are developing overweight and obesity worldwide. Being overweight as an adolescent can cause health problems, and people may be affected psychologically and in their social life. Puberty and moving into adulthood is a challenging time, and many struggle with their mental health. Overweight adolescents are likely to be overweight or obese as adults and continue to experience poor physical and mental health. What did we want to find out? We wanted to find out if strategies to help adolescents modify their diet or activity (or both) were effective at preventing obesity. We also wanted to know if these strategies were associated with any serious harms. What did we do? We searched scientific databases for studies that looked at ways of preventing obesity in children aged 12 to 18 years. We excluded studies aimed at adolescents who were already overweight or living with obesity. However, we included studies where the sample was a whole group (e.g. a school), which may have included those living with overweight or obesity. We only included studies if the methods they used aimed to change the children's diet, their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed children into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 74 studies involving 83,407 children and young people. Sixty studies were based in high‐income countries (e.g. USA and in Europe). In 57 studies, the strategies were tried in schools, although 12 were based at home or other places like community settings (five studies) such as youth groups. Fifty‐one strategies were implemented for fewer than nine months; the shortest intervention lasted one visit and the longest over 28 months. Sixty‐two studies declared non‐industry funding; five studies were partly funded by industry (food suppliers, a PlayStation manufacturer, a gym equipment supplier, a healthcare device manufacturer and a private healthcare facility). Our analyses included results from 54 studies of 46,358 adolescents (20 studies did not report their results in a way that could be included in our analyses). We found that adolescents who were helped with a strategy to change their diet or activity levels (or both) either did not reduce their BMI, or any reduction was meagre, compared to adolescents who were not given a strategy. Only a few studies reported any possible harms of the interventions, and none identified serious harms. What are the limitations of the evidence? Overall, we have limited confidence in the beneficial effects of these interventions in preventing obesity in children and adolescents. It is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. Many studies had limitations in how they were done (e.g. in some studies, the methods used to randomly place people into groups were not adequate or the results of some of the studies were not analysed correctly). 3. There were not enough studies reporting particular types of outcomes, such as BMI (an estimate of the amount of body fat according to height and weight) or zBMI (comparison of a child’s BMI with other children of the same age and sex) for a particular duration of follow‐up to be certain about the results for some comparisons. Also, certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way that we could include them in our analyses (e.g. without any detail of the difference in change between the intervention and control groups) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for adolescents with disabilities, or whether those implemented in community settings are effective. How up to date is this evidence? This review supersedes our previous review. The evidence is up‐to‐date until February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F; Tomlinson, E; Davies, AL; Moore, THM; Dawson, S; Breheny, K; Savović, J; Hodder, RK; Wolfenden, L; Higgins, JPT; Summerbell, CD", "articleTypes": [], "doi": "10.1002/14651858.CD015330.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "f01818d9-3460-46b7-bbfd-da9e15750867", "pmid": "", "title": "Antihypertensive drug therapy for mild to moderate hypertension during pregnancy", "imported": false, "abstract": "Abstract - Background Antihypertensive drugs are often used in the belief that lowering blood pressure will prevent progression to more severe disease, and thereby improve pregnancy outcome. This Cochrane Review is an updated review, first published in 2001 and subsequently updated in 2007 and 2014. Objectives To assess the effects of antihypertensive drug treatments for women with mild to moderate hypertension during pregnancy. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the WHO International Clinical Trials Registry Platform ( ICTRP ) (13 September 2017), and reference lists of retrieved studies. Selection criteria All randomised trials evaluating any antihypertensive drug treatment for mild to moderate hypertension during pregnancy, defined as systolic blood pressure 140 to 169 mmHg and/or diastolic blood pressure 90 to 109 mmHg. Comparisons were of one or more antihypertensive drug(s) with placebo, with no antihypertensive drug, or with another antihypertensive drug, and where treatment was planned to continue for at least seven days. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results For this update, we included 63 trials (data from 58 trials, 5909 women), with moderate to high risk of bias overall. We carried out GRADE assessments for the main 'antihypertensive drug versus placebo/no antihypertensive drug' comparison only. Evidence was graded from very low to moderate certainty, with downgrading mainly due to design limitations and imprecision.For many outcomes, trials contributing data evaluated different hypertensive drugs; while we did not downgrade for this indirectness, results should be interpreted with caution. Antihypertensive drug versus placebo/no antihypertensive drug (31 trials, 3485 women) Primary outcomes: moderate‐certainty evidence suggests that use of antihypertensive drug(s) probably halves the risk of developing severe hypertension (risk ratio (RR) 0.49; 95% confidence interval (CI) 0.40 to 0.60; 20 trials, 2558 women), but may have little or no effect on the risk of proteinuria/pre‐eclampsia (average risk ratio (aRR) 0.92; 95% CI 0.75 to 1.14; 23 trials, 2851 women; low‐certainty evidence). Moderate‐certainty evidence also shows that antihypertensive drug(s) probably have little or no effect in the risk of total reported fetal or neonatal death (including miscarriage) (aRR 0.72; 95% CI 0.50 to 1.04; 29 trials, 3365 women), small‐for‐gestational‐age babies (aRR 0.96; 95% CI 0.78 to 1.18; 21 trials, 2686 babies) or preterm birth less than 37 weeks (aRR 0.96; 95% CI 0.83 to 1.12; 15 trials, 2141 women). Secondary outcomes: we are uncertain of the effect of antihypertensive drug(s) on the risk of maternal death , severe pre‐eclampsia , or eclampsia, or impaired long‐term growth and development of the baby in infancy and childhood , because the certainty of this evidence is very low. There may be little or no effect on the risk of changed/stopped drugs due to maternal side‐effects, or admission to neonatal or intensive care nursery (low‐certainty evidence). There is probably little or no difference in the risk of elective delivery (moderate‐certainty evidence). Antihypertensive drug versus another antihypertensive drug (29 trials, 2774 women) Primary outcomes: beta blockers and calcium channel blockers together in the meta‐analysis appear to be more effective than methyldopa in avoiding an episode of severe hypertension (RR 0.70; 95% CI 0.56 to 0.88; 11 trials, 638 women). There was also an increase in this risk when other antihypertensive drugs were compared with calcium channel blockers (RR 1.86; 95% CI 1.09 to 3.15; 5 trials, 223 women), but no evidence of a difference when methyldopa and calcium channel blockers together were compared with beta blockers (RR1.18, 95% CI 0.95 to 1.48; 10 trials, 692 women). No evidence of a difference in the risk of proteinuria/pre‐eclampsia was found when alternative drugs were compared with methyldopa (aRR 0.78; 95% CI 0.58 to 1.06; 11 trials, 997 women), with calcium channel blockers (aRR: 1.24, 95% CI 0.70 to 2.19; 5 trials, 375 women), or with beta blockers (aRR 1.21, 95% CI 0.88 to 1.67; 12 trials, 1107 women). For the babies, we found no evidence of a difference in the risk of total reported fetal or neonatal death (including miscarriage) when comparing other antihypertensive drugs with methyldopa (aRR 0.77, 95% CI 0.52 to 1.14; 22 trials, 1791 babies), with calcium channel blockers (aRR 0.90, 95% CI 0.52 to 1.57; nine trials, 700 babies), or with beta blockers (aRR: 1.23, 95% CI 0.81 to 1.88; 19 trials, 1652 babies); nor in the risk for small‐for‐gestational age in the comparison with methyldopa (aRR 0.79, 95% CI 0.52 to 1.20; seven trials, 597 babies), with calcium channel blockers (aRR 1.05, 95% CI 0.64 to 1.73; four trials, 200 babies), or with beta blockers (average RR 1.13, 95% CI 0.80 to 1.60; 7 trials, 680 babies). No evidence of an overall difference among groups in the risk of preterm birth (less than 37 weeks) was found in the comparison with methyldopa (aRR: 0.91; 95% CI 0.68 to 1.22; 11 trials, 835 women), with calcium channel blockers (aRR 0.85, 95% CI 0.59 to 1.23; six trials, 330 women), or with beta blockers (aRR 1.22, 95% CI 0.90 to 1.66; 9 trials, 806 women). Secondary outcomes: There were no cases of maternal death and eclampsia. There is no evidence of a difference in the risk of severe pre‐eclampsia , changed/stopped drug due to maternal side‐effects , elective delivery, admission to neonatal or intensive care nursery when other antihypertensive drugs are compared with methyldopa, calcium channel blockers or beta blockers. Impaired long‐term growth and development in infancy and childhood was not reported for these comparisons. Authors' conclusions Antihypertensive drug therapy for mild to moderate hypertension during pregnancy reduces the risk of severe hypertension. The effect on other clinically important outcomes remains unclear. If antihypertensive drugs are used, beta blockers and calcium channel blockers appear to be more effective than the alternatives for preventing severe hypertension. High‐quality large sample‐sized randomised controlled trials are required in order to provide reliable estimates of the benefits and adverse effects of antihypertensive treatment for mild to moderate hypertension for both mother and baby, as well as costs to the health services, women and their families. Plain language summary Antihypertensive drug therapy for mild to moderate hypertension during pregnancy What is the issue? The aim of this review was to determine the benefits and adverse effects of blood pressure‐lowering drugs (antihypertensive drugs) for pregnant women with mild to moderate hypertension (high blood pressure). The other aim was to assess the benefits and adverse effects of these drugs for their babies. Why is this important? During pregnancy, up to one in 10 women have blood pressure readings that are above normal. For some women, their blood pressure remains slightly high (termed ‘mild to moderate high blood pressure’), with no apparent complications. Some of these women go on to develop very high blood pressure. Very high blood pressure can result in a medical emergency if it affects the woman’s organs (such as her liver, or brain in the form of a stroke). Also, it can seriously affect the growth and health of her baby. Drugs that lower blood pressure are used to treat mild to moderate high blood pressure, in the belief that this treatment will prevent the blood pressure from continuing to rise. Over the years, information from good quality research studies has been contradictory, so we cannot be sure if this drug treatment is worthwhile. What evidence did we find? This Cochrane Review is an update of a review that was first published in 2001 and updated in 2007 and 2014. We searched for randomised controlled trials in September 2017, and this review now includes data from 58 trials involving more than 5900 women. A total of 31 trials with 3485 women compared a number of different blood pressure‐lowering drugs to a placebo or no treatment. There were a further 29 trials involving 2774 women which compared one blood pressure‐lowering drug with another one. The evidence showed that treating pregnant women who had moderately raised blood pressure with blood pressure‐lowering drugs probably halved the number of the women developing severe high blood pressure (20 trials, 2558 women). However, blood pressure‐lowering drugs probably had little or no effect on the risk of the baby dying (29 trials, 3365 women), and there is insufficient data on maternal deaths to make a judgement on whether this risk is lowered (five trials, 525 women). The use of blood pressure‐lowering drugs may have little or no effect on the number of the women developing pre‐eclampsia (23 trials, 2851 women), or the number of women who had to change drugs because of side‐effects (16 trials, 1503 women). We found no difference in the number of babies born preterm, that is before 37 weeks (15 trials, 2141 women). There was also no difference in the number of babies born small for their gestational age (21 trials, 2686 babies). The quality of the evidence was mostly moderate (but for pre‐eclampsia it was low). This was due to a number of small studies, and problems with the way the studies were undertaken. The available evidence is still insufficient to demonstrate if there is any antihypertensive drug that is better than another. However, beta blockers and calcium channel blockers seem to be better than the alternative drugs for blood pressure control. What does this mean? More research is needed in order to confirm the true effect of antihypertensive drugs in mothers and in their babies, and to identify the drug which would be best.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Abalos, E, Duley, L, Steyn, DW, Gialdini, C", "articleTypes": [], "doi": "10.1002/14651858.CD002252.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.770Z" }, { "id": "f0223338-daa6-4a68-9eea-e31a88c7a717", "pmid": "", "title": "Acupuncture for acute management and rehabilitation of traumatic brain injury", "imported": false, "abstract": "Abstract - Background Traumatic brain injury (TBI) can be life threatening depending on the severity of the insult to the brain. It can also cause a range of debilitating sequelae which require cognitive, motor, communication, emotional, or behavioral rehabilitation of varying intensity and duration. A number of studies conducted and published in China have suggested that acupuncture may be beneficial in the acute treatment and rehabilitation of TBI. Objectives To determine the efficacy and safety of acupuncture in the acute management or rehabilitation (or both) of patients with a TBI, including cognitive, neurological, motor, communication, emotional, or behavioral complications, or a combination of such complications. Search methods We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials ( The Cochrane Library ), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO and others. We also searched the Chinese Acupuncture Studies Register, the Studies Register of the Cochrane Complementary Medicine Field, NCCAM, and NIH Clinical Studies Database. Three major Mainland Chinese academic literature databases (CNKI, VIP and Wang Fang Data) were also searched using keywords in simplified Chinese. We searched all databases through December 2009, and some searches have been updated to October 2012. Selection criteria Randomized controlled studies evaluating different variants of acupuncture and involving participants of any age who had suffered a TBI. Included trials compared acupuncture with placebo or sham treatment, or acupuncture plus other treatments compared with the same other treatments. We excluded trials that only compared different variants of acupuncture or compared acupuncture alone against other treatments alone, as they did not yield the net effect of acupuncture. Data collection and analysis Two review authors identified potential articles from the literature search and extracted data independently using a data extraction form. We performed methodological assessment of included studies using the Cochrane Collaboration's tool for assessing risk of bias. We were unable to perform quantitative data analysis due to insufficient included studies and available data. Main results Four RCTs, including 294 participants, reported outcomes specified by this review. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The results seem to suggest that acupuncture is efficacious for these indications, however the low methodological quality of these studies renders the results questionable. No adverse effects of acupuncture were reported in any of the studies. Authors' conclusions The low methodological quality of the included studies does not allow us to make conclusive judgments on the efficacy and safety of acupuncture in either the acute treatment and/or rehabilitation of TBI. Its beneficial role for these indications remains uncertain. Further research with high quality trials is required. Plain language summary Acupuncture for acute management and rehabilitation of traumatic brain injury Acupuncture used for the acute treatment, rehabilitation (or both) of traumatic brain injury (TBI) has been studied in China. We conducted a systematic review to evaluate the efficacy and safety of acupuncture for these conditions. Four randomized controlled trials were eligible for inclusion in this review, involving 294 patients. Three investigated electro‐acupuncture for TBI while one investigated acupuncture for acute TBI. The studies were of low methodological quality and were diverse in their objectives, participant characteristics, acupuncture modalities and strategies, and outcome measures. The small number of studies together with their low methodological quality means that they are inadequate to allow any conclusion to be drawn about the efficacy and safety of acupuncture in the treatment of TBI. Further methodologically robust studies are needed to generate evidence‐based conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Wong, V, Cheuk, DKL, Lee, S, Chu, V", "articleTypes": [], "doi": "10.1002/14651858.CD007700.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.090Z" }, { "id": "f03eb05b-e90e-4027-9483-15239b5ecc61", "pmid": "", "title": "Drugs for the acute treatment of migraine in children and adolescents", "imported": false, "abstract": "Abstract - Background Numerous medications are available for the acute treatment of migraine in adults, and some have now been approved for use in children and adolescents in the ambulatory setting. A systematic review of acute treatment of migraine medication trials in children and adolescents will help clinicians make evidence‐informed management choices. Objectives To assess the effects of pharmacological interventions by any route of administration versus placebo for migraine in children and adolescents 17 years of age or less. For the purposes of this review, children were defined as under 12 years of age and adolescents 12 to 17 years of age. Search methods We searched seven bibliographic databases and four clinical trial registers as well as gray literature for studies through February 2016. Selection criteria We included prospective randomized controlled clinical trials of children and adolescents with migraine, comparing acute symptom relieving migraine medications with placebo in the ambulatory setting. Data collection and analysis Two reviewers screened titles and abstracts and reviewed the full text of potentially eligible studies. Two independent reviewers extracted data for studies meeting inclusion criteria. We calculated the risk ratios (RRs) and number needed to treat for an additional beneficial outcome (NNTB) for dichotomous data. We calculated the risk difference (RD) and number needed to treat for an additional harmful outcome (NNTH) for proportions of adverse events. The percentage of pain‐free patients at two hours was the primary efficacy outcome measure. We used adverse events to evaluate safety and tolerability. Secondary outcome measures included headache relief, use of rescue medication, headache recurrence, presence of nausea, and presence of vomiting. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables. Main results We identified a total of 27 randomized controlled trials (RCTs) of migraine symptom‐relieving medications, in which 9158 children and adolescents were enrolled and 7630 (range of mean age between 8.2 and 14.7 years) received medication. Twenty‐four studies focused on drugs in the triptan class, including almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, sumatriptan + naproxen sodium, and zolmitriptan. Other medications studied included paracetamol (acetaminophen), ibuprofen, and dihydroergotamine (DHE). More than half of the studies evaluated sumatriptan. All but one study reported adverse event data. Most studies presented a low or unclear risk of bias, and the overall quality of evidence, according to GRADE criteria, was low to moderate, downgraded mostly due to imprecision and inconsistency. Ibuprofen was more effective than placebo for producing pain freedom at two hours in two small studies that included 162 children (RR 1.87, 95% confidence interval (CI) 1.15 to 3.04) with low quality evidence (due to imprecision). Paracetamol was not superior to placebo in one small study of 80 children. Triptans as a class of medication were superior to placebo in producing pain freedom in 3 studies involving 273 children (RR 1.67, 95% CI 1.06 to 2.62, NNTB 13) (moderate quality evidence) and 21 studies involving 7026 adolescents (RR 1.32, 95% CI 1.19 to 1.47, NNTB 6) (moderate quality evidence). There was no significant difference in the effect sizes between studies involving children versus adolescents. Triptans were associated with an increased risk of minor (non‐serious) adverse events in adolescents (RD 0.13, 95% CI 0.08 to 0.18, NNTH 8), but studies did not report any serious adverse events. The risk of minor adverse events was not significant in children (RD 0.06, 95% CI − 0.04 to 0.17, NNTH 17). Sumatriptan plus naproxen sodium was superior to placebo in one study involving 490 adolescents (RR 3.25, 95% CI 1.78 to 5.94, NNTB 6) (moderate quality evidence). Oral dihydroergotamine was not superior to placebo in one small study involving 13 children. Authors' conclusions Low quality evidence from two small trials shows that ibuprofen appears to improve pain freedom for the acute treatment of children with migraine. We have only limited information on adverse events associated with ibuprofen in the trials included in this review. Triptans as a class are also effective at providing pain freedom in children and adolescents but are associated with higher rates of minor adverse events. Sumatriptan plus naproxen sodium is also effective in treating adolescents with migraine. Plain language summary Drugs for the acute treatment of migraine in children and adolescents Background and review question Migraine is a painful and debilitating disorder that is common in children (under 12 years of age) and adolescents (12 to 17 years of age). Common symptoms reported during a migraine attack are headache, nausea, vomiting, and sensitivity to light and sound. Many treatments for migraine are available, of which the most common are paracetamol (also known as acetaminophen), ibuprofen and other anti‐inflammatories, and triptans. Not all triptan medications are approved for use in children or adolescents, and approvals vary from country to country. Study characteristics In our review, we looked at 27 randomized controlled trials of drugs compared to placebo to find out which treatments were effective at providing pain freedom two hours after treatment. We also wanted to know what side effects might be caused by the treatments. A total of 7630 children received medication in the studies. The evidence is current to February 2016. Each study had between 13 and 888 participants. Their average age was 12.9 years and ranged from 8.2 to 14.7 years. Nineteen of the studies were funded by the drug manufacturer. Key results Ibuprofen appears to be effective in treating children with migraine, but the evidence is limited to only two small trials. Ibuprofen is readily available and inexpensive, making it an excellent first choice for migraine treatment. Paracetamol was not shown to be effective in providing pain freedom in children, but we only found one small study. Triptans are a type of medication designed specifically to treat migraine and are often effective at providing greater pain freedom in children and adolescents. The triptans examined in children included rizatriptan and sumatriptan, while almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan were examined in adolescents. The combination of sumatriptan plus naproxen sodium is also effective at treating adolescents with migraine. Overall, there is a risk that the triptan medications may cause minor unwanted side effects like taste disturbance, nasal symptoms, dizziness, fatigue, low energy, nausea, or vomiting. The studies did not report any serious side effects. Quality of the evidence The overall quality of the evidence provided by the review was moderate for the triptans, but low for paracetamol and ibuprofen, as we only identified a few studies. More studies need to look at the effects of each of the migraine treatments in children and adolescents separately.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Richer, L; Billinghurst, L; Linsdell, MA; Russell, K; Vandermeer, B; Crumley, ET; Durec, T; Klassen, TP; Hartling, L", "articleTypes": [], "doi": "10.1002/14651858.CD005220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "f044a115-d146-4993-bf66-45cf63c22b91", "pmid": "", "title": "Bile acids for liver‐transplanted patients", "imported": false, "abstract": "Abstract - Background Liver transplantation has become a widely accepted form of treatment for numerous end‐stage liver diseases. Bile acids may decrease allograft rejection after liver transplantation by changing the expression of major histocompatibility complex class molecules in bile duct epithelium and central vein endothelium. Objectives To assess the beneficial and harmful effects of bile acids for liver‐transplanted patients. Search methods We performed searches of The Cochrane Hepato‐Biliary Group Controlled Trials Register , The Cochrane Central Register of Controlled Trials in The Cochrane Library , MEDLINE , EMBASE , and Science Citation Expanded to September, 2009. Selection criteria Randomised clinical trials comparing any dose of bile acids or duration of treatment in liver‐transplanted patients versus placebo, no intervention, or another intervention. We included randomised clinical trials irrespective of blinding, language, and publication status. Data collection and analysis Two review authors extracted and checked data independently. We evaluated the risk of bias of the trials from the method of allocation sequence generation, allocation concealment, blinding, outcome data analysis, outcome data reporting, and other potential sources of bias. We used the intention‐to‐treat principle to perform meta‐analyses and presented the outcomes as relative risks (RR) or mean differences (MD), both with 95% confidence intervals (CI). Main results The updated search resulted in no new trials meeting the inclusion criteria of this review, thus leaving it to the seven already included randomised trials (six evaluating ursodeoxycholic acid versus placebo or no intervention, and one evaluating tauro‐ursodeoxycholic acid versus no intervention) enrolling a total of 335 participants. The administration of bile acids began one day or more after liver transplantation. All patients received the standard triple‐drug immunosuppressive regimen (steroids, azathioprine, and cyclosporine or tacrolimus) to suppress the allograft rejection response after liver transplantation. Bile acids compared with placebo or no intervention did not significantly change all‐cause mortality (RR 0.85, 95% CI 0.53 to 1.36), mortality related to allograft rejection (RR 0.30, 95% CI 0.01 to 7.12), retransplantation (RR 0.76, 95% CI 0.20 to 2.86), acute cellular rejection, or number of patients with steroid‐resistant rejection. Bile acids significantly reduced the number of patients who had chronic rejection in a fixed‐effect model but not in a random‐effects model meta‐analysis. Bile acids were safe and well tolerated by liver‐transplanted patients. However, this observation is based on data analysis from three trials with only 187 patients. Authors' conclusions We did not find evidence to support or refute bile acids for liver‐transplanted patients. Further randomised trials are necessary before bile acids can be recommended to liver‐transplanted patients. Plain language summary Bile acids for liver‐transplanted patients Liver transplantation is a major surgical procedure that has been practiced for more than forty years and has nowadays become a generally accepted treatment option in patients with end‐stage liver disease. The most common cause for liver transplantation in adults is cirrhosis caused by various types of liver injuries such as infections (hepatitis B and C), alcohol, autoimmune liver diseases, early‐stage liver cancer, metabolic and hereditary disorders, but also diseases of unknown aetiology. All transplant recipients need lifetime immunosuppressive therapy to prevent transplant rejection. Bile acids are being used for a variety of chronic liver diseases, mainly primary biliary cirrhosis and primary sclerosing cholangitis. However, their mechanisms of action and beneficial and harmful effects are poorly understood. This has led to the idea of the potential use of bile acids to prevent rejection in liver‐transplanted patients. Results of the seven randomised clinical trials included in the review in which patients received standard immunosuppressive treatment (steroids, azathioprine, and cyclosporine or tacrolimus) with or without bile acids after liver transplantation, did not show any significant effects of bile acids on all‐cause mortality, mortality related to rejection, acute cellular rejection, steroid resistant rejection, or need for retransplantation. One analysis suggested that bile acids might beneficially influence number of patients with chronic rejection, but was contradicted by the analyses. The evidence that the use of ursodeoxycholic acid might have beneficial effects on chronic rejection and length of hospitalisation is weak as it is produced from trials with high risk of bias and insufficient number of included patients. That bile acids seemed well tolerated, with no reports of serious adverse events, is good knowledge, but much more research is needed before their use is acquitted. None of the randomised clinical trials assessed the effects of bile acids on quality of life or cost‐effectiveness.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Poropat, G, Giljaca, V, Stimac, D, Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005442.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.799Z" }, { "id": "f0641800-92d2-43fd-9d08-c4ad9523b970", "pmid": "", "title": "Acute and Repeated Impact of Sweeteners and Sweetness Enhancers on Food Behaviour, Physiology & Health (SWEET Work Package 2 Phase 2)", "imported": false, "abstract": "This study aims to evaluate the acute (1-day) and repeated (2-week) effects of combinations of Sweeteners & Sweetness Enhancer blends on metabolic, sensory, neuro-behavioural and microbiota-mediated processes involved in satiety, consumer preferences and health.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.162Z" }, { "id": "f08c71c5-eae5-4541-8b8d-a319342f8622", "pmid": "", "title": "Tranexamic acid for patients with nasal haemorrhage (epistaxis)", "imported": false, "abstract": "Abstract - Background Epistaxis (nosebleed) most commonly affects children and the elderly. The majority of episodes are managed at home with simple measures. In more severe cases medical intervention is required to either cauterise the bleeding vessel, or to pack the nose with various materials. Tranexamic acid is used in a number of clinical settings to stop bleeding by preventing clot breakdown (fibrinolysis). It may have a role in the management of epistaxis as an adjunct to standard treatments, reducing the need for further intervention. Objectives To determine the effects of tranexamic acid (oral, intravenous or topical) compared with placebo, no additional intervention or any other haemostatic agent in the management of patients with epistaxis. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register (via CRS Web); Central Register of Controlled Trials (CENTRAL) (via CRS Web); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 October 2018. Selection criteria Randomised controlled trials (RCTs) of tranexamic acid (in addition to usual care) compared with usual care plus placebo, usual care alone or usual care plus any other haemostatic agent, to control epistaxis in adults or children. Data collection and analysis We used the standard methodological procedures expected by Cochrane. The primary outcomes were control of epistaxis: re‐bleeding (as measured by the proportion of patients re‐bleeding within a period of up to 10 days) and significant adverse effects (seizures, thromboembolic events). Secondary outcomes were control of epistaxis as measured by the time to stop initial bleeding (the proportion of patients whose bleeding is controlled within a period of up to 30 minutes); severity of re‐bleeding (as measured by (a) the proportion of patients requiring any further intervention and (b) the proportion of patients requiring blood transfusion); length of hospital stay and other adverse effects. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results We included six RCTs (692 participants). The overall risk of bias in the studies was low. Two studies assessed oral administration of tranexamic acid, given regularly over several days, and compared it to placebo. In the other four studies, a single application of topical tranexamic acid was compared with placebo (one study) and a combination of epinephrine and lidocaine or phenylephrine (three studies). All participants were adults. Tranexamic acid versus placebo For our primary outcome, control of epistaxis: re‐bleeding (proportion re‐bleeding within 10 days), we were able to pool data from three studies. The pooled result demonstrated a benefit of tranexamic acid compared to placebo, the risk of re‐bleeding reducing from 67% to 47% (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; three studies; 225 participants; moderate‐quality evidence ). When we compared the effects of oral and topical tranexamic acid separately the risk of re‐bleeding with oral tranexamic acid reduced from 69% to 49%, RR 0.73 (95% CI 0.55 to 0.96; two studies, 157 participants; moderate‐quality evidence ) and with topical tranexamic acid it reduced from 66% to 43%, RR 0.66 (95% CI 0.41 to 1.05; single study, 68 participants). We rated the quality of evidence provided by the single study as low , therefore it is uncertain whether topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. No study specifically sought to identify and report our primary outcome: significant adverse effects (i.e. seizures, thromboembolic events). The secondary outcome time to stop initial bleeding (proportion with bleeding controlled within 30 minutes) was measured in one study using topical tranexamic acid and there was no evidence of a difference at 30 minutes (RR 0.79, 95% CI 0.56 to 1.11; 68 participants; low‐quality evidence ). No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery, embolisation). One study of oral tranexamic acid reported the proportion of patients requiring blood transfusion and found no difference between groups: 5/45 (11%) versus 6/44 (14%) (RR 0.81, 95% CI 0.27 to 2.48; 89 participants; low‐quality evidence ). Two studies reported hospital length of stay. One study reported a significantly shorter stay in the oral tranexamic acid group (mean difference (MD) ‐1.60 days, 95% CI ‐2.49 to ‐0.71; 68 participants). The other study found no evidence of a difference between the groups. Tranexamic acid versus other haemostatic agents When we pooled the data from three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the topical tranexamic acid group compared to the group receiving another haemostatic agent (70% versus 30%: RR 2.35, 95% CI 1.90 to 2.92; 460 participants) ( moderate‐quality evidence ). Adverse effects across all studies Five studies recorded 'adverse effects' in a general way. None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient developed a superficial thrombophlebitis of both legs following discharge, however it is not reported in which group this occurred. No \"other serious adverse effect\" was reported in any study. Authors' conclusions We found moderate‐quality evidence that there is probably a reduction in the risk of re‐bleeding with the use of either oral or topical tranexamic acid in addition to usual care in adult patients with epistaxis, compared to placebo with usual care. However, the quality of evidence relating solely to topical tranexamic acid was low (one study only), so we are uncertain whether or not topical tranexamic acid is effective in stopping bleeding in the 10‐day period after a single application. We found moderate‐quality evidence that topical tranexamic acid is probably better than other topical agents in stopping bleeding in the first 10 minutes. There have been only three RCTs on this subject since 1995. Since then there have been significant changes in nasal cauterisation and packing techniques (for example, techniques including nasal endoscopy and more invasive approaches such as endoscopic sphenopalatine artery ligation). New trials would inform us about the effectiveness of tranexamic acid in light of these developments. Plain language summary Tranexamic acid to help treat nosebleeds (epistaxis) Background Nosebleeds are a very common condition, with the majority of those affected either children or those over the age of 60. They usually stop on their own or by simply compressing the nose with fingers, although a small number require medical attention. This will involve either cauterising (sealing) the bleeding vessel, if it can be seen, or packing the inside of the nose with a material to cause pressure to build up and stop the bleeding ('usual care'). Occasionally bleeding continues despite these measures, or it restarts having initially been controlled. This can lead to a prolonged hospital stay and the possibility of further procedures such as repacking with a different type of nasal pack or an operation. Tranexamic acid is a drug that is known to help promote blood clotting by preventing a natural process called fibrinolysis (dissolution of a clot). It is already used in a number of situations where bleeding is a significant worry, such as after heart surgery or major trauma. It can be given by mouth (orally), directly to the bleeding site (topically) or by injection into a vein (intravenously). Study characteristics We searched for randomised controlled trials in patients of any age with nosebleed requiring intervention. Patients were treated with tranexamic acid (in addition to usual care) compared to placebo, no treatment or any other agent used to stop bleeding. We found six studies that met our inclusion criteria, with a total of 692 participants. Two studies used oral administration of tranexamic acid and four used topical administration. All participants in the studies were adults. Three of the six studies were conducted over 20 years ago. Key results Three studies measured re‐bleeding within 10 days. When we combined the results we found that fewer patients who were given either oral or topical tranexamic acid had further episodes of re‐bleeding following an initial nosebleed compared to those treated with usual care. The time to stop initial bleeding (control of bleeding within 30 minutes) was measured in four studies. In three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the group receiving topical tranexamic acid compared to the group receiving a different drug (topical epinephrine and lidocaine or phenylephrine). In the other study there was no significant difference at 30 minutes when topical tranexamic acid was compared with placebo. No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery). Only one study of oral tranexamic acid reported the proportion of patients requiring a blood transfusion and there was no evidence of a difference between the groups. Length of hospital stay was reported in two studies. One study reported a significantly shorter stay in the oral tranexamic acid group, while the other found no evidence of a difference. Five studies mention recording \"adverse effects\". None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient did develop a superficial thrombophlebitis (inflammation and a blood clot in a vein near the surface of the skin) of both legs following discharge, but the study did not report in which treatment group this happened. No serious adverse event was seen in any of the studies. Quality of the evidence and conclusions Overall, the risk of bias in the six studies was low. We graded the quality of the evidence for the main outcome (control of epistaxis: re‐bleeding within 10 days) as moderate, which means that further research is likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate. In light of this and the fact that 'usual care' has changed, with the development of more modern nasal cauterisation and packing techniques, since three of the included studies were carried out, there remains uncertainty about the role of tranexamic acid in the treatment of patients with epistaxis. Newer research into the effect of tranexamic acid as a treatment for nosebleeds would inform future management decisions for this condition. The evidence in this review is up to date to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Joseph, J; Martinez‐Devesa, P; Bellorini, J; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD004328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "f08d535a-a1a8-4c29-8377-c8f2a7dca929", "pmid": "", "title": "Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Wells, GA, Hsieh, S-C, Peterson, J, Zheng, C, Kelly, SE, Shea, B, Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD003376.pub4 AB - Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Etidronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts – bone cells that break down bone tissue. This is an update of a Cochrane review first published in 2008. For clinical relevance, we investigated etidronate's effects on postmenopausal women stratified by fracture risk (low versus high). Objectives To assess the benefits and harms of intermittent/cyclic etidronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE, Embase, two clinical trial registers, the websites of drug approval agencies, and the bibliographies of relevant systematic reviews. We identified eligible trials published between 1966 and February 2023. Selection criteria We included randomized controlled trials that assessed the benefits and harms of etidronate in the prevention of fractures for postmenopausal women. Women in the experimental arms must have received at least one year of etidronate, with or without other anti‐osteoporotic drugs and concurrent calcium/vitamin D. Eligible comparators were placebo (i.e. no treatment; or calcium, vitamin D, or both) or another anti‐osteoporotic drug. Major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. We classified a study as secondary prevention if its population fulfilled one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (≤ ‐2.5), or aged 75 years or older. If none of these criteria were met, we considered the study to be primary prevention. Data collection and analysis We used standard methodological procedures expected by Cochrane. The review has three main comparisons: (1) etidronate 400 mg/day versus placebo; (2) etidronate 200 mg/day versus placebo; (3) etidronate at any dosage versus another anti‐osteoporotic agent. We stratified the analyses for each comparison into primary and secondary prevention studies. For major outcomes in the placebo‐controlled studies of etidronate 400 mg/day, we followed our original review by defining a greater than 15% relative change as clinically important. For all outcomes of interest, we extracted outcome measurements at the longest time point in the study. Main results Thirty studies met the review's eligibility criteria. Of these, 26 studies, with a total of 2770 women, reported data that we could extract and quantitatively synthesize. There were nine primary and 17 secondary prevention studies. We had concerns about at least one risk of bias domain in each study. None of the studies described appropriate methods for allocation concealment, although 27% described adequate methods of random sequence generation. We judged that only 8% of the studies avoided performance bias, and provided adequate descriptions of appropriate blinding methods. One‐quarter of studies that reported efficacy outcomes were at high risk of attrition bias, whilst 23% of studies reporting safety outcomes were at high risk in this domain. The 30 included studies compared (1) etidronate 400 mg/day to placebo (13 studies: nine primary and four secondary prevention); (2) etidronate 200 mg/day to placebo (three studies, all secondary prevention); or (3) etidronate (both dosing regimens) to another anti‐osteoporotic agent (14 studies: one primary and 13 secondary prevention). We discuss only the etidronate 400 mg/day versus placebo comparison here. For primary prevention, we collected moderate‐ to very low‐certainty evidence from nine studies (one to four years in length) including 740 postmenopausal women at lower risk of fractures. Compared to placebo, etidronate 400 mg/day probably results in little to no difference in non‐vertebral fractures (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.20 to 1.61); absolute risk reduction (ARR) 4.8% fewer, 95% CI 8.9% fewer to 6.1% more) and serious adverse events (RR 0.90, 95% CI 0.52 to 1.54; ARR 1.1% fewer, 95% CI 4.9% fewer to 5.3% more), based on moderate‐certainty evidence. Etidronate 400 mg/day may result in little to no difference in clinical vertebral fractures (RR 3.03, 95% CI 0.32 to 28.44; ARR 0.02% more, 95% CI 0% fewer to 0% more) and withdrawals due to adverse events (RR 1.41, 95% CI 0.81 to 2.47; ARR 2.3% more, 95% CI 1.1% fewer to 8.4% more), based on low‐certainty evidence. We do not know the effect of etidronate on hip fractures because the evidence is very uncertain (RR not estimable based on very low‐certainty evidence). Wrist fractures were not reported in the included studies. For secondary prevention, four studies (two to four years in length) including 667 postmenopausal women at higher risk of fractures provided the evidence. Compared to placebo, etidronate 400 mg/day may make little or no difference to non‐vertebral fractures (RR 1.07, 95% CI 0.72 to 1.58; ARR 0.9% more, 95% CI 3.8% fewer to 8.1% more), based on low‐certainty evidence. The evidence is very uncertain about etidronate's effects on hip fractures (RR 0.93, 95% CI 0.17 to 5.19; ARR 0.0% fewer, 95% CI 1.2% fewer to 6.3% more), wrist fractures (RR 0.90, 95% CI 0.13 to 6.04; ARR 0.0% fewer, 95% CI 2.5% fewer to 15.9% more), withdrawals due to adverse events (RR 1.09, 95% CI 0.54 to 2.18; ARR 0.4% more, 95% CI 1.9% fewer to 4.9% more), and serious adverse events (RR not estimable), compared to placebo. Clinical vertebral fractures were not reported in the included studies. Authors' conclusions This update echoes the key findings of our previous review that etidronate probably makes or may make little to no difference to vertebral and non‐vertebral fractures for both primary and secondary prevention. Plain language summary Does etidronate prevent fractures caused by osteoporosis in postmenopausal women? Key messages • For women with close to normal bone density (bone strength) and no previous broken spinal bones, etidronate probably makes little or no difference to the likelihood of having a hip or wrist fracture or a serious adverse (unwanted/harmful) event.
 • For women who have low bone density and are at risk for or have had a previous broken spinal bone, etidronate may make little or no difference in preventing fractures in bones other than the spine. What is osteoporosis? Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow, and old bone cells break down to make room for new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break, even after a minor injury, such as a slight bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. What is etidronate? Etidronate belongs to the class of medicines called bisphosphonates, which slow down the cells that break down the old bone. It is given by mouth in an intermittent or cyclical schedule; for example, a 400 mg tablet daily for two weeks every 90 days, followed by calcium or no treatment for the remainder of each 90‐day treatment cycle. What did we want to find out? We wanted to find out if etidronate was better than placebo (inactive or 'dummy' medicine) or another medicine for osteoporosis in preventing broken bones in postmenopausal women. For clinical relevance, we looked at etidronate's effects on women, as grouped by their risk of fracture (lower versus higher risk). We also wanted to find out if etidronate was associated with any unwanted effects. What did we do? We searched for studies comparing etidronate to placebo or another medicine for preventing osteoporosis. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Overall, we found 30 studies, but 4 studies provided insufficient information about their results. Thus, we were able to analyse the results of 26 studies involving 2770 women. Nine studies were interested in 'primary prevention' of osteoporosis‐based fractures, meaning they focused on women at lower fracture risk, who had bones with near‐to‐normal density/strength and no previous broken spinal bones. Seventeen studies were interested in 'secondary prevention' with etidronate, meaning they focused on women at higher fracture risk, who already had weak bones (low bone density), had a broken spinal bone, or both. Most studies mainly included white women. The studies lasted between 1 and 4 years. Some studies gave the women 400 mg/day of etidronate, whilst other studies gave 200 mg/day. Main results for primary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate: • probably makes little or no difference to non‐vertebral (non‐spinal) fractures and serious adverse events; • may make little or no difference to clinical vertebral fractures (that is, spinal fractures suggested by clinical signs and symptoms) and the number of women who left the studies due to adverse events. The evidence is very uncertain about the effect of etidronate on hip fractures. None of the studies reported on the effect on wrist fractures. Main results for secondary prevention studies that gave women 400 mg of etidronate/day Compared to a placebo, etidronate may make little or no difference in preventing fractures in bones other than the spine. The evidence is very uncertain about the effect of etidronate on hip and wrist fractures, the number of women who left the studies due to adverse events, and serious adverse events. None of the studies reported on etidronate's effect on clinical vertebral fractures. What are the limitations of the evidence? Our confidence in the evidence ranged from very low to moderate. In general, we have little confidence in the evidence because it is possible that the women in the studies were aware of which treatment they were getting, which could influence the results, and because many of the studies were very small. How up to date is this evidence? The evidence is current to February 2023.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.130Z" }, { "id": "f08e10d1-68c7-4619-88ed-5d29a8e1e82b", "pmid": "", "title": "Omega‐3 fatty acid supplementation for depression in children and adolescents", "imported": false, "abstract": "Abstract - Background Mental health disorders including major depressive disorder (MDD) are well recognized as major contributors to the global burden of disease among adolescents. The prevalence of adolescent depression is estimated to have increased by at least 25% during the COVID‐19 pandemic, compounding the already challenging problem of insufficient mental health service and service accessibility that existed prepandemic. Omega‐3 polyunsaturated fatty acid (PUFA) supplementation is currently recommended as a preventive treatment for depression in high‐risk adults as well as a second‐line monotherapy for adults with mild to moderate MDD, and adjunctive to antidepressants for adults with moderate to severe MDD. The benefits of omega‐3 PUFA intake on depressive illness have been hypothesized to occur as a result of their effect on neurotransmission, maintenance of membrane fluidity, and anti‐inflammatory action. A comprehensive synthesis and quantification of the existing evidence on omega‐3 PUFA's efficacy in treating depression among children and adolescents is essential for clinicians to provide informed guidance to young people and their families, especially considering the absence of current guidelines for this age group. Objectives Primary objective To determine the impact of omega‐3 PUFA supplementation versus a comparator (e.g. placebo, wait list controls, no treatment/supplementation, or standard care) on clinician‐diagnosed depression or self‐reported depression symptoms in children and adolescents. Secondary objectives To estimate the size of the effect of omega‐3 PUFAs on depression symptoms. To estimate the effect of each type of omega‐3 PUFA (EPA or DHA), compared with placebo, on depression. To determine if the effect is modified by dosage, format (capsule or liquid), sex, or age. To determine compliance and attrition for omega‐3 PUFAs as an intervention for depression in children and adolescents. To determine the safety of omega‐3 PUFAs as an intervention for depression in children and adolescents. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases, reference lists of included studies, grey literature, and relevant reviews. The latest search date was 18 May 2023. Selection criteria We included randomized controlled trials (RCTs) involving males and females aged 19 years or younger with diagnosed depression comparing omega‐3 PUFA supplementation to placebo, wait list control, no treatment/supplementation, or standard care. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were self‐reported depression symptoms and clinically diagnosed resolution of depression. Our secondary outcomes were attrition, adverse effects, and compliance with the intervention. We used GRADE to assess the certainty of evidence for key outcomes. Main results We included five trials with 228 participants in our meta‐analysis. All trials used a placebo comparator; intervention duration ranged from 10 to 16 weeks (median: 12 weeks). Omega‐3 PUFA supplementation compared to placebo may reduce self‐reported depression symptoms, but the evidence is very uncertain (standardized mean difference [SMD] −0.34, 95% confidence interval [CI] −0.85 to 0.17; lower SMD means greater improvement in depression due to omega‐3 PUFA; 5 trials, 185 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may have little to no effect on remission of depression symptoms compared to placebo, but the evidence is very uncertain (omega‐3 PUFA versus placebo: 50% versus 48%; odds ratio [OR] 1.11, 95% CI 0.45 to 2.75; 4 trials, 127 participants; very low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in attrition (dropouts) compared to placebo (omega‐3 PUFA versus placebo: 18% versus 19%; OR 0.94, 95% CI 0.46 to 1.90; 5 trials, 228 participants; low‐certainty evidence). Omega‐3 PUFA supplementation may result in little to no difference in adverse effects, with one study reporting more muscle cramps in the fish oil group (13/27 participants) compared to the placebo group (6/29 participants); one study reported more frequent defecation in the omega‐3 group (1/29 participants) and one study identified mild skin rash and unusual/manic behavior in the placebo group (2/27 participants). None of the included studies reported serious adverse effects. Authors' conclusions Based on five small studies, omega‐3 PUFA supplementation may reduce self‐reported depression symptoms, but the evidence is very uncertain. Omega‐3 PUFA supplementation may have little to no effect on depression remission compared to placebo, but the evidence is very uncertain. Omega‐3 PUFA supplementation may result in little to no difference in attrition or adverse effects. The studies observed no serious adverse effects. This review highlights early‐stage research on omega‐3 PUFA and depression in young people. The evidence on the effects of omega‐3 PUFA supplementation in improving self‐reported depression symptoms or achieving depression remission in children and adolescents is very uncertain. While no harms are evident, more data are needed to confirm potential risks. Addressing current limitations in the evidence base through the design and conduct of methodologically rigorous studies — larger sample sizes, varied dosages, eicosapentaenoic acid/docosahexaenoic acid ratios, treatment durations, and safety profiles — is crucial to advance our understanding of the role of omega‐3 PUFA supplementation for depression in children and adolescents. Plain language summary Is omega‐3 polyunsaturated fatty acid supplementation better than a placebo for treating depression among children and adolescents? Key messages – Due to a lack of robust evidence, the benefits and unwanted effects of omega‐3 polyunsaturated fatty acids (which are important fats that you must obtain from your diet) supplementation for treating depression among children and adolescents are unclear. – Larger, well‐designed studies are needed to give better estimates of the potential benefits and harms of omega‐3 polyunsaturated fatty acid supplementation for child and adolescent depression. Why is it important to find treatments for children and adolescents with depression? People with depression have a low mood or lose pleasure or interest in usual activities. It is a long‐lasting (chronic) disorder that is both serious and recurrent (it can return after periods of feeling well). It often begins during childhood and adolescence, affecting up to eight in every 100 children. Unfortunately, response to current treatments for depression in children and adolescents is poor, and relieving symptoms (remission) can be challenging. In recent studies, supplements of omega‐3 polyunsaturated fatty acids have shown promise as a potential treatment for depression in adults. Our body cannot make these beneficial fats, but they are naturally present in oily fish, marine sources, and certain nuts and seeds. They can also be given as daily supplements in capsule or liquid forms (for example, as cod liver oil capsules). What did we want to find out? We wanted to find out: – if omega‐3 polyunsaturated fatty acids supplementation works to decrease symptoms of depression in children and adolescents; and – if omega‐3 polyunsaturated fatty acids supplementation helps children and adolescents achieve remission from depression. We also wanted to know if omega‐3 polyunsaturated fatty acids supplementation can cause any unwanted effects. What did we do? We searched for studies in which children and adolescents were assigned randomly to two or more treatment groups that compared omega‐3 polyunsaturated fatty acids supplementation with a placebo (pretend treatment with the same appearance), on a waiting list, no treatment/supplementation, or usual care. This is the best way to ensure that groups of people are similar and that investigators do not know who is in which group. We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found five studies that involved 228 children and adolescents ranging from 10 to 16 years of age with depression. The largest study included 60 people, and the smallest study included 28 people. Three studies were conducted in the USA, one in Israel, and one in Slovakia. Four studies lasted for around 12 weeks and one study lasted for 16 weeks. We found that omega‐3 polyunsaturated fatty acids supplementation may reduce self‐reported depression symptoms, but the results are very uncertain. If omega‐3 PUFA supplements and placebos were given to a group of 100 children and adolescents with depression, then 50 children receiving omega‐3 polyunsaturated fatty acids would achieve remission and 48 receiving the placebo would achieve remission. What are the limitations of the evidence? We are not confident in the evidence because there were not enough studies to be certain about the results, and the studies were very small. To date, there is insufficient evidence to determine if omega‐3 polyunsaturated fatty acids supplementation improves depression for children and adolescents. How up to date is this evidence? The evidence is up to date to 18 May 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Campisi, SC, Zasowski, C, Bradley-Ridout, G, Schumacher, A, Szatmari, P, Korczak, D", "articleTypes": [], "doi": "10.1002/14651858.CD014803.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.774Z" }, { "id": "f0af6804-9b98-41c2-a40e-4aa7d9ce47a0", "pmid": "", "title": "Interventions for latent autoimmune diabetes (LADA) in adults", "imported": false, "abstract": "Abstract - Background Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes. Objectives To compare interventions used for LADA. Search methods Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta‐analysis or descriptive methods. Main results Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow‐up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: ‐1.3% (95% confidence interval (CI) ‐2.4 to ‐0.1; P = 0.03, 160 participants, four studies, follow‐up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C‐peptide, but insulin maintained stimulated C‐peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow‐up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C‐peptide levels (20 μg group) were maintained after five years. Short term (three months) follow‐up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C‐peptide levels compared to insulin alone (0.07 µg/L (95% CI ‐0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C‐peptide levels in the vitamin D group but declining fasting C‐peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow‐up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health‐related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes). Authors' conclusions Two studies show SU leading to earlier insulin dependence and a meta‐analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 μg) have been suggested to maintain fasting and stimulated C‐peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA. Plain language summary Interventions for latent autoimmune diabetes (LADA) in adults LADA is a condition that at diagnosis looks like type 2 diabetes (non‐insulin requiring diabetes mellitus) but actually is a type 1 diabetes, where the patient will become insulin requiring. In the UK approximately 3.6% of people who look like they have type 2 diabetes actually have type 1 diabetes, while other studies suggest the prevalence is higher and treatment for these patients may need to be different from that used in type 2 diabetes. 
 We identified 15 publications (10 studies) looking at 1019 patients who were followed between three months to 10 years. We found many of the publications had poor quality of reporting and had small numbers of participants. However, there does seem to be evidence from this review that the drug sulphonylurea (like glibenclamide or glyburide, gliclazide) could make patients insulin dependent sooner and it does not control blood sugar as well as insulin. Therefore, this suggests that this drug should not be a first line treatment for patients with LADA. In addition, insulin combined with vitamin D, or Chinese herbs may maintain natural insulin production better than insulin alone. Similarly, glutamic acid decarboxylase (GAD65) may maintain natural insulin production. However, there was no conclusive evidence that any of the other remaining treatment methods were better than each other. Studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic attacks. This review represents very early days of our understanding of the best way to treat LADA. It is limited by the poor reporting quality of the studies, small sample sizes, no clear single definition of LADA and many of the studies being carried out in different ethnic groups (China, Japan, Cuba, UK, Sweden) with different clinical care systems. 
 None of the publications reported on complications of diabetes, health‐related quality of life, costs or health service utilisation. All but one of the publications reported there were no deaths. 
 In summary, this review demonstrates that insulin treatment may be preferable compared to sulphonylurea treatment but there is little evidence regarding other forms of treatment. Future studies are needed, should have a clear definition of LADA, investigate patient‐important outcomes and use a common method of measuring stimulated C‐peptide (a marker of natural insulin production reflecting improved beta‐cell function of the pancreas).", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Brophy, S; Davies, H; Mannan, S; Brunt, H; Williams, R", "articleTypes": [], "doi": "10.1002/14651858.CD006165.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "f0ba89f3-5544-438e-81a8-970fff0c392d", "pmid": "", "title": "Antibody tests for identification of current and past infection with SARS‐CoV‐2", "imported": false, "abstract": "Abstract - Background The diagnostic challenges associated with the COVID‐19 pandemic resulted in rapid development of diagnostic test methods for detecting SARS‐CoV‐2 infection. Serology tests to detect the presence of antibodies to SARS‐CoV‐2 enable detection of past infection and may detect cases of SARS‐CoV‐2 infection that were missed by earlier diagnostic tests. Understanding the diagnostic accuracy of serology tests for SARS‐CoV‐2 infection may enable development of effective diagnostic and management pathways, inform public health management decisions and understanding of SARS‐CoV‐2 epidemiology. Objectives To assess the accuracy of antibody tests, firstly, to determine if a person presenting in the community, or in primary or secondary care has current SARS‐CoV‐2 infection according to time after onset of infection and, secondly, to determine if a person has previously been infected with SARS‐CoV‐2. Sources of heterogeneity investigated included: timing of test, test method, SARS‐CoV‐2 antigen used, test brand, and reference standard for non‐SARS‐CoV‐2 cases. Search methods The COVID‐19 Open Access Project living evidence database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) was searched on 30 September 2020. We included additional publications from the Evidence for Policy and Practice Information and Co‐ordinating Centre (EPPI‐Centre) ‘COVID‐19: Living map of the evidence’ and the Norwegian Institute of Public Health ’NIPH systematic and living map on COVID‐19 evidence’. We did not apply language restrictions. Selection criteria We included test accuracy studies of any design that evaluated commercially produced serology tests, targeting IgG, IgM, IgA alone, or in combination. Studies must have provided data for sensitivity, that could be allocated to a predefined time period after onset of symptoms, or after a positive RT‐PCR test. Small studies with fewer than 25 SARS‐CoV‐2 infection cases were excluded. We included any reference standard to define the presence or absence of SARS‐CoV‐2 (including reverse transcription polymerase chain reaction tests (RT‐PCR), clinical diagnostic criteria, and pre‐pandemic samples). Data collection and analysis We use standard screening procedures with three reviewers. Quality assessment (using the QUADAS‐2 tool) and numeric study results were extracted independently by two people. Other study characteristics were extracted by one reviewer and checked by a second. We present sensitivity and specificity with 95% confidence intervals (CIs) for each test and, for meta‐analysis, we fitted univariate random‐effects logistic regression models for sensitivity by eligible time period and for specificity by reference standard group. Heterogeneity was investigated by including indicator variables in the random‐effects logistic regression models. We tabulated results by test manufacturer and summarised results for tests that were evaluated in 200 or more samples and that met a modification of UK Medicines and Healthcare products Regulatory Agency (MHRA) target performance criteria. Main results We included 178 separate studies (described in 177 study reports, with 45 as pre‐prints) providing 527 test evaluations. The studies included 64,688 samples including 25,724 from people with confirmed SARS‐CoV‐2; most compared the accuracy of two or more assays (102/178, 57%). Participants with confirmed SARS‐CoV‐2 infection were most commonly hospital inpatients (78/178, 44%), and pre‐pandemic samples were used by 45% (81/178) to estimate specificity. Over two‐thirds of studies recruited participants based on known SARS‐CoV‐2 infection status (123/178, 69%). All studies were conducted prior to the introduction of SARS‐CoV‐2 vaccines and present data for naturally acquired antibody responses. Seventy‐nine percent (141/178) of studies reported sensitivity by week after symptom onset and 66% (117/178) for convalescent phase infection. Studies evaluated enzyme‐linked immunosorbent assays (ELISA) (165/527; 31%), chemiluminescent assays (CLIA) (167/527; 32%) or lateral flow assays (LFA) (188/527; 36%). Risk of bias was high because of participant selection (172, 97%); application and interpretation of the index test (35, 20%); weaknesses in the reference standard (38, 21%); and issues related to participant flow and timing (148, 82%). We judged that there were high concerns about the applicability of the evidence related to participants in 170 (96%) studies, and about the applicability of the reference standard in 162 (91%) studies. Average sensitivities for current SARS‐CoV‐2 infection increased by week after onset for all target antibodies. Average sensitivity for the combination of either IgG or IgM was 41.1% in week one (95% CI 38.1 to 44.2; 103 evaluations; 3881 samples, 1593 cases), 74.9% in week two (95% CI 72.4 to 77.3; 96 evaluations, 3948 samples, 2904 cases) and 88.0% by week three after onset of symptoms (95% CI 86.3 to 89.5; 103 evaluations, 2929 samples, 2571 cases). Average sensitivity during the convalescent phase of infection (up to a maximum of 100 days since onset of symptoms, where reported) was 89.8% for IgG (95% CI 88.5 to 90.9; 253 evaluations, 16,846 samples, 14,183 cases), 92.9% for IgG or IgM combined (95% CI 91.0 to 94.4; 108 evaluations, 3571 samples, 3206 cases) and 94.3% for total antibodies (95% CI 92.8 to 95.5; 58 evaluations, 7063 samples, 6652 cases). Average sensitivities for IgM alone followed a similar pattern but were of a lower test accuracy in every time slot. Average specificities were consistently high and precise, particularly for pre‐pandemic samples which provide the least biased estimates of specificity (ranging from 98.6% for IgM to 99.8% for total antibodies). Subgroup analyses suggested small differences in sensitivity and specificity by test technology however heterogeneity in study results, timing of sample collection, and smaller sample numbers in some groups made comparisons difficult. For IgG, CLIAs were the most sensitive (convalescent‐phase infection) and specific (pre‐pandemic samples) compared to both ELISAs and LFAs (P < 0.001 for differences across test methods). The antigen(s) used (whether from the Spike‐protein or nucleocapsid) appeared to have some effect on average sensitivity in the first weeks after onset but there was no clear evidence of an effect during convalescent‐phase infection. Investigations of test performance by brand showed considerable variation in sensitivity between tests, and in results between studies evaluating the same test. For tests that were evaluated in 200 or more samples, the lower bound of the 95% CI for sensitivity was 90% or more for only a small number of tests (IgG, n = 5; IgG or IgM, n = 1; total antibodies, n = 4). More test brands met the MHRA minimum criteria for specificity of 98% or above (IgG, n = 16; IgG or IgM, n = 5; total antibodies, n = 7). Seven assays met the specified criteria for both sensitivity and specificity. In a low‐prevalence (2%) setting, where antibody testing is used to diagnose COVID‐19 in people with symptoms but who have had a negative PCR test, we would anticipate that 1 (1 to 2) case would be missed and 8 (5 to 15) would be falsely positive in 1000 people undergoing IgG or IgM testing in week three after onset of SARS‐CoV‐2 infection. In a seroprevalence survey, where prevalence of prior infection is 50%, we would anticipate that 51 (46 to 58) cases would be missed and 6 (5 to 7) would be falsely positive in 1000 people having IgG tests during the convalescent phase (21 to 100 days post‐symptom onset or post‐positive PCR) of SARS‐CoV‐2 infection. Authors' conclusions Some antibody tests could be a useful diagnostic tool for those in whom molecular‐ or antigen‐based tests have failed to detect the SARS‐CoV‐2 virus, including in those with ongoing symptoms of acute infection (from week three onwards) or those presenting with post‐acute sequelae of COVID‐19. However, antibody tests have an increasing likelihood of detecting an immune response to infection as time since onset of infection progresses and have demonstrated adequate performance for detection of prior infection for sero‐epidemiological purposes. The applicability of results for detection of vaccination‐induced antibodies is uncertain. Plain language summary What is the diagnostic accuracy of antibody tests for the detection of infection with the COVID‐19 virus? Background COVID‐19 is an infectious disease caused by the SARS‐CoV‐2 virus that spreads easily between people in a similar way to the common cold or ‘flu’. Most people with COVID‐19 have a mild‐to‐moderate respiratory illness, and some may have no symptoms (asymptomatic infection). Others experience severe symptoms and need specialist treatment and intensive care. In response to COVID‐19 infection, the immune system develops proteins called antibodies that can attack the virus as it circulates in their blood. People who have been vaccinated against COVID‐19 also produce these antibodies against the virus. Tests are available to detect antibodies in peoples' blood, which may indicate that they currently have COVID‐19 or have had it previously, or it may indicate that they have been vaccinated (although this group was not the focus of this review). Why are accurate tests important? Accurate testing allows identification of people who need to isolate themselves to prevent the spread of infection, or who might need treatment for their infection. Failure of diagnostic tests to detect infection with COVID‐19 when it is present (a false negative result) may delay treatment and risk further spread of infection to others. Incorrect diagnosis of COVID‐19 when it is not present (a false positive result) may lead to unnecessary further testing, treatment, and isolation of the person and close contacts. Accurate identification of people who have previously had COVID‐19 is important in measuring disease spread and assessing the success of public health interventions. To determine the accuracy of an antibody test in identifying COVID‐19, test results are compared in people known to have (or have had) COVID‐19 and in people known not to have (or have had) COVID‐19. The criteria used to determine whether people are known or not known to have COVID‐19 is called the ‘reference standard’. Many studies use a test called reverse transcriptase polymerase chain reaction (RT‐PCR) as the reference standard, with samples taken from the nose and throat. Additional tests that can be used include measuring symptoms, like coughing or high temperature, or ‘imaging’ tests like chest X‐rays. People known not to have COVID‐19 are sometimes identified from stored blood samples taken before COVID‐19 existed, or from patients with symptoms confirmed to be caused by other diseases. What did the review study? We wanted to find out whether antibody tests: ‐ are able to diagnose infection in people with or without symptoms of COVID‐19, and ‐ can be used to find out if someone has already had COVID‐19. The studies we included in our review looked at three types of antibodies. Most commonly, antibody tests measure two types known as IgG and IgM, but some tests only measure a single type of antibody or different combinations of the three types of antibodies (IgA, IgG, IgM). What did we do? We looked for studies that measured the diagnostic accuracy of antibody tests to detect current or past COVID‐19 infection and compared them with reference standard criteria. Since there are many antibody tests available, we included studies assessing any antibody test compared with any reference standard. People could be tested in hospital or in the community. The people tested may have been confirmed to have, or not to have, COVID‐19 infection, or they may be suspected of having COVID‐19. Study characteristics We found 178 relevant studies. Studies took place in Europe (94), Asia (45), North America (35), Australia (2), and South America (2). Seventy‐eight studies included people who were in hospital with suspected or confirmed COVID‐19 infection and 14 studies included people in community settings. Several studies included people from multiple settings (35) or did not report where the participants were recruited from (39). One hundred and forty‐one studies included recent infection cases (mainly week 1 to week 3 after onset of symptoms), and many also included people tested later (from day 21 onwards after infection) (117). Main results In participants that had COVID‐19 and were tested one week after symptoms developed, antibody tests detected only 27% to 41% of infections. In week 2 after first symptoms, 64% to 79% of infections were detected, rising to 78% to 88% in week 3. Tests that specifically detected IgG or IgM antibodies were the most accurate and, when testing people from 21 days after first symptoms, they detected 93% of people with COVID‐19. Tests gave false positive results for 1% of those without COVID‐19. Below we illustrate results for two different scenarios. If 1000 people were tested for IgG or IgM antibodies during the third week after onset of symptoms and only 20 (2%) of them actually had COVID‐19: ‐ 26 people would test positive. Of these, 8 people (31%) would not have COVID‐19 (false positive result). ‐ 974 people would test negative. Of these, 2 people (0.2%) would actually have COVID‐19 (false negative result). If 1000 people with no symptoms for COVID‐19 were tested for IgG antibodies and 500 (50%) of them had previously had COVID‐19 infection more than 21 days previously: ‐ 455 people would test positive. Of these, 6 people (1%) would not have been infected (false positive result). ‐ 545 people would test negative. Of these, 51 (9%) would actually have had a prior COVID‐19 infection (false negative result). How reliable were the results of the studies of this review? We have limited confidence in the evidence for several reasons. The number of samples contributed by studies for each week post‐symptom onset was often small, and there were sometimes problems with how studies were conducted. Participants included in the studies were often hospital patients who were more likely to have experienced severe symptoms of COVID‐19. The accuracy of antibody tests for detecting COVID‐19 in these patients may be different from the accuracy of the tests in people with mild or moderate symptoms. It is not possible to identify by how much the test results would differ in other populations. Who do the results of this review apply to? A high percentage of participants were in hospital with COVID‐19, so were likely to have more severe disease than people with COVID‐19 who were not hospitalised. Only a small number of studies assessed these tests in people with no symptoms. The results of the review may therefore be more applicable to those with severe disease than people with mild symptoms. Studies frequently did not report whether participants had symptoms at the time samples were taken for testing making it difficult to fully separate test results for early‐phase infection as opposed to later‐phase infections. The studies in our review assessed several test methods across a global population, therefore it is likely that test results would be similar in most areas of the world. What are the implications of this review? The review shows that antibody tests could have a useful role in detecting if someone has had COVID‐19, but the timing of test use is important. Some antibody tests may help to confirm COVID‐19 infection in people who have had symptoms for more than two weeks but who have been unable to confirm their infection using other methods. This is particularly useful if they are experiencing potentially serious symptoms that may be due to COVID‐19 as they may require specific treatment. Antibody tests may also be useful to determine how many people have had a previous COVID‐19 infection. We could not be certain about how well the tests work for people who have milder disease or no symptoms, or for detecting antibodies resulting from vaccination. How up‐to‐date is this review? This review updates our previous review. The evidence is up‐to‐date to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Fox, T, Geppert, J, Dinnes, J, Scandrett, K, Bigio, J, Sulis, G, Hettiarachchi, D, Mathangasinghe, Y, Weeratunga, P, Wickramasinghe, D, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.142Z" }, { "id": "f0d20c26-c460-4dbe-b30b-879613c7c8f6", "pmid": "", "title": "Central Dopamine Receptors In Obesity", "imported": false, "abstract": "Central dopamine is thought to play a significant role in obesity. In support of this idea, animal studies and one human positron emission tomography (PET) study have found reduced postsynaptic D2-like receptor availability in the striatum in obesity, with lower D2 receptor availability associated with higher weight. In addition, reward sensitivity and hedonic responses, known to be related to dopamine function, have also been implicated in obesity and obesity-related eating behavior. These reports have led to the concept that dopaminergic abnormalities (e.g. reduced D2-like receptors) influence reward sensitivity, leading to altered eating behaviors and eventually obesity. However, there are several critical limitations of the human D2 receptor studies that limit the strength of their conclusions and thus the interpretations and speculations embedded in literature that relies on this work. First, estimates of D2-like receptors in humans have been confounded by potential differences in endogenous dopamine release since the PET ligand (raclopride) used is known to be displaceable from receptors by endogenous dopamine. Second, failure to rigorously screen obese individuals for diabetes confounds conclusions, since diabetes has been independently associated with dopaminergic abnormalities such as reduced D2-like receptors and muted dopamine release in diabetic rats. Finally, no human studies have addressed whether reduced D2-like receptor levels are a risk factor for obesity, a consequence of engaging in obesity-related behaviors or being obese or all of the above.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.143Z" }, { "id": "f0dfc54f-49f2-49e5-9a7c-cbedb6337c0b", "pmid": "", "title": "Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five‐year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis. Objectives To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions. Search methods We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi‐randomised trials. The reference lists of relevant articles were also searched. Selection criteria All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded. Data collection and analysis Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author. Main results A total of 40 randomised or quasi‐randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials. For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights. Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects. Authors' conclusions There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials. Plain language summary Drug treatment for children with bedwetting (nocturnal enuresis) but not including the drug types desmopressin or tricyclics Bedwetting (nocturnal enuresis) is the involuntary loss of urine at night without an underlying organic disease as the cause. It can result in social problems, sibling teasing and lowered self esteem. It affects around 15% to 20% of five‐year olds, and up to 2% of adults. Many different types of drugs have been used to treat children with bed wetting. There is not enough reliable evidence to show that drugs other than desmopressin or tricyclics reduce bedwetting in children during treatment when used in isolation, despite their risk of unwanted side effects. In other Cochrane reviews, alarms triggered by wetting, desmopressin and tricyclic drugs have been shown to work during treatment. However, alarms have a more sustained effect than desmopressin and tricyclics after treatment has finished. The adverse effects of alarm therapy (tiredness and waking other members of the family) are relatively benign and self limiting compared with the adverse effects of drugs. One class of drugs (anticholinergic drugs) appears to improve the efficacy of other established treatments such as tricyclics, bedwetting alarms and desmopressin. The cost of treating children with bedwetting with alarm therapy or drugs may vary in different countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Deshpande, AV; Caldwell, PHY; Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "f0e4c684-4d82-44f4-ad5b-6be0eef7275b", "pmid": "", "title": "Corticosteroids for idiopathic pulmonary fibrosis", "imported": false, "abstract": "Abstract - Background Idiopathic pulmonary fibrosis (IPF) is a disease with significant morbidity and mortality. Patients short survival time, high mortality and generally rapid decline raise the importance of early treatment. Current guidelines suggest a combination of corticosteroids and immunosuppressants as \"gold standard\" for IPF treatment, although the evidence for this recommendation is weak. Based on animal models, it has been hypothesized a central role for aberrant wound healing following repeated epithelial lung injury, weakening the rationale for using corticosteroids in IPF, previously thought to be a chronic inflammatory disease. Objectives The aim of the review is to determine the efficacy of corticosteroids in the treatment of adults with familial and sporadic IPF. Search methods We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2008), MEDLINE (January 1966 to June 2008) and EMBASE (January 1985 to June 2008) and reference lists of articles. We searched reference lists of published articles to identify clinical trials. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) using corticosteroids alone for the treatment of adults with IPF. Data collection and analysis Abstracts of identified articles were retrieved and articles possibly fulfilling inclusion criteria were retrieved in full. Two reviewers would have independently assessed trial quality if there had been any included study. Main results Seventeen articles were selected as potentially eligible for meta‐analysis. After further analysis of full text papers, no RCTs or CCTs were identified as suitable and therefore no data was available for inclusion in any meta‐analysis. All studies were excluded due to inadequate methodologies. Authors' conclusions At present, there is no evidence for an effect of corticosteroid treatment in patients with IPF. On the other hand, other fibrotic lung diseases, such as non‐specific interstitial pneumonia (NSIP), are reported to show a better response to corticosteroids. Making a clear distinction between IPF and other entities grouped under the umbrella term interstitial lung disease is, therefore, essential as this may have therapeutic and prognostic implications. Plain language summary Currently there is no evidence to support the routine use of corticosteroids alone in the management of idiopathic pulmonary fibrosis. Idiopathic pulmonary fibrosis (IPF) is a chronic disorder of unknown cause that is progressive and leads to death. Existing evidence about the treatment of IPF is difficult to interpret because of evolving diagnostic criteria and classification schemes, grouping together diverse entities with markedly different natural histories and responses to therapy. Therefore, because the old studies did not include only IPF patients, their results cannot be extended to IPF as they are currently defined. In addition, methodologic problems mainly related to the lack of randomized placebo‐controlled treatment trials have made evidence‐based conclusions difficult. A systematic search for high quality placebo‐controlled randomised trials comparing corticosteroid treatment with placebo in subjects with a diagnosis of IPF was unable to identify any studies suitable for inclusion in the review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Richeldi, L; Davies, HRHR; Spagnolo, P; Luppi, F", "articleTypes": [], "doi": "10.1002/14651858.CD002880", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "f0eb1a8a-a27a-4e57-af98-2b83c35c9175", "pmid": "", "title": "Chinese herbal medicine for schizophrenia", "imported": false, "abstract": "Abstract - Background Traditional Chinese medicine (TCM) was the main form of treatment in China for psychiatric illnesses until the development of antipsychotic drugs in the 1950's. Antipsychotic drugs have become the primary intervention for schizophrenia, although herbal medicines can still form part of the treatment. Objectives To review Chinese herbal medicine, used alone or as part of a TCM approach, for people with schizophrenia and related psychoses. Search methods We undertook electronic searches of the Cochrane Schizophrenia Group's register (December 2003), the Traditional Chinese Medical Literature Analysis and Retrieval Database (TCMLARS) (October 2003), Chinese Biomedical Database (CBM) (December 2003), China National Knowledge Infrastructure Database (May 2004), Complementary Medicine Database (AMED) (December 2003). We contacted the Chinese Cochrane Centre, the Cochrane Complementary Medicine Field and first authors of included studies and inspected reference lists for additional studies. Selection criteria We included all relevant randomised controlled trials involving people with schizophrenia‐like illnesses, allocated to Chinese herbal medicine, including any Chinese herbs (single or mixture), compared with placebo/no treatment or antipsychotic drugs. We updated this search July 2012 and added 45 new trials to the awaiting classification section. Data collection and analysis We independently extracted data and calculated fixed effects relative risk (RR), the 95% confidence intervals (CI) for homogeneous dichotomous data, and, where appropriate, the number needed to treat (NNT) on an intention‐to‐treat basis. For continuous data, we calculated weighted mean differences (WMD). Main results Only one small trial of the seven included studies truly evaluated TCM for schizophrenia. The other trials evaluated Chinese herbs for schizophrenia. We found one study comparing Chinese herbal medicine with antipsychotic drugs. Data for the global state outcome 'no change/worse' favoured people allocated to antipsychotic medication (n=90, RR 1.88 CI 1.2 to 2.9, NNH 4 CI 2 to 12). Six trials compared Chinese herbal medicine in combination with antipsychotic with antipsychotic drugs alone. One trial found global state 'not improved/worse' favoured the herbal medicine/antipsychotic combination (n=123, RR 0.19 CI 0.1 to 0.6, NNT 6 CI 5 to 11). Two studies (n=103) also found short‐term data from the Clinical Global Impression scale favoured the herbal medicine plus antipsychotic group (WMD ‐0.46 CI ‐0.9 to ‐0.1) compared with those given only antipsychotics. Significantly fewer people in the experimental group left the study early compared with those given antipsychotics alone (n=1004, 6 RCTs, RR 0.30 CI 0.16 to 0.58, NNT 21 CI 18 to 35). Reports of constipation were significantly lower in the treatment group compared to those receiving antipsychotics (n=67, 1 RCT, RR 0.03 CI 0.0 to 0.5, NNH 2 CI 2 to 4). Authors' conclusions Chinese herbal medicines, given in a Western biomedical context, may be beneficial for people with schizophrenia when combined with antipsychotics. Traditional Chinese medicine is also under‐evaluated, but results from one pioneering study that attempted to evaluate TCM should encourage further trials. Note: the 45 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed. Plain language summary Chinese herbal medicine for schizophrenia Antipsychotic medication is the mainstay of treatment for people with schizophrenia, and although effective, still leaves some people with distressing symptoms and/or disabling adverse effects. Safer and more effective health care interventions are needed. Traditional Chinese medicine (TCM) has been used to treat mental health disorders, including schizophrenia, for more than 2000 years. Chinese herbs may also have antipsychotic properties when used in a Western biomedical context. In this review we sought and found trials relevant to the effects of both approaches for schizophrenia. Traditional Chinese medicine methodology has been evaluated for schizophrenia, but the one included study was too limited in terms of sample size and study length to guide good practice. However, this pioneering study does show that TCM can be evaluated for its efficacy for people with schizophrenia , and should encourage trialists to undertake further, more comprehensive trials in this area. The use of Chinese herbs in a Western medicine context, without incorporating TCM methodology, has been evaluated in six trials, although again these are limited by their sample size and study length. The results of these six trials suggest that using Chinese herbs alone for psychotic symptoms may not be indicated, but if used in conjunction with Western antipsychotic drugs, they may be beneficial in terms of mental state, global functioning and decrease of adverse effects. However, further trials are needed before the effects of TCM for people with schizophrenia can be evaluated with any real confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Rathbone, J, Zhang, L, Zhang, M, Xia, J, Liu, X, Yang, Y", "articleTypes": [], "doi": "10.1002/14651858.CD003444.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.133Z" }, { "id": "f0efefc9-85c1-4a07-a365-bd64d436c049", "pmid": "", "title": "Interventions for drooling in children with cerebral palsy", "imported": false, "abstract": "Abstract - Background Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation ( Blasco 1992 ; Van der Burg 2006 ). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP. Objectives (1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning. Search methods We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts. We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled‐trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts. Selection criteria Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included. Data collection and analysis Data were extracted independently by MW, MS and LP and differences resolved through discussion. Main results Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin‐A (BoNT‐A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro‐motor and oro‐sensory therapies, behavioural interventions, intra‐oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta‐analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies. Authors' conclusions It was not possible to reach a conclusion on the effectiveness and safety of either BoNT‐A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided. Plain language summary Interventions for drooling in children with cerebral palsy Many children with CP have difficulty controlling saliva. Drooling varies in severity and can be distressing for the children, families and caregivers. Excessive drooling can cause constant damp soiled clothing, unpleasant odour, irritated, chapped or sore skin around the mouth and chin, skin and mouth infections, dehydration, difficulties chewing, interference with speech, damage to books, communication aids, computer and audio equipment. There is also risk of social rejection and social isolation for these children. Many interventions are used to reduce or eliminate drooling. These include surgery, medications, botulinum toxin (BoNT‐A and BoNT‐B)), physical therapies, therapies to improve sensory function, behavioural therapies to assist the child in managing his/her own drooling, appliances placed in the mouth, and acupuncture. There is no clear consensus on which interventions are safe and effective in managing drooling in children with CP. This makes it hard to decide which intervention will be safest and most effective. Only RCTs and CCTs were included in this review. Trials were identified by electronic searches of databases, searches of clinical trials registers, peer reviewed journals, published conference proceedings and reference lists of relevant articles. Six trials were found. Four examined the safety and efficacy of BoNT‐A and two examined benztropine and glycopyrrolate. No trials were found on other interventions. The quality of trials was variable. The trials all differed in the children recruited, the product used, how the product was delivered and how its effectiveness was measured. All trials reported a positive reduction in drooling and all showed some statistically significant change for treatment groups up to 1 month post intervention. Few studies examined client and/or carer satisfaction with the intervention. Some looked at side effects of the intervention but no study examined the effect of interventions on the child's quality of life or psychological well being. There is insufficient evidence to support the use of one intervention over another. As trials on just two kinds of interventions were retrieved, and given the variation and quality of these studies, it is not possible to conclude that one intervention is more effective than another. The lack of trials on other interventions does not suggest that these interventions are ineffective. Adequately powered well designed trials are required across all interventions. In addition to using sensitive measures looking at change in salivary flow, measures are needed that examine client and carer satisfaction, changes in quality of life, psychological well being and in unwanted symptoms associated with drooling.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Walshe, M; Smith, M; Pennington, L", "articleTypes": [], "doi": "10.1002/14651858.CD008624.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "f0f2e004-fae5-4f69-9559-1994f70c0f64", "pmid": "", "title": "Sustained‐release naltrexone for opioid dependence", "imported": false, "abstract": "Abstract - Background Opioid dependence is a severe and often lifelong disorder with a high risk of overdose and premature death, as well as severe psychosocial difficulties. Sustained‐release naltrexone is a treatment option that works by blocking the euphoric and overdose effects of opioids. When injected intramuscularly, naltrexone provides blockade for one month, while the blocking effects with implants can last for up to six months. Objectives To assess the benefits and harms of sustained‐release naltrexone for the treatment of opioid dependence. Search methods For this update, we searched the following databases from 2007 up to 20 December 2023: the Cochrane Drugs and Alcohol Specialised Register of Trials, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, ISI Web of Science, LILACS, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We manually searched the reference lists of identified studies, published reviews and relevant websites. Selection criteria Randomised controlled trials comparing the effects of injectable or implantable naltrexone with other treatment, no treatment or placebo in adults with opioid dependence. Data collection and analysis Primary outcomes were illicit opioid use, retention in treatment, treatment acceptability and adverse events. Secondary outcomes were opioid craving, recreational use of substances other than opioids, mental health, quality of life and criminal activity. We assessed the risk of bias using the Cochrane risk of bias tool (RoB 1). We combined the results of individual trials through meta‐analysis where possible using a random‐effects model. Two review authors independently assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We identified 22 studies (3416 participants) that met our inclusion criteria. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. Sustained‐release naltrexone compared with opioid agonist treatment We found moderate‐certainty evidence that sustained‐release naltrexone probably increases in‐treatment illicit opioid use slightly (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.01 to 1.31; 1 study, 570 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 1.17, 95% CI 0.78 to 1.76; 3 studies, 773 participants) and treatment acceptability (RR 0.92, 95% CI 0.73 to 1.16; 3 studies, 773 participants). There was low‐certainty evidence that sustained‐release naltrexone may increase serious adverse events slightly in comparison with opioid agonist treatment for serious adverse events (RR 1.40, 95% CI 0.92 to 2.11; 2 studies, 713 participants). Sustained‐release naltrexone compared with oral naltrexone treatment We found low‐certainty evidence that sustained‐release naltrexone may reduce in‐treatment illicit opioid use (RR 0.65, 95% CI 0.45 to 0.93; 1 study, 69 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment (RR 2.40, 95% CI 1.64 to 3.52; 3 studies, 464 participants) and on serious adverse events (RR 1.25, 95% CI 0.46 to 3.36; 2 studies, 260 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in treatment acceptability in comparison with oral naltrexone treatment (RR 1.00, 95% CI 0.99 to 1.01; 3 studies, 474 participants). Sustained‐release naltrexone compared with placebo We found low‐certainty evidence that sustained‐release naltrexone may result in little to no difference in in‐treatment illicit opioid use (RR 0.83, 95% CI 0.66 to 1.03; 3 studies, 443 participants), treatment acceptability (RR 1.00, 95% CI 0.98 to 1.02; 1 study, 204 participants) and serious adverse events (RR 0.74, 95% CI 0.17 to 3.23; 3 studies, 443 participants). The evidence is very uncertain about the effect of sustained‐release naltrexone on retention in treatment in comparison with placebo (RR 2.10, 95% CI 1.23 to 3.60; 4 studies, 594 participants). Sustained‐release naltrexone compared with treatment as usual We found high‐certainty evidence that sustained‐release naltrexone reduces in‐treatment illicit opioid use (RR 0.72, 95% CI 0.57 to 0.90; 4 studies, 479 participants). There was low‐certainty evidence that sustained‐release naltrexone may result in little or no difference in retention in treatment (RR 1.20, 95% CI 0.79 to 1.82; 3 studies, 126 participants) and that it may result in a slight reduction in treatment acceptability (RR 0.79, 95% CI 0.69 to 0.90; 8 studies, 1094 participants). There was moderate‐certainty evidence that sustained‐release naltrexone probably reduces serious adverse events in comparison with treatment as usual (RR 0.59, 95% CI 0.36 to 0.95; 6 studies, 1009 participants). Our primary outcome measures were not reported for sustained‐release naltrexone compared with psychosocial treatments. Amongst the most common methodological weaknesses were the risk of performance bias and imprecision due to few studies and small sample size for many outcomes. Authors' conclusions Sustained‐release naltrexone may slightly increase illicit opioid use and serious adverse events compared to opioid agonists, with uncertain effects on retention and acceptability. It may reduce illicit opioid use compared to oral naltrexone but has uncertain effects on other outcomes. Compared to placebo, it may have little to no impact on key outcomes. Compared to treatment as usual, it reduces illicit opioid use and may reduce serious adverse events but has little effect on retention and slightly reduces acceptability. Significant gaps remain in the evidence on sustained‐release naltrexone for opioid dependence. Future research should include comparisons with psychosocial treatments, larger and higher‐quality studies, and analyses of differences between formulations and comparator treatments. Improved study designs are needed to reduce bias, and more inclusive research should address under‐represented populations and synthetic opioid users. The lack of long‐term outcome data limits understanding of sustained effects, highlighting the need for extended follow‐up and exploration of diverse treatment settings and populations. Plain language summary What are the benefits and risks of sustained‐release (long‐acting) naltrexone for the treatment of dependence on opioid drugs (addiction)? Key messages • It is unclear whether people treated with sustained‐release naltrexone use illicit opioids, such as heroin, less frequently than people treated with opioid agonists, such as buprenorphine or methadone. • People treated with sustained‐release naltrexone may use illicit opioids less frequently than people treated with oral naltrexone, placebo or treatment as usual. • Treatment with sustained‐release naltrexone may be less safe than opioid agonist treatment, but safer than treatment as usual. • Clinicians and patients should weigh the availability and characteristics of treatment options, noting that sustained‐release naltrexone aids abstinence without restricting freedom but requires detoxification; more evidence is needed on long‐term safety and retention. What is dependence on opioid drugs? Opioid drugs, including heroin and prescription painkillers like oxycodone, carry the risk of addiction and serious health consequences. Treatment often involves replacing these opioids with safer alternatives such as methadone or buprenorphine, although other options like therapy or naltrexone are available. However, overcoming opioid dependence remains a persistent challenge due to its complex nature and the associated risks of relapse and overdose. What did we want to find out? In this review we sought to compare sustained‐release naltrexone treatment with other treatments or no treatment for opioid dependence. Naltrexone should not be confused with naloxone, which is a short‐acting drug used for opioid overdose reversal. Other treatments include opioid agonist treatment (such as methadone or buprenorphine), oral naltrexone (taken by mouth, tablets), placebo (sham treatment, that does not contain any medicine but looks or tastes identical to the medicine being tested), treatment as usual and psychosocial treatments (therapeutic approaches that address both psychological and social aspects of mental health conditions, e.g. psychotherapy, psychoeducation and support groups). What did we do? We searched scientific databases for studies up to December 2023. We identified 22 randomised controlled trials (studies where people were allocated at random to one of two or more treatment or control conditions) involving 3416 adults and adolescents with opioid dependence. Seventy‐four per cent of the people in the studies were male, and they had an average age of 40 years. Twelve of the 22 studies were conducted in the USA or Canada, five in Russia, three in Norway, and one in the UK and Australia, respectively. The main outcomes we examined were opioid use and treatment safety. Three studies compared sustained‐release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. What did we find? We found that when comparing sustained‐release naltrexone to opioid agonist treatment, illicit opioid use probably increases slightly. On the other hand, when comparing sustained‐release naltrexone to treatment as usual, sustained‐release naltrexone reduces illicit opioid use. Compared to oral naltrexone, illicit opioid use may decrease, and compared to placebo, there may be little or no difference. We found no studies comparing sustained‐release naltrexone with psychosocial treatments for any of our primary outcomes. It is generally unclear whether people remain longer in sustained‐release naltrexone treatment than in other treatments or placebo. We do not know whether more people will initiate sustained‐release naltrexone treatment than opioid agonist treatment. When compared to oral naltrexone or placebo, there may be little or no difference in the proportion of people who will initiate treatment. Compared to treatment as usual, it may be that fewer people will initiate sustained‐release naltrexone treatment. Compared to opioid agonist treatment, sustained‐release naltrexone may increase serious adverse (unwanted or harmful) events slightly. It is unclear whether sustained‐release naltrexone results in more or fewer serious adverse events than oral naltrexone. When compared to placebo, there may be little or no difference in the proportion of people who will experience serious adverse events. Sustained‐release naltrexone probably reduces serious adverse events in comparison to treatment as usual. What were the limitations of the evidence? Overall, we have limited confidence in the evidence. One of the reasons is that it is very likely that participants knew which treatments they were assigned to, even if the researchers in many cases tried to conceal the assigned treatment condition for participants and treatment providers. Opioid dependence comes with strong drug cravings and an increased risk of relapse during any treatment. Therefore, participants experiencing cravings and those who maybe even tried to use drugs like heroin would have understood what type of treatment they were assigned to. Another major reason for our limited confidence in the evidence was that the number of studies, and people participating in them, was often too small to obtain precise results. Other reasons for lowering our confidence were inconsistencies in study results and national treatment policies in some studies that make it difficult to apply the results in other countries. How up‐to‐date is this evidence? The evidence is current to December 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kornør, H; Lobmaier, PPK; Kunøe, N", "articleTypes": [], "doi": "10.1002/14651858.CD006140.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "f136aa87-d1e7-47fe-b069-8946f059138a", "pmid": "", "title": "Interventions for cleaning dentures in adults", "imported": false, "abstract": "Abstract - Background Removing denture plaque may be essential for maintaining the oral health of edentulous people. Brushing and soaking in chemical products are two of the most commonly used methods of cleaning dentures. Objectives To evaluate the effectiveness and safety of different methods for cleansing removable dentures. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to May 2009); CENTRAL ( The Cochrane Library 2009, Issue 2); MEDLINE (1965 to May 2009); EMBASE (1980 to May 2009); LILACS (1980 to May 2009); and CINAHL (1997 to May 2009). There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing any mechanical method (e.g. brushing or ultrasound) or chemical (e.g. enzymes, sodium hypochlorite, oral rinses or peroxide solutions) in adults over the age of 18 wearing removable partial dentures or complete dentures. The primary outcomes considered were the health of denture bearing areas (soft tissues, periodontal tissues and teeth) and participants' satisfaction and preference. Secondary outcomes included denture plaque coverage area, indicators of halitosis and microbial counts on abutment teeth, soft tissues or denture base or saliva. Data collection and analysis Two independent review authors screened and extracted information from, and independently assessed the risk of bias in the included trials. Main results Although six RCTs were included in this review, the wide range of different interventions and outcome variables did not permit pooling of data in a meta‐analysis. Isolated reports indicated that chemicals and brushing appear to be more effective than placebo in the reduction of plaque coverage and microbial counts of anaerobes and aerobes on complete denture bases. Authors' conclusions There is a lack of evidence about the comparative effectiveness of the different denture cleaning methods considered in this review. Few well designed RCTs were found. Future research should focus on comparisons between mechanical and chemical methods; the assessment of the association of methods, primary variables and costs should also receive future attention. Plain language summary Interventions for cleaning dentures in adults Plaque formed on the surfaces of removable dentures can have a significant impact on oral health, as long as it can lead to infection of denture‐supporting mucosa (stomatitis), gum inflammation (gingivitis) and tooth decay. Denture plaque can be removed by several different methods which include: brushing with paste, soaking in chemicals (e.g. effervescent tablets or bleach) and using special devices (a microwave oven or ultrasonic device). This review found weak evidence in support of soaking of dentures in effervescent tablets or enzymatic solutions and that brushing with paste can remove plaque and kill microbes better than inactive treatments. It is, however, unclear which is the most effective and there is a paucity of data on the use of alternative methods. Futures studies should aim to provide reliable information about which method is more effective in maintaining oral health of removable denture wearers. The scarce data found was restricted to the cleansing of complete dentures made from an acrylic resin base. Further research should also investigate how removable partial dentures can be cleaned, and in particular on the corrosive effects of cleaners on their metallic components.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "de Souza, RF; de Freitas Oliveira Paranhos, H; Lovato da Silva, CH; Abu‐Naba'a, L; Fedorowicz, Z; Gurgan, CA", "articleTypes": [], "doi": "10.1002/14651858.CD007395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "f13fd0db-fe69-4146-ab62-8ca4e97f4fd4", "pmid": "", "title": "Metformin for endometrial hyperplasia", "imported": false, "abstract": "Abstract - Background Endometrial cancer is one of the most common gynaecological cancers in the world. Rates of endometrial cancer are rising, in part because of rising obesity rates. Endometrial hyperplasia is a precancerous condition in women that can lead to endometrial cancer if left untreated. Endometrial hyperplasia occurs more commonly than endometrial cancer. Progesterone tablets that are currently used to treat women with endometrial hyperplasia are associated with adverse effects in up to 84% of women. A levonorgestrel intrauterine device may improve compliance, but it is invasive, is not acceptable to all women, and is associated with irregular vaginal bleeding in 82% of cases. Therefore, an alternative treatment for women with endometrial hyperplasia is needed. Metformin, a drug that is often used to treat people with diabetes, has been shown, in some human studies, to reverse endometrial hyperplasia. However, the effectiveness and safety of metformin for treatment of endometrial hyperplasia remain uncertain. This is an update of a review first published in 2017. Objectives To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia. Search methods We searched the Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, PubMed, Embase, Google Scholar, OpenGrey, LILACS, and two trials registers from inception to 5 September 2022. We searched the bibliographies of all relevant studies, and contacted experts in the field for any additional trials. Selection criteria We included randomised controlled trials (RCTs) and cross‐over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo, no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type. Data collection and analysis Two review authors independently assessed studies for eligibility, extracted data from included studies, assessed the risk of bias in the included studies, and assessed the certainty of the evidence for each outcome. We resolved disagreements by discussion or by deferring to a third review author. When study details were missing, review authors contacted the study authors. The primary outcome of this review was regression of endometrial hyperplasia histology (with or without atypia) towards normal histology. Main results We included seven RCTs, in which a total of 387 women took part. In the comparison, Metformin plus megestrol versus megestrol alone, we rated the certainty of the evidence as low for the outcome, regression of endometrial hyperplasia. We rated the quality of the evidence as very low for the rest of the outcomes, in all three comparisons. Although there was a low risk of selection bias, there was a high risk of bias in the blinding of personnel and outcome assessment (performance bias and detection bias) in many studies. This update identified four new RCTs and six ongoing RCTs. Metformin versus megestrol We are uncertain whether metformin increases the regression of endometrial hyperplasia towards normal histology over megestrol (odds ratio (OR) 4.89, 95% confidence interval (CI) 1.56 to 15.32; P = 0.006; 2 RCTs, 83 participants; I² = 7%; very low‐certainty evidence). This evidence suggests that if the rate of regression with megestrol is 61%, the rate of regression with metformin would be between 71% and 96%. It is unresolved whether metformin results in different rates of abnormal uterine bleeding or hysterectomy compared to megestrol. No study in this comparison reported progression of hyperplasia to endometrial cancer, recurrence of endometrial hyperplasia, health‐related quality of life, or adverse effects during treatment. Metformin plus megestrol versus megestrol monotherapy The combination of metformin and megestrol may enhance the regression of endometrial hyperplasia towards normal histology more than megestrol alone (OR 3.27, 95% CI 1.65 to 6.51; P = 0.0007; 4 RCTs, 258 participants; I² = 0%, low‐certainty evidence). This suggests that if the rate of regression with megestrol monotherapy is 54%, the rate of regression with the addition of metformin would be between 66% and 84%. In one study, 3/8 (37.5%) of participants who took metformin had nausea that settled without further treatment. It is unresolved whether the combination of metformin and megestrol results in different rates of recurrence of endometrial hyperplasia, progression of endometrial hyperplasia to endometrial cancer, or hysterectomy compared to megestrol monotherapy. No study in this comparison reported abnormal uterine bleeding, or health‐related quality of life. Metformin plus levonorgestrel (intrauterine system) versus levonorgestrel (intrauterine system) monotherapy We are uncertain whether there is a difference between groups in the regression of endometrial hyperplasia towards normal histology (OR 0.29, 95% CI 0.01 to 7.56; 1 RCT, 46 participants; very low‐certainty evidence). This evidence suggests that if the rate of regression with levonorgestrel monotherapy is 96%, the rate of regression with the addition of metformin would be between 73% and 100%. It is unresolved whether the combination of metformin and levonorgestrel results in different rates of abnormal uterine bleeding, hysterectomy, or the development of adverse effects during treatment compared to levonorgestrel monotherapy. No study in this comparison reported recurrence of endometrial hyperplasia, progression of hyperplasia to endometrial cancer, or health‐related quality of life. Authors' conclusions Review authors found insufficient evidence to either support or refute the use of metformin, specifically megestrol acetate, given alone or in combination with standard therapy, for the treatment of women with endometrial hyperplasia. Robustly designed and adequately powered randomised controlled trials, yielding long‐term outcome data are still needed to address this clinical question. Plain language summary Metformin for endometrial hyperplasia Review question Is metformin an effective and safe treatment for women with endometrial hyperplasia? Background Endometrial cancer (cancer of the lining of the womb) is a common cancer that affects the reproductive organs in women worldwide. Endometrial hyperplasia (thickening of the lining of the womb) is a precancerous condition in women that can lead to endometrial cancer if left untreated. Successful treatment of women with endometrial hyperplasia can prevent endometrial cancer. Endometrial hyperplasia is usually treated by providing progesterone hormone tablets, inserting a levonorgestrel‐releasing intrauterine system (LNG‐IUS) into the womb, advising women with extra weight to lose weight, or performing a hysterectomy for women who do not want a future pregnancy. However, progesterone tablets are associated with side effects in up to 84% of women, and this can prevent women from completing treatment. Also, progesterone tablets do not always work, and endometrial hyperplasia can return in up to 14% to 30% of women after treatment. The LNG‐IUS is associated with irregular vaginal bleeding in up to 82% of women. Many women find it painful to use, or find it otherwise unacceptable. Therefore, an alternative treatment for endometrial hyperplasia is required. Metformin, an oral tablet that is usually used to treat diabetes, has been shown to cure endometrial hyperplasia in some human studies. Although women taking metformin may experience side effects, treatment is usually well tolerated. If women experience fewer side effects when taking metformin rather than progesterone tablets, and if metformin effectively treats endometrial hyperplasia, women would be more willing to complete treatment, and the cure rate would improve. This could reduce the number of women who end up with endometrial cancer. However, the effectiveness and safety of metformin used to treat women with endometrial hyperplasia remain uncertain. Study characteristics We included seven randomised controlled trials in which a total of 387 women took part. Five studies compared metformin to megestrol (a form of progesterone), and one study compared metformin plus megestrol to megestrol alone. Women in all studies received treatment for three to six months. The evidence is current to 5 September 2022. Key results Studies on metformin alone versus megestrol alone provided insufficient evidence to show differences in effectiveness for curing endometrial hyperplasia. Studies on metformin plus megestrol versus megestrol alone found that metformin may improve the thickened walls of the womb, but the evidence is uncertain about other outcomes. One small study provided insufficient evidence to support or refute the use of metformin plus the LNG‐IUS or the LNG‐IUS alone. Certainty of the evidence We rated the certainty of the evidence as low to very‐low for all outcomes, because of limitations in the way the studies were designed, and small sample sizes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Shiwani, H, Clement, NS, Daniels, JP, Atiomo, W", "articleTypes": [], "doi": "10.1002/14651858.CD012214.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.099Z" }, { "id": "f14ba87d-2a1d-40e3-bfec-c2da083ce2a0", "pmid": "", "title": "Adhesives for bonded molar tubes during fixed brace treatment", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Millett, DT, Mandall, NA, Mattick, RCR, Hickman, J, Glenny, AM", "articleTypes": [], "doi": "10.1002/14651858.CD008236.pub3 AB - Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. The success of a fixed appliance depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a fixed appliance. It can also be costly in terms of clinical time, materials and time lost from education/work for the patient. This is an update of the Cochrane review first published in 2011. A new full search was conducted on 15 February 2017 but no new studies were identified. We have only updated the search methods section in this new version. The conclusions of this Cochrane review remain the same. Objectives To evaluate the effectiveness of the adhesives used to attach bonded molar tubes, and the relative effectiveness of the adhesives used to attach bonded molar tubes versus adhesives used to attach bands, during fixed appliance treatment, in terms of: (1) how often the tubes (or bands) come off during treatment; and (2) whether they protect the bonded (or banded) teeth against decay. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (to 15 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library (searched 15 February 2017), MEDLINE Ovid (1946 to 15 February 2017), and Embase Ovid (1980 to 15 February 2017). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised controlled trials of participants with full arch fixed orthodontic appliance(s) with molar tubes, bonded to first or second permanent molars. Trials which compared any type of adhesive used to bond molar tubes (stainless steel or titanium) with any other adhesive, were included. Trials were also included where: (1) a tube was bonded to a molar tooth on one side of an arch and a band cemented to the same tooth type on the opposite side of the same arch;
 (2) molar tubes had been allocated to one tooth type in one patient group and molar bands to the same tooth type in another patient group. Data collection and analysis The selection of papers, decision about eligibility and data extraction were carried out independently and in duplicate without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Two trials (n = 190), at low risk of bias, were included in the review and both presented data on first time failure at the tooth level. Pooling of the data showed a statistically significant difference in favour of molar bands, with a hazard ratio of 2.92 (95% confidence intervals (CI) 1.80 to 4.72). No statistically significant heterogeneity was shown between the two studies. Data on first time failure at the patient level were also available and showed statistically different difference in favour of molar bands (risk ratio 2.30; 95% CI 1.56 to 3.41) (risk of event for molar tubes = 57%; risk of event for molar bands 25%). One trial presented data on decalcification again showing a statistically significant difference in favour of molar bands. No other adverse events identified. Authors' conclusions From the two well‐designed and low risk of bias trials included in this review it was shown that the failure of molar tubes bonded with either a chemically‐cured or light‐cured adhesive was considerably higher than that of molar bands cemented with glass ionomer cement. One trial indicated that there was less decalcification with molar bands cemented with glass ionomer cement than with bonded molar tubes cemented with a light‐cured adhesive. However, given there are limited data for this outcome, further evidence is required to draw more robust conclusions. Plain language summary Adhesives for bonded molar tubes during fixed brace treatment Background Orthodontic treatment involves using fixed or removable dental braces to correct the positions of teeth. The success of dental braces depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a dental brace. Study characteristics The evidence in this review, which was carried out together with Cochrane Oral Health, is up‐to‐date as of 15 February 2017. We included two studies that evaluated 190 participants. Both trials were conducted in the UK and both compared bonded molar tubes with molar bands. Key results From the limited data of two studies at low risk of bias, it would appear that bonded molar tubes are associated with a higher failure rate than with molar bands.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.092Z" }, { "id": "f16e9c33-ad5b-459a-887d-3d6496081136", "pmid": "", "title": "Pharmacological treatments for Friedreich ataxia", "imported": false, "abstract": "Abstract - Rationale Friedreich ataxia (FRDA) is a rare inherited autosomal recessive neurological disorder, characterised initially by unsteadiness in standing and walking, and slowly progressing to wheelchair dependency, usually in the late teens or early twenties. Scoliosis, pes cavus and cardiomyopathy are often present at diagnosis. As the disease progresses, individuals usually develop slurred speech, auditory impairment (especially in a noisy environment), urinary tract morbidity, diabetes, anxiety, depression, muscle spasticity and visual disturbances. Cardiac abnormalities cause premature death in 60% of people with FRDA. There is no easily defined clinical or biochemical marker to assess progression and no known curative treatment. This is the third update of a review published in 2009 and updated in 2012 and 2016. Objectives To assess the effects of pharmacological treatments for people with Friedreich ataxia (FRDA) after 12 months of treatment. Search methods To identify studies for inclusion in this review, we searched CENTRAL, MEDLINE, Embase, CINAHL Plus, TRIP, Orphanet, WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. We also checked reference lists of relevant studies and contacted study authors. The most recent search was on 4 February 2025. Eligibility criteria We were interested in randomised controlled trials (RCTs) and quasi‐RCTs of pharmacological treatments (including vitamins) in people with genetically‐confirmed FRDA. To be included in the review, studies had to last at least 12 months. Outcomes We assessed the following outcomes after 12 months of treatment: change in score on a validated ataxia rating scale; change in interventricular septal thickness in diastole (IVSTd) by cardiac magnetic resonance imaging or echocardiogram; change in activities of daily living (ADL) using a validated questionnaire; change in upper limb dexterity; and change in cardiopulmonary exercise testing (CPET). We also assessed treatment‐related adverse events with medication continued for the study period, and treatment‐emergent adverse events leading to cessation of medication or death during the study period. Risk of bias Using the Cochrane risk of bias tool RoB 2, we assessed the risk of bias in the seven outcomes reported in our summary of findings tables. Synthesis methods We synthesised the results of the studies for each outcome using meta‐analysis, where possible. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and the risk ratio (RR) for dichotomous outcomes, all with 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for our prespecified outcomes as high, moderate, low or very low. Included studies We included eight RCTs in this updated review. We included seven of them in meta‐analysis, and these studies enroled a total of 574 participants, with sample sizes ranging from 29 to 232 participants per study. One study was international, with centres in North America, Europe and Australia. There were four other multicentre studies (three in Europe and one in North America). Single‐centre studies were conducted in the UK, Italy and France. Participants in the studies ranged from eight to 70 years of age at enrolment, with the mean age in each study being between 18 years and 35 years (with an unweighted pooled mean age across studies of 25.9 years). All of the studies enroled both males and females, with the proportion of female participants ranging from 21% to 58%. Sixty‐eight per cent of participants had severe ataxia, while the other 32% had moderate ataxia. The studies tested epoetin alpha, CoQ10 and vitamin E, idebenone, leriglitazone, omaveloxolone, and RT001. One study tested pioglitazone but has not published any results. Four of the studies were pharmaceutical‐industry‐controlled. Synthesis of results Meta‐analysis of seven studies demonstrated that pharmacological treatment probably makes little or no difference to scores on the ataxia rating scale after 12 months of treatment (SMD 0.02, 95% CI −0.23 to 0.26; I² = 42%; 7 studies, 513 participants; moderate‐certainty evidence). The evidence was very uncertain about the effects of treatment on IVSTd (MD −0.51, 95% CI −1.10 to 0.09; I² = 80%; 2 studies, 72 participants; very low‐certainty evidence) and on ADL (MD −0.59, 95% CI −1.39 to 0.21; I² = 24%; 3 studies, 167 participants; very low‐certainty evidence). Meta‐analysis of three studies showed that treatment probably improves upper limb dexterity (SMD −0.42, 95% CI −0.73 to −0.11; I² = 0%; 3 studies, 166 participants; moderate‐certainty evidence). We are very uncertain about the effect of pharmacological treatment on CPET (SMD −0.16, 95% CI −0.46 to 0.13; I² = 0%; 3 studies, 181 participants; very low‐certainty evidence). We are very uncertain whether pharmacological treatment has any effect on treatment‐related adverse events (RR 0.88, 95% CI 0.63 to 1.22; I² = 0%; 2 studies, 104 participants; very low‐certainty evidence). There were only 104 participants in this analysis out of a total of 545 participants, so the result may have little relevance. Meta‐analysis of six studies found that there may be little to no difference between pharmacological treatment and placebo in treatment‐emergent adverse events leading to cessation of medication or death (RR 1.24, 95% CI 0.44 to 3.48; I² = 0%; 6 studies, 313 participants; low‐certainty evidence). Our certainty in the evidence ranged from very low to moderate. We downgraded all outcomes by one or two levels for imprecision, with further downgrades for inconsistency (for the outcomes of IVSTd, ADL, CPET) and suspected publication bias (for the outcomes of IVSTd, ADL, CPET and adverse events). Authors' conclusions In this updated Cochrane systematic review, meta‐analysis of results on the ataxia rating scale showed that pharmacological treatments probably make little or no difference compared with placebo after 12 months of treatment. Given this result, the probable improvement that we found in upper limb dexterity was unexpected. Treatment‐emergent adverse events leading to cessation of medication or death may be no more common in treatment groups than placebo groups as there were few adverse events detected in the treated groups. However, the studies may not have detected all rare and serious adverse events. Funding The authors in this review received no funding. Registration Protocol (2009) DOI: 10.1002/14651858.CD007791 Original review (2009) DOI: 10.1002/14651858.CD99791.pub2 Update (2012) DOI: 10.1002/14651858.CD007791.pub3 Update (2016) DOI: 10.1002/14651858.CD007791.pub4 Plain language summary Does taking medicine help people with Friedreich ataxia? Key messages For people with a progressive genetic condition called Friedreich ataxia, which affects nerves and muscles, taking medicine for a year probably has little to no effect on measures of ataxia (problems with co‐ordination and balance) or speech, although it probably improves upper limb dexterity (the ability to co‐ordinate the action of the arms, hands and fingers). We are uncertain whether taking medicine has any effect on heart health, the ability to perform daily tasks, or the body's response to exercise in people with Friedreich ataxia. From the available evidence, it is very uncertain whether the medicines cause any unwanted effects. What is Friedreich ataxia? Friedreich ataxia is a rare inherited condition affecting the nerves and muscles, which usually appears in childhood, at between 5 and 15 years of age. It causes clumsiness of movement, which progresses to unsteadiness in standing and walking, and to being dependent on a wheelchair by the late teens or early twenties. It can be associated with a curved spine (scoliosis), foot deformity (a high arch) and heart problems. As the disease progresses, slurred speech, hearing difficulties, problems going to the toilet, muscle spasticity, depression, anxiety and visual disturbances are common. Heart problems are a cause of early death in nearly two‐thirds of people with Friedreich ataxia. Clinical examination and laboratory tests are not very useful for judging the progression of the disease, which makes it difficult to understand the results of studies with Friedreich ataxia patients. What are the possible options for treating Friedreich ataxia? There is currently no cure for Friedreich ataxia. Various medicines have been tried. A new medicine, omaveloxolone, was recently approved in the USA and Europe for people over 16 years of age with Friedreich ataxia. What did we want to find out? We wanted to know if any of the medicines tested in randomised clinical trials help improve the lives of people with Friedreich ataxia. Randomised clinical trials are studies where some people take medicine and others take placebo, which is a substance that has no medical benefit but looks the same as the active medicine. No‐one involved with the study knows who is taking medicine and who is taking placebo. This is the third update of a Cochrane review that was first published in 2009. What did we do? We searched for randomised clinical trials that compared medicine to placebo in people with Friedreich ataxia and lasted at least 12 months. We combined the results of the studies and rated our confidence in this evidence, based on factors such as study methods and the number of people involved. What did we find? We found eight studies, seven of which reported results after taking medicine or placebo for 12 months. The studies included a total of 574 people, whose average ages were between 18 and 35 years. Most of the participants (68%) had severe ataxia, while 32% had moderate ataxia. The studies took place in Europe, North America and Australia. Four of them were carried out by the pharmaceutical industry (i.e. by companies who make the medicines). Two studies used a medicine called idebenone, and each of the others used a different medicine: co‐Q10 with vitamin E, epoetin alpha, omaveloxolone, leriglitazone, pioglitazone, and RT001. We found that, after one year, there was probably little to no difference in the level of ataxia that people experienced, regardless of whether they took medicine or placebo (7 studies, 513 people). We are very uncertain whether medicine has any effect on heart health (based on measuring the thickness of the heart muscle) or the ability to do daily tasks or how people score on special tests designed to measure the body's response to exercise. We found that medicine probably improves upper limb dexterity after one year (3 studies (testing leriglitazone, epoetin alpha and omaveloxolone), 166 people). With regard to safety, we are very uncertain whether the medicines cause any more unwanted effects than placebo. We found that there may be little to no difference between people taking medicine and people taking placebo in terms of the number of who either stopped taking the medicine or placebo, or the number of who died during the study years (6 studies, 313 people). What are the limitations of the evidence? Our confidence in the effect of medicine on ataxia is only moderate. This is because the results were not very precise. We are only moderately confident about the effect of medicine on upper limb dexterity because this was only reported in small studies. We had very little confidence in the other outcomes because of the small numbers of people in the studies. The studies reported varied results, and some studies did not publish the results for all the assessments that were carried out. It is difficult to measure an individual's perceptions of the positive effects of any new medicine, which may vary depending on their expectations prior to starting the medicine and whether their illness is early or advanced. How up to date is this evidence? The evidence is current to 4 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Lyons, S; Kearney, M; Fahey, MC; Janjal, P; Pandolfo, M; Patton, P", "articleTypes": [], "doi": "10.1002/14651858.CD007791.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "f184090c-9b91-4122-8097-4302b83d2244", "pmid": "", "title": "Oral xanthines as maintenance treatment for asthma in children", "imported": false, "abstract": "Abstract - Background Xanthines have been used in the treatment of asthma as a bronchodilator, though they may also have anti‐inflammatory effects. The current role of xanthines in the long‐term treatment of childhood asthma needs to be reassessed. Objectives To determine the efficacy of xanthines (e.g. theophylline) in the maintenance treatment of paediatric asthma. Search methods A search of the Cochrane Airways Group Specialised Register was undertaken with predefined search terms. Searches are current to May 2008. Selection criteria Randomised controlled trials, lasting at least four weeks comparing a xanthine with placebo, regular short‐acting beta‐agonist (SABA), inhaled corticosteroids (ICS), cromoglycate (SCG), ketotifen (KET) or leukotriene antagonist, in children with diagnosed with chronic asthma between 18 months and 18 years old. Data collection and analysis Two reviewers independently selected each study for inclusion in the review and extracted data. Primary outcome was percentage of symptom‐free days. Main results Thirty‐six studies (2838 participants) were included. Xanthine versus placebo (18 studies): The proportion of symptom free days was larger with xanthine compared with placebo (7.97% [95% CI 3.41, 12.53]). Rescue medication usage was lower with xanthine, with no significant difference in symptom scores or hospitalisations. FEV 1 , and PEF were better with xanthine. Xanthine was associated with non ‐ specific side‐effects. Data from behavioural scores were inconclusive. Xanthine versus ICS (four studies) : Exacerbations were less frequent with ICS, but no significant difference on lung function was observed. Individual studies reported significant improvements in symptom measures in favour of steroids, and one study reported a difference in growth rate in favour of xanthine. No difference was observed for study withdrawal or tremor. Xanthine was associated with more frequent headache and nausea. Xanthine versus regular SABA (10 studies): No significant difference in symptoms, rescue medication usage and spirometry. Individual studies reported improvement in PEF with beta‐agonist. Beta‐agonist treatment led to fewer hospitalisations and headaches. Xanthine was associated with less tremor. Xanthine versus SCG (six studies ): No significant difference in symptoms, exacerbations and rescue medication. Sodium cromoglycate was associated with fewer gastro‐intestinal side‐effects than xanthine. Xanthine versus KET (one study): No statistical tests of significance between xanthine and ketotifen were reported. : Xanthine + ICS versus placebo + same dose ICS (three studies) : Results were conflicting due to clinical/methodological differences, and could not be aggregated. Xanthine + ICS versus ICS + leukotriene (one study): Results from one trial One small parallel study did not measure the primary outcome of symptoms; differences between treatments in end of treatment values were not statistically significant. Authors' conclusions Xanthines as first‐line preventer alleviate symptoms and reduce requirement for rescue medication in children with mild to moderate asthma. When compared with ICS they were less effective in preventing exacerbations. Xanthines had similar efficacy as single preventative agent compared with regular SABA and SCG. Evidence on AEs (adverse effects) was equivocal: there was evidence for increased AEs overall, but no evidence that any specific AE (including effects on behaviour and attention) occurred more frequently than with placebo. There is insufficient evidence from available studies to make firm conclusions about the effectiveness of xanthines as add‐on preventative treatment to ICS, and there are no published paediatric studies comparing xanthines with alternatives in this role. Our data suggest that xanthines are only suitable as first‐line preventative asthma therapy in children when ICS are not available. Pre‐trial exposure to the agents assessed may have pre‐disposed the trial populations to tolerate the drug, and may have threatened blinding. They may have a role as add‐on therapy in more severe asthma not controlled by ICS, but further studies are needed to examine this, and to define the risk‐benefit ratio compared with other agents. Plain language summary The effects of oral xanthines (e.g. theophylline) for chronic asthma in children Xanthines (e.g. theophylline) are a group of drugs thought to have helpful preventative and reliever properties in the treatment of asthma in children. This review of studies has established that there is evidence for useful effects of these drugs in terms of symptom relief and lung function, but also some evidence of side‐effects. As a primary preventative therapy , whilst there is evidence that xanthines are effective, this review suggests that more effective alternative treatment options (inhaled steroids) are available. In children with more severe asthma, the role of xanthines as an add‐on therapy has only been assessed in a small number of trials, which report mixed effects. More studies in this area would help to generate a more reliable overview of the effects of treatment in these children. Xanthines are an effective preventative treatment in childhood asthma, but less effective than inhaled steroids, and with a less favourable side‐effect profile. There is insufficient evidence at present to assess their role as \"add‐on\" preventer treatment versus newer alternatives. Some of the trials exposed the children they recruited to a pre‐trial phase of xanthine in order to maintain effective dosing during the trial. This could have made the trial participants less representative of the general population by making them more inclined to tolerate the study drug. This exposure also may have meant that they could recognise what drug they were taking during the blinded phase of the study.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Seddon, P; Bara, A; Lasserson, TJ; Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "f1850026-c4e2-4ec5-9a6b-dbf6fd076640", "pmid": "", "title": "Interventions for reducing inflammation in familial Mediterranean fever", "imported": false, "abstract": "Abstract - Background Familial Mediterranean fever (FMF), a hereditary auto‐inflammatory disease, mainly affects ethnic groups living in the Mediterranean region. Early studies reported colchicine may potentially prevent FMF attacks. For people who are colchicine‐resistant or intolerant, drugs such as anakinra, rilonacept, canakinumab, etanercept, infliximab or adalimumab might be beneficial. This is an update of the review last published in 2018. Objectives To evaluate the efficacy and safety of interventions for reducing inflammation in people with FMF. Search methods We searched CENTRAL, MEDLINE, Embase and four Chinese databases on in August 2021. We searched clinical trials registries and references listed in relevant reports. The last search was 17 August 2021. Selection criteria We included randomized controlled trials (RCTs) of people with FMF, comparing active interventions (including colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (herbal dietary supplement)) with placebo or no treatment, or comparing active drugs to each other. Data collection and analysis We used standard Cochrane methodology. We assessed certainty of the evidence using GRADE. Main results We included 10 RCTs with 312 participants (aged three to 53 years), including five parallel and five cross‐over designed studies. Six studies used oral colchicine, one used oral ImmunoGuard, and the remaining three used rilonacept, anakinra or canakinumab as a subcutaneous injection. The duration of each study arm ranged from one to eight months. There were inadequacies in the design of the four older colchicine studies and the two studies comparing a single to a divided dose of colchicine. However, the four studies of ImmunoGuard, rilonacept, anakinra and canakinumab were generally well‐designed. We aimed to report on the number of participants experiencing an attack, the timing of attacks, the prevention of amyloid A amyloidosis, adverse drug reactions and the response of a number of biochemical markers from the acute phase of an attack; but no study reported on the prevention of amyloid A amyloidosis. Colchicine (oral) versus placebo After three months, colchicine 0.6 mg three times daily may reduce the number of people experiencing attacks (risk ratio (RR) 0.21, 95% confidence interval (CI) 0.05 to 0.95; 1 study, 10 participants; low‐certainty evidence). One study (20 participants) of colchicine 0.5 mg twice daily showed there may be no difference in the number of participants experiencing attacks at two months (RR 0.78, 95% CI 0.49 to 1.23; low‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; very low‐certainty evidence), or in the number of days between attacks: (narrative summary; very low‐certainty evidence). Regarding adverse drug reactions, one study reported loose stools and frequent bowel movements and a second reported diarrhea (narrative summary; both very low‐certainty evidence). There were no data on acute‐phase response. Rilonacept versus placebo There is probably no difference in the number of people experiencing attacks at three months (RR 0.87, 95% CI 0.59 to 1.26; moderate‐certainty evidence). There may be no differences in the duration of attacks (narrative summary; low‐certainty evidence) or in the number of days between attacks (narrative summary; low‐certainty evidence). Regarding adverse drug reactions, the rilonacept study reported there may be no differences in gastrointestinal symptoms, hypertension, headache, respiratory tract infections, injection site reactions and herpes, compared to placebo (narrative summary; low‐certainty evidence). The study narratively reported there may be no differences in acute‐phase response indicators after three months (low‐certainty evidence). ImmunoGuard versus placebo The ImmunoGuard study observed there are probably no differences in adverse effects (moderate‐certainty evidence) or in acute‐phase response indicators after one month of treatment (moderate‐certainty evidence). No data were reported for the number of people experiencing an attack, duration of attacks or days between attacks. Anakinra versus placebo A study of anakinra given to 25 colchicine‐resistant participants found there is probably no difference in the number of participants experiencing an attack at four months (RR 0.76, 95% CI 0.54 to 1.07; moderate‐certainty evidence). There were no data for duration of attacks or days between attacks. There are probably no differences between anakinra and placebo with regards to injection site reaction, headache, presyncope, dyspnea and itching (narrative summary; moderate‐certainty evidence). For acute‐phase response, anakinra probably reduced C‐reactive protein (CRP) after four months (narrative summary; moderate‐certainty evidence). Canakinumab versus placebo Canakinumab probably reduces the number of participants experiencing an attack at 16 weeks (RR 0.41, 95% CI 0.26 to 0.65; 1 study, 63 colchicine‐resistant participants; moderate‐certainty evidence). There were no data for the duration of attacks or days between attacks. The included study reported the number of serious adverse events per 100 patient‐years was probably 42.7 with canakinumab versus 97.4 with placebo among people with colchicine‐resistant FMF (moderate‐certainty evidence). For acute‐phase response, canakinumab probably caused a higher proportion of participants to have a CRP level of 10 mg/L or less compared to placebo (68% with canakinumab versus 6% with placebo; 1 study, 63 participants; moderate‐certainty evidence). Colchicine single dose versus divided dose There is probably no difference in the duration of attacks at three months (MD −0.04 hours, 95% CI −10.91 to 10.83) or six months (MD 2.80 hours, 95% CI −5.39 to 10.99; moderate‐certainty evidence). There were no data for the number of participants experiencing an attack or days between attacks. There is probably no difference in adverse events (including anorexia, nausea, diarrhea, abdominal pain, vomiting and elevated liver enzymes) between groups (narrative summary; moderate‐certainty evidence). For acute‐phase response, there may be no evidence of a difference between groups (narrative summary; low‐ to moderate‐certainty evidence). Authors' conclusions There were limited RCTs assessing interventions for people with FMF. Based on the evidence, three times daily colchicine may reduce the number of people experiencing attacks, colchicine single dose and divided dose may not be different for children with FMF, canakinumab probably reduces the number of people experiencing attacks, and anakinra or canakinumab probably reduce CRP in colchicine‐resistant participants; however, only a few RCTs contributed data for analysis. Further RCTs examining active interventions, not only colchicine, are necessary before a comprehensive conclusion regarding the efficacy and safety of interventions for reducing inflammation in FMF can be drawn. Plain language summary Medicines for reducing inflammation in people with familial Mediterranean fever Review question Can treatments such as colchicine, anakinra, rilonacept, canakinumab, etanercept, infliximab, adalimumab, thalidomide, tocilizumab, interferon‐α and ImmunoGuard (a herbal supplement)) reduce inflammation in people with familial Mediterranean fever (FMF)? Background FMF is a hereditary inflammatory disease, with symptoms of an attack often including fever over 38 °C, pain and inflammation of the membrane surrounding the chest cavity, the joints or the lungs. We wanted to discover whether these medicines were better for reducing inflammation for people with FMF than placebo (a dummy treatment containing no active medicine) or no treatment, and also to compare these medicines with each other. Search date The evidence is current to 17 August 2021. Study characteristics The review included 10 studies with 312 people with FMF aged between three and 53 years. Eight studies compared five medicines, colchicine, rilonacept, ImmunoGuard, anakinra and canakinumab, with placebo. Participants received one medicine or placebo at random over one to four months. The remaining two studies compared colchicine 1 mg per day once daily with colchicine two or three times daily in children for six to eight months. Key results We aimed to report on the number of participants experiencing an attack, the timing of attacks, prevention of amyloid A amyloidosis (which is a reaction to a chronic inflammatory disease or infection leading to a build‐up of an abnormal protein called amyloid in organs and tissues throughout the body stopping them working properly), and any side effects of treatment and the levels of a number of markers of inflammation during an attack. Not all studies reported these outcomes. Given the differences in treatments and study design, it was not possible to combine any of the results that we did obtain from these studies. One study (15 participants) with oral colchicine 0.6 mg three times a day and another study (63 participants) with subcutaneous (under the skin) canakinumab 150 mg every four weeks for 16 weeks may help to reduce the numbers of people with attacks of FMF. However, oral colchicine 0.5 mg twice a day (20 participants), rilonacept (14 participants) or anakinra (25 participants) did not reduce the numbers of people with attacks. ImmunoGuard (24 participants) did not reduce levels of the markers of inflammation in the blood which are raised during the attack phase of FMF; these include the rate of fall of red blood cells when placed in a test tube, the white blood cell count and the presence of C‐reactive protein (a protein that is produced in the liver). Anakinra and canakinumab reduced C‐reactive protein levels. Colchicine taken once daily and two or three times daily might not result in different outcomes including the timing of attacks, sider effects of the medicine and acute‐phase response indicators. Quality of the evidence Four studies were well‐designed, while the others had some design problems that might have affected the results. Four studies did not report clearly how the people were assigned to each treatment group. Four studies did not report whether researchers, who assessed the study outcomes, knew which individuals were assigned to which treatment. Four studies did not clearly explain the reasons for people withdrawing from a study and one study had a high percentage of participants who did not complete study. We could not confirm whether each planned outcome was reported in five studies. Five studies did not report the severity of FMF in groups at the beginning of treatment. We judged the evidence for the reported outcomes to be of moderate to very low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Yin, X, Tian, F, Wu, B, Xu, T", "articleTypes": [], "doi": "10.1002/14651858.CD010893.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.784Z" }, { "id": "f187e4b3-5a40-466e-a2ab-d3b385b63c1b", "pmid": "", "title": "Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta‐analyses", "imported": false, "abstract": "Abstract - Background Tobacco smoking is the leading preventable cause of death and disease worldwide. Stopping smoking can reduce this harm and many people would like to stop. There are a number of medicines licenced to help people quit globally, and e‐cigarettes are used for this purpose in many countries. Typically treatments work by reducing cravings to smoke, thus aiding initial abstinence and preventing relapse. More information on comparative effects of these treatments is needed to inform treatment decisions and policies. Objectives To investigate the comparative benefits, harms and tolerability of different smoking cessation pharmacotherapies and e‐cigarettes, when used to help people stop smoking tobacco. Search methods We identified studies from recent updates of Cochrane Reviews investigating our interventions of interest. We updated the searches for each review using the Cochrane Tobacco Addiction Group (TAG) specialised register to 29 April 2022. Selection criteria We included randomised controlled trials (RCTs), cluster‐RCTs and factorial RCTs, which measured smoking cessation at six months or longer, recruited adults who smoked combustible cigarettes at enrolment (excluding pregnant people) and randomised them to approved pharmacotherapies and technologies used for smoking cessation worldwide (varenicline, cytisine, nortriptyline, bupropion, nicotine replacement therapy (NRT) and e‐cigarettes) versus no pharmacological intervention, placebo (control) or another approved pharmacotherapy. Studies providing co‐interventions (e.g. behavioural support) were eligible if the co‐intervention was provided equally to study arms. Data collection and analysis We followed standard Cochrane methods for screening, data extraction and risk of bias (RoB) assessment (using the RoB 1 tool). Primary outcome measures were smoking cessation at six months or longer, and the number of people reporting serious adverse events (SAEs). We also measured withdrawals due to treatment. We used Bayesian component network meta‐analyses (cNMA) to examine intervention type, delivery mode, dose, duration, timing in relation to quit day and tapering of nicotine dose, using odds ratios (OR) and 95% credibility intervals (CrIs). We calculated an effect estimate for combination NRT using an additive model. We evaluated the influence of population and study characteristics, provision of behavioural support and control arm rates using meta‐regression. We evaluated certainty using GRADE. Main results Of our 332 eligible RCTs, 319 (835 study arms, 157,179 participants) provided sufficient data to be included in our cNMA. Of these, we judged 51 to be at low risk of bias overall, 104 at high risk and 164 at unclear risk, and 118 reported pharmaceutical or e‐cigarette/tobacco industry funding. Removing studies at high risk of bias did not change our interpretation of the results. Benefits We found high‐certainty evidence that nicotine e‐cigarettes (OR 2.37, 95% CrI 1.73 to 3.24; 16 RCTs, 3828 participants), varenicline (OR 2.33, 95% CrI 2.02 to 2.68; 67 RCTs, 16,430 participants) and cytisine (OR 2.21, 95% CrI 1.66 to 2.97; 7 RCTs, 3848 participants) were associated with higher quit rates than control. In absolute terms, this might lead to an additional eight (95% CrI 4 to 13), eight (95% CrI 6 to 10) and seven additional quitters per 100 (95% CrI 4 to 12), respectively. These interventions appeared to be more effective than the other interventions apart from combination NRT (patch and a fast‐acting form of NRT), which had a lower point estimate (calculated additive effect) but overlapping 95% CrIs (OR 1.93, 95% CrI 1.61 to 2.34). There was also high‐certainty evidence that nicotine patch alone (OR 1.37, 95% CrI 1.20 to 1.56; 105 RCTs, 37,319 participants), fast‐acting NRT alone (OR 1.41, 95% CrI 1.29 to 1.55; 120 RCTs, 31,756 participants) and bupropion (OR 1.43, 95% CrI 1.26 to 1.62; 71 RCTs, 14,759 participants) were more effective than control, resulting in two (95% CrI 1 to 3), three (95% CrI 2 to 3) and three (95% CrI 2 to 4) additional quitters per 100 respectively. Nortriptyline is probably associated with higher quit rates than control (OR 1.35, 95% CrI 1.02 to 1.81; 10 RCTs, 1290 participants; moderate‐certainty evidence), resulting in two (CrI 0 to 5) additional quitters per 100. Non‐nicotine/placebo e‐cigarettes (OR 1.16, 95% CrI 0.74 to 1.80; 8 RCTs, 1094 participants; low‐certainty evidence), equating to one additional quitter (95% CrI ‐2 to 5), had point estimates favouring the intervention over control, but CrIs encompassed the potential for no difference and harm. There was low‐certainty evidence that tapering the dose of NRT prior to stopping treatment may improve effectiveness; however, 95% CrIs also incorporated the null (OR 1.14, 95% CrI 1.00 to 1.29; 111 RCTs, 33,156 participants). This might lead to an additional one quitter per 100 (95% CrI 0 to 2). Harms There were insufficient data to include nortriptyline and non‐nicotine EC in the final SAE model. Overall rates of SAEs for the remaining treatments were low (average 3%). Low‐certainty evidence did not show a clear difference in the number of people reporting SAEs for nicotine e‐cigarettes, varenicline, cytisine or NRT when compared to no pharmacotherapy/e‐cigarettes or placebo. Bupropion may slightly increase rates of SAEs, although the CrI also incorporated no difference (moderate certainty). In absolute terms bupropion may cause one more person in 100 to experience an SAE (95% CrI 0 to 2). Authors' conclusions The most effective interventions were nicotine e‐cigarettes, varenicline and cytisine (all high certainty), as well as combination NRT (additive effect, certainty not rated). There was also high‐certainty evidence for the effectiveness of nicotine patch, fast‐acting NRT and bupropion. Less certain evidence of benefit was present for nortriptyline (moderate certainty), non‐nicotine e‐cigarettes and tapering of nicotine dose (both low certainty). There was moderate‐certainty evidence that bupropion may slightly increase the frequency of SAEs, although there was also the possibility of no increased risk. There was no clear evidence that any other tested interventions increased SAEs. Overall, SAE data were sparse with very low numbers of SAEs, and so further evidence may change our interpretation and certainty. Future studies should report SAEs to strengthen certainty in this outcome. More head‐to‐head comparisons of the most effective interventions are needed, as are tests of combinations of these. Future work should unify data from behavioural and pharmacological interventions to inform approaches to combined support for smoking cessation. Plain language summary How effective are medications and e‐cigarettes for quitting smoking, and what works best? Key messages Some medicines and e‐cigarettes (handheld devices that work by heating liquid that usually contains nicotine and flavourings) can help people to quit smoking for six months or longer. E‐cigarettes, and the medicines cytisine (otherwise known as Tabex) and varenicline (otherwise known as Chantix and Champix), appear to help the most people to quit smoking, followed by using two types of nicotine replacement therapy at once (nicotine patch and another type, such as gum or lozenge). We need more evidence on possible long‐term harms of e‐cigarettes and medicines to help people quit smoking, but there were very low numbers of serious harms found. Stopping smoking Tobacco smoking is bad for people's health and stopping can lead to significant improvements. Most people would like to quit smoking and there are medicines and e‐cigarettes available to help people to do that. These medicines are called nicotine replacement therapy, cytisine, varenicline, bupropion (sometimes known as Zyban or Wellbutrin) and nortriptyline (sometimes known as Norpress). Nortriptyline is only available for quitting smoking in New Zealand, and cytisine is not available in many countries. At time of writing, there are shortages of varenicline due to a manufacturing issue. These medicines and e‐cigarettes can be provided alongside behavioural support, such as counselling. Stop smoking medications and e‐cigarettes are designed to reduce people's craving to smoke. By finding out more information on how these treatments compare to each other, we hope this review will be used to decide the best treatments to help people stop smoking. Why we did this Cochrane Review We wanted to find out: ‐ which treatments (medicines and e‐cigarettes) help people to stop smoking; ‐ how these treatments compare to each other; ‐ whether there are ways of providing these treatments that mean they are more likely to help people stop smoking (e.g. different doses or treatment lengths); ‐ whether these treatments are likely to cause serious harms; and ‐ whether certain treatments are better tolerated, as indicated by fewer people leaving a study due to treatment. What did we do? We searched for studies that looked at these treatments to help adults quit smoking. We looked for randomised controlled trials, where the treatments people received were decided at random. This type of study usually gives the most reliable evidence about the effects of treatments. We compared all treatments with each other using a method called network meta‐analysis. Search date: 29 April 2022 What we found We found 332 studies that met our criteria and 319 of these provided information that we could use in our analyses. These included 157,179 adults who smoked tobacco cigarettes. Most of the studies took place in the USA or Europe. The studies compared the effects of the stop smoking treatments listed above with: ‐ no medicine/e‐cigarettes for stopping smoking; ‐ e‐cigarettes that did not contain nicotine; ‐ placebo (a dummy medication); and ‐ other types of stop smoking medicine or e‐cigarettes. What are the main results of our review? E‐cigarettes, varenicline and cytisine were most likely to help people quit smoking. For every 100 people, 10 to 19 are likely to quit using an e‐cigarette; 12 to 16 using varenicline; and 10 to 18 using cytisine. This is compared to the 6 in 100 people likely to quit when using no medicine/e‐cigarette or placebo. People using two forms of nicotine replacement therapy at the same time, for example, a combination of nicotine patch and nicotine gum, seemed to have similar rates of quitting to people using e‐cigarettes, varenicline and cytisine. Nicotine patches alone, another form of nicotine replacement therapy alone (such as gum, lozenge) and bupropion appeared to help fewer people quit but still work better than no medicine/e‐cigarette or placebo (8, 9 and 9 people per 100, respectively). Nortriptyline appeared to result in the lowest number of people quitting smoking; for every 100 people using nortriptyline 6 to 11 are likely to quit. We are moderately confident that bupropion could rarely cause some serious health effects. The information we have for other treatments does not provide clear evidence of serious harms. For all treatments, findings suggest very few people experience serious harms when using them. How confident are we in our results? We are confident that e‐cigarettes, cytisine, varenicline, nicotine replacement therapy and bupropion help people stop smoking. We do not expect more evidence will change these results. However, more evidence on how these treatments compare to one another, particularly in relation to harms, would be useful. Due to the nature of our analyses we were not able to judge our confidence in the evidence for combination nicotine replacement therapy (two types used together). We are moderately confident that nortriptyline also helps people to stop smoking, but are less confident in our results for non‐nicotine e‐cigarettes and for potential harms of most of the treatments. We still need more evidence on potential harms and hope more studies will report on these in future; however, nicotine replacement therapy has been used since the 1980s with no evidence of serious harms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Lindson, N; Theodoulou, A; Ordóñez-Mena, JM; Fanshawe, TR; Sutton, AJ; Livingstone-Banks, J; Hajizadeh, A; Zhu, S; Aveyard, P; Freeman, SC; Agrawal, S; Hartmann-Boyce, J", "articleTypes": [], "doi": "10.1002/14651858.CD015226.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "f18cbb54-ae2c-46be-8f4f-c437bcbe17b1", "pmid": "", "title": "Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)", "imported": false, "abstract": "Abstract - Background Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five‐year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis. Objectives To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions. Search methods We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi‐randomised trials. The reference lists of relevant articles were also searched. Selection criteria All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded. Data collection and analysis Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author. Main results A total of 40 randomised or quasi‐randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials. For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn. For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights. Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects. Authors' conclusions There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials. Plain language summary Drug treatment for children with bedwetting (nocturnal enuresis) but not including the drug types desmopressin or tricyclics Bedwetting (nocturnal enuresis) is the involuntary loss of urine at night without an underlying organic disease as the cause. It can result in social problems, sibling teasing and lowered self esteem. It affects around 15% to 20% of five‐year olds, and up to 2% of adults. Many different types of drugs have been used to treat children with bed wetting. There is not enough reliable evidence to show that drugs other than desmopressin or tricyclics reduce bedwetting in children during treatment when used in isolation, despite their risk of unwanted side effects. In other Cochrane reviews, alarms triggered by wetting, desmopressin and tricyclic drugs have been shown to work during treatment. However, alarms have a more sustained effect than desmopressin and tricyclics after treatment has finished. The adverse effects of alarm therapy (tiredness and waking other members of the family) are relatively benign and self limiting compared with the adverse effects of drugs. One class of drugs (anticholinergic drugs) appears to improve the efficacy of other established treatments such as tricyclics, bedwetting alarms and desmopressin. The cost of treating children with bedwetting with alarm therapy or drugs may vary in different countries.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Deshpande, AV, Caldwell, PHY, Sureshkumar, P", "articleTypes": [], "doi": "10.1002/14651858.CD002238.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.794Z" }, { "id": "f19250d1-a98e-4206-8dfb-c549b6101c13", "pmid": "", "title": "Antibiotics versus placebo for acute bacterial conjunctivitis", "imported": false, "abstract": "Abstract - Background Acute bacterial conjunctivitis is an infection of the conjunctiva and is one of the most common ocular disorders in primary care. Antibiotics are generally prescribed on the basis that they may speed recovery, reduce persistence, and prevent keratitis. However, many cases of acute bacterial conjunctivitis are self‐limited, resolving without antibiotic therapy. This Cochrane Review was first published in The Cochrane Library in 1999, then updated in 2006, 2012, and 2022. Objectives To assess the benefits and side effects of antibiotic therapy in the management of acute bacterial conjunctivitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2022, Issue 5), MEDLINE (January 1950 to May 2022), Embase (January 1980 to May 2022), the meta Register of Controlled Trials ( m RCT) ( www.controlled-trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ), and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases in May 2022. Selection criteria We included randomized controlled trials (RCTs) in which any form of antibiotic treatment, with or without steroid, had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical and systemic antibiotic treatments. Data collection and analysis Two authors independently reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies and determined the included RCTs, which were further assessed for risk of bias using Cochrane methodology. We performed data extraction in a standardized manner and conducted random‐effects meta‐analyses using RevMan Web. Main results We included 21 eligible RCTs, 10 of which were newly identified in this update. A total of 8805 participants were randomized. All treatments were topical in the form of drops or ointment. The trials were heterogeneous in terms of their eligibility criteria, the nature of the intervention (antibiotic drug class, which included fluoroquinolones [FQs] and non‐FQs; dosage frequency; duration of treatment), the outcomes assessed and the time points of assessment. We judged one trial to be of high risk of bias, four as low risk of bias, and the others as raising some concerns. Based on intention‐to‐treat (ITT) population, antibiotics likely improved clinical cure (resolution of clinical symptoms or signs) by 26% (RR 1.26, 95% CI 1.09 to 1.46; 5 trials, 1474 participants; moderate certainty) as compared with placebo. Subgroup analysis showed no differences by antibiotic class (P = 0.67) or treatment duration (P = 0.60). In the placebo group, 55.5% (408/735) of participants had spontaneous clinical resolution by days 4 to 9 versus 68.2% (504/739) of participants treated with an antibiotic. Based on modified ITT population, in which participants were analyzed after randomization on the basis of positive microbiological culture, antibiotics likely increased microbiological cure (RR 1.53, 95% CI 1.34 to 1.74; 10 trials, 2827 participants) compared with placebo at the end of therapy; there were no subgroup differences by drug class (P = 0.60). No study evaluated the cost‐effectiveness of antibiotic treatment. Patients receiving antibiotics had a lower risk of treatment incompletion than those in the placebo group (RR 0.64, 95% CI 0.52 to 0.78; 13 trials, 5573 participants; moderate certainty) and were 27% less likely to have persistent clinical infection (RR 0.73, 95% CI 0.65 to 0.81; 19 trials, 5280 participants; moderate certainty). There was no evidence of serious systemic side effects reported in either the antibiotic or placebo group (very low certainty). When compared with placebo, FQs (RR 0.70, 95% CI 0.54 to 0.90) but not non‐FQs (RR 4.05, 95% CI 1.36 to 12.00) may result in fewer participants with ocular side effects. However, the estimated effects were of very low certainty. Authors' conclusions The findings of this update suggest that the use of topical antibiotics is associated with a modestly improved chance of resolution in comparison to the use of placebo. Since no evidence of serious side effects was reported, use of antibiotics may therefore be considered to achieve better clinical and microbiologic efficacy than placebo. Increasing the proportion of participants with clinical cure or increasing the speed of recovery or both are important for individual return to work or school, allowing people to regain quality of life. Future studies may examine antiseptic treatments with topical antibiotics for reasons of cost and growing antibiotic resistance. Plain language summary What are the benefits and harms of antibiotics for acute bacterial conjunctivitis? Key messages Topical antibiotics may improve signs and symptoms as well as bacterial clearance in participants with acute bacterial conjunctivitis. However, some antibiotics can cause unwanted effects on the eyes or eyelids; no evidence suggests that antibiotics cause unwanted effects in other parts of the body. What is acute bacterial conjunctivitis? Acute bacterial conjunctivitis is a condition in which the thin layer over the white areas and the inside lining of the eyelids of one or both eyes becomes red and inflamed from a bacterial infection. Acute bacterial conjunctivitis is usually contagious and hence children and working adults are advised to avoid going to school or work when affected. Fortunately, it resolves spontaneously in most cases. How is acute bacterial conjunctivitis treated? People with acute bacterial conjunctivitis are often given treatment at the site of the infection, usually as antibiotic eye drops or ointment, to speed recovery. However, the benefits of antibiotics have been questioned when considering they can cause irritation or allergic reaction in and around the eyes or surrounding skin. What did we want to find out? We examined whether antibiotics alone or in combination with steroid, can improve signs and symptoms of conjunctivitis or help clear the associated bacteria. We also evaluated whether antibiotics would result in undesirable effects on the eyes. What did we do? We performed a systematic review by searching for studies that compared antibiotics in eyedrop, ointment, or tablet form with inactive controls. We summarized these study findings and reported the results together with our level of confidence in them based on how studies were conducted. What did we find? We found that antibiotics likely increase clinical cure and microbiological cure after a course of treatment in comparison with placebo. Antibiotic use also is associated with fewer participants stopping their treatment earlier than they are supposed to. However, for some individuals, non‐fluroquinolone but not fluoroquinolone antibiotics, may result in more unwanted effects on the eyes or eyelids than placebo though we were very uncertain about the relevant evidence. There was no evidence that antibiotics were associated with systemic side effects such as headache or altered sense of smell. What are the limitations of the evidence? The current update focused on adults and children aged one month or older. Therefore, the evidence does not pertain to antibiotic treatment for neonatal conjunctivitis in neonates younger than one month old. We did not find studies that compared effects of the same antibiotics used in short versus long duration. Therefore, the current review was unable to suggest for or against the prescription duration for acute bacterial conjunctivitis. How up‐to‐date is this evidence? The evidence is up‐to‐date as of April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Chen, Y-Y, Liu, A-HS, Nurmatov, U, van Schayck, OCP, Kuo, IC", "articleTypes": [], "doi": "10.1002/14651858.CD001211.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.782Z" }, { "id": "f1a5de9e-0618-4441-be64-b109a10e9568", "pmid": "", "title": "The Effect of Omega Galil Hazelnut Chocolate Spread \"O'Sweet Spread\" With 80% Reduced Sucrose on Glucose Response of People With TID - a Randomized, Double-blind, Active Control Trial", "imported": false, "abstract": "Omega Galil has developed a novel fatty sweetener that allows the use of up to 80% less sugar (particularly sucrose) and yet achieves a natural sweet flavor, using a novel technology of milling the natural sucrose crystals together with oil and thus creating a micro-suspension of sugar in oil or fat. The suspension increases the surface area of the sugar particles and thus a lower quantity of sugar is required in order to reach an enhanced perception of sweetness at the sweet taste receptors in the mouth. Omega Galil provides fatty food products that use up to 80% less sucrose, while tasting as sweet as regular sugar sweetened foods, with no aftertastes of sugar substitutes, and no chemical modifications or additives.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.156Z" }, { "id": "f1b026d2-05d9-4b38-8d1d-6226c330b9c9", "pmid": "", "title": "Community‐based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries", "imported": false, "abstract": "Abstract - Background Supplementary feeding is defined as the provision of extra food to children or families beyond the normal ration of their home diets. The impact of food supplementation on child growth merits careful evaluation in view of the reliance of many states and non‐governmental organisations on this intervention to improve child health in low and middle income countries (LMIC). This is an update of a Cochrane review first published in 2005. Objectives To evaluate the effectiveness of community‐based supplementary feeding for promoting the physical growth of children under five years of age in LMIC. Search methods For this updated review we searched the following databases on 31 January 2011: CENTRAL ( The Cochrane Library ), MEDLINE (1948 to January week 3, 2011), EMBASE (1980 to week 3, 2011), CINAHL (1937 to 27 January 2011), LILACS (all years), WorldCat for dissertations and theses (all years) and ClinicalTrials.gov (all years). Selection criteria Randomised controlled trials (RCTs) evaluating supplementary feeding in comparison to a control group (no intervention or a placebo such as food with a very low number of nutrients and calories) in children from birth to five years of age in LMIC. Data collection and analysis Two review authors independently extracted and analysed the data. Main results We included eight RCTs (n = 1243 children) that were at relatively high risk of bias. We found high levels of clinical heterogeneity in the participants, interventions and outcome measures across studies. Nevertheless, in order to quantify pooled effects of supplementary feeding, we decided to combine studies according to prespecified characteristics. These were the children's age (younger or older than 24 months), their nutritional status at baseline (stunted or wasted, or not stunted or wasted) and the duration of the intervention (less or more than 12 months). A statistically significant difference of effect was only found for length during the intervention in children aged less than 12 months (two studies; 795 children; mean difference 0.19 cm; 95% confidence interval (CI) 0.07 to 0.31). Based on the summary statistic calculated for each study, the mean difference (MD) between intervention and control groups ranged from 0.48 cm (95% CI 0.07 to 0.89) to 1.3 cm (95% CI 0.03 to 2.57) after 3 and 12 months of intervention, respectively. Data on potential adverse effects were lacking. Authors' conclusions The scarcity of available studies and their heterogeneity makes it difficult to reach any firm conclusions. The review findings suggest supplementary feeding has a negligible impact on child growth; however, the pooled results should be interpreted with great caution because the studies included in the review are clinically diverse. Future studies should address issues of research design, including sample size calculation, to detect meaningful clinical effects and adequate intervention allocation concealment. In the meantime, families and children in need should be provided appropriate feeding, health care and sanitation without waiting for new RCTs to establish a research basis for feeding children. Plain language summary Providing extra food for children under five years of age in low and middle income countries Undernutrition is one of the underlying causes of childhood illness and death in low‐ and middle‐income countries. Providing extra food to children or families beyond what they normally have at home is an intervention aimed at supporting the nutritional wellbeing of the target population. We included eight studies where the participants were randomly assigned to two groups: one group received the extra food and the other group was a control, either receiving no food or food with very low nutritional content. Although the impact of supplementary feeding on child growth appeared to be negligible, it is not possible to draw any conclusions until we have studies that involve larger numbers and do not allow assessors to know who is receiving the intervention. Although it is difficult to determine whether community‐based supplementary feeding helps to promote the growth of children from birth to five years in low‐ and middle‐income countries, it is obviously vital to continue to provide food, health care and sanitation to those who need them.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Sguassero, Y, de Onis, M, Bonotti, AM, Carroli, G", "articleTypes": [], "doi": "10.1002/14651858.CD005039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.808Z" }, { "id": "f1b13228-1070-4589-a894-590d6002cc4e", "pmid": "", "title": "Nedocromil sodium for chronic asthma in children", "imported": false, "abstract": "Abstract - Background Currently inhaled corticosteroids are the main stay in the maintenance treatment of chronic asthma in children. Although inhaled corticosteroids play a crucial role in the management of childhood asthma, the long‐term side effects of inhaled corticosteroids used in the management of chronic asthma in children are not clearly known. Objectives The objective of this review is to compare the safety and efficacy of inhaled nedocromil sodium with placebo in the treatment of chronic asthma in children. Search methods We searched the Cochrane Airway Group trials register, review articles, and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. We also searched abstracts of major respiratory society meetings. The last search was carried out in November 2009. Selection criteria Randomised placebo controlled trials comparing nedocromil sodium to placebo in the treatment of chronic asthma in children (0 to 18 years). Data collection and analysis Both authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Fifteen trials (twelve parallel group studies; three crossover trials recruiting 1422 children (837 males and 585 females)) were included. The studies were generally of good methodological quality. Two large long term studies used nedocromil for six months and four to six years and showed conflicting results in symptom free days. Short term studies (duration between 4 weeks to 12 weeks) showed that nedocromil sodium produced some improvement in a number of efficacy measures compared to placebo including FEV 1 , FVC, FEV 1 % predicted, PC20 FEV 1 , evening PEF and symptom scores. The parent's assessment of efficacy was in favour of nedocromil (odds ratio (OR) 0.5 (95% CI 0.3 to 0.8). Nedocromil sodium has a good safety profile. The only significant side effect observed was unpleasant taste. There was little evidence for a clinically dose response effect and only a few studies recruited participants with severe asthma. Authors' conclusions A limited number of small studies have shown that nedocromil is of benefit in improving lung function and some measures of symptoms, but the evidence with regard to the primary outcome of the review was conflicting. Two long‐term trials did not show consistent effects on lung function outcomes, whereas several small short‐term trials have shown benefit in these outcomes. Differing severities at baseline may explain this difference with milder participants experiencing less benefit, although the discrepancy between study findings may also reflect publication bias. Nedocromil sodium is associated with a very good safety profile with no significant short term or long‐ term adverse side effects. Although nedocromil may have advantages over inhaled corticosteroids in terms of side effects, there is a need for head to head trials of nedocromil and inhaled corticosteroids to establish whether asthma control is similar, especially in mild asthma. It is not yet clear where nedocromil should sit in relation to other therapies in the treatment of asthma in children. Plain language summary Nedocromil sodium for chronic asthma in children Nedocromil (or Tilade) is a 'preventer' therapy used to treat chronic asthma in children. It is thought to be safer than inhaled steroids and can be used for the management of mild to moderate asthma. The review of studies including 15 trials and 1422 children found that there were some encouraging results in short term studies when nedocromil was compared on its own with placebo, particularly with regard to lung function tests. However, these results were not confirmed in one large, longer term study of four to six years duration, which did not show significant difference in the primary outcome of symptom free days. This study was conducted in children who had mild asthma. There may be a role for nedocromil in the management of moderate asthma, but it should be assessed in relation to inhaled steroids, whose efficacy is well‐established. This particularly important in symptomatic asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Sridhar, AV; McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD004108.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "f1b779b4-90bd-4b21-bad2-438a5bf5f42e", "pmid": "", "title": "Interventions for cleaning dentures in adults", "imported": false, "abstract": "Abstract - Background Removing denture plaque may be essential for maintaining the oral health of edentulous people. Brushing and soaking in chemical products are two of the most commonly used methods of cleaning dentures. Objectives To evaluate the effectiveness and safety of different methods for cleansing removable dentures. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to May 2009); CENTRAL ( The Cochrane Library 2009, Issue 2); MEDLINE (1965 to May 2009); EMBASE (1980 to May 2009); LILACS (1980 to May 2009); and CINAHL (1997 to May 2009). There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing any mechanical method (e.g. brushing or ultrasound) or chemical (e.g. enzymes, sodium hypochlorite, oral rinses or peroxide solutions) in adults over the age of 18 wearing removable partial dentures or complete dentures. The primary outcomes considered were the health of denture bearing areas (soft tissues, periodontal tissues and teeth) and participants' satisfaction and preference. Secondary outcomes included denture plaque coverage area, indicators of halitosis and microbial counts on abutment teeth, soft tissues or denture base or saliva. Data collection and analysis Two independent review authors screened and extracted information from, and independently assessed the risk of bias in the included trials. Main results Although six RCTs were included in this review, the wide range of different interventions and outcome variables did not permit pooling of data in a meta‐analysis. Isolated reports indicated that chemicals and brushing appear to be more effective than placebo in the reduction of plaque coverage and microbial counts of anaerobes and aerobes on complete denture bases. Authors' conclusions There is a lack of evidence about the comparative effectiveness of the different denture cleaning methods considered in this review. Few well designed RCTs were found. Future research should focus on comparisons between mechanical and chemical methods; the assessment of the association of methods, primary variables and costs should also receive future attention. Plain language summary Interventions for cleaning dentures in adults Plaque formed on the surfaces of removable dentures can have a significant impact on oral health, as long as it can lead to infection of denture‐supporting mucosa (stomatitis), gum inflammation (gingivitis) and tooth decay. Denture plaque can be removed by several different methods which include: brushing with paste, soaking in chemicals (e.g. effervescent tablets or bleach) and using special devices (a microwave oven or ultrasonic device). This review found weak evidence in support of soaking of dentures in effervescent tablets or enzymatic solutions and that brushing with paste can remove plaque and kill microbes better than inactive treatments. It is, however, unclear which is the most effective and there is a paucity of data on the use of alternative methods. Futures studies should aim to provide reliable information about which method is more effective in maintaining oral health of removable denture wearers. The scarce data found was restricted to the cleansing of complete dentures made from an acrylic resin base. Further research should also investigate how removable partial dentures can be cleaned, and in particular on the corrosive effects of cleaners on their metallic components.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "de Souza, RF; de Freitas Oliveira Paranhos, H; Lovato da Silva, CH; Abu‐Naba'a, L; Fedorowicz, Z; Gurgan, CA", "articleTypes": [], "doi": "10.1002/14651858.CD007395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "f1bc4bf7-1462-48af-8006-2bf7ac80d15e", "pmid": "", "title": "Study of the Effect of Lactisole on the Responses to Intragastric Glucose Solution", "imported": false, "abstract": "The purpose of the study is to determine whether the sweet taste receptors in the gut are involved in sensing sweet substances and controlling appetite and the amount we eat. Lactisole is a substance commonly used in food products to reduce the perceived sweetness of certain sugars and sweeteners. The aim of this study is to investigate whether the responses to a glucose solution, intragastrically administered to healthy male and female volunteers, is affected by the presence of lactisole in the gut. Understanding the mechanisms by which nutrients are initially detected in the gut and how they influence food intake is critical to the development of novel food products that could reduce food consumption.", "journal": "", "year": "2010", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.259Z" }, { "id": "f1bde5c3-25b5-4507-a5be-e0737f063058", "pmid": "", "title": "Interventions for treating acute high altitude illness", "imported": false, "abstract": "Abstract - Background Acute high altitude illness is defined as a group of cerebral and pulmonary syndromes that can occur during travel to high altitudes. It is more common above 2500 metres, but can be seen at lower elevations, especially in susceptible people. Acute high altitude illness includes a wide spectrum of syndromes defined under the terms 'acute mountain sickness' (AMS), 'high altitude cerebral oedema' and 'high altitude pulmonary oedema'. There are several interventions available to treat this condition, both pharmacological and non‐pharmacological; however, there is a great uncertainty regarding their benefits and harms. Objectives To assess the clinical effectiveness, and safety of interventions (non‐pharmacological and pharmacological), as monotherapy or in any combination, for treating acute high altitude illness. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science, CINAHL, Wanfang database and the World Health Organization International Clinical Trials Registry Platform for ongoing studies on 10 August 2017. We did not apply any language restriction. Selection criteria We included randomized controlled trials evaluating the effects of pharmacological and non‐pharmacological interventions for individuals suffering from acute high altitude illness: acute mountain sickness, high altitude pulmonary oedema or high altitude cerebral oedema. Data collection and analysis Two review authors independently assessed the eligibility of study reports, the risk of bias for each and performed the data extraction. We resolved disagreements through discussion with a third author. We assessed the quality of evidence with GRADE. Main results We included 13 studies enrolling a total of 468 participants. We identified two ongoing studies. All studies included adults, and two studies included both teenagers and adults. The 13 studies took place in high altitude areas, mostly in the European Alps. Twelve studies included participants with acute mountain sickness, and one study included participants with high altitude pulmonary oedema. Follow‐up was usually less than one day. We downgraded the quality of the evidence in most cases due to risk of bias and imprecision. We report results for the main comparisons as follows. Non‐pharmacological interventions (3 studies, 124 participants) All‐cause mortality and complete relief of AMS symptoms were not reported in the three included trials. One study in 64 participants found that a simulated descent of 193 millibars versus 20 millibars may reduce the average of symptoms to 2.5 vs 3.1 units after 12 hours of treatment (clinical score ranged from 0 to 11 ‒ worse; reduction of 0.6 points on average with the intervention; low quality of evidence). In addition, no complications were found with use of hyperbaric chambers versus supplementary oxygen (one study; 29 participants; low‐quality evidence). Pharmacological interventions (11 trials, 375 participants) All‐cause mortality was not reported in the 11 included trials. One trial found a greater proportion of participants with complete relief of AMS symptoms after 12 and 16 hours when dexamethasone was administered in comparison with placebo (47.1% versus 0%, respectively; one study; 35 participants; low quality of evidence). Likewise, when acetazolamide was compared with placebo, the effects on symptom severity was uncertain (standardized mean difference (SMD) −1.15, 95% CI −2.56 to 0.27; 2 studies, 25 participants; low‐quality evidence). One trial of dexamethasone in comparison with placebo in 35 participants found a reduction in symptom severity (difference on change in the AMS score: 3.7 units reported by authors; moderate quality of evidence). The effects from two additional trials comparing gabapentin with placebo and magnesium with placebo on symptom severity at the end of treatment were uncertain. For gabapentin versus placebo: mean visual analogue scale (VAS) score of 2.92 versus 4.75, respectively; 24 participants; low quality of evidence. For magnesium versus placebo: mean scores of 9 and 10.3 units, respectively; 25 participants; low quality of evidence). The trials did not find adverse events from either treatment (low quality of evidence). One trial comparing magnesium sulphate versus placebo found that flushing was a frequent event in the magnesium sulphate arm (percentage of flushing: 75% versus 7.7%, respectively; one study; 25 participants; low quality of evidence). Authors' conclusions There is limited available evidence to determine the effects of non‐pharmacological and pharmacological interventions in treating acute high altitude illness. Low‐quality evidence suggests that dexamethasone and acetazolamide might reduce AMS score compared to placebo. However, the clinical benefits and harms related to these potential interventions remain unclear. Overall, the evidence is of limited practical significance in the clinical field. High‐quality research in this field is needed, since most trials were poorly conducted and reported. Plain language summary Treatments for high altitude (mountain) illness Background Acute high altitude illness, also known as acute mountain sickness, may present with a variety of symptoms. It is caused by the decreasing level of oxygen at increasingly high altitudes; and it can be experienced when reaching a high altitude when travelling, hiking or climbing mountains or other elevated areas. People going to altitudes over 4000 metres, females, people younger than mid‐adulthood , and people with a history of migraine are at greater risk of suffering from altitude sickness. The most common symptoms are headache, loss of appetite , insomnia, and nausea. However, severe forms can include confusion, difficulty walking, progressive cough, shortness of breath, and even death. Review question What are the benefits and risks of different treatments for people suffering from high altitude illness? Study characteristics We included 13 studies with a total of 468 participants. Most studies included participants with mild or moderate forms of mountain sickness, and only one study included the severe neurological (disorder of the nervous system) form. Follow‐up was usually less than one day. We also identified two ongoing studies. Key results We found studies evaluating the following interventions: simulated descent with a hyperbaric chamber (medical use of oxygen in a special chamber at greater than atmospheric pressure to increase the availability of oxygen in the body); oxygen; medicines: acetazolamide, dexamethasone, ibuprofen, paracetamol, gabapentin, sumatriptan, nitric oxide, and magnesium sulphate. None of the studies reported the effects of these interventions on all‐cause mortality. The report of complete relief from acute mountain sickness symptoms, and adverse events was infrequent. Studies related to simulated descent with the use of a hyperbaric chamber did not find additional benefits or harms related to this intervention (3 studies, 124 participants). In addition, studies related to administration of medicines found some benefits in terms of reduction of symptoms with the use of acetazolamide (2 studies, 25 participants), and dexamethasone (1 study, 35 participants), without an increase in side effects. Quality of the evidence The quality of the evidence we found was low, and thus our certainty in the findings is limited. There was insufficient information on how the studies were conducted, and in some cases there was evidence of tampering at some stages of the trials. Furthermore, the number of persons in each study was very small (< 30 participants), and therefore the results were not clear (imprecise). Some studies were not blinded (that is, participants knew what experimental treatment they were receiving), and this could have affected how the participants evaluated their own symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Simancas‐Racines, D, Arevalo‐Rodriguez, I, Osorio, D, Franco, JVA, Xu, Y, Hidalgo, R", "articleTypes": [], "doi": "10.1002/14651858.CD009567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.758Z" }, { "id": "f1c4b5ce-cba8-45f6-9f5a-6aae5b48f366", "pmid": "", "title": "Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery", "imported": false, "abstract": "Abstract - Background In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete. Objectives To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Date of the last search: 20 November 2014. Selection criteria Randomised and quasi‐randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention. Data collection and analysis Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta‐analyses were performed on available and relevant data. Main results Of the 16 identified trials, four (112 participants) were eligible for inclusion. Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon‐aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post‐operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re‐intervention was not reported by either trial. Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re‐intervention). In one trial a high‐dose rFVIIa regimen (90 μg/kg) was compared with a low‐dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety. Authors' conclusions There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well‐designed randomised controlled trials would be needed, in particular to address the cost‐effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies. Plain language summary Preventing bleeding in people with congenital bleeding disorders during and after surgery In haemophilia and other congenital bleeding disorders blood does not clot properly, which can cause excessive bleeding. This is particularly relevant during surgery, when the risk of bleeding depends on the type and severity of the clotting disorder and on the type of surgery. Therefore, during and after surgery, these individuals should receive treatment to improve the ability of their blood to clot and so prevent bleeding. Clotting factor concentrates (when available and appropriate in those individuals missing specific clotting proteins) or other non‐specific drugs for clotting, or a combination of both, are administered. It is not known what is the optimal dose or duration or method of administration of these treatments in these circumstances. We searched for randomised controlled trials comparing the efficacy (mortality, blood loss, need for re‐intervention, subjective assessment of efficacy, duration and dose of therapy) and the safety of any type of treatment given to people with congenital bleeding disorders during any type of surgery. We found four trials to be included in this review. Two trials evaluated 59 people with haemophilia A or B receiving antifibrinolytic drugs (agents that reduce the breakdown of clots) or placebo in addition to the initial standard treatment before dental extractions. The remaining two trials evaluated 53 people with haemophilia A or B and inhibitors (antibodies that act against the factor concentrate therapy) receiving an different clotting concentrate, recombinant activated factor VII, both during and after surgery. These two trials evaluated different treatment options: high‐dose compared with low‐dose and a single large (bolus) infusion compared with continuous infusion. The trials included in this review provide some information in two specific situations in people with congenital bleeding disorders undergoing surgery. However, on the whole, there is not enough evidence from trials to define the best treatments for the various types of disease and types of surgery. Further trials would be useful to improve our knowledge but are difficult to carry out and currently do not appear to be a clinical priority. Indeed, both major and minor surgery are safely performed in clinical practice in these individuals based on local experience and data from uncontrolled studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Coppola, A; Windyga, J; Tufano, A; Yeung, C; Di Minno, MND", "articleTypes": [], "doi": "10.1002/14651858.CD009961.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "f1c8b3a5-0801-4845-b030-9e39943b7819", "pmid": "", "title": "Antibody tests for identification of current and past infection with SARS‐CoV‐2", "imported": false, "abstract": "Abstract - Background The diagnostic challenges associated with the COVID‐19 pandemic resulted in rapid development of diagnostic test methods for detecting SARS‐CoV‐2 infection. Serology tests to detect the presence of antibodies to SARS‐CoV‐2 enable detection of past infection and may detect cases of SARS‐CoV‐2 infection that were missed by earlier diagnostic tests. Understanding the diagnostic accuracy of serology tests for SARS‐CoV‐2 infection may enable development of effective diagnostic and management pathways, inform public health management decisions and understanding of SARS‐CoV‐2 epidemiology. Objectives To assess the accuracy of antibody tests, firstly, to determine if a person presenting in the community, or in primary or secondary care has current SARS‐CoV‐2 infection according to time after onset of infection and, secondly, to determine if a person has previously been infected with SARS‐CoV‐2. Sources of heterogeneity investigated included: timing of test, test method, SARS‐CoV‐2 antigen used, test brand, and reference standard for non‐SARS‐CoV‐2 cases. Search methods The COVID‐19 Open Access Project living evidence database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) was searched on 30 September 2020. We included additional publications from the Evidence for Policy and Practice Information and Co‐ordinating Centre (EPPI‐Centre) ‘COVID‐19: Living map of the evidence’ and the Norwegian Institute of Public Health ’NIPH systematic and living map on COVID‐19 evidence’. We did not apply language restrictions. Selection criteria We included test accuracy studies of any design that evaluated commercially produced serology tests, targeting IgG, IgM, IgA alone, or in combination. Studies must have provided data for sensitivity, that could be allocated to a predefined time period after onset of symptoms, or after a positive RT‐PCR test. Small studies with fewer than 25 SARS‐CoV‐2 infection cases were excluded. We included any reference standard to define the presence or absence of SARS‐CoV‐2 (including reverse transcription polymerase chain reaction tests (RT‐PCR), clinical diagnostic criteria, and pre‐pandemic samples). Data collection and analysis We use standard screening procedures with three reviewers. Quality assessment (using the QUADAS‐2 tool) and numeric study results were extracted independently by two people. Other study characteristics were extracted by one reviewer and checked by a second. We present sensitivity and specificity with 95% confidence intervals (CIs) for each test and, for meta‐analysis, we fitted univariate random‐effects logistic regression models for sensitivity by eligible time period and for specificity by reference standard group. Heterogeneity was investigated by including indicator variables in the random‐effects logistic regression models. We tabulated results by test manufacturer and summarised results for tests that were evaluated in 200 or more samples and that met a modification of UK Medicines and Healthcare products Regulatory Agency (MHRA) target performance criteria. Main results We included 178 separate studies (described in 177 study reports, with 45 as pre‐prints) providing 527 test evaluations. The studies included 64,688 samples including 25,724 from people with confirmed SARS‐CoV‐2; most compared the accuracy of two or more assays (102/178, 57%). Participants with confirmed SARS‐CoV‐2 infection were most commonly hospital inpatients (78/178, 44%), and pre‐pandemic samples were used by 45% (81/178) to estimate specificity. Over two‐thirds of studies recruited participants based on known SARS‐CoV‐2 infection status (123/178, 69%). All studies were conducted prior to the introduction of SARS‐CoV‐2 vaccines and present data for naturally acquired antibody responses. Seventy‐nine percent (141/178) of studies reported sensitivity by week after symptom onset and 66% (117/178) for convalescent phase infection. Studies evaluated enzyme‐linked immunosorbent assays (ELISA) (165/527; 31%), chemiluminescent assays (CLIA) (167/527; 32%) or lateral flow assays (LFA) (188/527; 36%). Risk of bias was high because of participant selection (172, 97%); application and interpretation of the index test (35, 20%); weaknesses in the reference standard (38, 21%); and issues related to participant flow and timing (148, 82%). We judged that there were high concerns about the applicability of the evidence related to participants in 170 (96%) studies, and about the applicability of the reference standard in 162 (91%) studies. Average sensitivities for current SARS‐CoV‐2 infection increased by week after onset for all target antibodies. Average sensitivity for the combination of either IgG or IgM was 41.1% in week one (95% CI 38.1 to 44.2; 103 evaluations; 3881 samples, 1593 cases), 74.9% in week two (95% CI 72.4 to 77.3; 96 evaluations, 3948 samples, 2904 cases) and 88.0% by week three after onset of symptoms (95% CI 86.3 to 89.5; 103 evaluations, 2929 samples, 2571 cases). Average sensitivity during the convalescent phase of infection (up to a maximum of 100 days since onset of symptoms, where reported) was 89.8% for IgG (95% CI 88.5 to 90.9; 253 evaluations, 16,846 samples, 14,183 cases), 92.9% for IgG or IgM combined (95% CI 91.0 to 94.4; 108 evaluations, 3571 samples, 3206 cases) and 94.3% for total antibodies (95% CI 92.8 to 95.5; 58 evaluations, 7063 samples, 6652 cases). Average sensitivities for IgM alone followed a similar pattern but were of a lower test accuracy in every time slot. Average specificities were consistently high and precise, particularly for pre‐pandemic samples which provide the least biased estimates of specificity (ranging from 98.6% for IgM to 99.8% for total antibodies). Subgroup analyses suggested small differences in sensitivity and specificity by test technology however heterogeneity in study results, timing of sample collection, and smaller sample numbers in some groups made comparisons difficult. For IgG, CLIAs were the most sensitive (convalescent‐phase infection) and specific (pre‐pandemic samples) compared to both ELISAs and LFAs (P < 0.001 for differences across test methods). The antigen(s) used (whether from the Spike‐protein or nucleocapsid) appeared to have some effect on average sensitivity in the first weeks after onset but there was no clear evidence of an effect during convalescent‐phase infection. Investigations of test performance by brand showed considerable variation in sensitivity between tests, and in results between studies evaluating the same test. For tests that were evaluated in 200 or more samples, the lower bound of the 95% CI for sensitivity was 90% or more for only a small number of tests (IgG, n = 5; IgG or IgM, n = 1; total antibodies, n = 4). More test brands met the MHRA minimum criteria for specificity of 98% or above (IgG, n = 16; IgG or IgM, n = 5; total antibodies, n = 7). Seven assays met the specified criteria for both sensitivity and specificity. In a low‐prevalence (2%) setting, where antibody testing is used to diagnose COVID‐19 in people with symptoms but who have had a negative PCR test, we would anticipate that 1 (1 to 2) case would be missed and 8 (5 to 15) would be falsely positive in 1000 people undergoing IgG or IgM testing in week three after onset of SARS‐CoV‐2 infection. In a seroprevalence survey, where prevalence of prior infection is 50%, we would anticipate that 51 (46 to 58) cases would be missed and 6 (5 to 7) would be falsely positive in 1000 people having IgG tests during the convalescent phase (21 to 100 days post‐symptom onset or post‐positive PCR) of SARS‐CoV‐2 infection. Authors' conclusions Some antibody tests could be a useful diagnostic tool for those in whom molecular‐ or antigen‐based tests have failed to detect the SARS‐CoV‐2 virus, including in those with ongoing symptoms of acute infection (from week three onwards) or those presenting with post‐acute sequelae of COVID‐19. However, antibody tests have an increasing likelihood of detecting an immune response to infection as time since onset of infection progresses and have demonstrated adequate performance for detection of prior infection for sero‐epidemiological purposes. The applicability of results for detection of vaccination‐induced antibodies is uncertain. Plain language summary What is the diagnostic accuracy of antibody tests for the detection of infection with the COVID‐19 virus? Background COVID‐19 is an infectious disease caused by the SARS‐CoV‐2 virus that spreads easily between people in a similar way to the common cold or ‘flu’. Most people with COVID‐19 have a mild‐to‐moderate respiratory illness, and some may have no symptoms (asymptomatic infection). Others experience severe symptoms and need specialist treatment and intensive care. In response to COVID‐19 infection, the immune system develops proteins called antibodies that can attack the virus as it circulates in their blood. People who have been vaccinated against COVID‐19 also produce these antibodies against the virus. Tests are available to detect antibodies in peoples' blood, which may indicate that they currently have COVID‐19 or have had it previously, or it may indicate that they have been vaccinated (although this group was not the focus of this review). Why are accurate tests important? Accurate testing allows identification of people who need to isolate themselves to prevent the spread of infection, or who might need treatment for their infection. Failure of diagnostic tests to detect infection with COVID‐19 when it is present (a false negative result) may delay treatment and risk further spread of infection to others. Incorrect diagnosis of COVID‐19 when it is not present (a false positive result) may lead to unnecessary further testing, treatment, and isolation of the person and close contacts. Accurate identification of people who have previously had COVID‐19 is important in measuring disease spread and assessing the success of public health interventions. To determine the accuracy of an antibody test in identifying COVID‐19, test results are compared in people known to have (or have had) COVID‐19 and in people known not to have (or have had) COVID‐19. The criteria used to determine whether people are known or not known to have COVID‐19 is called the ‘reference standard’. Many studies use a test called reverse transcriptase polymerase chain reaction (RT‐PCR) as the reference standard, with samples taken from the nose and throat. Additional tests that can be used include measuring symptoms, like coughing or high temperature, or ‘imaging’ tests like chest X‐rays. People known not to have COVID‐19 are sometimes identified from stored blood samples taken before COVID‐19 existed, or from patients with symptoms confirmed to be caused by other diseases. What did the review study? We wanted to find out whether antibody tests: ‐ are able to diagnose infection in people with or without symptoms of COVID‐19, and ‐ can be used to find out if someone has already had COVID‐19. The studies we included in our review looked at three types of antibodies. Most commonly, antibody tests measure two types known as IgG and IgM, but some tests only measure a single type of antibody or different combinations of the three types of antibodies (IgA, IgG, IgM). What did we do? We looked for studies that measured the diagnostic accuracy of antibody tests to detect current or past COVID‐19 infection and compared them with reference standard criteria. Since there are many antibody tests available, we included studies assessing any antibody test compared with any reference standard. People could be tested in hospital or in the community. The people tested may have been confirmed to have, or not to have, COVID‐19 infection, or they may be suspected of having COVID‐19. Study characteristics We found 178 relevant studies. Studies took place in Europe (94), Asia (45), North America (35), Australia (2), and South America (2). Seventy‐eight studies included people who were in hospital with suspected or confirmed COVID‐19 infection and 14 studies included people in community settings. Several studies included people from multiple settings (35) or did not report where the participants were recruited from (39). One hundred and forty‐one studies included recent infection cases (mainly week 1 to week 3 after onset of symptoms), and many also included people tested later (from day 21 onwards after infection) (117). Main results In participants that had COVID‐19 and were tested one week after symptoms developed, antibody tests detected only 27% to 41% of infections. In week 2 after first symptoms, 64% to 79% of infections were detected, rising to 78% to 88% in week 3. Tests that specifically detected IgG or IgM antibodies were the most accurate and, when testing people from 21 days after first symptoms, they detected 93% of people with COVID‐19. Tests gave false positive results for 1% of those without COVID‐19. Below we illustrate results for two different scenarios. If 1000 people were tested for IgG or IgM antibodies during the third week after onset of symptoms and only 20 (2%) of them actually had COVID‐19: ‐ 26 people would test positive. Of these, 8 people (31%) would not have COVID‐19 (false positive result). ‐ 974 people would test negative. Of these, 2 people (0.2%) would actually have COVID‐19 (false negative result). If 1000 people with no symptoms for COVID‐19 were tested for IgG antibodies and 500 (50%) of them had previously had COVID‐19 infection more than 21 days previously: ‐ 455 people would test positive. Of these, 6 people (1%) would not have been infected (false positive result). ‐ 545 people would test negative. Of these, 51 (9%) would actually have had a prior COVID‐19 infection (false negative result). How reliable were the results of the studies of this review? We have limited confidence in the evidence for several reasons. The number of samples contributed by studies for each week post‐symptom onset was often small, and there were sometimes problems with how studies were conducted. Participants included in the studies were often hospital patients who were more likely to have experienced severe symptoms of COVID‐19. The accuracy of antibody tests for detecting COVID‐19 in these patients may be different from the accuracy of the tests in people with mild or moderate symptoms. It is not possible to identify by how much the test results would differ in other populations. Who do the results of this review apply to? A high percentage of participants were in hospital with COVID‐19, so were likely to have more severe disease than people with COVID‐19 who were not hospitalised. Only a small number of studies assessed these tests in people with no symptoms. The results of the review may therefore be more applicable to those with severe disease than people with mild symptoms. Studies frequently did not report whether participants had symptoms at the time samples were taken for testing making it difficult to fully separate test results for early‐phase infection as opposed to later‐phase infections. The studies in our review assessed several test methods across a global population, therefore it is likely that test results would be similar in most areas of the world. What are the implications of this review? The review shows that antibody tests could have a useful role in detecting if someone has had COVID‐19, but the timing of test use is important. Some antibody tests may help to confirm COVID‐19 infection in people who have had symptoms for more than two weeks but who have been unable to confirm their infection using other methods. This is particularly useful if they are experiencing potentially serious symptoms that may be due to COVID‐19 as they may require specific treatment. Antibody tests may also be useful to determine how many people have had a previous COVID‐19 infection. We could not be certain about how well the tests work for people who have milder disease or no symptoms, or for detecting antibodies resulting from vaccination. How up‐to‐date is this review? This review updates our previous review. The evidence is up‐to‐date to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Fox, T; Geppert, J; Dinnes, J; Scandrett, K; Bigio, J; Sulis, G; Hettiarachchi, D; Mathangasinghe, Y; Weeratunga, P; Wickramasinghe, D; Bergman, H; Buckley, BS; Probyn, K; Sguassero, Y; Davenport, C; Cunningham, J; Dittrich, S; Emperador, D; Hooft, L; Leeflang, MMG; McInnes, MDF; Spijker, R; Struyf, T; Van den Bruel, A; Verbakel, JY; Takwoingi, Y; Taylor-Phillips, S; Deeks, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD013652.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "f1e04fc5-f5bb-43ff-92ec-01c97ca1c823", "pmid": "", "title": "Oral xanthines as maintenance treatment for asthma in children", "imported": false, "abstract": "Abstract - Background Xanthines have been used in the treatment of asthma as a bronchodilator, though they may also have anti‐inflammatory effects. The current role of xanthines in the long‐term treatment of childhood asthma needs to be reassessed. Objectives To determine the efficacy of xanthines (e.g. theophylline) in the maintenance treatment of paediatric asthma. Search methods A search of the Cochrane Airways Group Specialised Register was undertaken with predefined search terms. Searches are current to May 2008. Selection criteria Randomised controlled trials, lasting at least four weeks comparing a xanthine with placebo, regular short‐acting beta‐agonist (SABA), inhaled corticosteroids (ICS), cromoglycate (SCG), ketotifen (KET) or leukotriene antagonist, in children with diagnosed with chronic asthma between 18 months and 18 years old. Data collection and analysis Two reviewers independently selected each study for inclusion in the review and extracted data. Primary outcome was percentage of symptom‐free days. Main results Thirty‐six studies (2838 participants) were included. Xanthine versus placebo (18 studies): The proportion of symptom free days was larger with xanthine compared with placebo (7.97% [95% CI 3.41, 12.53]). Rescue medication usage was lower with xanthine, with no significant difference in symptom scores or hospitalisations. FEV 1 , and PEF were better with xanthine. Xanthine was associated with non ‐ specific side‐effects. Data from behavioural scores were inconclusive. Xanthine versus ICS (four studies) : Exacerbations were less frequent with ICS, but no significant difference on lung function was observed. Individual studies reported significant improvements in symptom measures in favour of steroids, and one study reported a difference in growth rate in favour of xanthine. No difference was observed for study withdrawal or tremor. Xanthine was associated with more frequent headache and nausea. Xanthine versus regular SABA (10 studies): No significant difference in symptoms, rescue medication usage and spirometry. Individual studies reported improvement in PEF with beta‐agonist. Beta‐agonist treatment led to fewer hospitalisations and headaches. Xanthine was associated with less tremor. Xanthine versus SCG (six studies ): No significant difference in symptoms, exacerbations and rescue medication. Sodium cromoglycate was associated with fewer gastro‐intestinal side‐effects than xanthine. Xanthine versus KET (one study): No statistical tests of significance between xanthine and ketotifen were reported. : Xanthine + ICS versus placebo + same dose ICS (three studies) : Results were conflicting due to clinical/methodological differences, and could not be aggregated. Xanthine + ICS versus ICS + leukotriene (one study): Results from one trial One small parallel study did not measure the primary outcome of symptoms; differences between treatments in end of treatment values were not statistically significant. Authors' conclusions Xanthines as first‐line preventer alleviate symptoms and reduce requirement for rescue medication in children with mild to moderate asthma. When compared with ICS they were less effective in preventing exacerbations. Xanthines had similar efficacy as single preventative agent compared with regular SABA and SCG. Evidence on AEs (adverse effects) was equivocal: there was evidence for increased AEs overall, but no evidence that any specific AE (including effects on behaviour and attention) occurred more frequently than with placebo. There is insufficient evidence from available studies to make firm conclusions about the effectiveness of xanthines as add‐on preventative treatment to ICS, and there are no published paediatric studies comparing xanthines with alternatives in this role. Our data suggest that xanthines are only suitable as first‐line preventative asthma therapy in children when ICS are not available. Pre‐trial exposure to the agents assessed may have pre‐disposed the trial populations to tolerate the drug, and may have threatened blinding. They may have a role as add‐on therapy in more severe asthma not controlled by ICS, but further studies are needed to examine this, and to define the risk‐benefit ratio compared with other agents. Plain language summary The effects of oral xanthines (e.g. theophylline) for chronic asthma in children Xanthines (e.g. theophylline) are a group of drugs thought to have helpful preventative and reliever properties in the treatment of asthma in children. This review of studies has established that there is evidence for useful effects of these drugs in terms of symptom relief and lung function, but also some evidence of side‐effects. As a primary preventative therapy , whilst there is evidence that xanthines are effective, this review suggests that more effective alternative treatment options (inhaled steroids) are available. In children with more severe asthma, the role of xanthines as an add‐on therapy has only been assessed in a small number of trials, which report mixed effects. More studies in this area would help to generate a more reliable overview of the effects of treatment in these children. Xanthines are an effective preventative treatment in childhood asthma, but less effective than inhaled steroids, and with a less favourable side‐effect profile. There is insufficient evidence at present to assess their role as \"add‐on\" preventer treatment versus newer alternatives. Some of the trials exposed the children they recruited to a pre‐trial phase of xanthine in order to maintain effective dosing during the trial. This could have made the trial participants less representative of the general population by making them more inclined to tolerate the study drug. This exposure also may have meant that they could recognise what drug they were taking during the blinded phase of the study.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Seddon, P; Bara, A; Lasserson, TJ; Ducharme, FM", "articleTypes": [], "doi": "10.1002/14651858.CD002885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "f1f18961-be25-48dd-9a95-3af35b3ab87c", "pmid": "", "title": "Systemic administration of local anesthetic agents to relieve neuropathic pain", "imported": false, "abstract": "Abstract - Background Lidocaine, mexiletine, tocainide, and flecainide are local anesthetics which give an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain. Interest reappeared decades later when patient series and clinical trials reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients. With the recent publication of clinical trials with high quality standards, we have reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to update our knowledge, to measure their benefit and harm, and to better define their role in therapy. Objectives To evaluate pain relief and adverse effect rates between systemic local anesthetic‐type drugs and other control interventions. Search methods We searched MEDLINE (1966 through 15 May 2004), EMBASE (January 1980 to December 2002), Cancer Lit (through 15 December 2002), Cochrane Central Register of Controlled Trials (2nd Quarter, 2004), System for Information on Grey Literature in Europe (SIGLE), and LILACS, from January 1966 through March 2001. We also hand searched conference proceedings, textbooks, original articles and reviews. Selection criteria We included trials with random allocation, that were double blinded, with a parallel or crossover design. The control intervention was a placebo or an analgesic drug for neuropathic pain from any cause. Data collection and analysis We collected efficacy and safety data from all published and unpublished trials. We calculated combined effect sizes using continuous and binary data for pain relief and adverse effects as primary and secondary outcome measurements, respectively. Main results Thirty‐two controlled clinical trials met the selection criteria; two were duplicate articles. The treatment drugs were intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (one trial), and tocainide (one trial). Twenty‐one trials were crossover studies, and nine were parallel. Lidocaine and mexiletine were superior to placebo [weighted mean difference (WMD) = ‐11; 95% CI: ‐15 to ‐7; P < 0.00001], and limited data showed no difference in efficacy (WMD = ‐0.6; 95% CI: ‐7 to 6), or adverse effects versus carbamazepine, amantadine, gabapentin or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life‐threatening toxicities. Sensitivity analysis identified data distribution in three trials as a probable source of heterogeneity. There was no publication bias. Authors' conclusions Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. Future trials should enroll specific diseases and test novel lidocaine analogs with better toxicity profiles. More emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful. Plain language summary Systemic administration of local anesthetic agents to relieve neuropathic pain Intravenous lidocaine and oral derivatives relieve pain from damage to the nervous system (neuropathic pain). In early reports, intravenous lidocaine and its oral analogs mexiletine and tocainide relieved neuropathic pain, a type of pain caused by disease in the nervous system. However, the evidence was conflicting. The authors reviewed all randomized studies comparing these drugs with placebo or with other analgesics and found that: local anesthetics were superior to placebo in decreasing intensity of neuropathic pain; limited data showed no difference in efficacy or adverse effects between local anesthetics and carbamazepine, amantadine, gabapentin or morphine; local anesthetics had more adverse effects than placebo; and local anesthetics were safe.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Challapalli, V; Tremont-Lukats, IW; McNicol, ED; Lau, J; Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD003345.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "f1f340d1-46ad-414a-97f9-94f79d139abd", "pmid": "", "title": "Postnatal phenobarbital for the prevention of intraventricular haemorrhage in preterm infants", "imported": false, "abstract": "Abstract - Background Intraventricular haemorrhage (IVH) is a major complication of preterm birth. Large haemorrhages are associated with a high risk of disability and hydrocephalus. Instability of blood pressure and cerebral blood in the newborn flow are postulated as causative factors. Another mechanism may involve reperfusion damage from oxygen free radicals. It has been suggested that phenobarbital stabilises blood pressure and may protect against free radicals. This is an update of a review first published in 2001 and updated in 2007 and 2013. Objectives To assess the benefits and harms of the postnatal administration of phenobarbital in preterm infants at risk of developing IVH compared to control (i.e. no intervention or placebo). Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL and clinical trial registries in January 2022. A new, more sensitive search strategy was developed, and searches were conducted without date limits. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs in which phenobarbital was given within the first 24 hours of life to preterm infants identified as being at risk of IVH because of gestational age below 34 weeks, birth weight below 1500 g or respiratory failure. Phenobarbital was compared to no intervention or placebo. We excluded infants with serious congenital malformations. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were all grades of IVH and severe IVH (i.e. grade III and IV); secondary outcomes were ventricular dilation or hydrocephalus, hypotension, pneumothorax, hypercapnia, acidosis, mechanical ventilation, neurodevelopmental impairment and death. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 10 RCTs (792 infants). The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH of any grade compared with control (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.84 to 1.19; risk difference (RD) 0.00, 95% CI ‐0.06 to 0.07; I² for RD = 65%; 10 RCTs, 792 participants; low certainty evidence) and in severe IVH (RR 0.88, 95% CI 0.64 to 1.21; 10 RCTs, 792 participants; low certainty evidence). The evidence is very uncertain about the effect of phenobarbital on posthaemorrhagic ventricular dilation or hydrocephalus (RR 0.62, 95% CI 0.31 to 1.26; 4 RCTs, 271 participants; very low certainty evidence), mild neurodevelopmental impairment (RR 0.57, 95% CI 0.15 to 2.17; 1RCT, 101 participants; very low certainty evidence), and severe neurodevelopmental impairment (RR 1.12, 95% CI 0.44 to 2.82; 2 RCTs, 153 participants; very low certainty evidence). Phenobarbital may result in little to no difference in death before discharge (RR 0.88, 95% CI 0.64 to 1.21; 9 RCTs, 740 participants; low certainty evidence) and mortality during study period (RR 0.98, 95% CI 0.72 to 1.33; 10 RCTs, 792 participants; low certainty evidence) compared with control. We identified no ongoing trials. Authors' conclusions The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH (any grade or severe) compared with control (i.e. no intervention or placebo). The evidence is very uncertain about the effects of phenobarbital on ventricular dilation or hydrocephalus and on neurodevelopmental impairment. The evidence suggests that phenobarbital results in little to no difference in death before discharge and all deaths during the study period compared with control. Since 1993, no randomised studies have been published on phenobarbital for the prevention of IVH in preterm infants, and no trials are ongoing. The effects of postnatal phenobarbital might be assessed in infants with both neonatal seizures and IVH, in both randomised and observational studies. The assessment of benefits and harms should include long‐term outcomes. Plain language summary What are the benefits and risks of phenobarbital for preventing bleeding to the brain in babies born too early? Key messages • Giving phenobarbital (a medicine used to control seizures) to babies born too early may have little to no effect in preventing intraventricular haemorrhage (bleeding to the brain) and death. • The evidence is very uncertain about the effect of phenobarbital on preventing ventricular dilation (enlarged spaces in the brain) and long‐term brain development. What is bleeding to the brain (intraventricular haemorrhage)? Large bleeds in the centre of the brain can cause disability or death in babies born too early. Unstable blood pressure and blood flow to the brain are believed to cause bleeding into the fluid‐filled cavities of the brain (ventricles). What did we want to find out? Phenobarbital is believed to stabilise blood pressure and therefore potentially help prevent bleeding to the brain. We wanted to find out whether phenobarbital was better than no medicine or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) to prevent bleeding to the brain. What did we do? We searched for studies that compared giving phenobarbital against no medicines. We compared and summarised the results of these studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We included 10 studies (792 babies). The evidence suggests that phenobarbital has little to no effect in preventing bleeding to the brain. The evidence is very uncertain about the effect of phenobarbital on dilation of the ventricles in the brain and long‐term development. The evidence suggests that phenobarbital has little to no effect in preventing deaths. We identified no ongoing trials. What are the limitations of the evidence? It is possible that people conducting the studies were aware of what treatment they were giving. Not all the studies provided data about everything that we were interested in. The studies were very small. How up to date is this evidence? This review updates our previous review. The evidence is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Romantsik, O, Smit, E, Odd, DE, Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD001691.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.133Z" }, { "id": "f20b15ba-58bf-4a5c-94df-bf11940589f6", "pmid": "", "title": "Nedocromil sodium for chronic asthma in children", "imported": false, "abstract": "Abstract - Background Currently inhaled corticosteroids are the main stay in the maintenance treatment of chronic asthma in children. Although inhaled corticosteroids play a crucial role in the management of childhood asthma, the long‐term side effects of inhaled corticosteroids used in the management of chronic asthma in children are not clearly known. Objectives The objective of this review is to compare the safety and efficacy of inhaled nedocromil sodium with placebo in the treatment of chronic asthma in children. Search methods We searched the Cochrane Airway Group trials register, review articles, and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. We also searched abstracts of major respiratory society meetings. The last search was carried out in November 2009. Selection criteria Randomised placebo controlled trials comparing nedocromil sodium to placebo in the treatment of chronic asthma in children (0 to 18 years). Data collection and analysis Both authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Fifteen trials (twelve parallel group studies; three crossover trials recruiting 1422 children (837 males and 585 females)) were included. The studies were generally of good methodological quality. Two large long term studies used nedocromil for six months and four to six years and showed conflicting results in symptom free days. Short term studies (duration between 4 weeks to 12 weeks) showed that nedocromil sodium produced some improvement in a number of efficacy measures compared to placebo including FEV 1 , FVC, FEV 1 % predicted, PC20 FEV 1 , evening PEF and symptom scores. The parent's assessment of efficacy was in favour of nedocromil (odds ratio (OR) 0.5 (95% CI 0.3 to 0.8). Nedocromil sodium has a good safety profile. The only significant side effect observed was unpleasant taste. There was little evidence for a clinically dose response effect and only a few studies recruited participants with severe asthma. Authors' conclusions A limited number of small studies have shown that nedocromil is of benefit in improving lung function and some measures of symptoms, but the evidence with regard to the primary outcome of the review was conflicting. Two long‐term trials did not show consistent effects on lung function outcomes, whereas several small short‐term trials have shown benefit in these outcomes. Differing severities at baseline may explain this difference with milder participants experiencing less benefit, although the discrepancy between study findings may also reflect publication bias. Nedocromil sodium is associated with a very good safety profile with no significant short term or long‐ term adverse side effects. Although nedocromil may have advantages over inhaled corticosteroids in terms of side effects, there is a need for head to head trials of nedocromil and inhaled corticosteroids to establish whether asthma control is similar, especially in mild asthma. It is not yet clear where nedocromil should sit in relation to other therapies in the treatment of asthma in children. Plain language summary Nedocromil sodium for chronic asthma in children Nedocromil (or Tilade) is a 'preventer' therapy used to treat chronic asthma in children. It is thought to be safer than inhaled steroids and can be used for the management of mild to moderate asthma. The review of studies including 15 trials and 1422 children found that there were some encouraging results in short term studies when nedocromil was compared on its own with placebo, particularly with regard to lung function tests. However, these results were not confirmed in one large, longer term study of four to six years duration, which did not show significant difference in the primary outcome of symptom free days. This study was conducted in children who had mild asthma. There may be a role for nedocromil in the management of moderate asthma, but it should be assessed in relation to inhaled steroids, whose efficacy is well‐established. This particularly important in symptomatic asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Sridhar, AV, McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD004108.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.749Z" }, { "id": "f2182137-8c22-4655-bc58-73af56d156e4", "pmid": "", "title": "Melatonin and agomelatine for preventing seasonal affective disorder", "imported": false, "abstract": "Abstract - Background Seasonal affective disorder (SAD) is a seasonal pattern of recurrent major depressive episodes that most commonly starts in autumn or winter and remits in spring. The prevalence of SAD depends on latitude and ranges from 1.5% to 9%. The predictable seasonal aspect of SAD provides a promising opportunity for prevention in people who have a history of SAD. This is one of four reviews on the efficacy and safety of interventions to prevent SAD; we focus on agomelatine and melatonin as preventive interventions. Objectives To assess the efficacy and safety of agomelatine and melatonin (in comparison with each other, placebo, second‐generation antidepressants, light therapy, psychological therapy or lifestyle interventions) in preventing SAD and improving person‐centred outcomes among adults with a history of SAD. Search methods We searched Ovid MEDLINE (1950‐ ), Embase (1974‐ ), PsycINFO (1967‐ ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 19 June 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD‐CTR) (all years to 11 August 2015). Furthermore, we searched the Cumulative Index to Nursing and Allied Health Literature, Web of Science, the Cochrane Library , the Allied and Complementary Medicine Database and international trial registers (to 19 June 2018). We also conducted a grey literature search and handsearched the reference lists of included studies and pertinent review articles. Selection criteria To examine efficacy, we included randomised controlled trials (RCTs) on adults with a history of winter‐type SAD who were free of symptoms at the beginning of the study. For adverse events, we intended also to include non‐randomised studies. We planned to include studies that compared agomelatine versus melatonin, or agomelatine or melatonin versus placebo, any second‐generation antidepressant, light therapy, psychological therapies or lifestyle changes. We also intended to compare melatonin or agomelatine in combination with any of the comparator interventions mentioned above versus the same comparator intervention as monotherapy. Data collection and analysis Two review authors screened abstracts and full‐text publications, abstracted data and assessed risk of bias of included studies independently. We intended to pool data in a meta‐analysis using a random‐effects model, but included only one study. Main results We identified 3745 citations through electronic searches and reviews of reference lists after deduplication of search results. We excluded 3619 records during title and abstract review and assessed 126 full‐text papers for inclusion in the review. Only one study, providing data of 225 participants, met our eligibility criteria and compared agomelatine (25 mg/day) with placebo. We rated it as having high risk of attrition bias because nearly half of the participants left the study before completion. We rated the certainty of the evidence as very low for all outcomes, because of high risk of bias, indirectness, and imprecision. The main analysis based on data of 199 participants rendered an indeterminate result with wide confidence intervals (CIs) that may encompass both a relevant reduction as well as a relevant increase of SAD incidence by agomelatine (risk ratio (RR) 0.83, 95% CI 0.51 to 1.34; 199 participants; very low‐certainty evidence). Also the severity of SAD may be similar in both groups at the end of the study with a mean SIGH‐SAD (Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders) score of 8.3 (standard deviation (SD) 9.4) in the agomelatine group and 10.1 (SD 10.6) in the placebo group (mean difference (MD) ‐1.80, 95% CI ‐4.58 to 0.98; 199 participants; very low‐certainty evidence). The incidence of adverse events and serious adverse events may be similar in both groups. In the agomelatine group, 64 out of 112 participants experienced at least one adverse event, while 61 out of 113 did in the placebo group (RR 1.06, 95% CI 0.84 to 1.34; 225 participants; very low‐certainty evidence). Three out of 112 patients experienced serious adverse events in the agomelatine group, compared to 4 out of 113 in the placebo group (RR 0.76, 95% CI 0.17 to 3.30; 225 participants; very low‐certainty evidence). No data on quality of life or interpersonal functioning were reported. We did not identify any studies on melatonin. Authors' conclusions Given the uncertain evidence on agomelatine and the absence of studies on melatonin, no conclusion about efficacy and safety of agomelatine and melatonin for prevention of SAD can currently be drawn. The decision for or against initiating preventive treatment of SAD and the treatment selected should consider patient preferences and reflect on the evidence base of all available treatment options. Plain language summary Melatonin and agomelatine for prevention of winter depression Why is this review important? Many people in northern latitudes suffer from seasonal affective disorder (SAD), which occurs as a reaction to reduced sunlight. Three‐quarters of those affected are women. Lethargy, overeating, craving for carbohydrates and depressed mood are common symptoms. In some people, SAD becomes depression that seriously affects their daily lives. Up to two‐thirds experience depressive symptoms every winter. Who might be interested in this review? General practitioners, psychiatrists, pharmacists, other health professionals working in adult mental health services, and researchers could be interested in the results of this review. Anyone who has experienced winter depression, or who has friends or relatives who have experienced winter depression might also be interested. What questions does this review aim to answer? Because of the seasonal pattern and high recurrence of SAD, melatonin or agomelatine could be used to prevent the onset of depressed mood. The goal of this report is to examine whether benefits outweigh harms of melatonin or agomelatine when used to prevent onset of a new depressive episode in people with a history of SAD who were free of symptoms when the preventive intervention started. To date, this question has not been examined in a systematic way. This is one of four reviews on the efficacy and potential harms of interventions to prevent SAD. Which studies were included in the review? We searched databases up to June 2018 for studies on melatonin or agomelatine for prevention of winter depression. Among 3745 records, we found one randomised controlled study comparing agomelatine with placebo for one year. All 225 participants had a history of winter depression but were not depressed when the prevention study started. What does evidence from the review reveal? The included study showed neither a clear effect in favour nor against agomelatine as a preventive treatment. In addition, the certainty of evidence for all outcomes was very low, making it impossible to draw any conclusions about the efficacy and safety of agomelatine for the prevention of winter depression. No evidence on melatonin for prevention of SAD was identified. Doctors need to discuss with persons with a history of SAD that currently evidence on agomelatine or melatonin for preventive treatment options for SAD is inconclusive, therefore treatment selection should be strongly based on peoples' preferences and reflect on the evidence base of all available treatment options. What should happen next? Review authors recommend that future studies should evaluate the efficacy of agomelatine or melatonin in preventing SAD and should directly compare these interventions against other treatment options, such as light therapy, antidepressants, or psychological therapies to determine the best treatment option for prevention of SAD.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Nussbaumer‐Streit, B; Greenblatt, A; Kaminski‐Hartenthaler, A; Van Noord, MG; Forneris, CA; Morgan, LC; Gaynes, BN; Wipplinger, J; Lux, LJ; Winkler, D; Gartlehner, G", "articleTypes": [], "doi": "10.1002/14651858.CD011271.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "f2725ee3-979f-4c37-a25c-5196184b449d", "pmid": "", "title": "Outpatient Administration of Teclistamab or Talquetamab for Multiple Myeloma", "imported": false, "abstract": "This is a phase II study to evaluate the outpatient administration of Teclistamab or Talquetamab in Multiple Myeloma patients", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.247Z" }, { "id": "f27f8e05-dff2-439f-a018-c769ea05834a", "pmid": "", "title": "Sensory environment on health‐related outcomes of hospital patients", "imported": false, "abstract": "Abstract - Background Hospital environments have recently received renewed interest, with considerable investments into building and renovating healthcare estates. Understanding the effectiveness of environmental interventions is important for resource utilisation and providing quality care. Objectives To assess the effect of hospital environments on adult patient health‐related outcomes. Search methods We searched: the Cochrane Central Register of Controlled Trials (last searched January 2006); MEDLINE (1902 to December 2006); EMBASE (January 1980 to February 2006); 14 other databases covering health, psychology, and the built environment; reference lists; and organisation websites. This review is currently being updated (MEDLINE last search October 2010), see Studies awaiting classification. Selection criteria Randomised and non‐randomised controlled trials, controlled before‐and‐after studies, and interrupted times series of environmental interventions in adult hospital patients reporting health‐related outcomes. Data collection and analysis Two review authors independently undertook data extraction and 'Risk of bias' assessment. We contacted authors to obtain missing information. For continuous variables, we calculated a mean difference (MD) or standardized mean difference (SMD), and 95% confidence intervals (CI) for each study. For dichotomous variables, we calculated a risk ratio (RR) with 95% confidence intervals (95% CI). When appropriate, we used a random‐effects model of meta‐analysis. Heterogeneity was explored qualitatively and quantitatively based on risk of bias, case mix, hospital visit characteristics, and country of study. Main results Overall, 102 studies have been included in this review. Interventions explored were: 'positive distracters', to include aromas (two studies), audiovisual distractions (five studies), decoration (one study), and music (85 studies); interventions to reduce environmental stressors through physical changes, to include air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), and temperature (one study); and multifaceted interventions (two studies). We did not find any studies meeting the inclusion criteria to evaluate: art, access to nature for example, through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music may improve patient‐reported outcomes such as anxiety; however, the benefit for physiological outcomes, and medication consumption has less support. There are few studies to support or refute the implementation of physical changes, and except for air quality, the included studies demonstrated that physical changes to the hospital environment at least did no harm. Authors' conclusions Music may improve patient‐reported outcomes in certain circumstances, so support for this relatively inexpensive intervention may be justified. For some environmental interventions, well designed research studies have yet to take place. Plain language summary Sensory environment on health‐related outcomes of hospital patients The hospital environment (such as sounds, pictures, aromas, design, air quality, furnishings, architecture, and layout), may have an impact on the health of patients within it. This review aims to summarise the best available evidence on hospital environments, in order to help people involved in the design of hospital environments make decisions that will benefit patients' health. The review identified 102 relevant studies, 85 of which were on the use of music in hospital. Other environmental aspects considered were: aromas (two studies), audiovisual distractions (five studies), decoration (one study), air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), temperature (one study), and multiple design changes (two studies). No studies meeting the inclusion criteria were found to evaluate: art, access to nature for example through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way‐finding aids, or the provision of windows. Overall, it appears that music in hospital may help improve patient‐reported outcomes such as anxiety; however, there is less evidence to support the use of music for physiological outcomes (such as reducing heart rate and blood pressure) and for reducing the use of medications. For other aspects of hospital environments, there are not very many well designed studies to help with making evidence‐based design decisions. The studies that have been included in this review show that physical changes made to 'improve' the hospital environment on the whole do no harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Drahota, A; Ward, D; Mackenzie, H; Stores, R; Higgins, B; Gal, D; Dean, TP", "articleTypes": [], "doi": "10.1002/14651858.CD005315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "f28649b4-03cc-48e8-b509-e624efc67ce9", "pmid": "", "title": "Exposure to the smell and taste of milk to accelerate feeding in preterm infants", "imported": false, "abstract": "Abstract - Background Preterm infants (born before 37 weeks' gestation) are often unable to co‐ordinate sucking, swallowing, and breathing for oral feeding because of their immaturity. In such cases, initial nutrition is provided by orogastric or nasogastric tube feeding. Feeding intolerance is common and can delay attainment of full enteral and sucking feeds, prolonging the need for nutritional support and the hospital stay. Smell and taste play an important role in the activation of physiological pre‐absorptive processes that contribute to food digestion and absorption. However, during tube feeding, milk bypasses the nasal and oral cavities, limiting exposure to the smell and taste of milk. Provision of the smell and taste of milk with tube feeds offers a non‐invasive and low‐cost intervention that, if effective in accelerating the transition to enteral feeds and subsequently to sucking feeds, would bring considerable advantages to infants, their families, and healthcare systems. Objectives To assess whether exposure to the smell or taste (or both) of breastmilk or formula administered with tube feeds can accelerate the transition to full sucking feeds without adverse effects in preterm infants. Search methods We conducted searches in CENTRAL, MEDLINE, Embase, CINAHL, and Epistemonikos to 26 April 2023. We also searched clinical trial databases and conference proceedings. Selection criteria We included randomised and quasi‐randomised studies that evaluated exposure versus no exposure to the smell or taste of milk (or both) immediately before or at the time of tube feeds. Data collection and analysis Two review authors independently selected studies, assessed risk of bias, and extracted data according to Cochrane Neonatal methodology. We performed meta‐analyses using risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence. Main results We included eight studies (1277 preterm infants). Seven studies (1244 infants) contributed data for meta‐analysis. The evidence suggests that exposure to the smell and taste of milk with tube feeds has little to no effect on time taken to reach full sucking feeds (MD −1.07 days, 95% CI −2.63 to 0.50; 3 studies, 662 infants; very low‐certainty evidence). Two studies reported no adverse effects related to the intervention. The intervention may have little to no effect on duration of parenteral nutrition (MD 0.23 days, 95% CI −0.24 to 0.71; 3 studies, 977 infants; low‐certainty evidence), time to reach full enteral feeds (MD −0.16 days, 95% CI −0.45 to 0.12; 1 study, 736 infants; very low‐certainty evidence) or risk of necrotising enterocolitis (RR 0.93, 95% CI 0.47 to 1.84; 2 studies, 435 infants; low‐certainty evidence), although the evidence for time to reach full enteral feeds is very uncertain. Exposure to the smell and taste of milk with tube feeds probably has little to no effect on risk of late infection (RR 1.14, 95% CI 0.74 to 1.75; 2 studies, 436 infants; moderate‐certainty evidence). There were no data available to assess feeding intolerance. The included studies had small sample sizes and methodological limitations, including unclear or lack of randomisation (four studies), lack of blinding of participants and personnel (five studies), unclear or lack of blinding of the outcome assessor (all eight studies), and different inclusion criteria and methods of administering the interventions. Authors' conclusions The results of our meta‐analyses suggest that exposure to the smell and taste of milk with tube feeds may have little to no effect on time to reach full sucking feeds and time to reach full enteral feeds. We found no clear difference between exposure and no exposure to the smell or taste of milk on safety outcomes (adverse effects, necrotising enterocolitis, and late infection). Results from one ongoing study and two studies awaiting classification may alter the conclusions of this review. Future research should examine the effect of exposing preterm infants to the smell and taste of milk with tube feeds on health outcomes during hospitalisation, such as attainment of feeding skills, safety, feed tolerance, infection, and growth. Future studies should be powered to detect the effect of the intervention in infants of different gestational ages and on each sex separately. It is also important to determine the optimal method, frequency, and duration of exposure. Plain language summary Does exposure to the smell and taste of milk accelerate feeding in tube‐fed preterm infants? Key messages • Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time it takes preterm infants to reach full sucking feeds.
• We found no evidence of any unwanted effects of exposure to the smell and taste of milk with tube feeds in newborn infants. What is tube feeding? Infants born preterm (before 37 weeks of pregnancy) often need to be fed via a thin tube inserted through the mouth (orogastric tube) or nose (nasogastric tube) into the stomach until they are able to suck all of their feeds. Why is the smell and taste of milk important for tube‐fed babies? Initially, only small volumes of milk are given, and this is gradually increased depending on how well the babies tolerate the milk. Smell and taste have a significant role in helping with digestion and absorption of food, and since infants being fed by a tube may not experience the smell or taste of milk, they might be taking longer to tolerate larger volumes of milk. What did we want to find out? We wanted to find out if exposing infants to the smell and taste of milk before or while they were being fed through a tube could help them tolerate greater volumes of milk more quickly and improve their overall growth and development. We also wanted to know if this method had any unwanted effects. What did we do? We searched for studies that investigated exposing preterm infants to the smell or taste (or both) of milk with tube feeds, compared to no such exposure. We compared and summarised the results of the studies and rated the certainty of the evidence, based on factors such as study methods and number of infants included. What did we find? We identified eight completed studies involving 1277 preterm infants admitted to a neonatal intensive care unit. Exposure to the smell and taste of milk with tube feeds may have little to no effect on the time to reach full sucking feeds, but the results are very uncertain. Two studies reported that no infants had any unwanted effects related to exposure to the smell and taste of milk with tube feeds. Exposure to the smell and taste of milk may have little to no effect on duration of intravenous nutrition (feeding through a vein), time to reach full enteral feeds (feeds though a tube into the stomach), or on the risk of necrotising enterocolitis (a serious intestinal disease), although the results for time to full enteral feeds are very uncertain. Exposure to the smell and taste of milk probably has little or no effect on the risk of developing an infection more than two days after birth. What are the limitations of the evidence? We have little confidence in the evidence because: • we identified few studies;
• most studies were small and provided different types of exposure to smell and taste;
• in many studies, clinicians and parents were aware of which treatment the infant was receiving; and
• the studies did not investigate all the outcomes we were interested in. How up‐to‐date is this evidence? This review is current to April 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Delgado Paramo, L; Bronnert, A; Lin, L; Bloomfield, FH; Muelbert, M; Harding, JE", "articleTypes": [], "doi": "10.1002/14651858.CD013038.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "f28b13f1-c960-40b0-882c-8f2dcb83f645", "pmid": "", "title": "Corrector therapies (with or without potentiators) for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Background Cystic fibrosis (CF) is a common life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR variant F508del is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF)). The F508del variant lacks meaningful CFTR function ‐ faulty protein is degraded before reaching the cell membrane, where it needs to be to effect transepithelial salt transport. Corrective therapy could benefit many pwCF. This review evaluates single correctors (monotherapy) and any combination of correctors (most commonly lumacaftor, tezacaftor, elexacaftor, VX‐659, VX‐440 or VX‐152) and a potentiator (e.g. ivacaftor) (dual and triple therapies). Objectives To evaluate the effects of CFTR correctors (with or without potentiators) on clinically important benefits and harms in pwCF of any age with class II CFTR mutations (most commonly F508del). Search methods We searched the Cochrane CF Trials Register (28 November 2022), reference lists of relevant articles and online trials registries (3 December 2022). Selection criteria Randomised controlled trials (RCTs) (parallel design) comparing CFTR correctors to control in pwCF with class II mutations. Data collection and analysis Two authors independently extracted data, assessed risk of bias and judged evidence certainty (GRADE); we contacted investigators for additional data. Main results We included 34 RCTs (4781 participants), lasting between 1 day and 48 weeks; an extension of two lumacaftor‐ivacaftor studies provided additional 96‐week safety data (1029 participants). We assessed eight monotherapy RCTs (344 participants) (4PBA, CPX, lumacaftor, cavosonstat and FDL169), 16 dual‐therapy RCTs (2627 participants) (lumacaftor‐ivacaftor or tezacaftor‐ivacaftor) and 11 triple‐therapy RCTs (1804 participants) (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor). Participants in 21 RCTs had the genotype F508del/F508del, in seven RCTs they had F508del/minimal function (MF), in one RCT F508del/gating genotypes, in one RCT either F508del/F508del genotypes or F508del/residual function genotypes, in one RCT either F508del/gating or F508del/residual function genotypes, and in three RCTs either F508del/F508del genotypes or F508del/MF genotypes. Risk of bias judgements varied across different comparisons. Results from 16 RCTs may not be applicable to all pwCF due to age limits (e.g. adults only) or non‐standard designs (converting from monotherapy to combination therapy). Monotherapy Investigators reported no deaths or clinically relevant improvements in quality of life (QoL). There was insufficient evidence to determine effects on lung function. No placebo‐controlled monotherapy RCT demonstrated differences in mild, moderate or severe adverse effects (AEs); the clinical relevance of these events is difficult to assess due to their variety and few participants (all F508del/F508del). Dual therapy In a tezacaftor‐ivacaftor group there was one death (deemed unrelated to the study drug). QoL scores (respiratory domain) favoured both lumacaftor‐ivacaftor and tezacaftor‐ivacaftor therapy compared to placebo at all time points (moderate‐certainty evidence). At six months, relative change in forced expiratory volume in one second (FEV 1 ) % predicted improved with all dual combination therapies compared to placebo (high‐ to moderate‐certainty evidence). More pwCF reported early transient breathlessness with lumacaftor‐ivacaftor (odds ratio (OR) 2.05, 99% confidence interval (CI) 1.10 to 3.83; I 2 = 0%; 2 studies, 739 participants; high‐certainty evidence). Over 120 weeks (initial study period and follow‐up), systolic blood pressure rose by 5.1 mmHg and diastolic blood pressure by 4.1 mmHg with twice‐daily 400 mg lumacaftor‐ivacaftor (80 participants). The tezacaftor‐ivacaftor RCTs did not report these adverse effects. Pulmonary exacerbation rates decreased in pwCF receiving additional therapies to ivacaftor compared to placebo (all moderate‐certainty evidence): lumacaftor 600 mg (hazard ratio (HR) 0.70, 95% CI 0.57 to 0.87; I 2 = 0%; 2 studies, 739 participants); lumacaftor 400 mg (HR 0.61, 95% CI 0.49 to 0.76; I 2 = 0%; 2 studies, 740 participants); and tezacaftor (HR 0.64, 95% CI 0.46 to 0.89; 1 study, 506 participants). Triple therapy No study reported any deaths (high‐certainty evidence). All other evidence was low‐ to moderate‐certainty. QoL respiratory domain scores probably improved with triple therapy compared to control at six months (six studies). There was probably a greater relative and absolute change in FEV 1 % predicted with triple therapy (four studies each across all combinations). The absolute change in FEV 1 % predicted was probably greater for F508del/MF participants taking elexacaftor‐tezacaftor‐ivacaftor compared to placebo (mean difference 14.30, 95% CI 12.76 to 15.84; 1 study, 403 participants; moderate‐certainty evidence), with similar results for other drug combinations and genotypes. There was little or no difference in adverse events between triple therapy and control (10 studies). No study reported time to next pulmonary exacerbation, but fewer F508del/F508del participants experienced a pulmonary exacerbation with elexacaftor‐tezacaftor‐ivacaftor at four weeks (OR 0.17, 99% CI 0.06 to 0.45; 1 study, 175 participants) and 24 weeks (OR 0.29, 95% CI 0.14 to 0.60; 1 study, 405 participants); similar results were seen across other triple therapy and genotype combinations. Authors' conclusions There is insufficient evidence of clinically important effects from corrector monotherapy in pwCF with F508del/F508del. Additional data in this review reduced the evidence for efficacy of dual therapy; these agents can no longer be considered as standard therapy. Their use may be appropriate in exceptional circumstances (e.g. if triple therapy is not tolerated or due to age). Both dual therapies (lumacaftor‐ivacaftor, tezacaftor‐ivacaftor) result in similar small improvements in QoL and respiratory function with lower pulmonary exacerbation rates. While the effect sizes for QoL and FEV 1 still favour treatment, they have reduced compared to our previous findings. Lumacaftor‐ivacaftor was associated with an increase in early transient shortness of breath and longer‐term increases in blood pressure (not observed for tezacaftor‐ivacaftor). Tezacaftor‐ivacaftor has a better safety profile, although data are lacking in children under 12 years. In this population, lumacaftor‐ivacaftor had an important impact on respiratory function with no apparent immediate safety concerns, but this should be balanced against the blood pressure increase and shortness of breath seen in longer‐term adult data when considering lumacaftor‐ivacaftor. Data from triple therapy trials demonstrate improvements in several key outcomes, including FEV 1 and QoL. There is probably little or no difference in adverse events for triple therapy (elexacaftor‐tezacaftor‐ivacaftor/deutivacaftor; VX‐659‐tezacaftor‐ivacaftor/deutivacaftor; VX‐440‐tezacaftor‐ivacaftor; VX‐152‐tezacaftor‐ivacaftor) in pwCF with one or two F508del variants aged 12 years or older (moderate‐certainty evidence). Further RCTs are required in children under 12 years and those with more severe lung disease. Plain language summary CFTR correctors, a therapy for cystic fibrosis targeted at specific variants (most commonly F508del) Review question How do drugs (or drug combinations) for correcting the basic defect in the most common cystic fibrosis (CF)‐causing gene variant (F508del) impact on outcomes important to people with CF (pwCF), e.g. survival, quality of life (QoL), lung function and safety? Key messages There is a lack of evidence to support monotherapy and limited evidence to support dual therapy for pwCF who have the gene variant F508del. We found important differences across key outcomes, with fewer unwanted side effects in the triple therapy studies when compared to one dual therapy drug combination (lumacaftor plus ivacaftor). More research is needed to assess triple therapy combinations in children and to monitor their safety profiles over the longer term. How would drugs (or drug combinations) correct the basic defect in the most common CF‐causing gene variant (F508del)? The CF gene makes a protein that helps salts move across cells in many parts of the body. Over 80% of pwCF have at least one copy of the genetic variant F508del, meaning they make a full length of this protein, but it cannot move through the cell correctly. Laboratory experiments suggest that if this protein reaches the cell wall, it may be able to function, restore salt movement and correct the chronic problems that pwCF experience. What did we want to find out? How do drugs (or drug combinations) used to treat people of any age who have the genetic variant F508del impact their lives? Are these drugs associated with any unwanted side effects? What did we do? We searched for and included studies that looked at drugs (and drug combinations) used to treat pwCF who had at least one copy of the most common CF‐causing gene variant (F508del) compared to control medications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We included 34 studies that involved 4781 pwCF and which lasted between 1 day and 48 weeks; all studies compared an active drug treatment to a placebo (drug containing no active treatment). We do not have enough information to decide if 14 studies should be included or not and eight studies have not yet been completed. Eight studies looked at treatment with a single drug (monotherapy). These studies did not report any deaths or clinically relevant improvements in quality of life (QoL) scores. There was not enough evidence to show an effect on lung function. All studies reported side effects; there were a wide range of side effects each reported by a small number of participants in the studies. There were 16 studies assessing a combination of two drugs (dual therapy), either tezacaftor plus ivacaftor or lumacaftor plus ivacaftor. One participant taking tezacaftor plus ivacaftor died, but this was not thought to be related to the treatment. Both dual therapies resulted in improvements in QoL and lung function; rates of pulmonary exacerbations (a flare‐up of symptoms) were also lower. Neither dual therapy was linked to severe side effects, although people starting treatment with lumacaftor plus ivacaftor experienced shortness of breath for one to two weeks; this usually stopped without further treatment . More concerningly, in longer studies some people taking lumacaftor plus ivacaftor experienced a rise in blood pressure. Two people (out of over 500) even stopped lumacaftor plus ivacaftor treatment because of high blood pressure. These side effects were not reported for tezacaftor plus ivacaftor. There were 11 studies assessing different combinations of three drugs (triple therapy). The combinations were based on tezacaftor with ivacaftor (or deutivacaftor, which is a similar but chemically altered version of ivacaftor) and investigators then added either elexacaftor, VX‐659, VX‐440 or VX‐152 and compared these to either triple placebo, or tezacaftor with ivacaftor and one placebo. Some studies split groups by treatment and also by different genetic variants. No study reported any deaths. Triple therapies improved QoL scores and lung function in all comparisons, with no difference in the number or severity of side effects. Fewer people with two copies of F508del taking elexacaftor plus tezacaftor plus ivacaftor experienced a pulmonary exacerbation than those taking the control treatment. What are the limitations of the evidence? Our certainty in the evidence ranged from uncertain to very certain, but we were quite certain of the evidence for most results. While studies generally provided few details about their design, so we could not make clear judgements on potential biases, we had fewer concerns with the larger, more recent studies. Some of our findings are based on studies that were too small to show important effects and for 16 studies the results may not be applicable to all pwCF due to them only including people of certain ages (i.e. only adults or only children). Also, one study had an unusual design where people were given monotherapy and then later a dual therapy. How up‐to‐date is this evidence? This review updates our earlier review. We last looked for evidence on 28 November 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Heneghan, M; Southern, KW; Murphy, J; Sinha, IP; Nevitt, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD010966.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "f28c1e17-7605-4473-bf23-510c9accf232", "pmid": "", "title": "Effect of alcohol on blood pressure", "imported": false, "abstract": "Abstract - Background Alcohol is consumed by over 2 billion people worldwide. It is a common substance of abuse and its use can lead to more than 200 disorders including hypertension. Alcohol has both acute and chronic effects on blood pressure. This review aimed to quantify the acute effects of different doses of alcohol over time on blood pressure and heart rate in an adult population. Objectives Primary objective To determine short‐term dose‐related effects of alcohol versus placebo on systolic blood pressure and diastolic blood pressure in healthy and hypertensive adults over 18 years of age. Secondary objective To determine short‐term dose‐related effects of alcohol versus placebo on heart rate in healthy and hypertensive adults over 18 years of age. Search methods The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to March 2019: the Cochrane Hypertension Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2), in the Cochrane Library; MEDLINE (from 1946); Embase (from 1974); the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. We also contacted authors of relevant articles regarding further published and unpublished work. These searches had no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing effects of a single dose of alcohol versus placebo on blood pressure (BP) or heart rate (HR) in adults (≥ 18 years of age). Data collection and analysis Two review authors (ST and CT) independently extracted data and assessed the quality of included studies. We also contacted trial authors for missing or unclear information. Mean difference (MD) from placebo with 95% confidence interval (CI) was the outcome measure, and a fixed‐effect model was used to combine effect sizes across studies. Main results We included 32 RCTs involving 767 participants. Most of the study participants were male (N = 642) and were healthy. The mean age of participants was 33 years, and mean body weight was 78 kilograms. Low‐dose alcohol (< 14 g) within six hours (2 RCTs, N = 28) did not affect BP but did increase HR by 5.1 bpm (95% CI 1.9 to 8.2) (moderate‐certainty evidence). Medium‐dose alcohol (14 to 28 g) within six hours (10 RCTs, N = 149) decreased systolic blood pressure (SBP) by 5.6 mmHg (95% CI ‐8.3 to ‐3.0) and diastolic blood pressure (DBP) by 4.0 mmHg (95% CI ‐6.0 to ‐2.0) and increased HR by 4.6 bpm (95% CI 3.1 to 6.1) (moderate‐certainty evidence for all). Medium‐dose alcohol within 7 to 12 hours (4 RCTs, N = 54) did not affect BP or HR. Medium‐dose alcohol > 13 hours after consumption (4 RCTs, N = 66) did not affect BP or HR. High‐dose alcohol (> 30 g) within six hours (16 RCTs, N = 418) decreased SBP by 3.5 mmHg (95% CI ‐6.0 to ‐1.0), decreased DBP by 1.9 mmHg (95% CI‐3.9 to 0.04), and increased HR by 5.8 bpm (95% CI 4.0 to 7.5). The certainty of evidence was moderate for SBP and HR, and was low for DBP. High‐dose alcohol within 7 to 12 hours of consumption (3 RCTs, N = 54) decreased SBP by 3.7 mmHg (95% CI ‐7.0 to ‐0.5) and DBP by 1.7 mmHg (95% CI –4.6 to 1.8) and increased HR by 6.2 bpm (95% CI 3.0 to 9.3). The certainty of evidence was moderate for SBP and HR, and low for DBP. High‐dose alcohol ≥ 13 hours after consumption (4 RCTs, N = 154) increased SBP by 3.7 mmHg (95% CI 2.3 to 5.1), DBP by 2.4 mmHg (95% CI 0.2 to 4.5), and HR by 2.7 bpm (95% CI 0.8 to 4.6) (moderate‐certainty evidence for all). Authors' conclusions High‐dose alcohol has a biphasic effect on BP; it decreases BP up to 12 hours after consumption and increases BP > 13 hours after consumption. High‐dose alcohol increases HR at all times up to 24 hours. Findings of this review are relevant mainly to healthy males, as only small numbers of women were included in the included trials. Plain language summary Alcohol has a biphasic effect on blood pressure and increases heart rate Review question We reviewed available evidence about the short‐term effects of different doses of alcoholic drinks compared to non‐alcoholic drinks on blood pressure and heart rate in adults (≥ 18 years) with both normal and raised blood pressure. Background Drinking excessive alcohol is considered one of the most common causes of raised blood pressure. We wanted to quantify the effects of a single dose of alcohol on blood pressure and heart rate within 24 hours of consumption. Study characteristics We included 32 randomised controlled trials involving 767 participants published up to March 2019. Although these trials included adults from 18 to 96 years of age with various health conditions, most study participants were young healthy males. The source of funding was not reported for a majority of the studies. Key results For low doses of alcohol, we found that one glass of alcohol had little to no effect on blood pressure and increased heart rate within six hours of drinking. We are moderately certain that medium‐dose alcohol decreased blood pressure and increased heart rate within six hours of consumption. We did not see any significant change in blood pressure or heart rate after that, but the evidence was limited. We are also moderately certain that high‐dose alcohol decreased blood pressure within six hours, and the effect lasted up to 12 hours. After that, blood pressure was found to be increased. Heart rate increased significantly after alcohol consumption and remained increased at all times measured. Thus alcohol decreases blood pressure initially (up to 12 hours after ingestion) and increases blood pressure after that. Alcohol consistently increases heart rate at all times within 24 hours of consumption.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Tasnim, S, Tang, C, Musini, VM, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD012787.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.108Z" }, { "id": "f29f820c-ebda-445f-88fa-e858b62d36c0", "pmid": "", "title": "The Effect of Lactobacillus Reuteri ATCC PTA 6475 on Volumetric Bone Mineral Density in Patients With Osteopenia", "imported": false, "abstract": "Lactobacillus reuteri (L. reuteri) has been widely studied in clinical trials and has probiotic, health-promoting effects in both adults and children, and is safe for human consumption. Animal models indicate that treatment with L. reuteri has positive effects on bone metabolism and bone density. In other animal models of diabetes and the metabolic syndrome, positive effects on blood glucose and weight have been reported. The present double-blind, placebo-controlled, randomized study is designed to investigate if dietary supplementation with L. reuteri twice daily for 12 months has any effect on bone density, body composition, inflammation, or metabolic and endocrine markers in elderly women with osteopenia.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.152Z" }, { "id": "f2a5bb42-45e6-4f4f-8da2-ae1c62a949a0", "pmid": "", "title": "Lifestyle interventions for acute gout", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY, Sriranganathan, MK, Edwards, CJ, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010519.pub2 AB - Abstract - Background Although lifestyle interventions are often recommended in the management of chronic gout, the evidence from trial data of the benefits and safety of using lifestyle interventions for treating acute gout attacks have not previously been examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with acute gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies (up to 5 April 2013). We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials which compared lifestyle interventions to another therapy (active or placebo) in patients with acute gout. Outcomes of interest were the change in participant‐reported pain in the target joint(s), target joint inflammation and function, health‐related quality of life (HRQoL), patient global assessment, study participant withdrawals due to adverse events (AEs) and serious adverse events (SAEs). Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (19 participants) at high risk of bias was included in the review. Patients were randomised to receive oral prednisolone and colchicine with or without concomitant topical ice therapy. Topical ice therapy provided significant additional benefit over oral prednisolone and colchicine alone with respect to pain, but did not significantly reduce swelling during acute gout episodes. Mean pain reduction with standard medical treatment was 4.4 cm on a 0 to 10 cm visual analogue scale (VAS) after one week; the addition of topical ice reduced pain by an additional 3.33 cm (95% CI 5.84 to 0.82), or an absolute reduction of 33% (8% to 58% reduction). Joint swelling was reduced by a mean of 3.8 cm in the standard medical treatment group; the addition of topical ice therapy did not reduce swelling significantly (mean difference (MD) 2.07 cm, 95% CI ‐1.56 to 5.70). Target joint function, HRQoL, patient global assessment, study participant withdrawals due to AEs and SEAs were not reported in this study. Authors' conclusions There is low quality evidence, from a single trial at high risk of bias, that the addition of topical ice therapy to oral prednisolone and colchicine for oligoarticular attacks of acute gout results in significantly greater pain reduction at one week. Plain language summary Lifestyle interventions for treating acute gout attacks This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with acute gout. There was one study included in this review, which looked at the benefits and safety of adding topical ice therapy to medications commonly used for treating acute gout (prednisolone and colchicine). Over a one week period, in addition to prednisolone and colchicine, ice was applied to the skin overlying the joints affected by acute gout, for half‐an‐hour, four times per day, to relieve symptoms of pain and warmth and to reduce signs of redness and swelling. The review shows that in people with acute gout: We are uncertain whether the reduction in pain seen with the addition of topical ice to standard treatment of prednisolone and colchicine, compared to prednisolone and colchicine alone, is a true effect because of the very low quality evidence. Joint function, health‐related quality of life, patient global assessment and side effects and complications were not reported. We often do not have precise information about side effects and complications. Topical ice is likely to be a safe intervention. What is gout and what are lifestyle interventions? Gout is a very common cause of painful joint inflammation (arthritis) and is caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness, warmth and swelling of the affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic make‐up, being overweight, ingesting certain medications (for example cyclosporine), having impaired kidney function, and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Medications are the mainstay of acute gout treatment. Given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as consuming more water, coffee, dairy milk and cherry juice, and having fewer sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout to prevent recurrence of attacks. Best estimate of what happens to people with acute gout using topical ice in addition to medications: Joint pain (lower score means less pain) People who used topical ice (for half‐an‐hour, four times per day for one week) in addition to medical treatment (oral prednisolone and colchicine) rated their pain 3.33 points lower on a 0 to 10 point pain scale (33% absolute improvement).
 ‐ People who used topical ice in addition to medical treatment (prednisolone and colchicine) rated their pain to be 2.25 points on a scale of 0 to 10.
 ‐ People who used medical treatment alone rated their pain to be 5.58 points on a scale of 0 to 10. ‐ Three people would need to be treated with topical ice for one person to benefit from pain relief. Adverse events Side effects or complications of using topical ice in addition to medical therapy were not reported in the study.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.748Z" }, { "id": "f2baf248-fba0-4162-8ed9-897679430228", "pmid": "", "title": "Interventions for increasing fruit and vegetable consumption in children aged five years and under", "imported": false, "abstract": "Abstract - Background Insufficient consumption of fruits and vegetables in childhood increases the risk of future non‐communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child‐feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden. Objectives To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. Search methods We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials. Selection criteria We included randomised controlled trials (RCTs), including cluster‐randomised controlled trials (C‐RCTs) and cross‐over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no‐intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random‐effects models in meta‐analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures. Main results We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child‐feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child‐focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate‐certainty evidence that child‐feeding practice interventions versus no‐intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as‐desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post‐intervention follow‐up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low‐certainty evidence). Multicomponent interventions versus no‐intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate‐certainty evidence; mean post‐intervention follow‐up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden‐based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low‐certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short‐term impact on child consumption of fruit and vegetables versus no‐intervention control (SMD 0.10, 95% CI ‐0.02 to 0.22; 14 trials, 4122 participants; low‐certainty evidence; mean post‐intervention follow‐up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low‐certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low‐certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding. Authors' conclusions There was moderate‐certainty evidence that child‐feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low‐ and middle‐income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. Plain language summary What are the benefits and harms of interventions to increase eating of fruit and vegetables among children aged five years and under? Key messages • Child‐feeding interventions probably lead to a small increase in eating of vegetables in children aged five years and under. • Multicomponent interventions probably lead to a small increase in eating of fruit and vegetables in children aged five years and under. • Parent nutrition education interventions may lead to little or no increase in eating of fruit and vegetables in children aged five years and under. Why is eating enough fruit and vegetables important? Not eating enough fruit and vegetables leads to a considerable health burden in developed countries. Eating adequate amounts of fruit and vegetables is associated with a reduced risk of future non‐communicable diseases (such as heart and circulatory disease) amongst other immediate health benefits. Early childhood is a critical period for the establishment of dietary habits that track into adulthood. Interventions to increase consumption of fruit and vegetables in early childhood may therefore be an effective strategy to reduce this disease burden. What did we want to find out? We wanted to know the benefits and harms of interventions designed to increase eating of fruit or vegetables or both amongst children aged five years and under. What did we do? We searched various electronic databases to find studies. We contacted the authors of the included studies for additional potentially relevant studies. Any randomised study (where participants have the same chance of being assigned to treatment or a no‐treatment control) of interventions aiming to increase the intake of fruit or vegetables or both by children aged five years and under, which measured intake, was eligible. Two review authors independently searched for and extracted information from studies. We searched up to March 2023. What did we find? We included 53 studies with 12,350 people taking part. Sixteen studies examined child‐feeding practice interventions (e.g. repeated exposure to vegetables); 20 examined multicomponent interventions (e.g. combining two or more interventions, such as preschool policy changes with parent nutrition education); 17 examined parent nutrition education interventions; two examined child nutrition education interventions; and one each examined child‐focused mindfulness or providing families with fruit and vegetable interventions. Child‐feeding practice interventions and multicomponent interventions probably lead to small increases in children's intake of fruit and vegetables in the short term (less than 12 months). Parent nutrition education interventions may lead to little to no increase in children's eating of fruit and vegetables. Limited information was available on cost and unintended harms. Of the studies that did report these, intervention costs ranged from 325 to 1500 US dollars (USD). No unintended harms were found in the two studies that reported assessing them. Studies reporting funding support received governmental or charitable funds, except for one study that received industry funding. What are the limitations of the evidence? No studies were conducted in low‐income countries and only one study was conducted in a middle‐income country. Our confidence in the current evidence is moderate for child feeding and multicomponent interventions, and low for parent nutrition education interventions. How up‐to‐date is this evidence? This evidence is up‐to‐date to March 2023. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Hodder, RK, O'Brien, KM, Wyse, RJ, Tzelepis, F, Yoong, S, Stacey, FG, Wolfenden, L", "articleTypes": [], "doi": "10.1002/14651858.CD008552.pub8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.766Z" }, { "id": "f2d0f321-daa9-4da1-90a1-2a96d7c1e182", "pmid": "", "title": "Interventions for hyperthyroidism pre‐pregnancy and during pregnancy", "imported": false, "abstract": "Abstract - Background Women with hyperthyroidism in pregnancy have increased risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction; and they can develop severe pre‐eclampsia or placental abruption. Objectives To identify interventions used in the management of hyperthyroidism pre‐pregnancy or during pregnancy and to ascertain the impact of these interventions on important maternal, fetal, neonatal and childhood outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 September 2013). Selection criteria We planned to include randomised controlled trials, quasi‐randomised controlled trials, and cluster‐randomised trials comparing antithyroid interventions for hyperthyroidism pre‐pregnancy or during pregnancy with another intervention or no intervention (placebo or no treatment). Data collection and analysis Two review authors assessed trial eligibility and planned to assess trial quality and extract the data independently. Main results No trials were included in the review. Authors' conclusions As we did not identify any eligible trials, we are unable to comment on implications for practice, although early identification of hyperthyroidism before pregnancy may allow a woman to choose radioactive iodine therapy or surgery before planning to have a child. Designing and conducting a trial of antithyroid interventions for pregnant women with hyperthyroidism presents formidable challenges. Not only is hyperthyroidism a relatively rare condition, both of the two main drugs used have potential for harm, one for the mother and the other for the child. More observational research is required about the potential harms of methimazole in early pregnancy and about the potential liver damage from propylthiouracil. Plain language summary No evidence found from randomised trials for drugs to treat pregnant women with hyperthyroidism Hyperthyroidism in pregnancy is a rare, serious condition which can increase the risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction. Pregnant women who are hyperthyroid may also develop severe pre‐eclampsia or placental abruption. Most of these women have Graves' disease, an autoimmune disease most common in women aged 20 to 40 years. Most pregnant women with hyperthyroidism are diagnosed with thyroid disease prior to conception and will have previously received treatment for the condition. Generally only drug therapy is considered for treating pregnant women with hyperthyroidism. Radioiodine treatment is not used in pregnancy because it destroys the fetal thyroid gland, resulting in permanent hypothyroidism in the newborn. The main antithyroid drugs used are the thionamides, propylthiouracil (PTU), methimazole and carbimazole. PTU is currently the favoured drug for use in pregnancy, as it is associated with fewer teratogenic effects (scalp lesions) than methimazole. However, since there have been reports of liver damage in people taking PTU, it may be reasonable for pregnant hyperthyroid women to be treated with PTU in the first trimester (to reduce any teratogenic effects of methimazole) and then to change to methimazole. We did not identify any randomised trials to help inform women and their doctors about which antithyroid drugs are most effective, with the lowest potential for harm.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Earl, R, Crowther, CA, Middleton, P", "articleTypes": [], "doi": "10.1002/14651858.CD008633.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.770Z" }, { "id": "f2d55ea2-44f2-4085-9747-33235499e8e7", "pmid": "", "title": "Community‐based supplementary feeding for food insecure, vulnerable and malnourished populations – an overview of systematic reviews", "imported": false, "abstract": "Abstract - Background Supplementary feeding may help food insecure and vulnerable people by optimising the nutritional value and adequacy of the diet, improving quality of life and improving various health parameters of disadvantaged families. In low‐ and middle‐income countries (LMIC), the problems supplementary feeding aims to address are entangled with poverty and deprivation, the programmes are expensive and delivery is complicated. Objectives 1. To summarise the evidence from systematic reviews of supplementary feeding for food insecure, vulnerable and malnourished populations, including children under five years of age, school‐aged children, pregnant and lactating women, people with HIV or tuberculosis (or both), and older populations. 2. To describe and explore the effects of supplementary feeding given to people in these groups, and to describe the range of outcomes between reviews and range of effects in the different groups. Methods In January 2017, we searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase and nine other databases. We included systematic reviews evaluating community‐based supplementary feeding, and concerning food insecure, vulnerable and malnourished populations. Two review authors independently undertook selection of systematic reviews, data extraction and 'Risk of bias' assessment. We assessed review quality using the AMSTAR tool, and used GRADEpro 'Summary of findings' tables from each review to indicate the certainty of the evidence for the main comparisons. We summarised review findings in the text and reported the data for each outcome in additional tables. We also used forest plots to display results graphically. Main results This overview included eight systematic reviews (with last search dates between May 2006 and February 2016). Seven were Cochrane Reviews evaluating interventions in pregnant women; children (aged from birth to five years) from LMIC; disadvantaged infants and young children (aged three months to five years); children with moderate acute malnutrition (MAM); disadvantaged school children; adults and children who were HIV positive or with active tuberculosis (with or without HIV). One was a non‐Cochrane systematic review in older people with Alzheimer's disease. These reviews included 95 trials relevant to this overview, with the majority (74%) of participants from LMIC. The number of included participants varied between 91 and 7940 adults, and 271 and more than 12,595 children. Trials included a wide array of nutritional interventions that varied in duration, frequency and format, with micronutrients often reported as cointerventions. Follow‐up ranged from six weeks to two years; three trials investigated outcomes at four to 17 years of age. All reviews were rated as high quality (AMSTAR score between eight and 11). The GRADE certainty ratings ranged from very low to moderate for individual comparisons, with the evidence often comprising only one or two small trials, thereby resulting in many underpowered analyses (too small to detect small but important differences). The main outcome categories reported across reviews were death, anthropometry (adults and children) and other markers of nutritional status, disease‐related outcomes, neurocognitive development and psychosocial outcomes, and adverse events. Mortality data were limited and underpowered in meta‐analysis in all populations (children with MAM, in children with HIV, and in adults with tuberculosis) with the exception of balanced energy and protein supplementation in pregnancy, which may have reduced the risk of stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94; 5 trials, 3408 women). Supplementation in pregnancy also improved infant birth weight (mean difference (MD) 40.96 g, 95% CI 4.66 to 77.26; 11 trials, 5385 participants) and reduced risk of infants born small‐for‐gestational age (RR 0.79, 95% CI 0.69 to 0.90; 7 trials, 4408 participants). These effects did not translate into demonstrable long‐term benefits for children in terms of growth and neurocognitive development in the one to two trials reporting on longer‐term outcomes. In one study (505 participants), high‐protein supplementation was associated with increased risk of small‐for‐gestational age babies. Effects on growth in children were mixed. In children under five years of age from LMIC, one review found that supplementary feeding had a little or no effect on child growth; however, a more recent review in a similar population found that those who received food supplementation gained an average of 0.12 kg more in weight (MD 0.12 kg, 95% CI 0.05 to 0.18; 9 trials, 1057 participants) and 0.27 cm more in height (MD 0.27 cm, 95% CI 0.07 to 0.48; 9 trials, 1463 participants) than those who were not supplemented. Supplementary food was generally more effective for younger children (younger than two years of age) and for those who were poorer or less well‐nourished. In children with MAM, the provision of specially formulated food improved their weight, weight‐for‐height z scores and other key outcomes such as recovery rate (by 29%), as well as reducing the number of participants dropping out (by 70%). In LMIC, school meals seemed to lead to small benefits for children, including improvements in weight z scores, especially in children from lower‐income countries, height z scores, cognition or intelligence quotient tests, and maths and spelling performance. Supplementary feeding in adults who were HIV positive increased the daily energy and protein intake compared to nutritional counselling alone. Supplementation led to an initial improvement in weight gain or body mass index but did not seem to confer long‐term benefit. In adults with tuberculosis, one small trial found a significant benefit on treatment completion and sputum conversion rate. There were also significant but modest benefits in terms of weight gain (up to 2.60 kg) during active tuberculosis. The one study included in the Alzheimer's disease review found that three months of daily oral nutritional supplements improved nutritional outcomes in the intervention group. There was little or no evidence regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes. Authors' conclusions Considering the current evidence base included, supplementary food effects are modest at best, with inconsistent and limited mortality evidence. The trials reflected in the reviews mostly reported on short‐term outcomes and across the whole of the supplementation trial literature it appears important outcomes, such as quality of life and cost of programmes, are not systematically reported or summarised. Plain language summary Supplementary feeding for groups of people that are food insecure, vulnerable and malnourished What was the aim of this review? To summarise the effect of supplementary feeding on populations that were food insecure, vulnerable and malnourished. The overview authors found eight systematic reviews examining supplementary feeding in a variety of populations. Key messages Across a range of vulnerable populations, supplementary feeding programmes sometimes show modest benefit in nutritional outcomes. In a few studies examining mortality (death), effects were either small or absent, and research mostly looked at short‐term effects. What was studied in the review? Supplementary feeding means providing extra food to people or families over and above their home diet and has been used in populations that are food insecure (limited access to adequate and nutritious food) and vulnerable (including women and young children; school‐aged children; people living with diseases such as tuberculosis, HIV, and Alzheimer's disease; and older people) to improve their health and quality of life. What are the main results of the review? The evidence presented here was current to January 2017. We found eight systematic reviews to include in this summary. These reviews included 95 studies (including up to 7940 adults, and more than 12,595 children in a few studies). Most of the included studies lasted from six weeks to two years, with only three studies following people for longer periods of time (up to 17 years). In these reviews, there were a wide range of different types of supplementary feeding given to vulnerable groups over different periods of time, and often in combination with vitamins or minerals. In pregnancy, we found that energy and protein supplements that were balanced (i.e. providing adequate amounts of energy and nutrients, in this case protein) may have decreased the rate of stillbirth (death or loss of a baby before or during delivery), improved infant birth weight and reduced the risk of infants born small‐for‐gestational age (infants that are smaller than expected). We observed no long‐term benefits for children in terms of growth and cognitive (intellectual) development (although very few studies reported long‐term effects). High‐protein supplements (containing protein in higher amounts) were associated with risk and harm (increased risk of small‐for‐gestational age babies). We found that the effects of supplementary feeding on growth in children were varied. In children under five years of age from low‐ and middle‐income countries, supplementary feeding had a small impact on child growth. We observed some benefits in terms of weight and height gains, especially in younger children (those younger than two years of age) and in those who were poorer or less well‐nourished (or both). Some benefit could be seen in children with moderate acute malnutrition in terms of weight gain, other growth factors and recovery rate. School meals seemed to lead to a number of small benefits in school children (including improvements in weight, height, intelligence tests, and maths and spelling performance). Supplementary feeding in adults who were HIV positive increased the daily intake of energy and protein and led to an early improvement in weight gain or body mass index (measure of whether someone is overweight or underweight), or both, but did not seem to lead to long‐term benefits (although few studies reported long‐term effects). In adults with tuberculosis (serious infectious lung disease), we observed small benefits in terms of weight gain during active tuberculosis. In Alzheimer's disease (a type of dementia), providing a daily oral nutrition supplement for three months improved nutritional outcomes (such as weight and energy intake). There was little or no evidence available regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Visser, J, McLachlan, MH, Maayan, N, Garner, P", "articleTypes": [], "doi": "10.1002/14651858.CD010578.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.799Z" }, { "id": "f2dbfca4-9373-4ca4-aafb-996e918b2179", "pmid": "", "title": "Eszopiclone for insomnia", "imported": false, "abstract": "Abstract - Background Insomnia is a major public health issue affecting between 6% to 10% of the adult population in Western countries. Eszopiclone is a hypnotic drug belonging to a newer group of hypnotic agents, known as new generation hypnotics, which was marketed as being just as effective as benzodiazepines for this condition, while being safer and having a lower risk for abuse and dependence. It is the aim of the review to integrate evidence from randomised controlled trials and to draw conclusions on eszopiclone's efficacy and safety profile, while taking methodological features and bias risks into consideration. Objectives To assess the efficacy and safety of eszopiclone for the treatment of insomnia compared to placebo or active control. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, Embase, PsycINFO, PSYNDEX and registry databases (WHO trials portal, ClinicalTrials.gov) with results incorporated from searches to 10 February 2016. To identify trials not registered in electronic databases, we contacted key informants and searched reference lists of identified studies. We ran an update search (21 February 2018) and have placed studies of interest in awaiting classification/ongoing studies. These will be incorporated into the next version of the review, as appropriate. Selection criteria Parallel group randomised controlled trials (RCTs) comparing eszopiclone with either placebo or active control were included in the review. Participants were adults with insomnia, as diagnosed with a standardised diagnostic system, including primary insomnia and comorbid insomnia. Data collection and analysis Two authors independently extracted outcome data; one reviewer assessed trial quality and the second author cross‐checked it. Main results A total of 14 RCTs, with 4732 participants, were included in this review covering short‐term (≤ 4 weeks; 6 studies), medium‐term (> 4 weeks ≤ 6 months; 6 studies) and long‐term treatment (> 6 months; 2 studies) with eszopiclone. Most RCTs included in the review included participants aged between 18 and 64 years, three RCTs only included elderly participants (64 to 85 years) and one RCT included participants with a broader age range (35 to 85 years). Seven studies considered primary insomnia; the remaining studies considered secondary insomnia comorbid with depression (2), generalised anxiety (1), back pain (1), Parkinson's disease (1), rheumatoid arthritis (1) and menopausal transition (1). Meta‐analytic integrations of participant‐reported data on sleep efficacy outcomes demonstrated better results for eszopiclone compared to placebo: a 12‐minute decrease of sleep onset latency (mean difference (MD) ‐11.94 min, 95% confidence interval (CI) ‐16.03 to ‐7.86; 9 studies, 2890 participants, moderate quality evidence), a 17‐minute decrease of wake time after sleep onset (MD ‐17.02 min, 95% CI ‐24.89 to ‐9.15; 8 studies, 2295 participants, moderate quality evidence) and a 28‐minute increase of total sleep time (MD 27.70 min, 95% CI 20.30 to 35.09; 10 studies, 2965 participants, moderate quality evidence). There were no significant changes from baseline to the first three nights after drug discontinuation for sleep onset latency (MD 17.00 min, 95% CI ‐4.29 to 38.29; 1 study, 291 participants, low quality evidence) and wake time after sleep onset (MD ‐6.71 min, 95% CI ‐21.25 to 7.83; 1 study, 291 participants, low quality evidence). Adverse events during treatment that were documented more frequently under eszopiclone compared to placebo included unpleasant taste (risk difference (RD) 0.18, 95% CI 0.14 to 0.21; 9 studies, 3787 participants), dry mouth (RD 0.04, 95% CI 0.02 to 0.06; 6 studies, 2802 participants), somnolence (RD 0.04, 95% CI 0.02 to 0.06; 8 studies, 3532 participants) and dizziness (RD 0.03, 95% CI 0.01 to 0.05; 7 studies, 2933 participants). According to the GRADE criteria, evidence was rated as being of moderate quality for sleep efficacy outcomes and adverse events and of low quality for rebound effects and next‐day functioning. Authors' conclusions Eszopiclone appears to be an efficient drug with moderate effects on sleep onset and maintenance. There was no or little evidence of harm if taken as recommended. However, as certain patient subgroups were underrepresented in RCTs included in the review, findings might not have displayed the entire spectrum of possible adverse events. Further, increased caution is required in elderly individuals with cognitive and motor impairments and individuals who are at increased risk of using eszopiclone in a non‐recommended way. Plain language summary Eszopiclone (Lunesta) for sleep difficulty Why is this review important? Insomnia is the medical term for sleep difficulty covering trouble falling asleep, difficulties staying asleep, waking up too early or experiencing sleep as non‐restorative. Insomnia can be treated with different methods including behaviour modification, relaxation techniques, or sleeping medication. Eszopiclone (Lunesta) is a sleeping medication that belongs to a class of sleeping tablets known as non‐benzodiazepine hypnotics. Who will be interested in this review? People who are affected by insomnia, general practitioners, professionals working in health services, and addiction treatment and health policy makers. What questions does this review aim to answer? The review aimed to find out more about the wanted effects and unwanted effects of eszopiclone. Wanted effects included the immediate effects eszopiclone has on sleep; unwanted effects included side effects, effects on next‐day functioning, but also addictive properties of the drug. Which studies were included in the review? The review summarised findings from 14 clinical studies with 4732 people, either receiving eszopiclone or an identically‐appearing, but inert substance (placebo). What does the evidence from the review tell us? On average, people taking eszopiclone fell asleep 12 minutes faster than those taking placebo, were 17 minutes less awake during the night and had, in total, about half an hour more sleep than people in the placebo group. As side effects, eszopiclone can cause unpleasant taste, dizziness, dry mouth, and tiredness during the day. Clinical studies did not find evidence that eszopiclone was causing serious harm or withdrawal symptoms or whether it was addictive if it was stopped and not taken after several weeks or months of treatment. Nevertheless, as clinical studies included in the review did not cover certain groups (e.g. elderly people with cognitive or motor problems or certain conditions of medication intake), it is important for patients to consult their doctor who knows their medical history and condition. What should happen next? Future research needs to compare eszopiclone with other sleep medications to help physicians and patients decide which of the available treatment options to prefer. In addition, sleep medications that are also well tolerated by elderly individuals and individuals with alcohol or drug problems need to be identified.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Rösner, S; Englbrecht, C; Wehrle, R; Hajak, G; Soyka, M", "articleTypes": [], "doi": "10.1002/14651858.CD010703.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.728Z" }, { "id": "f2eae58c-1678-460a-bb7f-4fd032b48ffc", "pmid": "", "title": "Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen‐ultraviolet A photochemotherapy for psoriasis", "imported": false, "abstract": "Abstract - Background The most commonly used types of phototherapy for treating psoriasis are narrow‐band ultraviolet B (NB‐UVB); broad‐band ultraviolet B (BB‐UVB), which includes selective (delivering radiation with a wavelength range of 305 to 325 nm) and conventional BB‐UVB (280 to 320 nm); and psoralen ultraviolet A photochemotherapy (oral or bath PUVA). There is substantial controversy regarding their efficacy when compared with each other. Objectives To assess the effects of narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for psoriasis. Search methods We searched the following databases up to August 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 7), MEDLINE (from 1946), and EMBASE (from 1974). We searched the following databases up to November 2012: CNKI (from 1974) and CBM (from 1978). We also searched trials registers and the OpenGrey database. Selection criteria We included all randomised controlled trials (RCTs) that compared NB‐UVB phototherapy with BB‐UVB or PUVA for treating psoriasis, which included chronic plaque psoriasis (CPP), guttate psoriasis (GP), and palmoplantar psoriasis (PPP). Data collection and analysis Two review authors independently conducted the study selection, 'Risk of bias' assessment, and data extraction. Main results We included 13 RCTs, with a total of 662 participants. We report the results of intention‐to‐treat analyses (ITT) here. Our primary outcomes of interest were as follows: Participant‐rated global improvement, Percentage of participants reaching Psoriasis Area and Severity Index (PASI) 75 (which meant equal to or more than 75% reduction in PASI score), Withdrawal due to side‐effects, and Clearance rate. In one RCT of NB‐UVB compared with oral PUVA in participants with CPP, the difference in PASI 75 was not statistically significant (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.63 to 1.32; N = 51; low quality). In three other RCTs of CPP, the clearance rates were inconsistent because in one, there was no difference between the groups (RR 1.01, 95% CI 0.91 to 1.12; N = 54), and in the other two, the clearance rates were statistically significantly in favour of oral PUVA: RR 0.66, 95% CI 0.47 to 0.93; N = 93 and RR 0.75, 95% CI 0.59 to 0.96; N = 100, respectively. Pooled data from these three studies indicated that withdrawals due to adverse events were not significantly different between either group (RR 0.71, 95% CI 0.20 to 2.54; N = 247; low quality). The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate for CPP was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the NB‐UVB and bath PUVA groups (RR 1.79, 95% CI 0.46 to 6.91; N = 92; low quality), while a parallel RCT favoured bath PUVA (RR 0.18, 95% CI 0.05 to 0.71; N = 36; low quality). In participants with PPP, one RCT found there were no significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate (RR 0.09, 95% CI 0.01 to 1.56; N = 50; low quality). Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or GP in terms of clearance rate (RR 0.93, 95% CI 0.79 to 1.10; N = 90; low quality). One RCT in people with CPP found no significant differences between NB‐UVB and selective BB‐UVB in terms of clearance rate (RR 1.40, 95% CI 0.92 to 2.13; N = 100; low quality) and withdrawals due to adverse events (RR 3.00, 95% CI 0.32 to 27.87; N = 100; low quality). No studies reported our primary outcomes for NB‐UVB compared with conventional BB‐UVB. Authors' conclusions Current evidence is very heterogeneous and needs to be interpreted with caution. The clearance rate between oral PUVA and NB‐UVB is inconsistent among the included studies. Evidence regarding NB‐UVB versus bath PUVA is also inconsistent. Re‐NB‐UVB and re‐PUVA are similarly effective for treating people with CPP or GP. In practice, NB‐UVB may be more convenient to use since exogenous photosensitiser is not required before phototherapy. NB‐UVB is considered ineffective for PPP in clinical practice, and a small RCT did not detect a statistically significant difference between NB‐UVB and topical PUVA for clearing PPP. NB‐UVB seemed to be similar to selective BB‐UVB for clearing CPP. Larger prospective studies are needed to confirm the long‐term safety of NB‐UVB. Plain language summary Narrow‐band ultraviolet B phototherapy versus broad‐band ultraviolet B or psoralen ultraviolet A photochemotherapy for treating psoriasis Psoriasis is a common, chronic inflammatory skin disease, with an estimated global prevalence ranging from 0.5% to 4.6%. Based on clinical features, psoriasis is generally divided into the following: chronic plaque psoriasis (CPP); psoriasis associated with psoriatic arthritis; and pustular, erythrodermic, or guttate psoriasis. We also considered psoriasis affecting the palms and soles (palmoplantar psoriasis, or PPP). Although psoriasis is rarely life‐threatening, it can affect a person's quality of life significantly. Phototherapy is an essential treatment option for people with psoriasis. The most commonly used types of phototherapy are narrow‐band ultraviolet B (NB‐UVB), broad‐band ultraviolet B (BB‐UVB), and psoralen ultraviolet A photochemotherapy (PUVA). PUVA can be further divided into oral, bath, and topical PUVA according to the administrative route of psoralen. NB‐UVB delivers almost exclusively 311 nm radiation, whereas BB‐UVB can be divided into two types: selective BB‐UVB (305 to 325 nm radiation) and conventional BB‐UVB (280 to 320 nm radiation). This review included 13 small randomised controlled trials (RCT), with a total of 662 participants. Most of these were of poor methodological quality. For treating CPP, the clearance rate between the NB‐UVB and oral PUVA groups were inconsistent in three RCTs. In one, there was no difference between the groups, and in the other two, the clearance rate was in favour of oral PUVA. The evidence from the comparison of NB‐UVB with bath PUVA in terms of clearance rate was also inconsistent: Pooled data from two left‐right body comparison RCTs found no significant difference between the two groups, while another RCT favoured bath PUVA. Two RCTs found NB‐UVB plus retinoid (re‐NB‐UVB) and PUVA plus retinoid (re‐PUVA) had similar effects for treating people with CPP or guttate psoriasis. One RCT found no significant differences between NB‐UVB and selective BB‐UVB for clearing CPP or in the number of withdrawals due to side‐effects. In participants with PPP, one RCT found there were no statistically significant differences between NB‐UVB treated sides and topical PUVA treated sides in terms of clearance rate. In summary, NB‐UVB may be preferred to oral or bath PUVA because it is more convenient to use. NB‐UVB seemed to be equal to selective BB‐UVB for clearing CPP. Evidence regarding NB‐UVB and conventional BB‐UVB is limited. The long‐term safety of NB‐UVB needs to be confirmed. The efficacy of NB‐UVB for clearing PPP needs to be confirmed in future studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Chen, X; Yang, M; Cheng, Y; Liu, GJ; Zhang, M", "articleTypes": [], "doi": "10.1002/14651858.CD009481.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.733Z" }, { "id": "f31417f0-e868-45bd-bed4-8a23d3dc67f7", "pmid": "", "title": "Music‐based therapeutic interventions for people with dementia", "imported": false, "abstract": "Abstract - Background Dementia is a clinical syndrome with a number of different causes. It is characterised by deterioration in cognitive, behavioural, social and emotional functioning. Pharmacological interventions are available but have limited effect on many of the syndrome's features. However, receptivity to music may remain until the late phases of dementia, and music‐based therapeutic interventions (which include, but are not limited to, music therapy) are suitable for people with advanced dementia. As there is uncertainty about the effectiveness of music‐based therapeutic interventions, trials are being conducted to evaluate this. This review updates one last published in 2018 and examines the current evidence for the effects of music‐based interventions for people with dementia. Objectives To assess the effects of music‐based therapeutic interventions for people with dementia on emotional well‐being (including quality of life), mood disturbance or negative affect (i.e. depressive symptoms and anxiety), behavioural problems (i.e. overall behavioural problems or neuropsychiatric symptoms, and more specifically agitation or aggression), social behaviour and cognition, at the end of therapy and four or more weeks after the end of treatment, and to assess any adverse effects. Search methods We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organisation's meta‐register‐the International Clinical Trials Registry Platform on 30 November 2023. Selection criteria We included randomised controlled trials of music‐based therapeutic interventions (of at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music. Data collection and analysis Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data from included studies and assess their risk of bias. If necessary, we contacted trial authors to ask for additional data, such as relevant subscales. We pooled data using the random‐effects model. We assessed the certainty of the evidence for our two comparisons and our main outcomes of interest using GRADE. Main results We included 30 studies with 1720 randomised participants that were conducted in 15 countries. Twenty‐eight studies with 1366 participants contributed data to meta‐analyses. Ten studies contributed data to long‐term outcomes. Participants had dementia of varying degrees of severity and resided in institutions in most of the studies. Seven studies delivered an individual intervention; the other studies delivered the intervention to groups. Most interventions involved both active and receptive elements of musical experience. The studies were at high risk of performance bias and some were at high risk of detection or other bias. For music‐based therapeutic interventions compared to usual care, we found moderate‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions probably improved depressive symptoms slightly (standardised mean difference (SMD) −0.23, 95% confidence interval (CI) −0.42 to −0.04; 9 studies, 441 participants), and we found low‐certainty evidence that it may have improved overall behavioural problems (SMD −0.31, 95% CI −0.60 to −0.02; 10 studies, 385 participants). We found moderate‐certainty evidence that music‐based therapeutic interventions likely did not improve agitation or aggression (SMD −0.05, 95% CI −0.27 to 0.17; 11 studies, 503 participants). Low to very low certainty evidence showed that they did not improve emotional well‐being (SMD 0.14, 95% CI ‐0.29 to 0.56; 4 studies, 154 participants), anxiety (SMD −0.15, 95% CI −0.39 to 0.09; 7 studies, 282 participants), social behaviour (SMD 0.22, 95% CI −0.14 to 0.57; 2 studies; 121 participants) or cognition (SMD 0.19, 95% CI −0.02 to 0.41; 7 studies, 353 participants). Low or very‐low ‐certainty evidence showed that music‐based therapeutic interventions may not have been more effective than usual care in the long term (four weeks or more after the end of treatment) for any of the outcomes. For music‐based therapeutic interventions compared to other interventions, we found low‐certainty evidence that, at the end of treatment, music‐based therapeutic interventions may have been more effective than the other activities for social behaviour (SMD 0.52, 95% CI 0.08 to 0.96; 4 studies, 84 participants). We found very low‐certainty evidence of a positive effect on anxiety (SMD −0.75, 95% CI −1.27 to −0.24; 10 studies, 291 participants). For all other outcomes, low‐certainty evidence showed no evidence of an effect: emotional well‐being (SMD 0.20, 95% CI −0.09 to 0.49; 9 studies, 298 participants); depressive symptoms (SMD −0.14, 95% CI ‐0.36 to 0.08; 10 studies, 359 participants); agitation or aggression (SMD 0.01, 95% CI −0.31 to 0.32; 6 studies, 168 participants); overall behavioural problems (SMD −0.08, 95% CI −0.33 to 0.17; 8 studies, 292 participants) and cognition (SMD 0.12, 95% CI −0.21 to 0.45; 5 studies; 147 participants). We found low or very‐low certainty evidence that music‐based therapeutic interventions may not have been more effective than other interventions in the long term (four weeks or more after the end of treatment) for any of the outcomes. Adverse effects were inconsistently measured or recorded, but no serious adverse events were reported. Authors' conclusions When compared to usual care, providing people with dementia with at least five sessions of a music‐based therapeutic intervention probably improves depressive symptoms and may improve overall behavioural problems at the end of treatment. When compared to other activities, music‐based therapeutic interventions may improve social behaviour at the end of treatment. No conclusions can be reached about the outcome of anxiety as the certainty of the evidence is very low. There may be no effects on other outcomes at the end of treatment. There was no evidence of long‐term effects from music‐based therapeutic interventions. Adverse effects may be rare, but the studies were inconsistent in their reporting of adverse effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions. Plain language summary Does music‐based therapy help people with dementia? Key messages · Compared to usual care (i.e. without specific activities), providing people with dementia with music‐based therapy sessions probably improves depression, and may improve overall behavioural problems. · Compared to other activities, music‐based therapy may improve social behaviour, but we are unsure if it improves anxiety. · These effects may not last beyond the end of treatment. · There is no evidence that music‐based therapy makes a difference to the emotional well‐being, agitation or cognition (e.g. thinking and remembering) of people with dementia, although there is uncertainty about this. · There is uncertainty in the evidence for long‐term effects, but no long‐term effects were observed in the studies. · Adverse effects (unwanted side effects) may be rare, but the studies were inconsistent in their reporting, so we need more evidence before we can reach reliable conclusions. Why offer music‐based therapy to people with dementia? People with dementia gradually develop increasing difficulty with thinking and daily activities. Dementia is often associated with emotional and behavioural problems and may decrease a person's quality of life. In the later stages of dementia, it may be difficult for people to communicate with words, but even when they can no longer speak, they may still be able to hum or play along with music. Therapy involving music may therefore be especially suitable for people with dementia to improve their lives. Who provides music‐based therapy? Music therapists are certified to work with individuals or groups of people, using music to try to help meet their physical, psychological and social needs. Other professionals may also be trained to provide similar therapies. What did we want to find out? We wanted to find out if, for people with dementia, music‐based therapy works better than usual care or other activities, such as painting. We were interested in whether the therapy changed these outcomes at the end of treatment: · emotional well‐being including quality of life; · depression and anxiety; · agitation or aggression and overall behavioural problems; · social behaviour; and · cognition (e.g. thinking and remembering). We also wanted to find out if there were any long‐term effects after therapy ended or any unwanted effects. What did we do? We searched for studies in which people with dementia were randomly allocated to receive music‐based therapy (of at least five sessions) or to a comparison group with no activities or different activities. We combined the results of the studies to estimate the effects of music‐based therapy as accurately as possible. We also rated our level of confidence in the findings. What did we find? We found 30 studies performed in 15 countries. The studies involved 1720 people with dementia of varying severity. In most of the studies, the participants lived in nursing homes. Seven studies delivered the music‐based therapy to individuals; the other studies delivered the intervention to groups. We were able to use results from 28 studies involving 1366 people with dementia for one or more outcomes at the end of treatment. Ten studies contributed information about long‐term results. Main results At the end of treatment Music‐based therapy probably improves depression and may improve overall behavioural problems, compared with providing usual care. Music‐based therapy may improve social behaviour compared to other activities. We were less confident about the effects of music‐based therapy on anxiety compared to other activities. The available evidence does not suggest any benefit of music‐based therapy for emotional well‐being (including quality of life), agitation and aggression, or cognition, but the evidence is limited and there is uncertainty about this. In the longer term Some studies measured outcomes four weeks or more after treatment ended. We did not find any lasting effects, but there were fewer results measured in the longer term, and we are uncertain about this evidence. Further studies are likely to have a significant impact on what we know about the effects of music‐based therapy for people with dementia, so it is important that research continues. What are the limitations of the evidence? There was variation in the quality of the studies and how well they were reported. In all studies, participants and personnel might have known which treatment participants were getting, and in some, the assessors might have known this as well. This could have affected the results. Regarding effects at the end of music‐based therapy, we are moderately confident in the evidence for the beneficial effect on depression compared to usual care. We have little confidence in the effects or lack of effects on any of the other outcomes. Adverse effects were rarely reported. How up to date is this evidence? This review updates our previous review. We added eight new studies and reached new conclusions. The evidence is current to 30 November 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "van der Steen, JT; van der Wouden, JC; Methley, AM; Smaling, HJ A; Vink, AC; Bruinsma, MS", "articleTypes": [], "doi": "10.1002/14651858.CD003477.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "f31ed6ab-02b3-4e85-a797-ddf5db210986", "pmid": "", "title": "Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia", "imported": false, "abstract": "Abstract - Background Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases children's risk of developing pneumonia. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited. This is an update of a Cochrane Review first published in 2018. Objectives To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia. Search methods We searched CENTRAL, MEDLINE, Embase, and two trial registries on 28 December 2021. We applied no language restrictions. Selection criteria We included randomised controlled trials (RCTs) that compared vitamin D supplementation with placebo in children (aged one month to five years) hospitalised with acute community‐acquired pneumonia, as defined by the World Health Organization (WHO) acute respiratory infection guidelines. For this update, we reappraised eligible trials according to research integrity criteria, excluding RCTs published from April 2018 that were not prospectively registered in a trials registry according to WHO or Clinical Trials Registry – India (CTRI) guidelines (it was not mandatory to register clinical trials in India before April 2018). Data collection and analysis Two review authors independently assessed trials for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with number of participants in each group. We used standard methodological procedures expected by Cochrane. Main results In this update, we included three new trials involving 468 children, bringing the total number of trials to seven, with 1601 children (631 with pneumonia and 970 with severe or very severe pneumonia). We categorised three previously included studies and three new studies as 'awaiting classification' based on the research integrity screen.
Five trials used a single bolus dose of vitamin D (300,000 IU in one trial and 100,000 IU in four trials) at the onset of illness or within 24 hours of hospital admission; one used a daily dose of oral vitamin D (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used variable doses (on day 1, 20,000 IU in children younger than six months, 50,000 IU in children aged six to 12 months, and 100,000 IU in children aged 13 to 59 months; followed by 10,000 IU/day for four days or until discharge). Three trials performed microbiological diagnosis of pneumonia, radiological diagnosis of pneumonia, or both. Vitamin D probably has little or no effect on the time to resolution of acute illness (mean difference (MD) −1.28 hours, 95% confidence interval (CI) −5.47 to 2.91; 5 trials, 1188 children; moderate‐certainty evidence). We do not know if vitamin D has an effect on the duration of hospitalisation (MD 4.96 hours, 95% CI −8.28 to 18.21; 5 trials, 1023 children; very low‐certainty evidence). We do not know if vitamin D has an effect on mortality rate (risk ratio (RR) 0.69, 95% CI 0.44 to 1.07; 3 trials, 584 children; low‐certainty evidence). The trials reported no major adverse events. According to GRADE criteria, the evidence was of very low‐to‐moderate certainty for all outcomes, owing to serious trial limitations, inconsistency, indirectness, and imprecision. Three trials received funding: one from the New Zealand Aid Corporation, one from an institutional grant, and one from multigovernment organisations (Bangladesh, Sweden, and UK). The remaining four trials were unfunded. Authors' conclusions Based on the available evidence, we are uncertain whether vitamin D supplementation has important effects on outcomes of acute pneumonia when used as an adjunct to antibiotics. The trials reported no major adverse events. Uncertainty in the evidence is due to imprecision, risk of bias, inconsistency, and indirectness. Plain language summary Is vitamin D an effective and safe addition to antibiotics for treating children with acute pneumonia? What is pneumonia, and how can it be treated? Pneumonia is inflammation (swelling) of the lungs caused by an infection. Treatment for pneumonia includes antibiotics, providing oxygen through a mask, and other supportive therapies. Vitamin D boosts immune defences and reduces excessive inflammation: these effects may help children recover from an episode of pneumonia. What did we want to find out? We wanted to find out if vitamin D, taken together with antibiotics, can help children to recover from an episode of pneumonia. What did we do? We searched for trials that looked at vitamin D compared with placebo (dummy treatment) in children aged between one month and five years who had pneumonia. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. Study characteristics We included seven trials involving 1601 children from low‐ and middle‐income countries. In five trials, children received a single large dose of vitamin D when they joined the trial or within 24 hours of admission to hospital. In two trials, children received vitamin D for five days. One trial excluded children with normal vitamin D levels. Two trials reported the cause of children's pneumonia. Key results Vitamin D probably has little or no effect on the time it takes children to get better from pneumonia. We do not know if vitamin D has an effect on the time children spend in hospital or the number of children who die. The studies reported no major harmful events. What are the limitations of the evidence? We have only moderate confidence in the evidence on the time it took children to recover from pneumonia, because all children in this comparison were from low‐income regions, so the results may not apply to higher‐income populations. We have little confidence in the evidence on death rate, because of the same applicability problem outlined above, and because the result was compatible with both appreciable benefit and harm. We have very little confidence in the evidence on time spent in hospital, because of the same applicability problem outlined above, because the children and health providers in one study knew what the allocated treatment was, and because the results were very inconsistent across the studies included in the comparison. How up to date is the evidence? The evidence is current to 28 December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Das, RR; Singh, M; Naik, SS", "articleTypes": [], "doi": "10.1002/14651858.CD011597.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "f324ec81-b98c-4e70-84cb-1246cdb8b92b", "pmid": "", "title": "Interventions for hirsutism (excluding laser and photoepilation therapy alone)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "van Zuuren, EJ, Fedorowicz, Z, Carter, B, Pandis, N", "articleTypes": [], "doi": "10.1002/14651858.CD010334.pub2 AB - Abstract - Background Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen‐sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective. Objectives To assess the effects of interventions (except laser and light‐based therapies alone) for hirsutism. Search methods We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014. Selection criteria Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism. Data collection and analysis Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses. Main results We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty‐eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow‐up above 40%. Primary outcomes, 'participant‐reported improvement of hirsutism' and 'change in health‐related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin‐releasing hormone (GnRH) analogues)). Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one‐third of studies. The quality of evidence was moderate to very low for most outcomes. There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman‐Gallwey scores. The mean difference (MD) was ‐1.84 (95% confidence interval (CI) ‐3.86 to 0.18). There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman‐Gallwey scores more effectively than placebo (MD ‐7.60, 95% CI ‐10.53 to ‐4.67 and MD ‐7.20, 95% CI ‐10.15 to ‐4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87). Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman‐Gallwey scores (MD ‐7.69, 95% CI ‐10.12 to ‐5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD ‐1.90, 95% CI ‐5.01 to 1.21 and MD 0.49, 95% CI ‐1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI ‐0.58 to 3.56 and MD 0.40, 95% CI ‐1.18 to 1.98) (low quality evidence). Although there was very low quality evidence of a difference in reduction of Ferriman‐Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD ‐5.73, 95% CI ‐6.87 to ‐4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached. Metformin demonstrated no benefit over placebo in reduction of Ferriman‐Gallwey scores (MD 0.05, 95% CI ‐1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements. We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman‐Gallwey scores. Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman‐Gallwey scores (low quality evidence). Ferriman‐Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD ‐6.30, 95% CI ‐9.83 to ‐2.77) (very low quality evidence). Data showing reductions in Ferriman‐Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%). Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman‐Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs. Authors' conclusions Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision‐making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects. Further research should consist of well‐designed, rigorously reported, head‐to‐head trials examining OCPs combined with antiandrogens or 5α‐reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α‐reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment. Plain language summary Treatments for unwanted male pattern hair growth in women Background 
 Up to 5% to 10% of women are hirsute (hair in areas where normally only men have hairs such as moustache, beard area, chest, belly, back etc). The most common cause is polycystic ovary syndrome. Hirsutism can lead to psychological distress, low self esteem, decreased self image, depression, feelings of shame and social difficulties. Review question 
 Which treatments (except laser and light‐based therapies alone) work best for hirsutism? Study characteristics 
 We included 157 studies published up to June 2014, which examined 10,550 people. Participants included women with a mean age of 25 years. There was considerable variation in the quality of how the studies were conducted; more than half were not blinded and this may have had an impact on the reporting of the outcomes. Most studies were carried out in single centres in Europe and lasted six to 12 months. A range of treatments were evaluated, mostly in single studies. These included a few topical treatments, lifestyle modification, oral contraceptive pills (OCPs), medication to inhibit the effect of hormones that are responsible for male traits, and combination therapies. Participant‐assessed improvement and impact on quality of life were evaluated in a minority of the studies, whilst the majority of the studies measured physician‐assessed reduction in hirsutism, as well as androgen levels in the blood. Half of the studies reported adverse events and around one‐third other signs and symptoms, e.g. oily skin and menstrual irregularities that might be due to an increase of androgen levels in the blood. Key results 
 Oral contraceptive pills reduced the amount of hairs, but the reduction was not consistent across the studies, although two OCPs (ethinyl estradiol 35 µg + cyproterone acetate 2 mg compared to ethinyl estradiol 30 µg + desogestrel 0.15 mg) appeared to be effective in a way that can be considered important for women with hirsutism. Of the antiandrogen drugs, flutamide was considered to be more effective than placebo by both the women and the doctors. Spironolactone was also effective, but data were only available for the physicians' assessments. Finasteride did not show convincing effectiveness based on the evaluations of the hirsute women and those made by the investigators. The addition of cyproterone acetate (an antiandrogen) to OCP seemed to enhance the beneficial effect of OCPs on hair reduction. Insulin sensitisers (antidiabetic drugs) and lifestyle modification did not have any demonstrable benefit in terms of the severity of hirsutism. Unfortunately, the self assessments by the women, as well as the impact of hirsutism on their quality of life, were outcomes that were insufficiently addressed in the studies. The adverse events reported with the different drugs are well known, i.e. pain in the stomach and intestines, breast tenderness, reduced libido and dry skin with flutamide and finasteride; irregular bleeding with spironolactone; nausea, diarrhoea and abdominal bloating with metformin; and hot flushes, decreased libido, vaginal dryness, breast tenderness and headaches with the GnRH analogues. There were no important differences in blood androgen levels between the different treatment groups, OCPs had a positive effect on acne, and similarly insulin sensitisers improved the menstrual pattern. We were expecting to find evidence that combined therapies of an OCP with an antiandrogen were more effective than, for example, OCPs alone, but the lack of studies did not allow us to draw these conclusions. Overall we concluded that OCPs (especially with antiandrogenic activity), OCPs combined with cyproterone acetate, flutamide and spironolactone are effective in treating hirsutism. However, additional cosmetic measures (epilating, waxing, bleaching, electrolysis, laser and photoepilation) are generally required because all treatments need at least six to 12 months to reach the optimum effect. In addition, because of the distress associated with hirsutism and its impact on quality of life psychological support should be part of the treatment approach. Quality of the evidence 
 The overall quality of the evidence for the different outcomes was on average rated as moderate to very low. Important reasons for this were that studies were not blinded, or had a small sample size.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.801Z" }, { "id": "f3482069-0fb3-456d-8bfc-9d53882def00", "pmid": "", "title": "Systemic administration of local anesthetic agents to relieve neuropathic pain", "imported": false, "abstract": "Abstract - Background Lidocaine, mexiletine, tocainide, and flecainide are local anesthetics which give an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain. Interest reappeared decades later when patient series and clinical trials reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients. With the recent publication of clinical trials with high quality standards, we have reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to update our knowledge, to measure their benefit and harm, and to better define their role in therapy. Objectives To evaluate pain relief and adverse effect rates between systemic local anesthetic‐type drugs and other control interventions. Search methods We searched MEDLINE (1966 through 15 May 2004), EMBASE (January 1980 to December 2002), Cancer Lit (through 15 December 2002), Cochrane Central Register of Controlled Trials (2nd Quarter, 2004), System for Information on Grey Literature in Europe (SIGLE), and LILACS, from January 1966 through March 2001. We also hand searched conference proceedings, textbooks, original articles and reviews. Selection criteria We included trials with random allocation, that were double blinded, with a parallel or crossover design. The control intervention was a placebo or an analgesic drug for neuropathic pain from any cause. Data collection and analysis We collected efficacy and safety data from all published and unpublished trials. We calculated combined effect sizes using continuous and binary data for pain relief and adverse effects as primary and secondary outcome measurements, respectively. Main results Thirty‐two controlled clinical trials met the selection criteria; two were duplicate articles. The treatment drugs were intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (one trial), and tocainide (one trial). Twenty‐one trials were crossover studies, and nine were parallel. Lidocaine and mexiletine were superior to placebo [weighted mean difference (WMD) = ‐11; 95% CI: ‐15 to ‐7; P < 0.00001], and limited data showed no difference in efficacy (WMD = ‐0.6; 95% CI: ‐7 to 6), or adverse effects versus carbamazepine, amantadine, gabapentin or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life‐threatening toxicities. Sensitivity analysis identified data distribution in three trials as a probable source of heterogeneity. There was no publication bias. Authors' conclusions Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. Future trials should enroll specific diseases and test novel lidocaine analogs with better toxicity profiles. More emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful. Plain language summary Systemic administration of local anesthetic agents to relieve neuropathic pain Intravenous lidocaine and oral derivatives relieve pain from damage to the nervous system (neuropathic pain). In early reports, intravenous lidocaine and its oral analogs mexiletine and tocainide relieved neuropathic pain, a type of pain caused by disease in the nervous system. However, the evidence was conflicting. The authors reviewed all randomized studies comparing these drugs with placebo or with other analgesics and found that: local anesthetics were superior to placebo in decreasing intensity of neuropathic pain; limited data showed no difference in efficacy or adverse effects between local anesthetics and carbamazepine, amantadine, gabapentin or morphine; local anesthetics had more adverse effects than placebo; and local anesthetics were safe.", "journal": "Cochrane Database of Systematic Reviews", "year": "2005", "authors": "Challapalli, V; Tremont-Lukats, IW; McNicol, ED; Lau, J; Carr, DB", "articleTypes": [], "doi": "10.1002/14651858.CD003345.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "f36595f4-e23e-4b86-b55f-572ef40a123e", "pmid": "", "title": "Antiamoebic drugs for treating amoebic colitis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Gonzales, MLM, Dans, LF, Sio‐Aguilar, J", "articleTypes": [], "doi": "10.1002/14651858.CD006085.pub3 AB - Abstract - Background Infection with the protozoan Entamoeba histolytica is common in low‐ and middle‐income countries, and up to 100,000 people with severe disease die every year. Adequate therapy for amoebic colitis is necessary to reduce illness, prevent development of complicated disease and extraintestinal spread, and decrease transmission. Objectives To evaluate antiamoebic drugs for treating amoebic colitis. Search methods We searched the available literature up to 22 March 2018. We searched the Cochrane Infectious Diseases Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, m RCT, and conference proceedings. We contacted individual researchers, organizations, and pharmaceutical companies, and we checked reference lists. Selection criteria Randomized controlled trials of antiamoebic drugs given alone or in combination, compared with placebo or another antiamoebic drug, for treating adults and children with a diagnosis of amoebic colitis. Data collection and analysis Two review authors independently assessed the eligibility and methodological quality of trials and extracted and analysed the data. We calculated clinical and parasitological failure rates and rates of relapse and adverse events as risk ratios (RRs) with 95% confidence intervals (CIs), using a random‐effects model. We determined statistical heterogeneity and explored possible sources of heterogeneity using subgroup analyses. We carried out sensitivity analysis by using trial quality to assess the robustness of reported results. Main results In total, 41 trials (4999 participants) met the inclusion criteria of this review. In this update, we added four trials to the 37 trials included in the first published review version. Thirty trials were published over 20 years ago. Only one trial used adequate methods of randomization and allocation concealment, was blinded, and analysed all randomized participants. Only one trial used an E histolytica stool antigen test, and two trials used amoebic culture. Tinidazole may be more effective than metronidazole for reducing clinical failure (RR 0.28, 95% CI 0.15 to 0.51; 477 participants, eight trials; low‐certainty evidence) and is probably associated with fewer adverse events (RR 0.65, 95% CI 0.46 to 0.92; 477 participants, 8 trials; moderate‐certainty evidence). Compared with metronidazole, combination therapy may result in fewer parasitological failures (RR 0.36, 95% CI 0.15 to 0.86; 720 participants, 3 trials; low‐certainty evidence), but we are uncertain which combination is more effective than another. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Authors' conclusions Compared with metronidazole, tinidazole may be more effective in reducing clinical failure and may be associated with fewer adverse events. Combination drug therapy may be more effective for reducing parasitological failure compared with metronidazole alone. However, these results are based mostly on small trials conducted over 20 years ago with a variety of poorly defined outcomes. Tests that detect E histolytica more accurately are needed, particularly in countries where concomitant infection with other bacteria and parasites is common. 11 April 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (22 Mar, 2018) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section) Plain language summary Antiamoebic drugs for treating amoebic colitis What is the aim of this review? This Cochrane Review aims to determine the effectiveness and safety of drugs used to treat people with amoebic colitis, which is an infection of the large intestines caused by the parasite, Entamoeba histolytica . Cochrane researchers searched for all relevant studies to answer this question and included 41 relevant studies in this review. Key messages Tinidazole may be more effective than metronidazole for reducing clinical symptoms and may be associated with fewer adverse events. Combination therapy resulted in fewer parasitological failures than occurred with metronidazole alone. Evidence is insufficient to allow conclusions regarding the efficacy of other antiamoebic drugs. Better quality randomized trials using accurate diagnostic methods and standardized outcomes are needed to evaluate the efficacy of drugs for treating individuals with amoebic colitis. What was studied in the review? Entamoeba histolytica is distributed throughout the world and is commonly acquired by ingestion of contaminated food or water. An estimated 40 to 50 million people infected with E histolytica develop amoebic colitis or extraintestinal abscesses, resulting in up to 100,000 deaths per year. Metronidazole is currently the standard therapy for treating adults and children with invasive amoebiasis, but it may not be sufficient to eliminate amoebic cysts from the intestine. Some unpleasant adverse effects have been associated with metronidazole, and the possibility of parasite resistance to metronidazole has led to the development of alternative drugs. Combinations of metronidazole with other drugs that eradicate surviving cysts in the intestines have been recommended, so evidence to support this approach needs to be assessed. This review compares different drugs used against amoebic colitis, alone or in combination, and also assesses single‐dose regimens versus longer regimens. What are the main results of the review? This review included 41 studies, most of which were conducted in countries considered to be highly endemic for amoebiasis. Most trials were old: 30 were conducted before 1998. Trials varied in the inclusion criteria used to enrol participants and in the definition and timing of measured outcomes. Stool microscopy with direct wet saline smear was the method used most often to detect the presence of E histolytica in stools. Study participants ranged in age from seven months to 80 years. Included trials reported a variety of comparisons and involved 25 individual drugs, two herbal products, and 15 different combinations. The review shows that in individuals with amoebic colitis, tinidazole may be better for reducing clinical symptoms (low‐certainty evidence) and probably results in fewer adverse events when compared with metronidazole (moderate‐certainty evidence). However, we do not know whether it is more effective for eradicating amoebae from the stools. Combination drug therapy may be more effective than metronidazole alone for eradicating amoebae (low‐certainty evidence), but we are uncertain which drug combination is most effective, and if combination treatment will lead to more rapid resolution of clinical symptoms or in more adverse events (very low‐certainty evidence). Evidence is insufficient to allow conclusions regarding efficacy of the other antiamoebic drugs. How up‐to‐date is this review? 
 The review authors searched for studies that had been published up to 22 March 2018.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.728Z" }, { "id": "f37c49ad-6c7b-43b6-9feb-c9e9612690cf", "pmid": "", "title": "SARS‐CoV‐2‐neutralising monoclonal antibodies to prevent COVID‐19", "imported": false, "abstract": "Abstract - Background Monoclonal antibodies (mAbs) are laboratory‐produced molecules derived from the B cells of an infected host. They are being investigated as potential prophylaxis to prevent coronavirus disease 2019 (COVID‐19). Objectives To assess the effects of SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, to prevent infection with SARS‐CoV‐2 causing COVID‐19; and to maintain the currency of the evidence, using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register, MEDLINE, Embase, and three other databases on 27 April 2022. We checked references, searched citations, and contacted study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) that evaluated SARS‐CoV‐2‐neutralising mAbs, including mAb fragments, alone or combined, versus an active comparator, placebo, or no intervention, for pre‐exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) of COVID‐19. We excluded studies of SARS‐CoV‐2‐neutralising mAbs to treat COVID‐19, as these are part of another review. Data collection and analysis Two review authors independently assessed search results, extracted data, and assessed risk of bias using Cochrane RoB 2. Prioritised outcomes were infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, all‐cause mortality, admission to hospital, quality of life, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. Main results We included four RCTs of 9749 participants who were previously uninfected and unvaccinated at baseline. Median age was 42 to 76 years. Around 20% to 77.5% of participants in the PrEP studies and 35% to 100% in the PEP studies had at least one risk factor for severe COVID‐19. At baseline, 72.8% to 82.2% were SARS‐CoV‐2 antibody seronegative. We identified four ongoing studies, and two studies awaiting classification. Pre‐exposure prophylaxis Tixagevimab/cilgavimab versus placebo One study evaluated tixagevimab/cilgavimab versus placebo in participants exposed to SARS‐CoV‐2 wild‐type, Alpha, Beta, and Delta variant. About 39.3% of participants were censored for efficacy due to unblinding and 13.8% due to vaccination. Within six months, tixagevimab/cilgavimab probably decreases infection with SARS‐CoV‐2 (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.29 to 0.70; 4685 participants; moderate‐certainty evidence), decreases development of clinical COVID‐19 symptoms (RR 0.18, 95% CI 0.09 to 0.35; 5172 participants; high‐certainty evidence), and may decrease admission to hospital (RR 0.03, 95% CI 0 to 0.59; 5197 participants; low‐certainty evidence). Tixagevimab/cilgavimab may result in little to no difference on mortality within six months, all‐grade AEs, and SAEs (low‐certainty evidence). Quality of life was not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and Delta variant. About 36.5% of participants opted for SARS‐CoV‐2 vaccination and had a mean of 66.1 days between last dose of intervention and vaccination. Within six months, casirivimab/imdevimab may decrease infection with SARS‐CoV‐2 (RR 0.01, 95% CI 0 to 0.14; 825 seronegative participants; low‐certainty evidence) and may decrease development of clinical COVID‐19 symptoms (RR 0.02, 95% CI 0 to 0.27; 969 participants; low‐certainty evidence). We are uncertain whether casirivimab/imdevimab affects mortality regardless of the SARS‐CoV‐2 antibody serostatus. Casirivimab/imdevimab may increase all‐grade AEs slightly (RR 1.14, 95% CI 0.98 to 1.31; 969 participants; low‐certainty evidence). The evidence is very uncertain about the effects on grade 3 to 4 AEs and SAEs within six months. Admission to hospital and quality of life were not reported. Postexposure prophylaxis Bamlanivimab versus placebo One study evaluated bamlanivimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type. Bamlanivimab probably decreases infection with SARS‐CoV‐2 versus placebo by day 29 (RR 0.76, 95% CI 0.59 to 0.98; 966 participants; moderate‐certainty evidence), may result in little to no difference on all‐cause mortality by day 60 (R 0.83, 95% CI 0.25 to 2.70; 966 participants; low‐certainty evidence), may increase all‐grade AEs by week eight (RR 1.12, 95% CI 0.86 to 1.46; 966 participants; low‐certainty evidence), and may increase slightly SAEs (RR 1.46, 95% CI 0.73 to 2.91; 966 participants; low‐certainty evidence). Development of clinical COVID‐19 symptoms, admission to hospital within 30 days, and quality of life were not reported. Casirivimab/imdevimab versus placebo One study evaluated casirivimab/imdevimab versus placebo in participants who may have been exposed to SARS‐CoV‐2 wild‐type, Alpha, and potentially, but less likely to Delta variant. Within 30 days, casirivimab/imdevimab decreases infection with SARS‐CoV‐2 (RR 0.34, 95% CI 0.23 to 0.48; 1505 participants; high‐certainty evidence), development of clinical COVID‐19 symptoms (broad‐term definition) (RR 0.19, 95% CI 0.10 to 0.35; 1505 participants; high‐certainty evidence), may result in little to no difference on mortality (RR 3.00, 95% CI 0.12 to 73.43; 1505 participants; low‐certainty evidence), and may result in little to no difference in admission to hospital. Casirivimab/imdevimab may slightly decrease grade 3 to 4 AEs (RR 0.50, 95% CI 0.24 to 1.02; 2617 participants; low‐certainty evidence), decreases all‐grade AEs (RR 0.70, 95% CI 0.61 to 0.80; 2617 participants; high‐certainty evidence), and may result in little to no difference on SAEs in participants regardless of SARS‐CoV‐2 antibody serostatus. Quality of life was not reported. Authors' conclusions For PrEP, there is a decrease in development of clinical COVID‐19 symptoms (high certainty), infection with SARS‐CoV‐2 (moderate certainty), and admission to hospital (low certainty) with tixagevimab/cilgavimab. There is low certainty of a decrease in infection with SARS‐CoV‐2, and development of clinical COVID‐19 symptoms; and a higher rate for all‐grade AEs with casirivimab/imdevimab. For PEP, there is moderate certainty of a decrease in infection with SARS‐CoV‐2 and low certainty for a higher rate for all‐grade AEs with bamlanivimab. There is high certainty of a decrease in infection with SARS‐CoV‐2, development of clinical COVID‐19 symptoms, and a higher rate for all‐grade AEs with casirivimab/imdevimab. Although there is high‐to‐moderate certainty evidence for some outcomes, it is insufficient to draw meaningful conclusions. These findings only apply to people unvaccinated against COVID‐19. They are only applicable to the variants prevailing during the study and not other variants (e.g. Omicron). In vitro, tixagevimab/cilgavimab is effective against Omicron, but there are no clinical data. Bamlanivimab and casirivimab/imdevimab are ineffective against Omicron in vitro. Further studies are needed and publication of four ongoing studies may resolve the uncertainties. Plain language summary Are laboratory‐made COVID‐19‐specific monoclonal antibodies effective to prevent COVID‐19 in adults? Key messages Pre‐exposure prophylaxis of COVID‐19: – tixagevimab/cilgavimab probably reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may reduce number of people admitted to hospital; – casirivimab/imdevimab may reduce number of people infected with COVID‐19 and development of COVID‐19 symptoms, and may increase number of unwanted effects (any severity) slightly. Postexposure prophylaxis of COVID‐19: – bamlanivimab probably reduces number of people infected with COVID‐19; – casirivimab/imdevimab reduces number of people infected with COVID‐19 and development of COVID‐19 symptoms, and reduces number of unwanted effects (any severity). What are 'monoclonal' antibodies? The body makes antibodies to defend against disease. However, they may be produced in a laboratory from cells taken from people who have recovered from a disease. Antibodies that target only one specific protein – in this case, a protein on the SARS‐CoV‐2 virus (that causes COVID‐19) – are 'monoclonal'. They attach to the virus and stop it from entering and replicating in human cells to prevent and fight infection. They are relevant for people who do not respond or respond poorly to vaccinations. What did we want to find out? We wanted to know if COVID‐19‐specific monoclonal antibodies are effective at preventing COVID‐19 in people exposed to the virus or are at high risk of being exposed to the virus. We looked at: – confirmed COVID‐19 infections; – development of COVID‐19 symptoms; – death from any cause; – hospital admission; – quality of life; – unwanted effects, such as infections and cardiac disorders; – serious unwanted effects, such as life‐threatening, hospitalisation, disability, or death. What did we do? We searched for studies comparing monoclonal antibodies (e.g. bamlanivimab, tixagevimab/cilgavimab, and casirivimab/imdevimab) with placebo (sham treatment), another treatment, or no treatment to prevent COVID‐19 in people of any age, gender, or ethnicity. We summarised data and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? Four studies including 9749 people; two investigated people before being exposed to SARS‐CoV‐2 (pre‐exposure prophylaxis) and two investigated people who were in contact with an infected person (postexposure prophylaxis). Studies were conducted before the emergence of the Omicron variant and before or during widespread vaccine roll‐out. Participants were unvaccinated at baseline. Pre‐exposure prophylaxis One study (5197 people) compared tixagevimab/cilgavimab to placebo. Participants had been exposed to wild‐type, Alpha, Beta, and Delta variants. Tixagevimab/cilgavimab: – reduces development of symptoms; – probably reduces number of people infected; – may reduce number of hospital admissions; – may have little or no effect on deaths from any cause, unwanted effects (any severity), and serious unwanted effect. We found no data for quality of life, or mild and severe unwanted effects. One study (969 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and Delta variants. Casirivimab/imdevimab: – may reduce number of people infected and development of symptoms; – resulted in no deaths; – may increase unwanted effects (any severity) slightly; – we are uncertain whether casirivimab/imdevimab may have an effect on severe and serious unwanted effects. We found no data for number of people with COVID‐19 within 30 days, development of symptoms within 30 days, hospital admissions within 30 days, quality of life, and mild unwanted effects. Postexposure prophylaxis (two studies) One study (966 people) compared bamlanivimab to placebo. Participants may have been exposed to wild‐type variants. Bamlanivimab: – probably reduces number of people infected; – may have little or no effect on deaths from any cause; – may increase unwanted effects (any severity) and serious unwanted effects slightly. We found no data for number of people who developed symptoms, hospital admissions, quality of life, mild, and severe unwanted effects. One study (2617 people) compared casirivimab/imdevimab to placebo. Participants may have been exposed to wild‐type, Alpha, and potentially, but unlikely Delta variants. Casirivimab/ imdevimab: – reduces number of people infected, development of symptoms, and unwanted effects (any severity); – may slightly reduce severe unwanted effects; – may have little or no effect on deaths, hospital admissions, and serious unwanted effects. We found no data for quality of life and mild unwanted effects. What are the limitations of the evidence? One study reported each comparison. All participants were unvaccinated at the beginning of the studies, which were conducted prior to the occurrence of Omicron. Our confidence in the evidence is high to very low. Although we have high confidence in the evidence found for relevant outcomes, the findings are not transferable to vaccinated people and variants that occurred outside the study periods, such as Omicron. Although laboratory studies have shown that tixagevimab/cilgavimab is effective against Omicron, there are no data from clinical studies. The other monoclonal antibodies included in this review were ineffective against Omicron in laboratory studies. Four ongoing studies are likely to change our conclusions and may help us understand how new variants and COVID‐19 vaccines affect the effectiveness of monoclonal antibodies in preventing COVID‐19. How up to date is this evidence? The evidence is up‐to‐date to 27 April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hirsch, C; Park, YS; Piechotta, V; Chai, KL; Estcourt, LJ; Monsef, I; Salomon, S; Wood, EM; So-Osman, C; McQuilten, Z; Spinner, CD; Malin, JJ; Stegemann, M; Skoetz, N; Kreuzberger, N", "articleTypes": [], "doi": "10.1002/14651858.CD014945.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "f37f9429-c7ef-43ec-8dd0-7977e42d533d", "pmid": "", "title": "Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under", "imported": false, "abstract": "Abstract - Background Although complementary feeding is a universal practice, the methods and manner in which it is practiced vary between cultures, individuals and socioeconomic classes. The period of complementary feeding is a critical time of transition in the life of an infant, and inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. Educational interventions are widely acknowledged as effective in promoting public health strategy, and those aimed at improving complementary feeding practices provide information about proper complementary feeding practices to caregivers of infants/children. It is therefore important to summarise evidence on the effectiveness of educational interventions to improve the complementary feeding practices of caregivers of infants. Objectives To assess the effectiveness of educational interventions for improving the complementary feeding (weaning) practices of primary caregivers of children of complementary feeding age, and related health and growth outcomes in infants. Search methods In November 2017, we searched CENTRAL, MEDLINE, Embase, 10 other databases and two trials registers. We also searched the reference lists of relevant studies and reviews to identify any additional studies. We did not limit the searches by date, language or publication status. Selection criteria Randomised controlled trials (RCTs), comparing educational interventions to no intervention, usual practice, or educational interventions provided in conjunction with another intervention, so long as the educational intervention was only available in the experimental group and the adjunctive intervention was available to the control group. Study participants included caregivers of infants aged 4 to 24 months undergoing complementary feeding. Pregnant women who were expected to give birth and commence complementary feeding during the period of the study were also included. Data collection and analysis Two review authors independently extracted data on participants, settings, interventions, methodology and outcomes using a specifically‐developed and piloted data extraction form. We calculated risk ratios (RR) and 95% confidence intervals (CIs) for dichotomous data, and mean differences (MD) and 95% CIs for continuous data. Where data permitted, we conducted a meta‐analysis using a random‐effects model. We assessed the included studies for risk of bias and also assessed the quality of evidence using the GRADE approach. Main results We included 23 studies (from 35 reports) with a total of 11,170 caregiver‐infant pairs who were randomly assigned to receive an educational intervention delivered to the caregiver or usual care. Nineteen of the included studies were community‐based studies while four were facility‐based studies. In addition, 13 of the included studies were cluster‐randomised while the others were individually randomised. Generally, the interventions were focused on the introduction of complementary feeding at the appropriate time, the types and amount of complementary foods to be fed to infants, and hygiene. Using the GRADE criteria, we assessed the quality of the evidence as moderate, mostly due to inadequate allocation concealment and insufficient blinding. Educational interventions led to improvements in complementary feeding practices for age at introduction of complementary foods (average RR 0.88, 95% CI 0.83 to 0.94; 4 studies, 1738 children; moderate‐quality evidence) and hygiene practices (average RR 1.38, 95% CI 1.23 to 1.55; 4 studies, 2029 participants; moderate‐quality evidence). For duration of exclusive breastfeeding, pooled results were compatible with both a reduction and an increase in the outcome (average RR 1.58, 95% CI 0.77 to 3.22; 3 studies, 1544 children; very low‐quality evidence). There was limited (low to very low‐quality) evidence of an effect for all growth outcomes. Quality of evidence There is moderate to very low‐quality evidence that educational interventions can improve complementary feeding practices but insufficient evidence to conclude that it impacts growth outcomes. Authors' conclusions Overall, we found evidence that education improves complementary feeding practices. Plain language summary Educational interventions for improving complementary feeding practices Background Complementary feeding is the period when an infant moves from taking only breast milk or breast‐milk substitutes (such as infant formula) to family food. It is a critical period in the life of an infant. Inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. This is because inappropriate complementary feeding practices, such as introduction of semi‐solid foods too early (before six months of age), poor hygiene or giving foods that do not contain adequate nutrients, are all major causes of illness. Such illnesses include malnutrition, diarrhoea, poor growth, infections and poor mental development of children. Education has been proposed as an effective means of improving complementary feeding practices. Review question Does education improve complementary feeding practices of caregivers of infants as well as the health and growth of the infants? Study characteristics We searched for randomised controlled trials (a type of experiment in which people are randomly allocated to one or more treatment groups) up until November 2017. The search identified 23 studies involving a total of 11,170 caregivers and their children. The ages of the children ranged from birth to 24 months. The caregivers received educational interventions alone while the control group received no intervention, usual care or any other non‐educational intervention. The educational methods included printed materials such as leaflets, counselling, teaching sessions, peer support, videos and practical demonstrations. Generally, the education messages were focused on the introduction of semi‐solid foods at the appropriate age, the types and amount of complementary foods to be fed to infants, and hygiene. Key results Education reduced the number of caregivers that introduced semi‐solid foods to their infants before six months of age by up to 12% (moderate‐quality evidence). Hygiene practices of caregivers who received education also showed some improvement compared to those that did not (moderate‐quality evidence). In studies conducted in the community, education increased the duration of exclusive breastfeeding, but not in studies conducted in health facilities. There was no convincing evidence of an effect of education on the growth of children (low to very low‐quality evidence). We could not combine the results from different studies for diarrhoea, knowledge of caregivers and adequacy of complementary food. However, from the individual reports of the study authors, education led to a reduction in diarrhoea and an improvement in the knowledge of caregivers. It also led to improvement in the quality and quantity of complementary foods fed to infants. Overall, we found evidence that education improves complementary feeding practices.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Arikpo, D; Edet, ES; Chibuzor, MT; Odey, F; Caldwell, DM", "articleTypes": [], "doi": "10.1002/14651858.CD011768.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "f3b1db2a-d585-486a-b4d1-16e7c94cd0e9", "pmid": "", "title": "Oral versus intravenous steroids for treatment of relapses in multiple sclerosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Burton, JM, O'Connor, PW, Hohol, M, Beyene, J", "articleTypes": [], "doi": "10.1002/14651858.CD006921.pub3 AB - Abstract - Background This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD006921. DOI: 10.1002/14651858.CD006921.pub2). Multiple sclerosis (MS), a chronic inflammatory and neurodegenerative disease of the central nervous system (CNS), is characterized by recurrent relapses of CNS inflammation ranging from mild to severely disabling. Relapses have long been treated with steroids to reduce inflammation and hasten recovery. However, the commonly used intravenous methylprednisolone (IVMP) requires repeated infusions with the added costs of homecare or hospitalization, and may interfere with daily responsibilities. Oral steroids have been used in place of intravenous steroids, with lower direct and indirect costs. Objectives The primary objective was to compare efficacy of oral versus intravenous steroids in promoting disability recovery in MS relapses <= six weeks. Secondary objectives included subsequent relapse rate, disability, ambulation, hospitalization, immunological markers, radiological markers, and quality of life. Search methods A literature search was performed using Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group's Trials Register (January 2012), abstracts from meetings of the American Academy of Neurology (2008‐2012), the European Federation of Neurological Sciences (2008‐2012), the European Committee for Treatment and Research in Multiple Sclerosis and American Committee for Treatment and Research in Multiple Sclerosis (2008‐2012) handsearching. No language restrictions were applied. Selection criteria Randomized or quasi‐randomized trials comparing oral versus intravenous steroids for acute relapses (<= six weeks) in patients with clinically definite MSover age 16 were eligible. Data collection and analysis Three review authors (JB, PO and MH) participated in the independent assessment of all published articles as potentially relevant to the review. Any disagreement was resolved by discussion among review authors. We contacted study authors for additional information. Methodological quality was assessed by the same three review authors. Relevant data were extracted, and effect size was reported as mean difference (MD), mean difference (MD), odds ratio (OR) and absolute risk difference (ARD). Main results With this current update, a total of five eligible studies (215 patients) were identified. Only one outcome, the proportion of patients with Expanded Disability Status Scale (EDSS) improvement at four weeks, was common to three trials, while two trials examined magnetic resonance imaging (MRI) outcomes. The results of this review shows there is no significant difference in relapse recovery at week four (MD ‐0.22, 95% confidence interval (95% CI), 0.71 to 0.26, P = 0.20) nor differences in magnetic resonance imaging (MRI) gadolinium enhancement activity based on oral versus intravenous steroid treatment. However, only two of the five studies employed more current and rigorous methodological techniques, so these results must be taken with some caution. The Oral Megadose Corticosteroid Therapy of Acute Exacerbations of Multiple Sclerosis (OMEGA) trial and the \"Efficacy and Safety of Methylprednisolone Per os Versus IV for the Treatment of Multiple Sclerosis (MS) Relapses\" (COPOUSEP) trial, designed to address such limitations, are currently underway. Authors' conclusions The analysis of the five included trials comparing intravenous versus oral steroid therapy for MS relapses do not demonstrate any significant differences in clinical (benefits and adverse events), radiological or pharmacological outcomes. Based on the evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy in the treatment of MS relapses. Plain language summary A comparison of the efficacy of oral versus intravenous steroids in relapsing‐remitting multiple sclerosis (RRMS) RRMS is characterized by periods of disability (relapse) due to inflammation in the central nervous system. All research has shown that a \"speeding up\" of recovery is obtained by use of corticosteroids, given most often in intravenous form. If oral steroids worked as well as intravenous ones for relapse events, they would be easier to take and are more affordable. 
 
 The objective of this review was to assess if oral and intravenous steroids are equally effective and safe in aiding in the recovery from relapses. Among the pertinent literature, only five studies met the inclusion criteria, comprising a total of 215 participants. Despite some limitations in the methods used to conduct the studies (i.e. incomplete reporting of the participants who dropped out the studies and appropriateness of the sample size) and in the analysis of the data, all five studies found that there were no significant differences in term of benefits and adverse events and in the pharmacological and radiological outcomes in patients taking oral or intravenous steroids. Both treatments appear to be equally effective and safe. Based on this evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy for the treatment of MS relapses.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.785Z" }, { "id": "f3b24a1a-ad84-4372-9a2b-f6cc77e53634", "pmid": "", "title": "Omega‐6 fats for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐6 fats are polyunsaturated fats vital for many physiological functions, but their effect on cardiovascular disease (CVD) risk is debated. Objectives To assess effects of increasing omega‐6 fats (linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA)) on CVD and all‐cause mortality. Search methods We searched CENTRAL, MEDLINE and Embase to May 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher versus lower omega‐6 fat intake in adults with or without CVD, assessing effects over at least 12 months. We included full texts, abstracts, trials registry entries and unpublished studies. Outcomes were all‐cause mortality, CVD mortality, CVD events, risk factors (blood lipids, adiposity, blood pressure), and potential adverse events. We excluded trials where we could not separate omega‐6 fat effects from those of other dietary, lifestyle or medication interventions. Data collection and analysis Two authors independently screened titles/abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias of included trials. We wrote to authors of included studies. Meta‐analyses used random‐effects analysis, while sensitivity analyses used fixed‐effects and limited analyses to trials at low summary risk of bias. We assessed GRADE quality of evidence for 'Summary of findings' tables. Main results We included 19 RCTs in 6461 participants who were followed for one to eight years. Seven trials assessed the effects of supplemental GLA and 12 of LA, none DGLA or AA; the omega‐6 fats usually displaced dietary saturated or monounsaturated fats. We assessed three RCTs as being at low summary risk of bias. Primary outcomes : we found low‐quality evidence that increased intake of omega‐6 fats may make little or no difference to all‐cause mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.88 to 1.12, 740 deaths, 4506 randomised, 10 trials) or CVD events (RR 0.97, 95% CI 0.81 to 1.15, 1404 people experienced events of 4962 randomised, 7 trials). We are uncertain whether increasing omega‐6 fats affects CVD mortality (RR 1.09, 95% CI 0.76 to 1.55, 472 deaths, 4019 randomised, 7 trials), coronary heart disease events (RR 0.88, 95% CI 0.66 to 1.17, 1059 people with events of 3997 randomised, 7 trials), major adverse cardiac and cerebrovascular events (RR 0.84, 95% CI 0.59 to 1.20, 817 events, 2879 participants, 2 trials) or stroke (RR 1.36, 95% CI 0.45 to 4.11, 54 events, 3730 participants, 4 trials), as we assessed the evidence as being of very low quality. We found no evidence of dose‐response or duration effects for any primary outcome, but there was a suggestion of greater protection in participants with lower baseline omega‐6 intake across outcomes. Additional key outcomes : we found increased intake of omega‐6 fats may reduce myocardial infarction (MI) risk (RR 0.88, 95% CI 0.76 to 1.02, 609 events, 4606 participants, 7 trials, low‐quality evidence). High‐quality evidence suggests increasing omega‐6 fats reduces total serum cholesterol a little in the long term (mean difference (MD) −0.33 mmol/L, 95% CI −0.50 to −0.16, I 2 = 81%; heterogeneity partially explained by dose, 4280 participants, 10 trials). Increasing omega‐6 fats probably has little or no effect on adiposity (body mass index (BMI) MD −0.20 kg/m 2 , 95% CI −0.56 to 0.16, 371 participants, 1 trial, moderate‐quality evidence). It may make little or no difference to serum triglycerides (MD −0.01 mmol/L, 95% CI −0.23 to 0.21, 834 participants, 5 trials), HDL (MD −0.01 mmol/L, 95% CI −0.03 to 0.02, 1995 participants, 4 trials) or low‐density lipoprotein (MD −0.04 mmol/L, 95% CI −0.21 to 0.14, 244 participants, 2 trials, low‐quality evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐6 fats on cardiovascular health, mortality, lipids and adiposity to date, using previously unpublished data. We found no evidence that increasing omega‐6 fats reduces cardiovascular outcomes other than MI, where 53 people may need to increase omega‐6 fat intake to prevent 1 person from experiencing MI. Although benefits of omega‐6 fats remain to be proven, increasing omega‐6 fats may be of benefit in people at high risk of MI. Increased omega‐6 fats reduce serum total cholesterol but not other blood fat fractions or adiposity. Plain language summary Omega‐6 fats to prevent and treat heart and circulatory diseases Review question We reviewed randomised trials (participants had an equal chance to be assigned to either treatment) examining effects of higher omega‐6 fats compared to lower omega‐6 fats on deaths and heart and circulatory diseases (cardiovascular diseases (CVD), which include heart attacks and strokes). Background Omega‐6 fats are essential, we must obtain some from food. They are important for regulating energy production (part of metabolism), bone, skin and hair health. Many foods contain omega‐6 fats, particularly vegetable oils and nuts. Omega‐6 fats include linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA). Some evidence suggests that a higher intake of omega‐6 fats, along with a lower intake of saturated fat (from animal sources such as meat and cheese) can reduce coronary heart disease. In contrast, there is concern that high levels of omega‐6 fats may worsen cardiovascular risk by increasing inflammation. Overall, there is no conclusive evidence on the benefits or harms of omega‐6 fat intake on heart and circulatory diseases or on other health outcomes. Study characteristics Evidence in this review is current to May 2017. We found 19 studies recruiting 6461 adults. These studies assessed the effects of higher compared to lower omega‐6 fat intake on heart and circulatory diseases as well as deaths. We found that three trials were highly trustworthy (with good designs that produce reliable evidence). Studies took place in North America, Asia, Europe and Australia, and eight were funded only by national or charitable agencies. Participants increased their omega‐6 fats or maintained their usual fats for at least one year and up to eight years. Key results We found that increasing omega‐6 fats may make little or no difference to deaths or cardiovascular events but may reduce risk of heart attacks (low‐quality evidence). Evidence was weakened by study design problems, small numbers of events, low numbers of participants from developing countries, and few women. Evidence suggests that increasing omega‐6 fats reduces blood cholesterol (high‐quality evidence), probably has little or no effect on body weight adjusted for height (all moderate‐quality evidence), and may make little or no difference to triglycerides, high‐density lipoprotein (HDL, the 'good' cholesterol) or low‐density lipoprotein (LDL, the 'bad' cholesterol, low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hooper, L; Al‐Khudairy, L; Abdelhamid, AS; Rees, K; Brainard, JS; Brown, TJ; Ajabnoor, SM; O'Brien, AT; Winstanley, LE; Donaldson, DH; Song, F; Deane, KHO", "articleTypes": [], "doi": "10.1002/14651858.CD011094.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "f3c2c6d9-ef83-4d2c-8846-ea8f6fbccdfa", "pmid": "", "title": "Sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose or glucose with and without non‐nutritive sucking is frequently used as a non‐pharmacological intervention for needle‐related procedural pain relief in infants. Objectives To determine the effectiveness of sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet‐tasting solutions, or pharmacological or other non‐pharmacological pain‐relieving methods. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012); MEDLINE via Ovid (1966 to 2012); CINAHL via OVID (1982 to 2012). The World Health Organization International Clinical Trials Registry Platform was also searched for any ongoing trials. Clinical trial registries, conference proceedings and references for randomised controlled trials (RCTs) were also searched. An updated search was run to capture any new publications before finalising the review in April 2012 and no new included studies were identified. Two review authors (MK & JF) independently abstracted data and assessed quality using a standard form. Authors have been contacted for missing data. Selection criteria Randomised‐controlled trials using a sweet‐tasting solution to treat pain in healthy term infants (gestational age 37 weeks and over), between one month and 12 months of age who required needle‐related procedures. These procedures included but were not limited to: subcutaneous or intramuscular injections, venepuncture, and heel lance. Studies in which the painful procedure was circumcision, lumbar puncture or supra‐pubic bladder aspiration were not included as they are more severe and painful than needle‐related procedures. Control conditions included no treatment or placebo (water) or any other identical intervention (same appearance and consistency) without active ingredient, another sweet‐tasting solution, a pharmacological pain‐relieving method (e.g. paracetamol, topical anaesthetic cream), non‐pharmacological pain‐relieving method (e.g. distraction method, non‐nutritive sucking). Data collection and analysis Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Pain, Palliative and Supportive Care Group. We report mean differences (MD) with 95% confidence intervals (CI) using fixed‐effect models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. The Chi 2 test and I 2 statistic were used to assess between‐study heterogeneity. Main results Sixty‐five (65) studies were identified for possible inclusion in this review. Fourteen published RCTs with a total of 1551 participants met the inclusion criteria. Duration of cry was significantly reduced in infants who were administered a sweet‐tasting solution [MD ‐13.47 (95% CI ‐16.80 to ‐10.15)], P < 0.00001 compared with water. However, there was considerable heterogeneity between the studies (I 2 = 94%) that we were unable to explain. Meta‐analysis was not able to be undertaken for any of the other outcome measures, except for cry duration, because of differences in study design. However, most of the individual studies that measured pain found sucrose to significantly reduce pain compared with the control group. One study compared sucrose and Lidocaine‐prilocaine cream and no significant difference was found between the two treatments for the outcomes pain and cry duration. Due to the differences between the studies, we were unable to identify the optimal concentration, volume or method of administration of sweet‐tasting solutions in infants aged one to 12 months. Further large RCTs are needed. Authors' conclusions There is insufficient evidence to confidently judge the effectiveness of sweet‐tasting solutions in reducing needle‐related pain in infants (one month to 12 months of age). The treatments do, however, appear promising. Data from a series of individual trials are promising, as are the results from a subset meta‐analysis of studies measuring duration of crying. Further well controlled RCTs are warranted in this population to determine the optimal concentration, volume, method of administration, and possible adverse effects. Plain language summary Sweet‐tasting solutions for needle‐related pain in infants up to one year of age The use of needles that break the skin and cause pain is a common practice around the world with babies aged between one month and 12 months ( Appendix 4 ). In this review we were interested in whether giving babies sugar‐based solutions to taste when the needle breaks the skin will help reduce their pain. We found 14 separate studies that had asked this question. However, the differences between the studies were often too great to let us combine their findings. Overall, the studies show that different types of sugar‐based solutions were effective but we were not able to confidently assert that there is strong evidence for this treatment in reducing pain. We did find some evidence that babies may not cry for as long if given sugar‐based solutions. This review is broadly in agreement with two other reviews, one asking this question in younger children, and one in older children. There is a need for better studies in this field.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Kassab, M, Foster, JP, Foureur, M, Fowler, C", "articleTypes": [], "doi": "10.1002/14651858.CD008411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.726Z" }, { "id": "f3c740f7-9370-448d-9ab0-4e84cd35fb6d", "pmid": "", "title": "Oral anti‐diabetic pharmacological therapies for the treatment of women with gestational diabetes", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is a major public health issue with rates increasing globally. Gestational diabetes, glucose intolerance first recognised during pregnancy, usually resolves after birth and is associated with short‐ and long‐term complications for the mother and her infant. Treatment options can include oral anti‐diabetic pharmacological therapies. Objectives To evaluate the effects of oral anti‐diabetic pharmacological therapies for treating women with GDM. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (14 May 2016), ClinicalTrials.gov , WHO ICTRP (14 May 2016) and reference lists of retrieved studies. Selection criteria We included published and unpublished randomised controlled trials assessing the effects of oral anti‐diabetic pharmacological therapies for treating pregnant women with GDM. We included studies comparing oral anti‐diabetic pharmacological therapies with 1) placebo/standard care, 2) another oral anti‐diabetic pharmacological therapy, 3) combined oral anti‐diabetic pharmacological therapies. Trials using insulin as the comparator were excluded as they are the subject of a separate Cochrane systematic review. Women with pre‐existing type 1 or type 2 diabetes were excluded. Data collection and analysis Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and data were checked for accuracy. Main results We included 11 studies (19 publications) (1487 women and their babies). Eight studies had data that could be included in meta‐analyses. Studies were conducted in Brazil, India, Israel, UK, South Africa and USA. The studies varied in diagnostic criteria and treatment targets for glycaemic control for GDM. The overall risk of bias was 'unclear' due to inadequate reporting of methodology. Using GRADE the quality of the evidence ranged from moderate to very low quality . Evidence was downgraded for risk of bias (reporting bias, lack of blinding), inconsistency, indirectness, imprecision and for oral anti‐diabetic therapy versus placebo for generalisability. Oral anti‐diabetic pharmacological therapies versus placebo/standard care There was no evidence of a difference between glibenclamide and placebo groups for hypertensive disorders of pregnancy (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.81 to 1.90; one study, 375 women, very low‐quality evidence), birth by caesarean section (RR 1.03, 95% CI 0.79 to 1.34; one study, 375 women, very low‐quality evidence), perineal trauma (RR 0.98, 95% CI 0.06 to 15.62; one study, 375 women, very low‐quality evidence) or induction of labour (RR 1.18, 95% CI 0.79 to 1.76; one study, 375 women; very low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant, there was no evidence of a difference in the risk of being born large‐for‐gestational age (LGA) between infants whose mothers had been treated with glibenclamide and those in the placebo group (RR 0.89, 95% CI 0.51 to 1.58; one study, 375, low‐quality evidence). No data were reported for other infant primary or GRADE outcomes (perinatal mortality, death or serious morbidity composite, neurosensory disability in later childhood, neonatal hypoglycaemia, adiposity, diabetes). Metformin versus glibenclamide There was no evidence of a difference between metformin‐ and glibenclamide‐treated groups for the risk of hypertensive disorders of pregnancy (RR 0.70, 95% CI 0.38 to 1.30; three studies, 508 women, moderate‐quality evidence), birth by caesarean section (average RR 1.20, 95% CI 1.20; 95% CI 0.83 to 1.72, four studies, 554 women, I 2 = 61%, Tau 2 = 0.07 low‐quality evidence), induction of labour (0.81, 95% CI 0.61 to 1.07; one study, 159 women; low‐quality evidence) or perineal trauma (RR 1.67, 95% CI 0.22 to 12.52; two studies, 158 women; low‐quality evidence). No data were reported for development of type 2 diabetes or other pre‐specified GRADE maternal outcomes (return to pre‐pregnancy weight, postnatal depression). For the infant there was no evidence of a difference between the metformin‐ and glibenclamide‐exposed groups for the risk of being born LGA (average RR 0.67, 95% CI 0.24 to 1.83; two studies, 246 infants, I 2 = 54%, Tau 2 = 0.30 low‐quality evidence). Metformin was associated with a decrease in a death or serious morbidity composite (RR 0.54, 95% CI 0.31 to 0.94; one study, 159 infants, low‐quality evidence). There was no clear difference between groups for neonatal hypoglycaemia (RR 0.86, 95% CI 0.42 to 1.77; four studies, 554 infants, low‐quality evidence) or perinatal mortality (RR 0.92, 95% CI 0.06 to 14.55, two studies, 359 infants). No data were reported for neurosensory disability in later childhood or for adiposity or diabetes. Glibenclamide versus acarbose There was no evidence of a difference between glibenclamide and acarbose from one study (43 women) for any of their maternal or infant primary outcomes (caesarean section, RR 0.95, 95% CI 0.53 to 1.70; low‐quality evidence; perinatal mortality ‐ no events; low‐quality evidence; LGA , RR 2.38, 95% CI 0.54 to 10.46; low‐quality evidence). There was no evidence of a difference between glibenclamide and acarbose for neonatal hypoglycaemia (RR 6.33, 95% CI 0.87 to 46.32; low‐quality evidence). There were no data reported for other pre‐specified GRADE or primary maternal outcomes (hypertensive disorders of pregnancy, development of type 2 diabetes, perineal trauma, return to pre‐pregnancy weight, postnatal depression, induction of labour) or neonatal outcomes (death or serious morbidity composite, adiposity or diabetes). Authors' conclusions There were insufficient data comparing oral anti‐diabetic pharmacological therapies with placebo/standard care (lifestyle advice) to inform clinical practice. There was insufficient high‐quality evidence to be able to draw any meaningful conclusions as to the benefits of one oral anti‐diabetic pharmacological therapy over another due to limited reporting of data for the primary and secondary outcomes in this review. Short‐ and long‐term clinical outcomes for this review were inadequately reported or not reported. Current choice of oral anti‐diabetic pharmacological therapy appears to be based on clinical preference, availability and national clinical practice guidelines. The benefits and potential harms of one oral anti‐diabetic pharmacological therapy compared with another, or compared with placebo/standard care remains unclear and requires further research. Future trials should attempt to report on the core outcomes suggested in this review, in particular long‐term outcomes for the woman and the infant that have been poorly reported to date, women's experiences and cost benefit. Plain language summary Oral medication for the treatment of women with gestational diabetes What is the issue? Globally the number of women being diagnosed with gestational diabetes mellitus (GDM) is increasing. GDM is an intolerance to glucose leading to high blood sugars, first recognised during pregnancy and usually resolving after birth. Standard care involves lifestyle advice on diet and exercise. Treatment for some women includes oral anti‐diabetic medications, such as metformin and glibenclamide, which are an alternative to, or can be used alongside, insulin to control the blood sugar. This review aimed to investigate benefits of taking oral medication to treat GDM in pregnant women. Another Cochrane Review compares the effects of insulin with oral anti‐diabetic pharmacological therapies ( Brown 2016 ). Why is this important? Women diagnosed with GDM are at a greater risk of experiencing complications such as high blood pressure during pregnancy and at birth. They have an increased risk of developing diabetes later in life. The babies of women who have been diagnosed with GDM can be larger than normal and this can cause injuries to the mother and the baby at birth. The birth is more likely to be induced or the baby born by caesarean section. These babies are at risk of developing diabetes as children or young adults. Finding the best medications to treat the women and prevent the complications that are linked to GDM is therefore important. What evidence did we find? We searched for studies on 14 May 2016. We included 11 randomised controlled trials involving 1487 mothers and their babies (but only eight trials contributed data to our analyses). The evidence was limited by the quality and number of studies and we advise caution when looking at the results. The criteria for diagnosis of GDM and treatment targets varied between studies, and each outcome is based on few studies with low numbers of women. Three studies compared oral medication with placebo/standard care but the following findings are from a single study (375 women). The quality of the evidence was very low or low. We found no differences between the oral medication and placebo group for the risk of high blood pressure, birth by caesarean section, induction of labour or perineal trauma. The number of babies born large‐for‐gestational age, with low blood sugars or dying at birth was not clearly different between the groups. Two studies (434 women) reported no difference in the need for insulin between the oral medication and placebo group. Six studies compared metformin with glibenclamide. The quality of the evidence was very low to moderate. We found no difference between metformin and glibenclamide for the risk of high blood pressure (three studies, 508 women, moderate‐quality evidence), birth by caesarean section (four studies, 554 women, low‐quality evidence), perineal trauma (two studies, 308 women, low‐quality evidence) or induction of labour (one study, 159 women, low‐quality evidence). We found no difference between metformin and glibenclamide for the baby having low blood sugars (four studies, 554 infants, low‐quality evidence), being born large‐for‐gestational age (two studies, 246 infants) or dying at birth (all low‐ or very low‐quality evidence). In one study, the babies of the mothers taking metformin were at reduced risk of having any serious outcome (low blood sugar, jaundice, being born large, breathing problems, injury at birth or death combined) (low‐quality evidence). One small study (43 women) comparing glibenclamide with acarbose reported no differences in outcomes for mothers or their babies. None of the included studies provided any data on many of the outcomes pre‐specified in this review, including long‐term outcomes for the mother or for the baby as a child or an adult. What does this mean? There is not enough high‐quality evidence available to guide us on if oral medication has better outcomes for women with gestational diabetes, and their babies, compared with a placebo or if one oral medication has better health outcomes than another oral medication. Because we are still unclear, further research is needed. Future studies should be encouraged to report on the outcomes suggested in this review and in particular the long‐term outcomes for the woman and the infant that have been poorly reported to date.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Brown, J, Martis, R, Hughes, B, Rowan, J, Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD011967.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.795Z" }, { "id": "f3c810d6-211e-4788-8c48-bb7a69d8a9c7", "pmid": "", "title": "Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease", "imported": false, "abstract": "Abstract - Background Thyrotropin‐releasing hormones (TRH) added to prenatal corticosteroids has been suggested as a way to further reduce breathing problems and neonatal lung disease in infants born preterm. Objectives To assess the effects of giving prenatal TRH in addition to corticosteroids to women at risk of preterm birth for the prevention of neonatal respiratory disease. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013) and reference lists of retrieved studies. We also contacted trial authors. Selection criteria Randomised controlled trials in women at sufficient risk of preterm birth to warrant the use of prenatal corticosteroids to promote lung maturity. TRH and corticosteroids were compared with corticosteroids, with or without placebo. Data collection and analysis All assessments of trial eligibility, risk of bias and data extractions were independently carried out by at least two review authors. Main results Over 4600 women were recruited into the 15 trials included in the review, however two trials did not contribute any outcome data to the review. The trials had a moderate risk of bias. Overall, prenatal TRH, in addition to corticosteroids, did not reduce the risk of death prior to hospital discharge (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.86 to 1.27, six trials, 3694 infants), neonatal respiratory distress syndrome (average RR 1.05, 95% CI 0.91 to 1.22, nine trials, 3833 infants), or chronic lung disease (RR 1.01, 95% CI 0.85 to 1.19, five trials, 2511 infants), and did not improve any of the secondary fetal, neonatal or childhood outcomes assessed by intention‐to‐treat analyses. Indeed, the data showed prenatal TRH to have adverse effects for women and their infants. All side effects reported (nausea, vomiting, light headedness, urgency of micturition, facial flushing) were significantly more likely to occur in women receiving TRH. In the infants, prenatal TRH increased the risk of needing respiratory support (RR 1.16, 95% CI 1.03 to 1.29, three trials, 1969 infants), and of having a low Apgar score at five minutes (RR 1.48, 95% CI 1.14 to 1.92, three trials, 1969 infants). Only three trials provided data on childhood follow‐up, and while one trial suggested poorer outcomes for infants who were exposed to prenatal TRH, the other two trials, that assessed infants using an established developmental instrument, showed no clear differences between groups in follow‐up outcomes. Sensitivity analyses by trial quality, or subgroups with differing times from entry to birth, or different dose regimens of TRH, did not change these findings. Authors' conclusions Prenatal TRH in addition to corticosteroids, given to women at risk of preterm birth, does not improve infant outcomes and can cause maternal side effects. Plain language summary Thyrotropin‐releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease Thyrotropin‐releasing hormone (TRH) given with corticosteroids does not improve the benefit of corticosteroids on the lungs of babies born too early, and may increase harm. Babies born preterm (before 37 weeks of pregnancy) are at risk of breathing difficulties (such as respiratory distress syndrome). TRH increases thyroid hormones in the baby and it has been thought that adding TRH to corticosteroids for women giving birth early may increase the benefit of corticosteroids on the baby's lungs. This review included 15 trials, of a moderate risk of bias, that involved over 4600 women and their babies. In this review, TRH, given with corticosteroids to women at risk of early birth, was not shown to further reduce the breathing difficulties for the babies. Babies born to mothers who had received TRH with corticosteroids, were more likely to require support for breathing than babies born to mothers who received only corticosteroids. Women receiving TRH were more likely to experience adverse side effects, such as nausea, vomiting and flushing than women who only received corticosteroids. Therefore, based on the current available evidence, TRH is not recommended to be given to women at risk of preterm birth for preventing neonatal respiratory disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Crowther, CA, Alfirevic, Z, Han, S, Haslam, RR", "articleTypes": [], "doi": "10.1002/14651858.CD000019.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.109Z" }, { "id": "f3caa5a2-5a5a-4857-8269-1c0443ee2b17", "pmid": "", "title": "Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people", "imported": false, "abstract": "Abstract - Background There is evidence that water‐loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well‐being are compromised. Objectives To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water‐loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water‐loss dehydration was defined primarily as including everyone with either impending or current water‐loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). Search methods Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases ( The Cochrane Library ), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. Selection criteria Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. Data collection and analysis Diagnostic accuracy of each test was assessed against the best available reference standard for water‐loss dehydration (serum or plasma osmolality cut‐off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water‐loss dehydration (including either impending or current water‐loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water‐loss dehydration, but restricted to current dehydration in the final review. We conducted bivariate random‐effects meta‐analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre‐specified cut‐off points investigated. Pre‐set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre‐specifying three cut‐offs for each continuous test may have led to missing a cut‐off with useful sensitivity and specificity, we conducted post‐hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut‐off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. Main results There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water‐loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years. We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut‐offs for each continuous outcome) for diagnostic accuracy of water‐loss dehydration (primary target condition) and of current dehydration (secondary target condition). Only three tests showed any ability to diagnose water‐loss dehydration (including both impending and current water‐loss dehydration) as stand‐alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post‐hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study. Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97). There was sufficient evidence to suggest that several stand‐alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people. No tests were found consistently useful in diagnosing current water‐loss dehydration. Authors' conclusions There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water‐loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated. Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy. Plain language summary Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people Water‐loss dehydration results from drinking too little fluid. It is common in older people and associated with increased risk of many health problems. We wanted to find out whether simple tests (like skin turgor, dry mouth, urine colour and bioelectrical impedance) can usefully tell us whether an older person (aged at least 65 years) is drinking enough. Within the review we assessed 67 different tests, but no tests were consistently useful in telling us whether older people are drinking enough, or are dehydrated. Some tests did appear useful in some studies, and these promising tests should be re‐checked to see whether they are useful in specific older populations. There was sufficient evidence to suggest that some tests should not be used to indicate dehydration. Tests that should not be used include dry mouth, feeling thirsty, heart rate, urine colour, and urine volume.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hooper, L; Abdelhamid, A; Attreed, NJ; Campbell, WW; Channell, AM; Chassagne, P; Culp, KR; Fletcher, SJ; Fortes, MB; Fuller, N; Gaspar, PM; Gilbert, DJ; Heathcote, AC; Kafri, MW; Kajii, F; Lindner, G; Mack, GW; Mentes, JC; Merlani, P; Needham, RA; Olde Rikkert, MGM; Perren, A; Powers, J; Ranson, SC; Ritz, P; Rowat, AM; Sjöstrand, F; Smith, AC; Stookey, JJD; Stotts, NA; Thomas, DR; Vivanti, A; Wakefield, BJ; Waldréus, N; Walsh, NP; Ward, S; Potter, JF; Hunter, P", "articleTypes": [], "doi": "10.1002/14651858.CD009647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "f3d42938-86ca-4ee5-8a87-543710fc08aa", "pmid": "", "title": "School feeding programs for improving the physical and psychological health of school children experiencing socioeconomic disadvantage", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Kristjansson, E, Dignam, M, Rizvi, A, Osman, M, Magwood, O, Olarte, D, Cohen, JFW, Krasevec, J, Grover, T, Labelle, PR, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD014794.pub2 AB - Abstract - Rationale School feeding aims to alleviate hunger and enhance child outcomes. Since the first Cochrane systematic review of school meals, there has been a marked increase in studies and reviews of school feeding programs. However, most systematic reviews are geographically limited and use qualitative analysis. We reviewed worldwide papers and performed several meta‐analyses, providing a more comprehensive picture of the effectiveness of school feeding. Objectives 1. To assess effectiveness of school feeding programs for improving the physical and psychological health of children experiencing socioeconomic disadvantage worldwide.
2. To assess effectiveness of school feeding programs for improving the health of children experiencing socioeconomic disadvantage compared with children who are more advantaged. Search methods We searched 17 subject‐specific and multidisciplinary databases and registries up to November 2023. In November 2024, two Information Specialists ran a top‐up search for randomized controlled trials (RCTs). We handsearched references of included studies and relevant reviews. Eligibility criteria We included individually randomized, cluster‐randomized, and cross‐over trials, as well as longitudinal non‐randomized studies of interventions (NRSIs). Studies had to compare the provision of free or reduced‐price food in schools versus no school feeding, focusing on socioeconomically disadvantaged children. The food had to contain at least 3% of the daily energy requirement and at least 10% of the daily protein requirement for the specified age group(s). Eligible participants were primary or secondary school students aged five to 19 years. Outcomes Our critical outcomes were change in: math achievement, reading achievement, attendance, enrollment, height‐for‐age z‐score (HAZ), weight‐for‐age z‐score (WAZ), and overweight/obesity. Our important outcomes were change in: overall academic achievement, fluid intelligence, working memory, behavioral/emotional outcomes, height, weight, and anemia. We planned to study changes between baseline and final outcomes. In one study with extreme contamination, we used the first follow‐up. Risk of bias We assessed the risk of bias for RCTs by outcome using the appropriate version of the Cochrane risk of bias tool (RoB 2): RoB 2 for individually randomized trials, for cluster‐RCTs, and for cross‐over trials. We evaluated the quality of NRSIs using the School‐based Measurement & Assessment of Results Tool (SMART), which is adapted from the Newcastle Ottawa Scale. Synthesis methods We used standardized mean differences (SMDs) with 95% confidence intervals (CIs) for educational and cognitive outcomes. We used mean differences (MDs), odds ratios (ORs), or incidence rate ratios (IRRs) for others. All meta‐analyses used random‐effects generic inverse variance. We conducted equity subgroup analyses by sex and socioeconomic status. We used GRADE to assess our confidence in the evidence for critical outcomes reported in RCTs. Included studies We included 40 studies with 83 reports. There were 13 RCTs (12 cluster‐randomized trials and one individually randomized trial) and 27 NRSIs. Most studies (34) were from low‐ and middle‐income countries (LMICs). In total, there were more than 91,885 students (four studies didn't report sample size). One study involved 59,613 students, while the others had between 60 and 6038 students. The studies included 48 outcomes; we meta‐analyzed or reported 14. Synthesis of results Low‐ and middle‐income countries (LMICs) School feeding compared to no school feeding improves math achievement slightly (SMD 0.14, 95% CI 0.06 to 0.23; P = 0.001; I² = 68%; 6 cluster‐RCTs, 5587 participants; high‐certainty evidence), but may have little to no effect on reading achievement (SMD 0.02, 95% CI −0.06 to 0.11; P = 0.61; I 2 = 54%; 3 cluster‐RCTs, 3417 participants; low‐certainty evidence). School feeding programs lead to a slight increase in enrollment rates (MD 3.44% increase, 95% CI 0.83 to 6.04; P = 0.01; I² = 0%; 2 cluster‐RCTs, 5200 participants, high‐certainty evidence) but may have little to no effect on attendance (MD 0.17%, 95% CI −2.64% to 2.97%; P = 0.91; I 2 = 81%; 3 cluster‐RCTs, 3566 participants; low‐certainty evidence). School feeding programs likely lead to a slight increase in HAZ (MD 0.06, 95% CI 0.03 to 0.09; P < 0.001; I 2 = 0%; 2 cluster‐RCTs, 3678 participants; moderate‐certainty evidence) and WAZ (MD 0.08, 95% CI 0.05 to 0.12; P < 0.001; I 2 = 0%; 3 cluster‐RCTs, 2132 participants; moderate‐certainty evidence). Two cluster‐RCTs assessed change in obesity/overweight. One 10‐month study found that the odds of being overweight/obese were 53% lower among adolescents receiving school meals compared to control adolescents (OR 0.47, 95% CI 0.30 to 0.72). Another study found no cases of overweight/obesity before or after the intervention. These findings are of very low certainty. Some researchers encountered implementation problems beyond their control, including conflicts, delays, and bureaucratic decisions. Heterogeneity in contexts, outcomes, child populations, and statistics was a limitation of this review. High‐income countries (HICs) One NRSI found very uncertain evidence that children assigned to a breakfast club increased their attendance by more than 1.6% on average compared to children in the control group. Equity analyses The equity (subgroup) analyses by sex and by socio‐economic status were all non‐significant. There were only two studies in each subgroup analysis; they were likely underpowered. Authors' conclusions In LMICs, school feeding programs lead to a slight improvement in math achievement, but may have little to no effect on reading achievement. School feeding programs lead to a slight increase in enrollment, but may have little to no impact on attendance. They likely lead to slight gains in HAZ and WAZ. There may be little to no association between school feeding and overweight/obesity, but the evidence is very uncertain. We recommend that researchers and policymakers view research as an integral part of the implementation process. To reduce heterogeneity in outcomes, we recommend even greater co‐ordination of research, and that researchers and interest holders work together to identify a core set of outcomes. Funding The authors would like to thank the following donors for their generous support in making this review possible: Dubai Cares, the World Food Programme's School Meals and Social Protection Service, and the Research Consortium for School Health and Nutrition. Registration Protocol (2022): https://doi.org/10.1002/14651858.CD014794 
Original review (2007): https://doi.org/10.1002/14651858.CD004676.pub2 
Original Campbell protocol (2006): doi.org/10.1002/CL2.12 Plain language summary Can school meal programs improve health and educational goals in children experiencing socioeconomic disadvantage? Key messages School meal programs in low‐ and middle‐income countries lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. Research should be a key part of planning and running school meal programs. To make it easier to compare results from different studies, researchers, parents, and policymakers should work together to agree on a list of the most important goals for children's health, development, and success in school. Why did we want to review studies on school meals? Worldwide, many children do not get enough nutritious food to keep them healthy and ready to learn in school. This affects their ability to enroll, attend school regularly, and learn there. School meals aim to reduce hunger and improve children's learning, focus, and overall health. School meals are one of the world's largest social safety nets. We sought to understand their effectiveness for children in disadvantaged circumstances across the globe. Most previous reviews of the evidence are limited in geographical scope, and many use narrative analyses. What did we want to find out? We asked the following two health equity (fairness) questions. Do school meals improve the physical health of socioeconomically disadvantaged children worldwide? Do school meals benefit children who are disadvantaged by sex and low family income more than they benefit less disadvantaged children? What did we do? We searched for studies that evaluated the effects of school meals for school students aged five to 19 years. We included randomized studies, which allocate students or schools to different study groups at random. However, because randomized studies are not always possible, we included non‐randomized studies that compared school meal groups with groups that received no school meals. These non‐randomized studies needed to measure outcomes at least twice; once at the beginning of the study and once at the end. We rated our confidence in the findings separately for each outcome. What did we find? We found 13 randomized studies and 27 non‐randomized studies, which collectively involved more than 91,995 students aged five to 19 years. One study included 59,613 students, while others had student populations ranging from 40 to 6038 students. Across all studies, there was a similar number of boys and girls, although three studies included only girls. Most studies took place in low‐ and middle‐income countries (34 studies), while six were from high‐income countries. In low‐ and middle‐income countries, school meals lead to a small increase in math test scores, but may have little to no effect on reading test scores. School meals lead to a small increase in enrollment, but may have little to no effect on attendance. School meals probably result in small gains in height and weight for age. We are unsure whether they decrease overweight and obesity. In high‐income countries, one study presented very uncertain evidence that school meals may increase attendance slightly. What are the limitations of the evidence? Because we found very few eligible studies conducted in high‐income countries, we do not recommend applying our findings to this setting. We are confident in the results for math test scores and enrollment. We are moderately confident in the results for height and weight for age, because we had some concerns about the study methods. We have little confidence in the results for reading test scores and attendance, because we had some concerns about the study methods, and the results differed substantially among the trials. We are not confident in the results for overweight/obesity, because we have some concerns about the study methods, the two studies measured the outcome in different ways, and one of the studies was very small. Several studies faced barriers due to their context, such as conflict, droughts, bureaucratic delays, and difficulties in distributing funds to caterers, as well as eagerness to initiate school meal programs in control schools. We need more evidence on school meals and their impact on disadvantaged school students—especially those in secondary school—in countries of all income levels. We also need more studies that assess the difference between disadvantaged groups and more advantaged children in high‐income countries. We suggest that researchers, school feeding experts, teachers, and parents collaborate to develop a core set of key outcomes, and that these outcomes be put in an open‐access repository. How up‐to‐date is this evidence? This review updates and expands our 2007 review of school meal programs. The evidence is current to November 2024. Funding Dubai Cares funded this review through the World Food Program School Feeding Program. The London School of Hygiene and Tropical Medicine also funded this review. The funders had no influence on the review.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.794Z" }, { "id": "f3ee4567-6c5d-4fda-8559-292c7199846a", "pmid": "", "title": "Corticosteroids for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Inflammation and oedema of the facial nerve are implicated in causing Bell's palsy. Corticosteroids have a potent anti‐inflammatory action that should minimise nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Objectives To determine the effectiveness and safety of corticosteroid therapy in people with Bell's palsy. Search methods On 4 March 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS. We reviewed the bibliographies of the randomised trials and contacted known experts in the field to identify additional published or unpublished trials. We also searched clinical trials registries for ongoing trials. Selection criteria Randomised trials and quasi‐randomised trials comparing different routes of administration and dosage schemes of corticosteroid or adrenocorticotrophic hormone therapy versus a control group receiving no therapy considered effective for this condition, unless the same therapy was given in a similar way to the experimental group. Data collection and analysis We used standard Cochrane methodology. The main outcome of interest was incomplete recovery of facial motor function (i.e. residual facial weakness). Secondary outcomes were cosmetically disabling persistent sequelae, development of motor synkinesis or autonomic dysfunction (i.e. hemifacial spasm, crocodile tears) and adverse effects of corticosteroid therapy manifested during follow‐up. Main results We identified seven trials, with 895 evaluable participants for this review. All provided data suitable for the primary outcome meta‐analysis. One of the trials was new since the last version of this Cochrane systematic review. Risk of bias in the older, smaller studies included some unclear‐ or high‐risk assessments, whereas we deemed the larger studies at low risk of bias. Overall, 79/452 (17%) participants allocated to corticosteroids had incomplete recovery of facial motor function six months or more after randomisation; significantly fewer than the 125/447 (28%) in the control group (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.50 to 0.80, seven trials, n = 895). The number of people who need to be treated with corticosteroids to avoid one incomplete recovery was 10 (95% CI 6 to 20). The reduction in the proportion of participants with cosmetically disabling sequelae six months after randomisation was very similar in the corticosteroid and placebo groups (RR 0.96, 95% CI 0.40 to 2.29, two trials, n = 75, low‐quality evidence). However, there was a significant reduction in motor synkinesis during follow‐up in participants receiving corticosteroids (RR 0.64, 95% CI 0.45 to 0.91, three trials, n = 485, moderate‐quality evidence). Three studies explicitly recorded the absence of adverse effects attributable to corticosteroids. One trial reported that three participants receiving prednisolone had temporary sleep disturbances and two trials gave a detailed account of adverse effects occurring in 93 participants, all non‐serious; the combined analysis of data from these three trials found no significant difference in adverse effect rates between people receiving corticosteroids and people receiving placebo (RR 1.04, 95% CI 0.71 to 1.51, n = 715). Authors' conclusions The available moderate‐ to high‐quality evidence from randomised controlled trials showed significant benefit from treating Bell's palsy with corticosteroids. Plain language summary Corticosteroids for Bell's palsy Review question What are the effects of corticosteroids on Bell's palsy? Background Bell's palsy is a paralysis or weakness of muscles in the face, usually on one side, with no certain cause. Symptoms usually recover, although not always. Reducing inflammation of the facial nerve using corticosteroid medicines (steroids) is thought to limit nerve damage. This is an update of a review first published in 2002 and last updated in 2010. Study characteristics We identified seven clinical trials involving 895 people with one‐sided mild, moderate or severe Bell's palsy of unknown cause. All of these trials reported rates of incomplete recovery (the proportion of people left with facial weakness) and we were able to combine the results. People in the studies were aged from 2 to 84 years. They were treated with corticosteroids or placebo (inactive treatment), either alone or in combination with other therapies. One trial only involved children, from 24 months to 74 months old. The duration of the included studies for adults and children ranged from 157 days to 12 months. Key results and quality of the evidence Incomplete recovery According to moderate quality to high quality evidence, corticosteroids reduced the number of people left with facial weakness after Bell's palsy compared to placebo (a pretend medicine). This finding was based on data from seven studies involving 895 participants with Bell's palsy of varying degrees of severity. We calculated that to stop one person from being left with facial weakness, 10 people need to be treated. Five studies provided data on long‐term after‐effects of Bell's palsy following treatment. Two of the studies (75 participants) looked at persistent effects on facial appearance after six months or more. The effect was nearly the same for corticosteroids and placebo, showing that participants who had corticosteroids benefited slightly, although this evidence was low quality. Data from three studies (485 participants) showed clearly that people who received corticosteroids developed less motor synkinesis (unwanted facial movements) and crocodile tears (watery eyes when eating or chewing), compared with people who received placebo alone. This finding was based on moderate‐quality evidence. Side effects Three studies reported that no side effects could be attributed to corticosteroid treatment. Based on moderate‐quality evidence from three studies (715 participants), numbers experiencing side effects were similar with corticosteroids and placebo. The evidence is current to March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Madhok, VB; Gagyor, I; Daly, F; Somasundara, D; Sullivan, M; Gammie, F; Sullivan, F", "articleTypes": [], "doi": "10.1002/14651858.CD001942.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "f40f97a4-8997-4721-be4a-73cda47460fc", "pmid": "", "title": "Probiotics for induction of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Ulcerative colitis is an inflammatory condition affecting the colon, with an annual incidence of approximately 10 to 20 per 100,000 people. The majority of people with ulcerative colitis can be put into remission, leaving a group who do not respond to first‐ or second‐line therapies. There is a significant proportion of people who experience adverse effects with current therapies. Consequently, new alternatives for the treatment of ulcerative colitis are constantly being sought. Probiotics are live microbial feed supplements that may beneficially affect the host by improving intestinal microbial balance, enhancing gut barrier function and improving local immune response. Objectives To assess the efficacy of probiotics compared with placebo or standard medical treatment (5‐aminosalicylates, sulphasalazine or corticosteroids) for the induction of remission in people with active ulcerative colitis. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 31 October 2019. We contacted authors of relevant studies and manufacturers of probiotics regarding ongoing or unpublished trials that may be relevant to the review, and we searched ClinicalTrials.gov. We also searched references of trials for any additional trials. Selection criteria Randomised controlled trials (RCTs) investigating the effectiveness of probiotics compared to standard treatments or placebo in the induction of remission of active ulcerative colitis. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We analysed data using Review Manager 5. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE methodology. Main results In this review, we included 14 studies (865 randomised participants) that met the inclusion criteria. Twelve of the studies looked at adult participants and two studies looked at paediatric participants with mild to moderate ulcerative colitis, the average age was between 12.5 and 47.7 years. The studies compared probiotics to placebo, probiotics to 5‐ASA and a combination of probiotics plus 5‐ASA compared to 5‐ASA alone. Seven studies used a single probiotic strain and seven used a mixture of strains. The studies ranged from two weeks to 52 weeks. The risk of bias was high for all except two studies due to allocation concealment, blinding of participants, incomplete reports of outcome data and selective reporting. This led to GRADE ratings of the evidence ranging from moderate to very low. Probiotics versus placebo 
Probiotics may induce clinical remission when compared to placebo (RR 1.73, 95% CI 1.19 to 2.54; 9 studies, 594 participants; low‐certainty evidence; downgraded due to imprecision and risk of bias, number needed to treat for an additional beneficial outcome (NNTB) 5). Probiotics may lead to an improvement in clinical disease scores (RR 2.29, 95% CI 1.13 to 4.63; 2 studies, 54 participants; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.04, 95% CI 0.42 to 2.59; 7 studies, 520 participants). Reported adverse events included abdominal bloating and discomfort. Probiotics did not lead to any serious adverse events in any of the seven studies that reported on it, however five adverse events were reported in the placebo arm of one study (RR 0.09, CI 0.01 to 1.66; 1 study, 526 participants; very low‐certainty evidence; downgraded due to high risk of bias and imprecision). Probiotics may make little or no difference to withdrawals due to adverse events (RR 0.85, 95% CI 0.42 to 1.72; 4 studies, 401 participants; low‐certainty evidence). Probiotics versus 5‐ASA 
There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (RR 0.92, 95% CI 0.73 to 1.16; 1 study, 116 participants; low‐certainty evidence; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.33, 95% CI 0.53 to 3.33; 1 study, 116 participants). Reported adverse events included abdominal pain, nausea, headache and mouth ulcers. There were no serious adverse events with probiotics, however perforated sigmoid diverticulum and respiratory failure in a patient with severe emphysema were reported in the 5‐ASA arm (RR 0.21, 95% CI 0.01 to 4.22; 1 study, 116 participants; very low‐certainty evidence). Probiotics combined with 5‐ASA versus 5‐ASA alone 
Low‐certainty evidence from a single study shows that when combined with 5‐ASA, probiotics may slightly improve the induction of remission (based on the Sunderland disease activity index) compared to 5‐ASA alone (RR 1.22 CI 1.01 to 1.47; 1 study, 84 participants; low‐certainty evidence; downgraded due to unclear risk of bias and imprecision). No information about adverse events was reported. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes (progression to surgery, need for additional therapy, quality of life scores, or steroid withdrawal) were reported in any of the studies. Authors' conclusions Low‐certainty evidence suggests that probiotics may induce clinical remission in active ulcerative colitis when compared to placebo. There may be little or no difference in clinical remission with probiotics alone compared to 5‐ASA. There is limited evidence from a single study which failed to provide a definition of remission, that probiotics may slightly improve the induction of remission when used in combination with 5‐ASA. There was no evidence to assess whether probiotics are effective in people with severe and more extensive disease, or if specific preparations are superior to others. Further targeted and appropriately designed RCTs are needed to address the gaps in the evidence base. In particular, appropriate powering of studies and the use of standardised participant groups and outcome measures in line with the wider field are needed, as well as reporting to minimise risk of bias. Plain language summary Probiotics for the treatment of active ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can induce remission in people with ulcerative colitis. We analysed data from 14 studies to answer this question. Key messages Probiotics may be better at inducing remission than placebo (dummy treatment). It is unclear whether probiotics are better than 5‐aminosalicylic acid (5‐ASA, an anti‐inflammatory agent used to treat inflammatory bowel disease), however there is limited evidence that when both treatments are used as combined therapy they may be better than 5‐ASA alone in inducing remission. Most studies reported that no serious adverse events took place. For the studies that did report on it, serious adverse events did not occur in the probiotic group. Minor adverse events reported were bloating and diarrhoea. What was studied in the review? Ulcerative colitis is a relapsing and remitting disease which causes inflammation of the large bowel and leads to symptoms such as abdominal pain, diarrhoea and tiredness. There is some evidence to suggest that an imbalance in the bacteria of the gut is the cause of the disease, and therefore probiotics, which are live micro‐organisms, can alter the bacteria and possibly reduce the inflammation. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing probiotics with placebo, probiotics with 5‐ASA, and probiotics in combination with 5‐ASA. We found 14 RCTs looking at 865 participants. The trials looked at adult and paediatric participants. Eight studies allowed additional therapy to continue, whilst the other four studies were unclear about this. 1) Probiotics may improve induction of clinical remission when compared to placebo. 2) It is unclear whether probiotics lead to a difference in adverse events (minor and serious) when compared to placebo. 3) There is limited evidence to determine whether probiotics offer better disease improvement when compared to placebo. 4) There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (low‐certainty evidence). 5) There is limited evidence to suggest that when probiotics plus 5‐ASA are compared to 5‐ASA alone, probiotics may offer a slightly better chance of induction of remission. This is based on low‐certainty evidence from one study, and we are not sure of the type of remission studied. 6) Serious adverse events were reported when probiotics were compared with placebo, but only occurred in the placebo group. Conclusion Whilst the evidence suggests that probiotics may be better at improving induction than placebo, our confidence in the estimate is limited because of the low‐certainty evidence. This is attributed to the small number of participants in each study along with the unreliable methods utilised by the trials. With the evidence presented in these studies, we are unable to make strong conclusions into the effectiveness of probiotics; better designed studies with more participants are needed. How up‐to‐date is this review? This review is up‐to‐date as of October 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Kaur, L; Gordon, M; Baines, PA; Iheozor-Ejiofor, Z; Sinopoulou, V; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD005573.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "f41d194d-aab9-46d5-b8bc-2c5c5622cd8a", "pmid": "", "title": "Aspirin with or without an antiemetic for acute migraine headaches in adults", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010). Migraine is a common, disabling condition and a burden for the individual, health services and society. Many sufferers choose not to, or are unable to, seek professional help and rely on over‐the‐counter analgesics. Co‐therapy with an antiemetic should help to reduce nausea and vomiting commonly associated with migraine headaches. Objectives To determine the efficacy and tolerability of aspirin, alone or in combination with an antiemetic, compared to placebo and other active interventions in the treatment of acute migraine headaches in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, ClinicalTrials.gov, and reference lists for studies through 10 March 2010 for the original review and to 31 January 2013 for the update. Selection criteria We included randomised, double‐blind, placebo‐controlled or active‐controlled studies, or both, using aspirin to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and numbers needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment. Main results No new studies were found for this update. Thirteen studies (4222 participants) compared aspirin 900 mg or 1000 mg, alone or in combination with metoclopramide 10 mg, with placebo or other active comparators, mainly sumatriptan 50 mg or 100 mg. For all efficacy outcomes, all active treatments were superior to placebo, with NNTs of 8.1, 4.9 and 6.6 for 2‐hour pain‐free, 2‐hour headache relief, and 24‐hour headache relief with aspirin alone versus placebo, and 8.8, 3.3 and 6.2 with aspirin plus metoclopramide versus placebo. Sumatriptan 50 mg did not differ from aspirin alone for 2‐hour pain‐free and headache relief, while sumatriptan 100 mg was better than the combination of aspirin plus metoclopramide for 2‐hour pain‐free, but not headache relief; there were no data for 24‐hour headache relief. Adverse events were mostly mild and transient, occurring slightly more often with aspirin than placebo. Additional metoclopramide significantly reduced nausea (P < 0.00006) and vomiting (P = 0.002) compared with aspirin alone. Authors' conclusions We found no new studies since the last version of this review. Aspirin 1000 mg is an effective treatment for acute migraine headaches, similar to sumatriptan 50 mg or 100 mg. Addition of metoclopramide 10 mg improves relief of nausea and vomiting. Adverse events were mainly mild and transient, and were slightly more common with aspirin than placebo, but less common than with sumatriptan 100 mg. Plain language summary Aspirin with or without an antiemetic for acute migraine headaches in adults This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010); no new studies were found. A single oral dose of 1000 mg of aspirin reduced pain from moderate or severe to none by two hours in approximately 1 in 4 people (24%) taking aspirin, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (52%) taking aspirin compared with approximately 1 in 3 (32%) taking placebo. Of those who experienced effective headache relief at two hours, more had that relief sustained over 24 hours with aspirin than with placebo. Addition of 10 mg of the antiemetic metoclopramide substantially increased relief of nausea and vomiting compared with aspirin alone, but made little difference to pain. Oral sumatriptan 100 mg was better than aspirin plus metoclopramide for pain‐free response at two hours, but otherwise there were no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short‐term use were mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Kirthi, V, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008041.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.092Z" }, { "id": "f4220542-2ad3-47a3-bd38-178c26ac043a", "pmid": "", "title": "Effects of opioid, hypnotic and sedating medications on sleep‐disordered breathing in adults with obstructive sleep apnoea", "imported": false, "abstract": "Abstract - Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by partial or complete upper airway occlusion during sleep, leading to intermittent cessation (apnoea) or reduction (hypopnoea) of airflow and dips in arterial oxygen saturation during sleep. Many patients with recognised and unrecognised OSA receive hypnotics, sedatives and opiates/opioids to treat conditions including pain, anxiety and difficulty sleeping. Concerns have been expressed that administration of these drugs to people with co‐existing OSA may worsen OSA. Objectives To investigate whether administration of sedative and hypnotic drugs exacerbates the severity of OSA (as measured by the apnoea‐hypopnoea index (AHI) or the 4% oxygen desaturation index (ODI)) in people with known OSA. Search methods We searched the Cochrane Airways Group Specialised Register (CAGR) of trials. The search was current as of March 2015. Selection criteria Randomised, placebo‐controlled trials including adult participants with confirmed OSA, where participants were randomly assigned to use opiates or opioids, sedatives, hypnotics or placebo. We included participants already using continuous positive airway pressure (CPAP) or a mandibular advancement device. Data collection and analysis We used standard methodological procedures as recommended by The Cochrane Collaboration. Main results Fourteen studies examining the effects of 10 drugs and including a total of 293 participants contributed to this review. Trials were small, with only two trials, which used sodium oxybate, recruiting more than 40 participants, and all but three trials were of only one to three nights in duration. Most participants had mild to moderate OSA with a mean AHI of 11 to 25 events/h, and only two trials recruited patients with severe OSA. Two trials investigating the effects of ramelteon, a treatment option for insomnia, recruited adults over 60 years of age with OSA and concomitant insomnia. The drugs studied in this review included remifentanil (infusion) 0.75 mcg/kg/h, eszopiclone 3 mg, zolpidem 10 and 20 mg, brotizolam 0.25 mg, flurazepam 30 mg, nitrazepam 10 mg to 15 mg, temazepam 10 mg, triazolam 0.25 mg, ramelteon 8 mg and 16 mg and sodium oxybate 4.5 g and 9 g. We were unable to pool most of the data, with the exception of data for eszopiclone and ramelteon. None of the drugs in this review produced a significant increase in AHI or ODI. Two trials have shown a beneficial effect on OSA. One study showed that a single administration of eszopiclone 3 mg significantly decreased AHI compared with placebo (24 ± 4 vs 31 ± 5; P value < 0.05), and a second study of sodium oxybate 4.5 g showed a significant decrease in AHI compared with placebo (mean difference (MD) ‐7.41, 95% confidence interval (CI) ‐14.17 to ‐0.65; N = 48). Only four trials reported outcome data on ODI. No significant increase, in comparison with placebo, was shown with eszopiclone (21 (22 to 37) vs 28.0 (15 to 36); P value = NS), zolpidem (0.81 ± 0.29 vs 1.46 ± 0.53; P value = NS), flurazepam (18.6 ± 19 vs 19.6 ± 15.9; P value = NS) and temazepam (6.53 ± 9.4 vs 6.56 ± 8.3; P value = 0.98). A significant decrease in minimum nocturnal peripheral capillary oxygen saturation (SpO 2 ) was observed with zolpidem 20 mg (76.8 vs 85.2; P value = 0.002), flurazepam 30 mg (81.7 vs 85.2; P value = 0.002), remifentanil infusion (MD ‐7.00, 95% CI ‐11.95 to ‐2.05) and triazolam 0.25 mg in both rapid eye movement (REM) and non‐REM (NREM) sleep (MD ‐14.00, 95% CI ‐21.84 to ‐6.16; MD ‐10.20, 95% CI ‐16.08 to ‐4.32, respectively. One study investigated the effect of an opiate (remifentanil) on patients with moderate OSA. Remifentanil infusion did not significantly change AHI (MD 10.00, 95% CI ‐9.83 to 29.83); however it did significantly decrease the number of obstructive apnoeas (MD ‐9.00, 95% CI ‐17.40 to ‐0.60) and significantly increased the number of central apnoeas (MD 16.00, 95% CI ‐2.21 to 34.21). Similarly, although without significant effect on obstructive apnoeas, central apnoeas were increased in the sodium oxybate 9 g treatment group (MD 7.3 (18); P value = 0.005) in a cross‐over trial. Drugs studied in this review were generally well tolerated, apart from adverse events reported in 19 study participants prescribed remifentanil (n = 1), eszopiclone (n = 6), sodium oxybate (n = 9) or ramelteon (n = 3). Authors' conclusions The findings of this review show that currently no evidence suggests that the pharmacological compounds assessed have a deleterious effect on the severity of OSA as measured by change in AHI or ODI. Significant clinical and statistical decreases in minimum overnight SpO 2 were observed with remifentanil, zolpidem 20 mg and triazolam 0.25 mg. Eszopiclone 3 mg and sodium oxybate 4.5 g showed a beneficial effect on the severity of OSA with a reduction in AHI and may merit further assessment as a potential therapeutic option for a subgroup of patients with OSA. Only one trial assessed the effect of an opioid (remifentanil); some studies included CPAP treatment, whilst in a significant number of participants, previous treatment with CPAP was not stated and thus a residual treatment effect of CPAP could not be excluded. Most studies were small and of short duration, with indiscernible methodological quality.Caution is therefore required when such agents are prescribed for patients with OSA, especially outside the severity of the OSA cohorts and the corresponding dose of compounds given in the particular studies. Larger, longer trials involving patients across a broader spectrum of OSA severity are needed to clarify these results. Plain language summary Effects of opioid, hypnotic and sedating medications on obstructive sleep apnoea (OSA) in adults with known OSA Background Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by intermittent apnoeas (pauses in breathing) leading to dips in oxygen levels in the blood during sleep. Many people with known or unknown (undiagnosed) OSA receive hypnotics, sedatives and opiate/opioid drugs to treat other conditions including pain, anxiety and difficulty sleeping. Opiates/opioids are commonly prescribed to treat pain after major surgery. These drugs might make sleep apnoea worse ‐ increasing the frequency and duration of apnoeas. Review question We set out to look at evidence derived from randomised placebo‐controlled trials to identify the risks of these drugs for patients with known OSA. What we did We searched and reviewed all randomised placebo‐controlled trials involving adult patients with known OSA who received these drugs. Most of the trials were short at just one or two nights' duration, involved only a small number of patients and used poorly described methodology. Therefore it was difficult to find out the exact effects of these drugs on patients with OSA. Results We found 14 studies examining the effects of 10 drugs in trials including 293 people. Opiates and opioids (treatment of acute and chronic pain) Remifentanil infusion Remifentanil infusion did not significantly change severity of OSA as measured by numbers and duration of pauses in breathing during sleep, but it significantly lowered minimum oxygen levels during the night when compared with placebo. Sedatives and hypnotics 'Z drugs' (a treatment for insomnia, inability to fall asleep or inability to maintain sleep) Eszopiclone and zolpidem Eszopiclone did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, it reduced the severity of OSA, and it might be beneficial in treating this condition, although further studies are needed to assess this effect. Zolpidem did not significantly worsen OSA as measured by the numbers and duration of pauses in breathing during sleep, but in one trial, it significantly lowered minimum oxygen levels during the night when compared with placebo. Benzodiazepines (short‐term relief of severe anxiety, behavioural disturbance or agitation and panic disorders) Brotizolam, flurazepam, nitrazepam, temazepam and triazolam None of the drugs examined had significantly worsened OSA as measured by the numbers and duration of pauses in breathing during sleep. In small, single‐night studies, zolpidem 20 mg, flurazepam 20 mg and triazolam 0.25 mg showed a tendency to increase numbers and duration of pauses during sleep, which was not statistically significant, but these drugs significantly lowered minimum oxygen levels during the night when compared with placebo. Sodium oxybate (a treatment for narcolepsy, a condition causing excessive sleepiness during the day) Sodium oxybate was compared with placebo in two trials. Results showed that sodium oxybate did not worsen OSA as measured by the numbers and duration of pauses in breathing during sleep. In one study, sodium oxybate 4.5 g reduced the severity of OSA and might have proved beneficial in treating this condition, although further studies are needed to assess this effect. Melatonin and melatonin‐related drugs Ramelteon (a treatment drug for insomnia) Ramelteon was assessed in older adults, over 60 years of age, with OSA and insomnia and was found not to worsen OSA. Results of this review show that the drugs studied do not worsen the severity of OSA as measured by the numbers and duration of pauses in breathing during sleep, but significant clinical and statistical decreases in minimum oxygen levels during the night were observed with remifentanil, zolpidem and triazolam; therefore prescribing these drugs for patients with OSA still warrants caution. Sodium oxybate 4.5 g and eszopiclone reduced the severity of OSA and might be beneficial in treating this condition; nonetheless further studies are needed to support these results. Bottom line The long‐term effect and potential side effects of sedative drugs in people with OSA need to be assessed in larger, longer and methodologically robust studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Mason, M, Cates, CJ, Smith, I", "articleTypes": [], "doi": "10.1002/14651858.CD011090.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.771Z" }, { "id": "f433b008-11a8-4a75-93d8-9c36ef61d023", "pmid": "", "title": "Micronutrient supplementation in pregnant women with HIV infection", "imported": false, "abstract": "Abstract - Background Micronutrient deficiencies are widespread and compound the effects of HIV disease; micronutrient supplements may be effective and safe in reducing this burden. Objectives To assess whether micronutrient supplements are effective and safe in reducing mortality and morbidity in pregnant and lactating women with HIV infection and their infants. Search methods The review has been updated three times since publication in 2005. In reviews prior to this update (2011), we searched the CENTRAL, EMBASE, PubMed, and GATEWAY databases to identify randomised controlled trials of micronutrient supplements using the search methods of the Cochrane HIV/AIDS Group. In the 2011 review the PubMed, EMBASE, and CENTRAL databases were searched in July 2011. As the GATEWAY database does not include conference abstracts after 2006, we also searched the AIDS‐specific conference database, www.aegis.org , and contacted researchers and organisations active in the field of research to identify additional unpublished trials. Selection criteria Randomised controlled trials were selected that compared the effects of micronutrient supplements (vitamins, trace elements, and combinations of these) with other supplements, placebo or no treatment on mortality, morbidity, pregnancy outcomes, immunologic indicators, and anthropometric measures in HIV‐positive pregnant and lactating women. Any adverse effects of supplementation were recorded. Data collection and analysis Two reviewer authors independently selected trials, appraised trial quality for risk of bias using standardised criteria, and extracted data using standardised forms. Where disagreements arose, a third author, acted as arbiter. Main results One additional trial is included in this update in addition to the three trials included in the 2010 update of the initial Cochrane review. Four relatively large, well‐conducted randomised controlled trials of the benefits of micronutrient supplementation have been conducted in pregnant and lactating women infected with HIV. Each of the trials evaluated a different micronutrient supplement and no direct comparisons or analyses can be made across the four trials. The four trials were conducted between 1995 and 2006. The trials have all been conducted by the same research team in Dar es Salaam in Tanzania, in an urban setting in hospital‐based antenatal clinics. Pregnant women were recruited with gestational age ranging from 12 to 27 weeks in each of the trials. Sample sizes range from 400 to 1129 with a median of 1000 participants. Three of the trials were placebo‐controlled. Different interventions have been evaluated in each trial, viz.:Vitamin A versus Vitamin A and multivitamins versus Multivitamins versus placebo; Selenium versus placebo; Zinc versus placebo; and Multiple RDA multivitamins versus Single RDA multivitamins. None of the women were receiving antiretrovrial therapy (ART). Multiple micronutrient supplements conferred multiple clinical benefits to pregnant women and their offspring. No significant adverse effects were reported. No significant clinical benefits were found from zinc supplementation of pregnant Tanzanian women. Selenium supplements given during and after pregnancy did not delay maternal HIV disease progression or improve pregnancy outcomes, but may improve child survival and decrease maternal diarrhoeal morbidity. There were no differences in maternal and infant outcomes when women received single RDA multivitamins or multiple RDA multivitamin supplementation. The evidence is lacking for the effects of micronutrient supplementation given concomitantly to pregnant women already initiated on antiretroviral therapy for treatment purposes. GRADE assessments were conducted on outcomes for each trial and included reviewing the data and the potential biases in each trial before grading the level of evidence. None of the trials were graded as providing high quality evidence primarily because there was no replication of results in other trials in other settings. Authors' conclusions In keeping with previous World Health Organization (WHO) recommendations everything possible should be done to promote and support adequate dietary intake of micronutrients, while recognising that this may not be sufficient to correct specific micronutrient deficiencies in all HIV‐infected individuals. Specific recommendations for pregnant and lactating women infected with HIV would be to include the provision of multivitamin supplements in single RDA formulations during the antenatal period and at least for 6 weeks post‐partum, especially for women who are breast‐feeding. There is no conclusive evidence to provide stand‐alone zinc or selenium supplementation to HIV‐infected pregnant and lactating women. Micronutrient supplementation should not be used as a substitute for provision of recommended antiretroviral medication for preventing mother‐to‐child transmission of HIV and treating maternal HIV infection when this is recommended. Further trials of single supplements are required to build the evidence base. The long‐term clinical benefits, adverse effects, and optimal formulation of multiple micronutrient supplements require further investigation in pregnant women at different stages of HIV infection. Plain language summary Micronutrient supplementation interventions to reduce harm in pregnant and lactating women living with HIV Micronutrients are vital components of a person’s daily food intake. Though only a small portion is necessary, a lack of micronutrients has been linked to tiredness, anaemia (low iron in blood), reduced learning ability, weaker immune system, and night blindness. In pregnant women, inadequate micronutrients have been shown to affect the development of the foetus and also the well‐being of the mother. In regions with high HIV prevalence, food availability may be scarce, which could lead to a double burden of disease in vulnerable/at‐risk populations. Specifically, pregnant and lactating women living with HIV may encounter the challenge of adequate food (including micronutrients) consumption, a weakened immune system, and the nutritional demands of a growing foetus or child. In this review, four randomised controlled trials, conducted between 1995 and 2006, assessed the benefits of micronutrient supplementation. The trials took place in an urban setting in hospital‐based antenatal clinics, with participants being pregnant women who ranged between 12‐27 weeks of their pregnancy, and sample sizes ranging from 400 to 1129 participants. Multiple micronutrient supplements improved the health of pregnant women and their offspring. No significant adverse effects were reported. Zinc supplementation did not show any significant beneficcial effects. Although it did not have any effect on the mother's pregnancy or her HIV disease, supplementation with selenium may increase the likelihood of a child surviving, and may reduce the likelihood of the mothers having diarrhoea. However, there is not enough evidence to determine the effect of micronutrient supplementation to pregnant women living with HIV who are being treated with antiretroviral medications.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Siegfried, N, Irlam, JH, Visser, ME, Rollins, NN", "articleTypes": [], "doi": "10.1002/14651858.CD009755", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.808Z" }, { "id": "f43d87cd-6ff9-4e65-a7da-367fcce91f99", "pmid": "", "title": "The Role of the Endocannabinoid System in Sweet Taste Intensity and Liking", "imported": false, "abstract": "The endocannabinoid (eCB) system, a neurochemical signalling system consisting of CB-receptors and their endogenous ligands, has been found to be involved in food intake of sweet and palatable foods. Activation of the eCB system increases food intake and vice versa. The mechanism behind this effect is still unknown and the current study aims at clarifying why sweet food intake increases. It is hypothesized that sweet taste intensity increases and that sweet taste is experienced as more pleasant.", "journal": "", "year": "2014", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.234Z" }, { "id": "f44aa76f-cd09-4c2f-acaf-765c389d0e01", "pmid": "", "title": "Manipulating Tobacco Constituents in Male Menthol Smokers", "imported": false, "abstract": "This study examines the potential effect of reducing nicotine content or menthol or both in men. It will also examine whether there are gender differences in manipulating tobacco flavors and nicotine concentrations in cigarettes on smoking behavior.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.245Z" }, { "id": "f457bda7-bfd3-4b26-9de9-ea18931f22e8", "pmid": "", "title": "Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "van den Bosch, CH, van Woensel, J, van de Wetering, MD", "articleTypes": [], "doi": "10.1002/14651858.CD003295.pub4 AB - Abstract - Background This is an updated version of a Cochrane Review last published in 2013. Long‐term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating people with cancer. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infections remain a common complication. These infections are mainly caused by gram‐positive bacteria. Antimicrobial prevention strategies aimed at these micro‐organisms could potentially decrease the majority of CVC‐related infections. The aim of this review was to evaluate the efficacy of prophylactic antibiotics for the prevention of gram‐positive infections in people with cancer who have long‐term CVCs. Objectives To assess the effects of administering antibiotics prior to the insertion of long‐term CVCs or as a flush/lock solution, or both during long‐term CVC access to prevent gram‐positive CVC‐related infections in adults and children receiving treatment for cancer. Search methods The search for this updated review was conducted on 19 November 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE via Ovid and Embase via Ovid. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform portal for additional articles. Selection criteria We included randomised controlled trials (RCTs) that compared either the administration of prophylactic antibiotics prior to long‐term CVC insertion versus no administration of antibiotics, or the use of an antibiotic versus a non‐antibiotic flush/lock solution in long‐term CVCs, in adults and children receiving treatment for cancer. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two authors independently selected studies, classified them and extracted data onto a predesigned data collection form. The outcomes of interest were gram‐positive catheter‐related infection events and total number of CVCs and CVC days. We pooled the data using a random‐effects model for meta‐analyses. We used the GRADE approach to assess the certainty of the evidence. Main results For this update, we identified 310 potentially relevant studies and screened them for eligibility. We included one additional RCT with 404 participants. The original review included 11 RCTs with a total of 840 people with cancer (adults and children). In total this review included 12 RCTs with 1244 participants. Antibiotics prior to insertion of the CVC 
Six trials compared the use of antibiotics (vancomycin, teicoplanin, ceftazidime or cefazolin) versus no antibiotics given before the insertion of a long‐term CVC. One study did not observe any CVC‐related infection events in either group was not included in the quantitative analysis as it was not possible to calculate a risk ratio. Administering an antibiotic prior to insertion of the CVC may not reduce gram‐positive CVC‐related infections (pooled risk ratio 0.67, confidence interval (CI) 95% 0.32 to 1.43; control versus intervention group risk 10.4% versus 7.3% of the participants; 5 studies, 648 participants; moderate‐certainty evidence). We sought adverse event data, but these were not described by the authors. The overall risk of bias was deemed low. Antibiotics as a flushing or locking solution 
Six trials compared a combined antibiotic (vancomycin, amikacin or taurolidine) and heparin solution with a heparin‐only solution for flushing or locking the long‐term CVC after use. One study did not observe any CVC‐related sepsis events (CRS) and was not included in this study in the quantitative analysis as it was not possible to calculate a risk ratio. Flushing and locking long‐term CVCs with a combined antibiotic and heparin solution likely reduced the risk of gram‐positive CVC‐related infections compared to a heparin‐only solution (pooled rate ratio 0.47, CI 95% 0.26 to 0.85; control versus intervention group rate ratio 0.66 versus 0.27 per 1000 CVC‐days; 5 studies, 443 participants; moderate‐certainty evidence). One trial reported a higher incidence of occlusions and participants in one trial reported an unpleasant taste after flushing associated with a combined antibiotic and heparin solution. The overall risk of bias was deemed low. Authors' conclusions Since the last version of this review, we included one additional study. There was no observed benefit of administering antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing or locking long‐term CVCs with an antibiotic solution likely reduces gram‐positive CVC‐related infections experienced in people at risk of neutropenia through chemotherapy or disease. However, a limitation of this review is heterogeneity between the studies for both outcomes. Insufficient data were available to evaluate if the conclusions apply equally for different CVC types and for adults versus children. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if the baseline CVC‐related infection rates are high. Further research is needed to identify high‐risk groups most likely to benefit from these antibiotic flush/lock solutions. Plain language summary Prophylactic antibiotics for preventing gram‐positive infections associated with long‐term central venous catheters in adults and children receiving treatment for cancer The issue 
People undergoing anti‐cancer treatment (chemotherapy) often have a catheter (tube) inserted into a large vein, through which their chemotherapy is given. This is known as a central venous catheter (CVC). As chemotherapy is usually administered over several months to years, long‐term CVCs are used. Despite sterile insertion and care afterwards, these CVCs often become infected by a type of bacteria called gram‐positive bacteria. Giving antibiotics as a preventive (prophylactic antibiotics) before the catheter is inserted, or using the antibiotics as a lock or flush solution, or both, may prevent these infections. A lock/flush solution is instilled in the catheter when it is not in use. This solution often contains heparin, saline, or both, to prevent a clot forming in the catheter. The aim of the review 
The aim of this review was to determine whether giving antibiotics before catheter insertion or as a lock/flush solution can prevent gram‐positive CVC‐related infections. What are the main findings? 
We searched databases to identify randomised controlled trials (RCTs ‐ clinical studies where people are randomly put into one of two or more treatment groups). We identified 12 relevant studies, which included a total of 1244 adults and children with cancer. We included six studies (756 people) that compared giving antibiotics before the insertion of the CVC against not giving antibiotics. We found that giving an antibiotic before CVC insertion did not prevent infections. The studies authors' did not describe side‐effects. We included six studies (488 people) that compared an antibiotic solution with a heparin‐only solution to flush/lock a CVC. We found that an antibiotic lock/flush solution reduced the number of CVC‐related infections. People in one study reported an unpleasant taste after flushing, and one study found there were fewer CVC obstructions (e.g. a clot) in people who received the combined antibiotic and anticoagulant solution. Certainty of the evidence 
We have moderate confidence in the evidence for giving antibiotics prior to CVC insertion and antibiotic lock/flush solutions since the studies were done in different people, used different types of catheters and antibiotics, and measured their results in different ways. What are the conclusions? 
We did not observe any benefit of giving antibiotics before the insertion of long‐term CVCs to prevent gram‐positive CVC‐related infections. Flushing/locking long‐term CVCs with an antibiotic appeared to reduce gram‐positive CVC‐related infections in people with cancer. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high‐risk people or if baseline CVC‐related infection rates are high. This review updates our previous review. The evidence is up to date to 19 November 2020.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.757Z" }, { "id": "f45a7c5f-9cbc-46c2-857c-b7ffb921a0ad", "pmid": "", "title": "Magnesium for skeletal muscle cramps", "imported": false, "abstract": "Abstract - Background Skeletal muscle cramps are common and often occur in association with pregnancy, advanced age, exercise or motor neuron disorders (such as amyotrophic lateral sclerosis). Typically, such cramps have no obvious underlying pathology, and so are termed idiopathic. Magnesium supplements are marketed for the prophylaxis of cramps but the efficacy of magnesium for this purpose remains unclear. This is an update of a Cochrane Review first published in 2012, and performed to identify and incorporate more recent studies. Objectives To assess the effects of magnesium supplementation compared to no treatment, placebo control or other cramp therapies in people with skeletal muscle cramps. Search methods On 9 September 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, CINAHL Plus, AMED, and SPORTDiscus. We also searched WHO‐ICTRP and ClinicalTrials.gov for registered trials that might be ongoing or unpublished, and ISI Web of Science for studies citing the studies included in this review. Selection criteria Randomized controlled trials (RCTs) of magnesium supplementation (in any form) to prevent skeletal muscle cramps in any patient group (i.e. all clinical presentations of cramp). We considered comparisons of magnesium with no treatment, placebo control, or other therapy. Data collection and analysis Two review authors independently selected trials for inclusion and extracted data. Two review authors assessed risk of bias. We attempted to contact all study authors when questions arose and obtained participant‐level data for four of the included trials, one of which was unpublished. We collected all data on adverse effects from the included RCTs. Main results We identified 11 trials (nine parallel‐group, two cross‐over) enrolling a total of 735 individuals, amongst whom 118 cross‐over participants additionally served as their own controls. Five trials enrolled women with pregnancy‐associated leg cramps (408 participants) and five trials enrolled people with idiopathic cramps (271 participants, with 118 additionally crossed over to control). Another study enrolled 29 people with liver cirrhosis, only some of whom suffered muscle cramps. All trials provided magnesium as an oral supplement, except for one trial which provided magnesium as a series of slow intravenous infusions. Nine trials compared magnesium to placebo, one trial compared magnesium to no treatment, calcium carbonate or vitamin B, and another trial compared magnesium to vitamin E or calcium. We judged the single trial in people with liver cirrhosis and all five trials in participants with pregnancy‐associated leg cramps to be at high risk of bias. In contrast, we rated the risk of bias high in only one of five trials in participants with idiopathic rest cramps. For idiopathic cramps, largely in older adults (mean age 61.6 to 69.3 years) presumed to have nocturnal leg cramps (the commonest presentation), differences in measures of cramp frequency when comparing magnesium to placebo were small, not statistically significant, and showed minimal heterogeneity (I² = 0% to 12%). This includes the primary endpoint, percentage change from baseline in the number of cramps per week at four weeks (mean difference (MD) −9.59%, 95% confidence interval (CI) −23.14% to 3.97%; 3 studies, 177 participants; moderate‐certainty evidence); and the difference in the number of cramps per week at four weeks (MD −0.18 cramps/week, 95% CI −0.84 to 0.49; 5 studies, 307 participants; moderate‐certainty evidence). The percentage of individuals experiencing a 25% or better reduction in cramp rate from baseline was also no different (RR 1.04, 95% CI 0.84 to 1.29; 3 studies, 177 participants; high‐certainty evidence). Similarly, no statistically significant difference was found at four weeks in measures of cramp intensity or cramp duration. This includes the number of participants rating their cramps as moderate or severe at four weeks (RR 1.33, 95% CI 0.81 to 2.21; 2 studies, 91 participants; moderate‐certainty evidence); and the percentage of participants with the majority of cramp durations of one minute or more at four weeks (RR 1.83, 95% CI 0.74 to 4.53, 1 study, 46 participants; low‐certainty evidence). We were unable to perform meta‐analysis for trials of pregnancy‐associated leg cramps. The single study comparing magnesium to no treatment failed to find statistically significant benefit on a three‐point ordinal scale of overall treatment efficacy. Of the three trials comparing magnesium to placebo, one found no benefit on frequency or intensity measures, another found benefit for both, and a third reported inconsistent results for frequency that could not be reconciled. The single study in people with liver cirrhosis was small and had limited reporting of cramps, but found no difference in terms of cramp frequency or cramp intensity. Our analysis of adverse events pooled all studies, regardless of the setting in which cramps occurred. Major adverse events (occurring in 2 out of 72 magnesium recipients and 3 out of 68 placebo recipients), and withdrawals due to adverse events, were not significantly different from placebo. However, in the four studies for which it could be determined, more participants experienced minor adverse events in the magnesium group than in the placebo group (RR 1.51, 95% CI 0.98 to 2.33; 4 studies, 254 participants; low‐certainty evidence). Overall, oral magnesium was associated with mostly gastrointestinal adverse events (e.g. diarrhoea), experienced by 11% (10% in control) to 37% (14% in control) of participants. Authors' conclusions It is unlikely that magnesium supplementation provides clinically meaningful cramp prophylaxis to older adults experiencing skeletal muscle cramps. In contrast, for those experiencing pregnancy‐associated rest cramps the literature is conflicting and further research in this population is needed. We found no RCTs evaluating magnesium for exercise‐associated muscle cramps or disease‐state‐associated muscle cramps (for example amyotrophic lateral sclerosis/motor neuron disease) other than a single small (inconclusive) study in people with liver cirrhosis, only some of whom suffered cramps. Plain language summary Magnesium for muscle cramps Review question We reviewed the evidence about the effect of magnesium supplements on muscle cramps, and included the widest possible range of studies. This meant including studies on anyone suffering muscle cramps, regardless of why they suffered them. It also meant including studies where magnesium was given in any of the ways available. This includes being swallowed as a pill or liquid, being injected slowly over a number of hours directly into the blood ('intravenous infusion'), and being injected into muscle ('intramuscular injection'). We included studies comparing magnesium to placebo, comparing magnesium to no treatment, and comparing magnesium to other existing cramp treatments. We found a total of 11 studies. To assess benefit, we examined the effect of magnesium on cramp frequency, cramp pain, and cramp duration, and we examined the number of participants whose cramp rate reduced by 25% or more. To assess for potential harm, we examined how often major and minor adverse health events occurred. Background Muscle cramps are common and occur in a wide range of settings. Older adults and pregnant women commonly complain of leg cramps while they are resting, athletes can cramp when they are pushing the limits of their endurance, and some people develop muscle cramps as a symptom of other medical conditions. One potential treatment that is already being marketed to prevent muscle cramps is magnesium supplementation. Magnesium is a common mineral in our diets and extra oral supplements of this mineral are available either over the Internet or in health food stores and pharmacies (usually in the form of tablets or powders to be dissolved in water). We wanted to combine studies to get the best estimate of magnesium's effect on cramping. We also wanted to examine the effect of magnesium in different categories of cramp sufferers, in case it might work in one setting, and not another. Study characteristics We searched for all high‐quality published studies evaluating the effectiveness of magnesium to prevent muscle cramps and found five studies in older adults, five studies in pregnant women, and one study in people with liver cirrhosis. The studies in older adults included 271 participants (61.6 to 69.3 years of age) and the studies in pregnant women included 408 participants. The single study in people with liver cirrhosis enrolled only 29 people, not all of whom experienced cramping. There were no studies of people who cramp while exercising. Magnesium was compared to placebo in nine of 11 studies, and compared to calcium, vitamin E, vitamins B₁ and B₆, and no treatment, in two studies of pregnant women. The included studies ranged from 14 to 56 days of treatment. Magnesium was given orally in 10 of 11 studies, and by four‐hour intravenous infusion on five consecutive days in one study. Funding for included studies came from a manufacturer of magnesium tablets in two studies, independent sources in three studies, and was not reported in six studies. Key results and certainty of the evidence The combined results of five seemingly reliable studies suggest, with moderate‐certainty, that magnesium is unlikely to reduce the frequency or severity of muscle cramps in older adults. In contrast, the five studies in pregnant women had important limitations to their reliability (both in study design and reporting of results), did not consistently show benefit, and could not be combined. As a result we are very uncertain as to whether pregnant women experiencing muscle cramps would benefit from magnesium. The single study in people with liver cirrhosis reported no difference in cramp frequency or intensity but was too small for conclusions to be drawn. More research on magnesium in pregnant women is needed. The same is true for those who suffer cramps associated with medical conditions, or while exercising. However older adult cramp sufferers appear unlikely to benefit from this therapy. Major side effects were infrequent and participants withdrew from the study at similar rates when given magnesium or placebo. However minor side effects, mostly diarrhoea (as would be expected from magnesium salts) and nausea, were common and affected roughly 11% (10% in control) to 37% (14% in control) of participants. The review is up to date to September 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Garrison, SR, Korownyk, CS, Kolber, MR, Allan, GM, Musini, VM, Sekhon, RK, Dugré, N", "articleTypes": [], "doi": "10.1002/14651858.CD009402.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.803Z" }, { "id": "f45ac1a8-68e7-46f8-9527-f7d628e5c494", "pmid": "", "title": "Investigating the Potential Role of Aerosolized Retinoic Acid, a Potent Vitamin A Metabolite for Treating COVID-19 Anosmia and Retinoic Acid Insufficiency .A Novel Approach for Regaining Sense of Smell.", "imported": false, "abstract": "Investigating the potential role of Aerosolized retinoic acid, a potent Vitamin A metabolite for treating COVID-19 Anosmia and retinoic acid insufficiency .A novel approach for regaining Sense of Smell.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.160Z" }, { "id": "f46927f3-fddb-40b6-acbc-67360373c039", "pmid": "", "title": "Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Chronic obstructive pulmonary disease (COPD) is a chronic lung condition characterised by persistent respiratory symptoms and limited lung airflow, dyspnoea and recurrent exacerbations. Suboptimal therapy or non‐adherence may result in limited effectiveness of pharmacological treatments and subsequently poor health outcomes. Objectives To determine the efficacy and safety of interventions intended to improve adherence to single or combined pharmacological treatments compared with usual care or interventions that are not intended to improve adherence in people with COPD. Search methods We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register, CENTRAL, MEDLINE and Embase (search date 1 May 2020). We also searched web‐based clinical trial registers. Selection criteria RCTs included adults with COPD diagnosed by established criteria (e.g. Global Initiative for Obstructive Lung Disease). Interventions included change to pharmacological treatment regimens, adherence aids, education, behavioural or psychological interventions (e.g. cognitive behavioural therapy), communication or follow‐up by a health professional (e.g. telephone, text message or face‐to‐face), multi‐component interventions, and interventions to improve inhaler technique. Data collection and analysis We used standard Cochrane methodological procedures. Working in pairs, four review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We assessed confidence in the evidence for each primary outcome using GRADE. Primary outcomes were adherence, quality of life and hospital service utilisation. Adherence measures included the Adherence among Patients with Chronic Disease questionnaire (APCD). Quality of life measures included the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). Main results We included 14 trials (2191 participants) in the analysis with follow‐up ranging from six to 52 weeks. Age ranged from 54 to 75 years, and COPD severity ranged from mild to very severe. Trials were conducted in the USA, Spain, Germany, Japan, Jordan, Northern Ireland, Iran, South Korea, China and Belgium. Risk of bias was high due to lack of blinding. Evidence certainty was downgraded due to imprecision and small participant numbers. Single component interventions Six studies (55 to 212 participants) reported single component interventions including changes to pharmacological treatment (different roflumilast doses or different inhaler types), adherence aids (Bluetooth inhaler reminder device), educational (comprehensive verbal instruction), behavioural or psychological (motivational interview). Change in dose of roflumilast may result in little to no difference in adherence (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.22 to 1.99; studies = 1, participants = 55; low certainty). A Bluetooth inhaler reminder device did not improve adherence, but comprehensive verbal instruction from a health professional did improve mean adherence (prescription refills) (mean difference (MD) 1.00, 95% CI 0.46 to 1.54). Motivational interview improved mean adherence scores on the APCD scale (MD 22.22, 95% CI 8.42 to 36.02). Use of a single inhaler compared to two separate inhalers may have little to no impact on quality of life (SGRQ; MD 0.80, 95% CI –3.12 to 4.72; very low certainty). A Bluetooth inhaler monitoring device may provide a small improvement in quality of life on the CCQ (MD 0.40, 95% CI 0.07 to 0.73; very low certainty). Single inhaler use may have little to no impact on the number of people admitted to hospital compared to two separate inhalers (OR 1.47, 95% CI 0.75 to 2.90; very low certainty). Single component interventions may have little to no impact on the number of people expereincing adverse events (very low certainty evidence from studies of a change in pharmacotherapy or use of adherence aids). A change in pharmacotherapy may have little to no impact on exacerbations or deaths (very low certainty). Multi‐component interventions Eight studies (30 to 734 participants) reported multi‐component interventions including tailored care package that included adherence support as a key component or included inhaler technique as a component. A multi‐component intervention may result in more people adhering to pharmacotherapy compared to control at 40.5 weeks (risk ratio (RR) 1.37, 95% CI 1.18 to 1.59; studies = 4, participants = 446; I 2 = 0%; low certainty). There may be little to no impact on quality of life (SGRQ, Chronic Respiratory Disease Questionnaire, CAT) (studies = 3; low to very low certainty). Multi‐component interventions may help to reduce the number of people admitted to hospital for any cause (OR 0.37, 95% CI 0.22 to 0.63; studies = 2, participants = 877; low certainty), or COPD‐related hospitalisations (OR 0.15, 95% CI 0.07 to 0.34; studies = 2, participants = 220; moderate certainty). There may be a small benefit on people experiencing severe exacerbations. There may be little to no effect on adverse events, serious adverse events or deaths, but events were infrequently reported and were rare (low to very low certainty). Authors' conclusions Single component interventions (e.g. education or motivational interviewing provided by a health professional) can help to improve adherence to pharmacotherapy (low to very low certainty). There were slight improvements in quality of life with a Bluetooth inhaler device, but evidence is from one study and very low certainty. Change to pharmacotherapy (e.g. single inhaler instead of two, or different doses of roflumilast) has little impact on hospitalisations or exacerbations (very low certainty). There is no difference in people experiencing adverse events (all‐cause or COPD‐related), or deaths (very low certainty). Multi‐component interventions may improve adherence with education, motivational or behavioural components delivered by health professionals (low certainty). There is little to no impact on quality of life (low to very low certainty). They may help reduce the number of people admitted to hospital overall (specifically pharmacist‐led approaches) (low certainty), and fewer people may have COPD‐related hospital admissions (moderately certainty). There may be a small reduction in people experiencing severe exacerbations, but evidence is from one study (low certainty). Limited evidence found no difference in people experiencing adverse events, serious adverse events or deaths (low to very low certainty). The evidence presented should be interpreted with caution. Larger studies with more intervention types, especially single interventions, are needed. It is unclear which specific COPD subgroups would benefit, therefore discussions between health professionals and patients may help to determine whether they will help to improve health outcomes. Plain language summary Which approaches help people with COPD to maintain taking medication as prescribed? Review question Which approaches help people maintain taking prescribed medication(s), improve quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD)? Background COPD is a lung condition that can cause long‐term breathing problems and includes symptoms such as shortness of breath. Medications do exist that can help but sometimes people do not take them as prescribed. Different approaches could help people to take their medication as prescribed and help improve symptoms or quality of life and reduce hospital admissions. We wanted to find out if any approaches could help people with COPD take their medication(s) as prescribed. Studies identified and selected We searched databases to find the studies. Four people working in pairs looked at the lists of studies separately and agreed on which ones were included. The latest search for studies was conducted in May 2020. Study characteristics We included studies comparing simple ways to help improve medication use (e.g. different medication doses or single inhalers instead of two separate inhalers) to usual COPD care. We also included studies that tested combination approaches (e.g. information or training from nurses or pharmacists and monitoring medication use). What were the key results? We included 14 studies (2191 people) in our analysis. No studies were masked (people knew whether they were receiving an approach to help them with adherence or the alternative). Six studies used simple approaches (e.g. change to medication dosage, change to type of inhaler, or a Bluetooth inhaler reminder device), and eight studies used combined approaches (e.g. nurses or pharmacists giving advice or information about how to improve medication use). We were uncertain about the effects of a different medication dose on people adhering to medication because it was no different to usual care (one study). Two separate studies found that a Bluetooth inhaler reminder device or a change in oral medication dose did not help to improve adherence. Health professionals involved in giving information may help to improve adherence (one study). This was measured by prescription refills. Motivating people to change their behaviour could help to improve adherence their medication (one study). This was measured by people completing a questionnaire about adherence to their medication. One study found that a Bluetooth inhaler device might help to improve quality of life. There may be little to no difference between those using single inhalers in the number of people admitted to hospital compared to those using two separate inhalers (one study). We found no difference between single approaches and usual care on the number of people who had side effects. Combined approaches may help to improve the number of people taking their medication, but we were not confident of this finding (four studies). They may have little to no impact on quality of life (three studies). Combined approaches could be beneficial in reducing the number of people with COPD admitted to hospital for any reason or because of COPD symptoms (two studies). There was no difference between combined approaches and in the number of people who had adverse events. Take home message We could not say for certain that simple approaches are useful to help people with COPD to improve medication use because of very limited information. Combined approaches may help people to take their medication(s) as prescribed and can help to reduce the number of people admitted to hospital, however, more information is needed to help answer this question with confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Janjua, S; Pike, KC; Carr, R; Coles, A; Fortescue, R; Batavia, M", "articleTypes": [], "doi": "10.1002/14651858.CD013381.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "f46a7cbf-aa43-4c5e-9da4-5255702f2509", "pmid": "", "title": "Herbal interventions for chronic asthma in adults and children", "imported": false, "abstract": "Abstract - Background Herb and plant based preparations are a popular treatment for asthma, although there remain concerns as to their efficacy and safety. In Western societies, motivations for using such treatments may be both positive and negative, with their perceived safety and dissatisfaction with conventional medicine among them. In China such treatments are more commonly used and many compounds considered 'conventional' are derived from herbs or plants. Objectives To assess the efficacy and safety of herb and plant extracts in the management of chronic asthma. Search methods The Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, EMBASE and AMED were searched with pre‐defined terms. Searches are current as of February 2007. Selection criteria Randomised placebo controlled trials of any herb or plant extract were eligible. Study participants had to have a primary diagnosis of asthma. Studies in both adults and children were eligible for the review. Data collection and analysis Two reviewers assessed studies for suitability. Data were extracted and double‐checked. Main results Twenty‐seven studies (29 experimental groups) met the review entry criteria, randomising a total of 1925 participants. The studies identified assessed the effects of 21 different herbal preparations. Study quality varied considerably, and the sample sizes were often small. For primary outcomes (exacerbations, steroids use and lung function measurements): Two out of six studies reporting change in FEV1 were positive, with very few data available on the frequency of exacerbations. One study which did report these data was negative. Health‐related quality of life was only measured in one trial. Authors' conclusions The evidence base for the effects of herbal treatments is hampered by the variety of treatments assessed, poor reporting quality of the studies and lack of available data. The data that are available from the studies provide only a small insight into the long‐term efficacy and harm profiles of these treatments. The absence of common endpoint measurements limits the validity of our findings further. Positive findings in this review warrant additional well‐designed trials in this area. Plain language summary Herbal interventions for chronic asthma in adults and children Chronic asthma is a inflammatory disease of the airways characterised by wheeze and breathlessness. Drug therapy is usually used to control symptoms but complementary medicine is often used, including herbal treatments, and the efficacy and safety of such treatments is not clear. We reviewed evidence from 27 trials covering 21 different herbal treatments in both adults and children from both in‐patient and out‐patient settings. In general, the reporting of trials was poor. The outcomes measured by the trials varied considerably which made it difficult to compare the results of studies that did look at the same treatment. On the basis of the available evidence it is not possible to show whether any of these herbal treatments can improve asthma symptoms. Further trials of high quality are needed to assess the use of herbal treatments in asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Arnold, E; Clark, CE; Lasserson, TJ; Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD005989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "f46ae1df-4998-4148-8e3e-24b675a16c64", "pmid": "", "title": "Omega 3 fatty acids for preventing or slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Evidence from animal models and observational studies in humans has suggested that there is an inverse relationship between dietary intake of omega 3 long‐chain polyunsaturated fatty acids (LCPUFA) and risk of developing age‐related macular degeneration (AMD) or progression to advanced AMD. Objectives To review the evidence that increasing the levels of omega 3 LCPUFA in the diet (either by eating more foods rich in omega 3 or by taking nutritional supplements) prevents AMD or slows the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 1), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2015), EMBASE (January 1980 to February 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to February 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 February 2015. Selection criteria We included randomised controlled trials (RCTs) where increased dietary intake of omega 3 LCPUFA was compared to placebo or no intervention with the aim of preventing the development of AMD, or slowing its progression. Data collection and analysis Both authors independently selected studies, assessed them for risk of bias and extracted data. One author entered data into RevMan 5 and the other author checked the data entry. We conducted a meta‐analysis for one primary outcome, progression of AMD, using a fixed‐effect inverse variance model. Main results We included two RCTs in this review, in which 2343 participants with AMD were randomised to receive either omega 3 fatty acid supplements or a placebo. The trials, which had a low risk of bias, were conducted in the USA and France. Overall, there was no evidence that people who took omega 3 fatty acid supplements were at decreased (or increased risk) of progression to advanced AMD (pooled hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.84 to 1.10, high quality evidence). Similarly, people taking these supplements were no more (or less) likely to lose 15 or more letters of visual acuity (USA study HR 0.96, 95% CI 0.84 to 1.10; French study at 36 months risk ratio (RR) 1.25, 95% CI 0.69 to 2.26, participants = 230). The number of adverse events was similar in the intervention and placebo groups (USA study participants with one or more serious adverse event RR 1.00, 95% CI 0.91 to 1.09, participants = 2080; French study total adverse events RR 1.05, 95% CI 0.97 to 1.13, participants = 263). Authors' conclusions This review found that omega 3 LCPUFA supplementation in people with AMD for periods up to five years does not reduce the risk of progression to advanced AMD or the development of moderate to severe visual loss. No published randomised trials were identified on dietary omega 3 fatty acids for primary prevention of AMD. Currently available evidence does not support increasing dietary intake of omega 3 LCPUFA for the explicit purpose of preventing or slowing the progression of AMD. Plain language summary Omega 3 fatty acids for preventing and slowing the progression of age‐related macular degeneration Review question 
 We asked the question whether increased dietary intake of omega 3 fatty acids prevented or slowed the progression of age‐related macular degeneration. Background 
 Age‐related macular degeneration (AMD) is an eye condition that affects the central area of the retina (light‐sensitive tissue at the back of the eye). AMD is associated with a loss of detailed vision and adversely affects tasks such as reading, driving and face recognition. In the absence of a cure, there has been considerable interest in the role of modifiable risk factors to prevent or slow down the progression of AMD. Evidence from population studies suggests that people who have a diet with relatively high levels of omega 3 fatty acids (such as those derived from fish oils) are less likely to develop AMD. Study characteristics 
 We searched for studies up to 2 February 2015. We identified two trials with a total of 2343 participants. The trials were conducted in the USA and France and investigated the use of fish oil supplements in people with AMD who were at high risk of progressing to advanced disease. We judged the studies to be at low risk of bias. One study was funded by government grants and the other study was funded by the manufacturer of the dietary supplement. Key results 
 These studies found that omega 3 supplementation for periods up to five years did not reduce the rate of progression to advanced AMD or reduce significant visual loss compared to a placebo. The incidence of adverse effects was similar in the intervention and placebo groups. Quality of the evidence 
 We judged the quality of the evidence on rate of progression to AMD to be high, and the quality of the evidence for other outcomes to be moderate because the estimates were imprecise.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Lawrenson, JG; Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD010015.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "f485a3a5-7e2c-4b01-b50b-8e784c5f668f", "pmid": "", "title": "Interventions for treating oro‐antral communications and fistulae due to dental procedures", "imported": false, "abstract": "Abstract - Background An oro‐antral communication is an unnatural opening between the oral cavity and maxillary sinus. When it fails to close spontaneously, it remains patent and is epithelialized to develop into an oro‐antral fistula. Various surgical and non‐surgical techniques have been used for treating the condition. Surgical procedures include flaps, grafts and other techniques like re‐implantation of third molars. Non‐surgical techniques include allogenic materials and xenografts. This is an update of a review first published in May 2016. Objectives To assess the effectiveness and safety of various interventions for the treatment of oro‐antral communications and fistulae due to dental procedures. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 23 May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 4), MEDLINE Ovid (1946 to 23 May 2018), and Embase Ovid (1980 to 23 May 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the reference lists of included and excluded trials for any randomised controlled trials (RCTs). Selection criteria We included RCTs evaluating any intervention for treating oro‐antral communications or oro‐antral fistulae due to dental procedures. We excluded quasi‐RCTs and cross‐over trials. We excluded studies on participants who had oro‐antral communications, fistulae or both related to Caldwell‐Luc procedure or surgical excision of tumours. Data collection and analysis Two review authors independently selected trials. Two review authors assessed trial risk of bias and extracted data independently. We estimated risk ratios (RR) for dichotomous data, with 95% confidence intervals (CI). We assessed the overall quality of the evidence using the GRADE approach. Main results We included only one study in this review, which compared two surgical interventions: pedicled buccal fat pad flap and buccal flap for the treatment of oro‐antral communications. The study involved 20 participants. The risk of bias was unclear. The relevant outcome reported in this trial was successful (complete) closure of oro‐antral communication. The quality of the evidence for the primary outcome was very low. The study did not find evidence of a difference between interventions for the successful (complete) closure of an oro‐antral communication (RR 1.00, 95% Cl 0.83 to 1.20) one month after the surgery. All oro‐antral communications in both groups were successfully closed so there were no adverse effects due to treatment failure. We did not find trials evaluating any other intervention for treating oro‐antral communications or fistulae due to dental procedures. Authors' conclusions We found very low quality evidence from a single small study that compared pedicled buccal fat pad and buccal flap. The evidence was insufficient to judge whether there is a difference in the effectiveness of these interventions as all oro‐antral communications in the study were successfully closed by one month after surgery. Large, well‐conducted RCTs investigating different interventions for the treatment of oro‐antral communications and fistulae caused by dental procedures are needed to inform clinical practice. Plain language summary Treatment of communications between the oral cavity and the maxillary sinus due to dental procedures Review question What evidence is available for the safe and effective treatment of openings between the mouth and main sinus caused by dental procedures? Background The floor of the main sinus near the nose is thin and lies directly above the roots of the teeth at the back of the mouth. Sometimes following infection or dental treatment, this structure becomes damaged and openings or channels between the mouth and the sinus are formed. These are known as oro‐antral communications (OAC). If the OAC is left open (then described as an oro‐antral fistula (OAF), it may become permanent, leading to long‐lasting sinus infections. This condition can be treated surgically by using flaps, grafts and other techniques; or non‐surgically using a variety of methods and materials. There is little evidence for the most effective and safe treatments for closing OACs and OAFs and clinicians who treat these conditions have identified an urgent need for this. This is an update of a review first published in May 2016. Study characteristics We searched various databases until 23 May 2018. Only one study, which was conducted in Iran, is included in our review. The study ran for two years and involved 20 people with OAC aged between 25 and 56 years. Participants were divided into two groups and two surgical treatments were compared for treating oro‐antral communications; one group was treated with pedicled buccal fat pad flap (PBFPF) and the other with buccal flap (BF). Key results and quality of evidence The study did not find evidence of a difference between PBFPF and BF in terms of successful (complete) closure of OAC. Both interventions resulted in successful closure by one month after surgery. The study did not therefore report any adverse effects of treatment failure. It may not be possible to generalise these findings because the quality of the evidence was very low, due to unclear risk of bias and the small numbers studied in the single included trial. Conclusion The evidence currently available is insufficient to draw reliable conclusions regarding the effects of interventions used to treat OAC or fistulae due to dental procedures. More well‐designed and well‐reported trials evaluating different interventions are needed to provide reliable evidence to inform clinical decisions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Kiran Kumar Krishanappa, S; Eachempati, P; Kumbargere Nagraj, S; Shetty, NY; Moe, S; Aggarwal, H; Mathew, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD011784.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "f4962357-82df-4a0c-bc3a-cd07120f15d6", "pmid": "", "title": "Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia", "imported": false, "abstract": "Abstract - Background Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases children's risk of developing pneumonia. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited. This is an update of a Cochrane Review first published in 2018. Objectives To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia. Search methods We searched CENTRAL, MEDLINE, Embase, and two trial registries on 28 December 2021. We applied no language restrictions. Selection criteria We included randomised controlled trials (RCTs) that compared vitamin D supplementation with placebo in children (aged one month to five years) hospitalised with acute community‐acquired pneumonia, as defined by the World Health Organization (WHO) acute respiratory infection guidelines. For this update, we reappraised eligible trials according to research integrity criteria, excluding RCTs published from April 2018 that were not prospectively registered in a trials registry according to WHO or Clinical Trials Registry – India (CTRI) guidelines (it was not mandatory to register clinical trials in India before April 2018). Data collection and analysis Two review authors independently assessed trials for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with number of participants in each group. We used standard methodological procedures expected by Cochrane. Main results In this update, we included three new trials involving 468 children, bringing the total number of trials to seven, with 1601 children (631 with pneumonia and 970 with severe or very severe pneumonia). We categorised three previously included studies and three new studies as 'awaiting classification' based on the research integrity screen.
Five trials used a single bolus dose of vitamin D (300,000 IU in one trial and 100,000 IU in four trials) at the onset of illness or within 24 hours of hospital admission; one used a daily dose of oral vitamin D (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used variable doses (on day 1, 20,000 IU in children younger than six months, 50,000 IU in children aged six to 12 months, and 100,000 IU in children aged 13 to 59 months; followed by 10,000 IU/day for four days or until discharge). Three trials performed microbiological diagnosis of pneumonia, radiological diagnosis of pneumonia, or both. Vitamin D probably has little or no effect on the time to resolution of acute illness (mean difference (MD) −1.28 hours, 95% confidence interval (CI) −5.47 to 2.91; 5 trials, 1188 children; moderate‐certainty evidence). We do not know if vitamin D has an effect on the duration of hospitalisation (MD 4.96 hours, 95% CI −8.28 to 18.21; 5 trials, 1023 children; very low‐certainty evidence). We do not know if vitamin D has an effect on mortality rate (risk ratio (RR) 0.69, 95% CI 0.44 to 1.07; 3 trials, 584 children; low‐certainty evidence). The trials reported no major adverse events. According to GRADE criteria, the evidence was of very low‐to‐moderate certainty for all outcomes, owing to serious trial limitations, inconsistency, indirectness, and imprecision. Three trials received funding: one from the New Zealand Aid Corporation, one from an institutional grant, and one from multigovernment organisations (Bangladesh, Sweden, and UK). The remaining four trials were unfunded. Authors' conclusions Based on the available evidence, we are uncertain whether vitamin D supplementation has important effects on outcomes of acute pneumonia when used as an adjunct to antibiotics. The trials reported no major adverse events. Uncertainty in the evidence is due to imprecision, risk of bias, inconsistency, and indirectness. Plain language summary Is vitamin D an effective and safe addition to antibiotics for treating children with acute pneumonia? What is pneumonia, and how can it be treated? Pneumonia is inflammation (swelling) of the lungs caused by an infection. Treatment for pneumonia includes antibiotics, providing oxygen through a mask, and other supportive therapies. Vitamin D boosts immune defences and reduces excessive inflammation: these effects may help children recover from an episode of pneumonia. What did we want to find out? We wanted to find out if vitamin D, taken together with antibiotics, can help children to recover from an episode of pneumonia. What did we do? We searched for trials that looked at vitamin D compared with placebo (dummy treatment) in children aged between one month and five years who had pneumonia. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. Study characteristics We included seven trials involving 1601 children from low‐ and middle‐income countries. In five trials, children received a single large dose of vitamin D when they joined the trial or within 24 hours of admission to hospital. In two trials, children received vitamin D for five days. One trial excluded children with normal vitamin D levels. Two trials reported the cause of children's pneumonia. Key results Vitamin D probably has little or no effect on the time it takes children to get better from pneumonia. We do not know if vitamin D has an effect on the time children spend in hospital or the number of children who die. The studies reported no major harmful events. What are the limitations of the evidence? We have only moderate confidence in the evidence on the time it took children to recover from pneumonia, because all children in this comparison were from low‐income regions, so the results may not apply to higher‐income populations. We have little confidence in the evidence on death rate, because of the same applicability problem outlined above, and because the result was compatible with both appreciable benefit and harm. We have very little confidence in the evidence on time spent in hospital, because of the same applicability problem outlined above, because the children and health providers in one study knew what the allocated treatment was, and because the results were very inconsistent across the studies included in the comparison. How up to date is the evidence? The evidence is current to 28 December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Das, RR; Singh, M; Naik, SS", "articleTypes": [], "doi": "10.1002/14651858.CD011597.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "f4a5661f-849a-4afe-8e8a-6f34606566bd", "pmid": "", "title": "Topiramate for the prophylaxis of episodic migraine in adults", "imported": false, "abstract": "Abstract - Background Some antiepileptic drugs but not others are useful in clinical practice for the prophylaxis of migraine. This might be explained by the variety of actions of these drugs in the central nervous system. The present review is part of an update of a Cochrane review first published in 2004, and previously updated (conclusions not changed) in 2007. Objectives To describe and assess the evidence from controlled trials on the efficacy and tolerability of topiramate for preventing migraine attacks in adult patients with episodic migraine. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2012, Issue 12), PubMed/MEDLINE (1966 to 15 January 2013), MEDLINE In‐Process (current week, 15 January 2013), and EMBASE (1974 to 15 January 2013) and handsearched Headache and Cephalalgia through January 2013. Selection criteria Studies were required to be prospective, controlled trials of topiramate taken regularly to prevent the occurrence of migraine attacks, to improve migraine‐related quality of life, or both. Data collection and analysis Two review authors independently selected studies and extracted data. For headache frequency data, we calculated mean differences (MDs) between topiramate and comparator (placebo, active control, or topiramate in a different dose) for individual studies and pooled these across studies. For dichotomous data on responders (patients with ≥ 50% reduction in headache frequency), we calculated odds ratios (ORs) and, in select cases, risk ratios (RRs); we also calculated numbers needed to treat (NNTs). We calculated MDs for selected quality of life instruments. Finally, we summarised data on adverse events from placebo‐controlled trials and calculated risk differences (RDs) and numbers needed to harm (NNHs). Main results Twenty papers describing 17 unique trials met the inclusion criteria. Analysis of data from nine trials (1737 participants) showed that topiramate reduced headache frequency by about 1.2 attacks per 28 days as compared to placebo (MD ‐1.20; 95% confidence interval (CI) ‐1.59 to ‐0.80). Data from nine trials (1190 participants) show that topiramate approximately doubled the proportion of responders relative to placebo (RR 2.02; 95% CI 1.57 to 2.60; NNT 4; 95% CI 3 to 6). Separate analysis of different topiramate doses produced similar MDs versus placebo at 50 mg (‐0.95; 95% CI ‐1.95 to 0.04; three studies; 520 participants), 100 mg (‐1.15; 95% CI ‐1.58 to ‐0.71; six studies; 1620 participants), and 200 mg (‐0.94; 95% CI ‐1.53 to ‐0.36; five studies; 804 participants). All three doses significantly increased the proportion of responders relative to placebo; ORs were as follows: for 50 mg, 2.35 (95% CI 1.60 to 3.44; three studies; 519 participants); for 100 mg, 3.49 (95% CI 2.23 to 5.45; five studies; 852 participants); and for 200 mg, 2.49 (95% CI 1.61 to 3.87; six studies; 1025 participants). All three doses also significantly improved three or more domains of quality of life as compared to placebo. Meta‐analysis of the three studies that included more than one dose of topiramate suggests that 200 mg is no more effective than 100 mg. With regard to mean headache frequency and/or responder rate, seven trials using active comparators found (a) no significant difference between topiramate and amitriptyline (one study, 330 participants); (b) no significant difference between topiramate and flunarizine (one study, 83 participants); (c) no significant difference between topiramate and propranolol (two studies, 342 participants); (d) no significant difference between topiramate and relaxation (one study, 61 participants); but (e) a slight significant advantage of topiramate over valproate (two studies, 120 participants). Relaxation improved migraine‐specific quality of life significantly more than topiramate. In trials of topiramate against placebo, seven adverse events (AEs) were reported by at least three studies. These were usually mild and of a non‐serious nature. Except for taste disturbance and weight loss, there were no significant differences in the frequency of AEs in general, or of the seven specific AEs, between placebo and topiramate 50 mg. AEs in general and all of the specific AEs except nausea were significantly more common on topiramate 100 mg than on placebo, with NNHs varying from 3 to 25, and the RDs versus placebo were even higher for topiramate 200 mg, with NNHs varying from 2 to 17. Authors' conclusions Meta‐analysis demonstrates that topiramate in a 100 mg/day dosage is effective in reducing headache frequency and reasonably well‐tolerated in adult patients with episodic migraine. This provides good evidence to support its use in routine clinical management. More studies designed specifically to compare the efficacy or safety of topiramate versus other interventions with proven efficacy in the prophylaxis of migraine are needed. Plain language summary Topiramate for preventing migraine attacks in adults Various medicines, collectively termed 'antiepileptics', are used to treat epilepsy. For several years, some of these drugs have also been used for preventing migraine attacks. For the present review, researchers in The Cochrane Collaboration reviewed the evidence about the effects of topiramate in adult patients (≥ 16 years of age) with 'episodic' migraine (headache on < 15 days per month). They examined research published up to 15 January 2013 and found 17 relevant studies. Compared with placebo, topiramate reduced the frequency of migraine headaches by approximately 1.2 per month (nine studies, 1737 participants). Patients were also about twice as likely to reduce the number of their migraine headaches by 50% or more with topiramate than with placebo (nine studies, 1190 participants). Side effects associated with topiramate were common but generally mild; topiramate can, however, cause birth defects and so should be used with caution in women of childbearing age. Further research is needed comparing topiramate with other active drugs used for preventing migraine attacks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Linde, M, Mulleners, WM, Chronicle, EP, McCrory, DC", "articleTypes": [], "doi": "10.1002/14651858.CD010610", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.756Z" }, { "id": "f4bcf791-fcf3-4264-8093-33f7f557f2c0", "pmid": "", "title": "Chelation therapy for atherosclerotic cardiovascular disease", "imported": false, "abstract": "Abstract - Background Chelation therapy is promoted and practiced around the world as a form of alternative medicine in the treatment of atherosclerotic cardiovascular disease. It has been suggested as a safe, relatively inexpensive, non‐surgical method of restoring blood flow in atherosclerotic vessels. However, there is currently limited high‐quality, adequately‐powered research informing evidence‐based medicine on the topic, specifically regarding clinical outcomes. Due to this limited evidence, the benefit of chelation therapy remains controversial at present. This is an update of a review first published in 2002. Objectives To assess the effects of ethylene diamine tetra‐acetic acid (EDTA) chelation therapy versus placebo or no treatment on clinical outcomes among people with atherosclerotic cardiovascular disease. Search methods For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 6 August 2019. We searched the bibliographies of the studies retrieved by the literature searches for further trials. Selection criteria We included studies if they were randomised controlled trials of EDTA chelation therapy versus placebo or no treatment in participants with atherosclerotic cardiovascular disease. The main outcome measures we considered include all‐cause or cause‐specific mortality, non‐fatal cardiovascular events, direct or indirect measurement of disease severity, and subjective measures of improvement or adverse events. Data collection and analysis Two review authors independently extracted data and assessed trial quality using standard Cochrane procedures. A third author considered any unresolved issues, and we discussed any discrepancies until a consensus was reached. We contacted study authors for additional information. Main results We included five studies with a total of 1993 randomised participants. Three studies enrolled participants with peripheral vascular disease and two studies included participants with coronary artery disease, one of which specifically recruited people who had had a myocardial infarction. The number of participants in each study varied widely (from 10 to 1708 participants), but all studies compared EDTA chelation to a placebo. Risk of bias for the included studies was generally moderate to low, but one study had high risk of bias because the study investigators broke their randomisation code halfway through the study and rolled the placebo participants over to active treatment. Certainty of the evidence, as assessed by GRADE, was generally low to very low, which was mostly due to a paucity of data in each outcome's meta‐analysis. This limited our ability to draw any strong conclusions. We also had concerns about one study's risk of bias regarding blinding and outcome assessment that may have biased the results. Two studies with coronary artery disease participants reported no evidence of a difference in all‐cause mortality between chelation therapy and placebo (risk ratio (RR) 0.97, 95% CI 0.73 to 1.28; 1792 participants; low‐certainty). One study with coronary artery disease participants reported no evidence of a difference in coronary heart disease deaths between chelation therapy and placebo (RR 1.02, 95% CI 0.70 to 1.48; 1708 participants; very low‐certainty). Two studies with coronary artery disease participants reported no evidence of a difference in myocardial infarction (RR 0.81, 95% CI 0.57 to 1.14; 1792 participants; moderate‐certainty), angina (RR 0.95, 95% CI 0.55 to 1.67; 1792 participants; very low‐certainty), and coronary revascularisation (RR 0.46, 95% CI 0.07 to 3.25; 1792 participants). Two studies (one with coronary artery disease participants and one with peripheral vascular disease participants) reported no evidence of a difference in stroke (RR 0.88, 95% CI 0.40 to 1.92; 1867 participants; low‐certainty). Ankle‐brachial pressure index (ABPI; also known as ankle brachial index) was measured in three studies, all including participants with peripheral vascular disease; two studies found no evidence of a difference in the treatment groups after three months after treatment (mean difference (MD) 0.02, 95% CI ‐0.03 to 0.06; 181 participants; low‐certainty). A third study reported an improvement in ABPI in the EDTA chelation group, but this study was at high risk of bias. Meta‐analysis of maximum and pain‐free walking distances three months after treatment included participants with peripheral vascular disease and showed no evidence of a difference between the treatment groups (MD ‐31.46, 95% CI ‐87.63 to 24.71; 165 participants; 2 studies; low‐certainty). Quality of life outcomes were reported by two studies that included participants with coronary artery disease, but we were unable to pool the data due to different methods of reporting and varied criteria. However, there did not appear to be any major differences between the treatment groups. None of the included studies reported on vascular deaths. Overall, there was no evidence of major or minor adverse events associated with EDTA chelation treatment. Authors' conclusions There is currently insufficient evidence to determine the effectiveness or ineffectiveness of chelation therapy in improving clinical outcomes of people with atherosclerotic cardiovascular disease. More high‐quality, randomised controlled trials are needed that assess the effects of chelation therapy on longevity and quality of life among people with atherosclerotic cardiovascular disease. Plain language summary Chelation therapy for atherosclerotic cardiovascular (heart and circulation) disease Background Atherosclerosis is caused by fatty deposits that cause a narrowing of people's arteries and restrict blood flow. People with blocked arteries are more likely to have strokes, heart attacks, and narrow blood vessels in their feet. Chelation therapy involves infusions into the bloodstream of substances believed to remove metals from the blood. This treatment is offered to people with atherosclerotic cardiovascular disease as a way of breaking down the blockages in their blood vessels. Chelation therapy is practiced in several places around the world as an alternative form of medicine, but there is currently a lack of knowledge surrounding this treatment. More information is needed to understand if this treatment should be more widely recommended. Key results This review included evidence from five studies with a total of 1993 participants (current until August 2019). Three studies enrolled participants with peripheral vascular disease, and two of the studies included participants with coronary artery disease, one of which specifically recruited people who had had a heart attack. All five studies compared chelation therapy with no treatment or placebo. Only two of the studies (both of which included participants with coronary artery disease) reported death from any cause, and these reported no difference in overall deaths between those that received chelation therapy and those who did not. Ony one study (in people with coronary artery disease) reported cardiovascular death, and this study found no difference between in risk between those who had chelation therapy and those who did not. Two studies of people with coronary artery disease reported rates of heart attack and angina, and found no difference in the risk of these between participants who had chelation treatment and those who did not. Similarly, two studies (one in people with coronary artery disease and one in people with peripheral vascular disease) reported the chance of having a stroke, and found no clear difference in the chance of this between people who did or did not received chelation treatment. Two studies in people with peripheral vascular disease used an indirect measure of blood flow known as the ankle‐brachial pressure index (ABPI), or ankle brachial index. These studies did not show any differences in this measure between people who received chelation therapy for three or six months and those who did not get the treatment. There was also no clear differences in the distance participants could walk. We could not combine specific measures of quality of life in a single analysis. Looking at the two studies in people with coronary artery disease that reported this outcome, there was no difference in the quality of life reported by people who received chelation therapy and those who did not get the treatment. Two studies reported information about adverse events, but we could not combine this in a single analysis because they reported them in different ways and the events were different. However, the people who had chelation therapy did not appear to have any increase in either minor or major adverse events, compared with people who did not have the therapy. Certainty of the evidence We considered most of the data we found to be of low certainty, mostly because there were very few studies that provided data. Even though we included five studies, not all of them reported on each outcome. There is currently not enough evidence about the effects of chelation therapy on blockages in the blood vessels of people with atherosclerotic cardiovascular (heart and circulation) disease. Conclusions Overall, this review did not find any clear differences between people treated with chelation and people given the control, for the outcomes we evaluated. None of the outcomes included more than two studies, therefore it is difficult at this time to determine if these are true findings or just because there is not enough data. Further high‐quality trials that focus on clinical outcomes are necessary.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Villarruz-Sulit, MVanessa; Forster, R; Dans, AL; Tan, FN; Sulit, DV", "articleTypes": [], "doi": "10.1002/14651858.CD002785.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "f4d3efcd-8b1e-4a9c-b9f1-8e7c3b02e044", "pmid": "", "title": "Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people", "imported": false, "abstract": "Abstract - Background There is evidence that water‐loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well‐being are compromised. Objectives To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water‐loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water‐loss dehydration was defined primarily as including everyone with either impending or current water‐loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). Search methods Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases ( The Cochrane Library ), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. Selection criteria Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. Data collection and analysis Diagnostic accuracy of each test was assessed against the best available reference standard for water‐loss dehydration (serum or plasma osmolality cut���off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water‐loss dehydration (including either impending or current water‐loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water‐loss dehydration, but restricted to current dehydration in the final review. We conducted bivariate random‐effects meta‐analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre‐specified cut‐off points investigated. Pre‐set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre‐specifying three cut‐offs for each continuous test may have led to missing a cut‐off with useful sensitivity and specificity, we conducted post‐hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut‐off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. Main results There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water‐loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years. We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut‐offs for each continuous outcome) for diagnostic accuracy of water‐loss dehydration (primary target condition) and of current dehydration (secondary target condition). Only three tests showed any ability to diagnose water‐loss dehydration (including both impending and current water‐loss dehydration) as stand‐alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post‐hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study. Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97). There was sufficient evidence to suggest that several stand‐alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people. No tests were found consistently useful in diagnosing current water‐loss dehydration. Authors' conclusions There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water‐loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated. Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy. Plain language summary Clinical symptoms, signs and tests for identification of impending and current water‐loss dehydration in older people Water‐loss dehydration results from drinking too little fluid. It is common in older people and associated with increased risk of many health problems. We wanted to find out whether simple tests (like skin turgor, dry mouth, urine colour and bioelectrical impedance) can usefully tell us whether an older person (aged at least 65 years) is drinking enough. Within the review we assessed 67 different tests, but no tests were consistently useful in telling us whether older people are drinking enough, or are dehydrated. Some tests did appear useful in some studies, and these promising tests should be re‐checked to see whether they are useful in specific older populations. There was sufficient evidence to suggest that some tests should not be used to indicate dehydration. Tests that should not be used include dry mouth, feeling thirsty, heart rate, urine colour, and urine volume.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hooper, L, Abdelhamid, A, Attreed, NJ, Campbell, WW, Channell, AM, Chassagne, P, Culp, KR, Fletcher, SJ, Fortes, MB, Fuller, N, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD009647.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.798Z" }, { "id": "f5063b20-fb1b-44b8-9d31-aeb244fffb6e", "pmid": "", "title": "Vitamin C for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Vitamin C (ascorbic acid) for preventing and treating the common cold has been a subject of controversy for 70 years. Objectives To find out whether vitamin C reduces the incidence, the duration or severity of the common cold when used either as a continuous regular supplementation every day or as a therapy at the onset of cold symptoms. Search methods We searched CENTRAL 2012, Issue 11, MEDLINE (1966 to November week 3, 2012), EMBASE (1990 to November 2012), CINAHL (January 2010 to November 2012), LILACS (January 2010 to November 2012) and Web of Science (January 2010 to November 2012). We also searched the U.S. National Institutes of Health trials register and WHO ICTRP on 29 November 2012. Selection criteria We excluded trials which used less than 0.2 g per day of vitamin C and trials without a placebo comparison. We restricted our review to placebo‐controlled trials. Data collection and analysis Two review authors independently extracted data. We assessed 'incidence' of colds during regular supplementation as the proportion of participants experiencing one or more colds during the study period. 'Duration' was the mean number of days of illness of cold episodes. Main results Twenty‐nine trial comparisons involving 11,306 participants contributed to the meta‐analysis on the risk ratio (RR) of developing a cold whilst taking vitamin C regularly over the study period. In the general community trials involving 10,708 participants, the pooled RR was 0.97 (95% confidence interval (CI) 0.94 to 1.00). Five trials involving a total of 598 marathon runners, skiers and soldiers on subarctic exercises yielded a pooled RR of 0.48 (95% CI 0.35 to 0.64). Thirty‐one comparisons examined the effect of regular vitamin C on common cold duration (9745 episodes). In adults the duration of colds was reduced by 8% (3% to 12%) and in children by 14% (7% to 21%). In children, 1 to 2 g/day vitamin C shortened colds by 18%. The severity of colds was also reduced by regular vitamin C administration. Seven comparisons examined the effect of therapeutic vitamin C (3249 episodes). No consistent effect of vitamin C was seen on the duration or severity of colds in the therapeutic trials. The majority of included trials were randomised, double‐blind trials. The exclusion of trials that were either not randomised or not double‐blind had no effect on the conclusions. Authors' conclusions The failure of vitamin C supplementation to reduce the incidence of colds in the general population indicates that routine vitamin C supplementation is not justified, yet vitamin C may be useful for people exposed to brief periods of severe physical exercise. Regular supplementation trials have shown that vitamin C reduces the duration of colds, but this was not replicated in the few therapeutic trials that have been carried out. Nevertheless, given the consistent effect of vitamin C on the duration and severity of colds in the regular supplementation studies, and the low cost and safety, it may be worthwhile for common cold patients to test on an individual basis whether therapeutic vitamin C is beneficial for them. Further therapeutic RCTs are warranted. Plain language summary Vitamin C for preventing and treating the common cold The common cold is a major cause of visits to a doctor in high‐income countries and of absenteeism from work and school. There are over 200 viruses which can cause the common cold symptoms including runny nose, congestion, sneezing, sore throat, cough, and sometimes headache, fever and red eyes. Symptoms vary from person to person and cold to cold. Since the common cold is usually caused by one of the respiratory viruses, antibiotics are useless and therefore other potential treatment options are of substantial public health interest. Vitamin C has been proposed for treating respiratory infections since it was isolated in the 1930s. It became particularly popular in the 1970s when Nobel laureate Linus Pauling concluded from earlier placebo‐controlled trials that vitamin C would prevent and alleviate the common cold. Over two dozen new trials were undertaken thereafter. Vitamin C has been widely sold and used as a preventive and therapeutic agent. This review is restricted to placebo‐controlled trials testing 0.2 g/day or more of vitamin C. Regular ingestion of vitamin C had no effect on common cold incidence in the ordinary population, based on 29 trial comparisons involving 11,306 participants. However, regular supplementation had a modest but consistent effect in reducing the duration of common cold symptoms, which is based on 31 study comparisons with 9745 common cold episodes. In five trials with 598 participants exposed to short periods of extreme physical stress (including marathon runners and skiers) vitamin C halved the common cold risk. The published trials have not reported adverse effects of vitamin C. Trials of high doses of vitamin C administered therapeutically, starting after the onset of symptoms, showed no consistent effect on the duration or severity of common cold symptoms. However, only a few therapeutic trials have been carried out and none have examined children, although the effect of prophylactic vitamin C has been greater in children. One large trial with adults reported benefit from an 8 g therapeutic dose at the onset of symptoms, and two therapeutic trials using five‐day supplementation reported benefit. More trials are necessary to settle the possible role of therapeutic vitamin C, meaning administration immediately after the onset of symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H; Chalker, E", "articleTypes": [], "doi": "10.1002/14651858.CD000980.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "f50b8d1d-9117-4fdf-a56d-144c53688fba", "pmid": "", "title": "Roselle for hypertension in adults", "imported": false, "abstract": "Abstract - Background Hypertension is considered to be a serious health problem worldwide. Controlling and lowering blood pressure are of significant benefit to people with hypertension because hypertension is a risk factor for stroke, heart disease, and cardiovascular disease. Roselle, the tropical plant Hibiscus sabdariffa , also commonly called sour tea or red tea, has been used as both a thirst‐quenching drink and for medicinal purposes. Objectives To assess the effect of Roselle on blood pressure in people with primary hypertension. Search methods For this update, the Cochrane Hypertension Information Specialist searched the following databases and trials registers for randomised controlled trials (RCTs): the Cochrane Hypertension Specialised Register (to 6 August 2021), Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), MEDLINE Ovid (1946 to 5 August 2021), Embase Ovid (1974 to 5 August 2021), ProQuest Dissertations & Theses (to 6 August 2021), Web of Science Clarivate (to 7 August 2021), Food Science and Technology Abstracts Clarivate (to 7 August 2021), the WHO International Clinical Trials Registry Platform (to 6 August 2021), and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (to 6 August 2021). We searched Google Scholar and OpenSIGLE. We also handsearched local and regional Chinese databases: CBM, CMCC, TCMLARS, CNKI, CMAC, and the Index to Chinese Periodical Literature (to 14 September 2020), as well as Thai databases (ThaiJO, CUIR, TDC, CMU e‐Theses, TCTR) (to 3 October 2020). There were no language or publication date restrictions. Selection criteria We sought RCTs evaluating the use of any forms of Roselle with placebo or no treatment in adults with hypertension. Our primary outcome was change in trough and/or peak systolic and diastolic blood pressure (SBP, DBP). Secondary outcomes were withdrawals due to adverse effects, change in pulse pressure, and change in heart rate. Data collection and analysis All search results were managed using Covidence and re‐checked for the number of records, inclusion and exclusion of studies with Mendeley reference management software. We used standard methodological procedures expected by Cochrane. Two review authors worked independently in parallel for screening (titles and abstracts, and full reports), data extraction, risk of bias assessment, and assessment of the certainty of the evidence using the GRADE approach. Any disagreements were resolved by discussion or by consultation with the third review author if necessary. We presented mean difference (MD) of change in SBP and DBP with their corresponding 95% confidence interval (CI). Main results For this update, only one RCT with a parallel‐group design involving 60 participants with type 2 diabetes mellitus fulfilled the inclusion criteria. This study investigated the effect of Roselle extract capsules (total dose of 5600 mg) compared with placebo (lactose) at eight weeks. The study was at low risk of selection bias, performance bias, and detection bias. Conversely, it was at high risk of attrition bias, reporting bias, and other bias (baseline imbalance). We have very little confidence in the effect estimate of Roselle on change‐from‐baseline in both SBP and DBP between the two groups. The MD of change in SBP was 1.65, 95% CI −7.89 to 11.19 mmHg, 52 participants, very low‐certainty evidence. The MD of change in DBP was 4.60, 95% CI −1.38 to 10.58 mmHg, 52 participants, very low‐certainty evidence. Our secondary outcomes of withdrawals due to adverse effects, change in pulse pressure, and change in heart rate were not reported. Due to the limited available data, no secondary analyses were performed (subgroup and sensitivity analysis). Authors' conclusions The evidence is currently insufficient to determine the effectiveness of Roselle compared to placebo for controlling or lowering blood pressure in people with hypertension. The certainty of evidence was very low due to methodological limitations, imprecision, and indirectness. There is a need for rigorous RCTs that address the review question. Plain language summary Red tea (Roselle) for lowering blood pressure in adults Key messages: We don't know if taking Roselle lowers blood pressure in people with hypertension (high blood pressure). We don’t know if Roselle is safe for people with hypertension to consume or if it affects heart rate or pulse pressure. What did we want to find out? We wanted to know if red tea (Roselle) is a safe and effective treatment for lowering blood pressure in adults with high blood pressure when compared to placebo (dummy treatment) or no treatment. Roselle contains substances known as anthocyanins which have been shown to have lowered blood pressure in studies carried out in animals and humans. What did we do? We searched for studies that compared Roselle to placebo or no treatment in people with hypertension. What did we find? We included one study with 60 participants with type 2 diabetes and hypertension. Participants consumed either a capsule of pure Roselle extract or a placebo containing lactose for eight weeks. We are not sure if Roselle has an effect on blood pressure and the study did not report on the safety of Roselle or on changes to heart rate. What are the main limitations of the evidence? We found only one trial which included a small number of participants, all of whom had diabetes. More studies with various types of participants and different ways of taking Roselle (forms, amounts, and time of day, length of use) are needed. How up to date is the evidence? The review updates our previous review. We searched for randomised controlled trials (studies in which participants are randomly assigned to one of two or more treatment groups) in core databases up to August 2021, and searched local and regional Chinese and Thai databases by hand up to October 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Pattanittum, P, Ngamjarus, C, Buttramee, F, Somboonporn, C", "articleTypes": [], "doi": "10.1002/14651858.CD007894.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.103Z" }, { "id": "f52e54b2-ecf4-43b5-8867-8d824c131b99", "pmid": "", "title": "Interventions for hand eczema", "imported": false, "abstract": "Abstract - Background Hand eczema is an inflammation of the skin of the hands that tends to run a chronic, relapsing course. This common condition is often associated with itch, social stigma, and impairment in employment. Many different interventions of unknown effectiveness are used to treat hand eczema. Objectives To assess the effects of topical and systemic interventions for hand eczema in adults and children. Search methods We searched the following up to April 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, AMED, LILACS, GREAT, and four trials registries. We checked the reference lists of included studies for further references to relevant trials. Selection criteria We included randomised controlled trials (RCTs) that compared interventions for hand eczema, regardless of hand eczema type and other affected sites, versus no treatment, placebo, vehicle, or active treatments. Data collection and analysis We used standard methodological procedures expected by Cochrane. Primary outcomes were participant‐ and investigator‐rated good/excellent control of symptoms, and adverse events. Main results We included 60 RCTs, conducted in secondary care (5469 participants with mild to severe chronic hand eczema). Most participants were over 18 years old. The duration of treatment was short, generally up to four months. Only 24 studies included a follow‐up period. Clinical heterogeneity in treatments and outcome measures was evident. Few studies performed head‐to‐head comparisons of different interventions. Risk of bias varied considerably, with only five studies at low risk in all domains. Twenty‐two studies were industry‐funded. Eighteen trials studied topical corticosteroids or calcineurin inhibitors; 10 studies, phototherapy; three studies, systemic immunosuppressives; and five studies, oral retinoids. Most studies compared an active intervention against no treatment, variants of the same medication, or placebo (or vehicle). Below, we present results from the main comparisons. Corticosteroid creams/ointments: when assessed 15 days after the start of treatment, clobetasol propionate 0.05% foam probably improves participant‐rated control of symptoms compared to vehicle (risk ratio (RR) 2.32, 95% confidence interval (CI) 1.38 to 3.91; number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 8; 1 study, 125 participants); the effect of clobetasol compared to vehicle for investigator‐rated improvement is less clear (RR 1.43, 95% CI 0.86 to 2.40). More participants had at least one adverse event with clobetasol (11/62 versus 5/63; RR 2.24, 95% CI 0.82 to 6.06), including application site burning/pruritus. This evidence was rated as moderate certainty. When assessed 36 weeks after the start of treatment, mometasone furoate cream used thrice weekly may slightly improve investigator‐rated symptom control compared to twice weekly (RR 1.23, 95% CI 0.94 to 1.61; 1 study, 72 participants) after remission is reached. Participant‐rated symptoms were not measured. Some mild atrophy was reported in both groups (RR 1.76, 95% CI 0.45 to 6.83; 5/35 versus 3/37). This evidence was rated as low certainty. Irradiation with ultraviolet (UV) light: local combination ultraviolet light therapy (PUVA) may lead to improvement in investigator‐rated symptom control when compared to local narrow‐band UVB after 12 weeks of treatment (RR 0.50, 95% CI 0.22 to 1.16; 1 study, 60 participants). However, the 95% CI indicates that PUVA might make little or no difference. Participant‐rated symptoms were not measured. Adverse events (mainly erythema) were reported by 9/30 participants in the narrow‐band UVB group versus none in the PUVA group. This evidence was rated as moderate certainty. Topical calcineurin inhibitors: tacrolimus 0.1% over two weeks probably improves investigator‐rated symptom control measured after three weeks compared to vehicle (14/14 tacrolimus versus 0/14 vehicle; 1 study). Participant‐rated symptoms were not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. A within‐participant study in 16 participants compared 0.1% tacrolimus to 0.1% mometasone furoate but did not measure investigator‐ or participant‐rated symptoms. Both treatments were well tolerated when assessed at two weeks during four weeks of treatment. Evidence from these studies was rated as moderate certainty. Oral interventions: oral cyclosporin 3 mg/kg/d probably slightly improves investigator‐rated (RR 1.88, 95% CI 0.88 to 3.99; 1 study, 34 participants) or participant‐rated (RR 1.25, 95% CI 0.69 to 2.27) control of symptoms compared to topical betamethasone dipropionate 0.05% after six weeks of treatment. The risk of adverse events such as dizziness was similar between groups (up to 36 weeks; RR 1.22, 95% CI 0.80 to 1.86, n = 55; 15/27 betamethasone versus 19/28 cyclosporin). The evidence was rated as moderate certainty. Alitretinoin 10 mg improves investigator‐rated symptom control compared with placebo (RR 1.58, 95% CI 1.20 to 2.07; NNTB 11, 95% CI 6.3 to 26.5; 2 studies, n = 781) and alitretinoin 30 mg also improves this outcome compared with placebo (RR 2.75, 95% CI 2.20 to 3.43; NNTB 4, 95% CI 3 to 5; 2 studies, n = 1210). Similar results were found for participant‐rated symptom control: alitretinoin 10 mg RR 1.73 (95% CI 1.25 to 2.40) and 30 mg RR 2.75 (95% CI 2.18 to 3.48). Evidence was rated as high certainty. The number of adverse events (including headache) probably did not differ between alitretinoin 10 mg and placebo (RR 1.01, 95% CI 0.66 to 1.55; 1 study, n = 158; moderate‐certainty evidence), but the risk of headache increased with alitretinoin 30 mg (RR 3.43, 95% CI 2.45 to 4.81; 2 studies, n = 1210; high‐certainty evidence). Outcomes were assessed between 48 and 72 weeks. Authors' conclusions Most findings were from single studies with low precision, so they should be interpreted with caution. Topical corticosteroids and UV phototherapy were two of the major standard treatments, but evidence is insufficient to support one specific treatment over another. The effect of topical calcineurin inhibitors is not certain. Alitretinoin is more effective than placebo in controlling symptoms, but advantages over other treatments need evaluating. Well‐designed and well‐reported, long‐term (more than three months), head‐to‐head studies comparing different treatments are needed. Consensus is required regarding the definition of hand eczema and its subtypes, and a standard severity scale should be established. The main limitation was heterogeneity between studies. Small sample size impacted our ability to detect differences between treatments. Plain language summary Treatments for hand eczema Review question We reviewed evidence on the effects of topical and systemic (oral or injected medicines that work throughout the entire body) treatments for hand eczema when compared against placebo (an identical but inactive treatment), no treatment, vehicle (inactive ingredients that help deliver an active treatment), or another treatment. We included 60 randomised trials (5469 participants) published up to April 2018. Background Hand eczema is an inflammation of the skin of the hands that can be caused by contact allergens (i.e. substances that cause an allergic reaction) such as rubber chemicals, but other external factors (e.g. irritants such as water or detergents) and atopic predisposition are often important triggers. Hand eczema can cause a reduction in quality of life leading to many work‐related problems. Various types of hand eczema exist, and different topical (creams, ointments, or lotions) and systemic treatments with unknown effectiveness can be used. Study characteristics Most participants were hospital outpatients over 18 years of age with mild to severe chronic hand eczema. Treatment was usually given for up to four months, and outcomes were mainly assessed after treatment. A large variety of treatments were studied and compared to no treatment, variants of the same medication, placebo, or vehicle. Twenty‐two studies were funded by pharmaceutical companies. Key results Limited data are available to support the best way of managing hand eczema due to varying study quality and inability to pool data from studies with similar interventions. Corticosteroid creams/ointments and phototherapy (irradiation with UV light) are the major treatment options, although comparisons between these options are lacking. Below, we present results for the main comparisons of interest. Corticosteroid creams/ointments: clobetasol propionate foam probably increases participant‐rated good/excellent control of hand eczema when compared to vehicle (516 versus 222 per 1000), but the difference between groups was less clear for investigator‐rated control, and more adverse events were reported with clobetasol propionate (178 versus 79 per 1000) (all based on moderate‐certainty evidence). Mometasone furoate cream used thrice weekly may slightly improve investigator‐rated good/excellent control compared to twice weekly treatment, and participant‐rated control was not measured. Mild skin thinning occurred in both groups, but cases were few (all based on low‐certainty evidence). Irradiation with UV light: various types of irradiation (i.e. exposure to radiation) were compared. Local PUVA may improve investigator‐rated good/excellent control compared to narrow‐band UVB (400 versus 200 per 1000); however, we are uncertain of this finding because results also show that local PUVA may make little or no difference. Participant‐rated symptoms were not measured. Nine out of 30 participants in the narrow‐band UVB group reported adverse events (mainly redness) compared to none in the PUVA group (all based on moderate‐certainty evidence). Topical calcineurin inhibitors: people receiving tacrolimus are probably more likely to achieve improved investigator‐rated good/excellent symptom control compared to those given vehicle (14/14 participants with tacrolimus compared to none with vehicle), but participant‐rated control of symptoms was not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well‐tolerated application site burning/itching. One small study compared tacrolimus to mometasone furoate, which were both well tolerated, but did not measure investigator‐ or participant‐rated control (all based on moderate‐certainty evidence). Oral interventions: oral immunosuppressant (a drug that hinders the immune response) cyclosporin probably slightly improves investigator‐ or participant‐rated control of good/excellent symptoms compared to topical betamethasone cream (a corticosteroid). The risk of adverse events such as dizziness was similar between groups (all based on moderate‐certainty evidence). The oral vitamin A derivative (retinoid) alitretinoin (10 mg) achieved investigator‐rated good/excellent symptom control in 307 compared to 194 participants per 1000 with placebo, and alitretinoin 30 mg achieved investigator‐rated control in 432 compared to 157 participants per 1000 with placebo. Similar results were shown for participant‐rated control (high‐certainty evidence). When the dosage of alitretinoin was increased to 30 mg, risk of headache was higher compared to placebo (74 versus 251 per 1000; high‐certainty evidence), but this probably does not differ between alitretinoin 10 mg and placebo (based on moderate‐certainty evidence). Quality of the evidence The quality of evidence was mainly moderate, with most analyses based on single studies that had small sample sizes; therefore, some results should be interpreted with care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Christoffers, WA; Coenraads, PJ; Svensson, Å; Diepgen, TL; Dickinson‐Blok, JL; Xia, J; Williams, HC", "articleTypes": [], "doi": "10.1002/14651858.CD004055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.734Z" }, { "id": "f536b2da-85b1-40ec-b3cf-15a08f721aa8", "pmid": "", "title": "Chinese medicinal herbs for influenza", "imported": false, "abstract": "Abstract - Background Influenza is a communicable acute respiratory infection which, during epidemics, can cause high morbidity and mortality rates. Traditional Chinese medicinal herbs, often administered following a particular Chinese medical theory, may be a potential treatment of choice. Objectives To assess the effect of Chinese medicinal herbs used to prevent and treat influenza and to estimate the frequency of adverse effects. Search methods We searched CENTRAL (2012, Issue 11), MEDLINE (January 1966 to November week 2, 2012), EMBASE (January 1988 to November 2012) and CNKI (January 1988 to 29 March 2012). We also searched reference lists of articles and the WHO ICTRP search portal (November 2012). Selection criteria Randomised controlled trials (RCTs) comparing traditional Chinese medicinal herbs with placebo, no treatment or conventional medicine normally used in preventing and treating uncomplicated influenza. Data collection and analysis Two review authors independently extracted data and assessed trial quality. Main results We included 18 studies involving 2521 participants. The methodological quality of 17 included studies was poor. Included RCTs separately compared medicinal herbs with different antiviral drugs, precluding any pooling of results. Only three indicated that compared with antiviral drugs, Chinese medicinal herbs may be effective in preventing influenza and alleviating influenza symptoms. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and speeding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. Ten studies reported mild adverse reactions. Authors' conclusions Most Chinese medical herbs in the included studies showed similar effects to antiviral drugs in preventing or treating influenza. Few were shown to be superior to antiviral drugs. No obvious adverse events were reported in the included studies. However, current evidence remains weak due to methodological limitations of the trials. More high‐quality RCTs with larger numbers of participants and clear reporting are needed. Plain language summary Chinese medicinal herbs for influenza Influenza is a viral respiratory infection that causes an acute febrile illness with myalgia, headache and cough, and can result in high morbidity and mortality rates during an epidemic. Annual epidemics are thought to result in between three and five million cases of severe influenza and between 250,000 and 500,000 deaths worldwide. Currently, annual vaccination is the primary strategy for preventing influenza, and four influenza antiviral agents (amantadine, rimantadine, zanamivir and oseltamivir) have been approved for treatment of influenza. However, high levels of drug resistance have been recorded. Many Chinese medicinal herbs are used to treat and prevent this condition. This updated review assessed the therapeutic effects and safety of Chinese medicinal herbs as an alternative and adjunctive therapy to other commonly used drugs for influenza. Eighteen studies involving 2521 participants were included in the review. 'Ganmao' capsules were found to be more effective than amantadine in decreasing influenza symptoms and aiding recovery in one study (in which adverse reactions were mentioned in the amantadine group although no data were reported). There were no significant differences between 'E Shu You' and ribavirin in treating influenza, nor in the occurrence of adverse reactions. The remaining 17 Chinese herbal trials showed a similar effect to antiviral drugs in preventing or treating influenza. However, since these included studies were of poor quality, the evidence does not support or reject the use of any Chinese herbal preparations for influenza. High‐quality trials are required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Jiang, L, Deng, L, Wu, T", "articleTypes": [], "doi": "10.1002/14651858.CD004559.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.779Z" }, { "id": "f536e28a-bfee-47a0-9c60-4470dd8ae3c0", "pmid": "", "title": "CFTR modulator monotherapy for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del)", "imported": false, "abstract": "Abstract - Rationale Cystic fibrosis (CF) is a common, life‐shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR gene variant, F508del, is the commonest CF‐causing variant (found in up to 90% of people with CF (pwCF) in some populations). The F508del variant lacks meaningful CFTR function: the faulty protein is degraded before reaching the cell membrane, where it would normally transport salt across the epithelial membrane. Corrective therapy with CFTR modulators could benefit many pwCF. This review evaluates treatment with single modulators (monotherapy). Objectives To evaluate the clinically important benefits and harms of CFTR modulator monotherapy in people of any age with cystic fibrosis with class II CFTR gene variants (most commonly F508del). Search methods We last searched the Cochrane CF Trials Register and online trials registries on 27 June 2025. We also checked the reference lists of relevant articles for additional studies. Eligibility criteria We included parallel‐group randomised controlled trials (RCTs) comparing any single CFTR modulator to placebo or any other single CFTR modulator in pwCF of any age or disease severity with class II variants. Outcomes Our critical outcomes were survival, quality of life (total score and respiratory domain), and forced expiratory volume in one second (FEV 1 % predicted; relative and absolute change from baseline). Our important outcomes included adverse effects and time to first pulmonary exacerbation. We planned to assess outcomes in the immediate term, short term, and longer term. Risk of bias We assessed risk of bias using the original Cochrane tool (RoB 1). Synthesis methods We analysed available data with RevMan using a fixed‐effect model. We reported odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. For adverse events, we reported 99% confidence intervals (CIs); for all other outcomes, we reported 95% CIs. Where we were unable to analyse data, we reported the results narratively. We used GRADE to assess the certainty of the evidence. Included studies We included 10 early‐phase placebo‐controlled RCTs (424 participants) assessing eight different drugs (4PBA, CPX, N6022, cavosonstat, lumacaftor, FDL169, GLPG2222, and riociguat) in adults; one 4PBA study additionally included adolescents (age ≥ 14 years). All participants were homozygous for F508del. The longest study lasted just 29 days, so we could only assess immediate‐term outcomes. Only two studies received no funding from pharmaceutical companies. Our main results are for lumacaftor and cavosonstat, which were the only drugs selected for further investigation in subsequent studies. Synthesis of results Investigators reported no deaths, but also no clinically relevant improvements in quality of life. There was insufficient evidence to determine effects on any measure of lung function. No studies demonstrated differences in the risk of mild, moderate, or severe adverse effects, including pulmonary exacerbations, between CFTR modulator monotherapy and placebo. The clinical relevance of adverse effects is difficult to assess, because each occurred in only a few participants per trial. We assessed the certainty of the evidence for two comparisons (lumacaftor versus placebo and cavosonstat versus placebo), rating the certainty of the evidence to be very low. Authors' conclusions There is a lack of evidence to support monotherapy with a CFTR modulator for pwCF who have two F508del variants (F508del/F508del). Funding This review was completed under a programme of work that is part of the CF Foundation grant funding for Cochrane CF. Registration The protocol was registered on PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/view/CRD420251090914 ). Plain language summary Can single‐medicine treatment with CFTR modulators (medicines that correct the faulty protein in cystic fibrosis) help people who have specific genetic variants of cystic fibrosis (most commonly F508del)? Key messages All the studies only included people with two copies of the most common cystic fibrosis‐causing gene variant (F508del). Most studies were entirely or partly funded by medicine companies. No studies reported any deaths. None of the single medicines we looked at were clearly better than placebo (dummy treatment) for improving quality of life or lung function, and there was no evidence of the medicines causing more harm than placebo. However, we are unsure about these results. The evidence for using a single CFTR modulator is weak, and future research is likely to focus on combination therapies. What is cystic fibrosis and how can it be treated? Cystic fibrosis is a serious inherited illness that shortens life. It damages many organs in the body, particularly the lungs, pancreas, and liver. In the lungs, it causes a build‐up of thick, sticky mucus that leads to repeated infections and progressive damage. Most people with cystic fibrosis experience breathing difficulties, poor nutrition, and a reduced quality of life. Cystic fibrosis is caused by a fault in a gene that makes a protein called CFTR. CFTR regulates the movement of salt and water across cell surfaces, keeping the mucus thin and slippery. The most common CFTR gene variant (found in over 80% of people with cystic fibrosis) is F508del, which is a class II variant. People with two copies of F508del usually have more severe disease than people with one copy. In people with class II variants, the CFTR protein is degraded and cannot move properly through the cell. Laboratory experiments suggest that if the protein reaches the cell wall, it may be able to function, restore salt movement, and correct the chronic problems people with cystic fibrosis experience. CFTR modulators are medicines that help the faulty CFTR protein reach the cell wall. What did we want to find out? We wanted to know if CFTR modulator monotherapy (single‐medicine treatment) can help people of any age with cystic fibrosis who have a class II variant. Specifically, we wanted to know if these medicines can improve survival, quality of life, lung function, and time to the first worsening of lung symptoms. We also wanted to know if this treatment is associated with any unwanted effects. What did we do? We searched for studies that investigated the effects of any single CFTR modulator compared with placebo (dummy treatment) or any other single CFTR modulator in people with cystic fibrosis who had at least one copy of a class II variant. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes. What did we find? We found 10 studies (with 424 participants, all of whom had two copies of F508del) assessing eight different medicines given as monotherapy. Nine studies included only adults, and one study included people from age 14 years. All the studies were small (including between 18 and 89 participants) and lasted between one day and 29 days. They took place in North America (mainly the USA), Europe, and Australia. Our main findings are for two of the eight medicines, lumacaftor and cavosonstat, which have gone on to be evaluated in larger populations. Main findings No studies reported any deaths or meaningful improvements in quality of life. We did not find enough evidence to show any effect of CFTR modulators on lung function. The studies reported a wide range of unwanted effects, but each occurred in only a few participants per study. We did not find enough evidence to support using CFTR modulator monotherapy in people with cystic fibrosis who have two copies of F508del. What are the limitations of the evidence? We are not confident in the evidence, for the following reasons. The studies were small. Most results are based on evidence from a single study. The evidence is not applicable to children. Not all studies provided enough data for us to analyse the results. The evidence related to unwanted effects of treatment was based on very few events. How up‐to‐date is this evidence? This review updates our earlier review of single‐ and multiple‐medicine therapy. The evidence is current to 27 June 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Heneghan, M, Smith, S, Jahnke, N, Nevitt, S, Southern, KW", "articleTypes": [], "doi": "10.1002/14651858.CD016290", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.807Z" }, { "id": "f5378419-5443-4763-9c19-7f6b100f703f", "pmid": "", "title": "Etude du contrôle hédonique de la Prise Alimentaire Par l'Analyse Des Potentiels évoqués Gustatifs", "imported": false, "abstract": "Taste perception plays an important role in maintaining nutritional balance. Gustatory evoked potentials (GEP) can be detected in response to an intermittent stimulation of the gustatory receptors by a primary flavour. GEP are non invaisve, painless and safe.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.148Z" }, { "id": "f57456d9-88df-4dae-8d55-076491e91986", "pmid": "", "title": "Local interventions for the management of alveolar osteitis (dry socket)", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Daly, BJM, Sharif, MO, Jones, K, Worthington, HV, Beattie, A", "articleTypes": [], "doi": "10.1002/14651858.CD006968.pub3 AB - Abstract - Background Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012. Objectives To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction. Search methods An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies. Selection criteria We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews. Data collection and analysis We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random‐effects models. For some of the split‐mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence. Main results We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate‐certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively. Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate‐certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low‐certainty evidence). The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low‐certainty evidence). A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) ‐1.40, 95% CI ‐1.75 to ‐1.04; P < 0.00001; 2 studies, 80 participants; very low‐certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects. Authors' conclusions Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate‐certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. Plain language summary What treatments can be used to prevent and treat alveolar osteitis (dry socket)? Key messages ‐ Rinsing with chlorhexidine mouthwash before a dental extraction or beginning 24 hours after may help to prevent a dry socket.
‐ Placing a chlorhexidine gel directly into the socket immediately after tooth extraction may help to prevent a dry socket.
‐ Chlorhexidine rinses cause some minor adverse (unwanted) effects; chlorhexidine intrasocket gels do not appear to cause adverse effects.
‐ Alvogyl reduces the pain of a dry socket when compared to zinc oxide eugenol, but the evidence for this is very uncertain.
‐ Alvogyl does not appear to cause unwanted effects.
‐ We need future studies to strengthen the evidence and investigate the best ways to prevent and treat dry socket in all teeth. What is dry socket? Dry socket is a painful condition that sometimes arises after a tooth has been extracted and is more likely to occur following extraction of wisdom teeth in the lower jaw. What causes dry socket? It is thought to be linked to the loss of some or all of the blood clot that forms at the bottom of a tooth socket after a tooth is taken out. How can we prevent dry socket? An option for prevention of dry socket is to reduce debris and the bacterial load in the mouth, though dry socket is not bacterial in origin. People with poor oral hygiene (food debris and plaque) are at greater risk of dry socket. Improved oral hygiene and rinsing before a dental extraction or beginning 24 hours after may reduce the likelihood of dry socket. How can we treat dry socket ? Options for treating dry socket largely focus on reducing pain locally around the tooth extraction site by placing an obtundent (a soothing medicated dressing). What did we want to find out ? We wanted to find out if antiseptic rinses, gels, or healing patches could help to prevent dry socket. We also wanted to find out if placing a medicated dressing could treat a dry socket and whether any unwanted side effects were produced. What did we do? We searched for studies that compared antiseptic rinses or intrasocket gels with a placebo (dummy) rinse or nothing and a placebo (dummy) intrasocket gel or nothing. To find the best way to treat dry socket we searched for studies that compared different soothing agents with a placebo (dummy) with other soothing agents or with nothing. We compared the results of the studies and summarised the findings. We made an assessment of our confidence in the evidence based on the design of the study and the number of patients recruited. What did we find? We identified 49 trials; 39 trials (6219 participants) investigated prevention of dry socket and 10 trials (552 participants) investigated the treatment of dry socket. We found that: ‐ rinsing both before and after tooth extraction (commencing 24 hours after extraction) with chlorhexidine gluconate rinse (at 0.12% and 0.2% strength) probably results in a reduction in dry socket;
‐ placing chlorhexidine gel (0.2% strength) in the socket of an extracted tooth probably results in a reduction in dry socket;
‐ chlorhexidine rinses and gels are equally effective at reducing dry socket, but the evidence for this comparison is very uncertain;
‐ chlorhexidine rinses produced some minor unwanted effects; chlorhexidine intrasocket gels appeared to produce no unwanted effects;
‐ there was a small amount of evidence of very low certainty from two studies that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol. This evidence relates to the old formulation of Alvogyl which is no longer available. It should be noted that the formulation of Alvogyl has changed, it is now called Alveogyl. Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. What are the limitations of the evidence? The main limitation of the evidence are that studies: ‐ reported mostly on tooth extractions involving lower wisdom teeth;
‐ were undertaken in ways that introduced errors in the conduct of the study leading to errors in the results; and
‐ produced imprecise results when they were combined. Due to these errors we have some confidence in the results relating to chlorhexidine rinses and gels but further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. How up to date is this evidence? The search for existing studies was completed by 28 September 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.727Z" }, { "id": "f5758caa-c683-41c8-8a47-44731d6d509f", "pmid": "", "title": "Effects on Sleep Quality and Bioelectrical Parameters of Cellular Health After Administration of a Plant Protein Supplement Combined With Ashwagandha and Rhodiola", "imported": false, "abstract": "This study evaluates whether a combination of plant protein with adaptogenic herbs (ashwagandha and rhodiola) can improve sleep quality in middle-aged adults with sleep disturbances.", "journal": "", "year": "2026", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.248Z" }, { "id": "f57a40a4-9908-45a5-af2b-8e256db9af1b", "pmid": "", "title": "Control interventions in randomised trials among people with mental health disorders", "imported": false, "abstract": "Abstract - Background Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated. Objectives To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait‐list versus no‐treatment, (ii) usual care versus wait‐list or no‐treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait‐list or no‐treatment. Wait‐list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. Search methods In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers. Selection criteria We included randomised trials assessing patients with a mental health disorder that compared wait‐list, usual care, or placebo interventions with wait‐list or no‐treatment . Data collection and analysis Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane’s risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre‐planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random‐effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed‐effect model). Main results We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep‐wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait‐list versus no‐treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait‐list or no‐treatment and found a SMD –0.33 (95% CI ‐0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait‐list or no‐treatment was SMD −0.37 (95% CI −0.49 to −0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger’s test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD ‐0.49 (95% CI −0.64 to −0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait‐list or no‐treatment on benefits was SMD ‐0.14 (95% CI −0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD −0.21 (95% CI −0.35 to −0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep‐wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed‐effect model in a sensitivity analysis on the comparison for usual care versus wait‐list and no‐treatment, the results were significant with an SMD of –0.46 (95 % CI –0.64 to –0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains. Authors' conclusions We found marked variations in effects between placebo versus no‐treatment and wait‐list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait‐list or no‐treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research. Plain language summary Control interventions in randomised trials for people with a mental health disorder This systematic review assesses the effects of different control interventions in randomised trials including patients with a mental health disorder. In randomised trials, patients are assigned by chance to one of two or more groups – usually an experimental intervention and a control intervention. There are many types of control interventions in mental health intervention research. Some of the most common are different types of placebos that lack what is assumed to be the active component in the experimental intervention, and usual care, where patients receive the standard treatment for their mental health disorder in the area where they live. Two other types of control interventions are wait‐list or no‐treatment where patients receive no trial‐related care during the study (although some patients may receive care outside the studies). Wait‐list patients are often offered the experimental intervention after the trial has been finalised if it is likely to provide more benefits than harms, while no‐treatment participants are not offered the experimental intervention by the researchers. We searched for randomised trials with patients with mental health disorders where wait‐list, usual care, or placebo interventions were compared with either wait‐list or no‐treatment. We looked at differences between all the types of control interventions on beneficial effects and whether they caused any adverse effects. We included 96 trials with a total of 4200 participants. Only 83 trials (3614 participants) provided usable data. Fifteen different mental health disorders were included. We found that all the trials were at high risk of bias in how they had been conducted, which reduced the interpretability of our findings. However, the risk of bias was mostly due to lack of blinding in the placebo studies, which may be seen as an aspect of the review's methodological question rather than a flaw with the review itself. We found no clinically important differences for usual care or wait‐list control interventions in the main analyses, however in our secondary analyses we found a clinically important favourable difference for usual care. In general, placebo control interventions tended to be favourable over no‐treatment or wait‐list control interventions across mental health disorders. We found no clinically important differences on adverse events. This review suggests that different control interventions have a tendency to yield very different estimates for the effects of the experimental intervention and that the choice of control intervention has a large impact on how effective a mental health treatment appears to be. Control interventions in trials with patients with mental health disorders are often poorly reported upon, and guidelines are needed to inform researchers on how to properly design, report, and interpret these trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Faltinsen, E; Todorovac, A; Staxen Bruun, L; Hróbjartsson, A; Gluud, C; Kongerslev, MT; Simonsen, E; Storebø, OJ", "articleTypes": [], "doi": "10.1002/14651858.MR000050.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "f57dae7a-8cc9-4432-af4b-994039bca37a", "pmid": "", "title": "Interventions for fatigue management after traumatic brain injury", "imported": false, "abstract": "Abstract - Rationale Despite the high prevalence and medico‐social significance of fatigue in post‐traumatic brain injury (post‐TBI) populations, there are no validated management strategies to control this condition. It is timely to provide clinicians and patients with the best available evidence of the efficacy of current pharmacological and non‐pharmacological fatigue management practices. Objectives To assess the effectiveness of pharmacological and non‐pharmacological interventions for fatigue in people who have experienced a TBI. Search methods For this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO. We also searched relevant conference proceedings, and we searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for ongoing trials. The most recent searches were conducted on 12 February 2025. Eligibility criteria Eligible study designs were randomised controlled trials (RCTs) and randomised cross‐over trials (for pharmacological interventions only). Studies with participants of all ages (children and adults) with a TBI (of any severity) were included, where at least 75% of participants had a TBI. Any type of treatment for fatigue was considered. Four categories of interventions were prioritised: pharmacological, cognitive, stimulation/biofeedback, and psychoeducational. These interventions were compared to placebo groups, no treatment, or groups receiving other interventions. Outcomes The critical outcome was fatigue. Important outcomes include fatigue‐related outcomes of psychological functioning (depression and anxiety), cognitive functioning (processing speed), general quality of life, and daytime sleepiness. Risk of bias We assessed risk of bias using the original Cochrane risk of bias tool for RCTs (RoB 1). Synthesis methods We synthesised the results for each outcome by meta‐analysis where possible using mean differences (MDs) and standardised mean differences (SMDs) and a fixed‐effect model. Where meta‐analysis was not possible due to the nature of the data , we narratively reported the results. We used GRADE to assess the certainty of evidence for each outcome . We performed all statistical analyses using RevMan and presented results with 95% confidence intervals (CI). Included studies We included a total of 3518 trial participants (at baseline) across 40 studies, described in 49 publications. The 40 included studies are grouped by type of intervention. There were seven categories of interventions: pharmacological, cognitive, physical activity, stimulation/biofeedback, health visits, psychoeducational, and a final category for trials with multiple interventions (multi‐interventions). Four published studies identified in the most recent search are awaiting classification. Synthesis of results Pharmacological interventions (melatonin; recombinant human growth hormones (rhGH); psychostimulants; atorvastatin; monoaminergic stabiliser (‐)‐OSU6162) likely reduce fatigue slightly (SMD ‐0.25, 95% CI ‐0.44 to ‐0.06; 8 studies, 395 participants; moderate‐certainty evidence). Cognitive interventions (cognitive rehabilitation; technology‐enhanced training; functional skills training) may reduce fatigue slightly (MD ‐0.32, 95% CI ‐0.59 to ‐0.06; 6 studies, 222 participants; low‐certainty evidence). Stimulation/biofeedback interventions (light therapy; electrical/magnetic stimulation; acupressure) may reduce fatigue slightly, but the evidence is very uncertain (SMD ‐0.23, 95% CI ‐0.47 to 0.01; 8 studies, 295 participants; very low‐certainty evidence). Psychoeducation interventions (cognitive behavioural therapy; acceptance and commitment therapy; individualised occupational therapy; novel therapies) may reduce fatigue, but the evidence is very uncertain (SMD ‐0.55, 95% CI ‐0.74 to ‐0.35; 8 studies, 474 participants; very low‐certainty evidence). There may be little to no difference in psychological functioning (depression), psychological functioning (anxiety), cognitive functioning (processing speed), or daytime sleepiness. However, these results are very uncertain. Authors' conclusions There is very limited and moderate to very low‐certainty evidence from RCTs about treatments to reduce fatigue after TBI. Despite the prevalence of fatigue post‐TBI, we lack high‐quality studies that evaluate interventions to improve this disabling, but potentially treatable, symptom. There is a need for considerable further work to identify an effective treatment for fatigue in people with TBI. Funding This Cochrane review had no dedicated funding. Registration Protocol available via DOI: 10.1002/14651858.CD006448 Plain language summary Which treatments are effective for fatigue after traumatic brain injury? Key messages Medications (such as melatonin, growth hormones, brain stimulants, atorvastatin, or dopamine and serotonin regulators) likely reduce fatigue after a traumatic brain injury. Other treatments, such as talking therapies, sensory stimulation, and counselling, may reduce fatigue after a traumatic brain injury. Future studies should involve more people, including children and young people. They should investigate different kinds of treatments in different settings, and the severity and causes of traumatic brain injury. What is traumatic brain injury? Traumatic brain injury is damage to the brain following a bump or blow to the head. The injury might result from a traffic accident, fall, assault, sports injury, or an explosion. People with traumatic brain injury might experience headaches, become forgetful, and have difficulties sleeping and moving. They may also experience fatigue, which is defined as an overwhelming sense of tiredness unrelated to previous effort, which does not usually improve with rest. Fatigue makes it hard for people to concentrate and perform everyday activities, which affects their quality of life. How is fatigue after traumatic brain injury treated? Treatments for fatigue vary because the causes and symptoms of fatigue may be very different. Treatments include medication to stimulate or protect the brain, and hormones and antidepressants to help people sleep and improve their mood. Treatments that don’t involve medication include counselling, education, behavioural therapy and exercise. What did we want to find out? We mainly wanted to find out if different treatments reduce fatigue in people with traumatic brain injury. We were also interested in the effect of the treatments on people’s mood, memory or attention, quality of life, and sleepiness. What did we do? We searched for studies that randomly assigned people to receive treatment for fatigue, usual care (that is, no specific treatment for fatigue), or a placebo (dummy) treatment. We also looked at studies that compared different treatments. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 40 studies with 3518 adults and children living with traumatic brain injury. The studies took place in 12, mainly high‐income, countries in Europe, North America, and Oceania. They were conducted in different settings, including medical centres, rehabilitation clinics, military bases, clinical research facilities, and hospitals. Main results Fatigue Medications likely reduce fatigue after a traumatic brain injury (8 studies, 395 people). Medications included melatonin, growth hormones, psychostimulants, statins, and dopamine regulators. Other treatments (without medication) may reduce fatigue after a traumatic brain injury (31 studies, 2203 people). Treatments included cognitive behavioural therapy, technical‐enhanced training, functional skills training, sensory stimulation, electrical/magnetic stimulation, acupressure, counselling, acceptance and commitment therapy, individualised occupational therapy, cognitive symptom management rehabilitation therapy, aerobic exercise, prescribed light exercise, location of exercise, vestibular rehabilitation, health visits, and multi‐interventional therapies. For treatments with medication, there were some reported adverse (unwanted or harmful) events that are specific to particular studies. For other treatments (without medication), adverse events were often not reported. Fatigue‐related symptoms Medications may make little or no difference to depression, anxiety, processing speed, quality of life, and daytime sleepiness (21 studies, 1016 people). Of the treatments without medication, only cognitive therapy showed any noticeable effect; it may reduce anxiety (2 studies, 57 people). What are the limitations of the evidence? We have limited confidence in the evidence due to the small numbers of people in the different studies, and the variation in settings, treatments, ages of participants, and the severity and causes of traumatic brain injury. How up to date is this evidence? We searched for studies up to 12 February 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2026", "authors": "Senior, HE; Leung, JH; Meehan, B; Leao, S; Jordan, V; Barker-Collo, S; Crummey, S; Purdy, SC", "articleTypes": [], "doi": "10.1002/14651858.CD006448.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "f5802bb3-fc34-471f-96f1-1d4a6b6ca0f3", "pmid": "", "title": "Perioperative nutrition interventions for women with ovarian cancer", "imported": false, "abstract": "Abstract - Background Women with ovarian cancer have been shown to be at significant risk of malnutrition with incidence rates described as being between 28% to 67%. Nutrition interventions may improve clinical outcomes positively, nutritional status or quality of life measures in this patient group. Objectives This review was conducted to assess the effects of nutrition interventions during the perioperative period for women with ovarian cancer. Search methods Electronic searches were conducted of the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 7), Medline (1946 to July week 4 2012), Embase (1980 to 2012 week 31), DARE (to 7th August 2012) AMED (1985 to April 2012), BNI (1992 to April 2012), CINAHL (to April 2012). We also searched trials databases, conference proceedings and related citation lists. Reference listings were handsearched. No restrictions were applied on language or date. Selection criteria Randomised controlled trials (RCTs) in which women 18 years and over with any stage of ovarian cancer, including recurrent cancer, were in the perioperative phase of treatment and received any type of nutrition intervention. Data collection and analysis Titles and abstracts were screened by two review authors with study selection discussed by a team. Pairs of review authors worked independently on data collection and compared findings. Main results A total of 4092 titles were screened and 14 full text reports reviewed; a single small study met the inclusion criteria. In the included RCT, 40 women (35 with ovarian cancer) had extensive elective surgery including bowel resection for treatment of gynaecological malignancy. Randomisation was made to either early oral feeding (oral fluids in the first 24 hours, solid foods on the following day) or to a 'traditional' feeding regimen where oral fluids and foods were delayed until there was evidence of bowel function. Most women in the early feeding group (14/18) were able to resume eating solid food one day after surgery. This resulted in a significantly shorter hospital stay with no increase in postoperative complications or change in quality of life measures in comparison with the women on the 'traditional' feeding regimen. The incidence of nausea and vomiting during the postoperative stay was similar in both groups and was noted in slightly more than half of the women. Overall survival was evaluated until 30 days following discharge from hospital; in this period, there was one death of a woman who had been in the 'traditional oral feeding' group, cause of death was not noted. We assessed risk of bias and found no high risk of bias was identified in the methodology and reporting of the included study, although there was an increased risk of bias due to the small size of the study in which not all of the women had ovarian cancer. Authors' conclusions Although women with ovarian cancer have been shown to be at risk of malnutrition, there is a lack of evidence derived from RCTs evaluating the identification, assessment and treatment of malnutrition during the perioperative phase of treatment. There is evidence from one small study that some women with ovarian cancer undergoing surgery with associated bowel resection may safely commence oral fluids within 24 hours of surgery and solid foods on the following day. Further research is required, including a RCT, to generate guidance concerning the treatment of malnutrition in this patient group. Plain language summary Nutrition for women who are having surgery for ovarian cancer Women who have ovarian cancer, (a cancer which develops in the two organs (ovaries) that produce eggs in women) are more likely to have difficulties with food and with eating a nourishing diet in comparison to women with other types of gynaecological cancers. One reason may be because the symptoms of ovarian cancer can be difficult to recognise. Women may have a lack of interest in food, feel full, feel sick or have a painful or swollen abdomen. Some women become thinner in parts of their bodies while becoming bigger around their abdomen due to an abnormal build up of fluid or large tumours. There may be no change in body weight or weight may increase, this can make it difficult to know which women are developing problems due to a poor food intake. Women who are unable to eat and drink well are at risk of becoming malnourished and may then have more complications from the treatments for ovarian cancer than women who are not malnourished. It is recommended that people who are having difficulties with eating and drinking should be identified and helped when they receive hospital care. Currently, there is no agreed method for finding and treating nutritional problems for women with ovarian cancer. In this review, the authors looked for studies (randomised controlled trials (RCTs)) from around the world to find out how women with ovarian cancer were assessed to see if they were eating and drinking well and what help they may be given with nutrition before or after surgery. A lack of information was found on this topic. One RCT was found where a small group of women (40 including 35 with ovarian cancer) requiring extensive elective surgery for gynaecological cancer including surgery to the gut, were able to restart eating normal foods on the day after surgery. They were able to leave hospital earlier and did not have more complications in the month after surgery than women who were not allowed to resume eating normal foods until at least three days after the operation. More studies are needed to confirm whether restarting normal eating one day after surgery can be recommended for women having surgery for ovarian cancer. More research is needed to provide information about how to identify and treat problems of malnutrition in women with ovarian cancer.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Billson, HA; Holland, C; Curwell, J; Davey, VL; Kinsey, L; Lawton, LJ; Whitworth, AJ; Burden, S", "articleTypes": [], "doi": "10.1002/14651858.CD009884.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "f593036b-f4ac-4da1-8248-23abe80681d8", "pmid": "", "title": "Omega‐6 fats for the primary and secondary prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Omega‐6 fats are polyunsaturated fats vital for many physiological functions, but their effect on cardiovascular disease (CVD) risk is debated. Objectives To assess effects of increasing omega‐6 fats (linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA)) on CVD and all‐cause mortality. Search methods We searched CENTRAL, MEDLINE and Embase to May 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. Selection criteria We included randomised controlled trials (RCTs) comparing higher versus lower omega‐6 fat intake in adults with or without CVD, assessing effects over at least 12 months. We included full texts, abstracts, trials registry entries and unpublished studies. Outcomes were all‐cause mortality, CVD mortality, CVD events, risk factors (blood lipids, adiposity, blood pressure), and potential adverse events. We excluded trials where we could not separate omega‐6 fat effects from those of other dietary, lifestyle or medication interventions. Data collection and analysis Two authors independently screened titles/abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias of included trials. We wrote to authors of included studies. Meta‐analyses used random‐effects analysis, while sensitivity analyses used fixed‐effects and limited analyses to trials at low summary risk of bias. We assessed GRADE quality of evidence for 'Summary of findings' tables. Main results We included 19 RCTs in 6461 participants who were followed for one to eight years. Seven trials assessed the effects of supplemental GLA and 12 of LA, none DGLA or AA; the omega‐6 fats usually displaced dietary saturated or monounsaturated fats. We assessed three RCTs as being at low summary risk of bias. Primary outcomes : we found low‐quality evidence that increased intake of omega‐6 fats may make little or no difference to all‐cause mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.88 to 1.12, 740 deaths, 4506 randomised, 10 trials) or CVD events (RR 0.97, 95% CI 0.81 to 1.15, 1404 people experienced events of 4962 randomised, 7 trials). We are uncertain whether increasing omega‐6 fats affects CVD mortality (RR 1.09, 95% CI 0.76 to 1.55, 472 deaths, 4019 randomised, 7 trials), coronary heart disease events (RR 0.88, 95% CI 0.66 to 1.17, 1059 people with events of 3997 randomised, 7 trials), major adverse cardiac and cerebrovascular events (RR 0.84, 95% CI 0.59 to 1.20, 817 events, 2879 participants, 2 trials) or stroke (RR 1.36, 95% CI 0.45 to 4.11, 54 events, 3730 participants, 4 trials), as we assessed the evidence as being of very low quality. We found no evidence of dose‐response or duration effects for any primary outcome, but there was a suggestion of greater protection in participants with lower baseline omega‐6 intake across outcomes. Additional key outcomes : we found increased intake of omega‐6 fats may reduce myocardial infarction (MI) risk (RR 0.88, 95% CI 0.76 to 1.02, 609 events, 4606 participants, 7 trials, low‐quality evidence). High‐quality evidence suggests increasing omega‐6 fats reduces total serum cholesterol a little in the long term (mean difference (MD) −0.33 mmol/L, 95% CI −0.50 to −0.16, I 2 = 81%; heterogeneity partially explained by dose, 4280 participants, 10 trials). Increasing omega‐6 fats probably has little or no effect on adiposity (body mass index (BMI) MD −0.20 kg/m 2 , 95% CI −0.56 to 0.16, 371 participants, 1 trial, moderate‐quality evidence). It may make little or no difference to serum triglycerides (MD −0.01 mmol/L, 95% CI −0.23 to 0.21, 834 participants, 5 trials), HDL (MD −0.01 mmol/L, 95% CI −0.03 to 0.02, 1995 participants, 4 trials) or low‐density lipoprotein (MD −0.04 mmol/L, 95% CI −0.21 to 0.14, 244 participants, 2 trials, low‐quality evidence). Authors' conclusions This is the most extensive systematic assessment of effects of omega‐6 fats on cardiovascular health, mortality, lipids and adiposity to date, using previously unpublished data. We found no evidence that increasing omega‐6 fats reduces cardiovascular outcomes other than MI, where 53 people may need to increase omega‐6 fat intake to prevent 1 person from experiencing MI. Although benefits of omega‐6 fats remain to be proven, increasing omega‐6 fats may be of benefit in people at high risk of MI. Increased omega‐6 fats reduce serum total cholesterol but not other blood fat fractions or adiposity. Plain language summary Omega‐6 fats to prevent and treat heart and circulatory diseases Review question We reviewed randomised trials (participants had an equal chance to be assigned to either treatment) examining effects of higher omega‐6 fats compared to lower omega‐6 fats on deaths and heart and circulatory diseases (cardiovascular diseases (CVD), which include heart attacks and strokes). Background Omega‐6 fats are essential, we must obtain some from food. They are important for regulating energy production (part of metabolism), bone, skin and hair health. Many foods contain omega‐6 fats, particularly vegetable oils and nuts. Omega‐6 fats include linoleic acid (LA), gamma‐linolenic acid (GLA), dihomo‐gamma‐linolenic acid (DGLA) and arachidonic acid (AA). Some evidence suggests that a higher intake of omega‐6 fats, along with a lower intake of saturated fat (from animal sources such as meat and cheese) can reduce coronary heart disease. In contrast, there is concern that high levels of omega‐6 fats may worsen cardiovascular risk by increasing inflammation. Overall, there is no conclusive evidence on the benefits or harms of omega‐6 fat intake on heart and circulatory diseases or on other health outcomes. Study characteristics Evidence in this review is current to May 2017. We found 19 studies recruiting 6461 adults. These studies assessed the effects of higher compared to lower omega‐6 fat intake on heart and circulatory diseases as well as deaths. We found that three trials were highly trustworthy (with good designs that produce reliable evidence). Studies took place in North America, Asia, Europe and Australia, and eight were funded only by national or charitable agencies. Participants increased their omega‐6 fats or maintained their usual fats for at least one year and up to eight years. Key results We found that increasing omega‐6 fats may make little or no difference to deaths or cardiovascular events but may reduce risk of heart attacks (low‐quality evidence). Evidence was weakened by study design problems, small numbers of events, low numbers of participants from developing countries, and few women. Evidence suggests that increasing omega‐6 fats reduces blood cholesterol (high‐quality evidence), probably has little or no effect on body weight adjusted for height (all moderate‐quality evidence), and may make little or no difference to triglycerides, high‐density lipoprotein (HDL, the 'good' cholesterol) or low‐density lipoprotein (LDL, the 'bad' cholesterol, low‐quality evidence).", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hooper, L; Al‐Khudairy, L; Abdelhamid, AS; Rees, K; Brainard, JS; Brown, TJ; Ajabnoor, SM; O'Brien, AT; Winstanley, LE; Donaldson, DH; Song, F; Deane, KHO", "articleTypes": [], "doi": "10.1002/14651858.CD011094.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "f59a433b-3165-453c-9f2e-149d5bddce15", "pmid": "", "title": "Alterations in Nutrient-sensing Mechanisms May Play a Role in Symptom Generation in Patients With IBS", "imported": false, "abstract": "Clinical data, fresh feces and intestinal mucosal tissues of patients with diarrheal IBS were collected. High performance liquid chromatography, immunohistochemistry and immunofluorescence were used to study the amino acid levels in feces of patients with IBS, the expression of taste receptors in intestinal mucosa, and the correlation between symptoms of abdominal pain and diarrhea and the expression of taste receptors, so as to obtain the conclusion that \"intestinal amino acid perception abnormalities exist in patients with IBS. And correlated with clinical symptoms.\"", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.142Z" }, { "id": "f59a5f6d-169e-4372-bff4-62476ccb2ee1", "pmid": "", "title": "N‐acetylcysteine as an adjuvant therapy for Helicobacter pylori eradication", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) is one of the most common pathogens to establish and cause infection in human beings, affecting about 50% of the world's population. Prevalence may be as high as 83% in Latin American countries and as low as 17% in North America. Approximately 20% of infected people will manifest disease; people at high risk include those who live in low‐ and middle‐income countries with poor sanitary conditions, since the mechanism of transmission seems to be oral‐oral or faecal‐oral (mostly during infancy). There are several antibiotic regimens to treat the infection, but antibiotic resistance is growing around the world. New adjuvant drugs — such as probiotics, statins, curcumin, and N‐acetylcysteine (NAC) — are being tested to enhance eradication rates. N‐acetylcysteine can destabilise the biofilm structure; it also has synergic action with antibiotics, and bactericidal effects. In addition, NAC has antioxidant properties, and has a primary mucolytic effect by reducing the thickness of the gastric mucus layer, both of which may exert beneficial adjuvant effects on H pylori eradication. Objectives To assess the efficacy and safety of N‐acetylcysteine as an adjuvant therapy to antibiotics for Helicobacter pylori eradication. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to April 2018), Embase (1988 to April 2018), CINAHL (1982 to April 2018), LILACS (1982 to April 2018), grey literature databases and trials registries. We handsearched the reference lists of relevant studies. We screened 726 articles and assessed 18 for eligibility. Selection criteria We included randomised controlled trials (RCTs) of any antibiotic regimen plus NAC, in adults infected with H pylori . To be included, trials had to use a control consisting of the same antibiotic regimen with or without placebo. Outcomes of interest were eradication rates, and gastrointestinal, toxic, and allergic adverse events. Reporting of the primary outcomes listed here was not an inclusion criterion for the review. Data collection and analysis Two review authors independently reviewed and extracted data and completed the 'Risk of bias' assessments. A third review author independently confirmed the 'Risk of bias' assessments. We used Review Manager 5 software for data analysis. We contacted study authors if there was missing information. Main results We included eight RCTs (with a total of 559 participants) in this review. The studies recruited outpatients aged between 17 and 76 years who were referred to endoscopy centres in several different countries. The certainty of evidence was reduced for most outcomes due to the poor methodological quality of included studies; issues mainly related to the generation of allocation sequence, allocation concealment, and blinding (this last domain related specifically to adverse outcomes). We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates, compared with the addition of placebo or no NAC (38.8% versus 49.1%, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.51 to 1.08; participants = 559; studies = eight; very low‐certainty evidence). A post‐hoc sensitivity analysis, in which we removed studies that tested antibiotic regimens no longer recommended in clinical practice, showed that the addition of NAC may improve eradication rates compared to control (27.2% versus 37.6%, RR 0.71, 95% CI 0.53 to 0.94; participants = 397; published studies = five). We are uncertain whether NAC is associated with a higher risk of gastrointestinal adverse events compared to control (23.9% versus 18.9%, RR 1.25, 95% CI 0.85 to 1.85; participants = 336; studies = five; very low‐certaintyevidence), or allergic adverse events (2% versus 0%, RR 2.98, 95% CI 0.32 to 27.74; participants = 336; studies = five; very low‐certainty evidence). There were no reports of toxic adverse events amongst included studies. Authors' conclusions We are uncertain whether the addition of NAC to antibiotics improves H pylori eradication rates compared with the addition of placebo or no NAC. Due to the clinical, statistical and methodological heterogeneity found in included studies, and the uncertainty observed when analysing therapy subgroups, any possible beneficial effect of NAC should be regarded cautiously. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed, randomised clinical studies should be conducted, with good reporting standards and appropriate collection of efficacy and safety outcomes, especially for current recommended antibiotic regimens. Plain language summary N‐acetylcysteine taken with antibiotics for treatment of Helicobacter pylori infection Review question Is the addition of N‐acetylcysteine to antibiotics safe and does it improve cure rates for Helicobacter pylori infection? Background Helicobacter pylori ( H pylori ) is a bacteria that lives in the stomach and might cause several diseases such as gastric cancer, ulcer disease, and others. Colonisation occurs in about one‐half of the world's population and is more common in countries with poor sanitary conditions. People become infected by consuming contaminated water. The infection is treated using antibiotics and a drug which reduces acid production in the stomach. However, rates of antibiotic resistance are rising around the world, which is reducing the cure rates even with treatment. New medications are being tested to improve cure rates. One of these medications is N‐acetylcysteine (NAC). NAC is a drug that helps to dissolve mucus in respiratory diseases. It can be taken by mouth (orally) or injected into a vein (intravenous). NAC can destroy some mechanisms of survival of H pylori and could improve cure rates. Study characteristics We included eight studies (specifically, randomised controlled trials (RCTs)) with a total of 559 people aged between 17 and 76 years old. The evidence is current to April 2018. All studies recruited outpatients from endoscopy centres (centres that specialise in an examination done with a flexible tube with a camera that is inserted into stomach) in several countries. The antibiotic combinations tested were very different in the included studies, as were the doses of NAC (600 mg to 1800 mg per day). NAC was compared with placebo (dummy pill) or nothing. Key results We are uncertain whether the addition of NAC to antibiotics improves H pylori cure rates compared with the addition of placebo or no NAC. Any possible beneficial effect of NAC should be regarded cautiously because the included studies were very different and of low certainty, with some flaws that could have compromised their results and consequently, the results of this review. We are uncertain whether NAC is associated with a higher risk of gastrointestinal or allergic adverse events compared with placebo or no NAC. There were no reports of toxic adverse events amongst the included studies. Further large, well‐designed randomised clinical studies, with good reporting standards and appropriate collection of effectiveness and safety outcomes should be done, especially for current recommended antibiotic combinations. Quality of the evidence The overall certainty of the evidence for eradication rates ranged from very low to low. Five studies provided information on adverse events (side effects), and the certainy of evidence was very low. The included studies were poorly conducted and this reduced our confidence in the results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Fontes, LES, Martimbianco, ALC, Zanin, C, Riera, R", "articleTypes": [], "doi": "10.1002/14651858.CD012357.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.784Z" }, { "id": "f5a2efb3-5538-4f69-b2e7-a2b679242a10", "pmid": "", "title": "Non‐invasive diagnostic tests for Helicobacter pylori infection", "imported": false, "abstract": "Abstract - Background Helicobacter pylori ( H pylori ) infection has been implicated in a number of malignancies and non‐malignant conditions including peptic ulcers, non‐ulcer dyspepsia, recurrent peptic ulcer bleeding, unexplained iron deficiency anaemia, idiopathic thrombocytopaenia purpura, and colorectal adenomas. The confirmatory diagnosis of H pylori is by endoscopic biopsy, followed by histopathological examination using haemotoxylin and eosin (H & E) stain or special stains such as Giemsa stain and Warthin‐Starry stain. Special stains are more accurate than H & E stain. There is significant uncertainty about the diagnostic accuracy of non‐invasive tests for diagnosis of H pylori . Objectives To compare the diagnostic accuracy of urea breath test, serology, and stool antigen test, used alone or in combination, for diagnosis of H pylori infection in symptomatic and asymptomatic people, so that eradication therapy for H pylori can be started. Search methods We searched MEDLINE, Embase, the Science Citation Index and the National Institute for Health Research Health Technology Assessment Database on 4 March 2016. We screened references in the included studies to identify additional studies. We also conducted citation searches of relevant studies, most recently on 4 December 2016. We did not restrict studies by language or publication status, or whether data were collected prospectively or retrospectively. Selection criteria We included diagnostic accuracy studies that evaluated at least one of the index tests (urea breath test using isotopes such as 13 C or 14 C, serology and stool antigen test) against the reference standard (histopathological examination using H & E stain, special stains or immunohistochemical stain) in people suspected of having H pylori infection. Data collection and analysis Two review authors independently screened the references to identify relevant studies and independently extracted data. We assessed the methodological quality of studies using the QUADAS‐2 tool. We performed meta‐analysis by using the hierarchical summary receiver operating characteristic (HSROC) model to estimate and compare SROC curves. Where appropriate, we used bivariate or univariate logistic regression models to estimate summary sensitivities and specificities. Main results We included 101 studies involving 11,003 participants, of which 5839 participants (53.1%) had H pylori infection. The prevalence of H pylori infection in the studies ranged from 15.2% to 94.7%, with a median prevalence of 53.7% (interquartile range 42.0% to 66.5%). Most of the studies (57%) included participants with dyspepsia and 53 studies excluded participants who recently had proton pump inhibitors or antibiotics.There was at least an unclear risk of bias or unclear applicability concern for each study. Of the 101 studies, 15 compared the accuracy of two index tests and two studies compared the accuracy of three index tests. Thirty‐four studies (4242 participants) evaluated serology; 29 studies (2988 participants) evaluated stool antigen test; 34 studies (3139 participants) evaluated urea breath test‐ 13 C; 21 studies (1810 participants) evaluated urea breath test‐ 14 C; and two studies (127 participants) evaluated urea breath test but did not report the isotope used. The thresholds used to define test positivity and the staining techniques used for histopathological examination (reference standard) varied between studies. Due to sparse data for each threshold reported, it was not possible to identify the best threshold for each test. Using data from 99 studies in an indirect test comparison, there was statistical evidence of a difference in diagnostic accuracy between urea breath test‐ 13 C, urea breath test‐ 14 C, serology and stool antigen test (P = 0.024). The diagnostic odds ratios for urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test were 153 (95% confidence interval (CI) 73.7 to 316), 105 (95% CI 74.0 to 150), 47.4 (95% CI 25.5 to 88.1) and 45.1 (95% CI 24.2 to 84.1). The sensitivity (95% CI) estimated at a fixed specificity of 0.90 (median from studies across the four tests), was 0.94 (95% CI 0.89 to 0.97) for urea breath test‐ 13 C, 0.92 (95% CI 0.89 to 0.94) for urea breath test‐ 14 C, 0.84 (95% CI 0.74 to 0.91) for serology, and 0.83 (95% CI 0.73 to 0.90) for stool antigen test. This implies that on average, given a specificity of 0.90 and prevalence of 53.7% (median specificity and prevalence in the studies), out of 1000 people tested for H pylori infection, there will be 46 false positives (people without H pylori infection who will be diagnosed as having H pylori i nfection). In this hypothetical cohort, urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test will give 30 (95% CI 15 to 58), 42 (95% CI 30 to 58), 86 (95% CI 50 to 140), and 89 (95% CI 52 to 146) false negatives respectively (people with H pylori infection for whom the diagnosis of H pylori will be missed). Direct comparisons were based on few head‐to‐head studies. The ratios of diagnostic odds ratios (DORs) were 0.68 (95% CI 0.12 to 3.70; P = 0.56) for urea breath test‐ 13 C versus serology (seven studies), and 0.88 (95% CI 0.14 to 5.56; P = 0.84) for urea breath test‐ 13 C versus stool antigen test (seven studies). The 95% CIs of these estimates overlap with those of the ratios of DORs from the indirect comparison. Data were limited or unavailable for meta‐analysis of other direct comparisons. Authors' conclusions In people without a history of gastrectomy and those who have not recently had antibiotics or proton ,pump inhibitors, urea breath tests had high diagnostic accuracy while serology and stool antigen tests were less accurate for diagnosis of Helicobacter pylori infection.This is based on an indirect test comparison (with potential for bias due to confounding), as evidence from direct comparisons was limited or unavailable. The thresholds used for these tests were highly variable and we were unable to identify specific thresholds that might be useful in clinical practice. We need further comparative studies of high methodological quality to obtain more reliable evidence of relative accuracy between the tests. Such studies should be conducted prospectively in a representative spectrum of participants and clearly reported to ensure low risk of bias. Most importantly, studies should prespecify and clearly report thresholds used, and should avoid inappropriate exclusions. Plain language summary Accuracy of different non‐invasive methods for identifying Helicobacter pylori Why is it important to know whether someone has Helicobacter pylori ? Helicobacter pylori (H pylori) is a type of bacteria which may be present in the stomach of some people. H pylori is believed to cause a number of cancers, including stomach cancer, pancreatic cancer, and throat cancer. H pylori is also linked with other diseases including stomach ulcers, heart burn, and a bloated feeling. If H pylori is found in an individual, appropriate treatment can be started. What is the aim of this review? To compare the accuracy of three different types of test for H pylori. These are: urea breath tests, blood tests (the specific blood test is called serology), and stool tests (in faeces). What was studied in this review? There are two types of urea breath test which use two different forms of carbon known as 13 C and 14 C, as well as multiple versions of serology and stool tests. What are the main results of the review? We found 101 studies which included 11,003 people who were tested for H pylori . Of these 11,003 participants, 5839 (53.1%) had H pylori infection. All the studies used one of the three tests listed above and compared these test results with the diagnosis given by endoscopic biopsy. Endoscopic biopsy involves obtaining tissue from the stomach using a thin flexible tube introduced through the mouth and testing for the presence of H pylori under the microscope. It is currently the most accurate available test, however it causes physical discomfort to the patient, with associated risks for harm. This is in contrast to the alternative non‐invasive tests in this review which are significantly less uncomfortable and have minimal or no risk of harm, making them desirable alternatives if they can be shown to be as accurate at diagnosing H pylori as endoscopic biopsy. Most of the studies included participants with heart burn or similar problems in the stomach and excluded participants who had previously undergone partial removal of the stomach and those having treatment for H pylori . Thirty‐four studies (4242 participants) used serology; 29 studies (2988 participants) used stool antigen test; 34 studies (3139 participants) used urea breath test‐ 13 C; 21 studies (1810 participants) used urea breath test‐ 14 C; and two studies (127 participants) used urea breath test but did not report the type of carbon used. Studies varied in the limit they used before saying a test was positive for H pylori infection and the type of stains used to examine the biopsy material. When we looked at all the data we found that urea breath tests were more accurate than blood and stool tests. The results mean that, on average, if 1000 people are tested, there will be 46 people without H pylori who will be misdiagnosed as having H pylori . Also, there will be 30, 42, 86, and 89 people with H pylori infection for whom the diagnosis of H pylori infection will be missed by urea breath test‐ 13 C, urea breath test‐ 14 C, serology, and stool antigen test, respectively. When we looked at the seven studies which compared urea breath test‐ 13 C and serology, or urea breath test‐ 13 C and stool antigen tests in the same participants, the results were uncertain and we cannot tell which test is more accurate. How reliable are the results of the studies? Except for one study, all the studies were of poor methodological quality, which makes their results unreliable. Who do the results of this review apply to? These results apply to children and adults with suspected H pylori infection, but only in those who have not previously undergone stomach operations and those who have not recently had antibiotics or treatment for H pylori infection. What are the implications of this review? Urea breath tests, blood tests, and stool tests may be suitable for identifying whether someone has H pylori infection. However, the level of the result of urea breath test, blood test, or stool test which should be used to make a diagnosis of H pylori infection remains unclear. How up‐to‐date is the review? We performed a thorough literature search for studies reporting the accuracy of these different tests until 4 March 2016.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Best, LMJ; Takwoingi, Y; Siddique, S; Selladurai, A; Gandhi, A; Low, B; Yaghoobi, M; Gurusamy, KS", "articleTypes": [], "doi": "10.1002/14651858.CD012080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "f5bfda34-355a-44be-b7e3-c68c36407dfe", "pmid": "", "title": "Corticosteroids for hospitalised children with acute asthma", "imported": false, "abstract": "Abstract - Background Systemic corticosteroids are used routinely in the management of children with severe acute asthma. There is a lack of consensus regarding the agent, dose and route of corticosteroid administration. Objectives To determine the benefit of systemic corticosteroids (oral, intravenous, or intramuscular) compared to placebo and inhaled steroids in acute paediatric asthma. Search methods All controlled trials were identified from the Cochrane Airways Review Group Register, hand searching of respiratory journals, reference lists and contacts with experts and pharmaceutical companies. Selection criteria Studies were included if they described a randomised controlled trial (RCT) involving children aged 1‐18 years with severe acute asthma who received oral, inhaled, intravenous or intramuscular corticosteroids. Only studies in which patients required hospital admission were included. Data collection and analysis Two reviewers using a standard form extracted all data. All data, numeric calculations and graphic extrapolations were independently confirmed. Main results Seven trials were included with a total of 426 children studied (274 with oral prednisone vs. placebo, 106 with intravenous steroids vs placebo and 46 with nebulised budesonide vs prednisolone). A significant number of steroid treated children were discharged early after admission (>4 hours) with an OR of 7.00 (95% CI: 2.98 to 16.45) and NNT of 3 (95%CI: 2 to 8). The length of stay was shorter in the steroid groups with a WMD of ‐8.75 hours (95% CI: ‐19.23 to 1.74). There were no significant differences between groups in pulmonary function or oxygen saturation measurements. Children treated with steroids in hospital were less likely to relapse within one to three months with OR 0.19 (95%CI: 0.07 to 0.55) and NNT of 3 (95%CI: 2 to 7). The single small study that compared nebulised budesonide to oral prednisone failed to demonstrate equivalence or a difference between each therapy. Authors' conclusions Systemic corticosteroids produce some improvements for children admitted to hospital with acute asthma. The benefits may include earlier discharge and fewer relapses. Inhaled or nebulised corticosteroids cannot be recommended as equivalent to systemic steroids at this time. Further studies examining differing doses and routes of administration for corticosteroids will clarify the optimal therapy. Plain language summary Corticosteroids for hospitalised children with acute asthma An acute asthma attack in a child often results in a trip to the hospital. In the emergency department steroid drugs are given which may improve the child's condition and allow them to be sent home after a few hours observation. However, some children require continued treatment in hospital. This review asked the question \"do steroid drugs help children admitted to hospital with asthma?\" We found that steroids given by mouth or through an intravenous tube help children recover from acute asthma. The benefits may include earlier discharge or a shorter stay in hospital. Children were less likely to come back to hospital in the one to three months following the admission. However, the evidence was not overwhelming due to the limited number of studies available and different medicines used. Further research needs to concentrate on the best medications to use and the best route of administration.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "Smith, M; Iqbal, SMSI; Rowe, BH; N'Diaye, T", "articleTypes": [], "doi": "10.1002/14651858.CD002886", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "f5cdfc7c-73d1-4928-9cdf-83c285c1e16b", "pmid": "", "title": "Interventions for the treatment of Frey's syndrome", "imported": false, "abstract": "Abstract - Background Frey's syndrome is a rare disorder, the symptoms of which include sweating, flushing and warming over the preauricular and temporal areas following a gustatory stimulus. It often occurs in patients who have undergone parotidectomy, submandibular gland surgery, radical neck dissection, infection and traumatic injury in the parotid region, and is caused by the aberrant regrowth of facial autonomic nerve fibres. Currently there are several options used to treat patients with Frey's syndrome; for example, the topical application of anticholinergics and antiperspirants, and the intradermal injection of botulinum toxin. It is uncertain which treatment is most effective and safe. Objectives To assess the efficacy and safety of different interventions for the treatment of Frey's syndrome. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; ICTRP and additional sources for published and unpublished trials. The date of the search was 28 April 2014. Selection criteria We included randomised or quasi‐randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome using a clinical standard such as Minor's starch‐iodine test. We planned to include trials in which participants received any intervention versus no treatment (observation) or an alternative intervention, with or without a second active treatment. Our primary outcome measures were success rate (as assessed clinically by Minor's starch‐iodine test, the iodine‐sublimated paper histogram method, blotting paper technique or another method) and adverse events. Our secondary outcome measure was success rate as assessed by patients (disappearance or improvement of symptoms). Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no RCTs or quasi‐RCTs that fulfilled the inclusion criteria. Our searches retrieved eight potentially relevant studies, but after assessment of the full‐text reports we excluded all of them due to the absence of randomisation or because the patients did not have Frey's syndrome. We excluded one randomised controlled trial that compared two different doses of botulinum toxin in patients with Frey's syndrome because the comparator was not an alternative treatment. Authors' conclusions We are unable to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome. RCTs are urgently needed to assess the effectiveness of interventions for the treatment of Frey's syndrome. Future RCTs should include patients with Frey's syndrome of different ranges of severity and report these patients separately. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective assessment of Frey's syndrome should be considered as one of the outcome measures. Plain language summary Interventions for the treatment of Frey's syndrome Background Frey's syndrome is a rare disorder, the symptoms of which include sweating and flushing of the facial skin when eating, smelling, thinking or even dreaming about food. It usually happens in patients who have undergone surgery to the parotid (salivary) gland. This problem may have an impact on quality of life (for example, restricting normal activity such as eating in public). Many methods are currently used to treat Frey's syndrome, including topical application of anticholinergics and antiperspirants, and intradermal (into the skin) injections of botulinum toxin. This systematic review aimed to assess the efficacy and safety of these different methods for the treatment of Frey's syndrome. Study characteristics We carried out a comprehensive search for randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome. We planned to include trials in which participants received any intervention compared to no treatment (observation) or an alternative intervention, with or without a second active treatment. Despite extensive searching, we were unable to identify any studies that met our inclusion criteria. Key results There is no high‐quality evidence to establish which type of treatment is most effective for the treatment of Frey's syndrome. High‐quality clinical trials in this area should be urgently conducted. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective (patient) assessment of Frey's syndrome should be one of the outcome measures used. Quality of the evidence This review is up to date to 28 April 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Li, C; Wu, F; Zhang, Q; Gao, Q; Shi, Z; Li, L", "articleTypes": [], "doi": "10.1002/14651858.CD009959.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.076Z" }, { "id": "f5e38687-2817-4e3b-821b-16bd7d2d7a73", "pmid": "", "title": "A Novel Compound for Alcoholism Treatment: A Translational Strategy - Part II", "imported": false, "abstract": "Background:", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.261Z" }, { "id": "f5f07497-330a-4bf4-abf5-add9b6e647f7", "pmid": "", "title": "Interventions for the treatment of persistent post‐COVID‐19 olfactory dysfunction", "imported": false, "abstract": "Abstract - Background Olfactory dysfunction is a common consequence of COVID‐19 infection and persistent symptoms can have a profound impact on quality of life. At present there is little guidance on how best to treat this condition. A variety of interventions have been suggested to promote recovery, including medication and olfactory training. However, it is uncertain whether any intervention is of benefit. This is an update of the 2021 review with one additional study added. Objectives 1) To evaluate the benefits and harms of any intervention versus no treatment for people with persisting olfactory dysfunction due to COVID‐19 infection. 2) To keep the evidence up‐to‐date, using a living systematic review approach. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the latest search was 20 October 2021. Selection criteria We included randomised controlled trials (RCTs) in people with COVID‐19 related olfactory disturbance that had persisted for at least four weeks. We included any intervention compared to no treatment or placebo. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were the recovery of sense of smell, disease‐related quality of life and serious adverse effects. Secondary outcomes were the change in sense of smell, general quality of life, prevalence of parosmia and other adverse effects (including nosebleeds/bloody discharge). We used GRADE to assess the certainty of the evidence for each outcome. Main results We included two studies with 30 participants. The studies evaluated the following interventions: systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant and palmitoylethanolamide plus luteolin. Systemic corticosteroids plus intranasal corticosteroid/mucolytic/decongestant compared to no intervention We included a single RCT with 18 participants who had anosmia for at least 30 days following COVID‐19 infection. Participants received a 15‐day course of oral corticosteroids combined with nasal irrigation (consisting of an intranasal corticosteroid/mucolytic/decongestant solution) or no intervention. Psychophysical testing was used to assess olfactory function at 40 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Palmitoylethanolamide plus luteolin compared to no intervention We included a single RCT with 12 participants who had anosmia or hyposmia for at least 90 days following COVID‐19 infection. Participants received a 30‐day course of palmitoylethanolamide and luteolin or no intervention. Psychophysical testing was used to assess olfactory function at 30 days. This is a single, small study and for all outcomes the certainty of evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Authors' conclusions There is very limited evidence available on the efficacy and harms of treatments for persistent olfactory dysfunction following COVID‐19 infection. However, we have identified a number of ongoing trials in this area. As this is a living systematic review we will update the data regularly, as new results become available. Plain language summary Interventions for the treatment of persistent smell disorders (olfactory dysfunction) after COVID‐19 infection Why this is important The sense of smell is critical to one's enjoyment of odours and tastes, and is important for safety. During the COVID‐19 pandemic there has been an increasing focus on change in sense of smell as one of the early symptoms associated with infection. This can be a reduction, change or complete loss of the sense of smell. For most people this is temporary, however for some this lasts weeks or even months. If a person has lost their sense of smell for a long time (over four weeks after having COVID‐19), we do not know if there are any treatments that might help it to recover. How we identified and assessed the evidence We searched the medical literature, identifying relevant studies and summarising the results. We assessed the quality of the studies as well as the certainty of the evidence. Factors influencing this included the size of the studies, the methods used to perform them and how results were reported by researchers. Based on this, we classed the evidence as being of very low, low, moderate or high certainty. What we found We found two small studies to include in the review, including a total of 30 people. All participants had problems with their sense of smell that had lasted for at least four weeks, and started after a COVID‐19 infection. Problems with the sense of smell were identified using special smell identification tests carried out by the research team. The patients were randomly divided into two groups: those who would receive treatment and those who would not. The treatment in one study was a course of corticosteroid tablets ('systemic') and nasal irrigation (with a wash consisting of a mix of corticosteroids, decongestant and an agent that breaks down mucus). The second study used a course of a supplement known as palmitoylethanolamide and luteolin. Systemic corticosteroids and nasal irrigation (intranasal corticosteroids/decongestant/mucolytic) compared to no treatment We do not know whether corticosteroid tablets with nasal irrigation is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 40 days;
 ‐ changing the sense of smell after 40 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. Palmitoylethanolamide and luteolin compared to no treatment We do not know whether palmitoylethanolamide and luteolin is better or worse than no treatment at: ‐ restoring the sense of smell back to normal after 30 days;
 ‐ changing the sense of smell after 30 days;
 ‐ causing any unwanted side effects. This is because the evidence that we found was of very low certainty, mainly due to the fact that only one study was identified and it included a small number of patients. We did find a number of other studies that are being carried out, but no results from these studies are yet available to be included in this review. What this means It is unclear whether using corticosteroids with nasal irrigation, or using a palmitoylethanolamide and luteolin supplement, might treat problems with the sense of smell after COVID‐19, or whether these treatments can potentially cause harm. Other treatments are under investigation. This review is a 'living systematic review', meaning that we will keep checking for new studies that might be relevant, and the review will be continually updated when any extra results are available. How up‐to‐date is this review? The evidence in this Cochrane Review is current to October 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "O'Byrne, L; Webster, KE; MacKeith, S; Philpott, C; Hopkins, C; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD013876.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "f5f4555f-4710-4a17-8bbd-ab19d937086a", "pmid": "", "title": "The Real-world Treatment Satisfaction by Gefapixiant in Patients with Refractory Chronic Cough in Terms of Cough Improvement and Taste Disturbance. (The RESTORE Study)", "imported": false, "abstract": "Chronic cough has a high global prevalence and it is refractory to such treatments by approximately 20% of patients. Gafapixant is a P2X3 receptor antagonist that has demonstrated the reduction of cough in patients with refractory chronic cough(RCC). Taste disturbance is the most frequent adverse event by gefapixant (approximately 60-70%). Although gefapixant is well-tolerated even if taste disturbance has occurred, the impact of taste disturbance on cough-specific QoL remains to be unclear. Therefore, the investigator would like to evaluate factors related to treatment satisfaction by gefapixant in RCC patients. the investigator hypothesize that taste disturbance will be associated with the improvement of cough specific QoL and treatment satisfaction in RCC patients.", "journal": "", "year": "2024", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.235Z" }, { "id": "f5feee47-2d98-408e-89ea-00e9f81d6579", "pmid": "", "title": "Topiramate for the prophylaxis of episodic migraine in adults", "imported": false, "abstract": "Abstract - Background Some antiepileptic drugs but not others are useful in clinical practice for the prophylaxis of migraine. This might be explained by the variety of actions of these drugs in the central nervous system. The present review is part of an update of a Cochrane review first published in 2004, and previously updated (conclusions not changed) in 2007. Objectives To describe and assess the evidence from controlled trials on the efficacy and tolerability of topiramate for preventing migraine attacks in adult patients with episodic migraine. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2012, Issue 12), PubMed/MEDLINE (1966 to 15 January 2013), MEDLINE In‐Process (current week, 15 January 2013), and EMBASE (1974 to 15 January 2013) and handsearched Headache and Cephalalgia through January 2013. Selection criteria Studies were required to be prospective, controlled trials of topiramate taken regularly to prevent the occurrence of migraine attacks, to improve migraine‐related quality of life, or both. Data collection and analysis Two review authors independently selected studies and extracted data. For headache frequency data, we calculated mean differences (MDs) between topiramate and comparator (placebo, active control, or topiramate in a different dose) for individual studies and pooled these across studies. For dichotomous data on responders (patients with ≥ 50% reduction in headache frequency), we calculated odds ratios (ORs) and, in select cases, risk ratios (RRs); we also calculated numbers needed to treat (NNTs). We calculated MDs for selected quality of life instruments. Finally, we summarised data on adverse events from placebo‐controlled trials and calculated risk differences (RDs) and numbers needed to harm (NNHs). Main results Twenty papers describing 17 unique trials met the inclusion criteria. Analysis of data from nine trials (1737 participants) showed that topiramate reduced headache frequency by about 1.2 attacks per 28 days as compared to placebo (MD ‐1.20; 95% confidence interval (CI) ‐1.59 to ‐0.80). Data from nine trials (1190 participants) show that topiramate approximately doubled the proportion of responders relative to placebo (RR 2.02; 95% CI 1.57 to 2.60; NNT 4; 95% CI 3 to 6). Separate analysis of different topiramate doses produced similar MDs versus placebo at 50 mg (‐0.95; 95% CI ‐1.95 to 0.04; three studies; 520 participants), 100 mg (‐1.15; 95% CI ‐1.58 to ‐0.71; six studies; 1620 participants), and 200 mg (‐0.94; 95% CI ‐1.53 to ‐0.36; five studies; 804 participants). All three doses significantly increased the proportion of responders relative to placebo; ORs were as follows: for 50 mg, 2.35 (95% CI 1.60 to 3.44; three studies; 519 participants); for 100 mg, 3.49 (95% CI 2.23 to 5.45; five studies; 852 participants); and for 200 mg, 2.49 (95% CI 1.61 to 3.87; six studies; 1025 participants). All three doses also significantly improved three or more domains of quality of life as compared to placebo. Meta‐analysis of the three studies that included more than one dose of topiramate suggests that 200 mg is no more effective than 100 mg. With regard to mean headache frequency and/or responder rate, seven trials using active comparators found (a) no significant difference between topiramate and amitriptyline (one study, 330 participants); (b) no significant difference between topiramate and flunarizine (one study, 83 participants); (c) no significant difference between topiramate and propranolol (two studies, 342 participants); (d) no significant difference between topiramate and relaxation (one study, 61 participants); but (e) a slight significant advantage of topiramate over valproate (two studies, 120 participants). Relaxation improved migraine‐specific quality of life significantly more than topiramate. In trials of topiramate against placebo, seven adverse events (AEs) were reported by at least three studies. These were usually mild and of a non‐serious nature. Except for taste disturbance and weight loss, there were no significant differences in the frequency of AEs in general, or of the seven specific AEs, between placebo and topiramate 50 mg. AEs in general and all of the specific AEs except nausea were significantly more common on topiramate 100 mg than on placebo, with NNHs varying from 3 to 25, and the RDs versus placebo were even higher for topiramate 200 mg, with NNHs varying from 2 to 17. Authors' conclusions Meta‐analysis demonstrates that topiramate in a 100 mg/day dosage is effective in reducing headache frequency and reasonably well‐tolerated in adult patients with episodic migraine. This provides good evidence to support its use in routine clinical management. More studies designed specifically to compare the efficacy or safety of topiramate versus other interventions with proven efficacy in the prophylaxis of migraine are needed. Plain language summary Topiramate for preventing migraine attacks in adults Various medicines, collectively termed 'antiepileptics', are used to treat epilepsy. For several years, some of these drugs have also been used for preventing migraine attacks. For the present review, researchers in The Cochrane Collaboration reviewed the evidence about the effects of topiramate in adult patients (≥ 16 years of age) with 'episodic' migraine (headache on < 15 days per month). They examined research published up to 15 January 2013 and found 17 relevant studies. Compared with placebo, topiramate reduced the frequency of migraine headaches by approximately 1.2 per month (nine studies, 1737 participants). Patients were also about twice as likely to reduce the number of their migraine headaches by 50% or more with topiramate than with placebo (nine studies, 1190 participants). Side effects associated with topiramate were common but generally mild; topiramate can, however, cause birth defects and so should be used with caution in women of childbearing age. Further research is needed comparing topiramate with other active drugs used for preventing migraine attacks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Linde, M; Mulleners, WM; Chronicle, EP; McCrory, DC", "articleTypes": [], "doi": "10.1002/14651858.CD010610", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "f60dba0b-64dc-417d-b6f0-2b8cb08d2749", "pmid": "", "title": "A Randomized, Multicenter, Open-label, Phase III Study of Lapatinib (GW572016) in Combination With Weekly Paclitaxel Versus Weekly Paclitaxel Alone in the Second Line Treatment of ErbB2 Amplified Advanced Gastric Cancer", "imported": false, "abstract": "EGF104578 is two-part study (Pilot part/Randomized part).Pilot part is designed to find the optimal (best) doses of lapatinib and paclitaxel when given together,Randomized part is designed to evaluate the overall survival in patients receiving lapatinib and paclitaxel compared to patients receiving only paclitaxel.", "journal": "", "year": "2007", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.162Z" }, { "id": "f615443f-2c9b-44bd-8699-2f5ab7cabd0a", "pmid": "", "title": "Paracetamol (acetaminophen) for prevention or treatment of pain in newborns", "imported": false, "abstract": "Abstract - Background Newborn infants have the ability to experience pain. Hospitalised infants are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Objectives To determine the efficacy and safety of paracetamol for the prevention or treatment of procedural/postoperative pain or pain associated with clinical conditions in neonates. To review the effects of various doses and routes of administration (enteral, intravenous or rectal) of paracetamol for the prevention or treatment of pain in neonates. Search methods We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 4), MEDLINE via PubMed (1966 to 9 May 2016), Embase (1980 to 9 May 2016), and CINAHL (1982 to 9 May 2016). We searched clinical trials' databases, Google Scholar, conference proceedings, and the reference lists of retrieved articles. Selection criteria We included randomised and quasi‐randomised controlled trials of paracetamol for the prevention/treatment of pain in neonates (≤ 28 days of age). Data collection and analysis Two review authors independently extracted data from the articles using pre‐designed forms. We used this form to decide trial inclusion/exclusion, to extract data from eligible trials and to request additional published information from authors of the original reports. We entered and cross‐checked data using RevMan 5 software. When noted, we resolved differences by mutual discussion and consensus. We used the GRADE approach to assess the quality of evidence. Main results We included nine trials with low risk of bias, which assessed paracetamol for the treatment of pain in 728 infants. Painful procedures studied included heel lance, assisted vaginal birth, eye examination for retinopathy of prematurity assessment and postoperative care. Results of individual studies could not be combined in meta‐analyses as the painful conditions, the use of paracetamol and comparison interventions and the outcome measures differed. Paracetamol compared with water, cherry elixir or EMLA cream (eutectic mixture of lidocaine and prilocaine) did not significantly reduce pain following heel lance. The Premature Infant Pain Profile score (PIPP) within three minutes following lancing was higher in the paracetamol group than in the oral glucose group (mean difference (MD) 2.21, 95% confidence interval (CI) 0.72 to 3.70; one study, 38 infants). Paracetamol did not reduce \"modified facies scores\" after assisted vaginal birth (one study, 119 infants). In another study (n = 123), the Échelle de Douleur et d'Inconfort du Nouveau‐Né score at two hours of age was significantly higher in the group that received paracetamol suppositories than in the placebo suppositories group (MD 1.00, 95% CI 0.60 to 1.40). In that study, when infants were subjected to a heel lance at two to three days of age, Bernese Pain Scale for Neonates scores were higher in the paracetamol group than in the placebo group, and infants spent a longer time crying (MD 19 seconds, 95% CI 14 to 24). For eye examinations, no significant reduction in PIPP scores in the first or last 45 seconds of eye examination was reported, nor at five minutes after the eye examination. In one study (n = 81), the PIPP score was significantly higher in the paracetamol group than in the 24% sucrose group (MD 3.90, 95% CI 2.92 to 4.88). In one study (n = 114) the PIPP score during eye examination was significantly lower in the paracetamol group than in the water group (MD −2.70, 95% CI −3.55 to 1.85). For postoperative care following major surgery, the total amount of morphine (µg/kg) administered over 48 hours was significantly less among infants assigned to the paracetamol group than to the morphine group (MD −157 µg/kg, 95% CI −27 to −288). No adverse events were noted in any study. The quality of evidence according to GRADE was low. Authors' conclusions The paucity and low quality of existing data do not provide sufficient evidence to establish the role of paracetamol in reducing the effects of painful procedures in neonates. Paracetamol given after assisted vaginal birth may increase the response to later painful exposures. Paracetamol may reduce the total need for morphine following major surgery, and for this aspect of paracetamol use, further research is needed. Plain language summary Paracetamol (acetaminophen) for prevention or treatment of pain in newborns Review question: Is paracetamol effective and safe for the prevention or treatment of procedural or postoperative pain or pain associated with clinical conditions in newborn infants? Background: Newborn infants have the ability to experience pain. Newborns treated in neonatal intensive care units are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. Study characteristics: We identified nine studies that reported comparisons in 728 infants of paracetamol versus placebo or other pain‐reducing interventions. The literature search was updated in May 2016. Key results: Paracetamol for heel lance did not reduce pain compared with placebo (water or cherry elixir) or compared with EMLA cream (eutectic mixture of lidocaine and prilocaine). Paracetamol use was associated with a stronger response to pain than was seen with glucose. Paracetamol did not reduce pain in infants exposed to vacuum extraction or forceps at birth, and their response to a subsequent heel lance at two to three days of life was increased compared with placebo. For eye examination, paracetamol was effective in reducing pain compared with water in one study, but the pain response was stronger among paracetamol‐treated infants than in infants given 24% sucrose. In infants treated with paracetamol and morphine compared with morphine alone, the total amount of morphine required during the first 48 hours following major surgery to the chest or the abdomen was less in the paracetamol group. Paracetamol did not significantly reduce pain during heel lance. Paracetamol following assisted birth may increase the response to later exposure to painful interventions. Paraetamol may reduce the total need for morphine following major surgery, and further research is needed into this aspect of paracetamol use. Quality of evidence: In general the studies were of good quality but the numbers of infants enrolled in the different studies were small. The overall quality of evidence was low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Ohlsson, A; Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD011219.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "f61b4819-26da-4599-ab00-50afa3b36b7f", "pmid": "", "title": "Buspirone for Early Satiety and Symptoms of Gastroparesis: A Multicenter, Randomized, Placebo-Controlled, Double-Masked Trial (BESST)", "imported": false, "abstract": "This study evaluates whether the study medication, buspirone, an antianxiety drug, improves the symptoms of gastroparesis in patients with gastroparesis symptoms and at least moderately severe symptoms of fullness and/or inability to eat a full meal. Half the patients will receive buspirone and half the patients will receive a placebo.", "journal": "", "year": "2018", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.267Z" }, { "id": "f6209397-84c9-4994-90d7-ff353eea82b2", "pmid": "", "title": "Genital ulcer disease treatment for reducing sexual acquisition of HIV", "imported": false, "abstract": "Abstract - Background Genital ulcer disease by virtue of disruption of the mucosal surfaces may enhance HIV acquisition. Genital ulcer disease treatment with resolution of the ulcers may therefore contribute in reducing the sexual acquisition of HIV. Objectives To determine the effects of treatment of genital ulcer disease on sexual acquisition of HIV. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, LILACS, NLM Gateway, Web of Science, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and reference lists of relevant publications for eligible studies published between 1980 and August 2011. Selection criteria Randomized controlled trials of any treatment intervention aimed at curing genital ulcer disease compared with an alternative treatment, placebo, or no treatment. We included only trials whose unit of randomization was the individual with confirmed genital ulcer. Data collection and analysis We independently selected studies and extracted data in duplicate; resolving discrepancies by discussion, consensus, and arbitration by third review author. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI). Main results There were three randomized controlled trials that met our inclusion criteria recruited HIV‐negative participants with chancroid (two trials with 143 participants) and primary syphilis (one trial with 30 participants). The syphilis study, carried out in the US between 1995 and 1997, randomized participants to receive a single 2.0 g oral dose of azithromycin (11 participants); two 2.0 g oral doses of azithromycin administered six to eight days apart (eight participants); or benzathine penicillin G administered as either 2.4 million units intramuscular injection once or twice seven days apart (11 participants). No participant in the trial seroconverted during 12 months of follow‐up. The chancroid trials, conducted in Kenya by 1990, found no significant differences in HIV seroconversion rates during four to 12 weeks of follow‐up between 400 and 200 mg single oral doses of fleroxacin (one trial, 45 participants; RR 3.00; 95% CI 0.29 to 30.69), or between 400 mg fleroxacin and 800 mg sulfamethoxazole plus 160 mg trimethoprim (one trial, 98 participants; RR 0.33; 95% CI 0.04 to 3.09). Adverse events reported were mild to moderate in severity, and included Jarisch‐Herxheimer reactions and gastrointestinal symptoms. The differences between the treatment arms in the incidence of adverse events were not significant. The quality of this evidence on the effectiveness of genital ulcer disease treatment in reducing sexual acquisition of HIV, according to GRADE methodology, is of very low quality. Authors' conclusions At present, there is insufficient evidence to determine whether curative treatment of genital ulcer disease would reduce the risk of HIV acquisition. The very low quality of the evidence implies that the true effect of genital ulcer disease treatment on sexual acquisition of HIV may be substantially different from the effect estimated from currently available data. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not. Plain language summary Genital ulcer disease treatment for reducing sexual acquisition of HIV The presence of a genital ulcer would provide an entry point for the HIV virus if an HIV‐negative individual with an ulcer has unprotected sexual intercourse with an HIV‐infected person. Treatment of the condition causing the genital ulcer would allow the ulcer to heal and therefore reduce the chances of HIV acquisition. This review assessed whether giving treatment for diseases that present with ulcers in the genital region would reduce sexual acquisition of HIV. Three studies were identified involving 173 HIV‐negative patients with genital ulcers. These studies did not provide sufficient evidence that treatment of genital ulcer diseases reduces sexual acquisition of HIV infection. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Mutua, FM, M'Imunya, JM, Wiysonge, CS", "articleTypes": [], "doi": "10.1002/14651858.CD007933.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.784Z" }, { "id": "f63e9b67-49b2-411c-9bff-7ee50dbe235c", "pmid": "", "title": "Antibiotics for the induction and maintenance of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Antibiotics have been considered to treat ulcerative colitis (UC) due to their antimicrobial properties against intestinal bacteria linked to inflammation. However, there are concerns about their efficacy and safety. Objectives To determine whether antibiotic therapy is safe and effective for the induction and maintenance of remission in people with UC. Search methods We searched five electronic databases on 10 December 2021 for randomised controlled trials (RCTs) comparing antibiotic therapy to placebo or an active comparator. Selection criteria We considered people with UC of all ages, treated with antibiotics of any type, dose, and route of administration for inclusion. Induction studies required a minimum duration of two weeks for inclusion. Maintenance studies required a minimum duration of three months to be considered for inclusion. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcome for induction studies was failure to achieve remission and for maintenance studies was relapse, as defined by the primary studies. Main results We included 12 RCTs (847 participants). One maintenance of remission study used sole antibiotic therapy compared with 5‐aminosalicylic acid (5‐ASA). All other trials used concurrent medications or standard care regimens and antibiotics as an adjunct therapy or compared antibiotics with other adjunct therapies to examine the effect on induction of remission. There is high certainty evidence that antibiotics (154/304 participants) compared to placebo (175/304 participants) result in no difference in failure to achieve clinical remission (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.06). A subgroup analysis found no differences when steroids, steroids plus 5‐ASA, or steroids plus 5‐ASA plus probiotics were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (102/168 participants) compared to placebo (121/175 participants) may result in no difference in failure to achieve clinical response (RR 0.75, 95% CI 0.47 to 1.22). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (6/342 participants) compared to placebo (5/349 participants) may result in no difference in serious adverse events (RR 1.19, 95% CI 0.38 to 3.71). A subgroup analysis found no differences when steroids were additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (3/342 participants) compared to placebo (1/349 participants) may result in no difference in withdrawals due to adverse events (RR 2.06, 95% CI 0.27 to 15.72). A subgroup analysis found no differences when steroids or steroids plus 5‐ASA were additional therapies to antibiotics and placebo. It is unclear if there is any difference between antibiotics in combination with probiotics compared to no treatment or placebo for failure to achieve clinical remission (RR 0.68, 95% CI 0.39 to 1.19), serious adverse events (RR 1.00, 95% CI 0.07 to 15.08), or withdrawals due to adverse events (RR 1.00, 95% CI 0.07 to 15.08). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to achieve clinical remission (RR 2.20, 95% CI 1.17 to 4.14). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to probiotics for failure to achieve clinical remission (RR 0.47, 95% CI 0.23 to 0.94). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5‐ASA for failure to maintain clinical remission (RR 0.71, 95% CI 0.47 to 1.06). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to no treatment for failure to achieve clinical remission in a mixed population of people with active and inactive disease (RR 0.56, 95% CI 0.29 to 1.07). The certainty of the evidence is very low. For all other outcomes, no effects could be estimated due to a lack of data. Authors' conclusions There is high certainty evidence that there is no difference between antibiotics and placebo in the proportion of people who achieve clinical remission at the end of the intervention period. However, there is evidence that there may be a greater proportion of people who achieve clinical remission and probably a greater proportion who achieve clinical response with antibiotics when compared with placebo at 12 months. There may be no difference in serious adverse events or withdrawals due to adverse events between antibiotics and placebo. No clear conclusions can be drawn for any other comparisons. A clear direction for future research appears to be comparisons of antibiotics and placebo (in addition to standard therapies) with longer‐term measurement of outcomes. Additionally. As there were single studies of other head‐to‐head comparisons, there may be scope for future studies in this area. Plain language summary The use of antibiotics in the treatment of ulcerative colitis What was the aim of this review? This Cochrane Review aimed to determine whether antibiotics are useful and safe for people with ulcerative colitis (UC) in achieving or maintaining remission. Key messages We found that antibiotics, when added to standard therapies, are similar to placebo in how often they fail to achieve remission or disease improvement for people with UC, measured up to three months from taking them. We found that antibiotics when compared to placebo may be useful in achieving remission or some improvement of UC symptoms, measured at 12 months from taking them. In terms of safety, the evidence is of low certainty, but antibiotics may be as safe as placebo. We have confidence in the findings up to three months, but have less confidence in the evidence at 12 months due to low numbers of study participants. What is ulcerative colitis? UC is a chronic (long term) inflammatory disease that affects the large bowel. The most common symptoms include bloody diarrhoea, abdominal pain, and a sudden almost uncontrollable urge to pass stool. Some people have other symptoms including sore joints, mouth sores, and inflammation in their eyes. When someone is experiencing symptoms of UC, they are said to have 'active' disease. When symptoms improve with treatment, the disease is said to be responding to therapy. When symptoms stop, the disease is said to be in 'remission'. People with UC in remission are often given therapy with medicines to try and prolong (maintain) their remission or response to therapy. What did the review study? This review studied the use of antibiotics in the treatment of UC. Eleven studies considered antibiotics as a therapy for achieving remission and one study as therapy for maintaining remission. Antibiotics could theoretically be helpful as they might be able to fight harmful bacteria in the gut that are thought to be a partial cause for the presence of UC symptoms. Currently, most doctors do not recommend the use of antibiotics unless the patient has an infection. What were the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing antibiotics with another treatment or dummy treatment. We found 12 RCTs including 847 participants. The trials looked at people of all ages; using different types and doses of antibiotics; and at antibiotics taken as tablets, injections, or any other way. The main results from our review are as follows. 1. Antibiotics, when added to standard therapies, are no different from placebo in failing to achieve remission or improve disease symptoms for people with UC when measured up to three months from taking them. 2. Antibiotics probably fail less than placebo in achieving remission or some improvement of UC symptoms measured at 12 months from taking them. 3. In terms of safety, antibiotics may be similar to placebo, but the evidence is of low certainty. 4. We are uncertain about how antibiotics compare to other treatments because there is not enough good evidence to make a judgement. Conclusion There is no difference between antibiotics and placebo when added to standard therapies to achieve remission or improvement of symptoms in the short term. However, they may help to lessen the number of people who do not achieve remission, and they probably lead to fewer numbers of people who have not achieved improvement of symptoms at 12 months. No conclusions can be drawn on other treatments or safety due to lack of evidence, even though there may be a possibility that antibiotics are as safe as placebo. Further research would be needed to clarify the usefulness of antibiotics in the treatment of UC; however, such studies should focus on longer‐term outcomes given the findings of this review. How up‐to‐date is this review? This review is up‐to‐date as of December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Gordon, M; Sinopoulou, V; Grafton-Clarke, C; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD013743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "f6542b87-addd-4687-9554-339cbb8cc6a6", "pmid": "", "title": "Nirmatrelvir combined with ritonavir for preventing and treating COVID‐19", "imported": false, "abstract": "Abstract - Background Oral nirmatrelvir/ritonavir (Paxlovid) aims to avoid severe COVID‐19 in asymptomatic people or those with mild symptoms, thereby decreasing hospitalization and death. It remains to be evaluated for which indications and patient populations the drug is suitable. Objectives To assess the efficacy and safety of nirmatrelvir/ritonavir plus standard of care (SoC) compared to SoC with or without placebo, or any other intervention for treating COVID‐19 or preventing SARS‐CoV‐2 infection. To explore equity aspects in subgroup analyses. To keep up to date with the evolving evidence base using a living systematic review (LSR) approach and make new relevant studies available to readers in‐between publication of review updates. Search methods We searched the Cochrane COVID‐19 Study Register, Scopus, and World Health Organization COVID‐19 Research Database, identifying completed and ongoing studies without language restrictions and incorporating studies up to 15 May 2023. This is a LSR. We conduct update searches every two months and make them publicly available on the open science framework (OSF) platform. Selection criteria We included randomized controlled trials (RCTs) comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo, or any other intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. We screened all studies for research integrity. Studies were ineligible if they had been retracted, or if they were not prospectively registered including appropriate ethics approval. Data collection and analysis We followed standard Cochrane methodology and used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the following outcomes: 1. to treat outpatients with mild COVID‐19; 2. to treat inpatients with moderate to severe COVID‐19: mortality, clinical worsening or improvement, quality of life, (serious) adverse events, and viral clearance; 3. to prevent SARS‐CoV‐2 infection in postexposure prophylaxis (PEP); and 4. pre‐exposure prophylaxis (PrEP) scenarios: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, mortality, admission to hospital, quality of life, and (serious) adverse events. We explored inequity by subgroup analysis for elderly people, socially‐disadvantaged people with comorbidities, populations from low‐income countries and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. Main results As of 15 May 2023, we included two RCTs with 2510 participants with mild and mild to moderate symptomatic COVID‐19 in outpatient and inpatient settings comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo. All trial participants were without previous confirmed SARS‐CoV‐2 infection and at high risk for progression to severe disease. Randomization coincided with the Delta wave for outpatients and Omicron wave for inpatients. Outpatient trial participants and 73% of inpatients were unvaccinated. Symptom onset in outpatients was no more than five days before randomisation and prior or concomitant therapies including medications highly dependent on CYP3A4 were not allowed. We excluded two studies due to concerns with research integrity. We identified 13 ongoing studies. Three studies are currently awaiting classification. Nirmatrelvir/ritonavir for treating people with asymptomatic or mild COVID‐19 in outpatient settings Nirmatrelvir/ritonavir plus SoC compared to SoC plus placebo may reduce all‐cause mortality at 28 days (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.68; 1 study, 2224 participants; low‐certainty evidence) and admission to hospital or death within 28 days (RR 0.13, 95% CI 0.07 to 0.27; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC may reduce serious adverse events during the study period compared to SoC plus placebo (RR 0.24, 95% CI 0.15 to 0.41; 1 study, 2224 participants; low‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably has little or no effect on treatment‐emergent adverse events (RR 0.95, 95% CI 0.82 to 1.10; 1 study, 2224 participants; moderate‐certainty evidence), and probably increases treatment‐related adverse events such as dysgeusia and diarrhoea during the study period compared to SoC plus placebo (RR 2.06, 95% CI 1.44 to 2.95; 1 study, 2224 participants; moderate‐certainty evidence). Nirmatrelvir/ritonavir plus SoC probably decreases discontinuation of study drug due to adverse events compared to SoC plus placebo (RR 0.49, 95% CI 0.30 to 0.80; 1 study, 2224 participants; moderate‐certainty evidence). No studies reported improvement of clinical status, quality of life, or viral clearance. Nirmatrelvir/ritonavir for treating people with moderate to severe COVID‐19 in inpatient settings We are uncertain whether nirmatrelvir/ritonavir plus SoC compared to SoC reduces all‐cause mortality at 28 days (RR 0.63, 95% CI 0.21 to 1.86; 1 study, 264 participants; very low‐certainty evidence), or increases viral clearance at seven days (RR 1.06, 95% CI 0.71 to 1.58; 1 study, 264 participants; very low‐certainty evidence) and 14 days (RR 1.05, 95% CI 0.92 to 1.20; 1 study, 264 participants; very low‐certainty evidence). No studies reported improvement or worsening of clinical status and quality of life. We did not include data for safety outcomes due to insufficient and inconsistent information. Subgroup analyses for equity For outpatients, the outcome 'admission to hospital or death' was investigated for equity regarding age (less than 65 years versus 65 years or greater) and ethnicity. There were no subgroup differences for age or ethnicity. For inpatients, the outcome 'all‐cause mortality' was investigated for equity regarding age (65 years or less versus greater than 65 years). There was no difference between subgroups of age. No further equity‐related subgroups were reported, and no subgroups were reported for other outcomes. Nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection (PrEP and PEP) No studies available. Authors' conclusions Low‐certainty evidence suggests nirmatrelvir/ritonavir reduces the risk of all‐cause mortality and hospital admission or death in high‐risk, unvaccinated COVID‐19 outpatients infected with the Delta variant of SARS‐CoV‐2. There is low‐ to moderate‐certainty evidence of the safety of nirmatrelvir/ritonavir. Very low‐certainty evidence exists regarding the effects of nirmatrelvir/ritonavir on all‐cause mortality and viral clearance in mildly to moderately affected, mostly unvaccinated COVID‐19 inpatients infected with the Omicron variant of SARS‐CoV‐2. Insufficient and inconsistent information prevents the assessment of safety outcomes. No reliable differences in effect size and direction were found regarding equity aspects. There is no available evidence supporting the use of nirmatrelvir/ritonavir for preventing SARS‐CoV‐2 infection. We are continually updating our search and making search results available on the OSF platform. Plain language summary Is the combination of nirmatrelvir plus ritonavir effective for treating or preventing COVID‐19? Key messages Nirmatrelvir/ritonavir (Paxlovid) is evaluated for the treatment of coronavirus disease 2019 (COVID‐19). Nirmatrelvir/ritonavir may lead to fewer deaths and improve patient condition, as assessed by need for hospitalization or death within 28 days for unvaccinated outpatients at increased risk for disease progression receiving treatment within five days of symptom onset. We are very uncertain about the effectiveness of nirmatrelvir/ritonavir in inpatients. We excluded two studies due to concerns with research integrity. We found 13 ongoing studies. What is nirmatrelvir/ritonavir? The combination of nirmatrelvir with ritonavir is a new medicine developed to treat infection with the SARS‐CoV‐2 virus and aims to avoid severe COVID‐19 in people without symptoms, or those with mild symptoms. Ritonavir increases the effectiveness of nirmatrelvir but it can interact with many other medicines, which can increase side effects. What did we want to find out? We wanted to know if nirmatrelvir/ritonavir reduces death, illness, and length of infection in people with COVID‐19, or if it is useful in prevention of the disease. We included studies comparing the medicine with placebo (dummy treatment), no treatment, usual care, or any other treatments for COVID‐19. We addressed equity and wanted to know whether there are certain groups of people for which nirmatrelvir/ritonavir works best or is less effective. We looked at elderly people, socially disadvantaged people with other illnesses (comorbidities), people from low‐income and low‐ to middle‐income countries, and people from different ethnic and racial backgrounds. We evaluated the effects of nirmatrelvir/ritonavir in people with COVID‐19 regarding: – people dying; – whether COVID‐19 symptoms got better or worse; – quality of life; – unwanted effects of the medicine; – virus elimination. For prevention, we sought the effect on preventing COVID‐19 and SARS‐CoV‐2 infection. What did we do? We searched for randomized controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that investigated nirmatrelvir/ritonavir to prevent or treat COVID‐19. People receiving nirmatrelvir/ritonavir as treatment had to have laboratory‐confirmed COVID‐19 and be treated in hospital or as outpatients. People receiving nirmatrelvir/ritonavir to prevent an infection had to have a high risk of contracting the disease or had to have had a high‐risk contact with a person with confirmed COVID‐19. We summarized the results of the studies and rated our confidence in the evidence, based on common criteria as to how reliable the evidence was. We examined differences with respect to age, level of comorbidity, country according to the World Bank country classification by income level, and ethnicity. What did we find? We found two studies with 2510 participants that investigated nirmatrelvir/ritonavir compared to placebo or standard of care for the treatment of COVID‐19 in people without previous confirmed SARS‐CoV‐2 infection and at increased risk for progression to severe disease due to a comorbidity or risk factor such as current smoking. Included outpatients were enrolled during the Delta wave, unvaccinated, and had a symptom onset of up to five days before starting treatment. Included inpatients were enrolled during the Omicron wave, mostly unvaccinated, and mildly to moderately affected. We found 13 ongoing studies that have not yet been completed, and three studies are currently awaiting classification. Main results Treating outpatients with COVID‐19 For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir may: – lead to fewer deaths; – improve patients' condition assessed by need for admission to hospital or death within 28 days; – reduce serious unwanted events. For the specific population of unvaccinated, high‐risk patients, nirmatrelvir/ritonavir probably: – has little effect on any unwanted events; – increases any treatment‐related unwanted events (mostly taste disturbance and diarrhoea); – decreases discontinuation of study medicine due to unwanted events. Equity aspects Most study participants were younger than 65 years and of white ethnicity. There was no difference in effectiveness between younger and older participants and participants from different ethnic groups. No subgroups were reported for different levels of comorbidity and World Bank country classification by income level. Treating inpatients with COVID‐19 We are uncertain whether, for the specific population of mildly to moderately affected, high‐risk patients, nirmatrelvir/ritonavir: – leads to fewer deaths; and – increases virus elimination Equity aspects Most study participants were older than 65 years. There was no difference in effectiveness between younger and older participants. No subgroups were reported for different levels of comorbidity, ethnicity, and World Bank country classification by income level. No subgroups were reported for other outcomes. What are the limitations of the evidence? Our confidence in the evidence is low to moderate for outpatients and very low for inpatients. The studies did not report everything we were interested in, such as quality of life and symptom resolution, and had a highly specific population of people at high risk of progression to severe COVID‐19. How up to date is this evidence? The evidence is up to date to 15 May 2023. According to this review's living approach, we will update our search every two months. We are making search results and new relevant studies publicly available.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Reis, S; Metzendorf, M-I; Kuehn, R; Popp, M; Gagyor, I; Kranke, P; Meybohm, P; Skoetz, N; Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015395.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "f661179b-30d0-4715-81dc-aa147120ea56", "pmid": "", "title": "Vigabatrin add‐on therapy for drug‐resistant focal epilepsy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane Review published in 2008 and updated in 2013. Epilepsy is a common neurological condition which affects up to 1% of the population. Approximately 30% of people with epilepsy do not respond to treatment with currently available drugs. The majority of these people have focal epilepsy. Vigabatrin is an antiepileptic drug licensed for use in drug‐resistant epilepsy. Objectives To assess the efficacy and tolerability of vigabatrin as an add‐on therapy for people with drug‐resistant focal epilepsy. Search methods For the latest update of this review, we searched the following databases on 1 November 2018: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid 1946 to 31 October 2018), ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. The Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL) are both included in the Cochrane Register of Studies (CRS Web). We checked reference lists of retrieved studies for additional reports of relevant studies and contacted Hoechst Marion Roussel (manufacturers of vigabatrin) in 2000. Selection criteria We included randomised, double‐blind, placebo‐controlled, fully published trials of vigabatrin in people of any age with drug‐resistant focal epilepsy. Data collection and analysis Two review authors assessed trials for inclusion and extracted data using the standard methodological procedures expected by Cochrane. Primary analysis was by intention‐to‐treat (ITT). We evaluated: 50% or greater reduction in seizure frequency, treatment withdrawal, adverse effects, dose‐response analysis, cognitive outcomes and quality of life. We presented results as risk ratios (RR) with 95% or 99% confidence intervals (CI). Main results We identified 11 trials that included 756 participants (age range: 10 to 64 years). The trials tested vigabatrin doses between 1 g/day and 6 g/day. All 11 trials displayed a risk of bias across at least three risk of bias domains. Predominantly, the risk of bias was associated with: allocation concealment (selection bias), blinding of outcome assessment (detection bias) and incomplete outcome data (attrition bias). Participants treated with vigabatrin may be two to three times more likely to obtain a 50% or greater reduction in seizure frequency compared with those treated with placebo (RR 2.60, 95% CI 1.87 to 3.63; 4 studies; low‐certainty evidence). Those treated with vigabatrin may also be three times more likely to have treatment withdrawn although we are uncertain (RR 2.86, 95% CI 1.25 to 6.55; 4 studies; very low‐certainty evidence). Compared to placebo, participants given vigabatrin were more likely to experience adverse effects: dizziness/light‐headedness (RR 1.74, 95% CI 1.05 to 2.87; 9 studies; low‐certainty evidence), fatigue (RR 1.65, 95% CI 1.08 to 2.51; 9 studies; low‐certainty evidence), drowsiness (RR 1.70, 95% CI 1.18 to 2.44; 8 studies) and depression (RR 3.28, 95% CI 1.30 to 8.27; 6 studies). Although the incidence rates were higher among participants receiving vigabatrin compared to those receiving placebo, the effect was not significant for the following adverse effects: ataxia (RR 2.76, 95% CI 0.96 to 7.94; 7 studies; very low‐certainty evidence), nausea (RR 3.57, 95% CI 0.63 to 20.30; 4 studies), abnormal vision (RR 1.64, 95% CI 0.67 to 4.02; 5 studies; very low‐certainty evidence), headache (RR 1.23, 95% CI 0.79 to 1.92; 9 studies), diplopia (RR 1.76, 99% CI 0.94 to 3.30) and nystagmus (RR 1.53, 99% CI 0.62 to 3.76; 2 studies; low‐certainty evidence). Vigabatrin had little to no effect on cognitive outcomes or quality of life. Authors' conclusions Vigabatrin may significantly reduce seizure frequency in people with drug‐resistant focal epilepsy. The results largely apply to adults and should not be extrapolated to children under 10 years old. Short‐term follow‐up of participants showed that some adverse effects were associated with its use. Analysis of longer‐term observational studies elsewhere, however, has demonstrated that vigabatrin use can lead to the development of visual field defects. Plain language summary Vigabatrin add‐on for drug‐resistant focal epilepsy Background Epilepsy is a common neurological disorder affecting approximately 1 in 100 people. Around 30% of these people cannot control their epilepsy with currently available antiepileptic medication and are said to have drug‐resistant epilepsy. Most often, drug‐resistant epilepsy is focal in nature, meaning that the seizures start in one specific area of the brain. Vigabatrin is an antiepileptic medication that can be used as an add‐on treatment for drug‐resistant focal epilepsy, meaning that it is taken in addition to other antiepileptic medications. Main results We found 11 clinical trials, involving 756 people, which investigated vigabatrin as an add‐on for people with drug‐resistant focal epilepsy. The people in the trials were aged between 10 to 64 years and were given doses of 1 g/day to 6 g/day vigabatrin. We found that people given vigabatrin may be two to three times more likely to experience a 50% or greater reduction in seizure frequency than people given placebo (a non‐active treatment). We also suggest that people given vigabatrin may be up to three times more likely to stop treatment than people given placebo. People given vigabatrin were more likely to experience side effects: dizziness/light‐headedness, fatigue, drowsiness and depression, than people given placebo. However, the evidence suggested that they should not be more likely to experience: ataxia (disorders that affect co‐ordination, balance and speech), feeling sick (nausea), abnormal vision, headache, seeing double (diplopia), or involuntary movement of the eyes (nystagmus) than people given placebo. Reliability of the evidence We judged that all studies had significant risk of bias. The studies did not explain how people were allocated to treatment groups and did not say whether investigators knew which treatment people were receiving. Alongside other reasons, this reduced our confidence (certainty) in the results. Overall, we are uncertain to very uncertain whether the results we have reported are reliable. The true effect of vigabatrin could be significantly different to that reported here. Conclusions Vigabatrin may significantly reduce seizure frequency for people with drug‐resistant focal epilepsy but we are uncertain. Most of the evidence was gathered from adults, therefore, the effects of vigabatrin could be different in children. All of the included trials were of short duration; therefore, we cannot report any long‐term effects of vigabatrin. Importantly, reviews of long‐term studies have reported that long‐term vigabatrin use can lead to the development of visual problems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Bresnahan, R, Gianatsi, M, Maguire, MJ, Tudur Smith, C, Marson, AG", "articleTypes": [], "doi": "10.1002/14651858.CD007302.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.785Z" }, { "id": "f668af0d-1cc3-4355-a1fb-40bc4a9ecc20", "pmid": "", "title": "Guided imagery for treating hypertension in pregnancy", "imported": false, "abstract": "Abstract - Background Hypertension (high blood pressure) in pregnancy carries a high risk of maternal morbidity and mortality. Although antihypertensive drugs are commonly used, they have adverse effects on mothers and fetuses. Guided imagery is a non‐pharmacological technique that has the potential to lower blood pressure among pregnant women with hypertension. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. Objectives To determine the effect of guided imagery as a non‐pharmacological treatment of hypertension in pregnancy and its influence on perinatal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, and two trials registers (October 2018). We also searched relevant conference proceedings and journals, and scanned the reference lists of retrieved studies. Selection criteria We included randomised controlled trials (RCTs). We would have included RCTs using a cluster‐randomised design, but none were identified. We excluded quasi‐RCTs and cross‐over trials. We sought intervention studies of various guided imagery techniques performed during pregnancy in comparison with no intervention or other non‐pharmacological treatments for hypertension (e.g. quiet rest, music therapy, aromatherapy, relaxation therapy, acupuncture, acupressure, massage, device‐guided slow breathing, hypnosis, physical exercise, and yoga). Data collection and analysis Three review authors independently assessed the trials for inclusion, extracted data, and assessed risk of bias for the included studies. We checked extracted data for accuracy, and resolved differences in assessments by discussion. We assessed the certainty of the evidence using the GRADE approach. Main results We included two small trials (involving a total of 99 pregnant women) that compared guided imagery with quiet rest. The trials were conducted in Canada and the USA. We assessed both trials as at high risk of performance bias, and low risk of attrition bias; one trial was at low risk for selection, detection, and reporting bias, while the other was at unclear risk for the same domains. We could not perform a meta‐analysis because the two included studies reported different outcomes, and the frequency of the intervention was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks, or until the baby was born (whichever came first). In the other study, the intervention included guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for four total hours; the participants were instructed to practice the procedures twice daily and complete at least three relief relaxation breaks each day. The control groups were similar ‐ one was quiet rest, and the other was quiet rest as bed rest. None of our primary outcomes were reported in the included trials: severe hypertension (either systolic blood pressure of 160 mmHg or higher, or diastolic blood pressure of 110 mmHg or higher); severe pre‐eclampsia, or perinatal death (stillbirths plus deaths in the first week of life). Only one of the secondary outcomes was measured. Low‐certainty evidence from one trial (69 women) suggests that guided imagery may make little or no difference in the use of antihypertensive drugs (risk ratio 1.27, 95% confidence interval 0.72 to 2.22). Authors' conclusions There is insufficient evidence to inform practice about the use of guided imagery for hypertension in pregnancy. The available evidence for this review topic is sparse, and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. There was low‐certainty evidence that guided imagery made little or no difference to the use of antihypertensive drugs, downgraded because of imprecision. The two included trials did not report on any of the primary outcomes of this review. We did not identify any trials comparing guided imagery with no intervention, or with another non‐pharmacological method for hypertension. Large and well‐designed RCTs are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with short‐term and long‐term maternal and neonatal health. Trials could also consider utilisation and costs of health service. Plain language summary Guided imagery for treating hypertension in pregnancy What is the issue? Some women have long‐term high blood pressure, or hypertension, whereas approximately 10% of pregnant women develop high blood pressure as a complication of pregnancy. Guided imagery is a mind‐body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. It can be performed by oneself, one‐to‐one, or in groups with an instructor using audio or scripts. Why is this important? High blood pressure during pregnancy is associated with an increased risk of the mother developing pre‐eclampsia with proteinuria, eclampsia with seizures and liver and blood disorders, and kidney failure. The baby of a pregnant woman with high blood pressure is more likely to be born too soon, be too small, and may need neonatal intensive care. High blood pressure drugs are recommended for women with severe high blood pressure and pre‐eclampsia because of the risk of life‐threatening complications, but such drugs can have adverse effects for the mother (including headache, decreased mental alertness, and exercise intolerance). Such drugs can also cross the placenta and may affect the unborn baby, and are not generally recommended for pregnant women with mild to moderate high blood pressure, which is when other ways of managing blood pressure are sought. Guided imagery is a non‐pharmacological technique that could potentially lower blood pressure among pregnant women with hypertension and improve pregnancy outcomes for the mother and her baby. What evidence did we find? We searched for evidence (October 2018) and found two trials (involving 99 women) conducted in Canada and the USA. Both trials compared guided imagery with quiet rest. There were no trials comparing guided imagery with no intervention, or other with another non‐pharmacological method for hypertension. The two included studies reported different outcomes and the Intervention frequency was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks or until the baby was born (whichever came first). The other study involved guided imagery, self‐monitoring of blood pressure, and thermal biofeedback‐assisted relaxation training for a total of four hours; the women were instructed to practice the procedures twice daily and complete at least three relaxation breaks each day. The control groups between the two studies were similar ‐ one used quiet rest and the other used quiet rest as bed rest. Neither trial reported data for our main outcomes of interest: severe hypertension, severe pre‐eclampsia, or death of the baby during birth or within the first week of life. The trials provided data for only one of our secondary outcomes of interest. Low‐certainty evidence from the one trial (69 women) suggests that, compared with quiet rest, guided imagery may make little or no difference in the use of antihypertensive drugs. What does this mean? We included two small trials comparing guided imagery with quiet rest. We did not identify any trials comparing guided imagery with no intervention, or another non‐pharmacological treatment for hypertension. The available evidence for this review is sparse and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. The included trials did not report on any of the main outcomes in this review and only provided low‐certainty evidence on the uncertain effect on the use of antihypertensive drugs. There is insufficient evidence to inform practice about using guided imagery for hypertension in pregnancy. Large and well‐designed studies are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with the short‐term and long‐term health of mothers and their babies. The trials should also consider the use and costs of health services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Haruna, M, Matsuzaki, M, Ota, E, Shiraishi, M, Hanada, N, Mori, R", "articleTypes": [], "doi": "10.1002/14651858.CD011337.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.776Z" }, { "id": "f6736b7a-3f35-4995-b493-0c64ebe9cc29", "pmid": "", "title": "Evaluating the Effect of a Food for Special Medical Purposes Containing Essential Amino Acids (EAA), Carnitine, Arginine, and Sucrosomial Minerals on the Preservation of Appendicular Skeletal Muscle Mass (ASMM) During a Weight Loss Program With GLP-1 Receptor Agonists", "imported": false, "abstract": "This study evaluates whether a Food for Special Medical Purposes (FSMP) can help to preserve appendicular skeletal muscle mass (ASMM) in adults undergoing weight loss treatment with GLP-1 receptor agonists or dual GIP/GLP-1 receptor agonists. Participants will receive the FSMP or a matching placebo for 24 weeks while continuing standard GLP-1-based therapy. ASMM will be measured using Bioelectrical Impedance Vector Analysis (BIVA).", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.150Z" }, { "id": "f67acd04-8e31-4e15-aebe-9114cf0c9e4e", "pmid": "", "title": "Xylitol for preventing acute otitis media in children up to 12 years of age", "imported": false, "abstract": "Abstract - Background Acute otitis media (AOM) is the most common bacterial infection among young children in the United States. There are limitations and concerns over its treatment with antibiotics and surgery and so effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk of dental decay. Xylitol can reduce the adherence of Streptococcus pneumoniae ( S pneumoniae ) and Haemophilus influenzae ( H influenzae ) to nasopharyngeal cells in vitro. This is an update of a review first published in 2011. Objectives To assess the efficacy and safety of xylitol to prevent AOM in children aged up to 12 years. Search methods We searched CENTRAL (to Issue 12, 2015), MEDLINE (1950 to January 2016), Embase (1974 to January 2016), CINAHL (1981 to January 2016), LILACS (1982 to January 2016), Web of Science (2011 to January 2016) and International Pharmaceutical Abstracts (2000 to January 2016). Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs of children aged 12 years or younger where xylitol supplementation was compared with placebo or no treatment to prevent AOM. Data collection and analysis Two review authors independently selected trials from search results, assessed and rated study quality and extracted relevant data for inclusion in the review. We contacted trial authors to request missing data. We noted data on any adverse events of xylitol. We extracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR), risk difference (RD) and associated 95% confidence intervals (CI). Main results We identified five clinical trials that involved 3405 children for inclusion. For this 2016 update, we identified one new trial for inclusion. This trial was systematically reviewed but due to several sources of heterogeneity, was not included in the meta‐analysis. The remaining four trials were of adequate methodological quality. In three RCTs that involved a total of 1826 healthy Finnish children attending daycare, there is moderate quality evidence that xylitol (in any form) can reduce the risk of AOM from 30% to around 22% compared with the control group (RR 0.75, 95% CI 0.65 to 0.88). Among the reasons for dropouts, there were no significant differences in abdominal discomfort and rash between the xylitol and the control groups. Xylitol was not effective in reducing AOM among healthy children during a respiratory infection (RR 1.13, 95% CI 0.83 to 1.53; moderate quality evidence) or among otitis‐prone healthy children (RR 0.90, 95% CI 0.67 to 1.21; low‐quality evidence). Authors' conclusions There is moderate quality evidence showing that the prophylactic administration of xylitol among healthy children attending daycare centres can reduce the occurrence of AOM. There is inconclusive evidence with regard to the efficacy of xylitol in preventing AOM among children with respiratory infection, or among otitis‐prone children. The meta‐analysis was limited because data came from a small number of studies, and most were from the same research group. Plain language summary Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age Review question 
 We reviewed the evidence about the effectiveness and safety of xylitol to prevent acute middle ear infection (acute otitis media; AOM) in children up to 12 years old. Background 
 AOM is the most common bacterial infection among young children in the United States. Although serious complications are rare, this common childhood ailment imposes a huge impact on the healthcare system. In the United States, it accounted for almost 20 million office visits. Antibiotic treatment of AOM is costly and raises concerns about the development of antibiotic‐resistant strains of bacteria. Surgery is invasive and costly, and because of these factors, effective measures for preventing AOM are sought. An alternative treatment is xylitol or birch sugar. Xylitol has been used for decades as a natural non‐sugar sweetener principally in chewing gums, confectionery, toothpaste and medicines, and can reduce the risk of tooth decay. Search date We searched the literature up to January 2016. This is an update of a review that was last published in 2011. Study characteristics 
 We identified five clinical trials that involved 3405 children, mostly from the same research group. Four trials were conducted in Finland and enrolled healthy children (three trials) or children with an acute respiratory infection (one trial). The fifth trial was conducted in the USA and enrolled otitis‐prone children who were recruited from attendance at general medical practices. Study funding sources All five trials received governmental funding; and the Finnish study investigators have a US patent for the use of xylitol to treat respiratory infections. Key results Xylitol, administered in chewing gum, lozenges or syrup, can reduce the occurrence of AOM among healthy children with no acute upper respiratory infection from 30% to 22%. There is no difference in side effects (namely, abdominal discomfort and rash). Based on these results we would expect that out of 1000 children up to 12 years of age, 299 would experience an AOM compared with between 194 and 263 children who would experience an AOM if they are provided with xylitol chewing gum. The preventive effect among healthy children with respiratory infection or among otitis‐prone children is inconclusive. Quality of the evidence 
 The quality of evidence was moderate for healthy children and children with respiratory infections but low for otitis‐prone children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Azarpazhooh, A; Lawrence, HP; Shah, PS", "articleTypes": [], "doi": "10.1002/14651858.CD007095.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "f68733fe-6f82-428f-887f-ddc20be1d6a6", "pmid": "", "title": "Donepezil for dementia due to Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Alzheimer's disease is the most common cause of dementia in older people. One approach to symptomatic treatment of Alzheimer's disease is to enhance cholinergic neurotransmission in the brain by blocking the action of the enzyme responsible for the breakdown of the neurotransmitter acetylcholine. This can be done by a group of drugs known as cholinesterase inhibitors. Donepezil is a cholinesterase inhibitor. This review is an updated version of a review first published in 1998. Objectives To assess the clinical efficacy and safety of donepezil in people with mild, moderate or severe dementia due to Alzheimer's disease; to compare the efficacy and safety of different doses of donepezil; and to assess the effect of donepezil on healthcare resource use and costs. Search methods We searched Cochrane Dementia and Cognitive Improvement’s Specialized Register, MEDLINE, Embase, PsycINFO and a number of other sources on 20 May 2017 to ensure that the search was as comprehensive and up‐to‐date as possible. In addition, we contacted members of the Donepezil Study Group and Eisai Inc. Selection criteria We included all double‐blind, randomised controlled trials in which treatment with donepezil was administered to people with mild, moderate or severe dementia due to Alzheimer's disease for 12 weeks or more and its effects compared with those of placebo in a parallel group of patients, or where two different doses of donepezil were compared. Data collection and analysis One reviewer (JSB) extracted data on cognitive function, activities of daily living, behavioural symptoms, global clinical state, quality of life, adverse events, deaths and healthcare resource costs. Where appropriate and possible, we estimated pooled treatment effects. We used GRADE methods to assess the quality of the evidence for each outcome. Main results Thirty studies involving 8257 participants met the inclusion criteria of the review, of which 28 studies reported results in sufficient detail for the meta‐analyses. Most studies were of six months' duration or less. Only one small trial lasted 52 weeks. The studies tested mainly donepezil capsules at a dose of 5 mg/day or 10 mg/day. Two studies tested a slow‐release oral formulation that delivered 23 mg/day. Participants in 21 studies had mild to moderate disease, in five studies moderate to severe, and in four severe disease. Seventeen studies were industry funded or sponsored, four studies were funded independently of industry and for nine studies there was no information on source of funding. Our main analysis compared the safety and efficacy of donepezil 10 mg/day with placebo at 24 to 26 weeks of treatment. Thirteen studies contributed data from 3396 participants to this analysis. Eleven of these studies were multicentre studies. Seven studies recruited patients with mild to moderate Alzheimer's disease, two with moderate to severe, and four with severe Alzheimer's disease, with a mean age of about 75 years. Almost all evidence was of moderate quality, downgraded due to study limitations. After 26 weeks of treatment, donepezil compared with placebo was associated with better outcomes for cognitive function measured with the Alzheimer's Disease Assessment Scale‐Cognitive (ADAS‐Cog, range 0 to 70) (mean difference (MD) ‐2.67, 95% confidence interval (CI) ‐3.31 to ‐2.02, 1130 participants, 5 studies), the Mini‐Mental State Examination (MMSE) score (MD 1.05, 95% CI 0.73 to 1.37, 1757 participants, 7 studies) and the Severe Impairment Battery (SIB, range 0 to 100) (MD 5.92, 95% CI 4.53 to 7.31, 1348 participants, 5 studies). Donepezil was also associated with better function measured with the Alzheimer's Disease Cooperative Study activities of daily living score for severe Alzheimer's disease (ADCS‐ADL‐sev) (MD 1.03, 95% CI 0.21 to 1.85, 733 participants, 3 studies). A higher proportion of participants treated with donepezil experienced improvement on the clinician‐rated global impression of change scale (odds ratio (OR) 1.92, 95% CI 1.54 to 2.39, 1674 participants, 6 studies). There was no difference between donepezil and placebo for behavioural symptoms measured by the Neuropsychiatric Inventory (NPI) (MD ‐1.62, 95% CI ‐3.43 to 0.19, 1035 participants, 4 studies) or by the Behavioural Pathology in Alzheimer's Disease (BEHAVE‐AD) scale (MD 0.4, 95% CI ‐1.28 to 2.08, 194 participants, 1 study). There was also no difference between donepezil and placebo for Quality of Life (QoL) (MD ‐2.79, 95% CI ‐8.15 to 2.56, 815 participants, 2 studies). Participants receiving donepezil were more likely to withdraw from the studies before the end of treatment (24% versus 20%, OR 1.25, 95% CI 1.05 to 1.50, 2846 participants, 12 studies) or to experience an adverse event during the studies (72% vs 65%, OR 1.59, 95% 1.31 to 1.95, 2500 participants, 10 studies). There was no evidence of a difference between donepezil and placebo for patient total healthcare resource utilisation. Three studies compared donepezil 10 mg/day to donepezil 5 mg/day over 26 weeks. The 5 mg dose was associated with slightly worse cognitive function on the ADAS‐Cog, but not on the MMSE or SIB, with slightly better QoL and with fewer adverse events and withdrawals from treatment. Two studies compared donepezil 10 mg/day to donepezil 23 mg/day. There were no differences on efficacy outcomes, but fewer participants on 10 mg/day experienced adverse events or withdrew from treatment. Authors' conclusions There is moderate‐quality evidence that people with mild, moderate or severe dementia due to Alzheimer's disease treated for periods of 12 or 24 weeks with donepezil experience small benefits in cognitive function, activities of daily living and clinician‐rated global clinical state. There is some evidence that use of donepezil is neither more nor less expensive compared with placebo when assessing total healthcare resource costs. Benefits on 23 mg/day were no greater than on 10 mg/day, and benefits on the 10 mg/day dose were marginally larger than on the 5 mg/day dose, but the rates of withdrawal and of adverse events before end of treatment were higher the higher the dose. Plain language summary Donepezil for people with dementia due to Alzheimer's disease Review question What effects (benefits or harms) does donepezil have on people with dementia due to Alzheimer's disease? Background Alzheimer's disease is the most common cause of dementia. As the disease progresses, people lose the ability to remember, communicate, think clearly and perform the activities of daily living. Their behaviour may also change. In severe Alzheimer's disease people lose the ability to care for themselves. The most commonly used treatment for Alzheimer's disease are medicines known as acetylcholinesterase inhibitors. Donepezil is one of these medicines. It is taken as a pill once a day. In Alzheimer's disease, one of the changes in the brain is a reduced number of nerve cells called cholinergic neurones. These are nerve cells that signal to other cells using a chemical called acetylcholine. Acetylcholinesterase inhibitors, such as donepezil, work by preventing acetylcholine from being broken down. This may improve the symptoms of dementia. However, acetylcholine is also found elsewhere in the body and so drugs of this type may have unwanted effects. Review methods In this review we examined evidence about benefits and harms from studies that compared donepezil, taken for at least 12 weeks, to placebo (a dummy pill), or that compared different doses of donepezil. The studies had to be double‐blind and randomised, that is, the decision whether people taking part got donepezil or placebo had to be made randomly and neither they nor the researchers should have known which treatment they were getting while the trial was going on. This was to make the comparison as unbiased, or fair, as possible. We searched for studies up to May 2017. We assessed the quality of all the studies we included. When it was sensible to do so, we analysed the results of studies together to get an overall result. Key results We included 30 studies with 8257 participants. Most of the people in the studies had mild or moderate dementia due to Alzheimer's disease, but in nine studies they had moderate or severe dementia. Almost all of the studies lasted six months or less. The majority of the studies were known to have been funded by the manufacturer of donepezil. We found that people with Alzheimer's disease who took 10 mg of donepezil a day for six months did slightly better than people taking placebo, on scales measuring their cognitive function (e.g. thinking and remembering), how well they could manage their daily activities, and the overall impression of a trained researcher. We did not find any effect on behaviour or quality of life. People taking donepezil were more likely than those taking placebo to report side effects and to drop out of the studies. Most side effects were described as mild. Nausea, vomiting and diarrhoea were most common. Comparing 5 mg of donepezil a day with 10 mg/day, people on 5 mg had fewer side effects, but did slightly less well on cognitive function tests. A higher dose (23 mg/day) offered no advantages and was associated with more side effects. There is some evidence that use of donepezil is neither more nor less expensive than placebo when total health care costs are taken into account. Quality of the evidence In general, we thought that the quality of the evidence was moderate. The main factor reducing our confidence was concern that the results of some studies might have been biased by the way they were done. We cannot be sure that the results apply to treatment longer than six months. Conclusions After six months of treatment, there are benefits of donepezil that are large enough to measure in studies. It is associated with side effects that are mainly mild, but that may cause people to stop treatment. Being able to stabilise cognitive performance or ability to maintain activities of daily living may be important clinically. In terms of total healthcare costs the use of donepezil appears cost neutral. However, there does not appear to be an effect on quality of life. More data are still required from longer‐term clinical studies examining measures of disease progression or time to needing full time care.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Birks, JS; Harvey, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD001190.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "f696ea8d-a47e-43ed-b3be-a9497d66e7bf", "pmid": "", "title": "Parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review on parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy (published in Issue 3, 2007). Salivary gland dysfunction is a predictable side effect of radiotherapy to the head and neck region. Pilocarpine hydrochloride (a choline ester) is licensed in many countries for the treatment of radiation‐induced salivary gland dysfunction. Other parasympathomimetics have also been used 'off licence' in the treatment of this condition. Objectives To determine the efficacy and tolerability of parasympathomimetic drugs in the treatment of radiation‐induced salivary gland dysfunction (specifically radiation‐induced xerostomia). Search methods For this update, we ran searches of the Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 6), MEDLINE, EMBASE, and CINAHL in July 2015. We checked the reference lists of retrieved articles for additional studies, contacted experts in the field for unpublished and ongoing trials, and contacted relevant pharmaceutical companies for unpublished and ongoing trials. Selection criteria The selection criteria for the review were: 1) randomised controlled trials; 2) people suffering from radiation‐induced salivary gland dysfunction; 3) people treated with parasympathomimetic drugs; and 4) assessable data available on primary outcome measure. Data collection and analysis The two review authors independently collected data from the full‐text version of relevant papers including: 1) citation details; 2) participants; 3) interventions; 4) assessments; 5) outcomes (that is efficacy, tolerability); and 6) quality issues. Due to a lack of appropriate data, we were unable to perform a meta‐analysis. Main results In the original review, three studies, including a total of 298 participants, fulfilled the inclusion criteria. All three studies involved the use of pilocarpine hydrochloride. We have included no additional studies in the update of the review; we have excluded eight additional studies. The data suggest that pilocarpine hydrochloride is more effective than placebo and at least as effective as artificial saliva. The response rate was 42% to 51%. The time to response was up to 12 weeks. The overall side effect rate was high, and side effects were the main reason for withdrawal (6% to 15% of participants taking 5 mg three times a day had to withdraw). The side effects were usually the result of generalised parasympathomimetic stimulation (for example sweating, headaches, urinary frequency, vasodilatation). Response rates were not dose dependent, but side effect rates were dose dependent. Authors' conclusions There is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced xerostomia. Currently, there is little evidence to support the use of other parasympathomimetic drugs in the treatment of radiation‐induced xerostomia. Available studies suggest that approximately half of patients will respond, but side effects can be problematic. The conclusions of the update are the same as the conclusions of the original review, since no new relevant studies have been published in the interim. Plain language summary Parasympathomimetic drugs for the treatment of 'dry mouth' due to radiotherapy This updated review found there is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced salivary gland dysfunction ('dry mouth'). Salivary gland damage is a frequent and important complication of radiotherapy to the head and neck area; it causes dryness of the mouth with resultant problems with eating, talking, and local infection. The parasympathomimetic group of drugs have been used to treat radiotherapy‐induced salivary gland damage. We identified three studies that involved a total of 289 participants, and they all used the drug pilocarpine. The review found that 42% to 51% of participants (4 to 5 in 10) responded to pilocarpine, although in some participants the response did not occur for up to 12 weeks. Pilocarpine was more effective than a placebo treatment, and at least as effective as an artificial saliva. Side effects were common with pilocarpine (for example sweating, headache, passing urine frequently, flushing), but were usually reported to be mild; 6% to 15% (0.6 to 1.5 in 10) participants had to stop taking pilocarpine due to side effects. The findings of this review are limited by the small number of good‐quality trials that have been performed in this area. The update of this review did not find any new information on this topic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Davies, AN; Thompson, J", "articleTypes": [], "doi": "10.1002/14651858.CD003782.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "f6ac752e-12c9-4959-9188-387a80e55398", "pmid": "", "title": "Antibiotics for community‐acquired pneumonia in adult outpatients", "imported": false, "abstract": "Abstract - Background Lower respiratory tract infection (LRTI) is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Community‐acquired pneumonia (CAP) is a common condition that causes a significant disease burden for the community, particularly in children younger than five years, the elderly and immunocompromised people. Antibiotics are the standard treatment for CAP. However, increasing antibiotic use is associated with the development of bacterial resistance and side effects for the patient. Several studies have been published regarding optimal antibiotic treatment for CAP but many of these data address treatments in hospitalised patients. This is an update of our 2009 Cochrane Review and addresses antibiotic therapies for CAP in outpatient settings. Objectives To compare the efficacy and safety of different antibiotic treatments for CAP in participants older than 12 years treated in outpatient settings with respect to clinical, radiological and bacteriological outcomes. Search methods We searched CENTRAL (2014, Issue 1), MEDLINE (January 1966 to March week 3, 2014), EMBASE (January 1974 to March 2014), CINAHL (2009 to March 2014), Web of Science (2009 to March 2014) and LILACS (2009 to March 2014). Selection criteria We looked for randomised controlled trials (RCTs), fully published in peer‐reviewed journals, of antibiotics versus placebo as well as antibiotics versus another antibiotic for the treatment of CAP in outpatient settings in participants older than 12 years of age. However, we did not find any studies of antibiotics versus placebo. Therefore, this review includes RCTs of one or more antibiotics, which report the diagnostic criteria and describe the clinical outcomes considered for inclusion in this review. Data collection and analysis Two review authors (LMB, TJMV) independently assessed study reports in the first publication. In the 2009 update, LMB performed study selection, which was checked by TJMV and MMK. In this 2014 update, two review authors (SP, SM) independently performed and checked study selection. We contacted trial authors to resolve any ambiguities in the study reports. We compiled and analysed the data. We resolved differences between review authors by discussion and consensus. Main results We included 11 RCTs in this review update (3352 participants older than 12 years with a diagnosis of CAP); 10 RCTs assessed nine antibiotic pairs (3321 participants) and one RCT assessed four antibiotics (31 participants) in people with CAP. The study quality was generally good, with some differences in the extent of the reporting. A variety of clinical, bacteriological and adverse events were reported. Overall, there was no significant difference in the efficacy of the various antibiotics. Studies evaluating clarithromycin and amoxicillin provided only descriptive data regarding the primary outcome. Though the majority of adverse events were similar between all antibiotics, nemonoxacin demonstrated higher gastrointestinal and nervous system adverse events when compared to levofloxacin, while cethromycin demonstrated significantly more nervous system side effects, especially dysgeusia, when compared to clarithromycin. Similarly, high‐dose amoxicillin (1 g three times a day) was associated with higher incidence of gastritis and diarrhoea compared to clarithromycin, azithromycin and levofloxacin. Authors' conclusions Available evidence from recent RCTs is insufficient to make new evidence‐based recommendations for the choice of antibiotic to be used for the treatment of CAP in outpatient settings. Pooling of study data was limited by the very low number of studies assessing the same antibiotic pairs. Individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups. However, two studies did find significantly more adverse events with use of cethromycin as compared to clarithromycin and nemonoxacin when compared to levofloxacin. Multi‐drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations. Further studies focusing on diagnosis, management, cost‐effectiveness and misuse of antibiotics in CAP and LRTI are warranted in high‐, middle‐ and low‐income countries. Plain language summary Antibiotics for community‐acquired pneumonia in adolescent and adult outpatients Review question This review studied the effects of antibiotics on adolescents and adults with pneumonia acquired and treated in the community (as opposed to acquiring pneumonia in hospital and/or being treated for pneumonia in hospital). The evidence is current to March 2014. Background Lower respiratory tract infection is the third leading cause of death worldwide and the first leading cause of death in low‐income countries. Pneumonia, or infection of the lungs, is a common condition representing a significant disease burden for the community. Pneumonia is especially life‐threatening in children younger than five years, in older people and in people with other illnesses that may affect their immune system (such as diabetes or HIV/AIDS, or solid organ transplant recipients). Antibiotics are the most common treatment for pneumonia and these can vary in their effectiveness and adverse effects. Study characteristics We identified 11 trials (with 3352 participants older than 12 years with a diagnosis of community‐acquired pneumonia), fully published in peer‐reviewed journals, focused on treatment of pneumonia in adolescents and adults treated in the community in outpatient settings. This included five new trials included since our last review published in 2009. None of the trials included antibiotics versus placebo; all trials included one or more antibiotics. All participants were diagnosed with pneumonia based upon clinical diagnosis by the physician and chest X‐ray. Study funding sources All included trials were well conducted; nine of the 11 trials were sponsored by bio‐pharmaceutical companies manufacturing the antibiotics used in the study, or their authors were closely linked with the company. Key results Nine of the included trials compared different antibiotics and, hence, we could not combine the results of the individual trials to present our overall conclusion. There were some notable adverse events in seven studies: 1) erythromycin demonstrated significant gastrointestinal side effects compared to clarithromycin in two studies; 2) nemonoxacin demonstrated higher gastrointestinal (nausea, diarrhoea) and nervous system (dizziness, headache) adverse events compared to levofloxacin; 3) cethromycin demonstrated more side effects, especially a distortion of the sense of taste, than clarithromycin; 4) gastritis and diarrhoea were more common in the high‐dose amoxicillin group (1 g three times a day) compared to the other three antibiotic groups (clarithromycin, azithromycin and levofloxacin). Conclusion Unfortunately, there were not enough trials to compare the effects of different antibiotics for pneumonia acquired and treated in the community.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Pakhale, S, Mulpuru, S, Verheij, TJM, Kochen, MM, Rohde, GGU, Bjerre, LM", "articleTypes": [], "doi": "10.1002/14651858.CD002109.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.127Z" }, { "id": "f6ae16d9-ccb5-40ce-82c1-9e2e30936a8d", "pmid": "", "title": "Oral deferiprone for iron chelation in people with thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. A commonly used iron chelator, deferiprone, has been found to be pharmacologically efficacious. However, important questions exist about the efficacy and safety of deferiprone compared to another iron chelator, desferrioxamine. Objectives To summarise data from trials on the clinical efficacy and safety of deferiprone and to compare the clinical efficacy and safety of deferiprone with desferrioxamine for thalassaemia. Search methods We searched the Cochrane Cystic fibrosis and Genetic Disorders Group's Haemoglobinopathies trials Register and MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus registers of ongoing trials and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). We also contacted the manufacturers of deferiprone and desferrioxamine. All searches were updated to 05 March 2013. Selection criteria Randomised controlled trials comparing deferiprone with another iron chelator; or comparing two schedules or doses of deferiprone, in people with transfusion‐dependent thalassaemia. Data collection and analysis Two authors independently assessed trials for risk of bias and extracted data. Missing data were requested from the original investigators. Main results A total of 17 trials involving 1061 participants (range 13 to 213 participants per trial) were included. Of these, 16 trials compared either deferiprone alone with desferrioxamine alone, or a combined therapy of deferiprone and desferrioxamine with either deferiprone alone or desferrioxamine alone; one compared different schedules of deferiprone. There was little consistency between outcomes and limited information to fully assess the risk of bias of most of the included trials. Four trials reported mortality; each reported the death of one individual receiving deferiprone with or without desferrioxamine. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage. Earlier trials measuring the cardiac iron load indirectly by magnetic resonance imaging (MRI) T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, a meta‐analysis of two trials suggested that left ventricular ejection fraction was significantly reduced in patients who received desferrioxamine alone compared with combination therapy. One trial, which planned five years of follow up, was stopped early due to the beneficial effects of combined treatment compared with deferiprone alone in terms of serum ferritin levels reduction. The results of this and three other trials suggest an advantage of combined therapy over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no conclusive or consistent evidence for the improved efficacy of combined deferiprone and desferrioxamine therapy over monotherapy from direct or indirect measures of liver iron. Both deferiprone and desferrioxamine produce a significant reduction in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised controlled trials to suggest that either has a greater reduction of clinically significant end organ damage. Evidence of adverse events were observed in all treatment groups. Occurrence of any adverse event was significantly more likely with deferiprone than desferrioxamine in one trial, RR 2.24 (95% CI 1.19 to 4.23). Meta‐analysis of a further two trials showed a significant increased risk of adverse events associated with combined deferiprone and desferrioxamine compared with desferrioxamine alone, RR 3.04 (95% CI 1.18 to 7.83). The most commonly reported adverse event was joint pain, which occurred significantly more frequently in patients receiving deferiprone than desferrioxamine, RR 2.64 (95% CI 1.21 to 5.77). Other common adverse events included gastrointestinal disturbances as well as neutropenia or leucopenia, or both. Authors' conclusions In the absence of data from randomised controlled trials, there is no evidence to suggest the need for a change in current treatment recommendations; namely that deferiprone is indicated for treating iron overload in people with thalassaemia major when desferrioxamine is contraindicated or inadequate. Intensified desferrioxamine treatment (by either subcutaneous or intravenous route) or use of other oral iron chelators, or both, remains the established treatment to reverse cardiac dysfunction due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently only gave support for deferiprone to be used as a last resort for treating iron overload in thalassaemia, myelodysplasia and sickle cell disease. However, there is evidence that adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcome of deferiprone with desferrioxamine. Plain language summary The use of the iron chelator deferiprone in people with thalassaemia who are dependent on blood transfusions In thalassaemia sometimes the body cannot produce enough haemoglobin. Regular blood transfusions can manage this, but may lead to excess iron in the body, which, if not removed, may damage major organs. Iron chelation therapy removes excess iron; one common chelator is deferiprone. Questions exist about whether deferiprone is as good and safe as the most widely‐used iron chelator, desferrioxamine. Desferrioxamine is administered by a needle under the skin or into a vein, and was the standard monotherapy for 20 years. Seventeen randomised controlled trials compared deferiprone with desferrioxamine. They report little data on death or end organ damage, so we report the effects of therapy using mainly other markers. Removing excess iron was assessed by iron concentration in the blood and liver; heart function; and the amount of iron passed in urine. However, the amount of iron removed with either deferiprone or desferrioxamine was not consistent; one reason being that outcomes were measured differently. This makes it difficult to compare results between trials. Adverse events included joint pain, nausea, stomach upsets and low white blood cell count with deferiprone and pain or skin reactions at the injection site and joint pain with desferrioxamine. In one trial, the risk of an adverse event with deferiprone was twice that of the risk with desferrioxamine. Two further trials showed a three‐fold increased risk of an adverse event with combined deferiprone and desferrioxamine therapy compared with desferrioxamine alone. We found no evidence to change current recommendations to treat iron overload in thalassaemia with deferiprone when desferrioxamine cannot be used or is inadequate. Intensified desferrioxamine treatment or use of other oral iron chelators (or both of these) remains the established treatment to reverse heart problems due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently gave support for deferiprone only to be used as a last resort treatment in patients with thalassaemia, myelodysplasia and sickle cell disease. The danger of raised liver enzymes or a very low white blood cell count with deferiprone means that this treatment should not be used unless close monitoring of full blood counts and liver function is possible. Large trials of chelation therapy with standardised measures of iron stores and end organ damage are needed so valuable trial data can be compared and analysed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA; Brunskill, SJ; Doree, C; Chowdhury, O; Gooding, S; Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004839.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "f6c58b12-7520-45a0-abda-5f7c7f687b96", "pmid": "", "title": "Optimisation of antiretroviral therapy in HIV‐infected children under 3 years of age", "imported": false, "abstract": "Abstract - Background In the absence of antiretroviral therapy (ART), over 50% of HIV‐infected infants progress to AIDS and death by 2 years of age. However, there are challenges to initiation of ART in early life, including the possibility of drug resistance in the context of prevention of mother‐to‐child transmission (PMTCT) programs, a paucity of drug choices , uncertain dosing for some medications and long‐term toxicities. Key management decisions include when to start ART, what regimen to start, and whether and when to substitute drugs or interrupt therapy. This review, an update of a previous review, aims to summarize the currently available evidence on this topic and inform the ART management in HIV‐infected children less than 3 years of age. Objectives To evaluate 1) when to start ART in young children (less than 3 years); 2) what ART to start with, comparing first‐line non‐nucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI)‐based regimens; and 3) whether alternative strategies should be used to optimize antiretroviral treatment in this population: induction (initiation with 4 drugs rather than 3 drugs) followed by maintenance ART, interruption of ART and substitution of PI with NNRTI drugs once virological suppression is achieved on a PI‐based regimen. Search methods Search methods We searched for published studies in the Cochrane HIV/AIDS Review Group Trials Register, The Cochrane Library, Pubmed, EMBASE and CENTRAL. We screened abstracts from relevant conference proceedings and searched for unpublished and ongoing trials in clinical trial registries (ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform). Selection criteria We identified RCTs that recruited perinatally HIV‐infected children under 3 years of age without restriction of setting. We rejected trials that did not include children less than 3 years of age, did not provide stratified outcomes for those less than 3 years or did not evaluate either timing of ART initiation, choice of drug regimen or treatment switch/interruption strategy. Data collection and analysis Two reviewers independently applied study selection criteria, assessed study quality and extracted data. Effects were assessed using the hazard ratio (HR) for time‐to‐event outcomes, relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes. Main results A search of the databases identified a total of 735 unique, previously unreviewed studies, of which 731 were excluded to leave 4 new studies to incorporate into the review. Four additional studies were identified in conference proceedings, for a total of 8 studies addressing when to start treatment (n=2), what to start (n=3), whether to substitute lopinavir/ritonavir (LPV/r) with nevirapine (NVP) (n=1), whether to use an induction‐maintenance ART strategy (n=1) and whether to interrupt treatment (n=1). Treatment initiation in asymptomatic infants with good immunological status was associated with a 75% reduction (HR=0.25; 95%CI 0.12‐0.51; p=0.0002) in mortality or disease progression in the one trial with sufficient power to address this question. In a smaller pilot trial, median CD4 cell count was not significantly different between early and deferred treatment groups 12 months after ART. Regardless of previous exposure to nevirapine for PMTCT, the hazard for treatment failure at 24 weeks was 1.79 (95%CI 1.33, 2.41) times higher in children starting ART with a NVP‐based regimen compared to those starting with a LPV/r‐based regimen (p=0.0001) with no clear difference in the effect observed for children younger or older than 1 year. The hazard for virological failure at 24 weeks was overall 1.84 (95%CI 1.29, 2.63) times higher for children starting ART with a NVP‐based regimen compared to those starting with a LPV/r‐based regimen (p=0.0008) with a larger difference in time to virological failure (or death) between the NVP and LPV/r‐based regimens when ART was initiated in the first year of life. Infants starting a LPV/r regimen and achieving sustained virological suppression who then substituted LPV/r with NVP after median 9 months on LPV/r were less likely to develop virological failure (defined as at least one VL greater than 50 copies/mL) compared with infants who started and stayed on LPV/r (HR=0.62, 95%CI 0.41, 0.92, p=0.02). However the hazard for confirmed failure at a higher viral load (>1000 copies/mL) was greater among children who switched to NVP compared to those who remained on LPV/r (HR=10.19, 95% CI 2.36, 43.94, p=0.002). Children undergoing an induction‐maintenance ART approach with a 4‐drug NNRTI‐based regimen for 36 weeks, followed by 3‐drug ART, had significantly greater CD4 rise than children receiving a standard 3‐drug NNRTI‐based ART at 36 weeks (mean difference 1.70 [95%CI 0.61, 2.79] p=0.002) and significantly better viral load response at 24 weeks (OR 1.99 [95%CI 1.09, 3.62] p=0.02). However, the immunological and virological benefits were short‐term. The one trial of treatment interruption that compared children initiating continuous ART from infancy with children interrupting ART was terminated early because the duration of treatment interruption was less than 3 months in most infants. Children interrupting treatment had similar growth and occurrence of serious adverse events as those in the continuous arm. Authors' conclusions ART initiation in asymptomatic children under 1 year of age reduces morbidity and mortality, but it remains unclear whether there are clinical benefits to starting ART in asymptomatic children diagnosed with HIV infection between 1‐3 years. The available evidence shows that a LPV/r‐based first‐line regimen is more efficacious than a NVP‐based regimen, regardless of PMTCT exposure status. New formulations of LPV/r are urgently required to enable new WHO recommendations to be implemented. An alternative approach to long‐term LPV/r is substituting LPV/r with NVP once virological suppression is achieved. This strategy looked promising in the one trial undertaken, but may be difficult to implement in the absence of routine viral load testing. A 4‐drug induction‐maintenance approach showed short‐term virological and immunological benefits during the induction phase but, in the absence of sustained benefits, is not recommended as a routine treatment strategy. Treatment interruption following early ART initiation in infancy was challenging for children who were severely immunocompromised in the context of poor clinical immunological condition at ART initiation due to the short duration of interruption, and is therefore not practical in ART treatment programmes where close monitoring is not feasible. Plain language summary Using antiretroviral drugs to treat children under 3 years old who have HIV infection Children under 3 years of age who have HIV infection have a high risk of dying without antiretroviral therapy (ART). However, treatment in this age group is challenging because there are high levels of virus in the blood and few suitable drug choices. Results from this systematic review show that ART soon after birth is preferable to delaying treatment, because infants are less likely to die or become sick. Starting a first‐line treatment regimen that includes lopinavir/ritonavir rather than nevirapine is preferable, because infants and young children are less likely to have to stop treatment, whether or not they had previously been exposed to nevirapine. However, lopinavir/ritonavir is more expensive than nevirapine. It is also currently only available as an inconvenient liquid, which tastes bitter and has to be refrigerated, making it challenging to implement in all parts of the world. While waiting for better formulations to become available, it may be possible to switch from lopinavir/ritonavir to nevirapine once the HIV virus levels become undetectable. However, based on the evidence currently available, a viral load test would be required to identify those children who could safely substitute lopinavir/ritonavir with nevirapine. Viral loads are expensive and not widely available in most countries in sub‐Saharan Africa. An alternative treatment approach is to give a stronger drug combination (four different drugs together) when treatment is first started, then reduce down to three drugs after a short while. However, this strategy did not appear to have long‐term benefits. A 'treatment interruption' strategy, in which infants start ART soon after birth but then stop medication after 1‐2 years, is difficult to implement. Children stopping ART need to restart it very quickly to prevent them becoming sick, and monitoring a child off treatment is challenging in settings with few resources.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Penazzato, M, Prendergast, AJ, Muhe, LM, Tindyebwa, D, Abrams, E", "articleTypes": [], "doi": "10.1002/14651858.CD004772.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.816Z" }, { "id": "f6cd7c7e-0861-4383-a62d-c3f1cd954d4b", "pmid": "", "title": "Polyunsaturated fatty acid supplementation for schizophrenia", "imported": false, "abstract": "Abstract - Background Limited evidence supports a hypothesis suggesting that the symptoms of schizophrenia may be the result of altered neuronal membrane structure and metabolism. The structure and metabolism is dependent on blood plasma levels of certain essential fatty acids and their metabolites. Objectives To assess the effects of polyunsaturated fatty acids for people with schizophrenia. Search methods We have updated the initial searches of 1998, 2002 and 2005 with a search of the Cochrane Schizophrenia Group's Register, November 2008, which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. Where necessary, we contacted authors and relevant pharmaceutical companies for additional information. Selection criteria We included all randomised controlled trials of polyunsaturated fatty acid treatment for schizophrenia. Data collection and analysis Working independently, we selected studies for quality assessment and extracted relevant data. We analysed on an intention‐to‐treat basis. Where possible and appropriate we calculated the Relative Risk (RR) and their 95% confidence intervals (CI) and estimated the number needed to treat (NNT). For continuous data we calculated weighted mean differences (WMD) and their 95% confidence intervals. We also inspected the data for heterogeneity. Main results Eight studies are now included in this review. When any dose omega‐3 (E‐EPA or EPA) is compared with placebo, small short trials suggest that the need for neuroleptics appears to be reduced for people allocated omega‐3 supplementation (n=30, 1 RCT, RR 0.73 CI 0.54 to 1.00) and mental state may improve (n=30, 1 RCT, RR not gaining 25% change in PANSS scores 0.54 CI 0.30 to 0.96, NNT 3 CI 2 to 29). There are no differences in the number of people leaving the study early (n=595, 6 RCTs, RR 0.86 CI 0.50 to 1.48). There are few data on the comparison of any dose omega‐6 (GLA) with placebo. For movement disorder outcomes, the one small study we found does not show any difference for average short‐term endpoint AIMS score (n=16, 1 RCT, WMD 1.30 CI ‐1.96 to 4.56). When any dose omega‐3 (E‐EPA or EPA) is compared with any dose omega‐3 (DHA) there is no significant difference for mental state outcome of not gaining 25% change in PANSS scores (n=31, 1 RCT, RR 0.66 CI 0.39 to 1.11). When different doses of omega‐3 (E‐EPA) are compared with placebo there are no differences in measures of global and mental state between the studies. For the outcome of 'experiencing at least one adverse effect' no differences between groups are found for any dose (1 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.97 CI 0.60 to 1.56; 2 g/day E‐EPA vs placebo n=63, 1 RCT, RR 0.67 CI 0.37 to 1.20; 4 g/day E‐EPA vs placebo n=58, 1 RCT, RR 1.15 CI 0.72 to 1.82). Authors' conclusions Three updates of this review have resulted in more included studies and more people randomised but still relatively little useful additional data. The results remain inconclusive. The new trials all compare the omega‐3 polyunsaturated fatty acids, in particular eicosapentaenoic acid and its ester, ethyl‐eicosapentaenoic acid. The use of omega‐3 polyunsaturated fatty acids for schizophrenia still remains experimental and this review highlights the need for large, well designed, conducted and reported studies. Plain language summary Polyunsaturated fatty acid supplementation for schizophrenia Schizophrenia is a serious mental health problem that affects about one percent of any population. For some people it can become an illness that they have to live with for their entire life. Early research has suggested that supplementing the diet with omega 3 or omega 6 fatty acids may have a positive effect on the symptoms of schizophrenia. This review looks at randomised control trials where omega 3 or omega 6 were used in combination with antipsychotic medication, or as a treatment in their own right for schizophrenia. Eight studies were found which included a total of 517 people who had a diagnosis of schizophrenia or schizoaffective disorder (combined symptoms of schizophrenia and a mood disorder). They ranged from six to 16 weeks in length and were in both hospital and community settings. The majority of the trials compared two different types of omega 3 fatty acids, EPA (usually as E‐EPA) and DHA with placebo, in people with schizophrenia who are stable on antipsychotic medication. Some of these trials show some improvement in general functioning and in mental state but not to a statistically significant degree. In the longest trial there was no difference between the two groups at the end of the study. One trial compared E‐EPA with DHA and found a suggestion that E‐EPA works better than DHA, but again it was not statistically significant. Where EPA was compared to placebo as a first line treatment for schizophrenia (30 people), those taking EPA had a better overall outcome and improvement in mental state. However, this was a short trial with few people. Finally, one trial compared a type of omega 6 with placebo in men who had the movement disorder tardive dykinesia (16 people). There was no improvement in the symptoms of movement adverse effects in either group at the end of six weeks. These trials were both small and short. In addition most of the data they reported were not able to be used, and half of the trials were funded by the group supplying the trial medication. Therefore it is still not clear whether taking manufactured omega 3 or 6 improves overall functioning or mental state in people with schizophrenia. (Plain language summary prepared for this review by Janey Antoniou of RETHINK, UK www.rethink.org )", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Irving, CB, Mumby‐Croft, R, Joy, LA", "articleTypes": [], "doi": "10.1002/14651858.CD001257.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.769Z" }, { "id": "f6d35667-9031-4220-8f7a-eaae0a8d0c63", "pmid": "", "title": "The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement", "imported": false, "abstract": "Abstract - Background The World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework is an holistic, settings‐based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed. Objectives To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well‐being of students and their academic achievement. Search methods We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov , Current controlled trials , and WHO International Clinical Trials Registry Platform . We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles. Selection criteria We included cluster‐randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school’s ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements. Data collection and analysis At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random‐effects meta‐analyses to provide a summary of results across studies. Main results We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand‐washing (2), multiple risk behaviours (7), cycle‐helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self‐reported data and high attrition rates for some studies. In addition, there was a lack of long‐term follow‐up data for most studies. We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta‐analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school‐related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement. Authors' conclusions The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well‐designed research is required to establish the effectiveness of this approach for other health topics and academic achievement. Plain language summary The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement Background Health and education are strongly connected: healthy children achieve better results at school, which in turn are associated with improved health later in life. This relationship between health and education forms the basis of the World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework, an approach to promoting health in schools that addresses the whole school environment. Although the HPS framework is used in many schools, we currently do not know if it is effective. This review aimed to assess whether the HPS framework can improve students’ health and well‐being and their performance at school. Study characteristics We searched 20 health, education, and social science databases, as well as trials registries and relevant websites, for cluster‐randomised controlled trials of school‐based interventions aiming to improve the health of young people aged four to 18 years. We only included trials of programmes that addressed all three points in the HPS framework: including health education in the curriculum; changing the school’s social or physical environment, or both; and involving students’ families or the local community, or both. Key results We found 67 trials, comprising 1345 schools and 98 districts, that fulfilled our criteria. These focused on a wide range of health topics, including physical activity, nutrition, substance use (tobacco, alcohol, and drugs), bullying, violence, mental health, sexual health, hand‐washing, cycle‐helmet use, sun protection, eating disorders, and oral health. For each study, two review authors independently extracted relevant data and assessed the risk of the study being biased. We grouped together studies according to the health topic(s) they focused on. We found that interventions using the HPS approach were able to reduce students’ body mass index (BMI), increase physical activity and fitness levels, improve fruit and vegetable consumption, decrease cigarette use, and reduce reports of being bullied. However, we found little evidence of an effect on BMI when age and gender were taken into account (zBMI), and no evidence of effectiveness on fat intake, alcohol and drug use, mental health, violence, and bullying others. We did not have enough data to draw conclusions about the effectiveness of the HPS approach for sexual health, hand‐washing, cycle‐helmet use, eating disorders, sun protection, oral health or academic outcomes. Few studies discussed whether the health promotion activities, or the collection of data relating to these, could have caused any harm to the students involved. Quality of the evidence Overall, the quality of evidence was low to moderate. We identified some problems with the way studies were conducted, which may have introduced bias, including many studies relying on students’ accounts of their own behaviours (rather than these being measured objectively) and high numbers of students dropping out of studies. These problems, and the small number of studies included in our analysis, limit our ability to draw clear conclusions about the effectiveness of the HPS framework in general. Conclusions Overall, we found some evidence to suggest the HPS approach can produce improvements in certain areas of health, but there are not enough data to draw conclusions about its effectiveness for others. We need more studies to find out if this approach can improve other aspects of health and how students perform at school.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Langford, R; Bonell, CP; Jones, HE; Pouliou, T; Murphy, SM; Waters, E; Komro, KA; Gibbs, LF; Magnus, D; Campbell, R", "articleTypes": [], "doi": "10.1002/14651858.CD008958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.067Z" }, { "id": "f6d5bd8f-e378-4c24-81be-5c2a1320cb75", "pmid": "", "title": "Desferrioxamine mesylate for managing transfusional iron overload in people with transfusion‐dependent thalassaemia", "imported": false, "abstract": "Abstract - Background Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions. Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. Desferrioxamine mesylate (desferrioxamine) is one of the most widely used iron chelators. Substantial data have shown the beneficial effects of desferrioxamine, although adherence to desferrioxamine therapy is a challenge. Alternative oral iron chelators, deferiprone and deferasirox, are now commonly used. Important questions exist about whether desferrioxamine, as monotherapy or in combination with an oral iron chelator, is the best treatment for iron chelation therapy. Objectives To determine the effectiveness (dose and method of administration) of desferrioxamine in people with transfusion‐dependent thalassaemia. To summarise data from trials on the clinical efficacy and safety of desferrioxamine for thalassaemia and to compare these with deferiprone and deferasirox. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We also searched MEDLINE, EMBASE, CENTRAL ( The Cochrane Library), LILACS and other international medical databases, plus ongoing trials registers and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). All searches were updated to 5 March 2013. Selection criteria Randomised controlled trials comparing desferrioxamine with placebo, with another iron chelator, or comparing two schedules or doses of desferrioxamine, in people with transfusion‐dependent thalassaemia. Data collection and analysis Six authors working independently were involved in trial quality assessment and data extraction. For one trial, investigators supplied additional data upon request. Main results A total of 22 trials involving 2187 participants (range 11 to 586 people) were included. These trials included eight comparisons between desferrioxamine alone and deferiprone alone; five comparisons between desferrioxamine combined with deferiprone and deferiprone alone; eight comparisons between desferrioxamine alone and desferrioxamine combined with deferiprone; two comparisons of desferrioxamine with deferasirox; and two comparisons of different routes of desferrioxamine administration (bolus versus continuous infusion). Overall, few trials measured the same or long‐term outcomes. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage; none of these included a comparison with deferasirox. Five trials reported a total of seven deaths; three in patients who received desferrioxamine alone, two in patients who received desferrioxamine and deferiprone. A further death occurred in a patient who received deferiprone in another who received deferasirox alone. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. One trial planned five years of follow up but was stopped early due to the beneficial effects of a reduction in serum ferritin levels in those receiving combined desferrioxamine and deferiprone treatment compared with deferiprone alone. The results of this and three other trials suggest an advantage of combined therapy with desferrioxamine and deferiprone over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no evidence for the improved efficacy of combined desferrioxamine and deferiprone therapy against monotherapy from direct or indirect measures of liver iron. Earlier trials measuring the cardiac iron load indirectly by measurement of the magnetic resonance imaging T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, meta‐analysis of two trials showed a significantly lower left ventricular ejection fraction in patients who received desferrioxamine alone compared with those who received combination therapy using desferrioxamine with deferiprone. Adverse events were recorded by 18 trials. These occurred with all treatments, but were significantly less likely with desferrioxamine than deferiprone in one trial, relative risk 0.45 (95% confidence interval 0.24 to 0.84) and significantly less likely with desferrioxamine alone than desferrioxamine combined with deferiprone in two other trials, relative risk 0.33 (95% confidence interval 0.13 to 0.84). In particular, four studies reported permanent treatment withdrawal due to adverse events from deferiprone; only one of these reported permanent withdrawals associated with desferrioxamine. Adverse events also occurred at a higher frequency in patients who received deferasirox than desferrioxamine in one trial. Eight trials reported local adverse reactions at the site of desferrioxamine infusion including pain and swelling. Adverse events associated with deferiprone included joint pain, gastrointestinal disturbance, increases in liver enzymes and neutropenia; adverse events associated with deferasirox comprised increases in liver enzymes and renal impairment. Regular monitoring of white cell counts has been recommended for deferiprone and monitoring of liver and renal function for deferasirox. In summary, desferrioxamine and the oral iron chelators deferiprone and deferasirox produce significant reductions in iron stores in transfusion‐dependent, iron‐overloaded people. There is no evidence from randomised clinical trials to suggest that any one of these has a greater reduction of clinically significant end organ damage, although in two trials, combination therapy with desferrioxamine and deferiprone showed a greater improvement in left ventricular ejection fraction than desferrioxamine used alone. Authors' conclusions Desferrioxamine is the recommended first‐line therapy for iron overload in people with thalassaemia major and deferiprone or deferasirox are indicated for treating iron overload when desferrioxamine is contraindicated or inadequate. Oral deferasirox has been licensed for use in children aged over six years who receive frequent blood transfusions and in children aged two to five years who receive infrequent blood transfusions. In the absence of randomised controlled trials with long‐term follow up, there is no compelling evidence to change this conclusion. Worsening iron deposition in the myocardium in patients receiving desferrioxamine alone would suggest a change of therapy by intensification of desferrioxamine treatment or the use of desferrioxamine and deferiprone combination therapy. Adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. People treated with all chelators must be kept under close medical supervision and treatment with deferiprone or deferasirox requires regular monitoring of neutrophil counts or renal function respectively. There is an urgent need for adequately‐powered, high‐quality trials comparing the overall clinical efficacy and long‐term outcomes of deferiprone, deferasirox and desferrioxamine. Plain language summary Desferrioxamine mesylate (desferrioxamine) for managing excess iron levels in the blood of people with thalassaemia who depend on blood transfusions Haemoglobin carries oxygen in the blood. In thalassaemia, a genetic disease, sometimes the body cannot produce enough haemoglobin. This can be managed by receiving regular blood transfusions, but may lead to excess iron in the body which must be removed to prevent organ damage. Iron is removed by iron chelation therapy using a substance called an iron chelator. This works by sticking to excess iron molecules in the body. When patients go to the toilet, this excess iron leaves the body. Three iron chelators are commonly used. One (desferrioxamine) is injected and two (deferiprone and deferasirox) are taken orally. Deferasirox is licensed for use in children. Desferrioxamine is inconvenient and expensive; motivating researchers to find safe, effective oral iron chelators. We found 22 randomised controlled trials comparing iron chelators. These do not provide enough information about death or organ damage. However, they showed all three chelators performed similarly well in removing excess iron. Several trials found combining desferrioxamine and deferiprone removed more excess iron than using just one iron chelator. Trials showing side effects must be considered carefully. Side effects with desferrioxamine included pain or skin reactions at the injection site and joint pain. Side effects with deferiprone included joint pain, nausea, stomach upsets and low white blood cell count. Side effects with deferasirox included skin rashes, increases in liver enzymes and reduced kidney function. Low white blood cell count and reduced kidney function are important side effects and in patients receiving deferiprone or deferasirox these should be monitored regularly. Patients were three times more likely to experience a side effect when deferiprone and desferrioxamine were combined, compared with desferrioxamine alone. Three studies showed that patients using deferiprone were two and a half times more likely to have joint pain compared with using desferrioxamine alone. We have found no evidence for changing current treatment recommendations, which state that deferiprone or deferasirox should be used to remove excess iron when desferrioxamine cannot be used or is inadequate. The Food and Drug Administration in the United States of America have approved deferiprone only as \"last resort treatment of iron overload in thalassemia\". Larger randomised control trials of iron chelation therapy are needed, using standardised agreed measures of iron levels and organ damage to allow comparison of such valuable treatments.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Fisher, SA; Brunskill, SJ; Doree, C; Gooding, S; Chowdhury, O; Roberts, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD004450.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "f6d5efba-7283-4fe1-a957-d54f80c7ba51", "pmid": "", "title": "Smell, Taste, Salivary Flow, and Oral Health in Patient Receiving Dialysis: A Before and After Study", "imported": false, "abstract": "Studies show that the change of smell and taste, also dry mouth are the most common symptoms in end stage renal disease patients, the accumulation of uremic toxins would damage the intrinsinc antioxidant systems of the olfactory epithelium and olfactory bulb, which leads to smell dysfunction compared to healthy group. Previous studies show different results about if getting rid of uremic toxins would help improve smell, even if they say olfactory identification is improved after hemodialysis episode, but there's no short term reliability of Sniffin'sticks to prove the credibility of the findings. Reduction of the whole saliva and unstimulated salivary flow rate cause dry mouth, also change oral environment, which makes dental plaque easily attach to teeth. And the accumulation of uremic in oral cavity causes oral odor, plus lack of zinc iron and reduction of saliva would affect the tastants transferred to its receptors which leads to taste dysfunction. Besides, when the patients has olfactory dysfunction, the taste will be affected as well, plus the accumulation of uremic toxin in the oral cavity also stops the conjunction of smell and taste receptors which affects taste. To understand smell, taste and oral condition in end stage renal disease patients, and due to there's no short term reliability of Sniffin'sticks, plus it's expensive and time-consuming to implement the taste assessment tool. Thus the main purpose of this study is: 1. To investigate smell and taste function, salivary secretion, oral condition, plaque index and dry mouth in end stage renal disease patients who haven't been under hemodialysis. 2. To investigate the short term reliability of Sniffin'sticks, the measuring tool of olfactory with 3-4 hours interval. 3. To investigate if Taste and Smell Survey could be the tool which detects abnormality of taste 4. To investigate the change of smell, taste and salivary secretion within 24 hours after the first episode of hemodialysis.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.256Z" }, { "id": "f6e9a0d0-bf40-4a4d-be32-f329acc6dd91", "pmid": "", "title": "Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders", "imported": false, "abstract": "Abstract - Background About 5% of school children have a specific learning disorder, defined as unexpected failure to acquire adequate abilities in reading, writing or mathematics that is not a result of reduced intellectual ability, inadequate teaching or social deprivation. Of these events, 80% are reading disorders. Polyunsaturated fatty acids (PUFAs), in particular, omega‐3 and omega‐6 fatty acids, which normally are abundant in the brain and in the retina, are important for learning. Some children with specific learning disorders have been found to be deficient in these PUFAs, and it is argued that supplementation of PUFAs may help these children improve their learning abilities. Objectives 1. To assess effects on learning outcomes of supplementation of polyunsaturated fatty acids (PUFAs) for children with specific learning disorders.
 2. To determine whether adverse effects of supplementation of PUFAs are reported in these children. Search methods In November 2015, we searched CENTRAL, Ovid MEDLINE, Embase, PsycINFO, 10 other databases and two trials registers. We also searched the reference lists of relevant articles. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing PUFAs with placebo or no treatment in children younger than 18 years with specific learning disabilities, as diagnosed in accordance with the fifth (or earlier) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5), or the 10th (or earlier) revision of the International Classification of Diseases (ICD‐10) or equivalent criteria. We included children with coexisting developmental disorders such as attention deficit hyperactivity disorder (ADHD) or autism. Data collection and analysis Two review authors (MLT and KHT) independently screened the titles and abstracts of articles identified by the search and eliminated all studies that did not meet the inclusion criteria. We contacted study authors to ask for missing information and clarification, when needed. We used the GRADE approach to assess the quality of evidence. Main results Two small studies involving 116 children, mainly boys between 10 and 18 years of age, met the inclusion criteria. One study was conducted in a school setting, the other at a specialised clinic. Both studies used three months of a combination of omega‐3 and omega‐6 supplements as the intervention compared with placebo. Although both studies had generally low risk of bias, we judged the risk of reporting bias as unclear in one study, and as high in the other study. In addition, one of the studies was funded by industry and reported active company involvement in the study. None of the studies reported data on the primary outcomes of reading, writing, spelling and mathematics scores, as assessed by standardised tests. Evidence of low quality indicates that supplementation of PUFAs did not increase the risk of gastrointestinal disturbances (risk ratio 1.43, 95% confidence interval 0.25 to 8.15; two studies, 116 children). Investigators reported no other adverse effects. Both studies reported attention deficit hyperactivity disorder (ADHD)‐related behaviour outcomes. We were unable to combine the results in a meta‐analysis because one study reported findings as a continuous outcome, and the other as a dichotomous outcome. No other secondary outcomes were reported. We excluded one study because it used a cointervention (carnosine), and five other studies because they did not provide a robust diagnosis of a specific learning disorder. We identified one ongoing study and found three studies awaiting classification. Authors' conclusions Evidence is insufficient to permit any conclusions about the effect of PUFAs on the learning abilities of children with specific learning disorders. Well‐designed RCTs with clearly defined populations of children with specific learning disorders who have been diagnosed by standardised diagnostic criteria are needed. Plain language summary Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders Review question We reviewed the evidence on the effects of polyunsaturated fatty acids (PUFAs), compared with placebo or no treatment, on reading, writing or mathematical abilities of children up to 18 years of age who have specific learning disorders. Background Children with specific learning disorders are those whose abilities in reading, spelling, writing and mathematics are considerably below what is expected for their age, and whose problems are not a result of lower intelligence, inadequate teaching or social deprivation. A child may have a single disorder, such as a reading disorder, or a combined disorder, such as a reading and mathematics disorder. Children may have other problems too, such as attention deficit hyperactivity disorder (ADHD), along with a specific learning disorder. Polyunsaturated fatty acids are known to be necessary for normal brain development and function. The best known PUFAs are the omega‐3 fatty acids, which include docosahexaenoic acid (commonly known as DHA), but the omega‐6 fatty acids are also well known. Polyunsaturated fatty acids must be obtained from foods or supplements, as the human body cannot make them from other types of fat. Because they are needed for normal brain growth and development, PUFAs might help children with specific learning disorders. Study characteristics The evidence is current to November 2015. We found two small studies involving 116 children that met our inclusion criteria. Both studies gave children a combination of omega‐3 and omega‐6 capsules as the intervention for three months. Most of these studies involved boys between 10 and 18 years of age ‐ one was conducted in a school setting, and the other at a specialised clinic. One of the studies was funded by the company that supplied the omega‐3 and omega‐6 supplements. Another study could not be included in this review because investigators added carnosine (an amino acid that is highly concentrated in the brain) to the PUFAs. Carnosine and PUFAs might have similar effects, so it would not be possible to separate the effects of the two ingredients. Review authors excluded five studies because it was not confirmed that a specific learning disorder was diagnosed in these children. Key results None of the included studies reported effects of PUFAs on reading, writing, spelling or mathematical abilities of children. Evidence of low quality (because studies included few participants and showed evidence of bias) suggests that using PUFAs did not increase the risk of minor disturbances to the digestive system. Included studies reported no other types of adverse effects. Both studies reported on ADHD‐related behaviour. However, the format of available data did not allow us to readily combine them or to reach any conclusions. Included studies reported no other secondary outcomes. Conclusion Evidence is not sufficient to support or refute the use of PUFAs in children with specific learning disorders.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Tan, ML; Ho, JJ; Teh, KH", "articleTypes": [], "doi": "10.1002/14651858.CD009398.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "f6f2cf0e-3b86-420a-aeee-db61e7d8dd99", "pmid": "", "title": "Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery", "imported": false, "abstract": "Abstract - Background Postoperative pain may lead to adverse effects on the body, which might result in an increase in morbidity. Its management therefore poses a unique challenge for the clinician. Major shoulder surgery is associated with severe postoperative pain, and different modalities are available to manage such pain, including opioid and non‐opioid analgesics, local anaesthetics infiltrated into and around the shoulder joint and regional anaesthesia. All of these techniques, alone or in combination, have been used to treat the postoperative pain of major shoulder surgery but with varying success. Objectives The objective of this review was to compare the analgesic efficacy of continuous interscalene brachial plexus block (ISBPB) with parenteral opioid analgesia for pain relief after major shoulder surgery. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12), MEDLINE (1950 to December 2012), EMBASE (1980 to December 2012), Web of Science (1954 to December 2012), CINAHL (1982 to December 2012) and bibliographies of published studies. Selection criteria We included randomized controlled trials assessing the effectiveness of continuous ISBPB compared with different forms of parenteral opioid analgesia in relieving pain in adult participants undergoing elective major shoulder surgery. Data collection and analysis Two review authors independently assessed trial quality and extracted outcome data. Main results We included two randomized controlled trials (147 participants). A total of 17 participants were excluded from one trial because of complications related to continuous ISBPB (16) or parenteral opioid analgesia (one). Thus we have information on 130 participants (66 in the continuous ISBPB group and 64 in the parenteral opioid group). The studies were clinically heterogeneous. No meta‐analysis was undertaken. However, results of the two included studies showed better pain relief with continuous ISBPB following major shoulder surgery and a lower incidence of complications when interscalene block is performed under ultrasound guidance rather than without it. Authors' conclusions Because of the small number of studies (two) relevant to the subject and the high risk of bias of the selected studies, no reasonable conclusion can be drawn. Plain language summary Comparison of an upper limb nerve block using local anaesthetic with opioid analgesia for pain relief following major shoulder surgery Pain following surgical procedures can sometimes increase the incidence of complications in the body. It is important to manage this pain effectively. Major shoulder surgery can cause severe pain. Effectively treating this pain will help reduce complications and will promote early mobilization. A wide range of methods are used to treat pain after major shoulder surgery, including administration of opioid (derived from opium) and non‐opioid pain killers and administration of drugs that produce numbness and hence pain relief in and around the shoulder joint or around the nerves supplying the upper limb. We compared the usefulness of a continuous upper limb nerve block performed by injecting local anaesthetic into the neck close to where the nerves originate (interscalene brachial plexus block—ISBPB group) with the administration of opioid pain killers into a vein, into a muscle or under the skin (any route other than by mouth)—the parenteral opioid group. Evidence obtained is current to December 2012. We included two studies involving 147 participants. Seventeen participants were excluded (16 from the ISBPB group and one from the other), leaving 130 participants: 66 in the ISBPB group and 64 in the parenteral opioid group. The studies were of medium to low quality because of issues with study design, and one of the trials was sponsored by a drug company. The severity of pain was assessed by the patient using a numerical scale on which zero was considered as no pain and 10 or 100 as the worst imaginable pain for 72 hours in one study and 48 hours in the other. The severity of postoperative pain was significantly less for the ISBPB group at all time points in one study and at all but one time point in the other study. No concrete conclusions can be drawn because of the small number of studies, which were not of high quality. However, from the available evidence, it can be seen that in one of the trials, the requirement for additional painkiller (piritramide) was significantly higher in the parenteral opioid group, whereas the other trial did not mention this. The incidence of nausea and vomiting was significantly less in the ISBPB group when compared with the parenteral opioid group. Complications related to ISBPB were virtually eliminated when ultrasound was used to perform ISBPB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Ullah, H, Samad, K, Khan, FA", "articleTypes": [], "doi": "10.1002/14651858.CD007080.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.735Z" }, { "id": "f6f2ef94-dad2-43d1-8cf0-b683ec6e9a91", "pmid": "", "title": "Padma 28 for intermittent claudication", "imported": false, "abstract": "Abstract - Background Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease that develops in a limb during exercise and is relieved with rest. Most drug treatments of IC have a limited effect in improving walking distance. Padma 28, a Tibetan herbal preparation, has been used to treat IC, but there is debate as to whether Padma 28 produces a clinical benefit beyond the placebo effect. This is an update of a review first published in 2013. Objectives To determine whether Padma 28 is effective, compared with placebo or other medications, in increasing pain‐free and maximum walking distance for patients with intermittent claudication. Search methods For this update the Cochrane Vascular Trials Search Co‐ordinator searched the Specialised Register (September 2015), the Cochrane Register of Studies ((CENTRAL) (2015, Issue 8)) and clinical trials databases. Selection criteria Randomised controlled trials of Padma 28 compared with placebo or other pharmacological treatments in people suffering from IC. Data collection and analysis All review authors independently assessed the selected studies and extracted the data. Risk of bias was evaluated independently by two review authors. Depending on the data provided in the individual trials, we extracted mean or median walking distance at the end of the trial, or change in walking distance over the course of the trial, or both. Where not provided, and whenever possible, the statistical significance of differences in these parameters between treatment and placebo groups in individual trials was calculated. Where possible, data were combined by meta‐analysis. Main results No new trials were identified in the search for this review update. In total five trials involving 365 participants were included in this review. All trials compared Padma 28 with placebo for at least 16 weeks of follow‐up. Pain‐free and maximum walking distances both increased significantly in the groups treated with Padma 28, with no significant change in the placebo group. In general, the studies presented results comparing the treatment arms before and after treatment but made no comparisons between the Padma 28 and placebo groups. Pooled data of maximum walking distance after treatment with Padma 28 and placebo from two studies (193 participants) indicated a higher maximum walking distance (mean difference (MD) 95.97 m, 95% confidence interval (CI) 79.07 m to 112.88 m, P < 0.00001, very low quality evidence) in the Padma 28 group compared with placebo. The clinical importance of these observed changes in walking distance is unclear as no quality of life data were reported. There was no effect on ankle brachial index (ABI): change in ABI values between baseline and six months follow up MD ‐0.01, 95% CI ‐0.07 to 0.05, 1 study, 56 participants, P = 0.72, very low quality evidence). Mild side effects, especially gastrointestinal discomfort, tiredness and skin eruption, were reported but this outcome was not different between the Padma 28 and placebo groups (odds ratio 1.09, 95% CI 0.42 to 2.83, four studies, 231 participants, P = 0.86, very low quality evidence). Authors' conclusions Some evidence exists from individual trials to suggest that Padma 28 may be effective in increasing walking distances, at least in the short term (four months), in people with IC. Side effects do not appear to be a problem. However, the longer term effects of treatment are unknown and the clinical significance of the improvements in walking distance are questionable. Moreover, the quality of the evidence is limited by the small sample size of the available trials, limited reporting of statistical analyses that compared treatment groups, and relatively high withdrawal rates that were linked to the outcome. That is, patients were withdrawn if they failed to improve walking distance. There was also evidence of publication bias. We therefore feel there is currently insufficient evidence to draw conclusions regards the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation. Plain language summary Padma 28 for intermittent claudication Background Intermittent claudication (IC) is pain in the leg that occurs on exercise and is relieved by rest. It is caused by an inadequate blood supply to the legs due to blockage of arteries. Conservative drug treatment is commonly used in an attempt to improve walking distance in these patients. Padma 28 is a Tibetan herbal preparation used for treating intermittent claudication. Study characteristics and key results This review on the effects of Padma 28 includes five trials with a total of 365 participants (current until September 2015). The review showed that Padma 28 has some beneficial effects in improving maximum and pain‐free walking distance. The groups treated with placebo did not show an improved maximum and pain‐free walking distance. Unfortunately the studies reported insufficient data to allow the comparison of the change in walking distances in the Padma 28 group with the change in walking distances in the placebo group. Combining the data of maximum walking distance after treatment in two studies showed that there was a longer maximum walking distance in the Padma 28 group compared with the placebo group after 16 weeks of treatment. No change in ankle brachial pressure was observed. Mild side effects such as gastrointestinal discomfort, tiredness and skin eruption were also noted but these were not different between the Padma 28 and placebo groups. Quality of the evidence Overall, the quality of the studies was low, with evidence of publication bias, small number of trials, limited reporting of the analyses that compared treatment groups and bias due to a high percentage of withdrawals in the placebo groups because of lack of improvement or deterioration of the overall condition. We therefore feel there is currently insufficient evidence to draw conclusions about the effectiveness of Padma 28 in the routine management of IC. Further well‐designed research would be required to determine the true effects of this herbal preparation.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stewart, M; Morling, JR; Maxwell, H", "articleTypes": [], "doi": "10.1002/14651858.CD007371.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "f6fd13fd-7887-4912-aab0-bf5c3c6ead33", "pmid": "", "title": "Pharmacological interventions for smoking cessation: an overview and network meta‐analysis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Cahill, K, Stevens, S, Perera, R, Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD009329.pub2 AB - Abstract - Background Smoking is the leading preventable cause of illness and premature death worldwide. Some medications have been proven to help people to quit, with three licensed for this purpose in Europe and the USA: nicotine replacement therapy (NRT), bupropion, and varenicline. Cytisine (a treatment pharmacologically similar to varenicline) is also licensed for use in Russia and some of the former socialist economy countries. Other therapies, including nortriptyline, have also been tested for effectiveness. Objectives How do NRT, bupropion and varenicline compare with placebo and with each other in achieving long‐term abstinence (six months or longer)?
 How do the remaining treatments compare with placebo in achieving long‐term abstinence?
 How do the risks of adverse and serious adverse events (SAEs) compare between the treatments, and are there instances where the harms may outweigh the benefits? Methods The overview is restricted to Cochrane reviews, all of which include randomised trials. Participants are usually adult smokers, but we exclude reviews of smoking cessation for pregnant women and in particular disease groups or specific settings. We cover nicotine replacement therapy (NRT), antidepressants (bupropion and nortriptyline), nicotine receptor partial agonists (varenicline and cytisine), anxiolytics, selective type 1 cannabinoid receptor antagonists (rimonabant), clonidine, lobeline, dianicline, mecamylamine, Nicobrevin, opioid antagonists, nicotine vaccines, and silver acetate. Our outcome for benefit is continuous or prolonged abstinence at least six months from the start of treatment. Our outcome for harms is the incidence of serious adverse events associated with each of the treatments.
 We searched the Cochrane Database of Systematic Reviews (CDSR) in The Cochrane Library , for any reviews with 'smoking' in the title, abstract or keyword fields. The last search was conducted in November 2012. We assessed methodological quality using a revised version of the AMSTAR scale. For NRT, bupropion and varenicline we conducted network meta‐analyses, comparing each with the others and with placebo for benefit, and varenicline and bupropion for risks of serious adverse events. Main results We identified 12 treatment‐specific reviews. The analyses covered 267 studies, involving 101,804 participants. Both NRT and bupropion were superior to placebo (odds ratios (OR) 1.84; 95% credible interval (CredI) 1.71 to 1.99, and 1.82; 95% CredI 1.60 to 2.06 respectively). Varenicline increased the odds of quitting compared with placebo (OR 2.88; 95% CredI 2.40 to 3.47). Head‐to‐head comparisons between bupropion and NRT showed equal efficacy (OR 0.99; 95% CredI 0.86 to 1.13). Varenicline was superior to single forms of NRT (OR 1.57; 95% CredI 1.29 to 1.91), and to bupropion (OR 1.59; 95% CredI 1.29 to 1.96).
 Varenicline was more effective than nicotine patch (OR 1.51; 95% CredI 1.22 to 1.87), than nicotine gum (OR 1.72; 95% CredI 1.38 to 2.13), and than 'other' NRT (inhaler, spray, tablets, lozenges; OR 1.42; 95% CredI 1.12 to 1.79), but was not more effective than combination NRT (OR 1.06; 95% CredI 0.75 to 1.48). Combination NRT also outperformed single formulations. The four categories of NRT performed similarly against each other, apart from 'other' NRT, which was marginally more effective than NRT gum (OR 1.21; 95% CredI 1.01 to 1.46).
 Cytisine (a nicotine receptor partial agonist) returned positive findings (risk ratio (RR) 3.98; 95% CI 2.01 to 7.87), without significant adverse events or SAEs.
 Across the 82 included and excluded bupropion trials, our estimate of six seizures in the bupropion arms versus none in the placebo arms was lower than the expected rate (1:1000), at about 1:1500. SAE meta‐analysis of the bupropion studies demonstrated no excess of neuropsychiatric (RR 0.88; 95% CI 0.31 to 2.50) or cardiovascular events (RR 0.77; 95% CI 0.37 to 1.59). SAE meta‐analysis of 14 varenicline trials found no difference between the varenicline and placebo arms (RR 1.06; 95% CI 0.72 to 1.55), and subgroup analyses detected no significant excess of neuropsychiatric events (RR 0.53; 95% CI 0.17 to 1.67), or of cardiac events (RR 1.26; 95% CI 0.62 to 2.56).
 Nortriptyline increased the chances of quitting (RR 2.03; 95% CI 1.48 to 2.78). Neither nortriptyline nor bupropion were shown to enhance the effect of NRT compared with NRT alone. Clonidine increased the chances of quitting (RR 1.63; 95% CI 1.22 to 2.18), but this was offset by a dose‐dependent rise in adverse events. Mecamylamine in combination with NRT may increase the chances of quitting, but the current evidence is inconclusive. Other treatments failed to demonstrate a benefit compared with placebo. Nicotine vaccines are not yet licensed for use as an aid to smoking cessation or relapse prevention. Nicobrevin's UK license is now revoked, and the manufacturers of rimonabant, taranabant and dianicline are no longer supporting the development or testing of these treatments. Authors' conclusions NRT, bupropion, varenicline and cytisine have been shown to improve the chances of quitting. Combination NRT and varenicline are equally effective as quitting aids. Nortriptyline also improves the chances of quitting. On current evidence, none of the treatments appear to have an incidence of adverse events that would mitigate their use.
 Further research is warranted into the safety of varenicline and into cytisine's potential as an effective and affordable treatment, but not into the efficacy and safety of NRT. Plain language summary Medications to help people to stop smoking: an overview of reviews Background 
 Smoking is a main cause of early death throughout the world. There are a number of medications which can help people to quit smoking. Three of these, nicotine replacement therapy (NRT), bupropion and varenicline, are licensed for this purpose in the USA and Europe. Cytisine (similar to varenicline) is licensed for use in Russia and Eastern Europe. We reviewed studies of these and other treatments, including nortriptyline, to compare their benefits and risks.
 Methods 
 We found 12 Cochrane reviews of different treatments. The treatments include nicotine replacement therapy (NRT); antidepressants (bupropion and nortriptyline); nicotine receptor partial agonists (varenicline and cytisine); anxiolytics; selective type 1 cannabinoid receptor antagonists (rimonabant); clonidine; lobeline; dianicline; mecamylamine; Nicobrevin; opioid antagonists; nicotine vaccines; and silver acetate. The reviews were conducted between 2008 and 2012, and analysed 267 trials, covering more than 101,000 smokers. All the reviews used randomised controlled trials, and compared the active treatment with a placebo, and sometimes with other treatments. The outcomes were measured at least six months from the start of treatment, and the results were usually checked by testing breath, blood or urine. We also assessed the risk of harms from each treatment. We then compared NRT, bupropion and varenicline with each other, using a network meta‐analysis.
 Results 
 NRT and bupropion helped about 80% more people to quit than placebo; this means that for every 10 people who quit with placebo about 18 could be expected to quit with NRT or with bupropion. Varenicline more than doubled the chances of quitting compared with placebo, so that for every 10 who quit with placebo about 28 could be expected to quit with varenicline.
 Varenicline helped about 50% more people to quit than nicotine patch and 'other' NRT (tablets, sprays, lozenges and inhalers), and about 70% more people than nicotine gum. So for every 10 people who quit with NRT patch or with 'other' NRT, about 15 could be expected to quit with varenicline, and for every 10 who quit with NRT gum about 17 could be expected to quit with varenicline. Combining two type of NRT was as effective as using varenicline, and helped more people to quit than single types of NRT. There was little to choose between different types of NRT, apart from 'other' NRT, which helped slightly more people than nicotine gum; for every 10 people who quit with NRT gum, about 12 could be expected to quit with 'other' NRT.
 NRT combined with nortriptyline or with bupropion was not more effective than NRT alone.
 Both cytisine and nortriptyline compared with placebo improved the chances of quitting, with minimal risk of harms.
 
 Bupropion carries a known risk of seizures (about 1 per 1000 users), but we found fewer than expected in the included and excluded trials, at about 1 in 1500. Although there may be a marginal increase in the likelihood of any serious adverse event while taking bupropion, we did not find increased risks of neuropsychiatric or heart and circulatory problems in the bupropion studies. The evidence for the safety of varenicline is still under investigation; we found no evidence from the trials that it is linked to an increase in neuropsychiatric problems, or with increased heart and circulatory problems.
 
 Clonidine helped people to quit, but caused side effects. It is not clear whether or not mecamylamine used with NRT helps people to quit. Other treatments did not seem to help. So far, nicotine vaccines are not licensed for use anywhere in the world. Nicobrevin is no longer available in the UK, and rimonabant, taranabant and dianicline have all been withdrawn from the market.
 Conclusions 
 NRT, bupropion and varenicline all improve the chances of quitting, with a low risk of harms.
 Combination use of NRT is as effective as varenicline, and more effective than single types of NRT.
 Cytisine has potential as a safe, effective and affordable treatment.
 Nortriptyline improves the chances of quitting, with little evidence of harmful events.
 We need continued monitoring of the safety of varenicline.
 More research into NRT versus placebo is unlikely to change our understanding of the treatment.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.793Z" }, { "id": "f704cd36-a95e-4702-9d88-03159d8e20f6", "pmid": "", "title": "Longitudinal Observation of Clinical and Immunological Profiles After SARS-Cov-2 Infection", "imported": false, "abstract": "There are very few long-term studies that analyze the immune responses in patients recovered from COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.265Z" }, { "id": "f7143636-b015-436b-912c-616dbcc37da6", "pmid": "", "title": "Environmental and behavioural modifications for improving food and fluid intake in people with dementia", "imported": false, "abstract": "Abstract - Background Weight loss, malnutrition and dehydration are common problems for people with dementia. Environmental modifications such as, change of routine, context or ambience at mealtimes, or behavioural modifications, such as education or training of people with dementia or caregivers, may be considered to try to improve food and fluid intake and nutritional status of people with dementia. Objectives Primary: To assess the effects of environmental or behavioural modifications on food and fluid intake and nutritional status in people with dementia. Secondary: To assess the effects of environmental or behavioural modifications in connection with nutrition on mealtime behaviour, cognitive and functional outcomes and quality of life, in specific settings (i.e. home care, residential care and nursing home care) for different stages of dementia. To assess the adverse consequences or effects of the included interventions. Search methods We searched the Specialized Register of Cochrane Dementia and Cognitive Improvement (ALOIS), MEDLINE, Eembase, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 17 January 2018. We scanned reference lists of other reviews and of included articles. Selection criteria We included randomised controlled trials (RCTs) investigating interventions designed to modify the mealtime environment of people with dementia, to modify the mealtime behaviour of people with dementia or their caregivers, or both, with the intention of improving food and fluid intake. We included people with any common dementia subtype. Data collection and analysis Two review authors independently selected studies, extracted data and assessed the risk of bias of included trials. We assessed the quality of evidence for each outcome using the GRADE approach. Main results We included nine studies, investigating 1502 people. Three studies explicitly investigated participants with Alzheimer's disease; six did not specify the type of dementia. Five studies provided clear measures to identify the severity of dementia at baseline, and overall very mild to severe stages were covered. The interventions and outcome measures were diverse. The overall quality of evidence was mainly low to very low. One study implemented environmental as well as behavioural modifications by providing additional food items between meals and personal encouragement to consume them. The control group received no intervention. Differences between groups were very small and the quality of the evidence from this study was very low, so we are very uncertain of any effect of this intervention. The remaining eight studies implemented behavioural modifications. Three studies provided nutritional education and nutrition promotion programmes. Control groups did not receive these programmes. After 12 months, the intervention group showed slightly higher protein intake per day (mean difference (MD) 0.11 g/kg, 95% confidence interval (CI) ‐0.01 to 0.23; n = 78, 1 study; low‐quality evidence), but there was no clear evidence of a difference in nutritional status assessed with body mass index (BMI) (MD ‐0.26 kg/m² favouring control, 95% CI ‐0.70 to 0.19; n = 734, 2 studies; moderate‐quality evidence), body weight (MD ‐1.60 kg favouring control, 95% CI ‐3.47 to 0.27; n = 656, 1 study; moderate‐quality evidence), or score on Mini Nutritional Assessment (MNA) (MD ‐0.10 favouring control, 95% CI ‐0.67 to 0.47; n = 656, 1 study; low‐quality evidence). After six months, the intervention group in one study had slightly lower BMI (MD ‐1.79 kg/m² favouring control, 95% CI ‐1.28 to ‐2.30; n = 52, 1 study; moderate‐quality evidence) and body weight (MD ‐8.11 kg favouring control, 95% CI ‐2.06 to ‐12.56; n = 52, 1 study; moderate‐quality evidence). This type of intervention may have a small positive effect on food intake, but little or no effect, or a negative effect, on nutritional status. Two studies compared self‐feeding skills training programmes. In one study, the control group received no training and in the other study the control group received a different self‐feeding skills training programme. For both comparisons the quality of the evidence was very low and we are very uncertain whether these interventions have any effect. One study investigated general training of nurses to impart knowledge on how to feed people with dementia and improve attitudes towards people with dementia. Again, the quality of the evidence was very low so that we cannot be certain of any effect. Two studies investigated vocal or tactile positive feedback provided by caregivers while feeding participants. After three weeks, the intervention group showed an increase in calories consumed per meal (MD 200 kcal, 95% CI 119.81 to 280.19; n = 42, 1 study; low‐quality evidence) and protein consumed per meal (MD 15g, 95% CI 7.74 to 22.26; n = 42, 1 study; low‐quality evidence). This intervention may increase the intake of food and liquids slightly; nutritional status was not assessed. Authors' conclusions Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia. Plain language summary Environmental and behavioural modifications for improving food and fluid intake in people with dementia What we wanted to know Weight loss, malnutrition and dehydration are common problems for people with dementia and can occur at any stage of the illness. People with dementia often develop psychological symptoms or behaviours which cause them to eat or drink less. In the later stages of the illness, they become dependent on others to help them eat or drink. We wanted to investigate how to keep people with dementia eating and drinking as well as possible. We looked for studies which changed the way food and drink are presented to people with dementia, and for studies which attempted to change the behaviour of people with dementia or of those helping them to eat. We called these environmental and behavioural modifications respectively, though some interventions include aspects of both. We were mainly interested in the effect on how much people with dementia ate and drank and on measures of how well‐nourished they were (e.g. body weight or body mass index (BMI)), but we also looked for effects on eating behaviour, symptoms of dementia and quality of life. How we tried to answer the question We searched for all the randomised controlled trials (RCTs) which were relevant to our question. In these trials, some people with dementia got an environmental or behavioural modification intended to improve their eating and drinking and were then compared with other people who had not had the intervention (the control group). Whether someone got the intervention or not was decided at random. We found nine RCTs to include in our review. In total, there were 1502 people in these trials. They had varying degrees of dementia, probably mostly due to Alzheimer's disease. Seven of the trials took place in care homes. In one trial, people were given extra snacks between meals and encouraged to eat them. In three trials, people with dementia were given education about diet and eating. In two trials, people with dementia were taught skills to help them to eat independently. In three trials, training was given to the carers responsible for helping people with dementia to eat. What we found out All the trials we found tested different interventions and measured their effects in different ways. Generally, the trials were small and there were problems with the way they were done, which reduced our confidence in the results. For some interventions, the quality of the evidence was so low that we could not draw any conclusions. For others, there was a mixture of positive and negative effects. What we concluded Because of the amount and quality of the evidence we found, we cannot at the moment, identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Herke, M; Fink, A; Langer, G; Wustmann, T; Watzke, S; Hanff, AM; Burckhardt, M", "articleTypes": [], "doi": "10.1002/14651858.CD011542.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.080Z" }, { "id": "f714b09f-a39d-4d6a-a997-2d8503024617", "pmid": "", "title": "Topical anaesthetic or vasoconstrictor preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy", "imported": false, "abstract": "Abstract - Background Nasal pharyngolaryngoscopy (NPL) is performed as an outpatient and inpatient procedure on a daily basis, for a variety of indications. It frequently causes some degree of discomfort to the patient. Various different topical agents, which are intended to reduce this discomfort, are in common use. This review aimed to assess the effectiveness of the various agents. Objectives To assess the effectiveness of topical preparations used to reduce discomfort and facilitate NPL in adults. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 14 April 2010. Selection criteria Randomised controlled trials (RCTs) looking at the effect of topical anaesthetic or vasoconstrictor agents used reduce discomfort and facilitate NPL in adult patients. Data collection and analysis Two review authors independently selected studies, extracted data and assessed risk of bias. We contacted trial authors for further information where necessary. The primary outcome measured was pain/discomfort. Secondary outcomes that were looked at included side effects of the topical medications, ease of the procedure and the quality of the view from the operator's perspective. Main results We included eight RCTs (746 participants) in the review. The risk of bias in the studies was generally low. Five studies did not demonstrate any advantage in using a topical treatment prior to endoscopy. One study suggested that a vasoconstrictor alone should be used to reduce the general level of unpleasantness. Two studies did not compare treatment against placebo or no treatment, so it was not possible to draw meaningful conclusions from them. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. There was variation in the format of the outcome data and a lack of complete data; none of the included studies reported their results in a way that would allow pooling and we could not therefore perform meta‐analysis. Authors' conclusions The included studies do not demonstrate any evidence to support the use of topical treatments prior to the use of a fibre‐optic nasal endoscope. Some go as far as to suggest that these agents should not be used due to cost and unpleasant side effects. Five studies did not demonstrate any advantage in terms of reducing pain or discomfort when using a topical treatment prior to endoscopy. The absence of demonstrable effect may be due to relatively small patient groups. It is therefore possible that there is a small effect of using these sprays. Further research using standardised reporting methods is needed. Plain language summary Topical anaesthetic or vasoconstrictor (blood vessel narrowing) preparations for flexible fibre‐optic nasal pharyngoscopy and laryngoscopy Topical medications are often applied to the inside of a patient's nose prior to examining the nose, sinuses and throat with a flexible nasopharyngolaryngoscope. The aim of this is to reduce any discomfort the patient may feel and also to improve the adequacy of the examination. Types of preparation include lidocaine, phenylephrine and lidocaine, oxymetazoline, xylometazoline and cocaine and they are usually administered as a spray, although they may also be in the form of a solution which can be applied to cotton wool and placed in the nasal cavity, or as gels, pastes or creams. We looked for randomised controlled trials comparing any of these topical treatments with placebo, no treatment or another topical treatment in adult patients undergoing nasal pharyngolaryngoscopy (NPL). We included eight studies in the review (with a total of 746 patients). It was not possible to combine data from any of the studies, therefore we assessed the individual study results. Five of the studies did not demonstrate any advantage, in terms of reducing pain or discomfort, of using a topical treatment prior to endoscopy. One of these suggested that a vasoconstrictor (xylometazoline) alone reduced the level of \"general unpleasantness\". Two studies did not compare the treatment against placebo or no treatment. A final study actually suggested an increase in pain with the use of topical agents. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste. Further standardised research is required.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Sunkaraneni, VS; Jones, SEM", "articleTypes": [], "doi": "10.1002/14651858.CD005606.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "f72202a6-bcae-41b3-9e03-64c689e4fda5", "pmid": "", "title": "Adhesives for fixed orthodontic bands", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Millett, DT, Glenny, AM, Mattick, RCR, Hickman, J, Mandall, NA", "articleTypes": [], "doi": "10.1002/14651858.CD004485.pub4 AB - Abstract - Background Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. It has been shown that the quality of treatment result obtained with fixed appliances is much better than with removable appliances. Fixed appliances are, therefore, favoured by most orthodontists for treatment. The success of a fixed orthodontic appliance depends on the metal attachments (brackets and bands) being attached securely to the teeth so that they do not become loose during treatment. Brackets are usually attached to the front and side teeth, whereas bands (metal rings that go round the teeth) are more commonly used on the back teeth (molars). A number of adhesives are available to attach bands to teeth and it is important to understand which group of adhesives bond most reliably, as well as reducing or preventing dental decay during the treatment period. Objectives To evaluate the effectiveness of the adhesives used to attach bands to teeth during fixed appliance treatment, in terms of:
 (1) how often the bands come off during treatment; and
 (2) whether they protect the banded teeth against decay during fixed appliance treatment. Search methods The following electronic databases were searched: Cochrane Oral Health's Trials Register (searched 2 June 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5) in the Cochrane Library (searched 2 June 2016), MEDLINE Ovid (1946 to 2 June 2016) and EMBASE Ovid (1980 to 2 June 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria Randomised and controlled clinical trials (RCTs and CCTs) (including split‐mouth studies) of adhesives used to attach orthodontic bands to molar teeth were selected. Patients with full arch fixed orthodontic appliance(s) who had bands attached to molars were included. Data collection and analysis All review authors were involved in study selection, validity assessment and data extraction without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. Main results Five RCTs and three CCTs were identified as meeting the review's inclusion criteria. All the included trials were of split‐mouth design. Four trials compared chemically cured zinc phosphate and chemically cured glass ionomer; three trials compared chemically cured glass ionomer cement with light cured compomer; one trial compared chemically cured glass ionomer with a chemically cured glass phosphonate. Data analysis was often inappropriate within the studies meeting the inclusion criteria. Authors' conclusions There is insufficient high quality evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth. Further RCTs are required. Plain language summary Adhesives for fixed orthodontic bands There is insufficient evidence to determine the most effective adhesive for attaching orthodontic bands to molar teeth in patients with full arch fixed orthodontic appliances.
 Orthodontic treatment involves using fixed or removable appliances (braces) on teeth to correct their position. It has been shown that the quality of treatment result obtained with fixed dental appliances is much better than with removable appliances. The success of a fixed dental appliance depends on the metal attachments (brackets and bands) being securely attached to the teeth so that they do not become loose during treatment. Brackets are usually attached to teeth other than molars, where bands (metal rings that go round the teeth) are more commonly used. There is insufficient evidence with regard to the most effective adhesive for attaching orthodontic bands to molar teeth.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.752Z" }, { "id": "f738b204-e149-4624-8108-acc5923b6ecb", "pmid": "", "title": "Interventions for the prevention and management of oropharyngeal candidiasis associated with HIV infection in adults and children", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Pienaar, ED, Young, T, Holmes, H", "articleTypes": [], "doi": "10.1002/14651858.CD003940.pub3 AB - Abstract - Background Oral candidiasis (OC) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Left untreated, these lesions contribute considerably to the morbidity associated with HIV infection. Interventions aimed at preventing and treating HIV‐associated oral candidal lesions form an integral component of maintaining the quality of life for affected individuals. Objectives To determine the effects of any intervention in preventing or treating OC in children and adults with HIV infection. Search methods The search strategy was based on that of the Cochrane HIV/AIDS Review Group. The following electronic databases were searched for randomised controlled trials for the years 1982 to 2005: Medline, AIDSearch, EMBASE and CINAHL. The Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectiveness, and the Cochrane Central Register of Controlled Trials (CENTRAL) were also searched through May 2005. The abstracts of relevant conferences, including the International Conferences on AIDS and the Conference on Retroviruses and Opportunistic Infections, as indexed by AIDSLINE, were also reviewed. The strategy was iterative, in that references of included studies were searched for additional references. All languages were included. The updated database search was done for the period 2005 up to 2009. The following databases were searched: Medline, EMBASE, the Cochrane Database of Systematic Reviews , Database of Abstracts of Reviews of Effectivenes s and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library. AIDSearch was not searched for the updated search as it ceased publication during 2008. Selection criteria Randomised controlled trials (RCTs) of palliative, preventative or curative therapy were considered, irrespective of whether the control group received a placebo. Participants were HIV positive adults and children. Data collection and analysis Two authors independently assessed the methodological quality of the trials and extracted data. Study authors were contacted for additional data where necessary. Main results For the first publication of the review in 2006, forty studies were retrieved. Twenty eight trials (n=3225) met inclusion criteria. During the update search for the review a, further six studies were identified. Of these, five met the inclusion criteria and were included in the review. The review now includes 33 studies (n=3445): 22 assessing treatment and 11 assessing prevention of oropharyngeal candidiasis. Six studies were done in developing countries, 16 in the United States of America and the remainder in Europe. Treatment 
 Treatment was assessed in the majority of trials looking at both clinical and mycological cures. In the majority of comparisons there was only one trial. Compared to nystatin, fluconazole favoured clinical cure in adults (1 RCT; n=167; RR 1.69; 95% CI 1.27 to 2.23). There was no difference with regard to clinical cure between fluconazole compared to ketoconazole (2 RCTs; n=83; RR 1.27; 95% CI 0.97 to 1.66), itraconazole (2 RCTs; n=434; RR 1.05; 95% CI 0.94 to 1.16), clotrimazole (2 RCTs; n=358; RR 1.14; 95% CI 0.92 to 1.42) or posaconazole (1 RCT; n=366; RR1.32; 95% CI 0.36 to 4.83). Two trials compared different dosages of fluconazole with no difference in clinical cure. When compared with clotrimazole, both fluconazole (2 RCTs; n=358; RR 1.47; 95% CI 1.16 to 1.87) and itraconazole (1 RCT; n=123; RR 2.20; 95% CI 1.43 to3.39) proved to be better for mycological cure. Both gentian violet (1 RCT; n=96; RR 5.28; 95% CI 1.23 to 22.55) and ketoconazole (1 RCT; n=92; RR 5.22; 95% CI 1.21 to 22.53) were superior to nystatin in bringing about clinical cure. A single trial compared gentian violet with lemon juice and lemon grass with no significant difference in clinical cure between the groups. 
 
 Prevention 
 Successful prevention was defined as the prevention of a relapse while receiving prophylaxis. Fluconazole was compared with placebo in five studies (5 RCTs; n=599; RR 0.61; 95% CI 0.5 to 0.74) and with no treatment in another (1 RCT; n=65; RR 0.16; 95% CI 0.08 to 0.34). In both instances the prevention of clinical episodes was favoured by fluconazole. Comparing continuous fluconazole treatment with intermittent treatment (2 RCTs; n=891; RR 0.65; 95% CI 0.23 to 1.83), there was no significant difference between the two treatment arms. Chlorhexidine was compared with normal saline in a single study with no significant difference between the treatment arms. Authors' conclusions Five new studies were added to the review, but their results do not alter the final conclusion of the review. Implications for practice 
 Due to there being only one study in children, it is not possible to make recommendations for treatment or prevention of OC in children. Amongst adults, there were few studies per comparison. Due to insufficient evidence, no conclusion could be made about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole or ketoconazole with regard to OC prophylaxis. In comparison to placebo, fluconazole is an effective preventative intervention. However, the potential for resistant Candida organisms to develop, as well as the cost of prophylaxis, might impact the feasibility of implementation. No studies were found comparing fluconazole with other interventions. The direction of findings suggests that ketoconazole, fluconazole, itraconazole and clotrimazole improved the treatment outcomes. Implications for research 
 It is encouraging that low‐cost alternatives are being tested, but more research needs to be on in this area and on interventions like gentian violet and other less expensive anti‐fungal drugs to treat OC. More well‐designed treatment trials with larger samples are needed to allow for sufficient power to detect differences in not only clinical, but also mycological, response and relapse rates. There is also a strong need for more research to be done on the treatment and prevention of OC in children as it is reported that OC is the most frequent fungal infection in children and adolescents who are HIV positive. More research on the effectiveness of less expensive interventions also needs to be done in resource‐poor settings. Currently few trials report outcomes related to quality of life, nutrition, or survival. Future researchers should consider measuring these when planning trials. Development of resistance remains under‐studied and more work must be done in this area. It is recommended that trials be more standardised and conform more closely to CONSORT. Plain language summary Interventions for the prevention and management of oral thrush associated with HIV infection in adults and children Oral candidiasis (thrush) associated with human immunodeficiency virus (HIV) infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Interventions aimed at preventing and treating HIV‐associated oral thrush form an integral component of maintaining the quality of life for affected individuals. This review evaluated the effects of interventions in preventing or treating oral thrush in children and adults with HIV infection. Thirty three trials (n=3445) were included. Twenty two trials investigated treatment and eleven trials investigate prevention. There was no difference with regard to clinical cure between fluconazole compared to ketoconazole, itraconazole, clotrimazole and posaconazole. Fluconazole, gentian violet and ketoconazole were superior to nystatin. Compared to placebo and no treatment, fluconazole was effective in preventing clinical episodes from occurring. Continuous fluconazole was better than intermittent treatment. Insufficient evidence was found to come to any conclusion about the effectiveness of clotrimazole, nystatin, amphotericin B, itraconazole, ketoconazole or chlorhexidine with regard to OC prophylaxis.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.777Z" }, { "id": "f744496c-12ef-45bb-976a-42af95701845", "pmid": "", "title": "Misoprostol for intrauterine device placement", "imported": false, "abstract": "Abstract - Rationale Identifying effective approaches to reduce pain and improve providers' ease of intrauterine device (IUD) placement may reduce barriers to IUD access and use. The cervical softening and dilation effects of misoprostol might make IUD placement less painful for women and technically easier for providers. However, evidence suggests that misoprostol does not improve many outcomes and may only be helpful for some patients (e.g. those with a recent failed IUD placement). Objectives To examine the effect of misoprostol for routine IUD placement on patient and provider outcomes compared to placebo or no treatment. Search methods In November 2021 we searched CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ClinicalTrials.gov. We conducted update searches in July 2022 and September 2024. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in July 2025. Eligibility criteria We included randomized controlled trials (RCTs) of women undergoing interval IUD placement (i.e. placement outside the postabortion or postpartum period) that compared misoprostol to placebo or no treatment. We included trials that examined the placement of currently available levonorgestrel (LNG)‐releasing IUDs, or any copper T IUD, for women of any age, of any parity, and for any indication. Outcomes Our core critical and important outcomes were pain (during tenaculum placement, during IUD placement, and after IUD placement before clinic discharge); providers' ease of placement; need for cervical dilation; placement success; patient satisfaction; misoprostol side effects (preplacement abdominal pain or cramping, and diarrhea); and adverse events (vasovagal reaction). Risk of bias We used the Risk of Bias 2 tool (RoB 2) to assess the risk of bias for outcomes. Synthesis methods We synthesized results for each outcome using meta‐analysis. We calculated mean differences (MD) for continuous outcomes using inverse variance estimation and random‐effects models. We calculated risk ratios (RR) for dichotomous outcomes using Mantel‐Haenszel estimation and random‐effects models. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included 14 RCTs with a total of 1972 women. The trials were conducted in North America, South America, Europe and Africa, and were published between 2007 and 2022. Synthesis of results The results below summarize the effect of misoprostol on outcomes compared to placebo or no treatment. Pain: misoprostol results in little to no difference in pain during tenaculum placement (MD −0.73, 95% confidence interval [CI] −1.19 to −0.28; 3 RCTs, 261 women; high‐certainty evidence) and after IUD placement before clinic discharge (MD −0.01, 95% CI −0.45 to 0.43; 5 RCTs, 448 women; high‐certainty evidence). Misoprostol may result in little to no difference in pain during IUD placement (MD −0.47, 95% CI −1.23 to 0.29; 7 RCTs, 766 women; low‐certainty evidence). Providers' ease of placement: misoprostol may result in little to no difference in a clinically meaningful effect on ease of IUD placement for providers (MD −0.89, 95% CI −1.55 to −0.22; 8 RCTs, 848 women; low‐certainty evidence). Need for cervical dilation: misoprostol may result in little to no difference in need for cervical dilation for women without a recent failed placement attempt (RR 0.84, 95% CI 0.38 to 1.85; 6 RCTs, 562 women; low‐certainty evidence). Misoprostol probably results in little to no difference in need for cervical dilation for women with a recent failed placement attempt (RR 0.88, 95% CI 0.56 to 1.36; 1 RCT, 90 women; moderate‐certainty evidence). Placement success: misoprostol probably results in little to no difference in placement success for women without a recent failed placement attempt (RR 1.01, 95% CI 0.98 to 1.04; 12 RCTs, 1579 women; moderate‐certainty evidence) but probably results in a slight increase in placement success for women with a recent failed placement attempt (RR 1.41, 95% CI 1.09 to 1.83; 1 RCT, 90 women; moderate‐certainty evidence). Patient satisfaction: misoprostol may increase women's satisfaction with the IUD placement procedure, but the evidence is very uncertain (MD 2.00, 95% CI −0.05 to 4.06; 2 RCTs, 226 women; very low‐certainty evidence) Misoprostol side effects before clinic discharge: misoprostol probably results in an increase in preplacement abdominal pain or cramping (RR 2.14, 95% CI 1.42 to 3.23; 7 RCTs, 781 women; moderate‐certainty evidence)and probably results in a slight increase in diarrhea (RR 1.76, 95% CI 1.01 to 3.06; 9 RCTs, 940 women; moderate‐certainty evidence). Adverse events before clinic discharge: misoprostol may result in little to no difference in vasovagal reaction (RR 0.94, 95% CI 0.37 to 2.37; 6 RCTs [3 RCTs had 0 events], 780 women; low‐certainty evidence). We downgraded the evidence due to serious concerns about inconsistency and serious or very serious concerns about imprecision. Authors' conclusions Evidence from RCTs of women seeking routine IUD placement suggests that receiving misoprostol compared to placebo or no treatment makes little to no difference to pain during tenaculum placement or after IUD placement; and may make little to no difference to pain during IUD placement. Misoprostol may make little to no difference to reduced vasovagal reaction, improved providers' ease of placement, or reduced need for cervical dilation; and probably makes little to no difference to placement success, except for women with a recent failed IUD placement attempt, where misoprostol probably leads to a clinically meaningful increase in placement success. Misoprostol use probably leads to clinically important increases in harms, specifically preplacement abdominal pain or cramping and diarrhea. Misoprostol may increase patient satisfaction with the IUD placement procedure, but the evidence is very uncertain. The number of available RCTs did not support examining effect modifiers such as prior vaginal delivery status, misoprostol dose, or IUD type. Funding This review was supported in part by an appointment to the Research Participation Program at the Centers for Disease Control and Prevention (CDC) administered by the Oak Ridge Institute for Science and Education. Registration Protocol (2022): doi.org/10.1002/14651858.CD015584 Plain language summary Is misoprostol an effective treatment for routine intrauterine device (IUD) placement and does it cause unwanted effects? Key messages Using misoprostol (a medication that softens and widens the cervix ‐ the neck of the womb) before placing an intrauterine device (IUD ‐ a contraceptive device placed inside the womb) makes little to no difference to pain when a tool (a tenaculum) is used to hold the cervix in place during IUD placement or pain after IUD placement. It may make little to no difference to pain during placement, ease of placement for providers, or need for cervical widening; and probably makes little to no difference to placement success, except for women who recently tried unsuccessfully to have an IUD placed. Misoprostol‐related unwanted effects like stomach cramps and diarrhea probably increase, but it may make little to no difference to other unwanted events. We don't know whether misoprostol use affects women's satisfaction with the procedure. What is an intrauterine device? An intrauterine device (IUD) is a small t‐shaped device inserted through the cervix (the neck of the womb) into the womb to prevent pregnancy. IUDs need to be placed by a trained doctor, nurse, or healthcare provider. IUD placement may be a painful procedure, and it may be more difficult for women who have not had a baby or who have already tried unsuccessfully to have an IUD placed. Serious unwanted events are rare with IUD placement but women may experience non‐serious unwanted effects similar to period pain (cramps) or light bleeding. What is misoprostol? Misoprostol is a medication that is commonly used to start labor and to treat bleeding following birth. It causes the cervix to soften and widen, and so might make IUD placement less painful for women and easier for providers. Misoprostol may cause some unwanted effects like cramps, sickness or diarrhea. Sometimes women may feel dizzy, sweaty or light‐headed. An IUD is an effective and reversible contraceptive method, so identifying ways to reduce pain and improve ease of placement for providers may reduce barriers to IUD access and use. What did we want to find out? We wanted to find out if misoprostol reduces pain, makes IUD placement easier for providers, reduces the need for other methods to widen the cervix, improves placement success and women's satisfaction with the procedure, and whether it causes unwanted effects. What did we do? We searched for studies that examined misoprostol for routine IUD placement compared to placebo (a sham medication) or no treatment. We combined and analyzed the studies' results and rated our confidence in the evidence, based on factors such as study methods. What did we find? We found 14 RCTs with 1972 women. The studies took place in North America, South America, Europe, and Africa. All the studies compared misoprostol with placebo or no treatment. Main results Pain. Misoprostol: results in little to no difference in pain during tenaculum placement (a tenaculum is a tool that holds the cervix in place during IUD placement) (3 studies, 261 women); may result in little to no difference in pain during IUD placement (7 studies, 766 women); results in little to no difference in pain after IUD placement before leaving the clinic (5 studies, 448 women). Providers' ease of placing the IUD Misoprostol may result in little to no difference in ease of IUD placement for providers (8 studies, 848 women). Need for cervical dilation. Misoprostol: may result in little to no difference in the need for cervical widening for women without a recent failed placement attempt (6 studies, 562 women); probably results in little to no difference in the need for cervical widening for women with a recent failed placement attempt (1 study, 90 women). Placement success. Misoprostol: probably results in little to no difference in placement success for women without a recent failed placement attempt (12 studies, 1579 women); probably results in a slight increase in placement success for women with a recent failed placement attempt (1 study, 90 women). Patient satisfaction We are not sure whether misoprostol increases patient satisfaction with the IUD placement procedure (2 studies, 226 women). Unwanted effects. Misoprostol: probably results in an increase in stomach cramps (7 studies, 781 women); probably results in a slight increase in diarrhea (9 studies, 940 women); may result in little to no difference in dizziness or light‐headedness (6 studies, 780 women). What are the limitations of the evidence? Some studies did not report key information about what we wanted to know, and some studies were different from each other, so we couldn't include them in our analyses. We had planned to examine whether certain factors affected the results, such as whether women had previously given birth vaginally, the dose of misoprostol used, or the type of IUD placed, but there were not enough studies to do this in a meaningful way. How up to date is this evidence? The evidence is up to date to 23 September 2024.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Zapata, LB; Snyder, E; Nguyen, AT; Kapp, N; Ti, A; Whiteman, MK; Curtis, KM", "articleTypes": [], "doi": "10.1002/14651858.CD015584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "f7456af9-144f-4abb-8287-c6a24afddb6b", "pmid": "", "title": "Parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy", "imported": false, "abstract": "Abstract - Background This is an updated version of the original Cochrane review on parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy (published in Issue 3, 2007). Salivary gland dysfunction is a predictable side effect of radiotherapy to the head and neck region. Pilocarpine hydrochloride (a choline ester) is licensed in many countries for the treatment of radiation‐induced salivary gland dysfunction. Other parasympathomimetics have also been used 'off licence' in the treatment of this condition. Objectives To determine the efficacy and tolerability of parasympathomimetic drugs in the treatment of radiation‐induced salivary gland dysfunction (specifically radiation‐induced xerostomia). Search methods For this update, we ran searches of the Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 6), MEDLINE, EMBASE, and CINAHL in July 2015. We checked the reference lists of retrieved articles for additional studies, contacted experts in the field for unpublished and ongoing trials, and contacted relevant pharmaceutical companies for unpublished and ongoing trials. Selection criteria The selection criteria for the review were: 1) randomised controlled trials; 2) people suffering from radiation‐induced salivary gland dysfunction; 3) people treated with parasympathomimetic drugs; and 4) assessable data available on primary outcome measure. Data collection and analysis The two review authors independently collected data from the full‐text version of relevant papers including: 1) citation details; 2) participants; 3) interventions; 4) assessments; 5) outcomes (that is efficacy, tolerability); and 6) quality issues. Due to a lack of appropriate data, we were unable to perform a meta‐analysis. Main results In the original review, three studies, including a total of 298 participants, fulfilled the inclusion criteria. All three studies involved the use of pilocarpine hydrochloride. We have included no additional studies in the update of the review; we have excluded eight additional studies. The data suggest that pilocarpine hydrochloride is more effective than placebo and at least as effective as artificial saliva. The response rate was 42% to 51%. The time to response was up to 12 weeks. The overall side effect rate was high, and side effects were the main reason for withdrawal (6% to 15% of participants taking 5 mg three times a day had to withdraw). The side effects were usually the result of generalised parasympathomimetic stimulation (for example sweating, headaches, urinary frequency, vasodilatation). Response rates were not dose dependent, but side effect rates were dose dependent. Authors' conclusions There is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced xerostomia. Currently, there is little evidence to support the use of other parasympathomimetic drugs in the treatment of radiation‐induced xerostomia. Available studies suggest that approximately half of patients will respond, but side effects can be problematic. The conclusions of the update are the same as the conclusions of the original review, since no new relevant studies have been published in the interim. Plain language summary Parasympathomimetic drugs for the treatment of 'dry mouth' due to radiotherapy This updated review found there is limited evidence to support the use of pilocarpine hydrochloride in the treatment of radiation‐induced salivary gland dysfunction ('dry mouth'). Salivary gland damage is a frequent and important complication of radiotherapy to the head and neck area; it causes dryness of the mouth with resultant problems with eating, talking, and local infection. The parasympathomimetic group of drugs have been used to treat radiotherapy‐induced salivary gland damage. We identified three studies that involved a total of 289 participants, and they all used the drug pilocarpine. The review found that 42% to 51% of participants (4 to 5 in 10) responded to pilocarpine, although in some participants the response did not occur for up to 12 weeks. Pilocarpine was more effective than a placebo treatment, and at least as effective as an artificial saliva. Side effects were common with pilocarpine (for example sweating, headache, passing urine frequently, flushing), but were usually reported to be mild; 6% to 15% (0.6 to 1.5 in 10) participants had to stop taking pilocarpine due to side effects. The findings of this review are limited by the small number of good‐quality trials that have been performed in this area. The update of this review did not find any new information on this topic.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Davies, AN; Thompson, J", "articleTypes": [], "doi": "10.1002/14651858.CD003782.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "f7571c7a-ec82-4130-9692-560d03cf5f1e", "pmid": "", "title": "Listening to music for insomnia in adults", "imported": false, "abstract": "Abstract - Background Insomnia is a common problem in modern society. It is associated with reduced quality of life and impairments in physical and mental health. Listening to music is widely used as a sleep aid, but it remains unclear if it can actually improve insomnia in adults. This Cochrane Review is an update of a review published in 2015. Objectives To assess the effects of listening to music on sleep in adults with insomnia and to assess the influence of specific variables that may moderate the effect . Search methods For this update, we searched CENTRAL, MEDLINE, Embase, nine other databases and two trials registers up to December 2021. In addition, we handsearched reference lists of included studies, and contacted authors of published studies to identify additional studies eligible for inclusion, including any unpublished or ongoing trials. Selection criteria Randomised controlled trials comparing the effects of listening to music with no treatment or treatment as usual (TAU) in adults complaining of sleep difficulties. Data collection and analysis Two review authors independently screened records for eligibility, selected studies for inclusion, extracted data and assessed risk of bias of the included studies. We assessed the certainty of the evidence using GRADE. The primary outcomes were sleep quality, insomnia severity, sleep‐onset latency, total sleep time, sleep interruption, sleep efficiency and adverse events. Data on the predefined outcome measures were included in meta‐analyses when consistently reported by at least two studies that were homogeneous in terms of participants, interventions and outcomes. We undertook meta‐analyses using random‐effects models. Main results We included 13 studies (eight studies new to this update) comprising 1007 participants. The studies examined the effect of listening to prerecorded music daily, for 25 to 60 minutes, for a period of three days to three months. The risk of bias within the studies varied, with all studies being at high risk of performance bias, because of limited possibilities to blind participants to the music intervention. Some studies were at high risk of detection bias or other bias. Four studies reported funding from national research councils, three studies reported financial support from university sources and one study reported a grant from a private foundation. Five studies did not report any financial support. At the end of the intervention, we found moderate‐certainty evidence for improved sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI) in themusic groups compared to no intervention or TAU (mean difference (MD) −2.79, 95% confidence interval (CI) −3.86 to −1.72; 10 studies, 708 participants). The PSQI scale ranges from 0 to 21 with higher scores indicating poorer sleep. The size of the effect indicates an increase in sleep quality of the size of about one standard deviation in favour of the intervention. We found no clear evidence of a difference in the effects of listening to music compared to no treatment or TAU on insomnia severity (MD −6.96, 95% CI −15.21 to 1.28; 2 studies, 63 participants; very low‐certainty evidence). We found low‐certainty evidence that, compared to no treatment or TAU, listening to music may reduce problems with sleep‐onset latency (MD −0.60, 95% CI −0.83 to −0.37; 3 studies, 197 participants), total sleep time (MD −0.69, 95% CI −1.16 to −0.23; 3 studies, 197 participants) and sleep efficiency (MD −0.96, 95% CI −1.38 to −0.54; 3 studies, 197 participants), but may have no effect on perceived sleep interruption (MD −0.53, 95% CI −1.47 to 0.40; 3 studies, 197 participants). In addition, three studies (136 participants) included objective measures of sleep‐onset latency, total sleep time, sleep efficiency and sleep interruption and showed that listening to music may not improve these outcomes compared to no treatment or TAU. None of the included studies reported any adverse events. Authors' conclusions The findings of this review provide evidence that music may be effective for improving subjective sleep quality in adults with symptoms of insomnia. More research is needed to establish the effect of listening to music on other aspects of sleep as well as the daytime consequences of insomnia. Plain language summary Music for insomnia in adults Review question This review assessed the effects of listening to music on insomnia (sleep problems) in adults and the impact of factors that may influence the effect. Key messages We found a beneficial effect of music on sleep quality. For all the other outcomes, we did not find enough good‐quality evidence as there were too few participants and the people doing the scoring of the data were aware of the treatment. What is insomnia? Worldwide, millions of people experience insomnia. People can have difficulties getting to sleep, staying asleep or may experience poor sleep quality. Poor sleep affects people's physical and mental health. The consequences of poor sleep are costly, for both individuals and society. Many people listen to music to improve their sleep, but the effect of listening to music is unclear. What did we do? We searched electronic databases to identify relevant studies. We included 13 studies with 1007 participants. The studies compared the effect of listening to music to treatment as usual or no treatment. Treatment as usual could be sleep hygiene education (learning a set of rituals to help with sleep) or standard care for participants with insomnia related to chronic medical conditions. The studies examined the effect of listening to prerecorded music daily, for 25 to 50 minutes, for three days to three months. Seven of the included studies reported funding from national research councils or university sources, and one study reported funding from a private foundation. Five studies did not report any funding sources. What did we find? Ten studies measured sleep quality, and the results showed that music probably facilitates a large improvement in the quality of sleep compared to no treatment or treatment as usual. We do not know if listening to music has an effect on the severity of insomnia (difficulty in falling or staying asleep) or the number of times a person wakes up (broken sleep) compared to no treatment or treatment as usual. Listening to music may improve slightly sleep‐onset latency (how quickly a person falls asleep), sleep duration (length of time a person is asleep) and sleep efficiency (amount of a time a person is asleep compared to the total time spent in bed), compared to no treatment or treatment as usual. None of the studies reported any negative effects caused by listening to music. What are the limitations of the evidence? The quality of evidence from the 10 studies that examined sleep quality was moderate. Our confidence in the evidence for the quality of sleep is only moderate because the people in the studies were aware of which treatment they were getting and the people scoring the data were also sometimes aware of which treatment the participants were getting, which could introduce bias. We have little confidence in the evidence for the severity of insomnia because the studies were very small and were done in different types of people who knew which treatment they were getting. Our confidence in the evidence on sleep‐onset latency, sleep duration and sleep efficiency is low because the studies used very different methods to measure these outcomes, and the people in the studies were aware of the nature of the treatment. We have little confidence in the evidence on sleep interruption because the studies used different methods and showed different results. Furthermore, the participants in the studies knew which treatment they were getting. Future studies should assess other aspects of sleep as well as measures of daytime functioning, such as mood, fatigue, concentration, and quality of life. How up to date is this evidence? The evidence is current to 31 December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Jespersen, KV; Pando-Naude, V; Koenig, J; Jennum, P; Vuust, P", "articleTypes": [], "doi": "10.1002/14651858.CD010459.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "f758f2e5-af9a-4b6b-85c9-21b3863d0acd", "pmid": "", "title": "Treatment for primary postpartum haemorrhage", "imported": false, "abstract": "Abstract - Background Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries. Objectives To assess the effectiveness and safety of any intervention used for the treatment of primary PPH. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013). Selection criteria Randomised controlled trials comparing any interventions for the treatment of primary PPH. Data collection and analysis We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information. Main results Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review. Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41). Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering. Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre‐specified outcomes. One study compared lower segment compression but was too small to assess impact on primary outcomes. We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics. Authors' conclusions Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first‐line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit. The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy. Plain language summary Treatment for excessive bleeding after childbirth After a woman gives birth, womb muscles contract, clamping down on the blood vessels and helping to limit bleeding when the placenta has detached. If the muscles do not contract strongly enough, very heavy bleeding (postpartum haemorrhage) can occur, which can be life threatening. These situations are common in resource‐poor countries, and maternal mortality is about 100 times higher than in resource‐rich countries. It is a very serious problem that requires effective treatments that might avoid the use of surgery to remove the womb (hysterectomy). This is often the last treatment option and leaves the woman unable to have more children. In most settings, women are given a drug at the time of birth (before excessive bleeding occurs) to reduce the likelihood of excessive blood loss. However, despite this intervention, some women bleed excessively, and this review looked to see what interventions might be used to reduce the amount of blood lost by these women. Treatment options include drugs to increase muscles contractions (such as oxytocin, ergometrine and prostaglandins like misoprostol), drugs to help with blood clotting (haemostatic drugs such as tranexamic acid and recombinant activated factor VII), surgical techniques (such as tying off or blocking of the uterine artery) and radiological interventions (to assist in blocking the main artery to the womb by using gel foams). The review identified 10 randomised controlled trials involving 4052 women. Seven of these trials looked at a drug called misoprostol, which is a prostaglandin and so works by increasing muscle contractions. Overall, the trials suggest that misoprostol does not work as well as oxytocin infusion, and it has more side effects. However, oxytocin needs to be kept in a refrigerator, and so in settings where refrigeration and infusions are not readily available, misoprostol can be used. Other clinical trials looked into using other types of drugs or squeezing the main artery that supplies blood to the woman. The number of women included in these studies was too small for any useful conclusions regarding their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Mousa, HA; Blum, J; Abou El Senoun, G; Shakur, H; Alfirevic, Z", "articleTypes": [], "doi": "10.1002/14651858.CD003249.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "f76b459e-05df-467a-aba4-7ced57902a1b", "pmid": "", "title": "Lifestyle interventions for chronic gout", "imported": false, "abstract": "Abstract - Background Although lifestyle interventions are commonly recommended in the management of patients with chronic gout, the evidence from trial data for their benefits and safety has not been previously examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with chronic gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies on 5 April 2013. We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi‐randomised controlled trials (RCTs or CCTs) which compared lifestyle interventions to another therapy (active or placebo) in patients with chronic gout. Outcomes of interest were changes in gout attack frequency, joint pain, serum urate levels, tophus size, function, quality of life and adverse effects. Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (120 participants), at moderate risk of bias, was included in the review. Patients were randomised to one of three interventions: either skim milk powder (SMP) enriched with glycomacropeptide (GMP) and G600, non‐enriched SMP or lactose powder, over a three‐month period. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the three‐month study period. Low quality evidence indicated that there was no difference between the SMP/GMP/G600 group and combined control groups (SMP and lactose powder) at three months (mean difference (MD) ‐0.21, 95% confidence interval (CI) ‐0.76 to 0.34). There were no significant between‐group differences in terms of withdrawals due to adverse effects (risk ratio (RR) 1.27, 95% CI 0.53 to 3.03), and serious adverse events resulting in hospitalisation (2/40 SMP/GMP/G600 group versus 3/80 controls; RR 1.33, 95% CI 0.23 to 7.66). Gastrointestinal adverse effects were the most commonly reported. Pain from self reported gout flares, measured on a 10‐point Likert scale, improved more in the SMP/GMP/G600 group compared to controls (MD ‐1.03, 95% CI ‐1.96 to ‐0.10), an absolute difference of 10% (absolute risk difference ‐0.10, 95% CI ‐0.20 to ‐0.01). This is unlikely to be of clinical significance. There was no significant difference in physical function between SMP/GMP/G600 and the control groups at three‐month followup (MD ‐0.03, 95% CI ‐0.14 to 0.08). Tophus regression and serum urate normalisation were not reported in this study. Authors' conclusions While there is good evidence from observational studies of an association between various lifestyle risk factors and gout development, there is a paucity of high‐quality evidence from randomised controlled trials to either support or refute the use of lifestyle modifications for improving outcomes in people with chronic gout. Plain language summary Lifestyle interventions for chronic gout This summary of a Cochrane review presents what we know from research about the effect of lifestyle modifications in the treatment of people with chronic gout. There was one study included in this review which looked at the benefits and safety of consuming skim milk powder (SMP) enriched with two components of dairy products (glycomacropeptide (GMP) and G600 milk fat extract) compared to standard skim milk or lactose powder in reducing the frequency of gout attacks over a three‐month period. The review shows that, in people with chronic gout : Compared with standard skim milk or lactose powder, SMP enriched with GMP and G600 may not reduce the frequency of gout attacks, may not improve physical function, but may reduce pain. We do not know if consuming these dairy preparations improves tophus size (tophi are gout crystal deposits commonly found in skin, on the surface of joints or in cartilage) or blood uric acid levels, as these were not reported. We do not have precise information about side effects and complications. Possible side effects may include nausea or diarrhoea. What is gout and what are lifestyle interventions? Gout is a very common form of painful joint inflammation (arthritis) caused by urate crystals forming either within or around joints. The inflammation can lead to pain, redness and swelling of affected joints, making the area difficult to touch or move. Some of the reasons why people get gout include their genetic makeup, being overweight, ingesting certain medications (e.g. diuretics), having impaired kidney function and lifestyle habits such as drinking excessive amounts of alcohol and sugar‐sweetened drinks. Although medications are the mainstay of gout treatment, given the recognised association between certain lifestyle risk factors and gout development, lifestyle changes such as losing weight, stopping smoking, exercising more, drinking more coffee and dairy products, and consuming less sugar‐sweetened drinks, alcoholic beverages, meat and seafood are commonly recommended to people with chronic gout. Best estimate of what happens to people with gout who consume enriched skim milk powder: Gout attacks People who consumed enriched skim milk powder had 0.21 fewer gout attacks per month at 3 months (or 2.5 fewer gout attacks per year) . ‐ People who consumed enriched skim milk powder had 0.49 gout attacks per month (or 6 gout attacks per year). ‐ People who consumed standard skim milk powder or lactose had 0.70 gout attacks per month (or 8 gout attacks per year). Withdrawals due to adverse events 4 more people out of 100 who consumed enriched skim milk powder discontinued the supplement at 3 months (4% more withdrawals absolute change, from 10% fewer to 18% more). ‐ 18 out of 100 stopped consuming enriched skim milk powder. ‐ 14 out of 100 stopped consuming standard skim milk powder or lactose. Pain (lower score means less pain) People who consumed enriched skim milk powder rated their pain 1 point lower on a 0 to 10 point pain scale (10% absolute improvement; 20% to 1% improvement) at 3 months. ‐ People who consumed enriched skim milk powder rated their pain to be 0.67 points on a scale of 0 to 10. ‐ People who consumed standard skim milk powder or lactose rated their pain to be 1.7 points on a scale of 0 to 10. Physical function (lower score means better function) People who consumed enriched skim milk powder rated their function 0.03 better (0.14 better to 0.08 worse) on a 0 to 3 point scale (1% absolute improvement; 5% improvement to 3% worse) at 3 months. ‐ People who consumed enriched skim milk powder rated their function to be 0.08 points on a scale of 0 to 3. ‐ People who consumed standard skim milk powder or lactose rated their function to be 0.11 points on a scale of 0 to 3. Serious adverse events 1 more person out of 100 who consumed enriched skim milk powder reported a serious adverse event. ‐ 5 out of 100 who consumed enriched skim milk powder had a serious adverse event. ‐ 4 out of 100 who consumed standard skim milk powder or lactose had a serious adverse event.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Moi, JHY, Sriranganathan, MK, Edwards, CJ, Buchbinder, R", "articleTypes": [], "doi": "10.1002/14651858.CD010039.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.748Z" }, { "id": "f76f4000-8106-47d6-9fa9-42d15e2de7e9", "pmid": "", "title": "Omega‐3 fatty acids for depression in adults", "imported": false, "abstract": "Abstract - Background Major depressive disorder (MDD) is highly debilitating, difficult to treat, has a high rate of recurrence, and negatively impacts the individual and society as a whole. One potential treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, some other seafood, and some nuts and seeds. Various lines of evidence suggest a role for n‐3PUFAs in MDD, but the evidence is far from conclusive. Reviews and meta‐analyses clearly demonstrate heterogeneity between studies. Investigations of heterogeneity suggest different effects of n‐3PUFAs, depending on the severity of depressive symptoms, where no effects of n‐3PUFAs are found in studies of individuals with mild depressive symptomology, but possible benefit may be suggested in studies of individuals with more severe depressive symptomology. Hence it is important to establish their effectiveness in treating MDD. This review updates and incorporates an earlier review with the same research objective (Appleton 2015). Objectives To assess the effects of n‐3 polyunsaturated fatty acids (also known as omega‐3 fatty acids) versus a comparator (e.g. placebo, antidepressant treatment, standard care, no treatment, wait‐list control) for major depressive disorder (MDD) in adults. Search methods We searched the Cochrane Central Register of Controlled trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO together with trial registries and grey literature sources (to 9 January 2021). We checked reference lists and contacted authors of included studies for additional information when necessary. Selection criteria We included studies in the review if they: used a randomised controlled trial design; provided n‐3PUFAs as an intervention; used a comparator; measured depressive symptomology as an outcome; and were conducted in adults with MDD. Primary outcomes were depressive symptomology (continuous data collected using a validated rating scale) and adverse events. Secondary outcomes were depressive symptomology (dichotomous data on remission and response), quality of life, and non‐completion of studies. Data collection and analysis We used standard methodological procedures as expected by Cochrane. We assessed the certainty of the evidence using GRADE criteria. Main results The review includes 35 relevant studies: 34 studies involving a total of 1924 participants investigated the impact of n‐3PUFA supplementation compared to placebo, and one study involving 40 participants investigated the impact of n‐3PUFA supplementation compared to antidepressant treatment. For the placebo comparison, n‐3PUFA supplementation resulted in a small to modest benefit for depressive symptomology, compared to placebo: standardised mean difference (SMD) (random‐effects model) −0.40 (95% confidence interval (CI) −0.64 to −0.16; 33 studies, 1848 participants; very low‐certainty evidence), but this effect is unlikely to be clinically meaningful. An SMD of 0.40 represents a difference between groups in scores on the HDRS (17‐item) of approximately 2.5 points (95% CI 1.0 to 4.0), where the minimal clinically important change score on this scale is 3.0 points. The confidence intervals include both a possible clinically important effect and a possible negligible effect, and there is considerable heterogeneity between studies. Sensitivity analyses, funnel plot inspection and comparison of our results with those of large well‐conducted trials also suggest that this effect estimate may be biased towards a positive finding for n‐3PUFAs. Although the numbers of individuals experiencing adverse events were similar in intervention and placebo groups (odds ratio (OR) 1.27, 95% CI 0.99 to 1.64; 24 studies, 1503 participants; very low‐certainty evidence), the confidence intervals include a small decrease to a modest increase in adverse events with n‐3PUFAs. There was no evidence for a difference between n‐3PUFA and placebo groups in remission rates (OR 1.13, 95% CI 0.74 to 1.72; 8 studies, 609 participants, low‐certainty evidence), response rates (OR 1.20, 95% CI 0.80 to 1.79; 17 studies, 794 participants; low‐certainty evidence), quality of life (SMD −0.38 (95% CI −0.82 to 0.06), 12 studies, 476 participants, very low‐certainty evidence), or trial non‐completion (OR 0.92, 95% CI 0.70 to 1.22; 29 studies, 1777 participants, very low‐certainty evidence). The evidence on which these results are based was also very limited, highly heterogeneous, and potentially biased. Only one study, involving 40 participants, was available for the antidepressant comparison. This study found no differences between treatment with n‐3PUFAs and treatment with antidepressants in depressive symptomology (mean difference (MD) −0.70, 95% CI −5.88 to 4.48), rates of response to treatment (OR 1.23, 95% CI 0.35 to 4.31), or trial non‐completion (OR 1.00, 95% CI 0.21 to 4.71). Confidence intervals are however very wide in all analyses, and do not rule out important beneficial or detrimental effects of n‐3PUFAs compared to antidepressants. Adverse events were not reported in a manner suitable for analysis, and rates of depression remission and quality of life were not reported. Authors' conclusions At present, we do not have sufficient high‐certainty evidence to determine the effects of n‐3PUFAs as a treatment for MDD. Our primary analyses may suggest a small‐to‐modest, non‐clinically beneficial effect of n‐3PUFAs on depressive symptomology compared to placebo; however the estimate is imprecise, and we judged the certainty of the evidence on which this result is based to be low to very low. Our data may also suggest similar rates of adverse events and trial non‐completion in n‐3PUFA and placebo groups, but again our estimates are very imprecise. Effects of n‐3PUFAs compared to antidepressants are very imprecise and uncertain. More complete evidence is required for both the potential positive and negative effects of n‐3PUFAs for MDD. Plain language summary Omega‐3 fatty acids for depression in adults Why is this review important? Major depressive disorder (MDD) is characterised by depressed mood or a markedly decreased pleasure or interest in all activities, or both. It has negative impacts on the individual and on society, often over the long term. One possible treatment for MDD is n‐3 polyunsaturated fatty acids (n‐3PUFAs), also known as omega‐3 oils, naturally found in fatty fish, in some other seafood and in some nuts and seeds. Various lines of evidence suggest that n‐3PUFAs may impact on depressive symptoms, but a lot of studies have different findings, making it difficult to draw conclusions. Who will be interested in this review? Health professionals, including general practitioners, mental health and psychiatric specialists; individuals with MDD; and the people around them. What questions does this review aim to answer? Do n‐3PUFAs, compared to an alternative, have an effect on depressive symptoms, negative side effects, rates of recovery, quality of life, and rates of study non‐completion, in individuals with MDD? Which studies were included in the review? This review is an update of earlier work (Appleton 2015), using the same methods. We searched scientific databases for all randomised controlled trials in adults with MDD, where individuals received either n‐3PUFAs or an alternative, that were completed up to January 2021. We have included 35 relevant studies: 34 of them involving 1924 people compared the effects of n‐3PUFAs with those of placebo, and one study involving 40 people compared the effects of n‐3PUFAs with those of antidepressants. All studies were of direct relevance to our review, but we considered the certainty of the evidence to be low to very low. What does the evidence from the review tell us? At present, we do not have enough high quality evidence to determine the effects of n‐3PUFAs as a treatment for MDD. We found a small‐to‐modest positive effect of n‐3PUFAs compared to placebo, but the size of this effect is unlikely to be meaningful to people with MDD, and we considered the evidence to be of low or very low certainty, with many differences between studies. There was also insufficient high quality evidence to determine the effects of n‐3PUFAs on negative side effects or numbers not completing studies. What should happen next? We need more evidence, particularly to explain the differences between study findings, e.g. by looking at individuals who may or may not benefit from n‐3PUFAs. Future studies should also compare n‐3PUFAs with usual antidepressant treatment, and investigate the way these treatments may work.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Appleton, KM; Voyias, PD; Sallis, HM; Dawson, S; Ness, AR; Churchill, R; Perry, R", "articleTypes": [], "doi": "10.1002/14651858.CD004692.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "f772c0fc-f435-45fa-8b1a-9f7fa622fb74", "pmid": "", "title": "Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children", "imported": false, "abstract": "Abstract - Background Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide and its prevalence among children has significantly increased over the last two decades. Prevalence and severity are related to age, with children of school age most commonly affected. Objectives To assess the effectiveness and adverse event profile of antihistamines (oral or topical) used as an adjunct to topical nasal steroids for intermittent and persistent allergic rhinitis in children. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 21 September 2009. Selection criteria Randomised controlled trials (RCTs) in children under the age of 18 with a history of allergic rhinitis, with or without allergic conjunctivitis or asthma, comparing topical nasal steroids with antihistamines to topical nasal steroids only. Data collection and analysis Two review authors independently screened studies, extracted data and assessed risk of bias. Main results One study including 24 participants met the inclusion criteria for this review. This study compared the administration of topical nasal steroids with oral antihistamines to topical nasal steroids only in children, but it did not provide sufficient data to address the clinical question of this review. Authors' conclusions In view of the lack of evidence for the benefit or lack of benefit of antihistamine add‐on therapy with topical nasal steroids for children with intermittent or persistent allergic rhinitis, it is important that clinicians are mindful of the adverse effects of antihistamines and the additional costs that may be incurred. Plain language summary Antihistamines as an addition to topical nasal steroids for allergic rhinitis in children Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide. Seasonal allergic rhinitis (hay fever) is most common around springtime. The symptoms are mostly sneezing, a runny nose and watery eyes. We looked for trials that compared antihistamines (either oral or topical) in addition to a topical nasal steroid with a topical nasal steroid alone in children who had allergic rhinitis. We wanted to know whether adding antihistamines (oral or topical) in the therapy of children with allergic rhinitis who already use topical nasal steroids would have additional benefits for them. We found one trial that had been carried out in children comparing oral antihistamines in addition to topical nasal steroids with topical nasal steroids alone but it did not provide sufficient data to draw any conclusions. Most of the trials focused only on adults or included a small number of children. Unfortunately, the trials which included children along with adults did not report whether there were any differences in the effect of treatment or adverse effects in children in comparison with adults. We are therefore unable to draw a conclusion as to whether or not this combination therapy has beneficial effect in children with allergic rhinitis or whether the benefits are acceptable in terms of the adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Nasser, M; Fedorowicz, Z; Aljufairi, H; McKerrow, W", "articleTypes": [], "doi": "10.1002/14651858.CD006989.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "f7741833-935f-438d-8ba1-9461762809f9", "pmid": "", "title": "Effect of Maternal Vitamin D3 Supplementation on Iron Status During Pregnancy and Early Infancy", "imported": false, "abstract": "This is a secondary-use study based on previously-collected data and blood samples from a previously completed double-blind, dose-ranging trial of maternal prenatal and postpartum vitamin D supplementation in Dhaka, Bangladesh (NCT01924013). The aim of this sub-study is to examine the effect of vitamin D supplementation on iron status during pregnancy and early infancy.", "journal": "", "year": "2021", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.153Z" }, { "id": "f7b8f0a9-29b3-4086-bf11-be60f736035d", "pmid": "", "title": "Pharmacotherapy for hypertension‐induced left ventricular hypertrophy", "imported": false, "abstract": "Abstract - Background Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension‐induced LVH. Objectives To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension‐induced LVH. Search methods Cochrane Hypertension’s Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) with at least 12 months’ follow‐up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension‐induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all‐cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. Data collection and analysis Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. Main results We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow‐up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention‐to‐treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add‐on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low‐certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low‐certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low‐certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low‐certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low‐certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. Authors' conclusions We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low‐certainty evidence requires that caution be used when interpreting the findings. High‐quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension‐induced LVH are warranted. Plain language summary What are the main benefits and risks of drugs for reducing blood pressure in the treatment of people with thickening of the heart muscle caused by high blood pressure? Key messages Given the lack of robust evidence, the benefits and risks of adding additional drugs for reducing blood pressure to treat people with thickening of the heart muscle and high blood pressure are unclear. It is unclear if adding drugs for reducing blood pressure causes more serious harms in patients than placebo (dummy treatment) or no treatment; however, it may increase treatment discontinuation due to unwanted effects. There is a need for future studies to better understand the benefits and harms of adding drugs for reducing blood pressure in people with thickening of the heart muscle caused by high blood pressure. What is thickening of the heart muscle? Thickening of the heart muscle is a condition where the muscle gets bigger and affects the function of the heart. This can happen when the heart has worked too hard over time and is mainly caused by high blood pressure. People with thickening of the heart muscle can experience shortness of breath, fatigue, chest pain, heart palpitations, and dizziness or fainting. How is thickening of the heart muscle treated? Thickening of the heart muscle can be treated with drugs for reducing blood pressure. What did we want to find out? We wanted to find out if adding drugs for reducing blood pressure was better than placebo or no drug treatment at preventing illness and death in people with thickening of the heart muscle and high blood pressure. We also wanted to learn if the addition of drugs for reducing blood pressure was associated with any unwanted or harmful effects. What did we do? We searched for studies that investigated the addition of drugs for reducing blood pressure compared with placebo or no drug treatment. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as methods and sizes of participant groups. What did we find? We found 3 studies that involved 930 people with thickening of the heart muscle and high blood pressure. The largest study was in 692 people, and the smallest study was in 15 people. Study participants were of both genders and on average between 66 and 75 years old. Participants were followed for between three and four years. The studies were conducted in several countries in Europe, Asia, and North and South America. One study received pharmaceutical industry funding. It is uncertain if adding drugs for reducing blood pressure has an effect on death, development of heart and blood vessel diseases, or on hospitalisation for heart failure. It is unclear if adding drugs for reducing blood pressure causes more serious harms than placebo or no drug treatment, but it may increase treatment discontinuations due to unwanted effects. It is unclear if adding drugs for reducing blood pressure has an effect on heart muscle mass. What are the limitations of the evidence? Our confidence in the evidence is lacking because of the small number of identified studies. The available evidence is based on a small percentage of people with thickening of the heart muscle and high blood pressure identified from larger populations in the included studies. Further evidence may change our results. How up‐to‐date is the evidence? The evidence is current to September 2020.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Leache, L, Gutiérrez-Valencia, M, Finizola, RM, Infante, E, Finizola, B, Pardo Pardo, J, Flores, Y, Granero, R, Arai, KJ", "articleTypes": [], "doi": "10.1002/14651858.CD012039.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.783Z" }, { "id": "f7c01acc-5695-43f3-855a-0cb8ef9d8bcc", "pmid": "", "title": "Triclosan/copolymer containing toothpastes for oral health", "imported": false, "abstract": "Abstract - Background Periodontal disease and dental caries are highly prevalent oral diseases that can lead to pain and discomfort, oral hygiene and aesthetic problems, and eventually tooth loss, all of which can be costly to treat and are a burden to healthcare systems. Triclosan is an antibacterial agent with low toxicity, which, along with a copolymer for aiding retention, can be added to toothpastes to reduce plaque and gingivitis (inflammation of the gums). It is important that these additional ingredients do not interfere with the anticaries effect of the fluoride present in toothpastes, and that they are safe. Objectives To assess the effects of triclosan/copolymer containing fluoride toothpastes, compared with fluoride toothpastes, for the long‐term control of caries, plaque and gingivitis in children and adults. Search methods We searched the Cochrane Oral Health's Trials Register (to 19 August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2013, Issue 7), MEDLINE via OVID (1946 to 19 August 2013), Embase via OVID (1980 to 19 August 2013), and the US National Institutes of Health Trials Register ( clinicaltrials.gov ) (to 19 August 2013). We applied no restrictions regarding language or date of publication in the searches of the electronic databases. Selection criteria We included randomised controlled trials (RCTs) assessing the effects triclosan/copolymer containing toothpastes on oral health. Data collection and analysis Two review authors independently assessed the search results against the inclusion criteria for this review, extracted data and carried out risk of bias assessments. We attempted to contact study authors for missing information or clarification when feasible. We combined sufficiently similar studies in meta‐analyses using random‐effects models when there were at least four studies (fixed‐effect models when fewer than four studies), reporting mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data. Main results We included 30 studies, analysing 14,835 participants, in this review. We assessed 10 studies (33%) as at low risk of bias, nine (30%) as at high risk of bias and 11 (37%) as unclear. Plaque Compared with control, after six to seven months of use, triclosan/copolymer toothpaste reduced plaque by 0.47 on a 0 to 5 scale (MD ‐0.47, 95% confidence interval (CI) ‐0.60 to ‐0.34, 20 studies, 2675 participants, moderate‐quality evidence). The control group mean was 2.17, representing a 22% reduction in plaque. After six to seven months of use, it also reduced the proportion of sites scoring 3 to 5 on a 0 to 5 scale by 0.15 (MD ‐0.15, 95% CI ‐0.20 to ‐0.10, 13 studies, 1850 participants, moderate‐quality evidence). The control group mean was 0.37, representing a 41% reduction in plaque severity. Gingivitis After six to nine months of use, triclosan/copolymer toothpaste reduced inflammation by 0.27 on a 0 to 3 scale (MD ‐0.27, 95% CI ‐0.33 to ‐0.21, 20 studies, 2743 participants, moderate‐quality evidence). The control group mean was 1.22, representing a 22% reduction in inflammation. After six to seven months of use, it reduced the proportion of bleeding sites (i.e. scoring 2 or 3 on the 0 to 3 scale) by 0.13 (MD ‐0.13, 95% CI ‐0.17 to ‐0.08, 15 studies, 1998 participants, moderate‐quality evidence). The control group mean was 0.27, representing a 48% reduction in bleeding. Periodontitis After 36 months of use, there was no evidence of a difference between triclosan/copolymer toothpaste and control in the development of periodontitis (attachment loss) (RR 0.92, 95% CI 0.67 to 1.27, one study, 480 participants, low‐quality evidence). Caries After 24 to 36 months of use, triclosan/copolymer toothpaste slightly reduced coronal caries when using the decayed and filled surfaces (DFS) index (MD ‐0.16, 95% CI ‐0.31 to ‐0.02, four studies, 9692 participants, high‐quality evidence). The control group mean was 3.44, representing a 5% reduction in coronal caries. After 36 months of use, triclosan/copolymer toothpaste probably reduced root caries (MD ‐0.31, 95% CI ‐0.39 to ‐0.23, one study, 1357 participants, moderate‐quality evidence). Calculus After six months of use, triclosan/copolymer toothpaste may have reduced the mean total calculus per participant by 2.12 mm (MD ‐2.12 mm, 95% CI ‐3.39 to ‐0.84, two studies, 415 participants, low‐quality evidence). The control group mean was 14.61 mm, representing a 15% reduction in calculus. Adverse effects There were no data available for meta‐analysis regarding adverse effects, but 22 studies (73%) reported that there were no adverse effects caused by either the experimental or control toothpaste. There was considerable heterogeneity present in the meta‐analyses for plaque, gingivitis and calculus. Plaque and gingivitis showed such consistent results that it did not affect our conclusions, but the reader may wish to interpret the results with more caution. Authors' conclusions There was moderate‐quality evidence showing that toothpastes containing triclosan/copolymer, in addition to fluoride, reduced plaque, gingival inflammation and gingival bleeding when compared with fluoride toothpastes without triclosan/copolymer. These reductions may or may not be clinically important, and are evident regardless of initial plaque and gingivitis levels, or whether a baseline oral prophylaxis had taken place or not. High‐quality evidence showed that triclosan/copolymer toothpastes lead to a small reduction in coronal caries. There was weaker evidence to show that triclosan/copolymer toothpastes may have reduced root caries and calculus, but insufficient evidence to show whether or not they prevented periodontitis. There do not appear to be any serious safety concerns regarding the use of triclosan/copolymer toothpastes in studies up to three years in duration. Plain language summary Triclosan/copolymer containing toothpastes for oral health Review question This Cochrane Review has been conducted to assess the effects of using a toothpaste containing triclosan (an antibacterial ingredient) plus copolymer (an ingredient to reduce the amount of triclosan that is washed away by rinsing or saliva) plus fluoride (a mineral that prevents tooth decay) compared with using a fluoride toothpaste (without triclosan/copolymer) for oral health. Background Gum disease and dental decay are the main reasons for tooth loss. Unless brushed away, plaque (a sticky film containing bacteria) can build up on the teeth. This can lead to gingivitis (a swelling and redness of the gums that affects most adults), which, if not treated, can then lead to a more serious form of gum disease called periodontitis (which affects up to one out of every five adults aged 35 to 44 years worldwide). Periodontitis can cause pain, eating difficulties, an unpleasant facial appearance and eventually tooth loss. Plaque build‐up can also lead to tooth decay, a problem affecting up to 90% of schoolchildren in industrialised countries, and the majority of adults. Vast healthcare resources are used worldwide to treat gum disease and tooth decay, which are both preventable. Currently there is a lot of ongoing research into possible links between periodontitis and other medical conditions such as diabetes, rheumatoid arthritis, heart disease and also to the premature (too early) birth of underweight babies. Adding an effective and safe antibacterial ingredient to toothpastes could be an easy and low‐cost answer to these problems. It is thought that triclosan could fight the harmful bacteria in plaque while also reducing the swelling that leads to serious gum disease. It is important that adding triclosan to fluoride toothpastes does not reduce the beneficial effects that fluoride has on preventing tooth decay. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 19 August 2013. It includes 30 studies published from 1990 to 2012 in which 14,835 participants were randomised to receive a triclosan/copolymer containing fluoride toothpaste or a fluoride toothpaste that did not include triclosan/copolymer. The toothpaste that was used in most of the studies is sold by the manufacturer Colgate. Key results The evidence produced shows benefits in using a triclosan/copolymer fluoride toothpaste when compared with a fluoride toothpaste (without triclosan/copolymer). There was a 22% reduction in plaque, a 22% reduction in gingivitis, a 48% reduction in bleeding gums and a 5% reduction in tooth decay. There was insufficient evidence to show a difference between either toothpaste in preventing periodontitis. There was no evidence of any harmful effects associated with the use of triclosan/copolymer toothpastes in studies up to three years in length. Quality of the evidence The evidence relating to plaque and gingivitis was considered to be of moderate quality. The evidence on tooth decay was high quality, while the evidence on periodontitis was low quality.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Riley, P, Lamont, T", "articleTypes": [], "doi": "10.1002/14651858.CD010514.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.748Z" }, { "id": "f7cd82b7-114f-4f11-a4dc-9a1105643187", "pmid": "", "title": "Antiviral treatment for preventing postherpetic neuralgia", "imported": false, "abstract": "Abstract - Background Postherpetic neuralgia (PHN) is a painful and refractory complication of herpes zoster. Treatments are either partially or totally ineffective for many people with PHN. Antiviral agents, used at the time of the rash, have been proposed as an intervention to prevent the development of PHN. This is the first update since the first publication of the review in 2009. Objectives To assess the effectiveness of antiviral agents in preventing PHN. Search methods On 26 April 2013, we updated the searches in the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and the Chinese Biomedical Retrieval System. We checked the references of published studies to identify additional trials, and contacted authors to obtain additional data. We searched other databases in The Cochrane Library for information for the Discussion and two clinical trials registries for ongoing trials. Selection criteria We considered all randomised controlled trials (RCTs) of antiviral treatment given within 72 hours after the onset of herpes zoster for preventing PHN. There were no language restrictions. Data collection and analysis Two authors independently selected trials, evaluated the risk of bias in included trials, and extracted and analysed data. Main results Six RCTs with a total of 1211 participants were eligible; five trials evaluated oral aciclovir, and one, with 419 participants, evaluated oral famciclovir. We were able to conduct meta‐analyses as there were sufficient similarities in the included studies, such as the reporting of the presence of PHN, duration of rash before treatment initiation and treatment regimen. For our primary outcome, based on three trials (609 participants) we found no significant difference between the aciclovir and control groups in the incidence of PHN four months after the onset of the acute herpetic rash (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.51 to 1.11), nor was there a significant difference at six months (RR 1.05, 95% CI 0.87 to 1.27, two trials, 476 participants). In four of the trials (692 participants), there was some evidence for a reduction in the incidence of pain four weeks after the onset of rash. In the trial of famciclovir versus placebo, neither 500 mg nor 750 mg doses of famciclovir reduced the incidence of herpetic neuralgia significantly. The most commonly reported adverse events were nausea, vomiting, diarrhoea and headache for aciclovir, and headache and nausea for famciclovir. For neither treatment was the incidence of adverse events significantly different from placebo. None of the studies were at high risk of bias, although the risk of bias was unclear in at least one domain for all but one study. We found no new RCTs when we updated the searches in April 2013. Authors' conclusions There is high quality evidence that oral aciclovir does not reduce the incidence of PHN significantly. In addition, there is insufficient evidence to determine the effect of other antiviral treatments; therefore, further well‐designed RCTs are needed to investigate famciclovir or other new antiviral agents in preventing PHN. Future trials should pay more attention to the severity of pain and quality of life of participants, and should be conducted among different subgroups of people, such as people who are immunocompromised. Plain language summary Antiviral treatment for preventing nerve pain after shingles (postherpetic neuralgia) Review question We reviewed the evidence about the effect of antiviral medicines for preventing postherpetic neuralgia (PHN). Background PHN is a painful condition that can occur after shingles (herpes zoster) in the area where the rash occurred. Many people with PHN find that treatments work only a little or not at all. Attention has therefore turned to stopping the development of PHN. Some people suggested that medicines that target the virus that causes shingles (antiviral medicines), given at the time of the rash, might prevent PHN. The aim of this review was to assess the whether antiviral medicines are able to prevent PHN. Study characteristics We identified six clinical trials that met our standards for inclusion in the review. They included a total of 1319 participants. We decided that our main measure of whether antiviral medicines work in preventing PHN would be whether or not PHN had developed six months after a first attack of shingles (some of the studies we included of aciclovir measured PHN at four months). Key results and quality of the evidence Aciclovir, which is an antiviral medicine, was used in five trials (900 participants) and was not better than a placebo (dummy pill) in preventing PHN. In the other trial (419 participants), famciclovir, which is another antiviral drug, was no better than placebo in preventing pain following healing of the shingles rash. The number of side effects with aciclovir and famciclovir was not very different from the number with placebo. The trials did not have any major problems of design or conduct that put the results in doubt, although most of the reports did not provide enough information to fully assess every aspect. We conclude that according to high quality evidence, oral aciclovir was ineffective in reducing the incidence of PHN and there is not enough evidence on other antiviral treatments. There need to be further well‐designed trials of famciclovir or other new antiviral agents with a greater number of participants. Future trials should pay more attention to the severity of pain and quality of life of participants, and should include different groups of people, such as those who have lowered immunity. The evidence is current to April 2013, when the searches were last updated. Because new evidence on this topic is slow to emerge, we have scheduled the next update of this review for 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Chen, N, Li, Q, Yang, J, Zhou, M, Zhou, D, He, L", "articleTypes": [], "doi": "10.1002/14651858.CD006866.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.793Z" }, { "id": "f7dde8a1-78d9-49e3-8e4d-54e0dd89009d", "pmid": "", "title": "Blood pressure lowering efficacy of potassium‐sparing diuretics (that block the epithelial sodium channel) for primary hypertension", "imported": false, "abstract": "Abstract - Background Potassium‐sparing diuretics, which block the epithelial sodium channel (ENaC), are widely prescribed for hypertension as a second‐line drug in patients taking other diuretics (e.g. thiazide diuretics) and much less commonly prescribed as monotherapy. Therefore, it is essential to determine the effects of ENaC blockers on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a first‐line or second‐line therapy. Objectives To quantify the dose‐related reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of ENaC blocker therapy as a first‐line or second‐line drug in patients with primary hypertension. Search methods We searched CENTRAL (The Cochrane Library 2012), MEDLINE (1950 to August 2012), EMBASE (1980 to August 2012) and reference lists of articles. Selection criteria Double‐blind, randomized, controlled trials in patients with primary hypertension that evaluate, for a duration of 3 to 12 weeks, the BP lowering efficacy of: 1) fixed‐dose monotherapy with an ENaC blocker compared with placebo; or 2) an ENaC blocker in combination with another class of anti‐hypertensive drugs compared with the respective monotherapy (without an ENaC blocker). Data collection and analysis Two authors independently assessed the risk of bias and extracted data. Study authors were contacted for additional information. WDAE information was also collected from the trials. Main results No trials evaluating the BP lowering efficacy of ENaC blockers as monotherapy in patients with primary hypertension were identified. Only 6 trials evaluated the BP lowering efficacy of low doses of amiloride and triamterene as a second drug in 496 participants with a baseline BP of 151/102 mm Hg. The additional BP reduction caused by the ENaC blocker as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. The addition of low doses of amiloride and triamterene in these trials did not reduce BP. An estimate of the dose‐related BP lowering efficacy for ENaC blockers was not possible because of a lack of trial data at higher doses. Authors' conclusions ENaC blockers do not have a statistically or clinically significant BP lowering effect at low doses but trials at higher doses are not available. The review did not provide a good estimate of the incidence of harms associated with ENaC blockers. Plain language summary The blood pressure lowering effect of ENaC blockers is not known Potassium‐sparing diuretics, which block the epithelial sodium channel (also called ENaC blockers), are a class of drugs commonly prescribed to prevent loss of potassium but also might help to lower elevated blood pressure. This class includes drugs such as amiloride (Midamor, Amilzide) and triamterene (Dyrenium, Dyazide). We asked how much this class of drugs lowers blood pressure, when used alone or when used as the second drug to treat hypertension. The available scientific literature was searched to find all the trials that had assessed this question. No trials were found studying the blood pressure lowering ability of ENaC blockers when used alone. We found 6 trials studying the blood pressure lowering ability of amiloride and triamterene, when added as a second drug, in 496 participants. All 6 trials studied the ENaC blockers at low doses and there was no blood pressure lowering effect. Trials studying these drugs at higher doses are needed in order to determine if they lower blood pressure. The harms associated with ENaC blockers could not be estimated in this review because of the low doses studied and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Heran, BS; Chen, JMH; Wang, JJ; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD008167.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "f7f2b209-89da-42e9-b5ce-34b32e573af1", "pmid": "", "title": "Non‐nutritive sweeteners for diabetes mellitus", "imported": false, "abstract": "Abstract - Background Products sweetened with non‐nutritive sweeteners (NNS) are widely available. Many people with type 1 or type 2 diabetes use NNS as a replacement for nutritive sweeteners to control their carbohydrate and energy intake. Health outcomes associated with NNS use in diabetes are unknown. Objectives To assess the effects of non‐nutritive sweeteners in people with diabetes mellitus. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Scopus, the WHO ICTRP, and ClinicalTrials.gov. The date of the last search of all databases (except for Scopus) was May 2019. We last searched Scopus in January 2019. We did not apply any language restrictions. Selection criteria We included randomised controlled trials (RCTs) with a duration of four weeks or more comparing any type of NNS with usual diet, no intervention, placebo, water, a different NNS, or a nutritive sweetener in individuals with type 1 or type 2 diabetes. Trials with concomitant behaviour‐changing interventions, such as diet, exercise, or both, were eligible for inclusion, given that the concomitant interventions were the same in the intervention and comparator groups. Data collection and analysis Two review authors independently screened abstracts, full texts, and records retrieved from trials registries, assessed the certainty of the evidence, and extracted data. We used a random‐effects model to perform meta‐analysis, and calculated effect estimates as risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs). We assessed risk of bias using the Cochrane 'Risk of bias' tool and the certainty of evidence using the GRADE approach. Main results We included nine RCTs that randomised a total of 979 people with type 1 or type 2 diabetes. The intervention duration ranged from 4 to 10 months. We judged none of these trials as at low risk of bias for all ’Risk of bias’ domains; most of the included trials did not report the method of randomisation. Three trials compared the effects of a dietary supplement containing NNS with sugar: glycosylated haemoglobin A1c (HbA1c) was 0.4% higher in the NNS group (95% CI −0.5 to 1.2; P = 0.44; 3 trials; 72 participants; very low‐certainty evidence). The MD in weight change was −0.1 kg (95% CI −2.7 to 2.6; P = 0.96; 3 trials; 72 participants; very low‐certainty evidence). None of the trials with sugar as comparator reported on adverse events. Five trials compared NNS with placebo. The MD for HbA1c was 0%, 95% CI −0.1 to 0.1; P = 0.99; 4 trials; 360 participants; very low‐certainty evidence. The 95% prediction interval ranged between −0.3% and 0.3%. The comparison of NNS versus placebo showed a MD in body weight of −0.2 kg, 95% CI −1 to 0.6; P = 0.64; 2 trials; 184 participants; very low‐certainty evidence. Three trials reported the numbers of participants experiencing at least one non‐serious adverse event: 36/113 participants (31.9%) in the NNS group versus 42/118 participants (35.6%) in the placebo group (RR 0.78, 95% CI 0.39 to 1.56; P = 0.48; 3 trials; 231 participants; very low‐certainty evidence). One trial compared NNS with a nutritive low‐calorie sweetener (tagatose). HbA1c was 0.3% higher in the NNS group (95% CI 0.1 to 0.4; P = 0.01; 1 trial; 354 participants; very low‐certainty evidence). This trial did not report body weight data and adverse events. The included trials did not report data on health‐related quality of life, diabetes complications, all‐cause mortality, or socioeconomic effects. Authors' conclusions There is inconclusive evidence of very low certainty regarding the effects of NNS consumption compared with either sugar, placebo, or nutritive low‐calorie sweetener consumption on clinically relevant benefit or harm for HbA1c, body weight, and adverse events in people with type 1 or type 2 diabetes. Data on health‐related quality of life, diabetes complications, all‐cause mortality, and socioeconomic effects are lacking. Plain language summary Non‐nutritive sweeteners for diabetes mellitus Review question Are non‐nutritive sweeteners beneficial or harmful in people with diabetes? Background Non‐nutritive sweeteners are sweetening agents having higher sweetening intensity and lower calorie content per gram compared to caloric sweeteners like sucrose or corn syrups. Both the general population and diabetic people use non‐nutritive sweeteners as a caloric sweetener replacement to control their carbohydrate and energy intake. Most of the non‐nutritive sweeteners approved for human consumption are synthetic (artificial sweeteners); however, increasing numbers of natural non‐caloric sweeteners are becoming available for human consumption. Products sweetened with non‐nutritive sweeteners are widely available on the market: diet beverages, diet yoghourts, desserts, and chewing gums are the most common products containing non‐nutritive sweeteners. Non‐nutritive sweeteners are also available as table‐top sweeteners for use by consumers at home as a sweetening agent for beverages and for cooking and baking. There is very little information about the health consequences of this intensified non‐nutritive sweeteners consumption in people with diabetes. We wanted to find out whether non‐nutritive sweeteners consumption in people with diabetes has an effect on long‐term average blood sugar levels (glycosylated haemoglobin A1c ‐ HbA1c), body weight, side effects, diabetes complications (such as heart attack, eye or kidney disease), and health‐related quality of life. Study characteristics We found nine randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) that allocated people with diabetes to either a group that received a non‐nutritive sweetener or a comparator group. The comparator was usual diet with additional sugar in three studies; placebo (a dummy pill) in five studies; and tagatose (a nutritive low‐calorie sweetener) in one study. The studies included a total of 979 participants; most of the studies were small, with fewer than 100 participants. The length of the studies varied from 4 to 10 months. This evidence is up‐to‐date as of May 2019. Key results Data on health‐related quality of life, diabetes complications, death from any cause, and socioeconomic effects (such as absence from work, visits to general practitioner, medication consumption) were lacking, and data were generally sparse for all comparisons. The available data did not show a clear difference between non‐nutritive sweeteners and sugar, placebo, or the nutritive low‐calorie sweetener tagatose for HbA1c, body weight, and side effects. Certainty of the evidence We rated the overall certainty of the evidence as very low, mainly due to the small numbers of included studies and participants and methodological limitations of the included studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Lohner, S, Kuellenberg de Gaudry, D, Toews, I, Ferenci, T, Meerpohl, JJ", "articleTypes": [], "doi": "10.1002/14651858.CD012885.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.771Z" }, { "id": "f7f45a83-34f5-4b24-a093-21213253f195", "pmid": "", "title": "Needle size for vaccination procedures in children and adolescents", "imported": false, "abstract": "Abstract - Background This is an update of a Cochrane Review first published in 2015. The conclusions have not changed. Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller the diameter of the needle (e.g. a 23 G needle is 0.6 mm in diameter, whereas a 25 G needle is 0.5 mm in diameter). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. Guidelines conflict regarding the sizes of needles that should be used for vaccinating children and adolescents. Objectives To assess the effects of using needles of different sizes for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration). Search methods We updated our searches of CENTRAL, MEDLINE, Embase, and CINAHL to October 2017. We also searched proceedings of vaccine conferences and two trials registers. Selection criteria Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years. Data collection and analysis Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system. Main results We included five trials involving 1350 participants in the original review. The updated review identified no new trials. The evidence from two small trials (one trial including infants and one including adolescents) was insufficient to allow any definitive statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity. The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials included infants predominantly aged from two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole‐cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP‐Hib) and hepatitis B (DTwP‐Hib‐Hep B) antigen components. Primary outcomes Incidence of vaccine‐preventable diseases: No trials reported this outcome. Procedural pain and crying: Using a wider gauge 23 G 25 mm needle may slightly reduce procedural pain (low‐quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate‐quality evidence) compared with a narrower gauge 25 G 25 mm needle (one trial, 320 participants). The effects are probably not large enough to be clinically relevant. Secondary outcomes Immune response: There is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between use of 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP‐Hib vaccine at ages two, three, and four months (moderate‐quality evidence, one trial, numbers of participants in analyses range from 309 to 402. The immune response to the pertussis antigen was not measured). Severe and non‐severe local reactions: 25 mm needles (either 25 G or 23 G) probably lead to fewer severe and non‐severe local reactions after DTwP‐Hib vaccination compared with 25 G 16 mm needles (moderate‐quality evidence, one trial, 447 to 458 participants in analyses). We estimate that one fewer infant will experience a severe local reaction (extensive redness and swelling) after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat for an additional beneficial outcome (NNTB) with a 25 G 25 mm needle: 25 (95% confidence interval (CI) 15 to 100); NNTB with a 23 G 25 mm needle: 25 (95% CI 17 to 100)). We estimate that one fewer infant will experience a non‐severe local reaction (any redness, swelling, tenderness, or hardness (composite outcome)) at 24 hours after the first vaccine dose for every 5 or 6 infants vaccinated with a 25 mm rather than a 16 mm needle (NNTB with a 25 G 25 mm needle: 5 (95% CI 4 to 10); NNTB with a 23 G 25 mm needle: 6 (95% CI 4 to 13)). The results are similar after the second and third vaccine doses. Using a narrow gauge 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with a wider gauge 23 G 25 mm needle, but the effect estimates are imprecise (low‐quality evidence, two trials, 100 to 459 participants in analyses). Systemic reactions: The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of postvaccination fever and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence. Authors' conclusions Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole‐cell pertussis antigen component. These vaccines are predominantly used in low‐ and middle‐income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain. Plain language summary Needle size for vaccination procedures in children and adolescents Background Vaccines contain antigens that make the body's immune system produce antibodies that can protect against disease, which is known as an immune response. Antigens are modified or partial forms of the virus, bacteria, or toxin that cause the disease that the vaccine protects against. Because the antigen is altered from its original form, it cannot cause disease, but it can produce an immune response. Vaccines can be injected using needles of different lengths and gauges. The needle gauge (G) refers to the width (diameter) of the needle. The higher the gauge number, the narrower the needle. For example, a 25 G needle is approximately 0.5 mm in diameter and is narrower than a 23 G needle, which has a diameter of 0.6 mm. Guidelines conflict regarding the lengths and gauges of needles that should be used for vaccinating children and adolescents. Review question We wanted to find out if the length and gauge of needles used to vaccinate children and adolescents has an influence on the: 1) immune response to the injected vaccine; 2) pain experienced during the vaccination procedure; 3) occurrence of reactions such as swelling, tenderness, and redness at the site where the vaccine is given; fever (high temperature); and other side effects that can occur after vaccination. Quality of the evidence We included five studies involving 1350 people. We rated the quality of the evidence from studies as very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. There were problems with the design of some studies, and data were insufficient to answer some parts of our review question. The quality of the evidence from two studies was too low to allow us to draw any conclusions about the effects of the needles compared in the studies. However, there was sufficient evidence from the remaining three studies to allow us to reach conclusions. Study characteristics The three studies that allowed us to reach conclusions involved 1135 healthy infants aged mostly between two and six months. The infants were vaccinated in the thigh with either 25 G 25 mm (narrow, long needles), 23 G 25 mm (wide, long needles), or 25 G 16 mm needles (narrow, short needles). The needles were inserted at right angles (90° angle) into the skin and pushed down into the muscle of the thigh. The vaccines injected were combination vaccines designed to protect against several diseases including diphtheria (D), tetanus (T), whooping cough (pertussis), and Haemophilus influenzae type b disease (Hib). The vaccines all contained whole‐cell pertussis (wP) vaccine antigens. These vaccines are commonly used in low‐ and middle‐income countries but not in high‐income countries. Our review findings are therefore most relevant to low‐ and middle‐income countries. Key findings We found moderate‐quality evidence that infants vaccinated in the thigh with 25 mm needles probably have fewer severe reactions (extensive redness and swelling in the thigh) after DTwP‐Hib vaccination than infants vaccinated with 16 mm needles. We also found that the longer needles probably lead to fewer non‐severe reactions such as mild swelling, tenderness, and redness after vaccination. The immune response to the vaccine is probably similar with the long and the short needles. We found low‐quality evidence that the wide, long needle may slightly reduce the pain of the vaccination procedure compared with the narrow, long needle. We found moderate‐quality evidence that the wide, long needle probably slightly reduces the duration of crying immediately following vaccination compared with the narrow, long needle. The differences in pain and crying between use of the wide and narrow needles are probably too small to be of any practical importance. We found low‐quality evidence that infants vaccinated with the narrow, long needle may have slightly fewer non‐severe reactions than infants vaccinated with the wide, long needle. We do not know if needle size has an effect on fever or other reactions that sometimes occur after vaccination including drowsiness, loss of appetite, and vomiting due to the very low quality of the evidence. The evidence in our review is current to October 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Beirne, PV, Hennessy, S, Cadogan, SL, Shiely, F, Fitzgerald, T, MacLeod, F", "articleTypes": [], "doi": "10.1002/14651858.CD010720.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.803Z" }, { "id": "f7fbdd1c-e146-4082-9bb1-fae8e2bbad38", "pmid": "", "title": "Sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose or glucose with and without non‐nutritive sucking is frequently used as a non‐pharmacological intervention for needle‐related procedural pain relief in infants. Objectives To determine the effectiveness of sweet‐tasting solutions for needle‐related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet‐tasting solutions, or pharmacological or other non‐pharmacological pain‐relieving methods. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library 2012); MEDLINE via Ovid (1966 to 2012); CINAHL via OVID (1982 to 2012). The World Health Organization International Clinical Trials Registry Platform was also searched for any ongoing trials. Clinical trial registries, conference proceedings and references for randomised controlled trials (RCTs) were also searched. An updated search was run to capture any new publications before finalising the review in April 2012 and no new included studies were identified. Two review authors (MK & JF) independently abstracted data and assessed quality using a standard form. Authors have been contacted for missing data. Selection criteria Randomised‐controlled trials using a sweet‐tasting solution to treat pain in healthy term infants (gestational age 37 weeks and over), between one month and 12 months of age who required needle‐related procedures. These procedures included but were not limited to: subcutaneous or intramuscular injections, venepuncture, and heel lance. Studies in which the painful procedure was circumcision, lumbar puncture or supra‐pubic bladder aspiration were not included as they are more severe and painful than needle‐related procedures. Control conditions included no treatment or placebo (water) or any other identical intervention (same appearance and consistency) without active ingredient, another sweet‐tasting solution, a pharmacological pain‐relieving method (e.g. paracetamol, topical anaesthetic cream), non‐pharmacological pain‐relieving method (e.g. distraction method, non‐nutritive sucking). Data collection and analysis Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Pain, Palliative and Supportive Care Group. We report mean differences (MD) with 95% confidence intervals (CI) using fixed‐effect models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. The Chi 2 test and I 2 statistic were used to assess between‐study heterogeneity. Main results Sixty‐five (65) studies were identified for possible inclusion in this review. Fourteen published RCTs with a total of 1551 participants met the inclusion criteria. Duration of cry was significantly reduced in infants who were administered a sweet‐tasting solution [MD ‐13.47 (95% CI ‐16.80 to ‐10.15)], P < 0.00001 compared with water. However, there was considerable heterogeneity between the studies (I 2 = 94%) that we were unable to explain. Meta‐analysis was not able to be undertaken for any of the other outcome measures, except for cry duration, because of differences in study design. However, most of the individual studies that measured pain found sucrose to significantly reduce pain compared with the control group. One study compared sucrose and Lidocaine‐prilocaine cream and no significant difference was found between the two treatments for the outcomes pain and cry duration. Due to the differences between the studies, we were unable to identify the optimal concentration, volume or method of administration of sweet‐tasting solutions in infants aged one to 12 months. Further large RCTs are needed. Authors' conclusions There is insufficient evidence to confidently judge the effectiveness of sweet‐tasting solutions in reducing needle‐related pain in infants (one month to 12 months of age). The treatments do, however, appear promising. Data from a series of individual trials are promising, as are the results from a subset meta‐analysis of studies measuring duration of crying. Further well controlled RCTs are warranted in this population to determine the optimal concentration, volume, method of administration, and possible adverse effects. Plain language summary Sweet‐tasting solutions for needle‐related pain in infants up to one year of age The use of needles that break the skin and cause pain is a common practice around the world with babies aged between one month and 12 months ( Appendix 4 ). In this review we were interested in whether giving babies sugar‐based solutions to taste when the needle breaks the skin will help reduce their pain. We found 14 separate studies that had asked this question. However, the differences between the studies were often too great to let us combine their findings. Overall, the studies show that different types of sugar‐based solutions were effective but we were not able to confidently assert that there is strong evidence for this treatment in reducing pain. We did find some evidence that babies may not cry for as long if given sugar‐based solutions. This review is broadly in agreement with two other reviews, one asking this question in younger children, and one in older children. There is a need for better studies in this field.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Kassab, M, Foster, JP, Foureur, M, Fowler, C", "articleTypes": [], "doi": "10.1002/14651858.CD008411.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.062Z" }, { "id": "f81a123c-7077-428c-abfa-125560459a37", "pmid": "", "title": "Cannabis and cannabinoids for symptomatic treatment for people with multiple sclerosis", "imported": false, "abstract": "Abstract - Background Spasticity and chronic neuropathic pain are common and serious symptoms in people with multiple sclerosis (MS). These symptoms increase with disease progression and lead to worsening disability, impaired activities of daily living and quality of life. Anti‐spasticity medications and analgesics are of limited benefit or poorly tolerated. Cannabinoids may reduce spasticity and pain in people with MS. Demand for symptomatic treatment with cannabinoids is high. A thorough understanding of the current body of evidence regarding benefits and harms of these drugs is required. Objectives To assess benefit and harms of cannabinoids, including synthetic, or herbal and plant‐derived cannabinoids, for reducing symptoms for adults with MS. Search methods We searched the following databases from inception to December 2021: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), CINAHL (EBSCO host), LILACS, the Physiotherapy Evidence Database (PEDro), the World Health Organisation International Clinical Trials Registry Platform, the US National Institutes of Health clinical trial register, the European Union Clinical Trials Register, the International Association for Cannabinoid Medicines databank. We hand searched citation lists of included studies and relevant reviews. Selection criteria We included randomised parallel or cross‐over trials (RCTs) evaluating any cannabinoid (including herbal C annabis, C annabis flowers, plant‐based cannabinoids, or synthetic cannabinoids) irrespective of dose, route, frequency, or duration of use for adults with MS. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane Risk of bias 2 tool for parallel RCTs and crossover trials. We rated the certainty of evidence using the GRADE approach for the following outcomes: reduction of 30% in the spasticity Numeric Rating Scale, pain relief of 50% or greater in the Numeric Rating Scale‐Pain Intensity, much or very much improvement in the Patient Global Impression of Change (PGIC), Health‐Related Quality of Life (HRQoL), withdrawals due to adverse events (AEs) (tolerability), serious adverse events (SAEs), nervous system disorders, psychiatric disorders, physical dependence. Main results We included 25 RCTs with 3763 participants of whom 2290 received cannabinoids. Age ranged from 18 to 60 years, and between 50% and 88% participants across the studies were female. The included studies were 3 to 48 weeks long and compared nabiximols, an oromucosal spray with a plant derived equal (1:1) combination of tetrahydrocannabinol (THC) and cannabidiol (CBD) (13 studies), synthetic cannabinoids mimicking THC (7 studies), an oral THC extract of C annabis sativa (2 studies), inhaled herbal C annabis (1 study) against placebo. One study compared dronabinol, THC extract of C annabis sativa and placebo, one compared inhaled herbal C annabis , dronabinol and placebo. We identified eight ongoing studies. Critical outcomes • Spasticity: nabiximols probably increases the number of people who report an important reduction of perceived severity of spasticity compared with placebo (odds ratio (OR) 2.51, 95% confidence interval (CI) 1.56 to 4.04; 5 RCTs, 1143 participants; I 2 = 67%; moderate‐certainty evidence). The absolute effect was 216 more people (95% CI 99 more to 332 more) per 1000 reporting benefit with cannabinoids than with placebo. • Chronic neuropathic pain: we found only one small trial that measured the number of participants reporting substantial pain relief with a synthetic cannabinoid compared with placebo (OR 4.23, 95% CI 1.11 to 16.17; 1 study, 48 participants; very low‐certainty evidence). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity. • Treatment discontinuation due to AEs: cannabinoids may increase slightly the number of participants who discontinue treatment compared with placebo (OR 2.41, 95% CI 1.51 to 3.84; 21 studies, 3110 participants; I² = 17%; low‐certainty evidence); the absolute effect is 39 more people (95% CI 15 more to 76 more) per 1000 people. Important outcomes • PGIC: cannabinoids probably increase the number of people who report 'very much' or 'much' improvement in health status compared with placebo (OR 1.80, 95% CI 1.37 to 2.36; 8 studies, 1215 participants; I² = 0%; moderate‐certainty evidence). The absolute effect is 113 more people (95% CI 57 more to 175 more) per 1000 people reporting improvement. • HRQoL: cannabinoids may have little to no effect on HRQoL (SMD ‐0.08, 95% CI ‐0.17 to 0.02; 8 studies, 1942 participants; I 2 = 0%; low‐certainty evidence); • SAEs: cannabinoids may result in little to no difference in the number of participants who have SAEs compared with placebo (OR 1.38, 95% CI 0.96 to 1.99; 20 studies, 3124 participants; I² = 0%; low‐certainty evidence); • AEs of the nervous system: cannabinoids may increase nervous system disorders compared with placebo (OR 2.61, 95% CI 1.53 to 4.44; 7 studies, 1154 participants; I² = 63%; low‐certainty evidence); • Psychiatric disorders: cannabinoids may increase psychiatric disorders compared with placebo (OR 1.94, 95% CI 1.31 to 2.88; 6 studies, 1122 participants; I² = 0%; low‐certainty evidence); • Drug tolerance: the evidence is very uncertain about the effect of cannabinoids on drug tolerance (OR 3.07, 95% CI 0.12 to 75.95; 2 studies, 458 participants; very low‐certainty evidence). Authors' conclusions Compared with placebo, nabiximols probably reduces the severity of spasticity in the short‐term in people with MS. We are uncertain about the effect on chronic neurological pain and health‐related quality of life. Cannabinoids may increase slightly treatment discontinuation due to AEs, nervous system and psychiatric disorders compared with placebo. We are uncertain about the effect on drug tolerance. The overall certainty of evidence is limited by short‐term duration of the included studies. Plain language summary Cannabis and cannabinoids for people with multiple sclerosis Key messages 
• Treatment with nabiximols likely results in improvement of spasticity and may not increase serious harmful effects compared with placebo • Compared with placebo, cannabinoids (nabiximols, C annabis extract, synthetic cannabinoids) likely improve well‐being when measured with patient‐reported outcomes • Due to a lack of robust evidence, the benefit of these medicines for treating chronic neuropathic pain is unclear. What is the issue? Many people with multiple sclerosis (MS) experience spasticity that causes also pain and impacts on the ability to carry out daily activities. Spasticity is a form of increased muscle tone. Cannabis ‐based medicines refer to the use of Cannabis , or its ingredients called cannabinoids, as medical therapies to alleviate spasticity, chronic pain and other symptoms in MS. An international survey found that MS was one of the five medical conditions for which C annabis was most often used. Another survey conducted in the UK found that more than one in five people with MS reported they had used C annabis to try to manage their symptoms. What did we want to find out? We wanted to find out if cannabinoids were better than placebo in adults with MS to improve: • spasticity; • chronic neuropathic pain; • well‐being, We also wanted to find out if cannabinoids were associated with: • treatment discontinuation due to unwanted effects; • serious harmful effects; • nervous system disorders or psychiatric disorders; • drug tolerance defined as a condition that occurs when the body gets used to a medicine so that more medicine is needed. What did we do? 
We searched for studies that compared cannabinoids against placebo in adult people with MS. We compared and summarised their results, and rated our confidence in the evidence, based on factors such as study methods and certainty of evidence. What did we find? We found 25 studies that involved 3763 people with MS, 2290 of whom received cannabinoids. Fifteen studies were very short term or short‐term studies (two to 12 weeks), seven were intermediate term (12 to 26 weeks), and two were long term (50 and 156 weeks). One study reported results at three days only. The biggest study was conducted in 657 people and the smallest study involved 14 people. Most studies were done in European countries. Thirteen studies evaluated an oral spray (nabiximols) containing two compounds derived from the C annabis plant. The other studies compared different cannabinoids with placebo. Pharmaceutical companies funded 15 of the studies. Main results Compared with placebo, cannabinoids: • probably increase the number of people who report an important reduction of perceived severity of spasticity for up to 14 weeks (evidence from five studies in 1143 people); • may increase the number of people who report an important reduction of perceived severity of chronic neuropathic pain, but the evidence is very uncertain (evidence from one study in 48 people). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity: • probably increase the number of people who perceive their well‐being as 'very much' or 'much' improved (evidence from eight studies in 1215 people); • may increase slightly the number of people who discontinue treatment due to unwanted effects (evidence from 21 studies in 3110 people); • may result in little to no difference in the number of people who have serious harmful effects (evidence from 20 studies in 3124 people); • may increase nervous system disorders (evidence from seven studies in 1154 people) or psychiatric disorders (evidence from six studies in 1122 people); • may have little to no effect on the number of people who have drug tolerance, but the evidence is very uncertain (two studies in 458 people). What are the limitations of the evidence? There is no high‐quality evidence. We are moderately confident that cannabinoids work better versus no cannabinoids to improve severity of spasticity and well‐being in adults with MS. We have little confidence in our results for the effect on chronic neuropathic pain because the available evidence is limited. There is limited evidence to determine the effects of cannabinoids on serious harmful effects, nervous system or psychiatric disorders, and drug tolerance. How up to date is the evidence? 
The evidence is up‐to‐date to December 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Filippini, G; Minozzi, S; Borrelli, F; Cinquini, M; Dwan, K", "articleTypes": [], "doi": "10.1002/14651858.CD013444.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "f841c7e5-4f8c-47ec-a2e8-fdfdd78d9d57", "pmid": "", "title": "An Open-label, Non-randomized [11C]Carfentanil PET Study in Healthy Male Subjects to Investigate Brain Mu-opioid Receptor Occupancy, Pharmacokinetics, and Pharmacodynamics of Single Oral Doses of GSK1521498 and Naltrexone.", "imported": false, "abstract": "The purpose of this study is to determine whether GSK1521498 attaches to sites in the brain called mu-opioid receptors that are involved in the liking reactions to palatable high fat and high sugar foods. We hope that blocking these receptors may modify certain behaviours that may lead to obesity.", "journal": "", "year": "2009", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.149Z" }, { "id": "f8597da9-de63-4067-81b4-64fbba2b838e", "pmid": "", "title": "Short‐course oral steroids as an adjunct therapy for chronic rhinosinusitis", "imported": false, "abstract": "Abstract - Background This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. Objectives To assess the effects of a short course of oral corticosteroids as an adjunct ('add‐on') therapy in people with chronic rhinosinusitis who are already on standard treatments. Search methods The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Selection criteria Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids to placebo or no treatment, where all patients were also receiving pharmacological treatment for chronic rhinosinusitis. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score, and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics . Main results Two trials with a total of 78 participants met the inclusion criteria. Both the populations and the 'standard' treatments differed in the two studies. Oral steroids as an adjunct to intranasal corticosteroids One trial in adults with nasal polyps included 30 participants. All participants used intranasal corticosteroids and were randomised to either short‐course oral steroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 21‐day treatment course) or no additional treatment. None of the primary outcome measures of interest in this review were reported by the study. There may have been an important reduction in the size of the polyps (measured by the nasal polyps score, a secondary outcome measure) in patients receiving oral steroids and intranasal corticosteroids, compared to intranasal corticosteroids alone (mean difference (MD) ‐0.46, 95% confidence interval (CI) ‐0.87 to ‐0.05; 30 participants; scale 1 to 4) at the end of treatment (21 days). This corresponds to a large effect size, but we are very uncertain about this estimate as we judged the study to be at high risk of bias. Moreover, longer‐term data were not available and the other outcomes of interest were not reported. Oral steroids as an adjunct to antibiotics One trial in children (mean age of eight years) without nasal polyps included 48 participants. The trial compared oral corticosteroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 15‐day treatment course) with placebo in participants who also received a 30‐day course of antibiotics. This study addressed one of the primary outcome measures (disease severity) and one secondary outcome (CT score). For disease severity the four key symptoms used to define chronic rhinosinusitis in children (nasal blockage, nasal discharge, facial pressure, cough) were combined into one score. There was a greater improvement in symptom severity 30 days after the start of treatment in patients who received oral steroids and antibiotics compared with placebo and antibiotics (MD ‐7.10, 95% CI ‐9.59 to ‐4.61; 45 participants; scale 0 to 40). The observed mean difference corresponds to a large effect size. At the same time point there was a difference in CT scan score (MD ‐2.90, 95% CI ‐4.91 to ‐0.89; 45 participants; scale 0 to 24). We assessed the quality of the evidence to be low . There were no data available for the longer term (three months). Authors' conclusions There might be an improvement in symptom severity, polyps size and condition of the sinuses when assessed using CT scans in patients taking oral corticosteroids when these are used as an adjunct therapy to antibiotics or intranasal corticosteroids, but the quality of the evidence supporting this is low or very low (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). It is unclear whether the benefits of oral corticosteroids as an adjunct therapy are sustained beyond the short follow‐up period reported (up to 30 days), as no longer‐term data were available. There were no data in this review about the adverse effects associated with short courses of oral corticosteroids as an adjunct therapy. More research in this area, particularly research evaluating longer‐term outcomes and adverse effects, is required. Plain language summary Short‐term oral corticosteroids in addition to other treatments for chronic rhinosinusitis Review question We reviewed the evidence for the benefits and harms of adding a short course (typically up to 14 days) of corticosteroid given by mouth to people with chronic rhinosinusitis who were also receiving another type of treatment (such as corticosteroids delivered through the nose). Background Chronic rhinosinusitis is a common condition that is defined as inflammation of the nose and paranasal sinuses (a group of air‐filled spaces behind the nose, eyes and cheeks). Patients with chronic rhinosinusitis experience at least two or more of the following symptoms for at least 12 weeks: blocked nose, discharge from their nose or runny nose, pain or pressure in their face and/or a reduced sense of smell (hyposmia). Some people will also have nasal polyps, which are grape‐like swellings of the normal nasal lining inside the nasal passage and sinuses. Short courses of oral corticosteroids are a widely used treatment for chronic rhinosinusitis. They work by controlling inflammation and when polyps are present they rapidly reduce the size of the polyps to improve symptoms. The adverse effects of corticosteroids can include insomnia, mood changes and gastrointestinal changes (such as stomach pain, heartburn, diarrhoea, constipation, nausea and vomiting). When given over the longer term, or through many repeated short courses, it is also possible to develop osteoporosis (fragile bones). Study characteristics This review includes evidence up to 11 August 2015. We included two randomised controlled trials with a total of 78 participants. One trial involved 30 adults with nasal polyps. Participants received either intranasal corticosteroids and oral corticosteroids or only intranasal corticosteroids. The only result reported of interest to this review was whether the size of the nasal polyps was reduced, when these treatments were completed (three weeks). One trial involved 48 children (mean age of eight years) with chronic rhinosinusitis but no nasal polyps. Participants received either antibiotics and oral corticosteroids or only antibiotics and a placebo (sugar pill). The oral corticosteroids and placebo were given for 15 days and the antibiotics were given for 30 days. The trial reported findings when the antibiotic treatment was completed (at one month). Key results At the end of a three‐week treatment course, people who took both intranasal corticosteroids and oral steroids may have had smaller nasal polyps than people who just received intranasal corticosteroids. The trial did not follow up people to determine whether the polyp size increased after the end of the trial. The trial did not provide information on adverse events or other outcomes important to patients, such as symptom severity or quality of life. Children who received both antibiotics and oral corticosteroids seemed to have a lower total symptom score and better computerised tomography (CT) scan score after treatment compared with children who received antibiotics and control treatment. The reporting of adverse effects in this trial was not very clear and so is difficult to tell if any participant experienced gastrointestinal disturbances, mood changes or difficulty in sleeping. Quality of the evidence We judged the quality of the evidence for oral steroids plus intranasal steroids for adults with nasal polyps to be very low (we are very uncertain about the estimate) as the evidence comes from one trial that has a low number of participants. The trial had a high risk of bias due to the way it was conducted. The trial did not report adverse events and did not report results after the end of treatment. We judged the quality of the evidence for oral steroids plus antibiotics for children to be low (further research is very likely to have an important impact on our confidence in the effect estimate and is likely to change the estimate) as the evidence comes from one small trial. The trial did not have a high risk of bias, but it only included children without nasal polyps, who might not have the same results as adults with nasal polyps. The trial did not report results after the end of treatment and the adverse effects of treatment were not well reported.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Head, K; Chong, LY; Hopkins, C; Philpott, C; Schilder, AGM; Burton, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD011992.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "f8616bcc-b255-4aff-92f3-c728e18d52be", "pmid": "", "title": "Blood pressure lowering efficacy of potassium‐sparing diuretics (that block the epithelial sodium channel) for primary hypertension", "imported": false, "abstract": "Abstract - Background Potassium‐sparing diuretics, which block the epithelial sodium channel (ENaC), are widely prescribed for hypertension as a second‐line drug in patients taking other diuretics (e.g. thiazide diuretics) and much less commonly prescribed as monotherapy. Therefore, it is essential to determine the effects of ENaC blockers on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a first‐line or second‐line therapy. Objectives To quantify the dose‐related reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of ENaC blocker therapy as a first‐line or second‐line drug in patients with primary hypertension. Search methods We searched CENTRAL (The Cochrane Library 2012), MEDLINE (1950 to August 2012), EMBASE (1980 to August 2012) and reference lists of articles. Selection criteria Double‐blind, randomized, controlled trials in patients with primary hypertension that evaluate, for a duration of 3 to 12 weeks, the BP lowering efficacy of: 1) fixed‐dose monotherapy with an ENaC blocker compared with placebo; or 2) an ENaC blocker in combination with another class of anti‐hypertensive drugs compared with the respective monotherapy (without an ENaC blocker). Data collection and analysis Two authors independently assessed the risk of bias and extracted data. Study authors were contacted for additional information. WDAE information was also collected from the trials. Main results No trials evaluating the BP lowering efficacy of ENaC blockers as monotherapy in patients with primary hypertension were identified. Only 6 trials evaluated the BP lowering efficacy of low doses of amiloride and triamterene as a second drug in 496 participants with a baseline BP of 151/102 mm Hg. The additional BP reduction caused by the ENaC blocker as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. The addition of low doses of amiloride and triamterene in these trials did not reduce BP. An estimate of the dose‐related BP lowering efficacy for ENaC blockers was not possible because of a lack of trial data at higher doses. Authors' conclusions ENaC blockers do not have a statistically or clinically significant BP lowering effect at low doses but trials at higher doses are not available. The review did not provide a good estimate of the incidence of harms associated with ENaC blockers. Plain language summary The blood pressure lowering effect of ENaC blockers is not known Potassium‐sparing diuretics, which block the epithelial sodium channel (also called ENaC blockers), are a class of drugs commonly prescribed to prevent loss of potassium but also might help to lower elevated blood pressure. This class includes drugs such as amiloride (Midamor, Amilzide) and triamterene (Dyrenium, Dyazide). We asked how much this class of drugs lowers blood pressure, when used alone or when used as the second drug to treat hypertension. The available scientific literature was searched to find all the trials that had assessed this question. No trials were found studying the blood pressure lowering ability of ENaC blockers when used alone. We found 6 trials studying the blood pressure lowering ability of amiloride and triamterene, when added as a second drug, in 496 participants. All 6 trials studied the ENaC blockers at low doses and there was no blood pressure lowering effect. Trials studying these drugs at higher doses are needed in order to determine if they lower blood pressure. The harms associated with ENaC blockers could not be estimated in this review because of the low doses studied and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Heran, BS; Chen, JMH; Wang, JJ; Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD008167.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "f87b51fb-e1e5-49fe-9580-3f92ee222676", "pmid": "", "title": "Omega 3 fatty acids for preventing or slowing the progression of age‐related macular degeneration", "imported": false, "abstract": "Abstract - Background Evidence from animal models and observational studies in humans has suggested that there is an inverse relationship between dietary intake of omega 3 long‐chain polyunsaturated fatty acids (LCPUFA) and risk of developing age‐related macular degeneration (AMD) or progression to advanced AMD. Objectives To review the evidence that increasing the levels of omega 3 LCPUFA in the diet (either by eating more foods rich in omega 3 or by taking nutritional supplements) prevents AMD or slows the progression of AMD. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 1), Ovid MEDLINE, Ovid MEDLINE In‐Process and Other Non‐Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2015), EMBASE (January 1980 to February 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to February 2015), the ISRCTN registry ( www.isrctn.com/editAdvancedSearch ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 February 2015. Selection criteria We included randomised controlled trials (RCTs) where increased dietary intake of omega 3 LCPUFA was compared to placebo or no intervention with the aim of preventing the development of AMD, or slowing its progression. Data collection and analysis Both authors independently selected studies, assessed them for risk of bias and extracted data. One author entered data into RevMan 5 and the other author checked the data entry. We conducted a meta‐analysis for one primary outcome, progression of AMD, using a fixed‐effect inverse variance model. Main results We included two RCTs in this review, in which 2343 participants with AMD were randomised to receive either omega 3 fatty acid supplements or a placebo. The trials, which had a low risk of bias, were conducted in the USA and France. Overall, there was no evidence that people who took omega 3 fatty acid supplements were at decreased (or increased risk) of progression to advanced AMD (pooled hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.84 to 1.10, high quality evidence). Similarly, people taking these supplements were no more (or less) likely to lose 15 or more letters of visual acuity (USA study HR 0.96, 95% CI 0.84 to 1.10; French study at 36 months risk ratio (RR) 1.25, 95% CI 0.69 to 2.26, participants = 230). The number of adverse events was similar in the intervention and placebo groups (USA study participants with one or more serious adverse event RR 1.00, 95% CI 0.91 to 1.09, participants = 2080; French study total adverse events RR 1.05, 95% CI 0.97 to 1.13, participants = 263). Authors' conclusions This review found that omega 3 LCPUFA supplementation in people with AMD for periods up to five years does not reduce the risk of progression to advanced AMD or the development of moderate to severe visual loss. No published randomised trials were identified on dietary omega 3 fatty acids for primary prevention of AMD. Currently available evidence does not support increasing dietary intake of omega 3 LCPUFA for the explicit purpose of preventing or slowing the progression of AMD. Plain language summary Omega 3 fatty acids for preventing and slowing the progression of age‐related macular degeneration Review question 
 We asked the question whether increased dietary intake of omega 3 fatty acids prevented or slowed the progression of age‐related macular degeneration. Background 
 Age‐related macular degeneration (AMD) is an eye condition that affects the central area of the retina (light‐sensitive tissue at the back of the eye). AMD is associated with a loss of detailed vision and adversely affects tasks such as reading, driving and face recognition. In the absence of a cure, there has been considerable interest in the role of modifiable risk factors to prevent or slow down the progression of AMD. Evidence from population studies suggests that people who have a diet with relatively high levels of omega 3 fatty acids (such as those derived from fish oils) are less likely to develop AMD. Study characteristics 
 We searched for studies up to 2 February 2015. We identified two trials with a total of 2343 participants. The trials were conducted in the USA and France and investigated the use of fish oil supplements in people with AMD who were at high risk of progressing to advanced disease. We judged the studies to be at low risk of bias. One study was funded by government grants and the other study was funded by the manufacturer of the dietary supplement. Key results 
 These studies found that omega 3 supplementation for periods up to five years did not reduce the rate of progression to advanced AMD or reduce significant visual loss compared to a placebo. The incidence of adverse effects was similar in the intervention and placebo groups. Quality of the evidence 
 We judged the quality of the evidence on rate of progression to AMD to be high, and the quality of the evidence for other outcomes to be moderate because the estimates were imprecise.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Lawrenson, JG; Evans, JR", "articleTypes": [], "doi": "10.1002/14651858.CD010015.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "f881786f-3ce3-4d06-8068-99e4abafd503", "pmid": "", "title": "A Phase 2, Randomized, Double Blind, Placebo Controlled Study to Evaluate the Efficacy and Safety of Leronlimab in Patients Experiencing Prolonged Coronavirus Disease 2019 (COVID-19) Symptoms [Long-Haulers]", "imported": false, "abstract": "The purpose of this study is to assess the safety and efficacy of leronlimab (PRO 140) administered as weekly subcutaneous injections in subjects experiencing prolonged symptoms (> 12 weeks) of COVID-19.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.154Z" }, { "id": "f8880251-eb77-4b4a-aec2-d2430e87f46f", "pmid": "", "title": "Topical lidocaine for neuropathic pain in adults", "imported": false, "abstract": "Abstract - Background Lidocaine is a local anaesthetic that is sometimes used on the skin to treat neuropathic pain. Objectives To assess the analgesic efficacy of topical lidocaine for chronic neuropathic pain in adults, and to assess the associated adverse events. Search methods We searched CENTRAL, MEDLINE, and EMBASE from inception to 1 July 2014, together with the reference lists of retrieved papers and other reviews. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal to identify additional published or unpublished data. Selection criteria We included randomised, double‐blind studies of at least two weeks' duration comparing any formulation of topical lidocaine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 and over. We included only full journal publication articles. Data collection and analysis Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention‐to‐treat analysis without imputation for dropouts; at least 200 participants in the comparison, 8 to 12 weeks' duration, parallel design); second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison; and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. Main results We included 12 studies (508 participants) in comparisons with placebo or an active control. Six studies enrolled participants with moderate or severe postherpetic neuralgia, and the remaining studies enrolled different, or mixed, neuropathic pain conditions, including trigeminal neuralgia and postsurgical or post‐traumatic neuralgia. Four different formulations were used: 5% medicated patch, 5% cream, 5% gel, and 8% spray. Most studies used a cross‐over design, and two used a parallel‐group design. Two studies used enriched enrolment with randomised withdrawal. Seven studies used multiple doses, with one to four‐week treatment periods, and five used single applications. We judged all of the studies at high risk of bias because of small size or incomplete outcome assessment, or both. There was no first or second tier evidence, and no pooling of data was possible for efficacy outcomes. Only one multiple‐dose study reported our primary outcome of participants with ≥ 50% or ≥ 30% pain intensity reduction. Three single‐dose studies reported participants who were pain‐free at a particular time point, or had a 2‐point (of 10) reduction in pain intensity. The two enriched enrolment, randomised withdrawal studies reported time to loss of efficacy. In all but one study, third tier (very low quality) evidence indicated that lidocaine was better than placebo for some measure of pain relief. Pooling multiple‐dose studies across conditions demonstrated no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals, but there were few events and the withdrawal phase of enriched enrolment designs is not suitable to assess the true impact of adverse events (very low quality evidence). Authors' conclusions This review found no evidence from good quality randomised controlled studies to support the use of topical lidocaine to treat neuropathic pain, although individual studies indicated that it was effective for relief of pain. Clinical experience also supports efficacy in some patients. Several large ongoing studies, of adequate duration, with clinically useful outcomes should provide more robust conclusions about both efficacy and harm. Plain language summary Topical lidocaine for neuropathic pain in adults Neuropathic pain is pain coming from damaged nerves. It differs from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are usually not effective in neuropathic pain, while medicines that are sometimes used to treat epilepsy or depression can be very effective in some people with neuropathic pain. Other possible treatments include the use of local anaesthetic applied to the skin. Lidocaine is a local anaesthetic. It is available in plasters (or patches), sprays, and creams, as topical lidocaine. These contain high concentrations of lidocaine because it crosses the skin poorly. Treatment with plasters usually involves applying one, two, or three plasters for up to 12 hours a day. In July 2014 we performed searches to look for clinical trials where topical lidocaine was used to treat neuropathic pain. We found 12 small studies of modest quality that tested topical lidocaine against topical placebo for a number of weeks. One study also tested a cream containing amitriptyline, which is an antidepressant. The 508 people in the studies had different types of neuropathic pain, with pain after herpes zoster infection the most common. There was some indication that topical lidocaine was beneficial in these studies (very low quality evidence). There was no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals (very low quality evidence). A number of studies of topical lidocaine in neuropathic pain are ongoing. Several are large and of long duration. They will be of great help in working out the benefits of topical lidocaine when they are completed and results can be incorporated in this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Derry, S; Wiffen, PJ; Moore, RA; Quinlan, J", "articleTypes": [], "doi": "10.1002/14651858.CD010958.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "f88a7bba-7277-4549-a0be-7e7e1249efe8", "pmid": "", "title": "Impact of active placebo controls on estimated drug effects in randomised trials: a systematic review of trials with both active placebo and standard placebo", "imported": false, "abstract": "Abstract - Background An estimated 60% of pharmacological randomised trials use placebo control interventions to blind (i.e. mask) participants. However, standard placebos do not control for perceptible non‐therapeutic effects (i.e. side effects) of the experimental drug, which may unblind participants. Trials rarely use active placebo controls, which contain pharmacological compounds designed to mimic the non‐therapeutic experimental drug effects in order to reduce the risk of unblinding. A relevant improvement in the estimated effects of active placebo compared with standard placebo would imply that trials with standard placebo may overestimate experimental drug effects. Objectives We aimed to estimate the difference in drug effects when an experimental drug is compared with an active placebo versus a standard placebo control intervention, and to explore causes for heterogeneity. In the context of a randomised trial, this difference in drug effects can be estimated by directly comparing the effect difference between the active placebo and standard placebo intervention. Search methods We searched PubMed, CENTRAL, Embase, two other databases, and two trial registries up to October 2020. We also searched reference lists and citations and contacted trial authors. Selection criteria We included randomised trials that compared an active placebo versus a standard placebo intervention. We considered trials both with and without a matching experimental drug arm. Data collection and analysis We extracted data, assessed risk of bias, scored active placebos for adequacy and risk of unintended therapeutic effect, and categorised active placebos as unpleasant, neutral, or pleasant. We requested individual participant data from the authors of four cross‐over trials published after 1990 and one unpublished trial registered after 1990. Our primary inverse‐variance, random‐effects meta‐analysis used standardised mean differences (SMDs) of active versus standard placebo for participant‐reported outcomes at earliest post‐treatment assessment. A negative SMD favoured the active placebo. We stratified analyses by trial type (clinical or preclinical) and supplemented with sensitivity and subgroup analyses and meta‐regression. In secondary analyses, we investigated observer‐reported outcomes, harms, attrition, and co‐intervention outcomes. Main results We included 21 trials (1462 participants). We obtained individual participant data from four trials. Our primary analysis of participant‐reported outcomes at earliest post‐treatment assessment resulted in a pooled SMD of −0.08 (95% confidence interval (CI) −0.20 to 0.04; I 2 = 31%; 14 trials), with no clear difference between clinical and preclinical trials. Individual participant data contributed 43% of the weight of this analysis. Two of seven sensitivity analyses found more pronounced and statistically significant differences; for example, in the five trials with low overall risk of bias, the pooled SMD was −0.24 (95% CI −0.34 to −0.13). The pooled SMD of observer‐reported outcomes was similar to the primary analysis. The pooled odds ratio (OR) for harms was 3.08 (95% CI 1.56 to 6.07), and for attrition, 1.22 (95% CI 0.74 to 2.03). Co‐intervention data were limited. Meta‐regression found no statistically significant association with adequacy of the active placebo or risk of unintended therapeutic effect. Authors' conclusions We did not find a statistically significant difference between active and standard placebo control interventions in our primary analysis, but the result was imprecise and the CI compatible with a difference ranging from important to irrelevant. Furthermore, the result was not robust, because two sensitivity analyses produced a more pronounced and statistically significant difference. We suggest that trialists and users of information from trials carefully consider the type of placebo control intervention in trials with high risk of unblinding, such as those with pronounced non‐therapeutic effects and participant‐reported outcomes. Plain language summary Do treatment effects in randomised trials differ when using active placebo compared to standard placebo? Key messages 1. We found no clear difference in effect between active and standard placebos, but we are very uncertain about the results. 2. We suggest that researchers carefully consider the type of placebo when investigating medicines with clear side effects. What are standard placebos and active placebos? Blinding (or masking) is an important part of randomised trials and ensures that participants and healthcare providers are not influenced by knowing whether the participant is receiving the experimental treatment. If they had this knowledge, they might unintentionally overestimate (or underestimate) the effect of the treatment. One method of blinding is to give the non‐treated group of participants a placebo, which looks like the medicine (e.g. a tablet of similar shape, colour, smell, taste, and texture) but does not contain its active ingredients. Blinding with a placebo may not always be successful. The treatment may have side effects that distinguish it from the placebo so that the treatment effect is still not measured accurately. For this reason, some trials use active placebos, which mimic some of the side effects of the experimental medicine. However, it is unclear whether the choice of placebo type actually makes a difference to the treatment effects. What did we want to find out? We wanted to find out whether treatment effects in randomised trials differ when using active placebos compared to standard placebos. What did we do? We collected and analysed trials that directly compared the two types of placebo, or that compared both placebos with an experimental medicine. If people receiving active placebo experience better results than those receiving standard placebo, this difference might be due to them believing that they are receiving the experimental medicine. It would also mean that in trials that compare a medicine with standard placebo, the beneficial effect of the medicine is exaggerated. This is important if the measured benefits of the treatment are small or moderate and thus especially sensitive to changes in the methods used for the trial. What did we find? We included 21 trials in this review, covering subjects such as pain and psychiatry. We found no clear difference between the two types of placebo in participant‐reported outcomes (such as pain intensity). However, because the result was uncertain, the possible range of this result included both no difference and a potentially important difference in favour of active placebo. When we limited our analysis to higher‐quality trials, active placebos were more beneficial than standard placebos, but these trials were not typical clinical trials and might not be applicable to clinical scenarios.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Laursen, DRT; Nejstgaard, CH; Bjørkedal, E; Frost, AD; Hansen, MR; Paludan-Müller, AS; Prosenz, J; Werner, CP; Hróbjartsson, A", "articleTypes": [], "doi": "10.1002/14651858.MR000055.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "f89253b7-1d25-4cff-8ab3-f6b1ede1c3df", "pmid": "", "title": "Vitamin C for preventing and treating the common cold", "imported": false, "abstract": "Abstract - Background Vitamin C (ascorbic acid) for preventing and treating the common cold has been a subject of controversy for 70 years. Objectives To find out whether vitamin C reduces the incidence, the duration or severity of the common cold when used either as a continuous regular supplementation every day or as a therapy at the onset of cold symptoms. Search methods We searched CENTRAL 2012, Issue 11, MEDLINE (1966 to November week 3, 2012), EMBASE (1990 to November 2012), CINAHL (January 2010 to November 2012), LILACS (January 2010 to November 2012) and Web of Science (January 2010 to November 2012). We also searched the U.S. National Institutes of Health trials register and WHO ICTRP on 29 November 2012. Selection criteria We excluded trials which used less than 0.2 g per day of vitamin C and trials without a placebo comparison. We restricted our review to placebo‐controlled trials. Data collection and analysis Two review authors independently extracted data. We assessed 'incidence' of colds during regular supplementation as the proportion of participants experiencing one or more colds during the study period. 'Duration' was the mean number of days of illness of cold episodes. Main results Twenty‐nine trial comparisons involving 11,306 participants contributed to the meta‐analysis on the risk ratio (RR) of developing a cold whilst taking vitamin C regularly over the study period. In the general community trials involving 10,708 participants, the pooled RR was 0.97 (95% confidence interval (CI) 0.94 to 1.00). Five trials involving a total of 598 marathon runners, skiers and soldiers on subarctic exercises yielded a pooled RR of 0.48 (95% CI 0.35 to 0.64). Thirty‐one comparisons examined the effect of regular vitamin C on common cold duration (9745 episodes). In adults the duration of colds was reduced by 8% (3% to 12%) and in children by 14% (7% to 21%). In children, 1 to 2 g/day vitamin C shortened colds by 18%. The severity of colds was also reduced by regular vitamin C administration. Seven comparisons examined the effect of therapeutic vitamin C (3249 episodes). No consistent effect of vitamin C was seen on the duration or severity of colds in the therapeutic trials. The majority of included trials were randomised, double‐blind trials. The exclusion of trials that were either not randomised or not double‐blind had no effect on the conclusions. Authors' conclusions The failure of vitamin C supplementation to reduce the incidence of colds in the general population indicates that routine vitamin C supplementation is not justified, yet vitamin C may be useful for people exposed to brief periods of severe physical exercise. Regular supplementation trials have shown that vitamin C reduces the duration of colds, but this was not replicated in the few therapeutic trials that have been carried out. Nevertheless, given the consistent effect of vitamin C on the duration and severity of colds in the regular supplementation studies, and the low cost and safety, it may be worthwhile for common cold patients to test on an individual basis whether therapeutic vitamin C is beneficial for them. Further therapeutic RCTs are warranted. Plain language summary Vitamin C for preventing and treating the common cold The common cold is a major cause of visits to a doctor in high‐income countries and of absenteeism from work and school. There are over 200 viruses which can cause the common cold symptoms including runny nose, congestion, sneezing, sore throat, cough, and sometimes headache, fever and red eyes. Symptoms vary from person to person and cold to cold. Since the common cold is usually caused by one of the respiratory viruses, antibiotics are useless and therefore other potential treatment options are of substantial public health interest. Vitamin C has been proposed for treating respiratory infections since it was isolated in the 1930s. It became particularly popular in the 1970s when Nobel laureate Linus Pauling concluded from earlier placebo‐controlled trials that vitamin C would prevent and alleviate the common cold. Over two dozen new trials were undertaken thereafter. Vitamin C has been widely sold and used as a preventive and therapeutic agent. This review is restricted to placebo‐controlled trials testing 0.2 g/day or more of vitamin C. Regular ingestion of vitamin C had no effect on common cold incidence in the ordinary population, based on 29 trial comparisons involving 11,306 participants. However, regular supplementation had a modest but consistent effect in reducing the duration of common cold symptoms, which is based on 31 study comparisons with 9745 common cold episodes. In five trials with 598 participants exposed to short periods of extreme physical stress (including marathon runners and skiers) vitamin C halved the common cold risk. The published trials have not reported adverse effects of vitamin C. Trials of high doses of vitamin C administered therapeutically, starting after the onset of symptoms, showed no consistent effect on the duration or severity of common cold symptoms. However, only a few therapeutic trials have been carried out and none have examined children, although the effect of prophylactic vitamin C has been greater in children. One large trial with adults reported benefit from an 8 g therapeutic dose at the onset of symptoms, and two therapeutic trials using five‐day supplementation reported benefit. More trials are necessary to settle the possible role of therapeutic vitamin C, meaning administration immediately after the onset of symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Hemilä, H; Chalker, E", "articleTypes": [], "doi": "10.1002/14651858.CD000980.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "f8ace843-7164-4cc2-8ec5-15cb70653cfe", "pmid": "", "title": "Interventions for treating oro‐antral communications and fistulae due to dental procedures", "imported": false, "abstract": "Abstract - Background An oro‐antral communication is an unnatural opening between the oral cavity and maxillary sinus. When it fails to close spontaneously, it remains patent and is epithelialized to develop into an oro‐antral fistula. Various surgical and non‐surgical techniques have been used for treating the condition. Surgical procedures include flaps, grafts and other techniques like re‐implantation of third molars. Non‐surgical techniques include allogenic materials and xenografts. This is an update of a review first published in May 2016. Objectives To assess the effectiveness and safety of various interventions for the treatment of oro‐antral communications and fistulae due to dental procedures. Search methods Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 23 May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 4), MEDLINE Ovid (1946 to 23 May 2018), and Embase Ovid (1980 to 23 May 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the reference lists of included and excluded trials for any randomised controlled trials (RCTs). Selection criteria We included RCTs evaluating any intervention for treating oro‐antral communications or oro‐antral fistulae due to dental procedures. We excluded quasi‐RCTs and cross‐over trials. We excluded studies on participants who had oro‐antral communications, fistulae or both related to Caldwell‐Luc procedure or surgical excision of tumours. Data collection and analysis Two review authors independently selected trials. Two review authors assessed trial risk of bias and extracted data independently. We estimated risk ratios (RR) for dichotomous data, with 95% confidence intervals (CI). We assessed the overall quality of the evidence using the GRADE approach. Main results We included only one study in this review, which compared two surgical interventions: pedicled buccal fat pad flap and buccal flap for the treatment of oro‐antral communications. The study involved 20 participants. The risk of bias was unclear. The relevant outcome reported in this trial was successful (complete) closure of oro‐antral communication. The quality of the evidence for the primary outcome was very low. The study did not find evidence of a difference between interventions for the successful (complete) closure of an oro‐antral communication (RR 1.00, 95% Cl 0.83 to 1.20) one month after the surgery. All oro‐antral communications in both groups were successfully closed so there were no adverse effects due to treatment failure. We did not find trials evaluating any other intervention for treating oro‐antral communications or fistulae due to dental procedures. Authors' conclusions We found very low quality evidence from a single small study that compared pedicled buccal fat pad and buccal flap. The evidence was insufficient to judge whether there is a difference in the effectiveness of these interventions as all oro‐antral communications in the study were successfully closed by one month after surgery. Large, well‐conducted RCTs investigating different interventions for the treatment of oro‐antral communications and fistulae caused by dental procedures are needed to inform clinical practice. Plain language summary Treatment of communications between the oral cavity and the maxillary sinus due to dental procedures Review question What evidence is available for the safe and effective treatment of openings between the mouth and main sinus caused by dental procedures? Background The floor of the main sinus near the nose is thin and lies directly above the roots of the teeth at the back of the mouth. Sometimes following infection or dental treatment, this structure becomes damaged and openings or channels between the mouth and the sinus are formed. These are known as oro‐antral communications (OAC). If the OAC is left open (then described as an oro‐antral fistula (OAF), it may become permanent, leading to long‐lasting sinus infections. This condition can be treated surgically by using flaps, grafts and other techniques; or non‐surgically using a variety of methods and materials. There is little evidence for the most effective and safe treatments for closing OACs and OAFs and clinicians who treat these conditions have identified an urgent need for this. This is an update of a review first published in May 2016. Study characteristics We searched various databases until 23 May 2018. Only one study, which was conducted in Iran, is included in our review. The study ran for two years and involved 20 people with OAC aged between 25 and 56 years. Participants were divided into two groups and two surgical treatments were compared for treating oro‐antral communications; one group was treated with pedicled buccal fat pad flap (PBFPF) and the other with buccal flap (BF). Key results and quality of evidence The study did not find evidence of a difference between PBFPF and BF in terms of successful (complete) closure of OAC. Both interventions resulted in successful closure by one month after surgery. The study did not therefore report any adverse effects of treatment failure. It may not be possible to generalise these findings because the quality of the evidence was very low, due to unclear risk of bias and the small numbers studied in the single included trial. Conclusion The evidence currently available is insufficient to draw reliable conclusions regarding the effects of interventions used to treat OAC or fistulae due to dental procedures. More well‐designed and well‐reported trials evaluating different interventions are needed to provide reliable evidence to inform clinical decisions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Kiran Kumar Krishanappa, S, Eachempati, P, Kumbargere Nagraj, S, Shetty, NY, Moe, S, Aggarwal, H, Mathew, RJ", "articleTypes": [], "doi": "10.1002/14651858.CD011784.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.770Z" }, { "id": "f8c300b3-8836-412b-ac2d-804251eccec7", "pmid": "", "title": "Sweet potato for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Sweet potato ( Ipomoea batatas ) is among the most nutritious subtropical and tropical vegetables. It is also used in traditional medicine practices for type 2 diabetes mellitus. Research in animal and human models suggests a possible role of sweet potato in glycaemic control. Objectives To assess the effects of sweet potato for type 2 diabetes mellitus. Search methods We searched several electronic databases, including The Cochrane Library (2013, Issue 1), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2013), combined with handsearches. No language restrictions were used. Selection criteria We included randomised controlled trials (RCTs) that compared sweet potato with a placebo or a comparator intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently selected the trials and extracted the data. We evaluated risk of bias by assessing randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. Main results Three RCTs met our inclusion criteria: these investigated a total of 140 participants and ranged from six weeks to five months in duration. All three studies were performed by the same trialist. Overall, the risk of bias of these trials was unclear or high. All RCTs compared the effect of sweet potato preparations with placebo on glycaemic control in type 2 diabetes mellitus. There was a statistically significant improvement in glycosylated haemoglobin A1c (HbA1c) at three to five months with 4 g/day sweet potato preparation compared to placebo (mean difference ‐0.3% (95% confidence interval ‐0.6 to ‐0.04); P = 0.02; 122 participants; 2 trials). No serious adverse effects were reported. Diabetic complications and morbidity, death from any cause, health‐related quality of life, well‐being, functional outcomes and costs were not investigated. Authors' conclusions There is insufficient evidence about the use of sweet potato for type 2 diabetes mellitus. In addition to improvement in trial methodology, issues of standardization and quality control of preparations ‐ including other varieties of sweet potato ‐ need to be addressed. Further observational trials and RCTs evaluating the effects of sweet potato are needed to guide any recommendations in clinical practice. Plain language summary Sweet potato for type 2 diabetes mellitus Sweet potato ( Ipomoea batatas ) is a plant found in the tropical and subtropical belts and is one of the most nutritious tropical and subtropical vegetables. As well as being popular in cooking in countries in Asia‐Pacific, Africa and North America, sweet potato is also used in traditional medicine for the treatment of diabetes mellitus. We decided to investigate whether there is enough evidence from medical trials to show whether sweet potato works as a treatment for diabetes. This review of randomised controlled trials found only three studies (with a total of 140 participants) that evaluated the effects of sweet potato for type 2 diabetes mellitus compared with a fake medicine (placebo). All these trials were of very low quality. Two studies with 122 participants showed improved long‐term metabolic control of blood sugar levels as measured by glycosylated haemoglobin A1c (HbA1c) which was moderately lowered by 0.3% in participants who were given 4 g sweet potato tablets a day for three to five months. The duration of treatment ranged from six weeks to five months. No study investigated diabetic complications, death from any cause, health‐related quality of life, well‐being, functional outcomes or costs. Adverse effects were mostly mild, and included abdominal distension and pain. There are many varieties of sweet potatoes and sweet potato preparations. More trials are needed to assess the quality of the various sweet potato preparations as well as to evaluate further the use of different varieties of sweet potato in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Ooi, CP; Loke, SC", "articleTypes": [], "doi": "10.1002/14651858.CD009128.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "f8c33069-6f6d-4b20-871f-7f06f7e693f4", "pmid": "", "title": "Glutamine for induction of remission in Crohn's disease", "imported": false, "abstract": "Abstract - Background Crohn's disease is a chronic relapsing condition of the alimentary tract with a high morbidity secondary to bowel inflammation. Glutamine plays a key role in maintaining the integrity of the intestinal mucosa and has been shown to reduce inflammation and disease activity in experimental models of Crohn's disease. Objectives To evaluate the efficacy and safety of glutamine supplementation for induction of remission in Crohn's disease. Search methods We searched the following databases from inception to November 15, 2015: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane IBD Group Specialised Register. Study references were also searched for additional trials. There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) that compared glutamine supplementation administered by any route to a placebo, active comparator or no intervention in people with active Crohn's disease were considered for inclusion. Data collection and analysis Two authors independently extracted data and assessed the methodological quality of the included studies. The Cochrane risk of bias tool was used to assess methodological quality. The primary outcome measure was clinical or endoscopic remission. Secondary outcomes included intestinal permeability, clinical response, quality of life, growth in children and adverse events. Risk ratios and 95% confidence intervals were calculated for dichotomous outcomes. The overall quality of the evidence supporting the primary outcome was evaluated using the GRADE criteria. Main results Two small RCTs (total 42 patients) met the inclusion criteria and were included in the review. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. The other study (24 patients) compared glutamine‐supplemented total parenteral nutrition to non‐supplemented total parenteral nutrition in adult patients (> 18 years of age) with acute exacerbation of inflammatory bowel disease. The paediatric study was rated as low risk of bias. The study in adult patients was rated as unclear risk of bias for blinding and low risk of bias for all other items. It was not possible to pool data for meta‐analysis because of significant differences in study populations, nature of interventions, and the way outcomes were assessed. Data from one study showed no statistically significant difference in clinical remission rates at four weeks. Forty‐four per cent (4/9) of patients who received a glutamine‐enriched polymeric diet achieved remission compared to 56% (5/9) of patients who received a standard low‐glutamine polymeric diet (RR 0.80, 95% CI 0.31 to 2.04). A GRADE analysis indicated that the overall quality of evidence for this outcome was low due to serious imprecision (9 events). In both included studies, no statistically significant changes in intestinal permeability were found between patients who received glutamine supplementation and those who did not. Neither study reported on clinical response, quality of life or growth in children. Adverse event data were not well documented. There were no serious adverse events in the paediatric study. The study in adult patients reported three central catheter infections with positive blood cultures in the glutamine group compared to none in the control group (RR 7.00, 95% CI 0.40 to 122.44). Authors' conclusions Currently there is insufficient evidence to allow firm conclusions regarding the efficacy and safety of glutamine for induction of remission in Crohn's disease. Data from two small studies suggest that glutamine supplementation may not be beneficial in active Crohn's disease but these results need to be interpreted with caution as they are based on small numbers of patients. This review highlights the need for adequately powered randomised controlled trials to investigate the efficacy and safety of glutamine for induction of remission in Crohn's disease. Plain language summary Glutamine for treatment of active Crohn's disease What is Crohn's disease? Crohn's disease is a chronic inflammatory disorder of the intestines which has periods of inactivity and periods when it flares up. Crohn's disease can affect any part of the digestive tract, from the mouth to the anus. The most common symptoms of the disease include abdominal pain, non‐bloody diarrhoea and weight loss. When people with Crohn's disease are experiencing symptoms of the disease it is said to be ‘active’; periods when the symptoms stop are called ‘remission’. What is glutamine? Glutamine is an amino acid that plays a key role in maintaining the integrity of the intestinal mucosa (lining of the intestines) and has been shown to reduce inflammation and disease activity in animal models of Crohn's disease. It has therefore been suggested that glutamine may reduce intestinal inflammation in people with Crohn's disease. What did the researchers investigate? The researchers investigated whether glutamine is effective for inducing remission in people with active Crohn's disease and whether this treatment causes any harms (side effects). The researchers searched the medical literature up to November 15, 2015. What did the researchers find? The researchers identified two randomised controlled trials (total 42 participants) that investigated the role of glutamine for the treatment of active Crohn's disease. One study (18 patients) compared four weeks of treatment with a glutamine‐enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. Participants were encouraged to consume the diet orally. If this was not possible the diet was administered via a fine‐bore nasogastric tube. The other study (24 participants) compared glutamine‐supplemented total parenteral nutrition (TPN) to non‐supplemented TPN in adult patients (> 18 years of age) with sudden worsening of inflammatory bowel disease. The TPN diet was administered intravenously via a central catheter (a thin tube) for at least one week. Both studies were generally high quality. Neither study demonstrated any beneficial effects for glutamine. Side effects were not well documented in the two studies. There were no serious side effects noted in the paediatric study. The study in adult patients reported three central catheter‐related blood infections in the glutamine group compared to none in the non‐glutamine control group. Currently, there is insufficient evidence to allow any firm conclusions regarding the effectiveness and harms of glutamine for the treatment of active Crohn's disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Akobeng, AK, Elawad, M, Gordon, M", "articleTypes": [], "doi": "10.1002/14651858.CD007348.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.769Z" }, { "id": "f8c53f37-c57c-4cb4-870b-ff2fe2f5ef0a", "pmid": "", "title": "Efficacy of Bitter Taste Blockers on Flavor Acceptance in Pediatric Populations", "imported": false, "abstract": "This proposal describes 2 basic research studies that will be conducted sequentially. Study 1 will test the efficacy of both classic and newly developed \"generally recognized as a safe\" (GRAS) bitter blockers on the perceived bitterness and acceptance of different classes of bitter-tasting compounds by children and compare their responses to adults. Because variations among and between children and adults in terms of sensitivity to different bitter compounds are due in part to genetically determined receptor variation, the investigators will consider genotype when assessing how well bitter blockers perform. In Study 2, the investigators aim to evaluate different methods (forced-choice procedures, hedonic face scales) used for testing children to determine their reliability and reproducibility.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "f8c8fd58-ae5d-4805-99e7-b793ece5b98c", "pmid": "", "title": "Nebulized and oral thiol derivatives for pulmonary disease in cystic fibrosis", "imported": false, "abstract": "Abstract - Background Cystic fibrosis is an inherited condition resulting in thickened, sticky respiratory secretions. Respiratory failure, due to recurrent pulmonary infection and inflammation, is the most common cause of mortality. Muco‐active therapies (e.g. dornase alfa and nebulized hypertonic saline) may decrease sputum viscosity, increase airway clearance of sputum, reduce infection and inflammation and improve lung function. Thiol derivatives, either oral or nebulized, have shown benefit in other respiratory diseases. Their mode of action is likely to differ according to the route of administration. There are several thiol derivatives, and it is unclear which of these may be beneficial in cystic fibrosis. Objectives To evaluate the efficacy and safety of nebulized and oral thiol derivatives in people with cystic fibrosis. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches, hand searches of relevant journals, abstract books and conference proceedings. Most recent search: 13 June 2013. We also conducted a PubMed search on 26 February 2013 for relevant published articles. Selection criteria Randomized and quasi‐randomized controlled trials comparing nebulized or oral thiol derivatives to placebo or another thiol derivative in people with cystic fibrosis. Data collection and analysis The authors independently assessed trials for inclusion, analysed risk of bias and extracted data. Main results Searches identified 23 trials; nine trials (255 participants) are included, of these seven trials are more than 10 years old. Three trials of nebulized thiol derivatives were identified (one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and another compared glutathione to 4% hypertonic saline). Although generally well‐tolerated with no significant adverse effects, there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Six trials of oral thiol derivatives were identified. Three trials compared N‐acetylcysteine to placebo; one compared N‐acetylcysteine, ambroxol and placebo; one compared carbocysteine to ambroxol; and one compared low and high‐dose N‐acetylcysteine. Oral thiol derivatives were generally well‐tolerated with no significant adverse effects, however there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. Authors' conclusions We found no evidence to recommend the use of either nebulized or oral thiol derivatives in people with cystic fibrosis. There are very few good quality trials investigating the effect of these medications in cystic fibrosis, and further research is required to investigate the potential role of these medications in improving the outcomes of people with cystic fibrosis. Plain language summary Compounds which can break down the structure of mucus for lung disease in cystic fibrosis Cystic fibrosis is a genetic disorder which mainly affects the lungs. Chest infections recur in people with cystic fibrosis due to a build up of thick sputum (phlegm) in the air passages. Several treatments, including thiol derivatives, aim to loosen this sputum and so improve lung function and reduce the frequency of chest infections. Thiol derivatives may be either nebulized (breathed in) or oral (by mouth). They have been shown to help in other lung conditions, such as chronic obstructive pulmonary disease. This review aims to find out if there is enough evidence to recommend the use of nebulized or oral thiol derivatives for people with cystic fibrosis. We included nine trials; three assessed the effect of nebulized thiol derivatives. Of the nebulized trials, one compared 20% N‐acetylcysteine to 2% N‐acetylcysteine; another compared sodium‐2‐mercaptoethane sulphonate to 7% hypertonic saline; and the other compared glutathione to 4% hypertonic saline. Nebulized thiol derivatives were generally well‐tolerated with no major adverse effects. However they showed no significant improvements in any of our outcome measures. Six included trials assessed the effects of oral thiol derivatives.Three of these trials compared oral N‐acetylcysteine to placebo; one compared oral N‐acetylcysteine, oral ambroxol and placebo; and one compared oral carbocysteine and oral ambroxol (no placebo). None of the trials showed an overall significant benefit in any of the outcome measures of this review. Oral thiol derivatives were generally well‐tolerated with no major adverse effects. In summary, the trials included in the review did not provide any evidence that nebulized or oral thiol derivatives were either beneficial or harmful to people with cystic fibrosis. Further research investigating the effects of thiol derivatives in people with cystic fibrosis is required before their use can be recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Tam, J, Nash, EF, Ratjen, F, Tullis, E, Stephenson, A", "articleTypes": [], "doi": "10.1002/14651858.CD007168.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.746Z" }, { "id": "f8d03ef6-2ece-4e3e-8a03-c1ad89b7efe3", "pmid": "", "title": "Nicotine replacement therapy versus control for smoking cessation", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence. Objectives To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long‐term smoking cessation, compared to placebo or 'no NRT' interventions. Search methods We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017. Selection criteria Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow‐up of less than six months. We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews. Data collection and analysis Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow‐up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta‐analysis using a Mantel‐Haenszel fixed‐effect model. Main results We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non‐NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare. Authors' conclusions There is high‐quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non‐ischaemic chest pain and palpitations. Plain language summary Can nicotine replacement therapy (NRT) help people quit smoking? Background We reviewed the evidence about whether NRT helps people who want to quit smoking to stop smoking at six months or longer. NRT aims to reduce withdrawal symptoms associated with stopping smoking by replacing the nicotine from cigarettes. NRT is available as skin patches that deliver nicotine slowly, and chewing gum, nasal and oral sprays, inhalators, and lozenges/tablets, all of which deliver nicotine to the brain more quickly than skin patches, but less rapidly than from smoking cigarettes. Study characteristics This review includes 136 trials of NRT, with 64,640 people in the main analysis. All studies were conducted in people who wanted to quit smoking. Most studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. The evidence is current to July 2017. Trials lasted for at least six months. Key results We found evidence that all forms of NRT made it more likely that a person's attempt to quit smoking would succeed. The chances of stopping smoking were increased by 50% to 60%. NRT works with or without additional counselling, and does not need to be prescribed by a doctor. Side effects from using NRT are related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. There is no evidence that NRT increases the risk of heart attacks. Quality of evidence The overall quality of the evidence is high, meaning that further research is very unlikely to change our conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Hartmann‐Boyce, J, Chepkin, SC, Ye, W, Bullen, C, Lancaster, T", "articleTypes": [], "doi": "10.1002/14651858.CD000146.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.724Z" }, { "id": "f8d4b2bc-ac45-4949-aabe-75dedaf1153a", "pmid": "", "title": "Interventions for paracetamol (acetaminophen) overdose", "imported": false, "abstract": "Abstract - Background Paracetamol (acetaminophen) is the most widely used non‐prescription analgesic in the world. Paracetamol is commonly taken in overdose either deliberately or unintentionally. In high‐income countries, paracetamol toxicity is a common cause of acute liver injury. There are various interventions to treat paracetamol poisoning, depending on the clinical status of the person. These interventions include inhibiting the absorption of paracetamol from the gastrointestinal tract (decontamination), removal of paracetamol from the vascular system, and antidotes to prevent the formation of, or to detoxify, metabolites. Objectives To assess the benefits and harms of interventions for paracetamol overdosage irrespective of the cause of the overdose. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register (January 2017), CENTRAL (2016, Issue 11), MEDLINE (1946 to January 2017), Embase (1974 to January 2017), and Science Citation Index Expanded (1900 to January 2017). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov database (US National Institute of Health) for any ongoing or completed trials (January 2017). We examined the reference lists of relevant papers identified by the search and other published reviews. Selection criteria Randomised clinical trials assessing benefits and harms of interventions in people who have ingested a paracetamol overdose. The interventions could have been gastric lavage, ipecacuanha, or activated charcoal, or various extracorporeal treatments, or antidotes. The interventions could have been compared with placebo, no intervention, or to each other in differing regimens. Data collection and analysis Two review authors independently extracted data from the included trials. We used fixed‐effect and random‐effects Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of the review outcomes. We used the Cochrane 'Risk of bias' tool to assess the risks of bias (i.e. systematic errors leading to overestimation of benefits and underestimation of harms). We used Trial Sequential Analysis to control risks of random errors (i.e. play of chance) and GRADE to assess the quality of the evidence and constructed 'Summary of findings' tables using GRADE software. Main results We identified 11 randomised clinical trials (of which one acetylcysteine trial was abandoned due to low numbers recruited), assessing several different interventions in 700 participants. The variety of interventions studied included decontamination, extracorporeal measures, and antidotes to detoxify paracetamol's toxic metabolite; which included methionine, cysteamine, dimercaprol, or acetylcysteine. There were no randomised clinical trials of agents that inhibit cytochrome P‐450 to decrease the activation of the toxic metabolite N ‐acetyl‐ p ‐benzoquinone imine. Of the 11 trials, only two had two common outcomes, and hence, we could only meta‐analyse two comparisons. Each of the remaining comparisons included outcome data from one trial only and hence their results are presented as described in the trials. All trial analyses lack power to access efficacy. Furthermore, all the trials were at high risk of bias. Accordingly, the quality of evidence was low or very low for all comparisons. Interventions that prevent absorption, such as gastric lavage, ipecacuanha, or activated charcoal were compared with placebo or no intervention and with each other in one four‐armed randomised clinical trial involving 60 participants with an uncertain randomisation procedure and hence very low quality. The trial presented results on lowering plasma paracetamol levels. Activated charcoal seemed to reduce the absorption of paracetamol, but the clinical benefits were unclear. Activated charcoal seemed to have the best risk:benefit ratio among gastric lavage, ipecacuanha, or supportive treatment if given within four hours of ingestion. There seemed to be no difference between gastric lavage and ipecacuanha, but gastric lavage and ipecacuanha seemed more effective than no treatment (very low quality of evidence). Extracorporeal interventions included charcoal haemoperfusion compared with conventional treatment (supportive care including gastric lavage, intravenous fluids, and fresh frozen plasma) in one trial with 16 participants. The mean cumulative amount of paracetamol removed was 1.4 g. One participant from the haemoperfusion group who had ingested 135 g of paracetamol, died. There were no deaths in the conventional treatment group. Accordingly, we found no benefit of charcoal haemoperfusion (very low quality of evidence). Acetylcysteine appeared superior to placebo and had fewer adverse effects when compared with dimercaprol or cysteamine. Acetylcysteine superiority to methionine was unproven. One small trial (low quality evidence) found that acetylcysteine may reduce mortality in people with fulminant hepatic failure (Peto OR 0.29, 95% CI 0.09 to 0.94). The most recent randomised clinical trials studied different acetylcysteine regimens, with the primary outcome being adverse events. It was unclear which acetylcysteine treatment protocol offered the best efficacy, as most trials were underpowered to look at this outcome. One trial showed that a modified 12‐hour acetylcysteine regimen with a two‐hour acetylcysteine 100 mg/kg bodyweight loading dose was associated with significantly fewer adverse reactions compared with the traditional three‐bag 20.25‐hour regimen (low quality of evidence). All Trial Sequential Analyses showed lack of sufficient power. Children were not included in the majority of trials. Hence, the evidence pertains only to adults. Authors' conclusions These results highlight the paucity of randomised clinical trials comparing different interventions for paracetamol overdose and their routes of administration and the low or very low level quality of the evidence that is available. Evidence from a single trial found activated charcoal seemed the best choice to reduce absorption of paracetamol. Acetylcysteine should be given to people at risk of toxicity including people presenting with liver failure. Further randomised clinical trials with low risk of bias and adequate number of participants are required to determine which regimen results in the fewest adverse effects with the best efficacy. Current management of paracetamol poisoning worldwide involves the administration of intravenous or oral acetylcysteine which is based mainly on observational studies. Results from these observational studies indicate that treatment with acetylcysteine seems to result in a decrease in morbidity and mortality, However, further evidence from randomised clinical trials comparing different treatments are needed. Plain language summary Interventions for paracetamol (acetaminophen) overdose Review question: in this review, we looked at the evidence for the interventions (treatments) used to treat people with paracetamol (acetaminophen) poisoning. Mainly, we tried to assess what effects the interventions had on the number of deaths and the need for a liver transplant. Background: paracetamol is one of the most common drugs taken in overdose. Intentional or accidental poisoning with paracetamol is a common cause of liver injury. Search date: the evidence is current to January 2017. Study characteristics: randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) where participants had come to medical attention because they had taken a paracetamol overdose, intentionally or by accident, regardless of the amount of paracetamol taken or the age, sex, or other medical conditions of the person involved. There are many different interventions that can be used to try to treat people with paracetamol poisoning. These interventions include decreasing the absorption of the paracetamol ingested and hence decreasing the amount absorbed into the bloodstream. The agents include activated charcoal (that binds paracetamol together in the stomach), gastric lavage (stomach washout to remove as much paracetamol as possible), or ipecacuanha (a syrup that is swallowed and causes vomiting (being sick)). Paracetamol once absorbed into the bloodstream goes to the liver where the majority is broken down to harmless products. However, a small amount of the medicine is converted into a toxic product that the liver can normally handle but, when large amounts of paracetamol are taken, the liver is overwhelmed. As a consequence, the toxic product can damage the liver leading to liver failure, kidney failure, and in some cases death. Other interventions to treat paracetamol poisoning include medicines (antidotes) that may decrease the amount of the toxic products (such as a medicine called cimetidine) or breakdown the toxic products (including medicines called methionine, cysteamine, dimercaprol, or acetylcysteine). Finally, attempts can be made to remove paracetamol and its toxic products from the bloodstream using special blood cleansing equipment. All these treatments were examined. We found 11 randomised clinical trials with 700 participants. Most of these trials looked at different treatments. Key results: activated charcoal, gastric lavage, and ipecacuanha may reduce absorption of paracetamol if started within one to two hours of paracetamol ingestion, but the clinical benefit was unclear. Activated charcoal seems to be the best choice if the person is able to take it. People may not be able to take charcoal if they are drowsy and some may dislike its taste or texture (or both). Of the treatments that remove the toxic products of paracetamol, acetylcysteine seems to reduce the rate of liver injury from paracetamol poisoning. Furthermore, it has fewer side effects than some other antidotes such as dimercaprol and cysteamine; its superiority to methionine was unclear. Acetylcysteine should be given to people with paracetamol poisoning at risk of liver damage, risk is determined by the dose ingested, time of ingestion, and investigations. More recent clinical trials have looked at ways to decrease side effects of intravenous (into a vein) acetylcysteine treatment, by altering the way it is given. These trials have shown that by using a slower infusion and lower initial dose of acetylcysteine, the proportion of side effects such as nausea (feeling sick) and vomiting, and allergy (the body's bad reaction to the medicine such as a rash) may be lowered. Quality of the evidence: this review of interventions for paracetamol poisoning found surprisingly few published randomised clinical trials for this very common condition. Furthermore, the majority of trials had few participants and all were at high risk of bias. Accordingly, the quality of the evidence should be considered as low or very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Chiew, AL; Gluud, C; Brok, J; Buckley, NA", "articleTypes": [], "doi": "10.1002/14651858.CD003328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "f8fd21b5-801f-4b2c-b951-8d66a24b5f91", "pmid": "", "title": "A Randomized Placebo-Controlled Study to Assess the Efficacy and Safety of AF-219, a P2X3 Receptor Antagonist, in Subjects With Idiopathic Pulmonary Fibrosis (IPF) With Persistent Cough", "imported": false, "abstract": "A randomized, double-blind, placebo-controlled, crossover, dose escalation study of gefapixant (AF-219) in participants with Idiopathic Pulmonary Fibrosis (IPF) with persistent cough.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.153Z" }, { "id": "f9094e2e-be19-4cc0-800f-06c599ee37cc", "pmid": "", "title": "Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents", "imported": false, "abstract": "Abstract - Background Vomiting is a common manifestation of acute gastroenteritis in children and adolescents. When untreated it can be a hindrance to oral rehydration therapy, which is the cornerstone in the management of acute gastroenteritis. Evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in acute gastroenteritis in children. Objectives To assess the safety and effectiveness of antiemetics on gastroenteritis induced vomiting in children and adolescents. Search methods We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conferences.The search was re‐run and is up to date as on 20 July 2010. Selection criteria Randomized controlled trials comparing antiemetics with placebo or no treatment, in children and adolescents under the age of 18, for vomiting due to gastroenteritis. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results We included seven trials involving 1,020 participants. Mean time to cessation of vomiting in one study was 0.34 days less with dimenhydrinate suppository compared to placebo (P value = 0.036). Pooled data from three studies comparing oral ondansetron with placebo showed: a reduction in the immediate hospital admission rate (RR 0.40, NNT 17, 95% CI 10 to 100) but no difference between the hospitalization rates at 72 hours after discharge from the Emergency Department (ED); a reduction in IV rehydration rates both during the ED stay (RR 0.41, NNT 5, 95% CI 4 to 8), and in follow‐up to 72 hours after discharge from the ED stay (worst‐best scenario for ondansetron RR 0.57, NNT 6, 95% CI 4 to 13) and an increase in the proportion of patients with cessation of vomiting (RR 1.34, NNT 5, 95% CI 3 to 7)). No significant difference was noted in the revisit rates or adverse events, although diarrhea was reported as a side effect in four of the five ondansetron studies. In one study the proportion of patients with cessation of vomiting in 24 hours was (58%) with IV ondansetron, (17%) placebo and (33%) in the metoclopramide group (P value = 0.039). Authors' conclusions Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting. Plain language summary Anti‐sickness medication for vomiting in acute stomach upsets in children Vomiting caused by acute gastroenteritis is very common in children and adolescents. Treatment of vomiting in children with acute gastroenteritis can be problematic and there is lack of agreement among clinicians on the indications for the use of antiemetics. There have also been concerns expressed about apparently unacceptable levels of side effects with some of the older generation of antiemetics. The small number of included trials provided evidence which appeared to favour the use of antiemetics over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. A single oral dose of ondansetron given to children with mild to moderate dehydration can control vomiting, avoid hospitalization and intravenous fluid administration which would otherwise be needed. There were no major side effects other than a few reports of increased frequency of diarrhea.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Fedorowicz, Z, Jagannath, VA, Carter, B", "articleTypes": [], "doi": "10.1002/14651858.CD005506.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.127Z" }, { "id": "f92e65bc-1d2d-42d2-85f1-c55eb5f813e7", "pmid": "", "title": "Postnatal phenobarbital for the prevention of intraventricular haemorrhage in preterm infants", "imported": false, "abstract": "Abstract - Background Intraventricular haemorrhage (IVH) is a major complication of preterm birth. Large haemorrhages are associated with a high risk of disability and hydrocephalus. Instability of blood pressure and cerebral blood in the newborn flow are postulated as causative factors. Another mechanism may involve reperfusion damage from oxygen free radicals. It has been suggested that phenobarbital stabilises blood pressure and may protect against free radicals. This is an update of a review first published in 2001 and updated in 2007 and 2013. Objectives To assess the benefits and harms of the postnatal administration of phenobarbital in preterm infants at risk of developing IVH compared to control (i.e. no intervention or placebo). Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL and clinical trial registries in January 2022. A new, more sensitive search strategy was developed, and searches were conducted without date limits. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs in which phenobarbital was given within the first 24 hours of life to preterm infants identified as being at risk of IVH because of gestational age below 34 weeks, birth weight below 1500 g or respiratory failure. Phenobarbital was compared to no intervention or placebo. We excluded infants with serious congenital malformations. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were all grades of IVH and severe IVH (i.e. grade III and IV); secondary outcomes were ventricular dilation or hydrocephalus, hypotension, pneumothorax, hypercapnia, acidosis, mechanical ventilation, neurodevelopmental impairment and death. We used GRADE to assess the certainty of the evidence for each outcome. Main results We included 10 RCTs (792 infants). The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH of any grade compared with control (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.84 to 1.19; risk difference (RD) 0.00, 95% CI ‐0.06 to 0.07; I² for RD = 65%; 10 RCTs, 792 participants; low certainty evidence) and in severe IVH (RR 0.88, 95% CI 0.64 to 1.21; 10 RCTs, 792 participants; low certainty evidence). The evidence is very uncertain about the effect of phenobarbital on posthaemorrhagic ventricular dilation or hydrocephalus (RR 0.62, 95% CI 0.31 to 1.26; 4 RCTs, 271 participants; very low certainty evidence), mild neurodevelopmental impairment (RR 0.57, 95% CI 0.15 to 2.17; 1RCT, 101 participants; very low certainty evidence), and severe neurodevelopmental impairment (RR 1.12, 95% CI 0.44 to 2.82; 2 RCTs, 153 participants; very low certainty evidence). Phenobarbital may result in little to no difference in death before discharge (RR 0.88, 95% CI 0.64 to 1.21; 9 RCTs, 740 participants; low certainty evidence) and mortality during study period (RR 0.98, 95% CI 0.72 to 1.33; 10 RCTs, 792 participants; low certainty evidence) compared with control. We identified no ongoing trials. Authors' conclusions The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH (any grade or severe) compared with control (i.e. no intervention or placebo). The evidence is very uncertain about the effects of phenobarbital on ventricular dilation or hydrocephalus and on neurodevelopmental impairment. The evidence suggests that phenobarbital results in little to no difference in death before discharge and all deaths during the study period compared with control. Since 1993, no randomised studies have been published on phenobarbital for the prevention of IVH in preterm infants, and no trials are ongoing. The effects of postnatal phenobarbital might be assessed in infants with both neonatal seizures and IVH, in both randomised and observational studies. The assessment of benefits and harms should include long‐term outcomes. Plain language summary What are the benefits and risks of phenobarbital for preventing bleeding to the brain in babies born too early? Key messages • Giving phenobarbital (a medicine used to control seizures) to babies born too early may have little to no effect in preventing intraventricular haemorrhage (bleeding to the brain) and death. • The evidence is very uncertain about the effect of phenobarbital on preventing ventricular dilation (enlarged spaces in the brain) and long‐term brain development. What is bleeding to the brain (intraventricular haemorrhage)? Large bleeds in the centre of the brain can cause disability or death in babies born too early. Unstable blood pressure and blood flow to the brain are believed to cause bleeding into the fluid‐filled cavities of the brain (ventricles). What did we want to find out? Phenobarbital is believed to stabilise blood pressure and therefore potentially help prevent bleeding to the brain. We wanted to find out whether phenobarbital was better than no medicine or a placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) to prevent bleeding to the brain. What did we do? We searched for studies that compared giving phenobarbital against no medicines. We compared and summarised the results of these studies and rated our confidence in the evidence, based on factors such as study methods and size. What did we find? We included 10 studies (792 babies). The evidence suggests that phenobarbital has little to no effect in preventing bleeding to the brain. The evidence is very uncertain about the effect of phenobarbital on dilation of the ventricles in the brain and long‐term development. The evidence suggests that phenobarbital has little to no effect in preventing deaths. We identified no ongoing trials. What are the limitations of the evidence? It is possible that people conducting the studies were aware of what treatment they were giving. Not all the studies provided data about everything that we were interested in. The studies were very small. How up to date is this evidence? This review updates our previous review. The evidence is up to date to January 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Romantsik, O; Smit, E; Odd, DE; Bruschettini, M", "articleTypes": [], "doi": "10.1002/14651858.CD001691.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.066Z" }, { "id": "f933466a-7b4d-44ef-9e43-e8e5f615d41e", "pmid": "", "title": "Interventions for chronic palmoplantar pustulosis", "imported": false, "abstract": "Abstract - Background Palmoplantar pustulosis is a chronic inflammatory disease in which sterile, relapsing pustules appear on the palms and soles, possibly in conjunction with other symptoms. The previous Cochrane Review on this topic was published in 2006, before biological treatments were extensively used. Objectives To assess the effects of interventions for chronic palmoplantar pustulosis to induce and maintain complete remission. Search methods We searched the following databases up to March 2019: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of the included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria We considered RCTs including people with palmoplantar pustulosis or chronic palmoplantar pustular psoriasis assessing topical therapy, systemic therapy, combinations of topical or systemic therapies, or non‐pharmacological therapies compared with placebo, no intervention, or each other. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our outcomes included 'Proportion of participants cleared or almost cleared', 'Proportion of participants with adverse effects serious or severe enough to cause withdrawal', 'Proportion of participants with at least 50% improvement in disease severity', and 'Proportion of participants with adverse effects'. Main results We included 37 studies (1663 participants; mean age 50 years (range 34 to 63); 24% males). These studies reported condition severity differently. Around half of the included trials stated the setting (hospitals, community clinics, or both). More than half of the studies were at high risk of bias in at least one domain. Our included studies assessed mainly systemic treatments (retinoids, ciclosporin, biologics, etretinate + PUVA (combination of psoralens and long‐wave ultraviolet radiation) therapy combined, and antibiotics), but also topical treatments (dermocorticoids, vitamin D) and phototherapy (PUVA, ultraviolet A1 (UVA1)). Other interventions were assessed by single studies. The most common comparator was placebo. All results presented in this abstract were assessed in the short term (mean treatment duration was 11 weeks (range 8 to 24 weeks)) and are based on participants with chronic palmoplantar pustulosis. All outcome time point measurements were taken from baseline and assessed at the end of treatment. Short‐term and long‐term outcomes were defined as measurement up to 24 weeks after randomisation and between 24 and 104 weeks after randomisation, respectively. One trial (188 participants) assessed the topical vitamin D derivative maxacalcitol versus placebo and found that maxacalcitol may be more effective than placebo in achieving clearance (risk ratio (RR) 7.83, 95% confidence interval (CI) 1.85 to 33.12; low‐quality evidence), and the risk of adverse effects (such as mild local irritation, pruritus, and haematological or urinary test abnormalities) is probably similar in both groups (RR 0.87, 95% CI 0.64 to 1.19; moderate‐quality evidence). Severity was not reported. Two trials (49 participants) assessed PUVA therapy versus placebo or no treatment, providing very low‐quality evidence. Adverse effects were reported with oral PUVA (including nausea, ankle swelling, and non‐purulent conjunctivitis) and with local PUVA (including blistering, erythema, and pruritus). With regard to the systemic retinoid alitretinoin, one trial (33 participants; moderate‐quality evidence) showed that alitretinoin probably makes little or no difference in reducing severity when compared to placebo (RR 0.69, 95% CI 0.36 to 1.30). A similar number of adverse events were reported in both treatment groups, including headache, cheilitis, nausea, arthralgia, and nasopharyngitis (RR 0.84, 95% CI 0.61 to 1.17). Clearance was not reported. There may be little or no difference between etanercept and placebo in achieving clearance (RR 1.64, 95% CI 0.08 to 34.28; 1 study; 15 participants; low‐quality evidence); however, the 95% CI was very wide, showing there may be a difference between groups. Severity was not measured. More patients treated with placebo may achieve reduced severity than those treated with ustekinumab, but the wide 95% CI indicates there might be little or no difference between groups and there might be greater effect with ustekinumab (RR 0.48, 95% CI 0.11 to 2.13; 1 study; 33 participants; low‐quality evidence). Clearance was not reported. It is uncertain whether guselkumab increases clearance when compared to placebo (2 studies; 154 participants) because the quality of evidence is very low, but guselkumab probably better reduces disease severity (RR 2.88, 95% CI 1.24 to 6.69; 1 study; 49 participants; moderate‐quality evidence). Secukinumab is probably superior to placebo in reducing severity (RR 1.55, 95% CI 1.02 to 2.35; 1 study; 157 participants; moderate‐quality evidence), but our clearance outcome was not reported. None of these trials reported on occurrence of adverse effects. Only two of the studies discussed above reported adverse effects serious or severe enough to cause withdrawal. Guselkumab may cause more serious adverse events when compared to placebo, but there is uncertainty due to the very wide 95% CI showing there may be little or no difference and showing more events with placebo (RR 2.88, 95% CI 0.32 to 25.80; 1 study; 49 participants; low‐quality evidence). Secukinumab probably causes more serious adverse events than placebo (RR 3.29, 95% CI 1.40 to 7.75; 1 study; 157 participants; moderate‐quality evidence). Authors' conclusions Evidence is lacking for major chronic palmoplantar pustulosis treatments such as superpotent corticosteroids, phototherapy, acitretin, methotrexate, and ciclosporin. Risk of bias and imprecision limit our confidence. Maxacalcitol may be more effective than placebo in achieving clearance in the short term (low‐quality evidence), and the risk of adverse effects is probably similar (moderate‐quality evidence). Oral alitretinoin is probably no more effective than placebo in reducing severity, with a similar risk of adverse effects (moderate‐quality evidence). Regarding biological treatments, we are uncertain of the effect of etanercept on clearance and the effect of ustekinumab on severity (low‐quality evidence). Secukinumab and guselkumab are probably superior to placebo in reducing severity (moderate‐quality evidence). Adverse events not requiring withdrawal were not reported for these treatments. Reporting of serious adverse effects was incomplete: compared to placebo, secukinumab probably caused more participant withdrawals (moderate‐quality evidence), but we are uncertain of the effect of guselkumab (low‐quality evidence). Future trials should assess commonly used treatments using validated severity and quality of life scales. Plain language summary Treating long‐term palmoplantar pustulosis (pustules on the hands and feet) Review question We wanted to assess treatments for palmoplantar pustulosis (a persistent condition characterised by small, pus‐filled blisters on the hands and feet), when compared to an inactive substance (placebo), no intervention, or each other. We included 37 studies. Background Palmoplantar pustulosis negatively affects a person's life; there is no cure or standard treatment. Over time, the skin becomes thicker and redder, and may develop cracks or flake off as scales. Symptoms are treated with topical medicines (usually corticosteroids), systemic medicines (medicines injected or taken by mouth that work throughout the entire body; usually medicines based on vitamin A or D), or phototherapy (ultraviolet light treatment). Study characteristics The studies involved 1663 adults (mostly women) 34 to 63 years of age (average age 50 years). In 19 studies, participants had had palmoplantar pustulosis from two to 16 years (average 6.4 years). Participants had palmoplantar pustular psoriasis (6 studies), palmoplantar pustulosis (29 studies), or both (2 studies). Study authors reported condition severity differently. The included studies assessed a variety of different treatments: mainly systemic treatments (including biologic medicines, vitamin A medicines, immunosuppressants, antibiotics, and light therapy combined with a vitamin A medicine), but also topical medicines (containing steroids or vitamin D) and light treatments. Single studies assessed other treatments. Treatments were most commonly compared against placebo. Treatment length varied; for our key results, this ranged from 8 to 24 weeks (average 11 weeks). When reported, studies were conducted in hospitals, community clinics, or both. Pharmaceutical companies funded 18 studies. Key results Low‐quality evidence suggests that maxacalcitol (a topical vitamin D derivative) may work better than placebo in achieving clearance; moderate‐quality evidence indicates that the number of side effects is probably similar in both groups (participants experienced itching, irritation, and blood or urine test abnormalities) (1 trial; 188 participants). Severity was not measured. We found very low‐quality evidence for PUVA therapy (i.e. psoralen, a drug to sensitise the skin, and ultraviolet light A) versus placebo or no treatment (2 studies; 49 participants), so we are unable to draw conclusions. Side effects with PUVA included skin blisters, redness, itching, swelling, and feeling sick. Oral alitretinoin probably makes little or no difference in reducing severity when compared to placebo (moderate‐quality evidence; 1 study; 33 participants). A similar result was found for side effects, with headache, sickness, joint pain, high cholesterol, and colds reported in both groups. Clearance was not reported. Five studies assessed biological treatments (etanercept, ustekinumab, guselkumab, secukinumab), which use substances made from living organisms, or synthetic versions, to target the immune system. Low‐quality evidence (1 study; 15 participants) suggests that etanercept may make little or no difference in clearance when compared to placebo, but we are very uncertain of this result. Side effects and severity were not measured. We found low‐quality evidence suggesting that ustekinumab may be worse than placebo in reducing disease severity, but we are very uncertain of this result. Side effects and clearance were not reported (1 study; 33 participants). Compared to placebo, guselkumab probably reduces severity (moderate‐quality evidence; 1 study; 49 participants), but its effects on clearance are uncertain (very low‐quality evidence; 2 studies; 154 participants). Side effects were not measured. Moderate‐quality evidence shows that secukinumab was probably superior to placebo in reducing severity, but skin clearance and side effects were not reported (1 study; 157 participants). Only two studies described above reported withdrawals from treatment due to serious side effects; these are probably more frequent with secukinumab than with placebo (157 participants), and may occur more often with guselkumab than with placebo (49 participants), but we are very uncertain of the guselkumab result. For these key results, outcomes were assessed between 8 and 24 weeks, which we deemed short term. This evidence is current to March 2019. Quality of the evidence The key comparisons reported clearance most often, but evidence quality was mainly very low. Only two key studies reported side effects causing withdrawal (low‐ and moderate‐quality evidence). The evidence underlying our severity and side effects outcomes was variable in quality (very low to moderate). Small participant numbers, results with wide margins of error, and selective reporting have limited our confidence in the evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Obeid, G, Do, G, Kirby, L, Hughes, C, Sbidian, E, Le Cleach, L", "articleTypes": [], "doi": "10.1002/14651858.CD011628.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.792Z" }, { "id": "f933fd63-5ce9-4e18-ad36-2cb455a64a48", "pmid": "", "title": "Vitamin B12 supplementation during pregnancy for maternal and child health outcomes", "imported": false, "abstract": "Abstract - Background Vitamin B 12 deficiency is a major public health problem worldwide, with the highest burden in elderly people, pregnant women, and young children. Due to its role in DNA synthesis and methylation, folate metabolism, and erythropoiesis, vitamin B 12 supplementation during pregnancy may confer longer‐term benefits to maternal and child health outcomes. Objectives To evaluate the benefits and harms of oral vitamin B 12 supplementation during pregnancy on maternal and child health outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov , the World Health Organization International Clinical Trials Registry Platform ( ICTRP ) on 2 June 2023, and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs), quasi‐RCTs, or cluster‐RCTs evaluating the effects of oral vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation during pregnancy. Data collection and analysis We used standard Cochrane methods. Four review authors independently assessed trial eligibility. Two review authors independently extracted data from included studies and conducted checks for accuracy. Three review authors independently assessed the risk of bias of the included studies using the Cochrane RoB 1 tool. We used GRADE to evaluate the certainty of evidence for primary outcomes. Main results The review included five trials with 984 pregnant women. All trials were conducted in low‐ and middle‐income countries, including India, Bangladesh, South Africa, and Croatia. At enrolment, 26% to 51% of pregnant women had vitamin B 12 deficiency (less than 150 pmol/L), and the prevalence of anaemia (haemoglobin less than 11.0 g/dL) ranged from 30% to 46%. The dosage of vitamin B 12 supplementation varied from 5 μg/day to 250 μg/day, with administration beginning at 8 to 28 weeks' gestation through to delivery or three months' postpartum, and the duration of supplementation ranged from 8 to 16 weeks to 32 to 38 weeks. Three trials, involving 609 pregnant women, contributed data for meta‐analyses of the effects of vitamin B 12 supplementation compared to placebo or no vitamin B 12 supplementation. Maternal anaemia: there may be little to no difference for maternal anaemia by intervention group, but the evidence is very uncertain (70.9% versus 65.0%; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.93 to 1.26; 2 trials, 284 women; very low‐certainty evidence). Maternal vitamin B 12 status: vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain (25.9% versus 67.9%; RR 0.38, 95% CI 0.28 to 0.51; 2 trials, 272 women; very low‐certainty evidence). Women who received vitamin B 12 supplements during pregnancy may have higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (mean difference (MD) 60.89 pmol/L, 95% CI 40.86 to 80.92; 3 trials, 412 women). However, there was substantial heterogeneity (I 2 = 85%). Adverse pregnancy outcomes: the evidence is uncertain about the effect on adverse pregnancy outcomes, including preterm birth (RR 0.97, 95% CI 0.55 to 1.74; 2 trials, 340 women; low‐certainty evidence), and low birthweight (RR 1.50, 95% CI 0.93 to 2.43; 2 trials, 344 women; low‐certainty evidence). Two trials reported data on spontaneous abortion (or miscarriage); however, the trials did not report quantitative data for meta‐analysis and there was no clear definition of spontaneous abortion in the study reports. No trials evaluated the effects of vitamin B 12 supplementation during pregnancy on neural tube defects. Infant vitamin B 12 status: children born to women who received vitamin B 12 supplementation had higher total vitamin B 12 concentrations compared to placebo or no vitamin B 12 supplementation (MD 71.89 pmol/L, 95% CI 20.23 to 123.54; 2 trials, 144 children). Child cognitive outcomes : three ancillary analyses of one trial reported child cognitive outcomes; however, data were not reported in a format that could be included in quantitative meta‐analyses. In one study, maternal vitamin B 12 supplementation did not improve neurodevelopment status (e.g. cognitive, language (receptive and expressive), motor (fine and gross), social‐emotional, or adaptive (conceptual, social, practical) domains) in children compared to placebo (9 months, Bayley Scales of Infant and Toddler Development Third Edition (BSID‐III); 1 trial; low‐certainty evidence) or neurophysiological outcomes (72 months, event‐related potential measures; 1 trial; low‐certainty evidence), though children born to women who received vitamin B 12 supplementation had improved expressive language domain compared to placebo (30 months, BSID‐III; 1 trial; low‐certainty evidence). Authors' conclusions Oral vitamin B 12 supplementation during pregnancy may reduce the risk of maternal vitamin B 12 deficiency and may improve maternal vitamin B 12 concentrations during pregnancy or postpartum compared to placebo or no vitamin B 12 supplementation, but the evidence is very uncertain. The effects of vitamin B 12 supplementation on other primary outcomes assessed in this review were not reported, or were not reported in a format for inclusion in quantitative analyses. Vitamin B 12 supplementation during pregnancy may improve maternal and infant vitamin B 12 status, but the potential impact on longer‐term clinical and functional maternal and child health outcomes has not yet been established. Plain language summary Vitamin B 12 supplementation for women during pregnancy Key messages – Women who took vitamin B 12 supplements during pregnancy may have improved vitamin B 12 status during pregnancy or postpartum, including less vitamin B 12 deficiency and higher vitamin B 12 levels, compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. – The effects of taking vitamin B 12 supplements during pregnancy on other health outcomes in pregnant women or their children are not known. Public health implications Vitamin B 12 is an important nutrient that helps keep your body's blood and nerve cells healthy. Vitamin B 12 deficiency is an important public health problem, particularly in low‐ and middle‐income countries, with a high burden amongst pregnant women and children. Lower vitamin B 12 levels in pregnancy have been linked to greater risk of some adverse pregnancy outcomes such as miscarriage, poor growth of the baby in the womb, problems with the baby's brain or spinal cord (called neural tube defects), and lower vitamin B 12 status in infants. Vitamin B 12 supplementation during pregnancy may help improve the health and nutrition of women and their babies. However, this has not been examined in well‐conducted reviews, and vitamin B 12 is not part of supplements recommended by the World Health Organization (WHO; a specialised agency of the United Nations responsible for international public health) for women during pregnancy. What did we want to find out? We wanted to find out if taking vitamin B 12 supplements during pregnancy would improve the health and nutrition of women and their babies. What did we do? We searched for clinical trials that looked at vitamin B 12 supplementation during pregnancy. We compared and summarised the results of the trials and rated our confidence in the information, based on factors such as trial methods and sizes. What did we find? We included five trials with 984 pregnant women. Three trials, including 609 pregnant women, had data included in analyses. Women who took vitamin B 12 supplements during pregnancy had less vitamin B 12 deficiency and higher vitamin B 12 levels compared to women who did not take vitamin B 12 supplements, but the evidence is uncertain. There were no differences between groups for maternal anaemia. We could not assess the effects of vitamin B 12 supplementation on other outcomes such as miscarriage, neural tube defects, and child cognition (a child's ability to gain knowledge through thought, understanding, and the senses) due to limited or no availability of results for analysis. What are the limitations of the evidence? The small number of trials and small size of trials were limitations in this review. Not all the trials provided data about the outcomes we were interested in. We are very unsure about the results. How up to date is this evidence? The evidence is up to date as of June 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Finkelstein, JL; Fothergill, A; Venkatramanan, S; Layden, AJ; Williams, JL; Crider, KS; Qi, YP", "articleTypes": [], "doi": "10.1002/14651858.CD013823.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.078Z" }, { "id": "f9456655-4e88-4621-b1fe-0d574703c18b", "pmid": "", "title": "Taste Preferences for Nutritive and Non Nutritive Sweeteners Among Children and Adults", "imported": false, "abstract": "The goal of the study is to determine whether there are age-, diet- and genetically-related differences in the perception of sweeteners, both nutritive and non-nutritive.", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.255Z" }, { "id": "f94b029d-9668-45b7-a4d9-1703d8be2221", "pmid": "", "title": "Sucrose for analgesia in newborn infants undergoing painful procedures", "imported": false, "abstract": "Abstract - Background Administration of oral sucrose with and without non‐nutritive sucking is the most frequently studied non‐pharmacological intervention for procedural pain relief in neonates. Objectives To determine the efficacy, effect of dose, method of administration and safety of sucrose for relieving procedural pain in neonates as assessed by validated composite pain scores, physiological pain indicators (heart rate, respiratory rate, saturation of peripheral oxygen in the blood, transcutaneous oxygen and carbon dioxide (gas exchange measured across the skin ‐ TcpO 2 , TcpCO 2 ), n ear i nfra r ed s pectroscopy (NIRS), e lectro e ncephalo g ram (EEG), or behavioural pain indicators (cry duration, proportion of time crying, proportion of time facial actions (e.g. grimace) are present), or a combination of these and long‐term neurodevelopmental outcomes. Search methods We used the standard methods of the Cochrane Neonatal. We performed electronic and manual literature searches in February 2016 for published randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library , Issue 1, 2016), MEDLINE (1950 to 2016), EMBASE (1980 to 2016), and CINAHL (1982 to 2016) . We did not impose language restrictions. Selection criteria RCTs in which term or preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age), or both, received sucrose for procedural pain. Control interventions included no treatment, water, glucose, breast milk, breastfeeding, local anaesthetic, pacifier, positioning/containing or acupuncture. Data collection and analysis Our main outcome measures were composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We reported a mean difference (MD) or weighted MD (WMD) with 95% confidence intervals (CI) using the fixed‐effect model for continuous outcome measures. For categorical data we used risk ratio (RR) and risk difference. We assessed heterogeneity by the I 2 test. We assessed the risk of bias of included trials using the Cochrane 'Risk of bias' tool, and assessed the quality of the evidence using the GRADE system. Main results Seventy‐four studies enrolling 7049 infants were included. Results from only a few studies could be combined in meta‐analyses and for most analyses the GRADE assessments indicated low‐ or moderate‐quality evidence. There was high‐quality evidence for the beneficial effect of sucrose (24%) with non‐nutritive sucking (pacifier dipped in sucrose) or 0.5 mL of sucrose orally in preterm and term infants: Premature Infant Pain Profile (PIPP) 30 s after heel lance WMD ‐1.70 (95% CI ‐2.13 to ‐1.26; I 2 = 0% (no heterogeneity); 3 studies, n = 278); PIPP 60 s after heel lance WMD ‐2.14 (95% CI ‐3.34 to ‐0.94; I 2 = 0% (no heterogeneity; 2 studies, n = 164). There was high‐quality evidence for the use of 2 mL 24% sucrose prior to venipuncture: PIPP during venipuncture WMD ‐2.79 (95% CI ‐3.76 to ‐1.83; I 2 = 0% (no heterogeneity; 2 groups in 1 study, n = 213); and intramuscular injections: PIPP during intramuscular injection WMD ‐1.05 (95% CI ‐1.98 to ‐0.12; I 2 = 0% (2 groups in 1 study, n = 232). Evidence from studies that could not be included in RevMan‐analyses supported these findings. Reported adverse effects were minor and similar in the sucrose and control groups. Sucrose is not effective in reducing pain from circumcision. The effectiveness of sucrose for reducing pain/stress from other interventions such as arterial puncture, subcutaneous injection, insertion of nasogastric or orogastric tubes, bladder catherization, eye examinations and echocardiography examinations are inconclusive. Most trials indicated some benefit of sucrose use but that the evidence for other painful procedures is of lower quality as it is based on few studies of small sample sizes. The effects of sucrose on long‐term neurodevelopmental outcomes are unknown. Authors' conclusions Sucrose is effective for reducing procedural pain from single events such as heel lance, venipuncture and intramuscular injection in both preterm and term infants. No serious side effects or harms have been documented with this intervention. We could not identify an optimal dose due to inconsistency in effective sucrose dosage among studies. Further investigation of repeated administration of sucrose in neonates is needed. There is some moderate‐quality evidence that sucrose in combination with other non‐pharmacological interventions such as non‐nutritive sucking is more effective than sucrose alone, but more research of this and sucrose in combination with pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long‐term (neurodevelopmental) outcomes. Plain language summary Sucrose for analgesia (pain relief) in newborn infants undergoing painful procedures Review question Cochrane reviewers investigated how well sucrose (table sugar) works as a reliever of pain in newborn babies who are having painful procedures (e.g. an injection, or heel lance, or insertion of a needle to obtain a blood sample (venipuncture), or eye examinations). The babies' pain responses (e.g. crying, grimacing) were assessed by scoring systems for pain used by health care professionals to measure the pain that babies are experiencing. In addition, the reviewers wanted to investigate whether the level of pain relief is related to the dose of sucrose, or the method of delivery (e.g. as a solution squirted into the mouth, or on a pacifier (also called a soother or dummy), and whether there are any safety concerns about using sucrose to relieve pain. Background Although there are ways to manage the pain of surgery, medical illness and major procedures, ways of preventing or reducing pain from minor medical procedures (e.g. heel lance and venipuncture) have, until relatively recently, been lacking. Sucrose has been examined for its calming effects in crying newborns and its pain‐relieving effects for invasive procedures in full‐term and premature newborns. Study characteristics We searched the medical literature widely up to February 2016 for studies that investigated the pain‐relieving effect of sucrose for minor medical procedures in newborn full‐term and premature babies. We included randomised controlled trials only, as these provide the most reliable medical evidence. We identified 74 studies that reported on a total of more than 7000 infants in this Cochrane Review. Thirty‐eight studies included full‐term babies only, 31 included premature babies only, and five included both full‐term and premature babies. Heel lance was the painful procedure in 38 studies, and venipuncture in nine; the remaining studies investigated a wide variety of other minor painful procedures. The studies used a variety of delivery methods for the sucrose solution (oral syringe, dropper or sucrose‐dipped pacifier), as well as a range of concentrations and volumes of dose. Sucrose treatment was compared with giving the babies a similar volume of water, a pacifier, routine care, breastfeeding, 'facilitated tucking' (holding the infant in a flexed position with arms close to the body and hands placed to promote sucking), laser acupuncture, swaddling, warmth, anaesthetic cream for the skin (EMLA), or a combination of these. The studies used a range of pain assessment scales to measure their results. Study funding sources We did not identify any studies that received funding from the industry. Key results There was high‐quality evidence that sucrose reduces different measures of newborn pain during heel lance, venipuncture and intramuscular injection. However, sucrose does not provide effective pain relief during circumcision. There is conflicting evidence for whether sucrose reduces pain for other minor painful procedures and further research is needed to investigate these more thoroughly. Twenty‐nine studies reported on adverse events (harms of the sucrose and other treatments) and found that the number of minor adverse events (e.g. choking or gagging) was very low, and was similar in the different groups (so not attributable to the sucrose treatment). No major adverse events were reported. Quality of evidence Although sucrose has been widely studied as a pain reliever for newborn babies, most studies have included few babies and have used many different measures of pain to assess its effectiveness. We identified high‐quality evidence that sucrose reduces pain for heel lance, venipuncture and intramuscular injection. The quality of evidence was low or moderate in favour for the use of sucrose for other painful procedures.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Stevens, B; Yamada, J; Ohlsson, A; Haliburton, S; Shorkey, A", "articleTypes": [], "doi": "10.1002/14651858.CD001069.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "f94fcffd-c688-43ef-81cc-8e2e6dc61328", "pmid": "", "title": "Oral antifungal medication for toenail onychomycosis", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Kreijkamp‐Kaspers, S, Hawke, K, Guo, L, Kerin, G, Bell‐Syer, SEM, Magin, P, Bell‐Syer, SV, van Driel, ML", "articleTypes": [], "doi": "10.1002/14651858.CD010031.pub2 AB - Abstract - Background Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence‐based choice for treatment. Objectives To assess the effects of oral antifungal treatments for toenail onychomycosis. Search methods We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies. Selection criteria RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years. We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high‐risk domain was 'blinding of personnel and participants'. We found high‐quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine‐treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate‐quality evidence). There was high‐quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu‐like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate‐quality evidence). Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low‐quality evidence). There is moderate‐quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate‐quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low‐quality evidence). Common adverse events in both groups included headache, viral infection, and nausea. Moderate‐quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate‐quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin‐treated participants) along with nausea and vomiting (in azole‐treated participants). Very low‐quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants). There is low‐quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low‐quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin‐treated participants) as well as taste loss and nausea (in terbinafine‐treated participants). No studies addressed recurrence rate for this comparison. No study addressed quality of life. Authors' conclusions We found high‐quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate‐quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate‐quality evidence). Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate‐quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low‐quality evidence). Only four comparisons assessed recurrence rate: low‐quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them. Only a limited number of studies reported adverse events, and the severity of the events was not taken into account. Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding. Plain language summary What is the best medication for a fungal infection of the toenail? Review question We aimed to find out which medications, taken by mouth for at least six weeks, are the most effective at curing fungal infection of the toenail, a condition that is known as onychomycosis, in people of any age. We compared these medications to each other or placebo (an inactive drug or treatment). Background Fungal infection of the toenails is a common condition, which has a low risk of complications and associated health risks. However, for those severely affected, it might affect normal daily activities. Medication taken by mouth appears to cure the condition more quickly and effectively than topical treatment. There are three main antifungal medications: griseofulvin, different medications in the azole group (itraconazole, fluconazole, albaconazole, posaconazole, ravuconazole), and terbinafine. We wanted to assess the following two main outcomes. 1. Does the nail look normal after treatment (clinical cure)?
 2. Is the nail free from fungus at a microscopic level (mycological cure)? Study characteristics We identified 48 studies with 10,200 participants of both sexes. The average age of the participants across studies ranged from 36 to 68; most studies included participants aged 18 and over. Our included studies compared the three main groups of medication against each other or to placebo. Most studies took place in outpatient dermatology settings in the USA and Europe. The participants mainly had fungal infection under the toenails. A small number of studies included a specific group of participants, such as those with diabetes. All but one study looked at fungal infections caused by dermatophyte, which are fungi that digest keratin. Study duration ranged from 4 months to 2 years, with most lasting 12 to 15 months. Key results The evidence is current to October 2016. We found high‐quality evidence that compared with placebo, both terbinafine and azoles are more effective for achieving a normal‐looking nail and curing the toenail infection (i.e. looking at the microscopic level to see if the fungus is gone). Terbinafine or azoles may also prevent the infection reoccurring more than placebo (low‐quality evidence). There was probably no significant difference in the risk of adverse events reported when comparing either azoles or terbinafine with placebo (moderate‐quality evidence). The most common adverse events amongst terbinafine‐treated and azole‐treated participants included stomach problems and headache. We found that compared to azoles, terbinafine was probably more effective in curing the nails in terms of appearance and infection (moderate‐quality evidence). The risk of side effects was probably the same for both treatments (moderate‐quality evidence), and the most common adverse events in both groups were headache, viral infection, and rash. There may be no difference in recurrence rate (low‐quality evidence). A third type of treatment, griseofulvin, was probably as effective as the azole medications in curing the nails in terms of appearance and infection (moderate‐quality evidence), but it may be less effective than terbinafine when assessing the same outcomes (low‐quality evidence). Griseofulvin caused more side effects than the other two treatments, although the quality of the evidence was moderate (compared to azole) to low (compared to terbinafine). The most common adverse events in both groups included stomach problems and feeling sick. We are uncertain about the effect of griseofulvin compared to azoles on the rate of recurrence, and studies comparing terbinafine and griseofulvin did not assess this outcome. Quality of the evidence The evidence for the primary outcomes of cure (in terms of appearance and infection) was high to moderate quality except for the comparisons of griseofulvin versus terbinafine (low quality) and combination terbinafine plus azole versus terbinafine alone (very low quality). The evidence quality for side effects was mainly moderate, but two comparisons had low evidence for this outcome. Not all comparisons measured recurrence rate, and the available evidence was based on low‐ to very low‐quality evidence. No studies reported on participants' quality of life. Many studies had problems in the study design: it was often unclear how they decided which participants would receive which treatment or ensured that participants weren't aware of the treatment allocation. Many studies also did not use a placebo.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.755Z" }, { "id": "f955415c-ae15-46ea-8158-f875f43e8378", "pmid": "", "title": "Factors influencing the uptake and use of nicotine replacement therapy and e‐cigarettes in pregnant women who smoke: a qualitative evidence synthesis", "imported": false, "abstract": "Abstract - Background Nicotine replacement therapy (NRT) delivers nicotine without the toxic chemicals present in tobacco smoke. It is an effective smoking cessation aid in non‐pregnant smokers, but there is less evidence of effectiveness in pregnancy. Systematic review evidence suggests that pregnant women do not adhere to NRT as prescribed, which might undermine effectiveness. Electronic cigarettes (e‐cigarettes) have grown in popularity, but effectiveness and safety in pregnancy are not yet established. The determinants of uptake and use of NRT and e‐cigarettes in pregnancy are unknown. Objectives To explore factors affecting uptake and use of NRT and e‐cigarettes in pregnancy. Search methods We searched MEDLINE(R), CINAHL and PsycINFO on 1 February 2019. We manually searched OpenGrey database and screened references of included studies and relevant reviews. We also conducted forward citation searches of included studies. Selection criteria We selected studies that used qualitative methods of data collection and analysis, included women who had smoked in pregnancy, and elicited participants' views about using NRT/e‐cigarettes for smoking cessation or harm reduction (i.e. to smoke fewer cigarettes) during pregnancy. Data collection and analysis We identified determinants of uptake and use of NRT/e‐cigarettes in pregnancy using a thematic synthesis approach. Two review authors assessed the quality of included studies with the Wallace tool. Two review authors used the CERQual approach to assess confidence in review findings. The contexts of studies from this review and the relevant Cochrane effectiveness review were not similar enough to fully integrate findings; however, we created a matrix to juxtapose findings from this review with the descriptions of behavioural support from trials in the effectiveness review. Main results We included 21 studies: 15 focused on NRT, 3 on e‐cigarettes, and 3 on both. Studies took place in five high‐income countries. Most studies contributed few relevant data; substantially fewer data were available on determinants of e‐cigarettes. Many studies focused predominantly on issues relating to smoking cessation, and determinants of NRT/e‐cigarette use was often presented as one of the themes. We identified six descriptive themes and 18 findings within those themes; from these we developed three overarching analytical themes representing key determinants of uptake and adherence to NRT and/or e‐cigarettes in pregnancy. The analytical themes show that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. Furthermore, women consider advice from health professionals when deciding whether to use NRT or e‐cigarettes; when health professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay for them to use these in pregnancy, women report feeling more confident about using them. Conversely, women who are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them during pregnancy feel less confident about using them. Women's past experiences with NRT can also affect their willingness to use NRT in pregnancy; women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. No trials on e‐cigarette use in pregnancy were included in the Cochrane effectiveness review, so we considered only NRT findings when integrating results from this review and the effectiveness review. No qualitative studies were conducted alongside trials, making full integration of the findings challenging. Women enrolled in trials would have agreed to being allocated to NRT or control group and would have received standardised information on NRT at the start of the trial. Overall, the findings of this synthesis are less relevant to women's decisions about starting NRT in trials and more likely to help explain trial participants' adherence to NRT after starting it. We considered most findings to be of moderate certainty; we assessed findings on NRT use as being of higher certainty than those on e‐cigarette use. This was mainly due to the limited data from fewer studies (only in the UK and USA) that contributed to e‐cigarette findings. Overall, we judged studies to be of acceptable quality with only minor methodological issues. Authors' conclusions Consistent messages from health professionals, based on high‐quality evidence and clearly explaining the safety of NRT and e‐cigarettes compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and subsequently encourage them to stay smoke‐free. Plain language summary Factors affecting use of nicotine replacement therapy and e‐cigarettes in pregnancy What was studied in this review? Nicotine replacement therapy (NRT) delivers nicotine without the harmful chemicals found in tobacco smoke. NRT helps some non‐pregnant adults to stop smoking, but it does not seem to work so well in pregnancy. This may be because pregnant women generally do not use NRT as prescribed. Studies show that some pregnant women use e‐cigarettes to help them cut down or quit, although their safety and effectiveness in pregnancy is not known. Little is known about the issues that influence pregnant women's use of NRT/e‐cigarettes. What is the aim of this review? To explore factors that affect whether women take up and use NRT or e‐cigarettes to reduce or quit smoking in pregnancy. What are the key messages of this review? Three main factors influence whether women take up and use NRT and e‐cigarettes in pregnancy: advice women receive from health professionals on using NRT or e‐cigarette in pregnancy, women's desire to protect their unborn baby from harm, and past personal experience with NRT. Each of these factors can either encourage or discourage women from using these products. What are the key findings? We included 21 studies; 15 of these focused on NRT, 3 on e‐cigarettes and 3 on both. Our findings suggest that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. They also consider the advice from their health professionals; when professionals tell women that NRT or e‐cigarettes are safer than smoking and that it is okay to use them in pregnancy, their confidence about using them increases. When women are told that NRT or e‐cigarettes are as dangerous or more dangerous than smoking and that they should not use them when they are pregnant, they feel less confident about using them. Women's past experiences with NRT will also affect how willing they are to use NRT in pregnancy. For example, women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. We conclude that consistent messages that are based on high‐quality research and clearly explain how safe NRT and e‐cigarettes are compared to smoking in pregnancy, could help women use NRT and e‐cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e‐cigarettes, increase their willingness to use these in their attempt to quit, and encourage them to stay smoke‐free. How up‐to‐date is this review? We searched for studies that had been published before 1 February 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Campbell, K; Coleman-Haynes, T; Bowker, K; Cooper, SE; Connelly, S; Coleman, T", "articleTypes": [], "doi": "10.1002/14651858.CD013629", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "f95f7d4c-8fef-40c7-861d-e464e4b46526", "pmid": "", "title": "Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment", "imported": false, "abstract": "Abstract - Background Vitamins and minerals have many functions in the nervous system which are important for brain health. It has been suggested that various different vitamin and mineral supplements might be useful in maintaining cognitive function and delaying the onset of dementia. In this review, we sought to examine the evidence for this in people who already had mild cognitive impairment (MCI). Objectives To evaluate the effects of vitamin and mineral supplementation on cognitive function and the incidence of dementia in people with mild cognitive impairment. Search methods We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group’s (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CENTRAL, CINAHL, LILACs, Web of Science Core Collection, ClinicalTrials.gov, and the WHO Portal/ICTRP, from inception to 25 January 2018. Selection criteria We included randomised or quasi‐randomised, placebo‐controlled trials which evaluated orally administered vitamin or mineral supplements in participants with a diagnosis of mild cognitive impairment and which assessed the incidence of dementia or cognitive outcomes, or both. We were interested in studies applicable to the general population of older people and therefore excluded studies in which participants had severe vitamin or mineral deficiencies. Data collection and analysis We sought data on our primary outcomes of dementia incidence and overall cognitive function and on secondary outcomes of episodic memory, executive function, speed of processing, quality of life, functional performance, clinical global impression, adverse events, and mortality. We conducted data collection and analysis according to standard Cochrane systematic review methods. We assessed the risk of bias of included studies using the Cochrane 'Risk of bias' assessment tool. We grouped vitamins and minerals according to their putative mechanism of action and, where we considered it to be clinically appropriate, we pooled data using random‐effects methods. We used GRADE methods to assess the overall quality of evidence for each comparison and outcome. Main results We included five trials with 879 participants which investigated B vitamin supplements. In four trials, the intervention was a combination of vitamins B6, B12, and folic acid; in one, it was folic acid only. Doses varied. We considered there to be some risks of performance and attrition bias and of selective outcome reporting among these trials. Our primary efficacy outcomes were the incidence of dementia and scores on measures of overall cognitive function. None of the trials reported the incidence of dementia and the evidence on overall cognitive function was of very low‐quality. There was probably little or no effect of B vitamins taken for six to 24 months on episodic memory, executive function, speed of processing, or quality of life. The evidence on our other secondary clinical outcomes, including harms, was very sparse or very low‐quality. There was evidence from one study that there may be a slower rate of brain atrophy over two years in participants taking B vitamins. The same study reported subgroup analyses based on the level of serum homocysteine (tHcy) at baseline and found evidence that B vitamins may improve episodic memory in those with tHcy above the median at baseline. We included one trial (n = 516) of vitamin E supplementation. Vitamin E was given as 1000 IU of alpha‐tocopherol twice daily. We considered this trial to be at risk of attrition and selective reporting bias. There was probably no effect of vitamin E on the probability of progression from MCI to Alzheimer's dementia over three years (HR 1.02; 95% CI 0.74 to 1.41; n = 516; 1 study, moderate‐quality evidence). There was also no evidence of an effect at intermediate time points. The available data did not allow us to conduct analyses, but the authors reported no significant effect of three years of supplementation with vitamin E on overall cognitive function, episodic memory, speed of processing, clinical global impression, functional performance, adverse events, or mortality (five deaths in each group). We considered this to be low‐quality evidence. We included one trial (n = 256) of combined vitamin E and vitamin C supplementation and one trial (n = 26) of supplementation with chromium picolinate. In both cases, there was a single eligible cognitive outcome, but we considered the evidence to be very low‐quality and so could not be sure of any effects. Authors' conclusions The evidence on vitamin and mineral supplements as treatments for MCI is very limited. Three years of treatment with high‐dose vitamin E probably does not reduce the risk of progression to dementia, but we have no data on this outcome for other supplements. Only B vitamins have been assessed in more than one RCT. There is no evidence for beneficial effects on cognition of supplementation with B vitamins for six to 24 months. Evidence from a single study of a reduced rate of brain atrophy in participants taking vitamin B and a beneficial effect of vitamin B on episodic memory in those with higher tHcy at baseline warrants attempted replication. Plain language summary Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment Review question This review investigated whether people with mild cognitive impairment can reduce their risk of developing dementia, or can prevent their memory or other thinking skills from deteriorating further, by taking vitamin or mineral supplements. Background Slight changes in memory and thinking skills are common as people get older. When these changes are worse than can be expected in normal ageing, but are not bad enough to make a person's usual activities difficult to manage, then the person is said to have mild cognitive impairment (MCI). People with MCI are at increased risk of developing dementia in the future. Vitamins and minerals are naturally occurring substances which are needed in the diet to maintain health. They have lots of different functions in the body and many are essential to keep the brain working properly. It has been suggested that supplementing a person's normal diet with extra doses of these vitamins or minerals might help to maintain thinking skills or prevent dementia. Study characteristics We found eight randomised controlled trials (RCTs), which investigated four different types of vitamin or mineral pills by comparing them to a placebo (a dummy pill). The vitamins tested were B vitamins (vitamin B6, vitamin B12 and folic acid), vitamin E, and vitamin E and C given together. The only mineral tested was chromium. Key results and quality of the evidence Vitamin B combination versus placebo Five trials with a total of 879 participants compared B vitamins with placebo. Four used combinations of vitamin B6, vitamin B12, and folic acid; one small study tested folic acid on its own. None of these studies reported whether or not participants developed dementia. These studies did not find that memory or thinking skills differed between the group of people who took vitamin B supplements and those who took placebo after treatment lasting six months to two years. Our confidence in the results on different tests used in the studies varied from moderate to very low. Two years of vitamin B supplements did seem to help memory in a small subgroup of participants in one study who could be identified by a particular blood test at the start of the trial. One study found that there was probably no effect on participants' quality of life. One study scanned the brains of some participants and reported that B vitamins may slow the rate of brain shrinkage. Harmful effects and deaths were reported in very few participants and we cannot conclude whether or not there are harms from taking these or similar combinations of B vitamins. Vitamin E versus placebo. One study with 516 participants compared a relatively high dose of vitamin E (2000 IU a day) to placebo in people who were also taking a multivitamin containing 15 IU of vitamin E (the daily requirement for vitamin E is approximately 30 IU). The risk of developing dementia due to Alzheimer’s disease (the commonest form of dementia) is probably not affected by three years of treatment with high‐dose vitamin E. The quality of the evidence for other outcomes was lower, but there may also be no effect of this dose of vitamin E on specific memory or thinking skills or on how well people could manage their daily activities. Vitamin E and C versus placebo One study with 256 participants compared a combination of vitamins C and E with placebo. It found no effect on overall memory and thinking skills, but we had little confidence in this result because of the quality of the evidence. Chromium picolinate versus placebo Only one very small study with 26 participants investigated the effect of chromium supplements. This study was too small for us to be able to draw any conclusions. Conclusions The amount and quality of research evidence about vitamin and mineral supplements for treating MCI in people without nutritional deficiency is limited. At the moment, it is not possible to identify any supplements which can reduce the risk of people with MCI developing dementia or which can effectively treat their symptoms. More research is needed before we can answer our review question.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "McCleery, J, Abraham, RP, Denton, DA, Rutjes, AWS, Chong, LY, Al‐Assaf, AS, Griffith, DJ, Rafeeq, S, Yaman, H, Malik, MA, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011905.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.773Z" }, { "id": "f9654986-68cb-44bf-8113-62f96ab61011", "pmid": "", "title": "Fixed‐dose combinations of drugs versus single‐drug formulations for treating pulmonary tuberculosis", "imported": false, "abstract": "Abstract - Background People who are newly diagnosed with pulmonary tuberculosis (TB) typically receive a standard first‐line treatment regimen that consists of two months of isoniazid, rifampicin, pyrazinamide, and ethambutol followed by four months of isoniazid and rifampicin. Fixed‐dose combinations (FDCs) of these drugs are widely recommended. Objectives To compare the efficacy, safety, and acceptability of anti‐tuberculosis regimens given as fixed‐dose combinations compared to single‐drug formulations for treating people with newly diagnosed pulmonary tuberculosis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL, published in the Cochrane Library, Issue 11 2015); MEDLINE (1966 to 20 November 2015); EMBASE (1980 to 20 November 2015); LILACS (1982 to 20 November 2015); the metaRegister of Controlled Trials; and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), without language restrictions, up to 20 November 2015. Selection criteria Randomized controlled trials that compared the use of FDCs with single‐drug formulations in adults (aged 15 years or more) newly diagnosed with pulmonary TB. Data collection and analysis Two review authors independently assessed studies for inclusion, and assessed the risk of bias and extracted data from the included trials. We used risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data with 95% confidence intervals (CIs). We attempted to assess the effect of treatment for time‐to‐event measures with hazard ratios and their 95% CIs. We used the Cochrane 'Risk of bias' assessment tool to determine the risk of bias in included trials. We used the fixed‐effect model when there was little heterogeneity and the random‐effects model with moderate heterogeneity. We used an I² statistic value of 75% or greater to denote significant heterogeneity, in which case we did not perform a meta‐analysis. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results We included 13 randomized controlled trials (RCTs) in the review, which enrolled 5824 participants. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. Overall there is little or no difference detected between FDCs and single‐drug formulations for most outcomes reported. We did not detect a difference in treatment failure between FDCs compared with single‐drug formulations (RR 1.28, 95% CI 0.82 to 2.00; 3606 participants, seven trials, moderate quality evidence ). Relapse may be more frequent in people treated with FDCs compared to single‐drug formulations, although the confidence interval (CI) includes no difference (RR 1.28, 95% CI 1.00 to 1.64; 3621 participants, 10 trials, low quality evidence ). We did not detect any difference in death between fixed‐dose and single‐drug formulation groups (RR 0.96, 95% CI 0.67 to 1.39; 4800 participants, 11 trials, moderate quality evidence ). When we compared FDCs with single‐drug formulations we found little or no difference for sputum smear or culture conversion at the end of treatment (RR 0.99, 95% CI 0.96 to 1.02; 2319 participants, seven trials, high quality evidence ), for serious adverse events (RR 1.45, 95% CI 0.90 to 2.33; 3388 participants, six trials, moderate quality evidence ), and for adverse events that led to discontinuation of therapy (RR 0.96, 95% CI 0.56 to 1.66; 5530 participants, 13 trials, low quality evidence ). We conducted a sensitivity analysis excluding studies at high risk of bias and this did not alter the review findings. Authors' conclusions Fixed‐dose combinations and single‐drug formulations probably have similar effects for treating people with newly diagnosed pulmonary TB. 23 April 2019 No update planned Other This is not a current research question. Plain language summary Fixed‐dose combinations for treating pulmonary tuberculosis What are fixed‐dose combinations and how might they improve care of people with tuberculosis Tuberculosis (TB) is an important health problem, especially in developing countries. The treatment for pulmonary TB in new patients includes four oral medicines taken for six months, sometimes as fixed‐dose combinations (FDCs) that are combined in one tablet, or taken separately as single‐drug formulations. The World Health Organization recommends prescribers use fixed‐dose combinations to reduce the number of tablets that people take. On the supply side, this might reduce prescribing errors and improve drug supply efficiency; on the patient's side, FDCS simplify treatment and improve adherence. We conducted a review to assess the efficacy, safety, and acceptability of FDCs compared with single‐drug formulations for treating people with newly diagnosed pulmonary TB. What the research says We searched for relevant trials up to 20 November 2015, and included 13 randomized controlled trials that enrolled 5824 people. Trials were published between 1987 and 2015 and included participants in treatment with newly diagnosed pulmonary TB in countries with high TB prevalence. Only two trials reported the HIV status of included participants. There is probably little or no difference in FDCs compared to single‐drug formulations for treatment failure ( moderate quality evidence ); relapse may be more frequent ( low quality evidence ); and the number of deaths were similar ( moderate quality evidence ). There is little or no difference in sputum smear or culture conversion ( high quality evidence ), and no difference was shown for serious adverse events ( moderate quality evidence ) or adverse events that led to discontinuation of therapy ( low quality evidence ). Authors’ conclusions We concluded that fixed‐dose combinations have similar efficacy to single‐drug formulations for treating people with newly diagnosed pulmonary TB.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Gallardo, CR; Rigau Comas, D; Valderrama Rodríguez, A; Roqué i Figuls, M; Parker, LA; Caylà, J; Bonfill Cosp, X", "articleTypes": [], "doi": "10.1002/14651858.CD009913.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "f9686bf5-4cf1-43b3-b785-bda56b419b57", "pmid": "", "title": "Medical interventions for treating anthracycline‐induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer", "imported": false, "abstract": "Abstract - Background Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline‐induced cardiotoxicity. This review is an update of a previously published Cochrane review. Objectives To compare the effect of medical interventions on anthracycline‐induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions, or no treatment. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 8), MEDLINE/PubMed (1949 to September 2015), and EMBASE/Ovid (1980 to September 2015) for potentially relevant articles. In addition, we searched reference lists of relevant articles, conference proceedings of the International Society for Paediatric Oncology (SIOP), the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), the International Conference on Long‐Term Complications of Treatment of Children & Adolescents for Cancer, and the European Symposium on Late Complications from Childhood Cancer (from 2005 to 2015), and ongoing trial databases (the ISRCTN Register, the National Institutes of Health (NIH) Register, and the trials register of the World Health Organization (WHO); all searched in September 2015). Selection criteria Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline‐induced cardiotoxicity with either placebo, other medical interventions, or no treatment. Data collection and analysis Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments, which another review author checked. We performed analyses according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results In the original version of the review we identified two RCTs; in this update we identified no additional studies. One trial (135 participants) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline‐induced cardiac dysfunction. The other trial (68 participants) compared a two‐week treatment of phosphocreatine with a control treatment (vitamin C, adenosine triphosphate, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline‐induced cardiotoxicity. Both studies had methodological limitations. The RCT on enalapril showed no statistically significant differences in overall survival, mortality due to heart failure, development of clinical heart failure, and quality of life between treatment and control groups. A post‐hoc analysis showed a decrease (that is improvement) in one measure of cardiac function (left ventricular end‐systolic wall stress (LVESWS): ‐8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Participants treated with enalapril had a higher risk of dizziness or hypotension (risk ratio 7.17, 95% confidence interval 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013). The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function, and adverse events between treatment and control groups. Authors' conclusions Only one trial evaluated the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side effects of enalapril in childhood cancer survivors with asymptomatic anthracycline‐induced cardiotoxicity. Only one trial evaluated the effect of phosphocreatine in childhood cancer patients with anthracycline‐induced cardiotoxicity. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatments on echocardiographic function and clinical outcomes. We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors. High‐quality studies should be performed. Plain language summary Treatment for cardiac problems caused by anthracycline chemotherapy for childhood cancer Anthracyclines are anticancer drugs used in the treatment of different types of childhood cancer. An important adverse effect of anthracyclines is damage to the heart, which can lead to asymptomatic (without complaints) or symptomatic (with complaints) cardiac problems during and after cancer treatment. While there are several drugs available to treat other types of cardiac problems in adults, it is not known if these drugs are beneficial in treating cardiac problems caused by anthracyclines in childhood cancer patients and survivors. A physician confronted with a childhood cancer patient or survivor with anthracycline‐induced cardiac problems should be able to make an informed decision on how to treat this patient based on high‐quality evidence about the beneficial and adverse effects of the treatment options. We searched for and summarised studies that evaluated drugs for treating anthracycline‐induced cardiac problems in childhood cancer patients and survivors. We identified two randomised studies evaluating two different drugs in two different types of patients. One of these drugs, an angiotensin‐converting enzyme (ACE) inhibitor (enalapril), had a short‐term beneficial effect on heart function in survivors of childhood cancer with asymptomatic cardiac problems caused by anthracyclines compared with placebo. However, the drug had no significant beneficial effect on other important outcomes and was associated with side effects such as dizziness and fatigue. This study was of reasonable/good quality. The other study was of low quality and found no effect of a short treatment with phosphocreatine in childhood leukaemia patients with symptomatic or asymptomatic cardiac problems compared with a control treatment with vitamin C, adenosine triphosphate, vitamin E, and oral coenzyme Q10. We could make no definitive conclusions about treatment options for anthracycline‐induced cardiac problems in childhood cancer patients and survivors. High‐quality studies are needed to determine if there are drugs that improve heart function in these patients.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Cheuk, DKL, Sieswerda, E, van Dalen, EC, Postma, A, Kremer, LCM", "articleTypes": [], "doi": "10.1002/14651858.CD008011.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.769Z" }, { "id": "f96ced47-18dc-4b66-a730-53739f5e4014", "pmid": "", "title": "Interventions for chronic palmoplantar pustulosis", "imported": false, "abstract": "Abstract - Background Palmoplantar pustulosis is a chronic inflammatory disease in which sterile, relapsing pustules appear on the palms and soles, possibly in conjunction with other symptoms. The previous Cochrane Review on this topic was published in 2006, before biological treatments were extensively used. Objectives To assess the effects of interventions for chronic palmoplantar pustulosis to induce and maintain complete remission. Search methods We searched the following databases up to March 2019: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of the included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria We considered RCTs including people with palmoplantar pustulosis or chronic palmoplantar pustular psoriasis assessing topical therapy, systemic therapy, combinations of topical or systemic therapies, or non‐pharmacological therapies compared with placebo, no intervention, or each other. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our outcomes included 'Proportion of participants cleared or almost cleared', 'Proportion of participants with adverse effects serious or severe enough to cause withdrawal', 'Proportion of participants with at least 50% improvement in disease severity', and 'Proportion of participants with adverse effects'. Main results We included 37 studies (1663 participants; mean age 50 years (range 34 to 63); 24% males). These studies reported condition severity differently. Around half of the included trials stated the setting (hospitals, community clinics, or both). More than half of the studies were at high risk of bias in at least one domain. Our included studies assessed mainly systemic treatments (retinoids, ciclosporin, biologics, etretinate + PUVA (combination of psoralens and long‐wave ultraviolet radiation) therapy combined, and antibiotics), but also topical treatments (dermocorticoids, vitamin D) and phototherapy (PUVA, ultraviolet A1 (UVA1)). Other interventions were assessed by single studies. The most common comparator was placebo. All results presented in this abstract were assessed in the short term (mean treatment duration was 11 weeks (range 8 to 24 weeks)) and are based on participants with chronic palmoplantar pustulosis. All outcome time point measurements were taken from baseline and assessed at the end of treatment. Short‐term and long‐term outcomes were defined as measurement up to 24 weeks after randomisation and between 24 and 104 weeks after randomisation, respectively. One trial (188 participants) assessed the topical vitamin D derivative maxacalcitol versus placebo and found that maxacalcitol may be more effective than placebo in achieving clearance (risk ratio (RR) 7.83, 95% confidence interval (CI) 1.85 to 33.12; low‐quality evidence), and the risk of adverse effects (such as mild local irritation, pruritus, and haematological or urinary test abnormalities) is probably similar in both groups (RR 0.87, 95% CI 0.64 to 1.19; moderate‐quality evidence). Severity was not reported. Two trials (49 participants) assessed PUVA therapy versus placebo or no treatment, providing very low‐quality evidence. Adverse effects were reported with oral PUVA (including nausea, ankle swelling, and non‐purulent conjunctivitis) and with local PUVA (including blistering, erythema, and pruritus). With regard to the systemic retinoid alitretinoin, one trial (33 participants; moderate‐quality evidence) showed that alitretinoin probably makes little or no difference in reducing severity when compared to placebo (RR 0.69, 95% CI 0.36 to 1.30). A similar number of adverse events were reported in both treatment groups, including headache, cheilitis, nausea, arthralgia, and nasopharyngitis (RR 0.84, 95% CI 0.61 to 1.17). Clearance was not reported. There may be little or no difference between etanercept and placebo in achieving clearance (RR 1.64, 95% CI 0.08 to 34.28; 1 study; 15 participants; low‐quality evidence); however, the 95% CI was very wide, showing there may be a difference between groups. Severity was not measured. More patients treated with placebo may achieve reduced severity than those treated with ustekinumab, but the wide 95% CI indicates there might be little or no difference between groups and there might be greater effect with ustekinumab (RR 0.48, 95% CI 0.11 to 2.13; 1 study; 33 participants; low‐quality evidence). Clearance was not reported. It is uncertain whether guselkumab increases clearance when compared to placebo (2 studies; 154 participants) because the quality of evidence is very low, but guselkumab probably better reduces disease severity (RR 2.88, 95% CI 1.24 to 6.69; 1 study; 49 participants; moderate‐quality evidence). Secukinumab is probably superior to placebo in reducing severity (RR 1.55, 95% CI 1.02 to 2.35; 1 study; 157 participants; moderate‐quality evidence), but our clearance outcome was not reported. None of these trials reported on occurrence of adverse effects. Only two of the studies discussed above reported adverse effects serious or severe enough to cause withdrawal. Guselkumab may cause more serious adverse events when compared to placebo, but there is uncertainty due to the very wide 95% CI showing there may be little or no difference and showing more events with placebo (RR 2.88, 95% CI 0.32 to 25.80; 1 study; 49 participants; low‐quality evidence). Secukinumab probably causes more serious adverse events than placebo (RR 3.29, 95% CI 1.40 to 7.75; 1 study; 157 participants; moderate‐quality evidence). Authors' conclusions Evidence is lacking for major chronic palmoplantar pustulosis treatments such as superpotent corticosteroids, phototherapy, acitretin, methotrexate, and ciclosporin. Risk of bias and imprecision limit our confidence. Maxacalcitol may be more effective than placebo in achieving clearance in the short term (low‐quality evidence), and the risk of adverse effects is probably similar (moderate‐quality evidence). Oral alitretinoin is probably no more effective than placebo in reducing severity, with a similar risk of adverse effects (moderate‐quality evidence). Regarding biological treatments, we are uncertain of the effect of etanercept on clearance and the effect of ustekinumab on severity (low‐quality evidence). Secukinumab and guselkumab are probably superior to placebo in reducing severity (moderate‐quality evidence). Adverse events not requiring withdrawal were not reported for these treatments. Reporting of serious adverse effects was incomplete: compared to placebo, secukinumab probably caused more participant withdrawals (moderate‐quality evidence), but we are uncertain of the effect of guselkumab (low‐quality evidence). Future trials should assess commonly used treatments using validated severity and quality of life scales. Plain language summary Treating long‐term palmoplantar pustulosis (pustules on the hands and feet) Review question We wanted to assess treatments for palmoplantar pustulosis (a persistent condition characterised by small, pus‐filled blisters on the hands and feet), when compared to an inactive substance (placebo), no intervention, or each other. We included 37 studies. Background Palmoplantar pustulosis negatively affects a person's life; there is no cure or standard treatment. Over time, the skin becomes thicker and redder, and may develop cracks or flake off as scales. Symptoms are treated with topical medicines (usually corticosteroids), systemic medicines (medicines injected or taken by mouth that work throughout the entire body; usually medicines based on vitamin A or D), or phototherapy (ultraviolet light treatment). Study characteristics The studies involved 1663 adults (mostly women) 34 to 63 years of age (average age 50 years). In 19 studies, participants had had palmoplantar pustulosis from two to 16 years (average 6.4 years). Participants had palmoplantar pustular psoriasis (6 studies), palmoplantar pustulosis (29 studies), or both (2 studies). Study authors reported condition severity differently. The included studies assessed a variety of different treatments: mainly systemic treatments (including biologic medicines, vitamin A medicines, immunosuppressants, antibiotics, and light therapy combined with a vitamin A medicine), but also topical medicines (containing steroids or vitamin D) and light treatments. Single studies assessed other treatments. Treatments were most commonly compared against placebo. Treatment length varied; for our key results, this ranged from 8 to 24 weeks (average 11 weeks). When reported, studies were conducted in hospitals, community clinics, or both. Pharmaceutical companies funded 18 studies. Key results Low‐quality evidence suggests that maxacalcitol (a topical vitamin D derivative) may work better than placebo in achieving clearance; moderate‐quality evidence indicates that the number of side effects is probably similar in both groups (participants experienced itching, irritation, and blood or urine test abnormalities) (1 trial; 188 participants). Severity was not measured. We found very low‐quality evidence for PUVA therapy (i.e. psoralen, a drug to sensitise the skin, and ultraviolet light A) versus placebo or no treatment (2 studies; 49 participants), so we are unable to draw conclusions. Side effects with PUVA included skin blisters, redness, itching, swelling, and feeling sick. Oral alitretinoin probably makes little or no difference in reducing severity when compared to placebo (moderate‐quality evidence; 1 study; 33 participants). A similar result was found for side effects, with headache, sickness, joint pain, high cholesterol, and colds reported in both groups. Clearance was not reported. Five studies assessed biological treatments (etanercept, ustekinumab, guselkumab, secukinumab), which use substances made from living organisms, or synthetic versions, to target the immune system. Low‐quality evidence (1 study; 15 participants) suggests that etanercept may make little or no difference in clearance when compared to placebo, but we are very uncertain of this result. Side effects and severity were not measured. We found low‐quality evidence suggesting that ustekinumab may be worse than placebo in reducing disease severity, but we are very uncertain of this result. Side effects and clearance were not reported (1 study; 33 participants). Compared to placebo, guselkumab probably reduces severity (moderate‐quality evidence; 1 study; 49 participants), but its effects on clearance are uncertain (very low‐quality evidence; 2 studies; 154 participants). Side effects were not measured. Moderate‐quality evidence shows that secukinumab was probably superior to placebo in reducing severity, but skin clearance and side effects were not reported (1 study; 157 participants). Only two studies described above reported withdrawals from treatment due to serious side effects; these are probably more frequent with secukinumab than with placebo (157 participants), and may occur more often with guselkumab than with placebo (49 participants), but we are very uncertain of the guselkumab result. For these key results, outcomes were assessed between 8 and 24 weeks, which we deemed short term. This evidence is current to March 2019. Quality of the evidence The key comparisons reported clearance most often, but evidence quality was mainly very low. Only two key studies reported side effects causing withdrawal (low‐ and moderate‐quality evidence). The evidence underlying our severity and side effects outcomes was variable in quality (very low to moderate). Small participant numbers, results with wide margins of error, and selective reporting have limited our confidence in the evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Obeid, G, Do, G, Kirby, L, Hughes, C, Sbidian, E, Le Cleach, L", "articleTypes": [], "doi": "10.1002/14651858.CD011628.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.815Z" }, { "id": "f9aa1afc-7028-47f7-a430-289859a346f6", "pmid": "", "title": "Interventions to prevent obesity in children aged 5 to 11 years old", "imported": false, "abstract": "Abstract - Background Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well‐being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review. Objectives To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or ‘activity’ levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short‐ (12 weeks to < 9 months from baseline), medium‐ (9 months to < 15 months) and long‐term (≥ 15 months) follow‐up. We used GRADE to assess the certainty of the evidence for each outcome. Main results This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta‐analyses. One hundred forty‐six studies were based in high‐income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short‐term follow‐up (mean difference (MD) 0, 95% confidence interval (CI) ‐0.10 to 0.10; 5 studies, 2107 participants; low‐certainty evidence) and at medium‐term follow‐up (MD ‐0.01, 95% CI ‐0.15 to 0.12; 9 studies, 6815 participants; low‐certainty evidence) or zBMI at long‐term follow‐up (MD ‐0.05, 95% CI ‐0.10 to 0.01; 7 studies, 5285 participants; low‐certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long‐term follow‐up (MD ‐0.17, 95% CI ‐0.48 to 0.13; 2 studies, 945 participants; moderate‐certainty evidence) and zBMI at short‐ or medium‐term follow‐up (MD ‐0.06, 95% CI ‐0.13 to 0.01; 8 studies, 3695 participants; MD ‐0.04, 95% CI ‐0.10 to 0.02; 9 studies, 7048 participants; moderate‐certainty evidence). Five studies (1913 participants; very low‐certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short‐term or long‐term follow‐up (BMI short‐term: MD ‐0.02, 95% CI ‐0.17 to 0.13; 14 studies, 4069 participants; zBMI short‐term: MD ‐0.02, 95% CI ‐0.07 to 0.02; 6 studies, 3580 participants; low‐certainty evidence; BMI long‐term: MD ‐0.07, 95% CI ‐0.24 to 0.10; 8 studies, 8302 participants; zBMI long‐term: MD ‐0.02, 95% CI ‐0.09 to 0.04; 6 studies, 6940 participants; low‐certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.18 to ‐0.05; 16 studies, 21,286 participants; zBMI: MD ‐0.05, 95% CI ‐0.09 to ‐0.02; 13 studies, 20,600 participants; moderate‐certainty evidence). Eleven studies (21,278 participants; low‐certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to ‐0.01; 27 studies, 16,066 participants; zBMI: MD ‐0.03, 95% CI ‐0.06 to 0.00; 26 studies, 12,784 participants; low‐certainty evidence) and likely result in a reduction of BMI and zBMI at medium‐term follow‐up (BMI: MD ‐0.11, 95% CI ‐0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD ‐0.05, 95% CI ‐0.07 to ‐0.02; 24 studies, 20,998 participants; moderate‐certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long‐term follow‐up (BMI: MD 0.03, 95% CI ‐0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD ‐0.02, 95% CI ‐0.06 to 0.01; 22 studies, 23,594 participants; low‐certainty evidence). Nineteen studies (27,882 participants; low‐certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow‐up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high‐income versus non‐high‐income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability. Authors' conclusions The body of evidence in this review demonstrates that a range of school‐based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short‐ and medium‐term, but not at long‐term follow‐up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community‐based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities. Plain language summary Do dietary and activity strategies help prevent obesity in children aged 5 to 11 years? Key messages ‐ Strategies for changing activity levels, or both activity levels and diet, of children to help prevent them developing overweight or obesity might be effective in making small reductions in body mass index (BMI) in children aged 5 to 11 years. ‐ There is very little information about whether the strategies resulted in serious adverse events (e.g. injuries), but from what we found there appears to be little or no effect. ‐ This change in BMI, when provided to many children across a whole population, is useful for parents concerned about their children becoming overweight as they move into adulthood and for governments in trying to tackle the problems of obesity through the life course. Why is preventing obesity in children important? More children are developing overweight and obesity worldwide. Being overweight as a child can cause health problems, and people may be affected psychologically and in their social life. Children that are overweight are likely to be overweight as adults and continue to experience poor physical and mental health. Indeed, childhood obesity is associated with type 2 diabetes and heart disease in adulthood and middle‐age mortality. What did we want to find out? We wanted to find out if strategies to help people modify their diet or activity (or both) are effective at preventing obesity in children aged 5 to 11 years. We also wanted to find out if these strategies were associated with any serious adverse events. What did we do? We searched many scientific databases to find studies that looked at ways of preventing obesity in children. We included studies aimed at children aged 5 to 11 years. We did not include studies only aimed at children who were already overweight or were already living with obesity. However, we included studies in which children who were overweight or living with obesity were included in the analysis. We only included studies if the methods they used were aimed at changing children's diet, or their level of activity (i.e. increasing physical activity or reducing inactive time), or both. We looked only for studies that randomly placed people into groups receiving different strategies (which may include changing nothing). We assessed the rigour of the studies to get a sense of how confident we were in their results. We grouped studies together for analysis depending on whether they aimed to improve diet, activity, or both. What did we find? We found 172 studies that involved 189,707 children. One hundred forty‐six studies were based in high‐income countries (e.g. the USA and in Europe). In 111 studies, the strategies were tried in schools, though 15 were based in the community, eight in the home and seven in clinical settings; one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty‐six strategies were implemented for less than nine months, with the shortest being conducted over one visit and the longest over four years. Non‐industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry (e.g. food suppliers, pharmaceutical industry and private healthcare services). Our statistical analyses included results from 149 studies of 160,267 children. We found that children who were helped with a strategy to change their activity levels alone or in combination with a strategy to change their diet may have their BMI reduced, compared with children who were not given any strategy. This means that these children may have been able to minimise their excess weight gain by a small amount which, for public health, is important. In contrast, children who were helped with a strategy to change their diet only did not have their BMI reduced. Only a few studies reported any possible harms of the strategies, and no serious harms were identified in these. What are the limitations of the evidence? Our confidence in the evidence is moderate to very low. However, it is difficult to be confident that funding more studies, at least more school‐based studies, would produce a much higher level of confidence in the results. Four main factors reduced our confidence in the evidence. 1. Results were very inconsistent across the different studies. 2. A lot of the studies had limitations in how they were done. 3. There were not enough studies reporting particular types of outcomes for a particular duration of follow‐up to be certain about the results for some comparisons, and also certain settings (e.g. community settings) were under‐represented. 4. Results from some studies were not reported in a way such that we could include them in our analyses (e.g. without any detail of the difference between the strategies examined) and this may have an impact on the results of our analyses. This review does not provide sufficient information to be able to assess how well strategies work for children with disabilities, or whether those implemented in community settings are effective. How up‐to‐date is this evidence? This review updates our previous review. The evidence is up‐to‐date to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Spiga, F, Davies, AL, Tomlinson, E, Moore, THM, Dawson, S, Breheny, K, Savović, J, Gao, Y, Phillips, SM, Hillier-Brown, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD015328.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.106Z" }, { "id": "f9aee0c9-1165-412c-ae9f-4df857da9f83", "pmid": "", "title": "Ivermectin for preventing and treating COVID‐19", "imported": false, "abstract": "Abstract - Background Ivermectin, an antiparasitic agent, inhibits the replication of viruses in vitro. The molecular hypothesis of ivermectin's antiviral mode of action suggests an inhibitory effect on severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) replication in early stages of infection. Currently, evidence on ivermectin for prevention of SARS‐CoV‐2 infection and COVID‐19 treatment is conflicting. Objectives To assess the efficacy and safety of ivermectin plus standard of care compared to standard of care plus/minus placebo, or any other proven intervention for people with COVID‐19 receiving treatment as inpatients or outpatients, and for prevention of an infection with SARS‐CoV‐2 (postexposure prophylaxis). Search methods We searched the Cochrane COVID‐19 Study Register, Web of Science (Emerging Citation Index and Science Citation Index), WHO COVID‐19 Global literature on coronavirus disease, and HTA database weekly to identify completed and ongoing trials without language restrictions to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022. Selection criteria We included randomized controlled trials (RCTs) comparing ivermectin to standard of care, placebo, or another proven intervention for treatment of people with confirmed COVID‐19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS‐CoV‐2 infection. Co‐interventions had to be the same in both study arms. For this review update, we reappraised eligible trials for research integrity: only RCTs prospectively registered in a trial registry according to WHO guidelines for clinical trial registration were eligible for inclusion. Data collection and analysis We assessed RCTs for bias, using the Cochrane RoB 2 tool. We used GRADE to rate the certainty of evidence for outcomes in the following settings and populations: 1) to treat inpatients with moderate‐to‐severe COVID‐19, 2) to treat outpatients with mild COVID‐19 (outcomes: mortality, clinical worsening or improvement, (serious) adverse events, quality of life, and viral clearance), and 3) to prevent SARS‐CoV‐2 infection (outcomes: SARS‐CoV‐2 infection, development of COVID‐19 symptoms, admission to hospital, mortality, adverse events and quality of life). Main results We excluded seven of the 14 trials included in the previous review version; six were not prospectively registered and one was non‐randomized. This updated review includes 11 trials with 3409 participants investigating ivermectin plus standard of care compared to standard of care plus/minus placebo. No trial investigated ivermectin for prevention of infection or compared ivermectin to an intervention with proven efficacy. Five trials treated participants with moderate COVID‐19 (inpatient settings); six treated mild COVID‐19 (outpatient settings). Eight trials were double‐blind and placebo‐controlled, and three were open‐label. We assessed around 50% of the trial results as low risk of bias. We identified 31 ongoing trials. In addition, there are 28 potentially eligible trials without publication of results, or with disparities in the reporting of the methods and results, held in ‘awaiting classification’ until the trial authors clarify questions upon request. Ivermectin for treating COVID‐19 in inpatient settings with moderate‐to‐severe disease We are uncertain whether ivermectin plus standard of care compared to standard of care plus/minus placebo reduces or increases all‐cause mortality at 28 days (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.14 to 2.51; 3 trials, 230 participants; very low‐certainty evidence); or clinical worsening, assessed by participants with new need for invasive mechanical ventilation or death at day 28 (RR 0.82, 95% CI 0.33 to 2.04; 2 trials, 118 participants; very low‐certainty evidence); or serious adverse events during the trial period (RR 1.55, 95% CI 0.07 to 35.89; 2 trials, 197 participants; very low‐certainty evidence). Ivermectin plus standard of care compared to standard of care plus placebo may have little or no effect on clinical improvement, assessed by the number of participants discharged alive at day 28 (RR 1.03, 95% CI 0.78 to 1.35; 1 trial, 73 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.04, 95% CI 0.61 to 1.79; 3 trials, 228 participants; low‐certainty evidence); and on viral clearance at 7 days (RR 1.12, 95% CI 0.80 to 1.58; 3 trials, 231 participants; low‐certainty evidence). No trial investigated quality of life at any time point. Ivermectin for treating COVID‐19 in outpatient settings with asymptomatic or mild disease Ivermectin plus standard of care compared to standard of care plus/minus placebo probably has little or no effect on all‐cause mortality at day 28 (RR 0.77, 95% CI 0.47 to 1.25; 6 trials, 2860 participants; moderate‐certainty evidence) and little or no effect on quality of life, measured with the PROMIS Global‐10 scale (physical component mean difference (MD) 0.00, 95% CI ‐0.98 to 0.98; and mental component MD 0.00, 95% CI ‐1.08 to 1.08; 1358 participants; high‐certainty evidence). Ivermectin may have little or no effect on clinical worsening, assessed by admission to hospital or death within 28 days (RR 1.09, 95% CI 0.20 to 6.02; 2 trials, 590 participants; low‐certainty evidence); on clinical improvement, assessed by the number of participants with all initial symptoms resolved up to 14 days (RR 0.90, 95% CI 0.60 to 1.36; 2 trials, 478 participants; low‐certainty evidence); on serious adverse events (RR 2.27, 95% CI 0.62 to 8.31; 5 trials, 1502 participants; low‐certainty evidence); on any adverse events during the trial period (RR 1.24, 95% CI 0.87 to 1.76; 5 trials, 1502 participants; low‐certainty evidence); and on viral clearance at day 7 compared to placebo(RR 1.01, 95% CI 0.69 to 1.48; 2 trials, 331 participants; low‐certainty evidence). None of the trials reporting duration of symptoms were eligible for meta‐analysis. Authors' conclusions For outpatients, there is currently low‐ to high‐certainty evidence that ivermectin has no beneficial effect for people with COVID‐19. Based on the very low‐certainty evidence for inpatients, we are still uncertain whether ivermectin prevents death or clinical worsening or increases serious adverse events, while there is low‐certainty evidence that it has no beneficial effect regarding clinical improvement, viral clearance and adverse events. No evidence is available on ivermectin to prevent SARS‐CoV‐2 infection. In this update, certainty of evidence increased through higher quality trials including more participants. According to this review's living approach, we will continually update our search. Plain language summary Ivermectin for preventing and treating COVID‐19 Is ivermectin effective for COVID‐19? Key messages We found no evidence to support the use of ivermectin for treating COVID‐19 or preventing SARS‐CoV‐2 infection. The evidence base improved slightly in this update, but is still limited. Evaluation of ivermectin is continuing in 31 ongoing trials, and we will update this review again when their results become available. What is ivermectin? Ivermectin is a medicine used to treat parasites, such as intestinal parasites in animals, and scabies in humans. It is inexpensive and is widely used in regions of the world where parasitic infestations are common. It has few unwanted effects. Medical regulators have not approved ivermectin for COVID‐19. What did we want to find out? We wanted to update our knowledge of whether ivermectin reduces death, illness, and length of infection in people with COVID‐19, or is useful in prevention of the infection. We included trials comparing the medicine to placebo (dummy treatment), usual care, or treatments for COVID‐19 that are known to work to some extent, such as dexamethasone. We excluded trials comparing ivermectin to other medicines that do not work, like hydroxychloroquine, or whose effectiveness against COVID‐19 is uncertain. We evaluated the effects of ivermectin in infected people on: – people dying;
– whether people's COVID‐19 got better or worse;
– quality of life;
– serious and non‐serious unwanted effects;
– viral clearance. For prevention, we sought the effect on preventing SARS‐CoV‐2 infection and COVID‐19 disease. What did we do? We searched for randomized controlled trials that investigated ivermectin to prevent or treat COVID‐19. People treated in hospital or as outpatients had to have laboratory‐confirmed COVID‐19. In this update, we also investigated the trustworthiness of the trials and only included them if they fulfilled clear ethical and scientific criteria. We compared and summarized the results of the trials and rated our confidence in the evidence, based on common criteria such as trial methods and sizes. What did we find? We excluded seven of the 14 trials included in the previous review as these trials did not fulfil the expected ethical and scientific criteria. Together with four new trials, we included 11 trials with 3409 participants that investigated ivermectin combined with any usual care compared to the same usual care or placebo. For treatment, there were five trials of people in hospital with moderate COVID‐19 and six trials of outpatients with mild COVID‐19. The trials used different doses of ivermectin and different durations of treatment. No trial investigated ivermectin to prevent SARS‐CoV‐2 infection. We also found 31 ongoing trials, and an additional 28 trials still requiring clarification from the authors or not yet published. Main results Treating people in hospital with COVID‐19 We do not know whether ivermectin compared with placebo or usual care 28 days after treatment: – leads to more or fewer deaths (3 trials, 230 people); 
– worsens or improves patients' condition, assessed by need for ventilation or death (2 trials, 118 people);
– increases or reduces serious unwanted events (2 trials, 197 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – improving patients' condition, assessed by discharge from hospital (1 trial, 73 people);
– non‐serious unwanted events (3 trials, 228 participants). Seven days after treatment, ivermectin may make little or no difference to reduction of negative COVID‐19 tests (3 trials, 231 participants) compared with placebo or usual care. Treating outpatients with COVID‐19 Ivermectin compared with placebo or usual care 28 days after treatment, probably makes little or no difference to people dying (6 trials, 2860 people). Ivermectin compared with placebo or usual care 28 days after treatment, makes little or no difference to quality of life (1 trial, 1358 people). Ivermectin compared with placebo or usual care 28 days after treatment, may make little or no difference to: – worsening patients' condition, assessed by admission to hospital or death (2 trials, 590 people);
– serious unwanted events (5 trials, 1502 people); 
– non‐serious unwanted events (5 trials, 1502 participants); 
– improving people's COVID‐19 symptoms in the 14 days after treatment (2 trials, 478 people);
– number of people with negative COVID‐19 tests 7 days after treatment (2 trials, 331 people). What are the limitations of the evidence? Our confidence in the evidence, especially for outpatients, improved since the last review version, because we could look at more participants included in high‐quality trials. Although we are quite certain regarding our results on risk of people dying and quality of life, the confidence in the evidence is still low for many other outpatient and inpatient outcomes because there were only few events measured. The methods differed between trials, and they did not report everything we were interested in, such as relevant outcomes. How up to date is this evidence? The systematic literature search is up to date to 16 December 2021. Additionally, we included trials with > 1000 participants up to April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Popp, M; Reis, S; Schießer, S; Hausinger, RIlona; Stegemann, M; Metzendorf, M-I; Kranke, P; Meybohm, P; Skoetz, N; Weibel, S", "articleTypes": [], "doi": "10.1002/14651858.CD015017.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "f9beb9bf-0a77-4687-8dee-8dda03236bbb", "pmid": "", "title": "Probiotic treatment for women with gestational diabetes to improve maternal and infant health and well‐being", "imported": false, "abstract": "Abstract - Background Gestational diabetes mellitus (GDM) is carbohydrate intolerance first recognised during pregnancy and associated with complications for mothers and babies. Probiotics are naturally occurring micro‐organisms, which when ingested in adequate amounts, may confer health benefits. Evidence of the role of probiotics as treatment for GDM is limited. Objectives To evaluate the safety and effectiveness of probiotics in treating women with GDM on maternal and infant outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth’s Trials Register ClinicalTrials.gov , WHO International Clinical Trials Registry Platform ( ICTRP ) (24 July 2019), and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing the use of probiotics versus placebo/standard care for the treatment of GDM. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, checked data accuracy, and assessed risk of bias of included trials. The certainty of evidence for selected maternal and infant/child outcomes was assessed using GRADE. Main results Nine RCTs (695 pregnant women with GDM) comparing probiotics versus placebo were identified. The overall risk of bias in the nine RCTs was low to unclear and the evidence was downgraded for imprecision due to the small numbers of women participating in the trials. The trials were carried out in hospitals and universities in Iran (seven trials), Thailand (one trial) and Ireland (one trial). All trials compared probiotics with placebo. Maternal outcomes We are uncertain if probiotics have any effect compared with placebo on hypertensive disorders of pregnancy, (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.64 to 3.53; participants = 256; studies = 3; low‐certainty evidence) and mode of birth as caesareans (average RR 0.64, 95% CI 0.30 to 1.35; participants = 267; studies = 3; low‐certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm . No trials reported primary outcomes of: mode of birth as vaginal/assisted and subsequent development of type 2 diabetes. We are uncertain if probiotics have any effect compared with placebo on induction of labour (RR 1.33, 95% CI 0.74 to 2.37; participants = 127; studies = 1; very low‐certainty evidence). For other secondary maternal outcomes, we are uncertain if there are differences between probiotics and placebo for: postpartum haemorrhage; weight gain during pregnancy intervention and total gestational weight gain; fasting plasma glucose and need for extra pharmacotherapy (insulin). Probiotics may be associated with a slight reduction in triglycerides and total cholesterol. In probiotics compared with placebo, there was evidence of reduction in markers for insulin resistance (HOMA‐IR) and HOMA‐B; and insulin secretion. There was also an increase in quantitative insulin sensitivity check index (QUICKI). Probiotics were associated with minor benefits in relevant bio‐markers with evidence of a reduction in inflammatory markers high‐sensitivity C‐reactive protein (hs‐CRP), interleukin 6 (IL‐6), and marker of oxidative stress malondialdehyde; and an increase in antioxidant total glutathione, but we are uncertain if there is any difference in total antioxidant capacity. No trials reported secondary outcomes: perineal trauma, postnatal weight retention or return to pre‐pregnancy weight and postnatal depression. Infant/child/adult outcomes We are uncertain if probiotics have any effect, compared with placebo, on the risk of large‐for‐gestational‐age babies (RR 0.73, 95% CI 0.35 to 1.52; participants = 174; studies = 2; low‐certainty evidence) or infant hypoglycaemia (RR 0.85, 95% CI 0.39 to 1.84; participants = 177; studies = 3; low ‐ certainty evidence) because the certainty of evidence is low and the 95% CIs span possible benefit and possible harm. No trials reported primary outcomes of: perinatal (fetal/neonatal) mortality; or neurosensory disability. For other secondary outcomes, we are uncertain if there is any difference between probiotics and placebo in gestational age at birth, preterm birth, macrosomia, birthweight, head circumference, length, infant hypoglycaemia, and neonatal intensive care unit (NICU) admissions. There was evidence of a reduction in infant hyperbilirubinaemia with probiotics compared with placebo. No trials reported secondary outcomes: infant adiposity, and later childhood adiposity. There were no adverse events reported by any of the trials. Authors' conclusions Low‐certainty evidence means we are not certain if there is any difference between probiotic and placebo groups in maternal hypertensive disorders of pregnancy, caesareans; and large‐for‐gestational‐age babies . There were no adverse events reported by the trials. Due to the variability of probiotics used and small sample sizes of trials, evidence from this review has limited ability to inform practice. Well‐designed adequately‐powered trials are needed to identify whether probiotics may improve maternal blood glucose levels and/or infant/child/adult outcomes; and whether they can be used to treat GDM. Plain language summary Probiotics as an added treatment for gestational diabetes to improve mother and baby outcomes What is the issue? Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in high blood glucose levels, first recognised during pregnancy. Pregnant women with GDM are at risk of high blood pressure, labour induction, and caesareans. Their babies are at risk of being born large, birth difficulties, respiratory distress, low blood glucose at birth and jaundice that can cause brain injury. There is increased risks of having long‐term diabetes in the mother, and the baby being overweight. Probiotics are micro‐organisms naturally in food and are in fermented milk, yogurt, or capsules. There are many different probiotics; the two most used are Lactobacillus and Bifidobacterium, and if consumed in adequate amounts may confer health benefits. Why is this important? Probiotics need to be safe and maternal blood glucose levels carefully managed during pregnancy. Women with GDM may receive dietary and physical activity education with monitoring blood glucose levels as initial management. When blood glucose levels are above a certain threshold, women with GDM are prescribed glucose‐lowering medications including metformin and/or insulin. This review aimed to determine the safety and effectiveness of probiotics in treating women with GDM. What evidence did we find? We searched for evidence for randomised controlled trials (latest July 2019). We identified nine studies, involving 695 women with GDM. All trials compared probiotics with placebo. The certainty of the evidence was assessed as very low or low. The overall risk of bias was low to unclear. Seven trials were conducted in Iran; one in Thailand, and one in Ireland. Trials took place in hospitals and universities. We are uncertain if there is any difference between probiotic and placebo in rates of: high blood‐pressure disorders (three studies, 256 participants, low‐certainty evidence); caesarean section (three studies, 267 women, low‐certainty evidence ); and large‐for‐gestational‐age babies (two studies, 174 participants, low‐certainty evidence). We are uncertain if there is any difference between probiotic and placebo for induction of labour (one study, 127 participants, very low‐certainty evidence) and low blood glucose levels in the newborn (three studies, 177 participants, low‐certainty evidence). We are also uncertain if there is any difference between probiotics and placebo for heavy bleeding immediately after birth, weight gain during pregnancy or total gestational weight gain. We are uncertain if there is any difference in fasting blood glucose between probiotics and placebo (seven studies, 554 participants). Probiotics may be assoicated with a slight reduction in triglycerides and total cholesterol (four studies, 320 participants). There was reduction in insulin secretion with probiotics (seven studies, 505 participants). One trial (60 participants) showed no difference between groups in need for insulin. Biomarkers, did show a reduction in insulin resistance (HOMA‐IR), (seven studies, 505 participants) and insulin resistance and β cell function (HOMA‐B) (two studies,130 participants) with probiotics. Quantitative insulin sensitivity check index (QUICKI) increased (four studies, 276 participants) with probiotics. Inflammatory markers, hs‐CRP (four studies, 248 participants) and interleukin 6 (two studies, 128 participants) were reduced with probiotics. Antioxidant total glutathione was increased (two studies, 120 participants) and the oxidative stress biomarker malondialdehyde was reduced with probiotics (three studies, 176 participants). We are uncertain if there is any difference in total antioxidant capacity (four studies 266 participants). For the newborn baby, we are uncertain if there is any difference between groups for: birthweight, gestational age at birth, preterm births, large babies, head circumference and length scores, or need for admission to the neonatal intensive care unit. The number of babies with high levels of bilirubin was reduced with probiotics. No adverse events were reported by the trials. What does this mean? Based on the clinical trials available, the evidence is limited to support the use of probiotics as treatment for women with GDM to improve pregnancy outcomes for mothers and their babies. Larger well‐designed randomised controlled trials are needed to assess the effects of probiotics on management of glucose levels and when available, they can be included in the update of this review.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Okesene-Gafa, KAM; Moore, AE; Jordan, V; McCowan, L; Crowther, CA", "articleTypes": [], "doi": "10.1002/14651858.CD012970.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "f9ed6fef-7a3f-449e-a47c-63ebd457a7e3", "pmid": "", "title": "Honey for acute cough in children", "imported": false, "abstract": "Abstract - Background Cough causes concern for parents and is a major cause of outpatient visits. Cough can impact quality of life, cause anxiety, and affect sleep in children and their parents. Honey has been used to alleviate cough symptoms. This is an update of reviews previously published in 2014, 2012, and 2010. Objectives To evaluate the effectiveness of honey for acute cough in children in ambulatory settings. Search methods We searched CENTRAL (2018, Issue 2), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (2014 to 8 February 2018), Embase (2014 to 8 February 2018), CINAHL (2014 to 8 February 2018), EBSCO (2014 to 8 February 2018), Web of Science (2014 to 8 February 2018), and LILACS (2014 to 8 February 2018). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trial Registry Platform (WHO ICTRP) on 12 February 2018. The 2014 review included searches of AMED and CAB Abstracts, but these were not searched for this update due to lack of institutional access. Selection criteria Randomised controlled trials comparing honey alone, or in combination with antibiotics, versus no treatment, placebo, honey‐based cough syrup, or other over‐the‐counter cough medications for children aged 12 months to 18 years for acute cough in ambulatory settings. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We included six randomised controlled trials involving 899 children; we added three studies (331 children) in this update. We assessed two studies as at high risk of performance and detection bias; three studies as at unclear risk of attrition bias; and three studies as at unclear risk of other bias. Studies compared honey with dextromethorphan, diphenhydramine, salbutamol, bromelin (an enzyme from the Bromeliaceae (pineapple) family), no treatment, and placebo. Five studies used 7‐point Likert scales to measure symptomatic relief of cough; one used an unclear 5‐point scale. In all studies, low score indicated better cough symptom relief. Using a 7‐point Likert scale, honey probably reduces cough frequency better than no treatment or placebo (no treatment: mean difference (MD) ‐1.05, 95% confidence interval (CI) ‐1.48 to ‐0.62; I² = 0%; 2 studies; 154 children; moderate‐certainty evidence; placebo: MD ‐1.62, 95% CI ‐3.02 to ‐0.22; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Honey may have a similar effect as dextromethorphan in reducing cough frequency (MD ‐0.07, 95% CI ‐1.07 to 0.94; I² = 87%; 2 studies; 149 children; low‐certainty evidence). Honey may be better than diphenhydramine in reducing cough frequency (MD ‐0.57, 95% CI ‐0.90 to ‐0.24; 1 study; 80 children; low‐certainty evidence). Giving honey for up to three days is probably more effective in relieving cough symptoms compared with placebo or salbutamol. Beyond three days honey probably had no advantage over salbutamol or placebo in reducing cough severity, bothersome cough, and impact of cough on sleep for parents and children (moderate‐certainty evidence). With a 5‐point cough scale, there was probably little or no difference between the effects of honey and bromelin mixed with honey in reducing cough frequency and severity. Adverse events included nervousness, insomnia, and hyperactivity, experienced by seven children (9.3%) treated with honey and two children (2.7%) treated with dextromethorphan (risk ratio (RR) 2.94, 95% Cl 0.74 to 11.71; I² = 0%; 2 studies; 149 children; low‐certainty evidence). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14, 95% Cl 0.01 to 2.68; 1 study; 80 children; low‐certainty evidence). When honey was compared with placebo, 34 children (12%) in the honey group and 13 (11%) in the placebo group complained of gastrointestinal symptoms (RR 1.91, 95% CI 1.12 to 3.24; I² = 0%; 2 studies; 402 children; moderate‐certainty evidence). Four children who received salbutamol had rashes compared to one child in the honey group (RR 0.19, 95% CI 0.02 to 1.63; 1 study; 100 children; moderate‐certainty evidence). No adverse events were reported in the no‐treatment group. Authors' conclusions Honey probably relieves cough symptoms to a greater extent than no treatment, diphenhydramine, and placebo, but may make little or no difference compared to dextromethorphan. Honey probably reduces cough duration better than placebo and salbutamol. There was no strong evidence for or against using honey. Most of the children received treatment for one night, which is a limitation to the results of this review. There was no difference in occurrence of adverse events between the honey and control arms. Plain language summary Honey for acute cough in children Review question Can honey reduce cough symptoms caused by bacteria and viruses in children? Background Cough causes concern for parents and is a major reason for outpatient visits. Honey is believed to prevent growth of germs and reduce inflammation. Search date We searched databases to 8 February 2018 and trial registers to 12 February 2018. Study characteristics We included six small trials involving 899 children aged 12 months to 18 years conducted in Iran, Israel, the USA, Brazil, and Kenya. This update included three new trials conducted between 2007 and 2016 that involved 331 children. Study funding sources Two studies were supported by pharmaceutical manufacturers; one by a university research centre; one by the Honey Board of Israel and non‐government agencies; and one by USA National Honey Board. One study did not report funding sources. Key results We compared honey to over‐the‐counter cough preparations, bromelin (a pineapple enzyme) mixed with honey, fake treatment (placebo), and no treatment. Honey probably reduces cough symptoms more than placebo and salbutamol (a drug that opens lung airways) when given for up to three days. Honey is probably more effective at providing cough relief and reducing the impact of cough on children's sleep at night than no treatment. There may be little or no difference between the effects of honey and dextromethorphan (an ingredient in over‐the‐counter cough remedies) or honey and bromelin with honey on all cough symptoms. Honey may be better than diphenhydramine (an antihistamine) at relieving and reducing children's cough. The parents of seven children given honey and two given dextromethorphan reported side effects in their children, such as not falling asleep easily, restlessness, and becoming overexcited. The parents of three children in the diphenhydramine group reported that their children were often sleepy. The parents of nine children given salbutamol, seven given honey, and six given placebo reported diarrhoea. The parents of four children who received salbutamol and one child given honey reported rash. We found no evidence for or against the use of honey to relieve cough in children. Using honey for infants aged up to 12 months is not advised because of poor immunity against bacteria that may be present, which can cause paralysis. Most of the children received honey for just one night, which is a limitation to the results of this review. Quality of the evidence Overall, evidence quality was low to moderate. Some studies did not blind participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Oduwole, O; Udoh, EE; Oyo‐Ita, A; Meremikwu, MM", "articleTypes": [], "doi": "10.1002/14651858.CD007094.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "fa0364a7-3795-4246-88c1-90d35b907312", "pmid": "", "title": "Capsaicin for non‐allergic rhinitis", "imported": false, "abstract": "Abstract - Background There are many forms of rhinitis. Patients are diagnosed with non‐allergic rhinitis when anatomic, infectious and allergic aetiologies have been excluded. The symptoms, including nasal congestion, blockage or obstruction, clear rhinorrhoea, sneezing and, less frequently, nasal itching, can range from mild to debilitating. It affects between 25% and 50% of patients with rhinitis. Several medications are widely used in the treatment of non‐allergic rhinitis, including oral and topical nasal antihistamines, intranasal and (rarely) systemic corticosteroids, and anticholinergics. Capsaicin, the active component of chili peppers, delivered intranasally, is considered a treatment option for non‐allergic rhinitis. Objectives To assess the effectiveness of capsaicin in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications, or two or more of the above therapies in combination, or different capsaicin regimens. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 5); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 24 June 2015. Selection criteria Randomised controlled trials in adult patients with non‐allergic rhinitis comparing intranasal capsaicin with no therapy, placebo or other topical or systemic medications, or their combinations. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We included four studies (five publications) involving 302 participants with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe, idiopathic non‐allergic rhinitis who were between the ages of 16 and 65. Studies had follow‐up periods ranging from four to 38 weeks. The overall risk of bias in the studies was either high or unclear (two studies had overall high risk of bias, while two others had low to unclear risk of bias). Using the GRADE system we assessed the evidence as being of low to moderate quality. A meta‐analysis was not possible, given lack of similarity of the reported outcomes. Two studies compared capsaicin with placebo. One study reported that capsaicin resulted in an improvement of overall nasal symptoms (a primary outcome) measured on a visual analogue scale (VAS) of 0 to 10. There was a mean difference (MD) of ‐3.34 (95% confidence interval (CI) ‐5.24 to ‐1.44), MD ‐3.73 (95% CI ‐5.45 to ‐2.01) and MD ‐3.52 (95% CI ‐5.55 to ‐1.48) at two, 12 and 36 weeks post‐treatment, respectively. Another study reported that, compared to placebo, capsaicin (at 4 µg/puff) was more likely to produce overall symptom resolution (reduction in nasal blockage, sneezing/itching/coughing and nasal secretion measured with a daily record chart) at four weeks post‐treatment (a primary outcome). The risk ratio (RR) was 3.17 (95% CI 1.38 to 7.29). One study compared capsaicin to budesonide (an intranasal corticosteroid). This study found that patients treated with capsaicin had a better overall symptom score compared to those treated with budesonide (MD 2.50, 95% CI 1.06 to 3.94, VAS of 0 to 10). However, there were no differences in the individual symptom scores for headache, postnasal drip, rhinorrhoea, nasal blockage, sneezing and sore throat assessed during the last three days of a four‐week treatment. One study compared two different regimens of capsaicin administration: five treatments in one day versus five treatments given every two to three days during two weeks. Using daily record charts, the study reported significant improvement of individual symptom scores for rhinorrhoea in patients treated five times per day, however numerical data were not presented. There were no improvements in the other outcomes: rhinorrhoea, nasal obstruction, sneezing and overall nasal symptoms, measured on a VAS. Finally, one of these studies also compared three doses of capsaicin (to placebo). Patients treated with a 1 µg versus 4 µg per puff dose of capsaicin had a worse daily record chart overall symptom score resolution (RR 0.63, 95% CI 0.34 to 1.16). Only one study attempted to measure adverse effects (a primary outcome), however due to methodological issues with the assessment we are unable to draw any conclusions. We sought to include other secondary outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Authors' conclusions Capsaicin may be an option in the treatment of idiopathic non‐allergic rhinitis. It is given in the form of brief treatments, usually during the same day. It appears to have beneficial effects on overall nasal symptoms up to 36 weeks after treatment, based on a few, small studies (low‐quality evidence). Well‐conducted randomised controlled trials are required to further advance our understanding of the effectiveness of capsaicin in non‐allergic rhinitis, especially in patients with non‐allergic rhinitis of different types and severity, and using different methods of capsaicin application. Plain language summary Capsaicin for non‐allergic rhinitis Review question Is capsaicin applied into the nose (intranasal) effective in the management of non‐allergic rhinitis compared with no therapy, placebo or other topical or systemic medications? Background Rhinitis means inflammation of the nose. It affects 30% to 40% of the general population. There are many forms of rhinitis: rhinosinusitis (or simply sinusitis), allergic rhinitis and non‐allergic rhinitis. Non‐allergic rhinitis is diagnosed in patients who have negative tests for allergies and also do not have sinusitis. The symptoms include congestion of the nose, a blocked or obstructed sensation in the nose that causes difficulty breathing, clear nasal discharge (runny nose), sneezing and nasal itching. There are several subtypes of non‐allergic rhinitis: occupational (from exposure to chemicals), smoking, gustatory (related to eating food or drinking fluid), hormonal (from changes in hormone levels in the body), pregnancy, senile or elderly (mostly affecting the older population), medication‐induced (for example, from overuse of decongestant nasal sprays) and local allergic (local allergy in the nose, while skin or blood allergy tests are negative). The most common subtype of non‐allergic rhinitis is 'idiopathic' or 'vasomotor' rhinitis, which results from imbalance of the neural (nerve) system that manages the function of the nose. The mechanisms of many of these subtypes remain unknown. Non‐allergic rhinitis affects about 25% to 50% of patients with rhinitis and is therefore very common. Capsaicin is the active ingredient of chili peppers. It has medicinal properties and is used elsewhere in medicine, for example for neuralgias (nerve pain) and psoriasis (a skin disease). The side effects of using capsaicin in the nose include irritation, burning, sneezing and coughing, however there are no known long‐term side effects of capsaicin use. Capsaicin is given in the form of brief treatments, usually during the same day. It works by down‐regulating transient receptor potential vanilloid (TRPV) receptor expression on C‐sensory fibres. TRPV represents special ion channels involved in the sensations of pain, cold, hotness, tastes, pressure and vision. C fibres help to conduct some of these sensations. There is ongoing research into the effects of capsaicin on these mechanisms and its clinical uses. Study characteristics We included four studies involving 302 patients with idiopathic non‐allergic rhinitis. All the included studies described patients with moderately severe idiopathic non‐allergic rhinitis, who were between the ages of 16 and 65. The studies had a follow‐up ranging from four to 38 weeks after treatment. Key results Individually, the studies reported that the overall function of the nose in patients with non‐allergic rhinitis improved when treated with capsaicin compared to placebo. Capsaicin also seems to work better than another common type of nasal medication, budesonide (a steroid). The best knowledge that we have on capsaicin treatment supports giving it five times in one day, and to use doses of at least 4 micrograms in each puff. We could not combine the results together. The included studies did not have sufficient information to allow us to draw a conclusion about side effects. We also wanted to include other outcomes (e.g. quality of life measures, treatment dropouts, endoscopic scores, turbinate or mucosal size, cost of therapy), but none of these were measured or reported in the included studies. Quality of the evidence Overall, we judged the quality of the evidence to be of low to moderate quality. The evidence is up to date to June 2015. Conclusions Given that many other options do not work well in non‐allergic rhinitis, capsaicin is a reasonable option to try under physician supervision.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Gevorgyan, A; Segboer, C; Gorissen, R; van Drunen, CM; Fokkens, W", "articleTypes": [], "doi": "10.1002/14651858.CD010591.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "fa25e2d2-bba8-4b01-8403-37e494a2ad3c", "pmid": "", "title": "The Effect of Caloric and Non-caloric Sweeteners on Hunger, Gastrointestinal Hormones as Well as on Antral and Duodenal Motility", "imported": false, "abstract": "In this study, the investigators aimed at evaluating the role of sweet taste receptors in the gastrointestinal tract (GIT). Intragastric administration of glucose, fructose or acesulfame-K were compared with placebo administration for their effects on gastrointestinal motility, gut hormone release (motilin, ghrelin, glucagon-like peptide-1 (GLP-1) and insulin) and hunger feelings.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.258Z" }, { "id": "fa315810-1da0-44a7-95a4-c06502fa2cf2", "pmid": "", "title": "Janus kinase inhibitors for the treatment of COVID‐19", "imported": false, "abstract": "Abstract - Background With potential antiviral and anti‐inflammatory properties, Janus kinase (JAK) inhibitors represent a potential treatment for symptomatic severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. They may modulate the exuberant immune response to SARS‐CoV‐2 infection. Furthermore, a direct antiviral effect has been described. An understanding of the current evidence regarding the efficacy and safety of JAK inhibitors as a treatment for coronavirus disease 2019 (COVID‐19) is required. Objectives To assess the effects of systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo) on clinical outcomes in individuals (outpatient or in‐hospital) with any severity of COVID‐19, and to maintain the currency of the evidence using a living systematic review approach. Search methods We searched the Cochrane COVID‐19 Study Register (comprising MEDLINE, Embase, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform, medRxiv, and Cochrane Central Register of Controlled Trials), Web of Science, WHO COVID‐19 Global literature on coronavirus disease, and the US Department of Veterans Affairs Evidence Synthesis Program (VA ESP) Covid‐19 Evidence Reviews to identify studies up to February 2022. We monitor newly published randomised controlled trials (RCTs) weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials from this source until the first week of April 2022. Selection criteria We included RCTs that compared systemic JAK inhibitors plus standard of care to standard of care alone (plus/minus placebo) for the treatment of individuals with COVID‐19. We used the WHO definitions of illness severity for COVID‐19. Data collection and analysis We assessed risk of bias of primary outcomes using Cochrane's Risk of Bias 2 (RoB 2) tool. We used GRADE to rate the certainty of evidence for the following primary outcomes: all‐cause mortality (up to day 28), all‐cause mortality (up to day 60), improvement in clinical status: alive and without need for in‐hospital medical care (up to day 28), worsening of clinical status: new need for invasive mechanical ventilation or death (up to day 28), adverse events (any grade), serious adverse events, secondary infections. Main results We included six RCTs with 11,145 participants investigating systemic JAK inhibitors plus standard of care compared to standard of care alone (plus/minus placebo). Standard of care followed local protocols and included the application of glucocorticoids (five studies reported their use in a range of 70% to 95% of their participants; one study restricted glucocorticoid use to non‐COVID‐19 specific indications), antibiotic agents, anticoagulants, and antiviral agents, as well as non‐pharmaceutical procedures. At study entry, about 65% of participants required low‐flow oxygen, about 23% required high‐flow oxygen or non‐invasive ventilation, about 8% did not need any respiratory support, and only about 4% were intubated. We also identified 13 ongoing studies, and 9 studies that are completed or terminated and where classification is pending. Individuals with moderate to severe disease Four studies investigated the single agent baricitinib (10,815 participants), one tofacitinib (289 participants), and one ruxolitinib (41 participants). Systemic JAK inhibitors probably decrease all‐cause mortality at up to day 28 (95 of 1000 participants in the intervention group versus 131 of 1000 participants in the control group; risk ratio (RR) 0.72, 95% confidence interval (CI) 0.57 to 0.91; 6 studies, 11,145 participants; moderate‐certainty evidence), and decrease all‐cause mortality at up to day 60 (125 of 1000 participants in the intervention group versus 181 of 1000 participants in the control group; RR 0.69, 95% CI 0.56 to 0.86; 2 studies, 1626 participants; high‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in improvement in clinical status (discharged alive or hospitalised, but no longer requiring ongoing medical care) (801 of 1000 participants in the intervention group versus 778 of 1000 participants in the control group; RR 1.03, 95% CI 1.00 to 1.06; 4 studies, 10,802 participants; moderate‐certainty evidence). They probably decrease the risk of worsening of clinical status (new need for invasive mechanical ventilation or death at day 28) (154 of 1000 participants in the intervention group versus 172 of 1000 participants in the control group; RR 0.90, 95% CI 0.82 to 0.98; 2 studies, 9417 participants; moderate‐certainty evidence). Systemic JAK inhibitors probably make little or no difference in the rate of adverse events (any grade) (427 of 1000 participants in the intervention group versus 441 of 1000 participants in the control group; RR 0.97, 95% CI 0.88 to 1.08; 3 studies, 1885 participants; moderate‐certainty evidence), and probably decrease the occurrence of serious adverse events (160 of 1000 participants in the intervention group versus 202 of 1000 participants in the control group; RR 0.79, 95% CI 0.68 to 0.92; 4 studies, 2901 participants; moderate‐certainty evidence). JAK inhibitors may make little or no difference to the rate of secondary infection (111 of 1000 participants in the intervention group versus 113 of 1000 participants in the control group; RR 0.98, 95% CI 0.89 to 1.09; 4 studies, 10,041 participants; low‐certainty evidence). Subgroup analysis by severity of COVID‐19 disease or type of JAK inhibitor did not identify specific subgroups which benefit more or less from systemic JAK inhibitors. Individuals with asymptomatic or mild disease We did not identify any trial for this population. Authors' conclusions In hospitalised individuals with moderate to severe COVID‐19, moderate‐certainty evidence shows that systemic JAK inhibitors probably decrease all‐cause mortality. Baricitinib was the most often evaluated JAK inhibitor. Moderate‐certainty evidence suggests that they probably make little or no difference in improvement in clinical status. Moderate‐certainty evidence indicates that systemic JAK inhibitors probably decrease the risk of worsening of clinical status and make little or no difference in the rate of adverse events of any grade, whilst they probably decrease the occurrence of serious adverse events. Based on low‐certainty evidence, JAK inhibitors may make little or no difference in the rate of secondary infection. Subgroup analysis by severity of COVID‐19 or type of agent failed to identify specific subgroups which benefit more or less from systemic JAK inhibitors. Currently, there is no evidence on the efficacy and safety of systemic JAK inhibitors for individuals with asymptomatic or mild disease (non‐hospitalised individuals). Plain language summary Are systemic Janus kinase inhibitors an effective treatment for people with COVID‐19? Key messages We found moderate‐ to high‐certainty evidence from 6 studies to conclude that systemic Janus kinase (JAK) inhibitors are an effective treatment for coronavirus disease 2019 (COVID‐19) in hospitalised people, because they resulted in fewer deaths and a lower rate of clinical deterioration. Evaluation of systemic JAK inhibitors is ongoing in 13 studies whilst the results of 9 further studies are awaiting publication. We will update this review and may adapt our conclusions when their results become available. What are JAK inhibitors? JAK inhibitors are medicines that block the activity of certain parts of the immune system that are sometimes problematic. They are taken orally (systemic) and usually are taken by people who suffer from autoimmune diseases, where the immune system attacks the body itself. JAK inhibitors might also be administered by inhalation but since this was not our focus, we refer to 'systemic JAK inhibitors' throughout the review. How might JAK inhibitors treat COVID‐19? In COVID‐19, the immune system sometimes overreacts, which can lead to a severe course of disease. JAK inhibitors can block parts of the immune system and counteract any clinical deteriorations. What did we want to find out? We wanted to know whether systemic JAK inhibitors, in addition to usual care, are effective for people with COVID‐19 when compared to usual care with or without a placebo (a treatment that looks and tastes the same as the study drug but with no active ingredient), and whether they cause unwanted effects. We were particularly interested in:
• number of deaths from any cause up to 60 days after treatment, or longer if reported;
• whether people got better or worse after treatment, based on their need for breathing support;
• unwanted effects of the treatment and infections acquired in hospital. What did we do? We searched for studies that reported on people with COVID‐19 who received systemic JAK inhibitors together with usual care, or usual care alone (plus/minus placebo). We compared and summarised the results of the studies and rated our confidence in the evidence, based on common criteria about the reliability of the evidence. What did we find? We found 6 suitable studies involving 11,145 people with COVID‐19. All studies compared systemic JAK inhibitors (baricitinib in 4 studies, tofacitinib in 1 study and ruxolitinib in 1 study) to usual care (in addition to placebo), and were performed in hospitalised people. We did not find studies performed in outpatients. Most participants needed oxygen supplementation through low‐flow devices (7220 participants) and few (463 participants) were mechanically ventilated at the study entry. We also identified 13 ongoing studies and 9 studies that are completed/terminated but unpublished yet. Main results Systemic JAK inhibitors plus usual care compared to usual care alone probably lead to fewer deaths from all causes at up to day 28 and lead to fewer deaths from all causes up to day 60 in the studies. It was not possible to identify subgroups of participants (according to severity of illness) who might benefit most from treatment with JAK inhibitors. Systemic JAK inhibitors probably make little or no difference in improvement in clinical status. They probably decrease the risk of worsening of clinical status. Systemic JAK inhibitors probably make little or no difference in the rate of unwanted effects, and probably decrease slightly the occurrence of serious unwanted effects. Systemic JAK inhibitors may result in little or no difference in the rate of infections acquired in hospital. What are the limitations of the evidence? As current studies on systemic JAK inhibitors in outpatients are lacking, evidence is limited in this group of people with COVID‐19. Studies used different ways to assess and report unwanted effects, especially in regard to infections acquired in hospital. In accordance with the living approach of this review, we will continually update our search and include eligible trials to fill this evidence gap. How up to date is this evidence? The evidence is up to date to February 2022. We monitor newly published studies weekly using the Cochrane COVID‐19 Study Register, and have incorporated all new trials identified from this source until the first week of April 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Kramer, A; Prinz, C; Fichtner, F; Fischer, A-L; Thieme, V; Grundeis, F; Spagl, M; Seeber, C; Piechotta, V; Metzendorf, M-I; Golinski, M; Moerer, O; Stephani, C; Mikolajewska, A; Kluge, S; Stegemann, M; Laudi, S; Skoetz, N", "articleTypes": [], "doi": "10.1002/14651858.CD015209", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "fa46138d-bbe4-452e-b966-a1c81115a165", "pmid": "", "title": "Nutritional labelling for healthier food or non‐alcoholic drink purchasing and consumption", "imported": false, "abstract": "Abstract - Background Nutritional labelling is advocated as a means to promote healthier food purchasing and consumption, including lower energy intake. Internationally, many different nutritional labelling schemes have been introduced. There is no consensus on whether such labelling is effective in promoting healthier behaviour. Objectives To assess the impact of nutritional labelling for food and non‐alcoholic drinks on purchasing and consumption of healthier items. Our secondary objective was to explore possible effect moderators of nutritional labelling on purchasing and consumption. Search methods We searched 13 electronic databases including CENTRAL, MEDLINE and Embase to 26 April 2017. We also handsearched references and citations and sought unpublished studies through websites and trials registries. Selection criteria Eligible studies: were randomised or quasi‐randomised controlled trials (RCTs/Q‐RCTs), controlled before‐and‐after studies, or interrupted time series (ITS) studies; compared a labelled product (with information on nutrients or energy) with the same product without a nutritional label; assessed objectively measured purchasing or consumption of foods or non‐alcoholic drinks in real‐world or laboratory settings. Data collection and analysis Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of bias' tool and GRADE to assess the quality of evidence. We pooled studies that evaluated similar interventions and outcomes using a random‐effects meta‐analysis, and we synthesised data from other studies in a narrative summary. Main results We included 28 studies, comprising 17 RCTs, 5 Q‐RCTs and 6 ITS studies. Most (21/28) took place in the USA, and 19 took place in university settings, 14 of which mainly involved university students or staff. Most (20/28) studies assessed the impact of labelling on menus or menu boards, or nutritional labelling placed on, or adjacent to, a range of foods or drinks from which participants could choose. Eight studies provided participants with only one labelled food or drink option (in which labelling was present on a container or packaging, adjacent to the food or on a display board) and measured the amount consumed. The most frequently assessed labelling type was energy (i.e. calorie) information (12/28). Eleven studies assessed the impact of nutritional labelling on purchasing food or drink options in real‐world settings, including purchases from vending machines (one cluster‐RCT), grocery stores (one ITS), or restaurants, cafeterias or coffee shops (three RCTs, one Q‐RCT and five ITS). Findings on vending machines and grocery stores were not interpretable, and were rated as very low quality. A meta‐analysis of the three RCTs, all of which assessed energy labelling on menus in restaurants, demonstrated a statistically significant reduction of 47 kcal in energy purchased (MD −46.72 kcal, 95% CI −78.35, −15.10, N = 1877). Assuming an average meal of 600 kcal, energy labelling on menus would reduce energy purchased per meal by 7.8% (95% CI 2.5% to 13.1%). The quality of the evidence for these three studies was rated as low, so our confidence in the effect estimate is limited and may change with further studies. Of the remaining six studies, only two (both ITS studies involving energy labels on menus or menus boards in a coffee shop or cafeteria) were at low risk of bias, and their results support the meta‐analysis. The results of the other four studies which were conducted in a restaurant, cafeterias (2 studies) or a coffee shop, were not clearly reported and were at high risk of bias. Seventeen studies assessed the impact of nutritional labels on consumption in artificial settings or scenarios (henceforth referred to as laboratory studies or settings). Of these, eight (all RCTs) assessed the effect of labels on menus or placed on a range of food options. A meta‐analysis of these studies did not conclusively demonstrate a reduction in energy consumed during a meal (MD −50 kcal, 95% CI −104.41, 3.88, N = 1705). We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. Six laboratory studies (four RCTs and two Q‐RCTs) assessed the impact of labelling a single food or drink option (such as chocolate, pasta or soft drinks) on energy consumed during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant difference in energy (kcal) consumed (SMD 0.05, 95% CI −0.17 to 0.27, N = 732). However, the confidence intervals were wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies. There was no evidence that nutritional labelling had the unintended harm of increasing energy purchased or consumed. Indirect evidence came from five laboratory studies that involved mislabelling single nutrient content (i.e. placing low energy or low fat labels on high‐energy foods) during a snack or meal. A meta‐analysis of these studies did not demonstrate a statistically significant increase in energy (kcal) consumed (SMD 0.19, 95% CI −0.14to 0.51, N = 718). The effect was small and the confidence intervals wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence from these studies as very low, providing very little confidence in the effect estimate. Authors' conclusions Findings from a small body of low‐quality evidence suggest that nutritional labelling comprising energy information on menus may reduce energy purchased in restaurants. The evidence assessing the impact on consumption of energy information on menus or on a range of food options in laboratory settings suggests a similar effect to that observed for purchasing, although the evidence is less definite and also of low quality. Accordingly, and in the absence of observed harms, we tentatively suggest that nutritional labelling on menus in restaurants could be used as part of a wider set of measures to tackle obesity. Additional high‐quality research in real‐world settings is needed to enable more certain conclusions. Further high‐quality research is also needed to address the dearth of evidence from grocery stores and vending machines and to assess potential moderators of the intervention effect, including socioeconomic status. Plain language summary Nutritional labelling to promote healthier consumption and purchasing of food or drinks A poor diet including excessive energy intake is an important cause of ill health. Nutritional labelling may help people to make healthier food choices. What is the aim of this review? This review investigated whether nutritional labels (i.e. labels providing information about nutritional content) persuade people to buy or consume different (healthy) kinds of food. We searched for all available evidence to answer this question and found 28 studies. Key messages There is evidence to suggest that nutritional labelling, with energy information (e.g. calorie counts) on menus, may reduce energy purchased in restaurants, but more high‐quality studies are needed to make this finding more certain. What was studied in the review? Some studies assessed buying food or drinks from vending machines, grocery stores, restaurants, cafeterias, or coffee shops. Others assessed the amount of food or drink consumed during a snack or meal in an artificial setting or scenario (referred to as laboratory studies or settings). What are the main results of the review? Nutritional labelling on restaurant menus reduced the amount of energy (i.e. calories) purchased, but the quality of the three studies that contributed to this finding was low, so our confidence in the effect estimate is limited and may change with further studies. Eight studies assessed this same type of intervention in laboratory settings, but instead of evaluating how much energy participants purchased, these studies evaluated how much energy participants consumed. These studies did not conclusively demonstrate a reduction in energy consumed when menus or foods were labelled, and they were also of low quality. In addition, six laboratory studies assessed how much energy participants consumed when they were given one food or drink option with or without labels, and five laboratory studies assessed how much energy participants consumed when foods were experimentally labelled as low energy or low fat when they were actually high‐energy foods (i.e. mislabelling). Results from these two groups of studies were inconclusive and of low, or in the case of mislabelling studies, very low quality. We found some studies that assessed labelling on vending machines and grocery stores, but their results were not easy to interpret, so we could not use them to inform this review. How up‐to‐date is this review? The evidence is current to 26 April 2017.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Crockett, RA, King, SE, Marteau, TM, Prevost, AT, Bignardi, G, Roberts, NW, Stubbs, B, Hollands, GJ, Jebb, SA", "articleTypes": [], "doi": "10.1002/14651858.CD009315.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.104Z" }, { "id": "fa4af641-5eb8-4fae-b41d-5d2d1ac89fb2", "pmid": "", "title": "Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy", "imported": false, "abstract": "Abstract - Background In the past women have been advised that lowering their salt intake might reduce their risk of pre‐eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of advice to alter dietary salt intake during pregnancy. Objectives The objective of this review was to assess the effects of dietary advice to alter salt intake compared to continuing a normal diet, on the risk of pre‐eclampsia and its consequences. Search methods We searched the register of trials maintained and updated by the Cochrane Pregnancy and Childbirth Group, and the Cochrane Controlled Trials Register Disc Issue 4, 1998. Selection criteria Studies were included if they were randomised trials of advice to either reduce or to increase dietary salt during pregnancy. Data collection and analysis All data were extracted independently by both reviewers. Main results Two trials were included, with 603 women. They compared advice about a low salt diet with no dietary advice. The confidence intervals for all of the outcomes reported were wide, and cross the no effect line. This includes pre‐eclampsia (relative risk 1.11, 95% confidence interval 0.46 to 2.66). Even when taken together, these trials are insufficient to provide reliable information about the effects of advice on salt restriction during normal pregnancy. None of the trials included women with pre‐eclampsia, so this review provides no reliable information about changes in salt intake for treatment of pre‐eclampsia. Authors' conclusions Salt consumption during pregnancy should remain a matter of personal preference. Plain language summary Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy To be prepared.", "journal": "Cochrane Database of Systematic Reviews", "year": "1999", "authors": "Duley, L, Henderson‐Smart, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD001687", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.740Z" }, { "id": "fa4b873f-53c4-4609-86aa-ae1d2e6884a1", "pmid": "", "title": "Do Appetitive Gut Hormones Reduce Addictive and Eating Behaviours in Obesity, and Nicotine and Alcohol Dependence?", "imported": false, "abstract": "The \"Gut Hormones in Addiction\" study is a proof-of-concept experimental medicine human study to answer the following questions:", "journal": "", "year": "2015", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.248Z" }, { "id": "fa5d24f4-0199-46d3-ac01-47b797702a83", "pmid": "", "title": "Point‐of‐use fortification of foods with micronutrient powders containing iron in children of preschool and school‐age", "imported": false, "abstract": "Abstract - Background Approximately 600 million children of preschool and school age are anaemic worldwide. It is estimated that at least half of the cases are due to iron deficiency. Point‐of‐use fortification of foods with micronutrient powders (MNP) has been proposed as a feasible intervention to prevent and treat anaemia. It refers to the addition of iron alone or in combination with other vitamins and minerals in powder form, to energy‐containing foods (excluding beverages) at home or in any other place where meals are to be consumed. MNPs can be added to foods either during or after cooking or immediately before consumption without the explicit purpose of improving the flavour or colour. Objectives To assess the effects of point‐of‐use fortification of foods with iron‐containing MNP alone, or in combination with other vitamins and minerals on nutrition, health and development among children at preschool (24 to 59 months) and school (five to 12 years) age, compared with no intervention, a placebo or iron‐containing supplements. Search methods In December 2016, we searched the following databases: CENTRAL, MEDLINE, Embase, BIOSIS, Science Citation Index, Social Science Citation Index, CINAHL, LILACS, IBECS, Popline and SciELO. We also searched two trials registers in April 2017, and contacted relevant organisations to identify ongoing and unpublished trials. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs trials with either individual or cluster randomisation. Participants were children aged between 24 months and 12 years at the time of intervention. For trials with children outside this age range, we included studies where we were able to disaggregate the data for children aged 24 months to 12 years, or when more than half of the participants were within the requisite age range. We included trials with apparently healthy children; however, we included studies carried out in settings where anaemia and iron deficiency are prevalent, and thus participants may have had these conditions at baseline. Data collection and analysis Two review authors independently assessed the eligibility of trials against the inclusion criteria, extracted data from included trials, assessed the risk of bias of the included trials and graded the quality of the evidence. Main results We included 13 studies involving 5810 participants from Latin America, Africa and Asia. We excluded 38 studies and identified six ongoing/unpublished trials. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. No trials compared the effects of MNP versus iron‐containing supplements (as drops, tablets or syrup). The sample sizes in the included trials ranged from 90 to 2193 participants. Six trials included participants younger than 59 months of age only, four included only children aged 60 months or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. The iron doses varied from 2.5 mg to 30 mg of elemental iron. Four trials reported giving 10 mg of elemental iron as sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), chelated ferrous sulphate or microencapsulated ferrous fumarate. Three trials gave 12.5 mg of elemental iron as microencapsulated ferrous fumarate. Three trials gave 2.5 mg or 2.86 mg of elemental iron as NaFeEDTA. One trial gave 30 mg and one trial provided 14 mg of elemental iron as microencapsulated ferrous fumarate, while one trial gave 28 mg of iron as ferrous glycine phosphate. In comparison with receiving no intervention or a placebo, children receiving iron‐containing MNP for point‐of‐use fortification of foods had lower risk of anaemia prevalence ratio (PR) 0.66, 95% confidence interval (CI) 0.49 to 0.88, 10 trials, 2448 children; moderate‐quality evidence) and iron deficiency (PR 0.35, 95% CI 0.27 to 0.47, 5 trials, 1364 children; moderate‐quality evidence) and had higher haemoglobin (mean difference (MD) 3.37 g/L, 95% CI 0.94 to 5.80, 11 trials, 2746 children; low‐quality evidence). Only one trial with 115 children reported on all‐cause mortality (zero cases; low‐quality evidence). There was no effect on diarrhoea (risk ratio (RR) 0.97, 95% CI 0.53 to 1.78, 2 trials, 366 children; low‐quality evidence). Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children. However, information on mortality, morbidity, developmental outcomes and adverse effects is still scarce. Plain language summary Powdered vitamins and minerals added to foods at the point‐of‐use reduces anaemia and iron deficiency in preschool‐ and school‐age children Background to the question Approximately one billion people worldwide are deficient in at least one vitamin or mineral (also known of micronutrients). Iron, vitamin A, zinc and iodine deficiencies are very frequent among children of preschool (aged 24 months to less than 5 years) and school age (5 to 12 years of age), limiting their health and daily physical performance. Anaemia, the condition in which red blood cells have limited capacity to carry oxygen, frequently results after prolonged iron deficiency. Point‐of‐use fortification with powdered vitamins and minerals has been proposed as a public health intervention to reduce micronutrient deficiencies in children. In this process, a powdered premix containing iron, and possibly other vitamins and minerals, is added to foods either during or after cooking, or immediately before consumption to improve their nutritious value but not their flavour or colour. In some cases, point‐of‐use fortification is also known as home fortification. Review question What are the effects of point‐of‐use fortification of foods with iron‐containing micronutrient powders (MNP) alone, or in combination with other vitamins and minerals, on nutrition, health and development among children of preschool and school age (24 months to 12 years of age) compared with no intervention, a placebo (dummy pill) or regular iron‐containing supplements (as drops, tablets or syrup)? Study characteristics This review included 13 trials with 5810 participants from Latin America, Africa and Asia. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. Six trials included participants younger than 59 months of age only, four included only children aged 60 months of age or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. We searched existing clinical trials in December 2016 and ongoing trials in April 2017. We also contacted relevant institutions for additional information upon publication of the protocol and in April 2017. Key results The review found that children receiving iron‐containing MNP for point‐of‐use fortification of foods were at significantly lower risk of having anaemia and iron deficiency and had higher haemoglobin concentrations. We did not find any positive or negative effect on diarrhoea or mortality, but the data on these two outcomes were very limited. Quality of the evidence We rated the overall quality of the evidence for the provision of multiple MNP versus no intervention or placebo as moderate for anaemia, iron deficiency and adverse effects. We judged the evidence to be of low quality for haemoglobin, mortality and diarrhoea, and to be very low‐quality for ferritin. In general, the most common risk of bias in the studies was the lack of blinding for participants, personnel and outcome assessors. Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children and seems feasible for public health purposes. However, future research should aim to increase the body of evidence on mortality, morbidity, developmental outcomes and adverse effects. Due to the lack of trials, we were unable to determine at this time if this intervention has comparable effects to those observed with iron supplements (provided as drops, tablets or syrup).", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "De‐Regil, LM, Jefferds, MED, Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009666.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.105Z" }, { "id": "fa62193c-0000-4f94-bac3-8165af26d1ce", "pmid": "", "title": "Corticosteroids for the long‐term treatment in multiple sclerosis", "imported": false, "abstract": "Abstract - Background Short term high dose corticosteroid treatment improves symptoms and short term disability after an acute exacerbation of multiple sclerosis (MS) but it is unknown whether its long‐term use can reduce the accumulation of disability. Objectives To determine the efficacy and safety of long‐term corticosteroid use in MS. Search methods We searched The Cochrane MS Group Trials Register (February 2007),the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to February 2007) and EMBASE (1980 to February 2007). In an effort to identify further published, unpublished and ongoing trials we searched reference lists and contacted trial authors and one pharmaceutical company. Selection criteria We considered controlled, randomised trials (RCTs), with or without blinding, of long term treatment (i.e. longer than 6 months) of any type of corticosteroid in MS, irrespective of disease course. Data collection and analysis Reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Three trials, all classified at high risk of bias, contributed to this review (Miller 1961; BPSM 1995; Zivadinov 2001) resulting in a total of 183 participants (91 treated). Corticosteroid therapy did not reduce the risk of being worse at the end of follow‐up (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.26 to 1.02) but there was a substantial heterogeneity between studies (I 2 : 78.4%). I. v. periodic high dose methylprednisolone (MP) was associated with a significant reduction in the risk of disability progression at 5 years in relapsing‐remitting (RR) MS (OR 0.26, 95% CI 0.10 to 0.66), while oral continuous low dose prednisolone was not associated with any risk reduction in disability progression at 18 months (OR 1.23, 95% CI 0.43 to 3.56). Risk of experiencing at least one exacerbation at end of follow‐up was not significantly reduced with corticosteroid treatment (OR 0.36; 95% CI 0.10 to 1.25). 
 Only one study recorded adverse events: in one patient i. v. MP was discontinued after the fourth pulse when he developed acute glomerulonephritis; a second patient was removed from the study after the fifth i. v. MP pulse because of severe osteoporosis. Authors' conclusions There is no enough evidence that long‐term corticosteroid treatment delays progression of long term disability in patients with MS. Since one study at high risk of bias showed that the administration of pulsed high dose i. v. MP is associated with a significant reduction in the risk of long term disability progression in patients with RR MS, an adequately powered, high quality RCT is needed to investigate this finding. Plain language summary The long‐term use of anti‐inflammatory corticosteroids for treating multiple sclerosis Multiple sclerosis is an inflammatory disease affecting the brain and spinal cord. It results in episodes of neurological deficit which recover (relapses) as well as accumulation of sustained disability with the passage of time. Corticosteroids are potent anti‐inflammatory drugs. It is postulated that long‐term use of steroids may reduce the accumulation of disability. The reviewers found three studies addressing this issue. A meta‐analysis showed a trend towards a beneficial effect of long‐term corticosteroids on accumulation of disability; however only two small studies contributed to this result. It was not possible to reliably comment on the effect of long‐term corticosteroids on the frequency of relapses. Side effects were poorly documented. Therefore rigorous randomised controlled trials of this treatment are warranted.", "journal": "Cochrane Database of Systematic Reviews", "year": "2008", "authors": "Ciccone, A; Beretta, S; Brusaferri, F; Galea, I; Protti, A; Spreafico, C", "articleTypes": [], "doi": "10.1002/14651858.CD006264.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "fa8f6a98-4d14-4b37-a749-73f145c23630", "pmid": "", "title": "Interventions for treating acute high altitude illness", "imported": false, "abstract": "Abstract - Background Acute high altitude illness is defined as a group of cerebral and pulmonary syndromes that can occur during travel to high altitudes. It is more common above 2500 metres, but can be seen at lower elevations, especially in susceptible people. Acute high altitude illness includes a wide spectrum of syndromes defined under the terms 'acute mountain sickness' (AMS), 'high altitude cerebral oedema' and 'high altitude pulmonary oedema'. There are several interventions available to treat this condition, both pharmacological and non‐pharmacological; however, there is a great uncertainty regarding their benefits and harms. Objectives To assess the clinical effectiveness, and safety of interventions (non‐pharmacological and pharmacological), as monotherapy or in any combination, for treating acute high altitude illness. Search methods We searched CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science, CINAHL, Wanfang database and the World Health Organization International Clinical Trials Registry Platform for ongoing studies on 10 August 2017. We did not apply any language restriction. Selection criteria We included randomized controlled trials evaluating the effects of pharmacological and non‐pharmacological interventions for individuals suffering from acute high altitude illness: acute mountain sickness, high altitude pulmonary oedema or high altitude cerebral oedema. Data collection and analysis Two review authors independently assessed the eligibility of study reports, the risk of bias for each and performed the data extraction. We resolved disagreements through discussion with a third author. We assessed the quality of evidence with GRADE. Main results We included 13 studies enrolling a total of 468 participants. We identified two ongoing studies. All studies included adults, and two studies included both teenagers and adults. The 13 studies took place in high altitude areas, mostly in the European Alps. Twelve studies included participants with acute mountain sickness, and one study included participants with high altitude pulmonary oedema. Follow‐up was usually less than one day. We downgraded the quality of the evidence in most cases due to risk of bias and imprecision. We report results for the main comparisons as follows. Non‐pharmacological interventions (3 studies, 124 participants) All‐cause mortality and complete relief of AMS symptoms were not reported in the three included trials. One study in 64 participants found that a simulated descent of 193 millibars versus 20 millibars may reduce the average of symptoms to 2.5 vs 3.1 units after 12 hours of treatment (clinical score ranged from 0 to 11 ‒ worse; reduction of 0.6 points on average with the intervention; low quality of evidence). In addition, no complications were found with use of hyperbaric chambers versus supplementary oxygen (one study; 29 participants; low‐quality evidence). Pharmacological interventions (11 trials, 375 participants) All‐cause mortality was not reported in the 11 included trials. One trial found a greater proportion of participants with complete relief of AMS symptoms after 12 and 16 hours when dexamethasone was administered in comparison with placebo (47.1% versus 0%, respectively; one study; 35 participants; low quality of evidence). Likewise, when acetazolamide was compared with placebo, the effects on symptom severity was uncertain (standardized mean difference (SMD) −1.15, 95% CI −2.56 to 0.27; 2 studies, 25 participants; low‐quality evidence). One trial of dexamethasone in comparison with placebo in 35 participants found a reduction in symptom severity (difference on change in the AMS score: 3.7 units reported by authors; moderate quality of evidence). The effects from two additional trials comparing gabapentin with placebo and magnesium with placebo on symptom severity at the end of treatment were uncertain. For gabapentin versus placebo: mean visual analogue scale (VAS) score of 2.92 versus 4.75, respectively; 24 participants; low quality of evidence. For magnesium versus placebo: mean scores of 9 and 10.3 units, respectively; 25 participants; low quality of evidence). The trials did not find adverse events from either treatment (low quality of evidence). One trial comparing magnesium sulphate versus placebo found that flushing was a frequent event in the magnesium sulphate arm (percentage of flushing: 75% versus 7.7%, respectively; one study; 25 participants; low quality of evidence). Authors' conclusions There is limited available evidence to determine the effects of non‐pharmacological and pharmacological interventions in treating acute high altitude illness. Low‐quality evidence suggests that dexamethasone and acetazolamide might reduce AMS score compared to placebo. However, the clinical benefits and harms related to these potential interventions remain unclear. Overall, the evidence is of limited practical significance in the clinical field. High‐quality research in this field is needed, since most trials were poorly conducted and reported. Plain language summary Treatments for high altitude (mountain) illness Background Acute high altitude illness, also known as acute mountain sickness, may present with a variety of symptoms. It is caused by the decreasing level of oxygen at increasingly high altitudes; and it can be experienced when reaching a high altitude when travelling, hiking or climbing mountains or other elevated areas. People going to altitudes over 4000 metres, females, people younger than mid‐adulthood , and people with a history of migraine are at greater risk of suffering from altitude sickness. The most common symptoms are headache, loss of appetite , insomnia, and nausea. However, severe forms can include confusion, difficulty walking, progressive cough, shortness of breath, and even death. Review question What are the benefits and risks of different treatments for people suffering from high altitude illness? Study characteristics We included 13 studies with a total of 468 participants. Most studies included participants with mild or moderate forms of mountain sickness, and only one study included the severe neurological (disorder of the nervous system) form. Follow‐up was usually less than one day. We also identified two ongoing studies. Key results We found studies evaluating the following interventions: simulated descent with a hyperbaric chamber (medical use of oxygen in a special chamber at greater than atmospheric pressure to increase the availability of oxygen in the body); oxygen; medicines: acetazolamide, dexamethasone, ibuprofen, paracetamol, gabapentin, sumatriptan, nitric oxide, and magnesium sulphate. None of the studies reported the effects of these interventions on all‐cause mortality. The report of complete relief from acute mountain sickness symptoms, and adverse events was infrequent. Studies related to simulated descent with the use of a hyperbaric chamber did not find additional benefits or harms related to this intervention (3 studies, 124 participants). In addition, studies related to administration of medicines found some benefits in terms of reduction of symptoms with the use of acetazolamide (2 studies, 25 participants), and dexamethasone (1 study, 35 participants), without an increase in side effects. Quality of the evidence The quality of the evidence we found was low, and thus our certainty in the findings is limited. There was insufficient information on how the studies were conducted, and in some cases there was evidence of tampering at some stages of the trials. Furthermore, the number of persons in each study was very small (< 30 participants), and therefore the results were not clear (imprecise). Some studies were not blinded (that is, participants knew what experimental treatment they were receiving), and this could have affected how the participants evaluated their own symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Simancas‐Racines, D, Arevalo‐Rodriguez, I, Osorio, D, Franco, JVA, Xu, Y, Hidalgo, R", "articleTypes": [], "doi": "10.1002/14651858.CD009567.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.073Z" }, { "id": "fa9195e0-2f6f-4616-a42a-8e6841c8970a", "pmid": "", "title": "Blood pressure lowering efficacy of diuretics as second‐line therapy for primary hypertension", "imported": false, "abstract": "Abstract - Background Diuretics are widely prescribed for hypertension not only as a first‐line drug but also as a second‐line drug. Therefore, it is essential to determine the effects of diuretics on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAEs) when given as a second‐line drug. Objectives To quantify the additional reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of diuretic therapy as a second‐line drug in patients with primary hypertension Search methods CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (1966‐July 2008), EMBASE (1988‐July 2008) and bibliographic citations of articles and reviews were searched. Selection criteria Double‐blind, randomized, controlled trials evaluating the BP lowering efficacy of a diuretic in combination therapy with another class of anti‐hypertensive drugs compared with the respective monotherapy (without a diuretic) for a duration of 3 to 12 weeks in patients with primary hypertension. Data collection and analysis Two review authors independently extracted the data and assessed trial quality. Main results Fifty‐three double‐blind RCTs evaluating a thiazide in 15129 hypertensive patients (baseline BP of 156/101 mmHg) were included. Hydrochlorothiazide was the thiazide used in 49/53 (92%) of the included studies. The additional BP reduction caused by the thiazide as a second drug was estimated by comparing the difference in BP reduction between the combination and monotherapy groups. Thiazides as a second‐line drug reduced BP by 6/3 and 8/4 mmHg at doses of 1 and 2 times the manufacturer's recommended starting dose respectively. The BP lowering effect was dose related. The effect was similar to that obtained when thiazides are used as a single agent. Only 3 double‐blind RCTs evaluating loop diuretics were identified. These RCTs showed a BP lowering effect of a starting dose of about 6/3 mmHg. Authors' conclusions Thiazides when given as a second‐line drug have a dose related effect to lower blood pressure that is similar to when they are added as a first‐line drug. This means that the BP lowering effect of thiazides is additive. Loop diuretics appear to have a similar blood pressure lowering effect as thiazides at 1 times the recommended starting dose. Because of the short duration of the trials and lack of reporting of adverse events, this review does not provide a good estimate of the incidence of adverse effects of diuretics given as a second‐line drug. Plain language summary Diuretics effective in lowering blood pressure when given as a second drug Diuretics are a good first‐line treatment for high blood pressure (BP). Diuretics include loop diuretics and thiazides. We asked how much do diuretics reduce BP when used as the second drug to treat hypertension. We performed a search of the available scientific literature to find all trial evidence to assess this question. Fifty‐six trials were found. Fifty‐three trials involved thiazide diuretics (92% with the drug hydrochlorothiazide) and included a total of 15310 participants. Adding a thiazide to another anti‐hypertensive drug further reduces the BP by an additional 6/3 mmHg when given at the starting dose and reduces BP by 8/4 mmHg at 2 times the starting dose. This is approximately the same effect as when the drugs are used alone. A good estimate of the harms associated with diuretics cannot be estimated in this review because of the lack of reporting and the short duration of the trials.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Chen, JMH, Heran, BS, Wright, JM", "articleTypes": [], "doi": "10.1002/14651858.CD007187.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.777Z" }, { "id": "faa736bd-57e8-4b28-babe-a2186eda4f9c", "pmid": "", "title": "Sweet potato for type 2 diabetes mellitus", "imported": false, "abstract": "Abstract - Background Sweet potato ( Ipomoea batatas ) is among the most nutritious subtropical and tropical vegetables. It is also used in traditional medicine practices for type 2 diabetes mellitus. Research in animal and human models suggests a possible role of sweet potato in glycaemic control. Objectives To assess the effects of sweet potato for type 2 diabetes mellitus. Search methods We searched several electronic databases, including The Cochrane Library (2013, Issue 1), MEDLINE, EMBASE, CINAHL, SIGLE and LILACS (all up to February 2013), combined with handsearches. No language restrictions were used. Selection criteria We included randomised controlled trials (RCTs) that compared sweet potato with a placebo or a comparator intervention, with or without pharmacological or non‐pharmacological interventions. Data collection and analysis Two authors independently selected the trials and extracted the data. We evaluated risk of bias by assessing randomisation, allocation concealment, blinding, completeness of outcome data, selective reporting and other potential sources of bias. Main results Three RCTs met our inclusion criteria: these investigated a total of 140 participants and ranged from six weeks to five months in duration. All three studies were performed by the same trialist. Overall, the risk of bias of these trials was unclear or high. All RCTs compared the effect of sweet potato preparations with placebo on glycaemic control in type 2 diabetes mellitus. There was a statistically significant improvement in glycosylated haemoglobin A1c (HbA1c) at three to five months with 4 g/day sweet potato preparation compared to placebo (mean difference ‐0.3% (95% confidence interval ‐0.6 to ‐0.04); P = 0.02; 122 participants; 2 trials). No serious adverse effects were reported. Diabetic complications and morbidity, death from any cause, health‐related quality of life, well‐being, functional outcomes and costs were not investigated. Authors' conclusions There is insufficient evidence about the use of sweet potato for type 2 diabetes mellitus. In addition to improvement in trial methodology, issues of standardization and quality control of preparations ‐ including other varieties of sweet potato ‐ need to be addressed. Further observational trials and RCTs evaluating the effects of sweet potato are needed to guide any recommendations in clinical practice. Plain language summary Sweet potato for type 2 diabetes mellitus Sweet potato ( Ipomoea batatas ) is a plant found in the tropical and subtropical belts and is one of the most nutritious tropical and subtropical vegetables. As well as being popular in cooking in countries in Asia‐Pacific, Africa and North America, sweet potato is also used in traditional medicine for the treatment of diabetes mellitus. We decided to investigate whether there is enough evidence from medical trials to show whether sweet potato works as a treatment for diabetes. This review of randomised controlled trials found only three studies (with a total of 140 participants) that evaluated the effects of sweet potato for type 2 diabetes mellitus compared with a fake medicine (placebo). All these trials were of very low quality. Two studies with 122 participants showed improved long‐term metabolic control of blood sugar levels as measured by glycosylated haemoglobin A1c (HbA1c) which was moderately lowered by 0.3% in participants who were given 4 g sweet potato tablets a day for three to five months. The duration of treatment ranged from six weeks to five months. No study investigated diabetic complications, death from any cause, health‐related quality of life, well‐being, functional outcomes or costs. Adverse effects were mostly mild, and included abdominal distension and pain. There are many varieties of sweet potatoes and sweet potato preparations. More trials are needed to assess the quality of the various sweet potato preparations as well as to evaluate further the use of different varieties of sweet potato in the diet of diabetic people.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Ooi, CP; Loke, SC", "articleTypes": [], "doi": "10.1002/14651858.CD009128.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "faacb19a-06d1-4e94-987c-04525db6bc98", "pmid": "", "title": "Interventions for chronic blepharitis", "imported": false, "abstract": "Abstract - Background Blepharitis, an inflammatory condition associated with itchiness, redness, flaking, and crusting of the eyelids, is a common eye condition that affects both children and adults. It is common in all ethnic groups and across all ages. Although infrequent, blepharitis can lead to permanent alterations to the eyelid margin or vision loss from superficial keratopathy (abnormality of the cornea), corneal neovascularization, and ulceration. Most importantly, blepharitis frequently causes significant ocular symptoms such as burning sensation, irritation, tearing, and red eyes as well as visual problems such as photophobia and blurred vision. The exact etiopathogenesis is unknown, but suspected to be multifactorial, including chronic low‐grade infections of the ocular surface with bacteria, infestations with certain parasites such as demodex, and inflammatory skin conditions such as atopy and seborrhea. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. Objectives To examine the effectiveness of interventions in the treatment of chronic blepharitis. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 1), MEDLINE (January 1950 to February 2012), EMBASE (January 1980 to February 2012), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 9 February 2012. Selection criteria We included randomized controlled trials (RCTs) and quasi‐randomized controlled trials (CCTs) in which participants were adults aged 16 years or older and clinically diagnosed with chronic blepharitis. We also included trials where participants with chronic blepharitis were a subset of the participants included in the study and data were reported separately for these participants. Interventions within the scope of this review included medical treatment and lid hygiene measures. Data collection and analysis Two authors independently assessed search results, reviewed full‐text copies for eligibility, examined risk of bias, and extracted data. Data were meta‐analyzed for studies comparing similar interventions and reporting comparable outcomes with the same timing. Otherwise, results for included studies were summarized in the text. Main results There were 34 studies (2169 participants with blepharitis) included in this review: 20 studies (14 RCTs and 6 CCTs) included 1661 participants with anterior or mixed blepharitis and 14 studies (12 RCTs and 2 CCTs) included 508 participants with posterior blepharitis (MGD). Due to the heterogeneity of study characteristics among the included studies, with respect to follow‐up periods and types of interventions, comparisons, and condition of participants, our ability to perform meta‐analyses was limited. Topical antibiotics were shown to provide some symptomatic relief and were effective in eradicating bacteria from the eyelid margin for anterior blepharitis. Lid hygiene may provide symptomatic relief for anterior and posterior blepharitis. The effectiveness of other treatments for blepharitis, such as topical steroids and oral antibiotics, were inconclusive. Authors' conclusions Despite identifying 34 trials related to treatments for blepharitis, there is no strong evidence for any of the treatments in terms of curing chronic blepharitis. Commercial products are marketed to consumers and prescribed to patients without substantial evidence of effectiveness. Further research is needed to evaluate the effectiveness of such treatments. Any RCT designed for this purpose should separate participants by type of condition (e.g. staphylococcal blepharitis or MGD) in order to minimize imbalances between groups (type I errors) and to achieve statistical power for analyses (prevent type II errors). Medical interventions and commercial products should be compared with conventional lid hygiene measures, such as warm compresses and eyelid margin washing, to determine effectiveness, as well as head‐to‐head to show comparative effectiveness between treatments. Outcomes of interest should be patient‐centered and measured using validated questionnaires or scales. It is important that participants be followed long‐term, at least one year, to assess chronic outcomes properly. Plain language summary Interventions for blepharitis Blepharitis, defined as inflammation of the eyelids, is a common eye condition and affects both children and adults. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. There were 34 studies (2169 participants with blepharitis) included in the review, 20 of which included participants with anterior blepharitis and 14 of which included participants with posterior blepharitis. For anterior blepharitis, topical antibiotics provided some symptomatic relief and were effective in clearing bacteria from the eyelid margins. There was no difference between the types of topical antibiotics used. Topical steroids also provided some symptomatic relief; however, they were ineffective in eliminating bacteria. Lid hygiene, including warm compresses and lid scrubs, showed some symptomatic relief in both anterior and posterior blepharitis. Overall, there was no strong evidence for any of the treatments in terms of curing chronic blepharitis. Further research should be done to evaluate the effectiveness of treatments for blepharitis, with particular attention paid to adequate diagnosis and classification of the disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Lindsley, K; Matsumura, S; Hatef, E; Akpek, EK", "articleTypes": [], "doi": "10.1002/14651858.CD005556.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "facac80a-6456-4b57-842e-235aad5fc1d0", "pmid": "", "title": "Metformin for endometrial hyperplasia", "imported": false, "abstract": "Abstract - Background Endometrial cancer is one of the most common gynaecological cancers in the world. Rates of endometrial cancer are rising, in part because of rising obesity rates. Endometrial hyperplasia is a precancerous condition in women that can lead to endometrial cancer if left untreated. Endometrial hyperplasia occurs more commonly than endometrial cancer. Progesterone tablets that are currently used to treat women with endometrial hyperplasia are associated with adverse effects in up to 84% of women. A levonorgestrel intrauterine device may improve compliance, but it is invasive, is not acceptable to all women, and is associated with irregular vaginal bleeding in 82% of cases. Therefore, an alternative treatment for women with endometrial hyperplasia is needed. Metformin, a drug that is often used to treat people with diabetes, has been shown, in some human studies, to reverse endometrial hyperplasia. However, the effectiveness and safety of metformin for treatment of endometrial hyperplasia remain uncertain. This is an update of a review first published in 2017. Objectives To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia. Search methods We searched the Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, PubMed, Embase, Google Scholar, OpenGrey, LILACS, and two trials registers from inception to 5 September 2022. We searched the bibliographies of all relevant studies, and contacted experts in the field for any additional trials. Selection criteria We included randomised controlled trials (RCTs) and cross‐over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo, no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type. Data collection and analysis Two review authors independently assessed studies for eligibility, extracted data from included studies, assessed the risk of bias in the included studies, and assessed the certainty of the evidence for each outcome. We resolved disagreements by discussion or by deferring to a third review author. When study details were missing, review authors contacted the study authors. The primary outcome of this review was regression of endometrial hyperplasia histology (with or without atypia) towards normal histology. Main results We included seven RCTs, in which a total of 387 women took part. In the comparison, Metformin plus megestrol versus megestrol alone, we rated the certainty of the evidence as low for the outcome, regression of endometrial hyperplasia. We rated the quality of the evidence as very low for the rest of the outcomes, in all three comparisons. Although there was a low risk of selection bias, there was a high risk of bias in the blinding of personnel and outcome assessment (performance bias and detection bias) in many studies. This update identified four new RCTs and six ongoing RCTs. Metformin versus megestrol We are uncertain whether metformin increases the regression of endometrial hyperplasia towards normal histology over megestrol (odds ratio (OR) 4.89, 95% confidence interval (CI) 1.56 to 15.32; P = 0.006; 2 RCTs, 83 participants; I² = 7%; very low‐certainty evidence). This evidence suggests that if the rate of regression with megestrol is 61%, the rate of regression with metformin would be between 71% and 96%. It is unresolved whether metformin results in different rates of abnormal uterine bleeding or hysterectomy compared to megestrol. No study in this comparison reported progression of hyperplasia to endometrial cancer, recurrence of endometrial hyperplasia, health‐related quality of life, or adverse effects during treatment. Metformin plus megestrol versus megestrol monotherapy The combination of metformin and megestrol may enhance the regression of endometrial hyperplasia towards normal histology more than megestrol alone (OR 3.27, 95% CI 1.65 to 6.51; P = 0.0007; 4 RCTs, 258 participants; I² = 0%, low‐certainty evidence). This suggests that if the rate of regression with megestrol monotherapy is 54%, the rate of regression with the addition of metformin would be between 66% and 84%. In one study, 3/8 (37.5%) of participants who took metformin had nausea that settled without further treatment. It is unresolved whether the combination of metformin and megestrol results in different rates of recurrence of endometrial hyperplasia, progression of endometrial hyperplasia to endometrial cancer, or hysterectomy compared to megestrol monotherapy. No study in this comparison reported abnormal uterine bleeding, or health‐related quality of life. Metformin plus levonorgestrel (intrauterine system) versus levonorgestrel (intrauterine system) monotherapy We are uncertain whether there is a difference between groups in the regression of endometrial hyperplasia towards normal histology (OR 0.29, 95% CI 0.01 to 7.56; 1 RCT, 46 participants; very low‐certainty evidence). This evidence suggests that if the rate of regression with levonorgestrel monotherapy is 96%, the rate of regression with the addition of metformin would be between 73% and 100%. It is unresolved whether the combination of metformin and levonorgestrel results in different rates of abnormal uterine bleeding, hysterectomy, or the development of adverse effects during treatment compared to levonorgestrel monotherapy. No study in this comparison reported recurrence of endometrial hyperplasia, progression of hyperplasia to endometrial cancer, or health‐related quality of life. Authors' conclusions Review authors found insufficient evidence to either support or refute the use of metformin, specifically megestrol acetate, given alone or in combination with standard therapy, for the treatment of women with endometrial hyperplasia. Robustly designed and adequately powered randomised controlled trials, yielding long‐term outcome data are still needed to address this clinical question. Plain language summary Metformin for endometrial hyperplasia Review question Is metformin an effective and safe treatment for women with endometrial hyperplasia? Background Endometrial cancer (cancer of the lining of the womb) is a common cancer that affects the reproductive organs in women worldwide. Endometrial hyperplasia (thickening of the lining of the womb) is a precancerous condition in women that can lead to endometrial cancer if left untreated. Successful treatment of women with endometrial hyperplasia can prevent endometrial cancer. Endometrial hyperplasia is usually treated by providing progesterone hormone tablets, inserting a levonorgestrel‐releasing intrauterine system (LNG‐IUS) into the womb, advising women with extra weight to lose weight, or performing a hysterectomy for women who do not want a future pregnancy. However, progesterone tablets are associated with side effects in up to 84% of women, and this can prevent women from completing treatment. Also, progesterone tablets do not always work, and endometrial hyperplasia can return in up to 14% to 30% of women after treatment. The LNG‐IUS is associated with irregular vaginal bleeding in up to 82% of women. Many women find it painful to use, or find it otherwise unacceptable. Therefore, an alternative treatment for endometrial hyperplasia is required. Metformin, an oral tablet that is usually used to treat diabetes, has been shown to cure endometrial hyperplasia in some human studies. Although women taking metformin may experience side effects, treatment is usually well tolerated. If women experience fewer side effects when taking metformin rather than progesterone tablets, and if metformin effectively treats endometrial hyperplasia, women would be more willing to complete treatment, and the cure rate would improve. This could reduce the number of women who end up with endometrial cancer. However, the effectiveness and safety of metformin used to treat women with endometrial hyperplasia remain uncertain. Study characteristics We included seven randomised controlled trials in which a total of 387 women took part. Five studies compared metformin to megestrol (a form of progesterone), and one study compared metformin plus megestrol to megestrol alone. Women in all studies received treatment for three to six months. The evidence is current to 5 September 2022. Key results Studies on metformin alone versus megestrol alone provided insufficient evidence to show differences in effectiveness for curing endometrial hyperplasia. Studies on metformin plus megestrol versus megestrol alone found that metformin may improve the thickened walls of the womb, but the evidence is uncertain about other outcomes. One small study provided insufficient evidence to support or refute the use of metformin plus the LNG‐IUS or the LNG‐IUS alone. Certainty of the evidence We rated the certainty of the evidence as low to very‐low for all outcomes, because of limitations in the way the studies were designed, and small sample sizes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Shiwani, H, Clement, NS, Daniels, JP, Atiomo, W", "articleTypes": [], "doi": "10.1002/14651858.CD012214.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.760Z" }, { "id": "facf295d-9339-4030-ae3e-a0d80c53accc", "pmid": "", "title": "Ready‐to‐use therapeutic food (RUTF) for home‐based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age", "imported": false, "abstract": "Abstract - Background Management of severe acute malnutrition (SAM) in children comprises two potential phases: stabilisation and rehabilitation. During the initial stabilisation phase, children receive treatment for dehydration, electrolyte imbalances, intercurrent infections and other complications. In the rehabilitation phase (applicable to children presenting with uncomplicated SAM or those with complicated SAM after complications have been resolved), catch‐up growth is the main focus and the recommended energy and protein requirements are much higher. In‐hospital rehabilitation of children with SAM is not always desirable or practical ‐ especially in rural settings ‐ and home‐based care can offer a better solution. Ready‐to‐use therapeutic food (RUTF) is a widely used option for home‐based rehabilitation, but the findings of our previous review were inconclusive. Objectives To assess the effects of home‐based RUTF used during the rehabilitation phase of SAM in children aged between six months and five years on recovery, relapse, mortality and rate of weight gain. Search methods We searched the following databases in October 2018: CENTRAL, MEDLINE, Embase, six other databases and three trials registers. We ran separate searches for cost‐effectiveness studies, contacted researchers and healthcare professionals in the field, and checked bibliographies of included studies and relevant reviews. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs, where children aged between six months and five years with SAM were, during the rehabilitation phase, treated at home with RUTF compared to an alternative dietary approach, or with different regimens and formulations of RUTF compared to each other. We assessed recovery, deterioration or relapse and mortality as primary outcomes; and rate of weight gain, time to recovery, anthropometrical changes, cognitive development and function, adverse outcomes and acceptability as secondary outcomes. Data collection and analysis We screened for eligible studies, extracted data and assessed risk of bias of those included, independently and in duplicate. Where data allowed, we performed a random‐effects meta‐analysis using Review Manager 5, and investigated substantial heterogeneity through subgroup and sensitivity analyses. For the main outcomes, we evaluated the quality of the evidence using GRADE, and presented results in a 'Summary of findings' table per comparison. Main results We included 15 eligible studies (n = 7976; effective sample size = 6630), four of which were cluster trials. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. Six studies received funding or donations from industry whereas eight did not, and one study did not report the funding source. The overall risk of bias was high for six studies, unclear for three studies, and low for six studies. Among the 14 studies that contributed to meta‐analyses, none (n = 5), some (n = 5) or all (n = 4) children were stabilised in hospital prior to commencement of the study. One small study included only children known to be HIV‐infected, another study stratified the analysis for 'recovery' according to HIV status, while the remaining studies included HIV‐uninfected or untested children. Across all studies, the intervention lasted between 8 and 16 weeks. Only five studies followed up children postintervention (maximum of six months), and generally reported on a limited number of outcomes. We found seven studies with 2261 children comparing home‐based RUTF meeting the World Health Organization (WHO) recommendations for nutritional composition (referred to in this review as standard RUTF) with an alternative dietary approach (effective sample size = 1964). RUTF probably improves recovery (risk ratio (RR) 1.33; 95% confidence interval (CI) 1.16 to 1.54; 6 studies, 1852 children; moderate‐quality evidence), and may increase the rate of weight gain slightly (mean difference (MD) 1.12 g/kg/day, 95% CI 0.27 to 1.96; 4 studies, 1450 children; low‐quality evidence), but we do not know the effects on relapse (RR 0.55, 95% CI 0.30 to 1.01; 4 studies, 1505 children; very low‐quality evidence) and mortality (RR 1.05, 95% CI 0.51 to 2.16; 4 studies, 1505 children; very low‐quality evidence). Two quasi‐randomised cluster trials compared standard, home‐based RUTF meeting total daily nutritional requirements with a similar RUTF but given as a supplement to the usual diet (213 children; effective sample size = 210). Meta‐analysis showed that standard RUTF meeting total daily nutritional requirements may improve recovery (RR 1.41, 95% CI 1.19 to 1.68; low‐quality evidence) and reduce relapse (RR 0.11, 95% CI 0.01 to 0.85; low‐quality evidence), but the effects are unknown for mortality (RR 1.36, 95% CI 0.46 to 4.04; very low‐quality evidence) and rate of weight gain (MD 1.21 g/kg/day, 95% CI ‐ 0.74 to 3.16; very low‐quality evidence). Eight studies randomised 5502 children (effective sample size = 4456) and compared standard home‐based RUTF with RUTFs of alternative formulations (e.g. using locally available ingredients, containing less or no milk powder, containing specific fatty acids, or with added pre‐ and probiotics). For recovery, it made little or no difference whether standard or alternative formulation RUTF was used (RR 1.03, 95% CI 0.99 to 1.08; 6 studies, 4188 children; high‐quality evidence). Standard RUTF decreases relapse (RR 0.84, 95% CI 0.72 to 0.98; 6 studies, 4188 children; high‐quality evidence). However, it probably makes little or no difference to mortality (RR 1.00, 95% CI 0.80 to 1.24; 7 studies, 4309 children; moderate‐quality evidence) and may make little or no difference to the rate of weight gain (MD 0.11 g/kg/day, 95% CI −0.32 to 0.54; 6 studies, 3807 children; low‐quality evidence) whether standard or alternative formulation RUTF is used. Authors' conclusions Compared to alternative dietary approaches, standard RUTF probably improves recovery and may increase rate of weight gain slightly, but the effects on relapse and mortality are unknown. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given as a supplement to the usual diet, but the effects on mortality and rate of weight gain are not clear. When comparing RUTFs with different formulations, the current evidence does not favour a particular formulation, except for relapse, which is reduced with standard RUTF. Well‐designed, adequately powered, pragmatic RCTs with standardised outcome measures, stratified by HIV status, and that include diarrhoea as an outcome, are needed. Plain language summary Ready‐to‐use therapeutic food (RUTF) as home‐based treatment for severely malnourished children between six months and five years Background Malnourished children usually look very thin or wasted and they have a high risk of death and illness. Treating severely malnourished children in hospitals is not always desirable or practical in rural settings, and home‐based treatment may be better. Home‐based treatment can be food prepared by a caregiver (such as flour porridge or energy‐ and nutrient‐dense locally available foods), or ready‐to‐use therapeutic food (RUTF) provided by a clinic. RUTF is usually made according to a standard, energy‐rich composition defined by the World Health Organization (WHO). Typically, the ingredients for standard RUTF include milk powder, sugar, peanut butter, vegetable oil, vitamins and minerals; but ingredients vary depending on local availability, cost and acceptability. Benefits of RUTF include a long shelf life without refrigeration and they require no preparation. This is an update of our previous review, where definite conclusions about the effects of RUTF could not be drawn from the four studies that were available at that time. Review question We assessed standard RUTF compared to an alternative dietary approach (e.g. flour porridge or locally available foods) and examined whether smaller amounts and different formulations of RUTF can achieve similar health outcomes in severely malnourished children aged between six months and five years. The main health outcomes that we investigated were recovery from severe malnutrition, deterioration or relapse, death and the rate of weight gain. Included study characteristics We searched databases for studies up to the October 2018, and found 15 studies with 7976 children. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. One small study included only children infected with HIV, another study analysed children with and without HIV separately for the main outcome (recovery), while the other studies included children who were not infected with HIV or who were untested. Overall, we judged six studies to be at high risk of bias, three studies to be at unclear risk of bias, and six studies to be at low risk of bias. (With 'risk of bias', we mean the extent to which the methods used in a study enable it to determine the truth.) All the studies lasted between 8 and 16 weeks. Only five studies followed up children after the study (for a maximum of six months), and generally reported on a limited number of outcomes. Of our 15 included studies, six were linked to funding or donations from industry, one did not report the source of funding, and eight studies reported funding where sponsors did not include industry. Key findings Compared to alternative dietary approaches, standard RUTF probably improves recovery (moderate‐quality evidence) and may increase the rate of weight gain slightly (low‐quality evidence), but the effects on relapse and death are unknown (very low‐quality evidence). With 'quality of evidence' we mean how confident we are that the particular finding represents the true effect. For example, 'very low‐quality' means we are very uncertain about the finding, 'low‐quality evidence' means the future research is very likely to change the finding, 'moderate‐quality evidence' means that future studies may change this finding, and 'high‐quality evidence' means that it is unlikely that future studies will change the finding. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given supplementary to the usual diet (low‐quality evidence), but for death and the rate of weight gain, the effects are not known (very low‐quality evidence). When comparing RUTFs of different formulations, it makes little or no difference for recovery whether a standard or alternative formulation RUTF is used (high‐quality evidence). For relapse, using standard RUTF decreases relapse (high‐quality evidence). It probably makes little or no difference to death (moderate‐quality evidence) and to the rate of weight gain (low‐quality evidence) whether standard or alternative formulation RUTF is used. Well‐designed, randomised controlled trials (experimental studies where participants meeting the inclusion criteria have an equal chance of being allocated to any of the intervention or control groups) in which analyses have been performed separately for children with and without HIV, and that also measure and report on diarrhoea occurrence, are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Schoonees, A, Lombard, MJ, Musekiwa, A, Nel, E, Volmink, J", "articleTypes": [], "doi": "10.1002/14651858.CD009000.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.115Z" }, { "id": "fb006d36-7281-4998-91b2-10aa31b98f37", "pmid": "", "title": "Targeting Triple-negative Breast Cancer or ER-positive, PR Positive her2 Negative by Alkaline Glucosodiene Molecules Via a Metabolic Pathway Phase I Clinical Trial", "imported": false, "abstract": "The diverse group of breast tumors known as triple-negative breast cancer (TNBC) which is lethally and deadly type of breast cancer and insensitive to endocrine therapy and HER2-targeted therapy because it lacks the expression of estrogen, progesterone, and human epidermal growth factor receptors TNBC makes up almost 15% of all invasive breast cancers, and of all breast tumor subtypes, it has the worst overall survival and the highest rate of metastatic occurrence. Cytotoxic chemotherapy is the main established systemic therapy for early and advanced TNBC disease at the moment because there is no authorized targeted therapy. Despite the fact that chemotherapy greatly improves clinical outcomes for TNBC patients, recurrence rates are still high and TNBC cancers frequently develop chemotherapeutic drug resistance ). In light of the few available therapy choices, so few choices for this subtype of breast cancer, and many cases are resistant to chemotherapy and recurrent and with a risk of high metastasis from previous literature and many experimental studies, the target of glucose environment is a promising weapon against this deadly type of breast cancer so glucose deprivation from tumor cells may cut the glucose entry as fuel to these cancer cells so this study uses a substitute energy fuel by using alkaline glucosodiene which is chemically invented by Maher M.AKL", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.243Z" }, { "id": "fb150d70-1174-4e68-89cd-3ed4e293987f", "pmid": "", "title": "Interventions for treating oral leukoplakia to prevent oral cancer", "imported": false, "abstract": "Abstract - Background Oral leukoplakia is a relatively common oral lesion that, in a small proportion of people, precedes the development of oral cancer. Most leukoplakias are asymptomatic; therefore, the primary objective of treatment should be to prevent onset of cancer. This review updates our previous review, published in 2006. Objectives To assess the effectiveness, safety and acceptability of treatments for leukoplakia in preventing oral cancer. Search methods We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 16 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) ( the Cochrane Library , 2016, Issue 4), MEDLINE Ovid (1946 to 16 May 2016), Embase Ovid (1980 to 16 May 2016) and CancerLit via PubMed (1950 to 16 May 2016). We searched the metaRegister of Controlled Trials (to 10 February 2015), ClinicalTrials.gov (to 16 May 2016) and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials (to 16 May 2016). We placed no restrictions on the language or date of publication when searching electronic databases. Selection criteria We included randomised controlled trials (RCTs) that enrolled people with a diagnosis of oral leukoplakia and compared any treatment versus placebo or no treatment. Data collection and analysis We collected data using a data extraction form. Oral cancer development, demonstrated by histopathological examination, was our primary outcome. Secondary outcomes were clinical resolution of the lesion, improvement of histological features and adverse events. We contacted trial authors for further details when information was unclear. When valid and relevant data were available, we conducted a meta‐analysis of the data using a fixed‐effect model when we identified fewer than four studies with no heterogeneity. For dichotomous outcomes, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We assessed risk of bias in studies by using the Cochrane tool. We assessed the overall quality of the evidence by using standardised criteria (Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE)). Main results We included 14 studies (909 participants) in this review. Surgical interventions, including laser therapy and cryotherapy, have never been studied by means of an RCT that included a no treatment or placebo arm. The included trials tested a range of medical and complementary treatments, in particular, vitamin A and retinoids (four studies); beta carotene or carotenoids (three studies); non‐steroidal anti‐inflammatory drugs (NSAIDs), specifically ketorolac and celecoxib (two studies); herbal extracts (four studies), including tea components, a Chinese herbal mixture and freeze‐dried black raspberry gel; bleomycin (one study); and Bowman‐Birk inhibitor (one study). We judged one study to be at low risk of bias, seven at unclear risk and six at high risk. In general, we judged the overall quality of the evidence to be low or very low, so findings are uncertain and further research is needed. Five studies recorded cancer incidence, only three of which provided useable data. None of the studies provided evidence that active treatment reduced the risk of oral cancer more than placebo: systemic vitamin A (RR 0.11, 95% CI 0.01 to 2.05; 85 participants, one study); systemic beta carotene (RR 0.71, 95% CI 0.24 to 2.09; 132 participants, two studies); and topical bleomycin (RR 3.00, 95% CI 0.32 to 27.83; 20 participants, one study). Follow‐up ranged between two and seven years. Some individual studies suggested effectiveness of some proposed treatments, namely, systemic vitamin A, beta carotene and lycopene, for achieving clinical resolution of lesions more often than placebo. Similarly, single studies found that systemic retinoic acid and lycopene may provide some benefit in terms of improvement in histological features. Some studies also reported a high rate of relapse. Side effects of varying severity were often described; however, it seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Authors' conclusions Surgical treatment for oral leukoplakia has not been assessed in an RCT that included a no treatment or placebo comparison. Nor has cessation of risk factors such as smoking been assessed. The available evidence on medical and complementary interventions for treating people with leukoplakia is very limited. We do not currently have evidence of a treatment that is effective for preventing the development of oral cancer. Treatments such as vitamin A and beta carotene may be effective in healing oral lesions, but relapses and adverse effects are common. Larger trials of longer duration are required to properly evaluate the effects of leukoplakia treatments on the risk of developing oral cancer. High‐quality research is particularly needed to assess surgical treatment and to assess the effects of risk factor cessation in people with leukoplakia. Plain language summary Interventions for treating oral leukoplakia to prevent oral cancer Review question People with oral leukoplakia are at higher risk of developing oral cancer than those with normal oral mucosa. This review, produced through Cochrane Oral Health , seeks to evaluate whether people affected by leukoplakia can benefit from surgical, medical or complementary treatments, either local or systemic. In particular, we conducted this review to find out which, if any, treatment is able to prevent people with leukoplakia of the mouth from getting oral cancer. This review updates our previous review published in 2006. Background Oral leukoplakia is a white patch formed in the mouth lining that cannot be rubbed off. It often does not hurt and may go unnoticed for years. People with leukoplakia develop oral cancer more often than people without it. Preventing this is critical because rates of oral cancer survival longer than five years after diagnosis are low. Drugs, surgery and other therapies have been tried for treatment of oral leukoplakia. Objectives This review aimed to evaluate whether treatments for oral leukoplakia are effective in preventing oral cancer, and safe and acceptable to patients. Study characteristics The evidence on which this review is based is up‐to‐date as of May 2016. We found 14 randomised controlled trials (RCTs) of medical and complementary treatments, which involved 909 participants in total. Treatments included herbal extracts, anti‐inflammatory drugs, vitamin A, beta carotene supplements and others. Surgical treatment has not been compared with placebo or no treatment in an RCT. Key results Cancer development was measured in studies of three treatments: systemic vitamin A, systemic beta carotene and topical bleomycin. None of these treatments showed effectiveness in preventing cancer development, as measured up to two years for vitamin A and beta carotene, and seven years for bleomycin. Some individual studies of vitamin A and beta carotene suggested that these treatments may be effective for improving or healing oral lesions. However, some studies observed a high rate of relapse in participants whose lesions were initially resolved by treatment. Most treatments caused side effects of differing severity in a high proportion of participants. It seems likely that interventions were well accepted by participants because drop‐out rates were similar between treatment and control groups. Quality of the evidence The available evidence is very limited. Most interventions were assessed by only one small study. Most studies had problems in the way they were conducted, making their results unreliable. We judged the quality of evidence for the outcome of cancer development to be very low. Author conclusions Larger, better studies of longer duration are required. As well as further studies of drug treatment and alternative treatments like vitamins, studies are needed to evaluate the effectiveness and safety of surgery, and of stopping risk factor habits such as smoking.", "journal": "Cochrane Database of Systematic Reviews", "year": "2016", "authors": "Lodi, G, Franchini, R, Warnakulasuriya, S, Varoni, EM, Sardella, A, Kerr, AR, Carrassi, A, MacDonald, LCI, Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD001829.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.760Z" }, { "id": "fb1766c9-6957-4a4c-ac2b-8b7c08ec4949", "pmid": "", "title": "Rinse‐free hand wash for reducing absenteeism among preschool and school children", "imported": false, "abstract": "Abstract - Background Illness‐related absenteeism is an important problem among preschool and school children for low‐, middle‐ and high‐ income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse‐free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness‐related absenteeism in preschool and school children. Objectives 1. To assess the effectiveness of rinse‐free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse‐free hand washing products are the most effective (if head‐to‐head comparisons exist), and what effect additional strategies in combination with rinse‐free hand washing have on the outcomes of interest. Search methods In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied. Selection criteria Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse‐free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions. Data collection and analysis Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings. Main results This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most‐notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse‐free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low‐certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse‐free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low‐certainty evidence), which indicates that rinse‐free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse‐free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low‐certainty evidence), which indicates rinse‐free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse‐free' group (eight days absent per 1000). There may be little to no difference between rinse‐free hand washing and 'no rinse‐free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low‐certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very‐low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse‐free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very‐low certainty evidence). Authors' conclusions The findings of this review may have identified a small yet potentially beneficial effect of rinse‐free hand washing regimes on illness‐related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse‐free hand washing regimens in order to provide more conclusive, higher‐certainty evidence regarding its impact. When considering the use of a rinse‐free hand washing program in a local setting, there needs to be consideration of the current rates of illness‐related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings. Plain language summary Rinse‐free hand wash for reducing absenteeism among preschool and school children Background Absenteeism from schooling is costly to parents, schools and governments and sustained absence is detrimental to student learning. Illness‐related absenteeism is a significant contributor to absenteeism from school, but can also result in parents missing work due to catching the illness themselves or having to stay home to care for their children. There are several strategies currently used to reduce illness‐related absenteeism, a common method is the implementation of appropriate hand hygiene practices. However, hand hygiene using soap and water is not always practical, and alternatives may prove to be more effective in reducing the overall rate of illness‐related absenteeism. One such alternative is the use of rinse‐free hand wash. Review question This review was designed to investigate if the use of rinse‐free hand wash can reduce the number of days spent absent from school in preschool and school children compared to no rinse‐free hand wash usage. Study characteristics The searches returned 19 relevant studies with a total of 30,747 participants. Eight studies were conducted in the USA, two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day‐care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to14 years). These studies were quite varied in the composition and application of the rinse‐free hand washing program. Only two studies included information on the primary outcome (absenteeism due to any reason), whilst for absenteeism for any illness there were six studies that provided information. The evidence presented is up to date to February 2020. Key results The application of, and adherence to a rinse‐free hand wash, hand hygiene program may be associated with small, but potentially beneficial effects in reducing the number of days students were absent from school due to illness compared to no rinse‐free hand wash, hygiene program. However rinse‐free hand washing may be no different to controls at reducing absenteeism for any reason. There may also be no difference in the number of skin irritations between students who received the rinse‐free hand wash compared to those who used soap and water. Most students and teachers responded favorably to using rinse‐free hand wash and complied relatively well with its use. Certainty of the evidence The certainty of the evidence included in this review was low or very low, mainly due to the included studies using poor methods, providing imprecise data, and being very inconsistent from one another. This means that we have low and very‐low certainty, or confidence, in these results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Munn, Z, Tufanaru, C, Lockwood, C, Stern, C, McAneney, H, Barker, TH", "articleTypes": [], "doi": "10.1002/14651858.CD012566.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.764Z" }, { "id": "fb30f7cf-5e47-4e1f-bdba-444283fa4006", "pmid": "", "title": "Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder", "imported": false, "abstract": "Abstract - Background Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. Objectives To assess the effects ‐ and review the acceptability and tolerability ‐ of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. Selection criteria Double‐ or single‐blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. Data collection and analysis Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. Main results Thirty‐one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D‐cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP‐101,606 (1), decoglurant (1), MK‐0657 (1), N‐acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty‐eight studies were placebo‐controlled, and 48 were two‐arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild‐to‐moderate depression. Nineteen studies recruited only patients with treatment‐resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low‐certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) ‐0.87, 95% CI ‐1.26 to ‐0.48; n = 231, studies = 8, very low‐certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low‐certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low‐certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low‐certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and midazolam (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low‐certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate‐certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD ‐0.31, 95% CI ‐0.45 to ‐0.17; n = 824, studies = 4, moderate‐certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low‐certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate‐certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. Authors' conclusions Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta‐analyses for each comparison and the majority of comparisons included only one study. Long term non‐inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real‐world monitoring are needed to establish comprehensive data on safety and efficacy. Plain language summary Ketamine and other glutamate receptor modulators for depression in adults Why is this review important? Depression is one of the most common mental disorders, estimated to affect 350 million people worldwide. Antidepressant medication tends to be given as a first treatment for people with major depression. These drugs are however only effective in about one in four people at one year. Effective alternative medications to treat depression are needed, especially for rapid treatment. A new group of medications is called ‘glutamate receptor modulators’, which act on the glutamergic system. This group includes the medicine ketamine. In this review we examined the evidence for glutamate receptor modulators, including ketamine, as a treatment for depression. Who will be interested in this review? ‐ People with depression, their friends and families. ‐ General practitioners, psychiatrists, psychologists and pharmacists. ‐ Professionals working in adult mental health services. What questions does this review aim to answer? 1. Is treatment with ketamine and other glutamate receptor modulators more effective than treatment with placebo (dummy pill) or other drugs? 2. Is treatment with ketamine and other glutamate receptor modulators more acceptable than placebo or other drugs? Which studies were included in the review? We searched medical databases to find all relevant studies (specifically randomised controlled trials) completed up to 30 July 2020. To be included in the review, studies had to compare ketamine or other glutamate receptor modulators with placebo, other medicines or electroconvulsive therapy (ECT) for depression in adults (aged 18 and over). The studies also had to be single‐blind (the participant does not know which treatment they are receiving) or double‐blind (neither the participant or researcher know which treatment the participant is receiving), to attempt to reduce bias. We included 64 studies in the review, involving a total of 5299 people. The studies investigated16 different glutamate receptor modulator medications. The majority of participants had treatment‐resistant depression (depression which had not responded to two or more medications) at the start of the studies. Most studies were two‐armed, where the glutamate receptor modulator was compared with one other intervention. What does the evidence from the review tell us? Among the 16 drugs included in this review, only ketamine and esketamine were more effective than placebo at reducing symptoms of depression. The effects of ketamine lasted no more than one week after treatment and clearly disappeared after two weeks. Ketamine did, however, cause more side effects than placebo. The effects of esketamine were seen at 24 hours and could last up to four weeks with repeated doses. Esketamine caused a lot more side effects than placebo. The certainty of evidence varied considerably. There was no evidence of a difference between the other glutamate receptor modulators included in this review and placebo or other medications. What should happen next? Ketamine and esketamine appear to reduce the symptoms of depression. However, the trials were all short term so we do not know about the long‐term effects. It is important to note that in some trials attempts to prevent participants and investigators from knowing what medicine was being given were not successful and this may have inflated the positive effects of the active drugs. Future studies should examine what happens when people are repeatedly given the drug, with the aim to mimic the real‐world practice and assess longer‐term effects. More non‐inferiority trials should be conducted, where glutamate receptor modulators are compared with other active medications rather than placebo to find out whether they are better than alternative treatments. In most of the ketamine trials in this review, participants were given the drug by injection into a vein. This restricts the wide‐scale application of ketamine in clinical settings, so trials of ketamine by other routes are needed. Esketamine trials usually used nasal sprays, which are easier to use and could potentially be taken at home if further monitoring and trials found that it was safe to do so. Further studies assessing administration are needed in order to draw more reliable and firm conclusions.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Dean, RL, Hurducas, C, Hawton, K, Spyridi, S, Cowen, PJ, Hollingsworth, S, Marquardt, T, Barnes, A, Smith, R, McShane, R, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD011612.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.130Z" }, { "id": "fb642739-8a60-4575-9cab-c66a6d02ff7c", "pmid": "", "title": "Oral nicotine pouches for cessation or reduction of use of other tobacco or nicotine products", "imported": false, "abstract": "Abstract - Rationale Oral nicotine pouches (ONP) emerged in the late 2000s, but have gained popularity since their introduction to the global market in 2016, with claims about their harm reduction potential. Objectives Primary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from combustible tobacco use (smoking). • To evaluate the impact of ONP on the prevalence of combustible tobacco use. Secondary objectives • To evaluate the benefits and harms of ONP when used to help people transition away from other non‐combustible tobacco/commercial nicotine product use. • To evaluate the impact of ONP on the prevalence of use of other non‐combustible tobacco/commercial nicotine products. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO from 2000 to 13 January 2025. We also covered ClinicalTrials.gov and the WHO ICTRP through our search of CENTRAL. Eligibility criteria We included randomised controlled trials (RCTs) of ONP in people using tobacco or other non‐combustible tobacco/non‐pharmaceutical nicotine products. RCTs must have reported tobacco/nicotine use at 4+ weeks or biomarkers or adverse events at 1+ weeks. We also sought interrupted/multiple time‐series studies of ONP's population‐level effects on the prevalence of use of other tobacco/nicotine products. Outcomes Our critical outcomes were: smoking abstinence at 4+ weeks; number of people reporting serious adverse events (SAEs) at 1+ weeks; and change in the prevalence of smoking. Important outcomes included tobacco‐specific nitrosamines (TSNAs), carboxyhaemoglobin (COHb), metals, and inflammatory markers detected in human biosamples. Risk of bias We used the Cochrane RoB 1 tool to assess risk of bias. Synthesis methods We synthesised results using random‐effects meta‐analysis where possible. We used I 2 to quantify statistical heterogeneity. Where meta‐analysis was not possible, we graphically plotted available data in forest plots. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CI). We assessed the certainty of evidence using GRADE. Included studies We included four small studies (n < 150 for each, total n = 284; 3 independent, 1 industry‐funded; 3 at high risk of bias and 1 at unclear risk of bias). All were RCTs in people who smoked combustible cigarettes at baseline. Three were conducted in the USA, and one in New Zealand. Two compared higher‐ versus lower‐nicotine dose ONP. Two compared ONP to instructions to continue smoking as usual. One each compared ONP to electronic cigarettes (e‐cigarettes), snus, and pharmaceutical nicotine replacement therapy (NRT). Synthesis of results Smoking abstinence Smoking abstinence may be slightly higher in people randomised to ONP compared to no intervention at eight‐week follow‐up (RR 1.58, 95% CI 0.07 to 35.32; 1 study, 27 participants; very low‐certainty evidence (risk of bias and imprecision; CI incorporated possibility of no difference)), but the evidence is very uncertain. Low‐certainty evidence (serious imprecision; CI incorporated possibility of no difference) suggests there may be lower abstinence rates in those randomised to ONP compared to e‐cigarettes (RR 0.25, 95% CI 0.03 to 2.02; 1 study, 36 participants). Evidence from one study (n = 30) comparing higher‐ versus lower‐dose ONP found a higher quit rate in the higher‐dose arm, but again with wide CI encompassing the possibility of no difference and of higher quit rates in the lower‐dose arm (RR 5.00, 95% CI 0.26 to 96.13; evidence certainty not assessed). Serious adverse events No SAEs occurred in the three studies reporting this outcome. Data were available for the comparisons ONP versus minimal control (2 studies, 124 participants; very low‐certainty evidence (risk of bias and serious imprecision)) and ONP versus e‐cigarettes (1 study, 26 participants; low‐certainty evidence (serious imprecision)). TSNA One study reported on a TSNA (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol (NNAL)) comparing ONP with instructions to continue smoking. There may be lower levels with ONP (MD −265.30 ng/g creatinine, 95% CI −350.64 to −179.96; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. Data from two studies suggested no difference in NNAL levels between higher‐ and lower‐dose ONP (SMD −0.16, 95% CI −1.87 to 1.56; I 2 = 0%; 77 participants; evidence certainty not assessed). COHb Based on one study, there may be lower levels of COHb with ONP compared to instructions to continue smoking (MD −6.7%, 95% CI −8.33 to −5.07; 53 participants; very low‐certainty evidence (risk of bias and imprecision)), but the evidence is very uncertain. When comparing higher‐ versus lower‐dose ONP, the same study found very slightly lower levels in the higher‐dose group, with the 95% CI incorporating the possibility of no difference (MD −0.40%, 95% CI −1.19 to 0.39; evidence certainty not assessed). No studies reported on prevalence, inflammatory markers, metals, or use of tobacco/nicotine products other than cigarettes. Authors' conclusions There is limited evidence on the use of ONP for cessation or reduction of cigarette use. There is no evidence on the use of ONP for cessation or reduction of other tobacco or nicotine products or on the effects of ONP on prevalence of tobacco use/nicotine vaping. Low‐certainty evidence suggests that people randomised to ONP may be slightly less likely to quit smoking than those randomised to e‐cigarettes, but data were from one small study and therefore imprecise. Limited, short‐term data did not identify any serious health harms from ONP when used to help people transition away from tobacco smoking. More research on the effects of ONP for cessation or reduction of use of other tobacco or non‐pharmaceutical nicotine products is urgently needed. Future trials should prioritise comparing ONP to other active interventions (e.g. NRT and e‐cigarettes). Funding This Cochrane review was funded by the National Cancer Institute of the National Institutes of Health (NIH) and FDA Center for Tobacco Products (CTP) under Award Number 2U54CA229974. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food & Drug Administration. Registration Registration: Cochrane, via protocol available via DOI:10.1002/14651858.CD016220. Plain language summary What are the benefits and risks of oral nicotine pouches when used to help people stop smoking, vaping nicotine, or using other forms of tobacco? Key messages Limited evidence from three small studies found no short‐term serious health harms of oral nicotine pouches in people who smoke. We are uncertain if oral nicotine pouches help people quit smoking compared to instructions to continue smoking as usual or no support to quit. Future research is needed, in particular comparing oral nicotine pouches to other active treatments (e.g. nicotine replacement therapy and e‐cigarettes). What are oral nicotine pouches? Oral nicotine pouches are preportioned pouches containing nicotine, sold in various flavours and nicotine strengths. They are similar in appearance and use to snus. Snus is a form of smokeless tobacco placed between the gum and lip that is popular in Nordic countries, but whose sale is banned in the UK and European Union countries excluding Sweden. Unlike snus, nicotine pouches do not contain tobacco leaf. Like nicotine e‐cigarettes and pharmaceutical forms of nicotine replacement therapy (such as nicotine patches and gums), oral nicotine pouches may be able to help people transition away from harmful forms of tobacco/nicotine product use by replacing them with a product that does not contain tobacco leaf and which, unlike e‐cigarettes, does not involve inhaling vapour into the lungs. Common brand names of oral nicotine pouches include Zyn, Velo, and Nordic Spirit. What did we want to find out? We wanted to find out if oral nicotine pouches can help people transition away from smoking, nicotine vaping, or other forms of tobacco use. We also wanted to know if oral nicotine pouches caused any unwanted effects when used for this purpose. What did we do? We searched for studies where people who smoked, vaped, or used other tobacco products were given oral nicotine pouches as a way to quit. We included studies if they tracked tobacco use or vaping for at least four weeks or looked at unwanted effects or chemical changes in the blood, breath, or urine for at least one week. What did we find? We found four studies including a total of 284 people who were smokers at study start. The studies were conducted between 2006 and 2023, and in those that reported race or ethnicity, were conducted in majority white populations. The average age across studies ranged from 34 to 50 years. The average number of cigarettes smoked by participants at study start was between 14 and 23 per day. The longest study ran for eight weeks. Three studies were independently funded, and one was funded by a tobacco manufacturer. Based on two small studies, it was not clear whether using nicotine pouches helped more people to quit smoking compared to instructions to continue smoking as usual or no support to quit, and there may be lower quit rates in those using nicotine pouches compared to those using a nicotine e‐cigarette (vaping). No serious health harms occurred in any group in the three studies that reported this information, so it is unclear if using nicotine pouches affects the chances of experiencing a serious health harm. We also looked at certain chemicals measured in blood, breath, or urine that can signal exposures to harmful substances. Tobacco use exposes the body to cancer‐causing chemicals. NNAL (4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol), a chemical formed when these cancer‐causing chemicals enter the body, measures exposure to harmful ingredients in tobacco smoke. One small study reported lower levels of NNAL in people using oral nicotine pouches compared to those given no specific treatment to stop smoking. Combined evidence from two studies suggested no difference in NNAL levels between people receiving higher‐ versus lower‐dose nicotine pouches. Carbon monoxide is a poisonous gas present in tobacco smoke. When carbon monoxide binds with blood haemoglobin, it forms a substance called carboxyhaemoglobin. Carboxyhaemoglobin measures how much carbon monoxide a person has been exposed to in their blood. One study found lower levels of carboxyhaemoglobin in people using oral nicotine pouches compared to those who continued smoking. When comparing higher‐ versus lower‐dose nicotine pouches, the same study found very slightly lower carboxyhaemoglobin levels in the higher‐dose group. What are the limitations of the evidence? We have little to very low confidence in the evidence because the studies were relatively small, and there are not enough studies to be certain about the results. Also, some studies had issues with the way they were designed that could have affected their results. Many studies are currently underway, and we plan to update this review when their findings become available. How up‐to‐date is this evidence? The evidence is current to January 2025.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Hartmann-Boyce, J; Tattan-Birch, H; Brown, J; Shahab, L; Goniewicz, ML; Ma, CL; Wu, AD; Travis, N; Jarman, H; Livingstone-Banks, J; Lindson, N", "articleTypes": [], "doi": "10.1002/14651858.CD016220.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "fb6ae3d7-460b-4325-b7a4-38920b78637d", "pmid": "", "title": "Replacing salt with low‐sodium salt substitutes (LSSS) for cardiovascular health in adults, children and pregnant women", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Brand, A, Visser, ME, Schoonees, A, Naude, CE", "articleTypes": [], "doi": "10.1002/14651858.CD015207 AB - Abstract - Background Elevated blood pressure, or hypertension, is the leading cause of preventable deaths globally. Diets high in sodium (predominantly sodium chloride) and low in potassium contribute to elevated blood pressure. The WHO recommends decreasing mean population sodium intake through effective and safe strategies to reduce hypertension and its associated disease burden. Incorporating low‐sodium salt substitutes (LSSS) into population strategies has increasingly been recognised as a possible sodium reduction strategy, particularly in populations where a substantial proportion of overall sodium intake comes from discretionary salt. The LSSS contain lower concentrations of sodium through its displacement with potassium predominantly, or other minerals. Potassium‐containing LSSS can potentially simultaneously decrease sodium intake and increase potassium intake. Benefits of LSSS include their potential blood pressure‐lowering effect and relatively low cost. However, there are concerns about potential adverse effects of LSSS, such as hyperkalaemia, particularly in people at risk, for example, those with chronic kidney disease (CKD) or taking medications that impair potassium excretion. Objectives To assess the effects and safety of replacing salt with LSSS to reduce sodium intake on cardiovascular health in adults, pregnant women and children. Search methods We searched MEDLINE (PubMed), Embase (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection (Clarivate Analytics), Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCOhost), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) up to 18 August 2021, and screened reference lists of included trials and relevant systematic reviews. No language or publication restrictions were applied. Selection criteria We included randomised controlled trials (RCTs) and prospective analytical cohort studies in participants of any age in the general population, from any setting in any country. This included participants with non‐communicable diseases and those taking medications that impair potassium excretion. Studies had to compare any type and method of implementation of LSSS with the use of regular salt, or no active intervention, at an individual, household or community level, for any duration. Data collection and analysis Two review authors independently screened titles, abstracts and full‐text articles to determine eligibility; and extracted data, assessed risk of bias (RoB) using the Cochrane RoB tool, and assessed the certainty of the evidence using GRADE. We stratified analyses by adults, children (≤ 18 years) and pregnant women. Primary effectiveness outcomes were change in diastolic and systolic blood pressure (DBP and SBP), hypertension and blood pressure control; cardiovascular events and cardiovascular mortality were additionally assessed as primary effectiveness outcomes in adults. Primary safety outcomes were change in blood potassium, hyperkalaemia and hypokalaemia. Main results We included 26 RCTs, 16 randomising individual participants and 10 randomising clusters (families, households or villages). A total of 34,961 adult participants and 92 children were randomised to either LSSS or regular salt, with the smallest trial including 10 and the largest including 20,995 participants. No studies in pregnant women were identified. Studies included only participants with hypertension (11/26), normal blood pressure (1/26), pre‐hypertension (1/26), or participants with and without hypertension (11/26). This was unknown in the remaining studies. The largest study included only participants with an elevated risk of stroke at baseline. Seven studies included adult participants possibly at risk of hyperkalaemia. All 26 trials specifically excluded participants in whom an increased potassium intake is known to be potentially harmful. The majority of trials were conducted in rural or suburban settings, with more than half (14/26) conducted in low‐ and middle‐income countries. The proportion of sodium chloride replacement in the LSSS interventions varied from approximately 3% to 77%. The majority of trials (23/26) investigated LSSS where potassium‐containing salts were used to substitute sodium. In most trials, LSSS implementation was discretionary (22/26). Trial duration ranged from two months to nearly five years. We assessed the overall risk of bias as high in six trials and unclear in 12 trials. LSSS compared to regular salt in adults: LSSS compared to regular salt probably reduce DBP on average (mean difference (MD) ‐2.43 mmHg, 95% confidence interval (CI) ‐3.50 to ‐1.36; 20,830 participants, 19 RCTs, moderate‐certainty evidence) and SBP (MD ‐4.76 mmHg, 95% CI ‐6.01 to ‐3.50; 21,414 participants, 20 RCTs, moderate‐certainty evidence) slightly. On average, LSSS probably reduce non‐fatal stroke (absolute effect (AE) 20 fewer/100,000 person‐years, 95% CI ‐40 to 2; 21,250 participants, 3 RCTs, moderate‐certainty evidence), non‐fatal acute coronary syndrome (AE 150 fewer/100,000 person‐years, 95% CI ‐250 to ‐30; 20,995 participants, 1 RCT, moderate‐certainty evidence) and cardiovascular mortality (AE 180 fewer/100,000 person‐years, 95% CI ‐310 to 0; 23,200 participants, 3 RCTs, moderate‐certainty evidence) slightly, and probably increase blood potassium slightly (MD 0.12 mmol/L, 95% CI 0.07 to 0.18; 784 participants, 6 RCTs, moderate‐certainty evidence), compared to regular salt. LSSS may result in little to no difference, on average, in hypertension (AE 17 fewer/1000, 95% CI ‐58 to 17; 2566 participants, 1 RCT, low‐certainty evidence) and hyperkalaemia (AE 4 more/100,000, 95% CI ‐47 to 121; 22,849 participants, 5 RCTs, moderate‐certainty evidence) compared to regular salt. The evidence is very uncertain about the effects of LSSS on blood pressure control, various cardiovascular events, stroke mortality, hypokalaemia, and other adverse events (very‐low certainty evidence). LSSS compared to regular salt in children: The evidence is very uncertain about the effects of LSSS on DBP and SBP in children. We found no evidence about the effects of LSSS on hypertension, blood pressure control, blood potassium, hyperkalaemia and hypokalaemia in children. Authors' conclusions When compared to regular salt, LSSS probably reduce blood pressure, non‐fatal cardiovascular events and cardiovascular mortality slightly in adults. However, LSSS also probably increase blood potassium slightly in adults. These small effects may be important when LSSS interventions are implemented at the population level. Evidence is limited for adults without elevated blood pressure, and there is a lack of evidence in pregnant women and people in whom an increased potassium intake is known to be potentially harmful, limiting conclusions on the safety of LSSS in the general population. We also cannot draw firm conclusions about effects of non‐discretionary LSSS implementations. The evidence is very uncertain about the effects of LSSS on blood pressure in children. Plain language summary Does using low‐sodium salt substitutes (LSSS) instead of regular salt reduce blood pressure and heart disease risks, and is it safe? Key messages • In adults, using LSSS instead of regular salt in food probably lowers blood pressure slightly. Adults using LSSS instead of regular salt probably have a slightly lower risk of non‐fatal heart conditions, such as stroke or a sudden reduced blood flow to the heart, and death from heart disease. • Using LSSS instead of regular salt probably also slightly increases the level of blood potassium (a mineral that keeps your heart beating at the right pace) in adults. This could be harmful for people who cannot effectively regulate the potassium in their bodies. Other evidence on safety is very limited. • We are not certain about effects of using LSSS instead of regular salt on blood pressure in children, or whether using LSSS is safe in children. • This evidence may not directly apply to people known to be at risk of high blood potassium, such as people with kidney problems or on certain medications. What are low‐sodium salt substitutes (LSSS)? LSSS are products with less sodium than regular salt. Amounts of sodium in LSSS are lowered by replacing some of the sodium with potassium or other minerals. LSSS may help lower risks of using regular salt, since eating lots of sodium and not enough potassium contributes to high blood pressure. Globally, high blood pressure is the largest cause of preventable deaths, mainly because it causes stroke, acute coronary syndrome (ACS; where less blood flows to the heart), and kidney problems. However, LSSS also has potential health risks. Using LSSS may lead to higher than normal blood potassium (hyperkalaemia), which causes problems with the heartbeat speed and rhythm, or can cause the heart to stop. These risks are greater in certain people, for example, those whose kidneys do not work properly to remove potassium. What did we want to find out? We wanted to find out what the effects of using LSSS instead of regular salt are on blood pressure as well as on events (stroke and ACS) and heart disease death. We also wanted to know if using LSSS instead of regular salt is safe, both in the general population and in people who are known to be at risk of high blood potassium levels. We wanted to find this out for adults, children and pregnant women. What did we do? 
We searched five electronic databases and trial registries for studies that compared using LSSS with using regular salt. We compared and summarised the results of the studies and rated our confidence in the combined evidence, based on factors such as study methods and sizes. What did we find? We found 26 trials* involving 34,961 adults and 92 children. No studies in pregnant women were found. Most trials were undertaken in rural or suburban areas, with more than half done in low‐ and middle‐income countries. Most trials included some people with high blood pressure (22); the largest included only people with a high risk of stroke. Seven trials were done in people at possible risk of high blood potassium. All trials excluded people where high potassium intake is known to be harmful, such as people with kidney problems or on certain medications. Nearly all trials (23) examined LSSS types where some sodium was replaced with potassium. The amount of sodium replaced in the various LSSS used in the trials ranged from very small (3%) to large (77%). *Trials are types of studies in which participants are assigned randomly to two or more treatment groups. This is the best way to ensure similar groups of participants. Main results In adults, LSSS probably lowers blood pressure (diastolic and systolic) slightly when compared to regular salt. Using LSSS also probably lowers risk of non‐fatal stroke, non‐fatal ACS and heart disease death slightly when compared to regular salt. However, using LSSS instead of regular salt probably also slightly increases the level of potassium in the blood. Compared to regular salt, LSSS may result in little to no difference in high blood pressure and hyperkalaemia. We could not draw any conclusions about effects of LSSS on blood pressure control, various heart disease events, death caused by stroke, lower than normal blood potassium (hypokalaemia), and other adverse events. We could not draw any conclusions about the effects or safety of using LSSS instead of regular salt in children. What are the limitations of the evidence? We are moderately confident in the evidence. Our confidence was lowered mainly because of concerns about how some trials were conducted, and whether the results apply to the general population. We are not sure about the effects and safety of LSSS in children, pregnant women, people known to have a risk of high blood potassium, or those who do not have high blood pressure. We are also unsure about the effects of LSSS when used in foods not prepared at home. Further research may change these results. How up to date is this evidence? The evidence is up‐to‐date to August 2021.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.752Z" }, { "id": "fb7aae82-20d5-495f-87ab-1ec12feabae7", "pmid": "", "title": "Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months", "imported": false, "abstract": "Abstract - Background Bronchiolitis is one of the most common respiratory problems in the first year of life. The sputum of infants with bronchiolitis has increased deoxyribonucleic acid (DNA) content, leading to mucous plugging and airway obstruction. Recombinant human deoxyribonuclease (rhDNase), an enzyme that digests extracellular DNA, might aid the clearance of mucus and relieve peripheral airway obstruction. Objectives To determine the effect of nebulised rhDNase on the severity and duration of viral bronchiolitis in children younger than 24 months of age in the hospital setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 7 which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July Week 4, 2012), EMBASE (1974 to August 2012) and LILACS (1982 to August 2012). Selection criteria Randomised controlled trials (RCTs) using nebulised rhDNase alone or with concomitant therapy in children younger than 24 months of age hospitalised with acute bronchiolitis. Data collection and analysis Two review authors independently performed literature searches, assessed trial quality and extracted data. We obtained unpublished data from trial authors. We used Review Manager 5.1 to pool treatment effects expressed as the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI). Main results Three RCTs (333 participants) were identified, two of which were multicentre trials comprising only participants positive for respiratory syncytial virus (RSV). The other trial enrolled participants clinically diagnosed with bronchiolitis from a hospital in Italy. All studies used 2.5 mL (1 mg/mL) of nebulised rhDNase compared with placebo either as a daily or a twice daily dose. Adjunctive therapy included nebulised salbutamol, steroids, supplemental oxygen, intravenous fluids or tube feeding, nasal washing, nasal decongestants and antibiotics. Overall, nebulised rhDNase showed no benefit in clinically meaningful outcomes. Meta‐analysis favoured the control group with a shorter duration of hospital stay (MD 0.50; 95% CI 0.10 to 0.90, P = 0.01) and better clinical score improvement (SMD ‐0.24; 95% CI ‐0.50 to 0.01, P = 0.06). The largest trial showed no difference in supplemental oxygen use or intensive care unit (ICU) admission. In one RCT, four out of 11 patients in the treatment group had atelectasis. Two of these patients showed distinctive clinical improvement after nebulised rhDNase. There was no significant difference in adverse events. These included temporary desaturation, temporary coughing, increased coughing, facial rash, hoarseness, dyspnoea and bad taste, reported in a total of 11 patients from both treatment groups. Authors' conclusions The results based on the three included studies in this review did not support the use of nebulised rhDNase in children under 24 months of age hospitalised with acute bronchiolitis. In these patients, treatment did not shorten the length of hospitalisation or improve clinical outcomes. It might have a role in severe bronchiolitis complicated by atelectasis, but further clinical studies would need to be performed. Plain language summary Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months Bronchiolitis is the most common respiratory illness leading to hospitalisations in infants. Viral infections, particularly respiratory syncytial virus, are the usual cause, which lead to blockage of the small airways of the lungs due to inflammation and increased mucus production. Afflicted children have fever, cough, wheezing and difficulty breathing. Treatment is usually supportive. In bronchiolitis, the mucus produced contains large amounts of DNA, which makes it thicker and stickier. Removal of this DNA facilitates clearance of the mucus. RhDNase is an enzyme that breaks down DNA and hence may improve symptoms. We performed this review to assess the effect of rhDNase delivered through a nebuliser in children under 24 months old hospitalised for bronchiolitis. We identified three randomised controlled trials involving 333 children up to 24 months of age hospitalised with bronchiolitis. All three studies compared nebulised rhDNase with placebo. Any additional treatments were given to both groups. Overall, the studies did not show that nebulised rhDNase shortened the duration of hospital admission, or improved the severity of symptoms. No serious side effects were reported by any of the studies. One study showed that in patients suffering from atelectasis, a severe complication of bronchiolitis wherein the lung does not expand completely, nebulised rhDNase treatment resulted in a distinct improvement within two days. To confirm this beneficial effect, further clinical studies in patients with severe bronchiolitis are needed. Currently, the use of this treatment in young children hospitalised with bronchiolitis is not recommended.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Enriquez, A, Chu, IW, Mellis, C, Lin, WY", "articleTypes": [], "doi": "10.1002/14651858.CD008395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.783Z" }, { "id": "fb803ce0-f9d8-41d1-87e6-cbbc64bd52c0", "pmid": "", "title": "Souvenaid for Alzheimer's disease", "imported": false, "abstract": "Abstract - Background Souvenaid is a dietary supplement with a patented composition (Fortasyn Connect™)which is intended to be used by people with Alzheimer's disease (AD). It has been designed to support the formation and function of synapses in the brain, which are thought to be strongly correlated with cognitive function. If effective, it might improve symptoms of Alzheimer's disease and also prevent the progression from prodromal Alzheimer's disease to dementia. We sought in this review to examine the evidence for this proposition. Objectives To assess the effects of Souvenaid on incidence of dementia, cognition, functional performance, and safety in people with Alzheimer's disease. Search methods We searched ALOIS, i.e. the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science (ISI Web of Science), Cinahl (EBSCOhost), Lilacs (BIREME), and clinical trials registries up to 24 June 2020. We also reviewed citations of reference lists of landmark papers, reviews, and included studies for additional studies and assessed their suitability for inclusion in the review. Selection criteria We included randomised, placebo‐controlled trials which evaluated Souvenaid in people diagnosed with mild cognitive impairment (MCI) due to AD (also termed prodromal AD) or with dementia due to AD, and with a treatment duration of at least 16 weeks. Data collection and analysis Our primary outcome measures were incidence of dementia, global and specific cognitive function, functional performance, combined cognitive‐functional outcomes and adverse events. We selected studies, extracted data, assessed the quality of trials and intended to conduct meta‐analyses according to the Cochrane Handbook for Systematic Reviews of Interventions . We rated the quality of the evidence using the GRADE approach. We present all outcomes grouped by stage of AD. Main results We included three randomised, placebo‐controlled trials investigating Souvenaid in 1097 community‐dwelling participants with Alzheimer's disease. One study each included participants with prodromal AD, mild AD dementia and mild‐to‐moderate AD dementia. We rated the risks of bias of all trials as low. One study (in prodromal AD) was funded by European grants. The other two studies were funded by the manufacturer of Souvenaid. One trial investigated the incidence of dementia in people with prodromal AD at baseline, and found little to no difference between the Souvenaid group and the placebo group after 24 months (RR 1.09, 95% CI 0.82 to 1.43; 1 trial, 311 participants; moderate quality of evidence). In prodromal AD, and in mild and mild‐to‐moderate Alzheimer's disease dementia, Souvenaid probably results in little or no difference in global or specific cognitive functions (moderate quality of evidence). Everyday function, or the ability to perform activities of daily living, were measured in mild and mild‐to‐moderate AD dementia. Neither study found evidence of a difference between the groups after 24 weeks of treatment (moderate quality of evidence). Two studies investigated combined cognitive‐functional outcomes with the Clinical Dementia Rating Sum of Boxes and observed conflicting results. Souvenaid probably results in slight improvement, which is below estimates of meaningful change, in participants with prodromal Alzheimer's disease after 24 months (moderate quality of evidence), but probably has little to no effect in mild‐to‐moderate Alzheimer's disease dementia after 24 weeks (moderate quality of evidence). Adverse effects observed were low in all trials, and the available data were insufficient to determine any connection with Souvenaid. Authors' conclusions Two years of treatment with Souvenaid probably does not reduce the risk of progression to dementia in people with prodromal AD. There is no convincing evidence that Souvenaid affects other outcomes important to people with AD in the prodromal stage or mild‐to‐moderate stages of dementia. Conflicting evidence on combined cognitive‐functional outcomes in prodromal AD and mild AD dementia warrants further investigation. Adverse effects of Souvenaid seem to be uncommon, but the evidence synthesised in this review does not permit us to make a definitive statement on the long‐term tolerability of Souvenaid. The effects of Souvenaid in more severe AD dementia or in people with AD at risk of nutritional deficiencies remain unclear. Plain language summary The dietary supplement Souvenaid for preventing dementia or delaying cognitive decline in people with Alzheimer's disease Review question We investigated whether people with mild cognitive impairment (MCI) due to Alzheimer's disease (AD) can reduce their risk of developing dementia with a patented dietary supplement called Souvenaid. We also investigated the effect of Souvenaid on memory or other thinking skills, ability to carry out daily activities, and side effects in people with MCI or any stage of dementia due to AD. Background Alzheimer's disease is a brain disease. It is the commonest cause of dementia among older people. A person is said to have dementia when there has been a decline in their memory and thinking skills which is severe enough to stop them being fully independent in all their daily activities. Because AD develops slowly, it is also possible to pick up symptoms before dementia is fully developed. This pre‐dementia stage, when people with AD have a detectable decline in memory and thinking skills but are still able to manage their usual activities independently, is known as mild cognitive impairment due to AD, or 'prodromal' AD. Souvenaid is a patented mix of vitamins and minerals (Fortasyn Connect™) which was designed to improve brain function in AD. It is a drink which is to be taken once a day. It is intended to be consumed under medical supervision, in addition to the usual diet. Search for evidence We systematically searched for randomised controlled trials (RCTs) which were published up to June 2020 and which compared treatment with Souvenaid for at least 16 weeks with treatment with a dummy supplement (a placebo). For the comparison to be fair, it had to be decided randomly whether each participant was given Souvenaid or the placebo. Key results We found three RCTs with a total of 1097 participants to include in the review. Two of the trials investigated Souvenaid in people with dementia over a treatment period of 24 weeks. One of these included 527 participants with mild‐to‐moderate dementia due to AD and the other included 259 participants with mild dementia due to AD. The third trial investigated the use of Souvenaid for two years in 311 people with prodromal AD. We considered all of the trials to be well‐designed, but because of differences between them in the severity of the participants' symptoms and in the way the researchers measured their results, we were not able to combine the data numerically from the single trials. All the results we report are therefore based on single trials, which leads us to have only moderate confidence in the findings of this review. This means that results could be changed by further research. We found that people with prodromal AD who took Souvenaid daily for two years were probably no more or less likely than those taking placebo to develop dementia. Souvenaid probably had little or no effect on measures of memory or other thinking skills in people with prodromal AD (after two years of treatment) or with mild or mild‐to‐moderate dementia due to AD (after 24 weeks of treatment). It also probably had little or no effect on the ability of people with mild or mild‐to‐moderate dementia due to AD to manage everyday activities (again after 24 weeks). Two studies used an outcome scale which combined memory and thinking skills with practical skills (described as a combined cognitive‐functional outcome). There was probably a small benefit of Souvenaid on this outcome among people with prodromal AD who took Souvenaid for two years. However, there was probably little or no effect of Souvenaid on this outcome among people with mild‐to‐moderate AD dementia who took it for 24 weeks. There were only a few adverse events reported in the trials, and it was not possible to know whether any of them were side effects of Souvenaid. Study funding sources Two studies were funded by the manufacturer of Souvenaid. The third study (in prodromal AD) was funded by European grants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Burckhardt, M; Watzke, S; Wienke, A; Langer, G; Fink, A", "articleTypes": [], "doi": "10.1002/14651858.CD011679.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "fb8c3600-61df-452c-bb2e-01b31523bef7", "pmid": "", "title": "Interventions for improving adherence to ocular hypotensive therapy", "imported": false, "abstract": "Abstract - Background Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open‐angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence. Objectives To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) ( The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) ( www.opengrey.eu/ ), the meta Register of Controlled Trials ( m RCT) ( www.controlled‐trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and the WHO International Clinical Trials Registry Platform (ICTRP) ( www.who.int/ictrp/search/en ). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma. Data collection and analysis At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity. Main results Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow‐up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross‐over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive. Authors' conclusions Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes. Plain language summary Interventions for helping people use eye drops as prescribed for raised eye pressure or glaucoma A large number of people do not use eye drops as prescribed. Glaucoma is a slowly progressive eye disease, which can result in severe vision loss. Drops prescribed for raised eye pressure or glaucoma are aimed at lowering the pressure to assist in reducing the rate of progression, or preventing the conversion of raised eye pressure to glaucoma. It is important that these eye drops are used continually, usually for life. Approximately one‐third of people who are prescribed eye drops for the first time fail to continue collecting prescriptions within the first year and even when patients collect prescriptions they do not always use the drops as frequently as they should. A number of reasons are thought to be the cause, for example, forgetfulness, being prescribed a large number of medications, difficulties instilling drops, lack of knowledge about glaucoma, a busy lifestyle and seeing no benefit. This review is based on 16 studies (1565 participants) that tried out different methods to help people to use drops as prescribed. All the studies took place in industrialised countries (Belgium, Denmark, France, Greece, Iceland, Japan, Sweden, Switzerland, UK and USA) and recruited participants in outpatient clinics. The following interventions were included: simplifying drop routines, reminder devices, automated telephone service, providing information about glaucoma and offering advice regarding day to day issues with eye care. Those studies which combined the provision of information about glaucoma and eye drops with other interventions, such as helping people to fit instillation of eye drops into their daily routine, appear to be more successful. Unfortunately, not all of these studies were of high quality and, therefore, until more evidence is available we cannot recommend any particular method. Good quality research is needed in this area in order to develop a better understanding of patients' individual needs and to help us provide more effective eye care services.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Waterman, H; Evans, JR; Gray, TA; Henson, D; Harper, R", "articleTypes": [], "doi": "10.1002/14651858.CD006132.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.081Z" }, { "id": "fba661ac-cf48-4ae6-9409-2d8a1e724e9b", "pmid": "", "title": "Anticoagulation for people receiving long‐term haemodialysis", "imported": false, "abstract": "Abstract - Background Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding. Objectives To assess the efficacy and safety of anticoagulation strategies (including both heparin and non‐heparin drugs) for long‐term HD in people with kidney failure. Any intervention preventing clotting within the extracorporeal circuit without establishing anticoagulation within the patient, such as regional citrate, citrate enriched dialysate, heparin‐coated dialysers, pre‐dilution haemodiafiltration (HDF), and saline flushes were also included. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to November 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐randomised controlled studies (quasi‐RCTs) evaluating anticoagulant agents administered during HD treatment in adults and children with kidney failure. Data collection and analysis Two authors independently assessed the risk of bias using the Cochrane tool and extracted data. Treatment effects were estimated using random effects meta‐analysis and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE). Main results We included 113 studies randomising 4535 participants. The risk of bias in each study was adjudicated as high or unclear for most risk domains. Compared to UFH, LMWH had uncertain effects on extracorporeal circuit thrombosis (3 studies, 91 participants: RR 1.58, 95% CI 0.46 to 5.42; I 2 = 8%; low certainty evidence), while major bleeding and minor bleeding were not adequately reported. Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH (2 studies, 82 participants: RR 0.34, 95% CI 0.14 to 0.85; I 2 = 0%; low certainty evidence). No studies reported data comparing regional citrate to UFH on risks of extracorporeal circuit thrombosis and major bleeding. The effects of very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors or heparin‐grafted membranes were uncertain due to insufficient data. The effects of different LMWH, different doses of LMWH, and the administration of LMWH anticoagulants using inlet versus outlet bloodline or bolus versus infusion were uncertain. Evidence to compare citrate to another citrate or control was scant. The effects of UFH compared to no anticoagulant therapy or different doses of UFH were uncertain. Death, dialysis vascular access outcomes, blood transfusions, measures of anticoagulation effect, and costs of interventions were rarely reported. No studies evaluated the effects of treatment on non‐fatal myocardial infarction, non‐fatal stroke and hospital admissions. Adverse events were inconsistently and rarely reported. Authors' conclusions Anticoagulant strategies, including UFH and LMWH, have uncertain comparative risks on extracorporeal circuit thrombosis, while major bleeding and minor bleeding were not adequately reported. Regional citrate may decrease minor bleeding, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported. Evidence supporting clinical decision‐making for different forms of anticoagulant strategies for HD is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes. Plain language summary Treatments to thin the blood during haemodialysis: which treatments reduce clotting problems without causing bleeding? What is the issue? When people have dialysis using a machine to clean their blood (called haemodialysis (HD)), blood‐thinning treatment helps prevent blood clots in the dialysis tubing. However, thinning the blood too much with treatment can lead to bleeding problems. There are several different medications to thin the blood, but it is not clear which is the best or the safest choice. What did we do? We searched for all the research trials that assessed the blood thinning treatments during HD for adults and children up until November 2023. We measured the certainty we could have about the results of this research using \"GRADE\". What did we find? We found 113 studies involving 4535 patients treated with HD. Patients were given different forms of blood thinning therapy. The treatment they got was decided by random chance (like the toss of a coin). Most of the studies looked at a treatment called \"low molecular weight heparin\" and compared this with standard blood thinning care (called \"standard heparin\"). Unfortunately, the studies included only a small number of patients and only looked for risks of clotting or bleeding during one or two months of therapy. Because of this short time frame, and other limitations of the research studies, we were very uncertain about the results. The current research doesn't tell us whether one blood thinning treatment is better or safer than another for patients during dialysis treatment. Conclusions We still can't be certain about the best way to thin the blood for HD treatment based on existing research.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Natale, P, Palmer, SC, Ruospo, M, Longmuir, H, Dodds, B, Prasad, R, Batt, TJ, Jose, MD, Strippoli, GFM", "articleTypes": [], "doi": "10.1002/14651858.CD011858.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.767Z" }, { "id": "fbaaa831-f044-4c2d-b8d9-e7374563f527", "pmid": "", "title": "Anticholinergic therapy for chronic asthma in children over two years of age", "imported": false, "abstract": "Abstract - Background In the intrinsic system of controlling airway calibre, the cholinergic (muscarinic) sympathetic nervous system has an important role. Anticholinergic, anti muscarinic bronchodilators such as ipratropium bromide are frequently used in the management of childhood airway disease. In asthma, ipratropium is a less potent bronchodilator than beta‐2 adrenergic agents but it is known to be a useful adjunct to other therapies, particularly in status asthmaticus. What remains unclear is the role of anticholinergic drugs in the maintenance treatment of chronic asthma. Objectives To determine the effectiveness of anticholinergic drugs in chronic asthma in children over the age of 2 years. Search methods The Cochrane Airways Group Specialised Register and reference lists of articles were searched. The most recent search was carried out in Febuary 2010. Selection criteria Randomised controlled trials in which anticholinergic drugs were given for chronic asthma in children over 2 years of age were included. Studies including comparison of: anticholinergics with placebo, and anticholinergics with any other drug were included. Data collection and analysis Eligibility for inclusion and quality of trials were assessed independently by two reviewers. Main results Eight studies met the inclusion criteria. Three papers compared the effects of anticholinergic drugs with placebo, and a meta‐analysis of these results demonstrated no statistically significant benefit of the use of anticholinergic drugs over placebo in any of the outcome measures used. The results of one of these trials could not be included in the meta‐analysis but the authors did report significantly lower symptom scores with inhaled anticholinergics compared with placebo. However, there was no significant difference between ipratropium bromide and placebo in the percentage of symptom‐free nights or days. Two trials studied the effects of anticholinergics on bronchial hyper responsiveness to histamine, by measuring the provocation dose of histamine needed to cause a fall of 20 % in FEV1 (PD 20). One study (comparing anticholinergics with placebo) reported a statistically significant increase in PD 20 but this was not found in another study (comparing anticholinergics with a beta‐2 agonist). Both trials also examined the effect of anticholinergic drugs on diurnal variation in peak expiratory flow rate (PEFR) and reported no significant effect. Two studies compared the addition of an anticholinergic drug to a beta‐2 agonist with the beta‐2 agonist alone. Both trials failed to show any significant benefit from the long term use of combined anticholinergics with beta‐2 agonists compared with beta‐2 agonists alone. One trial compared the effects of oral and inhaled anticholinergic drugs with placebo. No statistically significant differences were found in any of the outcome measures except for a higher FEV1 / VC ratio and RV / TLC ratio with oral anticholinergic therapy when compared with placebo. Authors' conclusions The present review summarises the best evidence available to date. Although there were some small beneficial findings in favour of anticholinergic therapy, there is insufficient data to support the use of anticholinergic drugs in the maintenance treatment of chronic asthma in children. Plain language summary Anticholinergic drugs versus either placebo or other medications for children over two years of age with asthma Anticholinergic drugs are widely used in the management of both acute and chronic asthma in children. Their effect is achieved through relief of narrowing of the airways that occurs in asthma. Current guidelines for the management of chronic asthma advise that anticholinergic drugs may be used if children are already on high dose inhaled steroids. This study undertook a comprehensive search of the literature unrestricted by country of publication or language. Unfortunately small numbers of relevant trials were found and these were of variable quality. This review found that although anticholinergic drugs are well tolerated, in children over two years of age, there is not enough data to be sure if they are better than placebo in terms of effects on lung function or symptoms.", "journal": "Cochrane Database of Systematic Reviews", "year": "2003", "authors": "McDonald, N; Bara, A; McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD003535", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.063Z" }, { "id": "fbb164d9-40f1-4dbd-ac0d-7f748b1a9778", "pmid": "", "title": "Interventions for managing halitosis", "imported": false, "abstract": "Abstract - Background Halitosis or bad breath is a symptom in which a noticeably unpleasant breath odour is present due to an underlying oral or systemic disease. 50% to 60% of the world population has experienced this problem which can lead to social stigma and loss of self‐confidence. Multiple interventions have been tried to control halitosis ranging from mouthwashes and toothpastes to lasers. This new Cochrane Review incorporates Cochrane Reviews previously published on tongue scraping and mouthrinses for halitosis. Objectives The objectives of this review were to assess the effects of various interventions used to control halitosis due to oral diseases only. We excluded studies including patients with halitosis secondary to systemic disease and halitosis‐masking interventions. Search methods Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 April 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3) in the Cochrane Library (searched 8 April 2019), MEDLINE Ovid (1946 to 8 April 2019), and Embase Ovid (1980 to 8 April 2019). We also searched LILACS BIREME (1982 to 19 April 2019), the National Database of Indian Medical Journals (1985 to 19 April 2019), OpenGrey (1992 to 19 April 2019), and CINAHL EBSCO (1937 to 19 April 2019). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (8 April 2019), the World Health Organization International Clinical Trials Registry Platform (8 April 2019), the ISRCTN Registry (19 April 2019), the Clinical Trials Registry ‐ India (19 April 2019), were searched for ongoing trials. We also searched the cross‐references of included studies and systematic reviews published on the topic. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials (RCTs) which involved adults over the age of 16, and any intervention for managing halitosis compared to another or placebo, or no intervention. The active interventions or controls were administered over a minimum of one week and with no upper time limit. We excluded quasi‐randomised trials, trials comparing the results for less than one week follow‐up, and studies including advanced periodontitis. Data collection and analysis Two pairs of review authors independently selected trials, extracted data, and assessed risk of bias. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach. Main results We included 44 trials in the review with 1809 participants comparing an intervention with a placebo or a control. The age of participants ranged from 17 to 77 years. Most of the trials reported on short‐term follow‐up (ranging from one week to four weeks). Only one trial reported long‐term follow‐up (three months). Three studies were at low overall risk of bias, 16 at high overall risk of bias, and the remaining 25 at unclear overall risk of bias. We compared different types of interventions which were categorised as mechanical debridement, chewing gums, systemic deodorising agents, topical agents, toothpastes, mouthrinse/mouthwash, tablets, and combination methods. Mechanical debridement: for mechanical tongue cleaning versus no tongue cleaning, the evidence was very uncertain for the outcome dentist‐reported organoleptic test (OLT) scores (MD ‐0.20, 95% CI ‐0.34 to ‐0.07; 2 trials, 46 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Chewing gums: for 0.6% eucalyptus chewing gum versus placebo chewing gum, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.10, 95% CI ‐0.31 to 0.11; 1 trial, 65 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Systemic deodorising agents: for 1000 mg champignon versus placebo, the evidence was very uncertain for the outcome patient‐reported visual analogue scale (VAS) scores (MD ‐1.07, 95% CI ‐14.51 to 12.37; 1 trial, 40 participants; very low‐certainty evidence). No data were reported for dentist‐reported OLT score or adverse events. Topical agents: for hinokitiol gel versus placebo gel, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.27, 95% CI ‐1.26 to 0.72; 1 trial, 18 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Toothpastes: for 0.3% triclosan toothpaste versus control toothpaste, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐3.48, 95% CI ‐3.77 to ‐3.19; 1 trial, 81 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Mouthrinse/mouthwash: for mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, the evidence was very uncertain for the outcome dentist‐reported OLT scores (MD ‐0.20, 95% CI ‐0.58 to 0.18; 1 trial, 44 participants; very low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Tablets: no data were reported on key outcomes for this comparison. Combination methods: for brushing plus cetylpyridium mouthwash versus brushing, the evidence was uncertain for the outcome dentist‐reported OLT scores (MD ‐0.48, 95% CI ‐0.72 to ‐0.24; 1 trial, 70 participants; low‐certainty evidence). No data were reported for patient‐reported OLT score or adverse events. Authors' conclusions We found low‐ to very low‐certainty evidence to support the effectiveness of interventions for managing halitosis compared to placebo or control for the OLT and patient‐reported outcomes tested. We were unable to draw any conclusions regarding the superiority of any intervention or concentration. Well‐planned RCTs need to be conducted by standardising the interventions and concentrations. Plain language summary Interventions for managing bad breath Review question With this Cochrane Review we tried to find out the best way to control bad breath, also called halitosis, due to a disease within the mouth in adults. Background Bad breath or halitosis is caused by too much bacteria or small food parts left inside the mouth, most commonly at the back of the tongue. It can be a sign of a disease within the mouth or other body diseases. People with bad breath can have low self‐esteem and feel embarrassed. It can affect their personal relationships and work. In this review, we looked at treatments for bad breath due to a disease within the mouth and at treatments that aim to control not just mask bad breath. Study characteristics This review is up‐to‐date as of 8 April 2019. The review includes 44 studies involving 1809 people who were 17 to 77 years old. The review compared an intervention with another intervention, a placebo or a control. It looked at eight different ways to control bad breath: mechanical cleaning (e.g. tongue cleaners and toothbrushes), chewing gums, systemic deodorising agents (e.g. mushroom extract that you eat), topical agents (e.g. gel that you apply), toothpastes, mouthrinse/mouthwash, tablets, and combination of different treatments. Key results The evidence was very uncertain for mechanical tongue cleaning versus no tongue cleaning, 0.6% eucalyptus chewing gum versus placebo chewing gum, 1000 mg mushroom extract versus placebo, hinokitiol gel versus placebo gel, 0.3% triclosan toothpaste versus control toothpaste, mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, and brushing plus cetylpyridium mouthwash versus brushing. Harmful effects of the different interventions were not reported or were not important. Certainty of the evidence The level of certainty we have in these findings is low to very low. This was due mainly to risk of bias and the small number of people studied in the included trials. Conclusion We do not have enough evidence to say which intervention works better to control bad breath.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Kumbargere Nagraj, S; Eachempati, P; Uma, E; Singh, VP; Ismail, NM; Varghese, E", "articleTypes": [], "doi": "10.1002/14651858.CD012213.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.061Z" }, { "id": "fbcadc98-ee26-4443-89dd-80fd060b7546", "pmid": "", "title": "External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta‐analysis", "imported": false, "abstract": "Abstract - Background Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion). Objectives To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. Search methods We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index‐Science (CPCI‐S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. Selection criteria We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. Data collection and analysis We used standard Cochrane methodology to collect data and performed a network meta‐analysis using the standard frequentist graph‐theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption. Main results We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy‐nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow‐up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low‐certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow‐up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled. Authors' conclusions Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method. Plain language summary Electrical shocks (electrical cardioversion) and drugs (pharmacological cardioversion) for restoring normal rhythm in patients with atrial fibrillation or atrial flutter Key Messages ‐ Electrical cardioversion and some drugs can be used to restore the normal rhythm in patients with atrial fibrillation (AF) and atrial flutter. While electrical cardioversion is highly effective in dealing with all arrhythmias, the efficacy of drugs varies, with some being only moderately effective or not working at all in persistent AF and atrial flutter. ‐ Electrical cardioversion seems to be a very safe option. The risk of severe complications with cardioversion using drugs was low, but additional precautions are needed. ‐ We need further studies to find out if these treatment options also have a positive effect on quality of life, or if they lead to relevant differences in the duration of hospital stay. What is atrial fibrillation? AF is the most frequent abnormal heart rhythm seen in the world. Patients with this condition may feel their heart beating rapidly and irregularly. This can occur for separate brief or long episodes (paroxysmal AF) or it may become continuous (persistent AF). Atrial flutter is a similar abnormal rhythm that causes similar symptoms, can cause episodes of variable duration and can also become continuous. What is cardioversion? Cardioversion is a treatment to restore the rhythm of the heart back to normal (sinus rhythm). What did we want to find out? We wanted to know if delivering a controlled electrical shock (i.e. electrical cardioversion) and drugs (i.e. pharmacological cardioversion) are effective and safe when restoring heart rhythm back to normal. What did we do? We searched for studies that investigated electrical and pharmacological cardioversion compared to each other or placebo (a medicine that looks like the real medicine but that has no active ingredient). We compared and summarised the results of the studies and rated our trust in these results, based on factors such as study methods and size. What did we find? We found 112 studies. We were able to combine and analyse the results from 72 studies, with 15,968 participants aged between 47 and 72 years. Thirty‐five studies included patients with paroxysmal AF (AF that terminates spontaneously or with intervention within 7 days of onset), 26 studies of patients with persistent AF (AF that is continuously sustained beyond seven days, including episodes terminated by cardioversion after ≥ 7 days), and 14 trials included patients with atrial flutter. The remaining included a mix of paroxysmal, persistent AF and atrial flutter. Main results For patients with paroxysmal AF, electrical cardioversion with biphasic incremental energy, fast‐acting drugs like intravenous vernakalant, flecainide, ibutilide and antazoline, and slower‐acting and/or oral drugs such as quinidine, propafenone, amiodarone and sotalol are effective at restoring sinus rhythm. For patients with persistent AF, electrical cardioversion with biphasic energy seems to be the most effective option; bepridil, quinidine and amiodarone tablets may also be effective in selected cases. For patients with atrial flutter, electrical cardioversion followed by dofetilide are the most effective options. The risk of death and stroke is very low for patients having cardioversion procedures. Malignant arrhythmias (torsade de pointes, sustained ventricular tachycardia or ventricular fibrillation, all of which are associated with high 1‐year mortality rate) were observed for dofetilide, ibutilide, sotalol, quinidine and vernakalant, justifying the need for special care and closer monitoring when using these drugs. Duration of hospitalisation data was available in three studies but, as there were variable timings in these studies, we could not combine them to assess their joint effectiveness. These studies suggest that the duration of hospitalisation may be lower with electrical cardioversion. Heart failure was observed in some patients treated with propafenone, flecainide, sotalol, amiodarone, vernakalant, and placebo, and was not observed in patients receiving electrical cardioversion, suggesting that the latter approach should be the preferred one if concerns exist regarding the occurrence of this outcome. Phlebitis (i.e. inflammation of the vein caused by using injectable drugs) occurred frequently in patients treated with amiodarone, and dysgeusia (i.e. impairment of the sense of taste) and sneezing occurred frequently in patients receiving vernakalant. What are the limitations of the observed results? We are sure or moderately sure of the results for the efficacy of treatments available for persistent AF and atrial flutter. We are less sure about the results for some of the treatment options for paroxysmal AF. Not enough data are available regarding quality of life, and data were limited regarding duration of hospital stay. The risk of stroke or dying was very low. How up to date are the studies and information on this review? The included studies and information are current to February 2023.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Kukendrarajah, K, Ahmad, M, Carrington, M, Ioannou, A, Taylor, J, Razvi, Y, Papageorgiou, N, Mead, GE, Nevis, IF, D'Ascenzo, F, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013255.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.825Z" }, { "id": "fbd3ac36-7627-47a8-83f5-e6dc8e3e2e72", "pmid": "", "title": "Point‐of‐use fortification of foods with micronutrient powders containing iron in children of preschool and school‐age", "imported": false, "abstract": "Abstract - Background Approximately 600 million children of preschool and school age are anaemic worldwide. It is estimated that at least half of the cases are due to iron deficiency. Point‐of‐use fortification of foods with micronutrient powders (MNP) has been proposed as a feasible intervention to prevent and treat anaemia. It refers to the addition of iron alone or in combination with other vitamins and minerals in powder form, to energy‐containing foods (excluding beverages) at home or in any other place where meals are to be consumed. MNPs can be added to foods either during or after cooking or immediately before consumption without the explicit purpose of improving the flavour or colour. Objectives To assess the effects of point‐of‐use fortification of foods with iron‐containing MNP alone, or in combination with other vitamins and minerals on nutrition, health and development among children at preschool (24 to 59 months) and school (five to 12 years) age, compared with no intervention, a placebo or iron‐containing supplements. Search methods In December 2016, we searched the following databases: CENTRAL, MEDLINE, Embase, BIOSIS, Science Citation Index, Social Science Citation Index, CINAHL, LILACS, IBECS, Popline and SciELO. We also searched two trials registers in April 2017, and contacted relevant organisations to identify ongoing and unpublished trials. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs trials with either individual or cluster randomisation. Participants were children aged between 24 months and 12 years at the time of intervention. For trials with children outside this age range, we included studies where we were able to disaggregate the data for children aged 24 months to 12 years, or when more than half of the participants were within the requisite age range. We included trials with apparently healthy children; however, we included studies carried out in settings where anaemia and iron deficiency are prevalent, and thus participants may have had these conditions at baseline. Data collection and analysis Two review authors independently assessed the eligibility of trials against the inclusion criteria, extracted data from included trials, assessed the risk of bias of the included trials and graded the quality of the evidence. Main results We included 13 studies involving 5810 participants from Latin America, Africa and Asia. We excluded 38 studies and identified six ongoing/unpublished trials. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. No trials compared the effects of MNP versus iron‐containing supplements (as drops, tablets or syrup). The sample sizes in the included trials ranged from 90 to 2193 participants. Six trials included participants younger than 59 months of age only, four included only children aged 60 months or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. The iron doses varied from 2.5 mg to 30 mg of elemental iron. Four trials reported giving 10 mg of elemental iron as sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), chelated ferrous sulphate or microencapsulated ferrous fumarate. Three trials gave 12.5 mg of elemental iron as microencapsulated ferrous fumarate. Three trials gave 2.5 mg or 2.86 mg of elemental iron as NaFeEDTA. One trial gave 30 mg and one trial provided 14 mg of elemental iron as microencapsulated ferrous fumarate, while one trial gave 28 mg of iron as ferrous glycine phosphate. In comparison with receiving no intervention or a placebo, children receiving iron‐containing MNP for point‐of‐use fortification of foods had lower risk of anaemia prevalence ratio (PR) 0.66, 95% confidence interval (CI) 0.49 to 0.88, 10 trials, 2448 children; moderate‐quality evidence) and iron deficiency (PR 0.35, 95% CI 0.27 to 0.47, 5 trials, 1364 children; moderate‐quality evidence) and had higher haemoglobin (mean difference (MD) 3.37 g/L, 95% CI 0.94 to 5.80, 11 trials, 2746 children; low‐quality evidence). Only one trial with 115 children reported on all‐cause mortality (zero cases; low‐quality evidence). There was no effect on diarrhoea (risk ratio (RR) 0.97, 95% CI 0.53 to 1.78, 2 trials, 366 children; low‐quality evidence). Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children. However, information on mortality, morbidity, developmental outcomes and adverse effects is still scarce. Plain language summary Powdered vitamins and minerals added to foods at the point‐of‐use reduces anaemia and iron deficiency in preschool‐ and school‐age children Background to the question Approximately one billion people worldwide are deficient in at least one vitamin or mineral (also known of micronutrients). Iron, vitamin A, zinc and iodine deficiencies are very frequent among children of preschool (aged 24 months to less than 5 years) and school age (5 to 12 years of age), limiting their health and daily physical performance. Anaemia, the condition in which red blood cells have limited capacity to carry oxygen, frequently results after prolonged iron deficiency. Point‐of‐use fortification with powdered vitamins and minerals has been proposed as a public health intervention to reduce micronutrient deficiencies in children. In this process, a powdered premix containing iron, and possibly other vitamins and minerals, is added to foods either during or after cooking, or immediately before consumption to improve their nutritious value but not their flavour or colour. In some cases, point‐of‐use fortification is also known as home fortification. Review question What are the effects of point‐of‐use fortification of foods with iron‐containing micronutrient powders (MNP) alone, or in combination with other vitamins and minerals, on nutrition, health and development among children of preschool and school age (24 months to 12 years of age) compared with no intervention, a placebo (dummy pill) or regular iron‐containing supplements (as drops, tablets or syrup)? Study characteristics This review included 13 trials with 5810 participants from Latin America, Africa and Asia. All trials compared the provision of MNP for point‐of‐use fortification with no intervention or placebo. Six trials included participants younger than 59 months of age only, four included only children aged 60 months of age or older, and three trials included children both younger and older than 59 months of age. MNPs contained from two to 18 vitamins and minerals. We searched existing clinical trials in December 2016 and ongoing trials in April 2017. We also contacted relevant institutions for additional information upon publication of the protocol and in April 2017. Key results The review found that children receiving iron‐containing MNP for point‐of‐use fortification of foods were at significantly lower risk of having anaemia and iron deficiency and had higher haemoglobin concentrations. We did not find any positive or negative effect on diarrhoea or mortality, but the data on these two outcomes were very limited. Quality of the evidence We rated the overall quality of the evidence for the provision of multiple MNP versus no intervention or placebo as moderate for anaemia, iron deficiency and adverse effects. We judged the evidence to be of low quality for haemoglobin, mortality and diarrhoea, and to be very low‐quality for ferritin. In general, the most common risk of bias in the studies was the lack of blinding for participants, personnel and outcome assessors. Authors' conclusions Point‐of‐use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool‐ and school‐age children and seems feasible for public health purposes. However, future research should aim to increase the body of evidence on mortality, morbidity, developmental outcomes and adverse effects. Due to the lack of trials, we were unable to determine at this time if this intervention has comparable effects to those observed with iron supplements (provided as drops, tablets or syrup).", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "De‐Regil, LM; Jefferds, MED; Peña‐Rosas, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009666.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.732Z" }, { "id": "fbd4c3f0-9f43-4436-aec3-e371668aae82", "pmid": "", "title": "Dietary sodium manipulation and asthma", "imported": false, "abstract": "Abstract - Background There is a wide geographical variation in the prevalence of asthma and observational studies have suggested that dietary sodium may play a role. Objectives To assess the effect of dietary sodium manipulation on asthma control. Search methods We carried out a search using the Cochrane Airways Group asthma register. We searched the bibliographies of included randomised controlled trials (RCTs) for additional studies. We carried out the most recent search in November 2010. Selection criteria We considered only RCTs that involved dietary sodium reduction or increased sodium intake in patients with asthma. Data collection and analysis Both review authors assessed study and extracted data. We conducted data analyses in RevMan 5 using mean differences and random effects. Main results We identified a total of nine studies in relation to sodium manipulation and asthma, of which five were in people with asthma (318 participants), and four in people with exercise‐induced asthma (63 participants). There were no significant benefits of salt restriction on the control of asthma. There was some evidence from the exercise‐induced asthma studies that a low sodium diet may improve lung function after exercise and possibly baseline lung function, but this is based on findings from a very small numbers of participants. Authors' conclusions This review did not find any evidence that dietary sodium reduction significantly improves asthma control. Although dietary sodium reduction may result in improvements in lung function in exercise‐induced asthma, the clinical significance of this effect is unclear. Plain language summary Does reducing the amount of salt in a diet improve asthma symptoms? A review of the current literature suggests that reduction in the amount of dietary sodium consumed has no significant effect on the symptoms of asthma but may be associated with improvements in some lung function measurements in exercise‐induced asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Pogson, Z, McKeever, T", "articleTypes": [], "doi": "10.1002/14651858.CD000436.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.077Z" }, { "id": "fbeec206-5bc0-4629-9654-2bb397878146", "pmid": "", "title": "Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Hip and knee replacement surgery is a well‐established means of improving quality of life, but is associated with a significant risk of bleeding. One‐third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care. Objectives To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta‐analysis (NMA) methodology. Search methods We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO host ), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). Selection criteria We included RCTs of people undergoing elective hip or knee surgery only. We excluded non‐elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon‐aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non‐fibrin sealants. Data collection and analysis We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all‐cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received. Main results We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra‐articularly and orally at a total dose of greater than 3 g pre‐incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate‐certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre‐incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low‐certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low‐certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low‐certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low‐certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low‐certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all‐cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low‐certainty evidence). This was followed by TXA given intravenously and intra‐articularly at a total dose of 2 g pre‐incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low‐certainty evidence) and TXA given intravenously and intra‐articularly, total dose greater than 3 g pre‐incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low‐certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low‐certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials). Authors' conclusions We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra‐articular, oral and intravenous, or intravenous and intra‐articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review. Plain language summary What is the best medication to stop bleeding in those having non‐emergency hip or knee surgery? Key messages • Tranexamic acid may be an effective medicine to help blood to clot during hip or knee replacement surgery, which reduces bleeding and the need for a blood transfusion (replacing lost blood with donated blood). • A high dose of this medicine and administering it in more than one way (for example, as a tablet and injected into the joint at the end of surgery) appears to work best. • Tranexamic acid is potentially as effective when given as a tablet as when injected into a vein. • There is little to no evidence to indicate that higher doses of tranexamic acid increase the risk of blood clots in the leg or other harms. Background Why is it important to stop bleeding during hip or knee surgery? Controlling bleeding during surgery reduces the likelihood of the person developing anaemia and requiring a blood transfusion, which carries the risk of complications. Anaemia occurs when the number of red blood cells (haemoglobin) available to carry oxygen is lower than normal. This causes symptoms such as fatigue, weakness, dizziness, shortness of breath and, in severe cases, can be life‐threatening. Preventing blood loss during surgery improves patient outcomes, decreases healthcare costs and preserves the limited supplies of donated blood. Is there a medication that helps control bleeding? Many research studies have investigated whether certain medication, such as tranexamic acid, can help minimise blood loss during surgery. Most of the studies test different doses of medications, different methods of administration and different times of use, either before, during or after an operation. What did we want to find out? We wanted to find out whether medication can reduce blood loss and the need for blood transfusions in people having hip or knee replacement surgery. We also wanted to know the most effective way of giving this medication to patients. What did we do? We searched for studies comparing different medications that could help reduce bleeding in adults undergoing planned hip or knee replacement surgery. We also searched for studies comparing medication with a placebo. A placebo is a 'dummy' medication that looks or tastes identical to the medication being tested. What did we find? We found 102 studies. Twelve studies did not report the number of included participants; in the other 90 studies, there were 8418 included participants. On average, people were between 50 and 77 years of age and 64% were women. The smallest study included 16 people and the largest involved 300. Studies took place around the globe, with the highest number in Europe and Asia. Of those studies that reported a source of funding, seven were fully funded and five partly funded by pharmaceutical (medication) companies. All studies investigated medications that helped the blood to clot. However, most studies assessed the effectiveness and safety of tranexamic acid administered intravenously (injected into a vein), orally (swallowing a tablet or liquid), injected into the joint during surgery, or with a combination of these methods. Main results Our review of the studies showed the following: • Tranexamic acid was the most effective at controlling bleeding compared to other medications. • Adults who underwent hip or knee replacement surgery required fewer blood transfusions if they were given tranexamic acid. • Tranexamic acid given in higher doses using multiple methods of administration, such as orally and injected into the joint during surgery, may be more likely to prevent bleeding. • Taking tranexamic acid orally is probably as effective at preventing a blood transfusion as injecting the medication into a vein. We were unable to decide on the optimal dose, which combination of methods are best to administer tranexamic acid and when it is most beneficial to use it (before, during and after surgery). We did not find evidence to suggest that higher doses of tranexamic acid increase the risk of developing a blood clot, or any other harms. What are the limitations of the evidence? We are not able to definitively draw conclusions based on the trials included within this review. We have little confidence in the evidence for some outcomes, and are not confident about the evidence for others. This is because it is possible that people in the studies were aware of which treatment they were getting. Also, the studies were small and did not all provide data about everything in which we were interested. Ongoing studies and future updates Thirty studies with a planned total of 3776 participants are currently ongoing. These studies should be completed and published within the next few years. Once the authors publish their data, we may update our analyses and provide stronger answers than we can at present. How up‐to‐date is this evidence? The evidence is current to 18 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gibbs, VN, Champaneria, R, Sandercock, J, Welton, NJ, Geneen, LJ, Brunskill, SJ, Dorée, C, Kimber, C, Palmer, AJR, Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD013295.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.802Z" }, { "id": "fbf5617a-3c37-4533-9f87-f3375485d69d", "pmid": "", "title": "Probiotics for induction of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Ulcerative colitis is an inflammatory condition affecting the colon, with an annual incidence of approximately 10 to 20 per 100,000 people. The majority of people with ulcerative colitis can be put into remission, leaving a group who do not respond to first‐ or second‐line therapies. There is a significant proportion of people who experience adverse effects with current therapies. Consequently, new alternatives for the treatment of ulcerative colitis are constantly being sought. Probiotics are live microbial feed supplements that may beneficially affect the host by improving intestinal microbial balance, enhancing gut barrier function and improving local immune response. Objectives To assess the efficacy of probiotics compared with placebo or standard medical treatment (5‐aminosalicylates, sulphasalazine or corticosteroids) for the induction of remission in people with active ulcerative colitis. Search methods We searched CENTRAL, MEDLINE, Embase, and two other databases on 31 October 2019. We contacted authors of relevant studies and manufacturers of probiotics regarding ongoing or unpublished trials that may be relevant to the review, and we searched ClinicalTrials.gov. We also searched references of trials for any additional trials. Selection criteria Randomised controlled trials (RCTs) investigating the effectiveness of probiotics compared to standard treatments or placebo in the induction of remission of active ulcerative colitis. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors Data collection and analysis Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We analysed data using Review Manager 5. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE methodology. Main results In this review, we included 14 studies (865 randomised participants) that met the inclusion criteria. Twelve of the studies looked at adult participants and two studies looked at paediatric participants with mild to moderate ulcerative colitis, the average age was between 12.5 and 47.7 years. The studies compared probiotics to placebo, probiotics to 5‐ASA and a combination of probiotics plus 5‐ASA compared to 5‐ASA alone. Seven studies used a single probiotic strain and seven used a mixture of strains. The studies ranged from two weeks to 52 weeks. The risk of bias was high for all except two studies due to allocation concealment, blinding of participants, incomplete reports of outcome data and selective reporting. This led to GRADE ratings of the evidence ranging from moderate to very low. Probiotics versus placebo 
Probiotics may induce clinical remission when compared to placebo (RR 1.73, 95% CI 1.19 to 2.54; 9 studies, 594 participants; low‐certainty evidence; downgraded due to imprecision and risk of bias, number needed to treat for an additional beneficial outcome (NNTB) 5). Probiotics may lead to an improvement in clinical disease scores (RR 2.29, 95% CI 1.13 to 4.63; 2 studies, 54 participants; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.04, 95% CI 0.42 to 2.59; 7 studies, 520 participants). Reported adverse events included abdominal bloating and discomfort. Probiotics did not lead to any serious adverse events in any of the seven studies that reported on it, however five adverse events were reported in the placebo arm of one study (RR 0.09, CI 0.01 to 1.66; 1 study, 526 participants; very low‐certainty evidence; downgraded due to high risk of bias and imprecision). Probiotics may make little or no difference to withdrawals due to adverse events (RR 0.85, 95% CI 0.42 to 1.72; 4 studies, 401 participants; low‐certainty evidence). Probiotics versus 5‐ASA 
There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (RR 0.92, 95% CI 0.73 to 1.16; 1 study, 116 participants; low‐certainty evidence; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.33, 95% CI 0.53 to 3.33; 1 study, 116 participants). Reported adverse events included abdominal pain, nausea, headache and mouth ulcers. There were no serious adverse events with probiotics, however perforated sigmoid diverticulum and respiratory failure in a patient with severe emphysema were reported in the 5‐ASA arm (RR 0.21, 95% CI 0.01 to 4.22; 1 study, 116 participants; very low‐certainty evidence). Probiotics combined with 5‐ASA versus 5‐ASA alone 
Low‐certainty evidence from a single study shows that when combined with 5‐ASA, probiotics may slightly improve the induction of remission (based on the Sunderland disease activity index) compared to 5‐ASA alone (RR 1.22 CI 1.01 to 1.47; 1 study, 84 participants; low‐certainty evidence; downgraded due to unclear risk of bias and imprecision). No information about adverse events was reported. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes (progression to surgery, need for additional therapy, quality of life scores, or steroid withdrawal) were reported in any of the studies. Authors' conclusions Low‐certainty evidence suggests that probiotics may induce clinical remission in active ulcerative colitis when compared to placebo. There may be little or no difference in clinical remission with probiotics alone compared to 5‐ASA. There is limited evidence from a single study which failed to provide a definition of remission, that probiotics may slightly improve the induction of remission when used in combination with 5‐ASA. There was no evidence to assess whether probiotics are effective in people with severe and more extensive disease, or if specific preparations are superior to others. Further targeted and appropriately designed RCTs are needed to address the gaps in the evidence base. In particular, appropriate powering of studies and the use of standardised participant groups and outcome measures in line with the wider field are needed, as well as reporting to minimise risk of bias. Plain language summary Probiotics for the treatment of active ulcerative colitis What is the aim of this review? The aim of this Cochrane Review was to find out whether probiotics can induce remission in people with ulcerative colitis. We analysed data from 14 studies to answer this question. Key messages Probiotics may be better at inducing remission than placebo (dummy treatment). It is unclear whether probiotics are better than 5‐aminosalicylic acid (5‐ASA, an anti‐inflammatory agent used to treat inflammatory bowel disease), however there is limited evidence that when both treatments are used as combined therapy they may be better than 5‐ASA alone in inducing remission. Most studies reported that no serious adverse events took place. For the studies that did report on it, serious adverse events did not occur in the probiotic group. Minor adverse events reported were bloating and diarrhoea. What was studied in the review? Ulcerative colitis is a relapsing and remitting disease which causes inflammation of the large bowel and leads to symptoms such as abdominal pain, diarrhoea and tiredness. There is some evidence to suggest that an imbalance in the bacteria of the gut is the cause of the disease, and therefore probiotics, which are live micro‐organisms, can alter the bacteria and possibly reduce the inflammation. What are the main results of the review? We searched for randomised controlled trials (RCTs; clinical studies where people are randomly put into one of two or more treatment groups) comparing probiotics with placebo, probiotics with 5‐ASA, and probiotics in combination with 5‐ASA. We found 14 RCTs looking at 865 participants. The trials looked at adult and paediatric participants. Eight studies allowed additional therapy to continue, whilst the other four studies were unclear about this. 1) Probiotics may improve induction of clinical remission when compared to placebo. 2) It is unclear whether probiotics lead to a difference in adverse events (minor and serious) when compared to placebo. 3) There is limited evidence to determine whether probiotics offer better disease improvement when compared to placebo. 4) There may be little or no difference in the induction of remission with probiotics when compared to 5‐ASA (low‐certainty evidence). 5) There is limited evidence to suggest that when probiotics plus 5‐ASA are compared to 5‐ASA alone, probiotics may offer a slightly better chance of induction of remission. This is based on low‐certainty evidence from one study, and we are not sure of the type of remission studied. 6) Serious adverse events were reported when probiotics were compared with placebo, but only occurred in the placebo group. Conclusion Whilst the evidence suggests that probiotics may be better at improving induction than placebo, our confidence in the estimate is limited because of the low‐certainty evidence. This is attributed to the small number of participants in each study along with the unreliable methods utilised by the trials. With the evidence presented in these studies, we are unable to make strong conclusions into the effectiveness of probiotics; better designed studies with more participants are needed. How up‐to‐date is this review? This review is up‐to‐date as of October 2019.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Kaur, L; Gordon, M; Baines, PA; Iheozor-Ejiofor, Z; Sinopoulou, V; Akobeng, AK", "articleTypes": [], "doi": "10.1002/14651858.CD005573.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.065Z" }, { "id": "fc0dbb36-0587-43a7-aebb-e66e2145cb83", "pmid": "", "title": "Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years", "imported": false, "abstract": "Abstract - Background Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health. Objectives To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non‐dietary intervention. Secondary objectives were to assess the impact of ECEC‐based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality‐of‐life outcomes. We also report on cost and adverse consequences of ECEC‐based healthy eating interventions. Search methods We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers. Selection criteria We included randomised controlled trials (RCTs), including cluster‐RCTs, stepped‐wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross‐over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both. Data collection and analysis Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta‐analyses using a random‐effects model; otherwise, we described findings using vote‐counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes. Main results We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster‐RCTs. Twenty‐nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty‐eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC‐based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I 2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I 2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC‐based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI −0.01 to 0.25; P =0.08, I 2 = 70%; 13 studies, 3335 children). There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely result in little to no difference in children's consumption of non‐core (i.e. less healthy/discretionary) foods (SMD −0.05, 95% CI −0.17 to 0.08; P = 0.48, I 2 = 16%; 7 studies, 1369 children) or consumption of sugar‐sweetened beverages (SMD −0.10, 95% CI −0.34 to 0.14; P = 0.41, I 2 = 45%; 3 studies, 522 children). Thirty‐six studies measured BMI, BMI z‐score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC‐based healthy eating interventions may result in little to no difference in child BMI (MD −0.08, 95% CI −0.23 to 0.07; P = 0.30, I 2 = 65%; 15 studies, 3932 children) or in child BMI z‐score (MD −0.03, 95% CI −0.09 to 0.03; P = 0.36, I 2 = 0%; 17 studies; 4766 children). ECEC‐based healthy eating interventions may decrease child weight (MD −0.23, 95% CI −0.49 to 0.03; P = 0.09, I 2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I 2 = 0%; 5 studies, 1070 children). ECEC‐based healthy eating interventions may be cost‐effective but the evidence is very uncertain (6 studies). ECEC‐based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3). Authors' conclusions ECEC‐based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC‐based healthy eating interventions on vegetable consumption. ECEC‐based healthy eating interventions may result in little to no difference in child consumption of non‐core foods and sugar‐sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z‐scores. Future studies exploring the impact of specific intervention components, and describing cost‐effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC‐based healthy eating interventions. Plain language summary How successful are healthy eating programmes in preschools, kindergartens and childcare settings? Key messages • Healthy eating programmes delivered in early childhood education and care (ECEC) settings (e.g. preschools, kindergarten, family day care) may improve child diet quality, likely increase fruit consumption, may have favourable effects on vegetable consumption, and likely have no impact on consumption of less healthy foods and sugar‐sweetened drinks. They may have favourable effects on child weight and may reduce the risk of being overweight or obese. • We don't know if healthy eating interventions save money or cause unwanted effects because very few studies provided information about these points. • We found little evidence from low‐ and middle‐income countries, but healthy eating programmes in high‐income countries may benefit child health. We don't know how to support educators and staff to implement these programmes in practice. We need more research about delivering programmes and about their effect in low‐income countries. Why is it important to improve young children's diet? Having a poor diet puts people at risk of many long‐term diseases including heart disease, type 2 diabetes and certain types of cancers. Research estimates that over 11 million deaths worldwide are caused by having an unhealthy diet. Dietary behaviours and preferences are established early in life and persist into adulthood. What are healthy eating programmes? Healthy eating programmes aim to encourage children to eat a healthier diet. They may involve changes to lessons and the culture in preschools, kindergartens and day care centres (early childhood education and care (ECEC) settings), and working with children's families, teachers and healthcare staff. For example, introducing new fruits and vegetables to children, changing the menu to include healthier options or providing families with information about child healthy eating. Healthy eating programmes may establish lifelong healthy eating patterns, reduce excessive weight gain and improve overall health. What did we want to find out? We wanted to find out what impact healthy eating interventions have on child diet and health. We were interested in changes to diet, weight, language and cognitive performance, social, emotional and quality of life outcomes in children aged six months to six years attending preschool, long day care, nurseries, kindergartens and family day care services. We also wanted to know the cost of interventions and whether they had any potential unwanted effects. What did we do? We searched for studies that compared healthy eating programmes against no action, delayed delivery of the programme, or a programme that did not aim to change child diet. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 52 studies that looked at the effects of 58 healthy eating programmes in ECEC settings for children aged six months to six years. All studies were published in high and high‐middle‐income countries. The programmes were very different from each other. They: • lasted from 4 weeks to 3 years; • were delivered by a range of people including healthcare providers, ECEC staff, and researchers; • used different delivery methods (telephone, face‐to‐face, online, printed materials); and • measured results in a variety of ways (e.g. parent or staff surveys, observations of children's eating, and weighing foods before and after meals). Overall, the programmes aimed to: • change the ECEC environment (e.g. staff demonstrated healthy eating to children, and provided healthier foods); • change the curriculum (e.g. they provided lessons about foods and healthy eating); and • establish partnerships (e.g. they provided educational resources to families); and • increase children's physical activity (e.g. by structured physical activity lessons and encouraging less screen time). Healthy eating programmes may lead to small improvements in child diet quality, increase fruit consumption by 0.11 servings, potentially improve vegetable consumption by 0.12 servings and may have no effect on consumption of less healthy foods and sugar‐sweetened drinks. Further, we found child weight is potentially reduced by 230 g and for every 100 children, 19 would have better weight status. However, we found no evidence of impact on body mass index. The programmes may be cost‐effective and likely to have no unwanted effects, although few studies reported these points. Few studies reported on other learning, social and developmental outcomes. What are the limitations of the evidence? Our confidence in the evidence is low because the healthy eating programmes were conducted, delivered and assessed in different ways. Also, many of the people who received the healthy eating programmes were aware that they were being assessed and this can sometimes influence how they report their effects. For example, parents who reported their child's diet may have been more inclined to give positive answers because they felt they were doing what society expected or because they were grateful for the support and wanted to please the researchers. Also, not all studies provided information about everything we were interested in and there was often missing data when children were followed up after the study. How up‐to‐date is the evidence? The evidence is up‐to‐date to February 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Yoong, SL, Lum, M, Wolfenden, L, Jackson, J, Barnes, C, Hall, AE, McCrabb, S, Pearson, N, Lane, C, Jones, JZ, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD013862.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.800Z" }, { "id": "fc17921b-ffa1-44e4-be61-b6a3c32644f0", "pmid": "", "title": "Oral treatments for fungal infections of the skin of the foot", "imported": false, "abstract": "Abstract - Background About 15% of the world population have fungal infections of the feet (tinea pedis or athlete's foot). There are many clinical presentations of tinea pedis, and most commonly, tinea pedis is seen between the toes (interdigital) and on the soles, heels, and sides of the foot (plantar). Plantar tinea pedis is known as moccasin foot. Once acquired, the infection can spread to other sites including the nails, which can be a source of re‐infection. Oral therapy is usually used for chronic conditions or when topical treatment has failed. Objectives To assess the effects of oral treatments for fungal infections of the skin of the foot (tinea pedis). Search methods For this update we searched the following databases to July 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library , MEDLINE (from 1946), EMBASE (from 1974), and CINAHL (from 1981). We checked the bibliographies of retrieved trials for further references to relevant trials, and we searched online trials registers. Selection criteria Randomised controlled trials of oral treatments in participants who have a clinically diagnosed tinea pedis, confirmed by microscopy and growth of dermatophytes (fungi) in culture. Data collection and analysis Two review authors independently undertook study selection, 'Risk of bias' assessment, and data extraction. Main results We included 15 trials, involving 1438 participants. The 2 trials (71 participants) comparing terbinafine and griseofulvin produced a pooled risk ratio (RR) of 2.26 (95% confidence interval (CI) 1.49 to 3.44) in favour of terbinafine's ability to cure infection. No significant difference was detected between terbinafine and itraconazole, fluconazole and itraconazole, fluconazole and ketoconazole, or between griseofulvin and ketoconazole, although the trials were generally small. Two trials showed that terbinafine and itraconazole were effective compared with placebo: terbinafine (31 participants, RR 24.54, 95% CI 1.57 to 384.32) and itraconazole (72 participants, RR 6.67, 95% CI 2.17 to 20.48). All drugs reported adverse effects, with gastrointestinal effects most commonly reported. Ten of the trials were published over 15 years ago, and this is reflected by the poor reporting of information from which to make a clear 'Risk of bias' assessment. Only one trial was at low risk of bias overall. The majority of the remaining trials were judged as 'unclear' risk of bias because of the lack of clear statements with respect to methods of generating the randomisation sequence and allocation concealment. More trials achieved blinding of participants and personnel than blinding of the outcome assessors, which was again poorly reported. Authors' conclusions The evidence suggests that terbinafine is more effective than griseofulvin, and terbinafine and itraconazole are more effective than no treatment. In order to produce more reliable data, a rigorous evaluation of different drug therapies needs to be undertaken with larger sample sizes to ensure they are large enough to show any real difference when two treatments are being compared. It is also important to continue to follow up and collect data, preferably for six months after the end of the intervention period, to establish whether or not the infection recurred. Plain language summary Oral antifungal drugs for treating athlete's foot (tinea pedis) Athlete's foot (tinea pedis) is a fungal infection of the feet that is easily spread and difficult to get rid of. This review compared different oral antifungal drugs (i.e. drugs taken by mouth), and it included 15 trials, involving 1438 participants. There are several different kinds of oral treatments, and the trials we found considered all the oral drugs used to treat athlete's foot. We found terbinafine and itraconazole to be more effective than placebo. And we found terbinafine to be more effective than griseofulvin. Griseofulvin is a treatment that was developed much earlier than the new treatments, such as terbinafine and itraconazole; these newer treatments tend to be most evaluated. Trials of other drugs were not large enough to show differences between them. All drugs had side‐effects; gastrointestinal effects were the most common. In future clinical trials, larger numbers of participants are needed to test different treatments in order to produce more reliable data. Also, future research should consider the costs of the different treatment approaches.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Bell‐Syer, SEM, Khan, SM, Torgerson, DJ", "articleTypes": [], "doi": "10.1002/14651858.CD003584.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.783Z" }, { "id": "fc3bf18d-9de0-4a24-896f-329e69c763a3", "pmid": "", "title": "Fluvoxamine versus other anti‐depressive agents for depression", "imported": false, "abstract": "Abstract - Background Fluvoxamine, one of the oldest selective serotonin reuptake inhibitors (SSRIs), is prescribed to patients with major depression in many countries. Several studies have previously reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are now outdated. Objectives Our objective is to evaluate the effectiveness, tolerability and side effect profile of fluvoxamine for major depression in comparison with other anti‐depressive agents, including tricyclics (TCAs), heterocyclics, other SSRIs, SNRIs, other newer agents and other conventional psychotropic drugs. Search methods We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register. Trial databases and ongoing trial registers in North America, Europe, Japan and Australia, were handsearched for randomised controlled trials. We checked reference lists of the articles included in the review, previous systematic reviews and major textbooks of affective disorder for published reports and citations of unpublished research. The date of last search was 31 August 2008. Selection criteria We included all randomised controlled trials, published in any language, that compared fluvoxamine with any other active antidepressants in the acute phase treatment of major depression. Data collection and analysis Two independent review authors inspected citations and abstracts, obtained papers, extracted data and assessed the risk of bias of included studies. We analysed dichotomous data using odds ratios (ORs) and continuous data using the standardised mean difference (SMD). A random effects model was used to combine studies. Main results A total of 54 randomised controlled trials (n = 5122) were included. No strong evidence was found to indicate that fluvoxamine was either superior or inferior to other antidepressants regarding response, remission and tolerability. However, differing side effect profiles were evident, especially with regard to gastrointestinal side effects of fluvoxamine when compared to other antidepressants. For example, fluvoxamine was generally associated with a higher incidence of vomiting/nausea (versus imipramine, OR 2.23, CI 1.59 to 3.14; versus clomipramine, OR 2.13, CI 1.06 to 4.27; versus amitriptyline, OR 2.86, CI 1.31 to 2.63). Authors' conclusions We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, differing side effect profiles were evident. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations, including these differences in side effect profiles. Plain language summary Fluvoxamine versus other anti‐depressive agents for depression Major depression is a severe mental illness characterised by a persistent and unreactive low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms including appetite change, sleep disturbance, fatigue, loss of energy, poor concentration, psychomotor symptoms, inappropriate guilt and morbid thoughts of death. Although pharmacological and psychological interventions are both effective for major depression, antidepressant (AD) drugs remain the mainstay for treatment of moderate or severe depression. Fluvoxamine is one of the oldest selective serotonin reuptake inhibitors (SSRIs) and is prescribed to patients with major depression in many countries. This review reports trials comparing fluvoxamine with other antidepressants for treatment of major depression. We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, there is evidence of differing side‐effect profiles, especially when comparing gastrointestinal side effects between fluvoxamine and tricyclic antidepressants (TCAs). Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations including these differences in side effect profiles.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Omori, IM, Watanabe, N, Nakagawa, A, Cipriani, A, Barbui, C, McGuire, H, Churchill, R, Furukawa, TA", "articleTypes": [], "doi": "10.1002/14651858.CD006114.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.756Z" }, { "id": "fc4c5003-2a46-474c-a656-093e4c5068ef", "pmid": "", "title": "Quinine for muscle cramps", "imported": false, "abstract": "Abstract - Background Muscle cramps can occur anywhere and for many reasons. Quinine has been used to treat cramps of all causes. However, controversy continues about its efficacy and safety. This review was first published in 2010 and searches were updated in 2014. Objectives To assess the efficacy and safety of quinine‐based agents in treating muscle cramps. Search methods On 27 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE. We searched reference lists of articles up to 2014. We also searched for ongoing trials in November 2014. Selection criteria Randomised controlled trials of people of all ages with muscle cramps in any location and of any cause, treated with quinine or its derivatives. Data collection and analysis Three review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We contacted study authors for additional information. For comparisons including more than one trial, we assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Main results We identified 23 trials with a total of 1586 participants. Fifty‐eight per cent of these participants were from five unpublished studies. Quinine was compared to placebo (20 trials, n = 1140), vitamin E (four trials, n = 543), a quinine‐vitamin E combination (three trials, n = 510), a quinine‐theophylline combination (one trial, n = 77), and xylocaine injections into the gastrocnemius muscle (one trial, n = 24). The most commonly used quinine dosage was 300 mg/day (range 200 to 500 mg). We found no new trials for inclusion when searches were updated in 2014. The risk of bias in the trials varied considerably. All 23 trials claimed to be randomised, but only a minority described randomisation and allocation concealment adequately. Compared to placebo, quinine significantly reduced cramp number over two weeks by 28%, cramp intensity by 10%, and cramp days by 20%. Cramp duration was not significantly affected. A significantly greater number of people suffered minor adverse events on quinine than placebo (risk difference (RD) 3%, 95% confidence interval (CI) 0% to 6%), mainly gastrointestinal symptoms. Overdoses of quinine have been reported elsewhere to cause potentially fatal adverse effects, but in the included trials there was no significant difference in major adverse events compared with placebo (RD 0%, 95% CI ‐1% to 2%). One participant suffered from thrombocytopenia (0.12% risk) on quinine. A quinine‐vitamin E combination, vitamin E alone, and xylocaine injections into gastrocnemius were not significantly different to quinine across all outcomes, including adverse effects. Based on a single trial comparison, quinine alone was significantly less effective than a quinine‐theophylline combination but with no significant differences in adverse events. Authors' conclusions There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that with use up to 60 days, the incidence of serious adverse events is not significantly greater than for placebo in the identified trials, but because serious adverse events can be rarely fatal, in some countries prescription of quinine is severely restricted. Evidence from single trials suggests that theophylline combined with quinine improves cramps more than quinine alone, and the effects of xylocaine injections into gastrocnemius are not significantly different to quinine across all outcomes. Low or moderate quality evidence shows no significant difference between quinine and vitamin E or quinine and quinine‐vitamin E mixture. Further research into these alternatives, as well other pharmacological and non‐pharmacological treatments, is thus warranted. There is no evidence to judge optimal dosage or duration of quinine treatment. Further studies using different dosages and measurement of serum quinine levels will allow a therapeutic range to be defined for muscle cramp. Because serious adverse events are not common, large population studies are required to more accurately inform incidence. Longer lengths of follow‐up in future trials will help determine the duration of action following cessation of quinine as well as long‐term adverse events. The search for new therapies, pharmacological and nonpharmacological, should continue and further trials should compare vitamin E, quinine‐vitamin E combination, and quinine‐theophylline mixture with quinine. Plain language summary Quinine for muscle cramps Review question We reviewed the evidence about the effect of quinine on muscle cramps. Background Muscle cramps can occur anywhere and in anyone; however, leg cramps are especially common in older people. Quinine is a medicine which has been used to treat cramps for many years. There is conflicting evidence for its ability to reduce cramps. Quinine can cause serious, even fatal adverse events, especially in overdosage. Study characteristics This review includes 23 trials, with 1586 participants. The trials compared quinine or quinine‐based medicines against inactive treatment (placebo) or other active treatments. We found no new studies when we searched the medical literature again and updated the review in 2014. Key results and quality of the evidence The risk of bias in the included trials varied considerably. All 23 trials claimed to be randomised, but many failed to clearly describe how participants were assigned to treatments. There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that there are more minor adverse events with quinine compared to placebo but no increase in major adverse events. However, there are reliable reports from other sources that an overdose of quinine can cause serious harm including death. Low or moderate quality evidence shows there is no significant difference when comparing quinine to vitamin E or to a quinine‐vitamin E mixture. There is evidence from one trial that theophylline combined with quinine improves cramps more than quinine alone. In a single trial there was no significant difference when comparing quinine to xylocaine injections. More research is needed to clarify the best dose and duration of treatment, as well as alternatives to quinine for cramps. The evidence is current to October 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "El‐Tawil, S, Al Musa, T, Valli, H, Lunn, MPT, Brassington, R, El‐Tawil, T, Weber, M", "articleTypes": [], "doi": "10.1002/14651858.CD005044.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.757Z" }, { "id": "fc5b8ea1-6b67-44ce-abc6-4fa177a3889c", "pmid": "", "title": "Herbal medicines for fatty liver diseases", "imported": false, "abstract": "Abstract - Background Fatty liver disease is potentially a reversible condition that may lead to end‐stage liver disease. Since herbal medicines such as Crataegus pinnatifida and Salvia miltiorrhiza have increasingly been used in the management of fatty liver disease, a systematic review on herbal medicine for fatty liver disease is needed. Objectives To assess the beneficial and harmful effects of herbal medicines for people with alcoholic or non‐alcoholic fatty liver disease. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2012), MEDLINE, EMBASE, and Science Citation Index Expanded to 1 March 2012. We also searched the Chinese BioMedical Database, Traditional Chinese Medical Literature Analysis and Retrieval System, China National Knowledge Infrastructure, Chinese VIP Information, Chinese Academic Conference Papers Database and Chinese Dissertation Database, and the Allied and Complementary Medicine Database to 2 March 2012. Selection criteria We included randomised clinical trials comparing herbal medicines with placebo, no treatment, a pharmacological intervention, or a non‐pharmacological intervention such as diet or lifestyle, or Western interventions in participants with fatty liver disease. Data collection and analysis Two review authors extracted data independently. We used the 'risk of bias' tool to assess the risk of bias of the included trials. We assessed the following domains: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. We presented the effects estimates as risk ratios (RR) with 95% confidence intervals (CI) or as mean differences (MD) with 95% CI, depending on the variables of the outcome measures. Main results We included 77 randomised clinical trials, which included 6753 participants with fatty liver disease. The risks of bias (overestimation of benefits and underestimation of harms) was high in all trials. The mean sample size was 88 participants (ranging from 40 to 200 participants) per trial. Seventy‐five different herbal medicine products were tested. Herbal medicines tested in the randomised trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca) , proprietary herbal medicines commercially available, and combination formulas prescribed by practitioners. The most commonly used herbs were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia, Astragalus membranaceous, and Rheum palmatum . None of the trials reported death, hepatic‐related morbidity, quality of life, or costs. A large number of trials reported positive effects on putative surrogate outcomes such as serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases, ultrasound, and computed tomography scan. Twenty‐seven trials reported adverse effects and found no significant difference between herbal medicines versus control. However, the risk of bias of the included trials was high. The outcomes were ultrasound findings in 22 trials, liver computed tomography findings in eight trials, aspartate aminotransferase levels in 64 trials, alanine aminotransferase activity in 77 trials, and glutamyltransferase activities in 44 trials. Six herbal medicines showed statistically significant beneficial effects on ultrasound, four on liver computed tomography, 42 on aspartate aminotransferase activity, 49 on alanine aminotransferase activity, three on alkaline phosphatases activity, and 32 on glutamyltransferase activity compared with control interventions. Authors' conclusions Some herbal medicines seemed to have positive effects on aspartate aminotransferase, alanine aminotransferase, ultrasound, and computed tomography. We found no significant difference on adverse effects between herbal medicine and control groups. The findings are not conclusive due to the high risk of bias of the included trials and the limited number of trials testing individual herbal medicines. Accordingly, there is also high risk of random errors. Plain language summary Herbal medicines for fatty liver diseases Fatty liver disease is a potentially reversible illness where fat builds up within the cells of the liver. It may lead to the liver no longer being able to function properly; this is called end‐stage liver disease. This systematic review evaluated the effects and safety of herbal medicines (single herbs, branded herbal medicines, and prescribed formulas) for treating fatty liver disease. We included 77 randomised clinical trials in this review, which tested 75 herbal medicines. All trials had high risk of systematic errors (ie, bias or risk of overestimation of benefits and overestimation of harms) as well as high risks of random errors (ie, play of chance) due to the small number of people in the trials. Herbal medicines tested in the randomised clinical trials included single‐herb products ( Gynostemma pentaphyllum , Panax notoginseng , and Prunus armeniaca ), commercially available branded herbal medicines, and combination formulas prescribed by practitioners. Herbs most commonly included as an ingredient in different products were Crataegus pinnatifida , Salvia miltiorrhiza , Alisma orientalis , Bupleurum chinense , Cassia obtusifolia , Astragalus membranaceous , and Rheum palmatum . We could not combine the results of the trials due to the range of different herbs used. We could not reach any conclusions about the use of herbal medicines for people with fatty liver disease as none of the trials reported results on death, liver‐related illnesses, quality of life, or costs. A number of trials showed positive effects of herbal medicines compared with control interventions on enzyme activity (enzymes are proteins that cause chemical reactions in the body; eg, serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases), ultrasound scan findings, and computed tomography scan findings. No serious adverse effects were reported for herbal medicines. However, the methodology of the trials had high risk of systematic errors (bias). Furthermore, the individual herbs were seldomly retested, and all trials had relatively low numbers of people, which increases the risk of random errors (play of chance). Therefore, the findings are inconclusive, and rigorously conducted randomised clinical trials are required to establish the benefits and harms of herbal medicines for fatty liver disease.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Liu, ZL; Xie, LZ; Zhu, J; Li, GQ; Grant, SJ; Liu, JP", "articleTypes": [], "doi": "10.1002/14651858.CD009059.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "fc69fcdf-c57e-44d2-a3bd-55e25011ba30", "pmid": "", "title": "Brexpiprazole versus placebo or other antidepressive agents for treating depression", "imported": false, "abstract": "Abstract - Background Brexpiprazole is the newest antipsychotic drug approved as an adjunctive for treatment‐resistant depression. This systematic review provides comprehensive, high‐quality evidence for the effects of brexpiprazole in major depressive disorder (MDD) based on existing and emerging randomised controlled trials (RCTs). Objectives To evaluate the benefits and harms of brexpiprazole as monotherapy or adjunct treatment in the acute and longer‐term treatment of MDD compared to placebo or other antidepressive agents. Search methods We used standard, extensive Cochrane search methods. The latest search date was November 2021. Selection criteria We included RCTs in people with a history of non‐response to one or more antidepressant monotherapies comparing brexpiprazole as monotherapy or adjunct treatment with placebo or other antidepressive agents. Data collection and analysis We used standard Cochrane methods. Primary outcomes were 1. response to treatment, measured as number of participants who achieved 50% or more reduction of the score on a validated scale for depression, 2. dropouts due to any reason, and 3. dropouts due to adverse effects, all measured at eight weeks (acute treatment). Our secondary outcomes were 4. number of participants who responded to treatment after two and 18 weeks, number of participants who achieved remission after eight weeks, 5. total number of participants with any adverse events, 6. social functioning or adjustment, and 7. health‐related quality of life. We used GRADE to assess certainty of evidence for each outcome. Main results We retrieved nine studies with 3424 participants with treatment‐resistant depression, defined as lack of response to at least two trials of antidepressant monotherapy. The age of participants was 18 to 65 years in seven studies, 18 to 75 years in one study, and older than 65 years in one study. Inclusion criteria for all studies required a diagnosis of MDD with a current major depressive episode per Diagnostic and Statistical Manual of Mental Disorders Text Revision Fourth Edition criteria and additional criteria on minimal scores on Montgomery–Åsberg Depression Rating Scale (MADRS) and Hamilton Depression Rating Scale which varied across studies. Eight studies compared brexpiprazole as adjunctive treatment to an antidepressant versus placebo as adjunctive treatment to an antidepressant. One study added brexpiprazole or placebo to a combination of antidepressant and ketamine. Four studies used fixed dosages and five studies used flexible dosages of brexpiprazole. The manufacturer sponsored eight studies and one study was independently funded. Brexpiprazole was superior in achieving response at eight weeks (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.23 to 1.75; 8 studies, 3409 participants; high‐certainty evidence). More participants randomised to brexpiprazole dropped out due to any cause at eight weeks (OR 1.37, 95% CI 1.02 to 1.83; 7 studies, 2523 participants; high‐certainty evidence) or due to adverse effects (OR 2.88, 95% CI 1.37 to 6.05; 6 studies, 2472 participants; high‐certainty evidence). Brexpiprazole was superior to placebo when added to an antidepressant for achieving remission at eight weeks (OR 1.46, 95% CI 1.19 to 1.79; 7 studies, 3358 participants; high‐certainty evidence). When response was defined based on a change in the score on MADRS, brexpiprazole also demonstrated better efficacy than placebo (mean difference (MD) –1.39, 95% CI –1.96 to –0.82; 8 studies, 3263 participants; high‐certainty evidence). Compared to placebo, add‐on brexpiprazole is probably more likely to result in akathisia (OR 2.95, 95% CI 2.06 to 4.21; 7 studies, 3358 participants; moderate‐certainty evidence) and weight gain (OR 3.14, 95% CI 2.19 to 4.49; 9 studies, 3424 participants; moderate‐certainty evidence). The risk of bias varied between low and unclear for most studies. Only one study was at high risk of selective reporting bias and other bias; however, this study had a small sample size and its impact on overall risk of bias was not considered significant. The certainty of the evidence on five of the main outcomes (response to treatment, measured as number of participants who achieved response and change in depressive symptoms, remission, dropouts due to any cause, dropouts due to adverse effects) was high. The certainty of evidence for akathisia and weight gain was downgraded one level to moderate due to indirectness. Authors' conclusions Our review supports the superior efficacy of add‐on brexpiprazole in comparison to placebo in adults with treatment‐resistant depression for the short‐term and acute treatment of depression. Our findings were limited by the small number of studies and the moderate‐certainty evidence for the most common adverse effects (akathisia and weight gain). There was insufficient evidence for the effects of brexpiprazole for depression in older people or children. In addition, we found no studies that compared brexpiprazole to other antidepressants or where brexpiprazole was added after lack of response to only one antidepressant. We also lacked sufficient data to establish the long‐term efficacy of brexpiprazole as adjunctive treatment. Active comparators, long‐term studies in different age groups and cost‐effect analyses are needed to more precisely establish the clinical role of brexpiprazole in the treatment of MDD. Plain language summary What are the benefits and harms of brexpiprazole, a new antipsychotic medication, for the treatment of depression when compared to dummy tablets or antidepressants? Key messages – Brexpiprazole added to an antidepressant is better at reducing the symptoms of depression than placebo (dummy tablet) added to an antidepressant. – Brexpiprazole might be more commonly associated with weight gain and akathisia (a feeling of restlessness that causes a compelling need to move all the time). What is depression? Depression is a common mental health condition which leads to low mood, inability to experience pleasure, sleep disruption, weight loss, fatigue or low energy, slower speech and movements, feeling worthless or excessively guilty, being unable to concentrate and having thoughts of committing suicide. To be diagnosed with depression, a person should experience five or more of these symptoms, including low mood or loss of sense of pleasure for at least two weeks. How is the condition treated? Unless the symptoms of depression are mild, the first option for treatment is an antidepressant medication, but antidepressants only help in half of cases when prescribed for the first time. When an antidepressant is not enough to treat depression, one available option is to add another medication to help the effects of the antidepressant. Other options include changing the antidepressant to another antidepressant, talking therapy or stimulation of the brain through electrical pulses. Brexpiprazole is a new medication which can be added to an antidepressant that has not worked by itself. Brexpiprazole can be prescribed in doses from 0.5 mg to 3 mg for the treatment of depression. It has also been approved for the treatment of schizophrenia. What did we want to find out? We wanted to examine the effects of brexpiprazole in the treatment of depression when prescribed by itself or when added to another antidepressant and how its effects compare to the effects of antidepressants or placebo. To do so we explored several effects. First, we looked into how well brexpiprazole decreased the symptoms of depression. Second, we explored how many participants gave up taking part in the studies for any reason. Third, we investigated how many stopped participating because of the unwanted effects they experienced. Fourth, we explored what unwanted effects emerged with the use of brexpiprazole. We also wanted to know how brexpiprazole affected the quality of life of the participants and how it affected the way they functioned in their everyday lives. What did we do? We searched scientific databases for studies that reported the effects of brexpiprazole versus placebo or antidepressants for depression. We included only studies in which the participants were assigned randomly to one or the other treatment. Neither them nor the team that was evaluating the effects of the treatment knew what was prescribed and this helped to objectively evaluate the results without the knowledge of what was prescribed impacting on the outcome. We compared and summarised the results and evaluated how confident we were that the results of the studies represented the real effects of the medication. We based our confidence on different factors such as the size of the effects, the methods used, and what and how the results were reported. What did we find and what were the limitations of our findings? We found nine studies, which included 3424 participants; two‐thirds of them were women and one‐third were men. We only found studies in which brexpiprazole was added after the participants had tried treatment with two or more antidepressants on their own. We have a high level of confidence that brexpiprazole added to an antidepressant reduced the symptoms of depression more after eight weeks of treatment than placebo added to an antidepressant. Brexpiprazole was also more likely to lead to no symptoms of depression than placebo when either of them was added to an antidepressant. We are moderately confident that brexpiprazole caused weight gain or subjective feelings of restlessness more often than placebo. We are less confident about the results around these unwanted effects as we could not find information about how they were measured and whether all studies used the same methods to measure them. What did we fail to find? We found no studies that explored how brexpiprazole would work for children or older people who have depression. We wanted to find how brexpiprazole would work when given for depression for longer periods of time, such as 18 to 24 weeks, but we found only one study and its results were not enough to draw a conclusion. How up‐to‐date is this evidence? Our evidence is up‐to‐date to 1 November 2021.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Ralovska, S; Koychev, I; Marinov, P; Furukawa, TA; Mulsant, B; Cipriani, A", "articleTypes": [], "doi": "10.1002/14651858.CD013866.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "fc8a2777-55cb-4d9f-a8d3-9e4ba8232055", "pmid": "", "title": "Homeopathic medicinal products for preventing and treating acute respiratory tract infections in children", "imported": false, "abstract": "Abstract - Background Acute respiratory tract infections (ARTIs) are common and may lead to complications. Most children experience between three and six ARTIs annually. Although most infections are self‐limiting, symptoms can be distressing. Many treatments are used to control symptoms and shorten illness duration. Most treatments have minimal benefit and may lead to adverse events. Oral homeopathic medicinal products could play a role in childhood ARTI management if evidence for their effectiveness is established. This is an update of a review first published in 2018. Objectives To assess the effectiveness and safety of oral homeopathic medicinal products compared with placebo or conventional therapy to prevent and treat ARTIs in children. Search methods We searched CENTRAL (2022, Issue 3), including the Cochrane Acute Respiratory Infections Specialised Register, MEDLINE (1946 to 16 March 2022), Embase (2010 to 16 March 2022), CINAHL (1981 to 16 March 2022), AMED (1985 to 16 March 2022), CAMbase (searched 16 March 2022), and British Homeopathic Library (searched 26 June 2013 ‐ no longer operating). We also searched the WHO ICTRP and ClinicalTrials.gov (16 March 2022), checked references, and contacted study authors to identify additional studies. Selection criteria We included double‐blind randomised controlled trials (RCTs) or double‐blind cluster‐RCTs comparing oral homeopathy medicinal products with identical placebo or self‐selected conventional treatments to prevent or treat ARTIs in children aged 0 to 16 years. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results In this 2022 update, we identified three new RCTs involving 251 children, for a total of 11 included RCTs with 1813 children receiving oral homeopathic medicinal products or a control treatment (placebo or conventional treatment) for ARTIs. All studies focused on upper respiratory tract infections (URTIs), with only one study including some lower respiratory tract infections (LRTIs). Six treatment studies examined the effect on URTI recovery, and five studies investigated the effect on preventing URTIs after one to four months of treatment. Two treatment and three prevention studies involved homeopaths individualising treatment. The other studies used predetermined, non‐individualised treatments. All studies involved highly diluted homeopathic medicinal products, with dilutions ranging from 1 x 10 ‐4 to 1 x 10 ‐200 . We identified several limitations to the included studies, in particular methodological inconsistencies and high attrition rates, failure to conduct intention‐to‐treat analysis, selective reporting, and apparent protocol deviations. We assessed three studies as at high risk of bias in at least one domain, and many studies had additional domains with unclear risk of bias. Four studies received funding from homeopathy manufacturers; one study support from a non‐government organisation; two studies government support; one study was co‐sponsored by a university; and three studies did not report funding support. Methodological inconsistencies and significant clinical and statistical heterogeneity precluded robust quantitative meta‐analysis. Only four outcomes were common to more than one study and could be combined for analysis. Odds ratios (OR) were generally small with wide confidence intervals (CI), and the contributing studies found conflicting effects, so there was little certainty that the efficacy of the intervention could be ascertained. All studies assessed as at low risk of bias showed no benefit from oral homeopathic medicinal products, whilst trials at unclear or high risk of bias reported beneficial effects. For the comparison of individualised homeopathy versus placebo or usual care for the prevention of ARTIs, two trials reported on disease severity; due to heterogeneity the data were not combined, but neither study demonstrated a clinically significant difference. We combined data from two trials for the outcome need for antibiotics (OR 0.79, 95% CI 0.35 to 1.76; low‐certainty evidence). For the comparison of non‐individualised homeopathy versus placebo or usual care for the prevention of ARTIs, only the outcome recurrence of ARTI was reported by more than one trial; data from three studies were combined for this outcome (OR 0.60, 95% CI 0.21 to 1.72; low‐certainty evidence). For the comparison of both individualised and non‐individualised homeopathy versus placebo or usual care for the treatment of ARTIs, two studies provided data on short‐term cure (OR 1.31, 95% CI 0.09 to 19.54) and long‐term cure (OR 1.01, 95% CI 0.10 to 9.96; very low‐certainty evidence). The studies demonstrated an opposite direction of effect for both outcomes. Six studies reported on disease severity but were not combined as they used different scoring systems and scales. Three studies reported adverse events (OR 0.79, 95% CI 0.16 to 4.03; low‐certainty evidence). Authors' conclusions Pooling of five prevention and six treatment studies did not show any consistent benefit of homeopathic medicinal products compared to placebo on ARTI recurrence or cure rates in children. We assessed the certainty of the evidence as low to very low for the majority of outcomes. We found no evidence to support the efficacy of homeopathic medicinal products for ARTIs in children. Adverse events were poorly reported, and we could not draw conclusions regarding safety. Plain language summary What are the benefits and risks of oral homeopathic medicines in preventing and treating acute respiratory tract infections in children? Key messages Homeopathy is a type of complementary and alternative medicine. It is based on two main ideas: that substances that may cause illness or symptoms in a healthy person can, in very small doses, treat those symptoms in a person who is unwell; and that molecules in highly diluted substances retain a memory of the original substance. Due to a lack of solid evidence, the benefits and risks of oral homeopathic medicines for preventing and treating acute respiratory tract infections (ARTIs) in children are unclear. Studies of lower quality in design and reporting often suggest a possible benefit for oral homeopathic medicines, but studies of higher quality do not find benefit. What are respiratory tract infections? Respiratory infections are commonly caused by viruses, especially colds and influenza, though some lung and ear infections are caused by bacteria. It may be difficult to tell these infections apart, and sometimes they occur together. Most such infections improve without treatment, but sometimes symptoms persist after the initial infection has gone. Treatment is therefore aimed at relieving symptoms. Why is this important in children? Children have on average three to six respiratory tract infections each year. Although most are mild and treatable, they are sometimes acute (serious, swift, or sudden onset) respiratory tract infections that may require hospital treatment, but very rarely result in death. How are ARTIs treated? Antibiotic medicines taken orally (by mouth/swallowed, usually in the form of a tablet, pill, lozenge, or liquid) are often prescribed for ARTIs, even though they are ineffective against viruses. Homeopathic medicines may treat ARTIs with few side effects, but their effectiveness and safety has not been well researched. What did we want to find out? We wanted to know whether homeopathic medicines help children with ARTIs. We were interested in the effect of homeopathic medicines compared to placebo (a 'dummy' treatment that does not contain any medicine but looks or tastes identical to the medicine being tested) or to usual care therapies for ARTIs. We were also interested in the effect of homeopathic medicines on improvement in the severity or symptoms of infection, the need for antibiotics, duration of illness (that would affect days off school or days off work for parents), symptom reappearance, and any medicine adverse effects. What did we do? We searched for randomised controlled trials (studies where people are randomly assigned to one of two or more treatment groups) that investigated whether oral homeopathic medicines, compared to placebo or usual care ARTI therapies, were effective in the prevention or treatment of ARTIs in children aged up to 16 years. We compared and summarised the results of the studies, and rated our confidence in the evidence based on factors such as study methods and number of participants. What did we find? We found 11 studies involving 1813 children (5 studies for prevention and 6 studies for treatment of ARTIs). All studies investigated upper respiratory tract (from the nose to the windpipe (trachea)) infections, but one study combined reporting of upper and lower respiratory tract (from the windpipe to the lungs and pleura (membranes covering the lungs)) infections, so the numbers of children with upper or lower ARTIs is unknown. Main results In the treatment or prevention of ARTIs in children, homeopathic medicines showed little or no beneficial effects, whether individualised by a trained homeopath or a standard commercially available homeopathic therapy (11 studies, 1813 children). Where results could be combined, there was little or no difference between groups for short‐term cure (2 studies, 155 participants) or long‐term cure (2 studies, 155 participants), but the evidence is very uncertain. There may be little or no difference between groups for prevention of ARTI (3 studies, 735 participants). There was no important difference between homeopathy and placebo groups for parents' time off work, antibiotic use, or adverse events. We are unsure about the safety of homeopathic medicines because data on adverse events were poorly reported. Overall, the findings of this review do not support the use of homeopathic medicinal products for ARTIs in children. What are the limitations of the evidence? We have little confidence in the evidence because the studies involved only small numbers of children, used different types of homeopathic medicines for various ARTIs, contained numerous biases, and failed to report information about important outcomes. Further research could provide results that differ from the results of this review. How up‐to‐date is this evidence? The evidence is current to 16 March 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Hawke, K; King, D; van Driel, ML; McGuire, TM", "articleTypes": [], "doi": "10.1002/14651858.CD005974.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "fc8d93b0-f7d3-47d7-ad7b-2fc9209d101d", "pmid": "", "title": "Xylitol‐containing products for preventing dental caries in children and adults", "imported": false, "abstract": "Abstract - Background Dental caries is a highly prevalent chronic disease which affects the majority of people. It has been postulated that the consumption of xylitol could help to prevent caries. The evidence on the effects of xylitol products is not clear and therefore it is important to summarise the available evidence to determine its effectiveness and safety. Objectives To assess the effects of different xylitol‐containing products for the prevention of dental caries in children and adults. Search methods We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 14 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library , 2014, Issue 7), MEDLINE via OVID (1946 to 14 August 2014), EMBASE via OVID (1980 to 14 August 2014), CINAHL via EBSCO (1980 to 14 August 2014), Web of Science Conference Proceedings (1990 to 14 August 2014), Proquest Dissertations and Theses (1861 to 14 August 2014). We searched the US National Institutes of Health Trials Register ( http://clinicaltrials.gov ) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria We included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults. Data collection and analysis Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference and 95% confidence interval (CI). We used the continuous data to calculate prevented fractions (PF) and 95% CIs to summarise the percentage reduction in caries. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. As there were less than four studies included in the meta‐analysis, we used a fixed‐effect model. We planned to use a random‐effects model in the event that there were four or more studies in a meta‐analysis. Main results We included 10 studies that analysed a total of 5903 participants. One study was assessed as being at low risk of bias, two were assessed as being at unclear risk of bias, with the remaining seven being at high risk of bias. The main finding of the review was that, over 2.5 to 3 years of use, a fluoride toothpaste containing 10% xylitol may reduce caries by 13% when compared to a fluoride‐only toothpaste (PF ‐0.13, 95% CI ‐0.18 to ‐0.08, 4216 children analysed, low‐quality evidence). The remaining evidence on children, from small single studies with risk of bias issues and great uncertainty associated with the effect estimates, was insufficient to determine a benefit from xylitol products. One study reported that xylitol syrup (8 g per day) reduced caries by 58% (95% CI 33% to 83%, 94 infants analysed, low quality evidence) when compared to a low‐dose xylitol syrup (2.67 g per day) consumed for 1 year. The following results had 95% CIs that were compatible with both a reduction and an increase in caries associated with xylitol: xylitol lozenges versus no treatment in children (very low quality body of evidence); xylitol sucking tablets versus no treatment in infants (very low quality body of evidence); xylitol tablets versus control (sorbitol) tablets in infants (very low quality body of evidence); xylitol wipes versus control wipes in infants (low quality body of evidence). There was only one study investigating the effects of xylitol lozenges, when compared to control lozenges, in adults (low quality body of evidence). The effect estimate had a 95% CI that was compatible with both a reduction and an increase in caries associated with xylitol. Four studies reported that there were no adverse effects from any of the interventions. Two studies reported similar rates of adverse effects between study arms. The remaining studies either mentioned adverse effects but did not report any usable data, or did not mention them at all. Adverse effects include sores in the mouth, cramps, bloating, constipation, flatulence, and loose stool or diarrhoea. Authors' conclusions We found some low quality evidence to suggest that fluoride toothpaste containing xylitol may be more effective than fluoride‐only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse‐effects from such toothpastes. The effect estimate should be interpreted with caution due to high risk of bias and the fact that it results from two studies that were carried out by the same authors in the same population. The remaining evidence we found is of low to very low quality and is insufficient to determine whether any other xylitol‐containing products can prevent caries in infants, older children, or adults. Plain language summary Can xylitol used in products like sweets, candy, chewing gum and toothpaste help prevent tooth decay in children and adults? Review question This review has been produced to assess whether or not xylitol, a natural sweetener used in products such as sweets, candy, chewing gum and toothpaste, can help prevent tooth decay in children and adults. Background Tooth decay is a common disease affecting up to 90% of children and most adults worldwide. It impacts on quality of life and can be the reason for thousands of children needing dental treatment under general anaesthetic in hospital. However, it can easily be prevented and treated by good oral health habits such as brushing teeth regularly with toothpaste that contains fluoride and cutting down on sugary food and drinks. If left undisturbed, the unhelpful bacteria in the mouth ‐ which cause decay ‐ multiply and stick to the surfaces of teeth producing a sticky film. Then, when sugar is eaten or drank, the bad bacteria in the film are able to make acid resulting in tooth decay. Xylitol is a natural sweetener, which is equally as sweet as normal sugar (sucrose). As well as providing an alternative to sugar, it has other properties that are thought to help prevent tooth decay, such as increasing the production of saliva and reducing the growth of bad bacteria in the mouth so that less acid is produced. In humans, xylitol is known to cause possible side effects such as bloating, wind and diarrhoea. Study characteristics Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 14 August 2014. It includes 10 studies published from 1991 to 2014 in which 7969 participants were randomised (5903 of whom were included in the analyses) to receive xylitol products or a placebo (a substitute without xylitol) or no treatment, and the amount of tooth decay was compared. One study included adults, the others included children aged from 1 month to 13 years. The products tested were the kind that are held in the mouth and sucked (lozenges, sucking tablets and sweets) or slowly released through a dummy/pacifier, as well as toothpastes, syrups, and wipes. Key results There is some evidence to suggest that using a fluoride toothpaste containing xylitol may reduce tooth decay in the permanent teeth of children by 13% over a 3 year period when compared to a fluoride‐only toothpaste. Over this period, there were no side effects reported by the children. The remaining evidence we found did not allow us to conclude whether or not any other xylitol‐containing products can prevent tooth decay in infants, older children, or adults. Quality of the evidence The evidence presented is of low to very low quality due to the small amount of available studies, uncertain results, and issues with the way in which they were conducted.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Riley, P; Moore, D; Ahmed, F; Sharif, MO; Worthington, HV", "articleTypes": [], "doi": "10.1002/14651858.CD010743.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.735Z" }, { "id": "fcb898e6-c207-4474-990d-b85a92b4be7b", "pmid": "", "title": "Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption", "imported": false, "abstract": "Abstract - Background Overconsumption of food, alcohol, and tobacco products increases the risk of non‐communicable diseases. Interventions to change characteristics of physical micro‐environments where people may select or consume these products ‐ including shops, restaurants, workplaces, and schools – are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers. Objectives 1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non‐alcoholic beverages), (b) alcohol, and (c) tobacco products. 2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii. participants. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches. Selection criteria We included randomised controlled trials with between‐participants (parallel group) or within‐participants (cross‐over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product. Data collection and analysis We used a novel semi‐automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random‐effects meta‐analysis and meta‐regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE. Main results We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between‐participants designs (19/24). All studies were conducted in high‐income countries, predominantly in the USA (14/24). Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less‐healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta‐analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD −1.13 (95% confidence interval (CI) −1.90 to −0.37) (low certainty evidence). For consumption outcomes, meta‐analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD −0.55 (95% CI −1.27 to 0.18) (low certainty evidence). Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD −0.65 (95% CI −1.29 to −0.01) (very low certainty evidence). For consumption outcomes, meta‐analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD −0.60 (95% CI −0.84 to −0.36) (low certainty evidence). Meta‐regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias. Authors' conclusions The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real‐world settings, intervening across a wider range of foods ‐ as well as alcohol and tobacco products ‐ and over sustained time periods. Plain language summary Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption Unhealthy patterns of consumption of food, alcohol, and tobacco products are important causes of ill health. Changing the availability (the range or amount of options, or both) of these products or their proximity (the distance at which they are positioned) to potential consumers could help people make healthier choices. What is the aim of this review? This review investigated whether altering the availability or proximity of food (including non‐alcoholic beverages), alcohol, and tobacco products changed people's selection (such as purchasing) or consumption of those products. We searched for all available evidence from randomised controlled trials (a type of study in which participants are assigned to one of two or more treatment groups using a random method) to answer this question, and found 24 studies, all of which were conducted in high‐income countries. What are the main results of the review? Six studies involved availability interventions, of which four changed the relative proportion of less‐healthy to healthier options, and two changed the absolute number of different options available. In statistical analyses that combined results from multiple studies, it was found that reducing the number of available options for a particular range or category of food(s) reduced selection of those food products (from analysing 154 participants) and possibly reduced consumption of those products (from 150 participants). However, the certainty of the evidence for these effects was low. Eighteen studies involved proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. One study found that this reduced selection of food (from analysing 41 participants), whilst in a statistical analysis combining results from multiple studies, it was found that placing food farther away reduced consumption of those food products (from analysing 1098 participants). However, the certainty of the evidence for these effects was very low and low, respectively. Key messages Mindful of its limitations, the current evidence suggests that changing the number of available food options or changing where foods are positioned could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes to food environments. However, more high‐quality studies in real‐world settings are needed to make this finding more certain. How up‐to‐date is this review? The evidence is current to 23 July 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Hollands, GJ, Carter, P, Anwer, S, King, SE, Jebb, SA, Ogilvie, D, Shemilt, I, Higgins, JPT, Marteau, TM", "articleTypes": [], "doi": "10.1002/14651858.CD012573.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.814Z" }, { "id": "fce30995-ba65-44e9-9bdd-4f08ad77e716", "pmid": "", "title": "Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years", "imported": false, "abstract": "Abstract - Background Child and adolescent overweight and obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages. Objectives To assess the effects of diet, physical activity and behavioural interventions (behaviour‐changing interventions) for the treatment of overweight or obese children aged 6 to 11 years. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases. Selection criteria We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour‐changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow‐up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. Data collection and analysis Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta‐analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions . Main results We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty‐five trials compared a behaviour‐changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour‐changing intervention. Sixty‐four trials were parallel RCTs, and four were cluster RCTs. Sixty‐four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2. Primary analyses demonstrated that behaviour‐changing interventions compared to no treatment/usual care control at longest follow‐up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was ‐0.53 kg/m 2 (95% confidence interval (CI) ‐0.82 to ‐0.24); P < 0.00001; 24 trials; 2785 participants; low‐quality evidence. MD in BMI z score was ‐0.06 units (95% CI ‐0.10 to ‐0.02); P = 0.001; 37 trials; 4019 participants; low‐quality evidence and MD in weight was ‐1.45 kg (95% CI ‐1.88 to ‐1.02); P < 0.00001; 17 trials; 1774 participants; low‐quality evidence. Thirty‐one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health‐related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI ‐12.88 to ‐0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all‐cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta‐analysed. As the meta‐analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post‐intervention follow‐up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post‐intervention was no longer evident at follow‐up at less than six months, which has to be investigated in further trials. Authors' conclusions Multi‐component behaviour‐changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short‐term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour‐changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour‐changing interventions on health‐related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer‐term follow‐up and further research on the most appropriate forms of post‐intervention maintenance in order to ensure intervention benefits are sustained over the longer term. Plain language summary Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years Review question How effective are diet, physical activity and behavioural interventions in reducing the weight of overweight or obese children aged 6 to 11 years? Background Across the world more children are becoming overweight and obese. These children are more likely to suffer from health problems, both while as children and in later life. More information is needed about what works best for treating this problem. Study characteristics We found 70 randomised controlled trials (clinical trials where people are randomly put into one of two or more treatment groups) comparing diet, physical activity, and behavioural (where habits are changed or improved) treatments to a variety of control groups delivered to 8461 overweight or obese children aged 6 to 11 years. We reported on the effects of 64 multicomponent interventions (different combinations of diet and physical activity and behaviour change), four physical activity interventions and two dietary interventions compared with no intervention, 'usual care’ or some other therapy if it was also delivered in the intervention arm. The children in the included studies were followed up between six months and three years. Key results The average age of the children was 10 years. Most studies reported the body mass index (BMI) z score: BMI is a measure of body fat and is calculated by dividing weight (in kilograms) by the square of the body height measured in metres (kg/m²). In children, BMI is often measured in a way that takes into account sex and age, weight, and height changes as children grow older (BMI z score). We summarised the results of 37 trials in 4019 children reporting the BMI z score, which on average was 0.06 units lower in the intervention groups compared with the control groups. We summarised the results of 24 trials in 2785 children reporting BMI, which on average was 0.53 kg/m 2 lower in the intervention groups compared with the control groups. We summarised the results of 17 trials in 1774 children reporting weight, which on average was 1.45 kg lower in the intervention groups compared with the control groups. Other effects of the interventions, such as improvements in health‐related quality of life were less clear. No study investigated death from any cause, morbidity or socioeconomic effects. Serious adverse events were rare: only two of 31 trials with data reported any serious adverse events (4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). This evidence is up to date as of July 2016. Quality of the evidence The overall quality of the evidence was low or very low, mainly because of limited confidence in how studies were performed, and the results were inconsistent between the studies. Also there were just a few studies for some outcomes, with small numbers of included children.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Mead, E, Brown, T, Rees, K, Azevedo, LB, Whittaker, V, Jones, D, Olajide, J, Mainardi, GM, Corpeleijn, E, O'Malley, C, et al.", "articleTypes": [], "doi": "10.1002/14651858.CD012651", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.826Z" }, { "id": "fd35b28d-bdc3-4dcb-bf44-dac9d6f5c531", "pmid": "", "title": "Oral water soluble contrast for malignant bowel obstruction", "imported": false, "abstract": "Abstract - Background Malignant bowel obstruction (MBO) is a common problem in patients with intra‐abdominal cancer. Oral water soluble contrast (OWSC) has been shown to be useful in the management of adhesive small bowel obstruction in identifying patients who will recover with conservative management alone and also in reducing the length of hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in patients with MBO. Objectives To determine the reliability of OWSC media and follow‐up abdominal radiographs in predicting the success of conservative treatment in resolving inoperable MBO with conservative management. To determine the efficacy and safety of OWSC media in reducing the duration of obstruction and reducing hospital stay in people with MBO. Search methods We identified studies from searching Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in Process, Embase, CINAHL, Science Citation Index (Web of Science) and Conference Proceedings Citation Index ‐ Science (Web of Science). We also searched registries of clinical trials and the CareSearch Grey Literature database. The date of the search was the 6 June 2017. Selection criteria Randomised controlled trials (RCTs), or prospective controlled studies, that evaluated the diagnostic potential of OWSC in predicting which malignant bowel obstructions will resolve with conservative treatment. RCTs, or prospective controlled studies, that assessed the therapeutic potential of OWSC in managing MBO at any level compared with placebo, no intervention or usual treatment or supportive care. Data collection and analysis We used standard methodological procedures expected by Cochrane. We assessed risk of bias and assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We found only one RCT meeting the selection criteria for the second objective (therapeutic potential) of this review. This study recruited nine participants. It compared the use of gastrografin versus placebo in adult patients with MBO with no indication for further intervention (surgery, endoscopy) apart from standardised conservative management. The overall risk of bias for the study was high due to issues with low numbers of participants, selective reporting of outcomes and a high attrition rate for the intervention arm. Primary outcomes The included trial was a pilot study whose primary outcome was to test the feasibility for a large study. The authors reported specifically on the number of patients screened, the number recruited and reasons for exclusion; this was not the focus of our review. Due to the low number of participants, the authors of the study decided not to report on our primary outcome of assessing the ability of OWSC to predict the likelihood of malignant small bowel obstruction resolving with conservative treatment alone (diagnostic effect). It also did not report on our primary outcome of rate of resolution of MBO in patients receiving OWSC compared with those not receiving it (therapeutic effect). The study reported that no issues regarding safety or tolerability of either gastrografin or placebo were identified. The overall quality of the evidence for the incidence of adverse events with OWSC was very low, downgraded twice for serious limitations to study quality (high risk of selective reporting and attrition bias) and downgraded once for imprecision (sparse data). Secondary outcomes The study planned to report on this review’s secondary outcome measures of length of hospital stay and time from administration of OWSC to resolution of MBO. However the authors of the study decided not to do so due to the low numbers of patients recruited. The study did not report on our secondary outcome measure of survival times from onset of inoperable MBO until death. Authors' conclusions There is insufficient evidence from RCTs to determine the place of OWSC in predicting which patients with inoperable MBO will respond with conservative treatment alone. There is also insufficient evidence from RCTs to determine the therapeutic effects and safety of OWSC in patients with malignant small bowel obstruction. Plain language summary Oral water soluble contrast for cancer‐related bowel obstruction Background Intra‐abdominal cancer is where the cancer has either started elsewhere in the body and spread into the stomach area or started in the bowel itself. It can commonly grow and block the movement of food or faeces through the bowel. A blockage of the bowel caused by cancer is known as malignant bowel obstruction (MBO). Some patients with MBO benefit from surgery to reverse the blockage. In others it is not possible to reverse the MBO and it either resolves or becomes permanent (limiting prognosis to days or weeks). Scar tissue around the bowel (called adhesions) can also cause a blockage, this is known as adhesive small bowel obstruction. Adhesive obstructions often resolve with conservative management in hospital (allowing the bowel to \"rest\" and recover). However in some, the obstruction requires surgery to remove the scar tissue and fix the blockage. Oral water soluble contrast (OWSC) is often prepared in liquid form and when swallowed before an x‐ray or computed tomography (CT) scan will show up clearly in the bowel. It can predict which people with adhesive small bowel obstruction will require surgery. In some patients it may also speed recovery leading to reduced hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in MBO. Study characteristics We searched for evidence that OWSC could be used to identify which patients with inoperable MBO would recover with conservative management. We also wanted to know if OWSC increased the likelihood of recovery from MBO, reduced hospital stay or improved prognosis. Finally, we wished to know what side effects OWSC might cause for patients with MBO. We conducted the search in June 2017 and found one study. It only recruited nine participants and did not fully report on the outcomes of using OWSC in MBO. Key Findings We found insufficient evidence that OWSC can identify which patients with MBO will recover with conservative management. We found insufficient evidence that patients with MBO benefit from OWSC in terms of length of hospital stay, recovery time or survival. No conclusions could be made about side effects from OWSC. Quality of Evidence We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. We rated the quality of the evidence as very low due to the lack of studies reporting on the benefits of using OWSC in MBO and the only study we found reporting on side effects recruited very few participants (nine). The low quality of the evidence means that we are very uncertain about the use of OWSC in the management of MBO and cannot confirm its benefits or harms in patients with this condition.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Syrmis, W; Richard, R; Jenkins-Marsh, S; Chia, SC; Good, P", "articleTypes": [], "doi": "10.1002/14651858.CD012014.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "fd3ab051-db57-45c0-87c8-51e437d659f0", "pmid": "", "title": "Dietary Peanut Intake and Nutrition-Related Outcomes in Individuals Using GLP-1 Receptor Agonists: A Randomized Controlled Trial", "imported": false, "abstract": "This study will look at how eating peanuts every day might affect participants weight, how healthy their diet is, and how they feel when eating. Investigators want to see if adding peanuts to meals for 12 weeks helps participants feel fuller, have more energy, and improve body composition. The study will include adults who have been taking GLP-1 medicines like semaglutide or tirzepatide for at least three months. Investigators also want to see if eating peanuts improves overall diet quality and health markers like tiredness and certain levels in blood.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.241Z" }, { "id": "fd46c20e-4264-417d-9b4e-d8b67783301b", "pmid": "", "title": "Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2022", "authors": "Wells, GA, Hsieh, S-C, Zheng, C, Peterson, J, Liu, W, Kelly, SE, Tugwell, P", "articleTypes": [], "doi": "10.1002/14651858.CD004523.pub4 AB - Abstract - Background Osteoporosis is an abnormal reduction in bone mass and bone deterioration leading to increased fracture risk. Risedronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts. This is an update of a Cochrane Review that was originally published in 2003. Objectives We assessed the benefits and harms of risedronate in the primary and secondary prevention of osteoporotic fractures for postmenopausal women at lower and higher risk for fractures, respectively. Search methods With broader and updated strategies, we searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE and Embase. A grey literature search, including the online databases ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), and drug approval agencies, as well as bibliography checks of relevant systematic reviews was also performed. Eligible trials published between 1966 to 24 March 2021 were identified. Selection criteria We included randomised controlled trials that assessed the benefits and harms of risedronate in the prevention of fractures for postmenopausal women. Participants must have received at least one year of risedronate, placebo or other anti‐osteoporotic drugs, with or without concurrent calcium/vitamin D. Major outcomes were clinical vertebral, non‐vertebral, hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. In the interest of clinical relevance and applicability, we classified a study as secondary prevention if its population fulfilled more than one of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, low bone mineral density (BMD)T score ≤ ‐2.5, and age ≥ 75 years old. If none of these criteria was met, the study was considered to be primary prevention. Data collection and analysis We used standard methodology expected by Cochrane. We pooled the relative risk (RR) of fractures using a fixed‐effect model based on the expectation that the clinical and methodological characteristics of the respective primary and secondary prevention studies would be homogeneous, and the experience from the previous review suggesting that there would be a small number of studies. The base case included the data available for the longest treatment period in each placebo‐controlled trial and a >15% relative change was considered clinically important. The main findings of the review were presented in summary of findings tables, using the GRADE approach. In addition, we looked at benefit and harm comparisons between different dosage regimens for risedronate and between risedronate and other anti‐osteoporotic drugs. Main results Forty‐three trials fulfilled the eligibility criteria, among which 33 studies (27,348 participants) reported data that could be extracted and quantitatively synthesized. We had concerns about particular domains of risk of bias in each trial. Selection bias was the most frequent concern, with only 24% of the studies describing appropriate methods for both sequence generation and allocation concealment. Fifty per cent and 39% of the studies reporting benefit and harm outcomes, respectively, were subject to high risk. None of the studies included in the quantitative syntheses were judged to be at low risk of bias in all seven domains. The results described below pertain to the comparisons for daily risedronate 5 mg versus placebo which reported major outcomes. Other comparisons are described in the full text. For primary prevention, low‐ to very low‐certainty evidence was collected from four studies (one to two years in length) including 989 postmenopausal women at lower risk of fractures. Risedronate 5 mg/day may make little or no difference to wrist fractures [RR 0.48 ( 95% CI 0.03 to 7.50; two studies, 243 participants); absolute risk reduction (ARR) 0.6% fewer (95% CI 1% fewer to 7% more)] and withdrawals due to adverse events [RR 0.67 (95% CI 0.38 to 1.18; three studies, 748 participants); ARR 2% fewer (95% CI 5% fewer to 1% more)], based on low‐certainty evidence. However, its preventive effects on non‐vertebral fractures and serious adverse events are not known due to the very low‐certainty evidence. There were zero clinical vertebral and hip fractures reported therefore the effects of risedronate for these outcomes are not estimable. For secondary prevention, nine studies (one to three years in length) including 14,354 postmenopausal women at higher risk of fractures provided evidence. Risedronate 5 mg/day probably prevents non‐vertebral fractures [RR 0.80 (95% CI 0.72 to 0.90; six studies, 12,173 participants); RRR 20% (95% CI 10% to 28%) and ARR 2% fewer (95% CI 1% fewer to 3% fewer), moderate certainty], and may reduce hip fractures [RR 0.73 (95% CI 0.56 to 0.94); RRR 27% (95% CI 6% to 44%) and ARR 1% fewer (95% CI 0.2% fewer to 1% fewer), low certainty]. Both of these effects are probably clinically important. However, risedronate's effects are not known for wrist fractures [RR 0.64 (95% CI 0.33 to 1.24); three studies,1746 participants); ARR 1% fewer (95% CI 2% fewer to 1% more), very‐low certainty] and not estimable for clinical vertebral fractures due to zero events reported (low certainty). Risedronate results in little to no difference in withdrawals due to adverse events [RR 0.98 (95% CI 0.90 to 1.07; eight studies, 9529 participants); ARR 0.3% fewer (95% CI 2% fewer to 1% more); 16.9% in risedronate versus 17.2% in control, high certainty] and probably results in little to no difference in serious adverse events [RR 1.00 (95% CI 0.94 to 1.07; six studies, 9435 participants); ARR 0% fewer (95% CI 2% fewer to 2% more; 29.2% in both groups, moderate certainty). Authors' conclusions This update recaps the key findings from our previous review that, for secondary prevention, risedronate 5 mg/day probably prevents non‐vertebral fracture, and may reduce the risk of hip fractures. We are uncertain on whether risedronate 5mg/day reduces clinical vertebral and wrist fractures. Compared to placebo, risedronate probably does not increase the risk of serious adverse events. For primary prevention, the benefit and harms of risedronate were supported by limited evidence with high uncertainty. Plain language summary Risedronate for preventing fractures caused by osteoporosis in postmenopausal women This summary of a Cochrane Review presents what we know from the evidence up to 24 March 2021 about the effect of risedronate for preventing fractures (broken bones) caused by osteoporosis. What is osteoporosis and what is risedronate? 
Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow and old bone cells break down to make room for the new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break even after a minor injury, like a little bump or fall. Women who have gone through menopause are more likely to get osteoporosis than other people. Risedronate belongs to the class of drugs called bisphosphonates. It is a type of medication that slows down the cells that break down the old bone. In postmenopausal women whose bone density is closer to normal or who may not yet have had a fracture in the bones of their spine therefore putting them at lower risk for fractures: ‐ there is insufficient evidence to tell us if risedronate leads to any reduction in the number of women sustaining bone fractures; ‐ based on limited data there is no evidence of an increase in adverse events for postmenopausal women at lower risk for fractures. In postmenopausal women who have already been diagnosed with osteoporosis (who have low bone density, or who have already had a fracture in the bones of their spine) putting them at higher risk for fractures, risedronate: ‐ probably prevents fractures in the bones of the hip and in bones other than in the spine; ‐ may not lead to any difference in preventing wrist fractures; ‐ does not have enough evidence to show if it may prevent fractures in the bones of the spine suggested by clinical signs and symptoms; ‐ might make little or no difference in adverse events for postmenopausal women at higher risk for fractures. Best estimate of what happens to postmenopausal women at lower risk for fractures who take risedronate or placebo: ‐ for spine fractures suggested by clinical signs and symptoms and hip fractures, it was not possible to calculate the effect because none of these fractures were reported in any of the studies; ‐ compared to placebo, there is not enough information to tell if risedronate prevents fractures in wrist and bones other than in the spine. Best estimate of what happens to postmenopausal women at higher risk for fractures who take risedronate or placebo: Fractures of the spine suggested by clinical signs and symptoms were not reported in any of the studies. Fractures in bones other than the spine: ‐ 10 out of 100 women had a fracture when taking a placebo; ‐ 8 out of 100 women had a fracture when taking risedronate; Fractures of the hip ‐ 3 out of 100 women had a fracture when taking a placebo; ‐ 2 out of 100 women had a fracture when taking risedronate. Fractures of the wrist: ‐ there is not enough information to tell if risedronate prevents wrist fractures.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.812Z" }, { "id": "fd4e5cce-9917-4bd7-a622-b414d07bd52e", "pmid": "", "title": "Interventions for preventing high altitude illness: Part 2. Less commonly‐used drugs", "imported": false, "abstract": "Abstract - Background High altitude illness (HAI) is a term used to describe a group of mainly cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres (˜ 8200 feet). Acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude ascent. In this second review, in a series of three about preventive strategies for HAI, we assessed the effectiveness of five of the less commonly used classes of pharmacological interventions. Objectives To assess the clinical effectiveness and adverse events of five of the less commonly used pharmacological interventions for preventing acute HAI in participants who are at risk of developing high altitude illness in any setting. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in May 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus‐based and free‐text search terms. We scanned the reference lists and citations of included trials and any relevant systematic reviews that we identified for further references to additional trials. Selection criteria We included randomized controlled trials conducted in any setting where one of five classes of drugs was employed to prevent acute HAI: selective 5‐hydroxytryptamine(1) receptor agonists; N‐methyl‐D‐aspartate (NMDA) antagonist; endothelin‐1 antagonist; anticonvulsant drugs; and spironolactone. We included trials involving participants who are at risk of developing high altitude illness (AMS or HACE, or HAPE, or both). We included participants with and without a history of high altitude illness. We applied no age or gender restrictions. We included trials where the relevant medication was administered before the beginning of ascent. We excluded trials using these drugs during ascent or after ascent. Data collection and analysis We used the standard methodological procedures employed by Cochrane. Main results We included eight studies (334 participants, 9 references) in this review. Twelve studies are ongoing and will be considered in future versions of this review as appropriate. We have been unable to obtain full‐text versions of a further 12 studies and have designated them as 'awaiting classification'. Four studies were at a low risk of bias for randomization; two at a low risk of bias for allocation concealment. Four studies were at a low risk of bias for blinding of participants and personnel. We considered three studies at a low risk of bias for blinding of outcome assessors. We considered most studies at a high risk of selective reporting bias. We report results for the following four main comparisons. Sumatriptan versus placebo (1 parallel study; 102 participants) Data on sumatriptan showed a reduction of the risk of AMS when compared with a placebo (risk ratio (RR) = 0.43, CI 95% 0.21 to 0.84; 1 study, 102 participants; low quality of evidence). The one included study did not report events of HAPE, HACE or adverse events related to administrations of sumatriptan. Magnesium citrate versus placebo (1 parallel study; 70 participants) The estimated RR for AMS, comparing magnesium citrate tablets versus placebo, was 1.09 (95% CI 0.55 to 2.13; 1 study; 70 participants; low quality of evidence). In addition, the estimated RR for loose stools was 3.25 (95% CI 1.17 to 8.99; 1 study; 70 participants; low quality of evidence). The one included study did not report events of HAPE or HACE. Spironolactone versus placebo (2 parallel studies; 205 participants) Pooled estimation of RR for AMS was not performed due to considerable heterogeneity between the included studies (I² = 72%). RR from individual studies was 0.40 (95% CI 0.12 to 1.31) and 1.44 (95% CI 0.79 to 2.01; very low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Acetazolamide versus spironolactone (1 parallel study; 232 participants) Data on acetazolamide compared with spironolactone showed a reduction of the risk of AMS with the administration of acetazolamide (RR = 0.36, 95% CI 0.18 to 0.70; 232 participants; low quality of evidence). No events of HAPE or HACE were reported. Adverse events were not evaluated. Authors' conclusions This Cochrane Review is the second in a series of three providing relevant information to clinicians and other interested parties on how to prevent high altitude illness. The assessment of five of the less commonly used classes of drugs suggests that there is a scarcity of evidence related to these interventions. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Overall, the evidence is limited due to the low number of studies identified (for most of the comparison only one study was identified); limitations in the quality of the evidence (moderate to low); and the number of studies pending classification (24 studies awaiting classification or ongoing). We lack the large and methodologically sound studies required to establish or refute the efficacy and safety of most of the pharmacological agents evaluated in this review. Plain language summary Medicines less commonly used for preventing high altitude illness Background High altitude illness (HAI) is a term used to describe a group of brain and lung conditions that can occur during travel to altitudes above 2500 metres (˜ 8200 feet). HAI‐related conditions are generally characterized by headache, nausea, vomiting and tiredness (often called acute mountain sickness), but primarily affect the brain (drowsiness, confusion or unconsciousness) or the lungs (cough, breathlessness) in different individuals. We assessed five classes of medicines less commonly used to prevent the onset of this illness in this review. Study characteristics The evidence is current to May 2017. We included eight studies and 334 participants related to five different classes of medicines sometimes recommended for HAI prevention. These medicines included those that mimic the action of serotonin at selected sites (selective 5‐hydroxytryptamine(1) receptor agonists), medicines that regulate the action of calcium (N‐methyl‐D‐aspartate (NMDA) antagonist), medicines that promote dilation of the blood vessels (endothelin‐1 antagonist), medicines that prevent a neuron (nerve cell) from 'firing' (initiating an action) and convulsions from developing (anticonvulsant medicines), as well as medicines that regulate the body´s sodium and water levels (spironolactone). All studies were undertaken in high altitude mountain areas. The participants ranged between 16 and 65 years of age. Only one study included people at a high risk of this condition due to their history of HAI. Four trials provided the intervention between one to three days prior to the ascent (50%), and three trials less than 24 hours prior (37.5%). The participants in all these studies reached a final altitude of between 3500 and 5895 metres above sea level. Only one of the eight included studies did not provide clear information about the source of funding (12.5%). Twenty‐four additional studies were classified as ongoing (12), or awaiting classification (12; unable to obtain full texts). Key results The assessment of the less commonly used pharmacological interventions suggest that there is a scarcity of evidence related to these interventions. For most of the assessed comparisons, we only found evidence from a single study. Clinical benefits and harms related to potential interventions such as sumatriptan are still unclear. Quality of the evidence The quality of the evidence was rated from low to very low. Several studies had quality shortcomings such as only having small sample sizes and therefore generating uncertain results. For most of the medicines evaluated, additional research is required to clarify their effectiveness and safety.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Gonzalez Garay, AG; Molano Franco, D; Nieto Estrada, VH; Martí‐Carvajal, AJ; Arevalo‐Rodriguez, I", "articleTypes": [], "doi": "10.1002/14651858.CD012983", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.077Z" }, { "id": "fd505f4f-3366-494e-94f4-62c689de9dab", "pmid": "", "title": "Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD)", "imported": false, "abstract": "Abstract - Background Chronic obstructive pulmonary disease (COPD) is a chronic lung condition characterised by persistent respiratory symptoms and limited lung airflow, dyspnoea and recurrent exacerbations. Suboptimal therapy or non‐adherence may result in limited effectiveness of pharmacological treatments and subsequently poor health outcomes. Objectives To determine the efficacy and safety of interventions intended to improve adherence to single or combined pharmacological treatments compared with usual care or interventions that are not intended to improve adherence in people with COPD. Search methods We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register, CENTRAL, MEDLINE and Embase (search date 1 May 2020). We also searched web‐based clinical trial registers. Selection criteria RCTs included adults with COPD diagnosed by established criteria (e.g. Global Initiative for Obstructive Lung Disease). Interventions included change to pharmacological treatment regimens, adherence aids, education, behavioural or psychological interventions (e.g. cognitive behavioural therapy), communication or follow‐up by a health professional (e.g. telephone, text message or face‐to‐face), multi‐component interventions, and interventions to improve inhaler technique. Data collection and analysis We used standard Cochrane methodological procedures. Working in pairs, four review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We assessed confidence in the evidence for each primary outcome using GRADE. Primary outcomes were adherence, quality of life and hospital service utilisation. Adherence measures included the Adherence among Patients with Chronic Disease questionnaire (APCD). Quality of life measures included the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). Main results We included 14 trials (2191 participants) in the analysis with follow‐up ranging from six to 52 weeks. Age ranged from 54 to 75 years, and COPD severity ranged from mild to very severe. Trials were conducted in the USA, Spain, Germany, Japan, Jordan, Northern Ireland, Iran, South Korea, China and Belgium. Risk of bias was high due to lack of blinding. Evidence certainty was downgraded due to imprecision and small participant numbers. Single component interventions Six studies (55 to 212 participants) reported single component interventions including changes to pharmacological treatment (different roflumilast doses or different inhaler types), adherence aids (Bluetooth inhaler reminder device), educational (comprehensive verbal instruction), behavioural or psychological (motivational interview). Change in dose of roflumilast may result in little to no difference in adherence (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.22 to 1.99; studies = 1, participants = 55; low certainty). A Bluetooth inhaler reminder device did not improve adherence, but comprehensive verbal instruction from a health professional did improve mean adherence (prescription refills) (mean difference (MD) 1.00, 95% CI 0.46 to 1.54). Motivational interview improved mean adherence scores on the APCD scale (MD 22.22, 95% CI 8.42 to 36.02). Use of a single inhaler compared to two separate inhalers may have little to no impact on quality of life (SGRQ; MD 0.80, 95% CI –3.12 to 4.72; very low certainty). A Bluetooth inhaler monitoring device may provide a small improvement in quality of life on the CCQ (MD 0.40, 95% CI 0.07 to 0.73; very low certainty). Single inhaler use may have little to no impact on the number of people admitted to hospital compared to two separate inhalers (OR 1.47, 95% CI 0.75 to 2.90; very low certainty). Single component interventions may have little to no impact on the number of people expereincing adverse events (very low certainty evidence from studies of a change in pharmacotherapy or use of adherence aids). A change in pharmacotherapy may have little to no impact on exacerbations or deaths (very low certainty). Multi‐component interventions Eight studies (30 to 734 participants) reported multi‐component interventions including tailored care package that included adherence support as a key component or included inhaler technique as a component. A multi‐component intervention may result in more people adhering to pharmacotherapy compared to control at 40.5 weeks (risk ratio (RR) 1.37, 95% CI 1.18 to 1.59; studies = 4, participants = 446; I 2 = 0%; low certainty). There may be little to no impact on quality of life (SGRQ, Chronic Respiratory Disease Questionnaire, CAT) (studies = 3; low to very low certainty). Multi‐component interventions may help to reduce the number of people admitted to hospital for any cause (OR 0.37, 95% CI 0.22 to 0.63; studies = 2, participants = 877; low certainty), or COPD‐related hospitalisations (OR 0.15, 95% CI 0.07 to 0.34; studies = 2, participants = 220; moderate certainty). There may be a small benefit on people experiencing severe exacerbations. There may be little to no effect on adverse events, serious adverse events or deaths, but events were infrequently reported and were rare (low to very low certainty). Authors' conclusions Single component interventions (e.g. education or motivational interviewing provided by a health professional) can help to improve adherence to pharmacotherapy (low to very low certainty). There were slight improvements in quality of life with a Bluetooth inhaler device, but evidence is from one study and very low certainty. Change to pharmacotherapy (e.g. single inhaler instead of two, or different doses of roflumilast) has little impact on hospitalisations or exacerbations (very low certainty). There is no difference in people experiencing adverse events (all‐cause or COPD‐related), or deaths (very low certainty). Multi‐component interventions may improve adherence with education, motivational or behavioural components delivered by health professionals (low certainty). There is little to no impact on quality of life (low to very low certainty). They may help reduce the number of people admitted to hospital overall (specifically pharmacist‐led approaches) (low certainty), and fewer people may have COPD‐related hospital admissions (moderately certainty). There may be a small reduction in people experiencing severe exacerbations, but evidence is from one study (low certainty). Limited evidence found no difference in people experiencing adverse events, serious adverse events or deaths (low to very low certainty). The evidence presented should be interpreted with caution. Larger studies with more intervention types, especially single interventions, are needed. It is unclear which specific COPD subgroups would benefit, therefore discussions between health professionals and patients may help to determine whether they will help to improve health outcomes. Plain language summary Which approaches help people with COPD to maintain taking medication as prescribed? Review question Which approaches help people maintain taking prescribed medication(s), improve quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD)? Background COPD is a lung condition that can cause long‐term breathing problems and includes symptoms such as shortness of breath. Medications do exist that can help but sometimes people do not take them as prescribed. Different approaches could help people to take their medication as prescribed and help improve symptoms or quality of life and reduce hospital admissions. We wanted to find out if any approaches could help people with COPD take their medication(s) as prescribed. Studies identified and selected We searched databases to find the studies. Four people working in pairs looked at the lists of studies separately and agreed on which ones were included. The latest search for studies was conducted in May 2020. Study characteristics We included studies comparing simple ways to help improve medication use (e.g. different medication doses or single inhalers instead of two separate inhalers) to usual COPD care. We also included studies that tested combination approaches (e.g. information or training from nurses or pharmacists and monitoring medication use). What were the key results? We included 14 studies (2191 people) in our analysis. No studies were masked (people knew whether they were receiving an approach to help them with adherence or the alternative). Six studies used simple approaches (e.g. change to medication dosage, change to type of inhaler, or a Bluetooth inhaler reminder device), and eight studies used combined approaches (e.g. nurses or pharmacists giving advice or information about how to improve medication use). We were uncertain about the effects of a different medication dose on people adhering to medication because it was no different to usual care (one study). Two separate studies found that a Bluetooth inhaler reminder device or a change in oral medication dose did not help to improve adherence. Health professionals involved in giving information may help to improve adherence (one study). This was measured by prescription refills. Motivating people to change their behaviour could help to improve adherence their medication (one study). This was measured by people completing a questionnaire about adherence to their medication. One study found that a Bluetooth inhaler device might help to improve quality of life. There may be little to no difference between those using single inhalers in the number of people admitted to hospital compared to those using two separate inhalers (one study). We found no difference between single approaches and usual care on the number of people who had side effects. Combined approaches may help to improve the number of people taking their medication, but we were not confident of this finding (four studies). They may have little to no impact on quality of life (three studies). Combined approaches could be beneficial in reducing the number of people with COPD admitted to hospital for any reason or because of COPD symptoms (two studies). There was no difference between combined approaches and in the number of people who had adverse events. Take home message We could not say for certain that simple approaches are useful to help people with COPD to improve medication use because of very limited information. Combined approaches may help people to take their medication(s) as prescribed and can help to reduce the number of people admitted to hospital, however, more information is needed to help answer this question with confidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2021", "authors": "Janjua, S, Pike, KC, Carr, R, Coles, A, Fortescue, R, Batavia, M", "articleTypes": [], "doi": "10.1002/14651858.CD013381.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.778Z" }, { "id": "fd606d6e-31f5-47ec-869e-d0fcac9429f0", "pmid": "", "title": "Advice to reduce dietary salt for prevention of cardiovascular disease", "imported": false, "abstract": "Abstract - Background Restricting sodium intake in hypertensive patients over short periods of time reduces blood pressure. Long term effects (on mortality, morbidity or blood pressure) of advice to reduce salt in patients with elevated or normal blood pressure are unclear. Objectives To assess in adults the long term effects (mortality, cardiovascular events, blood pressure, quality of life, weight, urinary sodium excretion, other nutrients and use of anti‐hypertensive medications) of advice to restrict dietary sodium using all relevant randomised controlled trials. Search methods The Cochrane Library, MEDLINE, EMBASE, bibliographies of included studies and related systematic reviews were searched for unconfounded randomised trials in healthy adults aiming to reduce sodium intake over at least 6 months. Attempts were made to trace unpublished or missed studies and authors of all included trials were contacted. There were no language restrictions. Selection criteria Inclusion decisions were independently duplicated and based on the following criteria: 1) randomisation was adequate; 2) there was a usual or control diet group; 3) the intervention aimed to reduce sodium intake; 4) the intervention was not multifactorial; 5) the participants were not children, acutely ill, pregnant or institutionalised; 6) follow‐up was at least 26 weeks; 7) data on any of the outcomes of interest were available. Data collection and analysis Decisions on validity and data extraction were made independently by two reviewers, disagreements were resolved by discussion or if necessary by a third reviewer. Random effects meta‐analysis, sub‐grouping, sensitivity analysis and meta‐regression were performed. Main results Three trials in normotensives (n=2326), five in untreated hypertensives (n=387) and three in treated hypertensives (n=801) were included, with follow up from six months to seven years. The large, high quality (and therefore most informative) studies used intensive behavioural interventions. Deaths and cardiovascular events were inconsistently defined and reported; only 17 deaths equally distributed between intervention and control groups occurred. Systolic and diastolic blood pressures were reduced at 13 to 60 months in those given low sodium advice as compared with controls (systolic by 1.1 mm Hg, 95% CI 1.8 to 0.4, diastolic by 0.6 mm hg, 95% CI 1.5 to ‐0.3), as was urinary 24 hour sodium excretion (by 35.5 mmol/ 24 hours, 95% CI 47.2 to 23.9). Degree of reduction in sodium intake and change in blood pressure were not related. People on anti‐hypertensive medications were able to stop their medication more often on a reduced sodium diet as compared with controls, while maintaining similar blood pressure control. Authors' conclusions Intensive interventions, unsuited to primary care or population prevention programmes, provide only minimal reductions in blood pressure during long‐term trials. Further evaluations to assess effects on morbidity and mortality outcomes are needed for populations as a whole and for patients with elevated blood pressure. A low sodium diet may help in maintenance of lower blood pressure following withdrawal of antihypertensives. If this is confirmed, with no increase in cardiovascular events, then targeting of comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. Plain language summary The long term effects of advice to cut down on salt in food on deaths, cardiovascular disease and blood pressure in adults Intensive support and encouragement to reduce salt intake did lead to reduction in salt eaten. It also lowered blood pressure but only by a small amount (about 1 mmHg for systolic blood pressure, less for diastolic) after more than a year. This reduction was not enough to expect an important health benefit. It was also very hard to keep to a low salt diet. However, the reduction in blood pressure appeared larger for people with higher blood pressure. There was not enough information to assess the effect of these changes in salt intake on health or deaths. Evidence from a large and small trial showed that advice to reduce salt helps to maintain lower blood pressure following withdrawal of antihypertensive medication. If this is confirmed, with no increase in cardiovascular events, then comprehensive dietary and behavioural programmes in patients with elevated blood pressure requiring drug treatment would be justified. See also the Cochrane review of short‐term salt reduction trials: Jurgens 2003 .", "journal": "Cochrane Database of Systematic Reviews", "year": "2004", "authors": "Hooper, L, Bartlett, C, Davey Smith, G, Ebrahim, S", "articleTypes": [], "doi": "10.1002/14651858.CD003656.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.724Z" }, { "id": "fd64a58e-afd2-4d6a-8c24-223359997953", "pmid": "", "title": "Bitter Taste and Allele-specific Expression of the Human TAS2R38 Gene", "imported": false, "abstract": "This single-site, within-subject experimental basic research study is designed to analyze the hypothesis that allele-specific expression of the bitter taste receptor T2R38 in taste tissue of individuals heterozygous for the taste receptor gene TAS2R38 correlates with that in nasal epithelium, and is responsible for differences in acyl-homoserine lactone-induced respiratory defenses. Subjects will include 100 predominantly European adults without chronic rhinosinusitis who will be undergoing a sinonasal procedure for reconstructive purposes. All subjects will provide saliva samples for genotyping, from which 25 subjects heterozygous for TAS2R38 (AVI/PAV) will be identified. These individuals will be asked to complete a beverage frequency questionnaire and taste test prior to the procedure that will evaluate for a number of compounds, among them bitter ligands specific to T2R38. Their tongue will also be photographed to evaluate the anatomy of their fungiform papillae, the mushroom-like structures on the tongue which contain taste buds. Subjects will subsequently provide nasal epithelium and taste tissue, which will be processed to 1) evaluate for allele-specific expression of TAS2R38 mRNA in both the taste and nasal tissue, with the nasal tissue concurrently being cultured in an air-liquid interface system to 2) assess the AHL-induced respiratory defenses of ciliary beat frequency (CBF) and nitric oxide (NO) production. Should subjects require a subsequent sinonasal procedure for clinically-determined reasons, taste and nasal tissue will again be obtained and analyzed for TAS2R38 mRNA, allowing for 3) longitudinal evaluation of mRNA expression level.", "journal": "", "year": "2016", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.142Z" }, { "id": "fd663709-7585-45b3-8f94-3b8f80833efc", "pmid": "", "title": "Smell, Taste, Salivary Flow, and Oral Health in Patient Receiving Dialysis: A Before and After Study", "imported": false, "abstract": "Studies show that the change of smell and taste, also dry mouth are the most common symptoms in end stage renal disease patients, the accumulation of uremic toxins would damage the intrinsinc antioxidant systems of the olfactory epithelium and olfactory bulb, which leads to smell dysfunction compared to healthy group. Previous studies show different results about if getting rid of uremic toxins would help improve smell, even if they say olfactory identification is improved after hemodialysis episode, but there's no short term reliability of Sniffin'sticks to prove the credibility of the findings. Reduction of the whole saliva and unstimulated salivary flow rate cause dry mouth, also change oral environment, which makes dental plaque easily attach to teeth. And the accumulation of uremic in oral cavity causes oral odor, plus lack of zinc iron and reduction of saliva would affect the tastants transferred to its receptors which leads to taste dysfunction. Besides, when the patients has olfactory dysfunction, the taste will be affected as well, plus the accumulation of uremic toxin in the oral cavity also stops the conjunction of smell and taste receptors which affects taste. To understand smell, taste and oral condition in end stage renal disease patients, and due to there's no short term reliability of Sniffin'sticks, plus it's expensive and time-consuming to implement the taste assessment tool. Thus the main purpose of this study is: 1. To investigate smell and taste function, salivary secretion, oral condition, plaque index and dry mouth in end stage renal disease patients who haven't been under hemodialysis. 2. To investigate the short term reliability of Sniffin'sticks, the measuring tool of olfactory with 3-4 hours interval. 3. To investigate if Taste and Smell Survey could be the tool which detects abnormality of taste 4. To investigate the change of smell, taste and salivary secretion within 24 hours after the first episode of hemodialysis.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.235Z" }, { "id": "fd7590b6-87f9-4880-bef8-f180946de9d6", "pmid": "", "title": "Acupuncture for Bell's palsy", "imported": false, "abstract": "Abstract - Background Bell's palsy or idiopathic facial palsy is an acute facial paralysis due to inflammation of the facial nerve. A number of studies published in China have suggested acupuncture is beneficial for facial palsy. Objectives The objective of this review was to examine the efficacy of acupuncture in hastening recovery and reducing long‐term morbidity from Bell's palsy. Search methods We updated the searches of the Cochrane Neuromuscular Disease Group Trials Specialized Register (24 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2010), MEDLINE (January 1966 to May 2010), EMBASE (January 1980 to May 2010), AMED (January 1985 to May 2010), LILACS (from January 1982 to May 2010) and the Chinese Biomedical Retrieval System (January 1978 to May 2010) for randomised controlled trials using 'Bell's palsy' and its synonyms, 'idiopathic facial paralysis' or 'facial palsy' as well as search terms including 'acupuncture'. Chinese journals in which we thought we might find randomised controlled trials relevant to our study were handsearched. We reviewed the bibliographies of the randomised trials and contacted the authors and known experts in the field to identify additional published or unpublished data. Selection criteria We included all randomised controlled trials involving acupuncture by needle insertion in the treatment of Bell's palsy irrespective of any language restrictions. Data collection and analysis Two review authors identified potential articles from the literature search, extracted data and assessed quality of each trial independently. All disagreements were resolved by discussion between the review authors. Main results The literature search and handsearching identified 49 potentially relevant articles. Of these, six RCTs were included involving 537 participants with Bell's palsy. Two more possible trials were identified in the update than the previous version of this systematic review, but both were excluded because they were not real RCTs. Of the six included trials, five used acupuncture while the other one used acupuncture combined with drugs. No trial reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. Authors' conclusions The quality of the included trials was inadequate to allow any conclusion about the efficacy of acupuncture. More research with high quality trials is needed. Plain language summary Acupuncture for Bell's palsy Bell's palsy or idiopathic facial palsy is the most common disorder affecting the facial nerves and results in weakness or paralysis on one side of the face. The paralysis causes distortion of the face and interferes with normal functions, such as closing the eye and eating. It is thought to be caused by inflammation of the facial nerve. According to Traditional Chinese Medicine, facial paralysis is known as 'deviated mouth'. It was attributed to 'wind' by past dynasties. 'Qi' refers to the vital substances comprising the human body and the physiological functions of viscera and bowels, channels and collaterals. It maintains life activities and reflects the resistance of the human body. Deficiency of 'qi' allows the invasion of exogenous pathogenic wind. Acupuncture is part of Traditional Chinese Medicine and dates back thousands of years. It involves inserting fine needles into specific points on the skin or applying various other techniques to the acupuncture points to bring about healing. In Bell's palsy, acupuncture treatment might have numerous beneficial effects. This review aimed to review systematically all randomised controlled trials and controlled clinical trials, which examined the effectiveness of acupuncture by needle insertion for Bell's palsy. Six studies including a total of 537 participants met the inclusion criteria. Five studies used acupuncture while the other used acupuncture combined with drugs. No trials reported on the outcomes specified for this review. Harmful side effects were not reported in any of the trials. Poor quality caused by flaws in study design or reporting (including uncertain method of randomisation, allocation concealment and blinding) and clinical differences between trials prevented reliable conclusions about the efficacy of acupuncture. More research with high quality trials is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2010", "authors": "Chen, N, Zhou, M, He, L, Zhou, D, Li, N", "articleTypes": [], "doi": "10.1002/14651858.CD002914.pub5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.741Z" }, { "id": "fd9239d2-9c27-4282-8f7f-599ea4431313", "pmid": "", "title": "The Role of Bladder Cancer TAS2R38 Expression on Chemotherapy-Induced Bitter Taste", "imported": false, "abstract": "Alteration in the sense of taste is a frequent symptom that is closely linked to chemotherapy exposure, lowering quality of life and nutritional status. Malnutrition is of particular concern in muscle-invasive bladder cancer (MIBC), as malnutrition is associated with many negative outcomes from radical cystectomy (the surgical procedure in MIBC), which include higher morbidity, poor wound healing, and higher rate of infections after surgery.", "journal": "", "year": "2020", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.144Z" }, { "id": "fdc31808-9b5f-4b98-8e44-bdf1fb3e92c6", "pmid": "", "title": "Tobacco packaging design for reducing tobacco use", "imported": false, "abstract": "Abstract - Background Tobacco use is the largest single preventable cause of death and disease worldwide. Standardised tobacco packaging is an intervention intended to reduce the promotional appeal of packs and can be defined as packaging with a uniform colour (and in some cases shape and size) with no logos or branding, apart from health warnings and other government‐mandated information, and the brand name in a prescribed uniform font, colour and size. Australia was the first country to implement standardised tobacco packaging between October and December 2012, France implemented standardised tobacco packaging on 1 January 2017 and several other countries are implementing, or intending to implement, standardised tobacco packaging. Objectives To assess the effect of standardised tobacco packaging on tobacco use uptake, cessation and reduction. Search methods We searched MEDLINE, Embase, PsycINFO and six other databases from 1980 to January 2016. We checked bibliographies and contacted study authors to identify additional peer‐reviewed studies. Selection criteria Primary outcomes included changes in tobacco use prevalence incorporating tobacco use uptake, cessation, consumption and relapse prevention. Secondary outcomes covered intermediate outcomes that can be measured and are relevant to tobacco use uptake, cessation or reduction. We considered multiple study designs: randomised controlled trials, quasi‐experimental and experimental studies, observational cross‐sectional and cohort studies. The review focused on all populations and people of any age; to be included, studies had to be published in peer‐reviewed journals. We examined studies that assessed the impact of changes in tobacco packaging such as colour, design, size and type of health warnings on the packs in relation to branded packaging. In experiments, the control condition was branded tobacco packaging but could include variations of standardised packaging. Data collection and analysis Screening and data extraction followed standard Cochrane methods. We used different 'Risk of bias' domains for different study types. We have summarised findings narratively. Main results Fifty‐one studies met our inclusion criteria, involving approximately 800,000 participants. The studies included were diverse, including observational studies, between‐ and within‐participant experimental studies, cohort and cross‐sectional studies, and time‐series analyses. Few studies assessed behavioural outcomes in youth and non‐smokers. Five studies assessed the primary outcomes: one observational study assessed smoking prevalence among 700,000 participants until one year after standardised packaging in Australia; four studies assessed consumption in 9394 participants, including a series of Australian national cross‐sectional surveys of 8811 current smokers, in addition to three smaller studies. No studies assessed uptake, cessation, or relapse prevention. Two studies assessed quit attempts. Twenty studies examined other behavioural outcomes and 45 studies examined non‐behavioural outcomes (e.g. appeal, perceptions of harm). In line with the challenges inherent in evaluating standardised tobacco packaging, a number of methodological imitations were apparent in the included studies and overall we judged most studies to be at high or unclear risk of bias in at least one domain. The one included study assessing the impact of standardised tobacco packaging on smoking prevalence in Australia found a 3.7% reduction in odds when comparing before to after the packaging change, or a 0.5 percentage point drop in smoking prevalence, when adjusting for confounders. Confidence in this finding is limited, due to the nature of the evidence available, and is therefore rated low by GRADE standards. Findings were mixed amongst the four studies assessing consumption, with some studies finding no difference and some studies finding evidence of a decrease; certainty in this outcome was rated very low by GRADE standards due to the limitations in study design. One national study of Australian adult smoker cohorts (5441 participants) found that quit attempts increased from 20.2% prior to the introduction of standardised packaging to 26.6% one year post‐implementation. A second study of calls to quitlines provides indirect support for this finding, with a 78% increase observed in the number of calls after the implementation of standardised packaging. Here again, certainty is low. Studies of other behavioural outcomes found evidence of increased avoidance behaviours when using standardised packs, reduced demand for standardised packs and reduced craving. Evidence from studies measuring eye‐tracking showed increased visual attention to health warnings on standardised compared to branded packs. Corroborative evidence for the latter finding came from studies assessing non‐behavioural outcomes, which in general found greater warning salience when viewing standardised, than branded packs. There was mixed evidence for quitting cognitions, whereas findings with youth generally pointed towards standardised packs being less likely to motivate smoking initiation than branded packs. We found the most consistent evidence for appeal, with standardised packs rating lower than branded packs. Tobacco in standardised packs was also generally perceived as worse‐tasting and lower quality than tobacco in branded packs. Standardised packaging also appeared to reduce misperceptions that some cigarettes are less harmful than others, but only when dark colours were used for the uniform colour of the pack. Authors' conclusions The available evidence suggests that standardised packaging may reduce smoking prevalence. Only one country had implemented standardised packaging at the time of this review, so evidence comes from one large observational study that provides evidence for this effect. A reduction in smoking behaviour is supported by routinely collected data by the Australian government. Data on the effects of standardised packaging on non‐behavioural outcomes (e.g. appeal) are clearer and provide plausible mechanisms of effect consistent with the observed decline in prevalence. As standardised packaging is implemented in different countries, research programmes should be initiated to capture long term effects on tobacco use prevalence, behaviour, and uptake. We did not find any evidence suggesting standardised packaging may increase tobacco use. Plain language summary Can the use of standardised packaging for tobacco products reduce the use of tobacco? Background Tobacco use kills more people worldwide than any other preventable cause of death. The best way to reduce tobacco use is by stopping people from starting to use tobacco and encouraging and helping existing users to stop. This can be done by introducing policies that can reach a wide number of people in a country, together with offering individual treatment and support to individuals who are already using tobacco to help them to stop. Many countries have introduced bans on tobacco advertising but have not controlled the look of the tobacco pack itself. Tobacco packs can be colourful and attractive, with exciting new shapes and sizes. Standardised tobacco packaging is a government policy which removes these bright designs by, for example, only allowing tobacco packs to be in one colour, shape or size. Standardised packaging generally involves the use of the same uniform colour on all tobacco packs, with no brand imagery, and the brand name written in a specified font, colour and size. Health warnings and other information that governments wish to put on the packs can remain. Australia was the first country to introduce standardised tobacco packaging by December 2012. France was the second by January 2017. Several other countries are introducing standardised packaging or planning to do so. We examined whether standardised packaging reduces tobacco use. Study characteristics We searched nine databases for articles evaluating standardised packaging that had been already reviewed by academics and published before January 2016. We also checked references in those papers to other studies and contacted the authors where necessary. Key results We found 51 studies involving approximately 800,000 participants. These studies varied considerably. Some studies focused on the effect of standardised packaging in Australia, and included looking at overall smoking levels, whether smokers altered their behaviour such as by cutting down the number of cigarettes they smoked, and whether smokers were making more quit attempts. We also included experiments in which people used or viewed standardised tobacco packs and examined their responses, compared to when they were viewing branded packs. We also included studies that assessed people’s eye movements when they looked at different packs and how willing people were to buy, and how much they were willing to pay for, standardised compared to branded packs. Only five studies looked at our key outcomes. One study in Australia looked at data from 700,000 people before and after standardised packaging was introduced. This study found that there was a half a percentage point drop in the proportion of people who used tobacco after the introduction of standardised packaging, compared to before, when adjusting for other factors which could affect this. Four other studies looked at whether current smokers changed the number of cigarettes they smoked. Two studies from Australia looked at this, one using surveys which included 8811 current smokers, and found no change in the number of cigarettes smoked. The three smaller studies found mixed results. Two further studies looked at quit attempts and observed increases in these in Australia after standardised packaging was introduced. The remainder of the studies looked at other outcomes, and the most consistent finding was that standardised packaging reduced how appealing people found the packs compared with branded packs. No studies reported the number of people who quit using tobacco, the number of people who started using tobacco, or the number of people who returned to using tobacco after quitting. Quality of the evidence Certainty in these findings is limited for several reasons, including the difficulties involved in studying national policies like standardised packaging. However, findings suggesting standardised packaging may decrease tobacco use are supported by routine data from the Australian government and studies looking at other outcomes. For example, in our included studies people consistently found standardised packs less appealing than branded packs. We did not find any evidence suggesting standardised packaging may increase tobacco use.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "McNeill, A; Gravely, S; Hitchman, SC; Bauld, L; Hammond, D; Hartmann‐Boyce, J", "articleTypes": [], "doi": "10.1002/14651858.CD011244.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "fdcea9d8-6485-4f96-8e3c-30eeccfb01ba", "pmid": "", "title": "Fish oil for induction of remission in ulcerative colitis", "imported": false, "abstract": "Abstract - Background Fish oil supplements, which are rich in n‐3 fatty acids, may reduce inflammation, decrease the need for anti‐inflammatory drugs, and promote normal weight gain in people with ulcerative colitis. Objectives This review evaluates the efficacy of fish oil for induction of remission in ulcerative colitis using all available randomised controlled trials. Search methods The Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, EMBASE, CINAHL, the database of ongoing trials and the reference lists of all publications of included or excluded trials were searched. Selection criteria Randomised controlled trials and quasi‐randomised controlled trials with active ulcerative colitis patients who were treated with fish oil. Data collection and analysis The reviewers performed study selection, assessment of methodological quality by using different approaches: including Cochrane assessment of allocation concealment and Jadad quality assessment score. Data extraction forms were used by the two reviewers to extract the data independently. Authors were contacted for additional information. Main results Six studies were included. Three were of cross‐over design and three were of parallel design. No data were pooled for analysis due to differences in outcomes and methodology among the included studies. One small study shows a positive benefit for induction of remission (RR 19.00; 95% CI 1.27 to 284.24). Some of the other included studies show some positive benefits for secondary outcomes. However, these results need to be interpreted with caution due to small study size and poor study quality. Authors' conclusions The current data does not allow for a definitive conclusion regarding the efficacy of fish oil. There is no adequate information to make recommendations for clinical practice. More research is required. Plain language summary Fish oil for the treatment of active ulcerative colitis Ulcerative colitis is an inflammation of the large intestine that causes diarrhea, abdominal pain, rectal bleeding and fever. Since there is no cure for the disease the aim of treatment is to cause a reduction of the unpleasant and painful signs and symptoms. Current, proven, treatment options for active ulcerative colitis include corticosteroids, aminosalicylates, immunosuppressive and biological agents. However, these drugs can cause side effects. New treatments which cause fewer side effects are being sought. Fish oil, which is rich in omega‐3 fatty acids may reduce inflammation and decrease the need for anti‐inflammatory drugs in patients with ulcerative colitis. Six studies looking at the effects of fish oil in active ulcerative colitis were included in the review. Study quality was mostly poor. One small study showed a positive benefit for the treatment of active ulcerative colitis. However, this result should be interpreted with caution due to small study size and poor study quality. Due to limited data there is not enough information available to determine whether fish oil treatment is effective for induction of remission in ulcerative colitis.", "journal": "Cochrane Database of Systematic Reviews", "year": "2007", "authors": "De Ley, M; de Vos, R; Hommes, DW; Stokkers, PC", "articleTypes": [], "doi": "10.1002/14651858.CD005986.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.729Z" }, { "id": "fdd92f0b-7277-464d-b714-0772c2a722c1", "pmid": "", "title": "Ribavirin monotherapy for chronic hepatitis C", "imported": false, "abstract": "Abstract - Background Hepatitis C is a major cause of liver‐related morbidity and mortality. A high proportion of patients never experience symptoms. Peginterferon plus ribavirin is the recommended treatment for chronic hepatitis C. However, ribavirin monotherapy may be considered for some patients. Objectives To assess the beneficial and harmful effects of ribavirin monotherapy for patients with chronic hepatitis C. Search methods We identified trials through electronic databases, manual searches of bibliographies and journals, authors of trials, and pharmaceutical companies until March 2009. Selection criteria We included all randomised trials irrespective of blinding, language, or publication status comparing ribavirin versus no intervention, placebo, or interferon for chronic hepatitis C. Data collection and analysis The primary outcome measures were serum sustained virological response (loss of hepatitis C virus RNA at least six months after treatment), liver‐related morbidity plus all‐cause mortality, and adverse events. Secondary outcome measures were end of treatment virological response, biochemical response (transaminase activity), and histological response. Randomisation methods, blinding, data handling, and funding were extracted as measures of bias control. Random‐effects and fixed‐effect meta‐analyses were performed for all outcomes. We only present the results of the fixed‐effect model if both models provide the same result regarding statistical significance. We present data as risk difference (RD) with 95% confidence intervals (CI). Main results We included 14 randomised trials with 657 patients. The majority of trials had unclear control of bias. Compared with placebo or no intervention, ribavirin had no significant effect on the sustained virological response (RD 0%, 95% CI ‐2% to 3%, five trials) or end of treatment virological response (RD 0% 95% CI ‐3% to 3%, ten trials). Ribavirin had no significant effect on liver‐related morbidity plus mortality (RD 0%, 95% CI ‐2% to 3%, 11 trials). Ribavirin significantly increased the risk of adverse reactions, including anaemia. Ribavirin significantly improved end of treatment biochemical and histological response but not the sustained biochemical response. Ribavirin was significantly inferior to interferon regarding virological and biochemical responses (five trials). Authors' conclusions Ribavirin seems without beneficial effects on serum virological response and liver‐related morbidity or mortality, and significantly increased the risk of adverse reactions. Ribavirin monotherapy seems significantly inferior to interferon monotherapy. The total number of included patients is small, and more trials are perhaps needed. The use of ribavirin monotherapy for chronic hepatitis C cannot be recommended outside randomised trials. Plain language summary Treatment of patients infected with hepatitis C virus Globally, about 170 million people are chronically infected with hepatitis C virus. Hepatitis C is a blood‐borne virus and routes of transmission include intravenous drug use, mother‐to‐infant transmission, unsafe medical practices, high‐risk sexual behaviour, and blood transfusion. Chronic hepatitis C is in most patients a benign viral infection, but a minority of patients develop liver cirrhosis and may suffer from complications due to cirrhosis or die from it. Treatment with interferon clears hepatitis C virus from the blood in about 15% of the patients. Adding ribavirin to interferon (combination therapy) significantly improves the number that clears hepatitis C from the blood to about 40%. Not all patients are tolerant to interferon, and also interferon is costly. This is why ribavirin given as a single drug may be considered as an option for patients with chronic hepatitis C. This review identified 11 randomised trials comparing ribavirin with no antiviral treatment in patient with chronic hepatitis C. Combining the results from all identified trials ribavirin alone seemed without beneficial effects for patients with chronic hepatitis C. Moreover, ribavirin given alone was significantly inferior compared with interferon regarding clearing hepatitis C from the blood and regarding reducing liver enzymes activity in the blood. Furthermore, ribavirin given alone increased the risk of anaemia. Thus, ribavirin given alone cannot be recommended, but more trials may be needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "Brok, J; Gluud, LL; Gluud, C", "articleTypes": [], "doi": "10.1002/14651858.CD005527.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "fdfe7d22-5314-4947-9709-0b659ff967f6", "pmid": "", "title": "Multimodal interventions for cachexia management", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Reid, J, Blair, C, Dempster, M, McKeaveney, C, Slee, A, Fitzsimons, D", "articleTypes": [], "doi": "10.1002/14651858.CD015749.pub2 AB - Abstract - Background Cachexia (disease‐related wasting) is a complex metabolic syndrome which occurs in people with chronic illnesses, including cancer, HIV/AIDS, kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People with cachexia experience unintentional weight loss, muscle loss, fatigue, loss of appetite, and reduced quality of life. Multimodal interventions which work synergistically to treat the syndrome could lead to benefits. Objectives To assess the benefits and harms of multimodal interventions aimed at alleviating or stabilising cachexia in people with a chronic illness. Search methods We searched CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers in July 2024, together with reference checking, citation searching, and contact with study authors to identify studies. Selection criteria We included randomised controlled trials (RCTs) in adults with or at risk of cachexia, comparing multimodal interventions combining two or more modalities (of pharmacology, nutrition, exercise) to treatment as usual, variation of the intervention, or unimodal intervention. Data collection and analysis Two review authors independently screened potentially eligible studies, extracted data, and assessed risk of bias (RoB 1). Primary outcomes were physical function, strength, and adverse events. Secondary outcomes were body composition and weight, quality of life (QoL), appetite, fatigue, and biochemical markers. We assessed the certainty of evidence with GRADE. Main results We included nine studies with 926 adults (mean age: 63 years). Study sample sizes ranged from 20 to 332 participants. Six studies were conducted in Europe, and one each in Turkey, New Zealand, and the USA. There were six studies in people with cancer, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. We judged four studies to be at an overall high risk of bias, and five at an overall unclear risk. All outcomes in all comparisons had very low‐certainty evidence, downgraded once for risk of bias and/or indirectness and twice for imprecision. Multimodal intervention (pharmacological, nutritional, and/or exercise) compared to treatment as usual One cancer study randomised 46 participants, with 41 included in all analyses except adverse events. The study assessed outcomes immediately after treatment, lasting six weeks. Compared to treatment as usual, there is no clear evidence for an effect of a multimodal intervention on: physical function (mean difference (MD) −16.10 m, 95% confidence interval (CI) −79.06 to 46.86; 41 participants); strength (MD 3.80 kg, 95% CI −3.21 to 10.81; 41 participants); adverse events (risk ratio (RR) 1.36, 95% CI 0.70 to 2.65; 46 participants); body composition (MD 7.89 cm 2 , 95% CI −10.43 to 26.21; 41 participants); weight (MD 5.89 kg, 95% CI −1.45 to 13.23; 41 participants); appetite (MD 0.68 points, 95% CI −0.60 to 1.96; 41 participants); fatigue (MD 0.12, 95% CI −1.05 to 1.29; 41 participants); and biochemical markers (MD 2%, 95% CI 0.99 to 3.01; 41 participants), but the evidence was very uncertain; QoL was not reported. Multimodal intervention compared to variation of the intervention Three cancer studies and one HIV/AIDS study randomised 192 participants. We could not use the available data, nor obtain additional data, from two studies (one in cancer, one in HIV/AIDS). The studies assessed outcomes immediately after treatment, ranging from three to seven months. Compared to a variation of the intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (MD 10.0 m, 95% CI −36.27 to 56.27; 1 study, 56 participants); strength (MD 0.7 kg, 95% CI −3.75 to 5.15; 1 study, 56 participants); adverse events (RR 0.87, 95% CI 0.38 to 2.02; P = 0.75, I 2 = 0%; 2 studies, 95 participants); body composition (MD −2.67 kg, 95% CI −5.89 to 0.54; P = 0.10, I 2 = 0%; 2 studies, 95 participants); weight (MD −2.47 kg, 95% CI −7.11 to 2.16; P = 0.30, I 2 = 0%; 2 studies, 95 participants); QoL (standardised mean difference (SMD) −0.15, 95% CI ���0.55 to 0.26; P = 0.47, I 2 = 0%; 2 studies, 95 participants); appetite (SMD −0.34, 95% CI −1.27 to 0.59; P = 0.48, I 2 = 79%; 2 studies, 95 participants); fatigue (MD 6.40 points, 95% CI −1.10 to 13.90; 1 study, 56 participants); or biochemical markers (MD 9.80 pg/mL, 95% CI −6.25 to 25.85; P = 0.23, I 2 = 73%; 2 studies, 95 participants), but the evidence is very uncertain. Multimodal intervention compared to unimodal intervention We included six studies (802 participants) in this comparison: three cancer studies, and one each in people with COPD, chronic kidney disease, and HIV/AIDS. The studies assessed outcomes immediately after treatment, ranging from three to seven months. We could not use the available data, nor obtain additional data, from the HIV/AIDS study. Compared to a unimodal intervention, there is no clear evidence for an effect of a multimodal intervention on: physical function (SMD 0.02, 95% CI −0.22 to 0.26; P = 0.86, I 2 = 0%; 2 studies, 348 participants); strength (SMD 0.23, 95% CI −0.81 to 1.27; P = 0.66, I 2 = 0%; 2 studies, 348 participants); adverse events (RR 0.87, 95% CI −0.43 to 1.73; P = 0.68, I 2 = 45%; 2 studies, 395 participants); body composition (SMD 0.11, 95% CI −0.28 to 0.50; P = 0.58, I 2 = 74%; 5 studies, 742 participants); body weight (SMD −0.02, 95% CI −0.38 to 0.33; P = 0.90, I 2 = 49%; 4 studies, 431 participants); QoL (SMD 0.22, 95% CI −0.29 to 0.73; P = 0.39, I 2 = 61%; 3 studies, 411 participants); appetite (SMD −0.09, 95% CI −0.58 to 0.40; P = 0.72, I 2 = 58%; 2 studies, 395 participants); fatigue (MD −6.80 points, 95% CI −12.44 to −1.17; 1 study, 244 participants); and biochemical markers (SMD 0.11, 95% CI −0.59 to 0.80; P = 0.76, I 2 = 79%; 3 studies, 411 participants), but the evidence is very uncertain. Authors' conclusions The review found insufficient evidence to support or refute the use of multimodal interventions in managing cachexia. The certainty of the evidence was very low. Methodologically rigorous, well‐powered RCTs with adequate interaction times are needed to assess the effectiveness of multimodal interventions in managing cachexia across chronic illnesses. Plain language summary What are the benefits and risks of using a combination of treatments to manage cachexia (disease‐related wasting)? Key messages: • We do not know if combinations of two or more treatments (of medication, diet, and exercise) benefit people who have or are at risk of developing cachexia (disease‐related wasting). This is because there are currently not enough robust studies in this area. • We need future research to increase our confidence in the evidence by conducting better designed and larger studies. What is cachexia? Cachexia is a complex metabolic syndrome that occurs in people with long‐term illnesses (known as chronic illnesses), such as cancer, HIV/AIDS, chronic kidney disease, heart disease, and chronic obstructive pulmonary disease (COPD). People who have cachexia may: • lose weight unintentionally;
• lose muscle;
• feel tired, weak, or both; 
• lose their appetite. Cachexia affects well‐being and can be life‐threatening. How is cachexia treated? Studies are investigating how to best manage cachexia with different treatments. These treatments can include medications, diet, and exercise, provided in a single (unimodal) or combined (multimodal) treatment. It is thought that due to the complex biology of cachexia, a combination of treatments may work in a complementary way (synergistically) to help improve the symptoms associated with cachexia and people's well‐being, extend life, or both. What did we want to find out? We wanted to find out if combining at least two treatments (out of diet, exercise, and medication) helped to improve: physical function and strength; muscle loss; weight; well‐being; appetite; fatigue; and biological indicators within the blood (biochemical markers). We also wanted to find out if these interventions were associated with any unwanted or harmful (adverse) effects. What did we do? We searched for studies that compared treatment combinations of diet, exercise and/or medication (where at least two treatments were used together) to: different combinations of treatments; a single treatment; or treatment as usual (standard care) in adults with cachexia or at risk of developing cachexia. We compared and summarised the results of the included studies. We rated our confidence in the evidence based on factors such as study methods and the number of people included. What did we find? We found nine studies that included a total of 926 adults, with an average age of 63 years. Just over half of participants (57%) were men. Studies took place around the world, including Europe (six studies), Turkey (one study), New Zealand (one study), and the USA (one study). One study included people with HIV/AIDS (average age 43 years; 35 of 50 people in the study were men); one study included people with COPD (average age 72 years; 20 of 28 people in the study were men); and one study included people with chronic kidney disease (average age 70 years; 11 of 21 in the study were men). Six studies included people with cancer (average age 64 years; 461 of 893 people in the studies were men). The studies lasted six weeks to two years. The studies used combinations of treatments which could have included diet, exercise, and/or medication, where at least two treatments were used together, and compared these to: • treatment as usual (1 study, 46 people);
• different combinations of treatments (4 studies, 192 people);
• a single treatment (6 studies, 802 people). The studies did not provide enough robust evidence to determine if multimodal interventions are associated with benefits or harms in people with or at risk of cachexia. What are the limitations of the evidence? We are not confident in the evidence because not all the studies provided information about everything that we were interested in. Additionally, the studies used different ways of measuring results, and most of the studies included only small numbers of people. Importantly, future studies may change the conclusions of this review. How current is this review? The evidence is current to June 2024.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.791Z" }, { "id": "fe022f75-e89b-4cfe-8c2a-271deae9c76f", "pmid": "", "title": "A Multicenter, RandoMized, Double-blind, Parallel-grOup, Afluxin® Stick Pack vs. Inactive contRol Clinical Investigation to Evaluate the Performance and Safety in Patients With Gastroesophageal Reflux Disease (GERD)", "imported": false, "abstract": "Gastroesophageal Reflux Disease (GERD) is a chronic condition in which stomach acid flows back into the esophagus, causing irritation and inflammation. GERD is categorized into Nonerosive Reflux Disease (NERD), Erosive Esophagitis (EE), and Barrett's esophagus (BE). Common symptoms include heartburn and acid regurgitation. Lifestyle factors such as smoking, obesity, and Helicobacter pylori infection can increase the risk of developing GERD. The clinical management of GERD typically involves Proton Pump Inhibitors (PPIs) therapy, which, although effective, may not benefit all patients and can be associated with long-term risks. The American College of Gastroenterology (ACG) suggests PPIs discontinuation or on-demand therapy for uncomplicated GERD after an 8-week trial. However, evidence indicates that PPIs are used more frequently, often long-term and in high doses, and not necessarily according to recommendations. Moreover, the availability of Over-The-Counter (OTC) PPIs has led to prolonged use by patients without medical guidance. Concerns have been raised due to potential side effects of long-term PPIs use, including enteric, respiratory, and urinary tract infections, as well as an increased risk of vitamin and mineral deficiencies and osteoporosis.", "journal": "", "year": "2025", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:23.268Z" }, { "id": "fe3e2bcf-7648-41aa-a69a-ef3652886b24", "pmid": "", "title": "Physical therapy for Bell's palsy (idiopathic facial paralysis)", "imported": false, "abstract": "Abstract - Background Bell's palsy (idiopathic facial paralysis) is commonly treated by various physical therapy strategies and devices, but there are many questions about their efficacy. Objectives To evaluate physical therapies for Bell's palsy (idiopathic facial palsy). Search methods We searched the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials ( The Cochrane Library , Issue 1, 2011), MEDLINE (January 1966 to February 2011), EMBASE (January 1946 to February 2011), LILACS (January 1982 to February 2011), PEDro (from 1929 to February 2011), and CINAHL (January 1982 to February 2011). We included searches in clinical trials register databases until February 2011. Selection criteria We selected randomised or quasi‐randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention. Data collection and analysis Two authors independently scrutinised titles and abstracts identified from the search results. Two authors independently carried out risk of bias assessments, which took into account secure methods of randomisation, allocation concealment, observer blinding, patient blinding, incomplete outcome data, selective outcome reporting and other bias. Two authors independently extracted data using a specially constructed data extraction form. We undertook separate subgroup analyses of participants with more and less severe disability. Main results For this update to the original review, the search identified 65 potentially relevant articles. Twelve studies met the inclusion criteria (872 participants). Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies compared or combined some form of physical therapy with acupuncture (360 participants). For most outcomes we were unable to perform meta‐analysis because the interventions and outcomes were not comparable. For the primary outcome of incomplete recovery after six months, electrostimulation produced no benefit over placebo (moderate quality evidence from one study with 86 participants). Low quality comparisons of electrostimulation with prednisolone (an active treatment) (149 participants), or the addition of electrostimulation to hot packs, massage and facial exercises (22 participants), reported no significant differences. Similarly a meta‐analysis from two studies, one of three months and the other of six months duration (142 participants) found no statistically significant difference in synkinesis, a complication of Bell's palsy, between participants receiving electrostimulation and controls. A single low quality study (56 participants), which reported at three months, found worse functional recovery with electrostimulation (mean difference (MD) 12.00 points (scale of 0 to 100) 95% confidence interval (CI) 1.26 to 22.74). Two trials of facial exercises, both at high risk of bias, found no difference in incomplete recovery at six months when exercises were compared to waiting list controls or conventional therapy. There is evidence from a single small study (34 participants) of moderate quality that exercises are beneficial on measures of facial disability to people with chronic facial palsy when compared with controls (MD 20.40 points (scale of 0 to 100), 95% CI 8.76 to 32.04) and from another single low quality study with 145 people with acute cases treated for three months, in which significantly fewer participants developed facial motor synkinesis after exercise (risk ratio 0.24, 95% CI 0.08 to 0.69). The same study showed statistically significant reduction in time for complete recovery, mainly in more severe cases (47 participants, MD ‐2.10 weeks, 95% CI ‐3.15 to ‐1.05) but this was not a prespecified outcome in this meta analysis. Acupuncture studies did not provide useful data as all were short and at high risk of bias. None of the studies included adverse events as an outcome. Authors' conclusions There is no high quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. There is low quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases. There is low quality evidence that facial exercise reduces sequelae in acute cases. The suggested effects of tailored facial exercises need to be confirmed with good quality randomised controlled trials. Plain language summary Physical treatments for idiopathic facial paralysis Bell's palsy is an acute disorder of the facial nerve, which produces full or partial loss of movement on one side of the face. The facial palsy gets completely better without treatment in most, but not all, people. Physical therapies, such as exercise, biofeedback, laser treatment, electrotherapy, massage and thermotherapy, are used to hasten recovery, improve facial function and minimise sequelae. For this updated review we found a total of 12 studies with 872 participants, most with high risk of bias. Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies combined some form of physical therapy and compared with acupuncture (360 participants). There is evidence from a single study of moderate quality that exercises are beneficial to people with chronic facial palsy when compared with controls and from another low quality study that it is possible that facial exercises could help to reduce synkinesis (a complication of Bell's palsy), and the time to recover. There is insufficient evidence to decide whether electrical stimulation works, to identify risks of these treatments or to assess whether the addition of acupuncture to facial exercises or other physical therapy could produce improvement. In conclusion, tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases, and early facial exercise may reduce recovery time and long term paralysis in acute cases, but the evidence for this is of poor quality. More trials are needed to assess the effects of facial exercises and any risks.", "journal": "Cochrane Database of Systematic Reviews", "year": "2011", "authors": "Teixeira, LJ; Valbuza, JS; Prado, GF", "articleTypes": [], "doi": "10.1002/14651858.CD006283.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "fe40ac8c-1347-4790-86c1-19473c65aa42", "pmid": "", "title": "Skin‐to‐skin care for procedural pain in neonates", "imported": false, "abstract": "Abstract - Background Skin‐to‐skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal‐infant contact, is one non‐pharmacological intervention for pain control in infants. Objectives The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonates The secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants. Search methods For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi‐randomized trials. Selection criteria Studies with randomisation or quasi‐randomisation, double‐ or single‐blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals. Data collection and analysis The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed‐effect model was reported for continuous outcome measures. We included variations on type of tissue‐damaging procedure, provider of care, and duration of SSC. Main results Twenty‐five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes. Seventeen studies (n = 810) compared SSC to a no‐treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of −10.78 beats per minute (95% CI −13.63 to −7.93) favouring SSC. Meta‐analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI −4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta‐analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta‐analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = −34.16, 95% CI −42.86 to −25.45), and two (n = 100) following IM injection (MD = −8.83, 95% CI −14.63 to −3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD −3.21, 95% CI −3.94 to −2.47), at 60 seconds (3 studies; n = 156) (MD −1.64, 95% CI −2.86 to −0.43), and at 90 seconds (n = 156) (MD −1.28, 95% CI −2.53 to −0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI −1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta‐analysis findings. Eight studies compared SSC to another intervention with or without a no‐treatment control. Two cross‐over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no‐treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies. Authors' conclusions SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother‐providers to others, with non‐significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long‐term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions. Plain language summary Skin‐to‐skin care with newborns cuts down procedural pain Review question: Is skin‐to‐skin care effective in cutting down pain from procedures in newborns? Are there any safety issues? Background: Newborns wearing only a diaper being held next to their mother's bare chest is referred to as skin‐to‐skin contact and is also sometimes called 'kangaroo care' because of its similarity to the way kangaroo mothers care for their young. Newborns, especially those who must spend time in a Neonatal Intensive Care Unit, must have various tests and procedures as part of their care, for example heel stick, venous puncture, and injections. Giving analgesic drugs for these procedures can often pose problems so that alternatives to drugs must be found. Study characteristics: Twenty‐eight studies in which newborn babies who were by chance in the kangaroo care group or condition were included from an extensive search of the literature. Skin‐to‐skin care was clearly defined and could have been compared to no pain‐reducing strategies or other pain‐reducing strategies such as sweet taste. Studies were examined which examined well‐established signs of pain, both physiological and behavioural, as well as a combination of physiological and behavioural signs. Different providers of skin‐to‐skin care other than the mother were included. Key results: Kangaroo care appears to reduce the pain response to, and recovery from, these frequent procedures, although few studies could be combined to provide strong evidence. As far as it has been reported, skin‐to‐skin care is safe. Although it appears that skin‐to‐skin care is effective, the size of the benefit remains uncertain. Quality of evidence: The quality of evidence in these studies was generally low for the response to the actual procedure but was moderate for recovery from the procedure.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Johnston, C, Campbell‐Yeo, M, Disher, T, Benoit, B, Fernandes, A, Streiner, D, Inglis, D, Zee, R", "articleTypes": [], "doi": "10.1002/14651858.CD008435.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.753Z" }, { "id": "fe5daade-dd62-49b7-9c03-6bf81797933d", "pmid": "", "title": "Serenoa repens for the treatment of lower urinary tract symptoms due to benign prostatic enlargement", "imported": false, "abstract": "Abstract - Background Benign prostatic hyperplasia (BPH) is a non‐malignant enlargement of the prostate, which can lead to obstructive and irritative lower urinary tract symptoms (LUTS). The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS associated with BPH is common. The extract of the berry of the American saw palmetto or dwarf palm plant, Serenoa repens (SR), which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of BPH. Objectives To assess the effects of Serenoa repens in the treatment of men with LUTS consistent with BPH. Search methods We performed a comprehensive search of multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to 16 September 2022, with no restrictions on language or publication status. Selection criteria We included randomized controlled trials of participants with BPH who were treated with Serenoa repens or placebo/no treatment. Data collection and analysis Two review authors independently assessed studies for inclusion at each stage and undertook data extraction and risk of bias assessment and GRADE assessment of the certainty of the evidence. We considered review outcomes measured up to 12 months after randomization as short term, and beyond 12 months as long term. Our main outcomes included urologic symptom scores, quality of life, and adverse events. Main results For this update, we narrowed the review question to only comparisons with placebo. We included 27 studies (of which 9 were new) involving a total of 4656 participants, 19 studies comparing Serenoa repens with placebo, and 8 studies comparing Serenoa repens in combination with other phytotherapeutic agents versus placebo. Most studies included men aged > 50 (mean age range 52 to 68) with moderate urologic symptoms (International Prostate Symptom Score [IPSS] range 8 to 19). Ten studies were funded by the pharmaceutical industry; two studies were funded by government agencies; and the remaining studies did not specify funding sources. Serenoa repens versus placebo or no intervention Results for this comparison are based on predefined sensitivity analyses limited to studies at low risk of bias. Serenoa repens results in little to no difference in urologic symptoms at short‐term follow‐up (3 to 6 months; IPSS score range 0 to 35, higher scores indicate worse symptoms; mean difference (MD) −0.90, 95% confidence interval (CI) −1.74 to −0.07; I 2 = 68%; 9 studies, 1681 participants; high‐certainty evidence). Serenoa repens results in little to no difference in the quality of life at short‐term follow‐up (3 to 6 months; IPSS quality of life domain range 0 to 6, higher scores indicate worse quality of life; MD −0.20, 95% CI −0.40 to −0.00; I 2 = 39%; 5 studies, 1001 participants; high‐certainty evidence). Serenoa repens probably results in little to no difference in adverse events (1 to 17 months; risk ratio (RR) 1.01, 95% CI 0.77 to 1.31; I 2 = 18%; 12 studies, 2399 participants; moderate‐certainty evidence). Based on 164 cases per 1000 men in the placebo group, this corresponds to 2 more (38 fewer to 51 more) per 1000 men in the Serenoa repens group. Serenoa repens results in little to no difference in urologic symptoms at long‐term follow‐up (12 to 17 months, IPSS score, MD 0.07, 95% CI −0.75 to 0.88; I 2 = 34%; 3 studies, 898 participants; high‐certainty evidence). Serenoa repens results in little to no difference in quality of life at long‐term follow‐up (12 to 17 months, IPSS quality of life, MD −0.11, 95% CI −0.41 to 0.19; I 2 = 65%; 3 studies, 882 participants; high‐certainty evidence). There were no data on long‐term adverse events for this comparison. Serenoa repens in combination with other phytotherapy versus placebo or no intervention Different phytotherapeutic agents that include Serenoa repens may result in little to no difference in urologic symptoms compared to placebo at short‐term follow‐up (12 to 24 weeks, IPSS score, MD −2.41, 95% CI −4.54 to −0.29; I 2 = 67%; 4 studies, 460 participants; low‐certainty evidence). We are very uncertain about the effects of these agents on quality of life (very low‐certainty evidence). These agents may result in little to no difference in the occurrence of adverse events; however, the CIs included substantial benefits and harms (12 to 48 weeks, RR 0.91, 95% CI 0.58 to 1.41; I 2 = 0%; 4 studies, 481 participants; low‐certainty evidence). Based on 132 cases per 1000 men in the placebo group, this corresponds to 12 fewer (55 fewer to 54 more) per 1000 men in the combined phytotherapeutic agents with Serenoa repens group. Authors' conclusions Serenoa repens alone provides little to no benefits for men with lower urinary tract symptoms due to benign prostatic enlargement. There is more uncertainty about the role of Serenoa repens in combination with other phytotherapeutic agents. Plain language summary Serenoa repens for benign prostatic hyperplasia Review question Does Serenoa repens alone or in combination with other phytotherapeutic agents improve symptoms in men with benign prostatic enlargement? Background An enlarged prostate may cause bothersome urinary tract symptoms, such as having to urinate often during the day or night, having a weak stream, and the feeling of not completely emptying the bladder. Besides other common drug interventions, using plants and herbs (phytotherapy) is common and has been growing steadily in most Western countries. The extract of the berry of the American saw palmetto, or dwarf palm plant, Serenoa repens , which is also known by its botanical name of Sabal serrulatum , is one of several phytotherapeutic agents available for the treatment of this condition. Study characteristics We found 27 studies with 4656 men comparing Serenoa repens alone or in combination with other herbal products to a placebo (participants are made to believe they received treatment when in fact they did not). Most studies included men over 50 with moderate symptoms. Ten studies were funded by pharmaceutical organizations; two studies received government funding; and the remaining studies did not specify funding sources. Key results Based on the most trustworthy studies, Serenoa repens alone results in little to no difference in urinary tract symptoms or quality of life compared to placebo at three to six months. This treatment is also likely not associated with adverse events. Results were similar at 12 to 17 months. Serenoa repens in combination with other herbal products may result in little to no difference in urinary tract symptoms, but there is more uncertainty about effects on quality of life and adverse events. The findings of this review are current to 16 September 2022. Certainty of the evidence The certainty of the evidence is primarily high or moderate for Serenoa repens alone, but low for Serenoa repens in combination with other agents, meaning our confidence in the results is high, moderate, or low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Franco, JVA; Trivisonno, L; Sgarbossa, NJ; Alvez, GA; Fieiras, C; Escobar Liquitay, CM; Jung, JH", "articleTypes": [], "doi": "10.1002/14651858.CD001423.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "fe5eb2dc-094e-49b1-973a-f43a4545e335", "pmid": "", "title": "Cough and Taste Preferences in Adolescents and Adults", "imported": false, "abstract": "This single-site, within-subject, experimental study is designed to test the hypothesis children who live in a household in which one or both of their parent smoke will exhibit a higher cough threshold and will prefer more intense sweet tastes than children who live in a household where neither parent smokes. Subjects will include at least 50 racially and ethnically diverse, healthy children aged 10 to 17 years (a critical time for experimenting with tobacco) and a parent. The sample will comprise two groups: Non-Environmental Tobacco Smoke (ETS) Exposed (neither the child nor parents has ever smoked or been exposed to environmental tobacco smoke (ETS) in the home), and ETS-Exposed (the parent has smoked at least 3 cigarettes per day for at least five years in the home, with the child living in the home continuously). Cough sensitivity will be measured using a standard single-inhalation challenge, a test of the minimum concentration of capsaicin (the spicy chemical in hot peppers) needed to elicit cough. Sweet taste preferences will be measured using a forced-choice paired comparison method of liquids which differ in sucrose content. Measures of breath carbon monoxide will validate the smoking status of parents and their adolescent children. The key comparison will be between Non-ETS Exposed and ETS-Exposed children, with the difference between smoking and non-smoking parents as a positive control. Because smoking and non-smoking families may differ in ways besides tobacco exposure, the investigators will obtain health histories (with a focus on respiratory illness), smoking histories, measures of body weight, diet, and responses to personality tests (including susceptibility to addiction). The investigators will also obtain genomic DNA from saliva samples. Genes for chemosensory receptors that are part of the cough reflex pathway and genotype may account for aspects of cough sensitivity.", "journal": "", "year": "2011", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:42.145Z" }, { "id": "fe66b8ad-dcbf-4c41-836e-0a22739d0a7e", "pmid": "", "title": "Chewing gum for postoperative recovery of gastrointestinal function", "imported": false, "abstract": "Abstract - Background Ileus commonly occurs after abdominal surgery, and is associated with complications and increased length of hospital stay (LOHS). Onset of ileus is considered to be multifactorial, and a variety of preventative methods have been investigated. Chewing gum (CG) is hypothesised to reduce postoperative ileus by stimulating early recovery of gastrointestinal (GI) function, through cephalo‐vagal stimulation. There is no comprehensive review of this intervention in abdominal surgery. Objectives To examine whether chewing gum after surgery hastens the return of gastrointestinal function. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), MEDLINE (via PubMed), EMBASE (via Ovid), CINAHL (via EBSCO) and ISI Web of Science (June 2014). We hand‐searched reference lists of identified studies and previous reviews and systematic reviews, and contacted CG companies to ask for information on any studies using their products. We identified proposed and ongoing studies from clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform and meta Register of Controlled Trials. Selection criteria We included completed randomised controlled trials (RCTs) that used postoperative CG as an intervention compared to a control group. Data collection and analysis Two authors independently collected data and assessed study quality using an adapted Cochrane risk of bias (ROB) tool, and resolved disagreements by discussion. We assessed overall quality of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Studies were split into subgroups: colorectal surgery (CRS), caesarean section (CS) and other surgery (OS). We assessed the effect of CG on time to first flatus (TFF), time to bowel movement (TBM), LOHS and time to bowel sounds (TBS) through meta‐analyses using a random‐effects model. We investigated the influence of study quality, reviewers’ methodological estimations and use of Enhanced Recovery After Surgery (ERAS) programmes using sensitivity analyses. We used meta‐regression to explore if surgical site or ROB scores predicted the extent of the effect estimate of the intervention on continuous outcomes. We reported frequency of complications, and descriptions of tolerability of gum and cost. Main results We identified 81 studies that comprised 9072 participants for inclusion in our review. We categorised many studies at high or unclear risk of the bias' assessed. There was statistical evidence that use of CG reduced TFF [overall reduction of 10.4 hours (95% CI: ‐11.9, ‐8.9): 12.5 hours (95% CI: ‐17.2, ‐7.8) in CRS, 7.9 hours (95% CI: –10.0, ‐5.8) in CS, 10.6 hours (95% CI: ‐12.7, ‐8.5) in OS]. There was also statistical evidence that use of CG reduced TBM [overall reduction of 12.7 hours (95% CI: ‐14.5, ‐10.9): 18.1 hours (95% CI: ‐25.3, ‐10.9) in CRS, 9.1 hours (95% CI: ‐11.4, ‐6.7) in CS, 12.3 hours (95% CI: ‐14.9, ‐9.7) in OS]. There was statistical evidence that use of CG slightly reduced LOHS [overall reduction of 0.7 days (95% CI: ‐0.8, ‐0.5): 1.0 days in CRS (95% CI: ‐1.6, ‐0.4), 0.2 days (95% CI: ‐0.3, ‐0.1) in CS, 0.8 days (95% CI: ‐1.1, ‐0.5) in OS]. There was statistical evidence that use of CG slightly reduced TBS [overall reduction of 5.0 hours (95% CI: ‐6.4, ‐3.7): 3.21 hours (95% CI: ‐7.0, 0.6) in CRS, 4.4 hours (95% CI: ‐5.9, ‐2.8) in CS, 6.3 hours (95% CI: ‐8.7, ‐3.8) in OS]. Effect sizes were largest in CRS and smallest in CS. There was statistical evidence of heterogeneity in all analyses other than TBS in CRS. There was little difference in mortality, infection risk and readmission rate between the groups. Some studies reported reduced nausea and vomiting and other complications in the intervention group. CG was generally well‐tolerated by participants. There was little difference in cost between the groups in the two studies reporting this outcome. Sensitivity analyses by quality of studies and robustness of review estimates revealed no clinically important differences in effect estimates. Sensitivity analysis of ERAS studies showed a smaller effect size on TFF, larger effect size on TBM, and no difference between groups for LOHS. Meta‐regression analyses indicated that surgical site is associated with the extent of the effect size on LOHS (all surgical subgroups), and TFF and TBM (CS and CRS subgroups only). There was no evidence that ROB score predicted the extent of the effect size on any outcome. Neither variable explained the identified heterogeneity between studies. Authors' conclusions This review identified some evidence for the benefit of postoperative CG in improving recovery of GI function. However, the research to date has primarily focussed on CS and CRS, and largely consisted of small, poor quality trials. Many components of the ERAS programme also target ileus, therefore the benefit of CG alongside ERAS may be reduced, as we observed in this review. Therefore larger, better quality RCTS in an ERAS setting in wider surgical disciplines would be needed to improve the evidence base for use of CG after surgery. Plain language summary Chewing gum after surgery to help recovery of the digestive system Background When people have surgery on their abdomen, the digestive system can stop working for a few days. This is called ileus, and can be painful and uncomfortable. There are different causes of ileus, and several ways of treating or preventing it. One possible way of preventing ileus is by chewing gum. The idea is that chewing gum tricks the body into thinking it is eating, causing the digestive system to start working again. It is important to do this review because ileus is common: it is estimated that up to a third of people having bowel surgery suffer from ileus. Main Findings This review found 81 relevant studies that recruited over 9000 participants in total. The studies mainly focussed on people having bowel surgery or caesarean section, but there were some studies of other surgery types. There were few studies of children. Most studies were of poor quality, which may mean their results are less reliable. We found some evidence that people who chewed gum after an operation were able to pass wind and have bowel movements sooner than people who did not chew gum. We also found some evidence that people who chewed gum after an operation had bowel sounds (gurgling sounds heard using a stethoscope held to the abdomen) slightly sooner than people who did not chew gum. There was a small difference in how long people stayed in hospital between people who did or did not chew gum. There were no differences in complications (such as infection or death) between people who did or did not chew gum. There was also no difference in the overall cost of treatment between people who did or did not chew gum. Conclusions There is some evidence that chewing gum after surgery may help the digestive system to recover. However, the studies included in this review are generally of poor quality, which meant that their results may not be reliable. We also know that there are many factors affecting ileus, and that modern treatment plans attempt to reduce risk of ileus. Therefore to further explore using chewing gum after surgery, more studies would be needed which are larger, of better quality, include different types of surgery, and consider recent changes in health care systems.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Short, V; Herbert, G; Perry, R; Atkinson, C; Ness, AR; Penfold, C; Thomas, S; Andersen, HK; Lewis, SJ", "articleTypes": [], "doi": "10.1002/14651858.CD006506.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.731Z" }, { "id": "fe742c3d-4be6-4ebb-b46f-3ad3ec760e16", "pmid": "", "title": "Interventions for the treatment of Frey's syndrome", "imported": false, "abstract": "Abstract - Background Frey's syndrome is a rare disorder, the symptoms of which include sweating, flushing and warming over the preauricular and temporal areas following a gustatory stimulus. It often occurs in patients who have undergone parotidectomy, submandibular gland surgery, radical neck dissection, infection and traumatic injury in the parotid region, and is caused by the aberrant regrowth of facial autonomic nerve fibres. Currently there are several options used to treat patients with Frey's syndrome; for example, the topical application of anticholinergics and antiperspirants, and the intradermal injection of botulinum toxin. It is uncertain which treatment is most effective and safe. Objectives To assess the efficacy and safety of different interventions for the treatment of Frey's syndrome. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; ICTRP and additional sources for published and unpublished trials. The date of the search was 28 April 2014. Selection criteria We included randomised or quasi‐randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome using a clinical standard such as Minor's starch‐iodine test. We planned to include trials in which participants received any intervention versus no treatment (observation) or an alternative intervention, with or without a second active treatment. Our primary outcome measures were success rate (as assessed clinically by Minor's starch‐iodine test, the iodine‐sublimated paper histogram method, blotting paper technique or another method) and adverse events. Our secondary outcome measure was success rate as assessed by patients (disappearance or improvement of symptoms). Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no RCTs or quasi‐RCTs that fulfilled the inclusion criteria. Our searches retrieved eight potentially relevant studies, but after assessment of the full‐text reports we excluded all of them due to the absence of randomisation or because the patients did not have Frey's syndrome. We excluded one randomised controlled trial that compared two different doses of botulinum toxin in patients with Frey's syndrome because the comparator was not an alternative treatment. Authors' conclusions We are unable to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome. RCTs are urgently needed to assess the effectiveness of interventions for the treatment of Frey's syndrome. Future RCTs should include patients with Frey's syndrome of different ranges of severity and report these patients separately. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective assessment of Frey's syndrome should be considered as one of the outcome measures. Plain language summary Interventions for the treatment of Frey's syndrome Background Frey's syndrome is a rare disorder, the symptoms of which include sweating and flushing of the facial skin when eating, smelling, thinking or even dreaming about food. It usually happens in patients who have undergone surgery to the parotid (salivary) gland. This problem may have an impact on quality of life (for example, restricting normal activity such as eating in public). Many methods are currently used to treat Frey's syndrome, including topical application of anticholinergics and antiperspirants, and intradermal (into the skin) injections of botulinum toxin. This systematic review aimed to assess the efficacy and safety of these different methods for the treatment of Frey's syndrome. Study characteristics We carried out a comprehensive search for randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome. We planned to include trials in which participants received any intervention compared to no treatment (observation) or an alternative intervention, with or without a second active treatment. Despite extensive searching, we were unable to identify any studies that met our inclusion criteria. Key results There is no high‐quality evidence to establish which type of treatment is most effective for the treatment of Frey's syndrome. High‐quality clinical trials in this area should be urgently conducted. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective (patient) assessment of Frey's syndrome should be one of the outcome measures used. Quality of the evidence This review is up to date to 28 April 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Li, C, Wu, F, Zhang, Q, Gao, Q, Shi, Z, Li, L", "articleTypes": [], "doi": "10.1002/14651858.CD009959.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.062Z" }, { "id": "fe792d53-a12d-4284-8487-29a27973932b", "pmid": "", "title": "Diet or exercise, or both, for weight reduction in women after childbirth", "imported": false, "abstract": "Abstract - Background Weight retention after pregnancy may contribute to obesity. It is known that diet and exercise are recommended components of any weight loss programme in the general population. However, strategies to achieve healthy body weight among postpartum women have not been adequately evaluated. Objectives The objectives of this review were to evaluate the effect of diet, exercise or both for weight reduction in women after childbirth, and to assess the impact of these interventions on maternal body composition, cardiorespiratory fitness, breastfeeding performance and other child and maternal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012) and LILACS (31 January 2012). We scanned secondary references and contacted experts in the field. We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 30 April 2013 and added the results to the awaiting classification section of the review. Selection criteria All published and unpublished randomised controlled trials (RCTs) and quasi‐randomised trials of diet or exercise or both, among women during the postpartum period. Data collection and analysis Both review authors independently assessed trial quality and extracted data. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data. Data were analysed with a fixed‐effect model. A random‐effects model was used in the presence of heterogeneity. Main results Fourteen trials were included, but only 12 trials involving 910 women contributed data to outcome analysis. Women who exercised did not lose significantly more weight than women in the usual care group (two trials; n = 53; MD ‐0.10 kg; 95% confidence interval (CI) ‐1.90 to 1.71). Women who took part in a diet (one trial; n = 45; MD ‐1.70 kg; 95% CI ‐2.08 to ‐1.32), or diet plus exercise programme (seven trials; n = 573; MD ‐1.93 kg; 95% CI ‐2.96 to ‐0.89; random‐effects, T² = 1.09, I² = 71%), lost significantly more weight than women in the usual care group. There was no difference in the magnitude of weight loss between diet alone and diet plus exercise group (one trial; n = 43; MD 0.30 kg; 95% CI ‐0.06 to 0.66). The interventions seemed not to affect breastfeeding performance adversely. Authors' conclusions Evidence from this review suggests that both diet and exercise together and diet alone help women to lose weight after childbirth. Nevertheless, it may be preferable to lose weight through a combination of diet and exercise as this improves maternal cardiorespiratory fitness and preserves fat‐free mass, while diet alone reduces fat‐free mass. This needs confirmation in large trials of high methodological quality. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby. Plain language summary Diet or exercise, or both, for weight reduction in women carrying excess weight after childbirth Women naturally gain weight during pregnancy and many gradually lose it afterwards. Some women, though, find it difficult to lose the gained weight in the year or two following the birth of the baby and there is concern that this may be a health risk for them. The retention of weight gained during pregnancy may contribute to obesity, which can increase the risk of diabetes, heart disease and high blood pressure. It is suggested that women who return to their pre‐pregnancy weight by about six months have a lower risk of being overweight 10 years later. The review looked for randomised studies to assess the impact of dieting or exercise, or both, on women's weight loss in the months after giving birth. It paid particular attention to breastfeeding women to be sure that breastfeeding was not compromised. The review of trials found 14 studies, with 12 studies involving 910 women carrying excess weight after childbirth that contributed data for analysis. The findings suggest that diet combined with exercise or diet alone compared with usual care seemed to help with weight loss after giving birth. There is potential for these interventions to play a role in preventing future maternal obesity. There was not sufficient evidence to be sure that exercise or diet did not interfere with breastfeeding though it appeared not to in the included studies. It seems preferable to lose weight through a combination of dieting and exercise, compared to dieting alone, because exercise is thought to improve circulation and heart fitness, and to preserve lean body mass. Further research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Amorim Adegboye, AR; Linne, YM", "articleTypes": [], "doi": "10.1002/14651858.CD005627.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.062Z" }, { "id": "fea24001-be77-4d45-8f98-4842cd8cdbb0", "pmid": "", "title": "Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta‐analysis", "imported": false, "abstract": "Abstract - Background Hip and knee replacement surgery is a well‐established means of improving quality of life, but is associated with a significant risk of bleeding. One‐third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care. Objectives To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta‐analysis (NMA) methodology. Search methods We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO host ), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). Selection criteria We included RCTs of people undergoing elective hip or knee surgery only. We excluded non‐elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon‐aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non‐fibrin sealants. Data collection and analysis We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all‐cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received. Main results We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra‐articularly and orally at a total dose of greater than 3 g pre‐incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate‐certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre‐incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low‐certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low‐certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low‐certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low‐certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low‐certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all‐cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low‐certainty evidence). This was followed by TXA given intravenously and intra‐articularly at a total dose of 2 g pre‐incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low‐certainty evidence) and TXA given intravenously and intra‐articularly, total dose greater than 3 g pre‐incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low‐certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low‐certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re‐operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials). Authors' conclusions We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra‐articular, oral and intravenous, or intravenous and intra‐articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review. Plain language summary What is the best medication to stop bleeding in those having non‐emergency hip or knee surgery? Key messages • Tranexamic acid may be an effective medicine to help blood to clot during hip or knee replacement surgery, which reduces bleeding and the need for a blood transfusion (replacing lost blood with donated blood). • A high dose of this medicine and administering it in more than one way (for example, as a tablet and injected into the joint at the end of surgery) appears to work best. • Tranexamic acid is potentially as effective when given as a tablet as when injected into a vein. • There is little to no evidence to indicate that higher doses of tranexamic acid increase the risk of blood clots in the leg or other harms. Background Why is it important to stop bleeding during hip or knee surgery? Controlling bleeding during surgery reduces the likelihood of the person developing anaemia and requiring a blood transfusion, which carries the risk of complications. Anaemia occurs when the number of red blood cells (haemoglobin) available to carry oxygen is lower than normal. This causes symptoms such as fatigue, weakness, dizziness, shortness of breath and, in severe cases, can be life‐threatening. Preventing blood loss during surgery improves patient outcomes, decreases healthcare costs and preserves the limited supplies of donated blood. Is there a medication that helps control bleeding? Many research studies have investigated whether certain medication, such as tranexamic acid, can help minimise blood loss during surgery. Most of the studies test different doses of medications, different methods of administration and different times of use, either before, during or after an operation. What did we want to find out? We wanted to find out whether medication can reduce blood loss and the need for blood transfusions in people having hip or knee replacement surgery. We also wanted to know the most effective way of giving this medication to patients. What did we do? We searched for studies comparing different medications that could help reduce bleeding in adults undergoing planned hip or knee replacement surgery. We also searched for studies comparing medication with a placebo. A placebo is a 'dummy' medication that looks or tastes identical to the medication being tested. What did we find? We found 102 studies. Twelve studies did not report the number of included participants; in the other 90 studies, there were 8418 included participants. On average, people were between 50 and 77 years of age and 64% were women. The smallest study included 16 people and the largest involved 300. Studies took place around the globe, with the highest number in Europe and Asia. Of those studies that reported a source of funding, seven were fully funded and five partly funded by pharmaceutical (medication) companies. All studies investigated medications that helped the blood to clot. However, most studies assessed the effectiveness and safety of tranexamic acid administered intravenously (injected into a vein), orally (swallowing a tablet or liquid), injected into the joint during surgery, or with a combination of these methods. Main results Our review of the studies showed the following: • Tranexamic acid was the most effective at controlling bleeding compared to other medications. • Adults who underwent hip or knee replacement surgery required fewer blood transfusions if they were given tranexamic acid. • Tranexamic acid given in higher doses using multiple methods of administration, such as orally and injected into the joint during surgery, may be more likely to prevent bleeding. • Taking tranexamic acid orally is probably as effective at preventing a blood transfusion as injecting the medication into a vein. We were unable to decide on the optimal dose, which combination of methods are best to administer tranexamic acid and when it is most beneficial to use it (before, during and after surgery). We did not find evidence to suggest that higher doses of tranexamic acid increase the risk of developing a blood clot, or any other harms. What are the limitations of the evidence? We are not able to definitively draw conclusions based on the trials included within this review. We have little confidence in the evidence for some outcomes, and are not confident about the evidence for others. This is because it is possible that people in the studies were aware of which treatment they were getting. Also, the studies were small and did not all provide data about everything in which we were interested. Ongoing studies and future updates Thirty studies with a planned total of 3776 participants are currently ongoing. These studies should be completed and published within the next few years. Once the authors publish their data, we may update our analyses and provide stronger answers than we can at present. How up‐to‐date is this evidence? The evidence is current to 18 October 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2024", "authors": "Gibbs, VN; Champaneria, R; Sandercock, J; Welton, NJ; Geneen, LJ; Brunskill, SJ; Dorée, C; Kimber, C; Palmer, AJR; Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD013295.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.083Z" }, { "id": "feba46a1-32de-4eee-a525-8f9cce4c3c7c", "pmid": "", "title": "Antibiotics versus topical antiseptics for chronic suppurative otitis media", "imported": false, "abstract": "Abstract - Background Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media, is a chronic inflammation and often polymicrobial infection of the middle ear and mastoid cavity. It is characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Antibiotics and antiseptics kill or inhibit the micro‐organisms that may be responsible for the infection. Antibiotics can be applied topically or administered systemically via the oral or injection route. Antiseptics are always directly applied to the ear (topically). Objectives To assess the benefits and harms of antibiotics versus antiseptics for people with chronic suppurative otitis media (CSOM). Search methods We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, and five other databases. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP). The latest search date was 15 June 2022. Selection criteria We included randomised controlled trials (RCTs) with at least a one‐week follow‐up involving adults and children who had chronic ear discharge of unknown cause or CSOM, where ear discharge had continued for more than two weeks. The intervention was any single, or combination of, antibiotic agent, whether applied topically (without steroids) or systemically. The comparison was any single, or combination of, topical antiseptic agent, applied as ear drops, powders, or irrigations, or as part of an aural toileting procedure. The comparisons were 1. topical antiseptics compared to topical antibiotics, and 2. topical antiseptics compared to systemic antibiotics. We further separated these comparisons into those in which a. both groups of participants received aural toileting in addition to the intervention, or b. both groups received some other add‐on therapy treatment (such as systemic antibiotics) to both arms. Data collection and analysis We used standard Cochrane methodology. Our primary outcomes were resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks, and after four weeks; health‐related quality of life using a validated instrument; and ear pain (otalgia) or discomfort or local irritation. Secondary outcomes were hearing, serious complications, and ototoxicity. We used GRADE to assess the certainty of the evidence for each outcome. Main results This updated review included eight new studies. Overall, we identified 15 studies (2371 participants) across seven comparisons with antibiotics compared to acetic acid, aluminium acetate, boric acid, and povidone‐iodine. None of the included studies reported health‐related quality of life or serious complications. 1. Topical antibiotics (quinolones or aminoglycosides) versus topical antiseptic (acetic acid) We included seven studies (835 participants). Acetic acid may increase resolution of ear discharge when compared to aminoglycoside at one to two weeks (low‐certainty evidence). It is very uncertain whether acetic acid may increase resolution of ear discharge at one to two weeks when compared to topical quinolone. Results after four weeks were only presented narratively. It is very uncertain whether acetic acid may cause more ear pain, discomfort, local irritation, or combinations of these compared to topical antibiotics (aminoglycosides and quinolones) (risk ratio (RR) 0.20, 95% confidence interval (CI) 0.03 to 1.12; I 2 = 0%; 3 studies, 277 participants; very low‐certainty evidence). An additional two studies (350 participants) provided narrative results. There may be little to no difference in hearing between groups reported narratively (quinolones; low‐certainty evidence). The evidence is very uncertain for serious complications (aminoglycosides) or suspected ototoxicity (aminoglycosides) (very low‐certainty evidence). 2. Topical antibiotics (quinolones) versus topical antiseptic (boric acid) We included two studies (532 participants). Topical quinolones are likely to increase resolution of ear discharge at one to two weeks compared with boric acid ear drops (RR 1.86, 95% CI 1.48 to 2.35; 1 study, 411 participants; moderate‐certainty evidence). This means that one additional person will have resolution of ear discharge for every four people receiving topical antibiotics (compared with boric acid) at two weeks. No study reported results for ear discharge after four weeks. There may be less ear pain, discomfort, or irritation with quinolones compared with boric acid (RR 0.56, 95% CI 0.32 to 0.98; 2 studies, 510 participants; low‐certainty evidence). Suspected ototoxicity and serious complications were not reported. Topical quinolones may result in a greater improvement in mean hearing from baseline compared to topical boric acid (mean difference (MD) 2.79 decibels, 95% CI 0.48 to 5.10; 1 study, 390 participants; low‐certainty evidence), but this difference may not be clinically significant. 3. Topical antibiotics (quinolones) versus topical antiseptic (povidone‐iodine) We included one study (40 participants). It is very uncertain if there is a difference between quinolones and povidone‐iodine with respect to resolution of ear discharge at one to two weeks (RR 1.02, 95% CI 0.82 to 1.26; 1 RCT, 39 participants; very low‐certainty evidence). The study reported qualitatively that there were no differences between the groups for hearing and no participants developed ototoxic effects (very low‐certainty evidence). There were no results reported for resolution of ear discharge beyond four weeks; ear pain, discomfort, or irritation; or serious complications. 4. Topical antibiotics versus topical antiseptic (aluminium acetate) We included one study (51 participants; 60 ears) that presented results for resolution of ear discharge at two to four weeks results narratively. No other results were reported. 5. Other comparisons Five studies (966 participants) were assessed over an additional three comparisons; however, these results have not been included in the abstract. Authors' conclusions Treatment of CSOM with topical antibiotics (quinolones) likely results in an increase in resolution of ear discharge compared with boric acid at up to two weeks. There was limited evidence for the efficacy of other topical antibiotics or topical antiseptics and so we are unable to draw conclusions. Harmful effects were not well reported. Limitations of the review include lack of recent data, limitations in the quality of included studies, and limited information on certain population groups or interventions. Plain language summary Which are better, antibiotics or topical antiseptics, for treating chronic suppurative otitis media? Key message – There is limited evidence comparing topical antibiotics with topical antiseptics in people with swelling and infection of the middle ear (called chronic suppurative otitis media). The evidence is very uncertain whether antibiotics or topical antiseptics are more effective for reducing ear discharge, except that topical antibiotics are likely to be more effective than boric acid (an antiseptic). What is chronic suppurative otitis media? Chronic suppurative otitis media is a long‐term (chronic) swelling and infection of the middle ear, with ear discharge (otorrhoea) through a perforated tympanic membrane (where the eardrum has a hole or tear in it). The main symptoms of chronic suppurative otitis media are ear discharge (pus that leaks out from a hole in the eardrum) and hearing loss. How can chronic suppurative otitis media be treated? Antibiotics (which kill bacteria) are the most commonly used treatment for chronic suppurative otitis media. Antibiotics can either be 'topical' (put into the ear canal as ear drops, ointments, sprays, or creams) or 'systemic' (taken either by mouth or by an injection into a muscle or vein). Topical antiseptics (antiseptics put directly into the ear as ear drops or powders) are a possible treatment for chronic suppurative otitis media. Both antibiotics and topical antiseptics kill or stop the growth of the germs that may be responsible for the infection. Antibiotics and topical antiseptics can be used on their own or added to other treatments for chronic suppurative otitis media, such as other antibiotics or ear cleaning (called aural toileting). It was important in this review to examine whether there were any unwanted effects from using antibiotics and antiseptics, such as irritation of the skin within the outer ear, which may cause discomfort, pain, or itching. Some antibiotics and antiseptics (such as alcohol) can also be toxic to the inner ear (called ototoxicity), which means that they may cause permanent hearing loss, dizziness, or ringing in the ear (called tinnitus). What was the aim of this review? We wanted to compare antibiotics and antiseptics for the treatment of chronic suppurative otitis media. In particular, we wanted to know whether they stopped ear discharge, and whether they affected people's quality of life or hearing. We also wanted to know if they caused pain, discomfort, or irritation in the ear; had unwanted effects such as dizziness or ear bleeding; or any serious complications. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and consistency of results. What were the main results of the review? We found 15 studies, which included 2371 people, that compared antibiotics to a variety of antiseptics (acetic acid, boric acid, povidone‐iodine, and aluminium acetate). One study recruited only children, two studies recruited only adults, and 12 studies included both adults and children. About 40 in every 100 people were females. We presented the main comparisons below. Comparison of antibiotics to acetic acid We included seven studies (835 people). We have little to no confidence in the evidence of whether topical antibiotics or acetic acid improved ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to boric acid We included two studies (532 people). Topical antibiotics (quinolones) are likely to be better than boric acid at reducing ear discharge after one to two weeks. There may also be less ear discomfort (pain, irritation, and bleeding). Topical quinolones may result in a greater improvement in hearing compared to topical boric acid, but this difference may be too small for the person to notice a difference. Comparison of antibiotics to povidone‐iodine We included one study (40 people). We have little to no confidence in the evidence of whether topical or systemic antibiotics or povidone‐iodine improve the resolution of ear discharge in people with chronic suppurative otitis media. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. Comparison of antibiotics to aluminium acetate We included one study (51 people) that stated there was improvement in ear discharge at two to four weeks, but they did not present their results in a way that we could use. It was not possible to know whether there was a difference between treatments for any other symptoms or effects that we were interested in. What are the limitations of the evidence? The studies were small with many being poorly reported, and results varied widely between studies. We also need more information about harmful effects. How up to date is this review? This is the first update of a review published in 2020. The evidence is up to date to June 2022.", "journal": "Cochrane Database of Systematic Reviews", "year": "2025", "authors": "Head, K, Chong, LY, Bhutta, MF, Daw, J, Veselinović, T, Morris, PS, Vijayasekaran, S, Schilder, AGM, Brennan-Jones, CG", "articleTypes": [], "doi": "10.1002/14651858.CD013056.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.770Z" }, { "id": "fede5933-ca25-4ded-b7d5-87e43f4db763", "pmid": "", "title": "Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age", "imported": false, "abstract": "Abstract - Background Vitamin and mineral deficiencies, particularly those of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Multiple micronutrient powders (MNPs) are single‐dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi‐solid food for children six months of age or older. The use of MNPs for home or point‐of‐use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out‐of‐date. Objectives To assess the effects and safety of home (point‐of‐use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi‐solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point‐of‐use fortification. Search methods We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs with individual randomisation or cluster‐randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron‐containing supplements, which is standard practice. Data collection and analysis Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, and assessed the risk of bias of included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence. Main results We included 29 studies (33,147 children) conducted in low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty‐six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron‐only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate‐certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high‐certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low‐certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate‐certainty evidence) at follow‐up compared with children receiving the control intervention. We did not find an effect on weight‐for‐age (MD 0.02, 95% CI −0.03 to 0.07; 10 studies; 9287 children; moderate‐certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all‐cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low‐certainty evidence) and haemoglobin concentrations (MD −2.81 g/L, 95% CI −10.84 to 5.22; 2 studies; 278 children; very low‐certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low‐certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Authors' conclusions Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Plain language summary Using a vitamin and mineral powder, mixed into complementary foods, to improve health and nutrition in children under two years of age Review question Does using a vitamin and mineral powder, mixed into complementary foods, improve health and nutrition in children under two years of age? Background Deficiencies of vitamins and minerals, particularly of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Exclusive breastfeeding until six months of age, followed by complementary feeding combined with continued breastfeeding for at least two years, is recommended to maintain children's adequate health and nutrition. After six months of age, infants start to receive semi‐solid foods, but the quantities of vitamins and minerals can be insufficient to fulfil all of their requirements for growth and development. Multiple micronutrient powders (MNPs) are single‐dose packets of powder containing iron, vitamin A, zinc, and other vitamins and minerals that can be mixed into any semi‐solid food at home or at any other point of use, to increase the content of essential vitamins and minerals in the diet of infants and young children during this period. This is done without making any other changes to their usual diet. Study characteristics We searched up to July 2019 for all studies that assessed the use of MNP for improving the health and nutrition of children under two years of age. We included 29 studies that involved 33,147 infants and young children from low‐ and middle‐income countries in Asia, Africa, Latin America, and the Caribbean. Twenty‐six studies with 27,051 children contributed data. Of these 26 studies, 24 compared the use of MNP versus no intervention or placebo, and 2 compared the use of MNP versus an iron‐only supplement (iron drops) given daily. We found that a variety of MNP formulations containing between 5 and 22 vitamins and minerals were given for 2 to 44 months to infants and young children aged 6 to 23 months. Most studies were funded by government programmes or foundations; only 2 were funded by industry. Key results The use of MNP containing at least iron, zinc, and vitamin A for home fortification of foods was associated with reduced risk of anaemia of 18% and iron deficiency of 53% in children aged six months to two years compared with no intervention. Also, haemoglobin concentration and iron status improved. Studies did not find any effects on growth. There was no additional benefit in reducing risk of anaemia and improving haemoglobin concentration compared to usually recommended iron drops or syrups; however, only two studies compared these different interventions. No trials reported death attributable to the intervention. Information on deaths, side effects, and morbidity, including malaria and diarrhoea, was scarce. The use of MNP was beneficial for young children 6 to 23 months of age, independent of whether they lived in settings with different anaemia and malaria backgrounds and regardless of the length of the intervention. MNP is better than no intervention or placebo and may be comparable to daily iron supplementation.The benefits of this intervention as a child survival strategy or for developmental outcomes are still unclear, and further investigation is required. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. Certainty of the evidence For the comparison of MNP versus no intervention or placebo, we judged the certainty of evidence to be moderate for anaemia and high for iron deficiency. The certainty of evidence for all other outcomes in this comparison was either low or moderate. Two trials that compared the use of MNP versus iron supplement showed similar effects on anaemia and haemoglobin but less diarrhoea; however, we judged the certainty of evidence as low for anaemia and very low for haemoglobin concentration due to the small number of study participants.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Suchdev, PS, Jefferds, MED, Ota, E, da Silva Lopes, K, De‐Regil, LM", "articleTypes": [], "doi": "10.1002/14651858.CD008959.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.770Z" }, { "id": "fee2bdc0-28bf-424e-9c6d-426956f862af", "pmid": "", "title": "Effect of cocoa on blood pressure", "imported": false, "abstract": "Abstract - Background High blood pressure is an important risk factor for cardiovascular disease, contributing to about 50% of cardiovascular events worldwide and 37% of cardiovascular‐related deaths in Western populations. Epidemiological studies suggest that cocoa‐rich products reduce the risk of cardiovascular disease. Flavanols found in cocoa have been shown to increase the formation of endothelial nitric oxide which promotes vasodilation and therefore blood pressure reduction. Here we update previous meta‐analyses on the effect of cocoa on blood pressure. Objectives To assess the effects on blood pressure of chocolate or cocoa products versus low‐flavanol products or placebo in adults with or without hypertension when consumed for two weeks or longer. Search methods This is an updated version of the review initially published in 2012. In this updated version, we searched the following electronic databases from inception to November 2016: Cochrane Hypertension Group Specialised Register, CENTRAL, MEDLINE and Embase. We also searched international trial registries, and the reference lists of review articles and included trials. Selection criteria Randomised controlled trials (RCTs) investigating the effects of chocolate or cocoa products on systolic and diastolic blood pressure in adults for a minimum of two weeks duration. Data collection and analysis Two review authors independently extracted data and assessed the risks of bias in each trial. We conducted random‐effects meta‐analyses on the included studies using Review Manager 5. We explored heterogeneity with subgroup analyses by baseline blood pressure, flavanol content of control group, blinding, age and duration. Sensitivity analyses explored the influence of unusual study design. Main results Thirty‐five trials (including 40 treatment comparisons) met the inclusion criteria. Of these, we added 17 trials (20 treatment comparisons) to the 18 trials (20 treatment comparisons) in the previous version of this updated review. Trials provided participants with 30 to 1218 mg of flavanols (mean = 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. The control group received either a flavanol‐free product (n = 26 treatment comparisons) or a low‐flavanol‐containing cocoa powder (range 6.4 to 88 mg flavanols (mean = 55 mg, 13 treatment comparisons; 259 mg, 1 trial). Meta‐analyses of the 40 treatment comparisons involving 1804 mainly healthy participants revealed a small but statistically significant blood pressure‐reducing effect of flavanol‐rich cocoa products compared with control in trials of two to 18 weeks duration (mean nine weeks):
 Mean difference systolic blood pressure (SBP) (95% confidence interval (CI): ‐1.76 (‐3.09 to ‐0.43) mmHg, P = 0.009, n = 40 treatment comparisons, 1804 participants;
 Mean difference diastolic blood pressure (DBP) (95% CI): ‐1.76 (‐2.57 to ‐0.94) mmHg, P < 0.001, n = 39 treatment comparisons, 1772 participants. Baseline blood pressure may play a role in the effect of cocoa on blood pressure. While systolic blood pressure was reduced significantly by 4 mmHg in hypertensive people (n = 9 treatment comparisons, 401 participants), and tended to be lowered in prehypertensive people (n= 8 treatment comparisons, 340 participants), there was no significant difference in normotensive people (n = 23 treatment comparisons, 1063 participants); however, the test for subgroup differences was of borderline significance (P = 0.08; I 2 = 60%), requiring further research to confirm the findings. Subgroup meta‐analysis by blinding suggested a trend towards greater blood pressure reduction in unblinded trials compared to double‐blinded trials, albeit statistically not significant. Further research is needed to confirm whether participant expectation may influence blood pressure results. Subgroup analysis by type of control (flavanol‐free versus low‐flavanol control) did not reveal a significant difference. Whether the age of participants plays a role in the effect of cocoa on blood pressure, with younger participants responding with greater blood pressure reduction, needs to be further investigated. Sensitivity analysis excluding trials with authors employed by trials sponsoring industry (33 trials, 1482 participants) revealed a small reduction in effect size, indicating some reporting bias. Due to the remaining heterogeneity, which we could not explain in terms of blinding, flavanol content of the control groups, age of participants, or study duration, we downgraded the quality of the evidence from high to moderate. Results of subgroup analyses should be interpreted with caution and need to be confirmed or refuted in trials using direct randomised comparisons. Generally, cocoa products were highly tolerable, with adverse effects including gastrointestinal complaints and nausea being reported by 1% of participants in the active cocoa intervention group and 0.4% of participants in the control groups (moderate‐quality evidence). Authors' conclusions This review provides moderate‐quality evidence that flavanol‐rich chocolate and cocoa products cause a small (2 mmHg) blood pressure‐lowering effect in mainly healthy adults in the short term. These findings are limited by the heterogeneity between trials, which could not be explained by prespecified subgroup analyses, including blinding, flavanol content of the control groups, age of participants, or study duration. However, baseline blood pressure may play a role in the effect of cocoa on blood pressure; subgroup analysis of trials with (pre)hypertensive participants revealed a greater blood pressure‐reducing effect of cocoa compared to normotensive participants with borderline significance. Long‐term trials investigating the effect of cocoa on clinical outcomes are also needed to assess whether cocoa has an effect on cardiovascular events and to assess potential adverse effects associated with chronic ingestion of cocoa products. Plain language summary Effect of cocoa on blood pressure Review question We assessed the effect of cocoa products on blood pressure in adults when consumed daily for at least two weeks. We found 35 studies, covering 40 treatment comparisons. Background Dark chocolate and cocoa products are rich in chemical compounds called flavanols. Flavanols have attracted interest as they might help to reduce blood pressure, a known risk factor for cardiovascular disease (disorders of the heart and blood vessels). The blood pressure‐lowering properties of flavanols are thought to be related to widening of the blood vessels, caused by nitric oxide. Study characteristics Studies were short, mostly between two and12 weeks, with only one of 18 weeks. The studies involved 1804 mainly healthy adults. They provided participants with 30 to 1218 mg of flavanols (average of 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. Seven of the studies were funded by companies with a commercial interest in their results, and the reported effect was slightly larger in these studies, indicating possible bias. The evidence is current to November 2016. Key results Meta‐analysis of 40 treatment comparisons revealed a small but statistically significant lowering of blood pressure (systolic and diastolic) of 1.8 mmHg. This small reduction in blood pressure might complement other treatment options and might contribute to reducing the risk of cardiovascular disease. We investigated whether participants' blood pressure at the start of the study, their age, an awareness of group allocation (active or control), the flavanol content used in the control group, or how long the study lasted may explain variations between trials. While blood pressure status (high blood pressure or normal blood pressure) is a likely factor in the effect size of cocoa on blood pressure, the impact of other factors needs to be confirmed or rejected in further trials. Side effects including digestive complaints and dislike of the trial product were reported by only 1% of people in the active cocoa intervention group and 0.4% of people in the control groups. Longer‐term trials are needed to establish whether regularly eating flavanol‐rich cocoa products has a beneficial effect on blood pressure and cardiovascular health over time, and whether there are any side effects of long‐term use of cocoa products on a daily basis. Quality of evidence The evidence is of moderate quality. We were unable to identify any randomised controlled trials that tested the effect of long‐term daily use of cocoa products on blood pressure, and there were no trials that measured the health consequences of high blood pressure, such as heart attacks or strokes.", "journal": "Cochrane Database of Systematic Reviews", "year": "2017", "authors": "Ried, K; Fakler, P; Stocks, NP", "articleTypes": [], "doi": "10.1002/14651858.CD008893.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:26.730Z" }, { "id": "fee57ceb-2fed-4adb-af85-c2d5d9ef6dfa", "pmid": "", "title": "Interventions for cleaning dentures in adults", "imported": false, "abstract": "Abstract - Background Removing denture plaque may be essential for maintaining the oral health of edentulous people. Brushing and soaking in chemical products are two of the most commonly used methods of cleaning dentures. Objectives To evaluate the effectiveness and safety of different methods for cleansing removable dentures. Search methods We searched the following databases: the Cochrane Oral Health Group Trials Register (to May 2009); CENTRAL ( The Cochrane Library 2009, Issue 2); MEDLINE (1965 to May 2009); EMBASE (1980 to May 2009); LILACS (1980 to May 2009); and CINAHL (1997 to May 2009). There were no language restrictions. Selection criteria Randomised controlled trials (RCTs) comparing any mechanical method (e.g. brushing or ultrasound) or chemical (e.g. enzymes, sodium hypochlorite, oral rinses or peroxide solutions) in adults over the age of 18 wearing removable partial dentures or complete dentures. The primary outcomes considered were the health of denture bearing areas (soft tissues, periodontal tissues and teeth) and participants' satisfaction and preference. Secondary outcomes included denture plaque coverage area, indicators of halitosis and microbial counts on abutment teeth, soft tissues or denture base or saliva. Data collection and analysis Two independent review authors screened and extracted information from, and independently assessed the risk of bias in the included trials. Main results Although six RCTs were included in this review, the wide range of different interventions and outcome variables did not permit pooling of data in a meta‐analysis. Isolated reports indicated that chemicals and brushing appear to be more effective than placebo in the reduction of plaque coverage and microbial counts of anaerobes and aerobes on complete denture bases. Authors' conclusions There is a lack of evidence about the comparative effectiveness of the different denture cleaning methods considered in this review. Few well designed RCTs were found. Future research should focus on comparisons between mechanical and chemical methods; the assessment of the association of methods, primary variables and costs should also receive future attention. Plain language summary Interventions for cleaning dentures in adults Plaque formed on the surfaces of removable dentures can have a significant impact on oral health, as long as it can lead to infection of denture‐supporting mucosa (stomatitis), gum inflammation (gingivitis) and tooth decay. Denture plaque can be removed by several different methods which include: brushing with paste, soaking in chemicals (e.g. effervescent tablets or bleach) and using special devices (a microwave oven or ultrasonic device). This review found weak evidence in support of soaking of dentures in effervescent tablets or enzymatic solutions and that brushing with paste can remove plaque and kill microbes better than inactive treatments. It is, however, unclear which is the most effective and there is a paucity of data on the use of alternative methods. Futures studies should aim to provide reliable information about which method is more effective in maintaining oral health of removable denture wearers. The scarce data found was restricted to the cleansing of complete dentures made from an acrylic resin base. Further research should also investigate how removable partial dentures can be cleaned, and in particular on the corrosive effects of cleaners on their metallic components.", "journal": "Cochrane Database of Systematic Reviews", "year": "2009", "authors": "de Souza, RF, de Freitas Oliveira Paranhos, H, Lovato da Silva, CH, Abu‐Naba'a, L, Fedorowicz, Z, Gurgan, CA", "articleTypes": [], "doi": "10.1002/14651858.CD007395.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.766Z" }, { "id": "fee76153-d89a-4885-9040-9bd71daf4aec", "pmid": "", "title": "Pimozide for schizophrenia or related psychoses", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2013", "authors": "Mothi, M, Sampson, S", "articleTypes": [], "doi": "10.1002/14651858.CD001949.pub3 AB - Abstract - Background Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been associated with cardiotoxicity and sudden unexplained death. Electrocardiogram monitoring is now required before and during use. Objectives To review the effects of pimozide for people with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medication. A secondary objective was to examine the effects of pimozide for people with delusional disorder. Search methods We searched the Cochrane Schizophrenia Group's Register (28 January 2013). Selection criteria We sought all relevant randomised clinical trials (RCTs) comparing pimozide with other treatments. Data collection and analysis Working independently, we inspected citations, ordered papers and then re‐inspected and assessed the quality of the studies and of extracted data. For homogeneous dichotomous data, we calculated the relative risk (RR), the 95% confidence interval (CI) and mean differences (MDs) for continuous data. We excluded data if loss to follow‐up was greater than 50%. We assessed risk of bias for included studies and used GRADE to rate the quality of the evidence. Main results We included 32 studies in total: Among the five studies that compared pimozide versus placebo, only one study provided data for global state relapse, for which no difference between groups was noted at medium term (1 RCT n = 20, RR 0.22 CI 0.03 to 1.78, very low quality of evidence ). None of the five studies provided data for no improvement or first‐rank symptoms in mental state. Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (1 RCT, n = 19, RR 5.50 CI 0.30 to 101.28, very low quality of evidence ) or at medium term (1 RCT n = 25, RR 1.33 CI 0.14 to 12.82, very low quality of evidence ), or for Parkinsonism (tremor) at medium term (1 RCT n = 25, RR 1 CI 0.2 to 4.95, very low quality of evidence ). No data were reported for quality of life at medium term. Of the 26 studies comparing pimozide versus any antipsychotic, seven studies provided data for global state relapse at medium term, for which no difference was noted (7 RCTs n = 227, RR 0.82 CI 0.57 to 1.17, moderate quality of evidence ). Data from one study demonstrated no difference in mental state (no improvement) at medium term (1 RCT n = 23, RR 1.09 CI 0.08 to 15.41, very low quality evidence ); another study demonstrated no difference in the presence of first‐rank symptoms at medium term (1 RCT n = 44, RR 0.53 CI 0.25 to 1.11, low quality of evidence ). Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (6 RCTs n = 186, RR 1.21 CI 0.71 to 2.05, low quality of evidence ) or medium term (5 RCTs n = 219, RR 1.12 CI 0.24 to 5.25, low quality of evidence ), or for Parkinsonism (tremor) at medium term (4 RCTs n = 174, RR 1.46 CI 0.68 to 3.11, very low quality of evidence ). No data were reported for quality of life at medium term. In the one study that compared pimozide plus any antipsychotic versus the same antipsychotic, significantly fewer relapses were noted in the augmented pimozide group at medium term (1 RCT n = 69, RR 0.28 CI 0.15 to 0.50, low quality evidence ). No data were reported for mental state outcomes or for extrapyramidal symptoms (EPS). Data were skewed for quality of life scores, which were not included in the meta‐analysis but were presented separately. Two studies compared pimozide plus any antipsychotics versus antipsychotic plus placebo; neither study reported data for outcomes of interest, apart from Parkinsonism at medium term and quality of life using the Specific Level of Functioning scale (SLOF); however, data were skewed. Only one study compared pimozide plus any antipsychotic versus antipsychotics plus antipsychotic; no data were reported for global state and mental state outcomes of interest. Data were provided for Parkinsonism (rigidity and tremor) using the Extrapyramidal Symptom Rating Scale (ESRS); however, these data were skewed. Authors' conclusions Although shortcomings in the data are evident, enough overall consistency over different outcomes and time scales is present to confirm that pimozide is a drug with efficacy similar to that of other, more commonly used antipsychotic drugs such as chlorpromazine for people with schizophrenia. No data support or refute its use for those with delusional disorder. Plain language summary Pimozide for schizophrenia or related psychoses People with schizophrenia have ‘positive symptoms’ such as hearing voices and seeing things (hallucinations) and fixed strange beliefs (delusions). People with schizophrenia also have ‘negative symptoms’ such as tiredness, apathy and loss of emotion. Antipsychotic drugs are the main treatment for the symptoms of schizophrenia and can be grouped into older drugs (first generation or ‘typical’) and newer drugs (second generation or ‘atypical’). Pimozide is a ‘typical’ antipsychotic drug that was first introduced in the late 1960s and was given to people with schizophrenia. Pimozide is thought to be effective in treating the positive and negative symptoms of schizophrenia or similar mental health problems such as delusional disorder, but it produces serious side effects such as muscle stiffness, tremors and slow body movements. Pimozide may also cause heart problems and has been linked to sudden unexplained death. Monitoring the heart via electrocardiogram is now required before and during treatment with pimozide. It is well known that people with mental health problems suffer from physical illnesses such as heart disease and diabetes and can die on average twenty years younger than those in the general population.
 An update search for this review was carried out 28 January 2013; the review now includes 32 studies that assess the effects of pimozide for people with schizophrenia or similar mental health problems. Pimozide was compared with other antipsychotic drugs, placebo (‘dummy’ treatment) or no treatment. Results suggest that pimozide is probably just as effective as other commonly used ‘typical’ antipsychotic drugs (for outcomes such as treating mental state, relapse, leaving the study early). No studies included delusional disorders, so no information is available on this group of people. No evidence was found to support the concern that pimozide causes heart problems (although this may be result of the fact that the studies were small and short term and the participants did not receive doses above recommended limits of 20 mg/d). Pimozide may cause less sleepiness than other typical antipsychotic drugs, but it may cause more tremors and uncontrollable shaking. The claim that pimozide is useful for treating people with negative symptoms also is not supported and proven. However, the quality of evidence in the main was low or very low quality, studies were small and of short duration and were poorly reported. Large‐scale, well‐conducted and well‐reported studies are required to assess the effectiveness of pimozide in the treatment of schizophrenia and other mental health problems such as delusional disorder. This plain language summary has been written by a consumer, Benjamin Gray (Service User and Service User Expert, Rethink Mental Illness).", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.794Z" }, { "id": "fef5ad71-4ca1-433e-a76c-fb53321516e8", "pmid": "", "title": "Sodium channel blockers for cystic fibrosis", "imported": false, "abstract": "Abstract - Background People with cystic fibrosis (CF) have increased transport of the salt, sodium across their airway lining. Over‐absorption of sodium results in the dehydration of the liquid that lines the airway surface and (along with defective chloride secretion) is a primary defect in people with CF. Objectives To determine whether the topical administration of drugs that block sodium transport improves the respiratory condition of people with CF. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We contacted principal investigators known to work in the field, previous authors and pharmaceutical companies who manufacture ion transport agents for unpublished or follow‐up data. Most recent search of the Group's register: 19 December 2013. Selection criteria Published or unpublished randomised controlled trials (RCTs) or quasi‐randomised controlled trials of sodium channel blockers compared to placebo or another sodium channel blocker or the same sodium channel blocker at a different dosing regimen. Data collection and analysis Two authors independently extracted data. Meta‐analysis was limited due to differing study designs. Main results Five RCTs, with a total of 226 participants, examining the topical administration of the short‐acting sodium channel blocker, amiloride, compared to placebo were identified as eligible for inclusion in the review. In three studies over six months, there was a significant difference found in the difference in relative change in FVC in favour of placebo (weighted mean difference 1.51% (95% confidence interval ‐2.77 to ‐0.25), although heterogeneity was evident. A two‐week study demonstrated that hypertonic saline with amiloride pre‐treatment did not result in a significant improvement in respiratory function or mucus clearance, in contrast to pre‐treatment with placebo. There were no significant differences identified in other clinically relevant outcomes. Authors' conclusions We found no evidence that the topical administration of a short‐acting sodium channel blocker improves respiratory condition in people with cystic fibrosis and some limited evidence of deterioration in lung function. Plain language summary Drugs to control the movement of salt in the lungs of people with cystic fibrosis Usually salt is absorbed from liquid on the surface of the lungs to stop fluid building up there. In cystic fibrosis too much salt is absorbed and there is little liquid left on the airway surfaces. As a result people with cystic fibrosis have problems clearing their lungs of sticky secretions. Thus the lungs are left open to infection. Drugs applied directly to the lungs may prevent too much salt being absorbed. This may lead to better clearance of mucus and less lung infection and damage. The review includes five studies with a total of 226 participants. All studies looked at short‐acting drugs applied directly to the lungs compared to placebo. When the results from three studies over six months were combined, the placebo group showed a slower rate of decline in forced vital capacity than the treatment group. However, each of these differed in their results. A further study showed that people receiving a sodium channel blocker before receiving hypertonic saline did not achieve better lung function or mucus clearance than those receiving placebo before hypertonic saline. We found no evidence that short‐acting sodium channel blockers administered directly to the lungs improve respiratory status in people with cystic fibrosis. There was even some limited evidence of a decline in lung function. Trials of long‐acting sodium channel blockers are ongoing.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Burrows, EF; Southern, KW; Noone, PG", "articleTypes": [], "doi": "10.1002/14651858.CD005087.pub4", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.060Z" }, { "id": "fef7bed3-7244-4066-9a76-460de2f6883f", "pmid": "", "title": "Spironolactone in Alcohol Use Disorder (SAUD): A Double-Blind, Placebo-Controlled, Ascending Dose, Phase 1b Study", "imported": false, "abstract": "Background:", "journal": "", "year": "2023", "authors": "", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:32.245Z" }, { "id": "ff0ef988-b241-4ecb-b774-910429d099bf", "pmid": "", "title": "Pain relief in hysterosalpingography", "imported": false, "abstract": "Abstract - Background Hysterosalpingography (HSG) is a method of testing for tubal patency. However, women struggle to tolerate the procedure, as it is associated with some discomfort. Various pharmacological strategies are available that may reduce pain during the procedure, though there is no consensus as to the best method. Objectives To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing HSG for investigation of subfertility. Search methods This review has drawn on the search strategy developed for the Cochrane Menstrual Disorders and Subfertility Group (MDSG). We searched the following databases to 15 April 2015: MDSG Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO. Selection criteria All identified randomised controlled trials investigating pharmacological interventions for pain relief during HSG were investigated for selection. Data collection and analysis Four review authors independently extracted data. We combined data to calculate mean differences (MDs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I² statistic. We assessed the overall quality of the evidence for the main comparisons using GRADE methods. Main results The search identified 23 trials (1272 women) that were eligible for inclusion into the study. Oral opioid analgesia versus placebo/no treatment There was no evidence of effect for oral opioid analgesia in reducing pain during the procedure (MD −0.91, 95% CI −1.88 to 0.06, 1 study, n = 128, low quality evidence) or more than 30 minutes after the procedure (MD −0.99, 95% CI −1.75 to −0.23, 1 study, n = 128, moderate quality evidence) No studies reported on the effect of oral opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes after the procedure There was insufficient evidence to reach conclusions regarding adverse effects. Intravenous opioid analgesia versus placebo/no treatment There was evidence that intravenous opioids may improve pain relief during the procedure compared to no treatment (MD −3.53, 95% CI −4.29 to −2.77, 1 study, n = 62, moderate quality evidence) No studies reported on the effect of intravenous opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes and more than 30 minutes after the procedure In terms of adverse effects, one trial reported 1/32 participants had apnoea with intravenous remifentanil. Recovery time was nearly 4 minutes longer in the remifentanil group compared to the control. Oral non‐opioid analgesia versus placebo/no treatment There was no evidence of effect for oral non‐opioid analgesia in reducing pain during the procedure (MD −0.13, 95% CI −0.48 to 0.23, 3 studies, n = 133, I² = 61%, low quality evidence), less than 30 minutes after the procedure (MD −0.30, 95% CI −1.03 to 0.43, 2 studies, n = 45, I² = 97%, very low quality evidence), or more than 30 minutes after the procedure (MD −0.36, 95% CI −1.06 to 0.34, 3 studies, n = 133, I² = 58%, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Topical anaesthesia versus placebo/no treatment There was evidence that topical anaesthetics may reduce pain during the procedure (MD −0.63, 95% CI −1.06 to −0.19, 9 studies, n = 613, I² = 66%, low quality evidence). There was no evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD 0.42, 95% CI ‐0.03 to 0.86, 5 studies, n = 373, I² = 59%, very low quality evidence). There was evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain more than 30 minutes after the procedure (MD −1.38, 95% CI ‐3.44 to −0.68, 2 studies, n = 166, I² = 92%, very low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Locally injected anaesthesia versus placebo/no treatment There was evidence of effect that locally injected anaesthetic can reduce pain during the procedure (MD −1.31, 95% CI −1.55 to −1.07, 2 studies, n = 125, I² = 0%, very low quality evidence). There was no evidence of effect for locally injected anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD −1.31, 95% CI −2.14 to −0.49, 2 studies, n = 125, I² = 46%, low quality evidence). No studies were included into the analysis of the effect of locally injected anaesthesia, when injected prior to the procedure, in reducing pain more than 30 minutes after the procedure. There was insufficient evidence to reach conclusions regarding adverse effects. Any analgesic versus any other analgesic There was no evidence of a difference between the groups when oral non‐opioid analgesia was compared to opioid analgesia for pain relief during the procedure (MD 1.10, 95% CI −0.26 to 2.46, 1 study, n = 91, low quality evidence); less than 30 minutes following the procedure (MD −0.30, 95% CI −1.00 to 0.40, 1 study, n = 91, low quality evidence); and more than 30 minutes following the procedure (MD −0.60, 95% CI −1.56 to 0.36, 1 study, n = 91, low quality evidence). Topical anaesthetics were found to be more effective than paracervical block for pain relief during HSG (MD −2.73, 95% CI −3.86 to −1.60, 1 study, n = 20, moderate quality evidence). This benefit did not extend to within 30 minutes following HSG (MD −1.03, 95% CI −2.52 to 0.46, 1 study, n = 20, low quality evidence); or 30 minutes or more after HSG (MD 0.31, 95% CI −0.87 to 1.49, 1 study, n = 20, low quality evidence). There was insufficient evidence to reach conclusions regarding adverse effects. Authors' conclusions Topical anaesthetic applied before the procedure may be associated with effective pain relief during HSG, though the quality of this evidence is low. Intravenous opioids may also be effective in pain relief, though this must be weighed against their side effects and their effects on the recovery time. There is insufficient evidence to draw conclusions on the efficacy of other analgesics for HSG, or to reach any other conclusions regarding adverse effects. Plain language summary Drug treatments for pain relief in hysterosalpingography Review question: Which pain‐killers are effective at reducing the discomfort experienced with hysterosalpingography? Background: Hysterosalpingography (HSG) is a test used in investigating infertility in women. HSG involves a dye being introduced into the uterus and the connecting tubes, which enables them to be visualised using an x‐ray, allowing the clinician to assess how open the connecting tubes are. This can be a painful procedure. There is disagreement regarding the best form of pain relief during the procedure. Study characteristics: We identified 19 randomised controlled trials that compared a specific drug treatment to a placebo/no treatment. Four trials compared two different drug treatments to establish if one was better. All studies took place in a clinical setting. Age of participants ranged from 18 to 42 years. Studies took place in India, Australia, United Kingdom, United States of America, Turkey, Israel, Netherlands, Italy, Iran, Nigeria, Spain, Brazil, and Belgium (1272 women in total). We included 15 of these trials in a meta‐analysis. The remaining eight trials, while eligible for inclusion, did not have data in a format that could be entered into meta‐analysis (seven compared a specific drug to a placebo/no treatment, one compared two different drug treatments). The evidence is current to April 2015. Key results : Topical anaesthetic was associated with a mild reduction in the pain experienced during HSG (low quality evidence). However, it has no effect on the discomfort experienced by participants following the procedure (very low quality evidence). Locally injected anaesthetics, on the other hand, were not associated with any benefit. Only one study investigated this (moderate quality evidence). One study directly compared locally injected anaesthetics to topical anaesthetics. This study found that topical anaesthesia was associated with improved pain relief during the procedure (moderate quality evidence) No oral drug was found to be effective in reducing pain experienced during the procedure. This was true for both opioid (low quality evidence) and non‐opioid (low quality evidence) analgesia. One trial however reported that tramadol may be of benefit in reducing the pain experienced more than 30 minutes after the procedure (moderate quality evidence). Quality of the evidence: The quality of the combined results was mainly downgraded for two reasons: 1) studies having methods that may be at risk of bias/inaccuracy; 2) substantially different conclusions between studies that investigate the same drug. The included studies did not report side effects in large enough numbers to make definitive conclusions regarding the side effects of particular drugs during the procedure. Conclusions: Only topical anaesthetics and intravenous opioids were found to be of benefit in reducing pain during the procedure, though the quality of this evidence is low to moderate, and there is no evidence that these are effective at relieving pain following the procedure. There is insufficient evidence for other drug treatments in reducing pain during HSG. There was insufficient evidence to reach any conclusions regarding adverse effects.", "journal": "Cochrane Database of Systematic Reviews", "year": "2015", "authors": "Hindocha, A, Beere, L, O'Flynn, H, Watson, A, Ahmad, G", "articleTypes": [], "doi": "10.1002/14651858.CD006106.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.132Z" }, { "id": "ff12fc56-3c42-41a2-9f84-49e5d0880c86", "pmid": "", "title": "Iodised salt for preventing iodine deficiency disorders", "imported": false, "abstract": "Abstract - Background Iodine deficiency is the main cause for potentially preventable mental retardation in childhood, as well as causing goitre and hypothyroidism in people of all ages. It is still prevalent in large parts of the world. Objectives To assess the effects of iodised salt in comparison with other forms of iodine supplementation or placebo in the prevention of iodine deficiency disorders. Search methods We searched The Cochrane Library , MEDLINE, the Register of Chinese trials developed by the Chinese Cochrane Centre, and the Chinese Med Database, China National knowledge Infrastructure, and searched reference lists, databases of ongoing trials and the Internet. Selection criteria We included prospective controlled studies of iodised salt versus other forms of iodine supplementation or placebo in people living in areas of iodine deficiency. Studies reported mainly goitre rates and urinary iodine excretion as outcome measures. Data collection and analysis The initial data selection and quality assessment of trials was done independently by two reviewers. Subsequently, after the scope of the review was slightly widened from including only randomised controlled trials to including non‐randomised prospective comparative studies, a third reviewer repeated the trials selection and quality assessment. As the studies identified were not sufficiently similar and not of sufficient quality, we did not do a meta‐analysis but summarised the data in a narrative format. Main results We found six prospective controlled trials relating to our question. Four of these were described as randomised controlled trials, one was a prospective controlled trial that did not specify allocation to comparison groups, and one was a repeated cross‐sectional study comparing different interventions. Comparison interventions included non‐iodised salt, iodised water, iodised oil, and salt iodisation with potassium iodide versus potassium iodate. Numbers of participants in the trials ranged from 35 to 334; over 20,000 people were included in the cross‐sectional study. Three studies were in children only, two investigated both groups of children and adults and one investigated pregnant women. There was a tendency towards goitre reduction with iodised salt, although this was not significant in all studies. There was also an improved iodine status in most studies (except in small children in one of the studies), although urinary iodine excretion did not always reach the levels recommended by the WHO. None of the studies observed any adverse effects of iodised salt. Authors' conclusions The results suggest that iodised salt is an effective means of improving iodine status. No conclusions can be made about improvements in other, more patient‐oriented outcomes, such as physical and mental development in children and mortality. None of the studies specifically investigated development of iodine‐induced hyperthyroidism, which can be easily overlooked if just assessed on the basis of symptoms. High quality controlled studies investigating relevant long term outcome measures are needed to address questions of dosage and best means of iodine supplementation in different population groups and settings. Plain language summary Iodised salt for preventing iodine deficiency disorders Iodine deficiency causes mental retardation in children as well as enlarged thyroid glands (goitre) and deficiencies in thyroid hormones in people of all ages. It still exists in large parts of the world. This review looked at studies of iodised salt in the diet that included a comparison group. Six studies, most of them in children but some also in adults, were included. Iodine in the urine increased in all but one studies, but there was some concern that small children did not eat enough salt to achieve adequate iodine status. Some studies, but not all, also showed a reduction in the enlargement of the thyroid gland (goitre) that can accompany lack of iodine in the diet. Adverse effects were not reported, but these may not have been studied adequately. More high quality long term studies measuring outcomes related to child development, to deaths associated with iodine‐deficiency and to adverse effects are needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2002", "authors": "Wu, T; Liu, GJ; Li, P; Clar, C", "articleTypes": [], "doi": "10.1002/14651858.CD003204", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.079Z" }, { "id": "ff42f3a6-918c-4181-9805-bf9c0c910285", "pmid": "", "title": "Interventions for chronic palmoplantar pustulosis", "imported": false, "abstract": "Abstract - Background Palmoplantar pustulosis is a chronic inflammatory disease in which sterile, relapsing pustules appear on the palms and soles, possibly in conjunction with other symptoms. The previous Cochrane Review on this topic was published in 2006, before biological treatments were extensively used. Objectives To assess the effects of interventions for chronic palmoplantar pustulosis to induce and maintain complete remission. Search methods We searched the following databases up to March 2019: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of the included studies for further references to relevant randomised controlled trials (RCTs). Selection criteria We considered RCTs including people with palmoplantar pustulosis or chronic palmoplantar pustular psoriasis assessing topical therapy, systemic therapy, combinations of topical or systemic therapies, or non‐pharmacological therapies compared with placebo, no intervention, or each other. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our outcomes included 'Proportion of participants cleared or almost cleared', 'Proportion of participants with adverse effects serious or severe enough to cause withdrawal', 'Proportion of participants with at least 50% improvement in disease severity', and 'Proportion of participants with adverse effects'. Main results We included 37 studies (1663 participants; mean age 50 years (range 34 to 63); 24% males). These studies reported condition severity differently. Around half of the included trials stated the setting (hospitals, community clinics, or both). More than half of the studies were at high risk of bias in at least one domain. Our included studies assessed mainly systemic treatments (retinoids, ciclosporin, biologics, etretinate + PUVA (combination of psoralens and long‐wave ultraviolet radiation) therapy combined, and antibiotics), but also topical treatments (dermocorticoids, vitamin D) and phototherapy (PUVA, ultraviolet A1 (UVA1)). Other interventions were assessed by single studies. The most common comparator was placebo. All results presented in this abstract were assessed in the short term (mean treatment duration was 11 weeks (range 8 to 24 weeks)) and are based on participants with chronic palmoplantar pustulosis. All outcome time point measurements were taken from baseline and assessed at the end of treatment. Short‐term and long‐term outcomes were defined as measurement up to 24 weeks after randomisation and between 24 and 104 weeks after randomisation, respectively. One trial (188 participants) assessed the topical vitamin D derivative maxacalcitol versus placebo and found that maxacalcitol may be more effective than placebo in achieving clearance (risk ratio (RR) 7.83, 95% confidence interval (CI) 1.85 to 33.12; low‐quality evidence), and the risk of adverse effects (such as mild local irritation, pruritus, and haematological or urinary test abnormalities) is probably similar in both groups (RR 0.87, 95% CI 0.64 to 1.19; moderate‐quality evidence). Severity was not reported. Two trials (49 participants) assessed PUVA therapy versus placebo or no treatment, providing very low‐quality evidence. Adverse effects were reported with oral PUVA (including nausea, ankle swelling, and non‐purulent conjunctivitis) and with local PUVA (including blistering, erythema, and pruritus). With regard to the systemic retinoid alitretinoin, one trial (33 participants; moderate‐quality evidence) showed that alitretinoin probably makes little or no difference in reducing severity when compared to placebo (RR 0.69, 95% CI 0.36 to 1.30). A similar number of adverse events were reported in both treatment groups, including headache, cheilitis, nausea, arthralgia, and nasopharyngitis (RR 0.84, 95% CI 0.61 to 1.17). Clearance was not reported. There may be little or no difference between etanercept and placebo in achieving clearance (RR 1.64, 95% CI 0.08 to 34.28; 1 study; 15 participants; low‐quality evidence); however, the 95% CI was very wide, showing there may be a difference between groups. Severity was not measured. More patients treated with placebo may achieve reduced severity than those treated with ustekinumab, but the wide 95% CI indicates there might be little or no difference between groups and there might be greater effect with ustekinumab (RR 0.48, 95% CI 0.11 to 2.13; 1 study; 33 participants; low‐quality evidence). Clearance was not reported. It is uncertain whether guselkumab increases clearance when compared to placebo (2 studies; 154 participants) because the quality of evidence is very low, but guselkumab probably better reduces disease severity (RR 2.88, 95% CI 1.24 to 6.69; 1 study; 49 participants; moderate‐quality evidence). Secukinumab is probably superior to placebo in reducing severity (RR 1.55, 95% CI 1.02 to 2.35; 1 study; 157 participants; moderate‐quality evidence), but our clearance outcome was not reported. None of these trials reported on occurrence of adverse effects. Only two of the studies discussed above reported adverse effects serious or severe enough to cause withdrawal. Guselkumab may cause more serious adverse events when compared to placebo, but there is uncertainty due to the very wide 95% CI showing there may be little or no difference and showing more events with placebo (RR 2.88, 95% CI 0.32 to 25.80; 1 study; 49 participants; low‐quality evidence). Secukinumab probably causes more serious adverse events than placebo (RR 3.29, 95% CI 1.40 to 7.75; 1 study; 157 participants; moderate‐quality evidence). Authors' conclusions Evidence is lacking for major chronic palmoplantar pustulosis treatments such as superpotent corticosteroids, phototherapy, acitretin, methotrexate, and ciclosporin. Risk of bias and imprecision limit our confidence. Maxacalcitol may be more effective than placebo in achieving clearance in the short term (low‐quality evidence), and the risk of adverse effects is probably similar (moderate‐quality evidence). Oral alitretinoin is probably no more effective than placebo in reducing severity, with a similar risk of adverse effects (moderate‐quality evidence). Regarding biological treatments, we are uncertain of the effect of etanercept on clearance and the effect of ustekinumab on severity (low‐quality evidence). Secukinumab and guselkumab are probably superior to placebo in reducing severity (moderate‐quality evidence). Adverse events not requiring withdrawal were not reported for these treatments. Reporting of serious adverse effects was incomplete: compared to placebo, secukinumab probably caused more participant withdrawals (moderate‐quality evidence), but we are uncertain of the effect of guselkumab (low‐quality evidence). Future trials should assess commonly used treatments using validated severity and quality of life scales. Plain language summary Treating long‐term palmoplantar pustulosis (pustules on the hands and feet) Review question We wanted to assess treatments for palmoplantar pustulosis (a persistent condition characterised by small, pus‐filled blisters on the hands and feet), when compared to an inactive substance (placebo), no intervention, or each other. We included 37 studies. Background Palmoplantar pustulosis negatively affects a person's life; there is no cure or standard treatment. Over time, the skin becomes thicker and redder, and may develop cracks or flake off as scales. Symptoms are treated with topical medicines (usually corticosteroids), systemic medicines (medicines injected or taken by mouth that work throughout the entire body; usually medicines based on vitamin A or D), or phototherapy (ultraviolet light treatment). Study characteristics The studies involved 1663 adults (mostly women) 34 to 63 years of age (average age 50 years). In 19 studies, participants had had palmoplantar pustulosis from two to 16 years (average 6.4 years). Participants had palmoplantar pustular psoriasis (6 studies), palmoplantar pustulosis (29 studies), or both (2 studies). Study authors reported condition severity differently. The included studies assessed a variety of different treatments: mainly systemic treatments (including biologic medicines, vitamin A medicines, immunosuppressants, antibiotics, and light therapy combined with a vitamin A medicine), but also topical medicines (containing steroids or vitamin D) and light treatments. Single studies assessed other treatments. Treatments were most commonly compared against placebo. Treatment length varied; for our key results, this ranged from 8 to 24 weeks (average 11 weeks). When reported, studies were conducted in hospitals, community clinics, or both. Pharmaceutical companies funded 18 studies. Key results Low‐quality evidence suggests that maxacalcitol (a topical vitamin D derivative) may work better than placebo in achieving clearance; moderate‐quality evidence indicates that the number of side effects is probably similar in both groups (participants experienced itching, irritation, and blood or urine test abnormalities) (1 trial; 188 participants). Severity was not measured. We found very low‐quality evidence for PUVA therapy (i.e. psoralen, a drug to sensitise the skin, and ultraviolet light A) versus placebo or no treatment (2 studies; 49 participants), so we are unable to draw conclusions. Side effects with PUVA included skin blisters, redness, itching, swelling, and feeling sick. Oral alitretinoin probably makes little or no difference in reducing severity when compared to placebo (moderate‐quality evidence; 1 study; 33 participants). A similar result was found for side effects, with headache, sickness, joint pain, high cholesterol, and colds reported in both groups. Clearance was not reported. Five studies assessed biological treatments (etanercept, ustekinumab, guselkumab, secukinumab), which use substances made from living organisms, or synthetic versions, to target the immune system. Low‐quality evidence (1 study; 15 participants) suggests that etanercept may make little or no difference in clearance when compared to placebo, but we are very uncertain of this result. Side effects and severity were not measured. We found low‐quality evidence suggesting that ustekinumab may be worse than placebo in reducing disease severity, but we are very uncertain of this result. Side effects and clearance were not reported (1 study; 33 participants). Compared to placebo, guselkumab probably reduces severity (moderate‐quality evidence; 1 study; 49 participants), but its effects on clearance are uncertain (very low‐quality evidence; 2 studies; 154 participants). Side effects were not measured. Moderate‐quality evidence shows that secukinumab was probably superior to placebo in reducing severity, but skin clearance and side effects were not reported (1 study; 157 participants). Only two studies described above reported withdrawals from treatment due to serious side effects; these are probably more frequent with secukinumab than with placebo (157 participants), and may occur more often with guselkumab than with placebo (49 participants), but we are very uncertain of the guselkumab result. For these key results, outcomes were assessed between 8 and 24 weeks, which we deemed short term. This evidence is current to March 2019. Quality of the evidence The key comparisons reported clearance most often, but evidence quality was mainly very low. Only two key studies reported side effects causing withdrawal (low‐ and moderate‐quality evidence). The evidence underlying our severity and side effects outcomes was variable in quality (very low to moderate). Small participant numbers, results with wide margins of error, and selective reporting have limited our confidence in the evidence.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Obeid, G; Do, G; Kirby, L; Hughes, C; Sbidian, E; Le Cleach, L", "articleTypes": [], "doi": "10.1002/14651858.CD011628.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:47.082Z" }, { "id": "ff49792b-e386-4b85-be2d-1b9cc0374ecb", "pmid": "", "title": "Sumatriptan (oral route of administration) for acute migraine attacks in adults", "imported": false, "abstract": "Abstract - Background Migraine is a highly disabling condition for the individual and also has wide‐reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Objectives To determine the efficacy and tolerability of oral sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011. Selection criteria We included randomised, double‐blind, placebo‐ and/or active‐controlled studies using oral sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment. Main results Sixty‐one studies (37,250 participants) compared oral sumatriptan with placebo or an active comparator. Most of the data were for the 50 mg and 100 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 50 mg versus placebo the NNTs were 6.1, 7.5, and 4.0 for pain‐free at two hours and headache relief at one and two hours, respectively. NNTs for sustained pain‐free and sustained headache relief during the 24 hours postdose were 9.5 and 6.0, respectively. For sumatriptan 100 mg versus placebo the NNTs were 4.7, 6.8, 3.5, 6.5, and 5.2, respectively, for the same outcomes. Results for the 25 mg dose were similar to the 50 mg dose, while sumatriptan 100 mg was significantly better than 50 mg for pain‐free and headache relief at two hours, and for sustained pain‐free during 24 hours. Treating early, during the mild pain phase, gave significantly better NNTs for pain‐free at two hours and sustained pain‐free during 24 hours than did treating established attacks with moderate or severe pain intensity. Relief of associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than with placebo. For the most part, adverse events were transient and mild and were more common with the sumatriptan than with placebo, with a clear dose response relationship (25 mg to 100 mg). Sumatriptan was compared directly with a number of active treatments, including other triptans, paracetamol (acetaminophen), acetylsalicylic acid, non‐steroidal anti‐inflammatory drugs (NSAIDs), and ergotamine combinations. Authors' conclusions Oral sumatriptan is effective as an abortive treatment for migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events. Plain language summary Sumatriptan (oral route of administration) for acute migraine attacks in adults Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is widely available as an oral tablet. This review found that a single dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in about 3 in 10 people (32%) taking sumatriptan 100 mg, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 6 in 10 people (61%) taking sumatriptan 100 mg, compared with about 3 in 10 (32%) taking placebo. Almost a quarter (24%) of people taking sumatriptan 100 mg had freedom from pain at two hours which was sustained during 24 hours without the use of rescue medication, compared with fewer than 1 in 10 (8%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one‐third of those taking placebo. Adverse events were mostly of short duration and mild or moderate in severity, and were experienced by about 4 in 10 (43%) of people taking sumatriptan 100 mg, and by 2 in 10 (23%) taking placebo. The 50 mg dose had slightly lower efficacy, but was associated with fewer adverse events. Treating attacks while pain was still mild was more effective than treating established attacks with moderate or severe pain intensity.", "journal": "Cochrane Database of Systematic Reviews", "year": "2012", "authors": "Derry, CJ, Derry, S, Moore, RA", "articleTypes": [], "doi": "10.1002/14651858.CD008615.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.760Z" }, { "id": "ff52e4b9-0f48-4e5c-a3dd-5f5333ef44f7", "pmid": "", "title": "Interventions for chronic kidney disease in people with sickle cell disease", "imported": false, "abstract": "Abstract - Background Sickle cell disease (SCD), one of the commonest severe monogenic disorders, is caused by the inheritance of two abnormal haemoglobin (beta‐globin) genes. SCD can cause severe pain, significant end‐organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD. Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD. Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, with increased prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end‐stage renal disease. This is an update of a review first published in 2017. Objectives To assess the effectiveness of any intervention for preventing or reducing kidney complications or chronic kidney disease in people with sickle cell disease. Possible interventions include red blood cell transfusions, hydroxyurea, and angiotensin‐converting enzyme inhibitors (ACEIs), either alone or in combination. Search methods We searched for relevant trials in the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, CENTRAL, MEDLINE, Embase, seven other databases, and two other trials registers. Selection criteria Randomised controlled trials (RCTs) comparing interventions to prevent or reduce kidney complications or CKD in people with SCD. We applied no restrictions related to outcomes examined, language, or publication status. Data collection and analysis Two review authors independently assessed trial eligibility, extracted data, assessed the risk of bias, and assessed the certainty of the evidence (GRADE). Main results We included three RCTs with 385 participants. We rated the certainty of the evidence as low to very low across different outcomes according to GRADE methodology, downgrading for risk of bias concerns, indirectness, and imprecision. Hydroxyurea versus placebo One RCT published in 2011 compared hydroxyurea to placebo in 193 children aged nine to 18 months. We are unsure if hydroxyurea compared to placebo reduces or prevents progression of kidney disease assessed by change in glomerular filtration rate (mean difference (MD) 0.58 mL/min /1.73 m 2 , 95% confidence interval (CI) −14.60 to 15.76; 142 participants; very low certainty). Hydroxyurea compared to placebo may improve the ability to concentrate urine (MD 42.23 mOsm/kg, 95% CI 12.14 to 72.32; 178 participants; low certainty), and may make little or no difference to SCD‐related serious adverse events, including acute chest syndrome (risk ratio (RR) 0.39, 99% CI 0.13 to 1.16; 193 participants; low certainty), painful crisis (RR 0.68, 99% CI 0.45 to 1.02; 193 participants; low certainty); and hospitalisations (RR 0.83, 99% CI 0.68 to 1.01; 193 participants; low certainty). No deaths occurred in either trial arm and the RCT did not report quality of life. Angiotensin‐converting enzyme inhibitors versus placebo One RCT published in 1998 compared an ACEI (captopril) to placebo in 22 adults with normal blood pressure and microalbuminuria. We are unsure if captopril compared to placebo reduces proteinuria (MD −49.00 mg/day, 95% CI −124.10 to 26.10; 22 participants; very low certainty). We are unsure if captopril reduces or prevents kidney disease as measured by creatinine clearance; the trial authors stated that creatinine clearance remained constant over six months in both groups, but provided no comparative data (very low certainty). The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Angiotensin‐converting enzyme inhibitors versus vitamin C One RCT published in 2020 compared an ACEI (lisinopril) with vitamin C in 170 children aged one to 18 years with normal blood pressure and microalbuminuria. It reported no data we could analyse. We are unsure if lisinopril compared to vitamin C reduces proteinuria in this population: the large drop in microalbuminuria in both arms of the trial after only one month on treatment may have been due to an overestimation of microalbuminuria at baseline rather than a true effect. The RCT did not report serious adverse events, all‐cause mortality, or quality of life. Authors' conclusions We are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. We are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. We are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria. No RCTs assessed red blood cell transfusions or any combined interventions to prevent or reduce kidney complications. Due to lack of evidence, we cannot comment on the management of children aged over 18 months or adults with any known genotype of SCD. We have identified a lack of adequately designed and powered studies, although we found four ongoing trials since the last version of this review. Only one ongoing trial addresses renal function as a primary outcome in the short term, but such interventions have long‐term effects. Trials of hydroxyurea, ACEIs or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction of kidney complications in people with SCD. Plain language summary Interventions to prevent or reduce kidney complications in people with sickle cell disease Review question Are there any safe and effective interventions that prevent or reduce kidney complications in people with sickle cell disease (SCD)? Background SCD is a serious inherited blood disorder where the red blood cells, which carry oxygen around the body, develop abnormally. Normal red blood cells are flexible and disc‐shaped, but sickled cells are rigid and crescent‐shaped, and stickier than normal red blood cells. This can lead to blockage of blood vessels, resulting in tissue and organ damage and episodes of severe pain. The abnormal cells are fragile and break apart easily, which leads to a decreased number of red blood cells, known as anaemia. Kidney complications can start at an early age in children with SCD and are common in adults with the condition. Kidney complications leading to kidney protein leak and chronic kidney disease can be severe, with serious effects on health. Severe complications include the need for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) or a kidney transplant. Identifying therapies that can prevent or slow down the decline in kidney function in people with SCD is critical for improving health outcomes. Search date The evidence is current to 22 September 2022. Study characteristics We found three randomised controlled trials, which enroled a total of 385 people. One trial, published in 2011, compared the drug hydroxyurea (which helps to maintain the shape and flexibility of red blood cells), to placebo (dummy treatment) in 193 children aged nine to 18 months. The second trial, published in 1998, compared captopril (a drug used to treat high blood pressure) to placebo in 22 adults with normal blood pressure and microalbuminuria (high levels of protein in the urine). The third trial, published in 2020, compared lisinopril (a drug used to treat high blood pressure) to vitamin C in 170 children aged one to 18 years. Two trials received government funding; it was unclear how the third trial was funded. Key results In children aged nine to 18 months, hydroxyurea may increase the ability to produce normal urine, but we are unsure if it has any effect on the glomerular filtration rate (network of filters in the kidney that filter waste from the blood). Hydroxyurea may make little or no difference to the occurrence of serious complications including acute chest syndrome (pain, cough, fever, low oxygen levels, and abnormal substances in the lungs), painful crises, and hospitalisations. We are unsure if giving captopril to adults with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. We are unsure if giving lisinopril to children aged one to 18 years with SCD who have normal blood pressure and early signs of kidney damage (microalbuminuria) reduces progression of kidney damage. No trials reported quality of life. Limitations of the evidence We have little or very little confidence in the evidence because we only found three trials, and they had specific populations (only children or only adults), few participants, and wide variations in results.", "journal": "Cochrane Database of Systematic Reviews", "year": "2023", "authors": "Roy, NBA; Carpenter, A; Dale-Harris, I; Dorée, C; Estcourt, LJ", "articleTypes": [], "doi": "10.1002/14651858.CD012380.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:38.064Z" }, { "id": "ff78cad2-e98e-4315-b935-3336e96bcfa1", "pmid": "", "title": "Modifying the consistency of food and fluids for swallowing difficulties in dementia", "imported": false, "abstract": "Abstract - Background People with dementia can have feeding and swallowing difficulties (dysphagia). Modification of the consistency of food or fluids, or both, is a common management strategy. However, diet modification can affect quality of life and may lead to dehydration and malnutrition. Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia. Objectives To determine the effectiveness and adverse effects associated with modifying the consistency of food and fluids in improving oral intake and eliminating aspiration in adults with dysphagia and dementia. Search methods We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE via Ovid SP, Embase via Ovid SP, PsycINFO via Ovid SP, CINAHL via EBSCOhost, LILACS via BIREME, ClinicalTrials.gov and the World Health Organization (WHO) Portal on 9 May 2018. We also checked the reference lists of relevant articles to identify any additional studies. Selection criteria We included randomised controlled trials (RCTs), quasi‐RCTs and cluster‐RCTs published in any language that measured any of the outcomes of interest. We included trials with adults with a clinical diagnosis of dementia with symptoms and signs of dysphagia confirmed on instrumental assessment. We included participants with all types, stages and severities of dementia. Control groups received either no intervention or interventions not involving diet modification or modification to sensory properties of food. Data collection and analysis Two review authors independently assessed for inclusion all potential studies identified. Data were extracted independently along with assessment of methodological quality using standard Cochrane methods. We contacted study authors for additional unpublished information. Main results No trials on modification of food met the inclusion criteria. We included two studies that examined modification to fluids. Both were part of the same large multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. Participation in the second trial was determined by results from the first trial. With unpublished data supplied by study authors, we examined data from participants with dementia only. The first study, a cross‐over trial, investigated the immediate effects on aspiration of two viscosities of liquids (nectar thick and honey thick) compared to regular liquids in 351 participants with dementia using videofluoroscopy. Regular liquids with a chin down head posture, as well as regular liquids without any intervention were also compared. The sequence of interventions during videofluoroscopy may have influenced response to intervention. The second study, a parallel designed RCT, compared the effect of nectar and honey thick liquids with a chin down head posture over a three‐month period in a subgroup of 260 participants with dementia. Outcomes were pneumonia and adverse intervention effects. Honey thick liquids, which are more consistent with descriptors for 'spoon thick' or 'extremely thick' liquids, showed a more positive impact on immediate elimination of aspiration during videofluoroscopy, but this consistency showed more adverse effects in the second follow‐up study. During the second three‐month follow‐up trial, there were a greater number of incidents of pneumonia in participants receiving honey thick liquids than those receiving nectar thick liquids or taking regular liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of fluids prescribed. Neither trial addressed quality of life. Risk of bias for both studies is high. The overall quality of evidence for outcomes in this review is low. Authors' conclusions We are uncertain about the immediate and long‐term effects of modifying the consistency of fluid for swallowing difficulties in dementia as too few studies have been completed. There may be differences in outcomes depending on the grade of thickness of fluids and the sequence of interventions trialled in videofluoroscopy for people with dementia. Clinicians should be aware that while thickening fluids may have an immediate positive effect on swallowing, the long‐term impact of thickened fluids on the health of the person with dementia should be considered. Further high‐quality clinical trials are required. Plain language summary Modifying the consistency of food and fluids for swallowing difficulties in dementia Background Individuals with dementia often present with swallowing difficulties (dysphagia). The consequences can include choking, dehydration, malnutrition, weight loss, pneumonia and death. Modification of food and liquid is a popular management strategy. It is believed that increasing the viscosity of liquids or altering the consistency of food allows individuals a better opportunity to swallow, with a reduced risk of choking or liquids entering the airway. However, there is growing evidence suggesting that this strategy can lead to dehydration, malnutrition, negative psychological/social consequences, and can affect quality of life for the person with dementia. Review question We wished to find out if changing the viscosity or consistency of food or fluids, or both, makes swallowing safer and has positive outcomes for people with dementia in terms of respiratory status, nutritional status and quality of life. We wanted to examine if modifying food or fluids, or both, also had any adverse effects for the person with dementia. Study characteristics We found two studies, which were both part of the same multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. We included data on people with dementia only. The first of the two studies looked at the immediate effects of two viscosities of liquids compared to regular thin liquids on aspiration (entry of food or fluid into the lungs) in 351 people with dementia. This study also compared drinking regular thin liquids using a chin down head posture as well as drinking regular thin liquids without any changes to head position; the main outcome was fluid entering the lungs. Using a subgroup of 260 people with dementia from the first study, the second study compared the effect of the same liquid viscosities with a chin down head posture. The effectiveness of these interventions on the incidence of pneumonia and adverse effects of these interventions was examined over a three‐month period. Study results Honey thick viscosity liquids, which clinically are similar to descriptions of 'very thick liquids', had a more positive immediate impact on preventing fluid entering the lungs when examined during videofluoroscopy (specialised swallow x‐ray) examination. However, during the three‐month follow‐up period there were a greater number of incidents of pneumonia in the group of people with dementia receiving these honey thick liquids, than those receiving nectar thick liquids and those receiving regular thin liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of liquids that the person with dementia was receiving. Conclusion There were a number of methodological flaws in both studies in this review and these were acknowledged by the authors. While thickening fluids may have an immediate positive effect on swallow function, clinicians should consider the effects of this intervention on the person with dementia in the longer‐term. People with dementia on thickened fluids require long‐term follow‐up. The overall risk of bias of included studies is high. The quality of evidence is low. Further well‐designed research is needed.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Flynn, E, Smith, CH, Walsh, CD, Walshe, M", "articleTypes": [], "doi": "10.1002/14651858.CD011077.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.764Z" }, { "id": "ffb4087c-7b77-48e5-bb16-6dfddb41beed", "pmid": "", "title": "Surgical interventions for chronic rhinosinusitis with nasal polyps", "imported": false, "abstract": "Abstract - Background Surgical treatment of chronic rhinosinusitis with nasal polyps is an established treatment for medically resistant nasal polyp disease. Whether a nasal polypectomy with additional sinus dissection offers any advantage over an isolated nasal polypectomy has not been systematically reviewed. Objectives To assess the effectiveness of simple polyp surgery versus more extensive surgical clearance in chronic rhinosinusitis with nasal polyps. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 1); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. Selection criteria Randomised and quasi‐randomised controlled trials in patients over 16 with chronic rhinosinusitis with nasal polyps, who have failed a course of medical management and who have not previously undergone any previous surgical intervention for their nasal disease. Studies compared nasal polypectomy with more extensive sinus clearance in this patient cohort. Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Main results We identified no trials which met our inclusion criteria. Six controlled trials (five randomised) met some but not all of the inclusion criteria and were therefore excluded from the review. Authors' conclusions We are unable to reach any conclusions as to whether isolated nasal polypectomy or more extensive sinus surgery is a superior surgical treatment modality for chronic rhinosinusitis with nasal polyps. There is a need for high‐quality randomised controlled trials to assess whether additional sinus surgery confers any benefit when compared to nasal polypectomy performed in isolation. Plain language summary Surgical interventions for chronic rhinosinusitis with nasal polyps Background Benign nasal polyps are abnormal tissue growths inside the nasal passages and sinuses, often on both sides of the nose. They can cause a wide array of symptoms including blocked nose, poor sense of smell that can lead to a loss of taste, runny nose and nasal congestion. Sinuses are air‐filled cavities in the bones of the face, which are in continuity with the nasal passages. The first‐line treatment for nasal polyps is usually medical therapy in the form of steroids ‐ as sprays (topically) or by mouth (orally). In patients where this treatment has failed to relieve the symptoms, the polyps can be removed surgically. These surgical procedures are often not curative and patients may need to continue medical therapy or undergo further surgeries. A number of well‐established surgical techniques can be used to remove polyps. What has not been established is whether removing the nasal polyps and clearing out the sinuses offers any advantage in the control of the disease when compared to simply removing the polyps and leaving the sinuses unchanged. We sought evidence in the literature to establish whether there was any difference in patients who underwent nasal polyp removal alone versus those who had nasal polyps removed as well as opening up of the sinuses. Study characteristics No trials met our inclusion criteria. We did identify six controlled trials (five of which were randomised) in which some but not all of our inclusion criteria were met, but we had to exclude these studies from the review. Key results No trials met our inclusion criteria. Quality of evidence At present, we cannot comment on whether taking nasal polyps out alone or also opening up the sinuses at the same time is a better treatment for patients with this disease. There is a need for high‐quality randomised controlled trials to answer this question. This evidence is current to February 2014.", "journal": "Cochrane Database of Systematic Reviews", "year": "2014", "authors": "Sharma, R, Lakhani, R, Rimmer, J, Hopkins, C", "articleTypes": [], "doi": "10.1002/14651858.CD006990.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.798Z" }, { "id": "ffb58940-5e62-4d4b-b69b-d7798ccbb473", "pmid": "", "title": "Interventions for paracetamol (acetaminophen) overdose", "imported": false, "abstract": "Abstract - Background Paracetamol (acetaminophen) is the most widely used non‐prescription analgesic in the world. Paracetamol is commonly taken in overdose either deliberately or unintentionally. In high‐income countries, paracetamol toxicity is a common cause of acute liver injury. There are various interventions to treat paracetamol poisoning, depending on the clinical status of the person. These interventions include inhibiting the absorption of paracetamol from the gastrointestinal tract (decontamination), removal of paracetamol from the vascular system, and antidotes to prevent the formation of, or to detoxify, metabolites. Objectives To assess the benefits and harms of interventions for paracetamol overdosage irrespective of the cause of the overdose. Search methods We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register (January 2017), CENTRAL (2016, Issue 11), MEDLINE (1946 to January 2017), Embase (1974 to January 2017), and Science Citation Index Expanded (1900 to January 2017). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov database (US National Institute of Health) for any ongoing or completed trials (January 2017). We examined the reference lists of relevant papers identified by the search and other published reviews. Selection criteria Randomised clinical trials assessing benefits and harms of interventions in people who have ingested a paracetamol overdose. The interventions could have been gastric lavage, ipecacuanha, or activated charcoal, or various extracorporeal treatments, or antidotes. The interventions could have been compared with placebo, no intervention, or to each other in differing regimens. Data collection and analysis Two review authors independently extracted data from the included trials. We used fixed‐effect and random‐effects Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of the review outcomes. We used the Cochrane 'Risk of bias' tool to assess the risks of bias (i.e. systematic errors leading to overestimation of benefits and underestimation of harms). We used Trial Sequential Analysis to control risks of random errors (i.e. play of chance) and GRADE to assess the quality of the evidence and constructed 'Summary of findings' tables using GRADE software. Main results We identified 11 randomised clinical trials (of which one acetylcysteine trial was abandoned due to low numbers recruited), assessing several different interventions in 700 participants. The variety of interventions studied included decontamination, extracorporeal measures, and antidotes to detoxify paracetamol's toxic metabolite; which included methionine, cysteamine, dimercaprol, or acetylcysteine. There were no randomised clinical trials of agents that inhibit cytochrome P‐450 to decrease the activation of the toxic metabolite N ‐acetyl‐ p ‐benzoquinone imine. Of the 11 trials, only two had two common outcomes, and hence, we could only meta‐analyse two comparisons. Each of the remaining comparisons included outcome data from one trial only and hence their results are presented as described in the trials. All trial analyses lack power to access efficacy. Furthermore, all the trials were at high risk of bias. Accordingly, the quality of evidence was low or very low for all comparisons. Interventions that prevent absorption, such as gastric lavage, ipecacuanha, or activated charcoal were compared with placebo or no intervention and with each other in one four‐armed randomised clinical trial involving 60 participants with an uncertain randomisation procedure and hence very low quality. The trial presented results on lowering plasma paracetamol levels. Activated charcoal seemed to reduce the absorption of paracetamol, but the clinical benefits were unclear. Activated charcoal seemed to have the best risk:benefit ratio among gastric lavage, ipecacuanha, or supportive treatment if given within four hours of ingestion. There seemed to be no difference between gastric lavage and ipecacuanha, but gastric lavage and ipecacuanha seemed more effective than no treatment (very low quality of evidence). Extracorporeal interventions included charcoal haemoperfusion compared with conventional treatment (supportive care including gastric lavage, intravenous fluids, and fresh frozen plasma) in one trial with 16 participants. The mean cumulative amount of paracetamol removed was 1.4 g. One participant from the haemoperfusion group who had ingested 135 g of paracetamol, died. There were no deaths in the conventional treatment group. Accordingly, we found no benefit of charcoal haemoperfusion (very low quality of evidence). Acetylcysteine appeared superior to placebo and had fewer adverse effects when compared with dimercaprol or cysteamine. Acetylcysteine superiority to methionine was unproven. One small trial (low quality evidence) found that acetylcysteine may reduce mortality in people with fulminant hepatic failure (Peto OR 0.29, 95% CI 0.09 to 0.94). The most recent randomised clinical trials studied different acetylcysteine regimens, with the primary outcome being adverse events. It was unclear which acetylcysteine treatment protocol offered the best efficacy, as most trials were underpowered to look at this outcome. One trial showed that a modified 12‐hour acetylcysteine regimen with a two‐hour acetylcysteine 100 mg/kg bodyweight loading dose was associated with significantly fewer adverse reactions compared with the traditional three‐bag 20.25‐hour regimen (low quality of evidence). All Trial Sequential Analyses showed lack of sufficient power. Children were not included in the majority of trials. Hence, the evidence pertains only to adults. Authors' conclusions These results highlight the paucity of randomised clinical trials comparing different interventions for paracetamol overdose and their routes of administration and the low or very low level quality of the evidence that is available. Evidence from a single trial found activated charcoal seemed the best choice to reduce absorption of paracetamol. Acetylcysteine should be given to people at risk of toxicity including people presenting with liver failure. Further randomised clinical trials with low risk of bias and adequate number of participants are required to determine which regimen results in the fewest adverse effects with the best efficacy. Current management of paracetamol poisoning worldwide involves the administration of intravenous or oral acetylcysteine which is based mainly on observational studies. Results from these observational studies indicate that treatment with acetylcysteine seems to result in a decrease in morbidity and mortality, However, further evidence from randomised clinical trials comparing different treatments are needed. Plain language summary Interventions for paracetamol (acetaminophen) overdose Review question: in this review, we looked at the evidence for the interventions (treatments) used to treat people with paracetamol (acetaminophen) poisoning. Mainly, we tried to assess what effects the interventions had on the number of deaths and the need for a liver transplant. Background: paracetamol is one of the most common drugs taken in overdose. Intentional or accidental poisoning with paracetamol is a common cause of liver injury. Search date: the evidence is current to January 2017. Study characteristics: randomised clinical trials (studies where people are randomly put into one of two or more treatment groups) where participants had come to medical attention because they had taken a paracetamol overdose, intentionally or by accident, regardless of the amount of paracetamol taken or the age, sex, or other medical conditions of the person involved. There are many different interventions that can be used to try to treat people with paracetamol poisoning. These interventions include decreasing the absorption of the paracetamol ingested and hence decreasing the amount absorbed into the bloodstream. The agents include activated charcoal (that binds paracetamol together in the stomach), gastric lavage (stomach washout to remove as much paracetamol as possible), or ipecacuanha (a syrup that is swallowed and causes vomiting (being sick)). Paracetamol once absorbed into the bloodstream goes to the liver where the majority is broken down to harmless products. However, a small amount of the medicine is converted into a toxic product that the liver can normally handle but, when large amounts of paracetamol are taken, the liver is overwhelmed. As a consequence, the toxic product can damage the liver leading to liver failure, kidney failure, and in some cases death. Other interventions to treat paracetamol poisoning include medicines (antidotes) that may decrease the amount of the toxic products (such as a medicine called cimetidine) or breakdown the toxic products (including medicines called methionine, cysteamine, dimercaprol, or acetylcysteine). Finally, attempts can be made to remove paracetamol and its toxic products from the bloodstream using special blood cleansing equipment. All these treatments were examined. We found 11 randomised clinical trials with 700 participants. Most of these trials looked at different treatments. Key results: activated charcoal, gastric lavage, and ipecacuanha may reduce absorption of paracetamol if started within one to two hours of paracetamol ingestion, but the clinical benefit was unclear. Activated charcoal seems to be the best choice if the person is able to take it. People may not be able to take charcoal if they are drowsy and some may dislike its taste or texture (or both). Of the treatments that remove the toxic products of paracetamol, acetylcysteine seems to reduce the rate of liver injury from paracetamol poisoning. Furthermore, it has fewer side effects than some other antidotes such as dimercaprol and cysteamine; its superiority to methionine was unclear. Acetylcysteine should be given to people with paracetamol poisoning at risk of liver damage, risk is determined by the dose ingested, time of ingestion, and investigations. More recent clinical trials have looked at ways to decrease side effects of intravenous (into a vein) acetylcysteine treatment, by altering the way it is given. These trials have shown that by using a slower infusion and lower initial dose of acetylcysteine, the proportion of side effects such as nausea (feeling sick) and vomiting, and allergy (the body's bad reaction to the medicine such as a rash) may be lowered. Quality of the evidence: this review of interventions for paracetamol poisoning found surprisingly few published randomised clinical trials for this very common condition. Furthermore, the majority of trials had few participants and all were at high risk of bias. Accordingly, the quality of the evidence should be considered as low or very low.", "journal": "Cochrane Database of Systematic Reviews", "year": "2018", "authors": "Chiew, AL, Gluud, C, Brok, J, Buckley, NA", "articleTypes": [], "doi": "10.1002/14651858.CD003328.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.136Z" }, { "id": "ffc4ca60-b88e-44b9-afd9-52196184d08d", "pmid": "", "title": "Dietary marine fatty acids (fish oil) for asthma in adults and children", "imported": false, "abstract": "", "journal": "Cochrane Database of Systematic Reviews", "year": "2000", "authors": "Thien, FCK, De Luca, S, Woods, RK, Abramson, MJ", "articleTypes": [], "doi": "10.1002/14651858.CD001283 AB - Abstract - Background Epidemiological studies suggest that a diet high in marine fatty acids (fish oil) may have beneficial effects on inflammatory conditions such as rheumatoid arthritis and possibly asthma. Objectives (1) To determine the effect of marine n‐3 fatty acid (fish oil) supplementation in asthma.
 (2) To determine the effect of a diet high in fish oil in asthma. Search methods We searched the Cochrane Airways Group Specialised Register. We also searched bibliographies of retrieved trials and contacted fish oil manufacturers. Searches were current as of May 2010. Selection criteria We included randomised controlled trials in patients with asthma more than two years of age. The study duration had to be in excess of four weeks. Double blind trials were preferred, but we also reviewed single‐blind and open trials for possible inclusion. All four reviewers read each paper, blind to its identity. Decisions concerning inclusion were made by simple majority. We all performed quality assessment independently. Data collection and analysis The only comparison possible was between marine n‐3 fatty acid supplementation and placebo. There were insufficient trials to examine dietary manipulation alone. Main results Nine randomised controlled trials conducted between 1986 and 2001 satisfied the inclusion criteria. Seven were of parallel design and two were cross‐over studies. Eight compared fish oil with placebo whilst one compared high dose versus low dose marine n‐3 fatty acid supplementation. Two studies were conducted in children, whilst the remaining seven studies were conducted in adults. None of the included studies reported asthma exacerbations, health status or hospital admissions. There was no consistent effect on any of the analysable outcomes: FEV1, peak flow rate, asthma symptoms, asthma medication use or bronchial hyper reactivity. One of the studies performed in children which combined dietary manipulation with fish oil supplementation showed improved peak flow and reduced asthma medication use. There were no adverse events associated with fish oil supplements. Authors' conclusions There is little evidence to recommend that people with asthma supplement or modify their dietary intake of marine n‐3 fatty acids (fish oil) in order to improve their asthma control. Equally, there is no evidence that they are at risk if they do so. Plain language summary Dietary marine fatty acids (fish oil) for asthma in adults and children Eating more fish has been recommended as one way of possibly reducing asthma. Populations (such as Eskimo communities) with diets high in fish also have low rates of asthma. As diets in other communities have become higher in saturated fats, asthma has also increased. The theory has been that an ingredient in fish oil may reduce inflammation. Inflammation causes the swelling in the airways of the lungs that leads to asthma attacks. However, this review of trials found that people with asthma changing their diets to include more fish oil did not improve their asthma.", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:04.758Z" }, { "id": "ffc509b8-827b-45ea-88e2-31fdad73d7c1", "pmid": "", "title": "Omega‐3 fatty acid supplementation for cystic fibrosis", "imported": false, "abstract": "Abstract - Background Studies suggest that a diet rich in omega‐3 essential fatty acids may have beneficial anti‐inflammatory effects for chronic conditions such as cystic fibrosis. This is an updated version of a previously published review. Objectives To determine whether there is evidence that omega‐3 polyunsaturated fatty acid supplementation reduces morbidity and mortality and to identify any adverse events associated with supplementation. Search methods We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of last search: 01 April 2020. We also searched online study registries and contacted authors. Date of last search: 12 February 2020. Selection criteria Randomised controlled trials in people with cystic fibrosis comparing omega‐3 fatty acid supplements with placebo. Data collection and analysis Two authors independently selected studies for inclusion, extracted data and assessed the risk of bias of the studies. The quality of the evidence was assessed using GRADE. Main results The searches identified 23 studies; five studies with 106 participants (children and adults) were included; duration of studies and interventions differed. Two studies compared omega‐3 fatty acids to olive oil for six weeks; one study compared omega‐3 fatty acids and omega‐6 fatty acids to control capsules (customised fatty acid blends) for three months; one study compared a liquid dietary supplement containing omega‐3 fatty acids to one without for six months; and one study compared omega‐3 fatty acids to a placebo for 12 months. Three studies had a low risk of bias for randomisation, but the risk was unclear in the remaining two studies; all studies had an unclear risk of bias for allocation concealment. Three of the studies adequately blinded participants; the risk of bias for selective reporting was high in one study and unclear for four studies. Two studies reported the number of respiratory exacerbations. At three months, one study (43 participants) reported no change in antibiotic usage. At 12 months the second study (15 participants) reported a reduction in the number of pulmonary exacerbations and cumulative antibiotic days in the supplement group compared to the previous year (no data for the control group); very low‐quality evidence means we are unsure whether supplementation has any effect on this outcome. With regards to adverse events, one six‐week study (12 participants) reported no difference in diarrhoea between omega‐3 or placebo capsules; the very low‐quality evidence means we are unsure if supplementation has any effect on this outcome. Additionally, one study reported an increase in steatorrhoea requiring participants to increase their daily dose of pancreatic enzymes, but three studies had already increased pancreatic enzyme dose at study begin so as to reduce the incidence of steatorrhoea. One study (43 participants) reported stomach pains at three months (treatment or control group not specified). One six‐week study (19 participants) reported three asthma exacerbations leading to exclusion of participants since corticosteroid treatment could affect affect essential fatty acid metabolism. Four studies reported lung function. One six‐week study (19 participants) reported an increase in forced expiratory volume in one second (FEV 1 ) (L) and forced vital capacity (FVC) (L), but the very low‐quality evidence means we are unsure if supplementation has any effect on lung function. The remaining studies did not report any difference in lung function at three months (unit of measurement not specified) or at six months and one year (FEV 1 % predicted and FVC % predicted). No deaths were reported in any of the five studies. Four studies reported clinical variables. One study reported an increase in Schwachman score and weight alongside a reduction in sputum volume with supplementation compared to placebo at three months (data not analysable). However, three studies reported no differences in either weight at six weeks, in body mass index (BMI) standard deviation (SD) score at six months (very low‐quality evidence) or BMI Z score at 12 months. Three studies reported biochemical markers of fatty acid status. One study showed an increase from baseline in both EPA and DHA content of serum phospholipids in the omega‐3 group compared to placebo at three months and also a significant decrease in n‐6/n‐3 ratio in the supplement group compared to placebo; since the quality of the evidence is very low we are not certain that these changes are due to supplementation. One six‐month cross‐over study showed a higher EPA content of the neutrophil membrane in the supplement group compared to the placebo group, but, no difference in DHA membrane concentration. Furthermore, the leukotriene B 4 to leukotriene B 5 ratio was lower at six months in the omega‐3 group compared to placebo. A one‐year study reported a greater increase in the essential fatty acid profile and a decrease in AA levels in the treatment arm compared to placebo. Authors' conclusions This review found that regular omega‐3 supplements may provide some limited benefits for people with cystic fibrosis with relatively few adverse effects: however, the quality of the evidence across all outcomes was very low. The current evidence is insufficient to draw firm conclusions or recommend routine use of these supplements in people with cystic fibrosis. A large, long‐term, multicentre, randomised controlled study is needed to determine any significant therapeutic effect and to assess the influence of disease severity, dosage and duration of treatment. Future researchers should note the need for additional pancreatic enzymes when providing omega‐3 supplementation or olive oil placebo capsules. More research is required to determine the exact dose of pancreatic enzyme required. Plain language summary The use of omega‐3 supplements in people with cystic fibrosis Review question We reviewed the evidence about the effect of giving omega‐3 supplements to people with cystic fibrosis. Background In people with cystic fibrosis recurring cycles of infection and inflammation are thought to worsen lung function. Studies suggest that omega‐3 fatty acids, such as those derived from fish oils, may work to counter the inflammation and may be of benefit in chronic inflammatory diseases including cystic fibrosis. This is an updated version of the review. Search date The evidence is current to: 01 April 2020. Study characteristics This review includes five small studies which compare omega‐3 supplements to a different supplement without omega‐3. In total there were 106 participants, including both children and adults. The studies lasted between six weeks and 12 months. Key results Due to the very low‐quality evidence, we are uncertain whether the following effects are due to supplementation or not. One 12‐month study reported a reduction in pulmonary exacerbations and antibiotic use when taking omega‐3 supplementation compared to placebo and one three‐month study reported no change in antibiotic use during the study period. Few side effects were reported in any of the studies. One six‐week study reported that lung function and clinical status improved when taking omega‐3 supplements. Sputum levels were also noted to be reduced in this six‐week study. Three studies reported no difference in lung function when taking omega‐3 supplementation compared to placebo. Two longer studies found that people taking omega‐3 supplements showed definite increases in levels of essential fatty acids in their white blood cell membranes and also in levels of phospholipids (molecules that provide structure and protection to cells) measured in blood samples. We are uncertain whether regular omega‐3 supplements benefit people with cystic fibrosis and whether they cause side effects, or not. We are not able to draw firm conclusions or recommend the routine use of these supplements in people with cystic fibrosis. Larger and longer studies are needed to assess the clinical benefit of omega‐3 supplementation and to determine the appropriate dosage. Quality of the evidence We judged the quality of the evidence to be very low due to very low participant numbers, low event rates, limited reporting and poor study design. There was no consistency with regards to the time points when results were reported or the measurements used for the same outcome in different studies.", "journal": "Cochrane Database of Systematic Reviews", "year": "2020", "authors": "Watson, H, Stackhouse, C", "articleTypes": [], "doi": "10.1002/14651858.CD002201.pub6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.089Z" }, { "id": "ffe152a1-2680-4e8e-82d1-d75e78b5223f", "pmid": "", "title": "Preventive lipid‐based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes", "imported": false, "abstract": "Abstract - Background One nutritional intervention advocated to prevent malnutrition among children is lipid‐based nutrient supplements (LNS). LNS provide a range of vitamins and minerals, but unlike most other micronutrient supplements, LNS also provide energy, protein and essential fatty acids. Alternative recipes and formulations to LNS include fortified blended foods (FBF), which are foods fortified with vitamins and minerals, and micronutrient powders (MNP), which are a combination of vitamins and minerals, Objectives To assess the effects and safety of preventive LNS given with complementary foods on health, nutrition and developmental outcomes of non‐hospitalised infants and children six to 23 months of age, and whether or not they are more effective than other foods (including FBF or MNP). This review did not assess the effects of LNS as supplementary foods or therapeutic foods in the management of moderate and severe acute malnutrition. Search methods In October 2018, we searched CENTRAL, MEDLINE, Embase, 21 other databases and two trials registers for relevant studies. We also checked the reference lists of included studies and relevant reviews and contacted the authors of studies and other experts in the area for any ongoing and unpublished studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs that evaluated the impact of LNS plus complementary foods given at point‐of‐use (for any dose, frequency, duration) to non‐hospitalised infants and young children aged six to 23 months in stable or emergency settings and compared to no intervention, other supplementary foods (i.e. FBF), nutrition counselling or multiple micronutrient supplements or powders for point‐of‐use fortification of complementary foods. Data collection and analysis Two review authors independently screened studies for relevance and, for those studies included in the review, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software. We used a random‐effects meta‐analysis for combining data as the interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables,. Main results Our search identified a total of 8124 records, from which we included 17 studies (54 papers) with 23,200 children in the review. The included studies reported on one or more of the pre‐specified primary outcomes, and five studies included multiple comparison groups. Overall, the majority of trials were at low risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias, but at high risk of bias for blinding of participants and personnel due to the nature of the intervention. Using the GRADE approach, we judged the quality of the evidence for most outcomes as low or moderate. LNS+complementary feeding compared with no intervention Thirteen studies compared LNS plus complementary feeding with no intervention. LNS plus complementary feeding reduced the prevalence of moderate stunting by 7% (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.88 to 0.98; nine studies, 13,372 participants; moderate‐quality evidence), severe stunting by 15% (RR 0.85, 95% CI 0.74 to 0.98; five studies, 6151 participants; moderate‐quality evidence), moderate wasting by 18% (RR 0.82, 95% CI 0.74 to 0.91; eight studies; 13,172 participants; moderate‐quality evidence), moderate underweight by 15% (RR 0.85, 95% CI 0.80 to 0.91; eight studies, 13,073 participants; moderate‐quality evidence), and anaemia by 21% (RR 0.79, 95% CI 0.69 to 0.90; five studies, 2332 participants; low‐quality evidence). There was no impact of LNS plus complementary feeding on severe wasting (RR 1.27, 95% CI 0.66 to 2.46; three studies, 2329 participants) and severe underweight (RR 0.78, 95%CI 0.54 to 1.13; two studies, 1729 participants). Adverse effects did not differ between the groups (RR 0.86, 95% CI 0.74 to 1.01; three studies, 3382 participants). LNS+complementary feeding compared with FBF Five studies compared LNS plus complementary feeding with other FBF, including corn soy blend and UNIMIX. We pooled four of the five studies in meta‐analyses and found that, when compared to other FBF, LNS plus complementary feeding significantly reduced the prevalence of moderate stunting (RR 0.89, 95% CI 0.82 to 0.97; three studies, 2828 participants; moderate‐quality evidence), moderate wasting (RR 0.79, 95% CI 0.65 to 0.97; two studies, 2290 participants; moderate‐quality evidence), and moderate underweight (RR 0.81, 95% CI 0.73 to 0.91; two studies, 2280 participants; moderate‐quality evidence). We found no difference between LNS plus complementary feeding and FBF for severe stunting (RR 0.41, 95% CI 0.12 to 1.42; two studies, 729 participants; low‐quality evidence), severe wasting (RR 0.64, 95% CI 0.19 to 2.81; two studies, 735 participants; moderate‐quality evidence), and severe underweight (RR 1.23, 95% CI 0.67 to 2.25; one study, 173 participants; low‐quality evidence). LNS+complementary feeding compared with MNP Four studies compared LNS plus complementary feeding with MNP. We pooled data from three of the four studies in meta‐analyses and found that compared to MNP, LNS plus complementary feeding significantly reduced the prevalence of moderate underweight (RR 0.88, 95% CI 0.78 to 0.99; two studies, 2004 participants; moderate‐quality evidence) and anaemia (RR 0.38, 95% CI 0.21 to 0.68; two studies, 557 participants; low‐quality evidence). There was no difference between LNS plus complementary feeding and MNP for moderate stunting (RR 0.92, 95% CI 0.82 to 1.02; three studies, 2365 participants) and moderate wasting (RR 0.97, 95% CI 0.77 to 1.23; two studies, 2004 participants). Authors' conclusions The findings of this review suggest that LNS plus complementary feeding compared to no intervention is effective at improving growth outcomes and anaemia without adverse effects among children aged six to 23 months in low‐ and middle‐income countries (LMIC) in Asia and Africa, and more effective if provided over a longer duration of time (over 12 months). Limited evidence also suggests that LNS plus complementary feeding is more effective than FBF and MNP at improving growth outcomes. Plain language summary Effect of lipid‐based nutrient supplementation on infants and young children Review question What is the impact of lipid‐based nutrient supplements (LNS) plus complementary foods on health, nutrition and developmental outcomes among infants and young children? Background LNS are food products which contain energy, minerals and vitamins that can improve growth in children. LNS provide vitamins, minerals and energy in the form of protein and essential fatty acids. We sought to assess the effect of LNS given jointly with complementary feeding, compared to no intervention, micronutrient powders (MNP; a mixture of vitamins and minerals that is sprinkled onto food) and other fortified blended food (FBF) products in healthy children. Study characteristics This review includes 17 studies (from 54 reports) with 23,200 children. Four of the included studies were conducted in Malawi, three in Bangladesh, two in Ghana and one each in Burkina Faso, Haiti, Honduras, Chad, Congo, Kenya, Niger, Peru, Guatemala, and Indonesia. Four included studies enrolled pregnant women and provided LNS plus complementary feeding during pregnancy and post‐partum, followed by infant supplementation starting at six months of age. The other studies provided LNS plus complementary feeding to children after six months of age. None of the included studies were conducted in emergency settings. Key results Findings of this review suggest that LNS plus complementary feeding is probably an effective intervention for improving growth outcomes and reducing the occurrence of children who are of short stature for their age (stunting), have low weight for their age (moderate underweight), have low weight for their height (moderate wasting) and anaemia. Additionally, LNS plus complementary feeding probably improves height and weight for age as well as mid‐upper arm circumference without adverse effects among children aged six to 23 months. The intervention seems to be more effective if provided for a duration longer than 12 months. Evidence also suggests that LNS plus complementary probably reduces moderate stunting, moderate wasting and moderate underweight, compared to other FBF. Furthermore, LNS plus complementary feeding is probably more effective than MNP at reducing moderate underweight and improving height and weight. Quality of evidence Overall, we considered most studies to be at high risk of bias for blinding of participants and personnel due to the nature of intervention. We rated the quality of the evidence for most outcomes as either low or moderate. Currentness of evidence The evidence is current to October 2018.", "journal": "Cochrane Database of Systematic Reviews", "year": "2019", "authors": "Das, JK, Salam, RA, Hadi, YB, Sadiq Sheikh, S, Bhutta, AZ, Weise Prinzo, Z, Bhutta, ZA", "articleTypes": [], "doi": "10.1002/14651858.CD012611.pub3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:28:13.787Z" }, { "id": "fff3b387-bef1-4c2e-adfb-cef230d08b0e", "pmid": "", "title": "Nedocromil sodium for chronic asthma in children", "imported": false, "abstract": "Abstract - Background Currently inhaled corticosteroids are the main stay in the maintenance treatment of chronic asthma in children. Although inhaled corticosteroids play a crucial role in the management of childhood asthma, the long‐term side effects of inhaled corticosteroids used in the management of chronic asthma in children are not clearly known. Objectives The objective of this review is to compare the safety and efficacy of inhaled nedocromil sodium with placebo in the treatment of chronic asthma in children. Search methods We searched the Cochrane Airway Group trials register, review articles, and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. We also searched abstracts of major respiratory society meetings. The last search was carried out in November 2009. Selection criteria Randomised placebo controlled trials comparing nedocromil sodium to placebo in the treatment of chronic asthma in children (0 to 18 years). Data collection and analysis Both authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Fifteen trials (twelve parallel group studies; three crossover trials recruiting 1422 children (837 males and 585 females)) were included. The studies were generally of good methodological quality. Two large long term studies used nedocromil for six months and four to six years and showed conflicting results in symptom free days. Short term studies (duration between 4 weeks to 12 weeks) showed that nedocromil sodium produced some improvement in a number of efficacy measures compared to placebo including FEV 1 , FVC, FEV 1 % predicted, PC20 FEV 1 , evening PEF and symptom scores. The parent's assessment of efficacy was in favour of nedocromil (odds ratio (OR) 0.5 (95% CI 0.3 to 0.8). Nedocromil sodium has a good safety profile. The only significant side effect observed was unpleasant taste. There was little evidence for a clinically dose response effect and only a few studies recruited participants with severe asthma. Authors' conclusions A limited number of small studies have shown that nedocromil is of benefit in improving lung function and some measures of symptoms, but the evidence with regard to the primary outcome of the review was conflicting. Two long‐term trials did not show consistent effects on lung function outcomes, whereas several small short‐term trials have shown benefit in these outcomes. Differing severities at baseline may explain this difference with milder participants experiencing less benefit, although the discrepancy between study findings may also reflect publication bias. Nedocromil sodium is associated with a very good safety profile with no significant short term or long‐ term adverse side effects. Although nedocromil may have advantages over inhaled corticosteroids in terms of side effects, there is a need for head to head trials of nedocromil and inhaled corticosteroids to establish whether asthma control is similar, especially in mild asthma. It is not yet clear where nedocromil should sit in relation to other therapies in the treatment of asthma in children. Plain language summary Nedocromil sodium for chronic asthma in children Nedocromil (or Tilade) is a 'preventer' therapy used to treat chronic asthma in children. It is thought to be safer than inhaled steroids and can be used for the management of mild to moderate asthma. The review of studies including 15 trials and 1422 children found that there were some encouraging results in short term studies when nedocromil was compared on its own with placebo, particularly with regard to lung function tests. However, these results were not confirmed in one large, longer term study of four to six years duration, which did not show significant difference in the primary outcome of symptom free days. This study was conducted in children who had mild asthma. There may be a role for nedocromil in the management of moderate asthma, but it should be assessed in relation to inhaled steroids, whose efficacy is well‐established. This particularly important in symptomatic asthma.", "journal": "Cochrane Database of Systematic Reviews", "year": "2006", "authors": "Sridhar, AV, McKean, MC", "articleTypes": [], "doi": "10.1002/14651858.CD004108.pub2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:56.064Z" }, { "id": "fff5b230-8e91-425a-a48e-8042c1c3b9c6", "pmid": "", "title": "Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women", "imported": false, "abstract": "Abstract - Rationale Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Alendronate belongs to the bisphosphonate class of drugs, which inhibit bone resorption by interfering with the activity of osteoclasts (bone cells that break down bone tissue). This is an update of a Cochrane review first published in 2008. Objectives To assess the benefits and harms of alendronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. Search methods We searched Evidence‐Based Medicine Reviews (which includes CENTRAL), MEDLINE, Embase, two trial registers, drug approval agency websites, and the bibliographies of relevant systematic reviews to identify the studies included in this review. The latest search date was 01 February 2023. We imposed no restrictions on language, date, form of publication, or reported outcomes. Eligibility criteria We included only randomized controlled trials that assessed the effects of alendronate on postmenopausal women. Targeted participants must have received at least one year of alendronate. We classified a study as secondary prevention if its population met one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T‐score (‐2.5 or lower), and 75 years old or older. If a study population met none of those criteria, we classified it as a primary prevention study. Outcomes Our major outcomes were clinical vertebral, non‐vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. Risk of bias We used the Cochrane risk of bias 1 tool. Synthesis methods We used standard methodological procedures expected by Cochrane. Based on the previous review experience, in which the clinical and methodological characteristics in the primary and secondary prevention studies were homogeneous, we used a fixed‐effect model for meta‐analysis and estimated effects using the risk ratio (RR) for dichotomous outcomes. Our base case analyses included all eligible placebo‐controlled studies with usable data. We selected the data available for the longest treatment period. We consider a relative change exceeding 15% as clinically important. Included studies We included 119 studies, of which 102 studies provided data for quantitative synthesis. Of these, we classified 34 studies (15,188 participants) as primary prevention and 68 studies (29,577 participants) as secondary prevention. We had concerns about risks of bias in most studies. Selection bias was the most frequently overlooked domain, with only 20 studies (19%) describing appropriate methods for both sequence generation and allocation concealment. Eight studies (8%) were at low risk of bias in all seven domains. Synthesis of results The base case analyses included 16 primary prevention studies (one to five years in length; 10,057 women) and 20 secondary prevention studies (one to three years in length; 7375 women) which compared alendronate 10 mg/day (or 70 mg/week) to placebo, no treatment, or both. Indirectness, imprecision, and risk of bias emerged as the main factors contributing to the downgrading of the certainty of the evidence. For primary prevention, alendronate may lead to a clinically important reduction in clinical vertebral fractures (16/1190 in the alendronate group versus 24/926 in the placebo group; RR 0.45, 95% confidence interval [CI] 0.25 to 0.84; absolute risk reduction [ARR] 1.4% fewer, 95% CI 1.9% fewer to 0.4% fewer; low‐certainty evidence) and non‐vertebral fractures (RR 0.83, 95% CI 0.72 to 0.97; ARR 1.6% fewer, 95% CI 2.6% fewer to 0.3% fewer; low‐certainty evidence). However, clinically important differences were not observed for the following outcomes: hip fractures (RR 0.76, 95% CI 0.43 to 1.32; ARR 0.2% fewer, 95% CI 0.4% fewer to 0.2% more; low‐certainty evidence); wrist fractures (RR 1.12, 95% CI 0.84 to 1.49; ARR 0.3% more, 95% CI 0.4% fewer to 1.1% more; low‐certainty evidence); withdrawals due to adverse events (RR 1.03, 95% CI 0.89 to 1.18; ARR 0.2% more, 95% CI 0.9% fewer to 1.5% more; low‐certainty evidence); and serious adverse events (RR 1.08, 95% CI 0.82 to 1.43; ARR 0.5% more, 95% CI 1.2% fewer to 2.8% more; low‐certainty evidence). For secondary prevention, alendronate probably results in a clinically important reduction in clinical vertebral fractures (24/1114 in the alendronate group versus 51/1055 in the placebo group; RR 0.45, 95% CI 0.28 to 0.73; ARR 2.7% fewer, 95% CI 3.5% fewer to 1.3% fewer; moderate‐certainty evidence). It may lead to a clinically important reduction in non‐vertebral fractures (RR 0.80, 95% CI 0.64 to 0.99; ARR 2.8% fewer, 95% CI 5.1% fewer to 0.1% fewer; low‐certainty evidence); hip fractures (RR 0.49, 95% CI 0.25 to 0.96; ARR 1.0% fewer, 95% CI 1.5% fewer to 0.1% fewer; low‐certainty evidence); wrist fractures (RR 0.54, 95% CI 0.33 to 0.90; ARR 1.8% fewer, 95% CI 2.6% fewer to 0.4% fewer; low‐certainty evidence); and serious adverse events (RR 0.75, 95% CI 0.59 to 0.96; ARR 3.5% fewer, 95% CI 5.8% fewer to 0.6% fewer; low‐certainty evidence). However, the effects of alendronate for withdrawals due to adverse events are uncertain (RR 0.95, 95% CI 0.78 to 1.16; ARR 0.4% fewer, 95% CI 1.7% fewer to 1.3% more; very low‐certainty evidence). Furthermore, the updated evidence for the safety risks of alendronate suggests that, irrespective of participants' risk of fracture, alendronate may lead to little or no difference for gastrointestinal adverse events. Zero incidents of osteonecrosis of the jaw and atypical femoral fracture were observed. Authors' conclusions For primary prevention, compared to placebo, alendronate 10 mg/day may reduce clinical vertebral and non‐vertebral fractures, but it might make little or no difference to hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. For secondary prevention, alendronate probably reduces clinical vertebral fractures, and may reduce non‐vertebral, hip, and wrist fractures, and serious adverse events, compared to placebo. The evidence is very uncertain about the effect of alendronate on withdrawals due to adverse events. Funding This Cochrane review had no dedicated funding. Registration This review is an update of the previous review (DOI: 10.1002/14651858.CD001155). Plain language summary Does alendronate help prevent fractures caused by osteoporosis in postmenopausal women? Key messages • Alendronate used for up to five years may prevent spinal fractures in women who are at lower risk for fractures, or in those who have not yet had a fracture of the spine. • Alendronate used for up to three years in women diagnosed with osteoporosis, with low bone density, or who have already had a fracture of the spine, probably prevents fractures of the spine. What is osteoporosis? Osteoporosis is a disease which makes bones weak and fragile. Bone is living tissue that is constantly being broken down and replaced. In osteoporosis, old bone breaks down faster than new bone can replace it. As this happens, the bones lose minerals (such as calcium). This makes bones more likely to break even after a minor injury, such as a bump or fall. Women are more likely to get osteoporosis after menopause. What is alendronate? Alendronate is a bisphosphonate, a type of medicine which slows down the cells that break down the old bone. What did we want to find out? We aimed to find out if alendronate is better than placebo (an inactive or 'dummy' medicine) or other medicines in preventing or reducing fractures in postmenopausal women. What did we do? We searched for studies that compared alendronate with placebo or other anti‐osteoporotic medicines for osteoporosis in postmenopausal women. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? We found 119 eligible studies. Of these, 102 studies provided usable data, and 40 studies compared alendronate to placebo (dummy pill). Key findings In women who are at a lower risk for fractures because they have bone density closer to normal, or they may not yet have a fracture in the bones of their spine, alendronate used for up to five years: may prevent clinical spinal fractures – that is, fractures indicated by clinical signs and symptoms, without radiographic evidence; may prevent fractures in bones other than the spine. However, specifically in hip and wrist fractures, alendronate may make no difference; may make no difference to the number of women who withdrew from the study due to adverse events – that is, unwanted, harmful events; may make no difference to the number of women experiencing serious adverse events. In women who are at a higher risk for fractures because they have already been diagnosed with osteoporosis, have low bone density, or have already had a spinal fracture, alendronate used for up to three years: probably prevents clinical spinal fractures; may prevent fractures in bones other than the spine; may prevent hip and wrist fractures; may reduce serious adverse events; We do not know if alendronate reduces withdrawals due to adverse events in this group of women. The best estimates for women at lower fracture risk taking alendronate or placebo are as follows. For clinical spinal fractures, evidence suggests that if 3 out of 100 women taking placebo experience a fracture, only 1 out of 100 women taking alendronate will. If 10 out of 100 women on placebo have a fracture in bones other than the spine, only 8 out of 100 on alendronate are likely to. For hip and wrist fractures, there may be no difference between the two groups in the number of women experiencing fractures. The best estimates for women at higher fracture risk taking alendronate or placebo are as follows. If 5 out of 100 women on placebo have a clinical spinal fracture, only 2 out of 100 women on alendronate are likely to. If 14 out of 100 women on placebo have a fracture in bones other than the spine, only 11 out of 100 on alendronate are likely to. If 2 out of 100 women on placebo have a hip fracture, only 1 out of 100 on alendronate are likely to. If 4 out of 100 women on placebo have a wrist fracture, only 2 out of 100 on alendronate are likely to. What are the limitations of the evidence? For most findings, our confidence in the evidence was low, because it is possible that the women in the studies, and the researchers assessing outcomes, were aware of which treatment the women received. Additionally, some of the evidence focused on specific alendronate doses, whereas the question we wanted to answer was broader. Finally, for some fracture outcomes, the evidence was based on few cases. How current is the evidence? The evidence is current to 1 February 2023. 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Biochemical studies in suicides and depressed patients suggest that 5-HT uptake function is frequently reduced in affective illness. Furthermore, 5-HTT is targeted by widely used antidepressant drugs such as fluoxetine. We have performed an association study of a short variant of the 5-HTT-linked polymorphic region (5-HTTLPR), which restricts transcriptional activity of the 5-HTT promoter leading to low functional expression of the 5-HTT, in 454 patients with bipolar or unipolar affective disorder and 570 controls, derived from three European Centres (London, Milan and Würzburg). In all three centres, the frequency of the low activity allele was higher in patients than in controls (50% vs 45% in London, 45% vs 43% in Milan, 47% vs 40% in Würzburg). Although these differences were not individually significant, a stratified analysis of all three samples gave a significant overall odds ratio of 1.23 (95% confidence interval 1.02-1.49, P = 0.03). The excess of the homozygous low-activity genotype among the patients was even greater (odds ratio 1.53, 95% confidence interval 1.04-2.23, P = 0.02), suggesting partial recessively of the low-activity allele. Given the functional role of 5-HTT, our findings suggest that 5-HTTLPR-dependent variation in functional 5-HTT expression is a potential genetic susceptibility factor for affective disorders. If this finding is replicated, further work on genetic variants with low 5-HTT activity may facilitate the differential diagnosis of affective disorders, the assessment of suicidal behaviour, and the prediction of good clinical response to antidepressants.", "journal": "Molecular psychiatry", "year": "1996", "authors": "Collier DA, Stöber G, Li T, Heils A, Catalano M, Di Bella D, Arranz MJ, Murray RM, Vallada HP, Bengel D, Müller CR, Roberts GW, Smeraldi E, Kirov G, Sham P, Lesch KP", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.860Z" }, { "id": "95c3670d-6cbc-4b27-9593-be5f374e8bb4", "pmid": "9154246", "title": "A novel functional polymorphism within the promoter of the serotonin transporter gene: possible role in susceptibility to affective disorders.", "imported": false, "abstract": "The serotonin transporter (5-HTT) is a candidate locus for aetiological involvement in affective disorders. Biochemical studies in suicides and depressed patients suggest that 5-HT uptake function is frequently reduced in affective illness. Furthermore, 5-HTT is targeted by widely used antidepressant drugs such as fluoxetine. We have performed an association study of a short variant of the 5-HTT-linked polymorphic region (5-HTTLPR), which restricts transcriptional activity of the 5-HTT promoter leading to low functional expression of the 5-HTT, in 454 patients with bipolar or unipolar affective disorder and 570 controls, derived from three European Centres (London, Milan and Würzburg). In all three centres, the frequency of the low activity allele was higher in patients than in controls (50% vs 45% in London, 45% vs 43% in Milan, 47% vs 40% in Würzburg). Although these differences were not individually significant, a stratified analysis of all three samples gave a significant overall odds ratio of 1.23 (95% confidence interval 1.02-1.49, P = 0.03). The excess of the homozygous low-activity genotype among the patients was even greater (odds ratio 1.53, 95% confidence interval 1.04-2.23, P = 0.02), suggesting partial recessively of the low-activity allele. Given the functional role of 5-HTT, our findings suggest that 5-HTTLPR-dependent variation in functional 5-HTT expression is a potential genetic susceptibility factor for affective disorders. If this finding is replicated, further work on genetic variants with low 5-HTT activity may facilitate the differential diagnosis of affective disorders, the assessment of suicidal behaviour, and the prediction of good clinical response to antidepressants.", "journal": "Molecular psychiatry", "year": "1996", "authors": "Collier DA, Stöber G, Li T, Heils A, Catalano M, Di Bella D, Arranz MJ, Murray RM, Vallada HP, Bengel D, Müller CR, Roberts GW, Smeraldi E, Kirov G, Sham P, Lesch KP", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR 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{ "id": "7fc2a7c5-e911-4ed3-878a-ede95ed7615e", "pmid": "10920459", "title": "A serotonin transporter gene promoter polymorphism (5-HTTLPR) and prefrontal cortical binding in major depression and suicide.", "imported": false, "abstract": "BACKGROUND: Major depression and suicide are associated with fewer serotonin transporter (5-HTT) sites. The 5'-flanking promoter region of the 5-HTT gene has a biallelic insertion/deletion (5-HTTLPR). We assayed prefrontal cortical (PFC) 5-HTT binding in major depression and suicide and examine the relationship to the 5-HTTLPR allele.\n\nMETHODS: Postmortem brain samples from 220 individuals were genotyped for the 5-HTTLPR polymorphism. Binding of 5-HTT was assayed by quantitative autoradiography in the PFC of a subset of subjects (n = 159). Clinical information, including DSM-III-R Axis I diagnoses, was obtained by psychological autopsy and medical chart review.\n\nRESULTS: Binding to 5-HTT was lower in the ventral PFC of suicides compared with nonsuicides and was lower throughout the PFC of subjects with a history of major depression. The 5-HTTLPR genotype was associated with major depression but not with suicide or 5-HTT binding.\n\nCONCLUSIONS: A diffuse reduction of 5-HTT binding in the PFC of individuals with major depression may reflect a widespread impairment of serotonergic function consistent with the range of psychopathologic features in major depression. The localized reduction in 5-HTT binding in the ventral PFC of suicides may reflect reduced serotonin input to that brain region, underlying the predisposition to act on suicidal thoughts. The 5-HTTLPR genotype was not related to the level of 5-HTT binding and does not explain why 5-HTT binding is lower in major depression or suicide. Arch Gen Psychiatry. 2000;57:729-738", "journal": "Archives of general psychiatry", "year": "2000", "authors": "Mann JJ, Huang YY, Underwood MD, Kassir SA, Oppenheim S, Kelly TM, Dwork AJ, Arango V", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Research Support, U.S. Gov't, P.H.S." ], "doi": "10.1001/archpsyc.57.8.729", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.917Z" }, { "id": "df20df09-d344-48ed-b967-112e73ceff38", "pmid": "10920459", "title": "A serotonin transporter gene promoter polymorphism (5-HTTLPR) and prefrontal cortical binding in major depression and suicide.", "imported": false, "abstract": "BACKGROUND: Major depression and suicide are associated with fewer serotonin transporter (5-HTT) sites. The 5'-flanking promoter region of the 5-HTT gene has a biallelic insertion/deletion (5-HTTLPR). We assayed prefrontal cortical (PFC) 5-HTT binding in major depression and suicide and examine the relationship to the 5-HTTLPR allele.\n\nMETHODS: Postmortem brain samples from 220 individuals were genotyped for the 5-HTTLPR polymorphism. Binding of 5-HTT was assayed by quantitative autoradiography in the PFC of a subset of subjects (n = 159). Clinical information, including DSM-III-R Axis I diagnoses, was obtained by psychological autopsy and medical chart review.\n\nRESULTS: Binding to 5-HTT was lower in the ventral PFC of suicides compared with nonsuicides and was lower throughout the PFC of subjects with a history of major depression. The 5-HTTLPR genotype was associated with major depression but not with suicide or 5-HTT binding.\n\nCONCLUSIONS: A diffuse reduction of 5-HTT binding in the PFC of individuals with major depression may reflect a widespread impairment of serotonergic function consistent with the range of psychopathologic features in major depression. The localized reduction in 5-HTT binding in the ventral PFC of suicides may reflect reduced serotonin input to that brain region, underlying the predisposition to act on suicidal thoughts. The 5-HTTLPR genotype was not related to the level of 5-HTT binding and does not explain why 5-HTT binding is lower in major depression or suicide. Arch Gen Psychiatry. 2000;57:729-738", "journal": "Archives of general psychiatry", "year": "2000", "authors": "Mann JJ, Huang YY, Underwood MD, Kassir SA, Oppenheim S, Kelly TM, Dwork AJ, Arango V", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Research Support, U.S. Gov't, P.H.S." ], "doi": "10.1001/archpsyc.57.8.729", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.860Z" }, { "id": "e571d906-f661-44db-b8d5-7f0708a74c41", "pmid": "10920459", "title": "A serotonin transporter gene promoter polymorphism (5-HTTLPR) and prefrontal cortical binding in major depression and suicide.", "imported": false, "abstract": "BACKGROUND: Major depression and suicide are associated with fewer serotonin transporter (5-HTT) sites. The 5'-flanking promoter region of the 5-HTT gene has a biallelic insertion/deletion (5-HTTLPR). We assayed prefrontal cortical (PFC) 5-HTT binding in major depression and suicide and examine the relationship to the 5-HTTLPR allele.\n\nMETHODS: Postmortem brain samples from 220 individuals were genotyped for the 5-HTTLPR polymorphism. Binding of 5-HTT was assayed by quantitative autoradiography in the PFC of a subset of subjects (n = 159). Clinical information, including DSM-III-R Axis I diagnoses, was obtained by psychological autopsy and medical chart review.\n\nRESULTS: Binding to 5-HTT was lower in the ventral PFC of suicides compared with nonsuicides and was lower throughout the PFC of subjects with a history of major depression. The 5-HTTLPR genotype was associated with major depression but not with suicide or 5-HTT binding.\n\nCONCLUSIONS: A diffuse reduction of 5-HTT binding in the PFC of individuals with major depression may reflect a widespread impairment of serotonergic function consistent with the range of psychopathologic features in major depression. The localized reduction in 5-HTT binding in the ventral PFC of suicides may reflect reduced serotonin input to that brain region, underlying the predisposition to act on suicidal thoughts. The 5-HTTLPR genotype was not related to the level of 5-HTT binding and does not explain why 5-HTT binding is lower in major depression or suicide. Arch Gen Psychiatry. 2000;57:729-738", "journal": "Archives of general psychiatry", "year": "2000", "authors": "Mann JJ, Huang YY, Underwood MD, Kassir SA, Oppenheim S, Kelly TM, Dwork AJ, Arango V", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Research Support, U.S. Gov't, P.H.S." ], "doi": "10.1001/archpsyc.57.8.729", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH 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increased SREBP-1c lead to mixed insulin resistance and sensitivity in livers of lipodystrophic and ob/ob mice", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Shimomura I, Matsuda M, Hammer RE, Bashmakov Y, Brown MS, Goldstein JL.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.911Z" }, { "id": "b80c29cd-3c89-442a-99cc-53f1fb5e0366", "pmid": "10949029", "title": "Decreased IRS-2 and increased SREBP-1c lead to mixed insulin resistance and sensitivity in livers of lipodystrophic and ob/ob mice", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Shimomura I, Matsuda M, Hammer RE, Bashmakov Y, Brown MS, Goldstein JL.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.794Z" }, { "id": "f6915e46-9d2b-481d-978a-91b1c9b66494", "pmid": "10949029", "title": 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"10.1016/s0196-9781(00)00210-2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.800Z" }, { "id": "c6f27148-4970-4073-9b38-ace72980ccfd", "pmid": "10958999", "title": "Melanocortin signaling is decreased during neurotoxin-induced transient hyperphagia and increased body-weight gain", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Dube MG, Pu S, Kalra SP, Kalra PS.", "articleTypes": [], "doi": "10.1016/s0196-9781(00)00210-2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.915Z" }, { "id": "e99c1208-5aab-4136-ad3c-5de580c713a7", "pmid": "10958999", "title": "Melanocortin signaling is decreased during neurotoxin-induced transient hyperphagia and increased body-weight gain", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Dube MG, Pu S, Kalra SP, Kalra PS.", "articleTypes": [], "doi": "10.1016/s0196-9781(00)00210-2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.413Z" }, { "id": "f11556cf-9139-4066-94f0-81fe42535d1f", "pmid": "10958999", "title": "Melanocortin signaling is decreased during neurotoxin-induced transient hyperphagia and increased body-weight gain", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Dube MG, Pu S, Kalra SP, Kalra PS.", "articleTypes": [], "doi": "10.1016/s0196-9781(00)00210-2", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.445Z" }, { "id": "6193f458-c52c-4128-8ad0-feb0c3947b88", "pmid": "10960156", "title": "Serotonin transporter gene polymorphisms, alcoholism, and suicidal behavior.", "imported": false, "abstract": "BACKGROUND: Dysfunction of serotoninergic transmission could predispose to excessive alcohol consumption and dependence. The functional polymorphism of the serotonin transporter gene (5-HTTLPR) has been associated with different disorders, including alcoholism. Considering the likelihood of heterogeneity in the \"alcohol dependence\" phenotype, 5-HTTLPR may be more specifically implicated in subsamples of patients or in related traits of alcoholism, such as impulsivity.\n\nMETHODS: We analyzed the role of this functional polymorphism in the risk for suicide attempt in a population of male alcohol-dependent subjects. One hundred ten male alcohol-dependent patients (DSM-III-R criteria), French for at least two generations, were personally interviewed with the Diagnostic Interview for Genetic Studies and compared with 61 unaffected blood donors.\n\nRESULTS: The \"short\" (S) allele of the 5-HTTLPR appeared to be unrelated to alcohol dependence and comorbid depression in our sample, but was found associated with an increased risk for suicide attempts. This association was predominantly observed in severe and repetitive suicide attempts, with a significant dose effect of the S allele (0, 1, or 2) on the number and the severity of suicide attempts.\n\nCONCLUSIONS: Mood disorders and alcohol dependence may interact with a genetic (relative) deficiency in serotonin reuptake, thereby increasing the risk for aggressive/impulsive behaviors such as suicide attempts.", "journal": "Biological psychiatry", "year": "2000", "authors": "Gorwood P, Batel P, Adès J, Hamon M, Boni C", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0006-3223(00)00840-4", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.860Z" }, { "id": "82067901-8190-4531-91b5-63c0eb71938d", "pmid": "10960156", "title": "Serotonin transporter gene polymorphisms, alcoholism, and suicidal behavior.", "imported": false, "abstract": "BACKGROUND: Dysfunction of serotoninergic transmission could predispose to excessive alcohol consumption and dependence. The functional polymorphism of the serotonin transporter gene (5-HTTLPR) has been associated with different disorders, including alcoholism. Considering the likelihood of heterogeneity in the \"alcohol dependence\" phenotype, 5-HTTLPR may be more specifically implicated in subsamples of patients or in related traits of alcoholism, such as impulsivity.\n\nMETHODS: We analyzed the role of this functional polymorphism in the risk for suicide attempt in a population of male alcohol-dependent subjects. One hundred ten male alcohol-dependent patients (DSM-III-R criteria), French for at least two generations, were personally interviewed with the Diagnostic Interview for Genetic Studies and compared with 61 unaffected blood donors.\n\nRESULTS: The \"short\" (S) allele of the 5-HTTLPR appeared to be unrelated to alcohol dependence and comorbid depression in our sample, but was found associated with an increased risk for suicide attempts. This association was predominantly observed in severe and repetitive suicide attempts, with a significant dose effect of the S allele (0, 1, or 2) on the number and the severity of suicide attempts.\n\nCONCLUSIONS: Mood disorders and alcohol dependence may interact with a genetic (relative) deficiency in serotonin reuptake, thereby increasing the risk for aggressive/impulsive behaviors such as suicide attempts.", "journal": "Biological psychiatry", "year": "2000", "authors": "Gorwood P, Batel P, Adès J, Hamon M, Boni C", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0006-3223(00)00840-4", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.917Z" }, { "id": "9e92e76c-4e75-4279-856c-5c8bb339c85b", "pmid": "10960156", "title": "Serotonin transporter gene polymorphisms, alcoholism, and suicidal behavior.", "imported": false, "abstract": "BACKGROUND: Dysfunction of serotoninergic transmission could predispose to excessive alcohol consumption and dependence. The functional polymorphism of the serotonin transporter gene (5-HTTLPR) has been associated with different disorders, including alcoholism. Considering the likelihood of heterogeneity in the \"alcohol dependence\" phenotype, 5-HTTLPR may be more specifically implicated in subsamples of patients or in related traits of alcoholism, such as impulsivity.\n\nMETHODS: We analyzed the role of this functional polymorphism in the risk for suicide attempt in a population of male alcohol-dependent subjects. One hundred ten male alcohol-dependent patients (DSM-III-R criteria), French for at least two generations, were personally interviewed with the Diagnostic Interview for Genetic Studies and compared with 61 unaffected blood donors.\n\nRESULTS: The \"short\" (S) allele of the 5-HTTLPR appeared to be unrelated to alcohol dependence and comorbid depression in our sample, but was found associated with an increased risk for suicide attempts. This association was predominantly observed in severe and repetitive suicide attempts, with a significant dose effect of the S allele (0, 1, or 2) on the number and the severity of suicide attempts.\n\nCONCLUSIONS: Mood disorders and alcohol dependence may interact with a genetic (relative) deficiency in serotonin reuptake, thereby increasing the risk for aggressive/impulsive behaviors such as suicide attempts.", "journal": "Biological psychiatry", "year": "2000", "authors": "Gorwood P, Batel P, Adès J, Hamon M, Boni C", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0006-3223(00)00840-4", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.046Z" }, { "id": "7ed4b1e9-4919-453d-965e-6f254a2bfe91", "pmid": "10960164", "title": "Possible association between serotonin transporter gene polymorphism and violent suicidal behavior in mood disorders.", "imported": false, "abstract": "BACKGROUND: Genes involved in the serotonin system are major candidates in association studies of suicidal behavior. In this case-control study we investigated whether the serotonin transporter (5-HTT) gene encoding the protein responsible for the reuptake of serotonin from the synapse after its release from serotonergic neurons is a susceptibility factor for suicidal behavior.\n\nMETHODS: A functional polymorphism of the 5-HTT gene (a 44-base pair insertion/deletion in the 5-HTT-linked polymorphic region [5-HTTLPR]) was studied in a population of 237 consecutive patients with affective disorder (unipolar or bipolar) and 187 control subjects. Ninety-nine patients had attempted suicide at least once, of whom 26 made a violent attempt.\n\nRESULTS: No association was found between the \"s\" allele of the 5-HTTLPR and suicide attempt; however, there was a significant difference in allele distributions between patients who had made violent suicide attempts and control subjects.\n\nCONCLUSIONS: A genetic variant of the 5-HTT gene may predispose individuals to violent suicidal behavior. The precise phenotype associated with the 5-HTT gene is unclear, and therefore further studies are required to replicate these findings.", "journal": "Biological psychiatry", "year": "2000", "authors": "Bellivier F, Szöke A, Henry C, Lacoste J, Bottos C, Nosten-Bertrand M, Hardy P, Rouillon F, Launay JM, Laplanche JL, Leboyer M", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0006-3223(00)00891-x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.917Z" }, { "id": "aaf47dff-4699-48fb-bc64-2819b9e3bf83", "pmid": "10960164", "title": "Possible association between serotonin transporter gene polymorphism and violent suicidal behavior in mood disorders.", "imported": false, "abstract": "BACKGROUND: Genes involved in the serotonin system are major candidates in association studies of suicidal behavior. In this case-control study we investigated whether the serotonin transporter (5-HTT) gene encoding the protein responsible for the reuptake of serotonin from the synapse after its release from serotonergic neurons is a susceptibility factor for suicidal behavior.\n\nMETHODS: A functional polymorphism of the 5-HTT gene (a 44-base pair insertion/deletion in the 5-HTT-linked polymorphic region [5-HTTLPR]) was studied in a population of 237 consecutive patients with affective disorder (unipolar or bipolar) and 187 control subjects. Ninety-nine patients had attempted suicide at least once, of whom 26 made a violent attempt.\n\nRESULTS: No association was found between the \"s\" allele of the 5-HTTLPR and suicide attempt; however, there was a significant difference in allele distributions between patients who had made violent suicide attempts and control subjects.\n\nCONCLUSIONS: A genetic variant of the 5-HTT gene may predispose individuals to violent suicidal behavior. The precise phenotype associated with the 5-HTT gene is unclear, and therefore further studies are required to replicate these findings.", "journal": "Biological psychiatry", "year": "2000", "authors": "Bellivier F, Szöke A, Henry C, Lacoste J, Bottos C, Nosten-Bertrand M, Hardy P, Rouillon F, Launay JM, Laplanche JL, Leboyer M", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0006-3223(00)00891-x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.046Z" }, { "id": "e1b54ff2-6774-4a0d-a591-8d74a514daf9", "pmid": "10960164", "title": "Possible association between serotonin transporter gene polymorphism and violent suicidal behavior in mood disorders.", "imported": false, "abstract": "BACKGROUND: Genes involved in the serotonin system are major candidates in association studies of suicidal behavior. In this case-control study we investigated whether the serotonin transporter (5-HTT) gene encoding the protein responsible for the reuptake of serotonin from the synapse after its release from serotonergic neurons is a susceptibility factor for suicidal behavior.\n\nMETHODS: A functional polymorphism of the 5-HTT gene (a 44-base pair insertion/deletion in the 5-HTT-linked polymorphic region [5-HTTLPR]) was studied in a population of 237 consecutive patients with affective disorder (unipolar or bipolar) and 187 control subjects. Ninety-nine patients had attempted suicide at least once, of whom 26 made a violent attempt.\n\nRESULTS: No association was found between the \"s\" allele of the 5-HTTLPR and suicide attempt; however, there was a significant difference in allele distributions between patients who had made violent suicide attempts and control subjects.\n\nCONCLUSIONS: A genetic variant of the 5-HTT gene may predispose individuals to violent suicidal behavior. The precise phenotype associated with the 5-HTT gene is unclear, and therefore further studies are required to replicate these findings.", "journal": "Biological psychiatry", "year": "2000", "authors": "Bellivier F, Szöke A, Henry C, Lacoste J, Bottos C, Nosten-Bertrand M, Hardy P, Rouillon F, Launay JM, Laplanche JL, Leboyer M", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0006-3223(00)00891-x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.860Z" }, { "id": "00549641-83cd-4a59-9216-df19fe346311", "pmid": "10962198", "title": "Long form leptin receptor mRNA expression in the brain, pituitary, and other tissues in the pig", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Lin J, Barb CR, Matteri RL, Kraeling RR, Chen X, Meinersmann RJ, Rampacek GB.", "articleTypes": [], "doi": "10.1016/s0739-7240(00)00064-3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.924Z" }, { "id": "129699bb-b85e-4cab-9fe0-e521cb91374b", "pmid": "10962198", "title": "Long form leptin receptor mRNA expression in the brain, pituitary, and other tissues in the pig", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Lin J, Barb CR, Matteri RL, Kraeling RR, Chen X, Meinersmann RJ, Rampacek GB.", "articleTypes": [], "doi": "10.1016/s0739-7240(00)00064-3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.810Z" }, { "id": "6405b4cf-3d9f-4ed9-b255-7c54b9d6664b", "pmid": "10962198", "title": "Long form leptin receptor mRNA expression in the brain, pituitary, and other tissues in the pig", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Lin J, Barb CR, Matteri RL, Kraeling RR, Chen X, Meinersmann RJ, Rampacek GB.", "articleTypes": [], "doi": "10.1016/s0739-7240(00)00064-3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.455Z" }, { "id": "ed262f44-25b2-4ea9-8bef-88aae3ff8ff9", "pmid": "10962198", "title": "Long form leptin receptor mRNA expression in the brain, pituitary, and other tissues in the pig", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Lin J, Barb CR, Matteri RL, Kraeling RR, Chen X, Meinersmann RJ, Rampacek GB.", "articleTypes": [], "doi": "10.1016/s0739-7240(00)00064-3", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.424Z" }, { "id": "31087a32-ea2b-47ea-9a79-2b29fb60fb2c", "pmid": "10962883", "title": "[Relationship between leptin and insulin blood levels in obese and lean Chilean women]", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Albala C, Pérez F, Santos JL, Yáñez M, Arroyo P, Díaz J, Díaz E.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.356Z" }, { "id": "855d3cf3-5655-43b9-a269-36dc688c8910", "pmid": "10962883", "title": "[Relationship between leptin and insulin blood levels in obese and lean Chilean women]", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Albala C, Pérez F, Santos JL, Yáñez M, Arroyo P, Díaz J, Díaz E.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.868Z" }, { "id": "b06a53c0-8e69-44d4-9058-5c16201ac0f9", "pmid": "10962883", "title": "[Relationship between leptin and insulin blood levels in obese and lean Chilean women]", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Albala C, Pérez F, Santos JL, Yáñez M, Arroyo P, Díaz J, Díaz E.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.747Z" }, { "id": "f77bfdcf-3a96-4923-ba84-9768670416c4", "pmid": "10962883", "title": "[Relationship between leptin and insulin blood levels in obese and lean Chilean women]", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Albala C, Pérez F, Santos JL, Yáñez M, Arroyo P, Díaz J, Díaz E.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.390Z" }, { "id": "6dd8ca7b-aea9-463c-a0a4-d7c25a1ec0f4", "pmid": "10965205", "title": "Leptin levels in menopause: effect of estrogen replacement therapy", "imported": false, "abstract": "", "journal": "", "year": "1999", "authors": "Cento RM, Proto C, Spada RS, Napolitano V, Ciampelli M, Cucinelli F, Lanzone A.", "articleTypes": [], "doi": "10.1159/000023493", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.389Z" }, { "id": "78e944cf-6c40-40f7-b508-3bc36ea5b745", "pmid": "10965205", "title": "Leptin levels in menopause: effect of estrogen replacement therapy", "imported": false, "abstract": "", "journal": "", "year": "1999", "authors": "Cento RM, Proto C, Spada RS, Napolitano V, Ciampelli M, Cucinelli F, Lanzone A.", "articleTypes": [], "doi": "10.1159/000023493", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.355Z" }, { "id": "d2eca00d-c4cd-4f4c-bf0c-22494ab8319a", "pmid": "10965205", "title": "Leptin levels in menopause: effect of estrogen replacement therapy", "imported": false, "abstract": "", "journal": "", "year": "1999", "authors": "Cento RM, Proto C, Spada RS, Napolitano V, Ciampelli M, Cucinelli F, Lanzone A.", "articleTypes": [], "doi": "10.1159/000023493", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.746Z" }, { "id": "eee05592-770c-4d0a-b05e-f818941160af", "pmid": "10965205", "title": "Leptin levels in menopause: effect of estrogen replacement therapy", "imported": false, "abstract": "", "journal": "", "year": "1999", "authors": "Cento RM, Proto C, Spada RS, Napolitano V, Ciampelli M, Cucinelli F, Lanzone A.", "articleTypes": [], "doi": "10.1159/000023493", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.868Z" }, { "id": "068f5b04-0baa-4d65-9513-9a73e9d365ea", "pmid": "10969827", "title": "Identification of leptin-induced transcripts in the mouse hypothalamus", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "White DW, Zhou J, Stricker-Krongrad A, Ge P, Morgenstern JP, Dembski M, Tartaglia LA.", "articleTypes": [], "doi": "10.2337/diabetes.49.9.1443", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.772Z" }, { "id": "88d66658-df57-4f4b-9d21-70285427d9bc", "pmid": "10969827", "title": "Identification of leptin-induced transcripts in the mouse hypothalamus", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "White DW, Zhou J, Stricker-Krongrad A, Ge P, Morgenstern JP, Dembski M, Tartaglia LA.", "articleTypes": [], "doi": "10.2337/diabetes.49.9.1443", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.892Z" }, { "id": "e5f6eb03-bdd7-4f53-bc27-49bf3fd24559", "pmid": "10969827", "title": "Identification of leptin-induced transcripts in the mouse hypothalamus", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "White DW, Zhou J, Stricker-Krongrad A, Ge P, Morgenstern JP, Dembski M, Tartaglia LA.", "articleTypes": [], "doi": "10.2337/diabetes.49.9.1443", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.385Z" }, { "id": "f1f70f3f-ae41-4de3-992c-58b4d9f9b75e", "pmid": "10969827", "title": "Identification of leptin-induced transcripts in the mouse hypothalamus", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "White DW, Zhou J, Stricker-Krongrad A, Ge P, Morgenstern JP, Dembski M, Tartaglia LA.", "articleTypes": [], "doi": "10.2337/diabetes.49.9.1443", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.418Z" }, { "id": "1a848e76-68a0-4015-ad48-f4db8380b85f", "pmid": "10969840", "title": "Elimination of glucagon-like peptide 1R signaling does not modify weight gain and islet adaptation in mice with combined disruption of leptin and GLP-1 action", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Scrocchi LA, Hill ME, Saleh J, Perkins B, Drucker DJ.", "articleTypes": [], "doi": "10.2337/diabetes.49.9.1552", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.389Z" }, { "id": "add3d03a-9556-4225-8dd2-79c97c1e5f57", "pmid": "10969840", "title": "Elimination of glucagon-like peptide 1R signaling does not modify weight gain and islet adaptation in mice with combined disruption of leptin and GLP-1 action", "imported": false, "abstract": "", "journal": "", "year": "2000", "authors": "Scrocchi LA, Hill ME, Saleh J, Perkins B, Drucker DJ.", "articleTypes": [], "doi": 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There are two predominant alleles in the polymorphic promotor region [5-HT transporter gene-linked polymorphic region (5-HTTLPR)] of this gene: a long and a short allele with 16 and 14 repeat units, respectively. The short allele has lower activity and is associated with several psychiatric disorders and personality traits. We identified and sequenced a novel allele with 13 repeat units, 23 base pairs shorter than the common short allele. This unique allele was detected in a schizophrenic patient of Jewish Libyan origin. The patient exhibited extreme aggressive behavior and committed suicide after several attempts. The novel short allele was not detected in 172 healthy control subjects and 361 patients with various mental disorders. The presence of a very short unique allele in a severely aggressive schizophrenic patient may reflect a specific effect on the particular phenotype, although it is unlikely that this allele has a major contribution to susceptibility to schizophrenia. 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The role of the allele in serotonin transport and possible association with disease phenotype should be further investigated.", "journal": "Psychiatric genetics", "year": "2000", "authors": "Frisch A, Finkel B, Michaelovsky E, Sigal M, Laor N, Weizman R", "articleTypes": [ "Case Reports", "Journal Article" ], "doi": "10.1097/00041444-200010040-00005", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.046Z" }, { "id": "f641d5bd-6afc-41e2-b276-399baee364c1", "pmid": "11324943", "title": "A rare short allele of the serotonin transporter promoter region (5-HTTLPR) found in an aggressive schizophrenic patient of Jewish Libyan origin.", "imported": false, "abstract": "The serotonin transporter gene (SLC6A4), which plays a key role in the serotonergic pathway in the brain, is a candidate for mediating genetic susceptibility to various psychiatric disorders. There are two predominant alleles in the polymorphic promotor region [5-HT transporter gene-linked polymorphic region (5-HTTLPR)] of this gene: a long and a short allele with 16 and 14 repeat units, respectively. The short allele has lower activity and is associated with several psychiatric disorders and personality traits. We identified and sequenced a novel allele with 13 repeat units, 23 base pairs shorter than the common short allele. This unique allele was detected in a schizophrenic patient of Jewish Libyan origin. The patient exhibited extreme aggressive behavior and committed suicide after several attempts. The novel short allele was not detected in 172 healthy control subjects and 361 patients with various mental disorders. The presence of a very short unique allele in a severely aggressive schizophrenic patient may reflect a specific effect on the particular phenotype, although it is unlikely that this allele has a major contribution to susceptibility to schizophrenia. 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A functional polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was recently identified and the presence of the short allele found to be associated with a lower level of expression of the gene, lower levels of 5-HT uptake, suicidal behavior and anxiety-related traits. We genotyped 51 West European Caucasians who had made violent suicide attempts and 139 controls of the same ethnic origin, with no history of suicidal behavior. The frequencies of the S allele and the SS genotype were significantly higher in the violent suicide attempters than in the controls. The odds ratio for the SS genotype vs the LL genotype was 3.63 (95% CI (1.27--10.40)). 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"title": "Leptin in the control of gastric secretion and gut hormones in humans infected with Helicobacter pylori", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Konturek JW, Konturek SJ, Kwiecień N, Bielański W, Pawlik T, Rembiasz K, Domschke W.", "articleTypes": [], "doi": "10.1080/00365520152584761", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.781Z" }, { "id": "ac848b39-c2f7-43ab-8a6a-96c59315bb97", "pmid": "11686213", "title": "Leptin in the control of gastric secretion and gut hormones in humans infected with Helicobacter pylori", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Konturek JW, Konturek SJ, Kwiecień N, Bielański W, Pawlik T, Rembiasz K, Domschke W.", "articleTypes": [], "doi": "10.1080/00365520152584761", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.394Z" }, { "id": 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Thus, the identification of vulnerability genes could uncover pathophysiological links for both syndromes. A significant association between suicide attempts and the 5-HTT promoter polymorphisms (5-HTTLPR) S-allele has been reported in a sample of French alcohol-dependent subjects, and this paper evaluates this phenomenon in a German sample.\n\nMETHODS: One hundred and sixty-three patients meeting DSM-IV criteria for alcohol dependence and 117 healthy controls were investigated. Blood samples were taken to genotype the 5-HTTLPR by using polymerase chain reaction (PCR) of lymphocyte DNA.\n\nRESULTS: 5-HTTLPR-S alleles were seen more frequently in suicidal compared to nonsuicidal alcohol-dependent subjects. Furthermore, significant effects from suicide attempts on the number of S-alleles were found.\n\nCONCLUSIONS: The results are consistent with an association between the 5-HTTLPR-S-allele and suicide attempts in alcohol-dependent subjects.", "journal": "Biological psychiatry", "year": "2001", "authors": "Preuss UW, Koller G, Soyka M, Bondy B", "articleTypes": [ "Journal Article" ], "doi": "10.1016/s0006-3223(01)01196-9", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.916Z" }, { "id": "d4dd4e9d-a8b0-4301-9dd1-d8c7b46cbbbc", "pmid": "11690601", "title": "Association between suicide attempts and 5-HTTLPR-S-allele in alcohol-dependent and control subjects: further evidence from a German alcohol-dependent inpatient sample.", "imported": false, "abstract": "BACKGROUND: Genetically-mediated alterations in serotonergic transmission have been implicated in both the pathogenesis of alcoholism and suicidal behavior. Thus, the identification of vulnerability genes could uncover pathophysiological links for both syndromes. A significant association between suicide attempts and the 5-HTT promoter polymorphisms (5-HTTLPR) S-allele has been reported in a sample of French alcohol-dependent subjects, and this paper evaluates this phenomenon in a German sample.\n\nMETHODS: One hundred and sixty-three patients meeting DSM-IV criteria for alcohol dependence and 117 healthy controls were investigated. Blood samples were taken to genotype the 5-HTTLPR by using polymerase chain reaction (PCR) of lymphocyte DNA.\n\nRESULTS: 5-HTTLPR-S alleles were seen more frequently in suicidal compared to nonsuicidal alcohol-dependent subjects. Furthermore, significant effects from suicide attempts on the number of S-alleles were found.\n\nCONCLUSIONS: The results are consistent with an association between the 5-HTTLPR-S-allele and suicide attempts in alcohol-dependent subjects.", "journal": "Biological psychiatry", "year": "2001", "authors": "Preuss UW, Koller G, Soyka M, Bondy B", "articleTypes": [ "Journal Article" ], "doi": "10.1016/s0006-3223(01)01196-9", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.859Z" }, { "id": "e0fb83b3-d4ae-49d4-b8f8-f1c5a608f894", "pmid": "11690601", "title": "Association between suicide attempts and 5-HTTLPR-S-allele in alcohol-dependent and control subjects: further evidence from a German alcohol-dependent inpatient sample.", "imported": false, "abstract": "BACKGROUND: Genetically-mediated alterations in serotonergic transmission have been implicated in both the pathogenesis of alcoholism and suicidal behavior. Thus, the identification of vulnerability genes could uncover pathophysiological links for both syndromes. A significant association between suicide attempts and the 5-HTT promoter polymorphisms (5-HTTLPR) S-allele has been reported in a sample of French alcohol-dependent subjects, and this paper evaluates this phenomenon in a German sample.\n\nMETHODS: One hundred and sixty-three patients meeting DSM-IV criteria for alcohol dependence and 117 healthy controls were investigated. Blood samples were taken to genotype the 5-HTTLPR by using polymerase chain reaction (PCR) of lymphocyte DNA.\n\nRESULTS: 5-HTTLPR-S alleles were seen more frequently in suicidal compared to nonsuicidal alcohol-dependent subjects. Furthermore, significant effects from suicide attempts on the number of S-alleles were found.\n\nCONCLUSIONS: The results are consistent with an association between the 5-HTTLPR-S-allele and suicide attempts in alcohol-dependent subjects.", "journal": "Biological psychiatry", "year": "2001", "authors": "Preuss UW, Koller G, Soyka M, Bondy B", "articleTypes": [ "Journal Article" ], "doi": "10.1016/s0006-3223(01)01196-9", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.044Z" }, { "id": "2e1f1a01-ccda-4b64-aac5-71042bfa1f22", "pmid": "11692184", "title": "A missense mutation in the human melanocortin-4 receptor gene in relation to abdominal obesity and salivary cortisol", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Rosmond R, Chagnon M, Bouchard C, Björntorp P.", "articleTypes": [], "doi": "10.1007/s001250100649", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.378Z" }, { "id": "35635bde-bbcd-4627-8c5f-1c3c3b391bb8", "pmid": "11692184", "title": "A missense mutation in the human melanocortin-4 receptor gene in relation to abdominal obesity and salivary cortisol", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Rosmond R, Chagnon M, Bouchard C, Björntorp P.", "articleTypes": [], "doi": "10.1007/s001250100649", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.857Z" }, { "id": "654f76ad-6684-4798-a268-8f380fee71a9", "pmid": "11692184", "title": "A missense mutation in the human melanocortin-4 receptor gene in relation to abdominal obesity and salivary cortisol", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Rosmond R, Chagnon M, Bouchard C, Björntorp P.", "articleTypes": [], "doi": "10.1007/s001250100649", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.736Z" }, { "id": "952aa40a-fc1c-4d77-84c4-a90652f1ee1d", "pmid": "11692184", "title": "A missense mutation in the human melanocortin-4 receptor gene in relation to abdominal obesity and salivary cortisol", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Rosmond R, Chagnon M, Bouchard C, Björntorp P.", "articleTypes": [], "doi": "10.1007/s001250100649", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.345Z" }, { "id": "067e25c7-88d8-450e-a99f-e94f8717785a", "pmid": "11702061", "title": "A polymorphism in the promoter of the serotonin transporter gene is not associated with suicidal behavior.", "imported": false, "abstract": "A 44 base pair deletion/insertion polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was examined in 124 German suicide attempters, who were consecutively hospitalized, and 185 German normal control subjects without a history of any DSM-IV axis I or II mental disorder. Both patients and control subjects were recruited from the same geographic area. There was no significant difference in allele or genotype frequency between patients and control subjects. There were also no differences when the patients were divided into several subgroups (suicide attempters with a violent method, and suicide attempters with a lifetime history of mood disorders, unipolar depression, personality disorders). These results suggest that the 5-HTTLPR polymorphism is unlikely to play a major role in the genetic susceptibility to suicide attempts. Conflicting results among the present and previous studies regarding an association between the polymorphism and suicidal behavior, however, suggest the possibility that there may be unidentified specific subtypes of suicidal behavior that are significantly associated with the polymorphism or, alternatively, simply reflect false-positive association results.", "journal": "Psychiatric genetics", "year": "2001", "authors": "Rujescu D, Giegling I, Sato T, Moeller HJ", "articleTypes": [ "Comparative Study", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1097/00041444-200109000-00011", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.045Z" }, { "id": "4bf4f352-c9f8-4cdc-ab64-8c8b27feeacb", "pmid": "11702061", "title": "A polymorphism in the promoter of the serotonin transporter gene is not associated with suicidal behavior.", "imported": false, "abstract": "A 44 base pair deletion/insertion polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was examined in 124 German suicide attempters, who were consecutively hospitalized, and 185 German normal control subjects without a history of any DSM-IV axis I or II mental disorder. Both patients and control subjects were recruited from the same geographic area. There was no significant difference in allele or genotype frequency between patients and control subjects. There were also no differences when the patients were divided into several subgroups (suicide attempters with a violent method, and suicide attempters with a lifetime history of mood disorders, unipolar depression, personality disorders). These results suggest that the 5-HTTLPR polymorphism is unlikely to play a major role in the genetic susceptibility to suicide attempts. Conflicting results among the present and previous studies regarding an association between the polymorphism and suicidal behavior, however, suggest the possibility that there may be unidentified specific subtypes of suicidal behavior that are significantly associated with the polymorphism or, alternatively, simply reflect false-positive association results.", "journal": "Psychiatric genetics", "year": "2001", "authors": "Rujescu D, Giegling I, Sato T, Moeller HJ", "articleTypes": [ "Comparative Study", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1097/00041444-200109000-00011", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.859Z" }, { "id": "e288848f-46b3-425d-89cf-80a1121c3c07", "pmid": "11702061", "title": "A polymorphism in the promoter of the serotonin transporter gene is not associated with suicidal behavior.", "imported": false, "abstract": "A 44 base pair deletion/insertion polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was examined in 124 German suicide attempters, who were consecutively hospitalized, and 185 German normal control subjects without a history of any DSM-IV axis I or II mental disorder. Both patients and control subjects were recruited from the same geographic area. There was no significant difference in allele or genotype frequency between patients and control subjects. There were also no differences when the patients were divided into several subgroups (suicide attempters with a violent method, and suicide attempters with a lifetime history of mood disorders, unipolar depression, personality disorders). These results suggest that the 5-HTTLPR polymorphism is unlikely to play a major role in the genetic susceptibility to suicide attempts. Conflicting results among the present and previous studies regarding an association between the polymorphism and suicidal behavior, however, suggest the possibility that there may be unidentified specific subtypes of suicidal behavior that are significantly associated with the polymorphism or, alternatively, simply reflect false-positive association results.", "journal": "Psychiatric genetics", "year": "2001", "authors": "Rujescu D, Giegling I, Sato T, Moeller HJ", "articleTypes": [ "Comparative Study", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1097/00041444-200109000-00011", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.916Z" }, { "id": "041c0749-9dd9-465a-8874-d9c31c5b2435", "pmid": "11704425", "title": "Drug target discovery by pharmacogenetics: mutations in the melanocortin system and eating disorders", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Adan RA, Vink T.", "articleTypes": [], "doi": "10.1016/s0924-977x(01)00125-0", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.806Z" }, { "id": "10a62874-b365-4b41-bdb1-fd95b3647417", "pmid": "11704425", "title": "Drug target discovery by pharmacogenetics: mutations in the melanocortin system and eating disorders", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Adan RA, Vink T.", "articleTypes": [], "doi": "10.1016/s0924-977x(01)00125-0", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.420Z" }, { "id": "abd9c70f-07f5-45c0-a517-b69bd558103c", "pmid": "11704425", "title": "Drug target discovery by pharmacogenetics: mutations in the melanocortin system and eating disorders", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Adan RA, Vink T.", "articleTypes": [], "doi": "10.1016/s0924-977x(01)00125-0", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.451Z" }, { "id": "cc08246e-397c-4e94-b16d-3d1832572c17", "pmid": "11704425", "title": "Drug target discovery by pharmacogenetics: mutations in the melanocortin system and eating disorders", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Adan RA, Vink T.", "articleTypes": [], "doi": "10.1016/s0924-977x(01)00125-0", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.921Z" }, { "id": "3400b1be-9de7-4953-ab4f-2aaa8ce620e0", "pmid": "11705792", "title": "Constitutive activation of STAT-3 and downregulation of SOCS-3 expression induced by adrenalectomy", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Madiehe AM, Lin L, White C, Braymer HD, Bray GA, York DA.", "articleTypes": [], "doi": "10.1152/ajpregu.2001.281.6.R2048", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.422Z" }, { "id": "6f8fc488-7a69-46b9-b689-3da74ca68f9b", "pmid": "11705792", "title": "Constitutive activation of STAT-3 and downregulation of SOCS-3 expression induced by adrenalectomy", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Madiehe AM, Lin L, White C, Braymer HD, Bray GA, York DA.", "articleTypes": [], "doi": "10.1152/ajpregu.2001.281.6.R2048", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.777Z" }, { "id": "f9728aa9-a325-448c-8689-6b7f64ee8744", "pmid": "11705792", "title": "Constitutive activation of STAT-3 and downregulation of SOCS-3 expression induced by adrenalectomy", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Madiehe AM, Lin L, White C, Braymer HD, Bray GA, York DA.", "articleTypes": [], "doi": "10.1152/ajpregu.2001.281.6.R2048", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.897Z" }, { "id": "fd20614f-cb17-450f-a0e1-5588b13b2bed", "pmid": "11705792", "title": "Constitutive activation of STAT-3 and downregulation of SOCS-3 expression induced by adrenalectomy", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Madiehe AM, Lin L, White C, Braymer HD, Bray GA, York DA.", "articleTypes": [], "doi": "10.1152/ajpregu.2001.281.6.R2048", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.390Z" }, { "id": "425b0bfd-e604-4398-8a80-28e2a7e9cf72", "pmid": "11709414", "title": "Altered leptin signaling is sufficient, but not required, for hypotension associated with caloric restriction", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Swoap SJ.", "articleTypes": [], "doi": "10.1152/ajpheart.2001.281.6.H2473", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.419Z" }, { "id": "9d8b5ede-ce3a-4dd3-861b-9c7ff790809d", "pmid": "11709414", "title": "Altered leptin signaling is sufficient, but not required, for hypotension associated with caloric restriction", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Swoap 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Arnett DK, Sholinsky P, Myers RH, Leppert M, Province MA.", "articleTypes": [], "doi": "10.1086/338144", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.376Z" }, { "id": "69157d81-5cc2-455c-8fb3-c057a279634d", "pmid": "11713718", "title": "Quantitative-trait loci influencing body-mass index reside on chromosomes 7 and 13: the National Heart, Lung, and Blood Institute Family Heart Study", "imported": false, "abstract": "", "journal": "", "year": "2002", "authors": "Feitosa MF, Borecki IB, Rich SS, Arnett DK, Sholinsky P, Myers RH, Leppert M, Province MA.", "articleTypes": [], "doi": "10.1086/338144", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.885Z" }, { "id": "70f63baa-1e8c-4e68-860d-f96b85cbdcae", "pmid": "11713718", "title": "Quantitative-trait loci influencing body-mass index reside on chromosomes 7 and 13: the National Heart, Lung, and Blood Institute Family Heart Study", "imported": false, "abstract": "", "journal": "", "year": "2002", "authors": "Feitosa MF, Borecki IB, Rich SS, Arnett DK, Sholinsky P, Myers RH, Leppert M, Province MA.", "articleTypes": [], "doi": "10.1086/338144", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.764Z" }, { "id": "23643f01-2a21-4bf5-b276-96f97e874906", "pmid": "11714028", "title": "CDNA cloning of feline leptin and its mRNA expression in adipose tissue", "imported": false, "abstract": "", "journal": "", "year": "2001", "authors": "Sasaki N, Shibata H, Honjoh T, Kimura K, Saito M, Ohishi I.", "articleTypes": [], "doi": "10.1292/jvms.63.1115", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.380Z" }, { "id": "582c1b4f-909b-4457-84b6-a2040dadcfbc", "pmid": "11714028", "title": "CDNA cloning of feline leptin and its mRNA expression in adipose tissue", "imported": false, "abstract": "", "journal": "", 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Comorbid affective disorders, anxiety disorders, and suicide are frequently observed during NF1. The promoter marker (5-HTTLPR) of the serotonin transporter gene (5-HTT) has been shown to be associated with major affective disorders, anxiety-related trait, and more recently with suicidal behavior. This gene is adjacent to the NF1 gene, raising the question of the implication of the 5-HTT gene in the psychiatric comorbidity during NF1. Eighty-eight patients with NF1 and 184 screened controls were typed for the 5-HTTLPR. No deviation from the Hardy-Weinberg equilibrium in patients was observed. In addition, allele and genotype frequencies were similar in the two groups. 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Our data do not support the implication of the 5-HTT gene in the psychiatric comorbidities of NF1.", "journal": "American journal of medical genetics", "year": "2001", "authors": "Bellivier F, Laplanche JL, Fournier G, Wolkenstein P", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1002/ajmg.10037", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR 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impulsivity in Koreans.", "imported": false, "abstract": "Serotonin has become the major focus of biological studies of suicidal behavior and impulsive-aggressive behavior in humans. The serotonin transporter (5-HTT) gene is one of the important genes involved in the regulation of serotonin transmission. We examined the association of impulsivity in Korean populations with a functional polymorphism of the promoter region of the 5-HTT gene (5-HTTLPR). We recruited 186 adolescent prisoners and 64 medical students. Impulsivity was measured using the Barratt Impulsiveness Scale and we divided all subjects into three groups: impulsive subjects (IS, N=121), non-impulsive subjects (NIS, N=115) and an intermediate group (excluded, N=14). The 5-HTTLPR genotype was determined by polymerase chain reaction. All subjects were Korean men unrelated to each other. There were no significant differences in the genotype frequency of 5-HTTLPR-S/S, S/L and -L/L between the two groups in the Korean population (IS vs. NIS: 47.9 vs. 61.7%; 43.0 vs. 32.2%; and 9.1 vs. 6.1%, respectively). However, there was a statistically significant difference in allelic frequency of 5-HTTLPR-S and 5-HTTLPR-L between the two groups in the Korean population (IS vs. NIS: 69.4 vs. 77.8%; and 30.6 vs. 22.2%, respectively. 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The serotonin transporter (5-HTT) gene is one of the important genes involved in the regulation of serotonin transmission. We examined the association of impulsivity in Korean populations with a functional polymorphism of the promoter region of the 5-HTT gene (5-HTTLPR). We recruited 186 adolescent prisoners and 64 medical students. Impulsivity was measured using the Barratt Impulsiveness Scale and we divided all subjects into three groups: impulsive subjects (IS, N=121), non-impulsive subjects (NIS, N=115) and an intermediate group (excluded, N=14). The 5-HTTLPR genotype was determined by polymerase chain reaction. All subjects were Korean men unrelated to each other. There were no significant differences in the genotype frequency of 5-HTTLPR-S/S, S/L and -L/L between the two groups in the Korean population (IS vs. NIS: 47.9 vs. 61.7%; 43.0 vs. 32.2%; and 9.1 vs. 6.1%, respectively). However, there was a statistically significant difference in allelic frequency of 5-HTTLPR-S and 5-HTTLPR-L between the two groups in the Korean population (IS vs. NIS: 69.4 vs. 77.8%; and 30.6 vs. 22.2%, respectively. 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The serotonin transporter (5-HTT) gene is one of the important genes involved in the regulation of serotonin transmission. We examined the association of impulsivity in Korean populations with a functional polymorphism of the promoter region of the 5-HTT gene (5-HTTLPR). We recruited 186 adolescent prisoners and 64 medical students. Impulsivity was measured using the Barratt Impulsiveness Scale and we divided all subjects into three groups: impulsive subjects (IS, N=121), non-impulsive subjects (NIS, N=115) and an intermediate group (excluded, N=14). The 5-HTTLPR genotype was determined by polymerase chain reaction. All subjects were Korean men unrelated to each other. There were no significant differences in the genotype frequency of 5-HTTLPR-S/S, S/L and -L/L between the two groups in the Korean population (IS vs. NIS: 47.9 vs. 61.7%; 43.0 vs. 32.2%; and 9.1 vs. 6.1%, respectively). However, there was a statistically significant difference in allelic frequency of 5-HTTLPR-S and 5-HTTLPR-L between the two groups in the Korean population (IS vs. NIS: 69.4 vs. 77.8%; and 30.6 vs. 22.2%, respectively. 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Neurotransmitter alterations are implicated in the etiology of psychopathology based, in part, on studies of neurotransmitter receptors and their biosynthetic or degradative enzymes in postmortem tissue. Identification of the altered receptors and enzymes serves to identify candidate genes of potential etiological significance. Polymorphisms in these genes can contribute to alterations in protein function in vivo that are part of the neurochemical underpinnings of psychopathologies such as major depressive disorder, psychoses, alcoholism, personality disorders, aggressive-impulsive traits, or suicidal behavior. Altered serotonergic function is implicated in the etiology and pathogenesis of several major psychiatric conditions. In particular, there is much evidence for an association of lower serotonergic function and suicidal behavior. Thus genes related to the serotonergic system are candidate genes worthy of study as part of the genetic diathesis for suicidal behavior. This review examines the following polymorphisms in the serotonin biosynthetic enzyme tryptophan hydroxylase (TPH; A779C substitution), the serotonin transporter (5-HTT, 5-HTTLPR allele), the 5-HT(1B) receptor (G861C, C129T substitution) and the 5-HT(2A) receptor (T102C) for their relationship to suicidal behavior. For the TPH gene, we found the less common U or A allele variant of the A779C polymorphism was associated with suicide attempt. Other studies have found the U allele to be associated with aggression and lower serotonergic function in vivo. A 44 base pair insertion/deletion in the 5' flanking promoter region of the 5-HTT gene may result in less 5-HTT expression and 5-HTT binding. We examined 220 cases postmortem and found no association between the promoter genotype and 5-HTT binding. We also found no association with major depressive disorder (MDD), suicide or pathological aggression, despite finding significantly fewer 5-HTT sites in the prefrontal cortex of depressed and/or suicide cases. In genomic DNA samples from 178 unrelated subjects, we detected two polymorphisms for the 5-HT(1B) receptor at nucleotides 861 and 129. However, no association between either polymorphism and depression, suicide, aggression, or alcoholism was observed. There are two common polymorphisms for the 5-HT(2A) receptor gene in humans. The results of studies of 5-HT(2A) receptor gene polymorphisms do not indicate significant major associations with suicidal behavior. In contrast, the 5-HT(2A) receptor itself is reported to be increased in suicide. Functional polymorphisms involving the promoter region that affect gene expression may explain this finding. 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This review examines the following polymorphisms in the serotonin biosynthetic enzyme tryptophan hydroxylase (TPH; A779C substitution), the serotonin transporter (5-HTT, 5-HTTLPR allele), the 5-HT(1B) receptor (G861C, C129T substitution) and the 5-HT(2A) receptor (T102C) for their relationship to suicidal behavior. For the TPH gene, we found the less common U or A allele variant of the A779C polymorphism was associated with suicide attempt. Other studies have found the U allele to be associated with aggression and lower serotonergic function in vivo. A 44 base pair insertion/deletion in the 5' flanking promoter region of the 5-HTT gene may result in less 5-HTT expression and 5-HTT binding. We examined 220 cases postmortem and found no association between the promoter genotype and 5-HTT binding. We also found no association with major depressive disorder (MDD), suicide or pathological aggression, despite finding significantly fewer 5-HTT sites in the prefrontal cortex of depressed and/or suicide cases. In genomic DNA samples from 178 unrelated subjects, we detected two polymorphisms for the 5-HT(1B) receptor at nucleotides 861 and 129. However, no association between either polymorphism and depression, suicide, aggression, or alcoholism was observed. There are two common polymorphisms for the 5-HT(2A) receptor gene in humans. The results of studies of 5-HT(2A) receptor gene polymorphisms do not indicate significant major associations with suicidal behavior. In contrast, the 5-HT(2A) receptor itself is reported to be increased in suicide. Functional polymorphisms involving the promoter region that affect gene expression may explain this finding. Studies of candidate genes related to serotonergic function in brain are increasingly used to establish genetic alterations contributing to psychiatric illness. The most meaningful studies combine the study of candidate genes with direct measures of related proteins as well as psychopathology.", "journal": "Journal of psychiatric research", "year": "2003", "authors": "Arango V, Huang YY, Underwood MD, Mann JJ", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Research Support, U.S. Gov't, P.H.S.", "Review" ], "doi": "10.1016/s0022-3956(03)00048-7", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.044Z" }, { "id": "bd0ede5b-dc6d-4f15-af18-304885a2fa88", "pmid": "12849930", "title": "Genetics of the serotonergic system in suicidal behavior.", "imported": false, "abstract": "Genetic factors contribute to the risk of psychopathology in many psychiatric conditions, but the specific genes are yet to be identified. Neurotransmitter alterations are implicated in the etiology of psychopathology based, in part, on studies of neurotransmitter receptors and their biosynthetic or degradative enzymes in postmortem tissue. Identification of the altered receptors and enzymes serves to identify candidate genes of potential etiological significance. Polymorphisms in these genes can contribute to alterations in protein function in vivo that are part of the neurochemical underpinnings of psychopathologies such as major depressive disorder, psychoses, alcoholism, personality disorders, aggressive-impulsive traits, or suicidal behavior. Altered serotonergic function is implicated in the etiology and pathogenesis of several major psychiatric conditions. In particular, there is much evidence for an association of lower serotonergic function and suicidal behavior. Thus genes related to the serotonergic system are candidate genes worthy of study as part of the genetic diathesis for suicidal behavior. This review examines the following polymorphisms in the serotonin biosynthetic enzyme tryptophan hydroxylase (TPH; A779C substitution), the serotonin transporter (5-HTT, 5-HTTLPR allele), the 5-HT(1B) receptor (G861C, C129T substitution) and the 5-HT(2A) receptor (T102C) for their relationship to suicidal behavior. For the TPH gene, we found the less common U or A allele variant of the A779C polymorphism was associated with suicide attempt. Other studies have found the U allele to be associated with aggression and lower serotonergic function in vivo. A 44 base pair insertion/deletion in the 5' flanking promoter region of the 5-HTT gene may result in less 5-HTT expression and 5-HTT binding. We examined 220 cases postmortem and found no association between the promoter genotype and 5-HTT binding. We also found no association with major depressive disorder (MDD), suicide or pathological aggression, despite finding significantly fewer 5-HTT sites in the prefrontal cortex of depressed and/or suicide cases. In genomic DNA samples from 178 unrelated subjects, we detected two polymorphisms for the 5-HT(1B) receptor at nucleotides 861 and 129. However, no association between either polymorphism and depression, suicide, aggression, or alcoholism was observed. There are two common polymorphisms for the 5-HT(2A) receptor gene in humans. The results of studies of 5-HT(2A) receptor gene polymorphisms do not indicate significant major associations with suicidal behavior. In contrast, the 5-HT(2A) receptor itself is reported to be increased in suicide. Functional polymorphisms involving the promoter region that affect gene expression may explain this finding. Studies of candidate genes related to serotonergic function in brain are increasingly used to establish genetic alterations contributing to psychiatric illness. The most meaningful studies combine the study of candidate genes with direct measures of related proteins as well as psychopathology.", "journal": "Journal of psychiatric research", "year": "2003", "authors": "Arango V, Huang YY, Underwood MD, Mann JJ", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Research Support, U.S. Gov't, P.H.S.", "Review" ], "doi": "10.1016/s0022-3956(03)00048-7", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR 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"searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.355Z" }, { "id": "4bf3b389-9ccf-4104-b494-47ab72eb2934", "pmid": "14573315", "title": "Serotonin transporter gene promoter (5-HTTLPR) and intron 2 (VNTR) polymorphisms in Croatian suicide victims.", "imported": false, "abstract": "BACKGROUND: Disturbances in serotonin (5HT) transmission are the most frequently reported neurobiological substrates of suicidal behavior. Because 5HT transporter plays a central role in the regulation of 5HT synaptic function and its gene contains two functional polymorphisms (5-HTTLPR in the promoter region and VNTR in the second intron), it represents an interesting candidate for association studies in suicidal behavior.\n\nMETHODS: In this study, a possible association of 5-HTTLPR and intron 2-VNTR polymorphisms of the 5HT transporter gene with suicidal behavior was investigated in a sample of 135 suicide victims and 299 healthy control subjects of Croatian/southern Slavic origin.\n\nRESULTS: There were no significant differences in 5-HTTLPR and intron 2-VNTR genotype- and allele- frequency distributions between suicide victims and healthy control subjects; however, a tendency toward an increase of 5-HTTLPR allele L and VNTR-allele 10 were observed in suicide group. Analysis of distribution of estimated haplotype frequencies revealed differences between suicide victims and control subjects, with an excess of haplotype L10 among suicide victims (p =.0112).\n\nCONCLUSIONS: Our results provide modest evidence for a possible association of the 5HT transporter gene with a completed suicide. Further studies are needed to determine whether alterations in 5HTt gene expression are involved in suicidal behavior.", "journal": "Biological psychiatry", "year": "2003", "authors": "Hranilovic D, Stefulj J, Furac I, Kubat M, Balija M, Jernej B", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0006-3223(03)00179-3", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.044Z" }, { "id": "808a5b5c-a60a-4f17-88d6-786638713483", "pmid": "14573315", "title": "Serotonin transporter gene promoter (5-HTTLPR) and intron 2 (VNTR) polymorphisms in Croatian suicide victims.", "imported": false, "abstract": "BACKGROUND: Disturbances in serotonin (5HT) transmission are the most frequently reported neurobiological substrates of suicidal behavior. Because 5HT transporter plays a central role in the regulation of 5HT synaptic function and its gene contains two functional polymorphisms (5-HTTLPR in the promoter region and VNTR in the second intron), it represents an interesting candidate for association studies in suicidal behavior.\n\nMETHODS: In this study, a possible association of 5-HTTLPR and intron 2-VNTR polymorphisms of the 5HT transporter gene with suicidal behavior was investigated in a sample of 135 suicide victims and 299 healthy control subjects of Croatian/southern Slavic origin.\n\nRESULTS: There were no significant differences in 5-HTTLPR and intron 2-VNTR genotype- and allele- frequency distributions between suicide victims and healthy control subjects; however, a tendency toward an increase of 5-HTTLPR allele L and VNTR-allele 10 were observed in suicide group. Analysis of distribution of estimated haplotype frequencies revealed differences between suicide victims and control subjects, with an excess of haplotype L10 among suicide victims (p =.0112).\n\nCONCLUSIONS: Our results provide modest evidence for a possible association of the 5HT transporter gene with a completed suicide. Further studies are needed to determine whether alterations in 5HTt gene expression are involved in suicidal behavior.", "journal": "Biological psychiatry", "year": "2003", "authors": "Hranilovic D, Stefulj J, Furac I, Kubat M, Balija M, Jernej B", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0006-3223(03)00179-3", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.916Z" }, { "id": "ac6eb6eb-b51e-49c7-8e4b-c2ccff5e135a", "pmid": "14573315", "title": "Serotonin transporter gene promoter (5-HTTLPR) and intron 2 (VNTR) polymorphisms in Croatian suicide victims.", "imported": false, "abstract": "BACKGROUND: Disturbances in serotonin (5HT) transmission are the most frequently reported neurobiological substrates of suicidal behavior. Because 5HT transporter plays a central role in the regulation of 5HT synaptic function and its gene contains two functional polymorphisms (5-HTTLPR in the promoter region and VNTR in the second intron), it represents an interesting candidate for association studies in suicidal behavior.\n\nMETHODS: In this study, a possible association of 5-HTTLPR and intron 2-VNTR polymorphisms of the 5HT transporter gene with suicidal behavior was investigated in a sample of 135 suicide victims and 299 healthy control subjects of Croatian/southern Slavic origin.\n\nRESULTS: There were no significant differences in 5-HTTLPR and intron 2-VNTR genotype- and allele- frequency distributions between suicide victims and healthy control subjects; however, a tendency toward an increase of 5-HTTLPR allele L and VNTR-allele 10 were observed in suicide group. Analysis of distribution of estimated haplotype frequencies revealed differences between suicide victims and control subjects, with an excess of haplotype L10 among suicide victims (p =.0112).\n\nCONCLUSIONS: Our results provide modest evidence for a possible association of the 5HT transporter gene with a completed suicide. Further studies are needed to determine whether alterations in 5HTt gene expression are involved in suicidal behavior.", "journal": "Biological psychiatry", "year": "2003", "authors": "Hranilovic D, Stefulj J, Furac I, Kubat M, Balija M, Jernej B", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0006-3223(03)00179-3", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR 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false, "abstract": "", "journal": "", "year": "2003", "authors": "Sleeman MW, Garcia K, Liu R, Murray JD, Malinova L, Moncrieffe M, Yancopoulos GD, Wiegand SJ.", "articleTypes": [], "doi": "10.1073/pnas.2335926100", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.458Z" }, { "id": "231cef21-9efd-451c-84f9-e37141497cc7", "pmid": "14610276", "title": "Ciliary neurotrophic factor improves diabetic parameters and hepatic steatosis and increases basal metabolic rate in db/db mice", "imported": false, "abstract": "", "journal": "", "year": "2003", "authors": "Sleeman MW, Garcia K, Liu R, Murray JD, Malinova L, Moncrieffe M, Yancopoulos GD, Wiegand SJ.", "articleTypes": [], "doi": "10.1073/pnas.2335926100", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.814Z" }, { "id": "36dcb7ec-eab3-4539-b0d4-02166b514e67", "pmid": "14610276", "title": "Ciliary neurotrophic factor improves 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This study will attempt to add further evidence to that body of literature by examining the relationship between the serotonin transporter gene and a family history of depression while controlling for a family history of completed suicide.\n\nMETHODS: Forty-seven volunteers responded to questionnaires regarding family history of depression and suicide, and provided buccal swabs to allow for analysis of the 5-HTTLPR polymorphism.\n\nRESULTS: Individuals with the s/s genotype were significantly more likely to have two or more first-degree relatives with a history of depression even when controlling for a family history of completed suicides.\n\nLIMITATIONS: The small sample size, particularly in the group of individuals with the s/s genotype, is a limitation of this study. Assessment of family history was conducted in abbreviated fashion. Information regarding participants' personal history of depression and suicide was not collected, so no conclusions regarding participants' own mental health can be drawn.\n\nCONCLUSIONS: A significant relationship between family history of depression and the s/s genotype was found, despite the small sample size and while controlling for family history of suicide. Whatever risk short alleles may confer for depression may be distinct from the risk they confer for suicidality.", "journal": "Journal of affective disorders", "year": "2003", "authors": "Joiner TE, Johnson F, Soderstrom K, Brown JS", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0165-0327(02)00171-4", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.858Z" }, { "id": "64e77cfd-f72c-4583-b270-ce0b405337ed", "pmid": "14612228", "title": "Is there an association between serotonin transporter gene polymorphism and family history of depression?", "imported": false, "abstract": "BACKGROUND: To date, research examining the relationship between the serotonin transporter gene and depression has yielded both positive and negative results. This study will attempt to add further evidence to that body of literature by examining the relationship between the serotonin transporter gene and a family history of depression while controlling for a family history of completed suicide.\n\nMETHODS: Forty-seven volunteers responded to questionnaires regarding family history of depression and suicide, and provided buccal swabs to allow for analysis of the 5-HTTLPR polymorphism.\n\nRESULTS: Individuals with the s/s genotype were significantly more likely to have two or more first-degree relatives with a history of depression even when controlling for a family history of completed suicides.\n\nLIMITATIONS: The small sample size, particularly in the group of individuals with the s/s genotype, is a limitation of this study. Assessment of family history was conducted in abbreviated fashion. Information regarding participants' personal history of depression and suicide was not collected, so no conclusions regarding participants' own mental health can be drawn.\n\nCONCLUSIONS: A significant relationship between family history of depression and the s/s genotype was found, despite the small sample size and while controlling for family history of suicide. Whatever risk short alleles may confer for depression may be distinct from the risk they confer for suicidality.", "journal": "Journal of affective disorders", "year": "2003", "authors": "Joiner TE, Johnson F, Soderstrom K, Brown JS", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0165-0327(02)00171-4", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.915Z" }, { "id": "8376af67-2bbd-4fbe-956a-529ec878a49b", "pmid": "14612228", "title": "Is there an association between serotonin transporter gene polymorphism and family history of depression?", "imported": false, "abstract": "BACKGROUND: To date, research examining the relationship between the serotonin transporter gene and depression has yielded both positive and negative results. This study will attempt to add further evidence to that body of literature by examining the relationship between the serotonin transporter gene and a family history of depression while controlling for a family history of completed suicide.\n\nMETHODS: Forty-seven volunteers responded to questionnaires regarding family history of depression and suicide, and provided buccal swabs to allow for analysis of the 5-HTTLPR polymorphism.\n\nRESULTS: Individuals with the s/s genotype were significantly more likely to have two or more first-degree relatives with a history of depression even when controlling for a family history of completed suicides.\n\nLIMITATIONS: The small sample size, particularly in the group of individuals with the s/s genotype, is a limitation of this study. Assessment of family history was conducted in abbreviated fashion. Information regarding participants' personal history of depression and suicide was not collected, so no conclusions regarding participants' own mental health can be drawn.\n\nCONCLUSIONS: A significant relationship between family history of depression and the s/s genotype was found, despite the small sample size and while controlling for family history of suicide. Whatever risk short alleles may confer for depression may be distinct from the risk they confer for suicidality.", "journal": "Journal of affective disorders", "year": "2003", "authors": "Joiner TE, Johnson F, Soderstrom K, Brown JS", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/s0165-0327(02)00171-4", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.044Z" }, { "id": "160c0fb7-c6d0-4355-b351-dfd50c402c5f", "pmid": "14615386", "title": "Leptin promotes vascular remodeling and neointimal growth in mice", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Schäfer K, Halle M, Goeschen C, Dellas C, Pynn M, Loskutoff DJ, Konstantinides S.", "articleTypes": [], "doi": "10.1161/01.ATV.0000105904.02142.e7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.881Z" }, { "id": "3e7986b3-f5c2-4b0f-ade3-2382286f47cc", "pmid": "14615386", "title": "Leptin promotes vascular remodeling and neointimal growth in mice", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Schäfer K, Halle M, Goeschen C, Dellas C, Pynn M, Loskutoff DJ, Konstantinides S.", 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GQ, Davydova Z, Fried SK, Leibowitz SF.", "articleTypes": [], "doi": "10.1016/j.regpep.2003.08.005", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.364Z" }, { "id": "15167fcc-206d-421e-a150-0825b71b14f6", "pmid": "14706424", "title": "Serotonin transporter gene may be involved in short-term risk of subsequent suicide attempts.", "imported": false, "abstract": "BACKGROUND: In the first year following a suicide attempt, patients are at high risk for reattempt and for completed suicide. We aim to determine the predictive value of two serotonin-related genes, the tryptophan hydroxylase (TPH) and serotonin transporter (5-HTTLPR) genes that have been involved in the susceptibility to suicidal behavior.\n\nMETHODS: After a one-year follow-up study of 103 patients hospitalized after a suicide attempt, patients have been genotyped for both the A218C TPH and the functional S/L 5-HTTLPR polymorphisms.\n\nRESULTS: Patients who reattempted suicide during the follow-up period had significantly higher frequencies of the S allele and the SS genotype. The odds ratio for the SS genotype vs. the LL genotype was 6.5 (95% CI [1.18-35.84]). No difference was observed for TPH gene. Patients carrying the SS genotype were more impulsive. However, multivariate analysis suggested an independent effect of both the SS genotype and impulsivity on the risk of repeated suicide attempts.\n\nCONCLUSIONS: These results suggest that the 5-HTTLPR SS genotype is associated with further suicide attempts among patients who have previously attempted suicide.", "journal": "Biological psychiatry", "year": "2004", "authors": "Courtet P, Picot MC, Bellivier F, Torres S, Jollant F, Michelon C, Castelnau D, Astruc B, Buresi C, Malafosse A", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.biopsych.2003.07.004", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.915Z" }, { "id": "3f111cea-b6de-4b84-a3e5-c46a9e14cf2f", "pmid": "14706424", "title": "Serotonin transporter gene may be involved in short-term risk of subsequent suicide attempts.", "imported": false, "abstract": "BACKGROUND: In the first year following a suicide attempt, patients are at high risk for reattempt and for completed suicide. We aim to determine the predictive value of two serotonin-related genes, the tryptophan hydroxylase (TPH) and serotonin transporter (5-HTTLPR) genes that have been involved in the susceptibility to suicidal behavior.\n\nMETHODS: After a one-year follow-up study of 103 patients hospitalized after a suicide attempt, patients have been genotyped for both the A218C TPH and the functional S/L 5-HTTLPR polymorphisms.\n\nRESULTS: Patients who reattempted suicide during the follow-up period had significantly higher frequencies of the S allele and the SS genotype. The odds ratio for the SS genotype vs. the LL genotype was 6.5 (95% CI [1.18-35.84]). No difference was observed for TPH gene. Patients carrying the SS genotype were more impulsive. However, multivariate analysis suggested an independent effect of both the SS genotype and impulsivity on the risk of repeated suicide attempts.\n\nCONCLUSIONS: These results suggest that the 5-HTTLPR SS genotype is associated with further suicide attempts among patients who have previously attempted suicide.", "journal": "Biological psychiatry", "year": "2004", "authors": "Courtet P, Picot MC, Bellivier F, Torres S, Jollant F, Michelon C, Castelnau D, Astruc B, Buresi C, Malafosse A", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.biopsych.2003.07.004", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.858Z" }, { "id": "8fa9263c-b74e-4703-98f7-0e2a6532ac29", "pmid": "14706424", "title": "Serotonin transporter gene may be involved in short-term risk of subsequent suicide attempts.", "imported": false, "abstract": "BACKGROUND: In the first year following a suicide attempt, patients are at high risk for reattempt and for completed suicide. We aim to determine the predictive value of two serotonin-related genes, the tryptophan hydroxylase (TPH) and serotonin transporter (5-HTTLPR) genes that have been involved in the susceptibility to suicidal behavior.\n\nMETHODS: After a one-year follow-up study of 103 patients hospitalized after a suicide attempt, patients have been genotyped for both the A218C TPH and the functional S/L 5-HTTLPR polymorphisms.\n\nRESULTS: Patients who reattempted suicide during the follow-up period had significantly higher frequencies of the S allele and the SS genotype. The odds ratio for the SS genotype vs. the LL genotype was 6.5 (95% CI [1.18-35.84]). No difference was observed for TPH gene. Patients carrying the SS genotype were more impulsive. However, multivariate analysis suggested an independent effect of both the SS genotype and impulsivity on the risk of repeated suicide attempts.\n\nCONCLUSIONS: These results suggest that the 5-HTTLPR SS genotype is associated with further suicide attempts among patients who have previously attempted suicide.", "journal": "Biological psychiatry", "year": "2004", "authors": "Courtet P, Picot MC, Bellivier F, Torres S, Jollant F, Michelon C, Castelnau D, Astruc B, Buresi C, Malafosse A", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.biopsych.2003.07.004", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal 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Many studies have examined the association between a functional polymorphism of the serotonin transporter gene promoter (5-HTTLPR) and suicide but have yielded inconsistent results. Our goal here, by analyzing the cumulative data from primary literature, was to determine conclusively whether there is an association.\n\nMETHODS: Three meta-analyses were performed. One compared the 5-HTTLPR polymorphism between suicidal subjects and normal control subjects; another compared suicide attempters with nonattempters of the same psychiatric diagnoses; the last one compared either violent or nonviolent suicidal subjects with normal control subjects.\n\nRESULTS: We found no association between 5-HTTLPR polymorphism and suicidal behavior (p =.379). When we compared subjects with the same psychiatric diagnoses, the genotypes carrying the s allele were significantly more frequent in suicide attempters than in nonattempters (p =.004). 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In addition, the s allele was associated with violent suicide (p =.0001) but not with nonviolent suicide (p = 1.00).\n\nCONCLUSIONS: Our results provide significant evidence supporting the association of the s allele of 5-HTTLPR polymorphism with suicidal behavior in the psychiatric population, also with violent suicide. These support a role for decreased serotonin transporter function in the vulnerability to suicide in a select population.", "journal": "Biological psychiatry", "year": "2004", "authors": "Lin PY, Tsai G", "articleTypes": [ "Comparative Study", "Journal Article", "Meta-Analysis", "Research Support, Non-U.S. Gov't", "Research Support, U.S. Gov't, P.H.S." ], "doi": "10.1016/j.biopsych.2004.02.006", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.914Z" }, { "id": "cffeea6d-d0df-4a60-baa0-5668f6ae2f69", "pmid": "15121487", "title": "Association between serotonin transporter gene promoter polymorphism and suicide: results of a meta-analysis.", "imported": false, "abstract": "BACKGROUND: There is strong evidence supporting a role for serotonin system dysfunction in the pathology of suicidal behavior. Many studies have examined the association between a functional polymorphism of the serotonin transporter gene promoter (5-HTTLPR) and suicide but have yielded inconsistent results. Our goal here, by analyzing the cumulative data from primary literature, was to determine conclusively whether there is an association.\n\nMETHODS: Three meta-analyses were performed. One compared the 5-HTTLPR polymorphism between suicidal subjects and normal control subjects; another compared suicide attempters with nonattempters of the same psychiatric diagnoses; the last one compared either violent or nonviolent suicidal subjects with normal control subjects.\n\nRESULTS: We found no association between 5-HTTLPR polymorphism and suicidal behavior (p =.379). When we compared subjects with the same psychiatric diagnoses, the genotypes carrying the s allele were significantly more frequent in suicide attempters than in nonattempters (p =.004). In addition, the s allele was associated with violent suicide (p =.0001) but not with nonviolent suicide (p = 1.00).\n\nCONCLUSIONS: Our results provide significant evidence supporting the association of the s allele of 5-HTTLPR polymorphism with suicidal behavior in the psychiatric population, also with violent suicide. 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Thus, the serotonin-related genes are the major candidates. Previously a functional polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was identified and the presence of the short allele (S) was found to be associated with a lower level of expression of the gene and lower levels of 5-HT uptake when compared with the long allele (L). The purpose of this study was to evaluate the association between family suicide behaviour history and probands' suicide attempt (SA) history, SA characteristics and 5-HTTLPR genotype.\n\nMETHOD: We genotyped 237 probands (major depressed or schizophrenic patients) and used a semistructured interview to determine probands' SA characteristics and first- and second-degree family suicidal behaviour.\n\nRESULTS: An association between suicidal family history and proband's SA but not with SA characteristics and probands genotype was found.\n\nCONCLUSION: Our results suggest that multiple biological and environmental factors underlie familial transmission of suicidal behaviour.", "journal": "Acta psychiatrica Scandinavica", "year": "2004", "authors": "Correa H, Campi-Azevedo AC, De Marco L, Boson W, Viana MM, Guimarães MM, Costa E, Miranda DM, Romano-Silva MA", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/j.1600-0447.2004.00340.x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.039Z" }, { "id": "b8c2bacc-5e24-4160-bde9-1a000ae28728", "pmid": "15521831", "title": "Familial suicide behaviour: association with probands suicide attempt characteristics and 5-HTTLPR polymorphism.", "imported": false, "abstract": "OBJECTIVE: There is compelling evidence that a serotonergic dysfunction may play a major role in suicide behaviour and it has also been demonstrated that suicide is, at least partially, genetically determined. 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The purpose of this study was to evaluate the association between family suicide behaviour history and probands' suicide attempt (SA) history, SA characteristics and 5-HTTLPR genotype.\n\nMETHOD: We genotyped 237 probands (major depressed or schizophrenic patients) and used a semistructured interview to determine probands' SA characteristics and first- and second-degree family suicidal behaviour.\n\nRESULTS: An association between suicidal family history and proband's SA but not with SA characteristics and probands genotype was found.\n\nCONCLUSION: Our results suggest that multiple biological and environmental factors underlie familial transmission of suicidal behaviour.", "journal": "Acta psychiatrica Scandinavica", "year": "2004", "authors": "Correa H, Campi-Azevedo AC, De Marco L, Boson W, Viana MM, Guimarães MM, Costa E, Miranda DM, Romano-Silva MA", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/j.1600-0447.2004.00340.x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.914Z" }, { "id": "c3ececfa-c885-47ae-818b-1bd3002fcc49", "pmid": "15521831", "title": "Familial suicide behaviour: association with probands suicide attempt characteristics and 5-HTTLPR polymorphism.", "imported": false, "abstract": "OBJECTIVE: There is compelling evidence that a serotonergic dysfunction may play a major role in suicide behaviour and it has also been demonstrated that suicide is, at least partially, genetically determined. Thus, the serotonin-related genes are the major candidates. Previously a functional polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was identified and the presence of the short allele (S) was found to be associated with a lower level of expression of the gene and lower levels of 5-HT uptake when compared with the long allele (L). The purpose of this study was to evaluate the association between family suicide behaviour history and probands' suicide attempt (SA) history, SA characteristics and 5-HTTLPR genotype.\n\nMETHOD: We genotyped 237 probands (major depressed or schizophrenic patients) and used a semistructured interview to determine probands' SA characteristics and first- and second-degree family suicidal behaviour.\n\nRESULTS: An association between suicidal family history and proband's SA but not with SA characteristics and probands genotype was found.\n\nCONCLUSION: Our results suggest that multiple biological and environmental factors underlie familial transmission of suicidal behaviour.", "journal": "Acta psychiatrica Scandinavica", "year": "2004", "authors": "Correa H, Campi-Azevedo AC, De Marco L, Boson W, Viana MM, Guimarães MM, Costa E, Miranda DM, Romano-Silva MA", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/j.1600-0447.2004.00340.x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.857Z" }, { "id": "2d3c8557-516b-450f-a57e-7f5e51554499", "pmid": "15528950", "title": "Effects of leptin on intracellular calcium concentrations in isolated porcine somatotropes", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Glavaski-Joksimovic A, Rowe EW, Jeftinija K, Scanes CG, Anderson LL, Jeftinija S.", "articleTypes": [], "doi": "10.1159/000081843", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.781Z" }, { "id": "66c36511-c3d4-420c-9b43-f11bc963570c", "pmid": "15528950", "title": "Effects of leptin on intracellular calcium concentrations in isolated porcine somatotropes", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Glavaski-Joksimovic A, Rowe EW, Jeftinija K, Scanes CG, Anderson LL, Jeftinija S.", "articleTypes": [], "doi": "10.1159/000081843", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.425Z" }, { "id": "7f36da94-074f-4e9b-96c4-d2ae65cc49c2", "pmid": "15528950", "title": "Effects of leptin on intracellular calcium concentrations in isolated porcine somatotropes", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Glavaski-Joksimovic A, Rowe EW, Jeftinija K, Scanes CG, Anderson LL, Jeftinija S.", "articleTypes": [], "doi": "10.1159/000081843", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.900Z" }, { "id": "8131382f-5a26-40b4-b811-3bb093c11d11", "pmid": "15528950", "title": "Effects of leptin on intracellular calcium concentrations in isolated porcine somatotropes", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Glavaski-Joksimovic A, Rowe EW, Jeftinija K, Scanes CG, Anderson LL, Jeftinija S.", "articleTypes": [], "doi": "10.1159/000081843", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.394Z" }, { "id": "4152ed49-2e4f-4055-a380-44a433835d0a", "pmid": "15531095", "title": "Relationship between suicidal behavior of psychotic inpatients and serotonin transporter gene in Han Chinese.", "imported": false, "abstract": "Strong evidence indicates that central serotoninergic system dysfunction is associated with suicidal behavior. The relationship between the serotonin transporter protein (5-HTT) gene of psychotic patients in Han Chinese with suicidal behavior was studied since the 5-HTT plays an important role in serotoninergic transmission. Two hundred and seventy-two psychotic inpatients with suicidal behavior (suicide group) and 275 psychotic inpatients without suicidal behavior (patient control group) were recruited from six mental health facilities in Shanghai, China. Another 628 healthy adults (healthy control group) without suicidal behavior and mental disorder history were enrolled from Shanghai, China. All subjects were Han Chinese. The genotypes and the alleles of 5-HTT genes of the three groups were examined by PCR amplification. Neither the intron 2 variable number tandem repeat (VNTR) polymorphism and 5-HTTLPR (5-HTT gene-linked polymorphic region), nor the haplotype frequencies of this gene have significant differences between the suicide group and the two control groups. However, there was a significant difference in 5-HTTLPR polymorphism between inpatients with a first episode of suicidal behavior and those with recurrent suicidal behavior. Except for the possible heterogeneity between inpatients with a first episode of suicidal behavior and those with more than one, the 5-HTT gene was unlikely to be associated with suicidal behavior of psychotic patient in Han Chinese.", "journal": "Neuroscience letters", "year": "2004", "authors": "Shen Y, Li H, Gu N, Tan Z, Tang J, Fan J, Li X, Sun W, He L", "articleTypes": [ "Comparative Study", "Journal Article", "Multicenter Study", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.neulet.2004.09.018", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.914Z" }, { "id": "c09eb5f2-1cf8-4ea4-8768-4483b41958f0", "pmid": "15531095", "title": "Relationship between suicidal behavior of psychotic inpatients and serotonin transporter gene in Han Chinese.", "imported": false, "abstract": "Strong evidence indicates that central serotoninergic system dysfunction is associated with suicidal behavior. The relationship between the serotonin transporter protein (5-HTT) gene of psychotic patients in Han Chinese with suicidal behavior was studied since the 5-HTT plays an important role in serotoninergic transmission. Two hundred and seventy-two psychotic inpatients with suicidal behavior (suicide group) and 275 psychotic inpatients without suicidal behavior (patient control group) were recruited from six mental health facilities in Shanghai, China. Another 628 healthy adults (healthy control group) without suicidal behavior and mental disorder history were enrolled from Shanghai, China. All subjects were Han Chinese. The genotypes and the alleles of 5-HTT genes of the three groups were examined by PCR amplification. Neither the intron 2 variable number tandem repeat (VNTR) polymorphism and 5-HTTLPR (5-HTT gene-linked polymorphic region), nor the haplotype frequencies of this gene have significant differences between the suicide group and the two control groups. However, there was a significant difference in 5-HTTLPR polymorphism between inpatients with a first episode of suicidal behavior and those with recurrent suicidal behavior. Except for the possible heterogeneity between inpatients with a first episode of suicidal behavior and those with more than one, the 5-HTT gene was unlikely to be associated with suicidal behavior of psychotic patient in Han Chinese.", "journal": "Neuroscience letters", "year": "2004", "authors": "Shen Y, Li H, Gu N, Tan Z, Tang J, Fan J, Li X, Sun W, He L", "articleTypes": [ "Comparative Study", "Journal Article", "Multicenter Study", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.neulet.2004.09.018", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.039Z" }, { "id": "ce3affa3-6c51-472a-a69f-202c09ac5b1f", "pmid": "15531095", "title": "Relationship between suicidal behavior of psychotic inpatients and serotonin transporter gene in Han Chinese.", "imported": false, "abstract": "Strong evidence indicates that central serotoninergic system dysfunction is associated with suicidal behavior. The relationship between the serotonin transporter protein (5-HTT) gene of psychotic patients in Han Chinese with suicidal behavior was studied since the 5-HTT plays an important role in serotoninergic transmission. Two hundred and seventy-two psychotic inpatients with suicidal behavior (suicide group) and 275 psychotic inpatients without suicidal behavior (patient control group) were recruited from six mental health facilities in Shanghai, China. Another 628 healthy adults (healthy control group) without suicidal behavior and mental disorder history were enrolled from Shanghai, China. All subjects were Han Chinese. The genotypes and the alleles of 5-HTT genes of the three groups were examined by PCR amplification. Neither the intron 2 variable number tandem repeat (VNTR) polymorphism and 5-HTTLPR (5-HTT gene-linked polymorphic region), nor the haplotype frequencies of this gene have significant differences between the suicide group and the two control groups. However, there was a significant difference in 5-HTTLPR polymorphism between inpatients with a first episode of suicidal behavior and those with recurrent suicidal behavior. Except for the possible heterogeneity between inpatients with a first episode of suicidal behavior and those with more than one, the 5-HTT gene was unlikely to be associated with suicidal behavior of psychotic patient in Han Chinese.", "journal": "Neuroscience letters", "year": "2004", "authors": "Shen Y, Li H, Gu N, Tan Z, Tang J, Fan J, Li X, Sun W, He L", "articleTypes": [ "Comparative Study", "Journal Article", "Multicenter Study", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.neulet.2004.09.018", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.857Z" }, { "id": "0f62bd9a-c16c-4253-9bdc-5d3ceb3cb587", "pmid": "15531694", "title": "Quantitative trait locus determining dietary macronutrient intakes is located on human chromosome 2p22", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Cai G, Cole SA, Bastarrachea RA, Maccluer JW, Blangero J, Comuzzie AG.", "articleTypes": [], "doi": "10.1093/ajcn/80.5.1410", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.909Z" }, { "id": "c47ee436-4cb5-4183-b6a8-c956ecb91b84", "pmid": "15531694", "title": "Quantitative trait locus determining dietary macronutrient intakes is located on human chromosome 2p22", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Cai G, Cole SA, Bastarrachea RA, Maccluer JW, Blangero J, Comuzzie AG.", "articleTypes": [], "doi": "10.1093/ajcn/80.5.1410", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.405Z" }, { "id": "d30fcaf4-8191-4e1c-bee8-aeed7de3464f", "pmid": "15531694", "title": "Quantitative trait locus determining dietary macronutrient intakes is located on human chromosome 2p22", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Cai G, Cole SA, Bastarrachea RA, Maccluer JW, Blangero J, Comuzzie AG.", "articleTypes": [], "doi": "10.1093/ajcn/80.5.1410", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.437Z" }, { "id": "d42403f5-0115-4958-afd3-9b60f2b3ce4a", "pmid": "15531694", "title": "Quantitative trait locus determining dietary macronutrient intakes is located on human chromosome 2p22", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Cai G, Cole SA, Bastarrachea RA, Maccluer JW, Blangero J, Comuzzie AG.", "articleTypes": [], "doi": "10.1093/ajcn/80.5.1410", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.793Z" }, { "id": "4e858e3c-2548-464d-94a9-2647ee504803", "pmid": "15533870", "title": "Weight-loss-associated induction of peroxisome proliferator-activated receptor-alpha and peroxisome proliferator-activated receptor-gamma correlate with reduced atherosclerosis and improved cardiovascular function in obese insulin-resistant mice", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Verreth W, De Keyzer D, Pelat M, Verhamme P, Ganame J, Bielicki JK, Mertens A, Quarck R, Benhabilès N, Marguerie G, Mackness B, Mackness M, Ninio E, Herregods MC, Balligand JL, Holvoet P.", "articleTypes": [], "doi": "10.1161/01.CIR.0000147614.85888.7A", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.349Z" }, { "id": "84f200bd-fd3d-47dc-abad-3e9fe563ce01", "pmid": "15533870", "title": "Weight-loss-associated induction of peroxisome proliferator-activated receptor-alpha and peroxisome proliferator-activated receptor-gamma correlate with reduced atherosclerosis and improved cardiovascular function in obese insulin-resistant mice", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Verreth W, De Keyzer D, Pelat M, Verhamme P, Ganame J, Bielicki JK, Mertens A, Quarck R, Benhabilès N, Marguerie G, Mackness B, Mackness M, Ninio E, Herregods MC, Balligand JL, Holvoet P.", "articleTypes": [], "doi": "10.1161/01.CIR.0000147614.85888.7A", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.382Z" }, { "id": "de149190-9885-42bd-8db2-5a945f266710", "pmid": "15533870", "title": "Weight-loss-associated induction of peroxisome proliferator-activated receptor-alpha and peroxisome proliferator-activated receptor-gamma correlate with reduced atherosclerosis and improved cardiovascular function in obese insulin-resistant mice", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Verreth W, De Keyzer D, Pelat M, Verhamme P, Ganame J, Bielicki JK, Mertens A, Quarck R, Benhabilès N, Marguerie G, Mackness B, Mackness M, Ninio E, Herregods MC, Balligand JL, Holvoet P.", "articleTypes": [], "doi": "10.1161/01.CIR.0000147614.85888.7A", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.861Z" }, { "id": "df44624a-5481-43c1-a870-1441b0847b81", "pmid": "15533870", "title": "Weight-loss-associated induction of peroxisome proliferator-activated receptor-alpha and peroxisome proliferator-activated receptor-gamma correlate with reduced atherosclerosis and improved cardiovascular function in obese insulin-resistant mice", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Verreth W, De Keyzer D, Pelat M, Verhamme P, Ganame J, Bielicki JK, Mertens A, Quarck R, Benhabilès N, Marguerie G, Mackness B, Mackness M, Ninio E, Herregods MC, Balligand JL, Holvoet P.", "articleTypes": [], "doi": "10.1161/01.CIR.0000147614.85888.7A", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.740Z" }, { "id": "1c63456a-6024-4420-b554-2876d35d17d2", "pmid": "15536223", "title": "S 23521 decreases food intake and body weight gain in diet-induced obese rats", "imported": false, "abstract": "", "journal": "", "year": "2004", "authors": "Claret M, Corominola H, Canals I, Nadal B, Chavanieu A, Pfeiffer B, Renard P, Gorostiaga C, Delagrange P, Grassy G, Gomis R.", "articleTypes": [], "doi": "10.1038/oby.2004.199", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": 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Billestrup N.", "articleTypes": [], "doi": "10.1677/jme.1.01694", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.766Z" }, { "id": "045e34ea-6d68-4ad4-83e7-ebef0c23536f", "pmid": "15833818", "title": "Deletion of PPARgamma in adipose tissues of mice protects against high fat diet-induced obesity and insulin resistance", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Jones JR, Barrick C, Kim KA, Lindner J, Blondeau B, Fujimoto Y, Shiota M, Kesterson RA, Kahn BB, Magnuson MA.", "articleTypes": [], "doi": "10.1073/pnas.0306743102", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.917Z" }, { "id": "4ace220a-ed7b-4853-94b3-4c551ffe39cd", "pmid": "15833818", "title": "Deletion of PPARgamma in adipose tissues of mice protects against high fat diet-induced obesity and insulin resistance", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Jones JR, Barrick C, Kim KA, Lindner J, Blondeau B, Fujimoto Y, Shiota M, Kesterson RA, Kahn BB, Magnuson MA.", "articleTypes": [], "doi": "10.1073/pnas.0306743102", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.415Z" }, { "id": "6f0337e7-8104-44c8-a1cb-2cefc659bf1c", "pmid": "15833818", "title": "Deletion of PPARgamma in adipose tissues of mice protects against high fat diet-induced obesity and insulin resistance", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Jones JR, Barrick C, Kim KA, Lindner J, Blondeau B, Fujimoto Y, Shiota M, Kesterson RA, Kahn BB, Magnuson MA.", "articleTypes": [], "doi": "10.1073/pnas.0306743102", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.446Z" }, { "id": "b70af3d9-ec99-4674-88b4-2ddfe9dd7adb", "pmid": "15833818", "title": "Deletion of PPARgamma in adipose tissues of mice protects against 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"", "journal": "", "year": "2005", "authors": "Zacharova J, Chiasson JL, Laakso M.", "articleTypes": [], "doi": "10.1038/oby.2005.52", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.889Z" }, { "id": "0a5d32dd-0c63-4ae0-baa5-4fac94be135f", "pmid": "15833945", "title": "Alleles on rat chromosome 4 (D4Got41-Fabp1/Tacr1) regulate subphenotypes of obesity", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Klöting N, Wilke B, Klöting I.", "articleTypes": [], "doi": "10.1038/oby.2005.63", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.861Z" }, { "id": "403ae43c-e608-4876-80a4-1b920667bf3c", "pmid": "15833945", "title": "Alleles on rat chromosome 4 (D4Got41-Fabp1/Tacr1) regulate subphenotypes of obesity", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Klöting N, Wilke B, Klöting I.", "articleTypes": [], "doi": 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"2026-10-07T06:27:08.348Z" }, { "id": "3f57a6ef-919c-4d6a-bcf3-2e2971c15d8f", "pmid": "15837636", "title": "[Cloning of human obesity gene and its expression in E. coli]", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Zhu J, Ma WL, Mao XM, Li L, Song YB, Zheng WL.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.366Z" }, { "id": "d10157ff-393a-4ab0-9207-1df375b160bf", "pmid": "15837636", "title": "[Cloning of human obesity gene and its expression in E. coli]", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Zhu J, Ma WL, Mao XM, Li L, Song YB, Zheng WL.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.399Z" }, { "id": "f2916fe2-70c5-49bd-a4c1-642a959b2fc6", "pmid": "15837636", "title": "[Cloning of human obesity gene and its expression in E. coli]", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Zhu J, Ma WL, Mao XM, Li L, Song YB, Zheng WL.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.876Z" }, { "id": "ff484ff0-1f02-49b9-8b23-b9774676ed42", "pmid": "15837636", "title": "[Cloning of human obesity gene and its expression in E. coli]", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Zhu J, Ma WL, Mao XM, Li L, Song YB, Zheng WL.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.755Z" }, { "id": "510c38fc-9f1d-4f0b-bb0e-6926ea893ada", "pmid": "15842834", "title": "[The study on mechanism of appetite regulation in diet-induced obesity resistant rats]", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Liu R, Sun CH, Weng Y.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.374Z" }, { "id": "5aec36af-5506-4ae1-ac24-9d25346b4f09", "pmid": "15842834", "title": "[The study on mechanism of appetite regulation in diet-induced obesity resistant rats]", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Liu R, Sun CH, Weng Y.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.408Z" }, { "id": "7badc0f9-a080-4843-9ac4-f320d891c645", "pmid": "15842834", "title": "[The study on mechanism of appetite regulation in diet-induced obesity resistant rats]", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Liu R, Sun CH, Weng Y.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.763Z" }, { "id": "f313ab0e-9a22-44ee-8fbc-0a7ef93284a6", "pmid": "15842834", "title": "[The study on mechanism of appetite regulation in diet-induced obesity resistant rats]", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Liu R, Sun CH, Weng Y.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.884Z" }, { "id": "0e7e70f3-9c04-4988-bd0b-0255f46b7604", "pmid": "15845877", "title": "Obesity and metabolic syndrome in circadian Clock mutant mice", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Turek FW, Joshu C, Kohsaka A, Lin E, Ivanova G, McDearmon E, Laposky A, Losee-Olson S, Easton A, Jensen DR, Eckel RH, Takahashi JS, Bass J.", "articleTypes": [], "doi": "10.1126/science.1108750", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.873Z" }, { "id": "5ded31ef-29e0-4568-a817-7fef90745881", "pmid": "15845877", "title": "Obesity and metabolic syndrome in circadian Clock mutant mice", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Turek FW, Joshu C, Kohsaka A, Lin E, Ivanova G, McDearmon E, Laposky A, Losee-Olson S, Easton A, Jensen DR, Eckel RH, Takahashi JS, Bass J.", "articleTypes": [], "doi": "10.1126/science.1108750", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.362Z" }, { "id": "792be34b-745c-4ab5-896c-322677b47aa7", "pmid": "15845877", "title": "Obesity and metabolic syndrome in circadian Clock mutant mice", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Turek FW, Joshu C, Kohsaka A, Lin E, Ivanova G, McDearmon E, Laposky A, Losee-Olson S, Easton A, Jensen DR, Eckel RH, Takahashi JS, Bass J.", "articleTypes": [], "doi": "10.1126/science.1108750", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.752Z" }, { "id": "b95f12ff-0db6-4442-89e3-9fc0bc9a297e", "pmid": "15845877", "title": "Obesity and metabolic syndrome in circadian Clock mutant mice", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Turek FW, Joshu C, Kohsaka A, Lin E, Ivanova G, McDearmon E, Laposky A, Losee-Olson S, Easton A, Jensen DR, Eckel RH, Takahashi JS, Bass J.", "articleTypes": [], "doi": "10.1126/science.1108750", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.396Z" }, { "id": "60878448-2b01-4e5c-a966-4dedd39c6c21", "pmid": "15850715", "title": "A defect in the activity of Delta6 and Delta5 desaturases may be a factor predisposing to the development of insulin resistance syndrome", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Das UN.", "articleTypes": [], "doi": "10.1016/j.plefa.2005.01.002", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.815Z" }, { "id": "6f04e2cd-7743-4193-967c-a74f2ec0cdbf", "pmid": "15850715", "title": "A defect in the activity of Delta6 and Delta5 desaturases may be a factor predisposing to the development of insulin resistance syndrome", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Das UN.", "articleTypes": [], "doi": "10.1016/j.plefa.2005.01.002", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.929Z" }, { "id": "91c4b42a-9d15-4144-b5ec-9ef4826dec2e", "pmid": "15850715", "title": "A defect in the activity of Delta6 and Delta5 desaturases may be a factor predisposing to the development of insulin resistance syndrome", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Das UN.", "articleTypes": [], "doi": "10.1016/j.plefa.2005.01.002", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.430Z" }, { "id": "cea5a323-d179-4e4e-8be7-a9025f597103", "pmid": "15850715", "title": "A defect in the activity of Delta6 and Delta5 desaturases may be a factor predisposing to the development of insulin resistance syndrome", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Das UN.", "articleTypes": [], "doi": "10.1016/j.plefa.2005.01.002", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.460Z" }, { "id": "58c1471d-01dd-40c8-a48d-cce449f3c6a8", "pmid": "15855315", "title": "Effects of diet and genetic background on sterol regulatory element-binding protein-1c, stearoyl-CoA desaturase 1, and the development of the metabolic syndrome", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Biddinger SB, Almind K, Miyazaki M, Kokkotou E, Ntambi JM, Kahn CR.", "articleTypes": [], "doi": "10.2337/diabetes.54.5.1314", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.398Z" }, { "id": "9c3512a4-cd6c-428e-9fee-86c28737791c", "pmid": "15855315", "title": "Effects of diet and genetic background on sterol regulatory element-binding protein-1c, stearoyl-CoA desaturase 1, and the development of the metabolic syndrome", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Biddinger SB, Almind K, Miyazaki M, Kokkotou E, Ntambi JM, Kahn CR.", "articleTypes": [], "doi": "10.2337/diabetes.54.5.1314", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.903Z" }, { "id": "a7eb7570-3b4e-4b68-9424-2dfaec4a68bb", "pmid": "15855315", "title": "Effects of diet and genetic background on sterol regulatory element-binding protein-1c, stearoyl-CoA desaturase 1, and the development of the metabolic syndrome", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Biddinger SB, Almind K, Miyazaki M, Kokkotou E, Ntambi JM, Kahn CR.", "articleTypes": [], "doi": "10.2337/diabetes.54.5.1314", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.785Z" }, { "id": "f9fb712b-9d28-4fb1-be79-4c1760039bf6", "pmid": "15855315", "title": "Effects of diet and genetic background on sterol regulatory element-binding protein-1c, stearoyl-CoA desaturase 1, and the development of the metabolic syndrome", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Biddinger SB, Almind K, Miyazaki M, Kokkotou E, Ntambi JM, Kahn CR.", "articleTypes": [], "doi": "10.2337/diabetes.54.5.1314", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.429Z" }, { "id": "29962168-13d8-4b0d-a135-9f9e28ed3d31", "pmid": "15856722", "title": "The socio-economic status of communities predicts variation in brain serotonergic responsivity.", "imported": false, "abstract": "BACKGROUND: We reported previously that the socio-economic status (SES) of individuals predicts variation in brain serotonergic responsivity, as assessed by neuropharmacological challenge in an adult community sample, and that this association is qualified by allelic variation in the serotonin transporter gene-linked polymorphic region (5-HTTLPR). Here we examine whether serotonergic responsivity covaries similarly with the SES of communities, as indexed by US Census data in the same study sample.\n\nMETHOD: Community SES was defined by levels of income, economic disadvantage, housing costs, and educational attainment of census tracts in which 249 locally recruited study participants (54% male) resided. Serotonergic responsivity was assessed as the baseline-adjusted, peak plasma prolactin (Prl) concentration following acute administration of the serotonin-releasing agent, fenfluramine; tissue for DNA extraction and 5-HTTLPR genotyping was available on 131 participants.\n\nRESULTS: Subjects residing in census tracts of lower SES showed a blunted Prl response to fenfluramine (diminished serotonergic responsivity) relative to individuals living in more affluent neighborhoods. When adjusted for personal income and education, SES at the community level continued to predict fenfluramine-stimulated Prl responses and did so independently of 5-HTTLPR genotype.\n\nCONCLUSIONS: Area-level indices of relative social and economic disadvantage covary with individual differences in brain serotonergic responsivity, and this association is, in part, independent of individually defined SES. These findings may be relevant to reported effects of low community SES on the prevalence of psychiatric disorders or behaviors associated with dysregulation of central serotonergic function, such as depression, impulsive aggression, and suicide.", "journal": "Psychological medicine", "year": "2005", "authors": "Manuck SB, Bleil ME, Petersen KL, Flory JD, Mann JJ, Ferrell RE, Muldoon MF", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, U.S. Gov't, P.H.S." ], "doi": "10.1017/s0033291704003757", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.856Z" }, { "id": "a73c447a-d2e6-4dd4-afae-0fc6858e7a01", "pmid": "15856722", "title": "The socio-economic status of communities predicts variation in brain serotonergic responsivity.", "imported": false, "abstract": "BACKGROUND: We reported previously that the socio-economic status (SES) of individuals predicts variation in brain serotonergic responsivity, as assessed by neuropharmacological challenge in an adult community sample, and that this association is qualified by allelic variation in the serotonin transporter gene-linked polymorphic region (5-HTTLPR). Here we examine whether serotonergic responsivity covaries similarly with the SES of communities, as indexed by US Census data in the same study sample.\n\nMETHOD: Community SES was defined by levels of income, economic disadvantage, housing costs, and educational attainment of census tracts in which 249 locally recruited study participants (54% male) resided. Serotonergic responsivity was assessed as the baseline-adjusted, peak plasma prolactin (Prl) concentration following acute administration of the serotonin-releasing agent, fenfluramine; tissue for DNA extraction and 5-HTTLPR genotyping was available on 131 participants.\n\nRESULTS: Subjects residing in census tracts of lower SES showed a blunted Prl response to fenfluramine (diminished serotonergic responsivity) relative to individuals living in more affluent neighborhoods. When adjusted for personal income and education, SES at the community level continued to predict fenfluramine-stimulated Prl responses and did so independently of 5-HTTLPR genotype.\n\nCONCLUSIONS: Area-level indices of relative social and economic disadvantage covary with individual differences in brain serotonergic responsivity, and this association is, in part, independent of individually defined SES. These findings may be relevant to reported effects of low community SES on the prevalence of psychiatric disorders or behaviors associated with dysregulation of central serotonergic function, such as depression, impulsive aggression, and suicide.", "journal": "Psychological medicine", "year": "2005", "authors": "Manuck SB, Bleil ME, Petersen KL, Flory JD, Mann JJ, Ferrell RE, Muldoon MF", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, U.S. Gov't, P.H.S." ], "doi": "10.1017/s0033291704003757", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.037Z" }, { "id": "c8f8cc6c-976c-420b-a596-c702a4ab906f", "pmid": "15856722", "title": "The socio-economic status of communities predicts variation in brain serotonergic responsivity.", "imported": false, "abstract": "BACKGROUND: We reported previously that the socio-economic status (SES) of individuals predicts variation in brain serotonergic responsivity, as assessed by neuropharmacological challenge in an adult community sample, and that this association is qualified by allelic variation in the serotonin transporter gene-linked polymorphic region (5-HTTLPR). Here we examine whether serotonergic responsivity covaries similarly with the SES of communities, as indexed by US Census data in the same study sample.\n\nMETHOD: Community SES was defined by levels of income, economic disadvantage, housing costs, and educational attainment of census tracts in which 249 locally recruited study participants (54% male) resided. Serotonergic responsivity was assessed as the baseline-adjusted, peak plasma prolactin (Prl) concentration following acute administration of the serotonin-releasing agent, fenfluramine; tissue for DNA extraction and 5-HTTLPR genotyping was available on 131 participants.\n\nRESULTS: Subjects residing in census tracts of lower SES showed a blunted Prl response to fenfluramine (diminished serotonergic responsivity) relative to individuals living in more affluent neighborhoods. When adjusted for personal income and education, SES at the community level continued to predict fenfluramine-stimulated Prl responses and did so independently of 5-HTTLPR genotype.\n\nCONCLUSIONS: Area-level indices of relative social and economic disadvantage covary with individual differences in brain serotonergic responsivity, and this association is, in part, independent of individually defined SES. These findings may be relevant to reported effects of low community SES on the prevalence of psychiatric disorders or behaviors associated with dysregulation of central serotonergic function, such as depression, impulsive aggression, and suicide.", "journal": "Psychological medicine", "year": "2005", "authors": "Manuck SB, Bleil ME, Petersen KL, Flory JD, Mann JJ, Ferrell RE, Muldoon MF", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, U.S. Gov't, P.H.S." ], "doi": "10.1017/s0033291704003757", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.912Z" }, { "id": "45ec25d1-42ff-41bd-b30f-0ec1f15f84fc", "pmid": "15864110", "title": "Weight gain with antipsychotic drugs: the role of the 5-HT2C receptor (HTR2C) and other genes", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Harrison PJ.", "articleTypes": [], "doi": "10.1097/01213011-200504000-00001", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.740Z" }, { "id": "5071210d-f513-4dac-812e-d90750408a6a", "pmid": "15864110", "title": "Weight gain with antipsychotic drugs: the role of the 5-HT2C receptor 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"year": "2005", "authors": "Cowey SL, Quast M, Belalcazar LM, Wei J, Deng X, Given R, Singh P.", "articleTypes": [], "doi": "10.1002/cncr.21094", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.356Z" }, { "id": "7b5d011d-68a2-49d4-986a-a43fd4cfd039", "pmid": "15864814", "title": "Abdominal obesity, insulin resistance, and colon carcinogenesis are increased in mutant mice lacking gastrin gene expression", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Cowey SL, Quast M, Belalcazar LM, Wei J, Deng X, Given R, Singh P.", "articleTypes": [], "doi": "10.1002/cncr.21094", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.747Z" }, { "id": "951b0563-ddf5-47cc-8d5f-2981dcb45a8e", "pmid": "15864814", "title": "Abdominal obesity, insulin resistance, and colon carcinogenesis are increased in mutant mice lacking gastrin gene expression", "imported": false, 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Young SF, Aguilera G, Puricelli E, Adler-Wailes DC, Sebring NG, Yanovski JA.", "articleTypes": [], "doi": "10.2337/diabetes.54.9.2663", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.883Z" }, { "id": "f0794429-b588-4d58-9738-be92cd524bf6", "pmid": "16123355", "title": "Co-occurrence of two partially inactivating polymorphisms of MC3R is associated with pediatric-onset obesity", "imported": false, "abstract": "", "journal": "", "year": "2005", "authors": "Feng N, Young SF, Aguilera G, Puricelli E, Adler-Wailes DC, Sebring NG, Yanovski JA.", "articleTypes": [], "doi": "10.2337/diabetes.54.9.2663", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.374Z" }, { "id": "68a70c79-140b-4f30-85ac-c62ef2728950", "pmid": "16125146", "title": "STin2 variant and family history of suicide as significant predictors of suicide completion in major depression.", "imported": false, "abstract": "BACKGROUND: Suicide is the most serious outcome of major depression, yet not all depressed patients will commit suicide. Genes, along with other factors, might account for this difference. Serotonergic alterations have been observed in suicide and depression and impulsive-aggressive behaviors. Therefore, we aimed to identify predictors of suicide, considering genetic variation at the serotonin transporter (5-HTT) gene.\n\nMETHODS: We investigated the 5-HTT gene-linked polymorphic region (5-HTTLPR) and intron 2 (STin2) variants of this gene and their relationship to behavioral and clinical risk factors for suicide in a sample of depressed suicides (n =106) and depressed control subjects (n =152), diagnosed by means of proxy-based interviews.\n\nRESULTS: We found a significant association of suicide completion with having at least one copy of the STin2 10 allele [chi(2)(1) = 10.833, p = .002]. No differences were found for the 5-HTTLPR variable number of tandem repeats. After controlling for behavioral and clinical risk factors for suicide, the STin2 variant remained a significant predictor of suicide in major depression when jointly considered with a family history of suicide (odds ratio 5.560, 95% confidence interval 1.057-29.247).\n\nCONCLUSIONS: The STin2 locus might account, at least in part, for the observed familial aggregation of suicidal behavior. These results should be further explored in families where clustering of suicidal behavior is observed.", "journal": "Biological psychiatry", "year": "2006", "authors": "Lopez de Lara C, Dumais A, Rouleau G, Lesage A, Dumont M, Chawky N, Alda M, Benkelfat C, Turecki G", "articleTypes": [ "Controlled Clinical Trial", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.biopsych.2005.06.021", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.037Z" }, { "id": "bede3892-2c70-4cd3-a603-8aa3c944c73a", "pmid": "16125146", "title": "STin2 variant and family history of suicide as significant predictors of suicide completion in major depression.", "imported": false, "abstract": "BACKGROUND: Suicide is the most serious outcome of major depression, yet not all depressed patients will commit suicide. Genes, along with other factors, might account for this difference. Serotonergic alterations have been observed in suicide and depression and impulsive-aggressive behaviors. Therefore, we aimed to identify predictors of suicide, considering genetic variation at the serotonin transporter (5-HTT) gene.\n\nMETHODS: We investigated the 5-HTT gene-linked polymorphic region (5-HTTLPR) and intron 2 (STin2) variants of this gene and their relationship to behavioral and clinical risk factors for suicide in a sample of depressed suicides (n =106) and depressed control subjects (n =152), diagnosed by means of proxy-based interviews.\n\nRESULTS: We found a significant association of suicide completion with having at least one copy of the STin2 10 allele [chi(2)(1) = 10.833, p = .002]. No differences were found for the 5-HTTLPR variable number of tandem repeats. After controlling for behavioral and clinical risk factors for suicide, the STin2 variant remained a significant predictor of suicide in major depression when jointly considered with a family history of suicide (odds ratio 5.560, 95% confidence interval 1.057-29.247).\n\nCONCLUSIONS: The STin2 locus might account, at least in part, for the observed familial aggregation of suicidal behavior. These results should be further explored in families where clustering of suicidal behavior is observed.", "journal": "Biological psychiatry", "year": "2006", "authors": "Lopez de Lara C, Dumais A, Rouleau G, Lesage A, Dumont M, Chawky N, Alda M, Benkelfat C, Turecki G", "articleTypes": [ "Controlled Clinical Trial", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.biopsych.2005.06.021", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.856Z" }, { "id": "c4bcbd29-d2af-42eb-807f-14a4d3d93553", "pmid": "16125146", "title": "STin2 variant and family history of suicide as significant predictors of suicide completion in major depression.", "imported": false, "abstract": "BACKGROUND: Suicide is the most serious outcome of major depression, yet not all depressed patients will commit suicide. Genes, along with other factors, might account for this difference. Serotonergic alterations have been observed in suicide and depression and impulsive-aggressive behaviors. Therefore, we aimed to identify predictors of suicide, considering genetic variation at the serotonin transporter (5-HTT) gene.\n\nMETHODS: We investigated the 5-HTT gene-linked polymorphic region (5-HTTLPR) and intron 2 (STin2) variants of this gene and their relationship to behavioral and clinical risk factors for suicide in a sample of depressed suicides (n =106) and depressed control subjects (n =152), diagnosed by means of proxy-based interviews.\n\nRESULTS: We found a significant association of suicide completion with having at least one copy of the STin2 10 allele [chi(2)(1) = 10.833, p = .002]. No differences were found for the 5-HTTLPR variable number of tandem repeats. After controlling for behavioral and clinical risk factors for suicide, the STin2 variant remained a significant predictor of suicide in major depression when jointly considered with a family history of suicide (odds ratio 5.560, 95% confidence interval 1.057-29.247).\n\nCONCLUSIONS: The STin2 locus might account, at least in part, for the observed familial aggregation of suicidal behavior. These results should be further explored in families where clustering of suicidal behavior is observed.", "journal": "Biological psychiatry", "year": "2006", "authors": "Lopez de Lara C, Dumais A, Rouleau G, Lesage A, Dumont M, Chawky N, Alda M, Benkelfat C, Turecki G", "articleTypes": [ "Controlled Clinical Trial", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.biopsych.2005.06.021", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR 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The current study was designed to examine whether the new long (A/G) variant polymorphism of the 5-HTT gene may be associated with suicide attempts of 290 Caucasian schizophrenic patients. Among these patients, 92 had a history of suicide attempt. No association with history of suicide attempt was found in the multiallelic 5-HTTLPR (p = 0.305), however we found significant association with the intron 2 VNTR polymorphism (p = 0.018). When we performed a haplotype analysis, we found association between suicide attempt and haplotype distribution (p = 0.031). 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Thus genes coding for proteins of the serotonergic pathways are leading candidates for investigating possible associations.\n\nMETHOD: We studied three serotonergic gene polymorphisms (5-HTTLPR S/L, TPH A779C, 5-HT1B G861C) in a sample of 114 unrelated suicide attempters (mainly non-violent methods), in 112 patients, 23 siblings and 56 healthy controls. Genotyping was done using polymerase chain reaction (PCR) based assays. The primary analyses compared allele and genotype frequencies between patients and controls and to test for presence of linkage disequilibrium using the family based association test (FBAT). The genotypes were further related to clinical characteristics and to psychological traits.\n\nRESULTS: There was a trend towards an increase in the L-allele frequency of the 5-HTTLPR in suicidal patients (p=0.066, OR=1,57, 95%CI 0,96-2,52). No other polymorphisms were associated with suicidal behaviour and the FBAT showed no excess transmission of any allele from parents to the offsprings. We found a slight reduction in \"Novelty Seeking Scores\" in patients having at least one S-allele (one-way ANOVA F=3,90, p=0.024). All the other traits were not related to any of the genotypes.\n\nCONCLUSION: Our data extend the evidence that genetic factors do not play a major role in non-violent suicidal behaviour. 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Thus genes coding for proteins of the serotonergic pathways are leading candidates for investigating possible associations.\n\nMETHOD: We studied three serotonergic gene polymorphisms (5-HTTLPR S/L, TPH A779C, 5-HT1B G861C) in a sample of 114 unrelated suicide attempters (mainly non-violent methods), in 112 patients, 23 siblings and 56 healthy controls. Genotyping was done using polymerase chain reaction (PCR) based assays. The primary analyses compared allele and genotype frequencies between patients and controls and to test for presence of linkage disequilibrium using the family based association test (FBAT). The genotypes were further related to clinical characteristics and to psychological traits.\n\nRESULTS: There was a trend towards an increase in the L-allele frequency of the 5-HTTLPR in suicidal patients (p=0.066, OR=1,57, 95%CI 0,96-2,52). No other polymorphisms were associated with suicidal behaviour and the FBAT showed no excess transmission of any allele from parents to the offsprings. We found a slight reduction in \"Novelty Seeking Scores\" in patients having at least one S-allele (one-way ANOVA F=3,90, p=0.024). All the other traits were not related to any of the genotypes.\n\nCONCLUSION: Our data extend the evidence that genetic factors do not play a major role in non-violent suicidal behaviour. The 5-HTTLPR S/L variants may have an impact on personality traits.", "journal": "Psychiatria Hungarica : A Magyar Pszichiatriai Tarsasag tudomanyos folyoirata", "year": "2005", "authors": "Fekete S, Zill P, Bondy B", "articleTypes": [ "English Abstract", "Journal Article" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:02.039Z" }, { "id": "b65bdd3f-5307-45d1-a198-b562ff51de9e", "pmid": "16389730", "title": "[Suicide attempt, psychopathology and genetics].", "imported": false, "abstract": "BACKGROUND: There is compelling evidence that suicidal behaviour has a heritable component and is associated with disturbances in serotonergic mechanisms. Thus genes coding for proteins of the serotonergic pathways are leading candidates for investigating possible associations.\n\nMETHOD: We studied three serotonergic gene polymorphisms (5-HTTLPR S/L, TPH A779C, 5-HT1B G861C) in a sample of 114 unrelated suicide attempters (mainly non-violent methods), in 112 patients, 23 siblings and 56 healthy controls. Genotyping was done using polymerase chain reaction (PCR) based assays. The primary analyses compared allele and genotype frequencies between patients and controls and to test for presence of linkage disequilibrium using the family based association test (FBAT). The genotypes were further related to clinical characteristics and to psychological traits.\n\nRESULTS: There was a trend towards an increase in the L-allele frequency of the 5-HTTLPR in suicidal patients (p=0.066, OR=1,57, 95%CI 0,96-2,52). No other polymorphisms were associated with suicidal behaviour and the FBAT showed no excess transmission of any allele from parents to the offsprings. We found a slight reduction in \"Novelty Seeking Scores\" in patients having at least one S-allele (one-way ANOVA F=3,90, p=0.024). All the other traits were not related to any of the genotypes.\n\nCONCLUSION: Our data extend the evidence that genetic factors do not play a major role in non-violent suicidal behaviour. 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"abstract": "The concept that genetic factors contribute to the complex trait of suicidal behaviour has stimulated much work aimed at identifying susceptibility genes. So far molecular genetic studies focused on the serotonergic pathway as the intent to die and the lethality of suicide acts were related to the serotonergic system. Two genes have so far emerged as being involved in the vulnerability for suicidality: first, the intronic polymorphisms (A218C or A779C) of the tryptophan hydroxylase 1 (TPH1) gene, which was suggested as a quantitative risk factor for suicidal behaviour; second, the insertion/deletion polymorphism of the serotonin transporter gene (5-HTTLPR), which does not seem to be involved in general suicidal behaviour, but in violent and repeated suicide attempts. The data have further shown that the MAOA gene, which is consistently associated with impulsive-aggressive personality traits, is not related to suicide but might induce violent methods in subjects with other suicide risk factors. Predominantly negative were the findings with any type of the serotonin receptors and inconsistent with catecholamine-synthesizing and -metabolizing enzymes or with the dopaminergic receptors. 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So far molecular genetic studies focused on the serotonergic pathway as the intent to die and the lethality of suicide acts were related to the serotonergic system. Two genes have so far emerged as being involved in the vulnerability for suicidality: first, the intronic polymorphisms (A218C or A779C) of the tryptophan hydroxylase 1 (TPH1) gene, which was suggested as a quantitative risk factor for suicidal behaviour; second, the insertion/deletion polymorphism of the serotonin transporter gene (5-HTTLPR), which does not seem to be involved in general suicidal behaviour, but in violent and repeated suicide attempts. The data have further shown that the MAOA gene, which is consistently associated with impulsive-aggressive personality traits, is not related to suicide but might induce violent methods in subjects with other suicide risk factors. Predominantly negative were the findings with any type of the serotonin receptors and inconsistent with catecholamine-synthesizing and -metabolizing enzymes or with the dopaminergic receptors. This paper reviews the status of current knowledge in this area, points to the weakness of the investigations and presents new approaches beyond the serotonergic system.", "journal": "Molecular psychiatry", "year": "2006", "authors": "Bondy B, Buettner A, Zill P", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Review" ], "doi": "10.1038/sj.mp.4001803", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.911Z" }, { "id": "e9e685da-c9aa-477e-812c-8047d39c8343", "pmid": "16462816", "title": "Genetics of suicide.", "imported": false, "abstract": "The concept that genetic factors contribute to the complex trait of suicidal behaviour has stimulated much work aimed at identifying susceptibility genes. So far molecular genetic studies focused on the serotonergic pathway as the intent to die and the lethality of suicide acts were related to the serotonergic system. Two genes have so far emerged as being involved in the vulnerability for suicidality: first, the intronic polymorphisms (A218C or A779C) of the tryptophan hydroxylase 1 (TPH1) gene, which was suggested as a quantitative risk factor for suicidal behaviour; second, the insertion/deletion polymorphism of the serotonin transporter gene (5-HTTLPR), which does not seem to be involved in general suicidal behaviour, but in violent and repeated suicide attempts. The data have further shown that the MAOA gene, which is consistently associated with impulsive-aggressive personality traits, is not related to suicide but might induce violent methods in subjects with other suicide risk factors. Predominantly negative were the findings with any type of the serotonin receptors and inconsistent with catecholamine-synthesizing and -metabolizing enzymes or with the dopaminergic receptors. This paper reviews the status of current knowledge in this area, points to the weakness of the investigations and presents new approaches beyond the serotonergic system.", "journal": "Molecular psychiatry", "year": "2006", "authors": "Bondy B, Buettner A, Zill P", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Review" ], "doi": "10.1038/sj.mp.4001803", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR 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A functional polymorphism (a 44-base pair insertion (L)/deletion (S)) in the promoter of the gene encoding the serotonin transporter (5-HTTLPR), associated with mood disorders, has been inconsistently associated with suicidality. To add to this debate, we designed a case-control study involving 62 suicide victims and 72 controls matched for age, gender and ethnicity. All subjects underwent forensic investigation. No association could be detected between the 5-HTTLPR polymorphism and suicide. 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"year": "2006", "authors": "Rink C, Roy S, Khanna S, Rink T, Bagchi D, Sen CK.", "articleTypes": [], "doi": "10.1152/physiolgenomics.00071.2006", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.904Z" }, { "id": "1963d87e-2cc9-4499-83c8-99df2c624b19", "pmid": "16940707", "title": "Expression of endothelin-1 and adrenomedullin was not altered by leptin or resistin in bovine brain microvascular endothelial cells", "imported": false, "abstract": "", "journal": "", "year": "2006", "authors": "Takahashi K, Totsune K, Kikuchi K, Murakami O.", "articleTypes": [], "doi": "10.1291/hypres.29.443", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.390Z" }, { "id": "beef7a50-ea55-4908-9d42-705a7d65cfac", "pmid": "16940707", "title": "Expression of endothelin-1 and adrenomedullin was not altered by leptin or resistin in bovine brain microvascular endothelial cells", "imported": false, 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"imported": false, "abstract": "", "journal": "", "year": "2006", "authors": "Takahashi K, Totsune K, Kikuchi K, Murakami O.", "articleTypes": [], "doi": "10.1291/hypres.29.443", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.897Z" }, { "id": "1ce26113-f0ae-416e-96ba-496c6501aa0c", "pmid": "16946185", "title": "Association of a triallelic serotonin transporter gene promoter region (5-HTTLPR) polymorphism with stressful life events and severity of depression.", "imported": false, "abstract": "OBJECTIVE: The lower expressing allele of the serotonin transporter gene 5' promoter region (5-HTTLPR) polymorphism is reported to be associated with susceptibility to depression and suicidality in response to stressful life events. The authors examined the relationship of a triallelic 5-HTTLPR polymorphism to stressful life events, severity of major depression, and suicidality.\n\nMETHOD: Mood disorder subjects (N=191) and healthy volunteers (N=125), all Caucasian subjects of European origin, were genotyped for the triallelic 5-HTTLPR polymorphism (higher expressing allele: L(A); lower expressing alleles: L(G), S). All subjects underwent structured clinical interviews to determine DSM-IV diagnoses, ratings of psychopathology, stressful life events, developmental history, and suicidal behavior. CSF 5-HIAA was assayed in a subgroup of subjects.\n\nRESULTS: Lower expressing alleles independently predicted greater depression severity and predicted greater severity of major depression with moderate to severe life events compared with the higher expressing L(A) allele. No associations with suicidal behavior and CSF 5-HIAA were found.\n\nCONCLUSIONS: Lower expressing transporter alleles, directly and by increasing the impact of stressful life events on severity, explain 31% of the variance in major depression severity. The biological phenotype responsible for these effects remains to be elucidated.", "journal": "The American journal of psychiatry", "year": "2006", "authors": "Zalsman G, Huang YY, Oquendo MA, Burke AK, Hu XZ, Brent DA, Ellis SP, Goldman D, Mann JJ", "articleTypes": [ "Comparative Study", "Journal Article", "Research Support, N.I.H., Extramural" ], "doi": "10.1176/ajp.2006.163.9.1588", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.642Z" }, { "id": "32c7b606-57c2-4614-ae68-723c535515f6", "pmid": "16946185", "title": "Association of a triallelic serotonin transporter gene promoter region (5-HTTLPR) polymorphism with stressful life events and severity of depression.", "imported": false, "abstract": "OBJECTIVE: The lower expressing allele of the serotonin transporter gene 5' promoter region (5-HTTLPR) polymorphism is reported to be associated with susceptibility to depression and suicidality in response to stressful life events. The authors examined the relationship of a triallelic 5-HTTLPR polymorphism to stressful life events, severity of major depression, and suicidality.\n\nMETHOD: Mood disorder subjects (N=191) and healthy volunteers (N=125), all Caucasian subjects of European origin, were genotyped for the triallelic 5-HTTLPR polymorphism (higher expressing allele: L(A); lower expressing alleles: L(G), S). All subjects underwent structured clinical interviews to determine DSM-IV diagnoses, ratings of psychopathology, stressful life events, developmental history, and suicidal behavior. CSF 5-HIAA was assayed in a subgroup of subjects.\n\nRESULTS: Lower expressing alleles independently predicted greater depression severity and predicted greater severity of major depression with moderate to severe life events compared with the higher expressing L(A) allele. No associations with suicidal behavior and CSF 5-HIAA were found.\n\nCONCLUSIONS: Lower expressing transporter alleles, directly and by increasing the impact of stressful life events on severity, explain 31% of the variance in major depression severity. The biological phenotype responsible for these effects remains to be elucidated.", "journal": "The American journal of psychiatry", "year": "2006", "authors": "Zalsman G, Huang YY, Oquendo MA, Burke AK, Hu XZ, Brent DA, Ellis SP, Goldman D, Mann JJ", "articleTypes": [ "Comparative Study", "Journal Article", "Research Support, N.I.H., Extramural" ], "doi": "10.1176/ajp.2006.163.9.1588", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.582Z" }, { "id": "a2f21030-1b11-4652-84f8-e893483c6791", "pmid": "16946185", "title": "Association of a triallelic serotonin transporter gene promoter region (5-HTTLPR) polymorphism with stressful life events and severity of depression.", "imported": false, "abstract": "OBJECTIVE: The lower expressing allele of the serotonin transporter gene 5' promoter region (5-HTTLPR) polymorphism is reported to be associated with susceptibility to depression and suicidality in response to stressful life events. The authors examined the relationship of a triallelic 5-HTTLPR polymorphism to stressful life events, severity of major depression, and suicidality.\n\nMETHOD: Mood disorder subjects (N=191) and healthy volunteers (N=125), all Caucasian subjects of European origin, were genotyped for the triallelic 5-HTTLPR polymorphism (higher expressing allele: L(A); lower expressing alleles: L(G), S). All subjects underwent structured clinical interviews to determine DSM-IV diagnoses, ratings of psychopathology, stressful life events, developmental history, and suicidal behavior. CSF 5-HIAA was assayed in a subgroup of subjects.\n\nRESULTS: Lower expressing alleles independently predicted greater depression severity and predicted greater severity of major depression with moderate to severe life events compared with the higher expressing L(A) allele. No associations with suicidal behavior and CSF 5-HIAA were found.\n\nCONCLUSIONS: Lower expressing transporter alleles, directly and by increasing the impact of stressful life events on severity, explain 31% of the variance in major depression severity. The biological phenotype responsible for these effects remains to be elucidated.", "journal": "The American journal of psychiatry", "year": "2006", "authors": "Zalsman G, Huang YY, Oquendo MA, Burke AK, Hu XZ, Brent DA, Ellis SP, Goldman D, Mann JJ", "articleTypes": [ "Comparative Study", "Journal Article", "Research Support, N.I.H., Extramural" ], "doi": "10.1176/ajp.2006.163.9.1588", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR 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"authors": "Klimcakova E, Polak J, Moro C, Hejnova J, Majercik M, Viguerie N, Berlan M, Langin D, Stich V.", "articleTypes": [], "doi": "10.1210/jc.2006-0382", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.744Z" }, { "id": "ef0c491a-b693-451c-95aa-9e2f756e9186", "pmid": "16968804", "title": "Dynamic strength training improves insulin sensitivity without altering plasma levels and gene expression of adipokines in subcutaneous adipose tissue in obese men", "imported": false, "abstract": "", "journal": "", "year": "2006", "authors": "Klimcakova E, Polak J, Moro C, Hejnova J, Majercik M, Viguerie N, Berlan M, Langin D, Stich V.", "articleTypes": [], "doi": "10.1210/jc.2006-0382", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.388Z" }, { "id": "fd3ba66d-e596-4db7-ad57-a62c2783e07f", "pmid": "16968804", "title": "Dynamic strength training improves insulin sensitivity without altering plasma levels and gene expression of adipokines in subcutaneous adipose tissue in obese men", "imported": false, "abstract": "", "journal": "", "year": "2006", "authors": "Klimcakova E, Polak J, Moro C, Hejnova J, Majercik M, Viguerie N, Berlan M, Langin D, Stich V.", "articleTypes": [], "doi": "10.1210/jc.2006-0382", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.866Z" }, { "id": "06f8df90-24bb-4b48-8025-f192760c07a9", "pmid": "16969272", "title": "Serotonin transporter gene promoter (5-HTTLPR) and intron 2 (VNTR) polymorphisms: a study on Slovenian population of suicide victims.", "imported": false, "abstract": "Several studies have been carried out to investigate how genetic variants of gene encoding for the serotonin transporter (5-HTT) may confer susceptibility to suicide. It was demonstrated that polymorphisms in the promoter region (5-HTTLPR) and in the second intron (VNTR) have functional consequences and are for this reason of particular interest in relation to various psychiatric disorders. In our study, we analyzed 5-HTTLPR and VNTR polymorphisms in 235 suicide victims and 233 controls in a Slovenian population to find a possible association of the polymorphisms and suicidal behavior. No statistically important differences between genotypes of controls and suicide group (5-HTTLPR: Pearson's chi2=1.597, df=2, P=0.455; VNTR: Pearson's chi=1.961, df=4, P=0.744), as well as no differences in allele distribution (5-HTTLPR: Pearson's chi2=0.598, df=1, P=0.467; VNTR: Pearson's chi2=0.837, df=2, P=0.654) were found, although a slightly higher frequency of LL genotype and of L allele was observed in the suicide group. Haplotype frequency analysis showed no excess of particular haplotypes between the two groups. Our study showed no association of serotonin transporter polymorphisms and suicide. The study, however, was performed on a population with a very high suicide rate (27.1 victims/100,000 citizens) and the role of 5-HTTLPR polymorphisms may be different in other populations.", "journal": "Psychiatric genetics", "year": "2006", "authors": "Pungercic G, Videtic A, Pestotnik A, Pajnic IZ, Zupanc T, Balazic J, Tomori M, Komel R", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1097/01.ypg.0000218617.65633.9e", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.582Z" }, { "id": "654c8f72-dfed-4d56-8afa-d8dc4be49909", "pmid": "16969272", "title": "Serotonin transporter gene promoter (5-HTTLPR) and intron 2 (VNTR) polymorphisms: a study on Slovenian population of suicide victims.", "imported": false, "abstract": "Several studies have been carried out to investigate how genetic variants of gene encoding for the serotonin transporter (5-HTT) may confer susceptibility to suicide. 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Studies have shown association between the serotonin transporter (5-HTT) gene and suicidal behavior, although a proportion of alternative studies have produced contrary results both in terms of positive and negative findings, possibly reflecting inadequate statistical power and the use of different populations. Using the cumulative data from recent years in both European and, more particularly, Asian populations, this updated meta-analysis seeks to examine whether the aggregate data provide evidence of statistical significance, and to clarify the contradictory findings suggested by previous studies. It covers all published studies using multiple research methods up to January 2006. Compared with a previous meta-analysis, which found no association between the 5-HTTLPR polymorphism and suicidal behavior (P=0.38), the current results (39 studies) suggest a significant association with a P-value of 0.0068 (overall odds ratio=0.88 (0.8,0.97)), and supports the involvement of the brain 5-HTT in the pathogenesis of suicidal behavior.", "journal": "Molecular psychiatry", "year": "2007", "authors": "Li D, He L", "articleTypes": [ "Journal Article", "Meta-Analysis", "Research Support, Non-U.S. Gov't" ], "doi": "10.1038/sj.mp.4001890", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] 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Further investigations of this gene in different phenotypic groups are necessary.", "journal": "Neuropsychobiology", "year": "2006", "authors": "Gaysina D, Zainullina A, Gabdulhakov R, Khusnutdinova E", "articleTypes": [ "Comparative Study", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1159/000096041", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:40.911Z" }, { "id": "a81375e0-9a58-4d32-846a-946a2020bd6c", "pmid": "17028448", "title": "The serotonin transporter gene: polymorphism and haplotype analysis in Russian suicide attempters.", "imported": false, "abstract": "The focus on gender-specific genes associated with female suicide is justified by the possible dimorphic nature of the serotonergic system and by the greater number of suicide attempts in females. We performed analysis of the promoter (5-HTTLPR) and intron 2 (STin2 VNTR) polymorphisms and haplotypes of the serotonin transporter gene in Russian suicide attempters, separately in men and women. Our findings indicate the contribution of the SLC6A4 gene to susceptibility for suicidal behavior in women, but not in men. The L/L genotype (p = 0.013, OR = 2.09) and L10 haplotype (p = 0.04, OR = 1.77) were associated with suicide in Russian women only. Further investigations of this gene in different phenotypic groups are necessary.", "journal": "Neuropsychobiology", "year": "2006", "authors": "Gaysina D, Zainullina A, Gabdulhakov R, Khusnutdinova E", "articleTypes": [ "Comparative Study", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1159/000096041", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 100, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:09.856Z" }, { "id": "18a63de9-8c2b-4a06-a9c5-34a9e6ef6f27", "pmid": "17029913", "title": "Association of the serotonin transporter promotor polymorphism with suicide attempters with a high medical damage.", "imported": false, "abstract": "Serotonergic neurotransmission has been implicated in suicidal behavior, including inconsistent results concerning the serotonin transporter promoter polymorphism (5-HTTLPR). Here, we analyzed the 5-HTTLPR in suicide attempters (n=85). Comparing the presence of SS with SL+LL genotypes showed a significantly higher prevalence of the SS genotype in suicide attempters with high medical damage scores (chi2=9.054, df=1, p=0.0026). The results suggest that the S-allele may predispose for suicidal behavior characterized by high determination.", "journal": "European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology", "year": "2007", "authors": "Wasserman D, Geijer T, Sokolowski M, Frisch A, Michaelovsky E, Weizman A, Rozanov V, Wasserman J", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.euroneuro.2006.08.006", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.641Z" }, { "id": "aaacc12b-a37a-4671-afa7-a93ee85b619b", "pmid": "17029913", "title": "Association of the serotonin transporter promotor polymorphism with suicide attempters with a high medical damage.", "imported": false, "abstract": "Serotonergic neurotransmission has been implicated in suicidal behavior, including inconsistent results concerning the serotonin transporter promoter polymorphism (5-HTTLPR). Here, we analyzed the 5-HTTLPR in suicide attempters (n=85). Comparing the presence of SS with SL+LL genotypes showed a significantly higher prevalence of the SS genotype in suicide attempters with high medical damage scores (chi2=9.054, df=1, p=0.0026). The results suggest that the S-allele may predispose for suicidal behavior characterized by high determination.", "journal": "European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology", "year": "2007", "authors": "Wasserman D, Geijer T, Sokolowski M, Frisch A, Michaelovsky E, Weizman A, Rozanov V, Wasserman J", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.euroneuro.2006.08.006", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.176Z" }, { "id": "e4a57d24-d46a-4661-ab1b-637319112543", "pmid": "17029913", "title": "Association of the serotonin transporter promotor polymorphism with suicide attempters with a high medical damage.", "imported": false, "abstract": "Serotonergic neurotransmission has been implicated in suicidal behavior, including inconsistent results concerning the serotonin transporter promoter polymorphism (5-HTTLPR). Here, we analyzed the 5-HTTLPR in suicide attempters (n=85). Comparing the presence of SS with SL+LL genotypes showed a significantly higher prevalence of the SS genotype in suicide attempters with high medical damage scores (chi2=9.054, df=1, p=0.0026). The results suggest that the S-allele may predispose for suicidal behavior characterized by high determination.", "journal": "European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology", "year": "2007", "authors": "Wasserman D, Geijer T, Sokolowski M, Frisch A, Michaelovsky E, Weizman A, Rozanov V, Wasserman J", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.euroneuro.2006.08.006", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR 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Recently, a third functional allele of 5-HTTLPR was discovered enabling more of the interindividual variation in serotonin transporter expression to be predicted by genotype. We examined whether the 5-HTTLPR gene alone, or interacting with childhood trauma, was predictive of suicidal behavior in substance-dependent patients, a clinical population that is at high risk of suicide, as well as childhood trauma and other stress. We interviewed 306 abstinent male African-American substance-dependent patients about whether they had ever attempted suicide and administered the 34-item Childhood Trauma Questionnaire (CTQ). Patients and 132 male African-American controls were genotyped to determine the S, L(G), and L(A) 5-HTTLPR alleles; some analyses grouped the S and L(G) alleles on the basis of equivalent function. The distribution of 5-HTTLPR genotypes did not differ between patients and controls, nor between suicide attempters and non-attempters. However, patients with low expression 5-HTTLPR genotypes and above-median CTQ scores were more likely to have attempted suicide. Logistic regression showed increasing risk of a suicide attempt with increasing reports of childhood trauma scores; in addition, this increase was exaggerated among those with low expression forms of the 5-HTTLPR genotype. 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Recently, a third functional allele of 5-HTTLPR was discovered enabling more of the interindividual variation in serotonin transporter expression to be predicted by genotype. We examined whether the 5-HTTLPR gene alone, or interacting with childhood trauma, was predictive of suicidal behavior in substance-dependent patients, a clinical population that is at high risk of suicide, as well as childhood trauma and other stress. We interviewed 306 abstinent male African-American substance-dependent patients about whether they had ever attempted suicide and administered the 34-item Childhood Trauma Questionnaire (CTQ). Patients and 132 male African-American controls were genotyped to determine the S, L(G), and L(A) 5-HTTLPR alleles; some analyses grouped the S and L(G) alleles on the basis of equivalent function. The distribution of 5-HTTLPR genotypes did not differ between patients and controls, nor between suicide attempters and non-attempters. However, patients with low expression 5-HTTLPR genotypes and above-median CTQ scores were more likely to have attempted suicide. Logistic regression showed increasing risk of a suicide attempt with increasing reports of childhood trauma scores; in addition, this increase was exaggerated among those with low expression forms of the 5-HTTLPR genotype. Childhood trauma interacts with low expressing 5-HTTLPR genotypes to increase the risk of suicidal behavior among patients with substance dependence.", "journal": "Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology", "year": "2007", "authors": "Roy A, Hu XZ, Janal MN, Goldman D", "articleTypes": [ "Journal Article" ], "doi": "10.1038/sj.npp.1301331", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] 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Methamphetamine (MAP) abusers are commonly noted as having psychosis, depression and suicidal behavior. The goals of the present study were (i) to investigate relations of clinical correlates, such as gender, drug use behavior, psychiatric comorbidity and psychiatry family history, with suicidal behavior among Chinese MAP abusers; and (ii) to investigate whether there is an association between a polymorphism in the promotor region of the serotonin transporter gene (5-HTTLPR) and suicidal behavior among Chinese MAP abusers. A total of 439 MAP abusers from a hospital and detention center in Taipei were interviewed with the Diagnostic Interview for Genetic Study and the Family Interview for Genetic Study. The 5-HTTLPR polymorphism was compared between 94 MAP abusers with suicide attempts and 294 MAP abusers without suicide attempts, for whom DNA data were available. The results of the present study indicate that among MAP abusers in Taiwan, suicide attempts were significantly related to female gender, history of MAP-induced psychotic disorder, history of MAP-induced depressive disorder, and family history of psychotic disorders. Among suicide attempters, the attempters with moderate to severe lethality used higher MAP doses than those with minimal to mild lethality. In the present sample the triallelic 5-HTTLPR polymorphism (S, L(G), L(A)) was not associated with MAP-induced depressive disorder, MAP-induced psychotic disorder or suicidal behavior, but studies with larger sample sizes are warranted before excluding the role of the 5-HTTLPR polymorphisms in suicidal behavior among MAP abusers.", "journal": "Psychiatry and clinical neurosciences", "year": "2007", "authors": "Chen CK, Lin SK, Huang MC, Su LW, Hsiao CC, Chiang YL, Ree SC, Chiang SC, Liu HC", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/j.1440-1819.2007.01696.x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.582Z" }, { "id": "aee581fa-da85-4d3c-bca5-c0c175366a1f", "pmid": "17875025", "title": "Analysis of association of clinical correlates and 5-HTTLPR polymorphism with suicidal behavior among Chinese methamphetamine abusers.", "imported": false, "abstract": "Substance use disorders are familial, and genetic factors explain a substantial degree of their familial aggregation. 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The results of the present study indicate that among MAP abusers in Taiwan, suicide attempts were significantly related to female gender, history of MAP-induced psychotic disorder, history of MAP-induced depressive disorder, and family history of psychotic disorders. Among suicide attempters, the attempters with moderate to severe lethality used higher MAP doses than those with minimal to mild lethality. In the present sample the triallelic 5-HTTLPR polymorphism (S, L(G), L(A)) was not associated with MAP-induced depressive disorder, MAP-induced psychotic disorder or suicidal behavior, but studies with larger sample sizes are warranted before excluding the role of the 5-HTTLPR polymorphisms in suicidal behavior among MAP abusers.", "journal": "Psychiatry and clinical neurosciences", "year": "2007", "authors": "Chen CK, Lin SK, Huang MC, Su LW, Hsiao CC, Chiang YL, Ree SC, Chiang SC, Liu HC", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/j.1440-1819.2007.01696.x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.641Z" }, { "id": "d24f9679-157d-4144-88cf-1e3f3e9e35e1", "pmid": "17875025", "title": "Analysis of association of clinical correlates and 5-HTTLPR polymorphism with suicidal behavior among Chinese methamphetamine abusers.", "imported": false, "abstract": "Substance use disorders are familial, and genetic factors explain a substantial degree of their familial aggregation. Methamphetamine (MAP) abusers are commonly noted as having psychosis, depression and suicidal behavior. The goals of the present study were (i) to investigate relations of clinical correlates, such as gender, drug use behavior, psychiatric comorbidity and psychiatry family history, with suicidal behavior among Chinese MAP abusers; and (ii) to investigate whether there is an association between a polymorphism in the promotor region of the serotonin transporter gene (5-HTTLPR) and suicidal behavior among Chinese MAP abusers. A total of 439 MAP abusers from a hospital and detention center in Taipei were interviewed with the Diagnostic Interview for Genetic Study and the Family Interview for Genetic Study. The 5-HTTLPR polymorphism was compared between 94 MAP abusers with suicide attempts and 294 MAP abusers without suicide attempts, for whom DNA data were available. The results of the present study indicate that among MAP abusers in Taiwan, suicide attempts were significantly related to female gender, history of MAP-induced psychotic disorder, history of MAP-induced depressive disorder, and family history of psychotic disorders. Among suicide attempters, the attempters with moderate to severe lethality used higher MAP doses than those with minimal to mild lethality. In the present sample the triallelic 5-HTTLPR polymorphism (S, L(G), L(A)) was not associated with MAP-induced depressive disorder, MAP-induced psychotic disorder or suicidal behavior, but studies with larger sample sizes are warranted before excluding the role of the 5-HTTLPR polymorphisms in suicidal behavior among MAP abusers.", "journal": "Psychiatry and clinical neurosciences", "year": "2007", "authors": "Chen CK, Lin SK, Huang MC, Su LW, Hsiao CC, Chiang YL, Ree SC, Chiang SC, Liu HC", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/j.1440-1819.2007.01696.x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR 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"year": "2007", "authors": "Liu CL, Chang YC, Cheng SP, Chern SR, Yang TL, Lee JJ, Guo IC, Chen CP.", "articleTypes": [], "doi": "10.1159/000111097", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.402Z" }, { "id": "c0f54c8c-2512-47e0-b6d1-efe19f1449bd", "pmid": "18004080", "title": "The roles of serum leptin concentration and polymorphism in leptin receptor gene at codon 109 in breast cancer", "imported": false, "abstract": "", "journal": "", "year": "2007", "authors": "Liu CL, Chang YC, Cheng SP, Chern SR, Yang TL, Lee JJ, Guo IC, Chen CP.", "articleTypes": [], "doi": "10.1159/000111097", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.758Z" }, { "id": "52d3a9c8-0b04-496c-b348-0175a5ff4981", "pmid": "18004675", "title": "Association between the serotonin transporter gene and personality traits in borderline personality disorder patients evaluated with Zuckerman-Zuhlman Personality Questionnaire (ZKPQ).", "imported": false, "abstract": "INTRODUCTION: The serotoninergic system seems to be implicated in characteristic symptoms of borderline personality disorder (BPD) such as affective instability, impulsivity or suicide. Some studies suggest an association between serotonin transporter gene (5-HTT) polymorphisms and some BPD symptoms. Short allele (S) of the 5-HTTLPR polymorphism in the promoter region has been shown to be associated with impulsivity, aggressive behavior, anxiety and neuroticism. Of the variable number of tandem repeat (VNTR) polymorphism in intron 2, BPD patients showed higher frequencies of the allele with the 10 repeats. The aim of this study was to determine the association between 5- HTTLPR and VNTR polymorphism of 5-HTT and personality traits in borderline personality disorder.\n\nMETHOD: A total of 65 BPD patients diagnosed by means of semi-structured interviews SCID-II and DIB-R were included. Two common polymorphisms of 5-HTT were genotyped: the 5-HTTLPR in the promoter region and VNTR in intron 2. Personality traits were assessed by the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ).\n\nRESULTS: Patients with L allele (L/S or L/L) in the 5-HTTLPR polymorphism showed lower scores on the subscale of liking parties and friends. Patients with the allele with 10 repeat of the VNTR polymorphism, showed lower scores in impulsivity, sensation seeking and in the subscale liking of parties and friends.\n\nCONCLUSIONS: The results suggest a significant association between the 5-HTT gene and some personality traits in BPD. This gene may play a role in the etiology of borderline personality disorder.", "journal": "Actas espanolas de psiquiatria", "year": "2007", "authors": "Pascual JC, Soler J, Baiget M, Cortés A, Menoyo A, Barrachina J, Ropero M, Gomà M, Alvarez E, Perez V", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Validation Study" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.175Z" }, { "id": "a7b6e12f-b3d6-4ab1-9173-de973a59a3de", "pmid": "18004675", "title": "Association between the serotonin transporter gene and personality traits in borderline personality disorder patients evaluated with Zuckerman-Zuhlman Personality Questionnaire (ZKPQ).", "imported": false, "abstract": "INTRODUCTION: The serotoninergic system seems to be implicated in characteristic symptoms of borderline personality disorder (BPD) such as affective instability, impulsivity or suicide. Some studies suggest an association between serotonin transporter gene (5-HTT) polymorphisms and some BPD symptoms. Short allele (S) of the 5-HTTLPR polymorphism in the promoter region has been shown to be associated with impulsivity, aggressive behavior, anxiety and neuroticism. Of the variable number of tandem repeat (VNTR) polymorphism in intron 2, BPD patients showed higher frequencies of the allele with the 10 repeats. The aim of this study was to determine the association between 5- HTTLPR and VNTR polymorphism of 5-HTT and personality traits in borderline personality disorder.\n\nMETHOD: A total of 65 BPD patients diagnosed by means of semi-structured interviews SCID-II and DIB-R were included. Two common polymorphisms of 5-HTT were genotyped: the 5-HTTLPR in the promoter region and VNTR in intron 2. Personality traits were assessed by the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ).\n\nRESULTS: Patients with L allele (L/S or L/L) in the 5-HTTLPR polymorphism showed lower scores on the subscale of liking parties and friends. Patients with the allele with 10 repeat of the VNTR polymorphism, showed lower scores in impulsivity, sensation seeking and in the subscale liking of parties and friends.\n\nCONCLUSIONS: The results suggest a significant association between the 5-HTT gene and some personality traits in BPD. This gene may play a role in the etiology of borderline personality disorder.", "journal": "Actas espanolas de psiquiatria", "year": "2007", "authors": "Pascual JC, Soler J, Baiget M, Cortés A, Menoyo A, Barrachina J, Ropero M, Gomà M, Alvarez E, Perez V", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Validation Study" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.641Z" }, { "id": "ab179a71-b306-4e2d-a3d6-588d7310289c", "pmid": "18004675", "title": "Association between the serotonin transporter gene and personality traits in borderline personality disorder patients evaluated with Zuckerman-Zuhlman Personality Questionnaire (ZKPQ).", "imported": false, "abstract": "INTRODUCTION: The serotoninergic system seems to be implicated in characteristic symptoms of borderline personality disorder (BPD) such as affective instability, impulsivity or suicide. Some studies suggest an association between serotonin transporter gene (5-HTT) polymorphisms and some BPD symptoms. Short allele (S) of the 5-HTTLPR polymorphism in the promoter region has been shown to be associated with impulsivity, aggressive behavior, anxiety and neuroticism. Of the variable number of tandem repeat (VNTR) polymorphism in intron 2, BPD patients showed higher frequencies of the allele with the 10 repeats. The aim of this study was to determine the association between 5- HTTLPR and VNTR polymorphism of 5-HTT and personality traits in borderline personality disorder.\n\nMETHOD: A total of 65 BPD patients diagnosed by means of semi-structured interviews SCID-II and DIB-R were included. Two common polymorphisms of 5-HTT were genotyped: the 5-HTTLPR in the promoter region and VNTR in intron 2. Personality traits were assessed by the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ).\n\nRESULTS: Patients with L allele (L/S or L/L) in the 5-HTTLPR polymorphism showed lower scores on the subscale of liking parties and friends. Patients with the allele with 10 repeat of the VNTR polymorphism, showed lower scores in impulsivity, sensation seeking and in the subscale liking of parties and friends.\n\nCONCLUSIONS: The results suggest a significant association between the 5-HTT gene and some personality traits in BPD. This gene may play a role in the etiology of borderline personality disorder.", "journal": "Actas espanolas de psiquiatria", "year": "2007", "authors": "Pascual JC, Soler J, Baiget M, Cortés A, Menoyo A, Barrachina J, Ropero M, Gomà M, Alvarez E, Perez V", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Validation Study" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.581Z" }, { "id": "108c1d4c-d734-4dee-9172-c2d2e78c0fba", "pmid": "18006469", "title": "Leptin signalling reduces the severity of cardiac dysfunction and remodelling after chronic ischaemic injury", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "McGaffin KR, Sun CK, Rager JJ, Romano LC, Zou B, Mathier MA, O'Doherty RM, McTiernan CF, O'Donnell CP.", "articleTypes": [], "doi": "10.1093/cvr/cvm023", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.770Z" }, { "id": "66e5174b-e06b-4919-80c9-78b98f811177", "pmid": "18006469", "title": "Leptin signalling reduces the severity of cardiac dysfunction and remodelling after chronic ischaemic injury", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "McGaffin KR, Sun CK, Rager JJ, Romano LC, Zou B, Mathier MA, O'Doherty RM, McTiernan CF, O'Donnell CP.", "articleTypes": [], "doi": "10.1093/cvr/cvm023", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.383Z" }, { "id": "8f8e5caf-c8ac-4fa9-8007-27a05e7d293c", "pmid": "18006469", "title": "Leptin signalling reduces the severity of cardiac dysfunction and remodelling after chronic ischaemic injury", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "McGaffin KR, Sun CK, Rager JJ, Romano LC, Zou B, Mathier MA, O'Doherty RM, McTiernan CF, O'Donnell CP.", "articleTypes": [], "doi": "10.1093/cvr/cvm023", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.891Z" }, { "id": "c3ce0323-9cc7-47b5-b9c9-fcaab3ad1680", "pmid": "18006469", "title": "Leptin signalling reduces the severity of cardiac dysfunction and remodelling after chronic 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Data suggest that polymorphisms in SLC6A4 may influence the expression of the brain serotonin transporter in suicide attempters.", "journal": "Psychiatry research", "year": "2008", "authors": "Bah J, Lindström M, Westberg L, Mannerås L, Ryding E, Henningsson S, Melke J, Rosén I, Träskman-Bendz L, Eriksson E", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.pscychresns.2007.07.004", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.640Z" }, { "id": "e89682fa-51ec-4d3e-bb64-cb1ff02dbbfc", "pmid": "18314311", "title": "Serotonin transporter gene polymorphisms: effect on serotonin transporter availability in the brain of suicide attempters.", "imported": false, "abstract": "The efficacy of serotonin reuptake inhibitors in depression and anxiety disorders suggests the gene coding for the serotonin transporter (5-HTT), SLC6A4, as a candidate of importance for these conditions. Positive findings regarding associations between polymorphisms in SLC6A4 have been reported, indicating that these polymorphisms may influence anxiety-related personality traits, as well as the risk of developing depression and suicidality. Serotonin 5-HTT availability was assessed with single photon emission computed tomography (SPECT), using (123)I-beta-CIT as ligand, in a population of unmedicated male suicide attempters (n=9) and in matched controls (n=9). Two polymorphisms in SLC6A4 were assessed, including the 5-HTTLPR located in the promoter region and a variable number of tandem repeats (VNTR) polymorphism in intron 2 (STin2). In suicide attempters, but not in controls, low 5-HTT availability was associated with the S allele of 5-HTTLPR and with the 12 repeat allele of STin2. Data suggest that polymorphisms in SLC6A4 may influence the expression of the brain serotonin transporter in suicide attempters.", "journal": "Psychiatry research", "year": "2008", "authors": "Bah J, Lindström M, Westberg L, Mannerås L, Ryding E, Henningsson S, Melke J, Rosén I, Träskman-Bendz L, Eriksson E", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.pscychresns.2007.07.004", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.581Z" }, { "id": "0515f36b-af1d-46a7-aeeb-84e11844beaf", "pmid": "18315446", "title": "Serotonin transporter polymorphism (5-HTTLPR) and citalopram effectiveness and side effects in children with depression and/or anxiety disorders.", "imported": false, "abstract": "OBJECTIVE: The aim of this study was to examine the association between polymorphism in the serotonin transporter gene and citalopram effectiveness and side effects in children and adolescents with major depressive disorder (MDD) and/or anxiety disorders.\n\nMETHODS: Outpatients, aged 7- 18 years with a Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) MDD and/or anxiety disorder were treated in an 8-week open trial with 20-40 mg/day of citalopram. Subjects were genotyped with respect to short (s) versus long (l) forms of the 5-HTTLPR polymorphism of the serotonin transporter, and the relationship between genotype and outcome and side effects was assessed.\n\nRESULTS: Subjects with 5-HTTLPR ss genotype showed a less vigorous response with regard to depressive symptoms measured by the Children's Depression Rating Scale-Revised (CDRS-R) scores over time compared to subjects with sl/ll genotypes (beta = 0.67, z = 2.02, p = 0.04). In addition, the 5-HTTLPR ss group exhibited lower rates of agitation compared to those with sl/ll genotype (6.3% vs. 32.8%, p = 0.05). Also, subjects with 5-HTTLPR ss genotype had consistently higher scores of suicidality at each week compared to the sl/ll group (beta = 0.76, z = 2.04, p = 0.04) as measured by item number 13 of the CDRS-R.\n\nCONCLUSIONS: The 5-HTTLPR ss genotype was associated with a poorer clinical response with regard to depressive symptoms as well with fewer reports of agitation. The 5-HTTLPR polymorphism may be a genetic marker of response to citalopram in children and adolescents with depression and/or anxiety.", "journal": "Journal of child and adolescent psychopharmacology", "year": "2007", "authors": "Kronenberg S, Apter A, Brent D, Schirman S, Melhem N, Pick N, Gothelf D, Carmel M, Frisch A, Weizman A", "articleTypes": [ "Clinical Trial", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1089/cap.2006.0144", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.641Z" }, { "id": "1aa36ea2-bef4-49fe-890b-34f486d12116", "pmid": "18315446", "title": "Serotonin transporter polymorphism (5-HTTLPR) and citalopram effectiveness and side effects in children with depression and/or anxiety disorders.", "imported": false, "abstract": "OBJECTIVE: The aim of this study was to examine the association between polymorphism in the serotonin transporter gene and citalopram effectiveness and side effects in children and adolescents with major depressive disorder (MDD) and/or anxiety disorders.\n\nMETHODS: Outpatients, aged 7- 18 years with a Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) MDD and/or anxiety disorder were treated in an 8-week open trial with 20-40 mg/day of citalopram. Subjects were genotyped with respect to short (s) versus long (l) forms of the 5-HTTLPR polymorphism of the serotonin transporter, and the relationship between genotype and outcome and side effects was assessed.\n\nRESULTS: Subjects with 5-HTTLPR ss genotype showed a less vigorous response with regard to depressive symptoms measured by the Children's Depression Rating Scale-Revised (CDRS-R) scores over time compared to subjects with sl/ll genotypes (beta = 0.67, z = 2.02, p = 0.04). In addition, the 5-HTTLPR ss group exhibited lower rates of agitation compared to those with sl/ll genotype (6.3% vs. 32.8%, p = 0.05). Also, subjects with 5-HTTLPR ss genotype had consistently higher scores of suicidality at each week compared to the sl/ll group (beta = 0.76, z = 2.04, p = 0.04) as measured by item number 13 of the CDRS-R.\n\nCONCLUSIONS: The 5-HTTLPR ss genotype was associated with a poorer clinical response with regard to depressive symptoms as well with fewer reports of agitation. The 5-HTTLPR polymorphism may be a genetic marker of response to citalopram in children and adolescents with depression and/or anxiety.", "journal": "Journal of child and adolescent psychopharmacology", "year": "2007", "authors": "Kronenberg S, Apter A, Brent D, Schirman S, Melhem N, Pick N, Gothelf D, Carmel M, Frisch A, Weizman A", "articleTypes": [ "Clinical Trial", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1089/cap.2006.0144", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.175Z" }, { "id": "dca475c9-561f-4b7e-9e99-49fcb2936cf7", "pmid": "18315446", "title": "Serotonin transporter polymorphism (5-HTTLPR) and citalopram effectiveness and side effects in children with depression and/or anxiety disorders.", "imported": false, "abstract": "OBJECTIVE: The aim of this study was to examine the association between polymorphism in the serotonin transporter gene and citalopram effectiveness and side effects in children and adolescents with major depressive disorder (MDD) and/or anxiety disorders.\n\nMETHODS: Outpatients, aged 7- 18 years with a Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) MDD and/or anxiety disorder were treated in an 8-week open trial with 20-40 mg/day of citalopram. Subjects were genotyped with respect to short (s) versus long (l) forms of the 5-HTTLPR polymorphism of the serotonin transporter, and the relationship between genotype and outcome and side effects was assessed.\n\nRESULTS: Subjects with 5-HTTLPR ss genotype showed a less vigorous response with regard to depressive symptoms measured by the Children's Depression Rating Scale-Revised (CDRS-R) scores over time compared to subjects with sl/ll genotypes (beta = 0.67, z = 2.02, p = 0.04). In addition, the 5-HTTLPR ss group exhibited lower rates of agitation compared to those with sl/ll genotype (6.3% vs. 32.8%, p = 0.05). Also, subjects with 5-HTTLPR ss genotype had consistently higher scores of suicidality at each week compared to the sl/ll group (beta = 0.76, z = 2.04, p = 0.04) as measured by item number 13 of the CDRS-R.\n\nCONCLUSIONS: The 5-HTTLPR ss genotype was associated with a poorer clinical response with regard to depressive symptoms as well with fewer reports of agitation. The 5-HTTLPR polymorphism may be a genetic marker of response to citalopram in children and adolescents with depression and/or anxiety.", "journal": "Journal of child and adolescent psychopharmacology", "year": "2007", "authors": "Kronenberg S, Apter A, Brent D, Schirman S, Melhem N, Pick N, Gothelf D, Carmel M, Frisch A, Weizman A", "articleTypes": [ "Clinical Trial", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1089/cap.2006.0144", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.581Z" }, { "id": "56f3903d-046f-48c1-9a7e-04abac7ccbfd", "pmid": "18316358", "title": "Genetic variants of FTO influence adiposity, insulin sensitivity, leptin levels, and resting metabolic rate in the Quebec Family Study", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Do R, Bailey SD, Desbiens K, Belisle A, Montpetit A, Bouchard C, Pérusse L, Vohl MC, Engert JC.", "articleTypes": [], "doi": "10.2337/db07-1267", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.407Z" }, { "id": "5d1bbb20-10c9-44ee-b4b3-4bdadb4d9e3a", "pmid": "18316358", "title": "Genetic variants of FTO influence adiposity, insulin sensitivity, leptin levels, and resting metabolic rate in the Quebec Family Study", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Do R, Bailey SD, Desbiens K, Belisle A, Montpetit A, Bouchard C, Pérusse L, Vohl MC, Engert JC.", "articleTypes": [], "doi": "10.2337/db07-1267", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.762Z" }, { "id": "83ed72a3-a4ad-4134-ac8b-2df111c30dc4", "pmid": "18316358", "title": "Genetic variants of FTO influence adiposity, insulin sensitivity, leptin levels, and resting metabolic rate in the Quebec Family Study", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Do R, Bailey SD, Desbiens K, Belisle A, Montpetit A, Bouchard C, Pérusse L, Vohl MC, Engert JC.", "articleTypes": [], "doi": "10.2337/db07-1267", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.883Z" }, { "id": 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In BPD patients, the genotype COMT Met(158)Met was over-represented compared to healthy controls (P = 0.0085; adjusted P = 0.034). We observed no differences in 5-HTTLPR genotypes between BPD and controls (P = 0.286). Additionally, the COMT Met(158)Met genotype was significantly over-represented in BPD patients carrying at least one 5-HTTLPR S allele (P = 0.0007; adjusted P = 0.028). Logistic regression analysis confirmed an interaction of the COMT Met(158) and the 5-HTTLPR S allele (P = 0.001). These data suggest an involvement of altered dopaminergic and/or noradrenergic neurotransmission as well as an interactive effect of COMT and 5-HTTLPR gene variants in the etiology of BPD, and underline the usefulness of analyses of gene-gene effects in diseases of complex inheritance with multiple genes involved.", "journal": "American journal of medical genetics. 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BPD patients display repeated self-injury, chronic suicidal tendencies and emotional dysregulation, mainly dysregulation of negative affect. In its etiology, genetic and environmental factors have been suggested. Recently, an investigation in male healthy volunteers found gene-gene effects of the catechol-O-methyl-transferase (COMT) low-activity (Met(158)) and the low-expression allele of the deletion/insertion (short/long or S/L, respectively) polymorphism in the serotonin transporter-linked promoter region (5-HTTLPR) on the central processing of aversive stimuli. The purpose of the present study was to test for association between BPD and the COMT Val(158)Met single nucleotide polymorphism (SNP), the 5-HTTLPR S/L variant and the interaction of these two gene variants. One hundred sixty one well-defined Caucasian BPD patients and 156 healthy controls were recruited from central Germany. In BPD patients, the genotype COMT Met(158)Met was over-represented compared to healthy controls (P = 0.0085; adjusted P = 0.034). We observed no differences in 5-HTTLPR genotypes between BPD and controls (P = 0.286). Additionally, the COMT Met(158)Met genotype was significantly over-represented in BPD patients carrying at least one 5-HTTLPR S allele (P = 0.0007; adjusted P = 0.028). Logistic regression analysis confirmed an interaction of the COMT Met(158) and the 5-HTTLPR S allele (P = 0.001). These data suggest an involvement of altered dopaminergic and/or noradrenergic neurotransmission as well as an interactive effect of COMT and 5-HTTLPR gene variants in the etiology of BPD, and underline the usefulness of analyses of gene-gene effects in diseases of complex inheritance with multiple genes involved.", "journal": "American journal of medical genetics. 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FR, Bermudez-Silva FJ, McPartland JM.", "articleTypes": [], "doi": "10.2174/187153008785700082", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.445Z" }, { "id": "a2befcae-aca8-4d83-a01a-28208d8b466d", "pmid": "18782018", "title": "Critical role of the endocannabinoid system in the regulation of food intake and energy metabolism, with phylogenetic, developmental, and pathophysiological implications", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Viveros MP, de Fonseca FR, Bermudez-Silva FJ, McPartland JM.", "articleTypes": [], "doi": "10.2174/187153008785700082", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.916Z" }, { "id": "edb043f5-0beb-46cf-84d5-6d7063392f4e", "pmid": "18782018", "title": "Critical role of the endocannabinoid system in the regulation of food intake and energy metabolism, with phylogenetic, developmental, and pathophysiological implications", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Viveros MP, de Fonseca FR, Bermudez-Silva FJ, McPartland JM.", "articleTypes": [], "doi": "10.2174/187153008785700082", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.414Z" }, { "id": "35cf7181-ec54-4404-8e64-e0611854b648", "pmid": "18785642", "title": "Relationship between obesity, adipocytokines, and blood pressure: possible common genetic and environmental factors", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "Pantsulaia Ia, Trofimova S, Kobyliansky E, Livshits G.", "articleTypes": [], "doi": "10.1002/ajhb.20821", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.800Z" }, { "id": "7300a89a-b966-4794-bd66-1665527e937c", "pmid": "18785642", "title": "Relationship between obesity, adipocytokines, and blood pressure: possible common genetic and environmental factors", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "Pantsulaia Ia, Trofimova S, Kobyliansky E, Livshits G.", "articleTypes": [], "doi": "10.1002/ajhb.20821", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.413Z" }, { "id": "7c3aa802-e140-4a5f-ba3f-1bddd1c4f8ca", "pmid": "18785642", "title": "Relationship between obesity, adipocytokines, and blood pressure: possible common genetic and environmental factors", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "Pantsulaia Ia, Trofimova S, Kobyliansky E, Livshits G.", "articleTypes": [], "doi": "10.1002/ajhb.20821", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.445Z" }, { "id": "f8af0b82-1541-4a6a-96a5-489e54cf7e29", "pmid": "18785642", "title": "Relationship between obesity, adipocytokines, and blood pressure: possible common genetic and environmental factors", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "Pantsulaia Ia, Trofimova S, Kobyliansky E, Livshits G.", "articleTypes": [], "doi": "10.1002/ajhb.20821", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.916Z" }, { "id": "11d585b0-c7e0-4652-8031-a17c74085511", "pmid": "18787032", "title": "Up-regulation of placental leptin by human chorionic gonadotropin", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "Maymó JL, Pérez Pérez A, Sánchez-Margalet V, Dueñas JL, Calvo JC, Varone CL.", "articleTypes": [], "doi": "10.1210/en.2008-0522", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.378Z" }, { "id": "22a5a8ff-66ba-475d-ba1c-7d9fd81e175c", "pmid": "18787032", "title": "Up-regulation of placental leptin by human chorionic gonadotropin", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "Maymó JL, Pérez Pérez A, Sánchez-Margalet V, Dueñas JL, Calvo JC, Varone CL.", "articleTypes": [], "doi": "10.1210/en.2008-0522", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.766Z" }, { "id": "378c87a2-39ca-4cfa-90b6-c1a24b75e8d3", "pmid": "18787032", "title": "Up-regulation of placental leptin by human chorionic gonadotropin", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "Maymó JL, Pérez Pérez A, Sánchez-Margalet V, Dueñas JL, Calvo JC, Varone CL.", "articleTypes": [], "doi": "10.1210/en.2008-0522", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.412Z" }, { "id": "5dfa3bfd-981e-4157-aa3e-6d7be1d67dc0", "pmid": "18787032", "title": "Up-regulation of placental leptin by human chorionic gonadotropin", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "Maymó JL, Pérez Pérez A, Sánchez-Margalet V, Dueñas JL, Calvo JC, Varone CL.", "articleTypes": [], "doi": "10.1210/en.2008-0522", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.887Z" }, { "id": "1f5fbd31-9c40-48b1-83a5-f3eaf8403e21", "pmid": "18787400", "title": "Concomitant activation of the JAK/STAT3 and ERK1/2 signaling is involved in leptin-mediated proliferation of renal cell carcinoma Caki-2 cells", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Li L, Gao Y, Zhang LL, He DL.", "articleTypes": [], "doi": "10.4161/cbt.7.11.6837", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.750Z" }, { "id": "7a92bd9b-9aba-4aff-ad19-564adacb9b9a", "pmid": "18787400", "title": "Concomitant activation of the JAK/STAT3 and ERK1/2 signaling is involved in leptin-mediated proliferation of renal cell carcinoma Caki-2 cells", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Li L, Gao Y, Zhang LL, He DL.", "articleTypes": [], "doi": "10.4161/cbt.7.11.6837", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.360Z" }, { "id": "8aa0fe68-143c-4f6d-95dd-6f33efd5a5ba", "pmid": "18787400", "title": "Concomitant activation of the JAK/STAT3 and ERK1/2 signaling is involved in leptin-mediated proliferation of renal cell carcinoma Caki-2 cells", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Li L, Gao Y, Zhang LL, He DL.", "articleTypes": [], "doi": "10.4161/cbt.7.11.6837", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.872Z" }, { "id": "c2f89f45-1b72-43bf-b8b7-057d83c20d9d", "pmid": "18787400", "title": "Concomitant activation of the JAK/STAT3 and ERK1/2 signaling is involved in leptin-mediated proliferation of renal cell carcinoma Caki-2 cells", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Li L, Gao Y, Zhang LL, He DL.", "articleTypes": [], "doi": "10.4161/cbt.7.11.6837", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.394Z" }, { "id": "3898fb6e-34df-4d1d-86e8-2a0e50fe938e", "pmid": "18797395", "title": "Association between the A-1438G polymorphism of the serotonin 2A receptor gene and nonimpulsive suicide attempts.", "imported": false, "abstract": "OBJECTIVE: To investigate the association between four serotonergic polymorphisms [A-1438G (rs6311) and T102C (rs6313) of the serotonin 2A receptor gene, and STin2 VNTR and 5-HTTLPR of the SLC6A4 gene] and suicidal behavior.\n\nPARTICIPANTS AND METHODS: One hundred and ninety-three suicide attempters (SA) and 420 unrelated healthy controls from Asturias (Northern Spain) were genotyped using standard methods.\n\nRESULTS: A-1438G and T102C polymorphisms were in complete linkage disequilibrium in our population. Genotype and allele distributions showed no differences between SA and control participants. In nonimpulsive suicide attempts, however, we found an excess of the -1438A allele as compared with impulsive suicide attempts and the control group [chi(2)=11.92, corrected P=0.021]. No other differences were found with regard to the impulsivity of the attempt. An excess of short allele carriers were found in the group of SA with high clinical lethality as compared with the low-lethality group [chi(1)=4.93, P=0.026, not significant after Bonferroni correction]. The haplotype analysis showed no association between suicide attempt and haplotype distribution [likelihood ratio test (5)=4.40, P=0.493].\n\nCONCLUSION: Our findings suggest that the -1438A allele may predispose for nonimpulsive suicidal behavior.", "journal": "Psychiatric genetics", "year": "2008", "authors": "Saiz PA, García-Portilla MP, Paredes B, Arango C, Morales B, Alvarez V, Coto E, Bascaran MT, Bousoño M, Bobes J", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1097/YPG.0b013e3283050ada", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.640Z" }, { "id": "94fd22ab-e1c7-4931-8ad3-b2bfcdd33e3e", "pmid": "18797395", "title": "Association between the A-1438G polymorphism of the serotonin 2A receptor gene and nonimpulsive suicide attempts.", "imported": false, "abstract": "OBJECTIVE: To investigate the association between four serotonergic polymorphisms [A-1438G (rs6311) and T102C (rs6313) of the serotonin 2A receptor gene, and STin2 VNTR and 5-HTTLPR of the SLC6A4 gene] and suicidal behavior.\n\nPARTICIPANTS AND METHODS: One hundred and ninety-three suicide attempters (SA) and 420 unrelated healthy controls from Asturias (Northern Spain) were genotyped using standard methods.\n\nRESULTS: A-1438G and T102C polymorphisms were in complete linkage disequilibrium in our population. Genotype and allele distributions showed no differences between SA and control participants. In nonimpulsive suicide attempts, however, we found an excess of the -1438A allele as compared with impulsive suicide attempts and the control group [chi(2)=11.92, corrected P=0.021]. No other differences were found with regard to the impulsivity of the attempt. An excess of short allele carriers were found in the group of SA with high clinical lethality as compared with the low-lethality group [chi(1)=4.93, P=0.026, not significant after Bonferroni correction]. The haplotype analysis showed no association between suicide attempt and haplotype distribution [likelihood ratio test (5)=4.40, P=0.493].\n\nCONCLUSION: Our findings suggest that the -1438A allele may predispose for nonimpulsive suicidal behavior.", "journal": "Psychiatric genetics", "year": "2008", "authors": "Saiz PA, García-Portilla MP, Paredes B, Arango C, Morales B, Alvarez V, Coto E, Bascaran MT, Bousoño M, Bobes J", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1097/YPG.0b013e3283050ada", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.175Z" }, { "id": "d1e82fcc-37ae-4135-a2bf-2fd6e8279ac9", "pmid": "18797395", "title": "Association between the A-1438G polymorphism of the serotonin 2A receptor gene and nonimpulsive suicide attempts.", "imported": false, "abstract": "OBJECTIVE: To investigate the association between four serotonergic polymorphisms [A-1438G (rs6311) and T102C (rs6313) of the serotonin 2A receptor gene, and STin2 VNTR and 5-HTTLPR of the SLC6A4 gene] and suicidal behavior.\n\nPARTICIPANTS AND METHODS: One hundred and ninety-three suicide attempters (SA) and 420 unrelated healthy controls from Asturias (Northern Spain) were genotyped using standard methods.\n\nRESULTS: A-1438G and T102C polymorphisms were in complete linkage disequilibrium in our population. Genotype and allele distributions showed no differences between SA and control participants. In nonimpulsive suicide attempts, however, we found an excess of the -1438A allele as compared with impulsive suicide attempts and the control group [chi(2)=11.92, corrected P=0.021]. No other differences were found with regard to the impulsivity of the attempt. An excess of short allele carriers were found in the group of SA with high clinical lethality as compared with the low-lethality group [chi(1)=4.93, P=0.026, not significant after Bonferroni correction]. The haplotype analysis showed no association between suicide attempt and haplotype distribution [likelihood ratio test (5)=4.40, P=0.493].\n\nCONCLUSION: Our findings suggest that the -1438A allele may predispose for nonimpulsive suicidal behavior.", "journal": "Psychiatric genetics", "year": "2008", "authors": "Saiz PA, García-Portilla MP, Paredes B, Arango C, Morales B, Alvarez V, Coto E, Bascaran MT, Bousoño M, Bobes J", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1097/YPG.0b013e3283050ada", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.581Z" }, { "id": "488590af-6083-4f3e-8131-e3843862ca3c", "pmid": "18801905", "title": "Central leptin regulates total ceramide content and sterol regulatory element binding protein-1C proteolytic maturation in rat white adipose tissue", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "Bonzón-Kulichenko E, Schwudke D, Gallardo N, Moltó E, Fernández-Agulló T, Shevchenko A, Andrés A.", "articleTypes": [], "doi": "10.1210/en.2008-0505", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.783Z" }, { "id": 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Abe Y, Takaya T, Horie T, Wada H, Kita T, Satoh N, Shimatsu A, Hasegawa K.", "articleTypes": [], "doi": "10.1016/j.bbrc.2008.09.050", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.905Z" }, { "id": "6c65ac5e-f3d8-4a32-b443-1620afcda26c", "pmid": "18809385", "title": "Up-regulated expression of microRNA-143 in association with obesity in adipose tissue of mice fed high-fat diet", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Takanabe R, Ono K, Abe Y, Takaya T, Horie T, Wada H, Kita T, Satoh N, Shimatsu A, Hasegawa K.", "articleTypes": [], "doi": "10.1016/j.bbrc.2008.09.050", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.433Z" }, { "id": "baff203e-5ca8-4866-99a0-bdfa1fbc4b62", "pmid": "18809385", "title": "Up-regulated expression of microRNA-143 in association with obesity in adipose tissue of mice fed high-fat diet", "imported": false, 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A new allelic variant within the 5-HTTLPR polymorphism was described but it has not been thoroughly analyzed in the recent literature. The SNP functional analysis demonstrated that the A variant of the L allele (L(A)) produces high levels of mRNA and that the G variant (L(G)) is equivalent to the S allele. Our aims were to compare the frequency of 5-HTTLPR alleles in 94 depressed patients who attempted suicide compared to 94 controls free of psychiatric disorder, including the embedded SNP rs25531. Using the biallelic classification, our sample contained 62 (33%) LL, 76 (40.4%) LS, and 50 (26.6%) SS individuals. Using the functional classification system, our sample contained 43 (22.5%) L'L', 84 (44.7%) L'S', and 61 (32.4%) S'S' individuals, with no significant differences between cases and controls in genotypic tests in either biallelic (chi(2)=2.543; df=2; p=0.280) and functional models (chi(2)=2.995; df=2; p=0.228). The minor allele frequency (MAF) - the S allele - did not show any distributional difference between cases and controls using biallelic classification system 0.51 vs. 0.43, (OR=1.41; CI95% 0.94 to 2.12; p=0.121). Also the S' allele of the functional classification system did not show any distributional difference between the two groups 0.59. vs. 0.51 (OR=1.35; CI95% 0.90 to 2.03; p=0.178). This study provided the possibility of a re-analysis of novell 5-HTTLPR functional variants identified within L allele that alters its mRNA production and thus changes its functionality. We could not find any association between both biallelic and functional 5-HTTLPR in depressed patients with suicide attempt, being the small sample size an important limitation for these results. 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We hypothesized that reported childhood abuse would be associated with lower brain serotonin transporter (5-HTT) binding potential (BP(P), proportional to the number of available transporters) in adults. We examined healthy volunteers and subjects with major depressive disorder, a sample enriched for childhood abuse.\n\nMETHODS: Regional brain 5-HTT BP(P) was measured using positron emission tomography (PET) with [(11)C]McN 5652 and a metabolite-corrected arterial input function in 43 healthy volunteers and 23 subjects in a major depressive episode, ten of whom reported a history of sexual and/or physical abuse before age 15, and 13 of whom did not. As only two healthy volunteers reported childhood abuse, primary analyses were restricted to the depressed sample, with healthy controls presented as comparators.\n\nRESULTS: Depressed subjects reporting childhood abuse had lower 5-HTT BP(P) than nonabused depressed subjects across all brain regions examined (P = 0.017). The groups did not differ in relevant demographic or clinical variables. Genotype frequencies of a functional polymorphism in the 5-HTT gene promoter (5-HTTLPR) did not differ between the groups.\n\nCONCLUSIONS: Reported childhood abuse is associated with lower 5-HTT BP(P) in this sample of subjects with major depression, consistent with other reports that childhood adversity can lower serotonergic function permanently. Lower 5-HTT BP(P) may represent a biological pathway through which early life stress predisposes to the development of subsequent psychiatric illness, including major depressive disorder.", "journal": "Synapse (New York, N.Y.)", "year": "2009", "authors": "Miller JM, Kinnally EL, Ogden RT, Oquendo MA, Mann JJ, Parsey RV", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1002/syn.20637", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.579Z" }, { "id": "7d58f977-c7b9-4c16-98d7-8cf700620c18", "pmid": "19288578", "title": "Reported childhood abuse is associated with low serotonin transporter binding in vivo in major depressive disorder.", "imported": false, "abstract": "BACKGROUND: Physical or psychological adversity in childhood is associated with a higher risk for depression in adulthood, and with persistent serotonergic abnormalities in humans and in animal models. We hypothesized that reported childhood abuse would be associated with lower brain serotonin transporter (5-HTT) binding potential (BP(P), proportional to the number of available transporters) in adults. We examined healthy volunteers and subjects with major depressive disorder, a sample enriched for childhood abuse.\n\nMETHODS: Regional brain 5-HTT BP(P) was measured using positron emission tomography (PET) with [(11)C]McN 5652 and a metabolite-corrected arterial input function in 43 healthy volunteers and 23 subjects in a major depressive episode, ten of whom reported a history of sexual and/or physical abuse before age 15, and 13 of whom did not. As only two healthy volunteers reported childhood abuse, primary analyses were restricted to the depressed sample, with healthy controls presented as comparators.\n\nRESULTS: Depressed subjects reporting childhood abuse had lower 5-HTT BP(P) than nonabused depressed subjects across all brain regions examined (P = 0.017). The groups did not differ in relevant demographic or clinical variables. Genotype frequencies of a functional polymorphism in the 5-HTT gene promoter (5-HTTLPR) did not differ between the groups.\n\nCONCLUSIONS: Reported childhood abuse is associated with lower 5-HTT BP(P) in this sample of subjects with major depression, consistent with other reports that childhood adversity can lower serotonergic function permanently. Lower 5-HTT BP(P) may represent a biological pathway through which early life stress predisposes to the development of subsequent psychiatric illness, including major depressive disorder.", "journal": "Synapse (New York, N.Y.)", "year": "2009", "authors": "Miller JM, Kinnally EL, Ogden RT, Oquendo MA, Mann JJ, Parsey RV", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1002/syn.20637", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.173Z" }, { "id": "cfd8640b-7f02-44a7-b246-9c6bfa3bd98c", "pmid": "19288578", "title": "Reported childhood abuse is associated with low serotonin transporter binding in vivo in major depressive disorder.", "imported": false, "abstract": "BACKGROUND: Physical or psychological adversity in childhood is associated with a higher risk for depression in adulthood, and with persistent serotonergic abnormalities in humans and in animal models. We hypothesized that reported childhood abuse would be associated with lower brain serotonin transporter (5-HTT) binding potential (BP(P), proportional to the number of available transporters) in adults. We examined healthy volunteers and subjects with major depressive disorder, a sample enriched for childhood abuse.\n\nMETHODS: Regional brain 5-HTT BP(P) was measured using positron emission tomography (PET) with [(11)C]McN 5652 and a metabolite-corrected arterial input function in 43 healthy volunteers and 23 subjects in a major depressive episode, ten of whom reported a history of sexual and/or physical abuse before age 15, and 13 of whom did not. As only two healthy volunteers reported childhood abuse, primary analyses were restricted to the depressed sample, with healthy controls presented as comparators.\n\nRESULTS: Depressed subjects reporting childhood abuse had lower 5-HTT BP(P) than nonabused depressed subjects across all brain regions examined (P = 0.017). The groups did not differ in relevant demographic or clinical variables. Genotype frequencies of a functional polymorphism in the 5-HTT gene promoter (5-HTTLPR) did not differ between the groups.\n\nCONCLUSIONS: Reported childhood abuse is associated with lower 5-HTT BP(P) in this sample of subjects with major depression, consistent with other reports that childhood adversity can lower serotonergic function permanently. Lower 5-HTT BP(P) may represent a biological pathway through which early life stress predisposes to the development of subsequent psychiatric illness, including major depressive disorder.", "journal": "Synapse (New York, N.Y.)", "year": "2009", "authors": "Miller JM, Kinnally EL, Ogden RT, Oquendo MA, Mann JJ, Parsey RV", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1002/syn.20637", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.638Z" }, { "id": "4c25ddf5-69f8-43f3-80be-ff8b645d68c1", "pmid": "19295193", "title": "Influence of Trp64Arg polymorphism of beta 3-adrenoreceptor gene on insulin resistance, adipocytokines and weight loss secondary to two hypocaloric diets", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "de Luis DA, González Sagrado M, Aller R, Izaola O, Conde R.", "articleTypes": [], "doi": "10.1159/000209268", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.393Z" }, { "id": "c240762e-e5d8-4c11-aab1-c2b16cae7a0c", "pmid": "19295193", "title": "Influence of Trp64Arg polymorphism of beta 3-adrenoreceptor gene 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regulates leukocyte recruitment into the brain following systemic LPS-induced inflammation", "imported": false, "abstract": "", "journal": "", "year": "2010", "authors": "Rummel C, Inoue W, Poole S, Luheshi GN.", "articleTypes": [], "doi": "10.1038/mp.2009.98", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.392Z" }, { "id": "9d5cc80d-86b6-4cfe-aa23-66a4f09a2248", "pmid": "19773811", "title": "Leptin regulates leukocyte recruitment into the brain following systemic LPS-induced inflammation", "imported": false, "abstract": "", "journal": "", "year": "2010", "authors": "Rummel C, Inoue W, Poole S, Luheshi GN.", "articleTypes": [], "doi": "10.1038/mp.2009.98", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.779Z" }, { "id": "140551cc-0a12-45c3-863f-be89e393426a", "pmid": "19776631", "title": "Effect of dietary calcium and dairy proteins on the adipose tissue gene expression profile in diet-induced obesity", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Pilvi TK, Storvik M, Louhelainen M, Merasto S, Korpela R, Mervaala EM.", "articleTypes": [], "doi": "10.1159/000151238", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.908Z" }, { "id": "1ff61347-611d-41fa-91b3-cfa68ffd634e", "pmid": "19776631", "title": "Effect of dietary calcium and dairy proteins on the adipose tissue gene expression profile in diet-induced obesity", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Pilvi TK, Storvik M, Louhelainen M, Merasto S, Korpela R, Mervaala EM.", "articleTypes": [], "doi": "10.1159/000151238", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.791Z" }, { "id": "ddb5886b-2a16-424f-a675-b83271923432", "pmid": "19776631", "title": "Effect of dietary calcium and dairy proteins on the adipose tissue gene expression profile in diet-induced obesity", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Pilvi TK, Storvik M, Louhelainen M, Merasto S, Korpela R, Mervaala EM.", "articleTypes": [], "doi": "10.1159/000151238", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.404Z" }, { "id": "faca5893-43f7-44e7-9614-0ff58124c142", "pmid": "19776631", "title": "Effect of dietary calcium and dairy proteins on the adipose tissue gene expression profile in diet-induced obesity", "imported": false, "abstract": "", "journal": "", "year": "2008", "authors": "Pilvi TK, Storvik M, Louhelainen M, Merasto S, Korpela R, Mervaala EM.", "articleTypes": [], "doi": "10.1159/000151238", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.436Z" }, { "id": "0b628eef-a055-425a-b5b5-c91a55aa7a84", "pmid": "19779024", "title": "Interaction of child maltreatment and 5-HTT polymorphisms: suicidal ideation among children from low-SES backgrounds.", "imported": false, "abstract": "OBJECTIVE: To investigate whether genotypic variation of the serotonin transporter gene-linked promoter region (5-HTTLPR) moderates the effect of maltreatment on suicidal ideation in school-aged children.\n\nMETHODS: Eight hundred and fifty low-income children (478 maltreated; 372 non-maltreated) provided DNA samples and self-reported depressive and suicidal symptoms. Genotypes of 5-HTTLPR (s/s or s/l vs. l/l) were determined by fragment analyses.\n\nRESULTS: Higher suicidal ideation was found among maltreated than non-maltreated children; the groups did not differ in 5-HTTLPR genotype frequencies. Children with one to two maltreatment subtypes and s/s or s/l genotypes had higher suicidal ideation than those with the l/l genotype; suicidal ideation did not differ in non-maltreated children or children with three to four maltreatment subtypes based on 5-HTTLPR variation. The results were applicable to emotionally maltreated/neglected and to physically/sexually abused children. Gene-environment interaction was not found for depressive symptoms.\n\nCONCLUSION: The protective effect of the 5-HTTLPR l/l genotype on suicidal ideation was limited to maltreated children experiencing fewer subtypes.", "journal": "Journal of pediatric psychology", "year": "2010", "authors": "Cicchetti D, Rogosch FA, Sturge-Apple M, Toth SL", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1093/jpepsy/jsp078", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.578Z" }, { "id": "49155778-bd9d-465c-abfc-f4c8790d0e1b", "pmid": "19779024", "title": "Interaction of child maltreatment and 5-HTT polymorphisms: suicidal ideation among children from low-SES backgrounds.", "imported": false, "abstract": "OBJECTIVE: To investigate whether genotypic variation of the serotonin transporter gene-linked promoter region (5-HTTLPR) moderates the effect of maltreatment on suicidal ideation in school-aged children.\n\nMETHODS: Eight hundred and fifty low-income children (478 maltreated; 372 non-maltreated) provided DNA samples and self-reported depressive and suicidal symptoms. Genotypes of 5-HTTLPR (s/s or s/l vs. l/l) were determined by fragment analyses.\n\nRESULTS: Higher suicidal ideation was found among maltreated than non-maltreated children; the groups did not differ in 5-HTTLPR genotype frequencies. Children with one to two maltreatment subtypes and s/s or s/l genotypes had higher suicidal ideation than those with the l/l genotype; suicidal ideation did not differ in non-maltreated children or children with three to four maltreatment subtypes based on 5-HTTLPR variation. The results were applicable to emotionally maltreated/neglected and to physically/sexually abused children. Gene-environment interaction was not found for depressive symptoms.\n\nCONCLUSION: The protective effect of the 5-HTTLPR l/l genotype on suicidal ideation was limited to maltreated children experiencing fewer subtypes.", "journal": "Journal of pediatric psychology", "year": "2010", "authors": "Cicchetti D, Rogosch FA, Sturge-Apple M, Toth SL", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1093/jpepsy/jsp078", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.638Z" }, { "id": "c009ee25-296b-4d74-9244-354cc2e94a00", "pmid": "19779024", "title": "Interaction of child maltreatment and 5-HTT polymorphisms: suicidal ideation among children from low-SES backgrounds.", "imported": false, "abstract": "OBJECTIVE: To investigate whether genotypic variation of the serotonin transporter gene-linked promoter region (5-HTTLPR) moderates the effect of maltreatment on suicidal ideation in school-aged children.\n\nMETHODS: Eight hundred and fifty low-income children (478 maltreated; 372 non-maltreated) provided DNA samples and self-reported depressive and suicidal symptoms. Genotypes of 5-HTTLPR (s/s or s/l vs. l/l) were determined by fragment analyses.\n\nRESULTS: Higher suicidal ideation was found among maltreated than non-maltreated children; the groups did not differ in 5-HTTLPR genotype frequencies. Children with one to two maltreatment subtypes and s/s or s/l genotypes had higher suicidal ideation than those with the l/l genotype; suicidal ideation did not differ in non-maltreated children or children with three to four maltreatment subtypes based on 5-HTTLPR variation. The results were applicable to emotionally maltreated/neglected and to physically/sexually abused children. Gene-environment interaction was not found for depressive symptoms.\n\nCONCLUSION: The protective effect of the 5-HTTLPR l/l genotype on suicidal ideation was limited to maltreated children experiencing fewer subtypes.", "journal": "Journal of pediatric psychology", "year": "2010", "authors": "Cicchetti D, Rogosch FA, Sturge-Apple M, Toth SL", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1093/jpepsy/jsp078", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.172Z" }, { "id": "1374bf52-b640-48d3-8397-2f8487763f26", "pmid": "19779754", "title": "Conjugated linoleic acid induces uncoupling protein 1 in white adipose tissue of ob/ob mice", "imported": false, "abstract": "", "journal": "", "year": "2009", "authors": "Wendel AA, Purushotham A, Liu LF, Belury MA.", "articleTypes": [], "doi": "10.1007/s11745-009-3348-9", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.373Z" }, { "id": "1dcb8e8e-1743-497b-8ae2-5604036a5705", "pmid": "19779754", "title": "Conjugated linoleic acid induces uncoupling protein 1 in white adipose tissue of ob/ob mice", 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"authors": "Wendel AA, Purushotham A, Liu LF, Belury MA.", "articleTypes": [], "doi": "10.1007/s11745-009-3348-9", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.883Z" }, { "id": "4efc9f7e-f0eb-4ff3-8340-42f5a8eb6e9a", "pmid": "19783811", "title": "FXR activation reverses insulin resistance and lipid abnormalities and protects against liver steatosis in Zucker (fa/fa) obese rats", "imported": false, "abstract": "", "journal": "", "year": "2010", "authors": "Cipriani S, Mencarelli A, Palladino G, Fiorucci S.", "articleTypes": [], "doi": "10.1194/jlr.M001602", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.911Z" }, { "id": "75b2c2c5-8747-4187-8397-19365ea39913", "pmid": "19783811", "title": "FXR activation reverses insulin resistance and lipid abnormalities and protects against liver steatosis in Zucker (fa/fa) obese rats", "imported": false, "abstract": "", "journal": "", 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"articleTypes": [], "doi": "10.3945/jn.109.108977", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.409Z" }, { "id": "fc2b998c-2b2c-459a-8e59-956a26aa6250", "pmid": "20089773", "title": "Isoleucine prevents the accumulation of tissue triglycerides and upregulates the expression of PPARalpha and uncoupling protein in diet-induced obese mice", "imported": false, "abstract": "", "journal": "", "year": "2010", "authors": "Nishimura J, Masaki T, Arakawa M, Seike M, Yoshimatsu H.", "articleTypes": [], "doi": "10.3945/jn.109.108977", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.441Z" }, { "id": "53678468-032b-4e07-811a-8a8a6a31da74", "pmid": "20096463", "title": "Is the serotonin transporter polymorphism (5-HTTLPR) a potential marker for suicidal behavior in bipolar disorder patients?", "imported": false, "abstract": "BACKGROUND: Suicide prediction is a huge challenge for mental health workers. Structured interviews based on epidemiological and clinical factors don't show effectiveness for suicide prevention. Biological markers, such as 5-HTTLPR, could help for identification of potential suicide attempters.\n\nMETHODS: We evaluated 198 bipolar patients and 103 health controls, using a structured interview according to DSM-IV criteria. Genotyping, blind of clinical assessment for identification of S carriers and structured interviews were performed in order to describe clinical and epidemiological factors which could be associated with suicide behavior. Statistical analyses were calculated by the x(2) test and logistic regression model.\n\nRESULTS: We found that 26.77% and 16.67% had a lifetime history of non violent suicide attempt and violent suicide attempt, respectively. The clinical factors associated with violent and non violent suicide attempt had several differences. Violent suicide attempters had an earlier illness onset and had a higher number of psychiatric comorbidities (borderline personality disorder, panic disorder and alcoholism). The frequency of S allele carriers was higher only in those patients who had made a violent suicide attempt in their lifetime (x(2)=16.969; p=0.0001). In a logistic regression model including these factors, S allele carrier (5-HTTLPR) was the only factor associated with violent suicide attempt.\n\nLIMITATIONS: Sample size and retrospective assessment of suicide behavior history are the limitations of this study.\n\nCONCLUSIONS: Our study showed that serotonin polymorphism (5-HTTLPR) is strongly associated with violent suicidal behavior in BD patients. If confirmed, our results could be an important step to create a genetic tool for long-term suicide prediction.", "journal": "Journal of affective disorders", "year": "2010", "authors": "Neves FS, Malloy-Diniz LF, Romano-Silva MA, Aguiar GC, de Matos LO, Correa H", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2009.12.026", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.637Z" }, { "id": "62a01f8f-65b0-44a2-9a3b-2b603c314859", "pmid": "20096463", "title": "Is the serotonin transporter polymorphism (5-HTTLPR) a potential marker for suicidal behavior in bipolar disorder patients?", "imported": false, "abstract": "BACKGROUND: Suicide prediction is a huge challenge for mental health workers. Structured interviews based on epidemiological and clinical factors don't show effectiveness for suicide prevention. Biological markers, such as 5-HTTLPR, could help for identification of potential suicide attempters.\n\nMETHODS: We evaluated 198 bipolar patients and 103 health controls, using a structured interview according to DSM-IV criteria. Genotyping, blind of clinical assessment for identification of S carriers and structured interviews were performed in order to describe clinical and epidemiological factors which could be associated with suicide behavior. Statistical analyses were calculated by the x(2) test and logistic regression model.\n\nRESULTS: We found that 26.77% and 16.67% had a lifetime history of non violent suicide attempt and violent suicide attempt, respectively. The clinical factors associated with violent and non violent suicide attempt had several differences. Violent suicide attempters had an earlier illness onset and had a higher number of psychiatric comorbidities (borderline personality disorder, panic disorder and alcoholism). The frequency of S allele carriers was higher only in those patients who had made a violent suicide attempt in their lifetime (x(2)=16.969; p=0.0001). In a logistic regression model including these factors, S allele carrier (5-HTTLPR) was the only factor associated with violent suicide attempt.\n\nLIMITATIONS: Sample size and retrospective assessment of suicide behavior history are the limitations of this study.\n\nCONCLUSIONS: Our study showed that serotonin polymorphism (5-HTTLPR) is strongly associated with violent suicidal behavior in BD patients. If confirmed, our results could be an important step to create a genetic tool for long-term suicide prediction.", "journal": "Journal of affective disorders", "year": "2010", "authors": "Neves FS, Malloy-Diniz LF, Romano-Silva MA, Aguiar GC, de Matos LO, Correa H", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2009.12.026", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.171Z" }, { "id": "921eaaa8-51a2-4f0a-9a79-44805075be5a", "pmid": "20096463", "title": "Is the serotonin transporter polymorphism (5-HTTLPR) a potential marker for suicidal behavior in bipolar disorder patients?", "imported": false, "abstract": "BACKGROUND: Suicide prediction is a huge challenge for mental health workers. Structured interviews based on epidemiological and clinical factors don't show effectiveness for suicide prevention. Biological markers, such as 5-HTTLPR, could help for identification of potential suicide attempters.\n\nMETHODS: We evaluated 198 bipolar patients and 103 health controls, using a structured interview according to DSM-IV criteria. Genotyping, blind of clinical assessment for identification of S carriers and structured interviews were performed in order to describe clinical and epidemiological factors which could be associated with suicide behavior. Statistical analyses were calculated by the x(2) test and logistic regression model.\n\nRESULTS: We found that 26.77% and 16.67% had a lifetime history of non violent suicide attempt and violent suicide attempt, respectively. The clinical factors associated with violent and non violent suicide attempt had several differences. Violent suicide attempters had an earlier illness onset and had a higher number of psychiatric comorbidities (borderline personality disorder, panic disorder and alcoholism). The frequency of S allele carriers was higher only in those patients who had made a violent suicide attempt in their lifetime (x(2)=16.969; p=0.0001). In a logistic regression model including these factors, S allele carrier (5-HTTLPR) was the only factor associated with violent suicide attempt.\n\nLIMITATIONS: Sample size and retrospective assessment of suicide behavior history are the limitations of this study.\n\nCONCLUSIONS: Our study showed that serotonin polymorphism (5-HTTLPR) is strongly associated with violent suicidal behavior in BD patients. If confirmed, our results could be an important step to create a genetic tool for long-term suicide prediction.", "journal": "Journal of affective disorders", "year": "2010", "authors": "Neves FS, Malloy-Diniz LF, Romano-Silva MA, Aguiar GC, de Matos LO, Correa H", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2009.12.026", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.578Z" }, { "id": "21fa1a08-b544-48f3-aa78-e0d47aa4f4b5", "pmid": "20097259", "title": "Metabolic and melanocortin gene expression alterations in male offspring of obese mice", "imported": false, "abstract": "", "journal": "", "year": "2010", "authors": "Gout J, Sarafian D, Mutel E, Vigier M, Rajas F, Mithieux G, Begeot M, Naville D.", "articleTypes": [], "doi": "10.1016/j.mce.2010.01.021", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.352Z" }, { "id": "4a872610-c6e1-401b-a7a7-aad8af2c2f48", "pmid": "20097259", "title": "Metabolic and melanocortin gene expression alterations in male offspring of obese mice", "imported": false, "abstract": "", "journal": "", "year": "2010", "authors": "Gout J, Sarafian D, Mutel E, Vigier M, Rajas F, Mithieux G, Begeot M, Naville D.", "articleTypes": [], "doi": "10.1016/j.mce.2010.01.021", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.864Z" }, { "id": "6b67ca40-d6f0-40d9-bc50-a3c8a9d20271", "pmid": "20097259", "title": "Metabolic and melanocortin gene expression alterations in male offspring of obese mice", "imported": false, "abstract": "", "journal": "", "year": "2010", "authors": "Gout J, Sarafian D, Mutel E, Vigier M, Rajas F, Mithieux G, Begeot M, Naville D.", "articleTypes": [], "doi": "10.1016/j.mce.2010.01.021", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.743Z" }, { "id": "b083270a-dbea-4cfe-a291-702e178db1ab", "pmid": "20097259", "title": "Metabolic and melanocortin gene expression alterations in male offspring of obese mice", "imported": false, "abstract": "", "journal": "", "year": "2010", "authors": "Gout J, Sarafian D, Mutel E, Vigier M, Rajas F, Mithieux G, Begeot M, Naville D.", "articleTypes": [], "doi": "10.1016/j.mce.2010.01.021", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.386Z" }, { "id": "0e9454cc-cb63-4161-a853-6616e96afe78", "pmid": "20098739", "title": "Hypothalamic-specific manipulation of Fto, the ortholog of the human obesity gene FTO, affects food intake in rats", "imported": false, "abstract": "", "journal": "", "year": "2010", "authors": "Tung YC, Ayuso E, Shan X, Bosch F, O'Rahilly S, Coll AP, Yeo GS.", "articleTypes": [], "doi": "10.1371/journal.pone.0008771", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.457Z" }, { "id": "3d58a284-3ae2-462e-b46e-c8af063175c2", "pmid": "20098739", "title": "Hypothalamic-specific manipulation of Fto, the ortholog of the human obesity gene FTO, affects food intake in rats", "imported": false, "abstract": "", "journal": "", "year": 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up to the age of 30; and exposure to childhood and adult adverse life events.\n\nRESULTS: A series of 104 regression models were fitted to four mental health outcomes (depressive symptoms, major depression, anxiety disorder and suicidal ideation) observed at ages 18, 21, 25 and 30 using 13 measures of life-course stress that spanned childhood and adult stressors. Both multiplicative and additive models were fitted to the data. No evidence was found that would support the hypothesis that 's' alleles of 5-HTTLPR are associated with increased responsivity to life stressors.\n\nCONCLUSIONS: The present findings add to the evidence suggesting that it is unlikely that there is a stable gene × environment interaction involving 5-HTTLPR, life stress and mental disorders.", "journal": "The British journal of psychiatry : the journal of mental science", "year": "2011", "authors": "Fergusson DM, Horwood LJ, Miller AL, Kennedy MA", "articleTypes": [ "Journal Article" ], "doi": "10.1192/bjp.bp.110.085993", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.577Z" }, { "id": "ce0489af-371b-4092-b91a-c49a19e2ab07", "pmid": "21282783", "title": "Life stress, 5-HTTLPR and mental disorder: findings from a 30-year longitudinal study.", "imported": false, "abstract": "BACKGROUND: Recent meta-analyses have raised concerns about the replicability of gene × environment interactions involving the serotonin transporter gene (5-HTTLPR) in moderating the associations between adverse life events and mental disorders.\n\nAIMS: To use data gathered over the course of a 30-year longitudinal study of a New Zealand birth cohort to test the hypothesis that the presence of short ('s') alleles of 5-HTTLPR are associated with an increased response to life stress.\n\nMETHOD: Participants were 893 individuals from the Christchurch Health and Development Study who had complete data on: the 5-HTTLPR genotype; psychiatric disorders up to the age of 30; and exposure to childhood and adult adverse life events.\n\nRESULTS: A series of 104 regression models were fitted to four mental health outcomes (depressive symptoms, major depression, anxiety disorder and suicidal ideation) observed at ages 18, 21, 25 and 30 using 13 measures of life-course stress that spanned childhood and adult stressors. Both multiplicative and additive models were fitted to the data. No evidence was found that would support the hypothesis that 's' alleles of 5-HTTLPR are associated with increased responsivity to life stressors.\n\nCONCLUSIONS: The present findings add to the evidence suggesting that it is unlikely that there is a stable gene × environment interaction involving 5-HTTLPR, life stress and mental disorders.", "journal": "The British journal of psychiatry : the journal of mental science", "year": "2011", "authors": "Fergusson DM, Horwood LJ, Miller AL, Kennedy MA", "articleTypes": [ "Journal Article" ], "doi": "10.1192/bjp.bp.110.085993", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.637Z" }, { "id": "d2a92dd3-667e-4eec-b854-069007efeef4", "pmid": "21282783", "title": "Life stress, 5-HTTLPR and mental disorder: findings from a 30-year longitudinal study.", "imported": false, "abstract": "BACKGROUND: Recent meta-analyses have raised concerns about the replicability of gene × environment interactions involving the serotonin transporter gene (5-HTTLPR) in moderating the associations between adverse life events and mental disorders.\n\nAIMS: To use data gathered over the course of a 30-year longitudinal study of a New Zealand birth cohort to test the hypothesis that the presence of short ('s') alleles of 5-HTTLPR are associated with an increased response to life stress.\n\nMETHOD: Participants were 893 individuals from the Christchurch Health and Development Study who had complete data on: the 5-HTTLPR genotype; psychiatric disorders up to the age of 30; and exposure to childhood and adult adverse life events.\n\nRESULTS: A series of 104 regression models were fitted to four mental health outcomes (depressive symptoms, major depression, anxiety disorder and suicidal ideation) observed at ages 18, 21, 25 and 30 using 13 measures of life-course stress that spanned childhood and adult stressors. Both multiplicative and additive models were fitted to the data. No evidence was found that would support the hypothesis that 's' alleles of 5-HTTLPR are associated with increased responsivity to life stressors.\n\nCONCLUSIONS: The present findings add to the evidence suggesting that it is unlikely that there is a stable gene × environment interaction involving 5-HTTLPR, life stress and mental disorders.", "journal": "The British journal of psychiatry : the journal of mental science", "year": "2011", "authors": "Fergusson DM, Horwood LJ, Miller AL, Kennedy MA", "articleTypes": [ "Journal Article" ], "doi": "10.1192/bjp.bp.110.085993", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR 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"title": "Molecular hydrogen improves obesity and diabetes by inducing hepatic FGF21 and stimulating energy metabolism in db/db mice", "imported": false, "abstract": "", "journal": "", "year": "2011", "authors": "Kamimura N, Nishimaki K, Ohsawa I, Ohta S.", "articleTypes": [], "doi": "10.1038/oby.2011.6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.407Z" }, { "id": "bb33d715-8b0f-4e07-b801-51c64aa7216a", "pmid": "21293445", "title": "Molecular hydrogen improves obesity and diabetes by inducing hepatic FGF21 and stimulating energy metabolism in db/db mice", "imported": false, "abstract": "", "journal": "", "year": "2011", "authors": "Kamimura N, Nishimaki K, Ohsawa I, Ohta S.", "articleTypes": [], "doi": "10.1038/oby.2011.6", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.439Z" }, { "id": "cdbd3e0d-1288-4c1c-968e-3cd3de51f5ac", "pmid": "21293445", "title": "Molecular 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has been associated both with depression and aggression/hostility. The multidirectional association between depression, aggression and the s allele may be important, since all these phenomena are related to suicidal behavior. Our aim was to investigate the association between 5-HTTLPR and aggressive/hostile traits in depressed patients and controls.\n\nMETHODS: 137 depressive and 118 control women completed the Buss-Durkee Hostility Inventory and were genotyped for 5-HTTLPR. BDHI scores in the different groups were investigated by Generalized Linear Model Analysis. Association between dependent and independent variables in the model was tested by the likelihood ratio Chi-square statistic.\n\nRESULTS: Diagnosis and genotype showed a significant association with several aggressive/hostile traits. Interaction of the two main effects was also significant in case of several subscales. Post hoc analyses indicated a significant association between BDHI subscales and s allele only in the depressed group.\n\nLIMITATION: Only women were studied and since gender differences are present both in aggressive behavior and putatively in the behavioral effects of 5-HTTLPR genotype, our findings pertain only to females.\n\nCONCLUSION: Our results indicate a robust relationship between aggression/hostility and 5-HTTLPR genotype, but this association is more marked in the presence of depression. The presence of the s allele thus not only contributes to a higher risk of depression, but in depressives also leads to higher aggression/hostility. Our results have important implications for suicide research, since the s allele is associated with violent suicide, and this association may be mediated through the emergence of increased aggression/hostility in depressed patients carrying the s allele.", "journal": "Journal of affective disorders", "year": "2011", "authors": "Gonda X, Fountoulakis KN, Csukly G, Bagdy G, Pap D, Molnár E, Laszik A, Lazary J, Sarosi A, Faludi G, Sasvari-Szekely M, Szekely A, Rihmer Z", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2011.03.029", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.171Z" }, { "id": "9d3899ac-e5f5-4dee-a5f2-1e6afea277de", "pmid": "21492940", "title": "Interaction of 5-HTTLPR genotype and unipolar major depression in the emergence of aggressive/hostile traits.", "imported": false, "abstract": "OBJECTIVE: The 5-HTTLPR polymorphism has been associated both with depression and aggression/hostility. The multidirectional association between depression, aggression and the s allele may be important, since all these phenomena are related to suicidal behavior. Our aim was to investigate the association between 5-HTTLPR and aggressive/hostile traits in depressed patients and controls.\n\nMETHODS: 137 depressive and 118 control women completed the Buss-Durkee Hostility Inventory and were genotyped for 5-HTTLPR. BDHI scores in the different groups were investigated by Generalized Linear Model Analysis. Association between dependent and independent variables in the model was tested by the likelihood ratio Chi-square statistic.\n\nRESULTS: Diagnosis and genotype showed a significant association with several aggressive/hostile traits. Interaction of the two main effects was also significant in case of several subscales. Post hoc analyses indicated a significant association between BDHI subscales and s allele only in the depressed group.\n\nLIMITATION: Only women were studied and since gender differences are present both in aggressive behavior and putatively in the behavioral effects of 5-HTTLPR genotype, our findings pertain only to females.\n\nCONCLUSION: Our results indicate a robust relationship between aggression/hostility and 5-HTTLPR genotype, but this association is more marked in the presence of depression. The presence of the s allele thus not only contributes to a higher risk of depression, but in depressives also leads to higher aggression/hostility. Our results have important implications for suicide research, since the s allele is associated with violent suicide, and this association may be mediated through the emergence of increased aggression/hostility in depressed patients carrying the s allele.", "journal": "Journal of affective disorders", "year": "2011", "authors": "Gonda X, Fountoulakis KN, Csukly G, Bagdy G, Pap D, Molnár E, Laszik A, Lazary J, Sarosi A, Faludi G, Sasvari-Szekely M, Szekely A, Rihmer Z", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2011.03.029", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.637Z" }, { "id": "dfb3074f-8ca5-4cc5-8d0a-af08b52635bf", "pmid": "21492940", "title": "Interaction of 5-HTTLPR genotype and unipolar major depression in the emergence of aggressive/hostile traits.", "imported": false, "abstract": "OBJECTIVE: The 5-HTTLPR polymorphism has been associated both with depression and aggression/hostility. The multidirectional association between depression, aggression and the s allele may be important, since all these phenomena are related to suicidal behavior. Our aim was to investigate the association between 5-HTTLPR and aggressive/hostile traits in depressed patients and controls.\n\nMETHODS: 137 depressive and 118 control women completed the Buss-Durkee Hostility Inventory and were genotyped for 5-HTTLPR. BDHI scores in the different groups were investigated by Generalized Linear Model Analysis. Association between dependent and independent variables in the model was tested by the likelihood ratio Chi-square statistic.\n\nRESULTS: Diagnosis and genotype showed a significant association with several aggressive/hostile traits. Interaction of the two main effects was also significant in case of several subscales. 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false, "abstract": "", "journal": "", "year": "2011", "authors": "Sasaki Y, Shimada T, Iizuka S, Suzuki W, Makihara H, Teraoka R, Tsuneyama K, Hokao R, Aburada M.", "articleTypes": [], "doi": "10.1016/j.ejphar.2011.04.051", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.408Z" }, { "id": "68e2bf2c-a148-496c-9d0a-dd40e52a233e", "pmid": "21549692", "title": "Effects of bezafibrate in nonalcoholic steatohepatitis model mice with monosodium glutamate-induced metabolic syndrome", "imported": false, "abstract": "", "journal": "", "year": "2011", "authors": "Sasaki Y, Shimada T, Iizuka S, Suzuki W, Makihara H, Teraoka R, Tsuneyama K, Hokao R, Aburada M.", "articleTypes": [], "doi": "10.1016/j.ejphar.2011.04.051", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.912Z" }, { "id": "9896409c-c1f7-44a4-9248-ae7ee32ade77", "pmid": "21549692", "title": "Effects of bezafibrate in 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"id": "19c38e37-0009-40f9-a1a6-e9703d20ad72", "pmid": "21550122", "title": "The 5-HTTLPR polymorphism, impulsivity and suicide behavior in euthymic bipolar patients.", "imported": false, "abstract": "BACKGROUND: Suicide behavior is very frequent in Bipolar Disorder (BD) and they are both closely associated with impulsivity. Furthermore they are, impulsivity, BD and suicide behavior, associated with serotonergic function, at least partially, under genetic determinism and somewhat associated with the serotonin transporter gene polymorphism, the 5-HTTLPR. We aimed to assess different impulsivity components in BD sub-grouped by suicidal attempt and healthy controls. We hypothesized that the non-planning/cognitive impulsivity, could be more closely associated with suicidal behavior. We further associated 5-HTTLPR genotypes with neuropsychological results to test the hypothesis that this polymorphism is associated with cognitive impulsivity.\n\nMETHOD: We assessed 95 euthymic bipolar patients sub-grouped by suicidal attempt history in comparison with 94 healthy controls. All subjects underwent a laboratory assessment of impulsivity (Continuous Performance Test and Iowa Gambling Test). Furthermore the genotyping of 5-HTTLPR was performed in all subjects.\n\nRESULTS: We found that bipolar patients are more impulsive than healthy controls in all impulsivity dimensions we studied. Furthermore bipolar patients with a suicide attempt history have a greater cognitive impulsivity when compared to both bipolar patients without such a history as well when compared to healthy controls. No association was found between 5-HTTLPR genotypes and neuropsychological measures of impulsive behavior.\n\nLIMITATIONS: The sample studied can be considered small and a potentially confounding variable - medication status - was not controlled.\n\nCONCLUSION: A lifetime suicide attempt seems associated with cognitive impulsivity independently of the socio-demographic and clinical variables studied as well with 5-HTTLPR genotype. Further studies in larger samples are necessary.", "journal": "Journal of affective disorders", "year": "2011", "authors": "Malloy-Diniz LF, Neves FS, de Moraes PH, De Marco LA, Romano-Silva MA, Krebs MO, Corrêa H", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2011.03.051", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.636Z" }, { "id": "5034457f-3248-4850-8654-c583c025e688", "pmid": "21550122", "title": "The 5-HTTLPR polymorphism, impulsivity and suicide behavior in euthymic bipolar patients.", "imported": false, "abstract": "BACKGROUND: Suicide behavior is very frequent in Bipolar Disorder (BD) and they are both closely associated with impulsivity. Furthermore they are, impulsivity, BD and suicide behavior, associated with serotonergic function, at least partially, under genetic determinism and somewhat associated with the serotonin transporter gene polymorphism, the 5-HTTLPR. We aimed to assess different impulsivity components in BD sub-grouped by suicidal attempt and healthy controls. We hypothesized that the non-planning/cognitive impulsivity, could be more closely associated with suicidal behavior. We further associated 5-HTTLPR genotypes with neuropsychological results to test the hypothesis that this polymorphism is associated with cognitive impulsivity.\n\nMETHOD: We assessed 95 euthymic bipolar patients sub-grouped by suicidal attempt history in comparison with 94 healthy controls. All subjects underwent a laboratory assessment of impulsivity (Continuous Performance Test and Iowa Gambling Test). Furthermore the genotyping of 5-HTTLPR was performed in all subjects.\n\nRESULTS: We found that bipolar patients are more impulsive than healthy controls in all impulsivity dimensions we studied. Furthermore bipolar patients with a suicide attempt history have a greater cognitive impulsivity when compared to both bipolar patients without such a history as well when compared to healthy controls. No association was found between 5-HTTLPR genotypes and neuropsychological measures of impulsive behavior.\n\nLIMITATIONS: The sample studied can be considered small and a potentially confounding variable - medication status - was not controlled.\n\nCONCLUSION: A lifetime suicide attempt seems associated with cognitive impulsivity independently of the socio-demographic and clinical variables studied as well with 5-HTTLPR genotype. Further studies in larger samples are necessary.", "journal": "Journal of affective disorders", "year": "2011", "authors": "Malloy-Diniz LF, Neves FS, de Moraes PH, De Marco LA, Romano-Silva MA, Krebs MO, Corrêa H", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2011.03.051", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.576Z" }, { "id": "6707084d-0d16-4d94-83d0-872a568f0803", "pmid": "21550122", "title": "The 5-HTTLPR polymorphism, impulsivity and suicide behavior in euthymic bipolar patients.", "imported": false, "abstract": "BACKGROUND: Suicide behavior is very frequent in Bipolar Disorder (BD) and they are both closely associated with impulsivity. Furthermore they are, impulsivity, BD and suicide behavior, associated with serotonergic function, at least partially, under genetic determinism and somewhat associated with the serotonin transporter gene polymorphism, the 5-HTTLPR. We aimed to assess different impulsivity components in BD sub-grouped by suicidal attempt and healthy controls. We hypothesized that the non-planning/cognitive impulsivity, could be more closely associated with suicidal behavior. We further associated 5-HTTLPR genotypes with neuropsychological results to test the hypothesis that this polymorphism is associated with cognitive impulsivity.\n\nMETHOD: We assessed 95 euthymic bipolar patients sub-grouped by suicidal attempt history in comparison with 94 healthy controls. All subjects underwent a laboratory assessment of impulsivity (Continuous Performance Test and Iowa Gambling Test). Furthermore the genotyping of 5-HTTLPR was performed in all subjects.\n\nRESULTS: We found that bipolar patients are more impulsive than healthy controls in all impulsivity dimensions we studied. Furthermore bipolar patients with a suicide attempt history have a greater cognitive impulsivity when compared to both bipolar patients without such a history as well when compared to healthy controls. No association was found between 5-HTTLPR genotypes and neuropsychological measures of impulsive behavior.\n\nLIMITATIONS: The sample studied can be considered small and a potentially confounding variable - medication status - was not controlled.\n\nCONCLUSION: A lifetime suicide attempt seems associated with cognitive impulsivity independently of the socio-demographic and clinical variables studied as well with 5-HTTLPR genotype. Further studies in larger samples are necessary.", "journal": "Journal of affective disorders", "year": "2011", "authors": "Malloy-Diniz LF, Neves FS, de Moraes PH, De Marco LA, Romano-Silva MA, Krebs MO, Corrêa H", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2011.03.051", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.170Z" }, { "id": "556b2728-f47a-4326-9ac7-04d6234d5587", "pmid": "21551960", "title": "Adipokines and aging", "imported": false, "abstract": "", "journal": "", "year": "2011", "authors": "Arai Y, Takayama M, Abe Y, Hirose N.", "articleTypes": [], "doi": "10.5551/jat.7039", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.411Z" }, { "id": "8d3a6364-0101-4911-af34-85e9daa4b816", "pmid": "21551960", "title": "Adipokines and aging", "imported": false, "abstract": "", "journal": "", "year": "2011", "authors": "Arai Y, Takayama M, Abe Y, Hirose N.", "articleTypes": [], "doi": "10.5551/jat.7039", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.798Z" }, { "id": "b5bd6678-995a-4587-9391-a7f2d381eae4", "pmid": 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Bian J, Zhao YL, Zhang X, Zou N, Li D.", "articleTypes": [], "doi": "10.1111/j.1463-1326.2011.01419.x", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.368Z" }, { "id": "72f41009-2282-4e5f-8971-2c30d9ec943c", "pmid": "21554522", "title": "Lentiviral vector-mediated knockdown of SOCS3 in the hypothalamus protects against the development of diet-induced obesity in rats", "imported": false, "abstract": "", "journal": "", "year": "2011", "authors": "Liu ZJ, Bian J, Zhao YL, Zhang X, Zou N, Li D.", "articleTypes": [], "doi": "10.1111/j.1463-1326.2011.01419.x", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.401Z" }, { "id": "b7804c9c-ddf6-4709-a0bc-f4e34699f477", "pmid": "21554522", "title": "Lentiviral vector-mediated knockdown of SOCS3 in the hypothalamus protects against the development of diet-induced obesity in rats", "imported": false, "abstract": "", "journal": "", 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"notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.889Z" }, { "id": "e86003c6-68a8-44a0-b1d7-56fe790b2ef6", "pmid": "21575521", "title": "[Relationship between the mutation of leptin receptor gene and tumorigenesis of breast cancer]", "imported": false, "abstract": "", "journal": "", "year": "2011", "authors": "Han CZ, DU LL, Jing JX, Zhao XW, Tian FG, Tian BG, Wu HM.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.380Z" }, { "id": "1e5c1e5f-8a1d-46f6-8feb-c3fda683d8c7", "pmid": "21575667", "title": "Role of serotonergic-related systems in suicidal behavior: Data from a case-control association study.", "imported": false, "abstract": "OBJECTIVE: To investigate whether functional polymorphisms directly (HTR2A and SLC6A4 genes) or indirectly (IL-1 gene complex, APOE and ACE genes) related with serotonergic neurotransmission were associated with suicidal behavior.\n\nSUBJECTS AND METHODS: 227 suicide attempters, 686 non-suicidal psychiatric patients, and 420 healthy controls from a homogeneous Spanish Caucasian population were genotyped using standard methods.\n\nRESULTS: There were no differences in genotype frequencies between the three groups. The -1438A/G [χ(2) (df)=9.80 (2), uncorrected p=0.007] and IL-1α -889C/T [χ(2) (df)=8.76 (2), uncorrected p=0.013] genotype frequencies between impulsive and planned suicide attempts trended toward being different (not significant after Bonferroni correction). Suicide attempts were more often impulsive in the presence of -1438G/G or IL-1α -889C/T or C/C genotypes. There was interaction between the polymorphism 5-HTTLPR and age [LRT (df)=6.84 (2), p=0.033] and between the polymorphisms APOE and IL-1RA (86bp)(n) [LRT (df)=12.21 (4), p=0.016] in relation to suicide attempt lethality.\n\nCONCLUSION: These findings further evidence the complexity of the association between genetics and suicidal behavior, the need to study homogenous forms of the behavior and the relevance of impulsive and aggressive traits as endophenotypes for suicidal behavior.", "journal": "Progress in neuro-psychopharmacology & biological psychiatry", "year": "2011", "authors": "Saiz PA, García-Portilla P, Paredes B, Corcoran P, Arango C, Morales B, Sotomayor E, Alvarez V, Coto E, Flórez G, Bascaran MT, Bousoño M, Bobes J", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.pnpbp.2011.04.011", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.576Z" }, { "id": "ae5fa7c5-b283-45c6-9f78-1a3c874931f0", "pmid": "21575667", "title": "Role of serotonergic-related systems in suicidal behavior: Data from a case-control association study.", "imported": false, "abstract": "OBJECTIVE: To investigate whether functional polymorphisms directly (HTR2A and SLC6A4 genes) or indirectly (IL-1 gene complex, APOE and ACE genes) related with serotonergic neurotransmission were associated with suicidal behavior.\n\nSUBJECTS AND METHODS: 227 suicide attempters, 686 non-suicidal psychiatric patients, and 420 healthy controls from a homogeneous Spanish Caucasian population were genotyped using standard methods.\n\nRESULTS: There were no differences in genotype frequencies between the three groups. The -1438A/G [χ(2) (df)=9.80 (2), uncorrected p=0.007] and IL-1α -889C/T [χ(2) (df)=8.76 (2), uncorrected p=0.013] genotype frequencies between impulsive and planned suicide attempts trended toward being different (not significant after Bonferroni correction). Suicide attempts were more often impulsive in the presence of -1438G/G or IL-1α -889C/T or C/C genotypes. There was interaction between the polymorphism 5-HTTLPR and age [LRT (df)=6.84 (2), p=0.033] and between the polymorphisms APOE and IL-1RA (86bp)(n) [LRT (df)=12.21 (4), p=0.016] in relation to suicide attempt lethality.\n\nCONCLUSION: These findings further evidence the complexity of the association between genetics and suicidal behavior, the need to study homogenous forms of the behavior and the relevance of impulsive and aggressive traits as endophenotypes for suicidal behavior.", "journal": "Progress in neuro-psychopharmacology & biological psychiatry", "year": "2011", "authors": "Saiz PA, García-Portilla P, Paredes B, Corcoran P, Arango C, Morales B, Sotomayor E, Alvarez V, Coto E, Flórez G, Bascaran MT, Bousoño M, Bobes J", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.pnpbp.2011.04.011", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.637Z" }, { "id": "dabd50a8-ad38-4e29-9042-4597fdab20b0", "pmid": "21575667", "title": "Role of serotonergic-related systems in suicidal behavior: Data from a case-control association study.", "imported": false, "abstract": "OBJECTIVE: To investigate whether functional polymorphisms directly (HTR2A and SLC6A4 genes) or indirectly (IL-1 gene complex, APOE and ACE genes) related with serotonergic neurotransmission were associated with suicidal behavior.\n\nSUBJECTS AND METHODS: 227 suicide attempters, 686 non-suicidal psychiatric patients, and 420 healthy controls from a homogeneous Spanish Caucasian population were genotyped using standard methods.\n\nRESULTS: There were no differences in genotype frequencies between the three groups. The -1438A/G [χ(2) (df)=9.80 (2), uncorrected p=0.007] and IL-1α -889C/T [χ(2) (df)=8.76 (2), uncorrected p=0.013] genotype frequencies between impulsive and planned suicide attempts trended toward being different (not significant after Bonferroni correction). Suicide attempts were more often impulsive in the presence of -1438G/G or IL-1α -889C/T or C/C genotypes. 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Recently, a novel variant of the 5-HTTLPR L allele was identified. The previously unknown L(G) allele produced similar levels of gene expression to the S allele and might have been misclassified as a \"high-expression\" allele in previous association studies. In this study, we aimed to compare the genotype distribution of the tri-allelic 5-HTTLPR polymorphism in 168 Chinese patients with schizophrenia, including 60 suicide attempters and 108 non-suicide attempters. In our analysis, which used the L(A) dominant model, it was found that the L(A) allele carriers were significantly more likely to have attempted suicide (p=0.035). Further analysis showed this association existed only in male patients (p=0.012). A similar association between the L(A) allele and violent suicide attempt was also found (p=0.028). 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Recently, a novel variant of the 5-HTTLPR L allele was identified. The previously unknown L(G) allele produced similar levels of gene expression to the S allele and might have been misclassified as a \"high-expression\" allele in previous association studies. In this study, we aimed to compare the genotype distribution of the tri-allelic 5-HTTLPR polymorphism in 168 Chinese patients with schizophrenia, including 60 suicide attempters and 108 non-suicide attempters. In our analysis, which used the L(A) dominant model, it was found that the L(A) allele carriers were significantly more likely to have attempted suicide (p=0.035). Further analysis showed this association existed only in male patients (p=0.012). A similar association between the L(A) allele and violent suicide attempt was also found (p=0.028). In addition, logistic regression confirmed our findings that male L(A) allele carriers were at a higher risk of suicide, although the lack of a significant association in females may reflect insufficient power due to small sample size. However, no association was found when we examined the traditional bi-allelic 5-HTTLPR. These findings differ from those reported in Caucasian subjects, where no associations have been reported. Different genetic backgrounds may give rise to different allelic distribution, causing differential effects on the expression of endophenotypes of suicide behaviours. Although the potential influence of multiple comparisons might weaken our findings, our study provides preliminary evidence for a potentially gender-specific role of a \"high-expression\" 5-HTTLPR polymorphism in susceptibility to suicide in Chinese patients with schizophrenia.", "journal": "Neuroscience letters", "year": "2011", "authors": "Hung CF, Lung FW, Chen CH, O'Nions E, Hung TH, Chong MY, Wu CK, Wen JK, Lin PY", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.neulet.2011.09.036", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.636Z" }, { "id": "777d834b-bb8c-4384-b83f-45e39f512f2e", "pmid": "21964390", "title": "Association between suicide attempt and a tri-allelic functional polymorphism in serotonin transporter gene promoter in Chinese patients with schizophrenia.", "imported": false, "abstract": "Mounting evidence supports the association between a polymorphism in the serotonin transporter gene promoter region (5-HTTLPR) and suicidal behaviour. Recently, a novel variant of the 5-HTTLPR L allele was identified. The previously unknown L(G) allele produced similar levels of gene expression to the S allele and might have been misclassified as a \"high-expression\" allele in previous association studies. In this study, we aimed to compare the genotype distribution of the tri-allelic 5-HTTLPR polymorphism in 168 Chinese patients with schizophrenia, including 60 suicide attempters and 108 non-suicide attempters. In our analysis, which used the L(A) dominant model, it was found that the L(A) allele carriers were significantly more likely to have attempted suicide (p=0.035). Further analysis showed this association existed only in male patients (p=0.012). A similar association between the L(A) allele and violent suicide attempt was also found (p=0.028). In addition, logistic regression confirmed our findings that male L(A) allele carriers were at a higher risk of suicide, although the lack of a significant association in females may reflect insufficient power due to small sample size. However, no association was found when we examined the traditional bi-allelic 5-HTTLPR. These findings differ from those reported in Caucasian subjects, where no associations have been reported. Different genetic backgrounds may give rise to different allelic distribution, causing differential effects on the expression of endophenotypes of suicide behaviours. Although the potential influence of multiple comparisons might weaken our findings, our study provides preliminary evidence for a potentially gender-specific role of a \"high-expression\" 5-HTTLPR polymorphism in susceptibility to suicide in Chinese patients with schizophrenia.", "journal": "Neuroscience letters", "year": "2011", "authors": "Hung CF, Lung FW, Chen CH, O'Nions E, Hung TH, Chong MY, Wu CK, Wen JK, Lin PY", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.neulet.2011.09.036", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND 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Short allele (SS) variation decreases the transcriptional efficacy of serotonin, causing psychiatric disorders, major depressive disorder (MDD) and major depression in response to stressful life events. The aim of this study was to determine the current understanding of the role of 5-HTTLPR polymorphism in the development of depressive episodes and its response to treatment. Twenty-five articles were identified from PubMed, utilizing the following keyword, 5-HTT transporter gene, polymorphism, depression, stressful condition, psychiatric disorder. All articles were read and notes were made regarding study participant, measures, data analysis and results, and were used to write this review. The distribution of the SS allele in patients is associated with an increased risk of MDD following exposure to stressful events of life. Additionally, this genetic variant is closely associated with several psychiatric conditions such as suicidal behaviour, psychoses, personality disorders, and aggressive-impulsive traits.", "journal": "In vivo (Athens, Greece)", "year": "2011", "authors": "Daniele A, Divella R, Paradiso A, Mattioli V, Romito F, Giotta F, Casamassima P, Quaranta M", "articleTypes": [ "Journal Article", "Review" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR 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S, Fam BC.", "articleTypes": [], "doi": "10.2337/db11-1511", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.785Z" }, { "id": "99bcce89-4f96-4c89-9154-a840d83ffd2d", "pmid": "22517657", "title": "The role of liver fructose-1,6-bisphosphatase in regulating appetite and adiposity", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Visinoni S, Khalid NF, Joannides CN, Shulkes A, Yim M, Whitehead J, Tiganis T, Lamont BJ, Favaloro JM, Proietto J, Andrikopoulos S, Fam BC.", "articleTypes": [], "doi": "10.2337/db11-1511", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.397Z" }, { "id": "e3b12b21-fc27-4786-9d33-967f7870fd7f", "pmid": "22517657", "title": "The role of liver fructose-1,6-bisphosphatase in regulating appetite and adiposity", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Visinoni S, Khalid NF, Joannides CN, Shulkes A, Yim M, Whitehead J, Tiganis T, Lamont BJ, Favaloro JM, Proietto J, Andrikopoulos S, Fam BC.", "articleTypes": [], "doi": "10.2337/db11-1511", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.428Z" }, { "id": "03a43884-1314-4c9e-b515-48503d982fd3", "pmid": "22518191", "title": "Leptin in anorexia and cachexia syndrome", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Engineer DR, Garcia JM.", "articleTypes": [], "doi": "10.1155/2012/287457", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.453Z" }, { "id": "17b870a9-f10a-44b0-b901-5eac064b63cf", "pmid": "22518191", "title": "Leptin in anorexia and cachexia syndrome", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Engineer DR, Garcia JM.", "articleTypes": [], "doi": "10.1155/2012/287457", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.423Z" }, { "id": "ed40fbe0-597b-44b6-b96c-d3f3ecab4b95", "pmid": "22518191", "title": "Leptin in anorexia and cachexia syndrome", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Engineer DR, Garcia JM.", "articleTypes": [], "doi": "10.1155/2012/287457", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.808Z" }, { "id": "f076f7b7-9140-42c2-b87f-8ca0fed04e49", "pmid": "22518191", "title": "Leptin in anorexia and cachexia syndrome", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Engineer DR, Garcia JM.", "articleTypes": [], "doi": "10.1155/2012/287457", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.923Z" }, { "id": "25dce99b-6513-4775-ad34-5355df5210a7", "pmid": "22520017", "title": "Suicide ideators and attempters with schizophrenia--the role of 5-HTTLPR, rs25531, and 5-HTT VNTR Intron 2 variants.", "imported": false, "abstract": "AIM: To examine the role of 5-HTTLPR, rs25531 and 5-HTT VNTR Intron 2 variants in subjects with psychotic disorders manifesting suicide ideation and behaviour.\n\nMETHODS: The study included 519 subsequently hospitalized subjects who were genotyped for 5-HTTLPR, rs25531 and 5-HTT VNTR In2 variants. Clinical assessments included structured psychiatric interview, sociodemographic characteristics, suicide ideation and behaviour (SIBQ), severity of psychopathology (PANSS) and depression (CDSS).\n\nRESULTS: Three subgroups were identified: suicide attempters (N = 161), suicide ideators (N = 174) and subjects who never reported suicide ideation or behaviour (comparative group, N = 184).\n\nMAJOR FINDINGS: 1) Suicide attempters scored highest on the CDSS, while no differences between the three clinical subgroups were detected in the PANSS scores; 2) Suicide attempters were more frequently the carriers of L(A) allele, while subjects in the comparative group were more frequently the carriers of low expression 5-HTTLPR/5-HTT rs25531 haplotype SL(G); 3) No difference was found between the three clinical groups in the 5-HTT VNTR In2 variants; 4) Subjects with 5-HTTLPR/5-HTT rs25531 intermediate expression haplotype (L(A)L(G,)SL(A)) scored higher on the PANSS general psychopathology subscale; 5) There was no association between suicide attempt or ideation and 5-HTTLPR/In2 or 5-HTTLPR/rs25531/In2 haplotype distribution.\n\nCONCLUSION: The suicide ideators, attempters and controls did not differ significantly in 5-HTTLPR or 5-HTT VNTR In 2 variants, but 5-HTTLPR/5-HTT rs25531 haplotype might be a useful genetic marker in distinguishing these three clinical groups.", "journal": "Journal of psychiatric research", "year": "2012", "authors": "Božina N, Jovanović N, Podlesek A, Rojnić Kuzman M, Kudumija Slijepčević M, Roguljić A, Dimitrović A, Božina T, Lovrić J, Ljubić H, Medved V", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jpsychires.2012.03.008", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.636Z" }, { "id": "beee3e59-a809-48a8-9ce3-ff6f2da81642", "pmid": "22520017", "title": "Suicide ideators and attempters with schizophrenia--the role of 5-HTTLPR, rs25531, and 5-HTT VNTR Intron 2 variants.", "imported": false, "abstract": "AIM: To examine the role of 5-HTTLPR, rs25531 and 5-HTT VNTR Intron 2 variants in subjects with psychotic disorders manifesting suicide ideation and behaviour.\n\nMETHODS: The study included 519 subsequently hospitalized subjects who were genotyped for 5-HTTLPR, rs25531 and 5-HTT VNTR In2 variants. Clinical assessments included structured psychiatric interview, sociodemographic characteristics, suicide ideation and behaviour (SIBQ), severity of psychopathology (PANSS) and depression (CDSS).\n\nRESULTS: Three subgroups were identified: suicide attempters (N = 161), suicide ideators (N = 174) and subjects who never reported suicide ideation or behaviour (comparative group, N = 184).\n\nMAJOR FINDINGS: 1) Suicide attempters scored highest on the CDSS, while no differences between the three clinical subgroups were detected in the PANSS scores; 2) Suicide attempters were more frequently the carriers of L(A) allele, while subjects in the comparative group were more frequently the carriers of low expression 5-HTTLPR/5-HTT rs25531 haplotype SL(G); 3) No difference was found between the three clinical groups in the 5-HTT VNTR In2 variants; 4) Subjects with 5-HTTLPR/5-HTT rs25531 intermediate expression haplotype (L(A)L(G,)SL(A)) scored higher on the PANSS general psychopathology subscale; 5) There was no association between suicide attempt or ideation and 5-HTTLPR/In2 or 5-HTTLPR/rs25531/In2 haplotype distribution.\n\nCONCLUSION: The suicide ideators, attempters and controls did not differ significantly in 5-HTTLPR or 5-HTT VNTR In 2 variants, but 5-HTTLPR/5-HTT rs25531 haplotype might be a useful genetic marker in distinguishing these three clinical groups.", "journal": "Journal of psychiatric research", "year": "2012", "authors": "Božina N, Jovanović N, Podlesek A, Rojnić Kuzman M, Kudumija Slijepčević M, Roguljić A, Dimitrović A, Božina T, Lovrić J, Ljubić H, Medved V", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jpsychires.2012.03.008", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.169Z" }, { "id": "c153fe47-d65a-4ccc-a128-191201200aeb", "pmid": "22520017", "title": "Suicide ideators and attempters with schizophrenia--the role of 5-HTTLPR, rs25531, and 5-HTT VNTR Intron 2 variants.", "imported": false, "abstract": "AIM: To examine the role of 5-HTTLPR, rs25531 and 5-HTT VNTR Intron 2 variants in subjects with psychotic disorders manifesting suicide ideation and behaviour.\n\nMETHODS: The study included 519 subsequently hospitalized subjects who were genotyped for 5-HTTLPR, rs25531 and 5-HTT VNTR In2 variants. Clinical assessments included structured psychiatric interview, sociodemographic characteristics, suicide ideation and behaviour (SIBQ), severity of psychopathology (PANSS) and depression (CDSS).\n\nRESULTS: Three subgroups were identified: suicide attempters (N = 161), suicide ideators (N = 174) and subjects who never reported suicide ideation or behaviour (comparative group, N = 184).\n\nMAJOR FINDINGS: 1) Suicide attempters scored highest on the CDSS, while no differences between the three clinical subgroups were detected in the PANSS scores; 2) Suicide attempters were more frequently the carriers of L(A) allele, while subjects in the comparative group were more frequently the carriers of low expression 5-HTTLPR/5-HTT rs25531 haplotype SL(G); 3) No difference was found between the three clinical groups in the 5-HTT VNTR In2 variants; 4) Subjects with 5-HTTLPR/5-HTT rs25531 intermediate expression haplotype (L(A)L(G,)SL(A)) scored higher on the PANSS general psychopathology subscale; 5) There was no association between suicide attempt or ideation and 5-HTTLPR/In2 or 5-HTTLPR/rs25531/In2 haplotype distribution.\n\nCONCLUSION: The suicide ideators, attempters and controls did not differ significantly in 5-HTTLPR or 5-HTT VNTR In 2 variants, but 5-HTTLPR/5-HTT rs25531 haplotype might be a useful genetic marker in distinguishing these three clinical groups.", "journal": "Journal of psychiatric research", "year": "2012", "authors": "Božina N, Jovanović N, Podlesek A, Rojnić Kuzman M, Kudumija Slijepčević M, Roguljić A, Dimitrović A, Božina T, Lovrić J, Ljubić H, Medved V", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jpsychires.2012.03.008", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.575Z" }, { "id": "09b90582-db37-407a-aa14-ae83a1043b7e", "pmid": "22529850", "title": "Little evidence of systemic and adipose tissue inflammation in overweight individuals(†)", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Tam CS, Covington JD, Ravussin E, Redman LM; Pennington CALERIE Team.", "articleTypes": [], "doi": "10.3389/fgene.2012.00058", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.924Z" }, { "id": "12a9300c-acc3-47c5-a938-4e80e3ba9dd0", "pmid": "22529850", "title": "Little evidence of systemic and adipose tissue inflammation in overweight individuals(†)", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Tam CS, Covington JD, Ravussin E, Redman LM; Pennington CALERIE Team.", "articleTypes": [], "doi": "10.3389/fgene.2012.00058", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.809Z" }, { "id": "2040b0ee-bd1c-445f-8e23-c628fe5eb2ef", "pmid": "22529850", "title": "Little evidence of systemic and adipose tissue inflammation in overweight individuals(†)", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Tam CS, Covington JD, Ravussin E, Redman LM; Pennington CALERIE Team.", "articleTypes": [], "doi": "10.3389/fgene.2012.00058", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.454Z" }, { "id": "92f6791d-4ed9-4ba0-a39e-7b4d754edcde", "pmid": "22529850", "title": "Little evidence of systemic and adipose tissue inflammation in overweight individuals(†)", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Tam CS, Covington JD, Ravussin E, Redman LM; Pennington CALERIE Team.", "articleTypes": [], "doi": "10.3389/fgene.2012.00058", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.424Z" }, { "id": "04dd2f86-bf01-40de-ad5d-41bce3bd40cb", "pmid": "22530350", "title": "Lys656Asn polymorphism of leptin receptor, leptin levels and insulin resistance in patients with non alcoholic fatty liver disease", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Aller R, De Luis DA, Izaola O, González Sagrado M, Conde R, Pacheco D, Velasco MC, Ovalle HF.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", 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"articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.777Z" }, { "id": "a98234b3-aa37-4f54-a904-c75a460dcea8", "pmid": "22530350", "title": "Lys656Asn polymorphism of leptin receptor, leptin levels and insulin resistance in patients with non alcoholic fatty liver disease", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Aller R, De Luis DA, Izaola O, González Sagrado M, Conde R, Pacheco D, Velasco MC, Ovalle HF.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.390Z" }, { "id": "0ef9b710-1291-4b51-aa10-b9c2c22adb87", "pmid": "22531980", "title": "Retinoids ameliorate insulin resistance in a leptin-dependent manner in mice", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Tsuchiya H, Ikeda Y, Ebata Y, Kojima C, Katsuma R, Tsuruyama T, Sakabe T, Shomori K, Komeda N, Oshiro S, Okamoto H, Takubo K, Hama S, Shudo K, Kogure K, Shiota G.", "articleTypes": [], "doi": "10.1002/hep.25798", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.896Z" }, { "id": "3786bb85-8d47-454a-b88e-67a853ff6e45", "pmid": "22531980", "title": "Retinoids ameliorate insulin resistance in a leptin-dependent manner in mice", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Tsuchiya H, Ikeda Y, Ebata Y, Kojima C, Katsuma R, Tsuruyama T, Sakabe T, Shomori K, Komeda N, Oshiro S, Okamoto H, Takubo K, Hama S, Shudo K, Kogure K, Shiota G.", "articleTypes": [], "doi": "10.1002/hep.25798", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.389Z" }, { "id": "7f802664-c719-4174-b844-485b55e746ad", "pmid": "22531980", "title": "Retinoids ameliorate insulin resistance in a leptin-dependent manner in mice", "imported": false, "abstract": "", 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"title": "Effects of hyperoxia exposure on metabolic markers and gene expression in 3T3-L1 adipocytes", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Quintero P, González-Muniesa P, García-Díaz DF, Martínez JA.", "articleTypes": [], "doi": "10.1007/s13105-012-0169-8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.912Z" }, { "id": "ab75108a-c490-4c7e-9dc0-8d8f2a01027c", "pmid": "22535284", "title": "Effects of hyperoxia exposure on metabolic markers and gene expression in 3T3-L1 adipocytes", "imported": false, "abstract": "", "journal": "", "year": "2012", "authors": "Quintero P, González-Muniesa P, García-Díaz DF, Martínez JA.", "articleTypes": [], "doi": "10.1007/s13105-012-0169-8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.441Z" }, { "id": "bfc8b7da-f941-4986-864e-e72c91078dfb", "pmid": "22535284", "title": "Effects of hyperoxia 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The association of the 5-HTTLPR s allele with season of birth in a healthy female population, and possible consequences for temperament, depression and suicide.", "imported": false, "abstract": "BACKGROUND: Birth season has well-known effects on neuropsychiatric disorders, and may also influence genotype distribution by possibly influencing chance of conception via parental idiosyncratic conception patterns or survival of foetuses or infants. The 5-HTTLPR is associated with phenomena including affective temperaments or suicide which are also associated with birth season. Our aim was to investigate the association of 5-HTTLPR genotype and birth season in a healthy female population.\n\nMETHODS: Birth date and 5-HTTLPR genotype was determined for 327 psychiatrically healthy women. The association between presence of s allele and time of birth was analysed using generalized linear models.\n\nRESULTS: A significant association between s allele frequency and time of birth was detected. S allele carrier frequency was marginally significantly higher in July borns and significantly lower in autumn borns.\n\nLIMITATIONS: We investigated an adult sample so genotype frequency data do not reflect birth frequencies. Our sample consisted exclusively of females.\n\nCONCLUSIONS: There is no clear explanation for the observed association, although idiosyncratic parental conception patterns, the association of 5-HTTLPR with sudden infant/intrauterine death, or other s allele-mediated behaviours may play a role. Our results are strikingly parallel with earlier data reporting a higher risk of completed suicide in July borns, and higher scores of July borns and lower scores of autumn borns on certain affective temperament scales, both of which are also associated with the s allele of 5-HTTLPR. Thus our results may add to the growing body of evidence regarding the etiological background of affective disorders.", "journal": "Journal of affective disorders", "year": "2012", "authors": "Gonda X, Fountoulakis KN, Csukly G, Dome P, Sarchiapone M, Laszik A, Bedi K, Juhasz G, Siamouli M, Rudisch T, Molnar E, Pap D, Bagdy G, Rihmer Z", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2012.05.031", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.169Z" }, { "id": "8bc53d53-2083-4d21-adc0-b668208adc6e", "pmid": "22840619", "title": "Star-crossed? The association of the 5-HTTLPR s allele with season of birth in a healthy female population, and possible consequences for temperament, depression and suicide.", "imported": false, "abstract": "BACKGROUND: Birth season has well-known effects on neuropsychiatric disorders, and may also influence genotype distribution by possibly influencing chance of conception via parental idiosyncratic conception patterns or survival of foetuses or infants. The 5-HTTLPR is associated with phenomena including affective temperaments or suicide which are also associated with birth season. Our aim was to investigate the association of 5-HTTLPR genotype and birth season in a healthy female population.\n\nMETHODS: Birth date and 5-HTTLPR genotype was determined for 327 psychiatrically healthy women. The association between presence of s allele and time of birth was analysed using generalized linear models.\n\nRESULTS: A significant association between s allele frequency and time of birth was detected. S allele carrier frequency was marginally significantly higher in July borns and significantly lower in autumn borns.\n\nLIMITATIONS: We investigated an adult sample so genotype frequency data do not reflect birth frequencies. Our sample consisted exclusively of females.\n\nCONCLUSIONS: There is no clear explanation for the observed association, although idiosyncratic parental conception patterns, the association of 5-HTTLPR with sudden infant/intrauterine death, or other s allele-mediated behaviours may play a role. Our results are strikingly parallel with earlier data reporting a higher risk of completed suicide in July borns, and higher scores of July borns and lower scores of autumn borns on certain affective temperament scales, both of which are also associated with the s allele of 5-HTTLPR. Thus our results may add to the growing body of evidence regarding the etiological background of affective disorders.", "journal": "Journal of affective disorders", "year": "2012", "authors": "Gonda X, Fountoulakis KN, Csukly G, Dome P, Sarchiapone M, Laszik A, Bedi K, Juhasz G, Siamouli M, Rudisch T, Molnar E, Pap D, Bagdy G, Rihmer Z", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2012.05.031", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.635Z" }, { "id": "b3ba52ff-61e9-46e1-a3ac-e2cb6b7da747", "pmid": "22840619", "title": "Star-crossed? The association of the 5-HTTLPR s allele with season of birth in a healthy female population, and possible consequences for temperament, depression and suicide.", "imported": false, "abstract": "BACKGROUND: Birth season has well-known effects on neuropsychiatric disorders, and may also influence genotype distribution by possibly influencing chance of conception via parental idiosyncratic conception patterns or survival of foetuses or infants. The 5-HTTLPR is associated with phenomena including affective temperaments or suicide which are also associated with birth season. Our aim was to investigate the association of 5-HTTLPR genotype and birth season in a healthy female population.\n\nMETHODS: Birth date and 5-HTTLPR genotype was determined for 327 psychiatrically healthy women. The association between presence of s allele and time of birth was analysed using generalized linear models.\n\nRESULTS: A significant association between s allele frequency and time of birth was detected. S allele carrier frequency was marginally significantly higher in July borns and significantly lower in autumn borns.\n\nLIMITATIONS: We investigated an adult sample so genotype frequency data do not reflect birth frequencies. Our sample consisted exclusively of females.\n\nCONCLUSIONS: There is no clear explanation for the observed association, although idiosyncratic parental conception patterns, the association of 5-HTTLPR with sudden infant/intrauterine death, or other s allele-mediated behaviours may play a role. Our results are strikingly parallel with earlier data reporting a higher risk of completed suicide in July borns, and higher scores of July borns and lower scores of autumn borns on certain affective temperament scales, both of which are also associated with the s allele of 5-HTTLPR. Thus our results may add to the growing body of evidence regarding the etiological background of affective disorders.", "journal": "Journal of affective disorders", "year": "2012", "authors": "Gonda X, Fountoulakis KN, Csukly G, Dome P, Sarchiapone M, Laszik A, Bedi K, Juhasz G, Siamouli M, Rudisch T, Molnar E, Pap D, Bagdy G, Rihmer Z", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2012.05.031", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR 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polymorphic region (5-HTTLPR) with environmental factors in determining Major Depressive Disorder (MDD). The current study contributes to this research area by comprehensively examining the interaction-effects and direct-effects of 5-HTTLPR and five environmental factors on MDD prevalence and course in a well-characterized longitudinal sample.\n\nMETHODS: The sample consisted of 1625 patients with a CIDI-confirmed diagnosis of MDD and 1698 screened controls from the Netherlands. Four MDD outcomes were studied as dependent variables: one main MDD prevalence-outcome (all MDD), two more severe MDD prevalence-outcomes (suicidal and chronic MDD), and one MDD course outcome (chronic versus non-chronic MDD). Because SNP rs25531 modifies the effect of 5-HTTLPR, haplotypes of 5-HTTLPR and rs25531 were measured. For the four MDD outcome measures, we examined the direct effects of 5-HTTLPR/rs25531-haplotypes, five environmental factors (lifetime and recent stressful life-events, sexual abuse, low educational attainment, and childhood trauma) and their interaction in logistic regression models.\n\nRESULTS: The environmental factors had large and consistent effects on all four MDD outcomes, including course of MDD. The 5-HTTLPR/rs25531-haplotype had a suggestive effect on course of MDD, but not on presence of MDD. Gene-by-environment interaction was significant (<0.05) for one of the 20 tests performed, which is not more than expected by chance.\n\nLIMITATIONS: Environmental factors were not assessed before the onset of MDD.\n\nCONCLUSIONS: Environmental factors had a strong impact on the presence and course of MDD, but no evidence for gene-by-environment interaction was found.", "journal": "Journal of affective disorders", "year": "2013", "authors": "Peyrot WJ, Middeldorp CM, Jansen R, Smit JH, de Geus EJ, Hottenga JJ, Willemsen G, Vink JM, Virding S, Barragan I, Ingelman-Sundberg M, Sim SC, Boomsma DI, Penninx BW", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2012.08.044", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.169Z" }, { "id": "c0bc87cb-2f6e-4cf2-8092-937e59f444ff", "pmid": "23021380", "title": "Strong effects of environmental factors on prevalence and course of major depressive disorder are not moderated by 5-HTTLPR polymorphisms in a large Dutch sample.", "imported": false, "abstract": "BACKGROUND: There is ongoing interest in the possible interaction of the serotonin-transporter-linked polymorphic region (5-HTTLPR) with environmental factors in determining Major Depressive Disorder (MDD). The current study contributes to this research area by comprehensively examining the interaction-effects and direct-effects of 5-HTTLPR and five environmental factors on MDD prevalence and course in a well-characterized longitudinal sample.\n\nMETHODS: The sample consisted of 1625 patients with a CIDI-confirmed diagnosis of MDD and 1698 screened controls from the Netherlands. Four MDD outcomes were studied as dependent variables: one main MDD prevalence-outcome (all MDD), two more severe MDD prevalence-outcomes (suicidal and chronic MDD), and one MDD course outcome (chronic versus non-chronic MDD). Because SNP rs25531 modifies the effect of 5-HTTLPR, haplotypes of 5-HTTLPR and rs25531 were measured. For the four MDD outcome measures, we examined the direct effects of 5-HTTLPR/rs25531-haplotypes, five environmental factors (lifetime and recent stressful life-events, sexual abuse, low educational attainment, and childhood trauma) and their interaction in logistic regression models.\n\nRESULTS: The environmental factors had large and consistent effects on all four MDD outcomes, including course of MDD. The 5-HTTLPR/rs25531-haplotype had a suggestive effect on course of MDD, but not on presence of MDD. Gene-by-environment interaction was significant (<0.05) for one of the 20 tests performed, which is not more than expected by chance.\n\nLIMITATIONS: Environmental factors were not assessed before the onset of MDD.\n\nCONCLUSIONS: Environmental factors had a strong impact on the presence and course of MDD, but no evidence for gene-by-environment interaction was found.", "journal": "Journal of affective disorders", "year": "2013", "authors": "Peyrot WJ, Middeldorp CM, Jansen R, Smit JH, de Geus EJ, Hottenga JJ, Willemsen G, Vink JM, Virding S, Barragan I, Ingelman-Sundberg M, Sim SC, Boomsma DI, Penninx BW", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2012.08.044", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.635Z" }, { "id": "e09770c7-d89a-409b-a15c-7be4df4e3c2a", "pmid": "23021380", "title": "Strong effects of environmental factors on prevalence and course of major depressive disorder are not moderated by 5-HTTLPR polymorphisms in a large Dutch sample.", "imported": false, "abstract": "BACKGROUND: There is ongoing interest in the possible interaction of the serotonin-transporter-linked polymorphic region (5-HTTLPR) with environmental factors in determining Major Depressive Disorder (MDD). The current study contributes to this research area by comprehensively examining the interaction-effects and direct-effects of 5-HTTLPR and five environmental factors on MDD prevalence and course in a well-characterized longitudinal sample.\n\nMETHODS: The sample consisted of 1625 patients with a CIDI-confirmed diagnosis of MDD and 1698 screened controls from the Netherlands. Four MDD outcomes were studied as dependent variables: one main MDD prevalence-outcome (all MDD), two more severe MDD prevalence-outcomes (suicidal and chronic MDD), and one MDD course outcome (chronic versus non-chronic MDD). Because SNP rs25531 modifies the effect of 5-HTTLPR, haplotypes of 5-HTTLPR and rs25531 were measured. For the four MDD outcome measures, we examined the direct effects of 5-HTTLPR/rs25531-haplotypes, five environmental factors (lifetime and recent stressful life-events, sexual abuse, low educational attainment, and childhood trauma) and their interaction in logistic regression models.\n\nRESULTS: The environmental factors had large and consistent effects on all four MDD outcomes, including course of MDD. The 5-HTTLPR/rs25531-haplotype had a suggestive effect on course of MDD, but not on presence of MDD. Gene-by-environment interaction was significant (<0.05) for one of the 20 tests performed, which is not more than expected by chance.\n\nLIMITATIONS: Environmental factors were not assessed before the onset of MDD.\n\nCONCLUSIONS: Environmental factors had a strong impact on the presence and course of MDD, but no evidence for gene-by-environment interaction was found.", "journal": "Journal of affective disorders", "year": "2013", "authors": "Peyrot WJ, Middeldorp CM, Jansen R, Smit JH, de Geus EJ, Hottenga JJ, Willemsen G, Vink JM, Virding S, Barragan I, Ingelman-Sundberg M, Sim SC, Boomsma DI, Penninx BW", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2012.08.044", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, 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By contrast, increased transcriptional activity of the L allele is considered protective for depression but is also associated with completed suicide, nicotine dependence, and attention deficit hyperactivity disorder. For some disorders, such as post-traumatic stress disorder and major depressive disorder, the research suggests that treatment response may vary by allele (such as an enhanced response to serotonin specific reuptake inhibitors in patients with major depressive disorder and post-traumatic stress disorder with L alleles), and for alcohol dependence, the association and treatment for S or L alleles may vary with alcoholic subtype. While some studies suggest that 5-HTTLPR polymorphism can moderate the response to pharmacotherapy, the association between 5-HTTLPR alleles and therapeutic outcomes is inconsistent. 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in the serotonergic system.", "imported": false, "abstract": "INTRODUCTION: Strong evidence demonstrates a genetic susceptibility to suicidal behaviour and a relationship between suicide and mental disorders. The aim of this study was to test for association between suicide and five selected genetic variants, which had shown association with suicide in other populations.\n\nMETHOD: We performed a nationwide case-control study on all suicide cases sent for autopsy in Denmark between the years 2000 and 2007. The study comprised 572 cases and 1049 controls and is one of the largest genetic studies in completed suicide to date. The analysed markers were located within the Serotonin Transporter (SLC6A4), Monoamine Oxidase-A (MAOA) and the Tryptophan Hydroxylase I and II (TPH1 and TPH2) genes.\n\nRESULTS: None of the genetic markers within SLC6A4, MAOA, TPH1 and TPH2 were significantly associated with completed suicide or suicide method in the basic association tests. Exploratory interaction test showed that the minor allele of rs1800532 in TPH1 has a protective effect for males younger than 35 years and females older than 50 years, whereas for the oldest male subjects, it tended to be a risk factor. We also observed a significant interaction between age-group and the 5-HTTLPR genotype (with and without rs25531) in SLC6A4. The long allele or high expression allele tends to have a protective effect in the middle age-group.\n\nLIMITATION: We only analysed a limited number of genetic variants.\n\nCONCLUSION: None of the analysed variants are strong risk factors. 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Exploratory interaction test showed that the minor allele of rs1800532 in TPH1 has a protective effect for males younger than 35 years and females older than 50 years, whereas for the oldest male subjects, it tended to be a risk factor. We also observed a significant interaction between age-group and the 5-HTTLPR genotype (with and without rs25531) in SLC6A4. The long allele or high expression allele tends to have a protective effect in the middle age-group.\n\nLIMITATION: We only analysed a limited number of genetic variants.\n\nCONCLUSION: None of the analysed variants are strong risk factors. 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The aim of this study was to test for association between suicide and five selected genetic variants, which had shown association with suicide in other populations.\n\nMETHOD: We performed a nationwide case-control study on all suicide cases sent for autopsy in Denmark between the years 2000 and 2007. The study comprised 572 cases and 1049 controls and is one of the largest genetic studies in completed suicide to date. The analysed markers were located within the Serotonin Transporter (SLC6A4), Monoamine Oxidase-A (MAOA) and the Tryptophan Hydroxylase I and II (TPH1 and TPH2) genes.\n\nRESULTS: None of the genetic markers within SLC6A4, MAOA, TPH1 and TPH2 were significantly associated with completed suicide or suicide method in the basic association tests. Exploratory interaction test showed that the minor allele of rs1800532 in TPH1 has a protective effect for males younger than 35 years and females older than 50 years, whereas for the oldest male subjects, it tended to be a risk factor. We also observed a significant interaction between age-group and the 5-HTTLPR genotype (with and without rs25531) in SLC6A4. The long allele or high expression allele tends to have a protective effect in the middle age-group.\n\nLIMITATION: We only analysed a limited number of genetic variants.\n\nCONCLUSION: None of the analysed variants are strong risk factors. 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Likewise, CT exposed carriers of the major rs3813034-rs1042173 ATAT diplotype had an increased risk of suicidal behavior relative to the ATCG/CGCG diplotype carriers (0.40 vs 0.31). Neither the 5' nor the 3' functional variants had an effect in individuals without CT: suicide attempt risk = 0.12-0.22. In individuals exposed to high CT the prevalence of suicide attempt was 0.56 in carriers of both 5' and 3' risk variants, 0.39 in carriers of one risk variant and 0.25 in individuals without either risk variant. 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Likewise, CT exposed carriers of the major rs3813034-rs1042173 ATAT diplotype had an increased risk of suicidal behavior relative to the ATCG/CGCG diplotype carriers (0.40 vs 0.31). Neither the 5' nor the 3' functional variants had an effect in individuals without CT: suicide attempt risk = 0.12-0.22. In individuals exposed to high CT the prevalence of suicide attempt was 0.56 in carriers of both 5' and 3' risk variants, 0.39 in carriers of one risk variant and 0.25 in individuals without either risk variant. 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Its aetiology is complex and diverse, however, epidemiological studies show that suicidal behavior is partly heritable. Neurobiological evidence implicates serotonergic dysfunction in suicidality, stimulating genetic research to focus on genes related to the serotonergic system. In this paper, we review evidence from studies examining the association between various serotonergic genes (Tryptophan Hydroxylase genes: TPH1; TPH2, Serotonin Transporter gene: 5-HTTLPR in SLC6A4, Serotonin Receptor genes: HTR1A, HTR2A, HTR1B, HTR2C and Monoamine Oxidase A gene: MAOA) and suicidal behavior. The data show associations between variation on the TPH1 gene and 5-HTTLPR gene and violent suicidal behavior in Caucasian populations, with the least inconsistencies. Results are mixed for the TPH2 gene and serotonin receptor genes, but for some genes, studies that include haplotypic analyses or that examine a larger coding region of the genes tend to provide more reliable results. Findings on endophenotypes of suicidality, such as aggression and impulsivity traits, show positive associations for the TPH1, HTR2A, and MAOA genes, but need further replication, since negative associations are also occasionally reported. Since genes can only partially explain suicidal risk, several studies during the past decade have tried to incorporate environmental factors in the susceptibility model. Studies to date show that variation on the 5-HTTLPR, MAOA and HTR2A gene can interact with stressful life events to increase risk for suicidal behavior. 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Its aetiology is complex and diverse, however, epidemiological studies show that suicidal behavior is partly heritable. Neurobiological evidence implicates serotonergic dysfunction in suicidality, stimulating genetic research to focus on genes related to the serotonergic system. In this paper, we review evidence from studies examining the association between various serotonergic genes (Tryptophan Hydroxylase genes: TPH1; TPH2, Serotonin Transporter gene: 5-HTTLPR in SLC6A4, Serotonin Receptor genes: HTR1A, HTR2A, HTR1B, HTR2C and Monoamine Oxidase A gene: MAOA) and suicidal behavior. The data show associations between variation on the TPH1 gene and 5-HTTLPR gene and violent suicidal behavior in Caucasian populations, with the least inconsistencies. Results are mixed for the TPH2 gene and serotonin receptor genes, but for some genes, studies that include haplotypic analyses or that examine a larger coding region of the genes tend to provide more reliable results. Findings on endophenotypes of suicidality, such as aggression and impulsivity traits, show positive associations for the TPH1, HTR2A, and MAOA genes, but need further replication, since negative associations are also occasionally reported. Since genes can only partially explain suicidal risk, several studies during the past decade have tried to incorporate environmental factors in the susceptibility model. Studies to date show that variation on the 5-HTTLPR, MAOA and HTR2A gene can interact with stressful life events to increase risk for suicidal behavior. Limitations of case-control studies are discussed and future considerations are put forward with regard to endophenotypic measurements and gene-environment interactions.", "journal": "European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology", "year": "2013", "authors": "Antypa N, Serretti A, Rujescu D", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Systematic Review" ], "doi": "10.1016/j.euroneuro.2013.03.013", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.573Z" }, { "id": "f9d8ca02-b9fd-47fa-8e63-42a329c0a1b6", "pmid": "23742855", "title": "Serotonergic genes and suicide: a systematic review.", "imported": false, "abstract": "Suicide is one of the leading causes of death in the world. Its aetiology is complex and diverse, however, epidemiological studies show that suicidal behavior is partly heritable. Neurobiological evidence implicates serotonergic dysfunction in suicidality, stimulating genetic research to focus on genes related to the serotonergic system. In this paper, we review evidence from studies examining the association between various serotonergic genes (Tryptophan Hydroxylase genes: TPH1; TPH2, Serotonin Transporter gene: 5-HTTLPR in SLC6A4, Serotonin Receptor genes: HTR1A, HTR2A, HTR1B, HTR2C and Monoamine Oxidase A gene: MAOA) and suicidal behavior. The data show associations between variation on the TPH1 gene and 5-HTTLPR gene and violent suicidal behavior in Caucasian populations, with the least inconsistencies. Results are mixed for the TPH2 gene and serotonin receptor genes, but for some genes, studies that include haplotypic analyses or that examine a larger coding region of the genes tend to provide more reliable results. Findings on endophenotypes of suicidality, such as aggression and impulsivity traits, show positive associations for the TPH1, HTR2A, and MAOA genes, but need further replication, since negative associations are also occasionally reported. Since genes can only partially explain suicidal risk, several studies during the past decade have tried to incorporate environmental factors in the susceptibility model. Studies to date show that variation on the 5-HTTLPR, MAOA and HTR2A gene can interact with stressful life events to increase risk for suicidal behavior. Limitations of case-control studies are discussed and future considerations are put forward with regard to endophenotypic measurements and gene-environment interactions.", "journal": "European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology", "year": "2013", "authors": "Antypa N, Serretti A, Rujescu D", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't", "Systematic Review" ], "doi": "10.1016/j.euroneuro.2013.03.013", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR 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survivors, however. In this study, we investigated whether serotonin transporter (5-HTT) and serotonin 2a receptor (5-HTR2a) genes were associated with suicidal ideation at 2 weeks and at 1 year after stroke.\n\nMETHODS: A total of 286 patients were evaluated 2 weeks after stroke, and 222 (78%) participated in a follow-up evaluation one year later. Suicidal ideation was ascertained using the \"suicidal thoughts\" item of the Montgomery and Asberg Depression Rating Scale. Associations between suicidal ideation and 5-HTTLPR, STin2 VNTR, 5-HTR2a 1438A/G, and 5-HTR2a 102T/C genotypes were estimated using logistic regression models, and gene-gene interactions were investigated using the generalized multifactor dimensionality reduction method after adjustment for potential covariates, including depression.\n\nRESULTS: The 5-HTR2a 1438 A/A genotype was significantly associated with suicidal ideation 2 weeks after stroke, before and after statistical adjustment. The 5-HTTLPR short allele was associated with suicidal ideation 2 weeks after stroke, although the significance of this finding was not evident after adjustment. No significant associations were observed between any genotype and suicidal ideation one year after stroke. No significant gene-gene interactions were detected.\n\nCONCLUSIONS: Individuals with the 5-HTR2a 1438 A/A genotype were more susceptible to suicidal ideation 2 weeks after stroke. Careful evaluation and management are indicated for those with increased genetic vulnerability, particularly during the acute phase of stroke.", "journal": "The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry", "year": "2014", "authors": "Kim JM, Kim SW, Kang HJ, Bae KY, Shin IS, Kim JT, Park MS, Park SW, Kim YH, Cho KH, Yoon JS", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jagp.2013.06.001", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.167Z" }, { "id": "4480f0b1-e576-43fb-9ebd-2afa74f2762f", "pmid": "23973249", "title": "Serotonergic genes and suicidal ideation 2 weeks and 1 year after stroke in Korea.", "imported": false, "abstract": "OBJECTIVES: Serotonergic genes are associated with suicidal behavior; this association has not been tested in stroke survivors, however. In this study, we investigated whether serotonin transporter (5-HTT) and serotonin 2a receptor (5-HTR2a) genes were associated with suicidal ideation at 2 weeks and at 1 year after stroke.\n\nMETHODS: A total of 286 patients were evaluated 2 weeks after stroke, and 222 (78%) participated in a follow-up evaluation one year later. Suicidal ideation was ascertained using the \"suicidal thoughts\" item of the Montgomery and Asberg Depression Rating Scale. Associations between suicidal ideation and 5-HTTLPR, STin2 VNTR, 5-HTR2a 1438A/G, and 5-HTR2a 102T/C genotypes were estimated using logistic regression models, and gene-gene interactions were investigated using the generalized multifactor dimensionality reduction method after adjustment for potential covariates, including depression.\n\nRESULTS: The 5-HTR2a 1438 A/A genotype was significantly associated with suicidal ideation 2 weeks after stroke, before and after statistical adjustment. The 5-HTTLPR short allele was associated with suicidal ideation 2 weeks after stroke, although the significance of this finding was not evident after adjustment. No significant associations were observed between any genotype and suicidal ideation one year after stroke. No significant gene-gene interactions were detected.\n\nCONCLUSIONS: Individuals with the 5-HTR2a 1438 A/A genotype were more susceptible to suicidal ideation 2 weeks after stroke. Careful evaluation and management are indicated for those with increased genetic vulnerability, particularly during the acute phase of stroke.", "journal": "The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry", "year": "2014", "authors": "Kim JM, Kim SW, Kang HJ, Bae KY, Shin IS, Kim JT, Park MS, Park SW, Kim YH, Cho KH, Yoon JS", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jagp.2013.06.001", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.633Z" }, { "id": "bcc06669-180b-4ee6-baac-570992a61efb", "pmid": "23973249", "title": "Serotonergic genes and suicidal ideation 2 weeks and 1 year after stroke in Korea.", "imported": false, "abstract": "OBJECTIVES: Serotonergic genes are associated with suicidal behavior; this association has not been tested in stroke survivors, however. In this study, we investigated whether serotonin transporter (5-HTT) and serotonin 2a receptor (5-HTR2a) genes were associated with suicidal ideation at 2 weeks and at 1 year after stroke.\n\nMETHODS: A total of 286 patients were evaluated 2 weeks after stroke, and 222 (78%) participated in a follow-up evaluation one year later. Suicidal ideation was ascertained using the \"suicidal thoughts\" item of the Montgomery and Asberg Depression Rating Scale. Associations between suicidal ideation and 5-HTTLPR, STin2 VNTR, 5-HTR2a 1438A/G, and 5-HTR2a 102T/C genotypes were estimated using logistic regression models, and gene-gene interactions were investigated using the generalized multifactor dimensionality reduction method after adjustment for potential covariates, including depression.\n\nRESULTS: The 5-HTR2a 1438 A/A genotype was significantly associated with suicidal ideation 2 weeks after stroke, before and after statistical adjustment. The 5-HTTLPR short allele was associated with suicidal ideation 2 weeks after stroke, although the significance of this finding was not evident after adjustment. No significant associations were observed between any genotype and suicidal ideation one year after stroke. No significant gene-gene interactions were detected.\n\nCONCLUSIONS: Individuals with the 5-HTR2a 1438 A/A genotype were more susceptible to suicidal ideation 2 weeks after stroke. 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"journal": "", "year": "2014", "authors": "Zhao Y, Hong N, Liu X, Wu B, Tang S, Yang J, Hu C, Jia W.", "articleTypes": [], "doi": "10.1155/2014/912052", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.391Z" }, { "id": "7433cefc-f001-4d0b-883c-b826e33c8de7", "pmid": "24709017", "title": "Interactions between a serotonin transporter gene, life events and social support on suicidal ideation in Korean elders.", "imported": false, "abstract": "INTRODUCTION: The functional polymorphism in the serotonin transporter gene linked promoter region (5-HTTLPR) may modify associations between environmental stressors and suicidality in adolescents and working-age adults. We investigated whether the 5-HTTLPR s/l polymorphism interacts with stressful life events (SLEs) and social support deficits (SSDs) on late-life suicidal ideation.\n\nMETHODS: 732 Korean community residents aged 65+ were evaluated and, of 639 without suicidal ideation, 579 (90.6%) were followed two years later. Prevalence and incidence of suicidal ideation was ascertained. Information on SLEs and SSDs were gathered, and covariates included socio-demographic characteristics, depressive symptoms, cognitive function, and disability.\n\nRESULTS: Significant interactions were observed between 5-HTTLPR genotype, SLEs and SSDs on both prevalence and incidence of suicidal ideation after adjustment for covariates. The associations of SLEs and SSDs with suicidal ideation were strengthened in combination with higher numbers of s alleles, and were only significant predictors in those with s/s genotype. A significant three-way interaction between 5-HTTLPR genotype, SLEs and SSDs was also found.\n\nLIMITATIONS: The generalizability of suicidal ideation as a marker of suicidality should be considered.\n\nCONCLUSIONS: Gene-environment interactions on suicidal behavior are therefore identifiable even in old age.", "journal": "Journal of affective disorders", "year": "2014", "authors": "Kim JM, Stewart R, Kim SW, Kang HJ, Kim SY, Lee JY, Bae KY, Shin IS, Yoon JS", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2014.02.030", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.573Z" }, { "id": "9797a9b3-9cba-4a4e-9dbb-ac65cc4eb32d", "pmid": "24709017", "title": "Interactions between a serotonin transporter gene, life events and social support on suicidal ideation in Korean elders.", "imported": false, "abstract": "INTRODUCTION: The functional polymorphism in the serotonin transporter gene linked promoter region (5-HTTLPR) may modify associations between environmental stressors and suicidality in adolescents and working-age adults. We investigated whether the 5-HTTLPR s/l polymorphism interacts with stressful life events (SLEs) and social support deficits (SSDs) on late-life suicidal ideation.\n\nMETHODS: 732 Korean community residents aged 65+ were evaluated and, of 639 without suicidal ideation, 579 (90.6%) were followed two years later. Prevalence and incidence of suicidal ideation was ascertained. Information on SLEs and SSDs were gathered, and covariates included socio-demographic characteristics, depressive symptoms, cognitive function, and disability.\n\nRESULTS: Significant interactions were observed between 5-HTTLPR genotype, SLEs and SSDs on both prevalence and incidence of suicidal ideation after adjustment for covariates. The associations of SLEs and SSDs with suicidal ideation were strengthened in combination with higher numbers of s alleles, and were only significant predictors in those with s/s genotype. A significant three-way interaction between 5-HTTLPR genotype, SLEs and SSDs was also found.\n\nLIMITATIONS: The generalizability of suicidal ideation as a marker of suicidality should be considered.\n\nCONCLUSIONS: Gene-environment interactions on suicidal behavior are therefore identifiable even in old age.", "journal": "Journal of affective disorders", "year": "2014", "authors": "Kim JM, Stewart R, Kim SW, Kang HJ, Kim SY, Lee JY, Bae KY, Shin IS, Yoon JS", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2014.02.030", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.167Z" }, { "id": "e71de37f-500e-4366-8d3a-a918f68f4579", "pmid": "24709017", "title": "Interactions between a serotonin transporter gene, life events and social support on suicidal ideation in Korean elders.", "imported": false, "abstract": "INTRODUCTION: The functional polymorphism in the serotonin transporter gene linked promoter region (5-HTTLPR) may modify associations between environmental stressors and suicidality in adolescents and working-age adults. We investigated whether the 5-HTTLPR s/l polymorphism interacts with stressful life events (SLEs) and social support deficits (SSDs) on late-life suicidal ideation.\n\nMETHODS: 732 Korean community residents aged 65+ were evaluated and, of 639 without suicidal ideation, 579 (90.6%) were followed two years later. Prevalence and incidence of suicidal ideation was ascertained. Information on SLEs and SSDs were gathered, and covariates included socio-demographic characteristics, depressive symptoms, cognitive function, and disability.\n\nRESULTS: Significant interactions were observed between 5-HTTLPR genotype, SLEs and SSDs on both prevalence and incidence of suicidal ideation after adjustment for covariates. The associations of SLEs and SSDs with suicidal ideation were strengthened in combination with higher numbers of s alleles, and were only significant predictors in those with s/s genotype. A significant three-way interaction between 5-HTTLPR genotype, SLEs and SSDs was also found.\n\nLIMITATIONS: The generalizability of suicidal ideation as a marker of suicidality should be considered.\n\nCONCLUSIONS: Gene-environment interactions on suicidal behavior are therefore identifiable even in old age.", "journal": "Journal of affective disorders", "year": "2014", "authors": "Kim JM, Stewart R, Kim SW, Kang HJ, Kim SY, Lee JY, Bae KY, Shin IS, Yoon JS", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2014.02.030", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR 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regulating the lipogenic genes expression and hepatic fatty acid composition", "imported": false, "abstract": "", "journal": "", "year": "2014", "authors": "Zhou J, Zhang L, Zhang J, Wan X.", "articleTypes": [], "doi": "10.1186/1472-6882-14-263", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.794Z" }, { "id": "9074510c-cb78-41b4-8a03-bcb2b92e937b", "pmid": "25055996", "title": "Aqueous extract of post-fermented tea reverts the hepatic steatosis of hyperlipidemia rat by regulating the lipogenic genes expression and hepatic fatty acid composition", "imported": false, "abstract": "", "journal": "", "year": "2014", "authors": "Zhou J, Zhang L, Zhang J, Wan X.", "articleTypes": [], "doi": "10.1186/1472-6882-14-263", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.438Z" }, { "id": "e8ec74ba-9655-4892-8236-26b109336fef", "pmid": "25055996", "title": "Aqueous extract of post-fermented tea reverts the hepatic steatosis of hyperlipidemia rat by regulating the lipogenic genes expression and hepatic fatty acid composition", "imported": false, "abstract": "", "journal": "", "year": "2014", "authors": "Zhou J, Zhang L, Zhang J, Wan X.", "articleTypes": [], "doi": "10.1186/1472-6882-14-263", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.910Z" }, { "id": "9e75e6e1-3d13-4842-ad12-3f88ed58b7f9", "pmid": "25065374", "title": "Increased severity of suicidal behavior in impulsive aggressive patients exposed to familial adversities.", "imported": false, "abstract": "BACKGROUND: The mechanisms by which childhood abuse and family history of suicidal behavior (FHS) lead to an increased risk of suicidal behavior are still unknown. Impulsive aggression may play an intermediate role. We investigated whether greater scores for aggression and impulsivity might be associated with the effects of FHS and/or childhood abuse on the severity of suicidal behavior.\n\nMETHOD: We examined the scores of three scales measuring impulsive aggression in a sample of 696 suicide attempters. We compared the highest and lowest scores with regard to reports of childhood abuse and FHS using adjusted multinomial regression models. Genetic polymorphisms of the serotonergic system known to be associated with impulsive aggression were also analyzed.\n\nRESULTS: Patients with high impulsive aggressive scores showed significant differences in sociodemographic, clinical and suicidal features compared with patients with low impulsive aggressive scores. Adjusted results showed that combinations of some types of childhood abuse and FHS, particularly emotional abuse and emotional neglect, are associated with high impulsivity and hostility scores. The SS genotype of the serotonin transporter gene (5-HTTLPR) was associated with high levels of impulsivity when the subjects reported emotional abuse [odds ratio (OR) 5.55, 95% confidence interval (CI) 1.75-17.5] or physical abuse (OR 5.03, 95% CI 1.50-16.9) in their childhood.\n\nCONCLUSIONS: Our results support the role of impulsive aggression as one of the links that may connect childhood abuse and FHS with severity of suicidal behavior.", "journal": "Psychological medicine", "year": "2014", "authors": "Lopez-Castroman J, Jaussent I, Beziat S, Guillaume S, Baca-Garcia E, Genty C, Olié E, Courtet P", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1017/S0033291714000646", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.572Z" }, { "id": "b2d4ab34-f9d6-4820-bff5-b5a5cb9ef08a", "pmid": "25065374", "title": "Increased severity of suicidal behavior in impulsive aggressive patients exposed to familial adversities.", "imported": false, "abstract": "BACKGROUND: The mechanisms by which childhood abuse and family history of suicidal behavior (FHS) lead to an increased risk of suicidal behavior are still unknown. Impulsive aggression may play an intermediate role. We investigated whether greater scores for aggression and impulsivity might be associated with the effects of FHS and/or childhood abuse on the severity of suicidal behavior.\n\nMETHOD: We examined the scores of three scales measuring impulsive aggression in a sample of 696 suicide attempters. We compared the highest and lowest scores with regard to reports of childhood abuse and FHS using adjusted multinomial regression models. Genetic polymorphisms of the serotonergic system known to be associated with impulsive aggression were also analyzed.\n\nRESULTS: Patients with high impulsive aggressive scores showed significant differences in sociodemographic, clinical and suicidal features compared with patients with low impulsive aggressive scores. Adjusted results showed that combinations of some types of childhood abuse and FHS, particularly emotional abuse and emotional neglect, are associated with high impulsivity and hostility scores. The SS genotype of the serotonin transporter gene (5-HTTLPR) was associated with high levels of impulsivity when the subjects reported emotional abuse [odds ratio (OR) 5.55, 95% confidence interval (CI) 1.75-17.5] or physical abuse (OR 5.03, 95% CI 1.50-16.9) in their childhood.\n\nCONCLUSIONS: Our results support the role of impulsive aggression as one of the links that may connect childhood abuse and FHS with severity of suicidal behavior.", "journal": "Psychological medicine", "year": "2014", "authors": "Lopez-Castroman J, Jaussent I, Beziat S, Guillaume S, Baca-Garcia E, Genty C, Olié E, Courtet P", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1017/S0033291714000646", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.167Z" }, { "id": "c36d848b-620e-4a46-86c4-60278d991280", "pmid": "25065374", "title": "Increased severity of suicidal behavior in impulsive aggressive patients exposed to familial adversities.", "imported": false, "abstract": "BACKGROUND: The mechanisms by which childhood abuse and family history of suicidal behavior (FHS) lead to an increased risk of suicidal behavior are still unknown. Impulsive aggression may play an intermediate role. We investigated whether greater scores for aggression and impulsivity might be associated with the effects of FHS and/or childhood abuse on the severity of suicidal behavior.\n\nMETHOD: We examined the scores of three scales measuring impulsive aggression in a sample of 696 suicide attempters. We compared the highest and lowest scores with regard to reports of childhood abuse and FHS using adjusted multinomial regression models. Genetic polymorphisms of the serotonergic system known to be associated with impulsive aggression were also analyzed.\n\nRESULTS: Patients with high impulsive aggressive scores showed significant differences in sociodemographic, clinical and suicidal features compared with patients with low impulsive aggressive scores. Adjusted results showed that combinations of some types of childhood abuse and FHS, particularly emotional abuse and emotional neglect, are associated with high impulsivity and hostility scores. The SS genotype of the serotonin transporter gene (5-HTTLPR) was associated with high levels of impulsivity when the subjects reported emotional abuse [odds ratio (OR) 5.55, 95% confidence interval (CI) 1.75-17.5] or physical abuse (OR 5.03, 95% CI 1.50-16.9) in their childhood.\n\nCONCLUSIONS: Our results support the role of impulsive aggression as one of the links that may connect childhood abuse and FHS with severity of suicidal behavior.", "journal": "Psychological medicine", "year": "2014", "authors": "Lopez-Castroman J, Jaussent I, Beziat S, Guillaume S, Baca-Garcia E, Genty C, Olié E, Courtet P", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1017/S0033291714000646", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": 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of Obesity-Related Non-alcoholic Fatty Liver Disease", "imported": false, "abstract": "", "journal": "", "year": "2015", "authors": "Chen J, Ma L, Huang L, Xie C, Pei H, He L, Fu S, Chen L.", "articleTypes": [], "doi": "10.1111/cbdd.12429", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.407Z" }, { "id": "20b8c506-030b-4101-aab3-7b020efe8357", "pmid": "25219494", "title": "The serotonin transporter genotype modulates the relationship between early stress and adult suicidality in bipolar disorder.", "imported": false, "abstract": "OBJECTIVE: Bipolar disorder (BD) is associated with a higher risk of suicide and with worse early life stress. A serotonin (5-hydroxytryptamine; 5-HT) transporter-linked polymorphic region (5-HTTLPR) has been shown to influence the relationship between stress and the risk of attempting suicide in the general population, but has not been investigated in BD.\n\nMETHODS: We studied 136 inpatients (93 females, 43 males) with a major depressive episode in the course of BD. Early and recent stressful life events were scored on the Social Readjustment Rating Scale (SRRS). Regional gray matter (GM) volumes were analyzed, acquiring T1-weighted images on a 3.0 Tesla scanner.\n\nRESULTS: Homozygote l/l patients attempted suicide in a higher proportion than *s carriers. A separate-slopes logistic regression showed a significant effect of 5-HTTLPR on the relationship between stress, depression, and suicide among *s carriers, but not among l/l homozygotes, early stress associated with worse probability of attempting suicide and with earlier age at onset of BD. Exposure to early stress correlated with GM volumes in the right prefrontal cortex (Brodmann area 46) - again, in *s carriers only.\n\nCONCLUSIONS: 5-HTTLPR modulated the relationship between early life stress and the core features of bipolar illness. 5-HTTLPR*s carriers showed a higher sensitivity to the effects of stress; when exposed to low levels of early stress, they were protected against suicide in respect to l/l, but higher levels of stress progressively increased their risk of suicide and reduced the age at onset of illness.", "journal": "Bipolar disorders", "year": "2014", "authors": "Benedetti F, Riccaboni R, Poletti S, Radaelli D, Locatelli C, Lorenzi C, Pirovano A, Smeraldi E, Colombo C", "articleTypes": [ "Journal Article" ], "doi": "10.1111/bdi.12250", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.632Z" }, { "id": "a2b799e7-2f20-4c50-bdbb-42152c9063b8", "pmid": "25219494", "title": "The serotonin transporter genotype modulates the relationship between early stress and adult suicidality in bipolar disorder.", "imported": false, "abstract": "OBJECTIVE: Bipolar disorder (BD) is associated with a higher risk of suicide and with worse early life stress. A serotonin (5-hydroxytryptamine; 5-HT) transporter-linked polymorphic region (5-HTTLPR) has been shown to influence the relationship between stress and the risk of attempting suicide in the general population, but has not been investigated in BD.\n\nMETHODS: We studied 136 inpatients (93 females, 43 males) with a major depressive episode in the course of BD. Early and recent stressful life events were scored on the Social Readjustment Rating Scale (SRRS). Regional gray matter (GM) volumes were analyzed, acquiring T1-weighted images on a 3.0 Tesla scanner.\n\nRESULTS: Homozygote l/l patients attempted suicide in a higher proportion than *s carriers. A separate-slopes logistic regression showed a significant effect of 5-HTTLPR on the relationship between stress, depression, and suicide among *s carriers, but not among l/l homozygotes, early stress associated with worse probability of attempting suicide and with earlier age at onset of BD. Exposure to early stress correlated with GM volumes in the right prefrontal cortex (Brodmann area 46) - again, in *s carriers only.\n\nCONCLUSIONS: 5-HTTLPR modulated the relationship between early life stress and the core features of bipolar illness. 5-HTTLPR*s carriers showed a higher sensitivity to the effects of stress; when exposed to low levels of early stress, they were protected against suicide in respect to l/l, but higher levels of stress progressively increased their risk of suicide and reduced the age at onset of illness.", "journal": "Bipolar disorders", "year": "2014", "authors": "Benedetti F, Riccaboni R, Poletti S, Radaelli D, Locatelli C, Lorenzi C, Pirovano A, Smeraldi E, Colombo C", "articleTypes": [ "Journal Article" ], "doi": "10.1111/bdi.12250", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.166Z" }, { "id": "f3da46a1-d68a-495a-8ca1-2fafc7834644", "pmid": "25219494", "title": "The serotonin transporter genotype modulates the relationship between early stress and adult suicidality in bipolar disorder.", "imported": false, "abstract": "OBJECTIVE: Bipolar disorder (BD) is associated with a higher risk of suicide and with worse early life stress. A serotonin (5-hydroxytryptamine; 5-HT) transporter-linked polymorphic region (5-HTTLPR) has been shown to influence the relationship between stress and the risk of attempting suicide in the general population, but has not been investigated in BD.\n\nMETHODS: We studied 136 inpatients (93 females, 43 males) with a major depressive episode in the course of BD. Early and recent stressful life events were scored on the Social Readjustment Rating Scale (SRRS). Regional gray matter (GM) volumes were analyzed, acquiring T1-weighted images on a 3.0 Tesla scanner.\n\nRESULTS: Homozygote l/l patients attempted suicide in a higher proportion than *s carriers. A separate-slopes logistic regression showed a significant effect of 5-HTTLPR on the relationship between stress, depression, and suicide among *s carriers, but not among l/l homozygotes, early stress associated with worse probability of attempting suicide and with earlier age at onset of BD. Exposure to early stress correlated with GM volumes in the right prefrontal cortex (Brodmann area 46) - again, in *s carriers only.\n\nCONCLUSIONS: 5-HTTLPR modulated the relationship between early life stress and the core features of bipolar illness. 5-HTTLPR*s carriers showed a higher sensitivity to the effects of stress; when exposed to low levels of early stress, they were protected against suicide in respect to l/l, but higher levels of stress progressively increased their risk of suicide and reduced the age at onset of illness.", "journal": "Bipolar disorders", "year": "2014", "authors": "Benedetti F, Riccaboni R, Poletti S, Radaelli D, Locatelli C, Lorenzi C, Pirovano A, Smeraldi E, Colombo C", "articleTypes": [ "Journal Article" ], "doi": "10.1111/bdi.12250", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, 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"year": "2015", "authors": "Andreoli MF, Stoker C, Rossetti MF, Alzamendi A, Castrogiovanni D, Luque EH, Ramos JG.", "articleTypes": [], "doi": "10.1016/j.mce.2014.12.002", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.915Z" }, { "id": "c7cbb5fb-cadf-42f4-b70e-29c6eee301fa", "pmid": "25486512", "title": "Withdrawal of dietary phytoestrogens in adult male rats affects hypothalamic regulation of food intake, induces obesity and alters glucose metabolism", "imported": false, "abstract": "", "journal": "", "year": "2015", "authors": "Andreoli MF, Stoker C, Rossetti MF, Alzamendi A, Castrogiovanni D, Luque EH, Ramos JG.", "articleTypes": [], "doi": "10.1016/j.mce.2014.12.002", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.444Z" }, { "id": "e2d510b0-c965-4cb2-9751-b286eaadaf98", "pmid": "25486512", "title": "Withdrawal of dietary phytoestrogens in adult male rats affects 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Sánchez-Hernández D, Kubant R, Dodington DW, Ward WE, Bazinet RP, Anderson GH.", "articleTypes": [], "doi": "10.1002/mnfr.201400663", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.762Z" }, { "id": "bf8fb58c-3470-4329-853b-08ae81f6a558", "pmid": "25488374", "title": "Methyl vitamins contribute to obesogenic effects of a high multivitamin gestational diet and epigenetic alterations in hypothalamic feeding pathways in Wistar rat offspring", "imported": false, "abstract": "", "journal": "", "year": "2015", "authors": "Cho CE, Pannia E, Huot PS, Sánchez-Hernández D, Kubant R, Dodington DW, Ward WE, Bazinet RP, Anderson GH.", "articleTypes": [], "doi": "10.1002/mnfr.201400663", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.374Z" }, { "id": "147d0570-7bca-4515-a0cd-64aa480b9e13", "pmid": "25488447", "title": "Role of leptin on the expression of low density lipoprotein 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"pmid": "25497341", "title": "20 years of leptin: from the discovery of the leptin gene to leptin in our therapeutic armamentarium", "imported": false, "abstract": "", "journal": "", "year": "2015", "authors": "Friedman JM, Mantzoros CS.", "articleTypes": [], "doi": "10.1016/j.metabol.2014.10.023", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.366Z" }, { "id": "6e486fcb-6daf-40f8-b123-dafba827af2c", "pmid": "25497341", "title": "20 years of leptin: from the discovery of the leptin gene to leptin in our therapeutic armamentarium", "imported": false, "abstract": "", "journal": "", "year": "2015", "authors": "Friedman JM, Mantzoros CS.", "articleTypes": [], "doi": "10.1016/j.metabol.2014.10.023", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.876Z" }, { "id": "fc2f1f65-107d-4ee2-9f3b-9fde3a6d08c5", "pmid": "25497341", "title": "20 years of leptin: from the discovery of the leptin gene to leptin in our therapeutic armamentarium", "imported": false, "abstract": "", "journal": "", "year": "2015", "authors": "Friedman JM, Mantzoros CS.", "articleTypes": [], "doi": "10.1016/j.metabol.2014.10.023", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.399Z" }, { "id": "00eee7a8-bba1-4677-b371-e9089b5b739f", "pmid": "25499444", "title": "New evidence of heterogeneity in social anxiety disorder: defining two qualitatively different personality profiles taking into account clinical, environmental and genetic factors.", "imported": false, "abstract": "PURPOSE: To study qualitatively different subgroups of social anxiety disorder (SAD) based on harm avoidance (HA) and novelty seeking (NS) dimensions.\n\nMETHOD: One hundred and forty-two university students with SAD (SCID-DSM-IV) were included in the study. The temperament dimensions HA and NS from the Cloninger's Temperament and Character Inventory were subjected to cluster analysis to identify meaningful subgroups. The identified subgroups were compared for sociodemographics, SAD severity, substance use, history of suicide and self-harm attempts, early life events, and two serotonin transporter gene polymorphisms (5-HTTLPR and STin2.VNTR).\n\nRESULTS: Two subgroups of SAD were identified by cluster analysis: a larger (61% of the sample) inhibited subgroup of subjects with \"high-HA/low-NS\", and a smaller (39%) atypical impulsive subgroup with high-moderate HA and NS. The two groups did not differ in social anxiety severity, but did differ in history of lifetime impulsive-related-problems. History of suicide attempts and self-harm were as twice as frequent in the impulsive subgroup. Significant differences were observed in the pattern of substance misuse. Whereas subjects in the inhibited subgroup showed a greater use of alcohol (P=0.002), subjects in the impulsive subgroup showed a greater use of substances with a high-sensation-seeking profile (P<0.001). The STin2.VNTR genotype frequency showed an inverse distribution between subgroups (P=0.005).\n\nCONCLUSIONS: Our study provides further evidence for the presence of qualitatively different SAD subgroups and the propensity of a subset of people with SAD to exhibit impulsive, high-risk behaviors.", "journal": "European psychiatry : the journal of the Association of European Psychiatrists", "year": "2015", "authors": "Binelli C, Muñiz A, Sanches S, Ortiz A, Navines R, Egmond E, Udina M, Batalla A, López-Sola C, Crippa JA, Subirà S, Martín-Santos R", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.eurpsy.2014.09.418", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.166Z" }, { "id": "aa6a3698-f7d8-49a5-aeea-c7d50a776a5e", "pmid": "25499444", "title": "New evidence of heterogeneity in social anxiety disorder: defining two qualitatively different personality profiles taking into account clinical, environmental and genetic factors.", "imported": false, "abstract": "PURPOSE: To study qualitatively different subgroups of social anxiety disorder (SAD) based on harm avoidance (HA) and novelty seeking (NS) dimensions.\n\nMETHOD: One hundred and forty-two university students with SAD (SCID-DSM-IV) were included in the study. The temperament dimensions HA and NS from the Cloninger's Temperament and Character Inventory were subjected to cluster analysis to identify meaningful subgroups. The identified subgroups were compared for sociodemographics, SAD severity, substance use, history of suicide and self-harm attempts, early life events, and two serotonin transporter gene polymorphisms (5-HTTLPR and STin2.VNTR).\n\nRESULTS: Two subgroups of SAD were identified by cluster analysis: a larger (61% of the sample) inhibited subgroup of subjects with \"high-HA/low-NS\", and a smaller (39%) atypical impulsive subgroup with high-moderate HA and NS. The two groups did not differ in social anxiety severity, but did differ in history of lifetime impulsive-related-problems. History of suicide attempts and self-harm were as twice as frequent in the impulsive subgroup. Significant differences were observed in the pattern of substance misuse. Whereas subjects in the inhibited subgroup showed a greater use of alcohol (P=0.002), subjects in the impulsive subgroup showed a greater use of substances with a high-sensation-seeking profile (P<0.001). The STin2.VNTR genotype frequency showed an inverse distribution between subgroups (P=0.005).\n\nCONCLUSIONS: Our study provides further evidence for the presence of qualitatively different SAD subgroups and the propensity of a subset of people with SAD to exhibit impulsive, high-risk behaviors.", "journal": "European psychiatry : the journal of the Association of European Psychiatrists", "year": "2015", "authors": "Binelli C, Muñiz A, Sanches S, Ortiz A, Navines R, Egmond E, Udina M, Batalla A, López-Sola C, Crippa JA, Subirà S, Martín-Santos R", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.eurpsy.2014.09.418", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.572Z" }, { "id": "e3effb18-09fa-4a30-94d4-53622a0e1b5c", "pmid": "25499444", "title": "New evidence of heterogeneity in social anxiety disorder: defining two qualitatively different personality profiles taking into account clinical, environmental and genetic factors.", "imported": false, "abstract": "PURPOSE: To study qualitatively different subgroups of social anxiety disorder (SAD) based on harm avoidance (HA) and novelty seeking (NS) dimensions.\n\nMETHOD: One hundred and forty-two university students with SAD (SCID-DSM-IV) were included in the study. The temperament dimensions HA and NS from the Cloninger's Temperament and Character Inventory were subjected to cluster analysis to identify meaningful subgroups. The identified subgroups were compared for sociodemographics, SAD severity, substance use, history of suicide and self-harm attempts, early life events, and two serotonin transporter gene polymorphisms (5-HTTLPR and STin2.VNTR).\n\nRESULTS: Two subgroups of SAD were identified by cluster analysis: a larger (61% of the sample) inhibited subgroup of subjects with \"high-HA/low-NS\", and a smaller (39%) atypical impulsive subgroup with high-moderate HA and NS. The two groups did not differ in social anxiety severity, but did differ in history of lifetime impulsive-related-problems. History of suicide attempts and self-harm were as twice as frequent in the impulsive subgroup. Significant differences were observed in the pattern of substance misuse. Whereas subjects in the inhibited subgroup showed a greater use of alcohol (P=0.002), subjects in the impulsive subgroup showed a greater use of substances with a high-sensation-seeking profile (P<0.001). The STin2.VNTR genotype frequency showed an inverse distribution between subgroups (P=0.005).\n\nCONCLUSIONS: Our study provides further evidence for the presence of qualitatively different SAD subgroups and the propensity of a subset of people with SAD to exhibit impulsive, high-risk behaviors.", "journal": "European psychiatry : the journal of the Association of European Psychiatrists", "year": "2015", "authors": "Binelli C, Muñiz A, Sanches S, Ortiz A, Navines R, Egmond E, Udina M, Batalla A, López-Sola C, Crippa JA, Subirà S, Martín-Santos R", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.eurpsy.2014.09.418", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.632Z" }, { "id": "370653e9-4748-45bc-a03d-6ddf3ec0d9e2", "pmid": "25500344", "title": "5-HTTLPR × interpersonal stress interaction and nonsuicidal self-injury in general community sample of youth.", "imported": false, "abstract": "No research with youth has investigated whether measured genetic risk interacts with stressful environment (G⁎E) to explain engagement in non-suicidal self-injury (NSSI). Two independent samples of youth were used to test the a priori hypothesis that the Transporter-Linked Polymorphic Region (5-HTTLPR) would interact with chronic interpersonal stress to predict NSSI. We tested this hypothesis with children and adolescents from United States public schools in two independent samples (N׳s=300 and 271) using identical procedures and methods. They were interviewed in person with the Self-Injurious Thoughts and Behaviors Interview to assess NSSI engagement and with the UCLA Chronic Stress Interview to assess interpersonal stress. Buccal cells were collected for genotyping of 5-HTTLPR. For both samples, ANOVAs revealed the hypothesized G*E. Specifically, short carriers who experienced severe interpersonal stress exhibited the highest level of NSSI engagement. 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Two independent samples of youth were used to test the a priori hypothesis that the Transporter-Linked Polymorphic Region (5-HTTLPR) would interact with chronic interpersonal stress to predict NSSI. We tested this hypothesis with children and adolescents from United States public schools in two independent samples (N׳s=300 and 271) using identical procedures and methods. They were interviewed in person with the Self-Injurious Thoughts and Behaviors Interview to assess NSSI engagement and with the UCLA Chronic Stress Interview to assess interpersonal stress. Buccal cells were collected for genotyping of 5-HTTLPR. For both samples, ANOVAs revealed the hypothesized G*E. Specifically, short carriers who experienced severe interpersonal stress exhibited the highest level of NSSI engagement. 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We investigated the association between serotonin transporter polymorphisms and suicidal behavior in patients with major depressive disorder (MDD).\n\nMETHODS: Serotonin transporter intron 2 VNTR polymorphism (5-HTTVNTR) and serotonin transporter linked polymorphic region polymorphism (5-HTTLPR) were analyzed in 132 depressed patients with suicidal attempt as well as in 122 normal controls. Hamilton's 17-item Depression Rating Scale (HDRS), the Risk-Rescue rating system (RRR) and the Lethality Suicide Attempt Rating Scale updated (LSARS-II) were assessed for the depressed patients.\n\nRESULTS: Although not statistically significant, a trend was found such that the 10/10 and 10/12 alleles of 5-HTTVNTR were more common in suicidal subjects than in control subjects. Comparing allele frequency, those with a 10 allele or 10 allele carriers were higher in suicidal subjects than in control subjects. No difference was noted in 5-HTTLPR genotypes and haplotype distribution between the suicidal subjects and control subjects. The RRR scores in subjects with the 10/10 5-HTTVNTR genotype or 10 5-HTTVNTR allele were significantly lower than those in subjects with other genotypes.\n\nCONCLUSION: These results show the possibility that 10 allele of 5-HTTVNTR is related to suicidal behavior in the suicidal subjects with MDD and suggest that 12 allele of 5-HTTVNTR might be related to more lethality in the suicidal subjects with MDD.", "journal": "Psychiatry investigation", "year": "2015", "authors": "Lee HY, Hong JP, Hwang JA, Lee HJ, Yoon HK, Lee BH, Kim YK", "articleTypes": [ "Journal Article" ], "doi": "10.4306/pi.2015.12.1.136", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.632Z" }, { "id": "9ece5bd4-dab3-44e7-a4f4-6de2b3c3a019", "pmid": "25670956", "title": "Possible Association between Serotonin Transporter Gene Polymorphism and Suicide Behavior in Major Depressive Disorder.", "imported": false, "abstract": "OBJECTIVE: The serotonin transporter (5-HTT) genes are major candidate genes for modulating the suicidal behavior. 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No difference was noted in 5-HTTLPR genotypes and haplotype distribution between the suicidal subjects and control subjects. The RRR scores in subjects with the 10/10 5-HTTVNTR genotype or 10 5-HTTVNTR allele were significantly lower than those in subjects with other genotypes.\n\nCONCLUSION: These results show the possibility that 10 allele of 5-HTTVNTR is related to suicidal behavior in the suicidal subjects with MDD and suggest that 12 allele of 5-HTTVNTR might be related to more lethality in the suicidal subjects with MDD.", "journal": "Psychiatry investigation", "year": "2015", "authors": "Lee HY, Hong JP, Hwang JA, Lee HJ, Yoon HK, Lee BH, Kim YK", "articleTypes": [ "Journal Article" ], "doi": "10.4306/pi.2015.12.1.136", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.572Z" }, { "id": "f15afd37-dc2c-4581-bc80-c19cf6521fc3", "pmid": "25670956", "title": "Possible Association between Serotonin Transporter Gene Polymorphism and Suicide Behavior in Major Depressive Disorder.", "imported": false, "abstract": "OBJECTIVE: The serotonin transporter (5-HTT) genes are major candidate genes for modulating the suicidal behavior. 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No difference was noted in 5-HTTLPR genotypes and haplotype distribution between the suicidal subjects and control subjects. 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Alcohol intoxication has been related to lower thresholds of aggressive behaviors. In this association study of two independent samples, a number of candidate gene variants (5HT2A T102C, 5-HTTLPR, DRD Ins-141Del, DAT1 VNTR) were related to violent criminal behavior and alcohol-related aggressive traits.\n\nMETHOD: Treatment-seeking alcohol-dependent individuals (293 patients and 499 controls from Germany, 180 patients and 402 controls from Poland) underwent a Semi-Structured Assessment for the Genetics of Alcoholism interview which gathered information on alcohol-related violence and criminal behaviors, beside alcohol dependence characteristics.\n\nRESULTS: Patients with a history of violent or non-violent crime were more often male, had an earlier onset of alcoholism, more withdrawal seizures and delirium tremens, and were more likely to have a history of suicide attempts. 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Health).", "imported": false, "abstract": "BACKGROUND: The low transcriptionally efficient short-allele of the 5HTTLPR serotonin transporter polymorphism has been implicated to moderate the relationship between the experience of stressful life events (SLEs) and depression. Despite numerous attempts at replicating this observation, results remain inconclusive.\n\nMETHODS: We examined this relationship in young-adult Non-Hispanic white males and females between the ages of 22 and 26 (n = 4724) participating in the National Longitudinal Study of Adolescent to Adult Health (Add Health) with follow-up information every six years since 1995.\n\nRESULTS: Linear and logistic regression models, corrected for multiple testing, indicated that carriers of one or more of the S-alleles were more sensitive to stress than those with two L-alleles and at a higher risk for depression. This relationship behaved in a dose-response manner such that the risk for depression was greatest among those who reported experiencing higher numbers of SLEs. In post-hoc analyses we were not able to replicate an interaction effect for suicide ideation but did find suggestive evidence that the effects of SLEs and 5HTTLPR on suicide ideation differed for males and females. There were no effects of childhood maltreatment.\n\nDISCUSSION: Our results provide partial support for the original hypothesis that 5-HTTLPR genotype interacts with the experience of stressful life events in the etiology of depression during young adulthood. However, even with this large sample, and a carefully constructed a priori analysis plan, the results were still not definitive. 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There were no effects of childhood maltreatment.\n\nDISCUSSION: Our results provide partial support for the original hypothesis that 5-HTTLPR genotype interacts with the experience of stressful life events in the etiology of depression during young adulthood. However, even with this large sample, and a carefully constructed a priori analysis plan, the results were still not definitive. 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self-mutilation can be regarded as the expression of self-directed aggression and both are common in prison populations. We investigated the influence of externalizing behaviors, depressive symptoms, childhood trauma, 5-HTTLPR variants on self-directed aggression (N = 145) in a group of 702 male Italian prisoners. Participants were comprehensively evaluated, including for psychiatric disorders, impulsive traits, lifetime aggressive behavior [Brown-Goodwin Lifetime History of Aggression (BGHA)], hostility, violent behavior during incarceration, depressive symptomatology [Hamilton Depression Rating Scale (HDRS)], childhood trauma [Childhood Trauma Questionnaire (CTQ)]. Logistic regression analysis showed false discovery rate corrected independent main effects of externalizing behaviors: BGHA (P = 0.001), violent behavior in jail (P = 0.007), extraversion (P = 0.015); HDRS (P = 0.0004), Axis I disorders (P = 0.015), CTQ (P = 0.004) and 5-HTTLPR genotype (P = 0.02). Carriers of 5-HTTLPR high (LA LA ), intermediate (LA LG , SLA ) activity variants were more likely to have exhibited self-directed aggression relative to the low activity (LG LG , SLG , SS) variant: high/low: odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.27-4.68, P = 0.007; intermediate/low: OR = 1.96, 95% CI 1.09-3.68, P = 0.025. The CTQ main effect was driven by physical abuse. There was no interactive effect of 5-HTTLPR and CTQ. Secondary logistic regression analyses in (1) all suicide attempters (N = 88) and (2) all self-mutilators (N = 104), compared with controls showed that in both groups, childhood trauma (P = 0.008-0.01), depression (P = 0.0004-0.001) were strong predictors. BGHA, violent behavior in jail predicted self-mutilation (P = 0.002) but not suicide attempts (P = 0.1). This study was able to distinguish differing influences on self-directed aggression between groups of closely related predictor variables within the externalizing behavioral domain. 5-HTTLPR had an independent, variant dosage effect.", "journal": "Genes, brain, and behavior", "year": "2016", "authors": "Gorodetsky E, Carli V, Sarchiapone M, Roy A, Goldman D, Enoch MA", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/gbb.12293", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.164Z" }, { "id": "717097e8-e83e-477c-9a5e-6a920204c6ac", "pmid": "27062586", "title": "Predictors for self-directed aggression in Italian prisoners include externalizing behaviors, childhood trauma and the serotonin transporter gene polymorphism 5-HTTLPR.", "imported": false, "abstract": "Suicidal behavior and self-mutilation can be regarded as the expression of self-directed aggression and both are common in prison populations. We investigated the influence of externalizing behaviors, depressive symptoms, childhood trauma, 5-HTTLPR variants on self-directed aggression (N = 145) in a group of 702 male Italian prisoners. Participants were comprehensively evaluated, including for psychiatric disorders, impulsive traits, lifetime aggressive behavior [Brown-Goodwin Lifetime History of Aggression (BGHA)], hostility, violent behavior during incarceration, depressive symptomatology [Hamilton Depression Rating Scale (HDRS)], childhood trauma [Childhood Trauma Questionnaire (CTQ)]. Logistic regression analysis showed false discovery rate corrected independent main effects of externalizing behaviors: BGHA (P = 0.001), violent behavior in jail (P = 0.007), extraversion (P = 0.015); HDRS (P = 0.0004), Axis I disorders (P = 0.015), CTQ (P = 0.004) and 5-HTTLPR genotype (P = 0.02). Carriers of 5-HTTLPR high (LA LA ), intermediate (LA LG , SLA ) activity variants were more likely to have exhibited self-directed aggression relative to the low activity (LG LG , SLG , SS) variant: high/low: odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.27-4.68, P = 0.007; intermediate/low: OR = 1.96, 95% CI 1.09-3.68, P = 0.025. The CTQ main effect was driven by physical abuse. There was no interactive effect of 5-HTTLPR and CTQ. Secondary logistic regression analyses in (1) all suicide attempters (N = 88) and (2) all self-mutilators (N = 104), compared with controls showed that in both groups, childhood trauma (P = 0.008-0.01), depression (P = 0.0004-0.001) were strong predictors. BGHA, violent behavior in jail predicted self-mutilation (P = 0.002) but not suicide attempts (P = 0.1). This study was able to distinguish differing influences on self-directed aggression between groups of closely related predictor variables within the externalizing behavioral domain. 5-HTTLPR had an independent, variant dosage effect.", "journal": "Genes, brain, and behavior", "year": "2016", "authors": "Gorodetsky E, Carli V, Sarchiapone M, Roy A, Goldman D, Enoch MA", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/gbb.12293", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.629Z" }, { "id": "b21a3019-3dee-478e-8b57-e951f23b8688", "pmid": "27062586", "title": "Predictors for self-directed aggression in Italian prisoners include externalizing behaviors, childhood trauma and the serotonin transporter gene polymorphism 5-HTTLPR.", "imported": false, "abstract": "Suicidal behavior and self-mutilation can be regarded as the expression of self-directed aggression and both are common in prison populations. We investigated the influence of externalizing behaviors, depressive symptoms, childhood trauma, 5-HTTLPR variants on self-directed aggression (N = 145) in a group of 702 male Italian prisoners. Participants were comprehensively evaluated, including for psychiatric disorders, impulsive traits, lifetime aggressive behavior [Brown-Goodwin Lifetime History of Aggression (BGHA)], hostility, violent behavior during incarceration, depressive symptomatology [Hamilton Depression Rating Scale (HDRS)], childhood trauma [Childhood Trauma Questionnaire (CTQ)]. Logistic regression analysis showed false discovery rate corrected independent main effects of externalizing behaviors: BGHA (P = 0.001), violent behavior in jail (P = 0.007), extraversion (P = 0.015); HDRS (P = 0.0004), Axis I disorders (P = 0.015), CTQ (P = 0.004) and 5-HTTLPR genotype (P = 0.02). Carriers of 5-HTTLPR high (LA LA ), intermediate (LA LG , SLA ) activity variants were more likely to have exhibited self-directed aggression relative to the low activity (LG LG , SLG , SS) variant: high/low: odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.27-4.68, P = 0.007; intermediate/low: OR = 1.96, 95% CI 1.09-3.68, P = 0.025. The CTQ main effect was driven by physical abuse. There was no interactive effect of 5-HTTLPR and CTQ. Secondary logistic regression analyses in (1) all suicide attempters (N = 88) and (2) all self-mutilators (N = 104), compared with controls showed that in both groups, childhood trauma (P = 0.008-0.01), depression (P = 0.0004-0.001) were strong predictors. BGHA, violent behavior in jail predicted self-mutilation (P = 0.002) but not suicide attempts (P = 0.1). 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background.", "imported": false, "abstract": "INTRODUCTION: Studies have not given yet a clear answer what is the genetic background of suicidal predisposition. The associations between polymorphisms of the TPH1 and 5-HTTLPR genes and violent suicidal behavior was revealed with the least inconsistencies.\n\nMETHOD: We selected 10 \"strong candidate genes\" and 35 SNPs, SLC6A4 and ACP1 for replication study. We searched associations between precisely described suicidal phenotype in 825 affective patients and polymorphisms of selected neurobiological pathways genes as well as their interactions that constitute suicidal risk.\n\nRESULTS: The results confirm the role of TPH1, TPH2, 5HT2A, CRHR1 and ACP1 variants in the risk of suicidal behavior.\n\nLIMITATIONS: In our study we analyzed limited number of candidate genes and only one of them is linked to lithium mechanism of action. We had no data on pharmacological treatment of investigated patients and its relation to the time of suicide attempt.\n\nCONCLUSION: Our results indicate that polymorphisms of various signaling pathways are involved in the pathogenesis of suicidal behavior. Non-genetic factors are also involved in the risk of suicidal attempts.", "journal": "Journal of affective disorders", "year": "2016", "authors": "Pawlak J, Dmitrzak-Weglarz M, Wilkosc M, Szczepankiewicz A, Leszczynska-Rodziewicz A, Zaremba D, Kapelski P, Rajewska-Rager A, Hauser J", "articleTypes": [ "Journal Article" ], "doi": "10.1016/j.jad.2016.07.029", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.628Z" }, { "id": "63e86e23-266f-465e-9eb5-f3730b70f7a1", "pmid": "27479537", "title": "Suicide behavior as a quantitative trait and its genetic background.", "imported": false, "abstract": "INTRODUCTION: Studies have not given yet a clear answer what is the genetic background of suicidal predisposition. The associations between polymorphisms of the TPH1 and 5-HTTLPR genes and violent suicidal behavior was revealed with the least inconsistencies.\n\nMETHOD: We selected 10 \"strong candidate genes\" and 35 SNPs, SLC6A4 and ACP1 for replication study. We searched associations between precisely described suicidal phenotype in 825 affective patients and polymorphisms of selected neurobiological pathways genes as well as their interactions that constitute suicidal risk.\n\nRESULTS: The results confirm the role of TPH1, TPH2, 5HT2A, CRHR1 and ACP1 variants in the risk of suicidal behavior.\n\nLIMITATIONS: In our study we analyzed limited number of candidate genes and only one of them is linked to lithium mechanism of action. We had no data on pharmacological treatment of investigated patients and its relation to the time of suicide attempt.\n\nCONCLUSION: Our results indicate that polymorphisms of various signaling pathways are involved in the pathogenesis of suicidal behavior. 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The associations between polymorphisms of the TPH1 and 5-HTTLPR genes and violent suicidal behavior was revealed with the least inconsistencies.\n\nMETHOD: We selected 10 \"strong candidate genes\" and 35 SNPs, SLC6A4 and ACP1 for replication study. We searched associations between precisely described suicidal phenotype in 825 affective patients and polymorphisms of selected neurobiological pathways genes as well as their interactions that constitute suicidal risk.\n\nRESULTS: The results confirm the role of TPH1, TPH2, 5HT2A, CRHR1 and ACP1 variants in the risk of suicidal behavior.\n\nLIMITATIONS: In our study we analyzed limited number of candidate genes and only one of them is linked to lithium mechanism of action. We had no data on pharmacological treatment of investigated patients and its relation to the time of suicide attempt.\n\nCONCLUSION: Our results indicate that polymorphisms of various signaling pathways are involved in the pathogenesis of suicidal behavior. 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"abstract": "", "journal": "", "year": "2016", "authors": "Ali O, Cerjak D, Kent JW Jr, James R, Blangero J, Carless MA, Zhang Y.", "articleTypes": [], "doi": "10.1080/15592294.2016.1216284", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.801Z" }, { "id": "cf97f88a-7f8f-4fa5-a38f-ff73881b6e1d", "pmid": "27564309", "title": "Methylation of SOCS3 is inversely associated with metabolic syndrome in an epigenome-wide association study of obesity", "imported": false, "abstract": "", "journal": "", "year": "2016", "authors": "Ali O, Cerjak D, Kent JW Jr, James R, Blangero J, Carless MA, Zhang Y.", "articleTypes": [], "doi": "10.1080/15592294.2016.1216284", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.414Z" }, { "id": "e2e51ed9-8c3f-4c4f-b9c7-a9c349c1563b", "pmid": "27573591", "title": "Personality traits as an endophenotype in genetic studies on suicidality in bipolar disorder.", "imported": false, "abstract": "UNLABELLED: Introduction The influence of personality traits on suicidal behaviour risk has been well documented. Personality traits and suicidal behaviour are partially genetically determined and personality has been described as an endophenotype of suicidal behaviour. The aim of this study was to investigate a possible association between personality traits with suicidal behaviour and selected serotonergic gene polymorphisms.\n\nMETHODS: In the study we included 156 patients meeting DSM-IV criteria for bipolar disorder (BP) and 93 healthy controls. The personality dimensions were assessed using the Temperament and Character Inventory (TCI). We genotyped two selected polymorphisms of the tryptophan hydroxylase 1 (TPH1) gene (rs1800532 218A>C and rs1799913 779A>C) and polymorphism in the promoter region of serotonin transporter gene (5-HTTLPR, rs25531) related to serotoninergic neurotransmission. Multiple poisson regression, logistic regression and Kruskal-Wallis tests were applied.\n\nRESULTS: We found numerous differences between the BP patients and the control group in terms of their TCI dimensions/subdimensions. Significant differences were found between patients with, and without, suicidal attempts in fatigability and asthenia (Ha4), as well as in harm avoidance (Ha). We also found that the interactions between TCI subdimensions (the interaction of disordiness (Ns4) and spiritual acceptance (St3), disordiness (Ns4) and integrated conscience (C5), extravagance (Ns3) and resourcefulness (Sd3)) were significantly contributing for suicidal behaviour risk. We found association between all studied genetic polymorphisms and several TCI dimensions and subdimensions.\n\nCONCLUSION: Our results confirm that personality traits are partially determined by genes. Both personality traits and the interactions between temperament and character traits, may be helpful in predicting suicidal behaviour.", "journal": "Acta neuropsychiatrica", "year": "2017", "authors": "Pawlak J, Dmitrzak-Węglarz M, Maciukiewicz M, Kapelski P, Czerski P, Leszczyńska-Rodziewicz A, Zaremba D, Hauser J", "articleTypes": [ "Journal Article" ], "doi": "10.1017/neu.2016.43", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.163Z" }, { "id": "ead6eb56-3f1d-4f8d-8521-a7f02c7f4413", "pmid": "27573591", "title": "Personality traits as an endophenotype in genetic studies on suicidality in bipolar disorder.", "imported": false, "abstract": "UNLABELLED: Introduction The influence of personality traits on suicidal behaviour risk has been well documented. Personality traits and suicidal behaviour are partially genetically determined and personality has been described as an endophenotype of suicidal behaviour. The aim of this study was to investigate a possible association between personality traits with suicidal behaviour and selected serotonergic gene polymorphisms.\n\nMETHODS: In the study we included 156 patients meeting DSM-IV criteria for bipolar disorder (BP) and 93 healthy controls. The personality dimensions were assessed using the Temperament and Character Inventory (TCI). We genotyped two selected polymorphisms of the tryptophan hydroxylase 1 (TPH1) gene (rs1800532 218A>C and rs1799913 779A>C) and polymorphism in the promoter region of serotonin transporter gene (5-HTTLPR, rs25531) related to serotoninergic neurotransmission. Multiple poisson regression, logistic regression and Kruskal-Wallis tests were applied.\n\nRESULTS: We found numerous differences between the BP patients and the control group in terms of their TCI dimensions/subdimensions. Significant differences were found between patients with, and without, suicidal attempts in fatigability and asthenia (Ha4), as well as in harm avoidance (Ha). We also found that the interactions between TCI subdimensions (the interaction of disordiness (Ns4) and spiritual acceptance (St3), disordiness (Ns4) and integrated conscience (C5), extravagance (Ns3) and resourcefulness (Sd3)) were significantly contributing for suicidal behaviour risk. We found association between all studied genetic polymorphisms and several TCI dimensions and subdimensions.\n\nCONCLUSION: Our results confirm that personality traits are partially determined by genes. Both personality traits and the interactions between temperament and character traits, may be helpful in predicting suicidal behaviour.", "journal": "Acta neuropsychiatrica", "year": "2017", "authors": "Pawlak J, Dmitrzak-Węglarz M, Maciukiewicz M, Kapelski P, Czerski P, Leszczyńska-Rodziewicz A, Zaremba D, Hauser J", "articleTypes": [ "Journal Article" ], "doi": "10.1017/neu.2016.43", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.569Z" }, { "id": "f740831d-966b-4433-ad7f-06fc5c829740", "pmid": "27573591", "title": "Personality traits as an endophenotype in genetic studies on suicidality in bipolar disorder.", "imported": false, "abstract": "UNLABELLED: Introduction The influence of personality traits on suicidal behaviour risk has been well documented. Personality traits and suicidal behaviour are partially genetically determined and personality has been described as an endophenotype of suicidal behaviour. The aim of this study was to investigate a possible association between personality traits with suicidal behaviour and selected serotonergic gene polymorphisms.\n\nMETHODS: In the study we included 156 patients meeting DSM-IV criteria for bipolar disorder (BP) and 93 healthy controls. The personality dimensions were assessed using the Temperament and Character Inventory (TCI). We genotyped two selected polymorphisms of the tryptophan hydroxylase 1 (TPH1) gene (rs1800532 218A>C and rs1799913 779A>C) and polymorphism in the promoter region of serotonin transporter gene (5-HTTLPR, rs25531) related to serotoninergic neurotransmission. Multiple poisson regression, logistic regression and Kruskal-Wallis tests were applied.\n\nRESULTS: We found numerous differences between the BP patients and the control group in terms of their TCI dimensions/subdimensions. Significant differences were found between patients with, and without, suicidal attempts in fatigability and asthenia (Ha4), as well as in harm avoidance (Ha). We also found that the interactions between TCI subdimensions (the interaction of disordiness (Ns4) and spiritual acceptance (St3), disordiness (Ns4) and integrated conscience (C5), extravagance (Ns3) and resourcefulness (Sd3)) were significantly contributing for suicidal behaviour risk. We found association between all studied genetic polymorphisms and several TCI dimensions and subdimensions.\n\nCONCLUSION: Our results confirm that personality traits are partially determined by genes. 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suicide: a case-control pilot study].", "imported": false, "abstract": "OBJECTIVES: Besides psychological and social effects, biological, biochemical and genetic factors also play a role in the background of suicide. The aim is developing a complex model incorporating all the above factors so that suicide could be predicted and prevented in those at risk. Based on several studies 5-HTTLPR s allele frequency is increased in case of violent completed suicides. The aim of the present study was to validate this association in a sample of completed suicides.\n\nMETHODS: During autopsy sample DNA samples were obtained for 5-HTTLPR genotyping from 200 subjects deceased due to suicide and 200 controls deceased due to other causes. Chi square tests and logistic regressions were performed according to additive, dominant and recessive models to analyse the possible association between 5-HTTLPR genotype distribution and suicide.\n\nRESULTS: Ratio of violent and non-violent suicides was 81% and 19% respectively. No significant difference was found in the distribution of 5-HTTLPR genotypes between the suicide and controls samples. No difference was found between violent and nonviolent suicides with respect to genotype distribution. A significant association was found between sl genotype and suicide at a younger age.\n\nCONCLUSIONS: Our pilot study did not support the supposed association between 5-HTTLPR and completed suicides or with violent completed suicides. 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No difference was found between violent and nonviolent suicides with respect to genotype distribution. A significant association was found between sl genotype and suicide at a younger age.\n\nCONCLUSIONS: Our pilot study did not support the supposed association between 5-HTTLPR and completed suicides or with violent completed suicides. 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The aim is developing a complex model incorporating all the above factors so that suicide could be predicted and prevented in those at risk. Based on several studies 5-HTTLPR s allele frequency is increased in case of violent completed suicides. The aim of the present study was to validate this association in a sample of completed suicides.\n\nMETHODS: During autopsy sample DNA samples were obtained for 5-HTTLPR genotyping from 200 subjects deceased due to suicide and 200 controls deceased due to other causes. Chi square tests and logistic regressions were performed according to additive, dominant and recessive models to analyse the possible association between 5-HTTLPR genotype distribution and suicide.\n\nRESULTS: Ratio of violent and non-violent suicides was 81% and 19% respectively. No significant difference was found in the distribution of 5-HTTLPR genotypes between the suicide and controls samples. 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"28648981", "title": "Leptin's Physiologic Role: Does the Emperor of Energy Balance Have No Clothes?", "imported": false, "abstract": "", "journal": "", "year": "2017", "authors": "Flier JS, Maratos-Flier E.", "articleTypes": [], "doi": "10.1016/j.cmet.2017.05.013", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.380Z" }, { "id": "fc048f8f-de14-43aa-aca1-1da31a3e9ad0", "pmid": "28648981", "title": "Leptin's Physiologic Role: Does the Emperor of Energy Balance Have No Clothes?", "imported": false, "abstract": "", "journal": "", "year": "2017", "authors": "Flier JS, Maratos-Flier E.", "articleTypes": [], "doi": "10.1016/j.cmet.2017.05.013", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.738Z" }, { "id": "1100759e-3030-4464-b8b8-729f308c681a", "pmid": "28652746", "title": "Association between serotonin transporter polymorphisms (5-HTTLPR) and the MADRS Dysphoria, Retardation, and Vegetative Subscale scores in the treatment of depression.", "imported": false, "abstract": "OBJECTIVE: We investigated the association between serotonin- or 5-hydroxytryptamine (5-HT)-related gene polymorphisms and response to antidepressant treatment in a specific symptom cluster of major depression by using the three-factor model of the Montgomery-Åsberg Depression Rating Scale (MADRS), ie, dysphoria (items of sadness, pessimistic thoughts, and suicidal thoughts), retardation (items of lassitude, inability to feel, apparent sadness, and concentration difficulties), and vegetative symptoms (items of reduced sleep, reduced appetite, and inner tension).\n\nMETHODS: This study was an open-label and nonrandomized trial. A total of 160 patients with baseline MADRS scores of ≥21, who were treated with fluvoxamine or milnacipran for 6 weeks, were included in the statistical analysis. Polymorphisms within a 5-HT transporter (5-HTT) gene-linked polymorphic region (5-HTTLPR), a variable number of tandem repeats in the second intron of the 5-HTT gene (5-HTTVNTR), and 5HT2A receptor (1438G/A) were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).\n\nRESULTS: The 5-HTTLPR polymorphisms affected the MADRS score change in dysphoria, but not in retardation, vegetative, or total symptoms. Dysphoria scores significantly decreased in patients with the S/S genotype compared to those in patients with the short (S)/long (L) + L/L genotype. However, 5-HTTVNTR and 1438G/A polymorphisms were not significantly associated with the treatment response to any cluster of depressive symptoms. When a Bonferroni correction was made, however, our results did not reach the criteria for statistical significance.\n\nCONCLUSION: The use of a single total depression rating scale may not be sufficient to accurately estimate the clinical response to antidepressants. 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A total of 160 patients with baseline MADRS scores of ≥21, who were treated with fluvoxamine or milnacipran for 6 weeks, were included in the statistical analysis. Polymorphisms within a 5-HT transporter (5-HTT) gene-linked polymorphic region (5-HTTLPR), a variable number of tandem repeats in the second intron of the 5-HTT gene (5-HTTVNTR), and 5HT2A receptor (1438G/A) were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).\n\nRESULTS: The 5-HTTLPR polymorphisms affected the MADRS score change in dysphoria, but not in retardation, vegetative, or total symptoms. Dysphoria scores significantly decreased in patients with the S/S genotype compared to those in patients with the short (S)/long (L) + L/L genotype. However, 5-HTTVNTR and 1438G/A polymorphisms were not significantly associated with the treatment response to any cluster of depressive symptoms. When a Bonferroni correction was made, however, our results did not reach the criteria for statistical significance.\n\nCONCLUSION: The use of a single total depression rating scale may not be sufficient to accurately estimate the clinical response to antidepressants. Analyzing a subset of symptoms in psychological scales could be important when performing pharmacogenetic studies.", "journal": "Neuropsychiatric disease and treatment", "year": "2017", "authors": "Takahashi H, Higuchi H, Sato K, Kamata M, Yoshida K, Nishimura K", "articleTypes": [ "Journal Article" ], "doi": "10.2147/NDT.S123708", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.569Z" }, { "id": "9b17b143-7666-4f9e-bf35-8623bd733c6f", "pmid": "28652746", "title": "Association between serotonin transporter polymorphisms (5-HTTLPR) and the MADRS Dysphoria, Retardation, and Vegetative Subscale scores in the treatment of depression.", "imported": false, "abstract": "OBJECTIVE: We investigated the association between serotonin- or 5-hydroxytryptamine (5-HT)-related gene polymorphisms and response to antidepressant treatment in a specific symptom cluster of major depression by using the three-factor model of the Montgomery-Åsberg Depression Rating Scale (MADRS), ie, dysphoria (items of sadness, pessimistic thoughts, and suicidal thoughts), retardation (items of lassitude, inability to feel, apparent sadness, and concentration difficulties), and vegetative symptoms (items of reduced sleep, reduced appetite, and inner tension).\n\nMETHODS: This study was an open-label and nonrandomized trial. A total of 160 patients with baseline MADRS scores of ≥21, who were treated with fluvoxamine or milnacipran for 6 weeks, were included in the statistical analysis. Polymorphisms within a 5-HT transporter (5-HTT) gene-linked polymorphic region (5-HTTLPR), a variable number of tandem repeats in the second intron of the 5-HTT gene (5-HTTVNTR), and 5HT2A receptor (1438G/A) were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).\n\nRESULTS: The 5-HTTLPR polymorphisms affected the MADRS score change in dysphoria, but not in retardation, vegetative, or total symptoms. Dysphoria scores significantly decreased in patients with the S/S genotype compared to those in patients with the short (S)/long (L) + L/L genotype. However, 5-HTTVNTR and 1438G/A polymorphisms were not significantly associated with the treatment response to any cluster of depressive symptoms. When a Bonferroni correction was made, however, our results did not reach the criteria for statistical significance.\n\nCONCLUSION: The use of a single total depression rating scale may not be sufficient to accurately estimate the clinical response to antidepressants. 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The length density of axons expressing SERT in the orbitofrontal cortex (OFC) was determined in 18 subjects with MDD and 17 age-matched control subjects. A monoclonal antibody was used to immunohistochemically label the SERT in fixed sections of OFC. The 3-dimensional length density of SERT-immunoreactive (ir) axons in layer VI of OFC was estimated. The age of subjects with MDD was negatively correlated with SERT axon length (r=-0.77, p<0.0005). The significant effect of age persisted when removing four depressed subjects with an antidepressant medication present at the time of death, or when removing nine depressed subjects that had a recent prescription for an antidepressant medication. Neither gender, tissue pH, postmortem interval, 5-HTTLPR genotype, time in fixative, nor death by suicide had a significant effect on axon length. The age-related decrease in SERT-ir axon length in MDD may reflect pathology of ascending axons passing through deep white matter hyperintensities. 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The length density of axons expressing SERT in the orbitofrontal cortex (OFC) was determined in 18 subjects with MDD and 17 age-matched control subjects. A monoclonal antibody was used to immunohistochemically label the SERT in fixed sections of OFC. The 3-dimensional length density of SERT-immunoreactive (ir) axons in layer VI of OFC was estimated. The age of subjects with MDD was negatively correlated with SERT axon length (r=-0.77, p<0.0005). The significant effect of age persisted when removing four depressed subjects with an antidepressant medication present at the time of death, or when removing nine depressed subjects that had a recent prescription for an antidepressant medication. Neither gender, tissue pH, postmortem interval, 5-HTTLPR genotype, time in fixative, nor death by suicide had a significant effect on axon length. The age-related decrease in SERT-ir axon length in MDD may reflect pathology of ascending axons passing through deep white matter hyperintensities. Greater length of axons expressing SERT in younger subjects with MDD may result in a significant deficit in serotonin availability in OFC.", "journal": "Neuroscience", "year": "2017", "authors": "Rajkowska G, Mahajan G, Legutko B, Challagundla L, Griswold M, Albert PR, Daigle M, Miguel-Hidalgo JJ, Austin MC, Blakely RD, Steffens DC, Stockmeier CA", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural" ], "doi": "10.1001/jamapsychiatry.2017.0984", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.568Z" }, { "id": "09ce1167-64f7-414c-a45b-a0c87aa4d248", "pmid": "28716530", "title": "Genetic association analysis of serotonin and signal transduction pathways in suicide attempters from an Italian sample of psychiatric patients.", "imported": false, "abstract": "Genetic factors have been reported to contribute to the liability of suicide. We aimed to investigate functional polymorphisms in eight genes (serotonin transporter, SLC6A4; receptors, 5HTR1A, 1B, 5HTR2A; Tryptophan Hydroxylase, TPH1, TPH2; Monoamine Oxidase, MAOA and G Protein Subunit Beta 3, GNB3) to investigate their predictive value for suicide. The possible confounding effects of gender and phenotypic patients dissection were also valued. A sample of 111 consecutive psychiatric inpatients was recruited and assessed using specific psychometric instruments. Genomic DNA was isolated from peripheral white blood cell samples and polymorphisms were genotyped by pyrosequencing technology. Although no differences were observed between allele and genotype frequencies for all polymorphisms and suicide attempt (SA), a polygenic risk score was detected for three genes HTR2A (A-1438G), TPH1 and TPH2 increasing the prediction of SA risk (Thresh=0.43, p=0.038, R2=0.053). Moreover some nominal associations were obtained after gender and phenotypic dissection stratification (TEMPS-A, TEMPs-H, GSMD, SHSS, GAF, CGI) for SLC6A4 (5-HTTLPR), HTR1A (C-1019G), HTR2A (A-1438G), TPH1 (A799C) and GNB3 (C825T) genes, that were lost after Bonferroni correction. This is a first evidence that specific additive combinations of genes could increase the prediction of SA risk and that gender and phenotypic dissection could influence the association of the genes with SA. This could represent a further study also for future meta-analyses on larger samples.", "journal": "Neuroscience letters", "year": "2017", "authors": "Pompili M, Gentile G, Scassellati C, Bonvicini C, Innamorati M, Erbuto D, Montebovi F, Ducci G, Forte A, De Pisa E, Ferracuti S, Serafini G, De Luca V, Amore M, Simmaco M, Girardi P", "articleTypes": [ "Journal Article" ], "doi": "10.1016/j.neulet.2017.07.020", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.161Z" }, { "id": "63c1c0c4-a633-4f03-a9ef-7edb16943742", "pmid": "28716530", "title": "Genetic association analysis of serotonin and signal transduction pathways in suicide attempters from an Italian sample of psychiatric patients.", "imported": false, "abstract": "Genetic factors have been reported to contribute to the liability of suicide. We aimed to investigate functional polymorphisms in eight genes (serotonin transporter, SLC6A4; receptors, 5HTR1A, 1B, 5HTR2A; Tryptophan Hydroxylase, TPH1, TPH2; Monoamine Oxidase, MAOA and G Protein Subunit Beta 3, GNB3) to investigate their predictive value for suicide. The possible confounding effects of gender and phenotypic patients dissection were also valued. A sample of 111 consecutive psychiatric inpatients was recruited and assessed using specific psychometric instruments. Genomic DNA was isolated from peripheral white blood cell samples and polymorphisms were genotyped by pyrosequencing technology. Although no differences were observed between allele and genotype frequencies for all polymorphisms and suicide attempt (SA), a polygenic risk score was detected for three genes HTR2A (A-1438G), TPH1 and TPH2 increasing the prediction of SA risk (Thresh=0.43, p=0.038, R2=0.053). Moreover some nominal associations were obtained after gender and phenotypic dissection stratification (TEMPS-A, TEMPs-H, GSMD, SHSS, GAF, CGI) for SLC6A4 (5-HTTLPR), HTR1A (C-1019G), HTR2A (A-1438G), TPH1 (A799C) and GNB3 (C825T) genes, that were lost after Bonferroni correction. This is a first evidence that specific additive combinations of genes could increase the prediction of SA risk and that gender and phenotypic dissection could influence the association of the genes with SA. This could represent a further study also for future meta-analyses on larger samples.", "journal": "Neuroscience letters", "year": "2017", "authors": "Pompili M, Gentile G, Scassellati C, Bonvicini C, Innamorati M, Erbuto D, Montebovi F, Ducci G, Forte A, De Pisa E, Ferracuti S, Serafini G, De Luca V, Amore M, Simmaco M, Girardi P", "articleTypes": [ "Journal Article" ], "doi": "10.1016/j.neulet.2017.07.020", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.627Z" }, { "id": "fdae76f1-0539-4f03-9f4c-31542b0820ca", "pmid": "28716530", "title": "Genetic association analysis of serotonin and signal transduction pathways in suicide attempters from an Italian sample of psychiatric patients.", "imported": false, "abstract": "Genetic factors have been reported to contribute to the liability of suicide. We aimed to investigate functional polymorphisms in eight genes (serotonin transporter, SLC6A4; receptors, 5HTR1A, 1B, 5HTR2A; Tryptophan Hydroxylase, TPH1, TPH2; Monoamine Oxidase, MAOA and G Protein Subunit Beta 3, GNB3) to investigate their predictive value for suicide. The possible confounding effects of gender and phenotypic patients dissection were also valued. A sample of 111 consecutive psychiatric inpatients was recruited and assessed using specific psychometric instruments. Genomic DNA was isolated from peripheral white blood cell samples and polymorphisms were genotyped by pyrosequencing technology. Although no differences were observed between allele and genotype frequencies for all polymorphisms and suicide attempt (SA), a polygenic risk score was detected for three genes HTR2A (A-1438G), TPH1 and TPH2 increasing the prediction of SA risk (Thresh=0.43, p=0.038, R2=0.053). Moreover some nominal associations were obtained after gender and phenotypic dissection stratification (TEMPS-A, TEMPs-H, GSMD, SHSS, GAF, CGI) for SLC6A4 (5-HTTLPR), HTR1A (C-1019G), HTR2A (A-1438G), TPH1 (A799C) and GNB3 (C825T) genes, that were lost after Bonferroni correction. This is a first evidence that specific additive combinations of genes could increase the prediction of SA risk and that gender and phenotypic dissection could influence the association of the genes with SA. This could represent a further study also for future meta-analyses on larger samples.", "journal": "Neuroscience letters", "year": "2017", "authors": "Pompili M, Gentile G, Scassellati C, Bonvicini C, Innamorati M, Erbuto D, Montebovi F, Ducci G, Forte A, De Pisa E, Ferracuti S, Serafini G, De Luca V, Amore M, Simmaco M, Girardi P", "articleTypes": [ "Journal Article" ], "doi": "10.1016/j.neulet.2017.07.020", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.568Z" }, { "id": "138b8880-1471-4a42-9454-2f05a1dfb20d", "pmid": "28719892", "title": "Cinnamaldehyde Ameliorates Diet-Induced Obesity in Mice by Inducing Browning of White Adipose Tissue", "imported": false, "abstract": "", "journal": "", "year": "2017", "authors": "Zuo J, Zhao D, Yu N, Fang X, Mu Q, Ma Y, Mo F, Wu R, Ma R, Wang L, Zhu R, Liu H, Zhang D, Gao S.", "articleTypes": [], "doi": "10.1159/000479268", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.365Z" }, { "id": "70152211-c200-4b67-8b1b-7dfca0bc6356", "pmid": "28719892", "title": "Cinnamaldehyde Ameliorates Diet-Induced Obesity in Mice by Inducing Browning of White Adipose Tissue", "imported": false, 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"authors": "da Fonseca ACP, Mastronardi C, Johar A, Arcos-Burgos M, Paz-Filho G.", "articleTypes": [], "doi": "10.1016/j.jdiacomp.2017.04.026", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.435Z" }, { "id": "5f431bd8-59f8-4218-bd17-593cd2623060", "pmid": "28739551", "title": "A Patient with Proopiomelanocortin Deficiency: An Increasingly Important Diagnosis to Make", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Çetinkaya S, Güran T, Kurnaz E, Keskin M, Sağsak E, Savaş Erdeve S, Suntharalingham JP, Buonocore F, Achermann JC, Aycan Z.", "articleTypes": [], "doi": "10.4274/jcrpe.4638", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.914Z" }, { "id": "7ab880d4-5b40-49ca-b910-0106e0df092c", "pmid": "28739551", "title": "A Patient with Proopiomelanocortin Deficiency: An Increasingly Important Diagnosis to Make", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Çetinkaya S, Güran T, Kurnaz E, Keskin M, Sağsak E, Savaş Erdeve S, Suntharalingham JP, Buonocore F, Achermann JC, Aycan Z.", "articleTypes": [], "doi": "10.4274/jcrpe.4638", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.412Z" }, { "id": "bf182853-a2f0-4d70-8961-279e8cf062c9", "pmid": "28739551", "title": "A Patient with Proopiomelanocortin Deficiency: An Increasingly Important Diagnosis to Make", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Çetinkaya S, Güran T, Kurnaz E, Keskin M, Sağsak E, Savaş Erdeve S, Suntharalingham JP, Buonocore F, Achermann JC, Aycan Z.", "articleTypes": [], "doi": "10.4274/jcrpe.4638", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.799Z" }, { "id": "e0cbdf0e-e07f-48e5-8bfb-cf7e6c275d0a", "pmid": "28739551", "title": "A Patient with Proopiomelanocortin Deficiency: An Increasingly Important Diagnosis to Make", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Çetinkaya S, Güran T, Kurnaz E, Keskin M, Sağsak E, Savaş Erdeve S, Suntharalingham JP, Buonocore F, Achermann JC, Aycan Z.", "articleTypes": [], "doi": "10.4274/jcrpe.4638", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.443Z" }, { "id": "1191b6f0-7032-4b54-b9b0-362e7b5435cf", "pmid": "28743254", "title": "Association between serotonin transporter gene polymorphisms and increased suicidal risk among HIV positive patients in Uganda.", "imported": false, "abstract": "BACKGROUND: Persons living with HIV/AIDS (PLWHA) are at an increased risk of suicide. Increased suicidal risk is a predictor of future attempted and completed suicides and has been associated with poor quality of life and poor adherence with antiretroviral therapy. Clinical risk factors have low predictive value for suicide, hence the interest in potential neurobiological correlates and specific heritable markers of suicide vulnerability. The serotonin transporter gene has previously been implicated in the aetiology of increased suicidal risk in non-HIV infected study populations and its variations may provide a platform for identifying genetic risk for suicidality among PLWHA. The present cross-sectional study aimed at identifying two common genetic variants of the serotonin transporter gene and their association with increased suicidal risk among human immunodeficiency virus (HIV)-positive adults in Uganda.\n\nRESULTS: The prevalence of increased suicidal risk (defined as moderate to high risk suicidality on the suicidality module of the Mini Neuropsychiatric Interview (M.I.N.I) was 3.3% (95% CI, 2.0-5.3). The 5-HTTLPR was found to be associated with increased suicidal risk before Bonferroni correction (p-value = 0.0174). A protective effect on increased suicidal risk was found for the 5-HTTLPR/rs25531 S A allele (p-value = 0.0046)- which directs reduced expression of the serotonin transporter gene (5-HTT).\n\nCONCLUSION: The S A allele at the 5-HTTLPR/rs25531 locus is associated with increased suicidal risk among Ugandan PLWHA. Further studies are needed to validate this finding in Ugandan and other sub-Saharan samples.", "journal": "BMC genetics", "year": "2017", "authors": "Kalungi A, Seedat S, Hemmings SMJ, van der Merwe L, Joloba ML, Nanteza A, Nakassujja N, Birabwa H, Serwanga J, Kaleebu P, Kinyanda E", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/j.1529-8817.2005.00213.x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.569Z" }, { "id": "658e35ad-5e65-4deb-a3c8-3fd8de9924ee", "pmid": "28743254", "title": "Association between serotonin transporter gene polymorphisms and increased suicidal risk among HIV positive patients in Uganda.", "imported": false, "abstract": "BACKGROUND: Persons living with HIV/AIDS (PLWHA) are at an increased risk of suicide. Increased suicidal risk is a predictor of future attempted and completed suicides and has been associated with poor quality of life and poor adherence with antiretroviral therapy. Clinical risk factors have low predictive value for suicide, hence the interest in potential neurobiological correlates and specific heritable markers of suicide vulnerability. The serotonin transporter gene has previously been implicated in the aetiology of increased suicidal risk in non-HIV infected study populations and its variations may provide a platform for identifying genetic risk for suicidality among PLWHA. The present cross-sectional study aimed at identifying two common genetic variants of the serotonin transporter gene and their association with increased suicidal risk among human immunodeficiency virus (HIV)-positive adults in Uganda.\n\nRESULTS: The prevalence of increased suicidal risk (defined as moderate to high risk suicidality on the suicidality module of the Mini Neuropsychiatric Interview (M.I.N.I) was 3.3% (95% CI, 2.0-5.3). The 5-HTTLPR was found to be associated with increased suicidal risk before Bonferroni correction (p-value = 0.0174). A protective effect on increased suicidal risk was found for the 5-HTTLPR/rs25531 S A allele (p-value = 0.0046)- which directs reduced expression of the serotonin transporter gene (5-HTT).\n\nCONCLUSION: The S A allele at the 5-HTTLPR/rs25531 locus is associated with increased suicidal risk among Ugandan PLWHA. Further studies are needed to validate this finding in Ugandan and other sub-Saharan samples.", "journal": "BMC genetics", "year": "2017", "authors": "Kalungi A, Seedat S, Hemmings SMJ, van der Merwe L, Joloba ML, Nanteza A, Nakassujja N, Birabwa H, Serwanga J, Kaleebu P, Kinyanda E", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/j.1529-8817.2005.00213.x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.162Z" }, { "id": "9660671b-b94b-48e4-9e2c-6207195a3183", "pmid": "28743254", "title": "Association between serotonin transporter gene polymorphisms and increased suicidal risk among HIV positive patients in Uganda.", "imported": false, "abstract": "BACKGROUND: Persons living with HIV/AIDS (PLWHA) are at an increased risk of suicide. Increased suicidal risk is a predictor of future attempted and completed suicides and has been associated with poor quality of life and poor adherence with antiretroviral therapy. Clinical risk factors have low predictive value for suicide, hence the interest in potential neurobiological correlates and specific heritable markers of suicide vulnerability. The serotonin transporter gene has previously been implicated in the aetiology of increased suicidal risk in non-HIV infected study populations and its variations may provide a platform for identifying genetic risk for suicidality among PLWHA. The present cross-sectional study aimed at identifying two common genetic variants of the serotonin transporter gene and their association with increased suicidal risk among human immunodeficiency virus (HIV)-positive adults in Uganda.\n\nRESULTS: The prevalence of increased suicidal risk (defined as moderate to high risk suicidality on the suicidality module of the Mini Neuropsychiatric Interview (M.I.N.I) was 3.3% (95% CI, 2.0-5.3). The 5-HTTLPR was found to be associated with increased suicidal risk before Bonferroni correction (p-value = 0.0174). A protective effect on increased suicidal risk was found for the 5-HTTLPR/rs25531 S A allele (p-value = 0.0046)- which directs reduced expression of the serotonin transporter gene (5-HTT).\n\nCONCLUSION: The S A allele at the 5-HTTLPR/rs25531 locus is associated with increased suicidal risk among Ugandan PLWHA. Further studies are needed to validate this finding in Ugandan and other sub-Saharan samples.", "journal": "BMC genetics", "year": "2017", "authors": "Kalungi A, Seedat S, Hemmings SMJ, van der Merwe L, Joloba ML, Nanteza A, Nakassujja N, Birabwa H, Serwanga J, Kaleebu P, Kinyanda E", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1111/j.1529-8817.2005.00213.x", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All 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"journal": "", "year": "2017", "authors": "Shintani T, Higashi S, Suzuki R, Takeuchi Y, Ikaga R, Yamazaki T, Kobayashi K, Noda M.", "articleTypes": [], "doi": "10.1038/s41598-017-12070-7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.757Z" }, { "id": "50492e5a-eb0e-4986-ba77-b223fd3baf0e", "pmid": "28912580", "title": "PTPRJ Inhibits Leptin Signaling, and Induction of PTPRJ in the Hypothalamus Is a Cause of the Development of Leptin Resistance", "imported": false, "abstract": "", "journal": "", "year": "2017", "authors": "Shintani T, Higashi S, Suzuki R, Takeuchi Y, Ikaga R, Yamazaki T, Kobayashi K, Noda M.", "articleTypes": [], "doi": "10.1038/s41598-017-12070-7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.401Z" }, { "id": "61525890-82ae-4eb4-b0b3-0c893eecc686", "pmid": "28912580", "title": "PTPRJ Inhibits Leptin Signaling, and Induction of PTPRJ in the Hypothalamus Is a Cause of the Development of Leptin Resistance", "imported": false, "abstract": "", "journal": "", "year": "2017", "authors": "Shintani T, Higashi S, Suzuki R, Takeuchi Y, Ikaga R, Yamazaki T, Kobayashi K, Noda M.", "articleTypes": [], "doi": "10.1038/s41598-017-12070-7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.878Z" }, { "id": "f352d9de-4454-4a45-abd3-567b104b949e", "pmid": "28912580", "title": "PTPRJ Inhibits Leptin Signaling, and Induction of PTPRJ in the Hypothalamus Is a Cause of the Development of Leptin Resistance", "imported": false, "abstract": "", "journal": "", "year": "2017", "authors": "Shintani T, Higashi S, Suzuki R, Takeuchi Y, Ikaga R, Yamazaki T, Kobayashi K, Noda M.", "articleTypes": [], "doi": "10.1038/s41598-017-12070-7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.369Z" }, { "id": "0580a98c-b452-4b59-88e8-49ef067771ea", "pmid": "28914102", "title": "5-HTTLPR-brain-derived neurotrophic factor (BDNF) gene interactions and early adverse life events effect on impulsivity in suicide attempters.", "imported": false, "abstract": "OBJECTIVES: An expanding body of research suggests that childhood adverse experiences can lead to different negative health outcomes, including attempted suicide. Serotonergic genes such as the promoter region of the serotonin transporter gene (5-HTTLPR) have been associated both with impulsivity in suicide attempts and reactivity to environmental stress exposure. BDNF gene may play an epigenetic role.\n\nMETHODS: We studied the influence of childhood stressful events and 5-HTTLPR genotype on impulsivity measured by Barratt Impulsivity Scale (BIS-10) in a multicentre sample of 1,655 suicide attempters (69.4% women, 30.6% men; mean age 40.13 years). A co-dominant additive genetic model was used for the statistical analyses. Interaction between 5-HTTLPR genotype and early trauma exposure was tested using moderated and multiple regression techniques. Interaction plots were used to explore BDNF genotype modulation.\n\nRESULTS: Mildly higher impulsivity scores were found in men with SS compared with SL or LL genotypes, and men with childhood emotional and physical abuse. Interaction analyses showed that combination of 5-HTTLPR-SS genotype and early trauma exposure increase impulsivity scores independently. Impulsivity scores were not affected by the modulation of BDNF genes.\n\nCONCLUSIONS: Childhood trauma and 5-HTTLPR genotype seem to be independently involved in suicide attempts, sharing a common pathway of increasing impulsivity.", "journal": "The world journal of biological psychiatry : the official journal of the World Federation of Societies of Biological Psychiatry", "year": "2019", "authors": "Jiménez-Treviño L, Saiz PA, García-Portilla MP, Blasco-Fontecilla H, Carli V, Iosue M, Jaussent I, López-Castroman J, Vaquero-Lorenzo C, Sarchiapone M, Baca-García E, Courtet P, Bobes J", "articleTypes": [ "Journal Article", "Multicenter Study" ], "doi": "10.1080/15622975.2017.1376112", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.566Z" }, { "id": "b4494c46-f97f-4cce-808f-fe831ecbb122", "pmid": "28914102", "title": "5-HTTLPR-brain-derived neurotrophic factor (BDNF) gene interactions and early adverse life events effect on impulsivity in suicide attempters.", "imported": false, "abstract": "OBJECTIVES: An expanding body of research suggests that childhood adverse experiences can lead to different negative health outcomes, including attempted suicide. Serotonergic genes such as the promoter region of the serotonin transporter gene (5-HTTLPR) have been associated both with impulsivity in suicide attempts and reactivity to environmental stress exposure. BDNF gene may play an epigenetic role.\n\nMETHODS: We studied the influence of childhood stressful events and 5-HTTLPR genotype on impulsivity measured by Barratt Impulsivity Scale (BIS-10) in a multicentre sample of 1,655 suicide attempters (69.4% women, 30.6% men; mean age 40.13 years). A co-dominant additive genetic model was used for the statistical analyses. Interaction between 5-HTTLPR genotype and early trauma exposure was tested using moderated and multiple regression techniques. Interaction plots were used to explore BDNF genotype modulation.\n\nRESULTS: Mildly higher impulsivity scores were found in men with SS compared with SL or LL genotypes, and men with childhood emotional and physical abuse. Interaction analyses showed that combination of 5-HTTLPR-SS genotype and early trauma exposure increase impulsivity scores independently. Impulsivity scores were not affected by the modulation of BDNF genes.\n\nCONCLUSIONS: Childhood trauma and 5-HTTLPR genotype seem to be independently involved in suicide attempts, sharing a common pathway of increasing impulsivity.", "journal": "The world journal of biological psychiatry : the official journal of the World Federation of Societies of Biological Psychiatry", "year": "2019", "authors": "Jiménez-Treviño L, Saiz PA, García-Portilla MP, Blasco-Fontecilla H, Carli V, Iosue M, Jaussent I, López-Castroman J, Vaquero-Lorenzo C, Sarchiapone M, Baca-García E, Courtet P, Bobes J", "articleTypes": [ "Journal Article", "Multicenter Study" ], "doi": "10.1080/15622975.2017.1376112", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.153Z" }, { "id": "cbe701ca-8f44-4e01-9fb8-a75e32585c7c", "pmid": "28914102", "title": "5-HTTLPR-brain-derived neurotrophic factor (BDNF) gene interactions and early adverse life events effect on impulsivity in suicide attempters.", "imported": false, "abstract": "OBJECTIVES: An expanding body of research suggests that childhood adverse experiences can lead to different negative health outcomes, including attempted suicide. Serotonergic genes such as the promoter region of the serotonin transporter gene (5-HTTLPR) have been associated both with impulsivity in suicide attempts and reactivity to environmental stress exposure. BDNF gene may play an epigenetic role.\n\nMETHODS: We studied the influence of childhood stressful events and 5-HTTLPR genotype on impulsivity measured by Barratt Impulsivity Scale (BIS-10) in a multicentre sample of 1,655 suicide attempters (69.4% women, 30.6% men; mean age 40.13 years). A co-dominant additive genetic model was used for the statistical analyses. Interaction between 5-HTTLPR genotype and early trauma exposure was tested using moderated and multiple regression techniques. Interaction plots were used to explore BDNF genotype modulation.\n\nRESULTS: Mildly higher impulsivity scores were found in men with SS compared with SL or LL genotypes, and men with childhood emotional and physical abuse. Interaction analyses showed that combination of 5-HTTLPR-SS genotype and early trauma exposure increase impulsivity scores independently. Impulsivity scores were not affected by the modulation of BDNF genes.\n\nCONCLUSIONS: Childhood trauma and 5-HTTLPR genotype seem to be independently involved in suicide attempts, sharing a common pathway of increasing impulsivity.", "journal": "The world journal of biological psychiatry : the official journal of the World Federation of Societies of Biological Psychiatry", "year": "2019", "authors": "Jiménez-Treviño L, Saiz PA, García-Portilla MP, Blasco-Fontecilla H, Carli V, Iosue M, Jaussent I, López-Castroman J, Vaquero-Lorenzo C, Sarchiapone M, Baca-García E, Courtet P, Bobes J", "articleTypes": [ "Journal Article", "Multicenter Study" ], "doi": "10.1080/15622975.2017.1376112", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], 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"", "year": "2018", "authors": "Moghanloo MN, Mohammadzadeh NA, Lotfi H, Mahmoudi R, Abbasi M, Alipour FG, Shool F, Porfaraj S, Zarghami N.", "articleTypes": [], "doi": "10.2174/1573399813666170915125043", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.351Z" }, { "id": "e012ffe4-90e6-4573-befa-7cc848db348e", "pmid": "28914195", "title": "Polymorphism rs9939609 of Fat Mass and Obesity-associated Gene Correlation with Leptin Level of Obese Women Suffered from Type 2 Diabetes", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Moghanloo MN, Mohammadzadeh NA, Lotfi H, Mahmoudi R, Abbasi M, Alipour FG, Shool F, Porfaraj S, Zarghami N.", "articleTypes": [], "doi": "10.2174/1573399813666170915125043", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.742Z" }, { "id": "4abbb5cd-a0a7-4bea-90b2-b62a9b89742b", "pmid": "28920084", "title": "EFFECTS OF 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Acute coronary syndrome (ACS) is associated with an increased risk of suicide, but few studies have explored the genetic predisposition toward suicide in ACS populations. Therefore, this longitudinal study explored the genetic predisposition toward suicidal ideation in ACS patients. In total, of 969 patients within 2 weeks after ACS, 711 were followed at 1 year after ACS. Suicidal ideation was evaluated with the relevant items on the Montgomery-Åsberg Depression Rating Scale. Ten genetic polymorphisms associated with serotonergic systems, neurotrophic factors, carbon metabolism, and inflammatory cytokines were examined. Associations between genetic polymorphisms and suicidal ideation within 2 weeks and 1 year of ACS were investigated using logistic regression models. The 5-HTTLPR s allele was significantly associated with suicidal ideation within 2 weeks of ACS after adjusting for covariates and after the Bonferroni correction. TNF-α -308G/A, IL-1β -511C/T, and IL-1β + 3953C/T were significantly associated with suicidal ideation within 2 weeks after ACS, but these associations did not reach significance after the Bonferroni correction in unadjusted analyses and after adjusting for covariance. However, no significant association between genetic polymorphisms and suicidal ideation was found at 1 year. 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Acute coronary syndrome (ACS) is associated with an increased risk of suicide, but few studies have explored the genetic predisposition toward suicide in ACS populations. Therefore, this longitudinal study explored the genetic predisposition toward suicidal ideation in ACS patients. In total, of 969 patients within 2 weeks after ACS, 711 were followed at 1 year after ACS. Suicidal ideation was evaluated with the relevant items on the Montgomery-Åsberg Depression Rating Scale. Ten genetic polymorphisms associated with serotonergic systems, neurotrophic factors, carbon metabolism, and inflammatory cytokines were examined. Associations between genetic polymorphisms and suicidal ideation within 2 weeks and 1 year of ACS were investigated using logistic regression models. The 5-HTTLPR s allele was significantly associated with suicidal ideation within 2 weeks of ACS after adjusting for covariates and after the Bonferroni correction. TNF-α -308G/A, IL-1β -511C/T, and IL-1β + 3953C/T were significantly associated with suicidal ideation within 2 weeks after ACS, but these associations did not reach significance after the Bonferroni correction in unadjusted analyses and after adjusting for covariance. However, no significant association between genetic polymorphisms and suicidal ideation was found at 1 year. Genetic predisposition, 5-HTTLPR s allele in particular, may confer susceptibility to suicidal ideation in ACS patients during the acute phase of ACS.", "journal": "Oncotarget", "year": "2017", "authors": "Kang HJ, Bae KY, Kim SW, Shin IS, Hong YJ, Ahn Y, Jeong MH, Yoon JS, Kim JM", "articleTypes": [ "Journal Article" ], "doi": "10.1093/ndt/gfw244", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.155Z" }, { "id": "bcd9e865-4ac7-4da4-91ef-a1b6d81622ec", "pmid": "29212281", "title": "Genetic predisposition toward suicidal ideation in patients with acute coronary syndrome.", "imported": false, "abstract": "The genetic predisposition toward suicidal ideation has been explored to identify subgroups at high risk and to prevent suicide. Acute coronary syndrome (ACS) is associated with an increased risk of suicide, but few studies have explored the genetic predisposition toward suicide in ACS populations. Therefore, this longitudinal study explored the genetic predisposition toward suicidal ideation in ACS patients. In total, of 969 patients within 2 weeks after ACS, 711 were followed at 1 year after ACS. Suicidal ideation was evaluated with the relevant items on the Montgomery-Åsberg Depression Rating Scale. Ten genetic polymorphisms associated with serotonergic systems, neurotrophic factors, carbon metabolism, and inflammatory cytokines were examined. Associations between genetic polymorphisms and suicidal ideation within 2 weeks and 1 year of ACS were investigated using logistic regression models. The 5-HTTLPR s allele was significantly associated with suicidal ideation within 2 weeks of ACS after adjusting for covariates and after the Bonferroni correction. TNF-α -308G/A, IL-1β -511C/T, and IL-1β + 3953C/T were significantly associated with suicidal ideation within 2 weeks after ACS, but these associations did not reach significance after the Bonferroni correction in unadjusted analyses and after adjusting for covariance. However, no significant association between genetic polymorphisms and suicidal ideation was found at 1 year. Genetic predisposition, 5-HTTLPR s allele in particular, may confer susceptibility to suicidal ideation in ACS patients during the acute phase of ACS.", "journal": "Oncotarget", "year": "2017", "authors": "Kang HJ, Bae KY, Kim SW, Shin IS, Hong YJ, Ahn Y, Jeong MH, Yoon JS, Kim JM", "articleTypes": [ "Journal Article" ], "doi": "10.1093/ndt/gfw244", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH 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"authors": "Haglund E, Nguyen L, Schafer NP, Lammert H, Jennings PA, Onuchic JN.", "articleTypes": [], "doi": "10.1074/jbc.RA118.003957", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.346Z" }, { "id": "5b7ce85c-c9a9-40cd-87ee-49b012719e88", "pmid": "29957477", "title": "5-HTT mRNA level as a potential biomarker of treatment response in patients with major depression in a clinical trial.", "imported": false, "abstract": "OBJECTIVES: To investigate whether the serotonin transporter (5-HTT or SERT or SLC6A4) mRNA level could be used as a biomarker of treatment response in patients with major depression treated with different antidepressants while controlling related factors.\n\nMETHODS: One hundred and nineteen patients with major depression were recruited; all genotyped for the 5-HTT polymorphism concerning 5-HTTLPR, rs25531, and STin2 VNTR, provided demographic data and completed relevant questionnaires. Duloxetine and paroxetine were administered over 32 weeks to these patients. The Hamilton depression rating scale (HDRS) and 5-HTT mRNA level were evaluated at baseline (Week 0), and at 8, 16, 24 and 32 weeks.\n\nRESULTS: Improvement in depressive symptoms (HDRS score declined) and increasing in 5-HTT mRNA level were found with longer duration of antidepressant treatment in patients with major depression. Patients with more 5-HTTPR long-form alleles and STin2.12 alleles had poor antidepressant treatment response. Duloxetine may give a better treatment response than paroxetine. Using structural equation modeling (SEM), the 5-HTTLPR long-form had a direct positive association with the 5-HTT mRNA level and an indirect adverse relationship with the 5-HTT mRNA level through neuroticism and previous suicide attempts.\n\nCONCLUSION: The 5-HTT mRNA level increased and correlated with the treatment response (HDRS score improvement) under 32-weeks antidepressants treatment clinical trial. We speculate that the 5-HTT mRNA level may be used as a potential biomarker of antidepressant treatment response.", "journal": "Journal of affective disorders", "year": "2018", "authors": "Kao WT, Chang CL, Lung FW", "articleTypes": [ "Clinical Trial", "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2018.06.035", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.625Z" }, { "id": "7c3eefbe-a659-4761-b6ec-6aaf541261b5", "pmid": "29957477", "title": "5-HTT mRNA level as a potential biomarker of treatment response in patients with major depression in a clinical trial.", "imported": false, "abstract": "OBJECTIVES: To investigate whether the serotonin transporter (5-HTT or SERT or SLC6A4) mRNA level could be used as a biomarker of treatment response in patients with major depression treated with different antidepressants while controlling related factors.\n\nMETHODS: One hundred and nineteen patients with major depression were recruited; all genotyped for the 5-HTT polymorphism concerning 5-HTTLPR, rs25531, and STin2 VNTR, provided demographic data and completed relevant questionnaires. Duloxetine and paroxetine were administered over 32 weeks to these patients. The Hamilton depression rating scale (HDRS) and 5-HTT mRNA level were evaluated at baseline (Week 0), and at 8, 16, 24 and 32 weeks.\n\nRESULTS: Improvement in depressive symptoms (HDRS score declined) and increasing in 5-HTT mRNA level were found with longer duration of antidepressant treatment in patients with major depression. Patients with more 5-HTTPR long-form alleles and STin2.12 alleles had poor antidepressant treatment response. Duloxetine may give a better treatment response than paroxetine. Using structural equation modeling (SEM), the 5-HTTLPR long-form had a direct positive association with the 5-HTT mRNA level and an indirect adverse relationship with the 5-HTT mRNA level through neuroticism and previous suicide attempts.\n\nCONCLUSION: The 5-HTT mRNA level increased and correlated with the treatment response (HDRS score improvement) under 32-weeks antidepressants treatment clinical trial. 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Duloxetine and paroxetine were administered over 32 weeks to these patients. The Hamilton depression rating scale (HDRS) and 5-HTT mRNA level were evaluated at baseline (Week 0), and at 8, 16, 24 and 32 weeks.\n\nRESULTS: Improvement in depressive symptoms (HDRS score declined) and increasing in 5-HTT mRNA level were found with longer duration of antidepressant treatment in patients with major depression. Patients with more 5-HTTPR long-form alleles and STin2.12 alleles had poor antidepressant treatment response. Duloxetine may give a better treatment response than paroxetine. Using structural equation modeling (SEM), the 5-HTTLPR long-form had a direct positive association with the 5-HTT mRNA level and an indirect adverse relationship with the 5-HTT mRNA level through neuroticism and previous suicide attempts.\n\nCONCLUSION: The 5-HTT mRNA level increased and correlated with the treatment response (HDRS score improvement) under 32-weeks antidepressants treatment clinical trial. 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of multiple low-modest effect size variants can predict the risk of obesity better than the individual SNPs", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Shabana, Shahid SU, Hasnain S.", "articleTypes": [], "doi": "10.1186/s12944-018-0806-5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.385Z" }, { "id": "ebfd4f7d-ef26-4d10-8f33-9b921e733383", "pmid": "30021629", "title": "Use of a gene score of multiple low-modest effect size variants can predict the risk of obesity better than the individual SNPs", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Shabana, Shahid SU, Hasnain S.", "articleTypes": [], "doi": "10.1186/s12944-018-0806-5", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.742Z" }, { "id": "f77a7a45-b10a-474c-843d-24650cc05945", "pmid": "30021629", "title": "Use of a gene score of multiple low-modest 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attenuates obesity cardiomyopathy", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Ceylan AF, Wang S, Kandadi MR, Chen J, Hua Y, Pei Z, Nair S, Ren J.", "articleTypes": [], "doi": "10.1016/j.bbadis.2018.07.020", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.913Z" }, { "id": "74d77c2f-34c4-45eb-a8e0-7b8b5270ced7", "pmid": "30031229", "title": "Cardiomyocyte-specific knockout of endothelin receptor a attenuates obesity cardiomyopathy", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Ceylan AF, Wang S, Kandadi MR, Chen J, Hua Y, Pei Z, Nair S, Ren J.", "articleTypes": [], "doi": "10.1016/j.bbadis.2018.07.020", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.442Z" }, { "id": "8ff94a49-1ce7-41e9-8b17-560e447cdea3", "pmid": "30031229", "title": "Cardiomyocyte-specific knockout of endothelin receptor a attenuates 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Y, Han J, Park YJ.", "articleTypes": [], "doi": "10.1016/j.nutres.2018.06.006", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.347Z" }, { "id": "059344a2-f490-4aa2-8507-5039bdbcb754", "pmid": "30036185", "title": "Implementation of environmental enrichment after middle age promotes healthy aging", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "McMurphy T, Huang W, Queen NJ, Ali S, Widstrom KJ, Liu X, Xiao R, Siu JJ, Cao L.", "articleTypes": [], "doi": "10.18632/aging.101502", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.432Z" }, { "id": "8528d0ec-44e6-4049-af6a-734c0f2b5257", "pmid": "30036185", "title": "Implementation of environmental enrichment after middle age promotes healthy aging", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "McMurphy T, Huang W, Queen NJ, Ali S, Widstrom KJ, Liu X, Xiao R, Siu JJ, Cao L.", "articleTypes": [], "doi": "10.18632/aging.101502", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.817Z" }, { "id": "89cf94d7-7450-4e5c-b4e0-0ce55333c2f0", "pmid": "30036185", "title": "Implementation of environmental enrichment after middle age promotes healthy aging", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "McMurphy T, Huang W, Queen NJ, Ali S, Widstrom KJ, Liu X, Xiao R, Siu JJ, Cao L.", "articleTypes": [], "doi": "10.18632/aging.101502", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.930Z" }, { "id": "fcec63e3-d4ae-4eb5-b3e5-6804616abc5d", "pmid": "30036185", "title": "Implementation of environmental enrichment after middle age promotes healthy aging", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "McMurphy T, Huang W, Queen NJ, Ali S, Widstrom KJ, Liu X, Xiao R, Siu JJ, Cao L.", "articleTypes": [], "doi": "10.18632/aging.101502", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.461Z" }, { "id": "0c8e5678-d136-43b6-9ec7-844bd482b125", "pmid": "30036761", "title": "Serotonin transporter gene polymorphism as a predictor of short-term risk of suicide reattempts.", "imported": false, "abstract": "OBJECTIVE: The serotonin-transporter-linked polymorphic region (5-HTTLPR) polymorphisms are associated with suicidal behavior; however, prospective studies are scarce. Herein we aim to determine if 5-HTTLPR polymorphisms predict risk of short-term suicide reattempt in a high-risk suicidal sample. We also explore possible mediators or moderators of this relationship.\n\nMETHODS: A multicenter prospective cohort study was designed to compare data obtained form 136 patients admitted to the emergency department for current suicidal ideation or a recent suicide attempt. Subjects were clinically evaluated, genotyped, and monitored for a new suicide attempt for 6 months.\n\nRESULTS: At 6 months of follow up, 21% of the subjects had a new suicide attempt. The frequency of L-allele and L-carrier was higher in reattempters when compared with non-reattempters (55.8% vs. 35.4%, p =  0.01 and 76.9% vs. 54.2%, p = 0.04, respectively). Reattempters also differ from non-reattempters patients with respect to age, history of previous suicide attempts, and age of onset of suicidal behavior. The logistic regression model showed that L-carriers had an odds ratio of 2.8 (95% CI: 1.0-7.6) for reattempts when compared to SS genotype. The adjusted model indicates that this association is not mediated or moderated by impulsivity.\n\nCONCLUSION: The 5-HTTLPR polymorphisms predicted short-term risk of suicidal reattempt independently of age and sex. L-carriers have almost three times more risk of relapse when compared with SS carriers.", "journal": "European psychiatry : the journal of the Association of European Psychiatrists", "year": "2018", "authors": "Daray FM, Arena ÁR, Armesto AR, Rodante DE, Puppo S, Vidjen P, Portela A, Grendas LN, Errasti AE", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.eurpsy.2018.07.001", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.154Z" }, { "id": "4fb15370-3a9a-46b9-8cc1-9152311541f4", "pmid": "30036761", "title": "Serotonin transporter gene polymorphism as a predictor of short-term risk of suicide reattempts.", "imported": false, "abstract": "OBJECTIVE: The serotonin-transporter-linked polymorphic region (5-HTTLPR) polymorphisms are associated with suicidal behavior; however, prospective studies are scarce. Herein we aim to determine if 5-HTTLPR polymorphisms predict risk of short-term suicide reattempt in a high-risk suicidal sample. We also explore possible mediators or moderators of this relationship.\n\nMETHODS: A multicenter prospective cohort study was designed to compare data obtained form 136 patients admitted to the emergency department for current suicidal ideation or a recent suicide attempt. Subjects were clinically evaluated, genotyped, and monitored for a new suicide attempt for 6 months.\n\nRESULTS: At 6 months of follow up, 21% of the subjects had a new suicide attempt. The frequency of L-allele and L-carrier was higher in reattempters when compared with non-reattempters (55.8% vs. 35.4%, p =  0.01 and 76.9% vs. 54.2%, p = 0.04, respectively). Reattempters also differ from non-reattempters patients with respect to age, history of previous suicide attempts, and age of onset of suicidal behavior. The logistic regression model showed that L-carriers had an odds ratio of 2.8 (95% CI: 1.0-7.6) for reattempts when compared to SS genotype. The adjusted model indicates that this association is not mediated or moderated by impulsivity.\n\nCONCLUSION: The 5-HTTLPR polymorphisms predicted short-term risk of suicidal reattempt independently of age and sex. L-carriers have almost three times more risk of relapse when compared with SS carriers.", "journal": "European psychiatry : the journal of the Association of European Psychiatrists", "year": "2018", "authors": "Daray FM, Arena ÁR, Armesto AR, Rodante DE, Puppo S, Vidjen P, Portela A, Grendas LN, Errasti AE", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.eurpsy.2018.07.001", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.610Z" }, { "id": "526ac112-fa63-43ea-a6e0-a7a6e9f62755", "pmid": "30036761", "title": "Serotonin transporter gene polymorphism as a predictor of short-term risk of suicide reattempts.", "imported": false, "abstract": "OBJECTIVE: The serotonin-transporter-linked polymorphic region (5-HTTLPR) polymorphisms are associated with suicidal behavior; however, prospective studies are scarce. Herein we aim to determine if 5-HTTLPR polymorphisms predict risk of short-term suicide reattempt in a high-risk suicidal sample. We also explore possible mediators or moderators of this relationship.\n\nMETHODS: A multicenter prospective cohort study was designed to compare data obtained form 136 patients admitted to the emergency department for current suicidal ideation or a recent suicide attempt. Subjects were clinically evaluated, genotyped, and monitored for a new suicide attempt for 6 months.\n\nRESULTS: At 6 months of follow up, 21% of the subjects had a new suicide attempt. The frequency of L-allele and L-carrier was higher in reattempters when compared with non-reattempters (55.8% vs. 35.4%, p =  0.01 and 76.9% vs. 54.2%, p = 0.04, respectively). Reattempters also differ from non-reattempters patients with respect to age, history of previous suicide attempts, and age of onset of suicidal behavior. The logistic regression model showed that L-carriers had an odds ratio of 2.8 (95% CI: 1.0-7.6) for reattempts when compared to SS genotype. The adjusted model indicates that this association is not mediated or moderated by impulsivity.\n\nCONCLUSION: The 5-HTTLPR polymorphisms predicted short-term risk of suicidal reattempt independently of age and sex. L-carriers have almost three times more risk of relapse when compared with SS carriers.", "journal": "European psychiatry : the journal of the Association of European Psychiatrists", "year": "2018", "authors": "Daray FM, Arena ÁR, Armesto AR, Rodante DE, Puppo S, Vidjen P, Portela A, Grendas LN, Errasti AE", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.eurpsy.2018.07.001", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.567Z" }, { "id": "53ed6ddc-a877-4438-b514-852c778ea432", "pmid": "30038584", "title": "Stanniocalcin 2 Ameliorates Hepatosteatosis Through Activation of STAT3 Signaling", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Zhao J, Jiao Y, Song Y, Liu J, Li X, Zhang H, Yang J, Lu Y.", "articleTypes": [], "doi": "10.3389/fphys.2018.00873", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.456Z" }, { "id": "63cc8eae-7cb0-4eb8-afe4-2a80642ccc95", "pmid": "30038584", "title": "Stanniocalcin 2 Ameliorates Hepatosteatosis Through Activation of STAT3 Signaling", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Zhao J, Jiao Y, Song Y, Liu J, Li X, Zhang H, Yang J, Lu Y.", "articleTypes": [], "doi": "10.3389/fphys.2018.00873", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.811Z" }, { "id": "728ec48c-5289-4dbe-adc2-bd33be254ee3", "pmid": "30038584", "title": "Stanniocalcin 2 Ameliorates Hepatosteatosis Through Activation of STAT3 Signaling", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Zhao J, Jiao Y, Song Y, Liu J, Li X, Zhang H, Yang J, Lu Y.", "articleTypes": [], "doi": "10.3389/fphys.2018.00873", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.926Z" }, { "id": "9e6d8986-8bf1-44cf-9daa-a675aeea58da", "pmid": "30038584", "title": "Stanniocalcin 2 Ameliorates Hepatosteatosis Through Activation of STAT3 Signaling", "imported": false, "abstract": "", "journal": "", "year": "2018", "authors": "Zhao J, Jiao Y, Song Y, Liu J, Li X, Zhang H, Yang J, Lu Y.", 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However, low-expressing alleles (S + LG) were associated with an increased risk of Violent Suicide Attempt (OR = 1.44, C.I. 1.17-1.78, p = .0007). An effect of the same alleles on SB was found in a subpopulation of substance abusers, but this result was not confirmed after the exclusion of healthy subjects from the control group. The other sensitivity meta-analyses did not show any significant effect. Our findings contribute to clarify the conflicting previous evidence by suggesting an association between the 5-HTTLPR and Violent SB. 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Inherited genetic differences have a role in suicidality with heritability ranging from 30 to 55%. The SLC6A4 5-HTTLPR gene variant has been largely investigated for association with SB, with controversial results. In this work, we sought to determine whether the results of previous meta-analyses were confirmed or modified subsequent to the inclusion of more recent literature data. An electronic literature search was performed to identify relevant studies published until July 2018. Data were analysed through RevMan v5.3. Subgroup and sensitivity meta-analyses were performed considering different SB sub-phenotypes, ethnicity, gender and psychiatric diagnostic categories. Our literature search yielded 1186 articles; among these, we identified 45 pertinent case-control studies (15,341 subjects). No association was found between low-expressing alleles or genotypes (S + LG alleles or S' carrier genotypes) and SB in the primary analyses. However, low-expressing alleles (S + LG) were associated with an increased risk of Violent Suicide Attempt (OR = 1.44, C.I. 1.17-1.78, p = .0007). An effect of the same alleles on SB was found in a subpopulation of substance abusers, but this result was not confirmed after the exclusion of healthy subjects from the control group. The other sensitivity meta-analyses did not show any significant effect. Our findings contribute to clarify the conflicting previous evidence by suggesting an association between the 5-HTTLPR and Violent SB. 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Depression is the most frequently related disorder with suicidal behaviors. There is increasing evidence that suicidal behavior has a strong genetic contribution. Several studies report an association between the genotype \"SS\" and the \"S\" allele of the 5-HTTLPR polymorphism of the serotonin transporter gene and suicidal behavior. The aim of the study was to determine the association of variants of the serotonin transporter gene with suicidal attempt and comorbidity in depressed adolescents.\n\nMETHODS: The frequencies of ss genotypes and s allele were compared between a sample of 200 adolescents with a diagnosis of depression and the antecedent of a suicide attempt who were evaluated with K-SADS-PL and a group of 235 healthy controls. Genotyping of the 5-HTTLPR polymorphism was performed by PCR.\n\nRESULTS: Analysis of the frequencies of genotypes and alleles showed a statistically significant difference between the groups (Genotypes: x2=11.1, df=2, p=0.004, Alleles: x2=11.9, df=1, p=0.0009). There were no associations with comorbid disorders.\n\nCONCLUSIONS: The results support the hypothesis that the serotonin transporter gene, specifically the s allele and the ss genotype of the 5-HTTLPR polymorphism, are related to the history of depression and suicide attempt in adolescents.", "journal": "Actas espanolas de psiquiatria", "year": "2019", "authors": "Sarmiento-Hernández EI, Ulloa-Flores RE, Camarena-Medellín B, Sanabrais-Jiménez MA, Aguilar-García A, Hernández-Muñoz S", "articleTypes": [ "Journal Article" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.154Z" }, { "id": "5285fe63-728e-4c4a-861f-9d510a729e5a", "pmid": "30724325", "title": "Association between 5-HTTLPR polymorphism, suicide attempt and comorbidity in Mexican adolescents with major depressive disorder.", "imported": false, "abstract": "INTRODUCTION: The World Health Organization reports that suicide is among the leading causes of death for young people. Depression is the most frequently related disorder with suicidal behaviors. There is increasing evidence that suicidal behavior has a strong genetic contribution. Several studies report an association between the genotype \"SS\" and the \"S\" allele of the 5-HTTLPR polymorphism of the serotonin transporter gene and suicidal behavior. The aim of the study was to determine the association of variants of the serotonin transporter gene with suicidal attempt and comorbidity in depressed adolescents.\n\nMETHODS: The frequencies of ss genotypes and s allele were compared between a sample of 200 adolescents with a diagnosis of depression and the antecedent of a suicide attempt who were evaluated with K-SADS-PL and a group of 235 healthy controls. Genotyping of the 5-HTTLPR polymorphism was performed by PCR.\n\nRESULTS: Analysis of the frequencies of genotypes and alleles showed a statistically significant difference between the groups (Genotypes: x2=11.1, df=2, p=0.004, Alleles: x2=11.9, df=1, p=0.0009). There were no associations with comorbid disorders.\n\nCONCLUSIONS: The results support the hypothesis that the serotonin transporter gene, specifically the s allele and the ss genotype of the 5-HTTLPR polymorphism, are related to the history of depression and suicide attempt in adolescents.", "journal": "Actas espanolas de psiquiatria", "year": "2019", "authors": "Sarmiento-Hernández EI, Ulloa-Flores RE, Camarena-Medellín B, Sanabrais-Jiménez MA, Aguilar-García A, Hernández-Muñoz S", "articleTypes": [ "Journal Article" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.610Z" }, { "id": "e2b4fc22-10fd-4995-8f39-966a2144c737", "pmid": "30724325", "title": "Association between 5-HTTLPR polymorphism, suicide attempt and comorbidity in Mexican adolescents with major depressive disorder.", "imported": false, "abstract": "INTRODUCTION: The World Health Organization reports that suicide is among the leading causes of death for young people. Depression is the most frequently related disorder with suicidal behaviors. There is increasing evidence that suicidal behavior has a strong genetic contribution. Several studies report an association between the genotype \"SS\" and the \"S\" allele of the 5-HTTLPR polymorphism of the serotonin transporter gene and suicidal behavior. The aim of the study was to determine the association of variants of the serotonin transporter gene with suicidal attempt and comorbidity in depressed adolescents.\n\nMETHODS: The frequencies of ss genotypes and s allele were compared between a sample of 200 adolescents with a diagnosis of depression and the antecedent of a suicide attempt who were evaluated with K-SADS-PL and a group of 235 healthy controls. Genotyping of the 5-HTTLPR polymorphism was performed by PCR.\n\nRESULTS: Analysis of the frequencies of genotypes and alleles showed a statistically significant difference between the groups (Genotypes: x2=11.1, df=2, p=0.004, Alleles: x2=11.9, df=1, p=0.0009). 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false, "abstract": "", "journal": "", "year": "2019", "authors": "Kornyushin OV, Bakhtyukov AA, Zorina II, Toropova YG, Derkach KV, Berko OM, Todosenko MN, Litvinova LS, Shpakov AO, Galagudza MM.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.385Z" }, { "id": "b0550a6b-1e64-43e8-b3bb-d0af7654967c", "pmid": "31228372", "title": "[The effect of different types of bariatric surgery on the metabolic and hormonal parameters in rats with decompensed form of type 2 diabetes mellitus.]", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Kornyushin OV, Bakhtyukov AA, Zorina II, Toropova YG, Derkach KV, Berko OM, Todosenko MN, Litvinova LS, Shpakov AO, Galagudza MM.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.892Z" }, { "id": "d9c19c18-eb5a-46d7-bd02-40607047aae4", "pmid": "31228372", "title": "[The effect of different types of bariatric surgery on the metabolic and hormonal parameters in rats with decompensed form of type 2 diabetes mellitus.]", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Kornyushin OV, Bakhtyukov AA, Zorina II, Toropova YG, Derkach KV, Berko OM, Todosenko MN, Litvinova LS, Shpakov AO, Galagudza MM.", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.772Z" }, { "id": "83d72bb0-cd17-4dc7-9791-78a7fcaf9a30", "pmid": "31228794", "title": "A preliminary association study between serotonin transporter (5-HTTLPR), receptor polymorphisms (5-HTR1A, 5-HTR2A) and depression symptom-clusters in a north Indian population suffering from Major Depressive Disorder (MDD).", "imported": false, "abstract": "INTRODUCTION: Major Depressive Disorder (MDD) is a broad heterogeneous diagnostic construct. Previous studies have shown that it can be resolved into several symptom-clusters which are proposed to be associated with single nucleotide polymorphisms (SNPs) of the serotonergic pathway (5-HTTLPR, 5HTR1A, 5-HTR2A).\n\nMETHODS AND MATERIAL: In a cross-sectional study conducted at a tertiary level mental health care set-up in north India, 80 out-patients with MDD were evaluated with Montgomery Asberg Depression Rating Scale (MADRS) and then genotyping was done. The different clinical and genetic variables were compared across the factor structures of MADRS. Also, the comparison of the genetic data of cases was done with the pre-existing database of the non-blood related healthy ethnically-matched controls.\n\nRESULTS: There was no significant association between age, gender, other clinical variables, SNPs like 5-HTTLPR SS/SL, rs6295 CC/CG/GG, rs6311GG/GA/AA, rs6313 CC/CT/TT and different factor-structures like 'detachment' consisting of items like concentration difficulty, lassitude, inability to feel; 'psychic anxiety' consisting of suicidal thoughts and inner tension; 'mood-pessimism' consisting of symptoms like apparent sadness, reported sadness, pessimistic thoughts and 'vegetative symptoms' like decreased sleep, poor appetite. Neither there was any association between genotype of the cases compared with the controls.\n\nCONCLUSIONS: No significant association was obtained between the four-factor structures of depression in MADRS and serotonin transporter and receptor SNPs in a study with a small sample size. This study evaluates whether depression symptom-clusters have distinct genotypic determinants and necessitates more comprehensive studies for unravelling the genetic determinants of depression.", "journal": "Asian journal of psychiatry", "year": "2019", "authors": "Basu A, Chadda RK, Sood M, Kaur H, Kukreti R", "articleTypes": [ "Journal Article" ], "doi": "10.1016/j.ajp.2019.05.028", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.153Z" }, { "id": "cc54264d-6263-4511-9235-326b120d0fda", "pmid": "31228794", "title": "A preliminary association study between serotonin transporter (5-HTTLPR), receptor polymorphisms (5-HTR1A, 5-HTR2A) and depression symptom-clusters in a north Indian population suffering from Major Depressive Disorder (MDD).", "imported": false, "abstract": "INTRODUCTION: Major Depressive Disorder (MDD) is a broad heterogeneous diagnostic construct. Previous studies have shown that it can be resolved into several symptom-clusters which are proposed to be associated with single nucleotide polymorphisms (SNPs) of the serotonergic pathway (5-HTTLPR, 5HTR1A, 5-HTR2A).\n\nMETHODS AND MATERIAL: In a cross-sectional study conducted at a tertiary level mental health care set-up in north India, 80 out-patients with MDD were evaluated with Montgomery Asberg Depression Rating Scale (MADRS) and then genotyping was done. The different clinical and genetic variables were compared across the factor structures of MADRS. Also, the comparison of the genetic data of cases was done with the pre-existing database of the non-blood related healthy ethnically-matched controls.\n\nRESULTS: There was no significant association between age, gender, other clinical variables, SNPs like 5-HTTLPR SS/SL, rs6295 CC/CG/GG, rs6311GG/GA/AA, rs6313 CC/CT/TT and different factor-structures like 'detachment' consisting of items like concentration difficulty, lassitude, inability to feel; 'psychic anxiety' consisting of suicidal thoughts and inner tension; 'mood-pessimism' consisting of symptoms like apparent sadness, reported sadness, pessimistic thoughts and 'vegetative symptoms' like decreased sleep, poor appetite. Neither there was any association between genotype of the cases compared with the controls.\n\nCONCLUSIONS: No significant association was obtained between the four-factor structures of depression in MADRS and serotonin transporter and receptor SNPs in a study with a small sample size. This study evaluates whether depression symptom-clusters have distinct genotypic determinants and necessitates more comprehensive studies for unravelling the genetic determinants of depression.", "journal": "Asian journal of psychiatry", "year": "2019", "authors": "Basu A, Chadda RK, Sood M, Kaur H, Kukreti R", "articleTypes": [ "Journal Article" ], "doi": "10.1016/j.ajp.2019.05.028", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.566Z" }, { "id": "e07acb20-5841-45ea-8c50-0d4381312eea", "pmid": "31228794", "title": "A preliminary association study between serotonin transporter (5-HTTLPR), receptor polymorphisms (5-HTR1A, 5-HTR2A) and depression symptom-clusters in a north Indian population suffering from Major Depressive Disorder (MDD).", "imported": false, "abstract": "INTRODUCTION: Major Depressive Disorder (MDD) is a broad heterogeneous diagnostic construct. Previous studies have shown that it can be resolved into several symptom-clusters which are proposed to be associated with single nucleotide polymorphisms (SNPs) of the serotonergic pathway (5-HTTLPR, 5HTR1A, 5-HTR2A).\n\nMETHODS AND MATERIAL: In a cross-sectional study conducted at a tertiary level mental health care set-up in north India, 80 out-patients with MDD were evaluated with Montgomery Asberg Depression Rating Scale (MADRS) and then genotyping was done. The different clinical and genetic variables were compared across the factor structures of MADRS. Also, the comparison of the genetic data of cases was done with the pre-existing database of the non-blood related healthy ethnically-matched controls.\n\nRESULTS: There was no significant association between age, gender, other clinical variables, SNPs like 5-HTTLPR SS/SL, rs6295 CC/CG/GG, rs6311GG/GA/AA, rs6313 CC/CT/TT and different factor-structures like 'detachment' consisting of items like concentration difficulty, lassitude, inability to feel; 'psychic anxiety' consisting of suicidal thoughts and inner tension; 'mood-pessimism' consisting of symptoms like apparent sadness, reported sadness, pessimistic thoughts and 'vegetative symptoms' like decreased sleep, poor appetite. Neither there was any association between genotype of the cases compared with the controls.\n\nCONCLUSIONS: No significant association was obtained between the four-factor structures of depression in MADRS and serotonin transporter and receptor SNPs in a study with a small sample size. This study evaluates whether depression symptom-clusters have distinct genotypic determinants and necessitates more comprehensive studies for unravelling the genetic determinants of depression.", "journal": "Asian journal of psychiatry", "year": "2019", "authors": "Basu A, Chadda RK, Sood M, Kaur H, Kukreti R", "articleTypes": [ "Journal Article" ], "doi": "10.1016/j.ajp.2019.05.028", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR 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false, "abstract": "", "journal": "", "year": "2019", "authors": "Mzhelskaya KV, Trusov NV, Apryatin SA, Soto CJ, Gmoshinski IV, Tutelyan VA.", "articleTypes": [], "doi": "10.24411/0042-8833-2019-10012", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.423Z" }, { "id": "966d4deb-a6fb-4d16-8af3-ae9a1db27910", "pmid": "31233683", "title": "[Effect of quercetin on the expression of the carbohydrate and lipid metabolism genes in the liver of rats with genetic]", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Mzhelskaya KV, Trusov NV, Apryatin SA, Soto CJ, Gmoshinski IV, Tutelyan VA.", "articleTypes": [], "doi": "10.24411/0042-8833-2019-10012", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.809Z" }, { "id": "e5b5d2aa-7aae-4de7-bbf9-de74de70c620", "pmid": "31233683", "title": "[Effect of quercetin on the expression of the carbohydrate and lipid 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"Monounsaturated Fatty Acids in a High-Fat Diet and Niacin Protect from White Fat Dysfunction in the Metabolic Syndrome", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Montserrat-de la Paz S, Naranjo MC, Millan-Linares MC, Lopez S, Abia R, Biessen EAL, Muriana FJG, Bermudez B.", "articleTypes": [], "doi": "10.1002/mnfr.201900425", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.884Z" }, { "id": "3e12b7eb-a861-4315-b89b-83f8eca68841", "pmid": "31357197", "title": "Leptin Is Not Essential for Obesity-Associated Hypertension", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "von Schnurbein J, Manzoor J, Brandt S, Denzer F, Kohlsdorf K, Fischer-Posovszky P, Weißenberger M, Frank-Podlech S, Mahmood S, Wabitsch M.", "articleTypes": [], "doi": "10.1159/000501319", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.872Z" }, 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}, { "id": "6a8565a2-a557-4e63-a1f7-92a355fe4331", "pmid": "31368189", "title": "Limited synergy of obesity and hypertension, prevalent risk factors in onset and progression of heart failure with preserved ejection fraction", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Brandt MM, Nguyen ITN, Krebber MM, van de Wouw J, Mokry M, Cramer MJ, Duncker DJ, Verhaar MC, Joles JA, Cheng C.", "articleTypes": [], "doi": "10.1111/jcmm.14542", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.431Z" }, { "id": "7766136b-7be7-4e14-ac6a-060634a8bd77", "pmid": "31368189", "title": "Limited synergy of obesity and hypertension, prevalent risk factors in onset and progression of heart failure with preserved ejection fraction", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Brandt MM, Nguyen ITN, Krebber MM, van de Wouw J, Mokry M, Cramer MJ, Duncker DJ, Verhaar MC, Joles JA, Cheng C.", "articleTypes": [], "doi": "10.1111/jcmm.14542", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.787Z" }, { "id": "7fc44b6a-b355-419b-90c1-35deba6f0e4e", "pmid": "31368189", "title": "Limited synergy of obesity and hypertension, prevalent risk factors in onset and progression of heart failure with preserved ejection fraction", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Brandt MM, Nguyen ITN, Krebber MM, van de Wouw J, Mokry M, Cramer MJ, Duncker DJ, Verhaar MC, Joles JA, Cheng C.", "articleTypes": [], "doi": "10.1111/jcmm.14542", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.399Z" }, { "id": "a8a04369-e0fd-41b2-8db9-943f1bccd859", "pmid": "31368189", "title": "Limited synergy of obesity and hypertension, prevalent risk factors in onset and progression of heart failure with preserved ejection fraction", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Brandt MM, Nguyen ITN, Krebber MM, van de Wouw J, Mokry M, Cramer MJ, Duncker DJ, Verhaar MC, Joles JA, Cheng C.", "articleTypes": [], "doi": "10.1111/jcmm.14542", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.904Z" }, { "id": "4e7dae8c-3e20-442d-b9b7-0ea60bca89f6", "pmid": "31370036", "title": "Treatment Emergent Violence To Self And Others; A Literature Review of Neuropsychiatric Adverse Reactions For Antidepressant And Neuroleptic Psychiatric Drugs And General Medications.", "imported": false, "abstract": "OBJECTIVE: This paper reviews the literature linking physical violence, directed towards self or others, to serotonergic and dopaminergic psychiatric drugs and general medications.\n\nDESIGN/METHODOLOGY/APPROACH: Data about side effects, pharmacogenetics and homeostasis are obtained from articles, electronic Medicines Compendium, DSM-IV-TR, British National Formulary (BNF) and academic books. Statistics have been obtained from articles, The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Mental Health and Risk, Manchester, Mental Health Equalities, National Mental Health Development Unit and the NHS Health and Social Care Information Centre. Classification for neurotoxic conditions and mental illness are obtained from the DSM-IV-TR, DSM-V and ICD-10.\n\nFINDINGS: Psychiatric drugs and some general medications have effects that are not always the ones intended. Reactions to different drugs and drug-drug combinations are governed by individual metabolising rates. Phase 1 metabolism takes place via the cytochrome P450 enzymes with 57 human genes identified that are genetically variable i.e. polymorphic. The population are coded as poor, extensive (known as normal), intermediate or ultra rapid metabolisers. Variations in the serotonin transporter gene (5-HTTLPR) and serotonin receptors (5-HT) influence the outcome of serotonergic medications. It is established genetic polymorphisms in the CYP450 and serotoninergic metabolising system cause higher drug blood levels which are associated with neuropsychiatric adverse drug reactions (ADRs), such as akathisia. If not recognised, akathisia, which often precedes violence, suicidality, homicide, mania and psychosis, may be mistaken for new or emergent mental illness and treated with further ineffective, counter-productive psychiatric drugs.\n\nRESEARCH LIMITATIONS/IMPLICATIONS: The absence of pharmaceutical data for CYP450 diminishing, null/non- functioning or multiple polymorphisms and variations in the 5-HTTLPR and 5-HT, linking general medications and psychiatric drugs with neuropsychiatric behavioural reactions is notable. There is limited information linking psychiatric drug disruption of homeostasis and neurotransmitters with violence. These issues indicate a need for greater pharmaceutical transparency and further research into the role of CYP450, 5-HTTLPR and 5-HT polymorphism associated neuropsychiatric ADRs for all psychiatric drugs and serotonergic general medications.\n\nPRACTICAL IMPLICATIONS: Safer prescribing is important and could be achieved by individual genotype testing, which would identify persons with genetic polymorphisms, who are unable to metabolise drugs. Prevention of violence would enhance peoples' well being, ground floor practitioner and public safety.\n\nCONCLUSION: This paper is the first review that implicates certain drugs as a cause of violence due to pharmacogentic polymorphisms and neurotransmitter disruption.", "journal": "Advances in mind-body medicine", "year": "2019", "authors": "Clarke C, Evans J, Brogan K", "articleTypes": [ "Journal Article", "Review" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.610Z" }, { "id": "d954fbca-7aab-41d1-b70e-69851722f030", "pmid": "31370036", "title": "Treatment Emergent Violence To Self And Others; A Literature Review of Neuropsychiatric Adverse Reactions For Antidepressant And Neuroleptic Psychiatric Drugs And General Medications.", "imported": false, "abstract": "OBJECTIVE: This paper reviews the literature linking physical violence, directed towards self or others, to serotonergic and dopaminergic psychiatric drugs and general medications.\n\nDESIGN/METHODOLOGY/APPROACH: Data about side effects, pharmacogenetics and homeostasis are obtained from articles, electronic Medicines Compendium, DSM-IV-TR, British National Formulary (BNF) and academic books. Statistics have been obtained from articles, The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Mental Health and Risk, Manchester, Mental Health Equalities, National Mental Health Development Unit and the NHS Health and Social Care Information Centre. Classification for neurotoxic conditions and mental illness are obtained from the DSM-IV-TR, DSM-V and ICD-10.\n\nFINDINGS: Psychiatric drugs and some general medications have effects that are not always the ones intended. Reactions to different drugs and drug-drug combinations are governed by individual metabolising rates. Phase 1 metabolism takes place via the cytochrome P450 enzymes with 57 human genes identified that are genetically variable i.e. polymorphic. The population are coded as poor, extensive (known as normal), intermediate or ultra rapid metabolisers. Variations in the serotonin transporter gene (5-HTTLPR) and serotonin receptors (5-HT) influence the outcome of serotonergic medications. It is established genetic polymorphisms in the CYP450 and serotoninergic metabolising system cause higher drug blood levels which are associated with neuropsychiatric adverse drug reactions (ADRs), such as akathisia. If not recognised, akathisia, which often precedes violence, suicidality, homicide, mania and psychosis, may be mistaken for new or emergent mental illness and treated with further ineffective, counter-productive psychiatric drugs.\n\nRESEARCH LIMITATIONS/IMPLICATIONS: The absence of pharmaceutical data for CYP450 diminishing, null/non- functioning or multiple polymorphisms and variations in the 5-HTTLPR and 5-HT, linking general medications and psychiatric drugs with neuropsychiatric behavioural reactions is notable. There is limited information linking psychiatric drug disruption of homeostasis and neurotransmitters with violence. These issues indicate a need for greater pharmaceutical transparency and further research into the role of CYP450, 5-HTTLPR and 5-HT polymorphism associated neuropsychiatric ADRs for all psychiatric drugs and serotonergic general medications.\n\nPRACTICAL IMPLICATIONS: Safer prescribing is important and could be achieved by individual genotype testing, which would identify persons with genetic polymorphisms, who are unable to metabolise drugs. Prevention of violence would enhance peoples' well being, ground floor practitioner and public safety.\n\nCONCLUSION: This paper is the first review that implicates certain drugs as a cause of violence due to pharmacogentic polymorphisms and neurotransmitter disruption.", "journal": "Advances in mind-body medicine", "year": "2019", "authors": "Clarke C, Evans J, Brogan K", "articleTypes": [ "Journal Article", "Review" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.154Z" }, { "id": "dd37bf19-a4f3-4b13-8fcd-cb796d9c29c1", "pmid": "31370036", "title": "Treatment Emergent Violence To Self And Others; A Literature Review of Neuropsychiatric Adverse Reactions For Antidepressant And Neuroleptic Psychiatric Drugs And General Medications.", "imported": false, "abstract": "OBJECTIVE: This paper reviews the literature linking physical violence, directed towards self or others, to serotonergic and dopaminergic psychiatric drugs and general medications.\n\nDESIGN/METHODOLOGY/APPROACH: Data about side effects, pharmacogenetics and homeostasis are obtained from articles, electronic Medicines Compendium, DSM-IV-TR, British National Formulary (BNF) and academic books. Statistics have been obtained from articles, The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Mental Health and Risk, Manchester, Mental Health Equalities, National Mental Health Development Unit and the NHS Health and Social Care Information Centre. Classification for neurotoxic conditions and mental illness are obtained from the DSM-IV-TR, DSM-V and ICD-10.\n\nFINDINGS: Psychiatric drugs and some general medications have effects that are not always the ones intended. Reactions to different drugs and drug-drug combinations are governed by individual metabolising rates. Phase 1 metabolism takes place via the cytochrome P450 enzymes with 57 human genes identified that are genetically variable i.e. polymorphic. The population are coded as poor, extensive (known as normal), intermediate or ultra rapid metabolisers. Variations in the serotonin transporter gene (5-HTTLPR) and serotonin receptors (5-HT) influence the outcome of serotonergic medications. It is established genetic polymorphisms in the CYP450 and serotoninergic metabolising system cause higher drug blood levels which are associated with neuropsychiatric adverse drug reactions (ADRs), such as akathisia. If not recognised, akathisia, which often precedes violence, suicidality, homicide, mania and psychosis, may be mistaken for new or emergent mental illness and treated with further ineffective, counter-productive psychiatric drugs.\n\nRESEARCH LIMITATIONS/IMPLICATIONS: The absence of pharmaceutical data for CYP450 diminishing, null/non- functioning or multiple polymorphisms and variations in the 5-HTTLPR and 5-HT, linking general medications and psychiatric drugs with neuropsychiatric behavioural reactions is notable. There is limited information linking psychiatric drug disruption of homeostasis and neurotransmitters with violence. These issues indicate a need for greater pharmaceutical transparency and further research into the role of CYP450, 5-HTTLPR and 5-HT polymorphism associated neuropsychiatric ADRs for all psychiatric drugs and serotonergic general medications.\n\nPRACTICAL IMPLICATIONS: Safer prescribing is important and could be achieved by individual genotype testing, which would identify persons with genetic polymorphisms, who are unable to metabolise drugs. Prevention of violence would enhance peoples' well being, ground floor practitioner and public safety.\n\nCONCLUSION: This paper is the first review that implicates certain drugs as a cause of violence due to pharmacogentic polymorphisms and neurotransmitter disruption.", "journal": "Advances in mind-body medicine", "year": "2019", "authors": "Clarke C, Evans J, Brogan K", "articleTypes": [ "Journal Article", "Review" ], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.566Z" }, { "id": "5dc4a344-0ec8-43b1-b70b-b5924eb5e615", "pmid": "31372721", "title": "Targeted Sequencing Analysis of the Leptin Receptor Gene Identifies Variants Associated with Obstructive Sleep Apnoea in Chinese Han Population", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Li J, Yang S, Jiao X, Yang Y, Sun H, Zhang M, Yang Y, Qin Y, Wei Y.", "articleTypes": [], "doi": "10.1007/s00408-019-00254-z", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.888Z" }, { "id": "5f837372-5429-4ab1-8f48-94e6fe90e22b", "pmid": "31372721", "title": "Targeted Sequencing Analysis of the Leptin Receptor Gene Identifies Variants Associated with Obstructive Sleep Apnoea in Chinese Han Population", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Li J, Yang S, Jiao X, Yang Y, Sun H, Zhang M, Yang Y, Qin Y, Wei Y.", "articleTypes": [], "doi": "10.1007/s00408-019-00254-z", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.413Z" }, { "id": "642be094-cd02-4105-bb5b-a7c610885ed7", "pmid": "31372721", "title": "Targeted Sequencing Analysis of the Leptin Receptor Gene Identifies Variants Associated with Obstructive Sleep Apnoea in Chinese Han Population", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Li J, Yang S, Jiao X, Yang Y, Sun H, Zhang M, Yang Y, Qin Y, Wei Y.", "articleTypes": [], "doi": "10.1007/s00408-019-00254-z", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.767Z" }, { "id": "f94cc976-7c6b-483b-b2c3-bd9601d5d811", "pmid": "31372721", "title": 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"2019", "authors": "Staub C, Venturi E, Cirot M, Léonard L, Barrière P, Blard T, Gaudé Y, Gascogne T, Yvon JM, Lecompte F, Ramé C, Reigner F, Dupont J.", "articleTypes": [], "doi": "10.1016/j.domaniend.2019.02.002", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.932Z" }, { "id": "da6650d3-cc41-4be3-bcbe-659adc6bab04", "pmid": "31374538", "title": "Ultrasonographic measures of body fatness and their relationship with plasma levels and adipose tissue expression of four adipokines in Welsh pony mares", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Staub C, Venturi E, Cirot M, Léonard L, Barrière P, Blard T, Gaudé Y, Gascogne T, Yvon JM, Lecompte F, Ramé C, Reigner F, Dupont J.", "articleTypes": [], "doi": "10.1016/j.domaniend.2019.02.002", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.463Z" }, { "id": "66bd08bd-1503-4a02-8043-31fc048822a7", 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"title": "[Influence of rs670 variant of APOA1 gene on serum HDL response to an enriched-polyunsaturated vs. an enriched-monounsaturated fat hypocaloric diet]", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "de Luis Román DA, Izaola Jáuregui O, Primo D, Aller R.", "articleTypes": [], "doi": "10.20960/nh.02390", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.406Z" }, { "id": "25fa91cc-341f-4686-8ea2-a40949deec2d", "pmid": "31696087", "title": "Comparing serum concentration of spexin among patients with metabolic syndrome, healthy overweight/obese, and normal-weight individuals", "imported": false, "abstract": "", "journal": "", "year": "2019", "authors": "Bitarafan V, Esteghamati A, Azam K, Yosaee S, Djafarian K.", "articleTypes": [], "doi": "10.34171/mjiri.33.93", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.418Z" }, { "id": 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"firstRetrievedAt": "2026-10-07T06:26:48.393Z" }, { "id": "afa0d108-f522-4973-a274-3ae064c3e901", "pmid": "31703240", "title": "Sex-specific effects of leptin administration to pregnant mice on the placentae and the metabolic phenotypes of offspring", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Denisova EI, Kozhevnikova VV, Bazhan NM, Makarova EN.", "articleTypes": [], "doi": "10.1002/2211-5463.12757", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.359Z" }, { "id": "07f5cfae-6c5d-4ee9-a5fa-4530618603b2", "pmid": "31707246", "title": "The interactive effect of the serotonin transporter genotype and drug use on suicidal behaviors in patients diagnosed with bipolar disorder.", "imported": false, "abstract": "BACKGROUND: Suicide is a public health crisis, accounting for more than 47,000 deaths in the United States annually. Individuals with Bipolar Disorder (BD) are at a disproportionately greater risk of suicidal behaviors. Prior studies indicate the significant role of genotype and drug use individually on suicidal behaviors. We hypothesized that, consistent with the gene X environment (GXE) framework, an interaction between serotonin receptor (5-HTTLPR) gene and drug use would influence suicidal behaviors in BD patients.\n\nMETHODS: One hundred and fifty BD patients at a public urban behavioral health clinic enrolled. The majority were females (n  104, 69.3%), between 19 and 65 years of age (M  39.5, SD= 10.9), African American (n  110, 73.3%), unemployed (78.7%, n  118) with 32% identifying as homeless (n  48). Measures of current mood symptoms, historic suicidal behaviors, and recent substance use were completed, and buccal swabs collected. A moderation analysis was employed for data analysis.\n\nRESULTS: Suicidal behaviors were significantly associated with genotype X drug use interaction (B  0.41, 95%CI= [0.06, 0.77], p= .03) followed by gender (B = 1.92, 95%CI= [0.59, 3.25], p= .005), genotype (B= -1.93, 95%CI= [-3.49, -0.36], p= .02), and employment (B= -1.72, 95%CI= [-3.12, -0.31], p= .02).\n\nLIMITATIONS: The relatively small sample size primarily comprised of an indigent urban population may limit generalizability. Drug use and suicide risk measures were self-reported and potentially influenced by social desirability bias.\n\nCONCLUSIONS: The 5-HTTLPR plays a moderating role on the association between drug use-suicidal behaviors with a differential impact of short and long alleles.", "journal": "Journal of affective disorders", "year": "2020", "authors": "Roane SJ, Kapoor S, Sun S, Cramer RJ, Lamis DA", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2019.10.049", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.566Z" }, { "id": "a7dce50a-bea2-4d1b-9381-359278e38d16", "pmid": "31707246", "title": "The interactive effect of the serotonin transporter genotype and drug use on suicidal behaviors in patients diagnosed with bipolar disorder.", "imported": false, "abstract": "BACKGROUND: Suicide is a public health crisis, accounting for more than 47,000 deaths in the United States annually. Individuals with Bipolar Disorder (BD) are at a disproportionately greater risk of suicidal behaviors. Prior studies indicate the significant role of genotype and drug use individually on suicidal behaviors. We hypothesized that, consistent with the gene X environment (GXE) framework, an interaction between serotonin receptor (5-HTTLPR) gene and drug use would influence suicidal behaviors in BD patients.\n\nMETHODS: One hundred and fifty BD patients at a public urban behavioral health clinic enrolled. The majority were females (n  104, 69.3%), between 19 and 65 years of age (M  39.5, SD= 10.9), African American (n  110, 73.3%), unemployed (78.7%, n  118) with 32% identifying as homeless (n  48). Measures of current mood symptoms, historic suicidal behaviors, and recent substance use were completed, and buccal swabs collected. A moderation analysis was employed for data analysis.\n\nRESULTS: Suicidal behaviors were significantly associated with genotype X drug use interaction (B  0.41, 95%CI= [0.06, 0.77], p= .03) followed by gender (B = 1.92, 95%CI= [0.59, 3.25], p= .005), genotype (B= -1.93, 95%CI= [-3.49, -0.36], p= .02), and employment (B= -1.72, 95%CI= [-3.12, -0.31], p= .02).\n\nLIMITATIONS: The relatively small sample size primarily comprised of an indigent urban population may limit generalizability. Drug use and suicide risk measures were self-reported and potentially influenced by social desirability bias.\n\nCONCLUSIONS: The 5-HTTLPR plays a moderating role on the association between drug use-suicidal behaviors with a differential impact of short and long alleles.", "journal": "Journal of affective disorders", "year": "2020", "authors": "Roane SJ, Kapoor S, Sun S, Cramer RJ, Lamis DA", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2019.10.049", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.609Z" }, { "id": "d619fe10-f989-412a-aca1-f557efe919e0", "pmid": "31707246", "title": "The interactive effect of the serotonin transporter genotype and drug use on suicidal behaviors in patients diagnosed with bipolar disorder.", "imported": false, "abstract": "BACKGROUND: Suicide is a public health crisis, accounting for more than 47,000 deaths in the United States annually. Individuals with Bipolar Disorder (BD) are at a disproportionately greater risk of suicidal behaviors. Prior studies indicate the significant role of genotype and drug use individually on suicidal behaviors. We hypothesized that, consistent with the gene X environment (GXE) framework, an interaction between serotonin receptor (5-HTTLPR) gene and drug use would influence suicidal behaviors in BD patients.\n\nMETHODS: One hundred and fifty BD patients at a public urban behavioral health clinic enrolled. The majority were females (n  104, 69.3%), between 19 and 65 years of age (M  39.5, SD= 10.9), African American (n  110, 73.3%), unemployed (78.7%, n  118) with 32% identifying as homeless (n  48). Measures of current mood symptoms, historic suicidal behaviors, and recent substance use were completed, and buccal swabs collected. A moderation analysis was employed for data analysis.\n\nRESULTS: Suicidal behaviors were significantly associated with genotype X drug use interaction (B  0.41, 95%CI= [0.06, 0.77], p= .03) followed by gender (B = 1.92, 95%CI= [0.59, 3.25], p= .005), genotype (B= -1.93, 95%CI= [-3.49, -0.36], p= .02), and employment (B= -1.72, 95%CI= [-3.12, -0.31], p= .02).\n\nLIMITATIONS: The relatively small sample size primarily comprised of an indigent urban population may limit generalizability. Drug use and suicide risk measures were self-reported and potentially influenced by social desirability bias.\n\nCONCLUSIONS: The 5-HTTLPR plays a moderating role on the association between drug use-suicidal behaviors with a differential impact of short and long alleles.", "journal": "Journal of affective disorders", "year": "2020", "authors": "Roane SJ, Kapoor S, Sun S, Cramer RJ, Lamis DA", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2019.10.049", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND 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suicide in adult life can be influenced by the interaction of adverse childhood experiences with the serotonin transporter polymorphism (5-HTTLPR). The cortico-limbic connectivity is a candidate endophenotype for the disorder, also related to suicidality and affected by the 5-HT system.\n\nMETHODS: In 64 (*s carriers = 41; l/l = 23) depressed BD patients, we explored the effect of 5-HTTLPR on corticolimbic functional connectivity (FC) during emotional processing, and the role of FC in moderating/mediating the effect of early stressful events on suicidality among 5-HTTLPR groups, by implementing Generalized Structural Equation Model.\n\nRESULTS: 5-HTTLPR affects FC between amygdala (Amy) and anterior cingulate cortex (ACC), temporal pole, putamen/thalamus, and precuneus. The short allele was associated to a more inefficient corticolimbic connectivity. In 5-HTTLPR*s carriers, but not in l/l, the Amy-ACC functional coupling mediated the relationship between stress load and current suicidality.\n\nLIMITATIONS: Patients were not drug-naive, and the recruitment took place in a single center, thus raising the possibility of population stratifications. The sample size is relatively small, but our findings can provide the background for replication study in independent and larger datasets.\n\nCONCLUSIONS: Our results confirm the link between the 5-HTT promoter polymorphism and susceptibility to stress in BD, and suggest that cortico-limbic functional connectivity mediates these effects. This pattern could identify a vulnerability factor for the exacerbation of mood episodes after stressful life events particularly relevant in *s carriers.", "journal": "Journal of affective disorders", "year": "2020", "authors": "Vai B, Serretti A, Poletti S, Mascia M, Lorenzi C, Colombo C, Benedetti F", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2019.11.142", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.609Z" }, { "id": "99dede47-f64a-4e68-ae25-5afe5355664a", "pmid": "31969273", "title": "Cortico-limbic functional connectivity mediates the effect of early life stress on suicidality in bipolar depressed 5-HTTLPR*s carriers.", "imported": false, "abstract": "BACKGROUND: In bipolar disorder (BD) the risk of suicide in adult life can be influenced by the interaction of adverse childhood experiences with the serotonin transporter polymorphism (5-HTTLPR). 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In 5-HTTLPR*s carriers, but not in l/l, the Amy-ACC functional coupling mediated the relationship between stress load and current suicidality.\n\nLIMITATIONS: Patients were not drug-naive, and the recruitment took place in a single center, thus raising the possibility of population stratifications. The sample size is relatively small, but our findings can provide the background for replication study in independent and larger datasets.\n\nCONCLUSIONS: Our results confirm the link between the 5-HTT promoter polymorphism and susceptibility to stress in BD, and suggest that cortico-limbic functional connectivity mediates these effects. This pattern could identify a vulnerability factor for the exacerbation of mood episodes after stressful life events particularly relevant in *s carriers.", "journal": "Journal of affective disorders", "year": "2020", "authors": "Vai B, Serretti A, Poletti S, Mascia M, Lorenzi C, Colombo C, Benedetti F", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2019.11.142", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.566Z" }, { "id": "d9b7e3e5-0e4c-4878-8264-c9888ada5f71", "pmid": "31969273", "title": "Cortico-limbic functional connectivity mediates the effect of early life stress on suicidality in bipolar depressed 5-HTTLPR*s carriers.", "imported": false, "abstract": "BACKGROUND: In bipolar disorder (BD) the risk of suicide in adult life can be influenced by the interaction of adverse childhood experiences with the serotonin transporter polymorphism (5-HTTLPR). The cortico-limbic connectivity is a candidate endophenotype for the disorder, also related to suicidality and affected by the 5-HT system.\n\nMETHODS: In 64 (*s carriers = 41; l/l = 23) depressed BD patients, we explored the effect of 5-HTTLPR on corticolimbic functional connectivity (FC) during emotional processing, and the role of FC in moderating/mediating the effect of early stressful events on suicidality among 5-HTTLPR groups, by implementing Generalized Structural Equation Model.\n\nRESULTS: 5-HTTLPR affects FC between amygdala (Amy) and anterior cingulate cortex (ACC), temporal pole, putamen/thalamus, and precuneus. The short allele was associated to a more inefficient corticolimbic connectivity. In 5-HTTLPR*s carriers, but not in l/l, the Amy-ACC functional coupling mediated the relationship between stress load and current suicidality.\n\nLIMITATIONS: Patients were not drug-naive, and the recruitment took place in a single center, thus raising the possibility of population stratifications. The sample size is relatively small, but our findings can provide the background for replication study in independent and larger datasets.\n\nCONCLUSIONS: Our results confirm the link between the 5-HTT promoter polymorphism and susceptibility to stress in BD, and suggest that cortico-limbic functional connectivity mediates these effects. This pattern could identify a vulnerability factor for the exacerbation of mood episodes after stressful life events particularly relevant in *s carriers.", "journal": "Journal of affective disorders", "year": "2020", "authors": "Vai B, Serretti A, Poletti S, Mascia M, Lorenzi C, Colombo C, Benedetti F", "articleTypes": [ "Journal Article", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2019.11.142", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR 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"id": "967bfed6-53dc-4f34-9f56-25faddcb288f", "pmid": "32659722", "title": "Differential Expression of Ormdl Genes in the Islets of Mice and Humans with Obesity", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Lee H, Fenske RJ, Akcan T, Domask E, Davis DB, Kimple ME, Engin F.", "articleTypes": [], "doi": "10.1016/j.isci.2020.101324", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.449Z" }, { "id": "03413c92-01e1-4b61-a72c-4387f33ba63d", "pmid": "32661330", "title": "Identification of distinct transcriptome signatures of human adipose tissue from fifteen depots", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Schleinitz D, Krause K, Wohland T, Gebhardt C, Linder N, Stumvoll M, Blüher M, Bechmann I, Kovacs P, Gericke M, Tönjes A.", "articleTypes": [], "doi": "10.1038/s41431-020-0681-1", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.812Z" }, { "id": "719e99c2-e090-46de-a0d7-b9a775930d70", "pmid": "32661330", "title": "Identification of distinct transcriptome signatures of human adipose tissue from fifteen depots", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Schleinitz D, Krause K, Wohland T, Gebhardt C, Linder N, Stumvoll M, Blüher M, Bechmann I, Kovacs P, Gericke M, Tönjes A.", "articleTypes": [], "doi": "10.1038/s41431-020-0681-1", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.456Z" }, { "id": "8584c453-1844-4744-a0f6-20233dd4e204", "pmid": "32661330", "title": "Identification of distinct transcriptome signatures of human adipose tissue from fifteen depots", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Schleinitz D, Krause K, Wohland T, Gebhardt C, Linder N, Stumvoll M, Blüher M, Bechmann I, Kovacs P, Gericke M, Tönjes A.", "articleTypes": [], "doi": "10.1038/s41431-020-0681-1", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.427Z" }, { "id": "fd000f1f-2a60-457b-9731-3118e925c56f", "pmid": "32661330", "title": "Identification of distinct transcriptome signatures of human adipose tissue from fifteen depots", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Schleinitz D, Krause K, Wohland T, Gebhardt C, Linder N, Stumvoll M, Blüher M, Bechmann I, Kovacs P, Gericke M, Tönjes A.", "articleTypes": [], "doi": "10.1038/s41431-020-0681-1", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.926Z" }, { "id": "01740fa2-66cf-4b76-93b1-87420dbd3ff6", "pmid": "32670063", "title": "Inhibition of Plasminogen Activator Inhibitor-1 Activation Suppresses High Fat Diet-Induced Weight Gain via Alleviation of Hypothalamic Leptin Resistance", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Hosaka S, Yamada T, Takahashi K, Dan T, Kaneko K, Kodama S, Asai Y, Munakata Y, Endo A, Sugawara H, Kawana Y, Yamamoto J, Izumi T, Sawada S, Imai J, Miyata T, Katagiri H.", "articleTypes": [], "doi": "10.3389/fphar.2020.00943", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.419Z" }, { "id": "62747a1a-df1e-482e-b177-8669a486c2aa", "pmid": "32670063", "title": "Inhibition of Plasminogen Activator Inhibitor-1 Activation Suppresses High Fat Diet-Induced Weight Gain via Alleviation of Hypothalamic Leptin Resistance", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Hosaka S, Yamada T, Takahashi K, Dan T, Kaneko K, Kodama S, Asai Y, Munakata Y, Endo A, Sugawara H, Kawana Y, Yamamoto J, Izumi T, Sawada S, Imai J, Miyata T, Katagiri H.", "articleTypes": [], "doi": "10.3389/fphar.2020.00943", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.805Z" }, { "id": "78221199-eb22-4c94-8824-0c859d46d791", "pmid": "32670063", "title": "Inhibition of Plasminogen Activator Inhibitor-1 Activation Suppresses High Fat Diet-Induced Weight Gain via Alleviation of Hypothalamic Leptin Resistance", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Hosaka S, Yamada T, Takahashi K, Dan T, Kaneko K, Kodama S, Asai Y, Munakata Y, Endo A, Sugawara H, Kawana Y, Yamamoto J, Izumi T, Sawada S, Imai J, Miyata T, Katagiri H.", "articleTypes": [], "doi": "10.3389/fphar.2020.00943", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.450Z" }, { "id": "d900c6f7-8d76-4b0b-b3e2-20e11663e1bd", "pmid": "32670063", "title": "Inhibition of Plasminogen Activator Inhibitor-1 Activation Suppresses High Fat Diet-Induced Weight Gain via Alleviation of Hypothalamic Leptin Resistance", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Hosaka S, Yamada T, Takahashi K, Dan T, Kaneko K, Kodama S, Asai Y, Munakata Y, Endo A, Sugawara H, Kawana Y, Yamamoto J, Izumi T, Sawada S, Imai J, Miyata T, Katagiri H.", "articleTypes": [], "doi": "10.3389/fphar.2020.00943", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.920Z" }, { "id": "165bae5d-cfd3-4a73-82c2-15d2e3e9c13b", "pmid": "32670107", "title": "\"Out, out, brief candle! Life's but a walking shadow\": 5-HTTLPR Is Associated With Current Suicidal Ideation but Not With Previous Suicide Attempts and Interacts With Recent Relationship Problems.", "imported": false, "abstract": "BACKGROUND: Suicide is an unresolved psychiatric and public health emergency, claiming 800,000 lives each year, however, its neurobiological etiology is still not understood. In spite of original reports concerning the involvement of 5-HTTLPR in interaction with recent stress in the appearance of suicidal ideation and attempts, replication studies have yielded contradictory results. In our study, we analyzed the association between 5-HTTLPR and lifetime suicide attempts, current suicidal ideation, hopelessness and thoughts of death as main effects, and in interaction with childhood adversities, recent stress, and different types of recent life events in a general population sample.\n\nMETHODS: Two thousand and three hundred fifty-eight unrelated European volunteers were genotyped for 5-HTTLPR, provided phenotypic data on previous suicide attempts, and current suicidal ideation, hopelessness and thoughts about death, and information on childhood adversities and recent life events. Logistic and linear regression models were run with age, gender, and population as covariates to test for the effect of 5-HTTLPR as a main effect and in interaction with childhood adversities and recent life events on previous suicide attempts and current suicidal ideation. Benjamini-Hochberg FDR Q values were calculated to correct for multiple testing.\n\nRESULTS: 5-HTTLPR had no significant effect on lifetime suicide attempts either as a main effect on in interaction with childhood adversities. 5-HTTLPR had a significant main effect on current suicidal ideation in the dominant model (Q=0.0344). 5-HTTLPR did not interact with childhood adversities or total number of recent life events on any phenotypes related to current suicidal risk, however, a significant interaction effect between 5-HTTLPR and current relationship problems emerged in the case of current suicidal ideation in the dominant model (Q=0.0218) and in the case of thoughts about death and dying in the dominant (Q=0.0094) and additive models (Q=0.0281).\n\nCONCLUSION: While 5-HTTLPR did not influence previous suicide attempts or interacted with childhood adversities, it did influence current suicidal ideation with, in addition, an interaction with recent relationship problems supporting the involvement of 5-HTTLPR in suicide. Our findings that 5-HTTLPR impacts only certain types of suicide risk-related behaviors and that it interacts with only distinct types of recent stressors provides a possible explanation for previous conflicting findings.", "journal": "Frontiers in psychiatry", "year": "2020", "authors": "Bokor J, Krause S, Torok D, Eszlari N, Sutori S, Gal Z, Petschner P, Anderson IM, Deakin B, Bagdy G, Juhasz G, Gonda X", "articleTypes": [ "Journal Article" ], "doi": "10.1007/s11606-010-1403-0", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.609Z" }, { "id": "de74830b-0750-4266-b604-432e54f3386d", "pmid": "32670107", "title": "\"Out, out, brief candle! Life's but a walking shadow\": 5-HTTLPR Is Associated With Current Suicidal Ideation but Not With Previous Suicide Attempts and Interacts With Recent Relationship Problems.", "imported": false, "abstract": "BACKGROUND: Suicide is an unresolved psychiatric and public health emergency, claiming 800,000 lives each year, however, its neurobiological etiology is still not understood. In spite of original reports concerning the involvement of 5-HTTLPR in interaction with recent stress in the appearance of suicidal ideation and attempts, replication studies have yielded contradictory results. In our study, we analyzed the association between 5-HTTLPR and lifetime suicide attempts, current suicidal ideation, hopelessness and thoughts of death as main effects, and in interaction with childhood adversities, recent stress, and different types of recent life events in a general population sample.\n\nMETHODS: Two thousand and three hundred fifty-eight unrelated European volunteers were genotyped for 5-HTTLPR, provided phenotypic data on previous suicide attempts, and current suicidal ideation, hopelessness and thoughts about death, and information on childhood adversities and recent life events. Logistic and linear regression models were run with age, gender, and population as covariates to test for the effect of 5-HTTLPR as a main effect and in interaction with childhood adversities and recent life events on previous suicide attempts and current suicidal ideation. Benjamini-Hochberg FDR Q values were calculated to correct for multiple testing.\n\nRESULTS: 5-HTTLPR had no significant effect on lifetime suicide attempts either as a main effect on in interaction with childhood adversities. 5-HTTLPR had a significant main effect on current suicidal ideation in the dominant model (Q=0.0344). 5-HTTLPR did not interact with childhood adversities or total number of recent life events on any phenotypes related to current suicidal risk, however, a significant interaction effect between 5-HTTLPR and current relationship problems emerged in the case of current suicidal ideation in the dominant model (Q=0.0218) and in the case of thoughts about death and dying in the dominant (Q=0.0094) and additive models (Q=0.0281).\n\nCONCLUSION: While 5-HTTLPR did not influence previous suicide attempts or interacted with childhood adversities, it did influence current suicidal ideation with, in addition, an interaction with recent relationship problems supporting the involvement of 5-HTTLPR in suicide. Our findings that 5-HTTLPR impacts only certain types of suicide risk-related behaviors and that it interacts with only distinct types of recent stressors provides a possible explanation for previous conflicting findings.", "journal": "Frontiers in psychiatry", "year": "2020", "authors": "Bokor J, Krause S, Torok D, Eszlari N, Sutori S, Gal Z, Petschner P, Anderson IM, Deakin B, Bagdy G, Juhasz G, Gonda X", "articleTypes": [ "Journal Article" ], "doi": "10.1007/s11606-010-1403-0", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.565Z" }, { "id": "f859ccdb-43c3-4190-a7ba-9e2d9cb791b4", "pmid": "32670107", "title": "\"Out, out, brief candle! Life's but a walking shadow\": 5-HTTLPR Is Associated With Current Suicidal Ideation but Not With Previous Suicide Attempts and Interacts With Recent Relationship Problems.", "imported": false, "abstract": "BACKGROUND: Suicide is an unresolved psychiatric and public health emergency, claiming 800,000 lives each year, however, its neurobiological etiology is still not understood. In spite of original reports concerning the involvement of 5-HTTLPR in interaction with recent stress in the appearance of suicidal ideation and attempts, replication studies have yielded contradictory results. In our study, we analyzed the association between 5-HTTLPR and lifetime suicide attempts, current suicidal ideation, hopelessness and thoughts of death as main effects, and in interaction with childhood adversities, recent stress, and different types of recent life events in a general population sample.\n\nMETHODS: Two thousand and three hundred fifty-eight unrelated European volunteers were genotyped for 5-HTTLPR, provided phenotypic data on previous suicide attempts, and current suicidal ideation, hopelessness and thoughts about death, and information on childhood adversities and recent life events. Logistic and linear regression models were run with age, gender, and population as covariates to test for the effect of 5-HTTLPR as a main effect and in interaction with childhood adversities and recent life events on previous suicide attempts and current suicidal ideation. Benjamini-Hochberg FDR Q values were calculated to correct for multiple testing.\n\nRESULTS: 5-HTTLPR had no significant effect on lifetime suicide attempts either as a main effect on in interaction with childhood adversities. 5-HTTLPR had a significant main effect on current suicidal ideation in the dominant model (Q=0.0344). 5-HTTLPR did not interact with childhood adversities or total number of recent life events on any phenotypes related to current suicidal risk, however, a significant interaction effect between 5-HTTLPR and current relationship problems emerged in the case of current suicidal ideation in the dominant model (Q=0.0218) and in the case of thoughts about death and dying in the dominant (Q=0.0094) and additive models (Q=0.0281).\n\nCONCLUSION: While 5-HTTLPR did not influence previous suicide attempts or interacted with childhood adversities, it did influence current suicidal ideation with, in addition, an interaction with recent relationship problems supporting the involvement of 5-HTTLPR in suicide. Our findings that 5-HTTLPR impacts only certain types of suicide risk-related behaviors and that it interacts with only distinct types of recent stressors provides a possible explanation for previous conflicting findings.", "journal": "Frontiers in psychiatry", "year": "2020", "authors": "Bokor J, Krause S, Torok D, Eszlari N, Sutori S, Gal Z, Petschner P, Anderson IM, Deakin B, Bagdy G, Juhasz G, Gonda X", "articleTypes": [ "Journal Article" ], "doi": "10.1007/s11606-010-1403-0", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.153Z" }, { "id": "5889cbbf-e434-40f9-b242-580cd26b4873", "pmid": "32673455", "title": "Polymorphisms of leptin-melanocortin system genes associated with obesity in an adult population from Barranquilla", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Garavito P, Mosquera-Heredia MI, Fang L, Payares F, Ruiz M, Arias I, Tuesca R, Navarro É, Silvera-Redondo C.", "articleTypes": [], "doi": "10.7705/biomedica.4827", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.736Z" }, { "id": "bfe1e8b7-ddaf-48e4-9bc6-dd221c5860f4", "pmid": "32673455", "title": "Polymorphisms of leptin-melanocortin system genes associated with obesity in an adult population from Barranquilla", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Garavito P, Mosquera-Heredia MI, Fang L, Payares F, Ruiz M, Arias I, Tuesca R, Navarro É, Silvera-Redondo C.", "articleTypes": [], "doi": "10.7705/biomedica.4827", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.857Z" }, { "id": "c95796bb-65f3-43c4-90b6-aa9216529489", "pmid": "32673455", "title": "Polymorphisms of leptin-melanocortin system genes associated with obesity in an adult population from Barranquilla", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Garavito P, Mosquera-Heredia MI, Fang L, Payares F, Ruiz M, Arias I, Tuesca R, Navarro É, Silvera-Redondo C.", "articleTypes": [], "doi": "10.7705/biomedica.4827", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.345Z" }, { "id": "cda3ece9-0918-402b-a567-505ca90935fb", "pmid": "32673455", "title": "Polymorphisms of leptin-melanocortin system genes associated with obesity in an adult population from Barranquilla", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Garavito P, Mosquera-Heredia MI, Fang L, Payares F, Ruiz M, Arias I, Tuesca R, Navarro É, Silvera-Redondo C.", "articleTypes": [], "doi": "10.7705/biomedica.4827", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.378Z" }, { "id": "0b3a8e2c-8b57-481d-a94f-cfebd87886af", "pmid": "32686763", "title": "Fas mutation reduces obesity by increasing IL-4 and IL-10 expression and promoting white adipose tissue browning", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Choi EW, Lee M, Song JW, Kim K, Lee J, Yang J, Lee SH, Kim IY, Choi JH, Seong JK.", "articleTypes": [], "doi": "10.1038/s41598-020-68971-7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.764Z" }, { "id": "18678a93-2fce-447a-9a87-77401a3920be", "pmid": "32686763", "title": "Fas mutation reduces obesity by increasing IL-4 and IL-10 expression and promoting white adipose tissue browning", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Choi EW, Lee M, Song JW, Kim K, Lee J, Yang J, Lee SH, Kim IY, Choi JH, Seong JK.", "articleTypes": [], "doi": "10.1038/s41598-020-68971-7", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.885Z" }, { "id": "31179875-d83f-491d-8485-c8dddad8bf70", "pmid": "32686763", "title": "Fas mutation reduces obesity by increasing IL-4 and IL-10 expression and promoting white adipose tissue browning", "imported": false, "abstract": "", "journal": "", "year": "2020", "authors": "Choi EW, Lee M, Song JW, Kim K, Lee J, Yang J, Lee SH, Kim IY, Choi JH, Seong JK.", 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However, there was a significant correlation between self-reported childhood maltreatment and fearlessness about death that emerged exclusively in homozygous S-allele carriers.\n\nCONCLUSION: Results suggest that there are no \"high-risk\"-alleles that generally increase capability for suicide. 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depressive symptoms in patients with chronic obstructive pulmonary disease.", "imported": false, "abstract": "Background: We examined the relationship between polymorphisms in the promoter region of the serotonin transport (SERT) gene (5-HTTLPR, short 'S' and long 'L' alleles) and in intron 2 variable number tandem repeat (STin2VNTR, 9, 10, or 12-repeat alleles) with depression or anxiety in patients with COPD.Methods: 302 patients with moderate to severe COPD participated in SERT study. History and number of prior depressive episodes were measured using the Structured Clinical Interview for Depression; Hospital Anxiety Depression Scale (HAD) depression ≥8 or a Patient Health Questionnaire-9 (PHQ-9) >,10.Results: 240 (80%) male sample had a mean age of 68.0 years. Current depression was 22% (HAD) or 21% (PHQ-9), anxiety was 25% (HAD), and suicidal ideation (6%). 5-HTTLPR or STin2 VNTR genotypes were not associated with current depressive or anxiety symptoms. The mean number of prior depressive episodes was higher for patients with the 5-HTTLPR genotype S/S or S/L compared with L/L (4.4 ± 6.1; 5.3 ± 6.8; 4.0 ± 6.1, p < 0.001) and with STin2VNTR high-risk genotype (9/12 or 12/12), medium risk (9/10 or 10/12) compared to low risk (10/10) genotypes (5.1 ± 6.8; 4.9 ± 6.7; 2.7 ± 4.5, p < 0.001).Conclusions: SERT 5-HTTLPR and STin2-VNTR polymorphisms were not associated with current depressive and anxiety symptoms, but the high-risk STin2-VNTR genotypes and S/L were associated with the number of prior depressive episodes.", "journal": "Expert review of respiratory medicine", "year": "2021", "authors": "Yohannes AM, Kohen R, Nguyen HQ, Pike KC, Borson S, Fan VS", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural" ], "doi": "10.1080/17476348.2021.1865159", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.564Z" }, { "id": "8dc6599f-842d-4d4b-b80e-227eb2064814", "pmid": "33325315", "title": "Serotonin transporter gene polymorphisms and depressive symptoms in patients with chronic obstructive pulmonary disease.", "imported": false, "abstract": "Background: We examined the relationship between polymorphisms in the promoter region of the serotonin transport (SERT) gene (5-HTTLPR, short 'S' and long 'L' alleles) and in intron 2 variable number tandem repeat (STin2VNTR, 9, 10, or 12-repeat alleles) with depression or anxiety in patients with COPD.Methods: 302 patients with moderate to severe COPD participated in SERT study. History and number of prior depressive episodes were measured using the Structured Clinical Interview for Depression; Hospital Anxiety Depression Scale (HAD) depression ≥8 or a Patient Health Questionnaire-9 (PHQ-9) >,10.Results: 240 (80%) male sample had a mean age of 68.0 years. Current depression was 22% (HAD) or 21% (PHQ-9), anxiety was 25% (HAD), and suicidal ideation (6%). 5-HTTLPR or STin2 VNTR genotypes were not associated with current depressive or anxiety symptoms. The mean number of prior depressive episodes was higher for patients with the 5-HTTLPR genotype S/S or S/L compared with L/L (4.4 ± 6.1; 5.3 ± 6.8; 4.0 ± 6.1, p < 0.001) and with STin2VNTR high-risk genotype (9/12 or 12/12), medium risk (9/10 or 10/12) compared to low risk (10/10) genotypes (5.1 ± 6.8; 4.9 ± 6.7; 2.7 ± 4.5, p < 0.001).Conclusions: SERT 5-HTTLPR and STin2-VNTR polymorphisms were not associated with current depressive and anxiety symptoms, but the high-risk STin2-VNTR genotypes and S/L were associated with the number of prior depressive episodes.", "journal": "Expert review of respiratory medicine", "year": "2021", "authors": "Yohannes AM, Kohen R, Nguyen HQ, Pike KC, Borson S, Fan VS", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural" ], "doi": "10.1080/17476348.2021.1865159", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.152Z" }, { "id": "c9673b0d-cc6b-480a-8b57-782caa6a9dc5", "pmid": "33325315", "title": "Serotonin transporter gene polymorphisms and depressive symptoms in patients with chronic obstructive pulmonary disease.", "imported": false, "abstract": "Background: We examined the relationship between polymorphisms in the promoter region of the serotonin transport (SERT) gene (5-HTTLPR, short 'S' and long 'L' alleles) and in intron 2 variable number tandem repeat (STin2VNTR, 9, 10, or 12-repeat alleles) with depression or anxiety in patients with COPD.Methods: 302 patients with moderate to severe COPD participated in SERT study. History and number of prior depressive episodes were measured using the Structured Clinical Interview for Depression; Hospital Anxiety Depression Scale (HAD) depression ≥8 or a Patient Health Questionnaire-9 (PHQ-9) >,10.Results: 240 (80%) male sample had a mean age of 68.0 years. Current depression was 22% (HAD) or 21% (PHQ-9), anxiety was 25% (HAD), and suicidal ideation (6%). 5-HTTLPR or STin2 VNTR genotypes were not associated with current depressive or anxiety symptoms. The mean number of prior depressive episodes was higher for patients with the 5-HTTLPR genotype S/S or S/L compared with L/L (4.4 ± 6.1; 5.3 ± 6.8; 4.0 ± 6.1, p < 0.001) and with STin2VNTR high-risk genotype (9/12 or 12/12), medium risk (9/10 or 10/12) compared to low risk (10/10) genotypes (5.1 ± 6.8; 4.9 ± 6.7; 2.7 ± 4.5, p < 0.001).Conclusions: SERT 5-HTTLPR and STin2-VNTR polymorphisms were not associated with current depressive and anxiety symptoms, but the high-risk STin2-VNTR genotypes and S/L were associated with the number of prior depressive episodes.", "journal": "Expert review of respiratory medicine", "year": "2021", "authors": "Yohannes AM, Kohen R, Nguyen HQ, Pike KC, Borson S, Fan VS", "articleTypes": [ "Journal Article", "Research Support, N.I.H., Extramural" ], "doi": "10.1080/17476348.2021.1865159", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": 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SLC6A4 5-HTTLPR + rs25531 locus was significant in the recessive model (p = 0.024), and also affected the severity of symptoms of depression (p = 0.044) and personal anxiety (p = 0.029). 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However, the extent to which this endogenous stress factor interacts with genetic vulnerability factors for predicting suicide risks remains unclear.\n\nMETHODS: We evaluated whether the severity of symptoms interacts with a genetic vulnerability factor (the serotonin transporter gene-linked promoter region variation) in predicting the frequency of lifetime suicide attempts in patients with a psychiatric disease. Symptom severity and 5-HTTLPR polymorphism were collected from a sample of 95 patients with obsessive-compulsive disorder (OCD). Lifetime suicide attempt was the primary outcome, and antecedent of multiple suicide attempts was the secondary outcome.\n\nRESULTS: The gene-by-symptoms interaction was associated with an excess risk of suicide attempts (OR = 4.39, 95CI[1.44, 13.38], p < 0.009) and of multiple suicide attempts (OR = 4.18, 95CI[1.04, 16.77], p = 0.043). Symptom severity (moderate, severe, or extreme) was associated with an approximately five-fold increase in the odds of a lifetime suicide attempt in patients carrying one or two copies of the short allele of 5-HTTLPR. No such relationship was found for patients carrying the long allele.\n\nCONCLUSION: This study provides preliminary evidence for the gene-by-stress interaction on suicide attempt when stress is operationalized as symptom severity. 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"241f857f-1798-4ba3-bc2a-17f86ce36aea", "pmid": "37155441", "title": "Association of Thyroid Function and Severity of Illness in Liver Cirrhosis as Measured by Child-Pugh Score.", "imported": false, "abstract": "Objective The main aim of this study is to understand the existing knowledge gap between thyroid function tests and the severity of liver cirrhosis as measured by the Child-Pugh score. Materials and methods This is a cross-sectional study conducted on 100 patients diagnosed with cirrhosis of liver. Serum triiodothyronine (free T3), thyroxine (free T4), and thyroid stimulating hormone (TSH) levels were measured, and the severity of liver cirrhosis was measured by Child-Pugh score and statistical analysis were done to investigate the association of free T3, free T4 and TSH levels with Child-A, Child-B, and Child-C severity groups. Results The results revealed that there is a statistically significant positive correlation between TSH levels and Child-Pugh score, whereas a statistically significant negative correlation was associated between free T3 (fT3), free T4 (fT4) levels, and Child-Pugh Score. Further, we also observed that the Child-C group has 7.5-fold risk of increased TSH levels (odds ratio {OR} = 7.553, 95% CI = 2.869-19.883, p = 0.000), has 5-fold risk of decreased fT3 levels (OR = 5.023, 95% CI = 1.369-18.431, p = 0.009) and has 6.4-fold risk of decreased fT4 levels (OR = 6.402, 95% CI = 2.516-16.290, p = 0.000). Conclusion Our results demonstrated that there is a positive and direct correlation associated between increasing TSH with severity of liver cirrhosis as measured by Child-Pugh score, whereas a negative and inverse correlation was observed between decreasing fT3 and fT4 levels with the severity of liver cirrhosis as measured by Child-Pugh score. This suggests that the Child-Pugh score can be used as a prognostic indicator in cirrhotic patients.", "journal": "Cureus", "year": "2023", "authors": "Raj A, Pillai G, Divakar A, Shivam V, Nair A", "articleTypes": [], "doi": "10.7759/cureus.36618", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.438Z" }, { "id": "5b4fa577-c2f5-4ecf-a715-3926860b8a16", "pmid": "37155441", "title": "Association of Thyroid Function and Severity of Illness in Liver Cirrhosis as Measured by Child-Pugh Score.", "imported": false, "abstract": "Objective The main aim of this study is to understand the existing knowledge gap between thyroid function tests and the severity of liver cirrhosis as measured by the Child-Pugh score. Materials and methods This is a cross-sectional study conducted on 100 patients diagnosed with cirrhosis of liver. Serum triiodothyronine (free T3), thyroxine (free T4), and thyroid stimulating hormone (TSH) levels were measured, and the severity of liver cirrhosis was measured by Child-Pugh score and statistical analysis were done to investigate the association of free T3, free T4 and TSH levels with Child-A, Child-B, and Child-C severity groups. Results The results revealed that there is a statistically significant positive correlation between TSH levels and Child-Pugh score, whereas a statistically significant negative correlation was associated between free T3 (fT3), free T4 (fT4) levels, and Child-Pugh Score. Further, we also observed that the Child-C group has 7.5-fold risk of increased TSH levels (odds ratio {OR} = 7.553, 95% CI = 2.869-19.883, p = 0.000), has 5-fold risk of decreased fT3 levels (OR = 5.023, 95% CI = 1.369-18.431, p = 0.009) and has 6.4-fold risk of decreased fT4 levels (OR = 6.402, 95% CI = 2.516-16.290, p = 0.000). Conclusion Our results demonstrated that there is a positive and direct correlation associated between increasing TSH with severity of liver cirrhosis as measured by Child-Pugh score, whereas a negative and inverse correlation was observed between decreasing fT3 and fT4 levels with the severity of liver cirrhosis as measured by Child-Pugh score. This suggests that the Child-Pugh score can be used as a prognostic indicator in cirrhotic patients.", "journal": "Cureus", "year": "2023", "authors": "Raj A, Pillai G, Divakar A, Shivam V, Nair A", "articleTypes": [], "doi": "10.7759/cureus.36618", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.438Z" }, { "id": "63e249e2-57ff-43db-910d-061f814c2cda", "pmid": "37155441", "title": "Association of Thyroid Function and Severity of Illness in Liver Cirrhosis as Measured by Child-Pugh Score.", "imported": false, "abstract": "Objective The main aim of this study is to understand the existing knowledge gap between thyroid function tests and the severity of liver cirrhosis as measured by the Child-Pugh score. Materials and methods This is a cross-sectional study conducted on 100 patients diagnosed with cirrhosis of liver. Serum triiodothyronine (free T3), thyroxine (free T4), and thyroid stimulating hormone (TSH) levels were measured, and the severity of liver cirrhosis was measured by Child-Pugh score and statistical analysis were done to investigate the association of free T3, free T4 and TSH levels with Child-A, Child-B, and Child-C severity groups. Results The results revealed that there is a statistically significant positive correlation between TSH levels and Child-Pugh score, whereas a statistically significant negative correlation was associated between free T3 (fT3), free T4 (fT4) levels, and Child-Pugh Score. Further, we also observed that the Child-C group has 7.5-fold risk of increased TSH levels (odds ratio {OR} = 7.553, 95% CI = 2.869-19.883, p = 0.000), has 5-fold risk of decreased fT3 levels (OR = 5.023, 95% CI = 1.369-18.431, p = 0.009) and has 6.4-fold risk of decreased fT4 levels (OR = 6.402, 95% CI = 2.516-16.290, p = 0.000). Conclusion Our results demonstrated that there is a positive and direct correlation associated between increasing TSH with severity of liver cirrhosis as measured by Child-Pugh score, whereas a negative and inverse correlation was observed between decreasing fT3 and fT4 levels with the severity of liver cirrhosis as measured by Child-Pugh score. This suggests that the Child-Pugh score can be used as a prognostic indicator in cirrhotic patients.", "journal": "Cureus", "year": "2023", "authors": "Raj A, Pillai G, Divakar A, Shivam V, Nair A", "articleTypes": [], "doi": "10.7759/cureus.36618", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.438Z" }, { "id": "2d3c33eb-fb08-43cf-82b0-7d39c1ae7bad", "pmid": "37155441", "title": "Association of Thyroid Function and Severity of Illness in Liver Cirrhosis as Measured by Child-Pugh Score.", "imported": false, "abstract": "Objective The main aim of this study is to understand the existing knowledge gap between thyroid function tests and the severity of liver cirrhosis as measured by the Child-Pugh score. Materials and methods This is a cross-sectional study conducted on 100 patients diagnosed with cirrhosis of liver. Serum triiodothyronine (free T3), thyroxine (free T4), and thyroid stimulating hormone (TSH) levels were measured, and the severity of liver cirrhosis was measured by Child-Pugh score and statistical analysis were done to investigate the association of free T3, free T4 and TSH levels with Child-A, Child-B, and Child-C severity groups. Results The results revealed that there is a statistically significant positive correlation between TSH levels and Child-Pugh score, whereas a statistically significant negative correlation was associated between free T3 (fT3), free T4 (fT4) levels, and Child-Pugh Score. Further, we also observed that the Child-C group has 7.5-fold risk of increased TSH levels (odds ratio {OR} = 7.553, 95% CI = 2.869-19.883, p = 0.000), has 5-fold risk of decreased fT3 levels (OR = 5.023, 95% CI = 1.369-18.431, p = 0.009) and has 6.4-fold risk of decreased fT4 levels (OR = 6.402, 95% CI = 2.516-16.290, p = 0.000). Conclusion Our results demonstrated that there is a positive and direct correlation associated between increasing TSH with severity of liver cirrhosis as measured by Child-Pugh score, whereas a negative and inverse correlation was observed between decreasing fT3 and fT4 levels with the severity of liver cirrhosis as measured by Child-Pugh score. This suggests that the Child-Pugh score can be used as a prognostic indicator in cirrhotic patients.", "journal": "Cureus", "year": "2023", "authors": "Raj A, Pillai G, Divakar A, Shivam V, Nair A", "articleTypes": [ "Journal Article" ], "doi": "10.7759/cureus.36618", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791355890868", "database": "PubMed", "query": "vishnu shivam", "searchedAt": "2026-10-07T06:51:30.868Z", "initialCount": 6, "retrievedCount": 6, "segments": [ { "startDate": null, "endDate": null, "count": 6 } ], "queryTranslation": "shivam, vishnu[Author]" } ], "firstRetrievedAt": "2026-10-07T06:51:33.706Z" }, { "id": "1575d721-0513-4d60-9d43-4d48913397ae", "pmid": "37155466", "title": "Effects of leptin on the viability of human ovarian cancer cells and changes in cytokine expression levels", "imported": false, "abstract": "", "journal": "", "year": "2023", "authors": "Dincer F, Atmaca H, Akman L, Oktay LM, Karaca B, Terek MC.", 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However, studies evaluating the factors associated with the risk of CLABSI in pediatric intensive care units (PICU) were limited in India. Objective The objective of our study is to evaluate the association of factors and the etiology causing CLABSI. Study design This is a hospital-based single-center prospective study conducted in the pediatric intensive care unit (PICU) of our tertiary care hospital spanning one year. Participants Children aged between two months to 15 years admitted in the PICU for more than 48 hours with central venous catheterization were included. Pearson's chi-squared test with Yates' continuity correction and logistic regression with odds ratio were calculated by R statistical software (R Foundation for Statistical Computing, Vienna, Austria) and a p-value less than 0.05 was considered statistically significant. Results Our analysis showed that factors such as young age (2-12 months), high pediatric risk of mortality (PRISM III) score (> 15), leukocytosis, neutrophilia, anemia, change of central venous catheter, duration of catheterization (>7 days), exposure to blood products, use of steroids, inotropes, and prophylactic antibiotics were significantly associated with increased risk of CLABSIs with an odds ratio of 4.53, 4.54, 2.91, 4.56, 4.76, 3.74, 2.49, 2.41, 7.22, 6.77 and 5.16 respectively (p<0.05). Further, factors such as older age (>12 months) and low PRISM III score (≤ 15) significantly reduce the risk of CLABSIs by 83.64% and 69.14% respectively (p<0.05). Conclusion In conclusion, our results revealed that factors such as young age, high PRISM III score, leukocytosis, neutrophilia, anemia, change of central venous catheter, duration of catheterization (> 7 days), exposure to blood products during the hospital stay, use of steroids, inotropes, and prophylactic antibiotics were identified as risk factors for CLABSI.", "journal": "", "year": "2023", "authors": "Sellamuthu R, Nair S, Chandrasekar J, Kesavan S, Shivam V", "articleTypes": [], "doi": "10.7759/cureus.43349", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.438Z" }, { "id": "90a76e27-200f-4264-be3a-0993f279fc8c", "pmid": "37700998", "title": "Risk Factors of Central Line-Associated Bloodstream Infection (CLABSI): A Prospective Study From a Paediatric Intensive Care Unit in South India.", "imported": false, "abstract": "", "journal": "Cureus", "year": "2023", "authors": "Sellamuthu R, Nair S, Chandrasekar J, Kesavan S, Shivam V", "articleTypes": [], "doi": "", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.438Z" }, { "id": "ee1682cf-e3b4-4bd6-93a0-fd101dba6128", "pmid": "37700998", "title": "Risk Factors of Central Line-Associated Bloodstream Infection (CLABSI): A Prospective Study From a Paediatric Intensive Care Unit in South India.", "imported": false, "abstract": "Background Central line-associated bloodstream infection (CLABSI) is the most common hospital-acquired infection. However, studies evaluating the factors associated with the risk of CLABSI in pediatric intensive care units (PICU) were limited in India. Objective The objective of our study is to evaluate the association of factors and the etiology causing CLABSI. Study design This is a hospital-based single-center prospective study conducted in the pediatric intensive care unit (PICU) of our tertiary care hospital spanning one year. Participants Children aged between two months to 15 years admitted in the PICU for more than 48 hours with central venous catheterization were included. Pearson's chi-squared test with Yates' continuity correction and logistic regression with odds ratio were calculated by R statistical software (R Foundation for Statistical Computing, Vienna, Austria) and a p-value less than 0.05 was considered statistically significant. Results Our analysis showed that factors such as young age (2-12 months), high pediatric risk of mortality (PRISM III) score (> 15), leukocytosis, neutrophilia, anemia, change of central venous catheter, duration of catheterization (>7 days), exposure to blood products, use of steroids, inotropes, and prophylactic antibiotics were significantly associated with increased risk of CLABSIs with an odds ratio of 4.53, 4.54, 2.91, 4.56, 4.76, 3.74, 2.49, 2.41, 7.22, 6.77 and 5.16 respectively (p<0.05). Further, factors such as older age (>12 months) and low PRISM III score (≤ 15) significantly reduce the risk of CLABSIs by 83.64% and 69.14% respectively (p<0.05). Conclusion In conclusion, our results revealed that factors such as young age, high PRISM III score, leukocytosis, neutrophilia, anemia, change of central venous catheter, duration of catheterization (> 7 days), exposure to blood products during the hospital stay, use of steroids, inotropes, and prophylactic antibiotics were identified as risk factors for CLABSI.", "journal": "Cureus", "year": "2023", "authors": "", "articleTypes": [], "doi": "10.7759/cureus.43349", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.438Z" }, { "id": "eff6d08a-10e6-4cb6-8d68-d4ddbe0a4397", "pmid": "37700998", "title": "Risk Factors of Central Line-Associated Bloodstream Infection (CLABSI): A Prospective Study From a Paediatric Intensive Care Unit in South India.", "imported": false, "abstract": "Background Central line-associated bloodstream infection (CLABSI) is the most common hospital-acquired infection. However, studies evaluating the factors associated with the risk of CLABSI in pediatric intensive care units (PICU) were limited in India. Objective The objective of our study is to evaluate the association of factors and the etiology causing CLABSI. Study design This is a hospital-based single-center prospective study conducted in the pediatric intensive care unit (PICU) of our tertiary care hospital spanning one year. Participants Children aged between two months to 15 years admitted in the PICU for more than 48 hours with central venous catheterization were included. Pearson's chi-squared test with Yates' continuity correction and logistic regression with odds ratio were calculated by R statistical software (R Foundation for Statistical Computing, Vienna, Austria) and a p-value less than 0.05 was considered statistically significant. Results Our analysis showed that factors such as young age (2-12 months), high pediatric risk of mortality (PRISM III) score (> 15), leukocytosis, neutrophilia, anemia, change of central venous catheter, duration of catheterization (>7 days), exposure to blood products, use of steroids, inotropes, and prophylactic antibiotics were significantly associated with increased risk of CLABSIs with an odds ratio of 4.53, 4.54, 2.91, 4.56, 4.76, 3.74, 2.49, 2.41, 7.22, 6.77 and 5.16 respectively (p<0.05). Further, factors such as older age (>12 months) and low PRISM III score (≤ 15) significantly reduce the risk of CLABSIs by 83.64% and 69.14% respectively (p<0.05). Conclusion In conclusion, our results revealed that factors such as young age, high PRISM III score, leukocytosis, neutrophilia, anemia, change of central venous catheter, duration of catheterization (> 7 days), exposure to blood products during the hospital stay, use of steroids, inotropes, and prophylactic antibiotics were identified as risk factors for CLABSI.", "journal": "Cureus", "year": "2023", "authors": "Sellamuthu R, Nair S, Chandrasekar J, Kesavan S, Shivam V", "articleTypes": [ "Journal Article" ], "doi": "10.7759/cureus.43349", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791355890868", "database": "PubMed", "query": "vishnu shivam", "searchedAt": "2026-10-07T06:51:30.868Z", "initialCount": 6, "retrievedCount": 6, "segments": [ { "startDate": null, "endDate": null, "count": 6 } ], "queryTranslation": "shivam, vishnu[Author]" } ], "firstRetrievedAt": "2026-10-07T06:51:33.706Z" }, { "id": "043a17dd-3924-4736-aefa-00eb00cae8a4", "pmid": 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"pmid": "38447916", "title": "Val/Met BDNF as a genetic risk for a false sense of security in post-discharge suicide risk.", "imported": false, "abstract": "BACKGROUND: The time after discharge from psychiatric inpatient care is one of the most dangerous periods in terms of suicide risk. Predicting who is at higher risk could help with resource allocation to assure patients at high risk of suicide attempts are most closely followed. We previously showed that inpatients who improve their suicide ideation levels faster while in inpatient treatment are the ones with highest rates of post-discharge suicide. Here, we studied the possible genetic underpinnings associated with such risk.\n\nMETHOD: We recorded the slope of suicide ideation recovery of 710 psychiatric inpatients from which we studied two genetic variants likely associated with suicide risk: The serotonin transporter variant 5-HTTLPR, and the BDNF gene variant Val66Met.\n\nRESULTS: We found that inpatients carrying the BDNF Met variant (hypothesized as conferring higher suicide risk) improved their suicide ideation scores faster than Val/Val carrying inpatients. No significant association was found for 5-HTTLPR.\n\nLIMITATIONS: The present sample was genetically homogenous, and future research should replicate these findings on a more diverse sample.\n\nCONCLUSIONS: In conclusion, we found a paradoxical result: Carrying the BDNF Met variant allows inpatients to improve faster, which was shown to confer higher risk at the post-discharge period. This may explain some inconsistencies in the literature in terms of the role of BDNF in suicide ideation and attempts.", "journal": "Journal of affective disorders", "year": "2024", "authors": "Rufino KA, Goli P, Patriquin MA, Kosten TR, Nielsen DA, Salas R", "articleTypes": [ "Journal Article", "Research Support, U.S. Gov't, Non-P.H.S.", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2024.03.001", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.562Z" }, { "id": "b70cacd2-311b-4e2a-8387-95abaed40c25", "pmid": "38447916", "title": "Val/Met BDNF as a genetic risk for a false sense of security in post-discharge suicide risk.", "imported": false, "abstract": "BACKGROUND: The time after discharge from psychiatric inpatient care is one of the most dangerous periods in terms of suicide risk. Predicting who is at higher risk could help with resource allocation to assure patients at high risk of suicide attempts are most closely followed. We previously showed that inpatients who improve their suicide ideation levels faster while in inpatient treatment are the ones with highest rates of post-discharge suicide. Here, we studied the possible genetic underpinnings associated with such risk.\n\nMETHOD: We recorded the slope of suicide ideation recovery of 710 psychiatric inpatients from which we studied two genetic variants likely associated with suicide risk: The serotonin transporter variant 5-HTTLPR, and the BDNF gene variant Val66Met.\n\nRESULTS: We found that inpatients carrying the BDNF Met variant (hypothesized as conferring higher suicide risk) improved their suicide ideation scores faster than Val/Val carrying inpatients. No significant association was found for 5-HTTLPR.\n\nLIMITATIONS: The present sample was genetically homogenous, and future research should replicate these findings on a more diverse sample.\n\nCONCLUSIONS: In conclusion, we found a paradoxical result: Carrying the BDNF Met variant allows inpatients to improve faster, which was shown to confer higher risk at the post-discharge period. This may explain some inconsistencies in the literature in terms of the role of BDNF in suicide ideation and attempts.", "journal": "Journal of affective disorders", "year": "2024", "authors": "Rufino KA, Goli P, Patriquin MA, Kosten TR, Nielsen DA, Salas R", "articleTypes": [ "Journal Article", "Research Support, U.S. Gov't, Non-P.H.S.", "Research Support, Non-U.S. Gov't" ], "doi": "10.1016/j.jad.2024.03.001", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.150Z" }, { "id": "fd56da41-a990-4924-8ae1-6796b74fd4e1", "pmid": "38447916", "title": "Val/Met BDNF as a genetic risk for a false sense of security in post-discharge suicide risk.", "imported": false, "abstract": "BACKGROUND: The time after discharge from psychiatric inpatient care is one of the most dangerous periods in terms of suicide risk. Predicting who is at higher risk could help with resource allocation to assure patients at high risk of suicide attempts are most closely followed. We previously showed that inpatients who improve their suicide ideation levels faster while in inpatient treatment are the ones with highest rates of post-discharge suicide. Here, we studied the possible genetic underpinnings associated with such risk.\n\nMETHOD: We recorded the slope of suicide ideation recovery of 710 psychiatric inpatients from which we studied two genetic variants likely associated with suicide risk: The serotonin transporter variant 5-HTTLPR, and the BDNF gene variant Val66Met.\n\nRESULTS: We found that inpatients carrying the BDNF Met variant (hypothesized as conferring higher suicide risk) improved their suicide ideation scores faster than Val/Val carrying inpatients. No significant association was found for 5-HTTLPR.\n\nLIMITATIONS: The present sample was genetically homogenous, and future research should replicate these findings on a more diverse sample.\n\nCONCLUSIONS: In conclusion, we found a paradoxical result: Carrying the BDNF Met variant allows inpatients to improve faster, which was shown to confer higher risk at the post-discharge period. 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A literature search was carried out in PubMed, ScienceDirect, Cochrane, and Wiley online library databases using the keyword \"(Bitter taste receptor genes OR TAS2R38) AND (PROP OR propylthiouracil) AND (PTC OR phenylthiocarbamide),\" \"(Bitter taste receptor genes OR TAS2R38) AND (alcohol),\" \"(Bitter taste receptor genes OR TAS2R38) AND (tobacco OR smoker)\" to find articles evaluating the association of taste phenotypes and TAS2R38 polymorphisms, and its association among persons who drink alcohol and individuals with smoking behavior. The analysis show that TAS2R38 taster genotype (proline-alanine-valine [PAV] allele) was significantly (OR, 5.88; CI [3.87, 8.95], p < .001) associated with taster phenotype for bitter compounds (PTC/PROP), and TAS2R38 nontaster genotype (alanine-valine-isoleucine allele) was significantly (OR, 6.73; CI [4.57, 9.90], p < .001) associated with nontaster phenotype for bitter compounds. 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A literature search was carried out in PubMed, ScienceDirect, Cochrane, and Wiley online library databases using the keyword \"(Bitter taste receptor genes OR TAS2R38) AND (PROP OR propylthiouracil) AND (PTC OR phenylthiocarbamide),\" \"(Bitter taste receptor genes OR TAS2R38) AND (alcohol),\" \"(Bitter taste receptor genes OR TAS2R38) AND (tobacco OR smoker)\" to find articles evaluating the association of taste phenotypes and TAS2R38 polymorphisms, and its association among persons who drink alcohol and individuals with smoking behavior. The analysis show that TAS2R38 taster genotype (proline-alanine-valine [PAV] allele) was significantly (OR, 5.88; CI [3.87, 8.95], p < .001) associated with taster phenotype for bitter compounds (PTC/PROP), and TAS2R38 nontaster genotype (alanine-valine-isoleucine allele) was significantly (OR, 6.73; CI [4.57, 9.90], p < .001) associated with nontaster phenotype for bitter compounds. Further, TAS2R38 taster genotypes (PAV homozygotes and heterozygotes) were significantly associated with higher alcohol intake (OR, 5.15; 95% CI [2.66, 9.98]; p < .001) and among individuals with smoking behavior (OR, 1.73; 95% CI [1.24, 2.42]; p = .001). This suggests that TAS2R38 single nucleotide polymorphisms can be identified by clinically assessing taste phenotype status for bitter compounds and can be used as a potential therapeutic target in the prevention and treatment of harmful higher alcohol intake and smoking behavior. (PsycInfo Database Record (c) 2024 APA, all rights reserved).", "journal": "Experimental and clinical psychopharmacology", "year": "2024", "authors": "Shivam V", "articleTypes": [], "doi": "10.1037/pha0000728", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.439Z" }, { "id": "0d85fae4-99c0-429f-a211-e2932b3d8fd6", "pmid": "38815112", "title": "A meta-analysis on polymorphic trait of taste perception mediated by TAS2R38 genotype.", "imported": false, "abstract": "The objective of this study is to review the association of TAS2R38 polymorphisms and taste phenotypes to bitter compounds (phenylthiocarbamide [PTC]/propylthiouracil [PROP]), and its association among persons who drink alcohol and individuals with smoking behavior. A literature search was carried out in PubMed, ScienceDirect, Cochrane, and Wiley online library databases using the keyword \"(Bitter taste receptor genes OR TAS2R38) AND (PROP OR propylthiouracil) AND (PTC OR phenylthiocarbamide),\" \"(Bitter taste receptor genes OR TAS2R38) AND (alcohol),\" \"(Bitter taste receptor genes OR TAS2R38) AND (tobacco OR smoker)\" to find articles evaluating the association of taste phenotypes and TAS2R38 polymorphisms, and its association among persons who drink alcohol and individuals with smoking behavior. The analysis show that TAS2R38 taster genotype (proline-alanine-valine [PAV] allele) was significantly (OR, 5.88; CI [3.87, 8.95], p < .001) associated with taster phenotype for bitter compounds (PTC/PROP), and TAS2R38 nontaster genotype (alanine-valine-isoleucine allele) was significantly (OR, 6.73; CI [4.57, 9.90], p < .001) associated with nontaster phenotype for bitter compounds. Further, TAS2R38 taster genotypes (PAV homozygotes and heterozygotes) were significantly associated with higher alcohol intake (OR, 5.15; 95% CI [2.66, 9.98]; p < .001) and among individuals with smoking behavior (OR, 1.73; 95% CI [1.24, 2.42]; p = .001). This suggests that TAS2R38 single nucleotide polymorphisms can be identified by clinically assessing taste phenotype status for bitter compounds and can be used as a potential therapeutic target in the prevention and treatment of harmful higher alcohol intake and smoking behavior. 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However, hypomanic mood swings after partial or total SD have also been described in people without diagnosed mental disorders. Studying this phenomenon in the general population may yield insights about the mechanisms of therapeutic SD, mania and bipolar disorders.\n\nMETHODS: A cross-sectional sample of young adults was recruited and classified into those who described having regularly occurring subclinical hypomanic experiences (ROHE) after SD and those who did not. History of psychiatric and physical illness, with screening for depression and mania, as well as alcohol or drug consumption, family history of depressive disorders or suicide, 5-HTTLPR polymorphism, and MEQ-SA chronotype were collected.\n\nRESULTS: A total of 251 participants were included; 39.0% indicated regularly having subclinical hypomanic experiences after SD. These experiences were not associated with depressive or mania screening, history of psychiatric illness, family history, 5-HTTLPR polymorphism, or MEQ-SA chronotype.\n\nCONCLUSIONS: ROHE after non-therapeutic SD seem to be a relatively common phenomenon in young adults, independent of depressive mood state. Our results suggest that therapeutic SD may depend on a physiological phenomenon of subclinical affective disturbance after SD that affects a part of the general population, independent of psychiatric diagnosis. 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However, hypomanic mood swings after partial or total SD have also been described in people without diagnosed mental disorders. Studying this phenomenon in the general population may yield insights about the mechanisms of therapeutic SD, mania and bipolar disorders.\n\nMETHODS: A cross-sectional sample of young adults was recruited and classified into those who described having regularly occurring subclinical hypomanic experiences (ROHE) after SD and those who did not. History of psychiatric and physical illness, with screening for depression and mania, as well as alcohol or drug consumption, family history of depressive disorders or suicide, 5-HTTLPR polymorphism, and MEQ-SA chronotype were collected.\n\nRESULTS: A total of 251 participants were included; 39.0% indicated regularly having subclinical hypomanic experiences after SD. These experiences were not associated with depressive or mania screening, history of psychiatric illness, family history, 5-HTTLPR polymorphism, or MEQ-SA chronotype.\n\nCONCLUSIONS: ROHE after non-therapeutic SD seem to be a relatively common phenomenon in young adults, independent of depressive mood state. Our results suggest that therapeutic SD may depend on a physiological phenomenon of subclinical affective disturbance after SD that affects a part of the general population, independent of psychiatric diagnosis. Further studies could elucidate associated factors and contribute to our understanding of (hypo-)manic mood states.", "journal": "The world journal of biological psychiatry : the official journal of the World Federation of Societies of Biological Psychiatry", "year": "2024", "authors": "Mauracher L, Serebriakova J, Niederstätter H, Parson W, Schurr T, Deisenhammer EA", "articleTypes": [ "Journal Article" ], "doi": "10.1080/15622975.2024.2382697", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.561Z" }, { "id": "e0e923bd-b2a0-4434-868f-09c474f228b8", "pmid": "39126213", "title": "Subclinical hypomanic experiences in young adults after sleep deprivation are independent of depressive disorders, chronotype or 5-HTTLPR polymorphism.", "imported": false, "abstract": "INTRODUCTION: The acute antidepressant effect of sleep deprivation (SD) in patients with depressive disorders has been studied for more than 60 years. 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These experiences were not associated with depressive or mania screening, history of psychiatric illness, family history, 5-HTTLPR polymorphism, or MEQ-SA chronotype.\n\nCONCLUSIONS: ROHE after non-therapeutic SD seem to be a relatively common phenomenon in young adults, independent of depressive mood state. Our results suggest that therapeutic SD may depend on a physiological phenomenon of subclinical affective disturbance after SD that affects a part of the general population, independent of psychiatric diagnosis. Further studies could elucidate associated factors and contribute to our understanding of (hypo-)manic mood states.", "journal": "The world journal of biological psychiatry : the official journal of the World Federation of Societies of Biological Psychiatry", "year": "2024", "authors": "Mauracher L, Serebriakova J, Niederstätter H, Parson W, Schurr T, Deisenhammer EA", "articleTypes": [ "Journal Article" ], "doi": "10.1080/15622975.2024.2382697", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR 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"Anti-obesity effect of Bifidobacterium adolescentis SPM2022, isolated from Korean adult", "imported": false, "abstract": "", "journal": "", "year": "2025", "authors": "Kang SW, Choi S.", "articleTypes": [], "doi": "10.1007/s10068-025-02013-8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.920Z" }, { "id": "5793d74e-bd5b-473d-899b-2ccc0839edb7", "pmid": "41523672", "title": "Anti-obesity effect of Bifidobacterium adolescentis SPM2022, isolated from Korean adult", "imported": false, "abstract": "", "journal": "", "year": "2025", "authors": "Kang SW, Choi S.", "articleTypes": [], "doi": "10.1007/s10068-025-02013-8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.418Z" }, { "id": "e9c07c6f-76a3-4296-9473-4ea14b0f0df7", "pmid": "41523672", "title": "Anti-obesity effect of Bifidobacterium adolescentis SPM2022, isolated from Korean adult", "imported": false, "abstract": "", "journal": "", "year": "2025", "authors": "Kang SW, Choi S.", "articleTypes": [], "doi": "10.1007/s10068-025-02013-8", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.449Z" }, { "id": "0553dbff-e212-4a01-8ceb-d799d5a2b080", "pmid": "41526462", "title": "Multidimensional risk impact of obesity on breast cancer incidence, treatment, and prognosis", "imported": false, "abstract": "", "journal": "", "year": "2026", "authors": "Liu Y, Xu S, Yang H, Wang Y.", "articleTypes": [], "doi": "10.1038/s41366-025-02008-9", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.443Z" }, { "id": "09119286-c71c-4630-acb6-ffe7e101f08d", "pmid": "41526462", "title": "Multidimensional risk impact of obesity on breast cancer incidence, treatment, and prognosis", "imported": false, "abstract": "", "journal": "", "year": "2026", "authors": "Liu Y, Xu S, Yang H, Wang Y.", "articleTypes": [], "doi": "10.1038/s41366-025-02008-9", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.914Z" }, { "id": "7db65991-ca01-42bb-a7d4-4b52b3310d3c", "pmid": "41526462", "title": "Multidimensional risk impact of obesity on breast cancer incidence, treatment, and prognosis", "imported": false, "abstract": "", "journal": "", "year": "2026", "authors": "Liu Y, Xu S, Yang H, Wang Y.", "articleTypes": [], "doi": "10.1038/s41366-025-02008-9", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.412Z" }, { "id": "857e2037-78ad-40c6-b0ec-cf8e7eba3a5e", "pmid": "41526462", "title": "Multidimensional risk impact of obesity on breast cancer incidence, treatment, and prognosis", "imported": false, "abstract": "", "journal": "", "year": "2026", "authors": "Liu Y, Xu S, Yang H, Wang Y.", "articleTypes": [], "doi": "10.1038/s41366-025-02008-9", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.798Z" }, { "id": "51585ed0-46e1-4887-b003-e5f4ad81f365", "pmid": "41531810", "title": "Single-nucleus transcriptional and chromatin accessibility profiling of mouse hypothalamic LepRb neurons reveals cell type-specific cis-regulatory elements linked to human obesity", "imported": false, "abstract": "", "journal": "", "year": "2025", "authors": "Heyward FD, Pan H, Dreyfuss JM.", "articleTypes": [], "doi": "10.1101/2025.10.06.680592", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:31.926Z" }, { "id": "982fd5d3-0838-4bcb-ad84-3f5c3ae2072d", "pmid": "41531810", "title": "Single-nucleus transcriptional and chromatin accessibility profiling of mouse hypothalamic LepRb neurons reveals cell type-specific cis-regulatory elements linked to human obesity", "imported": false, "abstract": "", "journal": "", "year": "2025", "authors": "Heyward FD, Pan H, Dreyfuss JM.", "articleTypes": [], "doi": "10.1101/2025.10.06.680592", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:27:08.426Z" }, { "id": "9e1aefaf-a7f5-40a1-b768-865a1b0d2d1f", "pmid": "41531810", "title": "Single-nucleus transcriptional and chromatin accessibility profiling of mouse hypothalamic LepRb neurons reveals cell type-specific cis-regulatory elements linked to human obesity", "imported": false, "abstract": "", "journal": "", "year": "2025", "authors": "Heyward FD, Pan H, Dreyfuss JM.", "articleTypes": [], "doi": "10.1101/2025.10.06.680592", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:48.456Z" }, { "id": "d584cccc-9a03-4856-993d-14ae8831c13f", "pmid": "41531810", "title": "Single-nucleus transcriptional and chromatin accessibility profiling of mouse hypothalamic LepRb neurons reveals cell type-specific cis-regulatory elements linked to human obesity", "imported": false, "abstract": "", "journal": "", "year": "2025", "authors": "Heyward FD, Pan H, Dreyfuss JM.", "articleTypes": [], "doi": "10.1101/2025.10.06.680592", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:26:59.811Z" }, { "id": "0962d391-467d-45d3-ac64-3ebcac00426d", "pmid": "41539590", "title": "Genomic Studies of Suicidal Thoughts and Behaviors in Latin American Populations: A Systematic Review.", "imported": false, "abstract": "BACKGROUND: Suicide is a leading cause of death globally, with disproportionately rising rates in Latin America. Despite increasing global interest in the biology of suicidal behavior, Latin American and Hispanic/Latinx populations remain underrepresented in genomic research. In this systematic review, we synthesized current evidence on genomic studies of suicidality in these populations.\n\nMETHODS: We reviewed molecular studies of suicidal ideation, suicide attempt, nonsuicidal self-injury, or suicide death among Latin American or Hispanic/Latinx individuals (PROSPERO registration: CRD42023416616). Eligible studies examined family risk, genetic, epigenetic, or transcriptomic markers. Searches were conducted in PubMed, SciELO, REDALyC, and regional journals. Synthesis used a narrative approach and random-effects meta-analyses when feasible. Risk of bias was assessed using the Newcastle-Ottawa Scale and the Q-Genie tool. A coauthorship network analysis was performed to characterize collaboration patterns.\n\nRESULTS: Fifty-nine studies met inclusion criteria: 3 family, 50 genetic, 6 transcriptomic, and 3 epigenetic studies (categories not mutually exclusive). Candidate gene studies mainly examined serotonergic and stress-response pathways but yielded inconsistent results. Meta-analyses for TPH1 (rs1800532), HTR2A rs6313 (T102C), and 5-HTTLPR (rs25531) showed no significant associations. Recent genome-wide and polygenic score studies identified ancestry-specific loci, although small samples and limited functional annotation resources hindered follow-up. Transcriptomic and epigenetic studies have implicated neurodevelopmental and immune-related processes. Collaboration networks were dominated by a single hub, with limited cross-group integration.\n\nCONCLUSIONS: Genomic research on suicidality in Latin America is growing but remains fragmented and underpowered. Increasing representative sampling, implementing ancestry-aware methods, and fostering collaborations are essential to advance research and inform prevention strategies in these populations.", "journal": "Biological psychiatry", "year": "2026", "authors": "Cabrera-Mendoza B, Panzenhagen AC, de Anda-Jáuregui G, He J, Magalhaes PVS, Martínez-Magaña JJ, Martínez-Levy GA, Qiu D, Sotelo D, Torres D, Medrano JV, Vidal G, Velásquez MM, Nicolini H, Polimanti R, Kaster MP, Docherty AR, Kimbrel NA, Genis-Mendoza AD, Ito LT, Shansis FM, Rovaris DL, Folego-Temoteo I, Fries GR, Suicide Working Group from the Latin American Genomics Consortium", "articleTypes": [ "Systematic Review", "Journal Article" ], "doi": "10.1016/j.biopsych.2025.12.009", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.560Z" }, { "id": "6c01eb16-25e2-49e8-9e20-79ad8b2d61e5", "pmid": "41539590", "title": "Genomic Studies of Suicidal Thoughts and Behaviors in Latin American Populations: A Systematic Review.", "imported": false, "abstract": "BACKGROUND: Suicide is a leading cause of death globally, with disproportionately rising rates in Latin America. Despite increasing global interest in the biology of suicidal behavior, Latin American and Hispanic/Latinx populations remain underrepresented in genomic research. In this systematic review, we synthesized current evidence on genomic studies of suicidality in these populations.\n\nMETHODS: We reviewed molecular studies of suicidal ideation, suicide attempt, nonsuicidal self-injury, or suicide death among Latin American or Hispanic/Latinx individuals (PROSPERO registration: CRD42023416616). Eligible studies examined family risk, genetic, epigenetic, or transcriptomic markers. Searches were conducted in PubMed, SciELO, REDALyC, and regional journals. Synthesis used a narrative approach and random-effects meta-analyses when feasible. Risk of bias was assessed using the Newcastle-Ottawa Scale and the Q-Genie tool. A coauthorship network analysis was performed to characterize collaboration patterns.\n\nRESULTS: Fifty-nine studies met inclusion criteria: 3 family, 50 genetic, 6 transcriptomic, and 3 epigenetic studies (categories not mutually exclusive). Candidate gene studies mainly examined serotonergic and stress-response pathways but yielded inconsistent results. Meta-analyses for TPH1 (rs1800532), HTR2A rs6313 (T102C), and 5-HTTLPR (rs25531) showed no significant associations. Recent genome-wide and polygenic score studies identified ancestry-specific loci, although small samples and limited functional annotation resources hindered follow-up. Transcriptomic and epigenetic studies have implicated neurodevelopmental and immune-related processes. Collaboration networks were dominated by a single hub, with limited cross-group integration.\n\nCONCLUSIONS: Genomic research on suicidality in Latin America is growing but remains fragmented and underpowered. Increasing representative sampling, implementing ancestry-aware methods, and fostering collaborations are essential to advance research and inform prevention strategies in these populations.", "journal": "Biological psychiatry", "year": "2026", "authors": "Cabrera-Mendoza B, Panzenhagen AC, de Anda-Jáuregui G, He J, Magalhaes PVS, Martínez-Magaña JJ, Martínez-Levy GA, Qiu D, Sotelo D, Torres D, Medrano JV, Vidal G, Velásquez MM, Nicolini H, Polimanti R, Kaster MP, Docherty AR, Kimbrel NA, Genis-Mendoza AD, Ito LT, Shansis FM, Rovaris DL, Folego-Temoteo I, Fries GR, Suicide Working Group from the Latin American Genomics Consortium", "articleTypes": [ "Systematic Review", "Journal Article" ], "doi": "10.1016/j.biopsych.2025.12.009", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.149Z" }, { "id": "9f0b7e37-acd2-4974-9c15-2a455aefbbc0", "pmid": "41539590", "title": "Genomic Studies of Suicidal Thoughts and Behaviors in Latin American Populations: A Systematic Review.", "imported": false, "abstract": "BACKGROUND: Suicide is a leading cause of death globally, with disproportionately rising rates in Latin America. Despite increasing global interest in the biology of suicidal behavior, Latin American and Hispanic/Latinx populations remain underrepresented in genomic research. In this systematic review, we synthesized current evidence on genomic studies of suicidality in these populations.\n\nMETHODS: We reviewed molecular studies of suicidal ideation, suicide attempt, nonsuicidal self-injury, or suicide death among Latin American or Hispanic/Latinx individuals (PROSPERO registration: CRD42023416616). Eligible studies examined family risk, genetic, epigenetic, or transcriptomic markers. Searches were conducted in PubMed, SciELO, REDALyC, and regional journals. Synthesis used a narrative approach and random-effects meta-analyses when feasible. Risk of bias was assessed using the Newcastle-Ottawa Scale and the Q-Genie tool. A coauthorship network analysis was performed to characterize collaboration patterns.\n\nRESULTS: Fifty-nine studies met inclusion criteria: 3 family, 50 genetic, 6 transcriptomic, and 3 epigenetic studies (categories not mutually exclusive). Candidate gene studies mainly examined serotonergic and stress-response pathways but yielded inconsistent results. Meta-analyses for TPH1 (rs1800532), HTR2A rs6313 (T102C), and 5-HTTLPR (rs25531) showed no significant associations. Recent genome-wide and polygenic score studies identified ancestry-specific loci, although small samples and limited functional annotation resources hindered follow-up. Transcriptomic and epigenetic studies have implicated neurodevelopmental and immune-related processes. Collaboration networks were dominated by a single hub, with limited cross-group integration.\n\nCONCLUSIONS: Genomic research on suicidality in Latin America is growing but remains fragmented and underpowered. Increasing representative sampling, implementing ancestry-aware methods, and fostering collaborations are essential to advance research and inform prevention strategies in these populations.", "journal": "Biological psychiatry", "year": "2026", "authors": "Cabrera-Mendoza B, Panzenhagen AC, de Anda-Jáuregui G, He J, Magalhaes PVS, Martínez-Magaña JJ, Martínez-Levy GA, Qiu D, Sotelo D, Torres D, Medrano JV, Vidal G, Velásquez MM, Nicolini H, Polimanti R, Kaster MP, Docherty AR, Kimbrel NA, Genis-Mendoza AD, Ito LT, Shansis FM, Rovaris DL, Folego-Temoteo I, Fries GR, Suicide Working Group from the Latin American Genomics Consortium", "articleTypes": [ "Systematic Review", "Journal Article" ], "doi": "10.1016/j.biopsych.2025.12.009", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354184481", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:23:04.481Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:08.605Z" }, { "id": "5c0e8789-df31-4a96-bc81-aa75b8442b2c", "pmid": "41546921", "title": "Childhood adversity and 5-HTTLPR across mental health outcomes: A transdiagnostic meta-analysis.", "imported": false, "abstract": "", "journal": "Child abuse & neglect", "year": "", "authors": "Shivam V", "articleTypes": [], "doi": "10.1016/j.chiabu.2026.107901", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.439Z" }, { "id": "69d3fb1d-a64c-437f-a382-4cff01065915", "pmid": "41546921", "title": "", "imported": false, "abstract": "BACKGROUND: Childhood maltreatment is associated with increased risk for various psychiatric disorders, although individual responses to early adversity vary. The serotonin transporter-linked polymorphic region (5-HTTLPR) has been examined as a potential moderator of sensitivity to environmental stress, but findings across studies have been inconsistent. OBJECTIVE: This meta-analysis examined whether 5-HTTLPR polymorphisms moderate the association between childhood adversity and clinically diagnosed psychiatric disorders. PARTICIPANTS AND SETTINGS: Fourteen studies (N = 3479) were included, representing community, population-based, and clinical samples from multiple regions. Childhood adversity was assessed using validated interviews, questionnaires, or official electronic records. METHODS: Systematic searches of eight databases (last updated 3 December 2025) identified studies reporting 5-HTTLPR genotype, childhood adversity, and psychiatric diagnoses. Ratio-of-odds-ratios (ROR) quantifies differences in adversity effects between S-allele carriers and LL homozygotes. Multilevel random-effects models generated pooled estimates. Sensitivity, moderator, and publication-bias analyses were performed. Study quality was assessed using the Newcastle-Ottawa Scale, and certainty of evidence using GRADE. RESULTS: Pooled analyses indicated no statistically significant interaction between childhood adversity and 5-HTTLPR genotype (ROR = 1.11, 95% CI 0.89-1.37). Analyses restricted to SS-only or SL-only groups and sexual abuse-specific subgroups produced similar results. Heterogeneity was moderate, and small-study effects were borderline. Moderator analyses did not identify consistent influences of diagnosis or ancestry. CONCLUSION: Across available studies, evidence for an interaction between childhood adversity and 5-HTTLPR genotype was limited. Unlike previous meta-analyses that focused primarily on symptom-level or trait-based measures, the present study evaluates clinically diagnosed outcomes, offering evidence that 5-HTTLPR is unlikely to represent a robust moderator of adversity effects. These findings may suggest that, within current research parameters, 5-HTTLPR does not show a consistent moderating role in clinically diagnosed psychiatric outcomes.", "journal": "Child abuse & neglect", "year": "2026", "authors": "Shivam V", "articleTypes": [], "doi": "10.1016/j.chiabu.2026.107901", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.439Z" }, { "id": "efeebc2e-5ada-4328-90c5-0f3cb622dc81", "pmid": "41546921", "title": "Childhood adversity and 5-HTTLPR across mental health outcomes: A transdiagnostic meta-analysis.", "imported": false, "abstract": "BACKGROUND: Childhood maltreatment is associated with increased risk for various psychiatric disorders, although individual responses to early adversity vary. The serotonin transporter-linked polymorphic region (5-HTTLPR) has been examined as a potential moderator of sensitivity to environmental stress, but findings across studies have been inconsistent. OBJECTIVE: This meta-analysis examined whether 5-HTTLPR polymorphisms moderate the association between childhood adversity and clinically diagnosed psychiatric disorders. PARTICIPANTS AND SETTINGS: Fourteen studies (N = 3479) were included, representing community, population-based, and clinical samples from multiple regions. Childhood adversity was assessed using validated interviews, questionnaires, or official electronic records. METHODS: Systematic searches of eight databases (last updated 3 December 2025) identified studies reporting 5-HTTLPR genotype, childhood adversity, and psychiatric diagnoses. Ratio-of-odds-ratios (ROR) quantifies differences in adversity effects between S-allele carriers and LL homozygotes. Multilevel random-effects models generated pooled estimates. Sensitivity, moderator, and publication-bias analyses were performed. Study quality was assessed using the Newcastle-Ottawa Scale, and certainty of evidence using GRADE. RESULTS: Pooled analyses indicated no statistically significant interaction between childhood adversity and 5-HTTLPR genotype (ROR = 1.11, 95% CI 0.89-1.37). Analyses restricted to SS-only or SL-only groups and sexual abuse-specific subgroups produced similar results. Heterogeneity was moderate, and small-study effects were borderline. Moderator analyses did not identify consistent influences of diagnosis or ancestry. CONCLUSION: Across available studies, evidence for an interaction between childhood adversity and 5-HTTLPR genotype was limited. Unlike previous meta-analyses that focused primarily on symptom-level or trait-based measures, the present study evaluates clinically diagnosed outcomes, offering evidence that 5-HTTLPR is unlikely to represent a robust moderator of adversity effects. These findings may suggest that, within current research parameters, 5-HTTLPR does not show a consistent moderating role in clinically diagnosed psychiatric outcomes.", "journal": "Child abuse & neglect", "year": "2026", "authors": "Shivam V", "articleTypes": [], "doi": "10.1016/j.chiabu.2026.107901", "decision": "", "reason": "", "notes": "", "searchSources": [], "firstRetrievedAt": "2026-10-07T06:29:32.439Z" }, { "id": "4f44fc4b-827f-401f-97bc-fec8a6f170fa", "pmid": "41546921", "title": "Childhood adversity and 5-HTTLPR across mental health outcomes: A transdiagnostic meta-analysis.", "imported": false, "abstract": "BACKGROUND: Childhood maltreatment is associated with increased risk for various psychiatric disorders, although individual responses to early adversity vary. The serotonin transporter-linked polymorphic region (5-HTTLPR) has been examined as a potential moderator of sensitivity to environmental stress, but findings across studies have been inconsistent.\n\nOBJECTIVE: This meta-analysis examined whether 5-HTTLPR polymorphisms moderate the association between childhood adversity and clinically diagnosed psychiatric disorders.\n\nPARTICIPANTS AND SETTINGS: Fourteen studies (N = 3479) were included, representing community, population-based, and clinical samples from multiple regions. Childhood adversity was assessed using validated interviews, questionnaires, or official electronic records.\n\nMETHODS: Systematic searches of eight databases (last updated 3 December 2025) identified studies reporting 5-HTTLPR genotype, childhood adversity, and psychiatric diagnoses. Ratio-of-odds-ratios (ROR) quantifies differences in adversity effects between S-allele carriers and LL homozygotes. Multilevel random-effects models generated pooled estimates. Sensitivity, moderator, and publication-bias analyses were performed. Study quality was assessed using the Newcastle-Ottawa Scale, and certainty of evidence using GRADE.\n\nRESULTS: Pooled analyses indicated no statistically significant interaction between childhood adversity and 5-HTTLPR genotype (ROR = 1.11, 95% CI 0.89-1.37). Analyses restricted to SS-only or SL-only groups and sexual abuse-specific subgroups produced similar results. Heterogeneity was moderate, and small-study effects were borderline. Moderator analyses did not identify consistent influences of diagnosis or ancestry.\n\nCONCLUSION: Across available studies, evidence for an interaction between childhood adversity and 5-HTTLPR genotype was limited. Unlike previous meta-analyses that focused primarily on symptom-level or trait-based measures, the present study evaluates clinically diagnosed outcomes, offering evidence that 5-HTTLPR is unlikely to represent a robust moderator of adversity effects. 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Dysregulation of the 5-hydroxytryptamine system has been implicated in suicide risk. The SLC6A4 gene encodes the serotonin transporter, which regulates synaptic 5-hydroxytryptamine levels. Its promoter region contains a 44-base-pair insertion/deletion polymorphism, known as the serotonin-transporter-linked polymorphic region (5-HTTLPR). We examined the association between the 5-HTTLPR polymorphism and suicide death in a Japanese cohort, representing the largest sample from an Asian population to date.\n\nMETHODS: We included 448 suicide decedents and 361 controls. Genomic DNA was extracted from peripheral blood, and 5-HTTLPR genotypes were determined using PCR. We evaluated genotype- and allele-level associations with suicide. Additionally, we conducted a meta-analysis incorporating previous studies.\n\nRESULTS: The distributions of 5-HTTLPR genotypes and alleles differed significantly between suicide decedents and controls (S allele: OR = 1.62, 95% CI = 1.26-2.09, p < 0.001). The associations remained significant in subgroup analyses by sex, age group, and violent methods. Age- and sex-matched analyses yielded consistent results. However, the random-effects meta-analysis did not demonstrate a significant association.\n\nCONCLUSION: Our findings indicate a potential association between 5-HTTLPR polymorphisms and suicide death in a Japanese population. Although further research in larger and diverse samples is warranted, these results may contribute to a better understanding of the biological underpinnings of suicide risk.", "journal": "Neuropsychopharmacology reports", "year": "2026", "authors": "Okada S, Shirai T, Miyachi M, Yamasaki G, Minami K, Tsukamoto R, Mouri K, Tanifuji T, Katada R, Okazaki S, Otsuka I, Hishimoto A", "articleTypes": [ "Journal Article", "Meta-Analysis" ], "doi": "10.1002/npr2.70120", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354153711", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:33.711Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:22:39.560Z" }, { "id": "a44e5483-b3be-4dd6-9779-b2f067c8666b", "pmid": "41968640", "title": "Japanese Cohort Study Identifies an Association Between the Serotonin Transporter-Linked Polymorphic Region and Suicide Death.", "imported": false, "abstract": "INTRODUCTION: More than 720 000 individuals die by suicide annually worldwide, making it a major public health concern and a leading cause of death among young people, particularly in Asian populations. Dysregulation of the 5-hydroxytryptamine system has been implicated in suicide risk. The SLC6A4 gene encodes the serotonin transporter, which regulates synaptic 5-hydroxytryptamine levels. Its promoter region contains a 44-base-pair insertion/deletion polymorphism, known as the serotonin-transporter-linked polymorphic region (5-HTTLPR). We examined the association between the 5-HTTLPR polymorphism and suicide death in a Japanese cohort, representing the largest sample from an Asian population to date.\n\nMETHODS: We included 448 suicide decedents and 361 controls. Genomic DNA was extracted from peripheral blood, and 5-HTTLPR genotypes were determined using PCR. We evaluated genotype- and allele-level associations with suicide. Additionally, we conducted a meta-analysis incorporating previous studies.\n\nRESULTS: The distributions of 5-HTTLPR genotypes and alleles differed significantly between suicide decedents and controls (S allele: OR = 1.62, 95% CI = 1.26-2.09, p < 0.001). The associations remained significant in subgroup analyses by sex, age group, and violent methods. Age- and sex-matched analyses yielded consistent results. However, the random-effects meta-analysis did not demonstrate a significant association.\n\nCONCLUSION: Our findings indicate a potential association between 5-HTTLPR polymorphisms and suicide death in a Japanese population. Although further research in larger and diverse samples is warranted, these results may contribute to a better understanding of the biological underpinnings of suicide risk.", "journal": "Neuropsychopharmacology reports", "year": "2026", "authors": "Okada S, Shirai T, Miyachi M, Yamasaki G, Minami K, Tsukamoto R, Mouri K, Tanifuji T, Katada R, Okazaki S, Otsuka I, Hishimoto A", "articleTypes": [ "Journal Article", "Meta-Analysis" ], "doi": "10.1002/npr2.70120", "decision": "", "reason": "", "notes": "", "searchSources": [ { "id": "search_1791354173444", "database": "PubMed", "query": "5-HTTLPR AND suicide", "searchedAt": "2026-10-07T06:22:53.444Z", "initialCount": 134, "retrievedCount": 0, "segments": [ { "startDate": null, "endDate": null, "count": 134 } ], "queryTranslation": "\"5-HTTLPR\"[All Fields] AND (\"suicid\"[All Fields] OR \"suicidal ideation\"[MeSH Terms] OR (\"suicidal\"[All Fields] AND \"ideation\"[All Fields]) OR \"suicidal ideation\"[All Fields] OR \"suicidality\"[All Fields] OR \"suicidal\"[All Fields] OR \"suicidally\"[All Fields] OR \"suicidals\"[All Fields] OR \"suicide\"[MeSH Terms] OR \"suicide\"[All Fields] OR \"suicides\"[All Fields] OR \"suicide s\"[All Fields] OR \"suicided\"[All Fields] OR \"suiciders\"[All Fields])" } ], "firstRetrievedAt": "2026-10-07T06:23:00.149Z" }, { "id": "ea3df044-cc34-4a66-90bc-c5b7899f7a4d", "pmid": "41968640", "title": "Japanese Cohort Study Identifies an Association Between the Serotonin Transporter-Linked Polymorphic Region and Suicide Death.", "imported": false, "abstract": "INTRODUCTION: More than 720 000 individuals die by suicide annually worldwide, making it a major public health concern and a leading cause of death among young people, particularly in Asian populations. Dysregulation of the 5-hydroxytryptamine system has been implicated in suicide risk. The SLC6A4 gene encodes the serotonin transporter, which regulates synaptic 5-hydroxytryptamine levels. Its promoter region contains a 44-base-pair insertion/deletion polymorphism, known as the serotonin-transporter-linked polymorphic region (5-HTTLPR). We examined the association between the 5-HTTLPR polymorphism and suicide death in a Japanese cohort, representing the largest sample from an Asian population to date.\n\nMETHODS: We included 448 suicide decedents and 361 controls. Genomic DNA was extracted from peripheral blood, and 5-HTTLPR genotypes were determined using PCR. We evaluated genotype- and allele-level associations with suicide. Additionally, we conducted a meta-analysis incorporating previous studies.\n\nRESULTS: The distributions of 5-HTTLPR genotypes and alleles differed significantly between suicide decedents and controls (S allele: OR = 1.62, 95% CI = 1.26-2.09, p < 0.001). The associations remained significant in subgroup analyses by sex, age group, and violent methods. Age- and sex-matched analyses yielded consistent results. However, the random-effects meta-analysis did not demonstrate a significant association.\n\nCONCLUSION: Our findings indicate a potential association between 5-HTTLPR polymorphisms and suicide death in a Japanese population. 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